editorial comment on the editorial policy of seejph with reference to the comments by bjegovic-mikanovic & marinkovic, and by jankovic ulrich laaser, co-editor, seejph as one of the editors of seejph, i welcome the discussion on the paper by jerliu et al. it demonstrates the vitality of the new journal. nevertheless, i believe that a scientific journal does not need to be politically correct, but rather scientifically accurate! both criteria have been questioned with regard to the paper by jerliu et al. in the comments of bjegovicmikanovic & marinkovic and of jankovic. whereas i admit that we as editors were not sufficiently aware of the political context when the paper was published on october 31 st , 2013 1 , we rather left it to the authors to take responsibility for political correctness regarding the status of kosovo according to the unscr 2 . one of us, prof. slavenka jankovic together with her colleagues from serbia clearly marked this deficit in their recent comments and even more the reference to independence of kosovo in the title, which was declared unilaterally on february 17 th , 2008, however judged not to violate international law by the international court of justice (1). the journal of course obeys to the political framework set by unscr, icj and the brussels agreement (2) and in the future we will take care of the proper designation of kosovo. much more relevant i consider the scientific critique on the paper. this is in my view most welcome and, as far as i understand the issues raised, widely justified. the kosovo was one of the least developed regions in the former yugoslavia and it underwent a positive development in most health indicators between the fifties and the eighties of the last century. although our criteria for reviews laid out in the section on instructions for authors are not fulfilled completely in all categories, nevertheless the reviewers accepted the paper in the early development phase of the journal. we always strive to improve the rigidity of our reviewers’ work and, therefore, i welcome the critique by prof. slavenka jankovic from a scientific point of view. it is essential to raise our standards and to enhance the quality of seejph. references 1. international court of justice. accordance with international law of the unilateral declaration of independence in respect of kosovo, advisory opinion. i.c.j. reports 2010, p.403. available at: http://www.icj-cij.org/docket/files/141/15987.pdf (accessed: may 01, 2014). 2. the brussels agreement of 2013. available at: http://eeas.europa.eu/top_stories/2013/190413__eu-facilitated_dialogue_en.htm (accessed: may 01, 2014). 1 the decision to publish the paper by jerliu at al. was reconfirmed by all editors in writing including prof. slavenka jankovic (by email of 26 february 2014) 2 this designation is without prejudice to positions on status, and is in line with unscr 1244 and the icj opinion on the kosovo declaration of independence”. http://ec.europa.eu/enlargement/countries/detailedcountry-information/kosovo/. burazeri g, laaser u, martin-moreno jm, schröder-bäck p. growing up the south eastern european journal of public health (editorial). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-89 1 editorial growing up the south eastern european journal of public health genc burazeri 1,2 , ulrich laaser 3 , jose m. martin-moreno 4,5 , peter schröder-bäck 2,6 1 school of public health, university of medicine, tirana, albania; 2 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life science, maastricht university, maastricht, the netherlands; 3 faculty of health sciences, university of bielefeld, bielefeld, germany; 4 department of preventive medicine and public health, university of valencia, spain; 5 incliva research institute, university of valencia clinical hospital, valencia, spain; 6 faculty of human and health sciences, university of bremen, bremen, germany. corresponding author: genc burazeri, md, phd; address: rr. “dibres”, no. 371, tirana, albania; e-mail: genc.burazeri@maastrichtuniversity.nl conflicts of interest: none. burazeri g, laaser u, martin-moreno jm, schröder-bäck p. growing up the south eastern european journal of public health (editorial). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-89 2 the south eastern european journal of public health (seejph) is an online, open-access, international, peer-reviewed journal, which was launched in 2013 (1). it covers all areas of health sciences, with a main focus on public health. seejph is a journal originating from the ten years of the stability pact for south eastern europe (2001-2011), but aiming to provide a forum for all countries in transition worldwide, whose research work would otherwise be hardly visible. from this point of view, this journal strives to promote particularly an area referred to as “health transition research” (1). time is passing, though, and our “baby”, the seejph, is already two years old by now, or more precisely four volumes “old” – volumes with excellent peer-reviewed contributions from many parts of the world and fascinating discussions e.g. on a view back to the maastricht treaty on european union by the leading negotiators of the time (2); “endorsement” of a public health profession (3); the south east european health network (seehn) (4); the european public health education accreditation system (5); public health ethics (6); as well as several other outstanding original research and review articles tackling a wide range of public health issues. time to prepare for preschool furtherance? yes, indeed! we moved to the open journal system (ojs), kindly hosted by the university of bielefeld in germany. ojs provides all the necessary technical facilities including online submission and review process. but, not only that! in addition, we are now registered in index copernicus and are currently under consideration by several other electronic databases. our executive editorship remains in tirana, albania, but we are happy to have engaged now regional editors covering the globe:  samir n. banoob, president, intenational health mangement, tampa, florida, usa, for the middle east.  evelyne de leeuw, editor-in-chief of health promotion international, , sydney, australia, for the western pacific region.  damen haile mariam, university of addis ababa, ethiopia, for the african region.  charles surjadi, faculty of medicine, atmajaya university, jakarta, indonesia, for the south east asian region.  laura magana valladares, secretaria académica, instituto nacional de salud pública, mexico, mexico, for latin america. however, the journal will grow only upon a firm and long-term commitment of experts and researchers worldwide who believe in the pprofessionalisation of public health in order to advance public health education, training, research and practice. we learned from many sides that seejph is considered a valuable contribution to public health in south eastern europe and transitional countries worldwide. we look forward to applying for an impact factor as soon as it looks promising. your high level contributions will help a lot. thus, no time to celebrate but to grow up our little child to adolescence and adulthood! recommended citation: burazeri g, laaser u, martin-moreno jm, schröder-bäck p. growing up the south eastern european journal of public health (editorial). seejph 2016: vol. v. doi 10.4119/unibi/seejph-2016-89 burazeri g, laaser u, martin-moreno jm, schröder-bäck p. growing up the south eastern european journal of public health (editorial). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-89 3 burazeri g, laaser u, martin-moreno jm, schröder-bäck p. growing up the south eastern european journal of public health (editorial). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-89 4 references 1. burazeri g, jankovic s, laaser u, martin-moreno jm. south eastern european journal of public health: a new international journal. seejph 2014;1. doi 10.12908/seejph-2013-01. 2. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives. seejph 2015;1. doi 10.12908/seejph-2014-36. 3. czabanowska k, laaser u, stjernberg l. shaping and authorising a public health profession. seejph 2014;2. doi 10.12908/seejph-2014-23. 4. ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health. seejph 2015;1. doi 10.12908/seejph2014-34. 5. goodman j. the history of european public health education accreditation in perspective. seejph 2015;1. doi 10.12908/seejph-2014-39. 6. schröder-bäck p, maeckelberghe e, royo-bordonada má. the ethics effect. seejph 2014;2. doi 10.12908/seejph-2014-31. ___________________________________________________________ © 2016 burazeri et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. public health perspective levett j. albanian castles in defence of balkan public health (public health perspective). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-06. 1 public health perspective albanian castles in defence of balkan public health jeffrey levett1 1 the national school of public health, athens, greece. corresponding author: prof. dr. jeffrey levett, national school of public health; address: ilia rogakou 2, athens 106 72, greece; telephone: +302103641607; email: jeffrey.levett@gmail.com levett j. albanian castles in defence of balkan public health (public health perspective). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-06. 2 public health is a rare lamp that can push back the dark shadows of vulnerability, misfortune and poverty in our increasingly complex world. in the balkans (south eastern europe, see) its wick must be turned up and its bright flame lengthened. political support can provide oil to fuel its lamp. health diplomacy and the principles of human security can be useful tools (1,2). when the political will falters or is subverted health damage may result. the world health organization (who) and the council of europe called attention to the growth of population vulnerability and the declining health status in the balkans. together and within the context of the stability pact, they targeted social cohesion. one outcome was the dubrovnik pledge, a political agreement that made a commitment to regional health development by meeting the health needs of vulnerable populations. country projects relating for example to infectious diseases (albania), nutrition (serbia), mental health (bih) and emergency medical services (fyrom) were additional outcomes. another outcome was the network for public health for southeast europe (ph-see) (3). this network has an impressive list of publications covering a wide range of subject materials and books for students and has addressed the development of schools of public health and the need for a health curriculum for peace (4). most recently it launched this journal, the south eastern european journal of public health (seejph). the value system of public health is succinctly and differently expressed in the skopje declaration, for peace, public health and human rights (5) another outcome of the ph-see network. it was later adopted by the world federation of public health associations. in words and spirit of the skopje declaration our actions must “build a better balkan world, closer to the human heart’s desire”. public health emphasizes a cybernetic or systems principle: its improvement must be addressed using strategies and action plans that are multidimensional, interdisciplinary and strongly backed by adequate human resources, by considerable ingenuity and with policy instruments commensurate to the same level of complexity of the problem space. training for competence improvement of public health professionals and the strengthening of schools of public health is a regional priority embedded in the same principle. throughout the region the role of knowledge for development is being vigorously debated (6). the emergence of a balkan research culture will depend upon abundant light and enlightenment. progress in public health will depend on the existence of more autonomous institutions for research and education, mechanisms for accreditation and evaluation, which can include scientific journals, such as this one as well as competence to innovate and implement and direct education towards human development. a place in the new world will depend on science, truth and reconciliation as well as a rightful place for the balkans in europe. development must be inseparable from socio-economic reform, target better wages, housing, living and working conditions and promote health security, which equates to “freedom from want and freedom from fear” (7). by use of metaphor, we can say that the regional intellectual capacity of public health is expressed and in the launch of the seejph, much akin to a line of new albanian castles (from lezha to shkodra), which can stem the tide of greed and corruption and pave a way for regional health development by building on what went before. the seejph is a new vehicle for discussion and debate. it can help institutional renewal of public health, give a boost to investment in training for competence, promote levett j. albanian castles in defence of balkan public health (public health perspective). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-06. 3 policy implementation and the design of multidimensional action plans to ensure human safety and health protection. it must be prepared to break down academic barriers and build the public health community of the balkans. it should be positively viewed and strongly supported as a channel for change promotion. asclepios and his disciple hippocrates, father of western medicine, acted as change agents when they proclaimed: “we have an opinion, let’s discuss it, if the evidence warrants, let’s change it”. today we have evidence-based medicine, health technology assessment and frequently modified or changed clinical guidelines. half of what is true today will be questioned in the next few years. can we predict which half? do we have such good discriminators? a competent seejph can help. public health training has become less fragmented and now presents a more uniform profile. this process was aided by the establishment in the balkans of the association of schools of public health in the european region (aspher, zagreb, 1968) as a contact point, then as a hub for informational exchanges between related schools and institutions. aspher is a network of expertise whose functional links integrate training, science and public health policy and promote cooperation in europe and between regions and continents. over the past three decades the balkan region has courted disaster (8), suffered from economic sanctions, political upheavals, radioactive fallout (chernobyl), armed conflict, wars (bosnia and kosovo), socioeconomic disaster and ecological calamity as well as earthquakes, floods and most recently a creeping health disaster in greece of uncertain dynamics, a result of austerity measures imposed by the government, in response to the global financial crisis (9). in 2005, i suggested that “within an enlarging and safer europe, the language of health is key to a better future…. without adequate socio-economic management, population vulnerability can trigger a creeping social disaster” (10). where cultures, religions, and national languages come together as in the balkans, public health can be the common denominator for development. i have also argued that the region’s best future is its organization without borders and within a single european space (this was implicit in the apt phrase of the late tony judt: “border breaking, community making”). the outcome of any complex activity is hard if not impossible to predict. all we can hope for is that ingenuity and leadership will prevail, that balkan governments will provide public health governance within a competent infrastructure capable of monitoring success and failure and with effective corrective mechanisms for the righting of wrongs. in the balkans let’s now hope for frequent, significant ups with fewer, smaller downs. development of schools of public health, journals such as this and the recent return of the presidency of aspher, albeit temporarily to the region where it was born (see) are some significant ups (professor vesna begovic, serbia assumed the aspher presidency in 2013). let’s hope that a new moment for regional public health has come. if the balkans makes it in public health, it will make it in europe! failing to manage the health of the balkan region can have serious consequences for europe (11,12). europe without its cradle will not sleep well. endnote: the title is a tribute to extensive activities between greece and albania, conducted by the athens school of public health sponsored by the greek ministry of health. it gave the writer opportunities to mentor students, visit castles and archaeological sites, interact with many directors of the institute of public health, tirana, several ngo’s and hospitals, university staff, members of levett j. albanian castles in defence of balkan public health (public health perspective). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-06. 4 parliament as well as health ministers, two who the writer interacted with in prizren and belgrade and one who was honored by the school. projects were conducted throughout albania one funded through phare. the athens school is one of two schools inaugurated by eleftherios venizelos (1919, 1929). he initiated a short-lived revolution in public health, with the help of the international community. the school conducted the first balkan public health forum when the creation of schools in albania and serbia were also discussed (1992). references 1. togo t, levett j. health diplomacy as an aid to human security, 12th world congress on public health, istanbul, wfpha, 2009. 2. declaration on implementation of the human security concept in the balkan region. sixth ecpd conference, national and inter-ethnic reconciliation, religious tolerance and human security in the balkans, brioni island, croatia, 2011. 3. founded by ulrich laaser (bielefeld) and luka kovacic (zagreb) in 2000: forum for public health in south eastern europe (ph-see): programmes for training and research in public health. available from: http://www.snz.unizg.hr/ph-see/index.htm (accessed: january 11, 2014). 4. levett j. contributing to balkan public health: a school for skopje. croat med j 2002;43:117-25. 5. donev d, laaser u, levett j. south eastern european conference on public health and peace. skopje declaration on public health, peace & human rights, december 2001. croat med j 2002;43:105-6. 6. new knowledge for new development. skopje, manu, 7 october 2013, ecpd web-page. 7. undp principle on human security 1994, human security report 2012. 8. levett j, mavrokefalos p. disaster’s imprint on balkan region health, id: 44, 18th world congress on disaster and emergency medicine, manchester uk. may 2013. 9. levett j. from cradle of european civilization to grave austerity: does greece face a creeping health disaster? prehosp disaster med. 2013;28:1-2. 10. levett j, kyriopoulos j. public health in the balkan region: one school’s experience. eur j public health 2005;15:97-9. 11. stoianovich t. balkan worlds: the first and last europe. armonk, new york, and london, england: m.e. sharpe, 1994. 12. stavrianos ls. the balkans since 1453. new york: holt, rinehart, 1958. ___________________________________________________________ © 2014 levett; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed?term=donev%20d%5bauthor%5d&cauthor=true&cauthor_uid=11885032 http://www.ncbi.nlm.nih.gov/pubmed?term=laaser%20u%5bauthor%5d&cauthor=true&cauthor_uid=11885032 http://www.ncbi.nlm.nih.gov/pubmed?term=levett%20j%5bauthor%5d&cauthor=true&cauthor_uid=11885032 http://www.ncbi.nlm.nih.gov/pubmed?term=south%20eastern%20european%20conference%20on%20public%20health%20and%20peace%5bcorporate%20author%5d http://www.ncbi.nlm.nih.gov/pubmed?term=south%20eastern%20european%20conference%20on%20public%20health%20and%20peace%5bcorporate%20author%5d http://www.ncbi.nlm.nih.gov/pubmed/11885032 martin-moreno jm. facing the covid-19 challenge: when the world depends on effective public health interventions [editorial]. seejph 2020, posted: 04 may 2020. doi : 10.4119/seejph-3442 p a g e 1 | 4 editorial facing the covid-19 challenge: when the world depends on effective public health interventions jose m. martin-moreno1,2 1editorial board, south eastern european journal of public health (seejph); 2department of preventive medicine & incliva, university of valencia, spain. corresponding author: jose m. martin-moreno professor of preventive medicine and public health, medical school and incliva – clinical hospital, university of valencia, spain; address: avenida blasco ibañez 10, e-46010 valencia, spain; email: jose.martin-moreno@uv.es martin-moreno jm. facing the covid-19 challenge: when the world depends on effective public health interventions [editorial]. seejph 2020, posted: 04 may 2020. doi : 10.4119/seejph-3442 p a g e 2 | 4 on december 31, 2019, the wuhan municipal health commission in hubei province, people's republic of china, reported a cluster of 27 cases of pneumonia of unknown aetiology with onset of symptoms on december 8. there was a common exposure to a wholesale market for seafood, fish, and live animals in wuhan city (1). it was a report that many of us in the field of epidemiology and public health read from the news and alerts notified by the who, but... at that time (almost) nobody could even imagine the tsunami that was coming for most of the world. after the initial outbreak in china, it was quickly determined (on january 7) that the disease was caused by a new coronavirus, which had many similarities to the one which caused the 2003 sars pandemic. these similarities explained why it was named as severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (2). this virus has characteristic club-shaped spikes that project from their surface, which in microscopic image resembles the solar corona, from which their name derives. as a curiosity to additionally explain the term, the original latin word corona meant 'garland worn on the head as a mark of honour or emblem of majesty,' and, by extension, 'halo around a celestial body.' in fact, the word has come down through time more or less unchanged in spanish and italian (and other latin-based romance languages), in which the word for 'crown' is today written exactly as 'corona'. in parallel to the identification of the causative viral microorganism, public health measures were initiated. according to the information disclosed by the chinese authorities, an epidemiological investigation led by a national team of specialists began on december 31, 2019, and the following public health procedures were implemented: case isolation, identification and follow-up of contacts, environmental sanitation and laboratory research (3). since then, the situation has changed dramatically. the who first declared a global public health emergency on january 31, then announced on february 11 that the new coronavirus disease should be renamed "covid19", and on march 11, declared the outbreak a pandemic (4). after the already described onset of the outbreak in china, coronavirus cases started to spike in south korea and other asian countries at the beginning of february, and later in the month, covid-19 cases began to increase in italy and spain sharply. many other european countries were also affected, and on march 11, president trump banned all travel from 26 european countries. on march 13,he declared the us national emergency. the situation has escalated to a scenario of severe consequences and, at the time of writing this editorial, there have already been identified 3.3 million cases in the world, with about 1.2 million being active and ongoing cases, roughly 1 million recoveries, and more than 234,000 deaths (5). the virus has spread to at least 185 countries and regions around the world in four months, with half of humanity being locked down, something unprecedented in the memory of those of us who are living in this moment. in terms of health alone, the challenge is unprecedented. coordinated national responses, along with intelligent use of field data tools for surveillance of cases and contact-tracing, are needed to prevent the unrestrained spread of the virus and reduce the impact on the normal functioning of hospital systems. it is also crucial to search for a vaccine and proper treatments. given the global dimension of this challenge, which requires worldwide and regional coordination and coherence, and despite criticism martin-moreno jm. facing the covid-19 challenge: when the world depends on effective public health interventions [editorial]. seejph 2020, posted: 04 may 2020. doi : 10.4119/seejph-3442 p a g e 3 | 4 from individual governments and specific circles, we should strengthen with total determination the role and resources available to the who and, in our european dimension, to the ecdc. when it comes to finding guidance to guide our actions, in addition to all the inspiration provided by the above-mentioned international institutions, our set of ten "essential public health operations" (ephos) framework has proven to be vital in tackling this challenge (6,7). in this case, it is obvious the importance of the surveillance of population health (epho 1), and the monitoring and response to health hazards and emergencies (epho 2). however, we cannot forget the relevance of all other essential operations, such as: the communication and social mobilization for health (epho 9); the one which allows us to articulate solutions for an effective vaccine (epho 10 and 5); the health protection interventions including environmental, occupational, and food safety (epho 3); the promotion of population health and wellbeing tackling inequalities and the broader social and environmental determinants (epho 4); the proper health governance for health, together with reliable infrastructures and financing to ensure the resources and viability of public health interventions (epho 6 and 8); and, the responsibility to ensure a competent workforce (epho 7). and speaking of the latter, which many of us are passionately committed to, aspher, as europe's representative organization for schools of public health, has made a courageous statement in response to the situation raised by the novel coronavirus disease (covid-19) outbreak emergency (8), including the demand for recognition of public health professionals, and the provision of resources required to carry out their mission properly. the full aspher statement can be read through the link https://www.aspher.org/articles,4,68.html, and the complete list of signatories is available at https://www.aspher.org/aspher-covid19statement-signatories.html. beyond the strict public health and healthcare dimension, our societies will also need to tackle the significant economic and social challenges posed by this appalling event. the new coronavirus will cause direct damage due to the sharp fall in demand and supplyside disruption. its consequences will depend on the duration of the crisis and how it is managed at every level (international, supranational and national). in many of our countries, we are already seeing or foreseeing an impact on employment, along with all the associated consequences for social cohesion and politics, and for people's health. effective leadership capability at these three levels is critical. moreover, if we do well, we have the potential to emerge even better and stronger than we are now. we can try to avoid old mistakes and build a fairer society. on the other hand, the effects of the crisis may be a motivation or incentive to improve in various economic areas, such as technology, mobility, and energy dependence. furthermore, the pandemic comes at a critical juncture for multilateralism and integration. let me conclude with a sentence from the spanish nobel laureate jacinto benavente: "life is like a journey on the sea: there are days of calm and days of stormy weather; the important thing is to be a good captain of our ship." this is sound advice for public health practice and, but it is not always easy to take, especially in the permanent situation of uncertainty, feelings of vulnerability, or over information, most of the time confusing and distressing, that brings the crisis of the covid-19 under its arm. nevertheless, we live in a world where we are interconnected, we share more than ever what https://www.aspher.org/articles,4,68.html https://www.aspher.org/articles,4,68.html https://www.aspher.org/aspher-covid19-statement-signatories.html https://www.aspher.org/aspher-covid19-statement-signatories.html martin-moreno jm. facing the covid-19 challenge: when the world depends on effective public health interventions [editorial]. seejph 2020, posted: 04 may 2020. doi : 10.4119/seejph-3442 p a g e 4 | 4 © 2020 martin-moreno jm. this is an open-access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. we know, and i am sure that solutions will come much sooner than we could ever conceive. for all these reasons, there is reason for optimism, and for thinking that public health will come out more recognized and strengthened not because of our selfish interest, but for the good of our people. references 1. li q, guan x, wu p, et al. early transmission dynamics in wuhan, china, of novel coronavirus–infected pneumonia. n engl j med 2020; 382:1199-1207. doi 10.1056/nejmoa2001316. 2. xu j, zhao s, teng t, et al. systematic comparison of two animal-tohuman transmitted human coronaviruses: sars-cov-2 and sarscov. viruses. 2020; 12(2): 244. doi 10.3390/v12020244. 3. adhikari sp, meng s, wu yj. epidemiology, causes, clinical manifestation and diagnosis, prevention, and control of coronavirus disease (covid-19) during the early outbreak period: a scoping review. infect dis poverty 2020; 9(1):29. doi 10.1186/s40249-020-00646-x. 4. world health organization. who director-general's opening remarks at the media briefing on covid-19 march 11 2020. geneva: who; 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-openingremarks-at-the-media-briefing-oncovid-19---11-march-2020. 5. johns hopkins university (jhu). covid-19 dashboard by the center for systems science and engineering (csse). baltimore: jhu; 2020. https://gisanddata.maps.arcgis.com/a pps/opsdashboard/index.html#/bda7594740fd402994234 67b48e9ecf6. 6. foldspang a. towards a public health profession: the roles of essential public health operations and lists of competences. european journal of public health 2015; 25(3): 361– 362.doi 10.1093/eurpub/ckv007. 7. martin-moreno jm. self-assessment tool for the evaluation of essential public health operations in the who european region. copenhagen: world health organization, regional office for europe; 2015. isbn 978 92 890 50999 8. middleton j, martin-moreno jm, barros h, chambaud l, signorelli c. aspher statement on the novel coronavirus disease (covid-19) outbreak emergency. int j public health 2020;65(3):237238. doi 10.1007/s00038-02001362-x. ___________________________________________________________ дългосрочна системна оценка на резултатите от лекарствени политики на ценови отстъпки и споразумения за контролиран достъп на пациентите в българия vekov ty. control of public expenditure on drug products in bulgaria – policies and outcomes (short report). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-28 1 short report control of public expenditure on drug products in bulgaria – policies and outcomes toni yonkov vekov1 1 faculty of public health, medical university, pleven, bulgaria. corresponding author: prof. toni yonkov vekov, medical university, pleven; address: 1 sv kliment ohridski st., 5800 pleven, bulgaria; telephone: +359 29625454; e-mail: t.vekov.mu.pleven@abv.bg vekov ty. control of public expenditure on drug products in bulgaria – policies and outcomes (short report). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-28 2 abstract aim: the aim of this study was to assess the economic performance of the application of the policy for negotiating discounts on drug products and agreements on the controlled access of patients in bulgaria. methods: the methodology involves comparison of the amounts of public spending on medicines in two periods – during the course of the analyzed drug policies (january 2007 – june 2009), and the period in which negotiations on the price of medicines and programs for the controlled access of the patients was discontinued (july 2009 – december 2012). results: in bulgaria, the government did not apply methods for controlling public expenditure on medicines bargaining price concessions from manufacturers and implementing agreements on controlled access of patients after june 2009. this led to an annual increase in the expenditures on drug products for home treatment (on average, 17% for the period 2009-2012). conclusion: this trend in bulgaria will continue in the future since expenditure control only through price control by means of a reference system and the positive list of medicines is ineffective. there is a need for implementation of combined drug policies in bulgaria in the form of negotiations on rebates with manufacturers and agreements on controlled access of patients and reference pricing. keywords: bulgaria, drugs, negotiation, national health insurance fund, prices. conflict of interest: none. vekov ty. control of public expenditure on drug products in bulgaria – policies and outcomes (short report). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-28 3 introduction the contemporary approaches to drug policy in a number of european union (eu) countries include negotiating discounts and rebates between the health insurance funds and the pharmaceutical manufacturers, as well as agreements for risk sharing in order to reduce the impact of the new patented medicines on the public budget. negotiating some form of discount between the manufacturers and the funds has different forms and ways of administration in different countries and, in some cases, pharmacies give up part of their statutory surcharges (e.g. the netherlands) (1). in other cases, they impose administrative requirements for discounts on the pharmaceutical manufacturers (germany, spain, portugal) (2), whereas in further cases manufacturers recover part of the cost of the reimbursed medicines when the previously agreed annual limits are exceeded (france) (3). such policies of paying back are becoming more and more popular and are currently being applied in at least ten eu countries. until june 2009, the national health insurance fund (nhif) in bulgaria negotiated discounts with manufacturers on the prices of patented medicines and administratively determined the conditions of pharmacies for their dispensing. for these products, pharmacists were not allowed to charge the statutory determined retail surcharge and received a minimum fixed fee for the dispensing of medicines. subsequently, in june 2009, with the adoption of a positive drug list (pdl), the possibility of nhif to negotiate prices and discounts on medicines were legally discontinued. the agreements for sharing the financial risk and the controlled access of patients to treatment with proprietary medicinal products are also a tool for the management and control of public spending. the need for such agreements highlights the rapidly growing share of drug costs for the treatment of certain diseases such as cancer, viral infections, neurological diseases, or diabetes and the increasing concern of the governments about the relatively high level of health consumption of new drugs compared to the standard therapeutic alternatives. in the eu countries, there exist several different schemes for financial risk sharing: • agreements of the type “price-quantity”. these are purely financial schemes that lead to recovery when there is an excess in the previously agreed schemes by the producers’ sales. • agreements of the type “controlled access for the patients”. they are based on an approach that the medicines are provided free-of-charge or at a lower price by the manufacturer for a limited period in order to facilitate financing (4). • agreements based on the results. they are based on the recovery of the costs, if a previously agreed upon level of therapeutic results is not reached, e.g. the desired improvement of health. ultimately, no matter what the specific approach will be, the agreements for risk sharing reduce the risk of overspending the budget of the public health insurance fund. they are particularly useful for restricting the use of drugs by those segments of the population which generate the least benefits (5). in the bulgarian health system, agreements for the controlled access of patients were applied until june 2009 in the form of health programs for expensive treatment of socially significant diseases such as diabetes, chronic renal failure, hepatitis, multiple sclerosis, schizophrenia, bipolar disorder, or parkinson’s disease. access to these health programs was granted for patients who met specific criteria for the disease and diagnostic indicators, confirmed by special medical commissions. these health programs for the controlled access of patients have been discontinued since june 2009 and the access was extended to all patients with these diagnoses. as a modern political tool that limits the impact on public spending, especially for innovative vekov ty. control of public expenditure on drug products in bulgaria – policies and outcomes (short report). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-28 4 drugs of uncertain benefit, the agreements for sharing the financial risk are an interesting and promising approach. at present, however, there is no systematic evaluation of their application and results achieved in bulgaria. in this context, the aim of the current study was to assess the economic results of the implementation of the policies for negotiating discounts and medical products and the agreements on the controlled access of patients in bulgaria. the study questions included a comparative analysis of the cost of the expenses for drug products throughout two periods, in which different practices for their regulation were employed – in the first period there were employed policies of negotiating the prices, internal reference pricing and programs for regulated access to patients, while in the next period only policies for external and internal reference pricing were used. the tested hypothesis was that the complex policy of reference pricing, negotiating prices and programs for a controlled access contribute to the success of a more effective regulation of the drug products costs, in comparison to the separate employment of policies for external and internal reference pricing. methods the methodology consisted of comparing the value of public spending on medicines in two periods – during the course of the analyzed drug policies (january 2007 – june 2009) (6) and the period when negotiating the price of medicines and the programs for the controlled access of patients was discontinued (july 2009 – december 2012) (7). the official data for the expenses of nhif for reimbursing the medicinal products were used for the current analysis. we compared the quantities and the value of the medicinal products, which have been completely reimbursed and were used for the treatment of multiple sclerosis, hepatitis, schizophrenia and diabetes. these expenses constitute 25% of the costs for the completely reimbursed medicinal products. at the beginning of the period under consideration (2007), medicines had patent protection and there were no registered generic products in the market. up to 2009, public expenses of these medicinal products were controlled through a complex of measures which included agreements for sharing the financial risk and policies of price discounts. results the public expenditure on nhif medicines for the period of 2007-2012 are presented in figure 1. the costs up to june 2009 are presented in two parts – partially reimbursed medicines and completely free medicines, which are controlled by negotiating discounts, an administrative reduction of the surplus charge of pharmacies and programs to control patient access to the expensive treatment of certain socially significant diseases. after june 2009, all the nhif approaches employed to control costs were terminated, and the cost of public funds for medicines were operated only by the pdl, based on external and internal reference pricing. the data analysis shows that during the period 2007-2009 (when discount policies and agreements on the controlled access were applied), the cost of medicines for three years increased from 282 million bgn to 325 million bgn, i.e. an increase of 15%. for a similar period (2010-2012), when the public spending was controlled only by external and internal reference pricing, the cost of medicines increased from 366 million bgn to 524 million bgn (up to 43%). therefore, it is reasonable to conclude that the long-term results of drug policies on discounts and programs for the controlled access of patients are more effective in terms of public spending, than the independent application of a reference price system within the pdl. vekov ty. control of public expenditure on drug products in bulgaria – policies and outcomes (short report). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-28 5 figure 1. public expenditure on nhif medicines for the period 2007-2012 (source: statement of the cash execution of the nhif budget) table 1 displays the quantitative analysis of the most commonly used medicines for the treatment of multiple sclerosis, hepatitis, schizophrenia and diabetes, which in 2008 were dispensed under the programs for controlled access that were discontinued after june 2009. after the termination of the agreements for controlled access, the reimbursed amounts of the nhif drug products increased between 14% (insulin human) and 157% (peginterferon) by 2012 compared to 2008. table 1. the amount of annual sales during the period 2008-2012 (source: ims health, 2008-2012) medicine 2008 (number) 2009 (number) 2010 (number) 2011 (number) 2012 (number) interferon β 12,277 15,863 19,364 21,175 25,741 peginterferon 14,087 18,285 35,435 34,731 36,244 olanzapinе 62,650 70,145 64,002 71,958 105,744 aripiprazole 24,224 26,799 35,265 39,147 41,429 insulin human 4,527,237 4,783,584 4, 854, 414 5,082,538 5,166,258 table 2 displays an analysis of the values that were reimbursed by the nhif for the same products. public spending on the examined medicinal products increased between 16% (insulin human) and 118% (peginterferon) by 2012. an exception is the reimbursed expense for olanzapine. the main reason is the expiry of the patent protection and the registration of generic medicines. table 2. the value of annual sales during the period of 2008-2012 (source: ims health, 2008-2012) medicine 2008, bgn 2009, bgn 2010, bgn 2011, bgn 2012, bgn interferon β 9,717,166 12,585,278 16,392,076 16,207,345 18,495,318 peginterferon 5,571,752 6,563,072 12,485,396 12,293,382 12,166,795 olanzapinе 11,871,082 11,319,137 9,592,246 8,795,552 7,686,233 aripiprazole 5,178,861 4,883,137 5,713,810 6,376,297 6,711,932 insulin human 44,209,976 45,246,122 44,617,054 49,667,806 51,433,736 175 161 105 107 134 63 157 366 473 524 0 100 200 300 400 500 600 2007 2008 2009 2009 2010 2011 2012 costs, controlled by external and internal reference policy costs, controlled by discounts, agreements and programs for controlled access 282 295 168 ja nu ar yju ne 2 00 9 ju ly -d ec em be r 2 00 9 million bgn vekov ty. control of public expenditure on drug products in bulgaria – policies and outcomes (short report). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-28 6 discussion the increased public spending after 2009 once again demonstrates that the combination of various drug policies like negotiating discounts with manufacturers, agreements for the controlled access of patients and reference pricing are much more effective for the management and control of costs, than the administration of external and internal reference pricing by a pdl. the complex approach is the only possibility for price control of the innovative medicinal products (interferon, peginterferon, insulin, aripiprazole), where there are no generic alternatives and the internal reference pricing approach cannot be applied. moreover, the pharmaceutical companies have control over the external reference pricing to a large degree and prefer to register their innovative products first at the high price markets in the eu (8). in these situations, the small pharmaceutical markets, such as the bulgarian market, are threatened by a delayed access to the contemporary drug therapies. there is a high probability that analogical cases would occur in all countries in southeast europe and it is recommended that complex drug policies are applied for the management of the public costs on medicinal products. the general rationale of the integrated approach to the drug policy is to accelerate the patient access towards innovative medicines, while ensuring that the financial risks are shared on the basis of estimated or actual cost-effectiveness and the impact of the consumption of medicines on the public budget. the decrease in the cost of the product olanzapine by 35% in 2012 compared to 2008, confirms the effectiveness of the approach for generic substitution, which regulates public spending without compromising the therapeutic goals. by 2015, according to the data from ims health, over 60% of the patent-protected drugs as of 2012 will be available as generics (9,10). the expiration of patent protection will make a large segment of the market available for generic medicines, and this will create a huge potential for saving financial resources. in addition, generics are just as good for health as original drugs are (11). conclusion after june 2009, the government of bulgaria did not apply methods to control the public expenditure of drug products, such as negotiating price discounts from manufacturers and the implementation of agreements for the controlled access to patients. this led to an annual increase in the expenditure of nhif for medicines for home treatment by an average of 17% for the period 2009-2012. this trend will continue in the future because the cost control only through price controls by the reference system and the pdl is ineffective. it is necessary to implement a combination of policies on medicines, like negotiating discounts with the manufacturers, agreements for the controlled access of patients and reference pricing (12,13). the contemporary drug policies presume that there is an increase in the role of pharmacoeconomic evaluation when making decisions for the reimbursement of the medicinal products and the management of public expenses (14). the countries of southeast europe are still beginners in this process, but the fast creation of academic structures for economic evaluation of the medicinal therapies, which help the decision making committees on reimbursement, will improve the future efficacy of the complex drug policies for control of public expenses on medicinal products (15). references 1. cameron a, ewen m, ross-degnan d, ball d, laing r. medicine prices, availability and affordability in 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pharmacoeconomical studies. journal of international scientific publications: economy & business 2013;7:540-51. ___________________________________________________________ © 2014 vekov; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed?term=adamski%20j%5bauthor%5d&cauthor=true&cauthor_uid=20529296 http://www.ncbi.nlm.nih.gov/pubmed?term=godman%20b%5bauthor%5d&cauthor=true&cauthor_uid=20529296 http://www.ncbi.nlm.nih.gov/pubmed?term=ofierska-sujkowska%20g%5bauthor%5d&cauthor=true&cauthor_uid=20529296 http://www.ncbi.nlm.nih.gov/pubmed?term=osi%c5%84ska%20b%5bauthor%5d&cauthor=true&cauthor_uid=20529296 http://www.ncbi.nlm.nih.gov/pubmed?term=herholz%20h%5bauthor%5d&cauthor=true&cauthor_uid=20529296 http://www.ncbi.nlm.nih.gov/pubmed?term=wendykowska%20k%5bauthor%5d&cauthor=true&cauthor_uid=20529296 http://www.ncbi.nlm.nih.gov/pubmed?term=wendykowska%20k%5bauthor%5d&cauthor=true&cauthor_uid=20529296 http://www.ncbi.nlm.nih.gov/pubmed?term=aaserud%20m%5bauthor%5d&cauthor=true&cauthor_uid=16625648 http://www.ncbi.nlm.nih.gov/pubmed?term=dahlgren%20at%5bauthor%5d&cauthor=true&cauthor_uid=16625648 http://www.ncbi.nlm.nih.gov/pubmed?term=k%c3%b6sters%20jp%5bauthor%5d&cauthor=true&cauthor_uid=16625648 http://www.ncbi.nlm.nih.gov/pubmed?term=oxman%20ad%5bauthor%5d&cauthor=true&cauthor_uid=16625648 http://www.ncbi.nlm.nih.gov/pubmed?term=ramsay%20c%5bauthor%5d&cauthor=true&cauthor_uid=16625648 http://www.ncbi.nlm.nih.gov/pubmed?term=sturm%20h%5bauthor%5d&cauthor=true&cauthor_uid=16625648 holst j. designing germany’s new global health strategy: some important recommendations (editorial). seejph 2019, posted: 02 april 2019. doi 10.4119/unibi/seejph-2019-211 page 1 of 7 e d i t o r i a l designing germany’s new global health strategy: some important recommendations jens holst1, on behalf of the german platform for global health 1 department of nursing and health sciences, fulda university of applied sciences, fulda, germany. corresponding author: jens holst, fulda university of applied sciences; address: leipziger strasse 123, d-36037 fulda, germany; telephone +496619640643; email: jens.holst@pg.hs-fulda.de holst j. designing germany’s new global health strategy: some important recommendations (editorial). seejph 2019, posted: 02 april 2019. doi 10.4119/unibi/seejph-2019-211 page 2 of 7 introduction the german government is currently preparing a new global-health concept. this is remarkable only five years after the adoption of the first national concept as an important step towards a coherent globalhealth policy (1). public-health experts had warned at the time that the 2013 strategy might fail to make a consolidated contribution to solving global health challenges. they identified important gaps, particularly in the areas of non-medical determinants of health, national and global inequity, and universal health coverage for migrants, refugees and sans papiers, as well as in the effective and transparent inter-ministerial institutionalisation of german global health policies and universal health coverage (2). for the re-launching of the global health strategy paper, the federal government organised two preparatory meetings with civil society and invited different actors to elaborate their priority recommendations. in the context of the participatory process initiated by the government, the german platform for global health (dpgg), an association of trade unions, nongovernmental organisations and researchers, now highlights a series of recommendations which will be crucial for making an effective and convincing contribution to the global health agenda. in particular, germany’s growing role as global-health actor (3) calls for a balanced, multidisciplinary, coherent and problemoriented policy for contributing to significant and sustained improvement in people’s health worldwide. based on inputs from a broad array of areas of expertise, the platform aims to emphasise the importance of the social determinants of health and disease in both the national and international health debate (4). in today's globalised world, the key conditions of people's well-being and health are no longer steerable and modifiable at the national level alone. a comprehensive approach has to acknowledge that global health starts at home. hence, the platform strives to bridge the divide between national and global health policies. starting from this understanding, the german platform for global health has developed the following key recommendations for the new german global-health strategy. equal health opportunities worldwide health is both a precious resource and a human right. all over the world, health opportunities depend far more on social conditions and social status than on individual health behaviours. people with lower education and income fall ill and die earlier than members of the upper socioeconomic class (5,6). this is not due to higher barriers to access to medical care, because even comprehensive social protection systems such as those in france, germany, the netherlands or the united kingdom do not alter the fact that life expectancy for the poorest quintile is shorter by many years, on average, than for the richest 20 percent of the population (7). these disparities in the health and life chances of people in germany, europe and world-wide are not ordained by nature but caused by social conditions and can therefore be influenced by political measures. responsible global health policies must strive to reduce these inequalities. however, as in most countries, the healthpolicy debate in germany is almost exclusively concerned with the scope and organisation of the health-care system, with financial contributions and the payment of health-care providers. restricting health and illness to individual self-responsibility is the wrong way to go and heightens inequalities rather than reducing them. often the causes of disease are primarily addressed as individual risk factors, while little attention is paid to the most harmful factors, the social, environmental, structural holst j. designing germany’s new global health strategy: some important recommendations (editorial). seejph 2019, posted: 02 april 2019. doi 10.4119/unibi/seejph-2019-211 page 3 of 7 and political determinants of health and disease. the forthcoming global health strategy of the german federal government should thus also highlight the creation and promotion of healthy living and environmental conditions at local, national and global levels. a healthpromoting policy must not only ensure good care in the event of illness, but above all create conditions that enable a healthy life. in any case, the health-care system can only contribute a small part to overcoming health inequalities. health policy must be cross-sectoral and target all areas that directly or indirectly affect people's wellbeing and health. who therefore calls for a coherent approach at various policy levels (health in all policies) involving government actors, business, civil society and global organisations (8). if it wants to contribute effectively to improving the health of the world's population, the federal government's global health strategy must also provide policy impact assessment tools; that is, approaches to review all policy areas for their social, environmental and, most importantly, health impacts. this is the only way to prevent regulations, projects and measures from having a negative impact on human health. the global health strategy should therefore:  create conditions that enable a healthy life;  reduce health inequalities;  pursue a health-in-all approach;  subject measures in all policy areas to a health impact assessment. social security for all especially in the countries of the global south, but also in the rich countries of the north, globalisation measures such as structural adjustment policies, public austerity programmes and privatisation have put pressure on or even dismantled public social security systems (9). in the case of illness, unemployment and disability, people must be able to build on reliable social protection systems. without overcoming social insecurity and hardship, the fundamental rights, opportunities for realisation and ultimately the freedom of the people are not guaranteed. universal social protection in the event of illness is not a mere economic cost factor, but the basis for individual and economic development and social welfare (10). the sustainable development goals (sdgs) also oblige germany to offer social protection to all people living in the country (11). this means making social benefits fully available to asylum seekers, non-working eu citizens and all people without a regular residence permit. at the global level, there must be a special emphasis on strengthening social protection systems, especially in the poor countries of the south. therefore, a country’s global health strategy must always include universal health coverage as well as more extensive social protection – both in that country and elsewhere in the world. but even strengthening health and social systems through international cooperation will not be sufficient in itself. the sustainable improvement of the social condition of all people on earth requires fair use of national resources, economic participation as well as financial support of poor societies and their people. the global health strategy should therefore include the following elements:  ensuring the universal right to social protection and mitigation of social risks;  developing social security systems worldwide with sustainable and solidarity-based financing, including access to guaranteed social benefits for all people living in germany;  establishing a global financial equalisation fund for social benefits, and particularly social protection in case of illness. holst j. designing germany’s new global health strategy: some important recommendations (editorial). seejph 2019, posted: 02 april 2019. doi 10.4119/unibi/seejph-2019-211 page 4 of 7 decent and healthy work adequate protection of the life and health of the working population, as well as social security to safeguard minimum income and comprehensive medical care, have long been central objectives of the international community. however, globalisation is increasingly putting pressure on labour standards worldwide and making their enforcement more difficult (12,13). wellbeing and health opportunities of the working population are often subordinated to the pursuit of growth and profit. even worse is the situation for the unemployed, who face a significantly higher risk of illness and death (14), for about 20 million people obliged to work as forced labourers, and over 200 million working children worldwide (15). therefore, a global health strategy should also include actions to reduce relevant detrimental risk factors for health, such as job insecurity, precarious employment, poor working conditions and lack of social protection for the unemployed. in today's global economic order, low wage levels, savings on health and safety protection in the workplace, flexible and hence unstable employment conditions, and weak trade unions or none at all, are considered positive business-location factors. until the logic of short-term profit maximisation and growth at any price can be reversed, equity in health remains unattainable. the global health strategy of the federal government must not only consider the working conditions of people all over the globe, but also the responsibility of german and international companies. those who are serious about better global health have to demand responsible, democratic governance of the global economy which respects economic, social, environmental and health aspects and reconciles different interests. the global health strategy should therefore include the following:  ensuring the fundamental right to work and adequate remuneration;  compliance with ilo health and safety regulations and eliminating hazardous working conditions worldwide;  greater focus of the global economy on societal, environmental and health criteria. climate change and health climate change threatens the very foundations of human life on the planet and is considered the greatest health threat in the 21st century (16). air pollution is one of the leading causes of illness and death worldwide (17,18); global warming and climate-related environmental damage endanger the basic conditions for health and well-being and are threatening to undermine the health improvements of recent decades. comprehensive, determined and quick action is needed to keep the consequences of global warming under control. environmental pollution and climate change have a direct and indirect health impact (19). given the potentially existential threat to our civilisation and human health from environmental degradation, climate change and health should be cornerstones of any global health strategy. effective climate protection is active health protection that goes beyond merely strengthening resilience. the global health strategy should therefore:  call for a rapid transition to a carbonneutral economy and society by means of emissions reductions, adequate taxation of fossil fuels and reduction of subsidies, which are harmful to the environment or the environment;  seek to use the additional funds for climate change and health;  financially and technologically support poorer countries to avoid development pathways based on environmental degradation and fossil energy generation;  understand global health as the health of human civilisation and its natural holst j. designing germany’s new global health strategy: some important recommendations (editorial). seejph 2019, posted: 02 april 2019. doi 10.4119/unibi/seejph-2019-211 page 5 of 7 resources. health: human right in public responsibility “everyone has the right to a standard of living adequate for the health and wellbeing of himself and of his family, including food, clothing, housing and medical care and necessary social services”, states the 1948 universal declaration of human rights (20). the 1966 social pact of the united nations establishes "the right of everyone to the enjoyment of the highest attainable standard of physical and mental health" and further specifies the “steps to be taken by the states parties to the present covenant to achieve the full realization of this right” (21). the world health organization also explicitly makes governments responsible for the state of health of the population (22). although civil society involvement is important, states should not shift that responsibility to them. despite these and other internationally binding rules, the implementation of the right to health remains a global challenge. privatisations and public-private partnerships (ppps), praised as a solution for tight budgets, are now showing undesirable effects such as rising consumer prices, lack of control over the use of public funds, and growing social and health inequalities (23,24). these consequences of the narrow business logic of marketoriented reforms have underlined the necessity and significance of social services in the general public interest, both in germany and in other countries of the world. without preserving and strengthening public social responsibility, the right to health remains unattainable. it is first and foremost the duty of states to ensure the social and institutional framework, bear responsibility for unimpeded access to care for all and reduce health inequalities. while the german global health strategy should involve civil society, it also has to emphasise the mandatory role of the public sector in providing services in the general public interest, health care and social security. conclusions the german government is currently preparing a new global health strategy, to be published in 2019. the former strategy from 2103 had received criticism for the inadequate consideration of non-medical determinants of health and insufficient political coherence. as social, political and economic determinants are highly relevant for population health, the new strategy will have to strive for increased political and inter-sectoral coherence which is indispensable for promoting equal opportunities and reducing inequalities in and between countries. for effectively improving global health, the german government will have to emphasise multilateral strategies and the crucial role of the public sector. the new global-health strategy needs to provide proof of germany’s commitment to reduce social and health inequalities, to support health system strengthening and universal health coverage, to promote decent work and healthy labour conditions, to fulfil its climate targets, and to enforce the right to health. conflicts of interest: none. holst j. designing germany’s new global health strategy: some important recommendations (editorial). seejph 2019, posted: 02 april 2019. doi 10.4119/unibi/seejph-2019-211 page 6 of 7 references 1. bundesministerium für gesundheit. shaping global health – taking joint action – embracing responsibility. the federal government's strategy paper. https://www.bundesgesundheitsminister ium.de/fileadmin/dateien/5_publikation en/gesundheit/broschueren/screen_glo bale_gesundheitspolitik_engl.pdf (accessed: march 28, 2018). 2. bozorgmehr k, bruchhausen w, hein w, et al. germany and global health: an unfinished agenda? lancet 2013;382:1702-3. 3. kickbusch i, franz c, holzscheiter a et al. germany’s expanding role in global health. lancet 2017;390:898-912. 4. dpgg. deutsche plattform für globale gesundheit 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2019). 22. gostin l, heywood m, ooms g,grover a, røttingen ja, chenguang w. national and global responsibilities for health. bull world health organ2010;88:719-719a. 23. brenck a, beckers t, heinrich m, von hirschhausen c. public-private partnerships in new eu member countries of central and eastern europe: an economic analysis with case studies from the highway sector. eib papers 2005;10:82–112: https://tudresden.de/bu/wirtschaft/ee2/ressource n/dateien/dateien/ordner_publikationen /wp_psm_08_brenck_beckers_heinrich _hirschhausen_2005_ppp_eastern_euro pe.pdf (accessed: march 26, 2019). 24. languille s. public private partnerships in education and health in the global south: a literature review. j int compar soc pol 2017;32:142-65. ______________________________________________________________________________________ © 2019 holst; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.ncbi.nlm.nih.gov/pubmed/?term=grover%20a%5bauthor%5d&cauthor=true&cauthor_uid=20931051 https://www.ncbi.nlm.nih.gov/pubmed/?term=r%c3%b8ttingen%20ja%5bauthor%5d&cauthor=true&cauthor_uid=20931051 https://www.ncbi.nlm.nih.gov/pubmed/?term=chenguang%20w%5bauthor%5d&cauthor=true&cauthor_uid=20931051 https://www.ncbi.nlm.nih.gov/pubmed/?term=chenguang%20w%5bauthor%5d&cauthor=true&cauthor_uid=20931051 vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi 10.12908/seejph-2014-48 1 original research public expenditure and drug policies in bulgaria in 2014 toni yonkov vekov 1 , silviya aleksandrova-yankulovska 1 1 department of medical ethics, management of health care and information technology, faculty of public health, medical university – pleven. corresponding author: prof. toni yonkov vekov, medical university, pleven; address: 1 sv kliment ohridski st., 5800 pleven, bulgaria; telephone: +35929625454; e-mail: t.vekov.mu.pleven@abv.bg vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi 10.12908/seejph-2014-48 2 abstract aim: the objective of this study was to provide an analysis of the factors which have a significant impact on the growth of public expenditure on medical products in bulgaria. methods: this research work consists of a critical analysis of the data reported by the national health insurance fund in bulgaria on the stability of the healthcare insurance model and the implementation of the budget for 2014. results: the results from the current analysis indicate that the growth of public expenditure is directly proportional to the number of reimbursed medical products and that the pattern of prescriptions including the innovative medical products mainly for the treatment of oncological and rare diseases has a significant impact on it. conclusion: the reasons for the increase of public expenditure in bulgaria include the nontransparent decisions in pricing and reimbursement of the products, the lack of guidelines for presenting pharmacological evidence and the lack of legislatively-defined drug policies for the management and control of the patterns of medical prescriptions. key words: bulgaria, drug policies, reimbursement, public expenditure. conflicts of interest: none. vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi 10.12908/seejph-2014-48 3 introduction healthcare in the european union (eu) countries including bulgaria is funded by the healthcare systems and/or through general taxation. the main objective of the healthcare systems is the protection of public health, based on the principles of solidarity and universal access. the drug policy in every country is part of the healthcare policy and adopts the same objectives and principles (1). the expenses on medical products are an important component of the healthcare budgets of all the eu member states. there is an increasing necessity to limit the escalating expenses on healthcare including those on medical products, as well as the effective spending of the financial resources (2). the good european practice on drug policy implies the determining of positive drug lists (pdl) provided by the healthcare system, and the regulation of the drug prices in a certain order. the main focus of the approaches to drug policies includes the rational use of medical products, which contributes to the control of public expenditure (3). considering the fiscal impact of the economical and financial crisis, as well as the expected healthcare expenses for the aging population, these policies are of an increasing interest to the institutions which pay for the public expenses in healthcare (4). the contemporary views of the european healthcare policies are that through the correct regulation of the pharmaceutical markets economies can be achieved, without having an impact on the provision of care (5). the drug policy in bulgaria is legally established by the ministry of health and practically applied by the national council on prices and reimbursement of medical products (ncprmp). this is the authority which regulates the prices and makes decisions regarding the reimbursement of the medical products with public funds. the control on prices is based on external and internal reference pricing and regressive margins for distributors and pharmacies. the reimbursing decisions are formally based on pharmaco-economic valuations, but the experts’ reports are not available to the public and the objectivity of these decisions cannot be established. in this context, the aim of this study was to analyze the public fund expenses on medical products in bulgaria in 2014 in order to determine the impact of the legislative approaches to drug policies and their possible impact on public health. methods this article is a critical analysis of data from the report of the national health insurance fund (nhif) in bulgaria on the stability of the healthcare insurance model and the implementation of the budget for 2014 (6). a commentary is provided concerning the existing prescribing patterns, national policies for the inclusion of medical products in pdl and their impact on the increasing public expenses. a detailed analysis of the expenses by disease groups and the pattern for the prescription of medicines is also provided. all graphs and tables included in this article are created on the basis of the data derived from the report of the nhif in bulgaria on the stability of the healthcare insurance model and the implementation of the budget for the year 2014 (6). the difference of costs and amount of reimbursed products in the pdl for the period under investigation is presented as a percentage and is calculated with a mathematical method based on the determination of proportionality coefficients. when trying to predict the future value, one follows the following basic idea: future value = present value + change from this idea, we obtain a differential, or a difference equation by noting that: vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi 10.12908/seejph-2014-48 4 change = future value – present value the growth of public expenses is influenced by a number of factors discussed in the report of the nhif in bulgaria on the stability of the healthcare insurance model and the implementation of the budget for 2014 (6). all prices are given in bgn with current exchange rates of: 1.95583 bgn = 1 eur. results the review of the development of the pdl in bulgaria in the past three years (2011-2014) from the viewpoint of quantitative indicators shows a big volume (1997 medical products) and a list with frequent changes (every 15 days). in 2011, the pdl included 1382 medical products, in 2012 it included 1673 products, and in 2014 there were 1997 products. during this three-year period, the number of reimbursed medical products increased by 45%. the proportion of public expenditure and the number of reimbursed medical products is presented in figure 1. the established relationship is directly proportional, whereas the cost of public expenses increased by 25%. figure 1. reimbursed medicines for home treatment and the cost of public expenses (both in bgn) in bulgaria; data for 2014 consists of estimates (source: nhif report for june 2014) the other factor which has a marked impact on public expenditure is the pattern of prescription of the medical products. the presented results (figure 2) of the average cost of public expenditure for the treatment of non-insulin diabetes in 2013 are indicative – the cost of the expense differs doubly in the various regions, considering that the list of the medical products, their prices and the reimbursed amounts are the same for all the regions of bulgaria. the different cost of public expenses in the various regions of bulgaria directly depends on the level of prescribing of dpp-4 inhibitors and glp-1 receptor antagonists. these are the two groups of innovative medical products for the oral therapy of diabetes, which are rather recommended as a second and a third line of treatment, due to unclear data for the long-term cost effectiveness and doubts about the safety profile (7). 1000 1500 2000 400 450 500 550 600 2011 2012 2013 2014 n u m b e r n u m b e r cost quantity vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi 10.12908/seejph-2014-48 5 figure 2. average cost per patient (in bgn) for the treatment of non-insulin dependent diabetes in bulgaria in 2013 (source: nhif report for june 2014) the analysis of public expenses by groups of diseases outlines the clear tendencies for an abrupt increase in the expenses for the treatment of rare diseases and oncological diseases. the expenses for the treatment of rare diseases increased by 36% in 2013 compared to 2012 and reached 59 million bgn, which constitutes 10.7% of all public expenses for medical products (table 1). this points to a pronounced imbalance of solidarity in the insurance system, because these public costs are absorbed by only 0.15% of the insured individuals. at the same time, public expenses for socially significant diseases such as the cardiovascular disease, diseases of the neural system and diseases of other systems are decreasing (6). these results are an expression of the flaws in the drug policy, part of which are the application of internal reference pricing without a system for the control of medical prescriptions (8), the lack of transparency in the decisions on pricing and reimbursement, based on an expert evaluation of pharmaco-economical evidence, the lack of a defined limit of public expenses for one gained quality-adjusted life year (qaly), and the like (9). table 1. expenses for the treatment of rare diseases in 2013 (source: nhif report for june 2014) disease public expense average annual cost per patient in bgn number of patients haemophilus 20 009 544 5290 3783 beta-thalassemia 8 323 230 3692 2254 gaucher disease 8 196 183 32 795 250 blonhopulmonal dysplasia 4 245 087 2828 1501 mukopolizaharoidosis 3 294 574 68 637 48 hereditary amyloidosis with neuropathy 1 625 885 27 098 60 pompe disease 477 953 47 795 10 0 100 200 300 400 500 600 700 rousse gabrovo sliven bourgas smolyan average cost vratsa shoumen silistra haskovo pernik n u m b e r vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi 10.12908/seejph-2014-48 6 the analysis of the expenses on the medical therapy for oncological diseases, paid outside the cost of clinical pathways emphasizes several main facts:  the expanding of the indications for innovative medicines, mainly for monoclonal antibodies and tyrosine kinase inhibitors. however, there is no data on the evaluation of the efficacy, benefits and costs of the new indications.  the addition of monoclonal antibodies to the target therapies, which increases the cost of the therapy more than 30 times, while the benefits, expressed as final health outcomes, are minimal. the willingness of society to pay such a high price for the gain of a qaly remains uncertain.  the inclusion of new international non-proprietary names in the pdl without a clear evaluation of their differential cost-effectiveness as compared to the existing therapies. as a result of all these factors, the public expenditure on oncological medical products significantly exceeded the settled budgets for the past years, as indicated in table 2. table 2. expenses of the medical therapy for oncological diseases, paid outside the costs of clinical pathways (source: report on the implementation of the budget of nhif, 2013-2014) year year 2013 2014 budget in bgn 90 000 000 145 000 000 public expenditure in bgn 172 443 480 203 472 732 * relative share of the overspending (%) 91,60 40,30 * data for 2014 consists of estimates. discussion several main factors have been identified which have an impact on the annually increasing public expenses on medical products in bulgaria:  non-transparent decisions for the inclusion of medical products in the pdl with unclear cost-effectiveness compared to the existing drug alternatives. there is no data on the recommendations of ncprmp for the pharmaceutical industry and set out denials for reimbursement justified by the lack of sufficient evidence of effectiveness and/or high prices. the practice in the economically developed countries is different. for example, the committee for the evaluation of medicinal products in canada refused to reimburse pemetrexed for the treatment of malignant pleural mesothelioma, because the product does not provide added value for the price difference compared to the existing alternatives (10). another canadian solution sets to reimburse sunitinib for the treatment of metastatic renal cell carcinoma only after negotiating the price because of poor costeffectiveness, despite the improved efficacy over the existing therapeutic alternatives. many similar negative decisions regarding the reimbursement of medical products for a specific diagnosis can be found in the scientific literature. their aim is both to facilitate the access of patients to therapies which give them additional therapeutic value and use, as well as to protect patients from health risks connected to severe adverse drug reactions (11,12). vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi 10.12908/seejph-2014-48 7  the lack of legally defined public expenditure related to one gained qaly. this is a widely used instrument for limiting public expenditure and for the control of the innovative medical therapies (13).  lack of legal control on the patterns of prescribing medicines. the eu states have a number of measures in working order for improving the patterns of prescribing medicines. most often they entail the monitoring of the prescriptions, recommendations and guidelines of advisory/obligatory nature regarding the prescriptions, including the requirements to prescribe an international non-proprietary name, a maximum limit on the prescribed medicines, prescription quotas, financial incentives, as well as educational and informational approaches (14-16). the aim of all enumerated policies is to promote the rational use of medical products for the benefit of public health. the combinations of diverse measures, as electronic monitoring in prescription and in guidelines, connected with electronic systems which support the process of decision-making and give feedback to the physician, are an effective way to improve the patterns in prescribing medicines (17). in addition, educational and informational instruments should be activated. the prescription of international non-proprietary names and prescription quotas, if possible in combination with target budgets and financial incentives, seem to be effective tools for the purpose of regulating public expenditure. conclusion the effectiveness of public expenditure in bulgaria will improve when it becomes the main objective in medical policy, i.e., when medical therapies are evaluated in a real and transparent way as a ratio of expenses and use as compared to the existing alternatives. it is necessary that the first steps are aimed at developing a control system of the prescription and evaluation of medicines’ pharmaco-economical evidence, as well as determining 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http://www.ncbi.nlm.nih.gov/pubmed/?term=vandoros%20s%5bauthor%5d&cauthor=true&cauthor_uid=22828053 http://www.ncbi.nlm.nih.gov/pubmed/?term=kanavos%20p%5bauthor%5d&cauthor=true&cauthor_uid=22828053 pampuri o, czabanowska k, hysa b, roshi e, burazeri g. public health leadership competency level among health professionals in a south eastern european country (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-40 1 original research public health leadership competency level among health professionals in a south eastern european country orjola pampuri 1 , katarzyna czabanowska 2,3 , bajram hysa 4 , enver roshi 1,4 , genc burazeri 2,4 1 institute of public health, tirana, albania; 2 department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 3 institute of public health, faculty of health sciences, jagiellonian university, medical college, krakow, poland; 4 faculty of public health, university of medicine, tirana, albania. corresponding author: orjola pampuri, institute of public health; address: rr. “aleksander moisiu”, no. 88, tirana, albania; telephone: +355672066183; e-mail: o.pampuri@yahoo.com pampuri o, czabanowska k, hysa b, roshi e, burazeri g. public health leadership competency level among health professionals in a south eastern european country (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-40 2 abstract aim: the aim of this study was to describe the current and the required leadership competency level of health professionals in albania, employing a recently established international instrument. methods: a nationwide cross-sectional study was conducted in albania in july-december 2014 including a representative sample of 267 health professionals (162 men and 105 women; mean age: 44.7±10.3 years; overall response rate: 89%). a structured questionnaire was administered to all health professionals aiming at self-assessing the current level of leadership competencies and the required (desirable) level of leadership competencies for their current job position. the questionnaire included 52 items grouped into eight subscales/domains. answers for each item of the tool ranged from 1 (“minimal competency level”) to 5 (“maximal competency level”). an overall summary score (range: 52-260) and a subscale summary score for each domain were calculated for both the current and the required leadership competency levels. wilcoxon signed ranks test was employed to compare the overall scores and the subscale scores of the current and the required level of leadership competencies among health professionals. results: mean value of the overall summary score for the 52 items of the instrument was significantly lower for the current leadership competency level compared with the required leadership competency level (138.4±11.2 vs. 159.7±25.3, respectively; p<0.001). most of the subscales’ scores were significantly higher for the required than for the current leadership competency level. conclusion: our study provides useful evidence about the current and the required level of leadership competencies among health professionals in transitional albania. findings of this study may help policymakers in albania to identify the gap between the required and the current level of leadership competencies among health professionals. furthermore, findings of this study should be expanded in the neighbouring countries of the south eastern european region and beyond. keywords: albania, competency level, health professionals, public health leadership, south eastern europe. acknowledgement: the authors thank colleagues and partners from the lephie project and the members of the aspher’s wgigp. conflicts of interest: none. pampuri o, czabanowska k, hysa b, roshi e, burazeri g. public health leadership competency level among health professionals in a south eastern european country (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-40 3 introduction to date, there have been developed a few competency frameworks in order to assess public health leadership and medical leadership competencies (1-4). these instruments have basically included the key principles and concepts of leadership (5,6). establishment and refinement of these tools is due to the urgent need to develop strong leadership skills and competencies among public health professionals at large (7). hence, these leadership frameworks are deemed useful for professional training and continuous medical education in particular, but also for continuous professional development in general (5,6). competencies in the area of public health leadership are regarded as a crucial element for the performance and activities of health professionals operating at all levels of health care services (public health, primary health care services, as well as hospital care) in different settings and cultures (7). a key driver in improving leadership within public health is that the nature of the challenges faced by such professionals is evolving. developing effective leadership is essential as many european countries are putting health systems under significant financial pressures and forcing them to deliver more with diminishing resources (8). notwithstanding the current progress towards development of leadership competencies in the area of medicine and public health, the existing frameworks are – on the face of it – too generic and not satisfactorily detailed for a proper assessment of the leadership competency level of health professionals operating in different levels of health care. it has been convincingly argued that a proper identification and assessment of the level of leadership competencies is a basic prerequisite for adjustment of the educational curriculum and training models for health professionals in different european countries (7). for this very reason, fairly recently, it has been developed a specific public health leadership competency framework with the aim to significantly foster the competency-based european public health leadership curriculum (7). as acknowledged earlier, this competency framework was designed in the context of the leaders for european public health (lephie) erasmus multilateral curriculum development project, supported by the european union lifelong learning programme (7). the information about public health leadership is scarce for albania, a former communist country in southeast europe, which is characterized by a rapid political and socioeconomic transition associated with deleterious health effects (9,10). the particularly rapid process of transition in albania over the past twenty five years has been associated with an intensive process of migration, both internal (from rural areas to urban areas of the country) and external (mainly to the neighbouring countries including greece and italy) (11). this has also affected the workforce, at least to some extent. indeed, regardless of the international financial crisis, the relatively poor economic situation and the lack of rapid economic expansion due to limited domestic resources continue to encourage albanian adults to emigrate (12). in 2013, it was established in albania a national school of public health under the auspices of the university of medicine. nevertheless, the curriculum of both undergraduate and postgraduate public health programs does not sufficiently promote leadership skills and competencies for future health professionals in albania. the new leadership competency framework was cross-culturally adapted in albania in may 2014 in a sample of health professionals operating at different levels of health care services (13). pampuri o, czabanowska k, hysa b, roshi e, burazeri g. public health leadership competency level among health professionals in a south eastern european country (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-40 4 in this context, the aim of our study was to describe the current and the required leadership competency level of health professionals in albania, employing this recently established international instrument, which was previously validated. methods a cross-sectional study was conducted in albania in july-december 2014 targeting a nationwide representative sample of 300 health professionals working at different health institutions all over the country (primary health care services, regional hospitals, university hospital centre “mother teresa”, institute of public health, and health insurance fund). of 300 targeted health professionals, 33 individuals refused to participate. the study sample consisted of 267 health professionals (162 men and 105 women; mean age: 44.7±10.3 years; overall response rate: 89%). a structured questionnaire was administered to all health professionals aiming at selfassessing the current level of leadership competencies and the required/desirable level of leadership competencies for their current job position. as reported previously, the questionnaire consisted of 52 items grouped into eight competency domains (subscales) including (7): i) systems thinking; ii) political leadership; iii) collaborative leadership: building and leading interdisciplinary teams; iv) leadership and communication; v) leading change; vi) emotional intelligence and leadership in team-based organizations; vii) leadership, organizational learning and development, and; viii) ethics and professionalism as explained elsewhere, each domain (subscale) of the instrument corresponds to one educational session within public health leadership curriculum (7,14). answers for each item of each subscale of the instrument ranged from 1 (“minimal competency level”) to 5 (“maximal competency level”). an overall summary score (range: 52-260) and a subscale summary score for each domain were calculated for both, the current level of competencies and the required level of competencies. the instrument was previously validated (cross-nationally adapted in the albanian context) in a sample of 53 health professionals in tirana in may 2014 (13), after a careful process of translation and back-translation of the original english version of the leadership competency questionnaire, following strict methodological rules (15). furthermore, the questionnaire included demographic information (age and sex of health professionals), place of work (urban areas vs. rural areas), type of diploma obtained (dichotomized into: health sciences vs. other diploma), years of working experience, as well as current job position (trichotomized into: high, middle and low managerial level). measures of central tendency and dispersion (mean values and standard deviations) were used to describe the distribution of age and working experience among male and female participants. conversely, absolute numbers and their respective percentages were used to describe the distribution of place of work, diploma obtained and the job position of health professionals. cronbach’s alpha was used to assess the internal consistency for both the current level of competencies and the required level of competencies (16,17). on the other hand, wilcoxon signed ranks test was used to compare the overall scores and the subscale scores of the current level of competencies and the required level of competencies among health professionals included in this study. pampuri o, czabanowska k, hysa b, roshi e, burazeri g. public health leadership competency level among health professionals in a south eastern european country (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-40 5 results mean age in the male sample of health professionals (n=162) was 44.9±10.6 years, whereas in females (n=105) it was 44.4±9.9 years (table 1). about 75% of health professionals were working in urban areas and 25% in rural areas of albania. around 87% (n=233) of participants had received a diploma in health sciences (medicine, public health, nursing, pharmacy, or dentistry), whereas 13% (n=34) had other backgrounds (law, economics, social sciences, or engineering). overall, mean working experience was 19.6±10.1 years. about 21% (n=55) of health professionals were working in high-level managerial positions compared with 32% (n=84) who were operating in low-level positions. table 1. baseline characteristics in a nationwide representative sample of health professionals in albania, in 2014 variable men (n=162) women (n=105) total (n=267) age (years) 44.9±10.6 * 44.4±9.9 44.7±10.3 place of work: urban areas rural areas 111 (68.5) † 51 (31.5) 90 (85.7) 15 (14.3) 201 (75.3) 66 (24.7) diploma: health sciences other 142 (87.7) 20 (12.3) 91 (86.7) 14 (13.3) 233 (87.3) 34 (12.7) working experience (years) 20.0±10.4 19.0±9.6 19.6±10.1 job position: high managerial level middle managerial level low managerial level 33 (20.4) 70 (43.2) 59 (36.4) 22 (21.0) 58 (55.2) 25 (23.8) 55 (20.6) 128 (47.9) 84 (31.5) * mean values ± standard deviations. † numbers and column percentages (in parentheses). the internal consistency of the overall scale (52 items) was cronbach’s alpha=0.86 for the current competency level and cronbach’s alpha=0.96 for the required competency level (table 2). for the current competency level, cronbach’s alpha was the lowest for the “ethics and professionalism” domain (0.49) and the “leadership, organizational learning and development” subscale (0.55) and the highest for the “political leadership” domain (0.94). similarly, for the required competency level, cronbach’s alpha was the lowest for the “ethics and professionalism” domain (0.65) and the highest for the “political leadership” domain (0.91). mean value of the overall summary score for the 52 items of the instrument was significantly lower for the current competency level compared with the required competency level (138.4±11.2 vs. 159.7±25.3, respectively; p<0.001) (table 3). all the subscales’ scores were significantly higher for the required competency level than for the current competency level, except for the “emotional intelligence and leadership in team-based organisations” and “leading change” domains (table 3). pampuri o, czabanowska k, hysa b, roshi e, burazeri g. public health leadership competency level among health professionals in a south eastern european country (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-40 6 table 2. internal consistency of the leadership competency instrument administered in a representative sample of health professionals in albania (n=267) domain (subscale) cronbach’s alpha current competency level required competency level overall scale (52 items) 0.86 0.96 systems thinking (7 items) 0.82 0.78 political leadership (8 items) 0.94 0.91 collaborative leadership: building and leading interdisciplinary teams (5 items) 0.89 0.85 leadership and communication (7 items) 0.62 0.87 leading change (6 items) 0.64 0.77 emotional intelligence and leadership in team-based organizations (6 items) 0.83 0.83 leadership, organizational learning and development (7 items) 0.55 0.79 ethics and professionalism (6 items) 0.49 0.65 table 3. summary score of each domain (subscale) of the leadership competency instrument for the current and the required competency level of albanian health professionals (n=267) domain (subscale) mean values ± standard deviations p-value * current competency level required competency level overall scale (52 items) 138.4±11.2 159.7±25.3 <0.001 systems thinking (7 items) 21.1±2.8 21.8±3.4 <0.001 political leadership (8 items) 20.1±5.0 20.9±5.4 <0.001 collaborative leadership: building and leading interdisciplinary teams (5 items) 11.7±2.9 12.9±3.6 <0.001 leadership and communication (7 items) 16.5±2.2 17.9±4.3 <0.001 leading change (6 items) 17.1±2.1 16.7±3.2 0.005 emotional intelligence and leadership in team-based organizations (6 items) 18.1±2.4 17.3±3.6 <0.001 leadership, organizational learning and development (7 items) 16.5±2.1 17.7±3.6 <0.001 ethics and professionalism (6 items) 17.2±2.0 17.6±2.7 0.018 * wilcoxon singed ranks test. discussion this study provides useful evidence about the level and distribution of leadership competencies among health professionals in transitional albania, based on a recently established international instrument, which was previously validated (cross-culturally adapted) in the albanian context. this measuring international instrument exhibited satisfactory internal consistency especially for assessment of the required (desirable) leadership competency level. during the previous pampuri o, czabanowska k, hysa b, roshi e, burazeri g. public health leadership competency level among health professionals in a south eastern european country (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-40 7 validation exercise, the tool had also displayed a high stability over time (i.e., a high testretest reliability for the overall scale and for each of the subscales of the instrument) (13). main findings of this survey include a higher self-perceived level of the required leadership competencies than the current (existing) level of leadership competencies among health care professionals in post-communist albania. interestingly, most of the subscale scores were significantly higher for the required competency level compared with the current competency level in this nationwide representative sample of health professionals in albania. findings of this study may help policymakers in albania to identify the gap between the required and the current level of leadership competencies among health professionals. as already reported elsewhere, the public health leadership competency-based curriculum was established in the framework of the lephie project (7). similarly, as czabanowska et al. point out that a starting point is to identify the competency capacities of future leaders in relation to population health and well-being and apply the study results to inform education, training and culture change throughout the workforce (14), we considered that the description of the competencies supports the curriculum design and it can be used as a self-assessment instrument for students and public health professionals, helping them to reflect and identify gaps in their knowledge, skills and competencies (7). the teaching of leadership is still not common in public health training programmes around the world and seems particularly rare in countries experiencing intensive public health reforms. there is a need for substantial investment in leadership training for public health professionals (18). in conclusion, we provide important evidence about the level and distribution of the leadership competency level among health professionals in albania, a country embarked in the long journey towards accession into the european union. our survey informs about both the self-perceived leadership competency level and the required/desirable level of leadership competencies for the respective job positions of health care professionals in albania. findings of our survey should be expanded further in large representative samples of health care professionals in the neighbouring countries in the western balkans and beyond. similar to albania, this type of survey will help to identify potential gaps in the level of existing leadership competencies and the required/desirable level of leadership competencies, which will ultimately inform the public health curricula about necessary content adjustments. references 1. maintenance of certification competencies and criteria. american board of medical specialties, (usa). available at: http://www.abms.org/maintenance_of_ certification/moc_competencies.aspx (accessed: february 3, 2014). 2. accreditation council on graduate medical education. general competences for residents. chicago, il: accreditation council on graduate medical education; 2007. 3. greiner ac, knebel e, editors. health professions education: a bridge to quality. washington, dc: institute of medicine; 2003. 4. institute of medicine. crossing the quality chasm: a new health system for the 21 st century. washington, dc: the national academies press; 2001. 5. tier 1, tier 2 and tier 3 core competencies for public health professionals. washington, dc: council on linkages between academia and public health practice, public health foundation; 2010. 6. aspher. provisional lists of public health core competencies. brussels: association of schools of public health in the european region; 2008. pampuri o, czabanowska k, hysa b, roshi e, burazeri g. public health leadership competency level among health professionals in a south eastern european country (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-40 8 7. czabanowska k, smith t, könings kd, sumskas l, 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___________________________________________________________ © 2015 pampuri et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed?term=czabanowska%20k%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=smith%20t%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=k%c3%b6nings%20kd%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=sumskas%20l%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=otok%20r%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=bjegovic-mikanovic%20v%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=brand%20h%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed/24121098 http://www.ncbi.nlm.nih.gov/pubmed/?term=czabanowska%20k%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=rethmeier%20ka%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=lueddeke%20g%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=smith%20t%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=malho%20a%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=otok%20r%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=stankunas%20m%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=stankunas%20m%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=stankunas%20m%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=retrieve&dopt=abstractplus&list_uids=17436387&query_hl=1&itool=pubmed_docsum http://www.ncbi.nlm.nih.gov/pubmed/?term=czabanowska%20k%5bauthor%5d&cauthor=true&cauthor_uid=23399070 http://www.ncbi.nlm.nih.gov/pubmed/?term=smith%20t%5bauthor%5d&cauthor=true&cauthor_uid=23399070 http://www.ncbi.nlm.nih.gov/pubmed/?term=stankunas%20m%5bauthor%5d&cauthor=true&cauthor_uid=23399070 http://www.ncbi.nlm.nih.gov/pubmed/?term=avery%20m%5bauthor%5d&cauthor=true&cauthor_uid=23399070 http://www.ncbi.nlm.nih.gov/pubmed/?term=otok%20r%5bauthor%5d&cauthor=true&cauthor_uid=23399070 collaku l, resuli m, gjermeni i, tase m. evidence of a higher burden of multimorbidity among female patients in albania (original research). seejph 2018, posted: 10 april 2018. doi 10.4119/unibi/seejph-2018-185 1 original research evidence of a higher burden of multimorbidity among female patients in albania ledio collaku 1 , margarita resuli 1 , ilir gjermeni 1 , mihal tase 1 1 internal medicine and hypertension service, university hospital center ―mother teresa‖, tirana, albania. corresponding author: dr. ledio collaku address: rr. ―dibres‖, no. 370, tirana, albania; e-mail: collaku_l@yahoo.com collaku l, resuli m, gjermeni i, tase m. evidence of a higher burden of multimorbidity among female patients in albania (original research). seejph 2018, posted: 10 april 2018. doi 10.4119/unibi/seejph-2018-185 2 abstract aim: the purpose of this study was to assess sex-differences in the prevalence of multimorbidity and the number of comorbid conditions among hospitalized patients in tirana, the capital of albania, a transitional country in southeastern europe. methods: the current study was a case-series, which was carried out in the period august 2013–june 2014. overall, 974 patients were enrolled (46.6% men with a mean age of 61.2±13.8 years, and 53.4% women with a mean age of 61.3±13.1 years), who were admitted at the service of internal medicine and hypertension, university hospital center ―mother teresa‖ in tirana. a comprehensive clinical profile was assembled for all patients in addition to socio-demographic data and information on lifestyle factors. general linear model was used to assess the association between multimorbidity (total number of diseases/conditions) and sex of the patients, controlling for socio-demographic characteristics and lifestyle factors. results: in crude (unadjusted) models and in age-adjusted models, female patients had a higher mean value of diseases/conditions compared to males (for both: 4.4 vs. 4.1, respectively, p=0.03). likewise, upon adjustment for all socio-demographic characteristics, the mean number of disease/conditions was significantly higher in female patients compared to their male counterparts (4.2 vs. 3.9, respectively; p=0.03). after additional adjustment for lifestyle factors, the association between sex and number diseases/conditions was not significant anymore (p=0.16), notwithstanding the evidence of a higher mean value in women compared to men (4.2 vs. 4.0). conclusion: current evidence from transitional albania suggests a higher burden of multimorbidity among female patients compared to males, which is a cause of concern. these findings should raise the awareness of health professionals and particularly policymakers and decision-makers in order to address gender issues and inequity gaps in health outcomes and burden of disease of the albanian population. keywords: albania, female patients, internal medicine, male patients, multimorbidity, patients, sex. conflicts of interest: none. collaku l, resuli m, gjermeni i, tase m. evidence of a higher burden of multimorbidity among female patients in albania (original research). seejph 2018, posted: 10 april 2018. doi 10.4119/unibi/seejph-2018-185 3 introduction the burden of non-communicable diseases and the burden of multimorbidity has increased in albania in the past few decades (1,2), a process which is also in line with an increase in life expectancy and continuous aging of the albanian population (3). regarding the major causes of mortality, the ischemic heart disease was the top cause of death in the albanian population in 2016, followed by cerebrovascular disease and lung cancer (1). notably, only during the past decade, there has been an increase of about 19% in the mortality rate attributable to the ischemic heart disease and/or lung cancer, and an increase of about 10% due to cerebrovascular disease in albania (1). in addition, in the past decade, there has been an increase of about 20% of other cardiovascular diseases, and an increase of 11% of the chronic obstructive pulmonary disease (1). it is assumed that a large share of especially the older albanian population suffer from multimorbidity and comorbidty (2,4). in terms of premature mortality, in the past decade, there has been a considerable increase (about 49%) in the mortality rate due to alzheimer disease in albania, followed by lung cancer (11%) and ischemic heart disease (6%). also, the burden of cerebrovascular disease in albania has increased by about 41% in the past decade (1). the five main risk factors contributing to the overall burden of disease (death and disability combined) in albania in 2016 consisted of high blood pressure, dietary risks, tobacco smoking, high body mass index, and high total cholesterol level (1). multimorbidity is conventionally considered as the presence of several diseases or conditions in a single individual or patient (5). in the contemporary clinical practice there are other important constructs including comorbidity (presence of other diseases/conditions along with a main pathology), morbidity burden (referring to the overall impact of various disease or conditions in a single patient), or disease complexity (referring not only to the presence of various disease/conditions in a single patient, but also to the severity and duration of each condition) (5). in all cases though, these classifications are largely based on considerations from medical doctors and other health professionals, but not necessarily on self-reports, or feelings and perceptions of patients suffering from several diseases (either in the framework of multimorbidity or comorbidity situations) (6). notwithstanding the lack of proper evidence and scientific documentation, the burden of multimorbidity is high in the albanian adult population, especially in the elderly people category (4). anecdotic evidence suggests a higher burden of multimorbidity among older women than in men, which may be partly explained by a higher life expectancy among albanian females compared to their male counterparts (3,4). yet, to date, scientific reports about the burden and impact of multimorbidity and comorbidity in albanian patients are scant. in this framework, the aim of the current study was to assess sex-differences in the prevalence of multimorbidity and the number of comorbid conditions among hospitalized patients in tirana, the capital of albania, a transitional country in southeastern europe. methods the current study consisted of a case-series design. this study was carried out between august 2013 and june 2014. during this period of time, there were recruited 974 patients admitted at the service of internal medicine and hypertension, university hospital center ―mother teresa‖ in tirana, which is the capital city of albania. of the 974 patients recruited in this study, 46.6% were men and 53.4% were women. for all the patients included in this study, it was performed a whole range of clinical examinations including assessment of the main disease, presence of comorbid conditions, hematological parameters, lipid profile, as well as other clinical examinations. collaku l, resuli m, gjermeni i, tase m. evidence of a higher burden of multimorbidity among female patients in albania (original research). seejph 2018, posted: 10 april 2018. doi 10.4119/unibi/seejph-2018-185 4 in addition, a structured questionnaire was administered to all the patients aiming at collecting useful information about their socio-demographic characteristics and lifestyle factors. the socio-demographic information included age (which was dichotomized in the analysis into: ≤60 years vs. ≥61 years), current place of residence (which was also dichotomized in the analysis into: tirana vs. other districts of albania) and current employment status (trichotomized in the analysis into: employed, unemployed, retired). on the other hand, the lifestyle (behavioral) factors consisted of tobacco smoking and alcohol consumption (in the analysis, these two variables were dichotomized into: yes vs. no). fisher’s exact test was used to assess the differences between male and female patients regarding the prevalence of multimorbidity (ranging from presence of at least two diseases/conditions up to ten diseases/conditions). spearman’s correlation coefficient (rho) was used to assess the linear association between the number of disease/conditions and age of the patients, number of their hospitalizations, and the length (duration) for the current hospitalization episode. conversely, general linear model was employed to assess the association between multimorbidity (total number of diseases/conditions) and sex of the patients included in this study. initially, crude (unadjusted) mean values, their 95% confidence intervals (95%cis) and p-values were calculated. next, general linear models were adjusted for the age of study participants. subsequently, general linear models were adjusted for all socio-demographic characteristics of the patients (age, current place of residence and current employment status). finally, general linear models were additionally adjusted for lifestyle/behavioral factors (smoking and alcohol consumption). multivariable-adjusted mean values, their 95%cis and p-values were calculated. all statistical analyses were performed with the statistical package for social sciences (spss for windows, version 19.0). results overall, mean age among patients included in this study was 61.3±13.1 years (median age: 62 years; interquartile range: 71-53=18 years). mean age was similar in male and female patients. around 54% of the patients were ≥61 years old; about 38% of participants were residing in tirana; and about 46% of the patients were currently employed. overall, the prevalence of smoking was 16%, whereas the prevalence of alcohol consumption was 9% (data not shown in the tables). table 1 presents the distribution of multimorbidity (total number of diseases) by sex of the patients included in this study. overall, about 96% of the patients had at least two diseases/conditions; 89% had at least three conditions; 76% had at least four conditions; 60% had at least five conditions; 42% had at least six conditions; 28% had at least seven conditions; 18% had at least eight conditions; 12% had at least nine conditions; and about 6% of the patients had at least ten diseases (conditions). as for sex-differences, there was a significant difference only for the presence of at least five or six conditions (p=0.04 and p<0.01, respectively) with men exhibiting a higher prevalence than women. conversely, there were no sex-differences for the other combinations. as a matter of fact, looking at the two extremes, the prevalence of at least two diseases/conditions (95% in men 96% in women) and the prevalence of at least ten diseases/conditions (5.5% in men 5.6% in women) were very similar in both sexes (table 1). collaku l, resuli m, gjermeni i, tase m. evidence of a higher burden of multimorbidity among female patients in albania (original research). seejph 2018, posted: 10 april 2018. doi 10.4119/unibi/seejph-2018-185 5 table 1. distribution of patients according to the number of diseases and sex number of diseases total (n=974) men (n=454) women (n=520) p † two diseases: no yes 41 (4.2) * 933 (95.8) 21 (4.6) 433 (95.4) 20 (3.8) 500 (96.2) 0.632 three diseases: no yes 112 (11.5) 862 (88.5) 51 (11.2) 403 (88.8) 61 (11.7) 459 (88.3) 0.841 four diseases: no yes 237 (24.3) 737 (75.7) 105 (23.1) 349 (76.9) 132 (25.4) 388 (74.6) 0.454 five diseases: no yes 388 (39.8) 586 (60.2) 165 (36.3) 289 (63.7) 223 (42.9) 297 (57.1) 0.042 six diseases: no yes 568 (58.3) 406 (41.7) 237 (52.2) 217 (47.8) 331 (63.7) 189 (36.3) <0.001 seven diseases: no yes 698 (71.7) 276 (28.3) 312 (68.7) 142 (31.3) 386 (74.2) 134 (25.8) 0.064 eight diseases: no yes 795 (81.6) 179 (18.4) 360 (79.3) 94 (20.7) 435 (83.7) 85 (16.3) 0.082 nine diseases: no yes 861 (88.4) 113 (11.6) 395 (87.0) 59 (13.0) 466 (89.6) 54 (10.4) 0.229 ten diseases: no yes 920 (94.5) 54 (5.5) 429 (94.5) 25 (5.5) 491 (94.4) 29 (5.6) 0.998 * absolute numbers and column percentages (in parentheses). † p-values from fisher’s exact test. there was evidence of a significant correlation between the number diseases/conditions and age of the patients (spearman’s rho=0.35, p<0.01), number hospitalizations (rho=0.15, p<0.01) and length of stay for the current hospitalization episode (rho=0.21, p<0.01) [data not shown]. table 2 presents the association between multimorbidity (number of diseases/conditions) with sex of the patients included in the study. in crude (unadjusted) models (model 1), there was evidence of a significant relationship with sex, with women displaying a higher mean value of diseases/conditions compared to men (about 4.4 vs. 4.1, p=0.03). similar findings were evident after adjustment for age of the patients (model 2): mean value of diseases/conditions was about 4.4 in women, whereas in men it was 4.1 (p=0.03). likewise, upon adjustment for all socio-demographic characteristics (model 3), the mean number of diseases/conditions was significantly higher in female patients compared to their male counterparts (4.2 vs. 3.9, respectively; p=0.03). however, after additional adjustment for lifestyle/behavioral factors (smoking and alcohol consumption) of study participants, the association between sex and number diseases/conditions was not significant anymore collaku l, resuli m, gjermeni i, tase m. evidence of a higher burden of multimorbidity among female patients in albania (original research). seejph 2018, posted: 10 april 2018. doi 10.4119/unibi/seejph-2018-185 6 (p=0.16), notwithstanding the evidence of a higher mean value in women compared to men (4.2 vs. 4.0) [table 2, model 4]. table 2. association of multimorbidity with sex of the patients; mean values, 95% confidence intervals (95%cis) and p-values from the general linear models model men women p mean 95%ci mean 95%ci model 1 * 4.11 3.91-4.30 4.43 4.22-4.64 0.028 model 2 † 4.06 3.87-4.25 4.37 4.16-4.57 0.029 model 3 ‡ 3.89 3.62-4.17 4.20 3.91-4.49 0.031 model 4 § 4.01 3.63-4.37 4.21 3.88-4.56 0.158 * crude (unadjusted) models. † age-adjusted models. ‡ adjusted for all socio-demographic characteristics (age, place of residence and employment status). § adjusted also for lifestyle/behavioral factors (smoking and alcohol consumption). discussion the main findings of this study consist of a significantly higher mean value of diseases among albania female patients compared to their male counterparts, e finding which was evident irrespective of several demographic and socio-economic characteristics. hence, female patients appeared to experience a higher burden of multimorbidity, which is a cause of concern pointing to a significant gender issue and health inequity gap in the context of transitional albania. nonetheless, the sex-difference in the burden of multimorbidity disappeared upon additional adjustment for lifestyle/behavioral factors including tobacco smoking and alcohol consumption. on the face of it, smoking and harmful alcohol consumption account for a considerable share of multimorbidity and comorbidity in albanian males, which goes in line with a previous report (4). currently, at a global scale, there is a great interest from health professionals, policymakers and decision-makers concerning the impact of comorbidity and multimorbidity on a whole range of clinical outcomes including mortality, health-related quality of life, physical functioning, and quality of health care services (5,7-9). as a matter of fact, healthcare systems worldwide are currently dealing with an increasing demand for provision of effective and efficient medical services for patients with evidence of multimorbidity and comorbidity (8). the burden of multimorbidity has a negative impact on the health status of the populations worldwide, but it also bears an enormous cost for the health care sectors and societies at large (8,10,11). indeed, patients with several diseases/conditions experience not only a higher mortality rate (12), but also require more frequent hospitalization episodes with a longer duration (length of stay) for each hospitalization episode (12,13). the current study may suffer from several drawbacks which may have stemmed from patients’ recruitment and the information gathering. as for study population representativeness, this study involved all consecutive hospitalized patients with evidence of multimorbidity over a certain period of time. all patients enrolled in the current study were admitted at the service of internal medicine and hypertension of the university hospital center ―mother teresa‖ in tirana which, to date, is the only tertiary care facility in albania. therefore, it is likely that most of the adult patients with evidence of multimorbidity are collaku l, resuli m, gjermeni i, tase m. evidence of a higher burden of multimorbidity among female patients in albania (original research). seejph 2018, posted: 10 april 2018. doi 10.4119/unibi/seejph-2018-185 7 hospitalized in this very university hospital center in tirana, which is specialized and in title of providing this type of qualified medical services. from this point of view, the sample of patients included in this study may be largely representative of the overall albanian adult patients with presence of multimorbidity requiring hospitalization. nonetheless, the sample of patients involved is representative only for the duration of the recruitment process that is the period of time over which this study was carried out. in addition, the diagnosis of different diseases and various conditions was based on contemporary guidelines and clinical protocols which consist of recent examination techniques and procedures employed also in other research and medical centers in different countries worldwide. yet, the information about demographic and socioeconomic characteristics, as well as about behavioral factors was collected through interviews and, therefore, it is not possible to completely exclude the possibility of information bias for these factors which were based on patients’ self-reports. notwithstanding these considerations, there is no evidence supporting a differential reporting of socio-demographic characteristics and lifestyle factors between male and female patients with presence of multimorbidity. comparison of morbidity trends including multimorbidity and comorbidity during the past decades in albania is very important because it provides valuable information for health professionals, and especially for policymakers and decision-makers who are involved particularly in the fight against non-communicable diseases, which are currently rising in albania, likewise the situation evidenced in most of the countries of the european region (14). in conclusion, this study informs about the sex-differences of multimorbidity among hospitalized patients in tirana, the albanian capital. our findings demonstrate that the burden of multimorbidity is higher in women than in men in this transitional society, which is a cause of concern. therefore, these findings should raise the awareness of health professionals and particularly policymakers and decision-makers in order to address gender issues and inequity gaps in health outcomes and the burden of disease in the albanian population. references 1. institute for health metrics and evaluation (ihme). country profile: albania. seattle, wa: ihme, university of washington; 2018. http://www.healthdata.org/albania?language=41 (accessed: april 05, 2018). 2. albanian institute of public health. national health report: health status of the albanian population. tirana, albania; 2014. 3. institute of statistics, albania. women and men in albania, 2017. available at: http://www.instat.gov.al/media/2316/burrat_dhe_grat__ne_shqiperi_2017_libri.pdf (accessed: april 04, 2018). 4. institute for health metrics and evaluation (ihme). global burden of disease database. seattle, wa: ihme, university of washington; 2014. http://www.healthdata.org (accessed: march 28, 2018). 5. valderas jm, starfield b, sibbald b, salisbury c, roland m. defining comorbidity: implications for understanding health and health services. ann fam med 2009;7:357-63. 6. bayliss ea, edwards ae, steiner jf, main ds. processes of care desired by elderly patients with multimorbidities. fam pract 2008;25:287-93. 7. smith sm, soubhi h, fortin m, hudon c, o’dowd t. managing patients with multimorbidity: systematic review of interventions in primary care and community settings. bmj 2012;345:e5205. https://www.ncbi.nlm.nih.gov/pubmed/?term=sibbald%20b%5bauthor%5d&cauthor=true&cauthor_uid=19597174 https://www.ncbi.nlm.nih.gov/pubmed/?term=salisbury%20c%5bauthor%5d&cauthor=true&cauthor_uid=19597174 https://www.ncbi.nlm.nih.gov/pubmed/?term=roland%20m%5bauthor%5d&cauthor=true&cauthor_uid=19597174 https://www.ncbi.nlm.nih.gov/pubmed/19597174 https://www.ncbi.nlm.nih.gov/pubmed/19597174 https://www.ncbi.nlm.nih.gov/pubmed/19597174 https://www.ncbi.nlm.nih.gov/pubmed/?term=smith%20sm%5bauthor%5d&cauthor=true&cauthor_uid=22945950 https://www.ncbi.nlm.nih.gov/pubmed/?term=soubhi%20h%5bauthor%5d&cauthor=true&cauthor_uid=22945950 https://www.ncbi.nlm.nih.gov/pubmed/?term=fortin%20m%5bauthor%5d&cauthor=true&cauthor_uid=22945950 https://www.ncbi.nlm.nih.gov/pubmed/?term=hudon%20c%5bauthor%5d&cauthor=true&cauthor_uid=22945950 https://www.ncbi.nlm.nih.gov/pubmed/?term=o%27dowd%20t%5bauthor%5d&cauthor=true&cauthor_uid=22945950 https://www.ncbi.nlm.nih.gov/pubmed/?term=managing+patients+with+multimorbidity%3a+systematic+review+of+interventions+in+primary+care+and+community+settings collaku l, resuli m, gjermeni i, tase m. evidence of a higher burden of multimorbidity among female patients in albania (original research). seejph 2018, posted: 10 april 2018. doi 10.4119/unibi/seejph-2018-185 8 8. fortin m, soubhi h, hudon c, bayliss ea, van den akker m. multimorbidity’s many challenges. bmj 2007;334:1016-7. 9. ritchie c. health care quality and multimorbidity: the jury is still out. med care 2007;45:477-9. 10. marengoni a, angleman s, melis r, mangialasche f, karp a, garmen a, et al. aging with multimorbidity: a systematic review of the literature. ageing res rev 2011;10:430-9. 11. taylor aw, price k, gill tk, adams r, pilkington r, carrangis n, et al. multimorbidity—not just an older person’s issue. results from an australian biomedical study. bmc public health 2010;10:718. 12. menotti a, mulder i, nissinen a, giampaoli s, feskens ej, kromhout d. prevalence of morbidity and multimorbidity in elderly male populations and their impact on 10year all-cause mortality: the fine study (finland, italy, netherlands, elderly). j clin epidemiol 2001;54:680-6. 13. vogeli c, shields ae, lee ta, gibson tb, marder wd, weiss kb, et al. multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. j gen intern med 2007;22(suppl 3):391-5. 14. world health organization. core health indicators in the who european region. copenhagen, denmark; 2017. ______________________________________________________________________________________ © 2018 collaku et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1 meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in the republic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 1 original research estimating health impacts and economic costs of air pollution in the republic of macedonia craig meisner 1 , dragan gjorgjev 2,3 , fimka tozija 2,3 1 the world bank, washington, dc, usa; 2 institute of public health, skopje, republic of macedonia 3 medical faculty, skopje, republic of macedonia corresponding author: craig meisner, senior environmental economist, the world bank, msn mc7-720; address: 1818 h street, nw, washington, dc 20433, usa; telephone: 202-473-6852; e-mail: cmeisner@worldbank.org tel:202-473-6852 mailto:cmeisner@worldbank.org meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in the republic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 2 abstract aim: this paper assesses the magnitude of health impacts and economic costs of fine particulate matter (pm) air pollution in the republic of macedonia. methods: ambient pm10 and pm2.5 monitoring data were combined with population characteristics and exposure-response functions to calculate the incidence of several health end-points known to be highly influenced by air pollution. health impacts were converted to disability-adjusted life years (dalys) and then translated into economic terms using three valuation approaches to form lower and higher bounds: the (adjusted) human capital approach (hca), value of a statistical life (vsl) and the coi (cost of illness). results: fine particulate matter frequently exceeds daily and annual limit values and influences a person‟s day-to-day health and their ability to work. converting lost years of life and disabilities into dalys these health effects represent an annual economic cost of approximately €253 million or 3.2% of gdp (midpoint estimate). premature death accounts for over 90% of the total health burden since this represents a loss of total life-long income. a reduction of even 1μg/m 3 in ambient pm10 or pm2.5 would imply 195 fewer deaths and represent an economic savings of €34 million per year in reduced health costs. conclusion: interventions that reduce ambient pm10 or pm2.5 have significant economic savings in both the short and long run. currently, these benefits (costs) are „hidden‟ due to the lack of information linking air quality and health outcomes and translating this into economic terms. policymakers seeking ways to improve the public‟s health and lessen the burden on the health system could focus on a narrow set of air pollution sources to achieve these goals. keywords: air pollution, health and economic costs, particulate matter. conflicts of interest: none. acknowledgements: the authors would like to first acknowledge the financial support of the green growth and climate change analytic and advisory support program launched in 2011, with funding support from the world bank and the governments of norway and sweden. we would also like to thank our local macedonian counterparts at the institute of public health and the ministry of environment and physical planning for their willingness to collect and share data. we would also like to thank the finnish meteorological institute (fmi) for their guidance and suggestions on earlier drafts of this work. fmi is currently working with the moepp in strengthening their air quality monitoring network through an eu-sponsored twinning project. meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in the republic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 3 introduction according to the global burden of disease (2010) estimates (1), the crude mortality rate from ambient particulate matter (pm) pollution in macedonia was 80.6 deaths per 100,000 in 2010. in comparable neighboring states such as serbia, it was 71.8 deaths per 100,000; in croatia it was 69.4 per 100,000; in hungary 92.0 per 100,000; and 70 per 100,000 in slovakia. the total disability-adjusted life years (dalys) attributable to pm were about 1,480 per 100,000 in macedonia (but, up to 1,600 in hungary) (1). the main sources of this ambient condition were the use of solid fuel for heating households in the winter, as well as the impact of industry and traffic. uncontrolled urbanization is also a significant source of particulate matter. in 2009, an average annual concentration of 90µg/m 3 was registered in skopje. compounding the situation, poor air circulation is another reason why the capital city of skopje has one of the worse air conditions in winter. air pollution is also significant throughout the european region, with only nine of the 34 member states reporting pm10 levels below the annual who air quality guideline (aqg) of 20μg/m 3 . almost 83% of the population in these cities is exposed to pm10 levels exceeding the aqg levels (2). results from a recent project improving knowledge and communication for decision-making on air pollution and health in europe (aphekom), which uses a traditional health impact assessment method, indicated that average life expectancy in the most polluted cities could be increased by approximately 20 months if long-term pm2.5 concentrations were reduced to who guidelines (3). one recent study in macedonia found that an increase of pm10 by 10μg/m 3 above the daily maximum permitted level (50μg/m 3 ) was associated with a 12% increase in cardiovascular disease (2). methods to estimate the health impacts and economic costs of air pollution, the approach required overlaying data from multiple sources. the method used ambient air quality data [information received from the ministry of environment and physical planning (moepp)] for pm10 and pm2.5, health statistics – annual deaths by disease type; frequency of chronic bronchitis, asthma, infant mortality; and health cost data (information received from the institute of public health and health insurance fund), exposure-response functions from health studies (information from international and local literature) and population characteristics – age groups, gender, urban/rural population (information from the state statistics bureau). these data were combined for a municipal (city) level analysis. the approach to estimating health impacts and economic costs encompassed five steps:  collection of monitored, ambient concentration data on pm10 and pm2.5  calculation of exposed population  exposure-response functions  calculation of physical health impacts (mortality, morbidity, dalys)  monetizing health impacts collection of monitored data on fine particulate matter currently, the ministry of environment and physical planning (moepp) has a network of 19 automatic monitoring stations: seven in skopje, two in bitola, two in veles and one in kicevo, kumanovo, kocani, tetovo, kavadarci, village lazaropole, and two near the okta oil refinery (near the villages of miladinovci and mrsevci). stations measure so2, no2, co, pm10, pm2.5, ozone, benzene, toluene, ethyl benzene and btx – although some stations do not measure all pollutants [monitored pm2.5 measurements began in november, 2011 in meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in the republic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 4 karpos and centar. in cases where pm2.5 is not actually monitored, observed pm10 is adjusted by the ratio pm2.5/pm10. the ratio, based on recent observations, is estimated at 0.71 in the case of macedonia; and is within ranges found in other international studies. see ostro (4) for a discussion]. this information is available electronically through their air quality portal (available at: http://airquality.moepp.gov.mk/?lang=en). calculation of exposed population population information for 2010 was used focusing on the working population as well as vulnerable segments of society (for example, those under the age of five or older than 65 are considered more vulnerable to the effects of air pollution – that is more prone to develop acute or chronic respiratory ailments). exposure-response functions the selection of exposure-response functions was based on epidemiological research between pm10 and pm2.5 and mortality and morbidity. for mortality, exposure-response functions for long-term exposure to pm2.5 were (4): relative risks (rr) were calculated as: cardiopulmonary (cp) mortality: rr =[(x+1)/(x0 +1)] 0.15515 lung cancer (lc) mortality: rr = exp[0.23218 (x-x0)] alri mortality in under-five children: rr = exp[0.00166 (x-x0)] with: x = current annual average pm2.5 concentration for cp and lc among adults, and pm10 concentrations for alri among children and x0 = target or baseline pm2.5 concentration. information on the crude death rate (cdr), cp, lc and alri data were used to set the mortality baseline. for morbidity, exposure-response coefficients (annual cases per 100,000 population) for pm10 from ostro (4,5) and abbey et al. (6) were applied. ostro (4) reflects a review of worldwide studies, and abbey et al., (6) provides estimates of chronic bronchitis associated with particulates (pm10). a baseline for pm concentrations a baseline level (natural background concentration) for pm2.5 = 7.5 µg/m 3 , as suggested by ostro (4), was used (some argue that the baseline should be set at zero since the literature does not support the existence of a concentration level of which there are no observable effects. however a baseline of zero is not realistic since natural background concentrations hover between 10-15 μg/m 3 in macedonia – and one would only look at investments which could reduce ambient concentrations to this level (i.e. at least from a benefit-cost standpoint of weighing alternative investments). given a pm2.5/pm10 ratio of 0.71 using observations in macedonia, the baseline level for pm10 is 10.6 µg/m 3 . these baseline concentrations were applied to both large and medium/small urban areas. calculation of physical health impacts (mortality, morbidity, dalys) using the population information and the exposure-response functions, mortality and morbidity impacts were calculated through the conversion of impacts to dalys (dalys = sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability). the daly method weights illnesses by severity: a mild illness or disability (e.g. morbidity effects) represents a small fraction of a daly and a severe illness represents a larger fraction (e.g. mortality = 1 daly). weights used in this context were adapted from larsen (7) and are presented in table 1. meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in the republic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 5 table 1. estimated health impacts of air pollution, urban and rural, 2010 (source: world bank, 2012) health impacts dalys /10,000 cases cp mortality (pm2.5) 80,000 lc mortality (pm2.5) 80,000 alri mortality (pm10) 340,000 chronic bronchitis (pm10) 22,000 hospital admissions (pm10) 160 emergency room visits (pm10) 45 restricted activity days (pm10) 3 lower respiratory illness in children (pm10) 65 respiratory symptoms (pm10) 0.75 total monetizing health impacts to create a set of bounds three alternative valuation approaches were used: the (adjusted) human capital approach (hca) [the adjusted version avoids the issue of assigning a value of zero to the lives of the retired and the disabled since the traditional approach is based on foregone earnings. it avoids this issue by assigning the same value – per capita gdp – to a year of life lost by all persons, regardless of age], value of a statistical life (vsl) and the coi (cost of illness). the hca estimates the indirect cost of productivity loss through the value of an individual‟s future earnings. thus, one daly corresponds to one person‟s contribution to production, or gdp per capita. this method provides a realistic lower bound for the loss of one daly. the vsl measures the willingness-to-pay (wtp) to avoid death – using actual behavior on the tradeoffs between risks and money. the vsl is calculated by dividing the marginal wtp to reduce the risk of death by the size of the risk reduction. measured this way, the value of one daly corresponds to the vsl divided by the number of discounted years lost because of death. the vsl typically forms an upper bound measure of health damages. the coi approach estimates the direct treatment costs associated to different health end-points (e.g. hospitalization, restricted activity days, and doctor visits). mortality was valued using hca as a lower bound and the vsl as an upper bound. for morbidity effects the coi was estimated as a lower bound and willingness-to-pay to avoid a case of illness was applied as a higher bound of cost (wtp was assumed to be two times the coi). results air quality data support the finding that particulate matter is one of the most serious concerns in the country. ambient pm10 concentrations frequently exceeded the eu standard of 40μg/m 3 over the years (figure 1). using information on ambient pm10 and pm2.5 in conjunction with the methods outlined above, it is estimated that in macedonia 1,350 deaths occur annually from cardiopulmonary disease and lung cancer (table 2). these deaths are considered „premature‟ in the sense that air pollution contributed to their early demise – since many factors actually influence a persons‟ lifespan (e.g. smoking, exposure to the outdoors, job, etc.). particulate matter can also influence a person‟s day-to-day health and their ability to work. in 2011, levels of pm10 and pm2.5 were primarily responsible for 485 new cases of chronic bronchitis, 770 hospital admissions, and 15,200 emergency visits. meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in the republic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 6 figure 1. annual average pm10 concentration at each automatic monitoring station in μg/m 3 (source: ministry of environment and physical planning, 2012) what do these translate to in terms of a total cost to society? converting lost years of life and disabilities to dalys (or disability-adjusted life years) these health effects represent an annual economic cost of €253 million or 3.2% of gdp (table 2). note that premature death accounts for over 90% of the total health cost since the loss of life is a loss of total (future) income. people also suffer from the day-to-day consequences of respiratory diseases. it is estimated that several thousand work-years are lost annually from chronic bronchitis, asthma, hospital admissions and days of restricted activity. these estimates are consistent with other recent studies – such as kosovo where annual deaths were estimated to be in the range of 805-861 from cardiovascular disease and lung cancer (8). it should be noted that our estimates are mid-points (middle) with lower and higher ranges reflecting different assumptions made on the pm2.5/pm10 ratio and the population‟s exposure to air pollution. what are the potential benefits of reducing particulate matter? if macedonia were to lower pm10 and pm2.5 to eu limit values this would avoid over 800 deaths and thousands of days in lost productivity – representing a health cost savings of €151 million per year (table 3). a reduction of even 1μg/m 3 in ambient pm10 and pm2.5 would result in 195 fewer deaths (1,648 fewer dalys) and imply an economic savings of €34 million per year in reduced health costs. p m 1 0 c o n c e n tr a ti o n ( u g /m 3 ) skopje bitola veles tetovo kumanovo kavadarci kocani kicevo rural eu std meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in the republic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 7 table 2. number of annual cases, dalys per year and economic cost in million euros, 2011 (source: authors’ calculations) health impact annual cases * total dalys per year annual economic cost (€ million) cardiopulmonary & lung cancer mortality (pm2.5) 1,351 10,809 232.0 alri † mortality (pm10) 1 17 0.1 chronic bronchitis (pm10) 485 1,066 3.0 hospital admissions (pm10) 770 12 0.4 emergency room visits (pm10) 15,200 68 0.9 restricted activity days (pm10) 3,213,000 964 8.6 lower respiratory illness in children (pm10) 22,400 146 1.5 respiratory symptoms (pm10) 10,197,000 765 6.8 total 13,847 253.3 * mid-point estimates using a baseline for pm10 = 15 µg/m 3 and pm2.5 = 7.5 µg/m 3 † alri: acute lower respiratory infections. table 3. the potential health ‘savings’ associated with reductions in pm10 and pm2.5 (€ million) [source: authors’ calculations] level of reduction in ambient pm10 and pm2.5 (μg/m 3 ) * reduced dalys annual health savings (€ million) 0 0 0.0 1 1,648 34.1 5 4,894 98.9 10 6,636 133.6 15 8,059 161.5 20 9,275 184.9 eu standards met † 7,840 151.5 * example reductions were equally applied to both pm10 and pm2.5 at the same time. † pm10 = 40 µg/m 3 and pm2.5 = 20 µg/m 3 . discussion there is significant evidence of the effects of short-term exposure to pm10 on respiratory health, but for mortality, and especially as a consequence of long-term exposure, pm2.5 is a more robust risk factor than the coarse part of pm10 (particles in the 2.5–10 μm range). allcause daily mortality is estimated to increase by 0.2 0.6% per 10 μg/m 3 of pm10 (9). furthermore, it has been estimated that exposure to pm2.5 reduces life expectancy by about 8.6 months on average in the european region. results from the study “improving knowledge and communication for decision-making on air pollution and health in europe” (aphekom), which uses traditional health impact assessment methods, indicates that average life expectancy in the most polluted cities could increase by approximately 20 months if longterm pm2.5 concentrations were reduced to who annual guidelines (10). monitored pm10 and pm2.5 concentrations have repeatedly exceeded eu standards in republic of macedonia and have contributed to short-term and chronic respiratory disease. this study estimated an annual (mid-point) loss of approximately 1,350 lives with thousands of lost-productive days, indirectly costing the economy u p w a r d s o f €253 million or 3.2% of gdp in 2011. the specific exposure-response functions used in this study were meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in the republic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 8 borrowed from the international literature – however the orders of magnitude have been shown to be robust in many developing country applications after adjusting for local conditions (4,5,7,8). from a policy standpoint, it is important to note that these estimated costs are generally “hidden” since they are not normally quantified, and benchmarked to the value of economic activity that generated the pollution (i.e. gdp). likewise the distribution of this burden is shared between the general public and the health care system – so total costs are not transparent. the results should motivate policy makers to be more focused on preventative measures, among them, local green options to reduce particulate matter including energy efficiency, fuel switching and the adoption of cleaner technologies. the benefits from such actions should find their way into the benefit-cost analysis of associated investments since the health “savings” could offset the investment costs of greening interventions. references 1. institute for health metrics and evaluation. global burden of disease, 2010. http://www.healthdata.org/search-gbd-data?s (accessed: february 2, 2015). 2. kochubovski m, kendrovski v. monitoring of the ambient air quality (pm10) in skopje and evaluation of the health effects in 2010. jepe 2012;13:789-96. 3. world health organization (who). who air quality guidelines, particulate matter, ozone, nitrogen dioxide and sulphur oxide; geneva, switzerland; 2006. 4. ostro b. outdoor air pollution assessing the environmental burden of disease at national and local levels. environmental burden of disease, series no. 5, geneva: who; 2004 (62p). 5. ostro b. estimating the health effects of air pollution: a method with an application to jakarta. policy research working paper no. 1301, washington, d.c.: the world bank; 1994. 6. abbey de, lebowitz md, mills pk, petersen ff, beeson wl, burchette rj. longterm ambient concentrations of particulates and oxidants and development of chronic disease in a cohort of nonsmoking california residents. inhal toxicol 1995;7:19-34. 7. larsen b. colombia. cost of environmental damage: a socio-economic and environmental health risk assessment. final report prepared for the ministry of environment, housing and land development of republic of colombia; 2004. 8. world bank. kosovo country environmental analysis: cost assessment of environmental degradation, institutional review, and public environmental expenditure review, washington, dc. the world bank; 2012. http://documents.worldbank.org/curated/en/2013/01/17485553/kosovo-countryenvironmental-analysis-kosovo-country-environmental-analysis-cea (accessed: february 2, 2015). 9. samoli e, peng r, ramsay t, pipikou m, touloumi g, dominici f, et al. acute effects of ambient particulate matter on mortality in europe and north america: results from the aphena study. environ health perspect 2008;116:1480-6. 10. world health organization (who) – regional office for europe. health effects of particulate matter: policy implications for countries in eastern europe, caucasus and central asia. copenhagen, denmark; 2013. ___________________________________________________________ © 2015 meisner et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. dobe m, sahu m. how the kurnool district in andhra pradesh, india, fought corona (case study). seejph 2020, posted: 18 november 2020. doi: 10.4119/seejph-3963 p a g e 1 | 9 case study how the kurnool district in andhra pradesh, india, fought corona madhumita dobe1, monalisha sahu1 1 department of health promotion and education, all india institute of hygiene and public health, west bengal, india. corresponding author: madhumita dobe; address: 110, chittaranjan avenue, kolkata 700073, west bengal, india; telephone: +9830123754; email:madhumitadobe@gmail.com dobe m, sahu m. how the kurnool district in andhra pradesh, india, fought corona (case study). seejph 2020, posted: 18 november 2020. doi: 10.4119/seejph-3963 p a g e 2 | 9 abstract background: kurnool, one of the four districts in the rayalaseema region of the indian state of andhra pradesh, emerged as a covid-19 hotspot by mid-april 2020. method: the authors compiled the publicly available information on different public health measures in kurnool district and related them to the progression of covid-19 from march to may 2020. results: two surges in pandemic progression of covid-19 were recorded in kurnool. the initial upsurge in cases was attributed to return of people from other indian states, along with return of participants of a religious congregation in delhi, followed by in-migration of workers and truckers from other states and other districts of andhra pradesh, particularly from the state of maharashtra (one of the worst affected states in india) and chennai (the koyambedu wholesale market epicenter of the largest cluster of covid-19 in tamil nadu). in a quick response to surging infections the state government launched operation ‘kurnool fights corona’ to contain the outbreak. kurnool had taken a targeted approach to testing, scaled up testing in areas with high case load, and conducted contact tracing for each positive case, along with requisitioning oxygenated beds in the district hospitals to meet the anticipated spurt in the number of positive cases. this combined approach paid rich dividends and from 26th april to may 9th, the growth curve flattened. conclusion: although the in migration of laborers and return of residents from other indian states and abroad during the covid-19 pandemic was a complex challenge, the timely actions of testing, tracing and isolation conducted by the district authorities in kurnool greatly reduced transmission. although this response assessment is based on a single district, the perspectives have revealed some important lessons regarding risk communication, preparedness and response for pandemics which will facilitate consolidation of the policy and program response to pandemics in future. keywords: contact tracing, covid-19, isolation, kurnool, preparedness, testing. acknowledgement: dr sanjoy sadhukhan (professor, aiih&ph) and district authorities of kurnool for their support. conflicts of interest: none. dobe m, sahu m. how the kurnool district in andhra pradesh, india, fought corona (case study). seejph 2020, posted: 18 november 2020. doi: 10.4119/seejph-3963 p a g e 3 | 9 background kurnool district is one of the four districts in the rayalaseema region of the indian state of andhra pradesh (1). the district is located in the west-central part of the state and is bounded by mahbubnagar district of telangana in the north, raichur district of karnataka in the northwest, bellary district of karnataka in the west, ananthapur district in the south, ysr kadapa district in the south east and prakasham district in the east. the district is the second largest by area and seventh largest by population in the state with a total population of 4.53 million as per 2011 census, 72% of which reside in rural areas. the main occupation and source of livelihood for this district is agriculture. more than 70% of the population in the kurnool district engages in farming. however, as kurnool is a drought prone area, many of the villagers are forced to migrate not only to other states but also to other districts within the state in search of livelihood. the district has three revenue divisions viz., kurnool, nandyal, adoni divisions with 54 mandalas and 53 panchayat samitis (blocks) under these revenue divisions (1,2). methods the authors compiled and reviewed all publicly available information (government database, newspaper articles, reports) and interviewed government officials during field visits on different public health measures taken in kurnool district to contain the ongoing covid-19 pandemic in progression from the month of march to may 2020. results everything seemed in line with the overall progress of the pandemic in india when the nation-wide lockdown was first announced on march 24 to contain covid-19 outbreak. over 300 foreign returnees from italy, uk/scotland, saudi arabia (mecca) were under surveillance and the district administration collected samples for tests. on march 28 the first case in the district was reported, as a 23-year-old male with a travel history to rajasthan tested positive for the virus (3). the number of positive cases remained low for the next two weeks. spikes of cases were reported on april 5 and april 6 with 49 and 18 cases emerging respectively in those two weeks till april 13 (4). but things changed from april 14 when the numbers kept shooting up. the first surge of cases: during midmarch, tablighi jamaat (religious congregation) was held at nizamuddin markaz in new delhi. many people from kurnool had attended the congregation. the first alarm went off when three persons from kurnool district, who attended the tablighi jamaat at nizamuddin, tested positive for covid-19 (5). the number of positive cases in the district went up from one to four with these three persons hailing from kurnool city, owk and banaganapalli. district officials felt that the influx of 357 tablighi jamaat (tj) congregation returnees from new delhi triggered the sudden spurt. the returnees and their primary and secondary contacts accounted for majority of the cases in the district which had the highest number of delhi returnees in the state. the challenge was formidable since on one hand, authorities were unable to precisely locate all tj meeting returnees and on the other, those traced by them did not come forward voluntarily for diagnostic tests and were unwilling to be taken https://en.wikipedia.org/wiki/rayalaseema https://en.wikipedia.org/wiki/states_and_union_territories_of_india https://en.wikipedia.org/wiki/states_and_union_territories_of_india https://en.wikipedia.org/wiki/andhra_pradesh https://en.wikipedia.org/wiki/mahabubnagar_district https://en.wikipedia.org/wiki/mahabubnagar_district https://en.wikipedia.org/wiki/telangana https://en.wikipedia.org/wiki/raichur_district https://en.wikipedia.org/wiki/raichur_district https://en.wikipedia.org/wiki/karnataka https://en.wikipedia.org/wiki/bellary_district https://en.wikipedia.org/wiki/bellary_district https://en.wikipedia.org/wiki/karnataka https://en.wikipedia.org/wiki/ananthapur_district https://en.wikipedia.org/wiki/ananthapur_district https://en.wikipedia.org/wiki/ysr_kadapa_district https://en.wikipedia.org/wiki/ysr_kadapa_district https://en.wikipedia.org/wiki/prakasham_district https://en.wikipedia.org/wiki/prakasham_district https://en.wikipedia.org/wiki/revenue_division https://en.wikipedia.org/wiki/revenue_division https://en.wikipedia.org/wiki/kurnool https://en.wikipedia.org/wiki/nandyal https://en.wikipedia.org/wiki/adoni https://en.wikipedia.org/wiki/mandal https://en.wikipedia.org/wiki/panchayat_samiti_(block) https://en.wikipedia.org/wiki/panchayat_samiti_(block) dobe m, sahu m. how the kurnool district in andhra pradesh, india, fought corona (case study). seejph 2020, posted: 18 november 2020. doi: 10.4119/seejph-3963 p a g e 4 | 9 to isolation or quarantine wards. since there was no single source which had details of all participants and their addresses, there was difficulty in identifying those who attended the meet in delhi. due to these issues, there was a delay of 10 days initially in identifying the tablighi jamaat returnees and their contacts which led to a spike in the number of cases in the district. also, problem lay in lack of vrdl (virus research and diagnostic laboratory) in kurnool and dependence on laboratories far away from the district headquarters. sample results were delayed thereby hindering initial contact tracing. one hundred and ninety-five cases emerged in 13 days, making kurnool one among the few districts in south india to see a dramatic surge (6). by april 25, the district administration had declared 40 red zones in 20 of a total 54 mandalas and urban areas including kurnool city with 239 active cases, 9 deaths, and 31 recoveries (4,6). the worstaffected areas were kurnool city and nandyal town (figure 1). figure 1. administrative map of kurnool district and the covid-19 affected mandalas. data as on 25th april 2020 (2,6) the district, now accounted for over a quarter of the cases in andhra pradesh and figured high on the list of districts with the highest number of covid cases in south india after chennai in tamil nadu, hyderabad in telangana and kasaragod in kerala (4). to battle against this, operation “kurnool fights corona (kfc)’ was launched (7). the second surge: with the lockdown imposed, the migrant workers from the district started to return without effective controls. in consequence a fresh upsurge of cases was noted with average daily increase to seven new cases (from 6th to 21st may 2020). most cases were seen among migrant workers and lorry drivers returning from maharashtra (one of the worst affected states in dobe m, sahu m. how the kurnool district in andhra pradesh, india, fought corona (case study). seejph 2020, posted: 18 november 2020. doi: 10.4119/seejph-3963 p a g e 5 | 9 india) and from koyambedu (chennai’s popular wholesale market, and the epicenter of the largest cluster of covid-19 in the neighbouring state of tamil nadu), along with their primary and secondary contacts. out of 8,069 workers who returned from other states, 236 were tested positive to covid-19. similarly, of another 3,337 workers who returned from mumbai, 314 tested positive to the virus (3). however, probably only those who had reported or were intercepted during their journey back were tested. in-migration from other districts: by 4th may another 40,000 migrant workers returned to kurnool district from other districts in the same state of andhra pradesh. almost all of them were working in chili fields at guntur and prakasam districts. most of these migrant laborers had left for work in january and february. containment measures: the district put well streamlined contact tracing and quarantine measures in place. the state formulated an action plan to bring back about 200,000 of its migrants held up in 13 states with well-planned quarantine measures. a. quarantine facilities for in migrants and returnees: responding to the upsurge, the existing number of 244 quarantine centers were increased to 1 in each village secretariat (one village secretariat has been set up for every population of 2,000 ), readying over 100,000 beds at village secretariats, with nutritious food, hygienic toilets for the returnees (10). each village secretariat was made suitable to accommodate 1015 people during quarantine. arrangements for quarantine were as follows:  home quarantine for asymptomatic migrants from within state;  community quarantine for symptomatic migrants from within state at village secretariat level / school buildings;  institutional quarantine at block level-school buildings for migrants from other low risk states;  institutional quarantine at district level (housing flats) for migrants from other high risk states e.g. maharashtra and chennai (koyembadu);  hotels & lodges for paid quarantine facilities for affordable rich persons/ foreign returnees. the health, medical and family welfare department of andhra pradesh directed all district collectors to establish quarantine centers at district level with 200 beds and constituency level with 100 beds each. by march 25, all district hospitals in the state were instructed by the health department of andhra pradesh, to setup isolation wards. the state, on 31 march, identified dedicated covid-19 hospitals4 at state and 13 at district level. on 31 march 2020, all district administration in andhra pradesh was directed by the state government to prepare shelter with lodging and boarding services for migrant labourers. these shelters were managed by individual 'nodal officer', appointed by the district collector or municipal commissioner. immediately after their entry into kurnool, the returnees coming from various high-risk states like maharashtra-the worst-hit state, were taken in specially-arranged buses to the institutional quarantine centers set up by the administration in kurnool and adoni before returning to their respective homes. covidhttps://www.thehindu.com/news/cities/chennai/did-authorities-fail-to-read-the-signs/article31513339.ece?homepage=true https://www.thehindu.com/news/cities/chennai/did-authorities-fail-to-read-the-signs/article31513339.ece?homepage=true https://en.wikipedia.org/wiki/andhra_pradesh dobe m, sahu m. how the kurnool district in andhra pradesh, india, fought corona (case study). seejph 2020, posted: 18 november 2020. doi: 10.4119/seejph-3963 p a g e 6 | 9 19 tests were done for all the migrants and they were allowed to go home only after 14 days of quarantine as per the protocol. counselling and other support systems were also being arranged by district authorities in the quarantine centers to help people cope up the stress and anxiety. limitations: on the flip side, mandatory quarantine was accompanied by fear, alarm, and panic. this, augmented by media, spread farther and aggravated the risk of being stigmatized. field workers reported that those returning from quarantine were discriminated in the form of:  other people avoiding or rejecting them;  verbal abuse; or  physical violence. this led to isolation, depression, anxiety, or public embarrassment for these individuals sometimes leading to challenges in contact tracing as reported by community health workers participating in active surveillance in the communities. even healthcare workers, sanitary workers and police, who were in the frontline for management of the outbreak, were facing discrimination on account of heightened fear and misinformation about infection. district authorities addressed these issues through busting the myths and sharing accurate information about how the virus spreads and does not spread. they used news media and social media, to speak out against stereotyping groups of people who experience stigma because of covid-19 and spoke out against negative behaviours and statements. b. contact tracing activities: contact tracing teams were put in action, manned by medical doctors and health workers. the data base and line listing was maintained rigorously by the contact tracing team (11). the line listing of the cases is presented in table 1. table 1. line listing of the cases among returnees in kurnool by 19 th may 2020 category total no. of persons total positives primary contacts traced primary contacts positive secondary contacts traced secondary contacts positive foreign returnees 840 1 2 0 12 0 delhi returnees 361 114 1048 35 2786 44 delhi returnees-contacts 3834 79 718 0 1756 1 koyembedu returnees 473 12 69 0 324 0 total 5508 206 1837 35 4878 45 after receiving line list of positive cases, the positive cases were contacted through phone calls. they were extended support and were inquired about their contacts. the contacts were listed, identified and classified into primary, secondary and tertiary contacts. the information of the contacts was shared with the sample testing team, home isolation department, integrated disease surveillance program and municipal health office to eensure they have access to medical care and social services. they are dobe m, sahu m. how the kurnool district in andhra pradesh, india, fought corona (case study). seejph 2020, posted: 18 november 2020. doi: 10.4119/seejph-3963 p a g e 7 | 9 notified about their exposure, offered treatment if required and instructed to limit their contact with other people. medical officers and auxiliary nurse midwives (anms) were informed to acquire further information on the contacts including associated comorbidities. follow up of the contacts for testing, quarantine and isolation was done by the local teams. monitoring of actions in collaboration and coordination with municipal health officers, medical officers, auxiliary nurse midwives and ward volunteers was done on regular basis. special challenge of contact tracing of koyembadu market returnees: koyambadu market complex is one of asia’s largest hubs for perishable goods. retail vendors come from a minimum radius of 100 km. kurnool is one of the main sources of onion for tamil nadu, and many sellers had travelled to the market even during lockdown period for business purposes and as vendors and market laborers including load men returning from koyembadu began to test positive, tracing and testing all index cases was aggressively undertaken, what marked the beginning of a challenging process was contact tracing. the cluster was different owing to the massive crowds involved (8,9). in a normal situation, a person who tests positive for covid-19 will have 20 to 30 contacts but this was not the case with the koyambedu cluster where some who tested positive had roughly 200 to 250 contacts. this combined approach paid rich dividends and from 26th april to may 9th, the number of new cases gradually declined with a doubling rate of 25 (figure 2). figure 2. graph representing temporal variation of new cases, cumulative cases and active cases from kurnool district till may 5th 2020 (source: district data provided by nodal officer) dobe m, sahu m. how the kurnool district in andhra pradesh, india, fought corona (case study). seejph 2020, posted: 18 november 2020. doi: 10.4119/seejph-3963 p a g e 8 | 9 conclusion although the in-migration of laborers during the covid-19 pandemic was a complex challenge, the timely actions conducted by the district authorities in kurnool greatly reduced transmission. hundreds of migrants and those who had close contact with the positives among them, were placed in quarantine centers run by the government. hot spots with high case load were locked down immediately, and the government communicated frequently with citizens to keep them informed and involved in the public health response. also, in a quick response to surging infections the state government launched operation ‘kurnool fights corona’ to contain the outbreak. in summary kurnool had taken a targeted approach to testing, scaled up testing in areas with high case load, and conducted contact tracing for each positive case, along with requisitioning oxygenated beds in the district hospitals to meet the anticipated spurt in the number of positive cases. this combined approach paid rich dividends and from 26th april to may 9th, the growth curve flattened. although this response assessment is based on a single district, the problems faced by kurnool have revealed some important lessons regarding risk communication, preparedness and response for pandemics which will facilitate consolidation of the policy and program response to pandemics in future. references 1. government of andhra pradesh. kurnool district. available from: https://kurnool.ap.gov.in/ (accessed: july 17, 2020). 2. government of andhra pradesh. andhra pradesh space applications centre. available from: https://apsac.ap.gov.in/ (accessed: july 17, 2020). 3. the times of india. kurnool reports first corona positive case. available from: https://timesofindia.indiatimes.com/city/vijayawada/kurnoolreports-first-corona-positive-case/articleshow/74867409.cms (accessed: july 17, 2020). 4. the new indian express. battle of kurnool: with over 279 coronavirus cases in one month govt steps up fight to stop spread. available from: https://www.newindianexpress.com/states/andhra-pradesh/2020/apr/27/battle-kurnoolwith-over-279-coronavirus-cases-inone-month-govt-steps-up-fight-tostop-spread-2135834.html (accessed: july 17, 2020). 5. the hindu.70 nizamuddin’s tablighi jamaat returnees identified in kurnool district. available from: https://www.thehindu.com/news/national/andhra-pradesh/70-nizamuddin-returnees-sent-to-quarantine/article31215260.ece (accessed: july 17, 2020). 6. arogya andhra on twitter: “kurnool district has the highest number of #covid19 positive cases in the state.” available from: https://twitter.com/arogyaandhra/status/1254039414956625920 (accessed: july 17, 2020). 7. the times of india. operation ‘kurnool fights corona’ launched; 14 new cases in district, 24 patients 24 patients discharged. available from: http://timesofindia.indihttps://kurnool.ap.gov.in/ https://apsac.ap.gov.in/ https://apsac.ap.gov.in/ https://timesofindia.indiatimes.com/city/vijayawada/kurnool-reports-first-corona-positive-case/articleshow/74867409.cms https://timesofindia.indiatimes.com/city/vijayawada/kurnool-reports-first-corona-positive-case/articleshow/74867409.cms https://timesofindia.indiatimes.com/city/vijayawada/kurnool-reports-first-corona-positive-case/articleshow/74867409.cms https://timesofindia.indiatimes.com/city/vijayawada/kurnool-reports-first-corona-positive-case/articleshow/74867409.cms https://www.newindianexpress.com/states/andhra-pradesh/2020/apr/27/battle-kurnool-with-over-279-coronavirus-cases-in-one-month-govt-steps-up-fight-to-stop-spread-2135834.html https://www.newindianexpress.com/states/andhra-pradesh/2020/apr/27/battle-kurnool-with-over-279-coronavirus-cases-in-one-month-govt-steps-up-fight-to-stop-spread-2135834.html https://www.newindianexpress.com/states/andhra-pradesh/2020/apr/27/battle-kurnool-with-over-279-coronavirus-cases-in-one-month-govt-steps-up-fight-to-stop-spread-2135834.html https://www.newindianexpress.com/states/andhra-pradesh/2020/apr/27/battle-kurnool-with-over-279-coronavirus-cases-in-one-month-govt-steps-up-fight-to-stop-spread-2135834.html https://www.newindianexpress.com/states/andhra-pradesh/2020/apr/27/battle-kurnool-with-over-279-coronavirus-cases-in-one-month-govt-steps-up-fight-to-stop-spread-2135834.html https://www.newindianexpress.com/states/andhra-pradesh/2020/apr/27/battle-kurnool-with-over-279-coronavirus-cases-in-one-month-govt-steps-up-fight-to-stop-spread-2135834.html https://www.thehindu.com/news/national/andhra-pradesh/70-nizamuddin-returnees-sent-to-quarantine/article31215260.ece https://www.thehindu.com/news/national/andhra-pradesh/70-nizamuddin-returnees-sent-to-quarantine/article31215260.ece https://www.thehindu.com/news/national/andhra-pradesh/70-nizamuddin-returnees-sent-to-quarantine/article31215260.ece https://www.thehindu.com/news/national/andhra-pradesh/70-nizamuddin-returnees-sent-to-quarantine/article31215260.ece http://timesofindia.indiatimes.com/articleshow/75383053.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst dobe m, sahu m. how the kurnool district in andhra pradesh, india, fought corona (case study). seejph 2020, posted: 18 november 2020. doi: 10.4119/seejph-3963 p a g e 9 | 9 atimes.com/articleshow/75383053.cms?utm_source =contentofinterest&utm_medium=text&utm_campaign=cppst (accessed: july 17, 2020). 8. the hindu. what turned koyambedu, chennai’s popular wholesale complex market, into a covid-19 hotspot? available from: https://www.thehindu.com/news/national/tamil-nadu/coronavirus-whatturned-koyambedu-chennais-popular-wholesale-complex-market-intoa-covid-19-hotspot/article31546292.ece (accessed: july 17, 2020). 9. the hindu. koyambedu market impacts four districts in andhra pradesh. available from: https://www.thehindu.com/news/national/andhra-pradesh/koyambedumarket-impacts-four-districts-in-andhra-pradesh/article31569117.ece (accessed: july 17, 2020). 10. deccan hearald. andhra uses village secretariat buildings to ready 1 lakh quarantine beds for people returning to state. available from: https://www.deccanherald.com/national/andhra-uses-village-secretariat-buildings-to-ready-1-lakh-quarantine-beds-for-people-returning-tostate-833076.html (accessed: july 17, 2020). 11. government of andhra pradesh. department of health & family welfare. available from: arogyaandhra (@arogyaandhra) | twitter; twitter.com › arogyaandhra. _______________________________________________________________ © 2020 dobe et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://timesofindia.indiatimes.com/articleshow/75383053.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst http://timesofindia.indiatimes.com/articleshow/75383053.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst http://timesofindia.indiatimes.com/articleshow/75383053.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst http://timesofindia.indiatimes.com/articleshow/75383053.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst 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https://www.thehindu.com/news/national/tamil-nadu/coronavirus-what-turned-koyambedu-chennais-popular-wholesale-complex-market-into-a-covid-19-hotspot/article31546292.ece https://www.thehindu.com/news/national/andhra-pradesh/koyambedu-market-impacts-four-districts-in-andhra-pradesh/article31569117.ece https://www.thehindu.com/news/national/andhra-pradesh/koyambedu-market-impacts-four-districts-in-andhra-pradesh/article31569117.ece https://www.thehindu.com/news/national/andhra-pradesh/koyambedu-market-impacts-four-districts-in-andhra-pradesh/article31569117.ece https://www.thehindu.com/news/national/andhra-pradesh/koyambedu-market-impacts-four-districts-in-andhra-pradesh/article31569117.ece https://www.deccanherald.com/national/andhra-uses-village-secretariat-buildings-to-ready-1-lakh-quarantine-beds-for-people-returning-to-state-833076.html https://www.deccanherald.com/national/andhra-uses-village-secretariat-buildings-to-ready-1-lakh-quarantine-beds-for-people-returning-to-state-833076.html https://www.deccanherald.com/national/andhra-uses-village-secretariat-buildings-to-ready-1-lakh-quarantine-beds-for-people-returning-to-state-833076.html https://www.deccanherald.com/national/andhra-uses-village-secretariat-buildings-to-ready-1-lakh-quarantine-beds-for-people-returning-to-state-833076.html https://www.deccanherald.com/national/andhra-uses-village-secretariat-buildings-to-ready-1-lakh-quarantine-beds-for-people-returning-to-state-833076.html https://twitter.com/arogyaandhra?lang=en https://twitter.com/arogyaandhra?lang=en https://twitter.com/arogyaandhra?lang=en https://twitter.com/arogyaandhra?lang=en cuschieri s. the diabetes epidemic in malta (original research). seejph 2020, posted: 19 february 2020. doi 10.4119/seejph-3322 p a g e 1 | 10 original research the diabetes epidemic in malta sarah cuschieri1 1 centre for molecular medicine and biobanking, university of malta, msida, malta. corresponding author: dr. sarah cuschieri, md ph.d; address: msida, msd 2080, malta; telephone: +356 79415298; e-mail: sarah.cuschieri@um.edu.mt mailto:sarah.cuschieri@um.edu.mt cuschieri s. the diabetes epidemic in malta (original research). seejph 2020, posted: 19 february 2020. doi 10.4119/seejph-3322 p a g e 2 | 10 abstract aim: the small european mediterranean island state of malta is a highly prevalent type 2 diabetes (t2dm) country. over recent decades drastic environmental, cultural and ethnic changes occurred and it was considered timely to undergo a cross-sectional survey to establish up-to-date prevalence of t2dm, its socio-geographical distribution and ultimately estimating the economic burden of t2dm. methods: a health examination survey was conducted (2014-16) including a representative sample of the adult population stratified by 18-70 years, gender and locality (n=3,947; males n=1,997 male). the survey consisted of a socio-demographic questionnaire, various health examination measurements and blood samples for fasting blood glucose (fbg). prevalence for t2dm (depending on medical history, medication and fbg >7mmol/l) were calculated for the general population as well as for each of the districts making up the maltese islands. the economic burden of t2dm for 2017 and projected burden for 2045 were calculated using secondary sources and by incorporating 2% compound interest per annum respectively. results: a total response rate of 47.15% was obtained, with a mean age of 48 years for males and 46 years for females. out of the total adjusted population (n=3,947, male n=1,998), the prevalence of t2dm was of 10.31%, with 6.31% already known to have t2dm while 4% were newly diagnosed. females were diagnosed with t2dm at an earlier age than the males. no significant geographical t2dm prevalence differences were established. the total annual diabetes health care expenditure was approximately €107,316,517.82 for 2017, while the projected expenditure for 2045 was estimated at €244,136,040. conclusion: malta is a country with a high prevalence of diabetes. the females were observed to be at an earlier risk of developing undiagnosed diabetes compared to males. although geographical location did not appear to have significant effect on t2dm distribution, this disease contributes to a high economic burden. the expected exponential increase in diabetes prevalence is subsequently expected to affect negatively the healthcare expenditure. this puts forward the recommendation for development of early screening programmes as part of preventive action strategies. keywords: diabetes, epidemic, health care, health expenditures, mass screening, type 2 diabetes. source of funding: the author is extremely grateful for the strong support forthcoming from the university of malta (through the medical school and research innovative development trust department) and from the alfred mizzi foundation as major sponsors, as well as that of a host of others, including atlas health insurance (malta). the in-kind support and encouragement of the parliamentary secretariat for health of the government of malta is also gratefully acknowledged. acknowledgment: a note of appreciation and acknowledgement is forwarded to professor julian mamo, professor josanne vassallo and professor neville calleja for their continuous support and advice during the academic progression. conflicts of interest: none declared. cuschieri s. the diabetes epidemic in malta (original research). seejph 2020, posted: 19 february 2020. doi 10.4119/seejph-3322 p a g e 3 | 10 introduction type 2 diabetes mellitus (t2dm) is a global epidemic with an estimated 463 million adults (20-79 years) suffering from this condition in 2019 (1). the mediterranean island of malta is no exception. in malta, diabetes has been reported to be a health problem since the eighteenth century (2). the first epidemiological study aiming at assessing the prevalence of t2dm in malta was conducted in 1964 (3). in 1981, the world health organization (who) conducted the first national representative diabetes prevalence study in malta (4). more recently, a pilot study was conducted in 2010 the european health examination survey (ehes) (5). this gave an estimate of the diabetes burden in malta (5). different studies reported increasingly higher diabetes prevalence within the maltese population, often higher than neighbouring countries (1). consequently, malta was considered a mediterranean hub for diabetes (6). over recent years, malta has sustained a cultural change, with more ethnical and socio-economic diversity, and new variety in the genetic imprints, as well as a shift to a more westernised lifestyle (7). all these factors are contributors for population metabolic transition, which could possibly increase the diabetes prevalence within the maltese population (7). a national representative survey was undertaken between 2014 and 2016 to update the dysglycaemic status of malta (8). it was hypothesised that with the drastic environmental, cultural and ethnic changes that have occurred in malta over the past few decades, the prevalence of t2dm and its distribution among the population have altered from the previous studies. the aim of this study was to update the prevalence of t2dm in malta as well as to determine the sociogeographical distribution of the disease and ultimately estimate the economic burden methods the university of malta conducted a nationally representative health examination survey (2014 – 2016) entitled sahhtek (your health). the detailed study methodology can be found elsewhere (8). briefly, a population-based sample stratified by age (18-70 years), gender and locality (approximately 1% from each of the 68 towns) was obtained from a national register. the selected individuals (n=3,947; males n=1,998) with a mean age of 48 years for males and 46 years for females, were invited to participate in the survey that consisted of a previously validated questionnaire, blood pressure measurements, weight, height, waist circumference and hip circumference measurements. blood samples for fasting blood glucose and a lipid profile were also gathered. informed written consent was obtained from every participant. ethical and data protection approvals were granted from the university of malta research ethical committee (urec) and the information and the data protection national commissioner, respectively. participants obtaining a fasting blood glucose (fbg) level between 5.60 to 6.99 mmol/l were referred to as impaired fasting glucose (ifg), while those with a fbg >=7 mmol/l were considered as newly diagnosed diabetes mellitus, provided they were not previously diagnosed as diabetics or were on oral hypoglycaemic agents (9). participants with a previous history of diabetes mellitus or on oral hypoglycemic agents, irrespective of their measured fasting plasma glucose, were considered as cases of previously diagnosed diabetes mellitus. the global t2dm prevalence level was calculated by dividing the sum of newly diagnosed and previously diagnosed diabetics over the total number of participating individuals. the prevalence levels for previously diagnosed diabetes and newly diagnosed diabetes were established separately and in total. the prevalence levels were stratified by age and gender and compared to the previously reported prevalence levels by the who 1981 study (4). following the eurostat system of local administrative units (laus), the diabetes prevalence was stratified into the six districts of southern harbour, northern harbour, south eastern, western, northern and gozo districts (10). for each district, the t2dm prevalence level (global, previously and newly diagnosed t2dm) were calculated. the economic burden of t2dm was calculated by multiplying the total diabetic maltese population by the estimated mean diabetes-related expenditure per person for malta as reported by the international diabetes federation (idf) atlas in 2017 (11). this expenditure incorporated the provision of health services (preventive and curative), family planning activities, nutritional activities, emergency aid for both public and private healthcare expenditures (11). the original idf estimation for healthcare expenditure was based on the idf diabetes prevalence (an overestimation for malta), the united nations population estimates, the who annual health care expenditure and mortality rates, as well as ratios of healthcare expenditure for diabetics compared to non-diabetics (11-14). the progressive diabetes prevalence between the twohealth examination surveys (1981 and 2016) was cuschieri s. the diabetes epidemic in malta (original research). seejph 2020, posted: 19 february 2020. doi 10.4119/seejph-3322 p a g e 4 | 10 calculated, while assuming that the progressive prevalence level remained constant across the 35 years duration. this progressive prevalence level was utilized to project the diabetes prevalence for the year 2045. the previously calculated diabetes expenditure per person was also projected for the year 2045 by incorporating a 2% compound interest increase per annum (15). using the eurostat projected total maltese population for the year 2045, the projected diabetes prevalence level for 2045 was then estimated (16). this 2045 diabetes population estimate was used to estimate the diabetes economic burden. results a total of 3,947 adults (1,998 male and 1,949 female) were invited to participate in the health examination survey held between november 2014 and november 2015. of these, 1,861 adults (836 male and 1,025 female) participated, giving a response rate of 47.15% (p=<0.01). since the responders were found to be significantly different from the non-responders, a weighting factor was applied to each of the responder. the weighting factor enabled the data to maintain its representative nature by ensuring that each town was represented by 1% by each age and sex. a detailed description of the weighting protocol can be found elsewhere (8). the final weighted (adjusted) population was of 3,947 (males n=1998), of whom 10.31% (ci 95%: 9.40%-11.30%) suffered from diabetes mellitus. this included those previously diagnosed (6.31%, ci 95%: 5.59%-7.11%), as well as newly diagnosed (4.00% ci 95%: 3.43%-4.66%) diabetics. comparing this study’s results to the last nationally representative study (1981), an increase in diabetes prevalence rate was observed (figure 1). a steeper increase was observed between 1981 and 2016 amongst the newly diagnosed diabetics. a slight increase was also observed when the current study was compared to the european health examination pilot study (n=212) conducted in 2010 (total diabetes prevalence of 9.8%). on age and gender stratification of the diabetes prevalence, the female population exhibited an earlier onset of diabetes mellitus (30-39 years) when compared to the male population (40-49 years) amongst the current study population. figure 2 compares the global diabetes prevalence levels between the 1981 and 2016 studies, by age group and gender. a more evident difference in the diabetes prevalence levels could be observed between the two studies amongst the elderly population (70 years). figure 1. comparison between the diabetes prevalence rate amongst the who 1981 and sahhtek 2014 – 2016 studies 7.70% 10.31% 5.90% 6.31% 1.80% 4.00% 0% 2% 4% 6% 8% 10% 12% who (1981) sahhtek (2016) d ia b e te s p re v a le n ce total dm previously dm newly dm cuschieri s. the diabetes epidemic in malta (original research). seejph 2020, posted: 19 february 2020. doi 10.4119/seejph-3322 p a g e 5 | 10 figure 2. diabetes prevalence rates amongst the who 1981 and sahhtek 2014 – 2016 studies, by age groups and gender the diabetes prevalence differed across the six districts (p=0.10), with the northern harbour and the western districts exhibiting the highest global diabetes prevalence rates (figure 3). the southern harbour, northern harbour and gozo districts had the same newly diagnosed diabetes prevalence level of 5%. while the western, south eastern and northern districts had lower 3% of newly diagnosed diabetes prevalence level each (p=0.47) (figure 4). the western district exhibited the highest previously diagnosed diabetes prevalence level as compared to the other districts (p=0.15) (figure 4). 1% 4% 14% 32% 44% 4%4% 18% 25% 52% 0% 10% 20% 30% 40% 50% 60% 20 29 30 39 40 49 50 59 60 69 70 d ia b e te s p re v a le n ce r a te age groups (years) male population 1981 (n=79) 2016 (n=271) 2% 9% 41% 45% 3%4% 3% 7% 32% 54% 30 39 40 49 50 59 60 69 70 d ia b e e ts p re v a le n ce r a te age groups (years) female population 1981 (n=128) 2016 (n=136) cuschieri s. the diabetes epidemic in malta (original research). seejph 2020, posted: 19 february 2020. doi 10.4119/seejph-3322 p a g e 6 | 10 figure 3. global diabetes prevalence levels by district in malta 2014 – 2016 the maltese diabetes economic burden for 2017 was estimated to be €2,416 per diabetic individual per year (11). considering the global diabetes prevalence of 10.31% and the total maltese adult population for 2017 to be 430,835 people, the total annual diabetes health care expenditure was estimated to be approximately €107,316,517.82 (€97,844,351.84 – €117,621,401.68). the projected mean diabetes expenditure per individual for the year 2045 is expected to be €4,206. while, the projected global diabetes prevalence for the year 2045 is expected to be 12.47% and the total projected maltese population (2045) to be 465,440 adults. hence, the total diabetes healthcare expenditure for that year would be approximately €244,136,040. cuschieri s. the diabetes epidemic in malta (original research). seejph 2020, posted: 19 february 2020. doi 10.4119/seejph-3322 p a g e 7 | 10 figure 4. previously diagnosed and newly diagnosed prevalence rates by district a. previously diagnosed diabetes b. newly diagnosed diabetes cuschieri s. the diabetes epidemic in malta (original research). seejph 2020, posted: 19 february 2020. doi 10.4119/seejph-3322 p a g e 8 | 10 discussion diabetes mellitus type 2 is a major health and economic burden at individual, population and global levels (1,15). over 35 years (1981 to 2016), an exponential rise was observed in the diabetes prevalence rate of malta, which is consistent with the ongoing global epidemic (1). the majority of this rise is attributed to population growth and ageing (17). consequently, the economic burden of diabetes will continue to increase in the years to come, particularly among the ever-aging population. concomitantly, the global economic burden for this disease is expected to increase by 104 billion from 2017 to 2045 (11). a parallel transition is envisaged for the maltese islands, with a projected estimated increase of €136,819,523 in the economic annual burden of the disease from 2017 to 2045. even though the current and projected official idf health expenditure figures are inflated, the growing economic burden of diabetes on the health system is significant and calls for action. the geographical residing location of the maltese population may have an effect on the diabetes burden. the highest undiagnosed diabetes levels were observed within the northern harbour, southern harbour and gozo districts, even though not statistically different from the other districts, may underlie some important trends. further research is recommended with possibility of targeted preventive actions. it is well documented that undiagnosed diabetes is subject to higher healthcare usage and therefore incur a larger healthcare expenditure (1). the presence of diabetes mellitus was observed to become frequent from a relatively young age, especially for the female population in malta. considering that 1 in 10 adults in malta eventually suffer from diabetes, it is worth considering the established criteria for early screening of this condition in the population, given its frequency and impact. in spite of the fact that international guidelines suggest that routine diabetes check-ups should initiate from the age of 45 years, it is evident that for malta this should be even earlier and possibly from the age of 30 years (9). over 35 years, there has also been a shift in the gender predominance of type 2 diabetes mellitus. the current study demonstrates a male diabetes predominance contrasting with findings of the 1981 and 2010 surveys, which showed a female diabetic predominance. similarly, a female predominance was also reported by a norwegian health examination survey conducted between 1984 and 1986 with a gender shift on repeating the survey between 1995 and 1997 (18). this gender shift is in keeping with the rest of the world, where diabetes seemingly now affects more males than females (11). the male diabetes predominance has been reported to be due to an increasing obesity level, from a young age, when compared to the female population. this increase in obesity susceptibility could have been the result of a change in social factors (18). nowadays, the majority of the jobs are sedentary in contrast to the early part of the past century where jobs were more labour intensive, and travelling was done by foot or bicycle (18). furthermore, males have greater hepatic and visceral fat stores and are physiologically less insulin sensitive than females (19). therefore, one can hypothesize that males require less weight gain than females to develop t2dm, which would explain the male diabetes predominance. in fact, it was reported that biological differences between males and females are the fundamental components for the development of t2dm (20,21). however, environmental, socioeconomic and cultural factors also play a role in t2dm susceptibility and gender differences (20-22). these may be the underlying factors contributing to the high diabetes prevalence rate. it is a very intriguing fact that malta “excels” in diabetes and obesity rates when compared to neighbouring countries. malta is highly dependent on imports of foods and goods especially from sicily, which is another island in the mediterranean sea, but yet, not as diabetic prevalent as malta. this raises the question whether it is the small size of the island along with the islandness state that are contributing to such a health burden or is it the multi-cultural and environmental changes that took place in malta. this calls for further research and interventions. study limitations the response rate obtained was 47.15%. this was considered as an adequate response rate considering the invasive measurements performed. in fact, when compared to other european health examination surveys such as the czech edition of the european health examination survey (ehes) obtained a response of 31.69% (23). while the better-established shes in scotland managed a response rate of 64% from all across scotland (24). however, potential selection bias might still have occurred. responders may have been different to non-responders and it remains difficult to remove this bias altogether. the decision to conduct weighting of the data by age, gender and towns was an effort to try to maintain the representation characteristics. even though the population data was weighted, some subgroups still cuschieri s. the diabetes epidemic in malta (original research). seejph 2020, posted: 19 february 2020. doi 10.4119/seejph-3322 p a g e 9 | 10 remained with small numbers. this may have affected the power of specific subgroups statistical testing, resulting in possible type ii errors. considering that the data collection took place over a period of oneyear, seasonal variations may have had an effect on the response rate as well as on the biological measures, such as blood pressure, fbg, blood lipid levels, bmi and waist circumference. the study was a health examination survey and hence clinical diagnosis could not be established. however, being a health examination survey high-risk population for particular conditions could be identified. the study does not cover the whole population but only a subset of the adult population. general demographic data was based on the published reports from 2013. the mean diabetes expenditure per individual was based on the idf’s maltese specific cost, which was generated from multiple sources. however, this expenditure did not differentiate between newly diagnosed and previously diagnosed diabetes, as well as it was based on overestimation of diabetes prevalence rate. the cost did not take in consideration intangible costs, which is difficult to quantify. the projections for 2045 were based on current conditions with the assumption that all demographic and risk factors would continue at their current rates. conclusion type 2 diabetes is an epidemic in malta same as globally. the onset of newly diagnosed diabetes appears to affect females from the very young as the fourth decade of life irrespective of their geographical habitat. furthermore, as the years progress, so do the estimated health expenditure contributed to this disease. this puts forward the recommendation that urgent preventive action is merited to tackle diabetes at a population level targeting the young generation. such action would consequently reduce the health burden on the health care system and economy. references 1. international diabetes federation. idf diabetes atlas 9th ed. brussels, belgium; 2019. 2. savona-ventura c. mortality trends from diabetes mellitus in a high prevalence island population. int j risk saf med 2001;14:8793. 3. zammit maemple j. diabetes in malta. lancet 1965;2:1197-200. 4. katona g, aganovic i, vuskan v, skrabalo z. national diabetes programme in malta: phase i and ii final report. geneva: world health organization; 1983. 5. directorate for health information and research. the european health examination survey pilot study 2010; 2012. 6. cuschieri s, mamo j. malta: mediterranean diabetes hub – a journey through the years. malta med j 2014;26. 7. formosa c, savona-ventura c, mandy a. cultural contributors to the development of diabetes mellitus in malta. int j diabetes metab 2012;20:25-9. 8. cuschieri s, vassallo j, calleja n, pace n, mamo j. diabetes, pre-diabetes and their risk factors in malta: a study profile of national cross-sectional prevalence study. glob health epidemiol genom 2016;1. available from: https://doi.org/10.1017/gheg.2016.18 (accessed: december 10, 2019). 9. american diabetes association. classification and diagnosis of diabetes: standards of medical care in diabetes 2018. diabetes care 2018;41:13-27. 10. national statistics office. regional statistics malta. valletta; 2017. 11. international diabetes federation. idf diabetes atlas, 8th ed. brussels, belgium; 2017. 12. world health organization. global health expenditure database. 2017. 13. world health organization. projections of mortality and burden of disease 2002 to 2030. 2006. 14. zhang p, zhang x, brown j, vistisen d, sicree r, shaw j, et al. global healthcare expenditure on diabetes for 2010 and 2030. diabetes res clin pract 2010;87:293-301. available from: https://doi.org/10.1016/j.diabres.2010.01.02 6 (accessed: december 10, 2019). 15. cuschieri s, vassallo j, calleja n, pace n, abela j, ali ba, et al. the diabesity health economic crisis-the size of the crisis in a european island state following a crosssectional study. arch public health 2016;74:52. available from: https://doi.org/10.1186/s13690-016-0164-6 (accessed: december 10, 2019). 16. eurostat european commission. eurostat country projections 2016. avilable from: http://ec.europa.eu/eurostat (accessed: may 23, 2019). https://doi.org/10.1017/gheg.2016.18 https://doi.org/10.1016/j.diabres.2010.01.026 https://doi.org/10.1016/j.diabres.2010.01.026 https://doi.org/10.1186/s13690-016-0164-6 cuschieri s. the diabetes epidemic in malta (original research). seejph 2020, posted: 19 february 2020. doi 10.4119/seejph-3322 p a g e 10 | 10 17. ncd risk factor collaboration (ncdrisc). worldwide trends in diabetes since 1980: a pooled analysis of 751 populationbased studies with 4.4 million participants. lancet 2016;387:1513-30. available from: https://doi.org/10.1016/s01406736(16)00618-8 (accessed: december 10, 2019). 18. gale eam, gillespie km. diabetes and gender. diabetologia 2001;44:3-15. available from: https://doi.org/10.1007/s001250051573 (accessed: december 10, 2019). 19. geer eb, shen w. gender differences in insulin resistance, body composition, and energy balance. gend med 2009;6:60-75. available from: https://doi.org/10.1016/j.genm.2009.02.002 (accessed: december 10, 2019). 20. kautzky-willer a, harreiter j, pacini g. sex and gender differences in risk, pathophysiology and complications of type 2 diabetes mellitus. endocr rev 2016;37:278-316. available from: https://doi.org/10.1210/er.2015-1137 (accessed: december 10, 2019). 21. karastergiou k, smith sr, greenberg as, fried sk. sex differences in human adipose tissues – the biology of pear shape. biol sex differ 2012;3:13. available from: https://doi.org/10.1186/2042-6410-3-13 (accessed: december 10, 2019). 22. krag mø, hasselbalch l, siersma v, nielsen abs, reventlow s, malterud k, et al. the impact of gender on the long-term morbidity and mortality of patients with type 2 diabetes receiving structured personal care: a 13 year follow-up study. diabetologia 2016;59:275-85. available from: https://doi.org/10.1007/s00125-0153804-4 (accessed: december 10, 2019). 23. čapková n, lustigová m, kratěnová j, žejglicová k, kubínová r. selected population health indicators in the czech republic – ehes 2014. hygiena 2017;62:35-7. available from: https://doi.org/10.21101/hygiena.a1511 (accessed: december 10, 2019). 24. scottish government. the scottish health survey. edinburgh; 2016. ______________________________________________________ © 2020 cuschieri; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://doi.org/10.1016/s0140-6736(16)00618-8 https://doi.org/10.1016/s0140-6736(16)00618-8 https://doi.org/10.1007/s001250051573 https://doi.org/10.1016/j.genm.2009.02.002 https://doi.org/10.1210/er.2015-1137 https://doi.org/10.1186/2042-6410-3-13 https://doi.org/10.1007/s00125-015-3804-4 https://doi.org/10.1007/s00125-015-3804-4 https://doi.org/10.21101/hygiena.a1511 kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 1 original research efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit ermira kola1, ermela çelaj1, iliriana bakalli1, robert lluka1, gjeorgjina kuli-lito2, sashenka sallabanda1 1 pediatric intensive care unit, university hospital center “mother teresa”, tirana, albania; 2 department of pediatric infectious diseases, university hospital center “mother teresa”, tirana, albania. corresponding author: dr. ermira kola, university hospital center “mother teresa”; address: rr. “dibrës”, no. 371, tirana, albania; telephone: +355672059975; email: ermirakola@gmail.com. kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 2 abstract aim: additional treatments for sepsis to be administered alongside the standard therapy recommended by the surviving sepsis campaign have recently undergone evaluation. due to its anti-bacterial, anti-inflammatory and immunomodulatory properties, intravenous polyvalent immunoglobulin m (igm)–enriched immunoglobulins (igm preparation) has been investigated as one of these potentially valid adjunctive therapies. the aim of this trial was to assess the efficacy of an igm preparation as adjuvant therapy in the treatment of pediatric patients with sepsis. methods: in our study, 78 septic patients admitted to a pediatric intensive care unit (picu) at the university hospital center “mother teresa” in tirana, albania, were randomized into two groups (intervention and control). all patients were treated according to standard picu sepsis guidelines. additionally, patients in the intervention group received the igm preparation pentaglobin® while patients in the control group received standard sepsis therapy, but no immunoglobulin administration. results: the survival rate was higher in the intervention group (87%, n=34) than in the control group (64%, n=25), and this difference was statistically significant (p=0.03). length of stay (los) was also significantly shorter in the intervention group. conclusion: in this study conducted in albania, use of an igm preparation, in addition to standard sepsis therapy, led to a significant increase in the survival rate as well as a significant reduction in los compared with placebo, when administered in picu patients with sepsis. keywords: bacterial infections, igm preparation, immunoglobulin, immunotherapy, pentaglobin®, sepsis. kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 3 introduction sepsis is a major cause of morbidity and mortality in critically ill pediatric patients (1,2). about 25% of all picu admissions are due to life–threatening infections in pediatric patients (2). although numerous advances in the management of critically ill children with severe infections have occurred in recent years, the mortality associated with severe sepsis and septic shock remains unacceptably high, with a rate between 20% to 56% (1,3-10). because of its broad and potent activity against bacteria and their exotoxins as well as against the excessively activated pro-inflammatory host response, an igm preparation was investigated as an adjunctive treatment for patients with severe bacterial infections (11-13). this igm preparation is the only approved intravenous immunoglobulin for treating severe bacterial infections and contains antibacterial, anti-inflammatory and immunomodulatory antibodies from the immunoglobulin classes igm, igg, and iga. in this respect, the preparation differs from all other standard intravenous immunoglobulin preparations, which contain almost only igg (3,14,15). to date, there are no studies conducted in albania assessing the efficacy of igm preparations in pediatric wards. in this framework, the objective of this trial was to assess the efficacy of an igm preparation as adjuvant therapy in the treatment of pediatric patients with sepsis in albania. we hypothesized that administration of the igm preparation in combination with standard-of-care antibiotics would increase the overall survival rate in septic patients admitted to picu. methods this was a prospective, double-blinded, randomized, placebo-controlled trial conducted in the picu of the university hospital center “mother teresa” in tirana, albania, between january 2009 and december 2010. the ethics committee of the university of tirana approved the study protocol and a written informed consent was obtained from the parents or guardians of all of the patients. the study was conducted in accordance with the declaration of helsinki and followed good clinical practice guidelines and national regulations. the study was registered in a clinical trial registry. to increase patient homogeneity and to strengthen internal validity, strict diagnostic criteria were applied. proven sepsis was defined according to 2001 accp/sccm sepsis criteria (16). patients with sepsis (sirs, sepsis, severe sepsis, septic shock) documented infection and dysfunction of an organ or hypotension were enrolled in the study. patients fulfilling one or more of the following criteria were not included in the study: severe immunosuppression, irreversible endstage damage of vital organs, a glasgow coma score of 3/15, comorbidities and/or contraindications to any of the study treatments. one hundred and three patients were assessed for eligibility in the study. eighteen children did not meet the inclusion criteria, whereas seven parents declined study participation of their children. intervention the study utilized a parallel-group design whereby patients were stratified by baseline characteristics such as age and gender and also according to diagnosis and severity of disease. patients were randomly assigned in a 1:1 ratio to the intervention or control group. treatment assignment was randomly generated by computer in stratified permuted blocks of two. the intervention group received the igm preparation while the control group did not receive any immunoglobulin administration (figure 1). fluid administration was protocolized. all patients received isotonic intravenous fluid bolus kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 4 20-40ml/kg in 1 hr. repeated boluses were administered depending on clinical parameters, including heart rate, capillary refill, blood pressure, urine output and level of consciousness. a researcher sealed envelopes labeled only with the patient number and containing the respective study medication. corresponding envelopes were opened by the researcher only after the enrolled participants had completed baseline assessments and were about to be allocated to a treatment group. other investigators, staff, parents of the children, the nurse who administered the treatment and endpoint assessors were all blinded to treatment assignment. study protocol all patients received standard sepsis therapy which comprised intravenous antibiotics. patients in the intervention group received the igm preparation pentaglobin® intravenously. administration of the igm preparation was started on the day of sepsis diagnosis at a volume of 5 ml/kg body weight per day and was infused over six hours for three consecutive days. patients in the control group received standard sepsis therapy, but no immunoglobulin administration. a detailed clinical history was taken from all cases who were also subjected to physical examination. demographic data (age and gender), body weight, height, [based on which the body mass index (bmi) was calculated] diagnosis at picu admission, duration of stay in the picu and outcome at discharge were recorded for each patient (table 1). study treatment was administered within eight hours after randomization. patients were observed throughout their stay in picu. compliance, laboratory parameters, vital signs, hemodynamic data laboratory parameters and organ dysfunction were monitored on a daily basis. protocol violations were defined before the start of the study. the study endpoint was death in pciu. statistical analysis based on literature review and in our previous experience, the expected mortality rate in the control group was anticipated as 60%, whereas the magnitude of the expected treatment effect was set at 40%. type i error was set as α=0.05 in a two-tailed test and type ii error as β=0.05. the 95% confidence interval (ci) for the difference between proportions was calculated as follows: (d) = d 0.236 to d + 0.236. after adjusting for a 5% drop-out rate, the sample size was estimated at 39 individuals in each group. the primary efficacy analysis was performed according to intention-to treat (itt) principles, rather than as an explanatory analysis. all randomized patients were included in the itt population and the per-protocol population included only patients who completed the treatment originally allocated in both groups. normal distribution of continuous variables was tested with the kolmogorov-smirnov test. mann-whitney test was used to compare age, height and body weight of patients between the two groups. chi-square test was used to compare gender differences and laboratory values in each treatment group and the independent sample t-test was used to compare the length of stay (los) in the picu as well as the bmi. mortality rates in the intervention and control group were compared with the chi-square test. the difference in survival rates between groups was assessed using the kaplan-meier method and the log-rank test. the censoring time for the survival analysis was the picu stay duration. all statistical analyses were performed with spss, version 16.0. kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 5 enrollment assessed for eligibility (n=103) excluded (n= 25) did not meet inclusion criteria (n=18) declined to participate (n=7) randomized (n=78) allocated to intervention (n= 39) received igm preparation (n= 38) did not receive igm preparation (died) (n= 1) allocation allocated to control (n=39) received placebo (n=38) did not receive placebo (died) (n=1) follow-up lost to follow-up (n= 0) discontinued treatment (n=0) lost to follow-up (n= 0) discontinued treatment (n=0) analysis included in itt analysis (n=39) excluded from analysis (n=0) included in itt analysis (n=39) excluded from analysis (n=0) figure 1. patients included in the study kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 6 results a total of 78 consecutive patients (aged from one month to thirteen years) with proven sepsis were included in the study after adjusting for drop-outs and non-evaluable patients. there were no statistical differences between treatment groups in baseline characteristics at picu admission (table 1). one patient in each group died before receiving the full course of therapy. a four-month old patient died on the first day of treatment in the intervention group and a sixmonth old patient died on the second day of treatment in the control group. there were no major or minor violations of the protocol. no withdrawals, patient exclusions and or losses to follow-up occurred in either treatment group. mean treatment duration in both groups was three days. no other concomitant treatments were given in addition to the study treatment in both groups. table 1. baseline characteristics in the itt population variable intervention group (n=39) control group (n=39) p age (years) 2.1 (3.1) (1.07 – 3.08)* 1.8 (2.7) (0.87 – 2.66) 0.6 picu stay (days) 5.1 (3.1) (4.08 – 6.06)* 7.1 (2.4) (6.35-7.90) <0.01 males (n, %) 25 (64.1) (48.4 – 77.2)† 29 (74.4) (58.9 – 85.4) 0.4 body weight (kg) 12.9 (8.1) (10.4 – 15.6)* 12.3 (6.9) (10.0 – 14.5) 0.7 height (cm) 84.7 (24.8) (76.7 – 92.8)* 83.0 (22.6) (69.9 – 87.8) 0.8 bmi 16.7 (0.92) (16.4 – 17.0)* 16.8 (24.8) (16.5 – 17.1) 0.8 * data reported as mean (sd) (95%ci). † number (%) (95%ci). ----------------------------------------- intention to treat analysis (itt) overall, of the 78 patients included in this study, 59 (75.6%) individuals survived. however, the survival rate was higher in the intervention group (87.2%, n=34) than in the control group (64.1%, n=25), with the difference of 23.1% being statistically significant (p=0.03). the odds ratio (or) for survival was 3.8 (95%ci=1.2-11.9). a kaplan-meier survival analysis also showed a statistically significant difference in the survival rate in the intervention group (log-rank=4.0, p=0.04) [figure 2]. furthermore, los in the picu was significantly shorter for patients in the intervention group, compared to the control group (5.1±3.1 days vs 7.1±2.4 days; p<0.01). twelve (30.8%) children in the intervention group and nine (23.1%) in the control group were mechanically ventilated without a significant difference between them (p=0.6). cardiac, pulmonary, renal, cns (central nervous system) and adrenal dysfunctions were involved, as well as glycemic control disturbances. mods (multiple organ dysfunction) in our study occurred in 8 (10.3 %) patients. we used hydrocortisone in 18 (23.1%) cases with catecholamine resistance and suspected or proven adrenal insufficiency (total cortisol concentration <18mg/dl). kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 7 100 90 80 70 60 group control 50 pentaglobin 40 30 20 10 0 2 4 6 8 10 12 14 icu days figure 2. kaplan-meier survival analysis inotropes and vasopressors were administered in 26 (33.3%) patients. there was no surgical procedure involved during the study period. the causes of death were renal failure, brain damage, hepatic failure, metabolic derangements, diffuse intravascular coagulation (dic), ventilator-associated pneumonia (vap). no adverse events occurred during the study period. additionally, no fatalities occurred after discharge from the hospital. in our study we focused on anaphylactic reaction or anaphylactic shock to define an adverse event. adverse reactions described in the enclosed leaflet of pentaglobine did not occur. blood samples were collected daily from each treatment group for the evaluation of hematological and laboratory parameters (table 2). there were no statistically significant differences in the total wbc count, platelets, base excess in blood, and c-reactive protein levels between the two groups at baseline. after treatment, the intervention group had statistically significant improvements in two inflammatory markers. proportions of patients with c-reactive protein levels and total leucocyte and neutrophil counts <10000 were significantly higher in the intervention group, compared with controls (p=0.04 and p<0.01, respectively). there were no significant differences in changes in platelet counts and base excess in blood between treatment groups. per-protocol analysis in total, 59 (77.6%) of the 76 patients who completed treatment survived. the survival rate was higher in the intervention group (89.5%) than in the control group (65.8%), with the difference being statistically significant (p=0.03). a kaplan-meier survival analysis also demonstrated a statistically significant difference in the survival rate for the intervention group, with a hazard ratio of 3.1 (95%ci=1.1-8.6). kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 8 table 2. patients with abnormal laboratory values before and after treatment laboratory parameter intervention group (n=39) n (%) of patients control group (n=39) n (%) of patients p baseline wbc <10000 24/39 (61.5%) 25/39 (64.1%) ns* platelets <40000 10/39 (25.7%) 9/39 (23.1%) ns base excess>8 19/39 (48.7%) 20/39 (51.2%) ns c-reactive protein >n 29/39 (74.3%) 29/39 (74.3%) ns after treatment wbc <10000 10/39 (25.6%) 18/39 (46.2%) <0.01 platelets <40000 6/39 (15.4%) 8/39 (20.5%) ns base excess>8 11/39 (28.2%) 20/39 (51.2%) ns c-reactive protein >n 12/39 (30.8%) 22/39 (56.4%) 0.04 *non-significant. -------------------------------- discussion treatment of sepsis is complicated and typically requires a multidisciplinary approach. in recent years, the immunotherapeutic approach has been extensively studied but the results of both experimental and clinical investigations have been puzzling. the administration of monoclonal antibodies directed against specific sepsis mediators has produced disappointing results, whereas the administration of polyvalent immunoglobulins has been associated with better outcomes across various subgroups of patients (1,4,13). recently, a number of studies have indicated that an igm preparation is associated with reduced morbidity and an increased survival rate in patients with sepsis, severe sepsis or septic shock (2,14,17). in children, however, all the trials have been relatively small and the evidence is insufficient to support a robust conclusion of the benefit. in the present study, administration of an adjunctive igm preparation in septic pediatric patients resulted in a statistically significant increase in survival rate of 23.1% in the intervention group, compared to control group. another interesting result was the significantly shorter mean los in the picu for patients receiving the igm preparation, compared with controls. a similar outcome in los was shown in a study by el nawawy et al. in which the mean los in the intervention group who received the adjuvant igm preparation was significantly shorter than in the control group, with durations of six and nine days, respectively (2). furthermore, a study published fairly recently showed that early administration of the igm preparation is crucial. delay in administration significantly increased the absolute risk of death by 2.8% every 24 hours. therefore, in this study, the igm preparation was administered additionally to antibiotics on the day of sepsis diagnosis and study inclusion (18,19). in a meta-analysis comparing two types of polyvalent immunoglobulin preparations, an igm preparation was found to be superior over a standard immunoglobulin preparation which contains mostly igg (20). statistically significant increases were shown in the survival rates of kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 9 adult and neonatal patients with sepsis and septic shock when treated with the igm preparation in addition to standard sepsis therapy (11). the pooled results showed a relative reduction in mortality of 34% in adult sepsis patients who received the adjunctive igm preparation (relative risk: 0.66; p=0.0009). the standard adjunctive immunoglobulin preparation showed a relative reduction in mortality of only 15% (relative risk: 0.85; p=0.04). in neonates with sepsis, a relative reduction in mortality of 50% was reported for the adjunctive igm preparation (relative risk: 0.50; p=0.0003). the standard adjunctive immunoglobulin preparation resulted in a relative reduction in mortality of only 37% (relative risk: 0.63; p=0.03) (11,14,21,22). a head-to-head clinical trial in neonates with sepsis showed similar results. haque et al. (20) conducted a clinical trial with these two different polyvalent immunoglobulin preparations (igm or standard immunoglobulin preparations). a statistically significant increase in the survival rate in the group treated with the igm preparation was shown when compared with the control group treated with the standard immunoglobulin preparation where no increase in survival rate was observed (8,9). moreover, other clinical studies in neonates and children have shown increases in survival rates due to administration of an adjunctive igm preparation of between 28%-56% (11,17,22,23) – further demonstrating a survival benefit from this treatment. efficacy of the igm preparation in patients of all ages is thought to be due to higher antibody titers against a broader variety of bacterial pathogens and their toxic products compared with standard immunoglobulin preparations (7,10,24). additionally, the immune system initially responds with the production of igm as the first line of defense against bacterial pathogens and hence igm antibody titers increase before igg antibody production starts (23,25). moreover, igm is more efficient in activating the complement cascade and leads to a more rapid and specific antibody response, compared with igg (15,25). with respect to neonatal sepsis, the efficacy of an igm preparation is possibly due to the relatively low igm levels in neonates after birth. during pregnancy, only a low level of igm is transferred via the placenta to the fetus and endogenous igm production in neonates starts only gradually. conclusion the use of an adjuvant igm preparation pentaglobin® in the treatment of pediatric sepsis patients resulted in an increase in the survival rate, a reduction in the los and an improvement in infection severity, all of which were found to be statistically significant in this study conducted in albania. conflicts of interest: none declared. references 1. goldstein b, giroir b, randolph a. international pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. pediatr crit care med 2005;6:2-8. 2. el-nawawy a, el-kinany h, el-sayed mh, boshra n. intravenous polyclonal immunoglobulin administration to sepsis syndrome patients: a prospective study in a pediatric intensive care unit. j trop pediatr 2005;51:271-8. 3. bayry j, misra n, latry v, et al. mechanisms of action of intravenous immunoglobulin in autoimmune and inflammatory diseases. transfus clin biol 2003;10:165-9. 4. martin gs, mannino dm, eaton s, moss m. the epidemiology of sepsis in the united states from 1979 through 2000. n engl j med 2003;348:1546-54. http://www.ncbi.nlm.nih.gov/pubmed/12798851 http://www.ncbi.nlm.nih.gov/pubmed/12798851 kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 10 5. cavazzuti i, girardis m. early use of immunoglobulin in septic shock. infection. (supplement ii). 5th international congress “sepsis and multiorgan dysfunction” vol 39; 2011. 6. khalid n. haque use of intravenous immunoglobulin in the treatment of neonatal sepsis: a pragmatic review and analysis. j med sciences 2010;3:160-7. 7. wilkinson jd, pollack mm, glass nl, kanter rk, katz rw, steinhart cm. mortality associated with multiple organ system failure and sepsis in pediatric intensive care unit. j pediatr 1987;111:324-8. 8. gašparović v, gornik i, ivanović d. sepsis syndrome in croatian intensive care units. croat med j 2006;47:404-9. 9. becker ju, theodosis c, jacob st, wira cr, groce ne. surviving sepsis in lowincome and middle-income countries: new directions for care and research. lancet infect dis 2009;9:577-82. 10. kissoon n, carcillo ja, espinosa v, argen a, devictor d, madden m, singhi s, van der voort e, jos latour j. world federation of pediatric intensive care and critical care societies: global sepsis initiative. pediatr crit care med 2011;12:494-503. 11. kreymann kg, de heer g, nierhaus a, kluge s. use of polyclonal immunoglobulins as adjunctive therapy for sepsis or septic shock. crit care med 2007;35:2677-85. 12. pildal j, gotzsche pc. polyclonal immunoglobulin for treatment of bacterial sepsis: a systematic review. clin infect dis 2004;39:38-46. 13. haque kn, remo c, bahakim h. comparison of two types of intravenous immunoglobulins in the treatment of neonatal sepsis. clin exp immunol 1995;101:32833. 14. rodríguez a, rello j, neira j, maskin b, ceraso d, vasta l, palizas f. effects of highdose of intravenous immunoglobulin and antibiotics on survival for severe sepsis undergoing surgery. shock 2005;23:298-304. 15. wang je, dahle mk, mcdonald m, foster sj, aasen ao, thiemermann c. peptidoglycan and lipoteichoic acid in gram-positive bacterial sepsis: receptors, signal transduction, biological effects, and synergism. shock 2003;20:402-14. 16. levy mm, fink mp, marshall jc, abraham e, angus d, cook d, cohen j, opal sm, vincent jl, ramsay g. 2001 sccm/esicm/accp/ats/sis international sepsis definitions conference. intensive care med 2003:29;530-8. 17. karatzas s, boutzouka e, venetsanou k, myrianthefs p, fildisis g, baltopoulos g. the effects of igm-enriched immunoglobulin preparations in patients with severe sepsis: another point of view. crit care 2002;6:543-4. 18. ehrenstein mr, notley ca. the importance of natural igm: scavenger, protector and regulator. nature reviews 2010;10:778-86. 19. trautmann m, held tk, susa m, karajan ma, wulf a, cross as, marre r. bacterial lipopolysaccaride (lps)-specific antibodes in commercial human immunoglobulin preparations: superior antibody content of an igm-enriched product. clin exp immunol 1998;111:81-90. 20. haque kn, zaidi mh, bahakim h. igm-enriched intravenous immunoglobulin therapy in neonatal sepsis. am j dis child 1988;142:1293-6. 21. alejandria mm, lansang ma, dans lf, mantaring jbv. intravenous immunoglobulin for treating sepsis and septic shock. cochrane database syst rev 2002:1. 22. nierhous a. immuno pathophysiology in sepsis the care for immunoglobulins. sepsis symposium, budapest 20-21 may, 2011. kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 11 23. norrby-teglund a, haque kn, hammarstrom l.a. intravenous polyclonal igmenriched immunoglobulin therapy in sepsis: a review of clinical efficacy in relation to microbiological aetiology and severity of sepsis. j intern med 2006;260:509-16. 24. berlot g, vassallo mc, busetto n, bianchi m, zornada f, rosato i, tomasini a. relationship between the timing of administration of igm and iga enriched immunoglobulins in patients with severe sepsis and septic shock and the outcome: a retrospective analysis. j crit care 2012;27:167-71. 25. olas k, butterweck h, teschner w, schwarz h, reipert b. immunomodulatory properties of human serum immunoglobulin a: anti-inflammatory and proinflammatory activities in human monocytes and peripheral blood mononuclear cells. clin exp immunol 2005;140:478–90. ___________________________________________________________ © 2014 kola et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. hoti a, gashi e, kraja f, sallaku a. association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania (original research). seejph 2018, posted: 01 january 2018. doi 10.4119/unibi/seejph-2018-178 1 original research association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania adrian hoti1, edmond gashi1, fationa kraja1, agim sallaku1 1 oncology service, university hospital centre “mother teresa”, tirana, albania. corresponding author: dr. adrian hoti address: rr. “dibres”, no. 370, tirana, albania; telephone: +355672024078; e-mail: dr.ahoti@yahoo.com mailto:dr.ahoti@yahoo.com� hoti a, gashi e, kraja f, sallaku a. association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania (original research). seejph 2018, posted: 01 january 2018. doi 10.4119/unibi/seejph-2018-178 2 abstract aim: the aim of our study was to assess the association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca15-3) with socio-demographic factors and metastases site in women diagnosed with metastatic breast cancer in post-communist albania. methods: a case-series study was carried out during the period january 2010 – september 2017 including 110 female patients diagnosed with breast cancer with metastases at the oncology service of the university hospital centre “mother teresa” in tirana, the albanian capital. of these, 57 (51.8%) patients had evidence of hepatic metastases, whereas the reaming 53 (48.2%) patients had metastases in the bones and/or in the lungs. cea and ca153 were measured at the time of diagnosis for all study participants. in addition, information on socio-demographic factors was collected. general linear model was used to assess the relationship of cea and ca15-3 with covariates. results: there was evidence of a significant correlation between cea and ca15-3 levels (spearman’s rho=0.59, p<0.001). upon simultaneous adjustment for all covariates, mean values of cea and ca15-3 were significantly higher in patients with metastases in the bones and/or in the lungs compared with their counterparts with metastases in the liver. also, ca15-3 levels were significantly higher in younger patients compared with their older counterparts. conclusion: this study provides valuable evidence on selected correlates of cea and ca153 in albanian female patients diagnosed with metastatic breast cancer. oncologists and other health professionals in albania, as well as decision-makers and policymakers should be aware of the burden and risk factors of breast cancer among women in this transitional society. keywords: albania, bone metastases, breast cancer, cancer antigen 15-3 (ca15-3), carcinoembryonic antigen (cea), hepatic metastases, lung metastases, oncology, tumours, tumour markers. conflicts of interest: none. hoti a, gashi e, kraja f, sallaku a. association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania (original research). seejph 2018, posted: 01 january 2018. doi 10.4119/unibi/seejph-2018-178 3 introduction breast cancer is a serious issue and an important public health problem in all countries worldwide. it has been convincingly documented that breast cancer leads to death of more women than any other type of malignant tumours (1). a recent systematic review reported that, at a global scale, breast cancer is the most frequently diagnosed cancer and the leading cause of cancer mortality among women (1). it has been reported that the incidence of breast cancer increases by 5% each year in lowand middle-income countries representing an increasingly urgent public health problem in these countries, similar to the situation observed in higher income countries (1-3). many studies on this matter have addressed several risk characteristics (etiological factors) for breast cancer including reproductive characteristics, growth, obesity, and postmenopausal hormones (1,4). nonetheless, these putative etiological factors are responsible only for a small proportion of breast cancer risk (1,4). the prognosis of breast cancer depends on a wide range of factors and circumstances including tumour biology, histology, peritumoural vascular invasion, tumour size, lymph node involvement, receptor status and presence of distant metastasis (5). furthermore, it has been indicated that the skeleton is the most frequent site of metastasis in breast cancer patients (5). cancer antigen 15-3 (ca15-3) and, to a lesser degree, carcinoembryonic antigen (cea) are the tumour markers most strongly related to recurrence in asymptomatic breast cancer patients (6,7). yet, these antigens lack specificity, and the american society of clinical oncology (asco) does not recommend their use in routine follow-up of patients treated for breast cancer (8). in addition, it has been argued that an increase in these tumour markers does not predict the number of involved sites or their localization (9). according to the global burden of disease (gbd) study, the mortality rate from breast cancer in albania was estimated at 15.2 deaths per 100,000 females in the year 2016 (10). on the other hand, for the same year, the disability-adjusted life years (dalys) for breast cancer were estimated at about 441 per 100,000 (10). according to the gbd estimates, there has been a steady increase in the mortality rate and the burden of breast cancer in albanian women for the period 1990-2010, which was followed by a plateau during the past few years (10). however, the validity of such estimates is questionable and open to criticism. on the other hand, according to the most recent world health organization (who) report released in 2017 (11), the estimated breast cancer incidence in females in albania is 30.8 per 100,000 population. the who european region average is 106.7 per 100,000 population, which is substantially higher than in albania. as a matter of fact, the incidence rate of breast cancer in albanian females is lower than in all countries of the south eastern european region. the highest incidence rate in this region is evident in slovenia (125.0 per 100,000 population) followed by croatia (116.1 per 100,000 population) and montenegro (114.9 per 100,000 population) (11). in any case, to date, the available scientific evidence about the burden of breast cancer in the general female population in albania is scarce. likewise, there are no scientific reports about the main risk factors or determinants related to breast cancer occurrence among albanian females during the transition period in the past two decades. in this framework, the aim of this study was to assess the association between cea and ca15-3 with socio-demographic factors and metastases site in women diagnosed with metastatic breast cancer in post-communist albania, a country characterized by a particularly rapid transition towards a market-oriented economy which is associated with tremendous changes also in lifestyle patterns of the adult population. hoti a, gashi e, kraja f, sallaku a. association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania (original research). seejph 2018, posted: 01 january 2018. doi 10.4119/unibi/seejph-2018-178 4 methods a case-series study was carried out in tirana during the period january 2010 – september 2017. this study involved 110 female patients diagnosed with breast cancer with metastases at the oncology service of the university hospital centre “mother teresa” in tirana, the albanian capital city. the different sites of metastases were dichotomized in the current analysis into: liver metastases vs. bones and/or lungs metastases. cea and ca15-3 levels were measured for each study participant at the time of diagnosis. in addition, a structured questionnaire was administered to all the female patients in order to collect information on socio-demographic characteristics including age (which in the analysis was dichotomized into: ≤50 years vs. ≥51 years) , district of current residence (dichotomized into: tirana vs. other districts of albania), place of residence (urban areas vs. rural areas), educational attainment (trichotomised in the analysis into: 0-8 years, 9-12 years and ≥13 years of formal schooling), economic level (also trichotomised into: low, middle, high) and employment status (nominal variable: employed, unemployed, retired). spearman’s correlation coefficients were used to assess the association between cea, ca153, age, and educational attainment (introduced as the number of years of formal schooling). on the other hand, general linear model was employed to assess the associations of cea and ca15-3 with socio-demographic characteristic and metastases site of female patients diagnosed with metastatic breast cancer. from a methodological point of view, the general linear model procedure provides regression analysis and analysis of variance for one dependent variable by one or more factors (referred to as variables). using the general linear model procedures one can test the null hypothesis about the effects of other variables on the means of various groupings of a single dependent variable. in the current analysis, this feature of the general linear model was used in order to compare the mean values of cea and ca15-3 by different categories of socio-demographic factors (age-group: ≤50 years vs. ≥51 years; district of residence: tirana vs. other districts of albania; place of residence: urban vs. rural areas; educational level: 0-8, 9-12, ≥13 years; economic lev el: low, middle, high; employment status: employed, unemployed, retired) and metastases site (liver vs. bones and/or lungs). initially, age-adjusted mean values and their respective 95% confidence intervals (95%cis) were calculated. subsequently, multivariable-adjusted (simultaneous adjustment for: age-group, district of residence, place of residence, educational attainment, income level, employment status and metastases site) mean values and their respective 95%cis were calculated. spss (statistical package for social sciences, version 17.0), was used for all the statistical analyses. results overall, mean age of the study population was 57.1±11.9 years (median age: 57.5 years; interquartile range: 48.0-66.0 years; age range: 26-83 years). of 110 women included in this study, 57 (51.8%) patients had evidence of hepatic metastases, whereas the reaming 53 (48.2%) patients had metastases in the bones and/or in the lungs. on the whole, 38% of participants had a low educational level; about 32% reported a low economic level; and 36% of participants were unemployed (data not shown in the tables). table 1 presents the distribution of cea and ca15-3 levels in the sample of female patients with breast cancer included in this study. hoti a, gashi e, kraja f, sallaku a. association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania (original research). seejph 2018, posted: 01 january 2018. doi 10.4119/unibi/seejph-2018-178 5 mean (sd) value of cea was 19.1±23.9 ng/ml (median value: 12.9 ng/ml; interquartile range: 4.7-22.1 ng/ml). on the other hand, mean (sd) value of ca15-3 was 167.2±205.2 u/ml (median value: 94.7 u/ml; interquartile range: 27.5-219.5 u/ml). of note, both cea and ca15-3 values displayed a highly skewed distribution as evidenced in table 1 by their respective measures of dispersion (that is standard deviation). table 1. distribution of cea and ca15-3 in the study population parameter cea (ng/ml) ca15-3 (u/ml) mean (±sd) 19.1±23.9 167.2±205.2 median (iqr) 12.9 (4.7-22.1) 94.7 (27.5-219.5) range 1.7-133.2 6.1-1026.0 there was evidence of a significant correlation between cea and ca15-3 levels (spearman’s rho=0.59, p<0.001) [table 2]. furthermore, there was evidence of a significant inverse linear association between ca15-3 and age (rho= 0.43, p<0.001), but a positive relationship with education which was only borderline statistically significant (rho=0.42, p=0.1). interestingly, there was a significant inverse correlation between age and educational attainment (rho= -0.52, p=0.02). table 2. correlational matrix of cea, ca15-3 and socio-demographic characteristics variable cea ca15-3 age ca15-3 0.59 (<0.001)* age -0.04 (0.704) -0.43 (<0.001) years of formal schooling 0.36 (0.109) 0.42 (0.097) -0.51 (0.023) * spearman’s correlation coefficients and their respective p-values (in parentheses). table 3 presents the association between cea and socio-demographic characteristics and metastases site. in age-adjusted general linear models, there was evidence of a borderline statistically significant association of cea with age-group (mean cea level was higher among younger participants) and district of residence (mean cea level was lower among tirana residents). furthermore, mean cea level was higher among the low-educated female patients compared with their high-educated counterparts (overall p=0.06). in particular, mean cea level was considerably higher in patients with metastases in the bones and/or lungs compared with those with metastases in the liver (27.2 ng/ml vs. 13.5 ng/ml, respectively; p<0.01). upon simultaneous adjustment for all covariates, there was no evidence of significant associations of cea with any socio-demographic factors, whereas the strong and significant relationship with metastases site persisted (mean cea level was 24.5 ng/ml in patients with bones and/or lungs metastases compared with 11.9 ng/ml in those with liver metastases; p<0.01). hoti a, gashi e, kraja f, sallaku a. association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania (original research). seejph 2018, posted: 01 january 2018. doi 10.4119/unibi/seejph-2018-178 6 table 3. association of cea with socio-demographic characteristics and metastases site; ageadjusted and multivariable-adjusted mean values from the general linear model * this model was simultaneously adjusted for age-group (≤50 years vs. ≥51 years), district of residence (tirana vs. other districts of albania), place of residence (urban vs. rural areas), educational level (0-8, 9-12, ≥13 years), economic level (low, middle, high), employment status (employed, unemployed, retired) and metastases site (liver vs. bones and/or lungs). † overall p-values and degrees of freedom (in parentheses). table 4 presents the association between ca15-3 and socio-demographic characteristics and metastases site. in age-adjusted general linear models, there was an inverse and statistically significant association of ca15-3 with the age and educational attainment of study participants (mean cea level was higher among the younger and the low-educated individuals). in addition, mean ca15-3 level was significantly higher in patients with metastases in the bones and/or lungs compared with those with metastases in the liver (235.7 u/ml vs. 150.4 u/ml, respectively; p<0.01). in multivariable-adjusted general linear models, there was evidence of a significant association of ca15-3 with the age-group (mean level was 246.6 u/ml in younger patients compared with 84.9 u/ml of their older counterparts; p<0.01) and metastases site (mean level was 203.6 u/ml in patients with bones and/or lungs metastases compared with 128.0 u/ml in those with liver metastases; p=0.04) [table 4]. variable age-adjusted multivariable-adjusted* mean 95% ci p mean 95% ci p age-group: ≤50 years ≥51 years 24.3 16.0 17.0-31.6 10.4-21.7 0.081 20.7 15.7 10.9-30.4 8.8-22.6 0.401 district of residence: tirana other districts 18.7 21.2 11.3-26.0 15.2-27.1 0.072 15.6 20.8 7.3-23.8 13.8-27.8 0.267 place of residence: urban areas rural areas 17.9 23.8 12.1-23.7 16.5-31.1 0.206 17.4 18.9 10.3-24.5 10.5-27.4 0.759 education: 0-8 years 9-12 years ≥13 years 26.4 18.3 11.2 19.1-33.7 11.7-24.9 0.3-22.2 0.056 (2)† 0.068 0.615 24.6 18.1 11.9 15.2-33.9 5.0-31.3 0.5-23.3 0.247 (2) 0.268 0.877 economic level: low middle high 24.7 18.1 16.2 16.8-32.7 12.0-24.3 2.8-29.6 0.363 (2) 0.628 0.991 18.8 17.8 18.0 8.4-29.2 8.1-27.5 2.6-33.3 0.991 (2) 0.994 0.997 employment status: employed unemployed retired 20.9 21.7 16.8 12.7-29.1 14.1-29.3 7.0-26.7 0.716 (2) 0.913 0.805 21.3 18.8 14.4 12.9-29.7 10.4-27.3 3.4-25.4 0.607 (2) 0.691 0.846 site of metastases: liver bones and/or lungs 13.5 27.2 7.4-19.6 20.9-33.5 0.002 11.9 24.5 4.3-19.6 16.9-32.0 0.008 hoti a, gashi e, kraja f, sallaku a. association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania (original research). seejph 2018, posted: 01 january 2018. doi 10.4119/unibi/seejph-2018-178 7 table 4. association of ca15-3 with socio-demographic characteristics and metastases site; ageadjusted and multivariable-adjusted mean values from the general linear model * this model was simultaneously adjusted for age-group (≤50 years vs. ≥51 years), district of residence (tirana vs. other districts of albania), place of residence (urban vs. rural areas), educational level (0-8, 9-12, ≥13 years), economic level (low, middle, high), employment status (employed, unemployed, retired) and metastases site (liver vs. bones and/or lungs). † overall p-values and degrees of freedom (in parentheses). variable age-adjusted multivariable-adjusted* mean 95% ci p mean 95% ci p age-group: ≤50 years ≥51 years 289.9 94.2 233.3-346.4 50.6-137.8 <0.001 246.6 84.9 170.1-323.1 31.2-138.7 0.001 district of residence: tirana other districts 188.7 194.2 131.9-245.5 148.2-240.3 0.881 153.9 177.8 89.1-218.7 123.1-232.3 0.519 place of residence: urban areas rural areas 177.8 214.9 132.9-222.7 158.4-271.4 0.303 161.7 169.9 106.1-217.3 103.6-236.1 0.834 education: 0-8 years 9-12 years ≥13 years 235.6 184.6 113.5 179.5-291.7 133.8-235.5 29.3-197.6 0.055 (2)† 0.052 0.388 220.2 150.8 126.4 146.9-293.6 47.8-253.7 37.1-215.6 0.249 (2) 0.314 0.982 economic level: low middle high 219.9 186.8 129.6 158.8-281.1 139.7-234.0 26.2-233.1 0.323 (2) 0.360 0.672 171.2 194.2 132.0 89.7-252.8 118.2-270.1 11.7-252.2 0.733 (2) 0.926 0.818 employment status: employed unemployed retired 197.1 207.1 163.0 134.0-260.1 148.3-265.9 87.3-238.7 0.637 (2) 0.893 0.719 189.8 177.5 130.1 124.3-255.2 111.3-243.7 43.8-216.5 0.506 (2) 0.620 0.680 site of metastases: liver bones and/or lungs 150.4 235.7 102.5-198.4 186.6-284.8 0.014 128.0 203.6 68.0-188.0 144.7-262.5 0.039 hoti a, gashi e, kraja f, sallaku a. association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania (original research). seejph 2018, posted: 01 january 2018. doi 10.4119/unibi/seejph-2018-178 8 discussion main findings of the current analysis include a higher mean value of both cea and ca15-3 levels in albanian female patients with breast cancer metastases in the bones and/or lungs compared with their counterparts with metastases in the liver. furthermore, mean ca15-3 level was considerably higher in the younger patients. there was a significant linear association between cea and ca15-3 levels. it should be noted that the current analysis of both cea and ca15-3 values relates to the time of diagnosis and not the subsequent treatment which certainly causes alterations of the cea and ca15-3 values. breast cancer is the most frequent cancer in women from western countries (9) and it is increasing in lowand middle-income countries as well (1-3). in western countries, the incidence of breast cancer has progressively increased in the past 30 years, whereas the specific mortality rate is relatively stable (9,12). it has been argued that this is a result of both extensive screening and great therapeutic strides (9,13). in the current study conducted in tirana, two important tumour markers were measured in all study participants at the time of diagnosis. however, to date, measurement of ca15-3 and cea serum levels are not recommended in the follow-up of breast cancer, in light of their lack of specificity (9,14). yet, some previous studies have indicated that the likelihood of discovering recurrence of breast cancer is influenced by the ca15-3 serum level and its doubling time (15,16). the current analysis may have some limitations related to the inclusion of study participants and the data collection procedures. regarding the possibility of selection bias, it should be noted that this study involved all patients with metastatic breast cancer diagnosed and treated over a seven-year period at the oncology service of the university hospital centre “mother teresa”, which is currently the only tertiary care institution in albania. based on this fact, the oncology service of the university hospital centre “mother teresa” in tirana is the only public institution in albania offering specialized services and most of the albanian female patients are assumed to be diagnosed with breast cancer and subsequently treated in this medical centre. therefore, the female patients included in our analysis comprise a representative sample of breast cancer patients for the whole period study period. as for the possibility of information bias, the diagnosis of breast cancer and the location of metastases were based on the best clinical protocols and contemporary examination techniques used in other countries. in any case, we cannot entirely exclude the possibility of information bias at least for the socio-demographic information which was collected through interviews. yes, seemingly, there is no plausible reason to assume a differential reporting of sociodemographic factors between women with different clinical characteristics or stage of disease progression. in conclusion, this study provides valuable evidence on selected correlates of cea and ca15-3 levels in albanian female patients diagnosed with metastatic breast cancer. oncologists and other health professionals in albania, as well as decision-makers and policymakers should be aware of the burden and risk factors of breast cancer among women in this transitional society. hoti a, gashi e, kraja f, sallaku a. association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania (original research). seejph 2018, posted: 01 january 2018. doi 10.4119/unibi/seejph-2018-178 9 references 1. lu c, sun h, huang j, yin s, hou w, zhang j, et al. long-term sleep duration as a risk factor for breast cancer: evidence from a systematic review and doseresponse meta-analysis. biomed res int 2017;2017:4845059. doi: 10.1155/2017/4845059. 2. anderson bo, lipscomb j, murillo rh, thomas db. breast cancer (in cancer: disease control priorities. gelband h, jha p, sankaranarayanan r, horton s, editors; 3rd edition). the international bank for reconstruction and development / the world bank, washington, dc, usa; 2015. 3. colditz ga. epidemiology and prevention of breast cancer. cancer epidemiol biomarkers prev 2005;14:768-72. 4. cappuccio fp, cooper d, delia l, strazzullo p, miller ma. sleep duration predicts cardiovascular outcomes: a systematic review and meta-analysis of prospective studies. eur heart j 2011;32:1484-92. 5. yildiz m, oral b, bozkurt m, cobaner a. relationship between bone scintigraphy and tumor markers in patients with breast cancer. ann nucl med 2004;18:501-5. 6. basuyau j, blanc-vincent m, bidart j, daver a, deneux l, eche n, et al. summary report of the standards, options and recommendations for the use of serum tumour markers in breast cancer: 2000. br j cancer 2003;89:s32-4. 7. molina r, barak v, van dalen a, duffy mj, einarsson r, gion m, et al. tumor markers in breast cancer—european group on tumor markers recommendations. tumor biol 2005;26:281-93. 8. harris l, fritsche h, mennel r, norton l, ravdin p, taube s, et al. american society of clinical oncology 2007: update of recommendations for the use of tumor markers in breast cancer. j clin oncol 2007;25:5287-91. 9. champion l, brain e, giraudet al, le stanc e, wartski m, edeline v, et al. breast cancer recurrence diagnosis suspected on tumor marker rising: value of whole-body 18fdg-pet/ct imaging and impact on patient management. cancer 2011;117:16219. 10. institute for health metrics and evaluation (ihme). global burden of disease database. seattle, wa: ihme, university of washington; 2017. http://www.healthdata.org (accessed: december 17, 2017). 11. world health organization. core health indicators in the who european region. copenhagen, denmark; 2017. 12. jemal a, siegel r, ward e, hao y, xu j, thun m. cancer statistics 2009. ca cancer j clin 2009;59:205-49. 13. european society of medical oncology. primary breast cancer: esmo clinical recommendations for diagnosis, treatment and follow up. ann oncol 2007;18:ii5-8. 14. zervoudis s, peitsidis p, iatrakis g, et al. increased levels of tumor markers in the follow-up of 400 patients with breast cancer without recurrence or metastasis: interpretation of false-positive results. j buon 2007;12:487-92. 15. suarez m, perez-castejon mj, jimenez a, domper m, ruiz g, montz r, carreras jl. early diagnosis of recurrent breast cancer with fdg-pet in patients with progressive elevation of serum tumor markers. q j nucl med 2002;46:113-21. 16. aide n, huchet v, switsers o, heutte n, delozier t, hardouin a, bardet s. influence of ca 15-3 blood level and doubling time on diagnostic performances of 18f-fdg pet in breast cancer patients with occult recurrence. nucl med commun 2007;28:267-72. https://www.ncbi.nlm.nih.gov/pubmed/?term=lu%20c%5bauthor%5d&cauthor=true&cauthor_uid=29130041� 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https://www.ncbi.nlm.nih.gov/pubmed/?term=cobaner%20a%5bauthor%5d&cauthor=true&cauthor_uid=15515750� https://www.ncbi.nlm.nih.gov/pubmed/?term=annals+of+nuclear+medicine+vol.+18%2c+no.+6%2c+501-505%2c+2004� https://www.ncbi.nlm.nih.gov/pubmed/?term=daver%20a%5bauthor%5d&cauthor=true&cauthor_uid=12915901� https://www.ncbi.nlm.nih.gov/pubmed/?term=deneux%20l%5bauthor%5d&cauthor=true&cauthor_uid=12915901� https://www.ncbi.nlm.nih.gov/pubmed/?term=eche%20n%5bauthor%5d&cauthor=true&cauthor_uid=12915901� https://www.ncbi.nlm.nih.gov/pubmed/?term=duffy%20mj%5bauthor%5d&cauthor=true&cauthor_uid=16254457� https://www.ncbi.nlm.nih.gov/pubmed/?term=einarsson%20r%5bauthor%5d&cauthor=true&cauthor_uid=16254457� https://www.ncbi.nlm.nih.gov/pubmed/?term=gion%20m%5bauthor%5d&cauthor=true&cauthor_uid=16254457� https://www.ncbi.nlm.nih.gov/pubmed/?term=norton%20l%5bauthor%5d&cauthor=true&cauthor_uid=17954709� 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10.4119/unibi/seejph-2018-178 10 ______________________________________________________________________________________ © 2018 hoti et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. schröder-bäck p, maeckelberghe e, royo-bordonada má. the ethics effect (editorial). seejph 2014, posted: 23 september 2014. doi 10.12908/seejph-2014-31 1 editorial the ethics effect peter schröder-bäck 1-4 , els maeckelberghe 3-5 , miguel ángel royo bordonada 4,6 1 department of international health, school for public health and primary care (caphri), maastricht university, the netherlands; 2 faculty for human and health sciences, bremen university, germany; 3 eupha section “ethics in public health”; 4 aspher working group on ethics and values; 5 institute for medical education, university medical center groningen, the netherlands; 6 national school of public health, institute of health carlos the third, madrid, spain. corresponding author: priv.-doz. dr. peter schröder-bäck, maastricht university, faculty of health, medicine and life science, school for public health and primary care (caphri), department of international health, postbus 616, 6200 md maastricht, the netherlands; telephone: +31(0)433882343; e-mail: peter.schroder@maastrichtuniversity.nl mailto:peter.schroder@maastrichtuniversity.nl schröder-bäck p, maeckelberghe e, royo-bordonada má. the ethics effect (editorial). seejph 2014, posted: 23 september 2014. doi 10.12908/seejph-2014-31 2 moral issues – also in public health sometimes researchers and practitioners of public health are confronted with situations where it is not self-evident which option for action is the better choice. a decision about implementing a particular public health intervention can be difficult because there is a lack of scientific evidence that would speak clearly for or against its effectiveness. moreover, a decision can be difficult because of moral values that are at stake. indeed, taking a decision might sometimes feel like replacing one evil with another; or at least accepting some restrictions of liberty of individuals in the trade-off for another good, e.g. the health of others. examples of difficult choices can be to implementing quarantines and isolations (like those being currently in place in relation to the ebola outbreak in west-africa), obligatory immunizations, prohibitions of risky behaviour or (re-)distributing resources. ethics is the discipline in which one asks systematically what the right and good choices are – in life in general, but also in academic and professional fields such as public health. ethics asks “why should i do this or that?” and the reply consists of giving reasons and developing an argument. ethics hereby draws on principles, values and virtues and has developed substantive theories in the last two-and-a-half-thousand years. in medicine, the value of ethics for taking the right choices in the context of professional conduct, deeply rooted in the hippocratic oath, has a successful tradition of some decades by now. in the last century the combination of ethical argumentation with medical problems lead to intensive discourses under the name “bioethics” (1). bioethics, however, focuses on the individual patient and does not (usually) have a public health perspective. yet, in public health there are, as just mentioned, many ethical challenges that request reasoning about choices. in 2003, gaare bernheim carried out a study with public health professionals. she found that public health practitioners “often feel ill-prepared to make the ethical trade-offs and perceive a need for more education and support to make these decisions” (2). thus, it is no surprise that more and more actors in public health research and practice requested to introduce the discipline of ethics into public health science, practice and education. schools of public health in the european region asked for more support from their association (aspher) to introduce ethics in their schools and curricula, because only some schools do offer ethics training in their bachelor or master programmes (3). integrating ethics into public health the implementations of difficult public health interventions have usually lacked explicit preceding ethical analyses or had to contend with conflictive and ambiguous ethical principles. yet, when we started several years ago to advocate introducing ethics into academic european public health discourses (4), we did not only preach to the converted. in fact, the term „ethics‟ also had a negative effect on some public health researchers. even though many researchers and practitioners applauded the introduction of ethical discourses into public health, we have also quite often heard that ethics is not the most urgently awaited for input for public health research. colleagues were sceptical because, in their opinion, ethics commissions are the institutions that may hinder proper public health research. sometimes public health practitioners were doubtful: can ethics really be helpful? the answer becomes obvious when we realize that no health intervention, including a preventive or health promotion program, is risk-free. even when the harm caused to a particular person by a public health intervention might be minimal, the impact can be extremely relevant if the intervention is targeted at the population level, most of whose recipients are healthy. among the opportunities ethics offers when being introduced into public health discourses are reflections about leading values and decision-making criteria, identification of normative loopholes or inconsistencies in argumentation, shifting burdens of proof among actors, and schröder-bäck p, maeckelberghe e, royo-bordonada má. the ethics effect (editorial). seejph 2014, posted: 23 september 2014. doi 10.12908/seejph-2014-31 3 the like. among the limits are that ethics does not offer a ready to use algorithm for making decisions and often the feeling prevails that after an ethical discussion one has not a definitive answer or is still confused – but on a higher level (as the physicist enrico fermi once formulated it in a different context). the way forward in our perspective, recent developments to establish public health ethics discourses are highly welcome, because of the ethics effect on human practice in general and public health research and practice in particular: having an understanding of what are the reasons for choosing a over b. ethics can help to identify good reasons and unmask bad reasons. it is through the exchange of arguments, within discourses, through which public health can get (even) better: doing the right thing for the right reason. because only if it is for the right reason – and not by chance, based on a prejudices or because of following a dogma – one can convince others; as sen says “bad reasoning can be confronted by better reasoning” (5). and to identify good and convincing arguments is a task of ethics. thus, ethics can and should be further integrated in public health education, research and practice – but it is still a long way to go until ethics is as well integrated into public health as it is into medicine. let‟s continue to bring ethical discourses onto the table of public health researchers and practitioners. to contribute to this endeavour, we welcome in this journal articles that have ethics integrated into the public health perspective; or articles that deal with public health ethics explicitly. references 1. beauchamp tl, childress jf. principles of biomedical ethics. 6th edition. oxford university press: new york, 2009. 2. bernheim rg. public health ethics: the voices of practitioners. j law med ethics 2003;31:104-9. 3. aceijas c, brall c, schröder-bäck p, otok r, maeckelberghe e, stjernberg l, strech d, tulchinsky t. teaching ethics in schools of public health in the european region – results of a screening survey. public health rev 2012;34:146-55. 4. maeckelberghe el, schröder-bäck p. public health ethics in europe – let ethicists enter the public health debate. eur j public health 2007;17:542. 5. sen a. the idea of justice. cambridge ma: belknap press, 2009. ___________________________________________________________ © 2014 schröder-bäck et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. jarke h, džindo a, jakob l. healthcare access in bosnia and herzegovina in the light of european union accession efforts (review article). seejph 2019, posted: 27 march 2019. doi 10.4119/unibi/seejph-2019-210 r e v i e w a r t i c l e healthcare access in bosnia and herzegovina in the light of european union accession efforts hannes jarke1, amra džindo2, lea jakob3 1 department of international health, school caphri, care and public health research institute, maastricht university, maastricht, the netherlands; 2 department of psychology, university of sarajevo, bosnia and herzegovina; 3 assessment systems international, prague, czech republic. corresponding author: hannes jarke address: maastricht university, po box 616, 6200 md maastricht, the netherlands; email: hannes.jarke@pscholars.org abstract european union (eu) member states are bound to ensure accessible, good quality healthcare for all of their citizens. in 2018, bosnia and herzegovina has been named as a candidate for accession to eu membership as part of the “strategy for the western balkans”. this scoping review identifies healthcare access issues in the country, aiming to inform policy-makers of challenges that may be faced in a possible membership application process and beyond. while the country has seemingly improved citizens’ healthcare access—as measured by the healthcare access and quality index—various specific problems remain unresolved. the main barrier to equal access appears to lie in the division of the healthcare system between the federation of bosnia and herzegovina, the republika srpska, and the brcko district, which also influences medicine availability and pricing. although not necessarily systematic, studies further report distance from healthcare providers, alleged widespread corruption, discrimination of minorities and vulnerable populations, as well as vaccination gaps as problems in healthcare access for specific groups. while certainly not easy to realise, this scoping review concludes that possible solutions could include efforts to unify the healthcare and pricing system, and the implementation of the world health organization’s essential medicines list, as well as investigating and tackling corruption and stigma issues. keywords: bosnia and herzegovina, european union membership, healthcare access, healthcare access and quality index, inequality. conflicts of interest: none. jarke h, džindo a, jakob l. healthcare access in bosnia and herzegovina in the light of european union accession efforts (review article). seejph 2019, posted: 27 march 2019. doi 10.4119/unibi/seejph-2019-210 introduction in february 2018, the european commission (ec) announced their “strategy for the western balkans” (1), featuring the discussion of a possible future european union (eu) membership for bosnia and herzegovina (b&h). since the treaty of the functioning of the european union (tfeu) entered into force in 2009, one of the eu’s key objectives is a high level of human health protection (2) with the aim to provide eu citizens access to good quality healthcare and a wide range of evidence-based treatments. however, healthcare access has been named as one of the biggest problems in the healthcare system of b&h (3). bosnia & herzegovina: history and numbers b&h is located on the balkan peninsula in south-eastern europe, with an overall population of 3,507,017inhabitants, and a gdp of 18.055 billion us$ (4). the country declared independence in 1992— during the breakdown of yugoslavia—but subsequently fell into a state of civil war and is still heavily affected by its aftermath, which included large-scale war crimes. the country features a very heterogeneous population (see figure 1 please note that this data is referring to the federation of b&h [fbh], not the whole country). people who have fled the war and have returned afterwards face additional difficulties: returned men are more likely to be unemployed than those who stayed, while formerly displaced women are dropping out of the labour force more often than others of the same sex (5), and all groups are more vulnerable to corruption than those who stayed (6). the organisation of healthcare is split between the fbh, republika srpska (rs), ten autonomous cantons, and the brcko district (bd) which makes it a heterogeneous structure split into 13 components (8). similarly, drug prescription systems are different between three entities (9). figure 1. ethnicities in the federation of bosnia and herzegovina (7) jarke h, džindo a, jakob l. healthcare access in bosnia and herzegovina in the light of european union accession efforts (review article). seejph 2019, posted: 27 march 2019. doi 10.4119/unibi/seejph-2019-210 figure 2. main stakeholders for drug prescription in the healthcare system of b&h [source: adapted from guzvic et al. (9)] while the peace treaty has been in effect for more than two decades, not all laws are in accordance with the conditions outlined in it. long-term health consequences of deteriorated living standards, high unemployment, and economic insecurity include post-traumatic stress disorder (ptsd) and impaired psychological wellbeing, not only among patients but also among their treating physicians (10). likewise, adverse childhood experiences appear to be more common than in the eu likely fostered by the post-war environment. a study on 400 hospital patients between 18 and 24 years of age found that 48.7% of respondents had experienced at least one form of childhood adversity and the results “demonstrated associations between adverse experiences in childhood and the probability of engaging in health risk behaviour” (11). this environment and the often-related financial hardships further reduce access to healthcare (12). other specific health challenges are physical war injuries. since the beginning of the war, close to 8,000 landmine victims have been reported (13). b&h remains one of the most landmine infested countries in the european region. while most victims die instantly, survivors often have to undergo amputations, great physical pain, long hospitalisation periods, and can develop anxiety and/or depression. data on patient safety in hospitals is scarce, but initial research found anecdotal evidence for an overall low perceived safety in three hospitals (14). a table containing the available health indicators can be found in the accompanying online repository (https://osf.io/axty3/). access to health services; inequities, and inequalities access to health services and healthcare is imperative for a healthy society. eu member states “have a clear mandate to ensure equitable access to high-quality health services for everyone living in their countries” (15). the exph clarifies that unmet healthcare needs should be addressed by allocating an appropriate amount of resources towards them. in that jarke h, džindo a, jakob l. healthcare access in bosnia and herzegovina in the light of european union accession efforts (review article). seejph 2019, posted: 27 march 2019. doi 10.4119/unibi/seejph-2019-210 sense, proper access to healthcare features the following eight characteristics: ● financial resources are linked to health needs ● services are affordable for everyone ● services are relevant, appropriate, and cost-effective ● facilities are within easy reach ● there are enough health workers, with the right skills, in the right place ● quality medicine and medical devices are available at fair prices ● people can use services when they need them ● services are acceptable to everyone this paper seeks to examine the status of healthcare access in the general population and vulnerable groups in b&h. areas for improvement are identified, so that they may inform further specific research and recommendations for the ec as outlined in art. 168 (2) in the tfeu should an accession process be put into motion. to do this, the countryand region-specific healthcare access problems are identified, inequities and inequalities are investigated, and compared to eu expectations (exph recommendations related to results can be found at: https://osf.io/zsq23). methods given the urgency of the issue, a scoping review was deemed to be the most fitting approach to identify healthcare access issues in b&h. while not fully exhaustive, scoping reviews allow for a faster (compared to systematic reviews) summary and dissemination of research findings, as well as the identification of research gaps (16), especially when the aim is to map broad topics. it has been argued that while there is no universally accepted precise definition of scoping reviews, their flexibility allows for the inclusion of more diverse evidence—such as grey literature— and therefore yields great potential to inform practice, policy, education, and further research into specific aspects (17). an iterative approach based on a framework by arksey and o’malley (18) was employed. to identify relevant studies, pubmed was searched first, but this endeavour showed only limited results. a search in google scholar revealed a much greater amount of hits, but also clearly showed a massive number of unrelated results. the full number of results using [“healthcare access” and “bosnia”] (n = 384), and an arbitrary number of results using [healthcare access and bosnia] (n = 250 out of 16,100) were scanned and included if relevant. based on these results, the identified topics were then again used in pubmed searches. lastly, databases in bosnian and croatian language were searched for healthcare access issues in b&h to include local research and grey literature. for a detailed overview of search strings and results, please see https://osf.io/yn6ed/. a total of 14 scientific papers and policy documents were included in the full evidence review, based on the criterion that they investigate a healthcare access issue related to one or more populations in b&h. results are portrayed in a narrative structure. whenever possible, the investigated studies are also compared to the overall ratings of the healthcare access and quality index (haq) which is based on data from the global burden of diseases, injuries, and risk factors study 2015 (gbd) (19), building on six factors: i. health expenditure per capita ii. hospital beds (per 1000 inhabitants) iii. universal health coverage tracer index of 11 interventions iv. physicians, nurses, and midwives (per 1000 inhabitants) v. proportion of population with formal health coverage vi. coverage index of three primary health-care interventions to calculate the haq, these were combined into a scale from 1 (lowest access jarke h, džindo a, jakob l. healthcare access in bosnia and herzegovina in the light of european union accession efforts (review article). seejph 2019, posted: 27 march 2019. doi 10.4119/unibi/seejph-2019-210 and quality) to 100 (highest possible access and quality) and measured per state and globally. results overall healthcare access and quality score the haq is generally improving globally and has even slightly improved in b&h during the war. it, therefore, may appear as if the war has hindered the development of overall access, but not thrown it back. however, the haq should not be taken as an indicator of equal healthcare access during 1990 and 1995, but merely interpreted as that the six outlined factors were invested in. when the war ended in 1995, b&h had an overall haq of 62.1 (compared to 60.9 in 1990) and has since constantly improved, up to a level of 78.2 in 2015 (19). the highest score was in diphtheria [100] and the lowest in adverse effects of medical treatments [45]. for comparison: b&h’s eu neighbour croatia had an overall haq of 70.4 in 1995 and improved to 81.6 in 2015. access to healthcare in bosnia & herzegovina the haq may only serve as a point of reference for specific problems in order to check whether improving one of the six factors could serve as a starting point in solving the problem. in 2006, the uptake of basic healthcare insurance in b&h—which covers medical services at an appointed general practitioner or through specialist recommendation, as well as specific drug prescriptions—was 84%, ranging from 63% in hercegbosanski kanton to 93% in sarajevo kanton, leaving around 380,000 citizens uninsured (20). coverage of basic healthcare for women in fbh and rs is lacking for 13–16% of the population, with the number rising up to 60% in roma women (21). in general, roma women, impoverished women, individuals living in rural areas, and people with disabilities have been found to have the lowest rates of healthcare coverage. a low number of available gynaecologist practices and a lack of basic information about the process of acquiring health insurance are further hindering equal healthcare access. employers do not always contribute regularly to workers healthcare schemes. this affected 27% of employees in 2015 in rs, with 16% receiving no payments at all towards their healthcare plan (21). regional inequalities in health care access and provisions the division of the healthcare system between fbh, rs, and bd likely poses the greatest challenge in providing equal healthcare and healthcare access to citizens of b&h. health policy making already proves to be extremely difficult because of a decentralised system and a large variety of decision makers in multiple regions (9). this also influences health technology assessment (hta), which is needed to ensure that proper technology and methodology for screenings, diagnoses, and treatments are available. while hta has been recognised in legislation, it has still not been introduced in full capacity due to lack of experts and education, and resistance from within the political environment (9). drug prescription and reimbursement are decentralised and differ between regions, leading to discrepancies in pricing (figure 2). this causes an inequity regarding access to essential medicines, with prescribed drugs being 20% more expensive on average in rs compared to fbh (22). the highest price difference was found for atorvastatin—used in the treatment of dyslipidaemia and prevention of cardiovascular disease—which is 39% more expensive in rs than in the fbh. in general, prices in bd are 14% lower, compared to fbh. prices and reimbursement for drugs also vary between cantons. neighbours divided by a simple jarke h, džindo a, jakob l. healthcare access in bosnia and herzegovina in the light of european union accession efforts (review article). seejph 2019, posted: 27 march 2019. doi 10.4119/unibi/seejph-2019-210 canton border may have different access to prescriptions and reimbursements. access to crucial medicine is further hindered by the limited number of drugs included on the fbh’s list of basic medicines (fbl). compared to the who’ essential medicines list (eml) it is not a sufficient list of important drugs which should be reimbursed (23). considering the scarce financial resources, the authors of the comparison conclude that the government should rather rely on the established, evidence informed eml. one example where this kind of inequity apparently has grave consequences is cancer treatment. kurtovic-kozaric et al. (24) claim that cancer patients in b&h either never receive the accurate therapy because it is missing from the list of government-reimbursed drugs, or they are put on a waiting list for one of the nine available drugs which are reimbursed still causing a delay in treatment, with some treatments supposedly not available at all. unmet healthcare needs long distance to the nearest primary healthcare provider is problematic for citizens in various regions (3). about a quarter of the inhabitants live 1.5–5 kilometres away from their nearest place of primary health care and 22% live more than 5 kilometres away (20). this further disadvantages vulnerable populations, such as children, the elderly, or individuals with chronic ailments, who may be in special need of timely treatment or regular checkups (21). rural areas also lack dental care specialists, compared to urban areas. mandic dokic (21) found that individuals with lower comprehension of written materials—with illiteracy being unequally distributed by gender (5.32% in men versus 0.93% in women)—face a barrier in understanding medical conditions or treatment information written at a level too complex for them to understand. healthcare access inequities and inequalities are often found for specific groups, especially minorities. in b&h, the number of sinti and roma is estimated to be around 35,000–40,000 (25). they are 2– 3 times more likely to report unmet health needs compared to non-roma living nearby, especially when uninsured (26). even when adjusted for “variation in gender, age, marital status, employment status, education, number of chronic conditions, health insurance status and geographical proximity to medical provider” (26) they are more likely to report unmet health needs in b&h specifically (odds ratio [or]=1.44 adjusted for the aforementioned factors, or=1.95 unadjusted). the authors call for increased inclusion of roma in the system and highlight the need for a detailed assessment of their needs within and outside of the health system. one of these unmet health needs is a gap in vaccination. an investigation (27) found that in central and eastern europe, “roma children have a lower probability of being vaccinated compared to non-roma ([or]= 0.325). the odds of being vaccinated for a roma child is 33.9% to that of a non-roma child for dpt [diphtheria, pertussis, tetanus], 34.4% for polio, 38.6% for mmr [measles, mumps, rubella] and 45.7% for bcg [tuberculosis]” (27). by comparing the means of vaccination coverage, the authors show that in b&h, the proportion of roma children having received any vaccination is 14.8% lower compared to non-roma. they are lower specifically by 21.2% for bcg vaccine, 35.3% for polio vaccine, 33.9% for dpt vaccine, and 35.8% for mmr vaccine. this is especially worrying, as roma tend to live in closed groups, making them less protected by the overall population’s herd immunity. the factors leading to low vaccination levels are relatively unknown but are likely related to a lack of access to healthcare in general, low level of education, and discrimination. jarke h, džindo a, jakob l. healthcare access in bosnia and herzegovina in the light of european union accession efforts (review article). seejph 2019, posted: 27 march 2019. doi 10.4119/unibi/seejph-2019-210 financial barriers in healthcare access people formerly displaced through the war may return to their home country to find the healthcare system not to be welcoming. a series of semi-structured interviews conducted among 33 refugees who returned to b&h after long-term residence in denmark provides an insight into their perception of the healthcare system (6). interviewees reported widespread corruption and added that it influenced them even more negatively than it does people who stayed. results indicate that corrupt physicians ask for larger bribes from returnees than from other citizens, facilitating a barrier to accessing various forms of healthcare. the situation is even worse for people suffering from chronic illnesses, as they are in need of frequent care. focus group interviews with returnees (28) found that healthcare quality in general was perceived as extremely low, going as far as to state that “[n]one of the participants could see any bright future in the healthcare system” (28). while the authors suggest that educational activities for healthcare professionals—teaching them how to meet the needs of returned migrants—are needed, success is questionable in the light of the apparent existence of widespread corruption. one public opinion survey (3) found that many people believed that corruption occurs in hospitals (77% agreed), health centres (68%), and outpatient clinics (60%). homoand bisexual men are reportedly facing barriers in obtaining healthcare. qualitative data obtained from 12 in-depth interviews suggests that stigmatisation, discrimination, prejudice, and inequities this group faces in bosnian & herzegovinian society extends to the healthcare sector (29). while further, quantitative, investigation is needed to estimate the extent of this situation, stojisavljevic and her colleagues (29) highlight the need for both educational trainings of professionals, as well as structural reform. this article features additional materials hosted on the open science framework at https://osf.io/z8sd3/. discussion the most important task goal b&h appears to be fostering re-unification of citizens and the healthcare system, whereas the latter is probably not possible without the former. if equity and equality in healthcare access ought to be improved as outlined by the exph (12), it is imperative that more treatments are made available and that they are available to all citizens, with medicine equally prescribed and reimbursed. a big step is an ordinance announced in january 2017 (30) by the agency for medicinal products and medical devices, which is supposed to harmonise medication prices. however, its implementation has been described as insufficient and hindered by bureaucracy (3). equity will also probably face a greater setback if b&h joined the eu: should the b&h health system stay similar to how it is now, some citizens are likely to choose medical travel to meet their health needs an option that is, however, too expensive for most citizens. while directive 2011/24/eu (31) constitutes a great opportunity to receive treatment which is not available in one’s own country, it is unlikely that—given the low income and overall gdp in b&h compared to the eu average—the majority of citizens will be able to profit from it. one straightforward option to work towards healthcare access equity would be to replace the national or regional medicine lists with the who’s eml and to adjust reimbursement schemes accordingly. if all three regions were to adopt the eml, this might also speed up the process of building a more unified healthcare and reimbursement system in general. another possibly beneficial innovation is telemedicine. while it is currently only being adapted slowly in b&h, naser et al. jarke h, džindo a, jakob l. healthcare access in bosnia and herzegovina in the light of european union accession efforts (review article). seejph 2019, posted: 27 march 2019. doi 10.4119/unibi/seejph-2019-210 (32) outline its potential, both in educating young professionals, as well as in treatment. however, the authors also note that its implementation is heavily reliant on investments in infrastructure and equipment, as well as a positive political climate welcoming it. while this seems highly ambitious, especially vulnerable groups could gain access to physicians of their choice more easily. should b&h continue in its accession plans, the way will be a long one—especially in healthcare— and will likely require some societal changes first. while many have called for more educational and change programmes, clear ideas on how these could look like or could be implemented are missing. as a scoping review, this investigation has a number of limitations by default. as it is supposed to serve as an overview of issues to address, there is no guarantee that it exhaustively covers all healthcare access issues in the country. the strength of evidence varies and is rather weak for certain areas; for example, while the vaccination gap in roma is rather well researched—and immediate, specific action may be recommended—especially qualitative evidence for discrimination and bribery—although definitely issues to be investigated—are hard to quantify and their actual spread hard to know. further, there is no indication to the extent of publication bias regarding the topic. in conclusion, both, the eu and b&h politics appear to be in need of addressing a multitude of healthcare access issues and establish solutions before accession seems sensible for both sides with regard to the goals set out by the exph. should they succeed in this, however, citizens in b&h may be able to benefit from better access through the implementation of health law harmonisation, and hopefully also even cross-border healthcare at a later point. references 1. strategy for the western balkans: eu sets out new flagship initiatives and support for the reform-driven region. available from: http://europa.eu/rapid/press-release_ip18-561_en.htm (accessed: october 9, 2018). 2. treaty of the functioning of the european union. part three: union policies and internal actions – title viv: public health article 168. 3. mujkic e. sistem zdravstva u bosni i hercegovini: stanje i pravci moguce reforme. sveske za javno pravo. 2011;2:46–58. available from: http://www.pfsa.unsa.ba/pf/wpcontent/uploads/2015/01/sistemzdravstva-u-bih.stanje-i-pravcimoguæe-reforme.pdf(accessed: october 12, 2018) [in bosnian]. 4. the world bank. bosnia and herzegovina. available from https://data.worldbank.org/country/bosn ia-and-herzegovina (accessed: february 5, 2019). 5. kondylis f. conflict displacement and labor market outcomes in post-war bosnia and herzegovina. j dev econ 2010;93:235–48. 6. neerup handlos l, fog olwig k, bygbjerg ib, norredam m. return migrants’ experience of access to care in corrupt healthcare systems: the bosnian example. int j environ res public health 2016;13:924. 7. federalni zavod za statistiku. konacni rezultati popisa 2013. available from: http://fzs.ba/index.php/popisstanovnistva/popis-stanovnistva2013/konacni-rezultati-popisa-2013/ (accessed: february 12, 2019) [in bosnian]. 8. the european union’s cards programme for bosnia and herzegovina. functional review of the health sector in bosnia and herzegovina: final report. 2016. available from: http://parco.gov.ba/wphttp://europa.eu/rapid/press-release_ip-18-561_en.htm http://europa.eu/rapid/press-release_ip-18-561_en.htm jarke h, džindo a, jakob l. healthcare access in bosnia and herzegovina in the light of european union accession efforts (review article). seejph 2019, posted: 27 march 2019. doi 10.4119/unibi/seejph-2019-210 content/uploads/2016/09/functionalreview-of-the-health-sector-in-bh.pdf (accessed: february 12, 2019). 9. guzvic v, catic t, kostic m. health technology assessment in centraleastern and south europe countries: bosnia and herzegovina. int j technol assess health care 2017;33:390–5. 10. hodgetts g, broers t, godwin m, bowering e, hasanovic m. posttraumatic stress disorder among family physicians in bosnia and herzegovina. fam pract 2003;20:489–91. 11. musa s, peek-asa c, jovanovic n, selimovic e. association of adverse childhood experiences and health risk behaviors among young adults visiting a regional primary healthcare center, federation of bosnia and herzegovina. plos one 2018;13:e0194439. 12. godwin m, hodgetts g, bardon e, seguin r, packer d, geddes j. primary care in bosnia and herzegovina health care and health status in general practice ambulatory care centres. can fam physician 2001;47:289–97. 13. ryken ko, hogue m, marsh jl, schweizer m. long-term consequences of landmine injury: a survey of civilian survivors in bosnia-herzegovina 20 years after the war. injury 2017;48:2688–92. 14. offermanns g, draganovic s, alispahic a. patient safety in bosnia and herzegovina hospitals: first insights and opportunities for improvement. eur j public health 2015;25. 15. expert panel on effective ways of investing in health. report on access to health services in the european union. available from: http://doi.org/10.2875/10002(accessed: february 12, 2019). 16. pham mt, rajic a, greig jd, sargeant jm, papadopoulos a, mcewen sa. a scoping review of scoping reviews: advancing the approach and enhancing the consistency. res synth methods 2014;5:371–85. 17. peterson j, pearce pf, ferguson la, langford ca. understanding scoping reviews: definition, purpose, and process. j am acad nurse pract 2017;29;12–6. 18. arksey h, o’malley l. scoping studies: towards a methodological framework. intj soc res methodol 2005;8:19-32. 19. barber r, fullman n, sorensen r, bollyky t, mckee m, nolte e, et al. healthcare access and quality index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990–2015: a novel analysis from the global burden of disease study 2015. lancet 2017;390:231–66. 20. federal ministry of health. strateski plan razvoja zdravstva u federaciji bosne i hercegovine u periodu od 2008. do 2018. godine. sarajevo, federation of bosnia and herzegovina: federal ministry of health; 2008 [in bosnian]. 21. mandic dokic t. pristup zdravstvenim uslugama i parvo na zdravlje zena u bosni i hercegovini. sarajevo: zalagacke platforme zena u bih; 2016. available from: http://www.fondacijacure.org/files/zala gackeplatforme/pristup%20zdravstveni m%20uslugama%20i%20pravo%20na %20zdravlje%20%c5%beena%20u% 20bosni%20i%20hercegovini.pdf (accessed: february 12, 2019) [in bosnian]. 22. catic t. differences in reimbursement prices and inequalities to access most commonly prescribed medicines in bosnia and herzegovina. value health 2015;18:a527. 23. mahmic-kaknjo m, marusic a. analysis of evidence supporting the federation of bosnia and herzegovina reimbursement medicines lists: role of the who essential medicines list, cochrane systematic reviews and jarke h, džindo a, jakob l. healthcare access in bosnia and herzegovina in the light of european union accession efforts (review article). seejph 2019, posted: 27 march 2019. doi 10.4119/unibi/seejph-2019-210 technology assessment reports. eur j clin pharmacol 2015;71:825–33. 24. kurtovic-kozaric a, vranic s, kurtovic s, hasic a, kozaric m, granov n, et al. lack of access to targeted cancer treatment modalities in the developing world in the era of precision medicine: real-life lessons from bosnia. j glob oncol 2018;4:1–5. 25. ministry of human and refugee rights of federation of bosnia and herzegovina. action plan of bosnia and herzegovina for addressing roma issues in the fields of employment, housing and health care 2017–2020. available from: http://www.mhrr.gov.ba/pdf/ljudska prava/4%20%20akcioni%20plan%20 bih%20za%20rjesavanje%20problem a%20roma%202017-2020_eng.pdf (accessed: february 12, 2019). 26. arora v, kühlbrandt c, mckee m. an examination of unmet health needs as perceived by roma in central and eastern europe. eur j public health 2016;26:737–42. 27. duval l, wolff f, mckee m, roberts b. the roma vaccination gap: evidence from twelve countries in central and south-east europe. vaccine 2016;34:5524–30. 28. krupic f, krupic r, jasarevic m, sadic s, fatahi n. being immigrant in their own country: experiences of bosnians immigrants in contact with health care system in bosnia and herzegovina. mater sociomed 2015;27:4–9. 29. stojisavljevic s, djikanovic b, matejic b. ‘the devil has entered you’: a qualitative study of men who have sex with men (msm) and the stigma and discrimination they experience from healthcare professionals and the general community in bosnia and herzegovina. plos one 2017;12:e0179101. 30. agency for medicinal products and medical devices. official gazette 3/17. 2017 march. 31. parliament directive 2011/24/eu of 9 march 2011 on the application of patients’ rights in cross-border healthcare. 32. naser n, tandir s, begic e. telemedicine in cardiology perspectives in bosnia and herzegovina. acta inform med 2017;25:263. ______________________________________________________________________________________ © 2019 jarke et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1 request for the retraction of the manuscript “public health in kosovo after five difficult years of independence” (review article). seejph 2013 by authors jerliu n, ramadani n, mone i, brand h. slavenka jankovic, co-editor, seejph dear executive editor, i have read carefully the manuscripts published in the first issue of the seejph. as a co-editor of the seejph, i have to request the retraction of the review article: “public health in kosovo 1 after five difficult years of independence” by authors jerliu n, ramadani n, mone i, brand h. this manuscript does not fulfil neither criteria for a review paper nor for any other type of scientific manuscripts that the seejph publishes, as outlined in the seejph authors’ instructions. according to the checklist for review papers (please see below) none of the several basic criteria was observed. criteria for review articles article: “public health in kosovo * after five difficult years of independence“ criterium observed (yes/no) review articles are an attempt to summarize the current state of understanding on a topic. they analyze or discuss research previously published…they come in the form of systematic reviews and literature reviews and are a form of secondary literature (1). no the paper reports on demographic and socioeconomic indicators, health profile, lifestyle factors, health reforms and health financing in kosovo using official data from the agency of statistics kosovo, the ministry of health kosovo, the world bank, the iph kosovo, etc. a systematic review is a review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research, and to collect and analyze data from the studies that are included in the review (2). no a review article is written about other articles, and does not report original research of its own. review articles draw upon the articles that they review to suggest new research directions, to strengthen support for existing theories and/or identify patterns among existing research studies (3). no reviews should stimulate thinking and further reading indicating other sources of information (3). no the review should include a broad update of recent developments (from the past 3-5 years) and their likely public health or clinical applications in primary and secondary care (4). no review articles provide an extensive overview of the existing literature on a topic (they should include a number of relevant references, mainly original research papers and reviews (up to 50 references according to seejph instruction for authors) (3-5). no there are only 10 references in the reference list (only four are original papers). half of all references (2,3,5,8,10) are incomplete (without url and the dates of access that is not in line with the seejph authors’ instructions). 1 this designation is without prejudice to positions on status, and is in line with unscr 1244 and the icj opinion on the kosovo declaration of independence: (http://ec.europa.eu/enlargement/countries/detailed-country-information/kosovo/ (accessed april 17, 2014). http://en.wikipedia.org/wiki/systematic_review http://en.wikipedia.org/wiki/literature_reviews http://en.wikipedia.org/wiki/secondary_literature http://en.wikipedia.org/wiki/kosovo_status_process http://en.wikipedia.org/wiki/united_nations_security_council_resolution_1244 http://en.wikipedia.org/wiki/international_court_of_justice_advisory_opinion_on_kosovo%27s_declaration_of_independence http://en.wikipedia.org/wiki/international_court_of_justice_advisory_opinion_on_kosovo%27s_declaration_of_independence 2 references 1. english encyclopedia. review article. http://www.encyclo.co.uk/define/review%20article (accessed: april 17, 2014). 2. moher d, liberati a, tetzlaff j, altman dg, the prisma group. preferred reporting items for systematic reviews and meta-analyses: the prisma statement. bmj 2009;339:b2535, doi: 10.1136/bmj.b2535. 3. american public university system. a review article: http://apus.libanswers.com/a.php?qid=153014 (accessed: april 17, 2014). 4. seejph. authors’ instructions: http://www.seejph.com/instructions-for-authors/ (accessed: april 17, 2014). 5. day ra, gastel b. how to write and publish a scientific paper. 7 th edition. oxford: greenwood press, 2011. http://www.encyclo.co.uk/define/review%20article http://www.bmj.com/cgi/content/full/339/jul21_1/b2535?view=long&pmid=19622551 http://www.bmj.com/cgi/content/full/339/jul21_1/b2535?view=long&pmid=19622551 http://apus.libanswers.com/a.php?qid=153014 http://www.seejph.com/instructions-for-authors/ brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 1 review article neglect, abuse and violence against older women: definitions and research frameworks patricia brownell1 1 fordham university, new york city, new york, usa. corresponding author: patricia brownell, phd, lmsw – associate professor emerita of social service, fordham university, new york city, new york, usa; email: brownell@fordham.edu. brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 2 abstract the aging of the global population with women living longer than men, resulting in the feminization of aging, focuses attention on the intersection of gender and age. women across the lifespan can be victims of violence but there has been little attention to date to the neglect, abuse and violence against older women. because of this gap in knowledge and remedies, little is known about neglect, abuse and violence against older women, particularly its prevalence as well as evidence-based prevention and intervention strategies. several definitions of neglect, abuse and violence are reviewed here, along with conceptual frameworks that operationalize these definitions differently, resulting in differences in findings on prevalence as well as fragmentation in the way that older women victims of abuse are viewed. three definitions of older adult abuse are discussed, including those formulated by the toronto declaration, the national research council, and the united states center for disease control. each focuses on a different aspect of abuse of older women: active ageing, old age dependency, and domestic violence in later life. a fourth conceptual framework, the human rights perspective, shows promise for addressing abuse of older women in a more holistic manner than the other definitions, but is not fully developed as a way of understanding neglect, abuse and violence against older women. this is the first of a four-part series on older women and abuse. keywords: ageing, elder abuse, neglect, older women, violence. brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 3 older women, socio-demographics, and human rights population aging is a global trend that is changing economies and societies around the world (1). in 2012, people aged 60 years and older represented almost 11.5% of the global population and by 2050 this is expected to double to 22%. older women outnumber older men: in 2012 for every 100 women aged 60, there were 84 men, and for every 100 older women aged 80 and above, there were only 61 men. the feminization of aging, representing the intersection of age and gender, has important implications for policy as the world continues to age. gender discrimination across the lifespan has a cumulative effect, and neglect, abuse and violence across the lifespan results in a high lifetime rate for older women. neglect, abuse and violence against older women have been largely overlooked as a focus of research; this is in spite of the fact that unique and compounded disadvantages are experienced by older women (2). older women aged 60 years and older have been identified as subject to discrimination by the convention to eliminate all forms of discrimination against women (cedaw) experts in 2010 and by the united nations (un) department of economic and social affairs (desa) in their 10-year review of the implementation of the madrid international plan of action on ageing (3). one area of discrimination in the form of human rights violations that has been largely overlooked by policy makers, researchers and advocates for girls’ and women’s rights is neglect, abuse and violence of older women. because of this gap in knowledge and remedies, little is known about neglect, abuse and violence against older women, particularly its prevalence as well as evidence-based prevention and intervention strategies. in november 2013, to begin to address this gap, the un desa held an expert group meeting (egm) inviting researchers and other experts from around the world to new york city to review the state of knowledge, gaps and next steps to address this area of human rights violations against women and older people. one of the recommendations in the final report, “neglect, abuse and violence against older women”, prepared by the un desa department of social policy and development, is that “while both quantitative and qualitative research have begun to develop salient factors in cultural differences, age-related differences and service needs and gaps for older women victims” (2), more data are needed both on prevalence as well as practices to prevent neglect, abuse and violence against older women. in addition, unifying themes that connect older women in developing and developed countries, and in both modern and traditional societies, should be identified along with unifying themes that connect women of all ages. discrimination against older women women across the lifespan can be victims of violence, but neither the women’s domestic violence movement nor the aging empowerment movement has mobilized to end violence against older women. while elder abuse has been the object of many studies, abuse of older women has had only modest attention in the gender based literature (4). older women have lacked status as battered women in domestic violence research and activism. older women are often excluded in studies of violence against women and often completely absent as though older women do not belong in the category of women. older women are often absent from discussions about shelters and hotlines, and there is the lack of a debate on circumstances and special needs of older women victims of abuse that may affect help seeking behavior. however, a gender analysis of violence against women and girls focuses on male dominance and subordination of women, and subordination seems especially relevant for older women (4). is the women’s domestic violence movement ageist? why haven’t older people taken ownership of mistreatment of their peers (5)? why hasn’t the professional leadership in this field joined with older people to form a grass roots movement like the women’s movement to speak out against elder abuse? could social ambivalence brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 4 about old age be one reason, and the double jeopardy of sexism and ageism another? abuse of older women is neglected by advocates of gender equity, women’s rights activists and aging advocates. is it because the link to frailty and dependency makes older abused women appear to lack agency? gender inequality and the life course the united nations special rapporteur on violence against women observes that the inequality and discrimination experienced by women intensifies with old age (6). discrimination against older women on the basis of age and gender can result in situations where they experience neglect, abuse and violence (7). ageism ageism is defined as “the systematic stereotyping and discrimination against older people because they are old, just as racism and sexism accomplished this with skin color and gender” (8). ageism reinforces systems of oppression in two ways. it focuses on individual perspectives and actions and leaves hidden insidious forms of discrimination. age blindness implicitly uses the privileged as the norm and judges others by that standard (9). ageism and sexism create a socially constructed dependency in old age of which feminization of poverty is a key factor. these factors make discrimination and disadvantage seem inevitable. for older women, invisibility is symbolic of this process (10). whittaker (10) suggests that the failure of gender experts to do this analysis is a measure of the entrenched ageism within the women’s movement. cultural norms and social expectations social expectations and changing social norms can also create a perception of abuse toward older family members (11). in studies of older adult abuse in asia and south asia, the daughter-in-law is often identified as an abuser for not serving a traditional role of caregiving in the home while engaging in paid work or a career (12). public policy and availability of social and health programs political decisions about social protections for older women, and availability of health, mental health, criminal justice and other resources can limit options within families and communities for addressing issues of neglect, abuse and violence, according to shankardass (13). multi-dimensional nature of neglect, abuse, and violence against older women manjoo (6) argues for a holistic approach to understanding abuse of older women and how to address it. recognizing intersectionality and the continuum of violence against older women requires analysis of violence in four spheres: violence in the family; violence in the community; violence that is perpetrated or condoned by the state, including custodial settings like care homes and hospitals; and violence in the transnational sphere as it affects migrant, refugee and asylum seeking older women (6). gender inclusion while abuse can affect all older adults, older women are arguably more likely to experience many of these forms and levels of abuse than older men. first, women live longer and with chronic impairments for which they may need support in the home and community. second, older women are less likely to have adequate pensions and other benefits than older men, giving them fewer resources to ensure their independence. finally, women across the lifespan brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 5 experience cumulative disadvantages and lower status than men, leaving them more vulnerable to abuse and neglect in old age. purpose the purpose of this series of articles is to discuss the current state of knowledge about abuse of older women. it explores various definitions of neglect, abuse and violence against older adults and discusses whether there are agreed upon definitions of neglect, abuse and violence against older women. it addresses main forms or categories, prevalence and risk factors of neglect, abuse and violence against older women, as well as health consequences of violence and abuse, and data sources along with problems in collecting such information. it also provides an overview of needs of older women survivors of neglect, abuse and violence. it discusses preventive measures to address the issue, presenting evaluations of their effectiveness where available. it provides an overview of main approaches to addressing abuse of older women, and key interventions including policies and programs for the protection of older women victims of abuse along with outcomes where evaluations have been completed. finally, recommendations are offered for further improvement of policies in these areas. this paper focuses on definitions of neglect, abuse and violence against older adults based on current conceptualizations of abuse. it proposes that there are three dominant conceptual frameworks for understanding neglect, abuse and violence against older women. these are: older adult mistreatment, informed by social gerontology and using a definition proposed in the toronto declaration on elder mistreatment (14); older adult protection, informed by geriatrics using a definition that was formalized by the national research council (15); and intimate partner violence or domestic violence against older women, informed by feminist gerontology and adapting a definition originally formulated by the usa centers for disease control (cdc) (16). a fourth, a human rights perspective, is an emergent framework for examining abuse of older women, and is currently under development (17) (bridget sleap, senior policy advisor, helpage international, personal communication, august 8, 2013). differing definitions have led to research findings, policy responses, and programs and practices that may appear contradictory and confusing to those not familiar with the field of elder abuse and neglect (18). each is linked to different assumptions and theoretical explanations for abuse of older women, and interventions including policies, and programs and practices to prevent and end neglect, abuse and violence against older women. forms of abuse main forms of abuse used to categorize mistreatment of older women include: physical, sexual, psychological (also called emotional, verbal and non-physical) abuse, financial (also called material) exploitation, neglect, and violation of personal rights (19). different conceptual frameworks use a combination of different forms to operationalize abuse. the elder mistreatment and older adult protection frames use most of the forms cited above, with the possible exception of violation of personal rights, sometimes termed social abuse (20). the intimate partner violence (ipv) frame uses physical, sexual, and psychological forms of abuse, and sometimes violation of personal rights, but not neglect and usually not financial exploitation (unless included in a measure of psychological abuse) (16). physical/sexual: some studies of older women and abuse categorize sexual abuse as a sub-set of physical abuse. physical abuse includes actions intended to cause physical pain or injury to an older adult, such as pushing, grabbing, slapping, hitting, or assaulting with a weapon or thrown object. sexual abuse can include offensive sexual behaviors as well as physical contact of a sexual nature (14). brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 6 psychological: this form of abuse is also called verbal or emotional abuse, which may be further defined as active or passive. this describes actions intended to inflict mental pain, anguish or distress on an older person (19). qualitative research studies have examined forms of psychological abuse against women in greater depth. montminy (21) found 14 types of psychological abuse, which can be active or passive, perpetrated by intimate partners against older women. these include: control, denigrate, deprive, intimidate, threaten, abdicate responsibility, manipulate, blame, harass, negate victim’s reality, sulk, infantilize, show indifference, and provoke guilt. in ipv studies, financial exploitation or material abuse (use of property or possessions without victims’ permission) can be a subset of psychological abuse. also in ipv research, psychological abuse may be limited to threats of physical or sexual violence. neglect: the national research council (nrc) definition of elder abuse, with its inclusion of vulnerability as a core concept associated with victims, provides the most explicit link with neglect of older care dependent adults. this definition is further operationalized to include neglect as an “omission by responsible caregivers that constitutes ‘neglect’ under applicable federal or state law” and caregiver as “a person who bears or has assumed responsibility for providing care or living assistance to an adult in need of such care or assistance” (15). it is further operationalized as refusal or failure of these responsible for providing a caredependent older adult with assistance in daily living tasks or essential supports such as food, clothing, shelter, health and medical care. this can also include desertion of a care dependent older adult, also called abandonment (14). there is no overarching theoretical framework for elder abuse (22). this makes it difficult to operationalize neglect of older women as part of a larger discussion of neglect, abuse and violence. in addition, in spite of a general observation that older adult caregiving dyads are most likely female (23), there is a paucity of studies that focus on neglect as a form of elder abuse perpetrated against elderly care dependent women by female formal or informal caregivers. research and discussions that link caregiving of care dependent older adults and neglect by caregivers in general are either gender neutral or treat gender as a study variable. financial exploitation and material abuse: this form of abuse describes actions of illegal or improper use of an older person’s money, property or assets. women have been found to be especially vulnerable to this form of abuse and were twice as likely to be victims of financial abuse as men in a recent study conducted in the usa (24). most victims in this study were between the ages of 80 and 89 years old, lived alone, and had some care needs that required help in their homes. violation of personal rights: linked to the concept of individual human rights, this form of abuse includes the infringement of personal rights as a form of elder abuse (19). it includes behaviors that violate an older person’s right to privacy, right to autonomy and freedom, and right to have access to family and friends. this form of abuse is also known as social abuse (20). definitions, differences and agreements most professionals in the field of elder abuse agree that lack of a generally accepted definition of abuse, mistreatment or maltreatment of older adults is a barrier to understanding this social problem. the lack of a commonly accepted definition of elder or older adult abuse is also a challenge for understanding the abuse of older women from a global perspective. because definitions tend to use similar language in different frameworks, it can be confusing to differentiate among them. the discussion below attempts to clarify some of this definitional confusion. brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 7 purposes of definitions definitions of elder abuse and neglect are used for research, particularly prevalence and population studies, policy and program development, and practice. three influential definitions reflecting divergent underlying assumptions about elder abuse and abuse of older women have guided research and policy decision making. they are presented here. mistreatment of older adults (elder mistreatment) in the toronto declaration on the global prevention of elder abuse, elder abuse is defined as “a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person. it can be of various forms: physical, psychological, emotional, sexual, and financial or simply reflect intentional or unintentional neglect” (14). this is linked to the active ageing concept of older adulthood, in which older women and men are considered to have the capacity to be productive contributors to society (25). this definition originated with a united kingdom ngo, action on elder abuse in 1995 (26), and was adopted by an expert group on elder abuse from the international network for the prevention of elder abuse (inpea) and the world health organization (who) that met in toronto, canada in 2002. age of the victim is not defined as part of this definition but is usually 60 years of age and older in studies that use this definition, because they tend to focus on older adults living in the community. this definition used in elder abuse research, policy and practice formulation is influenced by social gerontology. critics of the who definition state that while it has become popular for policy purposes, it is difficult for researchers to operationalize and includes data elements, such as ‘appropriate action’, ‘expectation of trust’, and ‘distress’, which are largely subjective. the use of ‘a single or repeated acts’ as a baseline measure has been identified as ambiguous (26). ‘trusting relationship’ is a key concept in both elder mistreatment and older adult protection frameworks. this speaks to the nature of the relationship between older adult victims and perpetrators of abuse: crimes committed against older women by strangers are not defined as elder abuse in these research frames. this is not the case in ipv research, where rape and other forms of violence can be perpetrated against girls and women of all ages through casual dating experiences and by strangers. abuse of vulnerable adults (older adult protection) abuse of vulnerable older adults refers to “intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder, or failure by a caregiver to satisfy the elder’s basic needs or protect the elder from harm” (15). this definition of elder abuse was developed by an expert panel (panel to review risk and prevalence of elder abuse and neglect) convened by the national research council of the united states national academy of science for the purpose of creating a suggested uniform definition and operationalized data elements on elder abuse for research, policy, and program development and practice purposes. in this definition, self-neglect, victimization by strangers, and intimate partner abuse of older adults, unless vulnerability exists above and beyond old age, is not considered elder mistreatment (27). the conceptualization of elder abuse victims as frail and vulnerable older adults in need of protection falls under this definition. care dependent older adults in home or institutional care settings with physical, mental or cognitive impairments, including alzheimer’s disease, may be viewed as potential victims of physical or emotional abuse, neglect, or financial brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 8 exploitation by family or professional caregivers with whom they have the expectation of a relationship of trust. the vulnerable older adult conceptualization of elder abuse has been criticized as reflecting too closely the measures used in child abuse (18). while the toronto definition is broad, the definition promoted by the us national research council on elder mistreatment has been criticized as overly narrow in defining victims as vulnerable, rendering it unusable for studies on late life domestic violence life, which can be experienced by able-bodied older people (26), and in precluding self-neglect. it has also been criticized as too broad in other definitional elements, such as “any harm ... and can include but is not limited to”, which allows too much discretion and latitude (26). the concept of vulnerable adult, which is a key dimension of the nrc definition, has been criticized for being ambiguous and meaning different things in different frames. goergen & beaulier (28) have engaged in a critical analysis to better understand the concept of vulnerability within the context of elder mistreatment. in the elder mistreatment frame, older adults may range from unimpaired and independent to impaired and dependent, with only the latter group identified as vulnerable. in the contemporary feminist frame, often older women are assumed to be vulnerable based on age alone, and grouped with other categories of marginalized women as reflected in the panel for international women’s day sponsored by un women at the united nations, new york, on march 8, 2013. intimate partner violence against girls and women of all ages intimate partner abuse is defined as violence against women that “incorporates intimate partner violence (ipv), sexual violence by any perpetrator, and other forms of violence against women, such as physical violence committed by acquaintances or strangers (28). this definition was developed by an expert panel convened by the united states centers for disease control and prevention in 1996 to formulate a uniform definition and recommended data elements for gathering surveillance data on intimate partner violence. it was intended to promote consistency in data collection for public health surveillance and as a technical reference for automation of the surveillance data (29). operationalized data elements broaden the scope of this definition somewhat. the victim is anyone who is the target of violence or abuse. the perpetrator is the person who inflicts the violence or abuse or causes the violence or abuse to be inflicted on the identified victim. in this definitional set, the perpetrator is assumed to be an intimate partner, defined as current or former spouse or common-law spouse, and current or former non-marital partner including dating partner (heterosexual or same sex), boyfriend or girlfriend. violence can include physical, sexual, threat of physical or sexual violence, and psychological or emotional abuse. psychological abuse is defined apart from threat of physical or sexual abuse to include humiliating the victim, controlling the victim’s behavior, withholding information from the victim, getting annoyed if the victim disagrees with perpetrator, deliberately doing something that makes the victim feel diminished, using the victims’ money, taking advantage of the victim, disregarding what the victim wants, isolating the victim from family or friends, prohibiting the victim’s access to transportation or telephone, getting the victim to engage in illegal activities, using the victims’ children to control victims’ behavior, threatening loss of custody of children, smashing objects or destroying property, denying the victim access to money or other basic necessities, and disclosing information that would tarnish the victims’ reputation. it also includes consequences such as impairment, injury, disability and use of health, mental health and substance abuse services (29). this conceptualization of abuse is not necessarily gender or age specific although it typically is applied to analyses of abuse and violence toward women of reproductive age. it does not brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 9 define the victim as incapacitated or care dependent. financial or material exploitation if included at all is defined as a form of psychological abuse. it assumes a power and control relationship between the victim and perpetrator. according to this definition, sexual abuse could be perpetrated by an acquaintance or stranger; physical abuse could be perpetrated by a one-time date. violence the world health organization (who) has used another definition of violence for a multicountry study of intimate partner violence against women. in this definition, violence is defined as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that results in or has a high likelihood of resulting in injury, death, psychological harm, or deprivation (30). it links intentionality with the commitment of the violent act, and] links the acts to a power relationship. this includes threats and intimidation as well as physical violence. it also includes neglect and all types of physical, sexual and psychological abuse, as well as selfabusive acts such as suicide (31). this definition of violence against women was used in the who multi-country study on women’s health and domestic violence against women focused on intimate partner abuse of women that includes physical and sexual violence, emotional abuse, controlling behaviors and physical violence in pregnancy. it also includes a life course perspective on violence by non-partners since 15 years of age, and childhood sexual abuse before 15 years of age. victim subjects were defined as ever partnered (currently or in the past) and even though the definition of victim did not specify age, in this study subjects were between the ages of 15-49 (22). lifetime abuse prevalence is sometimes calculated across the lifespan for girls and women of all ages: this provides a relatively standardized prevalence measure that can be used to compare abuse rates across cohorts of women into old age (32). human rights and abuse of older people human rights is a recent conceptual framework that was the subject of discussion in fora like the expert group meeting on neglect, abuse and violence of older women and the elder abuse symposium sponsored by the elder abuse interest group at the 2013 gerontological society of america meeting. the human rights framework is believed by some elder abuse experts to hold promise for understanding neglect, abuse and violence against older women in a holistic way without the potential for fragmentation of other frameworks (33). while it is still too early to propose a human rights theory of neglect, abuse and violence against older women, some of the elements of such a theory can be tested using existing data. this includes applying a life course perspective using longitudinal data, and focusing on the experiences of older women specifically, not older people in general or women in general. it also includes awareness of intersectionality, specifically related to gender and age, but also including race/ethnicity, class, access to health and mental health, and relationships. including the concept of intersectionality begins to draw on a human rights framework. this states that human rights are interdependent and the level of enjoyment of any one right is dependent on the level of realization of the other rights. the convention for the elimination of all forms of discrimination against women (cedaw) and the cedaw general recommendation no. 27 (human rights of older women) lay out the rights of older women to live lives of dignity free of discrimination and abuse (34). the human rights framework defines older adults as rights bearers, because they have a right to live lives of dignity, free of abuse, and family members and caregivers as duty bearers, to explain their obligation to ensure that older adults to whom they are related or to whom they brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 10 have a commitment to provide care. the state (government) is a duty enforcer, with the obligation to ensure that the rights of older people are upheld, and sometimes are duty bearers, when the state is directly responsible for older people’s care. the most recent research on older adults and abuse using this framework has been undertaken by helpage international in collaboration with the london school of economics. each of the frameworks used to study and understand neglect, abuse and violence against older women leads to different and conflicting findings, including prevalence and risk factors associated with the neglect, abuse and violence. in the next issue of the journal, findings from prevalence and qualitative studies as well as risk factors will be presented and discussed. acknowledgment dr. patricia brownell served as consultant to the united nations department of economic and social affairs (desa) in drafting a paper on neglect, abuse and violence against older women. in november 2013, the un desa held an expert group meeting (egm) inviting researchers and other experts from around the world to new york city to review the state of knowledge, gaps and next steps to address this area of human rights violations against women and older people. conflicts of interest: none declared. references 1. united nations population fund. ageing in the twenty-first century: a celebration and a challenge, united nations: new york, 2012. 2. united nations department of economic and social affairs. neglect, abuse and violence against older women, 2013: http://undesadspd.org/ageing/resources/papersandpublications.aspx (accessed: december 20, 2013). 3. united nations. political declaration and madrid international 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(eds.) world report on violence and health. geneva, switzerland: world health organization, 2002. 30. garcia-moreno c, jansen ha, ellsberg m, heise l, watts c. who multi-country study on women’s health and domestic violence against women: initial results on prevalence, health outcomes and women’s responses. geneva, switzerland: world health organization, 2005. brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 12 31. garcia-moreno c, pallitto c, devries h, stöckl h, watts c, abrahams n. global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. geneva, switzerland: world health organization, 2013. 32. united nations. convention on the elimination of all forms of discrimination against women: general recommendation no. 27 on older women and protection of their human rights,2010:http://daccessddsny.un.org/doc/undoc/gen/g10/472/53/pdf/g1047253.p df?openelement. 33. united nations human rights. human rights indicators: a guide to measurement and implementation. united nations human rights office of the high commissioner, geneva, switzerland, 2012. 34. centre for analysis of social exclusion (case) and helpage international. developing an indicator-based framework for monitoring older people’s human rights: panel, survey and key findings for peru, mozambique and kyrgyzstan. london, uk: case report 78, 2013. ___________________________________________________________ © 2014 brownell; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. malik ks, adoubi a, kouadio k, kouamé j, hounsa a, sackou j. overweight and obesity among women living in peri-urban areas in west africa (original research). seejph 2019, posted: 09 september 2019. doi 10.4119/unibi/seejph-2019-222 1 original research overweight and obesity among women living in peri-urban areas in west africa koussoh simone malik1, anicet adoubi2, kouamékouadio3, jérôme kouamé4, annita hounsa4, julie sackou4 1 cardiology unit, national institute of public health, abidjan, côte d’ivoire; 2 medical sciences training and research unit, cardiology department, university of bouaké, bouaké, côte d’ivoire; 3 eco epidemiology unit, department of environmental health, institut pasteur of côte d’ivoire, abidjan, côte d’ivoire; 4 department of public health, hydrology and toxicology, training and research unit of pharmaceutical and biological sciences, félix houphouët boigny university, abidjan, côte d’ivoire. corresponding author: malik koussoh simone; address: cardiology unit, national institute of public health of côte d’ivoire, bp v 47 abidjan, côte d’ivoire. telephone: +225-01-24-61-25; e-mail:simone.malik@medecins.ci mailto:simone.malik@medecins.ci malik ks, adoubi a, kouadio k, kouamé j, hounsa a, sackou j. overweight and obesity among women living in peri-urban areas in west africa (original research). seejph 2019, posted: 09 september 2019. doi 10.4119/unibi/seejph-2019-222 2 abstract aim: this study assessed selected correlates of overweight and obesity among women in a sub-urban population of abidjan, côte d’ivoire. methods: a cross-sectional study was conducted during april-may, 2014 in abobo-anonkoi 3, a peri-urban city of abidjan in côte d’ivoire. women of 18 years and older healthy in appearance were randomly recruited from households. overweight and obesity were measured by bmi respectively greater or equal to 25 and 30 kg/m2. abdominal obesity was defined by waist to hip ratio greater or equal to 0.80. the level of physical activity was evaluated by the ipaq questionnaire and the blood pressure according to the criteria of the jnc7 report. a regression analysis of the associated factors with overweight and obesity (age, marital status, level of study, level of physical activity, blood pressure, and socioeconomic status) was carried out. results: we visited 486 households in which 398 women were approached and 327 agreed to participate in the survey. the average age was 35.25 ± 12.4 years. the prevalence of overweight was 27.2% and that of obesity was 19.6%; 72.2%of women had abdominal obesity. the prevalence of abdominal obesity was 90.6% among obese people. age (p=0.006), marital status (p=0.002) and blood pressure (p=0.004) were significantly associated with obesity. with regard to abdominal obesity, there was a significant association of educational level in addition to the above factors. conclusion: overweight and obesity are a reality in this population of côte d’ivoire and about one in five people are affected by the scourge of obesity. keywords: abdominal obesity, africa, central obesity, overweight, women. malik ks, adoubi a, kouadio k, kouamé j, hounsa a, sackou j. overweight and obesity among women living in peri-urban areas in west africa (original research). seejph 2019, posted: 09 september 2019. doi 10.4119/unibi/seejph-2019-222 3 introduction in 2016, more than 1.9 billion adults, 18 years and older, were overweight and these over 650 million were obese (1) projections show that by 2030, about 2.16 billion adults will be overweight and 1.12 billion adults will be obese (2). the global prevalence estimate showed that the proportion of obese adults rose from 28.8% in 1980 to 36.9% in 2013 among men and from 29.8% to 38% among women (3). these increases have been observed in both developed and developing countries (3). in africa, in 2008, 26.9% of the adult population was overweight or obese (4). overweight and obesity are risk factors for chronic diseases such as cardiovascular disease, diabetes and some cancers (5). certain events in women's lives (childbirth, menopause) could promote the development of obesity (6). thus, several studies on obesity conducted both in developed countries and in africa, particularly in urban areas, have established that the prevalence of obesity was often higher among women (7-10). obesity affects women more often than men (11). in côte d'ivoire, the world health organization steps survey (measures of risk factors for chronic diseases) revealed a prevalence of overweight and obesity of 32.2% among the adult population in 2005 in the lagoon region, in the south of the country, which includes the city of abidjan (8). the same study confirmed a higher prevalence of overweight and obesity among women of 37.6% compared to 24.6% among men. the 2011 2012 demographic and health survey in côte d'ivoire reported an overweight prevalence of 19% and obesity of 6.6% among women of reproductive age (10). in these studies conducted in côte d'ivoire, the factors associated with overweight and obesity in women have been underresearched in the peri-urban environment. this environment is at the junction of urban and rural areas, it is distinct from these two areas in relation to eating habits (12). it is also an important place for epidemiological, demographic, social and nutritional transition (2). however, demographic, social, epidemiological and nutritional transitions are inseparable (11,13). the corollary of this transition in the field of nutrition is the substitution of problems of overweight and obesity for problems of nutritional deficiencies (13). thus, one marker of the ongoing nutritional transition is the increase in obesity (11). diet is the leading cause of overweight and obesity (11). what factors other than diet are associated with overweight and obesity in women in this particular space that is the peri-urban environment? to answer this question, we conducted a study to determine the prevalence and factors associated with overweight and obesity in women. methods framework of the study this survey was conducted in the autonomous district of abidjan. it was carried out in households in the anonkoi 3 district located in the municipality of abobo, which is the second most populated municipality in the autonomous district of abidjan after yopougon, with a density of 167 inhabitants per square kilometre (14). the autonomous district of abidjan is located in the lagoons region in the south of côte d'ivoire (15). type and period of study this was a cross-sectional study conducted from 24 april to 23 may 2014. the sample size was calculated using the formula: n = p (1-p) z2/i2 with n: sample size; p: prevalence of overweight and obesity 32.2%; z=1.96 for a 5% risk of error and i: accuracy (5%). malik ks, adoubi a, kouadio k, kouamé j, hounsa a, sackou j. overweight and obesity among women living in peri-urban areas in west africa (original research). seejph 2019, posted: 09 september 2019. doi 10.4119/unibi/seejph-2019-222 4 the sample size calculated was 336. considering a response rate of 80%, the minimum sample size was 420. sampling strategy the neighbourhood of anonkoi 3 is a village in the commune of abidjan. in this neighbourhood households are not numbered. in the general census of the population in 1998, the neighbourhood had 474 households (16). however during a comprehensive study in this area, sackou kouakou et al. identified 668 households (14). therefore, we conducted a random sample, we calculated a sampling interval of two (668/336 = 1.98). we considered household no. 1 the first household found when we had access to the area, and we visited one in two households. population the study included all women 18 years of age and older who were not in bed and were present at the time of the survey. women who were pregnant or breastfeeding were not included. in each household visited, the woman aged 18 and over present was selected. in the presence of more than one woman 18 years of age or older, only one was randomly selected. data collection data collection was based on a pre-tested questionnaire with the free and informed consent of the person selected (written or oral consent). overweight and obesity were defined from the quételet body mass index (17).overweight is defined as having a bmi greater than or equal to 25 and lower than 30 kg/m2; obesity is defined as having a bmi greater than or equal to 30. height was measured by a tape measure and weight by a camry® brand scale model scal160 that can support up to 160 kg. abdominal obesity was measured by a tape measure and defined as a waist circumference (wc) to hip circumference (th) ratio greater than 0.80 (18). the level of physical activity was assessed by the ipaq questionnaire which defined 3 categories of persons: category 1 (inactive or insufficiently active) category 2 (sufficiently active) category 3 (very active). blood pressure (bp) was measured with an omron electronic blood pressure monitor with an arm cuff after five minutes rest. women with systolic blood pressure greater or equal to 140 mmhg and/or diastolic blood pressure greater or equal to 90 mmhg with or without treatment were considered to have high blood pressure. systolic blood pressure below 90 mmhg and/or diastolic blood pressure below 60 mmhg were considered low blood pressure. the level of education was categorized into four (no education, primary level, secondary level and higher level) (19). the socioeconomic level was assessed by the poverty score or wealth index calculated on the basis of asset ownership. the wealth index was calculated using data on the ownership of assets selected by a household (e.g. televisions, bicycles, cars, materials used for housing construction, types of access to water and sanitation). the relative wealth scale was then classified into five categories (poorest, poor, middle, rich and richest) according to the quintile of the sample (19). other factors associated with overweight and obesity that were collected were age andmarital status. ethical considerations survey participants were informed of the reasons for the study. they all have accepted to fill out a personal identification form and submit to taking the settings. their free and informed consent was obtained before the investigation began. they were free to withdraw from the investigation at any time without prejudice. the data were collected anonymously. malik ks, adoubi a, kouadio k, kouamé j, hounsa a, sackou j. overweight and obesity among women living in peri-urban areas in west africa (original research). seejph 2019, posted: 09 september 2019. doi 10.4119/unibi/seejph-2019-222 5 data analysis the data were entered on the epi data software (version 3.1) and analyzed with the spss software (version 22.0). the quantitative variable bmi was transformed into a categorical variable with 4 modalities: lean, bmi less than 18.5; normal, bmi between 18.5 and 24.9; overweight, bmi between 25 and 29.9 and obese, bmi greater than or equal to 30. the ratio tt/th has been transformed into a binary variable (less than 0.80: no; greater or equal to 0.80: yes). the search of factors associated with bmi was done in two stages. first, we performed a univariate analysis using the pearson khi two test at the 0.05 significance level.in this analysis, bmi was considered as a qualitative variable with four modalities (skinny, normal weight, overweight and obesity). then, the variables having a value less than 0.05 p were included in a logistic regression model. for regression model, bmi (the dependent variable) has been categorized into two modalities (obesity / non-obesity). the non-obesity modality resulted from the combination of skinny, normal and overweight modalities. the adjusted odds ratio and the confidence intervals at 95% were calculated. results four hundred and eighty-six (486) households were visited. in 88 households there was no woman and in 398 households there was at least one woman aged 18 and over whom we approached. among them, 46 did not meet the inclusion criteria (29 were pregnant and 17 were bedridden). finally, 327 agreed to participate in the survey. the response rate was 93%. the average age was 35.25 years and the standard deviation was 12.40 years. the participation rate was 67.3%. the overall prevalence of overweight and obesity was 46.8%. the prevalence of overweight was 27.2% (89 women) and 64 women were obese (19.6%). table 1 presents the socio-demographic characteristics and association between women's bmi and the analyzed different factors. about 2 in 5 women had no education and just over 20% had only primary education. almost 3 out of 5 women were married. the prevalence of high blood pressure was 26%. very active women represented less than 2% of our study population. in this environment, the poor and the poorest represented nearly 60% of the population. the association between body mass index and age was significant. indeed, overweight and obesity were observed mainly between 30 and 45 years of age (54.68% obese, p=0.006). a significant association was also found between body mass index and marital status. married women were more overweight and obese (p=0.002). in addition, overweight and obese women had higher blood pressure (p=0.004). the factors involved in obesity are presented in table 2. according to our study, the factor involved in the onset of obesity is age. the 30-45 age group is three times more likely to be obese than other age groups. malik ks, adoubi a, kouadio k, kouamé j, hounsa a, sackou j. overweight and obesity among women living in peri-urban areas in west africa (original research). seejph 2019, posted: 09 september 2019. doi 10.4119/unibi/seejph-2019-222 6 table 1. socio-demographic characteristics and association between women's bmi and the analyzed different factors in anonkoi 3 variable number (%) n=327 (100 %) skinny n=18 (5.50%) normal n=156 (47.71%) overweight n=89 (2.21%) obese n=64 (19.57%) p age (years) 15-30 31-45 >45 128 (39.14) 129 (39.45) 70 (21.41) 8(44.45) 4(22.23) 6(33.33) 76 (48.72) 52 (33.33) 28(17.95) 29 (32.58) 38 (42.70) 22 (24.72) 15 (23.44) 35 (54.68) 14 (21.88) 0.006 marital status married single and widows 184 (56.27) 143 (43.73) 8(44.45) 10(55.55) 73 (46.79) 83 (53.21) 61 (68.54) 28 (31.46) 42 (65.63) 22 (34.37) 0.002 level of study none primary secondary higher 127 (38.84) 68 (20.8) 106 (32.41) 26 (7.95) 12 (66.67) 2 (11.11) 3 (16.67) 1 (5.55) 51 (32.69) 30 (19.23) 59 (37.82) 16 (10.26) 39 (43.82) 22 (24.72) 25 (28.09) 3 (3.37) 25 (39.06) 14 (21.88) 19 (29.68) 6 (9.38) 0.106 level of physical activity inactive active very active 170 (51.99) 151 (46,18) 6 (1.83) 10 (55.56) 7 (38.88) 1 (5.56) 77 (49.36) 77 (49.36) 2 (1.28) 46 (51.68) 41 (46.07) 2 (2.25) 37 (57.81) 26 (40.63) 1 (1.56) 0.761 blood pressure high normal low 85 (26.0) 188 (57.49) 54 (16.51) 4 (22.23) 6 (33.33) 8 (44.44) 33 (21.15) 96 (61.54) 27 (17.31) 23 (25.84) 55 (61.80) 11 (12.36) 25 (39.06) 31 (48.44) 8 (12.50) 0.004 socioeconomic situation very poor poor middle income rich very rich 61 (18.65) 127 (38.84) 88 (26.91) 33 (10.10) 18 (5.5) 6 (33.33) 8 (44.44) 3 (16.67) 1 (5.56) 0 (0.0) 28 (17.95) 62 (39.74) 42 (26.92) 19 (12.18) 5 (3.21) 15 (16.85) 31 (34.83) 28 (31.46) 8 (9.00) 7 (7.86) 12 (18.75) 26 (40.62) 15 (23.44) 5 (7.81) 6 (9.38) 0.51 table 2. relationship between the analyzed factors and the risk of being obese in anonkoi 3 independent variables n obesity (%) no obesity (%) adjusted or 95%ci age group 15 – 30 128 15 (23.44) 113 (42.97) 1.00 reference 30 – 45 129 35 (54.68) 94 (35.74) 2.80 1.44-5.44 45 – 60 70 14 (21.88) 56 (21.29) 1.88 0.84-4.16 marital status married 184 42 (65.63) 142(54.00) 1.62 0.91-2.87 single and widow 143 22 (34.37) 121(46.00) 1.00 reference blood pressure high bp 85 25 (39.06) 60(22.81) 2.39 0.98-5.79 normal bp 188 31 (48.44) 157(59.70) 1.13 0.48-2.64 low bp 54 8 (12.50) 46 (17.49) 1.00 reference or: odds ratio; ci: confidence interval; 1: reference category. malik ks, adoubi a, kouadio k, kouamé j, hounsa a, sackou j. overweight and obesity among women living in peri-urban areas in west africa (original research). seejph 2019, posted: 09 september 2019. doi 10.4119/unibi/seejph-2019-222 7 the prevalence of abdominal obesity was 90.6% among obese people. the different associations between abdominal obesity and factors are presented in table 3. the association between abdominal obesity and age was significant. indeed, abdominal obesity was observed in the 30-45 and 4560 age groups (p=0.001). the 30-45 age group is three times more likely to have abdominal obesity than the 15-30 age group. similarly, the 45-60 age group is four and a half times more likely to have abdominal obesity than the 15-30 age group. this abdominal obesity was also higher among women with no education and those with only primary education (p=0.004). thus, women with no education and those with primary education are three times more likely to have abdominal obesity than those with higher education. abdominal obesity was also higher in married women (p=0.002) and those with high blood pressure (p<103). married women are twice as likely to have abdominal obesity as those without a partner. women with high blood pressure are five times more likely to have abdominal obesity than women without high blood pressure. table 3. association between abdominal obesity among women (n=327) and the analyzed different factors in anonkoi 3 abdominal obesity or 95%ci p no n=91 n (%) yes n=236 n (%) age group 15 – 30 55(60.44) 73(30.93) 1.00 reference <0.001 30 – 45 26(28.57) 103(43.65) 2.98 1.71-5.19 45 – 60 10(10.99) 60(25.42) 4.52 2.12-9.62 level of study none 27(29.67) 100(42.37) 2.72 1.11-6.59 0.004 primary 13(14.29) 55(23.31) 3.10 1.15-8.31 secondary 40(43.95) 66(27.96) 1.21 0.50-2.89 higher 11(12.09) 15(6.36) 1.00 reference marital status married 39(42.86) 145(61.44) 2.12 1.30-3.47 0.002 single and widows 52(57.14) 91(38.56) 1.00 reference blood pressure (bp) high bp normal bp low bp 10(10.99) 59(64.84) 22(24.17) 75(31.78) 129(54.66) 32(13.56) 5.15 1.50 1.00 2.19-12.11 0.802.80 reference <0.001 or: odds ratio; ci: confidence interval; 1: reference category. discussion in our study, almost half of the women were overweight, about 20% of whom were obese. this prevalence shows that one in five women is at risk of developing a cardiovascular pathology, as some authors confirm. these reported that women are becoming increasingly at risk for non-communicable diseases or associated comorbidities including hypertension, diabetes, cancer and stroke (20). this obesity was related to various factors including age (between 30 and 45 years), marriage and high blood pressure. the active 30-45 age group is the obese age malik ks, adoubi a, kouadio k, kouamé j, hounsa a, sackou j. overweight and obesity among women living in peri-urban areas in west africa (original research). seejph 2019, posted: 09 september 2019. doi 10.4119/unibi/seejph-2019-222 8 group. these young adults are thus at higher risk of developing cardiovascular disease and dying prematurely, posing a serious threat to the economies of countries in sub-saharan africa (21,22). the prevalence of overweight and obesity increases steadily with age in developing countries (9,23). some studies in nigeria, cameroon and togo found an association between age and obesity later (after 40 years) than found in our study (9,23,24). the association between marital status and obesity can be explained by the fact that people after marriage have less physical activity, change their diet and may be less concerned about their weight (25). this is the observation in african society where culture considers that being overweight is a sign of material ease (19). the prevalence of overweight and obesity is high in peri-urban areas, in the middle of the epidemiological transition. this high prevalence could be explained by the culture and lifestyles of our population. indeed, in developing countries there is a shift from a low-fat diet and a physically active life to a diet richer in saturated animal fat and a sedentary lifestyle (2). overweight and obesity are no longer only predominant in high socioeconomic backgrounds, but this burden in developing countries is shifting to low socioeconomic groups and particularly to women (26). our work confirms the relationship between obesity and high blood pressure (27). high blood pressure is more frequent in obese subjects and hypertensive subjects develop overweight more easily. this epidemiological observation explains the link between high blood pressure and obesity. in addition, obesity potentiates the presence and severity of other cardiovascular risk factors (28). an excess weight of 10 kg is associated with an increase of 3 mmhg in systolic blood pressure and 2.3 mmhg in diastolic blood pressure. in anonkoi 3, the prevalence of abdominal obesity was also high (near ¾ of our total population and almost all obese women). waist circumference is a simple indicator of excess abdominal fat in adults. excess abdominal fat is associated, independently of bmi, with the development of metabolic and vascular complications of obesity (24,27). indeed, abdominal obesity, a toxic form of obesity, is a complex dysmetabolic state at the origin of a profound disorder of blood pressure, vascular endothelium and energy homeostasis. thus, at equivalent bmi, subjects with abdominal obesity develop more cardiovascular complications. beyond weight, the type of obesity has an even greater influence on the prognosis of patients (28). our study found that women with no education and those with only primary education are more overweight or obese. the lower the level of education, the higher the prevalence of obesity. in recent years, obesity rates have increased in all education groups, but more rapidly among less educated women (29). according to the centre de recherche pour l'étude et l'observation des conditions de vie (crédoc), those who have a healthy diet (more fruits and vegetables, higher nutrient intakes, better food indices) are those who have higher degrees. they are more interested in the links between nutrition and health (30). however, some studies have reported that women with a high level of education were more overweight or obese (25). study limitations however, we noted some limitations in our study. the number of study participants was lower than the anticipated sample size. this is partly due to the fact that in more than 10% of households, there were no women. moreover, we considered as married women, all women legally married or living in a couple. as far as parity is malik ks, adoubi a, kouadio k, kouamé j, hounsa a, sackou j. overweight and obesity among women living in peri-urban areas in west africa (original research). seejph 2019, posted: 09 september 2019. doi 10.4119/unibi/seejph-2019-222 9 concerned, it has not been sought. we considered snacking as diet data. in addition, it is a cross-sectional study over a relatively short period and for which there could be bias in the design. these biases could be related to the nonrepresentativeness of the sample, the mode of selection of households and women in households. we did not take into account the number of women eligible for the survey in each household visited, we limited ourselves to choosing a single woman. also, information on sociodemographic characteristics, level of physical activity and snacking were assessed using self-reporting which is a source of information bias. conclusion the prevalence of overweight and obesity is high among women in peri-urban areas. this obesity particularly affects young, married women with no education or primary education. our study shows the need for urgent intervention targeted at women with information, education and communication (iec). it is important to fight against this obesity through awareness sessions for women on the consequences of obesity, education sessions and management of this scourge during home visits. conflicts of interest: none declared. acknowledgments: the authors would like to thank the ngo asapsu (urban health self-promotion association) for its contribution during the investigation. we would like to thank also the staff member of the department of public health, hydrology and toxicology, training and research unit of pharmaceutical and biological sciences. references 1. world health organisation. obesity and overweight. available from: https://www.who.int/news-room/factsheets/detail/obesity-and-overweight (accessed: july 23, 2019). 2. popkin bm, adair ls, ng sw. global nutrition transition and the pandemic of obesity in developing countries. nutr rev2012;70:3-21. 3. ng m, fleming t, robinson m, thomson b, graetz n, margono c, et al. global, regional and national prevalence of overweight and obesity in children and adults 1980-2013: a systematic analysis. lancet 2014;384:766-81. 4. yatsuya h, li y, hilawe eh, ota a, wang c, chiang c, et al. global trend in overweight 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2004;94:433-4. 27. ahaneku gi, osuji cu, anisiuba bc, ikeh vo, oguejiofor oc, ahaneku je. evaluation of blood pressure and indices of obesity in a typical rural community in eastern nigeria. ann afr med 2011;10:120-6. 28. pathak a, galinier m, senard j-m. obésitéet maladies cardiovasculaires: physiopathologie, comorbidités et effet de laperte de poids. mt cardio 2007;3:187-92 [in french]. 29. ogden cl, carroll md, mcdowell ma, flegal km. obesity and socioeconomic status in adults: united states, 2005-2008. nchs data brief 2010;51:1-8. 30. recoursf,hébel p, chamaret c. les populationsmodestesont-ellesune alimentation déséquilibrée? paris: credoc (cahiers de recherche); 2006:113 [in french]. ______________________________________________________________________________________ ©2019 malik et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 1 original research health-related behaviour among managers of slovenian hospitals and institutes of public health jerneja farkas1,2, mitja lainscak2, andreja kukec1, mitja kosnik2 1 faculty of medicine, university of ljubljana, ljubljana, slovenia; 2 university clinic of respiratory and allergic diseases golnik, golnik, slovenia. corresponding author: jerneja farkas, md, phd, faculty of medicine, university of ljubljana; address: zaloska cesta 4, 1000 ljubljana, slovenia; telephone: +38615437566; e-mail: jerneja.farkas@mf.uni-lj.si mailto:jerneja.farkas@mf.uni-lj.si farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 2 abstract aim: behavioural risk factors have a significant impact on health. we aimed to assess healthrelated behaviour, health status, and use of healthcare services among managers of slovenian hospitals and institutes of public health. methods: this was a cross-sectional study which included management (directors, scientific directors, directors’ deputies) of slovenian hospitals and institutes of public health (63 respondents; 57% women; overall mean age: 51±7 years; response rate: 74%). data were obtained using an anonymous self-administered questionnaire. results: about 35% of respondents were directors. more than half of the respondents were overweight or obese (52%), the majority were not sufficiently physically active (59%) and overloaded with stress (87%). hypercholesterolemia (36%), spinal disease (17%), and arterial hypertension (16%) were most common chronic diseases. whilst only few participants visited their general practitioner due their health complaints, blood pressure (76%), cholesterol (51%), and glucose (54%) were measured within last year in most of the respondents. conclusion: our findings point to a high prevalence of overweight and obesity as well as workplace-related stress among slovenian public health managers. therefore, effective preventive strategies should be focused on stress management along with promotion of healthy behavioural patterns. keywords: behavioural risk factors, healthy lifestyle, health promotion, healthcare institutions, managers. farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 3 introduction behavioural risk factors such as smoking, excessive alcohol consumption, unhealthy diet, lack of physical activity, and stress have a significant impact on health. previous studies have shown that cardiovascular disease, cancer, diabetes mellitus and some other chronic diseases are main causes of morbidity and mortality in developed countries, which can be largely attributed to unhealthy lifestyle (1). in a large prospective randomized study (n=2,339), knoops and colleagues clearly indicated that individuals who followed the principles of the mediterranean diet, consumed alcohol moderately, were regularly physically active, and refrained from smoking, had significantly lower cardiovascular and cancer mortality when compared to those with at least one behavioural risk factor (2). significant changes in employment policies that have emerged recently have exposed employees to new risks in terms of workplace safety and health. these are not limited to physical, biological and chemical risks, but expand to work-related psychosocial risk in particular (1,3). funding restrictions, constant need for cost reduction, implementation of modern technology and clinical guidelines, as well as increased patient awareness and expectations increase the burden and responsibilities hospital managers need to cope with (3). sounan and colleagues reported about negative associations between performance and health of hospital managers with workload, stress, psychical burden, and burnout they are exposed to (4). furthermore, studies have shown that individual lifestyle pattern of managers also influences attitudes towards preventive activities and health promotion in the organisations they are employed in (5-8). in slovenia, there is scarce information about health-related behaviour and health status of healthcare institution managers. in 2005, stergar and urdih-lazar conducted a survey among slovenian managers about their attitudes towards own and employees’ health and their willingness to implement health promotion programs (9). they mailed 5,500 questionnaires to large, medium and small enterprises and public institutions (including healthcare institutions) and received reply from about one third. respondents were willing to take measures in different lifestyle areas, primarily in the fields of diet, physical activity, and weight management. more than two thirds, mostly those who already had health promotion in place and those who considered there is room for improvement of employees’ health, would take health promotion actions and would be involved personally (9). individual health-related behaviour and healthy lifestyle pattern can translate to wider community, in particular if the individual is in position and has capacity to involve appropriate mechanisms. healthcare institutions should serve as an example for preventive strategies and healthy lifestyle, which should be promoted and organized from a top-down perspective. with little available information, we aimed to assess health-related behaviour, health status and use of healthcare services among managers in slovenian hospitals and institutes of public health. our objectives were to have a snapshot of their daily habits, risk factor and disease burden, as well as their incentives to prevent diseases of modern age. methods study design and subjects in this cross-sectional study, we invited management (directors, scientific directors, directors’ deputies) of slovenian general hospitals, university clinics, regional institutes of public health and national institute of public health – figure 1. information on the composition of each healthcare institution management is publicly available and accessible through healthcare institutions’ websites; thus, we were able to invite all eligible subjects. farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 4 the study was conducted under auspices of slovenian network of health promoting hospitals and health services in collaboration with chair of public health, faculty of medicine, university of ljubljana. the study protocol was revised and approved by the national medical ethics committee. figure 1. healthcare institutions included in the study □ 1-regional institute of public health (riph) koper; 2-riph nova gorica; 3-riph kranj; 4-riph ljubljana; 5-national institute of public health of the republic of slovenia; 6-riph novo mesto; 7-riph celje; 8-riph ravne na koroskem; 9;riph maribor; 10;riph murska sobota. ○ 1-general hospital (gh) izola; 2-gh dr. franca derganca nova gorica; 3-gh jesenice; 4-university clinic of respiratory and allergic diseases golnik; 5-university medical centre ljubljana; 6-university rehabilitation institute of the republic of slovenia; 7-institute of oncology ljubljana; 8-gh novo mesto; 9-gh brezice; 10-gh trbovlje; 11-topolsica hospital; 12-gh slovenj gradec; 13-gh celje; 14-university medical centre maribor; 15-gh dr. jozeta potrca ptuj; 16-gh murska sobota. data collection the “countrywide integrated non-communicable disease intervention (cindi) health monitor core questionnaire”, a standardized, validated and publicly available questionnaire, previously used for national health-related behaviour studies in slovenia (10,11) was used to compile the study questionnaire. anonymity was provided for all participants. overall, 30 questions were organized into three sections: demographic and other basic characteristics, health-related behaviour (smoking status, dietary habits, alcohol intake, physical activity, body weight and height), and health status including use of healthcare services (self-rated health, care for health, healthcare services utilization, diseases, and medication use). questions regarding stress were also included. additionally, we inquired farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 5 about participants’ beliefs regarding the risk factor that predominantly contributes to poor health and high morbidity and mortality burden of the slovenian adult population. to reduce the risk for confounding responses the data collection was designed using a multiple-choice format with obligatory (required) items to be answered. in only five opened questions we inquired about year of birth, number of daily meals, body weight and height, and number of days per week and duration of physical exercise (all numerical values). questionnaires were mailed during april 2012 with study description, an invitation for study participation, and preaddressed return envelope. to enhance the study response, a gentle reminder notice was sent to all participants twice after first invitation and served as acknowledgement of participation (if individuals already responded), or as reminder to complete the questionnaire (if they did not respond to the initial invitation). one unit of fruit or vegetables corresponded to 100g of fruit or vegetables (e.g. two tomatoes, or one bowl of salad, or one pot of turnip for vegetables; one middle sized apple, or one small banana, or one pot of cherries for fruits), as already used previously (10). body mass index (bmi) was calculated as body weight in kilograms divided by square of body height in meters. malnutrition was defined as bmi<18.49 kg/m2, normal nutritional status as 18.50-24.99 kg/m2, overweight as 25.0-29.99 kg/m2, and obesity as >30.0 kg/m2 (12). we inquired about leisure-time physical activity, including type and intensity of exercise (vigorous intensity: aerobics, running; moderate intensity: brisk walking, slow swimming; low intensity: walking), usual number of days with activity per week, and usual duration of exercise (less than, or more than 30 minutes). as per world health organisation (who) recommendations, at least 150 minutes of moderate or more intensive exercise was considered as beneficial for health (13), and subjects were divided into two groups by this cut-off. when asked about contacts with their general practitioner or specialist, only visits related to personal issues were relevant for this study. statistical analysis descriptive statistics were used to present mean values and their respective standard deviations for the numerical variables, and absolute numbers and their respective proportions for the categorical variables. spss, version 19.0 (statistical package for social sciences, spss inc., chicago, illinois, usa) was used for all the statistical analyses. results response rate and study participants’ characteristics we mailed 85 questionnaires to all eligible management members, and received 66 responses (77.6%). of those, three questionnaires were incomplete; thus, our final sample consisted of 63 (74.1%) subjects with an average age of 51.3±7.5 years. most of them were women (57.1%), with at least a university degree (92.1%), and were acting as a director (34.9%). other basic characteristics of study participants are presented in table 1. health-related behaviour most of respondents never smoked (68.3%), whereas 12.7% were current smokers. three daily meals was the most common type of dietary pattern (50.8%), whilst 20.6% and 7.9% of respondents consumed two or five meals, respectively. when consuming dairy products, 74.6% would usually select low-fat products. whole-grain (27.0%), various sorts (25.4%) and white (15.9%) would usually be the first choice of bread. almost two thirds of respondents (63.5%) consumed daily 1-3 units of vegetables and 1-3 units of fruit. most of respondents farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 6 never used salt for served food (57.1%), and the rest would taste food prior to any additional salt. during last year, 19 (30.2%) respondents consumed alcohol few times yearly, 15 (23.8%) consumed alcohol twice a week, and 6 (9.5%) of respondents abstained completely. mean bmi was 25.2±4.2 kg/m2, with 28 (44.4%) subjects being overweight and 5 (7.9%) obese; 50.8% were satisfied with their weight, whereas 30 (47.6%) would have liked to lose weight. car was a usual means of transport for most of respondents (84.1%), and only 7.9% walked or ride a bike to workplace. very intense exercise was not practiced by 28 (44.4%), and the rest were usually active for >30 minutes per session, but mostly only once per week. most individuals (49.2%) practiced moderate exercise up to three times/week, for >30 minutes (63.6%). walking at least five times/week (65.0% of them for >30 minutes) was practiced by 17.5% of participants. who’s criteria for healthy physical activity were not met by 58.7% of respondents. table 1. basic characteristics of study participants basic characteristics number (column percentage) sex: women men 36 (57.1) 27 (42.9) age: 30-39 years 40-49 years 50-59 years 60-69 years 5 (8.0) 18 (28.7) 33 (52.4) 7 (11.2) marital status: married consensual union single divorced widowed 46 (73.0) 7 (11.1) 6 (9.5) 4 (6.3) 0 (0) education: secondary college university master or doctoral degree 1 (1.6) 4 (6.3) 31 (49.2) 27 (42.9) position: director scientific director deputy, nursing deputy, other 22 (34.9) 11 (17.5) 13 (20.6) 17 (27.0) residence community: urban suburban rural 33 (52.4) 16 (25.4) 14 (22.2) tension or stress was reported as daily, frequent and occasional experience by 6.3%, 31.7% and 49.2% of respondents, respectively. workplace was the main cause of stress (73.0%), followed by poor relations with co-workers (20.6%) and family issues (6.3%). figure 2 presents how respondents cope with stress. holiday leave pattern was balanced as 52.4% take few days several times per year and the rest prefers a longer leave. farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 7 we also inquired about participants’ beliefs regarding importance of risk factors for poor health, morbidity and mortality burden in slovenia (figure 3). figure 2. management of tensions, stress and pressures figure 3. the risk factor that predominantly contributes to poor health and high mortality of the adult population in slovenia farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 8 health status and use of healthcare services most of respondents rated their health as good (68.3%), or very good (19.0%). more than half (58.7%) considered they took sufficient care for their health, whereas about a third (28.6%) deemed their care as inadequate. during past year, 50.8% did not see their general practitioner or specialist, 44.4% cumulated three visits, and 4.8% had four or more visits. table 2 summarizes the prevalence of diseases or conditions diagnosed by a doctor and figure 4 provides information about various diagnostic tests. in the week prior to study, 63.5% of respondents regularly took one medication, 25.4% had two, and 9.5% had three drugs. vitamins and minerals (44.4%), medications against headache (27.0%), herbal medications (19.0%), antihypertensives (15.9%) and hypolipemics (12.7%) were the most commonly used medications. table 2. prevalence of diseases or conditions in study participants diagnosed by a doctor discussion among slovenian healthcare institution management, insufficient physical activity, overweight, and stress associated with workplace were most common behavioural risk factors. most of respondents assessed chronic disease risk factors within last three years, perceived their health as good or better and considered they take sufficient care of their health. the most common disease was hypercholesterolemia, with a prevalence higher than the prescription of hypolipemic medications. in comparison to results of “cindi health monitor survey 2008” (n=7,352, aged 25-74 years) managers in our study were somewhat more likely to report healthy dietary habits (e.g. low-fat dairy products, whole-grain bread, several units of fruit and vegetable daily) than the slovenian general population, with no difference in number of daily meals (14). additionally, managers in our study performed less often leisure-time physical activity, whilst frequent or daily exposure to stress was more common and usually associated with workplace burden and poor relations with co-workers. disease or condition number (percentage) arterial hypertension 10 (15.9) hypercholesterolemia 23 (36.5) diabetes mellitus 2 (3.2) myocardial infarction 1 (1.6) angina pectoris 0 (0) heart failure 0 (0) stroke 1 (1.6) diseases and injuries of spine 11 (17.5) arthritis or arthrosis 7 (11.1) chronic obstructive pulmonary disease 0 (0) asthma 3 (4.8) gastric or duodenal ulcer 1 (1.6) liver cirrhosis 0 (0) depression 0 (0) thyroid disease 1 (1.6) farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 9 many healthcare institution managers have medical background thus comparison with previous reports of healthcare workers are possible. fortic reported about regular smoking prevalence in the period 1972-1986, which was 30% among male healthcare workers and 20% among female healthcare workers (15). a recent slovenian national institute of public health study showed that 20.9% of healthcare workers are regular smokers, which is lower than a decade ago, and also lower than among general population. about half (52.9%) started smoking during the secondary school, but 15.6% started during the first years of work in a healthcare institution. moreover, about a quarter reported that employees in their institution are not following the smoking ban (16). similar information about smoking prevalence among healthcare workers is evident from greece, spain, portugal, france, and poland, with figures being the same or higher than among the general population (17). our findings (12.7%), however, are more comparable to a lifestyle survey among 1,770 italian cardiologists (12.4%), which in both cases is relevant and somehow balances inadequate physical activity and exposure to stress (18). figure 4. time periods in which study participants completed various diagnostic tests *women only; **men only. although most slovenian managers would like to stay physically active, this is mostly sporadic or limited to sport and recreational events. the latter is also driven with competitiveness; yet, the results usually are below expectations. importantly, balanced lifestyle with daily physical activity, healthy diet, and relaxation is the key to success and farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 10 satisfaction with daily work (19). our findings are in line with previous reports, as high intensity exercise was sporadic, and moderate intensity exercise was not meeting the quantity goal for health benefits. moreover, overweight or obesity was present in more than half of our respondents, as was dissatisfaction with body weight. european survey of enterprises on new and emerging risks (esener) showed that workplace related stress often induces issues for managers in healthcare and social sector (3). jericek et al. reported an association between stress and healthcare institution workplace specifics, including conflicts among co-workers, potential lack of skills and knowledge needed for patient care, and ever increasing expectations of patients and public (20). similar is mirrored by our finding that as many as 93.6% of respondents reported workplace-related stress that is difficult to manage. it is therefore not surprising that stress (followed by smoking and lack of physical activity) was identified as the most important risk factor contributing to poor health and high mortality among slovenian adult population. to tackle this burden, martincic emphasizes risk management strategies as well as communication, management and coordination skills, along with teamwork and regular assessment of organisational aspects (21). top managers need to recognize safety and health aspects over economical issues, which follows a general strategy in an institution or enterprise (22). healthcare workers need to be aware of their role model in promotion of healthy lifestyles, which also provides additional credibility in daily professional routine (23,24). it is wellknown that healthcare workers, who personally follow healthy lifestyle measures, are more in favour of health promotion and disease prevention activities in their clinical practice (18,2527). in a survey that included 496 swiss doctors, cornuz and colleagues reported that personal lifestyle (more than three units of alcohol daily, sedentary lifestyle, and poor awareness about arterial hypertension) predicted a lower chance of alcohol and smoking advice delivered to the patients (23). howe and colleagues studied personal health behaviours of 183 american hospital doctors in association with patient-related lifestyle counselling and reported an association between regular physical activity (>150min/week) and patient advice to exercise regularly and follow healthy diet (24). similar to this, healthcare institution managers have a similar role model and should give personal examples to foster recognition of preventive activities and health promotion among co-workers and patients. therefore, healthcare institutions have a certain degree of societal responsibility against patients and caregivers, employees, and local community. thus, they should act accordingly (5,6). according to reports of international network of health promoting hospitals and health services, hospital management attitudes are crucial for clinical health promotion among patients, implementation of health promotion activities for employees and quality control (58). we corroborated a previous report by stergar and urdih-lazar (9) for self-rated health, which predominantly was good or better; this is in contrast with results among the general population, where the proportion with good or better self-rated health is halved (14,28), whereas there is little difference in attitudes towards health (14). exact reasons are unknown but could be associated with better socioeconomic status and possibilities to implement healthy lifestyles. chronic diseases like hypercholesterolemia, spinal disease, and arterial hypertension were the most prevalent among our respondents. most of these conditions would require management; yet, the extent of pharmacological therapy was not meeting the epidemiological situation. it may well be that non-pharmacological measures were in place or patients did not meet the risk profile for treatment initiation. it could also be due to personal preferences or discontinuation of therapy. whilst most have had their risk factors assessed within last year, more than half of individuals had no appointment at their general practitioner or specialist. farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 11 managers usually attend their regular health check-ups (every 3-4 years) and in-between these visits, they prefer to have specialist assessment (e.g. cardiologist, sonography, etc.) but rarely make an appointment with their general practitioner (19). average age likely influenced screening for breast cancer, as almost two-thirds had no mammography (available for women between 50-69 years), and cervical carcinoma, with less than half having an exam within last year (29,30). screening for occult gastrointestinal bleeding, colonoscopy and measurement of prostate specific antigen was less common; whilst, this could be a procedure related for colonoscopy, no evident reason for the others was present. our results need to be interpreted in the context of available information and some limitations. cross-sectional studies in the field are lacking thus our findings contribute to present knowledge and action strategies. it also identifies issues that need more investigation to gain additional insight into health-related behaviours, health status, and use of healthcare services among this population. although sample size can be regarded as modest, the response rate in relative terms was considerable. due to study design, selection and recall bias as well as socially desirable answers are possible, particularly for behavioural risk factors. finally, it would be more appropriate to compare our findings to subjects of similar educational level and socioeconomic status rather than to general population, but there are no available studies in the slovenian population. conclusion managers of slovenian hospitals and institutes of public health tend to keep a healthy diet, drink alcohol with moderation and rarely smoke. nonetheless, more than half were either overweight or obese, most did not meet physical activity levels for a good health and reported significant exposure to stress, primarily due to workplace and poor relations with co-workers. hypercholesterolemia, spinal disease and arterial hypertension were the most commonly reported diseases, but not all were treated. risk factor assessment but not actual visits within 12 months were reported for most of respondents. our results suggest there are some burning issues among 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http://www.ncbi.nlm.nih.gov/pubmed/1983932 http://www.ncbi.nlm.nih.gov/pubmed/16563924 http://www.ncbi.nlm.nih.gov/pubmed/16563924 http://www.ncbi.nlm.nih.gov/pubmed/20033254 http://www.ncbi.nlm.nih.gov/pubmed/20033254 http://dora.onko-i.si/ http://zora.onko-i.si/ beshir s, shaheen w, saad-hussein a, saeed y. aflatoxin b1 as an endocrine disruptor among miller flour workers (original article). seejph 2020, posted: 04 may 2020. doi: 10.4119/seejph-3441 p a g e 1 | 12 original research aflatoxin b1 as an endocrine disruptor among miller flour workers safia beshir1, weam shaheen1, amal saad-hussein1, yuosra saeed2 1environmental and occupational medicine department, national research centre, giza, egypt; 2air pollution research department, national research centre, giza, egypt. corresponding author: weam shaheen; address: national research centre, dokki, giza, egypt. el-buhouth st., 12622; telephone: 01118983587; email: weamshaheen@gmail.com mailto:weamshaheen@gmail.com beshir s, shaheen w, saad-hussein a, saeed y. aflatoxin b1 as an endocrine disruptor among miller flour workers (original article). seejph 2020, posted: 04 may 2020. doi: 10.4119/seejph-3441 p a g e 2 | 12 abstract aim: aflatoxin в1 has been stated to inhibit the function of different endocrine glands. this study was proposed to clarify the possible effects of aflatoxin b1 as an endocrine disruptor on pituitary gland, thyroid gland and gonads among miller flour workers, and to evaluate its effects on human male sexual function. methods: a case-control study was conducted in a flour mill in helwan district cairo, egypt in 2019. the study included 42 exposed flour milling male workers from the grinding department which showed the highest level of aspergillus flavus in the air sampling of airborne fungi and 40 non-exposed males. serumaflatoxin в1/albumin, luteinizing hormone, follicle stimulating hormone, testosterone, 17-beta-estradiol, free triiodothyronine, free thyroxin and thyroid stimulating hormone were measured for the studied groups. results: sampling of airborne fungi revealed that aspergillus flavus and penicillum were the predominant fungal types in the flour mill. indoor/outdoor ratios for aspergillus flavus were ≥ 1 in all the locations indicating presence of indoor sources. serum aflatoxin в1/albumin, luteinizing hormone and follicle stimulating, the existence of various types of sexual disorders (decreased libido, impotence and premature ejaculation) were higher while testosterone was lower in the miller flour workers compared to non-exposed. however, there was no significant difference regarding 17-beta-estradioland thyroid hormone levels between both studied groups. conclusion: aflatoxin b1creates possible human male reproductive health distresses in miller flour workers. keywords: aflatoxin в1, egyptianflour workers, lh and fsh, sexual disorders, testosterone, thyroid hormones. acknowledgement: the authors are grateful to the national research centre for funding this research. funding: this study was funded by the national research centre, egypt. conflicts of interest: none declared. beshir s, shaheen w, saad-hussein a, saeed y. aflatoxin b1 as an endocrine disruptor among miller flour workers (original article). seejph 2020, posted: 04 may 2020. doi: 10.4119/seejph-3441 p a g e 3 | 12 introduction worldwide, human fertility is deteriorating; a state that cannot be referred only to the increase in contraception usage (1). many environmental factors, industrial and occupational compounds, dietary contaminants, lifestyle factors and medications were suggested to be other causes to this deterioration (1). male infertility causes may be pre testicular, testicular and post testicular. the pre testicular and the testicular causes are chiefly endocrine disorders that originate from the hypothalamic-pituitary-gonadal axis that have opposing effects on spermatogenesis (2). male reproduction is controlled by the hypothalamo-hypophyseal testicular axis: hypothalamic gonadotropin releasing hormone, pituitary luteinizing hormone (lh) and follicle stimulating hormone (fsh) and the gonadal steroid, principally, testosterone. it was proved that thyroid hormones have a changeable effect on this axis and thus affect the sexual and spermatogenic function of man (3). effects of thyroid hormones occur through binding to certain thyroid hormone receptors which are extensively spread in the testis (4). endocrine disrupting chemicals (edcs) may be of synthetic (pesticides, industrial chemicals, bisphenols) or natural origin (mycotoxins, phytoestrogens). some mycotoxins can act as probable endocrine disruptors and cause changes in hormone production (5). endocrine disruptors may simulate the action of sex hormones, affect reproduction (6), cause reproductive anomalies (morphological and functional gonadal dysfunction, e.g. infertility and decreased libido) and congenital malformations (altered embryonic and foetal intrauterine development) (7). egypt is one of the countries with high wheat consumption (8). fungi can produce varied types of mycotoxins under environmental conditions which are favourable to growth. aflatoxins are naturally occurring mycotoxins produced by certain fungi, mainly aspergillus flavus and aspergillus parasiticus. aflatoxins b1 (afb1) is one of the main aflatoxin types (9). afb1 has been stated to inhibit the function of different endocrine glands by disturbing the enzymes and its substrate that are responsible for the synthesis of different hormones (10). aflatoxins have the ability to generate hormonal dysfunction inducing cell toxicity which directly affects reproduction (11). previous studies stated that afb1 disturbs the hypothalamo-pituitary testicular axis resulting in production of malfunctioning spermatozoa (12,13). uriah and his colleagues (14), proved that aflatoxin levels in the blood and semen of infertile nigerians men were significantly higher than in the fertile men, suggesting that aflatoxin might be an influential factor in occurrence of men infertility. afb1 lower sensitivity of thyroid receptors by enhanced generation of reactive oxygen species, aggravating lipid peroxidation concentrations (15). mycotoxins could be raised in animal and human biological fluids after feeding of contaminated food products. however, nowadays contamination through inhalation of mycotoxins in indoor air has been taken in consideration (16). this study was proposed to clarify the possible effects of aflatoxin b1 as an endocrine disruptor on pituitary gland, thyroid gland and gonads among miller flour workers, and to evaluate its effects on human male sexual function. beshir s, shaheen w, saad-hussein a, saeed y. aflatoxin b1 as an endocrine disruptor among miller flour workers (original article). seejph 2020, posted: 04 may 2020. doi: 10.4119/seejph-3441 p a g e 4 | 12 methods study design this was a case-control study. the exposed workers were considered as cases compared to the non-exposed subjects (controls). the variable fertility/sub-fertility in this study was measured through estimation of the sex hormones as high lh and fsh and low testosterone and rate of occurrence of sexual male function disorders among the exposed workers compared to their non-exposed can affect the fertility of the exposed workers. study population and sampling this study included all the miller flour exposed male workers (42 workers) from the grinding department (which showed the highest level of aspergillus flavus in the air sampling of airborne fungi). forty male non exposed subjects were included in the study (they were all the available employees working in the area surrounding the flour mill). data collection written informed consent was obtained from all the included subjects. questionnaire was filled during personal interview with the participating groups. the questionnaire included (personal data, detailed occupational history, marital, sexual and medical history, types and use of personal protective equipment). available personal protective equipment included masks, protective goggles and gowns. exclusion criteria were obesity, history of diabetes, hypertension and thyroid diseases, which may be considered differential causes for infertility. sampling of airborne fungi the samples were taken during the normal working days, between 9.00 am to 2.00 pm to determine peak exposures inside the flour mill. the air sampler was positioned at a height of ~ 1.5 m (breathing zone) above the floor level in the middle of the sampling location. the control(comparison) samples were taken 10 m outside the building. andersen one-stage viable cascade impact or sampler (te-10-160, tisch environmental cleves, oh, usa) was used. it collects particles with aerodynamic diameter of < 2.5 µm. particles < 2.5 µm penetrate deeply into lungs. the sampler was operated at flow rate of 28.3 l/min for 5 min. malt extract agar (mea) were used to collect airborne fungi (bd biosciences, sparks, maryland, usa). three consecutive samples were taken during each sampling event (3 plates/location). fungal plates were incubated at 28 °c for 57 days and checked daily. the resultant colonies were counted and positive hole correction was conducted on all counts prior to the calculation of the colony forming units per cubic meter of air (cfu/m3) (17). fungal isolates were purified and identified by direct observation on the basis of micro and macro morphological features. identification was performed on the basis of reverse and surface coloration of colonies on sabouraud dextrose agar, czapekdoxagar, potato dextrose agar and malt extract agar. fungal isolates were identified to the genus or species level (18). laboratory investigations -the blood samples were collected in sterile dry tubes, left to clot for 30 min and then centrifuged at 3000 r/min for 10 min. the separated sera were kept at -20 ˚c for the laboratory investigations. -afb1 and serum alb:  aflatoxin b1 was firstly extracted using easiextract1 aflatoxin immune affinity column (scotland). afb1 concentrations of the samples were analyzed by micro-titer plate enzyme-linked immune-sorbent assay beshir s, shaheen w, saad-hussein a, saeed y. aflatoxin b1 as an endocrine disruptor among miller flour workers (original article). seejph 2020, posted: 04 may 2020. doi: 10.4119/seejph-3441 p a g e 5 | 12 (elisa) method using ridascreen1afb1 30/15 elisa, made in germany.  serum albumin (alb) was determined by colorimetric method according to doumas and biggs (19). -serum concentrations of lh,fsh, testosterone, free triiodothyronine (ft3), free thyroxin (ft4) and thyroid stimulating hormone (tsh) were measured using elisa kit by drg international, inc., (usa) at the research laboratory, 17-beta-estradiol (e2) using kit by biosource. ethical approval number (10142) was obtained from the research ethics committee of the national research centre, egypt, before the beginning of the study. data analysis statistical analysis was done through spss package version 20. quantitative data were expressed as mean ± sd. two independent sample t-test and chi-square test were used to assess statistical differences in the quantitative and qualitative data (for distribution of sexual disorders among the studied groups) respectively between the exposed and the non-exposed groups. pearson's correlation coefficient was calculated for exposure duration, aflatoxin в1 and studied hormones among the exposed workers. p-values were two-tailed and considered statistically significant at ≤0.05. results both studied groups were between 40 to 50 years, with mean age 45 ± 8.9 years for the exposed workers and 44± 9.2 years for the non-exposed group; without significant difference. there was no significant difference between both studied groups regarding smoking habits; number of smokers was 26 among the exposed group and 24 among the non-exposed group. the mean of duration of exposure of the miller flour workers was 15 ± 5.2 years. none of the workers in the flour mill used personal protective equipments. penicillium and aspergillus were the common airborne fungi in the flourmill. penicillium and aspergillus flavus concentrations ranged within39– 577 cfu/m3 and 12– 205 cfu/m3, respectively. penicillium and aspergillus flavus were found in the highest concentrations in the grinding unit. aspergillus niger concentrations ranged from 19– 180 cfu/m3, with the highest concentration found in garbling unit. table 1 shows indoor/outdoor (i/o) ratio, "a relative standard" used to document the presence or absence of indoor biologically derived contamination and differences between sampling sites (20). in the present study, i/o ratios for penicillium and aspergillus niger were ≤ 1 in almost all locations; suggesting that outdoor air was the main contaminant source. however, i/o ratios for aspergillus flavus were ≥ 1 in all the locations indicating presence of indoor sources table 1. i/o ratios of the common airborne fungi at the flourmill units locations penicillium species aspergillus flavus aspergillus niger aspergillus species* storage 0.07 6.68 0.5 garbling 0.2 6.67 0.75 0.42 beshir s, shaheen w, saad-hussein a, saeed y. aflatoxin b1 as an endocrine disruptor among miller flour workers (original article). seejph 2020, posted: 04 may 2020. doi: 10.4119/seejph-3441 p a g e 6 | 12 grinding 1.12 17.83 0.12 0.42 packaging 0.26 1.86 1.16 0.57 *aspergillus species include: aspergillus parasiticus, aspergillus terreus and aspergillus ochraceus. table 2 shows that afb1-albumin (afb1alb) level among the exposed group was significantly higher compared to the non-exposed. lh and fsh were significantly higher and testosterone was significantly lower among the exposed workers compared to the non-exposed. there was no significant difference regarding e2 and the thyroid hormones between the two studied groups. data in table 3 shows that among the exposed workers, afb1/alb is significantly positively correlated with lh and negatively correlated withft4 & ft3. ft4 is significantly negatively correlated with the duration of exposure. tsh was significantly negatively correlated with lh and fsh, and positively correlated with testosterone. lh was positively correlated with fsh on one side and negatively correlated with testosterone on the other side. twenty-five percent (10/40) of the non-exposed and 45.2% (19/42)of the exposed group complain of sexual disorders. fifteen percent (6/40) of the non-exposed versus 7.1% (3/42) of the exposed workers complained of one sexual disorder. while 10% (4/40) of non-exposed versus 38.1% (16/42) of the exposed workers complained of more than one sexual disorder. table 4 shows the distribution of various types of sexual disorders (decreased libido, impotence, premature ejaculation) which was higher in the exposed workers. table 2. comparison of afb1-albumin (afb1-alb) level, the male sex hormones, e2 and thyroid hormones between the two studied groups non-exposed (=40) exposed (=42) independent t-test mean sd mean sd t-test p-value afb1/alb ng/g 0.04 0.01 0.06 0.02 4.658 p< 0.001 lh (3-12miu/ml) 5.763 .1469 7.542 .3271 4.960 p< 0.001 fsh (2-10miu/ml) 6.442 .2644 30.542 3.9841 6.036 p< 0.001 testosterone (0.083 – 16ng/ml) 5.5268 .19092 4.0593 .47891 2.846 p= 0.006 17β-estradiol e2 (11.2-43.2pg/ml) 29.6789 1.96325 31.8016 2.70151 0.636 0.527 ft4 (0.93-1.7ng/dl) 1.33 0.17 1.32 0.22 1.52 0.880 ft3 (2-4.4pg/ml) 2.75 0.36 2.92 0.60 1.51 0.135 tsh (0.5-8.9uiu/ml) 1.89 0.55 2.11 0.67 1.59 0.117 beshir s, shaheen w, saad-hussein a, saeed y. aflatoxin b1 as an endocrine disruptor among miller flour workers (original article). seejph 2020, posted: 04 may 2020. doi: 10.4119/seejph-3441 p a g e 7 | 12 afb1-albumin (afb1-alb), lh= luteinizing hormone, fsh= follicle stimulating hormone, e2 =17β-estradiol, ft4= free thyroxin, ft3= free triiodothyronine, tsh= thyroid stimulating hormone. table 3. relation between exposure duration, aflatoxin в1 and studied hormones among the exposed workers exposure duration afb1/alb lh fsh testosterone e2 exposure duration r= 0.2 -.121 -.053 .200 .060 lh r= -.121 0.3* .779** -.322* -.067 fsh r= -.053 0.1 .779** -.294 -.110 testosterone r= .200 -0.1 -.322* -.294 -.051 e2 r= .060 -0.03 -.067 -.110 -.051 ft4 r= -.336* -0.3* .073 .097 -.020 .163 ft3 r= -.066 -0.3* .096 .004 -.050 .088 tsh r= -.063 -0.01 -.507** -.334* .342* -.161 ** p<0.01, * p<0.05, r= pearson's correlation;afb1-albumin (afb1-alb), lh= luteinizing hormone, fsh= follicle stimulating hormone, e2 =17β-estradiol, ft4= free thyroxine, ft3= free triiodothyronine, tsh= thyroid stimulating hormone. table 4. distribution of sexual disorders among the studied groups sexual symptoms non-exposed (40) exposed (42) chi-square number % number % p-value decreased libido 3 7.5 10 23.8 0.04 * impotence 5 12.5 12 28.6 0.07 premature ejaculation) 7 17.5 17 40.5 0.02* infertility 2 5 3 7.1 0.6 * p<0.05. discussion in the present study, sampling of airborne fungi revealed that aspergillus flavus & penicillum were the predominant fungal types in the flour mill. indoor/outdoor ratios for aspergillus flavus were ≥ 1 in all the locations indicating presence of indoor sources. serum afb1/alb, lh and fsh, existence of various sexual disorders (decreased libido, impotence and premature ejaculation) were higher while testosterone was lower in the miller flour workers compared to non-exposed. however, there was no significant difference regarding 17-beta-estradiol e2 and thyroid hormone levels between both studied groups. beshir s, shaheen w, saad-hussein a, saeed y. aflatoxin b1 as an endocrine disruptor among miller flour workers (original article). seejph 2020, posted: 04 may 2020. doi: 10.4119/seejph-3441 p a g e 8 | 12 afb1/alb is significantly positively correlated with lh and negatively correlated with ft4 & ft3. ft4 is significantly negatively correlated with the duration of exposure. the results in the present study agree with awad study (21) which found that aspergillus and penicillium were the dominant airborne fungi in flourmill buildings. the concentrations of aspergillus flavus inside the different flour mill units exceeded outdoor ones. the dominance of aspergillus flavus is an indication of inadequate storage conditions and high water content of grains (21). contamination of different grains by aspergillus niger, aspergillus flavus and fusariumoxysporium occurred due to poor environmental conditions during pre and postharvest of grains (22). in the present study, indoor/outdoor (i/o) ratios of penicillium, aspergillus niger and other aspergillus species almost did not exceed 1, meaning that outdoor was the main source. however, i/o ratio of aspergillus flavus exceeded 1, reached 17.83 (in grinding) indicating the presence of inside generative sources (23). afb1, have great effect on the endocrine glands and reproductive system both in humans and in experimental animals. however, literature on the effect of aflatoxin on human reproduction is scarce (24). serum afb1-albadduct level was significantly higher among the miller flour workers compared to the non-exposed in the present study. afb1-alb level detection in serum is a reliable indicator of long-term exposure to aflatoxin (25). so, the rise of afb1-alb level among the workers could be attributed to their occupational exposure to relatively high concentrations of aspergillus flavus through inhalation by handling flour dust which represents an additional exposure risk to those subjects than the general population, which was confirmed by the high i/o ratio of aspergillus flavus. the present study showed decreased serum testosterone and increased serum level of fsh and lh among the miller flour workers compared to the non-exposed. moreover, there is positive correlation between lh &afb1/alb in the exposed group. these findings may be due to increase level of afb1-alb among the exposed workers than the non-exposed, which could be due to the high concentration of aspergillus flavus in the air environment of the flour mill in the present study. previous studies (26,27) showed that concentrations of serum fsh, lh and testosterone were reduced in afb1 treated rats. another study (28) found similar results in male chicken fed on different concentrations of dietary aflatoxin. results showed decreased serum testosterone levels and lh in the aflatoxin treated groups compared to the control group. another author (29) administered afb1orally in male rats for 48 days at different doses. the concentrations of serum lh and testosterone were lower, but on the other hand serum fsh was higher in the treated groups. after the administration of different doses of afb1, the concentration of serum testosterone was significantly reduced, in a dosedependent manner in rabbit (30); in japanese breed quails (31); in white leghorn male chicken (32) and in goats (33). the diversity of results of various experimental animal studies could be due to species variances or due to difference in route of exposure, potency or the dose of afb1and the duration of exposure. in a previous study (34), the serum testosterone concentration was significantly lower while the levels of serum fsh and lh increased significantly in adult rats exposed to afb1 compared to non-exposed. these findings agreed with the results of the present study. beshir s, shaheen w, saad-hussein a, saeed y. aflatoxin b1 as an endocrine disruptor among miller flour workers (original article). seejph 2020, posted: 04 may 2020. doi: 10.4119/seejph-3441 p a g e 9 | 12 verma and his colleague (35) supported that reduced serum testosterone concentration is attributed to mitochondria dysfunction, to inhibition in protein synthesis or enzyme activity or to membrane changes of leydig cells. they added that increased level of lh along with decreased level of serum testosterone in experimental rats exposed to afb1 reflect decreased steroidogenic ability of the testes suggesting permanent changes in leydig cell function. the degenerative effect of the aflatoxin on germinal epithelium of the seminiferous tubules would breakout into sertoli cells, leading to decrease in inhibin b1 level thus reducing its inhibitory effect on secretion of fsh leading to its elevation (36). direct effect of afb1on leydig cells and sertoli cells in the testes leading to reduction of the gonadal hormones; testosterone and estradiol may be due to the action of afb1 on binding of dna to form complexes and inhibition of nucleic acid synthesis (32). in the current study, 45.2% of the exposed group versus 25% of the non-exposed group complained of sexual disorders. the distribution of different types of sexual disorders (decreased libido, impotence, premature ejaculation) was higher among the miller flour workers compared to non-exposed. this might be due to increase of (afb1-alb) level in the exposed group than in the non-exposed as some mycotoxins can act as probable endocrine disruptors and cause changes in hormone production (5) and can cause reproductive anomalies (morphological and functional gonadal dysfunction, e.g. infertility and decreased libido) (7). also, the decrease of testosterone in the exposed group might be the cause of decreased libido, and potency in this group, as testosterone is necessary to maintain male secondary sex characteristics, libido, and probably potency. thus patients with endocrine abnormalities may present with variety of symptoms, elevated levels of the gonadotropins, fsh and lh in the presence of decreased testosterone levels indicating primary testicular dysfunction (37), which agreed with the results of the present study. in the present study, although there was no significant difference between the exposed and the non-exposed groups regarding the levels of the thyroid hormones, yet, there was negative correlation between ft4 and duration of exposure, and between ft3, ft4 and afb1-alb. these findings might suggest thyroid gland affection by aflatoxin on the long run. moreover, there was a negative correlation between tsh and both lh, fsh, and positive correlation between tsh and testosterone, which means that decrease of tsh level occurred with lowering of testosterone and elevating lh & fsh levels indicating intact hypothalamo-pituitary-thyroid axis. limitation of the study information on sexual health was assessed using self-reporting which is a source of information bias. further studies are needed to be done on a larger scale. conclusion our results showed that afb1 causes alterations in the serum concentrations of the gonadotropic (fsh and lh), as well as gonadal (testosterone) hormones in the form of significant increase in the serum concentrations of lh and fsh, as well as significant decrease in testosterone levels among exposed workers. the lowered levels of testosterone with elevated levels of fsh and lh indicate intact pituitary testicular axis in afb1 exposed workers. these findings may confirm the ability of afb1as endocrine disruptor to affect human male reproductive health. that is why it is highly recommended to estimate the levels of both gonadotropic (fsh and lh) beshir s, shaheen w, saad-hussein a, saeed y. aflatoxin b1 as an endocrine disruptor among miller flour workers (original article). seejph 2020, posted: 04 may 2020. doi: 10.4119/seejph-3441 p a g e 10 | 12 hormones periodically in exposed workers to pick up any early changes in their levels. references 1. mohammed mn, ameen mm, mohammed oa, al-maghraby om, aziz oa, ahmed sr, et al. the effect of aflatoxins on male reproduction. med arh 2014;68:272-75. 2. emokpae ma, uadia po, omale-itodo a, orok tn. male infertility and endocrinopathies in kano, northwestern nigeria. ann afr med 2007;6:64-7. 3. kumar a, shekhar s, dhole b. thyroid and male reproduction. indian j endocr metab 2014;18:23-31. 4. flood de, fernandino ji, langlois vs. thyroid hormones in male 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supriya c, reddy ps. prenatal exposure to aflatoxin b1: developmental, behavioral and reproductive alterations in male rats. sci nat 2015;102:26. 35. verma rj, nair a. effect of aflatoxins on testicular steroidogenesis and amelioration by vitamin e. food chem toxicol 2002;40:669-72. 36. jensen tk, andersson am, jørgensen n, andersen ag, carlsen e, skakkebæk ne.body mass index in relation to semen quality and reproductive hormones among 1,558 danish men. fertil steril 2004;82:863-70. 37. beshir s, ibrahim ks, shaheen w, shahyem. hormonal perturbations in occupationally exposed nickel workers.open access maced j med sci2016;4:307-11. ___________________________________________________________ health development program for students at dormitories pilot scheme assessment sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 1 original research pilot scheme assessment: health development program for students at dormitories hulya sirin 1 , emine fusun karasahin 2 , basak tezel 1 , sema ozbas 1 , bekir keskinkilic 1 , secil ozkan 3 1 general directorate of public health, ankara, turkey; 2 erzurum provincial health directorate, erzurum, turkey; 3 gazi university, school of medicine, department of public health, ankara, turkey. corresponding author: emine fusun karasahin md, public health specialist, vice president. erzurum provincial health directorate, turkey; address: hastaneler cad. lapasa mah. no. 23, 25000, yakutiye, erzurum, turkey; telephone: +90442238 51 00; email: fusuncivil@gmail.com mailto:fusuncivil@gmail.com sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 2 abstract aim: this study, conducted in turkey, aims to increase the practicability of health counselling and protective services offered to young people in the long term. in the short term, it is aimed to determine health counselling needs of students at dormitories and it might enlighten researchers working in this field. methods: a pilot questionnaire, developed in order to determine health needs of students staying at dormitories, was conducted in two dormitories in ankara. focus group interviews were done, also. after that, in nine dormitories from nine provinces from all over the turkey, questionnaire and health screening tests were applied to 5,852 volunteers. results: the common topics for both sexes which students would like to receive counselling are nutrition and anxiety about exams. conclusion: as a result of the study, service has been planned for the identified needs of the students. keywords: counselling, dormitory, health, student, turkey, university. conflicts of interest: none. sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 3 introduction young population (aged 10-24 years) constituted 25% of the world population, 17% of the european population and 26% of the turkish population in 2013. years at university make up a new period in which important changes occur in the lives of this great population, considered to be a social and biologic transition. this period in which adolescence connects to adulthood and which includes a dynamic development and growth, requires careful research as it corresponds to the last stage of adolescence (1,2). those living at dormitories among university students constitute a group which has different social and emotional characteristics and which should be considered in terms of their needs and problems. these people generally stay far from home for the first time, need to cope with new situations without experience and support of their parents and are responsible for their health and lifestyle besides many other responsibilities. young adults develop behaviours to be conveyed to their adulthood or affect their health during this period. moreover, there are different lifestyles and challenging living conditions in the social area at university. many students adopt unhealthy behaviours and habits including malnutrition, smoking, physical inactivity, unsafe sex due to changes in their accustomed living conditions and patterns of education (3-6). the world health organization reported life quality of an individual depends on their own behaviours and lifestyles by 60%. many studies report health improving behaviours reduce the risk of diseases and death rate. many effects of health risk factors can be prevented by determining and changing unhealthy behaviours. a good health improving behaviour depends on living habits developed in the early period. considering “health in youth”, it should be noted that young people not only need to stay away from diseases physically and mentally, but also need to access necessary information and services to ensure this. for health of future generations, it is very important to understand, monitor, evaluate health behaviour tendencies and offer counselling to ensure adoption of a healthy lifestyle. unfortunately, information about health improving counselling services offered to young people at dormitories is limited in the literature (7-11). those in economically disadvantaged condition among students at universities in turkey mostly stat at state dormitories called “yurtkur" operating under the ministry of youth and sports, where our study was conducted. students live in high capacity rooms, at least 4 beds, use common bathrooms, toilettes and dining halls at these dormitories. this provides limited facilities to meet their personal needs. in our country, primary health care is offered in the family medicine system. although every citizen has a family physician according to registered address, students living away from their families generally have their physicians in the city of their families (as they do not transfer their registration). “youth counselling and health service centres" have been established to ensure young people benefit more from primary health care as they need a special treatment due to their age. these centres offer counselling services, training and information, diagnosis and treatment, referral to reference centres for adolescence at the primary care. the number of applications to these centres gradually decreased over the years. this study, conducted under the light of these conditions, aims at practicability of healthy counselling and protective services offered to this age group in the system. in the short term, it helps researchers try to determine health counselling needs of students at dormitories. methods operations to execute a program to promote health of students at dormitories began in january 2014. pilot schemes were implemented in 2 dormitories in ankara to provide a basis sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 4 for the scheme by the turkish public health institution department of child and adolescent health. after preliminary trial of the questionnaire, the questionnaire was applied to 26 males and 51 females in these 2 dormitories and a focus group interview was made with the dormitory managers. the results of the questionnaire and focus group interviews were shared at meetings held with the credit and dormitories institution (yurtkur) representatives, turkish public hospitals agency, general directorate of health promotion and cities where the pilot scheme would be implemented and the framework of the study were determined. health managers from 9 cities where 9 dormitories selected to implement the pilot practice on january 17 and february 4, 2014 were informed about the study in ankara and city plans were arranged. the project was initiated to implement the pilot practice in ankara, antalya, balikesir, diyarbakır, erzurum, istanbul, izmir, tekirdag and trabzon cities. as the sole purpose was to provide data for the program to be developed, these cities were selected randomly based on their sizes irrespective of representation of all students. there were approximately 4 million 300 thousand university students at 170 universities in our country as of 2013. according to yurtkur data, 365 dormitories in 81 cities, 145 districts and 2 points abroad offer service with a bed capacity of 310,000. eighteen thousand and fifty four students staying at dormitories were informed about general health, eye, teeth, skin and oral health, and the students were applied eye (2,351 students, 13.2%), teeth (3,410 students, 18.9%) and skin (2,130 students, 11.8%) screening on voluntary basis. the 14 item questionnaire developed to determine definitive characteristics of the students in the study was applied under supervision to 5,852 students (32.4%) who volunteered for participation (table 1). table 1. dormitories in the study, occupancy rates and rate of participation in the questionnaire name of province capacity survey participation percent * percent † female male total antalya 1,968 1,135 3,071 120 3.9 2.1 ankara 2,976 2,976 260 8.7 4.4 diyarbakır 1,020 1,020 494 48.4 8.4 i̇stanbul 1,072 536 1,608 725 45.1 12.4 i̇zmir 1,932 1,932 853 44.2 14.6 trabzon 2,611 2,611 1301 49.8 22.2 erzurum 1,500 1,500 352 23.5 6.0 balıkesir 1,136 888 2,024 1211 59.8 20.7 tekirdağ 696 616 1,312 536 40.9 9.2 (9 provinces 9 dormitories) 8,503 9,583 18,054 5,852 32.4 100.0 * row percentages. † column percentages. sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 5 the following findings were obtained from the pilot scheme conducted at 2 dormitories: • the top three health services requested by students are eye, teeth and skin health services. • the top topics they request counselling for are in the following order: – adequate and balanced nutrition – personal hygiene – anxiety about exams – anger management – healthy life habits – smoking, alcohol and drug use • students want to receive these counselling services especially from counsellors and medical personnel • information about hygiene and protective health services • psychosocial service personnel taking part in training of young people • visual based training about adequate and balanced nutrition, smoking, alcohol and drug abuse and sexually transmitted infections • separate planning for counselling and health service for male and female students • provide immediate and efficient information at periods of certain diseases (flu, measles etc.) • providing information about sleep problems • training about breathing exercises, methods of coping with stress the study protocol was approved by the gazi university ethics committee. the data used for this study do not include any identifiable personal information, and informed consent was waived by the committee. data was entered in the statistics package program and was analyzed with the same program. categorical variables were presented in figure and percentage and continuous ones were presented in mean ± standard deviation and median (min, max). chi-square, chi-square for trend tests and kruskal-wallis test were used. statistical significance level was determined as p≤0.05. results basing on the initial findings obtained from the pilot scheme, 5,852 students at dormitories accepted to take part in the questionnaire and/or screening. moreover, 8,000 students received training in conference forms about screened diseases (findings, clinics, etc.) and requested subjects. the screening results were shown in table 2. for female students, the mean age is 21.59 ± 1.99 and the median is 21 (16-41), the mean length is 163.72 ± 5.81 cm and the median is 164 (143 – 189) cm, the mean weight is 57.56 ± 8.45 kg and the median is 56 (37 – 110) kg, the body mass index mean is 21.46 ± 2.89 kg/m 2 and the median is 21.1(14.3 – 38.1) kg/m 2 ; for male students, the mean age is 21.85 ± 2.26 and the median is 22 (16 – 42), the mean length is 176.97 ± 6.41 cm and the median is 177 (152 – 197) cm, the mean weight is 74.07 ± 11.56 kg and the median is 73 (49 – 138) kg, the body mass index mean is 23.62 ± 3.28 kg/m 2 and the median is 23.4 (16.7 – 45.1) kg/m 2 . when distribution of body mass indexes of students was compared, the body mass indexes of male students were statistically significantly higher than female students (p<0.001). in all students, underweight rate was 9.8% (13.6% in girls; 3.6% in boys), normal weight rate was sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 6 73.5%, overweight rate was 14.3% (9.7% in girls; 23.8% in boys) and obesity rate was 2.4% (1.4% in girls; 4.5% in boys). the largest part of the students have stayed at dormitories for 1-3 years and the number of students staying in the same room is 3 for females and 4 and more for females for the highest level. table 2. pathologies identified in examined students the number of students diagnosed with pathologies the number of students who received a prescription the number of students referred to hospitals the number of students who received a recommendation eye diseases screening findings (n=2351) wink problems 595 64 315 190 eyelid diseases 31 5 5 17 eye infection 113 35 12 68 cross eye 15 1 3 6 other 278 65 64 136 total 1032 170 399 417 skin diseases screening findings (n=2130) allergic skin diseases 99 30 25 38 fungi 56 28 19 16 acne vulgaris 490 113 251 155 other 281 55 113 147 total 926 226 408 356 oral and dental diseases screening findings (n=3410) gingiva diseases 430 46 128 378 rate of decayed teeth 753 30 478 169 rate of filling 474 0 139 148 students with permanent teeth extracted 266 0 108 90 malocclusion and orthodontic disorders 99 0 55 61 other 94 1 10 13 total 2116 77 918 859 eight percent of the students have a chronic disease and 11.3% use regular medication. considering chronic diseases and regular medication intake by the time at the dormitory, there is not any significant difference in chronic disease frequency but the frequency of regular medication increases significantly with increased time at the dormitory (p=0.016). about 80% of the students are registered at a family physician. the highest frequency of application to a health centre is 1-11 months and it is generally less for male students. female and male students, who do regular sports, in other words 3 times a week or more, are less than 10%. sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 7 considering use of alcohol, male students are ahead of female students (9%-22%) and the largest group in all students reported to use alcohol once a month or less (about 75%). drug abuse was reported by 15 students out of 3823 students who answered this question (2 females 13 males). the frequency of use decreases significantly with increased time at the dormitory in the trend analysis (p=0.003). smoking is available in 37% of females and 63% of males (table 3). the frequency of smoking decreases significantly with increased time at the dormitory in the trend analysis (p=0.02). female students have been smoking for 3.6 ± 2.2 years and male students have been smoking for 4.2 ± 2.6 years. considering amount of smoking, females smoke 0.8 ± 0.4 and males smoke 1.0 ± 0.3 packages of cigarettes a day. table 3. distribution of certain characteristics and habits of students by gender females males n percent * n percent * total † p time at dormitory (n=3826) less than 1 year 566 61.4 356 38.6 24.1 0.002 1-3 years 1040 61.6 647 38.4 44.1 3-5 years 688 68.1 323 31.9 26.4 more than 5 years 121 58.7 85 41.3 5.4 number of students in the room (n=3821) 1 6 75.0 2 25.0 0.2 0.001 2 138 93.2 10 6.8 3.9 3 2008 77.9 570 22.1 67.5 4 and more 266 24.5 821 75.5 28.4 chronic disease (n=3008) yes 199 82.9 41 17.1 8.0 0.361 no 2228 80.5 540 19.5 92.0 regular medication intake (n=3837) yes 263 60.7 170 39.3 11.3 0.254 no 2163 63.5 1241 36.5 88.7 registry at the family physician (n=3757) yes 2022 65.2 1078 34.8 82.5 0.001 no 376 57.2 281 42.8 17.5 frequency of application to a medical centre (n=3808) less than 1 month 222 69.6 97 30.4 8.4 0.001 1-11 months 1460 65.9 755 34.1 58.2 1-3 years 528 59.0 367 41.0 23.5 more than 3 years 200 52.8 179 47.2 10.0 regular sports (n=3835) yes 449 47.7 493 52.3 24.6 0.001 no 1976 68.3 917 31.7 75.4 frequency of sports (n=3845) rarely (once a 2115 62.6 1263 37.4 87.9 0.006 sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 8 month or less) less than once a month-three weeks 57 64.0 32 36.0 2.3 1-2 times a week 45 59.2 31 40.8 2.0 3-4 times a week 147 67.7 70 32.3 5.6 everyday 67 78.8 18 21.2 2.2 alcohol use (n=3813) yes 218 41.8 304 58.2 13.7 0.001 no 2198 66.8 1093 33.2 86.3 frequency of alcohol use (n=263) rarely (once a month or less) 140 71.4 56 28.6 74.5 0.011 once a month-three weeks 32 66.7 16 33.3 18.3 twice a week and more 10 52.6 9 47.4 7.2 drug abuse (n=3823) yes 2 13.3 13 86.7 0.4 0.001 no 2418 63.5 1390 36.5 99.6 smoking (n=3841) yes 221 37.3 371 62.7 15.4 0.001 no 2208 68.0 1041 32.0 84.6 * row percentages. † column percentages. the top 5 topics for which female students would like to receive counseling are respectively nutrition, menstrual hygiene, communication in the family, anxiety about exams and personal hygiene. the top 5 topics for which male students would like to receive counseling are respectively nutrition, physical activity, healthy living habits, anger management and anxiety about exams (figure 1). considering change of request for counselling by the time at the dormitory, while demand for menstrual hygiene, anger management and anxiety about exams increases significantly with time (respectively, p=0.001; p=0.001, p=0.032); demand for personal hygiene, healthy living habits, physical activity and reproduction system habits significantly decreased with increased time (respectively, p=0.001; p=0.004; p=0.001; p=0.010). no significant change was observed in demand for other counselling topics (p>0.05). sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 9 figure 1. topics for which students would like to receive counseling based on gender 27.3 48.7 54.5 22.5 15.8 11.3 13.7 25.6 8.8 7.6 10.4 40.4 9.2 8.5 14.4 21.8 12.6 22 7.1 39.6 16.6 6.9 37.6 24.4 30.1 12.4 12.7 7.2 8.5 5.8 5.9 13.9 12.2 9.1 22.3 15.9 10.6 11.4 5.4 21.6 0 10 20 30 40 50 60 70 80 90 100 personal hygiene menstrual hygiene adequate and balanced nutrition healthy living habits physical activity tobacco, alcohol, drug abuse internet addiction reproductive system std reproductive health family relations family communication set limits peer relations anger management coping skills neglect violence explotation exam anxiety girl boy % discussion although the young population is generally considered to be "healthy", it constitutes 15% of the total disease burden in the world and about 1 million young people die of preventable reasons every year. of the deaths at early ages in adults, 70% depends on gender discrimination and habits adopted in adolescence including smoking, malnutrition and risky sexual behaviours (12). a study conducted at a university in turkey reported that half of 183 students had decayed teeth, one fourth had lost a tooth and more than half had filling in their teeth (13). this study reports that almost one fourth of the students had decayed teeth, one tenth had filling in their teeth and about 8% lost a tooth. although the oral-dental health screening results in this study are lower than those of the study conducted in 2012-2013 academic year, these rates are considered to be very high for young population with a long life expectancy. it is required to continue with these scans considering the results of the screening. a study conducted with the students at dormitories at alexandria university reported 6.5% of chronic disease or disability frequency in students (3). our study reported a chronic disease frequency of 8.0% in the students and this frequency does not vary depending on time at dormitories and causes significantly more frequent medication intake (47.7% vs. 6.1%) in this group. sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 10 a study conducted in a middle east country, egypt, reported that 33.8% of the university students were physically inactive and 25.3% were overweight (3). studies conducted in far east countries, thailand, china and japan reported a frequency of overweight between 2.9% 16%. bmi mean of male students was significantly higher than females in all studies (5,14,15). fifty-one percent of the students at dormitories at canada nova scotia university reported sports activities for less than three times a week and more than half were determined to be at normal weight limits (4). considering europe, a study conducted in germany reported more than half of the students were normal and 6.5% were overweight and only one fifth reported they did not engage in sports activities (16). a study made with university student in germany, poland and bulgaria reported that more than half of the participants were normal weight and the overweight frequency was 11.6% (10). a study made with university students from 23 different countries reported that more than three fourths of the students were normal weight (17). a study made with 233 university students in turkey in 2009 reported that one fifth of the students did not exercise and more than half were reported to exercise for 2-3 days a week or more (18). although over weight/obesity prevalence in our students was 16.7%, unfortunately, three fourths reported not to engage in sports and almost 90% of the students engaged in sports once a month or less. a study in egypt reported that 17.5% of male students smoked and 4.0% used drugs (3). a study conducted at helwan university in egypt reported that the frequency of currently smoking students was 8.6% (19). a study made to determine water pipe smoking prevalence of 1,454 students at 3 universities in 2008 in jordan reported a smoking prevalence of 30.7% (20). a study made with 355 students in total with 215 students staying at dormitories at 2 male medical faculties in iran in 2014 reported smoking, alcohol and drug abuse frequencies of 3.9%, 10.1% and 19.4% respectively (21). a study made in canada reported that 14.3% of the students at dormitories smoked (4). it was reported that out of 17,591 students at 152 universities studied in 2010 in usa, 16.8% were currently smoking and 34.6% reported to have smoked before (22). a study conducted in uk reported a smoking frequency of 15.9% in 937 students (23). a study made at 3 universities in germany, poland and bulgaria reported that 19.3% of the students smoked (10). a study conducted in germany, out of 650 students, 24.5% smoked and 88.5% used alcohol (16). a study conducted at linköping university in sweden reviewed alcohol consumption of 1,297 students and reported that 91% consumed alcohol in the last 3 months (24). another study made with 572 students in turkey reported that none of the participants used drug and almost all of them reported they never tried (98.4%) (25). this study determined smoking frequency as 15.4% and the frequency decreased to 12.7% with increased time at the dormitory. while the frequency of the students using alcohol is 13.7%, no significant change was obtained by years, the frequency of drug abuse is 0.4% and a significant decrease was obtained by years. it is considered that statements of alcohol and drug abuse can be low due to prohibition of substance use and hesitations about profiling. a study which evaluated health behaviours and health development needs of 650 students in germany reported that more than half of the students cared for their health and tried to be on a healthy diet. more than half of the students reported they would attend health oriented group programs, especially sports, relaxation and stress management programs and one fourth reported they would attend healthy nutrition and health classes. about one fourth of sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 11 students said they were interested in counselling about stress management and one fifth in nutrition and reproductive health (16). almost half of the students at canada nova scotia university reported they would attend stress management training (4). a study made in china in 2001-2002 academic years reported that almost half of the students would like to receive training about healthy nutrition (15). in our study, students reported they would like to have training about hygiene, healthy nutrition, physical activity and healthy living habits. recent studies on health of the young population indicate that a more holistic approach to the youth would prove to be more efficient rather than focusing on a single problematic behaviour and reducing specific risks. therefore, the young population needs programs which support healthy development. the purpose of this program is to support healthy psychological and social development and growth and to increase individual endurance. moreover, it is recommended to ensure that the young individual "adopts life skills". therefore, it would be ensured that the young individual undertakes responsibility for making healthy decisions, resisting negative pressures and avoiding risky behaviours (5,21). who determined obesity, physical inactivity and alcohol use and smoking as the risk factors of chronic diseases. our study clearly demonstrates the need for “healthy development” counselling for the young population to struggle with chronic diseases which are the main medical problem of our century, for which risk factors are evaluated in the study. risks can be prevented and a bright future can be ensured for the young population with a healthy living culture to be developed accordingly. this requirement has already reflected on demands of the young population and they reported they would like to have this kind of counselling. as a result of the study, service has been planned for the identified needs of the students. activities have been initiated to spread this study to cover all students at dormitories and dormitories have been put to contact with “youth counselling and medical care centres”. systems have started to be developed to increase use of primary health services by dormitory students. references 1. ilhan n, 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university students in sweden measured by anelectronic screening instrument. bmc public health 2009;9:229. doi:10.1186/1471-2458-9-229. 25. sungu h. attitudes towards substance addiction: a study of turkish university students. educ res rev 2015;10:1015-22. ______________________________________________________________________________________ © 2018 sirin h, et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. heinzelmann w. the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii (review article). seejph 2015, posted: 18 january 2015. doi 10.12908/seejph-2014-37 1 review article the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii wilfried heinzelmann corresponding author: dr. wilfried heinzelmann address: schoeneberger straße 22, d-33619 bielefeld, germany; e-mail: wilfried.heinzelmann@uni-bielefeld.de heinzelmann w. the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii (review article). seejph 2015, posted: 18 january 2015. doi 10.12908/seejph-2014-37 2 abstract during the thirties of the twentieth century, german medical doctors immigrated to turkey. among them, was the german-jewish paediatrician albert eckstein. in this short biography, the richness of the literature, written by or about eckstein, will be presented, and altogether combined. starting from 1937 and further on, albert eckstein undertook scientific surveys on children’s state of health and health care in the most remote areas of anatolia. the value of the socialhygienic approach could be recognized, even in this early stage, starting with epidemiological analysis and followed by basic comprehensive health care. social hygiene, as a young branch of health sciences at the time, was in the position even then to model the health care system for large population groups, at least in countries actively developing health care, as was turkey of that time. albert eckstein and his co-workers, such as ihsan dogramaci, stand out as founders of the modern turkish health care system today and health sciences in this country. keywords: albert eckstein, anatolia, health sciences, ihsan dogramaci, paediatrics, public health, social hygiene. conflict of interest: none. acknowledgement: the support by prof. ulrich laaser and the translation by dr. nikola ilic are gratefully acknowledged. heinzelmann w. the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii (review article). seejph 2015, posted: 18 january 2015. doi 10.12908/seejph-2014-37 3 introduction during the great remodelling of the turkish nation under the government of kemal atatürk (1881-1938), the german-jewish physician and emigrant albert eckstein (1891-1950), also often mentioned as “architect of the modern turkish health-care system” (1), made significant efforts in lowering child mortality. at the end of 1920s, the german scientist gerhard domagk had discovered the healing effects of sulfonamide and started the era of chemotherapy. he was awarded the nobel prize in medicine in 1939. albert eckstein left his homeland under pursue from national-socialists in 1935, with domagk’s new therapeutic instruments in his luggage and headed for ankara, the emerging capital of modern turkey, which at that time was a country with high child mortality. biographical background in the years before eckstein arrived to ankara, he had finished studies in the elite german medical schools. he worked during his medical studies with johannes von kries and eugen fisher on scientific research in the freiburg institute of physiology and anatomy. after 1920, eckstein turned his interests to paediatrics and obtained a degree in this field three years later under carl noeggerath in freiburg. since 1925, eckstein worked for years as a senior medical doctor under the social-hygienist arthur schlossmann in the paediatric clinic at the medical academy in düsseldorf. the textbook on social hygiene and medical care edited by arthur schlossmann together with the most famous social-hygienists adolf gottstein and ludwig teleky in the midst of the twenties, was a milestone in developing modern health sciences (2), thus supplying young german doctors with the latest scientific findings on those newly endeavoured fields. the young researcher we are speaking of found entrance to his director’s family through marriage with his daughter dr. erna schlossmann. she led the auguste-viktoria children’s home, and was also engaged in social hygiene. in the times coming, she will be of great help as associate on his undertakings in exile. being associated professor with schlossmann since 1925, eckstein was the permanent deputy of his father in law and – after his master’s death in 1932 – he followed him both on clinical and academic positions1 basically, one can explain eckstein’s path, a paradox turn in the carrier of this 45 year old man, through two historical phenomena: anti-semitism in germany on one side, and government and community reconstruction in turkey of the period, on the other. already in 1924, kemal atatürk signed a treaty of friendship with germany and a second one followed in 1941 (4). following the “seizure of power” in 1933, eckstein managed to stay only two and a half years more at his workplace in düsseldorf. after a year of harassment and humiliation by the regime, colleagues, and students, a decree signed by hitler and göring forced him to leave germany (3). in those years, germany and turkey were working together under an agreement on helping the young (turkish) republic on rebuilding new government structures and forming the university in istanbul and a new university in ankara (4). through this programme, in which germans without jewish roots could work as well, national-socialists let high-profiled german-jewish scientists seek exile in turkey (3,8). (3-6). until 1935, eckstein worked on infective diseases and tuberculosis and wrote a chapter on smallpox for the textbook of internal medicine (7). historical background 1 erichsen r (2012) exil tuerkei: der pädiater albert eckstein – wie er aus deutschland vertrieben wurde und was er in die tuerkei mitbrachte; and: erichsen r (2012) zwei pädiater im tuerkischen exil: erna und albert eckstein halfen kindern im ländlichen anatolien und fotografierten ihre welt. deutsch-tuerkische gesellschaft (dtg), bonn 03.05.2012. heinzelmann w. the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii (review article). seejph 2015, posted: 18 january 2015. doi 10.12908/seejph-2014-37 4 eckstein was “the last jewish professor at the medical academy in düsseldorf” (4,9). within a few weeks, eckstein arranged with the turkish government that he would be assigned first as “head of the paediatric department in the city hospital nümune hastanesi in ankara” (4), the only hospital in ankara with its population of 125,000 residents (10). later, in 1945, he advanced to a full professor of paediatrics and director of the paediatric clinic in the newly formed university. eckstein developed from earlier, small-scale medical scientific projects, the largest social-hygienic project of the time – an analysis of infant and small children care in turkey with its population of then 16 million (11). research in rural anatolia after the reorganisation of the newly established university paediatric clinic in ankara (4) the couple eckstein went twice in the period from 1936 to 1938 on three-month voyages through regions of west and central anatolia, accompanied by their turkish assistant dr. salahaddin cevdet tekand (see below) (5,11). they tended especially to pass the rural areas and reach “the remotest villages” where men, mothers, wives, and children “have never seen medical doctors” (12,13). the workgroup undertook systematic scientific investigations and offered “on the spot” medical care for those in need. the procedure corresponded to a classical demographic and statistical survey, which led to an epidemiology of childhood diseases in anatolia as basis for the creation of a comprehensive paediatric health care system (4,5,11). as in some of the visited provinces survey techniques could not be fully used, the solution was found in the “monographic, exemplary description of single villages” (5,14). the mutual relationship between the state of health of the individual and the population, a typical case of the social-hygienic double perspective (15), could be found here as a model for the first time in a project on large-scale. the turkish health minister refik saydam, later also turkish prime minister, became friend with eckstein and agreed that eckstein visited first the rural areas and produced a report on illness and health among children of anatolia as a basis for reform proposals: “i would …. like you to prepare a report on …. children’s health and diseases in turkey …. however a german approach may not be suitable for our country …. visit and examine all of anatolia and (return) with your proposals” (10,16,17). according to akar (1), malaria and necrotic ulcerative stomatitis or noma were the major illnesses for the paediatrician in turkey to treat. whereas for malaria prophylaxis as well as therapy was available, noma required the treatment of the mucous membrane of the mouth in children with a weak immune system and malnutrition, sometimes showing also progressive facial necrosis, which represented a daunting therapeutic challenge (18). the list of illnesses comprised in addition: diarrhoea, malnutrition, rickets, typhoid fever, tuberculosis, gonorrhoea, ascariasis, anaemia, trachoma, measles, bronchitis, injuries, scarlet fever, and diphtheria (4,5,11). eckstein’s inquiry in locally typical disease manifestations included basic social-hygienic data as diet, quality of water, hygienic habits, care for infants, and social status. observations were recorded in “detailed daily journals” (3), as a prerequisite for developing new structures of medical care (5). the research trips led eckstein and his small team especially into the central and western regions of anatolia. during only two years, they visited altogether 188 villages in 25 provinces, interviewing almost 25.000 women (4,5,11). the examination began usually with social-hygienic and demographic, and population data gathering. furthermore, the group studied the dominating diseases and the social conditions determining the rural environment in which families in anatolia typically lived (11), with a special focus on childhood diseases. living conditions and living standards (water and milk supply, fruit and vegetable growing) of the rural population stayed regularly in focus. the so-called “centres for fighting malaria” heinzelmann w. the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii (review article). seejph 2015, posted: 18 january 2015. doi 10.12908/seejph-2014-37 5 (4,5) were transformed into health centers (dispensaires) that provided consultations for mothers and health care for infants and, as such, formed footing for the future paediatric services (4,5). diarrheic diseases were – different from western europe – predominantly of bacterial origin, therefore, diarrhoea during the summer months required antibacterial medication (sulfonamide), or serum therapy (3,4). because of eckstein’s work before he returned to germany in 1949, the mortality among children in turkey deceased from 35%-40% to 12% (4,5,10,13). however, the ecksteins themselves indicated some statistical weaknesses in this account (4,13). workday routine how a typical workday for the two ecksteins looked like, we can see from the 44 page daily journal covering their visit to anatolia in 1937, published in 2005 by buergel (19). the ecksteins needed not to get alone on the road trough undeveloped parts of the land in order to reach mothers and children who lived in villages there. for transportation they used one ford cabriolet, bus lines, railroad, taurus-express, occasionally with sleeping car. but, they also travelled “using taxi, jeep, or horse” (12). primarily, albert eckstein described the strange remains of antic architecture spread throughout an ever changing landscape, its utilization, management, climate, living conditions, the diet of the population, conditions of accommodation, occupations, and standards of living. often he used the hospitality of the population in anatolia as advantage in building his own social network in the field. there were rarely days that would end without celebrations of new friendships. almost everywhere they were received by higher health service representatives, who would take them to residential areas. first ones to come to him were children, followed by women who openly showed their empathy, and at the end came the sick. the social-hygienic research work started latest at 11:00 in the morning and lasted until late involving visits, tuberculin vaccinations and their controls, gathering data on birth rates and child mortality, after that “polyclinic consultations” for malaria treatment including quinine prophylaxis for enteritis, rickets, ascariasis, measles, and whooping cough. eckstein’s personality it is out of question that this highly engaged and charismatic paediatrician with his efficient work and approach to people also won the hearts and managed to generate deep empathy by the population eckstein worked with. even today, eckstein’s name is mentioned in ankara and istanbul (20). the extraordinary personality as observed by his turkish colleagues and patients, his energy and happiness in life, genius, and a feeling for the right moment, eidetic disposition (descriptive representation of the undertaken voyages, surprisingly changing scenery of landscapes in anatolia), incredible memory, adaptability, promptness of his thoughts and team spirit. dr. salahaddin cevded tekand pointed out in 1998 that those who spoke about eckstein always indicate his success, while he was referring always to “us” (16,17). the “enthusiastic doctor” managed to combine two things together “that made him very popular and beloved”: his “calm responsibility” and “affectionate way” in which he was treating both children and parents (21). their children along with other children in ankara were vaccinated against smallpox, measles, typhus, received therapy for malaria or prophylaxis with quinine, and sulfonamide for diarrhoea. jülide gülizar was explicit when she in the cumhuriyet magazine expressed her feelings: “he left behind a lot of research and studies about turkish children and the special throne he built in the hearts of their mothers” (10). typical for the deeply grateful turkish people was the triumphal farewell which eckstein’s fans organised in 1950 at ankara’s central train station. just before the departure of heinzelmann w. the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii (review article). seejph 2015, posted: 18 january 2015. doi 10.12908/seejph-2014-37 6 the train “hundreds of turkish people, many of them with babies and children in arms, came to the train station, one more time to wave him farewell”. as reported later in the magazine, this was one of the greatest “red carpet treatment” ankara had experienced ever (13). as turkey declared war against germany in february 1945, all germans in the country were interned, only eckstein and his family escaped this measure because of his previous remarkable services (3). eckstein’s turkish assistants the turkish state realised the contractual agreements of hiring additional hands very reluctantly and attached assistants only one by one. in their historical sequence (dr.’s): bahtiyar demirag, who from 1950 on carried forward the work of his teacher in ankara (10); neriman olgür (16,17) and sabiha cura (10), just like selahattin cevded tekand and ihsan dogramaci (see for both below). eckstein met ihsan dogramaci (1915-2010) by chance during his “anatolian voyage” in 1938. the tall young doctor grew up in the highest society, was nephew to the local governor, and lived in the governor’s palace. this is where he received and hosted eckstein with his co-workers. upon return, eckstein invited him to accompany them as a paediatrician on a five-day research trip through the province and to become a paediatrician (10,13,16,17). after this trip, the young ihsan dogramaci became the third in the row of turkish assistants; later, he worked as a clinician in ankara. ihsan stayed in this position until 1940 when he went on his way to the united states and baghdad (10). one year later, signed with both names, the essay on “treatment of summer diarrhoea with bacteriophages” was published (22), which was a result of joint research work in the new capital of turkey. after that, the turkish paediatrician stayed some more time in washington d.c. and boston for studies from which he returned in 1949 to ankara for postdoctoral studies. dogramaci obviously like other friends shared the enthusiasm of his teacher for the appropriation of his new homeland by photography and film (5)2 2 dogramaci, burzu: die aneignung der exil-heimat durch photographie und film. vortrag gehalten bei der konradadenauer-stiftung, bonn am 22. september 1968. . he played an important role as a professor in instituting the new university. he was founder of the hacettepe university clinic in 1958 (which later became part of the university baring the same name) (16) and in 1984 of the private bilkent university (10), “the first full-fledged private university in turkey” (17), both of those in ankara, a city with three universities in total (19). by the end of the fifties of the last century, the german-jewish paediatrician and his “former student” (figure 1) stood among the most prominent persons, founders of the new institutions in ankara. eckstein already tried to provide safe and sustained care for children in the entire middle east by building the powdered milk factory in eastern turkey (4). later, it was dogramaci who provided this milk distribution in turkey and thus was able to considerably decrease the infant and child mortality in his country. the friendship between the two german and turkish paediatricians went even further: in 1954, almost two decades after his first assistant position, dogramaci gave to dr. erna eckstein-schlossmann the administrative position in the new haccettepe paediatric clinic, responsible for equipping the facilities. that led to the return of eckstein’s widow erna eckstein-schlossmann to ankara where she stayed for the next five years until 1961 (4,6). the lifetime achievement award, which was awarded to dogramaci in istanbul in 2009 at the 12th world congress of public health by the world federation of public health associations (wfpha), came – after numerous earlier awards – as a last point after the extraordinary work of this great man (20). heinzelmann w. the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii (review article). seejph 2015, posted: 18 january 2015. doi 10.12908/seejph-2014-37 7 figure 1. dr. eckstein and dr. dogramaci (screenshot taken from: http://www.ep.liu.se/ej/hygiea/v7/i1/a3/hygiea08v7i1a3.pdf) eckstein’s first turkish assistant was his “travelling assistant”, namely dr. salahaddin cevdet tekand. although his professional career did not compare to dogramaci, eckstein had to rely especially during his travelling through the rural provinces on his francophone assistant (13) and gave him credit for part of his success (19), especially with regard to the establishment of easy contacts with the turkish peasants and their “warm” and “often touching” hospitality. tekand gathered over the years as a field doctor an impressive array of experiences. he became the head of the paediatric clinic in his hometown izmir and worked there on children welfare programmes until 1997 (19). the scientific work the main question we are interested in here is whether we can agree with the claim made by henry sigerist in 1947 that findings and work of social-hygienic assailants acted worldwide as an accelerator in the development of health sciences (23). the unprecedented successes of eckstein prove that the amended social-hygienic model that he used had the potential for population wide health care. using this approach experts displaced from germany triggered innovations in the health services of their host countries. the essential factor for success of the assailants in the field of social-hygiene was the developmental status of the target countries. many of these were countries under development such as turkey, palestine, and latin america, where they could use their know-how in health sciences. on the other hand, they failed to achieve the same in industrialised developed countries, mostly because of the high professional competition. two factors were predominant in decision making of the german-jewish assailants: the degree of persecution in germany and the legislation regulating the medical profession in host countries. eckstein was heinzelmann w. the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii (review article). seejph 2015, posted: 18 january 2015. doi 10.12908/seejph-2014-37 8 afraid of the lack of social security in the us, wherefrom he got an invitation, but he was not afraid of the need to learn turkish. that was a new and strange language, in which he soon wrote a textbook, the first textbook in turkish on infant diseases (3). eckstein was led by a powerful urge to write. during almost 15 years in turkey, during long working days, on the road, along with never ending planning, helping, creating new guidelines, and organising other staff, he wrote 50 publications. many of those publications are even today relevant due to their clarity and realism. many of the data in these publications originated from the comprehensive research which started in 1940. in turkey, the still undeveloped country at the gates of asia, he was always following his favourite thesis about “quite different, non-textbook conditions” of otherwise well known paediatric diseases, especially in the rural villages they visited on their trips: “diseases and their forms show partially a different course from those we can find described in our textbooks. other diseases such as the examples of malaria or necrotic ulcerative stomatitis can confront the paediatrician with the task, to find new ways as... the specificities of childhood must be taken into account” (19). insight in scientific gains made by eckstein on his voyages could be seen in his monograph “malaria in childhood” (24), published in 1946. on the front page of this publication the author and professor in ankara described himself, 11 years after his flight from germany, still as “former full professor... at the medical academy in düsseldorf”. here he dedicated a 100-page chapter of the text to arthur schlossmann. the text was written on never before systematically described forms of diseases, here “nontextbook” forms of malaria among children that eckstein learned to diagnose and treat during the decade he travelled deeply into the turkish countryside. unusual forms of malaria among children revealed occasionally just strong thirst or insomnia with strange behaviour and consciousness disorders. lethality was strangely high and made up for a large part of total mortality in the population. child mortality from diarrhoea could be largely reduced in malaria regions through “energetic treatment” with anti-malarial drugs. with 90 case reports, eckstein showed some common childhood diseases with symptoms, temperature charts, differential diagnoses, congenital illness, and malaria among infants, complications, protracted and foudroyant coma, recurrence, combinations with other diseases, especially with typhus abdominalis and tuberculosis, chronic malaria, consequences and therapy. even more, he compiled “more than 1000 clinical observations of interest” from his survey research. already in one earlier publication “encephalitis in the children’s age”, published in 1929 (25), he collected with the same objective different forms of encephalitis among children and how they were described in the literature. this was a compilation of new observations which contributed to the understanding of encephalitis among children, to be distinguished from the clinical picture in adults. as an example, during chronic encephalitis in adults, physical changes manifest as immobility and lethargy, while among children and young people different types of asocial behaviour can be found. almost all cases of acute encephalitis among children lead to incomplete healing and transfer over time into chronic forms of illness. concluding remark for 14 years, eckstein lived and worked in ankara. after 1945, for the successful assailant, the question of remigration appeared. a number of honours from post-war germany indicated that eckstein not only was remembered, but he was also needed. the medical academy in düsseldorf awarded eckstein the honourable citizenship in 1948 (9,26), and that same university as well as four other german universities offered him a full university professorship in paediatrics. at the end, eckstein accepted the sixth offer from hamburg. his inaugural lecture covered the theme “problems of paediatric care in turkey” (3,4). in 1949, heinzelmann w. the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii (review article). seejph 2015, posted: 18 january 2015. doi 10.12908/seejph-2014-37 9 albert eckstein came back to germany [no more than 5% of the german-jewish émigrés returned to the country of their origin (27)], but one year later he died at the age of 59. among the exiled german-jewish professors, eckstein was the most outstanding professional in the field of social-hygiene and early health sciences, and vice versa, he was its classical product – if one can say so. eckstein stands among the assailed scientists in turkey as “grotesque deviation of history” to those who most impressively reflected back the “shameful expulsion” (28). references 1. akar n, eckstein a. a pioneer in paediatrics in turkey. turk j pediatr 2004;46:295-7. 2. gottstein a, schlossmann a, teleky l. handbuch der sozialen hygiene und gesundheitsfuersorge. heidelberg: springer, 1925. 3. johannsen l. eric aschenheim albert eckstein julius weyl. juedische paediater im vorstand der vereinigung rheinisch-westfälischer kinderaerzte, juedische miniaturen. berlin: hentrich, 2010: (vol.) 104. 4. bürgel k, riener k. wissenschaftsemigration im nationalsozialismus. der kinderarzt albert eckstein und die gesundheitsfuersorge in der tuerkei. duesseldorf: quellen und forschungen aus dem universitaetsarchiv duesseldorf, 2005. 5. erichsen r. medizinemigration in die tuerkei. in: scholz a, heidel cp (eds.). emigrantenschicksale, einfluss der jüdischen emigranten auf sozialpolitik und wissenschaft in den aufnahmeländern. frankfurt: 2005. available at: https://www.google.de/#q=erichsen+r.+medizinemigration+in+die+tuerkei (accessed: december 22, 2014). 6. moeckelmann, r. wartesaal ankara ernst reuter: exil und rückkehr nach berlin. berlin: berliner wissenschaftsverlag, 2013. 7. wunderlich p, renner k. arthur schloßmann und die duesseldorfer kinderklinik. duesseldorf: festschrift zur feier des 100. geburtstages am 16. dezember 1967, 1967. 8. widmann h. exil und bildungshilfe. die deutschsprachige akademische emigration in die tuerkei nach 1933. bern: herbert lang, 1973. 9. griese k, woelk w. juedische aerzte und aerztinnen in duesseldorf und in der emigration. in: duewell k et al. (eds.). vertreibung juedischer kuenstler und wissenschaftler aus duesseldorf 1933-1945. duesseldorf: hentrich,1998. 10. günay-erkol c, reisman a. emigre albert eckstein’s legacy on health care modernization in turkey: two generations of students who have made major contributions. hygiea internationlis 2008;7:27-48. 11. eckstein a. probleme und aufgaben der kinderheilkunde in der tuerkei. annales pädiatrici/international review of pediatrics 1940;155:16-35,57-83,113-139. 12. moll h. emigrierte deutsche paediater: albert eckstein, werner solmitz. monatsschr. kinderheilk. 1995;143:1204-10. 13. eckstein-schlossmann, e. eigentlich bin ich nirgendwo zu hause. edited by lorenz peter johannsen, berlin: hentrich, juedische memoiren 2012;17:99. 14. eckstein, a. beitrag zu der erforschung der gesundheitlichen und hygienischen verhältnisse auf dem lande mit besonderer beruecksichtigung der kinder (bericht ueber eine studienreise in zentralanatolien 1937 (translated). anadolu klinigi 1938;6:37-76. 15. heinzelmann w. sozialhygiene als gesundheitswissenschaft. die deutsch/deutschjüdische avantgarde 1897-1933. bielefeld: transcript publishing company, 2009. 16. akar n. modernizer of turkey’s pediatrics: albert eckstein in exile. ankara: 2005. heinzelmann w. the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii (review article). seejph 2015, posted: 18 january 2015. doi 10.12908/seejph-2014-37 10 17. akar n, reisman a, oral a. albert eckstein (1892-1950): modernizer of turkey’s paediatrics in exile. j med biogr 2007;4:213-18. 18. seidler e. kinderärzte, entrechtet/geflohen/ermordet. freiburg & basel: karger, 2007. 19. eckstein, a. reisetagebuch anatolische reise 1937. in: bürgel k, riener k. wissenschaftsemigration im nationalsozialismus. der kinderarzt albert eckstein und die gesundheitsfuersorge in der tuerkei. duesseldorf: quellen und forschungen aus dem 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introduction by helge peukert. marburg: metropolis, 1995. ___________________________________________________________ © 2015 heinzelmann; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 1 | 12 short report covid-19 in the gaza strip and the west bank under the political conflict in palestine yehia abed1 1 al quds university, school of public health, gaza city. corresponding author: prof. yehia abed md, mph, dr.ph; address: al quds university, school of public health, gaza city; e-mail: yabed333@yahoo.com mailto:yabed333@yahoo.com abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 2 | 12 abstract covid-19 is a serious pandemic with variation of spread, morbidity, and fatalities between countries. palestinians are facing the epidemic, with around 2 million inhabitants under siege in the highly populated gaza strip for the last 14 years. the siege may be the main threat for the spread of disease among the palestinian population. the palestinians faced the corona epidemic with limited facilities in their hand. however, the risk factors remain multiple, the most important are overcrowding in the gaza strip, poor health care facilities, and the risk of workers moving between the west bank and israel. palestinian health authorities responded directly to the pandemic and took strict closure measures to prevent rapid spread. the palestinian strategy has focused on social spacing, personal hygiene, control of border crossings and health preparedness to deal with medical cases while continuing to provide health services to the population. the difficult economic situation is the major obstacle facing palestinians to overcome the disease spread where workers continue their jobs inside israel and gaza cannot enforce low-income workers to stay at home. more is needed to ensure community engagement, support coordination among all health care providers in palestine, and take effective steps to promote social spacing. friendly countries and international organizations can assist and support the palestinian population in providing laboratory diagnostic materials, providing personal protective devices, strengthening intensive care units, and supporting outreach activities and training programmes. keywords: control measures, covid-19, gaza strip, palestine. conflicts of interest: none declared. abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 3 | 12 introduction palestine is located on the eastern coast of the mediterranean sea. its remaining area is divided into two geographically distinct regional units, the west bank and the gaza strip. according to the palestinian central bureau of statistics the total population in 2017 was about five million, thereof two million throughout the last 14 years locked in the gaza strip (gs) with its 365 square kilometers one of the most densely populated areas in the world (5,324 people per square kilometer) (1). in one of the unrwa refugee camps population density reaches even 80,000 per square kilometer (2). the unemployment rate in the gaza strip is around 52% (3) whereas 53% of the population are suffering from poverty (1), and 69% are exposed to food insecurity (4). historically the first known epidemic reported in palestine was “amwas plague, 639 a.d.” so-called by the name of a small palestinian village between jerusalem and ramallah. this plague spread throughout great syria leading to the death of estimated 25,000 people (5). in 1799 the plague of acre city erupted between the french soldiers led by napoleon bonaparte after a two-month siege of the city. this plague led to the death of about 2000 french soldiers (6). in the last 50 years, gaza was exposed to more than 20 epidemics including poliomyelitis 1974 and 1976, cholera 1981 and 1995, measles between 1971 and 1991, meningitis 1997, avian flu 2006, and swine flu 2009. this paper aims to study the extent and determinants of the covid-19 epidemic in the palestinian territories, to identify the readiness of the palestinian health sector to face the covid-19 epidemic, and to develop recommendations that may help decision-makers to reduce the spread of the epidemic. the palestinian health system and its challenges the palestinian national authority assumed responsibility for health services in the west bank and gaza strip which israel occupied in 1967 following the oslo peace agreement between the palestine liberation organisation (plo) and the government of israel in september 1994. the palestinian national authority (pna) was established in may 1994, and the ministry of health shortly thereafter. the health care system consists of four service providers: the ministry of health, the united nations relief and works agency (unrwa), non-governmental organisations (ngos), and the private sector. questions have been raised about the pna's limited ability to prioritize health services and interventions. political insecurity and socio-economic instability have affected the health of the population and the ability of palestinians to develop a modern health system, particularly intensive care rooms, respirators, and lack of access to serve residents in the neighbourhoods of jerusalem and the occupied areas "c" in the west bank (wb). despite increased health spending, the impact of the political split has been severe and harms the population of the gaza strip. there is a chronic shortage of basic medicines and health supplies for more than one-third of what is needed, especially with regard to emergency rooms, operations, intensive care, orthopaedic services, nephrology, and neonatal care. the palestinian people have faced many restrictions that have affected their ambition to create a functional palestinian health system that responds to the needs of the population, most important the containment for the last fourteen years. first, the blockade imposed on two million palestinians in the gaza strip deprives them abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 4 | 12 of the development of their scientific capabilities, prevents the entry of equipment, medicines and diagnostic materials and prevents patients from receiving their health services even within the palestinian territories, which have been torn apart by the division. second, the detention of palestinian tax funds, which have severely disrupted the life of palestinian society, thereby preventing palestinians from using their resources to operate the health system. seizing tax revenues by the israeli government lead to major obstacles in the daily work of the palestinian health care centres, including reduction of the salaries of health workers who in spite of that continued to work with minimum salaries. third, the usa assistance to the palestinian authority, including jerusalem hospitals and health projects in the gaza strip, has stopped by a political decision to put pressure on the palestinians. for example the author and his team spent more than one year preparing plans and responding to usaid requirements but finally the project was cancelled without implementing the planned field activities and abandoning multiple health activities that were prepared over a long period and after a lot of effort to respond to multiple requirements developed by usaid. fourth, the cut of financial aid to unrwa and pressure on other countries to cut off their support either. it is worth stating that the establishment of unrwa was based on the international resolution on action and relief for the palestinian population. this decision affects the most the population of the gaza strip, where 70% of the population are refugees receiving their primary health care services through unrwa. fifth, three devastating israeli military attacks on gaza in 2008, 2012 and 2014 destroyed buildings, schools, and health centres, requiring permanent efforts to restore buildings and functionality. the health and humanitarian needs and challenges facing the people of gaza remain tied to the continuing siege, lack of supplies and equipment, drugs, and human resources, as well as limited availability of electrical power. the increasing impact of ncds on the healthcare system; and the growing number of denials and delays related to requests for medical services abroad have resulted in increased morbidity and mortality. on average, the ministry of health (moh) in gaza is facing shortages accumulating e.g. to onethird of essential drugs and medical disposables. these restrictions have damaged the palestinian health system and deprived it of development and even the provision of basic health services to the population. the current covid-19 epidemic is increasing the burden on the system. the covid-19 pandemic during the past two decades, the world has been stricken by two pathogenic respiratory coronavirus pandemics; the severe acute respiratory syndrome (sars) (7) and the middle east respiratory syndrome (mers) (8). in december 2019, a third respiratory coronavirus has emerged starting from a large metropolitan area in china’s hubei province, wuhan. most of the cases present with fever, dry cough, and tiredness, although clinical presentation ranges from asymptomatic to atypical severe pneumonia (9). by 11 march 2020, the who declared covid19 a pandemic (10). neither medication nor a vaccine has been approved for example by the american food and drug administration (fda). preventive measures are the only solution to save lives and to provide the countries with more time to prepare for the arrival of the virus (11). within a short time, the disease spread to include most of the world countries. all countries in the arab region have reported covid-19 cases, yemen abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 5 | 12 was the last. most arab countries also have available a national rapid response for timely investigation and response to public health threats (12). similar to other countries, palestinians started preparations to face the coming virus with their scarce resources by forming scientific committees to review the available emergency plans and protocols supported by the world health organization and train the local staff for relevant subjects including infection prevention, proper use of personal protective devices, and case management including intensive care for seriously ill patients. the preparedness activities were followed by the response when the first case was reported in bethlehem city in the west bank (wb). the effort focused on the complete isolation of the city and closure of markets, schools, universities, mosques, and churches, as well as a ban of major social gatherings. in gaza, the first two cases appeared three weeks later than in the west bank which allowed time to prepare the same regulations. by may 20 (last modified date), 602 cases had been registered, of which 547 were in the west bank, including east jerusalem, and 55 in the gaza strip. it became clear that the limited prevalence of cases in the west bank was concentrated in the middle of the country, i.e. in the governorates of jerusalem and bethlehem with a northern expansion to include parts of ramallah and a south expansion to include parts of the hebron governorate. the integrity of the northern west bank was preserved, as no cases are reported in some governorates there. seventy-five percent of all cases can be attributed to a single source, the workers moving across the green line and their contacts, while in the gaza strip, the registration of cases is still limited to the quarantine centres and no positive endogenous cases have been reported so far. eighty percent of cases occurred among young people under 50 years of age and two-thirds of cases were identified among males, with a higher prevalence among workers. like for other countries, the risk groups are aged people with chronic disease and workers moving to and from inside israel where the latter constitute a major risk of disease transmission to wb. thousands of palestinian prisoners in israeli jails are also exposed to high risk. outbreak scenarios in palestine the palestinian public health institute, in collaboration with the world health organization and the advisory committees of the ministry of health, is working on preparing scenarios for the future of the epidemic in the palestinian territories and has developed scenarios in the west bank that will be studied and announced. in the gaza strip, it was difficult to implement the same scenarios as no endogenous cases are reported up to now. the extremely high population density in the gaza strip of 5,200 persons/km2 together with the long incubation period of 14 days according to who standard results in a worstcase scenario of 20,000 cases based on the record of wuhan, i.e. 8 cases per 1,000 citizens. to counter this scenario, we are prepared to take strict closures to flatten the epidemic curve to extend for a longer period of up to 10 months, with an estimated forecast of 2,000 cases per month. it is expected that 20% or 400 of the cases calculated per month will need hospital services. the gaza european hospital and surrounding areas have been prepared to accommodate these numbers (advisory committee-gaza). if endogenous cases in gaza are reported, the ministry of health will start case-investigation and draw on the basis of these data the real pandemic curve to be compared daily with the forecasted curve of 2,000 cases per month abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 6 | 12 and 400 hospitalisations. if the real curve remains below the forecasted curve, this indicates that the system can absorb the patients requiring hospital services. if, however, the real curve is out of the forecasted curve the health system is facing a pandemic beyond its absorption capacity. decision-makers will have to take then the necessary measures, either to increase the capacity of the health system or to establish stronger measures of isolation and social spacing, details outlined as follows. palestinian strategies to control the covid-19 pandemic 1. prevention of infection through social distance, personal hygiene, and use of protective devices. 2. virus containment through controlling entrance at border crossings by quarantine of travellers. 3. health care facilities preparedness and handling of the discovered cases. 4. early discovery of cases by pcr testing and contact tracing. 5. continuation of essential health services for the population. 6. surveillance and response based on the situation in palestine and neighbouring countries. 1. prevention of infection through social distance, personal hygiene, and use of protective devices facing a virus without specific treatment and without vaccines to prevent, we have to work in two directions, the first one is personal hygiene and environmental protection and the second is the social distance. prevention of infection will be applied at three levels:  support health education programmes propagating the importance of wearing face masks and the need to wash hands and disinfect surfaces of furniture and work offices.  closing overcrowded places such as schools, universities, mosques, sport clubs, wedding halls, funeral homes, and major markets.  isolation of communities with confirmed cases either by curfew or movement restriction between communities. in the west bank, the three levels were implemented while in the gaza strip activities were limited to the first 2 levels as zero cases were reported outside the quarantine departments. in gaza overcrowding continues in the markets and streets and the population has been encouraged by the false feeling of security, i.e. that the virus will not enter the gaza strip. as there are high rates of unemployment, which exceeds 70% among the youth, and daily individual work became the only means of achieving a limited income for thousands of palestinian families, the deteriorated economic status prevents the public to respond to social distance and reduced overcrowding in the markets. local voices call for curfew application for the entire gaza strip, but ethical considerations are to be considered too as people should be provided with basic needs as food, drink, safety measures, and medications for chronically ill people but the funds are not available to cover these expenses. 2. virus containment through controlling border crossings by quarantine of travellers crossings with jordan and egypt have been closed, but the crossings with israel are facing problems due to the multiplicity of crossing points in the west bank and the loss of abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 7 | 12 security control by palestinian guards in areas "c". a large number of workers – estimated to be around 180,000 pass through these crossings. they constitute the largest risk of virus transmission from israel to the palestinian territories. according to reports from the palestinian ministry of health, 75% of the positive cases reported in palestine are workers returning from inside israel and their contacts. as regards the gaza strip there is only scarce movement across borders due to the israeli restrictions. besides, there are only two crossings, the beit hanon (eretz) crossing for those coming through israeli and the rafah crossing for those coming through egypt. returnees from these crossings were required to be quarantined for two weeks, the quarantine policy to be compulsory within school buildings. the process was initially severely disturbed and the facilities not equipped for quarantine, lacking provision of basic needs. based on this experience a policy was developed for the quarantine process:  provision of daily basic needs such as food, drinks, medicine, and communications to all inhabitants.  ensuring that infections do not reach and spread within quarantine centres.  procedures to prevent spread of infections outside the centres. quarantine measures in the early phase have been extended to some hotels and health institutions. within a short period, 1,000 single quarantine rooms have been replaced in school buildings. the quarantine period in gaza exceeded the 14 days recommended by who by an extra week to take into consideration possible incubation periods longer than 2 weeks. 3. health care facilities preparedness and handling of discovered cases there is a small isolation hospital in the gaza strip with a capacity of 35 beds and 6 intensive care beds for positive cases located close to the egyptian border. the european hospital and surrounding areas have been set up to accommodate 400 cases to face the expansion of the epidemic. in the west bank, 13 hospitals were selected to isolate positive cases. in jerusalem, isolation departments have been set up at augusta victoria hospital, st. joseph's and makassed hospitals (13). respirator rate in palestine is 10 devices per 100,000 citizens and 4 in the gaza strip. compared to other countries, these rates are 30 in germany and 50 in israel while israelis are seeking to raise them to 150 devices per 100,000 inhabitants. many countries are investing a lot on more devices, germany for example has increased the health system's capacity to add 10,000 units. the united states of america has spent $2.9 billion to acquire 19,000 devices more. in contrast, the possibilities of the palestinian authority do not allow the purchase of any new equipment. obtaining an effective drug or obtaining a protective vaccine requires a longer time, because it takes meticulous scientific, legal and ethical procedures, starting with the identification of the genetic map of the virus and followed by success to form the required substance and its approval from international and scientific institutions such as the fda. then the drug or vaccine has to pass successfully in experimental animals, followed by guarantees of safety and effectiveness in humans and the authorization of testing the product on humans in small groups followed by large groups. if successful the compound is displayed for manufacturing and marketing and then who and experts will determine which categories should receive this drug or vaccine with adherence to the prohibitions of use if necessary. therefore, a long time is needed to produce a suitable drug or vaccine. also abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 8 | 12 some compounds are considered as promising that have been used previously in the treatment e.g. of malaria with chloroquine or hydroxychloroquine (14). another example is the oxford vaccine based on previous trials of mers and remdesivir which has been successful in treating ebola, sars and mers in laboratories but has not achieved clinically relevant results at that time. clinical trials are underway to determine the appropriate dose and treatment periods for use in coronatherapy. at the same time, who is conducting a large-scale solidarity trial that aims to rapidly discover whether any of the drugs slow disease progression or improve survival in different parts of the world including such as remdesivir and lopinavir/ritonavir with interferon beta-1a. accordingly, the advisory committee recommended not to rush to use drugs or vaccines that have not been proven globally and to wait for stronger evidence. people acquire long-term immunity to any microbe in one of two ways, either by vaccination or getting sick and recovering from a disease. from the advocates of the herd immunity scenario it is understood that 70% of a population should be infected which implies a high rate of case fatalities which is ethically unacceptable. therefore, social spacing remains for the time being the best and safest option to deal with the covid-19 pandemic. social spacing is expected to reduce the transmission, leading to a significant reduction in the epidemic dynamics. the pna has excellent health teams but a severe shortage of diagnostic facilities and equipment. therefore the main focus should be on personal hygiene social spacing. 4. early discovery of cases by pcr testing in the gaza strip, all arrivals to quarantine centres are examined physically and by pcr testing. this strategy has succeeded in detecting 66 cases up to date in gaza, preventing epidemic expansion among the population. in the west bank, all arrivals across the jordan bridge were screened by pcr testing. the success of this strategy depends on the availability of a sufficient number of pcr swaps and kits. 5. continuation of essential health services for the population who recommends that health services to the population continue to be provided in the face of the epidemic, particularly immunization programmes and care of chronic patients. some health centres were closed because of curfew in the wb and subsequent reallocation of health staff to work in isolation units. in the gaza strip 37 out of a total of 54 government centres are open. non-governmental health institutions provide also basic services to the population as the government sector is busy confronting the epidemic. unrwa provides excellent primary health-care activities by establishing a public hotline to provide people with home treatment and health consultations and is ready to reach all those registered for non-communicable disease services at home, as well as to provide social assistance at home to avoid overcrowding in the centres. the agency also continued vaccination programmes. during disease outbreaks and emergencies, the advisory committee stresses the importance of maintaining basic health services such as immunization, and effectively involving ngos and communities in health planning and service provision (1517). 6. surveillance and response based on the situation in palestine and neighbouring countries who advises in principle not to rush back to normal life before the final elimination of the abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 9 | 12 epidemic, but there is public pressure to return to open markets and mosques accompanied by a government eagerness to boost the economy and increase government incomes. who therefore recommends a return gradually to normal life, at least in communities with low risk. however, decision-makers should link the mitigation plan to pandemic indicators over time, i.e. to follow up on the rate of positive laboratory tests, the rate of growth and change over time of multiplication (number of new cases due to one source contact), to determine the effectiveness of these measures, to tighten them and mitigate them as the epidemic changes. the economic burden the current pandemic overburdens the system and aborts the response to population health needs. the economic factor is a major component responsible for variations between countries. israel allocated $2.8 billion to control the current pandemic i.e. to cover treatment and drugs as well as social insurance to their inhabitants. pna has no resources either to ensure the cost of the pandemic nor to ensure social insurance for the population. it is worthy to mention that gdp per capita in israel is 15 folds higher than in palestine. these economic variations are reflected the daily activities to control the pandemic. by the end of march, all examined blood samples for early detection amounted to 830 in palestine while in israel health authorities examined daily around 4000 blood samples. by early june 2020 the number of tests in israel is almost more than tenfold as compared to palestine, 593,499 vs. 44,876 or 11,637/100,000 vs. 1,360. it is noteworthy that the economic factor played a major role in the public's failure to accept preventive measures, even though people are aware of the seriousness of the matter. in the northern governorates, thousands of workers and their families still work within israel as a primary source of livelihood and the interruption of work will lose their entire income, which leads them to continue their work and move between the workplace and their places of residence. planning and funding based on the who guidelines health authorities in the gaza strip and the west bank have developed strategic plans to address the epidemic. prevention, and treatment protocols have been developed in quarantine departments, contact tracing and follow-up of cases, and estimates of expected costs. who has been involved in the work of the various committees. among the global strategic goals, who has recommended that government sectors mobilize all community sectors to ensure that they are responsible for reporting and reducing the number of cases through citizen hygiene practices and physical spacing between individuals. financial estimates, prepared by the ministry of health, estimated $137 for palestine in total. who has issued an appeal for $6.5 million for funding activities of the ministry of health, unrwa, and some health ngos. financial estimates have also been developed at the ministry of health in gaza. the health cluster april 2020 report states: "to respond to the growing health needs of covid, the health group requires a total of $19 million". having received $10.8 million a funding gap of $8.2 million remains. health group partners require $37.5 million to meet the health needs of the most vulnerable communities in the occupied palestinian territory for 2020. to date, a total of $10 million has been secured so far, leaving a gap of $27.5 million (13). no reports have been issued of the donor response, and everyone is looking for abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 10 | 12 ward to prepare a single strategic plan to address the epidemic, cover the requirements of the palestinian people, develop treatment protocols, and organise uniform and broader community participation to control the epidemic. main coordination deficit: absence of a palestinian central national committee facing the current pandemic different technical and administrative committees were formed in the gaza strip and the west bank with minimum coordination. committee members were mostly official governmental employees, universities were invited to participate in epidemiological and consultative committees, and ngos to participate in administrative committees. the absence of a central national coordination committee for both west bank and gaza resulted in a poor estimation of the needs, miscommunication with the donor community, an unclear role of the health care providers, and unfair distribution of resources. many delegates asked to expand the role of ngos, where their role is not clear and limited to clinical activities. furthermore technical and administrative protocols have been prepared separately for the west bank and the gaza strip without full communication between palestinian experts and as well resource allocation and requests for funding were poorly coordinated. recommendations  until the development of a covid19 vaccine, the constant urge to support the policy of social distance and personal hygiene among the population is the best, safest and most acceptable option to deal with the pandemic.  establishment of central national committee presenting governmental and non-governmental sectors to revise and set policies to control the spread of the epidemic, seek funding, define roles of players and ensure the equitable distribution of resources among the partners.  review the diagnostic and treatment protocols and update them according to international evidence-based recommendations and continue as well the training of health care providers and volunteer teams.  train community groups regarding personal protective devices and environmental and personal hygiene.  community involvement and participation to support the official authority in the field implementation of their plans and activities. clearly defined tasks are needed.  support economic development to establish solutions to solve problems related to working conditions within the green-line and advocate for productive jobs within the palestinian land.  urge donors to provide health authorities with laboratory diagnostic materials, personal protective devices, strengthening intensive care units, supporting outreach activities and training programmes. acknowledgment i would like to extend my appreciation to the palestinian center for policy research and strategic studies (masarat) for giving me the chance to prepare this paper, to present to a group of palestinian health experts, and to take their feedback. thanks for the epidemiology committee in the ministry of health and the covid19 consultation community in gaza for their support and provision of the required information. abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 11 | 12 references 1. palestinian central bureau of statistics. population, housing, and establishments census 2017: census final results. ramallah, palestine. 2. unrwa. where we work. available from: https://www.unrwa.org/where-wework (accessed: may 25, 2020). 3. palestinian central bureau of statistics. press report on the labor force survey results, labor force survey; 2019. available from: http://www.pcbs.gov.ps/portals/_pcbs/pressrelease/press_en_13-2-2019-lf-e.pdf (accessed: may 25, 2020). 4. palestinian central bureau of statistics. socio-economic food security survey: 2018. preliminary results. available from: 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https://www.who.int/immunization/documents/who_ivb_17.03/en/ (accessed: may 27, 2020). 17. miller np, milsom p, johnson g, bedford j, kapeu as, diallo ao, et al. community health workers during the ebola outbreak in guinea, liberia, and sierra leone. j glob health 2018;8. available from: http://www.jogh.org/documents/issue201802/jogh-08-020601.htm (accessed: may 27, 2020). _____________________________________________________________________________________________ © 2020 abed; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 1 review article the south eastern europe health network: a model for regional collaboration in public health maria ruseva 1 , snezhana chichevalieva 1,2 , meggan harris 3 , neda milevska kostova 4 , elke jakubowski 5 , hans kluge 6 , jose m. martin-moreno 3,7 1 executive committee, south eastern europe health network, skopje, republic of macedonia; 2 head of who country office in the former yugoslav republic of macedonia, skopje, republic of macedonia; 3 department of preventive medicine and public health, university of valencia, spain; 4 centre for regional policy research and cooperation ―studiorum‖, skopje, republic of macedonia; 5 public health services, division of health systems and public health, who regional office for europe, copenhagen, denmark; 6 division of health systems and public health, who regional office for europe, copenhagen, denmark; 7 incliva research institute, university of valencia clinical hospital, valencia, spain. corresponding author: maria ruseva, md address: bellmansgade 23, 7 tv., 2100 copenhagen ø, denmark; telephone: +4522500664; e-mail: rusevamaria33@gmail.com ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 2 abstract inter-country alliances, articulated through regional approaches, have increasingly been used to drive economic development and social progress in the past several decades. the south eastern europe health network (seehn) stands out among these types of initiatives for the tangible improvements it has achieved in regional governance for health, with several important lessons for public health leaders worldwide. this review paper, written by several key participants in seehn operation, follows the main milestones in network development, including its foundation under the stability pact’s initiative for social cohesion and the three ministerial forums that have shaped its evolution, in order to show how it can constitute a model for regional collaboration in public health. herewith we summarise the main accomplishments of the network and highlight the keys to its success, drawing lessons that both international bodies and other regions may use in their own design of collaborative initiatives in health and in other areas of public policy. keywords: collaborative networks, health systems, public health, regional cooperation, south eastern europe. conflict of interest: none. ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 3 introduction inter-country alliances, articulated through regional approaches, have increasingly been used to drive economic development and social progress in the past several decades. the european union (eu), with its common currency, open borders and well-established governing institutions, is the most consolidated regional political alliance, but many other blocs have been established across the globe as a way to catalyse development and cooperation. although founded primarily to promote free trade – not social cohesion or justice – their leaders have gradually begun to understand that social and economic development are inextricably linked. the charter of fundamental rights (part of the treaty of lisbon) set the stage for dozens – if not hundreds – of eu-led initiatives in public health and education, including the black sea cooperation and the union of the mediterranean. other regions have taken steps to articulate a common approach to public health as well, for example in asia (1) and south america (2). the south eastern europe health network (seehn) stands out among these types of initiatives for the tangible improvements it has achieved in regional governance for health, with several important lessons for public health leaders worldwide. this paper follows the main milestones in seehn development, including its founding and the ministerial forums that have shaped its evolution (http://www.myhistro.com/story/seehnfounding-story/147935/), in order to show how it can constitute a model for regional collaboration in public health. herewith we highlight the keys to success and draw lessons that both international bodies and other regions may use in their own design of collaborative initiatives, in health and in other areas of public policy, paying due attention to the specific context of the region. the roots of seehn development: public health as a bridge to peace, reconciliation and development in the decade following the disintegration of the soviet union and the neighbouring yugoslavia, the south eastern european (see) region plunged into a long period of turmoil, transitioning rapidly from a state-command to market economy amidst the violent combustion of ethnic tensions in the former yugoslavia. the consequent financial instability, decline in social expenditures and inadequate organisational structures (3,4) led to a breakdown of already tenuous health and social care systems. when albania, bosnia and herzegovina, bulgaria, croatia, the republic of macedonia, romania and yugoslavia signed the stability pact for south eastern europe in 1999, the health indicators in these regions reflected that crisis. as just one example, infant mortality in the see region nearly tripled that of the eu-15, at 13.9 deaths per 1000 live births (5). although the ―non-productive‖ social sector was deemed by the states as a consumer of income rather than as a producer of value (6), investing in public health was nevertheless considered a worthy way to maintain social unity. it was also considered as a particularly appropriate area for regional cooperation; after all, the tradition of public health in see dates back to one of the key architects in the creation of the world health organization (who), dr. andrija štampar, a fitting symbol of how health can function as a force of peace and cooperation between otherwise fractious governments. in 2001, the seehn was established as part of the stability pact’s initiative for social cohesion, under the leadership of the council of europe, the council of europe development bank and the who regional office for europe. at the same time, the need to reconstruct the training programmes for public health professionals, especially in the successor states of the former yugoslavia, became obvious. ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 4 therefore the german sponsored section of the european stability pact agreed to fund the forum for public health in south eastern europe (fph-see) (7) from 2000-2008 with the following main objectives: i. to develop up-to-date teaching materials for public health sciences; ii. to determine and analyse comparable health indicators for south eastern europe; iii. to support the institution building for public health, especially with regard to schools of public health, institutes of public health and public health associations; iv. to organise professional meetings, workshops and conferences in the south eastern european region. during this period, six volumes with more than 3500 pages of teaching materials were published (8) and their utilisation analysed (9) with a 2 nd online edition in 2014 (10); a revised shortlist of indicators was published in 2006 (11), and new schools of public health were established in belgrade, bucharest, chisinau, novi sad, pleven, skopje, sofia, tirana, and varna. by 2008, more than 25 conferences and summer schools had been organised and more than 50 articles been published, beginning with kovacic & laaser in 2001 (12). public health thus became the common denominator of both a political and academic movement to improve the health and wellbeing of the see populations. the strong commitment of the ministries of health in the region surfaced as an urge to address the emerging changes across the societies; together with the strategic guidance of seehn’s external partners and burgeoning academic communities, the ministers of health of seven countries 1 planted the seed for an exemplary initiative of regional cooperation. learning by doing: forging partnerships in public health to protect the most vulnerable populations (2001–2005) the who regional office for europe, along with the council of europe and the council of europe development bank, eleven donor states (belgium, france, greece, hungary, italy, norway, the netherlands, slovenia, sweden, switzerland and the united kingdom) and the health ministers of the founding member states themselves, worked to shape an institutional model capable of empowering national leadership as well as regional collaboration. the achievement of this goal is a testament to member states’ commitment to seehn’s goals, particularly that of professional exchange and regional partnership, but it is also a result of the wisdom of external leaders and donors, who knew how to make their role redundant in just seven years. the founding dubrovnik pledge committed the states to mobilising human and financial resources to meet the needs of their most vulnerable citizens. seven priorities were laid out: (i) enhanced access to quality health and public health services; (ii) development of community health services; (iii) regional self-sufficiency in the provision of safe blood and blood products; (iv) integrated and universal healthcare; (v) better surveillance and control of communicable diseases; (vi) food safety and security, and; (vii) regional exchange of social and health information (13). this first health minister’s forum set the political vision for seehn policy, but technical policy and implementation also had to be developed. at the beginning, the technical side was also led by experts from the council of europe, the council of europe development bank 1 the founding dubrovnik pledge included signatories from albania, bosnia and herzegovina, bulgaria, croatia, romania, the republic of macedonia and yugoslavia. however, the republic of moldova joined a year later (2002), and in 2006, two independent countries (montenegro and the republic of serbia) from the former yugoslavia formally pledged their adherence. finally, israel joined the network in 2011, bringing current seehn membership to ten countries. ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 5 and the who regional office, together with the national health coordinators (high-level officials designated by each member state). by 2004, however, this structure had given way to a rotating presidency, held personally by health ministers for a six-month term. these leaders, along with representatives of the regional office and donors, would hold a regional meeting of the national health coordinators, high-level officials designated by each member state. the regional meetings would forge the technical policy through consensus among all participants. as for implementation, regional project offices were established in the lead country for each technical area. since then, these offices have managed and coordinated technical work at a regional level, fostering a collaborative network of professionals region-wide. member states have chosen the project areas they led from the start, thereby cultivating ownership and leadership in one area and providing a natural incentive to collaborate and learn from initiatives led by other countries (14). the first major seehn project, on mental health, was led by bosnia and herzegovina (15). initially planned for just two years, its success led to a four-year extension, which has now been consolidated and given continuity through the transformation of the sarajevo regional project office into the network’s first regional health development centre, or rhdc (box 1). the mental health project also provided an excellent model on which to base subsequent initiatives during the first period of seehn development, which have successfully tackled blood safety (16), food safety (17), tobacco (18) and other challenges. box 1. tangible achievements in mental health through seehn three million euros from external donors provided the resources that experts within see needed to implement seehn’s flagship project, which started by establishing a regional project office in sarajevo as well as national offices and teams in all of the member states. these professionals worked together to analyse existing mental health policies in their countries and to set a common vision and strategy for the region; this work led to the endorsement of new national mental health strategies and laws in all member states. the second phase began in 2005 and saw the establishment of pilot mental health centres in every country, which provided a practical basis for the development of a regional model of service provision, including firsthand and collaborative experience in developing care standards, leadership modules and case management systems. a monitoring and evaluation system was also established, facilitating the exchange of data that would prove crucial to external consultants and regional partners in the refinement of policy and practice. eleven centres, serving a catchment area of over one million citizens, were fully integrated into the countries’ primary health care system, contributing greatly to the de-institutionalisation of people with mental health disorders. the final phase focused on training and advocacy programmes, which seeded the reform movement for mental health policy in the region. when see health ministers released a joint declaration on mental health in 2007 (19), all member states responded by revising their mental health policy in line with its recommendations. today, dozens of mental health centres operate in every see country, supported by a clearly articulated national policy and a coherent regional framework, which are all in line with current european recommendations (20). moving forward: reforming health systems and public health services (2005–2011) by the second health minister’s forum in 2005 in skopje, a reservoir of regional trust, expertise and leadership had accumulated. in recognition of the enhanced regional capacity for managing the network, an executive committee was established to oversee implementation of the decisions made during the ministerial forums, facilitate regional action ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 6 and monitor progress. the skopje pledge (21) also saw the assumption of seehn ownership over all regional projects, marking a decisive turning point towards a pro-active leadership. in 2008, and coinciding with the replacement of the stability pact by the regional cooperation council, seehn’s self-governance was consolidated through a memorandum of understanding. this document set new terms for network organization (figure 1) and operation included by means of a formal secretariat in skopje (inaugurated in 2013) and a number of regional health development centres (rhdcs) across see. starting in 2010, these were established to give continuity to the results achieved and to provide ongoing services and policy advice in particular areas of action. this structural configuration has allowed each country to benefit from the concentration of expertise in other member states, without having to maintain national centres in all the technical areas at anything close to the same level. by pooling the resources, member states all have access to world-class institutions in a variety of technical fields. these developments set the stage for see member states to take full control of the network, although the who regional office and other partners would continue to provide technical input and guidance. figure 1. governance of the see health network in 2014 the policy focus of seehn also shifted during this period. without abandoning the strategic launch of individual projects in specific technical areas (indeed, the goals pursued in dubrovnik were reiterated and affirmed), participants in skopje pledged to apply the efforts of the seehn towards a comprehensive reform of public health capacities and services. systematic problems in these areas had been identified during a study by the council of europe development bank and the regional office (22), including low levels of investment, poor workforce capacity, under-developed primary care services, and suboptimal follow-up and implementation of formal agreements. at the same time, the report highlighted the cascading effects of ill health on economic development, engaging the interest of the region’s finance ministers. together, the ministers of health and finance in see recognised health as a vital part of the economic development and regional integration processes; they committed ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 7 to further regional collaboration, advocacy for intersectoral policy and empowerment of health professionals, in order to optimise the full economic potential of health as a means to increase productivity and decrease public expenditures related to ill-health. the project that best illustrates this new focus was the evaluation of public health services in south eastern europe. a regional project manager in the republic of macedonia, along with the national focal points in other see states, collaborated at a technical level with the who regional office, which commissioned the development of an innovative web-based self-assessment tool to evaluate the delivery of ten essential public health operations. assessments were carried out in all member states in conjunction with technical experts from the who regional office, revealing a somewhat antiquated approach to public health services, which was still primarily focused on sanitation and hygiene rather than on a holistic integration of public health concepts throughout the health system and beyond. the final report (23) concluded with 11 specific recommendations for all see countries, as well as individual profiles on all member states. these recommendations and observations have constituted the basis for sweeping reforms to public health services and capacities in the see region, which are still ongoing today. likewise, the experience established see as a pioneer in efforts to strengthen public health services through a regional approach, setting an important precedent for the european action plan for strengthening public health capacities and services (24), which would be eventually adopted by the 53 member states of the who european region in 2012. connecting the dots: towards a whole-of-government, whole-of-society approach to public health (2011– present) after conceptually consecrating public health’s role as a pillar of the health system, the next milestone in the development of the network was to introduce a societal perspective. given the social and economic diversity in the region and the rapidly changing national, european and global landscape, the seehn ministers of health sought to make health a priority on the agendas of all sectors and in all policies. the third ministerial forum in 2011 brought the signing of the banja luka pledge (25), with the ministers’ unanimous commitment to sustain and strengthen the regional cooperation in public health in see; achieve equity and accountability in health; strengthen public health capacities and services; and foster intersectoral collaboration within national governments, with regional and international partners, and among all stakeholders interested in promoting sustainable health and wellbeing for the population. banja luka marked the first ministerial forum in which the see countries had full control over the finances, policy direction and technical agenda, but rather than cut ties with international partners, the network strengthened them. the role of the regional cooperation council was reaffirmed, and partnerships with almost all the important players from the international health and development scene were broadened. indeed, this period has even seen a geographical expansion of seehn membership through the acceptance of israel as a tenth member state, a decision made to deepen the existing collaboration with that country, which had supported seehn since its inception. likewise, the banja luka pledge explicitly supported the vision of the who regional office and its main projects for strengthening public health, namely health 2020 (26), the european action plan for strengthening public health capacities and services (24), and the european strategy for the prevention and control of non-communicable diseases (27). at a technical level, the consolidation of managerial control and implementation structures in the hands of see experts has been very positive. the establishment of rhdcs has taken off, ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 8 and today, ten centres focus on mental health, antibiotic resistance, organ transplantation, human resources for health, blood safety, health care accreditation and quality improvement, public health services, communicable diseases, non-communicable diseases and healthy ageing. together, the rhdcs represent a coherent, integrated, increasingly comprehensive response to the major public health challenges faced in the see region in the twenty-first century (14), both in the health sector and in the broader developmental agenda. likewise, and thanks to seehn action, the recently adopted south eastern europe growth strategy 2020 (28) saw the incorporation of the health dimension as an integral part of inclusive growth, economic development and prosperity of the region. this politically important move has helped seehn follow through on its commitment to work for better health side-by-side with other sectors, including other government ministries, academia, civil society, and the private sector, to truly realize a whole-of-government, whole-of-society approach to public health. regional learning, global lessons among the many regional initiatives that give life to cooperation in south eastern europe, the ever-changing seehn, now in its second decade of life, emerges as an outstanding example of one that has implemented a wide range of successful initiatives with positive results in the realm of public health (table 1). its founding documents planted the seed for success, while strong political commitments from members and partners cemented its effectiveness and influence in the region. meanwhile, the political direction was shaped by local, regional, and global trends, especially those promoted by who, from the health for all policy framework of 1998 (29) to the health 2020 programme, currently under implementation. isolated events (e.g., the 2014 floods affecting see, the h1n1 swine flu scare) have enabled a more mature understanding of the power the network embodies and of the moral obligation to cooperate for the benefit of the population. in the see context, a network approach has a particular added value. the fact that member states are relatively small, with limited leverage on the world stage, means that a unified position—in health or in health-related policies—amplifies their individual influence and power. this fact can be seen in international fora such as the who regional committee, where see countries speak with one voice. at the same time, the small size of these states may also constitute an advantage for governance, as involving relevant stakeholders and maintaining close links with the population is more straightforward than it would be in larger countries. indeed, several countries were able to quickly mobilise assistance where it was most needed in response to the 2014 floods thanks to close connections with national social media networks (30). this lesson is relevant for other coalitions composed of small countries, for example the incipient sub-regional network of countries with less than one million inhabitants in the who european region (still under development). ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 9 table 1. main accomplishments of the south eastern europe health network technical area main accomplishments mental health  establishment of ten pilot community mental health centres covering more than one million inhabitants as the basis for an entirely new mental health communityoriented system for see.  decreased stigmatisation of mental health patients and increased acceptance in the community.  establishment of information systems for community health services. antibiotic resistance  implementation of system for exchanging knowledge and expertise on antibiotic resistance and molecular diagnostics in see member states. non-communicable diseases  ratification of the who framework convention on tobacco control and approval of tobacco control laws in all see states.  passage of food safety laws and regulations to protect consumers. communicable diseases  development of regional hub for communicable diseases with online information portal and exchange platform (www.secids.com).  strengthening of communicable diseases surveillance and response in see.  support for implementation of the international health regulations, surveillance of communicable diseases and preparedness for disease threats and pandemics. organ donor and transplant medicine  establishment of regional centre of excellence for exchange of knowledge in organ donor and transplant medicine.  expert missions for transfer of knowledge and skills in transplantation medicine (to romania, macedonia, montenegro and albania).  bilateral collaboration in transplantation surgeries, with joint teams performing in montenegro (deceased donor transplantation) and macedonia (deceased donor and live kidney transplantations). accreditation and continuous quality improvement of healthcare  narrowing the gap with eu standards: promoting quality of care standards and patient safety in see.  regular training of professionals on patient safety and accreditation procedures for hospitals and maternity wards. blood safety  increase in regional self-sufficiency of safer blood and blood components.  narrowing the gap with eu standards: increasing blood availability and providing the highest donor and patient safety in transfusion therapy in emergency special circumstances. human resources in health  integrative and intersectoral approaches to provide excellence in human resources in health.  leadership in profiling human resources in health across the region. public health services  expanded integration of public health services and increased outreach for health promotion and disease prevention.  completion of a round of self-assessments of public health services of member states as coordinated sub-regional action.  development and updates of national strategies to improve maternal and neonatal health. healthy aging  work on participatory and empowering approaches, which include advocacy and stimulating activities for and with elderly people that result in ―healthy living/active aging‖.  enhance the ability of see countries and communities to identify and implement effective strategies and programs to promote and protect the health of elderly.  promotion of health and preservation of health-related quality of life for the elderly. although no regional public health alliance can be copy-pasted into a different geopolitical and socioeconomic context, there are a number of lessons for other coalitions, both in public health and in other areas of policy (table 2). http://www.secids.com/ ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 10 table 2. keys to success in the south eastern europe health network seehn strengths description structure  decision-making structures aligned with regional leadership capacity.  balance of power among regional partners; countries lead in some areas and are led in others.  continuity; project offices transformed into sustainable regional health development centres. promotion of ownership among national and local stakeholders  strong political commitment from national stakeholders required to move forward.  political direction for network decided by national leaders.  technical areas led by local/national stakeholders (with specific guidance solicited from external experts).  explicit recognition of leaders and good practices, supported by excellent monitoring and evaluation of programmes. utilization of regional assets  good governance practices through pooling of human and financial resources.  strong historic tradition in public health. adaptive capacity  dynamic organisation, with new decision-making structures emerging as experience accumulates.  policies are responsive to regional needs.  new partnerships emerging on a continuous and ad hoc basis, without compromising regional ownership.  proactive capitalisation on investments made over the course of the network.  continuous efforts to mitigate challenges and limit the role of special interests. alignment with european and global movements  close collaboration with who regional office for europe, including in implementation of european and global policy and programmes.  common commitment among see countries to the political goal of integration into the european union.  effective synergy between political and technical spheres of the network. intersectoral action  evidence-based arguments tying health gains to economic development and security for the see region.  integration of health into a broader agenda for growth. the most decisive strength of the network, perhaps, has been the positive role of see’s political institutions. although the countries making up the region had limited experience in government (indeed, many of the member states had only just achieved independence), their leaders still demonstrated a key quality necessary for good governance: the commitment to accomplish both political and technical objectives through collaborative learning. external donors and partners had an important role in guiding the network development at its inception, but it was the national stakeholders who knew how to take advantage of the guidance and achieve operational ownership of the initiative. today, both new and old challenges await the incoming seehn secretariat. to strengthen network operation, the skopje office must lead the renewal of political and financial commitments from see member states as well as initiate contacts with other regional initiatives and partnerships as part of the regional cooperation council, including with the who regional office and the european commission. in the same way, the network itself must be renewed by engaging new talents and allies within see and beyond. the official seehn website (http://studiorum.org.mk/seehn/) will see further development as a platform to disseminate network achievements, and the secretariat will also work to integrate seehn action into the daily work, not only of ministries of health, but also the authorities in charge of international affairs and trade. this new line of work in health diplomacy is incredibly http://studiorum.org.mk/seehn/ ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 11 timely, as globalisation has increased interdependence in human and economic development as well as internationalising public health emergencies. imminent projects to tackle these new challenges will be the formation of an emergency coordination aid task force and the development of a strategy to address health professional mobility, as the network continues to pave new roads for regional cooperation in public health. by strengthening the bonds among seehn member states through trust and shared governance for health, these countries will themselves become stronger and more capable of achieving common objectives. in essence, seehn exemplifies a positive policy cycle, in which population health, regional cooperation and economic development have mutually fed into each other for the benefit of everyone, from the most vulnerable populations all the way up to their highest elected officials. references 1. association of southeast asian nations. regional action plan on healthy asean lifestyles. http://www.asean.org/communities/asean-socio-culturalcommunity/item/regional-action-plan-on-healthy-asean-lifestyles (accessed: july 08, 2014). 2. south american institute of government in health. health council. http://www.isagsunasursalud.org/interna.asp?lang=2&idarea=37 (accessed: july 08, 2014). 3. shkolnikov v, mckee m, leon da. changes in life expectancy in russia in the mid1990s. lancet 2001;357:917-21. 4. atun ra, ibragimov a, ross g, editors. review of experience of family medicine in europe and central asia. vol. 1. world bank report no. 32354-eca. washington, dc: the world bank, 2005. 5. health for all database [internet]. who 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2006;45:67-80. 12. kovacic l, laaser u: public health training and research collaboration in south eastern europe. med arh 2001;55:13-15. 13. seehn. the dubrovnik pledge: meeting the health needs of the vulnerable populations in south east europe. seehn: dubrovnik, 2001. 14. who regional office for europe. a decade of regional cooperation on public health in south-eastern europe: a story of successful partnership. seehn: banja luka, 2011. 15. rdhc on mental health services. sarajevo (bosnia and herzegovina): seehn newsletter. vol. 1, no. 1, 2011. 16. seehn. current status and future strategies in safe blood and blood components transnational availability for medical emergencies and special circumstances, in south eastern europe. copenhagen: world health organization, 2011. 17. nitzan kaluski d, editor. strengthening food safety and nutrition policies and services in south-eastern europe. copenhagen: world health organization, 2009. 18. seehn. reversing the tobacco epidemic: saving lives in south-eastern europe. copenhagen: world health organization, 2008. 19. seehn. declaration on a long-term programme for regional collaboration and development on mental health: by the ministers of health of the member countries of the south-eastern europe health network. chisinau: seehn, 2007. 20. who regional office for europe. approaching mental health care reform regionally: the mental health project for south-eastern europe. copenhagen: world health organization, 2009. 21. seehn. the skopje pledge: health and economic development in see in the 21st century. skopje: seehn, 2005. 22. council of europe development bank, who regional office for europe. health and economic development in south-eastern europe. paris: who; 2006. http://coebank.org/upload/infocentre/brochure/en/health_in_see.pdf (accessed: october 16, 2014). 23. sedgley m, gjorgiev d, editors. evaluation of public health services in south eastern europe. copenhagen: who regional office for europe, 2009. 24. world health organization. resolution on the european action plan for strengthening public health capacities and services. regional committee for europe, 62nd session, malta, 10–13 september 2012; eur/rc62/r5. www.euro.who.int/en/aboutus/governance/regional-committee-for-europe/past-sessions/sixty-secondsession/documentation/working-documents/eurrc6212-rev.1-european-action-planfor-strengthening-public-health-capacities-and-services (accessed: october 30, 2014). 25. seehn. the banja luka pledge: health in all policies in south-eastern europe: a shared goal and responsibility. banja luka: seehn, 2011. 26. who regional office for europe. health 2020: a european policy framework and strategy for the 21st century. copenhagen: who, 2013. 27. who regional office for europe. action plan for implementation of the european strategy for the prevention and control of noncommunicable diseases 2012-2016. copenhagen: who, 2012. 28. regional cooperation council. south east europe 2020 strategy jobs and 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[online] 2013. www.rcc.int/pubs/20/south-east-europe2020-strategy (accessed: october 20, 2014). http://coebank.org/upload/infocentre/brochure/en/health_in_see.pdf ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 13 29. who regional office for europe. health 21: an introduction to the health for all policy framework for the who european region. copenhagen: who, 1998. 30. ivankovic i. new instruments, methods and systems of diplomacy. presentation at: global health diplomacy course; 2014 october 15-17; chisinau, republic of moldova. ___________________________________________________________ © 2014 ruseva et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 1 | 20 original research successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being valery chernyavskiy1, helmut wenzel2, julia mikhailova1, alla ivanova1,3, elena zemlyanova1,3, vesna bjegovic-mikanovic4, alexander mikhailov1, ulrich laaser5 1 federal research institute for health organization and informatics of the russian ministry of health, moscow, russian federation; 2 independent consultant, konstanz, germany; 3 institute of socio-political research of the russian academy of sciences, moscow, russian federation 4 university of belgrade, faculty of medicine, institute of social medicine, belgrade, serbia; 5 university of bielefeld, bielefeld school of public health, bielefeld, germany. corresponding author: prof. dr. med. ulrich laaser; address: bielefeld school of public health, university of bielefeld, germany; e-mail: ulrich.laaser@uni-bielefeld.de chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 2 | 20 abstract context: the ‘northern dimension on public health and social well-being’ is a platform for dialogue and cooperation of countries around the baltic sea, established in 2003, guided by the sustainable development goal 3 on health and social well-being and the strategy for the baltic sea region of the european union adopted in 2009. in this paper we determine the overall progress of the russian federation and its north west federal okrugin in particular, with regard to the reduction of mortality. methods: for the purpose of inter-country comparison and progress over time we make use of age-standardised potential years of life lost (pyll) applied to quantifiable strategic targets, the sustainable development goal 3 on health and social well-being and the european union strategy of the baltic sea region. a gap analysis is performed to determine whether the target achievement is in delay or on track. results: with reference to the baseline of 2009 – corresponding to the most relevant recent period 2009-2020 respectively 2009-2030 – the russian federation as a whole is on track achieving the two strategic targets in advance by 2.7 years. for the north west federal okrug around st. petersburg and kaliningrad bordering the baltic sea the target achievement is estimated to be 4.8 and 10.8 years in advance of the deadlines 2020 and 2030. in comparison to the baltic sea states the russian federation takes a middle position after estonia, latvia and finland. the early target achievement is confirmed if the period 2003-2020 respectively 20032030 is considered. conclusion: although the region is progressing there may be a slowdown towards 2030. a careful analysis is required to determine to which degree the activities of the partnership for health and social well-being have contributed to the success and what should be proposed to increase the impact on premature mortality. keywords: gap analysis, northern dimension, north west federal okrug, premature mortality, public health, russian federation. chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 3 | 20 introduction since 1999 the countries around the baltic sea (figure 1) initiated in several steps a platform for cooperation the ‘northern dimension’(nd) (1,2) with meanwhile four partnerships on culture, environment, health and social well-being, and transport. the ‘northern dimension partnership on public health and social well-being’ (ndphs) (2) was formally established at a ministerial-level meeting on 27 october 2003, in oslo, norway. today the membership comprises ten countries characterised by very diverse population size, history, health status and culture: estonia, finland, germany, iceland, latvia, lithuania, norway, poland, the russian federation, and sweden (denmark is not included) as well as related international organisations, the european union (eu), the baltic sea states sub-regional cooperation (bsssr), the northern dimension institute (ndi), the world health organisation (who-euro) and several more. coordinated by a secretariat in stockholm the ndphs promotes dialogue, practical cooperation and development (3) in two priority fields: i. to reduce the spread of major communicable diseases, and ii. to prevent life-style related noncommunicable diseases. emphasis is placed on encouraging proper nutrition, physical exercise, safe sexual behaviour, ensuring good social and work environments, as well as supporting alcohol, drug and smoke-free leisure activities. during the decade 2010-2020 two strategies for development of the baltic sea region have been most relevant: i. the sustainable development goals (sdg), especially sdg 3 on health and social well-being (4): sdg target 3.4, by 2030: reduce by one third premature mortality from non-communicable diseases (ncds) through prevention and treatment and promote mental health and well-being. ii. the eu strategy for the baltic sea region (eu-sbsr) adopted by the european council october 2009 (5): eu-sbsr action target, by 2020 1) reduce by at least 10% premature preventable mortality determined as potential years of life lost (pyll) in the countries of the baltic sea region. 2) reduce by at least 10% the difference between the lowest (best) and the highest (worst) pyll rates for women and men in the countries of the baltic sea region. in this framework, the russian federation (ruf) is fully engaged as an entire member state and especially regarding its northwest federal okrug (nwo) including st. petersburg and kaliningrad and stretching from the baltic to the barents sea with a territory of 1,686,970 km2. chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 4 | 20 figure 1. the geographical area of the northern dimension partnership on health and social well-being figure 2. the geographical area of the north west federal okrug of the russian federation chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 5 | 20 with our analysis, we attempt to determine to which extent it is possible for the ruf and the nwo to achieve the targets of the eu-sbsr and sdg. in addition, we try to identify the russian federation’s rank of target achievement in comparison with the other baltic sea states. for the nwo a specific strategy and action plan of social and economic development has been developed. it lists 109 activities together with the responsible institutions and timelines ending at the 4th quarter 2020: 12 activities relate to the health of the population, of which 3 are linked to maternal and child health (activities 63, 68, and 74). activity 71 refers to primary health care, and activity 77 to hiv. health related activities can also be found in other sections, e.g. activities 79 and 80 aiming at elderly services and 81 to rehabilitation. of interest is also activity 40 on the implementation of cross-border cooperation programmes. methods losses of years of life up to the age of 69 years inclusive are predominantly preventable. it is in this sense that we will use the terms “premature” and “preventable” losses as synonyms. the preventable years of life lost (pyll) were calculated by vienonen et al. (6) for all countries except the russian federation up to the age of 69, based on the method of haenszel (7) i.e. calculating the “...number of deaths in a theoretical standard population obtained by multiplying the specific death rates by the standard population”. to standardize the rates the oecd 1980 standard population (8) was applied. for age standardisation the direct method was used as recommended e.g. by armitage (9). the likelihood of achieving the sdg targets (4) and eu-sbsr (5) is determined by the indicators’ time gap (g), i.e. the time needed to achieve an agreed target deadline related to the time remaining between the year of observation and the target year. to this end we use the mathematical model of the united nations development program (undp) originally employed to assess advancement towards the target year of the millennium development goals (mdg) (10), based on linear progress between the value of an earlier ‘baseline year’ and the year of observation; for details of the calculation see bjegovic-mikanovic et al. (11,12). we applied the eu-sbsr targets for 2020 with an intended reduction of 10% (4) and for 2030 of 33% (5). as noncommunicable conditions make up for more than 2/3 of premature mortality, it seems to be justified for the purpose of intercountry comparison to apply the sdg-3 target to the calculated pyll rates. a positive time gap g indicates that the respective country is “on track” to achieve the target on time or even earlier; a negative value indicates that it may still be “likely” or even “unlikely” to achieve the target within the targeted timeframe i.e. here in 2020 respectively 2030. a country is still considered likely to achieve the target as long as a negative value does not make up for more than 25% of the remaining time (gap ratio). the gap ratio multiplied by the remaining time since the year of observation i.e. 2020-2013 = 7 or 2030-2013 = 17 indicates the number of years in advance or delay given the target year. table 1 provides details of the calculation using the year of observation 2013 and the russian federation as an example. the demographic data have been provided by the federal research institute for health organization and informatics of the russian ministry of health (annex 1). chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 6 | 20 table 1. calculation of premature years of life lost before age 70 (pyll) in 2013 for the russian federation (ruf) standardized death rates 2013 direct standardization study population (russian federation) standard population deaths population (oecd 1980) crude rate expected deaths (study pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di * (remaining years to upper age limit) 0-4 18,549 8,793,034 80,269,483 0.00211 169,329 11,429,730 5-9 1,878 7,551,502 84,285,393 0.00025 20,961 1,310,070 10-14 1,930 6,755,920 85,828,597 0.00029 24,519 1,409,849 15-19 5,479 7,053,780 87,597,591 0.00078 68,041 3,572,160 20-24 15,314 10,409,826 82,619,776 0.00147 121,543 5,773,282 25-29 29,730 12,539,043 77,252,661 0.00237 183,166 7,784,539 30-34 44,424 11,503,329 73,604,119 0.00386 284,247 10,659,271 35-39 51,039 10,536,321 61,676,142 0.00484 298,765 9,709,877 40-44 53,882 9,656,787 57,394,499 0.00558 320,244 8,806,717 45-49 68,120 9,365,912 54,245,506 0.00727 394,538 8,877,095 50-54 111,658 11,310,281 52,537,987 0.00987 518,669 9,076,699 55-59 146,852 10,508,048 48,323,994 0.01398 675,337 8,441,714 60-64 177,781 8,819,230 36,727,063 0.02016 740,356 5,552,674 65-69 126,245 4,861,125 36,887,734 0.02597 957,986 2,394,966 sum 852,881 129,664,138 919,250,545 0.00706 4,777,702 94,798,643 standardized rate (per 100 000) 520 10,313 results table 2 presents the premature years of life lost (pyll) for the russian federation (ruf). the data are used below for the calculation of the gap status for the target years 2020 and 2030 (for further details see annex 2). chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 7 | 20 table 2. overview of age standardized pyll rates of the russian federation, based on the oecd 1980 standard population age groups pyll 2003 pyll 2009 pyll 2013 0-4 18,229,269 12,183,235 11,429,730 5-9 2,215,671 1,612,951 1,310,070 10-14 2,146,975 1,681,090 1,409,849 15-19 5,589,625 4,317,138 3,572,160 20-24 9,726,159 6,893,909 5,773,282 25-29 12,106,799 9,949,936 7,784,539 30-34 13,094,532 11,961,014 10,659,271 35-39 12,824,630 9,977,662 9,709,877 40-44 14,212,643 10,036,011 8,806,717 45-49 15,208,226 10,587,880 8,877,095 50-54 16,014,381 11,134,913 9,076,699 55-59 13,353,138 10,139,068 8,441,714 60-64 8,350,403 6,339,159 5,552,674 65-69 3,546,838 2,902,400 2,394,966 sum of pyll 146,619,290 109,716,365 94,798,643 age standardised rate/100,000 15,950 11,935 10,313 we see in table 2 an impressive reduction of premature years of life lost from 15,950 in 2003 to 10,313 in 2013, which translates if continued at the same speed into a positive gap ratio for 2020 and 2030 standing for an early target achievement ranking 4th among the member states of ndphs (table 3). the gap ratios for the ruf based on 2009 of 0.39 for the target year 2020 and 0.16 for 2030 correspond to 2.7 years in advance of either target (calculated from 0.39 * 7 years and 0.16 * 17 years up to the corresponding target year). if 2003 is used as the baseline year the gap analysis shows the following results: pyll 2003 / 100,000 15,950 pyll 2013 / 100,000 10,313 target 2020 (-10%) = 9,282 target 2030 (-33%) = 6,875 gap value 2020 = 0.62 (4.4 years in advance) gap value 2030 = 0.40 (6.8 years in advance) table 4 presents the corresponding data for the now (for details see annex 3). progress between 2003 and 2009 is very slow but accelerates considerably between 2009 and 2013. chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 8 | 20 table 3. gap analysis of the mortality in the russian federation and ndphs member states (estonia, latvia, finland, poland, germany, russian federation, sweden, lithuania, ru) countries ranked according to achievement 2009-2013 -2020 change of country ranks 2009-2030 baseline value 2009 all death: pyll/ 100,000 observed value 2013 all death: pyll/ 100,000 target value 2020 (-10% as of 2013) all death: pyll/ 100,000 target value 2030 (-33% as of 2013) all death: pyll/ 100,000 gap ratio 2020 according to baseline 2009 gap ratio 2030 according to baseline 2009 1) est est1 6247 4979 4481 3319 0.557 0.299 2) lat lat2 8247 6837 6153 4558 0.487 0.237 3) fin fin3 3741 3115 2803 2077 0.477 0.229 4) ruf ruf4 11935 10313 9282 6875 0.390 0.160 5) pol pol5 5649 4901 4411 3267 0.379 0.152 6) ger ger7 3219 3008 2707 2005 0.076 -0.021 7) swe swe8 2670 2511 2260 1674 0.039 -0.038 8) lit lit6 8351 7369 6632 4913 0.033 0.118 lit swe 5681 4858 4372 3239 0.420 0.181 table 4. overview of age standardized pyll rates of the north west federal okrug, based on the oecd 1980 standard population age groups pyll 2003 pyll 2009 pyll 2013 0-4 15,994,997 9,627,834 8,660,105 5-9 2,279,635 2,512,981 1,189,746 10-14 2,066,224 2,939,012 1,180,353 15-19 5,248,957 5,051,446 2,998,759 20-24 9,630,348 7,584,853 4,984,555 25-29 13,542,067 12,095,659 6,912,712 30-34 15,222,446 16,309,283 10,162,831 35-39 15,455,366 16,274,079 9,581,213 40-44 17,978,711 17,318,045 8,800,723 45-49 18,879,238 16,853,065 9,053,049 50-54 19,914,378 18,018,859 9,311,518 55-59 15,444,599 17,242,066 8,640,291 60-64 9,238,993 12,450,710 5,528,433 65-69 3,712,069 6,661,087 2,323,054 sum of pyll 164,608,028 160,938,978 89,399,156 age standardised rate/100,000 17,907 17,508 9,725 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 9 | 20 the demographic and mortality data in table 4 provided for the nwo allow for the following calculation of the pyll target achievement for 2020 and 2030 (reduction of pyll, 0-69 years of age, direct agestandardisation, population base 2003, 2009 and 2013): baseline value 2009 (pyll nwo) 17,508 observed value 2013 (pyll nwo) 9,725 target value 2020 (-10% of 2013) 8,753 target value 2030 (-33% of 2013) 6,483 gap 2020 0.69 (4.8 years in advance) gap 2030 0.64 (10.8 years in advance) if 2003 is used as the baseline year the gap analysis shows the following results: pyll 2003 / 100,000 17,907 pyll 2013 / 100,000 9,725 target 2020 (-10%) = 8,753 target 2030 (-33%) = 6,483 gap 2020 = 0.31 (2.2 years in advance) gap 2030 = 0.55 (9.3 years in advance) discussion with reference to the baseline of 2009 corresponding to the most relevant recent period 2009-2020 respectively 2009-2030 the northern dimension and all its member states including the ruf and the now are on track or are likely to achieve the targets in time (sweden and germany with slight delays regarding the sdg targets [the borderline for “not likely” is a gap status <0.25. the status “likely” is indicated by a gap status <0 and >= -0.25]). this can be considered a success to which the ndphs contributed. however for all countries the positive gap (indicating achievement before the targeted time) is smaller for the sdg targets of 2030 than for 2020. this may indicate a slowing down of the dynamics in reducing mortality. the analysis is confirmed if the period 2003-2020 respectively 2003-2030 is considered. the russian federation keeps throughout the years a middle position among the ndphs member states included in table 3 whereas the nwo would even take a top position for its more than 12 million inhabitants in front of the neighbouring estonia. this relative good positioning is unlikely to be due to data inconsistencies as figure 3 shows an impressive homogeneity of mortality development throughout age groups in 2003, 2009 and 2013. nevertheless the nwo shows accelerated progress. chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 10 | 20 figure 3. percentage of deaths by age-groups in the russian federation 2003, 2009 and 2013 limitations the straight projection of past progress into the future may be modified by the realities of historical development with its unpredictable interference in positive as well as negative direction. however, advanced achievement of targets may encourage to continue along the path of success whereas delays should stimulate to add up efforts. for the target year 2020 most nd member states have already achieved the target one or two years ago, so did the russian federation. also in this paper we applied the targeted sdg-3 reduction by one third for non-communicable diseases to the pyll rates which include to a minor degree communicable diseases too. the russian government’s activities during the last decade were marked by big investments in healthcare (around 10bln us dollars per year) with main focus to reconstruction of old health facilities including purchasing of modern medical equipment for diagnostics and treatment. a model of avoidable mortality was used to analyze causes of death related to insufficient diagnostics and treatment (healthcare factor), and causes associated with behavioural risks (lifestyle factor) (13). a comparison of regions of north-western russia and neighbouring european countries confirmed that the higher the mortality levels the stronger the contribution of avoidable causes i.e. up to 50% in average in 0.00 5.00 10.00 15.00 20.00 25.00 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 age groups % of age groups 2003 % of age groups 2009 % of age groups 2013 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 11 | 20 north-western russia, varying between 45% in st. petersburg and 67% in pskov and novgorod. healthcare does substantially contribute to mortality reduction, however its role is not the leading one. for this moment our analysis could include only one federal okrug but it would be a fascinating task to analyse target achievement for all okrugs of the huge territory of the russian federation. as the russian federation borders the near and far east this may induce dynamic exchange and a more global than national perspective (14), especially if combined with a more precise sub-grouping according to gender and to specific disease groups. the very good ranking of the russian federation and its nwo are encouraging although it will be difficult to keep the pace of improvement as it started from very high levels of premature mortality in 2009 and even worse in 2003. a national strategy may be considered in this regard. also for the european union (15) a technical cooperation in this area may be of mutual interest. conflicts of interest: none declared. references 1. the european external action service (eeas). the northern dimension. available at: https://eeas.europa.eu/diplomaticnetwork/northerndimension/347/northern-dimension_en (accessed: 10 august, 2019). 2. chernyavskiy v, mikhailova j. russia: a key partner in the northern dimension partnership. seejph 2019;12. doi 10.4119/unibi/seejph-2019-218. 3. the northern dimension partnership on health and social well-being (ndphs). available at: http://www.ndphs.org/?about_ndphs#b ackground_about_ndphs (accessed: 10 august, 2019). 4. united nations: united nations: the sustainable development goals report 2016. available at: https://unstats.un.org/sdgs/report/2016/ (accessed: 10 august, 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office; 2006:107-11. https://eeas.europa.eu/diplomatic-network/northern-dimension/347/northern-dimension_en https://eeas.europa.eu/diplomatic-network/northern-dimension/347/northern-dimension_en https://eeas.europa.eu/diplomatic-network/northern-dimension/347/northern-dimension_en http://doi.org/10.4119/unibi/seejph-2019-218 http://www.ndphs.org/?about_ndphs#background_about_ndphs http://www.ndphs.org/?about_ndphs#background_about_ndphs https://unstats.un.org/sdgs/report/2016/ http://edz.bib.uni-mannheim.de/edz/pdf/swd/2017/swd-2017-0118-en.pdf http://edz.bib.uni-mannheim.de/edz/pdf/swd/2017/swd-2017-0118-en.pdf http://edz.bib.uni-mannheim.de/edz/pdf/swd/2017/swd-2017-0118-en.pdf https://stats.oecd.org/index.aspx?datasetcode=pop_five_hist https://stats.oecd.org/index.aspx?datasetcode=pop_five_hist chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 12 | 20 11. bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. a gap analysis of mother, new-born, and child health in west africa with reference to the sustainable development goals 2030. afr j reprod health 2018;22:123-34. doi: 10.29063/ajrh2018/v22i4.13. 12. bjegovic-mikanovic v, salem za, wenzel h, broniatowski r, nelson c, vukovic d, et al. a gap analysis of sdg 3 and mdg 4/5 mortality health targets in the six arabic countries of north africa: egypt, libya, tunisia, algeria, morocco, and mauritania. libyan j med 2019:14;1607698. available at: https://doi.org/10.1080/19932820.2019. 1607698 (accessed: 10 august, 2019). 13. ivanova a, zemlianova e. the factor of healthcare plays a crucial role in the russian loss of life expectancy. poster presentations at the 21stnordic demographic symposium, reykjavik, iceland; 2019. 14. laaser u, dorey s, nurse j. a plea for global health action bottom-up. front public health 2016;4:241. doi: 10.3389/fpubh.2016.00241. available at: http://journal.frontiersin.org/article/10.3 389/fpubh.2016.00241/full?&utm_sour ce=email_to_authors_&utm_medium= email&utm_content=t1_11.5e1_author &utm_campaign=email_publication&fi eld=&journalname=frontiers_in_publi c_health&id=209500 (accessed: 10 august, 2019). 15. european external activity service (eeas). european union and russian federation. available at: https://eeas.europa.eu/headquarters/hea dquarters-homepage/35939/europeanunion-and-russian-federation_en (accessed: 10 august, 2019). https://doi.org/10.1080/19932820.2019.1607698 https://doi.org/10.1080/19932820.2019.1607698 http://journal.frontiersin.org/article/10.3389/fpubh.2016.00241/full?&utm_source=email_to_authors_&utm_medium=email&utm_content=t1_11.5e1_author&utm_campaign=email_publication&field=&journalname=frontiers_in_public_health&id=209500 http://journal.frontiersin.org/article/10.3389/fpubh.2016.00241/full?&utm_source=email_to_authors_&utm_medium=email&utm_content=t1_11.5e1_author&utm_campaign=email_publication&field=&journalname=frontiers_in_public_health&id=209500 http://journal.frontiersin.org/article/10.3389/fpubh.2016.00241/full?&utm_source=email_to_authors_&utm_medium=email&utm_content=t1_11.5e1_author&utm_campaign=email_publication&field=&journalname=frontiers_in_public_health&id=209500 http://journal.frontiersin.org/article/10.3389/fpubh.2016.00241/full?&utm_source=email_to_authors_&utm_medium=email&utm_content=t1_11.5e1_author&utm_campaign=email_publication&field=&journalname=frontiers_in_public_health&id=209500 http://journal.frontiersin.org/article/10.3389/fpubh.2016.00241/full?&utm_source=email_to_authors_&utm_medium=email&utm_content=t1_11.5e1_author&utm_campaign=email_publication&field=&journalname=frontiers_in_public_health&id=209500 http://journal.frontiersin.org/article/10.3389/fpubh.2016.00241/full?&utm_source=email_to_authors_&utm_medium=email&utm_content=t1_11.5e1_author&utm_campaign=email_publication&field=&journalname=frontiers_in_public_health&id=209500 http://journal.frontiersin.org/article/10.3389/fpubh.2016.00241/full?&utm_source=email_to_authors_&utm_medium=email&utm_content=t1_11.5e1_author&utm_campaign=email_publication&field=&journalname=frontiers_in_public_health&id=209500 https://eeas.europa.eu/headquarters/headquarters-homepage/35939/european-union-and-russian-federation_en https://eeas.europa.eu/headquarters/headquarters-homepage/35939/european-union-and-russian-federation_en https://eeas.europa.eu/headquarters/headquarters-homepage/35939/european-union-and-russian-federation_en chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 13 | 20 annex 1: population and mortality data of the russian federation for 2003, 2009, and 2013 annex 1a: population and mortality in the russian federation 2003 age-group total population males females total mortality males females 00-04 6,565,695 3,364,592 3,201,103 22,090 12,754 9,336 05-09 6,818,772 3,486,662 3,332,110 2,868 1,791 1,077 10-14 9,760,069 4,985,362 4,774,707 4,246 2,778 1,468 15-19 12,669,554 6,432,752 6,236,802 15,399 11,128 4,271 20-24 11,713,409 5,913,034 5,800,375 29,030 23,001 6,029 25-29 10,717,142 5,360,243 5,356,899 39,519 31,466 8,053 30-34 9,963,892 4,973,305 4,990,587 47,270 37,095 10,175 35-39 9,888,714 4,863,197 5,025,517 63,268 49,281 13,987 40-44 12,324,267 5,972,742 6,351,525 110,977 85,938 25,039 45-49 11,777,383 5,564,681 6,212,702 146,751 111,219 35,532 50-54 10,316,215 4,737,479 5,578,736 179,688 131,720 47,968 55-59 5,976,065 2,638,995 3,337,070 132,107 91,857 40,250 60-64 7,045,054 2,854,945 4,190,109 213,572 141,469 72,103 65-69 6,718,590 2,573,559 4,145,031 258,403 155,124 103,279 00-69 132,254,821 63,721,548 68,533,273 1,265,188 886,621 378,567 annex 1b: population and mortality in the russian federation 2009 age-group total population males females total mortality males females 00-04 7,793,807 3,994,295 3,799,512 17,525 10,064 7,461 05-09 6,887,915 3,530,220 3,357,695 2,109 1,273 836 10-14 6,784,360 3,470,481 3,313,879 2,311 1,416 895 15-19 9,274,152 4,699,081 4,575,071 8,706 6,073 2,633 20-24 12,354,120 6,242,785 6,111,335 21,702 16,795 4,907 25-29 11,788,055 5,916,062 5,871,993 35,724 27,844 7,880 30-34 10,751,459 5,306,042 5,445,417 46,591 36,183 10,408 35-39 9,997,601 4,903,848 5,093,753 49,765 37,620 12,145 40-44 9,307,938 4,493,889 4,814,049 59,185 44,056 15,129 45-49 11,415,509 5,393,625 6,021,884 99,028 73,183 25,845 50-54 11,292,748 5,136,151 6,156,597 136,765 98,957 37,808 55-59 9,821,361 4,274,188 5,547,173 164,853 113,724 51,129 60-64 6,497,033 2,694,911 3,802,122 149,520 100,238 49,282 65-69 5,059,895 1,869,565 3,190,330 159,249 94,717 64,532 00-69 129,025,953 61,925,143 67,100,810 953,033 662,143 290,890 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 14 | 20 annex 1c: population and mortality in the russian federation 2013 age-group total population males females total mortality males females 00-04 8,793,034 4,513,291 4,279,743 18,549 10,567 7,982 05-09 7,551,502 3,865,465 3,686,037 1,878 1,120 758 10-14 6,755,920 3,462,420 3,293,500 1,930 1,234 696 15-19 7,053,780 3,608,295 3,445,485 5,479 3,930 1,549 20-24 10,409,826 5,300,627 5,109,199 15,314 12,034 3,280 25-29 12,539,043 6,323,822 6,215,221 29,730 22,980 6,750 30-34 11,503,329 5,734,090 5,769,239 44,424 33,885 10,539 35-39 10,536,321 5,145,842 5,390,479 51,039 38,699 12,340 40-44 9,656,787 4,689,062 4,967,725 53,882 39,702 14,180 45-49 9,365,912 4,444,475 4,921,437 68,120 49,808 18,312 50-54 11,310,281 5,204,736 6,105,545 111,658 80,673 30,985 55-59 10,508,048 4,587,151 5,920,897 146,852 101,408 45,444 60-64 8,819,230 3,635,352 5,183,878 177,781 118,451 59,330 65-69 4,861,125 1,877,877 2,983,248 126,245 76,787 49,458 00-69 129,664,138 62,392,505 67,271,633 852,881 591,278 261,603 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 15 | 20 annex 2: complete gap analysis based on the demographic data of the russian federation for 2003, 2009, and 2013 annex 2a: standardized death rates 2003, direct standardization study population (russian federation) standard population deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di * (remaining years to upper age limit) 0-4 22,090 6,565,695 80,269,483 0.00336 270,063 18,229,269 5-9 2,868 6,818,772 84,285,393 0.00042 35,451 2,215,671 10-14 4,246 9,760,069 85,828,597 0.00044 37,339 2,146,975 15-19 15,399 12,669,554 87,597,591 0.00122 106,469 5,589,625 20-24 29,030 11,713,409 82,619,776 0.00248 204,761 9,726,159 25-29 39,519 10,717,142 77,252,661 0.00369 284,866 12,106,799 30-34 47,270 9,963,892 73,604,119 0.00474 349,188 13,094,532 35-39 63,268 9,888,714 61,676,142 0.00640 394,604 12,824,630 40-44 110,977 12,324,267 57,394,499 0.00900 516,823 14,212,643 45-49 146,751 11,777,383 54,245,506 0.01246 675,921 15,208,226 50-54 179,688 10,316,215 52,537,987 0.01742 915,108 16,014,381 55-59 132,107 5,976,065 48,323,994 0.02211 1,068,251 13,353,138 60-64 213,572 7,045,054 36,727,063 0.03032 1,113,387 8,350,403 65-69 258,403 6,718,590 36,887,734 0.03846 1,418,735 3,546,838 sum 1,265,188 132,254,821 919,250,545 0.01089 7,390,966 146,619,290 standardized rate (per 100,000) 804 15,950 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 16 | 20 annex 2b: standardized death rates 2003, direct standardization study population (russian federation) standard population deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di * (remaining years to upper age limit) 0-4 17,525 7,793,807 80,269,483 0.00225 180,492 12,183,235 5-9 2,109 6,887,915 84,285,393 0.00031 25,807 1,612,951 10-14 2,311 6,784,360 85,828,597 0.00034 29,236 1,681,090 15-19 8,706 9,274,152 87,597,591 0.00094 82,231 4,317,138 20-24 21,702 12,354,120 82,619,776 0.00176 145,135 6,893,909 25-29 35,724 11,788,055 77,252,661 0.00303 234,116 9,949,936 30-34 46,591 10,751,459 73,604,119 0.00433 318,960 11,961,014 35-39 49,765 9,997,601 61,676,142 0.00498 307,005 9,977,662 40-44 59,185 9,307,938 57,394,499 0.00636 364,946 10,036,011 45-49 99,028 11,415,509 54,245,506 0.00867 470,572 10,587,880 50-54 136,765 11,292,748 52,537,987 0.01211 636,281 11,134,913 55-59 164,853 9,821,361 48,323,994 0.01679 811,125 10,139,068 60-64 149,520 6,497,033 36,727,063 0.02301 845,221 6,339,159 65-69 159,249 5,059,895 36,887,734 0.03147 1,160,960 2,902,400 sum 953,033 129,025,953 919,250,545 0.00831 5,612,089 109,716,365 standardized rate (per 100,000) 611 11,935 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 17 | 20 annex 2c: standardized death rates 2013, direct standardization study population (russian federation) standard population deaths population (oecd 1980) crude rate expected deaths (study pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di * (remaining years to upper age limit) 0-4 18,549 8,793,034 80,269,483 0.00211 169,329 11,429,730 5-9 1,878 7,551,502 84,285,393 0.00025 20,961 1,310,070 10-14 1,930 6,755,920 85,828,597 0.00029 24,519 1,409,849 15-19 5,479 7,053,780 87,597,591 0.00078 68,041 3,572,160 20-24 15,314 10,409,826 82,619,776 0.00147 121,543 5,773,282 25-29 29,730 12,539,043 77,252,661 0.00237 183,166 7,784,539 30-34 44,424 11,503,329 73,604,119 0.00386 284,247 10,659,271 35-39 51,039 10,536,321 61,676,142 0.00484 298,765 9,709,877 40-44 53,882 9,656,787 57,394,499 0.00558 320,244 8,806,717 45-49 68,120 9,365,912 54,245,506 0.00727 394,538 8,877,095 50-54 111,658 11,310,281 52,537,987 0.00987 518,669 9,076,699 55-59 146,852 10,508,048 48,323,994 0.01398 675,337 8,441,714 60-64 177,781 8,819,230 36,727,063 0.02016 740,356 5,552,674 65-69 126,245 4,861,125 36,887,734 0.02597 957,986 2,394,966 sum 852,881 129,664,138 919,250,545 0.00706 4,777,702 94,798,643 standardized rate (per 100,000) 520 10,313 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 18 | 20 annex 3. demographic and mortality data and the resulting pyll rates of the north west federal okrug (nwo) of the russian federation for 2003, 2009 and 2013 study population (nwo district) standard population annex 3a deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 0-4 1,666 564,500 80,269,483 0.00295 236,963 15,994,997 5-9 244 564,321 84,285,393 0.00043 36,474 2,279,635 10-14 357 852,259 85,828,597 0.00042 35,934 2,066,224 15-19 1,362 1,193,690 87,597,591 0.00114 99,980 5,248,957 20-24 2,787 1,135,751 82,619,776 0.00245 202,744 9,630,348 25-29 4,238 1,027,373 77,252,661 0.00412 318,637 13,542,067 30-34 5,264 954,497 73,604,119 0.00552 405,932 15,222,446 35-39 7,347 952,804 61,676,142 0.00771 475,550 15,455,366 40-44 13,686 1,201,468 57,394,499 0.01139 653,771 17,978,711 45-49 18,436 1,191,875 54,245,506 0.01547 839,077 18,879,238 50-54 23,048 1,064,075 52,537,987 0.02166 1,137,964 19,914,378 55-59 16,456 643,591 48,323,994 0.02557 1,235,568 15,444,599 60-64 21,782 649,414 36,727,063 0.03354 1,231,866 9,238,993 65-69 26,624 661,425 36,887,734 0.04025 1,484,828 3,712,069 sum 143,296 12,657,040 919,250,545 0.01233 8,395,289 164,608,028.34 standardized rate (per 100,000) 913.28 17,906.76 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 19 | 20 2009 study population (nwo district) standard population annex 3b deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 0-4 1,178 662,703 80,269,483 0.00178 142,635 9,627,834 5-9 281 590,035 84,285,393 0.00048 40,208 2,512,981 10-14 335 561,830 85,828,597 0.00060 51,113 2,939,012 15-19 880 801,242 87,597,591 0.00110 96,218 5,051,446 20-24 2,238 1,157,868 82,619,776 0.00193 159,681 7,584,853 25-29 4,207 1,141,931 77,252,661 0.00368 284,604 12,095,659 30-34 6,185 1,046,782 73,604,119 0.00591 434,914 16,309,283 35-39 7,872 969,565 61,676,142 0.00812 500,741 16,274,079 40-44 9,872 899,724 57,394,499 0.01097 629,747 17,318,045 45-49 15,352 1,111,823 54,245,506 0.01381 749,025 16,853,065 50-54 22,146 1,129,981 52,537,987 0.01960 1,029,649 18,018,859 55-59 28,516 999,024 48,323,994 0.02854 1,379,365 17,242,066 60-64 31,156 689,278 36,727,063 0.04520 1,660,095 12,450,710 65-69 33,458 463,209 36,887,734 0.07223 2,664,435 6,661,087 sum 163,675 12,224,992 919,250,545 0.01528 9,822,430 160,938,978.09 standardized rate (per 100,000) 1,068.53 17,507.63 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 20 | 20 2013 study population (nwo district) standard population annex 3c deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 0-4 1,220 757,156 80,269,483 0.00161 129,362 8,731,919 5-9 145 642,852 84,285,393 0.00023 19,036 1,189,746 10-14 137 573,546 85,828,597 0.00024 20,528 1,180,353 15-19 394 603,558 87,597,591 0.00065 57,119 2,998,759 20-24 1,252 985,677 82,619,776 0.00127 104,938 4,984,555 25-29 2,587 1,228,690 77,252,661 0.00211 162,652 6,912,712 30-34 4,193 1,138,908 73,604,119 0.00368 271,009 10,162,831 35-39 4,956 1,036,737 61,676,142 0.00478 294,807 9,581,213 40-44 5,259 943,130 57,394,499 0.00558 320,026 8,800,723 45-49 6,779 913,922 54,245,506 0.00742 402,358 9,053,049 50-54 11,182 1,104,138 52,537,987 0.01013 532,087 9,311,518 55-59 15,070 1,053,570 48,323,994 0.01430 691,223 8,640,291 60-64 17,942 893,981 36,727,063 0.02007 737,124 5,528,433 65-69 13,078 519,162 36,887,734 0.02519 929,222 2,323,054 sum 84,195 12,395,023 919,250,545 0.00695 4,671,490 89,399,155.82 standardized rate (per 100,000) 508.18 9,725.22 ___________________________________________________________________________ © 2019 chernyavskiy et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. "сhallenges(approaches to)forinternational standards application inhealth sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 1 review article approaches to the international standards application in healthcare and public health in different countries vitaliy sarancha1, vadym sulyma2, nenad pros3, ksenija vitale1 1 school of public health “a. stampar”, medical school, university of zagreb, zagreb, croatia; 2 department of traumatology, ivano frankivsk national medical university, ivano – frankivsk, ukraine; 3 quality management department, pastor tva jsc, croatia. corresponding author: vitaliy sarancha, md; address: 4 rockefeller st., zagreb 10000, croatia; email: saranchavi@gmail.com mailto:saranchavi@gmail.com� sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 2 abstract as a result of consequent development, and guided by an increasing demand of different types of the organizations regarding structured management, the system of standardization has been established. the idea behind standardization is adjusting the characteristics of a product, process or a production cycle to make them consistent and in line with the rules regarding what is proper and acceptable. the “standard” is a document that specifies such established set of criteria covering a broad range of topics and applicable to commissioners of health, specialists in primary care, public health staff, and social care providers, as well as the local authorities and service users. health products, ranging from medical devices and health informatics to traditional medicines and unconventional healing tools are all in the focus of standards’ application. different countries have their own quality management traditions based on their history, mentality, socio-economic environment and the local regulations. taking into consideration that community social system organization and the quality of social infrastructure are the main foundations of social relations and future prosperity, here we review the existing standardization environment in the health sector in different countries, both developed and those on a convergence path. we focused on standardization environment in the united states of america, great britain, germany, ukraine, russian federation, croatia and albania. in order to simplify comprehension, we also demonstrate the algorithm of standardization, as well as the opportunities for application of the international standards in healthcare and public health. keywords: healthcare, international standards, public health. conflicts of interest: none. sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 3 introduction first traces of quality development appeared more than four thousand years bc, at the time when commodity barter had been replaced by the development of trade among greek, roman, egyptian, arab and phoenician traders (1). artisans described to their suppliers, by experience, using simple words, what kinds of materials they preferred. this was common practice, since the craftsmen had no tools to measure the composition, strength, chemical or physical characteristics of a given material. industrial revolution contributed to the development of product specification (2). manufacturers began issuing precise descriptions of materials and processing methods in order to ensure that supplies met certain quality criteria (3). thus, producers were obliged to take samples from each batch, which was then subjected to tests determining its elasticity, tensile strength, etc. when the first factories were established, requirements for a higher degree of order, greater focus on precision and monitoring quality control of a product were introduced. evolving through different stages, beginning with the 'division of labour' in the late 1700s until the beginning of the 20th century, the scope of activities from the beginning of a production cycle to the final phase led to the occurrence of the first model-based managerial approach (4). when the demands of tasks became too complex basic managerial principles, such as planning, execution, monitoring, controlling, completion and improvement were implemented (5). therefore, to form a structurally oriented organization, systematic quality control became a necessity. later on, such quality patterns and models became generally accepted and are today known as the standards. in the modern society, social infrastructure quality is the main foundation of social relations and future prosperity, thus the purpose of this article is to review the existing standardization environment in the health sector in different countries, both developed and those on a convergence path; as well as to demonstrate a common algorithm for standardization and the opportunities for the application of international standards in healthcare and public health. definition and different types of standards the idea behind standardization is adjusting the characteristics of a product, process or a production cycle as to make them consistent and in line with the rules regarding what is proper and acceptable. standard is a document that specifies such established set of criteria. more than 21000 international standards covering almost all aspects of human activity, including healthcare, have been published since february 1947, when the delegates from 25 countries met at the institution of civil engineers in london and founded the international organization for standardization (iso). today, it encompasses 162 member countries and more than 238 technical committees taking care of the development of standards (6). after the foundation of the european union a network of new institutions, such as the european standardization organizations (esos) consisting of 33 european countries, and cen the european committee for standardization, has been established. cen together with the european committee for electro-technical standardization (cenelec) and the european telecommunications standards institute (etsi) are officially recognized by the european union and by the european free trade association to be responsible for developing voluntary standards on the european level (7). regarding various products, materials, services and processes, cen provides a platform for the european norms (ens) development (8). en is to be implemented on a national level by being given the status of a national standard, and by withdrawing any conflicting national standards used previously. therefore, the european standard becomes a national standard in each of the 33 cen-cenelec member countries once adopted by the national body (9). for example, croatia after entering eu had to harmonize the local hrns (croatian norms) to conform to the ens. sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 4 standardization process the functional diagram (figure 1) introduces an 11-step assessment construct having been passed by any organization in attempt to obtain a particular certificate. figure 1. the 11-step assessment construct that an organization needs to go through in order to obtain a certificate (source: sarancha v, nenad pros 2016) formalization of workflow, introduction, implementation and staff training internal audit audit by the certification body 1. analisys of actual working conditions and workflow manuals, procedures, instructions, check lists, etc., ... 2. introduction of norm general requirements 3. establishment of company policy, responsibilities assingment, processes definition 4. documentation set design document is valid 5. acceptance and authorization of the documentation system ready for use documentyesno policies, guidlines, summaries, process diagrams, etc., ... 6. implementation and staff training training confirmation record nonconformities revealed 7. internal audit record, report 8. corrective actions no yes notes, records documents in use system is adjustedyes no nonconformities revaled 10. corrective actions notes, records yes 11. document of conformity no 9. external audit system is adjusted noyes client report sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 5 certification body is a third party auditing firm that assesses organization against a specific international standard. taking into account a huge amount of relevant documents and the complexity of the procedures, it is important to correctly identify the procedure required for the certification process at the beginning. approaches in different countries different countries have their own quality management traditions based on their history, mentality, socio-economic environment and the local regulations (10,11). this otherness is fundamental when considering well-developed countries such as the usa, germany and great britain in comparison with the converging countries of eastern and south-east europe (12,13). thereby, the usa has developed a quality infrastructure and there are many organizations that provide accreditation services covering various aspects of healthcare and public health. some of them include the accreditation association for ambulatory health care (14), the community health accreditation partner, the joint commission and the accreditation commission for health care, the american accreditation council, and the healthcare quality association on accreditation (15). one of the main acknowledged bodies in healthcare is the national association for healthcare quality (nahq). it certifies professionals in healthcare awarding the certified professional in healthcare quality (cphq). cphq plays an important role in clinical outcomes, reliability and financial stability of the healthcare organizations. the key elements of their knowledge refer to information management, measurement and analytics, quality measurement and improvements as well as planning, implementation, evaluation, training, strategic and operational tasks concerning patient safety. in great britain, the national standards body is bsi group (16). one of the outstanding resulting documents created by a group of representatives from bsi to help organizations put in place occupational health and safety performance is the occupational health and safety assessment series 18000 (ohsas) with its next revision ohsas 18002 which was accepted as a standard. in the updated edition “health” component was given greater emphasis and current version became more closely aligned with the structures of iso 9000 and iso 14000. thereby organizations could more easily adopt ohsas alongside the existing management systems (17). another institution is the united kingdom accreditation forum or ukaf. founded in 1998 by a group of leading healthcare accreditation organizations, nowadays ukaf is an umbrella structure for organizations providing healthcare accreditation. it operates with an interest in developing assessment and accreditation programmes in healthcare and public health (18). the national institute for health and care excellence (nice) provides guidance and contains governance information, publications, and policies concerning healthcare. it collaborates with the public health institutions, social care professionals and service users, and it also designs concise sets of statements and guidelines to drive measurable quality improvements within a particular area of healthcare (19). furthermore, there is a supervisory structure in the uk called the professional standards authority. this body is responsible for overseeing the uk’s nine health and care professional regulatory bodies (20). referring to the topics that focus on the subject it is important to mention the united kingdom accreditation service (ukas), the national health service (nhs), the department of health, etc. in germany, as a result of agreement with the german federal government, the national standards body is the german institute for standardization (din). its experts administer about 29,500 standards and it was one of the first well-structured certification institutions in europe. din remains the competent authority in respect to the technical issues and widely known specifications for products and materials. the accreditation body for the federal republic of germany is dakks. it has a special health/forensics division, which among other tasks attests third-party certification bodies taking care of healthcare, forensic medicine, medical laboratory sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 6 diagnostics and medical devices. the german worker’s welfare association (awo) also plays an important role. together with iso they have formed an effective tandem that ensures quality in awo rehabilitation facilities and health organizations. the model combines requirements of iso 9001 with those of awo quality and risk assessment guidelines. consequently, quality of a particular facility is measured by the care provided, the organization structure and the satisfaction of patients and residents. in addition, important requirements for patient safety are formulated by a german initiative called the german coalition for patient safety. it provides a basis in processing the audits that are conducted in the client’s premises, with the aim of providing the client with a feedback regarding the degree of implementation of the quality dimension of “patient safety”, e.g. regarding a particular healthcare system unit. speaking of developed economies, it can be concluded that as of today standardization has taken a strong position. in our opinion this is due to understanding by the managers of its effectiveness, as well as the level of comfort regarding integration of standards, clear description of the processes and therefore adherence to the relevant rules and procedures. in spite of positive sides of standardization, we have to understand that human factor in healthcare should also be taken into account, which means inapplicability of one approach only, the engineering approach to the human being as a mechanism. in comparison with the quality management systems present in the developed countries, ukraine has relatively unbalanced quality infrastructure. it bears elements of the former ussr standardizing paradigm that has to be re-evaluated, updated and adapted to suit the existing economic and social environment. there are state and industry branch systems of standardization in ukraine (21). the state branch includes the ukrainian scientific research institute of standardization certification and informatics, and the ukrainian state research and production centre of standardization, metrology and certification (22,23). the most flexible are the service standards departments and the industrial standards departments. state social standards in the health sector are regulated by the ukrainian law “fundamentals of ukraine on healthcare” (24). since ukraine has become a participant of the eurointegration process, the reform on the adaptation of local standards to the european and international norms has been significantly accelerated (25). the main principles are shown in the “national strategy on reforming the healthcare system in ukraine” which has been accepted for implementation in the period from 2015 – 2020 (26). more often, private clinics and research centres all over the country engage certification bodies to perform an external audit with the aim of meeting international quality requirements. standardization in russian federation is based on gosts. the word gost (russian: гост) is an acronym for “государственный стандарт” which means the national standard. there is a set of technical norms maintained by the euro-asian council for standardization, metrology and certification (easc) (27). one of the steps towards the standardization is by issuing the ordinance of the ministry of health “on the introduction of standardization into healthcare” (28). there are also many national programmes and ordinances in russia dealing with the implementation of particular standards in public health (29). the problem in russia is actually in hyper-regulation as regards the standardization. numerous ordinances, guidelines and procedures on one hand, and a lack of specific implementation mechanisms on the other hand causes confusion and regress with regard to the harmonization of national standards with their international counterparts. thus, the organization for economic co-operation and development (oecd) series on principles of good laboratory practice (glp) currently operates with gost r53434-2009 “principles of good laboratory practice” together with the support of other 14 interstate standards which have already been successfully implemented. in croatia, accreditation is provided only by the croatian accreditation agency (haa) which is a national accreditation body that complies with the requirements of the international and european standard for accreditation bodies adopted in the republic of sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 7 croatia as the croatian standard hrn en iso/iec 17011: 2005. the haa is a member of the international laboratory accreditation cooperation (ilac) and the european cooperation for accreditation (ea). the ilac is an international organization for accreditation bodies operating in accordance with iso/iec 17011 and involved in the accreditation of conformity assessment bodies including calibration laboratories (using iso/iec 17025), testing laboratories (using iso/iec 17025), medical testing laboratories (using iso 15189) and inspection bodies (using iso/iec 17020). the ea is an association of national accreditation bodies in europe which are officially recognised by their national governments to assess and verify (in line with the international standards) the organizations that carry out evaluation services such as certification, verification, inspection, testing and calibration (also known as conformity assessment services). on the other hand there are agencies in croatia dealing with quality control issues on the national level. thus, the agency for quality and accreditation in health care is an authority whose competence refers to quality improvement in healthcare services and social care, as well as medical technology assessment according to the corresponding law (official gazette of the republic of croatia 124/11) (30). targeted assistance in further development of quality infrastructure in croatia has been successfully implemented by the joint research centre of the european commission with amended action programmes such as cards croatia project on the “development of national metrology, standardization, conformity assessment and accreditation system” (31). other institutions that cope with quality paradigm introduction into the croatian healthcare and public health system are andrija stampar school of public health and the european society of quality in healthcare (32). according to the 2009 ministry of health national background report “health in albania”, the country has performed very well in sustaining high rates of economic recovery after the financial collapse of 1997 (33). quality assurance of health systems has been outlined as a priority in primary healthcare reform: a pilot project to provide evidence for health policy (34). the national agencies are empowered by the government to be responsible for accreditation of hospitals and licensing medical personnel. albania maintains the initiatives and continuous a dialog with the public institutions such as the institute of public health, private laboratories and clinics as well as with the international ngos, who, unicef, wb and usaid regarding a more active participation of the country in the international activities of the quality system implementation (35). international quality bodies are successfully co-operating with the aim to internationalize standardizing efforts in healthcare. one of such example is the international society for quality in health care (isqua). it is a parent institution for bodies providing international healthcare accreditation. isqua provides services in guidance to health professionals, providers, researchers, agencies, policy makers and consumers as to achieve excellence in healthcare delivery to the public and to continuously improve the quality of care (36). among others, quality bodies working on the international level are astm international (37), the international accreditation forum (iaf) (38), and the council for health service accreditation of southern africa (39), the quality management institute, etc. quality paradigm implementation in healthcare and public health standards cover a broad range of topics and are applicable to commissioners of health, specialists in primary care, public health staff, and social care providers as well as the local authorities and service users. health products, ranging from medical devices and health informatics to traditional medicines and unconventional healing tools are all in the focus of standards application (40). standards are designed to establish patterns of quality and performance including the measures to protect and improve the safety of patients, to promote a culture of continual improvement, support efficient exchange of information and data protection while benefiting the environment. depending on the scope of responsibilities and http://www.european-accreditation.org/brochure/ea-slides-rev24-02-17� http://www.european-accreditation.org/brochure/ea-slides-rev24-02-17� sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 8 areas of activity every organization is able to voluntarily choose among the standards it wishes to implement. iso has created about 1200 health standards that are grouped in families. some of them, such as environmental management iso 14000, occupational health and safety ohsas 18000, guidance on social responsibility iso 26000, environmental management 14000 are featured as widely applicable to public health and healthcare. a family contains a number of standards, each focusing on different aspects of a corresponding topic. according to 2012 iso press release the most commonly used standard is quality management standard iso 9001 (belongs to iso 9000 quality management systems). due to its generic basis, it is applicable to all types of organizations. it enables a company to develop a quality management system (qms) which implies the introduction of quality planning, quality assurance, quality control and quality improvement, and it is a perfect tool to measure the fundamental way of developing health services. iso 9001 has been updated and together with the cooperation for transparency and quality (ktq) for hospitals became the most acknowledged “brand” for quality recognition in healthcare. ktq certification is aimed at hospitals, medical practitioners and institutions, rehabilitation centres, nursing homes, hospices, and emergency medical services. it shows that the focus is primarily on patient satisfaction, from the preparation of the patient’s stay until his discharge. a good example of such practical application of quality management in a combined clinic is perfectly demonstrated in the article by eckert h. and schulze u., (2004) (41). iso 13485:2016 – medical devices, is also a useful standard. it is designed to define the requirements of quality management system with the aim of demonstrating a company’s ability to provide medical devices and related services that meet the clients’ and regulatory requirements. together with en 15224:2012 certification of quality management systems in healthcare, with its emphasis on the hospital process and risk management, both standards become strong indicators of quality level of care provided at an institution. the best way to find a relative iso standard is to search through the work of a particular iso technical committee (tc) on the iso web page, as follows: tc 76, transfusion, infusion and injection, and blood processing equipment for medical and pharmaceutical use; tc 84, devices for administration of medicinal products and intravascular catheters; tc 94, personal safety protective clothing and equipment; tc 106, dentistry; tc 121, anaesthetic and respiratory equipment; tc 150, implants for surgery; tc 157, contraceptives/sti; tc 168, prosthetics and orthotics; tc 170, surgical instruments; tc 172, optics and photonics; tc 173, assistive products for persons with disability; tc 181, safety of toys; tc 194, biological evaluation of medical devices; tc 198, sterilization of healthcare products; tc 210, quality management and corresponding general aspects for medical devices; tc 212, clinical laboratory testing and in vitro diagnostic test systems; tc 215, health informatics; tc 249, traditional chinese medicine; iso/pc 283, occupational health and safety management systems. challenges, opportunities and benefits twenty-first century and the globalization bring new challenges to the organizations exposed to the global market. with a drastic number of competitors, growing demands of consumers and legislators, quality requirements of goods and services together with a lack of resources are constantly increasing (42). be it in environmental protection, in the food industry or public health objective testing and calibration play a notable role. assessments ensure that tested products, methods, services or systems are reliable with regard to their quality and safety, that they correspond to the technical criteria and conform with the characteristics, guidelines, and laws. observational findings 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http://www.iso.org/iso/home/standards_development/list_of_iso_technical_committees/iso_technical_committee.htm?commid=4857129� sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 9 healthcare is one of the world’s largest and fastest-growing sectors of the society. in 2009 about 12.4% of gross domestic product of oecd was spent on healthcare. these countries are the basis for research and development, as well as the improvement of international standardization environment. on the other hand, studies have shown that south european countries together with ukraine and russia are, in the long run, heading towards the social paradigm shift and understanding of standardization principles. most frequently cited problems refer to failure of recognizing positive effects of a systematic approach, financial means, long waiting lists, systematic delays in first aid providers, lack of competent staff due to “brain-drain” and insufficient organizations’ preparedness for the implementation of structural changes at all levels. some health centres, clinics and hospitals are funded by the state or county budget revenues (beveridge’s model) or partly from social insurance contributions deducted from the citizens’ wages (bismarck model), and consequently do not recognize the need to increase the level of quality, responsibility and international standards compliance (43). in addition, high payroll taxes in eastern and south european countries are discouraging formal employment, dampening labour demand and increasing employment in the informal sector (44). a study published in british medical journal estimates that medical errors are the third leading cause of death in the united states, that caused a quarter-million fatalities in 2013 alone (45). it obviously means that the reduction of risks of all kinds is also an important problem that needs to be resolved (46). despite relatively well-structured lex artis in standardizing processes, its efficiency in many cases remains controversial. sometimes, due to enormous amount of paperwork and bureaucracy, standardization can become a nuisance causing waste of time and human resources. combination of all these factors, together with the unfair competition, weak governance and corruption may cause unwillingness towards continuous improvement which is the ultimate precondition for an efficient functioning of standardization in healthcare and public health (47). public health and healthcare are vital and sensitive issues, and their importance pervades all aspects of social life due to their medical, social, political, ethical, business, and financial ramifications. looking into the future, it is impossible to predict exactly how our world is going evolve, but current trends suggest that together with climate change, migration, urbanization, a growing and ageing population, poverty, emerging diseases, food and water shortages and a lack of access to health services, the future of health sector appears to be complicated. new fields of expertise such as medical tourism are on the rise (48). they create a pool of migrating specialists whose services and reliability need to be properly examined and permanently reviewed. in our opinion standardization is a step-by-step process that requires commitment and cooperation of all parties. it may flow both in the bottom-up and in the top-down directions. the key element of this evolutionary process is the end-user of services the patient, in whose best interest the described changes should be made. the patient, service provider, health insurance officer, public health institution, legislative body all of them form an integral network of relationships and responsibility. therefore, awareness regarding the benefits of the standardization process and full understanding of its stages, by those included, are key factors in the overall success of its implementation. quality management systems based on the international standards should be a strategic decision of the national public health institutions in an attempt to meet long-term strategic goals. if an organization wishes to use one of the worldwide-recognized norms it has to ensure its adherence to best practices in everything it is involved in (49). it also includes the mapping processes, setting performance targets and making sure that it continually improves and meets the goals of shareholders, clients, and patients. regular audit processes and subsequent annual assessments meet the needs of health service providers, patients, in this way guaranteeing the quality of services and achieving maximum results. in this way, the standardization creates powerful tools in order to fine-tune the performance and manage the risks while operating in sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 10 more efficient ways that allow time and capacity for innovation and creativity, finally leading to an overall success. as a result, public health and healthcare sectors may become sustainable and reliable social partners with a high level of responsibility, encouraging committed and motivated employees and satisfied patients. references 1. d’amato r, salimbeti a. sea peoples of the bronze age mediterranean c. 1400 bc– 1000 bc. osprey publishing; 2015. isbn-10: 1472806816. 2. mathisen rw. ancient mediterranean civilizations: from prehistory to 640 ce. oxford university press; 2012. isbn-10: 0195378385. 3. lucas re. the industrial revolution, past and future, federal reserve bank of minneapolis, the region, annual report; 2003. 4. agarwal b, baily m, beffa jl, cooper rn, fagerberg j, helpman e, et al. the new 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this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://ec.europa.eu/progress� http://www.ncbi.nlm.nih.gov/pubmed/?term=mayberry%20rm%255bauth%255d� http://www.ncbi.nlm.nih.gov/pubmed/?term=nicewander%20da%255bauth%255d� http://www.ncbi.nlm.nih.gov/pubmed/?term=qin%20h%255bauth%255d� http://www.ncbi.nlm.nih.gov/pubmed/?term=ballard%20dj%255bauth%255d� http://link.springer.com/journal/11628� http://link.springer.com/journal/11628� http://link.springer.com/journal/11628� mayberry rm, nicewander da, qin h, ballard dj. improving quality and reducing inequities: a challenge in achieving best care. proc (bayl univ med cent) 2006;19:103-18. ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 1 | 16 original research women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 agima ljaljevic1, helmut wenzel2, ulrich laaser3 1 university of podgorica, montenegro; 2 freelance consultant, konstanz, germany; 3 faculty of medicine, belgrade, serbia. corresponding author: prof. dr. med. ulrich laaser, section of international health, faculty of health sciences, bielefeld university, bielefeld, germany; address: pob 10 01 31, d-33501 bielefeld, germany; e-mail: ulrich.laaser@uni-bielefeld.de. ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 2 | 16 abstract aim: montenegrin government is increasingly aware of the key role of women in the society and attempts to improve social cohesion among montenegrin people. precondition is a high degree of life satisfaction and happiness. methods: we used the multiple indicator cluster survey (mics) of 2018 to analyse the distribution and interaction of 22 potential determinants out of 383 variables available. the participation rate was 77.7 or 2,276 women aged 15-49 years out of 2,928 invited. as data quality turned out to be limited, we employed a data mining approach, i.e. an interactive classification and regression tree (c&rt). happiness was measured ranging from very happy to very unhappy on a categorical scale of 5 steps results: of all montenegrin women 70.7% declared themselves as very happy. likewise, a 10point scale of life satisfaction classifies 82.0% of the sample in the top ranks 8-10. furthermore, 73.6% of the women expect the next year to be even better. wealth, younger age, and marriage or living in union determine the status of happiness. conclusion: women in montenegro exhibit a high degree of self-reported happiness and life satisfaction. montenegrin policies should continue to support the role of women in the society. keywords: happiness, life satisfaction, mics, montenegro, women. conflicts of interest: none declared. ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 3 | 16 introduction building up its own institutions and services, montenegro is striving to advance human capital development and increase internationalization and visibility (1). during the last years, montenegrin government became increasingly aware that the role of women in the society has to get priority in order to develop successful strategies to improve the social cohesion in the montenegrin society (2). inclined to diener et al., (3) a positive social web may have three components, happiness related to moods, but frequently a consequence of life satisfaction (evaluative happiness (4)) or in other words subjective (and objective) success in life including social acknowledgement, and well-being as a consequence of both (5) and feeling secure as related to the social environment. we prefer to follow this use of the terminology although some authors understand happiness and life satisfaction as synonyms (6). others make a clear distinction (7,8). for nemati et al. (9) life satisfaction is a factor that influences both happiness and resilience. resilience on its part has an influence on happiness. determinants that possibly contribute to happiness according to e.g. galletta (10) or graham (11) are mostly seen in the categories of socio-demography, location of birth/residence, and wealth (12). as montenegro is a small country of less than one million inhabitants and limited resources, the last multiple indicator cluster survey, executed by the statistical office of montenegro (13) provides a good opportunity to interpret the information available regarding the position and role of women in the montenegrin society. our paper therefore tries to identify politically meaningful determinants of “happiness” and “life satisfaction” of the female population which would allow the government to further improve their stabilising role in the montenegrin society. methods the database of the multiple indicator cluster survey montenegro in (mics) (13) includes the file ‘wm.sav’ referring to 2018 with 2,928 women 15-49 years of age. the response rate was 77.7% or 2.276 women who participated in the highly standardized interview employed, 99.8% of the interviews executed from october to december 2018. however, in the protocols of the interviews several variables show a very high rate of non-response and therefore had to be eliminated from further consideration (we decided on a minimum response level of >=50% for a variable to be included). from the 383 variables available in the data file n = 22, listed in table 1, part i remained as relevant to have a potential impact on “happiness” respectively “life satisfaction” in other words are of “cultural relevance” and have a sufficiently high response rate. the 4 variables referring to happiness and life satisfaction (together understood as well-being) are listed in table 1, part ii. because of their high potential relevance we employed for two variables with a relatively high percentage of missing values (m7 married or lived with a man once or more than once and wagem age at first marriage/union of woman) a md imputation using a k-nn approach (14) to estimate missing values. the k-nearest neighbours is an algorithm that is used for simple classification. the algorithm uses ‘feature similarity’ to predict the values of any new data points. this means that the new point is assigned a value based on how closely it resembles the points in the training set (15). several other indicators of high interest as for example “age at ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 4 | 16 first sexual intercourse” could not be used, either because of an identified non-response rate of mostly >80% or because of a monocategorical formulation of the interview question (a complete table with all variables considered including those eliminated is attached as annex). nevertheless, the 26 variables selected in table 1 cover the categories mentioned above but their quality does not fully satisfy the suitability requirements for further statistical processing like multiple regression techniques. therefore, we employ a data mining approach, i.e. an interactive classification and regression tree (ic&rt) (14). this tree allows to analyse what-if-scenarios either by automatic splitting or manually according to specific research questions. in 1984 breiman (16) used a c&rt algorithm to identify high-risk patients, today it is also used to identify specific customers. the result of the analysis is then shown as a tree. at the various levels and nodes of the tree selected variables are used to split the data pool. a c&rt approach uses automatic (algorithmic) methods, user-defined rules and criteria specified with the help of a highly interactive graphical user interface (brushing tools). with this approach it is possible to provide an interactive environment for building classification or regression trees (via classic c&rt methods or a chi-square automatic interaction detector (chaid)) to enable users to try various predictors and split criteria. this allows to bring in expert knowledge of the researchers, instead of following only an automatic procedure. to evaluate the quality or appropriateness of the classification outcomes, several tools can be applied (14,15). table 1. selection of the 26 most relevant variables from the mics database (unicef 2019) having a sufficiently high response rate, at least bi-categorical answers, and missing values below 50% (full list in annex) part i: potential determinants of happiness and life satisfaction line numbers variable code long name variable format missing values 11 wm6m month of interview 2019 cat. none 30 wb4 age of woman quant. 22.26% missing values 32 wb6a highest level of school attended cat. 23.4% missing values 42 wb15 duration of living in current place quant. 22.26% missing values 45 cm1 ever given birth cat. 22.27% missing values 46 cm2 any sons or daughters living with you cat. 45.28% missing values 49 cm5 any sons or daughters not living with you cat. 45.29% missing values 191 cp3 ever used a method to avoid pregnancy cat. 34.4% missing values 229 un17 availability of private place for washing during last menstrual period cat. 26.33% missing values 234 dv1c if she argues with husband: wife beating justified cat. 22.26% missing values ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 5 | 16 235 dv1d if she refuses sex with husband: wife beating justified cat. 22.26% missing values 236 dv1e if she burns the food: wife beating justified cat. 22.27% missing values 259 vt20 feeling safe walking alone in neighbourhood after dark cat. 22.27% missing values 260 vt21 feeling safe at home alone after dark cat. 22.27% missing values 268 ma1 currently married or living with a man cat. 22.27% missing values 272 ma7 married or lived with a man once or more than once cat. 42.69% missing values 294 ha1 ever heard of hiv or aids cat. 22.27% missing values 325 ha31 children living with hiv should be allowed to attend school with other children cat. 26.47% missing values 331 ia1 do any vaccines cause serious adverse reactions after vaccination cat. 22.27% missing values 351 wage age-class 15-19, 20-24… quant. & cat. 22.27% missing values 353 wagem age at first marriage/union of woman quant. 42.69% missing values 369 hh7 region cat. none 373 windex10 wealth index decile quant. & cat. mixture of category and numbers part ii: happiness and life satisfaction 345 ls1-cat estimation of overall happiness quant. & cat. 22.27% missing values/ no response as category 346 ls2 satisfaction with ladder step quant. & cat. 22.27% missing values / no response as category 347 ls3 life satisfaction in comparison with last year cat. 22.27% missing values / no response as category 348 ls4 life satisfaction expectation one year from now cat. 22.27% missing values / no response as category results the descriptive table 2 shows the distribution of the selected variables potentially determining happiness and life satisfaction. with the exception of variables 5, 6, 9, 16, and 18 in table 2, missing values count for <800 or <27.3% out of a grand total of n = 2.928. variable 3 covering the ‘highest level of school attended’ points to a relatively well educated population with 55.1% having attended the secondary level and 33.1% levels higher than that, together 88.2%. this corresponds to a stable population where only 23.6% live at the present location for less than 15 years (variable 4); likewise, 98.1% indicate children living in the same household (variable 5), however, with a high number of missing answers, presumably being due to a large part of women without children as 29.6% indicate to have never given birth (variable 8). households seem to be well established as almost all women (97.7%) indicate that they have a private place for washing during the last menstrual period (variable 7). for a relatively traditional society speaks that 87.9% deny or may be too reluctant to admit to have used birth control methods ever (variable 9). however, if it comes to violence in the family the position is very clear: more than 98.4%% of females do not accept ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 6 | 16 to be beaten by the husband (variables 10, 11 and 12). although only 39.2% live in rural areas (variable 13) 86.0% feel safe walking alone in the neighbourhood after dark (variable 14) and 94.7% feel safe alone at home (variable 15). in 64.4% age at first marriage is between 15 and 25 years of age (variable 16) and 69.3% are currently married or live with a man (variable 17); almost all (96.1%) live in marriage or union only once (variable 18). almost all (variable 19) have heard of hiv/aids (95.0%), however, regarding the question, whether children with hiv should be allowed to attend school (variable 20) 32.7% say “no”. likewise, the opinion about vaccines (variable 21) is somewhat divided as 19.8% believe that vaccines could cause serious adverse reactions. the wealth index potentially of considerable impact – distributes quite evenly throughout the montenegrin population (variable 22). table 2. distribution of the variables listed in table 1, part i (n=22) name of variable and categories* number percentage missing women 15-49, grand total 2.928 1) month of interview 2019 (wm6m) january 5 0.2 october 1212 41.4 november 1219 41.6 december 492 16.8 2928 100.0 none 2) age (wb4) 15-24 501 22.0 25-34 769 33.8 35-49 1,006 44.2 15-49 2276 100.0 652 3) schooling (wb6a) primary 264 11.8 secondary 1,235 55.1 higher 743 33.1 2.242 100.0 686 4) residence (wb15) since birth 1.370 60.2 >15 years 370 16.3 <15 years 536 23.6 2.276 100.0 652 5) children who are living with you (cm2) yes 1.572 98.1 no 30 1.9 1.602 100.0 1326 6) children who are not living with you (cm5) yes 170 10.6 no 1,432 89.4 1,602 100.0 1326 7) private place for washing (un17) yes 2,102 97.7 no 50 2.3 ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 7 | 16 2,152 100.0 776 8) ever given birth (cm1) yes 1,602 70.4 no 674 29.6 2,276 100.0 652 9) ever used birth control methods(cp3) yes 230 12.1 no 1.675 87.9 1.905 100.0 1.023 10) beating by husband justified if she refuses sex (dv1d) yes 21 0.9 no 2.232 99.1 2.253 100.0 675 11) beating by husband justified if she burns food (dv1e) yes 20 0.9 no 2,239 99.1 2,259 100.0 669 12) beating by husband justified if she argues(dv1c) yes 37 1.6 no 2,210 98.4 2,928 100.0 681 13) area living (hh7) urban 1779 60.8 rural 1149 39.2 2,928 100.0 0 14) feeling safe walking alone (vt20) yes 1.952 86.0 no 319 14.0 2.271 100.0 657 15) feeling safe at home alone (vt20) very safe 1,123 49.9 safe 1,008 44.8 unsafe 119 5.3 2,250 100.0 678 16) age at first marriage (wagem) 10-14 21 1.3 15-24 1.081 64.4 25-34 527 31.4 35-49 49 2.9 1.678 100.0 1.250 17) currently married or living with a man (ma1) yes 1.575 69.3 no 699 30.7 2.274 100.0 654 18) married or lived in union (ma7) only once 1,623 96.9 more than once 52 3.1 1,675 100.0 1,250 19) ever heard of hiv/aids (ha1) yes 2153 95.0 no 114 5.0 2267 100,0 661 ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 8 | 16 20) children with hiv should attend school (ha31) yes 978 45.9 no 698 32.7 depends 457 21.4 2.133 100.0 795 21) vaccines cause serious adverse reactions (ia1) yes 449 19.8 no 1.360 60.0 no opinion 456 20.1 2.265 100.0 663 22) wealth index deciles (windex10) 1. decile 199 8.7 2. decile 217 9.6 3. decile 240 10.5 4. decile 218 9.6 5. decile 237 10.4 6. decile 235 10.3 7. decile 237 10.4 8. decile 262 11.5 9. decile 225 9.9 10. decile 206 9.1 2.276 100.0 652 * names of variables abbreviated, codes in brackets. life satisfaction was asked with a retrospective and a prospective projection of one year. life satisfaction relates to criteria like ranking according to income and social status whereas happiness has an emotional connotation. table 3 classifies life satisfaction in the upper third of a 10-point scale (ranks 8, 9, and 10) with n = 1.773 or 82.0%. however, with regard to the foregoing year only 46.8% or 1062 women consider it as better than the present one but on the other hand even 73.6% expect that regarding the next year. table 3. frequency distribution of life satisfaction (ls2-4) present levels number percentage 0-4 34 1.2 5-7 463 16.8 8-10 (highest) 1.773 82.0 total 2.270 100,0 levels last year worse 82 3.6 about the same 1.124 49.6 better 1.062 46.8 total 2.268 100.0 levels next year worse 14 0.6 about the same 580 25.8 better 1656 73.6 total 2250 100.0 ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 9 | 16 happiness was measured in the survey on a categorical scale with 5 steps (variable ranging from very happy to very unhappy). the interviewers asked to tick the appropriate category in the questionnaire. according to the data in table 4, 96.7% of females 15-49 in montenegro are very or somewhat happy. table 4. frequency distribution of happiness (ls1) categories number percentage very happy 1609 70.7 somewhat happy 592 26.0 neither nor 57 2.5 somewhat unhappy 10 0.4 very unhappy 3 0.1 no response 5 0.2 total 2276 100.0 the result of the c&rt analysis of likely determinants of happiness is shown in figure 1 below. from this tree we can induce general rules to predict who is likely to be very happy. the splitting process creates three levels of splitting. at each level the starting pool of the survey population is divided by predictors, i.e., variables that allow to break down the rating of happiness by expected variables of influence. at the first level 70.7% of the interviewed women according to their answers are very happy and 26.1% are somewhat happy. these figures seem to be relatively high, but change when breaking down the numbers by splitting variables. the 2,276 interviewees are split first according to their level of wealth. this level of wealth (windex10) groups the interviewees into deciles. in the tree 893 women belong to the category of lower wealth. for splitting the following categories of lower wealth were used according to their relevance in this specific population: 2nd, 5th, 3rd and 1st deciles. the variable level of wealth contributes most to the grouping of the interviewees; nevertheless, the remaining variables were also taken into account, but with less importance. in this group of lower wealth 61.3% are very happy and 32.9% somewhat happy. in the richer category with 1,383 women, 76.8% are very happy and 21.6% somewhat happy. if one splits then the group of lower wealth further by the age of women (wb4), from the 582 women in the age of 38 or younger 67.0% are very happy and 28.4% are somewhat happy, whereas in the group of 311 women that are older than 38 years 50.5% are very happy and 41.5% are somewhat happy. to characterise the better off group of 1,383 women, which is according to relevance described by 6th, 4th, 9th, 10th, 7th and 8th wealth deciles, the software splits it according to marital status respectively living in union: 383 women not living in union 66.8% are very happy. they split according to age into 200 women <=24 (74.5% very happy) and 183 women >24 (58.5% very happy). of those 1,000 women living in union 80.6% are very happy. they split into 144 women of (relatively) lower wealth 70.1% of them being very happy and into 856 of higher wealth and 82.4% of them very happy. ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 10 | 16 figure 1. c&rt graphic of selected variables with impact upon happiness* tree graph for ls1_cat num. of non-terminal nodes: 5, num. of terminal nodes: 6 model: c&rt id=1 n=2276 very happy 70.69% id=2 n=893 very happy 61.25% id=3 n=1383 very happy 76.79% id=6 n=383 very happy 66.84% id=7 n=1000 very happy 80.60% id=4 n=582 very happy 67.01% id=5 n=311 very happy 50.48% id=8 n=200 very happy 74.5% id=9 n=183 very happy 58.47% id=16 n=144 very happy 70.14% id=17 n=856 very happy 82.36% w index10 lower wealth higher wealth age <= 38 > 38 marital status = not in union = in union age <= 24 > 24 windex10 = lower wealth (1) = higher wealth (1) very happy somewhat happy neither happy nor unhappy somewhat unhappy no response very unhappy * for the variables m7 (‘in marriage or union once or more’) and wage (‘age at first marriage/union’) the missing values have been estimated (tibco software inc. 2017). discussion the strength of this study is the fact that it is one of the very first which tries to make use of the available data and analyses how women in montenegro think about their life. the optimistic view of the future, i.e. the expectation to be even happier next year, underlines that positive feelings dominate in the montenegrin culture. the c&rt analysis shows for montenegro that in all sub-groupings the category “very happy” dominates with percentages between 55.5 and 82.4% in any of the subgroups, bypassing e.g. the global spectrum between north america with 49% being very happy at the upper end and sub-saharan africa at the lower end with only 7% (4). hart et al. (17) found positive relations between happiness and the areas of living as well as social relations, determinants which are not dominant in our study, partly because not sufficiently covered in the mics dataset. this is a drawback of many studies in that the focus on individual-level strategies leaves out contextual factors. ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 11 | 16 the c&art analysis we employed identifies only 3 predictors (or splitting variables) as most important, namely wealth, living in union, and age. education, residence or the experience of violence and discrimination seem to have a lower impact on the dominant feeling of being happy or at least somewhat happy. this is supported by the equally prevalent indication of high satisfaction with life, reaching 82.0% at present, 76.6% expecting even higher levels next year. the high level of well-being in montenegro may be plausible looking at available data at national level and compare montenegro with the neighbouring countries: its national gdp reached with 21,470 usd ppp in 2019 the highest level whereas e.g. serbia ranges lowest with 18,233 usd ppp (18). likewise, female life expectancy in 1919 reaches in montenegro 79.3 years vs. serbia with 78.4 years and north macedonia in between with 78.8 years. last but not least, in montenegro 49.9% of females share the labour force as compared to serbia with 47.1 and north macedonia with 44.9%. taken together this seems to support the relatively high level of happiness and life satisfaction. another variable, not included in the c&art analysis because of the high number of missing values (45.3%), is the fact that 98.1% answer that they live together with their children in the same household, which indicates a healthy social family context. upbringing and parenting may define to a large degree later happiness and satisfaction with life (19). this would support the montenegrin policy to advance the societal status and role of women to strengthen social cohesion in the montenegrin society. however, we did not include in our analysis the perceived service quality of maternal care, available as antenatal care, delivery assistance and postnatal care as it would be relevant only for a smaller group of women. yet, it would be interesting to relate our results to the mortality patterns in montenegro as the impact of a reduced health status and of death on happiness has been looked at (20) but especially the reverse relationship lacks sufficient consideration. the british million women study (21) analysed both options but did not find an impact of happiness on mortality. the difficulties of research in this field are well analysed by viswanath et al. (22) pointing especially to the lack of a well-acknowledged definition of happiness. limitations of our study are in the first place the varying and for several variables very high number of missing information which led to their exclusion from the analysis. secondly, answers may be more positive than is true because of traditional elements in the montenegrin culture which lead women to hide weaknesses as others do not need to recognize them. on the other hand, the scales from 1-10 used in the survey are closed at both ends although personal experience may go far below or beyond. likewise, it is not clear how reliable is the information about wealth, especially as women often do not oversee all incomes created by their husband and facilities/household equipment as used in the survey may not correspond to the actual wealth. finally, to get the full picture a retrospective analysis as well as a comparative study in the region of south eastern europe should follow also including similar analyses of other family members i.e. fathers and children. conclusion montenegrin policies support the societal role of the family and of women in general. this analysis indicates a high degree of happiness and life satisfaction in montenegro also of women at older age, not living in marital union, and at lower levels of wealth. ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 12 | 16 montenegrin policies should continue to support the role of women in the society. references 1. united nations development programme (undp). national human development report: people are the greatest wealth of a country. how rich is montenegro? 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mortality? the prospective uk million women study. lancet 2016;387:874-81. available from: https://doi.org/10.1016/s01406736(15)01087-9 (accessed: november 15, 2020). 22. viswanath k, kubzansky ld. the science of happiness: the view from one research center. am j health promot 2019;33:1210-11. available from: https://doi.org/ 10.1177/0890117119878277b (accessed: november 15, 2020) __________________________________________________________________________ https://onlinelibrary.wiley.com/action/dosearch?contribauthorstored=ferrer-i-carbonell%2c+ada https://onlinelibrary.wiley.com/action/dosearch?contribauthorstored=frijters%2c+paul https://doi.org/10.1111/j.1468-0297.2004.00235.x https://doi.org/10.1111/j.1468-0297.2004.00235.x http://mics.unicef.org/surveys https://www.tibco.com/ https://data.worldbank.org/indicator/ny.gdp.pcap.pp.kd https://data.worldbank.org/indicator/ny.gdp.pcap.pp.kd https://doi.org/10.1016/s0140-6736(15)01087-9 https://doi.org/10.1016/s0140-6736(15)01087-9 https://pubmed.ncbi.nlm.nih.gov/31672052/ https://pubmed.ncbi.nlm.nih.gov/31672052/ https://pubmed.ncbi.nlm.nih.gov/31672052/ ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 14 | 16 annexed data annex: categorisation of all variables of potential relevance line variable code long name level of measurement missing values or coding problems suitable for analysis 10 wm6d day of interview i none no 11 wm6m month of interview cat. none yes 12 wm6y year of interview i none yes 29 wb3y year of birth of woman i 22.26% missing values yes 30 wb4 age of woman i 22.26% missing values yes 31 wb5 ever attended school cat. 22.26% missing values no 32 wb6a highest level of school attended cat. 23.4% missing values yes 33 wb6b highest grade attended at that level cat. 23.46% missing values no 34 wb7 ever completed that grade/year cat. 23.4% missing values no 35 wb9 attended school during current school year cat. 83% missing values no 36 wb10a level of education attended current school year cat. 89.2% missing values no 37 wb10b grade attended at that level during current school year i 89.2% missing values no 38 wb11 attended school previous school year cat. 83% missing values no 39 wb12a level of education attended previous school year cat. 88% .25% missing values no 40 wb12b grade attended at that level during previous school year cat. 88% .25% missing values no 41 wb14 can read part of the sentence cat. 97.78% missing values no 42 wb15 duration of living in current place i 22.26% missing values yes 43 wb16 place of living prior to moving to current place cat. 69.057% missing values no 44 wb17 region prior to moving to current place cat. 69.057% missing values no 45 cm1 ever given birth cat. 22.27% missing values yes 46 cm2 any sons or daughters living with you cat. 45.28% missing values yes 47 cm3 sons living with you i 46.31% missing values no 49 cm5 any sons or daughters not living with you cat. 45.29% missing values yes 50 cm12 confirm total number of children ever born cat. 22.26% missing values /1 code only "yes" no ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 15 | 16 58 cm15y year of last birth i 42.29% missing values yes 60 cm16by year of first birth i 54.04% missing values yes 75 cm32b no wish to have a child/another child cat. 97.13% missing values no 77 cm32d preferring to have a boy, while a girl was expected cat. 97.13% missing values no 78 cm32e preferring to have a girl, while a boy was expected cat. 97.13% missing values no 81 cm32h the parents were unmarried cat. 97.13% missing values no 93 mn4au weeks or months pregnant at first prenatal care unit cat. 85.42% missing values no 96 mn6a blood pressure cat. 85.42% missing values no 101-106 mn19a etc. assistance at delivery: doctor etc. cat. 97% and more missing values/ 1 code only no 111 mn23 after the birth, baby was put directly on the bare skin of mother's chest cat. 85.24% missing values no 116 mn32 size of child at birth cat. 85.24% missing values no 119 mn34 weight at birth (kilograms) i 85.38% missing values no 121 mn36 ever breastfeed cat. 85.24% missing values no 140 pn5 mother's health checked before leaving health facility cat. 85.31% missing values no 148-154 pn13n etc. how long after delivery did the first check of baby happen number etc. i& cat. 86% to 100% missing values no 181 un12d reason: hysterectomy cat. 98.9% missing values no 183 cp0i heard of: diaphragm cat. 98.9% missing values no 191 cp3 ever used a method to avoid pregnancy cat. 34.4% missing values yes 229 un17 availability of private place for washing during last menstrual period cat. 26.33% missing values yes 234 dv1c if she argues with husband: wife beating justified cat. 22.26% missing values yes 235 dv1d if she refuses sex with husband: wife beating justified cat. 22.26% missing values yes 236 dv1e if she burns the food: wife beating justified cat. 22.27% missing values yes 239 vt3 number of times victimisation happened in the last year cat. 99.96% missing values no 251 vt13 number of people involved in committing the offence cat. 99.6% missing values no 259 vt20 feeling safe walking alone in neighbourhood after dark cat. 22.27% missing values yes ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 16 | 16 260 vt21 feeling safe at home alone after dark cat. 22.27% missing values yes 268 ma1 currently married or living with a man cat. 22.27% missing values yes 270 ma5 ever married or lived with a man cat. 77.13% missing values no 271 ma6 marital status cat. 96.6% missing values no 272 ma7 married or lived with a man once or more than once cat. 42.7% missing values yes 284 sb1 age at first sexual intercourse i& cat. 22.7% missing values/ mixed coding no 290 sb7 sex with any other person in the last 12 months cat. 36.68% missing values yes 294 ha1 ever heard of hiv or aids cat. 22.27% missing values yes 325 ha31 children living with hiv should be allowed to attend school with other children cat. 26.47% missing values yes 331 ia1 do any vaccines cause serious adverse reactions after vaccination cat. 22.27% missing values yes 345 ls1 estimation of overall happiness i 22.27% missing values/ no response extra category yes ls1_cat estimation of overall happiness (categories) cat. 22.27% missing values yes 346 ls2 satisfaction with ladder step i& cat. 22.27% missing values / no response as category yes 347 ls3 life satisfaction in comparison with last year cat. 22.yesyes27% missing values / no response as category yes 348 ls4 life satisfaction expectation one year from now cat. 22.27% missing values / no response as category yes 353 wagem age at first marriage/union of woman i 42.69% missing values yes 361 welevel education cat. 22.7% missing values yes 364 migration length of stay in current place of residence cat. 22.27% missing values yes 369 hh7 region cat. none yes 373 windex5 wealth index quintile i& cat. mixture of category and numbers yes von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 1 original research evaluation of an implementation strategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania per m. von groote1-3, dimitrios skempes1,2, jerome e. bickenbach1,2 1department of health sciences and health policy, university of lucerne, lucerne, switzerland; 2swiss paraplegic research, nottwil, switzerland; 3institute of social and preventive medicine (ispm), university of bern, bern, switzerland corresponding author: per m. von groote, institute of social and preventive medicine (ispm), university of bern; address: finkenhubelweg 11, ch-3012, bern, switzerland; e-mail: per.vongroote@gmail.com von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 2 abstract aim: this paper aims to evaluate a strategy for the implementation of public health policy recommendations from the world health organization’s (who) report “international perspectives on spinal cord injury” in romania. more specifically, it seeks to: a) evaluate implementation actions with a focus on a number of people reached and status of completion at 12 months follow-up; b) describe implementation activities undertaken in the course of one year, and; c) evaluate perceived barriers and facilitators of implementation at 12 months follow-up. methods: a cross-sectional design was adopted with two surveys administered in 2014/15 among key implementers in romania. the questionnaires contained open-ended, multiple choice and 5-point likert scale questions. results on the implementation status, implementation activities performed and self-reported barriers and facilitators were analysed and reported using descriptive statistics. results: implementation completion rate was 75%, with 4390 persons directly or indirectly benefiting from the implementation-related activities listed in the final implementation plan reporting. a broad range of implementation experiences was reported. most common activity types were delivery of services, technical trainings, implementation coordination and development meetings. most useful tools and processes were the romanian language version summary of the report, educational meetings, and local consensuses processes. reported outcomes included the direct output produced, evidence of services provided, and individual or organizational level impact. most barriers were named for the policymakers and academia as stakeholder groups and most facilitating influences for the private sector, with dependence of policymakers on constituency interest scoring highest barrier and the general availability of european commission and european structural funds highest facilitator. conclusion: the surveys proved to be both feasible and useful tools to expand our understanding of implementation and to supplement the more standard used implementation strategies at country level. keywords: implementation, implementation strategy, public health report, spinal cord injury, world health organization. conflicts of interest: none. funding statement: the project received funds from the swiss-romanian cooperation programme as part of swiss contribution to the enlarged eu. acknowledgments: the authors would specifically like to thank dr. cristina ehrmannbostan for her continuous support in analysing the data and preparing display items, and dr. jan d. reinhardt for his conceptual feedback in drafting the manuscript. von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 3 introduction although spinal cord injury (sci) is a low-incident condition, it can be devastating and costly in both human and social terms (1). sci can occur as a consequence of trauma, infection, inflammation, degeneration, tumour, or another disease and often results in a significant decline of physical capacity (2). sci a principal cause of permanent disability has become a significant concern for public health mainly because it places substantial socioeconomic burden on affected individuals and their families, communities and the healthcare system (3). it is considered a particularly pervasive stressor as people who sustain these injuries experience profound alterations in almost all aspects of their life (4). however, many of the difficulties experienced by people with sci do not result from the condition itself, but from inadequate medical care and rehabilitation services, and from barriers in the physical, social and policy environments (5). implementation of measures aiming at removing barriers to access to healthcare and enhancing the effectiveness of rehabilitation and community reintegration is therefore imperative (1). to help propel the implementation of evidence-informed health care and policy for people with sci forward, the world health organization (who) in collaboration with the international spinal cord society in 2013 published a global report titled “international perspectives on spinal cord injury” (ipsci) (6). the report assembles and summarizes the best available scientific evidence and information on spinal cord injury together with the lived experience of people with spinal cord injury and makes recommendations for actions that are consistent with the aspirations for inclusion and participation as expressed in the united nations convention on the rights of persons with disabilities (crpd) (1). the crpd (7) reaffirms the universal human rights and fundamental freedoms of all people with disabilities and calls upon states to secure and promote their inclusion and participation in all aspects of civil, social, economic and community life. notably, the treaty marks a paradigm shift in understanding disability as the result of physical and social barriers interacting with impairments and health states in a way that deprives people of equal opportunities for societal participation. this view implies that multiple systems and stakeholders from health to social and employment sectors must undertake coordinated actions to translate the normative recommendations of international law into concrete benefits for those living with disability (8). for this reason, the who has recognized the necessity to strengthen governments’ capacities in implementing their legal obligations through evidence based programmatic guidance, including guidance on policy implementation. indeed, while the convention is among the “most significant policy catalysts” for disability policy at the global level, nonetheless, “the most significant implementation constraints are at the national level” (7,9). to investigate all aspects of implementation, including activities used to put interventions or innovations into practice and contextual factors that influence these activities, one can look toward implementation research (10). this discipline offers insights for selecting evidenceinformed policies and interventions, identifying how to implement these in the disability context across populations and resources, and evaluating outcomes. in implementation research, widespread development of programmatic instruments and innovative tools promises to expedite policy implementation in various contexts. these tools are to a large extent tailored to specific purposes and contexts and have limited prospects for large-scale or long-term prospective testing (11). it is now well-established, however, that the transfer of knowledge to support implementation is more complex than it usually appears and is more difficult in the trans-disciplinary domain of public health policy (12,13). pragmatically, there is no “one-size-fits all” health policy and it would be naive to expect von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 4 implementation tools to work across different domains of public health policy, from clinical care guidelines to policy recommendations of international public health organizations. generally, the who’s effort to strengthen health policy implementation research and practice has been led by the alliance for health policy and systems research with its international academic and civil society partners network (14).the alliance highlights the value in documenting and analysing implementation experiences and sharing lessons for unravelling the otherwise invisible facets of the complex process of policy implementation and allowing implementing agents, facilitators and ‘champions’ to better understand their practice and realize their roles by reframing their perspective and refocusing their expectations. this will lead to better judgments about whether a particular strategy works or is relevant to other circumstances and situations, leading to measurable improvements in efficient health systems (15). in light of this, the objective of this paper is to evaluate an implementation strategy for the who ipsci report in romania. the context the research project was led by a partnership between a romanian non-governmental organization dedicated to delivering health and social services to people with disabilities and a swiss health research institute specialized in sci. the partnership organized the development of a strategy to implement the ipsci report in romania in august 2012. the strategy consisted of a set of implementation actions or interventions described in a central implementation plan, to work in combination, and administered by a coordinated group of implementers. the resulting implementation activities that are evaluated in the present paper started in march 2014 and lasted for 12 months. implementation research is by definition a participatory, stakeholder-driven and evidenceinformed process (10). adopting this approach is particularly important in disability research as persons with disabilities have long been denied equal voice in research and policy processes due to power asymmetries and misallocation of technical and financial resources. in this project, the participatory process of developing the implementation strategy and its evaluation involved three main phases: the preparatory phase, the implementation strategy development phase, and the monitoring and evaluation phase. the preparatory phase consisted of a group discussion by the research project team to identify and select mechanisms to develop the strategy. the implementation strategy development phase encompassed focus group interviews (fg) of people with sci, policy makers, system and service developers and managers, and representatives of ngos to elicit insights into key implementation considerations, a stakeholder dialogue (sd) with participants from the same pool of fg participants from romania and international experts to develop an implementation strategy, including the use of tools and processes. the development process was informed by a conceptual framework and guiding principles which have been previously developed by the authors (16). the monitoring and evaluation phase included surveys administered over the course of one year to monitor implementation activities by a core implementation group and evaluate the strategy. the question was now, what actually happened on the ground during 12 months of implementation and in how far the development process infused implementation activities that were successful. more specifically, this paper seeks to: a) evaluate implementation actions with a focus on the number of people reached and the status of completion at 12 months follow-up; b) describe implementation activities undertaken in the course of one year; and c) evaluate perceived barriers and facilitators of implementation at 12 months follow-up. von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 5 methods due to the lack of validated instruments to measure activities using the conceptual implementation framework, and given the research aim of focusing on the tools developed during the sd and documenting their use in implementation activities undertaken, new and fit-for-purpose survey questions were developed by the research project team. as a result, two surveys were developed in the preparatory phase and finalized after the implementation strategy development phase: first, the online report card survey to document implementation activities throughout the course of one year, and second a one year sd follow-up survey to capture implementation experiences such as perceived barriers and facilitators, among others. in addition, the implementation plan was used as a basis for the summative evaluation of activities at 12 months after the start of implementation. surveys development: the online report card survey questions were first developed by the lead author along the central elements of the comprehensive implementation framework and based on insights from the fgs and sd (16). the survey was independently reviewed by an implementation science expert and an expert on rehabilitation systems and services from the research project team. the survey was tested by a third health scientist who was not involved in the project. the questions were revised based on feedback. the one year sd follow-up survey questions were developed based on the online survey and on first screening of response data to its questions. this survey was reviewed by two team members and reviewer comments were incorporated in the revision. setup and design: the surveys were self-administered, with both quantitative and qualitative data elements. they contained both open-ended questions and questions with predefined response options ranging from yes/no (‘did the activity take place in relation to another event or initiative?’) to five-level psychometric scales (‘what tools were used during the implementation activity and how useful where they?’ – ‘very useful’ to ‘not at all useful’). both surveys were administered in english. the online survey was administered beginning after the sd in four waves from march 2014 until february 2015 capturing implementation activities during 3-month reporting periods each. it took approximately 20 minutes to complete each time. the sd followup survey was a one time, one year follow up survey to the sd. components: the online survey was composed of nine personal and demographic questions followed by 26 questions categorized by the essential implementation components asking, among others, about the kind of implementation activity, relation to the three central themes identified during the sd (medical rehabilitation and follow up in the community, independent living, employment and inclusive education), tools used including those introduced during the sd, processes followed, relation of activity to ipsci recommendation, and perceived receptiveness of audience. in the one year sd follow-up survey participants were asked to judge the extent (0 -5 likert scale) of hindering and facilitating influence attributes or factors of stakeholder groups had on implementation. these attributes had been jointly identified during the sd and were now being evaluated based on 12 months of implementation experience. participant recruitment: participants included a convenience sample of ten residents of romania, seven who had participated in the sd and three from the focus groups. as described elsewhere, participants of the sd and focus groups had been recruited on a participant roster developed by the researchers to maximize heterogeneity and representativeness. all participants were given an information sheet about the survey and asked to sign a consent form. von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 6 data analysis: qualitative survey data from open-ended questions were content-analysed by two researchers. the specificity and intensity of responses were determined by means of a thematic, open and selective description of meaningful concepts and themes using sentences as units of analysis (17,18). categories were then produced using inductive reasoning. conversely, descriptive statistics of quantitative data, such as frequency distributions, were carried out. implementation plan during the sd, five documents were developed that separately described problems related to the three central themes identified during the sd (i.e., sci medical rehabilitation and follow up in the community, independent living, employment and inclusive education), options to target these problems, facilitators and barriers by stakeholder groups, and next steps. these documents then served as a baseline analysis for the development of the implementation plan. the final evaluation of the plan was based on the categories ‘number of people reached’ and ‘status’ defined as either ‘completed’ or ‘incomplete’ at 12 months implementation by the core implementation group. results implementation plan the implementation plan listed 40potential actions in the categories presentations, publications, report development activities, trainings, services, consultations, conferences, and social events. actions planned included, among others: the development of a group statement based on ipsci recommendations, which was disseminated among key stakeholders; a 2-day scientific conference held in bucharest; a disability gala that was broadcasted on national television; an emergency call centre for persons with sci; an sci rehabilitation guide; and a meeting with high ranking government officials. of those listed, 29 actions were rated as “completed” and 11 as “incomplete” (75% completion rate). those listed as incomplete included also activities already planned or still in progress at 12 months. in total, 4390 persons had directly or indirectly benefited from the implementation related activities listed in the final implementation plan reporting. they were either active participants in activities, such as trainings, or the audience of oral presentations. implementation activities captured although the response rate dropped in the online report card survey, all ten participants responded at least, and often more than, once over the course of the year (10, 8, 3, 4 at time points 14). the one year sd follow up survey to the same pool of core implementers had a response rate of 9/10, one survey was returned incomplete. overall, respondents seemed to have understood the questions well, as the large majority of open responses were clear and to the point intended. no respondent reported technical problems accessing the online survey platform or the paper based questionnaires. one respondent reported language difficulties and was assisted by a colleague. the online report card survey captured 36 (14, 12, 5, 5 in time points one to four) implementation activities overall. table 1 provides an overview of these implementation activities. von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 7 table 1. implementation activities reported implementation activities (number of reports: 36) type of activity percent (number) delivery of social support services 30.5% (11) icf training 19.4% (7) implementation coordination and development meeting 19.4% (7) icf implementation in support services 5.6% (2) oral presentation 5.6% (2) dissemination through personal communication 2.8% (1) expert workshop 2.8% (1) guideline development 2.8% (1) organizing a scientific conference 2.8% (1) review of current state and report development 2.8% (1) stakeholder meeting 2.8% (1) workshop at scientific conference 2.8% (1) venue or setting percent (number) within an organization 36.1% (13) workshop by invitation only 33.3% (12) meeting by invitation 27.8% (10) during a scientific conference 8.3% (3) other 8.3% (3) within government ministry 2.8% (1) link to other activity percent (number) yes 61.1% (22) no 38.9% (14) implementation goal percent (number) delivery of workshop 22.2% (8) development implementation content and/or group 19.4% (7) promotion or dissemination of implementation content 13.9% (5) professionalization of services 11.1% (4) social reintegration of wheelchair users 8.3% (3) implement specialized knowledge 8.3% (3) improve independence of people with sci 5.6% (2) increase awareness 5.6% (2) improve services and procedures 2.8% (1) raising level of acceptance and self-competence in pwsci 2.8% (1) influencing the revision of disability assessment 2.8% (1) publish report 2.8% (1) organizing a conference 2.8% (1) influence administration of existing services 2.8% (1) delivery of products and services 2.8% (1) main implementation theme percent (number) independent living 55.6% (20) medical rehabilitation and follow up in the community 27.8% (10) employment & inclusive education 16.7% (6) target audience percent (number) people with disabilities 50% (18) disability professionals 33.3% (12) representatives of government and public authorities 33.3% (12) civil society 22.2% (8) health professionals 19.4% (7) students 11.1% (4) family members of people with disabilities 8.3% (3) implementers, implementation and human rights experts 8.3% (3) von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 8 pupils and teachers 8.3% (3) support service professional 8.3% (3) representatives of international organizations 2.8% (1) link with ipsci recommendation percent (number) 2. empower people with spinal cord injury and their families 30.6% (11) 3. challenge negative attitudes to people with spinal cord injury 19.4% (7) 7. implement recommendations 19.4% (7) 1. improve health sector response to spinal cord injury 11.1% (4) 5. support employment and self-employment 11.1% (4) 6. promote appropriate research and data collection 5.6% (2) 4. ensure that buildings, transport and information are accessible 2.8% (1) use of materials and content percent (number) icf case studies (distributed) 69.4% (25) facilitators 66.7% (24) barriers 63.9% (23) the problem 50% (18) the options 50% (18) next steps 50% (18) scientific paper on implementation (distributed) 27.8% (10) other 16.7% (6) adaption of content to local context percent (number) no, the documents were used as they are 36.1% (13) yes, they were translated further 36.1% (13) yes, they were shortened 13.9% (5) other 13.9% (5) yes, they were rearranged 11.1% (4) yes, they were rewritten 11.1% (4) not applicable 5.6% (2) monitoring tools percent (number) longitudinal patient or recipient documentation 30.6% (11) outcome questionnaire 22.2% (8) activity documentation 8.3% (3) group discussion 2.8% (1) mapping of documents 2.8% (1) testimonials 2.8% (1) no monitoring of activities 30.6% (11) receptiveness of audience percent (number) in favour 66.7% (24) slightly in favour 30.6% (11) neither in favour nor against 2.7% (1) implementation activities respondents participated in most were by a large margin social support services (31%), followed by icf trainings and implementation coordination and development meetings (both 20%). the majority of implementation activities took place within an organization (34%) and participation was by invitation in 63% of activities. about two thirds of activities were related to other events or projects (63%). asked to state the explicit goal of the implementation activity they were part of, respondents named the delivery of a workshop or training (n=8) most often, followed by the development of implementation content and / or forming an implementation group (n=5), the promotion or dissemination of implementation content (n=4), and professionalization of services (n=4). in terms of goals targeting the person level, improving independence of people with sci (n=2), social reintegration of wheelchair users (n=2), their participation in services (n=3), and raising the level of acceptance and self-competence in people with sci (n=1) were named. von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 9 respondents were also asked to what main implementation theme, identified during the sd as main focus of implementation efforts, the activities related to. in 56% of cases and by a large margin these were related to the theme independent living. in addition, implementation activities mainly related to the ipsci recommendation empower people with spinal cord injury and their families (31%). the recommendation challenge negative attitudes to people with spinal cord injury (20%) and implement recommendations scored both second highest. key messages of activities were directed at raising awareness toward problems people with sci face in terms of accessibility barriers, poor health, denial of rights, and social exclusion. these messages highlighted an inclusive and rights based approach (obstacles can be overcome and people live independently with the right supports; people with disabilities should be socially and financially independent; people with disabilities have rights they should access). further key messages targeted the system and service level, calling for an improvement of medical sci rehabilitation, provision of services based on the icf approach, and stating that better access to at and mobility training improves the lives of people with disabilities and the elderly. in addition, employment services should consider all abilities of people with sci also in relation to their functioning capacity in a specific environment and not only assessed from a medical point of view. finally, key messages toward implementation stated that successful implementation of ipsci recommendations would first require a rethinking of legislation and policies on disability in line with crpd, and that it necessitates joint action by key experts, sustained by policy. the main target audience of activities were people with disabilities followed by disability professionals and representatives from government and public authorities. out of the seven total documents created or introduced during the sd, the icf case studies and the facilitators’ document were used most often. in 73% of cases respondents had adapted these documents to the local context, mostly by translation (36%). in terms of processes or techniques used and their usefulness (figure 1), respondents found in61% of their activities elements of educational meetings or teachings (of health professionals, government employees, people with sci and families) either fairly useful or very useful as well as local consensus processes (meeting to discuss and agree on implementation goals, steps, etc.) in 47% of cases. tools rated most useful during implementation activities (figure2) were the ipsci summary in romanian (83% of cases), the ipsci full report in english (61%), the icf and own documents or media (53%). other, very specific who media was in the majority of cases not used. twenty-five out of 36 activities were monitored. about 97% of the target audience reported to have been in favour or slightly in favour (0-5 likert scale) of the implementation activities. asked to describe the main outcomes of their activities, respondents named direct output produced, evidence of services provided, and individual or organizational level impact. activity related output included the development of and promotion of implementation content (n=11), such as an implementation plan, technical information, or a journal article. also, the organization of an expert group to develop an implementation plan was highlighted as one such direct output. evidence of service provision (n=13) included the recruitment of clients and services delivered (registration, assessment, program development, training). in addition, some activities were evaluated by participants (n=3) leading to sum scores of how far training participant’s expectations were met. individual level impact (n=23) was reported as knowledge gain or change of perspective and awareness in the target audiences, including a better understanding of rehabilitation von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 10 objectives, outcomes and problems by health professionals. furthermore, specific skills were acquired by the target audience, their independence improved, and their activity and social participation increased. finally, one respondent named improved working procedures and working tools used within the target organization as a direct organizational level impact (n=1). during the sd participants had listed most anticipated barriers for the stakeholder group policy makers and ngo. figure 1. implementation techniques and their perceived usefulness by number of cases von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 11 figure 2. implementation tools and their perceived usefulness by number of cases respondents also rated the extent of hindering and facilitating factors by stakeholders had on implementation during the last 12 months (figure 3). these factors had been jointly formulated during the sd and listed most barriers for the policy maker and academia stakeholder group (6 & 4) and most facilitating influences for the private sector (4). only nine out 26 factors had been rated of no influence and all as either of large or very large influence. the dependence of policy makers on constituency interest scored as highest barrier and the general availability of european commission and european structural funds highest facilitator, possibly counterbalancing the general lack of funds and resources as general barrier. von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 12 figure 3. perceived barriers and facilitators by stakeholder group and in general terms legend: ac academia; dpo – disabled people’s organization; ggeneral; ngo – nongovernmental organizations; pm – policy makers; ps – private sector; sci – people with sci; spp service and product providers. von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 13 discussion summary of main results when summarizing the main results of the surveys it is important to note that multiple and different kinds of implementation activities were undertaken over the course of the monitoring period. these were to a very large extent completed (75%) and had involved over 4000 people. the activities produced direct output, evidence of services provided, and indications of individual or organizational level impact. on closer examination patterns become apparent in the data. a majority of activities were concerned with the delivery of social support services, icf trainings, and implementation coordination and development meetings. these activities mostly took place within an organization, by invitation and related to other events or projects. consequently, goals were largely related to improving independence of people with sci, the delivery of workshops or trainings, and development of implementation content or formation of an implementation group. subsequently, activities largely related to the overall theme of independent living with key messages of the need for awareness raising, improvement of service provision, and the necessity to coordinate implementation efforts. evenly matched are the target audiences - people with disabilities, disability professionals and representatives from government and public authorities. the most useful processes were educational meetings or teachings and local consensus processes. most notably in terms of tool usefulness is that the ipsci summary in romanian, the ipsci full report in english, the icf and their own documents and media scored most useful, while who media products were least used or useful. although these tools had been introduced during the sd, implementers resorted to using tools that were more linguistically accessible or their own tools. an additional indication that language accessibility is an important issue is the fact that in one third of cases sd documents were translated for further use in implementation. finally, the implementers rated substantial hindering and facilitating influences stakeholder groups had on their implementation efforts. lessons learned beyond offering insights into actual implementation experiences, we can draw three lessons from the experience that can help in the development and application of an implementation strategy for a who public health report. first, we can see that the overall implementation strategy worked in terms of pre-defining activities in a plan and coordinating the implementation groups’ efforts. this was apparent in activity achievement as documented in the implementation plan and established through implementation content and group development meetings as documented in the monitoring survey. secondly, results indicate that the process of developing the implementation strategy had a positive impact of building the team for the core implementation group, ownership and participation, as well as on focus and the continuation of efforts, and, lastly, on implementation outcomes. finally, the monitoring mechanism drafted during the implementation strategy development process is feasible, faithful and useful as the surveys were able to display the broad range of implementation experiences with their many facets. this fact underscores the usefulness of the underlying conceptual implementation framework used to map out the survey questions across core implementation components toward planning, administering and monitoring implementation (16). von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 14 however, the surveys could also benefit from a closer alignment with recently developed surveys in similar contexts (19,20). in particular, this would mean adding survey questions within the online report card survey assessing the specific impacts the process to develop the strategy had, similar to those survey cycles used in stakeholder dialogue researched by boyko and colleagues (21). overall, survey design, analysis and interpretation can be standardized by further application in similar case studies to improve data quality. results in light of research in the field waltz and colleagues as part of the expert recommendations for implementing change (eric) study recruited a panel of experts in implementation science to sort 73 implementation strategies and to rate their relative importance and feasibility. the ratings reflect similar processes identified in the present case as the most important and feasible, for instance, identifying barriers and facilitators to implementation, developing stakeholder interrelationships, training and educating stakeholders, and engaging consumers (22). furthermore, participatory implementation strategy development mechanisms create strong coherence in the implementation group and a shared sense of commitment greatly benefiting outcomes. findings from the international consortium project ‘equitable’ of two european and four african countries highlight very similar lessons learned when developing and implementing a joint project (23). likewise, identifying implementers during strategy implementation in terms of professional knowledge, involvement in issue, networks, ability to influence, and interpersonal competencies will benefit implementation processes (24,25). finally, drawing on standard outcome variables proposed for implementation outcome research (26) this study shows that the following are the most relevant: reach in terms of the number of people directly or indirectly involved throughout romania; adoption and fidelity in terms of level of activity completion; perceived usefulness of implementation tools and processes; and signs of sustainability in terms of technical expertise introduced to services on the ground. limitations and implications for future research in the present case, much of the implementation success must be attributed to the core implementation group and the influence the individual implementers had in their respective organizations (27). this is particularly evident in the role of main project partners and their effective interplay. although the core implementation group members were selected from the pool of focus group and sd participants who in turn were invited based on a detailed participants’ recruitment scheme to reach heterogeneity in group composition, the group constitutes a small convenience sample lacking representativeness. this limits the generalisability of results. expanding on the number of implementers involved will increase reach and generalisability of results. however, inclusion of participants from one particular country only will always introduce a cultural bias. respondents could have over or underrated specific elements or tools of implementation that are either lacking in their country or are in general under prioritized. in effect, what was accomplished here is a pilot of two surveys that are innovative in their own right and fill an important gap in the toolset of implementation research. subsequent research using these, or modified versions of these surveys also in other contexts and countries will help to refine the methodology and strengthen the survey approach. another limitation might be the reporting bias of the implementers. the implementers might have felt obliged to report favourably on implementation interventions within the realm of their own organizations, although specific precautions were made in term of anonymity of responses and disclosure of implementation group composition. it must be kept in mind, however, that the concern here is not so much the accuracy of the reporting, as the selfvon groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 15 awareness of the implementers of what they have committed themselves to do. it is extremely difficult to avoid self-serving responses in this context, and independent verification of these results would go far beyond this study. when it comes to evaluation, defining appropriate impact indicators at the start of the project will help measure implementation outcomes and impact in wider contexts in addition to the project-related process and output indicators (28,29). context data and information on stakeholder influences on implementation could be set in reference to network analysis as it has been applied in health systems research (11,30). conclusion as who’s alliance for health policy and systems research has made clear, any effort to strengthen health policy implementation research and practice depends on clear documentation and analysis of the experience of implementers ‘on the ground’. agents, facilitators and other implementation ‘champions’ have always been the engine of implementation, and it is crucial to understand their motivations, experiences, and selfperception of their implementation roles. in this paper we have presented one important method for achieving this, in the form of surveys used to evaluate an implementation strategy for the who ipsci report in romania. despite limitations in this study – described above – it is clear from this initial, piloting of the surveys that they are both feasible and extremely useful tools to supplement the more standard used implementation strategies at country level. references 1. world health organization, international spinal cord society. international perspectives on spinal cord injury. geneva: who; 2013. 2. kirshblum sc, burns sp, biering-sorensen f, donovan w, graves de, jha a, et al. international standards for neurological classification of spinal cord injury (revised 2011). j spinal cord med 2011;34:535-46. 3. weerts e, wyndaele jj. accessibility to spinal cord injury care worldwide, the need for poverty reduction. spinal cord 2011;49:767. 4. post mw, van leeuwen cm. psychosocial issues in spinal cord injury, a review. spinal cord 2012;50:382-9. 5. von groote pm, shakespeare t, officer a. prevention of spinal cord injury. inj prev 2014;20:72. 6. biering-sorensen f, brown dj, officer a, shakespeare t, von groote p, wyndaele jj. ipsci, a who and iscos collaboration report. spinal cord 2014;52:87. 7. united nations. convention on the rights of persons with disabilities, resolution 61/106. new york, ny: united nations; 2006. 8. world health organization, world bank. world report on disability. geneva: who; 2011. 9. priestley m. in search of european disability policy, between national and global. alter 2007;1:61-74. 10. world health organization, alliance for health policy and systems research. implementation research in health, a practical guide. geneva: who; 2013. 11. contandriopoulos d, lemire m, denis jl, tremblay é. knowledge exchange processes in organizations and policy arenas, a narrative systematic review of the literature. milbank q 2010;88:444-83. 12. winter s. implementation, introduction. in: peters j, pierre bg, editors. handbook of public administration. london: sage; 2003:205-11. von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 16 13. ettelt s, mays n, nolte e. policy learning from abroad, why it is more difficult than it seems. policy & politics 2012;40:491-504. 14. world health organization alliance for health policy and systems research, geneva, switzerland.http://www.who.int/alliance-hpsr/en/(accessed: march 6, 2017). 15. world health organization, alliance for health policy and systems research. investing in knowledge for resilient health systems, strategic plan 2016-2020. geneva: who; 2016. 16. von groote pm, giustini a, bickenbach je. analysis and implementation of a world health organization health report, methodological concepts and strategies. am j phys med rehabil 2014;93:s12-s26. 17. zhang y, wildemuth b. qualitative analysis of content. in: wildemuth b, editor. applications of social research methods to questions in information and library science santa barbara, ca: greenwood press; 2009:308-19. 18. miles mb, huberman am. qualitative data analysis, an expanded sourcebook. beverly hills, california: sage; 1995. 19. lavis jn, boyko ja, gauvin f-p. evaluating deliberative dialogues focussed on healthy public policy. bmc public health 2014;14:1. 20. moat ka, lavis jn, clancy sj, el-jardali f, pantoja t. evidence briefs and deliberative dialogues, perceptions and intentions to act on what was learnt. bull world health organ 2014;92:20-8. 21. boyko j, lavis j, dobbins m. deliberative dialogues as a strategy for system-level knowledge translation and exchange. healthcare policy 2014;9:122-31. 22. waltz tj, powell bj, matthieu mm, damschroder lj, chinman mj, smith jl, et al. use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance, results from the expert recommendations for implementing change (eric) study. implement sci 2015;10:1. 23. maclachlan m, amin m, mji g, mannan h, mcveigh j, mcauliffe e, et al. learning from doing the equitable project, content, context, process, and impact of a multicountry research project on vulnerable populations in africa. afr j dis 2014;3:1-12. 24. greenhalgh t, robert g, macfarlane f, bate p, kyriakidou o. diffusion of innovations in service organizations, systematic review and recommendations. milbank q 2004;82:581-629. 25. newman j, cherney a, head bw. policy capacity and evidence-based policy in the public service. public management review 2016:1-20. 26. world health organization (who). a guide to implementation research in the prevention and control of noncommunicable diseases. geneva: who, 2016. 27. hupe p. what happens on the ground, persistent issues in implementation research. publ pol adm 2014;29:164-82. 28. fretheim a, oxman ad, lavis jn, lewin s. support tools for evidence-informed policymaking in health 18, planning monitoring and evaluation of policies. health res policy syst 2009;7:s1-s18. 29. oxman ad, bjorndal a, becerra-posada f, gibson m, block ma, haines a, et al. a framework for mandatory impact evaluation to ensure well informed public policy decisions. lancet 2010;375:427-31. 30. blanchet k, james p. how to do (or not to do), a social network analysis in health systems research. health policy plan 2012;27:438-46. ______________________________________________________________________________________ von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 17 © 2017 von groote et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. evaluation of an implementation strategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania abstract introduction methods results discussion conclusion holst j. when the world depends on effective public health intervention – and public health does not deliver (editorial). seejph 2020, posted: 23 may 2020. doi: 10.4119/seejph-3469 p a g e 1 | 7 editorial when the world depends on effective public health intervention – and public health does not deliver jens holst1 1 department of nursing and health sciences, fulda university of applied sciences, fulda, germany. corresponding author: jens holst; address: leipziger strasse 123, d-36037 fulda, germany; telephone +4966196406403; email: jens.holst@pg.hs-fulda.de holst j. when the world depends on effective public health intervention – and public health does not deliver (editorial). seejph 2020, posted: 18 may 2020. doi: p a g e 2 | 7 abstract the covid-19 crisis offers both special opportunities and challenges for public health. the initial management of the pandemic was dominated by virologists, supported by epidemiologists who did not always meet indispensable scientific requirements. interdisciplinary and complex public health concerns and expertise, however, did not have tangible impact in the covid-19 debate. since social and other upstream determinants of health play a central role, public health is universal and goes beyond health security. as an explicitly political concept public health must safeguard its broad socio-political approach and obviate all tendency towards biomedical reductionism. keywords: biomedical reductionism, covid-19, health security, power, public health, public policy, social determinants of health. conflicts of interest: none declared. holst j. when the world depends on effective public health intervention – and public health does not deliver (editorial). seejph 2020, posted: 18 may 2020. doi: p a g e 3 | 7 the covid-19 challenge in view of the covid-19 challenge, analysists cannot agree more with the world’s dependence on “effective public-health interventions” as stated by josé martín moreno in the editorial to this edition of the south eastern european journal of public health (1). however, the long-term outcome for and the effect of the covid-19 crisis on public health as well as on global health remain uncertain. instead of strengthening public health, which can be seen the national breakdown of global health, the current handling of the pandemic worldwide rather threatens to become a challenge for public health. in any case, the covid-19 crisis has highlighted more clearly than ever the complex nature of public health and likewise of global health. but at the same time, it has revealed the extent to which biomedicine and biotechnology still dominate the debate. for weeks, politicians and the media provided the populations in many countries around the world with a mix of partly meaningless epidemiological figures, sorrowful scenarios and disturbing images of intensive care units. apart from “old” public health in the form of mainly national public health services and epidemiologists, the voice of public health as theory and practice of protecting and improving people’s health was hardly to be perceived during the first weeks of the covid19 pandemic. the infodemics associated with the global spread of covid-19 shows that the complexity and transdisciplinarity inherent to public health failed to achieve sufficient impact in the media and general public (2). even more so, good science in the sense of “old” public health was challenged even by a hitherto respected public-health institution, johns hopkins university in baltimore, by unleashing continuously updated absolute numbers of confirmed covid-19 cases, deaths and recoveries to the global public (3), and the world health organization did not shy away from confronting and comparing absolute numbers among different countries and populations (4). presenting and publishing absolute figures without the slightest idea of what the reference values are, counteracts the most basic concepts and conventions of old public health. meaningful epidemiological data require both a numerator and a denominator; however, the latter is absolutely missing as there is an unknown number of unreported cases (5), and data about the number of tests realised were initially unavailable and are still likely to be incomplete. moreover, even the numerator is doubtful due to a mix of under-reporting (people with or without symptoms who are not tested) and over-reporting (as not all patients who die with positive tests die from covid-19). the attempts to address this problem by using the term “deaths in connection with covid-19” reduces the meaningfulness of figures while creating another level of incompleteness, namely the under-reporting of collateral fatalities indirectly caused by covid-19 (6). pandemic challenging public health in spite of all declarations about the relevance of public health in a pandemic outbreak, it was not public and global health experts other than virologists and epidemiologists to become the second group to enter the global and national scenes. instead, economists and business experts were next on the scene creating awareness of economic consequences of lock-down decisions, and law experts warning about cuts of civil and human rights. only at a later stage did public health experts make a noticeable appearance. recent experience during the early phases of the covid-19 crisis has shown that the rapid succession of epidemic and even pandemic holst j. when the world depends on effective public health intervention – and public health does not deliver (editorial). seejph 2020, posted: 18 may 2020. doi: p a g e 4 | 7 outbreaks does not automatically contribute to shape the awareness of public health or global health. in contrast, the initial dominance of virologists and epidemiologists in media and political crisis management will end up weakening public health as a whole rather than strengthening it. it has to be stressed that public health comprises much more than health security. the concept of public health is per se universal, whereas security-oriented policies tend to focus on safeguarding the status quo, however inequitable and unfair it may be. this will also apply to innovative vaccines and medicines, which are extremely unlikely to be equally available for all people living on earth. the great importance decision makers attach to biomedical and biotechnical solutions compared to the determination with which they address social determinants of health will corroborate the hegemony of the global north and contribute to release the pressure to address the upstream determinants of pandemic outbreaks. the huge amounts of money invested in developing covid-19 vaccines (7) and the megatrial launched by who for accelerating the research on medicines to fight the current coronavirus pandemic (8) will primarily benefit the better-off part of the world’s population. strikingly, there is and will certainly not be any comparable research fund in sight for investigating the social, political, economic and ecological determinants of the pandemic. the prevailing biomedical reductionism tends to supplant calls for more community health efforts and marginalise the perspective of social medicine and social determinants of health (9,10). the prevalent concentration of public health policy on the spread of dangerous infectious diseases often lacks an indepth understanding of political, social and economic conditions and requirements. policies and health strategies in the context of the coronavirus pandemic do not fully grasp the complexity, interdiscipinarity and universality of (new) public health since they are increasingly determined by cross-border relations, international policy priorities and particularly by often hegemonic security concerns, and the securitisation of health is meanwhile considered a key feature of health governance (11). politicising instead of securitising global health the desire for security is well understandable in an increasingly inequitable, unstable and frightening world. however, it often remains unclear what is meant by security, who defines security and how it is to be created. it is not the criticism of the actual causes of global health crises such as the social, economic and political determinants of health that is at the centre of the debate, but the question of how efficiently a crisis can be managed without having to tackle the underlying causes. the prevailing concept of public health does not pursue the question of how to combat risks at their origin, but how to deal with future risks in such a way that they do not threaten the status quo or put at risk vested interests. the focus is mostly on how the health problems resulting from the living and environmental conditions can be identified and contained as early and far as possible, instead of changing them. neither are upstream determinants of health usually high on the health agenda, nor political priorities, power relations or the influence of stakeholders (12). public health is by no means immune to being instrumentalised for economic and political interests, it is rather interspersed with power relations (13), which health-related policies need to explicitly acknowledge (14). indeed, the existing power relations determine the predominant understanding of public health and global health to a much holst j. when the world depends on effective public health intervention – and public health does not deliver (editorial). seejph 2020, posted: 18 may 2020. doi: p a g e 5 | 7 greater extent than usually assumed or often discussed. the whole debate about global health governance, governance for global health and global governance for health (15) falls short in regard of analysing underlying power and power relations (16). the recent covid-19 reaction has exhibited an interesting policy shift: the short-term return of the strong state. after many years of spreading the neoliberal ideology and increasingly evicting the state from its responsibilities, the state reasserted its claim to political control with surprising clarity and decision. governments decided to intervene in individual and social life and to restrict economic and entrepreneurial freedom. for protecting people’s health, the lock-down and the interventions of the reinvigorated state appeared comprehensible, as they were scientifically justified. the state's regained strength vis-à-vis the private sector and even transnational corporations must be maintained beyond the covid-19 crisis. the state is the only entity capable of guaranteeing and enforcing the right to health as it is ultimately the only one accountable for human rights violations (17). for improving and safeguarding people’s health, public policies must be geared to the rights and legal entitlements of people, as laid down in the charta of human rights and in the who constitution. public health requires protecting those who are most in need the poor and the marginalised – from health risks and bad health by overcoming poverty, inequities and social injustice. as important as good medical care is, it has less influence on people’s health than their living, labour, income and environmental conditions, education, equal opportunities and social cohesion. even in times of pandemic outbreaks, public health must consistently follow its broad socio-political approach instead of being deviated towards biomedical reductionism (12). conclusion in a world gone upside down due to a pandemic outbreak, public health must not be reduced to the search for medicines and vaccines. it must make a case for health-in-all policies require addressing the social, economic, political and environmental causes of dangerous virus infections and all upstream determinants of health. this will inevitably clash with powerful players and vested interests, as it touches the core of today’s global economy, the prevailing growth model and ultimately the distribution of power. for coming out “more recognized and strengthened” (1), as concluded by josé martín moreno, public health has to become more explicit, more straightforward and ultimately more politicised. references 1. martín-moreno j. facing the covid-19 challenge: when the world depends on effective public health interventions. seejph 2020, xiv. doi: 10.4119/seejph-3442. 2. nielsen n. coronavirus: tech giants must stop covid-19 'infodemic', say doctors. euobserver 7. may 2020. available from: https://euobserver.com/coronavirus/148281 (accessed: may 10, 2020). 3. jhu. covid-19 dashboard by the center for systems science and engineering (csse). baltimore: johns hopkins university; 2020. available from: https://coronavirus.jhu.edu/map.html (accessed: may 10, 2020). 4. world health organization. who coronavirus disease (covid-19) dashboard. data last updated: 2020/5/11. geneva: who; 2020. available from: https://euobserver.com/coronavirus/148281 https://euobserver.com/coronavirus/148281 https://coronavirus.jhu.edu/map.html https://coronavirus.jhu.edu/map.html holst j. when the world depends on effective public health intervention – and public health does not deliver (editorial). seejph 2020, posted: 18 may 2020. doi: p a g e 6 | 7 https://covid19.who.int (accessed: may 10, 2020). 5. ebmnetzwerk. covid-19 – where is the evidence? berlin: german network for evidence-based medicine; 2020. available from: https://www.ebmnetzwerk.de/en/publications/covid19 (accessed: may 10, 2020). 6. kansagra a, goyal m, hamilton s, albers g. collateral effect of covid19 on stroke evaluation in the united states. n engl j med 2020. doi: 10.1056/nejmc2014816. available from: https://www.nejm.org/doi/pdf/10.105 6/nejmc2014816 (accessed: may 10, 2020). 7. schäferhoff m, yamey g, mcdade kk. funding the development and manufacturing of covid-19 vaccines: the need for global collective action. brooking, april 24, 2020. available from: https://www.brookings.edu/blog/future-development/2020/04/24/funding-the-development-and-manufacturing-of-covid19-vaccines-the-need-for-global-collective-action/ (accessed: may 10, 2020). 8. kupferschmidt k, cohen j. who launches global megatrial of the four most promising coronavirus treatments. science mag, march 22, 2020. available from: https://www.sciencemag.org/news/2020/03/wholaunches-global-megatrial-fourmost-promising-coronavirus-treatments (accessed: may 10, 2020). 9. aggleton p, parker r. moving beyond biomedicalization in the hiv response: implications for community involvement and community leadership among men who have sex with men and transgender people. am j public health 2015;105:15528. 10. adams v, behague d, caduff c, löwy i, ortega f. re-imagining global health through social medicine. glob public health 2019;14:1383-400. doi: 10.1080/17441692.2019.15876 39. 11. labonté r, gagnon m. framing health and foreign policy: lessons for global health diplomacy. glob health 2010;6:14. doi: 10.1186/1744-8603-6-14. 12. holst j. global health – emergence, hegemonic trends and biomedical reductionism. glob health 2020;16:42. doi: 10.1186/s12992-020-00573-4. 13. moon s. power in global governance: an expanded typology from global health. glob health 2019;15:74. doi: 10.1186/s12992019-0515-5 14. shiffman j. global 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https://www.sciencemag.org/news/2020/03/who-launches-global-megatrial-four-most-promising-coronavirus-treatments https://www.sciencemag.org/news/2020/03/who-launches-global-megatrial-four-most-promising-coronavirus-treatments https://www.sciencemag.org/news/2020/03/who-launches-global-megatrial-four-most-promising-coronavirus-treatments https://www.sciencemag.org/news/2020/03/who-launches-global-megatrial-four-most-promising-coronavirus-treatments holst j. when the world depends on effective public health intervention – and public health does not deliver (editorial). seejph 2020, posted: 18 may 2020. doi: p a g e 7 | 7 © 2020 holst; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. . nations high commissioner for human rights. world health organization; 2007. available from: https://www.ohchr.org/documents/publications/factsheet31.pdf (accessed: may 10, 2020). ____________________________________________________________ https://www.ohchr.org/documents/publications/factsheet31.pdf https://www.ohchr.org/documents/publications/factsheet31.pdf burazeri g, achterberg p. health status in the transitional countries of south eastern europe (editorial). seejph 2015, posted: 09 march 2015. doi 10.12908/seejph-2014-43 1 editorial health status in the transitional countries of south eastern europe genc burazeri 1,2 , peter achterberg 3 1 school of public health, university of medicine, tirana, albania; 2 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 3 national institute for public health and the environment (rivm), bilthoven, the netherlands. corresponding author: genc burazeri, md, phd, school of public health, university of medicine, tirana; address: rr. “dibres”, no. 371, tirana, albania; telephone: +355674077260; e-mail: gburazeri@yahoo.com burazeri g, achterberg p. health status in the transitional countries of south eastern europe (editorial). seejph 2015, posted: 09 march 2015. doi 10.12908/seejph-2014-43 2 the former communist countries of south eastern europe (see) have been undergoing a rapid process of transformation from state-enforced rigid economies to market-oriented societies in the past 25 years. however, these fast changes have unevenly affected various countries and different segments of the populations within each country (1). according to the world health organization (who) (2), the estimated life expectancy in albania in 2012 was the lowest in the region among females (75 years vs. 83 years in greece, which exhibited the highest female life expectancy in the see region) (table 1). the lowest value for male life expectancy in 2012 was observed in serbia (72 years) followed by albania, macedonia and montenegro (73 years). a remarkable difference compared with the other neighbouring countries is the particularly small female-to-male gap in life expectancy in albania, which in 2012 was only two years, whereas it varied in the other see countries between five years (for most of the countries) and seven years (in croatia) (table 1). this may suggest that smoking has not been very frequent in albanian males a few decades ago. as a matter of fact, some evidence from the who suggests that lung cancer mortality for albania in the 1980s was much lower than in many other european countries (3). the male-to-female difference in life expectancy in eastern european countries is strongly influenced by risk differences mainly smoking, alcohol abuse and road traffic accidents (3). table 1. life expectancy at birth for selected years in the countries of south eastern europe (source: who, world health statistics, 2014) country year: 1990 year: 2000 year: 2012 male female total male female total male female total albania 67 71 69 68 73 70 73 75 74 bosnia and herzegovina 70 75 73 72 78 75 75 80 77 croatia 69 76 73 71 78 74 74 81 78 greece 75 80 77 76 81 78 78 83 81 macedonia 70 75 72 71 76 73 73 78 76 montenegro 73 79 76 72 77 75 73 78 76 serbia 69 75 72 69 75 72 72 77 75 slovenia 70 78 74 72 80 76 77 83 80 according to the global burden of disease (gbd) 2010 study (4), the age-standardized mortality rate in albania in 2010 was comparable to montenegro and macedonia, which were all remarkably higher than greece and slovenia. the known positive association between a higher gdp and health outcomes such as life expectancy and lower standardized mortality rates is certainly of influence in the see region too. conversely, in 1990, interestingly, the agestandardized mortality rate in albania was the lowest in the region, except greece. one of the possible explanations for this “paradox” (that is the low mortality rate in the impoverished albania during communist rule) may relate to albanians earlier deploying a mediterranean diet which is assumed to have been particularly protective against cardiovascular deaths (5). regarding the total burden of disease, the age-standardized disability-adjusted life years (daly) in 2010 were the highest among albanian males and females compared with all the other counterparts in the see region (4). on the other hand, the age-standardized dalys in 1990 in albanian males resembled the average value of the see region. interestingly, in 1990, the burazeri g, achterberg p. health status in the transitional countries of south eastern europe (editorial). seejph 2015, posted: 09 march 2015. doi 10.12908/seejph-2014-43 3 overall dalys in slovenian males were higher than among their albanian counterparts – a trend which was entirely reversed two decades later (4). this is a clear indication of the differential impact of the political and socioeconomic transition on the health of different populations in see region (1). hence, the poorest countries of the western balkans exhibit an unfavourable health profile associated with the rapid socioeconomic transition, whereas the wealthier societies including especially slovenia and croatia manifest a gradual improvement in the health status of their respective populations. regarding the cause-specific mortality, according to the gbd 2010 study, the death rate from ischemic heart disease in albania is the highest in the see region (4), in line with dramatic changes in dietary patterns in the past two decades with an increase in processed foods which are rich in salt, sugar and saturated fats (6) and an increase in the prevalence of smoking (6). furthermore, albania is the only country in the region which has experienced an increase in the mortality rate from ischemic heart disease and cerebrovascular diseases in the past two decades (4) – indicating an early evolutionary stage of the coronary epidemic, which was observed many decades ago in the western countries. conversely, the age-standardized mortality rate from neoplasms in albania in 2010 was the lowest in the region (4). this is logical given the low lung cancer mortality rate in albania, which correlates with all-cancer mortality rate (3). in 2010, croatia and slovenia exhibited the highest death rates from neoplasms in the region (4). regarding diabetes, in 2010, the age-standardized mortality rate was the lowest in albania and greece, whereas in macedonia it was exceptionally high compared with all the other countries in the region (4) probably due to the high rates of obesity in this population. the age-standardized death rate from chronic obstructive pulmonary disease (copd) in albania in 2010 was one of the highest in the region, whereas the bordering montenegro exhibited the lowest death rates from this chronic condition (4). as for the major risk factors, the highest burden of disease in the see region due to smoking is observed in macedonia, whereas slovenia has made a remarkable achievement in the past twenty years in terms of lowering the burden of disease attributable to smoking almost by halve (4). this is a clear indication of the fact that changes during the transition period have differentially affected different countries in the see region. greece and slovenia have the lowest burden of disease due to sedentary behaviour, whereas serbia and especially macedonia have the highest burden of disease attributable to physical inactivity (4). however, valid and reliable information on physical activity is difficult to obtain. currently, serbia and macedonia bear the highest burden of disease due to overweight and obesity in the region, whereas slovenia and greece have the lowest (4). interestingly, in 1990, the age-standardized total burden of disease attributable to overweight and obesity in albania was, by far and large, the lowest in the region (greece excluded). twenty years later, however, albania resembled the average toll of the region (4). at the fall of the communist rule, a particularly high burden of disease due to high blood pressure (hbp) was observed in several yugoslavian republics including bosnia and herzegovina, croatia and especially macedonia (4). compared with the other countries of the region, the total burden of disease attributable to raised blood pressure in albania in 1990 was below the average of the see countries (4). twenty years later, the burden of disease due to hbp in albania was higher than the regional average. even worse, albania is the only country in burazeri g, achterberg p. health status in the transitional countries of south eastern europe (editorial). seejph 2015, posted: 09 march 2015. doi 10.12908/seejph-2014-43 4 the region which has not implemented a program to ensure an effective control and management of hypertension at a population level, in contrast with most of the former yugoslavian republics which have made a significant progress in this regard (2,4). in addition, croatia followed by macedonia had the highest burden of high cholesterol level at the fall of the communist regime, whereas albania had the lowest in the see region (4). on the contrary, two decades later, albania had the highest burden of disease due to hypercholesterolemia after macedonia. all countries of the see region except albania have made a significant progress regarding a considerable lowering of the toll of disease attributable to hypercholesterolemia. hence, croatia currently shows a twofold decrease, whereas slovenia has reduced by 2.5 times the cholesterol-related disease burden (2,4). interestingly, in 1990, the age-standardized burden of disease attributable to dietary risks in albania was the lowest in the see region, excluding greece. conversely, in 2010, the burden of disease due to dietary risks in albania was the highest in the region after macedonia (4). essentially, regardless of cross-country differences, a cluster of preventable risk factors (smoking, alcohol abuse, overweight, unhealthy diet, and lack of physical activity) are currently contributing in a very important way to the observed increase in the total burden of noncommunicable diseases in see countries such as cancer, heart disease, lung and liver diseases, and diabetes. therefore, preventing youths from starting to smoke and refraining from alcohol abuse and refraining from unhealthy diets and promoting their physical activity are major challenges for all the countries of see region. these challenges are now major additions to the older but not yet finished challenge of reducing the existing risks by the still relatively high rates of mortality from infectious diseases, accidents and injuries and perinatal problems in these countries. at a broader level and given the indicated quick changes and large potential differences in health status and health risks, the health information systems of most of the see countries need serious revival, improvement and renewal to allow for an adequate management and assessment of the health status of the respective populations. this includes the monitoring of preventive interventions and of essential steps in healthcare reforms. furthermore, better statistics, regular health surveys and improved healthcare administrative data will allow for better research into the quality of the health systems and health status of the populations in see countries and inequalities within the countries, similar to the approach employed by their eu counterparts. from this point of view, strengthening of the health information systems will significantly support better evidence-based health policy making and priority setting in all of the see countries. references 1. burazeri g, brand h, laaser u. public health research needs and challenges in transitional countries of south eastern europe. ijph 2009;6:48-51. 2. world health organization (who). world health statistics 2014. who. geneva: switzerland, 2014. 3. world health organization (who) – regional office for europe. european health for all database. copenhagen: denmark, 2014. burazeri g, achterberg p. health status in the transitional countries of south eastern europe (editorial). seejph 2015, posted: 09 march 2015. doi 10.12908/seejph-2014-43 5 4. institute for health metrics and evaluation (ihme). global burden of disease database. seattle, wa: ihme, university of washington, 2014. http://www.healthdata.org (accessed: february 27, 2015). 5. gjonca a, bobak m. albanian paradox, another example of protective effect of mediterranean lifestyle? lancet 1997;350:1815-7. 6. albanian institute of public health. national health report: health status of the albanian population. tirana, albania, 2014. http://www.ishp.gov.al/wpcontent/uploads/2015/01/health-report-english-version.pdf (accessed: march 03, 2015). ___________________________________________________________ © 2015 burazeri et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 1 of 17 review article maternal and new-born health policy indicators for low-resourced countries: the example of liberia vesna bjegovic-mikanovic1, raphael broniatowski2, stephen byepu3, ulrich laaser4 1 belgrade university, faculty of medicine, centre school of public health and management, serbia; 2 epos health management, bad homburg, germany; 3 inha university, incheon, korea and monrovia, liberia; 4 faculty of health sciences, university of bielefeld, germany. corresponding author: prof. vesna bjegovic-mikanovic, md, msc, phd; address: university of belgrade, faculty of medicine, centre school of public health and management, dr subotica 15, 11000 belgrade, serbia; telephone: +381112643830; e-mail: vesna.bjegovic-mikanovic@med.bg.ac.rs mailto:bjegov@med.bg.ac.rs bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 2 of 17 abstract aim: over the past two decades, two catastrophic events caused a steep decline in health services in liberia: the long-lasting civil war (1989-2003) and the weak response of the health system to the ebola viral disease (evd) outbreak (2013-2015). in early 2015 the liberian government reacted and developed a strategic health policy framework. this paper reviews that framework with a focus on maternal and newborn health. methods: the study is designed as a narrative review executed during the second half of 2017 in monrovia. it takes advantage of triangulation, derived from recent international and national documents, relevant literature, and available information from primary and secondary sources and databases. results: in 2015 the severely compromised health system infrastructure included lack of functional refrigerators, low availability of vaccines and child immunization guidelines, high stock-out rates, and an absence of the cold chain minimum requirements in 46% of health facilities. the public health workforce on payroll during 2014/15 included only 117 physicians. skilled birth attendance as an indicator of maternal health services performance was 61%. presently, approximately 4.5 women die each day in liberia due to complications of pregnancy, delivery, and during the post-partum period, equalling about 1,100 women per 100,000 live births. of particular note is the adolescent birth rate of 147 per 1000 women aged 15-19 years, three times higher than the world average of 44. additionally, with a neonatal mortality rate of 19.2 neonatal deaths per 1,000 live births, liberia stands higher than the world average as well. the high mortality rates are caused by multiple factors, including a delay in recognition of complications and the need for medical care, the time it takes to reach a health facility due to a lack of suitable roads and transportation, and a delay in receiving competent care in the health facilities. conclusions: the fact that performance is above average for some indicators and far below for other points to unexplained discrepancies and a mismatch of international and national definitions or validity of data. therefore, it is recommended to concentrate on the core of tracer indicators adopted at the global level for universal health coverage and the sustainable development goals to enable a permanent update of relevant information for policymaking and adjustment. at present all health policy documents miss a thorough application of the smart objectives (specific, measurable, attainable, relevant and timely), notably missing in most documents are realistic and detailed budgeting and obligatory timelines for set targets. keywords: health system, liberia, maternal and newborn health, maternal mortality, policies, strategies. bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 3 of 17 introduction the liberian population is comprised of the descendants of the immigration from the united states in the early 19th century and of 17 major tribal affiliations. half of the population lives in urban areas (1), the majority being christians, a minority of about one-tenth are muslims. the civil war from 1989 to 2003 generated a death toll of about 18% of the population of 4.5 million and nearly one million displaced persons (2). living standards dropped considerably also as a consequence of the weak response of the health system to the subsequent outbreak of ebola viral disease (evd) 2013-2015 (3). accordingly resources for health services missed the so-called abuja target of 15% (4) by 2.6 percentage points. a restart and overhaul of the health system became mandatory. health system oriented towards women and children obtained particular attention of the liberian government (5). the “global strategy for women’s, children’s and adolescents’ health” (2016-2030) (6) in the context of the agenda for sustainable development (7) identify 9 areas for ‘reproductive, maternal, newborn, children, and adolescent health’ (rmncah) policies, calling on governmental initiatives and country leadership, financing for health, health system resilience, individual potential, community engagement, multi-sector action, humanitarian and fragile settings, research and innovation, and accountability for results, resources and rights. similarly, universal health coverage identifies availability, accessibility, acceptability, and quality of services (8). these target areas for rmncah are of similar priority for almost all countries in the economic community of west african states (ecowas) as recently analyzed (9). our narrative review investigates maternal and new-born health policies. also, review addresses the basic components of reproductive health specific for liberia as an example for other low-resourced countries especially in west-africa: fertility (actual bearing of live offspring), safe motherhood (pregnancy and delivery without risk for own life and child's life), family planning, prevention of unwanted pregnancies and abortions, as well as characteristic diseases for women in their reproductive age. methods we make use of a combination of quantitative and qualitative methodologies. a participatory process involving governmental stakeholders through several interviews was particularly helpful and supportive in ensuring that issues were explored across sectors to provide a holistic understanding of the situation. also, the paper takes advantage of triangulation based on national and international sources and publications as well as on data and documents of the government of liberia predominantly the ministry of health and the liberia institute of statistics and geo-information services. we employ further the current methodology proposed by the maternal mortality estimation inter-agency group (mmeig) (10). the main framework of analysis is following steps of the policy cycle (11) as necessary, moving towards universal health coverage. all actual policy documents are analyzed looking at 1) agenda-setting with problem definition and situation analysis, 2) policy formulation with goals and objectives, 3) implementation by government action and 4) monitoring/evaluation with revised agenda setting. bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 4 of 17 results 1) review of health policy documents related to maternal & new-born health (mnh) the key documents in this context are the “investment plan for building a resilient health system 2015-2021” (12)in line with the “national health and social welfare policy and plan 2011–2021” (13). also, recently the ministry of health (moh) in cooperation with national and international partners drafted and endorsed a document, the “investment case for reproductive, maternal, neonatal, child and adolescent health 2016-2020” (14) aiming to support high impact intervention for improving mnh (maternal and newborn health). we have retrieved in total 28 policy documents, which all involve maternal and new-born health, either as a general or specific priority health problem under concern and in need for accelerated action (table 1), as maternal mortality in liberia is among the highest worldwide being 1,072/100,000 live-births during the seven years preceding the 2013 ldhs (15). according to the 2007 ldhs, maternal mortality was even slightly less than today being 994/100,000 (16). approximately 4.5 women die each day in liberia due to complications of pregnancy, delivery, and during the postpartum period (17), equalling about 11 women for every 1,000 live births. table 1. liberian policy documents embracing mnh no title of the policy document time frame source (internet pages or references) 1 national health and social welfare policy and plan  national health and social welfare policy  national health and social welfare plan 2011-2021 http://moh.gov.lr/category/policies/ 2 national health and social welfare financing policy and plan 2011-2021 http://moh.gov.lr/category/policies/ 3 national human resources policy and plan for health and social welfare 2011-2021 http://moh.gov.lr/category/policies/ 4 national health and social welfare decentralization policy and strategy 2011-2021 not online 5 investment plan for building a resilient health system 2015-2021 http://moh.gov.lr/cabinet-endorses-investmentplan-for-building-a-resilient-health-system/ 6 investment case for reproductive, maternal, new-born, child, and adolescent health 2016-2020 http://www.globalfinancingfacility.org/sites/gff _new/files/documents/liberia%20rmncah% 20investment%20case%202016%20%202020.pdf 7 liberia community health road map 2014-2017 not online 8 revised national community health services strategic plan 2016-2021 not online 9 national policy and strategic plan on health promotion 2016-2021 http://www.afro.who.int/en/liberia/liberiapublications.html 10 national hiv & aids strategic plan 2015-2020 http://www.nacliberia.org/doc/liberia%20nsp %2020152020%20final%20_authorized_%20ok.pdf 11 national malaria control program. malaria communication strategy 2016-2020 http://www.thehealthcompass.org/sites/default/f iles/project_examples/liberia%20nmcs%2020 16-2020.pdf 12 national leprosy and tuberculosis strategic 2014-2018 http://www.lcm.org.lr/doc/tb%20and%20lepr http://moh.gov.lr/category/policies/ http://moh.gov.lr/category/policies/ http://www.afro.who.int/en/liberia/liberia-publications.html http://www.afro.who.int/en/liberia/liberia-publications.html http://www.nacliberia.org/doc/liberia%20nsp%202015-2020%20final%20_authorized_%20ok.pdf http://www.nacliberia.org/doc/liberia%20nsp%202015-2020%20final%20_authorized_%20ok.pdf http://www.nacliberia.org/doc/liberia%20nsp%202015-2020%20final%20_authorized_%20ok.pdf http://www.thehealthcompass.org/sites/default/files/project_examples/liberia%20nmcs%202016-2020.pdf http://www.thehealthcompass.org/sites/default/files/project_examples/liberia%20nmcs%202016-2020.pdf http://www.thehealthcompass.org/sites/default/files/project_examples/liberia%20nmcs%202016-2020.pdf http://www.lcm.org.lr/doc/tb%20and%20leprosy%20strategic%20plan%202014-2018%20consolidated%20(1)%20(1).pdf bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 5 of 17 plan osy%20strategic%20plan%2020142018%20consolidated%20(1)%20(1).pdf 13 the national traditional medicine policy and strategy (2015-2019) 2015-2019 http://moh.gov.lr/category/policies/ 14 strategic plan for integrated case management of neglected tropical diseases (ntds) 2016-2020 not online 15 consolidated operational plan (fy 2016/17) 2016-2017 http://moh.gov.lr/wpcontent/uploads/2017/04/operational-plan_fy17_-martin.pdf and: http://www.seejph.com/public/books/consolidat ed_operational_plan_2016-17.pdf 16 joint annual health sector review report 2016. 2016 http://www.seejph.com/public/books/joint_ann ual_health_sector_review_report_2016.pdf 17 family planning 2020 commitment 2011-2020 http://ec2-54-210-230-186.compute1.amazonaws.com/wpcontent/uploads/2016/10/govt.-of-liberiafp2020-commitment-2012.pdf 18 national gender policy 2010-2020 2010-2020 http://www.africanchildforum.org/clr/policy%2 0per%20country/liberia/liberia_gender_2009_e n.pdf 19 national therapeutic guidelines for liberia and essential medicine list 2011 ongoing https://www.medbox.org/countries/nationaltherapeutic-guidelines-for-liberia-and-essentialmedicines-list/preview?q= 20 essential package of health services (ephs) 2011 ongoing http://apps.who.int/medicinedocs/documents/s1 9420en/s19420en.pdf 21 road map for accelerating the reduction of maternal and new-born morbidity and mortality in liberia (2011-2015)(18) 2011-2015 ministry of health and social welfare, republic of liberia. roadmap for accelerating the reduction of maternal and new-born mortality 2011-2015 (an updated version of the original publication in 2007). monrovia, liberia: ministry of health, 2011. 22 accelerated action plan to reduce maternal and neonatal mortality 2012-2016 (19) 2012-2016 ministry of health and social welfare, family health division. accelerated action plan to reduce maternal and neonatal mortality. monrovia, liberia: ministry of health and social welfare, 2012 july. 23 the national roadmap for maternal mortality reduction “the reach every pregnant woman (rep) strategy” 2007 http://apps.who.int/pmnch/media/events/2013/li beria_mnh_roadmap.pdf 24 national strategy for child survival in liberia 2008-2011 http://liberiamohsw.org/policies%20&%20plans /national%20strategy%20for%20child%20sur vival.pdf 25 national sexual & reproductive health policy 2010 http://liberiamohsw.org/policies%20&%20plans /national%20sexual%20&%20reproductive%2 0health%20policy.pdf 26 poverty reduction strategy 2008 http://www.emansion.gov.lr/doc/final%20prs. pdf 27 national policy and strategic plan on integrated vector management 2012-2017 http://pdf.usaid.gov/pdf_docs/pa00j21w.pdf 28 liberia health system assessment (20) 2015 ministry of health, republic of liberia. liberia health system assessment. monrovia, liberia: ministry of health, 2015. http://www.lcm.org.lr/doc/tb%20and%20leprosy%20strategic%20plan%202014-2018%20consolidated%20(1)%20(1).pdf http://www.lcm.org.lr/doc/tb%20and%20leprosy%20strategic%20plan%202014-2018%20consolidated%20(1)%20(1).pdf http://moh.gov.lr/category/policies/ http://ec2-54-210-230-186.compute-1.amazonaws.com/wp-content/uploads/2016/10/govt.-of-liberia-fp2020-commitment-2012.pdf http://ec2-54-210-230-186.compute-1.amazonaws.com/wp-content/uploads/2016/10/govt.-of-liberia-fp2020-commitment-2012.pdf http://ec2-54-210-230-186.compute-1.amazonaws.com/wp-content/uploads/2016/10/govt.-of-liberia-fp2020-commitment-2012.pdf http://ec2-54-210-230-186.compute-1.amazonaws.com/wp-content/uploads/2016/10/govt.-of-liberia-fp2020-commitment-2012.pdf http://www.africanchildforum.org/clr/policy%20per%20country/liberia/liberia_gender_2009_en.pdf http://www.africanchildforum.org/clr/policy%20per%20country/liberia/liberia_gender_2009_en.pdf http://www.africanchildforum.org/clr/policy%20per%20country/liberia/liberia_gender_2009_en.pdf https://www.medbox.org/countries/national-therapeutic-guidelines-for-liberia-and-essential-medicines-list/preview?q https://www.medbox.org/countries/national-therapeutic-guidelines-for-liberia-and-essential-medicines-list/preview?q https://www.medbox.org/countries/national-therapeutic-guidelines-for-liberia-and-essential-medicines-list/preview?q http://apps.who.int/pmnch/media/events/2013/liberia_mnh_roadmap.pdf http://apps.who.int/pmnch/media/events/2013/liberia_mnh_roadmap.pdf http://liberiamohsw.org/policies%20&%20plans/national%20strategy%20for%20child%20survival.pdf http://liberiamohsw.org/policies%20&%20plans/national%20strategy%20for%20child%20survival.pdf http://liberiamohsw.org/policies%20&%20plans/national%20strategy%20for%20child%20survival.pdf http://www.emansion.gov.lr/doc/final%20prs.pdf http://www.emansion.gov.lr/doc/final%20prs.pdf bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 6 of 17 the most recent situation analysis is presented in the “liberia service availability and readiness assessment and quality of care report (sara and qoc)” (21), while the most recent documents covering mnh policy implementation are the “joint annual health sector review report 2016” (22) and the “consolidated operational plan (fy 2016/17)” (23). the most important of the documents listed in table 1 is the investment plan (number 5) for the period 2015-2021 making use of the more recent data of the dhs 2013. the political decision-maker drafting it employed the mdg targets and indicators (24) but not yet the more recent sdg indicators (25). the method of stating targets is not explained, in spite of the recommendation to tailor targets towards local context and embrace a more realistic approach. as an example, liberian policymakers envisioned a goal to reduce maternal mortality by three quarters between 1990 and 2015 as set in mdg-5. that would be equal to looking at the upper bound level in 1990 (figure 1 below) – 1,980 maternal deaths to be reduced to 495 per 100,000 live-births in 2015, which is at the same time close to the national target of 497 maternal deaths per 100,000 live-births set as a desirable goal only for 2021. due to such weaknesses and inconsistencies, it may be assumed that the selection of liberian objectives and targets in these documents often have been set at random. such assumption is mirrored in the recent mgds assessments (26) that criticize too ambitious mdgs, which do not take into account infrastructure and health system capacity in general, which is a strong request of the global strategy for women’s, children’s and adolescents’ health (2016-2030) (27-29). to enhance increased investment into health systems of resource-limited countries, ihp+ has been transformed into the international health partnership for universal health coverage (uhc) 2030, based on the 2005 paris declaration on aid effectiveness and the 2011 busan partnership agreement(30).during the first meeting of the uhc-2030 working group in march 2017 (31), the main focus was on low and middle-income countries facing many threats to their health systems including decrease in the external financial support. liberia potentially faces similar threats in the near future but joined ihp+ only in march 2016, however, a significant amount of donor support (about 75%) (32) remains off-budget with various parallel implementation arrangements. nevertheless, progress is visible in spite of the recent ebola crisis (2014/15), mainly due to the efforts of the liberian government to implement an essential package of health services (ephs) since 2011 (33,34). 2) analysis of maternal and neonatal mortality looking at time trends, from 1985 to 2015 (figure 1), the period of the first civil war (1989-1996) was when maternal mortality experienced a peak. in 1994 mortality ratios were 1,890 deaths per 100,000 livebirths (with the upper bound of 2,470 and a lower bound of 1,320). after a significant recovery, the second civil war (1999-2003) again caused a negligence to mnh and retardation of improvement. today liberian reproductive women have a 3 times higher chance than the average global population of women to experience premature death due to complications during pregnancy, delivery, and the postpartum period. between 2000 and 2015, the global maternal mortality ratio, or a number of maternal deaths per 100,000 live births, declined by 37 percent to an estimated ratio of 216 per 100,000 live births in 2015. in liberia maternal bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 7 of 17 mortality in the same period declined by 43% from 1,270 to an estimated ratio of 725 per 100,000 live births in 2015, indicating considerable improvement since the civil wars ended, although still higher than the global average. the national data based on the dhss published in 2008 and 2013 represent maternal mortality during the 7 preceding years. the main reason for differences is insufficient death statistics in liberia, with many failing to register the majority of causes of deaths in the population. the liberian moh information summarises: “the liberian public health law of 1976 mandates the moh to register all deaths within 24 hours. as a result of inadequate access, the coverage of registration has always been below 5% annually. death certificates are usually processed in liberia with the intent to obtain insurance benefits, to settle inheritance issues and not as a requirement for burial and documentation of the cause of death.” (35).as an example: in 2013, only 659 deaths were registered according to the rules. figure 1. maternal mortality ratio in liberia (9,15) data on maternal mortality presented in figure 1 are obtained from databases maintained by the who, undp, unicef, and world bank group. some of the earlier policy documents stated several reasons for high maternal mortality rates mainly related to the insufficient quantity and quality of the liberian human resources for health and health facilities’ performance (36). some of the problems cited were an inadequate number of skilled human resources for health in general and of experienced,skilled birth attendants specifically also inadequate emergency obstetric and new-born care services, inadequate referral mechanisms, inadequate essential drugs, equipment, and supplies were cited. the major non health factors include a lack of clearly defined community referral, lack of health financing mechanisms, and socio-cultural 994 1072 0 500 1000 1500 2000 2500 1 9 8 5 1 9 8 6 1 9 8 7 1 9 8 8 1 9 8 9 1 9 9 0 1 9 9 1 1 9 9 2 1 9 9 3 1 9 9 4 1 9 9 5 1 9 9 6 1 9 9 7 1 9 9 8 1 9 9 9 2 0 0 0 2 0 0 1 2 0 0 2 2 0 0 3 2 0 0 4 2 0 0 5 2 0 0 6 2 0 0 7 2 0 0 8 2 0 0 9 2 0 1 0 2 0 1 1 2 0 1 2 2 0 1 3 2 0 1 4 2 0 1 5 2 0 1 6 lower bound (80% ui) point estimate upper bound (50% ui) ldhs bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 8 of 17 inequities. there are significant delays which also contribute to maternal and newborn mortality: delays in recognition of danger signs and making the decision to seek health care, delays in reaching a health facility via an insufficient road system (37), and delays in receiving care at the health facility. consequentially, the leading causes of maternal deaths are haemorrhage (25%) and hypertension (16%) followed by sepsis and abortion (each 10%). the next important indicator of mnh in the sdg framework is neonatal mortality. with 24.1 neonates’ deaths up to 28 days per 1,000 live-births, liberia is still above the world average (19.2 per 1,000 livebirths). however, the historical decrease in neonatal mortality is significant (figure 2). the main causes of neonatal deaths are preterm birth complications (10%) and intrapartum related events: asphyxia (9%), and sepsis (8%). figure 2. neonatal mortality rate in liberia (15,38) 48.3 47 46.1 45 43.8 43.3 42.5 41.9 40.7 39.1 37.3 35.5 33.8 32.1 30.6 29.1 27.5 26.2 24.8 23.4 22.1 20.8 19.5 18.6 17.6 16.7 57 55.5 54.3 52.9 52 51.1 50.3 49.1 47.4 45.6 43.7 41.7 39.7 37.9 36.2 34.5 32.9 31.3 29.9 28.6 27.6 26.8 26 25.3 24.7 24.1 66.9 65.4 63.8 62.4 61 59.7 58.6 57 55.1 52.9 50.8 48.4 46.3 44.2 42.2 40.4 38.7 37.1 35.7 34.8 34.2 34.1 34.1 34.4 34.5 34.8 0 10 20 30 40 50 60 70 80 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 lower median upper per 1,000 live-births years legend: lower, median and upper refer to the lower, median and upper bound of a 90% uncertainty interval. despite these results, policymakers should carefully consider whether the relatively low neonatal mortality could be due to the insufficient liberian deaths registration (potential entrap of under-registration). the framework for sdg monitoring includes 27 indicators for monitoring of bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 9 of 17 sdg-3 (“ensure healthy lives and promote well-being for all at all ages”), out of which a group of 16 indicatorsis directly related to health status (39). though all indirectly are relevant for mnh, a particularly important indicator, within sdg-3, is the adolescent birth rate per 1,000 women aged 15-19 years. the main rationale for the recognition of this indicator is: “preventing unintended pregnancy and reducing adolescent childbearing through universal access to sexual and reproductive health-care services are critical to further advances in the health of women, children, and adolescents. childbearing in adolescence has steadily declined in almost all regions, but wide disparities persist: in 2015, the birth rate among adolescent girls aged 15 to 19 ranged from 7 births per 1,000 girls in eastern asia to 102 births per 1,000 girls in sub-saharan africa” (40). in liberia, this rate was even higher in 2015 and also higher than in ecowas and the african region. with 147 adolescent girls per 1,000 aged 15-19 years who gave birth to a baby, liberian female population is at 3 times higher risk in this regard than the world average (44.1 per 1,000) (41). 3) status of health services the second group of relevant indicators for the situation analysis of mnh in relation to sdg-3 is related to health system strengthening. these indicators refer to health system structure, quality, and effectiveness of performance, which holds a prominent place in the situation analyses of many liberian health policy documents. the investment plan for building a resilient health system (2015-2021) has been marked already as one of the best health policy documents in liberia. following this report (3), the public health workforce on payroll, during 2014/15, included only 117 physicians, 436 physician assistants, 2,137 nurses (rn/lpn), and 659 midwives (1.2 per 10,000 population). also 2,856 trained traditional midwives (ttm) are listed. ttms belong to the corpus of 8,052 community health volunteers (based on the 2013 mapping exercise). today, health workers’ density varies significantly between counties in liberia, the lowest being in nimba and the highest in bomi. though improvement in quantity is visible from 2010 to 2015, still numbers are far below the levels proposed by who to avoid critical shortage: 23 health workers per 10,000 are considered as necessary to secure essential maternal and child health services to the entire population (42).the roadmap for scaling up human resources for improved health service delivery in the african region 2012-2025 has determined the same threshold (43). skilled health professionals’ density is 25 per 10,000 globally, but in liberia almost nine times less (2.9 per 10,000). the difference stems partly from different definitions of a skilled health professional, and consequently, different counting in who and national statistics. for international comparison, who includes as skilled health professionals only the following: nurses, midwives and physicians (44). there liberia with 2.9/1.000 is the fourth to last place in the ecowas community and much below its nationally calculated average of 6.4/1.000 of skilled health professionals. maternal health services performance assessed by the proportion of births attended by skilled health personnel in liberia at 61% is better than the ecowas average of 57% and the average of the african region. according to these statistics, liberia still performs at a lower level than the global average where 3 out of 4 births (73%) were assisted by skilled health-care personnel in 2015. performance is above average for some bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 10 of 17 indicators and far below for others (e.g., maternal vs. neo-natal mortality), the disparity points to unexplained discrepancies and mismatch of international and national definitions or validity of data. for example a comparison of maternal and neonatal mortality throughout historical periods in liberia is misleading: researchers and authors of ldhs-2013 (page 285) (45) have rightfully warned that comparison is possible only with ldhs-2007, due to the fact that methods of estimates were significantly changed in 2007 and cannot serve for comparison with previous surveys – lsdh-1999/2000. furthermore, the interpretation of indicators does not account for the fact that ldhs provides direct estimates of maternal mortality for the seven years preceding each survey. finally, a tracer indicator, relevant for mnh and sdg-3, may serve to describe the status of the liberian health system and its infrastructure best: “infants receiving three doses of hepatitis b vaccine”. in liberia, only 50% of children received the vaccination in 2014 (46) (ecowas average 78%). such situation is well explained in a national situation analysis (47) as a consequence of the evd crisis (with declines not only of immunizations but also all other mnh services). the recent sara report (48) clarifies the situation by severely compromised health system infrastructure: lack of functional refrigerators, low availability of vaccines and child immunization guidelines, high stock-out rates, and absence of the cold chain minimum requirements in even 46% health facilities. 13% are also without direct access to water, 43% without incinerator, and 45% without regular electricity. discussion a main observation with regard to this policy analysis is that significant weaknesses of the national policy documents derive from missing links between objectives, realistic and measurable targets, activities with a quantifiable input, precise and controlled timelines for their implementation, and appropriate reliable budgetary allocation (49). an example of necessary links is given in figure 3. furthermore, liberia (in spite of the country’s low capacity) could use available opportunities to improve the insufficient registration of birth and death events. an immediate option is provided by the multiple indicator cluster survey (mics), organized and funded by unicef. preparation for the mics 6 is ongoing in many countries (50), while liberia implemented only the first round in 1995, with only three counties at the time (montserrado, parts of margibi and bassa) though with 60% of the total liberian population living in the same areas) (51). mics is a valuable data source covering the reproductive health of women, health outcomes for children and adolescents, child mortality, education, water, and sanitation. bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 11 of 17 figure 3. the complex linkage between a health problem, its determinants, areas of intervention, the regulatory framework and smart activities organise all donor conference/ compact upgrade facilities and replace outdated equipment curriculum update increasing study places supervised fieldwork guaranty 24/7 secure reimbursement reliable salaries and incentives reconsider ttm role and reduce waiting time accreditation of colleges/ schools obligatory ce for midwifery employing sufficient midwifery staff secure emonc services at all levels high maternal mortality staff quantity and qualification low connectivity, lack of (solar) electricity and tape water insufficient transport capacity & lack of maternal waiting homes availability of staff at point of access motivation of midwifery staff health problem: the maternal mortality rate in liberia was 1072/100,000 life-births in 2013. potential intervention areas determinants health problem regulatory changes smart activities developing workforce for maternal health planning workforce for maternal health define ce courses based on the model healthy plan-ittm of cdc atlanta. a final evaluation will only be possible upon completion of all planned activities in 2021. liberian moh policymakers should consider more closely (during monitoring activities) the international developments, which received a final endorsement in 2017. the universal health coverage (uhc) indicators for the sustainable development goals (sdgs) monitoring framework have been agreed on march 13, 2017 (52). the global indicator framework has been formally adopted by the united nations general assembly through the united nations economic and social council and will be instrumental for the national and international monitoring, evaluation,and comparison of achievements. particularly relevant for liberia is the sdg index, with tracer indicators that serve both for health workforce and health services’ monitoring. the index comprises only 12 indicators and serves for both national and international comparisons. the latest examples of such utilization can be found in the global strategy on human resources for health – workforce 2030 and the global strategy for women’s, children’s and adolescents’ health (2016-2030). conclusions and recommendations there are well-developed strategies in almost all health areas,but most of them are missing defined action plans with publicized targets following smart principles, therefore correspondingly there bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 12 of 17 is a severe gap in implementation. also, data used should be referenced, crosschecked, and critically evaluated regarding reliability and validity. it is recommended to go beyond simple presentation and analyze differences in outcomes for statistical significance, including multiple regressions to identify significant determinants of health outcomes. analyses and the discussion of their results should always be compared to west african, african, and global parameters, not restricted to the national perspective. for intra-national comparisons, the same data sources have to be used as otherwise comparability and conclusions are jeopardized. it is further recommended to initiate as soon as possible a process of developing new health policy documents in liberia for implementation after 2021 by moh stakeholders, involving inter-sectoral representation and independent expertise. a multidisciplinary team of health policymakers should analyze opportunities and strengths, based on existing national development plans (especially the liberia agenda for transformation: steps towards liberia rising 2030 (53)). the main intention is to have health policy documents fitting the local context and the new movement towards sdgs, strictly applying smart principles, especially obligatory timelines and budgetary allocation as a key element of the smart principle in realistic planning. acknowledging the local context, already now a first step could be the revision of the national health and social welfare decentralization policy and strategy:  development of a roadmap 2030 for the sdgs, which will allow for implementation and monitoring after 2021 (providing transparency of fragmented implementation and a database of ongoing projects in counties) is one of the immediate tasks for the liberian moh.  strengthening of policy planning at the county level is also a priority in policy formulation, preferably by using one of the proven models for programme planning, such as healthy plan-ittm by cdc (atlanta).  invited international expertise should be given full access to data, and technical assistance should have access (observer status) to policy meetings like the health sector coordination committee (hscc) and the pool-fund meetings (as otherwise a lateral and vertical information exchange within the moh is severely inhibited). derived from liberian health policy documents, the situation analysis, and the literature review, the following areas may be prioritized regarding mnh services (54):  ensure timely, equitable, respectful, evidence-based, and safe maternal– perinatal health care, delivered through context-appropriate implementation strategies;  build linkages within and between maternal–perinatal and other healthcare services to address the increasing diversity of the burden of poor maternal health;  increase the resilience and strength of health systems by optimizing the health workforce and improving facility capability;  guarantee sustainable financing for maternal–perinatal health; and  accelerate progress through evidence, advocacy, and accountability by: developing improved metrics, and support implementation research to promote accountable, evidencebased maternal health care and bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 13 of 17 translating evidence into action through effective advocacy and accountability for maternal health. finally, there is a significant opportunity for liberia and all african countries to make use of the new who leadership and dr. tedros adhanom ghebreyesus, who director-general, who recently pointed out (55): “universal health coverage is ultimately a political choice. it is the responsibility of every country and national government to pursue it. countries have unique needs, and tailored political negotiations will determine domestic resource mobilisation. who will catalyse proactive engagement and advocacy with global, regional, and national political structures and leaders including heads of state and national parliaments”. conflict of interest: none declared. ethical approval: not required as this paper does not contain any studies with human participants or animals performed by any of the authors. funding: this work has been done in the framework of project funding by the european commission: technical assistance to support the implementation of the national health plan and the roadmap for the reduction of maternal mortality in liberia (fed/2014/351/044). acknowledgments: the authors are grateful to the ministry of health of the republic of liberia, to richard gargli and roosevelt mccaco in monrovia for their help in identifying the relevant publications, and to nelson chase for english editing. references 1. lisgis. republic of liberia 2008 population and housing census. analytic report on population size and composition. monrovia, liberia: liberia institute of statistics and geoinformation services 2011. available from: https://www.lisgis.net/pg_img/populatio n%20size%20210512.pdf (accessed: august 15, 2019). 2. ministry of health and social 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transformation: steps towards liberia rising 2030; 2016. https://www.mfdp.gov.lr/index.php/nati onal-development-plan (accessed: august 15, 2019). 54. koblinsky m, moyer ca, calvert c, campbell j, campbell om, feigl ab,at al. quality maternity care for every woman, everywhere: a call to action. the lancet 2016;388:230720.available from: http://dx.doi.org/10.1016/s01406736(16)31333-2 (accessed: august 15, 2019). 55. who. all roads lead to universal health coverage. available from: http://www.who.int/mediacentre/comme ntaries/2017/universal-healthcoverage/en/ (accessed: august 15, 2019). © 2019 bjegovic-mikanovic et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. thomas-reilly rg, tozija f, soltan v, nikovska dg, crudu v, atun r, mckee m. multidrug-resistant tuberculosis in moldova and the former yugoslav republic of macedonia: the importance of the overall governance of the health systems (original research). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-85 1 original research multidrug-resistant tuberculosis in moldova and the former yugoslav republic of macedonia: the importance of health system governance r. gregory thomas-reilly 1 , fimka tozija 2 , viorel soltan 3 , dance g. nikovska 2,4 , valeriu crudu 3,5 , rifat atun 6 , martin mckee 1 1 london school of hygiene & tropical medicine, london, united kingdom; 2 ss. cyril & methodius university, skopje, the former yugoslav republic of macedonia; 3 center for health policies & studies, chisinau, moldova; 4 ministry of health, republic of macedonia; 5 phthisiopneumology institute, chisinau, moldova; 6 harvard university, cambridge ma, usa. corresponding author: r. gregory thomas-reilly ba, bscn, mscpph, pgdip, phd; address: 331 st. patrick street, ottawa, ontario, canada, k1n 5k6; telephone: +1613-315-0900 ; email: greg.thomas-reilly@lshtm.ac.uk thomas-reilly rg, tozija f, soltan v, nikovska dg, crudu v, atun r, mckee m. multidrug-resistant tuberculosis in moldova and the former yugoslav republic of macedonia: the importance of the overall governance of the health systems (original research). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-85 2 abstract aim: multidrug-resistant tuberculosis (mdr-tb) arises where treatment is interrupted or inadequate, when patients are treated inappropriately, or when an individual has impaired immune function, which can lead to a rapid progression from infection with an mdr-strain to disease. this study examines the role of health systems in amplifying or preventing the development of mdr-tb. methods: we present two comparative studies, which were undertaken in the former yugoslav republic of macedonia (tfyr macedonia) and moldova. results: the findings reveal several health systems-level factors that contribute to the different rates of mdr-tb observed in these two countries, including: pre-existing burden of disease; organization of the health system, with the existence of parallel systems; power dynamics among policy makers and disease programmes; and the accountability & effectiveness of programme oversight. conclusions: the findings do not offer a universal template for health system reform but do identify specific factors that may be contributing to the epidemic and are worthy of further attention in the two countries. keywords: drug-resistance, europe, health systems, mdr-tb, moldova, the former yugoslav republic of macedonia, tuberculosis. conflicts of interest: none. acknowledgements: this study was funded by the global fund to fight aids, tb and malaria. rgt-r was supported by a graduate teaching fellowship from the london school of hygiene and tropical medicine. thomas-reilly rg, tozija f, soltan v, nikovska dg, crudu v, atun r, mckee m. multidrug-resistant tuberculosis in moldova and the former yugoslav republic of macedonia: the importance of the overall governance of the health systems (original research). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-85 3 introduction multi-drug resistant tuberculosis (mdr-tb) is now a major problem in parts of europe (1). resistance arises when treatment regimens are interrupted or inadequate or when treatment is blind to the sensitivity of infecting organisms, allowing bacilli resistant to a single drug to reproduce. these conditions are most often found where health systems are weak (2) or inappropriately designed (3), providing some treatment, but not in a way that ensures that it is taken appropriately. in this study we use a comparative case design to gain insights into why two otherwise similar countries, moldova and tfyr macedonia, differ significantly in their burdens of tb and patterns of drug-resistance (table 1). table 1. surveillance data from macedonia, moldova, and the european region in 2013 (source: european center for disease prevention and control) indicator macedonia moldova non-eu/eea european region new tb cases 346 4,203 194,913 success n (%) 298 (86.1) 3,205 (76.3) 146,404 (75.1) died n (%) 28 (8.1) 418 (9.9) 14,203 (7.3) failed n (%) 3 (0.9) 125 (3.0) 12,312 (6.3) lost to follow up n (%) 16 (4.6) 331 (7.9) 12,843 (6.6) not evaluated n (%) 1 (0.3) 124 (3.0) 9,151 (4.7) laboratory confirmed 188 2,695 117,802 drug sensitivity testing n (% of those confirmed) 179 (95.2) 2,317 (86.0) 108,746 (92.3) mdr-tb n (% of those confirmed) 1 (0.5) 912 (33.8) 33,686 (30.9) xdr-tb n (% of those confirmed) 0 35 (1.2) 393 (0.3) tb case notification rate / 100,000 population 15.3 144.8 12.7 the notification rate in moldova per 100,000 population is almost ten times higher than in macedonia, where it is only slightly higher than the non-eu/eea countries of europe. the treatment success rate is about ten percentage points higher in macedonia than moldova. a third of laboratory confirmed infections in moldova (n=912) in 2013 were multi-drug resistant (mdr), with only one case in macedonia. in the same year moldova had 35 cases that were extensively drug resistant (xdr), while macedonia had none. methods we undertook an in-depth comparative case study (4). data were triangulated from a range of sources including documentary evidence, such as statistical reports, action plans, and activity reports, and interviews with key informants. key informants were identified using theoretical and snowball sampling to obtain a broad range of insights and perspectives (5). interviews were semi-structured, including open-ended questions, and were recorded, with contemporaneous notes taken. interviews continued until data saturation was achieved. field notes were kept throughout the research. letters were sent to key informants outlining the purpose of the research. this sought to ensure “buy-in”, both at individual and organizational levels. an initial conceptual framework, based on a literature review, was developed to identify systems-level drivers of mdr-tb but then refined during the interviews. we interviewed 23 (100% response) informants in macedonia, and 20 (55.6% response, 11% declined or cancelled, 33% did not respond) in moldova. details of those interviewed are presented in table 2. however, data saturation was achieved in both countries, with no new thomas-reilly rg, tozija f, soltan v, nikovska dg, crudu v, atun r, mckee m. multidrug-resistant tuberculosis in moldova and the former yugoslav republic of macedonia: the importance of the overall governance of the health systems (original research). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-85 4 themes arising after about 15 interviews, although further clarification and factual information was obtained in subsequent interviews. the participants were equally open, reflective and critical in both countries. table 2. characteristics of those interviewed category macedonia (n=23) moldova (n=20) stewardship (leadership responsibilities within the health system) senior managers within the tb system vice-minister of health senior managers & directors from the ministry of health hospital directors former deputy minister of health senior administrators in the penitentiary health sector national health insurance fund government administrators / managers n= 10 n=10 service delivery (responsibility for service provision within the health system) tb physicians tb physicians hiv/aids physicians general physicians tb patronage & public health nurses tb patronage & public health nurses prison health care staff pharmacists n= 10 n=6 non-government (representatives from various non-government organisations, with a defined focus, work or interest in tb issues) non-governmental organization working with vulnerable populations community agencies working with prisoners global fund country office who country representative national physicians association academic specialist in public health n= 3 n=4 this study received approval from the ethics committee of the london school of hygiene & tropical medicine and from corresponding ethics committees in each country. informed consent was obtained from each participant, prior to the initiation of data collection. all information was made available to participants in their language of choice. results the results from each country were categorised into primary and secondary themes, according to the consistency with which respondents presented topics, the emphasis that they placed on them, and the differences observed between the two countries. the primary (emerging) themes were: (i) pre-existing burden of (tb) disease; (ii) organisation of the health system; (iii) existence of parallel health systems; (iv) degree of accountability and oversight exercised within the system; and (v) power and relationships. pre-existing burden of disease respondents felt strongly that the pre-existing burden of disease contributed to the current epidemiology. however, in the early 1990s, when each country achieved independence, incidence rates were very similar (6) (figure 1). another aspect related to disease burden, raised by some informants in moldova but not in tfyr macedonia, was migration. moldova has experienced large-scale labour migration to western europe and the former ussr. precise data are difficult to obtain because many moldovans are entitled to, or hold, either romanian, and hence european union nationality, or russian or ukrainian nationality. however, it is estimated that t he number of moldovan citizens living abroad is between 11 and 17% of those living in the country (7), but the figure is about a third for those of working thomas-reilly rg, tozija f, soltan v, nikovska dg, crudu v, atun r, mckee m. multidrug-resistant tuberculosis in moldova and the former yugoslav republic of macedonia: the importance of the overall governance of the health systems (original research). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-85 5 age (8). the challenges of controlling tb where there is large-scale labour migration, are well recognised (9,10). figure 1. trends in tb incidence in moldova and macedonia (source: world development indicators) health system organisation we define organisation as being related to the structure of health systems, from its leadership downwards. macedonia has a national health insurance system, overseen by the health insurance fund (hif). in recent years primary health care delivery has been privatized, and general practitioners are paid by a blended model of capitation and incentive payments (i.e. completing specified health examinations). general practitioners act as gate-keepers to the health system, and have become more important, particularly as the number of acute care beds has decreased (11). the national tb programme (ntp) in tfyr macedonia is coordinated centrally from the national tb institute. the ntp is the sole provider of tb services in the country, working through the national institute in the capital, skopje, but with affiliated regional hospitals and community dispensaries. the ntp also employs community nurses with responsibilities for directly observed community-based therapy. moldova also has a national health insurance programme. while less well established than in macedonia, moldova has moved toward a family practitioner model of primary health care. this said, a large stock of hospital beds remains (12), and hospital physicians exercise considerable influence on the health system. tuberculosis care in moldova is provided in several systems (e.g. prison, military and general health systems), although points of connection exist throughout. the ntp is coordinated by a manager at the phthisiopneumology institute in chisinau, the capital. services are delivered through municipal and national hospitals, along with local specialists and family physicians in the more rural parts of the country. 0 20 40 60 80 100 120 140 160 180 200 1990 1995 2000 2005 2010 in ci d e n ce /1 0 0 ,0 0 0 moldova macedonia, fyr thomas-reilly rg, tozija f, soltan v, nikovska dg, crudu v, atun r, mckee m. multidrug-resistant tuberculosis in moldova and the former yugoslav republic of macedonia: the importance of the overall governance of the health systems (original research). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-85 6 in macedonia informants spoke positively of the structure, management and clinicians within the ntp, while counterparts in moldova were critical, specifically of the structure and management of the ntp. those in moldova raised particular concerns about the current and future capacity of the ntp, given challenges experienced in recruiting and retaining qualified staff. as tb care is a separate specialty, informants felt that it is not attractive to new clinicians, given the inherent risks to practitioners and the confined scope of practice. this is in contrast to macedonia, where those providing tb care have transitioned to a broader medical specialization of respiratory medicine. as both countries have similarly structured ntps, criticisms raised in moldova would seem to reflect how the structure translates into service. on closer examination, informants in macedonia tended to personalise their praise of individuals within the ntp. in moldova, there was less personification and more reflection on the frequent transitions of individuals. moldovan informants also reflected on a disconnection between the ntp leadership and local practices and realities, particularly in rural areas. although informants framed their reflection as an organisational critique, what they were in reality commenting on was the capacity of individuals within the system to deliver the leadership and outcomes desired. parallel health systems there was a consistent narrative in both countries about challenges associated with parallel health systems. in macedonia these had been addressed by having all tb services provided through a single ntp, including those in the prison system, with prisoners referred to the general health system for treatment. in contrast, moldova has dedicated prison-based facilities for the treatment of tb, which fall within the prison directorate. while informants highlighted significant advances within the moldovan prison system, specifically in regard to the treatment of tb, there were concerns about the risk of losing individuals as they transfer into, or out of parallel systems. accountability and oversight in macedonia, informants felt that service providers were accountable for their actions, supported by training and oversight from the ntp managers. informants described substantial uniformity in care provided across the country, which they associated with the good outcomes observed. in moldova there was conflict between the hospital and community service providers. those in the acute care sector blamed the community service providers for lax practices, whilst their counterparts in the community highlighted a lack of awareness of the realities in communities, particularly in rural settings. those who are responsible for oversight of the ntp described limited capacity for monitoring and enforcing practice standards, which they believed contribute to variations in practice. power and relationships power dynamics are an important theme, although this emerged implicitly from the interviews rather than being raised explicitly. those in moldova described a persistent tension between acute care institutions and emerging community care service providers. they also spoke about the lack of consistent leadership, which arose from frequent leadership transitions, often due to changing political fortunes. in macedonia informants also described frequent political transitions, but these spared the management of the ntp, enabling institutional stability. macedonian informants further described cordial, if not pleasant working relations and communications with many of their colleagues across the country. thomas-reilly rg, tozija f, soltan v, nikovska dg, crudu v, atun r, mckee m. multidrug-resistant tuberculosis in moldova and the former yugoslav republic of macedonia: the importance of the overall governance of the health systems (original research). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-85 7 secondary themes in addition to the primary themes, several secondary ones were identified, which, while not necessarily differentiating the two countries, emerged from the literature as being of potential relevance and, in some cases, offered additional nuanced insights to their performance (table 3). these will be discussed briefly. table 3. case study themes theme macedonia moldova major themes organisation  x pre-existing burden of disease  x parallel health systems  x power  x accountability & oversight  x secondary themes political commitment   infrastructure x  historical trajectory x x institutional memory  x  positive factor  mixed x challenges political commitment: in both countries informants described a high degree of political commitment to tackling tb but, perhaps surprisingly, none believed that this had any influence on the tb programme. it could be that this was taken for granted and it would have attracted more comment if it had been lacking. however, there was also a degree of cynicism as many felt that the commitment was because of the external funding attached to it, as both countries were recipients of global fund grants at the time of the study. infrastructure: moldovan informants highlighted particular challenges in instituting uniform practices and standards in rural settings where there are difficulties recruiting and retaining health workers and where clinicians are overworked and largely disconnected from the broader health system, with its focus on larger policlinics and hospitals (13). from our observations, it was apparent that moldova was well-equipped in respect to the diagnostic capacity available, particularly in the reference laboratories. this is the direct result of capacity building funds offered by the global fund to fight aids, tuberculosis and malaria; united states agency for international development (usaid); world bank, and other donors. in contrast, macedonia did not have in-house access to high-technology equipment (e.g. polymerase chain reaction or pcr), but this seemed to have little impact on the overall system of care. this observation strengthens our initial hypothesis, in that the systems of care have a greater impact on outcomes than does technology. historical trajectory: one phenomenon that characterised moldova‟s early postindependence years was the growth of social inequality and breakdown of health services (14,15). this was exacerbated by a lack of management capacity in all post-soviet republics outside russia, in part consequent on the previously centralised system in the ussr (16). it thomas-reilly rg, tozija f, soltan v, nikovska dg, crudu v, atun r, mckee m. multidrug-resistant tuberculosis in moldova and the former yugoslav republic of macedonia: the importance of the overall governance of the health systems (original research). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-85 8 is plausible that some differences between former soviet and former yugoslav republics can be accounted for by the long history of decentralization in the latter (17,18). institutional memory: a loss of institutional memory may have played a role in moldova, with frequent leadership changes in the political realm impacting substantially on the ntp. this has ripple effects on the continuity of policy, programmes and funding, as staff operate within an environment facing continual change (19,20). discussion this study points to the importance of tackling not just the immediate causes of infection and resistance, but also the upstream factors, related to the way in which the health system is governed and organised. key factors emerging from this research are congruent with those reported from other countries, including the challenges when patients cross boundaries between parallel health systems, or from a well-developed acute care sector to the community (21-23); a lack of accountability and oversight for tb treatment (14,23); the challenges arising from a strong centralized hospital sector, with consequent power imbalances (14,2426); and the challenges of recruiting and retaining health staff in rural areas (16). consistent with the now extensive body of research on how some countries achieve good outcomes at low cost (27), we see that there is no single reason why macedonia gets better outcomes than moldova. these other studies have failed to find a single „magic bullet‟, but have identified several factors that increase the likelihood of success, such as effective governance systems and institutional continuity, both present in macedonia, but weak in moldova. informants praised leaders in macedonia, but those in moldova were seen as weak, and afflicted by frequent changes. fragmentation was a key issue, with moldova unable to integrate prison care, contrary to what was done in macedonia. this creates inevitable problems as there are well known challenges in enforcing uniform standards across multiple systems of care (28). the risk of losing patients to follow-up in such circumstances, particularly for people who are vulnerable or marginalized, is ever present (29). prison health systems are a neglected political priority globally, and often provide substandard care compared with mainstream health systems (30). this being said, the moldovan prison system is not entirely separate, maintaining some connections, as is usual in countries with parallel systems (31). weak governance can also be inferred from the problematic relationships between different providers in moldova. this study has a number of limitations. the most obvious is attribution. while it is possible to infer certain relationships between observed characteristics of the two health systems and health outcomes, it is not possible, in a non-experimental study, to determine cause and effect. however, the associations observed, with weak governance, lack of institutional stability, and the existence of parallel health systems being seen in the country with the higher burden, and not in the one with less mdr-tb, is both plausible and consistent with the evidence on health systems performance more generally. the second is that, although the two countries have many similarities, they are not identical and have different historical legacies, and policies take place in different political, social, and economic contexts. these are likely, at least to some extent, to explain the differences in governance systems. notwithstanding these limitations, this study does add to the 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http://www.ncbi.nlm.nih.gov/pubmed/?term=soltan%20v%5bauthor%5d&cauthor=true&cauthor_uid=23407226 http://www.ncbi.nlm.nih.gov/pubmed/?term=cohen%20t%5bauthor%5d&cauthor=true&cauthor_uid=23407226 http://www.ncbi.nlm.nih.gov/pubmed/?term=international+journal+of+tuberculosis+and+lung+disease+2013%3b+17%283%29%3a+373-80 http://www.ncbi.nlm.nih.gov/pubmed/?term=30.%09stuckler+d%2c+basu+s%2c+mckee+m%2c+king+l disaster nursing grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 1 review article nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review thomas grochtdreis 1,2 , nynke de jong 3 , niels harenberg 2 , stefan görres 2 , peter schröder-bäck 4,5 1 department of health economics and health services research, hamburg centre for health economics, university medical centre hamburg-eppendorf, hamburg, germany; 2 institute for public health and nursing science, university of bremen, bremen, germany; 3 department of educational development and research, school of health professions education, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 4 department of international health, caphri school for public health and primary care, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 5 faculty for human and health sciences, university of bremen, bremen, germany. corresponding author: thomas grochtdreis, department of health economics and health services research, hamburg centre for health economics, university medical centre hamburg-eppendorf; address: martinistr. 52, 20246 hamburg, germany; telephone: +49407410-52405; email: t.grochtdreis@uke.de grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 2 abstract aim: nurses play a central role in disaster preparedness and management, as well as in emergency response, in many countries over the world. care in a disaster environment is different from day-to-day nursing care and nurses have special needs during a disaster. however, disaster nursing education is seldom provided and a lack of curricula exists in many countries around the world. the aim of this literature review is to provide an overview of nurses‟ roles, knowledge and experience in national disaster preparedness and emergency response. methods: an electronic search was conducted using multiple literature databases. all items were included, regardless of the publication year. all abstracts were screened for relevance and a synthesis of evidence of relevant articles was undertaken. relevant information was extracted, summarized and categorized. out of 432 reviewed references, information of 68 articles was included in this review. results: the sub-themes of the first main theme (a) roles of nurses during emergency response include the expectations of the hospital and the public, general and special roles of nurses, assignments of medical tasks, special role during a pandemic influenza, role conflicts during a disaster, willingness to respond to a disaster. for (b) disaster preparedness knowledge of nurses, the corresponding sub-themes include the definition of a disaster, core competencies and curriculum, undergraduate nursing education and continuing education programs, disaster drills, training and exercises, preparedness. the sub-themes for the last theme (c) disaster experiences of nurses include the work environment, nursing care, feelings, stressors, willingness to respond as well as lessons learned and impacts. conclusion: there is consensus in the literature that nurses are key players in emergency response. however, no clear mandate for nurses exists concerning their tasks during a disaster. for a nurse, to be able to respond to a disaster, personal and professional preparedness, in terms of education and training, are central. the framework of disaster nursing competencies of the who and icn, broken down into national core competencies, will serve as a sufficient complement to the knowledge and skills of nurses already acquired through basic nursing curricula. during and after a disaster, attention should be applied to the work environment, feelings and stressors of nurses, not only to raise the willingness to respond to a disaster. where non-existent, national directives and concepts for disaster nursing should be developed and nurses should be aware of their duties. nursing educators should prepare nurses for disasters, by adjusting the curricula and by meeting the increased need for education and training in disaster nursing for all groups of nurses. the appropriateness of theoretical and practical preparation of disaster nursing competencies in undergraduate nursing courses and continuing education programmes should be evaluated. keywords: disasters, disaster planning, emergencies, emergency preparedness, nurses. conflicts of interest: thomas grochtdreis is a member of the german red cross and vice president of the german red cross youth. the other authors do not declare any conflicts of interest. grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 3 introduction disasters are defined by the centre for research on the epidemiology of disasters (cred) as “a situation or event, which overwhelms local capacity, necessitating a request to a national or international level for external assistance; an unforeseen and often sudden event that causes great damage, destruction and human suffering” (1). disasters are classified as natural, biological, geophysical, climatological, hydrological, meteorological, and technological (2). recent examples of major disasters are the earthquake in haiti in 2010 as an example of a natural disaster and the earthquake followed by a tsunami and the nuclear catastrophe in japan in 2011 as an example of a mixed natural and manmade disaster. within the countries of western europe, more than five million people have been affected by a variety of disaster types (e.g., 4,295,600 people affected by storms, 684,492 by floods, and 816 by epidemics) in the last 20 years. within this timeframe, 8,835 people were injured and 38,643 people were killed (3). in order to master a huge number of affected people due to a disaster within a short period, it is important to have well trained first-response personnel or volunteers. here, an essential role is allotted to nurses for integrating communicating efforts across these protagonists and for having role competencies in disaster preparation. it is quite probable that at some time in the future, nurses may be called upon to respond to a mass casualty event or disaster outside of the hospitals. therefore, a need for nurses, who are well trained and prepared, arises on a national as well as on an international level (4). referring to the conditions in the usa, four strengths of nurses, which are key to a central role in disaster preparedness and management, as well as in emergency response, can be stated (5): (i) nurses are team players and work effectively in interdisciplinary teams needed in disaster situations; (ii) nurses have been advocates for primary, secondary, and tertiary prevention, which means that nurses can play key roles at the forefront in disaster prevention, preparedness, response, recovery, and evaluation; (iii) nurses historically integrate the psychological, social support, and family-oriented aspects of care with psychological needs of patients/clients; and (iv) nurses are available and practicing across the spectrum of health care delivery system settings and can be mobilized rapidly if necessary. however, approximately two out of five health care professionals would not respond during health emergencies. the nurses‟ intention to respond to disasters, the needs of nurses who respond to disasters and other health emergencies, and as well as the influence of the nursing shortage and the lack of education preparing nurses for disaster response are important issues which need to be approached (6). concerning the anticipated needs of nurses during a disaster, giarratano, orlando and savage (7) report that during a disaster nurses have to live through the uncertainty of the situation and have to be prepared to adapt to the needs that arise in both patient care and selfpreservation situations. in order to prepare for emergency response, education within the field of disaster nursing is essential. disaster nursing curricula and preparation of nursing faculty members are distinctly needed to teach disaster nursing in order to prepare nursing students for possible disaster situations adequately in future (6). extensive work towards a comprehensive list of core competencies has been done by the who and icn in their framework of disaster nursing competencies (8). pang, chan and cheng (9) suggest that this framework should equip nurses with similar competencies from around the world while giving attention to local applications. grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 4 there is no comprehensive review covering all relevant fields of professional socialization: role, knowledge and experience. recent reviews do concentrate on either the nurses‟ disaster preparedness, or the response of nurses working during a bioterrorism event (10). the aim of this literature review is to provide an overview of the nurses‟ role, knowledge and experience in national disaster preparedness and emergency response within the international scientific literature. methods search strategy a database search was conducted during september-november 2012 using cinahl (ebsco), pubmed, cochrane library, and carelit. a search strategy was used utilizing the terms „disaster‟ and „nursing‟ as keyword searches or subject headings, where applicable. all study designs as well as expert opinions were included in the review. inclusion criteria were the existence of a relevant abstract on the role, knowledge and experience in the field of disaster nursing. all results, independent of their publication year and country of publication, written in english or german language, were included. selection criteria in total, 503 articles were identified within the databases; out of these, 71 appeared in more than one database. the abstracts of all included literature (432 references) were scanned for their relevance on the topic. articles were excluded if they definitely lacked relevance, meaning that the topic of disaster nursing did not appear at all (242 references). as a second step, the articles, which were deemed relevant (190 references), were evaluated in-depth by the first author by initial reading and appraising the relevance in relation to the aim of the literature review. articles were excluded if they failed to address nurses‟ role, knowledge or experience in national disaster preparedness and emergency response in their full text (103 references) or if they were not available for evaluation (19 references) resulting in 68 included references. a flow chart of the selection process is presented in figure 1. figure 1. flow chart of the selection process grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 5 data analysis as articles differed in their (study) design, no meta-analysis was possible. therefore, synthesis of the written evidence was undertaken. categories for analysis, which were predefined through the aim of this literature review, included: (a) roles of nurses during emergency response, (b) disaster preparedness knowledge of nurses and (c) disaster experiences of nurses. for each category, sub-themes were determined out of the different focuses of the articles on disaster nursing (11). for each article, the narratives about a particular sub-theme were extracted. the narratives were paraphrased and generalized, where possible. results in total, 68 relevant sources were identified from the literature search. the majority of the studies were descriptive (40%), or expert opinions/case reports (40%). furthermore, 15% of the studies were qualitative and correlational studies, whereas 3% were systematic reviews. the three categories, according to which the articles where analysed, represented also the most important themes: (a) roles of nurses during emergency response, (b) disaster preparedness knowledge of nurses and (c) disaster experiences of nurses. most of the articles on disaster nursing were drafted in north america. in europe, no articles concerning disaster experiences of nurses had been published. below, each theme is divided into paragraphs, which are equivalent to the determined sub-themes. roles of nurses during emergency response the six identified sub-themes include expectations of the public and the hospital, general and special roles of nurses, assignments of medical tasks, special role during a pandemic influenza and biological terrorism, role conflicts during a disaster and willingness to respond to a disaster. expectations of the public and the hospital: the public expects that nurses are prepared at a personal and professional level and that they have procedures in place, which enable them to carelit: n=34 cochrane: n=2 cinahl: n=297 n=190 abstract not relevant: n=242 double: n=71 n=68 article not relevant: n=103 no full text available: n=19 pubmed: n=170 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 6 serve in an emergency (12). reinforcing, the public has a right to expect effective response from healthcare professional, including nurses (13). moreover, it is anticipated from the hospitals that nurses know before a disaster what will be expected from them in such a situation, what tasks will have to be fulfilled and who is authorized to issue directives towards them and many employees in hospitals do not know what their role during a disaster will be (14). in order to develop or to optimize the field of disaster nursing nationwide, it is proposed to develop a national committee to help define the discipline, build disaster curricula, and to set disaster competencies. furthermore, nurses need to participate in disaster preparedness planning to become familiar with their responsibilities in disaster situations (15). general and special roles of nurses: in general, nurses will have to provide care in a very different context than in their usual practice during disasters (16,17). further, it is imperative that nurses are able to continue working to provide care to additional patients (18). different authors acknowledge that nurses are key players in emergency response (15,17-22). in other words, it can be determined that nurses are in a natural position to assist in a disaster (23), they are the most vital resources in dealing with disasters (24), they have been part of disaster response as long as nurses have existed, nurses will continue to be key players (20) and when nurses are not involved yet in the aspects of disaster care, the involvement should become mandatory (25). particularly, nurses working in disaster-prone areas need to know their professional role in a disaster (26). not every nurse is expected to fulfil any assigned role, and special roles before, during and after a disaster are assigned to nurses with different qualifications (table 1). table 1. general and special roles of nurses groups of persons role description nurses meeting surge capacity needs (20) conducting surveillance in the field dispensing mass medication or vaccination in shelters staffing information hotlines in departments of health admitting patients in hospitals nurses within hospitals (20,27) identify signs and symptoms of injuries and exposures work in a disciplined team follow clear lines of communication perform according their assigned role directions and responsibilities nurses in general (28-30) establish disaster plans train responders coordinate the disaster response provision of care for disaster victims support and protect others from health hazards make life-and-death decisions and decisions about prioritization nursing executives (31) preserve open lines of communication ensure the quality of patient care, provide current education influence policy and political decisions provide security for staff, patients and families. public health nurses (20) screening administer first aid and psychosocial support implement infection control procedures and monitoring assignments of medical tasks: during a disaster, nurses are expected to be able to fulfil the role of a medical practitioner in some ways. this role can be described as outside of the normal scope of nursing practice, their knowledge or their abilities (32). nevertheless, it is imgrochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 7 perative that nurses are trained in disaster medicine in order to be assigned to medical tasks in emergency response (30). the task of triaging patients as an assigned medical task is figured prominently in the literature (19,29,32). special role during a pandemic influenza and biological terrorism: the tasks during epidemic situations are contact tracing, conducting case investigations, engaging in surveillance and reporting, collecting specimens, administering immunizations and educating the community (20). furthermore, in hospital settings, it is expected from nurses to be able to identify, manage and treat infectious outbreaks (32). role conflicts during a disaster and willingness to respond to a disaster: nurses might have conflicts between their professional, their private and their community role, respectively (33). nurses might be therefore less willing to respond to work during a disaster. other reasons influencing the willingness to respond are low baseline knowledge, low perception of personal safety, and low perception of clinical competence (34). it is also stated that these factors will lead to a shortage of nurses to provide care during a disaster. nurses not responding to a disaster describe having feelings of guilt towards their jobs and co-workers, recognizing the impact of their decision. on the other hand, it is also possible that nurses maintain being able to respond to disasters beyond normal working hours (33). disaster preparedness and knowledge of nurses the six identified sub-themes include definition of a disaster, core competencies and curriculum, undergraduate nursing education and continuing education programs, disaster drills, training and exercises, as well as preparedness. definition of a disaster: it is acknowledged that nurses might perceive a disaster differently than described from official definitions and classifications such as the one of the cred (1,2). in a study by fung et al. (29), nurses described their perception of a disaster in a fourfold manner. most of the nurses attributed specific characteristics to disasters. exemplarily, these characteristics are being unpredictable, sudden, unexpected or unpreventable, being out of control and not manageable, urgent response, horrible crisis or unknown disease with no treatment available. another way of describing a disaster is by impact, as for example: large numbers of victims, damage to the environment, adverse psychological effects, loss of family, and serious consequences. moreover, disasters were described as demanding emergency services and care. examples are being in need for immediate medical attention, a challenge to professional services or requiring extensive work force to cope. only few nurses described disasters in a way a definition would do: epidemics, accidents, terrorist attacks, natural disasters, extreme weather and war. core competencies and curriculum: for preparedness purposes, it is very important to have core competencies for education and training as well as for the effectiveness and efficiency of response during a disaster (35). the identification of core competencies and knowledge needed to help and protect self and others during a disaster is an important first step to qualify nurses for disaster response (20,35). weiner (36) refers to the core competencies defined by the nursing education preparedness education coalition (nepec) (table 2). when comparing knowledge and experiences underpinning these competencies with nursing practice, it can be concluded that many of them are basic to a nursing curriculum (35). furthermore, others claim that nurses already possess the skills enabling them to respond to a disaster. these are purported to be the values of human caring, creativity, the ability to improvise, communication and management skills (20,23). on the other hand, usher and mayner (22) state that working in an emergency department or a similar area is (still) not good enough to meet the grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 8 required competencies to respond to a disaster. others claim that nurses working in acute care already have specific disaster nursing core competencies (28). some authors annotate that the area of disaster nursing is underrepresented or lacking in undergraduate nursing curricula, nurses and nurse practitioners are not able to meet required disaster nursing competencies and that it is urgent to include content in order to enable nurses to respond in times of disasters (6,12,15,17). nursing educators are hold accountable to preparing nurses for disasters, for example by adjusting the curricula and by meeting the increased need for education and training in disaster nursing for all groups of nurses (6,17,37). concerning a disaster curriculum, lund et al. (30) propose seven modules for a comprehensive nursing curriculum to address chemical and biological warfare (table 2). elsewhere, such a training of specialized skills and knowledge is criticized because they are unlikely to be retained until an opportunity to use them is afforded (38). others propose educational components that are more medically oriented (table 2) (14,24). undergraduate nursing education and continuing education programs: the fields of undergraduate education and continuing education programmes for nurses are widely discussed in the literature. because nurses have to be aware of disasters and be prepared for them, it is imperative that disaster management and nursing contents and experience are integrated into undergraduate nursing and continuing education programme curricula (15,17,22,24,35,3941). it has to be acknowledged that all nurses, irrespective of being educated and trained or not, may be called during a disaster and therefore, all nurses must have a minimal knowledge and skills for appropriateness of their response (17,26,29,35). education is critical to the feeling of safety and competence as well as the willingness to participate in an emergency (32,34), but it needs to be tailored according to the specific needs of the location such as capacity and expected role of nurses (16). for australia, usher and mayner (22) state that the theoretical and practical preparation of disaster nursing competencies in undergraduate nursing courses are inadequate or only little is known about the inclusion and that professional development opportunities are needed. one possibility for an adequate provision of knowledge and skills required in a disaster could be the collaboration and sharing of knowledge between nursing schools and the military medical communities as well as other trained medical professionals, for example volunteers from the red cross or red crescent and other medical response teams (17). another effective strategy might be the dissemination of information and educational materials related to disasters (18). it is central that nurses receive education which is specific to their actual knowledge and skills in order to not duplicate efforts or miss important content because the more advanced nurses are, concerning both experience and knowledge, the more likely they are to implement advanced disaster nursing (15,32,35). disaster drills, training and exercises: drills and training play also an important role for disaster preparedness. it is concluded, that intensive training and periodical drill programs simulating hospitals‟ emergency plans will improve capabilities of nurses for emergency response (15,20,21,31,42,43). all nurses are recommended to participate in periodic emergency response drills and disaster training, and nursing schools should collaborate with the local ems to give their students a disaster field experience and to expedite teamwork between first responders and first receivers, because during a disaster an enormous pool of nurses will be needed (20,21,23,25,35). further reasons for participating in and specific issues for disaster training are described in table 3. others contrarily describe specific medical tasks and conclude that these tasks should be tailored to the nurses‟ background knowledge and clinical experience (13,16). grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 9 with any disaster training, a broad range of topics should be covered in order to prepare nurses to function in disasters due to any hazard and settings other than their work settings (41). goodhue et al. (21) conclude that having disaster training, besides having a specified role in the workplace disaster plan, is the most easily modifiable variable with the most impact on increasing the likelihood of response in the event of a disaster. preparedness: disaster preparedness of nurses is pivotal to the ability and capacity to respond as well as the delivery of effective disaster response (6,18,24,33). there are two ways of viewing preparedness, personal preparedness and professional preparedness. special attention is given to bioterrorism preparedness, because being especially prepared for bioterrorism and thus infectious disease emergencies, has a positive impact on patients, families and the nurses themselves, for example by preventing a secondary spread (18,45). furthermore, bioterrorism preparedness readies nurses for other disasters, because the skills and response actions are the same and misconceptions can be prevented (46). due to this importance, bioterrorism preparedness should be part of continuing education and nursing school curricula (18,43). other special fields where preparedness is necessary are described in table 4. grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 10 table 2. core competencies and disaster curriculum description contents core competencies defined by the nursing emergency preparedness education coalition (nepec) (36) protect self and others from harm participate in a multidisciplinary, coordinated response communicate in a professional manner recognize disaster situations and potential for mass casualty events seek additional information and resources needed to manage the event recognize your roles and limitations in disaster response efforts cope with challenges that occur in disaster situations define terms relative to disaster management response discuss ethical issues related to mass casualty events describe community health issues related to mass casualty events already existing specific disaster nursing core competencies of nurses working in acute care (28,41) triage securing of personnel, supplies and equipment recordkeeping patient transport decontamination patient management of specific illnesses and injuries patient management of special needs population evacuation development of disaster plans ethics response to stress reactions disaster curriculum modules of lund et al. (30) anatomy of a disaster epidemiology of disaster disaster planning communications in disaster introduction to disaster medicine introduction to pathophysiology of disaster the disaster response nursing curriculum to address chemical and biological warfare (40) introduction to biological and chemical terrorism surveillance systems for bioterrorism identification of agencies communication response systems biological and chemical agents of concern mass immunization decontamination and mass triage therapy and pharmacology psychosocial effects of terrorism nursing leadership during emergencies medically oriented educational components (14,24) first aid basic life support advanced cardiovascular life support infection control field triage pre-hospital trauma life support advanced trauma care nursing post-traumatic psychological care peri-trauma counselling grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 11 table 3. reasons for participating and specific issues for disaster training description contents reasons for participating in disaster training (10,13,15,18,21,24,26,27) test and maintain disaster preparedness create awareness for disasters in general create awareness for physical and mental limits increase personal safety increase confidence in disaster management minimize emotional and psychological trauma specific issues for disaster training (38,43,44) triage mass casualty management (bio-) terrorism preparedness communications command and control interagency cooperation waste management decontamination personal protection specific medical tasks (13,16) cardiopulmonary resuscitation central venous catheter insertion trauma care table 4. personal and professional disaster preparedness description contents personal preparedness (15,18-20,27,47) go-pack containing essential personal supplies preparing and protecting the family personal plan for times of disaster knowing employment contract statement about obligation to report to duty during a disaster professional preparedness (15,19,26,27,29,47) pre-registering in a disaster registry developing and knowing disaster plans assembling emergency supplies studying evacuation or shelter options ongoing training and drills experience in disaster nursing special fields of disaster preparedness (33,34,40) bioterrorism disasters involving special need populations chemical or radiation disasters according to al khalaileh et al. (15), jordanian nurses consider themselves being weakly to moderately prepared for a disaster and think that additional training would be beneficial. the same issues are made out for hong kong nurses and the existence of a lack of understanding their preparedness needs with regard to disaster is concluded (24,29). being prepared for a disaster as a nurse might maximise safe conditions, decrease vulnerability and minimise risk to individuals during a disaster (12). disaster experiences of nurses the six identified sub-themes are work environment, nursing care, feelings, stressors, and willingness to respond to disasters and to treat patients as well as lessons learned and impacts. grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 12 work environment: nurses will experience challenging working conditions, an environment of fear and difficult infection control requirement conditions during a bioterrorist event (10). nurses believe that during a disaster will be a chaotic clinical environment without a clear chain of command, with insufficient protective equipment and little freedom to leave (47). manley et al. (38) assume, even if hospitals are well prepared, that during a disaster will be chaos, inadequate resources, deaths and injuries, confusion and contention over who is in command, lapses in security and breakdowns in communication. during a disaster, problems concerning organizational and social supports caused by challenges with care for children, elderly or pets during prolonged shifts and quarantine might also prevail (48). nursing care: nursing care during a disaster is a special type of care because of the exceptional situation and the change of routine. during a disaster, care is provided by an interdependent team of nurses, clinicians and ems professionals, each playing unique roles (41). thus, nurses especially feel as advocates for their patients, especially those who are frightened or most vulnerable, and their merits of caring and unity are the most appreciated aspects of their rescue experience, reinforced through communal sprit with their colleagues and the feeling of being rewarded by the victims (7,27). nurses are confronted with conflicts and ethical issues when working during a disaster. because of increased staff requirement and the allocation of resources nurses come into conflict with the delivery of dependent care (27,48). other challenges for nurses are the identification of unfamiliar infectious agents, long working hours, limited supplies, unfamiliar environments, provision of care to infected patients, or fear of infection (10). chaffee (49) concludes that tasks like triage, quarantine and mandatory administration of medication might be ethically challenging during a disaster. if uncertainty of the conditions worsens, nurses might experience discouragement and fear (7). feelings: on the one hand, nurses feel guilty when taking leave, are concerned about causing pain and distress to their patients, are overwhelmed by the scale of the tragedy, feel disgusted or distressed at the nature of the injuries and the scale of the suffering or felt apprehensive about being able to cope. on the other hand, nurses also feel excited and challenged by what they have to do, or feel to be valued as much-needed colleague (50). anger towards people in authority, because of the expectation to fulfil the duty to care, is another feeling described by nurses (7). fear, anxiety, stress and confusion are perceived to be felt in the event of bioterrorism. fears might arouse in consequence of the possibility of acquiring a lethal disease from exposure to an infectious agent, transmitting an infectious agent to other patients or the family, lack of knowledge about disease agents, isolation procedures, and access to content resources (47). other feelings might be uncertainty, hopelessness, or abandonment related to the issue of chaos in general and evacuation in special (7). stressors: there is a widespread assumption that nurses “by virtue of their training and personality traits are relatively impervious to the effects of distressing experiences”, such as disasters (50). newer studies disqualify this assumption, because for example, the work of nurses can be compromised when a lack of adequate rest, poor nutrition, erratic eating patterns and insufficient fluid intake prevails (26). other stressors might be information and work overload, crisis, confusion, uncertainty, chaos, disruption of services, casualties, or distractions with crowds and media, decline of infrastructure, limited medical supplies and loss of electricity and potable water (7,25,31,47,48). moreover, poor knowledge and working skills, combined with a heavy workload and lack of equipment, leads to emotional distress during a disaster (25). a disaster can also lead to personal trauma because of the experienced loss of homes, workplaces, and close relationships as well as suffering or dying patients (7). willingness to respond to a disaster and to treat patients: main issues related to a reduced willingness to treat patients during an epidemic include having a high level of concern about grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 13 an infection and lack of medical knowledge (46). during a disaster, nurses will have the same vulnerability to property damage, injury or displacement, will have fear and concern about own and family‟s safety and will, therefore, have to make a decision whether to report to work or to care for oneself, one‟s family, or personal property (49). other reasons for unwillingness to respond to a disaster are responsibilities to children or elderly, a second job, transportation issues or obligations to care for a pet (49). goodhue et al. (21) found out in their study that less than one third of paediatric nurse practitioners would definitely respond during a disaster. one result of the study of o‟boyle et al. (47) is that many nurses would leave hospitals or would not report for work when a bio-terroristic event occurred. not all nurses will be willing to respond to chemical, biological or radiological disasters, because of personal risk and not all nurses will be able to respond because of the unavailability of personal protective equipment (33). in order to raise the willingness to respond to a disaster, nurses need to be educated on what the hospital expects from them and what the implications of certain choices of not responding to work will be (49). other factors might be: knowing that family members are safe and provided for, having a home disaster plan, having disaster training, having an assigned role in the workplace disaster plan and prior disaster experience (21). lessons learned and consequences: based on experience, often lessons learned and consequences for the future are stated. ammartyothin et al. (42) conclude that medical personnel, such as volunteers, should be incorporated into the organic medical staff during a disaster as well as that communication systems are important for disaster management and have to withstand the actual event and the unavoidable. as a health institution, it is important to find out about the nurses‟ determinants of reporting for work when a disaster strikes in order to be better prepared (46). during a disaster, it is imperative, that food, water and a place to sleep or a quiet area are available for continued functioning of nurses. in order to ensure an effective response, nurses need to build functional partnerships with physicians, to support one another and to express a sense of responsibility and empathy for colleagues and patients (7,25,39). for future disaster responses, the performance of nurses during a disaster needs to be evaluated and the most frequently used skills need to be identified for further training (13). discussion concerning the general role of nurses in disasters, different attributions are observed. on the one hand, there is international consensus that nurses are key players in emergency response is somehow contemporary. on the other hand, it does not seem finally clear which expectations are cherished towards nurses. is it only the continuation of the provision of care in different circumstances or is the assumption of medical tasks, in fact? of course, not every nurse needs to be able to fulfil every role, but medical tasks during a disaster might be mandatory to undertake. it does not become finally clear from the literature review which medical tasks most certainly are needed in general and particularly for specific disasters. moreover, heterogeneity about the field of application of nurses exists in the literature. in some it is described, that nurses will work on-site of the disaster area in others nurses will be deployed in their own hospital or in a hospital in the proximity of the disaster area and yet in others nurses will work in the community. these heterogeneities surely are due to the different healthcare systems and professional qualifications in the different countries, a diversity that is remains unanswered in this review. however, it seems convincing that preparedness for a disaster as well as an effective response are expectations of the public towards nurses in all countries. special attention is given to the roles of nurses before and during a pandemic influenza and biological terrorism. nurses have a share in the identification, management and treatment of grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 14 infectious outbreaks. again, the specific tasks during such an event are dependent on the professional education of the nurses. the professional roles during a disaster might be in conflict with the personal duties in the family and in the community. such conflicts can undermine supply of work force during a disaster immensely. the definition of disaster is perceived differently by nurses than from the officially used definitions. officially used definitions mainly focus on the cause of a disaster. thereby, the passage between a mass casualty event and a disaster is fluent. for nurses, a disaster is mainly considered through the impact it has for their daily work, the persons who they care for and their own life. thus, the unpredictability and suddenness as well as the number of victims, their injuries and clinical picture play a greater role in the perceptions of nurses. furthermore, terrorism does not explicitly appear in the disaster classification of the cred; yet, nurses do think that terrorism might be a threat for their country (2). in order to be prepared for a disaster, it is important to define core competencies applicable to the different professional qualifications of nurses. a comprehensive list might be the who and icn in their framework of disaster nursing competencies (8). this supranational framework has to be broken down into national core competencies for nurses and a list of competencies for undergraduate and continuous nursing education, at the end, because it may very well be the case that some knowledge and skills acquired through basic nursing curricula already equip nurses for disaster response. on the other hand, some disaster nursing competencies might be highly specialized, and thus uncommon in practise as well as unlikely to be retained. thereby, a careful choice between specialization and generalization of skills and knowledge for undergraduate and continuous nursing education should be made. both, undergraduate education and continuing education programmes have to raise awareness and preparedness for a disaster adequately. by tailoring education to the local needs, such as the likelihood of specific disasters or existing disaster plans, and the needs of the nurses, such as the requirements for general disaster management knowledge or specialized medical skills, all nurses should be able to respond to a disaster appropriately. it remains unclear which strategy for the education of nurses in disaster management is the most effective. the collaboration with medical communities and other medical response teams, as well as the dissemination of information materials on the topic seem to be promising, not only for education but also for drills and training. emergency response drills and disaster training are important elements of individually and professionally preparing nurses for disaster and evaluating existing disaster plans. again, emergency response drills and disaster training need to be tailored according to the local needs and the needs of the nurses, leading to an improvement of the nurses‟ willingness to respond to a disaster and the response as such. being prepared for a disaster as a nurse means being personally and professionally prepared. nurses are considered to be personally prepared, when they are able to protect their family as well as when they know their obligation to report to duty during a disaster and have all their essential personal supplies standing by. professional preparedness of nurses means the registration in a relevant disaster registry, knowing the disaster plans and being trained. furthermore, special preparedness is needed for nurses‟ working areas with special needs populations and specific disaster types. the work environment of a nurse during a disaster will likely be challenging and chaotic. nurses need to know beforehand what they might expect; therefore, preparing them through education and training is essential. furthermore, a need for a good disaster plan, where chains of command and effective alternatives in communication are described, arises considering the high possibility of an adverse work environment. for nurses, it has to be clear, that care durgrochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 15 ing a disaster differs from the routine work. interdependence in a team will become even more important as well as advocacy for patients, the allocation of resources and ethically challenging decisions (for example, during triage). during a disaster, negative feelings, such as guiltiness, disgust, anger or fear, are dominant in descriptions of nurses‟ experiences, besides positive feelings of excitement or being challenged. no information is given on the impacts of those feelings on working capacity and mental health. nurses also experience specific stressors during a disaster, likely leading to emotional distress and possibly to personal trauma. these stressors can either have a personal character, such as uncertainty about the safety of the family or themselves, an organizational character, such as being cut-off from support sources, and an occupational character, such as hazards, lack of equipment or high workload. the willingness to respond to a disaster is dependent on the level of concern, responsibilities and the medical knowledge of nurses. concern may exist for example due to property damage or own and family‟s safety, responsibilities may be towards children, elderly or another employer. it is important that nurses are educated and trained on the expectations of the hospitals and that they have their own disaster plan. disaster experiences importantly should lead to impacts for the future, the so-called lessons learned. often, these lessons learned refer to optimizing communication systems, nurses‟ determinants of reporting for work, controlling the hospital environment during a disaster and the knowledge and skills of nurses. nurses themselves will acquire experience, and might rethink their commitment to nursing. in summary, it can be stated that, after a disaster is, with all probability, before a disaster and it is therefore inevitable to prepare anew. conclusions and implications it seems self-evident that nurses are key players in emergency response. in order to prepare nurses for disasters, clear roles should be defined according to the professional education of the nurses, which should be communicated beforehand. these roles of nurses during a disaster should be realistic in relation to their skills and practical experiences. in order to raise the availability of nurses during a disaster, roles should be adjusted to each nurses‟ personal duties in the family and in the community, in the best case. roles should also be tailored according to the characteristics of the different disaster types, with special attention to pandemic influenza and biological terrorism. in order to satisfy public expectations towards nurses, national directives and concepts for disaster nursing should be developed, where nonexistent, and nurses have to be called attention to their duties. moreover, distinctions towards roles of physicians and nurses during a disaster are needed in order to define the medical tasks of nurses clearly, which have to be trained and performed during a disaster. existent definitions of disasters seem not to be appropriate for the working environment of nurses. defining disasters out of the experience of nurses could help to give a better understanding for such a sweeping event. a definition from the perspective of a nurse could be an unpredictable, sudden event that is hardly but urgently manageable with serious consequences to the population and environment demanding an extensive need for professional health services personnel. in order to develop national disaster nursing core competencies, the framework of disaster nursing competencies from the who and icn (8) should be interpreted for the needs of each professional group of nurses. national disaster nursing core competencies then should be adjusted to the demands formulated in the undergraduate nursing curricula in order to meet the national criteria. nurses should receive education and training tailored to the local needs and their actual competencies. collaboration with relevant national institutions and organizagrochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 16 tions is indicated for making education and training in disaster nursing more efficient, precisely if nursing educators are not knowledgeable in the field of disaster nursing. for personal and professional preparedness and in order to raise willingness to respond, nurses need to pack their essential personal supplies standing by for emergencies, need to know that their families are protected and need to be registered in a disaster registry as well as know their relevant disaster plan. a personal disaster plan will help to arrange personal matters when responding to a disaster. in order to counteract the high possibility of challenging and chaotic working conditions during a disaster, nurses need to be prepared for many situations and hospitals need to develop or improve their disaster plans. it has to become a given for every nurse, that nursing care during a disaster will change from its routine way, including all consequences, such as the allocation of resources. not much is known about the feelings of nurses responding to a disaster and their resistance to stressors. in order to be able raise the willingness to work in a disaster, it is imperative that possible distressing situations during a disaster are identified and reduced, and nurses become prepared for coping. it is central to learn from a disaster experience and to prepare anew. not only will the optimizing of processes during a disaster written down in a disaster plan have to be evaluated, but the performance of the nurses who were on duty and the reasons of the nonperformance of the nurses who were not able or not willing to respond to the disaster, as well. an overview of the implications and the relevance to nursing practice, nursing education and research is presented in table 5. table 5. relevance to nursing practice, nursing education and research relevance to nursing practice: all nurses, regardless of their professionalization, need to receive disaster preparedness education in their undergraduate and continuous nursing education, in order to have a great pool of nurses during a disaster. all nurses should periodically take part in emergency response drills and disaster training in order to be prepared for disasters. for being prepared for a disaster and willing to respond, nurses need to be personally and professionally prepared. a personal disaster plan will help to arrange personal matters. hospitals need to have a disaster plan, wherein chains of commands, alternative communications and task descriptions for groups of nurses during disasters are described. during a disaster, the routine way of nursing care changes and nurses need to be prepared to make ethically challenging decisions. relevance to nursing education and research: nursing educators should prepare nurses for disasters, by adjusting the curricula and by meeting the increased need for education and training in disaster nursing for all groups of nurses. nursing research should find definitions of disasters appropriate for the working environment of nurses. research should be done in order to review the appropriateness of theoretical and practical preparation of disaster nursing competencies in undergraduate nursing courses and continuing education programmes. disaster preparedness of nurses needs to be 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[original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 1 | 12 original research can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? valery chernyavskiy1, helmut wenzel2, julia mikhailova1, alla ivanova3, elena zemlyanova3, vesna bjegovic-mikanovic4, alexander mikhailov1, ulrich laaser5 1 federal research institute for health organisation and informatics of the russian ministry of health, moscow, russian federation; 2 independent consultant, konstanz, germany; 3 institute for demographic research branch of the federal center of theoretical and applied sociology of the russian academy of sciences, moscow, russian federation 4 university of belgrade, faculty of medicine, institute of social medicine, belgrade, serbia; 5 university of bielefeld, bielefeld school of public health, bielefeld, germany. corresponding author: prof. dr. med. ulrich laaser address: bielefeld school of public health, university of bielefeld, germany; e-mail: ulrich.laaser@uni-bielefeld.de chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 2 | 12 abstract aim: this study reviews the ability of the russian federation to reduce the high mortality until 2030 evenly across the country and in accordance with the sustainable development goals (sdg). methods: we adopted the method suggested by haenszel for estimating premature years of life lost for the age group <70 years and applied a projected reduction of 33% by 2030 as proposed for sdg 3.4. to calculate the potential time gap we used the model of the united nations development programme and standardized the rates by the oecd 1980 standard population employing the direct method. results: if russia keeps the present level of effort the reduction by one third of the level of premature mortality as in 2013 will be in reach already in 2024 i.e. 5.9 years in advance of the sdg 3 target for 2030. this target is achieved quite evenly also throughout the 8 districts of the russian federation between 10.6 and 5.0 years in advance and in selected special districts/republics with the highest and lowest mortality rates. conclusion: after the steep decrease of life expectancy during the 1990ies the russian federation returned to the original trajectory. keywords: gap analysis, premature mortality, public health, russian federation, sdg. conflicts of interest: none declared. statement of funding: none declared. note: valery chernyavskiy, helmut wenzel, julia mikhailova, alla ivanova, elena zemlianova, vesna bjegovic-mikanovic, alexander mikhailov, ulrich laaser. can russia’s high mortality return until 2030 to trajectory of the 1980ies and reach the sdgs evenly across the country? published 13 november 2020 in parallel by: social'nye aspekty zdorov'a naselenia / social aspects of population health [serial online] 2020; 66(5):14; doi: 10.21045/2071-50212020-66-5-12. available from: http://vestnik.mednet.ru/content/view/1205/30/lang,ru http://vestnik.mednet.ru/content/view/1205/30/lang,ru/ chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 3 | 12 introduction the russian federation (rf) is with 17.1 million sqkm the largest country in the world with a population of 146 million, distributed over the territory quite unevenly. life-expectancy is increasing like in most regions of the world after a steep downturn in the 1990ies (1): for russia from 69.5 in 1988 to 64.5 years in 1994, to 65.5 in 2000 and to 72.4 in 2017, however with the highest gap worldwide between males and females (2), e.g. in 2017 67.1 vs. 77.4, a difference of 10.3 years, as compared to the european union (3) with a life-expectancy of 80.9 and a much smaller gender gap (e.g. in 201778.3 vs. 83.5). according to vlassov (4), vladimir putin when re-elected as president in 2018 declared a life expectancy at birth for both sexes of 76 years to be achieved in 2024 and of 80 in 2030. for the calculation of premature mortality, in russia mainly determined by non-communicable diseases (ncds), usually a borderline age of <70 years is considered as upper limit. the sustainable development goals (5) ask for a reduction by one third of ncds mortality up to 2030. for russia as a whole this seems to be in reach as published earlier (6). in this paper we analyse the eight federal districts of the russian federation with regard to their premature mortality as there are: north caucasus, south, privolzhskiy (volga), far east, uralskiy, siberian, central, and north west federal districts. in addition, we determine whether each of the eight districts is on track to reach the sdg target by 2030. furthermore we also try to analyse selected subunits e.g. oblasts as the russian federation consists in total of 85 subjects, including 22 republics (for example karelia, altai, tatarstan, chechnia etc.), 9 territories (e.g. perm territory), 46 regions (e.g. kaliningrad region), cities of federal significance (e.g. moscow and sankt petersburg), 1 autonomous oblast (jewish autonomous region) and 4 autonomous districts (chukotka, yamalo-nenets, khantymansijsk (yugra), and nenets). however, in this paper we do not consider a possible impact of the corona pandemic in 2020 but plan to do that on the basis of reliable figures later. methods we adopted the method suggested by haenszel (7) for estimating premature years of life lost (pyll) <70 years of age and applied a projected reduction of 33% by 2030 as proposed by the united nations for sdg 3.4 targeting non-communicable diseases (ncd) (5) which make up for 87% of the total mortality in russia (8). we gave preference to the determination of pyll instead of life expectancy (le) to avoid the instability of the highest age-groups. as for other components of total mortality: in russia the levels of the maternal mortality ratio (mmr, sdg 3.1) and neonatal mortality rate (nmr, sdg 3.2), are already well below the un targets (70 for mmr and 12 for nmr): mmr 17/100.000 live births; nmr 5.4/1.000 live births. sdg 3.3 refers to communicable diseases (5% of total mortality incl. mmr and nmr) and sdg 3.6 to road traffic accidents (8% of total mortality) for which reductions between appr. 30% and 90% are defined. in conclusion we consider it justified to apply an overall reduction by 1/3 to the total mortality until 2030, with reference to the years 2013, 2015 (estimated), and 2018. chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 4 | 12 to calculate the time gap (g), i.e. the time needed to achieve an agreed target deadline related to the time remaining between the year of observation and the target year, we use the mathematical model of the united nations development programme (9). the likelihood of achieving the sdg target 2030 will be determined by the indicators’ time gap, i.e. the time remaining to achieve an agreed target, according to the following equations: [1]tr = tt − tc and: [2]tn = tt − [tb + (tt − tb) ( xc – xb) / (xt – xb)] then the resulting time-gap g is calculated as: [3]g = tr − tn tr remaining time tn time needed to achieve the target (in linear progress) xb baseline value of the indicator xt target value of the indicator xc observed value of the indicator g time gap (gain or delay) tt target year tcyear of observation tb baseline year a positive time-gap g indicates that the respective country is “on track” to achieve the target on time or even earlier; a negative value indicates that it may still be “likely” or even “unlikely” to achieve the target within the target timeframe i.e. in 2030. a country is still considered likely to achieve the target as long as a negative value for g does not make up for less than -25% of the remaining time tr i.e. the relative gap gr is: gr = g / tr>= 0.25. we standardized the rates by the oecd 1980 standard population (10) (annex 1) employing the direct method (e.g. armitage (11). for details of the calculation see also chernyavskiy et al. (6). the federal research institute for health organization and informatics of the russian ministry of health provided the demographic data (annex 1 and 2) which are used to calculate the time gap for sdg 3 of the entire russian federation and separately for the 8 districts. on the basis of these data we analyze the age groups 0-<70, 0-<30, and 30-<70 as well as both sexes together and separate. for the determination of the gap in 2024 and 2030 and the analysis of the trajectory 19602030, based on life expectancy data, we made use of the database of the world bank (1) and identified the peak data before and after the crisis during the 1990ies. chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 5 | 12 results if russia keeps the present level of effort to improve the life of the russian citizens a reduction of one third of the level of premature mortality as in 2013 will be in reach already in 2024 (table 1) i.e. 6.1 years in advance of the sdg 3 target for 2030, here applied not only to ncd mortality in general but to the overall premature mortality before age 70. table 1. projected reduction of premature years of life lost (pyll) targeted 2013-2030 russian federation and federal districts pyll/ 100,000 2013* pyll/ 100,000 2018 pyll/ 100,000 target 2030 based on 2013 years up to 2030 in 2018 years needed as of 2018 years in advance/delay of 2030 gr to be >= -0.25 eu-27 (for comparison) 3,243 3,066 2,162 12 14.2 -2.2 -0.18 russian federation 0-<70 years of age 10,313 8,060 6,875 12 5.9 6.1 0.51 0-<30 years of age 6,283 4,043 4,189 12 -1.2 13.2 1.10 30-<70 years of age 15,073 12,881 10,049 12 9.6 2.4 0.20 males 0-<70 15,137 11,480 10,091 12 4.7 7.3 0.61 females 0-<70 5,809 4,689 3,873 12 7.2 4.8 0.40 federal districts: north caucasus 7,153 4,970 4,769 12 1.4 10.6 0.88 south 8,351 6,032 5,567 12 2.8 9.2 0.76 privolzhskiy (volga) 10,010 7,295 6,667 12 3.2 8.8 0.73 far east 12,529 9,203 8,352 12 3.5 8.5 0.71 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 6 | 12 * for sevastopol 2015-2020 all districts reach the target in advance of 2030, the district of north caucasus 10.6 years earlier and the north west district still 5 years in advance of 2030. for comparison, the progress of the eu-27 has been calculated which at a considerably lower level shows smaller rates of reduction and therefore a delay of -2.2 years in 2030. already in 2016 russia achieved the corresponding target for the younger age group 0<29 years of age and needs only 9.6 years to reach the target in the elder group 30-<70. for males the target will be achieved 7.3 years in advance i.e. in 2022 and for females 4.8 years in advance. the example of males and females 0-<70 is used in table 2 to demonstrate the level of uncertainty. the averaged trend we use is a conservative estimate between the straight continuation of the trend 2013-2018 and the target line for 2030. uralskiy 11,910 9,032 7,940 12 4.7 7.3 0.61 siberian 11,829 9,133 7,885 12 5.4 6.6 0.55 central 9,322 7,272 6,208 12 5.8 6.2 0.52 north west 9,726 7,824 6,483 12 7.0 5.0 0.41 special territories: crimea 0-<70 9,730 8,388 6,480 12 11.6 0.4 0.03 sevastopol 0-<70 10,085 7,252 6,723 12 9.6 2.4 0.80 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 7 | 12 table 2. projected reduction of premature years of life lost (pyll) targeted 2013-2030 for both sexes separately with levels of uncertainty trend projections males 0-<70 pyll/100,000 females 0-<70 pyll/100,000 targets based on 2013 reduced by 1/3 10,091 3,873 averaged estimate of trends 8,957 3,721 corresponding to 7.3 years in advance of 2030 for males and 4.8 years for females (see table 1) straight projection of the trend 20132018 to 2030 7,823 3,569 as the sdgs have been accepted in 2015/16 (2) we applied the 1/3 reduction in addition to the baseline in 2013 also to the data estimated for 2015 as an average of 2013 and 2018, and to the data of 2018 which constitutes a more demanding i.e. lower target for 2030 (annex 4a and b). however, the general impression is the same in that still all federal districts would achieve the target before 2030 whether the 1/3 reduction is based on 2015 or 2018. furthermore we applied different baselines for the entire russian federation, namely also 2003 and 2009 (annex 4c), which predict likewise an achievement of the targets before 2030. a look at the presidential targets, formulated as improvements in life expectancy (le), demonstrates that targeted achievements in 2024 and 2030 are possible with only small delays of 0.9 and 1.3 years respectively (annex 4d). finally we show data for smaller subunits i.e. the 4 oblasts with the highest mortality and 4 republics/autonomous districts with the lowest mortality (annex 5). the uralskiy district contains the highest as well as one of the lowest ranking oblasts. although the rates are already considerably lower in the caucasian republics, they show similar reductions of mortality as indicated for the north caucasus in table 1, in other words the positive developments seem to be similar across the entire russian federation. discussion the gap-analysis shows clearly that all districts of the russian federation are in line and will reach the targeted reduction of premature mortality several years before 2030. it is astonishing how the russian federation managed to continue the upward trend of the late 1980ies after the catastrophic down-turn in the mid-nineties (1), an observation which has been noted already very early in 2003 (12). an explanation may be a short-termed ‘glasgow-effect’ (13), the observation that life expectancy is persistently much lower in chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 8 | 12 one district of glasgow than in the rest of the united kingdom, likely due to persisting social deprivation. the deprivation of the midnineties has obviously been overcome in the early 2000s contrary to the united kingdom, taking the example of glasgow. nevertheless, russia had and has higher levels of mortality than the eu average, a situation that persists until today (3). the decrease in pyll began to slow down in the second half of the last decade. whereas the trajectory 2003-2018-2030 results in a gap ratio of 0.71 allowing to reach the target already in 2021, for the trajectory 2013-2018-2030 (used in the main body of this paper) we get a gap ratio of 0.51 corresponding to 2023 or 6.1 years in advance of 2030. accordingly gr is further reduced if we base the target calculation on the observation year 2018, however, still the 2030 target will be reached at least 2.8 years in advance. in the formula (9), as described above, the factor (xc − xb) / (xt – xb) determines the proportion of the remaining time to achieve the targets. the higher the baseline value (compared to the observed value) the faster the targeted reduction is achieved, and the lower the baseline, the flatter is the projected line of reduction. this phenomenon follows the rule of “diminishing marginal returns” as varian (14) states: “…the marginal product of a factor will diminish as we get more and more of that factor”. depending where a combination of input/output is located on a production curve, i.e. in a steep or more flatten part of the curve, the effectivity of the input will be higher or lower. to maintain nevertheless the same size of the product it would require more and more resources or time. the latter applies to the situation wherein we find the eu27: the projection of its trajectory 20132018 to 3030 is flatter than required and leads to a delay of at least -2.2 years or more whereas the corresponding trajectory of the rf is much steeper and indicates an earlier achievement by at least +6.1 years. there are other reasons to be skeptical about the future of the recent steep increase in russian life expectancy. in adulthood e.g. at age 30 to <70 years –the pyll rate did not decrease to a degree comparable to the younger age group under 30 years of age according to the data presented in table 1. this means that although russia went through the epidemiological transition already in the mid-20th century, progress in the prevention and management of chronic conditions remained weak. the initial question, posed in the headline of this paper, is whether the russian federation returned to the trajectory of 1988. based on the le data of the world bank (1) the calculations presented in table 3 demonstrate that this question can be answered positively: after the nineties russia returned to the earlier trajectory. chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 9 | 12 table 3. life expectancy at birth according to the trajectory 1960-1988 for the russian federation targeting 2017 and 2030 along the same trajectory year 1960 1988 improvement of le 1988-1960 per 10 years 2017 le target based on 1960-1988 2017 le observed 2030 le target based on 1960-1988 gapanalysis 19601988-2030 life expectancy (le) 66.1 69.5 +1.2 72.9 72.4 74.5 0.3 years in advance; gr = +0.01 the objective of increasing the longevity of russian people has been an important element of state policy for the past 18 years. the current health and demography national projects are aimed at improving the performance of health services and to raise the living standards of the russian citizens in such a way that they not only live longer but lead active lives in decent conditions. russia plans to spend 1.7 trillion rubles ($26.68 billion) on dramatically improving health care to accomplish the goal of raising life expectancy. these plans may be even accelerated given the devastating effects of the covid19 pandemic (15). conclusion the russian federation is on track with regard to sdg 3 and very likely will have reduced its mortality rates calculated as pyll by one third as of 2013. this is mainly due to a steep improvement in the age group 0-<30, a success which occurred after the deep decrease of life expectancy in the mid-nineties. the impressive improvement occurred quite evenly throughout the 8 administrative districts of the russian federation, between north caucasus best and the north west district still in advance. also the smaller subunits (oblasts or republics) obviously follow the same trajectories whether ranking highest or lowest regarding their mortality rates. in summary after the steep decrease of life expectancy during the 1990ies the russian federation returned to the original trajectory. key-points:  during the 1990ies russia experienced a steep decrease of life expectancy from 69.5 in 1988 to 64.5 years in 1994.  since the 2000nds premature years of life lost as well as life expectancy improved again so that russia is likely to reach the sdg target of mortality reduction by 1/3 in 2030.  the reduction of premature mortality is with some variation evenly distributed across all eight federal districts chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? 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[original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 11 | 12 1991-2001: analysis by cause and region. br med j 2003;327:964. 13. cowley j, kiely j, collins d. unravelling the glasgow effect: the relationship between accumulative biopsychosocial stress, stress reactivity and scotland's health problems. prev med rep 2016;4:370-5. doi: 10.1016/j.pmedr.2016.08.004. 14. varian hr. intermediate microeconomics a modern approach. 8th. new york, london: w. w. norton & company; 2010:339. 15. mckee m, stuckler d. if the world fails to protect the economy, covid-19 will damage health not just now but also in the future. nat med 2020;26:640-2. doi.org/10.1038/s41591-020-0863-y. _________________________________________________________________________________________ © 2020 chernyavskiy et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://dx.doi.org/10.1016%2fj.pmedr.2016.08.004 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 12 | 12 annexed data the annexed data are attached to this pdf (left upper corner of the screen). chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 1 | p a g e annex 1a): reference population and demographic data for the russian federation age group total total (%) age groups (%) (0-69 years) males females 0-4 80,269,483 8.12 0.09 41,086,449 39,183,034 5-9 84,285,393 8.52 0.09 43,136,842 41,148,551 10-14 85,828,597 8.68 0.09 43,940,121 41,888,476 15-19 87,597,591 8.86 0.10 44,669,180 42,928,411 20-24 82,619,776 8.36 0.09 41,732,681 40,887,095 25-29 77,252,661 7.81 0.08 38,886,927 38,365,734 30-34 73,604,119 7.44 0.08 37,039,695 36,564,424 35-39 61,676,142 6.24 0.07 30,868,724 30,807,418 40-44 57,394,499 5.80 0.06 28,587,578 28,806,921 45-49 54,245,506 5.49 0.06 26,895,533 27,349,973 50-54 52,537,987 5.31 0.06 25,502,142 27,035,845 55-59 48,323,994 4.89 0.05 22,432,778 25,891,216 60-64 36,727,063 3.71 0.04 16,649,007 20,078,056 65-69 36,887,734 3.73 0.04 16,137,708 20,750,026 subtotal 919,250,545 92.97 1.00 457,565,365 461,685,180 >= 70 years 69,516,189 7.031 total 988,766,734 100 oecd population as of 1980 used as reference population chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 2 | p a g e age group total total (%) age groups (%) (0-69 years) males females 0-4 8,793,034 6.13 0.07 4,513,291 4,279,743 5-9 7,551,503 5.26 0.06 3,865,465 3,686,038 10-14 6,755,921 4.71 0.05 3,462,421 3,293,500 15-19 7,053,773 4.92 0.05 3,608,288 3,445,485 20-24 10,409,834 7.25 0.08 5,300,635 5,109,200 25-29 12,539,045 8.74 0.10 6,323,823 6,215,222 30-34 11,503,330 8.02 0.09 5,734,091 5,769,239 35-39 10,536,322 7.34 0.08 5,145,843 5,390,480 40-44 9,656,787 6.73 0.07 4,689,062 4,967,725 45-49 9,365,913 6.53 0.07 4,444,476 4,921,438 50-54 11,310,282 7.88 0.09 5,204,737 6,105,546 55-59 10,508,049 7.32 0.08 4,587,152 5,920,897 60-64 8,819,230 6.15 0.07 3,635,352 5,183,878 65-69 4,861,126 3.39 0.04 1,877,878 2,983,249 subtotal 129,664,146 90.35 1 62,392,510 67,271,637 >= 70 years 13,842,849 9.65 total 143,506,995 100 russian federation population as of 2013 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 3 | p a g e age group total total (%) age groups (%) (0-69 years) males females 0-4 9,050,624 0.06 6.90 4,652,417 4,398,207 5-9 8,836,526 0.06 6.74 4,535,274 4,301,252 10-14 7,591,733 0.05 5.79 3,885,862 3,705,871 15-19 6,784,546 0.05 5.18 3,468,156 3,316,390 20-24 7,112,528 0.05 5.43 3,625,761 3,486,767 25-29 10,511,622 0.07 8.02 5,354,210 5,157,412 30-34 12,537,872 0.09 9.57 6,290,436 6,247,436 35-39 11,397,288 0.08 8.70 5,629,199 5,768,089 40-44 10,359,339 0.07 7.90 4,995,282 5,364,057 45-49 9,437,707 0.07 7.20 4,515,230 4,922,477 50-54 9,050,420 0.06 6.90 4,200,786 4,849,634 55-59 10,756,648 0.07 8.21 4,792,508 5,964,140 60-64 9,737,757 0.07 7.43 4,045,900 5,691,857 65-69 7,912,023 0.05 6.04 3,043,166 4,868,857 subtotal 131,076,633 0.91 100 63,034,187 68,042,446 >= 70 years 13,401,216 9.276 total 144,477,849 100 russian federation population as of 2018 (without crimea & sevastopol) chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 4 | p a g e age group total total (%) age groups (%) (0-69 years) males females 0-4 18,550 0.99 2.17 10,567 7,982 5-9 1,878 0.10 0.22 1,120 758 10-14 1,930 0.10 0.23 1,234 696 15-19 5,478 0.29 0.64 3,930 1,549 20-24 15,314 0.82 1.80 12,034 3,280 25-29 29,729 1.59 3.49 22,980 6,750 30-34 44,424 2.37 5.21 33,885 10,539 35-39 51,038 2.73 5.98 38,699 12,340 40-44 53,882 2.88 6.32 39,702 14,180 45-49 68,119 3.64 7.99 49,808 18,312 50-54 111,658 5.97 13.09 80,673 30,985 55-59 146,852 7.85 17.22 101,408 45,444 60-64 177,781 9.50 20.84 118,451 59,330 65-69 126,244 6.74 14.80 76,787 49,458 subtotal 852,878 45.56 100 591,277 261,601 >= 70 years 1,018,931 54.436 total 1,871,809 100 number of deaths, russian federation as of 2013 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 5 | p a g e study population (russian federation) deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 0-4 10,565 9,050,624 80,269,483 0.00117 93,698 6,316,727 5-9 1,624 8,836,526 84,285,393 0.00018 15,494 966,888 10-14 1,912 7,591,733 85,828,597 0.00025 21,617 1,240,846 15-19 4,073 6,784,546 87,597,591 0.00060 52,592 2,755,719 20-24 7,026 7,112,528 82,619,776 0.00099 81,614 3,874,045 25-29 15,858 10,511,622 77,252,661 0.00151 116,545 4,952,301 sum 41,058 49,887,579 497,853,501 0.00078 381,559 20,126,858.00 standardized rate (per 100 000) 76.64 4,042.73 russian federation age groups 0-29 standardized death rates 2018 direct standardization study population (russian federation) deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 0-4 18,550 8,793,034 80,269,483 0.00211 169,338 11,430,295 5-9 1,878 7,551,503 84,285,393 0.00025 20,957 1,309,802 10-14 1,930 6,755,921 85,828,597 0.00029 24,520 1,409,873 15-19 5,478 7,053,773 87,597,591 0.00078 68,034 3,571,808 20-24 15,314 10,409,834 82,619,776 0.00147 121,542 5,773,229 25-29 29,729 12,539,045 77,252,661 0.00237 183,161 7,784,361 sum 72,879 53,103,108 497,853,501 0.00121 587,552 31,279,367.54 standardized rate (per 100 000) 118.02 6,282.85 russian federation age groups 0-29 standardized death rates 2013 direct standardization chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 6 | p a g e study population (russian federation) deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 30-34 44,424 11,503,330 73,604,119 0.00386 284,247 10,659,263 35-39 51,038 10,536,322 61,676,142 0.00484 298,762 9,709,774 40-44 53,882 9,656,787 57,394,499 0.00558 320,243 8,806,685 45-49 68,119 9,365,913 54,245,506 0.00727 394,534 8,877,020 50-54 111,658 11,310,282 52,537,987 0.00987 518,668 9,076,695 55-59 146,852 10,508,049 48,323,994 0.01398 675,339 8,441,739 60-64 177,781 8,819,230 36,727,063 0.02016 740,355 5,552,659 65-69 126,244 4,861,126 36,887,734 0.02597 957,981 2,394,951 sum 779,999 76,561,038 421,397,044 0.01144 4,190,129 63,518,786.64 standardized rate (per 100 000) 994.34 15,073.38 russian federation age groups 30-69 standardized death rates 2013 direct standardization study population (russian federation) deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 30-34 31,700 12,537,872 73,604,119 0.00253 186,094 6,978,526 35-39 46,057 11,397,288 61,676,142 0.00404 249,236 8,100,156 40-44 54,854 10,359,339 57,394,499 0.00530 303,911 8,357,561 45-49 60,855 9,437,707 54,245,506 0.00645 349,779 7,870,031 50-54 79,395 9,050,420 52,537,987 0.00877 460,892 8,065,619 55-59 133,886 10,756,648 48,323,994 0.01245 601,481 7,518,515 60-64 177,631 9,737,757 36,727,063 0.01824 669,957 5,024,674 65-69 203,002 7,912,023 36,887,734 0.02566 946,444 2,366,111 sum 787,381 81,189,054 421,397,044 0.01043 3,767,795 54,281,192.39 standardized rate (per 100 000) 894.12 12,881.25 russian federation age groups 30-69 standardized death rates 2018 direct standardization without crimea and sevastopol chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 7 | p a g e study population (russian federation) deaths males population males (oecd 1980) males crude rate males expected deaths (standard pop.) males pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) males 0-4 10,567 4,513,291 41,086,449 0.00234 96,199.80 6,493,487 5-9 1,120 3,865,465 43,136,842 0.00029 12,496.00 781,002 10-14 1,234 3,462,421 43,940,121 0.00036 15,663.30 900,641 15-19 3,930 3,608,288 44,669,180 0.00109 48,648.30 2,554,034 20-24 12,034 5,300,635 41,732,681 0.00227 94,746.80 4,500,475 25-29 22,980 6,323,823 38,886,927 0.00363 141,308.60 6,005,616 30-34 33,885 5,734,091 37,039,695 0.00591 218,882.80 8,208,104 35-39 38,699 5,145,843 30,868,724 0.00752 232,143.80 7,544,673 40-44 39,702 4,689,062 28,587,578 0.00847 242,048.20 6,656,327 45-49 49,808 4,444,476 26,895,533 0.01121 301,409.60 6,781,716 50-54 80,673 5,204,737 25,502,142 0.0155 395,281.50 6,917,426 55-59 101,408 4,587,152 22,432,778 0.02211 495,921.80 6,199,023 60-64 118,451 3,635,352 16,649,007 0.03258 542,474.80 4,068,561 65-69 76,787 1,877,878 16,137,708 0.04089 659,871.90 1,649,680 sum 591,277 62,392,510 457,565,365 0.01101 3,497,097 69,260,763.68 standardized rate (per 100 000) 764.28 15,136.80 russian federation standardized death rates 2013 males direct standardization chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 8 | p a g e study population (russian federation) deaths females population females (oecd 1980) females crude rate females expected deaths (standard pop.) females pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) females 0-4 7,982 4,279,743 39,183,034 0.00187 73,083 4,933,134 5-9 758 3,686,038 41,148,551 0.00021 8,460 528,762 10-14 696 3,293,500 3,293,500 41,888,476 0.00021 8,849 508,837 15-19 1,549 3,445,485 42,928,411 0.00045 19,296 1,013,056 20-24 3,280 5,109,200 40,887,095 0.00064 26,246 1,246,696 25-29 6,750 6,215,222 38,365,734 0.00109 41,664 1,770,737 30-34 10,539 5,769,239 36,564,424 0.00183 66,794 2,504,757 35-39 12,340 5,390,480 30,807,418 0.00229 70,524 2,292,044 40-44 14,180 4,967,725 28,806,921 0.00285 82,227 2,261,244 45-49 18,312 4,921,438 27,349,973 0.00372 101,763 2,289,678 50-54 30,985 6,105,546 27,035,845 0.00507 137,204 2,401,064 55-59 45,444 5,920,897 25,891,216 0.00768 198,721 2,484,010 60-64 59,330 5,183,878 20,078,056 0.01145 229,795 1,723,460 65-69 49,458 2,983,249 20,750,026 0.01658 344,004 860,010 sum 261,601 67,271,637 461,685,180 1,408,631 26,817,489.06 standardized rate (per 100 000) 305.11 5,808.61 russian federation standardized death rates 2013 females direct standardization chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 9 | p a g e study population (russian federation) deaths males population males (oecd 1980) males crude rate males expected deaths (standard pop.) males pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) males 0-4 6,004 4,652,417 41,086,449 0.00129 0.00021 0.00031 0.00082 0.00146 0.00222 0.00374 0.00597 0.00793 0.00959 0.01345 0.01929 0.02945 0.04069 0.00974 53,021.0 3,578,915 5-9 963 4,535,274 43,136,842 0.00021 9,157.5 572,345 10-14 1,198 3,885,862 43,940,121 0.00031 13,552.0 779,238 15-19 2,829 3,468,156 44,669,180 0.00082 36,439.3 1,913,063 20-24 5,295 3,625,761 41,732,681 0.00146 60,949.8 2,895,115 25-29 11,860 5,354,210 38,886,927 0.00222 86,140.9 3,660,988 30-34 23,498 6,290,436 37,039,695 0.00374 138,364.4 5,188,665 35-39 33,579 5,629,199 30,868,724 0.00597 184,135.6 5,984,408 40-44 39,606 4,995,282 4,995,282 4,995,282 28,587,578 0.00793 226,659.8 6,233,143 45-49 43,288 4,515,230 26,895,533 0.00959 257,848.3 5,801,588 50-54 56,512 4,200,786 25,502,142 0.01345 343,074.5 6,003,803 55-59 92,468 4,792,508 22,432,778 0.01929 432,822.4 5,410,279 60-64 119,151 4,045,900 16,649,007 0.02945 490,310.9 3,677,332 65-69 123,829 3,043,166 16,137,708 0.04069 656,659.4 830,510 sum 560,081 63,034,187 457,565,365 0.00974 2,989,136 52,529,392.22 standardized rate (per 100 000) 653.27 11,480.19 russian federation standardized death rates 2018 males direct standardization without crimea and sevastopol chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 10 | p a g e study population (russian federation) deaths females population females (oecd 1980) females crude rate females expected deaths (standard pop.) females pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) females 0-4 4,559 4,398,207 39,183,034 0.00104 40,615 2,741,509 5-9 656 4,301,252 41,148,551 0.00015 6,272 391,992 10-14 707 3,705,871 41,888,476 0.00019 7,987 459,276 15-19 1,238 3,316,390 42,928,411 0.00037 16,027 841,402 20-24 1,724 3,486,767 40,887,095 0.00049 20,211 960,035 25-29 3,973 5,157,412 38,365,734 0.00077 29,552 1,255,968 30-34 8,133 6,247,436 36,564,424 0.00130 47,603 1,785,098 35-39 12,309 5,768,089 30,807,418 0.00213 65,744 2,136,675 40-44 14,938 5,364,057 28,806,921 0.00278 80,221 2,206,069 45-49 17,108 4,922,477 27,349,973 0.00348 95,053 2,138,688 50-54 22,275 4,849,634 27,035,845 0.00459 124,182 2,173,180 55-59 40,680 5,964,140 25,891,216 0.00682 176,599 2,207,488 60-64 57,538 5,691,857 20,078,056 0.01011 202,965 1,522,234 65-69 77,949 4,868,857 20,750,026 0.01601 332,204 830,510 sum 263,786 68,042,446 461,685,180 0.00359 1,245,234 21,650,123.93 standardized rate (per 100 000) 269.71 4,689.37 russian federation standardized death rates 2018 females direct standardization without crimea and sevastopol chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 11 | p a g e annex 1b): demographic data for eu-27 (2013 – 2018) population 2013 age group total males females 0-4 26,367,688 13,522,230 12,845,458 5-9 26,055,719 13,361,936 12,693,783 10-14 26,002,566 13,336,156 12,666,410 15-19 27,170,288 13,932,044 13,238,244 20-24 30,484,999 15,517,232 14,967,767 25-29 31,881,413 16,078,060 15,803,353 30-34 33,931,920 17,054,549 16,877,371 35-39 34,909,609 17,560,009 17,349,600 40-44 36,790,201 18,454,921 18,335,280 45-49 37,384,521 18,679,726 18,704,795 50-54 35,350,828 17,498,896 17,851,932 55-59 32,830,780 16,022,787 16,807,993 60-64 30,566,866 14,692,794 15,874,072 65-69 25,481,804 12,022,423 13,459,381 subtotal 435,209,202 217,733,763 217,475,439 >= 70 years 65,691,666 total 500,900,868 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 12 | p a g e population 2018 age group total males females 0-4 25,936,779 13,091,321 12,845,458 5-9 26,581,279 13,887,496 12,693,783 10-14 26,308,664 13,642,254 12,666,410 15-19 27,011,063 13,772,819 13,238,244 20-24 30,484,999 15,517,232 14,967,767 25-29 31,881,413 16,078,060 15,803,353 30-34 33,931,920 17,054,549 16,877,371 35-39 34,909,609 17,560,009 17,349,600 40-44 36,790,201 18,454,921 18,335,280 45-49 37,384,521 18,679,726 18,704,795 50-54 35,350,828 17,498,896 17,851,932 55-59 32,830,780 16,022,787 16,807,993 60-64 30,566,866 14,692,794 15,874,072 65-69 25,481,804 12,022,423 13,459,381 subtotal 435,450,726 217,975,287 217,475,439 >= 70 years 72,815,781 total 508,266,507 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 13 | p a g e direct standardization study population (europe-27) deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 0-4 22,551 26,367,688 80,269,483 0.00086 68,651 4,633,914 5-9 2,404 26,055,719 84,285,393 0.00009 7,776 486,031 10-14 2,649 26,002,566 85,828,597 0.00010 8,744 502,766 15-19 7,280 27,170,288 87,597,591 0.00027 23,471 1,232,221 20-24 12,239 30,484,999 82,619,776 0.00040 33,170 1,575,569 25-29 15,212 31,881,413 77,252,661 0.00048 36,861 1,566,575 30-34 20,527 33,931,920 73,604,119 0.00060 44,527 1,669,746 35-39 30,890 34,909,609 61,676,142 0.00088 54,575 1,773,673 40-44 51,336 36,790,201 57,394,499 0.00140 80,087 2,202,383 45-49 87,021 37,384,521 54,245,506 0.00233 126,269 2,841,048 50-54 139,002 35,350,828 52,537,987 0.00393 206,583 3,615,205 55-59 208,505 32,830,780 48,323,994 0.00635 306,901 3,836,261 60-64 288,697 30,566,866 36,727,063 0.00944 346,879 2,601,590 65-69 351,949 25,481,804 36,887,734 0.01381 509,485 1,273,713 sum 1,240,262 435,209,202 919,250,545 0.00292 1,853,977 29,810,693.11 standardized rate (per 100 000) 201.68 3,242.93 europe 27 standardized death rates 2013 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 14 | p a g e study population (europe-27) deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 0-4 20,568 25,936,779 80,269,483 0.00079 63,654 4,296,653 5-9 2,131 26,581,279 84,285,393 0.00008 6,757 422,318 10-14 2,620 26,308,664 85,828,597 0.00010 8,547 491,476 15-19 6,753 27,011,063 87,597,591 0.00025 21,900 1,149,758 20-24 10,496 30,484,999 82,619,776 0.00034 28,446 1,351,186 25-29 14,067 31,881,413 77,252,661 0.00044 34,086 1,448,659 30-34 19,823 33,931,920 73,604,119 0.00058 42,999 1,612,480 35-39 29,729 34,909,609 61,676,142 0.00085 52,523 1,707,009 40-44 47,033 36,790,201 57,394,499 0.00128 73,374 2,017,778 45-49 79,064 37,384,521 54,245,506 0.00211 114,723 2,581,269 50-54 129,631 35,350,828 52,537,987 0.00367 192,656 3,371,481 55-59 200,067 32,830,780 48,323,994 0.00609 294,481 3,681,011 60-64 292,481 30,566,866 36,727,063 0.00957 351,425 2,635,689 65-69 392,665 25,481,804 36,887,734 0.01541 568,426 1,421,065 sum 1,247,128 435,450,726 919,250,545 0.00297 1,853,999 28,187,834.47 standardized rate (per 100 000) 201.69 3,066.39 europe 27 standardized death rates 2018 direct standardization chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 15 | p a g e annex 2): demographic data for crimea and sevastopol 2015 – 2018 age group total total (%) males females 0-4 117,804 6.13 60,691 57,113 5-9 108,083 5.62 55,308 52,775 10-14 84,242 4.38 43,248 40,994 15-19 81,483 4.24 41,866 39,617 20-24 106,545 5.54 54,411 52,134 25-29 152,380 7.93 76,975 75,405 30-34 152,465 7.93 76,831 75,634 35-39 136,698 7.11 68,023 68,675 40-44 125,490 6.53 60,553 64,937 45-49 117,916 6.13 55,540 62,376 50-54 138,461 7.20 63,119 75,342 55-59 146,255 7.61 63,420 82,835 60-64 133,454 5.12 54,820 78,634 65-69 98,440 5.12 37,530 60,910 subtotal 1,699,716 86.60 812,335 887,381 >= 70 years 222,524 11.576 total 1,922,240 98 population of crimea as of 2015 source: копия pop-deaths-crimea 15-18.xlsx chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 16 | p a g e age group total total (%) males females 0-4 113,197 0.06 58,121 55,076 5-9 118,013 0.06 60,779 57,234 10-14 98,431 0.05 50,333 48,098 15-19 78,903 0.04 40,501 38,402 20-24 89,382 0.05 46,032 43,350 25-29 127,652 0.07 64,635 63,017 30-34 162,655 0.08 81,839 80,816 35-39 145,774 0.08 73,020 72,754 40-44 132,382 0.07 64,605 67,777 45-49 121,248 0.06 57,587 63,661 50-54 120,690 0.06 55,323 65,367 55-59 143,834 0.07 63,187 80,647 60-64 137,752 0.07 56,726 81,026 65-69 119,098 0.06 45,890 73,208 subtotal 1,709,011 0.88 818,578 890,433 >= 70 years 222,440 11.517 total 1,931,451 100 population of crimea as of 2018 source: копия pop-deaths-crimea 15-18.xlsx age group total total (%) males females 0-4 182 0.63 104 78 5-9 24 0.08 12 12 10-14 25 0.09 16 9 15-19 48 0.17 33 15 20-24 130 0.45 93 37 25-29 283 0.97 222 61 30-34 454 1.56 325 129 35-39 647 2.22 482 165 40-44 824 2.83 597 227 45-49 981 3.37 719 262 50-54 1,465 5.04 1,038 427 55-59 2,090 7.19 1,413 677 60-64 2,807 9.65 1,835 972 65-69 2,629 9.04 1,526 1,103 subtotal 12,589 43.28 8,415 4,174 >= 70 years 16,499 56.721 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 17 | p a g e total 29,088 100 258,475 270,288 number of deaths crimea as of 2015 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 18 | p a g e age group total total (%) males females 0-4 105 0.39 50 55 5-9 24 0.09 12 12 10-14 18 0.07 8 10 15-19 49 0.18 38 11 20-24 88 0.33 61 27 25-29 193 0.71 150 43 30-34 426 1.58 318 108 35-39 608 2.25 439 169 40-44 817 3.03 590 227 45-49 966 3.58 681 285 50-54 1,112 4.12 798 314 55-59 1,812 6.71 1,249 563 60-64 2,502 9.27 1,642 860 65-69 2,948 10.92 1,758 1,190 subtotal 11,668 43.22 7,794 3,874 >= 70 years 15,331 56.784 total 26,999 100 244,013 264,423 number of deaths crimea as of 2018 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 19 | p a g e study population crimea deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 0-4 182 117,804 80,269,483 0.00154 124,011 8,370,773 5-9 24 108,083 84,285,393 0.00022 18,716 1,169,731 10-14 25 84,242 85,828,597 0.00030 25,471 1,464,574 15-19 48 81,483 87,597,591 0.00059 51,602 2,709,104 20-24 130 106,545 82,619,776 0.00122 100,808 4,788,372 25-29 283 152,380 77,252,661 0.00186 143,474 6,097,627 30-34 454 152,465 73,604,119 0.00298 219,173 8,219,002 35-39 647 136,698 61,676,142 0.00473 291,917 9,487,301 40-44 824 125,490 57,394,499 0.00657 376,867 10,363,848 45-49 981 117,916 54,245,506 0.00832 451,294 10,154,126 50-54 1,465 138,461 52,537,987 0.01058 555,883 9,727,957 55-59 2,090 146,255 48,323,994 0.01429 690,555 8,631,940 60-64 2,807 133,454 36,727,063 0.02103 772,497 5,793,730 65-69 2,629 98,440 36,887,734 0.02671 985,147 2,462,867 sum 12,589 1,699,716 919,250,545 0.00721 4,807,416 89,440,953.28 standardized rate (per 100 000) 522.97 9,729.77 crimea standardized death rates 2015 direct standardization chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 20 | p a g e study population crimea deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 0-4 105 113,197 80,269,483 0.00093 74,457 5,025,840 5-9 24 118,013 84,285,393 0.00020 17,141 1,071,306 10-14 18 98,431 85,828,597 0.00018 15,695 902,486 15-19 49 78,903 87,597,591 0.00062 54,399 2,855,973 20-24 88 89,382 82,619,776 0.00098 81,342 3,863,761 25-29 193 127,652 77,252,661 0.00151 116,800 4,964,003 30-34 426 162,655 73,604,119 0.00262 192,772 7,228,956 35-39 608 145,774 61,676,142 0.00417 257,241 8,360,342 40-44 817 132,382 57,394,499 0.00617 354,212 9,740,833 45-49 966 121,248 54,245,506 0.00797 432,182 9,724,087 50-54 1,112 120,690 52,537,987 0.00921 484,069 8,471,201 55-59 1,812 143,834 48,323,994 0.01260 608,779 7,609,734 60-64 2,502 137,752 36,727,063 0.01816 667,076 5,003,073 65-69 2,948 119,098 36,887,734 0.02475 913,072 2,282,680 sum 11,668 1,709,011 919,250,545 0.00643 4,269,238 77,104,274.01 standardized rate (per 100 000) 464.43 8,387.73 crimea standardized death rates 2018 direct standardization chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 21 | p a g e age group total total (%) males females 0-4 23,079 5.60 11,926 11,153 5-9 20,924 5.07 10,630 10,294 10-14 16,881 4.09 8,638 8,243 15-19 17,514 4.25 9,729 7,785 20-24 24,960 6.05 14,442 10,518 25-29 34,683 8.41 17,600 17,083 30-34 35,612 8.64 17,951 17,661 35-39 31,119 7.55 15,453 15,666 40-44 28,121 6.82 14,043 14,078 45-49 24,114 5.85 11,548 12,566 50-54 26,996 6.55 12,170 14,826 55-59 29,216 7.08 12,258 16,958 60-64 28,561 5.49 11,436 17,125 65-69 22,647 5.49 8,456 14,191 subtotal 364,427 86.93 176,280 188,147 >= 70 years 47,987 11.636 total 412,414 99 sevastopol population as of 2015 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 22 | p a g e age group total total (%) males females 0-4 25,907 0.06 13,385 12,522 5-9 24,440 0.06 12,622 11,818 10-14 21,176 0.05 10,747 10,429 15-19 18,187 0.04 9,617 8,570 20-24 23,031 0.05 13,814 9,217 25-29 31,677 0.07 16,935 14,742 30-34 41,106 0.09 20,599 20,507 35-39 36,998 0.08 18,544 18,454 40-44 32,102 0.07 15,810 16,292 45-49 27,831 0.06 13,667 14,164 50-54 25,327 0.06 11,859 13,468 55-59 29,555 0.07 12,747 16,808 60-64 29,432 0.07 11,955 17,477 65-69 26,716 0.06 10,125 16,591 subtotal 393,485 0.89 192,426 201,059 >= 70 years 50,858 11.446 total 444,343 100 sevastopol population as of 2018 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 23 | p a g e age group total total (%) age groups (%) (0-69 years) males females 0-4 33 0.54 1.21 23 10 5-9 2 0.03 0.07 2 0 10-14 3 0.05 0.11 1 2 15-19 12 0.20 0.44 9 3 20-24 31 0.51 1.14 24 7 25-29 61 1.00 2.24 48 13 30-34 135 2.22 4.96 109 26 35-39 159 2.61 5.85 124 35 40-44 215 3.53 7.90 164 51 45-49 206 3.38 7.57 156 50 50-54 275 4.52 10.11 202 73 55-59 462 7.59 16.99 325 137 60-64 553 9.08 20.33 356 197 65-69 573 9.41 21.07 315 258 subtotal 2,720 44.67 100 1,858 862 >= 70 years 3,369 55.329 total 6,089 100 258,475 270,288 number of deaths sevastopol as of 2015 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 24 | p a g e age group total total (%) age groups (%) (0-69 years) males females 0-4 19 0.34 0.82 13 6 5-9 2 0.04 0.09 1 1 10-14 2 0.04 0.09 1 1 15-19 3 0.05 0.13 2 1 20-24 18 0.32 0.78 13 5 25-29 45 0.80 1.94 35 10 30-34 103 1.82 4.45 81 22 35-39 145 2.57 6.26 112 33 40-44 167 2.96 7.21 130 37 45-49 193 3.42 8.33 140 53 50-54 234 4.15 10.10 161 73 55-59 349 6.18 15.06 241 108 60-64 448 7.94 19.34 293 155 65-69 589 10.43 25.42 346 243 subtotal 2,317 41.05 100 1,569 748 >= 70 years 3,328 58.955 total 5,645 100 244,013 264,423 number of deaths of sevastopol as of 2018 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 25 | p a g e study population sevastopol deaths population (oecd 1980) crude rate expected deaths (oecd pop.) expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di = ri * std pi di* (remaining years to upper age limit) 0-4 33 23,079 80,269,483 0.00143 114,775.0 114,775 7,747,315 5-9 2 20,924 84,285,393 0.00010 8,056.3 8,056 503,521 10-14 3 16,881 85,828,597 0.00018 15,253.0 15,253 877,047 15-19 12 17,514 87,597,591 0.00069 60,018.9 60,019 3,150,992 20-24 31 24,960 82,619,776 0.00124 102,612.7 102,613 4,874,103 25-29 61 34,683 77,252,661 0.00176 135,871.0 135,871 5,774,516 30-34 135 35,612 73,604,119 0.00379 279,022.7 279,023 10,463,351 35-39 159 31,119 61,676,142 0.00511 315,129.2 315,129 10,241,700 40-44 215 28,121 57,394,499 0.00765 438,811.5 438,811 12,067,315 45-49 206 24,114 54,245,506 0.00854 463,406.1 463,406 10,426,637 50-54 275 26,996 52,537,987 0.01019 535,188.4 535,188 9,365,797 55-59 462 29,216 48,323,994 0.01581 764,159.5 764,160 9,551,994 60-64 553 28,561 36,727,063 0.01936 711,111.9 711,112 5,333,339 65-69 573 22,647 36,887,734 0.02530 933,310.0 933,310 2,333,275 sum 2,720 364,427 919,250,545 0.00722 4,876,726 4,876,726 92,710,902.83 standardized rate (per 100 000) 530.51 10,085.49 sevastopol standardized death rates 2015 direct standardization chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 26 | p a g e study population sevastopol deaths population (oecd 1980) crude rate expected deaths (oecd pop.) expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di = ri * std pi di* (remaining years to upper age limit) 0-4 19 25,907 80,269,483 0.00073 58,869.0 58,869 3,973,660 5-9 2 24,440 84,285,393 0.00008 6,897.3 6,897 431,083 10-14 2 21,176 85,828,597 0.00009 8,106.2 8,106 466,107 15-19 3 18,187 87,597,591 0.00016 14,449.5 14,449 758,598 20-24 18 23,031 82,619,776 0.00078 64,571.9 64,572 3,067,166 25-29 45 31,677 77,252,661 0.00142 109,744.3 109,744 4,664,132 30-34 103 41,106 73,604,119 0.00251 184,431.1 184,431 6,916,166 35-39 145 36,998 61,676,142 0.00392 241,716.9 241,717 7,855,798 40-44 167 32,102 57,394,499 0.00520 298,575.8 298,576 8,210,835 45-49 193 27,831 54,245,506 0.00693 376,177.0 376,177 8,463,983 50-54 234 25,327 52,537,987 0.00924 485,406.4 485,406 8,494,613 55-59 349 29,555 48,323,994 0.01181 570,633.5 570,634 7,132,919 60-64 448 29,432 36,727,063 0.01522 559,042.0 559,042 4,192,815 65-69 589 26,716 36,887,734 0.02205 813,253.3 813,253 2,033,133 sum 2,317 393,485 919,250,545 0.00573 3,791,874 3,791,874 66,661,009.41 standardized rate (per 100 000) 412.50 7,251.67 sevastopol standardized death rates 2018 direct standardization chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 27 | p a g e annex 3): demographic data of the 8 federal districts federal districts population 2013 2018 north caucasus 9,565,422 9,844,851 south* 13,937,027 14,095,516 privolzhkiy (volga) 29,755,536 29,469,957 far east 8,304,660 8,205,643 uralskiy 12,215,884 12,353,188 siberian 17,219,879 17,201,749 central 38,749,394 39,344,729 north-west 13,759,196 13,962,038 sum 143,506,998 144,477,671 russian federation 143,506,998 144,477,879 difference (districts rf) 0 -178 * without crimea and sevastopol chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 28 | p a g e annex 4a): projected reduction of premature years of life lost (pyll) for 8 federal districts, targeted as of 2015 (estimated) -2030 federal district pyll/ 100,000 2013 pyll/ 100,000 2018 pyll/ 100,000 2015 (estimated as average 2013/2018) pyll/ 100,000 target 2030 based on 2015 years needed years in advance gr to be >= -0.25 north caucasus 7,153 4,970 6,062 4,041 5.1 6.9 0.58 privolzhkiy (volga) 10,010 7,295 8,653 5,768 6.1 5.9 0.49 far est 12,529 9,203 10,866 7,243 6.3 5.7 0.47 uralskiy 11,910 9,032 10,471 6,980 7.1 4.9 0.41 siberian 11,829 9,133 10,481 6,987 7.5 4.5 0.37 south 8,351 6,032 7,359 4,906 7.8 4.2 0.35 central 9,322 7,272 8,297 5,531 7.8 4.2 0.35 north-west 9,726 7,824 8,775 5,849 8.7 3.3 0.28 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 29 | p a g e annex 4b): projected reduction of premature years of life lost (pyll) for 8 federal districts, targeted as of 2018-2030 federal district pyll/ 100,000 2013 pyll/ 100,000 2018 pyll/ 100,000 target 2030 based on 2018 years needed years in advance gr to be >= -0.25 south 8,351 6,032 4,245 7.1 4.9 0.41 north caucasus 7,153 4,970 3,313 7.3 4.7 0.39 privolzhkiy (volga) 10,010 7,295 4,863 8.0 4.0 0.33 far est 12,529 9,203 6,135 8.2 3.8 0.32 uralskiy 11,910 9,032 6,021 8.7 3.3 0.28 siberian 11,829 9,133 6,089 9.0 3.0 0.25 central 9,322 7,272 4,848 9.2 4.8 0.23 north-west 9,726 7,824 5,216 9.8 2.2 0.18 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 30 | p a g e annex 4c): calculation of target achievement of the russian federation using different baseline years 2003 2009 2013 2018 2030 based on 2013 2030 based on 2018 different baselines pyll/ 100,000 pyll/ 100,000 based on 2013 years in adv. gr based on 2018 years in adv. gr 2003 15950 8060 6875 8.5 0.71 5373 5.1 0.43 2009 11935 8060 6875 7.1 0.58 5373 3.4 0.28 2013 10313 8060 6875 6.1 0.51 5373 2.8 0.23 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 31 | p a g e annex 4d): achievability of the presidential targets for 2024 and 2030 target le 2024 target le 2030 le 2013 le 2017 target 2024 target 2030 76 80 70.6 72.4 -0.9 -1.3 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 32 | p a g e annex 5): selected oblasts respectively districts, republics and autonomous regions with the highest and the lowest mortality rate per 100.000 population * autonomous district 2013 2018 2030 oblasts, republics or districts with the highest /lowest mortality in the russian federation death rate per 100,000 population part of larger administra tive district or region deaths per 100,000 populati on pyll per 100,000 populat ion deaths per 100,000 populati on pyll per 100,000 population target value pyll/ 100,000 target achieved, years in advance highest tyumen oblast 2,066 uralskiy federal district 1,155 25,054 976 18,479 16,703 8.4 pskov oblast 1,859 northwestern district 661 12,650 567 10,024 8,433 5.6 tver oblast 1,801 central federal district 637 12,765 549 9,932 8,510 6.3 novgorod oblast 1,783 northwestern district 662 13,322 562 10,369 8,881 6.3 lowest republic dagestan 550 north caucasus 252 7,033 211 5,014 4,689 9.6 yamalo-nenets district * 513 uralskiy federal district 354 9,831 301 7,023 6,554 9.6 republic chechenskaya 493 north caucasus 369 7,050 306 4,603 4,700 12.7 republic ingushetia 350 north caucasus 243 5,325 189 3,756 3,550 10 laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 1 global health competences revised shortlist for a global public health curriculum (16 august 2018) the aspher working group on education for global public health edited by ulrich laaser correspondence: prof. dr. med. ulrich laaser dtm&h, mph section of international public health (s-iph) faculty of health sciences, university of bielefeld pob 10 01 31, d-33501 bielefeld e-mail: ulrich.laaser@uni-bielefeld.de; laaseru@gmail.com the 1st edition of the global public health curriculum has been published in the south eastern european journal of public health, end of 2016 as a special volume (editors ulrich laaser & florida beluli) at: http://www.seejph.com/index.php/seejph/article/view/106/82. the curriculum targets the postgraduate education and training of public health professionals including their continued professional development (cpd). however, specific competences for the curricular modules remained to be identified in a more systematic approach. a first comprehensive draft version of related competences has been published in february 2018 (laaser u, editor: the global public health curriculum: specific global health competences. seejph 2018, vol. 9. doi 10.4119/unibi/seejph-2018-180). the two main categories for the grouping of required competences have been adopted from a. foldspang (public health core competences for essential public health operations, volume 3, aspher 2016 at: http://aspher.org/download/76/booklet-competencesephosvolume-3.pdf): 1.0 the public health professional shall know and understand: 2.0 the public health professional shall be able to: in this 2nd edition we aim at a more operational shortlist of 15 most relevant competences extracted from the 1st edition and based on additional comments from authors of the modules of the global public health curriculum. the rationale behind this approach is that a minimum of 5 competences in each category can be expected to differentiate sufficiently and a maximum of 15 competences in total might have a realistic chance to be remembered and introduced into regular teaching. for relevant literature please refer to the 1st edition. as in the meantime the sustainable development goals (sdg) are operational we included also an additional section (numbered as 2.9b). additional information on a pilot-survey: in the context of preparing the 2nd edition we also run a pilot-survey on the use of the global health modules as published at: http://www.seejph.com/index.php/seejph/article/view/106/82. eleven schools and departments of public health (sdph) from 8 out of 19 european countries (42%) returned the questionnaire with the following results: mailto:ulrich.laaser@uni-bielefeld.de mailto:laaseru@gmail.com http://www.seejph.com/index.php/seejph/article/view/106/82 http://doi.org/10.4119/unibi/seejph-2017-180 http://aspher.org/download/76/booklet-competencesephos-volume-3.pdf http://aspher.org/download/76/booklet-competencesephos-volume-3.pdf http://www.seejph.com/index.php/seejph/article/view/106/82 laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 2 out of the 11 participating sdph 6 have a separate module on global health, 5 of them as obligatory module with teaching hours between 13 and 240 per year, mainly lectures and small group work. 7 sdph have global health content in other modules (out of them 3 with no separate module); 6 institutions publish on global health, 7 participate in projects, mainly on education or research, 4 cooperate with other sdph and 3 are member of a global health organisation. although in no way representative it is of interest that the analytical modules (r 2.0 ff.) got in general considerably better rankings in terms of their relevance than the interventive modules (r 3.0 ff.). participants of the pilot study: genc burazeri, ansgar gerhardus, jouni j. k. jaakkola & timo hugg, mihail kochubovski, anneli milen &mikko perkio, elpida pavi, oliver razum & alexander kraemer, gabriela scintee, mindaugas stankūnas, vesna velikj stefanovska, lijana zaletel kragelj. special thanks go to assistant professor liang-yin hsu, tzu chi university, hualien, taiwan for providing global public health expertise. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 3 r 2.1 demographic challenges (charles surjadi, luka kovacic1, muzaffar malik) there is growing interest in demography, among the public, politicians, and professionals: “demographic change” has become the subject of debates in many developed and developing countries. this is because it impacts on all aspects of people`s life, social relations, economy, and culture. the world population will continue to grow in the 21st century, but at a slower rate compared to the recent past. the annual growth rate reached its peak in the late 1960s, when it was at 2% and above. better health, economic and social conditions resulted in longer life and an ageing population. it is projected that by 2025 more than 20% of europeans will be 65 or over. better living conditions in cities lead to higher urbanization, more than 55% of the world’s population residing in urban areas in 2015. 1.0 the public health professional shall know and understand: 1.1 the definitions of demography, aging, social status, and urbanisation. 1.2 the major determinants of population dynamics. 1.3 the five stages of the global transition model. 1.4 the global distribution of major diseases according to climate, gender and age, social status and culture. 1.5 major environmental effects of urbanization. 2.0 the public health professional shall be able to: 2.1 develop specific population projections and identify their determinants. 2.2 identify the problems accruing from population growth, aging, and urbanisation. 2.3 apply the six determinants of active aging according to the who policy framework to selected populations/countries. 2.4 design realistic improvements of slums and informal settlements. 2.5 develop interventions in interdisciplinary and multi-professional environments. r 2.2 burden of disease (milena santric-milicevic, zorica terzic-supic) health systems today face challenges in the management of available resources. the implemented set of interventions and the criteria used for resource allocation are publicly debated. during reforms and in particular due to tough squeezing of resources, it is crucial to understand a proposed health plan and to have it supported by the public, health professionals, policy makers from other relevant sectors and international community. however, data on health and mortality in populations are not as comprehensive and consistent nor relevant as professionals require, rather are fragmentary and sometimes heterogeneous. the framework of burden of disease and injury study provides information and tools for integration, validation, exploration, and distribution of consistent and comparative descriptors of the burden of diseases, injuries and attributed risk factors, over time and across different health systems. as of 1992, when the first global burden of 1 see obituary at: http://www.seejph.com/index.php/seejph/article/view/19/17 http://www.seejph.com/index.php/seejph/article/view/19/17 laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 4 diseases study was executed, many national burden of disease studies have been undertaken and this framework is currently refining and updating. 1.0 the public health professional shall know and understand: 1.1 health data sources and tools; data integration analysis and reporting. 1.2 surveillance of health system performance. 1.3 identification and monitoring of health hazards; occupational health protection; food safety; road safety. 1.4 primary prevention; secondary prevention; tertiary/quaternary prevention; social support. 1.5 economic assessment (e.g. cost-effectiveness analysis) of different healthcare procedures or programmes. 1.6 setting a national research agenda. 1.7 advocacy for public health improvement. 2.0 a public health student should be able to: 2.1 explore global health data sources and understand the limitations of these data. 2.2 identify the composite health measures and their use for health program monitoring, evaluation and priority setting. 2.3 examine the major categories of morbidity and mortality used by the world health organization (who) and institute of health metrics and evaluation ihme (communicable and parasitic diseases, maternal, perinatal and childhood conditions, and nutritional deficiencies, non-communicable conditions importance and injuries). 2.4 describe the concept of premature mortality including age, sex and cause specific mortality rates, life expectancy and years of life lost (yll). 2.5 demonstrate knowledge of the major global causes of morbidity and health risks, by describing the concepts of years lived with disability (yld) and disability adjusted life-year (daly). 2.6 describe the relative importance of each global burden of disease (gbd) category, how the leading gbd diagnoses (15 causes) within each category vary by age, gender and time, and explain potential contributors to the observed variations. 2.7 explain how life expectancy, yld, yll and daly may be used to make general health comparisons within and/or between countries and who regions, and between high, middle and low-income regions, and draw implications for policy and practice. r 2.3 environmental health (dragan gjorgjev, fimka tozija) the concept of limits of growth – how far we can go? the ecological concept of health, ecological public health – reshaping the conditions for good health. from demographic to democratic transitions to be addressed by public health; different dpseea models of environmental health assessment – conceptual framework of environmental health wellbeing. environmental and climate change (cc), burden of diseases (daly, yll). environment and health inequalities. environment and health risk assessment studies. environmental health indicators to assess health effects of climate change – threats to be reduced and opportunities to be adopted. importance of the intersectoral work. vulnerability, mitigation, and adaptation of the health sector. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 5 1.0 the public health professional shall know and understand: 1.1 the basic concept of relationships between ecosystem, environmental degradation, pollution, and human health. 1.2 the dependence of human health on local and global ecological systems and the context of policies, practices and beliefs required to address global environmental changes (such as climate change, biodiversity loss and resource depletion). 1.3 the impact of major driving forces like industrialization, transport, rapid population growth and of unsustainable and inequitable consumption on important resources essential to human health including air, water, sanitation, food supply and living/housing and know how these resources vary across world regions. 1.4 the interactions between inadequate clean water supplies and good sanitation and diarrheal and parasitic diseases. 1.5 the effects of air pollution on acute and chronic lung, cardiovascular disease and other systems diseases. 2.0 the public health professional shall be able to: 2.1 use an ecological public health model within a specific social-economic context to discuss how global forces impact health aiming to improve the promotion of health and management of environment and health risks and effects. 2.2 applying the basic methods for environment and health impact assessment (ehia) 2.3 analyse the relationship between the availability of adequate nutrition, potable water, and sanitation and the risk of communicable and non-communicable diseases. 2.4 analyse the relationship between environmental pollution and cancers (air pollution, radon and lung cancer; benzene and leukaemia etc.). 2.5 communicate the environment and health risks and inform the public how the driving forces like globalisation and others affects environment and health inequalities within and between countries. 2.6 develop the skills to provide evidence based support to policy makers in order to mitigate the effects of global environmental change on health. r 2.4 global migration and migrant health (muhammad wasif alam, vesna bjegovic-mikanovic) nowadays, global migration is considered even more important than in the past. the main reason for that is the number of migrants, which is steadily increasing at the end of the 20th century and will continue to grow in the twenty-first. in general, migrants are supposed to have bad opportunities for health as a consequence of their migrant status. the most important issue in analytical models for the health effects of migration is the type of migration – whether it is voluntary, involuntary, or irregular migration. usually, migration brings improvement in social well-being and health. the wide variety of health conditions and consequences is associated with the profile of the mobile population: “what migrants bring, what they find, and what they build in the host country”. many authors stress three temporal and successive phases associated with individual movements: the pre-departure phase, the journey phase, and the post-journey phase. though different in many ways they suffer from globally dominant health problems: tuberculosis, trauma/rape/torture/ptsd, hiv/aids, cardiovascular disease etc. prevention of the public health consequences is laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 6 particularly relevant and important among the migrant. a clear strategy at the local, regional, and international levels is needed for efficient interventions. there is a human right of migrants to be treated properly if necessary. 1.0 the public health professional shall know and understand: 1.1 the concept of a pandemic and how global commerce and travel contribute to the spread of pandemics. 1.2 the epidemiology of global migration. 1.3 the interplay between national and international conflict, interpersonal violence, and health as well as the direct and indirect threats to both individual and population. 1.4 health threats posed by violent conflict and natural disaster, and ways in which such threats may extend beyond the borders of the country directly affected. 1.5 the health challenges (including accessing healthcare) that refugees, asylum seekers and other migrants are faced with during life in their country of origin. 2.0 the public health professional shall be able to: 2.1 analyse the health risks related to migration, with emphasis on the potential risks and appropriate resources. 2.2 consider the utility and limitations of common infection control and public health measures in dealing with local or global outbreaks. 2.3 control outbreaks of communicable diseases such as measles in a context of local and international populations with varying levels of immunization. 2.4 liaise with local or regional public health authorities and be aware of national and international public health organizations responsible for issuing health advisory recommendations. 2.5 analyse general trends and influences in the global availability and movement of health workers. 2.6 regard the impact on health of cross-border flows, including international trade, information and communications technology, and health worker migration. r 2.5 social determinants of health inequalities (janko jankovic) the largest contribution to health inequalities both within and between countries around the world is attributable to the social circumstances in which people live and work, i.e. to the social determinants of health. educational attainment, income, occupational category and social class are probably the most often used indicators of current socioeconomic status in studies on social inequalities in health which present differences in health that are unnecessary, avoidable, unfair and unjust. they are also systematic (not distributed randomly) and socially produced and therefore modifiable. the fairest way to combat against social inequalities in health is to improve the health of the most disadvantaged faster than that among the rich. 1.0 the public health professional shall know and understand: 1.1 that health is not only a medical, but also a social issue. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 7 1.2 the major social determinants of health and their impact on differences in life expectancy, major causes of morbidity and mortality and access to healthcare between and within countries (topics include absolute and relative poverty, income, education, employment status, social gradient, gender, ethnicity and other social determinants). 1.3 the relationship between health and social determinants of health, and how social determinants vary across world regions. 1.4 how social determinants operates at different levels (individual, household, community, national and international). 1.5 the relationship between health, human rights, and global inequities. 2.0 the public health professional shall be able to: 2.1 define health inequity and health inequalities. 2.2 demonstrate how one can inform policy makers about the importance of addressing health inequalities, and advocate for strategies to address health inequalities at a local, national or international level. 2.3 describe major public health efforts to reduce disparities in global health (such as sustainable development goals, europe 2020 and health 2020). 2.4 analyse local, national or international interventions to address health determinants such as strategies to engage marginalized and vulnerable populations in making decisions that affect their health and well-being. 2.5 analyse distribution of resources to meet the health needs of marginalized and vulnerable groups. 2.6 advance strategic thinking on tackling health inequalities. r 2.6 gender and health (bosiljka djikanovic) while sex in genetically and biologically determined, gender is socially constructed identity that shapes many aspects of person’s functioning and has implications on health as well. there are historically present gender disparities that are related to the power, decision making, and different societal expectations of women and men. although gender norms and values are deeply rooted in the culture, they are not fixed and unchangeable. they might evolve over time and may vary substantially in different environments. gender analysis aims to identify gender differences that will inform actions to address gender inequality. gender mainstreaming in medical education is important for eliminating gender biases in existing routines of health professionals. 1.0 the public health professional shall know and understand: 1.1 the basic differences between sex and gender and their overall importance on health. 1.2 how different levels of development of civil society and human rights affect identification and respect of gender differences. 1.3 the factors that influence construction of gender identity, and the impact of gender identity on achieving full potentials for health, including an access to health promotion and disease prevention. 1.4 the historical perspective of gender differences and their impact on social functioning and health 1.5 the relationship between sex and other mediating factors with different health outcomes. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 8 1.6 how gender affects different risk-taking behaviours and other mediating factors of the importance for disease prevention, treatment and rehabilitation. 1.7 how transgender identity is associated with different health outcomes. 2.0 the public health professional shall be able to: 2.1 elaborate on differences and interrelationship between sex, gender and health, and corresponding challenges that appear at primary, secondary and tertiary level of prevention. 2.2 identify windows of opportunities in public health for addressing gender differences that have an impact on health. 2.3. use different tools and mechanisms that better recognise, identify and articulate gender differences in health-related matters. 2.4. conduct proper gender analysis in order to identify gender inequities and gender inequalities that exist in certain communities and societies, with the relevance for health. 2.5 apply gender mainstreaming, as a process of assessing implications for women and men of any planned action, including legislation, policies or programs, in any area, and at all levels. 2.6 apply gender mainstreaming as an integral part of the design, implementation, monitoring and evaluation of policies and programs in all political, economic and societal spheres, so that women and men benefit equally. 2.7 propose set of actions that would overcome gender gap in achieving the fullest potential for health. r 2.7 structural and social violence (fimka tozija) theoretical and conceptual basis is provided for understanding structural and social violence, collective violence and armed conflicts as a public health problem: definitions, typology, burden, context, root causes and risk factors, public health approach, structural interventions and multilevel prevention. general overview of public health approach, ecological model and human rights approach is presented. the module also explains the impact of structural and social violence on health, human rights, the role of the health sector, and suggests a number of practical approaches for prevention and policy intervention. 1.0 the public health professional shall know and understand: 1.1 the theoretical and conceptual basis of structural and social violence, and armed conflicts as a public health problem: definitions, typology, burden and context. 1.2 root causes and risk factors for structural and social violence. 1.3 the main analytical methods and tools for structural and social violence: public health approach, ecological model and human rights approach as defined by the who. 1.4 the impact of structural and social violence on health and human rights. 1.5 the role of the health sector for prevention of structural and social violence. 1.6 health in all policies and evidence-based multilevel prevention programmes for structural and social violence. 1.7 practical approaches for prevention and policy intervention for structural and social violence prevention and the impact of resilient factors on structural and social violence prevention. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 9 2.0 the public health professional shall be able to: 2.1 apply analytical tools for structural and social violence: public health approach and ecological method. 2.2 determine the magnitude, burden and economic consequences of structural and social violence applying who methodology. 2.3 identify root causes and risk factors for structural and social violence at different levels and compare in different countries. 2.4 do case problem analysis and review of evidence-based multilevel prevention measures for structural and social violence. 2.5 translate knowledge in practice consider and apply successful practices from other countries for structural and social violence. 2.6 develop sustainable multilevel prevention programs for structural and social violence. 2.7 identify resilient factors to strengthen community capabilities, and contribute to reduction of structural and social violence. r 2.8 disaster preparedness (elisaveta stikova) the disaster and emergency preparedness and response core competences were created to establish a common performance goal for the public health preparedness workforce. this goal is defined as the ability to proficiently perform assigned prevention, preparedness, response, and recovery role(s) in accordance with established national, state, and local health security and public health policies, laws, and systems. much of an individual's ability to meet this performance goal is based on competences acquired from three sources: foundational public health competences, generic health security or emergency core competences, and position-specific or professional competences. 1.0 the public health professional shall know and understand: 1.1 the main definitions of disaster and emergencies (similarities and differences); role of hazard and vulnerability in disaster occurrence. 1.2 the aim of the disaster/emergency management and main components of the disaster’s management cycle. 1.3 the basic principles for development of disaster preparedness and importance of the appropriate risk assessment analysis. 1.4 the importance and the scope of the preparedness plan for the protection of the critical infrastructure, across the ten community’s essential sectors. 1.5 the specificity of the public health emergency preparedness plan and importance of the early warning and surveillance systems as key elements for assessing of the state of emergency. 1.6 the opportunities for using a combined remote sensing technology, geographic information systems (gis), spatial statistical techniques and mathematical models which can help in modelling of the dispersion of the harmful agent and exposure of the population to the harmful agent. 1.7 being familiar with the structure and components of the hospital preparedness plan and infrastructure safety. 2.0 the public health professional shall be able to: laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 10 2.1 demonstrate operational skills to use administrative measures, to implement strategies, and to improve coping capacities in order to lessen the adverse impacts of hazards and to minimize the opportunity for development of disaster. 2.2 apply analytical tools and to perform early and initial risk assessment. 2.3 design a specific preparedness plan for the protection and strengthen the resilience of the critical infrastructure of the community, across the ten essential sectors. 2.4 develop the government preparedness actions grouped into five general categories: planning, resources and equipment, exercise, training and statutory authority. 2.5 identify the 15 public health and health-care preparedness capabilities as the basis for state and local public health and health-care preparedness. 2.6 develop an emergency response plan (erp) and associated early warning and surveillance functions, training and exercises using an “all-hazard/whole-health” approach applicable in public health emergency. 2.7 to communicate and manage the need for use of the public national/international network of public health laboratories for rapid detection and identification of unknown agents and/or confirmation of known agents. 2.8 develop hospital preparedness plan taking into account such factors as the appropriateness and adequacy of physical facilities, organizational structures, human resources, and communication systems. r 2.9a millennium and sustainable development goals (marta lomazzi) the millennium development goals (mdgs) are eight international development goals to be achieved by 2015 addressing extreme poverty, hunger, maternal and child mortality, communicable disease, education, gender equality and women empowerment, environmental sustainability and the global partnership. most activities worldwide have focused on maternal and child health as well as communicable diseases, while less attention has been addressed to environmental sustainability and the development of a global partnership. in 2015, numerous targets have been at least partially attained. however, some goals have not been achieved, particularly in the poorest regions, due to different challenges. the post-2015 agenda is now set. the new goals, the sustainable development goals (sdg), reflect today’s geopolitical, economic and social situation and adopt an all-inclusive, intersectoral and accountable approach. 1.0 the public health professionals shall know and understand: 1.1 what are the millennium development goals, including targets and indicators? 1.2 achievements and failures of mdgs at global, regional and national levels. 1.3 mdgs and inequalities: how and where the goals have or not reduced inequalities and disparities. 1.4 the impact of the mdgs in shaping the public health agenda 2000-2015, mobilizing the public health community and in revitalizing the development aid. 1.5 how progresses have been measured and evaluated. availability and accountability of data on mdgs achievements and failures. 1.6 whether and how mdgs have impacted local and global governance, policies set-up and education approaches. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 11 1.7 the basic concepts underlying the subsequent sdgs. 2.0 the public health professional shall be able to: 2.1 demonstrate a basic understanding of the relationship between mdgs, health, economic growth and governance. 2.2 understand the tools and reports used to evaluate mdgs and make a critical reading of the results and articles. this should include also analysis and critical evaluation of the impact of donors in shaping the agenda and achieving the targets. 2.3 compare the results of the mdgs to the intended achievements of the sdgs at local, regional and global level. 2.4 identify root causes and facilitators that impacted most the failure or achievements of mdgs. 2.5 translate knowledge in practice consider and apply successful practices from effective mdgs and early sdgs activities that can be applied in other contexts. 2.6 identify methods for assuring health sector programme sustainability and apply them to model implementation. 2.9b the un-2030 sustainable development goals (george lueddeke) following the millennium summit of the united nations in 2000, the adoption of the united nations (un) millennium declaration by 189 nations, including the eight millennium development goals (mdgs), was hailed as a unique achievement in international development.1 although the mdgs raised the profile of global health, particularly in low and middle-income countries, underpinned by the urgent need to address poverty worldwide, progress was uneven both between and within countries.1 with over one billion people, africa is a case in point. aside from children completing a full course in primary school and achieving gender equality in primary school, none of the twelve main targets set for ss africa has been met. a key reason suggested for this lack of progress was that the mdgs fell far short in terms of addressing the broader concept of development encapsulated in the millennium declaration, which included human rights, equity, democracy, and governance.2 on 25 september 2015, 193 member states of the united nations general assembly ratified the un 2030 sustainable development goals (sdgs) or un -2030 global goals, as they are also called.3 extending the breadth and depth of the mdgs dramatically, the sdgs, as shown in figure 2.9.1, are ‘a universal call to action to end poverty, protect the planet and ensure that all people enjoy peace and prosperity.3 framing the sdgs involved the largest consultatory process within the history of the un with contributions from more than a million people and an ‘expert group’ of over 3000 participants from over a hundred countries and six continents. the 17 sdgs are intended to be ‘integrated and indivisible, global in nature and universally applicable’ while ‘respecting national policies and priorities’3 and officially came into force in january 2016. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 12 figure 2.9.1: the un -2030 sustainable development goals4 the sdgs provide a synthesis of major global issues and place collaborative partnerships (#17) at the centre of strategic implementation strategies. given the state of the planet, their adoption could not come too soon as, according to marco lambertini, director general of wwf international, transformative change is now imperative challenging global leaders to respond to three main questions5:  ‘what kind of future are we heading toward?  what kind of future do we want?’  ‘can we justify eroding our natural capital and allocating nature’s resources so inequitably?’ his concerns go beyond the immediate un -2030 global goals and demand finding, first and foremost, a lasting ‘unity around a common cause.’5,6 his message is intended for the public, private and civil society sectors and implores these stakeholders to be proactive, to “pull together in a bold and coordinated effort,” for “heads of state” to think globally; businesses and consumers, ‘to stop behaving as if live in a limitless world’ – before facing inevitable and potentially disastrous consequences. the three un historical milestones in 2015 the addis ababa conference, the un-2030 sdgs and the paris climate accord7 represent major un achievements although translating the vision and the goals into viable policies and enabling strategies, nationally and locally “on the ground”, presents considerable hurdles.6,7 social, political and economic dichotomies remain and finding “middle ground,” without sacrificing basic values and principles, of all stakeholders will be key to their success. the new goals, the sustainable development goals (sdg), reflect today’s geopolitical, economic and social situation and adopt an all-inclusive, inter-sectoral and accountable approach.6 1.0 the public health professionals shall know and understand: 1.1 the achievements and failures of mdgs at global, regional and national levels. 1.2 mdgs and inequalities: how and where the goals have or not reduced inequalities and disparities. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 13 1.3 the impact of the mdgs in shaping the public health agenda 2000-2015, mobilizing the public health community and in revitalizing the development aid. 1.4 beginning with the rio+20 conference the future we want, describe the process (e.g., “global conversations, world survey) leading up to the un 2030 sustainable development goals and how it differed from the mdgs. 1.5 the 17 goals and targets agreed by the un general assembly in 2015 and the indicators8 identified to date. 2.0 the public health professional shall be able to: 2.1 understand the tools and reports used to evaluate the sdgs and make a critical reading of the results and articles. this should include also analysis and critical evaluation of the impact of donors in shaping the agenda and achieving the targets. 2.2 determine the impact to date of the sdgs at local, regional and global levels. 2.3 identify the roles played by various un groups responsible for implementing the sdgs the un general assembly, the economic and social council , the united nations high-level political forum on sustainable development (hlpf), division for sustainable development goals (un-desa), the united nations development program (undp).9 2.4 determine extent to which your country is involved with advancing the sdgs and progress to date. 2.5 examine how the implementation of the sdgs could be informed and strengthened by the one health and well-being concept and approach.6 2.6 translate knowledge in practice consider and apply successful practices from effective sdgs activities that can be applied in other contexts. develop preventive programs on that basis. 2.7 identify methods for assuring prevention program sustainability. 2.8 explore how public health professionals might play a much more pivotal role –locally, regionally, nationally and globally in the implementation of the sdgs.6,7 references2 2 references: (1) united nations. the millennium development goals report 2015. available at: http://www.un.org/millenniumgoals/2015_mdg_report/pdf/mdg%202015%20rev%20(july%201).pdf (2) lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights. available at: http://www.seejph.com/index.php/seejph/article/view/42 (3) united nations. transforming our world: the 2030 agenda for sustainable development. available at: https://sustainabledevelopment.un.org/post2015/transformingourworld (4) united nations. sustainable development goals. available at: https://www.un.org/sustainabledevelopment/sustainable-development-goals/ (5) wwf. living planet index 2014. available at: https://www.wwf.or.jp/activities/data/wwf_lpr_2014.pdf (6) lueddeke g. survival: one health, one planet, one future. london: routledge; 2019. (available at: https://www.crcpress.com/survival-one-health-one-planet-onefuture/lueddeke/p/book/9781138334953) (7) lueddeke g .global population health and well-being. toward new paradigms, policy and practice. new york: springer publications; 2016. (8) united nations. sdg indicators. available at: https://unstats.un.org/sdgs/indicators/indicators-list/ (9)united nations. sustainable development. knowledge platform. available at: https://sustainabledevelopment.un.org/ https://sustainabledevelopment.un.org/index.php?menu=1298 https://www.un.org/ecosoc/en/ http://www.un.org/millenniumgoals/2015_mdg_report/pdf/mdg%202015%20rev%20(july%201).pdf http://www.seejph.com/index.php/seejph/article/view/42 https://sustainabledevelopment.un.org/post2015/transformingourworld https://www.un.org/sustainabledevelopment/sustainable-development-goals/ https://www.wwf.or.jp/activities/data/wwf_lpr_2014.pdf https://www.crcpress.com/survival-one-health-one-planet-one-future/lueddeke/p/book/9781138334953 https://www.crcpress.com/survival-one-health-one-planet-one-future/lueddeke/p/book/9781138334953 https://unstats.un.org/sdgs/indicators/indicators-list/ laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 14 r 2.10 health and wellbeing (francesco lietz) teach a man to fish and you feed him for a lifetime” they say: promoting well-being is not so distant a concept from teaching how to fish, since high levels of well-being are correlated to a reduction of diseases and mental disorders, and vice versa. well-being can be studied at two different levels: internal/subjective, whose measures rely on how a respondent places him or herself on a scale; or external/objective, measured through demographics and material conditions. the promotion of well-being has been indicated by the united nations as one of the 17 sustainable development global goals sdg 3) to be achieved over the next 15 years. in order to face this workload public health professionals with the ability to think globally and act locally are needed. 1.0 the public health professional shall know and understand: 1.1 main concepts of well-being, happiness, quality of life, wealth, and life satisfaction. 1.2 main determinants of well-being: from the definitions to the potential applications in programs and interventions. 1.3 the optimal research tools for well-being in the different cultures and the different life stages. 1.4 the application of the theory in the context of the sustainable development goals. 1.5 the different strategies of the health sector to implement well-being programs and initiatives. 1.6 how to predict future pathways of well-being at regional and national levels. 2.0 the public health professional shall be able to: 2.1 choose the best measurement tools for well-being according to the environment’s requests. 2.2 take into account the importance of cross-culturalism and different population groups in well-being assessment. 2.3 optimize the process of communicating knowledge in the scientific environment. 2.4 taking under consideration the multidimensional aspect of well-being when developing prevention programmes. 2.5 anticipate future trends in order to assure programme sustainability. 2.6 implement concepts to empower the stakeholder at all levels so that they can strengthen community capabilities. r 2.11 the global financial crisis and health (helmut wenzel) the economic situation influences the health status of a population in many ways. the financial crisis has now given greater weight on an old debate about the financial sustainability of health systems in europe. drivers of health expenditures will be critically analysed. the vulnerability of public budgets and its consequences for health budgets is depicted. the toolset of politics, and policies applied by policy-makers will be analysed. managed care approaches are presented and evaluated. 1.0 the public health professional shall know and understand: laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 15 1.1 the interdependencies of health and national economies at times of global market and global competition. 1.2 the relationship between unemployment, unsecure living conditions and related health problems. 1.3 the constraints of financing and setting up health budgets and measures to cope with discrepancy between needs and financial power. 1.4 the main drivers of health care demand and the arguments of changing demand of health care by quantity and quality. 1.5 the operation and financing of health care systems with respect to their underlying national premises (beveridge, bismarck etc.). 1.6 managed care and integrated care approaches, their organisational structures and their opportunities to improve cooperation and increase efficiency of provision of care. 2.0 the public health professional shall be able to: 2.1 critically analyse health care systems and their connected budgeting processes 2.2 apply knowledge and skills needed for recommending a redesign of selected health care systems. 2.3 apply analytical tools to identify particularly vulnerable areas of health care in a constrained environment such as neonatal medical care. 2.4 identify imbalances in care delivery like the affordability of out-of-pocket purchased medicines among the elderly and retired citizens. 2.5 identify imbalances in access to the most expensive medical technologies such as targeted biologicals indicated in cancer and autoimmune diseases, radiation therapy; various implantbased interventional radiology, orthopaedic and cardiovascular surgical procedures. 2.6 to understand the relevance of catastrophic household expenditure imposed by illness among the world’s poor residing in low and middle income countries (increased vulnerability during crisis evidenced). 2.7 review the literature and design a case study for analysing the impact of the crises on health outcomes, based on secondary statistics. r 3.1 global governance of population health and well-being (george lueddeke) strengthening the health of populations and the health systems requires a “glocal” perspective being aware of the essential role of governments and to consider the adoption of a new mindset in meeting global challenges to planet health and well-being, applying, where appropriate and feasible, the ‘one world, one health’ concept. furthermore, there is the need for a new form of global governance that is ‘fit for the 21st century’ and is able to effectively respond to unprecedented environmental, societal, economic and geopolitical hurdles and lead the way to a safer, fairer and equitable future for all. 1.0 the public health professional shall know and understand: 1.1 how global trends in public health practice, in commerce and in culture contribute to health and the quality and availability of health services locally and internationally. 1.2 the role of key actors in global health including the world health organization, united laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 16 nations, world bank, multilateral and bilateral organisations, foundations, non-governmental organisations (ngos); and their interactions, power, governance and different approaches to global health. 1.3 how global actors provide resources, funding and direction for health practice and research locally and globally, and the effects that this has on individual and population health. 1.4 how global funding mechanisms can influence the design and outcome of research strategies and policies, and how policies made at a global or national level can impact on health at a local level. 1.5 different national models for public and/or private provision of health services and their impact on the health of the population and individuals. 1.6 how globalisation and trade including trade agreements affect availability of public health services and commodities such as patented or essential medicines. 1.7 the barriers to recruitment, training and retention of human resources in underserved areas such as rural, inner-city and indigenous communities within highand low-income countries. 2.0 the public health professional shall be able to: 2.1 promote the function/intention of the sdgs and identify health-related objectives, including: 1. reduce child mortality; 2. improve maternal health; 3. eradicate extreme poverty and hunger; 4. combat hiv/aids, malaria, tuberculosis and other diseases. 2.2 critically comment on policies with respect to impact on health equity and social justice. 2.3 explain the advantages of collaborating and partnering and to select, recruit, and work with a diverse range of global health stakeholders to advance research, policy, and practice goals, and to foster open dialogue and effective communication. 2.4 identify barriers to appropriate prevention and treatment in low-resource settings and publicise especially the effect of distance and inadequate infrastructure (roads, facilities) on the delivery of health services. 2.5 develop health service delivery strategies in low-resource settings, especially the role of community-based health services and primary care models taking into consideration the benefits and disadvantages of horizontal and vertical implementation strategies. 2.6 advise on the impact of trade regulations on health, for example through impact on access to clean water, taxation, tobacco use, alcohol and fast-food consumption, antibiotic use and health service provision. 2.7 advocate for effective systems to facilitate global responses to international health emergencies, including timely, well-supported and appropriate movement of health professionals across borders during and after the event. 2.8 participate in responsible social media use to promote health locally, nationally or globally, informed by an understanding of how telecommunications influence global and local health. r 3.2 health programme management (christopher potter) health development interventions are described as falling under four modalities: personnel, projects, programmes and policy reform initiatives underpinned by new financial support mechanisms, particularly sector-wide approaches (swaps). these modalities are briefly analysed to provide an introduction to readers about how and why such interventions are used, and their strengths and weaknesses. it is emphasised that the modalities are not hard laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 17 and fast entities but frequently overlap. indeed one of the problems facing those designing and implementing interventions is the fuzzy nature of many management terms. such issues as vertical and horizontal programme design and the transaction costs to governments who have to deal with many donors in an often relatively short-term and fragmentary manner are considered. swaps are considered as one way of dealing with some of these issues but it is noted that as many other non-state stakeholders, including industrial and commercial interests, have entered the health development arena, the possible, although contended advantages, of swaps have been compromised. finally, it is recognised that the public health challenges and their socio-political and economic contexts facing poorer countries are ever changing, so finding effective ways to deliver health development to the world’s most needy will also be an on-going challenge. 1.0 the public health professional shall know and understand: 1.1 to participate effectively in the world of actual global health care development. 1.2 the key expressions widely used within international health development activities such as “project” and “project management”, “programme,” including “vertical” and “horizontal” programmes, and “log-frame” among others. 1.3 common management techniques related to project design, monitoring and evaluation, and different approaches for activities with which they are engaged. 1.4 the action and interaction of the various development agencies and other stakeholders active within applied health development activities. 1.5 the concerns that underpin attempts at health sector reform, and the importance socioeconomic drivers that mean more nuanced approaches must be used in different locations. 2.0 the public health professional shall be able to: 2.1 work efficiently within health development environments carrying out such activities as bidding for projects, designing project implementation and appreciating the needs of different stakeholders, including political and commercial actors. 2.2 apply scientific evidence throughout program planning, implementation, and evaluation. 2.3 design program work plans based on logic models. 2.4 develop proposals to secure donor and stakeholder support. 2.5 plan evidence-based interventions to meet internationally established health targets. 2.6 develop monitoring and evaluation frameworks to assess programmes. 2.7 develop context-specific implementation strategies for scaling up best-practice interventions. r 3.3 civil society organisations in health (motasem hamdan) the role of the civil society for health is increasingly recognized, mainly due to the historical development of non-governmental organizations. their role in health and social development as well as in global scale is nowadays indispensable. there should be, however, a regulating framework or code of conduct. 1.0. the public health professional shall know and understand: 1.1 the concepts of civil society organizations. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 18 1.2 the historical development and the roots of ngos work. 1.3 the types, features of ngos and area of activity in different countries. 1.4 the methods of funding ngos. 1.5 the role of ngos in health system development, health policy, and health research. 1.6 the challenges of regulating and coordinating the work of ngos. 2.0 the public health professional shall be able to: 2.1 to analyze the impact of ngos on health, and health care systems. 2.2 to identify measures to enhance accountability and regulate the work of ngos. 2.3 to apply analytical tools to understand the coordination and harmonization of the work of the civil society organizations to national health priorities. 2.4 help to assure the capacity of the government to control the work of ngos based on regular full reporting. 2.5 apply mechanisms to provide, prolong or deny the permission for ngos to work in the country. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 19 r 3.4 universal health coverage (jose m. martin-moreno, meggan harris) nearly half of all countries worldwide are pursuing policies to achieve universal health coverage. this undertaking has the potential to improve health indicators dramatically, contributing to human development and more generally to global equity. however, the path towards uhc is often rocky, and every country must work to channel resources, adapt existing institutions and build health system capacity in order to accomplish its goals. global health advocates must understand what elements contribute to the success of uhc strategies, as well as how to measure real progress, so that they will be prepared to substantially contribute to policies in their own country or worldwide. 1.0. the public health professional shall know and understand: 1.1 the concepts and the rationale of universal health coverage (uhc) and its linkage with health financing and public-private partnership for health. 1.2 the roles and contributions of the private sector, communities, and the traditional medicine in promoting and sustaining uhc. 1.3 the political, social, economic and technical aspects of the health financing transition. 1.4 specific reasons for slow and stagnating progress in uhc. 1.5 the role of international cooperation in implementing uhc successfully. 2.0 the public health professional shall be able to: 2.1 advocate in favour of uhc strategies in health policies and programmes at global, regional, and national levels. 2.2 assess progress towards uhc employing a standardised methodology. 2.4 bring national and international partners together to advance the implementation of uhc. 2.3 enhance critical and strategic thinking when designing a uhc programme, both in a national context and as part of an external development strategy. 2.5 secure the sustainability of uhc implementation by highest level political and legal approval. r 3.5 public health leadership in a globalised world (katarzyna czabanowska, tony smith, kenneth a. rethmeier) leadership is a well-known concept within organisational science, public health leadership has still not been well-defined. a recent who report acknowledges that contemporary health improvement is more complex than ever before and requires leadership that is “more fluid, multilevel, multi-stakeholder and adaptive” rather than of a traditional command and control management variety. today’s public health professionals therefore need to be able to lead in contexts where there is considerable uncertainty and ambiguity, and where there is often imperfect evidence and an absence of agreement about both the precise nature of the problem and the solutions to it. the impact of the evolving growth of the eu and its impact on the potential mobility of healthcare professionals to re-locate across many geographic regions has left, in some communities, a gap in the resources of seasoned healthcare leaders. while this trend opens new opportunities for emerging young healthcare professionals to take on greater roles guiding their healthcare systems, it has also produced a significant need for high quality leadership development educational needs. there is a need to discuss and laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 20 provide professional development with a concentration on the vital role of leadership and governance play in public health globally. indeed, the presence of competent leaders is crucial to achieve progress in the field. a number of studies have identified the capability of effective leaders in dealing with the complexity of introducing new innovations or evidencebased practice more successfully. 1.0 the public health professional shall know and understand: 1.1 to demonstrate diplomacy and build trust with community partners. 1.2 to communicate joint lessons learned to community partners and global constituencies. 1.3 to exhibit inter-professional values and communication skills that demonstrate respect for, and awareness of, the unique cultures, values, roles/responsibilities and expertise represented by other professionals and groups that work in global health. 1.4 to apply leadership that support collaborative practice and team effectiveness. 2.0 the public health professional shall be able to3: 2.1 communicate in a credible and effective way: expresses oneself clearly in conversations and interactions with others; listens actively. 2.2 to produce effective written communications and ensures that information is shared. positive: speaks and writes clearly, adapting communication style and content so they are appropriate to the needs of the intended audience conveys information and opinions in a structured and credible way encourages others to share their views; takes time to understand and consider these views ensures that messages have been heard and understood keeps others informed of key and relevant issues negative: does not share useful information with others does little to facilitate open communication interrupts or argues with others rather than listening uses jargon inappropriately in interaction with others lacks coherence in structure of oral and written communications; overlooks key points 2.3 to produce and deliver quality results; is action oriented and committed to achieving outcomes. positive: demonstrates a systematic and efficient approach to work produces high-quality results and workable solutions that meet client needs monitors own progress against objectives and takes any corrective actions necessary acts without being prompted and makes things happen; handles problems effectively takes responsibility for own work sees tasks through to completion negative: focuses on the trivial at the expense of more important issues provides solutions that are inappropriate or in conflict with other needs. 3 for this section on public health leadership the positive/negative categorization otherwise not employed has been kept as an interesting example of future conceptual improvement of competence development. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 21 focuses on process rather than on outcomes delivers incomplete, incorrect or inaccurate work fails to monitor progress towards goals; fails to respect deadlines delays decisions and actions 2.4 to succeed as an effective and efficient health system manager positive: personal qualities (leadership): manages ambiguity and pressure in a self-reflective way. uses criticism as a development opportunity. seeks opportunities for continuous learning and professional growth. works productively in an environment where clear information or direction is not always available remains productive when under pressure stays positive in the face of challenges and recovers quickly from setbacks uses constructive criticism to improve performance shows willingness to learn from previous experience and mistakes, and applies lessons to improve performance seeks feedback to improve skills, knowledge and performance negative: demonstrates helplessness when confronted with ambiguous situations demonstrates a lack of emotional control during difficult situations reacts in a hostile and overly defensive way to constructive criticism fails to make use of opportunities to fill knowledge and skills gaps consistently demonstrates the same behaviour despite being given feedback to change transfers own stress or pressure to others r 3.6 public health ethics (alexandra jovic-vranes) the basic concept of public health ethics covers principles and values that support an ethical approach to public health practice and provide examples of some of the complex areas which those practicing, analysing, and planning the health of populations have to navigate; a code of ethics is the first explicit statement of ethical principles inherent to public health. 1.0 the public health professional shall know and understand: 1.1 how to identify an ethical issue and the principles of ethical decision-making. 1.2 the various conceptions of human rights, including those of the community. 1.3 basic ethical concepts such as justice, virtue and human rights. 1.4 the tension between rights of individuals and community health, and the relevance of consent at the individual and group level. 1.6 the ethical value the public health community gives to prevention. 1.7 how to build and maintain public trust. 2.0 the public health professional shall be able to: 2.1 consider the values of diverse stakeholders when conducting needs assessments and evaluations. 2.2 recognise the ways that advocacy and empowerment can be done. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 22 2.3 represent the needs and perspectives of all relative stakeholders with particular attention to the disenfranchised 2.4 identify the range of options for obtaining consent at the individual and group level 2.5 discern the risks and benefits of not acting quickly or not acting at all. 2.6 determine the range of appropriate actions for addressing unethical behaviour. 2.7 identify interests and conflicts of interest between potential partners. r 3.7 the global public health workforce (milena santric-milicevic, vesna bjegovic-mikanovic, muhammad wasiful alam) the progress of health sciences and technological innovations including modern medicine and health care technologies has increased our expectations for quality of life and health care. that has influenced the public health vision, the scope of public health interventions, and the composition of public health workforce. the outline the text includes description of the current situation of the public health workforce globally; future needs assessment; public health workforce challenges and mitigation globally. it underscores the demand for valid, reliable data sources and tools for mobilization of capacities of skilled public health staff in order to appropriately address global health challenges. 1.0 the public health professional shall know and understand: 1.1 health data sources and tools; data integration analysis and reporting; 1.2 surveillance of health system performance; 1.3 identification and monitoring of health hazards; occupational health protection; food safety; road safety; 1.4 primary prevention; secondary prevention; tertiary/quaternary prevention; social support; 1.5 economic assessment (e.g. cost-effectiveness analysis) of different healthcare procedures or programmes. 1.6 setting a national research agenda; 1.7 advocacy for public health improvement 2.0 the public health professional should be able to: 2.1 explore global health data sources and understand the limitations of these data. 2.2 identify the composite health measures and their use for health program monitoring, evaluation and priority setting. 2.3 examine the major categories of morbidity and mortality used by the world health organization (who) and institute of health metrics and evaluation ihme (communicable and parasitic diseases, maternal, perinatal and childhood conditions, and nutritional deficiencies, non-communicable conditions importance and injuries) 2.4 describe the concept of premature mortality including age, sex and cause specific mortality rates, life expectancy and years of life lost (yll). 2.5 demonstrate knowledge of the major global causes of morbidity and health risks, by describing the concepts of years lived with disability (yld) and disability adjusted life-year (daly). 2.6 describe the relative importance of each global burden of disease (gbd) category, how the leading gbd diagnoses (15 causes) within each category vary by age, gender and time, and explain potential contributors to the observed variations. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 23 2.7 explain how life expectancy, yld, yll and daly may be used to make general health comparisons within and/or between countries and who regions, and between high, middle and low-income regions, and draw implications for policy and practice. r 3.8 education and training of professionals for global public health (suzanne babich, egil marstein) by addressing the critical need for public health education and training within the global health workforce, we have in this program an opportunity to contribute substantially to efforts to improve the health of people worldwide through improved project management and resource application. topics introduced and discussed address the complexities of working with country specific agents, organizational representatives and formal and informal stakeholders who may influence the outcome of global health operations. 1.0 the public health professional shall know and understand: 1.1 key concepts related to stakeholder theory: how political, organizational and socioeconomic conditions affect critical operational premises in the governance of global health. 1.2 complexities associated with working with country specific agents: appreciate the makeup and workings of context specific forces as these impact global health initiatives; e.g. (i) identify key stakeholders and their impacts on health governance and leadership; (ii) evaluate culture-specific traits relevant for the professions, teams and organizational processes; (iii) analyze institutional governance as it applies to fieldwork planning and program execution; and (iv) recognize the dynamics of the global health field and how this needs be incorporated in operational strategies and actions. 1.3 principles of project management and resource application 1.4 how global health initiatives are financed through international aid 1.5 international standards for health program performance evaluation 2.0 the public health professional should be able to: 2.1 critique policies with respect to impact on health equity and social justice 2.2 describe the roles and relationships of the entities influencing global health 2.3 analyze the impact of transnational movements on population health 2.4 analyze context-specific policy making processes that impact health 2.5 describe the interrelationship of foreign policy and health diplomacy 2.6 conduct a situation analysis across a range of cultural, economic, and health contexts r 3.9 blended learning (željka stamenkovic, suzanne babic) blended learning is an educational model with great potential to increase student learning outcomes and to create new roles for teachers. in its basic and simplest definition, blended learning is an instructional methodology, a teaching and learning approach that combines face-to-face classroom methods with online activities. as a cost-effective way to overcome the issue of overcrowded classrooms, blended learning adds flexibility for students and offers a convenient alternative to learning. but it has quickly become much more than that. institutions with blended learning models may also choose to reallocate resources to boost laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 24 student achievement outcomes. the question of how to blend face-to-face and online instruction effectively is one of the most important we can consider as we move into the future. 1.0 the public health professional shall know and understand: 1.1 main concept of blended learning and 4 basic blended learning models: (1) rotation model, (2) flex model, (3) a la carte model and (4) enriched virtual model. 1.2 the differences between blended learning models and when each model should be applied. 1.3 how to integrate face-to-face and online learning in order to improve the learning outcomes. 1.4 how to implement and successfully accomplished blended learning process. 1.5 the main drivers of blended learning. 1.6 the advantages and disadvantages of blended learning for teachers. 1.7 the advantages and disadvantages of blended learning for students. 1.8 how global trends in technology may affect blended learning in public health. 2.0 the public health professional shall be able to: 2.1 use the technology tools and resources in order to support blended learning. 2.2 work in different environments and have the flexible time schedule. 2.3 know when blended learning is the best choice for the particular course. 2.4 design a successful blended learning strategy and identify methods for assuring successfully accomplished blended learning process. 2.5 target learning opportunities and act as a learning facilitator. 2.6 constantly support students who are learning different things, at different paces, through different approaches. r 3.10 global health law (joaquin cayon) transnational public health problems have been traditionally addressed through international health law whose proper implementation faces two important handicaps: the absence of an international authority that can enforce it, and the absence of a comprehensive concept. despite this, international agreements and treaties are among the most important intermediate public health goods because they provide a legal foundation for many other intermediate products with global public health benefits. nowadays, according to the emergence of the idea of global public health, a new concept -“global health law”has been born. there is an important distinction between international health law and global health law. international health law connotes a more traditional approach derived from rules governing relations among states. on the other hand, global health law is developing an international structure based on the world as a community, not just a collection of nations. there is also an important international trend leaded by some prestigious scholars who have urged adoption of a legally binding global health treaty: a framework convention on global health grounded in the right to health. in this context, an interdisciplinary approach to global public health inevitably requires the study of global health law for any healthcare professional. it is undoubtedly necessary to study and analyse the emergence and development of global health law just because it arises as an important tool to address the phenomenon of laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 25 globalization of health. in this regard, the future of global public health is directly dependent on the strength of global health law understood in a comprehensive way. 1.0 the public health professional shall know and understand: 1.1 theoretical and conceptual basis of global health law. 1.2 the rationale of studying global health law. 1.3 the increasingly interactive relationship between global health law and global public health. 1.4 the role of global health law as an important tool to deal with the phenomenon of globalization of health. 1.5 differences between international health law, global health law and global health jurisprudence. 1.6 how global health diplomacy brings together the disciplines of public health, international law and economics and focuses on negotiations that manage the global policy environment for health. 1.7 how international trade law, international labour law and international humanitarian law impact on national health systems. 2.0 the public health professional shall be able to: 2.1 demonstrate a basic understanding of the relationship between global health law and global public health. 2.2 develop skills for critical analysis of legal data and health information. 2.3 develop critical thinking skills and explore critically health systems from a legalnormative perspective. 2.4 do literature review and critical reading for globalization of health and the role of law. 2.5 identify the main international treaties on communicable disease control, world trade, environmental protection and working conditions that impact on public health. 2.6 employ a comprehensive and multidisciplinary approach for the analysis of the role of global law as a determinant of health. 2.7 compare differences between national and international legal framework on public health and develop proposals to improve health legislation both at national and international level. 2.8 identify key points to be included in a future global framework on public health. r 3.11 human rights and health (fiona haigh) human rights and health are intrinsically linked. health policies and practice can impact positively or negatively on rights and in turn human rights infringements and enhancements can influence health. increasingly human rights based approaches are being used to strengthen public health policies and programmes and as a powerful tool to advocate for the action on the social determinants of health. 1.0 the public health professional shall know and understand: 1.1 the key human rights concepts and the un treaty system. 1.2 the relationship between health and human rights. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 26 1.3 how social, economic, political and cultural factors may affect an individual’s or community’s right to health services (e.g. availability, accessibility, affordability, and quality). 1.4 the rationale for using human rights based approaches to health. 1.5 the relevance of human rights to global public health. 1.6 the key values in population ethics and the limitations of the utilitarian principle. in the implementation of public health programmes. the public health professional shall be able to: 2.1 analyse the right to health and how this right is defined under international agreements such as the united nations’ universal declaration of human rights or the declaration of alma-ata. 2.2 introduce the main objective of policies and programmes with regard to the fulfilment of human rights. 2.3 to identify rights holders and duty bearers, and the capacities of rights holders to make claims on duty bearers to meet their obligations. 2.4 operationalise in public health programmes the principles of population ethics as there are e.g. solidarity, equity, efficiency, respect for autonomy, and justice. 2.5 initiate collaborative efforts of multiple disciplines working locally, nationally, and globally, to achieve the best health and well-being. r 3.12 global financial management for health (ulrich laaser) world population growth takes place predominantly in the poor countries of the south whereas most of the resources are available in the north. the economic inequalities are related to key health indicators. although official development assistance (oda) and development assistance for health (dha) grew considerable during the last decade the objective of 0.7% of the northern gdp to be transferred to the south has not been reached by far. in order to correct the main weaknesses the international community agreed on the socalled paris indicators but failed the set timelines. the underlying reasons may be sought in the fragmentation and incoherence of international financial assistance. 1.0 the public health professional shall know and understand: 1.1 the major social and economic determinants of health and their effects on the access to and quality of health services and on differences in morbidity and mortality between and within countries. 1.2 the deeper reasons for the gap in wealth between the south and the north corresponding to vast disparities in standards of living, health, and opportunities. 1.3 the structures of international financial management in the health sector and their terminology as for example oda and dah 1.4 the five principles of the paris declaration on aid effectiveness and the results of the subsequent conferences. 1.5 the key global strategies to reduce the north-south gap including sdg 3. 1.6 how to analyse the critical aspects of loans to developing countries regarding intergenerational effects, and monetary back flows to the donors for experts and equipment. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 27 2.0 the public health professional shall be able to: 2.1 analyse the underlying reasons for the failure in efficiently organizing international assistance as there is the extreme fragmentation and therefore ineffectiveness of international aid, and the insufficient coordinating capacities and competences in the national ministries of health making it difficult to secure ownership. 2.2 follow up and promote the latest evaluation of the paris indicators. 2.3 argue and act against imbalances in oda and dah due to political and economic interests of the donor countries. 2.4 design global, regional, national and local structures, organisational principles and mechanisms to improve and sustain global health and well-being, including universal health coverage. 2.5 work in a constructive and contributing way in the environment of a sector-wide approach or pool-funding. 2.6 contribute to the management of a medium term expenditure framework and to the improvement of debt and debt relief management (national health accounts, nha). 2.7 promote a code of ethics for ngos taking into consideration their increasing relevance in channelling aid to developing countries. © 2018 laaser u (ed.); this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. a comprehensive understanding of the children’s and women’s health as a state of complete physical, mental and social wellbeing , is essential to the health of current and future generations jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 1 original research health and health status of children in serbia and the desired millennium development goals aleksandra jovic-vranes 1 , vesna bjegovic-mikanovic 1 1 institute of social medicine, medical faculty, belgrade university, serbia. corresponding author: aleksandra jovic-vranes, belgrade university, serbia; address: dr subotica 15, 1100 belgrade, serbia; telephone: +381112643830; e-mail: aljvranes@yahoo.co.uk mailto:aljvranes@yahoo.co.uk jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 2 abstract aim: children represent the future, and ensuring their healthy growth and development should be a prime concern of all societies. better health for all children is one of the leading objectives of the national plan of action for children and a key element of the tailored millennium development goals for serbia. methods: our analysis was based on relevant literature and available information from the primary and secondary sources and databases. we analyzed health status of children that can be illustrated by indicators of child and infant mortality, morbidity, and nutritional status. results: there has been a significant reduction in the mortality rates at the national level, particularly with regard to infants and children under five years of age. however, the current mortality rate of roma children is still three times as high as the millennium goal set at the national level for serbia. most deaths of children under the age of five are due to preterm birth complications, congenital anomalies, birth asphyxia and trauma, pneumonia and sepsis. the rate of malnourished children among the poor and in roma settlements is twice as high as in the general population of serbian children. a growing number of obese children was also noted in the roma population. conclusion: political awareness, commitment and leadership are required to ensure that child health receives receive the attention and the resources needed to accelerate the progress of serbia. keywords: children, health status, millennium development goals, serbia. conflicts of interest: none. jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 3 introduction a comprehensive understanding of the children’s and women’s health as a state of complete physical, mental and social wellbeing (1) is essential to the health of current and future generations. almost every culture holds that a society has a responsibility to ensure a nearly equal start in life for children, which implies developing their full health potential (2). however, there are still significant ethnical and regional differences that need to be considered while developing the global health policy framework. the differences in people health are determined by their exposures to health risks, which are, in turn, the social determinants of health (3). the prevention of disease requires overall investment in the social determinants of health and reduction of inequalities and unfairness in health. the foundations for adult health and, indeed, the health of future generations are laid in early childhood and even before birth. therefore, better health for all children is one of the leading objectives of the national plan of action for children (4) and a key element of the tailored millennium development goals for serbia. progress in the reduction of child mortality is one of the leading public health challenges in all countries (1). reducing child mortality is also one of the millennium development goals, and the first of the total of 27 goals adopted at the world summit for children. it has also been incorporated into many national plans of action for children. in spite of major improvements, national reports on progress in attaining the millennium development goals, even in countries in which child mortality has been reduced by two thirds on the average, highlight that the problem is still present in rural areas, among people living below the accepted poverty line and – as regards southeastern europe – in particular, among roma subpopulations (1,5). child mortality due to preventable causes is further compounded by poverty, unfavorable living conditions, low educational level of mothers, social exclusion, neglect, violence against children and insufficiently accessible antenatal and postnatal health care (6,7). deaths among children under the age of five years represent one of the most serious challenges currently faced by the international community. to address this challenge, it is necessary to measure accurately the levels and causes of mortality among this population group (8). major causes of under-five mortality remain the same globally; their relative importance varies across regions of the world. while in low-income countries infectious diseases account for a large proportion of under-five deaths, the main killers of children in high-income countries are non-communicable diseases such as congenital anomalies, prematurity, injuries and birth asphyxia (9). monitoring of the nutritional status plays an important role in the analysis of the health of children, particularly when health risks and preventive actions need to be assessed and considered. irregular and insufficient nutrition during infancy and later can significantly impair the growth and development of children and have adverse health effects (physical fitness, mental functions, immune system). at the same time, excessive food intake and an imbalanced diet may also result in obesity and negative health consequences (10). the aim of our study was to analyze children mortality rates in serbia, leading causes of death, differences in mortality rates between the average population of children and roma children and diet and nutritional status of children under the age of five years. jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 4 methods this situation analysis has been done on the basis of relevant literature and available information from the following primary and secondary sources and databases: published documents including strategies, policies, programs, plans, laws and other regulations of the government of the republic of serbia, health regulations and guidelines of the ministry of health, published reviews, scientific and professional articles on health and health status of the serbian population in national and international journals, national surveys and project reports of international organizations (unicef, who, eu, world bank) that deal with issues of children’s and women’s health in serbia; publications in the area of routine health statistics, national e-databases (institute of public health of serbia, dr. milan “jovanović batut”, statistical office of the republic of serbia and international e-databases (who/eurostat) for comparison purposes. this statistical information often is only available in aggregated sets of data which do not allow for detailed analyses. health outcomes and health status of children are illustrated by the following indicators: infant mortality rate (deaths of children in the first year of life), perinatal mortality rate (fetal deaths from the 22 nd week of gestation or achieved 1000g in intrauterine development and deaths by the seventh day of life), neonatal mortality rate (deaths in the first 27 days of life only), and morality of children under five years of age (deaths before children turn five years); morbidity, nutritional status and comparisons with relevant national and international benchmarks and objectives. a special focus was placed on disparities and social inequalities in health among population groups within serbia, which are considered unfair, unjust, avoidable and unnecessary. the results were presented in tables and graphs. results in serbia, there has been a significant reduction in the mortality rates at the national level, particularly with regard to infants and children under five (figure 1), while the reduction of the mortality rate in the prenatal period was somewhat more limited. figure 1. children mortality rates in serbia: situation analysis and the desired millennium goal by 2015 i-infant mortality rate; ii-perinatal mortality rate; iii-neonatal mortality rate; iv-children under 5-year mortality rate. 10.6 11.2 7.7 12.7 8.0 9.3 5.8 9.2 6.3 8.8 4.7 7.1 4.5 6.5 3 5 0 2 4 6 8 10 12 14 i ii iii iv 2000 2005 2011 mdg 2015. jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 5 mortality among roma children remains high, the rate has almost halved over the last five years bringing the number closer to the national millennium goal of reducing roma under-five child mortality to 14 and infant mortality to 12. however, the current mortality rate of roma children is still three times as high as the millennium goal set at the national level for serbia (figure 2). figure 2. differences in mortality rates between the average population of children and roma children in 2005 and 2010 in serbia figure 3 presents the leading causes of death in serbian children under-five years. most deaths of under-five children are due to preterm birth complications, congenital anomalies, birth asphyxia and trauma, pneumonia and sepsis. figure 3. distribution of the leading causes of death of children under-five in serbia 25.9 29 14 15 12 14 8 9.2 6.7 7.9 4.5 5 0 5 10 15 20 25 30 35 infant mortality under 5 years mortality roma children roma children2 2015: mdg for roma children 2005: average population 2010:average population 2015: mdg for serbia roma settlements roma settlementsserbia serbia rate per 1000 live births 29 32 31 30 30 28 31 36 35 36 41 5 4 3 6 6 6 4 7 5 6 4 0 5 10 15 20 25 30 35 40 45 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 consequences of pre-term birth congenital anoma other diseases asfixia during birth pneumonia injuries sepsis jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 6 the indicators of diet and nutritional status of children under-five years of age are presented in table 1. the rate of malnourished children among the poor and in roma settlements is twice as high as in the general population of serbian children. surprisingly, a growing number of obese children were also noted in the roma population, from 6.7% to 12.8%, which points to irregular nutrition. the corresponding millennium development goal in serbia aims to bring the share of obese children down to 9.1% by 2015. breastfeeding habits have not substantially changed, except in the roma population where the number of exclusive breastfeeding up to the age of six months has decreased. the rate of exclusive breastfeeding is still only half of the desired millennium development goal in serbia (30% of exclusively breastfed children from birth until the six month of age). table 1. diet and nutritional status of children under five years of age in 2005 and 2010 in serbia indicator serbia the poor roma settlements mdg 2005 2010 2005 2010 2005 2010 2015 live births with low birth weight 4.9 4.8 8.6 8.3 9.3 10.2 percent of children first breastfed within a day after birth 68.8 61.9 71.7 69.1 72.5 70.3 percent of children with exclusive breastfeeding for the first six month 14.9 13.7 15.4 19.5 18.0 9.1 30.0 percent of children 6-23 months who receive the minimum number of meals na 84.3 na 80.0 na 71.9 prevalence of malnourishment among children under-five (body weight for the given height ≤2sd) 3.2 2.3 3.8 5.2 4.1 5.2 prevalence of obesity among children under-five (body weight for the given height ≤2sd) 15.6 12.7 15.5 12.5 6.7 12.8 9.1 discussion this situation analysis covers the health status of serbian children that can be illustrated by indicators of child and infant mortality, morbidity and nutritional status which are compared with relevant national and international benchmarks and objectives. a special focus was placed on disparities and social inequalities in health among population groups within serbia, which are considered unfair, unjust, avoidable and unnecessary since they open a systematic burden on vulnerable population groups. it is believed that the unfair differences in health of children result from social structures and political, economic and legal relations: they are derived from the system, and are result of the social system (so that they can be changed) and they are unjust (11). marmot insists that they are not a natural phenomenon by any means; instead, they are a combination of poor conditions and low standards of living, poverty, risky life-styles, social exclusion, scarcely formulated, inappropriate health programs and sometimes toxic national and local policies (12). infant mortality is generally regarded as a basic indicator of population health and a measure of long-term consequences of perinatal events. this parameter is particularly jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 7 important for monitoring and assessing health outcomes in high risk groups such as pre-term children and children with developmental difficulties. trends show that serbia has made significant progress towards the millennium development goal relating to infant mortality (13,14). an analysis of routine statistical data, although infant mortality is still above the european union–27 average (for example, in 2010, the eu-27 infant mortality average was 4.1 vs. 6.7 in serbia), suggests that serbia may achieve the proposed national millennium goals in 2015: an infant mortality rate of 4.5 and an under-five mortality rate of 5 per 1000 live births. earlier comparisons of infant mortality revealed rates in serbia two times higher than the eu rates, but this difference has been substantially reduced to date (15,16). recent studies conducted by unicef and other organizations indicate that the majority of the roma population face social disadvantage and exclusion, and most of them live in poverty (17). many roma individuals are also unemployed, have limited education, as well as insufficient access to information, which combined with a lack of trust in institutions often prevent them from using healthcare services in case of need. the multiple indicator cluster surveys (mics), which have been conducted periodically in serbia since 1996 with the help of unicef, have been extremely valuable in gaining a better understanding of the challenges involved. from 2005, these surveys have provided assessments of child mortality in the roma population using the brass method for estimating child mortality taking into account the risk of death to which the children are exposed to (18). although mortality among roma children remains high, the rate has almost halved over the last five years bringing the number closer to the national millennium goal of reducing roma under-five child mortality to 14, and infant mortality to 12. however, the current mortality rate of roma children is still three times as high as the millennium goal set at the national level for serbia (15). according to the world health organization, most deaths of children under the age of five years are due to a small number of diseases and conditions. forty-three per cent of these deaths occur among babies aged 0-28 days (newborns) and are mainly due to preterm birth complications, birth asphyxia and trauma, and sepsis. after the first 28 days until the age of five years, the majority of deaths are attributable to infectious diseases such as pneumonia (22%), diarrhoeal diseases (15%), malaria (12%) and hiv/aids (3%) (8,9). while international efforts to address mortality among children under the age of five have resulted in significant reductions globally, persistent inequities between and within countries exist. these are not only driven by poverty, but are intrinsically linked to social exclusion and discrimination. therefore, continued efforts to eliminate under-five mortality must take into consideration both direct causes and underlying determinants. this requires a comprehensive and holistic approach, which must explicitly recognize human rights’ standards as essential and integral elements. also, poor nutritional status in children is strongly correlated with vulnerability to diseases, delayed physical and mental development, and an increased risk of dying. while, between 1990 and 2011, the proportion of children under the age of five years who were underweight declined by 36%, under-nutrition is still estimated to be associated with 45% of child deaths worldwide. in 2011, there were 165 million children under the age of five years who were stunted, and 52 million who were wasted (10,19,20). low birth weight is closely associated with increased risks of neonatal mortality, cognitive problems and chronic diseases in later life (20). our jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 8 analysis shows that the national average share of live births with low birth weight (under 2,500 grams) has remained constant in serbia in the last decade. the share of low birth weight is significantly higher for roma and poor children. more preventive approaches and consistent efforts for improvement are needed in serbia, to ensure that child health receives the attention and resources needed and secure the benefits that children and families require. identifying the health outcomes that matter most for the children, and set out the contribution that each part of the health system needs to make in order that desired health outcomes are achieved, would be an effective way to reach progress. reference 1. who constitution. http://www.who.int/governance/eb/who_constitution_en.pdf (accessed: may 16, 2015). 2. barros fc, victora cg, scherpbier r, gwatkin d. socioeconomic inequities in the health and nutrition of children in low/middle income countries. rev saude publica 2010;44:1-16. 3. marmot m, allen j, bell r, bloomer e, goldblatt p; consortium for the european review of social determinants of health and the health divide. who european review of social determinants of health and the health divide. lancet 2012;380:1011-29. doi: 10.1016/s0140-6736(12)61228-84. 4. government of serbia. national plan of action for children in serbia. http://www.arhiva.serbia.gov.rs (accessed: may 16, 2015). 5. unicef (un inter-agency group for child mortality estimation). levels and trends in child mortality. report 2012. new york: unicef headquarters, 2012. 6. parekh n, rose t. health inequalities of the roma in europe: a literature review. cent eur j public health 2011;19:139-42. 7. statistical office of the republic of serbia. republic of serbia multiple indicator cluster survey 2011, final report. belgrade, republic of serbia: statistical office of the republic of serbia; 2010. http://www.childinfo.org/files/mics4_serbia_finalreport_eng.pdf (accessed: may 16, 2015). 8. world health organization. “health status statistics: mortality”. http://www.who.int/healthinfo/statistics/indunder5mortality/en/ (accessed: september 02, 2014). 9. united nations inter-agency group for child mortality estimation. levels and trends in child mortality: report 2012. new york, united nations children’s fund, 2012. 10. black re, victora cg, walker sp, bhutta za, christian p, de onis m, et al. maternal and child undernutrition and overweight in low-income and middleincome countries. lancet 2013;382:427-51. 11. whitehead m, dalgren g. concepts and principles for tackling social inequities in health: levelling up. copenhagen: who regional office for europe; 2006. 12. marmot m. global action on social determinants of health. bull world health org 2011;89:702. http://www.childinfo.org/files/mics4_serbia_finalreport_eng.pdf http://www.ncbi.nlm.nih.gov/pubmed/?term=black%20re%5bauthor%5d&cauthor=true&cauthor_uid=23746772 http://www.ncbi.nlm.nih.gov/pubmed/?term=victora%20cg%5bauthor%5d&cauthor=true&cauthor_uid=23746772 http://www.ncbi.nlm.nih.gov/pubmed/?term=walker%20sp%5bauthor%5d&cauthor=true&cauthor_uid=23746772 http://www.ncbi.nlm.nih.gov/pubmed/?term=bhutta%20za%5bauthor%5d&cauthor=true&cauthor_uid=23746772 http://www.ncbi.nlm.nih.gov/pubmed/?term=christian%20p%5bauthor%5d&cauthor=true&cauthor_uid=23746772 http://www.ncbi.nlm.nih.gov/pubmed/?term=de%20onis%20m%5bauthor%5d&cauthor=true&cauthor_uid=23746772 jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 9 13. institut za javno zdravlje srbije “dr milan jovanović batut”. zdravlje stanovnika srbije. analitička studija 1997-2007. beograd: institut za javno zdravlje srbije; 2008. 14. institut za javno zdravlje srbije „dr milan jovanović batut“. republikasrbija.odabranizdravstvenipokazateljiza 2011. godinu. beograd: izjzs; 2012. 15. vlada republike srbije. nacionalni milenijumski ciljevi razvoja u republici srbiji. beograd vs; 2006. 16. vlada republike srbije. progres u realizaciji milenijumskih ciljeva razvoja u republici srbiji. beograd: vs i undp; 2009. 17. unicef. serbia. multiple indicator cluster survey 2005. monitoring the situation of children and women. belgrade: unicef belgrade; 2007. 18. unicef. srbija. istraživanje višestrukih pokazatelja 2010. praćenje stanja i položaja dece i žena. beograd: unicef beograd; 2012. 19. united nations children’s fund/world health organization/world bank. levels and trends in child malnutrition: report 2012; 2012. http://www.who.int/nutgrowthdb/jme_unicef_who_wb.pdf (accessed: may 16, 2015). 20. united nations children’s fund/world health organization. low birth weight: country, regional, and global estimates. unicef: new york; 2004. ___________________________________________________________ © 2015 jovic-vranes et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.who.int/nutgrowthdb/jme_unicef_who_wb.pdf nauka ima za cilj da promovira saznanja prikupljanjem i otkrivanjem objektivnih istina; činjenica koje su nezavisne od ljudskih interesa, njihovoh vrijednosti ideologija i biasa masic i. ethics in research and publication of research articles (review article). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-29 1 review article ethics in research and publication of research articles izet masic1 1 faculty of medicine, university of sarajevo, sarajevo, bosnia and herzegovina. corresponding author: prof. izet masic, president of academy of medical sciences in bosnia and herzegovina; address: faculty of medicine, university of sarajevo, bosnia and herzegovina, 71000, sarajevo, cekalusa 90; e-mail: imasic@lol.ba; izetmasic@gmail.com masic i. ethics in research and publication of research articles (review article). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-29 2 abstract science aims at promoting knowledge by gathering and discovering the objective truth, the facts that are independent of human interests, their values, ideology and biases. the way in which scientists come to this goal is through the universally accepted and thoroughly regulated processes – the scientific method. there is no clear definition which will answer the question what is unethical in biomedical research. all people recognize some common ethical norms but different individuals interpret, apply, and balance these norms in different ways in light of their own values and life experiences. generally, it can be said that unethical behaviour in science is any significant mistreatment of intellectual property or participation of other parties, deliberately hampering the research process or distortion of scientific evidence, as well as all the behaviours that affect the integrity of scientific practice. given the importance of the primary goal of scientific enterprise, that is search for truth and trustworthy results, ethics in science has increasingly come into focus. there are several reasons why it is important to adhere to ethical norms in research. norms promote the aims of research, such as knowledge and truth, variety of moral and social values and help to build public support for research. this paper analyzes the major principles of ethical conduct in science and closely related topics on ghost authorship, conflict of interest, co-authorship assignment, redundant/repetitive and duplicate publications. furthermore, the paper provides an insight into the fabrication and falsification of data, as the most common forms of scientific fraud. keywords: conflict of interest, ethics, fabrication and falsification of data, ghost authorship, publication, redundant and duplicate publication, research. conflict of interest: none. masic i. ethics in research and publication of research articles (review article). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-29 3 ethics in science and scientific research science aims at promoting knowledge by gathering and discovering the objective truth, the facts that are independent of human interests, their values, ideology and biases. the way in which scientists come to this goal is through the universally accepted and thoroughly regulated processes – the scientific method (1-8). every step of this method, if implemented correctly and truthfully, helps to reach objective goals, with significant contribution to the welfare of the society as a whole (1). there is no clear definition which will answer the question what is unethical in biomedical research. all people recognize some common ethical norms but different individuals interpret, apply, and balance these norms in different ways in light of their own values and life experiences. generally, it can be said that unethical behaviour in science is any significant mistreatment of intellectual property or participation of other parties, deliberately hampering the research process or distortion of scientific evidence, as well as all the behaviours that affect the integrity of scientific practice. in 2000, in the united states, fraud in scientific research was defined as fabrication, falsifying and plagiarism in the process of proposing, conducting and publishing the results (1). the nordic countries proposed a much broader definition of fraud in scientific research describing it as “any degree of dishonesty”. given the importance of the primary goal of scientific enterprise, search for truth and trustworthy results, ethics in science has increasingly come into focus. william lipscomb, 1976 nobel-prize-winner in chemistry, states that: “i no longer put my most original ideas in my research proposals, which are read by many referees and officials. i hold back anything that another investigator might hop on and carry out. when i was starting out, people respected each-other’s research more than they do today, and there was less stealing of ideas”. the following is a general summary of some ethical principles in scientific research and publication: honesty, objectivity, integrity, carefulness, openness, respect for intellectual property, confidentiality, responsible publication, responsible mentoring, respect for colleagues, social responsibility, non-discrimination, competence, legality, animal care, and human subjects’ protection. there are several reasons why it is important to adhere to ethical norms in research. norms promote the aims of research, such as knowledge and truth, variety of moral and social values and help to build public support for research. whatever the definition be, there are numerous examples of unethical behaviour in biomedical research which include (1): bringing patients at risk (inadequate study design, inadequate supervision of the research, ignoring side effects or inadequate implementation of the protocol of the study); participation in fraud; creation or falsification of scientific results; falsification of consent letters; plagiarism. there is no single solution that would allow full ethics in scientific research. studies show that the misconduct is directly related to the following factors (1): increased academic expectations and greater desire for publishing papers; personal ambition, vanity and desire for fame; predilection; greed, which is directly linked to the financial gain; lack of moral capacity to distinguish the right from the wrong. masic i. ethics in research and publication of research articles (review article). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-29 4 in regard to the above listed values of the characteristic of many of us is to be expected that the behaviour that we are talking about can only be more pronounced over time and, as such, it may leave many consequences to science in general. it is therefore very important to take preventive measures that will greatly limit the implementation of these unethical measures. as a rule of thumb, the following preventive measures should be undertaken: make ethical standards very clear to all researchers; provide education and training for all researchers; clearly identify methods of sanctioning such behaviour; introduce stricter control of sponsored research. forms of unethical behaviour in biomedical articles the various forms of unethical behaviour in publishing of the results of scientific research are described in the vast scientific literature (1). the most frequent types include: redundant publications (24%), animal welfare concerns (16%), duplicate publications (15%), authors’ disputes (14%), data fabrication (8%), human welfare concerns (8%), plagiarism (7%), conflict of interest (5%), other forms including reviewer bias, or submission irregularities (3%). ghost authorship ghost authorship occurs when an individual who has significantly contributed to and participated in the development of a specific scientific work is not mentioned as an author. a special form of ghost authorship is a publication from an “invisible” author by the request of industry, where the credibility of results is questionable on account of the conflict of interest. an example is a situation where influential pharmaceutical industry or any other party can offer the benefit, employs professional writers or agencies to produce an article that will later be attributed to a certain recognized scientific researcher. example from practice: • redux case: medications dexfenfluramine and phentermine (fen-phen) are drugs that have been prescribed for the simultaneous use in the treatment of excess weight until 1997 when it was found that the application of phentermine leads to primary pulmonary hypertension and heart valve damage. in may 1999, it was revealed that wyeth-ayerst laboratories, a company that produces dexfenfluramine (redux), hired ghost authors to write the results of research on this drug but the results were published under the names of prominent researchers. also, during this period the company had participated in the destruction of data concerning the negative effects of the drug, which were published in medical journals. ghost authorship raises many ethical questions: • conflict of interest: conflict of interest is a serious problem. evidence-based medicine requires that clinical decisions are based on clear empirical evidences published in medical journals which are regularly audited. if clinicians base their decisions on such inadequate research results, it can have serious negative consequences for patients. for example, a certain medication that may not be the best drug of choice for a particular disease or patient but, for example, is strongly promoted by an influential expert in a reputable medical journal. in this way, patients may receive suboptimal treatment. • academic integrity: authorship in certain research papers is often described as academic currency. employment, wages and reputation in academic circles is largely related to the number, quality and frequency of publication of research papers, and regularly is considered as a valid indicator of one’s work and abilities. in the case of masic i. ethics in research and publication of research articles (review article). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-29 5 ghost authorship, when often a particular author is hired for a specific publication, which was actually written by another person, this publication is no longer an adequate measure of his/her work. furthermore, ghost authorship separates the author from the responsibility. universally accepted, an individual or group of authors are considered responsible for the information presented to the public. knowing that they will be held responsible for their results presented in the paper, the researchers are trying to implement all the measures to better prepare the work before its publication. therefore, if a person is listed as an author, but did not contribute to any stage of work or research project, his/her responsibility is questioned. the international committee of medical journal editors has clearly published guides in which the author of a scientific paper must take an active participation in its preparation and publication, and accepts responsibility for its content. hence, assigning co-authorship must be based on a significant contribution to the work, either in the feasibility study, analysis, interpretation, editing facilities, revision, and approval of the final version, as well as publication of the study. redundant / repetitive publication it is considered as a special form of plagiarism. redundant/repetitive publication is defined as the publication of copyright material with the addition of new, unpublished data. thus, this is a form of un-ethics in science, where part or parts of already published article, but not the complete article, are published again. there are several reasons why this form of publishing is unethical. first, it undermines the international copyrights. second, duplication of data with new data consumes the (valuable) time of peer-reviewers. third, it leads to unnecessary expansion of already huge amount of published literature. fourth, it leads to inadequate highlighting of certain information. this may also lead to potential interferences with subsequent meta-analysis. committee on publication ethics (cope) proposes several recommendations concerning repetitive publications (1): already published studies should not be republished if they do not further support the actual study; repeated publication of an article that has been published in another language is allowed only when is clearly stated the original source; at the time of the article submission, the authors must submit the materials that are used in their article. therefore, the basis is that authors should not attempt to publish information that is already published in other articles. if authors consider that the already published data are of utmost importance for their study, then they should repeat the study or parts of the research, and use these data in the new publication. duplicate publication it is defined as a publication of an article which is identical or largely overlaps with the article already published, with or without acknowledgments. two articles share the same hypothesis, results and conclusions. why scientists try to republish the same article? one reason is their perception that if someone wants to survive in the highly competitive field of science, one must create voluminous curriculum vitae. this is true in certain situations, especially subsequently when the number of articles rather than their quality, are largely valued as a factor in promotion and academic progress. another, perhaps more justifiable reason for resorting to such unethical behaviour, lies in the fact that the authors sometimes try to reach the readers who are not so familiar with the journals in which the first article was already masic i. ethics in research and publication of research articles (review article). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-29 6 published, especially if the article was published in another language, such as for example the chinese language which is relatively inaccessible. however, authors must have the consent of both journals before they decide to republish a certain article. duplicate publication is considered unethical for several reasons (4,5). the first is that, in an inadequate manner, the authors attempt to increase the scope of their own published works. another important reason is that the article has the potential to change the image of documents. for example, if the results were taken into account twice or even more in a metaanalysis conducted to outline some best practices, the results would not be valid. this was the case of a study including all the published papers in which authors investigated the effect of the drug ondansetron on postoperative vomiting. it was observed that 17% of the published papers were duplicates, of which 28% of the patient data were duplicated. this led to a situation in which the efficacy of this drug was overestimated by 23%. this example points out the danger of duplication of publications by scientists who have conducted research, especially when making conclusions about the efficacy and safety of a certain drug. good practice in publishing scientific work requires that authors can submit drafts of their work only to one journal at a given moment. authors may choose to re-propose to the same or another journal a revised version of the scientific work only when the first application receives negative answer on its publication. regardless of these considerations, duplicate papers still occur and as such continue to be a significant problem across scientific journals. with the increasing availability of computerized medical databases such as pubmed, it becomes increasingly difficult for scientists to duplicate the previously published works. when the duplicated article is detected and reported by the reviewer, the journal rejects the proposed work or withdraws the article if it is already published. a statement on duplication is published in pubmed, which can have serious consequences for the author’s reputation. conflict of interest in the research and publication of scientific papers it is vital to ensure objectivity in order to preserve the integrity of the research, the reputation of the institution and the journals which published the study. from the author that conducted a study, it is expected to objectively present the results of the research, whereas from the reviewers it is expected to evaluate these results objectively. when experts at prominent positions get into a conflict of interest, it results in a biased or a poor decision-making; hence, the information that reaches the scientific circles and the readers in general can be modified and can be potentially devastating. conflict of interest may be individual or institutional. recognizing the potential conflict of interest is usually simple, but sometimes it can be a challenge to determine whether a conflict exists or not, if it is not communicated. this is serious, because everything which is not transparent can be interpreted as a bias or corruption. therefore, authors must clearly highlight potential conflicts, so as they can be treated appropriately. since 1995, the national institute of health (nih) has decided to terminate a number of restrictions that had previously existed in terms of external cooperation, all in order to get the renowned scientists from different fields. this means the abolition of limits on the amount of articles that scientists can publish, or the time that can be spent on work outside the institute, as long as it does not affect their current job. yet, it is very important for all scientists to clearly specify each source of income beside their regular employment. however, it turned out that the big problem is the cooperation with pharmaceutical and biotech companies, and many experts share the opinion that such cooperation should be terminated. this also led the new england journal of medicine to ban the authors to write review articles if they had a financial interest in the company concerning the research. masic i. ethics in research and publication of research articles (review article). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-29 7 however, in recent years it is increasingly difficult to identify authors who are completely independent of the industry. financial interest means everything from salaries or other income, interest in shares and intellectual property (patents, copyrights, etc.). authorship being the author of a scientific paper is a privilege and a great academic satisfaction. not only that authorship contributes to science in general, but it also brings respect and reputation and also serves as a measure for the promotion and advancement. however, this seems only a part of the author’s equation. another aspect is that authorship entails a great responsibility. every scientist has its own vision of what it takes to become the author. but often, among the authors of a project, these visions are different. personal conflicts and turmoil can often lead to disagreements on the issue of whom belongs the authorship. there are some guides, issued by the nih, that define the authorship. in a broad sense, the author is any person who has significant intellectual contribution to a particular study. the international committee of medical journal editors (icmje) is a recognized organization dealing with ethical issues in biomedical research, and defines authorship as follows (1): a) significant contribution to the concept, design, collection, analysis and interpretation of the study; b) writing study template or revision in terms of intellectual content; c) final approval of the version which will be sent for publication. the author needs to meet “a”, “b” and “c” criteria. also, the first author should coordinate the study, and should respect all the rules of the study results submission. in addition, he/she should be responsible for communicating with the editors and the reviewers of the scientific journals. fabrication and falsification of data fabrication and falsification of data represents half of all cases reported as a form of unethical behaviour. falsification of data includes its creation, selective publication of results (e.g. those corresponding to the study goals) and the omission of conflicting data, as well as the conscious exclusion or modification of data. this can include everything from the rejection of unwanted pieces of information to their unfounded creation. this is unethical for several reasons (1,2): it affects the integrity of other studies, also the authors which are their creators and other authors in the same field of science; if such article is not discovered on time, the other authors lose their energy and time in vain trying to take advantage of the presented results in their studies; creates a negative image of science in general and affects the general trust. the problem of this kind of behaviour is particularly evident in clinical studies and may have negative consequences for the patients. for a scientist who carries out a study concerning a potential new treatment or management of a disease, the impact on the patient can be fatal or at the very least psychologically devastating, if the crucial information is false or deleted. the number of such papers containing falsified or fabricated data is increasing. therefore, each author must faithfully and accurately collect, present and publish the experimental data. masic 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global context. acad med 2012;87:51-4. doi: 10.1097/acm.0b013e31823aadc7. 8. masic i. the importance of proper citation of references in biomedical articles. acta inform med 2013;21:148-55. doi: 10.5455/aim.2013.21.148-155. ___________________________________________________________ © 2014 masic; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed?term=benos%20dj%5bauthor%5d&cauthor=true&cauthor_uid=15905149 http://www.ncbi.nlm.nih.gov/pubmed?term=fabres%20j%5bauthor%5d&cauthor=true&cauthor_uid=15905149 http://www.ncbi.nlm.nih.gov/pubmed?term=farmer%20j%5bauthor%5d&cauthor=true&cauthor_uid=15905149 http://www.ncbi.nlm.nih.gov/pubmed?term=gutierrez%20jp%5bauthor%5d&cauthor=true&cauthor_uid=15905149 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18 february 2015. doi 10.12908/seejph-2014-41 1 original research health seeking behaviour among caregivers of under-five children in edo state, nigeria adesuwa q. aigbokhaode 1 , essy c. isah 1 , alphonsus r. isara 1 1 department of community health, university teaching hospital of benin, benin city, nigeria. corresponding author: dr. alphonsus r. isara; address: university teaching hospital, p. m. b. 1111, benin city, nigeria; telephone: +2348034057565; email: mansaray2001@yahoo.com mailto:mansaray2001@yahoo.com aigbokhaode aq, isah ec, isara ar. health seeking behaviour among caregivers of under five children in edo state, nigeria (original research). seejph 2015, posted: 18 february 2015. doi 10.12908/seejph-2014-41 2 abstract aim: timely and appropriate healthcare seeking behaviours if practiced by caregivers of under-five children can have a significant impact on child survival. this study assessed the knowledge of, and general health seeking practices among mothers of under-five children in nigeria. methods: this descriptive cross-sectional study was carried out among caregivers of underfive children in edo state, nigeria, in 2013. a multi-staged sampling technique was used to recruit respondents. data collection was done by means of a structured intervieweradministered questionnaire adapted from unicef/imci household baseline survey questionnaire. results: a total of 370 caregivers (mean age: 31.1±5.9 years) participated in the study. almost all of them were females 368 (99.5%), 234 (63.2%) had secondary education and 283 (76.5%) were in the unskilled social class. over 70%, 76%, 72%, 76% and 82% of participants did not know that being unable to eat/drink, fast breathing, blood in stool and convulsion, respectively, were symptoms of a child not feeling well. the place of primary care of children by caregivers was at home 142 (38.4%), chemist shop 91 (24.6%) and health facility 80 (21.6%). cost and long waiting time were major reasons for not seeking care in health facilities. conclusion: this study showed poor health seeking practices among caregivers of under-five children in edo state, nigeria. there should be continuous education of caregivers on recognition of danger signs in children and the need to seek appropriate medical care in health facilities. keywords: caregivers, health seeking behaviour, nigeria, under-five children. acknowledgement: the authors wish to appreciate the contribution of the network on behavioural research for child survival in nigeria to the success of this research. we also thank the pan african thoracic society’s methods in epidemiological, clinical and operational research (pats mecor) programme for the training imparted on researchers from africa. we appreciate the role of the 2014 pats mecor level 3 faculty; prof. stephen gordon, prof. nigel bruce and prof. john balmes in developing this paper. conflicts of interest: none. aigbokhaode aq, isah ec, isara ar. health seeking behaviour among caregivers of under five children in edo state, nigeria (original research). seejph 2015, posted: 18 february 2015. doi 10.12908/seejph-2014-41 3 introduction nigeria is facing huge challenges in meeting the millennium development goal (mdg) 4 (1), due to high morbidity and mortality rates among under-five year old children. although households and communities have a major responsibility in recognizing when children need treatment outside the home, a recent national survey found that this has not been the case due to poor health seeking knowledge and practices in households (2). generally, the poor health seeking practices among caregivers of under-five children, which is a consequence of poor knowledge among other factors such as poverty, lack of family support and competing work demands of carers, is one of the leading causes of the high infant and under-five mortality rates of 69/1,000 live births and 128/1000 live births respectively (2). in edo state, nigeria, infant and under-five mortality rates are reported to be higher (at 100/1000 and 191/1000 live births respectively) (3). the major causes of underfive morbidity and mortality in nigeria are diseases like malaria (24%), pneumonia (20%), diarrhoea (16%), measles (6%), hiv (5%), neonatal conditions (26%), malnutrition and injuries (4,5). diseases and deaths due to these causes are preventable through application of community-oriented cost-effective interventions in the households/communities, such as the unicef/who key household practices (1,4). in nigeria, according to the national demographic and health survey (ndhs) of 2013, slightly more than one-third (35%) of children with symptoms of acute respiratory infections (ari) were taken for treatment to a health facility, 29% of children with diarrhoea were taken to a health facility, whereas 38% of the children with diarrhoea were treated with oral rehydration therapy (ort) (2). the edo state strategic health plan assessment found that only 2% owned insecticide treated nets (itns), only 6% of children under-five slept under a mosquito net and only 13% of children aged 12-23 months had received the recommended course of immunization (3). the nigerian experience is part of wider problem, with a majority of child deaths in (developing countries) continuing to occur at home, often with no contact with a health care facility (6). it has been documented in some sub-saharan africa countries that factors such as lack of money, distance to health facility and perception of the illness not being serious were the major reasons why mothers and caregivers of under-five children do not seek care for their ill children (6,7). studies from india and mexico have reported poor knowledge and practice of health seeking among mothers and caregivers of children less than five years mainly due to careers and not recognizing signs of childhood illness for seeking care immediately for common childhood diseases such as diarrhoea, respiratory tract infections and fevers (8,9). a study in guatemala revealed that 63%-83% of mothers relied on home care the last time their children under the age of five suffered from diarrhoea, fever, cough, and the use of health services (western or traditional) was consistently low among them (10). the resultant effect of this is an increased morbidity and mortality among under-five children. however, a qualitative study carried out in germany among 11 mothers with turkish background and nine mothers with german background showed that mothers had good knowledge of childhood fever and good practice of seeking care for their children’s fever. the mothers perceive their child’s fever not merely as elevated temperature, but as a potentially dangerous event. a deeply rooted urge to protect the child from harm was central to all participants’ experience (11). this good knowledge and practice will make room for prompt and appropriate action thus reducing complications and mortality. studies have shown that timely and appropriate healthcare seeking behaviours can have a significant impact on child survival, if practiced by the majority of caregivers of children less than five years of age (2,3,6). aigbokhaode aq, isah ec, isara ar. health seeking behaviour among caregivers of under five children in edo state, nigeria (original research). seejph 2015, posted: 18 february 2015. doi 10.12908/seejph-2014-41 4 in this framework, our study sought to assess the knowledge of, and general health care seeking practice among mothers of under-five children in edo state, nigeria, with the aim of improving their health practices through the design of appropriate interventions. methods study design a descriptive cross-sectional study using a questionnaire survey method was done. setting the study was carried out in edo state, nigeria, in july 2013. edo state, which is made up of 18 local government areas, is located in the heart of the tropical rain forest and it lies between longitudes 5 o e and 6 o 42" e and latitudes 5 o 45" n and 7 o 35" n of the equator (12). the state has a total population of 3,233,366 with 1,633,946 males and 1,599,420 females, and a total land area of 19,819,277 square kilometres (13). study population the study population consisted of caregivers of under-five children in edo state, nigeria. inclusion criteria: caregivers of under-five children who were presently caring for an underfive child (the biological parents, or the primary caregivers). sampling method: a multi-staged sampling technique was used in selecting the respondents for this study:  stage one: three local government areas was selected by balloting from the three senatorial districts in edo state.  stage two: from the three selected local government areas, one ward in each was selected by simple random sampling using a table of random numbers from a list of all the wards in the selected local government areas.  stage three: from the wards selected, one community in each was selected by simple random sampling using a table of random numbers from a list of all the communities in the selected wards.  stage four: in the three selected communities, a systematic sampling method was then used to select the houses corresponding to the total number of respondents allocated to the respective communities. the sampling interval was determined by dividing the total number of houses in the community with the sample size allocated to the community. the starting point was chosen by simple random sampling of the houses within the sampling interval starting for the house of the community head. the study unit was households with the informant being the primary caregiver. where there was more than one household in a house, a single household was selected by simple random sampling. where a caregiver was responsible for more than one under-five child, the youngest was selected as the index child for the study. sample size calculation: the sample size for this survey was calculated using the cochran’s formula (14) for sample size determination in a cross-sectional study (n=z 2 pq/d 2 ). using a prevalence of 68% (0.68) being the percentage of caregivers with poor knowledge of schedules of childhood immunization and diseases preventable by vaccines given to children in kano state, nigeria (15), and accounting for a 10% non response, the calculated sample size for this study was 370. the sample size was proportionately allocated to the three selected local government areas according to their respective sizes. data collection aigbokhaode aq, isah ec, isara ar. health seeking behaviour among caregivers of under five children in edo state, nigeria (original research). seejph 2015, posted: 18 february 2015. doi 10.12908/seejph-2014-41 5 a structured interviewer-administered questionnaire adapted from unicef/imci household baseline survey questionnaire (16) and the imci pictorial counselling and community practices for maternal, newborn and child health booklet (17) were used for data collection. the questionnaire covered caregivers’ general knowledge and practice of health seeking including recognition of a sick child, symptoms of illness in a child, recognition of when a child needs treatment outside the home and the primary care services for a sick child. ethical considerations: ethical approval was obtained from the research ethics committee of the university teaching hospital of benin. permission was also sought from the administrators of the three selected local government areas and the traditional heads. confidentiality and privacy of the respondents was assured and respected during the interviews. a written informed consent was obtained from each respondent before conducting the questionnaire interviews. health education on the various components of the key household practices was carried out at the end of the study. data analysis the questionnaires were screened for completeness by the researcher, coded and entered into the statistical package for social sciences, version 16.0 (spss inc. chicago, illinois, usa). categorical data such as occupational and educational statuses were presented as percentages. results a total of 370 respondents participated in the study. all the eligible respondents selected consented to the interview giving a response rate of 100%. majority of the respondents (230, or 62%) were in the age-group of 25-34 years. mean age of the respondents was 31.1±5.9 years. almost all the respondents were females 368 (99.5%). greater than four-fifths of the respondents (325, or 88%) were married, 38 (10%) were cohabiting, while 2 (0.5%) were single. majority 338 (91%) of the respondents were christians and 32 (9%) were muslims. a greater proportion 234 (63%) had secondary education, 76 (21%) had primary education, 55 (15%) had tertiary education, while 5 (1%) had no education (data not shown in the tables). over three quarters (283, or 77%) of the respondents were in the unskilled social class, 79 (21%) were in the middle level social class and 8 (2%) were in the professional social class. respondents of esan, afemai and benin ethnicity made up 109 (29%), 92 (25%) and 76 (21%), respectively. more than a third 137 (37%) of children were in the age-group 12-23 months, followed by 88 (24%) in the 0-11 age-group. mean age of the children was 21.8±1.5 months. more than half (209, or 57%) of the children were boys and 161 (43%) were girls. over 70%, 76%, 72%, 76% and 82% of respondents did not know that being unable to eat/drink, fast breathing, blood in stool and convulsion, respectively, were symptoms of a child not feeling well (table 1). table 1. respondents’ correct knowledge of symptoms of illness in children symptoms number (n= 370) percent not playing normally 269 72.7 fever for more than 24 hours 170 45.9 vomiting 147 39.7 fast breathing 103 27.8 blood in stool 90 24.3 unable to eat or drink 89 24.1 convulsion 68 18.4 drinks poorly 63 17.0 aigbokhaode aq, isah ec, isara ar. health seeking behaviour among caregivers of under five children in edo state, nigeria (original research). seejph 2015, posted: 18 february 2015. doi 10.12908/seejph-2014-41 6 over three quarters of the respondents (279, or 75%) were aware of the importance of consultation of medical personnel for advice for a sick child. health personnel known to respondents that can be consulted were patent medicine dealer (115, or 41%), nurses (71, or 26%), and doctors (22, or 8%). a little below one third of the respondents (109, or 29%) knew the recommended distance to the nearest health facilities of less than 5 km (table 2). table 2. knowledge of primary care services among respondents variables number percent aware of the importance of consulting the health personnel (n=370): yes no 279 91 75.4 24.6 categories of health personnel that can be consulted (n=279): patent medicine dealer nurses community health workers doctors traditional birth attendants 115 71 60 22 11 41.2 25.5 21.5 7.9 3.9 knowledge of the recommended distance to the nearest health facility (n=370): <5 km 5-10 km >10 km do not know 109 28 5 228 29.4 7.6 1.4 61.6 almost all of the respondents (354, or 96%) had heard of antenatal care. respondents’ major sources of information about antenatal care were from hospital/health workers (304, or 86%), television (31, or 9%), and from relatives (10, or 3%). the majority of the respondents (335, or 95%) knew the meaning of antenatal care and 19 (5%) reported that it was the use of concoctions and herbs during pregnancy. over four-fifths (66%) of respondents who had heard of antenatal care were of the opinion that antenatal visits should take place as many times as possible, while only 28 (8%) of the respondents knew that antenatal care visits should be 3-4 times, and further 38 (11%) individuals did not know. the major symptoms that prompt immediate treatment among respondents were vomiting 279 (75%), frequent stooling 261 (71%), fever 252 (68%), while fast breathing came forth with a little above half (189 or, 51% of respondents). major reasons by respondents for not seeking treatment for children were child’s condition not being serious (184, or 50%) and cost of treatment (154, or 41%) (table 3). the place of primary care by more than a third of the respondents (142, or 38%) was at home, followed by the chemist shop (91, or 25%), whereas the use of health facility was reported by less than a quarter of the respondents (80, or 22%). sixty nine (86%) of the respondents did not carry out instructions of the health workers and the major reasons for caregivers not complying with instructions of health workers were the cost of treatment (53, or 77% of respondents) and the distance to the health facility (42, or 61% of participants) (table 4). aigbokhaode aq, isah ec, isara ar. health seeking behaviour among caregivers of under five children in edo state, nigeria (original research). seejph 2015, posted: 18 february 2015. doi 10.12908/seejph-2014-41 7 table 3. symptoms that prompt care seeking and reasons for not seeking immediate treatment among respondents variables number (n=370) percent symptoms of ill health in a child that will prompt immediate treatment * : drinks poorly fever vomiting frequent stooling fast breathing skin rashes playing poor oral hygiene scalp infection not eating well 74 252 279 261 101 11 5 9 7 4 20.0 68.1 75.4 70.5 27.3 3.0 1.4 2.4 1.9 1.1 reasons for not seeking immediate treatment * : condition not serious unavailability of nearby health provider cost long waiting time long distance dissatisfaction with medical care discouragement by family member competing domestic duties social traditions and values 184 74 154 18 16 6 5 5 2 49.7 20.0 41.4 4.9 4.3 1.6 1.4 1.4 0.5 * multiple responses. table 4. health seeking practices among respondents variables number percent respondents place of first treatment when child is ill (n=370): home chemist shop health facility health care provider church traditional birth attendant (tba) 142 91 80 53 3 1 38.4 24.6 21.6 14.3 0.8 0.3 compliance to health workers instructions (n=80): yes no 11 69 13.8 86.2 reasons for non compliance of health workers instructions * (n=69): cost distance fear of bigger hospitals not sure of the health workers 53 42 26 7 76.8 60.8 37.7 10.1 * multiple responses. aigbokhaode aq, isah ec, isara ar. health seeking behaviour among caregivers of under five children in edo state, nigeria (original research). seejph 2015, posted: 18 february 2015. doi 10.12908/seejph-2014-41 8 discussion in this study, there was poor knowledge of caregivers concerning recognition of children who were ill and when to seek medical care. health personnel most known to caregivers that could be consulted were patent medicine dealers, whereas the major reasons by caregivers for not seeking treatment for ill children were child’s condition not being serious, cost of treatment and long waiting time. in our study, over two third of the respondents were in their mid twenties to early thirties, this is within the reproductive age group for women. the act of care giving for children is mainly the responsibility of females in nigeria and other sub-saharan african countries. hence, it was not surprising that almost all the under-five caregivers in this study were females. a greater proportion of the caregivers had a secondary level of education, which is consistent with findings from the 2013 ndhs where a greater proportion of the respondents from edo state had secondary education (2). this information will be helpful when it comes to health education of caregivers in order to improve their health care seeking knowledge and practice. the finding of poor knowledge of caregivers concerning recognition of children who were ill was surprising. they could recognise vomiting and fever but could hardly recognise fast breathing and drinking poorly as symptoms for which to seek immediate medical care for their children. this is probably due to the fact that caregivers’ knowledge of symptoms of danger sign for the different diseases differed, but it is expected that fast breathing in a child should be of great concern to a mother. another possible reason could be that health care workers pay more attention to diseases like malaria and diarrhoea at the clinics during routine antenatal attendance since the major source of information for the caregivers was from the health care workers and the health centres. therefore, healthcare professional need to pay more attention to other life threatening childhood conditions such as febrile convulsion and pneumonias in the health facilities during health education. this finding of poor knowledge on recognition of disease symptoms by the respondents was similar to findings from studies carried out in mexico (9) and in nigeria (18-20), and also consistent with findings from the multiple indicator cluster survey (mics) (21), in which only 10% of women knew of the two danger signs of pneumonia (fast and difficult breathing) that could prompt them seeking immediate care for their children. appropriate knowledge and recognition of danger signs and symptoms in ill children by caregivers is necessary in seeking immediate and an appropriate management of disease conditions, thereby reducing complications and deaths in these children. in our study, the health seeking practices of the caregivers with regards to using identified symptoms was also poor. the most commonly identified symptoms for taking a child to a health facility/health care provider were vomiting, fever and frequent stooling, whereas drinking poorly and fast breathing were less common. this finding is in agreement with the health seeking practice found in the mics in which fever was the most commonly identified symptom for taking children to health facility by their caregivers and only 19% and 23% of mothers identified fast breathing and difficult breathing respectively as symptoms for taking children immediately to a health care provider (21). this could be a result of poor knowledge of the caregivers with regards to recognizing the dangers signs of ill health in these children and also taking for granted that these symptoms were not serious enough to warrant immediate treatment or intervention. this may also explain the reason why the first place of treatment by a greater proportion of the caregivers was at home and patent medicine stores rather than the hospitals/health facilities. mothers’ knowledge of the danger signs is an important determinant of care seeking behaviour and the secondary level of education of most of the caregivers in the study can be exploited to improve their health seeking practices. aigbokhaode aq, isah ec, isara ar. health seeking behaviour among caregivers of under five children in edo state, nigeria (original research). seejph 2015, posted: 18 february 2015. doi 10.12908/seejph-2014-41 9 although majority of the respondents were aware of the importance of consulting medical personnel when their children were ill, only 14.3% of them consulted a health care provider for an ill child. the poor knowledge danger signs in a child that should necessitate health care seeking demonstrated by caregivers in this study may have contributed to this practice. this poor health seeking practice could also be due in part to the poor economic situation in nigeria and by extension edo state and the long waiting time in health facilities. the main reason for not seeking immediate treatment by a greater proportion of respondents in this study was that the condition was not serious, followed by cost of treatment and unavailability of nearby health provider. this was compounded by the fact that most of the respondents who visited the health facilities do not carry out the instructions of the healthcare providers. this poor health seeking behaviour by the respondents will result in delays in obtaining proper treatment for the children and an increase in cases of complications from different disease conditions that are preventable. this ultimately will result in morbidities and mortality in the children, thereby hindering the attainment of mdg 4. this poor health seeking behaviour is consistent with findings from a study in anyigba, north-central, nigeria where the major reason for the delay in seeking treatment by more than half of respondents was the thought that they would get over the ailment without treatment, about a quarter of respondents delayed because of lack of money for treatment, while about one fifth of the respondents delayed seeking treatment due to the far distance to the health facility (18). it, however, contrasted the findings from a study in igbeagu community in south-east nigeria where the health centre was the most preferred choice for treatment (19). good health seeking behaviour will reduce complications, morbidities and mortality in the households and promote family health especially maternal and child health. in conclusion, this study showed poor health seeking practices among caregivers of underfive children in edo state, nigeria. the major factors associated with this poor health seeking behaviour were: poor recognition of danger signs, cost of treatment, and long waiting time in the health facilities. appropriate knowledge of danger signs and symptoms of ill health in a child and prompt and proper treatment by caregivers is necessary to reduce morbidity and mortality among under-five children. therefore, there should be continuous education of caregivers on recognition of danger signs in children and the need to seek appropriate medical care in health facilities. references 1. federal ministry of health. integrated maternal, newborn and child health strategy. abuja, nigeria; 2007. 2. national population commission (npc) [nigeria] and icf international. nigeria demographic and health survey 2013. abuja, nigeria, and rockville, maryland, usa: npc and icf international; 2014. 3. edo state ministry of health. 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nigeria limited. edo state investors’ guide (1 st edition international). enimeg publishers. lagos; 1999. 13. national population commission of nigeria. 2006 population and housing census facts and figures. http://www.population.gov.ng (accessed: february 16, 2015). 14. cochrane wg. sampling techniques, 3 rd edition. new york: john wiley and sons; 1977. 15. kabir m, iliyasu z, abubakar is, gajida au. knowledge, perception and beliefs of mothers on routine childhood immunization in a northern nigerian village. ann nigerian med 2005;1:21-6. 16. united nations children fund. child health/imci household baseline survey. draft generic tool prepared by epp/evaluation and health section of unicef in collaboration with imci inter-agency working groups. october 1999. http://www.unicef.org/health/files/health_generic.pdf (accessed: february 16, 2015). 17. federal ministry of health, nigeria. who/unicef. integrated management of childhood illness (imci) promotion of key household and community 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license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed?term=p%c3%a9rez-cuevas%20r%5bauthor%5d&cauthor=true&cauthor_uid=9203789 http://www.ncbi.nlm.nih.gov/pubmed?term=guiscafr%c3%a9%20h%5bauthor%5d&cauthor=true&cauthor_uid=9203789 http://www.ncbi.nlm.nih.gov/pubmed?term=romero%20g%5bauthor%5d&cauthor=true&cauthor_uid=9203789 http://www.ncbi.nlm.nih.gov/pubmed?term=rodr%c3%adguez%20l%5bauthor%5d&cauthor=true&cauthor_uid=9203789 http://www.ncbi.nlm.nih.gov/pubmed?term=guti%c3%a9rrez%20g%5bauthor%5d&cauthor=true&cauthor_uid=9203789 http://www.population.gov.ng/factssand%20figures%202006 http://scialert.net/asci/author.php?author=tanimola&last= http://scialert.net/asci/author.php?author=tanimola&last= http://scialert.net/asci/author.php?author=tanimola&last= http://scialert.net/asci/author.php?author=tanimola&last= http://scialert.net/asci/author.php?author=julius%20o.%20owoyemi&last= qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and selfperceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi 10.12908/seejph-2014-50 1 original research reaction to political and socioeconomic transition and self-perceived health status in the adult population of gjilan region, kosovo musa qazimi 1 , luljeta cakerri 2 , zejdush tahiri 2 , genc burazeri 3 1 principal family medicine centre, gjilan, kosovo; 2 faculty of medicine, tirana university, tirana, albania; 3 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands. corresponding author: dr. musa qazimi address: rr. “avdulla tahiri”, p.n. 60000, gjilan, kosovo telephone: +381280323066; e-mail: micro_dental@hotmail.com qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and selfperceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi 10.12908/seejph-2014-50 2 abstract aim: the objective of our study was to assess the association of reaction to political and socioeconomic transition with self-perceived general health status in adult men and women in a region of kosovo, a post-war country in the western balkans which has proclaimed independence in 2008. methods: this was a cross-sectional study carried out in gjilan region of kosovo in 2014, including a representative sample of 867 primary health care users aged ≥35 years (419 men aged 54.3±10.9 years and 448 women aged 54.0±10.1 years; overall response rate: 87%). reaction to political and socioeconomic aspects of transition was assessed by a three-item scale (trichotomized in the analysis into positive attitude, intermediate attitude, and negative attitude towards transition), which was previously used in the neighbouring albania. selfreported health status was measured on a 5-point scale which was dichotomized in the analysis into “good” vs. “poor” health. demographic and socioeconomic data were also collected. binary logistic regression was used to assess the association of reaction to transition with self-rated health status. results: in crude/unadjusted models, negative attitude to transition was a “strong” predictor of poor self-perceived health (or=2.5, 95%ci=1.7-3.8). upon multivariable adjustment for all the demographic factors and socioeconomic characteristics, the association was attenuated and was only borderline statistically significant (or=1.6, 95%ci=1.0-2.6, p=0.07). conclusion: our findings indicate an important association between reaction to transition and self-perceived health status in the adult population of the newly independent kosovo. policymakers and decision-makers in post-war countries such as kosovo should be aware of the health effects of attitudes towards political and socioeconomic aspects of transition, which is seemingly an important psychosocial factor. keywords: attitude to transition, gjilan, kosovo, psychosocial factors, reaction to transition, self-perceived health, self-rated health. conflicts of interest: none. qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and selfperceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi 10.12908/seejph-2014-50 3 introduction in several post-communist countries including russia, negative attitudes towards the political transition and socioeconomic reforms have been linked to poor self-perceived health among adult men and women (1,2). similarly, a negative or a pessimistic reaction to transition has been more recently linked to development of acute coronary syndrome in albania (3), a country which shares the same language and culture with the nowadays republic of kosovo. according to this previous study conducted in albania, a plausible mechanism linking pessimism, or negative attitude with excess coronary risk was deemed the stressor effect of inadequate coping with change in this transitional society (3). nonetheless, the evidence from many former communist countries of southeast europe, including kosovo, is scarce. after a long war against serbia and its proclaimed independence in 2008, kosovo has been undergoing a very difficult process of political and socioeconomic transition (4) associated with a particularly high unemployment rate and a rather poor socioeconomic situation of the general population (5), which leads to an intensive process of emigration to different european union countries and beyond (6). given this particularly difficult socioeconomic situation, the attitudes and perceptions of the adult population in kosovo towards the political reforms and socioeconomic aspects of transition are considered to have been negatively affected notwithstanding the lack of systematic documentation (6). as a matter of fact, regardless of its natural resources, kosovo is one of the poorest countries in europe (4-6). current evidence suggests an increase in the morbidity and mortality rates from non-communicable diseases in adult men and women in kosovo (7,8), which is explained by an increase in unhealthy behaviours (9) and presumably psychosocial factors (9). according to a recent review, alongside with unhealthy lifestyle including dietary patterns and physical inactivity, unfavourable socioeconomic and psychosocial conditions are considered as important determinants of the excess morbidity and mortality from chronic diseases in kosovo including diabetes and cardiovascular diseases (9). notably, it has been argued that changes in behavioural patterns may have unevenly affected different population subgroups, especially the vulnerable and the marginalized categories who are unable to cope with the dramatic changes of the rapid transition occurring in post-communist societies including kosovo (6,9,10). nonetheless, the negative health effects of psychosocial factors in the adult population of kosovo have not been scientifically documented to date. in this context, our aim was to determine the association of reaction to political and socioeconomic aspects of transition with self-perceived general health status among adult men and women in a region of post-war kosovo. based on a previous report from albania (3), we hypothesized a negative health effect of pessimistic attitudes towards transition, suggesting inadequate coping with change, independent of (or, mediated through) demographic factors and socioeconomic characteristics. methods this was a cross-sectional study which was carried out in gjilan region, kosovo, in 2014. study population this study included a representative sample of primary health care users of both sexes aged 35 years and above. a minimum of 740 individuals was required for participation in this study, based on the initial sample size calculations. nevertheless, it was decided to invite 1000 individuals in order to increase the study power accounting also for non-response. therefore, 1000 consecutive primary health care users aged 35 years and above who were resident in gjilan region were invited to participate in this study. qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and selfperceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi 10.12908/seejph-2014-50 4 of 1000 individuals who were invited to participate, 62 primary health care users were ineligible (individuals aged <35 years and/or very sick to participate), whereas 71 individuals refused to participate. hence, the final study population included 867 individuals (419 men and 448 women) with an overall mean age of 54.2±10.5 years (54.3±10.9 years in men and 54.0±10.1 years in women). the overall response rate in this study was: 867/1000=87%. data collection a structured questionnaire was administered to all participants including information on demographic and socioeconomic characteristics, reaction to political and socioeconomic transition in kosovo and self-perceived health status. reaction to political and socioeconomic aspects of transition among study participants was assessed by a three-item scale which was previously used in the neighbouring albania (3). this scale employed in albania was adapted from an instrument originally used in russia (1,2,11). in the current study conducted in kosovo, all participants were asked to rate their agreement/disagreement about the following three statements: a) “overall, the current economic system in kosovo is better than the old system” [range from 0 (strongly agree) to 3 (strongly disagree)]; b) “the transition toward the new system in kosovo is difficult; however, it’s worthwhile in view of the forthcoming prosperity” [range from 0 (strongly agree) to 3 (strongly disagree)], and; c) “compared with the previous system, most of the people in kosovo are poorer now” [range from 0 (strongly disagree) to 3 (strongly agree)]. a summary score was calculated for each individual (referred to as “overall reaction to transition”) ranging from 0 (most positive or optimistic attitude towards political and socioeconomic aspects of transition) to 9 (most negative or pessimistic reaction to transition). cronbach’s alpha of the three-item scale in our study conducted in kosovo was 0.94, which was slightly lower than a previous study conducted in albania (3). in the statistical analysis, the summary score of attitudes to transition was categorized into three groups [positive attitude (score: 0-3), intermediate attitude (score: 4-6), and negative attitude (score: 7-9)]. in addition, all participants were asked to rate their general health status: “overall, during the past year, how would you rate your general health status: excellent, very good, good, poor, or very poor?”. in the analysis, the self-perceived health status was dichotomized into: “good” vs. “poor”. demographic factors included age of study participants (in the analysis grouped into: 35-44 years, 45-54 years, 55-64 years and ≥65 years), sex and marital status (in the analysis, dichotomized into: married vs. not married), whereas socioeconomic characteristics consisted of educational attainment (categorized into: low, middle and high), employment status (trichotomized into: employed, unemployed and retired), income level (categorized into: low, middle and high) and social status (similarly trichotomized into: low, middle and high). statistical analysis measures of central tendency [mean values (± standard deviations) and median values (with their respective interquartile ranges iqr)] were used to describe the distribution of reaction to transition scores separately in male and female study participants. on the other hand, the distribution of different categories of the reaction to transition scores (positive, intermediate and negative) was expressed in absolute numbers together with their respective percentages separately in men and in women. chi-square test was used to assess the crude (unadjusted) association of reaction to transition scores (trichotomized into: positive, intermediate, negative) with the socio-demographic characteristics and self-perceived health status of study participants. qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and selfperceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi 10.12908/seejph-2014-50 5 conversely, binary logistic regression was used to assess the crude (unadjusted) and subsequently the multivariable-adjusted associations of self-reported health status (outcome variable dichotomized into: “good” vs. “poor” health status) and reaction to transition (independent variable) of study participants. initially, crude (unadjusted) odds ratios (ors) and their respective 95% confidence intervals (95%cis) were calculated. next, the logistic regression models were adjusted for age of participants. subsequently, the other demographic factors (sex and marital status) were entered simultaneously into the logistic regression models. finally, socioeconomic characteristics (educational attainment, employment status, income level and social status) were entered simultaneously into the logistic regression models. in all logistic regression models, the self-perceived health status was the outcome variable and reaction to transition (introduced in three categories: positive, intermediate and negative) was the main independent variable. multivariable-adjusted ors and their respective 95%cis were calculated. hosmer-lemeshow test was used to assess the overall goodness-offit of the logistic regression models (12). in all cases, a p-value of ≤0.05 was considered as statistical significant. statistical package for social sciences (spss, version 17.0) was used for all the statistical analyses. results overall mean (sd) summary score of reaction to transition was 4.2±2.8 (4.1±2.8 in men and 4.2±2.7 in women) [table 1]. furthermore, median (iqr) was quite similar in men and in women [sex-pooled median (iqr): 3.0 (3.0)]. overall, 494 (57%) of participants reported a positive attitude towards the political and socioeconomic transition in kosovo, as opposed to 181 (21%) of individuals who had a negative reaction to transition. the negative attitude to transition was higher in men than in women (23% vs. 19%, respectively) [table 1]. table 1. distribution of reaction to political and socioeconomic transition scores in a representative sample of primary health care users in gjilan region, kosovo, in 2014 reaction to transition score men (n=419) women (n=448) total (n=867) mean (standard deviation) 4.1±2.8 4.2±2.7 4.2±2.8 median (interquartile range) 3.0 (4.0) 3.0 (3.0) 3.0 (3.0) positive (score: 0-3) intermediate (score: 4-6) negative (score: 7-9) 243 (58.0) 79 (18.9) 97 (23.2) 251 (56.0) 113 (25.2) 84 (18.8) 494 (57.0) 192 (22.1) 181 (20.9) table 2 presents the distribution of demographic factors, socioeconomic characteristics and self-perceived health status by reaction to transition scores (trichotomized into: positive, intermediate and negative scores) among study participants. as noted above, the prevalence of negative attitudes to transition was significantly higher in men compared to women (p=0.05). furthermore, older individuals (65 years and above) displayed the most negative (pessimistic) attitudes to transition compared with their younger counterparts (p<0.001). similarly, the prevalence of a negative reaction to transition was the highest among the retirees (p<0.001), given the aging of this population subgroup. there was no significant association with marital status. remarkably, low-educated participants had a significantly higher prevalence of negative attitudes to transition compared with their highly educated counterparts (40% vs. 7%, respectively, p<0.001). likewise, albeit with smaller differences, low-income individuals and those with a lower social status displayed a higher prevalence of negative reaction to transition compared to high-income participants (33% vs. 18%, qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and selfperceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi 10.12908/seejph-2014-50 6 respectively, p<0.001), and individuals with a higher social status (29% vs. 12%, respectively, p<0.001). participants with a poor self-perceived health status had a significantly higher prevalence of negative reaction to political and socioeconomic transition compared with individuals who reported a good health status (34% vs. 18%, respectively, p<0.001) [table 2]. it should be noted that, on the whole, there were 696 (80.5%) participants who reported a “good” health status compared with 169 (19.5%) individuals who perceived their health status as “poor”. table 2. distribution of socio-demographic characteristics and self-perceived health status by reaction to transition scores in the study population (n=867) variable positive (score: 0-3) [n=494] intermediate (score: 4-6) [n=192] negative (score: 7-9) [n=181] p † sex: men women 243 (58.0) * 251 (56.0) 79 (18.9) 113 (25.2) 97 (23.2) 84 (18.8) 0.047 age-group: 35-44 years 45-54 years 55-64 years ≥65 years 132 (69.8) 171 (68.7) 131 (52.8) 60 (33.1) 37 (19.6) 56 (22.5) 59 (23.8) 40 (22.1) 20 (10.6) 22 (8.8) 58 (23.4) 81 (44.8) <0.001 employment: employed unemployed retired 272 (71.0) 129 (62.0) 93 (33.8) 78 (20.4) 52 (25.0) 62 (22.5) 33 (8.6) 27 (13.0) 120 (43.6) <0.001 marital status: not married married 63 (49.2) 431 (58.4) 31 (24.2) 161 (21.8) 34 (26.6) 146 (19.8) 0.116 educational level: low middle high 101 (30.5) 246 (69.9) 145 (80.1) 96 (29.0) 73 (20.7) 23 (12.7) 134 (40.5) 33 (9.4) 13 (7.2) <0.001 income level: low middle high 46 (35.7) 118 (47.0) 330 (68.2) 40 (31.0) 85 (33.9) 66 (13.6) 43 (33.3) 48 (19.1) 88 (18.2) <0.001 social status: low middle high 40 (40.0) 318 (55.4) 136 (71.6) 31 (31.0) 128 (22.3) 32 (16.8) 29 (29.0) 128 (22.3) 22 (11.6) <0.001 self-perceived health: good poor 416 (59.8) 78 (46.2) 158 (22.7) 33 (19.5) 122 (17.5) 58 (34.3) <0.001 * absolute numbers and their respective row percentages (in parentheses). discrepancies in the totals are due to the missing values. † p-values from the chi-square test. table 3 presents the association of reaction to transition with self-perceived health status of study participants. in crude (unadjusted) logistic regression models (model 1), there was qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and selfperceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi 10.12908/seejph-2014-50 7 evidence of a strong positive association between negative reaction to transition and poor self-rated health: or(negative vs. positive scores)=2.5, 95%ci=1.7-3.8. adjustment for age (model 2) attenuated the findings (or=1.8, 95%ci=1.2-2.8). additional adjustment for sex and marital status (model 3) did not affect the findings (or=1.8, 95%ci=1.2-2.8). further adjustment for socioeconomic characteristics including education, employment, income level and social status (model 4) attenuated the strength of the association which, in fully-adjusted models, was only borderline statistically significant (or=1.6, 95%ci=1.0-2.6, p=0.07). on the other hand, there was no difference in the odds of self-perceived health status between participants with intermediate scores and those with positive scores of reaction to transition, even in crude (unadjusted) logistic regression models (table 3, models 1-4). table 3. association of reaction to transition with self-perceived health status in a representative sample of primary health care users in gjilan region, kosovo model or * 95%ci * p * model 1 † positive attitude (score: 0-3) intermediate attitude (score: 4-6) negative attitude (score: 7-9) 1.00 1.11 2.54 reference 0.71-1.74 1.71-3.76 <0.001 (2) ‡ 0.636 <0.001 model 2 ¶ positive attitude (score: 0-3) intermediate attitude (score: 4-6) negative attitude (score: 7-9) 1.00 0.99 1.81 reference 0.63-1.56 1.18-2.78 0.014 (2) 0.958 0.007 model 3 § positive attitude (score: 0-3) intermediate attitude (score: 4-6) negative attitude (score: 7-9) 1.00 0.97 1.84 reference 0.62-1.53 1.20-2.83 0.011 (2) 0.897 0.005 model 4 ** positive attitude (score: 0-3) intermediate attitude (score: 4-6) negative attitude (score: 7-9) 1.00 0.88 1.58 reference 0.54-1.43 0.96-2.61 0.079 (2) 0.605 0.072 * odds ratios (or: “poor health” vs. “good health”), 95% confidence intervals (95%cis) and p-values from binary logistic regression. † model 1: crude (unadjusted). ‡ overall p-value and degrees of freedom (in parentheses). ¶ model 2: adjusted for age (35-44 years, 45-54 years, 55-64 years and ≥65 years). § model 3: adjusted for age, sex (men vs. women) and marital status (married vs. unmarried). ** model 4: adjusted for age, sex, marital status, educational level (low, middle, high), employment status (employed, unemployed, retired), income level (low, middle, high) and social status (low, middle, high). discussion the main finding of this study consists of a positive association of pessimistic reaction towards political reforms and socioeconomic transition with poor self-rated health among adult men and women in post-war kosovo, a country characterized by dramatic and rapid changes in the past few years. the association of poor self-perceived health with negative reaction to transition was strong, but upon multivariable adjustment for a wide array of demographic and socioeconomic characteristics the relationship was only borderline qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and selfperceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi 10.12908/seejph-2014-50 8 statistically significant. our findings are largely compatible with previous reports from former communist countries including russia (1,2,11) and albania (3). overall, the prevalence of negative reaction (score 0-3) towards socioeconomic aspects of transition in our study population was 21%, which is higher than a previous study carried out in albania which reported a sex-pooled prevalence of 13% (3). nevertheless, the prevalence of pessimistic reaction in our sample is much lower than in russia, where 49% of a representative sample of the adult population reported a nostalgic reaction to political and socioeconomic changes (disapproving the new system and approving the old system) according to a previous study (2). it should be pointed out that, in russia, it was considered that the attitudes towards the political and socioeconomic reforms in 1990s were significantly more negative than in other post-communist countries in europe (2,3). in our study, there was no evidence of a graded relationship with pessimistic or negative attitudes to transition. hence, the association was evident only between negative vs. positive attitude groups, with no differences between neutral (intermediate) and positive attitude categories (table 3). on the other hand, a previous study conducted in albania reported a graded relationship between acute coronary syndrome and negative attitudes towards socioeconomic transition consistent in both sexes and irrespective of demographic and socioeconomic characteristics and a wide range of conventional risk factors (3). potential mechanisms of psychosocial factors including reaction towards political and socioeconomic aspects of transition have been suggested to operate either directly through the neuro-endocrine system (13), or indirectly through induction of unhealthy behaviour such as smoking, excessive alcohol consumption, unhealthy diet and sedentary lifestyle (3,13). furthermore, regarding the negative effect of psychosocial factors on cardiovascular risk, it has been suggested that psychological distress may act chronically through pathological modifications of the cardiovascular system, such as changes in lipid profile and elevation of arterial blood pressure (3,14). in our study, the mechanism of excess self-perceived poor health among pessimists may be related to poor adaptation to critical circumstances associated with the particularly rapid transition in kosovo, as suggested by previous research on this field (3), where obvious differences in coping strategies between optimists and pessimists have been convincingly demonstrated (3,15,16). conversely, negative reaction towards political and socioeconomic aspects of transition may also serve as a marker of depression (17,18), which may lead to poor health status in general. this study may suffer from several limitations including its design, representativeness of the study population and the possibility of information bias. firstly, findings from cross-sectional studies do not imply causality and, therefore, future prospective studies should robustly assess and establish the directionality of the relationship between self-reported health status and attitudes to political and socioeconomic transition in kosovo and other transitional settings. secondly, we cannot exclude the possibility of selection bias in our study sample notwithstanding the inclusion of a fairly large sample of consecutive primary health care users of both sexes in gjilan region. in addition, we obtained a very high response rate (87%), which is reassuring. yet, we cannot generalize our findings to the general adult population of gjilan region given the fact that our study population was confined merely to primary health users. more importantly, findings from this study cannot be generalized to the overall adult population of kosovo, as our survey was conducted only in gjilan region. thirdly, the instrument used for measurement of reaction to transition may be subject to information bias, regardless of the fact that this tool was previously validated in albania (3). in our study population, the measuring instrument of reaction to transition exhibited a very qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and selfperceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi 10.12908/seejph-2014-50 9 high internal consistency and discriminated well between population subgroups distinguished in their educational attainment, income level and social status – similar to previous reports including the neighbouring albania (3). in conclusion, regardless of these potential limitations, our findings indicate an important association between reaction to transition and self-perceived health status in the adult men and women of post-war kosovo. health professionals and policymakers in developing countries and transitional populations should be aware of the negative health effects of psychosocial factors including also the general attitude towards political and socioeconomic aspects of transition, as evidenced in the current study conducted in kosovo. references 1. rose r. new russia barometer vi: after the presidential election. studies in public policy, no. 272. glasgow: center for the study of public policy, university of strathclyde; 1996. 2. bobak m, pikhart h, hertzman c, rose r, marmot m. socio-economic factors, perceived control and self-reported health in russia. a cross-sectional survey. soc 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(original research). seejph 2015, posted: 29 june 2015. doi 10.12908/seejph-2014-50 10 13. rozanski a, blumenthal ja, kaplan j. impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. circulation 1999;99:2192-217. 14. pignalberi c, patti g, chimenti c, pasceri v, maseri a. role of different determinants of psychological distress in acute coronary syndromes. j am coll cardiol 1998;32:613-9. 15. wrosch c, scheier mf. personality and quality of life: the importance of optimism and goal adjustment. qual life res 2003;12(suppl 1):59-72. 16. carver cs, scheier mf, weintraub jk. assessing coping strategies: a theoretically based approach. j pers soc psychol 1989;56:267-83. 17. scheier mf, carver cs, bridges mw. optimism, pessimism, and psychological wellbeing. in: e.c. chang (ed.). optimism and pessimism: implications for theory, research, and practice. washington, dc: american psychological association; 2001. pp.189-216. 18. kubzansky ld, davidson kw, rozanski a. the clinical impact of negative psychological states: expanding the spectrum of risk for coronary artery disease. psychosom med 2005;67(suppl 1):s10-4. ___________________________________________________________ © 2015 qazimi et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed/?term=rozanski%20a%5bauthor%5d&cauthor=true&cauthor_uid=10217662 http://www.ncbi.nlm.nih.gov/pubmed/?term=blumenthal%20ja%5bauthor%5d&cauthor=true&cauthor_uid=10217662 http://www.ncbi.nlm.nih.gov/pubmed/?term=kaplan%20j%5bauthor%5d&cauthor=true&cauthor_uid=10217662 http://www.ncbi.nlm.nih.gov/pubmed/?term=rozanski+a%2c+1999%2c+circulation http://www.ncbi.nlm.nih.gov/pubmed/?term=pignalberi%20c%5bauthor%5d&cauthor=true&cauthor_uid=9741501 http://www.ncbi.nlm.nih.gov/pubmed/?term=patti%20g%5bauthor%5d&cauthor=true&cauthor_uid=9741501 http://www.ncbi.nlm.nih.gov/pubmed/?term=chimenti%20c%5bauthor%5d&cauthor=true&cauthor_uid=9741501 http://www.ncbi.nlm.nih.gov/pubmed/?term=pasceri%20v%5bauthor%5d&cauthor=true&cauthor_uid=9741501 http://www.ncbi.nlm.nih.gov/pubmed/?term=maseri%20a%5bauthor%5d&cauthor=true&cauthor_uid=9741501 http://www.ncbi.nlm.nih.gov/pubmed/?term=role+of+different+determinants+of+psychological+distress+in+acute+coronary+syndromes http://www.ncbi.nlm.nih.gov/pubmed/?term=role+of+different+determinants+of+psychological+distress+in+acute+coronary+syndromes http://www.ncbi.nlm.nih.gov/pubmed/?term=role+of+different+determinants+of+psychological+distress+in+acute+coronary+syndromes http://www.ncbi.nlm.nih.gov/pubmed/?term=wrosch%20c%5bauthor%5d&cauthor=true&cauthor_uid=12803312 http://www.ncbi.nlm.nih.gov/pubmed/?term=scheier%20mf%5bauthor%5d&cauthor=true&cauthor_uid=12803312 http://www.ncbi.nlm.nih.gov/pubmed/?term=personality+and+quality+of+life%3a+the+importance+of+optimism+and+goal+adjustment http://www.ncbi.nlm.nih.gov/pubmed/?term=carver%20cs%5bauthor%5d&cauthor=true&cauthor_uid=2926629 http://www.ncbi.nlm.nih.gov/pubmed/?term=scheier%20mf%5bauthor%5d&cauthor=true&cauthor_uid=2926629 http://www.ncbi.nlm.nih.gov/pubmed/?term=weintraub%20jk%5bauthor%5d&cauthor=true&cauthor_uid=2926629 http://www.ncbi.nlm.nih.gov/pubmed/2926629 http://www.ncbi.nlm.nih.gov/pubmed/?term=kubzansky%20ld%5bauthor%5d&cauthor=true&cauthor_uid=15953792 http://www.ncbi.nlm.nih.gov/pubmed/?term=davidson%20kw%5bauthor%5d&cauthor=true&cauthor_uid=15953792 http://www.ncbi.nlm.nih.gov/pubmed/?term=rozanski%20a%5bauthor%5d&cauthor=true&cauthor_uid=15953792 http://www.ncbi.nlm.nih.gov/pubmed/?term=the+clinical+impact+of+negative+psychological+states%3a+expanding+the+spectrum+of+risk+for+coronary+artery+disease. lueddeke g. high level communiqué from the interaction council(letter to editors). seejph 2017, posted: 07 july 2017. doi: 10.4119/unibi/seejph-2017-146 1 letter to editors high level communiqué from the interaction council george lueddeke1 1 consultant in higher and medical education, united kingdom. corresponding author: george r. lueddeke, co-chair, one health education task force; address: 9 lakeland gardens, southampton, hampshire, so40 4xg, united kingdom; email: glueddeke@aol.com lueddeke g. high level communiqué from the interaction council(letter to editors). seejph 2017, posted: 07 july 2017. doi: 10.4119/unibi/seejph-2017-146 2 dear colleagues, here is a link to a copy of a high level communiqué from the interactioncouncil that may also be of interest to seejph readers. as you may be aware, the council brings together former world leaders (heads of government and senior officials) and focuses on issues related, among others, to global security and has been examining the role of health security over the last few years. at this year’s meeting (30-31 may), co-chaired by he obasanjo from nigeria and he bertie ahern from ireland, the session on planetary health, coordinated by professor john wyn owen, resulted in the endorsement of the “dublin charter for one health”. dr joanna nurse presented on the policy implications of planetary and one health in this session and is tasked by the interaction council with advancing the one health charter in collaboration with key partners. below is a summary of the main actions in the charter for one health that may in due course help to inform trans-disciplinary research, education and practice at national, regional and global levels with a view to sustaining people and planet health and well-being. your comments on how best to advance these key areas are requested-i.e. please let us know what is already happening, gaps and suggestions for how to advance the following: 1. strengthening multi-sector solutions for the sdgs the one health approach has the potential to act as a unifying theme; 2. resilience to emerging threats -including amr, disease outbreaks, climate change and environmental impacts; 3. mainstreaming one health within public health systems for uhc -including environmental health; 4. strengthen one health governance mechanisms for systems reform; 5. building leadership for one health for future generations; 6. establish an independent accountability mechanism for advancing action on one health. please send your comment to glueddeke@aol.com by 10 july. many thanks and best wishes! george lueddeke phd chair, one health education task force the one health commission in association with the one health initiative convenor/chair, one health global think tank for sustainable health & well-being 2030 consultant in higher and medical education southampton, united kingdom linked-in connection: http://www.linkedin.com/pub/dr-george-lueddeke/42/4b0/401 * link to the one health initiative news item: http://www.onehealthinitiative.com/news.php?query=interaction+council+issues+%91the +dublin+charter+for+one+health%92+communiqu%e9 http://interactioncouncil.org/final-communiqu-53� http://interactioncouncil.org/final-communiqu-53� https://www.onehealthcommission.org/� http://www.onehealthinitiative.com/� http://www.seejph.com/index.php/seejph/article/view/114� http://www.linkedin.com/pub/dr-george-lueddeke/42/4b0/401� lueddeke g. high level communiqué from the interaction council(letter to editors). seejph 2017, posted: 07 july 2017. doi: 10.4119/unibi/seejph-2017-146 3 link to a one health primary to tertiary education article and proposal supporting the sdgs and one health: http://africahealthnews.com/development-project-proposal-supportingsustainable-future-people-planet/. conflicts of interest: none. __________________________________________________________ © 2017 lueddeke et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://africahealthnews.com/development-project-proposal-supporting-sustainable-future-people-planet/� http://africahealthnews.com/development-project-proposal-supporting-sustainable-future-people-planet/� burazeri g, jankovic s, laaser u, martin-moreno jm. south eastern european journal of public health: a new international journal (editorial). seejph 2013, posted: 31 october 2013. doi 10.12908/seejph-2013-01. 1 editorial south eastern european journal of public health: a new international online journal genc burazeri1,2, slavenka jankovic3, ulrich laaser4, jose m. martin-moreno5 1 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 2 faculty of public health, university of medicine, tirana, albania; 3 faculty of medicine, university of belgrade, belgrade, serbia; 4 faculty of health sciences, university of bielefeld, bielefeld, germany; 5 faculty of medicine, university of valencia, valencia, spain. corresponding author: genc burazeri, md, phd address: university of medicine, rr. “dibres”, no. 371, tirana, albania; telephone: +355672071652; e-mail: gburazeri@yahoo.com burazeri g, jankovic s, laaser u, martin-moreno jm. south eastern european journal of public health: a new international journal (editorial). seejph 2013, posted: 31 october 2013. doi 10.12908/seejph-2013-01. 2 the south eastern european journal of public health (seejph) is an online, openaccess, international, peer-reviewed journal, published by jacobs company in germany (1). starting from 2014, the journal will initially release two issues per year, at the end of june and the end of december, although articles will be immediately published online following acceptance – a unique advantage of open-access journals, whose relevance within the corpus of scientific literature has been growing in recent years. seejph follows the achievements of the forum for public health in south eastern europe, funded by the german stability pact during the first decade of this century (2). seejph covers all areas of health sciences, although its main focus is public health. the journal particularly encourages submissions from scientists and researchers from eastern european transitional countries in order to promote their research work and increase their scientific visibility in europe and beyond. the need for scientific journals such as seejph springs from the peculiar geopolitical history of the region. during the late 1980s and early 1990s, the disintegration of the communist regimes in most of southeastern europe hastened the collapse—or at least enormous challenges—in the economies of the region. subsequently, a marketoriented economic system emerged involving major social, cultural, and economic reforms, with similar changes observed in all former communist countries in central and eastern europe. the rapid transition from state-enforced collectivism towards a market-oriented system brought with it increasing poverty levels, high unemployment rates, financial downturn, and massive emigration. the situation was further aggravated by the devastating ethnic wars which involved most of the countries of the former yugoslavia. today, life expectancy in the transition countries is still significantly lower than in western europe (3), with most of the east-west gap explained by the higher death rates from cardiovascular diseases and injuries in eastern european populations (4-6). the particularly high levels of smoking, alcohol consumption, unhealthy dietary habits including low intake of fresh fruits and vegetables (3,6,7), and adverse socioeconomic and psychosocial conditions (8,9) have been persuasively linked with an excess risk of cardiovascular disease, diabetes and other chronic conditions (4,7). nonetheless, the health effects of such rapid transition, especially in the distinctive context of countries of the western balkans, have not been sufficiently investigated. to date, ongoing research on the deleterious health effects of transition is scant and has not received sufficient attention in the international literature. there is an evident need to promote scientific publications pertinent to researchers from transitional countries in europe, to promote the development of a field we will refer to as “health transition research”. seejph aims to fill this void by offering a unique opportunity for the exchange of scientific information, active and rapid communication between researchers and scientists, and dissemination of findings from research conducted in central, eastern, and south eastern europe. we look forward to fostering the advance of scientific knowledge in the region, in the hope that a solid and context-specific evidence base for public health will lay the foundation for more effective health policies to serve eastern european populations. burazeri g, jankovic s, laaser u, martin-moreno jm. south eastern european journal of public health: a new international journal (editorial). seejph 2013, posted: 31 october 2013. doi 10.12908/seejph-2013-01. 3 references 1. south eastern european journal of public health (issn: 2197-5248). available from: http://www.seejph.com/?cat=7 (accessed: 12 october, 2013). 2. stability pact for south eastern europe. available from: http://www.stabilitypact.org/ and http://www. snz.unizg.hr/ph-see/index.htm (accessed: 12 october, 2013). 3. world health organization, regional office for europe. european health for all database (hfa-db). copenhagen, denmark, 2013. 4. marmot m, bobak m. international comparators and poverty and health in europe. bmj 2000;321:1124-1128. 5. ginter e. cardiovascular risk factors in the former communist countries. analysis of 40 european monica populations. eur j epidemiol 1995;11:199-205. 6. ginter e. high cardiovascular mortality in postcommunist countries: participation of oxidative stress? int j vit nutr res 1996;66:183-189. 7. rechel b, mckee m. healing the crisis: a prescription for public health action in south eastern europe. new york: open society institute press, 2003. 8. bobak m, pikhart h, rose r, hertzman c, marmot m. socioeconomic factors, material inequalities, and perceived control in self-rated health: crosssectional data from seven post-communist countries. soc sci med 2000;51:1343-1350. 9. burazeri g, goda a, tavanxhi n, sulo g, stefa j, kark jd. the health effects of emigration on those who remain at home. int j epidemiol 2007;36:12651272. ___________________________________________________________ © 2013 burazeri et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. stability pact for south eastern europe. available from: http://www.stabilitypact.org/ and http://www. snz.unizg.hr/ph-see/index.htm (accessed: 12 october, 2013). houghton f, o’doherty d, mcinerney d, duncan b. anti-tobacco text warnings in italy: geography, language, and south tyrol (short report). seejph 2019, posted: 21 may 2019. doi 10.4119/unibi/seejph-2019-218 page 1 of 4 short report anti-tobacco text warnings in italy: geography, language and south tyrol frank houghton1, diane o’doherty1, derek mcinerney2, bruce duncan3 1 department of applied social sciences, limerick institute of technology, moylish, limerick, ireland; 2 department of sport, limerick institute of technology, moylish, limerick, ireland; 3 hauora tairawhiti, gisborne, new zealand. corresponding author: frank houghton, phd, mphe, ma, msc, director healr research group; department of applied social sciences, limerick institute of technology, limerick, ireland; telephone: +353-87-7101346; email: frank.houghton@lit.ie houghton f, o’doherty d, mcinerney d, duncan b. anti-tobacco text warnings in italy: geography, language, and south tyrol (short report). seejph 2019, posted: 21 may 2019. doi 10.4119/unibi/seejph-2019-218 page 2 of 4 the global death toll from tobacco is now estimated to be in excess of 6 million annually, with projections of this burden reaching 8 million by 2030 (1). the impact of smoking on morbidity is equally alarming, as well as it having a significant adverse impact on individual and family finances. focusing on italy, the tobacco atlas notes that 28.3% of men aged 15 and over, and 19.7% of women of a similar age smoke (2). the annual death-toll of 93,300 from tobacco-induced illness, and an economic cost of 26041 million euro. although smoking is not highly regulated in italy (2), under european union legislation all tobacco products sold there carry mandated combined graphical and text warnings. an example of one of the current italian cancer warnings contained on cigarette packets is given in figure 1a. as the one official language of the italian state, it is perhaps no surprise that this warning is written in italian. however, this one-size-fits-all approach glosses over important linguistic differences within italy, most notably in relation to south tyrol (südtirol [german] / alto adige [italian]) in the northeast of the country. previously part of the austro-hungarian empire, the south tyrol region was annexed by italy following the end of world war one. although german speaking, the region was subject to a policy of italianization and italian inmigration during the fascist era under mussolini. although agreement on a solution was reached between hitler and mussolini, de facto annexation of the region by occupying german forces occurred after italy surrendered and then joined the allies in world war ii. in 1946 italy and austria signed the paris treaty which secured cultural, economic and linguistic rights for the region. fifteen years later this treaty had still not been enacted, which led to a campaign of violence in support of the rights of the german speaking population. this culminated in debates in the un and ultimately the 1972 second autonomy statute, known as the ‘package’. this agreement officially ended the dispute between austria and italy over the status of south tyrol in 1992. this agreement created an autonomous zone in south tyrol and contained over 130 measures designed to safeguard the germanspeaking minority there (3). the south tyrol population is 511,750, the majority of which is (62.3%; 314,604) german speaking (italian census, 2011). less than a quarter of the population (23.4%; 118,120) speak italian, with the third recognized linguistic group, ladin speakers, constituting just 4.1% (20,548) of the populace. these statistics are important because emerging evidence from anti-smoking research in ireland (4) supports basic marketing communication theory which stresses the importance of language ability and preference in health warnings, as well as the need for ease and speed in health communications. under primary and secondary elements of the ‘package’ the south tyrol rgion already has a legal remit in relation to matters of language, health and public health. the south tyrol region therefore should strongly consider legislation to require either bilingual (german then italian), or preferably trilingual antismoking text warnings (german then italian, followed by ladin). south tyrol would then join other areas within the eu with more than one language in its combined graphical anti-smoking warnings. such linguistic diversity is currently reflected in the anti-smoking warnings in the five countries that are officially bilingual (malta [see figure 1b), ireland, finland, cyprus, & luxembourg) and belgium which is officially trilingual (see figure 1c). houghton f, o’doherty d, mcinerney d, duncan b. anti-tobacco text warnings in italy: geography, language, and south tyrol (short report). seejph 2019, posted: 21 may 2019. doi 10.4119/unibi/seejph-2019-218 page 3 of 4 the relatively small population of south tyrol is not a reason to justify continuing with an ‘italian only’ approach on the combined text and graphic warnings. the population of the region is considerably larger than that of malta (approximately 430,000), an eu state with its own unique requirements in antismoking warnings. as can be seen from figure 1b current maltese legislation requires warnings in both english and maltese (5). figure 1. examples of current anti-smoking combined graphic and text warnings from italy, malta & belgium 1aitalian warning 1bmaltese warning 1cbelgium warning it is easy to overlook the importance of text warnings in an era of graphic pictorial warnings. however, evidence suggests that text based warnings are still an important element of health education and in some ways may be more influential than graphic warnings (6-8). it is also notable, as noar et al. point out, that if one assumes an average consumption of 20 cigarettes per day for a year, this equals a total of 7,300 potential opportunities to view the combined text and graphic warnings annually (9). this form of direct marketing to smokers therefore may achieve incomparable penetration to the target audience. the damage wrought by smoking is such that continuing with a generic italian only approach is no longer acceptable. every effort must be taken to reduce smoking using a multiplicity of approaches. this proposal has two crucial factors in its favour. most importantly, the population in south tyrol, like those elsewhere within the eu, are familiar with, and largely accepting of, combined text and graphic anti-smoking warnings. as such this initiative is largely a fine-tuning of current protections, rather than a new development. therefore it is unlikely to encounter significant opposition, and given the strength of feeling towards language exhibited by the german-speaking population of south tyrol, may well be welcomed. an additional advantage of this approach is that the cost of this intervention is borne solely by the tobacco producers. this development therefore is attractive to regulators and policy makers operating in fiscally constrained environments. conflicts of interest: none. houghton f, o’doherty d, mcinerney d, duncan b. anti-tobacco text warnings in italy: geography, language, and south tyrol (short report). seejph 2019, posted: 21 may 2019. doi 10.4119/unibi/seejph-2019-218 page 4 of 4 references 1. world health organisation. who report on the global tobacco epidemic, 2011. geneva: world health organisation; 2011. 2. italy | tobacco atlas [internet]. tobacco atlas. 2018 [cited: 5 november 2018]. https://tobaccoatlas.org/country/italy/ (accessed: 13 may 2019). 3. alcock a. from tragedy to triumph: the german language in south tyrol, 1922-2000. in: hogan-brun g, ed. by. national varieties of german outside germany: a european perspective. bern, switzerland: peter lang; 2000. p. 161-94. 4. o’doherty d, houghton f, mcinerney d. tobacco control in ireland: how effective are dual health warnings on tobacco packaging? tob prev cessat 2018; 4(supplement):a72. doi: https://doi.org/10.18332/tpc/90316. 5. o’doherty d, houghton f, mcinerney d. asleep at the helm? language and malta's new combined tobacco control warnings. public health 2018;163:1557. 6. pepper jk, cameron ld, reiter pl, mcree, a-l, brewer nt. nonsmoking male adolescents’ reactions to cigarette warnings. plos one 2013;8:e65533. doi: 10.1371/journal.pone.0065533. 7. sabbane li, lowrey tm, chebat j. the effectiveness of cigarette warning label threats on nonsmoking adolescents. j consum aff 2009;43:332-45. 8. evans at, peters f, shoben ab, meilleur lr, klein eg, tompkins mk, et al. cigarette graphic warning labels are not created equal: they can increase or decrease smokers’ quit intentions relative to text-only warnings. nicotine tob res 2017;19:1155-62. 9. noar sm, hall mg, francis db, ribisl km, pepper jk, brewer nt. pictorial cigarette pack warnings: a metaanalysis of experimental studies. tob control 2016;25:341-54. ______________________________________________________________________________________ © 2019 houghton et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. spallek j, breckenkamp j, kraywinkel k, schwabe w, krieg v, greiner w, damm o, razum o. need for nursing care support in cancer patients: registry-linkage study in germany (original article). seejph 2018, posted: 19 october 2018. doi 10.4119/unibi/seejph-2018-204 page 1 of 10 o r i gi n a l a r t i c l e need for nursing care support in cancer patients: registrylinkage study in germany jacob spallek1,2*, jürgen breckenkamp1*, klaus kraywinkel3,4, wolfgang schwabe5, volker krieg3, wolfgang greiner6, oliver damm6, oliver razum1 abstract aim: in germany, very little is known about the need for assistance and nursing care support among cancer patients after hospitalization. the aim of this study was to describe nursing care support for cancer patients and to analyse whether these patients need more care assistance than other persons in need for care. methods: this was a registry linkage study conducted in 2011. cases were identified from the population-based cancer registry for the muenster district in north-western germany and in factually anonymised form linked by a semi-automatic probabilistic procedure (the standard procedure of the cancer registry) with medical examination records of patients applying for assistance and nursing care support from the regional statutory health insurance. the application records of 4,029 patients with colon, breast and prostate cancer were compared to a reference group of 13,104 non-cancer patients. results: in only 41.7% of colon, 45.8% of breast and 37.4% of prostate cancer patients was the malignancy the main underlying diagnostic cause for the application of assistance and nursing care. these patients were on average younger (mean age 71.1 vs. 76.8 years) than the non-cancer reference group, required higher levels of support (79.5 vs. 58.1% “considerable” or higher level care need) and their applications were less likely to be rejected (odds ratios [ors] 0.26, 0.28, and 0.31, respectively). by contrast, the proportion of successful applications and the level of support granted did not differ between multimorbid cancer patients with other main diagnoses as compared to non-cancer applicants. conclusion: patients with colon, breast or prostate cancer do not need per se more nursing care than non-cancer patients. only if cancer is the main underlying diagnosis for nursing care support, higher levels of support are needed. keywords: cancer patients, germany, nursing care. 1 department of epidemiology and international public health, school of public health, bielefeld university, bielefeld, germany; 2 department of public health, brandenburg university of technology cottbus-senftenberg, senftenberg, germany; 3 epidemiologic cancer registry nrw ggmbh, münster, germany; 4 german centre for cancer registry data, robert koch-institute, berlin, germany; 5 medical service of the health insurance westphalia-lippe, administrative centre, münster, germany; 6 department of health economics and health care management, school of public health bielefeld university, bielefeld, germany. *j. spallek and j. breckenkamp contributed equally to this paper. corresponding author: dr. jürgen breckenkamp, department of epidemiology and international public health, school of public health, bielefeld university; address: d-33615 bielefeld, germany; telephone: +49(0)521-106 3803; e-mail: juergen.breckenkamp@uni-bielefeld.de mailto:juergen.breckenkamp@uni-bielefeld.de spallek j, breckenkamp j, kraywinkel k, schwabe w, krieg v, greiner w, damm o, razum o. need for nursing care support in cancer patients: registry-linkage study in germany (original article). seejph 2018, posted: 08 october 2018. doi 10.4119/unibi/seejph-2018-204 page 2 of 10 introduction the population in germany, like in other industrialized countries, is ageing. consequently, the burden of disease due to chronic conditions such as cancer is increasing.improved early detection and medical care result in longer survival of cancer patients (1).cancer survivors not only require in-hospital or ambulatory medical treatment but they may also need assistance and nursing care, either permanently or during certain periods in the course of their disease. internationally the access to, the implication for and the coordination of care after treatment for cancer is a subject of research (2). geriatric assessment (3), the use of care plans (4) and their improvement (5) as well as the use of multidisciplinary teams are discussed as ways to improve care (6). in germany, depending on the individual need (determined by the type of disease, stage of disease and age of the patient) and on the personal financial resources, the patient or his/her family are entitled to apply for support from the statutory health insurances’ nursing care provision program (gesetzliche pflegeversicherung). this insurance covers about 70.5 million of the 80 million people residing in germany (all those insured in the compulsory health insurance). after applying for support, the medical service of the health insurance (medizinischer dienst der kranken-versicherung, mdk) will entrust trained medical personal with conducting a standardized assessment of the actual need of home nursing care in order to assess the eligibility for support and the type of support granted (financial, ambulatory nursing care, or institutional care) (7).the medical assessment results as well as information on the type of support granted are stored in regional databases maintained by the mdk. the mdk databases contain one main and one concomitant diagnosis underlying the need for nursing care support. thus, older and multimorbid patients, even if they are cancer survivors and have been granted nursing care support, may not be registered as cancer cases in the mdk database. hence, with this database alone, it is not possible to assess the level of nursing care support that cancer patients require relative to non-cancer patients. the complementing information may be retrieved from population-based cancer registries, which, however, usually do not contain information on nursing care (8). therefore, very little is known about the need for nursing care support of cancer survivors after hospitalization in germany. this study aims to describe nursing care support for cancer patients and to analyse whether these patients need more care assistance than other persons in need for care. all requirements of the german data protection act and the responsible ethical committee were adhered to. methods the study was conducted in the muenster district in the north-west of germany with a population of about 2.6 million persons in 2011. the epidemiologic cancer registry for the muenster district (ekr) registers all cancer cases, with a completeness of recording of more than 95% and a proportion of death certificate only cases of about 7% (9). the number of incident cancer diagnoses in the muenster district is about 13,000 per year (10). data of the regional mdk of westphalialippe (mdk-wl) were used to determine the need for and the type of nursing care support granted in the period of 2004 to 2008. the mdk-wl maintains a quasi-complete database of all claims for nursing care in westphalialippe (7). westphalia-lippe comprises three of the five districts of north rhinewestphalia (nrw), among them the district of muenster. in this district, about 73,000 persons received support for nursing care in 2009, corresponding to 2,810 cases per 100,000 inhabitants (11). spallek j, breckenkamp j, kraywinkel k, schwabe w, krieg v, greiner w, damm o, razum o. need for nursing care support in cancer patients: registry-linkage study in germany (original article). seejph 2018, posted: 08 october 2018. doi 10.4119/unibi/seejph-2018-204 page 3 of 10 as described elsewhere, records of the ekr and the mdk were pseudonymised and linked using a semi-automatic probabilistic procedure in accordance with the cancer registry act of nrw (12). the resulting database contained detailed information about cancer cases (site, time of diagnosis, etc.) as well as their need for nursing care and the type of nursing care granted by the mdk. about 18,900 cancer cases could be identified in the ekr who had at least one medical examination recorded in the mdk database. a reference group of patients with no records in the ekr was drawn from the mdk database for comparison (about 21,400 non-cancer patients). we used temporary record numbers to identify the patients not registered in the cancer registry and to draw the reference group. in cases of changes in the need for nursing care (or appeals against the mdk’s decision), a follow-up medical examination is conducted. here, data of the first mdk follow-up examination is used to assess nursing care needs in relation to disease progress. the analysis was restricted to cancer of the breast, colon and prostate (icd10 c-18, icd10 c-50, icd10 c-61, total n= 4,029), the most frequent malignancies. a cancer record in the ekr and the main diagnosis leading to nursing care in the mdk database were used to define three subgroups: i) cancer according to ekr (yes) and to main diagnosis in the mdk (yes): n=1,707 patients; ii) cancer according to ekr (yes) but not to mdk (no): n=2,322 patients, and; iii) ekr (no) and mdk (no): n=13,104 patients (reference group). due to the small number of patients (n=181) the fourth group (no/yes) was not considered. the age range was restricted to 38-95 years, so that groups of equal age are compared. the outcome of interest was the “need for nursing care support” as assessed by mdk in the medical examination. it was defined according to the german nursing act in five levels (0 to 3+)[box 1]. descriptive analyses compared groups with regard to baseline characteristics and levels of need. logistic regression models were used to adjust dichotomous outcomes for age (in years) and sex (colon cancer only). analyses were performed with sas 9.2. results age and sex distribution of patients who applied for nursing care are shown in table 1, stratified by cancer case status in the ekr and the mdk database. cancer patients with cancer as main diagnosis justifying nursing care (group 1) were about eight years younger than cancer patients whose need for nursing care was justified by another condition (group 2) and patients with main diagnoses other than cancer (group 3, reference). differences by sex were fairly small, although statistically significant. in more than 50% of mdk patients who suffered from colon, breast or prostate cancer, cancer was not the main diagnosis leading to nursing care (table 2). nursing care level between 20.5% (group 1) and 41.9% (group 3) of mdk patients did not fulfil the criteria to receive nursing care support according to the first mdk medical examination. spallek j, breckenkamp j, kraywinkel k, schwabe w, krieg v, greiner w, damm o, razum o. need for nursing care support in cancer patients: registry-linkage study in germany (original article). seejph 2018, posted: 08 october 2018. doi 10.4119/unibi/seejph-2018-204 page 4 of 10 textbox 1: levels of need for nursing care support adapted from [8] -level 0: no need of nursing care support the need for nursing care is below the threshold of 90 minutes/day on average (see level 1 below), so no support is granted. -level 1: considerable need for nursing care support need for assistance is required at least once a day and covers at least two activities in one or more areas of basic care (body care, feeding and mobility). in addition, domestic help is required several times a week.the weekly expenditure of time is at least 90minutes/day on average, with more than 45 minutes for basic care. -level 2: extensive need for nursing care support need for assistance in basic care (body care, feeding and mobility) is required at least three times daily at different times of the day. in addition, domestic help is required several times a week.the weekly expenditure of time is at least 3 hours/day on average, with more than 2 hours for basic care. -level 3: very extensive need for nursing care support there is need for assistance in basic care around the clock, also at night. in addition, domestic help is required several times a week.the weekly expenditure of time is at least 5 hours/day on average, with more than 4 hours for basic care. -level 3+: “härtefall” if the conditions of level 3 are satisfied and there is an unusually high or intensive need of assistance, the hardship regulation with higher payments can be applied. nursing care support was more often granted (nursing care level 1 and higher) in mdk patients in whom cancer was the main diagnosis justifying nursing care support (group 1). for cancer patients who had another main diagnosis that justified nursing care support (group 2), the rejection rate was considerably higher than in group 1, but similar to patients without cancer (group 3). table 1. age and sex of mdk patients grouped by cancer case status in cancer registry (ekr) and mdk database (cancer cases in groups 1 and 2 restricted to colon, breast and prostate cancer) variable group 1 *(ekr yes/ mdk yes) group 2 †(ekr yes/ mdk no) group 3 ‡(ekr no/ mdk no) p age mean ±sd 71.1±11.0 79.2±8.0 76.8±11.1 <0.001median 73 80 79 range 38-95 38-95 38-95 sex male n, (%) 623 (36.5) 920 (39.6) 4.320 (33.0) <0.001female n, (%) 1,084 (63.5) 1.402 (60.4) 8.784 (67.0) total 1,707 (100) 2,322 (100) 13,104 (100) * cancer case in ekr + cancer is main diagnosis justifying nursing care also if nursing care is not granted (level 0). † cancer case in ekr + cancer is not main diagnosis justifying nursing care also if nursing care is not granted (level 0). ‡ non-cancer case in ekr + cancer is not main diagnosis justifying nursing care also if nursing care is not granted (level 0), reference. patients in group 1 also needed extensive nursing care of level 2 or level 3 (including level 3+) more frequently than patients in the other groups (table 3). spallek j, breckenkamp j, kraywinkel k, schwabe w, krieg v, greiner w, damm o, razum o. need for nursing care support in cancer patients: registry-linkage study in germany (original article). seejph 2018, posted: 08 october 2018. doi 10.4119/unibi/seejph-2018-204 page 5 of 10 of all persons registered in the ekr applying for nursing care support (groups 1 and 2) a need for nursing care support (level 1 and higher) was confirmed at the first medical examination in 69.2 % of colon cancer patients (mean age: 77.1 years), 65.1 % of breast cancer patients (mean age: 73.4 years), and 72.4 % of prostate cancer patients (mean age 76.4 years) (table 3). table 2. age distribution of mdk patients stratified by cancer location, grouped by cancer case status in cancer registry (ekr) and mdk database group 1 *yes/ mdk yes)(ekr group 2 †(ekr yes/ mdk no) group ‡(ekr no/ mdk no) icd10 c-18: n, (%) (cancer of the colon) 483 (41.7) 675 (58.3) mean(±sd) age females 75.1±10.0 82.0±7.0 78.6±10.3 mean(±sd) age males 70.6±10.5 77.8±7.8 73.2±11.8 icd10 c-50: n, (%) (female breast cancer) 811 (45.8) 958 (54.2) mean(±sd) age females 68.4±12.2 79.1±8.9 78.6±10.3 icd10 c-61: n, (%) (cancer of prostate) 413 (37.4) 689 (62.6) mean(±sd) age males 73.8±7.7 77.9±6.9 73.2±11.8 *cancer case in ekr + cancer is main diagnosis justifying nursing care also if nursing care is not granted (level 0). † cancer case in ekr + cancer is not main diagnosis justifying nursing care also if nursing care is not granted (level 0). ‡ non-cancer case in ekr + cancer is not main diagnosis justifying nursing care also if nursing care is not granted (level 0), reference. to assess what determines the chances of nursing care support being refused by mdk, we calculated odds ratios separately for the three cancer types (table 4). the reference was group 3 (table 4). the chance of receiving no support (level 0) was statistically significantly lower when cancer was the main diagnosis justifying nursing care, irrespective of the type of cancer (or=0.26-0.31). table 3. nursing care level of mdk patients as per first medical examination by cancer case status in cancer registry (ekr) and mdk database (cancer cases in groups 1 and 2 restricted to colon, breast and prostate cancer) group 1 (ekr yes/ mdk yes)* group 2 (ekr yes/ mdk no)* group 3 (ekr no/ mdkno)* nursing care level as per first medical opinion (n, %) level 0 (no support) 350 (20.5) 928 (40.0) 5.492 (41.9) level 1 and higher 1.357 (79.5) 1.394 (60.0) 7.612 (58.1) level 1† 673 (49.6) 1.065 (76.4) 5.741 (75.4) level 2 614 (45.3) 310 (22.2) 1.711 (22.5) level 3‡ 70 (5.1) 19 (1.4) 160 (2.1) * see footnotes to table 1. †subgroups with level 1, 2 and 3 add up to 100% (as do level 0 plus “level 1 and higher”). ‡ includes level 3+ cases. spallek j, breckenkamp j, kraywinkel k, schwabe w, krieg v, greiner w, damm o, razum o. need for nursing care support in cancer patients: registry-linkage study in germany (original article). seejph 2018, posted: 08 october 2018. doi 10.4119/unibi/seejph-2018-202 page 6 of 10 by contrast, cancer patients who had another main diagnosis justifying their nursing care need (group 2) had equally high chances of refusal as the cancer-free reference group 3. table 4. chance of receiving no nursing care support (level 0) among mdk patients by type of cancer, adjusted for age (breast and prostate cancer) and for age and sex (colon cancer), by cancer case status in cancer registry (ekr) and mdk database group 1 (ekr yes/ mdk yes)* group 2 (ekr yes/ mdk no)* group 3 (ekr no/ mdk no)* n or [95% ci] n or [95% ci] n or cancer of colon level 0 92 0.28 [0.22-0.36] 265 1.01 [0.86-1.18] 5,492 1.00 (ref.) level 1 and higher 391 410 7,612 female breast cancer level 0 201 0.31 [0.26-0.37] 416 1.00 [0.87-1.14] 3,848 1.00 (ref.) level 1 and higher 610 542 4,936 cancer of prostate level 0 57 0.26 [0.20-0.35] 247 1.12 [0.94-1.33] 1,644 1.00 (ref.) level 1 and higher 356 442 2,676 * see footnotes to table 1. disease progression the number of patients in our dataset with a second medical examination was limited (see numbers in table 5). an increase in the need for nursing care support over time is evident, which is compatible with a progression of the malignancy. the strongest increment in terms of a need for level 2 or higher care was found in patients from group 1. for example, 11% of colon cancer patients were in level 2+ at the first examination. this increased to almost 52% at the second examination, a far larger increase than in the non-cancer reference group (12% to 39%). the difference between mean ages (as estimated from the mean ages in table 5) is smallest in group 1, suggesting a shorter time-span between first and second medical examination. discussion in this population of patients with colon, breast or prostate cancer who had applied for nursing care support (groups 1+2), the malignant disease was in less than half of the cases the underlying justification for support being granted (group 1). in other words, more than every second cancer patient (group 2) had another underlying diagnosis that was the main reason for nursing care support. the mean age of the cancer patients was high, so the combination of cancer with one or more other (presumably chronic) conditions reflects the well-known multimorbidity of the elderly in germany (13-15). studies analyzing german claims data indicate that the most common conditions in multimorbid patients are hypertension, lipid metabolism disorders, chronic low back pain diabetes spallek j, breckenkamp j, kraywinkel k, schwabe w, krieg v, greiner w, damm o, razum o. need for nursing care support in cancer patients: registry-linkage study in germany (original article). seejph 2018, posted: 08 october 2018. doi 10.4119/unibi/seejph-2018-204 page 7 of 10 table 5. changes from first to second medical examination to establish level of nursing care support among mdk patients, by cancer case status in cancer registry (ekr) and mdk database group 1 (ekr yes/ mdk yes)* group 2 (ekr yes/ mdk no)* group 3 (ekr no/ mdk no)* level n % n % n % cancer of colon 234 5,205 first medical examination 0 23.8 32.9 32.9 1 65.3 55.1 54.8 2+ 10.9 12.0 12.4 mean age 74.3 79.9 77.0 second med. examination 0 20.8 26.5 25.6 1 27.7 33.3 35.7 2+ 51.5 40.2 38.7 mean age 74.8 80.7 77.7 female breast cancer 194 354 3,506 first med. examination 0 22.7 39.8 34.3 1 88.0 87.8 82.7 2+ 12.0 12.2 17.3 mean age 69.9 79.5 78.6 second med. examination 0 19.6 25.7 26.7 1 39.7 49.1 47.8 2+ 60.3 51.0 52.2 mean age 70.4 80.2 79.4 cancer of prostate 108 262 1699 first med. examination 0 15.7 29.8 29.8 1 84.6 83.7 79.5 2+ 15.4 16.3 20.5 mean age 73.0 78.0 73.5 second med. examination 0 13.0 21.0 24.3 1 25.5 46.9 48.4 2+ 74.5 53.1 51.6 mean age 73.5 78.9 74.2 * see footnotes to table 1. mellitus, osteoarthritis and chronic ischemic heart disease (16,17). these often occur in dyads or triads together with cancer. accordingly, diseases other than cancer are the major reasons for claiming nursing care support in germany: psychological and behavioural disorders take first place (18) while cancer ranges at the fifth rank (19). our study shows, however, that if cancer was the diagnosis justifying nursing care support (patient group 1), then the probability of actually being granted support was significantly higher than in the reference group of non-cancer patients. despite having greater need for care support, cancer patients in group 1 were significantly younger than patients in the other groups (more than 10 years in case of breast cancer). it can be concluded that there is a group of cancer patients who apparently is more severely ill and in need of nursing care support relatively early in life (group 1); and a second, older group of cancer first med. examination first med. examination spallek j, breckenkamp j, kraywinkel k, schwabe w, krieg v, greiner w, damm o, razum o. need for nursing care support in cancer patients: registry-linkage study in germany (original article). seejph 2018, posted: 08 october 2018. doi 10.4119/unibi/seejph-2018-204 page 8 of 10 patients who is multimorbid and in whom cancer survivorship is a concomitant condition of less severity (group 2). the need for nursing care support of the latter group is not substantially different from that of non-cancer patients (group 3). our findings regarding the temporal development of the need for support seem to support this interpretation. second medical examinations were conducted sooner in patients from group 1 than in the other two patient groups, indicating that the course of disease in this group was more severe requiring reassessment of the condition. also, the proportion of patients being upgraded to higher levels of support was substantially higher in group 1 than in the other groups, despite younger age and earlier reassessment. while this might reflect a comparatively quick worsening of health among this group of cancer patients, differences in mean age could also partly be an effect of a higher case fatality rate in group 1. discussions in other countries highlight unmet needs of cancer patients, often calling for specialised oncology nursing in hospital and nursing home care (2,22-23). hansen et al. (20) reported an association of unmet needs with health-related quality of live. according to puts et al. (21) the most common needs are psychological and physical needs as well as needs for information. another focus is on improvement and coordination of nursing care (2-6). salz and baxi (5) assume that patients with serious health problems will benefit most from care coordination. though the system of nursing care support in germany is different from systems in other countries, our findings confirm among cancer specific care needs patients. comparative studies should establish how the different systems are performing, relative to each other. -strengths: firstly, the medical examinations from mdk are performed by experts following highly standardized procedures, so information about need for nursing care and the underlying main diagnosis is reliable. secondly, the completeness of data in the cancer registry and mdk databases is high. about 95% of cancer cases are registered. about 94% of persons in the study population are insured in the compulsory nursing care insurance, so all their claims for nursing care are registered by the mdk. thirdly, the results of our study are representative for the study region of muenster district. as muenster is a typical west german district with rural and urban areas, the findings may be generally indicative of needs of the population in the western part of germany. fourthly, we could combine administrative with medical data, thus obtaining information that is not available in single databases such as claims data (16,17). to achieve this, we had to solve a methodological problem, namely linking routine data while maintaining data protection. there is no system of unique national identification numbers (24) that would allow a simple linkage of routine health data from different sources (25) in germany, as in case of countries like canada or the united kingdom. we overcame this problem by developing an approach using pseudonymisation of personal identifiers, data encryption and probabilistic record linkage (17). -limitations: only information available in the datasets of mdk and the cancer registry could be used. as complete data could only be obtained from one region, the number of cancer cases was sufficiently large to analyze only the three most common cancer diagnoses. data on follow-up (second medical examination) was limited and this may compromise the interpretation of findings on the progression of nursing care needs. also, deaths are documented in the cancer registry but not by the mdk database, which could bias comparisons between cancer and non-cancer patients. studies with larger study populations and spallek j, breckenkamp j, kraywinkel k, schwabe w, krieg v, greiner w, damm o, razum o. need for nursing care support in cancer patients: registry-linkage study in germany (original article). seejph 2018, posted: 08 october 2018. doi 10.4119/unibi/seejph-2018-204 page 9 of 10 preferably a prospective design could help to analyse the need for nursing care among other cancer diagnoses and to obtain more reliable data about the progression of nursing care needs of cancer patients. enrolling incident cancer cases prospectively would also allow estimating the proportion of cancer patients applying for nursing care support. however, until sufficient patient-years among elderly people have been accrued in large cohortstudies, registry-based studies such as ours are needed to fill the gap. conclusion patients applying for nursing care support because of colon, breast or prostate cancer needed higher levels of support in spite of being younger than non-cancer patients (reference group). also, their condition seems to deteriorate faster as they are reexamined after shorter time periods. multimorbid cancer survivor patients, in references 1. brenner h. long-term survival rates of cancer patients achieved by the end of the 20th century: a period analysis. lancet 2002;360:1131-5. 2. cockle-hearne j, charnay-sonnek f, denis l, fairbanks he, kelly d, kav s, et al. the impact of supportive nursing care on the needs of men with prostate cancer: a study across seven european countries. brit j cancer 2013;109:2121-30. 3. magnuson a, allore h, cohen hj, mohile sg, williams gr, chapman a, et al. geriatric assessment with management in cancer care: current evidence and potential mechanisms for future research. j geriatr oncol 2016;7:242-8. 4. guerard ej, nightingale g, bellizzi k, burhenn p, rosko a, artz as, et al. survivorship care for older adults with cancer: u 13 conference report. j geriatr oncol 2016;7:305-12. 5. salz t, baxi s. moving survivorship care plans forward: focus on care coordination. cancer med 2016;5:1717-22. 6. karnakiis t, gattás-vernaglia if, saraiva md, gil-junior la, kanaji al, jacob-filho w. the geriatrician’s perspective on practical aspects of the multidisciplinary care of older adults with cancer. j geriatr oncol 2016;7:341-5. 7. medizinischer dienst der krankenversicherung westfalen-lippe. wir über uns – aufgaben und leistungen. available from: whom cancer was not the main reason for their application for nursing care support, did not differ from the reference group in most parameters. conflict of interest: none. authors’ contribution js and or conceived the study. kk, ws, jb, and vk provided the data and prepared the datasets. jb, kk, vk and js performed the data analysis. jb, js and or wrote the first draft of the manuscript. all authors contributed to discussion of the results and revised the manuscript. all authors have read and approved the final manuscript. acknowledgements funded by german cancer aid (“deutsche krebshilfe”, project number 108232). the study sponsor had no involvement in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. we acknowledge support for the article processing charge by the deutsche forschungsgemeinschaft and the open access publication fund of bielefeld university. 8. robert koch-institut und die gesellschaft der epidemiologischen krebsregister (eds). krebs in deutschland 2005/2006. häufigkeiten und trends. berlin; 2010. 9. gekid. cancer in germany, incidence and trends. saarbrücken, gekid; 2006. available from: http://www.ekr.med.unierlangen.de/gekid/doc/kid2006.pdf (accessed: july 30, 2018). 10. ekr epidemiologisches krebsregister für den regierungsbezirk münster (eds.). krebserkrankungen im regierungsbezirk münster, band 3. bericht für die jahre 1998 – 2002. münster, ekr; 2004. 11. landeszentrum gesundheit nordrheinwestfalen. indikatoren der ländergesundheitsberichterstattung. indikator 3.49_01, jahr 2009. available from: http://www.lzg.gc.nrw.de/00indi/0data/03/html/030 4901052009.html (accessed: july 30, 2018). 12. breckenkamp j, spallek j, kraywinkel k, krieg v, schwabe w, greiner w, et al. abgleich von verwaltungsdaten des medizinischen dienstes der krankenversicherung mit krebsregisterdaten. das gesundheitswesen 2012;74:e52-60. spallek j, breckenkamp j, kraywinkel k, schwabe w, krieg v, greiner w, damm o, razum o. need for nursing care support in cancer patients: registry-linkage study in germany (original article). seejph 2018, posted: 08 october 2018. doi 10.4119/unibi/seejph-2018-204 page 10 of 10 13. sgb §15; sozialgesetzbuch (sgb), elftes buch (xi) – soziale pflegeversicherung. artikel 1 des gesetzes vom 26. mai 1994. §15 stufen der pflegebedürftigkeit. available from: http://www.gesetze-iminternet.de/sgb_11/__15.html (accessed: july 30, 2018). 14. kirchberger i, meisinger c, heier m, zimmermann ak, thorand b, autenrieth cs, et al. patterns of multimorbidity in the aged population. results from the kora-age study. plos one 2012;7:1. 15. fuchs j, busch m, lange c, scheidt-nave c. prevalence and patterns of morbidity among adults in germany. results of the german telephone health interview survey german health update (geda) 2009. bundesgesundheitsblatt gesundheitsforschung gesundheitsschutz 2012;55:576-8. 16. van den bussche h, koller d, kolonko t, hansen h, wegscheider k, glaeske g, et al. which chronic diseases and disease combinations are specific to multimorbidity in the elderly? results of a claims data based cross-sectional study in germany. bmc public health 2011;11:101. 17. schäfer i. does multimorbidity influence the occurrence rates of chronic conditions? a claims data based comparison of expected and observed prevalence rates. plos one 2012;7:e45390. 18. wagner a, fleer b. pflegebericht des medizinischen dienstes 2006. medizinischer dienst des spitzenverbandes bund der krankenkassen e.v. essen; 2007. 19. wagner a, brucker u. pflegebericht des medizinischen dienstes 2001-2002. medizinischer dienst des spitzenverbandes bund der krankenkassen e.v. essen; 2003. 20. hansen dg, larsen pv, holm lv, rottmann n, bergholdt sh, søndergaard j. association between unmet needs and quality of life of cancer patients: a population-based study. acta oncol 2013;52:391-9. 21. puts mte, papoutsis a, springall e, tourangeau ae. a systematic review of unmet needs of newly diagnosed older cancer patients undergoing active cancer treatment. support care canser 2012;20:1377-94. 22. maguire r, papadopoulou c, kotronoulas g, simpson mf, mcphelim j, irvine l. a systematic review of supportive care needs of people living with lung cancer. eur j oncol nurs 2013;17:449-64. 23. fennell ml. nursing homes and cancer care. health serv res 2009;44:6. 24. nitsch d, morton s, de stavola b, clark h, leon da. how good is probabilistic record linkage to reconstruct reproductive histories?results from the aberdeen children of the 1950s study. bmc med res methodol 2006;6:15. 25. ronellenfitsch u, kyobutungi c, becher h, razum o. large-scale, population-based epidemiological studies with record linkage can be done in germany. eur j epidemiol 2004;19:1073-4. © 2018 spallek et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. kureta e, basho m, murati e, roshi e, burazeri g, bino s. screening for viral hepatitis b in the roma community in tirana, albania (original research). seejph 2019, posted: 03 october 2019. doi 10.4119/seejph-2355 1 original research screening for viral hepatitis b in the roma community in tirana, albania elona kureta1, mimoza basho1, ermelinda murati2, eugena tomini1, enver roshi3, silvia bino1,3 1 institute of public health, tirana, albania; 2 directorate of public health, tirana, albania; 3 faculty of medicine, university of medicine, tirana, albania. corresponding author: elona kureta, md address: rr. “aleksander moisiu”, no. 80, tirana, albania; telephone: +355693600966; e-mail: ekureta@gmail.com kureta e, basho m, murati e, roshi e, burazeri g, bino s. screening for viral hepatitis b in the roma community in tirana, albania (original research). seejph 2019, posted: 03 october 2019. doi 10.4119/seejph-2355 2 abstract aim: according to the previous studies conducted in albania involving roma communities and in general populations, the prevalence of hbv was 13% and 7%-9%, respectively. due to this high prevalence of hbv and difficulties accessing adequate healthcare, a screening was performed in some areas where roma populations live. the aim of this study was to assess the prevalence of hbv in the roma population in albania in order to make evidencebased recommendations for increasing the awareness of the population about this disease and increase the access to the vaccination. methods: a cross-sectional study was conducted in three rural areas and in four urban areas in tirana district with known limited population movement. openepi was used to calculate the sample size. the laboratory methods used consisted of the immune chromatographic method, rapid test and elisa. results: 27 out of 174 specimens tested positive for hbv. the prevalence of hbsag was 15.5% (95%ci=10.8%-21.6%). the age-related positivity of hbsag was 10.6% for the agegroup 19-24 years, 19.4% for the age 25-44 years and 11.8% for the age 45-59 years. of the positive cases, 15 were females and 12 were males. the areas with the highest positivity rate for hbsag were tufina (24%), health care center no.8 (23.1%) and sauk (15.4%). conclusion: a higher prevalence of hbv was found among roma population in tirana district compared to the general population. the age-group 25-44 years, males, and people residing in tufina area showed a higher hbsag positivity rate. improvement of the sentinel surveillance, increase of the awareness about the disease, promotion of vaccination and healthy behaviour, are the recommended actions that should target the roma population. keywords: hbv, prevalence, roma, screening. conflicts of interest: none. kureta e, basho m, murati e, roshi e, burazeri g, bino s. screening for viral hepatitis b in the roma community in tirana, albania (original research). seejph 2019, posted: 03 october 2019. doi 10.4119/seejph-2355 3 introduction hepatitis b represents inflammation of the liver caused by hepatitis b virus (1). the disease spreads through contact with infected blood, infected semen or other infected body fluids or from infected mother to baby at birth. hiv, multiple sex partners, homosexual relations and unprotected sex increase the risk of hbv. hbv can cause acute or chronic infection; the acute infection could be very mild (mostly undetected) to severe forms requiring hospitalization (2). most persons infected with hbv are able to “clear” the virus. chronic hbv could lead to serious liver and overall health problems, including liver cancer and death. the best way to prevent hbv is through vaccination (3). pregnant women and blood donors are usually considered as representatives of general population regarding prevalence of hbv whereas high risk groups comprise injecting drug users, males who have sex with males, migrants, etc (4). roma in albania are recognized as an important ethnic minority. official sources state that there are about 35,000 roma individuals in albania. roma communities are found all over the country, but the largest are settled in central and southeast regions of albania. roma population is a vulnerable group in albania (5). according to previous studies conducted in roma communities, the prevalence of hbv was 13% (6), and the prevalence of hbv in the general population is 7%-9%. vaccination is mandatory in albania since 1994 for all newborns within 24 hours of birth. the national immunization program (under iph department of control of infectious diseases) has conducted several vaccination campaigns in order to reduce the gap and increase the immunization into the roma population. vaccination coverage of roma children is high on the first doses due to vaccination at birth done in maternities. for example, during 2014, in tirana, in 114 roma children born, 113 (99%) were vaccinated at 24 hours of birth. after that, there is a gradual decrease of coverage for further doses of basal vaccination (from 90% at 2 months 67% at 4 months 57% at 6 months) (7). vaccination is free-of-charge for the roma population and other vulnerable groups near gp practitioners. roma families have difficulties accessing adequate healthcare because they do not pay health insurance within the insurance scheme, which in turn, denies them benefiting from the services in due way (8). the aim of this study is to estimate the prevalence of viral hepatitis in this population at risk in order to make evidence-based recommendations for increasing the awareness of population about these diseases and promote the vaccination. methods this cross-sectional study was conducted among roma population in tirana district during the year 2016. the total roma population in tirana is around 16,000 persons. rural areas of tufine, babrru, sauk and urban areas that correspond to health care center no.11, no.8, no.7 and no.10 were selected for the study. the total study population consists of 2,022 individuals including all roma population resident in these areas. for each positive person was recommended to visit the specialist for further follow-up. screening tests the methods used included the immune chromatographic method, the rapid test and elisa. hbsag rapid test: infection with the hepatitis b virus is characterized by the appearance of certain viral markers including hepatitis b surface antigen (hbsag) in the blood. hbsag rapid test is a visually read, qualitative immunoassay kureta e, basho m, murati e, roshi e, burazeri g, bino s. screening for viral hepatitis b in the roma community in tirana, albania (original research). seejph 2019, posted: 03 october 2019. doi 10.4119/seejph-2355 4 for in vitro detection of hepatitis b surface antigen in serum or plasma. the test is intended as an aid to diagnosis of hepatitis b infection. the antigen found in the envelope of hbv is designated hepatitis b surface antigen (hbsag) and its presence in serum or plasma indicates active hbv infection. hbsag rapid test is a simple, one-step test that detects the presence of hbsag. this is only a screening test. the test does not rule out hepatitis b infection because hbsag may not be present in sufficient quantity to be detected at a very early stage of infection. positive results must be confirmed by other diagnostic procedures and clinical data. the systematic use of rapid tests performed at points-of-care may facilitate hepatitis b virus (hbv) screening and substantially increase hbv infection awareness. case definition: a positive case is considered any person that tested positive for hbsag with rapid test and then confirmed with elisa method. sample size: openepi (9) was used to calculate the sample size. areas where the process was conducted were selected according to the number of population and their internal migration. there were taken into consideration the areas where the movement of the population is stable and the number of them is higher than the other areas where roma lives. the selected areas were rural ones of tufine, babrru, sauk and urban areas corresponding to health care center no.11, no.8, no.7 and no.10. a total of 174 individuals were included in the study according to the method of probability proportional to size. recruitment process / selection of individuals the working group was composed by state and territorial epidemiologists and microbiologists. the chart below shows the steps that the working group did in the field. step 1. step 2. step 3. step 1 in each area we contacted the director of the health care center, general practitioners, and representatives of the relevant roma associations who were informed in advance with the procedure of screening. they all agreed for this screening. step 2 meeting with each roma resident in the hcc. they were selected randomly at site. to all of them it was explained about the disease and the reason of this screening test. before performing the procedure each person signed a consent form. step 3 the process of the blood samples collection. data and specimens collection inclusion criteria: eligible for the study were only individuals aged 19 years and older. exclusion criteria: individuals aged 0-18 years because they were already vaccinated against hbv. also from the agreement for the screening sign the consent form from each person meeting the director, gp of each hcc, roma representatives meeting with roma in hcc sample collection kureta e, basho m, murati e, roshi e, burazeri g, bino s. screening for viral hepatitis b in the roma community in tirana, albania (original research). seejph 2019, posted: 03 october 2019. doi 10.4119/seejph-2355 5 study were excluded all persons that suffered from other liver diseases. the reason for both these exclusion criteria was to control for the confounding factors that could affect the results of the study. an individual questionnaire with demographic and vaccination data was matched to each serum sample. all sera samples collected were analyzed in national virology laboratory in institute of public health. statistical analysis data was analyzed using the statistical package for the social sciences (spss) (version 20.0). categorical variables are presented as absolute frequencies and percentages. chi-square test was used to compare the proportions between categorical variables. a p-value ≤0.05 was considered significant. results in total, 174 individuals were tested for viral hepatitis b. 29.9% of them were males and 70.1% females with a mean age 33.7 (10.7) years and range 19 to 59 years. the majority of individuals (53.4%) belonged to age group of 25-44 years old (p<0.01). overall, 27 individual tested positive for hbv. the prevalence of hbsag was 15.5% (95% ci 10.8% to 21.6%). the positivity rate for hbv among males was (23.1%) as compared to females (12.3%), without significant difference p=0.1 (table 1). table 1. testing results by gender gender tested cases for hbv positive cases percent positive female 122 15 12.3 male 52 12 23.1 the most affected was the age group 25-44 years (19.4%), followed by age group 45-59 years (11.8%) p=0.3 (table 2). table 2. testing results by age group age-group total cases positive for hbsag percent positive 19-24 years 47 5 10.6 25-44 years 93 18 19.4 45-59 years 34 4 11.8 no significant difference in positivity rate for hbv was found by areas of the study, as shown in table 3. kureta e, basho m, murati e, roshi e, burazeri g, bino s. screening for viral hepatitis b in the roma community in tirana, albania (original research). seejph 2019, posted: 03 october 2019. doi 10.4119/seejph-2355 6 table 3. distribution of hbv cases by areas study area no. of samples no. of samples positive for hbsag percent positive tufine 49 12 24.5 babrru 9 1 11.1 health center no.8 26 6 23.1 health center no.7 12 1 8.3 sauk 13 2 15.4 health center no.11 14 1 7.1 health center no.10 51 4 7.8 total 174 27 15.5 figure 1. distribution of hbv cases by area in tirana district discussion albania is among countries with a relatively high prevalence of hbsag. a previous study conducted in general population in 2009 reported a prevalence of 9.5% (10). the presence of one or more serological markers of hbv infection and the high rate of infection in children aged 1 to 10 years confirms the endemic nature of this virus in albania. the abovementioned data of hbv infection in albania were undoubtedly related to low kureta e, basho m, murati e, roshi e, burazeri g, bino s. screening for viral hepatitis b in the roma community in tirana, albania (original research). seejph 2019, posted: 03 october 2019. doi 10.4119/seejph-2355 7 hygiene and poor economic situation, overcrowded conditions, lack of disposable needles and syringes, lack of safe blood and its products for transfusion, inadequate sterilization of reusable equipment, difficulties in obtaining appropriate personal equipment to prevent exposure to blood, and lack of an immunization program against hbv before the year 1994. taking into consideration the reinforcement of the general preventive measures, such as the implementation of the safe injection procedures, proper sterilization of the medical and dental equipment, proper screening of the blood and its products, and progress in health education and vaccination of some high-risk groups (health care workers, hemodialysis and thalassemic patients), the significant reduction of hbv markers among the nonvaccinated general population (9.5%) compared to the previous rate of 19931995 (18%-19%), may be attributed to the 12 consecutive years of vaccination of newborn children against hbv. in a study conducted in 2011 the prevalence of hbsag in adolescents of area peze-ndroq in tirana was 22.4% versus 15.1% in adults (11). in our study conducted in 2018 a higher prevalence of hbv was found among roma population in tirana district compared to the general population. considering the high prevalence of hbv in roma population and the problems that this vulnerable group has towards the vaccination process and difficulties accessing adequate healthcare, the institute of public health (iph) in collaboration with the directorate of public health of tirana have performed screening in some areas where roma populations live. limitations: the study was conducted only in the areas with known limited population and using a convenience sampling approach which potentially introduces a selection bias. the laboratory testing included only the rapid test and elisa and not pcr which is a confirmatory method in diagnosing hbv. conclusion improvement of the sentinel surveillance for detecting new hbv cases, increasing of the awareness about the disease, promoting healthy behaviour, health education and vaccination in order to increase vaccination coverage are the recommended actions that should target the roma population. references 1. world health organization. hepatitis b in the who european region; 2017. available from: http://www.euro.who.int/__data/assets/ pdf_file/0009/283356/fact-sheet-enhep-b-edited-2.pdf?ua=1 (accessed: july 10, 2019). 2. european centre for disease prevention and control. surveillance of hepatitis b and c in the eu/eea – 2017 data. available from: https://ecdc.europa.eu/en/hepatitis-b (accessed: july 10, 2019). 3. hahné sj, veldhuijzen ik, wiessing l, lim ta, salminen m, van de laar m. infection with hepatitis b and c virus in europe: a systematic review of prevalence and cost-effectiveness of screening. bmc infect dis 2013;13:181. doi:10.1186/14712334-13-181. 4. ulqinaku d, basho m, hajdini m, qyra s, bino s, kakarriqi e. prevalenca e hepatiteve virale te gratë shtatëzëna në shqiperi. [surveillance systems for acute viral hepatitis in albania]. revista mjekësore (albanian medical journal) 2006;3:55-63. 5. kondili la, ulqinaku d, hajdini m, basho m, chionne p, madonna e, et al. hepatitis b virus infection in health http://www.euro.who.int/__data/assets/pdf_file/0009/283356/fact-sheet-en-hep-b-edited-2.pdf?ua=1 http://www.euro.who.int/__data/assets/pdf_file/0009/283356/fact-sheet-en-hep-b-edited-2.pdf?ua=1 http://www.euro.who.int/__data/assets/pdf_file/0009/283356/fact-sheet-en-hep-b-edited-2.pdf?ua=1 https://ecdc.europa.eu/en/hepatitis-b kureta e, basho m, murati e, roshi e, burazeri g, bino s. screening for viral hepatitis b in the roma community in tirana, albania (original research). seejph 2019, posted: 03 october 2019. doi 10.4119/seejph-2355 8 care workers in albania: a country still highly endemic for hbv infection. infection 2007;35:94-7. 6. albania behavioral and biological surveillance study report-biobss 2005. usaids & family health international; 2006. 7. simon p, galanxhi e, dhono o. roma and egyptians in albania: a socio demographic and economic profile based on the 2011 census. united nations support to social inclusion in albania programme; 2015. 8. institute of public health. vaccination in albania. available from: http://www.ishp.gov.al/category/vaksin imi/ (accessed: july 10, 2019). 9. open source epidemiologic statistics for public health. www.openepi.com. 10. resuli b, prifti s, kraja b, nurka t, basho m, sadiku e. epidemiology of hepatitis b virus infection in albania. world j gastroenterol 2009;15:849-52. doi: 10.3748/wjg. 15.849. 11. kone e, ceka x, ostreni v, shehu b, arapi i. prevalence of hepatitis b virus infection in adolescents in tirana area (albania). j environ prot ecol 2011;12:271-8. ________________________________________________________________________ © 2019 kureta et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ishp.gov.al/category/vaksinimi/ http://www.ishp.gov.al/category/vaksinimi/ http://www.openepi.com/ relative income and acute coronary syndrome: a population-based case-control study in tirana, albania kurti v, hafizi h, kurti b, marku f, mema d, burazeri g. sex-differences in socioeconomic status and healthseeking behaviour among tuberculosis patients in transitional albania in 2012-2013 (original research). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-30 1 original research sex-differences in socioeconomic status and health-seeking behaviour among tuberculosis patients in transitional albania in 2012-2013 vera kurti 1 , hasan hafizi 2 , bardhyl kurti 3 , fitim marku 3 , donika mema 2 , genc burazeri 2,4 1 primary health care centre “dispensary for chest diseases”, tirana, albania; 2 university of medicine, tirana, albania; 3 university hospital of trauma, tirana, albania; 4 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, the netherlands. corresponding author: dr. vera kurti address: rr. “reshit petrela”, lgj. no. 4, tirana, albania; telephone: +355672088785; e-mail: verakurti68@yahoo.com kurti v, hafizi h, kurti b, marku f, mema d, burazeri g. sex-differences in socioeconomic status and healthseeking behaviour among tuberculosis patients in transitional albania in 2012-2013 (original research). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-30 2 abstract aim: there is little scientific evidence about the main determinants of sex discrepancies in tuberculosis rates in albania. the aim of this study was to assess the sex-differences in socioeconomic characteristics, knowledge and attitudes about tuberculosis and access to health care among tuberculosis patients in albania, a transitional country in the western balkans. methods: our analysis involved all the new cases of pulmonary tuberculosis diagnosed in albania during the period june 2012 – june 2013 (n=197; 69% males; overall mean age: 44±19 years). the recording and reporting system of tuberculosis cases was performed according to the who and eurotb surveillance guidelines. information on socioeconomic characteristics of the patients, knowledge and attitudes about tuberculosis and access to health care was also collected. logistic regression was used to assess the correlates of sexdifferences among tuberculosis patients. results: in multivariable-adjusted models, female sex was positively related to unemployment (or=3.7, 95%ci=1.8-7.7), bad living conditions (or=3.0, 95%ci=1.4-6.5), a longer distance to health care facility (or=3.0, 95%ci=1.4-6.3), a lower level of knowledge about tuberculosis (or=3.1, 95%ci=1.3-7.1) and a higher level of stigma against tuberculosis (or=3.6, 95%ci=1.6-7.9). conclusion: our study informs about selected correlates of sex-differences in tuberculosis rates in post-communist albania. future studies should more vigorously explore determinants of sex-differences in tuberculosis rates in countries of the western balkans. keywords: access to health care, albania, case detection rate, health seeking behaviour, pulmonary tuberculosis, sex-differences, socioeconomic characteristics. conflicts of interest: none. kurti v, hafizi h, kurti b, marku f, mema d, burazeri g. sex-differences in socioeconomic status and healthseeking behaviour among tuberculosis patients in transitional albania in 2012-2013 (original research). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-30 3 introduction to date, the information about determinants of sex-differences in tuberculosis occurrence is scant (1,2), notwithstanding the available evidence suggesting that, at a global level, tuberculosis affects men more frequently than women (3). in any case, tuberculosis remains a crucial public health issue at a global scale which, regardless of sex, affects mostly the disadvantaged young population subgroups (4,5). hence, only for the year 2012, there were reported 8.6 million new tuberculosis cases and 1.3 million tuberculosis deaths (6). for the european region, the tuberculosis case notification rate in 2012 was substantially higher than the global average notification rates (7). however, the relatively higher casenotification rate in the european region on the whole does not necessarily apply for the former communist countries of the western balkans including albania and kosovo. among all countries of the western balkans, kosovo exhibits the highest incidence rate of tuberculosis (8,9). it should be noted that in both albania and kosovo, the tuberculosis notification rates resemble the respective incidence rates (8,9). furthermore, both albania and kosovo have a low prevalence of hiv infection (8,9). however, the information about the sex-differences of tuberculosis rates in albania is scarce. after the breakdown of the communist regime in 1990, albania undertook a difficult journey from a rigid communist regime towards an open society (10,11). nevertheless, the transition towards a democratic regime was associated with considerable socio-economic changes coupled with huge internal and external migration (12), which are believed to affect also the case-notification rates of tuberculosis. yet, there are no recent scientific reports informing about the magnitude and determinants of tuberculosis in albania. in this context, the aim of our study was to assess the sex-differences in socioeconomic characteristics, knowledge and attitudes about tuberculosis and access to health care among male and female tuberculosis patients in albania, a transitional country in the western balkans with a low prevalence of hiv/aids. methods design and study population a cross-sectional study was conducted including all new pulmonary tuberculosis patients diagnosed in albania from june 2012 to june 2013. during this time period, overall, there were recorded 197 new tuberculosis patients in albania (69% males and 31% females; overall mean age: 43.84±19.2 years). data collection all the recorded tuberculosis data from registers of the tuberculosis program in albania were used for this analysis. the recording and reporting system was performed according to the who and eurotb surveillance guidelines (13). all tuberculosis patients underwent a structured interview inquiring about factors related to access to health care, health seeking behavior and demographic and socioeconomic characteristics. information about access to health care and health seeking behaviour included data on the distance to health care facility (dichotomized into: ≤10 km vs. >10 km), knowledge about tuberculosis (dichotomized into: yes vs. no) and stigma against tuberculosis (yes vs. no). demographic and socioeconomic characteristics included age (dichotomized into: ≤45 vs. >45 years), gender (males vs. females), place of residence (urban areas vs. rural areas), employment status (dichotomized into: unemployed vs. employed/students/retired), educational attainment (dichotomized into: 0-8 years of formal schooling, vs. ≥9 years of formal schooling) and living conditions (dichotomized into: good/average vs. bad). kurti v, hafizi h, kurti b, marku f, mema d, burazeri g. sex-differences in socioeconomic status and healthseeking behaviour among tuberculosis patients in transitional albania in 2012-2013 (original research). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-30 4 statistical analysis chi-square test was used to compare the distribution of socioeconomic characteristics, knowledge and attitudes about tuberculosis and access to health care among male and female tuberculosis patients. binary logistic regression was used to assess sex-differences in socioeconomic characteristics, knowledge and attitudes about tuberculosis and access to health care among tuberculosis patients. initially, crude (unadjusted) odds ratios (ors), their respective 95% confidence intervals (95%cis) and p-values were calculated. subsequently, multivariable-adjusted ors, their respective 95%cis and p-values were calculated. hosmer-lemeshow test was used to assess the goodness of fit of the logistic regression models. in all cases, a p-value of ≤0.05 was considered statistically significant. statistical package for social sciences (spss, version 15.0) was used for all the statistical analysis. results table 1 presents the distribution of socioeconomic characteristics, knowledge and attitudes about tuberculosis and access to health care among tuberculosis patients in albania by sex. males were somehow younger than females, a finding which was not statistically significant (p=0.09). there was no sex-difference in the proportions of urban/rural residents. conversely, the unemployment rate was considerably higher among females (59% vs. 29% in males, p<0.001). similarly, the proportion of low-educated (0-8 years of formal schooling) and individuals with bad living conditions was higher among females than in males (77% vs. 60%, p=0.02 and 46% vs. 24%, p=0.02, respectively). a significantly higher proportion of females reported a longer distance to health care facility (>10 km) compared with their male counterparts (64% vs. 40%, respectively, p=0.002). the knowledge about tuberculosis was lower among females (66% vs. 81% in males, p=0.03), whereas the level of stigma against tuberculosis was considerably higher (71% vs. 49%, respectively, p=0.008) [table 1]. table 1. distribution of socioeconomic characteristics, knowledge and attitudes about tuberculosis, and access to health care among tuberculosis patients in albania by sex variable females (n=61) males (n=136) p † age: ≤45 years >45 years 27 (44.3) * 34 (55.7) 79 (58.1) 57 (41.9) 0.089 place of residence: urban areas rural areas 24 (39.3) 37 (60.7) 64 (47.1) 72 (52.9) 0.354 employment status: unemployed employed/students/retired 36 (59.0) 25 (41.0) 40 (29.4) 96 (70.6) <0.001 educational level: 0-8 years ≥9 years 47 (77.0) 14 (23.0) 81 (59.6) 55 (40.4) 0.023 living conditions: good/average bad 33 (54.1) 28 (45.9) 104 (76.5) 32 (23.5) 0.002 distance to health facility: ≤10 km >10 km 22 (36.1) 39 (63.9) 82 (60.3) 54 (39.7) 0.002 tuberculosis knowledge: kurti v, hafizi h, kurti b, marku f, mema d, burazeri g. sex-differences in socioeconomic status and healthseeking behaviour among tuberculosis patients in transitional albania in 2012-2013 (original research). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-30 5 yes no 40 (65.6) 21 (34.4) 110 (80.9) 26 (19.1) 0.029 stigma: no yes 18 (29.5) 43 (70.5) 69 (50.7) 67 (49.3) 0.008 * absolute numbers and their respective column percentages (in parentheses). † p-values from the chi-square test. in crude (unadjusted) logistic regression models, there was no significant sex-difference in the age or place of residence of tuberculosis patients (table 2). on the other hand, female gender was positively and significantly associated with unemployment (or=3.5, 95%ci=1.8-6.5), a lower educational attainment (or=2.3, 95%ci=1.2-4.5), bad living conditions (or=2.8, 95%ci=1.5-5.2), a longer distance to health care facility (or=2.7, 95%ci=1.4-5.0), a lower level of knowledge about tuberculosis (or=2.2, 95%ci=1.1-4.4) and a higher level of stigma against tuberculosis (or=2.5, 95%ci=1.3-4.7) [table 2]. table 2. sex-differences in socioeconomic characteristics, knowledge and attitudes about tuberculosis, and access to health care among tuberculosis patients in albania; crude/unadjusted odds ratios from binary logistic regression variable or * 95%ci * p * age: ≤45 years >45 years 1.00 1.75 reference 0.95-3.21 0.073 place of residence: urban areas rural areas 1.00 1.37 reference 0.74-2.53 0.315 employment status: employed/students/retired unemployed 1.00 3.46 reference 1.84-6.45 <0.001 educational level: ≥9 years 0-8 years 1.00 2.28 reference 1.15-4.54 0.019 living conditions: good/average bad 1.00 2.76 reference 1.45-5.23 0.002 distance to health facility: ≤10 km >10 km 1.00 2.69 reference 1.44-5.03 0.002 tuberculosis knowledge: yes no 1.00 2.22 reference 1.13-4.38 0.021 stigma: no yes 1.00 2.46 reference 1.29-4.69 0.006 * crude/unadjusted odds ratios (or: female vs. male), 95% confidence intervals (95%ci) and p-values from binary logistic regression. upon simultaneous adjustment for all covariates (table 3), female sex was positively related to unemployment (or=3.7, 95%ci=1.8-7.7), bad living conditions (or=3.0, 95%ci=1.46.5), a longer distance to health care facility (or=3.0, 95%ci=1.4-6.3), a lower level of kurti v, hafizi h, kurti b, marku f, mema d, burazeri g. sex-differences in socioeconomic status and healthseeking behaviour among tuberculosis patients in transitional albania in 2012-2013 (original research). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-30 6 knowledge about tuberculosis (or=3.1, 95%ci=1.3-7.1) and a higher level of stigma against tuberculosis (or=3.6, 95%ci=1.6-7.9). table 3. sex-differences in socioeconomic characteristics, knowledge and attitudes about tuberculosis, and access to health care among tuberculosis patients in albania; multivariableadjusted odds ratios from binary logistic regression variable or * 95%ci * p * age: ≤45 years >45 years 1.00 1.87 reference 0.88-3.98 0.102 place of residence: urban areas rural areas 1.00 1.19 reference 0.57-2.50 0.645 employment status: employed/students/retired unemployed 1.00 3.68 reference 1.78-7.65 0.001 educational level: ≥9 years 0-8 years 1.00 1.64 reference 0.73-3.65 0.230 living conditions: good/average bad 1.00 2.97 reference 1.36-6.48 0.006 distance to health facility: ≤10 km >10 km 1.00 3.00 reference 1.42-6.34 0.004 tuberculosis knowledge: yes no 1.00 3.06 reference 1.33-7.08 0.009 stigma: no yes 1.00 3.57 reference 1.62-7.88 0.002 * multivariable-adjusted odds ratios (or: female vs. male), 95% confidence intervals (95%ci) and pvalues from binary logistic regression. discussion main findings of our study include a strong positive association of female gender with a lower socioeconomic status among tuberculosis patients diagnosed in albania during mid-2012 to mid-2013. in particular, unemployment and poor living conditions were considerably more prevalent among female patients with tuberculosis compared with their male counterparts. furthermore, a lower access to health care and scarce personal resources for a proper and effective health seeking behaviour were substantially more prevalent among female tuberculosis patients. the finding of a positive association of female sex with a lower socioeconomic status, a lower access to health care and a poor health seeking behaviour may point to a lower degree of case notification rate among females compared to males in albania. indeed, our finding pointing to a higher case notification rate of tuberculosis among males compared with the females is generally in line with the abundant global evidence on this matter (3-7). nonetheless, despite the current evidence obtained in various countries and regions, it is not clear whether these sex-differences reflect a distinctive tuberculosis epidemiology (14), or an under-notification kurti v, hafizi h, kurti b, marku f, mema d, burazeri g. sex-differences in socioeconomic status and healthseeking behaviour among tuberculosis patients in transitional albania in 2012-2013 (original research). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-30 7 driven by socio-cultural characteristics and/or access to health care services or health seeking behavior (15,16). regardless of sex, it has been shown that there is a high possibility of under-notification of tuberculosis cases in low-and-middle income countries due to their limited resources coupled with a weak tuberculosis surveillance system (17,18). in this context, the under-notification may affect mostly females, which are assumed to be more vulnerable in terms of their socioeconomic conditions and health seeking behaviour. thus, biological explanations aside, it has been argued that there is a link between female under-notification rates in the context of specific cultural factors which play an important role in developing and transitional societies (19), such as the case of albania and perhaps other former communist countries in the western balkans. in any case, given the lack of sufficient information, the world health organization stimulates further vigorous research related to determinants of sex-differences in case notification rates of tuberculosis (2). on the other hand, in our study, there was no evidence of sex-differences with regard to the place of residence (urban areas vs. rural areas) of tuberculosis patients. our analysis may have several limitations. notwithstanding the fact that we included all new patients with tuberculosis diagnosed during the period june 2012 – june 2013, the possibility of under-recording of tuberculosis cases may affect differentially males and females in albania. furthermore, it is reasonable to assume a differential recording of new cases based on the demographic and socioeconomic profiles of the patients with tuberculosis. also, measurement of socioeconomic characteristics and health seeking behaviour – which was based on interview – may have affected, to some degree, our findings. therefore, future studies in albania should more vigorously assess determinants of sex-differences in tuberculosis rates in the overall population. in conclusion, our study provides useful evidence about selected correlates of sex-differences among tuberculosis patients in albania. health care providers, policymakers and decisionmakers in albania should be aware of the current sex-differences in socioeconomic characteristics, access to health care and health seeking behaviour among tuberculosis patients in this post-communist society. future studies in albania and other transitional countries of the western balkans should further explore the main determinants of sex-differences in tuberculosis rates. references 1. weiss mg, sommerfeld j, uplekar mw. social and cultural dimensions of gender and tuberculosis. int j tuberc lung dis 2008;12:829-30. 2. uplekar m, rangan s, ogden j. gender and tuberculosis control: towards a strategy for research and action, who/tb/2000.280. geneva: world health organization, 1999. 3. world health organization (regional office for europe) and the european centre for disease prevention and control. tuberculosis surveillance and monitoring in europe 2014. http://www.ecdc.europa.eu/en/publications/publications/tuberculosissurveillance-monitoring-europe-2014.pdf (accessed: august: 25, 2014). 4. world health organization. global tuberculosis report 2012. geneva: world health organization, 2012. 5. glaziou p, falzon d, floyd k, raviglione m. global epidemiology of tuberculosis. semin respir crit care med 2013;34:3-16. 6. world health organization (who). global tuberculosis report 2012. who press, world health organization. geneva: switzerland, 2013. kurti v, hafizi h, kurti b, marku f, mema d, burazeri g. sex-differences in socioeconomic status and healthseeking behaviour among tuberculosis patients in transitional albania in 2012-2013 (original research). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-30 8 7. european centre for disease prevention and control and the world health organization, regional office for europe. tuberculosis surveillance and monitoring in europe, 2012. 8. kosovar aids committee. kosovar strategy for hiv/aids prevention 2004-2008. pristina: kosovo, 2009. 9. kurhasani x, hafizi h, toci e, burazeri g. tuberculosis incidence and case notification rates in kosovo and the balkans in 2012: cross-country comparison. mater sociomed 2014;26:55-8. 10. rechel b, mckee m. healing the crisis: a prescription for public health action in south eastern europe. new york, usa: open society institute press, 2003. 11. nuri b, tragakes e. health care systems in transition: albania. copenhagen: european observatory on health care systems, 2002. 12. burazeri g, goda a, tavanxhi n, sulo g, stefa j, kark jd.the health effects of emigration on those who remain at home. int j epidemiol. 2007;36:1265-72. 13. veen j, raviglione m, rieder hl, et al. standardized tuberculosis treatment outcome monitoring in europe. recommendations of a working group of the world health organization (who) and the european region of the international union against tuberculosis and lung disease (iuatld) for uniform reporting by cohort analysis of treatment outcome in tuberculosis patients. eur respir j 1998;12:505-10. 14. borgdorff mw, nagaldkerke nj, dye c, et al. gender and tuberculosis: a comparison of prevalence surveys with notification data to explore gender differences in case detection. int j tuberc lung dis 2000;4:123-32. 15. hudelson p. gender differentials in tuberculosis: the role of socio-economic and cultural factors. tubercle lung dis 1996;77:391-400. 16. weiss m, auer c, somma d, abouihia a. gender and tuberculosis: cross-site analysis and implications of a multi-country study in bangladesh, india, malawi and columbia. tdr/sdr/seb/rp/06.1. geneva, switzerland: who, 2006. 17. thorson a, hoa np, long nh, allebeck p, diwan vk. do women with tuberculosis have a lower likelihood of getting diagnosed? prevalence and case detection of sputum smear positive pulmonary tb, a population-based study from vietnam. j clin epidemiol 2004;57:398-402. 18. long nh, johansson e, lönnroth k, eriksson b, winkvist a, diwan vk. longer delays in tuberculosis diagnosis among women in vietnam. int j tuberc lung dis 1999;3:388-93. 19. johansson e, long nh, diwan vk, winkvist a. gender and tuberculosis control: perspectives on health seeking behaviour among men and women in vietnam. health policy 2000;52:33-51. ___________________________________________________________ © 2014 kurti et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed?term=kurhasani%20x%5bauthor%5d&cauthor=true&cauthor_uid=24757405 http://www.ncbi.nlm.nih.gov/pubmed?term=hafizi%20h%5bauthor%5d&cauthor=true&cauthor_uid=24757405 http://www.ncbi.nlm.nih.gov/pubmed?term=toci%20e%5bauthor%5d&cauthor=true&cauthor_uid=24757405 http://www.ncbi.nlm.nih.gov/pubmed?term=burazeri%20g%5bauthor%5d&cauthor=true&cauthor_uid=24757405 http://www.ncbi.nlm.nih.gov/pubmed/24757405 http://www.ncbi.nlm.nih.gov/pubmed?term=burazeri%20g%5bauthor%5d&cauthor=true&cauthor_uid=17768161 http://www.ncbi.nlm.nih.gov/pubmed?term=goda%20a%5bauthor%5d&cauthor=true&cauthor_uid=17768161 http://www.ncbi.nlm.nih.gov/pubmed?term=tavanxhi%20n%5bauthor%5d&cauthor=true&cauthor_uid=17768161 http://www.ncbi.nlm.nih.gov/pubmed?term=sulo%20g%5bauthor%5d&cauthor=true&cauthor_uid=17768161 http://www.ncbi.nlm.nih.gov/pubmed?term=stefa%20j%5bauthor%5d&cauthor=true&cauthor_uid=17768161 http://www.ncbi.nlm.nih.gov/pubmed?term=kark%20jd%5bauthor%5d&cauthor=true&cauthor_uid=17768161 http://www.ncbi.nlm.nih.gov/pubmed/?term=burazeri+g%2c+international+journal+of+epidmiology marstein e, babich sm. global health in transition: the coming of neoliberalism (original research). seejph 2018, posted: 04 january 2018. doi 10.4119/unibi/seejph-2018-179 1 original research global health in transition: the coming of neoliberalism egil marstein 1 , suzanne m. babich 1 1 department of health policy and management, richard m. fairbanks school of public health, indiana university, indianapolis, usa. corresponding author: egil marstein, phd department of health policy and management, richard m. fairbanks school of public health, indiana university; address: health sciences building (rg), 1050 wishard blvd. floor 5, indianapolis in 46202-2872, usa; telephone: 317-274-3850; email: egmars@iu.edu marstein e, babich sm. global health in transition: the coming of neoliberalism (original research). seejph 2018, posted: 04 january 2018. doi 10.4119/unibi/seejph-2018-179 2 abstract global health as a transnational, intergovernmental, value-based initiative led by the world health organization (who), working toward improving health and achieving equity in health for all people worldwide, has for years yielded to a growing reliance on corporate-led solutions. private organizations, non-governmental organizations (ngo), religious and other philanthropic and charitable organizations, increasingly serve a dominant role in setting the global health agenda. short-term success in combating epidemics and in the provision of funding for project-based initiatives appeals to supporters of marketization of health services. for 30 years, a neoliberal paradigm has dominated the international po litical economy and hence the governance of global health. a utilitarian logic or the ethics of consequentialism have attained prominence under such banners as effective altruism or venture philanthropy. this contrasts with the merits and relevance of deontological ethics in which rules and moral duty are central. this paper seeks to explain how neo-liberalism became a governing precept and paradigm for global health governance. a priority is to unmask terms and precepts serving as ethos or moral character for corporate actions that benefit vested stakeholders. keywords: global health governance, global health leadership, neoliberalism. conflicts of interest: none. marstein e, babich sm. global health in transition: the coming of neoliberalism (original research). seejph 2018, posted: 04 january 2018. doi 10.4119/unibi/seejph-2018-179 3 a new look at global health global health has generally been perceived as a universal call to assist developing nations mediate health disparities and inequities in access to health services. today, its transnational, institution-based foundation appears to be weakening. this is taking place at a time when we see an historic wave of migration, with refugees challenging the political will of sanctuary countries. the mass influx of refugees into european union (eu) member countries dramatizes and confirms this. some of the wealthiest regions of the world seem both unprepared and even hostile to the millions of multiethnic migrants seeking shelter (1). the humanitarian crisis appears endless, as politicians debate durable solutions to limit immigration, placing millions of people in limbo. sounding the alarm are barbara adams and jens martens stating that: “while global economic, social and ecological crises have intensified in recent years, the ability of states and multilateral organizations to tackle these crises appears to have diminished” (2). opinions on public health policy, global health initiatives and the potential for intergovernmental programs to “improve health and achieve equity in health for all people worldwide” vary within and between nations (3). achieving consensus on an approach will require reconciling divergent views and policies. however, the first step requires a discussion that is conceptual and philosophical in nature. a value-based challenge the global disarray in managing the migration crisis demonstrates the lack of a universal understanding of the underlying global health policy precept. to remedy this, it is important to explain the relevance of conceptual terms that in turn help to explain political actions governing national health, safety and security. for example, the migration crisis is said to constitute a fiscal uncertainty, motivating policy makers to safeguard national welfare state schemes, of which public health is a critical part. consequently, immigration policies of many countries have become more restrictive (2). another term refers to “the issue of the humanitarian border” (4). this concept invites a common agreement on the ethical issues surrounding global health initiatives. a humanitarian intervention, for example, may be initiated that would safeguard people from the consequences of a state failing to provide adequate protection and relief for its citizens (5). failure of the state to act in this case could incite a challenge to the political order of the countries involved. an intriguing new issue is the arrival of wealthy philanthropists and their foundations subscribing to venture philanthropy. venture-based philanthropy or effective altruism is a term coined by the australian professor peter singer (6). singer is credited with producing a canonical text outlining applied ethics employing principles of utilitarianism to resolve moral disagreements. singer’s concept encourages individuals to act in a way that brings about the greatest positive impact, based upon their empirical monetary values, distinguishing effective altruism from traditional altruism or charity. with regards to international relations and intergovernmental institutions, terms and concepts and their etymology play key roles in setting the agenda for global health. contributors to the lancet have claimed global health to be poorly defined but frequently referenced (3). authors tried to provide insights into the interpretations of terms and their conceptual relevance, suggesting key competencies for improved scholarship and practice. follow-up articles have sought to distinguish between national, international and global health. academia has fallen short of initiating a discourse necessary to understand the origins and current status of the conceptual debate and its implications for global health practice. https://en.wikipedia.org/wiki/altruism https://en.wikipedia.org/wiki/charity_(practice) marstein e, babich sm. global health in transition: the coming of neoliberalism (original research). seejph 2018, posted: 04 january 2018. doi 10.4119/unibi/seejph-2018-179 4 underscoring this, beaglehole and bonita point out that “without an accepted definition of global health, it will be difficult to agree on what global health is trying to achieve and how progress will be made and monitored” (7). in pursuing the semantic connections, the recent migration crisis, and the topics of climate change, the economic, food and energy crises all illuminate the need for different relief approaches supported by a common vision for global health. the avenue to conceptual clarity is broadened when mcinnes and lee revitalize the concept of social constructivism (8). mcinnes and lee draw on alfred schultz’s sociology of knowledge and durkheim’s concept of institutions when interpreting the relationship between human thoughts in a social context and the effects these ideas have on society. their argument is that varied positions on global health emerge as a product of different values and interests. following the fusion of schultz and durkheim´s theories, priorities of nations emerge as social facts reflecting “the power of ideas rather than an independent understanding based on objective observations of the world”. the concept of social constructivism is linked to jürgen habermas’s theory of communicative action, bringing in the eurocentric bias rooted in occidental rationalism (9). recognizing the ills and problems of the world is thus rooted in a weaker notion of rationality. any problem of universality is thus a cognitive cultural phenomenon. in historical and normative terms, mark nichter sees global health as the purview of our thinking about global health responsibility and our future roles in it (10). international health was largely limited to programs funded by bilateral aid, a few foundations, and the world health organization (who). now, health problems, issues, and concerns that transcend national boundaries are being influenced by circumstances or experiences in other countries, best addressed by cooperative actions and solutions (11). nichter offers an answer to the conceptual challenge in his quest for semantic universalism. global health should represent “collaborative transnational research and action for promoting health for all” (10). using a similar catchall tenet, beaglehole and bonita propose that global health should build on national public health efforts, whether population-wide or individually based actions, across all sectors, not just the health sector (7). though they may not fully diffuse the potential for cognitive bias, these broad concepts may be better than the rest for fostering cooperative efforts to resolve the global health challenges of the day. the “globalization” of global health given the diversity of opinions and the scope of resources involved, the issue of governance is paramount in effectively addressing issues of global health. given the range of current public and private stakeholders, in addition to those historically established, the locus of authority takes on special significance. the prominence of new global health actors and their divergent interests creates significant conflicts with the priorities of public institutions. acknowledging the influence of new and resourceful stakeholders, kay and williams have created a definition of global health governance to represent “any means or mechanism used by various public and private actors, acting at sub-national, national and international levels, that seek to control, regulate or ameliorate this global system of disease” (12). hence, with the appearance of multinational corporations, ngos, philanthropic and other nongovernmental organizations merging with intergovernmental institutions, the global health agenda has become linked to international relations. this broadening of the global health reach relates to the expansion of globalism where economic liberalism facilitates and impacts its governance. marstein e, babich sm. global health in transition: the coming of neoliberalism (original research). seejph 2018, posted: 04 january 2018. doi 10.4119/unibi/seejph-2018-179 5 kaye and williams challenge the view that global health is just a discrete area of activity driven by biomedicine and public health objectives. their work attests to the centrality of global economic institutions having created a particular neoliberal modality of global health governance inviting public and private international interests. mcinnes and leesee global health as having graduated to a broadened position in response to real world developments (13). global health has moved from a focus on technical competencies toward a more politicized view of relationships between growing numbers of stakeholders. clearly, the potential consequences of this fragmentation of actors and issues create a demand for coordination between nation-states and the increased number of non-state participants. to develop new forms of networking and governance, the reconciliation of interests and progress toward a common cause require a deeper understanding of stakeholders’ motives and the required means. reaching this common vision is particularly difficult given the influx of dominating private donors acting independently and governed by the precepts of venture philanthropy. in the ensuing discourse, we must scrutinize how public policies at local and intergovernmental levels have come to reflect revived liberal – or so-called neo-liberal – ideas. the orthodoxy of liberalism as a political philosophy, liberalism in its classical sense is associated with principles of individual freedom, such as freedom of speech, freedom of religion, civil rights, secular government and gender equality. as an ideology, it represents a set of ethical ideals, principles or even a social movement explaining how a society should work. as such, liberalism, in a contemporary fashion, functions as a political blueprint for social order. the modern intellectual history of liberalism dates back to the age of enlightenment. several principles critical to today’s understanding of neo-liberalism were debated as they pertained to economic policies of the day. proponents such as hugo grotius (1583-1645) and john locke (1632-1704) introduced the concept of social contract in which life, liberty and property were subject to governance. opposing this was thomas hobbes (1588-1679) arguing that individuals’ actions should be balanced only by their own consciences. locke and grotius warned that a state of nature, if unchecked, would eventually require individuals to act in abidance with a law of nature, ensuring a minimum of security, rights and liberty. the french philosopher, jean-jaques rousseau (1712-1778), balanced the state of nature through his social contract theory, introducing the notion of popular sovereignty, rejecting hobbes’s notion of individual sovereignty. here pierre-joseph proudhon (1809-1865) warned of a surrender of sovereignty: people should coexist in a state of nature, refraining from coercing or governing each other. everyone should have complete sovereignty over themselves. proudhon and other 19 th century philosophers such as david ricardo, thomas malthus, adam smith and james mill inspired precepts of economic liberalism or classical economics. common ideological ground was established with classical liberalism, conceptually transposing into today’s political neo-liberal tenets of privatization, deregulation, free trade, and reductions in government spending. per rosseau’s social contract theory, continental europe saw more than one hundred years of social welfare state program expansions. social insurance schemes of chancellor otto von bismarck and germany were introduced in the 1880s and 1890s, partly a result of escalating labor unrest but also an effort to build a strong and durable nation in an age of geo-political conflicts. https://en.wikipedia.org/wiki/ideal_(ethics) https://en.wikipedia.org/wiki/social_movement https://en.wikipedia.org/wiki/privatisation https://en.wikipedia.org/wiki/deregulation https://en.wikipedia.org/wiki/free_trade https://en.wikipedia.org/wiki/government_spending marstein e, babich sm. global health in transition: the coming of neoliberalism (original research). seejph 2018, posted: 04 january 2018. doi 10.4119/unibi/seejph-2018-179 6 the national insurance bill of 1911 in the uk, the social insurance law in 1928 in france, and the 1983 french free medical assistance program are three examples of such outcomes. pierre rosanvallon referred to this as the state being the “institutionalizer of the social”. in other words, the state began to be seen as an agency of social solidarity working to correct inequalities and increasingly intervening in aspects of everyday life, such as education, housing and transportation (14). these ideas mirrored those of the enlightenment, particularly as argued by john lock, jean j. rosseau, françois-marie arouet (voltaire) and charles montesquieu. after wwii, the uk developed a social welfare system, the hallmark being the introduction in 1948 of the national health service (nhs), a public health system that became the model for evolving social democracies throughout europe. inspired by economists such as john m. keynes and later the post-keynesian economics of john kenneth galbraith, their socioeconomic tenets promoted an active and comprehensive state governing to secure fair trade practices and workers’ social welfare. classical keynesian economics (as opposed to the later and much debated post/neo-keynesian economics) served as the standard economic model in developed nations during the latter part of the great depression, world war ii, and the postwar economic expansion (1945–1973). the most prominent of social reforms of its time, however, was the nhs. at the time, it was considered “the most civilized step by any country”, with universal health coverage, comprehensive and free at the point of delivery (15). the emergence of neoliberalism how neoliberal philosophies came into being as a dominating policy precept and governance model in global health may best be rationalized by studying the public policy reform agenda in the u.s., china and western europe over the past 40 years. the american professor of anthropology, david harvey, points to 1978–1980 as a revolutionary turning point in the world’s social and economic history. ronald regan was elected u.s. president, serving from1981 to 1989. only one year earlier, paul volcker took command of the u.s. federal reserve (1979-1987) and within a few months dramatically changed u.s. monetary policy. across the atlantic, margaret thatcher, england’s prime minister fro m 1979 to1990, advanced economic and social practices that deemed human well being could best be advanced by liberating individual entrepreneurial skills within an institutional freedom characterized by strong private property rights, free markets and free trade (16). the precept was clear. both thatcher and regan moved quickly to curb the power of unions, deregulate industry, agriculture and resource development while liberating the powers of finance. according to harvey, if markets did not exist in areas such as land, water, education, health care, social security and environmental pollution, then they had to be created, if necessary by the state. state intervention was kept to a minimum. so, too, began the process of deconstruction of the public health models in europe, models largely vested in universalistic principles. again, according to harvey the theoretical precept for neoliberalism emerged from a small and exclusive group of passionate advocates of the austrian political philosopher friedrich von hayek and the american economist milton friedman. neoliberal doctrines, as they emerged, were deeply opposed to state intervention. awarding the swedish national bank´s prize in economics sciences in memory of alfred nobel (often erroneously referred to as the nobel prize in economics) to both hayek (1974) and friedman (1976), though both controversial at the time, gave credence to the doctrines they professed. almost all countries, from those newly created after the collapse of the soviet union, to old-style social https://en.wikipedia.org/wiki/developed_nations https://en.wikipedia.org/wiki/great_depression https://en.wikipedia.org/wiki/world_war_ii https://en.wikipedia.org/wiki/post-world_war_ii_economic_expansion https://en.wikipedia.org/wiki/post-world_war_ii_economic_expansion marstein e, babich sm. global health in transition: the coming of neoliberalism (original research). seejph 2018, posted: 04 january 2018. doi 10.4119/unibi/seejph-2018-179 7 democracies such as the nordic countries, have since aligned their public policies, particularly within the public health under the health and social care act, which served to dismantle the constitutional basis of the nhs, making way for a market-driven system of health care. on the international scene, institutions such as the international monetary fund (imf), the world bank and the world trade organization encouraged and facilitated neoliberal measures through lending policies, making neoliberalism the hegemonic model. to conclude, neoliberalism has become the orthodoxy of global health. the implications for policy and practice should have prominence in discussions that seek to find effective and sustainable solutions to the world’s most critical and complex public health challenges. references 1. glasas ri. americas vital interest in global health. perspectives from the fogarty international center. institute of medicine; 24 march, 2008. 2. adams b, martens j. fit for whose purpose? private funding and corporate influence in the united nations. global policy forum/global policy watch; 27 july, 2015. 3. kopland jp, bond tc, merson mh, reddy ks, rodriguez mh, sewankambo nk et al. towards a common definition of global health. lancet 2009;9679:1993-5. 4. williams jm. from humanitarian exceptionalism to contingent care: care and enforcement at the humanitarian border. political geography, 2015;47:11-20. 5. brown bs. humanitarian intervention at a crossroad. william & mary law review 2000;41(5/6). 6. singer. p. practical ethics (3 rd ed.) melbourne: cambridge university press; 2011. 7. beaglehole r, bonita r. what is global health? global health action 2010;3. 8. mcinnes c, lee k. global health and international relations. john wiley & sons; 2012. 9. delanty g. habermas and occidental rationalism: the politics of identity, social learning, and the cultural limits of moral universalism. sociological theory 1997;15:30-59. 10. nichter m. global health: why cultural perceptions, social representations, and biopolitics matter. human ecology 2009;37:669-70. 11. the institute of medicine, board on international health. americas vital interest in global health. protecting our people, enhancing our economy, and advancing our international interests; 1997. 12. kay a. williams od (ed.). global health governance: crisis, institutions and political economy. palgrave mcmillan, uk; 2009. 13. mcinnes cj, lee, k. global health & international relations, cambridge; polity press; 2012. 14. rosanvallon p. the society of equals, cambridge, mass, harvard university press; 2013. 15. people’s health movement. global health watch # 4. alternative health report. london: zed books; 2014 (p. 96). 16. harvey d. a brief history of neoliberalism. new york: oxford university press; 2005. ______________________________________________________________________________________ © 2018 marstein et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. peposhi i, tafa h, bardhi d, hafizi h. clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 [original research]. seejph 2020, posted: 16 august 2020. doi: 10.4119/seejph-3631 p a g e 1 | 10 original research clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 ilir peposhi1, holta tafa1, donika bardhi1, hasan hafizi1 1university hospital of lung diseases “shefqet ndroqi”, tirana, albania. corresponding author: ilir peposhi, md; address: rr. “shefqet ndroqi”, tirana, albania telephone: +355682090755; email: ilirpeposhi@yahoo.com peposhi i, tafa h, bardhi d, hafizi h. clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 [original research]. seejph 2020, posted: 16 august 2020. doi: 10.4119/seejph-3631 p a g e 2 | 10 abstract aim: to estimate the clinical and epidemiological pattern of tuberculosis (tb) in albania over the period 2009-2018. methods: a retrospective analysis of clinical and epidemiological data based on tb individual notification forms during the period 2009-2018. results: during the 10-years period, tb incidence increased from 14 to 15.5, but without a significant increasing trend. the total number of tb cases increased from 440 to 447. the proportion of extra-pulmonary tb decreased from 32% to 25% in 2018 (p=0.015), with and average mean change of 29 cases. males prevail among tb cases and male-to-female ratio ranges from 2:1 to 3:1. drug susceptibility testing (dst) was carried out depending on the availability of the reagents and there were 54%, 18% and 96% culture cases confirmed positive in 2009, 2014 and 2019, respectively. the overall treatment completion rate was 85% and 88.2% in 2009 and 2018, respectively. however, there was a significant drop in cured cases from 26% in 9.3%, whereas the percentage of deaths has increased from 0.5% in 4.1%. all treatment outcomes exhibited a significant change (p<0.001). conclusion: tb continues to be a public health challenge in albania regardless of the seemingly generally stable epidemiological situation. keywords: drug resistance, epidemiology, incidence, treatment outcomes, tuberculosis. conflicts of interest: none declared. peposhi i, tafa h, bardhi d, hafizi h. clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 [original research]. seejph 2020, posted: 16 august 2020. doi: 10.4119/seejph-3631 p a g e 3 | 10 introduction tuberculosis (tb) is a communicable disease that is a major cause of ill health, one of the top 10 causes of death worldwide and the leading cause of death from a single infectious agent (ranking above hiv/aids). tb affects more than 10 million people, causing 1.6 million deaths worldwide and about a quarter of the world’s population is infected with m. tuberculosis (1). geographically, most tb cases in 2018 were in the who regions of south-east asia (44%), africa (24%) and the western pacific (18%), with smaller percentages in the eastern mediterranean (8%), the americas (3%) and europe (3%) (2). drug-resistant tb continues to be a public health threat. in 2018, there were about half a million new cases of rifampicin-resistant tb, of which 78% had multidrug-resistant tb (mdr) (3). despite the notable progress achieved in the fight against tb, countries still face a variety of challenges in reaching the goal to end the epidemic. proper and fast diagnosis of tb is essential. the sooner a patient is diagnosed, the faster their treatment can begin, easing suffering and preventing further disease transmission. since 1994, the world health organization (who) has developed three main strategies for tb prevention and control: directly observed treatment short course (dots), stop tb and end tb (4,5). those strategies focused on case notification and monitoring of treatment outcome as the essential measures to evaluate the effectiveness of interventions and identify potential gaps in tb control (6). the efficacy and successful management of any national tuberculosis control program requires reliable clinical and bacteriological diagnosis. in order to provide these data, a national tuberculosis surveillance system was implemented based on individual data since 2008. trend in case notification rate, age group affected by tb, bacteriological resistance, treatment outcomes and clinical form are the main indicators used to evaluate the national tb program. all these indicators were analysed in the current study (7-9). the aim of the present study was to estimate the clinical and epidemiological pattern of tb in albania over the period 2009-2018. methods the data were obtained from the register at the national tuberculosis control program (ntbp) at the university hospital of lung diseases "shefqet ndroqi" (susm), tirana, albania. data on tuberculosis patients are recorded and reported individually and in accordance with the guidelines of the world health organization and the european tb supervision centre (6). the data are collected and reported for each individual patient in accordance with the notification reporting form designed in 2001. the notification form includes detailed data on tb and other related factors. the study analyse the data reported, recorded and evaluated at ntbp and included general patient data, address, sex, occupation, age, diagnosis, direct sputum and culture results, as well as anti-tuberculosis drug sensitivity results and treatment outcomes. statistical analysis was performed in spss 25.0 (statistical package for social sciences). categorical variables were presented in absolute numbers and corresponding percentages. arithmetic averages were calculated for all numerical variables. differences between groups for discrete variables, nonparametric data, were performed using the hi-square test. the values of p≤0.05 were considered peposhi i, tafa h, bardhi d, hafizi h. clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 [original research]. seejph 2020, posted: 16 august 2020. doi: 10.4119/seejph-3631 p a g e 4 | 10 significant. population estimates were based on 2002 census data, with extrapolation. results trends analysis of tuberculosis incidence in the study period, the incidence rate of tb per 100,000 inhabitants/year went from 13.4 in 2009 to 14.2 in 2018 (figure 1); there is no evidence of any significant linear trend in the incidence rate of tuberculosis in albania in the past decade (p>0.05). the mean percentage of annual changes of tb notification rate from 2009 to 2018 was 6.6%. figure 1. tb incidence during the period 2009-2018 tuberculosis cases by site of disease the number of reported cases of pulmonary tb in albania varies by about 5.3% on average each year, from 2009 to 2018. as a result, the proportion of total cases with extra pulmonary decreased from 32% in 2009 to 25% in 2018 (p=0.015, difference between 2009 vs 2018).the average mean change is 29 cases, which shows a stable trend. figure 2 shows the total number of cases related to site of disease. 14 14 13.5 13.5 16.8 14 14.4 14.4 16.5 15.5 0 2 4 6 8 10 12 14 16 18 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 peposhi i, tafa h, bardhi d, hafizi h. clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 [original research]. seejph 2020, posted: 16 august 2020. doi: 10.4119/seejph-3631 p a g e 5 | 10 figure 2. total cases with tb, pulmonary and extra-pulmonary cases sex and age distribution males predominate among tb cases in all study period and male: female ratio ranges from 2:1 to 3:1. young adults (15-44) and the middle-aged (45-64) together represented 76.5% of all cases and respectively 47.4% and 29.1% in 2009. young adults and the middle-aged represented 73% in 2018, but there was a significant increase in the age group>65 from 19.7% in 2009 to 26.1% in 2018(p=0.014). table 1. tb by age groups *chi-square test. 447 445 430 420 474 408 414 413 503 440 305 275 301 312 333 261 296 299 346 330 142 170 129 108 141 147 118 114 157 110 0 100 200 300 400 500 600 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 n o . o f ca se s total tb cases pulmonary ex pulmonary age groups years p-value* 2009 n (%) 2018 n (%) 0-15 18 (4.03) 4 (0.91) 0.002 15-25 86 (19.24) 81 (18.41) 0.409 25-35 63 (14.09) 83 (18.86) 0.034 35-45 62 (13.87) 37 (8.41) 0.006 45-55 71 (15.88) 58 (13.18) 0.148 55-65 59 (13.20) 62 (14.09) 0.386 >65 88 (19.69) 115 (26.14) 0.014 peposhi i, tafa h, bardhi d, hafizi h. clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 [original research]. seejph 2020, posted: 16 august 2020. doi: 10.4119/seejph-3631 p a g e 6 | 10 figure 3. distribution (in %) according to age groups there was an increase in the age group 25-34 from 14.2% to 18.8% and in the age group over 65 from 19.4% to 26.1%, while there was a decrease in the age group 35-44 from13.9% to 8.5%. children accounted respectively for 4.1% and 0.9% in 2009 and 2018. young adults (15-44) and the middle-aged (45-64) together represented 76.5% of all cases and respectively 47.4% and 29.1% in 2009. young adults and the middle-aged represented 73% in 2018, but there was a significant increase in age group >65 in 2018(p=0.014). bacteriological confirmation and drug susceptibility testing the proportion of bacteriologically confirmed cases remained high during the study period and there was not great variation annually in smear confirmation cases. average mean change was 17 ± 13 cases per year, which shows a constant trend. drug susceptibility testing (dst) was carried out in a small proportion of pulmonary tb cases, only for 30% of cases in 2018 due to shortage of reagent. the number of cultures tested dropped from 201 in 2009 to 63 in 2018, but starting from 2013 the number of tests was reduced dramatically, and consequently the mdr data are not reliable for our country. 4.1 19.3 14.2 13.9 15.8 13.3 19.4 0.9 18.4 18.8 8.5 13.2 14.1 26.1 0-14 15-24 25-34 35-44 45-54 55-64 >65 year 2009 year 2018 peposhi i, tafa h, bardhi d, hafizi h. clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 [original research]. seejph 2020, posted: 16 august 2020. doi: 10.4119/seejph-3631 p a g e 7 | 10 table 2. proportion of smear positive cases, mdr and number of drug susceptibility testing year ptb smear positive % of smear positive mdr cases dst 2009 305 192 63% 0 201 2010 275 165 60% 2 182 2011 301 190 63% 5 203 2012 312 206 66% 0 163 2013 333 212 64% 1 27 2014 261 175 67% 2 29 2015 296 209 71% 3 13 2016 299 206 69% 1 40 2017 346 210 61% 0 79 2018 330 208 63% 2 63 treatment outcomes the overall treatment success rate was 85% and 88.2% in 2009 and 2018, respectively. there is a significant drop in cured cases in 2009 from 26% to 9.3% in 2018. also, the percentage of deaths increased from 0.5% to 4.1%. all treatment outcomes displayed a significant change (p<0.001). figure 4. treatment outcomes (in percent) 25.95 59.60 0.50 2.90 11.40 9.31 78.86 4.10 0.23 7.50 cured treatment completed dead failure lost to follow up 2018 2009 peposhi i, tafa h, bardhi d, hafizi h. clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 [original research]. seejph 2020, posted: 16 august 2020. doi: 10.4119/seejph-3631 p a g e 8 | 10 discussion the number of patients diagnosed with tuberculosis in the study period had a slight oscillation with an insignificant trend of increase in tb incidence. the incidence increased from 13.4% in 2008 to 15.3% in 2018. there was no evidence of a trend and a statistically significant change in the incidence rate over the study period. the incidence of tb appears to be more or less stable, but if we compare it with the neighbouring countries or other european countries, we notice that albania is the only country in the region with increased tb incidence and a positive mean annual change (table 3). there is a wide variation in tb incidence in the balkan region from 4 (greece) to 39 (kosova) cases per 100,000 population. table 3. tb incidence in the balkan region country tb incidence 2009 (cases per 100,000) tb incidence 2018 mach* 2014-2018 albania 13.4 15.3 2.0% kosova 60 39.2 -4.6% montenegro 19.2 13.4 -7.2% north macedonia 23.2 10.4 -6.6% serbia 17.2 9.4 -7.0% grecee 5.2 4 -4.1% this indicates that stability of tb incidence over the years in albania is not a good tb programme indicator and the national tb programme has to analyse the cause of this stagnation. furthermore, despite the stable incidence, the proportion of pulmonary tb cases increased to 75% in 2018, posing a serious risk of spreading cases with infectious tb and consequently increasing tb incidence in coming years. the proportion of extra pulmonary tb continues to be high despite the significant decrease during the last years. the lowest proportion 25% was in 2018 and the higher was 38% in 2010. there is a stable trend in decreasing the proportion of extra pulmonary cases, although the proportion remains high compared to the region. the proportion of extra-pulmonary tb was 14% in greece, 11% in serbia, 12% in monte negro, 24% in north macedonia and 29% in kosovo in 2019. the variances in the reporting of extra-pulmonary tb may result from different diagnostic practices across the country in the region or epidemiological factors and the prevailing m. tb strains (10). males predominate among tb cases in all study period and male: female ratio ranges from 2:1 to 3:1. there were twice as many males as females reported among all incident tb cases in european region, but large variation was observed for male predominance in the sex distribution of tb cases, ranging from almost an even distribution to over three times greater in armenia and albania. there are few publications on tb gender differences worldwide and it is not clear whether the differences in morbidity between the sexes are due to biological factors, socioeconomic context, or under diagnosis of tb in women who are peposhi i, tafa h, bardhi d, hafizi h. clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 [original research]. seejph 2020, posted: 16 august 2020. doi: 10.4119/seejph-3631 p a g e 9 | 10 likely to have the least access to health care (11,12). in albania, the disease of tuberculosis continues to be an important cause of morbidity in women. the differences between the sexes have been constantly ascertained, but there is no study to assess these changes (13). bacteriological confirmation of tb diagnosis was high during the study period, over 60%, and there was not great variation annually in smear confirmation cases. a high proportion of bacteriologically confirmed ptb cases might imply a delay in diagnosis and may reflect several gaps in diagnosis, such as lack of capacity by the program to accurately diagnose tb through bacteriological examination (14). the proportion of bacteriologically confirmed cases among pulmonary tb varied considerably among the countries in the region from 45% in kosovo to 95% in serbia. the increasing proportion in other countries in the region is due to the implementation of the new technology in these countries, specifically genexpert. thus, the proportion of bacteriologically confirmed cases before and after application of genexpert in monte negro was 59% and 86% respectively, in bosnia and herzegovina 42% and 74% and in north macedonia 65% and 90%, respectively. albania has installed last year two genexpert and we expect an increase in the bacteriological confirmation like in other neighbouring countries (15). mdr-tb is a major issue in the balkan region with the percentage of mdr-tb among all tb cases increasing over the last 10 years from 4.3% to 7.5% (16). drug susceptibility testing was carried out in a small proportion of pulmonary tb cases (only for 30% of the cases) and we cannot analyse this important indicator, but the proportion of mdr resistance remains low (less than 3% over the study period). albanian government must provide the necessary reagent for performing drug susceptibility test and evaluating the real situation of mdr in albania. over the study period, the treatment success rates continued to improve, but the cure rate decreased significantly due to the lack of bacteriological confirmation during the follow up treatment phase. the number of deaths increased, but there are only few numbers to draw a valid statistical conclusion. conclusion despite the stagnation of the total number of tb cases during the study period, the epidemiological situation should not be assessed as stable, but deteriorating. mdr situation is unknown due to the shortage of reagent and pose a threat to tb control. the other epidemiological indicators like treatment outcomes and age group improved during the study period. references 1. world health organization (who). global tuberculosis report 2018. geneva: who; 2018. available from: https://apps.who.int/iris/bitstream/handle/10665/274453/9789241565646eng.pdf?sequence=1&isallowed=y (accessed: august 1, 2019). 2. world health organization. moscow declaration to end tb; first who global ministerial conference on ending tb in the sustainable development era: a multisectoral response. geneva: world health organization and the ministry of health of the russian federation; 2017. available from: https://www.who.int/tb/features_archive/moscow_declaration_to_end_tb_final_english.pdf?ua=1(accessed: june 28, 2019). https://apps.who.int/iris/bitstream/handle/10665/274453/9789241565646-eng.pdf?sequence=1&isallowed=y https://apps.who.int/iris/bitstream/handle/10665/274453/9789241565646-eng.pdf?sequence=1&isallowed=y https://apps.who.int/iris/bitstream/handle/10665/274453/9789241565646-eng.pdf?sequence=1&isallowed=y https://www.who.int/tb/features_archive/moscow_declaration_to_end_tb_final_english.pdf?ua=1 https://www.who.int/tb/features_archive/moscow_declaration_to_end_tb_final_english.pdf?ua=1 https://www.who.int/tb/features_archive/moscow_declaration_to_end_tb_final_english.pdf?ua=1 https://www.who.int/tb/features_archive/moscow_declaration_to_end_tb_final_english.pdf?ua=1 peposhi i, tafa h, bardhi d, hafizi h. clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 [original research]. seejph 2020, posted: 16 august 2020. doi: 10.4119/seejph-3631 p a g e 10 | 10 3. world health organization.thirteenth general programme of work, 2019– 2023. geneva: who; 2018. available from: https://apps.who.int/iris/bitstream/handle/10665/324775/whoprp-18.1-eng.pdf(accessed: august 1, 2019). 4. world health organization (who) and stop tb partnership. the stop tb strategy. building on and enhancing dots to meet the tb-related millennium development goals. geneva: who;2006. 5. world health organization (who). implementing the end tb strategy: the essentials. geneva: who; 2015. 6. european centre for disease prevention and control (ecdc). tuberculosis surveillance and monitoring in europe, 2017. stockholm: ecdc; 2018. 7. schwoebel v, lambregts-van weezenbeek cs, moro ml, drobniewski f, hoffner se, raviglione mc, et al. standardization of anti-tuberculosis drug resistance surveillance in europe. recommendations of a world health organization (who) and international union against tuberculosis and lung disease (iuatld) working group. eur respir j 2000;16:364-71. 8. world health organization/international union against tuberculosis and lung disease. guidelines for surveillance of drug resistance in tuberculosis. int j tuberc lung dis 1998;2:72-89. 9. veen j, raviglione m, rieder hl, migliori gb, graf p, grzemska m, et al.standardized tuberculosis treatment outcome monitoring in europe.eur respir j 1998;12:505-10. 10. uplekar m, rangan s, ogden j. gender and tuberculosis control: towards a strategy for research and action. geneva: who; 1999:6-10 11. hudelson p. gender differentials in tuberculosis: the role of socio-economic and cultural factors. tuber lung dis1996;77:391-400. 12. caws m, thwaites g, dunstan s, hawn tr, lan nt, thuong nt, et al.the influence of host and bacterial genotype on the development of disseminated disease with mycobacterium tuberculosis. plos pathog 2008;4:e1000034. 13. hafizi h, dilika e, bardhi d, shehu e. the treatment outcomes for tb patients in albania from 2001-2006.gender differences in tb disease in albania. ajmhs 2008;2. 14. desikan p. sputum smear microscopy in tuberculosis: is it still relevant? indian j med res 2013;137:442-4. 15. agrawal m, bajaj a, bhatia v, dutt s. comparative study of genexpert with zn stain and culture in samples of suspected pulmonary tuberculosis. j clin diagn res 2016;10:9-12. 16. world health organization. tuberculosis surveillance and monitoring in europe 2020: 2018 data. who; 2020. _________________________________________________________________________ © 2020 peposhi et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. relative income and acute coronary syndrome: a population-based case-control study in tirana, albania bojaj g, czabanowska k, skeraj f, burazeri g. level of competencies of family physicians from patients’ viewpoint in post-war kosovo (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-05. 1 original research level of competencies of family physicians from patients’ viewpoint in postwar kosovo gazmend bojaj1,2, katarzyna czabanowska3,4, fitim skeraj2, genc burazeri2,3 1 principal family medicine center, kline, kosovo; 2 university of medicine, tirana, albania; 3 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 4 faculty of health sciences, jagiellonian university medical college, krakow, poland. corresponding author: gazmend bojaj, md, principal family medicine center, kline, kosovo; address: rr. “faruk elezi”, kline, kosovo; telephone: +37744251164; e-mail: drgazi2002@hotmail.com bojaj g, czabanowska k, skeraj f, burazeri g. level of competencies of family physicians from patients’ viewpoint in post-war kosovo (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-05. 2 abstract aim: besides the health professionals’ perspective, it is equally important to assess the perceptions of the users of health care services with regard to abilities, skills and competencies of their family physicians. our aim was to assess the level of competencies of family physicians from patients’ viewpoint in transitional kosovo. methods: a nationwide survey was conducted in kosovo in 2013, including a representative sample of 1340 primary health care users aged ≥18 years (49% males aged 50.7±18.4 years and 51% females aged 50.4±17.4 years; response rate: 89%). participants were asked to assess the level of competencies of their respective family physicians regarding different domains of the medical encounter. the self-administered questionnaire included 37 items structured into six domains. answers for each item of the instrument ranged from one (“novice” physicians) to five (“expert” physicians). an overall summary score related to family physicians’ competencies was calculated for each participant [range: from 37 (minimal competencies) to 185 (maximal competencies)]. furthermore, demographic and socioeconomic data were collected. general linear model was used to assess the demographic and socioeconomic correlates of the overall level of family physicians’ competences according to patients’ perspective. results: mean value of the overall summary score for the 37-item instrument was 118.0±19.7. it was higher among the younger and the low-income participants, and in patients who reported frequent health visits and those not satisfied with the quality of the medical encounter. conversely, no sex, or educational differences were noted. conclusions: our findings indicate a relatively high level of competencies of family physicians from patients’ perspective in post-war kosovo. future studies should comprehensively assess the main determinants of self-perceived competencies of family physicians among primary health care users in kosovo. keywords: competencies, family physicians, primary health care users, quality of care. bojaj g, czabanowska k, skeraj f, burazeri g. level of competencies of family physicians from patients’ viewpoint in post-war kosovo (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-05. 3 introduction recently, it has been argued that competency-based instruction is vital for professional development of health professionals (1). hence, competency-based education enhances the abilities and skills of the health personnel to address complex and changing demands for critical services at a population level (1-3). fostering competencies and skills of the health care workforce will lead to an increase in the satisfaction level of the users of health care services, which has been convincingly linked to a better quality of primary health care (4) and more favorable health outcomes (5,6). from this point of view, in order to meet patients’ demands, quality improvement and performance evaluation have recently developed into core issues in primary health care practice (7). we have previously argued about the need for development of useful tools for the continuous assessment of physicians’ performance in order to identify potential gaps in their level of skills, abilities and competencies with the ultimate goal of improving the quality of patient care (7,8). to meet this end, we have suggested a conceptual framework and a suitable instrument which help to self-assess competency gaps among primary health care professionals (7,8). however, besides the health professionals’ perspective, it is equally important to assess the perceptions of the users of health care services with regard to abilities, skills and competencies of their family physicians and the other health personnel. thus, there is a need to develop measuring instruments for health professionals’ competencies as viewed from patients’ perspective. in this line of argument, we have developed and tested an international instrument aiming at assessing the level of skills, abilities and competencies of health professionals from both family physicians’ perspective (self-assessment) and from primary health care users’ standpoint (8). this measuring instrument has been validated in albania among primary health care users (9) and in general practitioners and family physicians (10). more recently, a cross-cultural adaptation of this instrument has been also conducted in kosovo among primary health users (11) and family physicians (12). in this framework, we aimed to assess the level of skills, abilities and competencies of family physicians from primary health care users’ perspective in kosovo, a transitional country in the western balkans. we used the validated version of the international instrument developed with the support of the european community lifelong learning program. this standardized tool addresses the competency levels of general practitioners and family physicians regarding different domains of quality of health care (7,8). methods a nationwide cross-sectional study was conducted in kosovo in january-december 2013. study population a representative nationwide sample of 1340 primary health care users (both sexes aged ≥18 years) was included in this survey. calculation of the sample size was made by use of winpepi for a number of hypotheses related to patients’ socio-demographic and socioeconomic correlates such as sex, age and level of education. the significance level (twotailed) was set at 5%, and the power of the study at 80%. based on the most conservative calculations, the required minimal size was about 1200 individuals. we decided to recruit 1500 individuals in order to increase the power of the study. of the 1500 targeted individuals, 160 did not participate in the survey. overall, 1340 primary health care users were included in our survey [661 (49%) males and 679 (51%) females; bojaj g, czabanowska k, skeraj f, burazeri g. level of competencies of family physicians from patients’ viewpoint in post-war kosovo (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-05. 4 overall response rate: 1340/1500=89.3%]. the response rate was similar in each of the regions included in the survey. in addition, respondents and non-respondents had similar sex and age distribution in all of the regions included in the survey. data collection we employed an international instrument aiming at assessing the level of skills, abilities and competencies of family physicians from primary health care users’ perspective. all participants included in this survey were asked to assess the level of skills, abilities and competencies of their family physicians with regard to the following six crucial domains of the quality of primary health care: (i) patient care and safety (8 items); (ii) effectiveness and efficiency (7 items); (iii) equity and ethical practice (8 items); (iv) methods and tools (5 items); (v) leadership and management (4 items), and; (vi) continuing professional development (5 items). answers for each item of each subscale ranged from 1 (“novice”= physicians have little or no knowledge/ability, or no previous experience of the competency described and need close supervision or instruction) to 5 (“expert”=physicians are the primary sources of knowledge and information in the medical field) (9-12). an overall summary score [including 37 items; range: from 37 (minimal competencies) to 185 (maximal competencies)] was calculated for all participants included in this study. demographic and socioeconomic data (age and sex of participants, educational attainment, employment status and income level) and information on the overall satisfaction with the medical encounter and the number of health visits in the past year were also collected. the study was approved by the ethical board of the ministry of health of kosovo. all individuals who agreed to participate signed an informed consent form prior to the interview. statistical analysis cronbach’s alpha was used to assess the internal consistency of the 37-item instrument measuring family physicians’ competencies from primary health care users’ perspective. conversely, spearman’s rho was used to assess the linear association (correlation) of the subscale scores (domains) of the instrument. general linear model was employed to assess the association of the overall score of competencies of family physicians’ from patients’ viewpoint with their demographic and socioeconomic characteristics. unadjusted and age-adjusted mean values, their respective 95% confidence intervals (95%cis) and p-values were calculated. statistical package for social sciences (spss), version 17.0 was used for all the statistical analyses. results background characteristics of study participants the overall mean age of survey participants was 50.5±17.9 years – it was similar in males and females (table 1). on the whole, mean years of formal schooling were 9.4±4.0 years. the educational attainment was higher in males compared with female participants (mean years of formal schooling: 10.3±3.7 years vs. 8.5±4.1 years, respectively). about 20% of study participants reported a low income level (18% in males and 21% in females), whereas 7% reported a high income level (8% in males and 7% in females). the unemployment rate was quite high in this bojaj g, czabanowska k, skeraj f, burazeri g. level of competencies of family physicians from patients’ viewpoint in post-war kosovo (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-05. 5 representative sample of primary health care users in kosovo, particularly among female participants (53% vs. 22% in males). very few participants reported their first health visit at the primary health care services in the past year (overall n=16), about 19% reported 1-2 health visits, whereas 18% of individuals reported seven or more health visits in the past year. remarkably, survey participants reported a high degree of satisfaction with primary health care services: 75% of individuals perceived as “good” or “very good” the medical encounter, compared to only 3.4% of individuals who rated as “poor” or “very poor” the quality of primary health care services. there were no gender differences with regard to the overall satisfaction with the quality of primary health care services (table 1). table 1. distribution of socioeconomic characteristics and satisfaction with health care services in a representative sample of primary health care users in kosovo, in 2013 variable male (n=661) female (n=679) overall (n=1340) age (years) 50.7±18.4* 50.4±17.4 50.5±17.9 educational level (years) 10.3±3.7 8.5±4.1 9.4±4.0 income level: low middle high 119 (18.0)† 491 (74.3) 51 (7.7) 146 (21.5) 485 (71.4) 48 (7.1) 265 (19.8) 976 (72.8) 99 (7.4) employment status: employed unemployed students retired 288 (43.6) 146 (22.1) 66 (10.0) 161 (24.4) 168 (24.7) 363 (53.5) 55 (8.1) 93 (13.7) 456 (34.0) 509 (38.0) 121 (9.0) 254 (19.0) no. health visits in the past 12 months: 0 1-2 3-4 5-6 ≥7 7 (1.1) 131 (19.8) 268 (40.5) 136 (20.6) 119 (18.0) 9 (1.3) 125 (18.4) 214 (31.5) 204 (30.0) 127 (18.7) 16 (1.2) 256 (19.1) 482 (36.0) 340 (25.4) 246 (18.4) overall satisfaction with health services: very good/good average poor/very poor 500 (75.6) 140 (21.2) 21 (3.2) 503 (74.1) 151 (22.2) 25 (3.7) 1003 (74.9) 291 (21.7) 46 (3.4) * mean values ± standard deviations. † numbers and column percentages (in parentheses). ---------------------------------------------------- instrument for measuring competencies of family physicians overall, reliability (internal consistency) of the whole scale (37 items) was cronbach’s alpha=0.96 (95%ci=0.96-0.97); it was similar in male and female participants (0.97 vs. 0.96, respectively) [data not shown]. table 2 presents a correlation matrix between the subscale scores (that is domains of the measuring instrument). spearman’s correlation coefficients ranged from 0.55 (for the linear association of “leadership and management” with the “patient care and safety” and the “equity and ethical practice” domains) to 0.70 (for the “effectiveness and efficiency” and the “patient care and safety” subscales) – indicating a moderate linear relationship between the domains of the family physicians’ competencies instrument. bojaj g, czabanowska k, skeraj f, burazeri g. level of competencies of family physicians from patients’ viewpoint in post-war kosovo (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-05. 6 table 2. correlational matrix of subscale scores (alias domains of the instrument) domain continuing professional development patient care and safety effectiveness and efficiency equity and ethical practice methods and tools patient care and safety 0.57 (<0.001) * effectiveness and efficiency 0.56 (<0.001) 0.70 (<0.001) equity and ethical practice 0.58 (<0.001) 0.59 (<0.001) 0.64 (<0.001) methods and tools 0.66 (<0.001) 0.62 (<0.001) 0.68 (<0.001) 0.64 (<0.001) leadership and management 0.64 (<0.001) 0.55 (<0.001) 0.58 (<0.001) 0.55 (<0.001) 0.71 (<0.001) * spearman’s correlation coefficients and their respective p-values (in parentheses). ---------------------------------------------------- correlates of competencies of family physicians mean value of the overall summary score for the 37-item instrument was 118.0±19.7 [range from 37 (minimal competencies) to 185 (maximal competencies)]. mean value of the overall summary score of the competencies of family physicians from patients’ viewpoint was higher among the younger (<45 years) participants compared with their older (≥45 years) counterparts (119 vs. 117, respectively, p=0.04) [table 3]. there was no evidence of gender-differences in the mean scores of the overall competencies of family physicians even upon age-adjustment. furthermore, mean scores of competencies of family physicians were similar among participants with different levels of educational attainment. on the other hand, the low-income participants exhibited lower mean scores of their family physicians’ overall competencies compared with the high-income group (age-adjusted overall p<0.001). employed and unemployed individuals exhibited similar mean scores – a finding which persisted also upon age-adjustment. patients with frequent visits in the primary health care clinics (three or more visits in the past year) displayed the lowest scores of competencies of their family physicians (age-adjusted overall p<0.001). as expected, participants who were satisfied with the medical encounter showed a higher mean score of their family physicians’ competencies compared with the individuals who were less satisfied with the quality of primary health care services (overall p<0.001) [table 3]. table 3. association of competencies of family physicians from patients’ viewpoint with their demographic and socioeconomic characteristics; mean values from the general linear model patients’ socioeconomic characteristics unadjusted models age-adjusted models mean* 95%ci p mean* 95%ci p age: younger (≤44 years) older (≥45 years) 119.4 117.1 117.6-121.0 115.8-118.4 0.042 gender: males females 118.2 117.8 116.7-119.7 116.3-119.3 0.704 118.4 118.0 116.9-119.9 116.5-119.6 0.735 educational level: low (0-8 years) middle (9-12 years) high (≥13 years) 117.4 118.3 118.7 115.9-118.9 116.5-120.2 116.3-121.1 0.601 (2)† 0.371 0.802 reference 118.2 118.3 118.2 116.5-119.9 116.4-120.2 115.7-120.7 0.998 (2)† 0.992 0.954 reference income level: low 113.4 111.1-115.8 <0.001 (2) 0.037 113.9 111.5-116.3 <0.001 (2) 0.077 bojaj g, czabanowska k, skeraj f, burazeri g. level of competencies of family physicians from patients’ viewpoint in post-war kosovo (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-05. 7 middle high 119.2 118.2 118.0-120.4 114.4-122.1 0.649 reference 119.3 118.0 118.1-120.6 114.2-121.9 0.527 reference employment status: employed unemployed student retired 118.8 117.4 120.4 116.5 117.0-120.6 115.7-119.1 116.9-123.9 114.1-118.9 0.222 (3) 0.141 0.564 0.077 reference 118.7 117.7 119.8 117.2 116.8-120.5 115.9-119.5 116.2-123.5 114.5-120.0 0.690 (3) 0.400 0.758 0.289 reference no. health visits in the past 12 months: 0 1-2 ≥3 126.6 122.1 116.9 117.0-136.2 119.7-124.5 115.7-118.0 <0.001 (2) 0.048 <0.001 reference 126.3 122.0 117.1 116.6-135.9 119.6-124.4 115.8-118.3 0.001 (2) 0.064 <0.001 reference overall satisfaction with health services: very good/good average poor/very poor 119.8 112.4 113.5 118.6-121.0 110.1-114.6 107.9-119.1 <0.001 (2) 0.031 0.718 reference 120.0 112.7 113.8 118.7-121.2 110.4-114.9 108.2-119.5 <0.001 (2) 0.036 0.710 reference * range of the overall summary score from 37 (minimal competencies) to 185 (maximal competencies). † overall p-values and degrees of freedom (in parentheses). ---------------------------------------------------- discussion findings from this survey provide useful information on the level of skills, abilities and competencies of family physicians from primary health care users’ perspective in post-war kosovo. the assessment instrument administered in our study sample showed a very high internal consistency, which was similar in male and female participants. as a matter of fact, the overall internal consistency in our survey (cronbach’s alpha=0.96) was higher than in a prior cross-cultural adaptation exercise conducted in kosovo, which reported an overall cronbach’s alpha=0.88 (11). in addition, the internal consistency in the current study conducted in kosovo was higher than in a previous validation study conducted in albania (9). in our study, the reliability of the tool (i.e. the internal consistency) was similar in both sexes, a finding which is basically compatible with a previous report from albania (9). the overall level of competencies of family physicians – as assessed by the summary score of the 37-item instrument – was quite high in our study which included a nationwide representative sample of primary health care users in kosovo. there were no sex-differences with regard to the perceived levels of family physicians’ competencies according to patients’ standpoint. as pointed out earlier, this finding related to a high level of family physicians’ knowledge and competencies is in line with the very positive assessment of the quality of primary health care services among our study participants (13). thus, in our study, 75% of participants perceived as “good” or “very good” the medical encounter, a finding which is quite different from a previous study conducted in gjilan region, kosovo, in 2010 including a representative sample of 1039 primary health care users (14). in this survey, patients’ evaluation of primary health care services was assessed through europep, a 23-item instrument tapping different aspects of the medical encounter. findings from this study indicated that considerably fewer primary health care users in kosovo were satisfied with the overall medical encounter compared with their european counterparts (14). however, there are differences between the two studies: our survey included a nationwide representative sample in contrast with the previous study confined to gjilan region only (14). furthermore, we assessed only the self-perceived level of competencies of family physicians from patients’ bojaj g, czabanowska k, skeraj f, burazeri g. level of competencies of family physicians from patients’ viewpoint in post-war kosovo (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-05. 8 perspective. on the other hand, the prior survey conducted in gjilan region included other important dimensions of the quality of primary health care services which are not related to the level of knowledge, skills and competencies of health care professionals (14). furthermore, the overall level of competencies of family physicians in our study was higher compared to the previous validation study (cross-cultural adaptation) which was conducted in a sample of 98 primary health care users in kosovo (11). in addition, the overall summary score in our study was particularly higher compared to prior reports from the neighboring albania, where a similar survey employing exactly the same instrument was conducted (9,10). in our study conducted in kosovo, the level of skills, abilities and competencies of family physicians as assessed by patients’ perspective was positively related to income level, in contrast with the albanian study which reported lack of associations with socioeconomic characteristics of study participants (9). nonetheless, there was no evidence of relationship with educational attainment in the current survey, too. future studies in kosovo and albania should compare primary health care users’ assessment scores with the self-assessed scores of their respective family physicians in order to identify potential gaps in the perceived levels of skills and competencies. as argued earlier, primary health care users’ viewpoints about the quality of health care services including the skills and competencies of their respective family physicians may vary significantly from the selfperceived level of competencies of health care professionals themselves (13). competencies are considered as composites of individual attributes including knowledge, skills and attitudes that represent context-bound productivity (15). however, patients’ viewpoint on productivity may differ considerably from providers’ perspective. hence, future studies in albanian settings and elsewhere should explore this important issue in a robust manner. in conclusion, findings from this nationwide survey conducted in transitional kosovo provide useful information on the level of skills and competencies of family physicians from primary health care users’ perspective. nonetheless, findings from this survey should be replicated in future studies in albania and kosovo. source of support the instrument for this survey was developed with the support of the european commission lifelong learning program in the framework of the leonardo da vinci project “innovative lifelong learning of european general physicians in quality improvement supported by information technology” (ingpinqi): no. 2010-1-pl1-leo05-11473. conflicts of interest: none declared. references 1. czabanowska k, smith t, könings kd, sumskas l, otok r, bjegovic-mikanovic v, brand h. in search for a public health leadership competency framework to support leadership curriculum-a consensus study. eur j public health 2013 (epub ahead of print). 2. wright k, rowitz l, merkle a, et al. competency development in public health leadership. am j public health 2000;90:1202-7. 3. mckee m. seven goals for public health training in the 21st century. eur j public health 2013;23:186-7. 4. heje hn, vedsted p, olesen f. general practitioners’ experience and benefits from patient evaluations. bmc fam pract 2011;12:116. http://www.ncbi.nlm.nih.gov/pubmed?term=czabanowska%20k%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=smith%20t%5bauthor%5d&cauthor=true&cauthor_uid=24121098 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http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=general%20practitioners%e2%80%99%20experience%20and%20benefits%20from%20patient%20evaluations bojaj g, czabanowska k, skeraj f, burazeri g. level of competencies of family physicians from patients’ viewpoint in post-war kosovo (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-05. 9 5. van walraven c, oake n, jennings a, forster aj. the association between continuity of care and outcomes: a systematic and critical review. j eval clin pract 2010;16:94756. 6. hush jm, cameron k, mackey m. patient satisfaction with musculoskeletal physical therapy care: a systematic review. phys ther 2011;91:25-36. 7. czabanowska k, klemenc-ketis z, potter a, rochfort a, tomasik t, csiszar j, vanden bussche p. development of the competency framework in quality improvement for family medicine in europe: a qualitative study. j contin educ health prof 2012;32:174-80. 8. czabanowska k, burazeri g, klemens-ketic z, kijowska v, tomasik t, brand h. quality improvement competency gaps in primary care in albanian, polish and slovenian contexts: a study protocol. acta inform med 2012;20:254-8. 9. alla a, czabanowska k, klemenc-ketis z, roshi e, burazeri g. cross-cultural adaptation of an instrument measuring primary health care users’ perceptions on competencies of their family physicians in albania. med arh 2012;66:382-4. 10. alla a, czabanowska k, kijowska v, roshi e, burazeri g. cross-cultural adaptation of a questionnaire on self-perceived level of skills, abilities and competencies of family physicians in albania. mater sociomed 2012;24:220-2. 11. bojaj g, czabanowska k, klemens-ketic z, skeraj f, hysa b, tahiri z, burazeri g. validation of an instrument measuring primary health care users’ opinion about abilities, skills and competencies of their family physicians in kosovo. albanian medical journal 2013;1:79-83. 12. skeraj f, czabanowska k, bojaj g, hysa b, petrela e, hyska j, burazeri g. crosscultural adaptation of a questionnaire about competencies of family physicians in kosovo from practitioners’ and policymakers’ perspective. albanian medical journal 2013;1:19-24. 13. bojaj g, czabanowska k, skeraj f, tahiri z, burazeri g. primary health care users’ perceptions on competencies of their family physicians in kosovo: preliminary results from a cross-sectional study. albanian medical journal 2013;3:64-9. 14. tahiri z, toçi e, rrumbullaku l, hoti k, roshi e, burazeri g. patients’ evaluation of primary health care services in gjilan region, kosovo. j public health (oxf) 2013 (epub ahead of print). 15. loo jv, semeijn j. defining and measuring competences: an application to graduate surveys. qual quant 2004;38:331-49. ___________________________________________________________ © 2014 bojaj et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=van%20walraven%20c%5bauthor%5d&cauthor=true&cauthor_uid=20553366 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=oake%20n%5bauthor%5d&cauthor=true&cauthor_uid=20553366 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=jennings%20a%5bauthor%5d&cauthor=true&cauthor_uid=20553366 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=forster%20aj%5bauthor%5d&cauthor=true&cauthor_uid=20553366 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=the%20association%20between%20continuity%20of%20care%20and%20outcomes%3a%20a%20systematic%20and%20critical%20reviewjep_1235%20947..956 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=hush%20jm%5bauthor%5d&cauthor=true&cauthor_uid=21071504 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faculties of medicine in indonesia (case study). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-195 1 case study geriatric curriculum at faculties of medicine in indonesia charles surjadi 1 , dwi jani 1 , ursula yunita langoday 1 1 department of public health and preventive medicine, faculty of medicine, university atma jaya, jakarta, indonesia. corresponding author: prof. charles surjadi address: faculty medicine atmajaya university jl pluit raya no. 2, floor 4, room 413, jakarta 14350 indonesia; email: kotasehat@hotmail.com mailto:kotasehat@hotmail.com surjadi c, jani d, langoday uy. geriatric curriculum at faculties of medicine in indonesia (case study). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-195 2 abstract aim: in indonesia, the elderly population is growing rapidly and will comprise 35 million in 2035. the aim of this study was to assess how geriatric training is organised in medical faculties in indonesia. methods: in 2017, we asked through questionnaires the vice deans of the faculties of medicine about their perceptions towards health and ageing and how they organized the geriatric training in their respective schools. overall, we obtained data from 32 out of 71 (45.1%) faculties of medicine. results: all respondents perceived geriatrics as an important issue for faculties of medicine. only 12 (37.5%) faculties employ geriatric specialists, 28 (87.5%) teach geriatrics at the undergraduate level, and 12 (40.6%) at postgraduate level, whereas 4 (12.5%) universities teach at specialty level. conversely, at undergraduate level, only 18 (64.2%) faculties include the ‘geriatric giants’, and 5 (17.8%) include ageism. there are 13 (46.4%) geriatric classes implemented through skill laboratories, 5 (17.8%) through geriatric policlinics, and 4 (14.3%) through geriatric wards. conclusion: attention to geriatric training among medical schools in indonesia has to be improved. at national level, there should be a more specific formulation of geriatric competencies and how they can be operationalised. geriatric training is recommended to prepare lecturers in medical faculties. related to the content of aging curriculum, geriatric issues, attitudes towards aging, and ageism should be addressed. keywords: faculty of medicine, geriatric competency, indonesia, teaching geriatrics. conflict of interest: none. surjadi c, jani d, langoday uy. geriatric curriculum at faculties of medicine in indonesia (case study). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-195 3 introduction in indonesia, better health, due to improved economic and social conditions, has resulted in longer life and in consequence an ageing population. in 2010, there were 18.1 million elderly people (>60 years) in indonesia. in the year 2035, this number is predicted to be around 48.2 million or, 15.8% of the overall population (1). the world health organization (who) strongly advocates for all future medical doctors the need to be well-trained in caring of older people (2). currently, students need to acquire knowledge about how to treat older people from an interdisciplinary point of view (2). issues regarding education on geriatrics and the related competencies are also the concern of medical associations such as the society for family physicians and the association of gerontology higher education (aghe), while the association of international gerontology and geriatrics (iagg) pays more attention to specific themes as e.g. the relationship between generations, but also on advanced teaching methods (3-9). on the other hand, who develops manuals for primary care facilities which provide friendly services for the elderly (10). our aim was to assess how geriatric training is organised in medical faculties in indonesia. more specifically, we asked the vice deans of academic affairs pertinent to the faculties of medicine in indonesia about the way they organise training on geriatrics in their respective schools. methods based on the list of addresses and emails from deans’ offices and the ministry of education, we sent a questionnaire by post, email, and by phone to secretariats of the vice deans for key academic affairs of all medical faculties in indonesia. the questionnaire developed for this study consists of two main instruments. the general questionnaire inquired about characteristics of the persons completing the questionnaire (including information on sex, education, age and belonging to the medical profession or not). the specific questionnaire included questions regarding their perception of problems concerning the health of elderly people, whether they have taught geriatrics at undergraduate and postgraduate level and how they organised this training. the 6-pages questionnaire included some open-ended options and had already been tried out at the dean’s office of atma jaya university and at the neurological department and internal medicine department there by lecturers responsible for geriatric topics to look for inconsistencies and problems of understanding. based on this validation exercise, some revisions were done to make the questionnaire simpler and easier to be answered. for the current study, descriptive statistics are presented. results we were able to get data from 32 out of 71 (45.1 %) faculties of medicine in indonesia (table 1). all respondents perceived geriatrics as an important issue for the faculties of medicine. only 12 (37.5 %) faculties employ geriatric specialists, and 22 (68.8%) suggested that geriatrics should be integrated into the specialisation for internal medicine; 10 (31.3%) faculties consider that geriatrics is a discipline which needs participation from other medical disciplines. at present, 28 (87.5%) faculties teach geriatric topics at the undergraduate level but only 13 (40.6 %) schools teach this discipline at the doctoral level. surjadi c, jani d, langoday uy. geriatric curriculum at faculties of medicine in indonesia (case study). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-195 4 table 1. geriatric training at the faculties of medicine in indonesia (n=32) variable number percentage perceived geriatrics should get attention in the medical faculty 32 100.0 employed a geriatric specialist 12 37.5 geriatrics should be integrated into the department of internal medicine 22 68.8 geriatrics need participation of other disciplines 10 31.3 training at undergraduate level 28 87.5 training at doctoral level 13 40.6 training at specialty level 4 12.5 for the undergraduate level, we asked whether the faculties have a specific objective related to geriatric training. overall, there are 9 (32.1 %) schools which have developed a proper syllabus (table 2). related to specific issues of ageing, there are only 18 (64.3%) schools which include the ‘geriatric giants’, 5 (17.8%) include ageism and attitudes towards aging. in relation to the method of teaching geriatrics there are 13 (46.4%) classes supported by skill laboratories, 5 (17.8 %) through outpatient geriatric clinics, and 4 (14.3%) through geriatric wards. table 2. teaching geriatrics at the undergraduate level of medicine in indonesia (n=28) present situation number percentage there is a syllabus on geriatrics 9 32.1 ‘geriatric giants’ have been taught 18 64.3 ageism has been taught 5 17.9 geriatrics include education in skill laboratories 13 46.4 have a geriatric policlinic 5 17.8 have a geriatric ward 4 14.3 discussion in indonesia, at the national level, there are few standard sets of competencies for medical doctors, e.g. for dentists formulated in 2012 by the indonesian medical council (11). geriatrics are not specifically mentioned although students should be able to solve those problems of old age as part of their skills. curricula in indonesia should be focused around the four pillars of learning i) learning to know, ii) learning to do, iii) learning to live together, and iv) learning to be. in an inputprocess-outcomes framework, curricular content, textbooks, and learning materials are among the major teaching inputs as a dimension of quality education (12). however, a policy framework is needed that encourages geriatric training formats but is missing in indonesia. examples of structured training and corresponding sets of competencies can be found in the international literature e.g. in canada (4), the united states (13), or taiwan (14): taiwanese educators have developed and implemented several methods in the framework of a national project for excellence in geriatric care education:  curricula development for innovative teaching and learning consisting of a) curriculum development and goals b) curricula content and certification, for undergraduate as well as for postgraduate programmes. surjadi c, jani d, langoday uy. geriatric curriculum at faculties of medicine in indonesia (case study). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-195 5  excellence in teaching and learning: a) problem-based learning, b) geriatric care practicum, c) research practicum, d) learning by visiting rounds. in summary, it is recommended to include into the formal training by a gerontologist a clerkship in geriatrics which has to be supported at the national, the faculty and the individual level through national guidelines. in some american faculties of medicine, blended learning has been introduced with web-based modules, interactive videogames, and face to face learning such as ward rounds, case conferences, meet the team, community practice through nursing home and home visits (13). in the united states it is recommended that nine or more geriatric physicians are employed at a faculty of medicine; this criterion was met in 30% of medical schools in 2000 and in 49% in 2010. the main topics taught included geriatric syndromes and geriatric assessment (15). minimum geriatric competencies for medical students are presented in table 3. four criteria were used as guiding principles: i) competencies should focus on issues that really matter to health outcomes of elderly people. ii) competencies should be discussed before the start of one’s internship. iii) the total number of content domains and competencies should be limited, with no more than 5-8 domains, and no more than 3-5 competencies in each. iv) the competencies should be similar to quality indicators in that they are the ‘floor’ behaviours and could be taught and evaluated at any medical school (16). table 3. minimum geriatric competencies for medical students world geriatric and gerontology association (17) canada (3) united states (16) 1. medication management 2. cognitive and behavioural disorders 3. self care capacity 4. falls, balance, gait disorders 5. health care planning and promotion 6. atypical presentation of disease 7. palliative care 8. hospital care for elders 1. cognitive impairment 2. functional impairment 3. falls balance and gate disorder 4. medication management 5. biological of aging and atypical presentation of diseases 6. adverse event 7. urinary incontinence 8. transition of care 9. health care planning 1. medication management 2. cognitive and behavioural disorders 3. self care capacity 4. falls, balance, gait disorders 5. health care planning and promotion 6. atypical presentation of disease 7. palliative care 8. hospital care for elders conclusion attention of geriatric training among medical schools in indonesia should be improved. at national level there should be a more specific formulation on geriatric competency and how it could be implemented. also, there should be advocacy and awareness campaigns. geriatric training in medical faculties should include lectures and practical sessions. related to the content of geriatric curricula, topics on ‘geriatric giant’, attitudes towards aging and ageism should be addressed. surjadi c, jani d, langoday uy. geriatric curriculum at faculties of medicine in indonesia (case 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unesco press; 2005. 13. g duque, o demontiero. evaluation of a blended learning model in geriatric medicine a succesfull learning experiences to medical students austral j ageing 2013;32:103-9. 14. lee m-c, yen c-h, ho rfc, wang c-c, tang y-j, liao w-c, et al. national project for excellence in geriatric care education—a comprehensive, innovative and practical program for undergraduate and graduate students in taiwan. j clin gerontol geriatr 2010;1:12-6. 15. meteos-nozal j c-ja, ribera casado jm. a systematic review of surveys on undergraduate teaching of geriatrics in medical schools in the xxi century. eur geriat med 2014;5:119-24. 16. leipzig rm, granville l, simpson d, anderson mb, sauvigné k, soriano rp. keeping granny safe on july 1: a consensus on minimum geriatrics competencies for graduating medical students. acad med 2009;84:604-10. http://www.aghe.org/images/aghe/competencies/gerontology_competencies.pdf surjadi c, jani d, langoday uy. geriatric curriculum at faculties of medicine in indonesia (case study). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-195 7 17. association of american medical colleges/john a. hartford foundation, inc. july 2007 consensus conference on competencies in geriatrics education. acad med 2009;84:604-10. ______________________________________________________________________________________ © 2018 surjadi et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 1 review article a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level beatrice scholtes1, peter schröder-bäck1, morag mackay2, joanne vincenten2, helmut brand1 1 department of international health, maastricht university, maastricht, the netherlands; 2 european child safety alliance, birmingham, united kingdom. corresponding author: beatrice scholtes, department of international health, caphri; address: maastricht university, po box 616, 6200 md maastricht, the netherlands; telephone: +31433881710; fax: +31433884172; email: beatrice.scholtes@maastrichtuniversity.nl scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 2 abstract aim: risk factors for child injury are multi-faceted. social, environmental and economic factors place responsibility for prevention upon many stakeholders across traditional sectors such as health, justice, environment and education. multi-sectoral collaboration for injury prevention is thus essential. in addition, co-benefits due to injury prevention initiatives exist. however, multi-sectoral collaboration is often difficult to establish and maintain. we present an applied approach for practitioners and policy makers at the local level to use to explore and address the multi-sectoral nature of child injury. methods: we combined elements of the haddon matrix and the lens and telescope model, to develop a new approach for practitioners and policy makers at the local level. results: the approach offers the opportunity for diverse sectors at the local level to work together to identify their role in child injury prevention. based on ecological injury prevention and life-course epidemiology it encourages multi-disciplinary team building from the outset. the process has three phases: first, visualising the multi-sectoral responsibilities for child injury prevention in the local area; second, demonstrating the need for multi-sectoral collaboration and helping plan prevention activities together; and third, visualising potential co-benefits to other sectors and age groups that may arise from child injury prevention initiatives. conclusion: the approach and process encourages inter-sectoral collaboration for child injury prevention at the local level. it is a useful addition for child injury prevention at the local level, however testing the practicality of the approach in a real-world setting, and refinement of the process would improve it further. keywords: co-benefits, inter-sectoral collaboration, prevention and control, wounds and injuries. scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 3 introduction it is far from trivial to reiterate how devastating child injury is to the individual, family and society. among the measurable costs, are loss of life, long and short-term disability, psychological consequences, and financial costs (1). in addition, child injury remains the leading cause of death and a major cause of disability for children aged 5–19 in the european region (2). despite this varied and heavy burden, funding for prevention is comparatively low (3), and capacity and leadership resources, in terms of adequate numbers of personnel and availability of the relevant skills set, are limited (4). the determinants of child injury are multiple, broad, and not limited to the health sector (2,5). thus, in order to efficiently direct and fund child injury prevention, one must account for the cross-cutting, multi-sectoral determinants that result from a complex interplay between human factors and those in the physical and socio-cultural environments. since the multiple determinants of child injury cannot be addressed by the health sector alone, a whole-of-government approach is required—vertically, from international politics to local decision makers, and horizontally, across policy fields such as health, transport, housing, justice and education. preventive action must also work across society, employing a whole-of-society approach engaging actors and stakeholders within government, civil society, and the private sector (2,6). though inter-sectoral co-operation is essential, it is notoriously challenging (7,8). it is often difficult to engage relevant stakeholders and maintain their co-operation throughout the process from policy making through to implementation and evaluation. additionally, the complexity of government systems, where roles and responsibilities are divided into traditional silos (e.g., health, transport, education), and where responsibility and power are split between national, regional and local levels, can further hinder cooperation (9). thus, due to its complexity, child injury is one of the so-called ‘wicked’ problems of public health (7). however, its cross-cutting nature offers broad scope for interventions to result in or contribute to multi-sectoral co-benefits (10). in this paper we focus on the role of regional or local level decision makers and propose a model to facilitate the decision making process for the cross cutting issue of child injury prevention. existing models for injury prevention several models to guide injury prevention have been proposed, including those addressing the multiple determinants of injury (11,12) intervention planning (13,14) and inter-sectoral collaboration (15). these models provide useful theoretical frameworks to address injuries and their prevention. however, they do not address the specific nature of child injury and in some cases may be challenging for use at the local level. child injury prevention requires specific, directed attention. children participate in environments largely designed for adults where their physical and cognitive characteristics make them more vulnerable to injury. physical and cognitive developmental stages precipitate different periods of injury susceptibility. age is therefore an important factor in child injury prevention and models used must have the flexibility to address this heterogeneous group. children are also highly dependent upon the care and protection of adults, so factors affecting an adult’s capacity to supervise children can directly affect them (16,17). general injury prevention initiatives, designed for adults, do not always protect children to the same extent (18,19). in terms of governance for child injury prevention, a lack of leadership and capacity at the national level such as dedicated government departments or ministries or a lack of a specific scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 4 focal point within key departments for child safety has been identified (20). it is likely that if this is the situation at the national level that there is an even greater potential for lack of capacity at the regional or local level where much decision making for health lies (21). to our knowledge, no existing model or approach adequately addresses child injury, while simultaneously providing a practical, multi-sectoral process for practitioners and policy makers at the local level to use to guide prevention efforts. in order to adequately assess the specificities of child injury and its cross-cutting nature, as well as incorporate the potential co-benefits into prevention planning, practitioners and policy makers should be able to: • examine the issue and visualise the multi-sectoral responsibilities for child injury prevention in the local area • demonstrate the need for inter-sectoral collaboration and collective planning of prevention activities • identify the scope for co-benefits for other sectors, age groups or health issues arising from child injury prevention initiatives in this paper we propose a model based upon aspects of the haddon matrix (22) and the lens and telescope model (23) providing a practical approach and process to meet these requirements for the local level. the local level child injury prevention assessment approach the traditional haddon matrix depicts a time element in the first dimension (vertical axis), dividing factors associated with what haddon termed the pre-event, event and post-event phases of an injury event. in the second dimension (horizontal axis), of the simplest form of the matrix, are the three vertices of the epidemiological triangle the host (human), the agent (vehicle/vector) and the environment, with environment often divided into social and physical. the haddon matrix fits well into the traditional public health approach of primary, secondary and tertiary prevention and has been used to explore a variety of aspects of the public health process for injury prevention including assessing risk factors (5,24), identifying preventive strategies and assisting the decision making process (13) and for public health readiness and planning (25,26). the traditional, nine cell, haddon matrix maybe less suited to child injury prevention due to the separation between environment, host and agent. children’s dependence upon adult supervision to secure their environment and their lack of control over the environment is difficult to capture in this version of the haddon matrix. therefore, when developing our approach, we sub-divided the columns, host and agent into factors for human, social and physical environment. this allows the table to capture more detail that maybe particularly relevant for preventing child injury such as factors affecting parental supervision. the temporal element of injury prevention is well represented in the haddon matrix, however circumstances preceding the injury are limited to the pre-event phase. this makes it difficult to differentiate between long standing risk factors such as socio-economic status, and short-term factors such as bad lighting. a further reality of child injury is that the determinants of injury change with age. the inclusion of the life course approach developed in the lens and telescope model (23) is intended to provide a visual cue regarding the needs of the different age groups, encouraging one to think of enduring injury determinants such as socio-economic status and parental factors. the life course aspect of our tool is divided into five specific age groups relevant to child injury, 0-1, 2-4, 5-9, 10-14, and 15-19; with general phases for the foetal phase, adulthood, previous and the next generation. the slices representing age get larger towards older age groups to illustrate the breadth of influence preventive measures could have. scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 5 the resulting approach (figure 1) can be used to examine a specific injury event (e.g., a specific car pedestrian collision) or a group of injuries (e.g., child pedestrian injuries). further, in order to include and examine all relevant factors, the matrix (or matrices, if a separate matrix is needed to provide more space) should be completed with factors relevant to each affected person in the injury event. for example, in the case of a car – pedestrian collision, a matrix should be completed accommodating the perspectives of the injured child, the driver, passengers in the car and any other relevant people. figure 1. local level child injury prevention assessment approach using the local level child injury prevention assessment approach and process the approach and resulting process are intended for use by practitioners and policy makers at the local or regional level. they can be used in three ways: first, to examine and visualise the multi-sectoral responsibilities for child injury prevention in the local area; second, to demonstrate the need for inter-sectoral collaboration and collective planning of prevention activities and third to identify the scope for co-benefits for other sectors, age groups or health issues arising from child injury prevention initiatives. phase one – examining the issue and visualising multi-sectoral responsibilities the approach and process are designed for use in a collaborative setting from the outset. relevant partners and stakeholders from multiple sectors should contribute throughout the process to map each of the factors that contribute (or could contribute) to the injury event for each person involved in the injury. in line with concepts of life-course epidemiology, the factors should not be confined to the moment the injury occurred but should also include preexisting factors. the process of eliciting each of these factors aims first, to draw all of the stakeholders together to come to a common understanding of the problem and potential scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 6 solutions (7) and second, to identify the many sectors implicated within child injury prevention. phase two demonstrating the need for multi-sectoral cooperation once factors and involvement of sectors coming out of the injury analysis are identified, users can reflect on them and propose specific evidence based interventions and policies that address these factors and identify the appropriate sectors that would need to be involved. these specifics can then be used to make the case for investment and/or engage additional stakeholders. the integrated life course approach serves as a prompt to ensure age is being taken into consideration as interventions are considered. potential interventions can then be inserted into an empty matrix in the same way as the factors were placed in phase one. phase three – visualising the scope for co-benefits the third phase is designed to help identify potential co-benefits of child injury prevention strategies for other age-groups and issues within and outside the health sector. co-benefits can be achieved as a result of child injury prevention measures in three ways. first are the physical, economic and societal benefits for the child, family and community as a result of a reduction in intentional and unintentional injury (1,3). second are co-benefits for the target population or other groups arising as a result of injury prevention initiatives (e.g., the health benefits of swimming lessons or environmental and health benefits of a safer walking environment in terms of a reduction in car use); these are not dependent upon a reduction in injury incidence but are derived from the intervention itself. third are co-benefits for other groups that can be achieved as a result of the implementation of injury prevention strategies (e.g., providing training and employment to distributers of safety equipment). by reflecting on the age group segments of the approach, users are encouraged to consider the impact on other age-groups and identify which groups might directly and indirectly benefit from child injury prevention interventions and elaborate on these co-benefits. for example, an intervention to improve the walkability of an area surrounding a school would directly benefit age groups 5-9, 10-14 and 15-19 years, but may also benefit the elderly population of that area by providing a safer walking environment. discussion much responsibility for injury prevention lies with local practitioners and policy makers in terms of choice of intervention and process of implementation. however, for complex ‘wicked’ problems such as child injury, the key stakeholders at the local level are often unaware of their responsibilities for public health and the potential impact of their participation (27). local government officials have been found to lack awareness of the link between health and non-health sectors, and their experience of inter-sectoral collaboration is often limited (8). a key determinant of success for inter-sectoral collaboration, is the development of a multi-disciplinary team of multiple stakeholders (28,29) to first reach a common understanding of the problem and then, on that basis, to collaboratively design evidence based interventions that are specific and relevant to the needs of the target population (7). a significant difference between our approach and process and other existing models for child injury prevention is its interactive and collaborative nature. our approach provides a practical framework to engage diverse stakeholders from the outset. it has been designed to provide a comprehensive approach to child injury prevention in a simple (and familiar) format to maximise output at the local level of governance. the exercise of mapping factors using a matrix that addresses the specific physical and social environments for host and agent scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 7 separately helps identify the potential involvement for many sectors and the identification of roles and responsibilities as interventions are selected. a limitation of this approach is that it is unable to quantify the comparative or cumulative impact of the identified risk factors in the local setting. local knowledge of their relative importance in the target setting is therefore required to weight them appropriately, in terms of importance and prevalence, and to develop a suitable intervention. additionally, the approach does not help planners/researchers identify what interventions or policies are already in place or how to choose an intervention. however the third dimension of the haddon matrix as proposed by runyan (13) could be used in conjunction with this model to aid intervention choice. the opportunity to identify the potential co-benefits of injury prevention initiatives offered by this approach is particularly important in the context of advocacy and efforts to secure funds for prevention activities. a lack of funding is a common barrier to adoption and implementation of public health interventions, particularly for complex or wicked problems. (8) if co-benefits of prevention activities outside the target group or injury domain can be demonstrated, the chances of securing funding may be higher, particularly if the co-benefit addresses a priority area (e.g., obesity or healthy ageing). our proposed approach and process provide a way of demonstrating the interconnectivity between sectors and therefore the secondary impact child injury prevention strategies may have beyond childhood or outside the injury domain. however, it must be noted that when identifying co-benefits this approach does not offer any quantification of economical or health benefits associated with a given strategy. the use of a life course model is a central element of our approach. there are several advantages to this: first, it emphasises the importance of a child’s age for injury susceptibility and acts as a lens through which to consider relevant factors, particularly when looking at an overall injury issue (e.g., child drowning); second, it accommodates age in the design or choice of preventive interventions; third, it allows analysis of risk factors related to parents or carers and underlying causes; and, fourth, it provides a frame to reflect upon potential cobenefits for other age groups arising from child injury prevention interventions. additionally, some interventions in child injury prevention include longer timeframes between intervention implementation and results, especially when addressing the more complex risk factors such as substance abuse and mental health. these are often incompatible with the short-term pressures on policy makers (30). visualisation of co-benefits using a lifecourse approach could provide policy makers with solid arguments for the implementation of such interventions. conclusion this approach and three phase process to child injury prevention, based on combining haddon’s matrix with a life course model facilitates stakeholders identification of risk factors and solutions across policy sectors. when done collectively, engaging multiple stakeholders, it should result in a better understanding of the multi-sectoral nature of child injury prevention and the potential roles and responsibilities for the stakeholders at the local area. this, in turn, should assist in the planning of tailored inter-sectoral child injury prevention activities. further the broadened frame helps identify potential co-benefits across sectors, within and outside the injury domain, which may assist in gaining support for child injury prevention. this approach and process have been designed to provide a practical and user-friendly methodology to address the inter-sectoral issue of child injury prevention at the local level. scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 8 however it is yet to be tested in a real world setting and a study of its efficiency would be a useful addition to this research. acknowledgments: the authors would like to thank members of the european child safety alliance and the tactics scientific committee for input into early discussions. competing interests: none. funding: this paper is based on work conducted under the tactics project, which receives funding from the european union, in the framework of the health programme. contributorship: bs developed the idea for the approach and process and all authors contributed to the design. bs led the drafting of the paper and all authors were involved in revising it and approving the final version. references 1. lyons ra, finch cf, mcclure r, van b, ed, macey s. the injury list of all deficits (load) framework conceptualising the full range of deficits and adverse outcomes following injury and violence. int j inj contr saf promot 2010;17:145-59. 2. sethi d, towner e, vincenten j. european report on child injury prevention. geneva: world health organization, regional office for europe; 2008. 3. cohen l, miller t, sheppard ma, gordon e, gantz t, atnafou r. bridging the gap: bringing together intentional and unintentional injury prevention efforts to improve health and well being. j saf res 2003;34:473-83. 4. mackay jm, vincenten ja. leadership, infrastructure and capacity to support child injury prevention: can these concepts help explain differences in injury mortality rankings between 18 countries in europe? eur j public health 2010;22:66-71. 5. peden mm, oyebite k, ozanne-smith j. world report on child injury prevention. world health organization; 2008. 6. kickbusch i, gleicher d. governance for health in the 21st century. world health organization, regional office for europe; 2012. 7. hanson dw, finch cf, allegrante jp, sleet d. closing the gap between injury prevention research and community safety promotion practice: revisiting the public health model. 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matrix to public health readiness and response planning. environ health perspect 2005;113:561-6. 26. brand h, schroder p, davies jk et al. reference frameworks for the health management of measles, breast cancer and diabetes (type ii). cent eur j public health 2006;14:39-45. 27. hendriks am, jansen mwj, gubbels js, vries nkd. proposing a conceptual framework for integrated local public health policy, applied to childhood obesity-the behavior change ball. implement sci 2013;8. 28. axelsson r, axelsson sb. integration and collaboration in public health—a conceptual framework. int j health plann mgmt 2006;21:75-88. 29. warner m, gould n. integrating health in all policies at the local level: using network governance to create ‘virtual reorganization by design’. in: kickbusch i, editor. policy innovation for health. springer; 2009. p. 125-63. 30. exworthy m. policy to tackle the social determinants of health: using conceptual models to understand the policy process. health policy plann 2008;23:318-27. ___________________________________________________________ © 2014 scholtes et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. goodman j. the history of european public health education accreditation in perspective (review article). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-39 review article the history of european public health education accreditation in perspective julien d. goodman 1 1 agency for public health education accreditation (aphea). corresponding author: julien d. goodman, director, agency for public health education accreditation (aphea); address : avenue de l’armée / legerlaan 10, 1040 brussels, belgium; telephone: +3227350890; e-mail: julien.goodman@aphea.net 1 goodman j. the history of european public health education accreditation in perspective (review article). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-39 abstract aim: the aim of this paper is to investigate the history of accreditation of academic public health education and understand why there is a 65 year gap between the first system in america and the uptake of accreditation in europe. the paper intends to search for parallels and dissimilarities between the development in america and europe and then consider if any parallels could be used for determining the future role of accreditation in europe. methods: the paper draws heavily upon a literature review and analysis and the examination and interpretation of primary and secondary sources. firstly there is an exploration of the american development which is complemented by an evaluation of the developments in europe. results: the paper demonstrates that there are two key features required for the development of accreditation: interstate collaboration and a liberalisation or opening up of the education market. conclusions: since the second world war, europe has embraced interstate collaboration which has led to a liberalisation of certain economic markets. the future for sector based accreditation of public health education will be determined by the extent europe pursues liberalisation and whether a competitive environment will bring into question the transparency and trust in state sponsored accreditation agencies. keywords: european public health education accreditation. conflict of interest: none. 2 goodman j. the history of european public health education accreditation in perspective (review article). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-39 the accreditation of higher education programmes and institutions has its roots in american higher education (1) and the history of accreditation of public health education is no exception. however histories do differ in the role of the state in education. in 18th and 19 th century europe, education was taken away from the church and placed under state control to reinforce the legitimacy of the emerging, and competing, european nation states (2). american political development differed from the european model and when the states came together to form the us, education was not among the functions specifically expressed as a federal responsibility (3). europe continues to develop and embrace individual nation states with an increasing trend for laissez faire deregulation as a route to diminish barriers to free trade but it is yet unclear how this will affect the future of education and accreditation at a nation state level. the research is based around a literature review and search of key websites including the american journal of public health, pubmed and google scholar. the reviews took place between july and october 2014 based upon the search terms of “public health education accreditation”. the analysis of key themes highlighted mainly american development and this was complemented for european development, by the use of the physical archives from the association of schools of public health in the european region (aspher). the searches delivered over 150 separate books and articles covering the subject to varying degrees. together these allowed for a demonstration and reflection of the origins of public health accreditation in both europe and america. the american laissez faire approach to federal governmental responsibility toward education was not without its detractors especially when combined with a comparable economic approach. in 1910 abraham flexner criticised the free market nature of medical education in america, “overproduction of ill trained men is due in the main to the existence of a very large number of commercial schools” (4) and that, “the schools were essentially private ventures, money-making in spirit and object” (5). as a result, flexner recommended that 120 of the 155 medical schools should close. flexner was to become soon after the head of the general education board within the rockefeller foundation (6). five years after flexner’s report, wycliffe rose and william welch submitted their views on the development of schools of public health to the rockefeller foundation. given the utter calamitous state of contemporary medical education it was no surprise that the authors recommended that schools of public health should not be part of medical schools. apart from the notion that the public health worker was not identical with that of a practitioner of medicine no other reason for the independence of schools of public health was given in the report (7). institutionally splitting public health from medical education did not however allay concerns about the quality of public health training. in 1920, the american public health association (apha) established a committee on the standardisation of public health training and one year later it reported on what it saw: “the most serious defect in the whole system at present, however, lies in the fact that certain institutions give not only the certificate in public health but even the doctorate in public health for a course of a few weeks, while others require a period of almost three years, and it seems most desirable to effect some form of standardization in this field” (8). similar to the findings of flexner, there were also complaints of profit-making public health training programmes of questionable quality offering public health degrees (9). an editorial in the american journal of public health in 1924 noted that, “as far as the medical end of this scandal goes the matter can be left to the strictly medical journals but unfortunately public health is also involved” (10). this situation continued for the next twenty years with some schools being recognised as, “merely seeking to attract students by deliberately and grossly misleading prospectuses” (11). it took 26 years from the origins of the committee on standardisation until the adoption of an accreditation system in 1946 which coincided with the committee for professional education within apha taking on the responsibility for monitoring standards. this committee was headed by william shepard who strove for the recognition of public health as a profession, “whether we fully 3 goodman j. the history of european public health education accreditation in perspective (review article). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-39 realize it or not, public health has become a profession” (12). accreditation would play a role in producing well trained individuals and supplying relevant data on the needs of the national public health, as shepard noted, “to my knowledge this is the first occasion in modern times that a learned profession has kept its educational house in order as it developed. since becoming a recognized profession, we have been spared the developmental blight of having our ranks flooded with pseudotrained people” (12). in 1946 there were 11 criteria which comprised the minimum requirements of institutions to be accredited to the master of public health (13). the criteria had been developed by another member of the rockefeller board and pioneer of modern public health, charles-edward wilnslow, who had deliberately kept the criteria flexible and small enough to allow time for schools to comply and maintained that too much standardisation was undesirable (12). the basis for winslow’s criteria came from the notion that “public health is not a branch of medicine or of engineering, but a profession dedicated to a community service which involves the cooperative effort of a dozen different disciplines” (14). accreditation at this point consisted of seven criteria which looked at the institution and a further four criteria which were course specific (13). out of these latter four, one criterion stipulated the content, see table 1. by 1974, when accreditation became housed within the council on education for public health (ceph) (15), these criteria had evolved to express a mixture of educational and practical competencies (16), which saw the retraction of elements such as economics and parasitology but the addition of health systems. these criteria are kept in place into the modern period (17), albeit more succinctly phrased as biostatistics and epidemiology were included as part of investigation, measurement, and evaluation (18). the one omission is focussed on the biological features of the curriculum. table 1. changes in american accreditation compulsory curricula contents 1946 to 2014 apha 1946 ceph 1974 ceph 2014 1. the nature functioning of 1. biological, physical, and social 1. biostatistics, human organisms; factors; 2. epidemiology, 2. the nature behaviour of 2. social and behavioural sciences; 3. environmental health various forms of parasitic life; 3. health service delivery systems, sciences, 3. the physical environment; 4. community health needs; 4. health services 4. social and economic factors; 5. information collection, storage, administration 5. the major source of retrieval, analysis, and 5. social and behavioural quantitative information and dissemination; sciences. its numerical presentation and 6. environmental monitoring, analysis. analysis, and management. the history of american accreditation therefore took root at a time when public health was beginning to find its feet as a profession and against a laissez faire backdrop, which saw many schools geared toward profit making above quality and this is perhaps a situation which continues in a sense today with the growth of unrecognized, illegitimate degree and accreditation mills that “sell” (19). against these developments, were the architects of an alternative and earnest public health movement based on the research focus of the german schools and the practical training methods on the english schools (20). this period of development can be seen as 1916 to 1946, from the first rockefeller school of public health to the implementation of a fully functioning accreditation scheme. this period directly coincides with an epoch engrossed in war. although initially the criteria had been kept flexible to allow more schools to participate, the arithmetic growth of accreditation in the u.s. was not overwhelming until around the turn of the twenty first century (21) see figure 1. in 1946, there were nine schools of public health accredited in america (13). nearly 30 years later, in 1975 after the move to the ceph there were 19 schools 4 goodman j. the history of european public health education accreditation in perspective (review article). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-39 (22). this had risen to 27 in 2000 (23) and by 2014 there were over 50 schools accredited and over 100 programmes of public health accredited (17). figure 1. accredited american sphs by decade (compiled by rosenstock, l. et al) after the second world war, europe began a process of reconciliation culminating in the present union enshrined through the 1992 maastricht treaty where, under article 126, the role of union in education was to “encourage cooperation”. it is in these post war collaborative movements where european accreditation, like its american counterpart, found its foothold. as one commentator phrased, “there was an intensified development of accreditation during the 1990s in various european countries. this trend is parallel with the rapid growth in international and trans-national organisations after the second world war” (24). moreover, the first large scale appearance of accreditation was a direct result of competition and the post communist transformation in the central and eastern european region where the markets were opened up to private and foreign providers (25). this european movement of the 1980s and 1990s was to create a fertile environment for international collaborations at a public health school level with examples being, the european training consortium in public health (etc-ph) (26), brimhealth (27) and the european masters of public health (emph). the latter of these, the emph was a collaboration between aspher and the world health organisation (who) to develop a european master's degree in public health based on the who’s 38 health for all (hfa) principles (28). this followed from a momentum in european public health created by the elaboration of these principals into practice which was given the title of “new public health” (29). although this term was not new, it was first coined in 1913 as a bacteriological approach (30) and again in 1923 as health promotion (31), it did reflect the more comprehensive view of public health which still resounds today. the emph embraced three distinct areas: a) it should be concerned with the masters level, b) it should reflect the philosophy of the whos hfa and c) students should be exposed to a european perspective (32). it was enthusiastically anticipated that the emph would raise the standards of education and training across the european region and would provide a “gold standard” of which other schools and programmes would eagerly follow (33). alas, attempts to realise the programme failed. the failure of the emph was a product of several reasons: credit transfer mechanisms were poorly developed; systems didn’t accept qualifications from other institutions; the programme was too inflexible and did not respect the diversity and traditions of the countries; european content didn’t need to be all encompassing as it could be could be integrated into existing courses; and moreover, given the heterogeneity of public health training programmes in europe it was not possible to introduce a rigorous quality assessment and assurance (34). as a result of these failures the introduction of accreditation was seen as a necessary and fundamental step. however, accreditation 5 goodman j. the history of european public health education accreditation in perspective (review article). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-39 was not introduced but rather a process of mutual recognition of courses, modules, programmes and institutions was established entitled the public health education european review, more commonly known as the peer review (35). the three central principals of this review were a reflection of its emph foundations (33):  the course/module/programme/institution should be concerned with postgraduate training in public health.    the course/module/programme should be based on the philosophy of the health for all policy.   the students should be exposed to a european perspective.  the peer review was established by 1994 but it differed from accreditation as it was devised primarily as a quality improvement tool conducted through academic peers in a collegial manner. although the initial anticipation was for a multi-agency quality assurance approach this did not materialise until the advent of accreditation proper which was proposed and accepted in 2001. this was exactly the same time that aspher began to use the peer review for the establishment and quality improvement of new schools and programmes of public health in the central and eastern european region (36). this project gave valuable insights for accreditation (37) and also showed how peer could be used as a framework for development. in 2011, the accreditation agency was established and consisted of aspher and four other public health based ngos, european public health association (eupha), european public health alliance (epha), european health management association (ehma) and eurohealthnet. at the time of its establishment european accreditation focused solely upon the accreditation of postgraduate (so-called second cycle) public health degrees. similar to the american model, the processes also contained specific criteria on core curricula content: introduction, methods, population health and its determinants, health policy, economics and management, health education and promotion, cross-disciplinary themes and culminating experiences. these areas were based on the core subject domains developed through earlier aspher work on public health core competencies (38). in 2014, following a two-year review of its processes, aphea introduced two new aspects in addition to programme accreditation. the first was a curriculum validation process which replaced its initial eligibility criteria by ensuring that curricula contain the basic structure and core content expected from a modern comprehensive public health offering. the second addition was to focus on institutional accreditation which would assess the relationship of an institution, in terms of education, research and service, to the specific local, national, regional or international environments in which they serve, their so-called “social accountability” (39). this development represents a reversal of the american model which started with institutional accreditation followed by programme level accreditation. so far, the remit of aphea was in keeping with the first and third central principals of the earlier peer review. however, for future development, the postgraduate focus was also brought into question with proposals to develop accreditation for bachelor and phd programmes, thus covering the whole spectrum of school based education in public health. aphea also began consultations on the development of training accreditation which would cover smaller units from continuous personal development (cpd), moocs through to summer schools which can be delivered outside of school settings. finally, the role of using the accreditation criteria as a framework for quality improvement and development also requires future scrutiny as the peer review had worked exceptionally well in this regard (36). the second central principle of the previous peer review is based upon the health for all policies of the 1970s which has been superseded of late by the development of the whos essential public health operations (ephos) (40). an encompassing definition given for these is, “a set of fundamental actions that address determinants of health, and maintain and protect population 6 goodman j. the history of european public health education accreditation in perspective (review article). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-39 health through organized efforts of society” (41). the potential therefore lies in the ability to change the older hfa targets for these later ephos, for example, by translating the operations in to a series of competences and then assessing how these competences are integrated into the education of the workforce. however, care will need to be taken so that any system will be flexible enough to respect the diversity and traditions of different countries and thus, hopefully avoiding some of the reasons for the failure of the emph whilst learning the lessons from charles-edward winslow’s introduction of accreditation in america. all of these activities however are predicated on the future potential for sector based professional accreditation and there are two areas within the history of public health accreditation which may help determine its future trajectory. the first area is one of collaboration and second, the liberalisation of the education sector. the origins of both the american and european models of accreditation appeared as a result of interstate or supranational collaboration and an opening up of markets in education. the realisation of europe has installed significant economic liberalisation, especially in the service markets. many services in europe are now no longer a state responsibility but rather a subject of the free market and how far this free market extends remains to be seen. for example, what will be the influence of the mooted agreements between the north american free trade area (nafta) and the european union on the liberalisation of the educational market? in many ways perhaps the free movement of people already enshrined in the european project has created a quasi liberalised market with students being free to study in any country. this freedom of movement is often liberally extended to international students travelling the globe. equally important for the forthcoming years will be the influence of technologies in teaching which allow for students to receive a foreign based education without the need or hindrance of travel. the result of these present and future changes is conceivably then one of burgeoning competition above that of collaboration where education systems both within and between states increasingly compete for students and their own subsequent economic survival. the origins of the bologna declaration and the resultant european higher education area is a cooperation based on mutual trust between education systems of the member states (42) but the reason why america had accreditation before europe is because accreditation is not best suited to centralised governments (1). the question must then be raised, if collaboration turns in to competition, will the national state accreditation agencies be seen as a credible guardian of trust or will they be seen as protective of their national systems, anti-competitive and riddled with conflicts of interest? references 1. maassen pa. quality in european higher education: recent trends and their historical roots. eur j educ 1997;32:111-27. 2. ramirez fo, boli j. the political construction of mass schooling: european origins and worldwide institutionalization. sociol educ 1987;60:2-17. 3. evans p. accreditation in the united states: achieving quality in education. third european symposium. zurich; 2000. 4. flexner a. medical education in the united states and canada. from the carnegie foundation for the advancement of teaching, bulletin number four, 1910. bull world health organ 2002;80:594-602. 5. flexner a. i 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development of public health teaching programmes in central and eastern europe”. brussels, belgium: association of schools of public health in the european region (aspher); 2008. 37. otok r, levin i, sitko s, flahault a. european accreditation of public health education. . public health rev 2011;33:30-8. 38. birt ca, foldspang a. the developing role of systems of competences in public health education and practice. public health rev 2011;33:134-47. 39. boelen c, woollard b. social accountability and accreditation: a new frontier for educational institutions. med educ 2009;43:887-94. 40. world health organization (who). european action plan for strengthening public health capacities and services. world health organization, 10-13 september 2012. report no.: eur/rc62/conf.doc./6 rev.2. 41. bjegovic-mikanovic v, vukovic d, otok r, czabanowska k, laaser u. education and training of public health professionals in the european region: variation and convergence. int j public health 2013;58:801-10. 42. chauvigné c, ottenwaelter m. accreditation of public health training programs in europe: mapping and analysis of quality assurance and accreditation systems in public health education. rennes, france: working package 2 report, leonardo da vinci programme, 2006. ___________________________________________________________ © 2015 goodman; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 9 senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 1 review article the emerging public health legislation in ukraine iryna senyuta1 1 danylo halytskyi lviv national medical university, lviv, ukraine. corresponding author: assoc. prof. iryna senyuta, ph.d. in law, head of the department of medical law of the danylo halytskyi lviv national medical university; address: solodova street 10, 79010, lviv, ukraine; email: prlawlab@uk.net senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 2 abstract as ukraine has started the legal process for a public health legislation, this narrative review attempts to: i) characterize recent legal acts (which are current as well as drafts) and international standards in the sphere of public health; ii) analyze the definitions of public health legally relevant to ukraine, in particular: public health and public health protection; iii) discuss related definitions relevant to the health sector; iv) characterize the main subjects tasked to protect public health; v) and clarify the necessary educational innovations, which are the basis in the preparation of human resources for an efficient implementation of the public health concept. after referring to the current legislative process and a discussion of some of the concepts and terminologies available in the literature, the following understanding of the terminology is proposed here: i) ‘public health’ should be understood as mental and physical health of the population in a certain territory, determined by the best achievable demographic indicators, characterized by decreasing morbidity and mortality and increasing the potential to lead an active and long life; ii) the term ‘public health protection’ (or, ‘protection of public health’) should address a system of measures which are aimed at prevention and control of morbidity, optimization of demographic indicators, promoting a value-oriented state policy, securing biological and genetic safety and relying on joint societal efforts. it is essential that the implementation of a public health law is underpinned by adapting the postgraduate educational system to the new challenges in ukraine. keywords: health care, multiprofessionality, public health, public health protection, ukraine. conflicts of interest: none. acknowledgements: the author expresses her cordial gratitude to prof. ulrich laaser, faculty of health sciences, bielefeld, germany, for his valuable comments and input. senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 3 introduction ukraine entered an active process to integrate public health into the national health system as part of the wide spectrum of transformations of all ukrainian systems. the “embryo” of public health has a long national history. in the historical context, it is worth paying attention to the state sanitary-epidemiological service, which was responsible for protection of public health and had two main functions, i.e. control of communicable diseases and environmental protection (monitoring the quality of water, air, soil and food) (1). scholars, who worked on various aspects of public health development in ukraine include y. bazylevych, i. gryga, n. chala, v. moskalenko, v. lekhan, v. rudiy and others. in particular i. gryga researched the issue of public health funding in ukraine and proved the idea of introducing official patient payments in ukraine in order to avoid informal or quasiofficial payments (2). the system of state bodies responsible for public health protection was the focus of interest of v. lekhan and v. rudiy (1). this process started to actively develop when ukraine signed the association agreement with the european union in 2014 (3). the article 426 of chapter 22 of the association agreement foresees that the parties shall develop their cooperation in the field of public health, to raise the level of public health safety and protection of human health as a precondition for sustainable development and economic growth. a conceptual provision of the association agreement within its chapter 22 is the “health in all policies” approach. hence, public health and health care should be a starting point for the state authorities to develop policies benefitting their population, since human wellbeing constitutes the core of any health system. correspondingly, the article 3 of the constitution of ukraine states that an individual, his or her life and health, honour and dignity, inviolability and security shall be recognized in ukraine as the highest social value. value-oriented law-making foresees the satisfaction of universal human needs and interests and it creates a relevant social toolset to meet these objectives. in the philosophical-legal interpretation, a value means objects, phenomena, social processes and their features, which are treated by a human being as those, which satisfy his or her social needs, interests, desires and which he or she involves to one’s sphere of life activity (4). public health is a collective good, which has an individual value effect – human health. in this paper i try to elucidate some aspects of the formation and development of the public health concept as a national ukrainian paradigm; to clarify the terminological framework as a basis for the creation of the forthcoming public health legislation; to define public health in the ukrainian environment and characterize the main educational innovations to support the preparation of well-trained human resources. in order to achieve these objectives the following is required: i) to characterize recent legal acts (which are current as well as drafts) and international standards in the sphere of public health; ii) to analyze the definitions of public health legally relevant to ukraine, in particular: public health and public health protection; iii) to discuss related definitions relevant to the health sector; iv) to characterize the main subjects tasked to protect public health; v) and to clarify the necessary educational innovations, which are the basis in the preparation of human resources for an efficient implementation of the public health concept. recent legal initiatives in ukraine currently, the establishment of an effective public health system is one of the priorities of the ukrainian ministry of health (3). in a strategic document of the world health organization (who) regional office for europe, issued in 2012: “health 2020: a european policy framework supporting action across government and society for health and well-being” (5), it senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 4 is noted that “...all 53 member states in the who european region have agreed on a new common policy framework – health 2020. their shared goals are to “significantly improve the health and well-being of populations, reduce health inequalities, strengthen public health and ensure people-centred health systems that are universal, equitable, sustainable and of high quality”. recommendations of the parliamentary hearings on the topic: “on health care reform in ukraine” of 21 april 2016 (6), which is currently the sole strategic document for the envisaged transformations of the health system, also encompasses the public health sector. the ‘recommendations’ define the list of tasks of the state bodies with regard to public health, including: • development and approval of the concept of the public health system reform; • preparation of a draft-law on the public health system in ukraine; hence, the government started coordinating a process aiming at the legal foundation of a national system of public health, which should include the following elements: • a modern system of epidemiologic surveillance of communicable diseases; • a modern system of epidemiologic surveillance of non-communicable diseases; • creating a system of public health, which is based on the principle “ukraine 80+”. for the first time the principle “ukraine 80+” was mentioned in the agenda of the head of the committee on health of the verkhovna rada of ukraine, namely professor o. bogomolets (“health care reform: 25 steps to happiness”). in order to implement this principle it was foreseen that there should be developed such a system of public health which would secure an increase in life expectancy of the ukrainian people. however, this principle was not further legally established in order to be implemented, except for some initial measures of organizational character, in particular official meetings with the european union representatives. subsequently, the “concept of public health system development in ukraine” (7) (hereinafter – the “concept”) and the draft “law on principles of state policy of health care” (8) (hereinafter the “draft law”) have been issued. for the first time, the draft concept foresees the definition of the term ‘system of public health’, which is a set of instruments, procedures and measures, which are implemented by state and non-state institutions in order to strengthen the health of the population, prevent disease, support an active aging, and promote a healthy lifestyle, as a joint effort of the whole society. the draft law attempts to provide a legal definition of the public health notion as a set of activities aiming at the maintenance and strengthening of the health of the population and increasing life expectancy. the state agencies and the bodies of local self-government are responsible for the organization of these societal efforts. definitions of public health legally relevant to ukraine since the legal framework for a system of public health is under consideration, the terminology and meaning of the central term ‘public health’ has to be thoroughly examined. there are many scientific and legal definitions of this term. therefore, a comparative discussion has to be conducted with regard to terms and concepts relevant to the health system. one of the oldest definitions has been formulated by charles-edward winslow in 1920: “public health refers to the science and art of preventing disease, prolonging life and promoting health through organized efforts and informed choices of society, organizations, public and private, communities and individuals” (9). according to the who definition in 1978 (10): “public health is the science and art of preventing disease, prolonging life and https://en.wikipedia.org/wiki/health� senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 5 promoting mental and physical health and efficiency through organized community efforts for the sanitation of the environment, the control of communicable infections, the education of the individual in personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of social machinery to ensure to every individual a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity”. the dimension of health according to who refers to “...a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. also, this understanding of public health incorporates the interdisciplinary approaches of epidemiology, biostatistics, community health, behavioural health, health economics, health management, health policy, health insurance, mental health, and occupational health as important subfields. however, probably, the most common definition has been coined by donald acheson in 1988 (11): “public health is the science and art of preventing disease, prolonging life and promoting health through organised efforts of society”. in contrast, in john last’s famous dictionary of public health in 2006 (12), it reads as follows: “the mission of public health is to protect, preserve and promote the health of the public. public health is the art and science of promoting and protecting good health, preventing disease, disability, and premature death, restoring health when it is impaired, and maximizing the quality of life when health cannot be restored. public health requires collective action by society; collaborative teamwork involving physicians, nurses, engineers, environmental scientists, health educators, social workers, nutritionists, administrators, and other specialized professional and technical workers; and an effective partnership with all levels of government”. ukrainian laws in force do not foresee a legal definition of the term public health; the above mentioned draft legal acts do that for the first time. it is worth paying attention to the legislation of other countries, which have special laws with a relevant legal glossary. for instance, the article 3 of the ‘law of georgia on public health’ of 27 june 2007 (13) provides a definition of the term ‘protection of public health’ as a set of measures aimed at improving the health of the population, prevention and monitoring of diseases. the article 1 of the ‘law on public health’ of the kyrgyz republic of 25 june 2009 (14) defines ‘public health’ as the health of the population or certain groups and communities defined by a geographic, social or another characteristic, which is evaluated by demographic indicators, characteristics of physical development, morbidity and disability, whereas ‘public health protection’ is defined as a system of measures, directed at the protection of public health, prevention of diseases, prolongation of life and strengthening of human health owing to organizational efforts of all parties, the population, public and private organizations, communities and individuals. these two examples demonstrate that the respective legislators have adapted elements from the aforementioned definitions which are deemed relevant in their national contexts. related definitions relevant to the health sector however, terminological problems can easily occur importing and translating terms during the process of their adaptation to national legal systems. for example, in chapter 22 of the association agreement (3), the term ‘public health’ is used solely to define the name of the chapter but in the text of the agreement the term ‘health care’ is used, which has a different meaning underlining individual health rather than population health. https://en.wikipedia.org/wiki/interdisciplinary� https://en.wikipedia.org/wiki/epidemiology� https://en.wikipedia.org/wiki/biostatistics� https://en.wikipedia.org/wiki/community_health� https://en.wikipedia.org/wiki/behavioral_health� https://en.wikipedia.org/wiki/health_economics� https://en.wikipedia.org/wiki/public_policy� https://en.wikipedia.org/wiki/insurance_medicine� https://en.wikipedia.org/wiki/occupational_safety_and_health� senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 6 taking into consideration the definitions of public health discussed so far, it is worthwhile to relate the term ‘public health’ to other terms in the field of health care and identify its place in the relevant system. especially relevant for the ukrainian legislatory process is the understanding of public health as the health of the population impacted by activities which are not restricted to the public sector – a common misunderstanding of the terminology. therefore, we propose to consider in addition the term “public health protection” which denotes the set of activities to be performed not only by the public services in order to achieve the best possible public health (health of the population) as a vision and objective. also, verweij and dawson (15) for example argue that the term ‘public health’ combines two words, each of which can be ambiguous and that among the many definitions of public health, the word “public” has two general interpretations. in a straightforward interpretation, “public” is an aggregate concept and is equated with the “population”. in this meaning, “public health” refers to the state of population’s health in general or a certain population group. the second interpretation of “public” is in terms of “collective action”, which has the goal to protect and promote a population’s health alongside efforts to prevent diseases. although historically, the same term “public health” was used in both meanings to characterize the state of the population in general and to define joint measures, which have to be taken in order to protect and improve such health (16). in the ukrainian context, it seems preferable to apply two different terms: “public health” – to define a state of health of the population and “public health protection (or: “protection of public health” – to describe collective measures. however, most scholars agree that the essence of public health is the prevention of diseases, in order to maintain and strengthen both individual and collective (population’s) health (17). with reference to the above considerations, in the ukrainian legislatory process, the following understanding of the terminology should be adopted: • public health is understood as mental and physical health of the population in a certain territory, determined by the best achievable demographic indicators, characterized by decreasing morbidity and mortality and increasing the potential to lead an active and long life. • under the term ‘public health protection’ (or, ‘protection of ‘public health’) we understand a system of measures, which are aimed at prevention and control of morbidity, optimization of demographic indicators, promoting a value-oriented state policy, securing biological and genetic safety and relying on joint societal efforts. according to article 3 of the law of ukraine on: “principles of ukrainian health care legislation” (18), medical care is the activity of the professionally trained medical workers, aimed at prophylaxis, diagnosis, treatment and rehabilitation pertinent to diseases, injuries, intoxications and pathological conditions, as well as pregnancy and childbirth. consequently, the complexity of public health’s legal nature is caused by its multidisciplinary character, which generates the following formula: “medical care” and “public health protection” are partially overlapping in the area of prophylaxis. at the same time, both terms are part of the umbrella term ‘health care’. hence, both terms are within the realm of ‘health care’. the term ‘medical care’ by its content is narrower than ‘public health protection’, since providing equal access to effective and high quality medical care is only one of the functions of the protection of public health. on this basis, the main functions of the protection of public health include: • monitoring: evaluation, analysis, and comparison of the state of health of the population in order to identify the existing problems and develop priorities. senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 7 • control: provision of biological and genetic security, decreasing the morbidity level. • prevention: prophylaxis of diseases and formation of a healthy lifestyle of the population. • strategy and coordination: formation of the state and local policy on the basis of “health in all policies”. • communication: interaction of different subjects in terms of implementing the values of public health protection into social and state life. • medical: securing equal access of the population in general and each person in particular to high-quality and effective medical services. • integration: consolidation of the national and international efforts aimed at the protection of public health. public health service according to paragraph 1.2 of the concept (7), the key central body of executive power, which is responsible for the management of public health system, is the ministry of health of ukraine. the department of public health as a structural subdivision is targeted at securing proper management of the public health system. in order to implement policy and provide services in the sphere of public health at the national level, on 31 may 2016, the government established a state institution “centre of public health of the ministry of public health of ukraine” (hereinafter – the centre). according to its charter, the centre is a scientific and practical institution of medical profile, which fulfils the following functions: ensure the permanent strengthening of the population’s health; carrying out social and hygienic monitoring of diseases; epidemiological supervision and biological security; conducting the group and population oriented prophylaxis of morbidity; combating epidemics; and execute the strategic management of all public health issues. at the regional level, it is foreseen to create regional centres of public health. at the level of districts and cities, the provision of public health services will be coordinated by a public health specialist (epidemiologist) of the regional centre who will be appointed to a certain territory. the concept also envisages that family doctors, mid-level medical personnel and representatives of the civil society should be involved in public health services. preparing human resources for the implementation of the upcoming public health legislation when creating a new structure no less important are the human resources, which will be the element of the system that takes responsibility to implement a state policy in the sphere of public health. an important step in area of education was made after the resolution of the cabinet of ministers of ukraine passed on 23 november 2016. according to this resolution, a new specialty labelled “public health” was added to the list of fields of knowledge and specialties, according to which, persons who receive higher education, are trained. this step became a foundation for the implementation of bachelor and master programs on public health. consequently, this new sector will promote the professionalization of the public health workforce. currently, in ukraine, schools of public health are being actively established and these schools will be the major centres responsible for educating the new generation of public health professionals. on the one hand, according to the multidisciplinary character of public health, specialists can be trained after different undergraduate studies (bachelor programs) and, on the other hand, training of professionals is conducted with a focus on different competencies, which are necessary for the public health sphere (for instance, with a legal specialization). senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 8 one of the examples of innovations in the sphere of education includes the departments of medical law, which were established within medical schools. these departments are to provide advanced training for health care managers and physicians. therefore, they should be involved in the training of public health professionals, especially for those who are going to specialise on legal issues of public health. in this respect, the example of the department of medical law of the danylo halytskyi lviv national medical university is of interest, which became already an associated member of aspher (19). at this department, a postgraduate course on medical law has been established targeting physicians, health care managers, and lawyers. in addition, this department has implemented other innovative educational programs, among them for example “leadership in the sphere of health care, human rights and public health law”, focusing on an advanced training of health care managers and comprising 78 hours, including lectures, practical classes and individual work. conclusions the legislative initiative to formulate a public health law for ukraine requires a careful analysis of the concepts and the term ‘public health’ and the pre-existing services and service providers in ukraine. after referring to the current legislative process and a discussion of some of the concepts and terminologies available in the literature, the following understanding of the terminology is proposed here: • ‘public health’ should be understood as mental and physical health of the population in a certain territory, determined by the best achievable demographic indicators, characterized by decreasing morbidity and mortality and increasing the potential to lead an active and long life. • the term ‘public health protection’ (or, ‘protection of public health’) should address a system of measures which are aimed at prevention and control of morbidity, optimization of demographic indicators, promoting a value-oriented state policy, securing biological and genetic safety and relying on joint societal efforts. it is essential that the implementation of a public health law is underpinned by adapting the postgraduate educational system to the new challenges in ukraine. references 1. lekhan v, rudiy v, richardson e. ukraine: health system review. health syst transit 2010;12:1-183. 2. gryga i, stepurko t, danyliv a, gryga m, lynnyk o, pavlova m et al. attitudes towards patient payments in ukraine: is there a place for official patient charges? zdrowie publiczne i zarządzanie-zeszyty naukowe ochrony zdrowia. 2010;8:74-5. 3. association agreement between the european union and its member states, of the one part, and ukraine, of the other part; 2016. http://eeas.europa.eu/ukraine/docs/association_agreement_ukraine_2014_en.pdf (accessed: 2 october, 2016). 4. peterylo i. pravo yak tsinnisna katehoriya (law as a value category) [kand. yuryd. nauk]. instytut derzhavy i prava im. v.m. korets’ koho; 2006. 5. health 2020. a european 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base.spinform.ru. 2016 http://base.spinform.ru/show_doc.fwx?rgn=28650 (accessed: 2 october 2016). 15. dawson a, verweij m. ethics, prevention, and public health. oxford: clarendon press; 2007. 16. thurston, m. key themes in public health/ m. thurston. london: routledge; 2014. 17. gzhegots'kyy m, fedorenko v, shtabs'kyy b. narysy profilaktychnoyi medytsyny (essays on prophylaxis medicine). l'viv: medytsyna i pravo; 2008. 18. osnovy zakonodavstva ukrayiny pro okhoronu zdorov"ya: zakon ukrayiny vid 19.11.1992 r. principles of ukrainian health care legislation: law of ukraine” zakon5.rada.gov.ua. 2016 (accessed: 2 october 2016). http://zakon5.rada.gov.ua/laws/show/2801-12 (accessed: 2 october 2016). 19. association of schools of public health in the european region (aspher). www.aspher.org. __________________________________________________________ © 2017 senyuta; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. alderslade r, kokeny m, tsouros a. the health of the public: what has gone wrong? (review article). seejph 2020, posted: 07 december 2020. doi: 10.4119/seejph-3996 p a g e 1 | 10 review article the health of the public: what has gone wrong? richard alderslade1, mihaly kokeny2, agis tsouros3 1 st. georges hospital university of london, london, united kingdom; 2 global health centre, the graduate institute of international and development studies, geneva, switzerland; 3 visiting professor, institute for global health innovation, imperial college, london. corresponding author: richard alderslade; address: st. georges hospital university of london, london, united kingdom; telephone: +447742777465; email: richard.alderslade@gmail.com alderslade r, kokeny m, tsouros a. the health of the public: what has gone wrong? (review article). seejph 2020, posted: 07 december 2020. doi: 10.4119/seejph-3996 p a g e 2 | 10 abstract covid-19, a new pandemic, has swept the world. how could this have happened? in theory the world should have been prepared, armed as it has been since 2005 with a new set of international health regulations with universal commitment by who member states. yet disaster has struck. the authors of this paper consider that fundamental rethinking is needed, with a new review of the post-world war 2 international system for global governance for health. whilst who and its present and future actions will be scrutinized, the organization is fundamentally made up of 194 member states, which must share the responsibility for ensuring better global health protection in the future. it is clear the world needs a more effective who, but it also needs countries to support and develop their public health infrastructure to face today’s more complex health challenges, which can only grow in scope and complexity over coming years. the paper proposes several key steps to achieve these goals. keywords: covid-19, global health governance, international health regulations (2005), pandemic, public health strengthening, who strengthening. conflict of interest: none declared. alderslade r, kokeny m, tsouros a. the health of the public: what has gone wrong? (review article). seejph 2020, posted: 07 december 2020. doi: 10.4119/seejph-3996 p a g e 3 | 10 introduction a new pandemic covid 19 has swept across the world. globally as of 12 november 2020, there have been 51,547,733 million confirmed cases of covid-19, and 1,275,979 deaths, reported to who (1). how did this happen? could it have been prevented? we have all had to realize that the world is much more dangerous place than we thought. what lessons do we learn? what should we do in the future? in theory the world should have been prepared. it has happened before, for example during the 1918-19 influenza pandemic which is estimated to have killed some 50 million people worldwide (2). after the sars outbreak in 2003, which was globally contained, a new international legal instrument-the international health regulations (2005) (3) was agreed, putting in place new legal obligations on countries, to be open and honest about any new outbreak of communicable disease, and the cooperate fully with who in terms of management and containment. countries agreed to put in place a series of health system and laboratory “core capacities” to promote for preparedness and capacity, as well as outbreak surveillance and response. the mild h1n1 influenza pandemic of 200910 was a first challenge to the ihrs (2005). assessments suggest that country response was variable (4), whilst who was criticized for overestimating the threat (5). in the ebola outbreak in west africa in 2014 the criticism of who was the reverse, that is had not reacted with sufficient alacrity (6), and after internal and external review the organization reformed and reinvigorated its emergency response capacity (7). it worked to help countries develop their own capacities and systems, and to provide immediate support and global oversight to countries in case of an outbreak and necessary global response. over the next years since 2005, in a world of nation states, it became clear that implementation of the ihrs (2005) was patchy and incomplete. countries were not always open and immediate in the information they provided to who, and evaluations (8) revealed large gaps in core public health capacity and preparedness across a range of indicators. then, in late 2019, a new coronavirus mutation occurred, setting in train the worst human pandemic since the 1918 influenza pandemic. since then we have thought that the development of virology, and the advent of antibiotics and vaccines, meant that such a devastating outbreak could not happen again. we know better now. this paper will try to look behind what has gone wrong with our capacity to protect and secure the health of people-public health in our professional terminologyand to suggest what needs to be done now to safeguard the global population from such devastating events in the future. the characteristics of the pandemic whilst the virus first emerged in china, it spread quickly to south east asia, then to europe, then to the usa and canada, and later to south america. india and russia have been severely affected. until very recently the virus seemed better under control in most of europe, although now flare ups are being observed and new control restrictions introduced. this picture reflects however a moment in time, and the pandemic continues to expand both globally, and in individual countries e.g. the united states and across europe. whilst the virus is highly infectious, its population burden is hard to estimate. globally alderslade r, kokeny m, tsouros a. the health of the public: what has gone wrong? (review article). seejph 2020, posted: 07 december 2020. doi: 10.4119/seejph-3996 p a g e 4 | 10 there have been few population-based surveys of prevalence. recent research suggests that prevalence and mortality are substantially underestimated, and that across countries where data is available estimated cumulative covid cases may be underreported by several orders of magnitude. in addition, for every two covid-19 deaths counted, a third may be misattributed to other causes (9). the indications are that a significant proportion of those infected do not have symptoms yet can transmit the virus to others. it is also now clear that the virus seems largely transmitted through the airborne route, and transmission is much more likely in crowded places indoors than outdoors (10). these two characteristics of the virus make global control difficult and challenging. in the absence of a vaccine or definitive treatment, control measures rely on social distancing, wearing masks or face coverings, and avoided crowded and poorly ventilated places indoors. if these measures fail, either generalized or localized lockdowns remain the only control mechanism available. there is increasing evidence (11) that such restrictions are associated with severe adverse economic consequences, particularly for poor and disadvantaged groups, are characterized by adverse health consequences, and interfere with normal health system functioning. in response to the virus, there remain significant uncertainties. previously assumed knowledge and experience may be overwritten by new observations. for example, the previous assumption that mostly old people were affected has been shaded by recent experience where a greater proportion of the younger and the chronically ill have been affected (12). it is not clear why the infection appears to have spread faster in some countries than others. everywhere the return and maintenance of children at school is an urgent priority (13). also uncertain is the eventual effective management of the virus, through the development of a vaccine, the availability of effective antiviral treatments, and more widely available tests backed up by effective contact chasing and quarantine measures. there is a substantial global effort towards producing a safe and effective vaccine, with some concerns. safety must be assured, using usual scientific methods and judgements. the early distribution of a vaccine which proved not to be safe could have devastating negative consequences, for the recipients, and globally for public acceptability and willingness to take the vaccine. another concern is global production capacity, and the mechanism for global distribution. hopefully disruptive “vaccine nationalism” will be avoided. the global response in responding to the pandemic as it evolved, a main question is why the world’s previous arrangements with a focus on the international health regulations (2005) did not work as expected. at the world health assembly in may 2020 who member states agreed (14) that an enquiry should take place in due course. for that reasons present day questions must be presumptive, and open to later refinement. for who there are some compelling questions. was there a delay in the chinese government alerting who to the new and threatening viral mutation? did who respond appropriately and with alacrity? was who too close to the chinese government and if so, did this interfere with necessary operational responses? on the other hand, who clearly did engage in effective and high-quality public communication, issuing urgent warnings at an early alderslade r, kokeny m, tsouros a. the health of the public: what has gone wrong? (review article). seejph 2020, posted: 07 december 2020. doi: 10.4119/seejph-3996 p a g e 5 | 10 stage. did countries take sufficient and urgent notice, and necessary action? it must be said that throughout who acted as asked and authorized to do by its member states. yet should who have a stronger mandate and some capacity of enforcement when countries drag their heels. why were some countries’ reactions different to others? why did some countries delay or implement only half-heartedly the who-advised regime of testing, contact tracing and isolation? was the threatening nature of the disease misunderstood by some countries, basing judgements perhaps on the normal course of influenza outbreaks? what was the “herd immunity” model seemingly pursued by some countries, and not others? why were movement and other restrictions imposed earlier by some countries than others? covid-19 also caused a health crisis that amplified existing global health inequalities and disruptions, and the resultant lockdown restrictions have resulted in both economic and employment crises. different countries have pursued different paths in dealing with these consequences, opening many questions about the optimum way forward. this paper does not attempt to answer these questions. yet it does make the point that taken overall, and unlike the sars epidemic, the world’s arrangements failed in preventing a global pandemic. some part of this failure may be due to the nature of the virus itself. however, it is very difficult at this stage to suggest that the world’s arrangements worked well. this paper will attempt to get behind that conclusion, to explain, and to draw presumptive lessons for the future. the challenge of the coronavirus? covid-19 is a harsh reminder of the need to anticipate, to mitigate and to respond effectively to unexpected and emerging threats and hazards that can affect and severely disrupt every aspect of human existence. the virus has demonstrated clearly how fragile is our inter-connected world. we can be certain that this virus will not be the last threatening our global health and well-being. in addition, we will certainly be threatened by environmental and man-made disasters, and wars and complex emergencies, with climate change looming as an existential pending catastrophe and a marker of a critically deteriorating and unstable planet. now, suddenly, usual geopolitical considerations are being overridden by an imperative of survival where transparency and international cooperation and solidarity are vital. so far, in dealing with this virus these requirements have not been in place. for example, better coordination between countries has certainly been needed (15). this crisis demands a total rethinking of the way the world works together in response to such events, which have the potential to cost many lives and bring countries to their knees. yet so far it is hard to be optimistic. the postworld war 2 era of international rule-based cooperation looked increasingly fragile, affected as it has been by nationalist and populist political and social influences, even prior to this coronavirus crisis. this has not been a good time for multilateralism. in terms of global health protection and promotion since ww2 the world has been dependent on the work of the geneva-based world health organization (who), which in addition to its many other global health activities acts as a prime-mover as well as secretariat for the international health regulations (2005). now who must defend itself for its actions during the crisis in a climate of vocal criticism, easily transmitted as never before by technology in general, and social media in alderslade r, kokeny m, tsouros a. the health of the public: what has gone wrong? (review article). seejph 2020, posted: 07 december 2020. doi: 10.4119/seejph-3996 p a g e 6 | 10 particular. these media are filled with stories feeding into conspiracy theories which can divert attention from the political and technical determinants that influence who’s interaction with countries, particularly at a time of crisis. who is not a well-known or understood organization, and this makes it particularly vulnerable to criticism and an easy target for being made a scapegoat. an organization like who, at the heart of the global health architecture, can be analysed from several different perspectives: technical excellence and capacity; policies, strategies, plans and procedures; ability to support countries; resources and the ability to advocate and mobilize the international community and donors; access to and support of innovation; governance and leadership and communication. ultimately, however, who is an inter-governmental organization made up of 194 sovereign member states that it cannot instruct or cajole, but must inspire and influence. who has little in the way of sanctions available if member states fail to comply. the decline of public health institutions and capacities public health services are an important component of universal health coverage (uhc) (16). yet globally public health services are low in priority for health investment. there is a clear need to close the clear gap between political commitments to public health and the increased resources needed for public health to be effective; to place more focus on development of the public health workforce; to better organize governance arrangements (including accountability mechanisms); to start the work on mitigating the environmental footprint of healthcare; and to assign stronger legislative mandates for public health and public health legislation that is properly enforced. concerns about present day public health governance reflect the difficulties of developing effective multisectoral thinking and practice across different levels of government. as said previously, financing for public health is inadequate, both in absolute terms, and in comparison, with the money allocated to health care. public health infrastructure needs to be updated and upgraded to cope with today’s new issues, to deliver effective legal regulatory frameworks and surveillance frameworks. political and social legitimacy are both critical for success. public health should have an independent authoritative voice and be able to effectively communicate and report independently. in addition, effective public health services require structures to create and sustain a workforce with appropriate skills and knowledge (17). who a future perspective the nature of the challenges exposed by the coronavirus and the present crisis is such that the authors believe that future efforts to assess the role of who at this moment should extend much further than considering only its leverage and effectiveness in handling an emergency situation. the question rather is whether who as the lead united nations technical agency can continue to be relevant in the face of tomorrow’s demographic, environmental and technological challenges. how can it position itself to fulfil its public health mandate to full potential? the authors of this paper believe that over the last 30 years or so who’s governance and ways of working have become increasingly out of tune with its strategic objectives and newly available evidence about health and well-being. today whilst inter-sectoral action; whole of government, whole of society alderslade r, kokeny m, tsouros a. the health of the public: what has gone wrong? (review article). seejph 2020, posted: 07 december 2020. doi: 10.4119/seejph-3996 p a g e 7 | 10 and health in all policies approaches should be at the core of the organizations’ strategies, the reality in countries is that who’s governing bodies and working counterparts are predominantly health ministries, and for countries health continues to be mainly limited within the health sector. in most countries, ministries of health are preoccupied with diseases, and obtain little political engagement with the structural and non -health system determinants of disease. this is despite the vast literature on the determinants of health which calls for a much broader engagement of governmental and societal stakeholders. this multiple determinant understanding of health and the role of health as an essential precondition for human social and economic development is now made even more imperative in the light of the un 2030 agenda for sustainable development and the sustainable development goals (sdgs). ultimately health must be seen as important to human development as economic progress. in fact, we know that the two are intimately entwined. this is not a new idea. in 1946 john maynard keynes famously said: “the day is not far off when the economic problem will take the back seat where it belongs, and the arena of the heart and the head will be occupied or reoccupied, by our real problems — the problems of life and of human relations, of creation and behaviour and religion (18)”. equity is at the core of such consideration. it has been at the heart of who policies since the launch of health for all in 1981. here again the reality is that political, social, economic and health inequalities in the world are growing wider (19). specifically, for health most countries do not measure health inequities, or at best address these only in terms of access to health services. more widely across the global society it is increasingly clear that negative effects on health and wellbeing and violation of human rights are the consequences of unprincipled globalization; exploitation and mistreatment e.g. of migrants and refugees; environmental degradation and pollution; and political, social, and economic conflicts and complex emergencies. politics and diplomacy are a big part of the way who as an inter-governmental organization works. should not who be redesigned to be more vocal, assertive and effective in the face of crises and inequalities and also better configured to accommodate 21st century public health concepts and principles? yet at the same time who must preserve its scientific excellence and independence. transparency, honesty, integrity, together with local preparedness, are essential prerequisites for a sound relationship between politics and science, which is vital if the world is to be able to deal effectively with emerging threats. the role of countries the importance of public health has been illustrated during the covid-19 crisis through the performance of countries whose leaders relied upon professionalization, public health experts, and who provided accurate, timely and detailed information to the public. countries such as germany, vietnam and new zealand offer positive examples here. much less successful have been those countries where populist and nationalist perspectives predominate. yet all too often public health institutions and capacities have been allowed to decline and become degraded in many, or most, countries. there is an urgent need for this trend to be reversed, with investments made in public https://en.m.wikiquote.org/wiki/religion alderslade r, kokeny m, tsouros a. the health of the public: what has gone wrong? (review article). seejph 2020, posted: 07 december 2020. doi: 10.4119/seejph-3996 p a g e 8 | 10 health organizations, institutions and capabilities at all levels of governance (20). communities and multicultural societies need to be energized and empowered for public health. it also seems clear that public health staffing and skills need transformational changes in order to respond to the complexities of present-day and future health challenges, which will exhibit inevitable complexity, ambiguity and uncertainty in planning and implementing public health responses. the way forward today as the world attempts to deal with the coronavirus crisis there exists perhaps, and hopefully, a momentum to improve the establishment and performance of global public health institutions. the authors suggest a further strengthening and re-design of who to protect and promote global public health, particularly through the prevention, detection and response of future outbreaks. also, to be considered is the possible creation of new international health regulations, with a more pronounced accountability system. the authors suggest several key developments and changes to achieve these goals, focusing on: ensuring health and equity are and remain high on the world agenda. who being protected, resourced, and given space by global leaders in becoming an advocate for fairness, equity, universal coverage and well-being. who becoming more present in global politics, for example in trade agreements. changing the composition of who’s governing bodies, to ensure representation from different sectors and levels of government, including mayors. stepping up leadership by the director general and regional directors, expressing clear expectations that countries comply with the ihrs or face consequences in the case of noncompliance. building on inter-country agreements such as the recent european parliament resolution on the eu’s post covid public health strategy: the eu’s public health strategy post covid-19. helping countries invigorate and reform public health institutions, capacities and staffing. following up aggressively preparedness and response activities in all countries to deal with communicable disease, climate change and other emerging threats. developing platforms and supporting dialogue with different sectors and civil society. conclusion this is a formidable and ambitious list. it foretells a place for who within a new world order where health, health security, health equity and sustainable development are central on the world political agendas. accordingly, and ideally, who should have more leverage, be a stronger and courageous advocate, actively engage other sectors and civil society, and have a strong leadership role in world human, social and economic development. it is also clear that the world and the international global order does not look like this today. yet changes are essential if the world is not to repeat this recent coronavirus experience and is to ensure human survival during the coming period of dramatic, and likely existential, global health challenges and crises. alderslade r, kokeny m, tsouros a. the health of the public: what has gone wrong? 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and sustainable development. in: urban health. galea s, ettman k, vlahov d, eds). oxford university press; 2019:386-93. ______________________________________________________________________ © 2020 alderslade et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.ljmu.ac.uk/~/media/phi-reports/2020-07-direct-and-indirect-impacts-of-covid19-on-health-and-wellbeing.pdf https://www.ljmu.ac.uk/~/media/phi-reports/2020-07-direct-and-indirect-impacts-of-covid19-on-health-and-wellbeing.pdf https://www.ljmu.ac.uk/~/media/phi-reports/2020-07-direct-and-indirect-impacts-of-covid19-on-health-and-wellbeing.pdf file:///c:/users/g.burazeri/downloads/available%20from:%20https:/www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-and-covid-19-younger-adults-are-at-risk-too file:///c:/users/g.burazeri/downloads/available%20from:%20https:/www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-and-covid-19-younger-adults-are-at-risk-too file:///c:/users/g.burazeri/downloads/available%20from:%20https:/www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-and-covid-19-younger-adults-are-at-risk-too file:///c:/users/g.burazeri/downloads/available%20from:%20https:/www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-and-covid-19-younger-adults-are-at-risk-too file:///c:/users/g.burazeri/downloads/available%20from:%20https:/www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-and-covid-19-younger-adults-are-at-risk-too file:///c:/users/g.burazeri/downloads/available%20from:%20https:/www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-and-covid-19-younger-adults-are-at-risk-too https://www.weforum.org/agenda/2020/07/covid19-education-lockdown-children/ https://www.weforum.org/agenda/2020/07/covid19-education-lockdown-children/ https://www.weforum.org/agenda/2020/07/covid19-education-lockdown-children/ https://apps.who.int/gb/ebwha/pdf_files/wha73/a73_r1-en.pdf https://apps.who.int/gb/ebwha/pdf_files/wha73/a73_r1-en.pdf https://apps.who.int/gb/ebwha/pdf_files/wha73/a73_r1-en.pdf https://www.tuc.org.uk/blogs/interconnected-world-coronavirus-needs-coordinated-global-response https://www.tuc.org.uk/blogs/interconnected-world-coronavirus-needs-coordinated-global-response https://www.tuc.org.uk/blogs/interconnected-world-coronavirus-needs-coordinated-global-response file:///c:/users/g.burazeri/downloads/available%20from:%20https:/www.who.int/healthsystems/universal_health_coverage/en/ file:///c:/users/g.burazeri/downloads/available%20from:%20https:/www.who.int/healthsystems/universal_health_coverage/en/ file:///c:/users/g.burazeri/downloads/available%20from:%20https:/www.who.int/healthsystems/universal_health_coverage/en/ https://www.euro.who.int/__data/assets/pdf_file/0004/380029/68wd17e_advancepublichealth_180624.pdf https://www.euro.who.int/__data/assets/pdf_file/0004/380029/68wd17e_advancepublichealth_180624.pdf https://www.euro.who.int/__data/assets/pdf_file/0004/380029/68wd17e_advancepublichealth_180624.pdf https://www.economicshelp.org/blog/613/economics/quotes-by-john-maynard-keynes/ https://www.economicshelp.org/blog/613/economics/quotes-by-john-maynard-keynes/ https://www.economicshelp.org/blog/613/economics/quotes-by-john-maynard-keynes/ lueddeke g. toward holistic governance in an interdependent world (editorial). seejph 2017, posted: 26 november 2017. doi 10.4119/unibi/seejph-2017-176 1 editorial toward holistic governance in an interdependent world george r. lueddeke1 1 one health education task force. corresponding author: george r. lueddeke, chair, one health education task force; address: 9 lakeland gardens, southampton, hampshire, so40 4xg, united kingdom; email: glueddeke@aol.com lueddeke g. toward holistic governance in an interdependent world (editorial). seejph 2017, posted: 26 november 2017. doi 10.4119/unibi/seejph-2017-176 2 in an informative piece, ‘what do we mean by governance?’ (1), anna bruce-lockhart, editor at the world economic forum, cuts through a lot of the ‘buzzwords’ that are used to describe governance. she refers to governance in its ‘purest form’, that is ‘the structures and decisionmaking processes that allow a state, organization or group of people to conduct affairs’ and applies the term to organisations, such as the international monetary fund, the world bank and the united nations (un) that ‘have an authority that is recognized in the world’. in a business context, the label generally refers to how companies regulate themselves and contribute to the regulation of global frameworks. referencing the australian audit office, she shares the view that good governance is about openness, transparency, integrity, effective collaboration, and performance orientation. she emphasises that it is a central concept that applies to most areas and levels of human activity, and includes human rights, freedom of speech, economic transactions on a worldwide basis, full access to the internet, and to financial markets. unfortunately, however, given the risks facing us categorised as global warming, global divides, global security, global instability, and global health (2), few might question her conclusion: ‘global regimes are experiencing an erosion of authority in the face of intensifying threats’. more might agree that as things stand “textbook” political governance is generally not working on the global, regional and national stage anymore. on many counts, it is a failing concept.as edward lucas, former editor of the economist, points out, ‘the brexit vote and donald trump’s election in the us both stem from a widespread feeling that the system no longer works properly. in the advanced industrialised world, two thirds of the population, or 580 million people saw their incomes before taxpayer-financed top-ups stagnate or fall between 2004 and 2014. between 1993 and 2005 that figure was only 10 million (3). professor ian goldin at oxford martin school in his book “divided nations: why global governance is failing, andwhat we can do about it” (4), highlights that one of the main reasons why we are failing ‘to manage global issues’-migration, climate change, cybersecurity etc. alongside their preventionis that global institutions, such as the un as well as most other ones, have not kept pace with ‘their growing complexity and danger’ and as a result are no longer fit for purpose. the author puts forth that we need ‘a fundamental rethink of the way we approach global governance’. in his view governance is failing in global institutions because their power or authority is ‘circumscribed by its members.’ in other words, as we have seen time and time again in the un security council member allegiance is generally not to the unto which they all belong but to their respective nation-states. to make these institutions work for the benefit of the world or region would mean ceding powers to them, which as history has shown is highly unlikely. the difficult question, then, is howself-interests and cooperation for the common good can be reconciled? one option for professor goldin is to view sovereignty in a different light –‘to imagine a world where sovereignty is not just about preventing but also about enabling. if we redefine sovereignty, to look beyond coercion and exclusion but also consider cooperation and inclusion, it no longer makes sense as something one can monopolize’. a hallmark of the seventeen un -2030 sustainable development goals (5) with which most are now familiar,is their interconnectedness and interdependency-as examples, climate, health, food production, peace, education, prosperity, security and that progressing the goals and targets could be optimised by “building co-operative organisations out of self-interested components”. this fundamental principle underpinning the un-2030 agenda and the sdgs could apply equally well to other issues of global governance (trade, migration, conflicts), that is, ensuring that interactions and negotiations take a more holistic approach tackling https://www.weforum.org/agenda/authors/anna-bruce-lockhart� lueddeke g. toward holistic governance in an interdependent world (editorial). seejph 2017, posted: 26 november 2017. doi 10.4119/unibi/seejph-2017-176 3 complementary global issues so that what one nation may lose on one issue (e.g., migration), it can gain on another, rather than dealing with only one hurdle at a time often leading to an unsatisfactory outcome or at best a stalemate (6). streamlining the committee structures of many organisations (e.g., un, eu) could be a useful first step to dealing with multi-faceted issues or problems, arriving at more realistic outcomes while also saving time especially if a horizontal management structure is put in place, providing ‘a balanced equilibrium between bottom-up initiative and top-down support’ (7). while research into distinctive areas of knowledge continues to be vital in gaining a better understanding of the world we inhabit, it has also been the cause of fragmentation, competition and tensions (6). the differentiation of school subjects and medical specialisations (over 100 in us) are examples of how society has tried to cope with the everincreasing range, complexity and depth of knowledge integral to the planet and our relationship to it. one estimate is that knowledge is now doubling every twelve months and may soon do so every month. reductionism and silo approaches to tackling global issues as applied in the 19th and 20th centuries persist (e.g., ebola crisis) but no longer work when we know, as example, that the drought in california is linked to deforestation in the amazon rainforest and that unregulated migration to europe is related to political hegemony, ideological extremism, climate change, food insecurity, education, unemployment and regional conflicts.the separation of ecology, democracy, social justice, prosperity and peace and the impact these have on the health and well-being of people and the planet can no longer be justified and neither can effective governance that underpin these factors. rather than focusing strictly on human dimensions governance is tasked with taking a broader perspective considering the interplay between humans, animals, plants and the environment. the concept is known as one health (8,9) and has been taken on board by many organisations globally – the world medical association, the world veterinary association, the interaction council, made up of former heads of state and ministers, the oecd, and the cdc, among many others (9). the pressing need to adopt the concept and collaborative approach is exemplified by the devastation in syria: not only did it lead to the destruction of a society – over 500,000 lives half children needlessly lost along with countless farm animals and poisoned land but it also impacted severely on the constituents that make life possible in the first place -undermining biodiversity and the ecological systems in general. while agreeing with the attributes about ‘good governance, identified earlier (1), perhaps consideration might also be given to another,that is, recognising that ‘governance’ has a higher purpose the sustainability of people and planet. achieving this aim would require adoption of a new worldview to ensure that our needs as human beings are compatible with the needs of our ecosystem upon which all life and our activities depend (10). embracing the mantra ‘one health in all policies’ (6) could be a timely and ground-breaking first step toward realising the ‘governance’ we need. conflicts of interest: none. references 1. bruce-lockhart a. what do we mean by governance? https://www.weforum.org/agenda/2016/02/what-is-governance-and-why-does-itmatter/ (accessed: 26 february, 2016). 2. laaser u. a plea for good global governance. front public health 2015;3:46. doi: 10.3389/fpubh.2015.00046. lueddeke g. toward holistic governance in an interdependent world (editorial). seejph 2017, posted: 26 november 2017. doi 10.4119/unibi/seejph-2017-176 4 3. lucas e. it’s not only mugabe who has failed his people. the times (comment, p. 31); november 17, 2017. 4. goldin i. divided nations. why global governance is failing, andwhat we can do about it. oxford: oxford university press; 2013. 5. united nations. sustainable development knowledge platform. https://sustainabledevelopment.un.org/sdgs (accessed: 23 november, 2017). 6. lueddeke g. global population health and well-being. toward new paradigms, policy andpractice. new york: springer publishing company; 2016. 7. laaser u, dorey s, nurse j. a plea for global health action bottom-up. front public health 2016;4:241. doi: 10.3389/fpubh.2016.00241. 8. one health commission (ohc). mission. https://www.onehealthcommission.org (accessed: 23 november, 2017). 9. lueddeke g. achieving the un-2030 global goals for a sustainable future through one health principles and practice. 2nd global conference on one health. world veterinary association and the world medical association in association with the japan veterinary association and the japan medical association, kitakyushu city, japan; 10-11 nov 2016. 10. lueddeke g. toward a new worldview: one health, one planet, one future (in progress). ______________________________________________________________________________________ © 2017 lueddeke; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://urldefense.proofpoint.com/v2/url?u=https-3a__www.onehealthcommission.org_&d=dwmfaq&c=wo-rgvefibhhbzq3fl85hq&r=_gxceyeg6oihqft2wjoavyynkncfvlge7x4oso4jwxa&m=zaq1qmq5d6z5alwirzbi6bdag7codkthgtx9c-fhsd4&s=1mwq7emxydkru5t0xvp29bvnurut72vdjj3cuk4z2om&e=� in an informative piece, ‘what do we mean by governance?’ (1), anna bruce-lockhart, editor at the world economic forum, cuts through a lot of the ‘buzzwords’ that are used to describe governance. she refers to governance in its ‘purest form’, that is ... she emphasises that it is a central concept that applies to most areas and levels of human activity, and includes human rights, freedom of speech, economic transactions on a worldwide basis, full access to the internet, and to financial markets. unfor... more might agree that as things stand “textbook” political governance is generally not working on the global, regional and national stage anymore. on many counts, it is a failing concept.as edward lucas, former editor of the economist, points out, ‘th... professor ian goldin at oxford martin school in his book “divided nations: why global governance is failing, andwhat we can do about it” (4), highlights that one of the main reasons why we are failing ‘to manage global issues’-migration, climate chang... the author puts forth that we need ‘a fundamental rethink of the way we approach global governance’. in his view governance is failing in global institutions because their power or authority is ‘circumscribed by its members.’ in other words, as we hav... one option for professor goldin is to view sovereignty in a different light –‘to imagine a world where sovereignty is not just about preventing but also about enabling. if we redefine sovereignty, to look beyond coercion and exclusion but also conside... a hallmark of the seventeen un -2030 sustainable development goals (5) with which most are now familiar,is their interconnectedness and interdependency-as examples, climate, health, food production, peace, education, prosperity, security and that pr... this fundamental principle underpinning the un-2030 agenda and the sdgs could apply equally well to other issues of global governance (trade, migration, conflicts), that is, ensuring that interactions and negotiations take a more holistic approach tac... while research into distinctive areas of knowledge continues to be vital in gaining a better understanding of the world we inhabit, it has also been the cause of fragmentation, competition and tensions (6). the differentiation of school subjects and m... reductionism and silo approaches to tackling global issues as applied in the 19th and 20th centuries persist (e.g., ebola crisis) but no longer work when we know, as example, that the drought in california is linked to deforestation in the amazon rain... rather than focusing strictly on human dimensions governance is tasked with taking a broader perspective considering the interplay between humans, animals, plants and the environment. the concept is known as one health (8,9) and has been taken on boar... the pressing need to adopt the concept and collaborative approach is exemplified by the devastation in syria: not only did it lead to the destruction of a society – over 500,000 lives half children needlessly lost along with countless farm animals... while agreeing with the attributes about ‘good governance, identified earlier (1), perhaps consideration might also be given to another,that is, recognising that ‘governance’ has a higher purpose the sustainability of people and planet. achieving th... references bruce-lockhart a. what do we mean by governance? https://www.weforum.org/agenda/2016/02/what-is-governance-and-why-does-it-matter/ (accessed: 26 february, 2016). laaser u. a plea for good global governance. front public health 2015;3:46. doi: 10.3389/fpubh.2015.00046. lucas e. it’s not only mugabe who has failed his people. the times (comment, p. 31); november 17, 2017. goldin i. divided nations. why global governance is failing, andwhat we can do about it. oxford: oxford university press; 2013. united nations. sustainable development knowledge platform. https://sustainabledevelopment.un.org/sdgs (accessed: 23 november, 2017). lueddeke g. global population health and well-being. toward new paradigms, policy andpractice. new york: springer publishing company; 2016. laaser u, dorey s, nurse j. a plea for global health action bottom-up. front public health 2016;4:241. doi: 10.3389/fpubh.2016.00241. one health commission (ohc). mission. https://www.onehealthcommission.org (accessed: 23 november, 2017). lueddeke g. achieving the un-2030 global goals for a sustainable future through one health principles and practice. 2nd global conference on one health. world veterinary association and the world medical association in association with the japan veter... lueddeke g. toward a new worldview: one health, one planet, one future (in progress). analysis of the liberian health policy kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 1 original article the status of health services in the 15 counties of liberia roland y. kesselly 1 , nuaker k. kwenah 1 , ernest gonyon 1 , stephen byepu 2 , luke bawo 1 , george jacobs 1 , justin korvayan 1 , melanie s. graeser 1 , moses kortoyassah galakpai 3 , sandford wesseh 1 , ulrich laaser 4 1 ministry of health, monrovia, liberia; 2 inha university, incheon, korea; 3 epos, bad homburg, germany; 4 university of bielefeld, germany. corresponding author: prof. dr. med. ulrich laaser dtm&h, mph address: university of bielefeld, faculty of health sciences, pob 10 01 31, d 33501 bielefeld, germany; email: ulrich.laaser@uni-bielefeld.de kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 2 abstract aim: liberia, situated at the west african coast, is composed of 15 counties with an economic gradient steeply decreasing from the northwest to the southeast. health-related activities by government action in the 15 counties concentrate on the areas of family planning, antenatal and delivery care, as well as immunization, health workforce and infrastructure. the differences in this regard between the 15 liberian counties will be reviewed. methods: a narrative review is employed, making use of the recent international and national documents, relevant literature and available information from the following primary and secondary sources and databases. results: the results point to gross differences between the 15 counties of liberia in terms of health service provision. the overall readiness based on defined indicators for all 701 facilities was 59% with a range between facilities at the level of counties of 50% to 65%; for family planning services 88% (range 65% – 100%); for antenatal care 62% (range 55% – 100%); for immunization coverage 76% (range 66% – 86%). the health workforce of liberia comprises 11.8 health workers per 10.000 population, who target is 23, the counties range from 8.0 to 15.7. similarly, according to who standards, there should be 2 health facilities per 10.000 inhabitants, liberia comes up to 1.9 however the counties range from 1.1 – 3.0 per 10.000. conclusions: it is obvious that across almost all areas of women and child health and health services in general there exist large differences between counties, which points to considerable health inequities in this country. the government of liberia should consider reallocating the available resources per number of population instead of accepting historical developments, however with a correction factor in favour of disadvantaged regions and population groups. keywords: africa, health services, liberia, narrative review. conflict of interest: none. acknowledgements: the authors are grateful to richard gargli and roosevelt mccaco in monrovia, liberia for their help in identifying the relevant publications. kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 3 introduction liberia is one of the smaller west african countries, situated at the atlantic coast with a rainy season of approximately 6 months from mid-march to mid-october. together with the neighbouring countries sierra leone and guinea liberia experienced in 2014/15 the devastating effects of the ebola epidemic. the 4.5 million inhabitants – descendants of liberated american slaves with a majority indigenous tribal populations – are concentrated with more than 1 million in the capital monrovia in the central county of montserrado. there are 15 more or less populated counties with an economic gradient decreasing from the northwest to the southeast. with this paper we refer to the 2005 paris declaration on aid effectiveness and the 2011 busan partnership agreement (1) as well as the international health partnership for universal health coverage (uhc) 2030 (2). coverage of essential health services according to uhc relates to 4 categories: 1) reproductive, maternal, newborn and child health, 2) infectious diseases, 3) noncommunicable diseases, and 4) service capacity and access to services. the index of uhc presents an average coverage for 16 tracer indicators across the four categories, adjusted for coverage of the most disadvantaged population (3). during the first meeting of the uhc-2030 working group in march 2017 (4), the main focus was on low and middle-income countries facing ―a number of critical pressures on their health systems‖. some of these are particularly salient for countries that are currently or will soon be ―transitioning to much lower levels of external financial support‖. in preparation of the aforementioned situation, the ministry of health of liberia has established a health sector coordinating committee serving as a regulator to the already established pool fund with five donors since 2008. nevertheless, a significant amount of donor support which constitutes about 75% (5) remains off-budget with various parallel implementation arrangements. in our review, we focus on the intra-country differences of health services between the 15 liberian counties. methods the authors employed a narrative review, making use of the recent international and national documents, relevant literature and available information from the following primary and secondary sources and databases: a) published liberian documents including policies, strategies, plans, programs and reviews of the ministry of health and government of liberia; the most recent situation analysis is presented in the ―liberia service availability and readiness assessment and quality of care report (sara and qoc) (6), while the most recent documents covering mnh policy implementation are the ―joint annual health sector review report 2016‖(7) and the ―consolidated operational plan (fy 2016/17)‖(8). b) publications in the area of routine health statistics including population census and household surveys developed by the liberia institute of statistics and geo-information services with partners (2008 population and housing census, liberia demographic and health survey 2000, 2007, 2013), national e-databases with administrative data of liberia health information management system (dhis2) and international e-databases (who, unicef, unfpa, world bank group and the united nations population division, un inter-agency group for child mortality estimation) for purpose of comparison; kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 4 c) published reviews, scientific and professional articles on liberian maternal and new-born health in international journals, national surveys and project reports of international organizations (who, eu, world bank, unicef, unfpa) that deal with issues of women‘s and new-born health in liberia. results demonstration how resilience can be built after health crises like the ebola epidemic has been recently presented in several scientific papers (9-11). however, the purpose of the liberian actions in the field of health is to monitor progress throughout the implementation period of defined activities and achievements, following expressions in the investment plan (12). the purpose is described as building a resilient health system through: (a) improved access to safe and quality health services, (b) health emergency risk management, and (c) enabling environment and restoring trust. general services availability and readiness in 2016, based on the who sara report (6) encompasses assessment of basic amenities, basic equipment, and standard precautions for infectious disease prevention, diagnostics, and essential medicines by involving particular tracer items. the overall readiness to provide general health services in 701 facilities was 59%, while the best situation at the national level was found for basic equipment (77%), followed by standard precautions for prevention of infections (73%), basic amenities (57%), essential medicines (44%), and availability of diagnostics (42%). however, liberia‘s 15 counties differ significantly in their capacity to deliver basic health services (figure 1). the worst situation regarding general service readiness is found in bassa, maryland and sinoe (each county with only half of facilities ready to perform a comprehensive basic health services). the best situation is found in grand cape (65% readiness for general services), followed by bomi (64%), rivercess and grand kru (each 62%). diagnostics, which has included availability of 8 tracer items, (among them malaria and hiv diagnostic capacity, urine test for pregnancy), was the worst in maryland (only 24% of facilities were ready), followed by sinoe (27%) and bassa (readiness was 29%). nevertheless, it is worthwhile to mention that tracer items for malaria diagnostics were mostly present – in average in 88% of facilities with the least readiness interestingly in montserrado (51%). the uhc approach (13) embraces the following 4 core groups of indicators: 1. reproductive and newborn health (indicators adopted in liberia for family planning, four or more visits for antenatal care, skilled birth attendance and coverage of pregnant women with ipt). with regard to family planning, now in liberia defined as ‗number of total couple year protection (all methods), the indicator should be redefined according to the uhc approach as: ‗proportion of married or in union women of reproductive age who have their need for family planning satisfied with modern methods‘. kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 5 figure 1. general service availability and readiness (as percentage) in liberian counties (in total 701 health facilities were assessed) source of data: ministry of health, republic of liberia. liberia service availability and readiness assessment (sara) and quality of care report, 2016: pages 137-138. 2. child immunization (in liberia: ‗fully immunized infants‘). the corresponding uhc indicator is defined as: ‗dtp3 immunization coverage among 1-year olds‘. 3. infectious disease (in liberia: ‗antiretroviral therapy (art) for hiv positive pregnant women‘ and ‗tuberculosis (tb) detection rate‘. instead more appropriate: ‗utilization of tb treatment‘. 4. major social determinants of the population‘s health status as e.g. improved water sources and improved sanitary facilities. looking at these indicators planned to measure implementation throughout national health policies, it is not possible to track all tracer indicators and to calculate the index of uhc. nevertheless, international, as well as national databases contain values for the main indicators of relevance. the following sections describe availability and readiness for selected health services with a focus on the uhc priority of mother and new-born health (mnh): 81 75 77 86 69 79 74 7779 77 71 89 70 80 88 0 10 20 30 40 50 60 70 80 90 100 bomi bong bassa grand cape mount grand gedeh grand kru lofa margibimaryland montserr ado nimba rivercess sinoe river gee gbarpolu basic amenities basic equipment standard precautions diagnostics essential medicines kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 6 1) family planning despite 88% of health facilities are offering family planning services, still there are significant disparities in the availability between counties (figure 2). astonishingly, this service is more available in rural than in urban areas (97% versus 70%) and significantly more in government/ public facilities (97%) in comparison to private (62%) and mission/faith based facilities (60%). family planning readiness, in general 73%, is less present measured by availability of particular tracers: guidelines, check-lists, trained staff, and different modern methods of contraception. a particularly small number of facilities, only 14%, indicated to have at least one trained staff in the past two years for application of family planning counseling. figure 2. family planning – availability and readiness of services in counties as percentage (701 health facilities) source: ministry of health, republic of liberia. liberia service availability and readiness assessment (sara)and quality of care report, 2016: pages 143-144. 2) antenatal care: the next important uhc tracer indicator is antenatal and delivery care (14). routine antenatal care (anc) is clearly important for the health of the mother and her baby, but it also provides an important access point to the health-care system for pregnant women, and may include vaccination against tetanus, screening and treatment for high blood pressure, diabetes, anaemia, hiv, malaria and sexually transmitted diseases, dissemination of information on topics such as postpartum contraception and breastfeeding, and ultimately linkage to care during delivery. based on the sara assessment in 2016 liberia, in average, is doing well with 90% of facilities offering antenatal care, while 6 counties (bassa, grand cape, grand kru, rivercess, river gee, and gbarpolu) reported that all facilities are performing antenatal services and almost all have 84 79 80 74 70 81 80 7876 64 68 81 67 72 75 0 10 20 30 40 50 60 70 80 90 100 bomi bong grand bassa grand cape mount grand gedeh grand kru lofa margibimaryland montserrado nimba rivercess sinoe river gee gbarpolu facilities offering family planning family planning readiness kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 7 tracer items available: iron and folic acid supplementation, intermittent preventive therapy, tetanus toxoid vaccination, and monitoring for hypertensive disorders of pregnancy (figure3). figure 3. availability and readiness of antenatal care services in counties as percentage (701 health facilities) source: ministry of health, republic of liberia. liberia service availability and readiness assessment (sara) and quality of care report, 2016: pages 149-150. geographical location is also a factor with one third of world‘s countries having anc4 coverage at least 20% higher in urban than rural areas. in liberia the situation is, according to the recent assessment in 2016, opposite: 75% of urban facilities are offering antenatal care in contrast to 98% of rural facilities. even more: the most urbanized environment in liberia – montserrado county has the least availability and readiness of antenatal services (70% and 55% respectively). in general, the readiness in other areas expressed as availability of staff, guidelines, equipment, diagnostics, and medicines and commodities is considerably less. at the national level 62% of facilities are not fully ready to deliver antenatal care, predominantly due to the lack of diagnostics (only 27% of facilities are ready regarding diagnostics) followed by staff and guidelines (40% answered positively) (6). tracer items in diagnostics, which are the most problematic and contribute to the low readiness, were: haemoglobin test (available only in 12% of facilities) and urine dipstick protein test (availability of 42%). similar to the family planning services – low presence of continuing professional development (cpd) of staff is contributing to lower readiness of antenatal health services. only 15% of facilities had at least one trained staff in the two past years for antenatal care. so far, it seems that the availability of a well trained workforce in this field is still insufficient. 72 61 66 53 68 70 67 6769 55 57 75 62 62 60 0 10 20 30 40 50 60 70 80 90 100 bomi bong grand bassa grand cape mount grand gedeh grand kru lofa margibimaryland montserrado nimba rivercess sinoe river gee gbarpolu availability readiness score kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 8 3) immunization of children universal immunization is a core of one of uhc‘s objectives, and a key focus of global initiatives. notably, the global vaccine action plan (gvap) 2011–2020, which aims to achieve at least 90% national coverage by 2020 and at least 80% vaccination coverage in every district or equivalent administrative unit for all vaccines in national immunization programs is yet to reach the full target as planned. according to the sara report (6), liberia still did not reach this threshold with an average 82% of health facilities offering child immunization and an average readiness score of 76% of facilities out of 701. while in international statistics immunization coverage is at the level of 52% for liberia in 2015, the national figure for the same year is above 60%. such discrepancies can be a consequence of different definition of indicators or quality of the data. nevertheless, moh is reporting decrease in immunization for the two years stricken with evd (15). the investment plan has a target of 91% fully immunized infants and the real progress will be monitored during the population survey dhs 2018. only five counties (bomi, bong, rivercess, sinoe and gbarpolu) have readiness scores proposed as threshold in the uhc approach above 80% although all counties, except one, have health facilities stated to offer child immunization in average above 80%. extreme outlier is the highly populated montserrado county, where only 54% out of 261 health facilities offer immunization services with a readiness score of 70%. their readiness score encompasses (1) staff and guidelines, (2) equipment, and (3) medicines and commodities. one of the possible reasons could be the generally lower commitment to child immunization services in urban counties (only 61% are offering this service with 71% readiness). the same is the case regarding low immunization services offered by mission/ faith based health facilities, ngo/notfor-profit and particularly private-for-profit health facilities – possibly because they are more clinically oriented. while government/public facilities are offering immunization service in 95% of cases, private-for-profit institutions are doing so only in 47% of 235 registered facilities. regarding readiness score counties are more equalized (reaching from 66% to 86%) (figure 4). figure 4. availability and readiness of child immunization services in counties as percentage (701 health facilities) kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 9 source: ministry of health, republic of liberia. liberia service availability and readiness assessment (sara) and quality of care report, 2016. pages 147-148. the infrastructure regarding workforce, facilities and equipment is analysed in the following sections 5-7. 5) health workforce the investment plan 2015-2021 placed the health workforce as the first investment area: ―to build a fit-for-purpose productive and motivated health workforce that equitably and optimally delivers quality services‖ (16). despite, the pull of human resources for health was heavily hit by the ebola crisis, when 372 health workers obtained the disease and even 184 died (as of april 08 2015)(17), following the 2015/2016 health workforce census, the total number of health workers of 16,064(18) have exceeded the number projected in the national health and social welfare plan 2011-2021(19) and the national human resources policy and plan for health and social welfare 20112021(20), which aimed at 15,626 in 2021 for the population projected to be 4,555,985 in the same year. however, the actual composition of workforce does not follow the same positive path. if we look exclusively at the physician, physician assistants, registered nurses, certified midwifes and nursemidwifes, we would expect to see following the cited plans – more than 6,294 health workers and not as in reality only 4,756 of them placed on the governments payroll. that means, liberia still has to cover a 24% deficit of the nationally projected number of the core health workforce. the biggest deficit is with physician assistants, liberia is still missing 48% of the projected number for 2021, followed by physicians with deficit of 44%. the least deficit is with registered nurses, certified midwifes and nurse-midwifes – 20%. 81 80 66 79 73 75 75 79 75 70 73 86 82 75 84 0 10 20 30 40 50 60 70 80 90 100 bomi bong grand bassa grand cape mount grand gedeh grand kru lofa margibimaryland montserrado nimba rivercess sinoe river gee gbarpolu availability readiness score kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 10 if we look at the who‘s threshold of 23 health workers per 10,000 population, then liberia would need to speed up to reach the total number of 10,479 core health workforce. in other words, still 55% of health workforce is missing in comparison to the who threshold. achieving the sdg threshold of 44.5 per 10.000 would be even more unlikely. the global strategy on human resources for health ―workforce 2030‖ underlines the required progress towards uhc by strengthening health workforce (21). at the same time, inequitable distribution per 15 counties is remarkable and fluctuation of workforce is significant from year to year (figure 5). commitment to strengthen workforce for health in liberia by increasing investment through country resources is remarkable looking at the staff on payroll. the percentage of health workers placed on the national budget payroll increased from 58% in 2015 to 68% (7,214 out of 10,672 employed in governmental/ public health facilities) in 2016. kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 11 figure 5. density of health workforce by counties – health professionals per 10,000 population data sources merged: 1. ministry of health, republic of liberia. investment plan for building a resilient health system 2015 to 2021. monrovia, liberia: ministry of health, 2015. pages 8-35. 2. ministry of health republic of liberia. joint annual health sector review report 2016. . monrovia, liberia: ministry of health, 2016. page 44. available from: http://www.seejph.com/public/books/joint_annual_health_sector_review_report_2016.pdf [cited 2017 july 30] 6) construction of health facilities while lack of access to health services continues to be of major concern and central tenet of uhc, in many parts of the world, there are several forms of barriers, the most obvious being the lack of quality health services; but there are also obstacles such as a deficit of numbers of health facilities and distance to the nearest one (22). the who global threshold for health facilities is 2 per 10,000 population, while there is no set target for the indicator ―percentage of population living within 5 kilometres from nearest health facility‖ (national target for 2021 in liberia is 85%). figure 6 presents the density of public and private health facilities per 10,000 population. though, mal-distribution of health facilities by counties is still obvious, even six counties exceeded who threshold of 2 per 10,000 already in 2015, and the same situation appeared in 2016: sinoe, grand kru, rivercess, river gee, bomi and grand cape. in comparison to 2015, critical shortage of health facilities has decreased, however still three counties – bong, nimba and grand bassa have extremely low health facilities‘ density being <1.5 per 10,000 population. 15.7 14.9 12.3 12.2 11.5 11.4 11.3 11.2 9.9 9.9 9.5 9.4 9.2 8.5 8 11.8 8.6 6.3 14 23 0 5 10 15 20 25 2016 2015 2010 kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 12 kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 13 figure 6. health facilities’ density per 10,000 population by counties sources: 1. ministry of health, republic of liberia. investment plan for building a resilient health system 2015 to 2021. monrovia, liberia: ministry of health, 2015: page 7. available from: http://moh.gov.lr/cabinet-endorses-investment-plan-for-building-a-resilient-healthsystem/ [cited 2017 mar 17] 2. ministry of health republic of liberia. joint annual health sector review report 2016. . monrovia, liberia: ministry of health, 2016. page 54. available from: http://www.seejph.com/public/books/joint_annual_health_sector_review_report_2016.pdf [cited 2017 july 30] one example is county nimba. the projected figure of 70 public health facilities is not enough to reach a density of 2 per 10,000 population; in fact it would be necessary to have 121 facilities in this county. as of 2016, nimba has 68 public and private health facilities and therefore still 53 functional health institutions are missing in order to reach who‘s threshold. in 2011, moh reported 550 opened health facilities (378 public and 172 private) (23), while in the 2016 health sector performance report 727 health facilities were listed (out of 701 directly assessed: 437 public; 216 private-for-profit and 48 private-not-for-profit – together 264) (24). whereas in 2011, liberian health policy set out a projection of 543 public health facilities to be reached up to 2021with reference to the who‘s threshold of 2 functional health facilities per 10,000 population liberia would need a total of 911 health facilities serving the projected number of population being 4,555,985 in 2021. in conclusion liberia needs in addition to the 543 public facilities projected by gol and the 264 private ones, pre-existing in 2011 a number of 211 additional facilities, either public or private. 7) availability of equipment 2.8 2.5 2.2 2.2 2.5 2.2 1.9 1.7 1.4 1.2 1.5 1 1.2 1.1 1.6 3 2.9 2.3 2.3 2.2 2.2 1.9 1.8 1.6 1.6 1.6 1.2 1.2 1.1 1.9 2 0 0.5 1 1.5 2 2.5 3 3.5 2015 2016 kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 14 at this stage of implementation, the envisioned inventory of equipment and a comprehensive maintenance plan for facilities and equipment are still missing. with significant differences between counties, basic equipment is ready in 77% of 701 health facilities, however only 19% of facilities have all items (adult and child scale, thermometer, stethoscope, blood pressure apparatus, light source). while margibi and montserrado have problems with child scales, dramatic problems with light sources are reported in five counties which have less than 20% of facilities with permanent electricity: maryland, sinoe, river gee, grand kru and grand gedeh (6). discussion in spite of the described deficits liberia‘s position with regard to the 15 west-african countries is acceptable for a country after civil war and ebola epidemic (25). the health related sdg index for liberia is 33 i.e. the 9 th position where niger is the 15 th with a value of 23 and neighbouring sierra leone 13 th with 27. ghana takes the 2 nd position with 43 and capo verde islands the first with 53 (26). although the validity of the data used here may be questioned to some degree it is obvious that across almost all areas of women and child health and health services in general considerable differences between counties can be identified (even with regard to basic immunizations) which points to considerable health inequities in this country. the most impressive ones are demonstrated in figures 5 and 6 regarding the density of staff – ranging in 2016 from 8.0 to 15.7 and facilities per population ranging the same year from 1.1 to 3.0 per 10.000 population. whereas the national average of the number of facilities is close to the who recommendation of 2.0 facilities per 10.000 population, the number of staff in average is far below i.e. 11.8 vs. 23.0 with an interim goal of 14 per 10.000 in 2021 (7). nevertheless, the recent health workforce census has identified once more the low motivation of health workers and their deep frustration regarding financial incentives together with insufficient possibilities for professional development (27). this demonstrates very clearly that investments should go with priority into education and continuing training of qualified staff, paid regularly and reliably, especially registered midwifes (28). furthermore the poor infrastructure in liberia (lack of roads, electricity, water and sanitation) and the devastating economic situation appear to be the main threats to the health system in general (personal communications). in addition to the availability of sufficient health facilities, their staffing and quality of services, also accessibility in terms of distances and road quality are of highest relevance. the investment plan 2015-2021 set a percentage of population living within 5 km from the nearest health facility (approximately within one hour of walking distance). in 2016 71% of all liberian citizens have access within 5 kilometers of their place of living. nevertheless, liberia is yet to reach the nationally projected target of 85%. in addition, there are significant disparities across counties, with gbarpolu having only 32% of population with nearby access and montserrado with 96% respectively (29). in order to obtain more reliable estimates of the main health indicators across the liberian health sector, the government of liberia is preparing in collaboration with international partners -the next generation of demographic and health surveys together with the population census for the year 2018. kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 15 conclusions the ministry of health has the responsibility to take care of effective extension of coverage of health services to the entire population in liberia. one key instrument is transparent investment, i.e. timely and accurate reporting of local and international donor agencies including implementing partners and correspondingly to reallocate the available resources per number of population instead of accepting historical developments, however with a correction factor in favour of disadvantaged regions and population groups. references 1. world health organization. tracking universal health coverage: first global monitoring report. geneva: who, 2015. 2. international health partnership for uhc 2030. available from: https://www.internationalhealthpartnership.net/en/ (accessed: april 29, 2017). 3. world health organization. global tracking uhc report. geneva: world health organization and world bank 2016. 4. first meeting of uhc2030 working group on sustainability, transition from aid and health system strengthening. available from: https://www.internationalhealthpartnership.net/en/news-videos/article/first-meeting-ofuhc2030-working-group-on-sustainability-transition-from-aid-and-health-systemstrengthening-401839/ (accessed: april 29, 2017). 5. international health partnership for uhc 2030. available from: http://www.nationalplanningcycles.org/planning-cycle/lbr/ (accessed: april 29, 2017). 6. ministry of health. liberia service availability and readiness assessment (sara) and quality of care report. monrovia, liberia: ministry of health, 2016 oct. 7. ministry of health. joint annual health sector review report 2016. national health sector investment plan for building a resilient health system. monrovia, liberia: ministry of health, 2016 nov. 8. ministry of health, republic of liberia. consolidated operational plan (fy 2016/17). monrovia, liberia: ministry of health, 2016 sept. 9. kruk me, ling ej, bitton a, cammett m, cavanaugh k, chopra m, et al. building resilient health systems: a proposal for a resilience index. bmj 2017;357:j2323. doi: 10.1136/bmj.j2323. 10. luckow pw, kenny a, white e, ballard m, dorr l, erlandson k, et al. implementation research on community health workers‘ provision of maternal and child health services in rural liberia. bull world health organ 2017;95:113-20. doi: http://dx.doi.org/10.2471/blt.16.175513 11. shoman h, karafillakis e, rawaf s. the link between the west african ebola outbreak and health systems in guinea, liberia and sierra leone: a systematic review. global health 2017;13:1. doi 10.1186/s12992-016-0224-2. 12. ministry of health, republic of liberia. investment plan for building a resilient health system 2015 to 2021. monrovia, liberia: ministry of health, 2015:35. kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 16 13. world health organization. universal health coverage data portal. available from: http://apps.who.int/gho/cabinet/uhc.jsp (accessed: july 29, 2017). 14. who, wb. tracking universal health coverage. first global monitoring report. geneva: who department of health statistics and information systems 2015. 15. ministry of health, republic of liberia. health annual report 2015. monrovia, liberia: ministry of health, 2015. 16. ministry of health, republic of liberia. investment plan for building a resilient health system 2015 to 2021. monrovia, liberia: ministry of health, 2015:8-35. 17. un economic and social council. progress towards sustainable development goals. report of the secretary general. e/2016/75. available from: http://undocs.org/e/2016/75 (accessed: july 29, 2017). 18. ministry of health republic of liberia. joint annual health sector review report 2016. monrovia, liberia: ministry of health, 2016:43-50. available from: http://www.seejph.com/public/books/joint_annual_health_sector_review_report_2016 .pdf (accessed: july 30, 2017). 19. ministry of health and social welfare, republic of liberia. national health and social welfare policy and plan 2011-2021. monrovia, liberia: ministry of health and social welfare, 2010:59-61. available from: http://moh.gov.lr/category/policies/ (accessed: july 30, 2017). 20. ministry of health and social welfare, republic of liberia. national human resources policy and plan for health and social welfare 2011-2021. monrovia, liberia: ministry of health and social welfare, 2010:59-61. available from: http://moh.gov.lr/category/policies/ (accessed: july 30, 2017). 21. who. global strategy on human resources for health: workforce 2030. geneva: who document production services, 2016. available from: http://apps.who.int/iris/bitstream/10665/250368/1/9789241511131-eng.pdf?ua=1 (accessed: july 31, 2017). 22. who, wb. tracking universal health coverage. first global monitoring report. geneva: world health organization. available from: http://www.who.int/healthinfo/universal_health_coverage/report/2015/en/ (accessed: july 31, 2017). 23. ministry of health and social welfare, republic of liberia. national human resources policy and plan for health and social welfare 2011-2021. monrovia, liberia: ministry of health and social welfare, 2010: 7. available from: http://moh.gov.lr/category/policies/ (accessed: july 30, 2017). 24. ministry of health republic of liberia. joint annual health sector review report 2016. monrovia, liberia: ministry of health, 2016:53. available from: http://www.seejph.com/public/books/joint_annual_health_sector_review_report_2016 .pdf (accessed: july 31, 2017). 25. taylor a. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003. seejph 2017;8. doi 10.4119/unibi/seejph-2017-155. http://undocs.org/e/2016/75 kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 17 26. gdb 2015 sdg collaborators. measuring the health related sustainable development goals in 188 countries: a baseline analysis from the global burden of disease study 2015. lancet 2016;388:1813-50. 27. ministry of health republic of liberia. joint annual health sector review report 2016. monrovia, liberia: ministry of health, 2016:48. available from: http://www.seejph.com/public/books/joint_annual_health_sector_review_report_2016 .pdf (accessed: july 31, 2017). 28. michel-schuldt m, dayon mb, klar rt, subah m, king-lincoln e, kpangbala-flomo c, et al. continuous professional development of liberia's midwifery workforce—a coordinated multi-stakeholder approach. midwifery 2018;62:77-80. 29. ministry of health republic of liberia. joint annual health sector review report 2016. monrovia, liberia: ministry of health, 2016:52. available from: http://www.seejph.com/public/books/joint_annual_health_sector_review_report_2016 .pdf (accessed: july 30, 2017). ______________________________________________________________________________________ © 2018 kesselly et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 09 august 2020. doi : 10.4119/seejph-3614 p a g e 1 | 15 case study how the largest slum in india flattened the covid curve? a case study monalisha sahu1, madhumita dobe1 1 department of health promotion and education, all india institute of hygiene and public health, west bengal, india. corresponding author: monalisha sahu; address: 110, chittaranjan avenue, kolkata 700073, west bengal, india. telephone: +91 9873927966 e-mail: drmonalisha@outlook.com sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 2 | 15 abstract mumbai-the economic capital of india, shrivelled with panic as its infamous slum ‘dharavi’ recorded its first positive case of covid-19 on 1st april 2020. dharavi is the largest slum in india and one of the most densely populated areas in the world. its narrow lanes, teeming with people and chock-a-block with settlements, make physical distancing practically impossibleposing as an excellent breeding ground for the deadly virus. however, with a policy of ‘chasing the virus’ based on strategy of ‘tracing tracking testing and treating’ dharavi flattened its epidemic curve within a hundred days. this was achieved through the immediate public health response with strict containment measures, aggressive active and passive surveillance and integration of resources from government and private sectors to provide essential services. in this paper, we have summarized the ongoing measures for successful prevention and control of covid-19 in dharavi, which could provide useful learning for other similar settings worldwide. keywords: containment measures, covid-19, india, megacity-slum, mumbai. conflicts of interest: none declared. acknowledgments: to the health staff and officers of brihan mumbai corporation. author contributions: ms conceptualized the idea and wrote the first draft; md & ms reviewed and edited the final version. all authors have read and agreed to the published version of the manuscript. sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 3 | 15 background on the first day of april 2020 when the first case of covid-19 got diagnosed with subsequent death in baliga nagar dharavi, mumbai authorities sensed their worst nightmare was about to begin. people feared that the deadly virus may have already possibly taken a firm grip on the overcrowded shanties. what followed next was several deaths one after another as the sars cov-2 virus started spreading swiftly even amidst nationwide lockdown with a growth rate of 12% and doubling period of 18 days (1, 2). it took a little over a fortnight for dharavi to add 100 cases to its tally and by may 3, it crossed the 500 mark. till may 6, the doubling rate of covid-19 cases in dharavi was shortened to six days. subsequently, dharavi emerged as one of the most challenging hotspots in india (3). multiples strict measures to contain the spread have been implemented since the beginning of the outbreak in dharavi in april 2020. these measures resulted in the low spread of cases and reduced mortality by june 2020. this paper aims to focus on documenting the control measures taken to stop the spread of covid-19 in one of the world’s densest slums. the information presented in the paper was obtained through the analysis of recent policies, official press, articles, reports, presentations, and credible data sources. a thematic approach to analysis was used to identify the emerging lessons, which then informed the structure of the reported results. ms excel and google maps were used for processing the data and preparing spot maps of the containment zone. i. what makes dharavi such a ticking time bomb? located in the g north municipal ward of mumbai, dharavi is home to around 1 million people living in a 2.16 square kilometres maze of narrow, haphazard, dirty lanes, in shanties and ramshackle buildings next to open sewers. its narrow passages, overcrowded houses, miserable, unsafe and unhygienic living conditions offer the perfect breeding ground for pathogens like sars cov-2 (4). figure 1. administrative map of mumbai with ward divisions (4) * dharavi is located in g north ward of mumbai with mahim & dadar. sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 4 | 15 ii. the socio-demographic milieu dharavi is home to an estimated one million people with a population density of 270,000 per square kilometre, living mostly in g+1 low rise building, where upper floor act as factories (2). they mostly eke out a living as factory workers in some 5,000 small factories and 15,000 single-room workshops of leather, pottery and textile stitching businesses. many of its residents’ work as helpers and chauffeurs to the financial capital mumbai's well-heeled residents. dharavi also serves as the plastic recycling hub of mumbai. the original inhabitants of dharavi were kolis the fishermen but today their number is less than 2%. majority of dharavi population is made of migrants both formal and informal mostly from other districts of maharashtra, tamil nadu, gujrat, up and bihar (5). there has been slight increase of migrants from up and bihar over the last few years, and they mostly form the informal floating population of dharavi. most of them are informal dailywage workers who don't cook at home and go out to get their food on daily basis. figure 2. segmentation of residents living in dharavi* * formal migrants are mostly from states of other parts of maharashtra, gujrat and tamilnadu, whereas floating population is mostly from states of uttar pradesh & bihar. the situation became worse for the migrant workers when in view of the ongoing covid-19 pandemic, india went into nationwide lockdown on march 25, 2020, for maintaining adequate social distance to stop spread of the disease (1). many of the migrant workers living in dharavi left for their villages before the lockdown could be strictly implemented, possibly taking the virus far and wide. however, an even bigger number of migrant workers were struck in the slum with no money to buy food or other essential items. sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 5 | 15 iii. unsafe physical environment urban slums of dharavi constitute one of the most disadvantaged sections of society. health is a major challenge in the slums of dharavi, were the struggles to maintain it are faced with multi-layered challenges like: a. overcrowding: in dharavi eight to 10 people live typically in a cramped 150 sq. ft shanty with no natural light or ventilation and without provision for safe drinking water, sanitation or other basic services. b. poor sanitation: most of the (80%) slum households did not have a private toilet facility inside their homes (2). the limited public lavatories they share are filthy, unhygienic and unsafe. mahim creek is a local river that is widely used by local residents for open urination and defecation. also, the open sewers in the city drain to this creek facilitating the spread of contagious diseases. c. unsafe drinking water: in dharavi 30% of the residents don’t have kitchen in their houses and depend on outside food (6,7). almost 35% of the residents need to step out of their homes to collect drinking water from public taps, tube wells, and wells stationed throughout the slum (6,7). insanitary conditions coupled with people crowding around public taps and toilets makes social distancing impossible. also, hourly restrictions on water availability adds to the challenge of washing hands to keep away from infection. there is low acceptance for preventive measures amidst other pressing challenges like food, water and shelter. even simple precautionary measure like regular hand washing and physical distancing are privileges they are unable to afford. they only realize the need for health when it is lost and then most of them are not in position to afford existing medical services. in addition, within a densely packed slum like dharavi many people lack even a postal address, which itself poses unique challenges for health care services. iv. the first few covid-19 cases and contacts transmission investigation (ffx) the index case reportedly was a 56-year-old garment unit owner living in a 320 sqm flat in slum rehabilitation authority (sra) colony, baliga nagar. he initially developed mild cough and fever on 23rd april [8]. when his symptoms worsened even after consulting a local doctor, he was referred and admitted to the civic-run sion hospital where his throat swab was sent for testing. by the time the reports came positive for covid-19 he succumbed to the disease. a five-member team consisting of two medical officers, a sanitary inspector (si) and two community health volunteers (chvs) started contact tracing to identify source of infection and plan how to contain it. the team fanned out in the area to inspect the building and the common spaces between closely constructed squad of five buildings. the area had eight buildings comprising of 300 flats and 91 shops (8,9). during contact tracing it was found that the index case had possibly hosted some people who had attended a religious congregation in nizamuddin delhi in march, which was india’s first big cluster of covid-19 cases (10). based on contact tracing, a list of 15 immediate high-risk contacts including the deceased’s wife, his four sons, two daughters, immediate neighbours, the local doctor the man had visited and two of the staff at the doctor’s clinic were identified and tested. the family’s acquaintances were categorized as low risk and alerted. with the help of pest control officers (pco) the entire building sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 6 | 15 was disinfected and sealed. the sion hospital opd, was shifted outdoors while the building was sanitized. the entire baliga nagar housing society was sealed and declared containment zone with about 2,500 residents stamped for quarantine. parallelly, a nearby sports complex was converted into a 300-bed facility for isolation. a team of police was stationed outside the colony to ensure the quarantine is not violated. a containment officer (co) was deployed at the site to coordinate with the police, the bmc and the residents to ensure the residents get essential supplies like food, milk, water and medicines every day. in addition, six volunteers were identified who could step out for essentials on rotation basis. elderly people with co-morbidities like hypertension, asthma and diabetes were screened and nine particularly vulnerable people with respiratory illness were tested. apart from it, 75 people who came in contact of the visitors from delhi were isolated, in an attempt to break the chain of infection. second case was reported within 24 hrs as a 52-year-old conservancy worker from worli who was on duty in dharavi. third case was of a surgeon resident of vaibhav apartment in dharavi, who was working with one private hospital, which had earlier reported many infections among its healthcare workers. the doctor’s wife also tested positive later. so, all these cases had different source of exposure and were in building setup. the real alarm was set off on 4th april when a positive case was reported from a slum shanty of mukund nagar, where a 48-year-old-man living with his 11 family members in a tworoom house (100 sq. ft) came positive. due to emerging of multiple cases from multiple parts of dharavi, medical camps were started to screen people in areas with multiple cases. gauging the increasing spread maharashtra medical council officials in collaboration with bmc started active surveillance of cases by door-to-door screening. by 25th april total 214 active cases and 13 deaths were recorded mostly from the areas of mukund nagar, azad nagar, dharavi cross road, matunga labour camp and indira nagar. individual slum pockets were grouped together to form high risk zones based on the case load. five such slum pockets in dharavi were identified as hot spots and marked as high risk/red zones (11). within a span of one month, around four lakh residents in dharavi were screened for the symptoms of covid-19 by teams of 24 health practitioners. around 47,500 people were screened in high-risk zones by door-to-door visits by doctors and private clinics, about 14,970 people were screened with the help of mobile vans, and rest were surveyed by bmc health workers. out of these, 2,000 were suspect cases and 600 were subjected to tests. following the screening, about 5,857 were put in institutional quarantine and 31,725 residents were directed to remain under home quarantine. also, around 8246 senior citizens were surveyed and as part of its policy of ‘timely separation’ from the other community to effectively limit the transmission (2). even with all ongoing activities, a whopping 1,400 covid-19 patients were added to the tally by mid-may, a figure almost 380 percent higher than the april figures. with a rise in containment zones to 202 from a mere 49 such zones at the end of april, the hotspots or high-risk zones increased to 10 from five with matunga labour camp, 90 ft road, dharavi cross road, kunchi korve nagar being the particular focus areas due to rising cases (12 sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 7 | 15 figure 3. spatial distribution of five high-risk zones for covid-19 outbreak in dharavi as on 25th april 2020 legend: dharavi borders of dharavi 5 hot spots of covid-19 (dharavi kumbharwada, dharavi cross road, matunga labour camp, kunchikorve nagar, 90 feet road). figure 4. spatial distribution of high-risk zones of dharavi as on 23rd may 2020 legend: dharavi borders of dharavi 10 hot spots of covid-19 (mahim sion link road, rajiv gandhi nagar, mukund nagar, marlyamma temple, muslim nagar, transit camp, kumbharwada, matunga labour camp, chota sion hospital and dharavi cross road). sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 8 | 15 the maximum number of cases in dharavi were reported from the matunga labour camp (55 cases), followed by mukund nagar (49 cases), kumbharwada (45 cases) and dharavi cross road (38 cases). majority of cases in dharavi (75%) were reported in people aged 21 to 60 years. almost 35% of the cases had contracted infection within their families. dharavi also reported increased mortality due to covid10 in may (70 deaths) in comparison with april (18 deaths). v. specific processes and activities in implementation of ‘mission dharavi’ under the clear leadership of brihan mumbai corporation (bmc) the local civic body which is asia’s richest municipality, mission dharavi was launched with a slew of proactive steps to contain the virus (13). at the heart of mission dharavi, the motto was to chase the virus by tracing tracking testing & treating. ‘corona war room’ was launched in the disaster control unit for various activities like planning, prevention and management of the pandemic 24/7 functional. early diagnosis and early treatment were key measures to reduce the new infection and mortality rates. the major activities conducted under ‘mission dharavi’ are as follows: 1. focussed high risk areas with watertight containment zones: bmc’s covid containment strategy included identification of maximum possible containment zones, these are places where positives have been detected and those surrounding areas have been sealed to protect everyone inside and outside from further spread (13). the containment zones were further classified into the following for the purpose of triaging and focussed efforts (14): a. red which are congested areas; b. orange which are congested, but still more manageable than red; c. blue which are the buildings. the state government chalked out a threefold strategy of an effective containment, conducting comprehensive testing and ensuring uninterrupted supply of goods and essential supplies to the community. to make sure the harsh containment worked, officials partnered with non-profits to provide free meals rations and medicine to the residents and migrant workers left jobless by a weeks-long nationwide lockdown. community kitchen were opened to provide food packets (2). the g-north ward also launched a 12-hour helpline number to help people contact bmc for food, grocery, transportation and stay. social media platforms were used to inform residents about relief efforts. 2. perimeter control: to maintain the perimeter control, police were deputed. considering the overcrowding, bmc started monitoring movements within the red zones by drones which alerted police if residents attempted to leave their homes and a fine was imposed. local leaders and youth of the area were identified as volunteers named “corona yodhdhas” (corona warriors) to help the community with procurement of essential commodities. free meals and food rations were provided to residents trapped at home without work and income. 3. early diagnosis: early detection and treatment are of utmost importance for favourable outcomes and reducing the mortality rates (figure 4). dharavi was not only dealing with an increased number of cases but also increased mortality. it was seen that those who were brought late to the facility had higher mortality rates. to ensure early detection of disease targeted testing approach was tried. a. aggressive active surveillance: screening effort involving door to door active surveillance, taking help of private clin sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 9 | 15 ics/doctors, were conducted. teams comprising of community health volunteers (chvs) and local covid volunteers under the leadership of the medical officer conducted door to door active surveillance for cases. each team in personal protective gear on an average visited 100-150 households of high risk and low risk contacts and screened them for fever and oxygen concentration with the help of thermal guns and pulse oximetry. altogether 47,500 people from the high-risk zones and 1.25 lakh residents of containment zones of dharavi were screened (2). this became a game changer. b. passive surveillance at fever camps: fever camps were conducted at regular intervals in strategic locations of the slum. at each camp about 80100 residents were screened every day by medical officer with the help of health workers for fever and blood oxygen levels using infrared thermometers and pulse oximeters. the local private practitioners were also instructed to report and refer all the patients with fever or /and respiratory symptoms like cough, sore throat and shortness of breath to the fever clinics for further testing. those who tested positive were moved to local institutional quarantine facilities with the guidance of health workers. 4. early treatment with triaging of facilities: to ensure proper utilization of limited resources medical care centres for covid 19 were divided in four categories (13): a. corona care centre type 1 (ccc1): these facilities were meant for high-risk contacts and those awaiting reports and were arranged in hotels, lodges, halls or newly constructed buildings, and they don’t have round-the clock medical staff; b. corona care centre type 2 (ccc2) facilities for asymptomatic to mild positive patients. they have round-the clock medical staff and oxygen facilities. food, multi-vitamins and medicines are supplied free of cost to the people admitted; c. dedicated covid health centre (dchc) for moderate to critical patients; d. dedicated covid hospital (dch) for critical patients. there are five covid-19 dedicated hospitals, sai hospital, ayush hospital, life case hospital, family care hospital and prabhat nursing home, for residents of dharavi. the triaging helped in judicial utilization of resources and only critical patients were shifted for admission to hospitals and icus. centralized toll-free number for live availability of icu beds was generated for the community. ambulances and mobile vans with oxygen facility to transfer patients from ccc1/ccc2 to dch as and when required were made available. sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 10 | 15 figure 5. strategy for reducing the new infection rates and mortality due to covid-19 because of these proactive steps, even with limited resources the virus was detected early and promptly treated, increasing the recovery rates and lowering the mortality rates. dharavi reported recovery rate of about 51% as compared to 41% in the rest of mumbai, where most patients reached hospitals late. also, almost 90% of the patients were treated inside dharavi itself (2). 5. institutional quarantine facilities: instead of putting people in home quarantine, the government decided to put high-risk people from dharavi in institutional quarantine because at home they were still sharing the public toilet. in order to increase the capacity of quarantine centres, makeshift shelters and transit camps were erected. schools, colleges, hotels, lodges, marriage halls, sports complexes were transformed into quarantine centres, equipped with facilities like lights, fans, charging points & daily usable. the g north ward prepared a capacity of about 3,000 quarantine beds in facilities like rajiv gandhi sports complex, dharavi municipal school, manohar joshi vidyalaya, d’silva high school, ruparel college hostel, scout & guide hall, mahim nature park, and various other hotels and lodges in the ward. the ratio of positive to institutional quarantined ratio increased to 1:5.45 in may from 1:3.381 in april (15). every person in the isolation centres received three meals and round-theclock medical supervision free of cost. taking care of the religious sentiments during ramadan -the muslim holy month, authorities ensured they got fruits and dates and distributed proper meals at appropriate times for breaking their religious fasts at sunset. such activities increased the acceptance of institutional quarantine in the community. also, mental health aspect of quarantine inmates sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 11 | 15 was taken care of with the help of dedicated counsellors, yoga and meditation sessions. 6. improved sanitation: poor sanitation in community toilets in dharavi have been the key source of spread of infectious diseases like covid. in order to improve sanitation, the 225 public toilets were disinfected and fumigated twice daily. the g north ward also installed foot operated devices for using washbasins, toilet flush, and so on. public awareness campaigns about sanitising hands and washrooms were regularly conducted (16). 7. social mobilization processes were undertaken, exploring opportunities and innovative means to bring together all societal influences to raise awareness, like local leaders and bollywood stars to assist in the delivery of services and resources. it included: a. community engagement: community engagement is central to any public health intervention even more so during public health emergencies. it involves those affected in understanding the vulnerabilities they face, and involves them in response actions. the dharavi model adopted the process of working collaboratively with and through groups of people in the affected community to address issues to bring about environmental and behavioural changes that will improve the health of the community members. this involved recruitment of local volunteers to influence and serve as catalysts for changing practices, reaching out to and informing the community of policy directions of the government and build community awareness and understanding. frontline health workers played critical roles in the prevention by providing health education on preventive measures for all people in the containment zones. the transparency of updated information and clear communication messages on covid-19 through official and social media were important contributors to changing community behaviours towards wearing masks, hand washing, and social distancing, from february 2020. b. public private partnership (ppp): even when covid care facilities were ready, arrangement of manpower to run them was a real challenge. to tackle the issue of trained health workforce strategic public private partnerships were forged and all available ‘private’ practitioners from the nine dispensaries and 350 private clinics located in dharavi were roped in. all practitioners were encouraged and supported with resources to open their clinics to attend to the patients and communicate to bmc in case any covid-19 suspects were found. the added advantage of including the private practitioners was that they had the trust and confidence of the residents who will approach them even for slight fever, or any other symptoms making it easy for screen and test. 8. exodus of migrants: apart from the above initiatives, reverse migration of thousands of migrant workers residing in dharavi, towards their homes in other states also contributed directly and indirectly towards decreasing the case load in dharavi. vi. temporal variation of cases and the epidemic curve with the strategy of actively ‘chasing the virus’, the epidemic curve of dharavi displayed signs of flattening by late may (figure 3). a steady decline in the number of covid-19 cases was observed in late may which continued in june when daily reported new infections dropped to 5 cases in third week of june sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 12 | 15 from a high of 94 cases a day in early may (13). figure. 6. temporal variation in number of new covid-19 cases in dharavi legends: no. of cases the drop in the new cases in dharavi was also associated with a steep rise in the doubling time of 18 days in the last week of april to 78 days as of june 19. the growth rate declined to 1.02% and the case fatality rate dipped to 3.7% by the month of june (2,13). figure 7. comparative analysis of covid 19 growth rate and doubling time for dharavi 0 20 40 60 80 100 120 3/10/2020 3/30/2020 4/19/2020 5/9/2020 5/29/2020 6/18/2020 7/8/2020 n o . o f n e w c a se s days 12% 4.30% 1.02% 5% 4% 3.70% 0% 2% 4% 6% 8% 10% 12% 14% apr-20 may-20 jun-20 growth rate case fatality rate dp=18 dp =43 days dp=78 days sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 13 | 15 the ministry of health and family welfare (mohfw) also mobilized provision of medical equipment and organized several site visits for central inter-ministerial and public health teams to support local health facilities to prepare for combating covid-19. vii. challenges dharavi’s war against the virus is still far from over. the severe lockdown measures can’t continue forever. though relief efforts for providing food and ration are continued in the area, many are still not able to procure them and are forced to step out of their home to arrange meals. upcoming monsoon with waterlogging can pose a serious threat on the makeshift quarantine facilities. also, monsoon will increase the burden of other communicable diseases like dengue and malaria, which will further overburden the health system. with the unlock and start of local trains, buses and other modes of transportation the virus can easily make its way back to the slum. the community still lack awareness, and many are ignorant to preventive measures like wearing masks properly and maintaining physical distance. hence, the chances of a second wave in near future cannot be denied. arranging trained health workforce and icu beds can be difficult with the already overburdened health workers and health system. therefore, there should be continued administrative measures and screening at all points of entry till the virus is chased out from the state and the country which is again a challenge. conclusion almost a hundred days after dharavi began its fight against covid-19, asia’s largest slum seems to have flattened the curve. the dharavi model is based on the dogged approach to “chase the virus” by screening, contact-tracing and isolating infected patients along with multi-sectoral approach, social mobilization and community engagement. however, for sustaining the ‘mission dharavi win’, it is important to resolve the environment and sanitation issues on a longterm basis. this chase the virus approach could also be used as an example in similar settings like slums in pakistan, bangladesh, favelas of brazil or shanty towns in south africa. however, the wider applicability of these experiences is subject to differences in socio-political environments and further remodelling of this strategy can be done to fit the contextspecific needs of the affected communities. references 1. government of india. press information bureau, delhi. government of india issues orders 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______________________________________________________ https://stopcoronavirus.mcgm.gov.in/iom-treatment-facilities https://stopcoronavirus.mcgm.gov.in/iom-treatment-facilities https://stopcoronavirus.mcgm.gov.in/iom-treatment-facilities https://www.mumbailive.com/en/infrastructure/mumbai's-containment-areas-to-be-classified-into-red-orange-and-blue-zones-based-on-the-severity-of-cases-48568 https://www.mumbailive.com/en/infrastructure/mumbai's-containment-areas-to-be-classified-into-red-orange-and-blue-zones-based-on-the-severity-of-cases-48568 https://www.mumbailive.com/en/infrastructure/mumbai's-containment-areas-to-be-classified-into-red-orange-and-blue-zones-based-on-the-severity-of-cases-48568 https://www.mumbailive.com/en/infrastructure/mumbai's-containment-areas-to-be-classified-into-red-orange-and-blue-zones-based-on-the-severity-of-cases-48568 https://www.mumbailive.com/en/infrastructure/mumbai's-containment-areas-to-be-classified-into-red-orange-and-blue-zones-based-on-the-severity-of-cases-48568 https://www.mumbailive.com/en/infrastructure/mumbai's-containment-areas-to-be-classified-into-red-orange-and-blue-zones-based-on-the-severity-of-cases-48568 https://m.dailyhunt.in/news/india/english/mumbai+live+english-epaper-mliveng/bmc+has+quarantined+over+6+500+at+its+facility+in+dharavi+so+far-newsid-n185467382 https://m.dailyhunt.in/news/india/english/mumbai+live+english-epaper-mliveng/bmc+has+quarantined+over+6+500+at+its+facility+in+dharavi+so+far-newsid-n185467382 https://m.dailyhunt.in/news/india/english/mumbai+live+english-epaper-mliveng/bmc+has+quarantined+over+6+500+at+its+facility+in+dharavi+so+far-newsid-n185467382 https://m.dailyhunt.in/news/india/english/mumbai+live+english-epaper-mliveng/bmc+has+quarantined+over+6+500+at+its+facility+in+dharavi+so+far-newsid-n185467382 https://m.dailyhunt.in/news/india/english/mumbai+live+english-epaper-mliveng/bmc+has+quarantined+over+6+500+at+its+facility+in+dharavi+so+far-newsid-n185467382 https://m.dailyhunt.in/news/india/english/mumbai+live+english-epaper-mliveng/bmc+has+quarantined+over+6+500+at+its+facility+in+dharavi+so+far-newsid-n185467382 https://twitter.com/mybmc/status/1275386375945154562 https://twitter.com/mybmc/status/1275386375945154562 tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 1 | 12 original research prevalence of chronic obstructive pulmonary disease (copd) in albania holta tafa1, donika mema2, arian mezini1, jolanda nikolla3, alma teferici1, dafina todri1, genc burazeri4, hasan hafizi1 1 university hospital “shefqet ndroqi”, tirana, albania; 2 institute of public health, tirana, albania; 3 american hospital, tirana, albania; 4 faculty of medicine, university of medicine, tirana, albania. corresponding author: hasan hafizi, md, phd; address: rr. “shefqet ndroqi”, tirana, albania telephone: +355697491518; email: hasanhafizi@hotmail.com tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 2 | 12 abstract aim: the objective of this study was to determine the prevalence of copd and its associated factors among adults in albania. methods: this was a cross-sectional study conducted in albania in 2013-14. a nation-wide representative sample of 1200 adults aged ≥40 years was selected using multistage cluster sampling technique. all participants were interviewed about socio-demographic characteristics, respiratory symptoms, smoking status and clinical characteristics. spirometry was performed according to standard methods. copd was defined as post-bronchodilator fev1/fvc ratio <70% predicted. results: of the 1200 adults invited to participate, 939 adults or 78% (467 men and 472 women) were eligible for the study. the overall copd prevalence (gold stage 1 or higher) was 12.4%; it was higher in men (17.4%) than in women (7.7%). using lower limit of normal (lln), the prevalence of copd was 9.9%, again higher in men (13.2%) than women (6.6%). the prevalence of doctor-diagnosed copd was 1.3% (1.9% in men, 0.6 % in women). male sex, smoking and increasing age were significantly associated with copd diagnosis. conclusion: the overall prevalence of copd in albania was 9.9% using bold standards. smoking and increasing age were the main risk factors for copd. the study highlights the importance of raising awareness of copd among health professionals. keywords: albania, bold study, copd prevalence, risk factors. conflicts of interest: none declared. tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 3 | 12 introduction chronic obstructive pulmonary disease (copd) is currently the fourth leading cause of death in the world but is projected to be the 3rd leading cause of death by 2020 (1). globally, the copd burden is projected to increase in coming decades because of continued exposure to copd risk factors and aging of the population (2). copd prevalence, morbidity and mortality vary across countries and across different groups within countries. copd is the result of a complex interplay of long-term cumulative exposure to noxious gases and particles, combined with a variety of host factors including genetics, airway hyper-responsiveness and poor lung growth during childhood (3,4). often, the prevalence of copd is directly related to the prevalence of tobacco smoking, although in many countries outdoor, occupational and indoor air pollution (resulting from the burning of wood and other biomass fuels) are major copd risk factors (5,6). despite a growing burden, copd is often a neglected disease and its epidemiology is largely unknown in particular in low and middle income countries (7). existing copd prevalence data vary widely due to differences in survey methods, diagnostic criteria and analytical approaches (2). many patients with copd are still underdiagnosed, inadequately evaluated and under-recognized leading to significant underreporting of the disease (8,9). community based studies using appropriate methods are needed to determine the epidemiology of copd and to enable the development of prevention and management strategies for the future. the burden of obstructive lung disease (bold) initiative aimed at developing and using a standardized method to measure the prevalence of copd and its risk factors in various areas around the world (10,11). in our study, we used bold protocol to estimate the prevalence and burden of copd in albania. methods bold developed standardized methods including standardized spirometry equipment, meticulous quality control measures, standard protocols, validated and translated questionnaires and standard data entry and analysis. bold operations centre (oc) emphasized data quality control at every stage of the process. the study was conducted in close collaboration with the bold operations centre (oc) in london which provided oversight, training, materials, quality control, and data analysis. national bioethics committee’s approval was a prerequisite for study implementation. study design this was a cross-sectional study conducted in albania in 2013-14, which consisted of a copd prevalence survey among adults aged ≥40 years. a representative sample of adult individuals in this age range was asked to fill in the questionnaires and perform spirometry tests designed by bold. target population and sampling procedure: a nation-wide representative sample was drawn. a multi-stage cluster sample of 1200 individuals (600 men and 600 women) aged ≥40 years was drawn based on the sampling frame (alias the target population) available from the national institute of statistics (instat). boldoc in london, uk, reviewed and approved the sampling approach calculated by a local expert. recruitment of participants: participants were contacted through home visits and were tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 4 | 12 asked to provide an informed consent to schedule a clinic visit and where necessary. study measures spirometry was performed by eight trained and certified technicians (easyone spirometer; ndd medizintechnik; zurich, switzerland). copd was defined as a post-bronchodilator fev1/fvc <70% predicted. spirometry data were sent electronically to the oc where each spirogram was reviewed and graded using ats guidelines (12). post bronchodilator spirometry tests were performed at least 15 min after achievement of at least 3 acceptable and 2 reproducible pre bronchodilator spirometry tests. the number of pack-years of cigarette smoking was defined as the average number of cigarettes smoked per day divided by 20 (i.e., packs per day) times the duration of smoking in years. data recording and analysis data for bold study consisted of electronically generated spirometry records, responses to questionnaires administered to study participants, individual tracking data, and aggregate data about the target population. our data were reported to oc for validation and analysis. estimated population prevalence of copd for the overall city population was computed using survey data methods in stata v. 12 (stata corporation, college station, tx, usa), and stratified by sex, age and smoking status. the study was conducted from october 2012 to december 2013. results of the 1200 adults invited to participate, 997 (83%) of them were eligible for the study. among them 11 participants were excluded because of lost spirometry data due to the faulty spirometer and 47 other participants due to unacceptable post bd spirometry. table 2 shows that there were no differences between responders and non-responders who were eligible for the study, except for smoking status and other co-morbid conditions (p<0.001 and p<0.007, respectively). participants that were current smokers and those with co-morbid conditions were less likely to be responders. table 3 shows the prevalence of smoking in albania by sex and age. overall, 21.6% of individuals ≥40 years old were smokers at the time of the study. smoking was much more prevalent in males than in females. the percentage of smoker was higher in age group 50-59. the overall prevalence of gold stage i or higher copd was 12.4%, and was higher in male (17.4%) than female sex (7.7%) and in those >70-year old. using lower limit of normal (lln) the prevalence of copd was 9.9%, again higher in males (13.2%) than females (6.6%) and like using gold criteria was higher in individuals > 70 years old (table 4). the prevalence of copd was strongly related to smoking history expressed as pack years as shown in table 5. table 6 shows the prevalence of smoking in albania by sex and age. overall, 21.6% of individuals ≥ 40 years old were smokers at the time of the study. smoking was much more prevalent in males than in females. the percentage of smokers was higher in age group 50-59. the prevalence of doctordiagnosed copd was much lower than spirometry-confirmed copd, with an overall estimate of 1.3% (1.9% in males, 0.6 % in females) (table 28). it was higher in group >70 years. tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 5 | 12 table 1. disposition of study participants for bold site: tirana, albania outcome men women unknown total responders: full data collected (core ques plus qc acceptable post bd spirometry) 467 472 0 939 full data collected (core ques plus qc unacceptable post bd spirometry) 27 20 0 47 full data collected (spirometry data lost due to faulty spirometer)* 2 9 0 11 total responders 496 501 0 997 non-responders: partial data collected 51 49 0 100 refused (minimal data collected) 2 2 0 4 refused (no minimal data collected) 43 32 0 75 known to have temporarily left area 3 10 0 13 unreachable (couldn’t reach)† 4 5 0 9 total non-responders 103 98 0 201 ineligible: deceased 1 1 0 2 permanently left catchment area 0 0 0 0 age ineligible 0 0 0 0 institutionalized 0 0 0 0 untraceable (bad address & phone)‡ 0 0 0 0 total ineligible 1 1 0 2 total selected for recruitment¶ 600 600 0 1200 * some spirometry data was lost before it could be transferred, due to a faulty spirometer; † contact information apparently correct, but no response to contact attempts; ‡ contact information incorrect, no updated information available; ¶ number of responders + non-responders + ineligibles. table 2. comparison of responders* and non-responders† for albania responders non-responders p-value‡ age 40-49 351 (36%) 81 (40%) 0.382 50-59 330 (33%) 55 (27%) 60-69 191 (19%) 40 (20%) 70+ 114 (12%) 25 (12%) gender male 494 (50%) 103 (51%) 0.768 female 492 (50%) 98 (49%) smoking status current 213 (22%) 46 (23%) <0.001 ex 148 (15%) 9 (4%) never 625 (63%) 146 (73%) doctor diagnosed asthma, emphysema, cb or copd yes 64 (6%) 6 (3%) 0.056 no 922 (94%) 194 (97%) other co-morbid conditions yes 260 (26%) 72 (36%) 0.007 no 726 (74%) 129 (64%) * responders are those who completed post-bd spirometry (regardless of qc scores) and the core questionnaire. † non-responders are eligible individuals who are missing the core questionnaire and/or post-bd spirometry, but for whom the tabulated variable is known. ‡ two-sided p-value based on pearson’s chi-square test tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 6 | 12 table 3. estimated population prevalence (se) of gold stage 1 or higher copd* by age and sex for albania age-group sex 40-49 50-59 60-69 70+ total male 3.8 (0.5) 10.0 (2.3) 28.4 (6.7) 52.5 (7.5) 17.4 (2.5) female 2.3 (0.5) 4.1 (1.9) 17.0 (6.1) 14.7 (5.2) 7.7 (2.3) total 3.0 (0.4) 7.0 (1.5) 22.4 (4.7) 32.3 (4.9) 12.4 (1.7) * post-bd fev1/fvc <70%. table 4. estimated population prevalence (se) of copd in tirana, albania, using lower limit of normal (lln): modified stage 1 or higher copd* by age and sex (local equations) age-group sex 40-49 50-59 60-69 70+ total male 4.2 (0.9) 5.3 (2.3) 21.2 (2.2) 41.2 (11.0) 13.2 (2.6) female 3.8 (1.4) 4.1 (1.9) 12.3 (5.5) 10.7 (2.4) 6.6 (1.4) total 4.0 (0.8) 4.7 (1.5) 16.5 (3.2) 24.9 (5.4) 9.9 (1.4) * post-bd fev1/fvc < lln table 5. estimated population prevalence (se) of gold stage 1 or higher copd* by pack years and sex in tirana, albania pack-years sex never smokers 0-10 10-20 20+ total male 6.2 (2.2) 10.2 (4.8) 7.6 (2.3) 27.6 (4.6) 17.4 (2.5) female 6.1 (2.9) 19.8 (18.9) 24.2 (11.5) 9.0 (8.4) 7.7 (2.3) total 6.1 (2.1) 14.8 (9.5) 14.3 (5.5) 27.0 (4.5) 12.4 (1.7) * post-bd fev1/fvc < 70% and post-bd fev1 < 80% predicted table 6. prevalence of current smoking by age and sex in tirana, albania age-group sex 40-49 50-59 60-69 70+ total responders with usable data* male 40.5% 44.6% 29.3% 21.0% 35.8% female 7.8% 8.4% 5.3% 3.0% 7.3% total 22.5% 23.6% 19.9% 15.8% 21.6% population† male 44.5% (5.2) 46.7% (1.7) 29.4% (5.6) 21.1% (7.8) 38.7% (3.2) female 6.5% (3.2) 8.3% (1.8) 4.8% (4.2) 5.2% (4.5) 6.5% (0.9) total 25.3% (3.2) 27.9% (1.0) 17.1% (4.4) 12.4% (4.0) 22.4% (1.8) * non-weighted data for the sample of responders. † weighted population estimate, with se shown in parenthesis. tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 7 | 12 table 7. estimated population prevalence (se) of doctor-diagnosed copd* by age and sex in tirana, albania agegroup sex 40-49 50-59 60-69 70+ total male 0 1.7 (1.4) 3.8 (1.8) 4.4 (2.6) 1.9 (0.8) female 0 2.3 (0.7) 0 0 0.6 (0.1) total 0 2.0 (0.8) 1.9 (0.9) 2.0 (1.2) 1.3 (0.4) * includes chronic bronchitis, emphysema or copd discussion this is the first copd prevalence study ever conducted in albania. response rate for albania was high, both for males and females, 82.3%. response rates among females were slightly higher, 84% as compared to 83% for males, although not statistically significant. we did not observe any difference among the responders according to age groups, doctor diagnosed asthma, emphysema, chronic bronchitis (cb) or copd, but we found statistically significant difference in relation to smoking status and other co-morbid conditions. the percentage of responders and nonresponders among current smokers was similar, showing that completing questionnaires and performing spirometry was not easy for a current smoker. the percentage of never smokers for non-responders and responders was respectively 73% and 63%, (p<0.001), showing that never smokers are less concerned about respiratory health status. among participants with co-morbid conditions, the percentage of non-responders and responders was respectively 64% and 74%, (p<0.007), showing that presence of co-morbid conditions is likely to increase awareness about respiratory health status. our study showed that the overall copd prevalence (gold stage 1 or higher) in albania was 12.4%, and was higher in males (17.4%) than females (7.7%) and in those aged > 70 years old. using lower limit of normal (lln) the prevalence of copd was 9.9%, again higher in males (13.2%) than females (6.6%) and like when using gold criteria, was higher in those aged > 70 years old. thus, the prevalence of copd using lln was lower than the prevalence estimated using gold criteria. the global initiative for chronic obstructive lung disease (gold) uses a fixed ratio of fev1/fvc of 0.7 for the diagnosis of obstruction by spirometry, regardless of age, sex or height (13). this may result in falsepositive diagnose of copd in elderly subjects, as the ratio has a small but significant age related regression (14). the ats/ers task force has recommended the use of lower limit of normal (lln) rather than a fixed ratio to avoid overdiagnosis of copd (15). in our study we used lln for that purpose. a literature review of the epidemiology of chronic obstructive pulmonary disease showed that the prevalence estimates varied widely, depending on the methods used for diagnosis and classification of copd (1618). the reported prevalence of copd ranged from 0.2% in japan to 37% in usa (19). another systematic review for europe countries showed that prevalence estimates varied from 2.1% to 26.1%, depending on country, age group and methods used (20). comparing our data to the international bold studies we conclude that copd prevalence in albania is lower than that reported from many other countries like: austria tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 8 | 12 26.1% (21); iceland 18% (22); germany 13.2% (23), and higher than that of other countries like: china 8.2% (24) and australia 7.9% (25). these geographical differences, despite the use of the bold protocol, could be attributed to different levels of smoking in the local population, or possibly other risk factors, such as genetic predisposition, occupation, biomass and air pollution. our study showed a significant correlation between age and smoking history expressed as pack years (r = 0.500; p < 0.001). the association of copd with old age may be attributed to a greater exposure to risk factors (26,27). the prevalence of copd in women in our study was lower than in men like in most of the countries worldwide due to the fact that women traditionally smoke much less than men (28). this situation has changed in some developed countries, where the prevalence of smoking in women is now often as high as that in men (29). the prevalence of copd in never smokers was surprisingly similar for both men and women, which differs from that of most of the studies. the high prevalence of copd among women in most of the developing countries is attributed to biomass and cooking conditions (30-32). in albania it does not appear to be a major contributory factor. the prevalence of smoking in our study was 21.6%. it was higher in males than females, 35.8% and 7.3% respectively. the highest prevalence was in age groups 50-59 and 4049 years; there was a trend for smoking cessation with increasing age. we think that this fact is related to the co-morbidities that associate the age group above 60 years old. an important fact is noted in relation to female smoking status. in females over 40 years smoking was not as prevalent as in males in population. this is related to the fact that our society is a conservative one. but this trend has changed for younger generations: in females under 40 years old an increase in smoking prevalence was observed. our study showed that the prevalence of smoking was 17% in group age 20-39, as compared to 7.3% in other group ages above 40 years old. this high percentage was found mainly in the urban areas, whereas in rural areas smoking prevalence in this group age did not differ compared to other group ages. the prevalence of copd in the smoker group (both former and current smoker) was found to be much higher than that in the non smoker group. similar findings were reported in most studies and cigarette smoking is the most common risk factor for copd worldwide (26,33). consistent with the present understanding of the role of smoking, we found a strong doseresponse relationship with pack-years of smoking (27,34). as found in other studies there was also a positive trend with the increasing of packyears, confirming smoking as an important risk factor for disease development (35,36). our data showed a low prevalence of doctor diagnosed copd reported by participants, only 1.3% and this finding was similar to most of the countries where under-diagnosis of copd is common (37). but there are countries where prevalence of doctor-diagnosed copd was higher like in south arabia 9.8% (38) and in salzburg, austria 5.6% (39). skipping spirometric confirmation of copd, thus leading to over-diagnosis, might be the reason behind reported data in south arabia (38). our data are consistent with those of other countries where there is still a high level of under-diagnosis. the need for spirometry tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 9 | 12 testing should be brought to the attention of primary care physicians. our study has several strengths. this is the first study conducted in balkan areas using bold protocol. moreover, we applied the bold protocol with standardized methodology and high-quality post-bd spirometry. such standardized methodology included standardized spirometry equipment, meticulous quality control measures, standard protocols, validated questionnaires and standard data recording, reporting and analysis. moreover, the use of a large sample size represents the whole country. conclusion we found that the prevalence of copd among adults in albania was high, with an estimated prevalence of 12.4% in adults ≥40 years old; 17.4% and 7.7% in men and women respectively. using lln, the prevalence of copd was lower, 9.9% (13.2% and 6.6% in men and women respectively). copd prevalence was strongly related to smoking and national smoking cessation policies are needed. doctor diagnosed copd reported by the participants was very low. these numbers clearly show a high degree of copd underdiagnosis and highlight the need to improve physicians’ knowledge about copd diagnosis and greater use of spirometry references 1. lozano r, naghavi m, foreman k, lim s, shibuya k, aboyans v, et al. global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the global burden of disease study 2010. lancet 2012;380: 2095-128. 2. mathers cd, loncar d. projections of global mortality and burden of disease from 2002 to 2030. plos med 2006;3:e442. 3. lange p, celli b, agustí a, boje jensen g, divo m, faner r, et al. lung-function trajectories leading to chronic obstructive pulmonary 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pulmonary disease, 2014. bethesda, md, usa: gold, 2014. 13. celli br, halbert rj, isonaka s, schau b. population impact of different definitions of airway obstruction. eur respir j 2003;22:268-73. 14. pellegrino r, viegi g, brusasco v, crapo ro, burgos f, casaburi re, et al. interpretative strategies for lung function tests. eur respir j 2005;26:948-68. 15. lindberg a, jonsson ac, rönmark e, lundgren r, larsson lg, lundbäck b. prevalence of chronic obstructive pulmonary disease according to bts, ers, gold, and ats criteria in relation to doctor’s diagnosis, symptoms, age, gender, and smoking habits. respiration 2005;72:471-9. 16. hnizdo e, glindmeyer hw, petsonk el, enright p, buist as. case definitions for chronic obstructive pulmonary disease. copd 2006;3:95100. 17. vaz fragoso ca, concato j, mcavay g, van ness ph, rochester cl, yaggi hk, et al. the ratio of fev1 to fvc as a basis for establishing chronic obstructive pulmonary disease. am j respir crit care med 2010;181:446-51. 18. rycroft ce, heyes a, lanza l, becker k. epidemiology of chronic obstructive pulmonary disease: a literature review. int j chron obstruct pulmon dis 2012;7:457-94. 19. atsou k, chouaid c, hejblum g. variability of the chronic obstructive pulmonary disease key epidemiological data in europe systematic review. bmc med 2011;9:2-16. 20. schirnhofer l, lamprecht b, vollmer wm, allison mj, studnicka m, jensen rl, et al. copd prevalence in salzburg, austria: results from the burden of obstructive lung disease (bold) study. chest 2007;131:29-36. 21. benediktsdóttir b, gudmundsson g, jörundsdóttir kb, vollmer w, gíslason t. prevalence of copd in iceland: the bold study. laeknabladid 2007;93:471-7. 22. geldmacher h, biller h, herbst a, urbanski k, allison m, buist as, et al. the prevalence of chronic obstructive pulmonary disease (copd) in germany. results of the bold study. dtsch med wochenschr 2008;133:2609-14. 23. zhong n, wang c, yao w, chen p, kang j, huang s, et al. prevalence of tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 11 | 12 chronic obstructive pulmonary disease in china: a large, population based survey. am j respir crit care med 2007;176:753-60. 24. toelle bg, xuan w, bird te, abramson mj, atkinson dn, burton dl, et al. respiratory symptoms and illness in older australians: the burden of obstructive lung disease (bold) study. med j aust 2013;198:144-8. 25. raherison c, girodet po. epidemiology of copd. eur respir rev 2009;18:213-21. 26. alam ds, chowdhury ma, siddiquee at, ahmed s, clemens jd. prevalence and determinants of chronic obstructive pulmonary disease (copd) in bangladesh. copd: j chron obstruct pulmon dis 2015;12:658-67. 27. kim ds, kim ys, jung ks, chang jh, lim cm, lee jh, et al. prevalence of chronic obstructive pulmonary disease in korea: a populationbased spirometry survey. am j respir crit care med 2005;172:8427. 28. soriano jb, maier wc, egger p, visick g, thakrar b, sykes j, et al. recent trends in physician diagnosed copd in women and men in the uk. thorax 2000;55:789-94. 29. kiraz k, kart l, emir r, oymak s, gulmez i, unalacak m, et al. chronic pulmonary disease in rural women exposed to biomass fumes. clin invest med. 2003;26:243-8. 30. gordon sb, bruce ng, grigg j, hibberd pl, kurmi op, lam kb, et al. respiratory risks from household air pollution in low and middle income countries. lancet respir med 2014;2:823-60. 31. ramírez-venegas a, velázquez-uncal m, pérez-hernández r, guzmánbouilloud ne, falfán-valencia r, mayar-maya me, et al. prevalence of copd and respiratory symptoms associated with biomass smoke exposure in a suburban area. int j chron obstruct pulmon dis 2018;13:1727-34. 32. mannino dm, buist as. global burden of copd: risk factors, prevalence, and future trends. lancet 2007;370:765-73. 33. salvi s, barnes pj. is exposure to biomass smoke the biggest risk factor for copd globally? chest 2010;138:3-6. 34. buist as, mcburnie ma, vollmer wm, gillespie s, burney p, mannino dm, et al. international variation in the prevalence of copd (the bold study): a population-based prevalence study. lancet 2007;370:741-50. 35. vanfleteren le, franssen fm, wesseling g, wouters ef. the prevalence of chronic obstructive pulmonary disease in maastricht, the netherlands. respir med 2012;106:871-4. 36. hill k, goldstein rs, guyatt gh, blouin m, tan wc, davis ll, et al. prevalence and underdiagnosis of chronic obstructive pulmonary disease among patients at risk in primary care. cmaj 2010;182:673-8. 37. al ghobain m, alhamad eh, alorainy hs, al kassimi f, lababidi h, al-hajjaj ms. the prevalence of chronic obstructive pulmonary disease in riyadh, saudi arabia: a bold study. int j tuberc lung dis 2015;19:1252-7. 38. schirnhofer l, lamprecht b, vollmer wm, allison mj, studnicka tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 12 | 12 m, jensen rl, et al. copd prevalence in salzburg, austria: results from the burden of obstructive lung disease (bold) study. chest 2007;131:29-36. 39. penña vs, miravitlles m, gabriel r, jiménez-ruiz ca, villasante c, masa jf, et al. geographical variations in prevalence and underdiagnosis of copd: results of the iberpoc multicentre epidemiological study. chest 2000;118:981-9. ________________________________________________________________________________________ © 2021 tafa et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. merkel b. a growing competence: the unfinished story of the european union health policy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-2015-15 1 commentary a growing competence: the unfinished story of the european union health policy bernard merkel1 1 visiting research fellow, london school of hygiene and tropical medicine, london, uk. corresponding author: dr. bernard merkel address: dg sante, european commission, brussels; email: merkebe@gmail.com mailto:merkebe@gmail.com� merkel b. a growing competence: the unfinished story of the european union health policy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-2015-15 2 a few months ago, the south eastern european journal of public health (seejph) published a lengthy article by hans stein on the importance of the maastricht treaty of 1992 and how the european union (eu) health policy has developed since then (1). undoubtedly, dr. stein made a major contribution to this story himself and in his paper he sets out his own viewpoint on key events and trends, offering us a wealth of historical detail and many real insights. but, like all good commentators who try to condense and make sense of a tortuous and convoluted sequence of events spanning more than two decades and involving very many players, he inevitably omits parts of the story, and his interpretations can sometimes give rise to more questions than answers. in this review, i will entirely leave aside his general discussion of the overall evolution of the eu and its future prospects, and instead concentrate on a few specific points about the development of eu health policy to date. it is a truism, and the beginning of perceived wisdom on the history of eu health policy, that the maastricht treaty introduced the first explicit ec (european community) legal competence for public health, devoting an article to it (article 129). it is also true, as dr. stein mentions, that there was much health-related activity in the ec well before the advent of the maastricht treaty. such actions, in fact, go back many years. for instance, there was an ec directive on pharmaceuticals in 1971 and in the same year a regulation on coordination of social security systems providing rights to health care to workers in other ec countries. moreover, various public health programmes on cancer, aids and drugs also predate maastricht. yet, article 129 represented the first explicit framework for public health. however, dr stein makes the more interesting point that this competence was “often but never substantially changed in the subsequent treaties”. and, again, “the main components of article 129 were slightly reworded in the following treaties, but essentially are still valid”. in saying this he is implying that it was and remains after several treaty changes, a very weak competence which results from the “defensive and negative position of ms” (eu member states) and reflects their position “to keep the eu as far away as possible from influencing their health policy”. there is no doubt that the health ministries of the older ms, and most, if not all, of the newer ones, have never wanted the eu to tell them how to run their healthcare systems, or to subsume their health policies into an eu-wide policy as has been done in areas such as trade or agriculture. and it is certainly the case, as dr. stein emphasizes, that the article 129 competence is a weak one – as well as being very ill-defined. but, this raises some further issues. as he says, it was ms, not the commission or the european parliament, that dominated the process of negotiating and agreeing the maastricht treaty. the question then must arise of why did these very ms decide to put into the treaty a new competence in public health at all if they did not want the ec (eu as it has become) to do anything of significance in this field? later in his paper, dr. stein quotes approvingly from an article by scott greer who says that article 129 “was the harbinger of more effective promotion of health issues within eu policy-making. in time, however, the internal market and the single currency have had the biggest health consequences”. and then, dr. stein adds the interesting comment that: “this was not really what the ms had in mind when they established a specific eu public health mandate”. of course, in 1992, the ms could not really have been thinking about the impact of the single currency which was not introduced until 1999! it is true that the treaty did set out some clear steps towards achieving an economic and monetary union. but, it seems far merkel b. a growing competence: the unfinished story of the european union health policy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-2015-15 3 fetched, to say the least, to suppose that those involved in designing a new public health competence would have given any thought to the potential impact on health of such a theoretical eventuality. similarly, how likely is it that many of them were envisaging the creation of some kind of protective instrument to counter the single market’s potential impact on public health? this may have been on the mind of one influential player: hans stein, at least according to what he wrote in an article some years later (2). in this he states that: “single market regulations are sure to have an impact on health and health policy.....the full consequences of the internal market in the field of health and health care are as yet unknown. to analyse, to support or to counteract them can be done effectively only on an eu scale”. but, it is doubtful that others were so far-sighted. moreover, if ms had really wanted to establish a health competence that could act as a bastion to promote and defend the interests of public health against the possible negative consequences of the single market, why did they make the public health competence so feeble that it ‘is the weakest legal base possible’? what seems more plausible is that ms (most of them in any case) saw some advantages in european cooperation in some health areas either where they faced common health problems such as aids, and tobacco, and on some apparently non-contentious topics, such as improving health information, and health education, where they could exchange experience and expertise. in doing so it is arguable that they were trying to achieve two objectives: first to show that the ec was not just about markets and economics but could play a valuable role in other policy spheres. this indeed was a general underlying thread of the maastricht treaty. it is noteworthy in this context that article 129 is sandwiched by two rather similar articles, 128 on culture, and 129a on consumer protection. the second aim could be seen as being perhaps a more cynical one: it was to give the ec a formal competence to take some actions in health, which they had in any case been doing for some time in fields such as cancer, aids and drugs, while reducing the potential for any future action in areas where ms did not wish to see ec involvement by defining the scope of the ec’s public health activities and explicitly limiting its competence in this field. this view was common among commission officials involved in health policy, including this reviewer, who expressed it in an article in 1995 (3). a second contestable point is the claim that the treaty competence on public health has remained essentially the same over the last two decades. on the face of it, this cannot really be the case. indeed what is particularly striking about this competence is how greatly the legal provisions have changed from treaty to treaty. unlike many other policy areas where the treaty provisions have remained largely unchanged, the wording about health has been greatly amended and the provisions have become more and more detailed. in the treaty of amsterdam of 1997, for example, the public health article (article 129 of the maastricht treaty) was significantly lengthened and the new article (article 152), among other things, included for the first time the power to make binding eu legislation in a few specific areas, in relation to blood and organs, and in some veterinary and phytosanitary areas. a quick look at the current health article, (article 168 of the lisbon treaty) will show that it is again substantially different from the ones agreed in previous treaties, as well as being very much longer. the areas of binding legislative powers introduced in 1997 are retained and there is a further one: medicinal products and medical devices, additionally, the scope for taking legal measures is increased, and now also includes cross-border threats to health, merkel b. a growing competence: the unfinished story of the european union health policy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-2015-15 4 tobacco and alcohol; and the article includes soft law provisions similar to those of the so called ‘open method of coordination’ used in social and employment policy. the article also concedes for the first time that the eu in the framework of its public health competence may have a role in relation to health services, saying that the eu: “shall in particular encourage co-operation between the ms to improve the complementarity of their health services in cross-border areas”. finally, of course, in addition to article 168, the treaty of lisbon also incorporates the charter of fundamental rights of the eu. article 35 of this promulgates a right in respect of health care: “everyone has the right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices. a high level of human health protection shall be ensured in the definition and implementation of all the union’s policies and activities”. hence, clearly, the eu’s legal competence has considerably evolved since the maastricht treaty. but perhaps dr. stein is making a deeper point, that regardless of the specific textual amendments in successive treaties, the underlying scope of and limitations on the eu’s public health competence have not fundamentally changed. there is some strength in this argument. but the position is not as clear-cut as he maintains. the first point to be considered is similar to the one we have made in connection with the article 129 of the maastricht treaty. if ms wanted to preserve the eu’s public health power weak and nebulous, why did they not simply keep it as it was? why did they keep changing it (and adding to it!) in each treaty revision? we can advance several reasons. first, there was never unanimity among the ms about the extent of the eu’s role in public health, and in fact a diminishing degree of consensus as more ms joined the eu. some of them, notably the newer ms, actively welcomed a greater eu involvement not only in developing national public health policies but even in respect of the functioning of their health systems. second, the treaty reformulations represent (to some extent) responses to developments in europe and beyond. gradually, even against their basic instincts, most, if not all, ms came to appreciate that the eu could be of use in helping tackle some health problems that would be difficult to deal with by individual countries acting separately. these include for example • responding effectively to health threats from communicable diseases and man-made and natural disasters, • tackling various health determinants, • developing a framework for regulating health goods and related items that circulate in europe, and • responding to global health problems. thirdly, the ms were not negotiating in a vacuum; they had to take into account public opinion and, in particular, the views of the other eu institutions, notably the european parliament (ep) and the commission which both pressed at various points for the eu to be given additional powers in particular health fields. in relation to the maastricht treaty, for example, the commission may have had a limited role in the actual negotiations, but it made proposals for what it wanted to see, it liaised with ms about how texts were worded and certainly followed the negotiations extremely closely. the final draft of the new public health article therefore came as no surprise to the commission. and directly after the treaty had been ratified on 1 november 1993, it published a detailed communication setting out how it intended to implement the new provisions (4). similarly the ep played a very forceful role in the bse crisis which led both to a substantial shake–up in the organization of the commission services to separate agriculture from food safety and also to pressure to merkel b. a growing competence: the unfinished story of the european union health policy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-2015-15 5 strengthen the treaty provisions on the protection of public health. this resulted in the inclusion in article 152 of the amsterdam treaty of provisions allowing for binding measures to be taken in the veterinary and phytosanitary fields in relation to public health, and the extension of the overall scope of ec public health action to “preventing human illness and diseases, and obviating sources of danger to human health”. certainly, dr. stein is right in his contention that the health ministries of many ms have never been the warmest advocates of increasing eu competence in health. yet despite this the fact remains that it has increased, is increasing and seems likely to continue to increase. paradoxically, it is arguable that the prime movers of this growth in eu power have not generally been those in the health field, but rather those in charge of other policy areas who have never been so zealous about national prerogatives in relation to health. decades ago it was heads of government who pushed for action on the single market which led ultimately led to eu action on pharmaceuticals, mutual recognition of health professionals and reciprocity of health insurance coverage. later those same heads of government called for eu action on cancer and aids. in the last few years it has again been heads of government and finance ministers who have set up a new eu system of economic governance which has led to direct interventions in ms’s budgetary and economic policies and through those means intrusion into their national health care policies. today, as part of this system, we have an eu instrument, the semester, which enables the eu to give every ms specific (non-binding but very influential) recommendations on the main issues confronting their healthcare systems, their health spending and the reforms they should make. we have obviously travelled a very long way indeed from the arguments about whether the eu had a significant role in public health policy, let alone that it could have anything to do with the functioning of national health systems. dr. stein has written a thought-provoking article which helps us to trace the path that has been followed and offers us some pointers to what may come in the future for european health policy. as he wrote in 1995: “it may take some time, but i have little doubt that when the range of possibilities inherent in the new treaty provisions are really used, their impact on public health will be greater than anybody expects today” (5). now, twenty years and several treaties later, we can see just how prescient he was. references 1. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives. seejph 2014; posted: 23 december 2014. doi 10.12908/seejph-2014-36. 2. stein h. experiences of the german presidency: small steps towards integrating public health. eurohealth 1995;1:19-20. 3. merkel b. the public health competence of the european community. eurohealth 1995;1:21-2. 4. european commission. communication on the framework for action in the field of public health. com(93)559 final. 5. stein h. experiences of the german presidency: small steps towards integrating public health. eurohealth 1995;1:19-20. © 2015 merkel; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0)� commentary bernard merkel1 references adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria prosper adogu1, ifeoma udigwe1, achunam nwabueze1, echendu adinma1, gerald udigwe2, chika onwasigwe3 1 department of community medicine and primary health care, nauth, nnewi, nigeria; 2 department of obstetrics and gynaecology, nauth, nnewi, nigeria; 3 department of community medicine, unth, enugu, nigeria. corresponding author: dr prosper ou adogu, department of community medicine and primary health care, nauth, nnewi, nigeria; home address: ezekwuabo otolo, nnewi (opposite transformer), anambra state, nigeria; telephone: +2348037817707; e-mail: prosuperhealth@yahoo.com 1 adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 abstract aim: young people need protective information and skills in order to reduce the risk associated with unsafe sex. this study assessed and compared the sexual health knowledge, attitude and risk perception of in-school and out-of-school female unmarried adolescents in onitsha north local government area, anambra state, nigeria. methods: a comparative cross-sectional design was used in which 391 in-school female adolescents (mean age: 15.9±1.4 years) were selected from 25 private and 17 public schools in onitsha north local government area, anambra state, nigeria using multistage sampling method. a comparison group of 392 out-of school female adolescents (mean age: 15.5±2.5 years) was also selected from a major market in the same local government area using cluster sampling technique. data was collected from the respondents with pre-tested, interviewer-administered questionnaires on reproductive and sexual health knowledge, risk perception and attitude, sexual behaviour, contraceptive knowledge and sources of sexual health information. results: in-school girls demonstrated better knowledge of sexual and reproductive health compared to their out-of-school counterparts. the awareness of fertile period, contraception methods, sti and hiv transmission and prevention were all significantly better among the in-school adolescents compared to their out-of-school counterparts (p<0.05). they also had markedly higher risk perception of getting pregnant (p<0.05) or acquiring hiv infection (p<0.05) compared to their out-of-school counterparts. conclusion: about 21% of adolescents in this study area were involved in risky sexual behaviour and this was higher among the out-of-school adolescents than their in-school counterparts. all stakeholders in the state and the local government area should come together and develop interventions that would improve the sexual health knowledge and sexual risk perception of the adolescents. keywords: attitude, female adolescents, in-school, knowledge, nigeria, onitsha, out-ofschool, risk perception, sexual health. 2 adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 introduction adolescents (10-19 years), especially females, are most vulnerable to unsafe sex. they also bear the brunt of the consequences. it is estimated that nearly two-thirds of premature deaths and one-third of the total disease burden in adults are associated with behavioural factors that began in youth and unprotected sex is mentioned among these factors (1). most studies and interventions on adolescents in sub-saharan africa and nigeria target in-school adolescents because they are easily accessible, easier to organize and monitor compared to those who are not in school. however, most of the secondary school age youths in nigeria are not in school (63% of boys and 79% of girls) (2). worldwide, about 120 million school-aged children are out of school and slightly more than half of these are girls and one-third of these children are in sub-saharan africa and 10% in nigeria (3). a recent study in anambra state, nigeria, reported that 43% of pregnant girls were expelled from school and none was recalled back (4). similar studies conducted in botswana also reported that most pregnant teenagers drop out of school (5). studies have shown that most out-of-school adolescents do not live with their parents and are found most times on the street, market places or motor parks hawking or serving as shop assistants to others (6-9). this is why most are vulnerable to unsafe sex and have lower sexual health knowledge compared to their in-school counterparts. adolescents seek reproductive and sexual health information from a variety of non-formal sources that include peers, pornography and magazines. the unguided youth usually experiment with the information received and often become exposed to stis, unwanted pregnancy among others. young people need protective information and skills in order to reduce the risk associated with unsafe sex. studies in other parts of nigeria showed in-school adolescents reporting teachers and parents as their main sources of information while out-of-school adolescents reported friends and the media as their main sources of information on sexual health (10,11). the findings are consistent with studies carried out in other african countries like in uganda where as many as 69% of out-of-school adolescents receive their information from their peers compared to only 8% of their counterparts (12). research has shown that the knowledge of out-of-school adolescents on sexual health issues is poor. a study carried out in lagos reported that two-fifths of respondents did not know that pregnancy could occur during their first sexual intercourse, most felt there was no risk associated with sexual intercourse and some had misconceptions that abstinence after menarche was harmful. many of participants also felt that having sex was necessary to show love in relationships (13). in various studies, preferred sources of sexuality information include the health workers and parents (10,14-16). this is because they give reliable information unlike peers who could give wrong and misleading information. the out-of-school adolescents are not easily accessible, because they are always on the move and not available for follow-up activities (12). therefore, it is important to clarify the needs of both groups taking into consideration the social and environmental factors, peer norms, beliefs and values of the different groups in order to develop and implement successful prevention programmes for the two groups. onitsha, nigeria, holds the largest market in west africa, and second only to lagos in youth concentration. therefore, an area of large youth concentration such as onitsha is most suited for this proposed research. the objectives of this study were to assess and compare the sexual health knowledge, attitude and risk perception of in-school and out-of-school female unmarried adolescents in onitsha north local government area (lga), anambra state, nigeria. 3 adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 methods design and study area a cross-sectional, comparative study was carried out in 2012 including unmarried in-school and out-of-school female adolescents aged 10-19 years residing in onitsha north lga in anambra state, nigeria. the onitsha main market, reputedly the largest in west africa, enjoys large patronage by traders and visitors from all over nigeria and virtually all west african countries. there are other satellite markets (about 30) to relieve the enormous pressure on the main market. many out-of-school children are found in every part of the market hawking virtually anything. some are in the market as shop assistants, while some are left entirely on their own in some stores. this constitutes the setting for the out-of-school aspects of this study. also, the onitsha north lga has 25 private schools and 17 public schools, giving a total of 42 schools. there are 22 mixed schools, 12 boys’ only schools and 8 girls’ only schools. some of the schools belong to the mission, some a government-owned, while the rest are private schools. study population the study population consisted of unmarried female adolescents between the ages of 10-19 years and comprised: a) in-school adolescents and b) out-of-school adolescents. for inschool, only those in senior secondary school one to senior secondary school three (sss1sss3) were considered for the study for comparison with their counterparts. this is because most of the out-of-school adolescents are within the age range of those in these classes than the classes below. for out-of-school adolescents, those that had never been to secondary school, finished primary school but did not continue or had dropped out of secondary school were considered eligible. the exclusion criteria included, for in-school, all the post-secondary school adolescents, those with hearing, speech and mental disabilities; and for out-of-school, all adolescents employed or unemployed who had finished secondary school and those with mental, hearing or speech disabilities. minimum required sample size was determined for comparison of two independent groups (in-school vs. out-of school female adolescents) (17). based on reports from previous studies conducted in nigeria (13,18) and an anticipated response rate of 90%, a total of 236 individuals constituted the minimum sample size. however, it was decided to recruit a total sample of 800 female adolescents (400 among in-school adolescents and 400 among out-of school adolescents) in order to considerably increase the power of the study. selection of in-school adolescents consisted of a two-staged sampling technique which employed stratified sampling method in the first stage and simple random sampling method in the second stage. secondary schools in the area were stratified into four categories as follows: two female-only private, six female-only public, 17 mixed private and five mixed public schools. from each of the strata, one school was selected using stratified random sampling technique. from each selected school, 100 respondents were chosen using simple random sampling method and ensuring proportionate representation from classes sss1-sss3 reaching a total sample size of 400 respondents. out-of-school adolescents were selected using cluster sampling technique as was done in previous studies (12,19). the market is estimated to have more than 60 clusters. clusters of 30 were selected by simple random sampling from the sampling frame containing the list of all the clusters twice (13). using the who cluster sampling method, seven consenting adolescents were selected from each cluster until a total of 400 respondents was reached. since the clusters were in different directions, a bottle was spun and the direction of its mouth was used to show the starting point of the study. 4 adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 data collection the same pre-tested interviewer-administered questionnaires were used for both in-school and out-of-school adolescents to ensure uniformity. the questionnaires were pretested among 20 in-school adolescents and 20 out-of-school adolescents in nnewi north lga for suitability, reliability, acceptability and appropriateness. the questionnaires were used to collect information on variables such as: demographic characteristics, sexual health knowledge, attitude and hiv risk perception, pattern of sexual behaviour, contraceptive use and sources of sexual health information. eight hundred questionnaires were handed out, but 783 were returned (391 for in-school and 392 for out-of-school) – yielding an overall response rate of approximately 97.9%. data analysis spss version 17 was used for data entry and analysis. chi-square test was used to compare proportions of the categorical variables and t-test for comparison of mean values of the numerical variables. differences and associations yielding p-values ≤0.05 were considered statistically significant. results the mean age of in-school girls was 15.9±1.4 years and that of the out-of-school girls was 15.5±2.5 years. most respondents in both groups were catholics, though more predominant among in-school girls (59.8%) as shown in table 1. majority (57.9%) of the out-of-school girls lived most of their time with relatives, either of the two parents, friends and boyfriend compared to 77.7% of the in-school girls who lived most of their time with both parents (p=0.001). table 1. socio-demographic characteristics of the groups [numbers (column percentages)] socio-demographic characteristics in-school (n=391) out-of-school (n=392) p-value* age (in years): 10-13 14-15 16-17 18-19 9 (2.4) 135 (34.5) 204 (52.1) 43 (11.0) 84 (21.4) 91 (23.2) 118 (30.1) 99 (25.3) 0.001 religion: roman catholic protestant pentecostal islam others-sabbath, jehovah’s witness 234 (59.8) 90 (23.0) 54 (13.8) 4 (1.0) 9 (2.4) 187 (47.7) 132 (33.7) 69 (17.6) 4 (1.0) 0 (0.0) 0.001 who they live with most time? both parents relative either parent friends boyfriend other 297 (77.7) 31 (8.4) 33 (9.0) 4 (14.8) 1 (0.3) 2 (0.5) 162 ( 43.9) 133 (35.7) 55 (14.9) 23 (6.2) 9 (2.4) 0 (0) 0.001 * chi-square test. in-school girls demonstrated better knowledge of sexual health compared to their peers that were out-of-school, as shown in table 2. they had statistically significant knowledge of 5 adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 fertile period compared to their out-of-school counterparts (p=0.001). however, less than 30% of girls in both groups were aware of the fertile period in a woman’s cycle. also, the inschool respondents had better awareness of contraceptive methods, types of stis and hiv transmission and prevention than the out-of-school respondents, all of which were statistically significant. table 2. sexual health knowledge of the groups [numbers (percentages)] knowledge of sexual health in-school out-of-school p* knowledge of fertile period: during menstruation immediately after menstruation half way between two periods don’t know 45 (11.5) 124 (31.8) 108 (27.7) 109 (27.9) 76 (19.4) 95 (24.2) 40 (10.2) 181 (46.2) 0.001 knowledge/awareness of contraceptive methods:† condom abstinence oral pills safe period injectables withdrawal others none 285 (72.9) 120 (30.7) 84 (21.5) 57 (14.6) 38 (9.7) 47 (12.0) 2 (0.5) 52 (13.3) 267 (68.1) 98 (25.0) 60 (15.3) 14 (3.6) 28 (7.1) 13 (3.3) 0 (0.0) 75 (19.1) 0.001 knowledge/awareness of hiv/ aids/stis:† hiv/aids gonorrhea syphilis candidiasis chlamydia herpes others none 383 (98.0) 264 (67.5) 190 (48.6) 143 (36.6) 13 (3.3) 18 (4.6) 11(2.8) 41 (10.5) 383 (97.7) 217 (55.4) 163 (41.6) 108 (27.6) 12 (3.1) 8 (2.0) 8(2.0) 75 (19.1) 0.002 knowledge of hiv: hiv transmission can be:† by blood transfusion and sharing of sharp needles or blade through mother to child transmission by sharing food with a person with hiv through mosquito bite by witchcraft or supernatural means reduced by using condom reduced by not having sex at all 302 (77.2) 171 (43.7) 33 (8.4) 24 (6.1) 8 (2.1) 125 (32.0) 151(38.6) 315 (80.4) 97 (27.8) 64 (16.3) 66 (16.8) 30 (7.7) 47 (12.0) 36 (9.2) 0.001 * chi-square test. †multiple responses. the commonest methods of contraception known to both groups were condoms, followed by abstinence. less than 50% in both groups were not aware of other methods of contraception. almost all adolescents in both groups (98%) were aware of hiv as a type of sti, followed by gonorrhoea, syphilis and candidiasis. more than 50% of the girls in both groups knew that hiv can be transmitted by blood transfusion and sharing of sharp needles or blade. sixteen percent of out-of-school girls had the misconception that hiv can be transmitted by sharing food with an infected person and also through mosquito bites compared to less than 10% of the in-school girls. only 12% of the out-of school girls believed that hiv can be reduced 6 adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 using condoms, and a lower proportion of 9% believed it can be reduced by not having sex at all. this is in comparison to in-school girls with 32.0% and 38.6%, respectively (table 2). most of adolescents thought that a single sexual intercourse was enough for one to become pregnant or acquire hiv infection (table 3). in-school girls had better perception of risk of getting pregnant (x2=16.31, p=0.001) or acquiring hiv infection (χ2=21.98, p=0.001), following a single sexual exposure. however, a greater proportion of their out-of-school peers perceived their chance of acquiring hiv to be high (χ2=20.03, p=0.001). although most of adolescents could not rate their risk of acquiring hiv infection, most of them felt that their chance of getting the disease is nil or low. furthermore, although majority of adolescents believed that aids is real, in-school girls demonstrated better attitude. two hundred and forty five (62.7%) in-school girls compared to 36.0% out-of-school girls did not agree that girls should be sexually experienced prior to marriage. similarly, a significant proportion of adolescents agreed that unmarried couples should use condom sex (χ2=27.84, p=0.001) (table 3). table 3. knowledge, attitude and risk perception [numbers (column percentages)] attitude and risk perception in-school out-of-school p* number of sex before one can become pregnant: once 2-5 times >5 times don’t know 307 (78.5) 54 (13.8) 22 (5.6) 17 (4.4) 257 (65.6) 55 (14.0) 25 (6.4) 57 (14.5) 0.001 number of sex before one can get hiv infection: once 2-5 times >5 times don’t know 312 (79.8) 55 (14.1) 14 (3.6) 21 (5.4) 254 (64.8) 48(12.3) 26 (6.6) 64 (16.3) 0.001 perceives self at risk of acquiring hiv infection: none low moderate high don’t know 117 (29.9) 29 (7.4) 15 (3.8) 9 (2.3) 221 (56.5) 86 (21.9) 40 (10.2) 8 (2.0) 30 (7.7) 228 (58.2) 0.001 a girl should have sexual experience before marriage: agree dnk/unsure disagree 105 (26.9) 41(10.5) 245 (62.7) 89 (22.7) 162(41.3) 141 (36.0) 0.001 do you believe that aids is real? yes no don’t know 372 (95.1) 9 (2.3) 10 (2.6) 358 (91.3) 24 (6.1) 10 (2.6) 0.029 unmarried couples should use condom during sex: agree disagree don’t know 148 (37.9) 159 (40.7) 84 (21.5) 128 (32.7) 113 (28.8) 150 (38.3) 0.001 * chi-square test. discussion a major threat to health of the adolescent stems primarily from their sexual behaviour which is partly influenced by lack of knowledge of reproductive health issues. for example, only a 7 adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 small proportion of both groups knew that a woman is likely to become pregnant half way between periods and even a smaller proportion of out-of-school respondents (10%) significantly differed from in-school adolescent (28%) in this regard. this is consistent with the finding of the ndhs (2008) where only 19% of all women knew the women’s’ fertile period (20). the study conducted in the northern part of nigeria showed a lower result because only 3.1% knew when ovulation occurs (21). in south-africa (22), it is 11%, while it is higher in ethiopia (23) with 48%. this poor knowledge of fertile period amongst nigerian adolescents may be the reason why the level of unwanted pregnancies and abortions is high. currently, it is estimated that 23% of adolescents in nigeria have begun child bearing (20). this finding strengthens the need to educate adolescents on reproductive and sexual health issues. however, a large proportion of both groups in this study knew that pregnancy is likely to occur at first sexual contact. this finding is consistent with the studies carried out in three states in northern-eastern nigeria (49%) (15) and lagos (60.5%) (24), but slightly lower with that carried out in ethiopia (48%) (23). a higher percentage of the in-school girls had better awareness of contraceptive methods than the out-of-school girls. the condom is mostly known by both groups followed by abstinence and oral pills. this agrees with findings of other studies conducted among adolescents (6,2530). adolescents and most young people have high awareness of condoms than most contraceptive methods (26). this is probably due to the much publicity given to preventive measures such as the condom with the onset of hiv pandemic; sometimes it is even distributed free of charge to the sexually active individuals. ninety-eight percent of the two groups were aware of hiv/aids and this is consistent with the figures from the 2008 ndhs (20) and also with findings of studies carried out in ghana (25), malawi (27) and uganda (28). overall, the in-school adolescents significantly had better knowledge of hiv transmission and prevention than the out-of-school counterparts, 16.8% believed that mosquitoes can transmit hiv and only 9.2% believed that condom can prevent hiv transmission. this is not surprising as educational attainment is positively associated with increased awareness of hiv methods as reported in the 2008 ndhs (8) and other african countries (25,27-28). both groups had better awareness of hiv than other stis. this is common with most studies involving adolescents and is not surprising because of the pandemic nature and publicity given to hiv infection (13,16,25,27,28). it is a common finding in studies involving the youth to discover that most do not consider themselves at risk of contracting hiv (25,27,28). in this study, more than half of the respondents in both groups do not consider themselves at risk or do not know that they are at risk of acquiring hiv infection. misconceptions, ignorance, poverty, desire for pleasure and sex under the influence of alcohol amidst other factors may provide the possible explanation for the low risk perception (31). however, the in-school girls significantly had better perception of risk of getting pregnant (χ2=16.31, p<0.05), or acquiring hiv infection (χ2=21.98, p<0.05). they also had better attitude than their out-of-school counterparts. overall, most disagree that girls should have sexual intercourse before marriage. studies done in lagos (13), ethiopia (23) and portugal (32) have also reported a similar finding. ninety-nine percent of the respondents affirmed that people had talked to them on issues of sexuality. in-school respondents had received their information mainly from parents and school teachers, while out-of-school girls had received information from youth organizations, parents and friends. this is consistent with results of similar studies done in owerri (10), benin (11) and in four other african countries (16). in this study, in-school adolescents significantly had more knowledge on sexual health than out-of-school adolescents. involvement in schools and plans to attend higher education are all related to less sexual risk8 adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 taking and lower pregnancy. however, their knowledge of many sexual health issues was poor; a significant number of both groups did not know their fertile period and had some misconceptions of hiv/aids. our study may have some limitations. due to the sensitive nature of the topic, some respondents found it difficult to respond to some questions. furthermore, some of the parents were not willing to allow their adolescent children to be interviewed, especially for the outof-school girls. there was also the problem of privacy in the market. however, in order to circumvent these problems, painstaking explanations on the purpose and benefits of the study were offered to all adolescents and a good number responded positively thereafter. in addition, our findings should be interpreted with caution due to the cross-sectional nature of our study design. in conclusion, this study has revealed that in-school respondents showed higher knowledge of sexual and reproductive health issues than their out-of-school counterparts, probably because of the effect of the school environment. they had better knowledge of hiv transmission and prevention methods, stis and contraception. however, both groups had low knowledge of fertile period and other forms of contraception. the in-schools girls also had better risk perception of hiv/aids and demonstrated better attitudes than the out-of-school girls towards pre-marital sex and condom use. it is therefore recommended that out-of-school adolescents should be targeted to go through behavioural change communication (bcc) on sexual and reproductive health issues. using the findings of the study as a baseline data, the ministry of health and education, faith organizations, international and non-governmental bodies and all adolescent stakeholders should be encouraged to collaborate and cooperate with opinion leaders into impacting and improving the reproductive and sexual health knowledge of adolescents more so for the outof-school adolescents. these could also happen by training and retraining more teachers and peer educators on issues of reproductive and sexual health for impartation on their students and their out-of-school counterparts. parents are the primary sexual educators of the children. parents should be sensitized on the importance of providing a supportive home environment; maintaining strong ties with them and giving appropriate information on sexual issues according to their ages. this will bring about a level of family connectedness that will effect positive changes in the sexual behaviour of the adolescents. the responsibility of sensitizing parents can be taken up by the ministry of women affairs with cooperation from faith-based organizations, representatives of market women, parents, teachers association and other bodies. conflict of interest: none declared. acknowledgement: this report is part of the dissertation presented and successfully defended at the nigerian national postgraduate medical college, faculty of public health in april 2012. ethical consideration and permission: ethical clearance was secured from the ethics committee of the nnamdi azikiwe university teaching hospital nnewi. official permission was also obtained from anambra state education commission, onitsha north local government authorities, each selected school authority and the authorities in charge of the market. informed consents were obtained from the adolescents’ parent/guardian especially for out-of-school respondents and from all respondents after explaining the purpose, 9 adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 objectives and benefits of the research to them. they were assured of no harm in participation and were told that participation is entirely voluntary. references 1. world health organization. ten facts on adolescent health. geneva: who, 2008. 2. national population commission. reports on 2008 population census in nigeria, 2008. 3. egbochukwu eo, ekanem ib. attitude of nigerian secondary school adolescent towards sexual practices; implications for counseling practices. euro journals 2008;22:177-83. 4. onyeka in, miehola j, ilika al, vaskilampi t. unintended pregnancy and termination of studies among students in anambra state, nigeria. afr j reprod health 2011;15:109. 5. meekers d, ahmed g. pregnancy-related school dropouts in botswana. pop stud 1999;53:195-209. 6. sallah am. sexual behaviour and attitude towards condoms among unmarried in school and out-of-school adolescents in a high hiv prevalence region in ghana. int q community health educ 2009;29:167-81. 7. kipp w, diesfeld h, ndyanabangi b. reproductive health behaviour among in-school and out-of-school youths in kabarole district, uganda. afr j repr health 2004;8:557. 8. batwala v, nuwaha e, mulogo e, bagenda f, bajunirwe f, mirembe j. contraceptive use among in-school and out-of-school adolescents in rural southwest uganda. east afr med j 2006;83:18-24. 9. adebiyi ao, asuzu mc. condom use amongst out-of-school youth in a local government area in nigeria. afr health sci 2009;9:92-7. 10. nwangwu we. the internet as a source of reproductive health information among adolescent girls in an urban city in nigeria. bmc public health 2007;7:354. 11. otoide vo, oronsaye f, okonofua fe. sexual and contraceptive use among secondary students in benin city, nigeria. j obstet gynaecol 2001;23:261-5. 12. kipp w, 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anochie ic, ikpeme ee. prevalence of sexual activity and outcome among female secondary school students in port harcourt, nigeria. afr reprod health j 2001;5:637. 10 adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 19. national population commission (npc) and icf macro. nigeria demographic and health survey 2008. abuja, nigeria: national population commission and icf macro, 2009. 20. sallah am. sexual behaviour and attitude towards condoms among unmarried in school and out-of-school adolescents in a high hiv prevalence region in ghana. int q community health educ 2009;29:167-81. 21. adekunle la, ricketts oz, ajunwon aj, ladipo oa. sexual and reproductive health knowledge, behavior and education needs of in-school adolescents in northern nigeria. afr j reprod health 2009;13:37-9. 22. ibaya ga, amoko dh, ncagyana dj. adolescents’ sexual behaviors, knowledge and attitudes to sexuality among school girls in transkei, south-africa. east afr med j 1996;73:95-100. 23. seifu a, fantahun m, worku a. reproductive health needs of out-of-school adolescents: a cross – sectional comparative study of rural and urban areas in northwest ethiopia. ethiop journal health 2006;20:10-17. 24. ojikutu rk, adeleke ia, yusuf t, ajijola la. knowledge, risk perception and behaivour on hiv/aids among students of tertiary institutions in lagos state, nigeria. budepest: e-ledaer, 2010. 25. alan guttmacher institute. adolescents in ghana new york: alan guttmacher int, facts in brief , 2006. 26. okereke ci. sexually transmitted infections among adolescents in a rural nigeria. indian j soc sci 2010;7:32-40. 27. alan guttmacher institute. adolescents in malawi new york: alan guttmacher int, facts in brief, 2006. 28. alan guttmacher institute. adolescents in uganda new york: alan guttmacher int, facts in brief , 2006. 29. aderibigbe sa, araoye mo, akande tm, musa oi, monehin jo, babatunde oa teenage pregnancy and prevalence of abortion among school adolescent in north, central nigeria. asian social science 2011;7:20-2. 30. tripp j. sexual health contraception and teenage pregnancy. bmj 2005;330:590-3. 31. moore a, biddlecom a, zulu e. prevalence and meanings of exchange of money or gifts for sex in unmarried adolescent sexual relationships in sub-saharan africa. afr j repr health 2007;11:1-7. 32. aderibigbe sa, araoye mo. effect of health education on sexual behaviour of students of public secondary schools in llorin, nigeria. euro j 2008;24:33-41. ___________________________________________________________ © 2014 adogu et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 11 jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 1 original research population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe mihajlo jakovljevic1, ulrich laaser2 1 faculty of medical sciences, university of kragujevac, kragujevac, serbia; 2 section of international public health (s-iph), faculty of health sciences, university of bielefeld, bielefeld, germany. corresponding author: assoc. prof. mihajlo jakovljevic, md, phd, health economics and pharmacoeconomics graduate programme, faculty of medical sciences, university of kragujevac; address: svetozara markovica 69, 34000, kragujevac, serbia; telephone: +38134306800; e-mail: sidartagothama@gmail.com mailto:sidartagothama@gmail.com� jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 2 abstract aim: population aging has profoundly reshaped demographic landscapes in all south eastern european (see) countries. the aim of this study was to provide a thorough comparative intercountry assessment on the speed of population aging in the entire see region for the period 1950-2010. methods: descriptive observational analysis of long-term trends on core primary and composite indicators of population aging across seventeen countries of the wider see region, with panel data sets at a national level. results: during the past six decades, the entire see region has experienced a rapid increase in the median age (from 25.2 years in 1950 to 37.9 years in 2010), with a simultaneous fall of fertility rates for two children per woman (from 3.55 children per each childbearing woman in 1950 to 1.49 in 2010), coupled with significant rise in the population of elderly citizens. the speed of population aging has vastly accelerated (with a 2.5 fold increase) over the past three decades. the percentage of individuals over 65 years has doubled from 7% in 1950 to 14% in 2010. conclusion: complex national strategies are needed to cope with the shrinking labour force coupled with the growing proportion of the older population. with all likelihood, population aging will further accelerate in the near future. this profound long-term demographic transition will threaten financial sustainability of current health systems in all see countries. keywords: aging, demography, population; primary indicators; south eastern europe; syncretic indicators, trend. source of funding: the ministry of education, science and technological development of the republic of serbia has funded this study through grant oi 175014. publication of results was not contingent to ministry’s censorship or approval. conflicts of interest: none. jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 3 introduction according to the most realistic official forecasts scenario, global population aging will accelerate. the profound demographic transformation of contemporary societies started almost a century and a half ago in most of the developed nations (1). surprisingly, this phenomenon is currently moving from rich industrial north to the most emerging markets of the southern hemisphere. the aging of developing nations occurs at a far greater speed. for increasing the proportion of people over 60 years from 7% to 14%, it will take china only 26 years, whereas the same process in france occurred over 115 years (2). to date, most of global aging in absolute terms, by far and large, has occurred in more developed regions with enormous social and economic consequences (3). the wider south eastern europe (see) presents a myriad of societies in diverse ethno-religious traditions, prevailing lifestyle patterns and income levels (4). for the purpose of providing a comprehensive insight into the evolution of population aging in this region, a total of seventeen countries were examined in the region’s broadly accepted geographical boundaries. there is a significant gap in regional knowledge on population aging and its consequences in the broader eastern european region including the balkan peninsula (5). the aim of this study was to describe the long-term aging trends and identify the serious agingrelated public health challenges in the upcoming decades. the main hypothesis was that speed of population aging and stages of demographic transition differ substantially among the individual nations. methods this was a descriptive retrospective trend analysis conducted on complex national level datasets within 1950-2010 time spans. the data collection consisted of official release of medium range estimates on core population aging indicators provided by the united nations (un), department of economic and social affairs, population division issued within the report entitled: “world population prospects: the 2012 revision related to the period 1950-2010” (6). countries selected were the ones whose territory lies within geographic boundaries of see partially or in its entirety and which are covered by the un’s department of economic and social affairs official demographic reports. the countries observed included: albania; bulgaria; hungary; republic of moldova; romania; bosnia and herzegovina; croatia; italy; fyr macedonia; montenegro; serbia; slovenia; slovakia; cyprus; greece; turkey; and ukraine. transitional balkan countries were observed as a subgroup of economies whose territories reside entirely or in large parts within the geographic boundaries of the balkan peninsula, but were centrally planned economies during the cold war era (1945-1989): albania, bosnia and herzegovina, bulgaria, croatia, montenegro, the republic of moldova, romania, serbia and the former yugoslav republic of macedonia (excluding of greece and turkey which were free market economies prior to 1989). the time period 1950-2010 was selected for two reasons: extensive data availability as well as the fact that most local nations actually entered severe population aging in the early post world war ii decades, or at the end of the 20th century (7). for the purpose of this analysis there were no missing data, because un referral bodies provided comprehensive assessments for each nation during the observation period. jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 4 selected indicators of population aging were defined according to the list provided in anex i of the united nation’s department of economic and social affairs official projections entitled: “world population ageing: 1950-2050”. of the indicators listed, the vast majority were applied in this analysis with few minor exceptions of less relevant compound indicators. authors had at their disposal complete availability of data for all the seventeen countries and all relevant years/five year periods within the 1950-2010 time span. results due to the rapid population growth rates in the initial decades of global demographic explosion, many nations of the wider see region exhibited bold gains in population size, most prominent in large countries such as romania, italy, ukraine and turkey. top performers in terms of population growth were turkey and albania which even succeeded to triple their populations within these six decades (table 1). however, the entire region has recorded profound population aging trends in terms of all the relevant indicators. table 1. ground demographic indicators of population aging: medium range estimates by the united nations department of economic and social affairs population division for 1950 and 2010 country total population (both sexes, as of 1 july (millions) total fertility rate (children per woman) population growth rate (% of average annual rate of population change) median age of the total population (years) percentage of people aged 65+ years 1950 2010 19501955 2005 2010 19501955 2005 2010 1950 2010 1950 2010 albania 1.2 3.2 6.1 1.8 2.7 -0.29 20.9 31.9 5.9 10.1 bosnia 2.7 3.8 4.8 1.2 2.5 -0.2 20.0 38.6 4.0 15.1 bulgaria 7.3 7.4 2.5 1.4 0.8 -0.8 27.3 42.4 6.7 18.3 croatia 3.9 4.3 2.8 1.4 0.7 -0.2 27.9 41.9 7.9 17.5 cyprus 0.5 1.1 3.7 1.5 1.4 1.3 23.7 34.2 6.0 11.6 greece 7.6 11.1 2.3 1.5 1.0 0.1 26.0 41.8 6.8 19.0 hungary 9.3 10.0 2.7 1.3 1.0 -0. 2 30.1 39.9 7.8 16.7 italy 46.4 60.6 2.4 1.4 0.7 0.6 28.6 43.3 8.1 20.3 montenegro 0.4 0.6 4.0 1.7 2.2 0.1 21.6 36.3 7.4 12.5 moldova 2.3 3.6 3.5 1.5 2.3 -1.1 26.6 35.2 7.7 11.2 romania 16.2 21.9 2.9 1.3 1.4 -0.2 26.3 38.5 5.7 14.8 serbia 6.7 9.6 3.2 1.4 1.5 -0.6 25.8 37.8 7.6 13.7 slovakia 3.4 5.4 3.5 1.3 2.1 0.2 27.0 37.2 6.6 12.3 slovenia 1.5 2.1 2.6 1.4 0.8 0.5 27.7 41.5 7.0 16.7 fyr macedonia 1.3 2.1 4.0 1.5 1.8 0.1 21.8 36.1 7.1 11.7 turkey 21.2 72.1 6.6 2.2 2.7 1.3 19.7 28.3 3.0 7.1 ukraine 37.3 46.1 2.8 1.4 1.4 -0.5 27.6 39.4 7.6 15.8 transitional* mean ± sd range 4.7±4.9 0.4-16.2 6.3±6.4 0.6-21.9 3.8± 1.1 2.5-6.1 1.5±0.2 1.2-1.8 1. 8±0.7 0.7-2.7 -0.3±0.4 -1.1-0.1 24.2±3.1 20.0-27.9 37.6±3.3 31.9-42.4 6.7±1.3 4.0-7.9 13.9±2.81 0.1-18.3 wider see mean ± sd range 10.0±13.4 0.4-46.4 15.6±22.1 0.6-72.1 3.6± 1.3 2.3-6.6 1.5±0.2 1.2-2.2 1.6± 0.7 0.7-2.7 0.01±0.6 -1.1-1.3 25.2±3.3 19.7-30.1 37.9±4.0 28.3-43.3 7.0±1.0 3.0-8.1 14.0±4.0 7.1-20.3 * transitional balkan countries were considered the following countries: albania, bosnia and herzegovina, bulgaria, croatia, montenegro, the republic of moldova, romania, serbia and the former yugoslav republic of macedonia. jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 5 all countries have experienced rapid increase in median age (from 25.2 in 1950 to 37.9 in 2010), with a simultaneous fall of fertility rates for two children per woman (from 3.55 children per each childbearing woman in 1950 to 1.49 in 2010). population growth rate decreased steadily even among the youngest nations of the region from 1.6 in 1950 to 0.01 in 2010. crude death rates followed the general pattern of improved mortality-based indicators in all countries with a decrease from 13 (per 1000 population) in 1950 to 11 in 2010. old-age dependency ratio increased from 10.6 in 1950 to 20.9 in 2010. furthermore, the potential support ratio decreased from 9.9 in 1950 to 5.1 in 2010. life expectancy increased substantially: at birth (about 15 years 1950-2010) and ages over 60 (four years increase during 1950-2010) and 80 (1.8 years increase during 1950-2010) (table 2). table 2. dependency and support indicators of population aging and life expectancies in key age groups: medium range estimates by the united nations department of economic and social affairs population division for 1950 and 2010 country old-age dependency ratio (individuals 65+ per 100 people aged 15-64 years) potential support ratio (individuals aged 15-64 per population 65+ years) life expectancy at birth [both sexes combined (years)] life expectancy at age 60 [both sexes combined (years)] 1950 2010 1950 2010 1950 -1955 2005 -2010 19501955 20052010 albania 10.8 15.1 9.3 6.6 55.3 76.3 17.5 20.4 bosnia 6.9 22.3 14.5 4.5 53.7 75.5 13.9 19.7 bulgaria 10.1 26.8 9.9 3.7 62.1 72.9 17.4 18.5 croatia 12.1 26.1 8.3 3.8 61.3 76.1 14.4 20.0 cyprus 10.1 16.4 9.9 6.1 66.7 79.0 17.6 21.4 greece 10.5 28.6 9.5 3.5 65.8 79.78 16.4 22.9 hungary 11.6 24.4 8.6 4.1 64.0 73.8 16.0 19.4 italy 12.4 30.9 8.1 3.2 66.3 81.5 17.2 24.1 montenegro 13.2 18.3 7.6 5.5 59.8 74.2 15.5 18.9 moldova 12.0 15.5 8.3 6.5 59.0 68.2 14.2 16.0 romania 8.7 21.2 11.5 4.7 61.1 73.1 15. 8 19.0 serbia 11.9 19.8 8.4 5.1 59.1 73.3 15.4 18.3 slovakia 10.3 17.0 9.8 5.9 64.5 74.7 16.7 19.4 slovenia 10.7 24.0 9.3 4.2 65.6 78.6 15.4 22.2 fyr macedonia 12.5 16.4 8.0 6.1 54.9 74.4 14.5 18.6 turkey 5.2 10.6 19.3 9.4 41.0 73.4 13.3 20.0 ukraine 11.7 22.4 8.6 4.5 61.8 67.9 16.9 17.2 transitional* mean ± sd range 10.9±2.0 6.9-13.2 20.2±4.3 15.1-26.8 9.5±2.2 7.6-14.5 5.2±1.1 3.7-6.6 58.5±3.1 53. 7-62.1 73.8± 2.4 68.3-76.3 15.4± 1.3 13.9-17.5 18.8±1.3 16.0-20.4 wider see mean ± sd range 10.6±2.1 5.2-13.2 20.9±5.5 10.6-30.9 9.9±2.9 7.6-19.3 5.1±1.5 3.2-9.4 60.1± 6.4 41.0-66.7 74.9±3.6 67.9-81.5 15.7±1.4 13.3-17.6 19.8±2.0 16.0-24.1 * transitional balkan countries were considered the following countries: albania, bosnia and herzegovina, bulgaria, croatia, montenegro, the republic of moldova, romania, serbia and the former yugoslav republic of macedonia. jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 6 there was evidence of a significant rise in the elderly population, where the percentage of individuals aged over 60 years increased from 9.8% in 1950 to 19.6% in 2010, whereas the percentage of individuals aged over 80 years increased from 0.9% in 1950 to 3.1% in 2010. speed of aging was assessed independently in two thirty-year periods (1950-1980 and 19802010) using the percentage of individuals aged over 60 years in line with the methodology employed by the un population division in the world population ageing report issued in 2013. according to the official un estimates based on national data, the speed of population aging has vastly accelerated over the past three decades (with a percentage point increase of people over 60 years of 2.8% during 1980-2010) compared to the previous three decades (7.0% during 19501980). during the same period, transitional balkan countries aged considerably faster, from 1.4% increase in the early three decades to 8.1 % increase in the past three decades. extensive details on national estimates in five-year periods or single years during 1950-2010 time span, depending on the variable considered, are listed in tables 1-2. discussion in the early post ward war ii decades, many of populations in the wider see region were young, with high fertility rates and a rather modest longevity (8). the latter was determined by a modest literacy level and unhealthy lifestyle/behavioural factors attributable to the low socioeconomic levels of most of the countries. higher income levels and standards of living were initially observed in italy followed by greece and former yugoslavia (9) in the course of 1960s and 1970s. these countries had higher capabilities and capacities in terms of national health systems and better coverage of rural areas regarding the provision of health care services. we should revoke the fact the urbanization of balkan societies was still developing rapidly during the second half of the 20th century. most of the inhabitants were still living in rural communities and therefore reach of extended network of medical facilities increased the percentage of births attended by skilled personnel. in addition, the increase of youth vaccination rates and improved hygiene and availability of antibiotics significantly improved survival in the early childhood. such changes are clearly visible in the official data provided by regional governments to the various who offices including the european health for all database. these positive developments were initially visible among the semashko-type (10) health systems and much later in turkey (11). after the “baby boom” of post world war ii generations, a few health policymakers anticipated the scale of the population aging that was about to come. complex socio-cultural changes, as well as economic limitations gradually led to decreasing fertility rates among all of the nations of the region (figure 1). an essential event giving impetus to the changes was the massive absorption of female labour force into most of the world economies. women were getting easier access to education and consecutively had higher chances to build up a professional career path. this, in turn, led to governmental financial incentives to women for giving birth to fewer children and, instead, contribute to the community as employed citizens (12). jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 7 figure1. total fertility rate evolution 1950-2010 (above) and median age evolution 1950-2010 (beneath) in the wider south eastern europe, transitional balkan countries and four largest countries of the region (italy, romania, turkey and ukraine) 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 total fertility rate italy romania turkey ukraine transitional balkan countries wider south east europe 15.0 20.0 25.0 30.0 35.0 40.0 45.0 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 median age italy romania turkey ukraine transitional balkan countries wider south east europe jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 8 in historical terms, nations were at different stages of this demographic transition at the starting point of our observation (in 1950). albanian and turkish populations were quite young at the time with fertility rates above six (per woman), in bosnia almost five, while macedonia and montenegro over four. all the other nations were significantly above the simple population replacement level of 2.1. currently, after six decades, we have quite an opposite landscape across europe. turkey and ireland remain among the few nations with 2.1 fertility levels. legalized abortion procedures performed by gynaecologists had a profound impact on vulnerable fertility of eastern european nations (13). these changes coupled with a significant rise in longevity of almost fifteen years on average in the wider see region have ultimately led to dramatic changes of population pyramids in all nations (14). median age, broadly regarded as one of the most reliable indicators of population aging, has also increased as much as fifteen years (the four largest nations in the region are illustrated in figure 1). speed of population aging is another core issue in this research work. long-term perspective of six decades has allowed us to split it into two periods to observe the pace of the process across the local nations. during the initial three decades in the so called “take off” stage, there was a very slow pace and, in some countries, it has not even began before 1980s. but, in the latter stage, the scale of the process became much more intensive providing insight into evident acceleration in most countries of the region (15) (figure 2). population aging is about to remain a landmark change of our time in almost all regions of the world, with the exception of sub-saharan africa and a few mena countries – including a total of eighteen countries so-called “demographic outliers” (16). this global fact is constantly increasing the workload and economic burden to the national health systems. grounds are demanding medical needs of the elderly population (17) joined with significantly longer life expectancies among citizens aged over 60 and 80 years. the worsening of demographic balance of working age population and the elderly throughout the entire region is clearly present. old age dependency ratio has substantially increased, whereas the potential support ratio has heavily decreased in all countries within the 1950-2010 time span. this means that dwindling tax-base of employees is about to sustain even a heavier layer of retired citizens whose pension contributions to the national social insurance funds has to be supported by the current budget revenues. the most obvious and extreme example of this phenomenon is observed in the world’s oldest large nation of japan (18). universal health coverage that effectively functions in the second largest global health care market has contributed to the highest attainable longevity. most national health systems of the region ranked substantially lower in terms of patient satisfaction, quality and accessibility of medical care in the last who ranking of 2000. severe financial constraints throughout the region are worsened by macroeconomic crisis such as the case of italy (19), greece and serbia (20). such developments hampered national capacities to expand medical spending (21) and reimbursement of medicines for the retired to cover the needs of aging societies (22). among the few truly successful options to contain the sky rocketing costs of health care without severe trade-off for quality consists of the generic replacement of brand name drugs. governmental strategies targeted to give financial incentives to prescribers, dispensers and patients to use “copy cat” pharmaceuticals were already successfully implemented in major global markets such as the japanese one (23). innovative industrial manufacturers were at the same time protected from their revenue losses in order to compensate for their research and development expenses across the globe (24). jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 9 figure 2. speed of population aging expressed as proportion of people aged over 60 years in the entire population (percentage point increase) in two three-decade periods (1950-1980 and 19802010) providing clear evidence of a several-fold acceleration in most of the wider see countries another highly visible trend in regional pharmaceutical market transformation includes the prevailing domination of medicines used to treat non-communicable diseases which are very prevalent in the older age. this is the case with copd (chronic obstructive pulmonary disease) cancer, diabetes and cardiovascular disorders whose growing share of the market size both in terms of unit dose prescription as well as value-based was recently evidenced in a regional example (25). interestingly, the most expensive medical care is actually attributable to the patient’s last year of life which is most obvious in the case of malignant disorders (26). only a minor part of these costs might be partially contained by diverse screening and prevention strategies. national authorities have adopted different policies to cope with growing budget impacts of aging with various success stories. regardless of an almost unbearable burden imposed by this demographic transition, some promising developments in the emerging rapidly evolving economies such as turkey, might pose an excellent example on promising perspectives for the improved medical care for the elderly (27). 17.9 11.6 10 9.8 9.2 8.1 7.8 7.6 7.6 7.4 7.3 7.0 6.9 6.7 5.6 5.2 4.7 4.4 3.6 3.2 2.5 5.1 2.1 2.5 5.5 5.3 1.4 -0.6 1 4 7.5 -0.1 2.8 -1.5 4.2 5.2 -0.4 4.5 3.3 1.2 4 0.6 -5 0 5 10 15 20 25 japan bosnia croatia bulgaria italy transitional balkan countries fyr macedonia serbia slovenia greece montenegro wider south east europe albania romania hungary moldova ukraine slovakia turkey cyprus world 1980-2010 percentage point increase of citizens aged ≥ 60 1950-1980 percentage point increase of citizens aged ≥ 60 jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 10 study limitations the far reaching process of aging of human populations in europe dates back much earlier than 1950. actually, earliest roots of falling fertility levels might be tracked back almost two centuries ago (28). the process itself in some balkan nations such as serbia began much earlier, even a century ago (29). therefore, a minor study weakness could be considered the very time span of this study when taking into account long-term historical processes. nevertheless, in most of the nations, population aging becomes visible in demographic statistics only during 1980s. official data worldwide are lacking for most of the countries before 1950. thus, authors consider the selected time horizon to be the broadest attainable within this methodological framework. one political entity was omitted from the analysis because of lack of availability of official data although its territory resides within geographic boundaries of the wider see. kosovo (unsc 1244/99) was exempted from the analysis due to the fact that it is absent from the un registries during the period under observation. un estimates bear the minor risks of underor overestimating the real life population data. nevertheless, such assessments rely on a sound methodological framework and are most likely to reflect properly hidden demographic trends even in cases of missing data for some countries and some periods (30). of the overall un department of economic and social affairs list of core indicators of population ageing, a few of them were omitted based on partial or complete lack of such data or grounds for their calculation in the un’s public demographic registries. these indicators include: the illiteracy rate, labour force participation rate, the parent support ratio and the survival rate to a specific age. although they present a minor setback of the study design, the authors considered that these indicators would not change the demographic landscape of the aging process in any significant manner. inclusion of large countries such as italy, ukraine and turkey whose territories rely mostly outside strict geographical boundaries bears the risk of bias. national level extrapolations refer to the entire populations of these countries living in apennine peninsula, eastern europe and asia minor. regardless of this fact, the aim of the paper was to depict a comprehensive image of regional population fluctuations and describe the long-term demographic transition of the respective nations. conclusion accelerated pace of population aging across the globe will have a profound echo among the rapidly developing see markets. some of these nations have entered this demographic transition only in recent decades such as e.g. albania. other countries stand at the borderline of simple replacement fertility rates such as turkey, which is the region’s largest nation. italian, greek, romanian, hungarian and all the remaining slavic populations have undergone these changes many decades earlier. these trends will put an additional pressure to the national health systems and the entire regional economy. the balance between working age population and the retired citizens is worsening, thus, leading to a shrinking base of tax payers. at the same time, increased longevity will increase demands for medical care and the burden to families still supporting their elderly people. complex socioeconomic and health policy strategies will have to be adopted by regional governments to cope with probably the largest single long-term public health challenge of the 21st century. jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 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family planning. ann arbor, university of michigan press, 1969. pp. 3-24. 29. ševo g, despotovic n, erceg p, jankelic s, milosevic dp, davidovic m. aging in serbia. успехи геронтологии 2009;22:553-7. 30. united nations. world population prospects: the 2012 revision, methodology of the united nations population estimates and projections. department of economic and social affairs, population division, new york, usa, 2014. esa/p/wp.235. http://esa.un.org/unpd/wpp/documentation/pdf/wpp2012_methodology.pdf (accessed: february 18, 2015). ___________________________________________________________ © 2015 jakovljevic et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 1 | 17 original research facilitators and barriers to the use of economic evaluations in nutrition and public health alessandra lafranconi1-3, vera meusel3,4, sandra caldeira3, suzanne babich5, katarzyna czabanowska1,6 1department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 2centro di studio e ricerca sulla salute pubblica, università degli studi milano bicocca, italy; 3european commission, joint research centre, ispra, italy; 4friedrich-alexander-universität erlangen-nürnberg, germany; 5indiana university purdue university indianapolis, richard m. fairbanks school of public health, united states; 6national institute of public health, warsaw, poland. corresponding author: sandra caldeira; address: via enrico fermi 2749, i 21027 ispra (va), italia; telephone: +39 0332 78 38 87; e-mail:sandra.caldeira@ec.europa.eu mailto:sandra.caldeira@ec.europa.eu lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 2 | 17 abstract aims: interventions targeting diets have the potential to reduce a consistent fraction of the chronic disease burden. economic evaluations of such interventions can be an important tool in guiding public health practitioners and decision makers at various levels, yet there are still not many economic evaluations in this area. this qualitative study explored facilitators and barriers in conducting and using economic analyses to inform decision makers in the field of public health nutrition. methods: data were collected through written, open-ended questionnaires administered to twentythree participants (13 from academia and 10 from government) using purposive sampling and analysed through a conventional content analysis. results: the analysis revealed two broad categories of barriers, which included: i) “methodological challenges”, and; ii) “barriers related to application of economic evaluations.” two main categories of facilitators were also identified: i) “facilitators to improving the methodology of economic evaluations”, with subcategories further detailing frameworks and methods to be applied, and; ii) “facilitators to broaden the use of economic evaluations”, with most subcategories addressing science-into-policy translations. these barriers and facilitators to the use of economic evaluations in public health are perceived differently by researchers and policymakers, the former more focused on implementation aspects, the latter more concerned by methodological gaps. conclusion: public health nutrition policies seldom take into account data from formal economic evaluations. economic evaluation methodologies can be improved to ensure their broader application to decision making. keywords: economic evaluations, interviews, nutrition, public health, public policy. conflicts of interest: none declared. acknowledgements: the work of al is partially supported by a jean monnet erasmus+ grant (574376epp-1-2016-1-it-eppjmo-module). lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 3 | 17 introduction the social and economic burden of chronic diseases is a major source of concern for public health researchers and decision makers worldwide. according to the global burden of disease (gbd) study, over 91% of deaths and almost 87% of disability adjusted life years (dalys) in the european union are the result of non-communicable diseases (ncds), mainly cardiovascular disease and cancers (1). with regards to dietary risk factors, the gbd study group estimates that in the european union over 950,000 deaths and over 16 million dalys are attributable to dietary risks due to unhealthy diets, such as low whole grains, fruit and vegetables intake, low omega-3 intake and high sodium intake (2). along with an ageing population, obesity is a leading risk factor contributing to the burden of chronic diseases, and will play a key role in shaping the future use of healthcare services (3). mean body mass index (bmi) has increased worldwide over the last four decades (4). already in 2008, the prevalence of adult obesity in european countries reached “epidemic proportions”, with some countries recording obesity rates higher than 25% (5). the prevalence of overweight or obesity is about22% among 11-years-oldsin europe, and in southern and eastern europe such prevalence is as high as 38-39% (6,7). inequalities have been documented not only between, but also within countries. for example, there is a gradient throughout the educational attainment spectrum, where those with lower levels are more likely to be overweight or have obesity; the inequality gap is particularly marked in women (8,9). the future does not look brighter; according to projections modelled through 2030, on the basis of past and current bmi trends, obesity and obesity-related chronic diseases will continue increasing in almost all countries from the who european region(10) and worldwide (11,12). chronic disease risk factors associated with poor dietary habits are often modifiable and preventable. actions to reduce the exposure to such risk factors have the potential to reduce the social and economic burden of overweight, obesity (13), and chronic diseases (14). economic evaluations can be used to estimate costs and benefits related to different interventions or policy options and help to guide the decision making processes (15).in the field of nutrition, economic evaluations have shown that most of nutrition-related interventions and policies are cost-effective, especially those applied at the population level, such as reformulation initiatives to lower salt intake (16) or a legal limit on industrial trans-fat use in the european union (17). yet, as stated by some authors who performed economic evaluations of interventions aimed at improving dietary factors: “given the potential health gains related to such interventions, the paucity of such studies is alarming and indicates that additional evidence in this area is needed. it is difficult to design evidence-based policies with so little empirical evidence.” (18). although methodological challenges of economic evaluations in public health, and specifically in the field of nutrition, have been identified by various authors (19-22), to our knowledge there is little research on challenges and facilitators in transferring economic evidence of public health and nutrition interventions into policy (23). lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 4 | 17 the aim of this pilot study is to identify key barriers and facilitators to performing and applying data from economic evaluations in the decision making processes in nutrition and public health. we report on the perceptions of policymakers and academic experts in the field of nutrition, public health and economics, to better understand and encourage the use of economic evaluations in planning, implementing and evaluating future interventions and policies. methods study design open-ended written interview questions (two broad questions, each with three subquestions, box 1) were given to participants on a dedicated web platform. a link to the questionnaire was sent to each participant via e-mail. conventional content analysis was applied to analyse the qualitative data (24), with the overall purpose of describing participants’ experiences, field knowledge and views on a topic that has received little previous investigation (25). participants participants were recruited from a pool of 30experts who participated in the 2015 workshop “public health and nutrition economics: the numbers behind prevention?”, organized by the joint research centre of the european commission. participants of the workshop were purposively chosen to ensure a range in expertise (public health, nutrition, and economics), representation (policymaking, academia, private sector, advocacy groups), and reach of action (local, national or international). moreover, geographical criteria (eu and neighbouring countries) were taken into account. inclusion criteria consisted of being a policymaker or an academic expert in any of the abovementioned fields, and of having at least intermediate theoretical knowledge and/or work experience across all expertise domains (i.e. at least three years of study/experience in all domains: public health, nutrition and economics). twenty-seven people met the inclusion criteria, and 23 (13 from academia, 10 from government) participated in the study. procedure the participants were selected between july and october 2015, the workshop took place on november 12-13, 2015, and the written interview was administered two weeks before the workshop, with a reminder sent after one week. the interview was sent via email, with the indication that the answers would be made available to all workshop participants, to foster discussion. oral or written consent of all participants was obtained. the study adhered to principles of ethical research practice (26). data analysis data were analysed through conventional content analysis, according to which coding categories are derived directly from the text data, through an inductive process, in order to move from specific instances to general statements. the advantage of such technique is that information is obtained directly from study participants, without imposing preconceived categories or theoretical perspectives. an example of the process is illustrated in box 1. lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 5 | 17 box 1. themes of the written interview and example of meaning unit, condensed meaning unit and codes from content. bau = business as usual. tfa = trans-fatty acids. phee = public health economic evaluations. themes 1: how have economic evaluations of policies/interventions informed decision making in public health?  general observations on facilitators and barriers to the use of economic evaluations in public health, nutrition and prevention of chronic diseases  examples of success stories in public health o from direct experience o from literature  examples of success stories in nutrition and physical activity o from direct experience o from literature 2: what are examples of possible or existing policies/interventions where economic evaluations are needed to help decision makers?  general observations on facilitators and barriers to the use of economic evaluations in public health, nutrition and prevention of chronic diseases  examples of gaps in public health o from direct experience o from literature  examples of gaps in nutrition and physical activity o from direct experience o from literature meaning unit (mu) condensed mus codes categories “i think it was easy to argue in this case because there is hardly any controversy in this case in what regards the heart effects of tfa consumption and so there was/is no opposition to the ban but the calculation of the health effects and the costs saved are strong arguments to those that are perhaps less health-minded to prioritise and implement it.” when there are no controversies on health effects, it is possible to implement policies. scepticism barriers related to the use of phee in policy settings the calculation of health effects and costs in case of inaction is a strong argument to less health-minded policymakers. inclusion of bau scenarios to reveal costs of inaction facilitators to widen the use of phee in policy settings lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 6 | 17 data were already in written format, and firstly two researchers (al and vm) read all the texts consequently, to immerse themselves in the data, have a common understanding, and detect both manifest and latent content. secondly, al and vm selected four interviews (two for each participant category, i.e. academia and government), and, for each interview, independently identified and condensed simple meaning units (words, sentences or paragraphs containing aspects related to each other through their content and context).discussion and resolution of discrepancies by consensus followed this second stage. third, al extracted the condensed meaning units of the remaining interviews; vm reviewed the extraction process, and discrepancies were again discussed and resolved by consensus. at a fourth stage, al created and assigned codes to all condensed meaning units; subsequently, vm independently assigned the codes created by al and added new codes as necessary. subsequently, discussion between al and vm took place to reach consensus on the coding procedure. finally, similar codes were grouped into comprehensive subcategories and categories, through an inductive process carried out by al, which consisted of comparison, reflection and interpretation. the software qda data miner was used to facilitate the above processes. results twenty-three participants (10 from policymaking bodies, and 13 from academia) were engaged in this study, for a total of 5,436 words (median: 161 words; interquartile range iqr 25-75: 79-237 words).their main characteristics (gender, expertise, reach of action and geographic coverage) are presented in table 1. table 1. participants characterisation policymakers gender expertise area of action geographic area m 7 public health 4 eu 4 eu 9 f 3 economics 4 national or sub-national 6 non-eu 1 nutrition 2 researchers gender expertise area of action geographic area m 6 public health 3 non applicable eu 8 f 7 economics 7 non-eu 5 nutrition 3 lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 7 | 17 the participants identified two sets of barriers to performing phee, and two categories of facilitators: methodological challenges in performing phee, barriers related to the use of phee in policy settings, facilitators to improve the methodology of phee, facilitators to widen the use of phee in policy settings. these categories and their subcategories are summarized in table 2. table 2. facilitators and barriers classified in categories and subcategories, with examples obtained from data analysis sub-categories examples m e th o d o lo g ic a l c h a ll e n g e s definition and measurement of outcomes “public health interventions […] are supposed to have a substantial impact on health and health care systems, but the assessment and the consequences on health are not sufficiently analysed, for multiple reasons [such as] difficulties to measure the impact (indirect and/or direct consequences)”. (policymaker) “some questions arise: should we focus on health-related behaviours or on anthropometrics (weight, waist circumference,…)? how long should the intervention last in order to have an impact?” (researcher) “calculations for [long-term] cost-effectiveness should be [performed in] every project in the area of primary prevention. this would enable reviewers/decision makers to decide which of the proposed actions would give the highest long-lasting (i.e. longitudinal) impact for the money spent”. (researcher) lack of adequate frameworks “methods to evaluate public health interventions are less well established than those for medical interventions” (policymaker) “lack of standardised methodologies and evidence based approaches, and no special focus of hta units and bodies [are challenges encountered] in public health evaluations”. (policymaker) “[in public health nutrition,] the magnitude of the association [between exposure and outcome] is relatively small. so, the case for carefully designed cost-effectiveness analysis appears to be strong” (researcher) im p le m e n ta ti o n c h a ll e n g e s scepticism “my feeling is that there is still some controversy around the real effect [of ssb taxation] on [ssb] consumption and eventually health”. (policymaker) “requests for evaluations are happening in (and are a symptom of) a context in which policymakers are increasingly confronted with intractable problems to which science may not always be fully equipped to reply. policymakers are flooded with scientific literature (some of which of weak basis), institutional reports, lobbyists’ papers and social media posts”. (policymaker) lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 8 | 17 “i would highlight the decision of withdrawing the gras (generally recognized as safe) status to tfas (trans-fatty acids) in the us and the ongoing eu considerations of setting a limit to its content in foods as a success story. in both cases there were economical evaluations made that clearly demonstrated the added value of a "ban" on the industrially produced tfa both in health and economic terms. i think it was easy to argue in this case because there is hardly any controversy in this case in what regards the heart effects of tfa consumption and so there was/is no opposition to the ban”. (policymaker) lack of strategy for effective budget allocation “the conclusion [from an economic evaluation] was that there was no need [for a new highly specialized hospital yard], but the final decision was to open one any way”. (researcher) “actions and interventions [to promote healthy lifestyles and to reduce obesity] proposed in the national preventive program for public health […] fall within budget planning, without any solid proofs for (cost) effectiveness of actions and interventions undertaken”. (researcher) m e th o d o lo g ic a l fa c il it a to rs growing interest in frameworks and methods “[there is a growing] interest in the development of appropriate methodological frameworks and methods to assess interventions aimed at improving nutrition behaviour”. (researcher) “evidence based on result from nutrition studies following harmonized methodology, indicators and cut offs for different indicators [is available]”. (researcher) multidimensional evaluations (whole-of-society approach) “due to [its] complex nature and multiple causes, improving nutrition requires the collaboration of multiple sectors, including agriculture, health, education, trade, environment, and social protection. [practically, we should start suggesting] to include an expert in the field of health economics when planning a primary prevention programme or a scientific project”. (researcher) “it would be good to (…) have a solid and as much as possible global assessment of the effects of [fiscal] policies (by global i mean 360 degrees, what effects did it have on consumption, health, market, industry, reformulation, innovation, country finances, etc)”. (policymaker) data stratification at different levels “there is lacking economic evaluation of [breast, cervical and colon cancer] screenings and it is necessary to introduce national based evidence to support such interventions”. (researcher) “a lot of evaluations of obesity prevention programs have been performed, but there is more research needed on obesity prevention in lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 9 | 17 the socially deprived families. […] these people are the hardest to reach”. (researcher) “such programs [targeted to socially deprived families] will probably need more financial resources than prevention programs for the general population, but the cost-savings in the long-term could be potentially higher in this subgroup.” (researcher) sustainable research infrastructure “primary prevention actions and their evaluations must be continuous and must have continuous financial support because once the project stops almost all effort is lost”. (researcher) im p le m e n ta ti o n f a c il it a to rs production of comparative analysis “cost-effectiveness evaluations (…) may be crucial when deciding which actions from the same division are to be considered at the top priority”. (researcher) “economic evaluation contributes to evidence-based decision making by helping the public health community identify, measure, and compare activities”. (policymaker) targeted evaluations that respond to concrete needs “evaluations on the efficacy and efficiency of tools are useful to guide policymakers (…). the evaluation [of implementation processes], although not a full-fledged evaluation, [could be] important for political guidance.” (policymaker) “phe evaluations in general would support impact assessments for eu/national policies/initiatives (including repeals of existing legislation) in the area of food and health. examples are: measures addressing nutritional composition of foods; marketing (and not only advertising to children) of products; school/public workplace policies aiming to improve diet/physical activity”. (policymaker) transposal of good practices “many countries are considering ssb taxes in different forms and (…) a solid [economic evaluation] could inform other countries and other potential taxes, too”. (policymaker) inclusion of bau scenarios to reveal costs of inaction “given the potentially sizeable benefits of healthier lifestyles for improved population health, understanding the costs and impacts of lifestyle-focused health promotion interventions is an important policy priority” (policymaker) “the calculation of the health effects and the costs saved are strong arguments to those that are perhaps less health-minded to prioritise and implement [a nutrition policy]”. (policymaker) transparency “national governments should enhance the transparency and publicity of operation by disclosing all decisions and contracts” (researcher) “it is crucial to have transparent decision making based on evidence, including […] economic evidence”. (researcher) *bau = business as usual. lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 10 | 17 methodological challenges in performing phee participants considered issues related to definition and measurement of outcomes as fundamental barriers in performing phee. the choice and definition of the outcome to report on (from behaviours to biomarkers and the number of related diseases and deaths) are not trivial issues, as such choices can yield very different results in terms of costeffectiveness and may challenge the validity of the analysis. measurement difficulties identified pertained primarily to the assessment of exposures to dietary risk factors, outcomes related to such exposures, social and economic costs of diseases, and economic costs of policy interventions. moreover, the long time lag (between implementing an intervention and seeing health benefits at the population level) requires use of modelling techniques to project possible benefits into the future, and to relate them to changes in disease patterns. a second challenge, perceived by both researchers and policymakers, is the absence of adequate frameworks to guide a phee. the participants pointed out that, adequate frameworks exist and are commonly used in clinical settings, and mentioned health technology assessment (hta); on the contrary, there are no such frameworks and standardised methodologies for the evaluation of nutrition interventions. the need for carefully designed frameworks and methodologies suitable to public health nutrition is therefore high. barriers related to the use of phee in policy settings many participants noted that the background evidence, on which phee should be based, is at times controversial or scientifically weak, and other voices and stakeholders may easily discredit these efforts. there is therefore scepticism in using phee in policymaking settings, especially because of low quality evidence. when the level of scepticism towards a particular nutrition-related issue is low, as in the case of the effects of trans-fatty acids consumption on cardiovascular disease, the economic evaluation is more likely to succeed in influencing such policy. on the other hand, most of the interviewed researchers pointed out that the allocation of public budgets does not always reflect what is recommended by the evidence (economic evidence or, in more extreme cases, evidence of effect), and gave some examples of stakeholder influence in funding public health interventions. they considered this a barrier to the use of phee. facilitators for improvement of the methodology of phee this category consists of four subcategories, identified mainly by the researcher participants: 1) growing interest in frameworks and methods, 2) multidimensional evaluations, following a wholeof-society approach, 3) data stratification at different levels, according to ses and geographic regions, and 4) sustainable research infrastructure. lack of a suitable framework has been previously identified as a major methodological barrier in phee. researchers are optimistic that this issue will be addressed, as there is a growing interest in developing better frameworks and methods to perform economic evaluations in public health; for instance, the following areas have been mentioned: harmonized methodology, measurement of exposure and outcome, lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 11 | 17 identification of indicators and sensitive cutoffs for such indicators. a thorough identification of the stakeholders’ perspectives, such as the healthcare perspective or the whole of society perspective, appeared to be crucial for wellsuited economic evaluations, according to researchers and decision makers. interventions and policies in the field of nutrition and obesity prevention have an impact not only on the targeted population groups, but also on various sectors of our societies. economic analysis should therefore be multidimensional and address costs and benefits for all relevant stakeholders. health economists should attempt to provide costs and benefits for each group of stakeholders. in addition to assessing and reporting specific costs and benefits of interest to different stakeholders, there is also interest in disaggregating results according to geographic specificities, or to ses of populations. according to the researchers consulted, such stratifications, if available, would increase the credibility of phee. for example, estimates obtained using countrylevel data would be perceived as more reliable and more relevant than estimates obtained with regional or global data. last, a sustainable research infrastructure should be in place to ensure the production of methodologically sound phee. according to some researchers, such infrastructure should have a dedicated team or unit, and consistent financial support. facilitators to widen the use of phee in policy settings this category includes facilitators of the demand for phee and consists of five subcategories: 1) production of comparative analyses; 2) targeted evaluations that respond to concrete needs; 3) transposal of good practices; 4) inclusion of bau (business as usual) scenarios to reveal costs of inaction; 5) transparency in decision making. acknowledging the limitations on both financial and human resources, researchers and policymakers agreed on the importance of economic evaluations in comparing different policy options targeting nutrition and, more broadly, public health. comparative analysis enables the choice of the most cost-effective option and could increase the demand for phee. some of the policymakers interviewed have used economic evaluations “to guide” or influence colleagues in a decision-making process. there is the potential for demand for phee to rise if economic evaluations respond to concrete needs, thus having a direct impact on decision makers, and providing guidance in daily practices. moreover, some of the policymakers interviewed, indicated that having more examples of legislation informed by economic evidence may in itself stimulate the greater demand for phee. economic evaluations can be useful also in evaluating transposal of good practices from their inception into different practice contexts; for instance, economic evaluations of taxation interventions can be carried out in those countries where sound public health taxation has been already implemented, to best inform countries in the process to design similar schemes. according to some of the policymakers interviewed, such cases can increase the demand for phee. the costs of inaction need also to be known. this could be done, for example, by including bau scenarios when performing comparative economic analyses. a case in point is to clarify the high costs of inaction in lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 12 | 17 obesity and related chronic diseases, both in social and monetary terms, as noted by some policymakers. this could be a key driver for action but also for increasing the demand for phee. lastly, most researchers identify a desire for transparency in policy decision making as a very important rationale for economic evaluations. discussion main findings and comparison to the literature this qualitative analysis aimed to identify key barriers and facilitators of performing public health economic evaluations and in including them in the development of policies in the area of nutrition and prevention of chronic diseases. we found that barriers (methodological challenges and barriers related to the use of phee) were symmetrical to facilitators (facilitators to improve the methodology and increase the use of phee), meaning that facilitators were those factors that reduced barriers in either performing or using phee. policymakers and researchers diverged in their opinions and perspectives. for instance, in the category “barriers related to the use of phee”, researchers identified “lack of strategy for effective budget allocation.” in evaluations (whole-of-society approach), and data stratification at different levels (geographical and social determinants enable the inclusion of equity considerations in economic analyses). a wide variation in approaches and methodologies in economic studies on dietary factors, and the consequent call for an adequate framework, has also been documented (20,22). an expert meeting on nutrition economics has also previously identified and commented on key features of economic evaluations in nutrition, such as: societal perspective and multi-stakeholder approach in identification of costs and benefits, comparison of alternatives, and generalisability of results (28). our findings on methodological barriers and facilitators resonate with previous literature, indicating that researchers performing economic evaluations need to improve their communication of the structure and results of their analyses to decision makers (27). for instance, weatherly and colleagues (19) identified four main methodological challenges in assessing the cost-effectiveness of public health interventions: attribution of effect, measuring and valuing outcomes, identifying inter-sectoral costs and consequences, and incorporating equity considerations. they are similar to those identified in our study: definition and measurement of outcomes (where “definition” includes effect attribution and “measurement” includes measuring and valuing outcomes), multidimensional contrast, policymakers mentioned “scepticism” attributed largely to doubts about the quality of the data, conclusiveness of the findings, controversies and limitations of current phee practices. nonetheless, both groups provided numerous insights about methodological challenges and data paucity. with regards to facilitators, only researcher participants identified the availability of stratified data for geographical and social lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 13 | 17 conditions as a facilitator towards the production of methodologically sounder phee, and only policymaker participants highlighted the need for providing targeted evaluations responding to concrete needs as a facilitator of greater use of phee. generally speaking, researchers focused on methodological facilitators, while policymakers stressed a need for more widespread use of phee (figure 1). figure 1. main categories and subcategories of facilitators and barriers to phee identified by researchers only (light grey boxes), policymakers only (dark grey boxes) or both (white boxes) our findings on methodological barriers and facilitators resonate with previous literature, indicating that researchers performing economic evaluations need to improve their communication of the structure and results of their analyses to decision makers (27). for instance, weatherly and colleagues (19) identified four main methodological challenges in assessing the cost-effectiveness of public health interventions: attribution of effect, measuring and valuing outcomes, identifying inter-sectoral costs and consequences, and incorporating equity considerations. they are similar to those identified in our study: definition and measurement of outcomes (where “definition” includes effect attribution and “measurement” includes measuring and valuing outcomes), multidimensional evaluations (whole-of-society approach), and data stratification at different levels (geographical and social determinants enable the inclusion of equity considerations in economic analyses). a wide variation in approaches and methodologies in economic studies on dietary factors, and the consequent call for an adequate framework, has also been documented (20,22). an expert meeting on nutrition economics has also previously identified and commented on key features of economic evaluations in nutrition, such as: societal lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 14 | 17 perspective and multi-stakeholder approach in identification of costs and benefits, comparison of alternatives, and generalisability of results (28). strengths and limitations despite existing discussions on generalisability of qualitative studies, nonetheless we consider our analysis as the first attempt to systematically collect perceptions on barriers and facilitators in translating economic evidence into policy from a broad, though small, sample of both researchers and policymakers from the european region. while the general nature of the questions posed allowed for great freedom in responses and could accommodate the differences in the participants’ expertise, more specific questions would have returned more concrete thoughts and examples. the fact that answers were made available to all workshop participants without anonymity could also have influenced the respondents and resulted in their more cautious expressions and examples. because of the limited number of questions asked and the relatively small number of participants, findings should be taken with caution; subsequent work might be done, including a larger number of participants with a more in-depth interview questionnaire. implications for policy and research to our knowledge, there are no other studies addressing facilitators and barriers to the use of economic evidence in public health nutrition: so far studies have addressed only methodological gaps in economic evaluations of public health interventions (19,21,22) and nutrition interventions (20). the paucity of successful cases in which economic evaluations played a role in shaping policies should also be considered, as pointed out by most participants during in the questionnaire and during the workshop. some expressions, such as “my feeling” or “science may not always be fully equipped”, may reflect this fact. such observations may also reflect the difficulties in accounting for complex societal phenomena: changes in eating habits (29) or environmental sustainability (30) are two among numerous examples. the results from our analysis show an increasing interest and unmet demand for public health policies informed by economic evaluations. enablers of the use of economic evaluation should be further facilitated. expanding the application of sound phee to policymaking will ensure a better informed process and, presumably, better outcomes in terms of the intended effects of the policies. acknowledgements we wish to thank all the interviewed experts. we are indebted to jan wollgast for critical reading of the manuscript and constructive suggestions. conflicts of interest: none declared. references 1. james sl, abate d, abate kh, abay sm, abbafati c, abbasi n, et al. global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the global burden of disease study 2017. lancet 2018;392:1789-858. lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to 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'du bist was du isst': challenges in european nutrition policy. eur j public health 2017;27(suppl. 4):26-31. ___________________________________________________________ nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 1 original research dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem maha nubani-husseini 1,2 , elliot berry 1 , ziad abdeen 3 , milka donchin 1 1 braun school of public health, hadassah & the hebrew university-hadassah medical school, jerusalem, israel; 2 faculty of public health, al-quds university, palestine; 3 nutrition and health research institute, faculty of medicine, al-quds university, jerusalem, palestine. corresponding author: maha nubani-husseini maha, braun school of public health, hebrew university-hadassah medical school; address: p.o.box 19746, east jerusalem, israel; telephone: +972522520104; email: maha.husseini@mail.huji.ac.il. nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 2 abstract aim: this study aims to assess the palestinian girls’ dietary habits and physical activity patterns as a baseline for intervention. methods: a cross-sectional study of grade 4 and 5 pupils (mean age: 11 years) in 14 all-girl schools in east jerusalem, of four different types of school ownership (overall n=897), was conducted, using self-administered questionnaires and height and weight measurements. logistic regressions were conducted to determine predictors of healthy behaviours. results: only 36.6% of the pupils reported eating breakfast daily, with unrwa schools having the highest rate of daily breakfast consumption (42.6%). about 28% reported eating the recommended daily quantity of five portions of fruits and vegetables. only 15% of the pupils reported being active at least five days a week and more than one third of the schoolchildren viewed tv for ≥4 hours a day. the prevalence of overweight and obesity was 22.2% and 7.6%, respectively, with private schools having the highest rates, 29.6% and 12.8% respectively (p=0.001). additional predictors of overweight and obesity were: being the first child in the family, watching tv for more than four hours a day, always eating while watching tv and being physically active less than five days a week. conclusions: most palestinian pupils miss breakfast, eat less fruits and vegetables than recommended and have sedentary behaviours. these findings raise serious concerns and point to the urgent need for tailored interventions. keywords: dietary and physical activity behaviour, obesity, palestinian female schoolchildren. conflicts of interest: none. source of funding: this study is a part of ph.d. degree. maha nubani-husseini received a scholarship from joint distribution committee (jdc). she thanks nutrition and health research institute al-quds university for funding part of the research. the linda joy pollin cardiovascular wellness center for women at the division of cardiology of hadassah university medical center, directed by dr. donna zfat funded the mothers’ activities and lectures towards the end of the intervention, as well as the implementation of the programme at the control schools one year after the study ended, as they were promised when they got selected. acknowledgments: the authors thank the participating schools, the palestinian ministry of education, the unrwa office of education and jerusalem municipality for facilitating fieldwork. their gratitude also goes to mr. radwan qasrawi (al-quds university), dr. marrio baras and dr. deena jaffeh (hebrew university) for statistical support, and to mrs. suzy daher for editing. nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 3 introduction healthy nutrition and physical activity are the key factors in preventing and reducing obesity in children (1). additionally, adapting such a healthy lifestyle throughout one’s life span is essential for optimal physical growth and intellectual development (1). obesity is known to be a significant risk factor for chronic diseases including type ii diabetes mellitus, cardiovascular disease and certain types of cancer (2,3), and imposes a substantial economic burden (4). the obesity trend is especially alarming considering the increasing prevalence in children and adolescents. the need for effective preventive measures to control obesity has therefore become a major public health issue. in palestine, rapid urbanization, modernization and sedentary lifestyle have contributed to the increasing prevalence of overweight and obesity in all age groups (5). however, there are few local studies focusing on eating habits and physical activity patterns. one study was part of the health behaviour school children survey (hbsc) conducted in 2004 in the west bank and gaza strip. this survey acknowledged problems such as skipping breakfast particularly among girls, low consumption of vegetables and fruits and low intake of milk (6). such data is lacking for female schoolchildren from east jerusalem. the current study is done to fill this gap and is part of a baseline study of a school-based intervention programme in east jerusalem to promote healthy eating and physical activity among schoolchildren, their mothers and teachers. the purpose of this paper is to describe nutritional and physical activity habits and their socio-demographic determinants among palestinian girls in east jerusalem schools of different types of ownerships. methods study design and population a cross-sectional study was performed in april-june 2011 to provide the baseline data in a randomized controlled programme trial, before allocating schools into intervention and control groups. the primary target population was girls in grades 4 and 5, as those elementary schoolchildren are old enough to be able to answer the questions, however, they are not yet close to puberty when hormonal changes could have altered the results. all schoolgirls from the different types of ownership in east jerusalem were eligible for the study. this included 31 jerusalem municipality (jm) schools with 2,759 students, 23 palestinian authority (pa) schools with 2167 students, 40 private schools with 820 students and eight united nation relief and works agency (unrwa) schools with 1218 students. average number of students per class is 34, with different numbers according to school type of ownership. sampling was done in two stages: i) stratified sampling of schools according to their ownership; ii) a random selection of classes (by lottery). all students in the selected classes were included. sample size calculation was based on the estimated prevalence of healthy behaviours relating to physical activity (>5 days per week), which was estimated at 25% among girls in grade 6 in the hbsc study (6). assuming that this behaviour will increase among the intervention schools to 40%, and will remain at 25% in the control group, with a significance level of 5%, a power of 90%, intra-class correlation of 0.001 and a cluster size of 34, a sample of 14 schools was needed in order to provide 13% of the eligible population (952/6962). a random sample of schools was drawn in each of the four strata. this corresponded to six schools from the jerusalem municipality, four pa, two private and two unrwa schools, with 28 classes nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 4 and 935 students. data collection a structured self-administered anonymous questionnaire was given to the pupils based on the hbsc questionnaire (6),which in turn was based on the who format (7). it focused on dietary assessment (eating breakfast, drinking before leaving for school, consumption of fruit and vegetables, milk consumption), physical activity (mode of transport to and from school, days per week active in sport for at least one hour per day), physical inactivity (watching tv) and knowledge (recommended daily consumption of fruits and vegetables). the class teacher supervised filling the questionnaire by reading out aloud each question and then asking for an immediate response. the main researcher (mh) was present during administration of the questionnaires to clarify questions if required. respondents were informed that answering was voluntary and that information would be treated confidentially. the height and weight of each student were measured after they completed the questionnaire, students’ weights were measured in their lightweight clothes (schools’ uniform with no jackets) and without shoes before 10 o’clock break according to a standard protocol and instrument. care was taken to ensure that the measurements were done sensitively and separately in a private room with the presence of the class teacher’s supervisor. mothers’ level of education and occupation was based on the mothers’ self reported questionnaire and school files of the children for missing data. measures eating breakfast was assessed based on the question “do you always eat breakfast before you leave for school?” with response options (1) yes, every day, (2) yes, sometimes, (3) never. whereas drinking in the morning: (1) yes, always, (2) yes, sometimes, (3) never. next, both questions were categorized into yes (yes, every day) or no (sometimes or never). daily consumption and quantity of fruits and vegetables were calculated and converted to two categories <5 serving per day ≥5 servings per day. physical activity assessment was categorized into: (1) physical activity >5 days a week; (2) ≤5 days a week. bmi-for-age was computed for each child using the who software anthroplus 2007 program. this program deduced z-score and percentiles using the exact age in days (8). overweight was determined if a child’s z-score fell between ≤ + 1sd and +2 sd (85 th percentile). obesity was determined if the child’s z-score fell above and equal 2 sd (97 th percentile), while underweight was determined if z-score fell below minus 2 sd (3 rd percentile). mothers’ education was divided into three categories; (1) less than secondary, (2) secondary, (3) diploma and higher. employment was divided into two categories; (1) yes, (2) no. crowding index (the ratio between number of residents at home and number of rooms) was used as a proxy for socioeconomic status and divided into (1) less than one; (2) 1-2, (3) more than 2. statistical analysis data analysis was performed using spss version 20. chi-square tests were used to calculate associations between categorical variables by school ownership, grade, sociodemographic/economic variables. a stepwise forward logistic regression model was built for identifying independent predictors of eating breakfast daily, eating the recommended quantity of fruits and vegetables, physical activity and overweight and obesity. the variables in the final model of the stepwise forward logistic regression were tested again by entering them into the logistic regression models. ethical considerations nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 5 approval from the israeli ministry of education, palestinian ministry of education, unrwa office of education department and private school principals was obtained. the research program was approved by the hebrew university of jerusalem/authority for research students committee. results sample characteristics all 14 selected schools agreed to participate in the study. of the 935 eligible schoolchildren, 897 (95.9%) participated (49.9% children were from grade 4 and 50.1% were from grade 5). non-response was due to absence from school on the day of data collection. table 1 presents the socio-demographic characteristics of the study population by school ownership. table 1. socio-demographic characteristics of the study population by school ownership variable school type municipality (n=400) pa (n=236) unrwa (n=136) private (n=125) total (n=897) grade (%): 4 th grade 5 th grade 49.8 50.3 50.0 50.0 49.3 50.7 51.2 48.8 49.9 50.1 age: mean sd 11.02 0.70 11.00 0.78 11.10 0.87 10.98 0.71 11.02 0.71 order in the family (%): 1 2-3 4 ≥5 19.2 39.0 15.6 24.8 19.1 30.9 16.1 33.9 16.9 37.5 15.4 30.1 29.6 51.2 9.6 9.6 20.6 38.4 15.2 25.9 sibling (%): 0-2 3-4 ≥5 14.5 44.8 40.8 6.8 42.4 50.4 5.9 38.2 55.9 43.2 46.4 10.4 15.2 43.4 41.4 crowding index (%): <1 1-2 >2 9.0 54.5 36.5 6.4 66.1 27.1 8.1 51.5 40.4 17.6 62.4 20.0 9.4 58.3 32.3 religion (%): muslim christian 100.0 0.0 100.0 0.0 100.0 0.0 59.2 40.8 94.3 5.7 mother education (%): less than secondary secondary diploma & higher 45.6 40.0 14.4 49.0 34.3 16.7 52.7 36.4 10.9 7.1 38.1 54.9 42.2 37.7 20.1 mother employment (%): yes no 16.6 83.4 15.9 84.1 14.5 85.0 33.9 66.1 18.5 81.5 the age of students ranged between 9-14 years (mean: 11.02, sd±0.71). about 94% were muslims and 6% were christians, all attending private schools. the mean family size was nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 6 7.1; schoolchildren from municipality, p.a and unrwa had more siblings compared to those in private schools. schoolchildren from municipality and unrwa schools lived in higher crowding index (residents per room) compared to pa and private schools. about 81% of the mothers did not work and 20% had a diploma or higher education. dietary habits the percent of schoolchildren who reported having breakfast was 36.6%. there was a significant difference between school ownership with unrwa schools having the highest rate of daily breakfast consumption (42.6%), compared to municipality, pa and private (p=0.032) (table 2). more muslim schoolchildren (29.7%) consumed breakfast compared to christian schoolchildren (25.5%) in private schools. table 2. dietary pattern, physical activity, knowledge perception, overweight and obesity (%) by school type and crowding index behavioural characteristics school ownership crowding index jm n=400 pa n=236 unrwa n=136 private n=125 <1 (n=84) 1-2 (n=522) >2 (n=290) dietary pattern always eating breakfast 38.3 34.7 42.6 28.0 * 56.0 33.3 33.6 † always drinking in the morning 46.0 42.0 51.5 47.0 52.2 48.8 45.2 always eating vegetable at 10 o’clock break 18.3 8.5 22.8 16.0 ‡ 23.8 15.7 14.5 always eating fruits at 10 o’clock break 18.3 11.4 20.6 16.1 16.7 15.9 17.6 eating ≥5 serving of vegetables and fruits/day 35.8 22.1 14.0 27.2 ‡ 29.8 27.2 27.2 eating vegetables once or more per day 21.3 27.5 13.2 23.2 * 26.2 21.5 21.4 eating fruits once or more per day 23.3 19.6 16.9 23.2 29.8 22.2 17.0 * when thirsty water is the most used drink 69.5 90.3 79.0 68.0 ‡ 78.6 74.7 78.3 drinking milk every day 43.3 40.7 27.2 52.0 ‡ 59.5 41.8 35.5 ‡ lunch is the main meal at home 74.2 77.5 61.0 77.6 * 76.2 73.9 72.3 * eating with family or at least one parents 79.5 77.0 77.2 72.8 77.4 78.1 76.6 eating while watching tv 27.0 21.7 20.6 32.0 ‡ 28.6 24.9 25.3 eating while using computer 5.3 1.70 8.1 4.80 † 3.6 4.6 5.2 eating when bored/angry/stressed/frustrated 6.5 4.2 4.4 1.6 † 4.8 5.2 4.5 physical activity pattern walking to school in the morning 65.3 71.6 93.4 39.2 ‡ 57.1 64.4 76.2 ‡ walking back after school 73.3 76.3 97.1 40.0 ‡ 61.9 70.3 80.7 † physically active ≥5 days a week 16.8 13.6 8.1 16.0 20.2 16.5 9.30 sedentary behaviours using computer >4 hours 20.0 14.0 7.4 17.6 † 22.6 14.9 16.2 tv viewing ≥4 33.0 36.0 38.2 38.0 ‡ 33.3 33.5 34.5 knowledge acknowledge importance of breakfast 91.7 94.5 94.0 94.4 94.0 93.7 92.0 acknowledge importance of fruits & vegetables 97.7 97.0 95.6 100.0 96.4 98.1 96.9 acknowledge importance of water 98.0 95.8 100.0 99.2 * 97.6 98.1 97.9 know recommended serving vegetables/fruits 12.5 12.0 10.3 14.4 25.0 21.3 23.5 bmi overweight 24.8 14.4 21.3 29.6 29.8 19.3 25.2 obese 7.5 3.4 10.3 12.8‡ 7.1 8.4 6.2 * p<0.05; † p<0.01; ‡ p<0.001. eating breakfast daily was associated with the socio-economic status of the family, measured by crowding index. those living in a house with fewer than one person per room had a 2.4nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 7 fold increase in the likelihood of eating breakfast (or=2.38, 95%ci=1.36-4.18), controlling for school type (logistic regression, table 3). unrwa schoolchildren were more likely to eat breakfast (or=1.75, 95%ci=1.07-2.88) compared to other school types of ownership. if mothers always prepared breakfast for their daughters, there was a 4-fold increase in the likelihood of the child eating breakfast (or=3.83, 95%ci=0.82-17.96), although this finding was not statistically significant. these three determinants contributed independently to having breakfast daily (logistic regression, table 3). the mother’s level of education and employment status, beliefs, and knowledge regarding the importance of breakfast meals and birth order were found to have no effect on eating daily breakfast. “not feeling hungry” was the main reason for skipping breakfast (78.6%). table 3. determinants of eating breakfast – logistic regression models * variable number or p-value 95%ci crowding index: <1 1-2 >2 73 432 230 2.38 0.75 1.00 <0.001 (2) † 0.003 0.099 1.36-4.18 0.53-1.06 reference school ownership: jm pa unrwa private 341 193 86 115 1.00 0.91 1.75 0.55 0.004 (3) 0.640 0.030 0.018 0.62-1.34 1.07-2.88 0.34-0.90 reference mother preparing breakfast to her daughter: never sometimes always 13 235 487 1.00 1.41 3.83 <0.001 (2) 0.67 0.089 reference 0.29-6.76 0.82-17.96 * the last variables left of the stepwise forward logistic regression were entered into the logistic regression model. † overall p-value and degrees of freedom (in parentheses). the most commonly consumed food for breakfast was za’ater and oil with bread. this choice varied widely between school ownership type (p<0.001), where unrwa schoolchildren consumed the most (61.6%). other relevant variables were muslim religion (p<0.001) and mothers who had not attained secondary education (p<0.001). the proportion of schoolchildren who reported drinking in the morning before leaving for school was 46.2%. this was not found to be associated with school ownership, grade, or with socio-economic variables. about 28% of the schoolchildren reported consuming the recommended number of daily servings of fruits and vegetables (five servings a day), with a significant difference between school types of ownership (p<0.001) and the mother’s level of education (p=0.01). only 12.3% of schoolchildren reported the correct answer for the daily recommended consumption of fruits and vegetables. children of mothers with a diploma or higher level of education had a higher proportion of consuming the recommended number of servings (47.9%). school type of ownership and the mother’s level of education remained statistically significant in the final multilevel logistic regression model. being in a jm school increased the probability of consuming the recommended quantity of vegetables and fruit by 1.55 times (or=1.53, 95%ci=0.76-1.96). having a mother with a diploma or higher education increased it by 1.8 nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 8 times (or=1.80, 95%ci=1.25-2.60). the mother’s employment status, religion, and crowding index were found to have no effect. school ownership had a significant effect (p<0.001) on daily milk consumption, with private schools having the highest consumption (52%). another predictor was the crowding index, which was inversely associated (p<0.001). most of the schoolchildren had lunch as the main meal which they ate with at least one parent. physical activity the majority of schoolchildren reported walking to and from the school (67.6% and 72.9%, respectively). there was a significant difference between school ownership type (table2), with unrwa schools having the highest level (93.4% and 97.1%, respectively, p<0.001). the overall reported physical activity in schoolchildren showed that pupils were only slightly active in sport. about 14% of schoolchildren reported being active at least five days a week (table 2). this proportion was significantly inversely associated with the crowding index (20.2%, 16.5%, and 16.5% for up to one, between 1-2, and more than two, respectively, p=0.006). a positive significant association was also found with mothers’ level of education (12.9%, 13.4% and 21.5% for less than secondary, secondary and diploma or higher education, respectively, p=0.027). no other tested variables were associated with physical activity. sedentary behaviours one-third of the students (33.9%) viewed tv for ≥4 hours a day and this was significantly associated with the school ownership (p<0.001). the highest percentages reporting viewing television were found in unrwa and private schools (38.2% and 38.0%, respectively). (table 2). sedentary behaviour was not associated with the crowding index, mothers’ education or employment. no correlation was found between television viewing and being physically active. body weight the overall prevalence of overweight and obesity was 22.2% and 7.6%, respectively. the difference between school ownership types was statistically significant (p<0.001), where the highest proportion was among private schoolchildren (42.4%). more christian schoolchildren in the private schools (47.1%) were overweight and obese compared to muslim schoolchildren (39.2%). about 1% of schoolchildren were underweight, with highest rates among pa schoolchildren (3%) (table 2). a significant higher prevalence of overweight and obesity was noticed with the first child in the family. the other independent determinants of overweight and obesity (logistic regression) were: watching tv more than four hours a day (or=4.13, 95%ci=2.93-5.82); being physically inactive (less than five days a week) (or=1.95, 95%ci=1.17-3.24) and always eating while watching tv (or=3.42, 95%ci=2.27-5.13) (table 4). no association was found with crowding index, mothers’ level of education or employment. about 75% of overweight/obese children considered their weight as normal, whereas 66% of those who perceived themselves as “high weight for their age” were actually overweight/obese children (data not shown). nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 9 table 4. determinants of overweight and obesity – logistic regression models * variable number or p-value 95%ci family order: 1 2-3 4 ≥5 185 343 136 231 1.00 0.48 0.91 0.57 0.003 (3) † 0.001 0.74 0.024 reference 0.31-0.74 0.54-1.56 0.35-0.93 school ownership: jm pa unrwa private 399 235 136 125 1.00 0.38 0.90 1.71 <0.001 (3) <0.001 0.660 0.026 reference 0.24-0.59 0.56-1.45 1.07-2.75 physical activity: <5 days/week ≥5 days/week 761 135 1.95 1.00 0.010 1.17-3.24 reference tv viewing: ≤4 hours/day >4 hours/day 597 299 1.00 4.13 <0.001 2.93-5.82 reference eating while watching tv: never several times a week every day 315 534 266 1.00 0.71 3.42 <0.001 (2) 0.010 <0.001 reference 0.48-1.07 2.27-5.13 * overweight and obesity were combined. the last variables left of the stepwise forward logistic regression were entered into the logistic regression model. † overall p-value and degrees of freedom (in parentheses). discussion the aim of this study was to provide baseline information of schoolchildren living in east jerusalem as the first stage of a randomized controlled intervention programme. the results showed that most children fail to meet the international dietary and physical activity recommendations. there was a significant independent difference between school ownership and socio-economic groups, measured by the crowding index, but no significant difference was observed between grades for all the studied variables. approximately one third (36.6%) of female schoolchildren ate breakfast before school. this finding is consistent with the finding of dietary habits among palestinian adolescents where 34.7% ate breakfast (9). most of the schoolchildren reported “not feeling hungry” as the main reason for skipping breakfast, which is a growing concern worldwide, especially among females (10). in private schools, although the pupils come from higher social classes and are assumed to be in a better position to provide good food for their children, the level of skipping breakfast was the highest. za’ater and olive oil with bread is the most commonly consumed breakfast meal. this could be because of its prominent role in cultural heritage, due to the widely held belief that za’ater helps to keep mind alert especially prior to exams or school. olive oil is known to be a main component of the mediterranean diet, a rich source of monounsaturated fatty acids and an antioxidant agent, which has several beneficial biological functions for health (11). studies also have proved that olive oil intake is associated with the reduced risk of cardiovascular disease and mortality in individuals at high risk (12). nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 10 drinking milk was reported only by 40% of schoolchildren. adequate calcium intake for children is essential for the development of bone mass and mineral density (13) and in the maintenance of health and prevention of chronic diseases (14). strategies to encourage milk consumption by schoolchildren need special attention. the reported fruit and vegetable intake was lower in our study than that found in the 2004 palestinian hbsc survey (6). this could be due to rapid and progressive shifting among palestinian adults to western-style food patterns (9). less than one third of schoolchildren reached the recommended daily dietary intake of five servings of fruits and vegetables (1). this means that these children may fail to obtain appropriate nutritional intakes of vitamins, mineral and fiber to protect them from diet-related chronic diseases (15), including overweight and obesity (16,17), despite the fact that palestinian markets have a wide variety of vegetables and fruits at low prices. therefore, the need to promote the consumption of more vegetables and fruits is viable and a public health priority. regular physical activity plays an important role in improving the quality of life. although more than two thirds of schoolchildren reported walking in the morning to and from school, respondents did not engage in regular sport and physical activity in leisure time. therefore, they do not achieve the recommended level of being one hour or more physically active per day (18). in arab countries, including palestine, women are prohibited by the socio-cultural norms from participation in outdoor sports activities. therefore, there is a need to develop good physical education practices (e.g. skipping, which can be performed at home) to increase physical activities among girls. in parallel, there is an increase in sedentary behaviours among schoolchildren, which is due mainly to time spent watching television, as in many other countries (15). this is because television is so accessible and available. current recommendations are that children should spend no more than two hours watching television a day (19). the problem of obesity the prevalence of overweight and obesity is high among palestinian schoolchildren, associated with lack of physical activity and increased sedentary behaviours. childhood obesity is an increasingly worldwide problem. this study found that the prevalence of overweight is 22.2% and obesity is 7.6% which is higher than adolescents in the gaza strip (17.0% and 5.45%, respectively) (20), ramallah (18.9% and 3.3%, respectively), hebron (14.9% and 2.0%, respectively) (9), but slightly lower than a previous study conducted in east jerusalem in 2002 (24.3% and 9.9%, respectively) (21). the overweight/obese schoolchildren were found more likely to watch television for more than four hours. this is in accordance with several cross-sectional and longitudinal studies showing very strong associations between television viewing and childhood obesity (22,23). significant positive associations were found between eating while watching television and the risk of becoming overweight/obese. watching television for many hours may lead to a snacking while watching (24), which is independently associated with overweight/obesity among children (25). schoolchildren in private schools have higher standards of living. several studies have demonstrated that socioeconomic status is directly related to childhood obesity in developing countries (26), which is higher in urban areas (27,28). the discussed culture restrictions placed on girls which results in their staying at home with easy access to food, contribute to their increased risk of overweight and obesity. evidence suggests that measures should be introduced as early as possible, so that healthy lifestyle habits are learnt from childhood (29). nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 11 study limitations the study involved a cross-sectional design, and therefore cannot address causality. another limitation is using a self-reported questionnaire from schoolchildren in grades 4 and 5 which could have influenced its validity and reliability. however, studies show that results from self-administered questionnaires tend to minimize social desirability bias compared to interviewer-administered questionnaires (30). conclusion this study shows that palestinian girls miss breakfast, eat less fruits and vegetables than the recommended requirements, and have sedentary behaviours, which is associated with high prevalence of overweight and obesity. there is a need for developing effective intervention programmes to promote healthy eating and physical activity among palestinian schoolchildren. references 1. world health organization. diet, nutrition and the prevention of chronic disease. geneva: world health organization, 2003. available at: http://www.who.int/dietphysicalactivity/publications/trs916/en/ (accessed: january 16, 2016). 2. wyatt sb, winters kp, dubbert pm. overweight and obesity: prevalence, consequences, and causes of a growing public health problem. am j med sci 2006;331:166-74. 3. lobstein t, baur l, uauy r, obesity i. obesity in children and young people : a crisis in public health. obes rev 2004;5:4-85. 4. world health 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transition to young adulthood and correlates of calcium intake. j nutr educ behav 2009;41:254-60. 14. dietary guidelines for american 2005. u.s department of health and human services. department of agriculture. available at: http://health.gov/dietaryguidelines/dga2005/document/pdf/dga2005.pdf (accessed: january 16, 2016). 15. world health organization. young people’s health in context. health behaviour in school-aged children (hbsc) study: international report from the 2001/2002 survey. world health organization/ europe. available at: http://www.euro.who.int/en/publications/abstracts/young-peoples-health-in-context.health-behaviour-in-school-aged-children-hbsc-study-international-report-from-the20012002-survey (accessed: january 18, 2016). 16. rolls bj, ello-martin ja tb. what can intervention studies tell us about the relationship between fruit and vegetable consumption and weight management. nutr rev 2004;62:1-17. 17. i.tetens and s. alinia. the role of fruit consumption in the prevention of obesity. j hortic sci biotechnol 2009;84:47-51. 18. world health organization. global recommendations on physical activity for health.geneva : world health organization. geneva, 2010. available from: http://www.who.int/dietphysicalactivity/factsheet_recommendations/en/(accessed: february 11, 2016). 19. american academy of pediatrices. children, adolescents, and television. pediatrics 2001;107:423-6. 20. kanao bj, abu-nada os, zabut bm. nutritional status correlated with sociodemographic and economic factors among preparatory school-aged children in the gaza strip. j public health 2008;17:113-9. 21. jildeh c, papandreou c, abu mourad t, hatzis c, kafatos a, qasrawi r, et al. assessing the nutritional status of palestinian adolescents from east jerusalem: a school-based study 2002-03. j trop pediatr 2011;57:51-8. 22. temple jl, giacomelli am, kent km, roemmich jn, epstein lh. television watching increases motivated responding for food and energy intake in children. am j clin nutr 2007;85:355-61. 23. veldhuis l, vogel i, renders cm, van rossem l, oenema a, hirasing r a, et al. behavioral risk factors for overweight in early childhood; the “be active, eat right” study. int j behav nutr phys act 2012;9:74. 24. ouwens m a, cebolla a, van strien t. eating style, television viewing and snacking in pre-adolescent children. nutr hosp 2012;27:1072-8. 25. pate rr, mitchell ja, byun w, dowda m. sedentary behaviour in youth. br j sport med 2011;45:906-13. 26. mcdonald cm, baylin a, arsenault je, mora-plazas m, villamor e. overweight is more prevalent than stunting and is associated with socioeconomic status, maternal obesity , and a snacking dietary pattern in school children from bogota. j nutr 2009;139:370-6. nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 13 27. mirmiran p, azizi f. childhood obesity in the middle east : a review. east mediterr heal j 2010;16:1009-17. 28. neuman m, kawachi i, gortmaker s, subramanian s v. urban-rural differences in bmi in lowand middle-income countries : the role of socioeconomic status. am j clin nutr 2013;97:428-36. 29. doak cm, visscher tls, renders cm, seidell jc. the prevention of overweight and obesity in children and adolescents : a review of interventions and programmes. obes rev 2006;7:111-36. 30. hebert jr, clemow l, pbert l, ockene is, ockene jk. social desirability bias in dietary self-report may compromise the validity of dietary intake measures. int j epidemiol 1995;24:389-98. ___________________________________________________________ © 2016 nubani-husseini et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 1 original research adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria mariela stefanova kamburova 1 , petkana angelova hristova 1 , stela ludmilova georgieva 1 , azhar khan 1 1 department of public health sciences, faculty of public health, medical university, pleven, bulgaria. corresponding author: dr. mariela kamburova, medical university, pleven; address: 1, st. kliment ohridski, str, pleven, 5800, bulgaria telephone: +359887636599; email: mariela_kamburova@yahoo.com kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 2 abstract aim: this paper aims to study the relationship between mothers’ age, body mass index (bmi), gestational weight gain (gwg) and smoking and the risk for premature birth in pleven, bulgaria. methods: a case-control study was conducted in pleven in 2007. the study was comprehensive for all premature children (n=58) and representative for full-term infants (n=192, or 10.4% of all of the 1827 full-term children) born in 2007 at the university hospital of pleven and resident in the city of pleven. retrospective data on determinants under study were collected from all the mothers included in this study (n=250). results: mothers of premature children were more likely to be above 35 years old (27.6%), with a bmi ≥25 kg/m² (23.1%), gwg below the recommended value (38.5%) and to smoke during pregnancy (37.9%). the odds of being a smoker during pregnancy were five times higher among mothers with low birth weight (lbw) newborns compared with their counterparts with normal birth weight newborns (or=5.1, 95%ci=2.4-10.6). there was a positive association between bmi and lbw in infants whose mothers were overweight (or=2.1, 95%ci=1.0-4.0). the risk of lbw increased when gwg was less than recommended (or=1.8, 95%ci=1.0-3.1). conclusion: our results indicate that pre-pregnancy bmi ≥25 kg/m², less than recommended gwg and smoking during pregnancy are risk factors for premature birth in pleven region. findings from this study suggest the need for active health and educational actions by health professionals in order to avoid premature births in bulgaria. keywords: bulgaria, lifestyle, pleven, premature birth, risk factors. conflicts of interest: none. acknowledgements: the authors are very grateful to the staff of the obstetric clinic at university hospital in pleven, bulgaria, for their continuous support for the whole duration of this study. kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 3 introduction premature birth (pb) is a major public health problem worldwide (1). furthermore, pb is rated as one of the most important single causes of the global burden of diseases in neonatal period (2). it is associated with increased infant mortality, short and long-term negative effects on health and additional costly care needs (3). the interest of researchers in personal characteristics and lifestyle factors of the mothers is due to the fact that they are modifiable and they affect the incidence of premature birth. the challenge is to accurately measure the impact of these factors because of their complexity (4). several studies have shown young maternal age as a significant risk factor for premature birth (5,6). it has not been established with certainty yet, whether this risk is associated primarily with the biological immaturity of young mothers, or an increased incidence of certain risk factors associated with socioeconomic status such as age-appropriate educational level, parity, smoking status, prenatal care utilization and poverty status (7,8). women over the age of 35 years are also at increased risk of pre-term birth. astolfi and zonta (2002) found a 64% increase in the probability of giving premature birth for women over 35 years after controlling for educational status, birth order, and sex of the newborns (9). low or high pre-pregnancy body mass index (bmi) and inadequate or excess gestational weight gain (gwg) are linked to an increased risk of adverse neonatal outcomes (10,11). the weight of a woman before the pregnancy is related to her diet, quantity and quality of food (4). studies have shown that low weight of women before pregnancy is associated with an increased risk of preterm birth (12). campbell et al. (2012) found a link between low prepregnancy bmi and the birth of a premature baby, with a relative risk of >2.5 (6). a study conducted in 2010 in bulgaria on the role of some risk factors for preterm birth failed to establish a statistically significant difference in the weight of women bearing preterm children and those with to term births (13). smoking is defined as one of the most common and preventable causes of adverse outcomes of pregnancy (14,15). many chemicals in maternal smoking pass from the pregnant woman to the fetus through the placenta (16). smoking is associated with placental abruption and inadequate weight gain during pregnancy, but this relationship with the birth of a premature baby is not conclusive and is not proven in all studies. the probable reason for this is that the impact of smoking depends on its duration and intensity, and decreases in women who stop smoking at the beginning of pregnancy (17). some studies have found a strong causal association between smoking and pb of a child (18). a large number of studies have found a moderate influence of smoking in relation to pb of a baby (14,16,17). bulgaria is a country that is characterized by one of the highest indicators of age-specific fertility rate (above 40 per 1000) in europe in the age-group 15-20 years, which is a risk factor for giving birth to a premature baby (19). according to manolova (2004), 42.3% of women in bulgaria smoked during pregnancy (20). however, prematurity as a public health issue has not been subject to scientific inquiry in bulgaria in the past two decades. yet, there are a small number of scientific publications in terms of risk factors for pb in bulgarian children (21). in this context, there is a need to determine the lifestyle characteristics of mothers as important factors for pb in bulgaria. this paper aims at studying the relationship between mothers’ age, bmi, gwg and smoking during pregnancy and the risk for pb in the city of pleven, bulgaria. we hypothesized a positive association between pb and younger or older age and smoking habits of the mothers. furthermore, we assumed a positive link between low bmi and low weight gain during pregnancy and pb. kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 4 methods study design a case-control study was carried out in 2007 in the city of pleven, bulgaria. pleven is a typical township, located in central north bulgaria. at the beginning of the study (in 2007) the size of the population of the city was 139,573 people. in the same year, the birth rate was 8.96‰. maternal care was carried out only by the university hospital. there were 2004 children born at the university hospital, of whom, 1981 were live births. the proportion of preterm infants among all live births was 7.7%. study population the anticipated sample size for inclusion in this study consisted of 250 newborns. the study was comprehensive for all premature children (n=58) and representative for full-term infants (192, or 10.4% of all 1827 full-term children) born in 2007 at the university hospital of pleven and resident in the city of pleven. cases: 58 premature infants weighing 2500 g or less at birth. their gestational age was 37 weeks or less, and they resided in pleven. controls: 192 term infants who were matched to premature infants by date of birth. they were selected randomly among preterm children born on the same date. they weighed more than 2500 g. their gestational age was more than 37 weeks and they also resided in pleven. data collection document analysis: the information on birth weight, gestational age and home addresses of newborns was derived from medical records in a neonatal clinic at the university hospitalpleven. interview: the information for mother’s age, weight of women before the pregnancy, weight gain during pregnancy and smoking habits was gathered retrospectively by interviewing mothers during home visits. such information was not available in the records of mothers in the obstetrics ward, and not all women retained documents from antenatal visits. special questionnaires were designed for the purpose of the study. they were part of a larger study on risk factors for premature birth in the region of pleven, bulgaria. the questionnaire used for the documents’ analysis contained 39 questions, four of which were related to demographic and socio-economic status of the mother. the questionnaire for the interview comprised 92 questions, nine of which were about the lifestyle factors of the mother. for the validation of the questionnaires, a pilot study was conducted. before and after the pilot study questionnaires were discussed and approved by experts, pediatricians, obstetricians and public health professionals. all included mothers answered the questionnaire in the process of an interview. all data in this study were based on women’s reports during the survey interviews. ethical considerations the study was conducted under the supervision of the chair of the irb (institutional review board). the right of privacy of the studied subjects was guaranteed. only the leading investigator had access to the identifying information. mothers expressed their free will for participation and signed an informed consent before the interview. outcomes we studied two outcomes: preterm birth (pb<37 weeks completed gestation and birth weight <2500 g) and low birth weight (lbw: birth weight <2500 g). kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 5 determinants age of the mothers was determined as: ≤24 years, 25-29 years, 30-34 years and ≥35 years. pre-pregnancy bmi was categorized according to the world health organization (who) as either being underweight (bmi<18.5kg/m²), normal weight (18.5≤ bmi≤ 24.9), overweight (25≤bmi≤29.9), or obese (bmi≥30). we utilized the 2009 institute of medicine guidelines on gwg to categorize women’s weight gain for their bmi as below, within, or above the recommended value (22). smoking during pregnancy was determined based on the question “did you smoke during pregnancy?”. women who responded “yes” or “rarely” were categorized as “regular smokers” and “occasional smokers”. statistical analysis the survey data was processed with the statistical software packages spss (statistical package for social sciences), version 11.5, statgraphics and excel for windows. the results were described using tables. percentages were used to report the observed distribution of age of the mothers, bmi, gwg, smoking during pregnancy and other maternal characteristics. parametric tests for hypotheses testing at normal and near to normal distribution of cases: ttest, anova with post hoc tests (lsd, tukey, scheffe, bonferroni, newman-keuls, duncan) and nonparametric tests in other than normal distribution of cases pearson χ²-test, mann-whitney, kruskal-wallis h-test were applied. regression models for modeling and predicting of correlations and multiple logistic regression analyses controlled for covariates estimated the odds ratios with 95% confidence intervals of pb and lbw were used. using multivariable linear regression we assessed the relationships of studied determinants with outcomes (pb, lbw). odds ratios (or) were calculated to determine the effect of the age, weight and smoking during pregnancy, as factors for preterm birth. in all cases, a value of p≤0.05 was considered as statistically significant. results table 1 presents the distribution of basic characteristics of the participants by pb status. the distribution of maternal characteristics varied across mothers with pb and term birth. overall, 17.2% of women were above 35 years old. the share of older mothers was two times higher among those with pb compared to women with term-birth. overall, 23.3% of women were underweight and 12.5% were either overweight or obese. the proportion of overweight was more than two times higher among mothers with pb (19.2%) compared to mothers with term-birth (9.6%). around half (48.8%) of women gained above than the recommended weight for their bmi and a quarter (24.6%) gained less than the recommended weight. about 39% of women with pb compared to 21% of mothers with term-birth gained less than the recommended weight. smoking was reported by 38% of women: 16% of them were regular smokers and 22% occasional smokers. the proportion of mothers with pb who smoked (38%) was about four times higher compared to smoking women with term-birth (10%). compared to mothers with term-born infants, mothers of premature children were more likely to be above 35 years (27.6%), have a bmi≥25 (23,1%), have a gwg below the recommended value (38.5%), smoke during pregnancy (37.9%) and deliver pb children after the third delivery (17.2%). significant differences among mothers with pb were identified for maternal age, pre-pregnancy bmi, gwg, maternal smoking during pregnancy and birth order. conversely, there was no significant difference between groups with regard to their income level. kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 6 table 1. distribution of maternal characteristics characteristics all women (n=250) mothers with premature birth (n=58) mothers with term birth (n=192) p maternal age ≤24 years 25-29 years 30-34 years ≥35 years 25.8 27.4 29.1 17.2 10.4 37.9 24.1 27.6 30.5 24.2 30.5 14.8 0.001 0.049 ns 0.047 pre-pregnancy bmi <18.5 kg/m 2 18.5-24.9 kg/m 2 25.0-29.9 kg/m 2 ≥30 kg/m 2 23.3 64.2 11.7 0.8 15.4 61.5 19.2 3.9 25.5 64.9 9.6 ns ns ns gestational weight gain <recommended = recommended > recommended 24.6 26.7 48.8 38.5 26.9 34.6 20.7 26.6 52.7 0.010 ns 0.020 smoking during pregnancy regularly occasionally no 16.1 21.8 62.1 37.9 10.3 51.8 9.5 25.3 65.2 0.001 0.002 ns per capita income lowest (0-125 euro) middle (126-250 euro) highest (>250 euro) 36.0 46.4 17.6 41.4 41.4 17.2 34.4 47.9 17.7 ns ns ns birth order 1 2-3 ≥4 52.4 41.2 6.4 41.4 41.4 17.2 55.8 41.1 3.1 0.050 ns 0.005 table 2. maternal characteristics correlated with normal birth-weight and low birth-weight (g) characteristics linear regression logistic regression all (n=250) low birth weight (n=58) normal birth weight (n=192) low birth weight p mean±se p mean±se p mean±se p or (95%ci) maternal age 25-29 ≤24 30-34 ≥35 3120±85 3219±69 3168±71 2790±127 ns ns 0.007 2297±45 2256±47 2361±43 1876±88 ns ns 0.001 3491±46 3318±62 3318±53 3312±71 ns ns 0.005 reference 0.22 (0.08-0.58) 0.50 (0.23-0.99) 1.19 (0.54-2,65) 0.001 0.048 0.600 pre-pregnancy bmi 18.5-24.9 <18.5 25.0-29.9 ≥30 * 3185±59 3124±72 2844±101 2400±0 ns 0.040 0.010 2149±90 2163±72 2296±45 2400±0 ns ns ns 3427±41 3284±56 3148±96 ns 0.001 reference 0.64 (0.27-1.48) 2.12 (1.02-4.03) 0.280 0.049 gestational weight gain = recommended <recommended > recommended 3158±84 2955±74 3191±66 0.020 ns 2300±44 2307±40 1971±146 ns 0.002 3347±64 3287±61 3402±46 ns ns reference 1.83 (1.04-3.08) 0.65 (0.30-1.41) 0.048 0.270 smoking during pregnancy no regularly occasionally 3192±60 2666±72 3162±66 0.001 ns 2065±92 2328±29 2333±58 0.030 ns 3437±40 3080±86 3265±58 0.001 0.001 reference 5.05 (2.41-10.58) 0.52 (0.20–1.32) 0.001 0.160 * only two children weighing 2400 g were born from mothers with bmi≥30. kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 7 table 2 shows that maternal age at delivery, gwg and smoking during pregnancy were significantly associated with lbw. mothers who smoked regularly had a significant fivefold increase in lbw risk compared with nonsmoking mothers (or=5.05, 95%ci=2.41-10.58, p=0.001). the association between bmi and lbw was evident among infants whose mothers’ were overweight (or=2.12, 95%ci=1.02=4.03, p=0.049). we did not assess obesity as a risk factor for lbw, because there were no mothers of children with normal birth weight who had a bmi≥30. the risk of lbw increased when gwg was less than the recommended value (or=1.83, 95%ci=1.043.08, p=0.048). age of the mothers upon delivery less than 24 years (or=0.22, 95%ci=0.080.58, p=0.001) and between 30-34 years (or=0.50, 95%ci=0.23-0.99, p=0.048) was found as a protective factor for lbw. table 3 shows the results of fitting a multiple linear regression model to describe the relationship between prematurity and three independent variables: pre-pregnancy bmi, gwg and maternal age. the model explains 93% of the variability in pb. the equation of the fitted model was as follows: pb = 87.6117*bmi + 41.0981*gwg + 9.6293*maternal age table 3. multiple regression analysis: pre-pregnancy bmi, gwg and maternal age correlated with premature birth dependent variable: premature birth parameter estimate standard error t statistic p pre-pregnancy bmi gestational weight gain maternal age 87.6117 41.0981 19.6293 12.4486 7.13523 8.4454 7.03787 5.75988 2.32426 0.001 0.001 0.021 analysis of variance source sum of squares df mean square f-ratio p-value model residual 2.30485e9 1.70403e8 3 235 7.68283e8 725119.0 1059.53 0.001 total 2.47525e9 238 r-squared = 93.1157 %; r-squared (adjusted for d.f.) = 93.0571 %; standard error of est. = 851.539; mean absolute error = 646.141; durbin-watson statistic = 1.04712. discussion this study provides useful evidence about pb and lbw in the region of pleven, bulgaria. our results indicate that pre-pregnancy bmi, gwg related with personal bmi and smoking during pregnancy are important characteristics for pb in this population. the age of the mother is essential for normal pregnancy and delivery with a favorable outcome. from a biological point of view, the best age for childbirth is 20-29 years (8). the average age of women in our study was 26.3±5.8 years which was non-significantly lower than the average age for childbirth established in bulgaria (27.9 years of age) (23) and also lower than that established by yankova and dimitrov (2010) who stated an average age of 28 years at birth (24). the results for more than a twofold increased risk of premature birth to mothers aged under 20 years were reported by branum and schoendorf in 2005 (25). the association between the risk of a preterm labor and mother’s age is reported to be inverse (21,26), but we did not establish this. we found the age of the mothers at delivery less than 34 years as a protective factor for lbw. kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 8 we did not find a significant difference between the mean weight of mothers of premature (55 kg) and to term infants (54 kg) before pregnancy. we found a more than two times higher risk for lbw among mothers with pre-pregnancy bmi 25.0-29.9 kg/m², but there was no effect found of pre-pregnancy bmi<18.5 kg/m². the results of our study are compatible with the findings of a recent meta-analysis on the existence of a weak association or lack of association between low bmi before pregnancy and the birth of a premature baby (27). according to our results, the probability of giving birth to a premature baby in women who have had gwg less than recommended is around two times higher compared with mothers with recommended gwg. the insufficient weight gain during pregnancy increases the risk of having a premature baby, especially amongst women with low bmi before pregnancy: rr=1.5-2.5 (27). our results are similar to those of schieve la et al. (2000), who found out a three times higher risk of giving birth to a premature baby in women with a normal bmi, but not enough weight gain during pregnancy compared with women of normal weight and with adequate weight gain during pregnancy (28). our results concerning smoking during pregnancy (around 40% of all mothers) are close to a previous study from bulgaria conducted by manolova (2004), which reported that about 42% of all women smoked during the whole pregnancy (20). yet, the proportion of smoking mothers in our study was higher than a previous study conducted in bulgaria in 2007, which reported a prevalence of 33% (23). smoking is regarded as one of the most common and preventable causes of poor pregnancy outcomes (17). there is variability in the reported results for the relationship between smoking and pb, but a large number of studies establish an rr=1.2-1.5 when daily consumption of cigarettes is 10-20, and an rr=1.5-2.0 when more than 20 cigarettes are smoked per day. the same results were obtained by andriani and kuo for smoking mothers who lived in urban areas (17). our survey revealed a greater than fivefold increase in the risk of lbw among mothers who smoked during pregnancy, a finding which is in line with previous reports about the influence of smoking on the pb risk (14,17). study limitations this study may have several limitations. firstly, reports of the characteristics of mothers were retrospective after the child was born. additionally, self-reported data on bmi, gwg and smoking are highly correlated with pb and lbw, but they tend to underestimate these measures. women who smoked were categorized into three groups based on qualitative variables, and not according to the number of cigarettes smoked per day. the dissemination of information on adverse outcomes of smoking may have discouraged some mothers from disclosing it. secondly, because the place of study was an urban area we did not find enough mothers less than 19 years old. the result was that we did not establish the association between young maternal age and pb. thirdly, we utilized the institute of medicine guidelines to categorize women’s weight gain as below, within, or above recommended value (22), which maybe is not appropriate for bulgaria, but there are no other recommendations to be used. finally, we excluded from the analysis some women with either missing information on the principal determinants of interest (age, bmi, gwg, smoking), or missing information on gestational age and birth weight (needed for outcome variables), but the number of missing values was small. kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 9 obviously, there is a need for prospective studies from the registration of the pregnancy, in pleven and in other regions of bulgaria, in which such data should be collected in a standardized manner and the number of mothers and their children should be higher. conclusion our results confirm our research hypothesis that pre-pregnancy bmi>25 kg/m², less than recommended gwg related with their personal bmi and smoking during pregnancy are risk factors for pb. age of the mothers at delivery <34 years was a protective factor for lbw. this analysis was part of a study on the risk factors for pb and their impact on development and health status of children <3 years in bulgaria. our findings highlight the public health importance of promoting a healthy lifestyle of mothers in order to reduce the level of pb in bulgaria. references 1. blencove h, cousens s, oestergaard m, chou d, moller ab, narwal r, et al. national, regional and worldwide estimates of preterm birth in the year 2010 with time trends for selected countries since 1990: a systematic analysis and implications. lancet 2012;379:2162-72. 2. wang h, liddell ca, coates mm, mooney md, levitz ce, 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this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed/?term=sijtsma%20a%5bauthor%5d&cauthor=true&cauthor_uid=24510962 http://www.ncbi.nlm.nih.gov/pubmed/?term=sauer%20pj%5bauthor%5d&cauthor=true&cauthor_uid=24510962 http://www.ncbi.nlm.nih.gov/pubmed/?term=land%20ja%5bauthor%5d&cauthor=true&cauthor_uid=24510962 http://www.ncbi.nlm.nih.gov/pubmed/?term=laopaiboon%20m%5bauthor%5d&cauthor=true&cauthor_uid=24641534 http://www.ncbi.nlm.nih.gov/pubmed/?term=lumbiganon%20p%5bauthor%5d&cauthor=true&cauthor_uid=24641534 http://www.ncbi.nlm.nih.gov/pubmed/?term=zhang%20j%5bauthor%5d&cauthor=true&cauthor_uid=24641534 laaser u, bjegovic-mikanovic v. the united nations millennium development and post-2015 sustainable development goals: towards long-term social change and social stability (editorial). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-27 1 the united nations millennium development and post-2015 sustainable development goals: towards long-term social change and social stability an introduction ulrich laaser 1 , vesna bjegovic-mikanovic 2 1 faculty of health sciences, university of bielefeld, bielefeld, germany; 2 university of belgrade, faculty of medicine, centre school of public health and management, belgrade, serbia. corresponding author: prof. ulrich laaser, section of international public health, faculty of health sciences, university of bielefeld; address: faculty of health sciences, university of bielefeld, pob 100131, d-33501, bielefeld, germany; e-mail: ulrich.laaser@uni-bielefeld.de laaser u, bjegovic-mikanovic v. the united nations millennium development and post-2015 sustainable development goals: towards long-term social change and social stability (editorial). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-27 2 most millennium development goals (mdgs) show considerable progress on a global scale, but advance is inequitable if one, for example, compares the improvement in health between sub-saharan africa and eastern asia, or even other developing countries (1). whereas health and its social determinants play a major role in the debate on the post 2015 sustainable development goals (sdgs), another major issue is only marginally mentioned, the devastating impact of armed conflicts. conflict and war produce specific vulnerable groups: women, children, the elderly, and the special risk groups of technologically and drug dependent patients (intensive care, dialysis, incubator, radiotherapy, and chemotherapy). moreover, 90% of the victims in modern wars are civilians; always war causes mental health damage with long-term outcomes even in the next generation. although, for example, one of the latest documents (5-9 may 2014) of the united nations (un) sustainable development knowledge platform, the working document for the eleventh session of the open working group on sdgs (2), devotes its last 16 th focus area to peaceful and inclusive societies, typically that section deals only – important enough – with crime, violence, and exploitation especially of children and women. similarly, in the „health we want‟ report (1) security takes up a page (p. 35), but fig. 1 (p. 42) pictures the 16 commissions, conferences etc. before and after the turn of the century. the summarizing 10 principles and 6 new health goals (p. 54) do not refer to the social causes and the prevention of armed conflict at all. also, the un economic and social council (ecosoc) seem to concentrate on countries emerging from conflict (3,4) in contradiction to the mission statement on its homepage referring to prevention. armed conflicts cause more deaths and permanent invalidity than most diseases [in the 20 th century averaging to 460.000 deaths per year (5)] and analyses show that the fragile states at the lowest human development index (hdi) level contribute to most of the lack of achievement of the mdgs. the sdg debate has to be re-adjusted to the dominating problem of security in large parts of the world. in the joint statement of the un platform on social determinants of health (6), declared as an informal document, one of the chapters deals with conflict and fragility but the solutions offered do not seem to be very realistic e.g. expecting that developing health and information systems are possible to a relevant degree in a situation of conflict, and implicitly could prevent armed conflicts; rather, peace and security are a precondition for developing stable and sustainable health systems. hence, the third claim here, namely to strengthen the policy making functions, seems to be much more to the point. this request corresponds in a way to the results of the global survey of the world federation of public health associations on the experience of public health professionals from 71 countries with the mdgs (7-9), where the importance of “politics” was ranked highest in all continents, in particular by official spokespersons of public health associations. the modern concept of public health carries a great potential for healthy and therefore less aggressive societies. development of the health systems has to contribute to peace, since aggression, violence, and warfare are among the greatest risks for health and economic welfare (10). on the other hand, world military expenditure in 2013 totalled $1.75 trillion (11), more than enough to make a difference in people‟s health across the world. building on his book, transforming medical education for the 21 st century: megatrends, priorities and change (12), george lueddeke, a global consultant in higher and medical education, advances arguments along similar lines in a forthcoming publication, global population health and well-being in the 21 st century: towards a new worldview (published by march 2015). the south eastern european journal of public health (seejph) publishes in advance the chapter on the un-mdgs and the ongoing debate on the post-2015 sustainable development goals (sdgs). laaser u, bjegovic-mikanovic v. the united nations millennium development and post-2015 sustainable development goals: towards long-term social change and social stability (editorial). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-27 3 in total, the book comprises nine chapters, which range from historical perspectives on public/population health to contemporary challenges, including those triggered by „modernity‟, which might benefit from „fifth wave‟ interventions and the need to consider a new worldview. the author reviews the collective impact that external drivers are having on public health education and offers specific suggestions for modernizing public health curricula and learning. the volume includes an epilogue on „global health, governance and education‟, developed over the past few years by a think tank of 35 senior practitioners from 27 nations. it emphasizes that the core focus of the post-2015 sdgs needs to go beyond „sustainable development‟ and take its lead, as many others have advocated, from achieving global justice peace, security and basic human rights. references 1. health in the post-2015 agenda report of the global thematic consultation on health, april 2013: p.45. http://www.worldwewant2015.org/health (accessed: june 13, 2014). 2. working document for the eleventh session of the open working group on sdgs. http://sustainabledevelopment.un.org/content/documents/3686workingdoc_0205_add itionalsupporters.pdf (accessed: june 13, 2014). 3. un economic and social council. http://www.un.org/en/ecosoc/about/peacebuilding.shtml (accessed: june 13, 2014). 4. jonnalagadda haar r, rubenstein l. health in post-conflict and fragile states. united states institute of peace, 2012. 5. garfield, rn, neugut ai. epidemiologic analysis of warfare, a historical review. jama 1991;266:688-92. doi:10.1001/jama.1991.03470050088028. 6. health in the post-2015 development agenda: need for a social determinants of health approach; joint statement of the un platform on social determinants of health (undated). http://www.who.int/social_determinants/advocacy/health-post2015_sdh/en/ (accessed: june 13, 2014). 7. lomazzi m, theisling m, tapia l, borisch b, laaser u. mdgs – a public health professional‟s perspective from 71 countries. j public health policy 2013;34:e1–e22. doi:10.1057/jphp.2012.69. 8. lomazzi m, borisch b, laaser u: the millennium development goals: experiences, achievements and what‟s next. global health action 7 (2014). http://www.globalhealthaction.net/index.php/gha/issue/current (accessed: june 13, 2014). 9. lomazzi m, laaser u, theisling m, tapia l, borisch b: millennium development goals: public health professionals claim their role in the political debate. gha 2014 (submitted). 10. laaser, u., d. donev, v. bjegovic, y. sarolli: public health and peace (editorial). croat med j 2002;43:107-13. 11. stockholm international peace research institute (sipri). http://www.sipri.org/media/pressreleases/2014/milex_april_2014 (accessed: june 13, 2014). 12. lueddeke g. transforming medical education for the 21st century: megatrends, priorities and change. london: radcliffe publishing, 2012. ___________________________________________________________ © 2014 laaser et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.worldwewant2015.org/health http://sustainabledevelopment.un.org/content/documents/3686workingdoc_0205_additionalsupporters.pdf http://sustainabledevelopment.un.org/content/documents/3686workingdoc_0205_additionalsupporters.pdf http://sustainabledevelopment.un.org/content/documents/3686workingdoc_0205_additionalsupporters.pdf http://www.un.org/en/ecosoc/about/peacebuilding.shtml http://www.globalhealthaction.net/index.php/gha/issue/current http://www.sipri.org/media/pressreleases/2014/milex_april_2014 macassa g. integrated corporate social responsibility and human resources management for stakeholders health promotion (short report). seejph 2019, posted: 14 october 2019. doi 10.4119/seejph-2373 1 short report integrated corporate social responsibility and human resources management for stakeholders health promotion gloria macassa1 1department of public health and sports science, university of gävle, sweden. corresponding author: gloria macassa, md; address: department of public health and sports science, university of gävle, se-801 76, gävle, sweden; telephone: +4626648228; e-mail: gloria.macassa@hig.se abstract in the past decade, there has been an argument for the inclusion of corporate social responsibility (csr) in models and business strategies. however, the conversion of csr strategy into actual managerial practices and outcome values remains an issue of ongoing debate as well an important challenge for business organizations. furthermore, still is very little discussion on how business will influence stakeholder’s health promotion and surrounding environment as means to help address society’s most pressing challenges. this paper discusses the potential of public health literacy in advancing stakeholders’ health promotion beyond the workplace. the discussion argues that integrating corporate social responsibility (csr) and human resources management (hrm) is an effective strategy to achieve social sustainability in organizations in which stakeholders’ health and well-being are important components. this short report describes an integrated csr-hrm and describes how it can facilitate public health literacy. in the era of sustainable development, there is a need to discuss how business organizations can strategize to enhance internal and external stakeholders’ health and wellbeing. keywords: corporate social responsibility, human resources management, public health literacy, stakeholders’ health. macassa g. integrated corporate social responsibility and human resources management for stakeholders health promotion (short report). seejph 2019, posted: 14 october 2019. doi 10.4119/seejph-2373 2 the corporate social responsibility– human resources management nexus background in the past decade, there has been an argument for the inclusion of corporate social responsibility (csr) in models and business strategies (1-3). however, as suggested by jamali et al. (1), the conversion of csr strategy into actual managerial practices and outcome values remains an ongoing challenge for many organizations (1). various authors argue that human resources management (hrm) can provide interesting and dynamic support to csr strategy design, implementation, and delivery (1-3). although the definition of csr has been debated (4-9), there is agreement about its implementation and delivery. this short report defines csr as the social obligation of business enterprises to impact society beyond pure profit maximization (1,10) through an institutionalized responsive approach translated into and aligned with managerial practices, including human resource management (1,11). with that approach, csr can be seen as a planned process with strategic applications and links to the organization’s mission and core competences (12-14).several works have highlighted how csr can increase organizational performance (15) through generating a sense of belonging and commitment among stakeholders (16,17). in addition to the evidence for csr’s beneficial effects on employees (18), the main argument here is that hrm could provide a managerial framework to support organizational efforts to translate csr strategies into practical managerial actions and outcomes, especially within the internal organizational environment (2,19,20). similar to csr, hrm has been defined different ways, especially as it has evolved over time (21,22). there are also international differences in its definitions. for instance, kaufman argues that in the dominant american model, hrm is considered both a function and a process, thus making it difficult to disentangle from general management activities (23). in this short report i follow watson (24) in defining hrm as ‘institutions, discourses and practices focused on the management of people within an employment relationship enacted through networks comprising multiple public and private actors’. this definition allows us to understand hrm beyond its functional aspects, to consider both micro and macro levels of the phenomenon, and to expand the employer–worker dyad to include multiple institutions and stakeholders (24). hrm is seen to have capabilities and expertise in executing organizational strategies, participating in change management support and facilitation, and enhancing managerial efficiency and responsibility for learning, training, and development programmes to help to integrate csr into an organization’s culture. what makes its role all the more interesting and promising is that hrm is increasingly considered responsible not only for humanistic and social concerns, but also for adding value in a broader business sense (25,26). hrm is expected to reach out to communities and society in general as well as to have an important role in the search for sustainable organizations (22). in addition, hrm has the potential to target sustainability at the dual dimension of work and home, as well as contribute to responsible leadership (rl) within organizations. this type of leadership is known to transcend the traditional binary leadership-employee relationship to emphasize multiple leader-stakeholder relationships, paying attention to all stakeholders as well as the environment. hrm can help to create a win–win environment for business organizations macassa g. integrated corporate social responsibility and human resources management for stakeholders health promotion (short report). seejph 2019, posted: 14 october 2019. doi 10.4119/seejph-2373 3 and their multiple stakeholders (internal and external) through better alignment with the organization’s mission and strategic direction (27,28). hrm thus appears to be well positioned to be more involved in helping firms to amplify their csr efforts and achieve worthwhile and substantive outcome values (3). integrated human csr-hrm for stakeholders’ health promotion: the role of public health literacy socially responsible hrm, csr, and promotion of stakeholder’s health should be seen through the lens of stakeholder theory, in which the essence of business lies primarily in building and creating value for all stakeholders, internal and external (29,30). this theory helps to explain why is beneficial to integrate csr with business management to advance the health and well-being of all stakeholders within and beyond the workplace (31). csr is thus considered to be a process in which business organizations integrate social, ethical, environmental, and human rights and consumer concerns across its operations in order to maximize value for owners, stakeholders, and the broader society as well as identify, prevent, and mitigate potential adverse consequences on the environment (1,8,10). for instance, the introduction of socially responsible elements to daily management has been argued to legitimize companies’ activities vis-à-vis the groups with which they interact: shareholders, partners, suppliers, customers, public institutions, nongovernmental organizations, employees, and society in general (32,33). from a health promotion perspective, this integration could be an important vehicle for disseminating strategies that support sustainable population health (34). i argue that csr-hrm can be used within enterprises to implement stakeholders’ literacy in health and well-being in both the workplace and the larger society. contrary to individual health literacy (which is a predictor to individual health outcomes), public health literacy is defined as the public’s ability to make sound health decisions in the context of everyday life-at home, in the community, at the workplace, in the health care system, at the market place, and in the political arena (34). for instance, linking csr and health literacy can encourage both business and civic engagement in health, thus creating a reciprocal responsibility to create workplaces in which employees can obtain the information they need to understand and act on both individual and public health concerns (35). sorensen et al. argue that health literacy could benefit csr through widening opportunities to promote new partnerships and resources for its progress (35). they also suggest that business can play an important role in spreading health literacy not only among employees, but also in society (35). health literacy is important to business in ensuring the availability of a healthy workforce and its long-term sustainability, well-being, and performance (35,36). health literacy in the workplace can also be both a catalyst for a long-term return on investment and a way for companies to educate their workforce on the importance of societal well-being and sustainability (37). because public health literacy can be embedded in the company’s strategic csr-hrm, it can boost employees’ knowledge and motivate them to make decisions important to their health, the working environment, and the health and well-being of others (including the natural environment). burmeister argues that modern companies cannot operate without considering the social consequences of their actions (38). advancing public health literacy as a corporate strategic choice can fit the dynamic change from an add-on csr to a built-in csr, where social considerations are integrated into strategies and macassa g. integrated corporate social responsibility and human resources management for stakeholders health promotion (short report). seejph 2019, posted: 14 october 2019. doi 10.4119/seejph-2373 4 operations. it can also stimulate the shift form value protection to value creation (including social value), with a focus on innovation and competitive advantage rather than risk and reputation management (38,39). using the csr-hrm nexus to enhance public health literacy and stakeholders’ health and well-being may not necessarily require additional resources from businesses. instead, it might be accomplished using already available tools and past efforts, but now coordinated with 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health-literacy – a strategic asset for corporate social responsibility in europe. j health commun 2011;16 suppl 3:322-7. doi: 10.1080/10810730.2011.606072. 37. larsen ak, holterman a, mortensen os, punnett l, rod mh, jorgensen mb. organizing workplace health literacy to reduce musculoskeletal pain and consequences. bmc nurs 2015;14:46. 38. burmeister k. megatrends and the future of corporate social responsibility. forum csr international 2008;1:16-7. 39. maanavilija l. csr in europe. a look back and into the future. forum csr international 2010;1:76-7. ___________________________________________________________ © 2019 macassa; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://ilcuk.org.uk/wp-content/uploads/2018/10/navigatinghealth.pdf https://ilcuk.org.uk/wp-content/uploads/2018/10/navigatinghealth.pdf https://ilcuk.org.uk/wp-content/uploads/2018/10/navigatinghealth.pdf https://www.ncbi.nlm.nih.gov/pubmed/21951261 https://www.ncbi.nlm.nih.gov/pubmed/21951261 relative income and acute coronary syndrome: a population-based case-control study in tirana, albania bojaj g, czabanowska k, skeraj f, burazeri g. level of competencies of family physicians from patients’ viewpoint in post-war kosovo (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-05. 1 original research level of competencies of family physicians from patients’ viewpoint in postwar kosovo gazmend bojaj1,2, katarzyna czabanowska3,4, fitim skeraj2, genc burazeri2,3 1 principal family medicine center, kline, kosovo; 2 university of medicine, tirana, albania; 3 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 4 faculty of health sciences, jagiellonian university medical college, krakow, poland. corresponding author: gazmend bojaj, md, principal family medicine center, kline, kosovo; address: rr. “faruk elezi”, kline, kosovo; telephone: +37744251164; e-mail: drgazi2002@hotmail.com bojaj g, czabanowska k, skeraj f, burazeri g. level of competencies of family physicians from patients’ viewpoint in post-war kosovo (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-05. 2 abstract aim: besides the health professionals’ perspective, it is equally important to assess the perceptions of the users of health care services with regard to abilities, skills and competencies of their family physicians. our aim was to assess the level of competencies of family physicians from patients’ viewpoint in transitional kosovo. methods: a nationwide survey was conducted in kosovo in 2013, including a representative sample of 1340 primary health care users aged ≥18 years (49% males aged 50.7±18.4 years and 51% females aged 50.4±17.4 years; response rate: 89%). participants were asked to assess the level of competencies of their respective family physicians regarding different domains of the medical encounter. the self-administered questionnaire included 37 items structured into six domains. answers for each item of the instrument ranged from one (“novice” physicians) to five (“expert” physicians). an overall summary score related to family physicians’ competencies was calculated for each participant [range: from 37 (minimal competencies) to 185 (maximal competencies)]. furthermore, demographic and socioeconomic data were collected. general linear model was used to assess the demographic and socioeconomic correlates of the overall level of family physicians’ competences according to patients’ perspective. results: mean value of the overall summary score for the 37-item instrument was 118.0±19.7. it was higher among the younger and the low-income participants, and in patients who reported frequent health visits and those not satisfied with the quality of the medical encounter. conversely, no sex, or educational differences were noted. conclusions: our findings indicate a relatively high level of competencies of family physicians from patients’ perspective in post-war kosovo. future studies should comprehensively assess the main determinants of self-perceived competencies of family physicians among primary health care users in kosovo. keywords: competencies, family physicians, primary health care users, quality of care. bojaj g, czabanowska k, skeraj f, burazeri g. level of competencies of family physicians from patients’ viewpoint in post-war kosovo (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-05. 3 introduction recently, it has been argued that competency-based instruction is vital for professional development of health professionals (1). hence, competency-based education enhances the abilities and skills of the health personnel to address complex and changing demands for critical services at a population level (1-3). fostering competencies and skills of the health care workforce will lead to an increase in the satisfaction level of the users of health care services, which has been convincingly linked to a better quality of primary health care (4) and more favorable health outcomes (5,6). from this point of view, in order to meet patients’ demands, quality improvement and performance evaluation have recently developed into core issues in primary health care practice (7). we have previously argued about the need for development of useful tools for the continuous assessment of physicians’ performance in order to identify potential gaps in their level of skills, abilities and competencies with the ultimate goal of improving the quality of patient care (7,8). to meet this end, we have suggested a conceptual framework and a suitable instrument which help to self-assess competency gaps among primary health care professionals (7,8). however, besides the health professionals’ perspective, it is equally important to assess the perceptions of the users of health care services with regard to abilities, skills and competencies of their family physicians and the other health personnel. thus, there is a need to develop measuring instruments for health professionals’ competencies as viewed from patients’ perspective. in this line of argument, we have developed and tested an international instrument aiming at assessing the level of skills, abilities and competencies of health professionals from both family physicians’ perspective (self-assessment) and from primary health care users’ standpoint (8). this measuring instrument has been validated in albania among primary health care users (9) and in general practitioners and family physicians (10). more recently, a cross-cultural adaptation of this instrument has been also conducted in kosovo among primary health users (11) and family physicians (12). in this framework, we aimed to assess the level of skills, abilities and competencies of family physicians from primary health care users’ perspective in kosovo, a transitional country in the western balkans. we used the validated version of the international instrument developed with the support of the european community lifelong learning program. this standardized tool addresses the competency levels of general practitioners and family physicians regarding different domains of quality of health care (7,8). methods a nationwide cross-sectional study was conducted in kosovo in january-december 2013. study population a representative nationwide sample of 1340 primary health care users (both sexes aged ≥18 years) was included in this survey. calculation of the sample size was made by use of winpepi for a number of hypotheses related to patients’ socio-demographic and socioeconomic correlates such as sex, age and level of education. the significance level (twotailed) was set at 5%, and the power of the study at 80%. based on the most conservative calculations, the required minimal size was about 1200 individuals. we decided to recruit 1500 individuals in order to increase the power of the study. of the 1500 targeted individuals, 160 did not participate in the survey. overall, 1340 primary health care users were included in our survey [661 (49%) males and 679 (51%) females; bojaj g, czabanowska k, skeraj f, burazeri g. level of competencies of family physicians from patients’ viewpoint in post-war kosovo (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-05. 4 overall response rate: 1340/1500=89.3%]. the response rate was similar in each of the regions included in the survey. in addition, respondents and non-respondents had similar sex and age distribution in all of the regions included in the survey. data collection we employed an international instrument aiming at assessing the level of skills, abilities and competencies of family physicians from primary health care users’ perspective. all participants included in this survey were asked to assess the level of skills, abilities and competencies of their family physicians with regard to the following six crucial domains of the quality of primary health care: (i) patient care and safety (8 items); (ii) effectiveness and efficiency (7 items); (iii) equity and ethical practice (8 items); (iv) methods and tools (5 items); (v) leadership and management (4 items), and; (vi) continuing professional development (5 items). answers for each item of each subscale ranged from 1 (“novice”= physicians have little or no knowledge/ability, or no previous experience of the competency described and need close supervision or instruction) to 5 (“expert”=physicians are the primary sources of knowledge and information in the medical field) (9-12). an overall summary score [including 37 items; range: from 37 (minimal competencies) to 185 (maximal competencies)] was calculated for all participants included in this study. demographic and socioeconomic data (age and sex of participants, educational attainment, employment status and income level) and information on the overall satisfaction with the medical encounter and the number of health visits in the past year were also collected. the study was approved by the ethical board of the ministry of health of kosovo. all individuals who agreed to participate signed an informed consent form prior to the interview. statistical analysis cronbach’s alpha was used to assess the internal consistency of the 37-item instrument measuring family physicians’ competencies from primary health care users’ perspective. conversely, spearman’s rho was used to assess the linear association (correlation) of the subscale scores (domains) of the instrument. general linear model was employed to assess the association of the overall score of competencies of family physicians’ from patients’ viewpoint with their demographic and socioeconomic characteristics. unadjusted and age-adjusted mean values, their respective 95% confidence intervals (95%cis) and p-values were calculated. statistical package for social sciences (spss), version 17.0 was used for all the statistical analyses. results background characteristics of study participants the overall mean age of survey participants was 50.5±17.9 years – it was similar in males and females (table 1). on the whole, mean years of formal schooling were 9.4±4.0 years. the educational attainment was higher in males compared with female participants (mean years of formal schooling: 10.3±3.7 years vs. 8.5±4.1 years, respectively). about 20% of study participants reported a low income level (18% in males and 21% in females), whereas 7% reported a high income level (8% in males and 7% in females). the unemployment rate was quite high in this bojaj g, czabanowska k, skeraj f, burazeri g. level of competencies of family physicians from patients’ viewpoint in post-war kosovo (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-05. 5 representative sample of primary health care users in kosovo, particularly among female participants (53% vs. 22% in males). very few participants reported their first health visit at the primary health care services in the past year (overall n=16), about 19% reported 1-2 health visits, whereas 18% of individuals reported seven or more health visits in the past year. remarkably, survey participants reported a high degree of satisfaction with primary health care services: 75% of individuals perceived as “good” or “very good” the medical encounter, compared to only 3.4% of individuals who rated as “poor” or “very poor” the quality of primary health care services. there were no gender differences with regard to the overall satisfaction with the quality of primary health care services (table 1). table 1. distribution of socioeconomic characteristics and satisfaction with health care services in a representative sample of primary health care users in kosovo, in 2013 variable male (n=661) female (n=679) overall (n=1340) age (years) 50.7±18.4* 50.4±17.4 50.5±17.9 educational level (years) 10.3±3.7 8.5±4.1 9.4±4.0 income level: low middle high 119 (18.0)† 491 (74.3) 51 (7.7) 146 (21.5) 485 (71.4) 48 (7.1) 265 (19.8) 976 (72.8) 99 (7.4) employment status: employed unemployed students retired 288 (43.6) 146 (22.1) 66 (10.0) 161 (24.4) 168 (24.7) 363 (53.5) 55 (8.1) 93 (13.7) 456 (34.0) 509 (38.0) 121 (9.0) 254 (19.0) no. health visits in the past 12 months: 0 1-2 3-4 5-6 ≥7 7 (1.1) 131 (19.8) 268 (40.5) 136 (20.6) 119 (18.0) 9 (1.3) 125 (18.4) 214 (31.5) 204 (30.0) 127 (18.7) 16 (1.2) 256 (19.1) 482 (36.0) 340 (25.4) 246 (18.4) overall satisfaction with health services: very good/good average poor/very poor 500 (75.6) 140 (21.2) 21 (3.2) 503 (74.1) 151 (22.2) 25 (3.7) 1003 (74.9) 291 (21.7) 46 (3.4) * mean values ± standard deviations. † numbers and column percentages (in parentheses). ---------------------------------------------------- instrument for measuring competencies of family physicians overall, reliability (internal consistency) of the whole scale (37 items) was cronbach’s alpha=0.96 (95%ci=0.96-0.97); it was similar in male and female participants (0.97 vs. 0.96, respectively) [data not shown]. table 2 presents a correlation matrix between the subscale scores (that is domains of the measuring instrument). spearman’s correlation coefficients ranged from 0.55 (for the linear association of “leadership and management” with the “patient care and safety” and the “equity and ethical practice” domains) to 0.70 (for the “effectiveness and efficiency” and the “patient care and safety” subscales) – indicating a moderate linear relationship between the domains of the family physicians’ competencies instrument. bojaj g, czabanowska k, skeraj f, burazeri g. level of competencies of family physicians from patients’ viewpoint in post-war kosovo (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-05. 6 table 2. correlational matrix of subscale scores (alias domains of the instrument) domain continuing professional development patient care and safety effectiveness and efficiency equity and ethical practice methods and tools patient care and safety 0.57 (<0.001) * effectiveness and efficiency 0.56 (<0.001) 0.70 (<0.001) equity and ethical practice 0.58 (<0.001) 0.59 (<0.001) 0.64 (<0.001) methods and tools 0.66 (<0.001) 0.62 (<0.001) 0.68 (<0.001) 0.64 (<0.001) leadership and management 0.64 (<0.001) 0.55 (<0.001) 0.58 (<0.001) 0.55 (<0.001) 0.71 (<0.001) * spearman’s correlation coefficients and their respective p-values (in parentheses). ---------------------------------------------------- correlates of competencies of family physicians mean value of the overall summary score for the 37-item instrument was 118.0±19.7 [range from 37 (minimal competencies) to 185 (maximal competencies)]. mean value of the overall summary score of the competencies of family physicians from patients’ viewpoint was higher among the younger (<45 years) participants compared with their older (≥45 years) counterparts (119 vs. 117, respectively, p=0.04) [table 3]. there was no evidence of gender-differences in the mean scores of the overall competencies of family physicians even upon age-adjustment. furthermore, mean scores of competencies of family physicians were similar among participants with different levels of educational attainment. on the other hand, the low-income participants exhibited lower mean scores of their family physicians’ overall competencies compared with the high-income group (age-adjusted overall p<0.001). employed and unemployed individuals exhibited similar mean scores – a finding which persisted also upon age-adjustment. patients with frequent visits in the primary health care clinics (three or more visits in the past year) displayed the lowest scores of competencies of their family physicians (age-adjusted overall p<0.001). as expected, participants who were satisfied with the medical encounter showed a higher mean score of their family physicians’ competencies compared with the individuals who were less satisfied with the quality of primary health care services (overall p<0.001) [table 3]. table 3. association of competencies of family physicians from patients’ viewpoint with their demographic and socioeconomic characteristics; mean values from the general linear model patients’ socioeconomic characteristics unadjusted models age-adjusted models mean* 95%ci p mean* 95%ci p age: younger (≤44 years) older (≥45 years) 119.4 117.1 117.6-121.0 115.8-118.4 0.042 gender: males females 118.2 117.8 116.7-119.7 116.3-119.3 0.704 118.4 118.0 116.9-119.9 116.5-119.6 0.735 educational level: low (0-8 years) middle (9-12 years) high (≥13 years) 117.4 118.3 118.7 115.9-118.9 116.5-120.2 116.3-121.1 0.601 (2)† 0.371 0.802 reference 118.2 118.3 118.2 116.5-119.9 116.4-120.2 115.7-120.7 0.998 (2)† 0.992 0.954 reference income level: low 113.4 111.1-115.8 <0.001 (2) 0.037 113.9 111.5-116.3 <0.001 (2) 0.077 bojaj g, czabanowska k, skeraj f, burazeri g. level of competencies of family physicians from patients’ viewpoint in post-war kosovo (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-05. 7 middle high 119.2 118.2 118.0-120.4 114.4-122.1 0.649 reference 119.3 118.0 118.1-120.6 114.2-121.9 0.527 reference employment status: employed unemployed student retired 118.8 117.4 120.4 116.5 117.0-120.6 115.7-119.1 116.9-123.9 114.1-118.9 0.222 (3) 0.141 0.564 0.077 reference 118.7 117.7 119.8 117.2 116.8-120.5 115.9-119.5 116.2-123.5 114.5-120.0 0.690 (3) 0.400 0.758 0.289 reference no. health visits in the past 12 months: 0 1-2 ≥3 126.6 122.1 116.9 117.0-136.2 119.7-124.5 115.7-118.0 <0.001 (2) 0.048 <0.001 reference 126.3 122.0 117.1 116.6-135.9 119.6-124.4 115.8-118.3 0.001 (2) 0.064 <0.001 reference overall satisfaction with health services: very good/good average poor/very poor 119.8 112.4 113.5 118.6-121.0 110.1-114.6 107.9-119.1 <0.001 (2) 0.031 0.718 reference 120.0 112.7 113.8 118.7-121.2 110.4-114.9 108.2-119.5 <0.001 (2) 0.036 0.710 reference * range of the overall summary score from 37 (minimal competencies) to 185 (maximal competencies). † overall p-values and degrees of freedom (in parentheses). ---------------------------------------------------- discussion findings from this survey provide useful information on the level of skills, abilities and competencies of family physicians from primary health care users’ perspective in post-war kosovo. the assessment instrument administered in our study sample showed a very high internal consistency, which was similar in male and female participants. as a matter of fact, the overall internal consistency in our survey (cronbach’s alpha=0.96) was higher than in a prior cross-cultural adaptation exercise conducted in kosovo, which reported an overall cronbach’s alpha=0.88 (11). in addition, the internal consistency in the current study conducted in kosovo was higher than in a previous validation study conducted in albania (9). in our study, the reliability of the tool (i.e. the internal consistency) was similar in both sexes, a finding which is basically compatible with a previous report from albania (9). the overall level of competencies of family physicians – as assessed by the summary score of the 37-item instrument – was quite high in our study which included a nationwide representative sample of primary health care users in kosovo. there were no sex-differences with regard to the perceived levels of family physicians’ competencies according to patients’ standpoint. as pointed out earlier, this finding related to a high level of family physicians’ knowledge and competencies is in line with the very positive assessment of the quality of primary health care services among our study participants (13). thus, in our study, 75% of participants perceived as “good” or “very good” the medical encounter, a finding which is quite different from a previous study conducted in gjilan region, kosovo, in 2010 including a representative sample of 1039 primary health care users (14). in this survey, patients’ evaluation of primary health care services was assessed through europep, a 23-item instrument tapping different aspects of the medical encounter. findings from this study indicated that considerably fewer primary health care users in kosovo were satisfied with the overall medical encounter compared with their european counterparts (14). however, there are differences between the two studies: our survey included a nationwide representative sample in contrast with the previous study confined to gjilan region only (14). furthermore, we assessed only the self-perceived level of competencies of family physicians from patients’ bojaj g, czabanowska k, skeraj f, burazeri g. level of competencies of family physicians from patients’ viewpoint in post-war kosovo (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-05. 8 perspective. on the other hand, the prior survey conducted in gjilan region included other important dimensions of the quality of primary health care services which are not related to the level of knowledge, skills and competencies of health care professionals (14). furthermore, the overall level of competencies of family physicians in our study was higher compared to the previous validation study (cross-cultural adaptation) which was conducted in a sample of 98 primary health care users in kosovo (11). in addition, the overall summary score in our study was particularly higher compared to prior reports from the neighboring albania, where a similar survey employing exactly the same instrument was conducted (9,10). in our study conducted in kosovo, the level of skills, abilities and competencies of family physicians as assessed by patients’ perspective was positively related to income level, in contrast with the albanian study which reported lack of associations with socioeconomic characteristics of study participants (9). nonetheless, there was no evidence of relationship with educational attainment in the current survey, too. future studies in kosovo and albania should compare primary health care users’ assessment scores with the self-assessed scores of their respective family physicians in order to identify potential gaps in the perceived levels of skills and competencies. as argued earlier, primary health care users’ viewpoints about the quality of health care services including the skills and competencies of their respective family physicians may vary significantly from the selfperceived level of competencies of health care professionals themselves (13). competencies are considered as composites of individual attributes including knowledge, skills and attitudes that represent context-bound productivity (15). however, patients’ viewpoint on productivity may differ considerably from providers’ perspective. hence, future studies in albanian settings and elsewhere should explore this important issue in a robust manner. in conclusion, findings from this nationwide survey conducted in transitional kosovo provide useful information on the level of skills and competencies of family physicians from primary health care users’ perspective. nonetheless, findings from this survey should be replicated in future studies in albania and kosovo. source of support the instrument for this survey was developed with the support of the european commission lifelong learning program in the framework of the leonardo da vinci project “innovative lifelong learning of european general physicians in quality improvement supported by information technology” (ingpinqi): no. 2010-1-pl1-leo05-11473. conflicts of interest: none declared. references 1. czabanowska k, smith t, könings kd, sumskas l, otok r, bjegovic-mikanovic v, brand h. in search for a public health leadership competency framework to support leadership curriculum-a consensus study. eur j public health 2013 (epub ahead of print). 2. wright k, rowitz l, merkle a, et al. competency development in public health leadership. am j public health 2000;90:1202-7. 3. mckee m. seven goals for public health training in the 21st century. eur j public health 2013;23:186-7. 4. heje hn, vedsted p, olesen f. general practitioners’ experience and benefits from patient evaluations. bmc fam pract 2011;12:116. http://www.ncbi.nlm.nih.gov/pubmed?term=czabanowska%20k%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=smith%20t%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=k%c3%b6nings%20kd%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=sumskas%20l%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=otok%20r%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=bjegovic-mikanovic%20v%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=brand%20h%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed/24121098 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=heje%20hn%5bauthor%5d&cauthor=true&cauthor_uid=22040039 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=vedsted%20p%5bauthor%5d&cauthor=true&cauthor_uid=22040039 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=olesen%20f%5bauthor%5d&cauthor=true&cauthor_uid=22040039 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=general%20practitioners%e2%80%99%20experience%20and%20benefits%20from%20patient%20evaluations bojaj g, czabanowska k, skeraj f, burazeri g. level of competencies of family physicians from patients’ viewpoint in post-war kosovo (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-05. 9 5. van walraven c, oake n, jennings a, forster aj. the association between continuity of care and outcomes: a systematic and critical review. j eval clin pract 2010;16:94756. 6. hush jm, cameron k, mackey m. patient satisfaction with musculoskeletal physical therapy care: a systematic review. phys ther 2011;91:25-36. 7. czabanowska k, klemenc-ketis z, potter a, rochfort a, tomasik t, csiszar j, vanden bussche p. development of the competency framework in quality improvement for family medicine in europe: a qualitative study. j contin educ health prof 2012;32:174-80. 8. czabanowska k, burazeri g, klemens-ketic z, kijowska v, tomasik t, brand h. quality improvement competency gaps in primary care in albanian, polish and slovenian contexts: a study protocol. acta inform med 2012;20:254-8. 9. alla a, czabanowska k, klemenc-ketis z, roshi e, burazeri g. cross-cultural adaptation of an instrument measuring primary health care users’ perceptions on competencies of their family physicians in albania. med arh 2012;66:382-4. 10. alla a, czabanowska k, kijowska v, roshi e, burazeri g. cross-cultural adaptation of a questionnaire on self-perceived level of skills, abilities and competencies of family physicians in albania. mater sociomed 2012;24:220-2. 11. bojaj g, czabanowska k, klemens-ketic z, skeraj f, hysa b, tahiri z, burazeri g. validation of an instrument measuring primary health care users’ opinion about abilities, skills and competencies of their family physicians in kosovo. albanian medical journal 2013;1:79-83. 12. skeraj f, czabanowska k, bojaj g, hysa b, petrela e, hyska j, burazeri g. crosscultural adaptation of a questionnaire about competencies of family physicians in kosovo from practitioners’ and policymakers’ perspective. albanian medical journal 2013;1:19-24. 13. bojaj g, czabanowska k, skeraj f, tahiri z, burazeri g. primary health care users’ perceptions on competencies of their family physicians in kosovo: preliminary results from a cross-sectional study. albanian medical journal 2013;3:64-9. 14. tahiri z, toçi e, rrumbullaku l, hoti k, roshi e, burazeri g. patients’ evaluation of primary health care services in gjilan region, kosovo. j public health (oxf) 2013 (epub ahead of print). 15. loo jv, semeijn j. defining and measuring competences: an application to graduate surveys. qual quant 2004;38:331-49. ___________________________________________________________ © 2014 bojaj et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=van%20walraven%20c%5bauthor%5d&cauthor=true&cauthor_uid=20553366 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=oake%20n%5bauthor%5d&cauthor=true&cauthor_uid=20553366 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=jennings%20a%5bauthor%5d&cauthor=true&cauthor_uid=20553366 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=forster%20aj%5bauthor%5d&cauthor=true&cauthor_uid=20553366 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=the%20association%20between%20continuity%20of%20care%20and%20outcomes%3a%20a%20systematic%20and%20critical%20reviewjep_1235%20947..956 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=hush%20jm%5bauthor%5d&cauthor=true&cauthor_uid=21071504 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=cameron%20k%5bauthor%5d&cauthor=true&cauthor_uid=21071504 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=mackey%20m%5bauthor%5d&cauthor=true&cauthor_uid=21071504 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed/21071504 http://www.ncbi.nlm.nih.gov/pubmed?term=tahiri%20z%5bauthor%5d&cauthor=true&cauthor_uid=23596194 http://www.ncbi.nlm.nih.gov/pubmed?term=to%c3%a7i%20e%5bauthor%5d&cauthor=true&cauthor_uid=23596194 http://www.ncbi.nlm.nih.gov/pubmed?term=rrumbullaku%20l%5bauthor%5d&cauthor=true&cauthor_uid=23596194 http://www.ncbi.nlm.nih.gov/pubmed?term=hoti%20k%5bauthor%5d&cauthor=true&cauthor_uid=23596194 http://www.ncbi.nlm.nih.gov/pubmed?term=roshi%20e%5bauthor%5d&cauthor=true&cauthor_uid=23596194 http://www.ncbi.nlm.nih.gov/pubmed?term=burazeri%20g%5bauthor%5d&cauthor=true&cauthor_uid=23596194 http://www.ncbi.nlm.nih.gov/pubmed/23596194 comment bjegovic-mikanovic, marinkovic-eric. misunderstanding should be avoided by precise formulation: comment on jerliu et al. “public health in kosovo after five difficult years of independence” (letter to editors). seejph 2014, posted: 19 april 2014. doi 10.12908/seejph-2014-21. letter to editors misunderstanding should be avoided by precise formulation: comment on jerliu et al. “public health in kosovo after five difficult years of independence” vesna bjegovic-mikanovic1, jelena marinkovic-eric2 1 university of belgrade, faculty of medicine, centre-school of public health and management, institute of social medicine, belgrade, serbia; 2 university of belgrade, faculty of medicine, institute of medical statistics and informatics, belgrade, serbia. corresponding author: prof. dr. vesna bjegovic-mikanovic, faculty of medicine, belgrade university; address: dr subotica 15, 11000 belgrade, serbia; telephone: +381112643 830; email: bjegov@med.bg.ac.rs 1 bjegovic-mikanovic, marinkovic-eric. misunderstanding should be avoided by precise formulation: comment on jerliu et al. “public health in kosovo after five difficult years of independence” (letter to editors). seejph 2014, posted: 19 april 2014. doi 10.12908/seejph-2014-21. in this review paper, jerliu and co-authors describe the recent steps to reorganize the system of health care in kosovo1 (1-3). only at the end of the abstract and the conclusions the authors speak of five years since the (unilateral) kosovar declaration of independence (not cited among the references) or elsewhere in the text of “transformation to an independent state”, whereas in the title, unfortunately, they speak only of independence. also, the authors state that kosovo currently has been recognized by 105 countries, however, the un family consists of 193 countries, and – as they indicate correctly – kosovo is not yet a member of the world health organization. the precisely formulated expression in international documents is as follows: “the designation of kosovo is without prejudice to positions of status, and in line with the united nations security council resolution 1244/99 and the international court of justice opinion on the kosovo declaration of independence”. the imprecise wording in this paper can lead to misunderstanding which should be avoided (4). beyond the difficult definition of the status of kosovo in the current transition phase, a more important deficit of this paper is the lack of historical reference with regard to the development after world war ii. in 1950, infant mortality in that part of serbia was 141/1000 live births (5), down to 24 in 1995 (6). likewise, maternal mortality has been reduced due to improved health status in general, based on mother and child programmes, healthy community interventions, increased standards of living, and other interventions. health services in kosovo were the same as in the entire yugoslavia including the network of health institutions [796 inhabitants per physician (5)], particularly primary health care centres [a network of 22 “dom zdravlja’s” and 379 general practitioner units (5)], staffed with committed health professionals as is cited by the authors from the health sector strategy (hss) of kosovo. also, the state health insurance system of serbia, based on solidarity, included the population of kosovo as any other people in the former republics of yugoslavia. therefore, today, kosovo can build on the historical achievements during that period which should have been acknowledged in a more pronounced way. however, as the authors write, “…the nineties left kosovo with a very inefficient health system characterized by a lack of trained personnel, disparities in health force distribution, leading to variations in access to primary care, corruption and informal payments as well as deteriorated child and adult health indicators”. this statement seems to be somewhat contradictory to the hss, cited above from this paper. hopefully, one day, an unprejudiced analysis of the development of the health system in kosovo before and after world war ii will become possible. references 1. ec. enlargement. “kosovo* this designation is without prejudice to positions on status, and is in line with unscr 1244 and the icj opinion on the kosovo declaration of independence”. http://ec.europa.eu/enlargement/countries/detailedcountry-information/kosovo/ (accessed: april 19, 2014). 2. unscr resolution 1244, 1999. http://www.un.org/docs/scres/1999/sc99.htm (accessed: april 19, 2014). 3. international court of justice. accordance with international law of the unilateral declaration of independence in respect of kosovo, advisory opinion. i.c.j. reports 2010, p.403. http://www.icj-cij.org/docket/files/141/15987.pdf (accessed: april 19, 2014). 1 kosovo*: this designation is without prejudice to positions on status, and is in line with unscr 1244 and the icj opinion on the kosovo declaration of independence”. http://ec.europa.eu/enlargement/countries/detailedcountry-information/kosovo/ (accessed april 19, 2014). 2 bjegovic-mikanovic, marinkovic-eric. misunderstanding should be avoided by precise formulation: comment on jerliu et al. “public health in kosovo after five difficult years of independence” (letter to editors). seejph 2014, posted: 19 april 2014. doi 10.12908/seejph-2014-21. 4. the brussels agreement of 2013. http://eeas.europa.eu/top_stories/2013/190413__eufacilitated_dialogue_en.htm (accessed: april 19, 2014). 5. statistical office of the republic of serbia. statistical yearbook 1990. belgrade: sors 1990. http://webrzs.stat.gov.rs/website/default.aspx (accessed: april 19, 2014). 6. unmik. kosovo state of the environment report. http://enrin.grida.no/htmls/kosovo/kosovo_soe_part1.pdf (accessed: april 19, 2014). ___________________________________________________________ © 2014 bjegovic-mikanovic et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 3 la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 1 | 19 original research knowledge and perception about climate change among healthcare professionals and students: a cross-sectional study giuseppe la torre1, alice de paula baer2, cristina sestili1, rosario andrea cocchiara1, domenico barbato1, alice mannocci1, angela del cimmuto1 1 department of public health and infectious diseases, sapienza university of rome, italy; 2 faculty of medicine, university of sao paulo, brazil. corresponding author: giuseppe la torre; address: piazzale aldo moro 5 – 00161, rome, italy; telephone: +39(0)649694308; e-mail: giuseppe.latorre@uniroma1.it la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 2 | 19 abstract aim: the aim of this study was to assess knowledge on climate change (cc) and related consequences among students and professionals of healthcare setting. methods: a cross-sectional study involving 364 people was conducted. the survey was performed at sapienza university (rome) using questionnaire previously developed and validated by the same research group. results: findings indicate awareness about cc and its effects and correct identification of practices that could help to mitigate its repercussions. the majority of the participants believed that cc had an impact on the health of humans (96.7%), animals (99.5%) and on the environment (99.7%). results from the multivariate analysis regarding overall knowledge, show an increased odd in professionals (or=2.08; 95%ci=1.02-4.26), individuals from the north (or=3.34; 95%ci=1.37-8.15) and from the center (or=2.07; 95%ci=1.17-3.66). regarding factors able to modify earth's climate, correct answer had higher odds of being chosen by professionals (or=2.83; 95%ci=1.41–5.70), and from individuals from south/islands than by the ones from the center (or=0.65; 95%ci=0.40-1.06). the main sources of information resulted to be tv and school/university. conclusions: these new evidences could guide policymakers on increasing the awareness of the population about this fundamental subject. keywords: climate change, cross sectional, health professionals, italy, students, survey. funding: this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. author contributions: conceptualization, g.l.t. and a.d.c..; methodology, g.l.t. and a.m..; formal analysis, a.d.p.b., c.s., r.a.c., d.b.; investigation, a.d.p.b., c.s., r.a.c., d.b.; data curation, a.d.p.b., c.s.; writing – original draft preparation, r.a.c., d.b.; writing – review & editing, r.a.c., d.b., a.m..; supervision, g.l.t..; project administration, g.l.t. conflicts of interest: none declared. la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 3 | 19 introduction in 2009, the first lancet commission for global health identified climate change (cc) as “the biggest global health threat of the 21st century” (1). ten years later, the world meteorological organization registered that the global mean surface temperature in 2018 was about 1.0 °c higher than pre-industrial levels (1850-1900) (2). seventeen out of the 18 warmest years in the 136-year record conducted by nasa have all occurred since 2001, except for 1998 (3). this observed pattern of warming is known to be related to anthropogenic activity, and particularly to the use of fossil fuels. that is correlated to the increase of greenhouse gases, mainly carbon dioxide (co2). as consequence, sea levels are rising, glaciers are melting, weather-related natural disasters are becoming more frequent and precipitation patterns are changing. cc is strongly impacting on humans’ health: reduction in air quality; threatened food production and safety; increased water-related illnesses; increased morbidity and mortality from extreme temperatures; increased and new infectious disease exposures; negative consequences for mental health (e.g. anxiety, depression and substance abuse) (4,5). the best forecast for a low gas emission scenario, a world that takes sustainable energy use as a priority, is an air warming of 1.8°c. however, in a world that mainly uses fossil fuels and has rapid economic and global population growth, the best estimation is that temperatures will rise by 4.0°c (2.4°c to 6.4°c) (6). in order to mitigate the rising of earth temperature, it is essential that the population is aware of cc, its consequences and the actions that could be taken into account to avoid it. for this reason, an effective communication is fundamental. they need information in order to have an attitude of constructive engagement (7). in particular, health professionals could deeply contribute in making recommendations and supporting favorable policies as they have the expertise to recognize the health consequences related to cc and they have a strong impact on the public opinion (8). the scientific literature was investigated in order to assess the presence of studies addressing knowledge on cc of health professionals and students. a review was performed in june 2019 searching pubmed database. the following search string was used: “(climate change) and education and university students and (nurses or medicine)”. out of 59 studies, that were firstly retrieved, 14 were recognized as relevant for our purposes (9-22). the topic appears widespread all over the continents: four studies were performed in europe; four were conducted in asia; three were from oceania; two from america; one was performed in africa. these researches were published from 2009 on, with a peak that was recorded in 2018. the aim of the studies was to measure the knowledge and perceptions of health professionals and students about cc and its consequences. in this regard, surveying the population's knowledge on this topic becomes necessary, because these data could show what is already known, what are people's sources of information on cc and what are the knowledge gaps that need to be filled for allowing a proper adaptation of the society. the studies included in the review applied validate questionnaire: children’s environmental health knowledge questionnaire (9); children’s environmental health skills questionnaire (9); sustainability attitudes in nursing survey (sans-2) (11,18,20). according to the scientific evidences from the literature, the potential of communication and social marketing as means to influence population health and environmental outcomes is clear, but it has to be put into practice (23). it has been found, for example, that mass media could be an important source of information (13,24), but the issue has not gained much attention from it. a literature review concluded that most residents of developed countries have little knowledge about the health relevance of cc (7) and, according to other researches, this awareness could be related to level of education, country of residence and living environment (13,25). although surveys have been conducted in that matter, to our knowledge none has included the italian population. thus, the aim of this study was to collect data from italy to verify knowledge on cc within a population of students and professionals from the healthcare settings. methods study design a cross-sectional study, according to the strobe statement (26) was performed during the period february 2018-march 2019. participants and setting a total of 569 individuals were invited to take part to the survey. respondents were contacted through a mailing list of students of medical area (medicine, la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 4 | 19 nursing, prevention technicians) of sapienza university of rome and health professionals (nurses, doctors, technicians of the prevention). the link to access the anonymous online questionnaire, which also contained the informed consent form, was shared via mail with the audience. questionnaire an italian questionnaire previously developed and validated by the same research group on a sample of 64 individuals was used (27). the questionnaire contained a sociodemographic section on age, sex, marital status and educational level. the subsequent section contained 19 questions about cc. to complete the survey respondents were required to choose specific answers or enter free text in specific box. questions could include more than one correct answer. the survey covered different categories of questions: definition of cc and greenhouse gases; knowledge about the effects of global warming; respondents’ awareness about the argument and options to fight cc and pollution. annex 1 reports the administered questionnaire. approval by ethical committee was not required for this study, since this was an observational study. statistical analysis the statistical analysis was performed using statistical package for social sciences (spss) version 25. descriptive analysis was performed using frequencies, mean and sd. bivariate analysis was computed using chi-square test in order to assess the possible associations between the answers to the questionnaire and above listed socio-demographic variables. a scoring system was created by assigning one point for each correct answer to questions that evaluated cc knowledge. the highest achievable punctuation was 13. in the question about the possible implications of cc, in which more than one answer was possible, the assigned score went from 0 to 1, according to the number of chosen alternatives; the score 1 was given to those who pointed out all the correct options. furthermore, multivariate analysis including logistic regression and linear regression were performed. for logistic regression model, in order to verify the relationship between participants’ answers and gender, age, occupation and civil status, all the variables were dichotomized including the sum of the correct answer. zero was attributed to the ones who achieved less than mean score (9.2) and 1 to the ones who achieved 9.2 or more. a multiple linear regression analysis with stepwise using the backward wald selection was used to confirm the relationship between score and socio-demographic variables. the goodness of fit of linear regression model was assessed using the r2. a statistically significant difference was accepted at a p-value of less than 5%. results sample demographic characteristics a total of 364 people completed the questionnaire (chronbach alpha = 0.74), with a global response rate of 64.2%%. among students, the highest response rate was observed for medical students (77%) and the lowest for nursing students (23.5%). conversely, among professionals, no substantial differences between these two groups were observed (nurses 68.7% vs. doctors 68.9%). the mean age was 23.7 (sd: 6.6). all respondents lived in italy, mostly in the centre (56.3%). most of the respondents were female (65.1%). regarding civil status, 77.1% were single. as to professional situation, most of participants were medical students (63.7%), followed by nurse professionals (15.7%) (table 1). table 1. sample’s socio-demographic information variables n(%) or mean (sd) gender females 237 (65.1) males 127 (34.9) total 364 age 23.7 (6.587) civil status married 31 (8.5) cohabitant 47 (12.9) la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 5 | 19 separated 3 (0.8) single 281 (77.1) widow(er) 2 (0.5) professional status other 2 (0.5) phd student 1 (0.3) nurse 57 (15.7) doctor 20 (5.5) nursing student 24 (6.6) medical student 232 (63.7) prevention and environmental technician student 23 (6.3) prevention and environmental technician 5 (1.4) region of residence (macroarea) north 35 (9.6) center 205 (56.3) south and islands 66 (18.1) missing 58 (15.9) participants' source of information about climate change most respondents (98.1%) had already heard about cc, 72.3% of them in tv, the most common source, followed by school/university (33%) and internet (22.2%). statistically significant associations were found between having heard about cc and being under 24 years old (p=0.002) and from center (p=0.002). having school as a source of information was related with being under 24 (p< 0.001), single (p< 0.001), student (p< 0.001) and from the center of italy (p= 0.011). being female (p= 0.01) was also related with having newspaper as a source. being single was statistically associated with having the scientific literature as source of information (p=0.037). students and subjects younger than 24 showed statistically significant association with having heard about cc at home (p=0.007; p=0.012). lastly, hearing it from congresses was statistically associated with being male (p= 0.004). only 25.8% affirmed that university courses addressed global warming, mainly females (p= 0.010), people younger than 24 (p<0.001), single (p=0.003) and students (p< 0.001) (table 2). table 2. participants’ knowledge and source of information question yes/true gender n(%) age n(%) civil status n(%) professional status n(%) macro area n(%) n(%) female male <=24 >24 single cohabitant /married student profession al north center south/ islands have you heard of climate change before? 357 (98.1) 292(64.7) 141(35.3) 261 (73.1) 96 (26.9) 280(78.4) 77(21.6) 278(77.9) 79(22.1) 35(11.5) 203(67) 65(21.5) 0.429a 0.002 a 0.642 a 0.192 a 0.002 a where did you hear about it? tv 263(72.3) 166(63.1) 97(36.9) 189(71.9) 74(28.1) 203(77.2) 60(22.8) 200(76.9) 63(23.1) 27(12.3) 146(66.1) 48(21.6) 0.129 a 0.144 a 0.994 a 0.582 a 0.838 a where did you hear about it? school/unive 120 (33) 73(60.8) 47(39.2) 104 (86.7) 16 (13.3) 105 (87.5) 15 (12.5) 107 (89.2) 13 (10.8) 11 (9.9) 84 (75.7) 16 (14.4) 0.090 a <0.001 <0.001 a <0.001 a 0.011 a la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 6 | 19 rsity where did you hear about it? internet 81 (22.2) 54(66.7) 27(33.3) 54(66.7) 27(33.3) 58(71.6) 23(28.4) 59 (72.8) 22 (27.2) 8(11.4) 47(67.1) 15(21.4) 0.896 a 0.716 a 0.484 a 0.722 a 0.781 a where did you hear about it? newspaper 83(22.8) 46 (55.4) 37 (44.6) 52 (62.7) 31 (37.3) 59 (71.1) 24 (28.9) 61 (73.5) 22 (26.5) 13 (18.3) 40 (56.3) 18 (25.4) 0.015 a 0.773 a 0.540 a 0.507 a 0.249 a where did you hear about it? scientific literature 23 (6.3) 16(69.6) 7(30.4) 18(78.3) 5(21.7) 21(91.3) 2(8.7) 19(82.6) 4(17.4) 3(16.7) 9(50) 6(33.3) 0.819a 0.087 a 0.037 a 0.129 a 0.448 a where did you hear about it? home 15 (4.1) 8(53.3) 7(46.7) 14(93.3) 1(6.7) 14(93.3) 1(6.7) 15(100) 0(0) 2(14.3) 12(85.7) 0 (0) 0.260 a 0.012 a 0.071 a 0.007 a 0.114 a where did you hear about it? conventions 5 (1.4) 0 (0) 5 (100) 3 (60) 2 (40) 3 (60) 2 (40) 2 (28.6) 5 (71.4) 0 (0) 4(100) 0 (0) 0.004 a 0.516 a 0.516 a 0.676 a 0.296 a where did you hear about it? associations/ ongs 6 (1.6) 2 (33.3) 4 (66.7) 4 (66.7) 2 (33.3) 5(83.3) 1 (16.7) 6(100) 0(0) 1(16.7) 3(50) 2(33.3) 0.075a 0.800 a 0.557 a 0.093 a 0.796 a where did you hear about it? radio 4 (1.1) 2(50) 2 (50) 4(100) 0(0) 3(75) 1 (25) 4(100) 0 (0) 0(0) 4(100) 0(0) 0.469 a 0.301 a 0.914 a 0.175 a 0.302 a during the course of your university studies was the subject of global warming addressed? 94 (25.8) 51 (54.3) 43 (45.7) 82 (87.2) 12 (12.8) 84 (89.4) 10 (10.6) 87 (92.6) 7 (7.4) 5(5.5) 65(71.4) 19(20.9) 0.010 a <0.001 a 0.003 a <0.001 a 0.094 a a p-value of chi-square test bold: p<0.05 participants' knowledge on cc and its consequences the majority of the participants believed that cc had an impact on human (96.7%), animal (99.5%) and on the environment (99.7%) health. concerning greenhouse gases, 92.6% of respondents were aware of human responsibility in emissions; 62.6% of participants answered correctly that co2, methane (ch4) and nitrous oxide (n2o) were all responsible for rising earth's temperature. still, concerning causes of cc, 54.4% of participants recognized changes that occur in solar radiation, variations of the albedo and the introduction of gases as factors that could modify the chemical composition of the atmosphere. answering this correctly was related to be over 24 (p= 0.001). respondents (93.4%) mostly agreed that a healthcare professional could contribute in reducing the impact of cc, and this was associated with being younger. when asked in what way, most of them marked all alternatives as correct in the questions regarding transportation (67.3%), energy use (86.5%) and waste disposal (81.6%). correct answers regarding transports were associated with being over 24 years old (p=0.020) and student (p=0.018); regarding waste disposal, with being single (p=0.005) and from the center (p=0.012) (table 3 and table 4). la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 7 | 19 table 3. knowledge on the consequences of cc question yes/true gender n(%) age n(%) civil status n(%) professional status n(%) macro area n(%) female male <=24 >24 single cohabitant / married student professi onal north center south and islands most scientists agree that the warming is due to the increasing concentrations of greenhouse gases, which imprison the heat in the atmosphere, a process determined by human activities and not just by natural causes? 337 (92.6) 215(63.8) 122(36.2) 245(72.7) 92(27.3) 265(78.6) 72(21.4) 262(77.7) 75(22.3) 33(11.7) 193(68.4) 56(19.9) 0.123 a 0.541 a 0.927 a 0.751 a 0.238 a do you think global warming can have an impact in the environment’s health? 363 (99.7) 236(65) 127(35) 262(72.2) 101 (27.8) 286(78.8) 77(21.2) 282(77.7) 81(22.3) 35(11.4) 205(67) 66(21.6) 0.464 a 0.109 a 0.214 a 0.063 a 0.917 a do you think global warming can have an impact in animals’ health? 362 (99.5) 237(66.5) 125(34.5) 262(72.4) 100(27.6) 285(78.7) 77(21.3) 281(77.6) 81 (22.4) 35(11.5) 204(66.9) 66(21.6) 0.053 a 0.023 a 0.323 a 0.351 a 0.802 a do you think global warming can have an impact in humans’ health? 352 (96.7) 229(65.1) 123(34.9) 255(72.4) 97(27.6) 276(78.4) 76(21.6) 272(77.3) 80(22.7) 35(11.7) 200(67.1) 63(21.2) 0.908 a 0.285 a 0.683 a 0.621 a 0.009 a do you think a health professional can contribute to reduce the impact of climate change? 340 (93.4) 222(65.3) 118(34.7) 250(73.5) 90(26.5) 268(78.8) 72(21.2) 267(78.5) 73(21.5) 34(11.8) 193(67) 61(21.2) 0.781 a 0.013 a 0.659 a 0.069 a 0.190a a p-value of chi-square test bold: p<0.05 table 4. results of the bivariate analysis concerning causes, consequences and actions towards cc n (%) gender n(%) age n(%) civil status n(%) professional status n(%) macro area n(%) female male <=24 >24 single cohabitan t/ married student professional north center south/ islands in what way can a health professional contribute to diminish the impacts of climate change by transport? all are correct 245(67.3) 163(66.5) 82 (33.5) 167 (68.2) 78(31.8) 189 (77.1) 56 (22.9) 181 (73.9) 64 (26.1) 25 (12.3) 142 (70) 36 (17.7) error 119(32.7) 74 (62.2) 45(37.8) 95 (79.8) 24(20.2) 97 (81.5) 22(18.5) 101 (84.9) 18 (15.1) 10 (9.7) 64 (61.5) 30 (28.8) p-valuea 0.414 0.020 0.341 0.018 0.081 in what way can a health professional contribute to diminish the impacts of climate change by energy use? all are correct 315 (86.5) 203 (64.4) 112 (35.6) 223(70.8) 92(29.2) 245 (77.8) 70 (22.2) 240 (76.2) 75 (23.8) 33 (12.4) 180 (67.7) 53 (19.9) error 49 (13.5) 34 (69.4) 15 (30.6) 39(79.6) 10(20.4) 41 (83.7) 8 (16.3) 42 (85.7) 7 (14.3) 2 (5) 25(62.5) 13 (32.5) p-valuea 0.525 0.202 0.454 0.197 0.147 la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 8 | 19 in what way can a health professional contribute to diminish the impacts of climate change regarding waste disposal? all of the above are correct 297 (81.6) 198 (66.7) 99 (33.3) 209(70.4) 88(29.6) 225 (75.8) 72(24.2) 224(75.4) 73(24.6) 31(12.3) 174(68.8) 48(18.9) error 67 (18.4) 39(58.2) 28(41.8) 53(79.1) 14(20.9) 61 (91) 6 (9) 58(86.6) 9(13.4) 4(7.5) 31(58.5) 18(34) p-valuea 0.203 0.150 0.005 0.052 0.012 what are the main factors able to modify the climate on the earth? all are correct 198(54.4) 136 (68.7) 62(31.3) 111(63.1) 65(36.9) 156(78.8) 42(21.2) 150 (75.8) 48 (24.2) 22(13.1) 109(64.9) 37(22) error 166(45.6) 101(60.8) 65(39.2) 151(80.3) 37(19.7) 130(78.3) 36(21.7) 132(79.5) 34(20.5) 13(9.4) 96(69.6) 29(21) p-valuea 0.118 <0.001 0.912 0.392 0.718 which gases that are rising in the atmosphere as a consequence of human activities cause an increase in earth's temperature? all of the above 228(62.6) 150 (65.8) 78 (34.2) 142(71.7) 56(28.3) 168(73.7) 60(26.3) 160(70.2) 68(29.8) 29 (15.8) 117(63.5) 38(20.7) error 32(37.4) 25(78.1) 7(21.9) 120(72.3) 46(27.7) 21(65.6) 11(34.4) 18(56.3) 14(43.8) 2(9.5) 11(52.4) 8(38.1) p-valuea 0.164 0.904 0.338 0.112 0.181 which are the main repercussions of climate change? (more than one answer was possible to this question) rising of earth’s temperature 328 (90.1) 209 (63.7) 119 (36.3) 244 (7.4) 84 (25.6) 261(79.6) 67(20.4) 260 (79.3) 68 (20.7) 33 (11.7) 193 (68.7) 55 (19.6) p-valuea 0.993 0.002 0.160 0.013 0.017 melting of ice caps 313 (86) 203(64.9) 110(35.1) 231(73.8) 82(26.2) 249(79.6) 64(20.4) 243(77.6) 70(22.4) 31 (11.6) 186 (69.7) 50 (18.7) p-valuea 0.801 0.055 0.258 0.853 0.006 ice retraction 262 (72) 160(61.1) 102(38.9) 191(72.9) 71(27.1) 210(80.2) 52(19.8) 210(80.2) 52(19.8) 28 (12.4) 161 (71.2) 37(16.4) p-valuea 0.010 0.530 0.239 0.050 0.001 rising of sea level 254 (69.8) 149 (58.7) 105 (41.3) 188(74) 66(26) 201(79.1) 53(20.9) 205(80.7) 49(19.3) 25 (11.5) 153 (70.5) 39 (18) p-valuea <0.001 0.188 0.691 0.025 0.054 biodiversity will be reduced 236 (64.8) 150(63.6) 86(36.4) 172(72.9) 64(27.1) 188(79.7) 48(20.3) 185(78.4) 51(21.6) 20(9.8) 141(68.4) 45(21.8) p-valuea 0.399 0.602 0.492 0.569 0.393 the food production will be at risk 176 (48.4) 105 (59.7) 71 (40.3) 129(73.3) 47(26.7) 135(76.7) 41(23.3) 141(80.1) 35(19.9) 14(9.3) 106(70.2) 31(20.5) p-valuea 0.035 0.588 0.401 0.243 0.401 increased water shortage 163 (44.8) 93 (57.1) 70 (42.9) 117(71.8) 46(28.2) 126(77.3) 37(22.7) 130(79.8) 33(20.2) 17(12) 98(69) 27(19) p-valuea 0.004 0.939 0.595 0.348 0.598 weatherrelated natural disasters will occur more frequently: storms, droughts. floods and heat waves 307(84.3) 200(65.1) 107(34.9) 221(72) 86(28) 245(79.8) 62(20.2) 238(77.5) 69(22.5) 29(11) 176(66.9) 58(22.1) p-valuea 0.973 0.993 0.183 0.956 0.786 the economy will suffer 126 (34.6) 74(58.7) 52(41.3) 89(70.6) 37(29.4) 99(78.6) 27(21.4) 98(77.8) 28(22.2) 9(8.6) 75(71.4) 21(20) p-valuea 0.063 0.678 1.000 0.919 0.407 population will face 200 (54.9) 123(61.5) 77(38.5) 153(76.5) 47(23.5) 160(80) 40(20) 163(81.5) 37(18.5) 19(11.1) 120(70.2) 32(18.7) la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 9 | 19 food and water shortages. leading to conflicts and migration p-valuea 0.111 0.034 0.463 0.042 0.352 catastrophic transformati ons can occur 210 (57.7) 132(62.9) 78(37.1) 162(77.1) 48(22.9) 167(79.5) 43(20.5) 168 (80) 42 (20) 16(9.1) 126(71.6) 34(19.3) p-valuea 0.292 0.010 0.605 0.178 0.118 diseases will spread 153 (42) 91(59.5) 62(40.5) 114(74.5) 39(25.5) 119(77.8) 34(22.2) 122(79.7) 31(20.3) 14(10.7) 91(69.5) 26(19.8) p-valuea 0.055 0.360 0.753 0.378 0.727 a p-value of chi-square test bold: p<0.05 regarding the consequences of cc, the rising of earth temperature was selected by 90.1% of participants. being female was associated with marking ice retraction (p=0.010), rising of the sea level (p<0.001), risks for food production (p=0.035) and increased water shortage (p=0.004) as consequences. being younger resulted associated with considering that higher earth temperature (p=0.002), conflicts/migrations (p=0.034) and catastrophic transformations (p=0.010) could occur. other important associations are shown in table 4. a sum of all correct answers per participant was calculated, being 13 the highest achieved value, with all answers correct, and 4.42 the lowest; only 0.8% of participants reached the highest score. however, the mean sum was 9.2 (sd 1.76), which shows a high level of knowledge (figure 1). multivariate analysis results from the multivariate analysis regarding the dichotomous score show an increased odd for good knowledge in professionals (or=2.08; 95%ci=1.02-4.26), individuals from north (or= 3.34; 95%ci= 1.37-8.15) and center (or=2.07; 95%ci=1.17-3.66). regarding factors able to modify earth's climate, correct answers had higher odds of being chosen by professionals (or=2.83; 95%ci=1.41–5.70), and individuals from south/islands than from center (or=0.65; 95%ci= 0.40-1.06). the correct predicted increase in temperature for 2100 was associated with males (or=0.47; 95%ci=0.27–0.81) and cohabitant/ married participants (or=2.38; 95%ci=1.22–4.64). rising of earth’s temperature was recognized as possible repercussion for cc with higher odd by cohabitant/married individuals (or=2.38; 95%ci=1.22-4.64), and with lower odd from females (or=0.47; 95%ci= 0.27-0.81). females were associated with reductions in odds of having knowledge about cc repercussions, such as ice-retraction (or=0.48; 95%ci=0.27-0.86), rising of sea level (or= 0.35; 95%ci=0.19–0.64), risks to food production (or=0.66; 95%ci=0.41–1.06), increased water shortage (or= 0.52; 95%ci=0.32– 0.83) and conflicts and migration due to lack of resources (or=0.63; 95%ci=0.39–1.02). twentyfour year-old participants or older had a reduction on odds of choosing conflicts/migration (or=0.50; 95%ci=0.29–0.88) and catastrophic transfor mations (or= 0.44; 95%ci= 0.25–0.77) as consequence of cc. participants from center italy were associated with choosing ice retraction, rising of sea level, melting of ice caps and catastrophic transformations (respectively or= 2.97; 95%ci=1.63–5.41; or=2.06; 95%ci= 1.12–3.78; or=2.42; 95%ci=1.22–4.77; or=1.55; 95%ci=0.95-2.52). conversely, participants from the north of italy showed a higher odd of choosing ice retraction (or=3.50; 95%ci=1.32-9.27) and rising of sea level (or=2.34; 95%ci=0.92-5.97). students had higher odds of choosing rising of sea level as repercussion of cc (or= 0.47; 95%ci=0.24–0.95). on the questions about possible contributions that they could give to diminish these effects, choosing the correct answer regarding means of transportation had an increase in the odds for participants belonging to the professional category (or= 2.07; 95%ci=0.97–4.44) and from the center (or=1.6; 95%ci=0.96-2.66). on the subject of waste disposal, higher odds of giving the correct answer were found for participants from the north (or=2.77; 95%ci=0.84–9.15) and center (or= 2.41; 95%ci= 1.22–4.76), and also married/cohabitants people (or=6.47; 95%ci=1.50–27.9) (table 5). la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 10 | 19 figure 1. knowledge score's distribution table 5. multivariate analysis: logistic regression with “backward wald” elimination procedure question gender age civil status professional status macro area or (95% ci) or (95% ci) or (95% ci) or (95% ci) or (95% ci) female male* <=24* >24 single* cohabitant/ married student * professional north center south/ islands * binary codification of knowledge score 1 2.08 (1.02-4.26) 3.34 (1.378.15) 2.07 (1.17-3.66) 1 in what way can a health professional contribute to diminish the impacts of climate change by transport? all are correct 1 2.07 (0.97-4.44) 1.6 (0.96-2.66) 1 in what way can a health professional contribute to diminish the impacts of climate change regarding waste disposal? 1 6.47 (1.50-27.9) 2.77 (0.849.15) 2.41 (1.22-4.76) 1 la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 11 | 19 all are correct what are the main factors able to modify the climate on the earth? all are correct 1 2.83 (1.41-5.70) 0.65 (0.40-1.06) 1 which are the main repercussions of climate change? rising of earth’s temperature 0.47 (0.27-0.81) 1 1 2.38 (1.22-4.64) which are the main repercussions of climate change? ice retraction 0.48 (0.27-0.86) 1 3.50 (1.329.27) 2.97 (1.63-5.41) 1 which are the main repercussions of climate change? rising of sea level 0.35 (0.19-0.64) 1 1 0.47 (0.24-0.95) 2.34 (0.925.97) 2.06 (1.12-3.78) 1 which are the main repercussions of climate change? melting of ice caps 2.42 (1.22-4.77) 1 which are the main repercussions of climate change? the food production will be at risk 0.66 (0.41-1.06) 1 which are the main repercussions of climate change? increased water shortage 0.52 (0.32-0.83) 1 which are the main repercussions of climate change? population will face food and water shortages. leading to conflicts and migration 0.63 (0.39-1.02) 1 1 0.50 (0.29-0.88) which are the main repercussions of climate change? catastrophic transformations can occur 1 0.44 (0.25-0.77) 1.55 (0.95-2.52) 1 la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 12 | 19 do you think a health professional can contribute to reduce the impact of climate change? yes 1 0.31 (0.12-0.83) what temperature increase do un climate experts predict by 2100? 1.4°–5.8°c 0.47 (0.27-0.81) 1 1 2.38 (1.22-4.64) *reference group white cells indicate p-value>0.05 linear regression showed that being older is predictor for having higher knowledge scores (β=0.124; p=0.030). discussion results show that participants were sufficiently aware of cc and its effects, and mostly could identify individual practices that could help to mitigate its repercussions. significant differences on the amount of information regarding the consequences of global warming were found mainly related to the region of residence and to gender, with females having lower odds of giving the correct answers. most of participants had already heard about cc, with the main sources of information being tv and school/university. the results from this study show to be similar to the ones from a previous study conducted in china with health professionals (28), in which tv also appeared as main source. the importance of mass media is also highlighted in a survey conducted in bangladesh (29), while the key role of school as a source of information appears in a study made with iranian students, in which school was the main source, with 38, 5% of answers (30). however we cannot deny the role of social media in this field. lewandowsky et al. (31) underline the role of internet blogs that became a very useful tool for discussing scientific issues, and cc is now one of the most chosen in the discussions. these authors believe that the use of blogs, and particularly the comment sections of blogs, can play a very important role in disseminating different positions around this issue. it is possible to conclude that mass media have a fundamental role on the dialogue with the italian population about cc, and therefore should be used to disseminate information to the public. however, television coverage of public health issues has problems, such as individual selection of information of viewers, journalists’ unfamiliarity with the topics and spread of misinformation (32). taking this into account, television should be used carefully, and it should be as well important to valorize the key role that educational institutions play, being a more reliable information disseminator. also, it is worth paying attention that, although the question “where have you heard about climate change?” was open answered, no participant cited doctors or other health professionals. a research conducted at yale university showed that, for information about cc-related health problems, americans mostly trust their primary-care doctor (33). another study done in the usa concluded that the public health community has an important perspective about cc that, if shared, could help the public to better understand cc issues. their findings also suggest that the communication should not be focused on the problem of cc, but on solutions and co-benefits: a healthier future offers environmental benefits (34). the potential of health professionals as disseminators of information on global warming, according to these results, seems to be underused. concerning the causes of global warming, more than 50% of participants understood that greenhouse gases were co2, n2o and ch4, although a significantly amount choose only co2. still, on the matter of greenhouse gases, most of respondents (92.5%) were aware of human’s responsibility on their emissions and on scientists’ agreement on the subject, showing a positive consonance between italian population's knowledge and scientific consensus. also, in the usa research (35), more than one third of participants from 2009 mentioned mainly anthropogenic causes as "things that could cause global warming", such as cars and industries, and 26% specifically mentioned fossil fuel use. similar reasons were mentioned by the china participants (28). however, in the usa 18% affirmed that natural causes were also primary drivers of global warming and also in the study made with nursing students in arab countries respondents la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 13 | 19 believed cc was due to a balance between nature and human causes (13). in the arab region, most of respondents said that all presented health‐related effects had already increased due to cc; similar findings were presented by a study conducted in montana with nursing students (36). although this research did not specifically focus on the consequences of cc for health, options such as the spread of diseases, water shortage and risks to food production were chosen by less than 50% of participants, with the exception of the one related to conflicts and migration (54.2%). being this a cohort of mostly health professionals and students, the found results disagree with the existing literature. this should be seen as an aspect worthy of improvement: past experiences with smoking cessation, hiv prevention, physical activity promotion and other health issues have proved that health professionals can have an important and effective role on educating and empowering people about health. however, little of this understanding on effective health communication has been applied to cc (37). the proportion of male students that recognized possible consequences of cc was significantly higher compared to women. this gender difference was also found in the studies conducted in the arab region. it is known that some population groups are more vulnerable to the health effects of cc, and among these there are women, children and elderly, people with previous health problems or disabilities, and poor and marginalized communities (38). a study from 2016 in the usa showed that approaching cc as a health issue is an effective way of communicating with vulnerable audiences, specially addressing individual, immediate-term health effects and practical advices for protective behaviors (39). regarding the level of education, significant differences were found between students and professionals, related to source of information – students, younger and single had higher odds of having heard of it in school and during university studies. this evidence suggests the importance that education should have in informing new generations. the implementation of courses and conferences will help to increase the awareness among both students and professionals of the healthcare setting and this could also contribute to widespread correct information about cc within the society. in the multivariate analysis, professionals had higher odds of having a sum of correct answers above the mean. in other studies, dose-response associations were found between cc knowledge and the educational level (29). in this survey, associations were also related to age, with younger participants having bigger odds of having heard of cc and higher accuracy odds on the question about the related causes. regarding region of residence, south and islands were associated with lower odds of having a higher score. this might be related to socio-economic and cultural differences among different areas within the country, although no scientific evidence about this data was found. the limitations of this study include a small sample size and the recruitment of participants. the population was made of individuals specifically belonging to the university setting, which makes it difficult to generalize the results for the entire italian population. more important, the participants were professionally related to the health area and this even more limits the potential of this study to make generalizations. also, it must be underlined that the study design does not allow to derive inference from the results, since cross-sectional studies refer to punctual evidences in time and space. strengths of this study concern the geographic distribution of the sample size that offers a wide description of the italian scenery and gives robustness to the evidences. secondly, this study fills the gap in the scientific literature furnishing an innovative focus on this emerging issue. furthermore, it will be possible to replicate this investigation in order to assess changes in knowledge over time. conclusions it is possible to conclude that, although the italian students and professionals included in the study have a good knowledge on cc, it is essential to invest in informing the most vulnerable population groups and also to potentialize the role that health professionals can have on disseminating information on the subject. the results presented on this study will allow improvements in communication and in creating policies related to cc in this country and elsewhere, with the final objective of avoiding the rapid progression of cc and its consequences. finally, we must recognize the concept of “one world, one health”. we cannot forget the deep link between animal diseases, public health, and the environment (40). the use of the one health approach can be very important to increase the awareness of the usefulness of cooperation activities in this field. on the basis of these 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10.4119/seejph-3347 p a g e 17 | 19 annex 1: climate change and health dear participant, sapienza university of rome, a member of the planetary health alliance, is conducting a survey on the perception of the climate change issue. please answer with the most sincerity, thank you. socio-demographic 1. age: … 2. gender: o male o female 3. marital status: o single o married o divorced o widower o cohabitant 4. where do you live? specify the italian region… 5. occupation: o medical doctor o nurse o preventative health experts o scientist (biological, natural, environmental, chemical, physical and mathematical) o medical student o nursing student o student of preventative health o science student (biological, natural, environmental, chemical, physical and i. mathematical) o high school student o middle school student o other: ____ climate change 1. have you heard of climate change before? o yes o no 2. where did you hear about it? …. 3. during the course of your university studies was the subject of global warming addressed? o yes o no 4. most scientists agree that the warming is due to the increasing concentrations of greenhouse gases, which imprison the heat in the atmosphere, a process determined by human activities and not just by natural causes? o yes o no 5. what is the average temperature of the earth today? o 22°c o 18°c la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 18 | 19 o 15°c o 12°c o i don't know 6. what temperature increase do un climate experts predict by 2100? o 1°–3,8°c o 1,4°–5,8°c o 1,9°–6,8°c o i don't know 7. do you think global warming can have an impact in the environment’s health? o yes o no 8. do you think global warming can have an impact in animals’ health? o yes o no 9. do you think global warming can have an impact in humans’ health? o yes o no 10. do you think a health professional can contribute to reduce the impact of climate change? o yes o no 11. in what way can a health professional contribute to diminish the impacts of climate change by transport? o going on foot o taking public transports o taking the bus o moving by driving their own cars o taking the bike o using car pooling o taking flights o all previous answers are correct o none of the answers are correct o i don’t know 12. in what way can a health professional contribute to diminish the impacts of climate change by energy use? o reducing the consumption of home appliances o lowering the temperature of the heating systems o keeping chargers always plugged in o using devices with reduced consumption o keeping lights always on o turning off the lights that are not needed o all previous answers are correct o none of the answers are correct o i don’t know 13. in what way can a health professional contribute to diminish the impacts of climate change regarding waste disposal? o differentiating waste o using single-use devices o reusing the packaging o using plastic objects o reducing waste la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 19 | 19 o all previous answers are correct o none of the answers are correct o i don’t know 14. what are the main factors able to modify the climate on the earth? o changes that occur in solar radiation o variations of the albedo: the fraction of solar radiation that is reflected in various parts of the earth o the introduction of gases that modify the chemical composition of the atmosphere o all of these answers are correct o none of the answers are correct o i don't know o all of these answers are correct 15. which gases that are rising in the atmosphere as a consequence of human activities cause an increase in earth's temperature? o carbon dioxide o methane o nitrogen oxides o all previous answers are correct o none of the answers are correct o i don’t know 16. which are the main repercussions of climate change? (more than one answer was possible) o rising of earth’s temperature o melting of ice caps o ice retraction o rising of sea level o biodiversity will be reduced o the food production will be at risk o increased water shortage o weather-related natural disasters will occur more frequently: storms. droughts. floods and heat waves o the economy will suffer o population will face food and water shortages. leading to conflicts and migration o catastrophic transformations can occur o diseases will spread laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 1 short report the global public health curriculum: specific global health competences edited by ulrich laaser version i (1 february 2018) correspondence: prof. dr. med. ulrich laaser dtm&h, mph section of international public health (s-iph) faculty of health sciences, university of bielefeld pob 10 01 31, d-33501 bielefeld e-mail: ulrich.laaser@uni-bielefeld.de; laaseru@gmail.com the 2nd edition of the global public health curriculum has been published in the south eastern european journal of public health, end of 2016 as a special volume (editors ulrich laaser & florida beluli) at: http://www.seejph.com/index.php/seejph/article/view/106/82. the curriculum targets the postgraduate education and training of public health professionals including their continued professional development (cpd). however, specific competences for the curricular modules remained to be identified in a more systematic approach. to that end from the international literature the following references have been used as a general orientation: a) armed forces medical college (afmc) resource group, ghec committee, india: global health essential core competencies. at: https://lane.stanford.edu/portals/ihealthpdfs/basiccore_competencies_final2010.pdf b) dias m. et al.: global health competencies for uk health professionals. technical report · september 2015. at: http://www.researchgate.net/publication/283086441 c) association of schools and programs of public health (aspph): the global health competency model. at: www.aspph.org/educate/models/masters-global-health/ d) world health organisation (who): who global competency model. at: www.who.int/employment/competencies/who_competencies_en.pdf e) jogerst k et al.: identifying interprofessional global health competencies for 21st century. at: https://www.cfhi.org/sites/files/files/pages/global_health_competencies_article.pdf mailto:ulrich.laaser@uni-bielefeld.de� mailto:laaseru@gmail.com� http://www.seejph.com/index.php/seejph/article/view/106/82� https://lane.stanford.edu/portals/ihealth-pdfs/basiccore_competencies_final2010.pdf� https://lane.stanford.edu/portals/ihealth-pdfs/basiccore_competencies_final2010.pdf� http://www.researchgate.net/publication/283086441� http://www.aspph.org/educate/models/masters-global-health/� http://www.who.int/employment/competencies/who_competencies_en.pdf� https://www.cfhi.org/sites/files/files/pages/global_health_competencies_article.pdf� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 2 an overview of the published modules is available in the background section of the curriculum as an introductory module (numbered r1.1): 1.0 background 1.1 introduction (ulrich laaser) 1.2 global public health functions and services: the history (ehud miron) 1.3 global public health definitions and challenges (joanna nurse) 2.0 global health challenges 2.1 demographic challenges (charles surjadi et al.) 2.2 burden of disease (milena santric-milicevic et al.) 2.3 environmental health and climate change (dragan gjorgjev et al.) 2.4 global migration and migrant health (m. wasif alam et al.) 2.5 social determinants of health inequalities (janko jankovic) 2.6 gender and health (bosiljka djikanovic) 2.7 structural and social violence (fimka tosija) 2.8 disaster preparedness (elisaveta stikova) 2.9 millennium development goals (marta lomazzi) 2.10 health and wellbeing (francesco lietz) 2.11global financial crisis and health (helmut wenzel) 3.0 governance of global public health 3.1 global governance of population health and well-being (george lueddeke) 3.2 health programme management (christopher potter) 3.3 role of the civil society in health (motasem hamdan) 3.4 universal health coverage (jose moreno et al.) 3.5 public health leadership in a globalised world (katarzyna czabanowska et al.) 3.6 public health ethics (alexandra jovic-vranes) 3.7 the global public health workforce (milena santric-milicevic et al.) 3.8 education and training of professionals for global public health (suzanne babic et al.) 3.9 blended learning (željka stamenkovic-nikolic et al.) 3.10 global health law (joaquin cayon) 3.11 human rights and health (fiona haigh) 3.12 global financial management for health (ulrich laaser) 4.0 going global (ulrich laaser) the two main categories for the grouping of essential competences have been adopted from a. foldspang (public health core competences for essential public health operations, volume 3, aspher 2016 at: http://aspher.org/download/76/booklet-competencesephosvolume-3.pdf): 1.0 the public health professional shall know and understand: 2.0 the public health professional shall be able to: for these two categories competences have been drafted more or less detailed in this first version for all modules by the authors in sections r 2.0 on global health challenges and r http://aspher.org/download/76/booklet-competencesephos-volume-3.pdf� http://aspher.org/download/76/booklet-competencesephos-volume-3.pdf� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 3 3.0 on governance of global public health. sections 1.0 (background) and 4.0 (going global) are of a different character and in principle allow only for the first category, therefore not included here. in some sections below additional references have been indicated by the authors. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 4 r 2.1 demographic challenges (charles surjadi, luka kovacic1 health systems today face challenges in the management of available resources. the implemented set of interventions and the criteria used for resource allocation are publicly debated. during reforms and in particular due to tough squeezing of resources, it is crucial to understand a proposed health plan and to have it supported by the public, health professionals, policy makers from other relevant sectors and international community. however, data on health and mortality in populations are not as comprehensive and consistent nor relevant as professionals require, rather are fragmentary and sometimes heterogeneous. the framework of burden of disease and injury study provides information and tools for integration, validation, exploration, and distribution of consistent and , muzaffar malik) there is growing interest in demography, among the public, politicians, and professionals: “demographic change” has become the subject of debates in many developed and developing countries. this is because it impacts on all aspects of people`s life, social relations, economy, and culture. the world population will continue to grow in the 21st century, but at a slower rate compared to the recent past. the annual growth rate reached its peak in the late 1960s, when it was at 2% and above. better health, economic and social conditions resulted in longer life and an ageing population. it is projected that by 2025 more than 20% of europeans will be 65 or over. better living conditions in cities lead to higher urbanization, more than 55% of the world’s population residing in urban areas in 2015. 1.0 the public health professional shall know and understand: 1.1 the definitions of demography, aging, social status, and urbanisation. 1.2 the major determinants of population dynamics. 1.3 the five stages of the global transition model 1.4 the global distribution of major diseases according to climate, gender and age, social status and culture. 1.5 major environmental effects of urbanization 2.0 the public health professional shall be able to: 2.1 develop specific population projections and identify their determinants. 2.2 identify the problems accruing from population growth, aging, and urbanisation. 2.3 apply the six determinants of active aging according to the who policy framework to selected populations/countries 2.4 design realistic improvements of slums and informal settlements r 2.2 burden of disease (milena santric-milicevic, zorica terzic-supic) 1 see obituary at: http://www.seejph.com/index.php/seejph/article/view/19/17 http://www.seejph.com/index.php/seejph/article/view/19/17� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 5 comparative descriptors of the burden of diseases, injuries and attributed risk factors, over time and across different health systems. as of 1992, when the first global burden of diseases study was executed, many national burden of disease studies have been undertaken and this framework is currently refining and updating. 1.0 the public health professional shall know and understand2 2 taken from reference (1), p. 36 ff.: 1a1, 1a2, 1a4; 1b1-3, 1b7-14; 1c3, 1d2.3-1d2.5, 1d3-5; 2a1; 3b5, 3b6; 3c2,3e2, 5a, 5b, 5c, 5d, 10a,10b,10c,10e,10d; : 1.1 health data sources and tools; surveillance of population health and disease programmes; surveillance of health system performance; data integration analysis and reporting; 1.2 identification and monitoring of health hazards; occupational health protection; food safety; road safety; 1.3 primary prevention; secondary prevention; tertiary/quaternary prevention; social support; 1.4 setting a national research agenda; capacity-building; coordination of research activities; dissemination and knowledge brokering 2.0 a public health student should be able to: 2.1 efficiently access global health data from sources such as the who global burden of disease measures and understand the limitations of these data. 2.2 identify the composite measures of morbidity and mortality and their roles and limitations for health program monitoring, evaluation and priority setting. 2.3 examine the major categories of morbidity and mortality used by the world health organization (who) and institute of health metrics and evaluation ihme (communicable and parasitic diseases, maternal, perinatal and childhood conditions, and nutritional deficiencies, non-communicable conditions importance and injuries) 2.4 describe the concept of premature mortality including age, sex and cause specific mortality rates, life expectancy and years of life lost (yll). this will involve the ability to undertake calculation of indicators such as under 5 mortality rate, maternal mortality and hiv/aids mortality rates and yll due to selected causes of deaths in a target population. 2.5 demonstrate knowledge of the major global causes of morbidity and health risks, by describing the concepts of years lived with disability (yld) and disability adjusted life-year (daly). 2.6 describe how the relative importance of each category, and of the leading diagnoses (15 causes) within each category, vary by age, gender and time, and explain potential contributors to the observed variations. 2.7 explain how life expectancy, yld, yll and daly may be used to make general health comparisons within and/or between countries and who regions, and between high, middle and low-income regions, and draw implications for policy and practice. 2.8 perform a health economic assessment (e.g. cost-effectiveness analysis) for different procedures or programmes. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 6 additional reference: foldspang, a. on behalf of aspher: from potential to action, public health core competences for essential public health operations (edition for comments). volume 2, brussels: may 2016. at: http://www.aspher.org/download/75/booklet-competencesephosvolume-2.pdf r 2.3 environmental health (dragan gjorgjev, fimka tozija) the concept of limits of growth – how far we can go? the ecological concept of health, ecological public health – reshaping the conditions for good health. from demographic to democratic transitions to be addressed by public health; different dpseea models of environmental health assessment – conceptual framework of environmental health wellbeing. environmental and climate change (cc), burden of diseases (daly, yll). environment and health inequalities. environment and health risk assessment studies. environmental health indicators to assess health effects of climate change – threats to be reduced and opportunities to be adopted. importance of the intersectoral work. vulnerability, mitigation, and adaptation of the health sector. 1.0 the public health professional shall know and understand: 1.1 the basic concept of relationships between ecosystem, environmental degradation, pollution, and human health. 1.2 the dependence of human health on local and global ecological systems and the context of policies, practices and beliefs required to address global environmental changes (such as climate change, biodiversity loss and resource depletion). 1.3 the impact of major driving forces like industrialization, transport , rapid population growth and of unsustainable and inequitable consumption on important resources essential to human health including air, water, sanitation, food supply and living/housing and know how these resources vary across world regions. 2.0 the public health professional shall be able to: 2.1 use an ecological public health model within a specific social-economic context to discuss how global forces impact health aiming to improve the promotion of health and management of environment and health risks and effects. 2.2 applying the basic methods for environment and health impact assessment (ehia) 2.3 analyse the effects of air pollution on acute and chronic lung, cardiovascular disease and other systems diseases 2.4 analyse the interactions between inadequate clean water supplies and good sanitation and diarrheal and parasitic diseases. 2.5 analyse the relationship between the availability of adequate nutrition, potable water and sanitation and risk of communicable and chronic diseases. http://www.aspher.org/download/75/booklet-competencesephos-volume-2.pdf� http://www.aspher.org/download/75/booklet-competencesephos-volume-2.pdf� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 7 2.6 analyse the relationship between environmental pollution and cancers (air pollution, radon and lung cancer; benzene and leukaemia etc.). 2.7 analyse the relationship between climate change and human health. 2.8 communicate the environment and health risks and inform the public how the driving forces like globalisation and others affects environment and health inequalities within and between countries. 2.9 develop the skills to provide evidence based support to policy makers in order to mitigate the effects of global environmental change on health. r 2.4 global migration and migrant health (muhammad wasif alam, vesna bjegovic-mikanovic) nowadays, global migration is considered even more important than in the past. the main reason for that is the number of migrants, which is steadily increasing at the end of the 20th century and will continue to grow in the twenty-first. in general, migrants are supposed to have bad opportunities for health as a consequence of their migrant status. the most important issue in analytical models for the health effects of migration is the type of migration – whether it is voluntary, involuntary, or irregular migration. usually, migration does not bring improvement in social well-being and health. the wide variety of health conditions and consequences is associated with the profile of the mobile population: “what migrants bring, what they find, and what they build in the host country”. many authors stress three temporal and successive phases associated with individual movements: the predeparture phase, the journey phase, and the post-journey phase. though different in many ways they suffer from globally dominant health problems: tuberculosis, trauma/rape/torture/ptsd, hiv/aids, cardiovascular disease etc. prevention of the public health consequences is particularly relevant and important among the migrants and classified in three levels: primary, secondary, and tertiary. a clear strategy at the local, regional, and international levels is needed for efficient interventions. there is human right of migrants to be treated properly. 1.0 the public health professional shall know and understand: 1.1 the concept of a pandemic and how global commerce and travel contribute to the spread of pandemics. 1.2 the interplay between national and international conflict, interpersonal violence, and health as well as the direct and indirect threats to both individual and population. 1.3 health threats posed by violent conflict and natural disaster, and ways in which such threats may extend beyond the borders of the country directly affected. 1.4 the health challenges (including accessing healthcare) that refugees, asylum seekers and other migrants are faced with during life in their country of origin. 2.0 the public health professional shall be able to: laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 8 2.1 analyse the health risks related to migration, with emphasis on the potential risks and appropriate resources. 2.2 consider the utility and limitations of common infection control and public health measures in dealing with local or global outbreaks. 2.3 control outbreaks of communicable diseases such as measles in a context of local and international populations with varying levels of immunization. 2.4 liaise with local or regional public health authorities and be aware of national and international public health organizations responsible for issuing health advisory recommendations. 2.5 analyse general trends and influences in the global availability and movement of health workers. 2.6 regard the impact on health of cross-border flows, including international trade, information and communications technology, and health worker migration. r 2.5 social determinants of health inequalities (janko jankovic) the largest contribution to health inequalities both within and between countries around the world is attributable to the social circumstances in which people live and work, i.e. to the social determinants of health. educational attainment, income, occupational category and social class are probably the most often used indicators of current socioeconomic status in studies on social inequalities in health which present differences in health that are unnecessary, avoidable, unfair and unjust. they are also systematic (not distributed randomly) and socially produced and therefore modifiable. the fairest way to combat against social inequalities in health is to improve the health of the most disadvantaged faster than that among the rich. 1.0 the public health professional shall know and understand: 1.1 the relationship between health and social determinants of health, and how social determinants vary across world regions. 1.2 the major social determinants of health and their impact on differences in life expectancy, major causes of morbidity and mortality and access to healthcare between and within countries (topics include absolute and relative poverty, income, education, employment status, social gradient, gender, ethnicity and other social determinants). 1.3 the relationship between health, human rights, and global inequities. 2.0 the public health professional shall be able to: 2.1 define health inequity and health inequalities. 2.2 demonstrate how one can inform policy makers about the importance of addressing health inequalities, and advocate for strategies to address health inequalities at a local, national or international level. 2.3 describe major public health efforts to reduce disparities in global health (such as sustainable development goals, europe 2020 and health 2020). laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 9 2.4 analyse local, national or international interventions to address health determinants such as strategies to engage marginalized and vulnerable populations in making decisions that affect their health and well-being. 2.5 analyse distribution of resources to meet the health needs of marginalized and vulnerable groups. r 2.6 gender and health (bosiljka djikanovic) while sex in genetically and biologically determined, gender is socially constructed identity that shapes many aspects of person’s functioning and has implications on health as well. there are historically present gender disparities that are related to the power, decision making, and different societal expectations of women and men. although gender norms and values are deeply rooted in the culture, they are not fixed and unchangeable. they might evolve over time and may vary substantially in different environments. gender analysis aims to identify gender differences that will inform actions to address gender inequality. gender mainstreaming in medical education is important for eliminating gender biases in existing routines of health professionals. 1.0 the public health professional shall know and understand: 1.1 the basic differences between sex and gender and their overall importance on health. 1.2 how different levels of development of civil society and human rights affect identification and respect of gender differences. 1.3 the factors that influence construction of gender identity, and the impact of gender identity on achieving full potentials for health, including an access to health promotion and disease prevention. 1.4 the historical perspective of gender differences and their impact on social functioning and health 1.5 the relationship between sex and other mediating factors with different health outcomes. 1.6 how gender affects different risk-taking behaviours and other mediating factors of the importance for disease prevention, treatment and rehabilitation. 1.7 how transgender identity is associated with different health outcomes. 2.0 the public health professional shall be able to: 2.1 elaborate on differences and interrelationship between sex, gender and health, and corresponding challenges that appear at primary, secondary and tertiary level of prevention. 2.2 identify windows of opportunities in public health for addressing gender differences that have an impact on health. 2.3. use different tools and mechanisms that better recognise, identify and articulate gender differences in health-related matters. 2.4. conduct proper gender analysis in order to identify gender inequities and gender inequalities that exist in certain communities and societies, with the relevance for health. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 10 2.5 apply gender mainstreaming, as a process of assessing implications for women and men of any planned action, including legislation, policies or programs, in any area, and at all levels. 2.6 apply gender mainstreaming as an integral part of the design, implementation, monitoring and evaluation of policies and programs in all political, economic and societal spheres, so that women and men benefit equally. 2.7 propose set of actions that would overcome gender gap in achieving the fullest potential for health. r 2.7 structural and social violence (fimka tozija) theoretical and conceptual basis is provided for understanding structural and social violence, collective violence and armed conflicts as a public health problem: definitions, typology, burden, context, root causes and risk factors, public health approach, structural interventions and multilevel prevention. general overview of public health approach, ecological model and human rights approach is presented. the module also explains the impact of structural and social violence on health, human rights, the role of the health sector, and suggests a number of practical approaches for prevention and policy intervention. 1.0 the public health professional shall know and understand: 1.1 the main concepts of structural and social violence, collective violence and armed conflicts, human rights, public health approach, structural interventions and multilevel prevention. 1.2 the theoretical and conceptual basis of structural and social violence, and armed conflicts as a public health problem: definitions, typology, burden and context. 1.3 root causes and risk factors for structural and social violence. 1.4 the main analytical methods and tools for structural and social violence: public health approach, ecological model and human rights approach as defined by the who. 1.5 the impact of structural and social violence on health and human rights. 1.6 the role of the health sector for prevention of structural and social violence. 1.7 evidence-based multilevel prevention programmes for structural and social violence. 1.8 health in all policies for prevention of structural and social violence. 1.9 practical approaches for prevention and policy intervention for structural and social violence prevention. 1.10 the impact of resilient factors on structural and social violence prevention. 2.0 the public health professional shall be able to: 2.1 demonstrate a basic understanding of the relationship between health, human rights and structural and social violence. 2.2 apply analytical tools for structural and social violence: public health approach and ecological method. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 11 2.3 determine the magnitude, burden and economic consequences of structural and social violence applying who methodology. 2.4 identify root causes and risk factors for structural and social violence at different levels and compare in different countries. 2.5 perform literature review and critical reading for structural and social violence. 2.6 do case problem analysis and review of evidence-based multilevel prevention measures for structural and social violence. 2.7 translate knowledge in practice consider and apply successful practices from other countries for structural and social violence. 2.8 develop multilevel prevention programs for structural and social violence. 2.9 identify methods for assuring prevention program sustainability. 2.10 identify resilient factors to strengthen community capabilities, and contribute to reduction of structural and social violence. additional references: foldspang a, otok r, czabanowska k, bjegovic-mikanovic v. developing the public health workforce in europe: the european public health reference framework (ephrf): it’s council and online repository. concepts and policy brief. brussels: aspher, 2014. available from: http://www.aspher.org/download/27/ephrf_concept_and_policy_brief.pdf (accessed 21st december 2016). who. global strategy on human resources for health: workforce 2030. geneva: health workforce department 2016. available from: http://www.who.int/hrh/resources/pub_globstrathrh-2030/en/ (accessed 21st december 2016). background reading: eu joint action on health workforce planning & forecasting. http://healthworkforce.eu/ (accessed 19th december 2016). who. models and tools for health workforce planning and projections. geneva: who press 2010 teach-vip 2 users’ manual training, educating and advancing collaboration in health on violence and injury. geneva: vip department 2012. r 2.8 disaster preparedness (elisaveta stikova) the disaster and emergency preparedness and response core competences were created to establish a common performance goal for the public health preparedness workforce. this goal is defined as the ability to proficiently perform assigned prevention, preparedness, response, and recovery role(s) in accordance with established national, state, and local health security and public health policies, laws, and systems. much of an individual's ability to meet this performance goal is based on competences acquired from three sources: foundational public health competences, generic health security or emergency core competences, and position-specific or professional competences. 1.0 the public health professional shall know and understand: http://www.aspher.org/download/27/ephrf_concept_and_policy_brief.pdf� http://www.who.int/hrh/resources/pub_globstrathrh-2030/en/� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 12 1.1 the main definitions of disaster and emergencies (similarities and differences); role of the hazard and vulnerability in disaster occurrence. 1.2 the theoretical and conceptual basis of single and compound disaster, measurement of the consequences and threshold level of the responsibilities of the local/national/international communities in the scope of the required resources for planning and response during the local or state-wide incident, disaster, and crisis. 1.3 the aim of the disaster/emergency management and main components of the disaster’s management cycle 1.4 the basic principles for development of disaster preparedness and importance of the appropriate risk assessment analysis 1.5 the differences of the generic preparedness i.e. “all-hazard” and “specific” hazard’s related preparedness process 1.6 the importance and the scope of the preparedness plan for the protection and of the critical infrastructure, across the ten community’s essential sectors 1.7 the meaning and main components of the governmental, population/individuals and business preparedness planning activities 1.8 the definition of public health emergency and importance of appropriate public health emergency preparedness in the scope of the public health emergency functions 1.9 the specificity of the public health emergency preparedness plan and importance of the early warning and surveillance systems as a key elements for assessing of the state of emergency 1.10 the opportunities for using a combined remote sensing technology, geographic information systems (gis), spatial statistical techniques and mathematical models which can help in modelling of the dispersion of the harmful agent and exposure of the population to the harmful agent. 1.11 the use of the new rapid detection and identification of unknown agents or confirmation of known agents that can cause disaster. 1.12 being familiar with the structure and component of the hospital preparedness plan and infrastructure safety. 2.0 the public health professional shall be able to: 2.1 apply the activities which are necessary for ensuring an effective disaster management in a pre-event (disaster mitigation) and in a post-event (disaster response) period, aiming to ensure an appropriate (pre-event) and effective (post-event). 2.2 demonstrate basic understandings of disaster preparedness as a most effective disaster mitigation process. 2.3 demonstrate operational skills to use administrative measures, to implement strategies, and to improve coping capacities in order to lessen the adverse impacts of hazards and to minimize the opportunity for development of disaster. 2.4 apply analytical tools and to perform early and initial risk assessment. 2.5 do specific preparedness plan for the protection and strengthen the resilience of the critical infrastructure of the community, across the ten essential sectors. 2.6 develop the government preparedness actions grouped into five general categories: planning, resources and equipment, exercise, training and statutory authority. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 13 2.7 determine the differences of the public health functions in the prevention/mitigation and preparedness phases during public health emergencies. 2.8 identify the 15 public health and health-care preparedness capabilities, divided in six core groups, as the basis for state and local public health and health-care preparedness. 2.9 develop an emergency response plan (erp) and associated early warning and surveillance functions, training and exercises using an “all-hazard/whole-health” approach applicable in public health emergency. 2.10 know to use of remote sensing technology, geographic information systems (gis), spatial statistical techniques and mathematical models for modelling of the dispersion of the harmful agent and modelling of the exposure of the population to the harmful agent. 2.11 be able to communicate and manage the need for use of the public national/international network of public health laboratories for rapid detection and identification of unknown agents and/or confirmation of known agents 2.12 know to develop hospital preparedness plan taking into account such factors as the appropriateness and adequacy of physical facilities, organizational structures, human resources, and communication systems. background reading: council on linkages between academia and public health practice. core competencies for public health professionals. at: http://www.phf.org/resourcestools/pages/core_public_health_competencies.aspx centers for disease control and prevention, centers for disease control and prevention. public health preparedness capabilities: national standards for state and local planning. atlanta, ga: centers for disease control and prevention. 2011 subbarao i, lyznicki jm, hsu eb, gebbie km, markenson d, barzansky b, armstrong jh, cassimatis eg, coule pl, dallas ce, king rv. a consensus-based educational framework and competency set for the discipline of disaster medicine and public health preparedness. disaster medicine and public health preparedness. 2008 mar 1;2(01):57-68. r 2.9 millennium and sustainable development goals (marta lomazzi) the millennium development goals (mdgs) are eight international development goals to be achieved by 2015 addressing extreme poverty, hunger, maternal and child mortality, communicable disease, education, gender equality and women empowerment, environmental sustainability and the global partnership. most activities worldwide have focused on maternal and child health as well as communicable diseases, while less attention has been addressed to environmental sustainability and the development of a global partnership. in 2015, numerous targets have been at least partially attained. however, some goals have not been achieved, particularly in the poorest regions, due to different challenges. the post-2015 agenda is now set. the new goals, the sustainable development goals (sdg), reflect today’s geopolitical, economic and social situation and adopt an all-inclusive, intersectoral and accountable approach. http://www.phf.org/resourcestools/pages/core_public_health_competencies.aspx� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 14 1.0 the public health professionals shall know and understand: 1.1 what are the millennium development goals, including targets and indicators? 1.2 achievements and failures of mdgs at global, regional and national levels. 1.3 mdgs and inequalities: how and where the goals have or not reduced inequalities and disparities. 1.4 the impact of the mdgs in shaping the public health agenda 2000-2015, mobilizing the public health community and in revitalizing the development aid. 1.5 how progresses have been measured and evaluated. availability and accountability of data on mdgs achievements and failures. 1.6 whether and how mdgs have impacted local and global governance, policies set-up and education approaches. 2.0 the public health professional shall be able to: 2.1 demonstrate a basic understanding of the relationship between mdgs, health, economic growth and governance. 2.2 understand the tools and reports used to evaluate mdgs and make a critical reading of the results and articles. this should include also analysis and critical evaluation of the impact of donors in shaping the agenda and achieving the targets. 2.3 determine the impact of mdgs at local, regional and global level. 2.4 identify root causes and facilitators that impacted most the failure or achievements of mdgs. 2.5 translate knowledge in practice consider and apply successful practices from effective mdgs activities that can be applied in other contexts. develop preventive programs on that basis. 2.6 identify methods for assuring prevention program sustainability. additional references: un the millennium development goals report 2015 http://www.un.org/millenniumgoals/2015_mdg_report/pdf/mdg%202015%20rev%20%28 july%201%29.pdf health in 2015: from mdgs to sdgs http://www.who.int/gho/publications/mdgs-sdgs/en/ lomazzi, m., et al., mdgs – a public health professional’s perspective from 71 countries. journal of public health policy, 2013. 34(1): p. e1-e22. lomazi, marta; borisch bettina; laaser, ulrich. the millennium development goals: experiences, achievements and what’s next. global health action, [s.l.], v. 7, feb. 2014. issn 1654-9880. r 2.10 health and wellbeing (francesco lietz) teach a man to fish and you feed him for a lifetime” they say: promoting well-being is not so distant a concept from teaching how to fish, since high levels of well-being are correlated to a http://www.un.org/millenniumgoals/2015_mdg_report/pdf/mdg%202015%20rev%20%28july%201%29.pdf� http://www.un.org/millenniumgoals/2015_mdg_report/pdf/mdg%202015%20rev%20%28july%201%29.pdf� http://www.who.int/gho/publications/mdgs-sdgs/en/� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 15 reduction of diseases and mental disorders, and vice versa. well-being can be studied at two different levels: internal/subjective; whose measures rely on how a respondent places him or herself on a scale; or external/objective; measured through demographics and material conditions. the promotion of well-being has been indicated by the united nations as one of the 17 sustainable development global goals sdg 3) to be achieved over the next 15 years. in order to face this workload public health professionals with the ability to think globally and act locally are needed. 1.0 the public health professional shall know and understand: 1.1 main concepts of well-being, happiness, quality of life, wealth, and life satisfaction. 1.2 main determinants of well-being: from the definitions to the potential applications in programs and interventions. 1.3 the historical background of the well-being’s study. 1.4 the difference between the eudaimonic and the hedonic approach. 1.5 the optimal research tools for well-being in the different cultures and the different life stages. 1.6) the application of the theory in the context of the sustainable development goals. 1.7 the different strategies of the health sector to implement well-being programs and initiatives. 1.8 the latest evidence about well-being from different theoretical perspectives. 1.9 how to predict future pathways of well-being on regional and national plan. 1.10 how can the different trajectories of well-being’s determinants influence the health dynamics of a population? 2.0 the public health professional shall be able to: 2.1 effectively differentiate well-being from other similar concepts, such as happiness and quality of life. 2.2 choose the best measurement tools according the environment’s requests. 2.3 looking at the literature in order to determine the quality of well-being at every given moment. 2.4 understand the importance of cross-culturalism and different population groups in wellbeing assessment. 2.5 analytically review the literature. 2.6 react on the base of the researches’ results. 2.7 optimize the process of communication knowledge in the scientific environment. 2.8 taking under consideration the multidimensional aspect of well-being when developing prevention programs. 2.9 anticipate future trends in order to assure program sustainability. 2.10 empower the stakeholder at all levels so that they can strengthen community capabilities. additional references: laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 16 centers for disease control and prevention. well-being concepts. available from: https://www.cdc.gov/hrqol/wellbeing.htm (accessed 28th february 2017). dodge r, daly ap, huyton j, sanders ld. the challenge of defining wellbeing. international journal of wellbeing. 2012 aug 29;2(3). oecd. oecd guidelines on measuring subjective well-being. paris: oecd, 2013. helliwell jf, layard r, sachs j. world happiness report 2015. new york: sustainable development solutions network, 2015. sustainable development goals. goal 3: ensure healthy lives and promote well-being for all at all ages. available from: https://sustainabledevelopment.un.org/sdg3 (accessed 28th february 2017). background reading: oecd. measuring well-being and progress. available from: http://www.oecd.org/std/measuring%20well-being%20and%20progress%20brochure.pdf (accessed 28th february 2017). oecd. compendium of oecd well-being indicators. available from: https://www.oecd.org/std/47917288.pdf (accessed 28th february 2017). topp cw, østergaard sd, søndergaard s, bech p. the who-5 well-being index: a systematic review of the literature. psychotherapy and psychosomatics. 2015 mar 28;84(3):167-76. r 2.11 the global financial crisis and health (helmut wenzel) the economic situation influences the health status of a population in many ways. the financial crisis has now given greater weight on an old debate about the financial sustainability of health systems in europe. drivers of health expenditures will be critically analysed. the vulnerability of public budgets and its consequences for health budgets is depicted. the toolset of politics, and policies applied by policy-makers will be analysed. managed care approaches are presented and evaluated. 1.0 the public health professional shall know and understand: 1.1 the interdepencies of health and “structural determinants of health” 1.2 the principles of the global financial market 1.3 the interdependencies of health and national economies at times of global market and global competition 1.4 the impact of competitive production processes at times of a global market on worker’s health. e.g., the place of production heavily depends on the local production cost. 1.5 the relationship between unemployment, unsecure living conditions and related health problems 1.6 how fragile national economies cause falling budgets on all levels of a country 1.7 the interdependencies of national budgets and allocation of resources on health budgets 1.8 the financing gaps of health care and its possible causes laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 17 1.9 the constraints of financing and setting up health budgets 1.10 understand the various policy measures to cope with decreasing budgets 1.11 common measures to cope with discrepancy between needs and financial power 1.12the interdependencies of the financial crisis and economic crises in a global market and its dynamic nature 1.13 the concept of financial market and “frozen market” leading to shortage in the real economy 1.14 the four channels through which the “disease” spreads 1.15 the reasons of changing demand of health care by quantity and quality 1.16 the main drivers of health care demand 1.17 the operation and financing of health care systems with respect to their underlying national premises (beveridge, bismarckian etc.). 1.18 the advantages and disadvantages of the various national concepts to organise health care systems 1.19 approaches to improve health care efficiency and sustainable financing 1.20 managed care approaches, their organisational structures and their operations 1.21 integrated care approaches and their opportunities to improve cooperation and increase efficiency of provision of care 2.0 the public health professional shall be able to: 2.1 demonstrate a basic understanding of the relationship between global economy and health 2.2 critically analyse health care systems and their connected budgeting processes 2.3 apply knowledge and skills needed for recommending a redesigning of health care systems 2.4 apply analytical tools to identify particularly vulnerable areas of health care in constrained environment such as neonatal medical care 2.5 identify imbalances in care delivery like the affordability of out-of-pocket purchased medicines among the elderly and retired citizens 2.6 identify imbalances in access to the most expensive medical technologies such as targeted biologicals indicated in cancer and autoimmune diseases, radiation therapy; various implantbased interventional radiology, orthopaedic and cardiovascular surgical procedures 2.7 to understand the relevance of catastrophic household expenditure imposed by illness among the world’s poor residing in low and middle income countries (increased vulnerability during crisis evidenced) 2.8 review the literature and design a case study for analysing the impact of the crises on health outcomes, based on secondary statistics. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 18 r 3.1 global governance of population health and well-being (george lueddeke) strengthening the health of populations and the health systems requires a “glocal” perspective being aware of the essential role of governments and to consider the adoption of a new mindset in meeting global challenges to planet health and well-being, applying, where appropriate and feasible, the ‘one world, one health’ concept. furthermore, there is the need for a new form of global governance that is ‘fit for the 21st century’ and is able to effectively respond to unprecedented environmental, societal, economic and geopolitical hurdles and lead the way to a safer, fairer and equitable future for all. 1.0 the public health professional shall know and understand: 1.1 how global trends in public health practice, commerce and culture contribute to health and the quality and availability of health services locally and internationally. 1.2 the role of key actors in global health including the world health organization, united nations, world bank, multilateral and bilateral organisations, foundations, nongovernmental organisations (ngos); and their interactions, power, governance and different approaches to global health (for example, emergency aid versus long term development and horizontal versus vertical approaches: horizontal approach addressing a range of diseases and determinants of health, e.g. comprehensive primary care, versus a vertical approach focusing on one disease, e.g. a disease-specific immunization programme). 1.3 how global actors provide resources, funding and direction for health practice and research locally and globally, and the effects that this has on individual and population health. 1.4 how global funding mechanisms can influence the design and outcome of research strategies and policies, and how policies made at a global or national level can impact on health at a local level. 2.0 the public health professional shall be able to: 2.1 describe different national models for public and/or private provision of health services and their impact on the health of the population and individuals. 2.2 give examples of how globalization and trade including trade agreements affect availability of public health services and commodities such as patented or essential medicines. 2.3 promote the function/intention of the sdgs and identify health-related objectives, including: 1. reduce child mortality 2. improve maternal health 3. eradicate extreme poverty and hunger 4. combat hiv/aids, malaria, tuberculosis and other diseases 2.4 critically comment on policies with respect to impact on health equity and social justice. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 19 2.5 explain the advantages of collaborating and partnering and to select, recruit, and work with a diverse range of global health stakeholders to advance research, policy, and practice goals, and to foster open dialogue and effective communication. 2.6 identify barriers to health and health services in low resource settings locally and internationally. 2.7 describe barriers to recruitment, training and retention of human resources in underserved areas such as rural, inner-city and indigenous communities within highand low-income countries. 2.8 analyse the effect of distance and inadequate infrastructure on the delivery of health services (effects of travel costs, poor roads, lack of mailing address or phone system, lack of medicines, inadequate staffing, and inadequate and unreliable laboratory and diagnostic support). 2.9 identify barriers to appropriate prevention and treatment programs in low-resource settings (low literacy and health literacy, user fees, lack of health insurance, costs of medicines and treatments, therapies and procedures, advanced presentation of disease, lack of provider access to management guidelines and training including continuing professional development, concerns regarding quality of care, real or perceived, cultural barriers to care, underutilization of existing resources, issues facing scaling up and implementation of successful programs). 2.10 develop health service delivery strategies in low-resource settings, especially the role of community-based health services and primary care models. 2.11 differentiate between and highlight the benefits and disadvantages of horizontal and vertical implementation strategies. 2.12 refer to the essential medicines list and its role in ensuring access to standardized, effective treatments. 2.13 explain how international policies affect health locally, for example policies relating to global markets in healthcare (such as the pharmaceutical industry) and global resources for health (such as medications and transplant organs). 2.14 advise on the impact of trade regulations on health, for example through impact on access to clean water, taxation, tobacco use, alcohol and fast-food consumption, antibiotic use and health service provision. 2.15 propose how countries may work together to address shared health burdens or threats such as pandemics and natural disasters. 2.16 give examples how health can be a shared goal in conflict resolution and peace promotion at a local, regional, national and international level and investigate why governments may have competing aims regarding military and health intervention in conflict settings. 2.17 advocate for global trade regulations that promote public health, for example in relation to tobacco, fast-food and alcohol. 2.18 identify a organisation’s emergency response plans (including pandemic preparedness) and attend local emergency preparedness training to learn about your role during an international health emergency. 2.19 advocate for effective systems to facilitate global responses to international health emergencies, including timely, well-supported and appropriate movement of health professionals across borders during and after the event. 2.20 participate in responsible social media use to promote health locally or globally, informed by an understanding of how telecommunications influence global and local health laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 20 (for example by making health information available globally, and by enabling transnational advocacy about health issues). 2.21 exhibit interpersonal communication skills that demonstrate respect for other perspectives and cultures. r 3.2 health programme management (christopher potter) health development interventions are described as falling under four modalities: personnel, projects, programmes and policy reform initiatives underpinned by new financial support mechanisms, particularly sector-wide approaches (swaps). these modalities are briefly analysed to provide an introduction to readers about how and why such interventions are used, and their strengths and weaknesses. it is emphasised that the modalities are not hard and fast entities but frequently overlap. indeed one of the problems facing those designing and implementing interventions is the fuzzy nature of many management terms. such issues as vertical and horizontal programme design and the transaction costs to governments who have to deal with many donors in an often relatively short-term and fragmentary manner are considered. swaps are considered as one way of dealing with some of these issues but it is noted that as many other non-state stakeholders, including industrial and commercial interests, have entered the health development arena, the possible, although contended advantages, of swaps have been compromised. finally, it is recognised that the public health challenges and their socio-political and economic contexts facing poorer countries are ever changing, so finding effective ways to deliver health development to the world’s most needy will also be an on-going challenge. 1.0 the public health professional shall know and understand: 1.1 project management techniques throughout program planning, implementation, and evaluation. 1.2 the use of the terms project and programme in the context of public health interventions. 1.3 how skills/tools such as project management and log-frames can be used to improve the effectiveness of interventions. 1.4 key concepts of health policy reforms and effective interventions e.g. sip and swap 1.5 appreciate a range of interventions to promote public health improvements in disadvantaged countries. 2.0 the public health professional shall be able to: 2.1 apply scientific evidence throughout program planning, implementation, and evaluation. 2.2 design program work plans based on logic models. 2.3 develop proposals to secure donor and stakeholder support. 2.4 plan evidence-based interventions to meet internationally established health targets. 2.5 develop monitoring and evaluation frameworks to assess programs. 2.6 develop context-specific implementation strategies for scaling up best-practice interventions. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 21 2.7 plan, implement, and evaluate an evidence-based programme. r 3.3 civil society organisations in health (motasem hamdan) the role of the civil society for health is increasingly recognized, mainly due to the historical development of non-governmental organizations. their role in health and social development as well as in global scale is nowadays indispensable. there should be, however, a regulating framework or code of conduct. 1.0. the public health professional shall know and understand: 1.1 the concepts of civil society organizations. 1.2 the historical development and the roots of ngos work. 1.3 the types, features of ngos and area of activity in different countries. 1.4 the methods of funding ngos. 1.5 the role of ngos in health system development, health policy, and health research. 1.6 the challenges of regulating and coordinating the work of ngos. 2.0 the public health professional shall be able to: 2.1 to analyze the impact of ngos on health, and health care systems. 2.2 to identify measures to enhance accountability and regulate the work of ngos. 2.3 to apply analytical tools to understand the coordination and harmonization of the work of the civil society organizations to national health priorities. r 3.4 universal health coverage (jose m. martin-moreno, meggan harris) nearly half of all countries worldwide are pursuing policies to achieve universal health coverage. this undertaking has the potential to improve health indicators dramatically, contributing to human development and more generally to global equity. however, the path towards uhc is often rocky, and every country must work to channel resources, adapt existing institutions and build health system capacity in order to accomplish its goals. global health advocates must understand what elements contribute to the success of uhc strategies, as well as how to measure real progress, so that they will be prepared to substantially contribute to policies in their own country or worldwide. 1.0. the public health professional shall know and understand: 1.1 the concepts and the rationale of universal health coverage (uhc) and its linkage with health financing and public-private partnership for health. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 22 1.2 the roles and contributions of the private sector, communities, and the traditional medicine in promoting and sustaining uhc. 1.3 the political, social, economic and technical aspects of the health financing transition. 2.0 the public health professional shall be able to: 2.1 advocate in favour of uhc strategies in health policies and programmes at global, regional, and national levels. 2.2 assess progress towards uhc. 2.3 advance critical and strategic thinking when designing a uhc programme, both in a national context and as part of an external development strategy. r 3.5 public health leadership in a globalised world (katarzyna czabanowska, tony smith, kenneth a. rethmeier) leadership is a well-known concept within organisational science, public health leadership has still not been well-defined. a recent who report acknowledges that contemporary health improvement is more complex than ever before and requires leadership that is “more fluid, multilevel, multi-stakeholder and adaptive” rather than of a traditional command and control management variety. today’s public health professionals therefore need to be able to lead in contexts where there is considerable uncertainty and ambiguity, and where there is often imperfect evidence and an absence of agreement about both the precise nature of the problem and the solutions to it. the impact of the evolving growth of the eu and its impact on the potential mobility of healthcare professionals to re-locate across many geographic regions has left, in some communities, a gap in the resources of seasoned healthcare leaders. while this trend opens new opportunities for emerging young healthcare professionals to take on greater roles guiding their healthcare systems, it has also produced a significant need for high quality leadership development educational needs. there is a need to discuss and provide professional development with a concentration on the vital role of leadership and governance play in public health globally. indeed, the presence of competent leaders is crucial to achieve progress in the field. a number of studies have identified the capability of effective leaders in dealing with the complexity of introducing new innovations or evidencebased practice more successfully. 1.0 the public health professional shall know and understand: 1.1 to demonstrate diplomacy and build trust with community partners. 1.2 to communicate joint lessons learned to community partners and global constituencies. 1.3 to exhibit inter-professional values and communication skills that demonstrate respect for, and awareness of, the unique cultures, values, roles/responsibilities and expertise represented by other professionals and groups that work in global health. 1.4 to apply leadership practices that support collaborative practice and team effectiveness. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 23 2.0 the public health professional shall be able to: 2.1 communicate in a credible and effective way: expresses oneself clearly in conversations and interactions with others; listens actively. 2.2 to produce effective written communications and ensures that information is shared. positive: speaks and writes clearly, adapting communication style and content so they are appropriate to the needs of the intended audience conveys information and opinions in a structured and credible way encourages others to share their views; takes time to understand and consider these views ensures that messages have been heard and understood keeps others informed of key and relevant issues negative: does not share useful information with others does little to facilitate open communication interrupts or argues with others rather than listening uses jargon inappropriately in interaction with others lacks coherence in structure of oral and written communications; overlooks key points 2.3 to produce and deliver quality results; is action oriented and committed to achieving outcomes. positive: demonstrates a systematic and efficient approach to work produces high-quality results and workable solutions that meet client needs monitors own progress against objectives and takes any corrective actions necessary acts without being prompted and makes things happen; handles problems effectively takes responsibility for own work sees tasks through to completion negative: focuses on the trivial at the expense of more important issues provides solutions that are inappropriate or in conflict with other needs. focuses on process rather than on outcomes delivers incomplete, incorrect or inaccurate work fails to monitor progress towards goals; fails to respect deadlines delays decisions and actions 2.4 to succeed as an effective and efficient health system manager positive: personal qualities (leadership): manages ambiguity and pressure in a self-reflective way. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 24 uses criticism as a development opportunity. seeks opportunities for continuous learning and professional growth. works productively in an environment where clear information or direction is not always available remains productive when under pressure stays positive in the face of challenges and recovers quickly from setbacks uses constructive criticism to improve performance shows willingness to learn from previous experience and mistakes, and applies lessons to improve performance seeks feedback to improve skills, knowledge and performance negative: demonstrates helplessness when confronted with ambiguous situations demonstrates a lack of emotional control during difficult situations reacts in a hostile and overly defensive way to constructive criticism fails to make use of opportunities to fill knowledge and skills gaps consistently demonstrates the same behaviour despite being given feedback to change transfers own stress or pressure to others r 3.6 public health ethics (alexandra jovic-vranes) the basic concept of public health ethics covers principles and values that support an ethical approach to public health practice and provide examples of some of the complex areas which those practicing, analysing, and planning the health of populations have to navigate; a code of ethics is the first explicit statement of ethical principles inherent to public health. 1.0 the public health professional shall know and understand: 1.1 the ability to identify an ethical issue. 1.2 ethical decision-making. 1.3 understanding the full spectrum of the determinants of health. 1.4 understanding basic ethical concepts such as justice, virtue, and human rights. 1.5building and maintaining public trust. 2.0 the public health professional shall be able to: 2.1 recognizes the ethical value the public health community gives to prevention 2.2 considers the full spectrum of the determinants of health 2.3 identifies the range of options for interventions that correspond to the full spectrum of determinants of health 2.4 recognizes the tension between community health and rights of individuals 2.5 identifies the various conceptions of human rights, including those of the community 2.6 defines the legal authority of public health agencies laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 25 2.7 considers the values of diverse stakeholders when conducting needs assessments and evaluations 2.8 recognizes the ways that advocacy and empowerment can be done 2.9 represents the needs and perspectives of all relative stakeholders with particular attention to the disenfranchised 2.10 describes issues of access and barriers to public health services 2.11 recognizes the ethical priority the public health community gives to the health of the disenfranchised 2.12 determines research priorities with an understanding of areas of the community that have been underserved 2.13 specifies the meaning of consent at the individual and group level 2.14 identifies the range of options for obtaining consent at the individual and group level 2.15 recalls historical abuses of informed consent 2.16 discerns the risk and benefits of not acting quickly or not acting at all 2.17 identifies the range of options for responding to unethical practices observed outside of one’s realm of responsibility 2.18 recognizes that legal rules can fall short of the ethically required action 2.19 describes the full spectrum of the determinants of health 2.20 identifies best practices for achieving a particular health objective 2.21 discerns and applies different methods of maintaining confidentiality 2.22 describes the potential harms and benefits of giving information about individuals and communities while maintaining confidentiality 2.23 identifies specific circumstances when maintaining trust may justify with holding or delaying the communication of information 2.24 identifies best practices for one’s areas of responsibility and action 2.25 determines the range of appropriate actions for addressing unethical behavior 2.26 identifies interests and conflicts of interest between potential partners 2.27 articulates how public trust is built or undermined by partner collaboration 2.28 establishes transparency about collaborations to maintain public accountability additional references: 1) thomas j. skills for the ethical practice of public health. washington dc: public health leadership society; 2004; available at: http://phls.org/cmsuploads/skills-for-the-ethicalpractice-of-public-health-68547.pdf. background reading: 1) lee lm, wright b, semaan s. expected ethical competencies of public health professionals and graduate curricula in accredited schools of public health in north america. am j public health. 2013 may; 103(5): 938–942. 2) bernheim rg, nieburg p, bonnie jr. ethics and practice of public health. in goodman ar (editor) law in public health practice. 2nd edition. oxford university press, 2007: 110135. lee lm. public health ethical theory: review and path to convergence. j law med ethics. 2012;40(1):85–98. http://phls.org/cmsuploads/skills-for-the-ethical-practice-of-public-health-68547.pdf� http://phls.org/cmsuploads/skills-for-the-ethical-practice-of-public-health-68547.pdf� https://www.ncbi.nlm.nih.gov/pubmed/?term=lee%20lm%5bauthor%5d&cauthor=true&cauthor_uid=22994177� https://www.ncbi.nlm.nih.gov/pubmed/?term=wright%20b%5bauthor%5d&cauthor=true&cauthor_uid=22994177� https://www.ncbi.nlm.nih.gov/pubmed/?term=semaan%20s%5bauthor%5d&cauthor=true&cauthor_uid=22994177� https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3698833/� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 26 r 3.7 the global public health workforce3 3 see also reference (1), p. 36 ff.: 1a1,3,4; 1b,c,d; 2a4; 2b7-9; 2c2; 3a7, 3b3; 3c2; 3d3; 4a,b; 5a,d; 6a; 6b2-5; 6c; 7a; 7b, 7c; 7d; 8 a; 8b; (milena santric-milicevic, vesna bjegovic-mikanovic, muhammad wasiful alam) the progress of health sciences and technological innovations including modern medicine and health care technologies has increased our expectations for quality of life and health care. that has influenced the public health vision, the scope of public health interventions, and the composition of public health workforce. the outline the text includes description of the current situation of the public health workforce globally; future needs assessment; public health workforce challenges and mitigation globally. it underscores the demand for valid, reliable data sources and tools for mobilization of capacities of skilled public health staff in order to appropriately address global health challenges. 1.0 the public health professional shall know and understand: 1.1 the concepts of public health and public health workforce, including barriers and limitations of their application in the practice. 1.2 10 essential public health functions (services, operations) and the global framework for public health functions (see: wfpha. “a global charter for the public’s health” and related documents at https://www.wfpha.org/charter/the-charter). 1.3 the roles and responsibilities of public health professionals and wider public health workforce at the global, regional, national and local level. 1.4 the 6 ‘action fields’ of a comprehensive hrh action framework of the management systems of human resources for global public health : (1) hr management systems (2) leadership/governance, (3) partnership (4) finance, (5) education, and (6) policy and 4 phases (situation analysis, planning, implementation and monitoring, evaluation and research). 1.5 how global factors and country context influence the functioning of public health systems and the work of public health professionals. 1.6 how global trends in epidemiology, environmental change, economy, technology and medicines development, and resource availability may affect public health services supply and demand within and between countries. 1.7 methods and tools used for workforce planning in public health. 1.8 how decisions are made about workforce resource allocation in the context of local and global resource constraints and the contribution of economic evaluations and populationbased needs assessments to such decisions. 1.9 in the context of resource limitation, especially workforce, how best to identify key partners and work effectively and efficiently with the stake holders. 2.0 the public health professional should be able to: laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 27 2.1 efficiently access global health workforce data from national and international sources such as the who global health observatory (gho) data and understand the limitations of these data. 2.2 identify and compare services delivered by the public health professionals across countries and the alignment with public health priorities. 2.3 undertake the public health workforce analysis using the 6 action fields and 4 phases. 2.4 examine the major governance and organizational structures and mechanisms for provision of public health services nationally and internationally. 2.5 examine the drivers of health worker migration, and the impacts of such migration on health systems, as well as the wellbeing of health professionals and health service users. 2.6 consider successful practices from other health systems to improve national public health services equity, efficiency, access, quality applied to address global public health challenges. 2.7 identify and compare public health workforce planning and development systems across countries. 2.8 use methods for assessing the public health workforce requirements (services and capacities) locally and globally. 2.9design sustainable workforce development strategies for resource-limited settings. additional references: foldspang, a. on behalf of aspher: from potential to action, public health core competences for essential public health operations (edition for comments). volume 2, brussels: may 2016. at: http://www.aspher.org/download/75/booklet-competencesephosvolume-2.pdf foldspang, a. on behalf of aspher: public health core competences for essential public health operations. volume 3, brussels 2016. at: http://aspher.org/download/76/bookletcompetencesephos-volume-3.pdf r 3.8 education and training of professionals for global public health (suzanne babich, egil marstein) by addressing the critical need for public health education and training within the global health workforce, we have in this program an opportunity to contribute substantially to efforts to improve the health of people worldwide through improved project management and resource application. topics introduced and discussed address the complexities of working with country specific agents, organizational representatives and formal and informal stakeholders who may influence the outcome of global health operations. 1.0 the public health professional shall know and understand: 1.1 key concepts related to stakeholder theory: how political, organizational and socioeconomic conditions affect critical operational premises in the governance of global health. http://www.aspher.org/download/75/booklet-competencesephos-volume-2.pdf� http://www.aspher.org/download/75/booklet-competencesephos-volume-2.pdf� http://aspher.org/download/76/booklet-competencesephos-volume-3.pdf� http://aspher.org/download/76/booklet-competencesephos-volume-3.pdf� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 28 complexities associated with working with country specific agents: appreciate the makeup and workings of context specific forces as these impact global health initiatives; e.g. (i) identify key stakeholders and their impacts on health governance and leadership; (ii) evaluate culture-specific traits relevant for the professions, teams and organizational processes; (iii) analyze institutional governance as it applies to fieldwork planning and program execution; and (iv) recognize the dynamics of the global health field and how this needs be incorporated in operational strategies and actions. 1.3 principles of project management and resource application 1.4 how global health initiatives are financed through international aid 1.5 international standards for health program performance evaluation 2.0 the public health professional should be able to: 2.1 critique policies with respect to impact on health equity and social justice 2.2 describe the roles and relationships of the entities influencing global health 2.3 analyze the impact of transnational movements on population health 2.4 analyze context-specific policy making processes that impact health 2.5 describe the interrelationship of foreign policy and health diplomacy 2.6 conduct a situation analysis across a range of cultural, economic, and health contexts 2.4 analyze context-specific policy making processes that impact health 2.5 describe the interrelationship of foreign policy and health diplomacy 2.6 conduct a situation analysis across a range of cultural, economic, and health contexts r 3.9 blended learning (željka stamenkovic, suzanne babic) blended learning is an educational model with great potential to increase student learning outcomes and to create new roles for teachers. in this course you will learn about and then develop tools to build your own blended learning programme. 1.0 the public health professional shall know and understand: 1.1 main concept of blended learning and 4 basic blended learning models: (1) rotation model, (2) flex model, (3) a la carte model and (4) enriched virtual model. 1.2 the differences between blended learning models and when each model should be applied. 1.3 how to integrate face-to-face and online learning in order to improve the learning outcomes. 1.4 how to implement blended learning and successfully accomplished blended learning process. 1.5 the main drivers of blended learning. 1.6 the advantages and disadvantages of blended learning for teachers. 1.7 the advantages and disadvantages of blended learning for students. 1.8 how global trends in technology may affect blended learning in public health in the future. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 29 2.0 the public health professional shall be able to: 2.1 use the technology tools and resources in order to support blended learning. 2.2 work in different environments and have the flexible time schedule. 2.3 know when blended learning is the best choice for the particular course. 2.4 design a successful blended learning strategy and identify methods for assuring successfully accomplished blended learning process. 2.5 target learning opportunities. 2.6 act as a learning facilitator. 2.7 constantly support students who are learning different things, at different paces, through different approaches. 2.8 participate in students’ process of learning. additional references: bonk cj, graham cr (eds.) (2005). handbook of blended learning: global perspectives, local designs. san francisco, ca: pfeiffer publishing. carman jm (2005). blended learning design: five key ingredients. agilant learning. donoghue f (2011). the strength of online learning. the chronicle of higher education. http://chronicle.com/blogs/innovations/the-strengths-of-online-learning/29849 (accessed on december 31, 2016). friesen, n. (2012). report: defining blended learning. http://learningspaces.org/papers/defining_blended_learning_nf.pdf (accessed on december 31, 2016). kelly r (2012). blended learning: integrating online and f2f. online classroom 12: 1,3. lephie. leaders for european public health. http://www.lephie.eu (accessed on december 31, 2016). u.s. department of education, office of planning, evaluation, and policy development, evaluation of evidence-based practices in online learning: a meta-analysis and review of online learning studies, washington, d.c., 2010. r 3.10 global health law (joaquin cayon) transnational public health problems have been traditionally addressed through international health law whose proper implementation faces two important handicaps: the absence of an international authority that can enforce it, and the absence of a comprehensive concept. despite this, international agreements and treaties are among the most important intermediate public health goods because they provide a legal foundation for many other intermediate products with global public health benefits. nowadays, according to the emergence of the idea of global public health, a new concept -“global health law”has been born. there is an important distinction between international health law and global health law. international health law connotes a more traditional approach derived from rules governing relations among states. on the other hand, global health law is developing an international structure based on the world as a community, not just a collection of nations. there is also an http://chronicle.com/blogs/innovations/the-strengths-of-online-learning/29849� http://learningspaces.org/papers/defining_blended_learning_nf.pdf� http://www.lephie.eu/lephie_repository.html� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 30 important international trend leaded by some prestigious scholars who have urged adoption of a legally binding global health treaty: a framework convention on global health grounded in the right to health. in this context, an interdisciplinary approach to global public health inevitably requires the study of global health law for any healthcare professional. it is undoubtedly necessary to study and analyse the emergence and development of global health law just because it arises as an important tool to address the phenomenon of globalization of health. in this regard, the future of global public health is directly dependent on the strength of global health law understood in a comprehensive way. 1.0 the public health professional shall know and understand: 1.1 theoretical and conceptual basis of global health law. 1.2 the rationale of studying global health law. 1.3 the increasingly interactive relationship between global health law and global public health. 1.4 the role of global health law as an important tool to deal with the phenomenon of globalization of health. 1.5 differences between international health law, global health law and global health jurisprudence. 1.6 how global health diplomacy brings together the disciplines of public health, international law and economics and focuses on negotiations that manage the global policy environment for health. 1.7 how international trade law, international labour law and international humanitarian law impact on national health systems. 1.8 how the human rights approach constitutes an important strategy for challenging globalization's effects. 1.9 the connection between the prevention principle to sustainable development and international legal obligations regarding cross-border pollution. 1.10the challenge of a legally binding global health framework convention grounded in the right to health. 2.0 the public health professional shall be able to: 2.1 demonstrate a basic understanding of the relationship between global health law and global public health. 2.2 develop skills for critical analysis of legal data and health information. 2.3 develop critical thinking skills and explore critically health systems from a legalnormative perspective. 2.4 do literature review and critical reading for globalization of health and the role of law. 2.5 identify the main international treaties on communicable disease control, world trade, environmental protection and working conditions that impact on public health. 2.6 employ a comprehensive and multidisciplinary approach for the analysis of the role of global law as a determinant of health. 2.7 identify key points to be included in a future global framework on public health. 2.8 identify human rights and public health issues involved and affected by international treaties. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 31 2.9 compare differences between national and international legal framework on public health and develop proposals to improve health legislation both at national and international level. 2.10 apply basic legal tools for developing, exploring, and evaluating global health initiatives. additional references: ablah e (2014): improving global health education: development of a global health competency model. at: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3945704/ berkman be, rothemberg kh (2012): teaching health law, j law med ethics 40(1):14753. mcneill ransom m (2016): public health law competency model: version 1.0. at: https://www.cdc.gov/phlp/docs/phlcm-v1.pdf rowthorn v, olsen j (2014): all together now: developing a team competency domain for global health education, j law med ethics 42 (4): 550-63. r 3.11 human rights and health (fiona haigh) human rights and health are intrinsically linked. health policies and practice can impact positively or negatively on rights and in turn human rights infringements and enhancements can influence health. increasingly human rights based approaches are being used to strengthen public health policies and programs and as a powerful tool to advocate for the action on the social determinants of health. 1.0 the public health professional shall know and understand: 1.1 the key human rights concepts and the un treaty system. 1.2 the relationship between health and human rights. 1.3 how social, economic, political and cultural factors may affect an individual’s or community’s right to health services (e.g. availability, accessibility, affordability, and quality). 1.4 the rationale for using human rights based approaches to health. 1.5 the relevance of human rights to global public health. the public health professional shall be able to: 2.1 analyse the right to health and how this right is defined under international agreements such as the united nations’ universal declaration of human rights or the declaration of alma-ata. 2.2 introduce the main objective of policies and programmes with regard to the fulfilment of human rights. 2.3 to identify rights holders and duty bearers, and the capacities of rights holders to make claims on duty bearers to meet their obligations. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3945704/� https://www.cdc.gov/phlp/docs/phlcm-v1.pdf� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 32 r 3.12 global financial management for health (ulrich laaser) world population growth takes place predominantly in the poor countries of the south whereas most of the resources are available in the north. the economic inequalities are related to key health indicators. although official development assistance (oda) and development assistance for health (dha) grew considerable during the last decade the objective of 0.7% of the northern gdp to be transferred to the south has not been reached by far. in order to correct the main weaknesses the international community agreed on the socalled paris indicators but failed the set timelines. the underlying reasons may be sought in the fragmentation and incoherence of international financial assistance. 1.0 the public health professional shall know and understand: 1.1 the major social and economic determinants of health and their effects on the access to and quality of health services and on differences in morbidity and mortality between and within countries. 1.2 the deeper reasons for the gap in wealth between the south and the north corresponding to vast disparities in standards of living, health, and opportunities. 1.3 the structures of international financial management in the health sector. 1.4 the main terminologies of oda and dah. 1.5 the five principles of the paris declaration on aid effectiveness and the results of the subsequent conferences. 1.6 the key global strategies to reduce the north-south gap including sdg 3. 1.7 how to analyse the critical aspects of loans to developing countries regarding intergenerational effects, and monetary back flows to the donors for experts and equipment. 1.8 why capacity strengthening means sharing knowledge, skills, and resources for enhancing global public health programs, infrastructure, and workforce to address current and future global public health needs. 1.9 why assistance to developing countries is increasingly considered a moral obligation, although more often declared in resolutions than in deeds. 2.0 the public health professional shall be able to: 2.1 consider the underlying reasons for the failure in efficiently organizing international assistance as there is the extreme fragmentation and therefore ineffectiveness of international aid, and the insufficient coordinating capacities and competences in the national ministries of health making it difficult to secure ownership. 2.2 identify the deficits of global governance and to implement interim strategies to strengthen regional collaboration. 2.3 follow up and promote the latest evaluation of the paris indicators. 2.4 advocate effectively for an increase in oda to reach 0.7% of gdp of donor countries and for an increasing share of dah. 2.5 argue and act against imbalances in oda and dah due to political and economic interests of the donor countries. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 33 2.6 design global, regional, national and local structures, organisational principles and mechanisms to improve and sustain global health and well-being, including universal health coverage. 2.7 work in a constructive and contributing way in the environment of a sector-wide approach or pool-funding. 2.8 contribute to the management of a medium term expenditure framework and help to establish nhas. 2.9 contribute to the improvement of debt and debt relief management as important steps towards addressing the massive inequalities that currently deform global relationships and enable debtor countries to make a fresh start towards genuine social and economic development. 2.10 promote a code of ethics for ngos taking into consideration their increasing relevance in channelling aid to developing countries. 2.11 conduct a situation analysis across a range of cultural, economic, and health contexts. 2.12 develop a network of international health professionals for enhancement of professional work in areas of mutual interest. ablah e (2014): improving global health education: development of a global health competency model. at: berkman be, rothemberg kh (2012): teaching health law, j law med ethics 40(1):147-53. mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 1 | 16 original research professionalization of public health – an exploratory case study hilke mansholt1,2, katarzyna czabanowska2,3, robert otok4, jascha de nooijer5 1 department of new public health, osnabrück university, osnabrück, germany; 2 department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 3 institute of public health, faculty of health sciences, jagiellonian university, krakow, poland; 4 association of schools of public health in the european region (aspher), av de tervueren 153, 1150 brussels, belgium; 5 school of health professions education, maastricht university, maastricht, the netherlands. corresponding author: hilke mansholt, m.sc.; department of new public health, osnabrück university; address: barbarastraße, 22c 49076 osnabrück, germany; telefon: +49 (0)541 969-2078; email:hilke.mansholt@uni-osnabrueck.de mailto:email:hilke.mansholt@uni-osnabrueck.de mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 2 | 16 abstract introduction: public health is continuously challenged by a shortage of workforce. there are various reasons for this: 1) public health is less visible than traditional health professions and people may be unfamiliar with the nature and opportunities involved in entering this career field; 2) lack of official recognition of public health as a professional category; and 3) no umbrella organization that supports its members and governs professional standards as is the case of other more established professions. to adequately address the challenges of public health for the 21st century, a key policy element will need to focus on adequately cultivating, training and growing the future workforce of professionals in the field. the aim of this study was to examine why professionalization of public health in europe is not as robust as it deserves to be and what steps can be taken to assure an adequate supply of professionals with the proper education and training background, and career guidance to tackle the public health needs of the future. method: a case study approach was used collecting data via a scoping literature review, a focus group with public health students and interviews with public health experts for convergence. data was analysed using directed content analysis and pattern matching logic. results: public health fulfilled five out of seven attributes of a profession, such as skills, training and education, certification and an altruistic service. recognition of public health as multidisciplinary and multi-professional field, derived from the interviews as an additional characteristic. a code of ethics and professional conduct and a formal organization were missing. conclusion: public health professionals and organisations that govern best practices in this field should consider introducing a shared code of ethics and professional conduct as well as establishing a coordinated body to help advance the public status as a the profession to increase interest in studying and specializing in this area. keywords: professionalization, public health workforce, qualitative study conflicts of interest: none declared. mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 3 | 16 introduction healthcare is one of the largest economic sectors in the european union (eu) – accounting for around 17 million jobs (1). most of these jobs are done by the public health workforce (phw),“people who are involved in protecting, promoting and/or restoring the collective health of whole or specific populations” – and thus distinct from other medical practices (2). the phw is multidisciplinary and multi-professional in character (3), encompassing a core phw that identifies with a primary public health role and a wider phw including health professionals and others who impact on population health (4-5). according to czabanowska et al. the main task of public health professionals is to focus on the provision of essential public health operations (ephos) and thus display a more focused set of skills while providing leadership that ensures networking, coherence, synergy and strategic impact. the authors further perceive the public health workforce not only as “professionals in traditional public health occupations (such as medical doctors specialized in preventive medicine and public health, food safety inspectors, environmental health officers, communicable disease control staff, etc.) […] but also a range of “new” practitioners working in the broad field of public health protection, prevention, promotion, service delivery and quality assurance, such as those involved in projects and programmes (e.g., the healthy cities and healthpromoting schools movements)” (6). today, europe is faced with a shortage of phw due to many factors, such as low fertility rates and aging population leading to an imbalance between patients/overall population size and public health staff (7). further, the inconsistency in defining the phw has an impact on the shortage of workforce, demonstrating a significant challenge for european health systems. but the declining interest in the profession among young people is to be expected given the informal and fragmented nature of the public health profession, underlining the importance of a clear definition. cioffi et al. (8) claim that, “the fact that the public health workforce is not a single profession, but rather a fabric of many professions dedicated to a common endeavour, creates challenges to any singular approach to workforce development”. when following the definition of cruess et al. (9) who define a profession as “an occupation whose core element is work based upon the mastery of a complex body of knowledge and skills”, public health seems to be a profession. however, compared to medicine or pharmacy, public health does not enjoy the benefits of the directive 2005/36/ec (10) such as: recognition of professional qualifications by the eu member states, professional mobility or the assimilation of workers in the single market which apply only to regulated professions (11-12). the lack of professional categorisation and recognition at the regulatory level becomes apparent in the context of attracting prospective employees or students to pursue this field of study. bjegovic-mikanovic et al. (13) see an additional problem in the existence of many different study programmes that focus on individual aspects of public health rather than providing a broader and basic knowledge. this makes it difficult to state what the public health discipline really is, and where decision-makers can seek advice. therefore, there is a need for an authorised public health profession founded on graduation from comprehensive public health education (13). the establishment of public health as a profession follows with regulation and formal recognition as a “category” among the “listed” professions of europe and their taxonomy. the purpose of the taxonomy is to facilitate the systematic mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 4 | 16 characterisation of the public health workforce. currently, the international standard classification of occupation (isco-88), has two sub-major groups (health professionals and health associate professionals) within which only a few occupational titles refer explicitly to public health (14). there are several pathways to establishing a profession. professional status can be achieved via training and education resulting in a specific degree. in this respect public health follows the bologna process, an initiative that adjusts and harmonizes study programmes. moreover, there are social processes that transform an occupation into a profession, empowered by either employees and service users (bottomup process) or employers and government (top-down process) (15). for the employers, the professional status of an occupation means that they can require a diploma or certificate, which ensures, that the applicant possesses specific skills and knowledge. for the government, professionalization can require the development of educational standards and a unified curriculum. moreover, a professional status requires a code of professional conduct, which can help to enhance the quality and security of and for employees. additionally, degrees and diplomas can function as an assurance for customers, increasing their trust and confidence in making use of a service (16). although professionalization and formal recognition of the public health field may be a way to elevate the status of the public health profession and stir international interest, little has been done in the european region to address this pressing need. the current exploratory case study aims to find out hoand why public health is understood and recognised as a profession using multiple data sources: literature, public health experts and students of public health in view of the theory of professionalization (17). methodology this study uses a case study approach which investigates a contemporary phenomenon, in this case “professionalization”, within its real-life context, in particular when the boundaries between the phenomenon and the context are not clearly evident. it relies on multiple sources of evidence to converge in a triangulating fashion. it assumes a relativist orientation acknowledging multiple meanings, which are observant dependent (18). the study uses the theoretical propositions of the theory of professionalization to guide data collection and analysis (19-20). the propositions which represent the characteristics of a profession include: • skills based on abstract knowledge which is certified/licensed and credentialed; • provision of training and education, usually associated with a university; • certification based on competency testing; • formal organization, professional integration; • adherence to a code of conduct; • altruistic service. the data were collected using: 1) a scoping literature review, 2) a focus group with public health students and 3) individual interviews with public health experts for convergence. the data were analysed using directed content analysis (21) and pattern matching logic (20, 22). if empirical patterns appear to be similar, the results can help a case study to strengthen its internal validity (20). scoping review the scoping review (23-24) included articles which: 1) focus on the process of professionalization in relation to public health occupations; 2) are published in english and german; and 3) cover the period from 1st of january 1920 – 1st of july 2017. the following key words and their combinations were used: mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 5 | 16 professionalization, profession, skills, education, training, certificate, formal organization, professional integration, altruism, professional code of conduct, public health, workforce, health occupations and europe. the study made use of the following databases: pubmed, psychinfo, eric, springer, biomed central, science direct, google scholar and the websites of the european commission (ec) and world health organization (who). the information obtained guided the focus group and expert interviews. focus group the focus group (fg) aimed to get a deeper understanding of how the missing professional status of public health might affect future workforce expectations and how graduate students perceive this issue (25). in total, ten students (males n=4, females n=6) of the bachelor (b-eph) and master of european public health (m-eph) at maastricht university (nl) participated, representing two levels of higher education. thereby, the beph programme mainly focuses on the determinants of health and concrete health issues and how they are tackled in different countries. in comparison, the m-eph approaches public health from a perspective of collective action for sustained population-wide health improvement and reduction of inequalities within the institutional, legal and administrative boundaries of health systems. both programmes have a strictly public health focus and an international student population. students were selected on a voluntary basis via the electronic learning environment. during the fg, the moderator led the discussion following an interview guide referring to the awareness and recognition of the professionalization dimensions in relation to public health profession (table 1). the questions were open, in-depth and semistructured, meaning that they were adapted or added with the progress of the fg. further, the 90-minute fg, was audio-taped expert interviews four in-depth interviews were carried out at the association of schools of public health in the european region (aspher) deans and directors’ retreat in may 2017. experts were selected, representing leading ph organisations (world health organization (who), european centre for disease prevention and control (ecdc), agency for public health education accreditation (aphea) and a university providing ph educational programmes). the interviewer followed an interview protocol with openended, in-depth and semi-structured questions (table 2). each interview took about forty-five minutes and was audio-taped. both the students and the experts signed the informed consent and were offered to review the analysed results for validation. they were assured of the ethical principles including anonymity and confidentiality to increase honest answers. mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 6 | 16 table 1. focus group guiding questions examples of questions for students why did students choose a bachelor or master in public health? what are future job perspectives of public health students? how do studies in public health prepare students for the job market? how can studies in public health be improved? how necessary is a specialization in public health? what are characteristics of a profession? is public health a profession? which characteristics are missing? how is the public health workforce supported? what are concerns regarding the future of public health? table 2. individual interview guiding questions examples of questions for public health experts is public health a profession? which characteristics of a profession is public health missing? how can studies in public health be adapted to the job market? how can public health students be supported (to enter the job market)? will public health at the european level change in the future? is public health prepared to keep up with changes in knowledge and practices? is public health taken seriously on the european level or by the population? how to raise the importance of public health? directed content analysis and pattern matching the data of the fg and interviews were analysed using a directed content analysis based on predetermined codes representing the constructs from the attribute models and one additional code public health as a profession, which was derived from the data (18). the fg and interview data were matched with the results of the literature review to “provide predictions about the variables of interest, which helped to determine the initial coding scheme” (20), and to assure credibility and pattern matching, which is a strategy for aligning data to the theoretical propositions (22) and finally, providing theoretical explanations and developing the research outcome. the analysis and interpretation of the results were discussed among the researchers until consensus was reached to reduce a potential bias. mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 7 | 16 results scoping review comparison of the literature with the predicted pattern shows that both patterns match only partly. similarities and differences are explained hereafter. regarding a defined set of skills, major work was done by aspher, starting with defining a system of core competencies which could be applicable to public health education, research and practice throughout europe (26). since the start of the programme in 2006, much consideration was given to whether the skills taught in schools and programmes of public health reflect what is needed in reality (14, 27-29). that lead to further analyses and the development of the latest edition of the “european list of core competences for the public health professional” (30). the most recent “who-aspher competency framework for public health workforce in the european region” (31) is an example of a tool to support public health workforce development, professional self-assessment and staffing. regarding education and training, effective pedagogy and a public health curriculum that balances theoretical and practical education is essential to enable core competencies for future professionals. the seventh out of the ten ephos aims to “ensure that there is a relevant and competent public health workforce sufficient for the needs of the population it is designed to serve” (32). ephos self-assessment tools were developed and answered by public health services in 41 countries, to detect issues regarding the public health workforce and to give recommendations with respect to training, curriculum, core competencies, accreditation or continued professional development (34). in the following, aspher established the european degrees in public health project group to design a european master programme in public health (emph). the aim of this project was training harmonization, a recognition of degrees without restrictions and thus free movement of specialists within the european union; public health schools and programmes were invited to apply this curriculum and adapt their education (35). although further numerous initiatives took place to strengthen public health education and training (36-37), it illustrates a quite heterogeneous topic (34). therefore, public health follows other harmonizing frameworks like the bologna process or the european higher education area. thus, the basic education and training offer in public health is in place; further effort is required to ensure its comprehensiveness, including strong continuous professional development (cpd) – essential for the professional status. after successful finalisation of the studies in public health, schools of public health have to deliver a certificate that acknowledges the completion of the programme (38). further, certificates help to test the competencies and reveal whether a person, based on his or her skills and education, can be seen as a professional in the field and fulfils the requirements needed for the position. however, since programmes are not harmonized, certificates are not always comparable and may have a varying degree of significance. this makes the job application process more difficult for both employers and applicants. therefore, some initiatives, for instance by the us national board of public health examiners or the uk faculty of public health, are being undertaken to support academic certification with professional credentialing systems in public health. many organizations play a role and contribute to the european public health agenda representing different groups of stakeholders. mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 8 | 16 there is the european public health association (eupha) – an umbrella organisation for national public health associations (39), and the european group within the international association of national public health institutes (ianphi) (40). there are also the following networks: the european public health alliance (epha) – consisting of nongovernmental organisations and focusing on a wide range of advocacy efforts (41), the eurohealthnet – another not for profit partnership –of organisations, agencies and statutory bodies working to contribute to a healthier europe by promoting health and health equity between and within european countries (42), and aspher, “a key independent european organisation dedicated to strengthening the role of public health by improving education and training of public health professionals for both practice and research” (43). this is only a selection of five out of many organizations striving to improve and support different functions of public health in europe. however, one formal organization that covers and combines all aspects of public health and is responsible as well as representative to achieve a professional integration was missing. several attempts have been made to create guidelines and frameworks for the phw. nevertheless, a strict code of conduct that employees as well as employers working in the field of public health have to obey and follow when conducting their job, was lacking. this constitutes a problem because public health illustrates the need to “guide the behaviour of practitioners in the field, especially when it comes to morally or ethically ambiguous activities” (15). conversely, for epidemiological research, which is inter-related to public health, the declaration of helsinki is mandatory (44). consequently, with respect to the professionalisation of public health, foldspang (45) argued that “in each country, we should discuss the shaping of an authorised profession and about what that means in concrete terms, including, for example, the development of agreed public health professional standards and ethical rules”. concerning altruistic service, people within a profession should strive for the same goal and thus put the interest of the society over their own personal gain which is often described as a paradox, double role of professions as officers and servants of society. literature that described this altruism specifically in connection with public health was not found. however, according to yach and bettcher (46), in public health altruism was intersecting with self-interest. one example for this is globalization and the fact that “in a world of shared global problems, the moral imperatives of addressing these problems also bring mutual benefits” because nowadays poor and wealthy countries affect each other more and more and should therefore build “knowledge partnerships” to support as well as profit from each other (47). focus group similarity was found in the fact that students agreed that a certain set of skills is required for a professional status. they found that public health provides an insight into a broad range of topics, sectors and stakeholders having an effect on health and the width of public health made a career more accessible and attractive but also caused uncertainty since in an academic setting practical knowledge is often missing. the students feared not getting an adequate position or that some parts of the studies might change in the future or the degree might become less relevant. while a master degree in public health is perceived to have high relevance by the students, a bachelor degree seems to be less important and mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 9 | 16 vague. nevertheless, the students concur that the degree offers flexibility and the opportunity to switch between various careers. according to the students, a representing, professional body or organization is a requirement for a profession but it is missing in public health. the field of public health is emerging but is also lacking appreciation since outcomes are often not linked to the field. thus, the students emphasised the need for establishing a formal organization which could provide guidance for and promotion of the expanding field of public health and enforce awareness by the society. the students mentioned that a profession is characterized by a set of rules and guidelines one needs to follow when working in this field. however, none of the participants was aware of a specific code of conduct for public health. when studying public health, students have a certain way of thinking and the shared goal to improve the health and well-being of other humans, creating some kind of identity. although outcomes are not immediately visible and are often not linked to the work of public health professionals, they still continue and try to improve the health of a population. expert interviews the characteristics described by the experts are similar to the proposition of a public health profession with respect to four characteristics (skills, education/training, certification, and altruism). experts mentioned the need for a variety of skills and the need to use this broad knowledge to show flexibility. also, experts stressed the usefulness of a degree in public health, demonstrating knowledge in many fields that graduates, as well as employers, should see as a positive characteristic. further, increasing numbers of courses offered in public health is leading to younger generations that will be trained in public health and ensuring that the importance of a degree is rising and that jobs handling public health issues are occupied by professionals with an educational background in the field. a more specified job within public health will add, adjust or deepen certain skills, going beyond the basic education. further, experts recommended the involvement of major stakeholders in public health (e.g. employers, alumni) to connect education and work life. experts consequently recommended job fairs and improved career services within study programmes. public health education is a very fragmented system. the experts indicated that public health schools are often small departments within a large medical faculty, causing constant pressure to prove their usefulness. thus, collaboration between medicine and public health on an equal level should be achieved. additionally, experts felt it was necessary that public health schools develop more independently, not as small sections of a large medical faculty and with freedom to collaborate with other departments. public health is changing continuously and therefore education and training should be updated by increasing communication, also including younger generations. moreover, the ongoing changes that public health is confronted with, clarified that education has to be adjusted on a constant basis, illustrating the importance of continuous professional development. further, education in public health should focus more on public communication and leadership skills, making professionals more flexible and adaptable to future changes. in the opinion of the experts, studying and working in the field of public health clearly demonstrates an altruistic service. from their point of view, people in public health look out for the interest of others by preventing, mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 10 | 16 promoting and enhancing health and welfare more than for a high income or appreciation. regarding professional organisation and the code of conduct, the pattern found amongst experts differed from the proposition. experts agreed that a professional association and advocacy are necessary prerequisites to increase awareness about the field. however, when public health services are provided efficiently in a country, they become invisible and often go unnoticed by the population giving the impression that services lack importance and appreciation, making it difficult to promote public health. although a failure in public health can have huge impact on other sectors (e.g. economy), public health ranks low within the political context. therefore, much clearer guidance is needed on how to advocate for the evidence-based importance of public health, by e.g. demonstrating the cost-effectiveness of interventions. the question whether there is a code of conduct public health professionals can follow, caused uncertainty for the experts, who perceived it as a challenge. so far, no one was aware of a specific code of conduct, but they referred to ethics and the altruistic service that are present in public health. table 3 presents the excerpts of data assigned to the constructs of the professionalization theory. table 3. excerpts from the focus groups and expert interviews assigned to the six theoretical constructs related to professionalization advanced with a new derived category constructs citation skills “…once you have your basic academic profession there is a common ground, there are competencies that are common in public health and of course depending on what area of public health you are working in, it may look different. […] i think it is important too, within each domain of a larger public health, to define what are the competencies and then make sure that each of the professions that are working in that segment of public health have those additional competencies that go beyond their basic profession.” training & education “in many places, departments of public health are just a small piece of a much larger medical faculty and they are constantly under pressure to prove a usefulness. […] so yes, in several european countries, more needs to be done in structural terms to keep public health independent.” “this master […] is based on networking and connections that it should be super easy for them to have like a job fair, specifically for public health students […]. at least if not a job they can just give us connections for us to go forward.” certificate “there are two ways to look at it. one is to say that the glass is half empty […] i would say the glass is half full or at least three quarters full, because the advantage that you as public health graduates have is that you have some knowledge in a lot of fields. if i were an employer, not knowing what the future actually brings, i would rather have graduates who are able to think in various fields rather than graduates who are focused on a very narrow field but have some in depth knowledge.” formal organization “definitely, we need a strong professional association and strong institution, we need strong advocates. and there are strong advocates from the eu level or ngos working in the public health arena but not maybe doing that much public health work themselves but are lobbying and supporting.” “advocacy that is taking a strong role in the public debate. i think as a public health profession, we are very good at talking and communicating within a bubble. but we are less good at talking outside the bubble.” code of conduct “i think this is an interesting topic to pursue. so i take this as a challenge.” “i mean to my knowledge there is no formal code of conduct, at least i haven't seen one. i mean it might be that it is out there but, no visible to me.” altruistic service “…those who chose public health do it because there is an adherence involved of making something good for the society.” “i think that only because you have a degree in public health for example that just shows for me at least that you have a certain way of thinking.” recognition of public health as multidisciplinary and multi-professional “i think that there is a public health profession. but i recognize the risk of excluding people and the definition of public health should be about inclusion. […] that places us in this unique position to have a broad leadership role in the whole system.” “to me, i think it would be hard to say that it is one profession. i see it more as a coalition of various professions, […] different competencies working together.” mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 11 | 16 discussion by using pattern matching and directed content analysis we attempted to triangulate multiple data sources to describe the extent to which public health can be considered a true profession. the findings coming from the three sources (literature review, student focus group, and expert interviews) were overlapping and consistent with each other. they indicate that public health, as a profession, is not yet fully developed although various aspects required for a profession are fulfilled. the validation of the results against the theoretical model shows that four out of six professionalization dimensions (18) including: skills, education and training, certification, and altruistic service are fulfilled by public health, while formal organization and a professional code of conduct are lacking. however, the results reveal a separate category: recognition of public health as a multi-disciplinary and multi-professional field. while the majority of the participants did not perceive public health as a single profession but more as a job field or a coalition of different professions and multiple agencies, they still argued that it would be beneficial if the field were precisely defined. the fact that public health is very broad leads to uncertainty among the students who may sometimes doubt whether they are well prepared for later jobs as well as fear that they can be replaceable and disadvantaged compared to the students from more defined health fields. on the contrary, the experts considered the broad range of skills students are equipped with, as a benefit enabling students to be flexible and adaptable to new situations and challenges instead of being “stuck” in a narrow field. since today’s careers develop more horizontally, such an optimistic approach should be advertised in relation to public health study programmes to eliminate the fear in current and future students and present public health as a secure future. bjegovic-mikanovic et al. (14) state that the curriculum and skills have to be adapted to real work-life by the involvement of stakeholders, employers, and alumni. this was confirmed by the student respondents, who stated that experiences during their practical placements made it clear that focus on some skills should have been made more comprehensive within their classroom studies. it means that public health also needs to balance the scientific and social/relational aspects and enhance training in public communication and leadership. regarding education and training, many public health schools follow initiatives leading to the harmonization of study programmes. this enables easier application and recognition processes and thus increases the flexible movement of professionals. it is worth noting that all participants of the study agreed that altruistic service is a feature of public health, indicating that a person who works in public health aims to improve the health and well-being of other humans and puts the interests of others as their first priority rather than appreciation or financial gains. while on one hand the results of the study proved that there is no specific formal organization for the public health profession that the interviewees were aware of except for the united kingdom (uk faculty of public health or public health england), on the other they stressed the importance of such an organization for public health. it could help to ensure professional integration, increase advocacy and enhance the significance of public health within the political context to enable compliance with regulatory or legal requirements as well as issues related to salary, high quality study programmes, core mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 12 | 16 competencies and skills; consequently increasing the significance of public health degrees. moreover, a formal organization could promote public health and help to raise the awareness of the field within society thus building public trust and confidence. although the presented study is direction setting, there are limitations and it remains only exploratory. this is owing to a small sample size of the focus group and expert interviews although the focus group and the interviews were in-depth, providing rich descriptions and using more than one data source contributed to increasing the validity of the study (48). this study used two theoretical models often related to as “traits” theories. theorising of the professions, for many years, has been strongly shaped by twentieth century professional developments and societies. these approaches have highlighted universal ‘traits’ and functions of the professions (17, 49). however, the scholarly discussion on professionalization shows many different views concerning the professionalization process (49) and the “traits” approaches seem to be less adequate to describe contemporary processes of professionalization. more recently, the studies of professions have paid greater attention to the diversity of professional groups and to a wider range of factors that may promote successful professionalization. several authors have illustrated the benefits of a governance approach, as defined by who and others, and applied in cross-country comparison to health workforce research, thereby bringing health systems-based factors into view. for instance, cross-country comparative research shows that health systems vary in how they shape and target both organisations-based and professions-based reform strategies (7). the results of this study can be useful for educationalists, employers, accreditation agencies and public health schools to realise that putting public health into a clearer and more defined context will help to improve european public health systems and services and increase its importance and recognition as well as resources. conclusion the feeling of uncertainty and lack of trust as to whether public health is seen as a legitimate profession can be ameliorated by making public health more attractive. thereby, the interest in public health can be enhanced to convince the future workforce that it is a field with a secure future, worth studying, working and to staying in. public health professionals and organisations that govern best practices in this field should consider introducing a shared code of ethics and professional conduct as well as establishing a coordinated body to help advance the public status as a the profession to increase interest in studying and specializing in this area. acknowledgement we would like to thank the public health experts for their time and reflection on the issue of professionalization thus contributing to the interviews. the interviewees represented some aspher member schools and collaborating organisations such as who regional office for europe, ecdc, and aphea. furthermore, we would also like to thank the students of the bachelor and master of european public health from maastricht university for their very communicative and honest participation during the focus group. mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 13 | 16 appendix the directed content analysis of the focus group and the expert interviews, as well as the informed consents of the participants, can be delivered upon request. references 1. european commission. health workforce, brussels, belgium. available from: https://ec.europa.eu/health/workforce/overview_en (accessed: december 2, 2019). 2. rotem a, walters j, dewdney d. the public health workforce education and training study. aust j public health 1995;19:437-8. 3. martin-moreno jm, harris m, jakubowski e, kluge h. defining and assessing 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london: routledge; 2016:1-10. ________________________________________________________________________________ © 2020 mansholt; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited seasonal variations in emergency department visits of schizophrenic patients in sofia spasova z. seasonal variations of schizophrenic patients in emergency departments in sofia, bulgaria (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-07. 1 original research seasonal variations of schizophrenic patients in emergency departments in sofia, bulgaria zornitsa spasova1 1 department of health policy analysis, national center of public health and analysis. corresponding author: zornitsa spasova, national center of public health and analysis; address: 15 acad. ivan geshov blvd, sofia 1431, bulgaria; telephone: +35928056381; e-mail: z.spassova@ncpha.government.bg mailto:z.spassova@ncpha.government.bg spasova z. seasonal variations of schizophrenic patients in emergency departments in sofia, bulgaria (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-07. 2 abstract aim: the purpose of this study was to reveal the seasonal distribution of emergency department visits of schizophrenic patients in sofia, bulgaria. methods: we collected daily data for visits of patients with schizophrenia, schizotypal and delusional disorders in the emergency center of the regional dispenser for mental disorders in the city of sofia for the period 1998-2003. the total number of emergency visits was 5723 (mean daily visits: 5.04±2.4). t-test was used to compare the monthly and seasonal distribution of visits. results: the season with the highest levels of emergency visits was summer, and the lowest levels were observed in winter (p<0.0001). spring and autumn had intermediate values close to the mean value, and significantly differentiated from winter values. the month with the highest admission rates was september, followed by may and the three summer’s months. the lowest levels were observed in december, october and january, with statistically significant differences observed between the values of all the three months. differences between july values compared with december and october values were significant, but not with january values. conclusion: the study showed significant seasonal and monthly differences in emergency schizophrenics’ visits. the data confirm the outcome of similar studies conducted in countries with temperate climate in the northern hemisphere. these results could prove useful for psychiatrists, public health specialists, and governmental authorities dealing with team planning and prevention programs in the field of psychiatry. keywords: month, schizophrenia, season. spasova z. seasonal variations of schizophrenic patients in emergency departments in sofia, bulgaria (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-07. 3 introduction schizophrenia is a mental disorder characterized by enormous societal and economic costs due to the extensive therapeutic care and loss of economic productivity, as well as personal suffering and stigma which often affect the patient and his/her family for most of the patient’s life. as for schizophrenia patients, there is still no cure, the research of etiologic factors, particularly environmental ones that could be avoided and used in effective prevention programs, is essential (1). many studies have demonstrated evidence of seasonal patterns in the incidence of psychotic disorders, and schizophrenia in particular. it is known since the time of esquirol (1838) that the number of patients admitted in mental hospitals increases in summer months and decreases in winter (1). most of the studies for seasonal distribution of hospital admissions in schizophrenia also report summer peaks (2,3), some of these for female patients only (4). shiloh et al. (5) conducted research on admissions of schizophrenia and schizoaffective disorder patients to tel-aviv’s seven public psychiatric hospitals during 11 consecutive years. they found that the mean monthly admission rates are significantly higher during the summer (for schizophrenia patients) and fall (for schizoaffective patients). clarke et al. (6) studied first admissions for the diagnosis of schizophrenia, citing april and october as peak months. in a few publications (7-10), no significant difference between admissions in various seasons was observed. eastwood and stiasny (7) failed to replicate the summer peak in the admissions for schizophrenia in ontario, canada. partonen and lonnqvist (8), in a study of 295 schizophrenic patients, also reported no significant seasonal variation of admission with schizophrenia (cited by 9). de graaf et al. (11) did not find seasonal variations for schizophrenia. the authors concluded there are only limited seasonal variations in mental disorders in general population studies, at least in countries with a mild maritime climate. it is interesting that while most of the studies conducted in the northern hemisphere found summer peaks in hospital admissions for schizophrenia, results from three studies in the southern hemisphere show converse results – winter peaks (9,12,13). owеns and mcgorry (13) analyzed data for six years and found that only male cases of schizophrenia showed a significant seasonal distribution in the dates of onset of symptoms, with a peak in august. the other two studies: davies et al. (12) in first episode schizophrenia (strongly visible for the males, but the pattern for females also displayed annual periodicity) in queensland, australia and daniels et al. (9) in male patients with schizoaffective disorder in tasmania also showed austral winter peaks in admission data. while the problem of seasonal admissions of patients with schizophrenia has been widely discussed in western europe, america and australia, in eastern europe it has been neglected. in this region, we are only familiar with research conducted in poland by kotsur and gurski, where the authors confirmed the presence of seasonality in admission of schizophrenic patients (14). we are not aware of any published research on this subject in bulgaria, which makes the present study important as a contribution to the scientific literature on the problem in the country and in the south east europe (see) region. its findings could also raise the awareness of the problem of health care management for psychiatric patients in see countries besides bulgaria. the aim of the present research was to study the seasonal distribution of emergency department visits (not planned visits) of schizophrenic patients in the city of sofia, bulgaria (42°40' north latitude, 23°18' east longitude). methods we collected daily data for visits of patients with schizophrenia, schizotypal and delusional disorders (f20-f29, icd-10) in the emergency center of the regional dispenser for mental disorders in the city of sofia for the period 1 january 1998 – 30 june 2003. the total number of emergency visits of schizophrenic patients was 5723 (mean daily visits: x =5.04, σ=2.4). the total number of spasova z. seasonal variations of schizophrenic patients in emergency departments in sofia, bulgaria (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-07. 4 analyzed days was 1135 (data was missing for a part of the period). data was categorized by months and then by meteorological seasons – the winter season defined as december, january and february; the spring season as march, april and may; the summer season as the months of june, july and august; and the autumn (fall) season as the months of september, october and november. because of missing information for some of the days during the period, the mean daily (not monthly) values were calculated for the particular month and season, and then the values were compared by using t-test. mathematically, this method could be used by application of the following formula: 2 2 2 1 2 1 21 nn xx t σσ + − = where, 1x and 2x are the mean arithmetic values of the two samples, σ1 and σ2 are the dispersions of the two samples, and n1 and n2 are the numbers of the two samples. results obtained by t-test were compared with table values, which show the probability connected with the zero-hypothesis. for this purpose, the degrees of freedom are calculated using the following formula: 221 −+= nnk the calculated value of the degree of freedom was subsequently compared with the table critical value. if the t-test value is lower or equivalent to the critical value, then it is accepted that there are occasional differences between the two samples. if the t-test value is higher than the critical value it is accepted that the differences between the two samples are statistically significant, thus rejecting the zero-hypothesis. results the season with the highest levels of emergency visits was summer ( x =5.44) and the lowest levels were observed in winter ( x = 4.63) (figure 1), with statistically significant differences between these two seasons (t= 4.12*, p<0.0001) (table 1). spring and autumn had intermediate values close to the mean value (respectively, 5.15 and 5.02). spring and autumn values also significantly differentiated from winter values (t=2.78*, p=0.006 and t=2.07*, p=0.035, respectively) (figure 1). table 1. comparative analysis of the mean seasonal visits of schizophrenic patients in the emergency department of the regional dispenser for mental disorders in sofia, bulgaria, january 1998-june 2003 season winter spring summer autumn winter spring 2.78* summer 4.12* 1.36 autumn 2.07* 0.63 1.95 * the quotients marked with an asterisk are statistically significant (p<0.05). spasova z. seasonal variations of schizophrenic patients in emergency departments in sofia, bulgaria (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-07. 5 figure 1. seasonal patterns of admissions of schizophrenic patients in the emergency center of the regional dispanser for mental disorders in the city of sofia 4.63 5.15 5.44 5.02 4.2 4.4 4.6 4.8 5.0 5.2 5.4 5.6 winter spring summer autumn m ea n da ily a dm is si on n um be r the month with the highest admission levels was september ( x = 5.79), followed by may ( x = 5.63), and the summer months (august, june and july). the lowest levels were observed during the cold months: december ( x = 4.22), followed by october ( x = 4.58), and january ( x = 4.71) (figure 2). figure 2. monthly distribution of visits of schizophrenic patients in the emergency center of the regional dispenser in sofia 0 1 2 3 4 5 6 january february march april may june july august september october november december spasova z. seasonal variations of schizophrenic patients in emergency departments in sofia, bulgaria (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-07. 6 statistically significant differences were observed between the values of all the three months, with the highest levels compared with the three months with the lowest levels. differences between july values compared with december and october values were significant, but not with january values (table 2). table 2. comparative analysis of the mean monthly visits of patients with schizophrenia in the emergency department of the regional dispenser for mental disorders in sofia, bulgaria, january 1998 – june 2003 month jan feb march april may june july aug sept oct nov dec january february 1.07 march 0.61 0.35 april 0.78 0.29 0.09 may 2.76* 1.7 1.95 1.99* june 2.28* 1.22 1.5 1.51 0.47 july 1.86 0.78 1.06 1.05 0.97 0.5 august 2.51* 1.52 1.77 1.79 0.09 0.35 0.83 september 3.04* 2.03* 2.25* 2.3* 0.38 0.84 1.34 0.47 october 0.42 1.33 0.92 1.08 2.84* 2.41* 2.02* 2.62* 3.1* november 0.59 0.44 0.06 0.16 2.11* 1.64 1.19 1.91 2.41* 0.91 december 1.8 2.64* 2.11* 2.4* 4.1* 3.67* 3.35* 3.8* 4.3* 1.14 2.2* * the quotients marked with an asterisk are statistically significant (p<0.05). discussion the results obtained in this study confirm the presence of seasonality in the emergency visits of schizophrenic patients in sofia. our findings confirm many of the studies conducted in the northern hemisphere (summer peak) in countries with continental tempеrate climate (3,4,6). with respect to the factors responsible for the summer excess of admissions, myers and davies (15) have suggested a rise in ambient temperature; parker and walter (16), the increasing luminance; and carney et al. (17), the length of day. social factors, such as summer holidays, “are unlikely to have an effect” (4). some publications confirm a straight relationship between the ambient temperature and hospital admissions of patients with diagnosis schizophrenia. such a relationship was found by gupta and murray (18) and faust (19). hansen et al. investigated the effect of heat waves on mental health in australia (temperate climate) and found that hospital admissions were increased by 7.3% during heat waves. mortalities attributed to mental disorders also increased during heat waves in the age group of 65-74 years and in persons with schizophrenia (20). shiloh et al. (5) concluded that the mean rates of monthly admissions of patients with schizophrenia correlate with the maximum mean monthly environment temperature (r=0.35). they connect the admission rates with the higher summer temperatures, and conclude that “persistent high environmental temperature may be a contributing factor for psychotic exacerbation in schizophrenia patients and their consequent admission to mental hospitals”. in previous research (21) using the present data, we also found a positive straight relationship between mean ambient temperature and the emergency visits of schizophrenic patients in sofia. the analysis of the observed relationship is somehow complicated because of many uncertainties coming from the etiology of the mental disorders. from a physiological point of view, there are still not firm conclusions about the reasons for the outcome of these disorders in psychiatry, and spasova z. seasonal variations of schizophrenic patients in emergency departments in sofia, bulgaria (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-07. 7 many theories try to explain these uncertainties. yet, some conclusions could be made from a theoretical point of view and the literature review. since we have been interested in the effect of meteorological factors on the mental crises manifesting, comparatively most important is the theory connected with the fundamental physiological processes in the cerebral cortex – as we are interested in the changeable side of environmental factors influencing the damaged human psyche. first, the russian scientist pavlov developed on a theoretical level his hypothesis in relation to the concept of the so-called “patho-dynamical structures” (“sick point”). the patho-dynamical structure is characterized by a change in the ratio between the basic neural processes – excitement and suppression, which leads itself to the development of phase states. depending on the structures involved in the pathological process, the external manifestations of the disorders are different (22). with respect to schizophrenia, strategic guidance for the interpretation of the impact of the ambient temperature on the occurrence of mental crisis could be made by applying the theory of pavlov. according to him, the main emphasis should be placed on spilled retention, which covers the cortex and sometimes spread on the sub-cortex and brain stem departments, as well as the transition between wakefulness and sleep phases. the main reason for the increased retention of hemispheres in schizophrenia, the russian scientist sees, is the weakness of the nervous system, when multiple stimuli from the environment are super strong, causing over the limit detention. such detention in some departments of the brain can lead to release and positive induction of others, and ultimately to a distortion of the interaction of brain structures, such as the relationship between signaling systems, bark and under-bark (cited by 22). considering that the ambient temperature has a direct impact on the physiological processes in humans by thermo-receptors, it could be expected that its impact will play the role of these super strong as – pavlov calls them – stimuli. they act as stressors on the body – especially the nervous system – and consequently, in combination with other stimuli (predominantly of the social character), lead to disturbance of the balance and induce psychological crisis. conclusion our study shows significant seasonal and monthly differences in emergency visits of schizophrenia patients. the results confirm the outcome of many other studies conducted in countries with temperate climate in the northern hemisphere. results from this study could be useful for psychiatrists and medical staff working in emergency centers and mental health hospitals, public health specialists and governmental authorities dealing with team planning and prevention programs in the field of psychiatry. 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creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed/?term=singh%20gp%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=chavan%20bs%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=arun%20p%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=sidana%20a%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed?term=davies%20g%5bauthor%5d&cauthor=true&cauthor_uid=10728722 http://www.ncbi.nlm.nih.gov/pubmed?term=ahmad%20f%5bauthor%5d&cauthor=true&cauthor_uid=10728722 http://www.ncbi.nlm.nih.gov/pubmed?term=chant%20d%5bauthor%5d&cauthor=true&cauthor_uid=10728722 http://www.ncbi.nlm.nih.gov/pubmed/10728722## hoxha r, kosevska e, berisha m, ramadani n, jerliu n, zhjeqi v, gashi s. predictive factors for patient satisfaction in public and private hospitals in kosovo (original research). seejph 2019, posted: 08 october 2019. doi 10.4119/seejph-2362 page 1 of 9 original research predictive factors for patient satisfaction in public and private hospitals in kosovo rina hoxha1,2, elena kosevska3, merita berisha1,2, naser ramadani1,2, naim jerliu1,2, valbona zhjeqi1,2, sanije gashi1,2 1 national institute of public health of kosovo, prishtina, kosovo; 2 university of prishtina “hasan prishtina”, faculty of medicine, prishtina, kosovo; 3 institute of public health, faculty of medicine, skopje, republic of north macedonia. corresponding author: merita berisha, md, phd; address: national institute of public health of kosovo, nn. prishtina 10000, kosovo; telephone: +38344238136; e-mail: merita.berisha@uni-pr.edu abstract aim: the objective of this study was to assess predictive factors for patient satisfaction with healthcare services as a measure of the quality of hospital care in public and private hospitals in kosovo. methods: a cross-sectional study was conducted in kosovo during 2015-2016 including a representative sample of 2585 patients older than 18 years [1010 (48.6%) males and 1069 (51.4%) females from public hospitals; and 240 (47.4%) males and 266 (52.6%) females from private hospitals]. patient satisfaction dimensions such as satisfaction with medical care, nursing care, organization, and overall impression were the main variables measured. a riskadjusted multivariate analysis was applied. results: multiple linear regression analysis revealed as independent significant predictors of the total satisfaction of patients from public hospitals the following factors: age, length of stay in hospital in days, education, payment for additional analyzes during hospitalization and buying medications for hospital treatment. these five independent significant predictors accounted for 7.3% of the change in the total patients’ satisfaction (stepwise method r2 = 0.073). conversely, there were only four predictors of the total satisfaction of patients from private hospitals: length of stay in hospital in days, number of hospitalizations in the last 12 months, paying for hospitalization, and cost of hospitalization exceeds received services. only the variables “length of hospital stay” together with “cost of hospitalization exceeds received services” as independent predictors, explained 5.3% of the variability of total satisfaction. conclusion: structural and qualitative characteristics of hospitals have a significant impact on patients’ satisfaction. age, length of stay, education, payment for additional analyzes during hospitalization and the cost of hospitalization in public hospitals and length of stay, paying for hospitalization, and cost of hospitalization in private hospitals are useful predictors for total satisfaction of patients in kosovo. keywords: kosovo, predictors of patient satisfaction, public and private hospitals. mailto:merita.berisha@uni-pr.edu hoxha r, kosevska e, berisha m, ramadani n, jerliu n, zhjeqi v, gashi s. predictive factors for patient satisfaction in public and private hospitals in kosovo (original research). seejph 2019, posted: 08 october 2019. doi 10.4119/seejph-2362 page 2 of 9 introduction around the world, hospitals appear to gradually focus on their strategies of service quality. patient satisfaction is best understood as a multi-attribute model with completely different aspects of care decisive overall satisfaction. lower performance on an attribute creates much more dissatisfaction than the satisfaction generated by higher performance on another attribute, negative performance is more determinant in satisfaction than positive performance (1). patient satisfaction will offer valuable and distinctive insights into daily medical care and is widely accepted as a freelance dimension of quality of care as a result of an analysis of patient satisfaction includes “internal” (inward-looking) aspects of hospital care, which regularly stay unrecorded, like communica tion, fellow feeling or interaction (2,3-5). however, various studies and systematic reviews demonstrate a correlation between subjective patient perspective and clinical safety and effectiveness, and that they demonstrate that patient satisfaction reflects totally different dimensions of quality of care (3,6-12). thus, it comes as no surprise that the activity of patient satisfaction is usually used as a tool to enhance the quality of care (8,12). international studies additionally counsel that inprogress analysis and publication of patient surveys could complement public reportage on clinical outcomes and method quality to help patients in selecting a hospital and serve to enhance the standard of medical care on a long-run basis (7,8). research on health system satisfaction has known ways to boost health, scale back prices and implement reform (13). the lack of a solid abstract basis and an identical mensuration tool for client satisfaction has crystal rectifier over the past ten years to a proliferation of surveys that focus solely on patient expertise. i.e. aspects of the caring expertise like waiting time, quality of basic amenities, and communication with health care suppliers all facilitate tangible quality improvement priorities. according the idea of un agency, within the future measures of patient expertise, meant to capture the “responsiveness” of the health system (14), seemingly to receive even larger attention as physicians and hospitals return underneath growing pressure to enhance the standard of care, enhance patient safety and lower the value of services. health system responsiveness specifically refers to the manner and surroundings during which individuals are treated once seeking health care. hospitals have dominantly specialized in health care provision to fulfill, maintain and promote people's health desires of a community (15). within a study (16) has been found that private hospitals have higher name and image in the eyes of patients, and are far better than public ones in terms of service quality, giving importance to patients' satisfaction and physical look of the hospital buildings. several studies highlighted that the factors who influence patients’ satisfaction with attention services are classified into 2 broad categories: provider-related and patient-related (17,18). socioeconomic characteristics have impacted patients satisfaction. within the most systematic reviews (18) are found that providers’ ability, social skills and facility characteristics (e.g. physical surroundings, sort and level of the facility) were absolutely related to patients’ satisfaction. patient-related characteristics, for instance, gender, age, race, socioeconomic standing, health standing, and expectation were weak and inconsistent predictors of patients’ satisfaction. many studies additionally highlighted what proportion of patient’s hoxha r, kosevska e, berisha m, ramadani n, jerliu n, zhjeqi v, gashi s. predictive factors for patient satisfaction in public and private hospitals in kosovo (original research). seejph 2019, posted: 08 october 2019. doi 10.4119/seejph-2362 page 3 of 9 perceptions of care and actual aid experiences contribute to overall patients’ satisfaction level (17-19). the purpose of this study was to analyze the predictive factors for patient satisfaction in public and private hospitals in kosovo. methods a cross-sectional study was implemented for nine months in the period 2015-2016 in kosovo. the study sample consisted of 2585 patients randomly selected (i.e., the sample was representative of the population of kosovo for the level of significance of 95% and a confidence interval of ±5%). the main criteria for selecting patients were to be older than 18 years and to be hospitalized at the moment of study implementation. the study covered patients from all public and private hospitals in kosovo. after information related to study and confidentiality aspects, the participants were asked for oral consent. the ethical committee of niph kosovo approved the study. we used a standardized questionnaire (queensland, australia 2004) (20), translated into the albanian language and after piloting adapted to the national needs. a few questions were excluded and several other items were added to the final version of the study questionnaire. all six sections of the questionnaire covered 55 questions (first visit-5, before admission-3, admission-8, hospital stay-24, hospital environment -8 and discharged-7). possible answers were on a six-point likert scale (excellent, very good, good, fair, poor, and not sure), with lower scores corresponding to higher satisfaction. participants had the option to fulfill the questionnaire by themselves or to ask for assistance from the field researchers. statistical analysis data was statistically analyzed in spss software package, version 22.0 for windows (spss, chicago, il, usa). the qualitative series were processed by determining the coefficient of relations, proportions, and rates, and were shown as absolute and relative numbers. quantitative series were analyzed with measures of central tendency (average, median), as well as with dispersion measures (standard deviation, standard error). internal consistency on a set of questions was examined by cronbach’s аlpha. the mann-whitney u test was used to compare differences between two independent groups when the dependent variable was continuous, but not normally distributed. pearson’s chi-square test was used to determine the association between certain attributive dichotomies. a two-sided analysis with a significance level of p<0.05 was used to determine the statistical significance. results a total of 2585 hospitalized patients were involved in this study. reliability analysis for the items included exhibited a cronbach’s аlpha=0.872 (cronbach’s alpha based on standardized items: 0.874; n=55). there were 2079 patients from public hospitals: 1010 (48.58%) males and 1069 (51.42%) females; and 506 patients from private hospitals: 240 (47.43%) males and 266 (52.57%) females. no significant association was found between gender and the type of the hospital (pearson chisquare=0.6527; df=1; p=0.4191). mean age of public patients was 44.67±16.49 with median iqr=45 (30-56), and of private patients it was 42.71±15.76 with median iqr=42 (29-54), with significant differences in mean age between the two groups (mann-whitney u test: z=2.516; p=0.0119), implying a significantly lower age of patients from private hospitals. from rural areas, there were 995 (47.45%) of public hospital patients and 158 (31.11%) of private hospital patients, with two times significantly more patients from rural areas in public hospitals compared to private ones hoxha r, kosevska e, berisha m, ramadani n, jerliu n, zhjeqi v, gashi s. predictive factors for patient satisfaction in public and private hospitals in kosovo (original research). seejph 2019, posted: 08 october 2019. doi 10.4119/seejph-2362 page 4 of 9 [or=2.001 (1.63 – 2.46) 99% ci]. public and private hospital patients with high education were 497 (24.13%) vs. 206 (40.79%); with college degree there were 565 (27.43%) vs. 31 (6.14%); with elementary school there were 495 (24.03%) vs. 31 (6.14%); and with no education there were 81 (3.93%) vs. 6 (1.19%). there was a significant difference between patients from public and private hospitals in terms of individual overall satisfaction for each of the analyzed aspects (first visit, acceptance, stay, physical environment and output) with significantly greater satisfaction of patients from private hospitals. among the public hospital patients, for p<0.05, significant differences in the total satisfaction score were found related to reason for admission, number of hospitalizations in the last 12 months, education, payment for additional analysis while in hospital, cost of hospitalization exceeds received services, buying medication for hospital treatment, age, and length of hospital stay (enter method r2=0.076) (table 1). with multiple linear regression analysis (table 2), as independent significant predictors of the total satisfaction of patients from public hospitals, there were confirmed five factors: age, length of stay in hospital in days, education, payment for additional analyzes during hospitalization and buying medications for hospital treatment. these five independent significant predictors explained 7.3% of the changes in the total patients’ satisfaction (stepwise method r2 = 0.073). only the variables “pay for additional analysis during hospitalization”, together with “buying medications for hospital treatment”, as independent predictors, explained 4.1% of the variability of total satisfaction. table 1. binary linear regression total satisfaction score related to selected parameters parameters satisfaction score (public) satisfaction score (private) mean sd p mean sd p reason for admission surgical 2.358584 0.524215 kruskal-wallis test: h=18.451 p=0.0004** 1.528748 0.429106 kruskal-wallis test: h=50.001 p=0.0001** medical 2.325146 0.545558 1.921032 0.399125 maternity 2.507780 0.729963 1.669437 0.515809 emergency 2.253506 0.543969 1.686018 0.208065 transferred from another hospital yes 1.632222 0.200030 mann-whitney u test: z=-0.886 p=0.375 1.377778 0.452155 mann-whitney u test: z=-0.979 p=0.327 no 1.648361 0.469240 1.529697 0.521974 number of hospitalizations in the last 12 months one 2.310388 0.570299 kruskal-wallis test: h=10.658 p=0.005** 1.607373 0.438166 kruskal-wallis test: h=30.869 p=0.0001** two 2.413505 0.513785 1.841548 0.425020 ≥ three 2.337081 0.649830 1.481222 0.522291 gender male 2.338796 0.515792 mann-whitney u test: z=-0.174 p=0.862 1.602579 0.353156 mann-whitney u test: z=-1.039 p=0.298 female 2.347288 0.609724 1.686032 0.524438 place of living urban 2.359672 0.569754 mann-whitney u test: z=0.385 p=0.862 1.654048 0.424239 mann-whitney u test: z=1.523 p=0.128 rural 2.327131 0.557364 1.630998 0.516661 level of education hoxha r, kosevska e, berisha m, ramadani n, jerliu n, zhjeqi v, gashi s. predictive factors for patient satisfaction in public and private hospitals in kosovo (original research). seejph 2019, posted: 08 october 2019. doi 10.4119/seejph-2362 page 5 of 9 no education 2.179574 0.798358 kruskal-wallis test: h=21.758 p=0.0006** 1.318492 0.343095 kruskal-wallis test: h=46.714 p=0.0001** partly elementary 2.206693 0.634021 1.365179 0.215593 elementary 2.354832 0.577412 1.914056 0.480274 secondary 2.302739 0.565943 1.556413 0.423172 college 2.395024 0.526674 1.832815 0.410434 high 2.399455 0.511615 1.571029 0.456809 paying for hospitalization yes 2.347518 0.591523 mann-whitney u test: z=0.901 p=0.368 1.561964 0.398229 mann-whitney u test: z=-8.561 p=0.0001** no 2.339965 0.539951 2.169494 0.426998 paying for additional analysis while in hospital yes 2.428653 0.546035 mann-whitney u test: z=7.734 p=0.0001** 1.819382 0.591600 mann-whitney u test: z=-2.777 p=0.005** no 2.180322 0.563681 1.588795 0.380680 paid price for hospitalization is more than received services yes 2.458014 0.556340 kruskal-wallis test: h=49.759 p=0.0001** 1.650059 0.409010 kruskal-wallis test: h=2.956 p=0.228 no 2.229283 0.539610 1.602356 0.427372 don’t know 2.416133 0.575153 1.683548 0.557070 buying medication for hospital treatment yes 2.391366 0.567563 mann-whitney u test: z=-5.336 p=0.0001** 1.406746 0.331941 mann-whitney u test: z=1.081 p=0.279 no 2.169203 0.516799 1.651445 0.454457 cost of hospitalization exceeds received services yes 2.401185 0.551062 kruskal-wallis test: h=3.265 p=0.195 1.567328 0.371254 kruskal-wallis test: h=11.495 p=0.003** no 2.321112 0.525140 1.804324 0.619753 don’t know 2.341440 0.608008 1.741223 0.471197 length of hospital stay days spearman rank order correlation: r=-0.127* spearman rank order correlation: r=0.118* age years spearman rank order correlation: r=-0.147* spearman rank order correlation: r=0.037 * significant for p<0.05. ** significant for p<0.01. among the private hospital patients, for p<0.05, significant differences in total satisfaction score were found related to reason for admission, number of hospitalizations in the last 12 months, education, paying for hospitalization, payment for additional analysis while in hospital, cost of hospitalization exceeds received services, and length of hospital stay (table 1) (enter method r2=0.073) (table 2). hoxha r, kosevska e, berisha m, ramadani n, jerliu n, zhjeqi v, gashi s. predictive factors for patient satisfaction in public and private hospitals in kosovo (original research). seejph 2019, posted: 08 october 2019. doi 10.4119/seejph-2362 page 6 of 9 table 2. multiple linear regression – independent predictors for total satisfaction in public hospitals independent variable non-standardized coefficient standardized coefficient t sig. 95% ci for b b std. error beta upper level lower level (constant) 2.635 .119 22.087 .000 2.401 2.869 reason for admission (.012) .019 (.019) (.628) .530 (.048) .025 hospitalizations in the last 12 months .029 .024 .037 1.227 .220 (.017) .076 age .015 .003 .132 4.377 .000 .008 .022 length of hospital stay (.004) .001 (.100) (3.219) .001 (.006) (.001) level of education .035 .012 .087 2.868 .004 .011 .058 payment for additional analyzes (.156) .037 (.132) (4.251) .000 (.229) (.084) cost of hospitalization exceeds received services .022 .022 .029 .961 .337 (.023) .066 buying medication for hospital treatment (.191) .043 (.137) (4.476) .000 (.274) (.107) r=0.275 r2=0.076 f=11.362 p=0.0001 dependent variable=satisfaction score table 3. multiple linear regression – independent predictors for total satisfaction in private hospitals independent variable non-standardized coefficient standardized coefficient t sig. 95% ci for b b std. error beta upper level lower level (constant) 1.953 .107 18.272 .000 1.743 2.163 reason for admission .021 .018 .033 1.167 .243 (.014) .057 hospitalizations in the last 12 months .063 .026 .070 2.445 .015 .012 .113 length of hospital stay .021 .004 .150 5.367 .000 .013 .028 level of education (.010) .012 (.023) (.833) .405 (.034) .014 paying for hospitalisation .144 .039 .104 3.662 .000 .067 .221 payment for additional analyzes .011 .026 .012 .440 .660 (.039) .062 cost of hospitalization exceeds received services (.200) .029 (.191) (6.807) .000 (.257) (.142) r=0.269 r2=0.073 f=13.797 p=0.0001 dependent variable=satisfaction score. hoxha r, kosevska e, berisha m, ramadani n, jerliu n, zhjeqi v, gashi s. predictive factors for patient satisfaction in public and private hospitals in kosovo (original research). seejph 2019, posted: 08 october 2019. doi 10.4119/seejph-2362 page 7 of 9 with multiple linear regression analysis (table 3), as independent significant predictors of the total satisfaction of patients from private hospitals, there were confirmed only four factors: length of stay in hospital in days, number of hospitalizations in the last 12 months, paying for hospitalization, and cost of hospitalization exceeds received services. these four independent significant predictors accounted for 7.1% of the changes in total patient satisfaction (stepwise method r2 = 0.071). only the variables “length of hospital stay” together with “cost of hospitalization exceeds received services”, as independent predictors, explained 5.3% of the variability of total satisfaction. discussion this study has clearly demonstrated that there is a significant difference between patients from public and private hospitals in terms of individual overall satisfaction for each of the analyzed aspects (first visit, acceptance, stay, physical environment and output) with significantly greater satisfaction of patients from private hospitals. this finding is quite comparable to other studies (19,21,22). in this study, it is evident that age is a predictor factor, by increase of age, patients' satisfaction increases too regarding quality of health care, similar to other studies, older patients tended to have higher satisfaction scores (23-26). whereas for education as predictor factor, correlation is negative, with increase of education level, patient satisfaction decreases, similar to other studies (23). the findings from our study show that the length of stay in the hospital could determine significantly the overall patient satisfaction, similar to study conducted in japan (27). the longer the length of stay in the hospital generates lower patient satisfaction on specific domains such as comfort, visiting, and cleanliness, which seemed logical, as in other studies (28). an inverse correlation between inpatient satisfaction and length of stay was seen in other studies (29). as independent significant predictors of the total satisfaction of patients from public hospitals, we confirmed only five: payment for additional analyzes during hospitalization and buying medications for hospital treatment. main predictors in private hospitals are payment for hospitalization, and cost of hospitalization. predictors of the total satisfaction of patients from private hospitals, we confirmed only four: length of stay in hospital in days, number of hospitalizations in the last 12 months, paying for hospitalization, and cost of hospitalization exceeds received services. in the case of private physicians, the performance fell short of expectations, thus generating dissatisfaction (30). in conclusion, the structural and qualitative characteristics of hospitals have a significant impact on patient satisfaction. age, length of stay, education, payment for additional analyzes during hospitalization and the cost of hospitalization in public hospitals and length of stay, paying for hospitalization, and cost of hospitalization in private hospitals are predictor factors for total satisfaction of patients. conflicts of interest: none. hoxha r, kosevska e, berisha m, ramadani n, jerliu n, zhjeqi v, gashi s. predictive factors for patient satisfaction in public and private hospitals in kosovo (original research). seejph 2019, 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providers and systems survey responses. j arthroplasty 2019;34:824-33. doi: 10.1016/j.arth.2019.01.008. 30. naidu a. factors affecting patient satisfaction and healthcare quality. int j health care qual assur 2009;22:36681. doi: 10.1108/09526860910964834. ___________________________________________________________ © 2019 hoxha et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.pc.gov.au/research/supporting/patient-satisfaction/patientsatisfaction.pdf https://www.pc.gov.au/research/supporting/patient-satisfaction/patientsatisfaction.pdf https://www.pc.gov.au/research/supporting/patient-satisfaction/patientsatisfaction.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4565136/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4565136/ https://dx.doi.org/10.4102%2fphcfm.v4i1.384 https://www.ncbi.nlm.nih.gov/pubmed/?term=vovos%20tj%5bauthor%5d&cauthor=true&cauthor_uid=30777630 https://www.ncbi.nlm.nih.gov/pubmed/?term=ryan%20sp%5bauthor%5d&cauthor=true&cauthor_uid=30777630 https://www.ncbi.nlm.nih.gov/pubmed/?term=hong%20cs%5bauthor%5d&cauthor=true&cauthor_uid=30777630 https://www.ncbi.nlm.nih.gov/pubmed/?term=howell%20cb%5bauthor%5d&cauthor=true&cauthor_uid=30777630 https://www.ncbi.nlm.nih.gov/pubmed/?term=howell%20cb%5bauthor%5d&cauthor=true&cauthor_uid=30777630 https://www.ncbi.nlm.nih.gov/pubmed/?term=risoli%20tj%20jr%5bauthor%5d&cauthor=true&cauthor_uid=30777630 https://www.ncbi.nlm.nih.gov/pubmed/?term=attarian%20de%5bauthor%5d&cauthor=true&cauthor_uid=30777630 https://www.ncbi.nlm.nih.gov/pubmed/?term=seyler%20tm%5bauthor%5d&cauthor=true&cauthor_uid=30777630 https://www.ncbi.nlm.nih.gov/pubmed/30777630 https://www.ncbi.nlm.nih.gov/pubmed/30777630 public health in kosovo: five difficult years after independence jerliu n, ramadani n, mone i, brand h. public health in kosovo after five difficult years of independence (review article). seejph 2013, posted: 31 october 2013. doi 10.12908/seejph2013-02. 1 review article public health in kosovo after five difficult years of independence naim jerliu1,2, naser ramadani2, iris mone3, helmut brand1 1 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, the netherlands; 2 national institute of public health, prishtina, kosovo; 3 faculty of medicine, tirana medical university, tirana, albania. corresponding author: naim jerliu, md, mph national institute of public health, prishtina, kosovo; telephone: +38138550585; e-mail: naim.jerliu@maastrichtuniversity.nl jerliu n, ramadani n, mone i, brand h. public health in kosovo after five difficult years of independence (review article). seejph 2013, posted: 31 october 2013. doi 10.12908/seejph2013-02. 2 abstract kosovo is undergoing a rapid process of transformation to an independent state, which was formally proclaimed in 2008, after almost a decade under united nations administration. regarding the health status, five years after independence, compared with other european countries, post-war transitional kosovo is still characterized by higher mortality rates including traditional public health problems pertinent to infant mortality and maternal deaths. in parallel, however, kosovo is undergoing a rapid process of epidemiological transition characterized by an aging trend which is inevitably coupled with high cardiovascular and cancer mortality and morbidity along with an excess mortality in external causes of death and injuries among the adult population. adoption of the new health law in december 2012 by the kosovo assembly aims the transition from centralized health care system established under emergency conditions of the post-war period towards a contemporary modern health care system with a clear purchaser-provider split based on a high transparency and accountability of the health care providers and their contractors. the health care reform, leading eventually to significant changes within the health sector in kosovo, consists of two main pillars: (i) structural and functional reorganization of the health care system through establishment of kosovo health service (an autonomous and non-for-profit public enterprise at central level of the health care sector), and; (ii) establishment for the first time of the public health insurance system with a health insurance fund as its main body. nevertheless, five years after declaration of independence, kosovo, the newest state in europe consisting of the youngest population, is currently facing a particularly difficult socioeconomic and political transition and is additionally struggling and mainstreaming all energies and efforts in order to get full international recognition. keywords: independence, kosovo, public health, transitional countries, western balkans. jerliu n, ramadani n, mone i, brand h. public health in kosovo after five difficult years of independence (review article). seejph 2013, posted: 31 october 2013. doi 10.12908/seejph2013-02. 3 introduction after the war and the liberation from the serbian regime in 1999 and almost a decade under united nations administration, kosovo is undergoing a rapid process of transformation to an independent state, which was formally proclaimed in 2008. kosovo, currently recognized by 105 countries (but not yet a member of the world health organization), is the newest country in europe. notwithstanding the fact that kosovo is not an european union (eu) member state, this new country is nevertheless at a very early stage on its way to eu integration and has to cope already with the eu standards and policy reforms in both social and health care sectors. demographic and socioeconomic indicators kosovo consists of the youngest european population, with an average age of about 27 years (50% of the population is under 25 years) (table 1). notwithstanding its young population, kosovo is inevitably affected by the global aging trend characterized by a substantial reduction of population increase from 27% in 1981 to 9% in 2007 (1). this is reflected in a steady increase in the proportion of older people over the years. thus, official data indicate that from 2003 to 2009 the proportion of people aged ≤15 years decreased by five percent (from 33% to 28%), along with an increase (albeit less evident) in the proportion of individuals aged ≥65 years from 4.5 % (in 1981) to 6.7% (in 2011) (table 1). the ageing trend could be attributed to the lowering levels of fertility rates, a higher life-expectancy and emigration of workingage adults (2). according to a recent world bank report, kosovo is among the poorest countries in europe, with 34% of the population living below the national poverty line and 12% living in extreme poverty (3). furthermore, poverty in kosovo may be of particular concern for the older segments of the population as suggested from a recent report of the international labour organization (1). as a matter of fact, a fairly recent population-based study involving a large sample of older people (individuals aged ≥65 years), reported a high level of self-perceived poverty, especially among older women (52% vs. 41% in men) (4). another remarkable finding from this populationbased study of older men and women in kosovo was the low educational attainment, especially among women (4). thus, about 48% of the women had no formal education at all compared to 17% of men (4). in addition, in multivariable-adjusted analyses controlling simultaneously for all the demographic and socioeconomic characteristics, self-perceived poverty rates were higher among older women, the loweducated individuals, urban residents, and older people living alone (4). health profile life expectancy in kosovo was 67 years for males and 71 years for females in 2008 (2), whereas in 2011 the overall life expectancy was 70.0 years (table 1). currently, life expectancy in post-war kosovo is considerably lower than in the eu member states for both males and females (figure 1) (5). notwithstanding the higher infant mortality rate (17.1 per 100 live births in 2011 – table 1), the higher child mortality rate, as well as the higher maternal mortality rate (7.2 per 100.000 in 2011 – table 1), the excess mortality in kosovo is also due to the higher death rates from injuries and other external causes of death and, to a lesser jerliu n, ramadani n, mone i, brand h. public health in kosovo after five difficult years of independence (review article). seejph 2013, posted: 31 october 2013. doi 10.12908/seejph2013-02. 4 degree, from cardiovascular diseases and cancer (table 1). on the other hand, stroke mortality constitutes an exception: notwithstanding the absence of official reports, death rate from stroke in kosovo is considerably higher than in the eu member states – a situation which is similar to many countries in the western balkans. table 1. selected socioeconomic and health indicators in kosovo indicator year estimate source life expectancy at birth 2011 70.0 years kosovo human development report 2012. average age of the population 2012 27.1 years cia, world fact-book. population aged ≥65 years 2011 6.7% kosovo population and housing census 2011. percentage of urban population 2011 38.0% kosovo population and housing census 2011. gdp per capita 2012 2650 euro agency of statistics, kosovo, 2012. human development index 2011 0.713 kosovo human development report 2012. percentage of poor 2009 34.0% world bank, 2011. percentage of extremely poor 2009 12.0% world bank, 2011. illiteracy rate (population aged ≥10 years) 2011 3.85% kosovo population and housing census 2011. infant mortality rate (per 1000 live births) 2011 17.1 ministry of health, kosovo, 2012. maternal mortality rate (per 100.000) 2011 7.2 ministry of health, kosovo, 2012. cvd mortality rate (per 100.000 population) 2011 157.0 agency of statistics, kosovo, 2012. cancer mortality rate (per 100.000 population) 2011 34.2 agency of statistics, kosovo, 2012. infectious diseases mortality rate (per 100.000 population) 2011 1.36 agency of statistics, kosovo, 2012. external causes of death (per 100.000 population) 2011 7.7 agency of statistics, kosovo, 2012. proportional mortality from cvd 2011 59.3% agency of statistics, kosovo, 2012. proportional mortality from cancer 2011 15.0% agency of statistics, kosovo, 2012. proportional mortality from infectious diseases 2011 0.55% agency of statistics, kosovo, 2012. no. physicians per 100.000 population 2011 146 institute of public health, kosovo, 2011. no. nurses per 100.000 population 2011 412 institute of public health, kosovo, 2011. no. health visits per person per year 2010 2.8 world bank, 2010. public spending on health (in % of gdp) 2009 2.3 ministry of health, kosovo, 2010. public spending on health (in % of total government expenditure) 2009 7.6 ministry of health, kosovo, 2010. percentage of smokers in the population 1564 years 2011 28.4 % niph survey, kosovo, 2011. alcohol consumption 2011 25.0% espad, kosovo, 2011. as of a recent study involving a population-representative sample of older individuals in kosovo (n=1890), 83% of the elderly people reported at least one chronic condition (63% cardiovascular diseases), and 45% had at least two chronic diseases (6). in multivariable-adjusted analyses, factors associated with the presence of chronic conditions and/or multimorbidity were female sex, older age, self-perceived poverty and the inability to access medical care (6). hence, limited access to medical care was a significant and consistent predictor of chronic morbidity and chronic multimorbidity among older people in kosovo (6). the overwhelming majority of kosovo older jerliu n, ramadani n, mone i, brand h. public health in kosovo after five difficult years of independence (review article). seejph 2013, posted: 31 october 2013. doi 10.12908/seejph2013-02. 5 individuals who couldn’t access medical care (almost 90%) indicated the economic barriers as the main reason for this. the unfavorable health outcomes in the adult population including older people is noticeably a reflection of the difficult socioeconomic situation in kosovo vis-à-vis the ongoing reforms in the health sector (7). figure 1. life expectancy in kosovo vis-à-vis the european union in 2011 and in 2007 (just before the independence) lifestyle factors in kosovo, age and lifestyle related non-communicable diseases are increasing, especially cancer, cardiovascular diseases and diabetes (6) – diseases which are commonly related to a high consumption of tobacco, alcohol, and saturated fat. the prevalence of smoking in kosovo (overall: 28.4%, table 1) is lower than in the other countries of the western balkans including the neighboring albania (8). similarly, excessive alcohol consumption and binge drinking are considerably lower than in albania, reflecting a higher degree of traditionalism and religious observance in kosovo. on the other hand, unhealthy dietary habits including low intake of fresh fruits and vegetables are considered to be more prevalent in the kosovo population compared with the somehow mediterranean diet of albania. along with the unhealthy dietary patterns and the low levels of physical activity, unfavorable socioeconomic and psychosocial conditions are considered as the main drivers of the excess morbidity and mortality from chronic diseases in kosovo including diabetes, cardiovascular diseases and other chronic conditions. nevertheless, in kosovo, which is characterized by a traditional society, changes in lifestyle/behavioral patterns may have differentially affected different segments of the population, particularly the vulnerable and the marginalized individuals who suffer enormously the consequences of the rapid transition and are unable to cope with the dramatic changes (4,9). health care reforms jerliu n, ramadani n, mone i, brand h. public health in kosovo after five difficult years of independence (review article). seejph 2013, posted: 31 october 2013. doi 10.12908/seejph2013-02. 6 the analysis provided in the health sector strategy (hss) of the ministry of health indicates that the republic of kosovo has a network of health institutions staffed with committed health professionals, who provide regional comparable basic health care services including also a high immunization coverage. the hss, but also more recent analyses, highlights that kosovo, as one of the poorest countries in europe, needs to tackle a number of fundamental challenges before the health sector becomes a comprehensive system of preventive, diagnostic and treatment services attuned to the needs of the population and supporting the citizens in obtaining a health status comparable to the eu populations (10). with the youngest population in europe, kosovo’s health care system needs to respond to a high demand for reproductive health and family planning services. although infant mortality has fallen since 2000, the current level is high and places kosovo at the very bottom compared to the eu member states. furthermore, the existing high rate of maternal deaths points to the need and the requirements for establishing a system of services able to support all women (and men) with family planning, quality antenatal care and to ensure that hospitals, both at secondary and tertiary level, are prepared to assist in the case of complications (10). therefore, the current action plan of the ministry of health gives special attention to improving mother and child health to a european union comparable level, and hereby to achieve the millennium development goals (10). in kosovo, basic diagnostics and treatment services are currently provided by the public health care system and yet, comprehensive tertiary care services such as oncology and cardio-surgery are not fully available. therefore, the action plan of the ministry of health focuses on improving these services. further, the action plan addresses the development of preventive measures with a significant impact on the incidence and the survival rates of these diseases (10). conversely, kosovo is in urgent need of deep reforms as the armed conflict left the country with a very inefficient health system characterized by a lack of trained personnel, disparities in health force distribution leading to variations in access to primary care, corruption and informal payments, as well as deteriorated child and adult health indicators. in this context, the continuous reforming of the health sector has brought up a complex configuration of the stakeholders operating in the health system. under these conditions, little attention is paid to the growing community of vulnerable and marginalized individuals in kosovo which, combined with the inadequacy of financial resources, the economic insecurity and the unclear and unstable development of the health sector, pose a serious barrier for these population subgroups to access medical care (4,6). the inability of certain disadvantaged segments of the population to adapt to the new political and economic system inevitably leads to change in the position of individuals in the society, enhanced social mobility and increased inequalities, with some groups thriving and others falling behind, as it was previously demonstrated in the adult population of the neighboring albania (9). health care financing adoption of the new health law in december 2012 by the kosovo assembly aims the transition from a centralized health care system established under emergency conditions of the post-war period towards a contemporary modern health care system jerliu n, ramadani n, mone i, brand h. public health in kosovo after five difficult years of independence (review article). seejph 2013, posted: 31 october 2013. doi 10.12908/seejph2013-02. 7 with a clear purchaser-provider split based on a high transparency and accountability of the health care providers and their contractors. the main objective is a steady improvement of the quality of healthcare of the population in kosovo. this reform, leading eventually to significant changes within the health sector in kosovo, consists of two main pillars: (i) structural and functional reorganization of the health care system through establishment of kosovo health service (an autonomous and non-for-profit public enterprise at central level of the health care sector), and; (ii) establishment of the public health insurance system with the health insurance fund as its main body. in any case, the basic principles of the current health care reform in kosovo include the following principles: universal coverage, equity, transparency, sustainability, equity, accountability, inclusiveness, solidarity, reciprocity and participation. structural and functional reorganization of the overall health care system represents a rather challenging and complex process that includes a simultaneous process of purchaser-provider split through internal reorganization of the system. as a first step, the ministry of health is planning to establish the health financing agency (which, by law, represents the precursor of the health insurance fund) and further establishment of a contemporary system of service delivery. this step, in turn, foresees the establishment and proper functioning of the university clinical and hospital service of kosovo as a unique and integrated healthcare institution at the secondary and tertiary level, closely coordinated with healthcare institutions in the primary healthcare level through a system of performance-based payments from the health financing agency. in any case, the main step of the reform will consist of adoption of the already elaborated draft on health insurance law in the government of kosovo and establishment for the first time of the public health insurance system with the health insurance fund as its main body. the main objective of the health insurance law is to ensure optimal and sustainable healthcare financing. conclusion kosovo is undergoing a rapid transition involving major political, social and economic changes which are associated with deleterious health effects in the adult population, particularly among older people. nonetheless, current evidence about the exact magnitude of both acute and chronic morbidity and distribution of risk factors in the population of kosovo is scarce due to limited vigorous research work aiming at exploring the health effects of transition and the variations in health outcomes of the adult population. from this point of view, similar to the other countries in the western balkans region, there is an obvious need to promote research funding and especially to develop and strengthen research capacities in kosovo. in conclusion, five years after the declaration of independence, kosovo is currently facing a particularly difficult socioeconomic and political transition and is additionally struggling and mainstreaming all energies and efforts in order to get full international recognition. references 1. international labour organization. profile of the social security system in kosovo (within the meaning of unsc resolution 1244 [1999]). 2010. jerliu n, ramadani n, mone i, brand h. public health in kosovo after five difficult years of independence (review article). seejph 2013, posted: 31 october 2013. doi 10.12908/seejph2013-02. 8 available from: http://www.ilo.org/wcmsp5/groups/public/---europe/---rogeneva/---sro-budapest/documents/publication/wcms_168770.pdf (accessed: october 05, 2013). 2. statistical office of kosovo. demographic, social and reproductive health survey in kosovo, november 2009. pristina, kosovo; 2011. 3. the world bank. europe and central asia region. poverty reduction and economic management unit. statistical office of kosovo. consumption poverty in the republic of kosovo, in 2009. western balkans programmatic poverty assessment. 2011. 4. jerliu n, toçi e, burazeri g, ramadani n, brand h. socioeconomic conditions of elderly people in kosovo: a cross-sectional study. bmc public health 2012;12:512. 5. world health organization, regional office for europe. european health for all database. copenhagen, denmark, 2013. 6. jerliu n, toçi e, burazeri g, ramadani n, brand h. prevalence and socioeconomic correlates of chronic morbidity among elderly people in kosovo: a population-based survey. bmc geriatr 2013;13:22. 7. percival v, sondorp e. a case study of health sector reform in kosovo. conflict and health 2010;4:7. 8. institute of statistics, institute of public health [albania] and ifc macro. albania demographic and health survey 2008-09. tirana, albania, 2010. 9. burazeri g, goda a, sulo g, stefa j, roshi e, kark jd. conventional risk factors and acute coronary syndrome during a period of socioeconomic transition: population-based case-control study in tirana, albania. croat med j 2007;48:225-33. 10. ministry of health, kosovo. action plan 2011-2014. pristina, kosovo, 2011. ___________________________________________________________ © 2013 jerliu et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed?term=jerliu%20n%5bauthor%5d&cauthor=true&cauthor_uid=22776197 http://www.ncbi.nlm.nih.gov/pubmed?term=to%c3%a7i%20e%5bauthor%5d&cauthor=true&cauthor_uid=22776197 http://www.ncbi.nlm.nih.gov/pubmed?term=burazeri%20g%5bauthor%5d&cauthor=true&cauthor_uid=22776197 http://www.ncbi.nlm.nih.gov/pubmed?term=ramadani%20n%5bauthor%5d&cauthor=true&cauthor_uid=22776197 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http://www.ncbi.nlm.nih.gov/pubmed?term=sulo%20g%5bauthor%5d&cauthor=true&cauthor_uid=17436387 http://www.ncbi.nlm.nih.gov/pubmed?term=stefa%20j%5bauthor%5d&cauthor=true&cauthor_uid=17436387 http://www.ncbi.nlm.nih.gov/pubmed?term=roshi%20e%5bauthor%5d&cauthor=true&cauthor_uid=17436387 http://www.ncbi.nlm.nih.gov/pubmed?term=kark%20jd%5bauthor%5d&cauthor=true&cauthor_uid=17436387 http://www.ncbi.nlm.nih.gov/pubmed/17436387 http://www.ncbi.nlm.nih.gov/pubmed/17436387 kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-135 1 short report protecting the planet and sustainable development laura h. kahn1 1program on science and global security, woodrow wilson school of public and international affairs, princeton university, new jersey, usa. corresponding author: laura h. kahn, md, mph, mpp, woodrow wilson school of public and international affairs, princeton university; address: 221 nassau street, 2nd floor, princeton, new jersey 08542, usa; telephone: 609 258 6763; email: lkahn@princeton.edu mailto:lkahn@princeton.edu� kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-135 2 abstract the united nations has made a commitment for sustainable development. an important component of this is a healthy environment. but what exactly is a healthy environment? environmental health specialists typically focus on occupational exposures in workers; the field mainly addresses the abiotic (i.e. non-living) aspects of environments. ecosystem health addresses biotic (i.e. living) aspects of environments. merging these two realms is essential for sustainable development but will be challenging because the fields are so different. the united nations, individual countries, and schools of public health could do much to help merge these realms by implementing environmental/ecosystem health into their missions and curriculums. keywords: ecosystem, healthy environment, planet, sustainable development. conflicts of interest: none. kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-135 3 expanding the definition of environmental health the definition of environmental health must be expanded. the twenty-first century presents many challenges to global health. a growing human population, estimated to reach approximately 9 billion by 2050 if estimated growth rates continue, will require food, water, and other natural resources to survive. meeting humanity’s demands for natural resources threatens the environment including worsening deforestation, land degradation and contamination, water contamination, diminishing biodiversity, and spreading vector-borne and other zoonotic diseases. a warming climate with extreme weather conditions including drought and floods threatens agriculture and food security, the foundation of civilization. in the midst of all of these developments, a healthy environment seems almost impossible. but, the need for a healthy environment is imperative for life to continue, and the need to educate the next generation on the importance of sustainable development in a habitable world is essential (1,2). the question is:“what exactly is a healthy environment and how should it be defined?” the national environmental health association (neha) defines environmental health as “the science and practice of preventing human injury and illness and promoting well-being by identifying and evaluating environmental sources and hazardous agents and limiting exposures to hazardous physical, chemical, and biological agents in air, water, soil, food and other environmental media or settings that may adversely affect human health”(3). this definition focuses primarily on the hazards that affect humans. from a one health perspective, however, it leaves out animals and the environment, itself. one health is the concept that human, animal, and environmental health are linked, and because they are linked, complex subjects such as emerging diseases, food safety and security, antimicrobial resistance, and waterborne illnesses must be examined and addressed in an interdisciplinary, holistic way. the term is relatively new, but the concept is ancient. nevertheless, environmental health has been difficult to integrate into one health for a variety of reasons. first, those who work on environmental health, such as occupational and environmental physicians, nurses, and environmental health specialists, focus their work primarily on abiotic (i.e. non-living) contaminants, pesticides, and toxic waste exposures in occupational settings that affect workers. while this is extremely important, it is not the only aspect of what constitutes a healthy environment. ecosystem health focuses on the biotic (i.e. living) components of an environment and their interactions. many scientists and other professionals from a variety of academic disciplines work on ecosystem health such as wildlife veterinarians, biologists, geologists, ecologists, plant pathologists and others. they study the web of life, complex interactions between many interconnecting systems. man-made alterations to entire ecosystems have many consequences, both intentional and unintentional, potentially harming the health of current and future generations (4). environmental/ecosystem health would address the inter-action between the biotic (i.e. living) and abiotic components of environments and ecosystems. unchecked development, including the destruction of ecosystems for agricultural or other purposes, potentially jeopardizes the health of regions, including the health of animals and humans. the challenge is integrating both the environmental and ecosystem health realms into a unified field that incorporates the one health paradigm. a new inclusive term should be developed to reflect the expanded mandate. efforts are underway to establish new integrated environmental/ecosystem health fields. one is called “planetary health” (5). advocates for planetary health seek to educate a new cadre of individuals (6). the challenge with this strategy is that it focuses primarily on humans and the kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-134 environment, minimizing the importance of animal health and zoonotic diseases. also, planetary health is a broad, general term; it’s not entirely clear what exactly its practitioners would do, or who would hire them. one health recognizes the vast breadth of knowledge and skills needed for human, animal, and environmental/ecosystem health and seeks to increase communication and collaboration between medical, veterinary medical, and public health professionals and scientists to achieve these goals. a global international body and environmental protection a global, coordinating international body must be in charge of environmental monitoring and protection. currently, there is no united nations environmental protection organization, but there is an environment programme that was established in 1972 with the mission to promote wise use of the environment and assess global trends (7). for the fiscal year 2014-2015, its total planned budget, from voluntary contributions from member states, was approximately $619 million, which was a 134 percent increase from the previous fiscal year(8). to put this budget into perspective, the world health organization’s budget for 2014-2015 was almost $4 billion (9) (who has an environmental health section that addresses sanitation and water and air pollution but not necessarily ecosystems). the 2014-2015 budget for the food and agriculture organization (fao) was approximately $2 billion (10). fao focuses primarily on food safety and security. in contrast, the 2014-2015 budget for the world organization for animal health (oie) was €22 million (approximately $17.2 million in 2014 usd) (11,12). the oie’s mission is to ensure healthy food animals for food safety. vast disparities in international funding between human, animal, and environmental health makes implementing a global one health strategy extremely difficult, if not impossible. if world leaders were serious about protecting the environment/ecosystems of the planet, they should consider establishing a world environment/ecosystem protection organization with a mandate to examine and address environmental/ecosystem alterations and their resulting outcomes; the organization should have a budget at least comparable to the fao, and it should have enough power to influence nations to act in the best interest of humanity to ensure planetary habitability and survival. countries’ commitments countries must make commitments to study and protect their environments/ecosystems. analogous to the international level, many nations such as the u.s., allocate little for analyzing, managing, and protecting their environments/ecosystems. in the u.s., responsibilities for environmental/ecosystem health are split between government agencies, which can dilute the overall effectiveness of efforts. the u.s. department of the interior oversees the u.s. fish and wildlife service, which has the responsibility to manage biological resources and enforce laws like the marine mammal protection act and the endangered species act (13). in the fiscal year 2012, its budget was $1.48 billion, a two percent decrease from the previous year (14). the environmental protection agency (epa), established in 1970 because of public concern about environmental pollution, conducts monitoring, standard-setting, research, and enforcement activities to protect the public from environmental contaminants, toxic wastes, and other health hazards (15). in the fiscal year 2015, its budget was $7.89 billion, a 4 percent decrease from the fiscal year 2014 (16). president donald trump has vowed to eviscerate, and possibly eliminate, the epa (17). the us geological survey, under the aegis of the department of the interior, was created in 1879 to provide scientific information to understand the earth and to manage the nation’s water, biological, energy, and mineral resources in order to protect life (18). the usgs 4 kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-134 5 monitors, collects, and analyzes data concerning natural resources. they provide scientific information to policy makers, planners, and others (18). in the fiscal year 2012, the u.s. fish and wildlife service’s budget was approximately $ 1.48 billion, an approximate 2 percent decrease from the previous year (19). these entities do work together, but funding is tight, and efforts might not necessarily be coordinated. the trump administration and the republican-controlled congress threaten to undo many of the conservation and environmental/ecosystem protection efforts over the past sixty years (20). the role of schools of public health schools of public health should offer interdisciplinary courses in conjunction with geological sciences and agriculture and forestry on environmental and ecosystem health, sustainable agriculture and biodiversity, food safety and security, water management and others. schools of public health traditionally teach subjects such as biostatistics, epidemiology, health policy and management, socio-medical sciences, population and family health, and environmental health. environmental health concentrates primarily on reducing carcinogens, toxic waste exposures, and other harmful chemicals. however, the health threats we face in the 21st century extend well beyond traditional public health subject areas. massive waste production from megacities and large animal production facilities threatens water and land quality as run-off from sludge seeps into soils and groundwater. sanitation and hygiene will become one of the most important fields of public health, particularly in an era of worsening antimicrobial resistance. preventing disease by lowering microbial burdens must be a global priority. contaminated land and water contributes to food and water-borne illnesses. severe droughts, floods, and unpredictable weather threaten food security as well as food safety. arthropod-borne diseases are spreading, and will continue to do so with on-going deforestation, upending delicate ecosystems. the curricula of schools of public health need to change to meet the challenges of the 21st century. much more emphasis should be given to emerging zoonotic diseases, entomology, parasitology, virology, and bacteriology. food safety and security should to be taught along with sanitation and hygiene, environmental and ecosystem health, climate and health. one health policy should be taught to examine the intersection between public health, agriculture, and environmental/ecosystem health. the importance of agriculture is rarely discussed outside of agriculture and animal husbandry courses. this must change. with worsening climate change, agriculture will be threatened in unprecedented ways. food security and its impact on civil society will be an increasingly important subject in the decades ahead. one health education should be team-based (analogous to business schools) and should be focused on researching and analyzing national and international government infrastructures relevant to human, animal, and environmental health. most health policy courses focus on healthcare delivery such as in hospitals and clinics. health insurance coverage is another common area of study. but, policy education must be expanded to examine the larger issues such as biodefense, food safety and security, and disaster preparedness. the world needs creative thinkers and problem solves who can conduct fieldwork projects at local, regional, national, and international levels to improve global one health. conclusion in conclusion, environmental/ecosystem health must be better defined to meet the challenges of the 21st century. expanding human populations, deforestation, land degradation, water contamination, massive human and animal manure production, crumbling sanitation kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-134 6 infrastructures, the growth of megacities, diminishing biodiversity, food safety and security, agriculture and animal husbandry, emerging zoonotic diseases are all tied together and adversely impact the world’s environments/ecosystems, and ultimately, global health. these subjects must be examined and taught using an integrated one health framework to adequately understand and address them. united nations member states have already made a commitment for sustainable development. at a united nations sustainable development summit meeting in september 2015, world leaders adopted 17 sustainable development goals for the 2030 agenda for sustainable development. world leaders recognize the importance of setting goals for leaving future generations a habitable planet. expanding the definition of environmental health to include ecosystems and integrating it into a holistic, interdisciplinary one health framework would be an important first step forward. references 1. laaser u, lueddeke g, nurse j. launch of the ‘one health global think-tank for sustainable health & well-being’—2030 (ghw-2030). seejph 2016, vol. 6. doi 10.4119/unibi/seejph-2016-114. 2. lueddeke g, kaufman g, kahn l, krecek r, willingham a, stroud c, lindenmayer j, kaplan b, conti l, monath t, woodall j. preparing society to create the world we need through ‘one health’ education. seejph 2016, vol. 6. doi 10.4119/unibi/seejph-2016-122. 3. national environmental health association. about neha. definitions of environmental health. http://www.neha.org/about-neha/definitions-environmental health (accessed: december 7, 2016). 4. myers ss, gaffikin l, golden cd, et al. human health impacts of ecosystem alteration. pnas 2013;110: 18753-60. http://www.pnas.org/content/110/47/18753.full. 5. horton r, lo s. planetary health: a new science for exceptional action. the lancet 2015;386:1921-2. 6. planetary health alliance. why a planetary health alliance? http://planetaryhealthalliance.org/why-planetary-health-alliance (accessed: december 12, 2016). 7. united nations environmental programme. about. http://web.unep.org/about/ (accessed: december 12, 2016). 8. united nations environmental programme annual report. https://wedocs.unep.org/bitstream/handle/20.500.11822/7544/ unep_2015_annual_report-2016unep-annualreport-2015 en.pdf.pdf?sequence=8&isallowed=y (pages 56-7) (accessed: december 12, 2016). 9. world health organization. about. resources. http://www.who.int/about/resources_planning/a66_r2_en.pdf (accessed: december 14, 2016). 10. un food and agriculture organization. conference. fao 2014 audited accounts. http://www.fao.org/3/a-mo335e.pdf (page 7) (accessed: december 14, 2016). 11. world organization for animal health. http://www.oie.int/fileadmin/vademecum/pdf/rapport%20annuel/en_annualr eport_2014_lr.pdf (page 9) (accessed: december 14, 2016). 12. u.s. internal revenue service. yearly average currency exchange rates. https://www.irs.gov/individuals/international-taxpayers/yearly-average-currency exchange-rates (1 euro equals 0.784 dollars) (accessed: december 14, 2016). http://www.neha.org/about-neha/definitions-environmental-� http://www.pnas.org/content/110/47/18753.full� http://planetaryhealthalliance.org/why-planetary-health-alliance� http://web.unep.org/about/� http://www.who.int/about/resources_planning/a66_r2_en.pdf� http://www.fao.org/3/a-mo335e.pdf� http://www.oie.int/fileadmin/vademecum/pdf/rapport%20annuel/en_annualr� http://www.irs.gov/individuals/international-taxpayers/yearly-average-currency-� kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-134 7 13. u.s. department of the interior. fish and wildlife service. about the u.s. fish and wildlife service. https://www.fws.gov/help/about_us.html (accessed: december 15, 2016). 14. u.s. fish and wildlife service fy 2013 budget justification. https://www.fws.gov/budget/2013/pdf%20files%20fy%202013%20greenbook/3. %20budget%20at%20a%20glance.pdf (accessed: december 15, 2016). 15. u.s. environmental protection agency. epa history. https://www.epa.gov/history (accessed: december 15, 2016). 16. u.s. environmental protection agency. fy 2015. a budget in brief. https://www.epa.gov/sites/production/files/2014-03/documents/fy15_bib.pdf (accessed: december 19, 2016). 17. fountain h. “trump’s climate contrarian: myron ebell takes on the e.p.a.” new york times. nov. 11, 2016 (http://www.nytimes.com/2016/11/12/science/myron ebell-trump-epa.html) (accessed: december 19, 2016). 18. u.s. geological survey. who we are. https://www.usgs.gov/about/about-us/who-we are (accessed: december 19, 2016). 19. u.s. department of the interior. fish and wildlife service. budget at a glance. https://www.fws.gov/budget/2013/pdf%20files%20fy%202013%20greenbook/3. %20budget%20at%20a%20glance.pdf (accessed: december 19, 2016). 20. harvey c. these are the two environmental rules the republican congress is trying to kill first. washington post. january 17, 2017 https://www.washingtonpost.com/news/energy-environment/wp/2017/01/17/these are-the-two-environmental-rules-the-republican-congress-is-trying-to-kill first/?utm_term=.1f64715c54af (accessed: february 2, 2017). © 2017kahn; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.fws.gov/help/about_us.html� http://www.fws.gov/budget/2013/pdf%20files%20fy%202013%20greenbook/3� http://www.epa.gov/history� http://www.epa.gov/sites/production/files/2014-03/documents/fy15_bib.pdf� http://www.nytimes.com/2016/11/12/science/myron-� http://www.usgs.gov/about/about-us/who-we-� http://www.fws.gov/budget/2013/pdf%20files%20fy%202013%20greenbook/3� http://www.washingtonpost.com/news/energy-environment/wp/2017/01/17/these-� http://creativecommons.org/licenses/by/3.0)� short report laura h. kahn1 abstract conflicts of interest: none. a global international body and environmental protection countries’ commitments the role of schools of public health conclusion references sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 1 of 21 review article data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion tetine sentell1, saionara maria aires da câmara2, alban ylli3, maria p. velez4, marlos r. domingues5, diego g. bassani6, mary guo1, catherine m. pirkle1 1 office of public health studies, honolulu, hawaii, usa; 2 faculty of health sciences of trairi, federal university of rio grande do norte, santa cruz, brazil; 3 department of epidemiology and health systems, institute of public health, tirana, albania; 4 departments of obstetrics and gynaecology & public health sciences, queen’s university, kingston general hospital, ontario, canada; 5 postgraduate programme in physical education, federal university of pelotas, pelotas, brazil; 6 department of paediatrics, faculty of medicine & dalla lana school of public health university of toronto, toronto, canada. corresponding author: tetine sentell, phd; address: office of public health studies, 1960 east-west road, biomed t102, honolulu, hi 96822, usa; telephone: +18089565781; email: tsentell@hawaii.edu sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 2 of 21 abstract adolescent health is a major global priority. yet, as recently described by the world health organization (who), increased recognition of the importance of adolescent health rarely transforms into action. one challenge is lack of data, particularly on adolescent fertility. adolescent pregnancy and childbirth are widespread and affect lifetime health and social outcomes of women, men, and families. other important components of adolescent fertility include abortion, miscarriage, and stillbirth. access to reliable, consistently-collected data to understand the scope and complexity of adolescent fertility is critical for designing strong research, developing meaningful policies, building effective programs, and evaluating success in these domains. vital surveillance data can be challenging to obtain in general, and particularly in lowand middle-income countries and other under-resourced settings (including rural and indigenous communities in high-income countries). definitions also vary, making comparisons over time and across locations challenging. informed by the adolescence and motherhood research project in brazil and considering relevance to the southern eastern european (see) context, this article focuses on challenges in surveillance data for adolescent fertility for middleincome countries. specifically, we review the literature to: (1) discuss the importance of understanding adolescent fertility generally, and (2) highlight relevant challenges and complexity in collecting adolescent fertility data, then we (3) consider implications of data gaps on this topic for selected middle-income countries in latin america and see, and (4) propose next steps to improve adolescent fertility data for evidence-based health promotion in the middle-income country context. keywords: adolescent health, fertility, health promotion, surveillance. conflicts of interest: none. funding: this work was supported by the fogarty international center of the national institutes of health under award number r21 tw010466. the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. we thank the participants of the “supporting maternal health across the life-course: improving the evidence base to inform policy and practice” meeting in honolulu, hi august 2018 for their insights. sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 3 of 21 introduction adolescent health is a major global priority, particularly in the lowand middle-income countries where 90% of the 1.2 billion adolescents (aged 10-19 years) globally live, comprising over 20% of the total population in some countries (1,2). recent work highlights the urgent need for comprehensive, integrated, and sustained investment in adolescent health (3-5). this can reap immediate rewards, and pay dividends into adult health and future generations (3-5). a major challenge towards this goal is access to reliable surveillance data, which is critical to designing effective policies, programs, and research and then evaluating their impacts across populations (2-5). data gaps may be one critical reason why the growing recognition of the importance of adolescent health has not transformed into sufficient research, policy, and action (2-5). data limitations can be a specific problem in understanding adolescent fertility patterns, trends, and outcomes (6-13). adolescent pregnancy and childbirth are widespread and affect lifetime health and social outcomes of women, men, and families (6-9). other important components of adolescent fertility include abortion, miscarriage, and stillbirth (14-16). data on these topics can be challenging to obtain given the considerable stigma, measurement complexities, and cultural, demographic, and legal variation across regions and countries (6-16). there is also considerable overlap and variation in the terminology used to describe aspects and outcomes of adolescent fertility (6-13). (for clarity, table 1 describes key terminology as used in this article.) informed by the adolescence and motherhood research (amor) project in brazil (17) and considering the relevance to the southern eastern european (see) region, this article reviews the literature to: (1) discuss the importance of understanding adolescent fertility generally, and (2) highlight relevant challenges and complexity in collecting adolescent fertility data, then (3) considers implications of these data gaps for selected middle-income countries (mic) specifically in latin america and see, and (4) proposes next steps to improve adolescent fertility data for evidence-based health promotion in the mic context. table 1. key terminology as used in this article term this article adolescent fertility we use this term in a general sense to cover any pregnancyrelated experience among those 10-19 years of age, including live birth, abortion, stillbirth, or miscarriage. the live birth could lead to parenting or to adoption. this can include multiple pregnancies during this time of life. adolescent pregnancy the terms describes a specific physiological state of pregnancy among those 10-19 years of age. includes pregnancies ending in births, but also miscarriage and abortion*. adolescent live birth the term describes a specific outcome from an adolescent pregnancy among women, specifically the outcome of delivering a living child among those 10-19 years of age†. adolescent parenting this term describes one outcome that might follow a live birth. in contrast to the other definitions that apply to sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 4 of 21 women only, this term applies to both men and women. * http://origin.who.int/healthinfo/indicators/2015/chi_2015_37_fertility_adolescent.pdf. † https://data.worldbank.org/indicator/sp.ado.tfrt. section 1: importance of understanding adolescent fertility patterns and trends three major health risks stem from adolescent fertility. first, pregnancy during adolescence is associated with increased risk of maternal death and disability across a variety of outcomes, with unsafe abortion as one of the foremost contributors (14,16,1822). legal and social restrictions on access to safe abortion prompt adolescents to resort to procedures administered by unskilled providers and/or in unsafe conditions (14,16,20,21). secondly, pregnancy and delivery during adolescence is associated with elevated risks of respiratory diseases, birth trauma, and bearing premature newborns with low birth weight (22). finally, adolescent pregnancies are correlated with long-term consequences for the mother, including cardiovascular disease, mobility limitations, incontinence, and chronic pain (23,24). there are also social consequences. adolescent pregnancies, particularly those resulting in a child, may cause women to miss important life opportunities by dropping out of school and earning less over their lifetimes (1,2,25). adolescent childbearing can also perpetuate intergenerational poverty through successive waves of adolescent mothers (26,27). it is additionally associated with interpersonal violence and contributes to higher risks of experiencing violence, with a number of negative impacts (28). understanding the patterns of adolescent fertility globally and within specific populations is thus vital for regional, national, and international public health. this is particularly true as the critical role of adolescence on health outcomes across the lifespan is increasingly recognized. as highlighted by vinter et al (2015): “adolescence is second only to fetal and infant life in the rapidity of growth and pervasiveness of change across body systems” (29). section 2: adolescent fertility data gaps and challenges for mic despite the critical importance of this topic, finding relevant data can be challenging and/or have hidden complexities that obscures patterns, trends, and outcomes. others have documented critical gaps in adolescent fertility data surveillance and management (3,4,6,7,14,30). besides adolescent fertility, many other relevant metrics and measures exist around other aspects of adolescent reproductive health (1-8,30). some relevant examples include: adolescent abortion rate; adolescent marriage rate; access to contraception; use of contraception; use of modern contraception, a sdg (sustainable development goals) target goal for those 15-49 years (31); planning status of adolescent pregnancy (intended, mistimed, unwanted); age at the time of the last pregnancy under 20; age at the time of the first pregnancy; marital status during adolescent pregnancy; and fertility preferences of currently married teenage women (want a child now, within a year, 2 years, later). other important, related topics include sexual exploitation, sexual preferences, gender identity, sexually transmitted diseases (1-8,30). these sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 5 of 21 measures share many of the same challenges described in this article but are beyond the scope to discuss in detail. we highlight some issues with relevance to mic. research. first, it is important to note that research on adolescent health generally lags behind research in both child and adult health (1). this may help explain why the decrease in global burden of disease as measured in disability-adjusted life years for adolescents was less than the decrease for adults (3) and why adolescent health gains have been less than those for children (5). indicators. there are many relevant indicators in adolescent fertility, which are vital health indicators (30). for instance, rate of adolescent live birth is one of the 12 headline indicators proposed by the lancet commission on adolescent health and wellbeing and one of 13 global health target measures for the 2030 sdg (11,31). a recent paper by azzopardi et al (2019) provided definitive estimates across many nations for these sdg indicators, including adolescent live birth, and gave a cumulative accounting of 11.7 million live births to adolescents between 15–19 years old in 2016 worldwide (3). while rates of adolescent live birth are decreasing in most countries, patterns vary considerably (3). for instance, albania was one of only ten countries with an increase in the rate of adolescent live birth between 1990 and 2016 (3). it is important to note the complexity in the measure of adolescent live birth, including how “adolescent” is defined (11). in the azzopardi et al (2019) paper, the sdg “annual birth rate per 1000 adolescents aged 10-19 years” metric was measured by “live births per 1000 adolescents in females aged 15-19 years” (3). of course, across the 10-19 age range many pregnancies occurred that did not result in a live birth, which can have health consequences and are thus also important to measure. table 2 shows in detail three of the most common ways that relevant constructs in adolescent fertility are actually measured in surveillance, providing calculations for the measure, and targeted critiques for these metrics (adolescent fertility rate, adolescent pregnancy, and adolescent girl pregnancy) (30). comparative data. comparative data is important to understand regional differences and cumulative global needs, which necessitate similar time frames and harmonized data (14). adolescent health data in mic can be found through national and cross-national surveillance systems. many mic publish their own vital statistics reports, but the quality of civil registration and vital statistics systems vary, even across mic (32). many mic also participate in cross-country surveillance systems toward global consensus indicators, including the demographic and health survey (dhs), the multiple indicator cluster survey (mics), and reproductive health survey (rhs) (3336). these are administered by national health systems in conjunction with usaid (dhs & rhs) and unicef (mics) (3336). they use similar definitions of adolescent fertility, and often, have been administered consistently for many years. international comparison information for adolescent fertility and related measures are also compiled into databases by major organizations, including the united nations (un) (37), the world bank (38), and the global health data exchange (39). major international efforts generate point estimates sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 6 of 21 for country-level comparisons, allowing for cumulative global calculations for key indicators (3,14,21,33,40). table 2. selected definitions for adolescent fertility measures* source indicator name(s) calculation comments numerator comments denominator u n f p a adolescent birth rate adolescent fertility rate age-specific fertility rate number of live births to women 15-19 years / total number of women 15 to 19 years excludes very young adolescents (10-14-yearolds) excludes miscarriages, stillbirths, and abortions. measure of adolescent childbearing, not pregnancy requires vital statistics for denominator, which can be challenging in very low income settings assumption that all women 15-19 years are at risk of pregnancy and thus, presumably that all women in this age group have already hit puberty. this may not be the case in communities with elevated malnutrition or illness that affect pubertal timing. u n f p a adolescent pregnancy number of women aged 20-24 that had a live birth before the age of 18 / total number of women aged 20 to 24 excludes miscarriages, stillbirths, and abortions. measure of adolescent childbearing, not pregnancy excludes those who died prior to adulthood, such as those who died in childbirth and/or those living in violent communities. may underestimate adolescent pregnancy/childbirth in the most disadvantaged areas. requires vital statistics for denominator, which can be challenging in very low income settings u n f p a adolescent girl pregnancy number of women aged 20-24 that had a live birth before the age of 15 / total number of women aged 20 to 24 excludes miscarriages, stillbirths, and abortions. measure of adolescent girl childbearing, not pregnancy similar to above. the issue of deaths before reaching 2024 is particularly problematic in this group because of the very high risk of maternal mortality in lowincome settings, among adolescents having children. * loaiza e, liang m. (2013). adolescent pregnancy: a review of the evidence. new york, ny: unfpa. these readily available metrics are valuable, and provide vital comparative data, but as in the live birth example above, in the background is variation and complexity. many mic have incomplete data for adolescent reproductive health outcomes and/or contextual variables (income inequality, social determinants of health) to better understand variation, patterns, and reasons for those outcomes (12,13). the dhs, mics, and rhs are not completed yearly, and some countries have not done them recently or at all. for instance, brazil has not completed a post-2000 dhs (41). sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 7 of 21 countries, who have cost sharing for these surveys, have autonomy to add questions and determine sampling frames, which may vary. for instance, many locations did not include unmarried adolescents in questions about sexual activity, use of contraception, or childbearing intentions in past dhs; this continues in a few dhs programs (33,36). additionally, while many global health indicators seem straightforward when presented in tables comparing outcomes across countries, plotted in useful maps (41) or included in sophisticated data visualizations (43), they are often obtained from very complex statistical models, different time periods, and/or may have missing data generated through sophisticated algorithms (3,14,19,33). in some cases, cross-national comparisons are created where at least some studies have national data extrapolated from smaller studies (14,19). these estimates often do not provide region or focal population specific statistics, which can vary in critical ways within a country. whatever the indicator, there can be incentives to suppress data for political reasons (5), making the data unreliable in ways that will not be visible in public reports or comparisons. stigma. there are also critical gaps in adolescent fertility data due to underreporting (6). many adolescents do not want to admit to sexual behavior. these actions and consequences are stigmatized and can be illegal, particularly induced abortion. the implications of these issues for data quality vary by country, and by context within countries (6). school-based youth risk behavior surveys may omit sensitive questions due to stigma and discomfort, exclude younger adolescents, and miss those who are not attending school, but who are particularly vulnerable (44). informed consent at this age can be complex and parents may refuse to let their children participate in health surveys that include these issues. missing populations. many major yearly public health surveillance instruments (e.g., brfss in the us) exclude those younger than 18 as primary respondents. as in school-based settings, adolescent sexuality questions may be deemed too sensitive (or unreliable) for proxy respondents. population-based telephone surveys may also miss vulnerable communities, including refugee, migrant, homeless and street youth (6,7). school-based surveys miss students who have left school, including those who did so because they are parenting. thus, many critical communities related to adolescent fertility are excluded from surveillance. there is also a lack of attention to adolescent male fathers. this is problematic because many assume parenting roles and after doing so, like their female counterparts, become adversely impacted. for example, younger age at birth of first child in men, as well as women, has been associated with greater risk of cardivascular disease (45). however, global data is insufficient on the quantity of adolescent pregnancies fathered by those 10-19 themselves. some dhs programs do not survey adolescent men at all (46). adolescents less than 15 years of age. adolescents younger than 15 are often left out of measurement for fertility issues. for instance, much dhs data uses the 15-19 age category to determine adolescent births, excluding the very young and high-risk births. this is a problem because younger girls generally have more complications sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 8 of 21 with pregnancy and childbirth versus older ones (44,46). repeat births. limited guidance exists on repeat birth, especially rapid repeat pregnancy (within 2 years of the index pregnancy). data on this is particularly limited in mic, but evidence from higherincome settings indicate that rapid, unwanted repeat pregnancies are relatively common among adolescents (9). disaggregated data. there is a critical need to disaggregate data by community, vulnerability, and narrower age groups to identify true needs and risks (6). for instance, while adolescent health data is typically aggregated for 15-19-year-olds in many mic, the pregnancy rate is higher among 18-19-yearolds than among 15-17year-olds (14). abortions, miscarriages, and stillbirths. especially given that a large percentage of adolescent pregnancies are unwanted or unintended (82% in a us study) (14), not all adolescent pregnancies end in a live birth. while birth data are generally complete, collection and evaluation of abortion data and estimation of miscarriages globally and by country are limited (14). miscarriage among adolescents may go unrecognized (14). stillbirths, a major issue in many mic, can be hard to definitively quantify (47,48). these issues can vary greatly by location and reporting laws (voluntary or required, sanctions), and the role of the public and private health sectors; where abortion is legally or logistically restricted may be both the least likely to have relatable data on abortion as well as most likely to have unsafe abortions (14,16,20,21). abortion policies can vary greatly in a short time period, impacting data reporting patterns, validity, and completeness over time (14). in places were abortion is illegal, there are clandestine clinics unknown to the health system and that do not provide information to national registries or researchers resulting in underestimates of true prevalence. cross-sectional data. the cross-sectional nature of data typically collected on adolescent fertility also impacts research into the consequences of adolescent pregnancy or related issues, as socioeconomic characteristics are measured at the time of the survey, not at birth or during pregnancy (49). in retrospective surveys, a woman’s situation may have changed considerably. she may have experienced a socioeconomic downturn subsequent to the delivery; for instance, some adolescents are kicked out of their homes if they become pregnant. cohort effects can also be an issue; yet, little longitudinal research exists on this topic, especially from large, cross-cultural populations (50). good sexual health. most adolescent fertility surveillance metrics focus on risk and danger (pregnancy, sexually transmitted disease), treating all adolescent sexuality as negative (51,52). we know little about childbearing desires (6) or positive sexual health. in some communities, childbearing and marriage at this age are common and surveillance systems might build distrust by taking a completely negative perspective on this issue (7,53). consequences of these gaps and challenges. many adolescent pregnancies and the negative consequences are preventable, but inconsistent and unreliable sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 9 of 21 data can make it hard to design effective solutions across all populations. ignoring inequality between specific groups can hide critical disparities, including a fundamental cause of intergenerational cycles of poverty. there can be considerable variation in data quality across regions within countries, across countries, and across regional groupings of countries. this adds complexity (not always acknowledged) to international comparisons, and makesevidence-based policy and the evaluation of those policies challenging (4,5,54,55). yet, better surveillance may bring unwelcome or unexpected findings as key metrics may increase, impacting funding priorities or political momentum. without meaningful, nuanced, consistent data, including data sensitive to subtle and incremental change, it is challenging to design programs, policies, and research to address adolescent fertility issues and hard to measure intervention effects (49). section 3: data challenges in the mic context we now specifically consider these adolescent reproductive health data challenges from experiences in the amor project in a latin america context, followed by a consideration of these issues in the see context. the adolescence and motherhood research (amor) project. the amor project (17) is a research initiative with two complementary study aims of improving quantitative health research capacity in a low-income rural area of northeast brazil, while completing a pilot project towards the long-term objective of building sustainable infrastructure for research to elucidate pathways between adolescent childbirth and adverse health conditions across the lifecourse (23). as part of this study, a pilot cohort of adolescents, pregnant for the first time, was recruited in the first trimester of pregnancy and followed over time. measurement/regional data. brazil is a large mic with substantial socioeconomic regional divides. many states in northeast brazil, such as rio grande do norte, rank last for income, education and social services, while other states in the south of the country, such as são paulo, are relatively well off (56). in brazil, the national information system on live births (sinasc), implemented gradually in all states since 1990 (57), receives live birth information from all maternity hospitals and other health units. although there is increasing coverage of sinasc across the states, scale-up has occurred differentially across brazil. for example, it was estimated that the coverage rate of sinasc reached almost 100% for the south, southeast and midwest regions in 2011, but it was between 70-90% for most of the poorer northern and northeastern states (58). although sinasc provides useful data about rates of live birth for women of specific age-groups and regions over the years, incomplete data in some registers, particularly in the less advantaged regions, and the lack of information about miscarriages or abortions, limits its use for the understanding of adolescent pregnancies. the brazilian institutes of geography and statistics (ibge) performs a demographic census in brazil every decade and provide information about adolescent childbirth rates, but its use is limited given the large time lag between surveys. during the years between the censuses, the ibge performs an annual national household sample survey. sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 10 of 21 however, because data is collected on a sample of households for each state, information about the levels and patterns of adolescent fertility, as well as any spatial disaggregation generated by such estimates are limited by small sample sizes. moreover, questions about adolescent fertility are directed only for girls aged 15 or older. study recruitment. planning the amor project recruitment was difficult due to such data gaps. our target sample included adolescents in the first pregnancy aged between 13-18 years-old from the trairi region of the rio grande do norte state. using information from sinasc, we identified the number of live births from adolescents in the target towns during the previous years, but the data regarding adolescents from 13-18 years were aggregated into the 10-19-year age group. in particular, the number of adolescent pregancies increases dramatically when age 19 is included, showing the importance of relevant data disagregation. once the project was underway, we also needed adolescent birth rate for our focal location to understand the scope, representation, and success of our study recruitment. again, aggregated information by age groups from sinasc prevented us from being able to do these estimates. we also were unable to estimate miscarriages, which were not included in the sinasc data, but were ultimately seen in 8% of our adolescent sample after baseline evaluation. latin america context. regional relevance and knowledge are important for consideration of these data gaps in brazil. adolescent fertility rates in the who latin american and caribbean region are the second highest in the world, much higher than in other regions with similar levels of development (49). while total fertility has dropped in recent decades, adolescent fertility rates have dropped much less sharply (46). the high rates of adolescent fertility can be seen in the latin american table 3. table 3. adolescent birth rate (births per 1,000 women ages 15-19) available by selected countries in latin america and south eastern europe by source* indicator latin america examples south eastern european examples notes brazil colombia honduras albania romania serbia azzopardi et al, 2019, lancet article (data from 2016) † 66.8 41.6 72.6 21.8 32.2 16.1 data is “birth rate (live births per 1000 population per year) in females aged 15–19 years.” representing sdg metric: “annual birth rate per 1000 adolescents aged 10–19 years.” world bank database adolescent fertility rates (data from 2016) ‡ 62.7 49.5 72.1 20.7 33.7 19.3 yearly adolescent fertility rate since 1960 by countries with regional benchmarks. adolescent birth rate map 65 85 99 18 36 22 map with comparisons by countries. per sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 11 of 21 adolescent health unicef ¶ website “most recent estimates for each country taken from 2015 update for the mdg database: adolescent birth rate (unfpa/un population division).” united nations age-specific fertility rates (2010-2015)§ 67.0 57.7 77.8 20.7 36.4 21.0 5-year average agespecific fertility rates from 1950-1955 with regional benchmarks. who adolescent birth rate by who region, 20052016** 60.8 71.6 101.0 18.9 35.3 16.4 data visualization with comparisons by countries within who regions and global and regional benchmarks. demographic and health survey (dhs)†† (date of most recent dhs included on website) 87.9 (1996) 85.1 (2010) 99.0 (2011) 19.6 (2008) n/a n/a adolescent birth rate information by country. subnational information available by income quartiles and rural/urban. * as shown by source as of march 15, 2019. † azzopardi ps, hearps sjc, francis kl, et al. progress in adolescent health and wellbeing: tracking 12 headline indicators for 195 countries and territories, 1990–2016. lancet 2019; published online march 12. http://dx.doi.org/10.1016/s0140-6736(18)32427-9. ‡ sp.ado.tfrt from world bank website downloaded https://data.worldbank.org/indicator/sp.ado.tfrt 3.14.2019. ¶ https://data.unicef.org/topic/maternal-health/adolescent-health/ -adolescent birth rate by country (number of annual births per 1000 adolescents aged 15-19). . § https://population.un.org/wpp/download/standard/fertility/ fert/7: age-specific fertility rates by region, subregion and country, 1950-2100 (births per 1,000 women). ** http://apps.who.int/gho/data/node.sdg.3-7-viz-2?lang=en sdg target 3.7 world health statistics data visualizations dashboard sdg target 3.7 | sexual and reproductive health; adolescent birth. †† http://apps.who.int/gho/data/view.main.vurbadobirthtotv adolescent birth rate data by country; per website: last updated: 2016-03-23. though abortion and contraception are heavily restricted in this region, many occur nonetheless, often unsafely (46,49,59). adolescent fertility is considered to be high with little use of modern contraceptives; there are an estimated 600,000 unplanned pregnancies in adolescents, and about half of women giving birth for the first time are in their teens (50). many latin american nations have adolescent pregnancy and health inequalities by population or region, but these disparities are hidden by aggregated national-level data (46). genderbased violence is a significant problem in latin america, though sexual coercion and abuse from adult males are not reliably or consistently recorded in adolescent health surveillance data (46). examples. to demonstrate an example of the general data complexity mentioned in section 2 applied to the latin american context, table 3 provides comparative data specifically for one metric (adolescent fertility rate) for three latin american http://apps.who.int/gho/data/node.sdg.3-7-viz-2?lang=en sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 12 of 21 countries (brazil, colombia, and honduras) taken from current online resources or recent, influential publications from reliable sources. data is also provided for three see countries (albania, romania, and serbia). this table demonstrates inconsistent results, timing differences of data collection, and the importance of these issues on demonstrated trends. while some variation is to be expected over time, there are large differences across measures. for instance, measures for honduras vary from 72.1 to over 100 per 1000 women. table 4 summarizes some key challenges in the latin america context in adolescent fertility surveillance. table 4. some important data gaps by region for south eastern europe and latin america location what is missing for surveillance? context specific challenges specific areas in the country where there are data gaps and challenges s o u th e a st e rn e u ro p e e x a m p le s pregnancies teen pregnancies which end in abortion adolescent births outside the marriage teen pregnancies which end in miscarriages despite some standardized instruments there are differences in indicators used to monitor the problem. different indicators used by eu (eurostat) and un dhs is not carried out by all see countries. it is not planned for the future and needs to be substituted by good surveillance data important discrepancies especially in abortion rates among surveillance and dhs/rhs. limited studies in serbia, bulgaria and albania show very high risk among roma population compared to general. most surveillance data do not allow specific monitoring of this ethnic group. l a ti n a m e ri c a n e x a m p le s data about abortion: according to the most recent estimate, about 99% of abortions in colombia are performed outside the law (impossible to obtain direct data about these) data on interpersonal violence in pregnancy information relevant to infectious diseases such as zika, which may have influenced abortions stillbirths abortion in brazil and colombia are legal only in very specific circumstances. in colombia this includes the following circumstances since 2006: the continuation of the pregnancy constitutes a danger to the life or health of the mother; the existence of life-threatening fetal malformations; the pregnancy is the result of rape, non-consensual artificial insemination or incest. vulnerability is hidden and patterns of risk or illness may not reflect facts. northeastern brazil has lower surveillance, with relevance to adolescence and motherhood research study planning and recruitment evaluation, and to other studies on similar populations. while the rich in many latin american countries may have access to abortions, this is not the case for the poor. thus, more cases of microcephaly may have occurred from zika that were not reported as those who were rich could have received abortions that were never recorded. this can impact regional estimates as well as surveillance generally. southern eastern european context. the see region is mostly made of mic transitioning from ex-communist societies to european union (eu) associates, including albania, bosnia and herzegovina, bulgaria, croatia, northern macedonia, moldavia, montenegro, romania, serbia, and ukraine. this context has both similar and unique adolescent reproductive health data gaps to those discussed above (60,61). these sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 13 of 21 countries have a very different historical and economic background from the latin american context. while this region has some of the lowest rates of adolescent-girl pregnancies among all lmic (31), rates remain higher than the eu average. some eastern european eu members in the see region, notably romania and bulgaria, have high rates of adolescent pregnancy relative to peer states (62). also, although the see region is rated relatively high in terms of equality as measured by gini index, the trends of ‘adolescent-girl pregnancies’ rates are disproportionally unfavorable among the poorest (31,62,63). usage rates of contraceptive methods, including modern methods, remain very low in see (63). abortion has dropped significantly in the region, since the 1990s, but reliance on abortion as a means of fertility control remains high in some countries (62,63). variation and measurement challenges are demonstrated in table 3 for the see counties. misinterpretation of indicators or gaps in data can cause significant inconsistencies in reporting of adolescent fertility rates across sources for the same country in the region (63,64). when comparing adolescent fertility rates among see countries, albania appears to be the only one showing a reverse of the general decreasing trend during the last decade. romania has one of the highest adolescent birth rates in the region. the three major surveillance instruments (dhs, rhs, and mics) have been implemented in albania, in consecutive rounds, with the most recent published on december 2018. the latest dhs or rhs reports from other see countries are from more than 10 years ago. besides the metrics in table 3, albania also has official administrative data from birth registration. accordingly, the adolescent fertility rate is 15.96 (65), considerably lower than estimates from other surveybased surveillance sources. according to some estimations, romania has one of the highest “young adolescent” birth rates in the world (14). data from the 2005 romanian rhs, which could be outdated, show regional variation with the rate of young adolescent births per 1000 to be 10 in urban areas compared to 46 in rural areas (66). similarly, some data from the serbian mics 2014 allows detailed analyses of adolescent fertility indicators among roma settlements where rates are exceptionally high compared to general population (67,68). in some roma settlements, 32.8% of adolescents are having children (23.8% given birth; 9% pregnant) (68). as in latin america, most see lack reliable country-level data on abortion (14). when they do, the data conflict. for instance, 2017 albanian estimates of the adolescent abortion rate were 2.1 per 1000 live births among those 15-19 years from abortion surveillance data (69), while an estimate based on dhs is lower at 1 per 1000 women for those 15-19 years (70). data from romania is from 2005, which estimates the adolescent abortion rate (for three years prior to survey) at 10 per 1000 women 15-19 years, which is a decrease from 26 per 1000 women 15-19 in the rhs 2000. one additional interesting issue is that this region is defined differently by various international organizations (60,61). many other locations have similar benchmark/comparator issues. table 4 also summarizes some key challenges for see region in adolescent fertility surveillance. sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 14 of 21 section 4: ideas for solutions and conversations in order to design targeted interventions to improve adolescent health, there is a need to better understand data and needs around critical metrics of relevance to these population groups. darroch et al (6) provide some excellent solutions. these include: using creative analyses of existing data to consider reporting by those over 15 of their experiences before 15, though this is subject to limitations in report and recollection, particularly over time; broadening existing national surveillance to better include excluded groups (younger women, nevermarried women); and creating focused, youth-targeted surveys especially including vulnerable communities. harmonized data systems also are needed with consensus/standardization of various instruments used in various mic, with buyin from relevant organizations, including who, unicef, unfpa, world bank, usaid, and eurostat (1,71-73). shared goals (such as sdg targets) can provide momentum to achieve these goals. indeed, there are critical new movements towards health data collaboratives (1,71-73), though these have many challenges (74,75). engaging the health system may help fill in some data gaps, such as increasing the stimuli for the health units/ providers to provide the information properly, to fill out the forms, making them understand its importance or giving some credits for who does. this should be a priority especially in countries where population surveys have failed to overcome stigma and produced lower rates than surveillance systems. other options include using specific studies to represent larger regions, but these do not solve issues where there is no data or where it has critical gaps for underreported or missing groups. in fact, this could obscure these issues even more dramatically. also, for better data, more longitudinal studies are needed with data about teen pregnancy and the consequences over time, physically, emotionally, and situationally. one way to address these issues is to have conversations across settings. we invite interested readers with similar, or different, challenges to share their concerns to be compiled in future work. the survey will be open from april 1, 2019 to january 1, 2020: http://hawaiidphs.co1.qualtrics.com/jfe/form /sv_7utmvpgifhiq5kj. conclusions adolescent health is increasingly recognized as a major global priority, necessitating comprehensive, integrated, and sustained investment to allow this population to achieve their full potential and most optimal wellbeing (1,3). this investment can reap rewards. as the lancet commission on adolescent health and wellbeing highlighted, this time period is foundational to physical, cognitive, emotional, social, and economic resources, concluding that: “investments in adolescent health and wellbeing bring benefits today, for decades to come, and for the next generation” (5). variation in the measures, and the absence of other important metrics, may contribute to misleading conclusions about who is at risk, trends in rates, and the success or lack thereof of interventions. with improved collection of this health data, governments are better equipped and informed to prioritize health challenges, develop policies, deploy resources, and measure success (6,7,73-77). in the absence of this information, it is challenging to develop appropriate adolescent reproductive health programs and interventions. sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 15 of 21 while this paper focused on adolescent pregnancy, these data collection challenges could be relevant to many other adolescent health issues that are preventable but also neglected, such as mental health, drug abuse, intentional and unintentional injuries, or sexually transmitted infections (2). other sexual and reproductive health problems, including hiv/aids, remain a major concern for adolescent health, particularly in some regions. collecting substance use data and adolescent violence have related issues and also relationships with adolescent sexual choices 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ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 21 of 21 ______________________________________________________________________________________ © 2019 sentell et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 1 | 13 original research norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics peter schröder-bäck1, claire van duin1, caroline brall1,2, beatrice scholtes1,3, farhangtahzib4, elsmaeckelberghe5 1department of international health, school caphri (care and public health research institute), maastricht university, the netherlands; 2health ethics and policy lab, department of health sciences and technology, swiss federal institute of technology eth zurich, switzerland; 3department of public health sciences, university of liege, belgium; 4uk faculty for public health, london, united kingdom; 5university of groningen, institute for medical education, university medical center groningen, the netherlands. corresponding author: peter schröder-bäck address: maastricht university, po box 616, 6200 md maastricht, the netherlands; email: peter.schroder@maastrichtuniversity.nl schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 2 | 13 abstract this paper draws attention to the translation of ethical norms between the theoretical discourses of philosophers and practical discourses in public health. it is suggested that five levels can be identified describing categories of a transferral process of ethical norms – a process we will refer hereto as “translational ethics”. the aim of the described process is to generate understanding regarding how ethical norms come into public health policy documents and are eventually referred to in practice. categorizing several levels can show how ethical-philosophical concepts such as norms are transforming in meaning and scope. by subdividing the model to five levels, it is suggested that ethical concepts reduce their “content thickness” and complexity and trade this in for practicability and potential consensus in public health discourses from level to level. the model presented here is illustrated by showing how the philosophical-ethical terms “autonomy”, “dignity”, and “justice” are used at different levels of the translation process, from kant’s and rawls’ theories (level 1) to, in this example, who reports and communications (levels 4 and 5). a central role is seen for what is called “applied ethics” (level 3). keywords: ethics, practice, public health, theory, translation. conflicts of interest: none. schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 3 | 13 background there is growing interest in public health ethics as a distinct discipline from clinical ethics and critical to consideration of population health issues (1). as highlighted by michael marmot there is an urgent need to create better understanding between philosophers, the health community and the real world (2). he has lamented, at times, the contemptuous approach of some philosophers, not considering real life concerns and not engaging with nonphilosophers. these philosophers are often engaged in highly theoretical discussions, even in multidisciplinary gatherings. such issues are relevant since public health prides itself in evidence based knowledge and there is a question as to why evidence often does not translate into public health practice. it has been suggested that evidence is generated within a deliberate exchange process between scientists and practitioners, and that it is essential to take values, resources and interests of the different parties into account (3). consequently, consideration of ethical norms and values should be seen as a critical part of the translation process (4). this is more than just linking the philosophical ivory tower approach of academics with the practical world of practitioners but rather also appreciating the language, purpose and nature of philosophy and public health, and their essential roles for effective scholarship and practice. to give an example, ethical norms, such as “autonomy” and “justice”, are often mentioned in public health policy and practice discourses. when these normative concepts are used, public health practitioners probably understand them differently to – but not necessarily incompatibly with – philosophers. this presumed discrepancy leads to the question: how can one relate the ethical concepts in practice to their philosophical background theories? this paper provides a description of the potential pathway between the ivory tower and practice using case studies of some specific conceptual issues used in theoretical, policy and practical discourses. translation and transferral in medicine the term “translational research” or “translational medicine” is well established, generally referring to the translation of scientific research to clinical practice, a process often called “from bench to bedside” [e.g. (5)]. however, translation of knowledge does not only take place in sciences and medicine. ethical concepts also undergo a translation– from philosophical theory to, in this example, public health policy and practice. in the following discussion we focus on the translation of philosophical work into public health practice. the term “translational ethics” is relatively new. even though ethical concepts are frequently “transferred” or “translated” – both etymologically meaning “to carry over” – between and across different domains, there is scarce academic scholarship regarding the issue (6-8). unlike language translation it is not the name of the concept that is translated, but its specific content that is made applicable for practice: the meaning and scope of philosophical concepts is explained and made usable for – or “carried over” to – contexts of professional practice in a process that we can term “translation”. the metaphor “translation” is also used as a reference for other areas of “translational research”, as mentioned above, when one refers to the transferral of basic scientific knowledge (the laboratory “bench”) to the more applicable and practical use of the knowledge (the clinical practice at the “bedside”). in this discourse, however, the concepts sometimes schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 4 | 13 change in scope and meaning so that we consider the term “translation” to be appropriate. this translational process is by no means meant to be a one-way street (6). indeed practical discourses can initiate or inform developments in philosophical theory as well. however, in this paper – as a starting point – we focus on the translation of philosophical knowledge to public health practice. translational processes to give an example of the translational process, the concepts “autonomy” and “dignity” shall be mentioned. these concepts have been philosophically elaborated upon by the renowned eighteenth century philosopher immanuel kant. however, for him these concepts had a different meaning than they do for the public health practitioner who is, for example, considering the autonomy or dignity of a child and her parents who refuse immunization. even without knowing the precise philosophical aspects of the concept of “autonomy”, at least through common, every day or professional language, the physician possesses a normative understanding of the concept that usually derives from kant’s (and others’) conception of it. a normative appreciation of autonomy may lead the physician to accept a patient’s decision. another example is how public health practitioners formulate in the context of childhood immunization that […] the impulse to maximize benefit for the highest number of people is counterbalanced by the kantian threshold of a categorical imperative […] that preserves individual autonomy and emphasizes ideas such as informed consent” (9). however, this formulated kantian “side constraint” may not be as readily accepted by a more theoretically informed philosophical argumentation, such as that offered by the philosopher and kant scholar onora o’neill. in her argumentation, kantian autonomy may even put moral obligations on parents to have their child immunized for the sake of protecting the autonomy of others (10). this is not to say – and not the question of this paper – that either salmon and omer or o’neill are right in the interpretation of kant. it is to demonstrate that the understanding of both is significantly different even though both relate back to kant. indeed, autonomy is an ethical concept with a long standing philosophical tradition and strong and “content thick” background theories from which it has evolved (11). “content thick” means the involvement of sophisticated philosophical substantiation and differentiation, perhaps including explicit consideration of other philosophical fields, such as from epistemology or metaphysics. nevertheless, a public health practitioner is not (necessarily) aware of ethical theories behind this term when using it, even if he or she refers back to kant explicitly, as the example of salmon and olmer (9) – who claim that kantian autonomy is incompatible with involuntary immunization – shows. so, how does the practitioner come to use an ethical concept? it is the thesis of this paper that ethical concepts move from the “philosophical ivory tower” to – in this case – public health “practice” (including policy making and research). this happens while practitioners have, or display, only common knowledge of the philosophical backgrounds of the ethical concepts they are normatively applying. thus we suggest that if we could reconstruct the patterns of translation of meaning of the term “autonomy” from kant to the practitioners’ use of this concept, we could help to facilitate communication among the stakeholders involved in the normative elaboration and development of public schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 5 | 13 health. the aim of this paper is thus to propose a heuristic model for discussion and to stimulate scholarship on the translation of ethical terms for practice. towards a heuristic model the development of such a model draws on some assumptions of the philosophy and sociology of science in the tradition of thomas kuhn (12) and ludwik fleck (13). the concept held in common among these authors and underpinning the proposed model is that scientists and practitioners live and act in their respective paradigms and communities, which are partly constituent by their use of language. thus, for members of one community to understand members of other communities, care needs to be taken to ensure that their lexicon is the same. moreover, concepts should be made commensurable – meaning that the sense of a common concept or term is comparable in different discourses. however, this is not easy since the extension of concepts and their meanings can change. the model proposed here raises awareness of this challenge. the “content thickness” of elaborated philosophical concepts is relevant for practice, for example, to achieve a differentiated and critical understanding of terms, similarly “content-thinness” has some virtues. “content thin” concepts are more acceptable in pluralistic societies and policy making (because the concept could derive from and stand for many background theories and worldviews). practitioners can agree on the normative concept first – and then elaborate upon what this means exactly by referring back to elaborations and theories of earlier levels of the translational process. it is the assumption of the model proposed here that normative concepts have legitimacy and specific roles in each of these communities – be it in the philosophical ivory tower or in practice. yet, when “carrying over” or “handing over” the normative concept like a baton, even though the concept still looks the same, its meaning has often changed. a heuristic and descriptive model of translational ethics the proposed model consists office levels. these levels range – analogous to the concept of “from bench to bedside” – from the philosophical ivory tower (level one) to public health practice (levels four and five). normative concepts such as ethical principles are complex and “content thick” on a philosophical level and, in practice, are more “content thin”. thus, the model focuses upon the transformative journey that ethical concepts make from the ivory tower to practice. in the following section we describe the different levels of the model by using different examples: the strongly related concepts of autonomy, dignity, and justice and specifications of these. we illustrate levels 4 and 5 using the example of the who report on “health systems performance” from 2000 (14). level one: abstract and ideal philosophical theory the first level of the model refers to philosophical works that are often the foundation for normative ethical concepts. using the examples of autonomy, dignity and justice, one can refer to the works of immanuel kant. in his discussion of these concepts, kant already uses examples, such as the murderer at the door to whom one may not lie, even to protect an innocent friend– yet, they remain very abstract, often counterintuitive in the modern world. kant’s discussions would be too abstract and somewhat unconvincing if one were to apply them directly to public health practice. schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 6 | 13 furthermore, he also includes complex and controversial metaphysical concepts in his argumentation– such as the claim that a person as “homo noumenon” bears human dignity (15) – that are unsuitable for public health practices, as we have argued elsewhere (16). in fact, theories at this level often integrate a rich and wide scholarship of other areas of philosophy – including ontology, epistemology and metaphysics. john rawls (in 1971) in his theory of justice as fairness (17), has also drawn on kant’s insights. rawls’ theory also remains abstract in many regards, for instance due to his use of hypothetical models such as the contractarian approach to justify his concept of justice and the difficulties associated with the applicability of the concept to everyday concrete problems. in fact, rawls’ account has been considered an “ideal” theory (18). thus, we would consider this level as representing ideal theory; meaning that it abstracts from concrete real-world practice and conditions (7, p. 210). similarly, rawls is criticized by amartya sen for dealing with the design of “ideal” institutions (19, p. 15ff), as opposed to institutions that function in the real-world. marmot has highlighted that nonphilosophers are not familiar with complex philosophical concepts and that many think that “rawls were to do with building sites” (2), given that the british english word for “screw anchor” is “rawl plug”. level two: non-ideal theory for a field of practice the second level covers ethical theories that are already more concrete with regard to the field of practice in question, and are developed based on empiric knowledge of that setting. theorists build a theory for a concrete context referring to and basing it on level one theories such as rawls and kant. theorists from this level include figures such as health justice theorist norman daniels who developed a theory based on rawls’ basic ideas (20); or the philosopher madison powers and the bioethicist and public health researcher ruth faden, with their work on social justice (21). while developing, in their view, a sound theory of health justice, they also claim to develop a decided non-ideal theory. powers and faden (21) criticize rawls’ assumption of equality of persons in a hypothetical situation. instead, they look at real world inequalities and work on criteria of why these inequalities matter. however, without rawls’ ideal theory of justice (and indirectly kant’s concept of dignity) their own theory would probably not have been developed. despite this very theoretical difference between levels one and two, the intention to be more practical on level two and to try to deliver real world solutions for public health makes a significant difference. yet, both daniels and powers and fadens’ theoretical approaches, explicitly draw on level one theories, criticize them and dialectically develop their own, more accessible, level two theories for philosophers and practitioners. level two academic scholarship is often made more practical by collaborations between philosophers and public health scientists (e.g. daniels, kennedy and kawachi (22), powers and faden (21)). on level two, interdisciplinary perspectives and collaboration become more relevant. here, the aim is, as o’neill formulates it (23), to give more ethical substantial input to applied ethical debates, leading us to the next level. level three: applied ethics level three represents what is often called “applied ethics”, meaning that concepts and theories from previous levels are “applied” to concrete practical problems to receive schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 7 | 13 normative guidance – but this is also an area where normative convictions and judgements could be inductively connected to ethical theory. level three discourses are often initiated by practitioners. they look for interdisciplinary discourses with ethicists to find criteria or even solutions to moral questions. public health practitioners at this level are positive about the powers (and limits) of philosophical ethics, as they are often already ethically informed or educated. ethicists, when working on these issues – often in interdisciplinary teams or even commissions, like the nuffield council on bioethics and its report on public health ethics (24) – try to use generally understandable references of ethical theories. at level three the works of applied ethics such as the influential work of philosophers beauchamp and childress (25) is very prevalent. in their four-principle approach for biomedical ethics, they also refer to “autonomy” and “justice”. beauchamp and childress explain the background concepts of their principles such as “autonomy” and” justice” – making reference to level two and level one theories and approaches. in the context of “autonomy” for instance, they combine kantian ideas of autonomy and the related concept of dignity with other relevant philosophies (most notably the related concept of “liberty” of john stuart mill). yet, they explain this overlap so broadly and generally that practitioners can understand and apply the principles. this might mean a loss of theoretical complexity and content thickness (even though beauchamp and childress would argue that they have a unifying background theory of coherentism and might claim their work to be on level two). for the sake of being interdisciplinary, pluralistically communicable, agreeable and helpful as tools and criteria for decision making this is understandable and in fact very helpful. of course, as the example of beauchamp and childress shows, philosophers can work on different levels and levels should not be identified with persons. a good example is philosophers who engage in level one scholarship but also write on applied ethics or work in interdisciplinary ethics commissions (such as e.g. tom beauchamp, a renowned hume scholar). level four: applied ethics in practice the normative concepts used at level four mainly refer to literature from level three. authors of arguments using the terms “respect for dignity” or “autonomy” refer to the works of theorists such as beauchamp and childress. they understand these terms rudimentarily (in a philosophical sense). they are not (as) aware of the background theories. in this translation process the “content thickness” and depth of the norms are further lost, yet, these criteria help to make normative arguments around the acceptability of public health interventions. representatives of these levels would be public health researchers or practitioners aware of moral problems. they are also aware of these being norms and concepts coming from a rich ethical discourse. normative tools – including codes of conduct – that are established to guide practical conduct (1) arguably also belong to this level, or between levels three and four. the example we use to explain this level and level five is the use of ethical norms in a framework for health systems performance assessment developed for and used by the world health organization. the initial framework was developed by christopher murray and julio frenk and was improved and adopted for use in “the world health report 2000”. with their framework for health systems performance assessment, murray and frenk schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 8 | 13 aim to advise decision makers (26,27). in other words, their work should be of very practical use. within their framework, they formulate “health system goals”. the main goals are “health”, “responsiveness” and “fair financing and financial risk protection”. these goals are to be measured in health systems performance and efficiency assessments. “responsiveness” has two dimensions. the second one is “client orientation”, the first one, upon which we focus, is “respect for persons”. of the several sub-components, the first three explicitly use ethical norms and can be closely related to the philosophy of autonomy and dignity: “respect for the dignity of the person” as the first sub-component forbids instrumentalisation of persons. as they formulate, it is important to show “respect for the autonomy of the individual to make choices about his/her own health. individuals, when competent, or their agents, should have the right to choose what interventions they do and do not receive” (26). they further talk of “respect for confidentiality” (26). in referring to these ethical norms and applying them to their context, murray and frenk formulate precisely in the language of applied ethics and refer to 18 sources, many of which are works in applied ethics (level three), including beauchamp and childress. the third goal “fair financing and financial risk protection” makes explicit reference to the concept of fairness (related to the concept of justice). here they reference work by the philosopher daniels and colleagues where they apply his theory to concrete health care issues (28). here again it can be seen that normative arguments are clearly made, using ethical norms without going back to “content thick” theories of level one. level 5: reference to ethical-normative concepts in practice on the final level, practitioners use ethical concepts as normative terms without making any reference to theories of ethics or applied ethics (levels one -three). no explicit elaboration of the normative concepts can be found at level four. at this point these concepts have only a rudimentary link with the concepts of levels one and two. nevertheless, a certain normative essence is encapsulated. to illustrate this, we look at how “the world health report 2000” was further condensed and “translated” for practice and the public by an accompanying message from the former who director general, gro harlem brundtland, and by the press release of the who. gro harlem brundtland’s statement opens the report as a “message from the director-general”. brundtland starts by asking two (of three) questions relating explicitly to ethical concepts “what makes for a good health system? what makes a health system fair?” she continues by saying that it is the task of the who and of such a report to help all stakeholders “to reach a balanced judgment” (29, p. vii). moreover, she makes reference to values and norms we are already familiar with from level four, the framework paper by murray and frenk (26). she continues with stating the ethically relevant part: the goals of health systems “are concerned with fairness in the way people pay for health care, and with how systems respond to people’s expectations with regard to how they are treated. where health and responsiveness are concerned, achieving a high average level is not good enough: the goals of a health system must also include reducing inequalities in ways that improve the situation of the worst-off.” according to these (normative, ethics based) considerations, health system performance is schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 9 | 13 measured to give policy-makers information to act on. additionally, the translational function of journalism is considered by formulating a press release. in this press release, there are direct quotes by the director general but also by murray, frenk and others. the press release additionally refers to the ethical concepts and norms. it mentions “injustice” and treating with “respect”. however, it also refers to the main categories and components of the performance index “responsiveness” and “fairness of financial contribution”. the aspect of “responsiveness” based on the ethical norms is now concisely summarized as “respect for persons (including dignity, confidentiality and autonomy of individuals and families to decide about their own health)”. in the press – e.g. in the new york times (30)– the ethical concepts are even less prevalent. formerly used foundational norms such as “respect” and “dignity” are not used any longer, only the term “fairness” related to the measurements. in other words, the explicit ethical norms are even further in the background. yet, one could trace “fairness” back – translated through the levels – to rawls’ level one explication. discussion philosophers often develop their normative concepts and ideal theories without considering real world practice. public health practitioners, on the other hand, often refer to normative ethical concepts without explaining their specific meaning or referring to underlying ethical theories (and possible normative ambiguities). in many cases, practitioners use these norms because they are “common sense” or belong to the “common morality”, yet, in their normative explication they can generally be traced back to philosophical theories that substantiate the norms’ normative content. this paper explores how these norms make their way into the language of practitioners (e.g. health policy documents). it is the thesis of this paper that there is a translational process in the background through which the norms in practices are also connected to (underlying, foundational) ethical theories. the paper proposes a model with several levels highlighting how this translational process occurs. the model is intended to heuristically describe how ethical norms are used (and translated) between scholarship (levels one – three) and practice (levels four and five). whereas in public health the use of schematic models is widely accepted, even though models are always a simplification and models like the ‘policy action cycle’ are by no means meant to be exhaustive or static, this seems less common in ethics. we are aware that the differentiation between the levels can be debated and concepts like “applied ethics” are contested in philosophy, yet we deem such a model a heuristic starting point for discourses aiming to better connect philosophical theory to public health practice. in this model we observe what we call the inverse relationship thesis which is visualized in figure 1. on the one side (on level one), there is content thickness and complex original philosophical thought with regard to theory building in the foreground. on the other side (levels four and five) there is public health practice. here the content thickness and complexity of the normative concepts proportionally decreases while there is an increase of applicability and suitability for practice. in other words, we formulate the thesis that there is an inverse relationship between content thicknesses and practicability. in public health practice there are also often inherent unsaid value judgements which are made around content “thickness” and “thinness” and their suitability to practice and the issue of practice schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 10 | 13 is important in terms of generating knowledge and interdisciplinary research and practice. the developed model has several limitations that point in the direction of a need for further scholarship and development on this topic. the five levels have blurred boundaries and partly overlap (for example, the rich work of beauchamp and childress could be considered to be both level two and three). demarcations between these categories and levels are difficult to set. in fact, one could argue that there could be more or fewer categories and one would probably also find good reasons for these changes. having five levels, however, also makes visible the central role of applied ethics as an intermediary and interface between the academic and the practical world. we believe that such a model helps raising awareness that different discourses on ethical norms are taking place and that a “translation” process exists. awareness of this process is important to improve communication and ultimately to elaborate better arguments, consequently also improving public health practice. figure 1. the translational process of ethical norms: the relation of content thickness and suitability for use in practice applied ethics interdisciplinary discourses (level 3) (normative) practice public health practice (levels 4-5) complex theories philosophical discourses (levels 1 and 2) content thickness (suitability for) use & communication in practice schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 11 | 13 lastly, we have suggested that there is a linear, top-down direction of travel from level one to level five. despite this not (necessarily or always) being a linear process – where levels can be jumped or individuals can work on several levels at the same time – the process works in several directions (6,31). it can work its way backwards – more practical levels inspiring more philosophical levels. and, of course, practical levels can request from multiple philosophical levels to reflect on implications of the use and meaning of normative concepts. for instance, discussions on the concept of autonomy in the philosophical levels can be prompted and inspired by problems arising on the work floor in the practical levels. to illustrate, certain groups can be encountered to whom autonomy and informed consent cannot be readily applied, such as young children or patients with alzheimer`s disease. in such cases, it can be helpful to have discussions in the philosophical levels on the meaning and applicability of autonomy in different contexts (31). conclusion there seem to be transferral or transformative processes, here referred to as translational processes, of ethical concepts from the “philosophical ivory tower” to public health practice – and vice versa. the model presented here describes that a norm reduces philosophical-theoretical “content thickness” and complexity to become more applicable in practice and, in the other direction, that norms from practice are connected to ethical theories. awareness of these translational processes can ultimately help to improve the moral foundation of public health practice and critically inform practice of norms and values. more research would be helpful to validate this model, identify and discuss more examples of translational ethics as modelled here, and to investigate the relationships between the different levels. furthermore, attention needs to be given to the practical consequences of our model. references 1. laaser u, schröder-bäck p, eliakimu e, 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oxford university press; 1996. 29. brundtland gh. message from the director-general. in: who (editor) the world health report 2000 schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 13 | 13 health systems: improving performance. geneva, who: vii-x. 30. hilts p. europeans perform highest in ranking of world health. new york times, 2000 june 21 [internet]. available from: http://www.nytimes.com/2000/06/21 /world/europeans-perform-highestin-ranking-of-world-health.html (accessed: march 10, 2019). 31. van duin c. evaluation of amodel of translational ethics. maastricht university, bachelor thesis; 2016. ___________________________________________________________ © 2019 schröder-bäck et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. . http://www.nytimes.com/2000/06/21/world/europeans-perform-highest-in-ranking-of-world-health.html http://www.nytimes.com/2000/06/21/world/europeans-perform-highest-in-ranking-of-world-health.html http://www.nytimes.com/2000/06/21/world/europeans-perform-highest-in-ranking-of-world-health.html czabanowska k, cichowska myrup a, aleksandrova o. women leadership for public health: the added value and needs of women driving public health system reform in ukraine (case study). seejph 2018, posted:20 september 2018. doi 10.4119/unibi/seejph-2018-200 1 case study women leadership for public health: the added value and needs of women driving public health system reform in ukraine katarzyna czabanowska1,2, anna cichowska myrup3, olga aleksandrova4 1 department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 2 institute of public health, faculty of health sciences, jagiellonian university, krakow, poland. 3 division of health systems and public health, world health organization regional office for europe, copenhagen, denmark. 4 world health organization country office, kyiv, ukraine. corresponding author: katarzyna czabanowska, maastricht university; address: duboisdomein 30, 6229 gt maastricht, the netherlands; telephone: +31433881592; email: kasia.czabanowska@maastrichtuniversity.nl czabanowska k, cichowska myrup a, aleksandrova o. women leadership for public health: the added value and needs of women driving public health system reform in ukraine (case study). seejph 2018, posted:20 september 2018. doi 10.4119/unibi/seejph-2018-200 2 abstract the ukrainian health care system is undergoing reforms. although women constitute a driving force in the ukrainian health system transformation, their economic and decisionmaking participation remains extremely low. the existence of barriers such as: work/life balance, gender bias, stereotypes, lack of confidence, lack of mentoring, and lack of adequate networking and equal access to opportunities prevent women from reaching high leadership positions. with the aim to empower the current and future female public health leaders, the ministry of health of ukraine and who held a seminar entitled “women’s leadership in public health” in kyiv on 16-18 may 2017. the seminar was based on the assumption that contemporary public health demands require a more inclusive and less hierarchical style of leadership – focused on developing and working with stakeholder networks. such a leadership style is more effective in achieving public health goals. the international, interdisciplinary and inter-professional faculty engaged in the interactive meaning making around such topics as: the self-assessment of leadership competencies, public health leadership, leadership theories, system thinking, dealing with interests, power and stakeholders, barriers to women leadership and methods to address them, special leadership tools for women empowerment and leading change, communication and impact. strengthening health systems for better health was the red thread throughout the whole seminar. keywords: leadership, public health, ukraine, women. conflict of interest: none. acknowledgements: the authors would like to acknowledge the contributions and participation in the course and its development of: taru koivisto, ministry of of social affairs and health, finland, valia kalaitzi, mendor publishers, greece, aasa nihlen, who, denmark, dr. olena hankivsky, institute for intersectionality research and policy at simon fraser university, canada. the support and commitment of dr oksana syvak, the former deputy minister of health in ukraine, dr. marthe everard, who representative and head of country office to ukraine, oleksandr martynenko, project officer, who country office in ukraine, polina adamovych, technical assistant, who country office in ukraine, is highly appreciated. funding: the seminar was supported by the swiss agency for development and cooperation. czabanowska k, cichowska myrup a, aleksandrova o. women leadership for public health: the added value and needs of women driving public health system reform in ukraine (case study). seejph 2018, posted:20 september 2018. doi 10.4119/unibi/seejph-2018-200 3 introduction the ukrainian health care system is undergoing through reforms. one of the main objectives of the new reforms is the shift towards a policy of strengthening and maintaining health and preventing diseases through the life-course. women constitute a driving force in the ukrainian health system transformation however, according to the global gender gap report by the world economic forum (1), ukraine ranks 64th in terms of women’s income level, 22ndin terms of women’s education and 34thon economic participation and opportunities. women's participation in decision-making remains extremely low. women hold only 12% of seats in the parliament and make 11% of the cabinet of ministers. the european parliament stated that gender mainstreaming constitutes an essential factor for the achievement of a sustainable and inclusive society (2) and smart, sustainable and inclusive growth require higher gender equality scores (3). the united nations (un) included gender equality and the empowerment of women in its sustainable development goals (sgds) (goal no 5) for the 2030 agenda. both global gender gap report (1) and eu progress report (2012) (4) examine barriers existing in relation to women leadership such as work/life balance, gender bias and stereotypes, lack of confidence, lack of mentoring, and lack of adequate networking and equal access to opportunities. the recent publication of the world bank on gender assessment in ukraine (5) pointed out clear misbalances such as: male domination at the top managerial positions, political representation and decision making, persistent ‘glass ceiling’ in access to chief executive positions in public administration, stereotypes traditional roles of men and women, lower wages and devaluated social prestige often associated with female economic activity, vulnerability at the labour market and poverty risks, prevalent part-time employment, unequal income opportunities, limited access to business activities and financial resource, public tolerance to spousal violence, gender-based violence and trafficking to name a few. with the aim to empower and support the development of current and future female leaders who drive public health reform, the ministry of health of ukraine held a seminar entitled “women’s leadership in public health” in kyiv on 16-18 may 2017. it organized the seminar with technical support from who, contributions from the association of schools of public health in the european region (aspher) and maastricht university, the netherlands, and financial support from the swiss agency for development and cooperation. the seminar was delivered in the context of the implementation of the who european action plan to strengthen public health services and capacities and the who strategy on women’s health and well-being in the who european region. the seminar contributed directly to the implementation of the sdgs by developing a workforce with 21st century public health competencies. the seminar concept, mission, objectives and content the seminar was based on the assumption that contemporary public health demands a more inclusive, less hierarchical style of leadership – focused on developing and working with stakeholder networks to be effective in achieving public health goals (6,7). public health leaders “must be the transcendent, collaborative “servant leaders” (8) able to: articulate shared values, acknowledge the unfamiliarity, ambiguity, and paradox, combine administrative excellence with a strong sense of professional commitment (8), show passion, drive and perseverance in leading for change. the concept of the seminar was linked to the merizow’s transformative learning theory (9), according to which learning is “…the process by which we transform our taken-for-granted czabanowska k, cichowska myrup a, aleksandrova o. women leadership for public health: the added value and needs of women driving public health system reform in ukraine (case study). seejph 2018, posted:20 september 2018. doi 10.4119/unibi/seejph-2018-200 4 frames of reference (meaning perspectives, habits of mind, mind sets) to make them more inclusive, open, emotionally capable of change, and reflective so that they may generate beliefs and opinions that will prove more true or justified to guide action.” (9). the seminar was competency-based, structured around modern leadership theories especially suited to develop women leaders, reflecting real life experiences of role-models. it included the topics identified through research and local needs analysis. the seminar was supported by the executive coaching provided to the participants with the objective to develop, enhance and build personal leadership attributes for the successful career and growth in health care environment and develop the ability to set individual career goals to the benefit of population heath outcomes. the main topics included: self-assessment of leadership competencies, public health leadership and leadership theories, system thinking, dealing with interests, power and stakeholders, barriers to women leadership and methods to address them, special leadership tools for women empowerment and leading change, communication and impact. strengthening health systems for better health was the red thread throughout the whole seminar. the content was presented during the two and a half day training which included interactive lectures, discussions, group work and experiential learning. the core of the programme was reinforced with the leadership development life stories from female health professional leaders trainers and participants five lecturers and trainers came from various professional fields: policy, academia, public health practice, government and business. they also came from different countries to assure variety of perspectives and experience. they represented: the netherlands, greece, sweden, finland, canada and ukraine. the lead trainer was responsible for the design, main content, cohesion and coaching whereas other trainers presented specific topics and illustrations from their public health practice as well as their leadership development stories. all presenters engaged in the discussion with the participants. the consecutive high quality professional translation was provided which allowed for good communication and satisfaction from the learning and teaching experience. there were 22 participating women leaders who were carefully selected by the ministry of health in ukraine based on their role or potential new position in relation to the introduction of public health reforms. the women came from different regions of ukraine and represented a range of organisations which are vital in the change process including the ministry of health of ukraine, public health centre of the ministry of health of ukraine, regional health centres and hospitals, non-governmental organizations, and the like. evaluation method in order to gather the feedback from the participants we used a short open-ended questionnaire addressing the following dimensions: usefulness of the seminar for the public health reform and for personal development, satisfaction with the content, form and instructors, the highlights of the course and areas for improvement, further needs concerning a follow-up on women leadership in public health training and specific areas which the participants would like to cover. we also gave space for personal reflections about the course. 14 out of 22 participants filled in the questionnaires and five shared their observations faceto-face with the course leader with a help of a professional interpreter. the atmosphere was open and relaxed, building on trust and opinion sharing. the evaluation was carried out after the course and before the individual coaching sessions. the feedback on coaching was czabanowska k, cichowska myrup a, aleksandrova o. women leadership for public health: the added value and needs of women driving public health system reform in ukraine (case study). seejph 2018, posted:20 september 2018. doi 10.4119/unibi/seejph-2018-200 5 obtained in a follow-up conversation after the coaching sessions. the evaluation forms were filled in ukrainian language. the anonymity of responses was assured. the collected data was translated into english, analysed and synthesized according to the leading questions. next conventional content analysis was used (10) to develop categories and arrange the data around them. the five categories include: opinions about the course, aspects of special value, satisfaction with the trainer, areas for improvement and further training needs. feedback from the participants opinions about the course it was the first seminar about the leadership in public health for women. all the respondents were “100% positive” and found the seminar of high quality, extremely useful both form and content wise. it was very interesting, helpful, informative, comprehensive and consistent. the participants felt that “…three days passed with one breath”. new theories and different leadership tools that can be used at work in the field of public health combined with the leader experience of the participants helped them structure all previously gained knowledge. the participating women leaders had a unique opportunity to do self-assessment and selfappraise their leadership qualities which help them reveal the strong and weaker sides and discuss the ways to improve them as well as see themselves from the leadership prospective. they also valued learning about emotional intelligence and how to manage emotions “…i have a desire to invite the psychologist to work with us at the hospital...”. this helped them also understand why the authoritarian style is not the best approach especially when you work in an interdisciplinary team or if you are newly appointed to lead a department. the participants stated that owing to this training they realized that the inner power of women is able to move or change things which may seem unchangeable. they especially valued familiarity and open communication with other women leaders and professional trainers who provided useful information and tips for troubleshooting the situational problems and barriers. moreover, the experience of getting to know the colleagues from other regions who are inspired, fulfilled, beautiful women striving to use their skills as well as spiritual and cultural values for the general development of the country was very powerful. the presence, facilitation and sharing of experience of the international faculty was greatly appreciated. “…it showed the openness of the world towards my country ukraine from a different perspective”. aspects of special value the participants especially valued some specific aspects of the training. these included: the scientific evidence on which the public health leadership course for women was based, realizing the added value of women power in leading people regardless of age and position, systematically presented content, examples from personal lives of trainers and coaches which allowed for making comparisons with their own life experiences, possibility to improve oneself, importance of developing the vision and understanding what kind of a leader you want to be. “the value for me personally is that i realized my personal complexes, my claims toward myself which i have in my thoughts that i shouldn’t have”. the new theories of leadership, practical exercises on system thinking using a ”red ribbon” (a role play illustrating system thinking using a red ribbon to connect the elements of a system) and “thinking hats” (the de bono “six thinking hats”) technique provided the information that a woman-leader needs at work. “when i return to work, i will try to put into practice all gained knowledge and skills and will put special attention to my personal qualities”. http://context.reverso.net/%d0%bf%d0%b5%d1%80%d0%b5%d0%b2%d0%be%d0%b4/%d0%b0%d0%bd%d0%b3%d0%bb%d0%b8%d0%b9%d1%81%d0%ba%d0%b8%d0%b9-%d1%80%d1%83%d1%81%d1%81%d0%ba%d0%b8%d0%b9/authoritarian http://context.reverso.net/%d0%bf%d0%b5%d1%80%d0%b5%d0%b2%d0%be%d0%b4/%d0%b0%d0%bd%d0%b3%d0%bb%d0%b8%d0%b9%d1%81%d0%ba%d0%b8%d0%b9-%d1%80%d1%83%d1%81%d1%81%d0%ba%d0%b8%d0%b9/scientific+evidence czabanowska k, cichowska myrup a, aleksandrova o. women leadership for public health: the added value and needs of women driving public health system reform in ukraine (case study). seejph 2018, posted:20 september 2018. doi 10.4119/unibi/seejph-2018-200 6 satisfaction with the trainers the participants were very satisfied with the speakers’ performance. the presenters and trainers were pleasant, open-minded, attracted their attention, very outspoken, showing excellent knowledge of the subject matter and professionalism, they served as examples or role-models. “i realized how to work on myself to become better and on what to work on concerning my personality.” the combination of women`s stories from real life or previous experience, attractive way of presenting the material, availability and genuine interest to answer the questions were inspirational. the trainers were open to dialogue and able to merge with the participants due to their high level of qualification, commitment to the job, high motivation, integrity and gratitude. each speaker was an individuality holding their own position in the society and their own positive world view. their honesty, openness and equal attention to all the participants greatly contributed to the satisfaction from the course. on the whole “….everything was good, time flew fast and the emotions were running high, it was generally hard to say goodbye to them. i love them. good luck to them”. areas for improvement although everything was interesting and highly satisfactory, the participants identified some areas which might be improved in the future courses. they would generally welcome more time to get to know each other better, to have more possibility for discussions and communication with the speakers as well as time to solve some situational problems from their individual professional practice, using real-life examples and getting feedback on them from other colleagues. they would also appreciate more situational games, exercises and active group work like the ones with the “ribbon” and “hats” and have more space to delve into the emotional intelligence topic and more life stories or research on women leaders in medical sphere even if it means inviting more teachers. further training needs there was a strong conviction that the course on women leadership in public health needs to be continued in the context of theoretical knowledge and extended practical application with mentoring and coaching. the participants would be interested in getting more acquainted with such topics as: emotional intelligence, communication and social marketing, theory of negotiations, general management and time management to become more efficient and effective, short, consistent personal coaching, how to develop as a future leader and practical application of women leadership in public health practice including the dress code and personal preparedness for a role as a woman leader, leading change in the organisation, how to create a successful and effective team for a new public health centre in the region. they would also like to learn and practice how to lead public health system transformation in ukraine, how to collaborate with different sectors and stakeholders for the benefit of public health reform, how to use evidence for informed decision making, how to practically apply women leadership competences in specific public health practice and importantly how to reach a high level position “i have my personal need to get a high level job: just give me an opportunity and i will turn the world.” the list of needs is long which shows that there is a great need for such a training especially for women. the course on women leadership for public health in ukraine was a small drop filling a huge niche which is open. the participating women would like to be informed and invited for similar events in the future. some of them would like to be involved and collaborate with who in preparing future programmes to assure the inclusion of current and real issues of concern in ukraine. czabanowska k, cichowska myrup a, aleksandrova o. women leadership for public health: the added value and needs of women driving public health system reform in ukraine (case study). seejph 2018, posted:20 september 2018. doi 10.4119/unibi/seejph-2018-200 7 concluding remarks and recommendations the initiative proved to be empowering not only for the participants of the seminar but also for the trainers who were able to challenge their own frames of reference and show the added value of women leadership in times of transformation in the context of ukrainian health care and public health reforms. the women leaders from different regions of ukraine had a unique opportunity to build social capital around women leadership and develop their own professional public health network which, in order to be sustainable, needs further support and more focused and in-depth training. this initiative has further provided evidence of the need for practical, context-specific development of female public health leaders in ukraine. the programme will benefit from developing trainers and mentors from among the participants who can replicate the training model to meet the need of women working in the field of health in ukraine. references 1. world economic forum. the global gender gap report 2016. p. v. http://www3.weforum.org/docs/gggr16/wef_global_gender_gap_report_2016.p df (accessed: 10 june, 2017). 2. report on women’s careers in science and universities, and glass ceiling encountered, european parliament, 2014. 3. gender equality index 2015 − measuring gender equality in the european union 2005-2012. european institute for gender equality; 2015. 4. european commission. directorate-general for justice. women in economic decision-making in the eu: progress report, 2012, publications office of the european union. http://ec.europa.eu/justice/gender-equality/files/women-onboards_en.pdf (accessed: 12 june, 2017). 5. world bank. country gender assessment for ukraine 2016. world bank, kiev; 2016. https://openknowledge.worldbank.org/handle/10986/24976 license: cc by 3.0 igo. 6. day m, shickle d, smith k, zakariasen k, oliver t, moskol j. time for heroes: public health leadership in the 21st century. lancet 2012;380:1205-6. 7. czabanowska k, rethmeier ka, lueddeke g, smith t, malho a, otok r, stankunas m. public health in the 21st century: “working differently means leading and learning differently” (a qualitative study based on interviews with european public health leaders). eur j public health 2014;24:1047-52. 8. koh h. leadership in public health. j cancer educ 2009;24:s11-8. 9. mezirow j. & associates. learning as transformation, critical perspectives on a theory in progress. san francisco: jossey-bass inc; 2000. 10. hsieh hf, shannon se. three approaches to qualitative content analysis. qual health res 2005;15:1277-88. ______________________________________________________________________________________ © 2018 czabanowska et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 1 | 16 original research school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation maha nubani husseini1,2, milka donchin2,3 1 faculty of public health, al-quds university, palestine; 2 linda joy pollin cardiovascular wellness center for women, division of cardiology, hadassah university hospital, jerusalem, israel; 3 braun school of public health, hadassah & the hebrew university-hadassah medical school, israel corresponding author: maha nubani husseini, rn, mph, phd; address: po box 51915, abu dies campus, palestine; telephone: +972 (0) 522520104; email: dhus802@hadassah.org.il / m_nubani@hotmail.com nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 2 | 16 abstract aim: school-based interventions have the potential to intervene with the students and teachers, and to reach their families. a controlled program trial was designed to promote healthy eating and physical activity among palestinian females, while the process evaluation aimed to monitor the program’s implementation and identify factors that led to its success. methods: a randomized controlled program trial was conducted in 14-palestinian schools under 4-different jurisdictions, divided into 7-control and 7-intervention schools chosen randomly after applying a sample size calculation. a monitoring system, elucidated factors which contributed to improved outcomes, was applied in the intervention schools only, while the control schools continued with their regular curriculum. the process evaluation tracked the timing and implementation of interventions including changes in the school strategy, policy and structure, teachers’ capacity building, mothers’ education and involvement, the school’s supportive health environment, and integration food consumption records and physical activity into the daily class routine. results: the intervention included 3,805 schoolchildren and their mothers’ as-well-as 147 teachers. at the completion of the 18-month intervention the schools had successfully participated in the various intervention activities. only the private school did not sustain some of the interventions, which put it at 55% completion of the school supportive environment activities compared to the other schools which all reached the 100% completion of planned activities. conclusion: this process evaluation approach enabled a more comprehensive understanding of the intervention implementation and outcomes and identified factors that contribute to the sustainability of the intervention. each school required a different amount of time for understanding, applying and implementing the program depending on its needs. keywords: intervention, nutrition, physical activity, process evaluation, school, schoolchildren. acknowledgments: the authors thank the participating schools, the palestinian ministry of education, the unrwa office of education and jerusalem municipality for facilitating fieldwork. i would like to acknowledge my gratitude to my doctoral thesis supervisors, prof. elliot berry and prof. ziad abdeen. source of funding: this study is a part of ph.d. degree. the researcher received scholarship from joint distribution committee (jdc). the author thanks nutrition and health research institute al-quds university for funding part of the research. the linda joy pollin cardiovascular wellness center for women at the division of cardiology of hadassah university medical center, directed by dr. donna zfat funded the mothers’ activities and lectures towards the end of the intervention, as well as the implementation of the program at the control schools one year after the study ended, as they were promised when they got selected. conflicts of interest: none declared. nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 3 | 16 introduction obesity is a significant risk factor for chronic diseases, including type ii diabetes mellitus, coronary heart disease, hypertension, stroke and certain types of cancer (1-3). the prevalence of obesity in children and adolescents is increasing throughout the world (1). in palestine, there is a lack of a nationally representative survey that reveals the prevalence rates of overweight/obesity and physical activity among all age groups. a cross sectional study conducted in 2017 in palestine showed that the prevalence of overweight and obesity was 14.5 and 15.7% respectively among palestinian children between the ages of 6-12 years (2). while 15.1% of the female were overweight and 13.8% were obese. another systematic review showed that the prevalence of overweight and obesity in adults was 30% and 18% respectively (1). in east jerusalem, rapid urbanization, modernization, and sedentary lifestyles have contributed to the growing frequency of overweight and obesity in all age groups (3). the need for effective preventive and protective measures to control the obesity epidemic has become a major focus of attention. evidence suggests that increased childhood body mass index (bmi) can predict adulthood overweight and obesity (4) indicating that these interventions should be introduced as early as possible so that people employ a healthy lifestyle from childhood. healthy nutrition and physical activity are the key factors in preventing and reducing obesity in children (5). programs aimed at promoting healthy nutrition and physical activity may be best addressed in a school setting, as schools offer a safe and supportive environment where children can learn and implement these healthy practices (6,7). several published studies on weight management interventions in the school setting show promising results (8), but there is a lack of process evaluation data to assist investigators in designing optimal studies. process evaluation can illuminate how the intervention was implemented, participants’ level of engagement, and the level of maintenance during the intervention (9). process evaluation is crucial in providing a better understanding of the different factors influencing the implementation process (10). analysis of process data may clarify the causal mechanisms that lead to outcomes. process evaluation informs subsequent interventions, enabling replication in other settings (9). this paper describes a process evaluation of a school-based randomized controlled program trial that took place over two academic years in each school. the intervention was implemented in seven girls’ elementary schools in east jerusalem, with seven additional schools serving as a control group. the aim of this intervention was to promote healthy eating and physical activity among the schoolchildren, their mothers and teachers. the process evaluation aimed to monitor the program’s implementation and to elucidate which factors improved the outcomes. methods the study design and objectives have been described elsewhere in detail (11). briefly, the intervention aimed to improve knowledge, attitudes and health behaviors of schoolchildren, their teachers and their mothers with regard to healthy nutrition (12) and physical activity. the sample size calculation, described in detail elsewhere (11), was based on the estimated prevalence of healthy behaviors relating to physical activity (>5 days per week), which was estimated at 25% among girls in grade 6 in the heath behavior school children study nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 4 | 16 (13). fourteen girls' schools operating in east jerusalem under differing jurisdictions: (jerusalem municipality (jm), palestinian authority (pa), united nations relief and works agency (unrwa), and private schools) were stratified by jurisdiction and then randomized into 7 intervention and 7 control schools. the preand postintervention data for the outcome evaluation was collected from one 4th grade class and one 5th grade class in each of the schools; however, the intervention activities and monitoring were implemented within all the intervention schools’ body including all schoolchildren in all different grades, while control schools continued with regular curriculum. the study procedures were approved by the hebrew university of jerusalem/authority for research students committee, as well as the israeli ministry of education, palestinian ministry of education, unrwa office of education department and the private schools’ principals. intervention development and delivery the intervention was designed and implemented through the utilization of the socio-ecological model (figure 1) to promote healthy eating and physical activity in the intervention schools, whereas the control schools continued with their regular curriculum. the program was designed and implemented as a multi-level intervention, targeting schoolchildren, their mothers, and their teachers, as well as addressing school policies and the physical and social environments. the intervention included numerous components related to healthy eating and physical activity, and encompassed the entire school setting. the program had the support and commitment of the school principals. figure 1. ecological model nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 5 | 16 intervention strategy and structure: in each school, a teacher was appointed as the program coordinator and headed the health steering committee. the health steering committee consisted of representatives of teachers, mothers, schoolchildren, and the owner of the canteen (8-10 individuals). teachers’ capacity building: teachers were trained through five training sessions of 120150 minutes long given in the setting of inservice training for professional credit. mothers’ education and involvement: mothers were represented on the health steering committee and were invited to seven workshops held in each of the schools (120150 minutes long each), focusing on the importance of healthy eating (mediterranean diet pattern) and physical activity. supportive health environment and policy: the components of the program were developed by the school team in cooperation with the researcher. intervention activities are presented in table 2. successful and creative components that were suggested by school health steering committees were then disseminated to other schools as possible interventions. schools ended up implementing activities that included: a. changing the school canteen offerings to exclusively healthier food choices (no sugared drinks, candy, or chips, and more fresh juices, fruit, and vegetables); b. integrating health messages into the morning announcements (the importance of healthy food and regular exercise); c. a healthy wall magazine displayed in each class twice a year, created by the students under the supervision of their teacher; d. a healthy corner in each classroom; e. decorating the hallways with paintings encouraging healthy nutrition; f. decorating the play yards with games such as “snakes and ladders,” “tic tac toe,” and “hopscotch” to promote physical activity during breaks; g. morning aerobics supervised by the physical education teacher; h. health promotion checklist in each class to track schoolchildren’s daily healthy habits of eating breakfast, drinking milk, and bringing healthy lunches (i.e. sandwiches, fruit, and vegetables). after a few months, a number of other activities were added, such as an active break (with directed physical activity during the break.); i. alternative rewards. integrating food consumption records in the daily class routine: in addition to the health promotion checklists, a reward system was designed to encourage the children to opt for healthy food choices: students were incentivized with prizes such as healthy snacks or school stationery, instead of with candies or other unhealthy products, to emphasize the importance of staying healthy. process evaluation the process evaluation included using a checklist to monitor and document the implementation of the planned activities in the intervention schools, and an assessment of whether the intervention was proceeding as designed. the researcher visited the intervention schools on a bi-weekly basis to directly observe classrooms (decoration, healthy corner, class wall magazine, checklists and active break), hallways (decorations), canteens (products sold) and school yards (decorations and games). the health steering committee met every 4-6 weeks to discuss the current activities and the need for any changes or additions. these meetings were followed by semi-structured interviews (teachers, schoolchildren and their mothers) to monitor the intervention activities, progress and the schools’ performance. nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 6 | 16 in addition to the researcher’s regular observation visits to the schools throughout the 18 months of the program, specific program evaluation visits were conducted during february–april of the second year of the program, which included the postintervention questionnaire for the schoolchildren, mothers, and teachers, and interviews with the principals. these visits ensured that the activities were going according to plan and included periodic interviews with mothers and teachers regarding the program as a whole as well as their satisfaction with specific activities. in order to further explore the components leading to success in the intervention, at the end of the program, the researcher did faceto-face interviews with principals, health steering committee members, and mothers from the more successful intervention schools. results the total number of intervention participants was 3,805 schoolchildren and their mothers as well as 147 teachers in 7 different schools of the intervention. the timeline summarizing the implementation of the intervention is presented in table 1. the school principal designated one teacher as program coordinator, who was responsible for implementing and running the program at her school with the help of a health steering committee. the principal also nominated a health steering committee whose members represented teachers, mothers, schoolchildren, and the owner of the canteen (8-10 persons). the researcher met with the committee once every four-six weeks. during the first meeting, the results of each school’s baseline study were presented and compared with the data from all fourteen schools, serving as a basis for discussing the program elements. based on this data, the committee outlined objectives to meet their needs, then designed and implemented the intervention using their own resource. the program activities were then assigned to members of the teaching staff who were trained as part of the teachers’ capacity building (see below). for example, the art teacher was responsible for health promotion hallway decoration, the physical education teacher was assigned to leading morning aerobics, and the homeroom teacher oversaw the school’s health magazine and the health promotion checklist (details in table 2). these activities were monitored by the health steering committee. nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 7 | 16 table 1. program process evaluation timetable-school monthly performance *numbers in the table refer to schools that implemented the activity table 2. intervention activities components of the socioecological model steps of the intervention procedures providers schoolchildren (n=3,805) morning announcements the teacher in charge prepared a monthly list of topics related to health issues to be discussed during the morning announcements. a group of schoolchildren were assigned to a certain topic and directed to prepare to present it in a fun and informative way. schoolchildren nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 8 | 16 the teacher went through the information to certify what would be presented. morning aerobics every morning schoolchildren would participate in a physical activity such as aerobics, zumba, dancing, etc. before entering the classroom. physical education teacher health behavior checklist/ health promotion card a checklist to show schoolchildren healthy habits such as eating breakfast, drinking milk, and bringing a sandwich, water, and fruits and vegetables to school. different formats of a health promoting checklist were designed in each class to track schoolchildren’s daily healthy habits. schoolchildren were rewarded with healthy snacks or stationery. homeroom teacher mothers (n=3,805) mothers’ workshops 4 training sessions (120-150 minutes long each)  healthy eating  physical activity dietitian physical educator schools activities school health day school staff teachers (n=147) teachers’ training 5 training sessions (120-150 minutes long each)  healthy eating  physical activity  strategies for building school health programs and methods to integrate health into subjects being taught dietitian physical educator health promoter school’s policy & environment (n=7) active break schoolchildren started to eat their sandwiches in class before the 10 o’clock break so they could subsequently go outside for active playtime. teachers decorations the hallways and the walls of the schools play yards were decorated with paintings of water, fruit and vegetables. teachers and schoolchildren school yard games school play yards were decorated with games such as snakes and ladders, tic tac toe, and hopscotch to promote physical activity during breaks. teachers nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 9 | 16 wall magazine a wall magazine was created in each classroom twice every year. it included information on healthy habits, physical activity and specific foods with information about health benefits or harm. schoolchildren with the homeroom teacher health education and healthy corner in class teachers integrated health topics into the subjects they taught after receiving training in this field, and established a healthy corner with the help of the schoolchildren. material included three dimensional shapes for healthy food products, the food pyramid, etc. teachers healthy food choices in the canteen the owner of the canteen was part of the health steering committee and was included in all steps of the intervention. school canteens were given a transition period to change their food products to include healthier food choices and limit unhealthy food choices. the canteens stopped selling unhealthy snacks (sugared drinks, candy, chips, etc.) and started selling healthy fresh juices, lupin beans, fruit and vegetables, etc. owner of the canteen and the health steering committee the teachers’ capacity building training sessions were held separately in each of the schools. the training targeted 1st–6th grade teachers, 80% of whom received training on the principles and importance of healthy nutrition and physical activity, as well as methods for incorporating this content into class curricula. teachers were also trained in the principles and strategies of building a school health program. the majority of the training sessions for teachers were attended by the school principal and/or the viceprincipal. during the same period mothers’ workshops on importance of healthy nutrition and physical activity were conducted in each of the schools, followed by the opening day kick-off with a clown who presented the main messages of the program to the schoolchildren in a fun and interactive way. together with their children, mothers also participated in a field day physical activity program as well as several other activities devoted to healthy eating campaigns. mothers were also involved in preparing healthy lunches. toward the end of the first school term, all seven schools implemented the morning announcements and the healthy wall magazines. they also began changing the products sold at the canteen, except for the private school which did not apply this intervention (since their canteen was a private business and not owned by the school). health promotion checklists were initiated in each of the classes, monitoring the nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 10 | 16 schoolchildren’s healthy behaviors such as eating breakfast daily, drinking milk before arriving to school, bringing fruit and vegetables to school as snacks, etc. the morning aerobics were introduced in all seven schools at the beginning of the second term; however, the private school did not continue this component. the seven schools also decorated their hallways and created the healthy corner in every class. they began discussing health during the weekly homeroom period. the private school did not implement this activity as well. soon after, teachers in all seven schools were trained on how to introduce an active break and began implementation. this intervention distinguished between a recess designed for eating, supervised by teachers in the classroom, and an outdoor recess in the play yard. this encouraged the students to eat a healthy mid-morning snack and to use their time in the play yard for exercise. prior to this intervention, students were given one long break in the play yard, during which they were expected to both eat and play at their discretion. teachers received their final training session on integrating physical activity and healthy eating into the subjects they taught, toward the end of the academic year. mothers’ activities continued during this period. they received additional workshops on nutrition, followed by physical activity, reaching a total of four mothers’ workshops during the academic year in each of the schools. finally, the mothers participated in the school’s health activities, such as the open health day. school environment was addressed by the beginning of the second academic year of the program; all the schools except for the private school had decorated their schoolyards. at the completion of the 18 months’ intervention, the pa, jm, unrwa and private schools had successfully participated in the various intervention activities, including the school strategies and structure, the teachers’ trainings, and mothers’ workshops. however, when it came to implementing the school supportive environment, the private school did not sustain the morning announcements or decorate the hallways. they also did not decorate the school yard with games, or take part in changing the food products at the canteen. this put the private school at 55% completion of the school supportive environment activities while the other schools all reached the 100% completion. learning from success as mentioned earlier, interviews were conducted at the end of the intervention as part of the process evaluation in order to learn from the most successful school’s practices. the following insights were obtained: interviews with the school principals: a. school principals reported that their full support and commitment as well as the teachers’ support were of great impact to the success of the program. b. they also reported that parents played a crucial role in supporting the programs’ activities. parents helped decorate the hallways, covered the costs of printing the healthy messages, and participated in the workshops and open health days at the schools. c. school principals reported that the schoolchildren were eager to play a main role in the program. as such, they were motivated to compete to get more points on the checklist, or to be chosen to give the morning announcements. nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 11 | 16 d. according to the school principals, the program had a considerable overall impact on the school environment, the schoolchildren, and their lives inside and outside of school. interviews with the health steering committee: a. according to the health steering committee, the school principals’ full support, commitment and provision of the needed equipment was paramount. b. the health steering committee also reported that team spirit among teachers was a crucial factor to the program’s success. c. finally, the health steering committee noted that the physical education and science teachers were particularly active on the school health steering committee and played a main role in implementing the program. interviews with the mothers: a. the mothers were convinced of the health benefits and the program's positive impact on them, their daughters and whole family; as such, they were fully supportive of the program and showed increased interest in ensuring that their children consumed healthy food. b. the mothers felt involved in the program’s activities and were committed to implementing their new knowledge with their families and in their homes. c. the mothers ate breakfast daily with their children, especially once their daughters began requesting this. d. educating the mothers on the topic of nutrition, and on the impact of healthy nutrition on decreasing overweight and obesity, further improved their implementation. discussion during this 18-month randomized controlled trial of a school-based health promotion intervention, the process evaluation which monitored implementation was essential for understanding how the program worked, whether it had worked as planned, and identifying the challenges and achievements associated with implementation. building school capacity for implementing a sustainable health promotion program is known to be a long-term process (13,14). the process evaluation during the program helped the staff appreciate that each school needed a different time frame for understanding, applying, and implementing the program. environmental interventions presented one of the challenges, as decorating the hallways and yards—one of the program activities— could not take place at the pa schools before the second year as the schools were undergoing renovations at the end of the first school year. the private schools chose not to implement many of the environmental aspects of the program. as these schools are private businesses, there may have been economic factors that entered into the decision. it is important to note that several of the schools had already been made aware of the aspects of the health promotion program through municipality programs designed to encourage “health promoting schools.” there were training sessions available for individual teachers through standard inservice training; however, these training activities did not provide the specific tools necessary for designing, creating and building a program. nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 12 | 16 as the program progressed, the school health steering committee implemented its roles and duties more effectively by creating and instituting additional health activities after each meeting, which took place every 4–6 weeks. according to the literature, the sustainability of an intervention program depends greatly on the school health committee's role in planning and implementing the program (15,16). the incorporation of physical education and science teachers as part of the health steering committee was identified as a positive influence, as they both understood the material and were able to incorporate the program’s activities in their classes. differences have been reported in teachers’ ability to apply health education programs successfully (18), and science and physical education teachers in particular have been found to be most effective in teaching health related topics (19). through our study, we were able to observe that when the schoolchildren began eating in class as part of the “active break” intervention, they were directly encouraged by their teachers to consume healthier food products and to decrease their intake of less healthy foods such as salty snacks, chocolates, and sweetened juices (20). teachers also began eating foods both in school and at home that were healthier, consuming breakfast and more fruits and vegetables in order to be positive role models for their schoolchildren. as part of our program, schoolchildren detailed their health habits according to the health promotion checklist, which included eating breakfast at home, drinking milk, and bringing a sandwich, water, and fruits and vegetables to school. in the process of rewarding their students, teachers themselves became more directed toward healthy practices. teacher training played a crucial role in the intervention program’s success, as seen in other studies (16,21). the provision of training to guide teachers in incorporating health information into their teaching, as well as offering specific guidance in planning interventions was perceived as an important factor. in this study, 80% of the teachers received training. this represents a better coverage than the 50% of the teachers who received training in a program instituted in hong kong (22). also, our intervention study aimed to train the largest possible number of targeted teachers, whereas the hong kong study aimed to train at least one teacher in each school (23). in the second semester, additional training was encouraged by the administration and the principals at all of the schools, and was attended by all the teachers. here too, the private school was the exception, with very low participation in training by the teachers at this school. a systematic review showed that in 30 interventions which included training for teachers, 25 of the interventions showed statistically significant results in improving fundamental movement skills and physical activity among the schoolchildren (24). an additional study showed that when teachers enjoyed the trainings they received in physical education and learned its impact on health, they decided to share the experience with their students in order to further promote physical activity (25). the qualitative assessment revealed that different components of the intervention program, involving the various dimensions of the ecological model, each contributed to meeting the program objectives and led to behavioral change (14). an important factor in the program’s success was the schoolchildren’s participation in planning, application, and implementation of the program. children were trained on how to nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 13 | 16 perform an active break, while selected students rotated responsibility for leadership of this period’s activities, with new students chosen every 3–4 weeks. since these changes had been planned by their classmates, students found it easier to accept them. the mothers’ involvement positively influenced the intervention’s success, as the mothers helped plan and implement the program. the mothers’ role began with participation in the school health steering committee. although the committee included only 3–4 mothers, each of them spread the information that was discussed at the meetings and being applied at the schools. mothers also attended the workshops held at each school and the mother-daughter activities (25,26). their role was most effective at the private school since the school did not implement all the required changes, particularly those at the canteen. since the mothers were interested in the program and its offerings, they attended all of the workshops and prepared the healthy meals/sandwiches for their daughters. schmied and his colleagues (28) suggested that participation of family members in the intervention increases the program's impact. all of the school staff (the principal, coordinator, teachers, and the owner of the canteen) as well as the parents demonstrated their full support for the program throughout its implementation period and expressed their commitment to continuing the program. during the regular visits to the schools, the researcher followed the activities and gave her feedback on the progress of the program and informed the team whether the intervention was going as planned or not. in general, through tracking participants’ experiences before, during, and after the intervention, process evaluation enhances sustainability as well as providing an accurate description for designing future projects (29). in summary, the factors that emerge from the process evaluation that promoted successful implementation of this program included the commitment and involvement of the principal and administration, training of a large percentage of the teachers rather than a single representative, involvement of mothers and children as well as teachers and administration, and follow up and encouragement on the part of the researcher. the private schools opted to implement a smaller percentage of interventions, possibly due to economic factors. limitations of this study this study is limited by the absence of process data from control schools. since these schools had been randomized to the no intervention condition, we were concerned that any data collection other than the pre post-questionnaire would be perceived as an intervention and adversely affect the control condition, and promote them to do better on their own. the comprehensive multi-sector design of the intervention did not permit an isolated assessment of the different factors of the intervention. the study is also limited by the fact that the researcher conducted the process evaluation, but this enabled direct insight to witness the implementation of the program. conclusion up-front design of the quantitative and qualitative process evaluation enabled a structured evaluation throughout the entire intervention and added insight as to variability and factors that enabled or obstructed timely execution of planned activities. the process evaluation indicated the intervention with its several components was implemented with successful results leading to the desired changes in the school nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 14 | 16 environment and healthy habits of the participants. process evaluation further identified factors that will contribute to the sustainability of the intervention even when the researchers withdraw, and will facilitate the design of more effective interventions in the future. references 1. elessi k, albaraqouni l. prevalence of obesity and overweight in palestine: a systematic review. lancet 2019;393:s20. 2. 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promoting healthy eating and physical activity among school children: findings from health-epals, the first pilot intervention from lebanon. bmc public health 2014;14:1-11. 27. van lippevelde w, verloigne m, de bourdeaudhuij i, brug j, bjelland m, lien n, et al. does parental involvement make a difference in school-based nutrition and physical activity interventions? a systematic review of randomized controlled trials. int j public health 2012;57:673-8. available from: https://doi.org/10.1007/s00038-0120335-3 (accessed: december 10, 2019). 28. schmied e, parada h, horton l, ibarra l, ayala g. a process evaluation of an efficacious familybased intervention to promote healthy eating: the entre familia: reflejos de salud study. heal educ behav 2015;42:583-92. 29. roberts-gray c, sweitzer sj, ranjit n, potratz c, rood m, romopalafox mj, et al. structuring process evaluation to forecast use and sustainability of an intervention: theory and data from the efficacy trial for lunch is in the bag. heal educ behav 2017;44:559-69. ___________________________________________________________ https://doi.org/10.1007/s00038-012-0335-3 https://doi.org/10.1007/s00038-012-0335-3 poštovana obitelj deželić, poštovana obitelj kušan, poštovani kolege i prijatelji the editors of the south eastern european journal of public health express their deepest sorrow about the death of one of our most prominent members of the editorial board, professor luka kovačić, founder of the stability pact’s forum for public health in south eastern europe (fph-see) in 2000/2001 and strong supporter of the creation of this journal. genc burazeri (tirana, albania and maastricht, the netherlands) ulrich laaser (bielefeld, germany) jose martin-moreno (valencia, spain) peter schröder-bäck (maastricht, the netherlands) obituary professor luka kovacic, md, phd professor luka kovačić, md, phd, specialist in social medicine and organization of health care, retired full professor of the school of medicine, university of zagreb, passed away on 21 april 2015 fatigued by incurable malignant disease. luka kovačić was born on 13 october 1940 in a small town đurđevac some 100 km north of zagreb in the area called podravina, where he attended primary school and finished gymnasium in koprivnica. he graduated from the school of medicine in zagreb in 1965, and after a few years of medical practice he joined the andrija štampar school of public health which is a part of the school of medicine, university of zagreb. there he spent practically his entire working lifetime. he earned both, msc and phd degrees from the university of zagreb, school of medicine in 1972 and 1983. in his academic career he advanced from the assistant position at the chair for hygiene, social medicine, and epidemiology through positions as assistant professor (1984) and associate professor (1988) to full professorship (2003). he completed the specialization in social medicine and organization of health care successfully in 1974. he was also trained in sweden (1964), scotland (1966), usa (1968 and 1971, when he was trained in public health, epidemiology and research methods at the johns hopkins school of hygiene and public health in baltimore), finland (university of kuopio, 1977) and alma-ata (who training in planning and management in 1985). he paid study visits or served as a consultant in the uk, the ussr, kazakhstan, sudan, cameroon, india, iran (undp), nigeria (who) and elsewhere. at the andrija štampar school of public health he used to held numerous posts and responsibilities: he was a head of the department for hygiene, social medicine and epidemiology 1993-1997 and after its dissolution in three smaller departments in 1997 he continued to chair the department for social medicine and organization of health care; he was deputy coordinator from 1984 and coordinator 1997-2000 of the who collaborating centre for primary health care. he served as an assistant to the director and deputy director (1984-2004) and finally as the director of the school from 2004 till his retirement in 2006. he served firstly as the coordinator and later as director (1990-1996) of the international 9-week course "planning and management of primary health care in developing countries" which was held 16 times between 1978 and 1996 at the andrija štampar school of public health with the support of the government of the netherlands and had altogether more than 350 participants coming form 66 countries. luka kovacic was active member of the croatian medical association, president of its section for social medicine and organization of health care (1978-1986). later the section changed its name into the society for public health with him as president (1986-1999). his activities and duties were so numerous, both within his institution and in the broader croatian and international context, that we mentioned only those mostly pronounced or internationally visible. luka was a gifted and dedicated teacher, mentor of six msc theses and one phd dissertation as well as altogether more than 200 diploma works for medical and nursing students at the school of medicine and school of applied health sciences. he was principal investigator in many domestic projects and played a leading role in several international projects and networks. he actively participated in the work of the european network of districts "tipping the balance toward primary health care" (ttb) from 1987, being also its chairman of the board and president of the assembly from 1997 to 2005, and the coordinator of the whole network and the project "ttb second decennial survey of the health needs and health care for older people in europe", which was implemented in five european countries including croatia in 20052006. he was also a member of the european society for public health and its scientific committee since 2000. the cooperation between the school of public health, university of bielefeld and public health academic institutions in ten south eastern european (see) countries started in the year 2000 under his able leadership together with professor ulrich laaser, supported by the stability pact for south eastern europe. professor luka kovačić contributed enormously to the establishment of the forum for public health in south eastern europe (fph-see) as a network of academic institutions, aiming at the reestablishment of professional cooperation between public health teachers and professionals in see. as the result of this cooperation six book volumes were prepared and published between 2004 and 2010 encompassing altogether more than 4300 pages, containing some 250 teaching modules authored by more than 200 authors. among them professor kovačić co-edited the volume “management in health care practice” and authored four modules therein. luka kovačić was retired less than 9 years ago but he continued to be active and involved in teaching, especially in postgraduate specialist programmes and the phd programme "medicine and health sciences" where he coordinated courses in research methods in public health also at the school of applied health sciences in zagreb he taught several subjects and mentored diploma works. he was a full member of the croatian academy of medical sciences where he chaired the college of public health and participated in the work of the committee for food and the committee for telemedicine to which he was previously president during two terms. professor luka kovačić has published almost 200 scientific and professional articles and edited several books, among them also a textbook in social medicine. he coordinated a number of national and international projects and networks, and has organized numerous national and international conferences in the field of public health and health care organization. condolence arrived to family kovačić and his colleagues from many institutions and individuals not only from croatia but also from abroad, especially from colleagues from the south eastern european countries. their words once again proved not only how much professor kovačić was respected as an expert, but also how he was appreciated and loved as a co-worker, colleague and teacher. professor luka kovacic will remain in our memory forever as a creative and responsible teacher, an excellent organizer, a competent expert, but above all as a colleague and a friend always ready to assume obligations and help others, a modest and friendly man. a number of colleagues, former students, associates and friends from all over croatia together with those coming from neighbouring countries joined his beloved ones, his wife marija, sons mladen and damir, brother, daughters in law and four lovely grandchildren at his funeral as well as at the commemoration held in the andrija štampar school of public health on may 12 to pay a tribute to a conscientious and gifted teacher, diligent and organized scientists but above all to the dear colleague, a man who did not have and could not have enemies, because he was gentle and always ready to help, both students and colleagues. only ten days after luka passed away the global public health curriculum was published in the south eastern european journal of public health (seejph) including two modules (2.1 and 2.8) he authored. so it happened that his last two teaching texts appeared in seejph, let there be glory and praises to luka kovačić! may he rest in peace! on behalf of the andrija štampar school of public health, school of medicine, university of zagreb prof. jadranka bozikov selected papers of professor luka kovacic: 1. schach e, bice tw, haythrone df, kovačić l, matthews vl, paganini jm, rabin dv. methodologic results of the who/international collaborative study of medical care utilization. milbank memorial fund quaerterly 1972; 5:65-80. 2. kovačić l. dogovaranje pregleda i posjeta. [appointment system in health care]. lijec vjesn 1979;101:120-1. 3. kovačić l & al. dogovaranje pregleda u primarnoj zdravstvenoj zaštiti. [appointment system in primary health care]. zagreb: jugoslavenska medicinska naklada; 1979. 97 pp. 4. lemkau pv, kulčar ţ, kesić b, kovačić l. selected aspects of the epidemiology of psychoses in croatia. am j epid 1980; 112:661-74. 5. kovačić l, stipanov i. optimal development and utilization of primary health care in zadar. european journal of public health 1992; 2:212-4. 6. kovačić l, šošić z. organization of health care in croatia: needs and priorities. croatian med j 1998;39:24955. 7. kovačić l, lončarić s, paladino j, kern j. the croatian telemedicine. in: hasman et al. (eds). medical infobahn for europe. proceedings of mie 2000 and gmds 2000. ios press vol 77: 1146-50. 8. heslin jm, soveri pj, vinoy jb, lyons ra, buttanshaw ac, kovacic l, daley ja, gonzalo e. health status and service utilisation of older people in different european countries. scan j prim health care 2001;19:218-22. 9. kovačić l, laaser u. public health training and research collaboration in south eastern europe. medicinski arhiv 2001;55:13-5. 10. laaser u, kovačić l, editors.the reconstruction of public health training in south eastern europe. lage: hans jacobs editing company; 2001. 104 pp. (international public health working papers ; 4) 11. lang s, kovacic l, sogoric s, brborovic o. challenge of goodness iii: public health facing war. croat med j 2002; 43:156-65 12. babić-banaszak a, kovačić l, kovačević l, vuletić g, mujkić a, ebling z. impact of war on health related quality of life in croatia: population study. croat med j 2002; 43:396-402. 13. iveković h, boţikov j, mladinić-vulić d, ebling z, kern j, kovačić l. electronic health center (ehc): integration of continuing medical education, information and communication for general practitioners. stud health technol inform 2002; 90:788-92. 14. ebling z, kovačić l, šerić v, santo t, gmajnić r, kraljik n, lončar j. traheal, bronhial and lung cancer prevention in the osijek municipality. med fam croat 2003; 11 (1-2):15. 15. gazdek d, kovačić l. navika pušenja djelatnika u zdravstvu koprivničko-kriţevačke ţupanije – usporedna studija 1998. i 2002. [smoking habits among health staff in the county of koprivnica-krizevci--comparative study 1998 and 2002]. lijec vjesn 2004;126:6-10. 16. vrca botica m, kovačić l, kujundţić tiljak m, katić m, botica i, rapić m, novaković d, lovasić s. frequent attenders in family practice in croatia: retrospective study. croat med j. 2004;45:620-4. 17. vrca botica m, kovačić l, kujundţić tiljak m, katić m, botica i, rapić m, novaković d, lovasić s. frequent attenders in family practice in croatia: retrospective study. croat med j. 2004; 45:620-4. 18. kovačić l, boţikov j. master programs in public health – dilemmas and challenges. european phd programmes in biomedicine and health sciences. proceedings of the european conference on harmonisation of phd programmes in biomedicine and health sciences zagreb, croatia, april 24 and 25, 2004. zagreb: medical school, 2004; 52-4. 19. bjegović v, kovačić l, laaser u. the challenge of public health transition in south eastern europe. journal of public health 2006;14:184-9. 20. kovačić l, gazdek d, samardţić s. hrvatska zdravstvena anketa: pušenje [croatian health survey: cigarette smoking]. acta med croatica 2007;61:281-5. 21. kovačić l, zaletel kragelj l (eds.). management in health care practice. lage: hans jacobs verlag; 2008. 22. majnarić-trtica lj, vitale b, kovačić l, martinis m. trends and challenges in preventive medicine in european union countries. comment on the state in croatia. period biol. 2009;111:5-12. 23. kovačić l, laaser u. ten years of public health training and research collaboration in south eastern europe (phsee). snz.hr 2010;1(1):53-4. 24. tomek-roksandić s, tomasović mrčela n, kovačić l, šostar z. kardiovaskularno zdravlje, prehrana i prehrambeni unos soli kod starijih osoba. [cardiovascular health, diet and salt in the elderly]. acta med croatica 2010;64:151-7. 25. vadla d, boţikov j kovačić l. differences in health status and well-being of the elderly in three croatian districts. eur j public health 2011; 21(suppl 1):156. 26. vadla d, boţikov j, akerström b, cheung wy, kovačić l, mašanović m, merilainen s, mihel s, nummelinniemi h, stefanaki in, stencrantz b. differences in healthcare service utilisation in elderly, registered in eight districts of five european countries. scand j public health. 2011; 39, 3:272-9. 27. zaletel kragelj l, kovačić l, bjegović v, boţikov j, burazeri g, donev d, galan a, georgieva l, pavleković g, scintea sg, bardhele d, laaser u. the use and exchange of teaching modules published in the series of handbooks prepared within the frame of the „forum for public health in south-eastern europe“ network. zdrav var 2012; 51: 237-250. 28. keenan s, hammond j, leeks d, šogorić s, kovačić l, dţakula a, ganzleben c, guarinoni m, belin a. food safety and public health situation in croatia. european parliament, directorate-general for internal policies, brussels, october 2012 (monograph, 66 pages). available at: http://www.europarl.europa.eu/studies 29. polić-viţintin m, tomasović-mrčela n, kovačić l. mortalitet od cirkulacijskih bolesti i zloćudnih novotvorina u gradu zagrebu u osoba mlađih od 65 godina – stanje za uzbunu? [mortality rates of circulatory system diseases and malignant neoplasms in zagreb population younger than sixty-five – call for alarm?] acta med croatica. 2012: 66: 357-64. 30. vadla d, boţikov j, kovačić l. are the untreated anxiety and depression in elderly unrecognized sources of increased healthcare utilisation? eur j public health 2012; 22(suppl. 2):212-3. 31. bralic i, tahirovic h, matanić d, vrdoljak o, stojanović-špehar s, kovačić v, blaţeković-milaković s. association of early menarche age and overweight/obesity. j pediatr endocrinol metab. 2012;25(1-2):57-62. 32. vadla d, boţikov j, blaţeković-milaković s, kovačić l. anksioznost i depresivnost u starijih osoba pojavnost i povezanost s korištenjem zdravstvene zaštite. [anxiety and depression in elderly prevalence and association with health care]. lijec vjesn. 2013; 135:134-8. 33. vrcić keglević m, kovačić l, pavleković g. assessing primary care in croatia: could it be moved forward? coll. antropol. 2014; 38(suppl. 2): 3–9. 34. bendeković z, šimić d, gladović a, kovačić l. changes in the organizational structure of public health nurse service in the republic of croatia 1995 to 2012. coll antropol. 2014; 38(suppl. 2):85-9. 35. šimić d, bendeković z, gladović a, kovačić l. did the structure of work in the public health nurse service of the republic of croatia change in the period 1995-2012? coll antropol. 2014; 38(suppl 2):91-5. 36. kostanjšek d, topolovec niţetić v, razum z, kovačić l. getting some insight into the home care nursing service in croatia. coll antropol. 2014; 38(suppl 2):97-103. 37. kovačić l, malik m. n2.1 demographic challenges, population growth, ageing, and urbanization. seejph 2015; available at: http://www.seejph.com/n-2-1-demographic-challenges-population-growth-aging-and-urbanisation/ 38. kovačić l. n2.8 disaster preparedness. seejph 2015; available at: http://www.seejph.com/n-2-8-kovacicdisaster-preparedness-150322/ http://www.europarl.europa.eu/studies http://www.ncbi.nlm.nih.gov/pubmed/23898693 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 1 original research the dutch long-term care reform: moral conflicts in executing the social support act 2015 wesley jongen1, peter schröder-bäck1, jos mga schols2 1 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, the netherlands; 2 department of health services research and department of family medicine, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, the netherlands. corresponding author: wesley jongen, phd, department of international health, maastricht university; address: po box 616, 6200 md, maastricht, the netherlands; telephone: +31433882204; email: w.jongen@maastrichtuniversity.nl jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 2 abstract on 1 january 2015, a new long-term care reform entered into force in the netherlands, entailing amongst others a decentralization of long-term care responsibilities from the national government to the municipalities by means of a new law: the social support act 2015. given the often disputed nature of the reform, being characterized on the one hand by severe budget cuts and on the other hand by a normative reorientation towards a participation society, this article examines to what extent municipalities in the netherlands take (potential) moral conflicts into account in their execution of the social support act 2015. in doing so, the article applies a ‘coherentist’ approach (consisting of both rights-based and consequentialist strands of ethical reasoning), thereby putting six ethical principles at the core (non-maleficence & beneficence, social beneficence, respect for autonomy, social justice, efficiency and proportionality). it is argued that while municipalities are indeed aware of (potential) moral conflicts, the nature of the new law itself leaves insufficient room for municipalities to act in a sufficiently proactive and supportive/empowering manner on these challenges. keywords: ethical reasoning, long-term care reform, moral conflicts, the netherlands. conflicts of interest: none. jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 3 introduction background in 2006, the council of the european union made reference to “a set of values that are shared across europe” in its ‘council conclusions on common values and principles in european health systems’ (1). the council conclusions stipulate that “[t]he health systems of the european union are a central part of europe's high levels of social protection, and contribute to social cohesion and social justice as well as to sustainable development. the overarching values of universality, access to good quality care, equity, and solidarity have been widely accepted in the work of the different eu institutions” (1). this set of values was subsequently reinforced a year later in the european commission’s ‘white paper together for health: a strategic approach for the eu 2008-2013’ (2), comprising the eu’s health strategy supporting the overall ‘europe 2020’ strategy (3). the healthcare sector, and more specifically the long-term care sector, has always been a source for ethical debate. typical ethical issues (or moral conflicts) in long-term care decision-making include the debate on whether we should only look at people’s deficits or also to their rest capacities (4),“the nature and significance of the elder's diminished capacity for self-care and independent living”, the question “whether an older adult should continue to live at home”, “the obligation of the elder to recognize and respect the limits that family members may justifiably set on their care giving responsibilities”, a loss of autonomy “when the decision is made to change either the elder’s place of living or support services” and “the balance to be struck between independence and safety” (5). however, as argued by ranci and pavolini (6), “[o]ver the past two decades, many changes have happened to the social welfare policies of various industrial countries. citizens have seen their pensions, unemployment benefits, and general healthcare policies shrink as ‘belt tightening’ measures are enforced”. at the same time, ranci and pavolini (6) argue, “longterm care has seen a general growth in public financing, an expansion of beneficiaries, and, more generally, an attempt to define larger social responsibilities and related social rights”. consequently, pavolini and ranci (7) conclude that “[f]aced with the problems associated with an ageing society, many european countries have adopted innovative policies to achieve a better balance between the need to expand social care and the imperative to curb public spending”. the adoption of such innovative policies is referred to here as reforms in longterm care policies. the unfold of long-term care reforms even seems to be exacerbated in the aftermath of the 2008 economic crisis, when many european countries introduced austerity measures that in many cases appeared to have adverse effects on health systems and/or social determinants of health (8-12). moreover, schröder-bäck et al. argue that “[t]he current protracted economic crisis is giving rise to the scarcity of public health resources in europe. in response to budgetary pressures and the eurozone public debt crisis, decision makers resort to a shortterm solution: the introduction of austerity measures in diverse policy fields. health and social policy tend to be easy targets in this regard, and budget cuts often include a reduction of healthcare expenditure or social welfare benefits” (13). jongen et al. (14) add to this that “this crisis has had a much more direct and short-term influence on the quality of countries’ long-term care system than more gradual developments such as population aging and declining workforces, mainly due to austerity measures being the result of, or being accelerated by, this crisis”. also the council conclusions make reference to this changing context of many european countries’ long-term care system, by stating that “[i]t is an essential feature of all our systems that we aim to make them financially sustainable in a way which safeguards these values into the future” (1). moreover, the document stresses patient empowerment, by stating that “[a]ll jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 4 eu health systems aim to be patient-centred. this means they aim to involve patients in their treatment, to be transparent with them, and to offer them choices where this is possible, e.g. a choice between different health care service providers” (1). at the same time, the council conclusions acknowledge that “[d]emographic challenges and new medical technologies can give rise to difficult questions (of ethics and affordability), which all eu member states must answer. […] all systems have to deal with the challenge of prioritising health care in a way that balances the needs of individual patients with the financial resources available to treat the whole population” (1). although sharing some characteristics, every long-term care reform is embedded within peculiar national traditions and is therefore unique. this is true all the more for the latest dutch long-term care reform, that entered into force on 1 january 2015, and which can be considered as the latest major step in a more all-encompassing ‘market-oriented reform’ of the dutch healthcare system in general. the 2015 reform can be characterized as having a “hybrid structure” (15), characterized, on the one hand, by a “reign in expenditure growth to safeguard the fiscal sustainability of ltc” (16), and on the other hand by a “multiplicity of regulations to safeguard public values” (15). more concretely, as argued by maarse and jeurissen (16), the 2015 long-term care reform consists of four interrelated pillars: expenditure cuts, a shift from residential to non-residential care, decentralization of nonresidential care (implying a transfer of responsibilities in that policy domain from the national government to the municipalities), and a normative reorientation. the latter refers to the notion that “[u]niversal access and solidarity in ltc-financing can only be upheld as its normative cornerstone, if people, where possible, take on more individual and social responsibility. the underlying policy assumption is that various social care services may be provided by family members and local community networks” (16). indeed, a general shift in focus from formal care provision to informal care provision is added by jongen et al. (17) as a key element of the 2015 dutch long-term care reform. it is, however, exactly this normative reorientation, and its underlying assumption of an increased informal care provision, that is often disputed. as argued by maarse and jeurissen (16): “an important line of criticism is not only that informal care is already provided at a large scale, but also that the potential of ‘unexplored’ informal care is overestimated. furthermore, the negative externalities for caregivers who deliver informal care are underestimated”. moreover, while residential care remains under the responsibility of the national government after the entry into force of the 2015 long-term care reform, and a large part of non-residential care came under the responsibility of the health insurers, it is the municipalities that became under the social support act 2015 (ssc 2015) [in dutch: wet maatschappelijkeondersteuning (wmo) 2015] responsible for particularly those parts of non-residential care dealing with support directed towards the social participation of people with severe limitations (in the wordings of the official legal text of the social support act 2015 (authors’ own translation): “people with disabilities, chronic mental or psychosocial problems”), as well as with support for informal caregivers (17). indeed, the official legal text of the social support act 2015 stipulates that “citizens who themselves or together with people in their immediate environment are not sufficiently self-sufficient or insufficiently able to participate [in society], must be able to rely on organized support by the government” (authors’ own translation). however, municipalities have a large discretion in making this obligation to provide support concrete (the so-called ‘postcode [zip code] rationing’), which may lead to unequal access to long-term care in different municipalities (16). literature research so far, the academic literature has not extensively scrutinized the potential moral conflicts resulting from the implementation of the social support act 2015, and is more about jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 5 organization and logistics than about ethics. the available literature either touches upon mere elements of an all-encompassing ethical debate, or upon the perspective of specific groups. as an example of the former, van der aa et al. (18) consider the presumed impact of the 2015 long-term care reform on such elements as good quality of care and solidarity. van der aa et al. argue that the above-mentioned ‘zip code rationing’ might well lead to differences between municipalities in the degree of solidarity as perceived by citizens (‘zip code solidarity’). furthermore, van der aa et al. argue that it should not be taken for granted that municipalities, by simply making an efficiency move, can guarantee an equal level of care quality with the decreased budget they are faced with for executing their new long-term care tasks. next, grootegoed and tonkens (19) consider the impact of the dutch shift in focus from formal to informal care provision on such elements as respect for autonomy or human dignity and argue that “the turn to voluntarism does not always prompt recognition of the needs and autonomy of vulnerable citizens” and furthermore that “the virtues of voluntarism may be overstated by policy makers and that the bases of recognition should be reconsidered as welfare states implement reform”. examples of literature focusing on the perspective of specific groups include the articles by dwarswaard et al. (20) and dwarswaard and van de bovenkamp (21) on, respectively, self-management support considered from the perspective of patients and the ethical dilemmas faced by nurses in providing self-management support (whereby self-management is defined as “the involvement of patients in their own care process” (21), and in that way relates to the above-mentioned notion of individual responsibility). study objectives and research questions no comprehensive ethical approach towards the impact of the social support act 2015, however, appears yet to exist. the current study intends to fill in this gap, by answering the following research question: to what extent did/do municipalities in the netherlands take potential moral conflicts into account when implementing and executing the social support act 2015? as the core of the 2015 dutch long-term care reform is characterized by, on the one hand, severe budget cuts, and, on the other hand, by a normative reorientation towards a participation society wherein people are expected to take on more individual and social responsibility (16,17), we additionally formulated the following sub-research questions: 1. how do municipalities divide scarce resources in the social domain in a fair way?; 2. how do municipalities empower citizens towards a participation society? in answering both research questions we consider the potential moral conflicts experienced by municipalities, as executers of the social support act 2015, with regard to those entitled (or proclaim to be entitled) to receive support on the basis of the social support act 2015, as well as with regard to relatives providing informal care to the previous group. despite the fact that the nature, as well as corresponding reforms, of individual countries’ long-term care systems differ, the systematic approach of assessing moral conflicts resulting from the introduction of new longterm policies as applied in this study could also be transferred to other countries were longterm care reforms are being implemented. at the same time, several policy lessons could be derived from the experiences of dutch municipalities with the 2015 long-term care reform. methods research method and study design to answer our research question, a mixed-method research approach was chosen. first, a document analysis was conducted, in order to explore if, and to what extent, ethical values and principles are literally incorporated in the legal text of the social support act 2015. for jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 6 this analysis we only considered the primary source (the legal text itself) and no other, secondary documents (such as municipal policy documents). second, policy advisors (responsible for the long-term care policy domain) of all 390 dutch municipalities were invited to complete anonline survey. henceforth, no sampling technique had to be applied, although of course we had to compile a mail distribution listconsisting of either the general email addresses of municipalities, or the e-mail addresses of the specific departments the intended policy advisors are working. in some smaller municipalities these policy advisors were not only responsible for the long-term care policy domain, but for the whole social domain (next to the long-term care decentralization, municipalities were simultaneously also faced withdecentralizations in the field of youth care and in the field of labor participation of people with an occupationaldisability); in large municipalities more than one person might be responsible for the long-term care policy domain. however, in our explanatory notes we specifically asked to forward our demand to one of the intended policy advisors, in order to avoid multiple respondents from the same municipality. the reason for choosing policy advisors, instead of politicians, had to do with the potential political bias that politicians might have with regard to the topic of this study. indeed, the potential ethical implications surrounding the long-term care decentralization constitutes a politically sensitive issue in many municipalities, as clearly came to the forefront in one of the two test-interviews, which was conducted with the major of a municipality (the other test-interview was conducted with a professor of old age medicine). moreover, while each municipality also has several socalled ‘social support act consultants’ [in dutch: wmoconsulenten], who do the actual fieldwork, implying the one-to-one contact with individual (potential) clients, these employees are believed to lack an overarching helicopter view. in principle, participation in the online survey was anonymous, except when a respondent declared to be willing to participate in an in-depth telephonic interview. these in-depth interviews constituted the third step in our mixed-method research approach, and were intended to expand on the survey, instead of asking new questions. anonymity of these respondents has been guaranteed by omitting persons’ and municipalities’ names here. theoretical framework and conceptual model for the analysis of the potential moral conflicts surrounding the implementation and execution of the social support act 2015, we applied a ‘coherentist’ approach(consisting of both rights-based and consequentialist strands of ethical reasoning) as offered by schröderbäck et al. (22), thereby putting six ethical principles at the core that are considered to capture the specificities of the current study (non-maleficence & beneficence, health maximisation / social beneficence, respect for autonomy, social justice, efficiency and proportionality). taking into account the variety of seemingly similar concepts such as ‘ethical dilemmas’, ‘moral conflicts’, ‘moral dilemmas’, et cetera, it should however first be clarified which definition is applied in this study and what is meant with it. given the heavily-loaded connotation of the term ‘ethical dilemma’, we prefer the term ‘moral conflict’ here. subsequently, based on the stanford encyclopaedia of philosophy (23), we define a ‘moral conflict’ as follows: a moral conflict appears if one thinks one has good moral reasons to do one thing, but also good moral reasons to not do it, or do something that is in conflict with it. so either decision is not perfect. or, in other words: a moral conflict arises if the moral norms and values we would like to follow guide us to conflicting/opposing actions. a coherentist ethical approach, then, implies that an ethical analysis “should be based on a variety of plausible norms and values” and that none of the traditional ethical approaches is therefore superior to the other (22). instead, they all contribute important moral insights. schröder-bäck et al. (22) add to this that “their norms do weigh prima facie the same and need to be plausibly unfolded and specified in a given setting. when they are contextualised jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 7 and specified they develop their normative weight and power”. this prima facie status of the ethical principles thus “supports the process of careful ethical deliberation and reflection”. moreover, specifying the more ‘overarching’ ethical approaches into a concise set of ethical principles is considered as a useful, practical, tool for medical and public health ethics (24). each of these six principles will be discussed in detail in the following. non-maleficence and beneficence: non-maleficence implies that “a healthcare professional should act in such a way that he or she does no harm, even if her patient or client requests this” (25). beneficence is connected to non-maleficence, the only difference being that nonmaleficence involves the omission of harmful action and beneficence actively contributes to the well-being of others (25). because of their intimate connection, both principles are considered under one heading here. considering the overarching approaches to ethical reasoning as mentioned above, the principles of non-maleficenceand beneficencecorrespond to the ‘do no harm’ principle under the consequentialist approach to ethical reasoning. health maximisation / social beneficence: although in the literature one can find either of these terms, we refer to social beneficence as the norm that says that it is a moral goal to improve the wellbeing of people on an aggregated population level. social beneficence resembles in a significant way the consequentialist principle of utilitarianism. utilitarianism is the ethical theory that requests from an action or omission to be in such a way that the maximization of best consequences would follow. respect for autonomy: the ‘respect for autonomy’ principle implies a tempering of the “paternalistic benevolence contained in the principles of non-maleficence and beneficence” (25). in that way, the ‘respect for autonomy’ principle is closely related to the ‘human dignity’ principle under the rights-based approach to ethical reasoning. moreover, without taking into account the ‘respect for autonomy’ principle, it would under the principle of health maximisation / social beneficence alone be allowed “to use individuals (or whole groups) for other than their own ends and even sacrifice them if only this provided a greater net benefit, i.e. maximised health” (24). social justice: the principle of (social) justice as referred to under the rights-based approach to ethical reasoningcan be considered another side constraint to the principle of health maximisation / social beneficence. as schröder-bäck et al. (24) put it: “it does not only matter to enhance the net-benefit; it also matters how the benefits and burdens are distributed”. moreover, this also includes “a fair distribution of health outcomes in societies, which is often discussed in terms of public health as ‘health equity’” (25), which is considered by daniels as a matter of fairness and justice (26). in fact, the principle of ‘equity’ constitutes the core of the values of the ‘council conclusions on common values and principles in european health systems’. as schröder-bäck et al. (22) put it: “the other three overarching values can be conceptualised as specifications of equity (and of social justice). access to good quality of care and universality can be seen as a reiteration of the core demands of equity and justice”, while “solidarity is seen as a characteristic that describes the willingness of members of communities to be committed to the principle of justice or to each other”. in short, one could argue thus that “[j]ustice approaches in health care often demand nothing more than universal access to good quality care” (22). or, as the world health organization (who) puts it: “universal health coverage (uhc) is defined as ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship” (27). efficiency: efficiency requires the efficient use and distribution of scarce health resources (24). jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 8 proportionality:the principle of proportionality, finally, emphasizes that it is “essential to show that the probable public health benefits outweigh the infringed general moral considerations. all of the positive features and benefits must be balanced against the negative features and effects“ (24). in their ‘ethical criteria for immunization programmes’, verweij and dawson (28) combine the principles of efficiency and proportionality under one heading, by stating that a “programme’s burden/benefit ratio should be favourable in comparison with alternative […] options”. data collection for the document analysis, we specifically considered the presence of the values as stipulated by the ‘council conclusions on common values and principles in european union health systems’, as well as the six ethical principles elaborated on above. next, for the survey and in-depth interviews, these principles have been broken down into representative survey/interview questions, allowing for a structured and comparative analysis of potential moral conflicts. schröder-bäck et al. (25) applied a similar approach within the context of developing a curriculum for a short course on ethics in public health programmes, by suggesting a checklist consisting of several questions around each of the ethical principles they applied in their study (largely comparable to the six principles as applied in the current study). with the respective author of that study, one question for each of the above six principles was chosen, adapting them to the specificities of the current study, and translated into dutch (see table 1 for the final survey/interview questions). the reason for choosing merely one question per category had to do with the practical limitations of using open-ended questions in an online survey: based on andrews (29) as well as on two test-interviews we conducted, the response rate to open-ended survey questions is considered to be substantially lower than in the case of closed-ended survey questions, especially when the number of questions would be too high. the questions covering each of the six ethical principles were preceded by a general question on the identification of potential moral conflicts (intended to trigger respondents, before directing them into the six predefined categories), and followed by two general questions on the way (if applicable) municipalities deal with the identified moral conflicts. data analysis the document analysis implied a scrutinization of the presence (or non-presence) of the values and principles elaborated on abovein the legal text of the social support act 2015, either in terms of a literal incorporationin the legal text, or in terms of indirect referrals to the respective values and principles. the data of the surveys and interviews were analysed through the application of a directed approach to qualitative content analysis (30). we chose for this approach, as it allows for an analysis that “starts with a theory or relevant research findings as guidance for initial codes” (30). in that way, we were enabled to directly apply our theoretical framework of ethical reasoning in the interpretation and categorisation of the research data, with the six predefined ethical principles as initial coding categories. within each of these categories, we clustered the respondents’ answers in ‘dominant responseclusters’ as a way of quantifying to some extent our qualitative survey results. this approach allowed for an organized inclusion of the main results in this article. obviously, qualitative results can never completely be quantified, as each specific answer remains unique. therefore, in order to add some extra weight to our results, we included direct respondents’ quotes to several of the dominant response clusters. jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 9 table 1. survey/interview questions part 1: identifying potential moral conflicts q1: according to you,what are the most important moral conflicts (if any) your municipality has been faced with in the context of implementing and executing the social support act 2015? ethical principles original selected ‘check marks’(25) adapted questions ethical principle 1: non-maleficence & beneficence overall, for both non-maleficence and beneficence, is it possible to assess whether more benefit than harm is produced by intervening (or not intervening) and, if so, on what side (benefit or harm) does the equation finally fall? q2: according to you, will more people (both care recipients as informal caregivers) have advantage or disadvantage as a result of the introduction of the social support act 2015? how do these advantages and disadvantages look like? ethical principle 2: health maximization / social beneficence does it [the proposed intervention] have a sustainable, long-term effect on the public’s health? q3: according to you, will the social support act 2015 have a sustainable, long-term, effect on the quality of life of the entire (older) population? ethical principle 3: efficiency awareness of scarcity of public money; saved money can be used for other goods and services. q4: according to you, how does your municipality deal with the availability of the scarce resources that are available for the social support act 2015? ethical principle 4: respect for autonomy does the intervention promote the exercise of autonomy? q5: according to you, does the social support act 2015 provide sufficient opportunity for people’s freedom of choice with regard to the care and support they wish to receive (and the way how they receive it)? ethical principle 5: (social) justice does the intervention promote rather than endanger fair (and real) equality of opportunity and participation in social action? q6: according to you, do people under the social support act 2015 have an equal opportunity to live their lives the way they want (or, in other words: is the freedom of choice as mentioned in the previous question also practically possible for every person)? ethical principle 6: proportionality are costs and utility proportional? q7: according to you, will costs and utility under the social support act 2015 be proportional? part 2: dealing with moral conflicts q8: according to you, how does your municipality deal with the moral conflicts as identified under part 1? or, in other words: what are your municipality’s solutions to these moral conflicts? q9: according to you, are there, for your municipality, alternative ways of executing the social support act 2015, that will lead to less moral conflicts? jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 10 results document analysis in terms of the values as stipulated by the ‘council conclusions on common values and principles in european union health systems’, the legal text of the social support act 2015 only literally makes reference to the value of ‘access to good quality care’, although quality of care should be understood here as ‘good quality of (social) support’. indeed, as was explained in the previous chapter, the dutch long-term care system is, as of 1 january 2015, divided into three laws, of which the social support act 2015 constitutes the one mainly dealing with social types of care (directed at increasing or maintaining the self-sufficiency and social participation of vulnerable citizens) instead of traditional healthcare. the municipalities’ responsibility under this law can therefore best be understood as providing adequate social support services instead of providing actual healthcare services. nevertheless, this focus on social types of care instead of traditional types of healthcare, or on ‘well-being’ instead of ‘health’ as a desired outcome of support, does not imply that the social support act 2015 should not be based on certain key ethical values or principles. also the council conclusions (1) go further than traditional healthcare, by implying that “[t]he health systems of the european union are a central part of europe's high levels of social protection, and contribute to social cohesion and social justice as well as to sustainable development”. with regard to good quality of social support, then, article 2.1.1 of the social support act 2015 stipulates that “[t]he municipal council is responsible for the quality and continuity of services” (authors’ own translation), while article 3.1 continues by stating that “[t]he provider shall ensure the provision of good quality services” (authors’ own translation). services either refer here to ‘general services’ (in dutch: algemenevoorzieningen), or to ‘customized services’ (in dutch: maatwerkvoorzieningen). the latter, subsequently, is defined in the legal text as a “range of services, tools, home adaptations and other measures, tailored to the needs, personal characteristics and capabilities of a person” (authors’ own translation). solidarity is by definition an important component of this law, and is referred to in the first sentence of the legal text, which points out that “citizens bear a personal responsibility for the way they organize their lives and participate in society, and that may be expected of citizens to support each other in doing so to the best of their ability” (authors’ own translation). the values of universality and the, more overarching, value of equity (being part of the principle of social justice in our theoretical framework) are indirectly referred to in the introduction of the legal text by stating that “citizens who themselves or together with people in their immediate environment are not sufficiently self-sufficient or insufficiently able to participate [in society], must be able to rely on organized support by the government” (authors’ own translation). as a result of the limited literal inclusion of these ethical values, it is not surprising that the more specified ethical principles derived from these values are hardly included in literal terms in the legal text neither. the only exception here is the ‘respect for autonomy’ principle, that could be derived from the wording of article 2.1.2 (4.c), which stipulates that municipalities in their social support policy should specifically take the freedom of choice into account of those citizens that are entitled to customized support services. survey and interviews having considered the literal inclusion of the ethical values and principles in the legal text of the social support act 2015, a next step in our research process was to examine to what extent municipal policy advisors consider the execution of the social support act 2015 to be in compliance with the six ethical principles as applied in this study. in totality 70 policy advisors completed the survey, constituting 18 per cent of dutch municipalities. in total, ten jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 11 of these respondents also appeared to be willing to participate in an in-depth interview. the results of the surveys and in-depth interviews are described question by question in the followingsection and discussed simultaneously (as the in-depth interviews were intended to expand on the survey results instead of asking new questions).given the number of respondents, only those answers that most frequently resulted from our analysis (the ‘dominant response clusters’ mentioned above) are discussed here. the direct respondents’ quotes that are included are believed to represent the respective cluster best and are the authors’ own translations from dutch to english. question 1 (general identification of moral conflicts). although not all respondents confirmed the existence of moral conflicts with regard to the implementation and execution of the social support act 2015, most respondents did identify one or more moral conflicts. in general, our respondents identified threetypes ofmoral conflicts. first, the conflict of adhering to the social support act’s underlying theory of moving towards a participation society vs. the limited budget and time-frame that is offered to municipalities for supporting this change process. indeed, the theoretical idea of moving towards a society wherein citizens take up more individual and social responsibility and where care and support is provided on a customized basis and closer to home, is considered by many as a positive normative development. however, the severe budget cuts that accompany the long-term care decentralization (expected to lead to budgetary shortfalls), as well as the rapidity of the reform process, hamper municipalities’ opportunities for supporting this development. or, as one respondent put it: “pragmatism prevails over quality demands”. second, respondents identified the conflict of how to efficiently coordinate responsibilities between the three different long-term care acts. the fact that municipalities under the long-term care reform only got responsibility for parts of the long-term care sector might lead to unclarity and confusion, not the least among (potential) recipients of care/support, regarding under which act one is entitled to care/support. moreover, some respondents indicated that an insufficient coordination between the three laws sometimes results in a lack of incentives among municipalities to invest in prevention and informal care support, as the financial benefits of these investments might not be evident for the ‘own law’, but only for the ‘other laws’. the third moral conflict identified relates to the correct assessment of citizens’ self-sufficiency and their ability to social participation vs. their care/support needs and the urge to empowerment. the fact that municipalities have a large policy discretion in executing their responsibilities under the social support act 2015 even complicates this point, as similar situations might well lead to different assessments in different municipalities. particularly difficult, then, is how to justify these differences to citizens. question 2 (ethical principle 1: non-maleficence and beneficence). most respondents appeared to have a rather neutral stance when it comes to assessing the non-maleficence and beneficence of the social support act 2015, arguing that the act leads to advantages for some and disadvantages for others, especially on the short-term. or, as one respondent put it: “it depends on the individual perception of people whether they experience the introduction of the new social support act as an advantage or a disadvantage”. moreover, getting used to a new situation always takes time, especially for those citizens that were already entitled to care or support under the pre-2015 situation. advantages primarily include the provision of customized care closer to home, in line with people’s specific living conditions, instead of standard care provisions like in the pre-2015 situation. disadvantages primarily include the, already above-mentioned, high degree of policy discretion of municipalities regarding their allocation of support measures—which tends to lead to perceptions of ‘unfairness’ or ‘subjectivity’ among citizens—, a lower level of formal care provision as experienced by individual citizens and consequently the increasing burden on informal caregivers. jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 12 question 3 (ethical principle 2: health maximization / social beneficence). the decreasing level of formal care provision can also be considered as a disadvantage on a societal level, when considering the more long-term expected consequences of the implementation of the social support act 2015. at the same time, a decreasing level of formal care provision is not considered by all respondents as a disadvantageous development. as one respondent put it: “if we execute it [the social support act 2015] well, this will increase quality of life. however, this also entails that we should carefully deal with informal caregivers”. one of the more long-term advantages is indeed believed to be the creation of a better awareness and appreciation among citizens about care in general, as a result of the diminishing resources for formal care provision, leading to a more inclusive society—characterized by the emergence of a new quality of life—wherein people have a better esteem of their own possibilities as well as a better appreciation of each other. at the same time, many respondents pointed out that this ‘emergence of a new quality of life’ is not so much due to the social support act 2015 (or the long-term care reform in general), but more to overarching trends such as demographical developments (people get older and older), technological developments in healthcare (which facilitate people in achieving a decent quality of life) and changing ways of thinking about care in general (such as other perspectives on civic engagement and patient empowerment). as one respondent put it: “the quality of life has always had a different standard than the generation before”. or, as another respondent put it: “laws don’t have an influence on quality of life”. question 4 (ethical principle 3: respect for autonomy). respect for autonomy was considered by most respondents as being sufficiently covered by the social support act 2015, specifically through the inclusion of the freedom of choice as mentioned under article 2.1.2 of the social support act 2015. concretely, the freedom of choice as referred to in article 2.1.2 implies either the choice between several by the municipality selected providers (when one is entitled to customized care services) or a fully open choice (when one is entitled to a personal budget). yet, respondents did put several remarks to this freedom of choice. first, due to the large discretion municipalities have in executing the social support act 2015, the interpretation of freedom of choice differs between municipalities (indeed, some municipalities offer a larger selection of providers than others). as one respondent put it: “the new social support act isn’t designed as to ‘support wishes’, nor as a ‘right to support’. therefore, there is a strong dependence on supplemental local rules”. second, in practice, freedom of choice is not always considered as an added value by people, especially by vulnerable people that are often just looking for good quality support. as one respondent put it: “for that [freedom of choice] there is little attention among people. moreover, it is questionable whether that is actually needed; people merely want good quality care instead of freedom of choice” (author’s own translation). question 5 (ethical principle 4: social justice). in line with the previous question, the question about social justice was basically about people’s capabilities of making use of their right to freedom of choice. answers to this question were divided. on the one hand, many respondents considered the majority of people that are entitled to support under the social support act 2015 to be indeed capable of making use of their right to freedom of choice. moreover, when necessary, support is offered to clients by the municipality. as one respondent put it: “the municipality is actively cooperating with ‘client supporters’ to facilitate people as good as possible in their freedom of choice” (these ‘client supporters’ are people that work independently from the municipality). on the other hand, other respondents emphasized that not everyone, especially vulnerable groups in society, are capable of applying their freedom of choice, neither has everyone a social network at her/his disposal to support them in doing so. moreover, freedom of choice depends to some extent on people’s jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 13 own resources. indeed, under the social support act 2015, the own financial contributions people are expected to pay for the care/support they receive have grown as compared to the pre-2015 situation, which might lead to the avoidance of care/support (31). as a result, respondents argue, differences in society grow when it comes to the possibility of people to make use of their freedom of choice under the social support act 2015. as one respondent put it: “a barrier to care is created, that leads to a split in society: if you have money you can buy care yourself; if you little money you’ll have to do it with a stripped care system”. question 6 (ethical principle 5: efficiency). with regard to the allocation of scarce resources, respondents’ views could be divided into three main groups. one part considered the budget available for the execution of their long-term care responsibilities, which was substantially lowered as compared to the pre-2015 situation, to be leading in the allocation of resources, implying that care/support demands are (according to these respondents) considered more critically—on the basis of stricter indications—as compared to the pre-2015 situation. as one respondent put it: “the resources are distributed as indicated by the national government”. moreover, some municipalities try to focus on general (collective) support services instead of on customized (individual) support services in order to remain within their budgetary margins. a second groups considered demand to be key in decision-making, implying that as much as possible is done to do what is necessary, at least for the most vulnerable groups. in case of shortages, solutions are (according to these respondents) considered to be the appeal to general municipal resources or the transfer of resources from other policy domains within the municipality. indeed, many municipalities are currently searching for more integral ways of working between the different parts of the social domain within their municipality (17). one respondent formulated it as follows: “it starts with the client and we do what is necessary; many roads lead to rome”. a third, though smaller, group took a more neutral stance and considered the underlying idea of the long-term care reform (truly progressing towards a participation society) to be key in decision-making, implying that ‘new’, ‘creative’, or ‘innovative’ solutions have to be sought in balancing between a limited budget and the existing (or even growing) care/support demand. one respondent covered this point by stating that we should “learn people how to fish instead of supplying the fish”. apart from an increased focus on prevention (e.g. by supporting, or cooperating with, citizens’ initiatives and/or informal care organizations), it remains however unclear what is exactly meant by ‘innovative solutions’. question 7 (ethical principle 6: proportionality). next, respondents were asked whether they think the social support act 2015 can be considered as a proportionate measure for the goals it intends to pursue. in general, respondents considered this proportionality indeed to be present, thereby primarily making the comparison to the pre-2015 situation, which was considered by many as ‘unfair’ and ‘untenable’ due to the often exaggerated care demands of people (the so-called ‘claim-mentality’). or, in the words of one respondent: “a greater reliance on an own network / own resources will eventually replace the claim-mentality (‘i am entitled to’) and thus be cheaper”.another group of respondents considered the underlying idea of the decentralization (providing care and support on a customized basis and closer to home) as a positive normative development, while being worried about the budget cuts that accompanied the decentralization. as one respondent put it: “there will only be a balance in case of sufficient budget and autonomy for municipalities”. for this group of respondents, the social support act 2015 is considered to be putting a disproportionate burden on society. for part of this latter group, this disproportionality is likely to reduce in the longer-term, due to a gradually reducing ‘claim-mentality’ within society. for another part, however, the reduction of long-term care costs in the longer-term will not be the result of a more efficient provision of long-term care, but will simply be the result of the mere fact jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 14 of less available financial resources (and thus less possibilities), leading logically to less expenses in the long-term care sector. question 8 (dealing with moral conflicts). the last two questions of the survey referred to the way municipalities deal with the identified moral conflicts. in general, most respondents pointed to the importance of communication and transparency here. on the basis of regular deliberations, meetings and conversations with both care/support providers, surrounding municipalities, care/support recipients and their informal caregivers, and other stakeholders, the execution of the social support act 2015 is evaluated regularly and adapted where necessary. moreover, although the large discretion that municipalities have in assessing citizens’ care/support needs is considered by many citizens as unfair or subjective (as we mentioned before), the best way of dealing with this discretion according to our respondents is to critically assess each individual situation in-depth, offer customized support where possible, be open and transparent towards care/support recipients and their informal caregivers, and thoroughly explain the choices made where necessary. as one respondent captured it: “continue discussions, while in the meantime also ensuring that the necessary care delivery continues”. question 9 (dealing with moral conflicts: alternatives). subsequently, respondents were asked whether they foresaw alternatives with regard to the execution of municipalities’ longterm care responsibilities. many pointed to the unlikelihood of such an option, as the social support act 2015 is an established fact by law. others argued that neither option would be perfect and that turning to an alternative law now would be going back to square one. most respondents, however, interpreted this question not so much in terms of alternatives to the social support act 2015 in itself, but in terms of possible alternatives in the execution of this law. most of these respondents pointed to the potential release of more financial resources by the national government. at the same time, respondents acknowledged that although the availability of more financial resources would make life easier, it would not dissolve moral conflicts. a second alternative would be a clearer delineation between (or integration of) the different long-term care acts. respondents argued for example that it would have made more sense if the complete package of non-residential care services was put under responsibility of either the municipalities, or the health insurers. currently, the majority of non-residential care services is under responsibility of the health insurers, and only a small part under responsibility of the municipalities. finally, respondents pointed to the need for more innovative and unorthodox solutions, arguing that the social support act 2015 is not an aim in itself, but a means to deliver good care/support. or, as one respondent put it: “every law has an article 5”, implying that governments should sometimes turn a blind eye in the execution of policies. discussion principal findings and conclusions the aim of this study has been to examine to what extent municipalities in the netherlands take/took potential moral conflicts into account when implementing and executing the social support act 2015. we intend to answer our research question by relating the results corresponding to each of the six principles of our theoretical framework back to the coherentist approach of ethical reasoning this framework was based on. as was mentioned before, the coherentist approach is based on two main strands of ethical reasoning, being the ‘rights-based approach’ and the ‘consequentialist approach’. within a consequentialist approach, “actions are judged for their outcome and overall produced value” (22). this approach is basically founded on such principles as ‘health maximisation’ and ‘do no harm’ (22), corresponding to the principles of non-maleficence & beneficence and social jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 15 beneficence in our theoretical framework. in a public health context a consequentialist approach to ethical reasoning implies that health should be maximised, “as long as health maximisation is not endangering the maximisation of the overall utility of people” (22). as was described in the previous chapter, most of our respondents appeared to have a rather neutral stance with regard to assessing the non-maleficence and beneficence of the social support act 2015, emphasizing that it depends to a large extent on the individual perception of people whether they experience the introduction of the new social support act as an advantage or a disadvantage. with regard to social beneficence we found that, despite worries about the decreasing level of formal care provision, most respondents considered the creation of a better awareness and appreciation among citizens about care in general to be one of the more long-term advantages of the social support act 2015. at the same time there are also doubts about the impact that a law can have on such developments as new ways of thinking about long-term care (referred to above as a ‘normative reorientation’ towards long-term care). indeed, concepts such as the concept of ‘positive health’ as developed by huber et al. (4) are gaining importance within the healthcare sector.the conceptof ‘positive health’ considers health as “the ability to adapt and to self manage” (4) instead of considering it under the traditional who definition as “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” (32). a rights-based approach is basically founded on such principles as ‘human dignity’ and ‘justice’, corresponding to the principles of respect for autonomy and social justice of our theoretical framework, and claims that “persons have rights to fair equality of opportunity” (22). in a public health context this implies that people have a right to (equal opportunity) “to receive appropriate healthcare and live in environments in which social determinants of health are distributed in a fair way” (22). as we saw in the previous chapter, most respondents considered respect for autonomy to be sufficiently covered by the social support act 2015, mainly by its emphasis on freedom of choice. at the same time, however, our respondents pointed out that exactly freedom of choice is something that is not always of added value in a context wherein people are often just looking for good quality support. moreover, while social justice (people’s capabilities of making use of their right to freedom of choice) was considered to be sufficiently present for the majority of people, it is also exactly this point that respondents appeared to be most worried about in light of the social support act 2015, especially when applying it to vulnerable groups in society. indeed, the legal text of the social support act 2015 hardly stresses the importance of such notions as ‘equity’, one of the core underlying values of the principle of social justice. although the legal text stipulates that “citizens who themselves or together with people in their immediate environment are not sufficiently self-sufficient or insufficiently able to participate [in society], must be able to rely on organized support by the government”, it remains unclear when exactly someone is ‘insufficiently self-sufficient’, ‘insufficiently able to participate in society’, and (in case someone is entitled to support) when one is entitled to ‘general services’ and when to ‘customized services’. indeed, as was argued by maarse and jeurissen (16), municipalities actually have a large policy discretion with regard to the allocation of support measures (the so-called ‘zip code rationing’), which may lead to unequal access to long-term care. in fact, this point was one of the three main moral conflicts as identified by our respondents under question 1 of the survey. moreover, as argued by van der aa et al. (18), with the advent of the social support act 2015 a shift can be witnessed from a ‘right to care’ to a ‘right to customized support’. next, although solidarity is by definition an important component of the social support act 2015, the act foresees a shift from formal to informal solidarity (18). it remains, however, doubtful how much can be expected of this informal solidarity. as maarse and jeurissen (16) already pointed out, “the potential of jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 16 ‘unexplored’ informal care is overestimated. furthermore, the negative externalities for caregivers who deliver intense informal care are underestimated”. finally, the legal text of the social support act 2015 stipulates that “it is desirable to set new rules, in order to bring citizens’ rights and duties more in line with each other” (authors’ own translation), which tends to imply a decreasing government responsibility for citizens’ rights to equality of opportunities regarding access to good quality care/support. our first sub-research question was specifically directed towards the way municipalities divide scarce resources in the social domain in a fair way. as we saw in the previous chapter, our respondents’ views towards principles of efficiency and proportionality were quite divergent. on the one hand, the availability of less public resources for long-term care and the higher own financial contributions people are expected to pay for the care/support they receive might eventually lead to a more conscious use of care (and in that way contribute to the normative reorientation of creating a true participation society). on the other hand, however, these developmentsmight unconsciously lead to the creation of an access barrier to care (especially for the less affluent in society) or to the avoidance of necessary care. in fact, the conflict of adhering to the social support act’s underlying theory of moving towards a participation society while at the same time having to deal with the limited budget and timeframe that is offered to municipalities for supporting this change process was one of the three main moral conflicts as identified by our respondents under question 1 of the survey. moreover, within the context of the social support act 2015 ‘efficiency’ might primarily be understood as a way of justifying the budget cuts that accompanied the long-term care decentralization, instead of as a moral obligation to efficiently use scarce health resources. at least part of the solution to the dilemma of how municipalities then can divide scarce resources in the social domain in a fair way might be provided by the ‘accountability for reasonableness’ approach of procedural justice by daniels and sabin (33), which offers a “minimum ethical standard in times of economic downturn characterized by scarcity of resources and when not all needs are being satisfied” (13). the accountability for reasonableness approach requires certain conditions to be met in order for a process of allocating scarce healthcare resources to be ‘fair’: the process (including the reasoning behind it) has to be transparent to the public, the reasons by which decisions were made have to be relevant, and it should be possible to revise any decision in case of new evidence or arguments (13). these conditions are quite in line with our results under question 8 (dealing with moral conflicts), emphasizing the importance of communication and transparency in the process of dealing with moral conflicts (such as the division of scarce resources). finally, in order to answer our second sub-research question (regarding the way municipalities empower citizens towards a participation society), it has to be determined how the kind of efficiency goals as discussed under the previous sub-question can be reconciled with moving towards a participation society; or, in other words, does the latter lead to the former, or does the former require the latter? is thus “participation” a good value or a fig leaf or metaphor for a liberalist mindset? we argue that although participation is an intended goal of the social support act 2015, citizens are insufficiently supported to achieve that participation. as we argued before, ‘support’ under the social support act 2015 is intended to be limited to those citizens who themselves or together with people in their immediate environment are not sufficiently self-sufficient or insufficiently able to participate. or, as maarse and jeurissen (16) put it: “the wmo 2015 gives applicants a right to publicly funded support if they cannot run a household on their ownand/or participate in social life”. however, proactively supporting citizens towards the initial goal of creating a participation society (e.g. by focusing on preventive measures), is much less pronounced in the legal text of the social support act 2015. article 2.1.2 (c, d and e)points in general terms at, jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 17 respectively, the early determination of citizens’ support needs, the prevention of citizens’ reliance on support, and the provision of general support services (provided without the prior examination of the recipient’s need, characteristics and capabilities). however, how to achieve these points is left to the municipalities’ discretion. in the same vein, article 2.1.2b points out that “the different categories of informal caregivers should be enabled as much as possible to perform their duties as informal caregiver” (authors’ own translation), but this point is not specified in the remainder of the legal text. this point is therefore, we argue, much less concrete as compared to the old 2007 social support act (under which municipalities where merely responsible for domestic help), where support for informal caregivers was concretized in such sub-themes as information, advice, emotional support, education, practical support, respite care, financial support and material support. at the same time, this high degree of policy discretionfor municipalities under the 2015 social support act gives room for ‘innovative and unorthodox solutions’, as was indicated by several of our respondents, although this may require the availability of more financial resources and/or a clearer delineation between (or integration of) the different long-term care acts (the latter being one of the three main moral conflicts as identified by our respondents under question 1 of the survey). coming back to our main research question (“to what extent did/do municipalities in the netherlands take potential moral conflicts into account when implementing and executing the social support act 2015?”), we conclude by arguing that while municipalities are indeed aware of (potential) moral conflicts, the nature of the new law itself leaves insufficient room for municipalities to act in a sufficiently proactive and supportive/empowering manner on these challenges, as well as on the long-term aim of the social support act 2015 of achieving a true participation society. the reasoning behind this argumentation is that although the new law appears to emphasise such ethical principles as social beneficence and respect for autonomy, the lack of emphasis on notions of social justice threatens to impede the effectuation of the intended goals in practice. moreover, the social support act 2015 seems to be mainly directed towards achieving a certain outcome (the maximisation of social beneficence through the creation of a participation society), instead of stipulating how that outcome should exactly be achieved in a fair manner. as such, the social support act 2015 insufficiently seems to provide equality of opportunity with regard to long-term care access, both between citizens within the same municipality, as (and perhaps especially) between different municipalities. at the more short-term, taking into account a minimum set of ethical principles allows for the allocation of (seemingly scarce) resources that is, at the least, as fair as possible. study strengths and limitations and suggestions for further research the principle strength of this study has been the application of a broad ethical approach towards scrutinizing a new, and still sensitive, policy responsibility of dutch municipalities. we have shown that taking into account a minimum set of ethical principles, raises awareness of (potential) moral conflicts within the context of the new social support act. being aware of such conflicts, at its turn, helps in executing the new responsibilities under the social support act in an appropriate manner (or in justifying decisions towards citizens) and gives room for municipalities to act in a as proactively as possible manner on the challengesresulting from these new responsibilities. next, the fact that all dutch municipalities were invited to participate in our study led to a reasonable response rate, in terms of reaching a saturation point in our data analysis. at the same time, the limited response rate to the invitation for a telephonic interview might have led to a certain selection bias, as not all respondents have given the same level of in-depth explanation to their survey answers. moreover, it might have been valuable if additional questions were added to the injongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 18 depth interviews, although also the semi-structured character of these interviews already allowed for a certain (though 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[reform of long-term care in the netherlands: solidarity maintained?]. ned tijdschr geneeskd 2014;158(a8253). 19. grootegoed e, tonkens e. disabled and elderly citizens’ perceptions and experiences of voluntarism as an alternative to publically financed care in the netherlands. health soc care comm 2017;25:234-42. 20. dwarswaard j, bakker ej, van staa a, boeije hr. self-management support from the perspective of patients with a chronic condition: a thematic synthesis of qualitative studies. health expect 2016;19:194-208. 21. dwarswaard j, van de bovenkamp h. self-management support: a qualitative study of ethical dilemmas experienced by nurses. patient educcouns 2015;98:1131-6. 22. schröder-bäck p, clemens t, michelsen k, schulte in den bäumen t, sørensen k, borrett g, brand h. public health ethical perspectives on the values of the european commission’s white paper “together for health”. cent eur j public health 2012;20:95100. 23. mcconnell t [internet]. moral dilemmas. available from: the stanford encyclopedia of philosophy, http://plato.stanford.edu/archives/fall2014/entries/moral-dilemmas/ (accessed: march 21, 2016). 24. schröder-bäck p, brand h, escamilla i, davies jk, hall c, hickey k, et al. ethical evaluation of compulsory measles immunisation as a benchmark for good health management in the european union’, cent eur j public health 2009;17:183-6. 25. schröder-back p, duncan p, sherlaw w, brall c, czabanowska k. teaching seven principles for public health ethics: towards a curriculum for a short course on ethics in public health programmes. bmc medethics 2014;15(73). 26. daniels n. just health: meeting health needs fairly. cambridge: cambridge university press, 2008. 27. world health organization [internet]. what is universal coverage? available from: http://www.who.int/health_financing/universal_coverage_definition/en/ (accessed: march 21, 2016). 28. verweij m, dawson a. ethical principles for collective immunization programmes. vaccine 2004;22:3122-6. 29. andrews m. who is being heard? response bias in open-ended responses in a large government employee survey. public opin quart 2004;69:3760-6. 30. hsieh h, shannon se. three approaches to qualitative content analysis. qual health res 2005;15:1277-88. 31. de koster y [internet]. kwart zorggebruikers mijdt dure zorg [quarter of care users avoidsexpensive care]. binnenlandsbestuur 2016; feb 10. available from: http://www.binnenlandsbestuur.nl/sociaal/nieuws/kwart-zorggebruikers-mijdt-durezorg.9518647.lynkx (accessed: april 1, 2016). 32. world health organization [internet]. constitution of the world health organization. available from: http://www.who.int/governance/eb/who_constitution_en.pdf (accessed: april 4, 2016). 33. daniels n, sabin je. accountability for reasonableness: an update. bmj 2008;337(a1850). ______________________________________________________________________________________ © 2017 jongenet al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. burazeri g. mortality reduction in the russian federation: significant progress contrary to western beliefs (editorial). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3130 p a g e 1 | 3 editorial mortality reduction in the russian federation: significant progress contrary to western beliefs genc burazeri1,2 1department of public health, faculty of medicine, university of medicine, tirana, albania; 2department of international health, school caphri (care and public health research institute), maastricht university, maastricht, the netherlands. corresponding author: genc burazeri, md, phd; address: university of medicine, rr. “dibres”, no. 371, tirana, albania; email: genc.burazeri@maastrichtuniversity.nl burazeri g. mortality reduction in the russian federation: significant progress contrary to western beliefs (editorial). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3130 p a g e 2 | 3 the south eastern european journal of public health (seejph) continuously and successfully widens its global outreach especially to the southern and eastern world. hence, especially in the past years, seejph has placed a major focus on global health challenges and has covered health issues that transcend national boundaries calling for action in the various sectors, which determine the health of populations worldwide (1). however, the biggest and most important neighbour in the european region, the russian federation, is connected with western and south eastern europe through only a few channels. one of them is the technical cooperation in the framework of the northern dimension partnerships which includes the european union (eu) member states around the baltic sea and russia as a whole through its bordering north-west district including petersburg and kaliningrad (2). the eu and the russian federation contribute financially in similar dimensions. the paper published by chernyavskiy et al. in the current issue of seejph shows that the russian federation has made a considerable progress in the reduction of premature mortality, contrary to western expectations (3). the detailed and robust analysis presented in this article indicates a remarkable reduction of premature years of life lost (pyll) for the period 20032013 which, assuming the same pace of progress, will eventually lead into a “positive gap ratio” for the year 2020 and subsequently in 2030. of note, a positive gap ratio indicates an “on track” status for achievement of the respective sustainable development goal (sdg) target (4). interestingly, a comparison of regions of north-western russia and neighbouring european countries confirmed that the higher the mortality levels the stronger the contribution of avoidable causes. thus, on average, mortality reduction levels amounted to 50% in north-western russia, suggesting an impressive progress. among other things, this progress is due to increasing investments of the russian government in the last decade, which have largely focused on the renovation of old health care facilities including purchasing of modern medical equipment for diagnosis and treatment of a wide range of medical conditions (5). notwithstanding the importance of the healthcare investments in mortality reduction, this is however not the main contributor of the observed health improvements. based on these considerations, it is from our point of view extremely important to keep communication channels open between the eu member states and the russian federation, at least at the professional and technical level. from this perspective, the paper by chernyavskiy et al. (3) is timely and very relevant, providing a significant contribution on the understating of the health status progress and achievements observed in the russian federation in the past decades. burazeri g. mortality reduction in the russian federation: significant progress contrary to western beliefs (editorial). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3130 p a g e 3 | 3 references 1. jens holst, breckenkamp j, burazeri, martin-moreno jm, schröder-bäck p, laaser u. five years of the south eastern european journal of public health (seejph): focusing on health systems in transition and global health. seejph 2018; vol x. doi: https://doi.org/10.4119/seejph1870. 2. the northern dimension. https://eeas.europa.eu/diplomaticnetwork/northern-dimension_en (accessed: october 24, 2019). 3. chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovicmikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being. seejph 2019; vol xii. doi 10.4119/seejph-3129 4. bjegovic-mikanovic v, salem za, breckenkamp j, wenzel h, broniatowski r, nelson c, vukovic d, laaser u. a gap analysis of sdg 3 and mdg 4/5 mortality health targets in the six arabic countries of north africa: egypt, libya, tunisia, algeria, morocco, and mauritania. lib j med 2019:14/1. https://doi.org/10.1080/19932820.2019. 1607698 (accessed: october 24, 2019). 5. chernyavskiy v, mikhailova j. russia: a key partner in the northern dimension partnership. seejph 2019; vol xii. doi: 10.4119/unibi/seejph-2019-217. _________________________________________________________________________ © 2019 burazeri; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://doi.org/10.4119/seejph-1870 https://doi.org/10.4119/seejph-1870 marstein e, babich sm. the corporatization of global health: the impact of neoliberalism (original research). seejph 2018, posted: 14 june 2018. doi 10.4119/unibi/seejph-2018-191 original research the corporatization of global health: the impact of neoliberalism egil marstein 1 , suzanne m. babich 1 1 department of health policy and management, richard m. fairbanks school of public health, indiana university, indianapolis, usa. corresponding author: egil marstein, phd department of health policy and management, richard m. fairbanks school of public health, indiana university; address: health sciences building (rg), 1050 wishard blvd. floor 5, indianapolis in 462022872, usa; telephone: 317-274-3850; email: egmars@iu.edu marstein e, babich sm. the corporatization of global health: the impact of neoliberalism (original research). seejph 2018, posted: 14 june 2018. doi 10.4119/unibi/seejph-2018-191 abstract concomitant with the emergence of a neoliberal precept for global health is the decline in support for publicly funded programs working to alleviate health disparities in poor countries. an unequivocal faith in the privatization and marketization of public health services is evident in current day national policy reforms. commodification of health services is perceived as a cureall. privatization of global health initiatives contrasts with the past institutional paradigm. corporate and philanthropic power trumps intergovernmental governance. the epistemological precept is clear: global health is best served with mandated private initiatives. powerful foundations cause critical shifts in the balance of power among stakeholders and become preeminent players in global health policy agenda formation. the ethics of consequentialism have attained current day prominence. this contrasts with the merits and relevancy of deontological ethics in which rules and moral duty are central. in this paper, authors make a case for contesting the ethos of effective altruism or venture philanthropy, suggesting that this approach keeps nations and people from recognizing the oppressive nature of neoliberalism as a governing precept for global health. keywords: global health governance, global health leadership, venture philanthropy. conflicts of interest: none. marstein e, babich sm. the corporatization of global health: the impact of neoliberalism (original research). seejph 2018, posted: 14 june 2018. doi 10.4119/unibi/seejph-2018-191 the oligarchs of philanthropy over the past forty years of expanding globalization, waves of deregulation and privatization have facilitated the power of private actors. in a 2015 global policy forum (gpf) report, jens martens and karolin seitz highlighted widespread concern over the power exerted by the philanthropies of corporations, foundations, non-governmental organizations (ngos) and charitable organizations (1). transnational corporations – companies operating in multiple countries – exert significant influence within the global economic system, gaining political clout in the process. the gfp reports equate “big philanthropy” with “big business” in their expanding influence on global development policies through grant-making, personal networking and active advocacy. the report points to the need for a renewed political discourse that carefully scrutinizes the impact of these ngos on the global health policy agenda. it underscores the need to fully analyze the risks and consequences of letting organizations such as the bill & melinda gates foundation (gates foundation) and the rockefeller foundation shape the priorities of health programs in developing countries. in the first half of the last century, the rockefeller foundation was particularly influential in shaping the discourse on global health and building the institutional structure of global health governance (1). since the turn of the millennium, however, the gates foundation has become the leading actor. in 2012 and 2013, the amount spent by the gates foundation on global health was equal to one half of the total budget of the world health organization (who) (gates foundation: u.s. $1.98 billion; who: us$ 3.96 billion). the gates foundation demonstrates a strong preference for measures based on a biomedical view of public health and clearly embraces the application of innovations and new technologies. this is true despite the fact that in the beginning of the 20th century, public health improvements were mainly achieved through improvements in social conditions, such as hygiene, nutrition, improved housing and education. martens and seitz have suggested that the gates foundation approach to tackling global health challenges is disease-specific, using vertical health inventions through vaccines in lieu of a horizontal and holistic approach through overall health system strengthening. grants made by the gates foundation are earmarked or limited to specific program areas. this prompted former who director general margaret chan to state at the time that: “my budget is highly earmarked, so it is driven by what i call donor interests” (1). the who is the foremost proponent and caretaker of global health initiatives. it was founded in 1948 as part of the united nations (un) to act as “the directing and coordinating authority on international health work” (2). with the arrival of new and powerful actors in the global health arena its importance has steadily dwindled. these new actors dispose of significant resources made available by a wide range of private contributors and corporate philanthropy. the growing importance of private contributions coincides with a decreasing assessed contribution support provided by member states (who). assessed contributions are non-earmarked contributions, whereas voluntary contributions come from private organizations or public institutions and are earmarked for special programs, with donor conditions attached. earmarked contributions undermine the who’s capacity to remain true to its original role as a global health authority to direct and coordinate international health work (2). the arrival of modern philanthropy the history of modern philanthropy can be traced to the early 19th century in the united states. motivated primarily as a way to shield private and corporate fortune from taxation and to gain prestige and political influence, wealthy individuals such as john d. rockefeller (1913) and marstein e, babich sm. the corporatization of global health: the impact of neoliberalism (original research). seejph 2018, posted: 14 june 2018. doi 10.4119/unibi/seejph-2018-191 andrew carnegie (1911) set up the first charitable foundations. in the 1930s, increased income and estate taxes in the u.s. led to further proliferation of u.s. foundations set up by wealthy individuals, most notably by industrialists such as w. k. kellogg and henry ford, creating the most influential foundations with global reach and foundation-supported programs established all over the world (2). beyond charitable philanthropic foundations, the number of nongovernmental organizations has proliferated. the term ngo entered common usage through the un charter at the end of the world war ii (ww ii). prior to that, missionary groups, religious orders, and scientific societies engaged in activities crossing continents (3). whatever the motivation, the population of charitable foundations in the form of ngos alone now numbers 20,000 globally (3). criticism of the expanding influence and power of ngos is mounting. issa g. shivji argues that the sharp rise in the number and power of ngos is due to the neoliberal paradigm and does not purely represent altruistic objectives (4). shivji criticizes ngos for aiming to change the world without understanding it and warns that they perpetuate imperial, north-south relationships. james pfeiffer points to the fact that over the last decade, ngos (in mozambique) have fragmented the local health system, undermined local control of health programs, and contributed to growing local social inequality (5). in the geo-political scope, ngos have been criticized for representing an extension of the regular foreign-policy instruments of some western countries and groups of countries. according to michael bond, "most large ngos are striving to make their aid provisions more sustainable. however, some, “mostly in the us, are still exporting the ideologies of their backers."(6). viera pawliková -vilhanová has traced the evolution of ngos in africa , suggesting that their roles represent a continuation of the work of their predecessors, the missionaries and voluntary organizations that cooperated in europe’s colonization of africa. the author further maintains that the work of ngos today undermines the efforts of african people to emancipate themselves from economic, social and political oppression. development ngos have become part of the neoliberal system that has resulted in widespread impoverishment and loss of the authority of african states to determine their own agendas. ngos could, and some do, play a role in supporting an emancipatory agenda in africa, but that involves abandoning the role of missionary by disengaging from paternalistic roles in development initiatives (7). efforts to shape stakeholder interests into a uniform global health agenda have led to a recommendation to give intergovernmental institutions such as the who a greater diplomatic role, working with nations and philanthropic elites, ngos and international corporations (7). this could strengthen international cooperation and create needed synergies for confronting global health challenges. who director general gro harlem brundtland (1998-2003) is credited with first proposing that the who take on this political role. dr. brundtland advocated a normative dimension in global health. the approach emphasized the goal of a healthier world rather than serving a realpolitik line advancing individual state and institutional interests. from the who’s original position of promoting health as a human right, the organization has taken on a technocratic approach, prioritizing disease control. consequently, there is less emphasis on governance issues focusing on social control and the reallocation of resources. a significant factor associated with this policy has been a subscription to economic efficiency as espoused by the powerful foundations promoting their brands of venture philanthropy. the tenet has been to accept a reduced role for the state and intergovernmental institutions when faced with global health challenges. in this way, the system has enabled private organizations to assume a greater role in setting priorities and controlling project governance. https://en.wikipedia.org/wiki/issa_g._shivji https://en.wikipedia.org/wiki/neoliberal https://en.wikipedia.org/wiki/imperialism marstein e, babich sm. the corporatization of global health: the impact of neoliberalism (original research). seejph 2018, posted: 14 june 2018. doi 10.4119/unibi/seejph-2018-191 challenges the proliferation of neoliberalism has, according to global health watch # 4, produced a “global health crisis” in crafting a new global health agenda (8). as the scope of global health challenges grows, so does the call for comprehensive measures to alleviate immediate crises of disease and hunger. equally important is the need for strong governance institutions to strengthen public health programs and to ensure the capacity to meet future health challenges. to succeed, transnational preparedness will be necessary and attainable only through joint and transparent initiatives focusing on long term and comprehensive priorities. meanwhile there are power struggles underway between intergovernmental institutions with authorities mandated to act on behalf of a global consensus and the emerging corporate/philanthropic initiatives capable of thwarting any institutional momentum. non-bona fide actors are rendering intergovernmental institutions significantly weaker in their efforts to carry out their mandated roles of “directing and coordinating authority on international health work” (2). dominant philanthropic foundations have succeeded in creating a web of corporate, public and private actors working in unison and acting authoritatively relative to public governance. succumbing to this corporatization of global health, the who collaborates with powerful philanthropic foundations targeting specific projects, most commonly vaccine programs. the price paid is the relinquishing of global health governance to project organizations that do not answer to any national or international authorities with regard to priorities, transparency or any considerations relative to recipient countries. through a process of transforming global health into a neoliberal policy framework, it has brought about a refeudalization of global health. the community of nations comprising the who has abandoned moral and ethical ideals in favour of practical realities. in “the structure of scientific revolutions” (9), thomas kuhn paraphrased the old greek concept of paradigm, originally meaning a model or a pattern that the demiurge (the god) used when creating the cosmos, and thus offered a way to interpret the world. in more modern terms, kuhn describes a scientific paradigm as a universally recognized achievement that, for a time, provides a framework for solutions for a community of practitioners. the idea that a current paradigm represents the only conceivable reality works to protect the paradigm from being undermined. kuhn’s thesis may be considered relevant in light of the current neoliberal scheme in global health. corporate oligarchs seem currently secure in their capacities to enforce their desired objectives. the paradigm of neoliberalism seems unassailable, as its popularity is embedded in public health governance in national, international and intergovernmental organizations. generally, the greatest barrier to any paradigm shift is the inability or refusal of the public to see beyond the current model of thinking. opposition to neoliberalism appears to be insignificant, considering the present day scope of application. economic models promoting commodification and marketization of what were previously considered public goods and services are secure. global trade agreements facilitated by financing institutions such as the world bank, the international monetary fund (imf) and the european central bank (eub) enhance globalization, capital accumulation and the reconstituting of social class structures. reversing this embodiment of ideology, social construction of knowledge and related, powerful institutions today seems incomprehensible. marstein e, babich sm. the corporatization of global health: the impact of neoliberalism (original research). seejph 2018, posted: 14 june 2018. doi 10.4119/unibi/seejph-2018-191 a way forward? kuhn described the possibility for movements that could lead to a paradigm shift, an overthrow of an incumbent paradigm. in his classic book, “the structure of scientific revolutions” (9), kuhn concludes that, “the successive transition from one paradigm to another via revolution is the usual developmental pattern of mature science” (9). neoliberalism’s history vested in social philosophy and economic liberalism may hardly be termed a mature “science”. even metaphysics lost its significance with the arrival of the enlightenment, setting the stage for scientific revolutions. paradoxically, one may perceive hope for a paradigm shift or, in what foucault termed an epistemological shift, confronting a paradigm in the perspective of competing worldviews. the french philosopher michel foucault (1926-1984) employed the old greek term episteme and discourse, in a highly specialized sense, in his work, “the order of things” (10). an episteme referred to the historical a priori that grounds knowledge and its discourses. it represents the condition of their possibility within a particular epoch. herein lies hope for a paradigm shift, where foucault´s model of discourse may be applied to contest the current day epistemology and challenge the feudal order of global health. jeremy shiffman outlines such an approach, drawing on the theory of social constructivism (11). shiffman suggests that the rise and fall of a global health issue may have less to do with how “important” it is in any objective sense, and more to do with how supporters of the issue come to understand and portray its importance: “the rise, persistence and decline of a global health issue may best be explained by the way in which its policy community the network of individuals and organizations concerned with the problem comes to understand and portray the issue and establishes institutions that can sustain this portrayal” (11). beliefs and activities are best understood from the perspective of cultural origin. berger and luckman, suggest an explanation to aid in understanding the popularity of neoliberalism today when viewed in the context of global health. the qualitative understanding of society is a social construction of reality and a function of a cognitive bias. knowledge is socially constructed, as are ideologies, subjecting populations to norms and controlling their lives and institutions. michelle foucault´s perspectives of power and, particularly the power of profession, are a reminder of the role that power plays in the discourse of society. in much of his work, foucault’s thesis was that any dominant ideology serves the interest of the ruling class (10). in linking this latter precept of power to his thesis of modern medicine, foucault viewed the power and accomplishments of modern medicine as an epistemological shift ascribed to the consequence of the modern medical clinic manifested in its institutional power. it is perhaps a novel proposal of this paper to equate foucault’s thesis to the significance of modern day institutions such as the imf, the world bank and the world trade organization serving in empowerment capacities for neoliberalism. following foucault’s thesis, only the process of philosophical reasoning could generate an epistemological shift, thereby displacing the neoliberal paradigm and its governing precepts of global health. in what foucault labels discursive formations, a humanistically inspired exchange of views could be contrasted with corporate vested neoliberalism. this may ultimately displace the prevailing attachment to the governance of global health initiatives by corporate and philanthropic elites. it holds the promise of bringing about the re-emergence of global health governance vested in the transnational consensus of elected representatives. it increases the likelihood of global health policies and programs designed in the public interest, with resources https://en.wikipedia.org/wiki/discourse https://en.wikipedia.org/wiki/the_order_of_things https://en.wikipedia.org/wiki/a_priori_and_a_posteriori https://en.wikipedia.org/wiki/discourse https://en.wikipedia.org/wiki/condition_of_possibility marstein e, babich sm. the corporatization of global health: the impact of neoliberalism (original research). seejph 2018, posted: 14 june 2018. doi 10.4119/unibi/seejph-2018-191 directed to those initiatives of greatest priority to ensure improved health and health equity for all people worldwide. the implications for global public health practice are profound. the way forward must begin with broad, inclusive philosophical reasoning, discourse and debate about the role of corporate philanthropy and the ethics of treating health services as commodities. conclusion and implications for practice the obstacles to advancing global health in the best long-term public interests are not only related to accessing and prioritizing resources. they include disputes about ideologies, philosophies and competing vested interests. the commodification and marketization of health services, interventions and technologies attract powerful corporate actors capable of circumventing intergovernmental institutions and any other public governance initiative that poses a threat. the current situation highlights how the concepts of effective altruism, corporate philanthropy and the practice of utilitarianism sideline public institutions to bring about local and national autonomy. decades of neoliberal measures vested in the governing policies of developed countries encourage public-private partnerships that escalate the dominating role of the private sector. discussions and debates that critically analyze the impact of neoliberalism may seem unrealistic, considering how entrenched the precept of economic liberalism is around the world. it is embedded in the charters of international trade policies enforced by institutions such as the world bank, the imf and the world trade organization, with the supportive groundwork of the oecd. this union between the corporate world and a public sector vested in neoliberal dogma illustrates the need for powerful, transformative actions that can bring about change. the thomas kuhn theory of scientific revolutions is salient. replacement of the existing paradigm will require bold, determined efforts. a discursive formation to reach consensus is a necessary first step. references 1. martens j, seitz k. philanthropic power and development: who shapes the agenda? bischöfliches hilfswerk misereor, germany; 2015. 2. adams b, martens j. fit for whose purpose? private funding and corporate influence in the united nations. global policy forum, new york; 2015:59. 3. davis t. ngo’s: a long and turbulent history. the global journal 2013;15. 4. shivji ig. silences in ngo discourse: the role and future of ngos in africa. networks for social justice. nairobi & oxford; 2007. 5. pfeiffer j. ngos and primary 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issues. bull world health organ 2009;87:608-13. ______________________________________________________________________________________ © 2018 marstein et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 1 review article what we need to improve the public health workforce in europe? vesna bjegovic-mikanovic 1 , katarzyna czabanowska 2 , antoine flahault 3 , robert otok 4 , stephen m. shortell 5 , wendy wisbaum 6 , ulrich laaser 7 1 university of belgrade, faculty of medicine, centre school of public health and management, belgrade, serbia; 2 department of international health, school for public health and primary care (caphri), faculty of health, medicine, and life sciences, maastricht university, maastricht, the netherlands; 3 institut de santé globale, faculté de médecine de l‘université de genève, switzerland; 4 association of schools of public health in the european region (aspher), brussels office, brussels, belgium; 5 school of public health, haas school of business uc-berkeley, usa; 6 european observatory on health systems and services, who-euro, copenhagen, denmark; 7 faculty of health sciences, university of bielefeld, bielefeld, germany. corresponding author: prof. ulrich laaser, section of international public health, faculty of health sciences, university of bielefeld; address: faculty of health sciences, university of bielefeld, pob 10 01 31, d-33501, bielefeld, germany; e-mail: ulrich.laaser@uni-bielefeld.de bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 2 abstract with the growth and complexity of current challenges such as globalization, health threats, and ageing society, financial constraints, and social and health inequalities, a multidisciplinary public health workforce is needed, supported by new skills and expertise. it has been demonstrated that public health education needs to include a wider range of health related professionals including: managers, health promotion specialists, health economists, lawyers and pharmacists. in the future, public health professionals will increasingly require enhanced communication and leadership skills, as well as a broad, interdisciplinary focus, if they are to truly impact upon the health of the population and compete successfully in today‘s job market. new developments comprise flexible academic programmes, lifelong learning, employability, and accreditation. in europe‘s current climate of extreme funding constraints, the need for upgrading public health training and education is more important than ever. the broad supportive environment and context for change are in place. by focusing on assessment and evaluation of the current context, coordination and joint efforts to promote competency-based education, and support and growth of new developments, a stronger, more versatile and much needed workforce will be developed. keywords: public health competences, public health education, public health workforce. conflict of interest: none acknowledgement: this text has been prepared originally in the context of the policy summary 10 1 by the european observatory on health systems and policies and is published slightly modified and updated in the south eastern journal of public health with the kind permission of the european observatory. 1 bjegovic-mikanovic v, czabanowska k, flahault a, otok r, shortell s, wisbaum w, laaser u (2014) policy summary 10: adressing needs in the public health workforce in europe. european observatory on health systems and policies, who-euro: copenhagen, denmark. bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 3 introduction the bologna process and the who regional office for europe‘s new european policy for health – health 2020 – support the apparent move from interest in the traditional public health worker, a specialist physician, to a more generic worker who will be expected to work across organizational boundaries with a vast array of professionals to promote the public health agenda. new emphasis has been put on further developing public health systems, capacities and functions and promoting public health as a key function in society (1). to do this, public health education needs to include a wider range of health related professionals, including managers, health promotion specialists, health economists, lawyers, pharmacists etc. (2). in the future, public health professionals will increasingly require interdisciplinary and interagency team working and communication skills if they are to truly impact upon the health of the population. but how do we get there? how can this need and the favourable supportive context actually be translated into a better equipped public health workforce? first we need to work together to better understand the current situation. next we need to develop and agree upon core and emerging competences for a well-equipped work force. following this, we need to translate those competences into competency based training education. finally, we need to assess public health performance to determine how we are doing. the steps in figure 1 summarise this process. figure 1. from core public health functions to core competences, teaching curricula and public health performance competence based education and training public health competences may be defined as a “…unique set of applied knowledge, skills, and other attributes, grounded in theory and evidence for the broad practice of public health” (3). who defines competence even more precisely as the combination of technical knowledge, skills and behaviours (4). there is growing recognition that to adequately prepare public health students to meet the challenges of today, the schools must go beyond training in the traditional areas of biostatistics, epidemiology, environmental health sciences, health policy and management, ccoorree ppuubblliicc hheeaalltthh ffuunnccttiioonnss ccoorree ppuubblliicc hheeaalltthh ccoommppeetteenncceess ccoommppeetteennccee bbaasseedd eedduuccaattiioonn aanndd ttrraaiinniinngg eeffffiicciieenntt aanndd aaccccoouunnttaabbllee ppeerrffoorrmmaannccee bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 4 and the social and behavioural sciences. these areas provide the student with a specific set of knowledge and and/or skills in a particular content area. while necessary, they are not sufficient for effective public health practice because they do not equip students with the contextual and integrative competences required to adapt to the new challenges that they will face in practice. thus, in recent years, growing interest can be observed in competence-based medical education due to its focus on outcomes, an emphasis on abilities, a de-emphasis of time-based training, and the promotion of learner-centeredness (5). this method trains graduates in problem solving skills applied to reality-based situations or real time problems in cooperation with institutions in the field (6). competency-based education (cbe) is organized around competences, or predefined abilities, as outcomes of the curriculum. ‗‗competences‘‘ have become the units of medical educational planning (2). cbe has also been introduced in public health training and education to close the bridge between teaching methods and the competences required in practice. in an era of insecurity, educators should make sure that every graduate is prepared for practice in every domain of their future practice. a first step in cbe is the identification of key competences that graduates need in order to perform adequately when entering the public health labour market. box 1 below provides recommendations on developing competences. the professional development of public health leaders requires competence based instruction to increase their ability to address complex and changing demands for critical services (7). determining necessary competences provides a foundation for standards development that can be used to operationalise teaching objectives and design impact and outcome evaluation methods. measuring programme outcome and impact satisfies all stakeholders: providers, practitioners, consumers, and other relevant bodies. clusters of competences, aptitudes, or ability achieved may be indicative of the potential for future achievement. public health workforce development has resulted in pressure for competence-based programming and performance measurement to demonstrate quality and accountability. to support competence-based medical education, many frameworks have been developed: canmeds (8), and the outcome project of the (us) accreditation council for graduate medical education (9). these frameworks form the basis of training for the majority of medical learners in the western world (5). however, based on the results of a systematic literature review, frank et al. observe that competence-based medical education still needs to identify and clarify controversies, proposing definitions and concepts that could be useful to educators across various educational systems (10). still little is known about approaches to cbe in public health, its effectiveness and efforts made for educational quality assurance. therefore, it is important to explore future directions for this approach to prepare health professionals. among the current challenges facing schools of public health is how best to translate these competences into specific learning objectives with measurable outcomes. the role of employers in determining competences in order to assure that the schools of public health adequately address the skill needs of the employment market, close partnerships are needed between employers and educators, both of which are essential components of a ‗knowledge triangle‘ based around the interaction of education, research and innovation (11). many of the competences valued by employers are really enduring qualities, and the need is to find new and better ways for educators to develop them in students, so that they can then be applied in modern workplaces. in fact, the most important skill that europe‘s workers will need in order to adapt to the demands of the future is the ability to be lifelong learners irrespective of the discipline. bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 5 to determine competences, it is of utmost importance to ask public health employers. specifying competences needed by the public health labour market can result in a benchmark approach to competence-based education. the selected competences serving as benchmarks would standardize the criteria for change in education of public health professionals. the benchmarks are relevant, because there is a need for a rapid reform of the educational system as a result of economic and political changes or previous failures to meet employment market needs. moreover, the benchmarks will provide a framework for evaluating the effects of various educational strategies on competence-based education. therefore, there is a need to specify competence requirements for different types and levels of public health employers. thus, the question arises: what do employers consider as most important? some studies suggest that employers value tacit knowledge, generic skills and work-based attitudes more than academic or technical knowledge which they take for granted employing graduates holding an mph degree (12). they look for employees who are motivated, take responsibility and are willing to learn. in view of the contemporary public health employment market worldwide, it is important to acquire the right mix of general and specific skills that fits a certain job. further distinction between skills can be made between ―hard skills‖ and ―soft skills‖. the former refers to rather technical, knowledge-related skills, while the latter includes competences such as communication and team work (13). these ―people skills‖ are essential in order to make the workforce more adaptable. the reason for this might be that these set of competences will not only prepare people for change emotionally and mentally, but they will also have an easier time adapting to a new environment. ―people skills‖ seem to matter in both daily private life and at work. for example, it was found that nurses have higher level of patient satisfaction than doctors because of their better interpersonal skills identification of competences in the us and europe there is growing consensus in the u.s. and europe on the key competence areas in academic public health curricula. influential documents have been produced by the public health foundation, i.e. the tier 1, tier 2 and tier 3 core competences for public health professionals (adopted may 3, 2010) (14). the following key public health competences are stated: epidemiology and biostatistics; environmental health sciences; health policy, management of health services and health economics; health promotion and education; and orientation to public health. additionally, generic competences, like analytical skills, communication skills, financial planning and management skills, and cultural skills are recognized as important for every academic public health professional. in the united kingdom, a public health skills and career framework (15) was developed, which is an attempt to define competences for seven levels of public health employment. in addition, through a year-long process, the association of schools of public health in the european region (aspher) developed six main domains of public health competences (16, 17). there are also many other projects worldwide which aim at the development of more specific lists of competences e.g.: core competences framework for health promotion (18), core competences for public health epidemiologists (19) or competences in the area of public health leadership. the latter are especially of pivotal importance given the repeatedly stated need to develop strong leadership skills in public health professionals (1). bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 6 box 1. recommendations on competence development 1. agree on common definitions, concepts and approaches related to competences, competence standards and cbe. 2. review the existing lists of public health competences with the aim of finding synergies, common understanding, universality or individual health care system specificity as well as selecting best practice examples. 3. agree on the underpinning quality criteria. 4. develop public health educational competence framework comprising core and emerging defined competences (which could be accepted by educators and public health professionals worldwide irrespective of the system they work in), values and convictions. 5. ensure that adequate training is provided and help to develop the workforce in terms of career progression and staff recruitment and retention through such a framework. this should include quality assurance and solid accreditation mechanisms (16). 6. carry out studies on cbe (a limitation of these studies thus far is that they mainly use qualitative approaches, like delphi group rounds, panel studies and focus groups. while these approaches are very useful in identifying the perceptions of key competences, they preclude firm conclusions and have limited representativeness) (12). based on the developed lists of competences, surveys should be given to public health employers, graduates and educators to prioritize key competences and their level of importance. 7. use simple and comprehensive language and define competences as measurable units. 8. make training and research relevant to practice and community service to revitalize the key role of schools of public health in this endeavour (16). 9. study the effects of cbe on public health practice to make it evidence-based and see whether it makes a difference. table 1 illustrates the main emerging competences identified by the european commission for 19 economic sectors. as can be seen, these represent skills related to innovations (e-skills, green skills), ―people skills‖ (intercultural skills and team work) and management (entrepreneurship, intercultural management). moreover, it is emphasized that multi skilling and skill-mix of these factors will be common and necessary. table 1. emerging competences social/cultural technical managerial  intercultural skills  team work  self management  entrepreneurship and innovativeness  ict and e-skills (both at user and expert level)  skills/knowledge related to new materials and new processes  health and green skills (related to health and climiate and environmental solutions)  intercultural management  international value chain management  international financial management  green management (implementing and managing climate and environmental friendly policies and solutions). adapted from: european commission. (2010). transversal analysis on the evolution of skills needs in 19 economic sectors (13) in addition, a set of ―cross-cutting‖ competences has been developed by the association of schools of public health (asph) in the u.s. these include: 1) communication and informatics; 2) diversity and culture; 3) leadership; 4) professionalism; 5) programme planning; and 6) systems thinking (20). bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 7 in regard to communication and informatics, it is important that graduates have an understanding of and ability to use the newly emerging information technologies and social media tools (e.g. i-pads, i-phones, facebook, twitter, etc.) in designing and implementing health interventions and in communicating messages. these tools will become even more important in developing greater public health preparedness to deal with natural disasters, continuing infectious disease outbreaks, and the ongoing threat of bioterrorism. on a different but related note, they are also central to reaching new groups of potential public health professionals through online and distance learning technologies. providing training in the competences associated with diversity and culture is particularly germane to addressing the continued inequalities in health by socioeconomic status and race/ethnicity both within and across countries, and for addressing the health issues associated with increased migration. such skills are essential to understanding and empowering communities to improve health and to adapting public health interventions to local cultures and contexts. it is becoming increasingly evident that in public health, as in other areas of public service and in the private sector, leadership matters (see case study 1 annexed). little is accomplished without it. the fundamental understanding is that no public health problem in history has been successfully met with technical skills alone. while many public health students may not think of themselves as leaders and may not aspire to leadership positions, they should be exposed to different approaches and skills associated with exerting leadership whenever and wherever their careers may take them. investment should be made in the development of innovative and creative management and leadership programmes informed by systems thinking, information science and transformational change principles to strengthen public health leadership. moreover, the particular type of leadership required is not of a traditional command and control variety, but rather akin to what has been termed ―adaptive‖ leadership: leading in contexts where there is considerable uncertainty and ambiguity. these environments often contain imperfect evidence and an absence of agreement about both the precise nature of the problem and the solutions to it. in the future, much of the authority of public health leaders will not come from their position in the health system but rather from their ability to win over and convince others through influence rather than control (21). more schools of public health are placing increased emphasis on the development of leadership competences. in sum, the importance of cross-cutting core and emerging competences for adapting and adequately equipping academic programmes in schools of public health in europe merits further exploration. clearly, these competences will need to be adapted to local contexts associated with different historical, cultural, political and economic circumstances. understanding the different settings involved is of great importance for accountable performance in public health. public health practitioners are expected to be effective in different environments. effective public health practitioners have to work with many different partners and paradigms. along with determining core and emerging competences to in order to develop competence based education in public health, it is important to make an overall strategic plan for public health training and education. box 2 below outlines a strategic framework for capacity building in public health training and education that should be articulated. this should be based on needs, with concrete objectives and targets. bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 8 box 2. strategic framework for capacity building in public health education and training 1. a strategic plan for capacity building in public health education and training in europe should start from a swot analysis and should define specific capacity building objectives and targets (with minimum set of indicators for monitoring and evaluation), which will be linked to european public health needs as well as to the new european policy for health ―health 2020‖ and european public health operations as a public health framework for action; 2. the targets for a strategy to strengthen public health education and training should cover all areas of current conceptual models of public health capacity building within the bologna process as follows: organizational development and resource allocation; degree and curriculum reforms; quality assurance; qualification frameworks; international recognition of degrees and mobility within the european higher education area (ehea) and the rest of the world; policies on widening access to and increasing participation in higher education; attractiveness of european higher education and the global dimension of the bologna process; 3. workforce development in public health should be considered among the highest priorities at national and european level; 4. perspectives on public health and expectations in public health from representatives of other sectors and policy areas should be included to enrich capacity building and lay out a basis for health in all policies; 5. ―public health identity‖ needs to be strong, reflecting the diversification of professional functions in public health and reconciling them with a shared identity: 6. both public health generalists and specialists are needed, as well as "horizontal" public health workers who consider health issues in other key sectors policy areas;  education and training of public health professionals focuses on health incorporated into development policies and tackling the socioeconomic determinants of health;  public health education and training requests to be recognized and developed in other key sectors. public health topics, views and experiences should be included in medical studies and spread through curriculum from the very beginning, as an example: 10-15% proportion of overall medical teaching should become a target. 7. the strategy for capacity building in public health education and training needs to consider horizontal and vertical aspects: it must address all levels of government and administration (supranational to local), as well as in other domains (private, civil society, public, etc). 8. the pace of strategy development for capacity building in public health education and training must fit with the national and international context. one should proceed in a measurable way. new developments in public health education and training as we have seen, the articulation of and consensus on core and emerging competences can inform competency based education and training, leading to a better equipped public health workforce. at the same time, several areas are emerging in the field of public health in europe:  development of broader, more flexible academic public health programmes, based on mobility of students and professionals in the ehea;  expansion of lifelong learning (lll), which involves extending knowledge and gaining skills –acquisition of competences – in the sphs, and application of innovation in training, particularly with regard to information technology (internet and mobile technologies, opencourseware on selected topics, and supportive elements of distance learning in general); and  increased potential of higher education programmes, based at all levels on state of the art research fostering changes by innovation and creativity. regarding the first area, in this section we discuss the move towards joint degrees and collaborative approaches with other schools. with respect to the second, we describe the importance of lifelong learning for growth and especially, increased employability, a new bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 9 development of its own. finally, we explain the new accreditation agency in europe, supporting and bringing about increased possibilities, improved accountability and better performance for public health education. broader, more flexible academic public health programmes although public health has always been ―global‖, under the rubric of ―international health‖, recent efforts have been underway to redefine ―international‖ health as ―global health‖ and think of it as a new and somewhat different field. this movement is being led primarily by medical schools, arguing that the new global health challenges require skills and approaches not typically found in ―traditional‖ schools of public health (22), pointing to the need for greater problem solving based field work, leadership development, and exposure to other disciplines such as engineering, business, law, and public policy. while many schools of public health have provided such training for years (23), there is no doubt that more could be done. the challenges of global health concerns could provide an opportunity for closer relationships between schools of public health and schools of medicine in addition to the other health science professional schools. as we have illustrated, public health is interdisciplinary, drawing on many fields, including biology, mathematics and statistics, law, business, economics and numerous other social science disciplines. however, there is only limited inter-professional education in public health. despite recent renewed interest in inter-professional training – among medicine, dentistry, pharmacy and public health – relatively little is occurring (2). among the reasons are protection of professional turf; the lack of top academic leadership and resources; lack of time and alignment of academic calendars; lack of faculty training and incentives; and lack of recognition by accrediting bodies that inter-professional competences are important (24). however, the most limiting factor in the current conception of inter-professional training is the relative exclusion of the major focus of public health; namely, the health of populations and communities. when most people refer to inter-professional education, they are primarily talking about creating effective patient care centered teams. for example, a recent influential report defines ―inter-professionality‖ as involving “…continuous interaction and knowledge sharing between professionals, organized to solve or explore a variety of education and care issues all which seek to obtain the patient’s participation.” (25). thus, to the extent that inter-professional education gains traction, one of the challenges for schools of public health is to define its role within this area. three possible approaches to inter-professional education include concurrent degrees, joint degrees, and ―embedded‖ degrees that could be given by schools of public health and other health science professional schools, such as medicine, nursing, dentistry, and pharmacy. a concurrent degree involves the admission of students to two schools (e.g. medicine and public health) from the start of the programme with a defined sequencing and pathway of interrelated courses. upon successful completion of requirements, students are simultaneously awarded both degrees. for example, at the university of california at berkeley (usa) such programmes exist between public health and business, public policy, social welfare, city and regional planning, and journalism. however, this is not yet offered with the health science professional schools perhaps because they are not located on the berkeley campus. a joint degree, on the other hand, consists of students receiving two degrees, but typically not at the same time and with relatively little overlapping course work. usually the medical or nursing degree is completed first and then students enrol for their mph degree. in most cases, bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 10 the mph degree is considered ―secondary‖ to the students´ primary clinical degree. many schools of public health in the united states offer such joint degrees. finally, a new and different approach exists which is called an embedded degree. this is offered as an arrangement between the university of california at berkeley school of public health and stanford university´s school of medicine. in this arrangement, up to five stanford medical students interrupt their medical school education during the second year to participate in an intensive one year 42 credit hour set of courses at berkeley´s school of public health. the stanford students then complete their medical training. upon completion of a jointly overseen berkeley-stanford thesis project, students are awarded both their md and mph degrees. the embedded approach is perhaps the most innovative of the three approaches in that it involves placement of a medical degree programme inside a school of public health while still in collaboration with a medical school. in addition to the stanford arrangement ucberkeley school of public health and uc san francisco school of medicine offer a combined ―joint medical programme‖, in which students spend their first three years on the berkeley campus. instruction focuses on case-based individual and team-based problem solving, assessing patients and their illness within the larger context of the community and the social environment in which patients live. upon completion of the three years, students complete their medical training and board exams at the uc san francisco medical school campus. the extent to which these, and possibly other examples of inter-professional training, might be relevant to europe and other parts of the world is a topic worthy of further discussion. lifelong learning and the importance of employability we live in the era of learning, witnessing new educational policy discourse with neo-liberal tenets (26). policies of the eu support the ―learning drive‖. it can be stated that we are observing a shift from competitiveness, growth and employment to employability – the ability to become employed. currently, 21st century competences are on the front page of educational reforms in europe and worldwide. a green paper from the eu commission calls for greater investment in workforce planning, while the eu council has called for greater priority to be given to lifelong learning as ‗a basic component of the european social model‘ (27). in line with the establishment of lifelong learning programme (llp) (decision no 1720/2006/ec amended by 1357/2008 decision), and the "new skills for new jobs" communication, the need to anticipate and match future skills has been developed. with regards to knowledge and skills, there are several systems and frameworks set up on the eu level, especially the european reference framework that defines the eight main competences needed for any person to be able to function successfully in their job and in society. the advantage of using this reference tool is that it actually reflects on the learning outcome of a person instead of only using length of time in the educational system 2 . a classification structure called ‗european skills, competences and occupations‘ (esco) is another example of ongoing work from the eu. this system is planning to bring together the most relevant skills and qualifications for numerous jobs into one network 3 . the european commission supports the development of lifelong skills and competences both formally and informally and opens many financial instruments aiming to promote the development of european educational know how, including the use of modern technology to 2 information retrieved 16/08/2011 from http://ec.europa.eu/education/lifelong-learning-policy/doc44_en.htm. 3 information retrieved 16/08/2011 from http://www.cedefop.europa.eu/en/news/16575.aspx. bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 11 support learning. it has to be noted that effective use of the ec financial instruments contributes to the development of collaborative learning, exchange of good practices and rise of new forms of teaching and learning, ranging from problem-based, active, self-directed, student-centred approaches to blended or hybrid learning, which is a combination of face to face and online learning. a broad range of options exist, such as the principle of mutual recognition of programmes and diplomas through the erasmus mundus grant or simply individual mobility throughout europe. these programmes are not only restricted to european countries, but allow for wider global participation, an important factor to be considered by public health educators. moreover, programmes offered by the european commission support the learning of foreign languages, increasing intercultural understanding, raising awareness of the potential of languages, and calling on decision makers to ensure efficient language education. it should be recognized that public health does not have specific a continuing professional development programme, unlike other health professions, and uses courses from other health care fields. however, as has been illustrated, many possibilities exist that can support the development of continuing education in public health and can help give rise to the still underdeveloped area of lifelong learning in the field. european accreditation accreditation is an important step to help ensure or enhance the level and quality of public health curricula and improve the standardization of a core curriculum in public health education. recently, along with developing lists of competences for public health professionals and for master education, aspher has taken the initiative, together with partners – eupha, the european public health alliance (epha), the european health management association (ehma), and eurohealthnet – and in consultation with who europe and the eu commission, to establish a european agency for accreditation of public health educational programmes and schools of public health. the accreditation agency has become an independent body, the agency for public health education accreditation (aphea), assuring its credibility and gaining approval by international agencies in charge of accrediting bodies and entry into international quality assurance registers. the european accreditation process for master of public health (mph) programmes is now under way. all participant organizations and individuals who contributed to this process are confident that this process will set new and improved standards for mph training in europe. this will ultimately help to improve the competences and employability of those graduating from public health programmes and entering the workforce, thereby contributing to the advancement of the field of public health across the vast european region. membership in the aphea board of directors includes representatives from all five partner organizations, while guidelines require that the chair of the board of accreditation is an individual highly distinguished in the field, but not directly associated with any of the organizations in the consortium. the curriculum required by aphea is based on the core subject domains from the list developed in the european public health core competences programme, although slightly regrouped (table 2). the agency adopted a ―fitness for purpose‖ approach to assess an academic institution based on the premise that an academic institution will set its mission for education and research within the context of a specific regional or national environment. this approach requires institutions to be orderly in developing programme aims, in carrying out ongoing assessments, and in using this information to direct and revise final qualifications, bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 12 curriculum modules, strategies and operations. ongoing assessment is intended to lead to programme improvement as part of this approach. for purposes of determining conformity with aphea accreditation criteria, the board of accreditation will consider current developments and planned changes as they relate to the ―fitness for purpose‖ process. this approach takes into account the diversity of the european schools of public health, but simultaneously sets certain curriculum standards for high quality education and training in public health in europe. the call for commitment circulated to aspher members in october of 2010 indicates that there is great interest among aspher member institutions to undergo accreditation of their public health or equivalent programmes at the european level. the agency started with three accreditations in 2011 and hopes to reach a capacity of ten per year by 2015. table 2. aphea core subject domains for mph curricula core subject areas curriculum content ects * credit ranges** introduction introduction to public health 2 methods in public health epidemiological methods, biostatistical 18-20 methods, qualitative research methods, survey methods population health and environmental sciences (including physical, 18-20 its determinants chemical and biological factors), communicable and noncommunicable disease, occupational health, social and behavioural sciences, health risk assessment, health inequalities along social gradient health policy, economics, healthcare systems planning, 16-18 economics, and organization and management, health policy, management financing health services, health programme evaluation, health targets health education and health promotion, health education, health 16-18 promotion protection and regulation, disease prevention cross-disciplinary biology for public health, law, ethics, ageing, 21-23 themes nutrition, maternal and child health, mental (mandatory and/or health, demography, it use, health informatics, elective courses) leadership and decision-making, social psychology, global public health, marketing, communication and advocacy, health anthropology, human rights, programme planning and development, public health genomics, technology assessment internship/final project supervised by faculty (full time and/or 24-26 resulting in thesis/ adjunct) dissertation/memoire * european credit transfer and accumulation system (or equivalent). ** the subject areas and credit ranges above are recommended; the accreditation process will assess the credit division among subject areas for a given programme. aphea – http://www.aphea.net ceph http://ceph.org/pg_about.htm bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 13 conclusions public health is rapidly gaining prominence in the various public policy domains in europe. the increasing importance of preparedness towards major health threats, the growing recognition of the fact that health is an important resource for economic growth and sustainability, and the heightened awareness of important health inequalities in europe are powerful driving forces in this regard. however, many eu member states and candidate countries have insufficient institutional and professional capacity for public health and the process of reforming the relevant services is slow. compared to the united states and other industrialized countries, as well as some emerging economies (e.g., brazil), the relative lack of public health capacity in the eu is striking (28). in addition, the situations within countries differ a great deal. as stated in the european action plan: current public health capacities and arrangements of public health services vary considerably across the who european region. these differences reflect variations in political prioritization and organizational models of public health services, as well as the distribution of functions and responsibilities across different administrative levels. however, there are many similarities across the european region, mainly in basic needs for public health information, knowledge and competences. there are often continuing problems of under-resourcing, skill shortages, insufficient capacity, poor morale and low pay. competency frameworks for a public health workforce, as well as career pathways, remain under-developed. public health functions are fragmented and sections of the workforce may work in an isolated way. while research capacity is well established in some countries, effective facilitation of research capacities to support policy development and programmes still lags behind (21). as an essential element of good governance, the european ministers of health in the council of europe request that a competent post-graduate training institution is available at national level, as well as in large regions, with links to both academic and health administrations (29). the schools and departments of public health are the main structure to provide education and training for public health professionals, as well as consultation and applied research for health administrations. the public health services, comprised of qualified and certified public health professionals, have to address the four main deficits of information, prevention, social equity and a weak regulatory framework. it is estimated that an additional 22,000 public health professionals are required per year for the european union alone to maintain an appropriate level of services. almost three times the present educational capacity is needed to provide these numbers. however, in order to meet population health needs, significant efforts are required not only to increase the number of public health professionals, but also their quality and relevance to public health (21). traditional disciplinary, sectoral approaches are no longer sufficient to resolve complex health problems and provide different perspectives (30). investing in a multidisciplinary public health workforce is a prerequisite for current challenges. in fact, as stated in the european action plan for strengthening public health capacities and services “a sufficient and competent public health workforce constitutes the most important resource in delivering public health services.” (21). the european schools and departments of public health have widely adopted the bologna format of teaching, as 47 countries are committed to joint action for strengthening a european higher education area (ehea). in spite of this, and as we have indicated, inequalities and the need for harmonization still exist. therefore, agreement is sought especially on bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 14 standardized lists of competences required in order to perform specified service functions. the education and training of public health professionals in europe has to be interdisciplinary and multi-professional, comprising the medical as well as the social sciences. in addition to core competences, cross-cutting competences are important to consider, including broader, multidimensional areas, such as leadership and diversity and culture. these competences should inform and shape public health education and training programmes, leading to competence-based education. this approach closes the bridge between traditional teaching methods and the competences actually required in practice. moreover, it is recognized that education and training for public health should be continuously evaluated and updated by use of performance measurement in everyday public health practice. employability is one of the key criteria for successful training of public health professionals. therefore, two key questions have to be answered: 1) who employs the public health professionals and what are their agendas? 2) what is the performance of public health professionals? it is of utmost importance to measure preferences of public health employers with respect to the competences required by graduates of public health studies at bachelor and master degree levels. specifying competences required by the public health labour market can result in a benchmark approach to competence-based education. the selected competences serving as benchmarks would standardize the criteria for change in education of public health professionals (31). the european union has recognized the importance of developing the field of public health with its et2020 strategy and both the eu and who (health 2020) are cooperating. however, each country should develop a strategic plan for capacity building in public health education and training, starting from a swot analysis and defining specific capacity building objectives and targets with a minimum set of indicators for monitoring and evaluation (see case study 2 annexed). new developments are heading in the direction of broader approaches to training, employability, and better performance of public health professionals. the focus is on defining the underlying competences needed for students to become effective global health professionals and leaders. in the age of innovation, the most valuable knowledge will be tacit, and universities and business must create environments that promote imagination, inspiration, intuition, ingenuity, initiative, a sense-of-self, self-assurance, self-confidence and selfknowledge. in the future, the public health professional will increasingly require skills such as interdisciplinary and interagency team working and communication skills. to the extent that inter-professional education gains traction, one of the challenges for schools of public health is to define its role. three possible approaches include development of concurrent degrees, joint degrees, and ―embedded‖ degrees that could be implemented between schools of public health and other health science professional schools such as medicine, nursing, dentistry, and pharmacy. during recent years, the relevance of a concept of lifelong learning has been recognized by all actors, particularly the european union. supported by blended or hybrid learning and employing online technology, these developments will change the educational landscape for all professionals and help make professionals more employable. in addition, accreditation agencies can help raise the quality and standardization of a core curriculum in public health education. the recent development of the agency for public health education accreditation (aphea) in europe will support and promote improvements in training. finally, it should be recognized that for the public health workforce to truly be equipped to tackle current public health challenges, genuine leadership should exist at all levels. bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 15 leadership that is transformational and collaborative, not top-down, needs to be in place at the policy level, to bring about educational reform; at the teaching level, to implement change; and at the level of public health professionals, to put into practice the new skills. references 1. jakab z. opening ceremony medipol university istanbul, turkey, 18 october 2010. http://www.euro.who.int/__data/assets/pdf_file/0006/124593/rdspeech1810turmedipol-university.pdf (accessed: march 15, 2014). 2. frenk j, chen l, bhutta za, cohen j, crisp n, evans t, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376:1923-58. 3. asph, association of schools of public health: demonstrating excellence in practice-based teaching for public health, 2004. www.asph.org (accessed: march 15, 2014) 4. who: regional committee for europe eur/rc61/inf.doc./1 sixty-first session: baku, azerbaijan, 12–15 september 2011. http://www.euro.who.int/en/who-weare/governance/regional-committee-for-europe/sixty-firstsession/documentation/information-documents/inf-doc-1-strengthening-public-healthcapacities-and-services-in-europe-a-framework-for-action (accessed: march 15, 2014) 5. frank jr, snell ls, cate ot, holmboe es, carraccio c, swing sr, et al. competence-based medical education: theory to practice. med teach 2010;32:638-45. 6. steele re. the cdc/hrsa public health faculty agency forum: creating recommendations and guidelines for competence based public health education. internet j public health educ 2001;3:1-5. 7. wright k, rowitz l, merkle a, reid, wm, robinson g, herzog b et al. competence development in public health leadership. am j public health 2000;90:1202-7. 8. frank jr, editor. the canmeds 2005 physician competence framework: better standards, better physicians, better care. ottawa: the royal college of physicians and surgeons of canada, 2005. 9. swing sr. the acgme outcome project: retrospective and prospective. med teach 2007;29:648–54. 10. albanese ma, mejicano g, mullan p, kokotailo p, gruppen l. defining characteristics of educational competences. med educ 2008;42:248–55. 11. european university-business cooperation thematic forum. new skills for new jobsthe role of higher education institutions and business cooperation. report (october 2009). http://www.eurireland.ie/_fileupload/2010/final%20report%209%20dec%2009.pdf (accessed: march 15, 2014). 12. biesma rg, pavlova m, vaatstra r, van merode gg, czabanowska k, smith t, groot w. generic versus specific competences of entry-level public health graduates: employers perceptions in poland, the uk, and the netherlands. adv health sci educ theory pract 2008;13:325–43. 13. european commission, dg employment. transversal analysis on the evolution of skills needs in 19 economic sectors. european commission, 2010. http://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&ved=0cd sqfjad&url=http%3a%2f%2fec.europa.eu%2fsocial%2fblobservlet%3fdocid% 3d4689%26langid%3den&ei=ew0tu_kcdoirtaa4kibi&usg=afqjcnfvmup_v aqmihpm-4cc5ae1ahfr7w&bvm=bv.62286460,d.yms (accessed: march 15, 2014). http://www.ncbi.nlm.nih.gov/pubmed?term=frenk%20j%5bauthor%5d&cauthor=true&cauthor_uid=21112623 http://www.ncbi.nlm.nih.gov/pubmed?term=chen%20l%5bauthor%5d&cauthor=true&cauthor_uid=21112623 http://www.ncbi.nlm.nih.gov/pubmed?term=bhutta%20za%5bauthor%5d&cauthor=true&cauthor_uid=21112623 http://www.ncbi.nlm.nih.gov/pubmed?term=cohen%20j%5bauthor%5d&cauthor=true&cauthor_uid=21112623 http://www.ncbi.nlm.nih.gov/pubmed?term=crisp%20n%5bauthor%5d&cauthor=true&cauthor_uid=21112623 http://www.ncbi.nlm.nih.gov/pubmed?term=evans%20t%5bauthor%5d&cauthor=true&cauthor_uid=21112623 bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 16 14. public health foundation tier 1, tier 2 and tier 3 core competences for public health professionals. council on linkages between academia and public health practice. washington dc, 2010. 15. rao m. public health skills and career framework. england: department of health in england (public health skills and career framework), 2008. http://www.sph.nhs.uk/sphfiles/phskillscareerframework_launchdoc_april08.pdf/v iew (accessed: march 15, 2014). 16. aspher, association of schools of public health in the european region. provisional lists of public health core competences. brussels: 2008. 17. aspher, association of schools of public health in the european region. aspher‘s european public health core competences programme (christopher birt, anders foldspang): publication no. 5: european core competences for public health professionals (eccphp); publication no. 6: european core competences for mph education (eccmphe); publication no. 7: philosophy, process and vision. brussels, 2011. 18. iuhpe, 2011. http://www.iuhpe.org/index.php/en/global-working-groups-gwgs/wgon-competencies-and-workforce-development-cwdg (accessed: march 15, 2014). 19. ecdc, european centre for disease prevention and control: core competences for public health epidemiologists working in the area of communicable disease surveillance and response in the european union. stockholm, 2008. 20. asph, association of schools of public health. masters degree in public health core competence development project, version 2.3. asph education committee, washington, dc: 2006. 21. who. regional committee for europe, european action plan for strengthening public health capacities and services eur/rc62/conf.doc./6 rev.2, sixty-second session: malta, 10-13 september, 2012. 22. koplan jp, bond tc, merson mh, reddy ks, rodriguez mh, sewankambo nk, et al. towards a common definition of global health. lancet 2009;373:1993-5. 23. fried lp, bentley me, buekens p, burke ds, frenk jj, klag mj, spencer hc. global health is public health. lancet 2010;375:535-7. 24. interprofessional education collaborative: core competences for interprofessional collaborative practice, washington, dc: may 2011. 25. d‘amour d, oandasan. interprofessionality as the field of interprofessional practice and interprofessional education: an emerging concept. j interprof care 2005;suppl 1:8-20. 26. brine j. lifelong learning and the knowledge economy: those that know and those that do not—the discourse of the european union. brit educ res j 2006; 32:649-65. 27. european commission. communication from the commission to the european parliament, the council, the european economic and social committee and the committee of the regions. european commission: 2008. 28. bjegovic-mikanovic v, vukovic d, otok r, czabanowska k, laaser u. education and training of public health professionals in the european region: variation and convergence. int j public health 2013;58:801-10; doi: 10.1007/s00038-012-0425-2. 29. council of europe. committee of ministers, 2012. https://wcd.coe.int/viewdoc.jsp?ref=cm%282010%2914&language=lanenglish&s ite=cm&backcolorinternet=c3c3c3&backcolorintranet=edb021&backcolorlog ged=f5d383 (accessed: march 15, 2014). http://www.ncbi.nlm.nih.gov/pubmed?term=koplan%20jp%5bauthor%5d&cauthor=true&cauthor_uid=19493564 http://www.ncbi.nlm.nih.gov/pubmed?term=bond%20tc%5bauthor%5d&cauthor=true&cauthor_uid=19493564 http://www.ncbi.nlm.nih.gov/pubmed?term=merson%20mh%5bauthor%5d&cauthor=true&cauthor_uid=19493564 http://www.ncbi.nlm.nih.gov/pubmed?term=reddy%20ks%5bauthor%5d&cauthor=true&cauthor_uid=19493564 http://www.ncbi.nlm.nih.gov/pubmed?term=rodriguez%20mh%5bauthor%5d&cauthor=true&cauthor_uid=19493564 http://www.ncbi.nlm.nih.gov/pubmed?term=sewankambo%20nk%5bauthor%5d&cauthor=true&cauthor_uid=19493564 http://www.ncbi.nlm.nih.gov/pubmed?term=fried%20lp%5bauthor%5d&cauthor=true&cauthor_uid=20159277 http://www.ncbi.nlm.nih.gov/pubmed?term=bentley%20me%5bauthor%5d&cauthor=true&cauthor_uid=20159277 http://www.ncbi.nlm.nih.gov/pubmed?term=buekens%20p%5bauthor%5d&cauthor=true&cauthor_uid=20159277 http://www.ncbi.nlm.nih.gov/pubmed?term=burke%20ds%5bauthor%5d&cauthor=true&cauthor_uid=20159277 http://www.ncbi.nlm.nih.gov/pubmed?term=frenk%20jj%5bauthor%5d&cauthor=true&cauthor_uid=20159277 http://www.ncbi.nlm.nih.gov/pubmed?term=klag%20mj%5bauthor%5d&cauthor=true&cauthor_uid=20159277 http://www.ncbi.nlm.nih.gov/pubmed?term=spencer%20hc%5bauthor%5d&cauthor=true&cauthor_uid=20159277 bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 17 30. choi bc, pak aw. multidisciplinarity, interdisciplinarity and transdisciplinarity in health research, services, education and policy: 1. definitions, objectives, and evidence of effectiveness. clin invest med 2006;29:351-64. 31. vukovic d, bjegovic-mikanovic v, otok r, czabanowska k, nikolic z, laaser u. which level of competence and performance is expected? a survey among european employers of public health professionals. int j public health 2014;59:15-30; doi: 10.1007/s00038-013-0514-x. http://www.ncbi.nlm.nih.gov/pubmed/17330451 http://www.ncbi.nlm.nih.gov/pubmed/17330451 http://www.ncbi.nlm.nih.gov/pubmed/17330451 bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 18 annex case study 1: public health leadership in europe (katarzyna czabanowska) in october 2010, ‗leaders for european public health‘ (lephie) was developed, a european erasmus multilateral, curriculum development project in the lifelong learning (lll) format. this is a collaborative effort between maastricht university (nl), the sheffield hallam university (uk), lithuanian university of health sciences (lt), medical university of graz (at) and the association of schools of public health in the european region (aspher), and resulted from an aspher and eupha on-line survey 4 that highlighted the need for online, problem-based leadership courses. this module aims to develop leadership competences through the following:  examining the key debates around leadership in public health.  introducing key theoretical frameworks that underpin leadership learning, and applying theory to actual practice.  developing the ability to analyse the public health leadership role and development needs of individuals.  stimulating self-assessment of leadership competences to identify knowledge gaps and further training needs. the competence-based programme focuses on a variety of situations related to public health risks with special attention paid to ageing and chronic diseases, as reflected by identified priorities. the public health leadership content is aimed to be applicable to performance in diverse european public health practices and contexts, and reflects the priorities and objectives of the european health programme. 5 based on an extensive literature review and expert review panels, a framework was developed to support the curriculum and facilitate self-assessment. the module uses innovative training methods, such as problem-based and blended learning formats (a combination of face-to-face and online learning), and students are active participants in the process. thus, students have a common goal, share responsibilities, are mutually dependent on each other for their learning needs, and are able to reach agreement through open interaction (suzuki et al. 2007). such an educational approach proves to be successful in the lll context. the participants are offered interactive lectures, tutorial group meetings and other collaborative sessions at a distance. the course is delivered via an intranet, such as blackboard or moodle, and course material can be directly downloaded. after being successfully piloted in the uk, a mutually recognized international blended learning leadership course worth seven ects will be delivered by the international consortium. it is believed that the integration of modern learning technology with collaborative learning techniques, supported by interdisciplinary competence-based education transcending institutional boundaries, will result in transformative learning, which is about developing leadership attributes (frenk et al. 2010). this constitutes a small step towards inter-professional and trans-professional education. 4 available from: http://www.old.aspher.org/pliki/pdf/lll_liane.pdf. 5 http://ec.europa.eu/health/programme/policy/2008-2013/index_en.htm. bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 19 case study 2: regional cooperation – the development of a regional public health strategy in south eastern europe (vesna bjegovic-mikanovic) a regional public health strategy for south eastern europe was developed during a public health expert seminar in august 2004, belgrade, organised in the framework of the forum for public health in south eastern europe (fph-see). strengths, weaknesses, opportunities, threats and their interactions were defined based on a swot analysis. within this, a framework for a regional public health strategy, including strategic goals and objectives, was determined based on priorities identified by nominal group techniques. one of the identified goals was ―strengthening human resources in public health‖, and, within this was the objective of ―ensuring sustainable development of human resources.‖ activities included:  developing common curricula for public health on different academic levels.  providing a common glossary and terminology in public health. based on this process, there are the following proposed exercises: task 1: students split up into groups to discuss the draft strategic framework. they analyse strengths and weaknesses, considering a) the development process; b) the draft framework with its goals and objectives; and c) recommendations for improvement. each group prepares a summary report on strengths, weaknesses and their recommendations, and presents them in plenary. task 2: students compare the national public health strategy of their own country (or health policy if no specific public health strategy exists) with the draft framework for a regional strategy and compare them by highlighting similarities and differences. task 3: students experience participatory and consensus building methods: a swot analysis on the public health situation in their country (or province, district, community, or city) is conducted and subsequently, a priority setting method is applied so that a list of public health priorities can be identified in the selected setting. source: public health strategies: a tool for regional development. a handbook for teachers, researchers and health professionals. isbn 3-89918-145-x, lage, germany: hans jacobs, 2005: 583-647. ___________________________________________________________ © 2014 bjegovic-mikanovic et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. holst j, breckenkamp j, burazeri g, martin-moreno jm, schröder-bäck p, laaser u. five years of the south eastern european journal of public health (seejph): focusing on health systems in transition and global health [editorial]. seejph 2018, posted: 24 september 2018. doi 10.4119/unibi/seejph-2018-201 1 editorial five years of the south eastern european journal of public health (seejph): focusing on health systems in transition and global health jens holst1, jürgen breckenkamp1, genc burazeri1, jose m. martin-moreno1, peter schröder-bäck1, ulrich laaser1 1 editors, south eastern european journal of public health (seejph). corresponding author: ulrich laaser section of international public health, faculty of health sciences bsph, university of bielefeld, germany; address: pob 10 01 31, d-33501 bielefeld, germany; email: ulrich.laaser@uni-bielefeld.de mailto:ulrich.laaser@uni-bielefeld.de holst j, breckenkamp j, burazeri g, martin-moreno jm, schröder-bäck p, laaser u. five years of the south eastern european journal of public health (seejph): focusing on health systems in transition and global health [editorial]. seejph 2018, posted: 24 september 2018. doi 10.4119/unibi/seejph-2018-201 2 five years ago, in the spring of 2014, the first volume of a new open access journal was published by jacobs company (1). it was conceptualized in the framework of the european stability pact for south eastern europe, financed until 2010 by the german academic exchange service. yet, by that time, the project had supported the creation of schools of public health and public health training programmes in albania, bulgaria, moldova, romania, serbia, and slovenia, complementing the andrija stampar school of public health in zagreb, croatia, the oldest institution for teaching, research, and practice of public health in the region (since 1927). the south eastern european journal of public health (seejph) is an open access international peer-reviewed journal involving all areas of the health sciences and public health. seejph welcomes submissions of scientists, researchers, and practitioners from all over the world, but particularly pertinent to transition countries. in their introductory editorial, the editors wrote that: “the need for scientific journals such as seejph springs from the peculiar geopolitical history of the region. during the late 1980s and early 1990s, the disintegration of the communist regimes in most of south eastern europe hastened the collapse or at least enormous challenges in the economies of the region” (2). since then, the journal steadily widened its array with a focus on the southern and eastern regions of the world which are currently experiencing a process of transition similar to south eastern europe. as a consequence, we appointed regional editors for each of the world health organization (who) regions of africa, the americas, europe, south east asia, western pacific, and logically paying tribute to the genesis of the journal within south eastern europe (3). as the global dimension of the journal gained weight, the editors invited professor jens holst as coeditor and chair of the regional editorial group, taking office with this tenth issue of the journal. in this context, we are determined to widen the field of interest beyond a historical national or local vision of public health to a global health perspective which, of course, in our understanding, has increasingly developed from a kind of cosmopolitan cousin into an overarching concept in the globalised world. current trends in global health include demographic and epidemiological transitions, the changing burden of disease, climate change, and the increasing awareness of both national and global disparities in health. the most frequently cited definition was crafted by jeffrey koplan and colleagues in 2009: “global health emphasises transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care” (4). the concept of ‘global’ in global health goes beyond its geographic meaning. like international health, global health links to health equity and cross-border solidarity. apart from this, global health considers health from a human-rights perspective and as an explicitly social, economic, and political issue anywhere in the world (5). in this understanding, the editors perceive ‘public’ in the journal title as ‘global’ health. likewise, the term ‘south eastern european’ is not limited to its geographic meaning, but rather refers to the global south and some parts of the east in a developing world. starting with its 10th edition, seejph will put a major focus on global health challenges and cover health issues that transcend national boundaries calling for action in the various sectors, which determine people’s health. holst j, breckenkamp j, burazeri g, martin-moreno jm, schröder-bäck p, laaser u. five years of the south eastern european journal of public health (seejph): focusing on health systems in transition and global health [editorial]. seejph 2018, posted: 24 september 2018. doi 10.4119/unibi/seejph-2018-201 3 we believe that the challenges we are experiencing in this historical moment deserve such a commitment and we thank you in advance for your support to this initiative. references 1) the south eastern european journal of public health (seejph), published by jacobs verlag, hellweg 72, d-32791 lage, germany. 2) burazeri g, jankovic s, laaser u, martin-moreno j. south eastern european journal of public health: a new international online journal. seejph 2015, vol. 1. doi 10.4119/unibi/seejph-2014-21. 3) seejph, about: http://www.seejph.com/index.php/seejph/pages/view/editorialteam. 4) koplan jp, bond tc, mersonmh, reddy ks, rodriguez mh, sewankambo nk, wasserheit jn, for the consortium of universities for global health executive board. towards a common definition of global health. lancet 2009;373:1993-5. 5) bozorgmehr k. rethinking the ‘global’ in global health: a dialectic approach. global health 2010;6:19. doi: 10.1186/1744-8603-6-19. ______________________________________________________________________________________ © 2018 holst j, et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. burazeri g, jankovic s, laaser u, martin-moreno jm. south eastern european journal of public health: a new international journal (editorial). seejph 2013, posted: 31 october 2013. doi 10.12908/seejph-2013-01. 1 editorial south eastern european journal of public health: a new international online journal genc burazeri1,2, slavenka jankovic3, ulrich laaser4, jose m. martin-moreno5 1 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 2 faculty of public health, university of medicine, tirana, albania; 3 faculty of medicine, university of belgrade, belgrade, serbia; 4 faculty of health sciences, university of bielefeld, bielefeld, germany; 5 faculty of medicine, university of valencia, valencia, spain. corresponding author: genc burazeri, md, phd address: university of medicine, rr. “dibres”, no. 371, tirana, albania; telephone: +355672071652; e-mail: gburazeri@yahoo.com burazeri g, jankovic s, laaser u, martin-moreno jm. south eastern european journal of public health: a new international journal (editorial). seejph 2013, posted: 31 october 2013. doi 10.12908/seejph-2013-01. 2 the south eastern european journal of public health (seejph) is an online, openaccess, international, peer-reviewed journal, published by jacobs company in germany (1). starting from 2014, the journal will initially release two issues per year, at the end of june and the end of december, although articles will be immediately published online following acceptance – a unique advantage of open-access journals, whose relevance within the corpus of scientific literature has been growing in recent years. seejph follows the achievements of the forum for public health in south eastern europe, funded by the german stability pact during the first decade of this century (2). seejph covers all areas of health sciences, although its main focus is public health. the journal particularly encourages submissions from scientists and researchers from eastern european transitional countries in order to promote their research work and increase their scientific visibility in europe and beyond. the need for scientific journals such as seejph springs from the peculiar geopolitical history of the region. during the late 1980s and early 1990s, the disintegration of the communist regimes in most of southeastern europe hastened the collapse—or at least enormous challenges—in the economies of the region. subsequently, a marketoriented economic system emerged involving major social, cultural, and economic reforms, with similar changes observed in all former communist countries in central and eastern europe. the rapid transition from state-enforced collectivism towards a market-oriented system brought with it increasing poverty levels, high unemployment rates, financial downturn, and massive emigration. the situation was further aggravated by the devastating ethnic wars which involved most of the countries of the former yugoslavia. today, life expectancy in the transition countries is still significantly lower than in western europe (3), with most of the east-west gap explained by the higher death rates from cardiovascular diseases and injuries in eastern european populations (4-6). the particularly high levels of smoking, alcohol consumption, unhealthy dietary habits including low intake of fresh fruits and vegetables (3,6,7), and adverse socioeconomic and psychosocial conditions (8,9) have been persuasively linked with an excess risk of cardiovascular disease, diabetes and other chronic conditions (4,7). nonetheless, the health effects of such rapid transition, especially in the distinctive context of countries of the western balkans, have not been sufficiently investigated. to date, ongoing research on the deleterious health effects of transition is scant and has not received sufficient attention in the international literature. there is an evident need to promote scientific publications pertinent to researchers from transitional countries in europe, to promote the development of a field we will refer to as “health transition research”. seejph aims to fill this void by offering a unique opportunity for the exchange of scientific information, active and rapid communication between researchers and scientists, and dissemination of findings from research conducted in central, eastern, and south eastern europe. we look forward to fostering the advance of scientific knowledge in the region, in the hope that a solid and context-specific evidence base for public health will lay the foundation for more effective health policies to serve eastern european populations. burazeri g, jankovic s, laaser u, martin-moreno jm. south eastern european journal of public health: a new international journal (editorial). seejph 2013, posted: 31 october 2013. doi 10.12908/seejph-2013-01. 3 references 1. south eastern european journal of public health (issn: 2197-5248). available from: http://www.seejph.com/?cat=7 (accessed: 12 october, 2013). 2. stability pact for south eastern europe. available from: http://www.stabilitypact.org/ and http://www. snz.unizg.hr/ph-see/index.htm (accessed: 12 october, 2013). 3. world health organization, regional office for europe. european health for all database (hfa-db). copenhagen, denmark, 2013. 4. marmot m, bobak m. international comparators and poverty and health in europe. bmj 2000;321:1124-1128. 5. ginter e. cardiovascular risk factors in the former communist countries. analysis of 40 european monica populations. eur j epidemiol 1995;11:199-205. 6. ginter e. high cardiovascular mortality in postcommunist countries: participation of oxidative stress? int j vit nutr res 1996;66:183-189. 7. rechel b, mckee m. healing the crisis: a prescription for public health action in south eastern europe. new york: open society institute press, 2003. 8. bobak m, pikhart h, rose r, hertzman c, marmot m. socioeconomic factors, material inequalities, and perceived control in self-rated health: crosssectional data from seven post-communist countries. soc sci med 2000;51:1343-1350. 9. burazeri g, goda a, tavanxhi n, sulo g, stefa j, kark jd. the health effects of emigration on those who remain at home. int j epidemiol 2007;36:12651272. ___________________________________________________________ © 2013 burazeri et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. stability pact for south eastern europe. available from: http://www.stabilitypact.org/ and http://www. snz.unizg.hr/ph-see/index.htm (accessed: 12 october, 2013). kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 1 | 15 review article risk management and prevention of antibiotics resistance: the prevent it project kiranjeet kaur1, stefano greco2, sunil d. saroj3, shaikh shah hossain4, himanshu sekhar pradhan5, sanjeev k. singh6, francesca clerici7, meenakshi sood1, helmut brand4,8, preethi john1, peter schröder-bäck8 1 chitkara school of health sciences, chitkara university, punjab, india; 2 chitkara spaak centre for multidisciplinary european studies, chitkara university, punjab, india; 3 symbiosis school of biological sciences, symbiosis international (deemed university), pune, maharashtra, india; 4 prasanna school of public health, manipal academy of higher education, manipal, karnataka, india; 5 school of public health, kiit deemed to be university, bhubaneswar, odisha, india; 6 department of medical administration, amrita institute of medical sciences, kochi, india; 7 department of pharmaceutical sciences, university of milan, milan, italy; 8 department of international health, care and public health research institute (caphri), maastricht university, the netherlands. corresponding author: dr. kiranjeet kaur; address: chitkara school of health sciences, chitkara university, punjab campus, chandigarhpatiala national highway (nh-64), tehsil: rajpura, distt. patiala-140401, india; telephone: +91-9815193584; email: kiranjeet.kaur@chitkara.edu.in kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 2 | 15 abstract background: globally, a significant increase in the emergence of antibiotic resistant (abr) pathogens has rendered several groups of antibiotics ineffective for the treatment of life-threatening infections. it is an endemic in hospital settings and a major concern while handling pathogens involved in an epidemic or pandemic. abr is a matter of great concern due to its recusant impact on public health and cost to the healthcare system, especially in developing country like india. an indiscriminate and inappropriate usage of antimicrobials, poor infrastructure and sanitation are the major factors driving the evolution of abr in such countries. therefore, in addition to the development of novel therapeutics and safeguarding the efficacy of existing antibiotics, there is an urgent need for a programme focussed on the education in risk management and prevention of abr. aim: to promote qualitative teaching activities in academia and society to visualize a future where every individual is aware of abr and empowered with right education to address the issue. methods: the project ‘risk management and prevention of antibiotics resistance prevent it’, funded by the erasmus+ programme of the european union, converges academicians and non-government organizations (ngos) to inculcate a sense of awareness towards the increase in the frequency of abr pathogens, judicial usage of antimicrobials and the economic/health burden of abr, in students, academicians, clinicians and population at large. expected outcome: the project commissioned envisages a behavioural change in individuals and attempts to support policymakers by executing stable changes in the curricula of institutes of higher education, developing advanced workshop modules for the training of academicians and disseminating abr-related information through conferences/seminars, social media campaigns and an online platform dedicated to abr. in addition, the project aims to develop a europeanindian network for the management of risk and prevention of abr. keywords: antibiotic resistance, education, erasmus plus, europe, global action plan, india. conflicts of interest: none declared. kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 3 | 15 introduction of the various health issues faced by the world today including covid 19, antimicrobial resistance (amr) is a growing problem that poses a grave threat to global public health (1). the term amr pertains to the inability of the antibiotic to treat or cure the infection caused by microorganisms. reports from the world health organization (who), have also declared amr being the sole factor to be responsible for approximately 10 million deaths by 2050 (2). given the fact that amr is not constricted by demography or geography, it needs to be addressed globally (3). the global amr response is listed in the who’s core mandate, stressing the importance and priority to seek its remedy. the global action plan on antimicrobial resistance by who (4) and the national action plan on antimicrobial resistance napamr (5) by the govt. of india are some of the global and local initiatives to combat the predicted adverse conditions. these action plans hinge on a multi-pronged approach that include: 1. creating awareness through education and training 2. amr surveillance 3. prevention and control measures, including 3a. rational use of antibiotics 3b. research and innovative practices like improved diagnostics for reducing use of antibiotics 3c. therapeutics; that minimizes use of antibiotics 4. collaboration facilitation though, all the approaches mentioned above are equally significant, creating awareness through education, targets the problem at the base level. as per a review conducted in 2016 by o’neill (6), the emphasis was laid on the urgency of creating global awareness campaign to educate the public, particularly youngsters about the ramifications of drug resistance. these initiatives have the potential to bring about behavioral change in the mindset of the youth. it is said that developing countries, such as india, with their enormous youth population could see their economies rise, only if they invest profoundly in young people's education and health (7). an innovative project initiated to address these challenges, named risk management and prevention of antibiotics resistance prevent it, is being undertaken in india, in alignment with the national action plan (nap) and funded by the european commission under the erasmus+ scheme. the project comprises of seven indian partners and four european partners. the vision of the project is a future where every individual is aware of antibiotic resistance (abr) and empowered with the right education to address and seek remedial course of action to prevent the further development of drug resistance. it is imperative for all the key stakeholders academicians, researchers and non-governmental organizations to coordinate and collaborate to ensure that health systems are better prepared to prevent and tackle the amr threat. background the year 1928 ushered in the modern era of medicine with the discovery of the first antibiotic, penicillin (8) that transformed the consequence of infections. however, unfortunately the bacteria evolved to become resilient to antibiotic/s leading to ‘resistance’ viz. antibiotic resistance (abr). the likely causes of the increasing resistance are multifactorial including the involvement of three parties: humans, animals and the environment. it spans inappropriate antibiotic prescription, over-the-counter sale of antibiotics, disproportionate use of antibiotics in food of animals (livestock, aquatic, pets), and poor sanitation and hygiene (9). further, hospital kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 4 | 15 effluents, water from wastewater treatment plants (wwtp), industrial effluents appear to act as reservoir for abr in soil and aquatic environment (10,11). one cannot also ignore the contribution of other factors such as release of unused antibiotics or their non-metabolized residues into the environment via manure/feces and increased international travel. thus, it is vital to apprehend that amr is a multi-faceted problem which can only be tackled by employing the “one health approach” so that collaborative efforts can be made by the health authorities dealing with these spheres (12). a report by world health organization states that there will be approximately 10 million deaths worldwide due to antimicrobial resistance (amr), mostly due to resistant bacterial infections by 2050 (13). the problem is, if the present condition is not tackled rightly, the global economic burden may reach about $120 trillion (2). recent data suggests that at least 700,000 people die each year due to drug-resistant diseases (6). out of this, at least 230,000 people die only from multidrug-resistant tuberculosis (13). of all the developing countries, india bears the highest burden of resistant bacterial infections with a crude mortality rate from infectious diseases of 417 per 100,000 persons (14). at the same time, india ranks first in worldwide consumption of antibiotics for human use, with 10.7 units of antibiotics consumed per person in 2010. a rise of about 67% has been projected in antibiotic consumption by the year 2030 (15). also, the incidence will double in brics countries (brazil, russia, india, china, and south africa), which are developing at fast pace and are amongst the vastly populated countries of the world. in the absence of real data reflecting the current effect of abr indian scenario, few reports (16) have identified it as an emerging threat to public health. one of the major sources for environmental pollution in india are the hospital effluents and pharmaceutical waste waters which are passed into the nearby water bodies. moreover, there is no ample treatment and improper disposal of unused antibiotics which is thrown in water or landfill. a study conducted by akiba et al. (17) in south india found resistant escherichia coli strains to third generation cephalosporin in both domestic water and hospital effluents. not only this, 100% resistance to cephalosporin (third generation drug) was seen in case of 283 e. coli isolates obtained from indian river cauvery located in karnataka (18). furthermore, a variable percentage of oxytetracycline resistant gram-negative bacilli and staphylococcus aureus were detected in cow and buffalo milk in west bengal and gujarat. another study by sudha et al. (19) in shellfish and crabs in kerala found strains of vibrio cholera and v. parahaemolyticus 100% resistant to ampicillin. further, it has been reported that india will be contributing to the major relative rise in antibiotics consumption between 2010 and 2030, especially for use in livestock (20). various initiatives have been introduced both at global level and national level to fight against this adverse and alarming situation of amr. emphasizing the threat amr poses to human health in may 2015, the world health assembly (wha) recommended a global action plan (gap) on amr comprising abr (4). these initiatives include vigilant use of antibiotics and surveillance of antibiotics by engaging the “one health approach”. the wha resolution also emphasized on practical measures and requested the member states to align their national action plans with gap-amr by may 2017. in this framework, india has approved the national action plan on antimicrobial resistance in alignment with global action plan (20172021) (5). the initiative was coordinated by kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 5 | 15 ministry of health & family welfare, government of india. also, india has given due cognizance to the problem of amr and launched “national programme on the containment of antimicrobial resistance” prior under the aegis of the national centre for disease control (ncdc) in twelfth five-year plan (2012 2017) (21). further, recently in the year 2019, indian council of medical research published “treatment guidelines for antimicrobial use in common syndromes” (22). however, in spite of taking measures at the basal level, the final output could not stop the development of amr (23). both global and national action plan call for an increased awareness, hence it is very important the education sector must also be included strategically to make a difference. today this is a glaring gap. as at grassroot level – the communities, students both in school and higher education sector are not currently recipients/beneficiaries of this awareness programme. academic institutions across the globe including india need to introduce and modify the content of its courses to enable their students to grow intellectually, politically, socially and culturally. education of this type needs a new pedagogy where beings can develop skills to find out critically and contemplate systematically about difficulties/problems (24). a further study conducted by fien (25) has suggested that making change in curriculum will directly influence the overall political, economical, and social development. another approach is ‘capacity building’ which is one of the key prerequisites for its successful implementation, involving strategies, resources aiming to increase collective power of people. thus, there is an urgent need to influence curriculums by incorporating information related to risk management and prevention of amr/abr. the project entitled; “risk management and prevention of antibiotics resistance prevent it” aims to address these challenges via educational initiatives. context looking at the current scenario, it would not be wrong to say that india is becoming a hub of resistant infections not only for humans but animals as well. the poor sanitation, lack of infrastructure and huge population density are the contributing factors towards this situation. though historically, amr did not receive much attention in india, today tremendous efforts are being made in this direction. for instance, the initiation of a national action plan aligned to a global action plan and active participant in glass. however, even after such initiatives, the dearth of financial help in developing countries acts as barrier in the implementation of these plans. thus, use of primordial measure of prevention working at the grass root level with an aim to prevent any infection with low cost involvement is the need of the hour. one such initiative is creating awareness amongst society, especially youth of a country through education. in this regard, the innovative character of the prevent it project is to create the first indo-european collaboration aimed at developing abr specific curricula and disseminating expertise in abr prevention. the experts from academia will reach students from different background while non-governmental organizations (ngos) will be spreading awareness among citizens. the project will bring sustainable change by creating awareness both at organizational and societal level. functioning of the prevent it project: goal the goal of the project is to create a future where every individual will be aware of antibiotic resistance (abr) and empowered with the right education to address the issue of kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 6 | 15 abr. therefore, the project aims to promote qualitative learning activities in academia as well as in the society. objectives 1. to establish the first european-indian network for risk management and prevention of abr by developing interdisciplinary curricula on risk management and prevention of abr at indian partner universities. 2. to spread awareness in academicians, students, policy makers and general public through public events and awareness campaigns on social media. 3. to create super-expertise in delivering abr advanced vocational training to young indian academicians. 4. to create an interdisciplinary free online course for spreading awareness, enlarging the target groups empowered in the framework of the project. 5. to promote informative events at community level in cooperation with projects' ngos. funding agency and cohort of the project the erasmus+ programme of the european commission has opportunities for individuals as well as organizations aiming for research, teaching mobility, and policy reform acts. out of these key actions, prevent it was granted under the category of capacitybuilding in the field of higher education (cbhe) to support modernization, accessibility, and internationalization of higher education in developing and transition countries. the project is a consortium of partners from five countries, namely india, portugal, latvia, italy and netherlands. there are nine higher education institutions and two nongovernmental organizations involved, making a total of eleven partners. of these, seven partner organizations are situated in different states of india, thus justifying the diversity of the group (figure 1). the health sciences team of the project comprises of the experts from each higher education institutes (heis)/organizations responsible to undertake the academic and scientific tasks of the project. the detailed description of other stakeholders is given in figure 1. figure 1. geographical distribution of the partners kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 7 | 15 strategic priorities the prevent it project outlines interventions and priorities planned to be executed over 2019-2021 to combat the public health challenge of abr not only in india but globally too. the key strategic priorities include “education & training” and “dissemination & awareness” – which are in line with the global and national action plan. as it is said, “one always has time enough, if one applies it well”, the key activities (figure 2a & 2b) involved in achieving the strategic priorities are planned on yearly basis. figure 2a and 2b. strategic priorities of prevent it project kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 8 | 15  education and training education this project seeks to influence education by modifying the existing curriculum, or creating new course/s at the graduate, post graduate and doctoral level at indian universities, as well as ngos. this will serve to ensure the sustainable application of the knowledge on abr. an expert review committee was also established called the indo-european network whose functioning was to ensure a robust curriculum. create an indo-european expert network on abr in order to create an indo-european network on abr, the first milestone of the project was to organize three intra-consortium empowerment camps of four days each comprising a total of eighty four hours. these empowerment camps are very crucial in terms of skills and team building. the mission is to create the health sciences team of interdependent experts from heis and ngos with a great ingenuity in antibiotics prevention and risk management – with specific knowledge on indian milieu. the key role of the first two empowerment camps is to create the new/modernized curricula for the indian universities as well as ngos. creation and implementation of new/modernized curriculum on abr first of all, the existing curricula of healthcare programs will be reviewed by the respective partner organizations for the existence or non-existence of relevant topics that must be taught on abr. the gaps observed in curriculum will be enlisted and proposed revised or new curricula will be shared and presented in front of indo-european network during the empowerment camps. the feedback/s (online) on the curricula will be provided by indo-european expert group depending on the field of expertise (allied health sciences, optometry, physiotherapy, microbiology, pharmacy, biotechnology, bachelor of medicine and bachelor of surgery (mbbs), nursing, public health, bachelor of dental surgery (bds), doctorate level). the discussion/s will aim at evolving the teaching methodology and assessment pattern followed at different heis. for the sustainable implementation of the curricula, attempt will be made to ensure the incorporation of the proposed curricula as part of the existing syllabus. the curricula to be implemented at universities will be subjected to the approval from board of studies and academic councils while ngos need approval from their respective personnel/entities. the expected key outcomes of the first two camps is to finalize the list of teaching modules with details of updated course plan – including course nomenclature; target audience; teaching methodologies; assessment pattern; bibliography pattern at academic and community level. key output: the implementation of the finalized curricula is planned to begin at respective organizations by june, 2020, aiming to modernize the multidisciplinary courses in health sciences, thus influencing approximately nine hundred students. training the term “training” corresponds to strengthen the knowledge of young researchers in india so that they can emerge as the future experts in the field of abr. these experts will have capacity to conduct teaching activities and develop sustainable tools for creating awareness on abr besides developing online course, social media campaign, and carry out focused abr publications. also, the selection of young scientists on projects for their post-graduation and doctoral work based on amr is significant. kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 9 | 15 strengthening the knowledge of young researchers of india for this, five full time (associate researchers) will be engaged at the indian universities from the second year onwards. they will be trained through various capacity building trainings to emerge as subject experts engaged in teaching and creating online courses and publications dedicated to abr. the training to be imparted in two phases: the first phasetraining at chitkara university and the second phasetraining at the partner european universities, while training at host institutions will be there throughout. the training at indian university will be to understand the goal, objectives and key activities of the project along with team building. the exhaustive training will be provided at european universities for about four weeks. the content of the training will include expert talks on abr by european faculties, learning of new teaching methodology such as problem based learning, exposure to organization of the hospital/pharmacy prescribing antibiotics etc. the key idea is to use these subject specialists to further train the trainers at their respective host and intra-consortium organizations. it has also been observed that younger people wish to have health information via the internet or electronic means, thus attempts to update and stimulate a sub-group of a population by means of organized communication actions through explicit channels will be done (25). an interdisciplinary open access course will be developed by the young researchers under the guidance of health science expert group. the technical portion of the on-line course will be supervised by the european experts from maastricht university. the effort will be made to write and publish minimum six research/review articles in peer reviewed journal/s on abr in order to create awareness on the risk management and prevention of abr. key output: to prepare and equip abr experts to further share the knowledge on abr through teaching activities. further, there will be development of a free on-line certificate course for healthcare professionals. also, to publish minimum six research/review articles in peer reviewed journal/s on abr in order to spread awareness on the risk management and prevention of abr.  dissemination & awareness recent literature on social marketing campaigns, including online campaigns, advocate that the campaigns can impact people to bring out change in their behavior and can also inspire policy-makers (26). also, awareness campaigns are being documented as one of the most proficient means of communicating information especially to the general public. according to the state of change model, if the awareness campaign is propagated effectively for a specific issue, it will bring change in the attitudes of the society, finally reflecting the change in person’s perception about his/her own capacity to perform an act. however, it has been observed that often campaigns on health have been funded on short time-scales but in order to achieve behavior change, long term strategies are needed (27). thus, a series of comprehensive events are being planned to make students, academicians, policy makers and general public aware about the alarming situation on abr. the events will be planned in a way so that the intra-consortium mobility of europeans as well as indians is promoted. the key aim is to strengthen the network and understanding of team work for the noble cause. improve awareness on abr at university and societal level in total, nine dissemination events and fourteen network workshops will be conducted kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 10 | 15 during the tenure of the project. the key activities involved will be the more or less common for both the categories. the steps involved will be to: identify and consolidate existing communication/information resources/products on amr in various sectors/stakeholder groups; map the expertise of individual, stakeholders plus organizations (public/ private) to develop communication strategy. the content and teaching methodology for the event will vary according to the targeted stakeholders. the target audience varies from students of intra-consortium, students from other universities policy makers, academicians, accredited social health activist (asha) workers, self-help groups, farmers, pharmacists etc. maximizing the awareness on abr through social media a multifaceted approach will be undertaken to ensure the awareness and visibility via social media campaigns. one of the key activities will be website hosting which will be updated periodically, in order to share abr news, articles, information – which will boost visitor’s figures. social media will be used intensely for the visibility and outreach of the prevent it project. the communication will be done on three social sites viz. facebook, twitter and linkedin. the social media of the project handle will be shared by the young researchers and will do the needful for its further promotion. key output: outreach maximum population and spread the awareness to lower the incidence of abr expected outcome/s of the project:  help create a consensus amongst scientists working across the globe on the problem of amr and its remedies in an atmosphere of urgency and mutual cooperation.  develop and implement international, interdisciplinary teaching curricula at indian universities on risk management and prevention of abr.  invest in young talents, empowering indian super-experts having an international outlook.  spread awareness among academicians, students, policy makers and general public through events and social media campaigns.  create an interdisciplinary online course to educate a multidisciplinary audience.  establish the first european-indian network to develop further initiative for risk management and prevention of abr. perspective the proposal is the direct output of the collective preliminary-assessment study conducted since september 2016. in accordance with recent statement of the indian ministry of health & family care, historically antimicrobial/antibiotics resistance (amr/abr) did not receive adequate focus and attention in india (21). the topic was selected due to numerous scientific publications warnings – and reiterated world health assembly resolutions on global risks of antibiotics resistance. it is worthy to note that india, a developing country, is one of the nations with highest burden of bacterial infections (14). further, the emergence of resistant bacterial infections event to the newer class of antibiotics is making situation more worrisome (28). moreover, the preliminary research conducted by prevent it team has identified the following problems: i) lack of awareness in heis, civil society organizations and citizens; ii) lack of compulsory curricula for kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 11 | 15 heis’ students which requires antibiotics resistance prevention skills; iii) lack of projects in asia tackling antibiotics resistance at grassroots level; iv) legislative gap in indian context: absence in the legislation of restrictions on pharmacological pollution in water sources; v) few indian heis’ scientific publication on abr – correlation to brain drain; vi) lack of asian-centered mooc on abr – and skills’ glitches in mooc creation at indian heis. thus, in order to bridge the gap, this project will act as a stepping stone. key strengths: geographical spread and inter-disciplinary experts: the primary strength of the project is the diversity of the partners and collaboration amongst european and indian experts. creating a pool of super-expertise from different health sciences backgrounds with a great heterogeneity of geographical distribution is the key weapon of the project. there is involvement of the partners from europe (latvia, netherlands and portugal), who are known worldwide for being the countries with lowest and controlled incidence of abr (29). further, university of maastricht is well known for creating online courses (mooc) as well as the famous learning methodology i.e. problem based learning. another partner, university of milan is one of the largest universities in europe and is ranked among top five universities of italy. the pharmaceutical sciences departments have great experience both in the development of new antibiotics and studying antibiotic resistance mechanisms and in regulatory aspects and quality control. this inter-exchange of knowledge would definitely ensure in creating breakthrough knowledge bank, resources and expertise that would prove consequential in targeting the abr threat. all the indian universities have been associated with the erasmus plus funded projects at some point of time. the associated indian universities have well established departments and prowess in various domains to be influenced by the project. the range varies from public health – microbiology –nursing – medical doctors – dentists allied health sciences – biotechnology – pharmacy etc. the three universities, amrita vishwa vidyapeetham university, manipal academy of higher education and kalinga institute of industrial technology are already contributing to the clinical care and academic training seamlessly. the focus is on infection prevention and control (ipc) activities and antimicrobial stewardship (amsp) initiatives to combat hospital associated infections in association with who and quality council of india (qci). both the ngos are well equipped to provide capacity building through training and programs to be delivered to general public. looking at the dissimilitude of competence and geographical distribution of indian partners (including higher educational institutions and non-governmental organizations) within consortium needs no further explanation. empowering young talent: capacity building: one of the major outcomes of the project is training the young associate researchers to become subject expert on abr. these experts will be responsible for training the trainers, students and conducting different dissemination events for general public. sustainable goals and outcomes: the endeavor is to bring about sustainable changes in the form of curriculum, publication and mooc course. the curriculum is so created that it can be incorporated in the academic program guide to make sure the pervasive implementation of the same. this will definitely sensitize the students, ensuring the kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 12 | 15 fact that when they enter the health care sector, they are honed enough to contribute in decreasing the incidence of abr. another approach is to encourage reflection amongst academicians working in different fields of health care though publications. an effort will be made to bring on plate the sad reality of the current situation of abr and highlighting the steps involved in risk management and prevention of abr. last but not the least, in order to outreach student population at large, a free online certification course will be created using inter-disciplinary approach. this initiative will enable the project to reach out to the students across india as well as other parts of the world. creating awareness: one of the major outcomes of the project is to sensitize healthcare, non-healthcare students and general public. the mode of delivery will be through expert talks, skits, dramas, posters, etc. during dissemination events. however, the content of the delivery will change according to the target audience. this is setting in motion a very sustainable process as the students who are being trained are the ones entering healthcare workforce tomorrow as well as will become the future academicians and researchers. limitations a major limitation of this project, similarly to every other project promoting capacity building activities in a vast country as india, is the financial shortcoming vis-à-vis the magnitude of the challenges addressed. the project although targets a wide audience of students and general public but measures to involve farmers and animal husbandry, covering all hemispheres of ‘one health’ is lacking and the execution of the curriculum programme is restricted to regions within india. despite the direct involvement of five indian higher education institutions – and two non-governmental organizations, risk management and prevention of antibiotics resistance in india require an integrated approach, involving an enlarged and differentiated platform of stakeholders, combining the bottom-up approach utilized in the project, with coordinated topdown initiatives. also, at present, government agencies involved in policy making are not directly involved in the execution of the project. moreover, specific intervention studies such as counselling programs to bring a behavioural change in pharmacists, clinicians, farmers and animal husbandry are beyond the current objectives of the project. prevent it is expected to generate a major improvement in the capabilities of indian universities and ngos to educate different target groups with foundational and advanced skills in abr. due to the erasmus+ funding scope, the activities financed are only marginally focusing on research, partially hampering the scientific credibility – and visibility – of the project in the international academic community. conclusion projects like prevent it unify the researchers, students, academicians, non-governmental organizations from different parts of the world and provide them a common platform to work in unison for the noble cause assuring good health. these types of projects will accelerate the pace of curriculum change globally, keeping in line with changes in healthcare trends. preventing abr through a behavioural change is the first step of this collaborative process and the success of the project would open up further novel alternatives to combat abr. as it is rightly said, ‘he who has health, has hope; and he who has hope, has everything’; it is high time we should collaborate across disciplines to bring sustainable changes in the kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 13 | 15 healthcare sector for better, happier and healthier future. acknowledgment: the authors would like to acknowledge the contribution of partners from ngos, riga stradins university and catholic university of portugal for their continuous help and support. this project has been funded with support from the european commission. this manuscript reflects the views only of the author, and the commission cannot be held responsible for any use which may be made of the information contained therein. join this initiative: please follow us on facebook (www.facebook.com/preventit), twitter (https://twitter.com/itprevent) and linkedin (https://www.linkedin.com/in/prevent-it-1995a7192). references 1. ayukekbong ja, ntemgwa m, atabe an. the threat of antimicrobial resistance in developing countries: causes and control strategies. antimicrob resist infect control 2017;6:47. 2. o’neill j. tackling drug-resistant infections globally: final report and recommendations–the review on antimicrobial resistance [internet]. wellcome trust and hm government; 2016. available from: https://amr-review.org/sites/default/files/160518_final%20paper_with %20 cover.pdf (accessed: may 28, 2020). 3. prestinaci f, pezzotti p, pantosti a. antimicrobial resistance: a global multifaceted phenomenon. pathog glob health 2015;109:309-18. 4. world health organization. global action plan on antimicrobial resistance. geneva: who; 2015. 5. government of india. national action plan on antimicrobial resistance (nap-amr) 2017 2021 [internet]; 2017. available from: https://ncdc.gov.in/writereaddata/linkimages/amr/file645.pdf (accessed: may 28, 2020). 6. o’neill j. tackling drug-resistant infections globally: final report and recommendations–the review on antimicrobial resistance [internet]. wellcome trust and hm government; 2016. available from: https://amr-review.org/sites/default/files/160518_final%20paper_with %20 cover.pdf (accessed: may 28, 2020). 7. united nations. youth population trends and sustainable development. pop facts 2015:1. 8. fleming a. on the antibacterial action of cultures of a penicillium, with special reference to their use in the isolation of b. influenzae. br j exp pathol 1929;10:226-36. 9. michael ca, dominey-howes d, labbate m. the antimicrobial resistance crisis: causes, consequences, and management. front public health 2014;2:145. 10. baquero f, martínez jl, cantón r. antibiotics and antibiotic resistance in water environments. curr opin biotechnol 2008;19:260-5. 11. ram s, vajpayee p, shanker r. prevalence of multi-antimicrobialagent resistant, shiga toxin and enterotoxin producing escherichia coli in surface waters of river ganga. environ sci technol 2007;41:7383-8. 12. dahal r, upadhyay a, ewald b. one health in south asia and its kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 14 | 15 challenges in implementation from stakeholder perspective. vet rec 2017:249-53. 13. world health organization. global tuberculosis report 2017 [internet]; 2017. available from: https://www.who.int/tb/publications/global_report/gtbr2017_main_text.pdf (accessed: may 28, 2020). 14. klein ey, tseng kk, pant s, laxminarayan r. tracking global trends in the effectiveness of antibiotic therapy using the drug resistance index. bmj glob health 2019;4:e001315. 15. van boeckel tp, gandra s, ashok a, caudron q, grenfell bt, levin sa, et al. global antibiotic consumption 2000 to 2010: an analysis of national pharmaceutical sales data. lancet infect dis 2014;14:742-50. 16. sivalingam p, poté j, prabakar k. environmental prevalence of carbapenem resistance enterobacteriaceae (cre) in a tropical ecosystem in india: human health perspectives and future directives. pathogens 2019;8:174. 17. akiba m, senba h, otagiri h, prabhasankar vp, taniyasu s, yamashita n, et al. impact of wastewater from different sources on the prevalence of antimicrobial-resistant escherichia coli in sewage treatment plants in south india. ecotoxicol environ saf 2015;115:203-8. 18. skariyachan s, mahajanakatti ab, grandhi nj, prasanna a, sen b, sharma n, et al. environmental monitoring of bacterial contamination and antibiotic resistance patterns of the fecal coliforms isolated from cauvery river, a major drinking water source in karnataka, india. environ monit assess 2015;187:279. 19. sudha s, mridula c, silvester r, hatha aam. prevalence and antibiotic resistance of pathogenic vibrios in shellfishes from cochin market. indian j mar sci 2014;43:815-24. 20. van boeckel tp, brower c, gilbert m, grenfell bt, levin sa, robinson tp, et al. global trends in antimicrobial use in food animals. proc natl acad sci u s a 2015;112:5649-54 . 21. government of india. national programme on containment of anti-microbial resistance (amr) [internet]. available from: https://ncdc.gov.in/index1.php?lang=1&level=2&sublinkid =384&lid=344 (accessed: may 28, 2020). 22. indian council of medical research. treatment guidelines for antimicrobial use in common syndromes. 2nd edition. new delhi: icmr-hq; 2019. 23. gaur rk. antibiotic resistance: alternative approaches. indian j pharmacol 2017;49:208-10. 24. hayles cs, holdsworth se. curriculum change for sustainability. j educ built environ 2008;3:25-48. 25. fien j. education for sustainable consumption: towards a framework for curriculum and pedagogy. in: jensen bb, schnack k, simovka v. editors. critical environmental and health education: research issues and challenges. copenhagen: danish university of education; 2000:45-66. 26. maher ca, lewis lk, ferrar k, marshall s, de bourdeaudhuij i, vandelanotte c. are health behavior change interventions that use online kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 15 | 15 © 2020 kaur et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. social networks effective? a systematic review. j med internet res 2014;16:e40. 27. wakefield ma, loken b, hornik rc. use of mass media campaigns to change health behaviour. lancet 2010;376:1261-71. 28. lübbert c, baars c, dayakar a, lippmann n, rodloff ac, kinzig m, et al. environmental pollution with antimicrobial agents from bulk drug manufacturing industries in hyderabad, south india, is associated with dissemination of extended-spectrum beta-lactamase and carbapenemaseproducing pathogens. infection 2017;45:479-91. 29. altorf-van der kuil w, schoffelen af, de greeff sc, thijsen sf, alblas hj, notermans dw, et al. national laboratory-based surveillance system for antimicrobial resistance: a successful tool to support the control of antimicrobial resistance in the netherlands. euro surveill 2017;22. ______________________________________________________ harizi (shemsi) e, rroji a, cekaj e, gabrani s. anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania (original research). seejph 2014, posted: 20 december 2014. doi 10.12908/seejph-2014-35 1 original research anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania edlira harizi (shemsi)1,2, arben rroji3, elton cekaj1, sazan gabrani2 1 regional hospital, durres, albania; 2 university of medicine, tirana, albania; 3 neuro-radiology service, university hospital centre “mother teresa”, tirana, albania. corresponding author: dr. edlira harizi; regional hospital, durres; address: lagjia no. 8, rruga “aleksander goga”, durres, albania; telephone: +355676092814; e-mail: edliraharizi@hotmail.com harizi (shemsi) e, rroji a, cekaj e, gabrani s. anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania (original research). seejph 2014, posted: 20 december 2014. doi 10.12908/seejph-2014-35 2 abstract aim: the purpose of this study was twofold: i) in a case-control design, to determine the relationship between anatomical variations of the circle of willis and cerebrovascular accidents; ii) to assess the association between anatomical variations of the circle of willis and aneurisms among patients with subarachnoid hemorrhage. methods: a case-control study was conducted in albania in 2013-2014, including 100 patients with subarachnoid hemorrhage and 100 controls (individuals without cerebrovascular accidents). patients with subarachnoid hemorrhage underwent a ct angiography procedure, whereas individuals in the control group underwent a magnetic resonance angiography procedure. binary logistic regression was used to assess the association between cerebrovascular accidents and the anatomical variations of the circle of willis. conversely, fisher’s exact test was used to compare the prevalence of aneurisms between subarachnoid hemorrhage patients with and without anatomical variations of the circle of willis. results: among patients, there were 22 (22%) cases with anatomical variations of the circle of willis compared with 10 (10%) individuals in the control group (p=0.033). there was no evidence of a statistically significant difference in the types of the anatomical variations of the circle of willis between patients and controls (p=0.402). in ageand-sex adjusted logistic regression models, there was evidence of a significant positive association between cerebrovascular accidents and the anatomical variations of the circle of willis (or=1.87, 95%ci=1.03-4.68, p=0.048). within the patients’ group, of the 52 cases with aneurisms, there were 22 (42.3%) individuals with anatomical variations of the circle of willis compared with no individuals with anatomical variations among the 48 patients without aneurisms (p<0.001). conclusion: this study provides useful evidence on the association between anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania. furthermore, findings from this study confirm the role of the anatomical variations of the circle of willis in the occurrence of cerebral aneurisms. keywords: albania, aneurism, cerebrovascular accidents, circle of willis, subarachnoid hemorrhage. conflicts of interest: none. harizi (shemsi) e, rroji a, cekaj e, gabrani s. anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania (original research). seejph 2014, posted: 20 december 2014. doi 10.12908/seejph-2014-35 3 introduction there is convincing evidence linking the anatomical variations of the circle of willis with the development and harshness of cerebrovascular accidents including aneurysms, infarctions, or other vascular disorders which bear a significant negative health impact (1-3). normally, the circle of willis consists of a symmetrical arterial circle, with a single anterior communicating artery and bilateral posterior communicating arteries (4-6). however, different types of anatomical variations of the circle of willis have been described (1,4) including hypoplasia (of the posterior communicating artery, the circular part of the posterior cerebral artery, the circular part of the anterior cerebral artery, or the anterior communicating artery); accessory vessels (which are manifested as duplications or triplications of one of the components of the polygon); anomalous origin (persistence of the embryonic derivation of the posterior cerebral artery from the internal carotid); or absent vessels (of one or other posterior communicating arteries) (1,4). research has indicated that anatomical variations of the circle of willis may be genetically determined and develop in early embryonic stage, persisting in postnatal life (1,7). in addition to development of cerebrovascular accidents, there has been suggested a possible link between the anomalies of the circle of willis and mental illnesses and cerebrovascular catastrophe (1,8). the available evidence about the prevalence and distribution of the anatomical variations of the circle of willis in the adult population of albania is scarce. after the collapse of the communist regime in early 1990s, albania experienced a particularly rapid political and socioeconomic transition, which was associated with tremendous behavioral/lifestyle changes that have a significant health impact (9,10). currently, almost twenty five years after the breakdown of its stalinist regime, albania remains one of the poorest countries in south eastern europe. in this context, the aim of our study was twofold: i) in a case-control design, to determine the relationship between anatomical variations of the circle of willis and cerebrovascular accidents; ii) to assess the association between anatomical variations of the circle of willis and aneurisms among patients with subarachnoid hemorrhage. methods a case-control study was conducted in albania in 2013-2014, including 100 patients with subarachnoid hemorrhage (hospitalized at the university hospital centre “mother teresa”) and 100 controls (individuals who showed up at the university hospital centre “mother teresa” without cerebrovascular accidents, but with signs of tension-type headache, or vertiginous syndrome). all patients with subarachnoid hemorrhage underwent a ct angiography procedure. on the other hand, all individuals in the control group underwent a magnetic resonance angiography procedure either in tirana, or at the regional hospital in durres (second largest city in albania). based on these respective examinations, the presence of cerebrovascular accidents was determined, in addition to the presence and type of anatomical variation of the circle of willis. among patients with subarachnoid hemorrhage, the presence of aneurisms was additionally determined. data on age and sex of participants were also collected. fisher’s exact test was used to compare the prevalence and types of anatomical variations between cases and controls, and the prevalence of aneurisms between subarachnoid hemorrhage patients with and without anatomical variations of the circle of willis. conversely, mann-whitney u-test was used to compare the age distribution between patients harizi (shemsi) e, rroji a, cekaj e, gabrani s. anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania (original research). seejph 2014, posted: 20 december 2014. doi 10.12908/seejph-2014-35 4 and controls. binary logistic regression was used to assess the association between cerebrovascular accidents and the anatomical variations of the circle of willis. odds ratios (ors), their respective 95% confidence intervals (cis) and p-values were calculated. initially, crude (unadjusted) ors were calculated. subsequently, ageand-sex adjusted ors were calculated in a simultaneous multivariable-adjusted logistic regression model. the overall goodness-of-fit of the multivariate model was formally assessed through the hosmerlemeshow test. for all the statistical tests, a p-value of ≤0.05 was considered as statistically significant. statistical package for social sciences (spss, version 17.0) was used for all the data analyses. results table 1 describes the demographic characteristics of the patients and controls included in this case-control study. mean age was significantly higher among patients (53.4±9.8 years) compared with the control group (36.8±12.6 years) (mann-whitney u-test: p<0.001). there were 18 (18%) controls aged 50 years or older, compared with 47 (47%) individuals in the sample of patients. as for the sex distribution, 41 (41%) individuals in the control group were males and 59 (59%) were females, whereas in the sample of the patients there were 46 (46%) males and 54 (54%) females. table 1. demographic characteristics of the patients with subarachnoid hemorrhage and the control group characteristic cases (n=100) controls (n=100) p-value age (years): mean (sd) median (interquartile range) range 53.4±9.8 55.0 (8.0) 24-74 36.8±12.6 35.5 (20.0) 16-63 <0.001* age-group: <50 years ≥50 years 53 (53.0)† 47 (47.0) 82 (82.0) 18 (18.0) <0.001‡ sex: male female 46 (46.0) 54 (54.0) 41 (41.0) 59 (59.0) 0.568‡ * mann-whitney u-test. † absolute numbers and column percentages (in parentheses). ‡ fisher’s exact test. table 2 presents the anatomical variations of the circle of willis in the sample of patients and in the control group. in the sample of the patients, there were 22 (22%) cases with anatomical variations of the circle of willis compared with 10 (10%) individuals in the control group, with a statistically significant difference between the two groups (fisher’s exact test: p=0.033). in the sample of patients with any type of anatomical variation (n=22), there were 10 (45.5%) cases with aca (a1 segment) anomaly, 7 (31.8%) cases with a.com.a. variation (anterior communicant artery), 3 (13.6%) case with p.com.a. anomaly (posterior communicant artery) and 2 (9.1%) cases with pca (p1 segment) variation. the distribution of these anomalies among individuals in the control group who presented any type of harizi (shemsi) e, rroji a, cekaj e, gabrani s. anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania (original research). seejph 2014, posted: 20 december 2014. doi 10.12908/seejph-2014-35 5 anatomical variations of the circle of willis (n=10) was as follows: 3 (30.0%), 2 (20.0%), 4 (40.0%) and 1 (10.0%), respectively – with no evidence of a statistically significant difference with the sample of the patients (fisher’s exact test: p=0.402) (table 2). table 2. anatomical variations of the circle of willis in patients with subarachnoid hemorrhage and the control group characteristic cases controls p-value† circle of willis: normal variation total 78 (78.0)* 22 (22.0) 100 (100.0) 90 (90.0) 10 (10.0) 100 (100.0) 0.033 variation type: aca (a1 segment) a.com.a. p.com.a. pca (p1 segment) total 10 (45.5) 7 (31.8) 3 (13.6) 2 (9.1) 22 (100.0) 3 (30.0) 2 (20.0) 4 (40.0) 1 (10.0) 10 (100.0) 0.402 * absolute numbers and column percentages (in parentheses). † fisher’s exact test. table 3 presents the relationship between cerebrovascular disorders with the anatomical variations of the circle of willis. in unadjusted logistic regression models, there was evidence of a strong positive association between cerebrovascular accidents and the anatomical variations of the circle of willis, which was statistically significant: or=2.54, 95%ci=1.135.69, p=0.024) (table 3, model 1). findings were attenuated upon simultaneous adjustment for age and sex, but the significant positive association between cerebrovascular disorders and the anatomical variations of the circle of willis was still evident (or=1.87, 95%ci=1.034.68, p=0.048; table 3, model 2). table 3. association of cerebrovascular accidents with the anatomical variations of the circle of willis; odds ratios (ors) from binary logistic regression model or 95%ci p-value model 1* anatomical variations normal circle 2.54 1.00 1.13-5.69 reference 0.024 model 2† anatomical variations normal circle 1.87 1.00 1.03-4.68 reference 0.048 * crude (unadjusted) models (or: cases vs. controls). † ageand-sex adjusted models. within the patients’ group, the prevalence of aneurisms was 52% (n=52). of these, there were 22 (42.3%) cases with anatomical variations of the circle of willis compared with no harizi (shemsi) e, rroji a, cekaj e, gabrani s. anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania (original research). seejph 2014, posted: 20 december 2014. doi 10.12908/seejph-2014-35 6 cases with anatomical variations among the 48 patients without aneurisms – a finding which was highly statistically significant (p<0.001) (table 4). table 4. anatomical variations of the circle of willis by presence of aneurisms among patients with subarachnoid hemorrhage characteristic without aneurisms with aneurisms p-value† circle of willis: normal variation total 48 (100.0)* 48 (100.0) 30 (57.7) 22 (42.3) 52 (100.0) <0.001 * absolute numbers and column percentages (in parentheses). † fisher’s exact test. discussion this study informs about the link between anatomical variations of the circle of willis and cerebrovascular accidents consisting of subarachnoid hemorrhage in albanian adults. in addition, this study provides important evidence on the association between anatomical variations of the circle of willis and presence of aneurisms among patients with subarachnoid hemorrhage. the main finding of this study relates to a positive association between the anatomical variations of the circle of willis and subarachnoid hemorrhage. furthermore, among individuals who experienced subarachnoid hemorrhage, there was a positive association between anatomical variations of the circle of willis and the presence of aneurisms. our findings are compatible with previous international studies which have linked the anomalies of the circle of willis with the development and severity of symptoms of different cerebrovascular accidents including infarctions, aneurysms, and several other vascular disorders (1,3). based on the available scientific evidence, it is recommended to assess comprehensively the form of the circle of willis in order to determine the capacity of the brain circulation in operations for cerebral aneurysms, as well as in interventions involving the internal carotid artery (1). in this regard, magnetic resonance angiography displays the functional morphology of the arterial circle (2,4,11-13) and additionally provides a useful means for hemodynamic assessment of blood flow and direction through different techniques and procedures (3,4,14). in particular, detailed information about the anatomical variations of the circle of willis is rather valuable to surgeons for a suitable and rational planning of their operations, which involve complex situations associated with other serious co-morbid conditions (1). in our study, all patients with anatomical variations of the circle of willis had also aneurisms, a finding which confirms the evidence about the role of arterial variations of the circle of willis as a leading factor for cerebral hemodynamic disorders which cause aneurisms (1-3). these, in turn, are a risk factor for cerebrovascular accidents. indeed, in this sample of albanian patients, aneurisms were involved in the occurrence of subarachnoid hemorrhage. this study may have some limitations due to the relatively small sample size and the selection of the control group. during a two-year period, we included all consecutive patients harizi (shemsi) e, rroji a, cekaj e, gabrani s. anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania (original research). seejph 2014, posted: 20 december 2014. doi 10.12908/seejph-2014-35 7 with subarachnoid hemorrhage hospitalized at the university hospital center “mother teresa”, which is the only tertiary health care facility in albania. however, the relatively small sample size may have influenced the stability of the estimates. on the other hand, we cannot entirely exclude the possibility of selection bias in the control group. nonetheless, we included in the control group only individuals who did not had evidence of cerebrovascular disorders. in any case, if there is a positive link between cerebrovascular accidents and the anatomical variations of the circle of willis and if there were a few cases of unnoticed negligible cerebrovascular disorders in the control group, these possibilities would tend to diminish the strength of the association observed instead of producing a spurious finding. in conclusion, our study provides useful evidence on the association between anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania. furthermore, findings from this study confirm the role of the anatomical variations of the circle of willis in the occurrence of cerebral aneurisms. as reported from previous studies on this topic, the anomalies of the circle of willis play an important role in the occurrence, manifestation of symptoms, treatment options and recovery process of several cerebrovascular disorders (1). larger studies should be carried out in the future in albania and other countries in order to confirm and extend the findings of the current case-control study. references 1. iqbal s. a comprehensive study of the anatomical variations of the circle of willis in adult human brains. j clin diagn res 2013;7:2423-7. 2. miralles m, dolz jl, cotillas j, et al. the role of the circle of willis in carotid occlusion; assessment with phase contrast mr angiography and transcranial duplex. eur j vasc endovasc surg 1995;10:424-30. 3. marks mp, pelc nj, ross mr, enzmann dr. determination of cerebral blood flow with a phase-contrast cine mr imaging technique: evaluation of normal subjects and patients with arteriovenous malformations. radiology 1992;182:467-76. 4. hartkamp mj, van der grond j. investigation of the circle of willis using mr angiography. medicamundi 2000;44:20-7. 5. riggs he, rupp c. variation in form of circle of willis. the relation of the variations to collateral circulation: anatomic analysis. arch neurol 1963;8:8-14. 6. alpers bj, berry rg, paddison rm. anatomical studies of the circle of willis in normal brain. ama arc neurol psychiatry 1959;81:409-18. 7. crompton mr. the pathology of ruptured middle cerebral aneurysms with special reference to the differences between the sexes. lancet 1962;2:421-25. 8. kamath s. observations on the length and diameter of the vessels forming the circle of willis. j anat 1981;133:419-23. 9. nuri b, tragakes e. health care systems in transition: albania. european observatory on health care systems. copenhagen: denmark, 2002. 10. rechel b, mckee m. healing the crisis: a prescription for public health action in south eastern europe. new york, usa: open society institute press, 2003. 11. hoogeveen rm. vessel visualization and quantification by magnetic resonance angiography. thesis, university of utrecht, 1998. isbn: 90-393-1769-0. 12. stock kw, wetzel s, kirsch e, bongartz g, steinbrich w, radue ew. anatomical evaluation of the circle of willis: mr angiography versus intraarterial digital subtraction angiography. ajnr 1996;17:1495-9. http://www.ncbi.nlm.nih.gov/pubmed?term=iqbal%20s%5bauthor%5d&cauthor=true&cauthor_uid=24392362 http://www.ncbi.nlm.nih.gov/pubmed/?term=journal+of+clinical+and+diagnostic+research.+2013+nov%2c+vol-7%2811%29%3a+2423-2427 harizi (shemsi) e, rroji a, cekaj e, gabrani s. anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania (original research). seejph 2014, posted: 20 december 2014. doi 10.12908/seejph-2014-35 8 13. patrux b, laissy jp, jouini s, kawiecki w, coty p, thiébot j. magnetic resonance angiography (mra) of the circle of willis: a prospective comparison with conventional angiography in 54 subjects. neuroradiology 1994;36:193-7. 14. ross mr, pelc nj, enzmann dr. qualitative phase contrast mra in the normal and abnormal circle of willis. ajnr 1993;14:19-25. ___________________________________________________________ © 2014 harizi (shemsi) et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. laci i, spahiu a. concurrent validity of radiography and ultrasound examination for the diagnosis of aortic aneurisms in albanian patients (original research). seejph 2016, posted: 25 march 2016. doi 10.4119/unibi/seejph-2016-98 1 original research concurrent validity of radiography and ultrasound examination for the diagnosis of aortic aneurisms in albanian patients ilirian laci 1 , alketa spahiu 2 1 radiology and nuclear medicine service, university hospital center “mother teresa”, tirana, albania; 2 statistics service, university hospital center “mother teresa”, tirana, albania. corresponding author: dr. ilirian laci address: rr. “dibres”, no. 370, tirana, albania; telephone: +355672072668; e-mail: ilirianlaci@yahoo.com laci i, spahiu a. concurrent validity of radiography and ultrasound examination for the diagnosis of aortic aneurisms in albanian patients (original research). seejph 2016, posted: 25 march 2016. doi 10.4119/unibi/seejph-2016-98 2 abstract aim: the aim of our study was to assess the concurrent validity of radiography and ultrasound examination among patients diagnosed with aortic aneurisms in albania, a transitional country in south eastern europe. methods: this study included 75 consecutive patients diagnosed with aortic aneurisms (thoracic and/or abdominal) admitted at the university hospital centre “mother teresa” in tirana during 2012-2014 (56 men and 19 women). for each patient, computerized tomography (ct) scan with contrast was used to confirm the diagnosis of aortic aneurisms. in addition to the ct scan (“gold standard” for the diagnosis of aneurisms), in 37 patients, radiography and ultrasound examination were simultaneously performed in order to assess the validity of these techniques. furthermore, demographic data and other relevant clinical information were collected for each study participant. results: in 18 patients with thoracic aneurisms pertinent to ascendant aorta where radiography and ultrasound were simultaneously performed, ultrasound was able to diagnose 5 (27.8%) cases which were not detected through radiography (p=0.038). conversely, in 16 patients with abdominal aneurisms where radiography and ultrasound were simultaneously performed, ultrasound was able to diagnose 4 (25.0%) cases which were not detected through radiography (p=0.034). the remaining three patients diagnosed with thoracic-abdominal aneurisms were not detected either by ultrasound examination or radiography. conclusions: in this sample of albanian patients diagnosed with aortic aneurisms (n=75), overall, 9 (24.3%) subjects were detected through ultrasound examination but not radiography (p<0.001). findings from this study provide valuable clues about the concurrent validity and predictive value of these two key examinations for the diagnosis of aortic aneurisms. keywords: albania, aneurism, ct scan, predictive value, radiography, ultrasonography, ultrasound, validity. conflicts of interest: none. laci i, spahiu a. concurrent validity of radiography and ultrasound examination for the diagnosis of aortic aneurisms in albanian patients (original research). seejph 2016, posted: 25 march 2016. doi 10.4119/unibi/seejph-2016-98 3 introduction aortic aneurysms are defined as enlargements (dilations) of the aorta which is caused by a chronic weakness (thinness) of the arterial wall. under these conditions, there is a high risk for ruptures, as well as for other unfavourable cardiovascular events in subjects with aortic aneurisms (1-3). in the united kingdom, in patients with aortic aneurisms of a size about 40-55 mm, only 16% of deaths have been linked to surgical interventions or ruptures, whereas 50% of deaths have been linked to other cardiovascular events including myocardial infarction and stroke (4). aortic aneurisms affect about 8% of men aged 65 years and above, but the occurrence of this condition is increasing in women too (5,6). data available from the centre for disease control and prevention (cdc) in usa indicate that aortic aneurisms constitute the fifteenth leading cause of death in american men and women aged 60-84 years old (7). as aortic aneurisms remain one of the major causes of morbidity and mortality especially among older men, its prevalence is expected to increase gradually in parallel with population aging in most countries of the world. aortic aneurisms are usually asymptomatic and are often detected upon radiological examinations performed for other reasons. based on the radiological evidence, surgical or endovascular interventions are performed. especially under emergency conditions, radiography and ultrasound examinations are very important in order to identify aortic aneurisms and aortic dissections (8). in principle, however, the diagnosis of aortic aneurisms is made through the following techniques: ultrasound, ct scan without contrast and/or with intravenous contrast (cta), radiography, angiography (aortography) and magnetic resonance imaging (mri) (8). the risk for rupture of aneurisms is related to the level of dilation. several studies have convincingly argued that ultrasound may be a suitable method for the diagnosis of aortic aneurisms given the fact that it is a non-invasive technique, without radiation and relatively cheap (8). the sensitivity and specificity of ultrasound examination for detection of aortic aneurisms have been estimated at 87.4%-98.9% and 99.9%, respectively (9). nevertheless, the accuracy of ultrasound examination may be far lower in obese individuals and in those with intestinal meteorism (9). as a matter of fact, it is possible to assess only the ascendant thoracic aorta through trans-thoracic ultrasound examination, whereas assessment of the descendent thoracic aorta is possible only through trans-oesophageal ultrasound (10). in post-communist albania, there has been an increase in cardiovascular diseases in the past two decades (11). in particular, the death rate from ischemic heart disease in albania is the highest in south eastern europe (11), in line with the rapid changes in dietary patterns characterized by an increase in processed foods and an increase in the prevalence of smoking (12). in addition, albania is the only country in south eastern europe which has experienced an increase in the mortality rate from ischemic heart disease and cerebrovascular diseases in the past two decades (11,12). however, specific information about the frequency and distribution of aortic aneurisms in the albanian population is scant. in this framework, the aim of this study was to assess the concurrent validity of radiography and ultrasound examination among patients diagnosed with aortic aneurisms in albania, a transitional country in south eastern europe which, among other reforms, is also undergoing a deep reform in the health care sector. methods this study included 75 consecutive patients diagnosed with aortic aneurisms (thoracic and/or abdominal) admitted at the university hospital centre “mother teresa” in tirana (the only tertiary care facility in albania) for the period from january 2012 to december 2014 (56 men and 19 women). https://en.wikipedia.org/wiki/aorta laci i, spahiu a. concurrent validity of radiography and ultrasound examination for the diagnosis of aortic aneurisms in albanian patients (original research). seejph 2016, posted: 25 march 2016. doi 10.4119/unibi/seejph-2016-98 4 for each patient, computerized tomography (ct) scan with contrast was used to confirm the diagnosis of aortic aneurisms. in addition to the ct scan (which is considered as the “gold standard” for the diagnosis of aneurisms), radiography was performed in 56 (74.7%) patients, whereas ultrasound examination was conducted in 45 (60.0%) patients (table 1). table 1. examinations performed in a sample of albanian patients diagnosed with aortic aneurisms during 2012-2014 (n=75) radiography ultrasound ct scan with contrast number percent number percent number percent 56 74.7% 45 60.0% 75 100.0% on the other hand, in 37 patients, radiography and ultrasound examination were simultaneously performed in order to assess the validity of these techniques. in principle, radiography and ultrasound examination were performed in patients admitted at the emergency unit who were residents in tirana. ultrasound in emergency conditions consisted of trans-thoracic or trans-abdominal examination, but not trans-oesophageal examination, because such a procedure involves a careful preparation and is not recommended under emergency conditions. on the other hand, patients from other districts of albania for whom there was prior suspicion for aneurisms underwent directly ct scan examination. furthermore, other relevant clinical information and demographic data were collected for each study participant. mann-whitney u-test was used to compare mean age and mean duration of hospitalization between male and female participants. on the other hand, fisher’s exact test was used to compare the proportions of place of residence, smoking, hypertension and other chronic diseases between men and women. conversely, cramer’s v test (a measure of association between two nominal variables) was used to compare the concurrent validity of radiography and ultrasound examination. in all cases, a p-value of ≤0.05 was considered as statistically significant. statistical package for social sciences (spss, version 19.0) was used for the data analysis. results this study involved 75 patients with a confirmed diagnosis of aortic aneurism according to ct scan with contrast (“gold standard”). demographic characteristics and clinical data of the patients included in this study are presented in table 2. overall, 56 (74.7%) patients were men and 19 (25.3%) were women (male-to-female ratio about 3/1). mean age in women was higher than in men, a difference which nevertheless was not statistically significant (62.5±13.8 vs. 58.0±15.7 years, respectively, p=0.41). on the whole, 31 patients were residents in tirana compared with 44 patients who were residents in other districts of albania. mean duration of hospitalization was 7.4±8.9 days, with no statistically significant sex-difference (p=0.261), notwithstanding a longer duration in men (10.3±9.5) compared to women (6.4±8.6). the overall prevalence of smoking was 32/75=43%; it was considerably higher in men than in women (52% vs. 16%, respectively, p=0.007). the overall prevalence of hypertension was 55/75=73%, with no significant difference between men and women (p=0.249). overall, 60% (45 out 75) of the patients had other pre-existing chronic conditions, which were evenly distributed between men and women (table 2). https://en.wikipedia.org/wiki/association_%28statistics%29 https://en.wikipedia.org/wiki/nominal_data#nominal_scale laci i, spahiu a. concurrent validity of radiography and ultrasound examination for the diagnosis of aortic aneurisms in albanian patients (original research). seejph 2016, posted: 25 march 2016. doi 10.4119/unibi/seejph-2016-98 5 table 2. demographic data and clinical characteristics of the patients diagnosed with aortic aneurisms characteristic women (n=19) men (n=56) total (n=75) age (years) 58.0±15.7 * 62.5±13.8 59.1±15.3 place of residence: tirana other districts total 8 (25.8) † 11 (25.0) 19 (25.3) 23 (74.2) 33 (75.0) 56 (74.7) 31 (100.0) 44 (100.0) 75 (100.0) length of hospitalization (days) 6.4±8.6 10.3±9.5 7.4±8.9 smoking: yes no 3 (9.4) 16 (37.2) 29 (90.6) 27 (62.8) 32 (100.0) 43 (100.0) hypertension: yes no 16 (29.1) 3 (15.0) 39 (70.9) 17 (85.0) 55 (100.0) 20 (100.0) other chronic diseases: yes no 11 (24.4) 8 (26.7) 34 (75.6) 22 (73.3) 45 (100.0) 30 (100.0) * mean ± standard deviation. † number and row percentages (in parenthesis) radiography was able to detect 20 patients with a confirmed diagnosis of aortic aneurism. hence, 35.7% of suspected cases (20 out of 56 patients who underwent this procedure) were detected through radiography. it should be noted that radiography played a major role in thoracic aortic aneurisms, but less so for abdominal aortic aneurisms, except for old abdominal aneurisms with wall calcifications which enabled a prompt diagnosis upon radiography. conversely, trans-thoracic and trans-abdominal ultrasound examination was able to detect 36 patients with a confirmed diagnosis of aortic aneurism. thus, 80.0% of suspected cases (36 out of 45 patients who underwent this procedure) were detected through ultrasound examination (data not shown in the tables). it should be emphasized that complications such as ruptures, dissections, hematomas, or clots could not be detected either through radiography or by ultrasound examination. table 3 presents findings from radiography and ultrasound examination performed simultaneously in a sub-sample of 37 patients. in this sub-sample of patients diagnosed with aortic aneurisms (n=37), overall, 9 subjects (or, 24.3% of them) were detected through ultrasound examination but not radiography (cramer’s v=0.609, p<0.001). table 3. findings from radiography and ultrasound examination performed simultaneously in a sub-sample of 37 patients radiography ultrasound total yes no yes 14 (100.0%) 0 (0%) 14 (100.0%) no 9 (39.1%) 14 (60.9%) 23 (100.0%) total 23 (62.2%) 14 (37.8%) 37 (100.0%) laci i, spahiu a. concurrent validity of radiography and ultrasound examination for the diagnosis of aortic aneurisms in albanian patients (original research). seejph 2016, posted: 25 march 2016. doi 10.4119/unibi/seejph-2016-98 6 overall, 23 (or, 62.2%) of the cases in this sub-sample (n=37) were detected by one of the two examination methods (radiography or ultrasound). conversely, 14 (37.8%) of the cases in this-sample were not detected either by radiography or ultrasound examination (table 2). in 18 patients with thoracic aneurisms pertinent to ascendant aorta where radiography and ultrasound were simultaneously performed, ultrasound was able to diagnose 5 (27.8%) cases which were not detected through radiography (p=0.038) (not shown in the tables). conversely, in 16 patients with abdominal aneurisms where radiography and ultrasound were simultaneously performed, ultrasound was able to diagnose 4 (25.0%) cases which were not detected through radiography (p=0.034). the remaining three patients diagnosed with thoracic-abdominal aneurisms were not detected either by ultrasound examination or radiography. discussion this may be the first report from albania informing about clinical characteristics of a consecutive sample of patients diagnosed with aortic aneurisms according to ct scan with contrast examination which is regarded as the gold standard for the confirmation of the diagnosis of this condition. main findings of this study include a higher sensitivity of ultrasound examination compared to radiography. hence, of the 37 patients who underwent both of these procedures, 9 (24.3%) subjects were detected through ultrasound examination but not radiography (p<0.001). radiography in emergency conditions is feasible and is considered as a straightforward procedure (8). in our study, radiography was able to detect about 36% (20/56) of the cases with aortic aneurisms. in particular, radiography played a major role for detection of thoracic aortic aneurisms, whereas in cases of abdominal aortic aneurisms it was less effective (valid). similarly, trans-thoracic and trans-abdominal ultrasound examination is also feasible in emergency conditions (8,9). in our study, ultrasound examination was able to detect 80% (36/45) of the cases with aortic aneurisms. the remaining 9 (or, 20%) of the cases were not detected through ultrasound probably due to the inability of the examiners (lack of proper training) involved in this procedure. notwithstanding the higher detection rate of ultrasound examination compared to radiography, it was not possible in our study to assess the complications of aneurisms such as dissections, ruptures, fistulisation with other organs, involvement of blood vessels stemming from the respective aneurisms, or calcifications. on the other hand, in our study, hematomas were partly assessed through ultrasound examination. our findings related to radiography are generally in line with previous reports from the international literature (13). hence, according to a previous study, aortic aneurisms were confirmed in about 50% of the cases (13). in any case, it is argued that chest radiography has a limited value for the diagnosis of aortic aneurisms (8,13). radiography plays an important role only in cases of aortic aneurisms with wall calcifications. in all suspected cases of aortic aneurisms though, ct scan with intravenous contrast should be promptly conducted (8,13). this study may have several limitations. our study included all consecutive patients diagnosed with aortic aneurisms over a three-year period at the university hospital centre “mother teresa”, which is the only tertiary care facility in albania. based on this recruitment approach, our study population involved an all-inclusive sample for the three-year period under investigation. furthermore, the diagnosis of aortic aneurisms was based on the state-ofthe-art clinical protocols and up-to-date examination techniques employed in similar studies conducted in other countries. in any case, the self-reported information which was collected through semi-structured interviews may have been prone to different types of information laci i, spahiu a. concurrent validity of radiography and ultrasound examination for the diagnosis of aortic aneurisms in albanian patients (original research). seejph 2016, posted: 25 march 2016. doi 10.4119/unibi/seejph-2016-98 7 bias. this may have been the case of self-reported smoking, hypertension and other preexisting conditions. in conclusion, this study provides useful evidence about the detection rate of radiography and ultrasound examination among patients diagnosed with aortic aneurisms in albania, a transitional country in south eastern europe. findings from this study provide valuable clues about the concurrent validity and predictive value of these two key examinations for the diagnosis of 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___________________________________________________________ © 2016 laci et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed/?term=von%20kodolitsch%20y%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=nienaber%20ca%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=dieckmann%20c%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=schwartz%20ag%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=hofmann%20t%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=hofmann%20t%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=hofmann%20t%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=brekenfeld%20c%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=nicolas%20v%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=berger%20j%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=meinertz%20t%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=11.%09von+kodolitsch+y%2c+nienaber+ca%2c+dieckmann+c%2c+schwartz+ag%2c+hofmann+t%2c+brekenfeld+c%2c+nicolas+v%2c+berger+j%2c+meinertz+t skeraj f, czabanowska k, bojaj g, burazeri g. self-perceived level of competencies of family physicians in post-war kosovo (original research). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-22 1 original research self-perceived level of competencies of family physicians in transitional kosovo fitim skeraj1,2, katarzyna czabanowska3,4, gazmend bojaj2, genc burazeri2,3 1 principal family medicine center, prizren, kosovo; 2 university of medicine, tirana, albania; 3 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 4 institute of public health, faculty of health sciences, jagiellonian university, medical college, krakow, poland. corresponding author: dr fitim skeraj, principal family medicine center, prizren; address: rr. “xhemil fluku”, pn 20000, prizren, kosovo; telephone: +37744191073; e-mail: fitim_opoja@hotmail.com skeraj f, czabanowska k, bojaj g, burazeri g. self-perceived level of competencies of family physicians in post-war kosovo (original research). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-22 2 abstract aim: family physicians and general practitioners are currently facing increasing demands to meet patients’ expectations and rapid technological and scientific developments. the aim of this study was to determine the self-perceived level of competencies of primary health care physicians in kosovo, a post-war country in the western balkans. methods: a cross-sectional study was conducted in kosovo in 2013 including a representative sample of 597 primary health care physicians (295 men and 302 women; mean age: 46.0±9.4 years; response rate: 90%). a structured self-administered questionnaire was used in order to determine physicians’ competencies regarding different domains of the quality of health care. the questionnaire included 37 items organized into six subscales/domains. answers for each item of the tool ranged from 1 (“novice” physicians) to 5 (“expert” physicians). an overall summary score (range: 37-185) and a subscale summary score for each domain were calculated for each participant. general linear model was used to assess the association of physicians’ self-perceived level of competencies with covariates. results: the internal consistency of the whole scale (37 items) was cronbach’s alpha=0.98. mean summary score of the 37-item instrument and subscale summary scores were all higher in men than in women. in multivariable-adjusted models, mean level of self-perceived competencies was higher among older physicians, in men, those with >10 years of working experience, physicians serving >2500 people, specialized physicians and those involved in training activities. conclusion: our study provides useful evidence on the self-assessed level of competencies of primary health care physicians in post-war kosovo. future studies in kosovo and other transitional settings should identify the main determinants of possible gaps in self-perceived levels of physicians’ competencies vis-à-vis the level of physicians’ competencies from patients’ perspective. keywords: competencies, family physicians, general practitioners, primary health care. skeraj f, czabanowska k, bojaj g, burazeri g. self-perceived level of competencies of family physicians in post-war kosovo (original research). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-22 3 introduction in the past few years, there is evidence of a growing interest in competency-based medical education as – among other things – it focuses on outcomes such as development of abilities, skills and competencies (1). therefore, competency-based education has also been introduced in public health training and education in order to close the gap between public health educational content and the competencies required in public health practice (2). as a matter of fact, there is overwhelming evidence indicating that primary health care professionals are presently facing growing demands in order due to meet patients’ expectations for higher quality health care services, as well as the rapid technological developments and scientific progress (3,4). therefore, at a global scale, health care professionals are increasingly expected to provide better-quality health care services, especially in line with the aging population trend observed in most of the countries. consequently, quality improvement in different domains and components of health care services are currently recognized as essential issues in health care practice (3,4). for this very reason, quality improvement needs to be included at all levels of medical education and in all aspects of health care services with the ultimate goal of improving the health of the populations (4). the required competencies for quality improvement are especially relevant for primary health care professionals who face a continuous and huge demand for high-quality health care services from the serving populations. in order to cope with this situation, there have been recently suggested models of required or desirable abilities, skills and competences for medical doctors and health professionals at all levels of care including also continuous professional development (5). such frameworks or models of abilities, skills and competencies are also deemed as a valuable tool for self-assessment of primary health care professionals aiming at improving their health care practices, analyze their clinical experience, plan improvement strategies, and determine a supposed improvement integrating knowledge, skills and abilities into the routine daily practice (4,6,7). however, to date, the information about the content, structure and outcomes of teaching quality improvement topics within the medical curricula in european countries and beyond is scant. this is especially true for the former communist countries of southeast europe including albania and kosovo1. in 2008, kosovo emerged as the newest state of europe after ten years under united nations’ administration following a devastating war (8). currently, kosovo is trying to rebuild its health system (9,10) and, among the reforming efforts, an important aspect is the reorientation of health services to ensure basic medical care for all individuals but especially so for the vulnerable segments of the population (9-11). one of the main challenges of the reform concerns the human resources pertinent to the health sector. nevertheless, there are no well-documented reports informing on the level of competencies of physicians and other health care professionals in kosovo. in this framework, the aim of our study was to determine the self-perceived level of competencies of primary health care physicians in kosovo, a post-war country in the western balkans which is currently facing a difficult period of political and socioeconomic transition. methods a cross-sectional study was conducted in kosovo in 2013 including a representative sample of primary health care physicians. 1 kosovo: this designation is without prejudice to positions on status, and is in line with unscr 1244 and the icj opinion on the kosovo declaration of independence”. http://ec.europa.eu/enlargement/countries/detailedcountry-information/kosovo/ (accessed: april 19, 2014). skeraj f, czabanowska k, bojaj g, burazeri g. self-perceived level of competencies of family physicians in post-war kosovo (original research). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-22 4 study population our study targeted a representative sample of primary health care physicians in five regions of kosovo, namely pristine, gjilan, gjakove, prizren and peje. according to the calculations of the sample size, a minimum of 612 physicians was required for inclusion in this survey. we decided to recruit 660 physicians (220 in pristine and 110 in each of the other regions) in order to increase the power of the study. of the 660 targeted physicians, 597 participated in the survey (overall response rate: 597/660=90%). the response rate was somehow lower in peje (87%) and gjakove (88%), but higher in prizren (95%). in pristine, the capital of kosovo, the response rate was 91%. of the 597 physicians included in our study, 295 (49.4%) were men and 302 (50.6%) were women. mean age in the overall study population was 46.0±9.4 years. the study was approved by the ethical board of the ministry of health of kosovo. all physicians were sent an official invitation letter where the aims and procedures of the survey where explained in detail. data collection an international instrument was developed with the support of the european community lifelong learning program aiming to self-assess the level of skills, abilities and competencies of primary health care physicians (4). this instrument has been already validated (crossculturally adapted) in albanian settings (12,13). all physicians included in this survey were asked to self-assess their level of skills, abilities and competencies regarding the following six essential domains of quality of primary health care (4): (i) patient care and safety (8 items); (ii) effectiveness and efficiency (7 items); (iii) equity and ethical practice (8 items); (iv) methods and tools (5 items); (v) leadership and management (4 items), and; (vi) continuing professional development (5 items). responses for each item of each subscale ranged from 1 (“novice”= physicians have little or no knowledge/ability, or no previous experience of the competency described and need close supervision or instruction) to 5 (“expert”=physicians are the primary sources of knowledge and information in the medical field). an overall summary score (including 37 items; range: 37-185) and a subscale summary score for each of the six domains were calculated for all primary health care physicians included in this study. demographic data (age and sex of participants), information on working experience, number of population served, working place, type of specialization and involvement in teaching/training activities were also collected. statistical analysis median values (and their respective interquartile ranges) were used to describe the distribution of age, duration of work experience and the number of population served among male and female physicians included in this study. on the other hand, frequency distributions (absolute numbers and their respective percentages) were used to describe the distribution of sex, working place, specialization, involvement in teaching and training activities of study participants. cronbach’s alpha was employed to assess the internal consistency of the overall scale (37 items) and each of the six subscales/domains of the measuring instrument. mean values (and their respective standard deviations) were used to describe the distribution of the summary score of the overall tool (37 items) and the summary scores of each of the six subscales/domains. mann-whitney’s u-test was used to assess sex-differences in the mean values of the overall level of competencies (37 items) and the competency levels of each subscale of the instrument. skeraj f, czabanowska k, bojaj g, burazeri g. self-perceived level of competencies of family physicians in post-war kosovo (original research). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-22 5 general linear model was used to assess the association of self-assessed overall level of competencies with demographic characteristics, work experience, type of specialization and involvement in teaching/training of physicians included in this study. initially, crude (unadjusted) mean values of the overall level of physicians’ self-perceived competencies and their respective 95% confidence intervals (95%cis) were calculated for each category of the covariates (age, dichotomized into: ≤40 years vs. >40 years; sex: men vs. women; working experience, dichotomized into: ≤10 years vs. >10 years; number of population served, dichotomized into: ≤2500 people vs. >2500 people; working place, dichotomized into: pristina vs. other regions; specialization: general practice, family medicine, other specializations; and involvement in teaching/training activities: no vs. yes). subsequently, multivariable-adjusted mean values and their respective 95%cis were calculated. spss (statistical package for social sciences, version 15.0), was used for all the statistical analyses. results overall, median age among study participants was 47 years (interquartile range: 40-53 years) (table 1). conversely, median duration of working experience in the overall sample of physicians was 13 years (interquartile range: 6-21 years). about 34% of primary health care physicians worked in pristina, whereas 66% of them worked in the other regions of kosovo. about 31% of participants were general practitioners, 49% were family medicine, whereas 20% had received different medical specializations (such as cardiology, paediatrics, internal medicine, gastroenterology, rheumatology, or obstetrics-gynaecology). about 29% of the physicians were involved in teaching and training activities in family medicine (table 1). table 1. distribution of demographic characteristics, work experience and specialization in a representative sample of primary health care physicians in kosovo, in 2013 (n=597) variable distribution age (years) 47.0 (40.0-53.0)* sex: men women 295 (49.4)† 302 (50.6) working experience (years) 13.0 (6.5-21.0)* number of population served 3000 (2500-4000)* working place: prishtina gjilan gjakova prizren peje 201 (33.7)† 98 (16.4) 97 (16.2) 105 (17.6) 96 (16.1) specialization: general practice family medicine other specializations‡ 187 (31.3)† 292 (48.9) 118 (19.8) involved in teaching: no yes 427 (71.5)† 170 (28.5) * median values and interquartile ranges (in parentheses). † numbers and column percentages (in parentheses). ‡ cardiology, paediatrics, internal medicine, gastroenterology, or rheumatology. skeraj f, czabanowska k, bojaj g, burazeri g. self-perceived level of competencies of family physicians in post-war kosovo (original research). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-22 6 the internal consistency of the overall scale (37 items) was cronbach’s alpha=0.98 (table 2). in general, cronbach’s alpha was high for all the subscales [ranging from 0.86 (for the “leadership and management” domain) to 0.94 (for the “patient care and safety” and “methods and tools” subscales)]. table 2. internal consistency of each domain (subscale) of the instrument domain (subscale) cronbach’s alpha overall scale (37 items) 0.98 patient care and safety (8 items) 0.94 effectiveness and efficiency (7 items) 0.93 equity and ethical practice (8 items) 0.90 methods and tools (5 items) 0.94 leadership and management (4 items) 0.86 continuing professional development (5 items) 0.90 in the overall sample of male and female physicians (n=597), the summary score for the 37 items of the tool was 147.7±24.3 (table 3). the summary score of self-perceived competency level was significantly higher in men compared to women (151.2±24.3 vs. 144.1±23.8, respectively, p<0.001). as a matter of fact, the subscale scores were all significantly higher in men than in women, except the “methods and tools” domain which was not significantly different between men and women (19.6±4.0 vs. 19.0±4.0, respectively, p=0.09). table 3. summary score of each domain (subscale) of the instrument by sex domain (subscale) overall (n=597) sex-specific men (n=295) women (n=302) p† overall scale (score range: 37-185) 147.7±24.3* 151.2±24.3 144.1±23.8 <0.001 patient care and safety (score range: 8-40) 31.5±5.6 32.4±5.6 30.6±5.5 <0.001 effectiveness and efficiency (score range: 7-35) 27.1±4.9 27.8±4.9 26.3±4.9 <0.001 equity and ethical practice (score range: 8-40) 33.7±5.3 34.5±5.2 33.0±5.4 0.001 methods and tools (score range: 5-25) 19.3±4.0 19.6±4.0 19.0±4.0 0.090 leadership and management (score range: 4-20) 15.8±3.2 16.2±3.3 15.4±3.2 <0.001 continuing professional development (score range: 5-25) 20.2±3.4 20.8±3.4 19.7±3.4 <0.001 * mean values ± standard deviations. † p-values from mann-whitney u test. table 4 presents the association of self-perceived competencies with covariates. in crude/unadjusted general linear models, mean level of self-assessed competencies was significantly higher among older physicians, in men, those with >10 years of working experience, physicians serving >2500 people, specialized physicians and those involved in teaching and training activities (all p<0.001). physicians working in the capital city had a borderline significantly higher mean level of self-perceived competencies compared with their counterparts operating in the other regions of kosovo (p=0.052). upon multivariableskeraj f, czabanowska k, bojaj g, burazeri g. self-perceived level of competencies of family physicians in post-war kosovo (original research). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-22 7 adjustment, findings were somehow attenuated, but remained essentially the same and highly statistically significant. hence, mean level of self-perceived competencies was higher among older physicians (p=0.022), in men (p<0.001), those with >10 years of working experience (p<0.001), physicians serving >2500 people (p=0.007), specialized physicians (p<0.001) and those involved in teaching and training activities (p<0.001). on the other hand, in multivariable-adjusted models, physicians working in pristina had a significantly higher mean level of self-perceived competencies than those operating in the other regions of kosovo (150.1 vs. 145.6, respectively, p=0.008). table 4. association of self-assessed competencies with demographic characteristics, work experience and specialization of primary health care physicians in kosovo variable crude (unadjusted) models * multivariable-adjusted models† mean (95%ci) p mean (95%ci) p age: ≤40 years >40 years 129.3 (125.9-132.6) 154.5 (152.4-156.5) <0.001 145.2 (141.4-149.0) 150.5 (148.2-152.7) 0.022 sex: men women 151.2 (148.5-153.9) 144.1 (141.4-146.9) <0.001 150.9 (148.1-153.8) 144.7 (142.2-147.2) <0.001 working experience (years): ≤10 years >10 years 132.5 (129.9-135.0) 158.8 (156.6-160.9) <0.001 143.7 (140.7-146.8) 151.9 (148.8-155.1) <0.001 number of population served: ≤2500 >2500 137.3 (134.2-140.4) 153.4 (151.1-155.7) <0.001 145.5 (142.4-148.6) 150.2 (147.8-152.6) 0.007 working place: prishtina other regions 150.4 (147.0-153.7) 146.3 (143.9-148.7) 0.052 150.1 (147.0-153.2) 145.6 (143.3-147.9) 0.008 specialization: general practice family medicine other 126.9 (124.1-129.7) 154.9 (152.7-157.2) 162.8 (159.2-166.3) reference <0.001 <0.001 135.3 (131.9-138.7) 151.7 (148.8-154.6) 156.5 (152.3-160.7) reference <0.001 <0.001 involved in teaching: no yes 142.9 (140.7-145.1) 159.5 (156.0-163.0) <0.001 144.1 (141.9-146.4) 151.5 (148.3-154.8) <0.001 * mean values, 95% confidence intervals (95%ci) and p-values from the general linear model. † general linear models simultaneously adjusted for all the variables presented in the table. discussion our study obtained evidence on the self-perceived level of competencies of physicians working at primary health care services in post-war kosovo. the sample size included in this survey was big and representative of all the physicians working at primary health care services in kosovo. main findings of our study include a higher level of self-perceived competencies among male physicians, older participants, those with a long working experience, physicians serving a larger population size, specialized physicians and those involved in training activities. overall, the international instrument employed in this survey exhibited a high internal consistency in this representative sample of physicians operating at primary health care skeraj f, czabanowska k, bojaj g, burazeri g. self-perceived level of competencies of family physicians in post-war kosovo (original research). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-22 8 centres in different regions of kosovo. in general, the internal consistency was high for each domain/subscale of the instrument. it should be noted that each subscale/domain of the instrument employed in our survey taps a crucial component of the quality of primary health care. as reported elsewhere (4), the domains of the instrument imply reflection and self-assessment in order to improve the quality of health care provision (6). furthermore, each domain of the instrument measures a number of specific competencies which represent individual standards (7). many studies reported in the international literature have linked the quality of health care services with health outcomes of the population (14,15). this is especially relevant for primary health care services which are considered as the most important level of health care in many developed countries (16), but also developing and transitional countries. therefore, physicians and other health care professionals working at primary health care centers should be extremely concerned of users’ demands, a process which is related to the need for continuous improvement of the quality of primary health care services. furthermore, the “gate-keeping” function of primary health care services requires a substantial degree of patients’ satisfaction. future studies should be conducted in the western balkans and beyond employing a similar methodology and the same standardized instrument as reported in our study conducted in kosovo. if so, it would be interesting to compare our findings on the self-perceived level of primary health care physicians’ competencies with their counterparts from the neighbouring countries in southeast europe and beyond. also, determinants of self-perceived level of physicians’ competencies should be explored in future research studies. a study was conducted in kosovo in 2013 including a representative sample of 1340 primary health care users aged ≥18 years (49% males aged 50.7±18.4 years and 51% females aged 50.4±17.4 years) in order to assess their perceptions on the level of competencies of their primary health care physicians (17). according to this report, the level of competencies of family physicians from patients’ perspective was significantly lower than physicians’ selfassessed level of competencies evidenced in our study. hence, the mean value of the overall summary score for the 37-item instrument was 118.0±19.7 according to patients’ perspective (17), which is considerably lower compared with our findings related to the mean value of physicians’ self-assessed level of competencies (147.7±24.3) (table 3). in the primary health care users’ survey, the perceived level of physicians’ competencies was higher among the younger and the low-income participants, and in patients who reported frequent health visits and those not satisfied with the quality of the medical encounter (17). on the other hand, no sex, or educational differences were evident in the survey including primary health users (17). it is appealing to determine in future studies the underlying factors of this differential competency level between health care providers (physicians) and users of services (patients). our study may have several limitations. our survey included a large representative sample of primary health care physicians and the response rate was high. nevertheless, we cannot exclude the possibility of information bias. in any case, we used a standardized instrument which was cross-culturally adapted in the albanian settings (12,13). furthermore, there is no reason to assume differential reporting on the level of competencies by different demographic categories of physicians, or other background variables included in our study. in conclusion, our study provides useful evidence on the self-assessed level of competencies of primary health care physicians in post-war kosovo. findings from this study may help policymakers and decision-makers in kosovo to perform necessary adjustments to the job description and terms of references pertinent to the work contracts of primary health care physicians in this transitional country. nonetheless, future studies in kosovo and other transitional settings should identify the main determinants of the apparent gaps in selfskeraj f, czabanowska k, bojaj g, burazeri g. self-perceived level of competencies of family physicians in post-war kosovo (original research). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-22 9 perceived levels of physicians’ competencies vis-à-vis the level of physicians’ competencies from patients’ perspective. source of support: the instrument for this survey was developed with the support of the european commission lifelong learning program in the framework of the leonardo da vinci project “innovative lifelong learning of european general physicians in quality improvement supported by information technology” (ingpinqi): no. 2010-1-pl1-leo0511473. conflicts of interest: none declared. references 1. frank jr, snell ls, cate ot, et al. competency-based medical education: theory to practice. 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http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=lyratzopoulos%20g%5bauthor%5d&cauthor=true&cauthor_uid=15175489 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=edwards%20r%5bauthor%5d&cauthor=true&cauthor_uid=15175489 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=heller%20rf%5bauthor%5d&cauthor=true&cauthor_uid=15175489 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=shekelle%20p%5bauthor%5d&cauthor=true&cauthor_uid=15175489 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=roland%20m%5bauthor%5d&cauthor=true&cauthor_uid=15175489 skeraj f, czabanowska k, bojaj g, burazeri g. self-perceived level of competencies of family physicians in post-war kosovo (original research). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-22 10 incentives introduced to improve quality of care in the uk. qual saf health care 2004;13:191-7. 15. starfield b, shi l, macinko j. contribution of primary care to health systems and health. milbank q 2005;83:457-502. 16. atun r. what are the advantages and disadvantages of restructuring a health care system to be more focused on primary care services? health evidence network report. copenhagen: who regional office for europe, 2004. available from: http://www.euro.who.int/__data/assets/pdf_file/0004/74704/e82997.pdf (accessed: may 20, 2014). 17. bojaj g, czabanowska k, skeraj f, burazeri g. level of competencies of family physicians from patients’ viewpoint in post-war kosovo. seejph 2014;1. doi: 10.12908/seejph-2014-05. ___________________________________________________________ © 2014 skeraj et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=will%20changes%20in%20primary%20care%20improve%20health%20outcomes%3f%20modelling%20the%20impact%20of%20financial%20incentives%20introduced%20to%20improve%20quality%20of%20care%20in%20the%20uk http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=starfield%20b%5bauthor%5d&cauthor=true&cauthor_uid=16202000 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=shi%20l%5bauthor%5d&cauthor=true&cauthor_uid=16202000 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=macinko%20j%5bauthor%5d&cauthor=true&cauthor_uid=16202000 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed/16202000 relative income and acute coronary syndrome: a population-based case-control study in tirana, albania kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 1 original research lifestyle correlates of low bone mineral density in albanian women artur kollcaku1, julia kollcaku², valbona duraj1, teuta backa1, argjend tafaj1 1 rheumatology service, university hospital center “mother teresa”, tirana, albania; ² ambulatory health service, polyclinic, tirana, albania. corresponding author: dr. artur kollcaku address: rr. “dibres”, no. 371, tirana, albania; telephone: +355674039706; e-mail: artur_kollcaku@yahoo.com kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 2 abstract aim: the aim of this study was to assess the association of lifestyle/behavioral factors with low bone mineral density in albanian women, a transitional country in the western balkans. methods: a cross-sectional study was conducted in tirana city in 2010 including a population-based sample of 549 women aged 35 years and above (response rate: 92%). low bone mineral density (osteopenia and/or osteoporosis defined as a bone mineral density tscore less than -1) was assessed with a bone ultrasound device which is simple and easy to use for screening of bone mineral density in population-based studies. binary logistic regression was used to determine the relationship of low bone mineral density with behavioral factors in this study population. results: the prevalence of low bone mineral density in this study population was 28.4% (156/549). in multivariable-adjusted logistic regression models, low bone mineral density was positively associated with smoking (or=4.1, 95%ci=2.2-7.4) and coffee consumption (or=2.3, 95%ci=1.3-4.1), but inversely related to overweight and obesity (or=0.4, 95%ci=0.2-0.7 and or=0.3, 95%ci=0.2-0.6, respectively). conclusion: this study offers useful evidence about the lifestyle/behavioral determinants of low bone mineral density among women in this transitional south eastern european population. health professionals and policymakers in albania should be aware of the major behavioral factors which increase the risk of low bone mineral density in order to provide correct treatment and control of this condition in the general population. keywords: albania, bone mineral density, bone ultrasound, bone ultrasound device, osteopenia, osteoporosis, tirana. conflicts of interest: none. kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 3 introduction low bone mineral density, especially osteoporosis, is characterized by excessive skeletal fragility and susceptibility to trauma fracture (1), particularly among older individuals (2,3). conventionally, low bone mineral density includes osteopenia and osteoporosis. osteopenia is deemed as en initial step of osteoporosis notwithstanding the fact that not every person with osteopenia may inevitably experience osteoporosis (4-6). as a rule of thumb, osteopenia is defined as a bone mineral density t-score lower than -1.0 and greater than -2.5 (7). on the other hand, osteoporosis is defined as a bone mineral density t-score of -2.5 or lower (7). it is important to note that osteopenia is an indication of normal aging, as opposed to osteoporosis which is evident in pathologic aging (1,5). the prevalence of low mineral bone density, especially osteoporosis, increases with age (2,3,8). furthermore, the prevalence of osteoporosis is higher in women, especially after menopause (1,8,9). in addition, unhealthy behavioral patterns consisting of smoking, excessive alcohol consumption and physical inactivity increase the risk of low bone mineral density and/or exacerbate the conditions of osteopenia and osteoporosis (5,10,11). on the other hand, body weight has been shown to exert a beneficial effect on increasing bone mass which, in turn, reduces the risk of osteoporosis (1). furthermore, fat mass has been described as a protective factor against osteoporosis in several studies conducted worldwide (12-14). however, the findings related to excessive fat mass are not consistent and several other studies have reported that it may not protect against decreases in bone mass (15-17). the assessment of bone mineral density is typically done with dual x-ray absorptiometry (dexa) procedure (18). at the same time, assessment of bone mineral density can be also performed with portable scanners using ultrasound, and portable machines can measure density in the heel (19,20). as a matter of fact, quantitative ultrasound is currently used worldwide due to its low cost, simplicity of performance, mobility and due to the lack of ionizing radiation (19). after the fall of the communist regime in 1990, albania, a transitional country in the western balkans, has been characterized by a particularly difficult political and socioeconomic situation associated with periodic civil unrests and high rates of unemployment (21). according to a recent report, the burden of musculoskeletal disorders has increased in albania in the past two decades (22). the overall share of musculoskeletal disorders accounted for 8.5% of the total burden of disease in 1990, whereas in 2010 it amounted to 11.0% (22,23). there is evidence of a stronger increase in females than in males. in both sexes, there was a similar moderate yet steady increase from 1990-2005 (22,23). subsequently, there was a steeper increase in females, but a smaller increase in males, which additionally accentuated the excess burden of disease explained by the musculoskeletal disorders in females compared to males (22). the burden of musculoskeletal disorders in albania was similar to most of the countries in south eastern european (see) region in both 1990 and 2010 (22,23). in 2010, the share of musculoskeletal disorders was 11.0% of the total burden of disease in several see countries including albania. essentially, musculoskeletal disorders are said to have increased in albania probably due to a higher accessibility to the health care services in addition to the ageing pattern of the albanian population (22). to date though, data on the prevalence and determinants of osteopenia and osteoporosis in the albanian population is scarce. in this framework, the aim of our study was to assess the lifestyle/behavioral correlates of low bone mineral density (osteopenia and/or osteoporosis) in tirana city, the capital of albania, a transitional country in the western balkans http://en.wikipedia.org/wiki/osteoporosis� http://en.wikipedia.org/wiki/bone_mineral_density#t-score� http://en.wikipedia.org/wiki/aging� http://en.wikipedia.org/wiki/osteoporosis� http://en.wikipedia.org/wiki/dual_energy_x-ray_absorptiometry� kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 4 characterized by an intensive process of urbanization and internal migration of the population in the past twenty five years. methods a cross-sectional study was conducted in 2010 including a population-based sample of women aged 35 years and above residing in tirana city, the capital of albania. regarding the sample size, a minimum of 540 women was estimated as the minimal number required for inclusion in this study. in order to account for potential non-response, we decided to invite 600 women to participate in our study. the inclusion criteria consisted of women aged 35 years and above residing in tirana city. of 600 eligible individuals invited to take part in this study, 549 women agreed to participate (mean age: 55.6±9.1 years; response rate: 92%). the bone mineral density among study participants was assessed with a bone ultrasound device which is simple and easy to use for screening of bone mineral density in populationbased studies (19,20). from this point of view, ultrasound is considered as a quick, cheap and non-radiating device for assessing bone quality (19,20). low bone mineral density was defined as a bone mineral density t-score less than -1 that is osteopenia and/or osteoporosis. the physical examination included also measurement of height and weight for all study participants based on which body mass index (bmi) was calculated (kg/m2) and categorized in the analysis into normal weight (bmi≤25 kg/m2), overweight (bmi: 25.1-29.9 kg/m2) and obesity (bmi≥30 kg/m2). the other lifestyle/behavioral factors were assessed through an interviewer-administered structured questionnaire including information on smoking habits (dichotomized in the analysis into: yes vs. no), alcohol intake (yes vs. no), coffee consumption (yes vs. no) and tea consumption (yes vs. no). demographic and socioeconomic data (age, marital status, educational level and employment status of study participants) were also collected for all women included in this study. binary logistic regression was used to assess the association of low bone mineral density (outcome variable) with lifestyle/behavioral factors (independent variables). initially, crude (unadjusted) odds ratios (ors) and their respective 95% confidence intervals (95%cis) were calculated. next, all the lifestyle factors (smoking, alcohol intake, coffee and tea consumption and bmi) together with demographic and socioeconomic characteristics (age, marital status, educational level and employment status) were entered simultaneously into the logistic regression models. multivariable-adjusted ors and their respective 95%cis were calculated. in all cases, a p-value of ≤0.05 was considered as statistically significant. statistical package for social sciences (spss, version 15.0) was used for all the statistical analyses. results the prevalence of low bone mineral density (osteopenia and/or osteoporosis) in this study population was 156/549=28.4% (table 1). the prevalence of smoking was significantly higher in women with low bone mineral density compared with those with normal bone mineral density (25.6% vs. 8.7%, respectively; p<0.001). there were no differences regarding the prevalence of alcohol intake. the prevalence of both coffee consumption and tea consumption was significantly higher in women with low bone mineral density than in those with normal bone mineral density (83.3% vs. 68.2%, p<0.001 and 53.8% vs. 41.2%, p=0.005, respectively). kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 5 on the other hand, the prevalence of both overweight and obesity was significantly lower in women with low bone mineral density compared with women with normal bone mineral density (30.8% vs. 40.2% and 23.7% vs. 32.2%, respectively; overall p<0.001) (table 1). table 1. distribution of lifestyle/behavioral factors in a sample of albanian women by bone mineral density status variable total (n=549) normal bone mineral density (n=393) low bone mineral density (n=156) p † smoking: no yes 475 (86.5)* 74 (13.5) 359 (91.3) 34 (8.7) 116 (74.4) 40 (25.6) <0.001 alcohol intake: no yes 514 (93.8) 34 (6.2) 369 (93.9) 24 (6.1) 145 (93.5) 10 (6.5) 0.508 coffee consumption: no yes 151 (27.5) 398 (72.5) 125 (31.8) 268 (68.2) 26 (16.7) 130 (83.3) <0.001 tea consumption: no yes 303 (55.2) 246 (44.8) 231 (58.8) 162 (41.2) 72 (46.2) 84 (53.8) 0.005 bmi: normal weight overweight obesity 179 (32.7) 205 (37.5) 163 (29.8) 108 (27.6) 157 (40.2) 126 (32.2) 71 (45.5) 48 (30.8) 37 (23.7) <0.001 * absolute numbers and their respective column percentages (in parentheses). † p-values from fisher’s exact test. table 2 presents the association of low bone mineral density with lifestyle factors of the women included in this study. in crude (unadjusted) logistic regression models, there was evidence of a strong and statistically significant association of low bone mineral density with smoking (or=3.6, 95%ci=2.2-6.0), but not alcohol intake (or=1.1, 95%ci=0.5-2.3). on the other hand, there was a strong association of low bone mineral density with coffee consumption (or=2.3, 95%ci=1.5-3.7) and tea consumption (or=1.7, 95%ci=1.2-2.4). on the contrary, the odds of overweight and obesity were lower among women with a low bone mineral density compared with their counterparts with normal bone mineral density (or=0.5, 95%ci=0.3-0.7 and or=0.4, 95%ci=0.3-0.7, respectively). in multivariable-adjusted logistic regression models, low bone mineral density was positively associated with smoking (or=4.1, 95%ci=2.2-7.4), coffee consumption (or=2.3, 95%ci=1.3-4.1) and (non-significantly) with tea consumption (or=1.4, 95%ci=0.9-2.2), but inversely related to overweight and obesity (or=0.4, 95%ci=0.2-0.7 and or=0.3, 95%ci=0.2-0.6, respectively) (table 2). kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 6 table 2. association of low bone mineral density with lifestyle/behavioral factors among women in tirana, albania variable crude (unadjusted models) multivariable-adjusted models or (95%ci)* p* or (95%ci)* p* smoking: no yes 1.00 (reference) 3.64 (2.20-6.02) <0.001 1.00 (reference) 4.07 (2.23-7.40) <0.001 alcohol intake: no yes 1.00 (reference) 1.06 (0.49-2.27) 0.880 1.00 (reference) 0.73 (0.30-1.75) 0.478 coffee consumption: no yes 1.00 (reference) 2.33 (1.46-3.74) <0.001 1.00 (reference) 2.33 (1.34-4.07) 0.003 tea consumption: no yes 1.00 (reference) 1.66 (1.15-2.42) 0.008 1.00 (reference) 1.40 (0.90-2.16) 0.134 bmi: normal weight overweight obesity 1.00 (reference) 0.47 (0.30-0.72) 0.45 (0.28-0.72) <0.001 (2)† 0.001 0.001 1.00 (reference) 0.39 (0.23-0.65) 0.32 (0.18-0.55) <0.001 (2)† <0.001 <0.001 * odds ratios (or: low bone mineral density vs. normal bone mineral density), 95% confidence intervals (95%cis) and p-values from binary logistic regression. besides the variables presented in the table, multivariable-adjusted models were additionally controlled for age, marital status, employment status and educational level. † overall p-value and degrees of freedom (in parentheses). discussion this study including a representative sample of women residing in tirana – the capital city of transitional albania which was the most isolated country in europe during the communist regime – offers useful evidence about selected lifestyle/behavioral predictors of low bone mineral density (osteopenia and osteoporosis) in the adult female population. smoking and coffee consumption were positively associated, whereas overweight and obesity were inversely related to osteopenia and osteoporosis in this sample of albanian women, after controlling for other lifestyle factors and several demographic and socioeconomic characteristics. our findings related to a positive association between low bone mineral density with smoking and coffee consumption are in line with previous reports from the international literature (5). in our study, the association of osteopenia and osteoporosis with coffee consumption was strong and remained unaffected upon simultaneous adjustment for a wide array of covariates including alcohol intake and tea consumption. furthermore, the positive relationship with smoking was even stronger after multivariable adjustment for other behavioral characteristics. in our study, overweight and obesity were strong correlates of osteopenia and osteoporosis. the negative association of overweight and obesity with low bone mineral density was accentuated in multivariable-adjusted logistic regression models. our findings regarding body mass are compatible with several reports from the international literature (1,24). from this point of view, higher body weight or higher bmi is known to be a protective factor against bone loss in both men and women worldwide (1,24-26). nevertheless, overweight and kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 7 obesity are related to a gain in fat mass as well as an increase in lean mass. therefore, identification of the specific roles that fat mass itself plays in bone mass regulation is important to establish the clinical implications of osteoporosis (24). several studies have indicated that both fat mass and lean mass can lead to an increase in bone mass which, in turn, reduces the risk of osteoporosis (13,24). on the other hand, according to some other studies, fat mass has a negative effect on bone mass after controlling for body weight (1,27). importantly, regarding total fat mass, subcutaneous fat has been reported to be beneficial for bone mass, whereas visceral fat has negative effects (24,28). this study may have some limitations. notwithstanding the representativeness of the sample of women included in this study, the possibility of selection bias, at least to some extent, may be an issue which cannot be completely excluded. in any case, tirana women are not assumed to represent the overall albanian women and, hence, findings from this study cannot be generalized to the overall female population in albania. in our survey, we employed a standardized and internationally valid instrument for assessment of low bone mineral density in population-based studies. furthermore, findings from the quantitative ultrasound measurements of bone mineral density correlate well with the dual energy x-ray absorptiometry (dxa) (19), which is one of the most widely validated tools for measurement of bmd in clinical practice (18). on the other hand, the lifestyle/behavioral data collected through the interview may have been subject to information bias. this may be the case of smoking, alcohol intake, as well as coffee 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(original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 9 23. institute for health metrics and evaluation (ihme). global burden of disease database. seattle, wa: ihme, university of washington, 2014. http://www.healthdata.org (accessed: april 15, 2015). 24. kim jh, choi hj, kim mj, shin cs, cho nh. fat mass is negatively associated with bone mineral content in koreans. osteoporos int 2012;23:2009-16. 25. ravn p, cizza g, bjarnason nh, thompson d, daley m, wasnich rd, et al. low body mass index is an important risk factor for low bone mass and increased bone loss in early postmenopausal women. early postmenopausal intervention cohort (epic) study group. j bone miner res 1999;14:1622-7. 26. reid ir. relationships among body mass, its components, and bone. bone 2002;31:547-55. 27. zhao lj, liu yj, liu py, hamilton j, recker rr, deng hw. relationship of obesity with osteoporosis. j clin endocrinol metab 2007;92:1640-6. 28. gilsanz v, chalfant j, mo ao, lee dc, dorey fj, mittelman sd. reciprocal relations of subcutaneous and visceral fat to bone structure and strength. j clin endocrinol metab 2009;94:3387-93. ___________________________________________________________ © 2015 kollcaku et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. macassa g. responsible leadership styles and promotion of stakeholders’ health (short report). seejph 2019, posted: 07 march 2019. doi 10.4119/unibi/seejph-2019-207 page 1 of 5 s h o r t r e po r t responsible leadership styles and promotion of stakeholders’ health gloria macassa1 1department of public health and sports science, university of gävle, sweden. corresponding author: gloria macassa, md, professor of public health and epidemiology, department of public health and sports science, university of gävle, sweden; address: se-801 76, gävle, sweden; telephone: +4626648228; email: gloria.macassa@hig.se. macassa g. responsible leadership styles and promotion of stakeholders’ health (short report). seejph 2019, posted: 07 march 2019. doi 10.4119/unibi/seejph-2019-207 page 2 of 5 abstract the aim of this short report is to stimulate a conversation on the potential role to be played by responsible leadership in promoting the health and well-being of stakeholders (employees and society at large). the report first describes responsible leadership styles and then briefly discusses the potential connection with health promotion within the lens of the wider determinants of health and intersectorial collaboration. integrative responsible leadership and health promotion share a common vision: to alter the economic, environmental, and social contexts in which decisions relating to health and wellbeing are made, thus affecting health equity. keywords: health promotion; responsible leadership, stakeholders, sustainable development goals. conflicts of interest: none. macassa g. responsible leadership styles and promotion of stakeholders’ health (short report). seejph 2019, posted: 07 march 2019. doi 10.4119/unibi/seejph-2019-207 page 3 of 5 responsible leadership responsible leadership (rl) is a relational process between leaders and stakeholders aimed at establishing accountability in matters pertaining to organizational value creation (1). pless et al. define leadership style as an observable behaviour that reflects different degrees of such accountability in executive actions and discussions (2), and argue that this behaviour could be evaluated by other people like subordinates (who are classical followers, peers, and external constituencies) (2). this short report looks at rl styles and examines how they can influence health promotion through corporate social responsibility (csr) strategies and processes in the organization. this approach to rl is supported by doh and quigley’s understanding of rl behaviour, which they see as going beyond “doing no harm” to contributing to value creation in relation to multiple bottom lines (3). according to maak et al. (1) there are two rl behaviours with two distinct leadership styles: instrumental and integrative. instrumental rl is centred on driving business, with a strategic focus on business performance (1) and less attention paid to non-core business issues (2). this style entails a personalized vision based on the achievement of organizational goals such as maximization of profits, growth, and dominance over the competition (1). instrumental rl is also associated with weaker interactions with stakeholders, mostly based on key business stakeholders, employees, governments, and investors. regarding relations with internal stakeholders (employees), instrumental rl is suggested to lead by objectives, setting high performance goals as well as focusing on managing employees’ performance and excellence to meet the defined goals (2). relations with external stakeholders are suggested to come through economic means-end relationships (4) or beneficial in terms of power, or through relations with governments, legislation or media (for urgency issues). instrumental leaders are rational, as they search for information about selected societal issues that they see as providing business benefits (2,4). in contrast to this, an integrative rl style is characterised by a balanced approach towards value creation, leading the business towards societal as well as business objectives (the so-called “double-bottomline”) (1). integrative responsible leaders use communication and vision statements as an active leadership tool to convey positive messages regarding societal impact, taking boundary-spanning roles and connecting with a large range of stakeholders (1,4).these leaders are connected to external constituencies, governments, and investors as well as being facilitators of collaboration between stakeholders from different sectors and industries. they can also facilitate inclusive processes in decision making, use moral reasoning and often make pro-social choices (1). the two leadership styles are summarised in table 1. can responsible leaders contribute to public health promotion? according to the world health organization (who), health promotion is the process of enabling people to increase control over and improve their health (5). health promotion moves beyond the focus on individual behaviours towards a wide range of social, economic, and environmental interventions. it is strictly linked to the determinants of health and well-being which are known to be the conditions in which people are born, grow, live, work, and age. these conditions determine people’s chances for good health, and are sometimes called “the causes of the causes” (6). there is now a broader consensus that health is linked not only to behaviour or risk exposure, but also to how social and economic structures shape the health of the populations globally. macassa g. responsible leadership styles and promotion of stakeholders’ health (short report). seejph 2019, posted: 07 march 2019. doi 10.4119/unibi/seejph-2019-207 page 4 of 5 table 1. responsible leadership styles behavioural characteristics instrumental leader integrative leader vision personalized socialized focus of business leadership/value creation leading business with a focus on the financial bottom-line leading business with a focus on dual-bottom-line approach to leading leading by objective setting leading by mobilizing stakeholders stakeholders relations/scope of interaction low degree of interconnectedness boundary setting reactive narrow focus on powerful and urgent stakeholders high degree of interconnectedness boundary spanning proactive broader focus on all legitimate stakeholders decision making process/ applied logic/justification of choices exclusive economic cost – benefit logic business case justification inclusive pro-social cost logic logic of appropriateness source: adapted from maak et al 2016 (1). i argue that responsible leaders, especially those with an integrative behaviour style, will be more likely to advance csr strategies and processes that are inclusive and that involve collaboration with other stakeholders, in order to improve people’s health beyond the workplace. this inclusiveness and collaboration, which is a common feature of integrative responsible leaders, is very important in health promotion and is referred to as “intersectorial collaboration” (7). since its conception, health promotion was always thought to advance intersectorial collaboration beyond the health sector in pursuit of improving human health (5). this view was that by creating partnerships with sectors beyond the health sector, countries could better address the underlying causes of the conditions that create ill health, and especially health inequalities (7). business organizations, through their integrative responsible leaders, can help improve population health by collaborating in addressing the social determinants of health (e.g., tackling environmental, economic, social and health challenges) between and within countries in the era of sustainable development goals (sdgs). for instance, macassa and colleagues viewed responsible leaders as posited to achieve mutually shared objectives (for internal and external stakeholders) based on a vision of business as a force of good for the many, and not only for shareholders and managers (8). it is argued that health promotion offers a great opportunity and means to achieve the sdgs by equipping and empowering individuals and communities and by promoting inclusive models of governance via advocating health policies and environments (9,10). the sdgs are the foundation for supporting global health and international development work in the years to come. csr strategies promoted throughout integrative rl and health promotion share a common vision; that is, to alter the economic, environmental, and social contexts in which decisions relating to health and well-being are made, thus affecting health equity. macassa g. responsible leadership styles and promotion of stakeholders’ health (short report). seejph 2019, posted: 07 march 2019. doi 10.4119/unibi/seejph-2019-207 page 5 of 5 references 1. maak t, pless nm, voegtlin c. business statesman or shareholder advocate? ceo responsible leadership styles and the micro-foundations of political csr. j manag stud 2016;53:463-93. 2. pless n, maak t, waldmand, wang d. development of a measure of responsible leadership. acad manag proceed 2014;1:12973. 3. doh jp, quigley nr. responsible leadership and stakeholder management: influence pathways and organizational outcomes. acad manag perspect 2014;28:255-74. 4. hahn t, pless l, pinkse j, figge, f. cognitive frames in corporate sustainability: managerial sensemaking with paradoxical and business cases frames. acad manag rev 2014;39:46378. 5. world health organization.the ottawa charter for health promotion. geneva: world health organization; 1986. http://www.who.int/healthpromotion/co nferences/previous/ottawa/en/ (accessed: 12 february 2019). 6. world health organization commission on the social determinants of health (who csdh). closing the gap in a generation. health equity through action on the social determinants of health. geneva: world health organization; 2008. https://www.who.int/social_determinant s/thecommission/finalreport/en/ (accessed:14 february 2019) 7. corbin jh. health promotion, partnership and intersectorial collaboration. health promot int 2017;32:923-9. 8. macassa g, francisco jc, mcgrath c. corporate social responsibility and population health. health sj. 2017;11:5:528. 9. spencer g, corbin jh, miedema e. sustainable development goals for health promotion. health promot int 2018. doi: 10.1093/heapro/day036. 10. fortune k, becerra-posada f, buss p, galvao lac, contreras a, murphy m, et al. health promotion and the agenda for sustainable development, who region of the americas. bull world health organ 2018;96:621-6. _____________________________________________________________________________________ © 2019 macassa; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.who.int/healthpromotion/conferences/previous/ottawa/en/ http://www.who.int/healthpromotion/conferences/previous/ottawa/en/ https://www.who.int/social_determinants/thecommission/finalreport/en/ https://www.who.int/social_determinants/thecommission/finalreport/en/ dyakova m, drew c, wright n, clarke a, rees k. systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease: cochrane systematic review protocol (short report). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-02. 1 short report systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease: cochrane systematic review protocol mariana dyakova1, christian drew1, nicola wright2, aileen clarke1, karen rees1 1health sciences, warwick medical school, university of warwick, united kingdom; 2 public health, communities group, warwickshire county council, united kingdom. corresponding author: dr mariana dyakova, division of health sciences, warwick medical school, university of warwick; address: medical school building, gibbet hill campus, coventry, cv4 7al, england, united kingdom; email: m.dyakova@warwick.ac.uk dyakova m, drew c, wright n, clarke a, rees k. systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease: cochrane systematic review protocol (short report). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-02. 2 abstract a large number of people, considered at increased risk of vascular disease, remain unidentified, untreated and not reached by lifestyle advice or intervention, despite public health and clinical efforts. this has prompted the initiation of national screening/systematic risk assessment programmes for vascular disease in healthy populations. these exist in addition to the more ad hoc opportunistic risk assessment initiatives undertaken worldwide. there is currently not enough indisputable evidence either showing clear clinical or economic benefits of systematic screening-like programmes over opportunistic risk assessment of cardiovascular disease (cvd) in primary care. we present the rationale and methodology of a cochrane systematic review, assessing the effectiveness, costs and adverse effects of systematic risk assessment compared to opportunistic risk assessment for the primary prevention of cvd. keywords: cardiovascular disease, cochrane systematic review protocol, risk assessment. dyakova m, drew c, wright n, clarke a, rees k. systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease: cochrane systematic review protocol (short report). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-02. 3 introduction description of the condition many risk factors contribute to the development of cardiovascular disease (cvd), most of which are related to lifestyle, such as physical inactivity, smoking and unhealthy diet (1). in more than 90% of cases, the risk of a first heart attack is related to nine potentially modifiable risk factors (2): smoking/tobacco use; poor diet; high blood cholesterol; high blood pressure; insufficient physical activity; overweight/obesity; diabetes; psychosocial stress and excess alcohol consumption. the combined effect of different coexisting cardiovascular risk factors determines the total or global risk of developing cvd. many people are unaware of their risk status and total risk assessment is potentially useful for finding high-risk individuals and guiding clinical decisions (3). such a risk stratification approach is particularly suitable to settings with limited resources (1). short emphasises that there is no advantage in assessment, without the ability to intervene and to make changes to lower that risk (4). efficient and effective means of identifying high-risk individuals and then providing the support to enable them to modify their lifestyles requires a delivery system which gives priority to preventive services rather than focusing on treatment (5). description of the intervention the main objectives of a risk assessment are to assess health status, to estimate health risk, and to inform and provide feedback to participants in order to reduce health risks (6). systematic risk assessment systematic risk assessment (sra) for primary prevention of cvd is defined here as a screening-like programme, involving a pre-determined process for selection of people, who are systematically invited to attend a cvd health check in a primary care or similar setting. the selection, invitation and follow-up processes are determined in advance, for example specific inclusion/ exclusion criteria; a unified method of invitation, such as letter/birthday card/phone call; and there is a system for providing feedback or referral. such a programme is repeated at pre-defined intervals, for example every five or ten years. the assessment process includes finding out and measuring risk factors as well as estimating the total (global) cvd risk, using a specific risk scoring tool. the target population for such systematic risk assessment includes healthy individuals (not previously diagnosed with cvd but may already have been diagnosed with one or more cvd risk factors). similarly to other screening programmes, sra can be realised in two ways: population (universal/mass), including the general population in a certain age group with no regard to any underlying risk factors; high-risk targeted to a specific group of individuals, considered potentially to be at increased risk of cvd due to some pre-existing risk factors. opportunistic risk assessment opportunistic risk assessment (ora) for primary prevention of cvd is defined here as occurring sporadically in a primary setting, including primary care, pharmacy chains, supermarket chains, food companies, occupational health departments or small businesses. the range of such activities varies from no cvd risk assessment at all (no risk factors are measured/no total risk is scored in healthy individuals); through random (opportunistic) risk assessment in patients attending primary care for another reason; to incentivised case-finding, for example through the quality and outcomes framework for uk general practitioners (7). dyakova m, drew c, wright n, clarke a, rees k. systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease: cochrane systematic review protocol (short report). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-02. 4 how the intervention might work according to the nhs health checks programme (8), a standard assessment, based on simple questions and measurements to identify the risk of coronary heart disease (chd), stroke, diabetes and kidney disease, would be effective. after assessing the levels of the main risk factors and the total cvd risk, a follow-up is organised with an individually tailored assessment, setting out the person’s level of vascular risk and what steps they could take to reduce it. modelling work around the health checks approach has predicted that it would deliver significant benefits for the uk population: preventing at least 9500 heart attacks and strokes a year (2000 of which would be fatal); preventing at least 4000 people a year from developing diabetes; and detecting diabetes or kidney disease at least a year earlier for 25,000 people. it has predicted high levels of both clinical and cost-effectiveness against a range of assumptions when this approach is applied to all those aged 40 to 74 years (9). recent research suggests that targeting high-risk individuals (high risk based sra) rather than mass population screening is a preferred route (10,11). lawson identified that 16 people were needed to be screened, following the population approach, to identify one individual at high risk of cvd, costing gbp 370 per high-risk person. the alternative, e.g. targeted screening of deprived communities, estimated that only six people would need to be assessed for the identification of one high risk individual, reducing the costs to gbp 141 per positive identification. jackson et al identify that a screening programme targeted at individuals with likely or known cvd risk factors would be preferable from a cost-effectiveness point of view (12). previous research (13) suggests that when a population screening programme is undertaken, there is a persistent level of non-attendance and that whilst cardiac risk score for nonattenders is similar to those who attended, non-attenders have significantly more risk behaviours such as smoking. population-based (universal) risk assessment every five years was found to be cost-effective when compared with no screening; however a cost-analysis was not conducted on whether universal risk assessment would remain cost-effective when compared to targeted high-risk screening. objective: the primary objective of this review is to assess the effectiveness, costs and adverse effects of sra compared to ora for the primary prevention of cvd. methods types of studies: randomised controlled trials (rcts). types of participants: healthy adults (18 years old or over) from the general population, including those at moderate to high risk of cvd. intervention: sra for primary prevention of cvd, defined as a screening-like programme, involving a predetermined selection process of people, systematically invited to attend a cvd health check in a primary care or similar setting, assessing at least two of the following risk factors: • blood pressure (systolic and/or diastolic) or lipid profile (total cholesterol, ldl, ldl/hdl); and • any other modifiable risk factor (smoking, weight, diet, exercise, alcohol, stress). dyakova m, drew c, wright n, clarke a, rees k. systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease: cochrane systematic review protocol (short report). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-02. 5 control: ora for primary prevention of cvd, defined as a range of activities, occurring sporadically in any primary setting from no risk assessment at all to incentivised case finding. outcome measures primary outcomes • all-cause mortality; • cardiovascular mortality; • non-fatal endpoints, including chd, mi, cabg, ptca, stroke, transitory ischaemic attack (tia) and peripheral artery disease. secondary outcomes • cvd major risk factors: blood pressure, lipid levels, type 2 diabetes; • intermediate (programme) outcomes (if reported): attendance rates (number of individuals who came for examination); case finding rates (number of high-risk individuals, identified by the health check); acceptability and participants’ satisfaction; and follow-up rates (number of cases who were followed with some intervention in primary and secondary care); • costs; • adverse effects. search methods for identification of studies electronic searches the following electronic databases were searched: • the cochrane library (including the cochrane central register of controlled trials (central) and nhs centre for reviews and dissemination (crd) databases: health technology assessment (hta), database of abstracts of reviews of effects (dare) and nhs economic evaluation database (need); • medline (ovid); • embase (ovid); • science citation index expanded (sci-expanded), social sciences citation index (ssci), conference proceedings citation index science (cpci-s) on web of science; • amed allied and complementary medicine database. we will use medical subject headings (mesh) or equivalent and text word terms. we will design searches in accordance with the cochrane heart group methods and guidance. we will impose no language restrictions. searching other resources open grey for grey literature; meta-register of controlled trials (m-rct) (www.controlledtrials.com/mrct); clinicaltrials.gov (www.clinicaltrials.gov) and who international clinical trials registry platform (ictrp) (http://apps.who.int/trialsearch/). data collection and analysis data collection and analysis is realised through: selection of studies; data extraction and management; assessment of risk of bias in included studies; measures of treatment effect; assessment of heterogeneity; subgroup analysis, if sufficient studies are found. dyakova m, drew c, wright n, clarke a, rees k. systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease: cochrane systematic review protocol (short report). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-02. 6 we will also examine the effects of the intervention design (setting, personnel involved, invitation and follow-up system). we will carry out sensitivity analyses excluding studies with a high risk of bias. if there are sufficient trials, we will undertake assessment of funnel plots and tests of asymmetry (14) to assess possible publication bias. acknowledgment this protocol is published in full in the cochrane library (dyakova m, drew c, wright n, clarke a, rees k. systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease (protocol). cochrane database of systematic reviews 2013, issue 2. art. no.: cd010411. doi: 10.1002/14651858.cd010411) funding source: this project is funded by the national institute for health research. department of health disclaimer: the views and opinions expressed therein are those of the authors and do not necessarily reflect those of the nihr, nhs or the department of health. conflicts of interest: none declared. references 1. 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commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 1 short report socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania manushaqe rustani-batku1, ali tonuzi2 1 primary health care center no. 2, tirana, albania; 2 university hospital center “mother teresa”, tirana, albania. corresponding author: dr. manushaqe rustani-batku, primary health care center no. 2, tirana; address: rr. “arkitekt kasemi”, 51, tirana, albania; telephone: +355682359312; email: manushaqebatku@yahoo.com http://wikimapia.org/street/16408710/sq/rruga-arkitekt-kasemi� rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 2 abstract aim: the aim of our study was to assess the distribution of socio-demographic factors and the clinical profile of individuals diagnosed with retinal vein occlusion (rvo) in albania, a former communist country in south-eastern europe which has been undergoing a rapid transition in the past decades. methods: this study was carried out in 2013-2016 at the primary health care centre no. 2 in tirana municipality, which is the capital of albania. during this timeframe, on the whole, 44 patients were diagnosed with rvo at this primary health care centre (17 women and 27 men; overall mean age: 69.5±11.5 years). the diagnosis of rvo was based on signs and symptoms indicating a quick reduction of the sight (vision), fundoscopy, fluorescein angiography and the optical coherence tomography. data on socio-demographic factors and clinical characteristics were also gathered for each study participant. results: the prevalence of glaucoma was considerably higher in men than in women (67% vs. 24%, respectively, p=0.01). diabetic retinopathy was somehow more prevalent in women than in men (18% vs. 11%, respectively), whereas an opposite finding was noted for the presence of hypertensive retinopathy (6% vs. 11%, respectively). the prevalence of cataract was higher in female patients compared with their male counterparts (18% vs. 7%, respectively, p=0.36). both macular oedema and papillary oedema were almost equally distributed in men and in women (22% vs. 18% and 4% vs. 6%, respectively). all female patients had comorbid conditions compared to 85% of their male counterparts (p=0.15). the prevalence of hypertension was almost identical in both sexes (52% in men vs. 53% in women), whereas the prevalence of diabetes was somehow higher in men than in women (26% vs. 18%, respectively). conclusion: this is one of the very few studies informing about the distribution of sociodemographic factors and selected clinical characteristics of individuals diagnosed with rvo in transitional albania. keywords: albania, clinical profile, ophthalmology, retinal vein occlusion, sociodemographic factors. conflicts of interest: none. rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 3 introduction retinal vein occlusion (rvo) is a major reason for severe ocular impairment and blindness (1,2). the available evidence, based on many studies carried out in different countries of the world, indicates that rvo is linked to an increased risk of cardiovascular disease, especially hypertension, diabetes mellitus, and coronary artery disease (3-5). the incidence and prevalence of rvo is substantially higher among older people, notwithstanding the fact that this condition is a frequent cause of painless visual loss also in middle-aged individuals (6-8). data from the global burden of disease (gbd) 2010 study indicate that albania is the only country in the south-eastern european region that has experienced an increase in the mortality rate from ischemic heart disease and cerebrovascular diseases in the past two decades (9), exhibiting an early evolutionary stage of the coronary epidemic, which was evident many decades ago in the western countries (10). indeed, ischemic heart disease and cerebrovascular disease were among the highest ranking causes regarding the number of years of life lost due to premature mortality in albania in 2010 (9). furthermore, the burden of diabetes mellitus has almost doubled in albania in both sexes in the past two decades (10). in males, there was an increase of 96% in disability-adjusted life years (dalys) from diabetes, whereas in females this increase was 85%. overall, the sex-pooled proportional dalys for diabetes in albania in 2010 increased 50% compared with 1990 (9). currently, there is evidence of a gradual increase in the diabetes burden which is also due to improvements in the accessibility of health care (that is adequate registration and management of all cases with diabetes) coupled with a steady increase in the ageing population (which, in turn, is associated with an increase in the prevalence of diabetes) (10). yet, data on the prevalence and determinants of rvo in albania are scarce. indeed, to date, there are no scientific papers available providing evidence about the magnitude and occurrence of rvo in the population of albania. in this context, the aim of our study was to assess the distribution of socio-demographic factors and the clinical profile of individuals diagnosed with rvo in albania, a former communist country in south-eastern europe which has been undergoing a rapid transition in the past decades. methods a case-series study was carried out at the primary health care centre no. 2 in tirana municipality during the time period 2013-2016. overall, the number of patients diagnosed with rvo in this health centre during the study period was 44. of these, 27 (61%) patients were males and 17 (39%) were females. on the whole, mean age of the patients was 69.5±11.5 years (with a range from 42 years to 93 years). median age was 70.5 years (interquartile range: 60.3-77.8 years). the diagnosis of rvo was based on the following criteria: i) signs and symptoms indicating a quick decrease and reduction of the unilateral sight; ii) fundoscopy, a conventional examination technique of the fundus employed at the primary health care services in albania (a procedure which indicates the retinal veins that are dilated or tortuous, as well as the retinal haemorrhages); iii) fluorescein angiography, which was the main examination procedure in this study, and; iv) the optical coherence tomography (oct). furthermore, information about selected clinical characteristics of each patient diagnosed with rvo was gathered. more specifically, the clinical information for all the patients diagnosed with rvo included the presence of glaucoma (yes vs. no), the type of glaucoma (open angle, closed angle, secondary, or absolute glaucoma), presence of diabetic rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 4 retinopathy, hypertensive retinopathy, cataract, macular oedema, papillary oedema, or comorbidity (all dichotomized into: yes vs. no), as well as the type of comorbidity (hypertension, diabetes, or both conditions). information on socio-demographic characteristics was also collected based on a structured interview. more specifically, for each patient it was gathered information on demographic factors (age and sex) and selected socio-economic characteristics [place of residence (dichotomized into: urban vs. rural areas) and employment status (trichotomized into: employed, unemployed, retired)]. the study was approved by the faculty of medicine in tirana and all patients who agreed to participate in this study gave their informed consent. mean values and the respective standard deviations were calculated for the age of the overall sample of study participants, as well as separately in men and in women. conversely, absolute numbers and their respective percentages were calculated for the other sociodemographic factors (place of residence and employment status) and all the clinical characteristics of the patients. mann-whitney u-test was used to compare the age between male and female patients diagnosed with rvo. on the other hand, fisher’s exact test was used to assess sex-differences in the distribution of the other socio-demographic factors (see table 1) and all the clinical characteristics in the sample of patients included in this study (table 2). a p-value of ≤0.05 was considered as statistically significant in all ca ses. statistical package for social sciences (spss, version 17.0) was used for all the statistical analyses. results the distribution of socio-demographic characteristics of the patients included in this study is presented in table 1. mean age in men was 71.1±10.9 years, whereas in women it was 67.0±12.4 years. yet, there was no evidence of a significant sex-difference in the mean age of the patients included in this study (mann-whitney u-test: p=0.27). about 19% of male patients and 29% of females were residing in rural areas, without evidence of a sex-difference though (p=0.47). similarly, there was no evidence of a statistically significant difference in the distribution of employment status between genders, regardless of a higher rate of unemployment in women compared to men (29% vs. 15%, respectively, p=0.51) [table 1]. table 1. socio-demographic characteristics of a sample of patients diagnosed with rvo during 2013-2016 in tirana, albania variable men (n=27) women (n=17) p * total (n=44) age (in years) [mean±sd] 71.1±10.9 67.0±12.4 0.272 69.5±11.5 place of residence [n (column %)] urban areas rural areas 22 (81.5) 5 (18.5) 12 (70.6) 5 (29.4) 0.473 34 (77.3) 10 (22.7) employment status [n (column %)] employed unemployed retired 2 (7.4) 4 (14.8) 21 (77.8) 1 (5.9) 5 (29.4) 11 (64.7) 0.505 3 (6.8) 9 (20.5) 32 (72.7) * mann-whitney u-test was used for the comparison of age between men and women, whereas fisher’s exact test was used to test sex-differences regarding the distribution of place of residence and employment status. rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 5 the distribution of selected clinical characteristics of the patients included in this study is presented in table 2. the prevalence of glaucoma was considerably and significantly higher in men than in women (67% vs. 24%, respectively, p=0.01). absolute glaucoma was found in 26% of men, but only in 6% of women, notwithstanding the lack of a statistically significant sex-difference in the distribution of glaucoma types (p=0.26), possibly due to the modest sample sizes. diabetic retinopathy was somehow more prevalent in women than in men (18% vs. 11%, respectively), whereas an opposite finding was noted for the presence of hypertensive retinopathy (6% vs. 11%, respectively). yet, none of these differences was statistically significant. the prevalence of cataract was higher in female patients compared with their male counterparts (18% vs. 7%, respectively), regardless of the lack of statistical significance (p=0.36). both macular oedema and papillary oedema were almost equally distributed in men and in women (22% vs. 18% and 4% vs. 6%, respectively). table 2. distribution of clinical characteristics in a sample of patients diagnosed with rvo during 2013-2016 in tirana, albania clinical characteristic men (n=27) women (n=17) p † total (n=44) glaucoma: no yes 9 (33.3)* 18 (66.7) 13 (76.5) 4 (23.5) 0.012 22 (50.0) 22 (50.0) glaucoma type: open angle closed angle secondary absolute 5 (18.5) 4 (14.8) 11 (40.7) 7 (25.9) 5 (29.4) 5 (29.4) 6 (35.3) 1 (5.9) 0.261 10 (22.7) 9 (20.5) 17 (38.6) 8 (18.2) diabetic retinopathy: no yes 24 (88.9) 3 (11.1) 14 (82.4) 3 (17.6) 0.662 38 (86.4) 6 (13.6) hypertensive retinopathy: no yes 24 (88.9) 3 (11.1) 16 (94.1) 1 (5.9) 0.999 40 (90.9) 4 (9.1) cataract: no yes 25 (92.6) 2 (7.4) 14 (82.4) 3 (17.6) 0.359 39 (88.6) 5 (11.4) macular oedema: no yes 21 (77.8) 6 (22.2) 14 (82.4) 3 (17.6) 0.999 35 (79.5) 9 (20.5) papillary oedema: no yes 26 (96.3) 1 (3.7) 16 (94.1) 1 (5.9) 0.999 42 (95.5) 2 (4.5) comorbidity: no yes 4 (14.8) 23 (85.2) 0 (-) 17 (100.0) 0.147 4 (9.1) 40 (90.9) type of comorbidity: hypertension diabetes both 14 (51.9) 7 (25.9) 6 (22.2) 9 (52.9) 3 (17.6) 5 (29.4) 0.761 23 (52.3) 10 (22.7) 11 (25.0) rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 6 * absolute numbers and the respective column percentages (in parentheses). † fisher’s exact test was employed to test sex-differences regarding the distribution of all clinical characteristics presented in the table. all female patients had comorbid conditions compared to 85% of their male counterparts (p=0.15). the prevalence of hypertension was almost identical in both sexes (52% in men vs. 53% in women), whereas the prevalence of diabetes was somehow higher in men than in women (26% vs. 18%, respectively) [table 2]. discussion this study provides evidence about the distribution of socio-demographic factors and the clinical profile of individuals diagnosed with rvo at primary health care services in tirana, the capital and the largest city in post-communist albania. essentially, the main findings of this study consist of a higher prevalence of glaucoma, hypertensive retinopathy and diabetes in men than in women. on the other hand, women exhibited a higher prevalence of diabetic retinopathy, cataract and comorbid conditions. it should be noted that there are no previous studies describing the socio-demographic factors and clinical characteristics of albanian patients with rvo. the incidence and prevalence of rvo will increase steadily in albania in line with the population aging. thus, according to the last census conducted by the albanian institute of statistics in 2011, the proportion of individuals aged 65 years and over increased to 11% (11). this gradual increase of the older population bears important implications for the heath care sector including also provision of more specialized care against visual impairment. several systemic risk factors for rvo are also associated with arterial thromboembolic events including myocardial infarction and cerebrovascular disease (12,13). from this perspective, it has been shown that the retinal blood vessels exhibit similar anatomic features and physiologic characteristics with cerebral vessels (1,14). based on this evidence, it has been convincingly argued that there might be an association between rvo and myocardial infarction and cerebrovascular disease occurrence (1,14). our study may have several potential limitations due to the sample size and, particularly, sample representativeness. from this point of view, the number of individuals involved in this study was small and was confined only to one of the eleven primary health care centres of the municipality of tirana. in addition, some individuals suffering from rvo might have not preferred to seek care in primary health services. instead, some patients might have preferred more specialized care which is available at the university clinic of ophthalmology as a part of the university hospital centre “mother teresa”, the only public hospital in tirana. also, some patients might have used private ophthalmology clinics which may currently provide better care in albania. based on these considerations, the representativeness of our study sample may be questionable and, therefore, our findings should not be generalized to the general population of tirana and the overall population of albania. instead, findings of this study should be interpreted with extreme caution. on the other hand, the diagnosis of patients with rvo in our study was based on standardized and valid instruments, similar to studies conducted elsewhere. nonetheless, we cannot entirely exclude the possibility of information bias related to socio-demographic data, in particular regarding the employment status of study participants. rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 7 in conclusion, notwithstanding some possible limitations, this study offers useful information about the distribution of socio-demographic factors and the clinical profile of primary health care users diagnosed with rvo in transitional albania, an under-researched setting. population-based studies should be carried out in the future in albania in order to determine the magnitude and occurrence of rvo in the general population. rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 8 references 1. zhong c, you s, zhong x, chen gc, xu t, 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health and what ihpa can contribute to its advancement in practice richard alderslade 1 , ainna fawcett-henesy 2 , maria ruseva 3 1 international health partnerships association, chair, scientific advisory committee; 2 international health partnerships association, member, scientific advisory committee; 3 international health partnerships association, member, management board. corresponding author: dr. maria ruseva, member, management board, international health partnerships association; address: bellmansgade 23, 7 tv., copenhagen 2100, denmark telephone: +45 22 500 664; e-mail: rusevamaria33@gmail.com alderslade r, fawcett-henesy a, ruseva m. on the perspectives of public health and what ihpa can contribute to its advancement in practice (editorial). seejph 2018, posted: 07 july 2018. doi10.4119/unibi/seejph-2018194 2 today’s health challenges are formidable. they include patterns of behaviour leading to increased mortality and morbidity from noncommunicable diseases; the rapid spread of infectious pathogens and the potential for global pandemics; national disasters, conflicts and mass population movements; antimicrobial resistance; urbanization, and the health impacts of climate change and environmental pollution. the sustainable development goals (sdgs) (1), the health 2020 european health policy framework (2), and the european action plan for the strengthening of public health capacities and services (eap-phs) (3) all make clear that development programmes should aim to improve health and well-being equitably. this means that government priorities, policies, and budgets should be health orientated, based on health impact assessment, and focused on sustainability. to achieve this, governments require a national health policy that emphasizes a multisectoral approach across all their actions and the whole of society. a focus is needed on “upstream” determinants of health if better outcomes and reduced inequities are to be realised. this needs an interconnected, horizontal and networked system of governance which is open, collaborative and consensual. public health practitioners should be able to work with complexity and to speak the language of other sectors and share their agendas. to respond to this new environment, eap-phs is a main pillar of health 2020. the ten essential public health operations (ephos), provide a common frame for the member states (below). they deal comprehensively with genetic, political, social and economic, environmental, commercial, cultural and health system determinants. the essential public health operations for europe (4) 1. surveillance of population health and well-being 2. monitoring and response to health hazards and emergencies 3. health protection including environmental, occupational, food safety and others 4. health promotion including action to address social determinants and health inequity 5. disease prevention, including early detection of illness 6. assuring governance for health and well-being 7. assuring a sufficient and competent public health workforce 8. assuring sustainable organizational structures and financing 9. advocacy, communication and social mobilization for health 10. advancing public health research to inform policy and practice today’s public health practice needs to tackle inequalities, promote equity in health, and work across sectors. modern public health needs to work in a horizontal and distributed way, identifying matters of public health concern which are ever changing. in particular, the european public health workforce needs substantial development in capacities and skills. while much progress has been made in countries with the implementation of the eap-phs and the ephos, facilitated by the who european regional office, the full potential of public health strengthening has certainly not yet been realised. with this in mind, in 2014 the international health partnerships’ association, (ihpa – www.ihpa.eu), was established to aim for a worldwide society where everyone lives in healthy alderslade r, fawcett-henesy a, ruseva m. on the perspectives of public health and what ihpa can contribute to its advancement in practice (editorial). seejph 2018, posted: 07 july 2018. doi10.4119/unibi/seejph-2018194 3 communities and the benefit of good health is equally accessible to all. the ihpa and its members are driven by this view of public health, using their expertise to promote and protect health and well-being, preventing ill-health and prolonging life, through the organized efforts of societies, of professionals, leaders and community-based groups. the ihpa members believe those who have the least deserve our best; hence it has a stubborn insistence that tomorrow’s world must be better than today’s. ihpa is committed to acknowledging diversity, equity, and inclusion. the association believes in the need for health improvement through the reduction of inequalities and inequities in health, better housing and access to employment. it understands the underlying causes of disparity and the way those factors influence all of us, as well as the communities we serve. it recognizes the role of the state, and the underlying socio-economic and wider determinants of health and disease. it has a deep understanding of the responsibility of individuals in their lifestyle choices, and the need for population surveillance and monitoring of specific diseases and risk factors. there have been many resounding statements and manifesto pledges – and broken promises. ihpa aims to give those pledges reality by achieving change for the public good. at the strategic level, ihpa advises public and private healthcare companies, government and international organizations about their business plans, strategies and policies. ihpa also works at local levels, where it believes that important improvements may often best be made. our work is centred on evidence, health intelligence and evaluation which we use to understand and promote better health and better value health care. ihpa, a non-governmental organization, works with governments and others to promote the right to health for all, to strengthen health systems and develop strategies that promote health, prevent disease and encourage healthy lifestyles. it seeks international contacts, partnerships with other organizations, assists its members and performs and supports research and development in its field. since its onset, the ihpa has placed all its capacities and services in support of european countries by working with and for the who regional office for europe on public health services, prevention and control of noncommunicable diseases, health promotion, and migration. ihpa has also worked with and for the see health network, a multi-governmental platform and organization of nine countries in south east europe. the efforts of the see governments and health sectors will be supported by the ihpa which has a wealth of capacities needed to support countries at national, community and grass-roots levels. on 1 st -2 nd april 2017, the ministers of the see health network and their international partners held their 4 th ministerial forum in chisinau, the republic of moldova (v). as a result, the fourth ministerial pledge was adopted, committing the nine countries to cooperate and work jointly towards achieving the sustainable development goals 2030 of the united nations, by implementing the newest european and global policies and best practices. implementing the policies to achieve the sdgs 2030 requires strong health systems and public health services. ihpa will join forces with the national public health and other health institutions as it is only through networking and learning from each other that practical results will be achieved. conflicts of interest: none. alderslade r, fawcett-henesy a, ruseva m. on the perspectives of public health and what ihpa can contribute to its advancement in practice (editorial). seejph 2018, posted: 07 july 2018. doi10.4119/unibi/seejph-2018194 4 references 1. https://sustainabledevelopment.un.org/post2015/transformingourworld (accessed: july 04, 2018). 2. the european health policy framework “health 2020” ,who europe, 2013. http://www.euro.who.int/__data/assets/pdf_file/0011/199532/health2020-long.pdf (accessed: july 04, 2018). 3. european action plan for strengthening public health capacities and services, who europe, 2012. http://www.euro.who.int/__data/assets/pdf_file/0005/171770/rc62wd12rev1-eng.pdf (accessed: july 04, 2018). 4. the 10 essential public health operations (epho) for europe were endorsed by all 53 european member states’ ministers of health during the 62 nd session of the who europe regional committee. http://www.euro.who.int/en/health-topics/health-systems/publichealth-services/policy/the-10-essential-public-health-operations (accessed: july 04, 2018). 5. report of the fourth south-eastern europe health ministerial forum on “health, well-being and prosperity in south-eastern europe by 2030 in the context of the 2030 agenda for sustainable development”. http://seehn.org/report-of-the-fourth-south-eastern-europehealth-ministerial-forum-on-health-well-being-and-prosperity-in-south-eastern-europeby-2030-in-the-context-of-the-2030-agenda-for-sustainable-dev/ (accessed: july 04, 2018). ______________________________________________________________________________________ © 2018 alderslade et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. raport hyska j, mersini e, mone, i, bushi e, sadiku e, hoti k, bregu a. assessment of knowledge, attitudes and practices about public health nutrition among students of the university of medicine in tirana, albania (original research). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-01. 1 original research assessment of knowledge, attitudes and practices about public health nutrition among students of the university of medicine in tirana, albania jolanda hyska1,2, ehadu mersini1, iris mone2, entela bushi1, edite sadiku2, kliti hoti2, arjan bregu1 1 institute of public health, tirana, albania; 2 university of medicine, tirana, albania. corresponding author: jolanda hyska, md, phd, institute of public health; address: rr. “aleksander moisiu”, no. 88, tirana, albania; telephone: +355672052972; email: lhyska@yahoo.it hyska j, mersini e, mone, i, bushi e, sadiku e, hoti k, bregu a. assessment of knowledge, attitudes and practices about public health nutrition among students of the university of medicine in tirana, albania (original research). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-01. 2 abstract aim: the aim of this survey was twofold: (i): to assess medical students’ knowledge, attitudes and practices regarding nutrition in general, in order to identify their level of competences in the field of nutrition which will be useful in their future role of providers/health care professionals, and; (ii) to assess the knowledge, attitudes and practices regarding the discipline of public health nutrition in order to identify the needs for improving the curriculum of this subject in all the branches of the university of medicine in tirana. methods: a cross-sectional study was conducted in june-july 2013 including a representative sample of 347 students at the university of medicine in tirana, albania (61% females and 39% males; overall mean age: 23±2 years; response rate: 87%). a nutritional questionnaire, adopted according to the models used in previous international studies, was used to assess the level of knowledge, attitudes and practices among the university students. results: overall, about one third of the students was not satisfied with the quality and quantity of nutritional education and demanded a more scientifically rigorous curriculum. in general, students’ knowledge about infant feeding practices was adequate. however, there were gaps in the students’ knowledge regarding the commencement of breastfeeding, or the duration of exclusive breast-feeding. furthermore, there was evidence of an insufficient level of knowledge among students regarding diet and nutrition in general and their health impact, especially on development and prevention of chronic diseases. conclusion: this survey identified significant gaps in the current curriculum of public health nutrition at the university of medicine in tirana. our findings suggest the need for intervention programs to improve both the quantitative and the qualitative aspects of nutrition curricula in all the branches of the university of medicine tirana, in accordance with the professional expectations of this teaching institution, as well as the urge for a movement towards a more integrated curriculum and problem-based learning approach. keywords: albania, diet, knowledge, nutrition, students, university of medicine. hyska j, mersini e, mone, i, bushi e, sadiku e, hoti k, bregu a. assessment of knowledge, attitudes and practices about public health nutrition among students of the university of medicine in tirana, albania (original research). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-01. 3 introduction it is argued that the amount of nutritional education in the teaching curricula of different medical schools remains inadequate and does not meet the needs of this important area of health sciences (1,2). hence, many studies show that family physicians generally have little training in nutrition (3-5). furthermore, several studies have shown that the vast majority of medical students and incoming interns are dissatisfied with their education in medical nutrition and feel unprepared to counsel patients on nutritional topics (6-8). therefore, it is largely recognized that there is a critical need for improvements of teaching programs related to nutrition in medical schools and public health schools along with an increased education of the general population at large (9-11). public health nutrition is a discipline introduced already in all branches of the university of medicine in tirana, the albanian capital. however, there is no scientific evidence regarding the level of attitudes and knowledge in this field among the students at all levels and branches of this teaching institution in tirana, which is the only medical university in albania. in this context, the aim of this survey was twofold: (i): to assess medical students’ knowledge, attitudes and practices regarding nutrition in general, in order to identify their level of competences in the field of nutrition which will be useful in their future role of providers/health care professionals, and; (ii) to assess the knowledge, attitudes and practices regarding the discipline of public health nutrition in order to identify the needs for improving the curriculum of this subject in all the branches of the university of medicine in tirana. methods a cross-sectional study was conducted in june-july 2013 including a representative sample of 347 students at the university of medicine in tirana, the capital of albania. study population the study population consisted of a simple random sample of 347 students (out of 400 invited; response rate: 86.7%) of the university of medicine in tirana pertinent to the following branches: medicine (26.8%), nursing (32.9%), pharmacy (21.9%) and dentistry (18.4%). the sampling frame consisted of a list of all students who had undertaken a course on public health nutrition (280 medical students; 110 dentistry students; 108 pharmacy students; 312 nursing students). the response rate was somehow lower among the medical students (81.5%) compared with students from the other branches. on the other hand, the overall response rate was similar among male and female students. data collection a nutritional questionnaire, adopted according to the models used in previous international studies, was used to assess the level of knowledge, attitudes and practices among the university students. the first part of the questionnaire concerned the attitudes of the students about nutritional education in their respective faculties/schools. the attitudes were measured by means of an indicative scale from 1 to 5 regarding students’ concordance with several statements (1= strongly disagree; 5= strongly agree) (7). the second part of the questionnaire concerned the level of knowledge of the students about nutrition in general (4,5). hyska j, mersini e, mone, i, bushi e, sadiku e, hoti k, bregu a. assessment of knowledge, attitudes and practices about public health nutrition among students of the university of medicine in tirana, albania (original research). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-01. 4 data analysis spss (statistical package for social sciences) version 19.0 was used for data analysis. data were presented as frequency tables (for categorical variables) and as measures of central tendency (mean scores) [for numerical variables]. results overall, the survey sample included 136 (39.2%) male students and 211 (60.8%) female students (overall mean age: 22.8±2.1 years). students’ attitudes about their education in the discipline of nutrition overall, the students were somewhat satisfied with the quantity (mean score: 3.3; range from 1 [lowest] to 5 [highest]) and quality (mean score: 3.2) of the nutritional education in the course of their studies (table 1). students reported that more time should have been dedicated to the topic of nutrition at the university of medicine in tirana (overall mean score: 3.5), especially including more material relevant to the personal health and wellbeing (mean score: 3.8). conversely, students were quite neutral regarding the scientific rigor of the teaching curriculum (overall mean score: 2.9). table 1. students’ attitudes about their education in the discipline of nutrition students’ attitudes total (n=347) medicine (n=93) dentistry (n=64) pharmacy (n=76) nursing (n=114) i am satisfied with the quantity of my nutrition education. 3.26 2.69 2.81 3.47 3.83 i am satisfied with the quality of my nutrition education. 3.18 2.71 2.84 3.22 3.71 my medical school nutrition curriculum should have had more time specifically dedicated to the topic of nutrition (independent of organ system-based studies). 3.46 3.67 3.42 3.70 3.17 my medical school nutrition curriculum should have had more nutrition content formally integrated into the organ system-based courses. 3.38 3.91 3.36 3.21 3.07 my medical school nutrition curriculum should have included more online materials available for independent study. 2.90 3.32 2.52 3.05 2.67 my medical school nutrition curriculum should have included more material relevant to my personal health and wellbeing. 3.80 4.31 3.81 3.37 3.68 my medical school nutrition curriculum should have been more scientifically rigorous. 2.89 3.32 3.39 2.58 2.46 students of the faculty of medicine were the most unsatisfied group with regard to the quantity (mean score: 2.7) and quality (mean score: 2.7) of the information obtained in the nutrition course, considering that: • more time should be dedicated to the topic of nutrition in the course of their studies (mean score: 3.7); • more nutrition content should be formally integrated into the organ system-based courses (mean score: 3.9); • the curriculum should include more material relevant to personal health and well-being (4.3); hyska j, mersini e, mone, i, bushi e, sadiku e, hoti k, bregu a. assessment of knowledge, attitudes and practices about public health nutrition among students of the university of medicine in tirana, albania (original research). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-01. 5 • in addition, medical students felt that the teaching curriculum should be more scientifically rigorous (mean score: 3.3) [table 1]. however, almost similar attitudes were encountered among the students of the faculty of dentistry, but their mean scores were slightly higher compared to the students of the faculty of medicine. unlike the students of the faculty of medicine and dentistry, students of the faculty of pharmacy appeared to be more satisfied with the quantity (mean score: 3.5) and the quality (mean score: 3.2) of the nutritional education; nonetheless, they considered that more time should be dedicated to the topic of nutrition in the course curriculum (mean score: 3.7), but were generally satisfied regarding the scientific rigor of nutrition curriculum (mean score: 2.6). conversely, students of the faculty of nursing were the most satisfied group with regard to the quantity (mean score: 3.8) and quality (mean score: 3.7) of the nutritional education in their branch. their most obvious demand, however, was that more material relevant to personal health and wellbeing should be included in the teaching curriculum (mean score: 3.7) [table 1]. overall, about one third of the students was not satisfied with the quality and quantity of nutritional education and demanded a more scientifically rigorous curriculum. three out of four students demanded a more practical and useful curriculum regarding personal health and well-being; more than half of the students demanded an integrated curriculum into the organ system-based; and half of the students suggested that more time should be dedicated to the teaching curriculum independent of organ system-based studies (table 1). students’ knowledge about infant feeding practices overall, the level of students’ knowledge about infant feeding practices was satisfactory, as the percentage of correct answers for every question was in the range from 70%-92% (table 2). table 2. students’ knowledge on infant feeding practices item correct wrong don’t know according to who, the optimal duration for breastfeeding an infant is a minimum of twelve months. 71.8% 21.3% 6.9% infant formula contains all ingredients found in human breast milk. 1.4% 97.1% 1.4% infants consuming breast milk have fewer ear infections than infants consuming formula. 91.9% 4.6% 3.5% the percentage of wrong answers was higher among the students of the faculty of pharmacy, followed by the students of the faculty of dentistry (29.7% and 7.8% respectively). about 82% of the students knew “the most appropriate age to introduce other foods in the infant’s diet”, whereas one out of three students of the faculty of dentistry gave a wrong answer (data not shown). regarding the “commencement of breastfeeding”, 70% of the students did not know the recommended initiation of breastfeeding, which was especially apparent for students of the faculty of nursing and medicine (80% and 76%, respectively), although the nutrition curriculum of these two faculties regarding infant feeding practices is much more expanded than the other two faculties (data not shown in the tables). most of the students (about 77%) stated that exclusive breast feeding is important because “breast milk is the ideal food”, 10% of the students considered that “breastfeeding creates a hyska j, mersini e, mone, i, bushi e, sadiku e, hoti k, bregu a. assessment of knowledge, attitudes and practices about public health nutrition among students of the university of medicine in tirana, albania (original research). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-01. 6 physical/spiritual bond between mother and baby”, and 9% of the students believed that “breastfeeding protects the mother from pregnancy”. regarding the duration of exclusive breastfeeding, the opinion of the students was divided between the period of 6-9 months, and only 1.3% of the students considered that “breastfeeding should not be extended more than 1 month” (not shown). students’ knowledge on the health impact of diet and nutrients regarding the questions that aimed at assessing the students’ general knowledge about the health impact of diet and nutrients, students of the faculty of medicine, generally, exhibited the highest level of knowledge compared to the other branches (table 3). especially, medical students reported correctly on the following: “the nutrient that helps prevent thrombosis” (100%); “the nutrient closely related to the prevention of neural tube defects” (97%); “zinc is not an antioxidant” (87%); and “potassium has protective effect against hypertension” (75%). however, none of them knew that “excess proteins promote loss of ca”; “albanians are advised not to consume more than 30% fat” (8%); and “fruits and vegetables have a preventive role in the development of some types of cancer” (10%) [table 3]. table 3. students’ knowledge about diet and health item total* medicine* dentistry* pharmacy* nursing* a nutrient believed to help prevent thrombosis is: omega-3 fat 100 28.1 50 28.9 excess of which nutrient may increase body calcium loss? proteins 0 4.7 7.9 14 what is the type of dietary fiber helpful in lowering the blood cholesterol level? soluble fiber 67.7 42.2 28.9 15.8 the major type of fat in olive oil: monounsaturated fat 54.8 31.2 22.4 16.7 compared with unprocessed vegetable oil, hydrogenated fats contain: more trans fats 37.6 9.4 42.1 16.7 the nutrient is protective against hypertension potassium 75.3 14.1 44.7 45.6 if a person habitually consumes 10 tablets a day of vitamin mineral supplements, which nutrient is least likely to cause toxicity vitamin e 66.7 21.9 39.5 24.6 the most concentrated source of vitamin b12 is meat 43 6.2 18.4 31.6 which substance raises the blood hdlcholesterol level alcohol 41.9 9.4 17.1 22.8 nutrition recommendations for albanian recommends that the diet should contain the following percentage of energy as fat under 30% of daily energy 7.5 9.4 25 21.9 nutritional recommendations for albanian recommends that the diet should contain the following type and percentage of salt no more than 6 g iodized salt 44.1 3.1 19.7 37.7 a type of food believed to have a preventive effect on varioustypes of cancer is fruits and vegetables 9.7 34.4 57.9 41.2 the number of kilocalories in one gram of fat is 9 kkal 100 96.9 96.1 94.7 which of the following is not an antioxidant nutrient zinc 86 46.9 80.3 48.2 the nutrient strongly associated with the prevention of neural tube defects is folate 96.8 73.4 77.6 71.1 * percentages of correct answers. hyska j, mersini e, mone, i, bushi e, sadiku e, hoti k, bregu a. assessment of knowledge, attitudes and practices about public health nutrition among students of the university of medicine in tirana, albania (original research). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-01. 7 discussion our findings indicate that students of the university of medicine in tirana are not sufficiently satisfied with the quantity and quality of the knowledge obtained on public health nutrition, demanding more time to be dedicated to the topic of nutrition in the undergraduate curriculum including especially more material relevant to personal health and wellbeing. such requirements and demands were more pronounced among students of the faculty of medicine and dentistry. students’ knowledge about infant feeding practices were relatively satisfactory among the students of the faculty of medicine, and less so among students of the other faculties. however, there were also apparent gaps in the knowledge of medical students regarding the commencement of breastfeeding, or the duration of exclusive breastfeeding. our findings in this regard are compatible with previous reports from studies conducted elsewhere (12-14). regarding students’ general knowledge about diet and its impact on the development or prevention and treatment of diseases, especially of chronic diseases, it was often encountered an overrated concept about the role/influence of the dietary fat and individual health, suggesting insufficient knowledge among students regarding the specific role and impact of carbohydrates and proteins. similar findings have been previously reported in the uk (13,14), canada (15,16) and the usa (17). on the other hand, students included in the current survey did not have updated information regarding the “albanian recommendations for a healthy nutrition”, which points to the need for case-based teaching, and updated scientific rigor. overall, the current survey identified gaps in the current curriculum of public health nutrition which suggests the need for appropriate changes and amendments to the curriculum in all the branches of the university of medicine in tirana (general medicine, public health, nursing, pharmacy and dentistry). from this perspective, our study provides useful baseline information which should be eventually used to close the knowledge and competence gaps in the current teaching and training programs offered by the university of medicine in tirana. in addition, the assessment of knowledge, attitudes and practices of the students on nutritional aspects in general is a basic precondition for understanding their competences and roles as future health care providers and health professionals, hence, evaluating healthy nutrition as an important element in the prevention and treatment of a number of non-communicable diseases which are currently highly prevalent in albania (5,18). from this point of view, our study makes a useful contribution in the albanian context. in conclusion, our study suggests the need for intervention programs to improve both the quantitative and the qualitative aspects of nutrition curricula in all the branches of the university of medicine tirana, in accordance with the professional expectations of this teaching institution, as well as the urge for a movement towards a more integrated curriculum and problem-based learning approach. acknowledgements this survey was supported by the world health organization (tirana 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http://www.ncbi.nlm.nih.gov/pubmed/10067655 http://www.medalb.com/gazeta/medicus17.pdf http://www.ncbi.nlm.nih.gov/pubmed?term=ray%20s%5bauthor%5d&cauthor=true&cauthor_uid=22327628 http://www.ncbi.nlm.nih.gov/pubmed?term=udumyan%20r%5bauthor%5d&cauthor=true&cauthor_uid=22327628 http://www.ncbi.nlm.nih.gov/pubmed?term=rajput-ray%20m%5bauthor%5d&cauthor=true&cauthor_uid=22327628 http://www.ncbi.nlm.nih.gov/pubmed?term=thompson%20b%5bauthor%5d&cauthor=true&cauthor_uid=22327628 http://www.ncbi.nlm.nih.gov/pubmed?term=lodge%20km%5bauthor%5d&cauthor=true&cauthor_uid=22327628 http://www.ncbi.nlm.nih.gov/pubmed?term=douglas%20p%5bauthor%5d&cauthor=true&cauthor_uid=22327628 http://www.ncbi.nlm.nih.gov/pubmed/?term=sumantra+ray%2c+ruzan+udumyan%2c+minha+rajput-ray%2c+ben+thompson http://www.nutritionj.com/sfx_links?ui=1475-2891-4-2&bibl=b1� http://www.biomedcentral.com/sfx_links?ui=1472-6920-11-58&bibl=b14� http://www.biomedcentral.com/sfx_links?ui=1472-6920-11-58&bibl=b13� http://www.nutritionj.com/sfx_links?ui=1475-2891-4-2&bibl=b2� tozija f, lizana t. migrant health policy in european union (eu) and non eu country: current situation and future challenges for improvement (original research). seejph 2020, posted: 16 march 2020. doi: 10.4119/seejph-3369 p a g e 1 | 11 original research migrant health policy in european union (eu) and a non eu country: current situation and future challenges for improvement fimka tozija1, tona lizana2 1 institute of public health of republic of north macedonia, medical faculty, sts cyril and methodius university, skopje, republic of north macedonia; 2 public health agency of catalonia, barcelona, spain. corresponding author: fimka tozija, md, phd; address: 50 divizija no 6, 1000 skopje, republic of macedonia; telephone: +38970248619; e-mail: ftozija@t-home.mk tozija f, lizana t. migrant health policy in european union (eu) and non eu country: current situation and future challenges for improvement (original research). seejph 2020, posted: 16 march 2020. doi: 10.4119/seejph-3369 p a g e 2 | 11 abstract aim: the influx of refugees, asylum seekers and migrants in europe is an ongoing reality and migrant health has become very important public health problem. the aim of this paper is to analyze and compare the health profile, migrant situation and migration integration health policy in spain as a european union (eu) country and republic of north macedonia as a country in process of european union accession. methods: migration integration policy index (mipex) health strand questionnaire (2015) was applied to compare health policies for migrant integration in both countries. results: there are differences between spain and macedonia in health care coverage and access to health services for migrants. spain has health strand total score of 52 and is in the same group with austria, ireland, belgium, netherlands, denmark and sweden. macedonia has lower health strand total score 38 and is in the same group with turkey, cyprus, slovakia. targeted migrant health policies are stronger and services more responsive in spain compared to macedonia which offers migrants legal entitlements to healthcare, but health services should be more culturally responsive to migrant health needs. conclusion: health migration policy in both countries is closely tied to the general immigration policy. keywords: health, integration policy, migrant, mipex. conflicts of interest: none declared. tozija f, lizana t. migrant health policy in european union (eu) and non eu country: current situation and future challenges for improvement (original research). seejph 2020, posted: 16 march 2020. doi: 10.4119/seejph-3369 p a g e 3 | 11 introduction the influx of refugees, asylum seekers and migrants into the european region is an ongoing reality that will affect european countries, with security, economic and health implication. the number of refugees and migrants entering european states is increasing, driven by the wars in syria, iraq, afghanistan, eritrea and elsewhere. it is estimated that 75 million international migrants live in the european region, which is 8.4% of the total european population and one third of all international migrants worldwide. over 1 million refugees and migrants entered the european region in 2015. since 2013, the numbers of refugees and migrants crossing the mediterranean has increased significantly. more than 3,700 refugees drowned in the mediterranean sea (1). increases in arrivals have also been recorded in greece and spain. unhcr data shows that 63,311 migrants have risked their lives reaching europe by sea in 2019 (1,028 drowned in the sea). there are 5,690 sea arrivals registered so far in 2020, including refugees and migrants arriving by sea to italy, greece, spain, cyprus and malta and 1,152 land arrivals including refugees and migrants arriving by land to greece and spain (2). eu states without external borders need to accept far larger numbers of refugees who landed in the southern european member states (3). figure 1. immigration and european migrant crisis 2015 (source: http://geoawesomeness.com/wp-content/uploads/2017/03/map_of_the_ european_migrant_crisis_2015.png) http://geoawesomeness.com/wp-content/uploads/2017/03/map_of_the_%20european_migrant_crisis_2015.png http://geoawesomeness.com/wp-content/uploads/2017/03/map_of_the_%20european_migrant_crisis_2015.png tozija f, lizana t. migrant health policy in european union (eu) and non eu country: current situation and future challenges for improvement (original research). seejph 2020, posted: 16 march 2020. doi: 10.4119/seejph-3369 p a g e 4 | 11 the integration of the schengen area and the recent conflicts in the middle east increased the concentration of immigrants and refugees seeking better life chances in the european union (eu), due to the ease movement between the countries. the european union is home to around 1 million recognized refugees. the most attractive eu countries for asylum seekers that are hosting the most refugees are france, germany, united kingdom, sweden and italy. in 2008 eu member states signed the european pact on immigration and asylum (4), which was intended to be the basis for european union immigration and asylum policies in a spirit of mutual responsibility and solidarity between member states and a renewed partnership with non-eu countries. many asylum-seekers and refugees move and face difficulties in applying for asylum at borders, inadequate or insufficient reception conditions, or a lack of local integration prospects (1). underlying causes of refugee movements need to be tackled and eu states need to implement their global health strategies (5). spain, due to its geographical position, between the atlantic ocean, the mediterranean sea and its proximity to africa, is a destination point for immigrants and refugees from africa, to reach other countries in the northern part of europe, mainly germany. since 2000 spain has had one of the highest rates of immigration in the world, coinciding with a period of remarkable economic expansion. this influx began to decline rapidly after 2007 as the economy began to slow down. in 2015, 291,387 people immigrated to spain, thus increasing foreign population to 4,454,353, coming mainly from romania, morocco, italy, the united kingdom and venezuela (6). according to unhcr, in 2016, 59.5% of immigrants and refugees arrived by sea (2). in spain, the concentration of the immigrant population is in the autonomous communities of madrid, catalonia and valencia. in catalonia, 15.3% of the total population in 2016 was foreigners, mostly immigrants from morocco, romania and ecuador, with a mean age of 32.2 years and 111 men per 100 women. in catalonia there are 21% of the total number of foreigners in spain and 27% of the total non-eu population in spain (7). the immigration process in the republic of north macedonia (macedonia further in the text) is quite different than in spain. macedonia, largely a country of emigration, has become a country of transit and permanent immigration, experiencing several refugee crises. migrant health became serious public health problem in macedonia, as in other european countries with the migrant influx in 2015. there has been a notable growth of transit and illegal migration in macedonia from greece in 2015 mainly from syria, afghanistan, pakistan and iraq, and given the geographic position of the country, there is a high likelihood of further growth of such migratory developments. according to unhcr 747,240 refugees left the country from july 1st 2015 (up to 10,000 refugees daily). since september 2015, the proportion of women and children transiting the western balkans route has progressively increased to more than 50% (2). the aim of this paper is to analyze and compare the health profile, migrant situation and migration integration health policy in spain as a european union (eu) country and republic of north macedonia as a country in process of european union accession. tozija f, lizana t. migrant health policy in european union (eu) and non eu country: current situation and future challenges for improvement (original research). seejph 2020, posted: 16 march 2020. doi: 10.4119/seejph-3369 p a g e 5 | 11 methods migration integration health policy was compared in eu and non eu country, applying migration integration policy index (mipex) health strand as the most comprehensive and reliable tool. mipex was first published in 2004 as the european civic citizenship and inclusion index. there are 167 policy indicators on migrant integration in the mipex designed to benchmark current laws and policies against the highest standards in 8 policy areas, with 4 dimension scores for each area per country (8). health strand is a questionnaire designed to supplement the existing seven strands of mipex, which in its edition (2015) (9) monitors policies affecting migrant integration in 38 different countries. the health strand questionnaire is based on the recommendations on mobility, migration and access to health care adopted by the council of europe in 2011, which were based on a consultation process that lasted two years and involved researchers, intergovernmental organizations, nongovernmental organizations and a wide range of specialists in health care for migrants. the questionnaire measures the equitability of policies relating to four issues: migrants’ entitlements to health services; accessibility of health services for migrants; responsiveness to migrants’ needs; and measures to achieve change. mipex health strand survey was part of the equihealth project carried out by the international organization for migration (iom) from 2013 to 2016, in collaboration with the migration policy group (mpg) and cost action is1103, adapting european health services to diversity (adapt). mipex health strand study was conducted in all 38 countries, as well as bosnia and herzegovina and macedonia. data collection was organized by the iom, while experts and peer reviewers responsible for completing the health strand questionnaire were members of adapt. results from mipex 2015 health strand were analyzed. desk review was done on strategic documents, legislation, reports and studies for both countries. results health profiles the political and economic processes have brought new lifestyles to the society influencing the health of the population as well; new disease patterns emerged, with the non-communicable and chronic diseases taking over the lead in morbidity and mortality trends. when compared the basic health indicators for both countries it is obvious that the health of population in spain is much better than in macedonia, with 6 years longer life expectancy, lower rate of infant mortality, lower sdr of diseases of circulatory system, lower rate of tb incidence etc (10). this is directly correlated with the economic situation in the countries, spain is high income country with more than twice higher gross national income per capita (11) than macedonia an upper middle income country and higher total health expenditure 9% of gdp in spain compared to 6.5% in macedonia, despite the impact of the 2008 economic crisis. in macedonia noncommunicable diseases and injuries are generally on the rise, while communicable, maternal, neonatal, and nutritional causes of dalys are generally on the decline. cerebrovascular disease, ischemic heart disease and lung cancer were the three leading causes of premature death in 2015, followed by cardiomyopathy and diabetes (12). migration integration health policy migration in spain is regulated by the organic law 4/2000 on the rights and freedoms of foreigners in spain and its tozija f, lizana t. migrant health policy in european union (eu) and non eu country: current situation and future challenges for improvement (original research). seejph 2020, posted: 16 march 2020. doi: 10.4119/seejph-3369 p a g e 6 | 11 social integration (13). royal decree 240/2007 (14) makes the schengen treaty effective by containing freedom of movement for community citizens. in order to respond to the common european asylum system, law 12/2009 on the right of asylum and subsidiarity is created (15). spain is a member of the european union, so the right to health is protected with the charter of fundamental rights of the eu (16) and the universal declaration of human rights (1948) (17). at the national level, the right to health is regulated by act 14/1986 (18), with which all spanish and foreign citizens in the spanish territory have the right to health with the following characteristics: universal coverage, free services, public financing, high quality and comprehensive care. the reforms of the spanish constitution gave the autonomous communities some competences such as health planning, public health and health care. autonomous communities have the ability to manage public services and special programs for asylum seekers and foreigners (reform of the organic law of 2/2009) (19). since 2000, catalonia has been supporting and formalizing its migration competencies with the creation of the secretariat for immigration. the national pact for immigration integrated the efforts of the different catalan sectors that work on public policies of social integration (20). law 10/2010 (21) stipulates an annual report on the state of integration of immigration while the citizenship and migration plan 2016, considers the implementation of programs (22). from its establishment in 1981, the pillars of the catalan health system have been universal coverage, comprehensive health service basket and gate keeping model. it is funded by taxes and offers almost universal access to health services, free at the point of delivery, based on act 15/1990 or health ordinance of catalonia (23). macedonia has ratified the main united nations conventions, contributed to establishing integration policies with respect for cultural and social differences, human rights and dignity. with the overall mipex score of 44/100 (8) the country’s policies for societal integration is just below the european average and slightly better than other countries in the region, such as serbia, bosnia and herzegovina, croatia and bulgaria (24). the macedonian government adopted the first national strategy on integration of refugees and foreigners 20082015 (25) and the national plan of action (26), providing a national policy framework across sectors relevant to support the refugee integration. health care is a guaranteed universal right for citizens in macedonia (27, 28), and is financed by the compulsory health insurance and from the central budget through the ministry of health vertical programs. compulsory health insurance is based on solidarity, equity and equality providing universal coverage with basic benefit package to all insured persons and is defined by the health insurance law (29). foreigners (or legal migrants) in macedonia are covered by the same risk-sharing system for health care, but are subject to additional requirements such as permission to stay and paid employment. entitlement to health services including right to health insurance is regulated with law on foreigners (30) and with the health insurance law (29). migrants with access to compulsory health insurance are obliged to pay co-payments at the same level as nationals. asylum seekers are covered by the same system as nationals, with no additional requirements and no forms of care excluded. health care of asylum seekers is regulated tozija f, lizana t. migrant health policy in european union (eu) and non eu country: current situation and future challenges for improvement (original research). seejph 2020, posted: 16 march 2020. doi: 10.4119/seejph-3369 p a g e 7 | 11 with law on asylum and temporary protection (31), law on international and temporary protection (32) and health insurance law, and costs for the health insurance are covered by the ministry of labour and social policy. undocumented migrants have no access to the same system as nationals: private insurance or payment of full costs of the services is required. emergency care in life threatening situations should be delivered (documentation should be provided later). migrants that entered the country illegally are transferred to the transition centre of the ministry of interior and the costs for health services are paid by the government. if they seek asylum they become asylum seekers and are being transferred to asylum reception centre and have the same entitlements to health care as asylum seekers. although the law may grant migrants certain entitlements to healthcare coverage, administrative procedures often prevent them from exercising this right in macedonia. there are differences in migration integration policy between countries in europe in health as in other strands (9). the lowest total mipex health strand score in europe is in latvia 17, while the highest is in switzerland 70. spain has health strand total score of 52 and is in the same group with austria, ireland, belgium, netherlands, denmark and sweden. macedonia has lower health strand total score 38 and is in the same group with turkey, cyprus, slovakia (figure 2) (33). figure 2. mipex 2015 health strand total scores in europe (source: summary report on the mipex health strand and country reports) (33) tozija f, lizana t. migrant health policy in european union (eu) and non eu country: current situation and future challenges for improvement (original research). seejph 2020, posted: 16 march 2020. doi: 10.4119/seejph-3369 p a g e 8 | 11 in spain there are immigrant shelter centres responsible for providing social services and temporary shelter to immigrants and asylum seekers. the beneficiaries have access to health services, psychological support, legal services, training and recreation activities. however, they are only found in the two most important entry points, ceuta and melilla. in spain, act 16/2012 (34) denies the right to health of irregular migrants. irregular immigrants are only entitled to receive emergency health care, assistance in pregnancy and childbirth, health care for children under 18 years. the government of macedonia as a response to the migrant crisis in 2015 changed the legislation on june 19th 2015 providing free health services for all registered migrants, national coordination body was formed, technical expert group established, migrant action plan adopted and two transit centers opened at the borders with greece and serbia. the following problems were faced in macedonia during migrant crisis: huge number of undocumented migrants particularly upon arrival at entry points, no resources such as interpreters, intercultural mediators, communication problems between migrants and health care personnel and administrative staff (24). discussion migration exposes people to vulnerable situations and their health is related to different determinants: individual (behaviour, genetic factors, age, and gender), environmental factors (physical, economical, social and cultural) and health services (availability, accessibility and quality). migrant children and mothers are the most vulnerable and they require access to special protection and care (24). migrant health is very important and longoverdue issue in eu member states and of special concern is potential widening of the health gap between migrant and host populations. variation of national migration integration policies for entitlements to health services in european countries is a barrier to health care for refugees, asylum seekers and especially for un-documented migrants (35). health systems need to be responsive to the migrant health needs and cultural differences such as concept of health and disease, felt and expressed health needs, language barriers, etc. migrants arriving on european union territory should be treated in a responsible and dignified manner and the need for accessible health services is more than obvious (36). there are differences between spain and macedonia in health care coverage and access to health services for migrants. spain has relevant regulations for immigrants, refugees and international protection, but also regulations that guarantee basic human rights, such as the right to health. targeted migrant health policies are stronger and services more responsive in spain as a country with greater wealth (gdp), compared to macedonia which offers migrants legal entitlements to healthcare, but still more efforts should be undertaken to adapt services to their needs. effective health care delivery to migrant and minority groups is compromised by the absence of culturally sensitive health services in macedonia. no resources such as interpreters, cultural mediators (there are only roma mediators), health and social care professionals trained on multicultural approaches are available in macedonia. strategies and policies are relatively new in macedonia, along with the fact that such strategies are also subject to constant upgrade to the level of eu requirements (1) due to their wide socioeconomic impact and replaced migration developments. although government has taken commendable action to establish the necessary services, the tozija f, lizana t. migrant health policy in european union (eu) and non eu country: current situation and future challenges for improvement (original research). seejph 2020, posted: 16 march 2020. doi: 10.4119/seejph-3369 p a g e 9 | 11 country has limited resources and requires support. there is a need to invest more, and sooner, in the health care to address migrants' specific health needs. the integration of migrants into their host societies promotes equal opportunities for migrants and nationals (37), thereby fostering economic development in countries of origin and destination (38). limitations migrant integration health policy has been analyzed only in two countries, spain 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2009. overcoming barriers: human mobility and development. new york, usa; 2009. 38. ooms g, hammonds r. global constitutionalism, responsibility to protect, and extra-territorial obligations to realize the right to health: time to overcome the double standard (once again). int j equity health 2014;13:68. doi:10.1186/s12939-014-0068-4. ______________________________________________________________________________________ © 2020 tozija et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.boe.es/diario_boe/txt.php?id=boe-a-2012-5403 https://www.boe.es/diario_boe/txt.php?id=boe-a-2012-5403 https://publications.iom.int/books/international-migration-health-and-human-rights https://publications.iom.int/books/international-migration-health-and-human-rights https://publications.iom.int/books/international-migration-health-and-human-rights https://www.researchgate.net/deref/http%3a%2f%2fdx.doi.org%2f10.1007%2fs00038-015-0689-4?_sg%5b0%5d=hy6nod3dy8-oyv3iqoag9u6v7lkej9acaff1nub1ndgukculoi06k82lz9d9wragps_qwb3chcbbngg_9vlbgyl7gq.cqva9suvbm8dvuswqqjldj2cdbx3qshb1ucpiwts61qdasowx8ql4hw4tyfai3tupsw4thvihknpgs6v0dvupg https://doi.org/10.1186/s12939-014-0068-4 brownell p. future directions for research on neglect, abuse and violence against older women (editorial). seejph 2019, posted: 19 february 2019. doi 10.4119/unibi/seejph-2019-205 page 1 of 8 e d i t o r i a l future directions for research on neglect, abuse and violence against older women patricia brownell1 1 fordham university, new york city, new york, usa. corresponding author: patricia brownell, phd, lmsw – associate professor emerita of social service, fordham university, new york city, new york, usa. brownell p. future directions for research on neglect, abuse and violence against older women (editorial). seejph 2019, posted: 19 february 2019. doi 10.4119/unibi/seejph-2019-205 page 2 of 8 the elder abuse field has developed significantly since its inception as a field of practice along with gerontology in the 1970s. research on elder abuse evolved later, stimulated by the work of the late rosalie wolf, considered a founder of the elder mistreatment field (1). much of this work has been interdisciplinary, with medicine, law, nursing, psychiatry and social work collaborating, as well as sociology. as a result, important research initiatives have significantly broadened our understanding of prevalence, and other dimensions of elder abuse, within aging and vulnerable adult frameworks. however, some aspects of elder abuse remain underdeveloped and open for further exploration. feminist perspective/domestic violence much work still needs to be done to bring elder abuse into the domestic violence field. feminist scholars particularly in the disciplines of sociology, social work and psychology in the 1980s and 1990s began to consider elder abuse within a feminist perspective (2). some limited intervention research on elder abuse in this frame was initiated (3,4). feminist gerontology has also been developing as a perspective (5). coming out of social gerontology and critical theory, this perspective seeks to focus on gender relations in gerontology and builds on the pioneering work of mary brickerjenkins and feminist social work practice (6). bringing elder abuse within the domestic violence framework has resulted in increased understanding of why older women have been invisible as victims and survivors of intimate partner abuse (7). some novel research methodologies have emerged from the european union (8) and the world health organization (9) in examining prevalence of abuse experienced by older women. another direction that has yet to be fully explored in the elder abuse literature with respect to older women and abuse is that of the application of complex trauma to an understanding of neglect, abuse and violence against women in later life (1015). life course perspective bringing a life course trauma-focused perspective may also address another gap in the literature on older women and abuse: the failure of gerontology and the vulnerable adult fields to focus on older women and abuse in spite of evidence that abuse is more prevalent for women of all ages, compared with men; and the failure of the domestic violence field to include women above the age of 49 in prevalence studies and to relegate older women in an “other” category (susan b. somers, president, international network for the prevention of elder abuse, personal communication, january 5, 2019). to place elder abuse within the field of family violence, we need to move beyond a siloed approach to understanding abuse only as child abuse (vulnerable dependent) and spouse/partner abuse (reproductive age women as victims/survivors). these siloes when applied to elder abuse have resulted in a misunderstanding of older adults as frail care dependent victims or as experiencing negligible intimate partner violence in later life. it has also obscured an identified risk factor in elder abuse: abuse experienced earlier in the lifespan of elder abuse victims (16). trauma-informed care only very recently has trauma been considered a factor in elder abuse (14,17). social work is a leading profession that has placed trauma-focused care as a practice model in the fields of child abuse and spouse/partner abuse. however, the medical model dominating elder abuse has resulted in a lack of understanding of the role of trauma in elder abuse. both feminist gerontology and a life course brownell p. future directions for research on neglect, abuse and violence against older women (editorial). seejph 2019, posted: 19 february 2019. doi 10.4119/unibi/seejph-2019-205 page 3 of 8 perspective require a feminist perspective and an understanding of domestic violence as part of the life course. while theory has laggedobservation, a growing body of research has identified a correlation between abuse early in the lifespan and elder abuse (16,18). this required challenging the ageist bias in the field of domestic violence, as well as the wellmeaning but misguided effort to address a perceived sexist bias in gerontology research by applying a gender neutral lens (19). practitioners and researchers are beginning to develop and assess trauma-focused interventions and care. among promising models include psycho-educational support groups, groups promoting spirituality among older women who have experienced familial abuse, and interventions intended to target depression and abuse (4,20,21). acknowledgement of trauma as a central factor in abuse for girls and women of all ages not only provides an explanatory framework for what has been identified as a risk factor for elder abuse, experiencing abuse as a child, but can also provide a practice framework for interventions across the lifespan. it also has the potential for integrating older women into a life course perspective on neglect, abuse and violence against girls and women: older women are too often relegated to an “other” category as though old age renders older women gender neutral (see susan b. somers, above). interventions for children who have experienced abuse, as well as younger women who are victims of domestic violence, may mitigate against vulnerability to abuse in later life as older women. also, interest in unresolved trauma in later life has led to models of intervention that can begin to address late life trauma or earlier unresolved trauma. theoretical advances in understanding neglect, abuse and violence across the life course the field of elder abuse research has been hampered by lack of a unifying theory that explains abuse of older adults in domestic settings (22). this is also the case for understanding neglect, abuse and violence against older women from a life course perspective, and in explaining how abuse experienced in childhood can be a risk factor for abuse in later life. an understanding of trauma across the life course provides one framework for conceptually linking abuse experienced earlier in life to risk of late life abuse (23). research has found that the effects of childhood trauma may persist or surface intermittently with mental or physical effects that include continued revictimization (24). early life trauma has been associated with later life physical and mental health problems; in addition, the broad scope of early traumatic experience is also evident in risk behavior studies. one comprehensive literature review found that the correlates and consequences of childhood trauma on later life consequences is compelling (25). the effects of early trauma can be life-course persistent and negatively affect the wellbeing of individuals, families and communities. understanding this from a life course perspective can help to identify multiple points of intervention, with trauma-informed research and practice models. childhood trauma effects can persist into old age (26). the adverse childhood experiences (ace) study conducted by kaiser permanente in california has found that the more adverse experiences subjects reported experienced in childhood, the more difficulties they reported encountering in later life (27). in addition, brownell p. future directions for research on neglect, abuse and violence against older women (editorial). seejph 2019, posted: 19 february 2019. doi 10.4119/unibi/seejph-2019-205 page 4 of 8 older women who report interpersonal violence earlier in their lives experience adverse cumulative emotional and health symptoms that affect wellbeing later in life (28,29). lifetime prevalence of gender-based violence in women and the relationship with mental disorder and psychosocial functioning is often overlooked in prevalence studies of neglect, abuse and violence against older women (30). survey questions about interpersonal abuse within the past year or even five years might lead to misleading conclusions that older women experience minimal if any genderbased violence compared to younger ones, when in fact abuse experienced earlier in life can continue to be vividly experienced in late life as well. complex trauma and relevance to abuse in later life individuals with a history of interpersonal trauma rarely experience only a single traumatic event, and may have experienced exposure to sustained, repeated or multiple traumas: this has been proposed to lead to a complex symptom presentation that includes not only posttraumatic stress symptoms but also those predominately in affective and interpersonal domains (31). this is known as complex trauma, a type of trauma that occurs repeatedly and cumulatively and within specific relationships and contexts (32). while initially thought to be related to child abuse, including child sexual abuse, the expanded understanding now extends to all forms of domestic violence, including emotional abuse, and attachment trauma occurring with the context of family and other intimate relationships over extended periods of time (33,34). while complex trauma (developmental disorder for children) has been proposed as a diagnostic category for the dsm-5, to date it has not been accepted as a distinct diagnostic category (35). the 11th revision to the world health organization’s international classification of diseases (icd-11) does include complex post traumatic stress disorder (cptsd) as a diagnostic category distinct from ptsd (36). the icd-11 cptsd includes not only the three symptom clusters associated with ptsd (re-experiencing the trauma in the here and now; avoidance of traumatic reminders; and a persistent sense of current threat manifested by exaggerated startle and hypervigilance) but in addition three additional clusters, identified as disturbances in self-organization. these include affective dysregulation; negative self-concept; and disturbances in relationships (37). the basis of the concept of complex (developmental) trauma is attachment theory, originally formulated by bowlby (38). other clinicians and theorists began to examine the developmental timing of trauma exposure and emotional dysregulation in adulthood (39,40), the impact of the developmental timing of trauma exposure on ptsd symptoms and psychosocial functioning among older adults (10), and the relationship between childhood trauma and complex posttraumatic stress disorder symptoms in older adults (15). with a theoretical basis for understanding complex trauma from a developmental perspective, researchers and practitioners have begun to understand the links between childhood experiences of interpersonal trauma and abuse with experiences across the lifespan, including old age (14,17,31). as this understanding developed, intervention strategies evolved with gerontologists taking the lead in implementing and evaluating them (20). in addition, translational collaborations between researchers and clinicians have resulted in formulating clinical applications of the attachment framework (13) as well as designing phase-oriented clinical interventions (41). brownell p. future directions for research on neglect, abuse and violence against older women (editorial). seejph 2019, posted: 19 february 2019. doi 10.4119/unibi/seejph-2019-205 page 5 of 8 interventions for later life interpersonal victimization related to lifetime trauma history necessarily require cognitive capacity, access to treatment modalities with skilled practitioners, and motivation on the part of the victim, and may also require access to safe living alternatives and other community and social supports (42). cultural beliefs about the role of girls and women within the family, as well as perceived responsibilities of older mothers toward impaired adult children who are abusive (43,44), are salient, even without past histories of abuse. abuse of older women with dementia and/or severe physical care needs, particularly within care settings, requires different intervention strategies targeted to institutional or criminal justice remedies (45). however, for cognitively unimpaired victims living in the community who are struggling to resolve chronic abuse particularly as perpetrated by family members or trusted others, and who disclose a history of abuse as children and young adults, trauma focused interventions may be indicated. conclusion chronic interpersonal abuse experienced earlier in life, particularly if not within an enabling environment and if left unaddressed and unresolved, may predispose some victims to continued trauma during their lives, according to trauma-informed researchers (16,18). adoption of a public health framework to address trauma can assist researchers, practitioners and policy makers to develop a theoretically informed multi-faceted prevention and intervention strategy to address what is known as complex trauma (14). recently evolved methodologies for assessing, measuring (46,47) and treating this in older adults, including older adult victims of abuse, are beginning to make this feasible. conflicts of interest: none. references 1. bonnie rj, wallace rb. elder mistreatment: abuse, neglect, and exploitation in an aging america. washington dc: the national academies press; 2003. 2. nerenberg l. a feminist perspective on gender and elder abuse: a review of the literature; 2002. https://ncea.acl.gov/resources/docs/arch ive/feminist-perspective-ea-2002.pdf (accessed: september 24, 2018). 3. vinton l. a model collaborative project toward making domestic violence centers elder ready. violence against women 2003;9:1504-13. 4. brownell p, heiser d. psychoeducational support groups for older women victims of family mistreatment: a pilot study. j gerontol soc work 2006;46:145-60. 5. hooyman n, browne cv, ray r, richardson v. feminist gerontology and the life course. gerontol geriatr educ 2002;22:3-26. 6. bricker-jenkins m, hooyman nr (eds.). not for women only: social work practice for a feminist future. silver spring, md.: national association of social workers; 1986. 7. crockett c, brandl b, dabby fc. survivors in the margins: the invisibility of violence against older women. j elder abuse negl 2015;27:291-302. 8. luoma ml, koivusilta m, lang g, enzenhofer e, de donder l, verté d, et al. prevalence study of abuse and violence against older women: results of a multi-cultural survey in austria, belgium, finland, lithuania, and portugal (european report of the avow project). finland: national brownell p. future directions for research on neglect, abuse and violence against older women (editorial). seejph 2019, posted: 19 february 2019. doi 10.4119/unibi/seejph-2019-205 page 6 of 8 institute of health and welfare (thl); 2011. 9. garcía-moreno c, pallitto c, devries k, stöckl h, watts c, abrahams n. global and regional estimates of violence against women: prevalence and 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symptoms in older adults: a study of direct effects and socio-interpersonal factors as potential mediators. j trauma dissociation 2016;17:593-607. 16. acierno r, hernandez-tejada ma, anetzberger gj, loew d, muzzy w. the national elder mistreatment study: an 8-year longitudinal study of outcomes. j elder abuse negl 2017;29:254-69. 17. bright cl, bowland se. assessing interpersonal trauma in older women. j loss trauma 2008;13:373-93. 18. mcdonald l. the mistreatment of older canadians: findings from the 2015 national prevalence study. j elder abuse negl 2018;30:176208. 19. united nations (2013). neglect, abuse, and violence against older women. new york: department of economic and social affairs. https://www.un.org/esa/socdev/doc uments/ageing/neglect-abuseviolence-older-women.pdf (accessed: february 7, 2019). 20. bowland s, edmond t, fallot rd. evaluation of a spiritually focused intervention with older trauma victims. soc work 2012;57:73-82. 21. sirey ja, halkett a, chambers s, salamone a, bruce ml, raue pj, et al. protect: a pilot program to integrate mental health treatment into elder abuse services for older women. j elder abuse negl 2015;27:438-53. 22. jackson sl, hafemeister tl. understanding elder abuse: new directions for developing theories of elder abuse occurring in domestic settings. washington dc: u.s. department of justice: national institute of justice; 2013. 23. maschi t. draft policy statement – trauma informed care with elder abuse prevention and intervention: a “prescription’ for better health and well-being for elders and their families and communities. unpublished: institute for violence, abuse and trauma (ivat); 2015. 24. johannesen m, logiudice d. elder abuse: a systematic review of risk factors in community-dwelling elders. age ageing 2013;42:292-8. brownell p. future directions for research on neglect, abuse and violence against older women (editorial). seejph 2019, posted: 19 february 2019. doi 10.4119/unibi/seejph-2019-205 page 7 of 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psychosocial function. jama 2011;306:513-21. 31. cloitre m, stolbach bc, herman jl, kolk bv, pynoos r, wang j,et al. a developmental approach to complex ptsd: childhood and adult cumulative trauma as predictors of symptom complexity. j trauma stress 2009;22:399-408. 32. herman jl. complex ptsd: a syndrome in survivors of prolonged and repeated trauma. j trauma stress 1992;5:377-91. 33. courtois ca. complex trauma, complex reactions: assessment and treatment. psychother theor res pract train 2004;41:412-25. 34. riggs sa. childhood emotional abuse and the attachment system across the life cycle: what theory and research teach us. j aggress maltreat trauma 2010;19:5-51. 35. sar v. developmental trauma, complex ptsd, and the current proposal of dsm-5. eur j psychotraumatol 2011;2:1-9. 36. karatzias t, shevlin m, fyvie c, hyland p, efthymiadou e, wilson d, et al. evidence of distinct profiles of posttraumatic stress disorder (ptsd) and complex posttraumatic stress disorder (cptsd) based on 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february 2019. doi 10.4119/unibi/seejph-2019-205 page 8 of 8 treatment of structural dissociation in complex traumatization: overcoming trauma-related phobias. j trauma dissociation 2005;6:11-53. 42. solomon j. shelter: the missing link to a coordinated community response to elder abuse. new york: the harry and jeanette weinberg center for elder justice; 2019. 43. smith jr. expanding constructions of elder abuse and neglect: older mothers’ subjective experiences. j elder abuse negl 2015;27:32855. 44. smith jr. listening to older adult parents of adult children with mental illness. j fam soc work 2012;15:126-140. 45. ramsey-klawsnik h, teaster pb, mendiondo ms, marcum jl, abner el. sexual predators who target elders: findings from the first national study of sexual abuse in nursing homes. j elder abuse negl 2008;20:353-76. 46. elhai jd, gray mj, kashdan tb, franklin cl.which instruments are most commonly used to assess traumatic event exposure and posttraumatic effects: a survey of traumatic stress professionals. j trauma stress 2005;18:541-5. 47. widom cs, dutton ma, czaja sj, dumont ka. development and validation of a new instrument to assess lifetime trauma and victimization history. j trauma stress 2005;18:519-31. © 2019 brownell; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 1 original research geophagia: a cultural-nutrition health-seeking behaviour with no redeeming psycho-social qualities ishmael d. norman 1 , fred n. binka 2 , anthony h. godi 3 1 institute for security, disaster and emergency studies; 2 university of health and allied sciences, ho, vr, ghana; 3 department of biostatistics, school of public health, university of ghana, legon, accra, ghana. corresponding author: dr. ishmael d. norman, president and ceo, institute for security, disaster and emergency studies; address: sandpiper place no: 54/55, langma, cr, cantonments, accra, ghana; telephone: +233243201410; email: ishmael_norman@yahoo.com mailto:ishmael_norman@yahoo.com norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 2 abstract aim: we investigated if geophagia is restricted to only pregnant and lactating women in ghana. we also investigated if the key driver of geophagia is poverty and other sociocultural factors. methods: this analysis was part of a broader national study of resilience among the population of ghana (n=2,000). regional comparisons were made possible due to the stratified and random selection of representations that were similar in characteristics such as being urban or rural, ethnicity, religion and gender. results: it was found that geophagia was present among both females and males and was not restricted to pregnant and lactating women. geophagia was not driven by poverty or the lack of formal education or the presence of gainful employment. geophagia was practiced by both urban and rural residents irrespective of religious proclivities and devotion. the assertion that geophagia was an instinctive primordial response to gastro-intestinal disturbances was not sustained by the data in this study, although the literature review suggested such in calves and lambs. conclusion: in order to address the potential health threats posed by geophagia, the key cultural drivers need to be studied and understood. we also need to appreciate the shocks and stresses that create such desires. it is not a case of mental illness and it cannot be concluded that geophagia is driven by a psychiatric disorder. this paper would be disseminated to inform policy in ghana and beyond. keywords: food security, geophagia, ghana, poverty, psychiatric disorder, resilience, vulnerability. conflicts of interest: none. norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 3 introduction geophagia is the deliberate ingestion of soil or non-food substances (1,2). it is also known as pica (3). there are other types of the practice including pagophagia (ice eating), or coprophagia (feces eating) (4). it is practiced in the united states of america (5,6), in germany (7), turkey and other parts of asia (8-10), and in australia among the aborigines (11), as well as eastern africa (12), west africa (13) and in southern africa (14,15). the practice is now common in many nations of the world, irrespective of economic status due to migration and subsequent transfer of culture from one part of the world to the other (13). in other literature, geophagists are considered to have a psychiatric disorder (16). there are many studies on geophagia as a cultural-nutrition health-seeking behaviour for pregnant and lactating women. it may also be an instinctive response to gastro-intestinal disturbances (14). karaoglu et al. (2010) assessed nutritional anaemia in 823 pregnant women in an east anatolian province of turkey. in that study, they found anaemia (hb <11.0 gr/dl) prevalence in 27.1% of the respondents. of the anaemic cohort, 50% were deficient in iron, with another 35% being deficient in b12 (8). in a south african study conducted on calves and lambs on farms in the barkley west, postmasburg and vryburg districts of the northern cape and northwest province of the republic of south africa, geophagia had no relationship to pregnancy or lactation. the study found that suckling calves displayed an insatiable appetite for the mn rich soil and sometimes licked iron poles, which lead to severe constipation, dehydration and even death within a relatively short time. it was found that “lesions in the liver of the subjects can be attributed to a sub-acute to chronic form of manganese poisoning” from the soil eaten by the subjects. “the calves were situated in an area known as the ghaap plateau and have superficial outcrops of manganese-rich dolomitic or carboniferous rock of the reivilo formation. the soil on the affected farms contains numerous small round-to-ovoid black-grey mn rich carboniferous concretions ca. 1-10mm in diameter” (1). abraham, davies, solomon et al., (2013:1) have informed us that: “a review of the literature clearly indicates that geophagia is not limited to any particular age group, race, sex, geographic region or time period, though today the practice is most obviously common amongst the world‟s poorer or more tribally-oriented people and is therefore extensive in the tropics.” (13). in ghana, we are also informed by other researchers of the presence of geophagists (2,17). in the case of ghana, since vermeer’s research on geophagia in the 1970’s, not much appears to have been done on the topic. in almost three decades, only one paper appears to have been published on the topic by taye and lartey in 1999, although the focus was not entirely on the prevalence and incidence of the practice in the nation. that study researched “pica practice among pregnant ghanaians with particular emphasis on infant birth-weight and maternal haemoglobin level”. again, tayie in 2004, considered “the motivational factors and health effects of pica” in a select site (14). since then, other studies have been conducted elsewhere including that of kawai et al., 2009 and also young et al., 2010 which were carried out in tanzania, east africa. the kawai study considered “geophagy (soil-eating) in relation to anaemia and helminths infection among hiv-infected pregnant women in tanzania”. young focused on the “association of pica with anaemia and gastrointestinal distress among pregnant women in zanzibar, tanzania” (5,6). these studies, however, were conducted on selected communities in tanzania and did not truly represent the entire nation. although geophagia is a cultural-nutrition habit among pregnant and lactating women in many emerging economies, it appears that this is a common phenomenon among communities in sub-sahara africa and it is not limited to pregnant women. we seek to assess and document the prevalence of geophagia in a sample of 2,000 inhabitants in the population norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 4 of ghana in all of its ten administrative regions and to attempt to isolate the cultural underpinnings of this phenomenon. we would not delve into the medical, toxicological and psychiatric inquiry of geophagia on any particular group. none of the researches referred to, concentrated on the prevalence and incidence of the practice in the nations in which those researches were conducted. due to its originality, our work would contribute immensely in understanding the practice of geophagia, at least in ghana and the sub-region. the outcome would be truly representational of the nation, and would provide the baseline data for further research. the results would be analyzed and disseminated to inform policy on nutrition, mother to child transmission of lead and other substance poisoning, mother to child transmission of helminthes and other bacteria with the proximate cause to geophagia. methods sampling we were confronted with the difficulty of knowing beforehand the communities in ghana that practice geophagia. thus, targeting only the commonly known ones was not enough in determining the prevalence nationwide. targeting only pregnant women might also give a higher prevalence rate and limit the study just to them due to the practice’s wide association to pregnancy. we decided to target women of reproductive age in order to estimate the prevalence for a wider group. we also expanded this to include men since very little is known about the practice in men, although the practice is common in the generally known sites in ghana. in the end, we targeted pregnant women, women in general and men in order to estimate the prevalence for a wider group. we assumed 20% of persons in ghana practiced geophagia based upon a pilot study conducted in ashaiman, near tema municipality, ghana. this was part of a broader study on assessing the resilience of four communities within ghana and to identify the coping mechanisms to the observed effects of climate variability. this was done by asking respondents if they had ever willingly eaten earth or clay. the proportion who answered positively was used to estimate the prevalence. this yielded a sample size of 1,710 with 90% power to detect an effect size of 30% at 5% significance level. a sample size of 2,000 gave a reasonable degree of security against the effects of decline in response and a prevalence level closer to 50%. we randomly selected one or more district, municipality or metropolitan area from each of the ten regions (18). we randomly selected one or more communities from each of that and then used the random walk method to evaluate households within each community till the quota for the region was met (19). regional comparisons were made possible due to the stratified and random selection of representations. literature review and internet search for national standards on nutrition we searched through national legislation and grey paper to identify national food and nutritional guidelines or standards to evaluate if there is a nexus to geophagia. due to the paucity of literature on the subject, we were only able to access the food and drug act, the standards board act and the national nutritional policy. we also reviewed newspaper reports on geophagia as part of the build-up for the design of the study instrument. we conducted internet searches at sites such as biomed central, national institute of health, british medical council and accessed journals papers on the topic. the documentary search on the internet was conducted using carefully designed phrases like, “geophagia, a cultural nutritional artifact,” “geophagia in ghana, benefits and risks,” “typology of geophagia, pica, pagophagia (ice eating), coprophagia (feces eating),” “cultural beliefs, red earth eating and well-being”, “incidence and prevalence of geophagia, ghana only”. we summarized the findings into their respective units, and interpreted them based upon our norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 5 skills, knowledge and specialization in public health, risk communication and health promotion. statistical analysis data was entered into microsoft excel 2007, checked for accuracy and consistency to reduce errors. this was then transferred into stata version 11.0 mp for analysis. summary statistics such as frequencies, percentages, means and standard deviations were then estimated to compare the prevalence of geophagia across the various groups and backgrounds. chi-square and fisher’s exact tests were used to assess the associations between the prevalence of geophagia and background characteristics, history and its practice as well as differences between males and females in terms of experience with the practice. significant factors from the tests of association were then used in logistic regression to estimate the relative odds of such practice. ethical approval we applied for ethical approval to conduct the study for which approval was granted by the institutional review board of the ghana health service in protocol dated ghs-erc 01/11/13. study limitations many of the papers used in this write-up were the results of research conducted on small groups of people. a key aspect of this study was to document the practice of geophagia nationwide. despite, due to limited funds, we met several operational challenges. the most difficult of such challenges was the lack of comparison between urban and rural areas for each region. urban-rural comparison was done at the national level. despite this observation, we believe that the methodology used in this study was sound. we also covered the entire ten administrative regions of ghana and believe the sample size is large enough to allow us to generalize the outcome in as far as ghana is concerned. nevertheless, in order to assess the true prevalence of geophagia in west africa, a much bigger study needs to be undertaken in the future. results overall, mean (±sd) age of study participants was 33.3±12.8 years (among individuals, who ever practiced geophagia, mean age was: 35.2±13.0 years). basic demographics of geophagists from the basic demographics of the respondents, the overall finding is that geophagia was present in both females and males; in both rich and poor; in both urban and rural residents; and in both the educated and the non-educated individuals. the practice of geophagia was the highest (21.5%) within the 50-59 year age-group and the lowest (9.8%) within the under-20 year olds and this finding was statistically significant (p<0.05). it can also be seen that the practice was more predominant among females (26.2%) and this was also highly significant (p<0.001) as shown in table 1. it is interesting to show through this data that geophagia was not restricted to females, or pregnant and lactating women, but it was also evident among males. geophagia was also practiced by persons from different socio-economic groups distinguished with respect to education, marital status, religion, and employment. ethnicity and geophagia practice among the various ethnic groups in ghana, geophagia was highest in the akan-other with a figure of 26.4% (p<0.001). the akan-other would include the indigenous inhabitants of the norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 6 brong ahafo, eastern, central and western regions of ghana. in terms of regions, the eastern region has the highest geophagists among all the other regions with 35.7% followed by the upper west region with 22.8% (p<0.001). type of residence did not have an influence on the practice of geophagy (p=0.138). wealth was not a significant factor in the practice of geophagia (p=0.082) (table 1). table 1. background of respondents and the practice of geophagia characteristic number of individuals ever practised geophagia [n (%)] p-value * age-group (years): <20 20-29 30-39 40-49 50-59 ≥60 244 697 461 377 144 72 24 (9.8) 108 (15.5) 72 (15.6) 67 (17.8) 31 (21.5) 12 (16.7) p=0.005 sex: female male 1,049 948 275 (26.2) 39 (4.1) p<0.001 marital status: never married married/cohabiting divorced/separated/widowed 840 1127 29 94 (11.2) 209 (18.5) 11 (37.9) p<0.001 religion: none christian muslim traditional african 93 1409 416 73 25 (26.9) 212 (15.1) 58 (13.9) 19 (26.0) p<0.001 education: none primary secondary tertiary 75 565 1074 282 26 (34.7) 145 (25.7) 135 (12.6) 8 (2.8) p<0.001 employment status: not employed employed 375 1619 43 (11.5) 270 (16.7) p=0.005 occupation: unskilled labour agricultural clerical/secretarial professional/managerial sales and services skilled craftsmanship 82 167 53 274 454 589 13 (15.9) 31 (18.6) 7 (13.2) 8 (2.9) 126 (27.8) 85 (14.4) p<0.001 ethnicity: akan-ashanti akan-fante akan-other ewe ga-dangbe mole-dagbani grussi/gur nzema 438 208 265 206 138 252 155 140 57 (13.0) 23 (11.1) 70 (26.4) 33 (16.0) 28 (20.3) 28 (11.1) 31 (20.0) 27 (19.3) p<0.001 norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 7 other 148 16 (10.8) type of residence: urban rural 1546 451 233 (15.1) 81 (18.0) p=0.138 current residence: <5 years 5-9 years ≥10 years 920 605 466 115 (12.5) 99 (16.4) 99 (21.2) p<0.001 current community: <5 years 5-9 years ≥10 years 366 386 1239 43 (11.8) 48 (12.4) 221 (17.84) p<0.001 wealth quintile: lowest second middle fourth highest 12 286 401 664 622 3 (25.0) 47 (16.4) 63 (15.7) 119 (17.9) 79 (12.7) p=0.082 ever had biological children: no yes 924 1071 84 (9.1) 230 (21.5) p<0.001 related to people who practice geophagia: no yes 388 1195 14 (3.6) 300 (25.1) p<0.001 total 2000 314 (15.7) * p-values from chi-square test and fisher’s exact test in cases when the expected cell frequencies were <5. although the practice was highest within those with no formal education and those engaged in sales and service providers, this was not significant in determining familiarity with geophagia, or the lack of it. we also asked whether geophagia was a commonly known phenomenon (table 2). it was found that, of the respondents who had ever practiced geophagia, 19.3% of them had heard of geophagia elsewhere and another 19.8% had witnessed this practice. history and practice of geophagia among the sexes we also considered the history and practice of geophagia. the data showed that females had started the practice at a much earlier age compared to males (p<0.001). the practice being a social conduct, many of the users learned the habit from family members and friends. cultural nutrition health-seeking behaviour the data in table 2 also seems to suggest that geophagia is a culturally sanctioned activity between relatives, husbands and wives, as well as the children. geophagia was not driven by poverty, the lack of formal education, or the presence of gainful employment. in table 2 respondents who had ever been pregnant and practiced geophagia before, provide interesting insights into the social conduct. only a small fraction of the respondents (19.3%) accepted or agreed with the notion that geophagia is practiced by only pregnant women. while 92% of the respondents stated that their desire to eat dirt is stronger when pregnant, (42%) reported that they had strong desire to eat earth even when not pregnant. we did not see any evidence that supported the notion that geophagia was an instinctive primal response to gastronorman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 8 intestinal disturbances, although in the literature review, a study conducted in the cape region of south africa among calves and lamps on a farm supported this notion (1). that study also found that when the farmer withdrew the older calves from the mn rich soil, they did not demonstrate signs of withdrawal but fed normally without the display of appetite for the mn rich soil. table 2. history and practice of geophagia by sex of survey participants history and practice number (percentage) p-value * female male total age when geophagia started: <20 years 20-29 years ≥30 years do not remember 138 (50.2) 128 (46.6) 3 (1.1) 4 (1.5) 22 (56.4) 5 (12.8) 11 (28.2) 0 160 (51.0) 133 (42.4) 14 (4.5) 4 (1.3) p<0.001 last time of eating earth: <1 month 1-12 months >1 year 103 (37.5) 55 (20.0) 114 (41.5) 7 (18.0) 4 (10.3) 26 (66.7) 110 (35.0) 59 (18.8) 140 (44.6) p<0.001 frequency of eating earth: daily weekly monthly yearly 227 (82.6) 36 (13.1) 5 (1.8) 1 (0.4) 5 (12.8) 19 (48.7) 8 (20.5) 3 (7.7) 232 (73.9) 55 (17.5) 13 (4.1) 4 (1.3) p<0.001 geophagia hidden from others: no yes 191 (69.5) 81 (29.5) 16 (41.0) 21 (53.9) 207 (65.9) 102 (32.5) p<0.001 geophagia hidden from: partner/spouse parents siblings other family friends 39 (14.2) 47 (17.1) 10 (3.6) 27 (9.8) 13 (4.7) 4 (10.3) 13 (33.3) 6 (15.4) 10 (25.6) 6 (15.4) 43 (13.7) 60 (19.1) 16 (5.1) 37 (11.8) 19 (6.1) p=0.200 learnt geophagia from: no one family friends both 60 (21.8) 139 (50.6) 53 (19.3) 3 (1.1) 1 (2.6) 36 (92.3) 1 (2.6) 0 61 (19.4) 175 (55.7) 54 (17.2) 3 (1.0) p<0.001 ever had a health problem due to geophagia: no yes 249 (90.6) 25 (9.1) 38 (97.4) 0 287 (91.4) 25 (8.0) p=0.055 desire to eat earth stronger than food sometimes: no yes 197 (71.6) 77 (28.0) 38 (97.4) 0 235 (74.8) 77 (24.5) p<0.001 desire to eat earth heightens after rain: no yes 233 (84.7) 41 (14.9) 34 (87.2) 4 (10.3) 267 (85.0) 45 (14.3) p=0.624 reason: smell 40 (14.6) 4 (10.3) 44 (14.0) p=0.676 earth collected by self: p=0.648 norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 9 no yes 261 (94.9) 10 (3.6) 36 (92.3) 2 (5.1) 297 (94.6) 12 (3.8) other usual ways of acquiring earth: buying from family from friends 249 (90.6) 8 (2.9) 3 (1.1) 20 (51.3) 15 (38.5) 0 269 (85.7) 23 (7.3) 3 (1.0) p<0.001 mode of consumption: chewed licked as a drink 215 (78.2) 58 (21.1) 0 28 (71.8) 7 (18.0) 3 (7.7) 243 (77.4) 65 (20.7) 3 (1.0) p<0.001 additives added to earth before consumption: no yes 266 (96.7) 8 (2.9) 37 (94.9) 1 (2.6) 303 (96.5) 9 (2.9) p=1.000 time of day earth is normally eaten: before meals after meals no particular time 2 (0.7) 23 (8.4) 248 (90.2) 0 1 (2.6) 37 (94.9) 2 (0.6) 24 (7.6) 285 (90.8) p=0.486 total 275 (100.0) 39 (100.0) 314 (100.0) * p-values from chi-square test and fisher’s exact test in cases when the expected cell frequencies were <5. relative odds of practising geophagia based on demographics it was also noticed that females were more likely than males to practice geophagia: or=8.28, 95%ci=5.84-11.74, p<0.001 (table 3). this was still significant at almost the same level after adjusting for the other variables in the model, i.e. after taking those other characteristics into account. among different age-groups, 50-59 year olds were most likely (2.51 times) to practice geophagia compared to the under-20 year olds. however, this was not significant after adjusting for the other variables although they were still the most likely group to do so (or=2.90, 95% ci=0.88-9.58, p=0.555). the odds were against the divorcee, widowed and separated persons who were 4.85 times more likely to find comfort in eating earth than the married, cohabiting and those who had never married; this was however not significant after adjustment. table 3. relative odds of practising geophagia based on background characteristics characteristic crude adjusted or (95% ci) p-value or (95% ci) p-value age (years): <20 20-29 30-39 40-49 50-59 ≥60 1.00 (reference) 1.68 (1.05, 2.69) 1.69 (1.03, 2.77) 1.98 (1.20, 3.26) 2.51 (1.41, 4.49) 1.83 (0.87, 3.88) p=0.005 1.00 (reference) 2.34 (0.85, 6.45) 2.32 (0.79, 6.86) 2.68 (0.89, 8.08) 3.06 (0.94, 9.94) 3.00 (0.73, 12.33) p=0.558 sex: male female 1.00 (reference) 8.28 (5.84, 11.74) p<0.001 1.00 (reference) 7.73 (4.99, 11.96) p<0.001 norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 10 marital status: never married married/cohabiting divorced/separated/widowed 1.00 (reference) 1.81 (1.39, 2.35) 4.85 (2.22, 10.58) p<0.001 1.00 (reference) 1.34 (0.88, 2.06) 1.87 (0.44, 8.03) p=0.348 religion: none christian muslim traditional african 1.00 (reference) 0.48 (0.30, 0.78) 0.44 (0.26, 0.75) 0.96 (0.48, 1.92) p<0.001 1.00 (reference) 0.59 (0.32, 1.12) 0.44 (0.23, 0.86) 0.91 (0.38, 2.20) p=0.005 education: none primary secondary tertiary 1.00 (reference) 0.65 (0.39, 1.09) 0.27 (0.16, 0.45) 0.06 (0.02, 0.13) p<0.001 1.00 (reference) 0.87 (0.44, 1.70) 0.50 (0.24, 1.03) 0.17 (0.05, 0.59) p<0.001 employment status: not employed employed 1.00 (reference) 1.54 (1.10, 2.18) p<0.001 omitted due to collinearity occupation: unskilled labour agricultural clerical/secretarial professional/managerial sales and services skilled craftsmanship 1.00 (reference) 1.21 (0.60, 2.46) 0.81 (0.30, 2.18) 0.16 (0.06, 0.40) 2.04 (1.09, 3.82) 0.90 (0.47, 1.69) p<0.001 1.00 (reference) 0.96 (0.42, 2.20) 1.08 (0.34, 3.42) 0.64 (0.20, 2.03) 1.37 (0.69, 2.75) 1.33 (0.65, 2.73) p=0.512 discussion in this study we have been able to show that geophagia was not caused by food scarcity or insecurity. even in the farming communities of ghana, particularly in western, brong ahafo, ashanti and eastern regions where the average household has access to food grown on their own farms, geophagia was practiced all year round irrespective of food availability or harvest. in order to address the potential health threats posed by geophagia, the key cultural drivers need to be studied and understood. we also need to appreciate the shocks and stresses that create such desires. but first, we need to get the scientific data right without co-mingling it with social analyses. anything short of this would prolong the debate about whether geophagia is a cultural-nutrition health-seeking behaviour, or just a mere cultural imperative without redeeming psycho-social qualities (1,15,16). from the published papers accessed in this paper, we have noticed that, part of the reasons for the debate is that it appears many of the researchers try to explain the outcome of a purely laboratory investigation of the substances involved in geophagia within the cultural context (13). at other times, they attempt to explain the outcome of their social investigation of the behaviour, such as knowledge and attitude associated with the practice, with scientifically oriented language supported by laboratory measurements and equivalencies (14,16,17). there is a mixture of purposes and, therefore, the literature on geophagia is replete with claims and counter-claims or findings by the same researchers within the same studies (3,13,21). an example of a purely scientific research which was reported as such was conducted by dreyer et al. in 2004 (21). they conducted biochemical investigations into geophagia among certain ethnic group in southern africa and concluded that eating black earth among pregnant women in southern africa may be beneficial to them and may retard norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 11 the loss of iron and other properties. they reported that: “absorbent properties for sodium of black earth, though notable, were not homoeostatically significant. intake was estimated at only 7.5% of dietary guidelines, yet the serum concentration was normal. the same applies to magnesium. this was liberated from black earth in quite large amounts, dietary intake exceeded the rda (120%) and yet the serum concentration again was normal. intake of calcium was below the rda (43.5%), while the serum concentration was normal. possibly, the calcium liberated from black earth actually functioned as a dietary supplement.” on the basis of the outcome of their study, dreyer cautioned that before attributing adverse or beneficial outcomes to geophagia, the ion-exchange capacity of the substance in question should be evaluated. dreyer et al. did not attempt to extend their findings to any other issue except what they investigated. however, neser, de vries, et al. (2000) also conducted a purely scientific inquiry into „enzootic geophagia of calves and lambs‟ in the cape region of south africa and concluded among other laboratory findings that: “the cause of geophagia may not be completely understood”. the inquiry was not a cause-effect study (1). woymodt and kiss (2002:143) took the historical approach to understand the practice. in their review of the history of geophagia, they suggested that geophagia was an artifact of poverty, that “where poverty and famine are implicated, earth may serve as an appetite suppressant and filler” (3). that is to say, geophagia was an aspect of resilient building or adaptive capacity against food insecurity and food scarcity (16). although woymodt and kiss had previously maintained that geophagia was associated with poverty, they made immediate reversal of opinion that “geophagia is often observed in the absence of hunger”, but that it is “environmentally and culturally driven” (3). in the conclusion of their paper, they reversed themselves again that “the re-emergency of geophagia might be triggered by famine, cultural-change and psychiatric diseases”. to underscore geophagia as a psychiatric disease, woymodt and kiss quote from gabriel garcia marquez’s „one hundred years of solitude‟, in which one of the novel heroines: ‘rebecca got up in the middle of the night and ate handfuls of dirt in the garden with a suicidal drive, weeping with pain and fury, chewing tender earthworms and chipping her tooth on snail shells‟. researchers accorded and inured geophagia with neurosis or psychiatric disorder as exemplified in the apparently hysterical manner the apparently already crazy rebecca was „chewing tender earthworms and chipping her tooth on snail shells‟ (20). even though she was in pain, rebecca continued to chew the dirt, perhaps due to her apparent pre-existing mental disorder. such conclusions were reached in other scientific publications long before the cultural dimensions of the practice were subjected to empirical investigations (17). granted, rebecca is a fictitious character created out of a fertile, probably, male-centric mind (16,20). despite this statement, the thought that geophagia is a primal response to psychosomatic episode lingers on. for researchers to conclude that geophagia is a psychiatric disorder there has to be empirical studies to confirm this suspicion. without a contextual and clinical evaluation of a particular geophagist, it cannot be said that geophagia is driven by a psychiatric disorder. it appears the outcome reported in this study, debunks the thinking that geophagia is a sign of psychiatric condition. conclusion in this study, we have provided evidence that geophagia is not restricted to pregnant and lactating women and that it is a general practice among certain groups of people in ghana, west africa. we have proffered that, at least in ghana, geophagia is a cultural-nutritional, health-seeking behaviour. it is not a conduct which is practiced because of famine or food insecurity, but because of the utilitarian value derived from it. there is also no study on the norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 12 phenomenon on this level that has been published on ghana. therefore, this study brings to light all the findings associated with the practice of geophagia. in order not to confuse good laboratory investigation with the cultural impetus that drives the practice of geophagia, researchers of this behaviour need to focus their research questions on specific issues of the conduct. where there is comingling of cultural analyses with laboratory results, a great deal of confusion may be created, which may lead to the wrong inferences or interventions if need be. references 1. neser ja, de vries ma, de vries m, van der merwe aj, loock ah, smith hjc, van der vyver fh and elsenbrock jh. enzootic geophagia of calves and lambs in northern cape and northwest and the possible role of chronic manganese poisoning. s afr j anim sci 2000;30:105-6. 2. tayie f. pica: motivating factors and health issues. afr j food agr nut dev 2004; vol. 4, no.1. 3. woywodt a, kiss a. geophagia: the history of earth-eating. j r soc med 2002;95:143-6. 4. griffiths, m. international gaming research unit, nottingham trent university, nottingham, uk: http://en.wikipedia.org/wiki/geophagy (accessed: february 7, 2015). 5. kawai k, saathoff e, antelmam g, masamanga g, fawzi ww. geophagy (soileating) in relation to anemia and helminths infection among hiv-infected pregnant women in tanzania. am j trop med hyg 2009;80:36-43. 6. young sl, khalfan ss, farag th, kavle ja, ali sm, hajji h, et al. association of pica with anemia and gastrointestinal distress among pregnant women in zanzibar, tanzania. am j trop med hyg 2010;83:144-51. 7. menge h, lang a, cuntze h. pica in germany: amylophagia-associated iron deficiency anemia. j gastroenterol 1998;36:635-40. 8. karaoglu l, pehlivan e, egri m, deprem c, gunes g, genc mf, temel i. the prevalence of nutritional anemia in pregnancy in an east anatolian province, turkey. bmc public health 2010;10:329. doi: 10.1186/1471-2458-10-329 9. arcasoy a, cavdar ao, babacan e. decreased iron and zinc absorption in turkish children with iron deficiency and geophagia. acta haematol 1978;60:76-84. 10. ashworth m, hirdes jp, martin l. the social and recreational characteristics of adults with intellectual disability and pica living in institutions. res dev disabil 2008;30:512-20. 11. beteson em, lebroy t. clay eating by the aboriginals of the northern territory. med j aust 1978;1:51-3. 12. geissler pw, shulman ce, prince rj, mutemi w, mzani c, friis h, lowe b. geophagy, iron status and anaemia among pregnant women on the coast of kenya. trans r soc trop med hyg 1998;92: 549-53. 13. abrahams pw, davies tc, solomon ao, trow aj, wragg j. human geophagia, calabash chalk and undongo: mineral element nutritional implications. plos one 2013;8:e53304. doi: 10.1371/journal.pone.0053304 14. tayie fak, lartey a. pica practice among pregnant ghanaians: relationship with infant birth-weight and maternal haemoglobin level. ghan med j 1999;33:67-76. 15. kreulen da, jager t. herbivore nutrition in the tropics and subtropics. the science press: craighall; 1984; p. 204-221. norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 13 16. bisi-johnson ma, obi cl, ekosse ge. microbiological and health related perspectives of geophagia: an overview. afr j biotech 2010;9:5784-91. doi: 10.5897/ajb09.018. 17. vermeer de. geophagy among the ewe of ghana. ethnology 1971;10:56-72. 18. davis rh, valadez jj. improving the collection of knowledge, attitude and practice data with community surveys: a comparison of two second-stage sampling methods. health policy plan 2014;29:1054-60. doi: 10.1093/heapol/czt088. 19. milligan p, njie a, bennett s. comparison of two cluster sampling methods for health surveys in developing countries. int j epidemiol 2004;33:469-76. doi: 10.1093/ije/dyh096. 20. gabriel garcia marquez. one hundred years of solitude. translated by gregory rabassa, harper-collins publishers, ny; 1967. 21. dreyer mt, chaushev pg, gledhil rf. biochemical investigations in geophagia. j roy soc med 2004;97:48-53. ___________________________________________________________ © 2015 norman et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed/?term=davis%20rh%5bauthor%5d&cauthor=true&cauthor_uid=24281698 http://www.ncbi.nlm.nih.gov/pubmed/?term=valadez%20jj%5bauthor%5d&cauthor=true&cauthor_uid=24281698 italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 1 | 16 original research switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study salvatore italia1, peter schröder-bäck1, helmut brand1 1 department of international health, school caphri: care and public health research institute, maastricht university, the netherlands. corresponding author: salvatore italia address: duboisdomein 30, 6229 gt maastricht, the netherlands telephone: +31 433882343; e-mail: salvatore.italia@maastrichtuniversity.nl italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 2 | 16 abstract aim: unwanted pregnancy is an important social issue, not least among teenagers. emergency contraceptives (emcs) can prevent from unintended pregnancy, if taken quickly after unprotected sex. this study’s objective was assessing abortion/birth rates among adult and teenage women in europe before/after an emc switch to non-prescription status. methods: national authorities were consulted for emc consumption data and abortion/live birth statistics. rates (n=26 countries) in the year before the switch (= year of reference) were compared with rates before/after the change (up to ±15 years). the focus was laid on the european union and further countries closely related to the european union. results: all countries with available data (n=12) experienced a substantial increase of emc consumption after the switch. on average, abortion rates among women aged 15–49 years were 83% higher 15 years before (compared with the year of reference) and 14% lower 15 years after the switch. correspondingly, teenage abortion rates were 35% higher 15 years before and 40% lower 15 years after the switch. in 2017, no country had higher teen abortion rates than at time of the switch. teen birth rates continued decreasing at almost the same rate after the switch as before. conclusion: an emc switch to non-prescription status increases emc use and may contribute reducing unwanted pregnancy among teenage girls. keywords: emergency contraceptives, europe, levonorgestrel, over-the-counter, prescription status, ulipristal acetate. conflicts of interest: none declared. italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 3 | 16 introduction for 2008, about 41% of pregnancies worldwide were estimated to be unplanned (1). four years later, this proportion was stable at 40%, highest in latin america (56%) (2). unwanted pregnancies are an important social issue in europe as well (rate estimated at 45%), and many are likely to end in induced abortion (50%) or unplanned birth (about 38%). especially among teenagers, the rate of unintended pregnancy is supposed to be very high (roughly 80% of all pregnancies among american teenagers are unwanted) (1). using long lasting oral reversible hormonal contraceptives regularly could be an ongoing protection from unwanted pregnancy, but this reliable method is not used by all fertile women (in 2012, by 82.5% in portugal, but only by 33.2% in lithuania) (3). one effective option avoiding unintended pregnancy after unprotected sex is quickly taking an emergency contraceptive (emc). in europe, mainly two active ingredients are used for emergency contraception, levonorgestrel (lng) and ulipristal acetate (upa), which have to be taken within 72 hours (lng) or 120 hours (upa) after unprotected sex. as time is a crucial factor and emcs are considered to have a good safety profile, the european medicines agency (ema) recommended switching upa (ellaone®) from prescription-only to non-prescription status in november 2014 to speed up access to emcs. the following legally binding decision of the european commission valid (in principle) throughout the european union (eu) made upa available as an over-thecounter (otc) drug across the eu (3,4). about 20 years ago, when lng or upa were not (freely) available for emergency contraception, pregnancy rates among teenagers were higher in many european countries compared to 2017, e.g. 55 per 1000 adolescents aged 15–19 years (england and wales), or 68 per 1000 adolescents aged 15– 19 years in hungary (5), and most teen pregnancies ended in abortions or presumably unplanned births. one hope linked with facilitated access to emcs was reducing abortion/teen births rates. however, also concerns were expressed regarding prescription-free availability of emcs, moral worries as well as medical fears, e.g. that changes in sexual behaviour especially among adolescents could also lead to misuse and hence increase abortion rates instead of decreasing them (6), or that sexually transmitted infections might rise again (7,8). this study’s objective was to analyse the potential impact of an emc switch to nonprescription status on unwanted pregnancy. this was done by assessing abortion rates among women aged 15–49 years and abortion and live birth rates among adolescents <20 years in europe since and also before the switch of emcs to nonprescription status. within europe, we mainly focused on the european union (eu) and the european free trade association (efta). a further aim was collecting emc consumption data since their market introduction. methods consumption of emcs emc consumption was investigated at the national medicines authorities (direct contact or yearly consumption reports). another source for data on emc use were drug consumption databases and emc-related publications (9,10). year of reference italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 4 | 16 following emcs with their anatomical therapeutic chemical classification codes (atc) were under research: 1. atc code g03ad01 (lng); approved first in eastern europe in 1979 and marketed in western europe since the 1990s. 2. atc code g03ad02 (upa); approved in europe in 2009 and recommended by the ema in november 2014 to have nonprescription status. 3. atc code g03aa07 (levonorgestrel + ethinylestradiol); dedicated preparations (brand names tetragynon®, schering pc4®) marketed as prescription-only products in several european countries (since the 1980s) and first emc with non-prescription status in iceland (in 1998). the year/month of an emc switch to nonprescription status (date one out of the three emcs mentioned above was made available without medical prescription for the first time) was checked at the national medicines authorities (homepage or contact by e-mail). additionally, emc-related publications were screened. the year preceding the switch was defined as ‘year of reference’ for comparing development of rates after/before the switch, if the switch became operative between january and october. for countries where the switch came into force in november or december, the year of switch was defined as ‘year of reference’, as a switch towards the end of the year may hardly have had an impact on the same year’s abortion statistics. the year of switch was defined being the first year ‘after’ a switch. hence, statistics after the switch were compared with figures in the ‘year of reference’ ended. correspondingly, to take into account long-term trends, also rates in the years before the switch were compared with rates of the ‘year of reference’ ended. analysis of rates to obtain statistics on abortions and teen births, the homepages of national statistical offices were consulted or respective authorities were contacted directly (data sources available as supplementary material). for analysis of induced abortion rates (spontaneous abortions were not considered, as not mentioned in many abortion statistics) among the whole fertile female population, the total number of legally induced abortions was sought and referred to 1000 women aged 15–49 years. if stratified data were available, induced abortions performed to the countries’ residents only were considered. population structures were obtained from national statistical offices. respectively, the number of induced abortions and live births (still births were excluded, since not available for all countries) among adolescents <20 years was referred to 1000 women aged 15–19 years. if absolute numbers for abortions/live births were not available, rates were adopted as reported by the countries’ authorities. generally, abortion and live birth rates for women aged 15–19 years presented in this study mostly include the figures for girls <15 years, as this is mainly the method how authorities report the rates for this age group. however, abortion/birth figures for girls <15 years are almost negligible for the calculation of teenage abortion/birth rates. abortion statistics for residents from ireland and northern ireland were extracted from the annual abortion reports of the united kingdom, since ireland and northern ireland italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 5 | 16 have very restrictive abortion laws and only few abortions were performed in ireland and northern ireland. rates for countries (e.g. england and wales, the netherlands, sweden) generally reporting rates among women aged 15–44 years (instead of 15–49 years) were recalculated for the 15 to 49-year-old female population. for some years, figures on abortions or live births were not available from the national authorities. therefore, rates were extracted from graphs provided by national health/statistical authorities or calculated based on figures from the historical johnston archive (11), the world health organization (12), eurostat (13), or the world bank (14). data were collected up to the year 2017. results history of emc accessibility exactly 26 countries were included in this comparative study (23 eu countries, 3 efta countries). iceland (1998) and france (1999) were the first countries making emcs available without medical prescription. according to the icelandic medicines agency, the first emc available (tetragynon®) was classified as otc medicine immediately after receiving marketing authorization in june 1998, as well as lng, which was freely available since january 2003. among the last european countries changing at least one emc (upa or lng) to otc status were germany, italy, and croatia (all in 2015). hungary decided keeping the prescriptiononly status for all emcs, poland switched upa to otc status in april 2015, but the new polish government abolished the decision and re-switched upa to prescription-only status again in july 2017 (lng never received otc status in poland). the most recent european countries making emcs accessible without medical prescription were malta (december 2016) and andorra (june 2018). in gibraltar, a self-governing british overseas territory, emcs were switched to otc status in august 2017 only, about 8 years after the switch in the neighbouring country spain, and more than 16 years later than in the united kingdom itself. rates after the switch in the year before the switch, total abortion rates ranged between 3.2 (croatia) and 31.5 (estonia) abortions per 1000 women aged 15–49 years. the mean for the 26 included countries was 11.8. exactly 19 countries experienced a reduction of abortion rates since the switch. the sharpest decline was observed in latvia (-63% within 15 years). in 7 countries, abortion rates among the total female population were slightly higher in 2017 (or in the year with most recent available figure) compared with the year of reference (table 1). the development of abortion rates among adolescents aged 15–19 years revealed a relatively uniform picture (table 1). in all countries except belgium and greece (for which most recent figures were available for 2011 and 2012 only) abortion rates fell. the biggest reductions since the switch were visible in latvia (-73%) and norway (-67%). on average, abortion rates dropped from 12.0 at time of the switch to 6.9 abortions/1000 adolescents aged 15–19 years in 2017. italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 6 | 16 table 1. induced abortion and live birth rates at time of the otc switch compared with rates in 2017 rates in the year of referencea rates in 2017a country switch reference abortions 15-49 abortions 15-19 births 15-19 abortions 15-49 abortions 15-19 births 15-19 belgium apr 01 2000 5.6 6.9 10.7 7.8* 8.4* 5.8 bulgaria jan 06 2005 22.4 15.6 40.4 16.0 14.3 39.7 croatia apr 15 2014 3.2 1.8 10.3 2.7 1.5 9.3 czech republic nov 11 2011 9.6 7.1 11.3 8.2 5.6 11.9 denmark jun 01 2000 12.5 14.2 7.9 12.1*** 11.3*** 2.8 estonia sep 03 2002 31.5 28.9 23.0 13.9 10.8 10.1 finland jan 02 2001 8.9 15.5 10.7 8.2 7.6 4.9 franceb may 99 1998 13.4 13.2 7.1 14.4 10.4 4.7 germany mar 15 2014 5.6 4.4 6.1 5.8 4.0 6.3 greece jun 05 2004 6.0 2.1 10.8 6.8** 2.4** 9.0 iceland jun 98 1997 13.6 20.6 24.3 13.3 12.6 6.0 ireland feb 11 2010 3.7 3.2 14.4 2.6 1.4 6.9 italy apr 15 2014 7.0 5.4 5.6 6.2 4.3 4.3 latvia may 03 2002 25.1 17.0 21.5 9.2 4.6 15.0 lithuania jul 08 2007 11.7 7.3 19.5 6.9 3.2 12.2 netherlands jan 05 2004 7.4 8.2 4.6 7.2 5.3 2.0 norway jul 00 1999 13.4 19.0 11.7 10.6 6.3 3.0 romania nov 06 2006 28.3 23.1 40.1 12.4 10.2 38.5 slovak republic apr 04 2003 9.8 6.6 20.8 5.8 4.3 27.3 slovenia mar 11 2010 9.0 6.7 4.9 8.1 4.0 4.0 spain sep 09 2008 9.7 12.7 13.2 8.7 8.8 7.2 sweden apr 01 2000 15.6 21.1 5.0 16.8 13.0 3.1 switzerland (cantone berne)c oct 02 2001 5.2 4.9 3.4 5.0 3.2 2.1 uk (england & wales) jan 01 2000 14.1 23.7 29.3 14.4 14.7 12.7 uk (scotland) jan 01 2000 9.6 18.4 29.3 9.9 12.9 13.0 uk (northern ireland) jan 01 2000 3.7 4.8 25.6 2.2 2.1 12.4 mean 11.8 12.0 15.8 8.9 6.9 10.5 arates are displayed per 1000 women of the respective age group (figures for girls <15 years are normally included) bfrance métropolitaine (=france without guadeloupe, martinique, guyane, la réunion, mayotte) cno long-term abortion data available for switzerland as a whole rates in bold letters are higher compared with rates in the year of reference * 2011 figures ** 2012 figures ***2015 figures italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 7 | 16 live birth rates among women aged 15–19 years fell in most countries. only the czech republic and germany had slightly higher rates in 2017 compared with the year of reference. however, the slovak republic had clearly higher birth rates after the switch and was the only country in this study were the sum of teenage abortion and live birth rates was higher in 2017 compared to the year of reference. further abortion and live birth rates for some european countries with incomplete statistics are displayed in table 2. table 2. induced abortion and live birth rates for further european countries rates in the year of referencea rates in 2017a country switch reference abortions 15-49 abortions 15-19 births 15-19 abortions 15-49 abortions 15-19 births 15-19 andorra jun 18 2017 na na 3.4 na na 3.4 austria dec 09 2009 no stat no stat 10.4 no stat no stat 6.8 cyprus ? --no stat no stat --no stat no stat 6.6 hungary still rx --na na na 12.6 16.1 23.2 luxembourg may 05 2004 no stat no stat 10.9 no stat no stat 5.2 malta dec 16 2016 na na 13.6 na na 12.5 polandb apr 15 2014 na na 13.4 na na 11.1 portugal oct 00 1999 na na 21.1 6.7 5.5 8.0 rx=prescription-only na=not applicable (abortion illegal or emcs available with prescription only) no stat=no official data available ?=emcs have otc status, but date of switch not determinable arates are displayed per 1000 women of the respective age group (figures for girls <15 years are normally included) bemcs were re-switched to prescription-only status in july 2017 long-term analysis of rates fifteen years before the switch, the average abortion rates were 26.9 per 1000 women aged 15–49 years (data available for n=25 countries) and 15.2 per 1000 girls aged 15– 19 years (data available for n=20 countries), ranging from 4.4 (northern ireland) to 153.8 (romania) for all age groups and from 1.6 (greece) to 55.0 (romania) for teenagers. live birth rates (mean=24.4; data available for n=26 countries) were lowest in switzerland (3.0) and highest in bulgaria (69.9). in the mean, abortion rates among women aged 15–49 years were 83% higher 15 years before the switch in comparison with the year of reference, whereas 15 years after the switch, rates were 14% lower compared with the year of reference (figure 1). the corresponding percentages for abortions among teenagers were +35% (15 years before switch) and -40% (15 years after the switch). hence, the falling trend for abortions among teenagers was visible already before the emc switch, but the mean decline was stronger after the switch. in contrast, for all age groups the trend towards lower abortion italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 8 | 16 rates was almost stopped after the switch (also when considering that the slight decline after the switch is mostly attributable to the decline among adolescents, which are included in the figures for the total age groups). on average, live birth rates declined at almost the same rate after the switch as they did already before the emc change to otc status. figure 1. long-term analysis of abortion/live birth rates for n=26 european countries 15 years before and after the year of reference.* *for the calculation of the mean relative change (rate in the year concerned/rate in year of reference), each country contributes the relative change according to availability of data (e.g. denmark for all years from -15 to +15, ireland from -15 years to +7 years, etc.). in most countries from eastern europe, abortion rates declined extremely after the fall of the berlin wall in 1989, which might be explained by the fact that regular contraceptives were used less compared with western europe. hence, abortion might have been regarded being a common option for family planning. for eight countries from western europe only (finland, denmark, iceland, norway, sweden, switzerland, united kingdom (england & wales), united kingdom (scotland)), a full history of 15 years before and after the emc switch is available. these countries (figure 2) may therefore provide a picture which is biased less by social turmoil as it might have been if including also data from eastern europe (figure 1). moreover, almost all dispensing pharmacists from these eight countries may have respected nonprescription rules before the switch, which may possibly not be the case if viewing at all 26 included countries. italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 9 | 16 figure 2. long-term analysis of abortion/live birth rates 15 years before and after the year of reference for eight countries with a complete ±15 year-history before/after the emc switch.* *the eight included countries are finland, denmark, iceland, norway, sweden, switzerland, united kingdom (england & wales), united kingdom (scotland). emc sales figures for 12 countries, precise consumption numbers or sufficiently reliable estimations were available (figure 3). almost all countries showed a quick and strong increase of sales after the switch and reached an almost stable consumption peak after 8–10 years, seven countries evening out at about 80–100 used emcs per 1000 women aged 15–49 years per year. norway, showing the biggest increase, is observing a reduction of emc use since reaching the peak ten years after the switch, now also approaching a level of 100 emcs per 1000 women aged 15–49 years. across the included countries, a direct linear correlation of emc consumption and abortion rates is, however, not visible, as e.g. france and finland have now similar per capita emc consumptions, but different abortion rates. the results (figure 3) are approximately in line with corresponding results from a study providing estimations of emc consumption in 2013 for almost all eu countries (15). nevertheless, several countries with the lowest per capita consumption of emcs in 2013 are currently among the eu countries with the highest teenage abortion and/or live birth rates (romania, bulgaria, hungary, slovakia, england & wales, czech republic, poland). italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 10 | 16 figure 3. emc consumption over time (figures include atc codes g03ad01, g03ad02 and g03aa07).* *for scotland, the consumption may be underestimated between 2001 (year of switch) and 2008 (introduction of free-of-costs program) as figures for emcs sold without prescription are not available and hence are not included in data provided by the national health service in figure 3. for further countries with no long-term data on emc consumption, there have been reports of markedly higher emc use after the switch, e.g. switzerland, portugal, spain (1618). discussion emergency contraception is a highly controversially discussed topic, to which various societal institutions such as medical/pharmaceutical societies, the churches, or feminist organizations contribute their opinion, which may sometimes be based more on personal beliefs or interests rather than on crude facts. the issue of barrier-free access to emcs deserves, however, a sober analysis, evaluating its potential risks and benefits, as discussed for lng in a 2003 publication (19). the efficacy of emcs containing lng or upa has been proven sufficiently by several studies (20,21). similarly, the ema estimated that for women taking upa within five days after unprotected sex, it would be able to prevent about three-fifths of pregnancies. based on the positive riskbenefits ratio, the ema recommended upa to be changed to non-prescription status throughout europe (22). in contrast to some concerns expressed before, facilitated access to emcs did not increase teen abortion rates in general, e.g., due to a change of sexual behavior, incorrect or excessive use of emcs instead of ongoing hormonal contraception (23). no country (except belgium and greece, where latest italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 11 | 16 available figures are from 2011/2012 and may have fallen since then) showed longterm trends towards higher abortion rates among teenagers after the switch, and in only seven countries total abortion rates were slightly higher in 2017 than at time of the switch. interestingly, in andorra, having very restrictive abortion laws, live birth rates were almost stable from 2000 to 2008 for younger and older women as well. since 2009, rates began falling strongly until 2017 for the two youngest age groups (-60% for teenagers; 63% for women aged 20–24 years), while live birth rate for women aged 25–49 years fell by only 20%. two emc-related events may explain the drop especially among young girls: firstly, emcs were available in andorra at least with a medical prescription since 2008 (switch to otc in 2018 only), and secondly, emcs received otc-status in the bordering state of spain in 2009, easily accessible in case of need for women residing in andorra. a 2016 study found a direct correlation within germany of higher emc use with lower abortion rates. german regions with highest use (bavaria, baden-württemberg) showed the lowest abortion rates, those with lowest use had the highest abortion rates (saxony-anhalt, mecklenburgvorpommern) (24). on the other hand, the question arises whether in countries with a substantial growth of emcs sales after the switch abortion/teen birth rates should not have declined stronger and faster after the switch than observed in reality (e.g. france). possibly, country-specific social factors have also great weight, and perceptible reductions of abortion rates should not be expected quickly, anyway, as it takes roughly 8–10 years on average until emc consumption reaches an almost stable maximum. additionally, it may also take several years until most girls have learned using emcs correctly (quick administration; taking a second dose in case of emesis within 3 hours after the first dose; respecting interactions with other medicines; etc.). with concern to emcs’ action of mechanism, the who asserted clearly that lng and upa have no abortifacient effects (25). however, this debate has not been fully settled yet, and some authors state that emcs’ actions of mechanism (especially with regard to upa) might potentially be interpreted as being abortifacient (26-28). nevertheless, even if emcs should have abortifacient effects, the question rises, how many of the women not taking an emc (because of restricted access) after unprotected sex would finally anyway seek abortion service if getting pregnant unintentionally. hence, it could be discussed if a hypothetical early-stage abortion would not be preferable to having a real abortion at a later stage of pregnancy, which of course is a serious and stressing decision. unwanted pregnancy represents an economic burden for society as well, as shown for norway (for teenagers, direct and indirect costs estimated at €1573 per unwanted pregnancy) and the uk (direct health care costs estimated at £1663 per unwanted pregnancy) (29,30). thus, it may be worth it also from an economic point of view assessing whether emcs should be covered by social security (at least for teenagers), although an increase of emc consumption after a switch, of course a welcome business for the producing pharmaceutical companies, may be a challenge for those social security systems fully covering emcs (31). however, some studies/figures showed that barrier-free access to emcs seems sometimes to be more important rather than full coverage (32,33). italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 12 | 16 it is, finally, an ironic twist of fate, that the very country (hungary), where modern lng-containing emcs had been developed and approved first in 1979 is now one of the very few european countries keeping the prescription-only status for lng and upa (34,35). remarkably, in contrast to most of the other countries, abortion rates among hungarian teenagers fell only slightly since 2001 (16.1 in 2017 vs. 19.7 in 2001), and teen live births rates are almost on the same high level (23.2 in 2017 vs. 22.0 in 2001) as one and a half decades ago. today, both teen abortion and live birth rates in hungary are among the highest in europe. limitations for this study, recent/historical abortion statistics for most eu and efta countries were collected from national statistical offices or health authorities, which are supposed to provide the best possible national data on abortion and birth statistics. to our knowledge, this is the first study comparing on european level the development of abortion rates with respect to the year emcs were made available without medical prescription. however, no data were available for the efta country liechtenstein and for two micro-states closely related to the eu (san marino, monaco). the quality and methods of data collection may vary across the european countries as well as legal definitions of ‘abortion’ or differences between officially reported numbers of legally induced abortions and estimated numbers of induced abortions actually performed (e.g. greece) (36). several aspects may have interfered with the use of emcs and development of abortion rates over time. however, according to agestratified consumption data from denmark and sweden (precise data from other countries are scarce), use of conventional hormonal contraceptives (which may also have changed over time) was not directly linked to the development of abortion/birth rates during the respective observation periods. no reliable information is available about how the legal status of pharmaceuticals is respected by pharmacies in the included countries. in some countries, prescriptiononly status may exist pro forma only (37), thus self-medicated emcs may have influenced abortion/live birth rates already before the formal switch to over-the-counter status. finally, the exact levels of awareness about and correct use of emcs were not available, and it is likely that time to reach high levels of awareness about otc availability of emcs and their correct use differ between countries. conclusions this study cannot provide evidence of a causal link between an emc switch and subsequent changes in abortion/live birth rates. however, pooled data, timely correlation of drops in abortion/live birth rates with emc switch and the increase of emc use after the switch suggest that overthe-counter availability of emcs contributes reducing unwanted pregnancy especially among teenagers. further studies are necessary to explain why in many countries the reduction of abortion rates was limited mainly to younger age groups (according to danish data, per capita use of emcs is highest among teenagers, thus possibly older women use generally emcs less in other countries, too). also, the question should be addressed why in some countries the decline of abortion rate was visible several years after the emc switch only, despite of an italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 13 | 16 immediate and substantial rise in emc consumption after the change. weighing the pros and cons, it seems that in sum, the benefits of otc access to emcs may prevail. additional measures such as free-of-cost dispensing of emcs to minors or intensive information campaigns may support achieving lower abortion rates, if the switch to non-prescription status proves being not sufficient. reasonable self-medication, however, requires safe and affordable drugs, access to high-quality advice about emcs (e.g. in pharmacies) and/or well informed people. acknowledgements we would like to thank all authorities who contributed detailed information and also gedeon richter for providing data with regard to the date of switch of emcs in bulgaria and romania. references 1. the european society of contraception and reproductive health (esc) and the international federation of gynecology and obstetrics (figo) [internet]. the global epidemic of unintended pregnancies. available from: https://www.figo.org/sites/default/fil es/uploads/generalresources/figo_esc_unwanted%2 0pregnancy%20slides.pdf (accessed: may 11, 2019). 2. guttmacher institute [internet]. new study finds that 40% of pregnancies worldwide are unintended. 2014. available from: https://www.guttmacher.org/newsrelease/2014/new-study-finds-40pregnancies-worldwide-areunintended (accessed: may 11, 2019). 3. european consortium for emergency contraception [internet]. available from: www.ec-ec.org (accessed: may 11, 2019). 4. italia s, brand h. status of emergency contraceptives in europe one year after the european medicines agency’s recommendation to switch ulipristal acetate to non-prescription status. public health genomics 2016;19:203-10. 5. sedgh g, finer lb, bankole a, eilers ma, singh s. adolescent pregnancy, birth, and abortion rates across countries: levels and recent trends. j adolesc health 2015;56:223-30. 6. borsch j. 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[spanish] 28. rosato e, farris m, bastianelli c. mechanism of action of ulipristal acetate for emergency contraception: a systematic review. front pharmacol 2016;6:315. doi: 10.3389/fphar.2015.00315. 29. henry n, schlueter m, lowin j, lekander i, filonenko a, trussell j, et al. costs of unintended pregnancy in norway: a role for long-acting reversible contraception. j fam plann reprod health care 2015;41:109-15. 30. thomas cm, cameron s. can we reduce costs and prevent more unintended pregnancies? a cost of illness and cost-effectiveness study comparing two methods of ehc. bmj open 2013;3:e003815. doi: 10.1136/bmjopen-2013-003815. 31. taylor d. emergency contraception shock: 355 per cent rise in demand for morning after pill in scotland. daily record [internet] 2013 sep 4. available from: https://www.dailyrecord.co.uk/news/ health/355-rise-demand-morningafter-2248387 (accessed: may 11, 2019). 32. trilla c, senosiain r, calaf j, espinós jj. effect of changes to cost and availability of 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health matters 2004;12:174-83. 37. roshi d, italia s, burazeri g, brand h. prevalence and correlates of emergency contraceptive use in transitional albania. gesundheitswesen 2019;81:e127e132. doi: 10.1055/s-0043-119085. ___________________________________________________________ © 2020 italia s et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.abda.de/fileadmin/assets/zdf/zdf_2018/abda_zdf_2018_brosch.pdf https://www.abda.de/fileadmin/assets/zdf/zdf_2018/abda_zdf_2018_brosch.pdf https://www.abda.de/fileadmin/assets/zdf/zdf_2018/abda_zdf_2018_brosch.pdf https://postinorpill.com/about-richter-gedeon/ https://postinorpill.com/about-richter-gedeon/ kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 1 | 17 phd disseratation navigating barriers to gender equality in the european union context: the case of healthcare sector stavroula kalaitzi1 1 department of international health, care and public health research institute (caphri), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands. corresponding author: stavroula kalaitzi, phd; care and public health research institute (caphri), department of international health, maastricht university; address: duboisdomein 30, 6229 gt maastricht, the netherlands; telephone: +306932285055; email: valia.kalaitzi@maastrichtuniversity.nl. kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 2 | 17 abstract context: progress towards achieving gender equality in the european union context is reported slow and fragmented, although some achievements have been made. scholarship has been discussing extensively the gendered barriers, yet their manifestation on a comprehensive and prevalence basis has received scant attention so far. highlighting the big picture of all (in)visible gendered barriers and their manifestation in relation to countries’ specificity may contribute in understanding better the missing link between policy and practice. this study aims firstly, to identify comprehensively the gendered barriers and their prevalence, and secondly, to gain deeper insights on how a persisting policy problem at the eu and member states level remained poorly addressed for over two decades. methods: a mixed methods approach was adopted to ensure the qualitative research quality criteria. the systematic literature review, questionnaire and semi-structured interviews methods to obtain and analyze data were included. qualitative analysis was supplemented by the fundamental tenet of feminist research on the centrality of women. results: twenty-six gendered barriers with quantitative logic and varying degree of prevalence were identified and depicted in the barriers thematic map (btm) across healthcare, academia and business sectors. twenty and twenty-one gendered barriers in greek and maltese healthcare settings were found respectively unveiling the country’s specificity in barriers’ manifestation. the sustainable development thinking in gender equality objectives in eu and ms was found suffering from inconsistencies and misplaced priorities. conclusion: the gendered barriers are multiple, manifest themselves in chorus and with a varying degree of prevalence across sectors and are greatly influenced by country’s specificity. evidence informed gendered policies respecting national priorities may need to be revisited by policy actors to deliver the promised egalitarian social orderand sustainable future for the eu citizens. keywords: gendered barriers, gender equality, women’s leadership, barriers thematic map, european union gender policy. kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 3 | 17 introduction progress towards achieving gender equality in the european union context is reported slow, fragmented and uneven. arguably, the centrality of gender equality in eu’s legal and policy commitments has not yet been translated in adequate gender equality outcomes across member states, although some achievements have been made (1). for example, employment rates have reached historically the highest levels in the eu and more women are in leading positions than ever, whereas the gender gap in education is being closed and even reversed in some disciplines. yet, women participate in labor market at about 11,5% less than men, are paid at an average 16% lower than men and they hardly reach an equal share on the highest decisionmaking echelons assuming only 6,3% of ceo positions in major companies across eu (2). hence, many indicators on gender equality are stagnating, while others are worsened in several member states (3). scholarship on gender equality and women’s leadership is productive in dispelling myths and facts about several forms of gender inequalities, yet shedding light in a scattered and fragmented way on gendered barriers. the manifestation of barriers within an organization or a sector on a comprehensive and prevalence basis has received scant attention so far. for example, stereotypes, gender pay gap, bias, sexual harassment have been explored on a one to one basis, but rarely through the big picture perspective and how each barrier contributes to shape this picture (4-6). this study aspires to highlight the big picture of all (in) visible gendered barriers, the context within which they are developed, the underlying mechanisms that feed the durability and transferability of each barrier within socio-cultural and economic reality and which may be the missing link between policy and practice. thereby, understanding the barriers that make up the labyrinth of women’s leadership (7) may provide deeper insights on how to address effectively the complexities of gender equality challenges at both social and economy level. furthermore, it may make it easier to understand how to dismantle and de-power deeply rooted gendered perceptions, and to develop effective and gender responsive policies. thereby, this study aims firstly, to identify the gendered barriers and their prevalence across sectors, such as healthcare, academia and business on the grounds that these sectors cover a big part of society and economy, and, secondly, to gain deeper insights on how a persisting and central policy problem at the eu and member states level remained poorly addressed for over two decades (8,9). to have a clearer focus and gain deeper insights on gendered barriers, current research concentrated on healthcare sector for three reasons: firstly, women are significantly underrepresented in leading positions across healthcare although the sector being women populated and their added value is widely acknowledged; secondly, healthcare sector is currently considered one of the major employers, encompassing several domains, such as academic, clinical and medical, and job categories; and, thirdly, healthcare is of critical importance to health systems’ sustainability; health workforce is a key component to health systems, whereas the gender balanced health workforce is linked to health systems’ improved performance (10,11). these features are considered to offer ample ground to gain deeper insights on the research question. thereby, the research is developed at the intersection of gendered barriers in the healthcare sector within country’s socio-cultural and economic contexts. kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 4 | 17 methods this study applied a qualitative research methodology built on a profound concern to understand the explored phenomenon and offer an interpretation of informed and sophisticated knowledge reconstructions (12). adopting the social constructionism paradigm and on the grounds that some methods are more suited than others for conducting research on human construction of social realities (13), this study applied a mixed methods qualitative approach to ensure the quality criteria of trustworthiness, authenticity and triangulation incongruence of experiential and practical knowing (12). in alignment with the qualitative research commitments, the research included obtaining and analyzing textual data, such as comments on a questionnaire and interviews’ transcripts and data generated from the interaction between researchers and participants. reflexivity relied on critical subjectivity; transparency as the study progresses, contextual understanding of particular social processes and application of qualitative research findings to other situations were also included in methodology considerations (14). qualitative research was supplemented by the fundamental tenet of feminist research on the centrality of women aiming to “put the social construction of gender at the center of one’s enquiries” (15) and interpret the experiences through immersion in the data (16). study design and methods a mixed methods qualitative approach was applied to collect a variety of enriched data on the barriers to women’s leadership and gender equality, validate the findings and triangulate the results (17). following progressive analysis and comparison of collected data, an explanatory theory was formulated on addressing effectively the explored phenomenon and be plausibly applied and tested in other contexts (18). the study was supplemented by qualitative findings on eu gender equality policy and implementation to deduce conclusions on potential policy inconsistencies and ways of improvement. the study was grouped into three parts (figure 1). figure 1. study design and methods kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 5 | 17 i)problem statement and hypothesis: a systematic literature review was undertaken aiming a) to uncover gendered barriers across healthcare, academy and business sectors, b) to contrast the differences in gendered barriers across sectors and c) to develop the gendered barriers thematic map (btm)with quantitative logic and a prevalence chart. the geographical target of the study was europe with the time range for publications from 2000 to 2015 (19). ii) hypothesis testing: the hypothesis testing on btm and barriers’ prevalence was focused on healthcare sector within two eu countries’ socio-cultural and economic contexts: greece and malta. it was deployed in two sub-studies: one exploratory study conducted within one country’s healthcare sector and one comparative study realized in two countries’ healthcare sector (academic, clinical and medical facets): the exploratory study was set out aiming to forage for the most and the least important barriers to women’s leadership based on btm. the study was drawn upon perceptions of women healthcare leaders in greece in relation to gendered barriers; interest stemmed from country’s poor performance on gender equality index and current economic turbulence (20). the semi-structured interviews, comparative study was conducted aiming to assess empirically gendered barriers to women’s leadership in healthcare through the lens of national socio-cultural and economic contexts. study focused on greece and malta; interest was drawn from countries’ poor performance in the gender employment gap and the rapid socio-cultural and economic changes occurring in the european mediterranean region (21), and iii)eu policy and implementation level: an interpretive discourse analysis was followed to gain deeper insights of the sustainable development thinking in gender equality policy agenda adopted by eu and in relation to its relevance to interests and challenges faced by member states’ citizens. in particular, the relevance of eu sdg5 themes and indicators and the prioritization of policy objectives to actual social reality across member states was considered. a qualitative analysis of organizational change was used to explore the transformative capacity of the developed eu gender mainstreaming toolkits aiming to unpack the complexity among toolkits, organizational culture, climate and outcomes and to gain nuances on potential room for improvement. data collection to ensure the trustworthiness of the findings, qualitative and quantitative data was harvested from primary and secondary sources (12). primary data:  primary data on barriers to women’s leadership and their prevalence was harvested applying a systematic literature review method (19).  primary data of an online questionnaire harvested by 30 purposively invited women healthcare greek leaders (20).  primary data was collected from 36 semi-structured interviews with healthcare leaders, including women and men in greece and malta (21). secondary data:  a content analysis of ten websites of key organizations, such as european parliament, european institute for kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 6 | 17 gender equality, standing committee of european doctors, the world bank, mckinsley global institute.  eu evaluation reports and policy documents, communications, minutes of high level  a narrative literature search in google scholar, pubmed, web of science and on dedicated websites discussing the implications of economic crisis on gender equality and on healthcare sector.  a narrative literature search on interpretive discourse analysis of eu gender equality policy and the adoption of eu sustainable development goals (sdgs).  a narrative literature review on theory of organizational and social change and on implementation sciences. ethical approval ethical approval was received from ethics committees from maastricht university (no metc 16–4-266, january 19, 2017), national and kapodistrian university of athens (medical school) (february3, 2017) and from the university of malta (march 10, 2017). theoretical and conceptual considerations the explored topic involves several aspects and thus requires an all-encompassing approach which may not fall easily into a single theoretical framework. the study applies theories of gender equality, women’s leadership, gender equality policy and implementation at eu and member states level. gender equality in this study the concept of gender is approached as a cross-cutting socio-cultural and economic variable (22, 23). gender is understood as “the socially constructed roles, behaviors, activities and attributes that a given society considers appropriate for women and men” (24) in contrast to “sex” referring to “the different biological and physiological characteristics of males and females such as reproductive organs, chromosomes, hormones, etc.” (25). these characteristics tend to differentiate humans as men and women, whereas gender refers to a socially acquired identity connected to “being male or female in a given society at a given time and as a member of a specific community within that society” (26, 27). hence, gender identity prescribes what is expected, allowed or valued in a woman or a man within a given context (22, 23). gender equality refers to “equal visibility, empowerment, responsibility and participation of women and men in all spheres of public and private life. it also means an equal access to and distribution of resources between women and men and valuing them equally” (28). also known as “equality of opportunity” (29), it implies that women’s and men’s interest, needs and priorities are taken into consideration irrelevant to their gender. thus, it is recognized that gender equality is not a women’s issue but should interest and fully engage men and women in the sense of supporting women’s capacity to make life choices in a context where this capacity was previously denied to them (27,28). gender equality policy in the eu context european union anchored firmly the concept of gender equality in the european treaties and expressed its commitment with policies on economic development, social cohesion and democratic societies (30). the milestones of the trajectory of gender equality policy agendas arrayed from the treaty of rome (1957, art 141) focusing on “equal pay kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 7 | 17 for equal work” to the treaty of amsterdam (1997, art 3.2) “to eliminate inequalities and to promote equality between men and women” in all eu activities (31-33). later, in the treaty of lisbon (2009) (34) eu broadened its binding commitment to observe gender equality principle and pursuit gender equality objectives. in 2015 eu committed to fully integrate the un sustainable development goal towards achieving gender equality and women’s empowerment (sdg5) in eu policy framework under the concept of social and economic development. gender equality and women’s leadership women’s leadership has been perceived as central component towards achieving gender equality and women’s empowerment objectives within eu sustainable development policy framework (33). in particular, the target of women’s leadership advancement was embedded directly to the theme of “leadership positions”, but was also related indirectly to themes of “education” and “employment” (35). hence, women’s leadership advancement was approached to a certain extent by eu policy agenda as a driver to equal opportunities for full and effective participation to leading positions at all levels of decision making, in all employment areas and in all societal spheres (2). women’s leadership in the healthcare sector healthcare is populated mainly by women; 74% of health workforce are women but only 14% assume high level positions in decision making (10). the healthcare sector is regarded as an investment driver across european union (36,37) and, thereby, is considered a key component for health systems’ sustainability. it also enjoys a prominent position among the biggest employers in eu (35). however, health systems miss female talent and perspectives, especially in higher echelons and turn weaker, underperformed since the women who deliver them do not have an equal say in the management and leadership of the systems, they know best (38). hence, a substantial share of talents pool remains untapped, whereas the deficit for transformative leaders in healthcare grows bigger. findings the undertaken qualitative study produced the following findings: part i explored the barriers to women’s leadership and gender equality across three vital sectors, healthcare, academia and business in eu context. a comprehensive map of barriers to women’s leadership was devised. the barriers thematic map (btm)included twenty-six barriers with quantitative logic and varying degree of prevalence. the btm uncovered gendered inequalities across sectors and drew attention to under-studied barriers’ prevalence across sectors (figure 2, figure 3, figure 4) (19). kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 8 | 17 figure 2. gendered barriers across healthcare, academy and business sectors – systematic literature review findings figure 3. gendered barriers in business (%), academia (%) and in healthcare (%) kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 9 | 17 figure 4. barriers thematic map (btm) to gender equality part ii focused on hypothesis testing by investigating the btm within social reality, contextualizing and interpreting the findings and gaining in depth insights in relation to research hypothesis on healthcare sector within the context of two, comparable countries, greece and malta. firstly, empirical findings (online survey) on perceptions of greek women healthcare leaders on barriers to career advancement identified the twenty-six barriers included in btm (figure 5) (20). six barriers (stereotypes, work/life balance, lack of equal career advancement, lack of confidence, gender gap, and gender bias) prevailed in women leaders’ perceptions in constraining opportunities for pursuing leading positions in greek healthcare setting, whereas all twenty-six barriers presented varying degree of prevalence. secondly, qualitative research findings (semi-structured interviews) identified twenty and twenty-one barriers to women’s leadership within the greek and maltese healthcare settings, respectively (figure 6) (21). in both research settings prevailing barriers included work/life balance, lack of family (spousal) support, culture, stereotypes, gender bias and lack of social support, yet countries’ similarities and differences in prevalence of the identified barriers were observed. notably, cultural tightness was found to be experienced against socio-cultural transformation in maltese context; the recent economic crisis was found to be responsible for a backlash in previously achieved gender equality objectives in greece. thus, research findings unveiled underlying interactions kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 10 | 17 among gender, leadership and countries’ socio-cultural and economic contexts elucidating the varying degree of strength of norms and barriers embedded in a society’s egalitarian practice. figure 5. a btm-based best-worst scaling (bws) assessment on gendered barriers across greek women healthcare leaders part iii turned to gender equality policy agenda at the eu level. the chapter considered the sustainable development thinking in gender equality policy objectives in eu pertaining to its relevance to challenges faced by member states’ citizens. in particular, the chapter explored the relevance of eu sdg5 themes and indicators and the prioritization of policy objectives to actual social reality across member states. findings identified inconsistencies in application of gender equality related articles binding for both eu and ms (treaty of lisbon, art 2, art 3.3, art 6.1, and art 9), posing thus questions about the prioritization of gendered challenges from eu and national policy actors and stakeholders. the translation of sdg5 into national achievable targets was discussed under the perspective of persistent and uneven gender inequalities across ms. the study argued for eu’s proactive leadership, underpinned by academia and civil society contributions to optimize support to the ms to revisit their national policies and develop evidence-informed policies; thus, the sustainable development efforts may be strengthened to align with the gendered priorities and challenges at ms level. moving to the policy implementation realms, the study identified that the inherent duality of toolkits (gender and governance) may be held responsible for their suboptimal transformative capacity within organizational context; furthermore, the under-developed qualitative elements of the toolkits, such as the sesame features (simple, easy, specific, affordable, measurable and efficient) and the lack of gender expertise at policy and decision makers level may also need to be further developed to facilitate effectively the organizational change processes kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 11 | 17 figure 6. a btm-based semi-structured interviews study on gendered barriers across women and men healthcare leaders in greece and malta discussion european union’s high level legal and political commitment towards achieving gender equality objectives has produced suboptimal outcomes. the gendered priorities misplaced by policy makers and the inconsistent commitment across eu bodies and agencies fostered the persistence of gendered barriers and equal representation in economy and society, undermining thus the undertaken efforts. the policy intentions and policy implementation have not been sufficiently bridged; the suboptimal transferring of the academic knowledge to policy practice servants and the lack of gender disaggregated data feeding bottom up, customized policies at both country and eu level may be hold responsible, amongst others, for shortcomings in policy prioritization and effective implementation (3,9,39,40). inconsistent commitment and lack of collective action gender scholars argue that eu gender policies are the battleground for eu institutions underpinned by shifts in power relations (41). the way gender (in)equality is framed, engages differently the different actors across the eu policy making arena which results in fading away the centrality of the policy problem; hence, the gender equality policy objective is placed as the “side dish” of the actual eu policy making goals (42). for example, the european commission framed gender equality policies through gender mainstreaming in all policies undertaken by actors normally involved in policy making (40,41,43); yet it ended up to bureaucrats with a rather technical than political conceptualization of kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 12 | 17 gender equality principle shaping accordingly the policy agenda (44,45). on that note, inconsistencies in funding and budgeting may conflict directly with the eu’s full legal and political commitment (art 2, art 3.3, art 6.1, art 9; treaty of lisbon, 2007) (34) and, then, result to limited positive impact on gender equality issues, such as gendered unemployment (41,46). lack of gender disaggregated data putting evidence into practice is complicated and context dependent; yet, it remains a dynamic process with a continuous interaction between academic research and policy makers which may identify priorities and evaluate the level of responsiveness to key audiences. almost none of the eu gender related policies incorporate a systematic and consistent mechanism, such as disaggregated data collection, to evaluate whether the policy has successfully responded to its objectives and the potential room for improvement (3,47). the critical gap of a gender disaggregated data pool enhanced the fuzzy evaluation of the gender equality policies, in particular at member states implementation level (47). robust evidence generated by academic knowledge may fill in the gaps in the policy cycle and contribute in developing evidence informed gendered policies, responsive to gendered barriers faced within country’s specific socio-cultural and economic contexts. gendered barriers: the case of healthcare sector the interest of scholars, civil society, european and international agencies on the persisting underrepresentation of women in leading positions and the implications to health systems, economy and society has been growing rapidly during the latest years. for example, a growing interest on gender inequalities in health and healthcare from civil society actors has been observed in recent years. non-governmental organizations (ngos) (e.g., women in global health research initiative) and associations (e.g. european health management association) advocate gender equality in health workforce from several perspectives, such as equal opportunities to career advancement and equal pay. in the same line, european and international agencies keep a close eye to eu region and discussed intensively in recent years the women’s underrepresentation in healthcare. in particular, dr tedros, director general of who, re-stated the necessity for gender transformative action in health (38) and launched the who global health workforce equity hub in 2017 (48). arguably, the considerable, multi-disciplinary effort to unpack the complexity of barriers to gender equality demonstrates scholarship’s unanimous voice on achieving gender equality objectives and, thereby, on addressing the gendered barriers in a feasible and effective way. however, although all involved actors argue for the importance and urgency of gendered challenges in healthcare and established the relevance of gender equality in health workforce to sustainable transformation and governance of health systems, the results remain poor. health workforce is the beating heart of healthcare and health systems which are mainly populated by women. thereby, maybe the extra mile towards achieving a gender balance workforce may need to be undertaken by academia with the main aim to detail the health workforce’s capacity as a change agent towards achieving gender equality objectives within work and social contexts and project the gender balanced health workforce as a paradigm to society and economy. kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 13 | 17 implications the study introduces the feature of comprehensiveness and prevalence of gendered barriers; nonetheless, there is ample room for further research, which would be extremely informative and would maximize the impact of the findings at hand. additional study on the twenty-six identified barriers through a multi-disciplinary lens would be of added value to the field; in particular, the barriers’ contextuality in terms of their durability and transferability might have also been recognized and assessed differently through the lens of several academic disciplines, such as sociology, psychology, political science, management and organizational behavior science, gender science, feminism; similarly, gendered barriers manifestation across various sectors (e.g. ngos, agriculture) would offer interesting insights to the explored phenomenon’ prism. on the grounds of the provided evidence-informed insights on the context sensitive and country specific gendered barriers, policy actors and decision makers are invited to follow the “think globally – act locally” strategy in gender equality policies and practices in their efforts to close the gap between policy and reality. furthermore, the findings of this research may serve to raise awareness to policy and social actors on the gender asymmetries’ influence in terms of power and authority within a country’s social and cultural context. policy and social stakeholders are invited to revisit the level of responsiveness of adopted policies to social audiences and to re-evaluate the dynamic dialogue among societal culture, leadership and gender in enabling social and cultural change. at the author’s best knowledge, this study is one of the first to develop a barriers thematic map (btm) with a prevalence feature. the btm may be developed to a digital tool for self-awareness and a reality check on gendered challenges at organizational level. applying the btm, a snapshot of the gendered barriers’ manifestation and prevalence within organizations may be generated. providing data anonymization, the tool may offer the room to unveil both apparent and implicit barriers experienced by all genders bypassing, thus, potential power relations within organizations. this evidence-based overview may disclose policy gaps and be linked to organizational practices for improvement. the yielded evidence-based information will also contribute to effective use of resources, which may be channeled to fulfil customized needs and, therefore, improve organization’s change capabilities and performance. conclusions the study demonstrated that the gendered barriers are numerous, manifest themselves in chorus and with a varying degree of prevalence across and within sectors and are greatly influenced by country’s socio-cultural and economic contexts. hence, in contrast to published literature, the findings support that barriers to gender equality need to be addressed comprehensively, not on a one to one basis, aiming to capture the wholeness of the problem and, thus, design and implement effective strategies, policies and practices to address the actual priorities and challenges across sectors and within countries’ specificity. the lack of consistent and collective commitment on gender equality objectives at both eu and member states level, may have put forward misplaced gendered priorities and compromise the progress dynamics. thereby, policy and decision makers may find fertile avenues for efficient 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der vleuten a. eu gender equality policies and politics–new modes of governance. https://publications.europa.eu/en/publication-detail/-/publication/950dce57-6222-11e8-ab9c-01aa75ed71a1 https://publications.europa.eu/en/publication-detail/-/publication/950dce57-6222-11e8-ab9c-01aa75ed71a1 https://publications.europa.eu/en/publication-detail/-/publication/950dce57-6222-11e8-ab9c-01aa75ed71a1 https://publications.europa.eu/en/publication-detail/-/publication/950dce57-6222-11e8-ab9c-01aa75ed71a1 https://ec.europa.eu/eurostat/web/products-statistical-books/-/ks-01-18-656 https://ec.europa.eu/eurostat/web/products-statistical-books/-/ks-01-18-656 https://ec.europa.eu/eurostat/web/products-statistical-books/-/ks-01-18-656 kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 17 | 17 © 2020 kalaitzi; this is an open access 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increased the quantity and quality of distance education programs and the upcoming blended learning models. however, some basic difficulties in defining meaningful terms instead of buzzwords, often used in the present debate, will be discussed to raise consciousness of the rather vague terminology. the progress of digital technologies offered also a chance for better inclusion of disadvantaged parts of the population. the focus lies on the young generation of school attendants and how technology-oriented programs can provide better inclusion. we put a regional focus on development in latin america. to highlight some of the issues discussed before, we will present a detailed case study about the argentinean project “conectarigualdad”. we have also added a brief comparison with some other latin american initiatives. summarizing we list considerations for a successful inclusive application of digital technologies in education. keywords: argentina, conectarigualdad, digital, digitalization, digital technology, inclusion, netbooks, one laptop per child. conflicts of interest: none. mailto:wolframlaaaser@gmail.com laaser w, exeni c. introduction of digital technologies in education concepts and experiences (review article). seejph 2019, posted: 06 june 2019. doi 10.4119/unibi/seejph-2019-220 page 2 of 10 introduction during the last decades, information and communication technologies advanced at a fast rate and impacted on education, especially on distance education, both, in a qualitative and in a quantitative way. the range of options of how to introduce and apply the new technologies in online distance education were manifold. the recently upcoming format, called moocs (massive open online courses) is an example. moocs give open access to knowledge of well-known universities at zero or at least low cost, without asking for any necessary certificate about prior qualification. moocs range from free of charge short online courses with massive enrolment up to offers of complete online master degree course. some moocs are directed to an open non-expert general public, e.g. a mooc for integration of refugees, others are directed to the higher education segment. the structure then will be more curriculum bound. many moocs form part of continuous adult education or are applied in enterprises for “training on the job”. moocs attracted students from all over the globe. the first moocs started in canada with a constructivist studentcentred approach. later some well-known us american universities took over and changed moocs to a behaviouristic model. the open courses demonstrated their impact on distance learning by use of online pre-recorded video lectures instead of printed study units and multiplechoice tests instead of written or oral exams. however, the video presentation format was simple and the assessment and evaluation not very profound (1). today, moocs are offered by many national universities from all over the world. however, they represent only a small part compared to the total number of traditional courses. in this context we could observe nevertheless some changes of educational practices, though, even today we still find educational practices which emulate traditional classroom teaching approaches while applying new web-based technologies. however, more relevant is the stepwise upsurge of a pedagogy with tics. new affordances for teachers and students are required. a prominent example is the tepac (technological pedagogical content knowledge) model which describes the necessary qualifications, teachers must acquire to make meaningful use of the new technological devices. the concept has been developed during the years 2006 to 2009 at michigan state university (2). figure 1. tpak model (source: google images) with respect to students’ affordances bates postulates: “in order to develop the skills students need in the 21st century, we need to focus more on skills development than on the transmission of content. online learning can focus better on the development of soft skills, such as communication and knowledge management. everything on the internet is a potential study material” (3). a detailed example of the expected advances to be laaser w, exeni c. introduction of digital technologies in education concepts and experiences (review article). seejph 2019, posted: 06 june 2019. doi 10.4119/unibi/seejph-2019-220 page 3 of 10 achieved with the use of computers in schools is the expectation that the 1112years old kids should acquire the following abilities:  creativity and innovation  communication and collaboration  search and information management  critical thinking  problem solving  decision taking and being a digital citizen at the same time, technological tools have been developing according to the needs of these educational processes and the advancement of digital technologies. likewise, we have a variety of virtual platforms, educational portals, repositories, libraries with e-books, virtual labs, etc. accordingly, there has been a paradigmatic shift in the design and delivery of educational materials. at present, distance learning uses multimedia and interactive technologies, for example: animated graphs, simulators, educational video games, streamed podcasts and vodcasts, etc. deficiencies in the definition of some related concepts with the changes towards a digital environment, new concepts emerged with labels such as “digitization”, “digital school”, “university of the future”, “education for the digital century”, “intelligent learning” or “algorithmic learning”, to describe the introduction and/or application of technologies in education. the denomination of these terms is often sketchy but not very succinct. the word “digital”, for example, refers in mathematics to the representation of analogous information by a combination of the digits 1 and 0. digitization then is the process of transforming analogous information into its digital form. what then is a “digital school or university?” basically, the digitization in the educational field is seen as a process of transformation towards implementation of digital technologies in teaching and learning. but this transformation is more complex and not exclusively a technical problem. consequently, segura, quinteros & mon (4) confirm that the “digital university” is a social and material reality and is the product of the complex relationships that are established. digital is an adjective that no longer describes almost anything in the current university. many of the concepts used today refer to technologies as drivers of teaching and learning processes. people share beliefs that using the latest new technology is the most important way to modernize education and will solve most educational problems, ignoring the necessity of teachers who can work with digital tools and/or develop lesson plans or school projects. this perception is backed by companies who market the digital equipment and the respective software and thereby push the sale of their products. audrey watters calls it the “silicon valley” ideology: “educational technology is, after all, a series of practices itself-it is not just the hardware or software. ed tech carries with it ideologies and ideas” (5) and in another blog post she wrote: “the tech sector does love stories-grand narratives and make-believes and mythologies about revolution and disruption and innovation” (6). however, the way people accept, use and handle learning technologies is crucial in determining the success or failure of the introduction of new technologies. that is why we think, it is important to highlight how digital technologies can or should be implemented in the public educational sector. laaser w, exeni c. introduction of digital technologies in education concepts and experiences (review article). seejph 2019, posted: 06 june 2019. doi 10.4119/unibi/seejph-2019-220 page 4 of 10 new generation features information and communication technologies were created mainly for the private consumer market or business and not for educational use. however, they were very quickly adopted by the new generations who gave the mother uses: fun, games, socialization, informal learning, etc. in 2001 marc prensky (7) revolutionized the perspective on the relationship between the different generations and ict with the concepts “digital natives” and “digital immigrants”. a series of studies and research focus on the numerous and complex facets that link children and young people with ict education, such as: changes in social dynamics, the relocation of content, the new meaning of the learning process and schools, the connotation of technologies. for this reason, the works of emilia ferreiro (8) [“nuevastecnologías y escritura” -new technologies and writing], together with dussel [“aprender y enseñaren la cultura digital”learning and teaching in digital culture-], morduchowicz [“los adolescentes y las redessociales” -adolescents and social networks-] martin barbero [“estallido de losrelatos y pluralización de las lecturas” outbreak of the stories and pluralization of the readings-], virdo (los “neonativosdigitales” -the digital “neonatives”-]and sibilia [“la intimidadcomoespectáculo” -the intimacy as spectacle-], among others, tackle the conflicts and frictions that today marks the education of children and young people. today we know that ict increases the flow of personal interactions constantly, creates new bounds with knowledge and is used to legitimize ideological frameworks. it has a market and symbolic value that determines positions in indifferent social strata. that is why those who do not have access to digital technologies are excluded. silvia bacher (9) says: “the informational society brings a new social conception, where the disconnected (homeless children, teachers who do not feel safe in front of their students or seniors who do not access ict) are at risk of being segregated or even more to become live witnesses of a never greater deepening of already existing exclusions. today it is not possible to speak of a digital divide but of digital gaps framed by social gaps.” many students do not have access to the technologies, but it does not imply that they have a way of building knowledge determined by the logic of the screens, because that is the current reference today. emilia ferreiro (8) argues that those who are twenty-five years old or older did the trip from the notebooks to the screens and those who are younger are doing a reverse tour. the researcher also emphasizes the different organizations of technology and of the book industry, and analyses today’s school, in which the adults, as seldom times in history, can recognize a students’ specific knowledge and can learn from them (8). the “conectarigualdad” program (connecting equality) the context the significant impact, that involves the use of ict makes it part of the educational goals for 2021 (10) proposed by the organization of ibero-american states (ois). specifically, goal number 5 establishes the use of these in classroom practices, affirms the potential of ict in education and states: “it is not limited to the digital literacy of the population. it is also expected that these can be introduced across the teaching-learning process, facilitating the creation of modern skills and improving the educational laaser w, exeni c. introduction of digital technologies in education concepts and experiences (review article). seejph 2019, posted: 06 june 2019. doi 10.4119/unibi/seejph-2019-220 page 5 of 10 achievement of the scholar”. from the adhesion to the educational goals for 2021, several latin american countries implemented educational programs with ict, based on the negroponte model “one laptop per child”. the argentine program is in this line one of these programs. objectives and implementation in argentina, the national education act no. 26206 (10) is sanctioned. this law puts the focus on social inclusion and human rights. this framework establishes the use of ict in the classrooms. this is explained in article 100: the national executive branch, through the ministry of education, science and technology, will set the policy and develop educational options based on the use of information and communication technologies and the mass media of social communication, collaborative with the fulfilment of the purposes and objectives of this law (p. 20). accordingly, with this law, the “conectarigualdad” program was created with the purpose of implementing a digital inclusion policy that enhanced public school and reduced the digital, educational and social gaps in argentina. figure 2. conectar igualdad reaches the most vulnerable sectors (source: google images) the program focused on two lines of action:  deliver netbooks to students and teachers of middle school, high school, college (associate degree) and special education 1 to 1 (“one laptop per child”);  to train teachers in the pedagogical use of ict and to guide them in their classroom practices while using netbooks. equipment the implementation of the program began with building “technological floors” in each school. each one had a school server which was connected to each of the netbooks. each netbook was delivered to teachers and students of that school. it also disposed of a school network through a switch and access points placed in each of the classrooms. five million netbooks were delivered during five years of the program. two years later the “digital elementary” program was added. this program also provided netbooks to schools, but in the format of “mobile digital classrooms”. these included: 30 laaser w, exeni c. introduction of digital technologies in education concepts and experiences (review article). seejph 2019, posted: 06 june 2019. doi 10.4119/unibi/seejph-2019-220 page 6 of 10 netbooks, an interactive digital whiteboard, a projector, a router, a server and a cart to transport equipment. training and guidance education with technologies has many epistemological perspectives. considering the articulation between the specificities of each science and the inclusion of ict, unprecedented specializations were done in the field of education, communication and educational technology to be able to address them. for the netbooks, help desks were provided with software and educational materials according to each of the recipients. even today it is possible to find on the web and download the “teacher’s desk”, the “student’s desk”, the “student desk for ese (exceptional students education)”, etc. in addition, many multimedia educational materials have been developed and were available in different formats and platforms. for example, television channels such as “paka-paka” and “encuentro”, the first directed to early childhood and the second to audiovisual educational and cultural topics. in addition, the official educational portals, such as connect, educ.ar and digital elementary are accessible. at the same time, "huayra" gnu/linux was developed, an operating system for the argentine educational community based on debian. this operating system had applications, suggested by teachers and was constantly renewed. the netbooks carried two operating systems “huayra” and windows. the pros and cons of the “conectarigualdad” program over the course of its few years, the program has received both criticism as well as positive comments. detractors argue that no improvement in educational quality was visible. they also emphasized the fact that students use netbooks to connect to social networks and video games. those in favour of “conectarigualdad” said that the program improves learning and that the school does not consider in the classrooms. also, it evaluates the quality of education from paradigms that do not contemplate the ways that new generations are learning. the emphasis of the criticism was on the school, however the main objective of the program was to promote the inclusion of those more vulnerable social sectors that otherwise would not have had access to a computer with all that what it socially means. the criticism, based on the helpless, argue that “the poor need to cover basic needs: food, medicine, a home, etc.”. now, it is precisely about the consumption of “superficial” goods where the processes of distinction and classism are established in stratified societies such as ours. perhaps what irritates the people about the “conectarigualdad” program is that they are granted free goods that are expensive and could be used as signs of distinction by the dominant classes (12). laaser w, exeni c. introduction of digital technologies in education concepts and experiences (review article). seejph 2019, posted: 06 june 2019. doi 10.4119/unibi/seejph-2019-220 page 7 of 10 figure 3. drone and robot model of the “aprender conectados” (learning connected) program (source: ministry of education, argentina) the “conectarigualdad” program was disabled and in its replacement, “aprender conectados” (learn connected) was created. this new program changes the target and puts focus on competitiveness, innovation and digital inclusion. for their implementation, they take the existing equipment in the schools (that “conectarigualdad” left) and distribute robots and drones with different degree of complexity to kids, aged eight years or more. for about 30 students five items are at their disposal. the delivery of these resources has not been well received by the teachers. they argue that they cannot do very much. once students learn to program robots and drones, which they do quickly, the resource loses its educational function, unlike computers that have a lot more possibilities. in this regard, da porta (13) says: “the bombastic release of ‘aprender conectados’ put the emphasis on the promises and illusions of technology, it makes evident the rejection of an equal social policy that even with its issues was able to articulate school and educational rights as a chance to jump the deep gap in inequality.” comparative evaluation of similar programs in mexico and uruguay the literature about the effectiveness of delivering free computers to schools is quite limited. one reason may have been that projects have been used to increase political prestige and were losing support from the next government. in latin america, uruguay was a forerunner with the plan ‘ceibal’ as a partner in negropontes “one laptop per child” campaign. mexico followed next with the “@aprende” project, which was set up to create an internet platform with support material for using technology at school or at the university, and the micompumxprogram for introducing computers to basic schools. the following tables show some facts about these programs. laaser w, exeni c. introduction of digital technologies in education concepts and experiences (review article). seejph 2019, posted: 06 june 2019. doi 10.4119/unibi/seejph-2019-220 page 8 of 10 table 1. comparison of national programs program number of computers delivered program coverage number of trained teachers evaluation plan ceibal (uruguay) 2003 1.000,000computers have been delivered 99% of students with laptops and 99% of schools with online access 4000 teachers trained under this program it has been possible to universalize access to computers for homes with school-age children. likewise, the public school has become the axis of digital experience. micompumx (mexico) 240.000 computers delivered the pilot program was implemented in three states: colima, sonora and tabasco from 2009 to 2012 a total of 11.060 teachers have been trained. currently, there are no data on the results of the project or associated initiatives. all these actions are in the process of development and implementation. conectarigualdad (argentina) in 2004 100 % of the students have a computer. it is a total of 4.979.682 99,5 % covered 600.000 teachers trained it is said that there were changes in the way of teaching and the program promotes horizontal communication to improve the teacher/student relationship and to make students more active. the acceptance of the programs will be increased if the characteristics of the target groups are analysed before the program starts. for example:  some of the students, who received a laptop had no or deficient internet connection;  down loading of files was too slow;  the technical support was not sufficiently qualified;  teachers were not willing to spend extra time;  the training sessions were too short;  the quality of the teaching content was not well integrated with the curriculum. an important factor for success is a highspeed network infrastructure and wellstructured web-portals that contain free downloadable content as well as uploading of user created content. however, perhaps most important is the motivation of teachers to make creative use of digital facilities. it is interesting to state that there are few research papers that are checking the efficiency and sustainability of the huge latin american national programs, which aim at reduced exclusion from educational options and to raise the level of computer literacy by introduction of teaching and learning with digital technologies. however, the programs have their own dynamics and are changing and adjusted continuously. the answers given today will be different tomorrow. conclusion finally, we can conclude that the delivery of netbooks to the students and, by extension to their families was the right decision to take to increase inclusion and to reduce the digital gap. while schools should not follow the logic of the consumer market, when it comes to thinking about the incorporation laaser w, exeni c. introduction of digital technologies in education concepts and experiences (review article). seejph 2019, posted: 06 june 2019. doi 10.4119/unibi/seejph-2019-220 page 9 of 10 of technologies in educational processes, an important point to consider is the updating of technologies and their consequences in the social dynamics. today, young people weigh and value mobile devices over other technological artefacts. with this tool they communicate, fall in love, and have fun, play, do banking, work, report and study. for both private and public uses they found only one technology. in perspective, questions remain, how will education with technologies be in a not too distant future? what new concepts will emerge? what new tools will determine the social inclusion of young generations? who will determine the educational paradigms: teachers or the consumer market of technologies? references 1. laaser w, tolozaea. the changing role of the educational video in higher distance education. irrodl 2017;18.available at: https://files.eric.ed.gov/fulltext/ej1138780 .pdf (accessed: may 20, 2019). 2. koehler mj, mishra p. what is technological pedagogical content knowledge? cite 2009;9:60-70. https://www.researchgate.net/publicatio n/241616400_what_is_technological_ pedagogical_content_knowledge (accessed: may 20, 2019). 3. bates aw. online learning and disruptive change at the uk open university 2018. may 2: 2018. https://www.tonybates.ca/2018/05/02/o nline-learning-and-disruptive-changeat-the-uk-open-university/ (accessed: may 22, 2019). 4. segura j, quinteros l, mon f. towards ubersity? conflicts and contradictions of the digital university. ried 2018;21:51-68. doi: http://dx.doi.org/10.5944/ried.21.2.2066 9 5. watters a. 2015 trends. retrieved from:http://hackeducation.com/2017/12/ 20/top-ed-tech-trends-robots-kids (accessed: may 20, 2019). 6. watters a. the tech sector does love stories – grand narratives and makebelieves and mythologies about revolution and disruption and innovation. http://hackeducation.com/2018/04/26/cu ny-gc (accessed: may 20, 2019). 7. prensky m. digital natives, digital immigrants. by marc prensky. on the horizon. mcb university press 2001; 9, 5 (accessed may 20, 2019). 8. ferreiro e. presentación de cátedra emilia ferreiro. universidad nacional de rosario. https://www.youtube.com/watch?v=q8 c-v8owork (accessed: may 20, 2019). 9. bacher s. la infancia, ¿conectada? la nación, revista. http://silviabacher.com.ar/articulo3/ (accessed: may 20, 2019). 10. inter-american children’s institute and organization of ibero-american states. agreement of cooperation (2019). http://iin.oea.org/pdf-iin/informe90/en/agreement_cooperation_iin_o ei.pdf (accessed: may 20, 2019). 11. library of congress argentina: constitutional right to an education law 26,206 on national education, adopted on dec. 14, 2006. https://www.loc.gov/law/help/constitut ional-right-to-aneducation/argentina.php (accessed: may 20, 2019). 12. larghi b. selogio de unfracaso. la dimension simbólicadel programa conectarigualdad. (praise of a “failure”: the symbolic dimension of laaser w, exeni c. introduction of digital technologies in education concepts and experiences (review article). seejph 2019, posted: 06 june 2019. doi 10.4119/unibi/seejph-2019-220 page 10 of 10 the conectarigualdad program). juv;2016:10. 13. da porta e. aprender conectados o cómoborrar la igualdad pordecreto. conversaciones necesarias entre educación, cultura y política. https://conversacionesnecesarias.org/2 018/05/11/aprender-conectados-ocomo-borrar-la-igualdad-pordecreto/ (accessed: may 20, 2019). ______________________________________________________________________________________ © 2019 laaser et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. caushaj k, czabanowska k, roshi e, muja h, burazeri g. leadership competencies among male health professionals in a western balkan country (original research). seejph 2019, posted: 26 april 2019. doi 10.4119/unibi/seejph-2019-213 page 1 of 9 original research leadership competencies among male health professionals in a western balkan country klevis caushaj1,2, katarzyna czabanowska1,3, enver roshi4, herion muja4, genc burazeri1,4 1 department of international health, school caphri (care and public health research institute), maastricht university, maastricht, the netherlands; 2 american hospital, tirana, albania; 3 institute of public health, faculty of health sciences, jagiellonian university, krakow, poland; 4 department of public health, faculty of medicine, university of medicine, tirana, albania. corresponding author: katarzyna czabanowska, phd; department of international health, maastricht university, faculty of health, medicine and life sciences, school caphri, maastricht, the netherlands; email: kasia.czabanowska@maastrichtuniversity.nl caushaj k, czabanowska k, roshi e, muja h, burazeri g. leadership competencies among male health professionals in a western balkan country (original research). seejph 2019, posted: 26 april 2019. doi 10.4119/unibi/seejph-2019-213 page 2 of 9 abstract aim: our objective was to assess the current and the required level of leadership competencies among male health professionals in albania, a country which is characterized by an intensive process of emigration of the health workforce in the past few decades. methods: this was a cross-sectional study carried out in albania in june-november 2018 including a nationwide representative sample of 132 male health professionals working at different health institutions at both central and local level in albania (mean age: 41.4±10.1 years; overall response rate: 88%). a structured 52-item questionnaire was administered to all male health professionals aiming at self-assessing the current level and the required (necessary) level of leadership competencies for their actual job positions. answers for each item of the instrument ranged from 1 (“minimal competency level”) to 5 (“maximal competency level”). an overall summary score (range: 52-260) and a subscale summary score for each domain were calculated for both the current and the required leadership competency levels. paired sample t-test was used to compare the overall mean scores and the subscale mean scores of the current level and the required level of leadership competencies among male health professionals. results: mean value of the overall summary score of the instrument was lower for the current leadership competency level compared with the required leadership competency level (137.6±8.7 vs. 140.7±21.2, respectively; p=0.02). mean difference between the required and the current level of leadership competencies was higher for male health professionals working in top managerial positions and those working in urban areas of albania. conclusion: this study informs about the current and the required level of leadership competencies among male health professionals in albania, a transitional country in the western balkans. policymakers and decision-makers in albania and other countries in the european region should be aware of the existing gap between the required and the current level of leadership competencies among health professionals operating at all levels. keywords: albania, competency level, male health professionals, public health leadership, western balkans. conflicts of interest: none. caushaj k, czabanowska k, roshi e, muja h, burazeri g. leadership competencies among male health professionals in a western balkan country (original research). seejph 2019, posted: 26 april 2019. doi 10.4119/unibi/seejph-2019-213 page 3 of 9 introduction several competency frameworks have been established in the past decades in order to assess public health leadership and medical leadership competencies in different countries (1-4). all of these instruments consist of the core principles and concepts of leadership (5,6). however, most of the existing frameworks assessing leadership competencies in the field of medicine and public health are quite broad and non-specific enough. as a matter of fact, such general frameworks do not allow for an appropriate assessment of the level of leadership competencies, as a major requirement for modification and finetuning of the educational curriculum and training models for public health professionals (7). based on these considerations, in the past few years, it has been successfully developed a new and more specific public health leadership competency framework aiming at promoting considerably the competency-based european public health leadership curriculum (7). this competency framework was part of the “leaders for european public health (lephie) erasmus multilateral curriculum development project”, which was supported by the european union lifelong learning programme (7). this framework has been already adapted and used in the albanian context (8,9). albania is a post-communist country in the western balkans, which has experienced a rapid demographic and epidemiological transition in the past few decades (10). currently, non-communicable diseases (ncds) and its associated risk factors constitute the highest burden of disease in albania (10). hence, according to the estimates of the global burden of disease, the crude mortality rate from the overall ncds in albania in 2016 was about 731 (95%ci=646-804) deaths per 100,000 population (11). almost 94% of albanian people died from ncds in 2016 (11). furthermore, about 84% of the overall disease burden in 2016 was attributed to the ncds. for the same year, the burden of ncds was estimated at about 22,260 (95%ci=19,380-25,280) dalys per 100,000 (11). a whole range of risk factors are currently contributing to the ncd situation in albania. yet, the top three leading factors responsible for the disease burden in the albanian population include the arterial hypertension, nutritional-related risks and smoking (11). the albanian health system is currently facing a multitude of challenges including the sufficiency and sustainability of health financing mechanisms in line with the ongoing reforms in all sectors (12). furthermore, out-of-pocket payments still constitute almost half of the overall health expenditure in albania and bear significant impoverishing effects upon the poorest and vulnerable and marginalized population categories. also, human resources for health is another issue which currently represents a tremendous challenge (12) given the unabated brain drain from albania to the western countries, mainly to germany which has become particularly attractive in the past few years for young physicians and nurses. in the context of an intensive process of emigration of the health workforce in the past few years, our aim was to assess the current and the required leadership competency level of male health professionals in albania, using an internationally valid instrument, which has been already applied in albanian settings (8,9). methods a cross-sectional study was carried out in albania in june-november 2018 including a nationwide representative sample of 132 male health professionals working at different health institutions pertinent to caushaj k, czabanowska k, roshi e, muja h, burazeri g. leadership competencies among male health professionals in a western balkan country (original research). seejph 2019, posted: 26 april 2019. doi 10.4119/unibi/seejph-2019-213 page 4 of 9 both the central level (institute of public health, regional health directorates, university hospital centre “mother teresa”, and health insurance fund) and local level (primary health care services, and regional hospitals). initially, 150 male health professionals were targeted for recruitment; of these, 18 individuals did not participate. hence, the final study sample consisted of 132 male health professionals, with an overall response rate of: 132/150=88%. a structured questionnaire was administered to all male health professionals included in this survey. the questionnaire aimed at self-assessing the current level of leadership competencies and the required (necessary) level of leadership competencies based on the actual job position of health professionals. the questionnaire included 52 items categorized into the following eight competency domains (subscales) (7): i) systems thinking; ii) political leadership; iii) collaborative leadership: building and leading interdisciplinary teams; iv) leadership and communication; v) leading change; vi) emotional intelligence and leadership in team-based organizations; vii) leadership, organizational learning and development, and; viii) ethics and professionalism. possible answers for each item of each domain/subscale of the leadership instrument ranged from 1 (“minimal competency level”) to 5 (“maximal competency level”). an overall summary score (range: 52-260) and a subscale summary score for each domain were calculated for both, the current level of competencies and the required level of competencies. furthermore, the gap between the required (necessary) and the current level of leadership competencies was calculated for each participant, as a difference between the summary score of the required level and the current level of leadership competencies. of note, the leadership instrument was validated since 2014 in a sample of health professionals operating in tirana (8) and, after the respective cross-cultural adaptation, this tool was subsequently administered to a nationwide sample of male and female health professionals in albania (9). in addition to the leadership competency level, the structured questionnaire inquired about some basic demographic data (age of male health professionals and workplace: urban areas vs. rural areas); work experience (expressed in full years); main degree obtained (health sciences including medicine, public health, nursing, pharmacy, or dentistry vs. other degrees including economics, social sciences, law, engineering, or other disciplines; this variable was dichotomized in the analysis into: health sciences vs. other diploma); and the current job position (trichotomized in the analysis into: high, middle and low managerial level). this study was approved by the department of public health, faculty of medicine, university of medicine, tirana, albania. the distribution of age and working experience among male health professionals included in this study was presented by use of the measures of central tendency and dispersion (mean values and standard deviations). on the other hand, absolute numbers and their respective percentages were employed for presentation of the distribution of workplace (urban vs. rural areas), main degree obtained (health sciences vs. other degrees) and the job position (top, middle and low managerial positions) of health professionals. cronbach’s alpha was employed to assess the internal consistency for both the current level and the required level of leadership caushaj k, czabanowska k, roshi e, muja h, burazeri g. leadership competencies among male health professionals in a western balkan country (original research). seejph 2019, posted: 26 april 2019. doi 10.4119/unibi/seejph-2019-213 page 5 of 9 competencies (13). conversely, paired sample t-test was used to compare the overall mean scores and the subscale mean scores of the current level of competencies and the required level of competencies among male health professionals included in this survey. a p-value of ≤0.05 was considered as statistically significant. all statistical analyses were performed by use of the statistical package for social sciences (spss, version 19.0). results mean age in this nationwide representative sample of male health professionals (n=132) was 41.4±10.1 years (table 1). in turn, mean working experience was 14.8±9.4 years. about 71% of study participants were working in urban areas of albania, whereas the remaining 29% were operating in rural areas (mainly in tirana, but also in the other districts of albania). about 87% of participants had obtained their main degree in health sciences (including medicine, public health, nursing, pharmacy, or dentistry), whereas further 13% had obtained their main degree in other fields (including economics, social sciences, law, engineering, or other disciplines). regarding job position, about 34% of health professionals were operating in high managerial positions; 44% in middle managerial positions; and the remaining 22% were working in low managerial positions (table 1). table 1. demographic factors and characteristics of the workplace in a nationwide representative sample of 132 male health professionals in albania, in 2018 numerical variables mean standard deviation age (years) 41.4 10.1 working experience (years) 14.8 9.4 categorical variables number percentage place of work: urban areas rural areas total 94 38 132 71.2 28.8 100.0 diploma (main degree): health sciences other degrees 115 17 87.1 12.9 job position: high managerial level middle managerial level low managerial level 45 58 29 34.1 43.9 22.0 the internal consistency of the overall scale of the leadership instrument (52 items) was cronbach’s alpha=0.87 for the current competency level and cronbach’s alpha=0.95 for the required competency level (table 2). for the current competency level, cronbach’s alpha was the lowest for the “ethics and professionalism” domain (0.50) and the “leadership, organizational learning and development” subscale (0.51) and the highest for the “political leadership” caushaj k, czabanowska k, roshi e, muja h, burazeri g. leadership competencies among male health professionals in a western balkan country (original research). seejph 2019, posted: 26 april 2019. doi 10.4119/unibi/seejph-2019-213 page 6 of 9 domain (0.93) followed by the “collaborative leadership” subscale (0.89). likewise, for the required competency level, cronbach’s alpha was the lowest for the “ethics and professionalism” domain (0.67) and the highest for the “political leadership” subscale (0.90) and the “collaborative leadership” subscale (0.86). overall, cronbach’s alpha was higher for five of the domains of the required competency level compared with the current competency level. table 2. internal consistency of the leadership competency instrument in a nationwide sample of male health professionals in albania in 2018 (n=132) domain (subscale) cronbach’s alpha current competency level required competency level overall scale (52 items) 0.87 0.95 systems thinking (7 items) 0.69 0.75 political leadership (8 items) 0.93 0.90 collaborative leadership: building and leading interdisciplinary teams (5 items) 0.89 0.86 leadership and communication (7 items) 0.56 0.84 leading change (6 items) 0.65 0.76 emotional intelligence and leadership in team-based organizations (6 items) 0.82 0.81 leadership, organizational learning and development (7 items) 0.51 0.75 ethics and professionalism (6 items) 0.50 0.67 table 3 presents mean summary scores of each domain of the leadership instrument for both the current and the required competency level. mean value of the overall summary score for the 52 items of the instrument was somehow lower for the current competency level compared with the required competency level (137.6±8.7 vs. 140.7±21.2, respectively; p=0.02). most of the subscales’ scores were significantly higher for the required competency level than for the current competency level, except for the “emotional intelligence and leadership in team-based organisations” and “leading change” domains. conversely, mean scores of the “ethics and professionalism” subscale were similar for the current and the required leadership competency level (table 3). table 3. summary scores of the overall scale and subscales for the current and the required leadership competency level of albanian male health professionals in 2018 (n=132) domain (subscale) mean values ± standard deviations p-value* current competency level required competency level overall scale (52 items) 137.6±8.7 140.7±21.2 0.019 systems thinking (7 items) 20.8±1.7 21.9±3.2 0.004 political leadership (8 items) 19.5±4.7 20.2±5.0 0.001 collaborative leadership: building and 11.4±3.0 12.6±3.5 <0.001 caushaj k, czabanowska k, roshi e, muja h, burazeri g. leadership competencies among male health professionals in a western balkan country (original research). seejph 2019, posted: 26 april 2019. doi 10.4119/unibi/seejph-2019-213 page 7 of 9 leading interdisciplinary teams (5 items) leadership and communication (7 items) 16.2±2.1 17.4±3.9 <0.001 leading change (6 items) 17.5±2.2 16.8±3.1 0.005 emotional intelligence and leadership in team-based organizations (6 items) 18.4±2.4 16.9±3.3 <0.001 leadership, organizational learning and development (7 items) 16.3±2.0 17.5±3.3 <0.001 ethics and professionalism (6 items) 17.5±2.0 17.6±2.6 0.603 * paired sample t-test. the gap of leadership competency level (mean difference between the required and the current level of competencies) was higher for male health professionals working in top managerial positions (mean difference: 4.1) compared to those operating in middle managerial positions (mean difference: 3.2) and, particularly, individuals working in low managerial positions (mean difference: 1.5). furthermore, the gap in leadership competencies was higher among health professionals working in urban areas compared with their rural counterparts (mean differences: 3.6 vs. 2.0, respectively) [data not shown in the tables]. discussion main findings of the actual study consist of a higher self-perceived level of the required (necessary) leadership competencies than the current (existing) level of leadership competencies in this nationwide representative sample of male health professionals in transitional albania. this finding resembles a previous report which consisted of application of the same instrument in a nationwide representative sample of male and female health professionals in albania in 2014 (9). the internationally valid instrument for assessment of leadership competencies in the current study had an overall reasonable internal consistency, particularly for the required (necessary) leadership competency level. this was also the case in the previous study conducted in 2014 (9). interestingly, the mean difference between the required and the current level of leadership competencies was higher for male health professionals working in top managerial positions. this finding points to the urgent need for specific leadership training of public health professionals operating in key managerial positions in albania. furthermore, the mean difference between the required and the current level of leadership competencies was higher for male health professionals working in urban areas of albania. this finding is somehow intuitive considering the pressure and demands for high-quality services in urban areas, especially in large cities of albania (particularly in tirana). in the previous study, which was conducted in albania in 2014 employing the same measuring instrument (7,9), there were included 162 men aged 44.9±10.6 years and 105 women aged 44.4±9.9 years (9). in this sex-pooled sample of male and female health professionals in albania surveyed in 2014, the mean value of the overall summary score for the 52 items of the leadership instrument was 138.4±11.2 for the current leadership competency level compared with 159.7±25.3 for the required leadership competency level (p<0.001) (9). also, most of the subscales’ caushaj k, czabanowska k, roshi e, muja h, burazeri g. leadership competencies among male health professionals in a western balkan country (original research). seejph 2019, posted: 26 april 2019. doi 10.4119/unibi/seejph-2019-213 page 8 of 9 scores of the leadership instrument in the study conducted in 2014 were significantly higher for the required than for the current leadership competency level (9), a finding which is somehow similar to our current study conducted in 2018. competencies in the area of public health leadership are considered essential components for the performance and ongoing activities of health professionals at all levels of health care services in a wide range of settings and organizational structures (14). as described elsewhere, developing effective leadership is vital in most of the european countries given the considerable financial pressures of the public health systems and their need to deliver more services in line with declining resources and financial constrains (15). in the context of albania, the curriculum of both undergraduate and postgraduate public health programs does not adequately promote leadership skills and competencies for future health professionals (9). however, a similar trend is observed in many other countries where teaching of leadership is still not common in public health training programmes (14,15). this is especially the case in countries experiencing intensive public health reforms including albania. hence, there is an urgent call for a considerable investment in leadership training for public health professionals worldwide (16). this study may have several limitations including the study design, sampling strategy and the information obtained. regarding the possibility of selection bias, a nationwide representative sample of male health professionals was included, which is comforting. concerning the instruments of data collection, this study used an internationally standardized instrument (7), which had been previously validated in albania (8) and subsequently applied to a larger sample of health professionals (9). overall, the instrument used for the measurement of leadership competencies indicated good internal consistency. nevertheless, the internal consistency was not high enough for some subscales of, particularly, the current leadership competency level. regarding the possibility of information bias, there is no reason to assume differential reporting in the actual or the required levels of leadership competencies among male professionals involved in this study. nonetheless, the possibility of information bias cannot be entirely excluded, as it is never the case with this type of surveys. finally, findings from cross-sectional studies are not assumed to be causal and should be interpreted with caution. in conclusion, regardless of its potential limitations, this study provides recent information about the current and the required level of leadership competencies among male health professionals in transitional albania, based on an internationally valid instrument, which has been previously validated and administered in albanian settings. as convincingly argued (7,9), application of this useful instrument enables the recognition of possible gaps in the level of existing leadership competencies and the required (necessary) level of leadership competencies, which will eventually inform the public health curricula about necessary content adjustments. therefore, policymakers and decision-makers in albania and other countries in the european region should be aware of the existing gap between the required and the current level of leadership competencies among health professionals operating at all levels. caushaj k, czabanowska k, roshi e, muja h, burazeri g. leadership competencies among male health professionals in a western balkan country (original research). seejph 2019, posted: 26 april 2019. doi 10.4119/unibi/seejph-2019-213 page 9 of 9 references 1. maintenance of certification competencies and criteria. american board of medical specialties, (usa). available at: http://www.abms.org/maintenance_of_ certification/moc_competencies.aspx (accessed: february 3, 2014). 2. accreditation council on graduate medical education. general 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differently means leading and learning differently. eur j public health 2014;24:1047-52. doi: 10.1093/eurpub/cku043. 15. czabanowska k, smith t, de jong n, et al. leadership for public health in europe. nominal plan. maastricht: maastricht university; 2013. 16. czabanowska k, smith t, stankunas m, avery m, otok r. transforming public health specialists to public health leaders. lancet 2013;381:44950. ___________________________________________________________ © 2019 caushaj et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed?term=czabanowska%20k%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=smith%20t%5bauthor%5d&cauthor=true&cauthor_uid=24121098 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http://www.ncbi.nlm.nih.gov/pubmed/?term=avery%20m%5bauthor%5d&cauthor=true&cauthor_uid=23399070 http://www.ncbi.nlm.nih.gov/pubmed/?term=otok%20r%5bauthor%5d&cauthor=true&cauthor_uid=23399070 macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 1 | 15 original research socially responsible human resources management and stakeholders’ health promotion: a conceptual paper gloria macassa1,2, gianpaolo tomaselli3 1 department of public health and sports sciences, university of gävle, gävle, sweden; 2 epiunit – instituto de saúde pública, universidade do porto, porto, portugal; 3 department of health services management, faculty of health sciences, university of malta, malta. corresponding author: prof. gloria macassa; address: 801 76 gävle, sweden; e-mail: gloria.macassa@hig.se. macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 2 | 15 abstract the prime objective of this paper is to propose a new conceptual framework for how integrating corporate social responsibility (csr) and human resources management (hrm) can impact on stakeholders’ health and wellbeing. the proposed framework argues that integrative socially responsible hrm (sr-hrm) policies coupled with public health literacy and integrative responsible leadership can play a significant role in shaping health behaviour change of internal stakeholders, which in turn can spill over to external stakeholders (family and proximate communities). from a health promotion and population health perspective, we see human resources (hr) as a leading partner in educating employees on the value of csr and public health literacy programmes, and also as providing action plans on how to strategically and successfully implement these types of programmes. by helping to develop action plans to analyse crs and public health literacy activities, hr professionals will be promoting both corporate citizenship and health behaviour change. both of these are vital for developing a culture of social responsibility (and achieving the triple bottom line (tbl)) and sustainable population health promotion. henceforth, srhrm policies and practices could help business organizations to contribute to the achievement of the united nations’ sustainable development goals (sdgs) and specifically goals 3 and 8. this novel framework, which is especially pertinent to public health, has not yet been tested empirically. hence, future studies are warranted to empirically test the theoretical framework using field data collection. keywords: corporate social responsibility, public health literacy, responsible leadership, socially responsible human resources, stakeholders’ health and wellbeing. acknowledgements the authors would like to thank dr jesus barrena-martínez for his valuable comments and suggestions on the conceptual framework. gm is grateful for the support of the department of public health and sports science at the university of gävle, through the csr-pham programme and relesh project. conflicts of interest: none declared. macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 3 | 15 introduction in recent years, various scholars have argued that there is a need to integrate corporate social responsibility (csr) and human resources management (hrm) across business organizations in order to better advance a sustainability agenda and, ultimately, the triple bottom line (tbl) of profit, people, planet – or, differently put, economic, social and environmental sustainability (1,2). notwithstanding positive findings regarding the importance of csr as a potential strategic partner for hrm in management, there still is the need to better understand how this relationship can be understood in other disciplines such as public health. in the context of how business organizations can contribute to address society’s wicked problems, and especially the promotion of stakeholders’ health and wellbeing, it has recently been argued that integrated csr-hrm can contribute to improving population health through public health literacy (3). therefore, this paper attempts to propose a conceptual framework for how integrated csr-hrm can potentially affect stakeholders’ health and wellbeing within the context of sustainable development in terms of the tbl. the paper first discusses concepts regarding the integration of csr-hrm, then proposes a framework for how the nexus of csr-hrm can contribute to the promotion of internal and external stakeholders’ health and wellbeing, and finally identifies a future research agenda. the integration of corporate social responsibility and human resource management corporate social responsibility involves integrating social, environmental and ethical concerns, as well as respect for human rights and consumer concerns, in a business organization’s business operations and its basic strategy as a means to maximize the creation of value for its owners, stakeholders and society in the broad sense; and further identifying, preventing and mitigating their potential adverse consequences on the environment (4). for the business organization, it means the introduction of socially responsible elements in the daily management of its business that legitimize its activities across the groups with which it interacts (e.g. shareholders, partners, suppliers, customers, public institutions, non-governmental organizations, employees and their families, communities, and society in general). on the other hand, hrm is defined as the philosophy, policies, procedures and practices related to the management of an organization’s employees (1). also, hrm can be seen as a set of organizational and people-oriented functions or activities deliberately designed to influence the effectiveness of employees in the organization (5). it is suggested that hrm should be understood as concerned with all activities that are aimed to contribute to successfully attracting, developing and maintaining a high-performing workforce needed to achieve success within a business organization (5,6). however, in recent years, the hrm role appears to have transitioned from being an administrative support service within organizations to providing a strategic hrm, thus shifting focus from a narrow maintenance role to an active one in which hr strategies are employed that integrate overall business strategy, empower employees and help restructure the organization (1,5). according to some scholars, the csr-hrm nexus can be understood through a common thread, the stakeholder theory, which helps to explicate the integration of csr actions in the business organizations’ management (1,2,7). the stakeholder theory focuses on the importance of stakeholders in the course and macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 4 | 15 success of csr business activities. nonetheless, because business organizations have multiple stakeholders that are involved in their organizational activities, it is important that they differentiate these stakeholders and prioritize them (1). the literature has proposed dividing stakeholders into two groups: (i) primary stakeholders, who have a formal contract with the organization and are essential for its proper functioning (owners, shareholders, employees, unions, customers, suppliers, etc); and (ii) secondary stakeholders, who, though not directly involved in the economic activities of a company, can exercise a significant influence on its activities (employees’ families, citizens, competitors, the local community, government, public administration) (1,5,6). in this conceptual paper we consider employees as primary stakeholders, while the supply chain, consumers, local communities and society at large are considered as secondary stakeholders. corporate social responsibility cuts across different departments in any given organization and influences the way the organization conducts its business and relates with its stakeholders, both internally and externally; the hrm activities affect all units and departments in the organization. through the stakeholder theory bridge, hrm systems should take increasing responsibility in managing csr activities. this way csr would expand the hr agenda and help its effective implementation instead of the current overlap of activities which still takes place in many business organizations (5,7). furthermore, it has been argued that csr can also expand the role of hrm in supporting workplace practices that contribute to organizational efficiency and effectiveness (e.g. smart working, family-friendly policies, flexible hours) (5) and that a combined csr-hrm strategy can be the catalyst for the long-term success of business organizations (8,9). according to simmons, hrm needs to be seen both as a component and as a potential facilitator of csr (8). voegtlin and greenwood propose studying the link between csr and hrm from three theoretical perspectives: the instrumental, integrative and political perspective (10). the instrumental perspective posits that the involvement of workers in csr is instrumental in achieving greater economic outcomes for the organization. furthermore, this perspective considers the importance of profit maximization, simply said: how csr and hrm synergies can improve the business organization’s financial performance (2,10). in this perspective, csr is associated with hard hrm (e.g. focusing on the task that needs to be done, cost control, and achieving organizational goals). by contrast, the integrative, or social integrative, perspective looks at how csr and hrm can reinforce each other to create social benefit for the organization and its stakeholders. this approach bases itself in the relation between csr and soft hrm to examine how the integration of the social demands of employees can improve their wellbeing and motivation as well as overall stakeholder value (2,10). the integrative approach to csrhrm links csr strategies with soft hrm which views stakeholders (internal and external) as critical resources that are key to the business organization’s long-term business strategies (2,10). finally, the political approach to csr-hrm accommodates the power of corporations in society and the concomitant responsibilities this power implies. this perspective points to the relevance of contextual institutions (local, national and international) in csr and hrm (2,10). macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 5 | 15 there have been few studies that have investigated how the integrated csr and hrm nexus has contributed to stakeholders’ outcomes from a management perspective. for instance, a study by tekin regarding hrm dimensions in csr, which was carried out in turkey, found that csr led to improvements in recruitment to organizations and that these improvements had an impact on commitment to csr initiatives, thus making the organizations more attractive to potential employees (11). furthermore, there was a close relationship between csr and training activities that incorporated workplace policies (11). in another study, celma and colleagues analysed the effectiveness of several hrm practices that were considered socially responsible, according to internal institutions, in terms of three dimensions of wellbeing: job stress, job satisfaction, and trust in management. their results showed that higher job quality increased employees’ wellbeing at work, but some practices were more effective than others for each of the wellbeing dimensions (12). also, shao et al. found that socially responsible hr policies increased employees’ organizational citizenship behaviour while decreasing their task performance through roleambiguity mediation (13). in the same study, prosocial motivation served as a significant moderator in strengthening the positive relationship between socially responsible hr practices and organizational citizenship behaviour as well as the negative association between socially responsible hr practices and task performance (13). from lithuania, buciunene and kazlauskaite report that there is a relationship between hrm, csr and performance outcomes in an organization. in their study, organizations in which hrm was a function for csr were found to have better csr policies (14). elsewhere, a study by abdulmotaleb and saha that investigated the processes linking socially responsible hrm to employee wellbeing in egypt found that positive employee perceptions of organizational morality arising from socially responsible hr policies and practices led to an “enhanced state-based positive affect at work that ultimately increased employee vitality” (15). using insights from social exchange and social identity theories, newman and co-authors investigated the influence of three dimensions of sr-hrm, namely, legal compliance hrm, employee-oriented hrm, and general csr facilitation, on employees’ organizational citizenship behaviours in chinese organizations (16). their findings showed that, while organizational identification fully mediated the relationship between employee-oriented hrm and employees’ citizenship organizational behaviours, general csr facilitation of hrm had a direct effect on employee organizational citizenship behaviour. in addition, legal compliance hrm did not influence employee organizational citizenship behaviour either directly, or indirectly through organizational identification (16). barrena-martínez and colleagues suggest that the integrative model of hrm needs to be studied from four complementary management perspectives. the first of these is the universalistic perspective which posits that there is a common and universal successful way in which the management of human capital organizations should be done, independent of country or any other variable (7). however, this view has been criticized for ignoring the potential contribution of context as well other variables (e.g. business strategy, technology and investments). the second perspective, the contingency perspective, argues that socially responsible hr policies re macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 6 | 15 sult from a combination of contingent internal (e.g. structure, size, technology, business strategy) and external (e.g. organizational environment) variables to achieve a solid, responsible system (7). the third perspective, called the “configurational perspective”, sees socially responsible hr policies through the synergy and interactions of these policies with internal and external variables. this would mean a social orientation that is coherent with hr and csr strategies consistent practices resulting from the proposed policies. in addition, socially integrated hr policies would need to consider the potential role of institutional pressures and stakeholder requirements in the context in which the organization operates. to this end, the fourth and last perspective puts emphasis on how the identification of contextual aspects outside the organization (political, socio-economic, environmental, cultural, educational and trade union aspects) as well as inside the organization (company size, technology working environment, innovation, and different stakeholders’ interests) can be of great importance in the integration of socially responsible human resources management (srhrm) policies (7). in this paper we argue that an integrated srhrm approach that takes into account the context outside (political, socio-economic, environmental, etc; see above) and inside the organization (company size, technology working environment, innovation, etc) is best positioned to contribute to stakeholders’ health promotion. with this perspective in mind we expect sr-hrm policies within the organization to include public health literacy that might in the long term contribute to improvements in employees’ (and their families’) wellbeing. we assume that the hr component of the integration would help the messaging and implementation of initiatives aimed to improve wellbeing based on the tbl. this would occur through training of employees in matters regarding physical activity literacy, mental health literacy, and overall wellness strategies as well as environmental-related risks linked to health outcomes. this way workplaces would develop strategies that would increase health information and services aimed at employees as well as their families. according to freedman and colleagues, public health literacy is the degree to which individuals and groups can obtain, process, understand, evaluate, and act upon information needed to make public health decisions that benefit the community and all its stakeholders (17). public health literacy is seen as a challenge for public health and health promotion as it represents a new, higher level of health literacy, through which the population as a whole (and within different arenas) can better understand health information related not only to the individual, but also to the community (18). moreover, it is posited that, compared with individual health literacy, public health literacy includes a myriad of factors such as poverty, globalization and climate change that have an influence on public health. thus, public health literacy “takes into account the complex social, economic, environmental and systemic forces that affect health and wellbeing” (17). hence, public health literacy is the best synergetic partner for business organizations in their pursuit of implementing sr-hrm policies and practices for the tbl, as well as for the achievement of the united nations’ (un) sustainable development goal 3 (healthy lives and wellbeing for all at all ages) and goal 8 (decent work and economic growth). individual health literacy is considered to be a stronger predictor of individual and popula macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 7 | 15 tion health outcomes, even more than are income, ethnicity, education, employment status and age (19,20). low health literacy has been associated with less use of preventive health services; reduced ability to manage chronic conditions (e.g. diabetes, asthma, high blood pressure); and lower likelihood to follow provider orders, such as proper use of medication; as well as feelings of shame at having low skill levels, and reduced capacity to act upon health alerts. furthermore, low health literacy has been linked to poor selfreported health, and workplace injuries (1921). conceptual framework socially responsible human resources management and stakeholders’ health promotion in this paper, we posit that a socially integrated csr-hrm approach oriented through a contextual approach to management (taking into account the social, environmental, political and cultural aspects of the context in which business organizations operate) (7) will, through public health literacy at the workplace, educate employees on health and wellness. further, the employees will in turn disseminate health and wellbeing knowledge to other stakeholders (e.g. families and communities at large). the establishment of educational training with emphasis on physical activity, wellness and mental health literacy will contribute to the reduction of health care costs due to preventable diseases (including chronic disease), as well as to decreased levels of absenteeism and presenteeism (22). box 1 of the framework (figure 1) depicts the integration of the csr strategies with those from hrm within the context in which the organization operates (i.e. the local, national and/or international context). this way, as described above, hrm will become a function of csr and will help deliver public health literacy (including individual literacy) to primary stakeholders (the employees). box 2 (figure 1) of the framework displays potential intermediary variables in the business organization which can facilitate (or hinder) the implementation of an integrated csr-hrm. we suggest two potential mechanisms through which an integrated csrhrm can influence internal and external stakeholders’ health and wellbeing (physical and psychological health outcomes). figure 1. conceptual framework socially responsible human resource management and stakeholder’s health promotion (authors’ own adaptation of barrena-martinez et al. 2018 framework) macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 8 | 15 the first mechanism includes “socially responsible hrm policies” that impact employee and organizational wellbeing as well as organizational performance. barrena-martínez and colleagues identified eight srhrm policies: attraction and retention of employees; training and continuous development; management of employment relations; communication, transparency and social dialogue; diversity and equal opportunity; fair remuneration and social benefits; prevention, health, and safety at work; and work–family balance (1). empirical evidence has shown that socially responsible companies (companies that care about the tbl and sustainability in general) are likely to attract new workers (23). employees’ training and continuous development is an important part of social responsibility, and it ensures that the employees feel empowered and become motivated to change. employees are important assets and, hence, investment should be made in their training and development. it is argued that hr is the best change management partner for educating and empowering the entire workforce for change with regard to social responsibility, sustainability and the tbl. others go even further to suggest that hr has the responsibility to be proactive, thus leading the way in the establishment of a business organization-wide, csr-enabled culture (24). it is within this training and development of socially responsibility practices that we see the importance of public health literacy in contributing to the promotion of health and wellbeing. in such a context, employees will be educated about the importance of achievement of economic profit in tandem with environmental quality and social equity (25), and will also learn about how these contribute to the health and wellbeing of all stakeholders. human resource professionals are well positioned to help with the formulation, execution and monitoring of such training. strandberg argues that hr managers have not only the tools but also the opportunities to leverage commitment to, and engagement in, the business organization csr strategy (26). engagement in such strategy can enable employees to achieve physical activity, wellness and mental health literacy, which are important predictors for the achievement of positive health outcomes. the public health literacy training would include physical activity, mental health literacy and overall notions of wellness. here, “physical activity literacy” is defined as having the motivation, confidence, physical competence, knowledge and understanding to value and take responsibility for engagement in physical activities (27,28). on the other hand, “mental health literacy” goes beyond simple awareness of one’s mental health, to a place of greater understanding and skill development related to maintaining mental health and effectively coping with challenges. thus, mental health literacy becomes a fundamental element of mental health promotion, and prevention, early identification, and treatment of mental health disorders (29-31). to exemplify how an integrated csr-hrm strategy could potentially contribute to promote stakeholders’ health we can consider a “workplace wellness program”. such a program would aim to target modifiable risk factors of disease such as physical activity, nutrition, smoking cessation as well as mental and environmental literacy for employees and their families (3, 22). furthermore, these activities can extend to supply chain collaborators, thus covering both internal stakeholders (employees) and external stakeholders (family members and actors in the supply chain). however, carrying out wellness programs might pose challenges to employers and employees alike. for instance, business macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 9 | 15 organizations might be conflicted from the need to make profits as well as to motivate their employees for sustainable and healthy changes, especially in the short term. in addition, organizations might lack financial and leadership-related resources (32). mccoy and colleagues reported that regardless of company size, potential barriers to workplace wellness included cost, time, expertise and legal concerns (32). moreover, employees can be reticent to participate. for instance, a us study found that the most common barriers to employees’ participation were insufficient incentives, inconvenient locations, time limitations, lack of interest in topics presented, schedule, marketing and health beliefs (33). however, we see workplace wellness and public health literacy within it as a unique opportunity to promote health and wellbeing for all stakeholders but specifically for employees (primary stakeholders) and their families. a recent randomized clinical trial that studied the effect of a workplace wellness program on employees’ health in us found that employees exposed to the program reported significantly higher rates of some positive health behaviours (e.g. weight management and regular exercise) compared with those who were not exposed. nevertheless, the same study found no significant effects on clinical measures of health, health care spending and utilization, or employment outcomes after 18 months (34). commenting their findings, the authors argued that it was possible that behavioural change may precede improvements in other outcomes suggesting future improvements in health or reductions in health-care spending (34). this is in line with our suggested framework where we expect public health literacy policies to contribute to behavioural change in domains of healthy life style, mental health and environmental understanding conductive to improved health and wellbeing both in the workplace and society. according to mujtaba et al., a company’s investments in its employees’ health and wellness will “pay off” for the company in the long-run and will provide benefits for employees, their co-workers, families, communities, and society as a whole (35). regarding the socially responsible policy of management of employment relationship, this centres on decent work, respect for human rights, ethics, social responsibility and the labour rights of the workers. moreover, the policy encompasses employer–employee communication regarding potential changes in the organization that might alter the contractual employer–employee relationship and can contribute to employees being able to plan their careers (1). the sr-hrm policy relates to communication, and transparency in communication that promotes employee participation in the organization’s decisionmaking. it is suggested that employees feel empowered if they perceive that they can contribute with their opinions, ideas and proposals, and activities within the organization. of great importance here is the communication to employees, not only about the organization’s economic results, but also those related to its environmental and social performance (1,36). the diversity and equal opportunity policy is of importance in terms of employee motivation, creativity and commitment (37). it is a policy that argues for the promotion of equal opportunity and diversity at the workplace, in other words, a policy that ensures non-discrimination (e.g. based on age, ethnic background, disability) and fair policies in management practices. according to lee et al, if employees are aware of the social value of these practices within the organization, they macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 10 | 15 will be involved with and committed to the organization in the long term because of its system of work able to produce benefits from widespread cultures and different values (38). furthermore, the policy of “fair remuneration and social benefits” centres on the need to ensure pay equity and add value in social coverage or benefits offered to employees (1). the available evidence states that wage disparities can contribute to social conflicts between employees (39). prevention, health and safety at work is an sr-hrm policy that has an impact on internal and external stakeholders’ wellbeing. organizational health (including occupational health and wellness) is a growing concern for hrm today. workers who perform their tasks under safe physical and psychosocial working conditions contribute to long-term achievement of organizational goals (40,41). we argue that within this policy, a socially integrated csr-hrm approach will contribute to prevention because occupational health and safety, physical activity and mental health literacy will take a central stage. increased prevention knowledge will benefit not only individual employees, but also the organization and the employees’ families (which can spill over to the communities in which these employees live). improved public health literacy (including individual health literacy) is likely to contribute to a reduction in sickness absence and presenteeism, physical inactivity, obesity, diabetes type ii, cardiovascular disease, and distress which might cause depression among employees and their respective families (42-45). the work-life balance policy aims to provide conditions that have a positive impact on stakeholders’ wellbeing. employees need to have a balance between the time allocated for work and other aspects of life (e.g. family, social and leisure activities) (46). it is argued that organizations need to have in place mechanisms to facilitate changes in working hours to accommodate family needs, to provide time for parenthood for both men and women and, where possible, to grant transfers of employees who are geographically separated from their family. evidence has shown that employees who experience a greater work–life balance are likely to experience better mental outcomes (47). we argue that the policies outlined above can serve as a vehicle to deliver tbl concepts for a sustainable organization in which employees will acquire knowledge of wellness promotion (physical activity and mental health literacy), which is critical to improving health and wellbeing in and outside the walls of the organization. hence, the role of hr managers will be crucial to ensure employees’ adoption of both socially responsible and healthy behaviours. the second mechanism (see box 2 of the framework [figure 1]) is “integrative responsible leadership”, an important factor that can influence both the formulation of sr-hrm policies and the implementation of public health literacy within the organizations. according to macassa, integrative responsible leaders are well-positioned to be agents of change for the tbl, but also to take on the important role that business organizations are likely to play for all stakeholders beyond the workplace (48). according to maak and colleagues (49), integrative leaders exhibit behaviours that: (i) mobilize stakeholders; (ii) promote a high degree of stakeholder interaction (including the integration of legitimate but powerless constituencies) and inclusive decision making; (iii) consider strategic choices beyond the business case rationale; and (iv) show a proactive approach towards csr (49). we expect integrative business executives to be proactive in working with both macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 11 | 15 csr and hr managers in their organizations to provide knowledge on both sustainability and health promotion. the integrative responsibility towards all stakeholders is also expected from both csr and hr managers. integrative responsible leaders (ceo’s) will be more prone to support their csr and hr managers during the implementation of public health literacy and workplace wellness activities (made as part of their strategic csr within the organization). as pointed out, responsible leaders are more inclined to do “good” and avoid “harm” to all stakeholders especially in the contexts where their business operate (3,48,49). furthermore, as already stated these ceo’s will better understand the need to promote health and well-being beyond their workplaces. box 3 in the framework (figure 1) alludes to stakeholders’ health and wellbeing in the form of positive health behaviour changes for employees (internal stakeholders), but also for families and the communities where employees live (external stakeholders). these outcomes can range from healthy behaviour change (e.g. increased physical activity and improved mental) or improved and hedonic wellbeing, which is linked to employee happiness, satisfaction and pain avoidance, to eudaimonic wellbeing, which relates to the employee’s sense of meaning and self-realization (50). overall, the framework in this paper proposes two hypotheses which might be relevant in the relationship between sr-hrm and stakeholders’ health and wellbeing: (i) sr-hrm policies implemented within the organization that include public health literacy will be associated with behaviour change towards environmental and social aspects linked to sustainable development as well as improvement of health outcomes. public health literacy training (embedded within sr-hrm policies) will contribute to changes in health behaviour among employees (and their families), which might spill over to the communities in which they reside; and (ii) integrative responsible leadership (at the top level of the company) will positively impact the planning and implementation of sr-hrm policies, thus contributing to stakeholders’ health promotion. from a health promotion, and population health, perspective, embedding public health literacy in the strategic csr-hrm policies will not necessarily result in extra-costs for the organization; on the contrary, it might contribute to long-term profits (3). moreover, it will boost employees’ knowledge and motivate them to take decisions of importance to their health, the working environment, and the health and wellbeing of others, including the natural environment (3). however, as mentioned above, we expect that companies will adhere in different ways to an integrated csr-hrm policy and practice, depending on the (political and cultural) context in which they operate and/or on the company size, revenue and an array of other situational factors. conclusion and future research agenda this conceptual paper attempts to offer a theoretical framework for how socially responsible human resource management can help improve stakeholders’ health and wellbeing within the context of a business case for population health (and achievement of the tbl). the framework proposes two potential mechanisms: (i) socially responsible hr policies that include public health literacy (physical activity and mental health literacy); and (ii) integrative responsible leadership. although hrm has been linked to employee outcomes (e.g. job satisfaction), to our knowledge this is the first time that it has been proposed to macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 12 | 15 link integrated csr-hrm to population health outcomes in the context of sustainable development. however, the conceptual framework proposed here has not been tested empirically anywhere, let alone within the discipline of public health to which the authors pertain. this suggests the need for future studies to test the framework empirically through field data collection. an important argument as to why it is important to make a business case for population health is that for so long business organizations have distanced themselves from the health of those outside their organizations. but, there is now agreement that un agenda 2030 will not be achieved through governmental efforts alone, giving traction to the idea that business organizations (small, medium and 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is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. gjorgji p, kruja j. trends and demographic characteristics of hemorrhagic stroke in albania during the period 2004-2015 (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-123 1 original research trends and demographic characteristics of hemorrhagic stroke in albania during the period 2004-2015 petrit gjorgji 1 , jera kruja 2 1 university hospital centre “mother teresa”, tirana, albania; 2 faculty of medicine, university of medicine, tirana, albania. corresponding author: petrit gjorgji, md; address: university hospital center “mother teresa”, rr. dibres, no. 371, tirana, albania; telephone: 00355685175790; e-mail: gjorgji19@yahoo.com mailto:g@yahoo.com gjorgji p, kruja j. trends and demographic characteristics of hemorrhagic stroke in albania during the period 2004-2015 (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-123 2 abstract aim: our aim was to describe the trend over time and the demographic distribution of hemorrhagic stroke in albania in the past decade. methods: this study included all patients diagnosed with hemorrhagic stroke and admitted during the period 2004-2015 at the university hospital center “mother teresa” in tirana (988 cases overall; 34% women; overall mean age: 57.8±19.3 years). information about selected demographic characteristics was also collected for all study participants. results: the proportion of older patients (≥70 years) was slightly, but not significantly, higher in women than in men (32% vs. 27%, respectively; p=0.163). furthermore, the proportion of tirana residents was similar in both sexes (47% in men vs. 45% in women). overall, there was evidence of a significant linear trend over time (mann-kendall test: p<0.01), indicating a gradual increase in the number of hemorrhagic stroke cases in albania for the period 2004-2015. conclusion: this study provides useful information about the increasing trend of hemorrhagic stroke in albania, a transitional country in southeastern europe which is characterized by rapid changes including unhealthy dietary habits. keywords: albania, cerebrovascular disease, hemorrhagic stroke, time trend, western balkans. conflicts of interest: none. gjorgji p, kruja j. trends and demographic characteristics of hemorrhagic stroke in albania during the period 2004-2015 (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-123 3 introduction it has been shown that the sudden appearance of acute ischemic stroke is a consequence of a hasty interruption of blood flow to a part of the brain (1). it is argued that in most of the circumstances this situation occurs from embolic or thrombotic arterial vascular occlusion (1,2). in addition, lacunar strokes, arteritis, arterial dissections, and cortical venous occlusions constitute some other vascular events which may result in stroke syndromes (1,2). intraparenchymal intracranial hemorrhage from a variety of causes (including the spontaneous or hypertensive hemorrhages, vascular malformations, or aneurysmal origin) are observed fairly frequently in the clinical practice. normally, these additional conditions are involved in the initial differential diagnosis of stroke. actually, these different conditions have been referred to as stroke subtypes and are considered in the classification of this major disease. according to the first national health report for albania which was published in 2014, there is evidence of an increase in the mortality rate from cerebrovascular diseases in the past two decades in this post-communist country (3,4). as a matter of fact, albania is the only country in the southeastern european region that exhibits an increase in the death rate from cerebrovascular diseases (3,4), which raises serious concerns for health professionals and policymakers in this transitional country. the increase in the death rate from cerebrovascular diseases has been bigger in males (from about 85 per 100,000 population in 1990 to 157 per 100,000 population in 2010) compared to females (100 and 169 per 100,000 population, respectively) (3,4). it has been argued that this increase in the mortality rate of cerebrovascular diseases in albania indicates an early evolutionary stage of these conditions, a trend which was evident several decades ago in the western countries (3). in any case, accurate information on the extent of cerebrovascular diseases in albania is scant. as a matter of fact, there is no scientific information about the incidence or prevalence of cerebrovascular diseases in the albanian adult population. in this framework, we aimed to describe the distribution and the demographic characteristics of hemorrhagic stroke in albania, a transitional country in southeastern europe which has been undergoing a rapid change in the past decades including also drastic changes in lifestyle/behavioral factors. methods we conducted a case-series study which included all patients with hemorrhagic stroke admitted during the period 2004-2015 at the university hospital center “mother teresa” in tirana. it should be noted that this is the only tertiary care hospital in albania. overall, during the 12-year time period under investigation, there were hospitalized 988 patients (66.1% men and 33.9% women). for all cases included in this study, the diagnosis of stroke and differentiation of its subtype was done with magnetic resonance imaging (mri) and magnetic resonance angiography (mra) (5). data on selected demographic characteristics (age, sex and place of residence) of all study participants was also collected. age was categorized in the analysis into four groups: <50 years, 50-60 years, 61-70 years and >71 years. place of residence was dichotomized into: tirana vs. other districts of albania. the time period under investigation was treated as a discrete variable (for the purpose of time trend analyses), but it was also dichotomized into: 2004-2009 vs. 2010-2015. t-test was used to compare mean age between male and female stroke patients. on the other hand, fisher’s exact test was used to compare the sex-differences related to age-groups, place of residence and time period under investigation (2004-2009 vs. 2010-2015). conversely, gjorgji p, kruja j. trends and demographic characteristics of hemorrhagic stroke in albania during the period 2004-2015 (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-123 4 mann-kendall test was used to assess the linear trend in the distribution of the number of hemorrhagic stroke cases in albania for the period 2004-2015. in all cases, a p-value of ≤0.05 was considered as statistically significant. statistical package for social sciences (spss, version 15.0) was used for all the statistical analyses. results overall, mean age of study participants was 57.8±19.3 years, whereas median (interquartile range) was 61.0 years (51.5-71.3 years). mean age in men was slightly higher than in women (58.4±17.8 years vs. 56.6±21.9 years, respectively), but this difference was not statistically significant (p=0.174). the distribution of ischemic stroke cases by selected demographic characteristics of the study participants is displayed in table 1. on the whole, 29% of hemorrhagic stroke cases were 70 years or older; 24% were 61-70 years; 25% were 50-60 years; and 22% were less than 50 years of age. overall, 46% of the hemorrhagic stroke cases were residents in tirana, whereas the remaining 54% of the patients were residents in other districts of albania. notably, most of the hemorrhagic stroke cases (70%) occurred during the period 2010-2015 compared with only 30% of the cases registered in the period 2004-2009. table 1. distribution of hemorrhagic stroke cases by selected demographic characteristics in albania during the period 2004-2015 characteristic number percentage sex: men women total 653 335 988 66.1 33.9 100.0 age-group: <50 years 50-60 years 61-70 years >70 years 222 243 237 286 22.5 24.6 24.0 28.9 residence: tirana other districts 456 532 46.2 53.8 time period: 2004-2009 2010-2015 298 690 30.2 69.8 table 2 presents the distribution of selected demographic characteristics by sex of the hemorrhagic stroke cases. the proportion of older patients (70 years and above) was somehow higher in women than in men (32% vs. 27%, respectively), but this difference was not statistically significant (p=0.163). furthermore, the proportion of tirana residents was similar in both sexes (47% in men vs. 45% in women, p=0.638). also, there was no statistically significant difference between male and female hemorrhagic stroke cases regarding the time period under investigation dichotomized into 2004-2009 vs. 2010-2015 (p=0.213). gjorgji p, kruja j. trends and demographic characteristics of hemorrhagic stroke in albania during the period 2004-2015 (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-123 5 table 2. demographic distribution of hemorrhagic stroke cases by sex characteristic men (n=653) women (n=335) p-value * number (percentage) number (percentage) age-group: <50 years 50-60 years 61-70 years >70 years 142 (21.7) 165 (25.3) 168 (25.7) 178 (27.3) 80 (23.9) 78 (23.3) 69 (20.6) 108 (32.2) 0.163 residence: tirana other districts 305 (46.7) 348 (53.3) 151 (45.1) 184 (54.9) 0.638 time period: 2004-2009 2010-2015 188 (28.8) 465 (71.2) 110 (32.8) 225 (67.2) 0.213 * p-values from fisher’s exact test. figure 1 presents the overall and the sex-specific distribution of hemorrhagic stroke cases for each year included in the study (from 2004 to 2015). overall, the number of hemorrhagic stroke cases increased from 20 (in 2004) to 44 (in 2005) and, in the next couple of years, remained quite stable. from 2008 to 2012, the number of cases ranged from a minimum of 66 (in 2010) to a maximum of 85 (in 2011). next, there was a steep increase to 191 cases in 2013, and even more so in the following year (229 cases). conversely, in 2015, there was a sharp decrease, where there were registered only 47 cases of hemorrhagic stroke. the trend over time was more or less similar in both sexes, notwithstanding the generally higher number of cases in men for each year under investigation. figure 1. trend of hemorrhagic stroke cases in albania during the period 2004-2015 overall, there was evidence of a significant linear trend over time (mann-kendall test: p<0.01), indicating a gradual increase in the number of hemorrhagic stroke cases in albania for the period 2004-2015 (figure 1). 20 44 41 47 75 71 66 85 72 191 229 47 0 50 100 150 200 250 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 overall men women linear (overall) gjorgji p, kruja j. trends and demographic characteristics of hemorrhagic stroke in albania during the period 2004-2015 (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-123 6 discussion this study provides evidence on the distribution and demographic characteristics of hemorrhagic stroke cases hospitalized in tirana, the albanian capital for the period 20042015. the proportion of older patients was slightly but not significantly higher in women than in men. furthermore, the proportion of tirana residents was similar in both sexes. on the whole, there was evidence of a significant linear trend over time, which points to a steady increase in the number of hemorrhagic stroke cases in albania in the past decade. the reasons for the sharp decline of hemorrhagic stroke cases in albania in 2015 are difficult to explain. one reason may be the incomplete reporting for this particular year, pointing to quality deficits in the albanian health reporting system. another explanation may relate to the reduction of transferred stroke cases from other districts to tirana, the albanian capital, where the only tertiary health care facility is located. in any case, such considerable fluctuations in the number of hemorrhagic stroke cases in albania deserve further investigation. we have previously reported about the distribution and demographic characteristics of ischemic stroke in albania for the same period of time (from 2004 to 2015) (6). according to this previous report, the proportion of older women (70 years and above) with a diagnosis of ischemic stroke was significantly higher compared to men (55% vs. 41%, respectively, p<0.001). on the other hand, there was evidence of a higher proportion of men residing in tirana compared to women (35% vs. 30%, respectively, p=0.002). contrary to the current study involving hemorrhagic stroke patients, there was no evidence of a statistically significant trend over time for ischemic stroke for the period 2004-2015, notwithstanding a sharp increase in 2014 (6). the official reports from the albanian institute of statistics (instat) regarding the death rate from cerebrovascular disease are substantially lower than the global burden of disease (gbd) estimates for both men and women (4). from this point of view, instat reports that mortality rate from cerebrovascular disease in 2009 was about 100 and 120 (per 100,000 population) in males and females, respectively – values which are 57% lower in males and 41% lower in females compared with the gbd estimates for the year 2010 (4). regarding the age-standardized mortality rate from cerebrovascular disease, in albania, in the year 2010 it was about 147 deaths per 100,000 population – which constitutes the second highest rate in the region after macedonia (which, in turn, shows a particularly high mortality rate from this condition, with about 203 deaths per 100,000 population) (3). it should be noted that, among countries of southeastern europe, slovenia has achieved a remarkable decrease in the mortality rate from cerebrovascular accidents (from about 124 to 54 per 100,000 population in 1990 and 2010, respectively). as a matter of fact, all countries except albania have experienced various degrees of decline in the mortality rates from cerebrovascular disease due to effective treatment, as well as effective primary prevention measures introduced in several (routine) national health programs (3,7). in the clinical practice, the diagnosis of acute stroke is straightforward in most of the circumstances. from this perspective, the unexpected onset of a focal neurologic deficit in an identifiable vascular distribution with a common presentation (including hemiparesis, facial weakness and aphasia) indicates a common syndrome of “acute stroke” (6,8). however, there are several manifestations which are similar and very difficult to distinguish from an ischemic stroke syndrome (8,9). these are referred to as “stroke mimics” and include both processes occurring within the central nervous system and systemic events (8). taking into consideration the various treatment regimens of stroke which are currently very complex and gjorgji p, kruja j. trends and demographic characteristics of hemorrhagic stroke in albania during the period 2004-2015 (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-123 7 also bear the risk of undesirable effects, it is very important to differentiate these noncerebrovascular “stroke mimics” from real strokes, as argued elsewhere (8,9). this study may suffer from several limitations. stroke patients included in this study may not be fully representative of all stroke cases in albania. in any case, we included in our study all patients hospitalized in tirana during more than a decade, regardless of their place of residence (tirana, or other districts of albania). furthermore, the clinical diagnosis and discrimination of the stroke subtype was based on modern technology and scientific protocols employed in similar studies. demographic information for all patients was based on the medical charts and consisted of hard data such as age, sex and place of residence. given the administrative requirements, such demographic information is completed accurately and, therefore, there is no evidence of any kind of information biases in this regard. in conclusion, this study provides useful information about the increasing trend of hemorrhagic stroke in albania, a transitional country in southeastern europe which is characterized by rapid changes including unhealthy dietary habits. nevertheless, further studies should be conducted in albania at a national level in order to obtain valuable information about the extent, distribution and the main risk factors of both ischemic and hemorrhagic stroke. references 1. brott t, bogousslavsky j. treatment of acute ischemic stroke. n engl j med 2000;343:710-22. 2. allder sj, moody ar, martel al, morgan ps, delay gs, gladman jr, fentem p, lennox gg. limitations of clinical diagnosis in acute stroke. lancet 1999;354:1523. 3. albanian institute of public health. national health report: health status of the albanian population. tirana, albania; 2014. 4. institute for health metrics and evaluation (ihme). global burden of disease database. seattle, wa: ihme, university of washington; 2014. 5. weisberg la, nice cn. intracranial tumors simulating the presentation of cerebrovascular disease. am j med 1977;63:517-24. 6. gjorgji p, kruja j. ischemic stroke during the period 2004-2015 in transitional albania. management in health 2016;xx/2:16-8. 7. burazeri g, achterberg p. health status in the transitional countries of south eastern europe. seejph 2015;1. doi: 10.4119/unibi/seejph-2015-48. 8. kothari ru, brott t, broderick jp, hamilton ca. emergency physicians: accuracy in diagnosis of stroke. stroke 1995;26:2238-41. 9. norris jw, hachinski vc. misdiagnosis of stroke. lancet 1982;1:328-31. __________________________________________________________ © 2016 gjorgji et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://doi.org/10.4119/unibi/seejph-2015-48 wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 1 original research influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study helmut wenzel 1 , edgar unger 1 1 bodensee campus gmbh, kostanz, germany; corresponding author: helmut wenzel, m.a.s. address: d78464 konstanz, germany; e-mail: hkwen@aol.com wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 2 abstract aim: to assess the feasibility and effectiveness of resistance training on glycaemic control in adults with type 2 diabetes, the additional risk factors including low physical activity, measured by hba1c, body weight, cholesterol and triglycerides. methods: we conducted a pilot study as a pre-and-post study with no control group. participants had to meet the following inclusion criteria: type 2 diabetic person, 45-75 years old, duration of diabetes <10 years, no experience with resistance training within the last ten years, willingness to attend regularly the training sessions (two training units per week, with 45 minutes of duration each). furthermore, a certificate from the treating physician (diabetologist) was requested, testifying that there were no medical reasons against participation. patients with severe accompanying diseases, high blood pressure, heart failure (nyha iii), or retinopathy were excluded. eighteen persons (10 men, 8 women), aged 46-71 years could be included. due to dropouts, the pre-post-evaluation was based on 13 individuals only. mean age of this group (6 men, 7 women) was 63.6±5.5 years. mean body mass index at the beginning was 29.8±4.9. mean hba1c was 7.5%±0.6%; the triglycerides were in the range between 134 mg/dl and 335 mg/dl with an average value of 195.8±50.9 mg/dl. cholesterol level was between 149 mg/dl and 262 mg/dl, which corresponded to an average of 206.6±34.8 mg/dl. the training took place in a fitness centre under the supervision of a certified sports scientist between april 2010 and october 2010 for 28 weeks. during the training period, the patients were asked to report whether they changed their level of general physical activity during this period, as a potential confounder. possible treatment adaptations had to be recorded. results: at the end of the study, the average hba1c dropped from 7.5%±0.6% to 7.1%±0.8%. mean cholesterol level dropped from 206.6±34.8 mg/dl to 191.3± 30.85 mg/dl. mean triglycerides were lowered from 195.8±50.9 mg/dl to 144±30 mg/dl. these changes were all statistically significant (p<0.05). the dose-response curve was not significant, probably due to the small number of participants. conclusions: there is now suggestive evidence supporting the use of resistance training for improving glycaemic control and insulin sensitivity in type 2 diabetes. however, this has not been perceived clearly enough to date. it is also not in the focus of economic evaluations of diabetes preventing strategies. activating diabetic patients to perform resistance training is an effective and efficient way to reduce the burden of diabetes and, even more, to prevent this disease. keywords: cholesterol, hba1c, pilot study, triglycerides, type ii diabetes. conflicts of interest: none. wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 3 introduction diabetes affects patients and their families, health insurance and society. diabetes lowers average life expectancy of the patient increasing cardiovascular disease risk two to four fold, and is the leading cause of kidney failure, lower limb amputations, and adult-onset blindness. the disease puts a significant economic burden on society and healthcare programmes (1) and leads to considerable stagnation of national economies. the costs of caring for patients that are suffering the consequence of complications are four times higher than those without complications (2). as the international diabetes federation emphasizes, complications due to diabetes are a major cause of disability, reduced quality of life and death (3). just over 8.3% of the global population between 20 and 79 years has diabetes, which was about 415 million in 2015; by 2040, this figure will rise to 642 million (4). the number of people with diabetes in 2013 in europe was estimated at 56.3 million, which is 8.5% of the adult population. turkey has the highest prevalence (14.8%) and the russian federation has the greatest number of people with diabetes (10.9 million). by contrast, azerbaijan has an estimated prevalence of diabetes of just 2.4%. after turkey, the countries with the highest prevalence are montenegro (10.1%), macedonia (10.0%), serbia (9.9%), and bosnia and herzegovina (9.7%) (3). diabetes imposes a large economic burden on individuals and families, national health systems, and countries. according to a report of the international diabetes federation (3), health spending on diabetes accounted for 10.8% of total health expenditure worldwide in 2013. most of the money has to be spent for treating the complications. it is not diabetes or its management that causes most costs; rather, it is the consequences of the complications (4,5). at present, type 1 diabetes cannot be prevented. the environmental triggers that are thought to generate the process that results in the destruction of the body’s insulin-producing cells are still under investigation. but, there is significant evidence that lifestyle changes (achieving a healthy body weight and moderate physical activity) can help prevent the development of type 2 diabetes (6). obesity, particularly abdominal obesity, is linked to the development of type 2 diabetes. weight loss improves insulin resistance and reduces hypertension. people who are overweight or obese should therefore be encouraged to achieve and maintain a healthy body weight (6,7). a reduced capability of insulin to boost muscle blood flow is typical for insulinresistant obese individuals and individuals with type 2 diabetes. exercise training, however, has been found to help improve this problem, and substantially improve the control of insulin over blood glucose (8,9). implementing inexpensive, easy-to-use interventions can reduce the huge economic burden of diabetes. many of these interventions are cost-effective and/or cost saving, even in developing countries. vijgen et al. (10) provide a detailed overview on various approaches in primary, secondary and tertiary prevention. prospective studies and clinical trials have shown that moderate to high levels of physical activity and an increase in physical activity levels can prevent type 2 diabetes (11), or at least after onset slow down progression (12). consequently, diabetologists and others recommend physical activity (13-15). interestingly, the plea for physical activities in the treatment of persons with diabetes is not quite new. the importance of physical activity was already recognised at the beginning of the 20 th century. allen (16, p. 495) very early became aware of the possible impact of physical activity on the glucose metabolism. recent research shows the favourable impact of resistance training and/or aerobic training (17-22). there are also studies that show how type 2 diabetes can cause bone dysfunction and how resistance training positively impacts bone functioning (23). wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 4 in this context the purpose of this pilot study was to determine the feasibility and effectiveness of resistance training on glycaemic control in adults with type 2 diabetes, the additional risk factors including low physical activity, measured by hba1c, body weight, cholesterol and triglycerides. methods we conducted a pilot study as a pre-and-post study with no control group. four diabetologists/internists were asked to name eligible participants from their patients. the participants had to meet the following inclusion criteria: type 2 diabetic person (t2d), 45-75 years old, duration of diabetes less than 10 years, no experience with resistance training within the last ten years, willingness to attend regularly the training sessions (two training units per week, with 45 minutes of duration each). furthermore, a certificate from the treating physician (diabetologist) was requested, testifying that there was no medical reason against participation. patients with severe accompanying diseases, high blood pressure, heart failure (nyha iii), or retinopathy were excluded. eighteen persons (10 men, 8 women), in the age between 46 and 71 years, could be included. due to dropouts, the pre-and-post evaluation was based on 13 persons, only. the average age of this group (6 men, 7 women) was 63.6 (sd 5.5) years. mean body mass index (bmi) at the beginning was 29.8±4.9; the range was between 22.5 and 41.4. mean hba1c level was 7.5%±0.6%, ranging from 6.2% to 8.6%; the triglycerides were in the range between 134 mg/dl and 335 mg/dl, with an average value of 195.8±50.9 mg/dl. cholesterol level was between 149 mg/dl and 262 mg/dl, which corresponded to an average level of 206.6±34.8 mg/dl. according to the current guidelines, this group was likely to fall into the category “high risk” (24,25). the training took place in a fitness centre under the supervision of a certified sports scientist for 28 weeks. during the training period, the patients were asked to report whether they changed their level of general physical activity during this period, as a potential confounder. possible treatment adaptations had to be recorded. intervention the circuit programme consisted of two sessions per week. each session lasted 45 minutes, and was executed at eight different stations. the level of difficulty and the progression were determined individually with the intention not to surpass 60% of the maximum possible intensity of an untrained person. intensity was defined as a combination of weight moved, the number of repetitions, and the duration of the workout. twenty repetitions are approximately 60% of maximum intensity (26, p 229); depending on the individual situation of the test, person eighteen to twenty repetitions were carried out. this graduation was set because the study population was in relatively poor health and had to be protected against overloading. the workload was increased by 2.5 kg every two weeks until the final maximum possible capacity was reached. the only exception was the leg press where, for technical reasons, the increase steps were 5 kg. furthermore, the exercises were planned in such a way that both agonists and antagonists were trained likewise. the training started with a warm-up exercise on a stationary bicycle ergometer for 10 minutes. the strength training was made up of the following exercises: vertical traction, shoulder press, leg press, abductor training, low row, chest press, lower back and abdominal crunch. two cycles per machine and up to 20 repetitions were applied. the performance of the exercises was recorded with the help of a “training key” (i.e. workload), number of repetitions, speed, and extend of the movements. wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 5 we measured weight, height, hba1c, cholesterol, and triglycerides at baseline and weight, hba1c cholesterol, and triglycerides at the end of the intervention. statistical analysis for statistical analysis, we used the wilcoxon matched pairs test. the wilcoxon matched pairs test is a nonparametric alternative to the t-test for dependent samples, which fits with the pre-and-post comparison design (i.e., repeated observations of the same person). the application does not require a gaussian distribution of data. the variables must be measured in such a way that will allow the rank ordering of the observations (ordinal scale). we considered a p-value below 0.05 to be statistically significant (two-tailed test). statistics were calculated with xlstat 2009, version 4.07. results at the end of the study, mean hba1c dropped from 7.5%± 0.6% to 7.1%±0.8%. figure 1 and figure 2 provide overviews and show also the minimal and maximal values. figure 1. comparison of hba1c * * the red cross represents the mean, the box stands for the 1 st and 3 rd quintile, the line in the middle is the median. the whiskers represent the minimum and maximum value, the asterisks symbolize outliers. the height of the box is the interquartile range. the differences were significant (p<0.05); n=13. for type 2 diabetic patients the target range of hba1c is currently set between 6.5% and 7.5%; hence, participants were close to treatment recommendations. the average cholesterol level dropped from 206.6±34.8 mg/dl to 191.3±30.85 mg/dl, ranging from 150 mg/dl to 230 mg/dl. mean triglycerides were lowered from 195.8±50.9mg/dl to 144±30 mg/dl, with a maximum value of 182 mg/dl and a minimum of 87 mg/dl. these changes were all significant (p<0.05). figure 1 and 2 indicate that in the case of hba1c and total cholesterol, the interquartile range (height of the boxes) after intervention was lower than that of the initial hba1c hba1c(1) 0.06 0.065 0.07 0.075 0.08 0.085 0.09 0.095 comparison t0 t1 wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 6 starting point. this means that the data are less widely spread; the minimum and maximum values are also closer to the box. figure 2. comparison of triglycerides and total cholesterol * * the red cross represents the mean, the box stands for the 1 st and 3 rd quintile, the line in the middle is the median. the whiskers represent the minimum and maximum value, the asterisks symbolize outliers. the height of the box is the interquartile range. the differences were significant (p<0.05); n=13. dose-response smidt hansen and colleagues pointed out that there must be a dose-response relationship between physical activity and glucose metabolism (27). this means that, the higher the workload, the higher the reduction of hba1c. we therefore compared the cumulated size of the weight that was moved during the training period by all participants with the corresponding changes in hba1c achieved. we expected, in accordance with the principle of “diminishing marginal returns in production curves” (28), a rather s-shaped curve. the fitted curve of our data showed the expected incremental effect. the curve starts with a steep incline at the beginning and flattens towards the end. this is in accordance with the law of diminishing marginal returns. however, due to the small number of participants the explained variance was only 18%. therefore, it was not possible to identify the optimum of the doseresponse relationship. discussion we started the training with a relatively low workload despite the recommendations how to prevent, delay, or reverse the process of losing muscle power (29-31). to increase muscle mass a training intensity of 60% to 85% of the individual maximum possible intensity is triglycerides triglycerides (1) cholesterol cholesterol (1) 50 100 150 200 250 300 350 comparison t0 t1 wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 7 proposed, and for forcing the muscle development mayer et al. even advise more than 85% of maximum intensity (30). to influence sarcopenia, i.e. the age-related loss of muscle mass and function (32), this will be appropriate in a non-diabetic elderly population. to our knowledge, we have currently no training plans that are specially adapted to the needs of diabetic patients. it is also still under discussion whether it is more effective to increase the workload or the number of repetitions, mainly in the case of diabetic patients at higher ages. to determine the maximum possible intensity, the “one repetition maximum strength test [1-r]” is used mostly (30). applying a [1-rm] strength test is somewhat critical “because of the high stress on the musculoskeletal system and the high injury risk, especially for sportspersons involved in recreational sport” (33, p 1). this is even more valid for our study population. moreover, studies allow the assumption that the [1-rm] test is inappropriate for intensity control. compared with the “multiple repetition maximum test [m-rm]”, its reliability is questionable (33,34). therefore, we applied our multiple repetition test. persons with diabetes are at a higher risk to develop sarcopenia. among other things, decreased physical activity is also complemented by metabolic impairment (35); possible interactions are quite complex, and the underlying mechanism between sarcopenia and type 2 diabetes mellitus have not been clarified completely [36]. however, the baltimore longitudinal study of aging showed that hyperglycaemia is associated with lower muscle strength (37). with our restraint, we took into account that our participants were untrained for many years and that they even manifested sarcopenia in advanced stages, also in combination with obesity (39% of participants were obese). insofar, the effectiveness of our training concept might be at the lower end of a possible dose-response relationship. on the other hand, our results are consistent with the findings of healy and colleagues, who show that even small increments in physical activities are associated with improved metabolic control (38). smidt hansen and colleagues conclude that “for persons, increasing the amount of light physical activity might be a more realistic approach rather than increasing physical activity of moderate-to-vigorous character” (27). according to the ukpds and the dcct studies, improving the hba1c by 1% of a person with type 1 or type 2 diabetes reduces the risk of microvascular complications by 25% (39). the changes of the other risk factors are also substantial. the investigation was planned as a pilot study; nevertheless, the improvement of hba1c found here is compatible with the outcomes of other studies (21,40). according to könig et al. (40), meta-analyses show average changes of hba1c between 0.5 percentage points and 0.6 percentage points; mean changes in our study were 0.35 percentage points (sd: 0.4). sigal et al. report changes of 0.38 percentage points when applying resistance training alone (21). depending on the composition of the sample under examination and the training scheme, hba1c changes of >1 percentage points were also reported – actually, 18 percentage points in the case of a progressive resistance training over 10 weeks (41, p 5). cauza (42) observed a 28% reduction of cholesterol. baseline levels of total cholesterol significantly decreased in the training group from 205.5±14.1 mg/dl to 177.5±13.3 mg/dl. in our study, the average value dropped from 206.6±9.7 mg/dl to 191.3±8.6 mg/dl. in their strength training group, the triglyceride levels were reduced from 229±25 mg/dl to 150±15 mg/dl (42). our respective data showed a reduction from 188.8±14.12 mg/dl to 145.7±8.6 mg/dl. previous analyses have demonstrated that structured supervised training is more effective than unsupervised training at home (43-45). in a new meta-analysis, randomised studies with supervised training were analysed which directly compared aerobic training, resistance training and a combination of both. combination training (ct) led to a 0.6 percentage points wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 8 improvement of hba1c compared to resistance training. similarly, beneficial results were found for fasting glucose, triglycerides and systolic blood pressure (43). schwingshackel and colleagues conclude that ct might be the most effective exercise modality to improve glycaemic control and blood lipids (44). nevertheless, they recommend cautious interpretation, due to limited information on adverse outcomes of exercise. the outcomes of our pilot are statistically significant. however, are they significant from a medical/epidemiological viewpoint too? to assess further the health effect of the training and to evaluate the relevance of the changes, it would be worthwhile to extrapolate the changes of the risk factors to events like myocardial infarction and/or stroke. there are several risk functions available, for example the euro score (46), or the framingham risk function (47) and the like. the algorithms are mostly based on blood pressure, cholesterol, ldl, hdl and triglycerides. diabetes is coded as “yes/no” only. therefore, as a compromise, we used the framingham risk function to estimate in an exemplary manner the cardiovascular risk and its reduction. one of the participants in the age of 68 years with cholesterol level of 188 mg/dl, and an hba1c of 8%, reduced the total cholesterol level to 153 mg/dl and the hba1c level to 7.4%. if we assume that, the blood pressure (conservative) is at 140 mm hg and hdl at 40 mg/dl (also conservative), the 10 years risk of general cardiovascular events is about 24.22%. the reduction in cholesterol reduces his risk to 19.44%. if we further could assume here that the reduction of hba1c from 8% to 7.4% is equivalent to “no diabetes” coding, then the new 10-year risk would be 10.26%. looking at all 13 patients, the cholesterol dropped from 206.6 mg/dl on average to 191.3 mg/dl. based on the conservative assumptions on blood pressure and hdl, the risk would drop from 23.65% to 11.59%. admittedly, these calculations can only give a rough estimate of the training’s health impacts, especially because the improvement of hba1c can be modelled insufficiently only. however, the benefits for various stakeholders are obvious. the patient improves his quality of life and life expectancy, the health insurance saves money, employers have less sick days, and so on. at a first glance, it looks like a win-win situation. unfortunately, the “investment” has to be done by the individual. it is not only expenditures, but it is also the “cost of motivation”. to keep diabetic patients at it, sophisticated measures have to be introduced. they have to be based on a concept of motivation and identified barriers, which in turn possibly impede maintenance of training (48). special attention must be given to the peculiarities and possible differences in t2d and t1d (49). this pilot study, regardless of the small study population, is compatible with the respective literature. nevertheless, there are some weaknesses. first of all, the pre-and-post design cannot provide “class one evidence”; controlling for confounders was difficult. secondly, the small number of participants does not yield a high statistical power. on the other hand, there are many other studies involving small numbers too (41,50). thirdly, more sophisticated statistical analysis is not possible due to the small number of participants. a study with more participants and the collection of all health parameters that are needed to calculate health outcomes would be required. conclusions there is evidence supporting the use of resistance training for improving glycaemic control and insulin sensitivity in type 2 diabetes. however, this has not been perceived clearly enough to date. it is also not in the focus of economic evaluations of diabetes preventing strategies, i.e., lifestyle changes that were economically assed did not include resistance training. the fact that in many studies the participants had individually supervised training sessions requires larger, population-based (effectiveness) studies to ensure that these findings can be generalised. also, further research is needed to identify the efficiency of dose-response wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 9 relationship by describing frequency and intensity of training and the sustainability of the effects, i.e. the duration of acute and chronic improvements. activating diabetic patients to perform resistance training is an effective and efficient way to reduce the burden of diabetes, and, even more, to prevent diabetes. wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 10 references 1. world health organisation. diabetes: the cost of diabetes, fact sheet number 236. 2014 [21.11.2015]. available from: http://www.who.int/mediacentre/factsheets/fs236/en/ (accessed: march 11, 2016). 2. liebl a, neiss a, spannheimer a, reitberger u, wagner t, gortz a. 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appl psychol 2008;57:628-43. 50. marcus rl, smith s, morrell g, addison o, dibble le, wahoff-stice d, et al. comparison of combined aerobic and high-force eccentric resistance exercise with aerobic exercise only for people with type 2 diabetes mellitus. phys ther 2008;88:1345-54. ___________________________________________________________ © 2016 wenzel et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 1 original research developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania per m. von groote 1-3 , gabi m. comanescu 4 , claudia ungureanu 4 , jerome e. bickenbach 1,2 , john n. lavis 5 1 department of health sciences and health policy, university of lucerne, lucerne, switzerland; 2 swiss paraplegic research, nottwil, switzerland; 3 institute of social and preventive medicine (ispm), university of bern, bern, switzerland; 4 motivation romania foundation, ilfov county, romania; 5 mcmaster health forum, centre for health economics and policy analysis, department of clinical epidemiology and biostatistics, and department of political science, mcmaster university, hamilton, on, canada. corresponding author: per m. von groote, institute of social and preventive medicine (ispm), university of bern; address: mittelstrasse 43, 3012 bern, switzerland; telephone: +41316313076; email: per.vongroote@gmail.com von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 2 abstract aim: the world health organization (who) publishes a large number of health reports every year, containing recommendations to overcome societal and system barrier challenges toward targeting unmet health needs. one such report, the international perspectives on spinal cord injury (ipsci), specifically describes the situation of persons with spinal cord injury. against this backdrop, the question arises about how these recommendations can be incorporated into an implementation strategy. therefore, the aim of this paper is to describe a phased process of developing an implementation strategy for a who public health report with ipsci serving as a case example. methods: the process to develop the implementation strategy consisted of specific phases each employing particular mechanisms. the preparatory phase was composed of a group discussion to select development mechanisms. the implementation strategy development phase comprised focus-group interviews, as well as of a stakeholder dialogue. thematic content analysis was applied to qualitative data. results: the group discussion led to selection of specific development mechanisms. the focus group mechanism allowed key stakeholders to openly discuss implementation goals and processesand impacted the selection of the core implementation group members and the focus of the stakeholder dialogue (sd) discussion.the sd was instrumental in developing a specific implementation strategy based on the report‟s recommendations. the strategy consisted of a detailed implementation plan, provisions to coordinate an implementation group and expert guidance. conclusion: the findings from the current study can inform the ongoing development of systematic, evidence-informed, participatory and stakeholder-driven processes for the development of implementation strategies for recommendations from who public health reports. keywords: implementation, implementation framework, implementation principles, implementation plan, implementation strategy, romania, world health organization (who). conflict of interest: none. funding statement: the project received funds from the swiss-romanian cooperation programme as part of swiss contribution to the enlarged eu. acknowledgements: the authors would like to thank jan d. reinhardt and dimitrios skempes for their conceptual feedback in drafting the manuscript. von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 3 introduction unmet health needs of people with disabilities due to barriers to healthcare services can pose a considerable challenge and an unnecessary burden for people in their everyday lives (1). these problems are often worsened by ineffective and unresponsive social and educational systems, as can be the case in many former soviet states in eastern europe. in romania, for instance, the employment rate of people with disabilities is only 15.5% and a high number of children with disabilities are not registered in any form of education (2).the situation is very similar in hungary or bulgaria where the lack of active labour market measures in combination with the reduction in the level of disability benefits with the aim to incentivise disabled persons to seek a job lead to an increasing poverty risk (3). disability pensions and welfare benefits are generally below the level of a basic income and pay for people with disabilities on the free market far below the minimum wage. disability status is still defined on the basis of medical diagnosis with no individual functional capacity or needs assessment for social inclusion and participation. this invariable leads to further dependency on the state disability pension system. the united nations (un) convention on the rights of persons with disabilities (crpd), as the guiding international human rights document, mandates that signatory states comply with international standards of inclusion and full participation of people with disabilities in all major life areas and in particular to ensure access to life-improving provisions such as assistive technologies and medical rehabilitation (4). despite recent adoption of new national disability strategies, “romania is far from being an inclusive country for people with disabilities”. major challenges remain, spanning from finding a tool for monitoring the implementation of the measures proposed as well as “shifting the perspective of the public system to internalising the principles of the crpd in all areas, including education, access to work and independent living”. the world health organization (who), as the un specialized agency for health, issues several health policy reports every year that formulate health policy and system recommendations toward meeting these goals. in late 2013, the who launched one such public health report, entitled the international perspectives on spinal cord injury (ipsci) (5). following the example of the world report on disability (wrd), launched two years before, ipsci describes the situation of persons with spinal cord injury (sci) around the world, and in particular, highlights the barriers they face in accessing health and rehabilitation services, education, employment, and support services, and, most importantly, proposes ways to overcome these barriers (1,5). the report‟s policy recommendations follow directly from the human rights provisions set out in the crpd, and include technical recommendations, such as prescribing particular types of health care, assistive technology or other technical accommodations or modifications to the environment. early on, the question arose on how the globally formulated public health recommendations from such a who report can be translated to an implementation strategy for a specific, national context. the implementation of these evidence-based recommendations is a challenge, since international public health reports can call for sweeping changes and innovation across several policy areas beyond the health sector. in addition, policy decision makers, systems and service administrators are under pressure to make reliable and evidence-based decisions under considerable constraints (6). these may often include lack of technical expertise to von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 4 translate global public health recommendations to national contexts, lack of access to implementation relevant information or expertise, and minimal cross-sectoral collaboration. finally, a dialogue mechanism needs to be in place so that civil society and other groups affected by policy changes are consulted and empowered to participate in policy development processes. to benefit these audiences, this paper will introduce an easy-to-use approach to planning implementation of public health recommendations. this is in addition timely and strategically relevant to service managers as „the lack of sufficient specific evidence on how to implement specific policies and interventions in specific contexts to reduce health inequities creates policy confusion and partly explains the lack of progress on health inequalities‟ (7). therefore, this paper aims to describe a phased process of developing an implementation strategy for a who public health report with a focus on specific development mechanisms. we hypothesized that a practical, nationally applicable implementation strategy based on the recommendations of a who public health report can be developed using distinct participatory, stakeholder driven, expert guided and evidence-informed mechanisms. the work described in the present paper was part of efforts by a partnership between the motivation romania foundation (mrf) and swiss paraplegic research (spf) to support the implementation of the ipsci report in romania. the preparation of a competitive grant application in the third quarter of 2012 marked the starting point for the joint romanian-swiss project work, which was guided by an international implementation expert until the end of the study in may 2015. methods the implementation strategy development process consisted of two phases (box 1 presents a glossary of terms). box 1. glossary of implementation research terms [based on (10)] implementation strategy a set of implementation activities or interventions described in a central implementation plan or guideline, to work in combination, and administered by a coordinated group of implementers. implementation strategy development mechanism specific tools used to conceptualize, inform or frame, and draft an implementation strategy. multiple mechanism coordinated among each other form an implementation strategy development process. implementation activity actions taken or interventions performed through which inputs, such as funds, technical assistance and other types of resources are mobilized to produce specific outputs. in the context of this research the mechanisms for the development of the implementation strategy are also activities or interventions toward implementation. output the (tangible) products, capital goods and services, which result from an implementation activity. impact positive and negative, medium-term and long-term effects on the individual, organizational and systems level produced by an implementation activity, directly or indirectly, intended or unintended. in the context of this research, the impact includes the effect that mechanisms for implementation strategy development can have on their own or in combination as a process. von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 5 the preparatory phase was composed of group discussions by the research project team. the implementation strategy development phase comprised focus group interviews (fg) of people with sci, policy makers, system and service developers and managers, and representatives of non-governmental organizations (ngo); as well as of a stakeholder dialogue (sd) with participants from the same pool of fg participants from romania and an international implementation expert. this approach is based on the methodology of expert panel guided and scientific evidence informed consensus processes such as in the development of the who functioning and health classifications and sci research strategies (8,9). table 1 provides an overview of the preparatory and strategy development phases, respective input, corresponding mechanisms, and anticipated output. they are described in more detail in the following sections. table 1. implementation strategy development phases, their input, corresponding mechanisms, and anticipated output phase input mechanism anticipated output preparatory phase conceptual implementation framework guiding implementation planning principles group discussion of research project team selection of mechanisms to develop the implementation strategy and to monitoring and evaluate its application implementation strategy development phase information on ipsci report content and main topics, background information to sci in the romanian context focus group interviews collection of national context specific implementation goals, stakeholders, and possible implementation processes to inform the sd summary results of the focus group interviews conceptual paper on implementation (framework and tools) (15) stakeholder dialogue (sd) documentation of implementation goals, related activities, barriers and facilitators to implementation, and next steps per stakeholder preparatory phase who has been criticized in the past for the lack of implementation guidance in the reports it develops (11). the ipsci report itself only gives general implementation considerations, a common gap even in technical who guidelines, as reported in a review by wang et al. (12). who acknowledges this challenge and has, for example, called on researchers to document and share their experiences of implementation efforts (13). in research on health equity, where it is increasingly recognized that there is a need to expand the knowledge base toward actual implementation of solutions, a similar call has been voiced (7). when seeking implementation guidance in who‟s work, however, there are a variety of frameworks and strategies that could be used to support implementation, but only some aspects of these are suited to the case of a complex report like ipsci that covers such a broad spectrum of technical recommendations and normative principles targeted at policymakers. the who‟s „knowledge translation on ageing and health‟ framework and guide to implementation research has identified key conceptual considerations (14). the who sponsored von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 6 evidence-informed policy networks (evipnet), and particularly its use of evidence briefs and policy dialogues to inform policy development and implementation, as well as the support tools used to inform evipnet‟s approaches, offer a variety of useful practical mechanisms. aspects of evipnet‟s approach have been used by a research group from australia as part of their effort to devise a national sci research strategy (9). four team members, consulted by an international implementation expert, entered into a group discussion to select mechanisms to develop the implementation strategy, and to monitor and evaluate its application, to be added to the grant protocol. for the group discussion the team were provided with two sources of information. first, a previous scoping review of implementation science by the research team leader that, among other things, captures elements of the frameworks discussed above suitable for implementing a public health report (15). this review presented, along with a synthesis of central elements of a conceptual implementation framework, a set of implementation strategy development criteria for public health reports such as the ipsci. secondly, the group was provided with a set of guiding implementation strategy development principles(see box 2).the development of principles was based on a review of relevant documents including, but not limited to, peer reviewed articles from implementation science and policy implementation (16-21), innovation and organizational change research (22), and theories of deliberation (23), communication (24), and facilitation (25). box 2. guiding principles for the development of an implementation strategy participatory and inclusive active and meaningful involvement of those most affected by intended change or innovation in implementation planning, goal setting, administration and evaluation. deliberative encouraging the judgment-free exchange of different and potentially conflicting views. consensus-oriented seeking agreement on key features of implementation such as options to target the problem. ethical soundness adherence to basic ethical principles and human rights standards such as confidentiality of information, anonymity, informed consent and intellectual property rights. external control and evaluation independent review or control entity outside of the project such as a funding agency or ethics review committee. procedural evaluation evaluation at specific time points during processes. summative evaluation evaluation at the close of processes. team-based approach collaboration of multiple members of the research team in all phases of the project including conceptualization, planning, administration, analysis and reporting. ownership facilitating and building on the buy-in of key stakeholders to be drivers of change. transparency making information on project background, aims, funding and outcomes accessible to all involved stakeholders. research integrity and quality ensure trustworthiness of research results through adoption of standard criteria for the collection and analysis of data. von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 7 finally, as shown in table 2 with corresponding implementation strategy development criteria and guiding implementation strategy development principles, the following development mechanisms were selected: focus group interviews, a stakeholder dialogue, and monitoring and evaluation surveys. the rationale behind choosing these mechanisms is described briefly in the next section followed by a detailed presentation of the mechanisms within their development phase. the piloting of the strategy and its monitoring and evaluation organized in a third phase is not part of this paper and is described in more detail elsewhere (26) table 2. implementation strategy development criteria, corresponding mechanisms, guiding principles, and anticipated output implementation strategy development criteria(15) corresponding mechanism guiding principles anticipated output multi-stakeholder involvement (practitioners, consumers, policy makers) in identifying the nationally applicable implementation goals on the basis of the recommendations made […] focus group interviews participatory and inclusive; ethical soundness collection national context specific implementation goals, stakeholders, and possible implementation processes to inform the sd consensus-based national implementation strategy development including indicators with implementation experts and implementers for better buy-in stakeholder dialogue; revision process participatory and inclusive; deliberative; consensus oriented; ethical soundness documentation of implementation goals, related activities, barriers and facilitators to implementation, and next steps per stakeholder piloting of the implementation strategy including the collection of qualitative and quantitative process and output data pilot phase including revision of data collection mechanism (surveys) based on external expert review; half yearly review by funder; core implementation group as implementers; procedural evaluation; external control and evaluation; participatory and inclusive; team-based approach ownership comprehensive data on implementation activities; data on effect of strategy development process on implementation activities. evaluation and publication of results data analysis plan; team based data extraction, coding and interpretation of data; summative evaluation of project and report to funder; summative evaluation of implementation plan; preparation of scientific manuscript team-based approach; summative evaluation; transparency; ethical soundness; research integrity and quality project reports and peer reviewed publications von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 8 the focus group interview mechanism was chosen in order to bring together multiple romanian stakeholders so that they could bring out their insights into the development of an implementation strategy for ipsci in romania and make it easier for them to identify implementation goals and priorities. focus group interviews can be effective in encouraging an open exchange of ideas and concepts, to prioritize issues and reach consensus and is generally thought to trigger inputs through group discussion, inputs that might not be identified as relevant by respondents in single interviews (27). the focus group interview method has been widely used in social science research and it has been accepted as a method in implementation research in health (28,29). the stakeholder dialogue mechanism was chosen with the aim to bring together stakeholders to discuss the development of the ipsci implementation strategy for romania in a structured and focused meeting atmosphere. also, participants of the dialogue were to be encouraged to plan and lead implementation activities themselves as a core implementation group. stakeholder (or deliberative) dialogues (sd) originated in deliberative democratic theory but have since found application in many fields as practical tools to allow decision makers to consider ways to tackle complex issues taking a variety of views into account (23). the mechanism has been defined as a process that „convenes policymakers, stakeholders and researchers to deliberate about a policy issue, and […] ideally informed by a pre-circulated brief and organized to allow for a full airing of participants‟ tacit knowledge and real-world views and experiences (30). sd have been recognized as an innovative knowledge-sharing mechanism and has been applied in implementation science, health policy and health services research (31,32). implementation strategy development phase focus group interviews content development: the focus group materials were jointly developed by two research project team members and reviewed by a third. the materials consisted of an introductory text to the situation of people with sci in romania and the ipsci report, and a statement of confidentiality that opened the sessions; open ended questions based on the central elements of the comprehensive implementation framework (15) and central ipsci topics; a participant recruitment scheme for the recruitment of interviewees; and a self-administered pre-meeting survey to be sent to potential participants for group composition planning. central ipsci topics were: data and information about sci; prevention (primary) of sci; sci health care and rehabilitation; health systems and assistive technology for sci; attitudes, assistance and support; environmental barriers; education and employment. the participant recruitment scheme‟s purpose was to define central characteristics of suitable participants to reach heterogeneity in group composition, and describe the process of identification, discussion and invitation of focus group participants, and to also help identify people within the focus group candidate pool as participants to the later stakeholder dialogue. participants recruitment: participants were purposefully selected from known contacts of the romanian project partner and its network. they were contacted in writing by romanian project team members and followed up on with phone calls. 11 people with sci and 16 policy makers, systems and service developers or administrators, and representatives from ngos and think tanks were successfully recruited. setup and design: standard focus group operational guidelines were used (27,28). one focus group of people with sci, and two with the remaining participants were formed to increase von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 9 the likelihood that participants would feel comfortable to speak freely within a group of peers and reflect the perception of differing experience based on the information from the short survey (28). overall, group heterogeneity was reached. a moderator guided through the session, assisted by a local host, posed the questions and encouraged group interaction. simultaneous translation was available during the interviews. after an introduction to sci in romania and the ipsci report the central ipsci topics were handed out participants were first asked to choose and rank three topics they would want policy and decision makers to target in romania and explain why. subsequent questions asked about possible processes to target these topics, participants of such processes, role of people with sci, and monitoring and outcome indicators. data collection and analysis: participant observation notes were made by the focus group assistant and moderator. the sessions were audio-recorded, the data were transcribed verbatim, translated, and translations checked by a second researcher and spot-checked by a third one. an iterative thematic data analysis and manual extraction of meaningful concepts was performed (33). frequency and intensity counts were conducted for the ranking of the ipsci central topics in each fg group (27,33). a summary of results for each fg was compiled into short reports including the ranking and verbatim quotes by participants to inform the implementation strategy development during the stakeholder dialogue. stakeholder dialogue the mcmaster health forum stakeholder dialogue format was used as a guide to develop the stakeholder dialogue (34). development and participant recruitment: the sd development was led by one researcher, assisted by the romanian project partner and consulted by an international implementation expert. participants were purposefully selected and recruited from the focus group candidate pool based on the participant recruitment scheme by mailing and follow-up phone calls. materials (scientific paper on implementation, icf case studies, agenda, consent form) were jointly selected or developed by the project team. setup and design: participants to the three-day meeting were seven mid to high level romanian disability experts from the private and government sector, two international health policy and implementation science experts, one facilitator and one assistant took part in the meeting. one participant from romania with a sci participated and four other participants had first-hand research or service development and management experience in the field of sci. two participants were directly involved in the original development of the ipsci report. the appropriate use of research evidence was ensured by distributing the scientific paper on implementation and the ipsci report before and again during the meeting, and by a discussion during the sd on the kind and levels of evidence the report‟s recommendations are based on and in what form these are expressed. focus group reports, icf case studies (35), and the ipsci recommendations translated into romanian were distributed as well as examples of implementation tools and materials discussed during the meeting. a facilitator with in-depth knowledge of the ipsci report moderated the discussion (encouraging even participation, in-depth discussion; summarizing findings to assist in targeting open questions; documentation of results in living documents). two translators provided simultaneous translations and precautions were made to counterbalance effects on the flow and precision of the discussion (hand signalling, restriction of lengthy inputs, allowing translations to be completed, reiteration of arguments by facilitator). the chatham house rule was applied to encourage free expression of views. von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 10 after a deliberation about the implementation themes and goals based on focus group results, expert opinions and guided by the essential implementation components (15) the discussion turned to issues drafted into separate documents during the consultation(the problem, options to target problems, facilitators and barriers to implementation per stakeholder group, and next steps for each stakeholder present). participants were encouraged to suggest implementation activities they could lead in romania themselves and in partnership with others. participants were from then on defined as a core implementation group. results documentation and follow-up: audio recordings were made and notes taken by the meeting assistant. after the meeting final revisions were made of the documents developed during the sd in an online finalization process (three rounds) by participants. clarifications were sought in the form of exact wording of alternative text, arguments for changing the text or extending the document, and any additional, freely accessible information necessary. finally, an implementation plan was drafted by participants detailing the implementation activities based on these sd documents developed during the sd and finalized in the follow-up, which then marked the start of implementation activities. data collection and analysis: audio recordings and hand notes were used to check and supplement completeness of documents developed during the sd and help verify participant observations discussed after the meeting between project members. an iterative thematic data analysis and manual extraction of meaningful concepts was performed of hand notes summarizing the discussions. results the administration of the implementation strategy development process produced results thematically summarized in a structured, narrative report. these results need to be seen in context of the boundaries of the study setting and particularly that of the people involved. the focus group interviews represent the true voice of those most affected, conveying real world challenges people with sci face in romania. beyond that, the identification of relevant issues came from participants representing a cross-section of romanian civil society in the field of disability including from ngo‟s, think tanks and universities as well as health and social system and service administers as discussants of the remaining focus groups and specifically the sd. focus group the analysis of the focus group discussions revealed detailed information on the situation of people with sci in romania, including the definition of specific barriers and facilitators they face, as well as implementation considerations. the voices of people with sci were evenly represented (fg1: 11 participants and 63 responses) in comparison to those of the non-disabled experts (fg 2&3: 16 participants and 62 responses). all three fgs provided a clear rating of their three top priority topics for change (table 3). von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 11 table 3. ranking of the main ipsci themes by fg participants rank fg 1 fg 2 fg 3 1 st : education and employment education and employment education and employment 2 nd : health systems and assistive technology for sci health systems and assistive technology for sci health systems and assistive technology for sci 3 rd : sci health care and rehabilitation attitudes, assistance and support attitudes, assistance and support the reasons given for the ranking of topics were the same themes highlighted by the participants toward challenges people with sci face in romania and toward possible solutions to target these. the most salient of these themes were: attitudes of individual groups and the influence these have on change, portrayed as playing an important role in terms of self-awareness and awareness of others, such as teachers, physicians or decision makers; education meaning both educating and awareness raising of others about sci as stated by one participant, “it’s important to educate people to perceive us as we are, to consider us equal, not different”, and also in terms of knowledge and skills development of people with sci, as expressed clearly by another participant: “for me, a proper recovery process means that somebody in my situation taught me to do things”; lack of assistive technology and importance of availability and training to social participation in combination with the inaccessible environment in romania further hindering mobility and participation: “it does not matter if you have an appropriate wheelchair if you cannot use it because of an inaccessible environment, and, on the other side, it is useless to benefit from an accessible environment if you do not own a wheelchair because it might take years to get one”; poor state of social services and need to shift from medical to a social model of service provision; importance of employment as a great influence on social participation; cross-cutting and multi-facetted nature of issues, especially in terms of accessibility of the environmental most often as a pre-requisite to education and employment opportunities and the accessibility to rehabilitation programs. all three fgs presented a broad range of stakeholders that should be involved in implementation, ranging from policy (e.g. ministries of health, employment and education) to practice (e.g. physicians, teachers), and equally valued the importance of people with sci being involved at key stages of implementation. they are even perceived as being the best drivers of change, as one participant from fg1 pointed out, “neither the ngos in bucharest, nor the media will promote best our rights”. in terms of implementation processes to be considered, dissemination efforts such as distribution of ipsci copies to educational facilities or government bodies, or in the form of media campaigns were named in all three fgs. the stakeholder dialogue as a specific mechanism to involve people with sci and politicians so they receive first-hand accounts by people affected was brought up in fg1. in terms of tools, the use of the ipsci report and its recommendations was suggested to be used along with the crpd to submit official complaints to authorities in violation of rights of persons with disabilities and to inform the assessments of pwd by local authorities. von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 12 when discussing how to monitor implementation the issue of missing data and lack of appropriate data collection tools was named as a major problem (fg 2&3). where participants in fg1 emphasized the need to include pwd in monitoring and of independent, uncorrupted monitors, fg3 stressed the need for monitoring authority‟s collaboration on disability issues and that indicators should be based on the principles promoted by the crpd. stakeholder dialogue the dialogue started with discussing the main challenges in terms of sci and disability in romania based on the fg results. major issues voiced were the lack of cross-sectoral and inter-professional communication; the general lack of data and collaboration in terms of data collection; the lack of suitable regulations or provisions and generally of enforcement of accessibility standards; the small number of rehabilitation centres, of qualified staff and technical expertise in health and allied professionals; lack of vocational services including a comprehensive needs assessment; attitudes of employers as well as the resistance to change in the sci community due to fear of loss of benefits; lack of unity and initiative in the disability community. based on this discussion and the fg results, the group agreed to focus their attention and further deliberation on three broad headings: medical rehabilitation and follow up in the community, independent living, and employment & inclusive education overlapping with three out of four top priority topics for change ranked by the fgs (education & employment; health systems and assistive technology for sci; sci health care and rehabilitation). the dialogue group then used live documents on screen discussing each recommendation‟s applicability to the romanian context, positioning it under the three broad headings, reformulating the recommendations to context specific problem statements, and then defined options to target these. based on this review, participants then turned to suggesting implementation goals to target, specific implementation considerations, and concrete implementation activities. goals (g) suggested included:g1. raising awareness in the government to disseminate ipsci and information on sci; g2. presenting specific ipsci recommendations to policy decision makers; g3. raising the awareness of pwd; g4. improving access of pwsci to employment opportunities; g5. improving access of pwsci to medical rehabilitation services; g6. improving independence of pwsci; g7. introducing sci specific rehabilitation knowledge to romanian professionals; g8. improving inter-professional communication; g9. showing the benefits of a bio-psychosocial assessment and rehabilitation management approach; g10. developing an ipsci implementation plan; and g11. creating a multi-stakeholder working group with a concrete calendar of events. specific implementation considerations (ic) voiced were: ic1. to involve pwd as implementers; ic 2. use one group of pwd as symbolic case to trigger change; ic3. deliver technical training to professionals; ic 4. using existing foreign guidelines as examples; ic5. to start efforts in own organizations and networks; and ic6. to lead coordinated efforts such as to jointly consult the government on bio-psychosocial orientation of the disability assessment and provision of services. the group went on to formulate the following activities based on the expressed implementation goals and considerations:  development of a joint position paper defining goals and covering topics such as the employment quota system and highlighting a cost-benefit and business case to the human rights approach (g1&2; ic2, ic6)  icf workshops (g8&9; ic2-4) von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 13  icf conference (g1, g7-9;ic2)  employment service for pwsci (g3, g4, g6; ic5)  wheelchairs caravan to provide personalized mobility equipment, adaptations and repairs, together with independent living training (g3, g4, g6; ic1, ic5)  implementation of the icf into mrf rehabilitation as a good practice example (g1, g8, g9; ic 2-5);  sci rehabilitation guideline for romania (g7-9;ic3&4)  emergency help telephone line for people with sci (g3, g5&6; ic2)  translation of the full ipsci report into romanian (g1-3, g7-9; ic2, ic4) finally, participants came to an agreement to pursue these jointly devised implementation activities as a core implementation group, centrally coordination by the local romanian ngo as leader, and on next steps toward completion of the sd documents in online review cycles toward final development of an implementation plan. the implementation strategy at the core of the strategy was the implementation plan with the implementation activities to be administered (appendix 1). participants of the sd and two additional disability experts from romania who could not join the meeting agreed to work together as a core implementation group in implementing pre-defined and coordinated activities of the implementation plan and report back to the implementation leader to document progress. the implementation leader was to serve as a central communication and coordination hub for all implementers, contact international content experts on the use of the icf and the ipsci report to assist implementers in preparing and executing their activities, and link implementers within the core group to assist in activities if needed. the implementation group planned to meet in person or by teleconference regularly over the course of the one-year implementation period to discuss progress, challenges and ways to overcome these. discussion the main findings of the study can be summarized in terms of issues identified in the fg and sd relevant to challenges people face in romania and toward the implementation of recommendations to target these; the benefits of applying the described process; and contextual implications of the experiences gathered. first, the fgs and sd identified as main issues the attitudes of individual groups and selfawareness, education meaning both educating and awareness raising of others, the lack of assistive technology in combination with an inaccessible environment as major barrier, the general lack of appropriate health, education and employment systems and services. the cross-cutting nature of these issues call for developing solutions involving abroad range of stakeholders using mechanisms such as the sd and ipsci and the crpd as tools. secondly, this study showed that the described evidence-informed, stakeholder-driven and participatory process facilitated the development of an implementation strategy for a who health report. the process enabled the development of an implementation plan and the establishment of a core implementation group to carry out the implementation strategy. specifically, the fgs affected the selection of the core implementation group members and the focus of the sd discussion. insights from the focus group interviews in terms of who should be involved and what implementation should focus on further informed the discussion of implementation themes and goals during the sd itself. this was most apparent in implevon groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 14 mentation approaches or topics named in the fgs that were later part of the discussion in the sd or were even incorporated into the implementation plan. the mechanisms for developing the implementation strategy can themselves be characterized as implementation interventions, since they engaged key stakeholders, informed the process and educated the stakeholders into jointly taking actions. in this sense, standard implementation outcome variables used in implementation research (29) show the appropriateness of the mechanisms, and the fact that in this setting and with this target audience it was possible to successfully engage participants to contribute to the development of the implementation strategy. the mechanisms were also feasible, since they could be carried out in the settings and the way intended. the criterion of fidelity was satisfied as the mechanisms were implemented as designed by the research team. the intended coverage of stakeholder representativeness was achieved. also, process costs were sufficiently covered by the project grant. furthermore, network ties introduced or reaffirmed in the form of the core implementation group in combination with the implementation information embedded show signs of sustainability. finally, these results also have implications for the participation of civil society actors in the development of policies that influence them. this study has shown how the participatory process of issue identification, discussion and development of possible solutions served to actively engage civil society representatives and empower them in their crucial role in policy development and promotion of fundamental rights. in times of both legal and practical restrictions, these experiences will likely become ever more important (36). findings in relation to other studies the present study is also novel in its focused attempt at developing an implementation strategy for a who health report and thus limiting points of comparison to other studies. in a synthesis of guideline development and implementation advice towards the development of a checklist for implementation planning gagliardi and colleagues found overall „no evidence on the effectiveness of planning steps or considerations‟ in respect to planning for implementation of guidelines, arguing further that „the impact of forming an implementation team or developing an implementation plan on the conduct and outcomes of implementation planning is a logistical consideration‟ (18). however, results of the present case show that conceptualizing and planning corresponding development mechanisms involves more than just logistical considerations. guiding principles and characteristics of the present development process are however also reflected in other research. single guidelines and studies highlight the value of considering and assessing stakeholder needs and preferences through observations or focus groups (3739); forming an implementation team from the start including a wide range of stakeholders; and one or more knowledge translation experts (37-39)when planning for guideline implementation. all of these steps have also been proven to be useful in the present study. implications for health policy report development and implementation two implications for policy can be derived from these observations. first, comprehensive planning of implementation should begin alongside the development of the health policy report so as to realize the full potential of the implementation content or innovation being proposed. in an ideal world, the development team should not only be assisted by public relations or media specialists but also by implementation experts. early involvement of stakeholder groups through advisory structures is a common feature of the development of health policy report. a stronger and more immediate involvement of these stakeholders -in the von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 15 form of an implementation working group -should be part of the planning for publication and dissemination processes, including the process of applying for funding and developing a detailed implementation strategy using the mechanisms studied here. in essence, the developed public health report or guideline should include implementation advice (12,40). secondly, the nature of the mechanisms used here depended on the fact that the participants were not only knowledgeable in the overlapping areas of health, disability and sci, but they were also relevant stakeholders. the openness of decisionand policymakers and their availability ensured a timely, easily accessible, and evidence-appraised input through mechanisms such as the sd. much can be gained from such purposely planned approaches for implementation planning of health policy report recommendations. implications for future research the boundaries of this study leave unanswered questions for future research: how far does the context-specific environment impact on the implementation planning in terms of planning (feasibility), execution (barriers and facilitators) and outcomes? it is important to stress that the original intent of this study was to demonstrate the application of the mechanisms in the romanian context. future research is needed to test the transferability of the underlying theoretical framework and the application of the mechanisms in different contexts and countries similar to recent examples from the field and expand this research by an outcome or impact evaluation (17,41). strengths and limitations of the approach the approaches‟ strengths lie in the adherence to the guiding implementation strategy development principles set out at the beginning of the preparatory phase. specifically, the process was evidence-informed as it included scientific evidence summarized in key documents introduced to the preparatory and strategy development phase. the process was participatory and stakeholder driven involving people with sci, disability experts and policy makers from romania in every phase. furthermore, this study was a theoretically grounded, multi-method explorative effort. namely, in its design, the study was based on a theoretical framework derived from a scoping review and involved key informants and experts in its review. also, transparency was achieved by describing details of the mechanism selection, data collection, and the researcher‟s level of involvement. the studies‟ focus on civil society representatives as key participants to the fgs and sd, however, and the representativeness and completeness of what is a much more complex picture of societal and system interactions constitutes important limitations to the study. the involvement of policy decision-makers would have helped to solve the policy puzzle. in addition, the present case was a small-scale pragmatic study that took place in a naturally occurring (authentic) societal and policy environment with complex circumstance out of control of the researchers with methodological challenges to any study (42). this naturally limits the explanatory power of results and also their transferability to other contexts. also, it needs to be mentioned that the lead author fulfilled a dual role of moderator and observer. however, precautions were taken in the form of note taking by meeting assistants and discussion of observations after interactions to prevent this impacting the overall results. conclusion the findings from the current study can inform the ongoing development of systematic, evidence-informed, participatory and stakeholder driven processes for the development of imvon groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 16 plementation strategies for recommendations from who public health reports. given limitations of this study in terms of scope and focus, the study does support the conclusion that a strong conceptualization and careful consideration of contextual factors needs to inform the refinement and application of this process in other european or global scenarios. references 1. world health organization, world bank. world report on disability. geneva: who; 2011. 2. tudose e, căloiu o. european semester 2016/2017 country fiche on disability. romania. leeds; 2017. 3. the academic network of european disability experts (aned) 2018.http://www.disability-europe.net (accessed: 23 february, 2018). 4. united nations. convention on the rights of persons with disabilities. resolution 61/106. new york, ny: united nations; 2006. 5. world health organization, international spinal cord society. 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id. hiding in plain sight: communication theory in implementation science. implementation science 2015;10:58. 25. berta w, cranley l, dearing jw, dogherty ej, squires je, estabrooks ca. why (we think) facilitation works: insights from organizational learning theory. implementation science 2015;10:141. 26. von groote pm, skempes d, bickenbach jeb. evaluation of an implementation strategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania. seejph 2017;viii. 27. mayring p. qualitative inhaltsanalyse. grundlagen und techniken. 10 ed. weinheim: beltz; 2008. 28. barbour r. focus groups. in: bourgeault i, dingwall r, de vries r, editors. the sage handbook of qualitative methods in health research. london: sage; 2010. p. 32752. 29. world health organization, alliance for health policy and systems research. implementation research in health, a practical guide. geneva: who; 2013. 30. lavis j, figueras j. scoping study of approaches to brokering knowledge and research information to support the development and governance of health systems in europe. brussels: european observatory on health systems and policies; 2011. 31. watt am, hiller je, braunack-mayer aj, moss jr, buchan h, wale j, et al. the astute health study protocol: deliberative stakeholder engagements to inform implementation approaches to healthcare disinvestment. implementation science 2012;7:1-12. 32. boyko j, lavis j, dobbins m. deliberative dialogues as a strategy for system-level knowledge translation and exchange. healthcare policy = politiques de sante 2014;9:122-31. 33. miles mb, huberman am. qualitative data analysis: an expanded sourcebook. 2 nd ed. beverly hills, california: sage; 1995. von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on 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development manual instructions for generating implementation advice. implement science 2012;7:67. 41. haynes a, brennan s, carter s, o‟connor d, schneider ch, turner t, et al. protocol for the process evaluation of a complex intervention designed to increase the use of research in health policy and program organisations (the spirit study). implementation science 2014;9:1-12. 42. nilsen p, ståhl c, roback k, cairney p. never the twain shall meet? a comparison of implementation science and policy implementation research. implement science 2013;8:63. ______________________________________________________________________________________ © 2018 von groote et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 19 appendix 1. implementation plan action context, venue or event date & place relation to another event or initiative activity leader contributor from core group target audience tools & materials to be used ipsci link i presentations (n=6) ipsci presentation national conference of medical expertise and work capacity rehabilitation,evolution of invalidity in romania march, bucharest core implementation group member medical rehabilitation and work capacity specialists presentation; conference program book 1, 3 ipsci presentation debate on international day of health, organised by institute for human rights (irdo) april, bucharest national health day core implementation group member irdo, health ministry, parliament members, nongovernmental organizations (ngo) website 3, 6 ipsci presentation and mrf research report promotion (life in an wheelchair) seminar, ministry of labour, family and social protection may, bucharest technical assistance grant to support disability and development core implementation group leader core implementation group members ministry of labour, family and social protection ipsci presentation, research reports 6 ipsci presentation and mrf research report promotion (life in an wheelchair) workshop, ministry of labour, family and social protection may, bucharest technical assistance grant to support disability and development core implementation group member core implementation group members ministry of labour, family and social protection ipsci presentation, research reports 1-6 ipsci presentation and mrf research report promotion (life in an wheelchair) meeting with persons with disabilities committee may-june, prahova prahova directorate core implementation group leader disability experts, ngos ipsci presentation, research reports 6 three ipsci presentations national congress of medical rehabilitation september, sibiu core implementation group member core implementation group leader medical rehabilitation and allied health ipsci presentation, conference 1, 3 von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 20 action context, venue or event date & place relation to another event or initiative activity leader contributor from core group target audience tools & materials to be used ipsci link i professionals program book publications (n=4) translation of ipsci full report into romanian publication of romanian ipsci version januarydecember ipsci implementation core implementation group leader core implementation group members broad range of policy makers, civil society and people with sci ipsci full report 7 drafting of article on ipsci publication in the romanian institute for human rights (irdo) magazine june-july, nationwide debate on international day of health, organized by irdo core implementation group member irdo, health ministry, parliament members, ngos magazine article 3, 6 6 drafting of article on ipsci publication in magazine of national institute of medical expertise and work capacity november, nationwide conference of national institute of medical expertise and work capacity core implementation group member medical rehabilitation and work capacity specialists ipsci full report, group position paper 1, 3 ipsci report and group position paper dissemination dissemination by the national authority for the protection of child rights and adoption (anpdca) octoberdecember, nationwide anpdca core implementation group member anpdc evaluation services ipsci report, group position paper 1-6 development(n=5) website development accessibility map ongoing usaid project wheels of change core implementation group leader people with sci, wheelchair users, ngos website 2, 4 evaluation evaluating costs of rehabilitation services in hospitals, for introducing home rehabilitation may, bucharest in coordination with national who office core implementation group member core implementation group member health system and service providers, ministry of health, who hospital documentation and reports, ipsci report 1, 6 von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 21 action context, venue or event date & place relation to another event or initiative activity leader contributor from core group target audience tools & materials to be used ipsci link i proposal development proposal for department of teacher training (dppd, anpdca) for sci statistics in romania may-june, bucharest core implementation group leader core implementation group member dppd, anpdca proposal document, ipsci report 6 elaborating, signing and disseminating group statement ipsci implementation may – september, bucharest core implementation group member core implementation group members irdo, ministry of health, parliament members, ngos sd documents 1-6 development of sci rehabilitation guideline ipsci implementation in romanian medical rehabilitation system maydecember, sibiu core implementation group member core implementation group members rehabilitation medicine, other medical specialties, and allied health professions ipsci, international medical guidelines 1 training (n=9) delivery of trainings 4 icf trainings for disability professionals using sci and ipsci themes as cases in point may-june, bucharest; september, sibiu; october, bacău; november, brașov project look at abilities, forget incapacity core implementation group leader core implementation group members disability professionals ipsci presentation, handouts, website 1, 3 delivery of training independent living training camps july, varatec project usaid wheels of change core implementation group leader people with sci working tools based on icf, camp materials 2, 3, 5 delivery of training who accredited courses regarding adequate evaluation and september, bucharest project usaid wheelchair access to educacore implementation group leader wheelchair service personnel ipsci presentation, handouts, website 1, 3 von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 22 action context, venue or event date & place relation to another event or initiative activity leader contributor from core group target audience tools & materials to be used ipsci link i prescription of wheelchairs tion, services and community for wheelchair users delivery of training camp for educational inclusion september, bucharest project access core implementation group leader pupils with disabilities, teachers, parents presentations, handouts, website 2, 3, 5 delivery of training who accredited courses regarding adequate evaluation and prescription of wheelchairs september project vodafone mobile for good core implementation group leader core implementation group member rehabilitation specialists and allied health professionals ipsci presentation, handouts, website 1, 3 delivery of training who accredited courses regarding adequate evaluation and prescription of wheelchairs october & december, bucharest project access core implementation group leader rehabilitation system and service managers ipsci presentation, handouts, website 1, 3 development and delivery of training training on revised legislation for disabled children and icf-cy octobermarch, bucharest department of teacher training, national authority for child protection (dppd, anpdca) core implementation group member anpdca evaluation services icf training materials, website, ipsci report 1-6 development and delivery of training independent living training to be jointly developed and delivered by government authorities octoberdecember, bucharest anpdc, ngos federations core implementation group member ngos website, handouts 1-6 delivery of training seminar take part! in schools where pupils with disabilities learn november, bucharest project access core implementation group leader pupils with disabilities, teachers, presentations, handouts 2, 3 von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 23 action context, venue or event date & place relation to another event or initiative activity leader contributor from core group target audience tools & materials to be used ipsci link i parents service (n=8) development and delivery of service creation emergency call centre for people with sci including software and relevant sci information; equipping and training 10 hospitals sites mai december, nationwide project vodafone mobile for good core implementation group leader core implementation group member 10 neurology hospitals/ rehabilitation centres software, tablets, telephones 1, 2, 3, 6 delivery of service home care services for people with sci and otherfor wheelchair users maydecember project access core implementation group leader people with sci working tools based on icf 1, 2 delivery of service psychological support groups to empower people with sci to take part in social activities and to finding jobs maydecember project access & wheels of change core implementation group leader people with sci working tools based on icf 2, 5 delivery of service mobility caravan to provide personalized mobility equipment, adaptations and repairs, together with independent living training juneseptembre, varatec, tulcea, constanta, alba project vodafone mobility caravan core implementation group leader people with sci wheelchairs caravan vehicle; working tools based on icf 2, 3 delivery of service icf based rehabilitation assessment service for wheelchair users at main project partner julydecember project look at abilities, forget incapacity core implementation group leader people with sci working tools based on icf 2, 5 delivery of service employment services september november esf financed project motivation for occupation core implementation group leader people with disabilities working tools based on icf 2, 5 von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 24 action context, venue or event date & place relation to another event or initiative activity leader contributor from core group target audience tools & materials to be used ipsci link i delivery of service wheelchair services ongoing core implementation group leader people with sci, wheelchair users working tools based on icf 2, 5 delivery of service service of assisted transportation ongoing project access core implementation group leader people with sci, wheelchair users working tools based on icf 2, 4 consultation (n=3) consultancy and promotion on disability data collection meeting at the romanian ministry of labour, family, social protection and elderly may-june 2014 core implementation group leader core implementation group members government authorities responsible for data collection and maintenance position paper, ipsci report 6 consultancy and promotion on the use of the icf and ipsci meetings with representatives of the general directorate of social assistance and child protection may-june, prohava prohava directorate; core implementation group leader disabilities experts from government and civil society project presentation 1-6 consultancy and promotion on the use of the icf and ipsci meeting with stakeholders as part of government lead working group june technical assistance grant to support disability and development core implementation group leader core implementation group members disabilities experts from government and civil society project presentation 1-6 conference (n=1) organization and hosting of conference scientific conference look at abilities, forget incapacity 25-26 september project look at abilities, forget incapacity core implementation group leader core implementation group members disabilities experts from government and civil society, health prowebsite, handout, presentation 1-6 von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 25 action context, venue or event date & place relation to another event or initiative activity leader contributor from core group target audience tools & materials to be used ipsci link i fessionals event (n=4) organization of swimming event sport events for persons with/without disabilities may, bucharest project vodafone mobility caravan core implementation group leader people with sci, sports persons with disabilities website, social media 2, 3 organization of wheelchair sport demonstrations wheelchair sport demonstrations june, september, november, nationwide project access core implementation group leader pupils, teachers, trainers, people with sci website, social media 2, 3 organization of basketball event sport events for persons with/without disabilities october, bucharest project vodafone mobility caravan core implementation group leader people with sci, sports persons with disabilities website, social media 2, 3 organization of national television disability gala annual persons with disabilities gala november, bucharest project look at abilities, forget incapacity core implementation group leader core implementation group members persons with disabilities, tv audience tv, website, social media 2, 3,4, 5 i ipsci recommendations: 1. improve health sector response to spinal cord injury; 2. empower people with spinal cord injury and their families; 3. challenge negative attitudes to people with spinal cord injury; 4. ensure that buildings, transport and information are accessible; 5. support employment and self-employment; 6. promote appropriate research and data collection; 7. implement recommendations. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 1 foreword by ulrich laaser dr. hans stein has been on the european union (eu)-health stage for more than 25 years, starting with the very first health council in 1977. as an official of the german health ministry (head of the eu health policy unit) he represented germany in countless eu (council and commission) committees and working groups concerning health policy and public health research. he not only organised the health council of four german eu presidencies, but also published a large number of articles mainly in international journals and books. after his retirement in 2002, dr. stein continued as a free lance consultant to a number of eu institutions and a lecturer in german, dutch, austrian, and english schools of public health. personally, i probably met hans stein the first time in 1977 when in west germany a discussion started about a “big” population study on cardiovascular health. he worked already for several years in the ministry of health (the name of the ministry at that time may have been more complex and i forgot it) but, different from many political administrators, he was fascinated by contents and not by formalities. he paved the way for the german cardiovascular prevention study (gcp) targeting five regions with together around one million population for more than a decade (1979-1994). hans stein started his long chain of contributions to population health and health policy with a presentation in my then high blood pressure department in heidelberg and i remember how difficult it was to convince him to speak in public about prevention. that changed later completely when he became a european figure representing the german government in the endless and tiring deliberations foregoing the milestone treaty of maastricht. i shall never forget how dr. stein presented a historical dialogue with his former dutch colleague jos draijer at the 25 th anniversary of the treaty at a celebration in the very city of maastricht. hans stein remained an engaged sceptic with an insurmountable enthusiasm, truly a rare mélange, obvious also from his review below of the european health policy development since maastricht. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 2 the maastricht treaty 1992: taking stock of the past and looking at future perspectives hans stein 1 1 free lance consultant, bonn, germany. corresponding author: dr. hans stein address: ministerialrat a.d. bonn, germany email: dr.hans.stein@gmx.de stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 3 abstract aim: the article contains a personal view of the history as well as the future of the european union‟s (eu) health policy. describing and evaluating the developments on the road from the treaty of maastricht to a new europe it asks and tries to answer the question if we – especially the eu member states – really know where we want to go to and how to get there. method: based on personal experiences, countless eu documents, as well as scientific publications the paper shows the impact eu health policy has had in the member states in the past. historical development: considering that the legal basis for health has been and remains to be very weak limiting eu action to support, coordinate, and supplement actions of member states – which, as a rule, still consider health to be first and foremost a national responsibility and therefore do not want interference from international institutions – the amount and content of eu health activities in the past years has been quite remarkable. health policy may not be an eu priority and as a crosscutting policy sector it is dominated by many other eu policies. however, especially the “hard law” regulations and directives of the internal market give eu the power and competence to achieve health objectives. the size of this growing influence is shown by direct interventions, made possible by the legal acts to improve economic policy coordination. health and health care in this context are considered as a key policy area for economic growth and eu macroeconomic policy. on the other hand, there is a risk that such regulations affecting health policy and population health may be dominated too much by economic institutions and their interests, whereas health authorities play only a minor role to date. conclusion: for the future of eu health policy it is essential that its position is considerably strengthened, in order to assure that health interests of the eu population are sufficiently safeguarded. keywords: european union, future perspectives, health policy, maastricht treaty. conflict of interest: none. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 4 introduction as a rule, a 20 th anniversary, especially when it concerns an event considered to be a historical landmark, is a cause for celebration. the treaty of maastricht was finally negotiated in an intergovernmental conference by the member states of the european union (eu) and signed on the 7 th of february 1992 in maastricht, the netherlands (1). it came into force on the 1 st of november 1993 after it had been ratified in all member states by national parliaments, in some cases adopted even by a population referendum. it is not only a cornerstone in the general development of the european union, comparable to the establishment of an economic and monetary union with a common currency, but it also contains for the first time a specific legal basis for health as a european issue. it is worthwhile noting that, this process was dominated by the governments of the member states. commission and european parliament participated on the side lines with very limited power to influence content and process. nevertheless, this event certainly would have deserves to be celebrated. but, surprisingly, except for some small meetings in maastricht, initiated by local institutions, there were no celebrations by the european union in brussels, or in national capitals. this situation should be a cause for concern. is it considered to be so critical that nobody wants to be reminded of how, when and where european integration started? were the experiences during the last 20 years in general, as well as with the implementation of the health mandate specifically that bad and negative? has the european vision got lost or was it just forgotten? has the european dream ended? or, is it that the eu has too big difficulties occupying the minds in adapting itself to the present situation characterized by the economic crisis and globalisation? looking back as a base for future developments it is the purpose of this article not only to describe how the eu health policy has developed in the 20 years since the maastricht treaty was signed, but also to develop concepts for the future. whether and how much it was a success story and what future perspectives are needed and realistic, cannot be judged only by looking at health issues. no eu policy field develops in isolation. especially in health with its horizontal character progress depends to a great deal on the overall eu development, its problems, and how these are solved. the present eu crisis, in many ways related to the economic situation, was not caused by health issues but health problems and even national health policies are affected by the crisis and the measures taken to improve the situation. “health in all policies” (2) is not only a mandate, but also a description of the situation. it will be shown how the newly created instruments to establish a “european economic governance” such as the european semester (3), the stability pact (4) and others not only go far beyond the existing legal base, but will influence national health systems and policies by increasing the commission‟s power to intervene at a national level. lack of interest in the past the existing lack of interest in the historic development of the european integration in general, and especially in the eu health policies may be regretted, but it can be explained by two interrelated developments: lack of positive commitment of eu citizens to european unification, and; eu enlargement implies growing economic gap between member states. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 5 lack of commitment by the citizens the project of european unification faces presently the biggest existential crisis of its history. nobody really knows when and how the crisis can be overcome or, at least, be mitigated. timothy garton ash (5) in an essay “the crisis of europe” describes in great detail how the union came together and why right now it seems to be falling apart. in his view “the project of european unification for about 40 years could rely on at least a passive consensus among most of europe‟s national publics”, today there is a lack of commitment to european integration nearly everywhere. it is obvious that a growing number of citizens in many countries do not believe anymore that the eu can at least contribute to solving their problems. even worse, they consider the eu itself to be the problem. these sceptical and critical views about the eu have existed in many countries for quite a number of years. but, eurobarometer (6) as well as national polls, especially the results of the elections 2014 for the european parliament, show that a growing number of citizens in many countries have lost confidence in the eu. surprisingly, this feeling exists even in germany or the netherlands, two signatory nations of the maastricht treaty, for a long time firm believers in european integration, including even a political union, countries that are not suffering from the present economic crisis. european integration has been rightly described as a project of elites with little even indirect participation of the citizens. they were seldom asked if they agreed to european solutions. and they were certainly never asked, if they wanted european solutions in health matters. had this been the case, a clear “no” would have been the answer, even if they could not have imagined how these solutions would look like. eu enlargement and the economic gap in 1993, only 12 member states negotiated and signed the maastricht treaty. since then, we have had three new treaties – of amsterdam, nice and the still valid one of lisbon (7) – as well as a failed attempt to establish a european constitution. more importantly, the eu has increased tremendously in size. from 1993 to 2014, altogether 16 new states have joined the eu and even more association negotiations are going on and will soon lead to even more member states (ms). at the same time some ms – especially the united kingdom – consider to leave the eu unless their special interests are taken care of. for the new ms, the date of their own accession as well as a solution of their present day problems are more important than a treaty which was signed 20 years ago. the astonishing and unexpected enlargement and expansion of the eu from original six to now 29 and possibly soon 35 member states in a few years is not a question of numbers alone. whereas eu structures and mechanisms, originally designed for only six ms have largely remained unchanged, this enormous growth combined with a financial and economic crisis has created big, yet unsolved problems. on the one hand, there is a growing small vs. big ms situation. whereas eight ms have a population of five million or less (luxemburg, malta, and cyprus being the smallest with only 0.5 million inhabitants), seven ms have a population between 6-10 million, and only 12 have more than 10 million. small size populations lead to small size economies. there are enormous differences in the present economic situation of some, often new ms. in health, this means that not all ms have sufficient financial and personal resources to offer their population all health services that are needed. this has already led to a growing „health gap‟ (8). reducing these health inequalities is essential in that it will contribute to social cohesion, i.e. reducing poverty and social exclusion. it requires a new dimension of eu solidarity including support and assistance. the classical eu instruments of cooperation and coordination are not sufficient any more to cope with the present situation. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 6 weaknesses and shortcomings of eu health policy health – an eu priority? health has never been a priority of european integration and it is highly improbable that it will ever become so in the future. despite a number of positive achievements in the past, health has not become a central objective of eu policy making. contrary to environmental policy or research – to name just two health-related similar policy areas – health has not been named in any of the various eu treaties as an eu objective. in article 3 of the treaty of maastricht, where the purpose of the various eu policy areas has been described, it states about health as follows: “a contribution to the attainment of a high level of health protection”, which is not exactly a very ambitious objective. on the contrary, whenever in the past years a reduction of eu activities and competence has been demanded by ms, health always has been a strong candidate, offered even by the commission. with this background, it is not surprising that the power and influence of the health commissioner and his general directorate has never been high. his responsibilities were always limited, and the financial and personal resources are small, especially when compared with areas like agriculture or research. it is not surprising that big member states in the usual battle to get an influential commissioner have never shown any interest to get this office. in the past twenty, years health commissioners have therefore come from smaller countries like greece, ireland, cyprus, and malta. the same applies to the new commission coming into power in september 2014. the new commissioner for health and food safety, vytenis andriukaitis, comes from lithuania, also a small country. but, differing from all his predecessors, he has experience in eu matters as well as a very convincing health background: he is a surgeon and was lithuanian minister of health and, as such, responsible for an impressive health agenda during the lithuanian eu presidency in 2013. as health remains an independent eu policy area – combined with food safety, for a long time a major eu priority – the expectation can be justified that health might become more powerful in the future. the commission has always been called the „guardian of the treaty‟ (9), from whom it was expected to work for more integration. however, as far as health is concerned, it has shown only little interest in the past to improve the status of health as a european topic. it appears that most if not all successful proposals have come from others; in 1977, for example, a belgian initiative to establish a health council and in 1985 a french proposal in the rome summit to establish „europe against cancer‟ as a european responsibility (both, by the way, many years before health was established formally as a european task in the maastricht treaty). furthermore, in 1995, the initiative of the european parliament to strengthen the eu health mandate and legal competence resulted in the amsterdam treaty 1997; and, finally, the many decisions of the european court of justice, beginning 1998 with the famous “kohll and decker” cases about patient mobility. the last phase started in 2012 with various summit decisions to establish a „european economic governance‟ with new instruments including “health care as an answer to the economic and financial crisis, going far beyond the existing eu legal base” (10). it seems that others discovered much earlier than the commission the health potential of the main eu objective, namely the internal market. health and the internal market it is often overlooked that national health systems, however differently they are organised and financed, are strongly related to and have been integrated into the internal market with its stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 7 four freedoms (11) embracing the free movement of goods (pharmaceuticals and health technology), free services (physicians, nurses), cross-border capital (e.g. investing in rehabilitation clinics), and people, i.e. patients looking for treatment outside their home country. right from the beginning, health systems have been influenced and even regulated to some extent by regulations and directives of the eu market and the competition therein. health care is, and it has always been, a central element of european and national economies. it is a big, possibly the biggest part of the internal market and it is permanently growing. about 8.5% of the national gross domestic product is, on average, spent for health. in germany, this means every year more than 250 billion euro. millions of people – especially doctors and nurses – work in the health care systems. in germany, about 12% of the working population is employed in the health sector (12). many of them, especially in the new ms, make increasingly use of their right of free movement and work in other eu countries. in the receiving countries this contributes to solving the existing shortage problems, whereas at the same time it leads to growing difficulties in their home countries. the main objective of the regulations and directives, the most effective eu tools, is to establish a functional internal market (13).they apply fully to the health systems and influence the development and content of national health policy. in addition, they are a powerful treaty base for influencing and even removing those ms policies such as health that might interfere with the aims of the internal market. scott greer (14) describes the results and consequences of the maastricht treaty in his essay „glass half empty‟: “the euro zone and the internal market overshadow the health effects of maastricht: it is comparatively easy to find the treaty authority for legislation promoting the internal market and eu law and courts are sceptical of public health or other rationales for legislation impeding the markets development”. he names as prominent examples the patient mobility decisions of the european court of justice, which culminated in the directive on patients‟ rights in cross border mobility (15). furthermore, the application of competition and the state law for health care providers, and the integration of pharmaceuticals‟ regulation around the european medicines agency. finally, he summarises his considerations about the effects of the maastricht treaty on health as follows: “the first mention of health was the harbinger of more effective promotion of health issues within eu policy making. in time, however, the internal market and the single currency have had the biggest health consequences”. this was not really what the ms had in mind when in 1992 they established a specific eu public health mandate. position and interests of member states health has always been considered to be first and foremost a national responsibility. states all over the world with hardly any exception want to keep their complete and undiminished integrity and full autonomy to organize and run their health systems the way they want it. health systems, different as they are, often are considered as a part of the national heritage and culture. countries do not want any interference from outside, be it by the eu, or be it by the who, which by the way is more accepted than eu institutions, but not more effective. for many years national governments – in full agreement with their citizens and the medical professions – have jealously and on the whole successfully prevented the transfer of any substantial health policy issues to a supra-national level, except for the indirect effects of the internal market as discussed above. they, therefore, still have a great difficulty in accepting health policy as a matter of the eu concern. it seems that health policy is one of the last realms and retreats of national policy competence which had to be defended. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 8 it seems also that health policy is a political sector which more than others absorbs and reflects national developments, traditions, and cultures. health systems are seen as the result of decades of development and the individual response to a country‟s social situation and profile. the answers given a long time ago by bismarck and later by beveridge regarding health seem to be sacrosanct even if a lot has changed since their time. safeguarding the pluralism of national health systems is considered to be a value by itself which has to be kept safeguarded at all costs against influence from outside even if the problems faced everywhere are quite identical and the solutions are at least similar. it seems to be overlooked that the eu might be a supporting strategic partner to overcome vested stakeholder interests that at the national level would not be possible. these popular but nevertheless antiquated views neglect a number of essential facts important for health. individual ms alone cannot cope sufficiently with outbreaks of infectious diseases like h1n1, food safety issues, biological or chemical terrorism and health threats from climate change. growing new health dangers and threats which „don‟t respect borders‟ is a common saying, presently ebola being an example (16). the development and evaluation of new technologies and pharmaceuticals especially combating rare diseases and the establishment of whole new areas such as e-health and telemedicine expand beyond the national level. therefore, possibly the best argument for the need of an eu health policy is the undisputed fact that health is influenced and determined to a great extent by factors and policies far outside national health care systems namely environment, work, transport, education, research and, most importantly, the economic situation of society and the individual. as all these policy areas are shaped more and more at the eu or even global level in different ways by binding regulations or international treaties. health interests have a chance of success against powerful industrial lobbies only at this international level. the essential instrument for achieving this is “health in all policies”. it is not only named in the article 35 of the eu charter of fundamental rights (17), but it is also the most important part of the eu legal base for health. even if today it is still more a vision and not a reality, there is hope that at the eu level it can become true. commissioner david byrne (18) expressed this as follows: “the future of health is not characterized by national isolation but by international cooperation, governance, and partnership. a more cooperative, integrative and proactive health policy will lead to a more healthy society characterized by enhanced economic output and reduced strain on national health care systems”. to make this hope come true, it not only needs political will, but also sufficient instruments. does the eu have them? can they be developed? the biggest obstacle is the ms‟ attitude as described below. development of health competence from maastricht 1992 to lisbon 2010 article 129, treaty of maastricht, 1992 the eu “public health” competence as laid down for the first time in article 129 of the treaty of maastricht, often but never substantially changed in the subsequent treaties, fully reflects the defensive and negative position of ms. as only a „supportive competence‟ it always was and still is the weakest legal base possible – in great contrast to the other strong categories such as exclusive or shared competences. it gives the eu no power to establish binding legal regulations or directives. its competence is limited to “carry out actions to support, coordinate or supplement the actions of the member states” according to article 6 of the treaty on the functioning of the eu (treaty of lisbon). the “protection and improvement of human health” is on the same unsatisfactory level such as culture or tourism. the establishment of a legal base for eu health policy has never been the object of an overall plan or strategy of any eu institution. right from the beginning, there have been permanent stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 9 conflicts between european activities and differing national positions on the one hand, and economic interests versus health needs on the other. in these conflicts, health interests find only little support. the europeanization of health policy and the implementation of eu health competence were “a dynamic but still rather unplanned process of policy harmonization and policy adaption. it offers an example of effective and inspired muddling through, rather than of a consistent and clear cut european concerted strategy” (19). it is worthwhile to take a look at the evolution of the legal base of the eu public health mandate, especially as today treaty changes are being discussed to reduce eu power in favour of increased national responsibility. before the treaty of maastricht in 1992, there was no specific legal base for public health activities. the first eu action program „europe against cancer‟ 1985 initiated by a summit in rome and, therefore, had to be based on a catch of legal base, in that a commission proposal could be agreed unanimously if the treaties did not provide the necessary power. this legal base still exists today in the article 352 of the lisbon treaty, but it cannot be applied to health any more, as there is a specific legal base for public health, established in the article 129 of the treaty of maastricht in 1992. the main components of article 129 were slightly reworded in the following treaties, but essentially are still valid: community action should encourage and support ms‟ cooperation in order to achieve a high level of health protection, and; community action should be directed towards preventing human illnesses, especially by promoting research into their causes, their transmission, as well as health information and education. the only instrument to achieve this, were supportive activities. consequently the only activities that took place were „action programmes‟ and „recommendations‟. any binding legal measures such as regulations or directives are impossible. health care was not even mentioned and ms, especially the new ones, watched very carefully that eu action did not go an inch beyond these agreements. quite soon, it became obvious that this very limited and weak mandate and its legal base were not sufficient to enable the eu to react appropriately to new challenges or at least to contribute sufficiently to their solution. examples for these new problems, which most ms were unable to cope with alone, included new health threats such as aids, sars or ebola, the economic crisis and its effects on health systems, as well as bio-terrorism, to name just a few. regarding one threat, the bse crisis and the jacob-creutzfeld disease, the commission handling it was paying more attention to the commercial interests of farmers than to health risks for humans, which led the european parliament to demand a strengthening of the public health legal base, which took place in a new strengthened formulation in the article 152 of the treaty of amsterdam (20), which was not only upheld, but even strengthened in all further treaty changes (nice 2003, lisbon 2010). the lisbon treaty 2010 many years later, in 2010, the lisbon treaty was agreed to and ratified. its ratification was relatively easy because it was not a completely new text but just modified the pre-existing treaty of nice. it consists of two parts (treaty of the eu containing common provisions and principals and treaty on the eu functioning) containing the strengthened competences of the commission as proposed in the failed attempt to agree on a european constitution in 2004. despite the permanently ongoing discussion about increasing or decreasing eu competences, the necessary changes of the lisbon treaty seem highly improbable because the needed unanimous agreement and ratification by 28 ms and even more in the future. as the lisbon stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 10 treaty will be the legal base of all eu action for a long time, it is appropriate to look at the changes in the health provisions to see how far future challenges could be met by eu activities. the provisions in the treaty on the functioning of the eu are peculiar, difficult to understand, and even contradictory. whereas article 4 mentions health aspects as an area of shared competence: “common safety concerns in public health matters for the aspects defined in this treaty” [2k], the article 6 also names it as the first area for supportive, coordinative and supplementary competence : (a) “protection and improvement of human health”. health is the only policy area mentioned in two different competence categories. is there a difference between public health and human health? is there a difference between common safety and protection? most likely this is a badly formulated remnant of the foregoing discussion around a constitution, where health as a whole was originally planned to be a „shared competence‟, which many ms did not want. the background for a potential shared competence was the threat of „bio-terrorism‟, which was considered to be a common safety concern to society and not just a health threat. whatever the explanation may be, as the eu-related contents of public health are described in great detail in the title xiv of article 168, it is obvious that with few exceptions public health continues to be only a supportive competence, which aims at encouraging and supporting ms cooperation. in spite of the detailed description in the article 168, this leads to less and not more clarity. in comparison to the lengthy elaboration of one page in article 168, the really important area internal market consists of involves only some lines in article 26. the well-known ms position to keep the eu as far away as possible from influencing their health policy is fully upheld. there is no harmonization of systems in any way. there still is hardly any possibility for binding hard law legislation (exceptions: article 168 no. 4 dealing with quality and safety of organs and blood, veterinary and phytosanitary fields with direct relation to public health, and quality and safety of medicinal products as well as devices). however, there are at least some small improvements. the scope and content of the commission support of cooperation, i.e. financing, is increased by naming concrete possibilities such as establishment of guidelines and indicators – both basic for the establishment of a permanent eu health information system – as well as the organisation of the exchange of best practices, periodic monitoring and evaluation. furthermore, the door for the first time is slightly opened for health care as there are positive words about improving the complementarities of health services in cross-border areas, something that has been happening for a long time in many „euregios‟ without commission participation or support. health in all policies (hiap) the most important change, however, is the new first sentence introducing article 168, also contained in article 35 of the eu charter of fundamental rights: “a high level of human health protection shall be insured in the definition and implementation of all the unions policies and activities”. this very clear statement, which gives the eu an undisputable legal right und political mandate, is quite unique as it is not contained in any national constitution or bill of human rights. it not only means that all other policies have to avoid or at least limit negative health effects, but it also provides a legal base to use all policies directly or at least indirectly for binding and obligatory “health legislation”. it gives the eu the power and the competence to establish „hard law‟, to achieve health aims and targets. the eu fight against tobacco was the biggest eu health policy success story; it was made possible because „hard law‟, based on internal market competences, was used to establish the stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 11 needed binding directives. they were disputed and fought bitterly by the active and powerful tobacco lobby, but despite of all their attempts expressively legally confirmed and even promoted by a number of european court decisions. despite of this encouraging example, health in all policies today is mainly a vision and far away from being an overall reality. it is tremendously difficult to apply and implement it, as other policies which want to achieve their own aims and health impacts, as a rule, are of little concern to them. last but not least, powerful stakeholders – not only industry but also social partners – have foremost economic and not health interests and, at a political level, it is the economy that counts. as an example, the eu strategy to „reduce alcohol-related harm‟ failed to a great extent because of the negative consequences for various other eu policies and regulations (agricultural subsidies, harmonisation of taxation and the removal of trade barriers in the internal market). it is the most prominent example of failure of the hiap principle. despite the undisputable fact that alcohol is a main cause for diseases and health, the economic interests were stronger and prevailed. the eu is worldwide the biggest alcohol producer in a growing and very profitable market which had to be safeguarded. thus, the eu market laws weakened the restrictive alcohol policy in the nordic countries with the result that drinking alcohol already in adolescence became their biggest health problem. to transform the health in all policies principle from vision to reality it is essential to be able to compete with and to influence countervailing economic and industrial powers. this requires adequate organisational structures as well as institutional mechanisms for resolving conflicts and the development and permanent use of support tools such as health impact assessment. above all, it is essential that those who are responsible for health in the commission (health commissioner and health directorate) and in the ms (health ministries and stakeholders) have the political will, as well as the power to do it. all of that is missing nowadays in the eu. achievements and impact of eu health policy after more than 20 years, it is justified to ask two simple questions: i. have eu activities led to better health in the eu? ii. have eu health actions and health-related legal regulations had a noticeable impact in the ms and on the national health policies? both questions may be simple, but are difficult to answer. a short, but honest, answer would be: we just do not know! as, up to now, no overall evaluation (health impact assessment) of eu activities has been made in the eu or in any ms, we can only give some general indications based on eu/who/oecd health information systems and health monitoring, mostly created by eu funding and networks. this enormous increase of knowledge about the health situation and health systems and their development, easily available to everyone, is possible the biggest achievement of eu health policy, to date. we know today more than ever before, but the central question remains: are eu and national policies based on this knowledge? health status european countries have achieved major gains in population health in recent decades. the situation in the eu is better than in most of the other parts of the world. “life expectancy at birth in the eu has increased by more than six years than 1980 to reach 79 years in 2010, while premature mortality has reduced dramatically. over three quarters of these years can be expected to be lived free of activity limitation” (21). on average, across the eu, life expectancy at birth for the three-year period 2008-10 was 75. 3 years for men and 81.7 years stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 12 for women. the report explains this situation by “improved living and working conditions and some health-related behaviours, but better access to care and quality of care also deserves much credit”. the question is, if and how much these factors have been influenced by eu policies. a scientific evaluation in 2003 of the eu “europe against cancer program” (22) comes to the conclusion, that this programme appears to have been associated with the avoidance of 92,573 cancer deaths in the year 2000, or a reduction of about 10% of the eu overall. these exact figures might be questioned, but the phrase „appears to have been associated‟ is applicable also to the positive eu influence on the overall improvement of the health status of eu citizens. there can be little doubt that many eu activities that have been directed at reducing risk factors to health, be it tobacco smoking, alcohol consumption or overweight, have contributed at least to some extent to their reduction. the reduction of tobacco consumption by adults in most eu member states (examples: 15% in sweden and iceland from 30% in 1980, but still over 30% in greece, bulgaria, ireland and others) would not have happened without the eu activities such as public awareness campaigns, advertising bans, and increased taxation. indeed, the reduction of smoking is the biggest eu health success story until now. by influencing mainly non-medical factors, the eu has contributed quite substantially to the present positive health status, whereas „governance of health care‟ factors such as proper access to health care, number of doctors and nurses, health care spending and the like have hardly been effected by the eu. even if the health status within the eu can be considered to have improved overall, there still is the unsolved problem of large and still growing inequalities between different countries. the gap between eu-ms with the highest and lowest life expectancy at birth is around eight years for women and 12 years for men. but, there is also a large gap within countries mainly between socio-economic groups. however, the eu has tried to reduce these gaps, where it was not successful. impact in member states the process of transforming visions into reality, of developing eu health policy and implementing it in the ms had to overcome countless barriers, was not very transparent and still is very slow. it has been described by lamping (19), a german political scientist as “discontinuing, incoherent sometimes fairly accidental and even undemocratic with little logic and rationality , self dynamic, not political but technocratic, determined by interest groups, based mainly on voluntary cooperation with little room for binding legal acts”. on the same lines, hervey and vanhercke (22) describe eu health policy as “a patch work of actors and institutions which decide and implement law, policy, and governance”. they name five different domains as components of eu health policy that ms have to improve: public health, research (both are soft law areas with no binding obligations to ms), internal market, competition, and social laws. there is no overall leadership and more competition than cooperation. whereas national health policy as a rule is the domain of one political administration (the health ministry), supported by health experts, the eu health patch work consists of institutional structures and procedures that often were developed for domains that have no health interest at all. as a consequence, eu health is not only not an eu priority but also a highly contested area with a permanent conflict between health and economic interests. also, there is only little transparency. eu health policy is mainly a field for experts with little citizens‟ participation. scott greer (15) called it a „secret garden‟ which should be turned into a „public park‟. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 13 considering the weak legal base, the lack of political commitment and interest of the ms but also within the commission, and the limited financial and personal resources available, the amount of health and health-related activities that have been developed and undertaken by this „patch work‟ is quite astonishing. starting with its first programme “europe against cancer” in 1985, a countless number of soft law activities (strategies, recommendations, programmes, projects, studies, networks, frameworks, concerted actions, establishment of agencies, platforms, and committees etc.) have taken place. the amount of binding legislations (hard law) is of course much smaller, the most important being those on tobacco issues including advertising, blood safety, pharmaceuticals, medical devices, professional qualifications, food safety and – the first small step into health care – the “patient‟s rights” directive on cross-border health care. the latter was enforced by a number of decisions of the european court of justice. there is hardly any health problem or major disease that has not been the object of eu activities. the most comprehensive overview is contained in a “welcome package public health”, prepared in 2009 by the policy department “economic and scientific policy” (23) of the european parliament, to serve as a reference tool for incoming members of the european parliament. a similar document seemingly was not produced for the new european parliament 2014. in more than 120 pages, this document, available on the internet, names and describes all past, ongoing and planned eu activities. the integration of health into other policies, however, is described on just one page and these other policies are not even named. furthermore, the document says nothing about the impact on the ms. this is to some degree understandable because there is hardly any knowledge about the actual impact of eu healthrelated activities on the ms. there is no overall evaluation, no general health impact assessment. of course the many different activities, strategies, programs, and projects, as a rule are evaluated, but these evaluations say nothing about their impact. health impact assessments of health in all policies are conducted in a small number when new policies and regulations are being prepared, not when they have been implemented. there is hope for at least a partial improvement in the future. the “patient mobility directive 2011” not only had to be implemented by the ms until the end of 2013; they also have to report to the commission about what they have done. these reports have to include detailed information about patient movements and the cooperation between ms in border regions, european reference networks, rare diseases, e-health, and health-technology assessment. as of 2015 the commission has to give an overall report to the council and the european parliament, we will then know a little more about national impact, at least in some areas. today, we still know only little, actually too little, about the impact of eu health policy. only a few documents contain information about success or failure: i. the most negative report is an evaluation conducted by the european court of auditors in 2009 of the 3 rd eu public health programme 2007-2013 (24). this report considered it a waste of money, because it contained no strategy, was badly implemented, the projects funded had little policy connection, and there was no follow up. the commission accepted this harsh criticism and promised positive changes in its future programmes, especially in the following next 4 th programme. also, from author‟s experience as a project evaluator it seems justified to say that since 1978 the many hundreds, even thousands of projects funded in the various public health as well as research programmes very rarely had relations to political activities, be it in the eu, be it in the individual ms. although it was the expressive aim of all these programmes that the funded projects should contribute to the improvement of health of the european citizens, it was never really evaluated if and how they achieved this. many of the projects improved knowledge, but only a few led to political action. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 14 ii. surprisingly the most positive document is the “review of the balance of competences between the united kingdom and the european union in health”, published 2013 by the uk government (25). it is part of a comprehensive examination of the balance of competences between the uk and the eu to analyse what uk membership means to national interest. these documents were prepared for all eu policies to serve as a base for negotiations with the eu about a reduction of eu competences, which – if not successful – might even lead to the uk to leave the eu. this health review is quite remarkable for a number of reasons. it is the only document prepared by any ms government describing and evaluating the national impact of eu health activities. it not only contains the view of the uk government, but also – this is really unique – the views of uk citizens, industry and stakeholders, who were asked to give their opinion. altogether, it was recognized that with very few exceptions the eu in health matters had a positive impact especially in public health (tobacco use, tackling obesity, alcohol abuse), as well as health security (where even more efforts were welcomed), sharing of information and data, as well as research funding. benefits were also seen in internal market health care measures including the free movement of patients and of health professionals, to reduce shortages. only in a few areas adverse consequences of cross sector eu legislation were noted: the directives on clinical trials, data protection, and working time. the current balance of competences between eu and uk were considered appropriate, but should not be extended further. considering these positive views in a country where generally the eu is looked at in a negative and critical way, it may be good to have similar surveys in other countries. iii. a midterm evaluation about the implementation and impact of the eu health strategy 2008-2013 (26) contains some key conclusions that could be applied to the eu health policy as a whole. it acknowledges that there is a high level of activities at eu and member state level, but it is uncertain if the outputs at ms level can be attributed directly or exclusively to the eu health strategy. thematic or structural similarities between eu and ms activities were identified but considered to be a reflection of similar priorities, a discernable direct of eu measures was not found, its influence an national strategies was considered limited. the main value of the eu health strategy was described as follows: “it acts as a guiding framework and to some extent as a catalyst for action”. these findings coincide with the results of a conference on “european public health, 20 years of maastricht treaty“, 2013 in maastricht (27). it names a number of positive developments as the result of eu health policies: building of a public health infrastructure (agencies & permanent networks); establishment of the eu as a reference point for policy makers/professionals, i.e. the establishment of a change agent for innovation; demand for capacity building initiating a boom of new education; development of european-oriented knowledge and skills. it seems that the highly fragmented eu health policy as it is gradually taking shape has up to now only limited, indirect, and even unintended affects often on national health systems and policies. it has, however, contributed considerably to the development of public health, an area which in many ms is underdeveloped and needs this support. health and the eu crisis stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 15 the present eu crisis was not caused by health, but it influences eu health policy and the national health systems. the crisis started as a financial and economic one, but it has led to a general eu crisis. it still is uncertain, when and how it will be solved, but very likely the measures taken to control it will change eu objectives, structures, competences and instruments. the future eu will be quite different to the one existing in 2014. as early as in april 2012, the former eu health commissioner john dalli, who later was forced to retire under still not clarified circumstances, said at a cocir conference in brussels (28): “a key challenge we are facing today is to prevent the economic crisis from triggering a health crisis. this may sound dramatic but the risk of this should not be underestimated”. largely unnoticed by the media, the public opinion, and by the public health community as well, a health crisis soon became a reality in many eu-ms, especially in those which because of their critical economic situation received financial aid through the “economic adjustment programmes”. examples of impact and extent of the health crisis are shown by the following figures in the “briefing notes” of the european public health alliance (29): rise in unemployment in the eu-28 from 7.2% in 2007 to 9.7% in 2010 and 11.0% in 2013 (greece 27.5%, spain 26.2%, and croatia 17.6%), especially the deterioration of youth employment which in 19 of the 28 ms stood at over 20% in 2013. mental health and suicides rates, which until 2007 had been consistently decreasing rose in the eu from 11.4 % in 2007 to 11.8% in 2012, alarming in some ms such as greece, spain, ireland and italy. cutting health budgets as well as other resources and frequent measures to reduce costs in nearly all ms have reduced the availability of frontline services and institutions. austerity measures concerning health professionals such as reducing salaries (pay cuts between 10-40%) have led to a growing migration which endangered health services in some countries. all these measures concerning the organisation and delivery of health services belong fully to the responsibility of ms, which the european commission has to respect. although the treaty and therefore the limited eu health competence – excluding most aspects of health care – remain unchanged, the balance of power between the eu and ms in health care is changing in favour of the eu as a number of new instruments were created since 2011. they are intended to strengthen the eu governance of economic policy but have of course an impact also in the health sector. the new instruments should enable the commission to intervene directly in national health care policies from a financial perspective and force national health systems to contribute to the achievement of the economic eu goals. these interventions concern not only “crisis states” receiving financial aid from eu, the international monetary fund, and the european central bank, but all ms in the context of a common macroeconomic policy. direct interventions by international into national health systems are not within the eu competences. in the past, this kind of interventions has been restricted to developing countries receiving financial aid. however, those countries receiving financial aid from the eu “economic adjustment programmes” are in a quite similar situation. they have been obliged to undertake a wide range of austerity health actions demanded by the so-called troika. these austerity measures are not always fully in line with widely accepted health values such as full access for everyone and good quality of medical services. there are, on the other hand, also eu initiatives that address health care reforms in all ms in the context of a common economic policy. these direct interventions are slowly turning into a systematic eu surveillance, backed by the power to issue early warnings and to apply even sanctions. the most important new legal act that makes this possible is the so-called fiscal stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 16 pact (“treaty on stability, coordination and governance in the economic and monetary union”), agreed by only 25 eu-ms as an intergovernmental agreement which does not replace the eu treaty, but is nevertheless enforced by the commission. the most important tool to improve policy coordination of macro-economic structural issues in key policy areas is the “european semester for economic policy coordination” that was launched in 2011. at that time, health was not considered to be a key policy area that had to be included. but, this changed in the same year when the ecofin council demanded the commission to include health. since 2012, health care is included and considered to be a key policy area for economic growth and a permanent part of its five components. since then, it is described in the annual growth survey (ags), presented every year by the commission, a part of strategic advice & orientations, contained in the “national reform & stability convergence programmes of the member states”, and the object of country specific recommendations given by the commission and the ecofin council (30-33). although the eu health competence as laid down in the treaty is and will remain weak and limited mainly to public health, denying any eu actions in health care and health systems, it is firmly established as a key policy area of eu macroeconomic policy. all decisions are dominated and made by economic actors and structures in all of the european institutions with mainly economic interests in mind. those responsible for health play a minor role in the decision making process. future perspectives an article about the past developments in the eu would not be complete without taking a look at future options and perspectives. there is a large number of publications describing and criticising eu health policy, but there are hardly any books or scenarios about its possible future. scenarios of the future are manifold. as far as health is concerned, three factors have to be taken into account: i. the future eu ii. new challenges and new solutions iii. the role of health in a future eu the future eu the eu is here to stay. there will be changes. the number of its members will continue to grow – there seems to be almost no limit. industrial ties and economic interests will guarantee its pertaining future existence. some countries may leave the eu, the main candidate at the moment being the united kingdom. this for many reasons would have negative effects on both sides, especially in public health, as the english public health community appears to be the strongest one. growth, however, will also continue to increase problems in two ways. on the on hand, the differences between ms such as size, population, economic situation, resources and the like, will lead to more inequality, for many aspects including health. on the other hand, the eu will have to cope with its growth with structures and instruments that were designed for a small community of six countries, all of which similar regarding their economic situation. in order to adapt the eu to be able to better master new challenges and tasks, it is essential to change not only its objectives and priorities but also its competences, structures and instruments, including a new balance of power between the three institutions the council, the commission, and the european parliament. this normally could only be done by a fundamental change of the lisbon treaty, however, that is almost impossible, not only right now, but also in a foreseeable future. it needs unanimity by all ms and ratification – partly by a national referendum – again by all ms. because of this, the debate about a new treaty, stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 17 including the establishment of a political union, has stopped. we will have to live with the treaty of lisbon for a long time. the answer possible at the moment – and for some time – can only be a europe of two speeds, in no way a new development. we already have an eu of at least two speeds in areas in which not all ms could agree on a common way forward. the schengen agreement on border regulations and the creation of a monetary union, establishing the new currency euro in most but not all countries, are the most prominent examples. lately, and more relevant for the health, is the creation of the fiscal union (treaty on stability, coordination and governance) agreed up to 2012 by only 25 ms as an intergovernmental agreement, part of a new economic governance framework. in the future, supranational and intergovernmental agreements of this kind outside the eu “acquis communautaire” and its legal base will partly replace the existing eu instruments and influence national policies more than ever before in many areas including health. the impact of this new situation on national welfare, social as well as health systems, has not been considered sufficiently yet. to date, eu and national health authorities play only a minor role in this process dominated by economic interests. there is a danger that health values and interests could be neglected, especially when they clash directly with economic interests. for the future of health it is essential, even vital, to ensure that those responsible and accountable for health policy at the eu as well as national level take part in this process with sufficient power to safeguard health interests. new challenges and new solutions presently, eu health policy is faced with two main, totally different challenges: the overall eu crisis mainly caused by economic and financial problems; the outbreak of ebola, one of the biggest health threats ever. in both cases, the eu has done too little and too late. especially in the case of ebola, the eu was badly prepared and, so far, is largely invisible (16). even the new european centre for disease control, founded in 2005, was much too weak to create a common anti-ebola policy of the european institutions and the ms. as difficult as it may be to master these problems, they are at the same time an opportunity to move forward. the development of the eu health policy has often been crisis driven. there is justified hope that the new situation will lead to new solutions, only possible in a time of crisis. in the past, the progress of eu health policy was triggered by new challenges and dangers which could not be tackled sufficiently on the grounds of the existing legal base, structures and instruments. communicable disease outbreaks (aids and hiv-blood contamination, cjd, sars, and especially bse posed severe threats to health, similar to bio-terrorism) are prominent examples enabling progress that otherwise would not had taken place: ° treaty changes strengthening the eu legal base for public health; ° the eu health strategy with strategic objectives and principles; ° new organisational structures within the eu; ° shift of competences (food, pharmaceuticals) to health institutions; ° intensification & institutionalisation of new cooperation capacities; ° creation of comprehensive databases & information systems; ° establishment of agencies in health-related areas (altogether nine); ° the new instrument of “open method of coordination (omc)”, applied to health; ° closer cooperation of the eu with who and oecd. most importantly, they brought about changes in the attitude of ms. these were influenced to some extent by the needs and expectations of new ms which considered it essential to add stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 18 health care and finance issues to the eu health agenda. ms still consider health to be, first and foremost, national responsibility but there is a slowly growing feeling “…that health policy should no longer be discussed exclusively in terms of national autonomy and sovereignty” (19). eu power and influence related to “all other policies” has already changed the environment in which national health policy takes place. as there is also a feeling that many problems, be it in health care or fighting new health threats cannot be solved effectively at the national level, it is increasingly recognized that the eu health policy is not simply a continuation of national health policies, but it is in many ways different. the legal basis a new and more precise formulation of the eu health competence (article 168) is needed, but obviously not possible as it would require a change of the treaty. however, a new consensus could and should be achieved as to how the article 168 should be interpreted and implemented. the eu should not continue to be active in every possible health arena, many of which are already sufficiently covered by national health policies. it should concentrate and limit itself to those issues, where ms need eu support, because the objectives of the action cannot be sufficiently achieved by the ms. this is not new, but simply the subsidiarity principle as laid down in the article 5 of the treaty, which in the past has been neglected too often. if this is done, there is no need to continue the permanent debate about giving eu health competences back to the ms. a renationalisation desired by many would take place automatically. internal structural reforms to be better prepared for facing future challenges, structural reforms are essential, which include but go far beyond „complementing national policies‟ and „encouraging cooperation between ms‟, without intending a harmonisation of national health systems. these should include: i. the internal reorganisation of the commission which should increase and not decrease the areas for which the health commissioner is responsible, including all those with a priority health interest. ii. increasing, stabilizing, and institutionalising the eu problem-solving capacities by establishing new health agencies (examples: health technology assessment, rare diseases, e-health, or health information systems), strengthening the administrative power of the existing ones, and creating new observatories and permanent networks in order to improve the diffusion of best practices. iii. advance, even institutionalise, a closer cooperation with who and oecd making use of their reputation, knowledge, experiences, manpower, worldwide resources and avoid double work. in the long run, this should result in a common institutionalised global health policy with many partners. the role of health in a future european union again, eu health policy is here to stay. it is no longer questioned any more that public health should remain to be an eu policy of its own. nobody is demanding any more a total renationalisation. nevertheless, the eu public health policy as such is far away from being or becoming a european priority. it is, at best, only a side issue on the european stage with little power and low resources. but, this is not even half of the story. health as an issue, not as a policy, has been transformed during the past years from a non-topic to one of the most important eu fields. in the main stream of eu politics, i.e. policy coordination on macro-economic issues, health has become stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 19 and will remain a key policy area. this elevation is fully justified considering its economic implications and its position in the four freedoms of the internal market. nevertheless, the eu health policy is and will remain a patch work consisting of many different parts and partners. it is a complex cross-cutting policy sector and is part of and regulated in a multitude of other policy sectors like environment, consumer protection, industry, research, transport, agriculture, competition, information and – most importantly – the eu internal market policy. health policy and especially health care are an intrinsic and relevant part of the european market of goods and services, which are affected and partly even harmonized via simple market compatibility. the decisions are taken issue-specific, fragmented, not very transparent, and mostly guided by economic interests. the eu is foremost an economic union and partly even a political one, but not a social union. health, contrary to social progress or environment, is not mentioned as an eu objective in the lisbon treaty. health, as a key policy area, is only of interest as long as it is part of another policy and has positive or negative economic implications. health authorities within the eu-commission, the european parliament, and the council of ms, at best, play only a minor role in the economy dominated decision making process. it is obvious that health values and interests could easily be neglected, especially when there is a clash with economic interests. it is essential and vital for the role of health in a future eu to ensure that those accountable and responsible for health at the eu and national levels take an active part in this decision making process with sufficient power to safeguard health interests. in the past, this was partly achieved by shifting more competences within the commission from agriculture (food), or the internal market (free movement of patients and professionals, pharmaceuticals) to the health directorate. this was much more than just an internal organisational act by the commission because it had consequences for the decision-making process in other eu institutions. whatever belonged to the tasks of the health directorate was automatically decided by the health council and the health committee of the european parliament. conclusion eu health policy as a whole has not been an unequivocal success story: there are weaknesses but also strengths. its main strength is that it has become a permanent part of the european integration process. hardly anyone is demanding its renationalisation anymore. considering its weak legal base, the restrictive position of the ms, and the activities of recognised international organisations such as who or oecd, it is astonishing to observe what has been achieved. a „non-topic‟ has developed into a key policy area of the eu economic policy. this is not due to a sudden discovery of the value of public health – the esteem for eu action in this area is still low – but relies entirely on its economic consequences. however, there is also the danger and even to some degree a tendency that the eu health policy might be reduced to narrow public health issues alone. therefore, public health activities should not only be continued but, in due time, considerably broadened and strengthened. in the future, the main task will be to safeguard health interests in „all areas‟ including economy, to ensure that economic interests do not precede health. this task should not be left to non-governmental groups, as valuable as their contributions will continue to be, but should be the task of health authorities within the commission and in the ms. to be successful, this requires political power as well as adequate organisational structures, giving health authorities more power instead of taking it away from them. in addition, it needs scientific evidence that could be provided by the eu-funded public health actions and research. if this happens, there is no reason to have doubts about a positive future of the eu health policy. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 20 references 1. european community. treaty on european union. luxembourg: office for official publications of the european community, 1992. 2. ministry of social affairs and health. health in all policies prospects and potentials. helsinki, finland: ministry of social affairs and health, 2006. 3. european parliament. an assessment of the european semester, study 2012. european parliament, dir. gen. for internal policies: 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(http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. czabanowska k, laaser u, stjernberg l. shaping and authorising a public health profession (short report). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-23 short report shaping and authorising a public health profession katarzyna czabanowska1,2, ulrich laaser3,4, louise stjernberg5 1 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 2 institute of public health, faculty of health sciences, jagiellonian university medical college, krakow, poland; 3 faculty of health sciences, university of bielefeld, germany; 4 centre school of public health, faculty of medicine, university of belgrade, serbia; 5 department of health, blekinge institute of technology, karlskrona, sweden. corresponding author: prof. ulrich laaser, faculty of health sciences, university of bielefeld; address: pob 10 01 31, d-33501 bielefeld, germany; email: ulrich.laaser@uni-bielefeld.de 1 czabanowska k, laaser u, stjernberg l. shaping and authorising a public health profession (short report). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-23 abstract the aim of this short report is to stimulate a discussion on the state of a public health profession in europe and actions which need to be taken to authorise public health professionals based on their competencies. while regulated professions such as medical doctors, nurses, lawyers, and architects can enjoy the benefits of the 2005/36/ec directive amended by 2013/55/eu directive on the recognition of professional qualifications, public health professionals are left out from these influential (elite) professions. firstly, we use the profession traits theory as a framework in arguing whether public health can be a legitimate profession in itself; secondly, we explain who public health professionals are and what usually is required for shaping the public health profession; and thirdly, we attempt to sketch the road to the authorisation or licensing of public health professionals. finally, we propose some recommendations. keywords: profession, professionalization, public health, recognition of professional qualifications. 2 czabanowska k, laaser u, stjernberg l. shaping and authorising a public health profession (short report). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-23 introduction there are many professionals within the european union (eu) that are still waiting for the recognition of their qualifications. contrary to regulated professions such as doctors, nurses, midwives, pharmacists and architects, the public health (ph) profession being so multidisciplinary and system-dependent is still not clearly defined in the european states, which hinders professional mobility, rights to an automatic recognition and integration of public health professionals in the single market. the survey carried out by the association of the schools of public health in the european region (aspher) identified a profound need to develop clear-cut professional qualification models which would allow for the certification and licensing of the profession (1). the aim of this short communication is to stimulate debate on the state of a public health profession in europe and measures and actions which need to be taken to authorise public health professionals based on their competencies. the eu directives the eu introduced the directive 2005/36/ec (2) and adopted directive 2013/55/eu (3) on the modernisation of directive 2005/36/ec on the recognition of professional qualifications on the 20th of november 2013. this document was an attempt to provide a basic legislative framework of the recognition of qualifications. however, there are still many issues left unresolved by the directive. the directive 2005/36/ec was formulated to facilitate the mobility of professionals within the eu (4). depending on the national legislation and the profession in question, the document provides three different legal approaches to the recognition of a qualification. foster (2012) explained that the automatic recognition is the first possible procedure that is restricted to a limited number of regulated professions (5). in this case, the host country should recognize automatically the qualification. a second approach is the mutual recognition of qualification that is meant for the recognition of a “general system” profession. this procedure works on a case-by-case basis. in general, it establishes that an individual should undergo compensatory measures only when the education or the minimum required years of practice diverge drastically from the receiving country’s regulation. finally, the third approach is for individuals who establish themselves in another member state (ms) by working or providing a service on a temporary or occasional basis (5,6). the legislation might allow them to work without a prior recognition from the receiving country. however, article 7 of the directive is representing a restriction to this model (4). the article states that if there is a considerable difference between the individual’s qualification and/or the training required by the ms in particular in a profession having public health or safety implications, a prior check or compensation measures may be maintained (7). there are many controversial aspects within the directive: it is excluding a part of professionals from the mutual recognition by creating an inequality between the regulated and the unregulated professionals. moreover, the insecurity for the recognition of the qualification of non-regulated professionals, especially in the health sector, will contribute to a decline in the number of applications for this field (8). consequently, for a discipline such as public health there may be a shortage of labour force in the following years. these issues need to be solved to determine the needs of the job market. however, fortunately, the amendment to the 2005/36/ec directive article 16(a) states that: “the mobility of healthcare professionals should also be considered within the broader context of the european workforce for health” (2), thus, leaving room for public health professionals to be considered. therefore, there is a call for action directed to the public health community to shape the public health profession. 3 czabanowska k, laaser u, stjernberg l. shaping and authorising a public health profession (short report). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-23 shaping a profession different countries have their specific way of looking at public health, and shaping this profession is complex as public health is a very heterogeneous interdisciplinary composite with many different fields involved. however, the leadership should be provided by a highly trained professional workforce, specialised in the core areas of public health and formally recognized as a defined profession based on academic degrees. our focus is not on the role of medical staff covering also public health aspects in their work environment, neither on nonhealth professions adding to the assurance and advancement of public health. in order to discuss the shaping of a public health profession, a significant question relates to the extent that public health profession exhibits the characteristics of a profession. there are many sociological theories which describe the concept of a profession, the professional, and professionalization. while the precise content of these models varies, there are several characteristics that distinguish the professions from other occupations. the most commonly cited traits (9) include: i. skills based on abstract knowledge which is certified/licensed and credentialed; ii. provision of training and education, usually associated with a university; iii. certification based on competency testing; iv. formal organization, professional integration; v. adherence to a code of conduct; vi. altruistic service. firstly, we will use these traits as a framework in arguing whether public health can be a legitimate profession in itself; secondly, we will explain who public health professionals are and what usually is required for shaping a public health profession; and thirdly, we will attempt to sketch the road to the authorisation or licensing of ph professionals. finally, we will propose some recommendations and stimulate the debate with open questions. public health as a profession applying the trait framework to a public health profession, one can immediately observe that the first three characteristics are fulfilled. although public health is a multidisciplinary field, it encompasses abstract knowledge which can be reflected in public health competencies (aspher) when it relates to science, and in the essential public health operations (epho) when it relates to the art. both can serve as a strong base for licensing and certification of educational and practice qualifications. public health education is provided by higher educational establishments in the form of bachelor and master programmes with specialisation in public health, or a phd in public health (referring to the three cycles of the bologna system). public health programmes are in the majority of cases competency-based and, if not, their reform has been encouraged by the aspher competency project initiative (10,11). concerning the formal organisation and professional integration, contrary to what we observe in regulated professions such as medical doctors, nurses, midwives, lawyers, and architects, public health professionals do not have a specific organisation or chamber which would safeguard their rights and privileges. with respect to the specific code of conduct which would apply to the whole profession, we do not have many examples to follow (12,13). finally, considering an altruistic service as something what distinguishes public health professionals from other professions, we may state that the whole ethos of public health is based on altruistic principles of serving and protecting for the benefit of public and individual health. based on this short inventory we are able to prove that public health can be considered a profession if we put some effort in formalising and strengthening its professional integration. 4 czabanowska k, laaser u, stjernberg l. shaping and authorising a public health profession (short report). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-23 who are public health professionals? unlike the medical profession, defining public health professionals is more elusive. for example, beaglehole and dal poz define the public health workforce as “a diverse workforce whose prime responsibility is the provision of core public health activities, irrespective of their organizational base” (14), highlighting that public health workforce can be located both inside and outside the health sector (15). whitfield provides a theoretical conceptualization of public health activities and the related workforce. according to this concept, the public health workforce can be divided into three groups: i) “public health specialists”; ii) “people indirectly involved in public health activities through their work”; and iii) “people who should be aware of public health implications in their professional life” (16). distinguishing between these three categories of the public health workforce emphasizes the multidisciplinary and diverse character of public health itself. despite many differences among countries, public health professionals in europe often are physicians and have a medical public health/social medicine specialization, although there has been a shift towards more multidisciplinary teams since the 1990s and 2000s, with finland, ireland and the united kingdom among the first countries in europe in which professionals with different backgrounds were educated in public health (14). however, the multi-professionalism of the future public health profession is not represented in many european countries. for the purpose of this paper the public health workforce – whether actual or potential – consists of three main categories: i. public health professionals – professionals with sufficient public health competences at master level for public health services and/or doctor of philosophy (phd) for public health research. a bachelor degree can be considered as an entrance level, leading to a master in public health (mph)/phd degree, independent of working inor outside the health system, or: inor outside the public health services. ii. health professionals – health staff with more restricted public health competences and functions inor outside organised public health services; their main education would basically be a medical or other health-related programme with limited public health aspects – e.g., health promotion, or screening. iii. other staff with job functions bearing on the population’s health. examples would be teachers or policemen. we focus here on the first group, the public health professionals, which include: a. general public health professionals – individuals with a bachelor or master degree in public health. thus, they can be younger persons with no previous professional experience. they hold the academic degree, but not necessarily a licence for a profession. the content of the education provided by the university programmes shapes general public health professionals. needless to say, it should follow the aspher competency lists (10,11). b. public health specialists, i.e. general public health professionals who have added special competences to their general public health education and training from the areas such as: epidemiology, management and administration, health promotion, environmental health, public health genomics, or global public health which go beyond a selected specific track covered during their mph programme, or ideally accomplished a phd. what is usually required for shaping a profession? firstly, there are specific legal and regulatory steps which need to be taken in order for the profession to get a legitimate recognition. therefore, a specific national public health 5 czabanowska k, laaser u, stjernberg l. shaping and authorising a public health profession (short report). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-23 legislation should be granted to national public health councils or their equivalents, giving them the regulatory authority to protect the public’s health and including provisions on: a) public health positions, especially those related to leadership posts; b) second (mph) and third (phd) cycle academic degrees, and; c) an independent national public health chamber with the mandate to safeguard the right to enter and execute the profession, certify and license [including the mandatory minimum credits from accredited continuing education (ce)]. the support of who-int is needed here to provide a model public health law as well as the support of ce to allow for mutual recognition of academic degrees, certification, and licensing in order to enhance mobility. formal professional certification is a national prerogative. although some attempts have been made in some eu countries e.g. the uk qualification register (17), these are highly country-specific and do not necessarily fit the diverse ph systems in europe. secondly, formalized ce programmes (including an official statement on required credits), accredited at the national level by either a separate administration or a professional chamber should be made available for public health professional development. agency for public health education accreditation should provide the quality criteria for ce and offer to accredit the national accreditation procedures. thirdly, systematic development and adaptation of the existing public health competency models to meet the needs of continuing professional development, professional appraisal, and development of public health job profiles, should constitute the ongoing improvement process. this should be followed by the translation of the competency profiles to public health operations, thus, creating various competency-based job descriptions fitting possible eu public health qualification schemes. finally, the cooperation between all sectors of education, training, and the world of work is needed to improve sectoral identification and anticipation of skill and competence needs. potential conclusions and recommendations based on our analysis we see a potential in mobilizing the efforts of the public health professional community to build on the strengths and achievements of the profession so that it can join the elite of regulated professions. we strongly believe that no effort should be spared in identifying the possibilities in the eu regulatory documents and exerting influence on changing their content so that they are more inclusive in view of the common european market. above all, we should make sure that the public health profession fulfils all the necessary criteria to be considered a regulated profession and is supported by a strong formal organization at the national and european level (18)1. therefore, we recommend the following: i. strong lobbying of the professional public health community at the eu level to support the introduction of adequate legislation. ii. implementation of the professional qualification directive with broader mention of the recognition of public health professional qualifications. iii. advocating for public health laws to establish the requirements for leadership positions (see who database planned). iv. assuring that national qualifications are recognized eu-wide and beyond (european-wide recognition required for enhanced professional mobility). v. developing clear differentiating criteria related to academic (bologna cycles) and professional certification and re-licensing based on continuous professional development credits. 1we are obliged to prof. anders foldspang for the aspher concepts and policy brief on the classification of the public health workforce as an additional source for the publication. 6 czabanowska k, laaser u, stjernberg l. shaping and authorising a public health profession (short report). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-23 vi. provision of certification and licensing for all public health professionals. vii. acceptance of the national responsibility for certification and licensing. viii. advocating for the establishment of professional public health self-government (chamber) at the national level. acknowledgement the paper was presented at the deans’ & directors’ meeting in zagreb, croatia 30 may 2014, during session 5, organised by prof. anders foldspang. references 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2004. 17. united kingdom public health register. available from: http://www.publichealthregister.org.uk/sites/default/files/practitioner_introduction_pac k_april2011.pdf (accessed: april 30, 2014). 18. foldspang a, otok r, czabanowska k, bjegovic-mikanovic v. developing the public health workforce in europe. the european public health reference framework (ephrf): it’s council and online repository. concepts and policy brief. brussels: aspher, 30 april 2014. ___________________________________________________________ © 2014 czabanowska et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 8 laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 1 original research a code of ethical conduct for the public health profession ulrich laaser1,2, peter schröder-bäck3,4 eliudi eliakimu5, katarzyna czabanowska3,6, the one health global think-tank for sustainable health & well-being (ghw-2030)7 1 faculty of health sciences, university of bielefeld, bielefeld, germany; 2 institute of social medicine and school of public health and management, faculty of medicine, university of belgrade, belgrade, serbia; 3 department of international health, care and public health research institute (caphri), faculty of health, medicine and life science, maastricht university, maastricht, the netherlands; 4 faculty of human and health sciences, university of bremen, bremen, germany; 5 health services inspectorate and quality assurance section, health quality assurance division, ministry of health, community development, gender, elderly and children, dar es salaam, tanzania; 6faculty of health sciences, medical college, jagiellonian university, krakow, poland 7 george lueddeke, think-tank convenor/chair; southampton, united kingdom; membership of the “one health global think-tank for sustainable health & well-being (ghw 2030)”: moaz abdelwadoud, ibukun adepoju, muhammad mahmood afzal, muhammad wasif alam, john ashton, vesna bjegovic-mikanovic, bettina borisch, genc burazeri, sara carr, lisa conti, katarzyna czabanowska, eliudi eliakimu, kira fortune, luis galvão, iman hakim, n.k. ganguly, joshua godwin, james herington, tomiko hokama, howard hu, ehimario igumbor, paul johnstone, mitike getnet kassie, laura kahn, bruce kaplan, gretchen kaufman, daniella kingsley, ulrich laaser, joann lindenmayer, george lueddeke, qingyue meng, jay maddock, john middleton, geoff mccoll, thomas monath, joanna nurse, robert otok, giovanni piumatti, srinath reddy, helena ribeiro, barbara rimer, gautam saha, flavia senkubuge, neil squires, cheryl stroud, charles surjadi, john woodall. corresponding author: prof. dr. med. ulrich laaser dtm&h, mph section of international public health (s-iph) faculty of health sciences, university of bielefeld e-mail: ulrich.laaser@uni-bielefeld.de laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 2 abstract aim: agreeing on a code of ethical conduct is an essential step in the formation and definition of a public health profession in its own right. in this paper we attempt to identify a limited number of key ethical principles to be reflected as professional guidance. methods: we used a consensus building approach based on narrative review of pivotal literature and theoretical argumentation in search for corresponding terms and in a second step attempted to align them to a limited number of key values. the resulting draft code of ethical conduct was validated employing a framework of the council of europe and reviewed in two quasi delphi rounds by members of a global think tank. results: the alignment exercise demonstrated the acceptability of five preselected key principles: solidarity, equity, efficiency, respect for autonomy, and justice whereas three additional principles were identified during the discussion rounds: common good, stewardship, and keeping promises. conclusions: in the context of emerging and re-emerging diseases as well as increase in lifestyle-related diseases, the proposed code of ethical conduct may serve as a mirror which public health professionals will use to design and implement public health interventions. future public health professional chambers or an analogous structure should become responsible for the acknowledgement and enforcement of the code. keywords: code of ethics, moral obligations, principle-based ethics, professional standards, public health profession, population ethics, societal responsibility, utilitarian ethics. conflicts of interest: none. acknowledgements: the authors express their gratitude to george lueddeke who helped initiate the “one health global think-tank for sustainable health & well-being (ghw 2030)” and chairs it since. special thanks go to think tank members muhammad mahmood afzal, muhammad wasif alam, mitike getnet kassie, and joann lindenmayer for their extensive review and comments which were of invaluable help. laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 3 introduction the implementation of public health interventions raises ethical issues which require public health professionals to address them. the awareness of the ethical dimension of public health activities has given rise to the relevance of public health ethics, which meagher and lee refer to as “a subspecialty of bioethics” (1), and kass refers to as a “subfield of bioethics” (2). several authors have noted the importance of ethics for public health (3, 4), and public health professionals training (5). for example, ethical issues in public health also feature prominently in the efforts to control emerging infectious diseases at the population level (6, 7), which necessitated the world health organisation (who) to issue guidance on how to deal with ethical issues in infectious diseases control (8). also, the efforts to address antimicrobial resistance (amr) have raised a number of ethical questions (9). in a systematic review by klingler et al., they have identified a comprehensive catalogue of ethically relevant conditions (10). thus in order to address the ethical issues arising from public health practice and research, it has been noted that there is a need to establish a public health ethics framework and a code of conduct for public health professionals, as well as to train public health professionals in population ethics (11). several frameworks for public health ethics have been documented (2, 12-15); among them, marckmann et al. (12) have provided detailed reasoning on application in the field practice. however, a gap remains: the development of a code of ethics and professional conduct in the field of public health or in short: a code of ethical conduct for the public health profession. in a recent introductory paper, laaser and schröder-bäck (16) outlined the reasoning why a code of conduct is an essential step in the formation and definition of a public health profession in its own right at the national as well as the european level and with relevance to a global dimension. the european directive on the recognition of professional qualifications 2005/36/ec (17) acknowledges as regulated professions in the health sector only physicians, nurses, dentists, midwifes, and pharmacists. the amendment eight years later in directive 2013/55/eu opens the door to include additional professions when it refers to a ‘broader context of the european workforce for health’ (18) which should then include for example veterinarians given their high relevance for people’s health. in most of the european countries, public health professionals are not formally organised as an autonomous profession in its own right – as for example it is the case in the united kingdom (19) – and do not adhere to an agreed code of conduct (20). however, the “good public health practice framework published 2016 by the uk faculty of public health 2016 (21) constitutes rather – as the title says – a guide for ethical practice which may be derived from overarching principles as discussed in this paper. although there are organisations of schools of public health (22) and public health associations (23) as well as other associations related to areas of public health relevance, agreement on a code of conduct as one precondition for the formalisation and integration of a public health profession has not been promoted as necessary. the american public health leadership society (24) described the rationale for an ethical code of conduct in 2002 as: “…a code of ethics thus serves as a goal to guide public health institutions and practitioners and as a standard to which they can be held accountable”. the statement goes further beyond public health professionals to include institutions that are involved in public health to abide to ethical conduct. however, as a first attempt this did not initiate a lasting debate and the recent volume of the public health reviews on ethics in public health (25) touches the topic only indirectly. laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 4 in the introductory paper referred to above (16), laaser and schröder-bäck discussed the limitations of the often dominant utilitarian principle in population ethics. the utilitarian principle says that the moral worth of an action or inaction lies in the consequences that follow. an action (or inaction) is good if it maximises the good for a maximum of people and is better in this regard than any alternative action. intrinsic values – such as respecting persons or dignity – do not exist in utilitarian thinking. instead of applying the utilitarian principle, the authors propose “...that solidarity and equity are core values that have to be reflected in a european version of a code of conduct for public health professionals… also guided by the principles of efficiency and respect for autonomy”. as an additional principle they discuss justice, especially for resource sharing on a global scale. although these five principles reflect the european heritage, the authors underline the increasingly global dimension of the public’s health (26, 27, 28) and therefore of a public health profession welldefined by the same principles (29, 30). methods we used a consensus building approach based on narrative review of literature and theoretical argumentation: we 1) argued the proposed five core ethical principles from the theoretical standpoint using a narrative review of selected publications in the field and trying to be as comprehensive as possible and relevant; 2) extracted and confirmed the five core principles as essential values for public health professionals and institutions in an “overlapping consensus” based on several rounds of discussion among authors, then translated the core principles into a draft code of ethical conduct making use of ‘mapping the terrain’ as proposed by childress et al. (31); 3) validated the draft employing the ‘general framework for codes of conduct in the health sector’ adopted by the council of europe in 2010 (32); and finally, 4) sent out the resulting draft for comments in two quasi delphi rounds conducted by the global think tank ghw-2030 (33). the comments from members of the global think tank in round one have to a large degree been integrated by the authors. the second round revealed support in formulating the conclusions and recommendations and the approval of the second draft. results review of the literature with regard to corresponding terms table 1 presents the selected and scrutinised papers related to principles and norms regarding public health ethics. we carefully aligned and synthesised theoretical frameworks to find the best fit between them. the draft ethical code the identified literature revealed its best fit with the five core values identified earlier (16): solidarity, equity, efficiency, respect for autonomy and justice. three additional principles were identified in the alignment exercise, which are: common (public) good, stewardship, and keeping promises and commitments. in the following we explain their core normative meaning. solidarity laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 5 solidarity is a value that increases in significance in the health realm. whereas in the conclusions of the council of the european union (38) solidarity was solely defined as being closely “linked to the financial arrangement of our national health systems and the need to ensure accessibility to all”, the normative scope, its relevance and meaning for public health gets more and more developed during the last years. a recent report of the nuffield council on bioethics defines solidarity as a concept that “signifies shared practices reflecting a collective commitment to carry ‘costs’ (financial, social, emotional or otherwise) to assist others.” (41). ter meulen (42) emphasises that solidarity is more than respecting each other and assuming liberal negative rights of freedom but that positive relations among human beings should be in the forefront, next to rights and duties. he formulates: “health care policies and arrangements should go beyond merely meeting needs and rights, by exploring how people’s personal dignity and sense of belonging can be sustained within relations of recognition, reciprocity and support”. from these essential cornerstones defining solidarity, one can conclude that the value of solidarity acknowledges that human beings should not forget that they are united, bond to other humans by virtue of humanity. from this also follows the duty for mutual support and the strengthening of relations among human beings should therefore be in the forefront of public health practice. equity also “equity” is one of the core values that are discussed in public health. the european union defines equity in health simply as relating “to equal access according to need, regardless of ethnicity, gender, age, social status or ability to pay” (council of the european union 2006 (38)). however, equity is also the normative reminder that health inequalities have to be in the focus of all public health action if considered to be unjust and unfair (43), foremost all those which refer to religion, race, gender identity etc. efficiency despite the last values that focus on rights and stress the moral importance of every one, the value of “efficiency” stems from another philosophical school but the rights-based approach. “efficiency” follows more utilitarian thinking inclined to maximize the positive outcome with a minimum of resources. this economic reasoning has a value also from a moral perspective because it reminds public health professionals that one has to be careful when dealing with scarce resources. scarce resources should be invested wisely to have the best health effect and economic evaluations are therefore important for public health. for instance, in some circumstances such as in the area of hiv/aids, there are challenging questions on how to allocate resources in an ethically acceptable and efficient way between preventive and curative demands (39) or between different health programmes. also, in the example of antimicrobial resistance, the allocation of resources may require reprioritisation from other areas and sectors outside health in order to gather enough funding to support containment of the epidemic (9). laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 6 table 1. review of ethical principles and terminologies with relevance to public health sources of ethical principles and terminologies for public health ethical principles proposed for public health attempted alignment of ethical principles for public health professionals world health organisation [2016] (8) justice equity transparency inclusiveness/ community engagement accountability oversight utility proportionality efficiency respect of persons (autonomy, informed consent, privacy confidentiality) liberty solidarity reciprocity solidarity reciprocity community engagement equity utility efficiency liberty respect of persons (autonomy, informed consent, privacy confidentiality) proportionality justice transparency inclusiveness/ community engagement accountability oversight core ethical principles solidarity equity efficiency respect for autonomy justice littmann and viens [2015] (9) justice distributive fairness effectiveness reciprocity stewardship citizen obligations to self educate citizens obligations not to infect others citizen involvement in responsibility citizen obligations and actions solidarity public engagement reciprocity distributive fairness effectiveness responsibility priority setting and resource allocation risk information sharing justice distributive fairness health justice trust public engagement distribution of research outcomes laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 7 sources of ethical principles and terminologies for public health ethical principles proposed for public health attempted alignment of ethical principles for public health professionals lobbying risk information sharing distribution of research outcomes public engagement solidarity reciprocity health justice common good trust royo-bordonada and roman-maestre [2015] (11) autonomy solidarity transparency pluralism community perspectives rights of individuals common good partnerships (public-private partnerships) collection and use of data (information) solidarity partnerships (public-private partnerships) information (collection and use of data) resource allocation autonomy rights of individuals pluralism community perspectives core ethical principles solidarity equity efficiency respect for autonomy justice marckmann g et al. [2015] (12) maximizing health benefits preventing harm respecting autonomy equity efficiency compensatory justice transparency participation justification equity compensatory justice maximizing health benefits efficiency respect for autonomy justice participation justification transparency consistency laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 8 sources of ethical principles and terminologies for public health ethical principles proposed for public health attempted alignment of ethical principles for public health professionals consistency justification participation ortmann le et al. [2016] (13) utility equity justice reciprocity solidarity privacy confidentiality keeping promises effectiveness proportionality necessity least infringement public justification solidarity reciprocity necessity equity effectiveness utility privacy least infringement confidentiality proportionality justice public justification public health leadership society [2002] (24) information collaboration respect for individual rights diversity incorporation confidentiality collaboration information respect for individual rights, confidentiality diversity incorporation information core ethical principles solidarity equity efficiency respect for autonomy justice schröder-bäck p et al. [2014] (34) maleficence beneficence health-maximisation efficiency respect for autonomy justice proportionality justice justice efficiency health maximisation respect for autonomy proportionality justice laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 9 sources of ethical principles and terminologies for public health ethical principles proposed for public health attempted alignment of ethical principles for public health professionals laaser u et al. [2002] (35) solidarity equity efficiency sustainability participation subsidiarity reconciliation evidence empathy/altruism solidarity empathy/ altruism equity subsidiarity efficiency sustainability evidence reconciliation participation sustainability institute for global ethics [n.d.] (36) competence honesty responsibility respect fairness compassion compassion competence responsibility respect honesty fairness council of the european union [2006](38) equity universality solidarity solidarity universality equity world health organisation [2015] (39) equity solidarity social justice reciprocity trust individual liberty versus broader societal concerns public good distributive justice solidarity reciprocity equity allocating scarce resources individual liberty versus broader societal concerns distributive justice social justice trust core ethical principles solidarity equity efficiency respect for autonomy justice coughlin sts [2008] minimizing possible harms solidarity/social effectiveness least infringement treating others fairly laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 10 sources of ethical principles and terminologies for public health ethical principles proposed for public health attempted alignment of ethical principles for public health professionals (40) treating others (current & future generations) fairly sustainability solidarity/social cohesion precautionary principle utility public justification least infringement necessity proportionality efficiency effectiveness building and maintaining public trust transparency (speaking honestly and truthfully) keeping promises and commitments protecting privacy and confidentiality procedural justice (participation of the public and the participation of affected parties) cohesion necessity efficiency sustainability utility protecting privacy and confidentiality proportionality (minimising possible harms) procedural justice (participation of the public and the participation of affected parties) building and maintaining public trust transparency public justification core ethical principles (summarised): * additional ethical principles remaining after the attempted alignment (bold in the table) are: solidarity (reciprocity) equity efficiency (utility, effectiveness) respect for autonomy (respect for individual and community, justice (public justification) laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 11 sources of ethical principles and terminologies for public health ethical principles proposed for public health attempted alignment of ethical principles for public health professionals • common (public) good • stewardship • keeping promises and commitments privacy, confidentiality, least infringement) laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 12 respect for autonomy economic evaluation and utilitarian thinking have to be hold in check by the rights-reflecting values equity, justice and also respect for autonomy. the normative core of the latter value is to re-iterate and focus what also is reflected in justice and equity: every person has autonomy and thus the capacity to make own decisions (for children or other persons unable to consent, parents or guardians take this role). respect for autonomy thus reminds public health professionals to obtain informed consent of persons who are subject to health interventions but also stresses that persons have a dignity that must not be comprised. this value warns of stigmatisation and instrumentalisation of persons for the benefit of others. if the autonomy of persons is comprised, this has at least the strong burden of proof that such an autonomy limiting behaviour is justifiable. however, respecting the autonomy of everyone not only means “to back off” and respect the liberty of a decision of persons. rather, o’neill (44) reminds the public health community that respecting autonomy can also refer to a duty, e.g. to participate in health interventions like immunisation campaigns to achieve herd immunity. littman and viens (9) in this context have noted that in order to address antimicrobial resistance “citizens have obligations to educate themselves, obligation of not to infect others, and obligation to lobby for support from political leaders and industries.” there might be examples where the infringement of a will of a person can be justified. the use of spillover effects of an intervention as a basis to restrict autonomy of an individual has been well explained by royo-bordonada and roman-maestre (11, pp. 12 of 15): “…among public health officials, there is a political component in the form of the health authority, with legal capacity in certain instances, to take action targeted at the individual or the environment. this capacity to restrict the autonomy of the individual can … come to be justified on the basis of the externalities, positive or negative, induced by the intervention in third parties”. an example could be to restrict the free movement of people with infectious diseases if their free movement could lead to severe infections of others. justice when can we consider something as being unjust and unfair? a benchmark for justice theories in health is the work of norman daniels. daniels (2008 (45)) follows his teacher rawls in the assumption that public institutions are obliged to promote fair equality of opportunity for everyone. public institutions and resources should be organized in such a way that every person can participate in society – to take public offices but also to have resources to live a good life (which is not further specified). daniels continues the rawlsian approach by claiming that health significantly contributes to the opportunity range that people are having. and, as a consequence, justice requires to protect health and to meet health needs of every person. following the philosopher boorse (46), daniels also has a clear idea of what health means in this context: species typical normal functioning according to the functioning of others in the same (e.g., age) reference class. thus, for public health professionals, justice understood in this way should remind them of including everyone to benefit from health and thus getting fair equality of opportunity in life when the social and other determinants of health (incl. access to health care) do not support this goal for everyone. the concept of distributive fairness includes also the important question of how findings from scientific research are distributed since research evidence is key for an informed laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 13 decision-making in public health. for instance, the tension in resource allocation between prevention and treatment in hiv and aids services can better be solved if decision makers know the evidence that treatment helps to minimize the risk of transmission, therefore, we can take treatment as part of prevention. in this way, the evidence for treatment as prevention can assist in distributive justice in resource allocation in hiv/aids between preventive and curative interventions. also, by sharing research results, it will help communities to understand the value of interventions being implemented in public health and hence be more willing to support them. however, justice could also extend to include unproportionate focus on resource driven health programmes versus “other” public health calamities with significant impact. a key message to public health professionals is that distribution of research outcomes should be tailored to the audience, i.e., to the ordinary citizens; message should be prepared in simple, non-technical terms to ensure that it is clearly understood. the core principle of justice and its emphasis on transparency, inclusiveness, and community engagement provides an opportunity for people of different culture, values, and beliefs to participate in assembling public support. “lessons from the human genome project – ethical, legal, and social implications program” (1) indicate that engaging the public in an informed discussion aiming at reaching agreement on a particular public health intervention, can help to get support of the population or community. additional principles from table 1, three additional principles have emerged, namely: protection of common (public) good; stewardship; and keeping promises and commitments. common (public) good this principle focuses on the need to protect things that are shared by all for the benefit of all people in the community, population or a nation. in economic theories the characteristics of a “public good” are those of being “non-excludable” and “nonrivalrous”. this means that all people can benefit from the good, no one is (or can be excluded), and use of the common good does not diminish the good. the “common (public) good” has close links to communitarian theories of public health ethics (47). this also requires public health professionals to be able to solve ethical conflicts between the protection of public good and human rights of individuals within a particular community or population (48). knowing that priority is on preservation of common good should be the bottom-line for a public health professional when implementing an intervention that encroaches on individual’s rights and freedom. if a public health professional decides to focus on rights of individuals alone at the expense of a common good, this may put the whole community or population at risk. also, the principle requires the public health professional to be informed by scientific evidence while making decisions about a particular intervention. stewardship this normative value insists that public health professionals have a stewardship role, which means that they have to put the health of the population as their number one priority (37). in other words, the stewardship role of public health professionals makes them responsible for the health of the entire population. as stewards, public health professionals must have a vision for the health of the people they serve. this brings to them a need for using scientific information to analyse situation and design laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 14 (jointly with the population) appropriate interventions. also, public health professionals must build skills to engage the population and to reach consensus on public health interventions that will help to solve a problem at hand. if a public health professional behaves as a “good steward”, then all stakeholders will likely support the implementation of public health interventions. to this end, public health professionals must be able to communicate effectively all the interventions as well as research findings to the population. laws, regulations, and other tools for governance arrangements are part and parcel of the stewardship role. therefore, public health professionals in fulfilling their stewardship role should be able to participate in setting regulations and bylaws and support the populations to comply with in order to flourish healthy lives. keeping promises this principle calls for public health professionals to hold themselves responsible on the promises and commitments they make. it should be understood by the professionals that commitment to improve and preserve the health of the population they serve is central to their duties. when a planned intervention is to be implemented in a particular community, it is the responsibility of the public health professional to ensure that the promise is achieved in a transparent manner and that the resources earmarked for the intervention are used as planned. these three additional principles underline the relevance of operational ethical competence and are constitutive elements of public health professionalism. validating the draft code of conduct for validation we found most suitable the general framework for codes of conduct in the health sector, approved by the council of europe in 2010 (32). in table 2 we attempt to show that the core ethical principles we identified can be aligned to a large degree with the framework adopted by the council of europe. table 2. general framework for codes of conduct in the health sector of the council of europe (complete version in annex 1) main areas subareas selected examples corresponding core principle 4. areas to be regulated by a code of conduct in the health sector a. good professional practice i. respect for the dignity of people (employees…) ii. honesty and confidentiality … iv. use of the best scientific evidence … vi. compliance with regulations and legislation vii. awareness of the needs, demands and expectations of the population … 2.4 2.4 2.3 2.5 2.2 laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 15 b. use of resources of the service/system i. cost-effectiveness… ii. avoiding using public resources for private gain iii. prevention of fraud and corruption 2.3 2.5 2.5 c. handling of conflict of interests… i. economic: weighing between health benefits and economic gains on one side and individual gains (employment, etc.) (45). ii. non-economic: managing relationships with health authorities and other government officials (11, 45). 2.6.1 d. proper access, sharing and use of information … ii. duty to disclose all relevant information… … 2.4; 2.5 e. handling of gifts and benefits i. existence of an explicit policy concerning gifts … 2.5 f. research-related topics … ii. truthful claims of research potential … iv.* feedback to study populations on the results v.* research outcomes as part of public good need to be shared in order to facilitate evidence-based decisions. 2.4 2.4 2.5 g. relationships with other actors in the health sector … vii.* collaboration between public health professionals, communities and public health institutions. 2.1 2.6.1 h. good corporate governance of health institutions/services/centres i. issues of multiculturalism, tolerance and respect … ii.* participation in humanitarian activities 2.4 2.1 2.6.2 5. enforcement of the code of conduct a. recognition of violations b. composition of the body responsible for dealing with enforcement c. transparency of procedures and public scrutiny d. complaints system e.* use of nudging techniques in design of public health interventions (46). this emphasis is based on the consideration that public health professionals need to balance application of nudging and strict prohibition. 2.5 2.5 2.5 2.5 2.3 2.6.2 2.5 6. updating, a. process of development of 2.6.1 laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 16 monitoring and development of the code of conduct codes of conducts: initiative, ownership, legitimacy b. comprehensiveness c. limitations of codes of conduct d. codes of conduct and legislation 2.6.2 2.6.3 * amended by e. eliakimu. results of two quasi delphi rounds the final outcome of our integrating consensus oriented approach is summarised in table 3. laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 17 table 3. the aligned code of ethical conduct for the public health profession preamble: the public health profession is defined inter alia by an adopted set of principles guiding the ethical conduct of its members. these principles form a normative core of the profession. public health professionals should orient their conduct – their doing and omission – according to the following norms and values. in case of conflict of these values, professionals accept a burden of proof to argue the ethically best acceptable solution for their conduct while taking the normative guidance of all these norms and values into account. core ethical principles short characterisation taken from section 2.1-2.5 above 2.1 solidarity solidarity signifies shared practices reflecting a collective commitment to carry ‘costs’ together to assist others. human beings are united in the fact that they are bond to other humans by virtue of humanity. from this also follows the duty for mutual support for every human being. the strengthening of relations among human beings should therefore be in the forefront of public health. 2.2 equity equity is relating to equal access according to need, regardless of ethnicity, gender, age, social status or ability to pay. health inequities considered to be unjust and unfair have to be in the focus of all public health actions. 2.3 efficiency maximisation of the positive outcome with a minimum of resources, i.e., scarce resources should be invested wisely to have the best health effect. 2.4 respect for autonomy economic evaluation and utilitarian thinking have to be hold in check by the rights-reflecting values equity, justice and also respect for autonomy. persons have a dignity that must not be comprised. 2.5 justice public institutions and public health professionals are obliged to promote fair equality of opportunity for everyone. this principle also encompasses distributive justice on research, i.e. to consider how findings from scientific research are distributed. operational ethics short characterisation taken from section 2.6.1 2.6.3 above 2.6.1 common (public) good this principle focuses on the need to protect things that are shared by all for the benefit of all. public health professionals must be able to solve ethical conflicts between the protection of public good and human rights of individuals. knowing that priority is on preservation of common good should be the bottom-line for a public health professional. 2.6.2 stewardship stewardship makes public health professionals responsible for the health of the entire population. they have to build skills to engage the population and to reach consensus on public health interventions that will help to solve a problem at hand. they should also support the citizens to comply with various laws and regulations governing public health issues. 2.6.3 keeping promises this principle calls for public health professionals to hold themselves responsible for the promises and commitments they make. promoting and preserving the health of the population they serve is central to their duties. discussion the proposed code of ethical conduct for the public health profession hopefully will become relevant in global and not just in european contexts. for example anderson et al. (51) have highlighted a global health ethics in addressing the challenge of maternal and neonatal mortality. the identified principles make a significant contribution to the newer related field of “global health ethics”, which has been shown to adopt almost similar values but operates at or requires actions at global level (52). principles include equity, justice, laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 18 autonomy, human rights, application of scientific research, as well as related virtues such as compassion, trustworthiness, integrity, and conscientiousness. the world health organisation in its key document on global health ethics has identified three ethical challenges that closely relate to these principles: first – “… to specify the actions that wealthier countries should take, as a matter of global justice and solidarity, to promote global health equity”; second – “… is related to cultural relativity. it is sometimes asked whether ethical standards are universal, given that different people in different countries may hold different values or place different weights on common values; third concerns international research, especially when investigators from wealthy countries conduct research in impoverished settings where participants are especially vulnerable or where language and cultural barriers make informed consent difficult.”(39, pp. 19-20) the implementation of the code of ethical conduct for the public health profession, supports public health professionals addressing the ethical questions and dilemmas for the benefit of population health. ethical principles including equity, social justice, national and individual autonomy, transparency, accountability, open communication, trust, mutual respect, development of servant leadership are characterised as globally relevant to meet the global challenges. also, solidarity, stewardship, production of global public goods, and management of externalities across countries, have been shown to be the “essential functions of the global health system” (53). the role of human rights in health links both, public and global health ethics. to this end supporting, protecting and respecting human rights is essential both to public health ethics (54) and to global health ethics (55). however, e.g. out of fifty-five finalized project proposals identified in the second public health programme (2008-2013) of the european commission only ‘equity’ and ‘efficiency’ were explicitly considered in eighteen projects and four projects respectively while solidarity was only discussed in one project (56). limitations the limitations of our approach to public health or population ethics are obvious. firstly, the selected literature may not be comprehensive respectively the balance between the relevance of publications and preferences of the authoring team may be biased by prejudice. secondly our attempt to align relevant terms in the literature (see table 1) may similarly be biased by our prejudices, although our intensive discussions during the last year hopefully have minimised the effect of personal preferences. thirdly, the terminology in the subject area has not finally matured leaving boundaries foggy and allow for undefined overlaps taking the example of public health vs. population health and global public health vs. global health where the latter terms include individual health predominantly subject of clinical medicine and the former terms are restricting to public health services and thereby to the multitude of public health professions working in the public health services (physicians, economists, sociologists to name a few). the authors of this paper however, do not consider public health ethics as a subspecialty (1) or a subfield (2) of bioethics. although there are norms and values shared in bioethics and public health ethics, the latter has a basic normative orientation towards the good of the public and populations, whereas bioethics was designed for the clinical context of the patient-physician encounter (57). laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 19 fourth, we embrace a public health ethics perspective but the purpose of this paper is to narrow it down to a code of ethical conduct to guide multi-disciplinary public health professionals in their operations and to help defining a distinct profession targeting population health rather than individual health (16). this may imply the partly loss of a comprehensive picture, however, an elaborate guide or code would not serve the needs of the public health practitioner in the field. insofar, we adopted a somewhat different strategy focussing on a smaller but comprehensive set of core principles (see table 3 above) relevant to public health ethics rather than prescribing a lengthy set of concrete rules (like e.g. 21, 24). fifth, trying to be focused we did not elaborate on applications in the various fields of public health relevance as for example natural or man-made disasters and the resulting emergency state (58) which relates especially to the principle of solidarity, or the issue of universal health coverage (59) which requires the consideration of justice. sixth, the focus on populations leaves out personal conscience and self-determination values (60) or virtues (61, 62), most important being honesty and trustworthiness, integrity and excellence. finally, in light of the sustainable development goals, sdgs (33) and the case for people and planetary sustainability becoming increasingly more urgent, it seems timely, although beyond the scope of this paper, to reflect on aligning the proposed ethical principles with the attainment of the sdgs, and for public health to adopt a wider perspective that underpins a one health concept, that is, to encourage the collaborative efforts of multiple disciplines working locally, nationally, and globally, to achieve the best health (and well-being) for people, animals and our environment (63-66). conclusions and recommendations the prospects of the code of ethical conduct proposed here are related to its acknowledgement and enforcement which likely in the future can be done effectively only by own professional chambers or other suitable bodies for public health, not by common medical chambers as of now. the authors therefore urge public health professionals to use the proposed code of ethical conduct with its eight principles to guide them in pursuing their work so as to assure that citizens are living healthy. given 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http://www.seejph.com/index.php/seejph/article/view/106/82 (accessed: 5 july, 2017). 59. martin-moreno j, harris m. r 3.4 universal health coverage including the private sector and traditional medicine. in: laaser u, beluli f. a global public health curriculum. lage germany: jacobs verlag, 2016: 226. http://www.seejph.com/index.php/seejph/article/view/106/82 (accessed: 5 july, 2017). 60. knights j. transpersonal leadership series: white paper one: how to develop ethical leaders. tylor and francis: routledge, 2016. 61. rogers wa. virtue ethics and public health: a practice-based analysis. monash bioeth rev 2004;23:10-21. doi: 10.1007/bf03351406. 62. mooney g. public health – virtue ethics versus communitarianism: a response to wendy rogers. monash bioeth rev 2004;23:21-4. doi:10.1007/bf03351410. 63. united nations. sustainable development goals. http://www.un.org/sustainabledevelopment/sustainable-development-goals/ (accessed: 5 may, 2017). 64. kahn l. protecting the planet and sustainable development. seejph 2017;7. doi 10.4119/unibi/seejph-2017-135. 65. rüegg sr, mcmahon bj, häsler b, esposito r, nielsen lr, speranza ci, et al. a blueprint to evaluate one health. front public health 2017;5:20. doi: 10.3389/fpubh.2017.00020 66. one health commission. one health: linking human, animal and ecosystem health. available from: https://www.onehealthcommission.org/ (accessed: 4 may, 2017). 67. mckee m, stuckler d. “enemies of the people?” public health in the era of populist politics. comment on “the rise of post-truth populism in pluralist liberal http://dx.doi.org/10.1016/j.bpobgyn.2017.02.003� http://www.biomedcentral.com/1472-698x/8/2� http://www.biomedcentral.com/1472-698x/8/2� http://doi.org/10.4119/unibi/seejph-2017-138� http://www.un.org/sustainabledevelopment/sustainable-development-goals/� http://doi.org/10.4119/unibi/seejph-2017-135� https://dx.doi.org/10.3389%2ffpubh.2017.00020� laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 24 democracies: challenges for health policy”. int j health policy manag 2017;6:1-4. doi: 10.15171/ijhpm.2017.46 additional literature: • bjegovic-mikanovic v, vukovic d, otok r, czabanowska k, laaser u. education and training of public health professionals in the european region: variation and convergence. int j public health 2013;58:801-10. doi: 10.1007/s00038-012-0425-2 • bjegovic-mikanovic v, jovic-vranes a, czabanowska c, otok r. education for public health in europe and its global outreach. glob health action 2014;7:23570. doi: org/10.3402/gha.v7.23570. • lueddeke gr. global population health and well-being in the 21st century: toward new paradigms, policy and practice. new york: springer publishing, 2016. available from: http://www.springerpub.com/global-population-health-and-wellbeing-in-the-21st-century-toward-new-paradigms-policy-and-practice.html (accessed: 5 may, 2017). laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 25 annex 1. general framework for codes of conduct in the health sector of the council of europe (29) 1. introduction 2. values and ethical references 3. legal framework of reference 4. example of areas to be regulated by a code of conduct in the health sector nb. not all areas are applicable to all situations. the order of the items does not reflect priority ranking. the list is non-exhaustive and the items are for illustrative purposes only. a. good professional practice i. respect for the dignity of people (employees, patients, customers) ii. honesty and confidentiality iii. keeping up-to-date professional competence iv. use of the best scientific evidence v. compliance with accepted standards vi. compliance with regulations and legislation vii. awareness of the needs, demands and expectations of the population, patients and customers viii. co-operation with colleagues ix. spirit of moderation, reconciliation, tolerance and appeasement b. use of resources of the service/system i. cost-effectiveness practice in the use of resources ii. avoiding using public resources for private gain iii. prevention of fraud and corruption c. handling of conflict of interests in the best interest of patients and population, whether i. economic, or ii. non-economic d. proper access, sharing and use of information i. research of any information necessary for decision making ii. duty to disclose all relevant information to the public and authorities iii. duty to provide information to patients with respect to their needs and preferences e. handling of gifts and benefits i. existence of an explicit policy concerning gifts ii. transparency regarding gifts received from interested parties f. research-related topics i. clinical trials (helsinki declaration) ii. truthful claims of research potential iii. patient consent with full disclosure of risks g. relationships with other actors in the health sector i. colleagues and other health professionals ii. patients and their families iii. insurers, third-party payers laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 26 iv. health-related industries (pharmaceutical, food, advertisement, cosmetic, medical devices, etc.), and other interest groups v. government officers of health and other sectors (police) vi. patients and self-help organisations, ngos, etc. vii. media h. good corporate governance of health institutions/services/centres i. issues of multiculturalism, tolerance and respect 5. enforcement of the code of conduct a. recognition of violations b. composition of the body responsible for dealing with enforcement c. transparency of procedures and public scrutiny d. complaints system 6. updating, monitoring and development of the code of conduct a. process of development of codes of conducts: initiative, ownership, legitimacy b. comprehensiveness c. limitations of codes of conduct d. codes of conduct and legislation ______________________________________________________________________________________ © 2017 laaser et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. the uk faculty of public health. www.fph.org.uk/ (accessed: 19 february, 2016). lueddeke g. high level communiqué from the interaction council(letter to editors). seejph 2017, posted: 07 july 2017. doi: 10.4119/unibi/seejph-2017-146 1 letter to editors high level communiqué from the interaction council george lueddeke1 1 consultant in higher and medical education, united kingdom. corresponding author: george r. lueddeke, co-chair, one health education task force; address: 9 lakeland gardens, southampton, hampshire, so40 4xg, united kingdom; email: glueddeke@aol.com lueddeke g. high level communiqué from the interaction council(letter to editors). seejph 2017, posted: 07 july 2017. doi: 10.4119/unibi/seejph-2017-146 2 dear colleagues, here is a link to a copy of a high level communiqué from the interactioncouncil that may also be of interest to seejph readers. as you may be aware, the council brings together former world leaders (heads of government and senior officials) and focuses on issues related, among others, to global security and has been examining the role of health security over the last few years. at this year’s meeting (30-31 may), co-chaired by he obasanjo from nigeria and he bertie ahern from ireland, the session on planetary health, coordinated by professor john wyn owen, resulted in the endorsement of the “dublin charter for one health”. dr joanna nurse presented on the policy implications of planetary and one health in this session and is tasked by the interaction council with advancing the one health charter in collaboration with key partners. below is a summary of the main actions in the charter for one health that may in due course help to inform trans-disciplinary research, education and practice at national, regional and global levels with a view to sustaining people and planet health and well-being. your comments on how best to advance these key areas are requested-i.e. please let us know what is already happening, gaps and suggestions for how to advance the following: 1. strengthening multi-sector solutions for the sdgs the one health approach has the potential to act as a unifying theme; 2. resilience to emerging threats -including amr, disease outbreaks, climate change and environmental impacts; 3. mainstreaming one health within public health systems for uhc -including environmental health; 4. strengthen one health governance mechanisms for systems reform; 5. building leadership for one health for future generations; 6. establish an independent accountability mechanism for advancing action on one health. please send your comment to glueddeke@aol.com by 10 july. many thanks and best wishes! george lueddeke phd chair, one health education task force the one health commission in association with the one health initiative convenor/chair, one health global think tank for sustainable health & well-being 2030 consultant in higher and medical education southampton, united kingdom linked-in connection: http://www.linkedin.com/pub/dr-george-lueddeke/42/4b0/401 * link to the one health initiative news item: http://www.onehealthinitiative.com/news.php?query=interaction+council+issues+%91the +dublin+charter+for+one+health%92+communiqu%e9 http://interactioncouncil.org/final-communiqu-53� http://interactioncouncil.org/final-communiqu-53� https://www.onehealthcommission.org/� http://www.onehealthinitiative.com/� http://www.seejph.com/index.php/seejph/article/view/114� http://www.linkedin.com/pub/dr-george-lueddeke/42/4b0/401� lueddeke g. high level communiqué from the interaction council(letter to editors). seejph 2017, posted: 07 july 2017. doi: 10.4119/unibi/seejph-2017-146 3 link to a one health primary to tertiary education article and proposal supporting the sdgs and one health: http://africahealthnews.com/development-project-proposal-supportingsustainable-future-people-planet/. conflicts of interest: none. __________________________________________________________ © 2017 lueddeke et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://africahealthnews.com/development-project-proposal-supporting-sustainable-future-people-planet/� http://africahealthnews.com/development-project-proposal-supporting-sustainable-future-people-planet/� kamberi h, jerliu n, kamberi s, berisha i. knowledge about breastfeeding of children 0-6 months among mothers attending hospital services in kosovo (original article). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-196 1 original article knowledge about breastfeeding of children 0-6 months among mothers attending hospital services in kosovo haxhi kamberi 1,2 , naim jerliu 3,4 , safete kamberi 5 , idriz berisha 2 1 regional hospital “isa grezda”, gjakove, republic of kosovo; 2 faculty of medicine, university of gjakova, gjakove, republic of kosovo; 3 faculty of medicine, university of prishtina, prishtina, republic of kosovo; 4 national institute of public health of kosovo, prishtina, republic of kosovo; 5 regional centre of public health, gjakove, republic of kosovo. corresponding author: naim jerliu, md, phd, national institute of public health of kosovo and faculty of medicine, university of prishtina, prishtina, kosovo; address: rr. “instituti shendetesor”, 10000, prishtina, republic of kosovo; telephone: +38138541432; e-mail: naim.jerliu@uni-pr.edu mailto:naim.jerliu@uni-pr.edu kamberi h, jerliu n, kamberi s, berisha i. knowledge about breastfeeding of children 0-6 months among mothers attending hospital services in kosovo (original article). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-196 2 abstract aim: the aim of this study was to assess the level of knowledge and socio-demographic correlates of breastfeeding of children aged 0-6 months among mothers with young children in post-war kosovo. methods: a cross-sectional study was conducted in kosovo during the period december 2017 – february 2018 including a representative sample of 201 mothers (aged 29.4±6.0 years) with young children attending hospital services. in addition to socio-demographic data, a structured 13-item questionnaire inquiring about breastfeeding of children aged 0-6 months was administered to all women. a summary score was calculated for all 13 items related to women’s knowledge on breastfeeding (0 denoting incorrect answers to all 13 items, and 13 denoting correct answers to all 13 questions). general linear model was used to assess the association between summary score of the knowledge about breastfeeding and sociodemographic characteristics of the women. results: mean summary score of the 13 items related to knowledge about breastfeeding was 10.3±1.9; median score was 11 (interquartile range: 9-12). in multivariable-adjusted models, the mean summary score of knowledge about breastfeeding of children 0-6 months was slightly but non-significantly higher among “older” women, those residing in urban areas, highly educated women, those currently employed, and women with a higher income level. conclusion: generally, the level of knowledge about breastfeeding of children aged 0-6 months was satisfactory among mothers with young children included in this survey in kosovo. furthermore, there were seemingly no significant socio-demographic differences in the level of knowledge about breastfeeding of young infants among women in this study carried out in kosovo. keywords: breastfeeding, children 0-6 months, knowledge, mothers, kosovo, women. kamberi h, jerliu n, kamberi s, berisha i. knowledge about breastfeeding of children 0-6 months among mothers attending hospital services in kosovo (original article). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-196 3 introduction breastfeeding of newborns is very important and it significantly decreases the risk of neonatal complications (1), respiratory diseases and other diseases of young infants, as convincingly demonstrated in the vast international scientific literature (2-5). based on the considerable empirical evidence about the benefits of breastfeeding to both the mother and the baby, the world health organization (who) has recommended a two-year breastfeeding approach (6). more specifically, who has recommended exclusive breastfeeding for the first six months of life, with more than eight times breastfeeding of the baby per day in the first three months of a newborn’s life (6). however, a wide range of factors may influence the breastfeeding rates in different countries including maternal characteristics (7,8) and socioeconomic status of the families (9), different health issues and problems of the newborns (10), several psychosocial factors involved (11), as well as different ethnic and cultural norms pertinent to various countries and populations worldwide (8,12). after the war and the liberation from the serbian regime in 1999 and almost a decade under united nations administration, kosovo underwent an intensive process of transformation to an independent state, which was formally proclaimed in 2008. hence, kosovo is the newest country in europe with the youngest population of the continent (mean age of the kosovo population has been reported at about 27 years) (13). in kosovo, infant mortality rate is one of the highest in the who european region (17.1 deaths per 1000 live births in the year 2011) (13). similarly, maternal mortality rate is also high (7.2 deaths per 100.000 in 2011) (13). the available evidence, albeit not well-documented, suggests a relatively higher breastfeeding rate in kosovo compared with the other european countries. however, to date, the evidence about the level of knowledge, attitudes and practices related to breastfeeding of kosovo mothers with infants and young children is scarce. in this context, the aim of this study was to assess the level of knowledge and sociodemographic correlates of breastfeeding of children aged 0-6 months among mothers with young children in kosovo. methods a cross-sectional study was conducted in kosovo during the period december 2017 – february 2018. the study was carried out in four regions of the republic of kosovo including peja, gjakova, prizren and prishtina. a representative sample of 201 mothers with young children attending hospital services was included in this survey (overall, 92 women from rural areas and 109 women from urban areas). a structured 13-item questionnaire inquiring about breastfeeding of children aged 0-6 months was administered to all women (all 13 questions are presented in table 2). in the analysis, answers to each of the 13 items were dichotomized into: correct vs. incorrect. a summary score was calculated for all 13 items of the questionnaire (0 denoting incorrect answers to all 13 items, and 13 denoting correct answers to all 13 questions). in addition, data on demographic factors (age and place of residence) and socioeconomic characteristics (educational level, employment status, and self-perceived income) were collected for all study participants. the study was approved from the board of the national institute of public health of the republic of kosovo. fisher’s exact test was used to compare differences in socio-demographic characteristics (age, education, employment and income) between women residing in urban areas and their counterparts pertinent to rural areas. furthermore, fisher’s exact test was employed to kamberi h, jerliu n, kamberi s, berisha i. knowledge about breastfeeding of children 0-6 months among mothers attending hospital services in kosovo (original article). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-196 4 compare differences for each of the 13 items related to mothers’ knowledge about breastfeeding of children aged 0-6 months between urban and rural residents. on the other hand, general linear model was used to assess the association between summary score of the knowledge (13 items) about breastfeeding and socio-demographic characteristics of the women. initially, crude (unadjusted) mean values, their respective 95% confidence intervals (95%cis) and p-values were calculated. subsequently, multivariable-adjusted models were run adjusting simultaneously for all socio-demographic factors of the women (age-group, place of residence, educational attainment, employment status and income level). multivariable-adjusted mean values, their respective 95%cis and p-values were calculated. in all cases, a p-value ≤0.05 was considered as statistically significant. statistical package for social sciences (spss< version 19.0) was used for all the statistical analyses. results mean age (±sd) of women included in this study was 29.4±6.0 years; median age was 28 years (interquartile range: 25-33 years); the age range was: 17-48 years (data not shown in the tables). the distribution of demographic and socioeconomic characteristics of study participants by their place of residence is presented in table 1. overall, 40% of women were 30 years or older. compared to their rural counterparts, women residing in urban areas had a higher educational level (45% in urban areas vs. 24% in rural areas; p<0.01), a higher employment rate (48% in urban areas vs. 20% in rural areas; p<0.01) and a higher income level (a low income was reported only among 4% of urban women compared to 15% of women residing in rural areas; p=0.02). mean age was similar among women residing in urban areas and those pertinent to rural areas (29.7 years vs. 29.1 years, respectively; data not shown). table 1. demographic and socioeconomic characteristics in a sample of mothers with young children attending hospital services in kosovo, in 2017-2018 demographic and socioeconomic characteristics total (n=201) rural (n=92) urban (n=109) p-value † age-group: <30 years ≥30 years 120 (59.7) * 81 (40.3) 56 (60.9) 36 (39.1) 64 (58.7) 45 (41.3) 0.775 educational level: low middle high 46 (22.9) 84 (41.8) 71 (35.3) 31 (33.7) 39 (42.4) 22 (23.9) 15 (13.8) 45 (41.3) 49 (45.0) 0.001 employment status: employed unemployed 70 (34.8) 131 (65.2) 18 (19.6) 74 (80.4) 52 (47.7) 57 (52.3) <0.001 income level: low middle high 18 (9.0) 177 (88.1) 6 (3.0) 14 (15.2) 76 (82.6) 2 (2.2) 4 (3.7) 101 (92.7) 4 (3.7) 0.015 * numbers and column percentages (in parenthesis). † p-values from fisher’s exact test. the correct knowledge about a wide array of breastfeeding aspects of children 0-6 months among women residing in urban and rural areas is presented in table 2. for most of the items there were no significant differences by place of residence of study participants. overall, kamberi h, jerliu n, kamberi s, berisha i. knowledge about breastfeeding of children 0-6 months among mothers attending hospital services in kosovo (original article). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-196 5 almost all women (99%) knew correctly that breast milk is the best type of milk for feeding children aged 0-6 months. about 85% of the women correctly reported that newborns should be breastfed immediately after birth, and 77% of the women stated that newborns should be breastfed as frequently as needed. furthermore, about 63% of the women correctly stated that colostrum is very useful for the newborn. about three-quarters of the women correctly identified the duration of a normal breastfeeding session. the vast majority of the women (93%) correctly reported that breastfeeding improves the immune system of the newborn; 89% of the mothers stated that breastfeeding improves the mother-child emotional bond; and 88% of the women correctly knew that a newborn is properly fed when he/she attaches well the nipples and grasps a large portion of breast’s aureole. conversely, only 40% of the women correctly knew that breastfeeding reduces mother’s weight gained during pregnancy (47% of urban women vs. only 33% of rural women; p=0.05). a higher proportion of urban residents correctly knew that breastfeeding reduces the neonatal jaundice (76% vs. 60% among rural residents; p=0.02). similarly, a higher proportion of urban residents correctly knew that newborns who gain weight, have wet dippers and sleep well have received sufficient breast milk (95% vs. 87% among rural residents; p=0.04). on the other hand, there were no differences regarding the correct knowledge about bottlefeeding (overall, 78% of the women correctly reported that bottle-feeding should not be used for breastfed children 0-6 months), or complementary feeding (overall, 86% of the women correctly reported that, besides breastfeeding, children should start the complementary feeding six months after birth) [table 2]. table 2. knowledge about breastfeeding of children aged 0-6 months in a sample of mothers with young children attending hospital services in kosovo knowledge about breastfeeding of children 0-6 months total (n=201) rural (n=92) urban (n=109) p-value ‡ 1. which type of milk is the best for your child? breast milk * other (formula, etc.) 199 (99.0) † 2 (1.0) 90 (97.8) 2 (2.2) 109 (100.0) 0 (-) 0.208 2. when should the newborn be breastfed? immediately after birth * at least 4 hours after birth 170 (84.6) 31 (15.4) 78 (84.8) 14 (15.2) 92 (84.4) 17 (15.6) 0.999 3. is colostrum useful for the newborn? very useful * little or no useful at all 127 (63.2) 74 (36.8) 57 (62.0) 35 (38.0) 70 (64.2) 39 (35.8) 0.770 4. how many times should the newborn be breastfed? every time he/she needs * each 4 hours or longer 155 (77.1) 46 (22.9) 74 (80.4) 18 (19.6) 81 (74.3) 28 (25.7) 0.318 5. how long does a breastfeeding session last? 10-15 minutes * other 149 (74.1) 52 (25.9) 68 (73.9) 24 (26.1) 81 (74.3) 28 (25.7) 0.999 6. does breastfeeding improves the immune system of the newborn? yes * little or not at all 187 (93.0) 14 (7.0) 85 (92.4) 7 (7.6) 102 (93.6) 7 (6.4) 0.786 7. does breastfeeding influence the 0.111 kamberi h, jerliu n, kamberi s, berisha i. knowledge about breastfeeding of children 0-6 months among mothers attending hospital services in kosovo (original article). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-196 6 mother-and-child emotional bond? yes * little or not at all 179 (89.1) 22 (10.9) 78 (84.4) 14 (15.2) 101 (92.7) 8 (7.3) 8. does breastfeeding reduce the neonatal jaundice? yes * no 138 (68.7) 63 (31.3) 55 (59.8) 37 (40.2) 83 (76.1) 26 (23.9) 0.015 9. does breastfeeding reduce mother’s weight gained during pregnancy? yes * little or not at all 81 (40.3) 120 (59.7) 30 (32.6) 62 (67.4) 51 (46.8) 58 (53.2) 0.045 10. if the newborn attaches well the nipples and grasps a large portion of breast’s aureole, then: the newborn will be properly fed * the newborn should be repositioned or will not be properly fed 176 (87.6) 25 (12.4) 79 (85.9) 13 (14.1) 97 (89.0) 12 (11.0) 0.527 11. if the newborn gains weight, has wet dippers and sleeps well, then: he/she takes sufficient breast milk * he/she does not take sufficient breast milk, or is ill 184 (91.5) 17 (8.5) 80 (87.0) 12 (13.0) 104 (95.4) 5 (4.6) 0.041 12. should bottle-feeding be used for breastfed children 0-6 months? no * yes 156 (77.6) 45 (22.4) 75 (81.5) 17 (18.5) 81 (74.3) 28 (25.7) 0.239 13. besides breastfeeding, when should the newborn start the complementary feeding? 6 months after birth * other 172 (85.6) 29 (14.4) 78 (84.8) 14 (15.2) 94 (86.2) 15 (13.8) 0.841 * correct answer. † numbers and column percentages (in parenthesis). ‡ p-values from fisher’s exact test. a summary score was calculated for all 13 items displayed in table 2 regarding the correct level of knowledge of women about breastfeeding of children aged 0-6 months (a summary score of 0 denoting incorrect answers to all 13 items, and a summary score of 13 denoting correct answers to all 13 questions). mean summary score of the 13 knowledge items was 10.3±1.9; median score was 11 (interquartile range: 9-12); the range of the scores was: 1 (only one correct answer) to 13 (all 13 correct answers) [data not shown in the tables]. table 3 presents the association of summary score of knowledge about breastfeeding and demographic and socioeconomic characteristics of the women. in crude (unadjusted) general linear models, the mean summary score of the 13 knowledge items was (non-significantly) higher among older women, those residing in urban areas, highly educated women and those currently employed. women with a higher income level had a significantly higher mean summary score of the knowledge items compared with lowincome women (11.0 vs. 9.3, respectively, p=0.05). kamberi h, jerliu n, kamberi s, berisha i. knowledge about breastfeeding of children 0-6 months among mothers attending hospital services in kosovo (original article). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-196 7 in multivariable-adjusted models, there was evidence of the same findings compared with the unadjusted estimates. hence, mean summary score of knowledge about breastfeeding of children 0-6 months was (non-significantly) higher among older women, those residing in urban areas, highly educated women, those currently employed and women with a higher income level. table 3. association of the summary score of knowledge about breastfeeding and demographic and socioeconomic characteristics of the women; mean values from the general linear model socio-demographic characteristics unadjusted models multivariable-adjusted models mean * 95%ci p mean * 95%ci p age-group: <30 years ≥30 years 10.2 10.5 9.8-10.5 10.1-10.9 0.272 10.1 10.4 9.5-10.8 9.7-11.1 0.298 place of residence: rural areas urban areas 10.1 10.5 9.7-10.5 10.2-10.9 0.105 10.1 10.4 9.5-10.8 9.7-11.1 0.363 educational level: low middle high 9.9 10.3 10.5 9.4-10.5 9.9-10.8 10.1-11.2 0.344 (2) † 0.242 0.815 reference 10.1 10.3 10.5 9.3-10.9 9.5-11.3 9.7-11.6 0.596 (2) 0.867 0.444 reference employment status: unemployed employed 10.1 10.6 9.8-10.5 10.2-11.3 0.186 10.2 10.4 9.4-10.8 9.6-11.1 0.648 income level: low middle high 9.3 10.4 11.0 8.4-9.8 10.1-10.7 9.9-12.5 0.04 (2) 0.045 0.441 reference 9.4 10.4 11.0 8.5-10.4 10.1-10.7 9.4-12.6 0.120 (2) 0.098 0.447 reference * range of the summary score from 0 (all 13 incorrect answers) to 13 (all 13 correct answers). † overall p-values and degrees of freedom (in parentheses). there was evidence of a weak and non-significant linear association between the summary score of knowledge about breastfeeding and age of the women (spearman’s rho=0.11, p=0.14), but a borderline statistically significant correlation with the number of births (spearman’s rho=0.13, p=0.06) [data not shown]. discussion the main finding of this study consists of a quite satisfactory level of knowledge about breastfeeding of children aged 0-6 months among mothers attending hospital services in kosovo. in addition to the general level of knowledge, on the face of it, there were no significant demographic or socio-economic differences in the level of knowledge about breastfeeding of young infants among women in kosovo. indeed, in multivariable-adjusted general linear models (controlling simultaneously for key socio-demographic factors) there was no evidence of any statistically significant differences in the level of knowledge about breastfeeding of children aged 0-6 months among various categories and subgroups of women differentiated in terms of age-group, place of residence, educational attainment, employment status, or income level. such findings are quite appealing, but they should be interpreted with extreme caution due to the small sample size included in the current study. hence, findings from this report deserve further rigorous investigation and replication in more robust and larger studies. kamberi h, jerliu n, kamberi s, berisha i. knowledge about breastfeeding of children 0-6 months among mothers attending hospital services in kosovo (original article). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-196 8 to the best of our knowledge, there are no previous similar studies conducted in kosovo in order to compare our findings. on the other hand, a previous cross-sectional study conducted in kosovo in 2013 has assessed women’s knowledge and practices of complementary feeding from 28 cities, towns and villages across kosovo, including a sample of 492 mothers with infants aged 6-24 months (14). according to this report, about 88% of the women included in the study reported good knowledge of complementary feeding, whereas only about 38% of them employed good practices regarding time for starting complementary feeding (14). in addition, an association between maternal knowledge about complementary feeding and educational level was reported from this study (14). the current study conducted in kosovo revealed that the majority of the women included in the survey had good knowledge about breastfeeding of children aged 0-6 months. similar to the evidence obtained in previous studies conducted elsewhere, most of the mothers included in this study in kosovo correctly reported that breastfeeding promotes mother-baby emotional bonding (8,15,16), and the fact that breastfeeding in the early period can help reduce jaundice (8,17,18). nonetheless, there are several imitations of the current study including the size and representativeness of the study population involved, the possibility of information bias and the study design. the sample size included in this study (n=201) was not large, an issue which might have jeopardized the power of the study for detecting small differences in the level of knowledge about breastfeeding among women pertinent to different sociodemographic categories. more importantly, although the sample was meant to be representative to kosovo women with young children, the hospital-based selection approach does not allow generalization of the survey findings to all women in kosovo. at best, findings from the current analysis may be generalized only to women who attend hospital services in this transitional country. the instrument for data collection was based on a simple and standardized tool which has been largely employed in similar studies in many countries worldwide (8). yet, regardless of the lack of any evidence obtained, the possibility of differential reporting between groups of women pertinent to different socio-demographic categories cannot be completely excluded. finally, as this was a cross-sectional study, findings should be interpreted with caution and replicated and confirmed in future larger prospective studies. regardless of these potential limitations, this study provides useful evidence about the level of knowledge and socio-demographic correlates of breastfeeding of children aged 0-6 months among mothers with young children in kosovo. findings of this study should inform policy and shape future interventions and programs aiming at improving mother and child health status and health care services in kosovo. references 1. furman l, minch nm, hack m. breastfeeding of very low birth weight. j hum lact 1998;14:29-34. 2. akobeng ak, ramanan av, buchan i, heller rf. effect of breast feeding on risk of coeliac disease: a systematic review and meta-analysis of observational studies. arch dis child 2006;91:39-43. 3. chantry cj, howard cr, auinger p. full breastfeeding duration and associated decrease in respiratory tract infection in us children. pediatrics 2006;117:425-32. 4. cushing ah, samet jm, lambert we, skipper bj, hunt wc, young sa, mclaren lc: breastfeeding reduces risk of respiratory illness in infants. am j epidemiol 1998;147:863-70. kamberi h, jerliu n, kamberi s, berisha i. knowledge about breastfeeding of children 0-6 months among mothers attending hospital services in kosovo (original article). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-196 9 5. lópez-alarcón m, villalpando s, fajardo a. breast-feeding lowers the frequency and duration of acute respiratory infection and diarrhea in infants under six months of age. j nutr 1997;127:436-43. 6. world health organization (who). the global strategy for infant and young child feeding. geneva: who; 2003. http://whqlibdoc.who.int/publications/2003/9241562218.pdf (accessed: 24 july, 2018). 7. bertino e, varalda a, magnetti f, di nicola p, cester e, occhi l, perathoner c, soldi a, prandi g. is breastfeeding duration influenced by maternal attitude and knowledge? a longitudinal study during the first year of life. j matern fetal neonatal med 2012;25:32-6. 8. mbada ce, olowookere ae, faronbi jo, oyinlola-aromolaran fc, faremi fa, ogundele ao, et al. knowledge, attitude and techniques of breastfeeding among nigerian mothers from a semi-urban community. bmc research notes 2013;6:552. 9. flacking r, nyqvist kh, ewald u. effects of socioeconomic status on breastfeeding duration in mothers of preterm and term infants. eur j public health 2007;17:579-84. 10. narayan s, natarajan n, bawa ks. maternal and neonatal factors adversely affecting breastfeeding in the perinatal period. mjafi 2005;61:216-9. 11. kronborg h, vaeth m. the influence of psychosocial factors on the duration of breastfeeding. scand j public health 2004;32:210-6. 12. christopher k. breastfeeding perceptions and attitudes: the effect of race/ethnicity and cultural background. soc today 2012;10:2. 13. jerliu n, toçi e, burazeri g, ramadani n, brand h. socioeconomic conditions of elderly people in kosovo: a cross-sectional study. bmc public health 2012;12:512. 14. berisha m, ramadani n, hoxha r, gashi s, zhjeqi v, zajmi d, begolli i. knowledge, attitudes and practices of mothers in kosova about complementary feeding for infant and children 6-24 months. med arch 2017;71:37-41. 15. klaus mh, kennell jh, klaus ph. bonding: building the foundations of secure attachment and independence. in reading, mass. addison-wesley publishing; 1995. 16. uvnäs-moberg k, eriksson m. breastfeeding: physiological, endocrine and behavioural adaptations caused by oxytocin and local neurogenic activity in the nipple and mammary gland. acta paediatr 1996;85:525-30. 17. maisels mj, vain n, acquavita am, de blanco nv, cohen a, digregorio j. the effect of breast-feeding frequency on serum bilirubin levels. am j obstet gynecol 1994;170:880-3. 18. lin yy, tsao p-n, hsieh w-s, chen c-y, chou h-c. the impact of breastfeeding on early neonatal jaundice. clin neonatol 2008;15:31-5. ______________________________________________________________________________________ © 2018 kamberi et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed?term=jerliu%20n%5bauthor%5d&cauthor=true&cauthor_uid=22776197 http://www.ncbi.nlm.nih.gov/pubmed?term=to%c3%a7i%20e%5bauthor%5d&cauthor=true&cauthor_uid=22776197 http://www.ncbi.nlm.nih.gov/pubmed?term=burazeri%20g%5bauthor%5d&cauthor=true&cauthor_uid=22776197 http://www.ncbi.nlm.nih.gov/pubmed?term=ramadani%20n%5bauthor%5d&cauthor=true&cauthor_uid=22776197 http://www.ncbi.nlm.nih.gov/pubmed?term=brand%20h%5bauthor%5d&cauthor=true&cauthor_uid=22776197 http://www.ncbi.nlm.nih.gov/pubmed/22776197 chernyavskiy v, mikhailova j. russia: a key partner in the northern dimension partnership (editorial). seejph 2019, posted: 10 may 2019. doi 10.4119/unibi/seejph-2019-217 page 1 of 5 editorial russia: a key partner in the northern dimension partnership valery chernyavskiy1, julia mikhailova1 1federal research institute for health organization and informatics of the russian ministry of health, moscow, russian federation. corresponding author: dr. valery chernyavskiy phd, mph, dr.h.c., deputy head of the unit for coordination of the northern dimension partnership of public health and social well-being (ndphs),federal research institute for health organization and informatics of the russian ministry of health; address: 11, dobrolubova str. moscow, 127254, russian federation; e-mail: vch@mednet.ru. chernyavskiy v, mikhailova j. russia: a key partner in the northern dimension partnership (editorial). seejph 2019, posted: 10 may 2019. doi 10.4119/unibi/seejph-2019-217 page 2 of 5 nearly thirty years after the breakdown of the soviet union (ussr) in 1991, the countries of the former ussr that emerged from it still face a multitude of challenges including the need to reorganise the health services, their structure, budgeting, staffing, and quality. the soviet system, despite its many and profound flaws, represented also very real achievements (1-3). it provided a basis for community health activities including mandatory immunization and periodic health checks and it fostered a generation committed to solidarity in the provision of health care aiming at universal coverage and equitable access. despite the enormous challenges facing the country today, the belief in a health system centred on need rather than the ability to pay remains intact. however, the russian federation by far the biggest successor state of the former ussr carries most of the advantages as well as disadvantages of the soviet past (4). today, we observe a growing awareness of the necessity to increase the efficiency of the health system and a real desire to enhance user satisfaction in russia. these concerns coupled with recognition of the need to address issues of sustainability have prompted a major reform of the health system centred on appropriate financing mechanisms: funding which previously came from general taxation has shifted in part to a social insurance system and it is this shift which provides the fundament for the health reform process of the russian federation (5,6). two additional problems add to the need for change:  there is a major impact of environmental pollution on the health of the population, to a considerable degree caused by the historical break-down of central regulation and enforcement of health and safety standards in the nineties which allowed the industry to produce without regard to air and water pollution.  equally worrying is the unhealthy behaviour of russian citizens especially with regard to the high alcohol and cigarette consumption and poor nutritional status, i.e. high levels of energy intake from fat instead of vegetables and fruits (7). the subsequent deterioration of major health indicators foresees a long-term rise of morbidity and mortality of the present generations and correspondingly a very high burden of disease to be tackled by the health system. therefore, today, one of the key areas of work of the ministry of health of the russian federation is to strengthen the cooperation with experts from other countries in order to set up channels for exchange of knowledge and experience between health professionals, politicians and decision-makers (8). the northern dimension partnership on public health and social well-being (ndphs) as a cooperative effort of ten governments (estonia, finland, iceland, germany, latvia, lithuania, norway, poland, russian federation and sweden), the european commission and eight international organisations was formally established at a ministerial-level meeting on 27 october, 2003. since then, the northern dimension is steadily on track to reduce the preventable years of life lost in their respective populations and the difference between the member countries with reference to the sustainable development goals 2030 and the european union strategy for the baltic sea region 2020. from the very beginning, the russian federation has been actively involved in the cooperative work of the ndphs. summing up the contributions of the russian federation from 2003 until 2018, chernyavskiy v, mikhailova j. russia: a key partner in the northern dimension partnership (editorial). seejph 2019, posted: 10 may 2019. doi 10.4119/unibi/seejph-2019-217 page 3 of 5 the following three periods can be differentiated (9). i.the period from 2003 to 2009 this was the period of foundation of the partnership, the searching for its purpose and place in the international, as well as regional agenda of public health and social well-being. at the various international platforms, russia actively participated in discussions about the feasibility, goals, status, and mission of the new international network for regional cooperation at the northern dimension area. ii.the period from 2010 to 2014 during this period, the general goal of the partnership was determined, the first strategy was adopted (but, still, without an action plan), and objectives were defined. in accordance with the general goal of the partnership, two priority areas were identified: to reduce the spread of major communicable diseases and to prevent lifestyle related non-communicable diseases; to enhance peoples’ levels of social well-being and to promote socially rewarding lifestyles. to implement actions in these directions, terms of reference were developed and four expert groups were created, in which international experts from the ten partner countries including russia worked together. this period allowed the partner countries to outline common problems in health and to define mechanisms of interaction and cooperation. during 2010-2011, the partnership worked under the chairmanship of the russian federation. in this period, activities related to new challenges in the health of all partner countries were integrated: population aging, issues of prevention and control of non-communicable diseases including cardiovascular diseases and tumours as the main causes of mortality, the growth of resistance of microorganisms to antibacterial drugs, the increasing relevance of primary health care as an accessible, comprehensive, and highquality, component of the health sector. during this period, a ndphs secretariat with legal capacity was established, which is currently located in stockholm, sweden. iii.the period from 2015 to 2018 a new ndphs strategy 2020 was developed and, corresponding to its objectives, an action plan was adopted, as well as terms of reference and tasks of the meanwhile six expert groups were established. the new ndphs mission was formulated as an innovative regional cooperation network, making a significant contribution to improving the health and social well-being of the population in the northern dimension area. the current ndphs strategy 2020 is defined as a guiding tool to assist the partner countries and organizations in their joint efforts to achieve improvements in selected priority areas and to strengthen the recognition of health and social well-being on the political agenda in the northern dimension area and the russian federation, as well as ensuring greater stakeholder commitment to include aspects of health and quality of life in the process of developing national policies. it is important to note the increasing relevance of the political components during this most recent period: inclusion of the north-west federal district of the russian federation into the zone of activity and responsibility of the russian federation in the ndphs (until 2014 only the region of kaliningrad participated in ndphs activities). to determine the current problems in the health and healthcare of the north-west federal district, the federal research institute of health organization and chernyavskiy v, mikhailova j. russia: a key partner in the northern dimension partnership (editorial). seejph 2019, posted: 10 may 2019. doi 10.4119/unibi/seejph-2019-217 page 4 of 5 informatics of the ministry of health of the russian federation carried out extensive work on assessing the health of the population and the capacity of the health care organization in the region. the new policy of the northern dimension placed a strong emphasis on cooperation between the european union and russia with full participation of iceland and norway in matters relating to the northern dimension region. the russian federation has been actively involved in the ndphs from the beginning (that is 15 years ago) in all areas of the partnership. it should be emphasized that russian experts are actively promoting many aspects of health and health care presented and discussed in the expert groups and transfer the insights gained into the national strategic documents for further development of the health system in russia. ndphs now is at the stage of preparation the new strategy 2025 based on the national priorities of the partners. in parallel, the president of russia signed the decree “on the national goals and strategic objectives of the development of the russian federation for the period up to 2024”. based on the analysis of global and national trends and conditions in the years to come, the new policy indicates the trajectory of economic, social, and technological break-through, sustainable growth of well-being and competitiveness of individuals and the society as a whole on social and economic development. at this historical turning point, it is expected that the european union will likewise renew its strategy for the baltic sea region (eu-sbsr) including a reevaluation of the financial investment in order to combine all efforts in the region efficiently. the complex but steady progress during 15 years shows that international cooperation at expert level may be slow but in the long run can become effective. the well-resourced northern and western countries and the european union should realise their strategic interest in the unique platform of the northern dimension partnership on public health and social well-being. conflicts of interest: none. references 1. tchernyavskii v. research on public health in transitional russia. understanding and orientating national health systems. proceedings of the 3rd ficosser general conference helsinki, 1995; p. 271-8. 2. public health in russia. international handbook of public health. editors: klaus hurrelmann, ulrich laaser. greenwood press, westport, connecticut, usa, 1996; p. 297-315. 3. lessof s, chernyavskiy v. health care systems in transition: russian federation. who, regional office for europe, copenhagen; 1998. 4. tchernyvskii v. health and health care in the russian federation. in: “the cost of reform: the social aspect of transitional economies” (editors: jones jf, kumssa a). nova science publishers, inc., huntington. new york, 2000; p. 89-101. 5. problems of russian mortality, its consequences and priorities for actions (editors: starodubov vi, mikhailova yu v, ivanova ae). moscow, 2006. 6. the health of the population of russia in the social context of the 90s: problems and prospects (editors: starodubov vi, mikhailova yv, ivanov ae). moscow, 2003. chernyavskiy v, mikhailova j. russia: a key partner in the northern dimension partnership (editorial). seejph 2019, posted: 10 may 2019. doi 10.4119/unibi/seejph-2019-217 page 5 of 5 7. stanley j. tillinghast, valery e. tchernjavskii. building health promotion into health care reform in russia. journal of public health medicine vol.16, no 4, december 1996; p. 473-7. 8. chernyavskiy v. modern approaches in the implementation of international projects for the prevention and treatment of socially significant diseases (hiv, tuberculosis and malaria). materials of the 8th russian forum with international participation: “children’s health: prevention and treatment of socially significant diseases”. st. petersburg, 2014; p. 2716. 9. mikhailova yv, andreeva om, chernyavskiy v. work of the russian federation within ndphs in 20032018; may 2019. ______________________________________________________________________________________ © 2019 chernyavskiy et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. bishaw t. covid -19 pandemic increasing the african access to vaccination (editorial.). seejph 2020, posted: 24 july 2021. doi: 10.11576/seejph-4608 p a g e 1 | 5 editorial covid -19 pandemic increasing the african access to vaccination a strategy to curb the global spread of infection tewabech bishaw1 member of the lancet covid-19 commission africa task force, june 30, 2021 1) african federation of public health association –wfpha; hon. ass prof. public health, jimma university ethiopia; alliance for brain gain and innovative development, md, addis ababa, ethiopia. e-mail: bishawtewabech@yahoo.com corresponding author: dr. tewabech bishaw, bsc.ph; hlt ed. dip, mph, dr. hsc; address: african federation of public health association –wfpha; hon. ass prof. public health, jimma university ethiopia; alliance for brain gain and innovative development, md, addis ababa, ethiopia; e-mail: bishawtewabech@yahoo.com mailto:bishawtewabech@yahoo.com mailto:bishawtewabech@yahoo.com bishaw t. covid -19 pandemic increasing the african access to vaccination (editorial.). seejph 2020, posted: 24 july 2021. doi: 10.11576/seejph-4608 p a g e 2 | 5 africa recorded the first case of covid-19 on february 14, 2020, a global pandemic, the response to which continues to challenge known public health measures to effectively and sustainably curb the spread and magnitude of the epidemic. early in the epidemic, responses in most african countries were led by national governments. national emergencies were declared, and systems for multisectoral response were put in place. strengthened ministries of health remained responsible for guiding and coordinating national and subnational level responses. human, financial and material resources were leveraged and mobilized to equip national public health institutes and other national entities to ensure health workforce training, strengthen diagnostic capabilities, public information, and disease surveillance systems, including expansion of non-pharmaceutical interventions (npis). over the last two years, the unprecedented social, economic, and political impact of covid-19 negatively affected many countries. school closures, negative impact on businesses, reduced household income, increased inflation, and logistics restraints (global, regional, and national level) created significant blows to the life of millions of africans. the pandemic also disrupted social activities, including banning religious gatherings and other social events disrupting the life of communities. the covid19 pandemic is expected to have devastating health and socioeconomic consequences in many countries in africa, partly because of weak health systems plagued with inadequate surveillance and laboratory capacities. additionally, insufficient health workforce to effectively respond to the pandemic and the lack of vaccines could worsen the situation further. the challenge for many african countries remains to strike a balance between the gains on covid-19 prevention, management, and control with impacts on essential health services and its bearing on other nonhealth impacts (social, economic, and political). cognizant of this and as covid-19 is expected to remain a public health threat for the foreseeable future and the rapidly changing epidemiology of covid-19 variants, many countries are putting in place surveillance systems. these are expected to help monitor status that could guide decisionmaking in emergency preparedness and response by implementing effective mitigating strategies. in this regard, the african center for the prevention and control of communicable diseases the african cdc, a newly established center for disease control under the african union (au). according to reports by the african cdc it is playing an essential role in supporting african countries: training in emergency management and providing technical assistance and technology transfer for establishing disease surveillance systems at a continental level. such new procedures are intended to link with national systems to identify potential global health threats to prepare and respond effectively. through alliances with us cdc, academia, scientific organizations, and other partners, africa cdc developed and released training to address priority national response needs; as a result, covid-19 laboratory testing capacity grew from two countries early in the outbreak to all 55 au member states by august 2020. covid-19 pandemic remains a major concern at the continental and country levels. targeting high-risk populations and improving early diagnosis and treatment capacity are strategic approaches used to control rapidly increasing mortality rates. a new norm of integration of covid-19 services within the essential health services system would reduce morbidity and mortality that are directly and indirectly linked to covid19. however, with its weak health infrastructure and resources, the strategy of choice to combat the pandemic in africa remains early prevention of the spread in communities. key bishaw t. covid -19 pandemic increasing the african access to vaccination (editorial.). seejph 2020, posted: 24 july 2021. doi: 10.11576/seejph-4608 p a g e 3 | 5 to this has been the efforts by all countries to implement non-pharmaceutical interventions (npis) through increased public awareness and strict adherence to the npi norms and standards until vaccines are made accessible to the population. nonetheless, due to various socio-cultural and related factors, sustained adherence to the npi standards by populations in most african communities has increasingly become difficult. hence to combat the spread of infection, urgently calls for accessibility of vaccines to a reasonable proportion of the population in high-risk countries and communities. factors including the socio-political-economy of vaccine availability to countries in africa become both a global public health concern and an ethical consideration. while different companies in different countries produce vaccines, actual availability to countries in africa has become increasingly difficult, calling for more active international solidarity. according to the recent appeal by the lancet covid-19 commission taskforce for africa, the continent is currently experiencing the third and deadliest wave of the covid-19 epidemic. despite africa’s support to covax, africa has not been supplied with the required vaccines so far. while the us now has 46% of its population fully vaccinated as of june 2021, and the eu has 31 % of its population covered, africa has only1.2% of its population fully vaccinated. in total, africa has received just 1.6% of the vaccine doses administered worldwide, only 49 million doses out of the 2.9 billion doses worldwide. one could safely conclude that the global fight to curb the spread of covid-19 could only be realized with equitable global access to the vaccine. vaccine coverage in africa will benefit the entire global community. would you please let me know any advice you may have on how to go about getting this very urgently needed vaccine to the needy populations in africa? urgent appeal for 300 million doses of covid-19 vaccines for africa. the lancet covid-19 commission africa task force june 30, 2021: bishaw t. covid -19 pandemic increasing the african access to vaccination (editorial.). seejph 2020, posted: 24 july 2021. doi: 10.11576/seejph-4608 p a g e 4 | 5 urgent appeal for 300 million doses of covid-19 vaccines for africa the lancet covid-19 commission africa task force june 30, 2021 on behalf of the people of africa, we appeal urgently to the vaccine-producing nations for emergency donations and shipments of at least 300 million doses of vaccines to enable every country in africa to fully immunize at least 20 percent of its adult population by end of august 2021.1 africa is currently experiencing the third and deadliest wave of the covid-19 pandemic, driven by the highly contagious delta variant that was responsible for the recent devastating surge of disease and deaths in india. but africa lacks vaccine protection. it has the lowest vaccine coverage in the world, having received just 1.6 percent of the vaccine doses administered worldwide until june 26 (49 million doses out of 2.9 billion doses worldwide). while the u.s. now has 46 percent of its population fully vaccinated (as of june 30), the european union has about 33 percent, china around 40 percent, and russia around 12 percent, africa has only 1.1 percent of the population fully vaccinated. in absolute numbers, the us and european union have fully vaccinated 299 million individuals compared with just 15 million in all of africa, despite an african population (1.34 billion) that is 73 percent larger than the combined population of the us and european union (776 million). another 20 million africans have received one dose. we note that the scale of current production worldwide makes it now feasible to provide africa with 300 million doses in the next 9 weeks on an urgent and expedited basis. we also note that the us has reached a near saturation in vaccine uptake, meaning that us-based production is now available for shipments to the rest of the world. we emphasize that vaccine coverage in africa is not only for the benefit of africa, but for the entire globe. cases of covid-19 spill across national borders, as do instability and suffering from unabated epidemics. moreover, in regions with surging infections, there are greater opportunities for the emergence of new and dangerous variants of the virus, as has already happened on several occasions. 1we assume that 300 million doses would enable 270 million doses successfully administered. of those, 20 million would constitute the second dose of the current partially immunized individuals, and 250 million doses would be for individuals not yet immunized, resulting in an additional 125 million fully immunized individuals. in total, 160 million africans would be fully immunized, accounting for 20 percent of the 800 million population aged 15 and over. in addition to the provision of vaccines, the international community should provide urgent financial and technical support to the africa cdc and to national covid-19 control programs to support non-pharmaceutical interventions, disease surveillance, diagnostics, vaccination infrastructure for cold chain and vaccination stations, data management systems, and genomic bishaw t. covid -19 pandemic increasing the african access to vaccination (editorial.). seejph 2020, posted: 24 july 2021. doi: 10.11576/seejph-4608 p a g e 5 | 5 surveillance of breakthrough infections. several partner countries have existing programs in africa to support infectious disease control efforts (e.g., for hiv/aids, malaria, and tuberculosis). such programs should be provided with supplemental funding to enable them to extend coverage of covid-19 control, including the rapid scale-up of vaccination programs. members of the africa task force of the lancet covid-19 commission: prof. salim s. abdool karim, co‐chair of the africa task force, caprisa professor for global health in epidemiology, mailman school of public health prof. miriam khamadi were, co‐chair of the africa task force, vice chair, the champions of aids-free generation kenya dr. muhammad pate, co‐chair of the africa task force, global director for health, nutrition and population, the world bank dr. naphtali agata, chair of kemri board of management; health sector consultant at japan international cooperation agency dr. gordon awandare, director of west african center for cell biology of infectious pathogens prof. yanis ben amor, executive director, center for sustainable development in the earth institute; assistant professor of global health and microbiological sciences | secretariat of the lancet covid‐19 commission: yba2101@columbia.edu dr. tewabech bishaw, founder and managing director of alliance for brain‐gain and innovative development (abide prof. abderrahmane maaroufi, director of the institut pasteur maroc (national public health institute) dr. john n. nkengasong, director of the africa centres for disease control and prevention dr. francis omaswa, executive director, african center for global health and social transformation prof. amadou sall, director of the institut pasteur senegal prof. jeffrey sachs, chair of the lancet covid‐19 commission; university professor and director of the center for sustainable development, columbia university, and president of the un sustainable development solutions network dr. michel sidibe, african union special envoy for the african medicines agency (ama); former minister of health and social affairs for mali and executive director of unaids, former under-secretary‐general of the united nations © 2021 bishaw et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. mailto:yba2101@columbia.edu centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 1 | 11 short report serbian citizens’ opinion on the covid-19 epidemic centre for international public policy, department for public opinion research ivanović marta, đorđević mirjana, klarić aleksandar ma, mikanović filip, nikolić kristina, perić tamara, savić tamara, steljić katarina, subotić lazar, todorović marko, todorovski irena, totić bojan corresponding author: aleksandar klarić ma centre for international public policy, department for public opinion research belgrade, serbia email: aklaric@cmjp.rs centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 2 | 11 summary aim: the centre for international public policy has undertaken a public opinion research in which we tested the opinions of the citizens of serbia on the coronavirus epidemic. the respondents had the opportunity to express their opinion on measures undertaken by the serbian government to combat the virus, to state their trust in the media, as well as the health system in general. in addition, we tested the prevalence of different conspiracy theories among citizens, whether the pandemic gave china a new image in the minds of the people and, most importantly, the level of solidarity among serbian citizens as well as within the european / international community as a whole. methods: in seven days, from 8-15 th april 2020, we gathered a convenient sample of n=5989 respondents, which makes this the largest public opinion research project in serbia on the topic of covid-19 since the start of the epidemic. the electronic questionnaire consisted of 24 questions of mixed and closed type. results: the findings of this research suggest that citizens of serbia are not afraid of covid-19, but are nevertheless cautious (86%). the percentage of those willing to consult a doctor when they notice any symptoms lies at 70%. half of the respondents do not believe in alternative theories regarding the origin of the covid-19 virus. the majority of the respondents (55%) hold government officials accountable for spreading panic through public speeches and daily public addresses. moreover, 60% of the respondents do not trust the serbian media outlets that are currently reporting on the covid-19 pandemic. furthermore, over half of the respondents are prepared to report their neighbour when he or she is coming from abroad and violates the obligation to self-isolate. however, mostly due to the significant fines, 65% of the respondents would not report the elderly when they are breaking the limited-movement restriction measures. conclusion: as before the epidemic, opinions of the serbian population on current topics are somewhat polarized. although the majority of the respondents are cautious, a significant number also believes in conspiracy theories and does not fully trust the information provided by the media or the government. keywords: covid-19, opinion survey, epidemic. references: 1. johns hopkins university. covid-19 dashboard by the centre for systems science and engineering (csse). baltimore: johns hopkins university; 2020. https://coronavirus.jhu.edu/map.html. 2. martin-moreno, j. m. (2020) “facing the covid-19 challenge: when the world depends on effective public health interventions”, south eastern european journal of public health (seejph). doi: 10.4119/seejph-3442. https://coronavirus.jhu.edu/map.html centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 3 | 11 1) is there a presence of fear and which prevention measures have the citizens of serbia undertaken? we were astounded by the fact that 86% of the respondents said that they are not afraid that they or their family members are susceptible to being infected by the virus. still, in times when we are witnessing the heavy toll of the consequences due to the pandemic on mental health globally, this in an encouraging sign. the question of the level of responsibility among the citizens can be answered with the following data: of the above-mentioned 86%, 79% stated that, although they are not afraid, they are taking preventive measures. further data states that: 85% of respondents wash their hands more frequently, 85% implement social distancing measures and 75% use masks and gloves. also noticeably, 2,5% of respondents said they are not taking any preventive measures. there is noticeable optimism among respondents in the following topics: 60% of the respondents do not believe that we are likely to reach the “italian scenario” of exponential growth of new cases and overloading the health system, while as many as 90% believe that the virus will be contained by the 1st of june and that life will return to normal. 2) would the citizens of serbia report on their co-citizens who do not abide by the selfisolation measures? having in mind the special movement restrictions for citizens of the age 65 or above, we were interested in how many respondents would report on their senior co-citizens who leave their home, thus potentially endangering their lives. the largest number of respondents (65%) stated that they would not report on their co-citizens but would advise them not to go out, likely because of the expensive penalties that would be incurred by the senior citizens; 20% would not 14% 86% are you concerned that you or one of your family members may get infected? concerned not concerned 44% 90% 17% 5% until may 1st until june 1st until july 1st longer how long do you believe the state of emergency will last? centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 4 | 11 report them, as it does not concern them, while 15% would. the results showcase a lack of motivation for including government institutions in solving this problem, as many respondents would rely on self-initiative. this could point to the demotivating factor of high penalties for reporting third parties’ wrongdoings. the situation greatly differs regarding the question of the neighbour returning from abroad. half of the respondents would report a returning neighbour who does not abide by the self-isolation measures. about a quarter of the respondents would not report on their neighbour, but would be more careful, while 17% would alert other neighbours. there was a considerably lower number of indifferent respondents, since only 8% stated that this matter is none of their concern. this leads to the question of why this is so and what role did government authorities play in the formation of these opinions, given their open criticism of citizens returning from working abroad (the so called “gastarbeiter”). 3) how much trust do the citizens of serbia have in the health system and the crisis staff? even with the citizens’ outpouring of solidarity towards health workers “on the front lines” of the epidemic with the symbolic applause each evening at 20h on their balconies, we still wanted to test the level of trust citizens have in the health system. on the question “if you were to feel virus symptoms, would you call the doctor or stay at home”, 70% of the respondents would call the doctor, while a significant portion (25%) would only call if the situation drastically worsens. with the constantly changing recommendations of the crisis staff on the right measures to 15% 65% 20% i would i would advise them it doesn't concern me would you report on citizens above the age of 65 who are leaving their homes, thus potentially endangering their lives? 50% 25% 17% 8% i would i would be more careful i would alert other neighbors it doesn't concern me would you report on a neighbor who arrived from abroad and doesn’t abide by the self-isolation measures? centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 5 | 11 undertake, we chose to classify these 25% among those who do not have complete faith in the health system. additionally, 5% of the respondents stated that they would stay at home. the greatest experts among the doctors have been invited to form the crisis staff and their recommendations affect the measures further adopted by the government in handling the pandemic. for 6 weeks, every day at 3 pm we sit docked in front of the tv screen, waiting to hear the latest information on the number of infected and about future measures. therefore, we were interested in which member of the crisis staff citizens of serbia trust the most. in the first place, leading with 27%, there is prof. dr. predrag kon, then dr. darija kisić tepavčević with 20%, dr. goran stevanovic with 15%, while the least trusted member is prof. dr. branimir nestorovic with 8%. however, the most common answer given, (by as many as 30% of respondents!), is that the citizens did not trust any member of the crisis staff! these results are an indicator of citizens putting members’ expertise in the background, while their appearances in the media are mostly perceived in the context of the current political climate in the country, i.e. citizens often understand them as politicized. 4) how much do the citizens of serbia trust the media and high state officials? it has been repeatedly said that “the media is adherent to the doctors,” as one side fights the infectious virus and the other unverified information and fake news. in this regard, we were interested in the degree of trust that the citizens have in the information they receive from the media. the results of the research tell us that as many as 60% of respondents do not 25% 70% 5% if you were to feel virus symptoms, would you call the doctor or stay at home? would call the doctor if the situation worsens would call the doctor would stay at home 70% 30% do you trust the members of the crisis staff? i do i do not centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 6 | 11 trust the information they receive from the media about the corona virus! among them, 25% of the respondents think the virus is more dangerous, and that the number of infected and deceased is higher than the official information states. also, there are 35% of those who believe that the virus is not so dangerous and that the whole crisis is exaggerated to divert the publics’ attention from other problems. at the top of the crisis management chain is the state management. although politicians' ratings are often measured in opinion polls, we were interested in the kind of impression that high state officials give the citizens when addressing them about the virus. exactly 55% of respondents stated that government officials and their public appearances cause them distress and panic. on the other hand, 30% of the respondents rated their behaviour as responsible and serious and 15% of them rated it as positive “they calm us down and they bring hope that everything will be all right." when comparing these results to the previous questions’, one could ask: if 55% of respondents think politicians are bringing discomfort and panic, while at the same time, 86% say they are not concerned about the virus, are the politicians losing the trust of the people? 5) how much traction have conspiracy theories gained among serbian citizens? along with the first coronavirus cases came the emergence of the first conspiracy theories. by focusing all their resources on suppressing the exponential growth of the virus, countries failed to prevent the exponential growth of conspiracy theories. there are countless conspiracy theories today, but we have singled out a few. the answers to the popular question of whether the virus was transmitted from bats to humans or 40% 35% 25% how much do you trust the information received from the media? i believe it the virus isn't so dangerous the virus is more dangerous 17% 39% 44% how was the coronavirus created? transmitted from a bat made in a laboratory i don't know centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 7 | 11 if it was made in someone's lab showed that the highest percentage of people believe that the virus was made by scientists, as much as 44% of respondents! when combined with the undecided (39%), we conclude that a large percentage (83%!) of people either completely reject or distrust the theory that the transmission of the virus occurred from an animal to a human. only 17% of respondents believe that the pandemic came from one of the wet markets containing exotic animals in wuhan. while on the topic of wuhan, in addition to being considered the world's epicentre of the covid19 virus, it was also among the first cities in china where 5g technology was deployed. it didn't take long for new conspiracy theories to emerge, as we are already hearing about how the british are destroying their lampposts. what is the situation in serbia? as much as 15% of respondents think 5g technology is harmful and that there is a correlation between it and the pandemic, while twice as many people (30%) believe that this is a mere coincidence and do not believe this theory. most of the respondents were undetermined 55%. these respondents also differ from one another, as we have 40% who are suspiciously waiting for scientific evidence to be presented, and 15% of those who have no opinion on this matter. also, among the most popular in serbia are the following alternative interpretations: everything is a plot of the pharmaceutical mafia that only wants to profit, ”they created a virus in order to sell us the vaccine” (believed by 28%), a pandemic is a front for settling migrants in europe (27%) and the us made the virus to destroy china economically (24%). the reverse theory, also present in the world, but with a lower acceptance in the serbian public 10% of the respondents considered it to be a virus made by china in order to overtake the united states in a battle for the world's largest force. overall, it is encouraging that half of the respondents said that they hold no beliefs in conspiracy theories. 6) which country do citizens of serbia believe will be the first in developing a vaccine? the fact that the “made in china” label is no longer undesirable demonstrates to what extent crises can change the world, as well as peoples’ awareness about it. this is shown by the fact that more than half of the respondents (60%) 50% 50% do you believe in conspiracy theories? i do i don't centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 8 | 11 believe that chinese scientists will be the first to develop a vaccine for covid-19. former technological giants, countries who led the world in innovations and high standards of living are now ranked below china regarding the development of a vaccine. this is demonstrated by the fact that the united states enjoys only 24% of respondents’ trust, whereas a mere 11% of respondents believe germany will develop a vaccine first. 7) how do the citizens of serbia evaluate their government’s measures and its’ management of the crisis? when it comes to the capability of the domestic industry to develop respirators, surprisingly, almost half of the respondents (49%) believe that serbia has the capacity to develop them; 29% of the respondents disagree with this statement, whereas 22% of the respondents claim that yugoslavia would have been the country capable of doing so. when asked about the 24 hour (total) lockdown as ordered by the government, serbian public opinion as measured between the 8th and 15th of march has been significantly divided: 43% of the respondents stated that they support the lockdown, considering it ''the only measure that can put us in line and create order.'' an identical percentage (43%) believes that the 24 hour lockdown is too harsh of a measure and therefore do not condone it. the rest (14%) of the respondents do not have an opinion on the matter. a financial aid package of 5,1 billion euros has ignited tremendous public attention, especially regarding an initiative to give 100 euros to every adult serbian citizen. during the presentation of the economic measures, serbian president aleksandar vučić made a remarkable statement: ''people simply cannot believe that serbia has money''. with this remark in mind, we decided to pose the question to the public in this way: "do you believe that serbia has the money to overcome the crisis?’’ opinions were divided: 48% of the respondents agree that the money will be provided, but also believe that pursuing this policy will have negative long-term consequences; 35% of the respondents believe that serbia does not have enough money for such an endeavour, whereas 17% of them claim that, because of its responsible fiscal and monetary policy, serbia does have enough resources to overcome this crisis. centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 9 | 11 “only unity saves the serbs”, which is a famous and widely-used proverb in serbia, has had to share its’ symbolic and moral importance with another phrase that has gained almost the same weight over the course of the past 20 years – namely the saying that “there has never been a greater solidarity than during the (nato) bombing”. this made us wonder whether this pandemic and its’ ever-growing economic impact have had enough of an effect on the population as to re-awaken that reputable serbian unity. it appears that enthusiasm has been somewhat lost: 60% of the respondents are of the opinion that solidarity is somewhat higher than usual. however, the ends of the spectrum provide a more compelling analysis with only 10% of the respondents claiming that solidarity is at an all-time-high (like during the 1999 bombing), whereas 30% of them claim that people are more selfish than ever, as demonstrated by increased panic buying and the stockpiling of groceries. 8) how do the citizens of serbia evaluate other crisis management models (usa, eu, sweden)? although the evaluation of domestic solidarity was not very positive, it's surprising to see that 85% of the respondents believe that global issues such as a pandemic are most efficiently resolved through international cooperation. meanwhile, only 15% of the respondents believe that it is in every country's best interest to rely on its’ own capacities. the results show a growing awareness among the public of the necessity of a global approach when dealing with global issues. solidarity and cooperation between countries up until recently served as synonyms for the european union. how does this stand today? the results show that only 10% of the respondents believe that the eu is aiding the countries struck by the virus in every way it can. however, a large percentage of respondents (45%) believe that the response of the eu to this crisis was inadequate, stating that it left italy and spain stranded to their own devices. there is a 17% 35% 48% do you believe serbia has enough money to implement the economic stimulus package? yes no yes, but there will be negative consequences centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 10 | 11 surprisingly high percentage of respondents (45%) who do not have an opinion on the matter. such results imply a possible tendency of declining trust in eu institutions in serbia after the crisis. the research results have shown that there is little interest in the different models of crisis management, since 35% of the respondents have no opinion on president trump's plan regarding the pandemic and 60% do not have a clear opinion regarding the so-called swedish model, even though sweden is unique among european countries in its’ approach to the crisis. only 10% of the respondents support the swedish model, stating that it is adequate. when it comes to the us, almost half of the respondents consider saving human lives more important than president trump’s quest of salvaging the economy; 15% of the respondents condone the latter, considering his worry about the economy justified. in the end, the respondents were asked to pick the two, in their opinion, most important consequences of isolation and social distancing. more than half of (60%) believe a temporary economic halt and the arrival of a new economic crisis to be the main negative consequence. the positive consequences of the crisis, according to the respondents, would be the recovery of nature, as well as a decrease in climate change and air pollution. 10% 45% 45% do you believe the eu reaction was adequate? yes, the eu is sending help no, the eu left italy and spain on their own i don't have an opinion centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 11 | 11 discussion the goal of the centre for international public policy when conducting this online research was to enable citizens to indirectly state their opinion on current issues, which have proven themselves to be existentially important to them in these uncommon circumstances. we also wanted to provide a better insight for the public and for the media into the citizens’ personal positions regarding the current state of affairs, as well as their expectations for the time that lies ahead of them. the positive findings of this research suggest that citizens of serbia are not afraid of covid-19, but are nevertheless cautious (86%). the percentage of those willing to consult a doctor when they notice any symptoms lies at 70%. half of the respondents do not believe in alternative theories regarding the origin of the covid-19 virus, as they seem to approach the matter objectively. of particularly high concern is the fact that 55% of the respondents hold government officials accountable for spreading panic through public speeches and daily public addresses. moreover, 60% of the respondents do not trust the serbian media outlets that are currently reporting on the covid-19 pandemic. furthermore, over half of the respondents are prepared to report their neighbour when he or she is coming from abroad and violates the obligation to self-isolate. however, mostly due to the outrageously high fines, 65% of the respondents would not report the elderly when they are breaking the limited-movement restriction measures. taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 1 original research from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003 aloysius p. taylor1 1 affiliation: independent consultant corresponding author:aloysius p. taylor address: monrovia, liberia e-mail: aloysiustaylor@hotmail.com mailto:aloysiustaylor@hotmail.com� taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 2 abstract aim:to explore the experience of fighters disabled during the liberian civil war; what they did and what was done to them; and what happened after their demobilization. methods:six focus group discussions were organized in monrovia, the capital of liberia, with 50 invalid veterans aged 10 to 25 at their entrance into the war and eightwomen wounded, although civilians, sampled as in convenience. in addition,sevenkey-informant interviews took place. all encounters were agreeably taped, transcribed and summarized under the items of the discussion guide. results:most ex-combatants joined the fighting to protect themselves and their families who were targeted by rebel fighters or joined to revenge the killing of close family members by fighters from all sides including government soldiers. nearly all the former fighters interviewed expressed their desire to be trained in various areas of life skills. a vast majority of the ex-combatants are living from begging in the streets.those from factions feel that government cares for former regular soldiers and discriminates those from other warring factions. the lack of housing for ex-combatants with war related infirmities is of paramount concern to them. they feel that the post-war reintegration program did not achieve its objectives. in the communities, they are stigmatized, blamed as the ones who brought suffering to their own people. the key informants are calling for establishment of trust fund for survivors of the civil war who are disabled. recommendations: establishment of a trust fund for survivors of the civil war who are disabled; reform of the national bureau of veteran affairs to include the disabled ex combatants of all former warring factions; erection as planned of the proposed veterans hospital; a national census of disabled ex-combatants and war victims. keywords:civil war, demobilization, disabled combatants, liberia, reconciliation. conflicts of interest:none. acknowledgements: this study has been conducted with service providers in mind, based on the social, economic and health status of the former fighters who were wounded and made disabled by the liberian civil war. first and foremost, many thanks go to professor dr. ulrich laaser who took special interest in the disabled former combatants to the extent that he contributed the financial resources to enable the conduct of this study. he also encouraged colleagues of his to assist the research team implement. prominent among this is dr. moses galakpai who provided technical support to the research team and roosevelt mccaco who in his free time took care of the financial management. we appreciate the work of the research team members who made valuable contributions to the development of the documents leading to the completion of the study. special recognition goes to mr. richard duo of the amputees football club for his coordinating role in facilitating the key informant and focus group interviews. funding: private. taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 3 foreword the civil conflict has been over for nearly as many years as it lasted. the scars however are as visible today as were the horrible episodes of atrocities that characterized life during the war years. the wrecked economy of liberia following the onset of the civil war, gross human rights violations, involvement of child soldiers and use of harmful substances by both armed fighters and civilians are all hallmarks of the liberian civil war. thousands of young people who were active members in the numerous fighting forces got maimed and are today disabled for various causes. what is true for nearly all of them is the fact that they are living under difficult circumstances no jobs, no housing, and no sustainable care. with no preparation to face the harsh post conflict and post ebola environment in liberia, the disabled ex combatants deserve attention that will give them hope, attention that will harness their potentials not only for sustaining themselves but for promoting peace in the nation. this publication, though conducted in only one of the 15 counties of liberia, contributes to the knowledge needed for the attainment of a better living condition for disabled ex-combatants as well as promoting sustainable peace in liberia. dr. moses kortyassahgalakpai former deputy minister of health republic of liberia taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 4 introduction liberia, to mean „land of the free‟, was founded by freed american slaves who were sponsored to settle in africa as early as 1822. annexation of land from the indigenous tribes enabled the country to be formed until statehood was declared 1847. the lack of full integration of the indigenes was the main trigger for the civil war beginning on christmas eve in1989 (1). the large number of young people exposed to arms and use of harmful substances constitutes a significant risk for the sustainability of peace in the country.the idea to undertaking this explorative study into their feelings and experience comes from the general observation of the appalling conditions of disabled veterans. unable to earn a living due to the lack of skills compounded by the fact that they have lost parts of their bodies, the former combatants are in serious need of assistance which is not forthcoming. not only are the disabled ex-combatants unable to provide daily food for themselves, but they are under incessant barrage of accusations of bringing suffering to their people. such stance inhibits a free flow of material assistance to them as well as social acceptance (2). therefore this investigation attempts to documentfrom their own wordsthe past and present experience of former fighters who were disabled and traumatized during the civil war in liberia including a selected number of civilian women wounded. in addition key informants have been interviewedand asked for their analysis and recommendations. methods study population the qualitative studytook place inmontserrado county which includes the capital monrovia with more than a million inhabitants, about a quarter of liberia‟s entire population. the respondents were recruited by non-probability sampling as in convenience between march 29 and may 3, 2017 through the amputees football club in monrovia (4) and consisted of two categories of respondents: the first comprised of five focus groups of ten former combatants each, together 50participants who were disabled as a result of their participation in the fighting. these persons were from various fighting forces including those from the national army. additionally, there were eight women who received their disabilities from bullets and bombs even though they were civilians; some were targeted while others were accidental.the selection process did not allow anyone to attend more than one focus group. focus group discussions the study relied on a participatory approach and semi-structured narrative format.the discussion guide for the focus groups,taking about three hours,comprised a set of nine questions, assembled by four experts three liberian and one european familiar with the setting. the questions were introduced to the focus groups by a moderator: 1) why and for which faction (out of eight) did you join the fight? 2) what was your rank and war-name and what weapons did you use? 3) what made you brave and how did you get wounded? 4) did you commit atrocities yourself? 5) did you meet later your comrades or your victims? 6) what is your experience with the demobilization program after the war ended? 7) where and how do you live now and how are you received by the community? 8) are you satisfied with your living conditions and what are your expectations? 9) how did you as a women experience the civil war?voices of female survivors. taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 5 key-informant interviews the seven key informants contacted had witnessed events during the civil war and were knowledgeable about former fighters and the programs initiated for their return to civilian life. they saw what happened or took part in what happened such as rendering social, relief or medical services to the population affected by the war. these included stakeholders and others such as project officers, focal point persons in security sector institutions, community leaders, and relevant government personnel. although they were professionals in their own right, some of them were seen as rebel supporters because they operated in particular geographic locations controlled by warring factions. seven such persons were interviewed on issues surrounding the following topics: 1) the disarmament, demobilization, rehabilitation and reintegration program (ddrr) 2) key challenges facing ex-combatants 3) strategic recommendations information processing all encounters were agreeably taped, transcribed and summarized under the items of the discussion guide by a team of liberians under the guidance of the author. results i. the focus group interviews (fdg) characterization of the participants most of the discussants were young school-going children, when the war started. however, as the war progressed educational institutions in the war-affected areas were shut down, leaving thousands of idle youths susceptible to align themselves as child soldiers, boys and also girls (5),with the warring faction that was present in their areas of domicile. 1) why and for which fraction did you join the fight? for most, as seen from their age profile, serving in the military was never then thought of. the discussants disclosed that the war was brought home when they witnessed the gruesome murder and mutilation of their relatives, the personal pain inflicted on them by those bearing arms whether government troops or members of opposing warring factions, the looting of their family‟s properties or just the excitement of being with members of their age group, all thatserved according to them as motivating factors to become fighters themselves. a couple of others were forcefully recruited and others joined because they were used as porters of ammunition and goods for the men at arms.defections from the national army became commonplace joining one of the rebel factions (see box), some related to ethnical or religious background. their allegiance to the armed group to which they belonged became stronger than the bond with their families and socio-cultural institutions that nurtured them and that they once respected. 2) what was your rank and war name and what weapons did you use? in order to persuade their men to obey their authority, those in command assigned meaningless ranks to fighters under their command. such arbitrary ranks gave them an air of greatness. additionally, there was no previous training to back the ranks. the discussants informed that rebel training sometimes lasted for only two months. examples of these fake ranks given by the discussants are: field commander, full colonel, general, captain, brigadier general, lt. colonel, major, chief of staff. taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 6 war-names or nicknames played an important role in the behavior of the individual combatant and how he/she was perceived by comrades and commanders. besides being used as a means to motivate combatants into action, nicknames served to conceal the real identity of the fighter. nicknames were also used to promote certain behavior of the fighter. for example, “dog killer” could mean killer of the enemy (the dog). someone bearing such nick name would live to prove that he is a killer of the enemy. similar other nicknames of discussants were: major danger, super killer, no ma no pa. the discussants indicated that they used various weapons during the course of the war. the predominant one was the kalashnikov (ak47 and others in the series). the combatants used the guns to exploit the civilians in their controlled areas, a major factor for the mass exodus of people out of the country. the proliferation of small arms in all areas controlled by warring factions made the entire country unsafe at the time especially that the combatants according to them served as the “justice systems” in their controlled areas. many of these weapons were traded among warring factions as some combatants switched sides or needed money. however, heavier weapons fielded were more supervised by those in command. 3) what made you brave and how did you get wounded? myths and rumors surrounding the composition of rebel fighting forces and their use of mystic powers coupled with the government‟s mismanagement of the war, greatly aided the demoralization of the better trained government troops to the point of stimulating mass defections.the rapid advance of rebel forces mainly rested on the highly motivated youths most of whom were given drugs and other substances to influence their behavior, giving them a false sense of invincibility. some others mentioned the use of drugs and strong alcoholic drinks given them by their commanders as sources of their bravery. some wore amulets on their necks and “hands for protection” against bullets. a discussant explained that he was given a talisman belt to wear around his waist which could hold him tight and become very hot when enemies were around. these good luck charms turned up to be fake; many fighters died or got wounded due to their belief in these charms. other reasons cited as sources of their bravery are as follows: • colleagues made me brave • afl distributed the new testament bible • god and the arm given to me • the gun gave me power • the urge to revenge for the killing of relatives military groups named by participants as their own ones: armed forces of liberia (afl) • lofa defense force (ldf) • liberians united for reconciliation and democracy (lurd) • national patriotic front of liberia (npfl) o independent national patriotic front of liberia (inpfl) o national patriotic front of liberia-central revolutionary council (npfl-crc) • united liberation movement of liberia for democracy(ulimo) o united liberation movement of liberia for democracy-johnson faction (ulimo-j) united liberation movement of liberia for democracy-kromah faction (ulimo-k) https://en.wikipedia.org/wiki/armed_forces_of_liberia� https://en.wikipedia.org/wiki/lofa_defense_force� https://en.wikipedia.org/wiki/liberians_united_for_reconciliation_and_democracy� https://en.wikipedia.org/wiki/national_patriotic_front_of_liberia� https://en.wikipedia.org/wiki/independent_national_patriotic_front_of_liberia� https://en.wikipedia.org/wiki/national_patriotic_front_of_liberia-central_revolutionary_council� https://en.wikipedia.org/wiki/united_liberation_movement_of_liberia_for_democracy� https://en.wikipedia.org/wiki/united_liberation_movement_of_liberia_for_democracy-johnson_faction� https://en.wikipedia.org/wiki/united_liberation_movement_of_liberia_for_democracy-kromah_faction� https://en.wikipedia.org/wiki/united_liberation_movement_of_liberia_for_democracy-kromah_faction� https://en.wikipedia.org/wiki/united_liberation_movement_of_liberia_for_democracy-kromah_faction� taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 7 • american war movies • family members were not around, so fear left me when i joined. the discussants narrated various ways in which they received wounds which led to their disability today. to wit: • mistake from friendly forces • enemy fire, on the frontline • aerial bombardment by alpha jet • personal mistake handling grenade • fell in enemy ambush. some of the other causes of wounds which resulted into amputation of limbs are directly reflective of the low level of training of the fighters as regards safe handling of weapons. 4) did you commit atrocities yourself? discussants admitted that they also committed atrocities in response to what others did to them and their people. they said that they killed and raped in revenge for what was done to their family members or relatives. they informed that they saw wickedness in the extremes such disembowelling of pregnant women and using their intestines to intimidate other people at checkpoints. the discussants said that they burned houses and other peoples‟ properties because of anger. the discussants also admitted to beating people, looting goods and killing domesticated animals. asked if they have any regrets for also committing crimes against others, a few said they do regret but most of them said no, as they were under the influence of drugs or were forced by their commanders. one discussant said that he did not do anything to anyone but only killed enemies on the battlefield. 5) did you meet later your comrades or your victims? the participants said that they sometimes see their colleagues and those who commanded them during the war, most of them in same impoverished conditions as they are and sometimes even worse. these past commanders, they said, sometimes even asked for help from the disabled ex-combatants in this study: “our former commanders feel more frustrated than us, because they have no more power to do anything or command other people to do something for them”. some met also their victims and begged them to forgive, others saw them on the street but were not given a chance to talk to them or even beaten in revenge. 6) what is your experience with the demobilization program after the war ended? the most contentious issue reference the transition from active combatants to civilian life was the liberia disarmament, demobilization, rehabilitation and reintegration program (ddrr) up to 2009. nearly all of the discussants were not pleased with how it was handled. the vocational training to which some went was rather too short. they informed that they were promised packages at the end of the training which many of them did not receive. they said that their names were written down to be contacted when the packages were reading and up till now nothing has been done. a discussant informed that he entered the ddrr program and spent five days and afterwards used his id (identification) card to enter a vocational institution where he spent nine months, graduating with a certificate but the tools given him and his colleagues did not match the certificate. a few others admitted that they sold their id cards for money.according to discussants who fought for the warring factions, they are dissatisfied over how the government did not arrange a better package as that made for the regular soldiers when in their opinion all of them had served their country. • usd 150 was given to rebel fighters as a one-shot resettlement package taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 8 • government of liberia soldiers were given usd540 and also benefited from appropriate pension arrangement. 7) where and how do you live now and how are you received by the community? most of the disabled ex-combatants congregated in monrovia and its immediate environs for fear of reprisal as stigma against them in their original communities is described as high. most of them are blamed for the atrocities and the sufferings that the civilian population had to endure during the civil war. as a result the furthest distance from the city centre where most disabled are living turned out to becareysburg and gardnersville whereas the heaviest concentration is in paynesville, all less than 50 km away. the discussants were frankto also admitthat they wereashamed toreturn to their original places of residence. furthermore the high cost of rent, distance from their usual places of street begging and the fact that there are some people in their original locals who want them to die, were cited as compelling reason for finding new places to live.many of the fighters refused to go home even up to today. some participants were received well by their families but were rejected by their communities. one discussant said that his parents and other family members cried upon seeing him and later encouraged him not to harm himself. another discussant said that reception was good at first after ddrr but when the money they received from the ddrr was exhausted he was thrown out. yet another informed that he had a girl pregnant for him at time of disarmament but right after his money was finished too, she left him and said that the pregnancy was not his. the psychological anguish and social marginalization ex-combatants have been subjected to have led some of them to attempt suicide. the suicidal inclinations among freshly-wounded ex-combatants were motivated by feelings of being useless after losing limbs, ashamed of their conditions, thinking that they would be rejected by women, being mocked by children or just share embarrassment at the disability. asked why they did not carry out their desire to commit suicide after all, they gave the following reasons: • another disabled friend encouraged me not to kill myself • i made my own decision not to kill myself • nurses at the hospital talked to me and promised me “false legs” after one year. as a result of all these inconveniences, they move in groups and sleep in makeshift huts and market places where the night will find them after a hectic day of begging for alms from humanitarians in the street corners and in front of supermarkets and other public places. taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 9 figure 1. disabled war combatants 1017 8) are you satisfied with your living conditions and what are your expectations? the overwhelming majority of discussants indicated they are not satisfied with their present conditions, both physical and economic. however, they do accept the fact that their physical conditions in the given situation cannot be reversed, so they must live with it. they stated that “no one can be satisfied with this kind of condition, there is nothing we can do” (picture). all the respondents felt that the ddrr was hastily planed and haphazardly implemented and that the implementation period of less than 3 years was grossly inadequate. those who were enlisted in skills training programs were given 6 months to complete the training. they expected the program to last much longer to allow them acquire the knowledge and skills that are marketable. they expected the ddrr to provide free medical care and “we need housing and education for our children as well as jobs to move us from begging in the streets. we also need training to become peace ambassadors to reconcile our country and prevent war”. 9) how did you as a women experience the civil war?voices of female survivors “my son and his friend were hit when they went in our yard to get water from the well. i took them both to jfk hospital and when i went to front street, i was hit too and my hand got broken. i was assisted by government security and icrc; the ministry of finance gave me money to attend to my injury.” “i was a student in grade seven in 1996 when i got shot entering into my own father‟s house. the boy who shot me did it intentionally; five persons were also fired, 2 survived. i used tube for one year eight months.” “i got hit also in 1996. they took me to redemption hospital. one ecowas man helped me and carried me to ghana. i waited 9 month to remove the bullets. i lost one hand and foot.” “i made many attempts to kill myself, each time i tried to do so someone would interrupt.” “i did not go to school. i went to do business, when i got shot at the age of 23, only my mother stood by me, my boyfriend ran away.” “i have had two children since my injury. one is going to school.” “i am making and selling hand bags, neck ties, etc. don bosco taught me.” taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 10 “particles are still in my body; they can be removed but someone has to foot the bill.” “we need help. the government is not focused on the disabled.” “we need micro-loan, wheel chairs and all disabled materials” ii. perspectives of key informants during the study a number of key informants knowledgeable about the former fighters and the programs initiated for their return to civilian life were identified and interviewed. their perspectives have been summarized below. among the views expressed by all key informants is the fact that there was not a dependable exit strategy for the thousands of ex-fighters especially those who be invalids from the war. it is not surprising therefore that disabled ex-combatants are finding it difficult to survive today. having gained nothing from the war, physically impaired and not receiving any subsistence from government or other humanitarian organizations, the disabled ex-combatants civilians are the true victims of the liberian civil war. the key informants feel that for all practical purposes the ex-combatants are marginalized by the government of liberia and rejected by the larger society. 1) the disarmament, demobilization, rehabilitation and reintegration program (ddrr): all the key informants dubbed the ddrr program as a long-term failure exercise, not only because of its failure to retrieve all the weapons from the ex-combatants but its inability to implement a program for providing sustainable basis for marketable life skills. they were unanimous on their fact that the ddrr program also lacked credible trauma healing offering as well as the availability of psychosocial counselling. it is the view of some key informants that the major reason standing in the way of true reintegration of ex-combatants is that the ddrr only put a quick-fix program that did little to prepare the ex-fighters for the life they were destined to face after disarmament. 2) challenges facing ex-combatants: the current state of the disabled ex-combatants is appalling, their dependency on handouts to feed themselves and their dependents not guaranteed from day to day; hopelessness is written in their faces, said one key informant. their presence in the streets begging for livelihood reminds those who carry hurt in their hearts from the civil war. the informants generally believe that the provision of housing for disabled ex-combatants will not only dignify them and restore their self-esteem, but it will be easier to control or maintain them in any skilled training program that they may hereafter be given. they recommend skills training need assessment among disabled ex-combatants before any such training is initiated for them unlike the approach employed during the ddrr. a key informant who happens to be a medical doctor confided that some of those who sustained bullets wounds in their bodies need follow-up treatment but they lack the means. if their exit strategy had been thoroughly planned, a referral program could have been in place to address such persons‟ conditions.the need for access to free health care was discussed and emphasized. summary of some major findings • most ex-combatants joined the fighting to protect themselves and their families who were targeted by rebel fighters • others joined to revenge the killing of close family members by fighters from all sides including government soldiers • some ex-combatants joined the fighting because they were tired of carrying looted materials or taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 11 3) strategic recommendations the ex-combatants, especially those who are disabled and had come from the warring factions, are no longer in the mathematics associated with post-war assistance to fighters. the national bureau of veterans affairs caters exclusively to former armed forces of liberia (afl) fighters. there is no provision for free medical service. the afl still maintains a medical unit but does not have the mandate to give free treatment to disabled ex-fighters. an elaborate plan for the construction of a veterans hospital never got off the blueprint. aside from their inability to provide basic needs for themselves, disabled ex-combatants as well as their civilian victims need support to upkeep and educate their children. the need for conducting a census of those who became disabled by the war, ex-combatants as well as their victims, was underscored. women in this category were in significant number and are grappling with life‟s challenges. their leadership is calling for reparation for these innocent people and they have been advocating for this since the days of the trc, the truth and reconciliation commission, enacted by the parliament in 2005 but nothing has materialized. some disabled could be trained to perform a variety of tasks for their sustenance and for the promotion of national peace and security. they could be prepared to serve as receptionists, ticket sellers for the lma, the liberia marketing association, at city parking services, car washers and the like. discussion and recommendations certainly an explorative investigation as presented here does not allow generalizingthe results. however even the limited information collected indicates a major deficit in dealing with the sequelae of the liberian civil war. the hardship imposed on the disabled by the very nature of their disabilities is exacerbated by the lack of opportunities for gainful employment to match their various forms of disabilities and skills, the uncertain source of daily meal and sometimes hostile attitude from some of the community members. this investigation,however underlines the need to execute a more representative study including ammunition for fighters through long distances • nearly all the former fighters interviewed expressed their desire to be trained in several areas of life skills • a vast majority of the ex-combatants are living from begging in the streets. • several ex-combatants are concerned about the education of their children and are asking for educational support for them • ex-combatants want to serve as peace ambassadors and are requesting to be trained to serve as counsellors for other youths to deter them from engaging in violent activities and prevent war in this nation • those from factions feel that government cares for former afl soldiers and discriminates those from other warring factions • the lack of housing for ex-combatants with war related infirmities is of paramount concern to them • the ex-combatants feel that the ddrr program did not achieve its objectives because it was poorly planned and implemented in the rush • in the communities, they are stigmatized. they are blamed as people who brought suffering to their own people. • they are denied job opportunities even when the job requires only elementary school knowledge • they are discriminated against even by taxicabs especially if they carry crutches. • the key informants are calling for establishment of trust fund for survivors of the civil war who are disabled. taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 12 the disabled war veterans as well as their victims, a study which would allow representative data and their advanced qualitative and quantitative analysis. the present publication can only serve as a trigger. nevertheless the findings of the study demonstrate that the ex-combatants of the civil war and even more the disabled civilian victims are forgotten not only by the government of liberia, but also by aid agencies. the post-war status of the ex-combatants was not factored into the transitional arrangements such as the ddrr program for the combatants‟ return to civilian lifeconfirming an earlier analysis of 2007 (6). if government and the nation at large continue to ignore the plight of these sizable population groups, the security of the nation will remain fragile(7) and national reconciliation will be elusive and unachievable. it is therefore recommended with priority that: • the government of liberia revisits or reforms the national bureau of veteran affairs to include the disabled ex-combatants of all former warring factions. • the proposed veterans hospital be erected as planned to cater to the health needs of active service personnel, veterans of the civil war and disabled ex-combatants of former warring factions for whom no health service is available. while this is being done, it is recommended that the mandate of the afl medical unit be expanded to provide free medical service to the disabled ex-fighters and war victims. • a national census of disabled ex-combatants is executed, an imperative about peace building in the aftermath of the civil crisis. this exercise would provide a thorough needs assessment that will put into place client-responsive actions that promote peace building, reconciliation and inclusiveness of those who are disabled by the war either during active combat or civilians as a result of inadvertent explosions and wanton acts of cruelty (8). • arrangements be made for a minimal (financial) survival package for each disabled ex combatant which can enable them to afford at least a meal a day so that they will be able to contribute to national peace and reconciliation efforts. furthermore it is highly recommended that: • some low cost housing arrangement be put into place for all disabled victims of the war. • carefully designedlife skills training programs that are effective and efficient to make ex combatants marketable or capable of sustaining themselves instead of begging in the streets. • continued education programs for ex-combatants who have dropped out of school due to lack of support and are desirous of learning be established. • scholarship programs and tuition support for children of war victimsare put in place. references 1. gerdes f. civil war and state formation, the political economy of war and peace in liberia. campus frankfurt/new york; 2013. 2. lord je, stein ma: peacebuilding and reintegrating ex-combatants with disabilities. the international journal of human rightsvol. 19/3,2015. http://www.tandfonline.com/doi/full/10.1080/13642987.2015.1031515?src=recsys. 3. harrell mc, bradley ma. data collection methods semi-structured interviews and focus groups. rand corporation: santa monica, ca: 2009. http://www.rand.org/content/dam/rand/pubs/technical_reports/2009/rand_tr718.p df. 4. bloomfield s. liberia's amputee footballers: from civil war to african champions their injuries are a painful reminder of a bitter conflict, but this football team is http://www.tandfonline.com/doi/full/10.1080/13642987.2015.1031515?src=recsys� http://www.tandfonline.com/doi/full/10.1080/13642987.2015.1031515?src=recsys� http://www.tandfonline.com/doi/full/10.1080/13642987.2015.1031515?src=recsys� http://www.rand.org/content/dam/rand/pubs/technical_reports/2009/rand_tr718.p� http://www.rand.org/content/dam/rand/pubs/technical_reports/2009/rand_tr718.p� http://www.rand.org/content/dam/rand/pubs/technical_reports/2009/rand_tr718.p� taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 13 bringing pride to the country. the observer, 10 january 2010. https://www.theguardian.com/sport/2010/jan/10/liberia-amputee-football. 5. international labour office, programme on crisis response and reconstruction:red shoes experiences of girl-combatants in liberia. report coordinated by irma specht, geneva; 2017. http://www.ilo.org/wcmsp5/groups/public/@ed_emp/@emp_ent/@ifp_crisis/docume nts/publication/wcms_116435.pdf. 6. jennings km.the struggle to satisfy: ddr through the eyes of ex-combatants in liberia. international peacekeepingvol. 14/2,2007. http://www.tandfonline.com/doi/full/10.1080/13533310601150800?scroll=top&need access=true. 7. wiegink n.former military networks a threat to peace? the demobilisation and remobilization of renamo in central mozambique. stability: international journal of security and development. 4/1, 2015; p.art. 56. doi: http://doi.org/10.5334/sta.gk. 8. johnson k, asher j, rosborough s, raja a, panjabi r, beadling c, lawry l. association of combatant status and sexual violence with health and mental health outcomes in post-conflictliberia. jama 2008;300:676-90. doi: 10.1001/jama.300.6.676. © 2017 taylor; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.theguardian.com/sport/2010/jan/10/liberia-amputee-football� http://www.theguardian.com/sport/2010/jan/10/liberia-amputee-football� http://www.ilo.org/wcmsp5/groups/public/%40ed_emp/%40emp_ent/%40ifp_crisis/docume� http://www.ilo.org/wcmsp5/groups/public/%40ed_emp/%40emp_ent/%40ifp_crisis/docume� http://www.ilo.org/wcmsp5/groups/public/%40ed_emp/%40emp_ent/%40ifp_crisis/docume� http://www.tandfonline.com/doi/full/10.1080/13533310601150800?scroll=top&amp;need� http://www.tandfonline.com/doi/full/10.1080/13533310601150800?scroll=top&amp;need� http://www.tandfonline.com/doi/full/10.1080/13533310601150800?scroll=top&amp;need� http://doi.org/10.5334/sta.gk� https://www.ncbi.nlm.nih.gov/pubmed/?term=johnson%20k%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=johnson%20k%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=rosborough%20s%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=raja%20a%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=raja%20a%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=raja%20a%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=beadling%20c%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=beadling%20c%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/18698066� http://creativecommons.org/licenses/by/3.0)� original research aloysius p. taylor1 1 affiliation: independent consultant abstract conflicts of interest:none. foreword introduction methods study population focus group discussions key-informant interviews information processing results the focus group interviews (fdg) figure 1. disabled war combatants 1017 perspectives of key informants discussion and recommendations references burazeri g, laaser u. health status of the populations in the western balkans region (editorial). seejph 2021, posted: 11 march 2021. doi: 10.11576/seejph-4232 p a g e 1 | 3 editorial health status of the populations in the western balkans region genc burazeri1,2, ulrich laaser3 1 department of public health, faculty of medicine, university of medicine, tirana, albania; 2 department of international health, school caphri (care and public health research institute), maastricht university, maastricht, the netherlands; 3 section of international health, faulty of health sciences, university of bielefeld, bielefeld, germany. corresponding author: genc burazeri, university of medicine, tirana; address: rr. “dibres”, no. 371, tirana, albania; telephone: 00355674077260; email: genc.burazeri@maastrichtuniversity.nl burazeri g, laaser u. health status of the populations in the western balkans region (editorial). seejph 2021, posted: 11 march 2021. doi: 10.11576/seejph-4232 p a g e 2 | 3 for more than twenty years by now, the countries of the western balkans have enjoyed peace after a terrifying warfare in the nineties of the last century. it is time to look at the progress made since. all countries in the western balkans region are undergoing deep reforms aiming at accession to the european union (eu) which is a priority and a key policy driver for all sectors. albania, north macedonia, montenegro, and serbia are currently candidate countries (1). conversely, bosnia and herzegovina and kosovo are potential candidate countries with a prospect for eu accession in the future (1). regarding the health domain, countries report on acquis, which includes a chapter on consumer and health protection (2,3). the eu commission monitors these criteria in line with the administrative capacities of each country in their respective stages of the accession process (4). health status of the populations in the western balkans region is characterized by an excessive mortality compared with the eu average (5). life expectancy in the western balkan countries ranges from 76.3 years in serbia (the lowest) to 77.3 years in bosnia and herzegovina (the highest), whereas the average value in the eu countries in 2017 was 80.9 years (5). according to the global burden of disease (gbd) estimates (6), the age-standardized all-cause mortality rate in albania in 2019 was the lowest in the balkans region (about 575 deaths per 100,000 population), whereas in north macedonia it was the highest (around 929 deaths per 100,000 population). however, the overall mortality rates have declined steadily in all balkan countries in the past decade (figure 1). figure 1. age-standardized all-cause mortality rate (deaths per 100,000 population) in the western balkan countries in the past three decades [source: institute for health metrics and evaluation http://ghdx.healthdata.org/gbd-results-tool (6)] the vast majority of mortality is due to noncommunicable diseases (ncds), which explain from 93% of all deaths in albania (the lowest ncd share) to more than 95% in serbia (the highest) (6). age-standardized mortality rate due to cardiovascular diseases in albania bosnia-herzegovina montenegro serbia north macedonia http://ghdx.healthdata.org/gbd-results-tool burazeri g, laaser u. health status of the populations in the western balkans region (editorial). seejph 2021, posted: 11 march 2021. doi: 10.11576/seejph-4232 p a g e 3 | 3 © 2021 burazeri et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 2019 was the lowest in albania (estimated at 314 deaths per 100,000 population) and the highest in north macedonia (569 per 100,000 population) (6). for the same year, the age-standardized mortality rate due to neoplasms was the lowest in albania (113 deaths per 100,000 population) and the highest in serbia (184 per 100,000 population) (6). on the other hand, the age-standardized mortality rate from diabetes in 2019 was estimated at only 4 deaths per 100,000 in albania (the lowest in the region), but more than 38 deaths per 100,000 population in bosnia and herzegovina (the highest) (6). regarding the universal health coverage (uhc) index reported by the world health organization (who), the service coverage index in 2017 ranged from 59 in albania (the lowest in the region) to 72 in north macedonia (the highest) (5). however, the coronavirus disease (covid19) pandemic has undermined the health systems and uhc reforms in all countries of the western balkans region, similar to the rest of the world. the excessive mortality and morbidity associated with covid-19 in the past year has highlighted the lack of preparedness of most of health systems in the region, influencing rather negatively the achievement of the sustainable development goal for health (sdg 3) (5). there is an urgent need to increase investments in order to strengthen health systems and improve the service coverage in all countries of the western balkans to face the current health challenges imposed by the ongoing corona crisis. references 1. european commission. candidate countries and potential candidates. https://ec.europa.eu/environment/enlarg/candidates.htm#:~:text=albania%2c%20the%20republic%20of%20north,possible%20request%20for%20transition%20periods (accessed: february 26, 2021). 2. mckee m, maclehose l and nolte e. health policy and european union enlargement. open university press; 2004. 3. grabbe h. european union conditionality and the acquis communautaire. int polit sci rev 2002;23:24968. 4. copeland n. the european union accession procedure; 2013. https://www.europarl.europa.eu/regdata/bibliotheque/briefing/2013/130437/ldm_bri(2013)1 30437_rev3_en.pdf (accessed: february 26, 2021). 5. world health organization. world health statistics 2020: monitoring health for the sdgs, sustainable development goals. geneva: world health organization; 2020. https://apps.who.int/iris/bitstream/handle/10665/332070/9789240005105eng.pdf (accessed: february 26, 2021). 6. institute for health metrics and evaluation (ihme). global burden of disease estimates. http://ghdx.healthdata.org/gbd-results-tool (accessed: february 26, 2021). ____________________________________________________________________________ http://ghdx.healthdata.org/gbd-results-tool http://ghdx.healthdata.org/gbd-results-tool arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 1 original research an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity luz arenas-monreal1, lilian e pacheco-magana1, celina rueda-neria1, josue carrilloestrada1, margarita marquez-serrano1, laura magana-valladares2, marta riverapasquel3 1 centre for research in health systems, national institute of public health, cuernavaca, méxico; 2 academic secretariat, national institute of public health, cuernavaca, méxico; 3 centre for research in nutrition and health, national institute of public health, cuernavaca, méxico. corresponding author: luz arenas-monreal address: ave universidad 655 santa maría ahuacatitlán, cuernavaca, morelos. méxico cp 62100; telephone: (777)3293000 (ext: 5223); e-mail: luz.arenas@insp.mx arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 2 abstract aim: to present the results of a community initiative focused on strengthening physical activity and the consumption of fruits, vegetables and natural water while discouraging the use of highly energetic food and sugary drinks in public schools of morelos. methods: a quasi-experimental study with an educational initiative focused on the school community of two primary schools and two junior high schools. preand-post initiative measurements were made. the study took place in the municipality of yautepec, morelos, mexico, in a rural area and an urban area, from august 2010 to july 2011. results: water consumption among school-aged children increased from 15.1% to 20.1% and soda consumption decreased from 21.4% to 13.2%. a slight increase in the consumption of fruits and vegetables was also measured (oranges, jicamas, bananas, tomatoes, prickly pear pads, lettuces), that are accessible in the region. it was found that the supply of fresh food is limited and that high energy density foods have an oversupply in both study areas. physical activity increased with actions such as football and dancing, in accordance with the baseline measurement. no changes were observed in the nutritional condition of school-aged children (n=150; 13.3% with overweight and 7.3% with emaciation), or in adults who presented a body mass index higher than normal, 60.2% to 88.4%. conclusion: in addition to educational activities, schools need to implement strategies to improve the access and availability of fresh foods while limiting the access of high energydensity foods. keywords: diet, educational initiative, mexico, nutritional condition, school-aged children. conflicts of interest: none. arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 3 introduction currently, the number of mexican children and adolescents with overweight and obesity (o/o) is a public health problem (1), which has increased in school-aged children aged from 5 to 11 years. according to the national nutrition survey (enn in spanish) in 1999, the increase was of 19.5%. the national survey of health and nutrition (ensanut in spanish) in 2006 reached 26%, and the ensanut 2012 went up to 34.4%, representing an increase of over 80% (1-3). the “health in the world 2002” report of the world health organization (who), has pointed out health risks in different continents. in latin america, addictions, blood pressure, low weight, together with overweight and obesity, represent one sixth of the morbidity burden. in this report, different cost-effective actions are mentioned to reduce the risks, such as decreasing salt and saturated fats intake to diminish the risks associated with cardiovascular diseases. it also states that one of the priority actions is to promote healthy environments for children (4). strategies for healthy communities and schools consider that cities, towns and schools are the most adequate spaces to promote healthy lifestyles for the entire population and specifically for school-aged children. since children and young people are in a formative stage of life, schools become an ideal place for educational initiatives, so that they can incorporate knowledge, skills and health practices that not only circumvent risk behaviours, but improve health (5). various studies report educational initiatives aimed at school-aged children in their educational atmosphere. some of these studies focus on increasing the knowledge of schoolaged children in relation to healthy food (6,7). there are also researches about school-aged children’s food intake preferences, which indicate that vegetables are not the food of their choice (8). other initiatives are aimed at increasing school-aged children consumption of fruits, vegetables and reduce the consumption of beverages and high-energy density products and increase physical activity (9-13). some authors mention that in the educational initiatives they have carried out, they focus on the entire school community (school-aged children, parents and teachers) in order to obtain better results and because parents and teachers help shape school-aged children behaviour (9-11). the objective of this manuscript is to present the results of an educational initiative focused on strengthening physical activity and the consumption of fruits, vegetables and natural water, while discouraging the intake of highly energetic food and sugary drinks in the school community of public schools in morelos, mexico. methods a quasi-experimental study through an educational initiative focused on the school community of elementary and junior high schools was implemented. previous and postinitiative measurements were made. the study was conducted in the municipality of yautepec, morelos, in a rural area and an urban area, from august 2010 to july 2011. we employed a convenience sampling (n=150 students and n=178 adults) across rural and urban areas, and applied a pre-post test design based on quantitative and qualitative data. the educational initiative was carried out with students of the 4th, 5th and 6th grades of elementary school, and the 1st, 2nd and 3rd grades of junior high school located within the localities. in addition to school-aged children, teachers, managers and administrative staff of the schools, arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 4 as well as parents were included in order to strengthen the changes proposed for school-aged children and make them sustainable (9-11). tools and techniques for data collection school-aged children the following measurements were taken at the beginning and at the end of the study: weight and height using a standardized anthropometric methodology (14). the weight was measured with an electronic scale (tanita brand, model 1583, tokyo, japan) with capacity of 140 kg and accuracy of 100g. height was measured using a wooden stadiometer with capacity of 2 meters and precision of 1 mm. the ages and dates of birth were provided by the school-aged children and corroborated by their teachers or mothers. anthropometric measurements were taken by the research team, which was previously trained according to standard techniques (15). the anthropometric indicators used to assess the nutritional condition of school-aged children were weight/height and height/age. length and weight data were transformed into zscores by using the who/anthroplus (16). a cut-off of -2.0 sd was used for classifying children as stunted based on individual height-for-age z-scores. a cut-off of +2 sd was used to classify children as overweight or obese, based on individual weight-forheightage-z-scores (bmi)-for-age, according to international standards, sexand agespecific. questionnaires applied at the beginning and at the end of the study included (17): i) dietary information: food frequency questionnaire (ffq). this questionnaire was taken from the school-aged children section of the 2006 national health and nutrition survey, which is validated and was applied in all the regions of mexico. the information was obtained using a 7-day semi-quantitative ffq. for each food item, the number of days of intake per week, times-a-day, portion size (very small, small, medium, large, and very large), and number of portions consumed were asked. the food groups were as follows: milk and dairy, fruits, vegetables, sugar sweetened beverages and sugar-free beverages, water and sweets and candy, as well as consumption of fruits and vegetables; ii) physical activity questionnaire for school-aged children. adults initially, measurements of weight, height and waist and hip circumferences were made. the applied technique was in agreement with lohman and martorell and standardization was according to habicht (6,7). weight and height were measured with the same instruments used with school-aged children. adults’ waist was measured at the midpoint between the lower rib and upper margin of the iliac crest; it was taken with a rigid tape brand “seca” with capacity of 2 meters and precision of 1mm. hip circumference was measured horizontally at the widest portion of the buttocks. the indicators used to assess the nutritional status of adults were the body mass index (bmi) and waist-to-hip ratio (whr) circumference index. the classification used to categorize the bmi was taken from the who standards (18), which identifies four categories: malnutrition (<18.5kg/m2) normal bmi (18.5 to 24.9kg/m2), overweight (25.0 to 29.9 kg/m2), and obesity (≥30.0kg/m2). the classification of the international diabetes federation was used as a reference for the waist circumferences, which defines as cut-off waist circumference of >80 cm for women and >90 cm for men (19). whr was calculated as waist circumference divided by the hip circumference, and a whr ≥0.90 in men or a whr ≥0.85 in women was classified as that representing abdominal obesity (20). arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 5 schools and communities in schools and communities there were carried out: i) observation guides for the ethnographic record; ii) guided focus-group interviews, and; iii) community mapping. arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 6 description of educational activities the educational initiative was based on the paulo freire’s empowerment education theory, which departs of the knowledge, practices and circumstances of the population involved, and secondly is enriched with theory (new knowledge), so that people can make changes in their environment later on (21-23). during the educational sessions with school-aged children, participatory and playful techniques were used to promote collective reflection. the sessions were coordinated by facilitators previously trained and lasted 50 minutes. overall, 15 sessions were held once a week, in each of the school grades (4th, 5th and 6th grades of elementary school and 1st, 2nd and 3rd grades of junior high school). the sessions were divided into two axes: diet and physical activity. under the first axis, the following topics were addressed: a) the healthy eating plate (24); b) the importance of eating fresh fruits and vegetables; c) drinking natural water; d) the damage caused to the human body by high energy density foods and sugary drinks; e) personal commitments to increase the intake of fruits, vegetables and natural water, and; f) actions within their family, school and community for healthy eating. for the second axis, the following topics were addressed: a) the importance of physical activity; b) the damage caused when being sedentary; c) personal commitments to carry out physical activity, and; d) actions within their family, school and community to perform physical activity. school-aged children carried out a series of activities (mural newspaper, school radio, health fairs, community tours, poster competitions, murals, sports tournaments and races within the school and their community) to spread their knowledge and make practical actions, both in their school and in their community. at the end of the educational sessions, a school committee was established in each school in order to address nutrition and physical activity issues. it also carried out advocacy actions with the schools’ directors and local authorities to improve the type of food and beverages that are offered within the educational institutions and the community, as well as various other actions to promote physical activity. workshops with parents were conducted in eight weekly sessions (two hours per week). with teachers and school staff, the workshops were held in four monthly sessions, where each session lasted five hours long. at the end of each workshop, the groups of parents and teachers made commitments to carry out actions aimed at improving diet and physical activity in various fields such as: personal, family, school and community. data analysis quantitative component: for the anthropometric analysis, anthropometric indexes based on the measurements of weight, height and age were used. the indicator used for children, adolescents and adults was the bmi. for the classification of children in various categories, bmi distributions were used as well as the criteria proposed by the international obesity task force (iotf). this system identifies specific bmi breakpoints for each age and gender. the anthroplus program and the stata v13 statistical package were used. univariate and bivariate analyses were obtained from the questionnaires’ data. measures of central tendency were used for numerical variables, whereas frequency distributions were used for categorical variables. percentages were analyzed and described at the beginning and at the end of the arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 7 initiative. the following statistical programs were used for the analysis: stata v13, excel 2007 and winepi. qualitative component: systematization of community mapping, ethnographic records and focus groups. results the analysis was performed with 159 school-aged children with complete questionnaire data: food intake frequency, anthropometry, socio-demographic characteristics, and physical activity (preand post-intervention). mean age was 12.3±1.9 years. anthropometric data were presented with 150 school-aged children. there were no substantial changes in the nutritional condition (table 1). table 1. school-aged children anthropometry: body mass index (bmi) by community according to gender (percentages) parameter rural urban total men women men women (n=150) (n=17) (n=19) (n=59) (n=55) overweight pre 13.3 17.7 21.1 6.8 16.4 post 13.3 17.7 15.8 11.9 12.7 obesity pre 1.3 5.9 0.0 1.7 0.0 post 2.0 5.9 0.0 1.7 1.8 emaciation pre 7.3 11.8 15.8 3.4 7.3 post 7.3 11.8 15.8 3.4 7.3 the mean bmi in the pre-intervention phase was 19.4±3.8, whereas in the post-intervention phase it was 20.5±4.0. it was found that most of the adult population was above the normal range of the bmi. in the rural community (n=121), it was found that bmi was between 60.2% (community groups) and 85% (parents) above the cut-off that is considered adequate. in the urban community (n=77), bmi ranged from 69.8% (community groups) and 91.7% (parents). the results for teachers in rural schools were: bmi above normal in 88% of them. in urban schools it was 57.1% above the normal bmi. in 87% of rural schools parents, a whr≥0.85 was found and 90.5% of them had a >80 cm waist circumference. parents in urban areas showed 83.3% whr ≥0.85 and a >80 cm waist circumference (data not shown). consumption changes of drinks, fruits, vegetables and highly energetic food natural water consumption increased (not significantly) in school-aged children (from 15.1% to 20.1%) in a 2-4 day range per week. soda consumption significantly decreased in schoolaged children who consumed it daily (from 21.4% to 13.2%) and significantly increased in those who never consumed it or did it once a week (from 8.2% to 9.4% for the first case and from 30.8% to 42.2% for the second case) (table 2). arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 8 the consumption for at least once a week of some fruits and vegetables, increased regarding products that are common in the area, or inexpensive in certain periods of the year (jicama, apples, pineapples, lettuces, prickly pear pads, cucumbers, squashes and chayote). the intake of oranges, mangos and melons increased from once a week to 2-4 times per week. there was no increase in the consumption of broccoli, cauliflower, cabbage or green beans (figures 1 and 2). no significant gender differences were found in the consumption analysis of water, soda, fruits and vegetables. table 2. beverages’ consumption of school-aged children per community according to intervention phase (percentages) type of beverage total rural urban pre post pre post pre post (n=159) (n=38) (n=121) natural water consumption per week never 3.8 0.6 7.9 0.0 2.4 0.8 1 day 13.8 10.7 21.1 7.9 11.6 11.6 from 2 to 4 days 15.1 20.1 7.9 29.0 17.4 17.4 from 5 to 6 days 15.1 15.7 7.9 18.4 17.4 14.9 7 days 50.9 51.0 52.6 42.1 50.4 53.7 did not answer 1.3 1.9 2.6 2.6 0.8 1.6 soda consumption per week never 8.2 9.4 2.6 10.5 9.9 9.1 1 day 30.8 42.2 42.1 42.1 27.3 42.1 from 2 to 4 days 30.8 23.9 34.2 34.2 29.8 20.7 from 5 to 6 days 8.8 11.3 5.3 7.9 9.9 12.4 7 days 21.4 13.2 15.8 5.3 23.1 15.7 the frequency of fried food consumption decreased slightly (81.2% vs. 79.3%), as well as the intake of industrial pastries. figure 1. school-aged children’s fruit consumption percentage per week days (n=159) arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 9 in schools, teachers promoted the accessibility of natural water for school-aged children, and also made modifications (increased the consumption of fresh food and decreased the intake of high energy density food) in the type of food offered to school-aged children. focus groups with school-aged children reported that they increased natural water and fruits intake. simultaneously, they pointed out that they decreased their sugary drinks and junk food intake. figure 2. school-aged children’ vegetables consumption percentage per week days (n=159) in addition, drinking natural water sweetened with fruits and the absence of soft drinks was observed in the ethnographic record of the rural community: 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 banana day 1 jicama day 1 mango day 1 mango days 2-4 30.8 28.3 34.0 29.6 35.2 37.7 38.4 p e r c e n t fruit/days pre post 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 tomato day 1 squash day 1 cucumber day 1 cucumber days 2-4 32.1 31.4 24.5 28.9 34.6 35.2 30.8 32.7 p e r c e n t vegetables/days pre post arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 10 “according to what was taught, did you do any changes?” –“i drink more water and eat more fruits”. –“we hardly eat junk food now”. –“i barely use valentina sauce and i add less sugar to my coffee or tea” (junior high school and rural elementary school focus group: 33-44). differences were observed in focus groups with teachers, who reported positive changes for the urban elementary school and the rural junior high school: –“did you notice any changes in the children?” –“no doubt there were changes in the children and the school in general. although, as you just said, only 4th, 5th and 6th graders participated in the educational activity, and now the children who were in 4th grade are in 6th grade. there were changes in the school: we no longer sell candy or soft drinks. there has been a change in the food that the school offers to students because of the advices and information that you gave us at the beginning of this project, along with the directions that have been implemented by the basic education institute of the state of morelos” (urban elementary school teachers’ focus group). in community mapping exercises of all groups, it was identified that there is a limited offer of fresh food, fruits and vegetables in both communities, while there is an oversupply of high energy density food and sugary drinks. physical activity and sedentary lifestyle the calculation results of the metabolic rate measurement units (met’s) of the students were as follows: mild met: mean (sd)=17.8±13.7, corresponding to cleaning, games, board games, chats, music, reading and working; moderate met: 18.2±20.2 corresponding to games or sports with a moderate wear out (skating, gym, swimming, riding bikes or motorcycles); vigorous met: 64.4±48.1 including high physical performance activities (soccer, basketball, dancing, running, tennis, and the like). weekly hours dedicated to each of the activities were as follows: mild activities: mean (sd): 6.3±5.2 hours; moderate activities: 3.96±5.1 hours; vigorous activities: 8.5±7.1. there was a significant increase in the school-aged children’s physical activity like playing soccer (14% vs. 27%), and dancing (3% vs. 7%), among other activities, regarding the baseline. sedentary activities decreased: the percentage of students who did not watch movies increased (from 23.9% to 30.8%), or played videogames (from 40.9% to 44.0%), and the hours per week children used to watch movies decreased from 6 to 7 hours per week (from 3.8% to 0.6%). discussion this study fostered changes in the eating habits of school-aged children, drinking natural water and eating more fruits and vegetables, while diminishing sedentary activities from the actions taken by the educational initiative. there were no significant changes between the two anthropometric measurements carried out at the beginning and at the end of the initiative, which happens to be consistent with a study carried out with schoolchildren in hawaii, who showed no significant changes between the measurements of bmi (25). bayer et al. have reported similar results in a longitudinal study arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 11 in which no significant changes were obtained in the bmi (26). in a literature review of research carried out in brazil, it was reported that there was an increase in the level of knowledge and food choices in school-aged children, but there were no changes in the nutritional status (27). it was found that parents and teachers have high percentages of o/o, similar to the percentage reported by ensanut in 2012. this aspect is relevant since it points out that one of the factors associated with school-aged children o/o is the high bmi of their parents (28). due to the above, it is important to incorporate parents and teachers into educational initiatives aimed at school-aged children so that dietary changes can be sustainable. in fact, the incorporation of parents and teachers has been reported in several studies (9-11), and in a study carried out in mexico, the integration of parents and teachers was recommended since the beginning of the study in order to obtain better results (29). the post educational initiative data showed an increase in water consumption and the elimination of sugary drinks at school, which is consistent with the findings of james et al. (30), who reported an increase in water consumption and a reduction of sugary drinks. other studies have reported an increase in healthy eating knowledge but without showing any changes in the nutritional condition, which is similar to the results of this research (6,31), but differs in that school-aged children made changes in their eating habits with the intake of fruits, vegetables and natural water, which was the main objective of the educational initiative. the results obtained in our study are similar to those reported in other studies (9,11-13). changes in the nutritional condition of school-aged children require the link between the educational initiative and structural social actions such as public policies addressing the type of food that is sold at schools and community environments, the production and manufacture of high-energy food and the strict regulations on food advertising aimed at this population. wijesinha-bettoni et al. have reported that, in mexico, educational and health authorities do not have strategies or actions to provide vegetables and fruits to school-age children in food programs carried out in schools (32). the information gathered from the teachers’ focus groups showed that they appreciated the changes in school-aged children involved with the educational initiative, as well as their commitment and concern for school’s diet, which is similar to what schetzina et al. have previously reported (33). sedentary activities dropped after the initiative, which coincides with veugelers et al. (34), and lawlor et al. (11), who reported similar results in their studies. the limitations of this study were: the educational initiative was targeted for the 4th, 5th and 6th graders; the implementation time was short and did not include another school for comparison. other limitations of this study are related to the context of schools and communities, since the supply of fruits and vegetables is low in contrast to the oversupply of products and drinks of high energy density, and there are no spaces to perform physical activity. due to the size of the population included in the study, the results cannot be extrapolated to other regions of the country. conclusions this study shows that, although moderate, it is possible to achieve a change in behaviour with a specific educational initiative. this study should be expanded to increase the number of arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 12 educational sessions with school-aged children and with all members of the school community, to strengthen scientific evidence with diet and physical activity subjects that must be part of the school curriculum, to make progress on the health of this population group. educational activities that modify school-age children’s behaviours are not enough for reducing overweight and obesity. the implementation of diverse and simultaneous actions is needed, such as an increase in the supply access and availability of fresh and healthy foods. this is why the promotion of policies and regulations regarding the type of food and diet at schools and communities is essential. references 1. olaiz-fernández g, rivera-dommarco j, shamah-levy t rr, villalpandohernández s, hernández-ávila m, sepúlveda-amor j. encuesta nacional de salud y nutrición 2006. cuernavaca, méxico: instituto nacional de salud pública; 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evaluación de una intervención educativa para la prevención de la obesidad infantil en escuelas básicas de chile. nutrición hospitalaria 2013;20:1156-64 [in spanish]. 32. wijesinha-bettoni r, orito a, löwik m, mclean c, muehlhoff e. increasing fruit and vegetable consumption among schoolchildren: efforts in middle-income countries. food nutr bull 2013;34:75-94. 33. schetzina ke, dalton wt, lowe ef, azzazy n, vonwerssowetz km, givens c, stern hp. developing a coordinated school health approach to child obesity prevention in rural appalachia: results of focus groups with teachers, parents, and students. rural remote health 2009;9:1157. 34. veugelers p, fitzgerald al. effectiveness of school programs in preventing childhood obesity: a multilevel comparison. am j public health 2005;95:432-5. __________________________________________________________ © 2016 arenas-monreal et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 1 original research introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina martin rusnak1, predrag duric2, denisa jakubcova1, viera rusnakova1, amina obradovic-balihodzic3 1 department of public health, faculty of health sciences and social work, trnava university in trnava, slovakia; 2 institute for global health and development, queen margaret university, edinburgh, uk; 3 institute for public health of canton sarajevo, sarajevo, bosnia and herzegovina. corresponding author: prof. martin rusnak; address: trnava university in trnava, faculty of health sciences and social work, department of public health, univerzitnenamestie 1, 918 43 trnava, slovakia; telephone: +421335939495; e-mail: rusnakm@truni.sk rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 2 abstract aim: the public health reform ii project was implemented in bosnia and herzegovina from december 2011 to december 2013 and was funded by the european union aid schema. the principal aim of the project was to strengthen public health services in the country through improved control of public health threats. workshops for primary care physicians were provided to improve the situation and increase communicable diseases notification rates in eight selected primary care centres. they were followed with visits from the project’s implementing team to verify the effects of trainings. methods: the quality of notifications from physicians in tuzla region was compared before and after the workshop. the timeliness was used as an indicator of quality. medians of timeliness before and after the training were compared by use of wilcoxon test, whereas the averages of timeliness were compared by use of the t-test. results: there were 980 reported cases, 80% before the training and 20% after the training. a lower median of timeliness for all the reported cases after the training was statistically significant compared to the median value before the training. a similar picture was revealed for specific diseases i.e. tuberculosis and enteritis, not so for scarlet fever and scabies. conclusion: the significant reduction in time response between the first symptoms and disease diagnosis indicates the positive impact of the training program in tuzla. hence, primary care physicians provided better quality of reported data after the training course. keywords: bosnia and herzegovina, communicable diseases notification, surveillance, timeliness, tuzla. conflicts of interest: none. acknowledgements: the authors are grateful to all primary care physicians and epidemiologists for their interest in training topics and to the management teams of health care centres for their close cooperation. funding: the data used for this study were collected within the public health reform ii project in bosnia and herzegovina. the project was funded by the european union (eu) as a part of the instrument for pre-accession assistance (ipa). the project was implemented by the consortium comprising the ceu consulting gmbh, wien, austria and diadikasia, athens, greece. rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 3 introduction surveillance on communicable diseases is defined as an ongoing, systematic collection, analysis, interpretation and dissemination of infectious disease data for public health action (1,2). effective surveillance provides information on infections that are the most important causes of illness, disability and death, populations at risk, outbreaks, demands on health care services and effectiveness of control programs so priorities for prevention activities can be determined (3,4). the primary aim of infectious diseases surveillance is to eliminate and eradicate disease incidence with two core functions: early warning system for outbreaks and early response to disease occurrence, known also as epidemiological intelligence. an early warning and response system for the prevention and control of communicable diseases is essential for ensuring public health at the regional, national and global levels. recent cases of severe acute respiratory syndrome, avian influenza, haemorrhagic fevers and especially the threats arising from the possibility of misuse of biological and chemical agents demonstrate the need for an effective system of surveillance and early warning at national level providing a higher data structure (57). the structure of surveillance system is based on the existing legislation, goals and priorities, implementation strategies, identification of stakeholders and their mutual connections, networks and partnerships and also capacity for disease diagnosis. primary care physicians or general practitioners who provide the first contact with a patient play a crucial role in the system. the surveillance system relies on the detection of communicable disease in the patients and disease notification (8-10). the project public health reform ii (europe aid/128400/c/ser/ba)was implemented in bosnia and herzegovina from december 2011 till december 2013 and was funded by the european union aid schema. its principal aim was to strengthen public health services in the country through improved control of public health threats. one of the three components of the project dealt with enhancing and improving assessment of global public health and the system of communicable diseases notification. based on an interest from regional public health authorities, eight of them were selected to participate in some workshops. interviews with general practitioners in each region were taken during the initial phase of the activities. professionals who were interviewed indicated the following challenges for the surveillance system they contribute to: the list of mandatory notified diseases too long, clear case definitions and rationale for surveillance missing, mixture of case-based (11) and syndromic surveillance (12), lack of capacity for cases confirmation and a low level of communication among all surveillance stakeholders. the interview findings led to organization of workshops for primary care physicians in eight primary health care centres during march 2013. the aim was to improve the situation and increase notification rates. it was expected that acquiring deeper insights into the role of disease notification would lead to an increased effectiveness of the surveillance system. outcomes from the effort to improve the quality of notifications in the region of tuzla are reported in this paper. physicians from the county were invited in cooperation with the local public health office and notifications were stored in electronic format. this set-up of the endeavour was uniformly repeated across all the eight regions of bosnia and herzegovina. rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 4 methods study design the study was designed with the aim of revealing potential effects of updating primary care physicians with details of surveillance. thus, a cohort of primary care physicians was used to follow the effects. selection of participants was on the basis of interest. no attempts to randomize were undertaken. the project collected baseline data on notification from the database maintained by the tuzla epidemiologists for year 2012 up to february 2013. the workshop was carried in march 2013. the project attempted to keep contact with participants by email and by personal visits. data from the same source were collected until october 2013. there were 20 participants at the first workshop. estimating the proportion from the total of those who serve the region was not possible because of the lack of data. however, the total number of general practitioners listed in 2014 was 378 physicians (13) as our participants were mostly from offices within the city of tuzla. our estimate is based on the average number of citizens per general practitioners (gps) in the region which is 1263 inhabitants per gp. tuzla has 120441 inhabitants according to the census from 2013, which results in about 95 general practitioners in the city. hence, participation in the workshop represents approximately 21% of all primary care physicians in tuzla. workshop the workshop started with an introduction of aims and expected outcomes. assessment of knowledge on surveillance, disease reporting and attitudes to disease notification followed. principles of communicable disease surveillance and use of case definitions with emphasis on importance of surveillance, techniques, categories and use of the eu case definitions were presented by the project. following discussion dealt with everyday problems and opinions on the system of surveillance as well as the use of the eu case definitions. at the end of the workshop each participant received a copy of the eu case definitions, translated into the local language. local management of primary health care centres and people from epidemiology department were also invited to participate as observers. all data were anonymised and no ethical considerations were identified. data processing the timeliness for notifications obtained from primary care physicians in the town of tuzla was compared before and after the workshop. the timeliness was used as an indicator of quality, as it reflects the speed between steps in a public health surveillance system (14). we chose the following definition of timeliness out of several options: “average time interval between date of onset and date of notification by general practitioners/hospital (by disease, region and surveillance unit). it means time interval between the first symptoms of diseases and reporting”, as defined by the ecdc (15). timeliness was computed from dates stated in individual notifications separately for those noted before and after the workshop. the file was sorted based on the icd-10 diagnosis stated by the physician notifying the case and laboratory confirmation. timeliness was computed for all the diagnoses as well as selected icds for tuberculosis (a15), scarlet fever (a38), enteritis (a09) and scabies (b86). differences in medians before and after the workshop were compared by use of the two-sample wilcoxon rank sum test and signed rank tests and the average values were compared by the two-sample independent t-test from the r project (16), with a level of statistical significance set at p≤0.05. rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 5 results as table 1 illustrates, the sample comprised 980 reported cases, 784 (80%) were before the training and 196 (20%) were reported after the workshop. in total, 147 primary care physicians reported syndromic diagnosis of a communicable disease case (140 before the workshop and 69 after the workshop). table 1. timeliness for notified cases before and after the workshop total sample sample total before after p-value total cases 980 784 196 median 1 6 1 0.030* average 12 20.2 9.2 0.039† maximum minimum 152 0 152 0 133 0 tuberculosis sample total before after p-value total cases 159 99 60 median 58 60 13 0.014* average 57.1 57.6 27 0.019† maximum minimum 152 0 152 0 133 0 enteritis (a09) sample total before after p-value total cases 132 86 46 median 2 3 2 0.035* average 3.7 3.2 2.7 0.065† maximum minimum 41 0 41 0 23 0 scarlet fever (a38) sample total before after p-value total cases 33 17 16 median 0 1 0 0.487* average 1.8 1.6 1.5 0.611† maximum minimum 13 0 13 0 13 0 scabies (b86) sample total before after p-value total cases 98 71 27 median 0 1 0 0.512* average 1.7 3.9 2.7 0.481† maximum minimum 37 0 37 0 13 0 *p-values from wilcoxon test. †p-values from t-test. the difference in medians of timeliness for the total sample (table 1) indicates a reduction from 6 days to 1 day following the workshop; the average of the indicator was reduced to one half. the difference was statistically significant for both the median value (p=0.03) and the mean value (p=0.04). the reduction for notified cases of tuberculosis was more pronounced. it rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 6 went down from a median of 60 days to 13 days (p=0.01), whereas the mean from 57.6 days to 27.0 days and this difference was statistically significant too (p=0.02). the median of timeliness notification for enteritis cases was significantly lowered after the workshop from 3 days to 2 days and this difference was statistically significant (p=0.03). furthermore, this difference was also evident in the comparison of mean values. there were no significant differences in both median and mean values in the timeliness for scarlet fever and scabies before and after the workshop (table 1). discussion the surveillance system in bosnia and herzegovina suffered after the war. it is not stabilized yet, experiencing lack of funds, and it is both organizationally as well as politically divided. it is run on a regional basis, where all primary care physicians are legally required to notify cases based on syndromic diagnosis. such a system is characterized by underreporting due to lack of responsibility and weak supervision from authorities. nevertheless, some authors have demonstrated positive effects of an information campaign on improved notifications in a province of vojvodina, serbia (17) where public health services operate in a similar environment to bosnia and herzegovina. this project in bosnia and herzegovina aimed to increase syndromic notification rates through focused workshops as an example for regional epidemiologists how to continue with improving quality of the surveillance. however, we are aware that the quality consists of a multidimensional character and the timeliness is only one of them. thus, using it for a proxy of quality has its limitations. timeliness of a surveillance system depends on a number of factors and its assessment should include a consideration of how the data will be used and is specific for individual diseases under surveillance (3,18). other indicators of timeliness are also available, such as the average time interval between the date of outbreak notification and the date of the first investigation or proportion of outbreaks notified within 48 hours of detection and the like. obtaining a comprehensive assessment of surveillance quality requires considering more attributes, such as sensitivity, representativeness, usefulness, simplicity, acceptability and flexibility (15,19). therefore, even so, this report demonstrates a significant reduction in notification time between syndromic diagnosis and notifications, and the quality improvement was achieved incompletely. another opened question is whether or not achievements are to be sustained. nevertheless, the changes in notifications were observed after the workshops, based on a follow-up evaluation. our findings are congruent with similar studies where timeliness of disease notification was also followed and reported, before and after some type of intervention with a main aim to reduce time response between two steps in the process of reporting. implementation of electronic laboratory reporting resulted in reducing the median of timeliness to 20 days versus 25 days for non-electronic laboratory reporting (20). another study has demonstrated reduced median of timeliness for notifications by 17 days from the year 2000 to 2006 with a higher rate of notification completeness (21). the importance of increased interaction between primary care physicians and surveillance professionals in notifying communicable diseases was demonstrated in our study, as well. providing case definitions from the eu and along with the local ones was appreciated and probably contributed to improved notification rates. the fact that standard case definition is a premise for data quality and validity (22) was reconfirmed with similar studies reported (23,24), where increased dedication to reporting with data qualitytimeliness and completeness was observed. there are factors which are beyond the influence of physicians, such as patient’s awareness of symptoms, patient’s search for medical care, capacity for case confirmation, rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 7 reporting of laboratory test results back to the physician and to other surveillance stakeholders and public health agencies, which limit the validity of interpretation of the findings, too. another limitation stems from the limited time of the study, where 80% of cases were reported before the workshop and 20% of cases were notified after the workshop. another serious limitation of this study stems from the design used. given the specific audience we worked with, namely general practitioners from various parts of the administrative area, the selection of the study participants was "on the basis of interest". as an europeaid project we had no other choice. therefore, the results based on such constrained participation should not be utilized with valid statistical inference on the level of population. the sample representativeness may seriously affect the generalizability (external validity) of the findings. nevertheless, the study was intended to be more of a pilot nature, demonstrating the feasibility of monitoring the quality of the surveillance system. communicable disease surveillance is the first step towards prevention and it is one of the most important tools used in public health. the surveillance system should be regularly evaluated in terms of usefulness and quality by defined standards and recommendations. in this report, we shared results of the surveillance system evaluation in tuzla, bosnia and herzegovina by using one of quality standardstimeliness of disease notification before the training and after the training. this study underlined the importance and effectiveness of increased communication and feedback 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http://www.episouthnetwork.org/sites/default/files/meeting_report_ebs_march_2013_fina l.pdf (accessed: 29 march, 2017). 12. henning, kj. what is syndromic surveillance. mmwr morb mortal wkly rep 2004;53:7-11. 13. institute for public health fb& h. health statistics annual federation of bosnia and herzegovina. sarajevo; 2013. http://www.zzjzfbih.ba/wpcontent/uploads/2009/02/zdravstveno-statisticki-godisnjak-fbih-20121.pdf (accessed: 29 march, 2017). 14. thackers sb, stroup df. future directions for comprehensive public health surveillance and health information systems in the united states. am j epidemiol 1994;140:383-97. 15. european centre for disease control and prevention. data quality monitoring and surveillance system evaluation – a handbook of methods and applications. stockholm, sweden; 2014. http://ecdc.europa.eu/en/publications/publications/data-qualitymonitoring-surveillance-system-evaluation-sept-2014.pdf (accessed: 29 march, 2017). 16. the r project for statistical computing. vienna, austria.http://www.r-project.org/ (accessed: 29 march, 2017). 17. duric p, ilic s. quality of infectious diseases surveillance in primary health care. sri lank j infect dis 2012;2:37-46. 18. yoo hs, park o, park hk, leeeg, jeong ek, lee jk, et al. timeliness of national notifiable diseases surveillance system in korea: a cross-sectional study. bmc public health 2009;9:93. 19. buehler jw, hopkins sr, overhage jm, sosin dmt. framework for evaluating public health surveillance systems for early detection of outbreaks: recommendations from the cdc working group. mmwr recomm rep 2004;53:1-11. 20. samoff e, fangman mt, fleischauer at, waller ae, macdonald pd. improvements in timeliness resulting from implementation of electronic laboratory reporting and an electronic disease surveillance system. public health rep 2013;128:393-8. 21. jansonn a. timeliness of case reporting in the swedish statutory surveillance of communicable diseases 1998-2002. scand j infect dis 2004;36:865-72. 22. jajosky ra, groseclose s. evaluation of reporting timeliness of public health surveillance systems for infectious diseases. bmc public health 2004;4:29. 23. turnberg w, daniell w, duchin j. notifiable infectious disease reporting awareness among physicians and registered nurses in primary care and emergency department settings. am j infect control 2010;38:410-13. 24. keramarou m, evans mr. completeness of infectious disease notification in the united kingdom: a systematic review. j infect 2012;64:555-64. ______________________________________________________________________________________ http://www.episouthnetwork.org/sites/default/files/meeting_report_ebs_march_2013_final.pdf http://www.episouthnetwork.org/sites/default/files/meeting_report_ebs_march_2013_final.pdf http://www.zzjzfbih.ba/wp-content/uploads/2009/02/zdravstveno-statisticki-godisnjak-fbih-20121.pdf http://www.zzjzfbih.ba/wp-content/uploads/2009/02/zdravstveno-statisticki-godisnjak-fbih-20121.pdf http://ecdc.europa.eu/en/publications/publications/data-quality-monitoring-surveillance-system-evaluation-sept-2014.pdf http://ecdc.europa.eu/en/publications/publications/data-quality-monitoring-surveillance-system-evaluation-sept-2014.pdf http://www.r-project.org/ rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 9 © 2017 rusnak; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 1 review article towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights george r. lueddeke 1 1 consultant in higher and medical education, united kingdom. corresponding author: george r. lueddeke phd, consultant in higher and medical education; address: 9 lakeland gardens, southampton, hampshire, so40 4xg, united kingdom; e-mail: glueddeke@aol.com lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 2 abstract following the millennium summit of the united nations in 2000, the adoption of the united nations (un) millennium declaration by 189 nations, including the eight millennium development goals (mdgs), has been hailed as a unique achievement in international development. although the mdgs have raised the profile of global health, particularly in lowand middle-income countries, underpinned by the urgent need to address poverty worldwide, progress has been uneven both between and within countries. with over one billion people, africa is a case in point. aside from children completing a full course in primary school and achieving gender equality in primary school, none of the twelve main targets set for ss africa has been met. a key reason suggested for this lack of progress is that the mdgs fall far short in terms of addressing the broader concept of development encapsulated in the millennium declaration, which includes human rights, equity, democracy, and governance. to strengthen the likelihood of realizing the post-2015 sustainable development goals (sdgs), particularly with regard to “planet and population” health and well-being , un and other decision-makers are urged to consider the adoption of an integrated sdg framework that is based on (i) a vision of global justice underpinned by peace, security and basic human rights; (ii) the development of interdependent and interconnected strategies for each of the eleven thematic indicators identified in the un document the world we want; and (iii) the application of guiding principles to measure the impact of sdg strategies in terms of holism, equity, sustainability, ownership, and global obligation. while current discussions on the sdgs are making progress in a number of areas, the need for integration of these around a common global vision and purpose seems especially crucial to avoid mdg shortcomings. keywords: global justice, human rights, mdgs, peace, sdgs, security, sustainable development. conflict of interest: none. acknowledgement: appreciation is extended to springer publishing company for allowing the pre-publication of this section of the forthcoming book entitled global population health and well-being in the 21 st century: towards a new worldview with regard to potentially informing on-going and future discussions relating to the mdgs/sdgs. http://en.wikipedia.org/wiki/millennium_summit http://en.wikipedia.org/wiki/united_nations http://en.wikipedia.org/wiki/united_nations_millennium_declaration http://en.wikipedia.org/wiki/united_nations_millennium_declaration lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 3 “the adoption of the millennium declaration in 2000 by all united nations member states marked an historic moment, as world leaders committed to tackle extreme poverty in its many dimensions and create a better life for everyone” (1). the eight millennium development goals (mdgs) and indicators (2), “arguably, the most politically important pact ever made for international development”, (3) were adopted on a voluntary basis by 189 nations to “free a major portion of humanity from the shackles of extreme poverty, hunger, illiteracy and disease” (4), several recognizing fundamental human rights, such as health and education, to be achieved by 2015. in the foreword to the “millennium development goals report 2013” (5), ban ki-moon, secretary-general of the united nations (un), asserts that “[t]he millennium development goals (mdgs) have been the most successful global anti-poverty push in history”. he further adds: “[t]here have been visible improvements in all health areas as well as primary education.” progress on the millennium development goals according to who director-general, dr margaret chan, while “[a]ll eight of the mdgs have consequences for health”, three put health at front and centre – they concern child health (mdg 4), maternal health (mdg 5), and the control of hiv/aids, malaria, tuberculosis and other major communicable diseases (mdg 6) ” (6). mdg 1, “eradicating extreme poverty and hunger,” is on course to being achieved and has “fallen to under half of its 1990 value” (3), but remains a very serious problem in oceanian nations, according to world bank estimates. aside from “north korea and somalia,” where “the poor are getting poorer,” matt ridley in his article, „start spreading the good news on equality,‟ observes that global income inequality is “plunging downwards.”(7). from a mdg perspective, professors ulrich laaser and helmut brand point out these advances cannot be attributed to mdg commitments per se (8). their analysis shows that “the goal of 21% living below the poverty line defined as 1.25 usd/day was within reach in 2005. however, this was calculated from a baseline set at 1990, i.e., a decade before the mdgs were declared. if one compares the progress between 1990 and 1999 of 11 percentage points to the progress between 1999 and 2005 of 6 percentage points, then it becomes apparent that the pace of development has been quite similar before and after the mdg commitment in the year 2000” (8). in addition, the authors highlight “the largest chunk of progress is due to the over-achievement of china, not only halving but quartering its poorest population. the same argument can be made for malnutrition, according to the authors, standing at “19.8% in the developing countries in 1990 coming down to 16.8 in 1995 and remaining stagnant at 15.5% in 2006. however, the sheer numbers of malnourished remain stable at 848 million in 1990 vs. 850 in 2008. in sub-saharan africa, (ss africa) the numbers even increased in the last period (2003–2008) from 211 to 231 million” (9). reducing “by half the proportion of people without sustainable “access to drinking water has been achieved” (3), although the number of people without a “safe drinking water source” is still steadily increasing, and by mid-2014 there were close to 800,000 deaths from water-related diseases (10), more than 10 percent of those who do not have access to safe water. in terms of mdg 2, “[s]ignificant steps towards achieving universal primary education have also been made with “[m]ore than 9 million children … enrolled in primary education and more than 720, 000 primary school teachers have received training (2004-2009)” (11). progress has been slowest in the ss africa as well as the middle east and north africa lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 4 regions. however, according to the european union „gender equality‟ report, “the heavy focus on enrolment rates has come at the cost of educational quality and retention disproportionately affecting girls” (11). furthermore, the report underlines that “[s]econdary school completion is particularly important for gender equality and should command increasing attention.” the aim of mdg 3 is “[t]o promote gender equality and empower women”. and, while the targets and indicators within mdg 3 are important they were, according to the european union study (11), “narrowly defined,” and along with most other mdgs, “[p]rogress has been uneven both between and within countries, and indicators were inadequate to capture the lagging behind of the most marginalised groups and those facing multiple discrimination.” all ss african countries are lagging behind the mdgs, especially with regard to mdg 4 “to reduce child mortality” and mdg 5 on maternal mortality which calls for “a reduction in the number of child deaths from 12 million in 1990 to fewer than 4 million by 2015” (11). and, although “[a]ll regions have made progress, with the highest reductions in eastern asia (69%), northern africa (66%) and southern asia (64%)” (11) since the turn of the millennium progress toward mdg 4 and 5 is “well below the target to reduce the maternal mortality ratio by three-quarters by 2015” and “[o]n current trends, this is one of the targets least likely to be met by 2015” (11). as shown in figure 1, “significant disparities in infant mortality persist across regions. in sub-saharan africa, one in every 10 children born still dies before their fifth birthday, nearly 16 times the average rate in high-income countries” (12). faster progress in other regions has seen the burden of global under-five deaths shift increasingly to sub-saharan africa. figure 1: number in thousands and percent (of global total) of under-five deaths by region 2012 (12) the approach taken by the partnership for maternal, newborn and child health (pmnch) may hold important lessons for other mdgs (13). the pmnch‟s main aim is to enable lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 5 “partners to share strategies, align objectives and resources, and agree on interventions to achieve more together than they would be able to achieve individually”. partners who have joined from various organizations, including those from “the reproductive, maternal, newborn and child health (rmnch) communities” to form “an alliance of more than 500 members, across seven constituencies: academic, research and teaching institutions; donors and foundations; health-care professionals; multilateral agencies; non-governmental organizations; partner countries; and the private sector”. their evidence-based approach made clear the urgency of their work as studies revealed inter alia that “[n]early nine million children under the age of five die every year, with “[a]round 70% of these early child deaths...due to conditions that could be prevented or treated with access to simple, affordable interventions”. alarmingly, “[o]ver one third of all child deaths are linked to malnutrition” and “[c]hildren in developing countries are ten times more likely to die before the age of five than children in developed countries”. developed within the framework for the „every woman, every child initiative‟(14), their concerted action has been successful and led to the „every newborn action plan‟, which was endorsed by the 194 member-states at the 67 th world health assembly in 2014. the plan now paves “the way for national implementation and monitoring of key strategic actions to improve the health and well-being of newborns and their mothers around the world” (15). translating vision into reality includes establishing “effective quality improvement systems,” “competency-based curricula,” “regulatory frameworks for midwifery and other health care personnel” and “multidisciplinary teams” (15). mdg 6 focuses on combatting “hiv/aids, malaria and other diseases”. michel sidibé, unaids executive director, in his foreword to the “unaids report on the global aids epidemic 2013” (16), reflects that “[o]ver the years, the gloom and disappointments chronicled in the early editions of the unaids have given way to more promising tidings, including historic declines in aids-related deaths and new hiv infections and the mobilisation of unprecedented financing for hiv-related activities in lowand middle-income countries”. in his view much has been achieved since “the dawn of this century” when there was “a lack of critical hiv treatment and prevention tools” which “often hindered efforts to respond effectively to the epidemic”. today, he posits “we have the tools we need to lay the groundwork to end the aids epidemic”. achievements such as “the sharp reductions in the number of children newly infected with hiv” and “life-saving antiretroviral therapy” to the synergistic efforts of diverse can be traced to “stakeholders – the leadership and commitment of national governments, the solidarity of the international community, innovation by programme implementers, the historic advances achieved by the scientific research community and the passionate engagement of civil society, most notably people living with hiv themselves”. as with partnership (pmnch) for maternal, newborn and child health initiative (13), an important element of progressing the mdgs/sdgs lies with forming committed and workable alliances which have a common cause. while acknowledging the significant progress that has been made toward new hiv infections, zero discrimination and zero aids-related deaths, he is concerned that “[i]n several countries that have experienced significant declines in new hiv infections, disturbing signs have emerged of increases in sexual risk behaviours among people”. this ongoing uneasiness was highlighted at the prince mahidol award conference in 2014 in thailand with the overall theme, transformative learning for health equity (17). at this event dr. anthony fauci, director of the us institute of allergy and infectious diseases, outlined the challenges remaining in ending the hiv/aids pandemic, citing that in 2012 lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 6 there were over “70 million total hiv infections; 36 million total aids deaths; 35.5 million people living with aids” killing 1.6 million in 2012 alone; and 2.3 million new hiv infections. the intervention model adopted by the institute places reliance on treatment and prevention with basic and clinical research given highest priority, especially regarding antiretroviral drugs, with 12.7 million people receiving these in 2012 compared to about 200,00 in 2002. and, as mentioned, while treatment is having good results in some areas, preventive measures are faring less well as fewer “than 10 percent of people in the world who are at risk of hiv infection are reached with prevention services.” this low number is disappointing especially after “the global approach to hiv prevention” in the last three decades “has moved from a fragmented one, initiated by different communities affected by hiv, to a unified approach led by international and national organisations and governments” (18). two conclusions that may be drawn from these less-than-satisfactory statistics are, first, that “[e]xpansion of the combination prevention approach is essential to avoid future hiv infections and for the health and well-being of people living with hiv”. and, secondly, that prevention needs to be given much more priority especially in terms of resources for educational measures with a view to “empowering communities who are affected by hiv to deliver the prevention techniques that work for them”. progress with mdg 7, which seeks “to ensure environmental sustainability,” is „sluggish‟ in ss africa, southern and western asia, and oceanian countries. as one example, “[t]he proportion of people with sustainable access to safe drinking water increased from 76% to 89% between 1990 and 2011” but “accounts for just 63% in ss africa” (11). in addition, “while access to sanitation improved from 49 % to over 60%, it remains well below the target of 75%”, and has a major influence “on women and girls, for example, in their ability to go to school and in the prevention of violence. where water sources are still not available, women and girls do most of the collection”. moreover, alarmingly, high rates of deforestation hamper progress with regard to mdg 7. by mid-2014, losses in forest over a six month period were 2,187,086 hectares and land lost to soil erosion 2,944,409 hectares (10). mdg 8 “relates to the need to develop a global partnership for development” but “is conspicuous by the absence of any indicators to monitor progress” (11). this omission is highly significant as “[t]rade agreements, including intellectual property rights, discussed in 4.3, directly impact on the cost and availability of pharmaceutical products and therefore the right to health”. a millennium development goal „report card‟ table 1 shows average ratings of progress toward each of the eight mdg-2015 goals based on an informal survey involving twenty-four members of a universitas 21 health sciences mdg workshop group meeting in dublin, ireland (19). the main focus of the unmdg initiative, which comprises a network of 27 global research-intensive universities, is to facilitate incorporation of the unmdgs (future sdgs) into health care curricula through the use of interprofessional case-study pedagogy. to this end, in the past few years the unmdg team, drawn from members across the world, has conducted workshops in dublin, hong kong, nottingham, melbourne, lund, to name several locations. in addition, members have contributed to global mdg projects focusing on raising awareness about the unmdgs and networking with similar groups. mdgs 3, 6, and 8 received the highest scores but are still well below acceptable levels. mdgs 1, 3, 4 seem to fare slightly better than mdgs 5 and 7. lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 7 s c o r e -c a r d 1 (b e st ) – 5 ( w o r st ) 3 .1 3 .1 2 .8 3 .1 3 .4 2 .9 3 .4 2 .9 r e p o r te d a s o u ts ta n d in g a fr ic a p o v e rt y r is e ; 3 6 c o u n tr ie s (9 0 % o f w o rl d ‟s u n d e rn o u ri sh e d c h il d re n ); 1 o u t o f 8 p e o p le r e m a in h u n g ry ; 2 .5 b il li o n la c k i m p ro v e d s a n it a ti o n f a c il it ie s – 1 b il li o n p ra c ti c e o p e n d e fe c a ti o n , a m a jo r h e a lt h /e n v ir o n m e n ta l h a z a rd . c a . 7 2 m c h il d re n o f p ri m a ry s c h o o l a g e (5 7 % g ir ls ) n o t b e in g e d u c a te d a s o f 2 0 0 5 . f a r m o re w o m e n t h a n m e n w o rl d w id e m o re t h a n 6 0 % a re c o n tr ib u ti n g a s u n p a id f a m il y w o rk e rs ( w o rl d b a n k g ro u p g e n d e r a c ti o n p la n ) a c c e le ra te d i m p ro v e m e n ts n e e d e d u rg e n tl y i n s o u th a si a a n d s u b -s a h a ra n a fr ic a ; c a . 1 0 m c h il d re n < 5 d ie d i n 2 0 0 5 ; m o st d e a th s w e re f ro m p re v e n ta b le c a u se s (2 0 1 4 : 3 .1 m ). p ro b a b ly o n e o f th e l e a st l ik e ly m d g s to b e m e t. n u m e ro u s c a u se s o f m a te rn a l d e a th s re q u ir e a v a ri e ty o f h e a lt h c a re in te rv e n ti o n s to b e m a d e w id e ly a c c e ss ib le . f e w e r th a n 5 0 % o f b ir th s a tt e n d e d i n t h e a fr ic a n w h o r e g io n . a id s i s le a d in g c a u se o f d e a th i n s u b s a h a ra n a fr ic a ( 1 .6 m i n 2 0 0 7 ), c a se s o f h iv /a id s 3 6 m . 3 0 0 t o 5 0 0 m c a se s o f m a la ri a e a c h y e a r le a d in g t o m o re t h a n 1 m d e a th s. t re a tm e n t m e e ts o n ly 3 0 % o f n e e d . w o rl d i s a lr e a d y e x p e ri e n c in g e ff e c ts o f c li m a te c h a n g e . e m p h a si s o n p a rt n e rs h ip s e .g . t h e g lo b a l p a rt n e rs h ip f o r e d u c a ti o n a n d t h e w o rl d b a n k . c u r r e n t 1 9 9 0 -2 0 0 4 : p o v e rt y f e ll f ro m a lm o st a t h ir d to l e ss t h a n a f if th . c h il d re n i n s c h o o l in d e v e lo p in g c o u n tr ie s in c re a se d f ro m 8 0 % 1 9 9 1 t o 8 8 % i n 2 0 0 5 . t id e t u rn in g s lo w ly f o r w o m e n i n t h e la b o u r m a rk e t. s o m e i m p ro v e m e n t in s u rv iv a l ra te s g lo b a ll y . d e a th s o f c h il d re n l e ss t h a n 5 y e a rs o f a g e f e ll f ro m 1 2 m il li o n i n 1 9 9 1 t o 6 .9 m il li o n i n 2 0 0 5 . m o st o f a b o u t 5 0 0 ,0 0 0 w o m e n w h o d ie d u ri n g p re g n a n c y o r c h il d b ir th e v e ry y e a r li v e i n s o u th a si a a n d s u b -s a h a ra n a fr ic a . 2 0 1 2 : o v e r 7 0 m il li o n t o ta l h iv i n fe c ti o n s; 3 6 m il li o n t o ta l a id s d e a th s; 3 5 .5 m il li o n li v in g w it h a id s a n d k il li n g 1 .6 m il li o n ; a n d 2 .3 m il li o n n e w h iv i n fe c ti o n s. c o n ti n u in g l o ss e s o f fo re st s, s p e c ie s, a n d fi sh s to c k s a c ro ss t h e g lo b e . d o n o rs h a v e t o f u lf il t h e ir p le d g e s to m a tc h th e c u rr e n t ra te o f h e a lt h c a re p ro g ra m d e v e lo p m e n t. m d g 1 ) e r a d ic a te p o v e r ty a n d h u n g e r 2 )a c h ie v e u n iv e r sa l p r im a r y e d u c a ti o n 3 ) p r o m o te g e n d e r e q u a li ty 4 ) r e d u c e c h il d m o r ta li ty 5 ) im p r o v e m a te r n a l h e a lt h 6 ) c o m b a t h iv /a id s , m a la r ia , a n d o th e r d is e a se s 7 ) e n su r e e n v ir o n m e n ta l s u st a in a b il it y 8 ) in c r e a se g lo b a l p a r tn e r sh ip f o r d e v e lo p m e n t lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 8 lessons learned from the mdg initiative a key question the who director-general raises in her introduction to the world health report 2013, „research for universal health coverage‟(5), is how lessons learned in other nations can help to reduce deaths everywhere. one answer appears to be making better use of community-based interventions, which according to “randomized controlled trials provide the most persuasive evidence for action in public health”. by 2010, findings from “18 such trials in africa, asia and europe had shown that the participation of outreach workers, lay health workers, community midwives, community and village health workers, and trained birth attendants collectively reduced neonatal deaths by an average of 24%, stillbirths by 16% and perinatal mortality by 20%. maternal illness was also reduced by a quarter. these trials clearly do not give all the answers – for instance, the benefits of these interventions in reducing maternal mortality, as distinct from morbidity, are still unclear – but they are a powerful argument for involving community health workers in the care of mothers and newborn. contributors to a study conducted by the university of london international development centre (lidc) and published with the lancet, „the millennium development goals: a cross-sectoral analysis and principles for goal setting after 2015‟ (3), identify difficulties with the mdgs in four areas: “conceptualisation, execution, ownership, and equity.” in their view, the goals were “too narrow and fragmented, leaving gaps in which other important development objectives are missing”. rather than focusing on the wider vision of the millennium declaration, the mdgs concern only “development and poverty eradication,” not “peace, security and disarmament, and human rights”. moreover, investments have focused on vertical vs horizontal components (e.g. communicable diseases) with “variable effect on improving national health systems”. education targeted mostly primary education and mdg2 “under-develops secondary and tertiary education where substantial improvements income and in health are the greatest”, including the development of skilled workers. fragmentation between such areas as “education, poverty reduction, health and gender” at national and local levels with “responsibilities of different line ministries nationally, subnationally, and locally” [means] “that the potential for simultaneous actions in the same location, working with the same communities and households, is unlikely”. the same separation holds true for environmental sustainability “with potentials for synergies across sectors.” ownership has also been problematical as input from developing countries to the mdg framework “was small...mixed and often weak”, along with “t]erritorial issues with leadership”, with examples from communicable diseases (hiv/aids, tb, malaria), professional groups, the maternal and child health communities, and the pharmaceutical industry. another central issue for the mdgs is equity mainly because in their initial formulation the mdgs targeted poverty reduction and development goals aimed at poor countries rather than “global goals for all countries”, usually associated with economic aspects (e.g. income, education) but also distribution. the main shortcoming of the current mdg framework is that it is concerned “with just adequate provision for some, ignoring the needs of those who are too hard to reach and not addressing the difficulties of inequality in societies that have deleterious consequences for everyone, not only the poorest people”. it is clear that the mdgs have had considerable impact by “focusing resources and efforts on important development goals”, and more generally “in raising public and political interest in the development agenda, engaging for the first time a wide range of sectors and disciplines in a concerted effort”. lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 9 however, in the light of difficulties with „conceptualisation, execution, ownership, and equity‟, there appears to be a need for new mdg directions post-2015. the contributors to the lidc mdg report concluded that “future development goals should be framed by a vision of global justice at the present moment, when there are no appropriate institutions to deliver this vision”. an important feature of their thinking is that “it is important to focus on the choices that are actually on offer in a globally-inter-related world”, including plurality of principles and procedures and “permissibility of partial resolutions (i.e. that making some things a bit better than waiting for the best solutions”. the core of their thinking lies in the definition of „development,‟ which they define “as a dynamic process involving sustainable and equitable access to improving wellbeing”. drawing on amartya sen‟s work, the idea of justice,(20) in which he views wellbeing as a combination of the aspiration that “human lives can go much better”, they agree that “improvement can be brought about through a strengthening of human agency, a person‟s capability (vs capability deprivation) to pursue and realise things that he or she values and has reason to value”, thereby linking “wellbeing with the capability to make choices and act effectively with respect to, for example, health, education, nutrition, employment, security, participation, voice, consumption, and the claiming of rights”. finally, the authors suggest that future developments of millennium goals should follow – and ideally be measured through a lens consisting of five guiding principles:  holism-avoiding “gaps in a development agenda and realising synergies between components, acknowledging that „people‟s wellbeing and capabilities depend on human development, social development and environmental development”.  equity-achieving “the development of a more equitable world, built on more equitable societies in which there are adequate flows of information, understanding, resources, training, and respect to enable diverse individuals to attain a decent quality of life”.  sustainabilitydelivering “an outcome such as wellbeing, in terms of its capacity to persist, and to resist or recover from shocks that affects its productivity” [and] is “both viable in social and economic terms”.  ownership – beginning “from a comprehensive conceptualisation of development and the core development principles proposed to govern both the specifications of development goals and the processes by which they are specified”.  global obligation – arguing “for the importance of a position on global obligation that values human rights with respect to human, social, and environmental development”, ensuring that „concerns with wellbeing are not just limited to the obligations we have to citizens of our own country, but to individuals anywhere”. to a large extent, the lidc report findings are echoed by dr. tewabech bishaw, managing director of the alliance for brain-gain & innovative development and secretary general of the african federation of public health associations (afpha) in ethiopia. in her keynote address at the 7 th public health association of south africa (phasa) conference (2011), entitled „what public health actions are needed in african countries to confront health inequalities?‟ (21), she discusses the gaps that need to be addressed and shares her thoughts on public health actions “that could contribute to redressing existing gaps and inequalities”. with dismay she observes that by 2011 “out of the twelve mdg targets many of the countries in africa have scored positively on only two – children completing a full course in primary school and achieving gender equality in primary school”. calling for urgent action, she also notes that “many of the health problems that developing countries in africa are faced with are preventable. emerging new communicable diseases and expansion of the old due to lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 10 climate change has doubled the challenge. in addition, the increasing burden of non communicable diseases alongside the communicable diseases is further burdening the health system making the situation more challenging. many of the unnecessary and unjustified deaths especially death of newborns, children and mothers could be averted. many young talents are wasted due to poverty, environmental degradation, ill health, under nutrition, lack of access to health services, clean water, hygienic living conditions, education and other essential services. unemployment continues to weaken productive human resources with disabilities worsening the vicious circle of unproductively leading to perpetual poverty”. her recommendations reflect many of the guiding principles of the lidc mdg report for redressing inequalities and other challenges, highlighting especially the importance of health being fundamentally “a human rights issue”. in addition, she advocates the need for prioritizing policy, strategy and action based on accurate analysis of reliable health information and epidemiological data; engaging in collaborative partnerships and networks; promoting good governance and accountability; using national think tank groups; scaling up and sustaining critical intervention for sustainable health development; promoting and supporting problem solving research; and developing and using participatory monitoring and evaluation systems. a theme that weaves through her keynote address is the need to listen to and learn from many voices in trying to address the deep-seated and pressing issues facing africa. her determination is in keeping with professor david griggs, director of the monash sustainability institute (msi) in australia (22). he cites albert einstein, who reportedly „once said that if he had just one hour to find a solution on which his life depended, he would spend the first 55 minutes defining the problem‟, and „once he knew the right question to ask, he could solve the problem in less than five minutes‟. professor griggs emphasizes that “today, humanity faces such a life-threatening problem: how are we to provide adequate nutrition and a decent quality of life to a global population that is set to surpass nine billion by 2050, without irreparably damaging our planetary life-support system?”. it seems highly unlikely that even einstein‟s huge thinking capacity could easily resolve issues facing the planet and its people today. this question is, of course, one of many that confront the post-2015 sdg deliberations. in retrospect, while there is wide variability among global regions with regard to meeting the mdgs, according to some, by and large, they “did a good job in increasing aid spending and led to improved development policies, but left many of the bigger issues unresolved” (23). the main critique of the cross-sectorial analysis is that the mdg goals were “too narrow and fragmented,” and that they concern only “development and poverty eradication not peace, security and human rights.” other weaknesses are that investments focused on vertical vs horizontal components (e.g., communicable diseases) and that education targeted primary education and not secondary and tertiary education. the united nations conference on sustainable development the united nations conference on sustainable development (uncsd) – also known as rio 2012 and rio-20) from 13-22 june 2012, with 192 attending nations and about 45,000 participants made a commitment to the promotion of a sustainable future through sustainable development goals (sdgs) (24). redefining the sdgs as “development that meets the needs of the present while safeguarding earth‟s life‐support system, on which the welfare of current and future generations depends” (25), a group of international scientists go further than focusing just on improving people‟s lives. they posit that “[c]ountries must now link poverty eradication to protection of the lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 11 atmosphere, oceans and land” and propose six sustainable development goals (sdgs); including: goal 1: thriving lives and livelihoods goal 2: sustainable food security goal 3: sustainable water security goal 4: universal clean energy. goal 5: healthy and productive ecosystems goal 6: governance for sustainable societies taking into consideration the latter and other contributions, the mechanism to evolve new sdg goals has been through a two phase process by the un general assembly (unga) open working group (owg), co-chaired by csaba kőrösi, hungary ambassador to the united nations and macharia kamau, kenya ambassador to the united nations: the first phase focused on „stocktaking‟ from march 2013 to february 2014, followed by phase two from february-september 2014 which concentrated on the development of the report for the 68 th meeting of the un general assembly in september 2014 (26). while the deliberations are on-going, the mdg interim report in june 2013 concluded that „wide support‟ exists for a “single post-2015 un development framework containing a single set of goals”, which are universally applicable but adaptable to national priorities (27). in addition, the report proposes “the need for a narrative that frames and motivates the sdgs, in particular to focus on poverty eradication as the overarching objective and central proposal of the goals”. however, while this focus remains crucial, it is vital to emphasise that sustainable global poverty reduction can only be accomplished in a world that makes „peace, security and human rights‟ its core aspiration, as advocated by the contributors of the lidc mdg cross-sectoral analysis (3). these global ideals, so claim lant pritchett, and charles kenny, both senior fellows at harvard‟s center for global development, also recalling the lancet report, could “put into measurable form the high aspirations countries have for the well-being of their citizens” (28), thereby offering “a rationale for upper middle-income engagement with the post-2015 development agenda”, and providing “the rationale for a far broader engagement with development on the behalf of rich countries than attempting to kink progress through aid transfers”. „the world we want‟ however, their proposal may need to remain a future possibility as the un‟s top priorities through „the world we want‟ (29) and „beyond 2015‟ (30) lie with supporting 88 of the poorer countries “to convene national consultations on the post 2015 development agenda.” stakeholder inputs are requested “on current and emerging challenges in respect to eleven defined substantive issues”:  inequalities  health  population dynamics  education  energy  water  environmental sustainability  food security and nutrition  conflict and fragility  growth and employment lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 12  governance the overall aim is to build “a global, multi-stakeholder civil society movement for a legitimate post-2015 framework” (30,31). the national consultations – essentially a “global conversation” – are “organized by un country teams, under the leadership of the un resident coordinator”, and “are working with a wide range of stakeholders including governments, civil society, the private sector, media, universities and think tanks”. to date, over two million have contributed to the exercise, including considerable input through the myworld survey (32). it is pleasing to note the interest taken by the younger generation as 50 percent of the voters to date have been between 16to 30 years of age. their top priority is education (254,505), followed by healthcare (210,550), job opportunities (195,117), honest and responsive government (189,311), protection against crime and violence ( 156,687), and clean water and sanitation (152,434). conciliation resources, a peace-building ngo, reminds us that “war shatters lives. it creates poverty and wastes billions every year. the people living in the midst of the violence often have the greatest insight into its causes. yet they are often excluded from efforts to find a resolution” (33). in relation to the mdgs, dr. teresa dumasy, working on policy change and learning in the field of peace building at conciliation resources, draws attention to the 2011 „world development report‟ (34), which highlighted that “no conflict-affected or fragile state has achieved a single mdg, nor are they expected to do so by 2015. of the 42 countries at the bottom of undp‟s human development index, 29 are fragile states. countries where people are feeling the socially debilitating effects of fragility and conflict have simply been left behind”. she further notes that “[e]xperience shows that the targets set within the current mdgs have not proved sufficiently relevant to those countries grappling with the peace building and state building issues so central to their recovery”. moreover, she posits that the mdgs “speak to the symptoms, rather than the drivers of conflict” (33). referencing a statement by civil society organisations, „bringing peace into the post-2015 development framework: a joint statement by civil society organisations‟ (35), she mentions key elements “that address the fundamental notion of „fairness‟, the absence of which can drive conflict and that should be included in any successor framework”. these goals “are supported by more than 40 governments and multilateral organisations”:  legitimate politics foster inclusive political settlements and conflict resolution;  security establish and strengthen people‟s security;  justice address injustices and increase people‟s access to justice;  economic foundations generate employment and improve livelihoods;  revenues and services manage revenue and build capacity for accountable and fair service delivery. conciliation resources contend that “[t]he post-2015 targets must be much more broadly owned and also relevant to countries affected by fragility and conflict, as they persevere in their efforts to attain lasting peace and a significant reduction in poverty levels”. the importance that conciliation resources places on the causes and consequences of conflicts is echoed by war child international (36), a specialist agency, working in countries devastated by armed conflict such as iraq, afghanistan, dr congo, uganda, central african republic and syria. according to war child international, and as mentioned earlier, without focussing on the plight of children in conflict areas, there is no hope of achieving the mdgs, nor the sdgs, one may add. however, if we are to optimize the success of the post-2015-sdgs, we may lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 13 need to learn to work differently. this message is conveyed by co-founder of war child international, dr. samantha nutt, who, after close to 20 years visiting conflict zones, reflects on shortcomings of international aid, concluding that: “we‟re not spending enough time, effort and resources on the preventive aspects of it: programs that focus on education, people‟s employment and income opportunities for women and young people.... something happens in the news and we throw money at it and a year later we expect it to be better. until you start investing in the local community organizations and addressing these structural deficits, you‟ll always be chasing your tail” (37). her concern with „scaling up‟ community support and development is in keeping with who director-general dr. chan‟s reflections on how mdg/sdg interventions can be improved (5), and will assuredly contribute to “the process of setting the sdg agenda,” discussed at the 67 th world health assembly (wha) in geneva (38). at the latter wha, member states also agreed that health needs to be “at the core of the post-2015 development agenda” including “the unfinished work of the health millennium development goals, newborn health, as well as an increased focus on non-communicable diseases, mental health and neglected tropical diseases along with the importance of universal health coverage and the need to strengthen health systems”. completing the outstanding mdg work is of course of vital importance to ensuring global population health and well-being. however, taking into account lessons learned from the mdgs 2000-2015, achieving the „health‟ goals will depend largely on significant and expeditious progress being made alongside the other ten thematic indicators underpinned by „the world we want‟ initiative. dr. tewabech‟s keynote at the phasa conference is a case in point (21). too little progress has been made since 2000, and some areas have actually worsened despite timely and realistic strategic plans for improving health care. the gap between good intentions, meaningful application and outcomes remains vast, and, as argued compellingly by the london international development centre (3), conciliation resources (33), and war child international (36), the sdgs-2015 need to be conceptualized and enacted through a wider lens that subsumes, expands and interrelates the mdgs in a framework with a view to realizing „fairness‟ and „global justice – underpinned by peace, security and basic human rights‟. as one example, mdg 1 poverty and mdg 3, on gender equality, could become part of the inequalities indicator. it is of course too late from a planning perspective, but recognizing the threats imposed by „modernity‟, discussed in chapter 2.0, an additional thematic indicator could have drawn attention to „modern lifestyle and well-being‟, the probable cause in the rise of non-communicable diseases or conditions. to this end and, as an illustrative example, figure 2 juxtaposes goal guiding principles from the lancet report (3) and eleven indicators that underpin „the world we want‟ (29). emerging indicators, such as population dynamics and growth and employment, would require considerable global analyses of scope, priorities and enabling actions based to a large extent on the mdg experience. lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 14 figure 2. towards an integrated sustainable development goals framework inequalities health population dynamics education energy waterenvironmental sustainability food security and nutrition conflict and fragility growth and employment governance global justice (peace, security & basic human rights) global obligation ownership sustainability equity holism the african ‘health for all people’ campaign universal health coverage (uhc), discussed further in the next section, is about achieving health equity worldwide; it is also, to a large extent, an essential ingredient or „stepping stone‟ of a longer-term global aim for global justice „peace, security, and basic human rights‟. jonathan jay, coordinator of the health for all post-2015 campaign (39), launched in march 2014, commends policymakers for the progress achieved by the mdgs in areas such as „aids, childhood immunization, access to family planning and reproductive healthcare‟, along with helping to usher in a “golden age”. however, he also points out that “the rapid scale-up was leaving people behind”, and that “health inequalities continued to grow, both within and across countries”, (and) “[a]dvances in child survival and maternal care left a concentration of deaths in the poorest regions, with persistent gaps in access”. furthermore, while acknowledging considerable progress with regard to preventing and controlling aids/hivs, “hot spots of increased risk among groups that are marginalized and vulnerable” remain. these health concerns are now also being exacerbated by the increase in “non-communicable diseases”, which he labels a “growing hidden iceberg” in developing countries – so daunting a global health challenge that many key players have been virtually paralyzed. the global civil society campaign, health for all post-2015, that is now underway in ethiopia, nigeria and kenya calls “for an approach that would correct inequities and bring everyone along–ushering not just the next era, but truly a new era in global health”. achieving „a new era in global health‟ echoing the goals of the international scientists (25), according to a global alliance of research institutes, the independent research forum (irf), “sustainable development can only be achieved if four foundations exist” (40):  economic progress  equitable prosperity and opportunity http://www.healthmetricsandevaluation.org/publications/policy-report/financing-global-health-2012-end-golden-age http://www.undp.org/content/undp/en/home/librarypage/mdg/the-millennium-development-goals-report-2013/ http://www.thelancet.com/journals/lancet/article/piis0140-6736%2813%2961349-5/abstract http://healthforallcampaign.org/health-for-all-post-2015/about-the-post-2015-campaign/ http://www.iied.org/think-tank-alliance-identifies-eight-shifts-needed-for-sustainability lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 15  healthy and productive ecosystems  stakeholder engagement and collaboration achieving the sdgs that are more inclusive and integrated in terms of „planet and population‟ sustainability, as indicated in figure 3, according to the irf, will be optimized if eight major shifts take place:  from donor/beneficiary country relationships to meaningful international partnerships  from top-down decision-making to processes that involve everyone;  from economic models that do little to reduce inequalities to those that do;  from business models based on enriching shareholders to models that also benefit society and the environment;  from meeting relatively easy development targets – such as improving access to financial services to actually reducing poverty;  from conducting emergency response in the aftermath of crises to making countries and people resilient before crises occur;  from conducting pilot programmes to scaling-up the programmes that work;  from a single-sectoral approach, such as tackling a water shortage through the water ministry, to involving various sectors, like the agriculture and energy sectors, which also depend on water. bringing “fairness” and “civil society goals” into the development framework unquestionably, in order to meet un and other sdg challenges “[m]uch depends on the fulfilment of mdg-8 – the global partnership for development” (5), rightly recognized as a key factor by un secretary general, ban ki-moon in 2012. these “global partnerships”, he asserts, should stretch beyond volunteerism – and could be greatly enhanced if „fairness‟ and the civil society goals, mentioned previously (35), were simultaneously advanced by global leaders (41-44) – especially by those who place „global justice peace, security and basic human rights‟ ahead of self-interests. with proposed „global justice‟ at its sdg core, supported by a set of eleven thematic indicators to ensure „sustainable development‟, depicted in figure 3, the mdg refrain “progress has been uneven both between and within countries” should no longer be an acceptable option or convenient „escape route‟. the global challenge is huge, but the rewards for this and future generations are much greater. references 1. zagaya. united nation‟s millennium development goals. http://www.zagaya.org/news-and-events/united-nations-millenium-developmentgoals/ (accessed: april 10, 2014). 2. united nations. we can end poverty: millennium development goals and beyond 2015. http://www.un.org/millenniumgoals/ (accessed: january 20, 2014). 3. waage j, banerji r, campbell o, 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this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.thestar.com/life/2011/12/06/why_emergency_help_is_never_enough_in_wartorn_countries.html http://www.thestar.com/life/2011/12/06/why_emergency_help_is_never_enough_in_wartorn_countries.html piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 1 original research trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood giovanni piumatti1 1 department of psychiatry, university of oxford, oxford, uk. corresponding author: giovanni piumatti, phd; address: warneford hospital, ox3 7jx, oxford, uk; telephone: +393335251387; email: giovanni.piumatti@psych.ox.ac.uk piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 2 abstract aim: the aim of this study was to examine how university students’ achievement strategies in an academic context and perceptions of criteria for adulthood relate to life satisfaction trajectories across one year. methods: a convenience sample of 143 young adults 18-28 years (mean age: 20.9±2.7 years; 109 females and 34 males) attending the university of turin in northwest italy completed questionnaires at three points with a six-month interval between each measurement. latent growth curve modelling and latent class growth analysis were used to assess longitudinal changes in life satisfaction and the related heterogeneity within the current sample. results: three trajectories of life satisfaction emerged: high stable (37%), moderate decreasing (57%), and low stable (6%). at every time point high success expectations were related to a high stable life satisfaction trajectory. in turn, those adopting achievement avoidance strategies were more likely to have low-stable or moderately decreasing life satisfaction trajectories. the perception of the criteria deemed important to be defined as adults did not change across time points or across life satisfaction trajectories’ groups. conclusion: these findings suggest that self-reported measures of achievement strategies among university students relate longitudinally to life satisfaction levels. positive and optimistic dimensions of personal striving may be protective factors against the risk of decrease of life satisfaction among university students. keywords: achievement strategies, criteria for adulthood, developmental trajectories, life satisfaction, person-oriented approach. conflicts of interest: none. note of the author: some results of the present paper have been previously presented at the 7th conference of the society for the study of emerging adulthood in miami, florida, october 14-16, 2015. piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 3 introduction according to diener, emmons, larsen, and griffin (1) life satisfaction (ls) is defined as an individual’s overall appraisals of the quality of his or her life. in the social and psychological sciences this construct has become a key variable for analyzing individuals overall subjective well-being (2). longitudinal studies have shown that after adolescence the majority of people experience stability in ls over long periods of times (3). however, depending on the length of time, one may observe short-, intermediateand long-term influences on ls (4). indeed, in the field of life-span research, the development of ls over time has become a very important baseline through which more variegated trajectories of individual development are observed (5). especially among older cohorts (i.e., aged 18 and above), given the relative stable differences in ls between observed latent growth groups in comparison with the more turbulent adolescence years, many have adopted a person-oriented approach (6,7) to describe which other characteristics unite individuals of a certain developmental trajectory of ls. for example, ranta, chow, and salmela-aro (8) have associated trajectories of ls among young adults to their self-perceived financial situation, concluding that positive ls trajectories relate to being in a positive self-perceived financial situation. röcke and lachman (3) observed how to maintain stable trajectories of positive ls individuals need intact social relations as well as a high sense of control. in addition, salmela-aro and tuominen-soini (9) and salmela-aro and tynkkynen (7) found that education achievement during and after secondary education positively correlated with high stable ls. emerging adulthood research proposes that the growing acquisition of maturity regarding adulthood-related duties and roles such as the commitment to life-long relationships or the importance attributed to forming a family are parallel to a stable ls path (10). in general, in the age range 18-30 years, perceiving oneself as an adult correlates to higher levels of ls and positive affect (11). such findings contributed to give credit to the theoretical assumption stating that among young adults the increasing acquisition of an adult identity and the endorsement of adulthood-related criteria are concurrent factors in determining positive outcomes at the individual level, as for example higher ls. at the same time, if we adopt a person-oriented approach to look at this issue, we might expect that others characteristics may define those young adults proceeding through transitions while exhibiting a mature adult identity and high ls. in an academic context, for example, the kinds of cognitive and attributional strategies individuals deploy provide a basis for their success in various situations (12), as well as for the positive development of their well-being (13). accordingly, in the present study we aimed at integrating the research literature on the relationship between the attainment of adult maturity and well-being with indicators of individual achievement strategies typical of life-span studies. more specifically, through a longitudinal approach, we questioned whether university students’ ls changes during a one year period and what kind of trajectories can be found. secondly, we examined young adults’ perception of the criteria deemed important for adulthood and achievement strategies in the academic context in relation to ls trajectories. the italian context university students account for a good proportion of the population aged 18-30 years in italy, although italian national statistics show a steady decrease in the overall university enrolment rates (14). moreover, italy reports one of the highest rates of university withdrawals among oecd members (15), with some regional differences between north and south (with dropout rates being higher in the latter), but overall widespread across the country (16). despite the considerable high social cost related to dropout rates during tertiary education and the interrelation between motivation, education attainment and well-being among young adults piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 4 (17), very few studies have examined from a longitudinal and psychological perspective how self-reported measures of well-being such as ls interact with motivational strategies in an academic context in italy (18). accordingly, the present study aimed to test the specific research hypothesis that positive motivational attitudes in an academic context relate to higher ls levels among young adults attending university and, possibly, to a higher acquisition of adulthood maturity. methods sample the empirical data of the present study were collected through the submission at three time points of an online questionnaire to a convenience sample of university students in the northwestern italian city of turin. participants were reached in various university settings of the faculty of psychology, including libraries, canteens, cafeterias and public leisure spaces. the criteria to take part in the study were being enrolled as a full-time university student, being italian and aged between 18 to 30 years. students provided their email contacts if they were interested in taking part in the study. then, they received a link to the online questionnaire through email. at time 1, 645 individuals (76% females; mean age: 22.1 years) completed the questionnaire. at time 2, six months afterwards, 252 individuals (79% females; mean age: 22.3 years) completed again the same questionnaire. finally, at time 3, twelve months after time 1, 150 individuals (77% females; mean age: 22.1 years) filled in the questionnaire. the very high dropping rate from time 1 to time 2 and time 3 can be explained by the total absence of an incentive for the participants to take part in the study (e.g., money, or school credits). therefore, it is reasonable to imagine that only those personally interested in the topic or in the research itself were willing to fill in the questionnaire. in fact, while the dropping rate from time 1 to time 2 was equal to 61%, from time 2 to time 3 it was equal to 41% (of the total number of participants at time 2), indicating a significant decline in the number of people dropping out. this may be explained by the fact that at time 2 the proportion of participants interested in the research was higher than at time 1. moreover, only the participants who filled in the questionnaire at time 2 were contacted again at time 3. measures life satisfaction ls was measured using the satisfaction with life scale (1). participants rated five items (for example, “i am satisfied with my life”, and “the conditions of my life are excellent”) on a 7point likert-type scale ranging from 1 (totally disagree) to 7 (totally agree). a mean score was calculated for all items. cronbach’s alphas ranged from 0.69 to 0.79 across the three measurement points, indicating a good level of internal consistency with respect to the ls variable. achievement strategies four different types of achievement strategies in an academic context were assessed: success expectation, (cronbach’s alphas ranged from 0.68 to 0.73), measuring the extent to which people expect success and are not anxious about the possibility of failure (4 items, e.g., “when i get ready to start a task, i am usually certain that i will succeed in it”); taskirrelevant behaviour (α from 0.76 to 0.82), measuring the extent to which people tend to behave in a social situation in ways which prevent rather than promote involvement (7 items, e.g., “what often occurs is that i find something else to do when i have a difficult task in front of me”); seeking social support (α from 0.73 to 0.77) measuring the extent to which piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 5 people tend to seek social support from other people (6 items, e.g., “it is not worth complaining to others about your worries”); and avoidance (α from 0.77 to 0.76), measuring the extent to which people have a tendency to avoid social situations and feel anxious and uncomfortable in them (6 items, e.g., “i often feel uncomfortable in a large group of people”). the scales belong to the strategy and attribution questionnaire (19). criteria for adulthood participants rated the importance of 36 criteria for adulthood (20) on their degree of importance on a scale of 1 (not at all important) through 4 (very important). based on previous research (10,20), these criteria were grouped into six categories: interdependence (α from 0.60 to 0.65; 5 items; e.g., “committed to long-term love relationship”), role transitions (α from 0.84 to 0.86; 6 items; e.g., “have at least one child”), norm compliance (α from 0.77 to 0.82; 8 items; e.g., “avoid becoming drunk”), age/biological transitions (α from 0.70 to 0.74; 4 items; e.g., “grow to full height”), legal transitions(α from 0.81 to 0.86; 5 items; e.g., “have obtained license and can drive an automobile”) and family capacities (α from 0.75 to 0.77; 8 items; e.g., “become capable of caring for children”). analysis the analyses followed three steps. first, to examine how ls changes during a one-year period, latent growth curve modelling (lgcm) (21) estimated the average initial level and slope of ls among the participants. the following indicators assessed the goodness-of-fit of the estimated lgcm: χ²-test, the comparative fit index (cfi) with a cut-off value of ≥0 .95, and the standardized root mean square residual (srmr) with a cut-off value of ≤0 .09. subsequently, to evidence whether different types of ls trajectories emerge from the total sample, the analyses of this longitudinal data set extended into latent class growth analysis (lcga) (22). lcga examines unobserved heterogeneity in the development of an outcome over time, by identifying homogeneous subpopulations that differ with respect to their developmental trajectories within the larger heterogeneous population. lcga is exploratory by nature, which means that there are no specific a priori assumptions regarding the exact number of latent classes. when testing lcga models, different class solutions are specified. the best-fitting model is then selected based on the goodness-of-fit indices and theoretical considerations. here, the following goodness-of-fit indices evaluated the models: akaise’s information criteria (aic), bayesian information criteria (bic) and adjusted bayesian information criteria (abic) of the alternative models. entropy values were also examined, with values close to 1 indicating a clear classification. following marsh, lüdtke, trautwein, and morin (18), groups of ≥ 5% of the sample were considered the smallest to give an acceptable solution. practical usefulness, theoretical justification and interpretability of the latent group solutions were also taken into consideration (23). the analyses were controlled for age, gender and self-perceived socio-economic status (participants were asked how they would rate their actual socio-economical position on a scale from 1 – not good at all to 5 – very good). both lgcm and lcga analyses were conducted with the mplus 5.0 statistical software program. at last, one-way analysis of variance (anova) examined if the ls trajectory groups differed in terms of their achievement strategies and importance attributed to criteria for adulthood. post-hoc comparisons using the games-howell test examined differences between groups. piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 6 results development of life satisfaction the specified lgcm with a linear slope for ls change across the three time points fits the data well, χ²=3.99(1), p<0.05; cfi=0.98; srmr=0.04. in particular, while the intercept indicating the initial level of ls was statistically significant, the linear slope was not (intercept m= 3.02, se=0.05, p<0.001; slope m = -0.11, se=0.02, p>0.05). in addition, while the variance of the intercept was significant the variance of the slope was not (intercept variance =0.15, p<0.001; slope variance 0.01, p>0.05). together these results indicate that first, on average, there was no significant longitudinal change in ls across the three measurement points, and second, that there was a significant individual variance in the initial levels but not in the rate of change. thus, the significant heterogeneity among individuals was analyzed further adopting the person-oriented approach of latent class growth models. more specifically, these results suggest that, rather than investigating different rates of longitudinal change in ls within the overall sample, it would be more plausible to observe latent groups exhibiting stable trajectories of ls across time while being concurrently significantly different between each-other from baseline to the last follow-up. identifying life satisfaction trajectories lcga identified three sub-groups of individuals according to their levels of ls across measurement points. table 1 shows the fit indices and class frequencies for different latent class growth solutions. the four-class solution was unacceptable given the presence of a group with zero individuals. the three-class solution was thus the most optimal given the numerical balance of the observed groups and its higher entropy value with respect to the two-class solution (i.e., values closed to zero are indicative of better fit). figure 1 displays the estimated growth curves for the different latent trajectories of ls, whereas table 1 reports lcgm results. figure 1. life satisfaction trajectories (mean values in a scale 1-7) 0 1 2 3 4 5 6 7 t1 life satisfaction t2 life satisfaction t3 life satisfaction high stable (n = 52; 37%) moderate decreasing (n = 82; 57%) low stable (n = 9; 6%) piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 7 table 1. fit indices and class frequencies based on estimated posterior probabilities for latent class growth models of life satisfaction with different numbers of latent trajectory groups number of groups bic abic aic entropy 1 766.94 751.12 752.13 2 (n1 = 69%, n2 = 31%) 684.93 659.62 661.23 .747 3 (n1 = 37%, n2 = 6%, n3 = 57%) 652.44 617.64 619.85 .827 4 (n1 = 6%, n2 = 58%, n3 = 0%, n4 = 36%) 667.33 623.03 625.85 .863 note. bic = bayesian information criteria; abic = adjusted bayesian information criteria; aic = akaike information criteria. the chosen option is marked in bold. the latent trajectories of ls were labelled high stable (37%), moderate decreasing (57%), and low stable (6%). ls mean levels of the high and the low stable trajectory groups remained stable over time. on the other hand, the moderate decreasing group exhibited a significant decrease in ls mean levels over time (see table 2). anova and chi-square tests evidenced how the three sub-groups did not differ according to age, f(2, 150)=0.01, p>0.05, gender, x2 (2, 150)=1.56, p>0.05, and self-perceived socio-economic position, x2 (2, 150)=8.13, p>0.05. table 2. estimation results of the final growth mixture model with five latent classes (unstandardized estimates; standard errors in parentheses) high stable (n=52; 37%) moderate decreasing (n=82; 57%) low stable (n=9; 6%) mean structure level 3.42 (0.05)** 2.83 (0.05)** 1.91 (0.11)** change -.09 (0.06) -.25 (0.05)** -.14 (0.20) note. variance is kept equal across the different latent groups. ** p< .001 differences in achievement strategies and criteria for adulthood the second analytical step consisted of testing whether the three observed ls trajectory groups were significantly different at each time point concerning self-reported achievement strategies outcomes in the academic context and the importance attributed to criteria for adulthood. table 2 reports all effects and pairwise mean comparisons between ls groups. since we did not observe any significant effect of ls trajectory group membership on the mean levels of the importance attributed to the criteria for adulthood, we decided not to report in a table such results for parsimony reasons. on the other hand, it appears clear how the three developmental trajectories groups consistently differed across time points regarding the types of achievement strategies they adopted in their academic activities. more specifically, from time 1 to time 3, the high stable group showed the highest levels of success expectation and the lowest levels of task irrelevant behaviour and avoidance. diametrically opposite was the performance of individuals in the low stable group who consistently showed the lowest levels of success expectation and the highest levels of task irrelevant behaviour and avoidance. finally, the moderate decreasing group reported a stable success expectation over time, but a slight increasing in avoidance. in fact, while at time 1, the avoidance did not differ between the moderate and the high stable group, from time 2 to time 3, individuals in the moderate decreasing group showed the same level of avoidance as the individuals in the low stable group. piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 8 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 9 overall, these results indicate that the types of achievement strategies in the current sample are linked to different ls development trajectories. furthermore, such measures of personal agency did not relate to different perceptions of the criteria deemed important for adulthood, nor the latter seem to correlate with ls developmental trajectories. discussion the current research focused on a longitudinal convenience sample of young adults attending university in the north-western italian city of turin. the person-oriented model tested here provided theoretical evidence of the overtime interconnection between motivational strategies in an academic context and well-being among university students. the main contribution of the present study was the adoption of a person-oriented approach (6) to focus on the issue of the perception of adulthood among young adults. indeed, to date, very few studies (24) have opted not to focus entirely on the relations between singular variables but instead to look at more elaborated systems of individual characteristics to draw a ‘picture’ of different ‘types’ of emerging adults in western societies. moreover, the longitudinal nature of the trajectory analysis contributed to test whether for emerging adults the perception of what it means to be considered adults nowadays is a stable construct over time, even if just across only one-year period. in particular, the latent curve growth analysis implemented here has represented a more fruitful way for examining young adults’ individual development (22). indeed, a single growth trajectory would have oversimplified the heterogeneity of the changes in emerging adults’ life satisfaction over time, as some experience an increase and some a decrease in life satisfaction, although the majority seem to experience a significant stability (7). in this study, it was possible to identify meaningful latent classes of individuals according to the initial levels and the longitudinal changes in their life satisfaction across the three measurement points. adopting this multiple trajectories approach resulted in a model of three developmental trajectories. overall, two major conclusions can be drawn from the present study. first, starting from the non-significant findings, it appeared that the perception of the most important criteria for adulthood (i.e., family capacities, interdependence, norm compliance) are not correlated to life satisfaction trajectories, either low or high. second, achievement strategies reflecting notions of agency were closely linked to life satisfaction, both about initial level and development. the first findings can reasonably be the result of the limited time span across which we aimed at observing developmental changes. indeed, we already know that emerging adults are more prone to change their perception of adulthood especially in correspondence with crucial life events, such as getting married, experience of parenthood, finishing the studies and start working (10,11). therefore, the impossibility to control for such events in the present study or simply the fact that the very small sample did not include a sufficient number of people going through specific transitions’ thresholds, can explain why we did not observe significant differences across developmental groups who instead remained stable in their opinions over the curse of one year. however, we were not just interested in looking at changes, but we argued for stable differences across developmental trajectory groups. again, despite the fact that we observed trajectory groups that showed significant differences in motivational strategies across time, these did not relate to adulthood self-perception. these results might confirm how the major sources of adulthood identity variation over time are significant experiences related to it. the significant differences between groups in terms of achievement strategies suggest that these measures of motivation and life satisfaction are strictly related. specifically, individuals with a high level of positive achievement approach strategies demonstrated high levels of life satisfaction. on the contrary, high levels of avoidance and irrelevant behaviours mostly piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 10 related to low levels of life satisfaction. a closer look revealed that individuals in the moderate decreasing life satisfaction trajectory maintained a more stable level of avoidance over time than the other two groups that both showed instead a decreasing in avoidance. thus, personal strivings and strategies may be protective factors against a decrease in life satisfaction. in summary, the findings from the current study are aligned with previous research work focusing on samples of young adults attending university and evidencing how individuals’ achievement strategies measured during university studies affect subjective well-being outcomes (25,26), including life satisfaction (27,28). in particular, in accordance with our results, success expectations are positively associated with higher satisfaction (29) and poor engagement relate to low well-being (27). these evidences should guide future research with the aim of further investigating the role of different types of agentic personality traits among university students in relation to positive life outcomes and health behaviours as factors strongly related to subjective well-being outcomes. study limitations and conclusions it is important to point out the main limitations of the current study. firstly, owning to the person-oriented statistical approach 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self-perception and life and education satisfaction. int j psychol psychol ther 2015;15:241-57. 29. nurmi je, aunola k, salmela-aro k, lindroos m. the role of success expectation and task-avoidance in academic performance and satisfaction: three studies on antecedents, consequences and correlates. contemp educ psychol 2003;28:59-90. ___________________________________________________________ © 2017 piumatti; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. lueddeke gr. survival: one health, one planet, one future. interview by daniele dionisio. seejph 2019, posted: 16 december 2019. doi 10.4119/seejph-3231 p a g e 1 | 7 book reviews survival: one health, one planet, one future george r. lueddeke interviewed by daniele dionisio re-published with permission from dr. daniele dionisio, member, european parliament working group on innovation, access to medicines and poverty-related diseases, and head of research project: policies for equitable access to health (peah) at: http://www.peah.it/2019/10/interview-survival-one-health-one-planet-one-future-routledge-1stedition-2019/) and https://twitter.com/danieledionisio http://www.peah.it/2019/10/interview-survival-one-health-one-planet-one-future-routledge-1st-edition-2019/ http://www.peah.it/2019/10/interview-survival-one-health-one-planet-one-future-routledge-1st-edition-2019/ https://twitter.com/danieledionisio lueddeke gr. survival: one health, one planet, one future. interview by daniele dionisio. seejph 2019, posted: 16 december 2019. doi 10.4119/seejph-3231 p a g e 2 | 7 ways forward to ensure the sustainability of people and the planet are needed at a time when the interdependencies among humans, animals, plants and the environment are to be recognized as the cornerstone to drive/steer the un 2030 sustainable development goals (sdgs). in this connection, peah had the pleasure to interview dr. george r. lueddeke as the author of the recently published cross-disciplinary book survival: one health, one planet, one future routledge, 1st edition, 2019. including contributions from the world bank, interaction council, chatham house, unesco, world economic forum, the tripartite one health collaboration (un food and agriculture organization, world organisation for animal health and world health organization), one health commission and more this book cuts across sociopolitical, economic and environmental lines. george r. lueddeke consultant in higher and medical education, southampton, uk george r. lueddeke phd med dipl.aves (hon.) is an educational advisor in higher and medical education and chairs the global one health education task force for the one health commission and the one health initiative as well as the international one health for one planet education initiative (1 hope). he has published widely on educational transformation, innovation and leadership and been invited as a plenary speaker to different corners of the world. bio https://www.routledge.com/survival-one-health-one-planet-one-future/lueddeke/p/book/9781138334953 http://www.peah.it/wp-content/uploads/2019/10/lueddeke-06.08.19-gl-short-bio-1.pdf http://www.peah.it/wp-content/uploads/2019/10/lueddeke-pic.png lueddeke gr. survival: one health, one planet, one future. interview by daniele dionisio. seejph 2019, posted: 16 december 2019. doi 10.4119/seejph-3231 p a g e 3 | 7 peah: dr. lueddeke, the international one health for one planet education (1hope) initiative was created to address perhaps the most important social problem of our time: ‘how to change the way humans relate to the planet and each other to ensure a more sustainable future to all life’. on this wavelength, what about the main purpose of your book survival: one health, one planet, one future? lueddeke: the book tries to make sense of the uncertain and tense (“rattling”) times we are experiencing and asserts that the one health & well-being concept (ohwb) that recognises the interdependencies among humans, animals, plants and their shared environment – is critical to safeguarding our future while also providing a “unity around a common purpose” that seems to be missing globally. i prefer the term one health & well-being (vs just ‘one health’) as it emphasises not only the crucial importance of human physical and mental well-being but also the need to strive toward meeting socioeconomic, geopolitical and ecological conditions to ensure the sustainability of all living species and the planet. table of contents: here i also argue that the ohwb approach ought to drive/steer the 17 un-2030 sustainable development goals (sdgs) that were agreed by all 193 member states of the united nations in september 2015. the main aim of the un global goals is to create ‘a more just, sustainable and peaceful world.’ the ohwb perspective needs to inform and encourage decision-makers at all levels – especially civil societyto get behind the un global initiative regardless of ideological persuasion or divisions. the challenge is how to get government, business and civil society behind ohwb and the sdgs across all nations – those that are more economically developed and those that are developing and of course those that are in disarray – many for reasons that defy logic. concentrating on local needs guided by global/national priorities that are in keeping with sustainability values and practices is without a doubt the best way forward. there are about 7.7 billion people on the planet, and it is estimated that there will be over 9.8 billion by 2050 and 11.2 billion in 2100. climate change, urbanisation, pandemics, conflicts (globally we spend over us $7 trillion on war and only $ 3% on peace-c. $6 billion! ) and food security are main issues we need to tackle now and feature in the book along with health care – perhaps prompting reconsideration of the term “public health” and widening its remit to the more inclusive “global health and well-being” as the focus must shift to ecocentrism. changing the way we think and behave should no longer be a question of why but how -although our main concerns continue to be political and economic rather than sustaining the planet. populism, nationalism and isolationism are the antithesis of the paths toward which we ought to be striving. the root causes of these movements need to https://www.routledge.com/survival-one-health-one-planet-one-future/lueddeke/p/book/9781138334953 https://www.routledge.com/survival-one-health-one-planet-one-future/lueddeke/p/book/9781138334953 https://www.routledge.com/survival-one-health-one-planet-one-future/lueddeke/p/book/9781138334953 http://www.peah.it/wp-content/uploads/2019/10/lueddeke-cover-image.jpg lueddeke gr. survival: one health, one planet, one future. interview by daniele dionisio. seejph 2019, posted: 16 december 2019. doi 10.4119/seejph-3231 p a g e 4 | 7 be investigated and solutions found that ensure global equity, peace and sustainability. it may be important to remind global decision-makers that if we fail to save the planet none of the other human activities will matter. shelley’s poem ozymandias (1818) comes to mind. i am also reminded of a quote by economist and author john kenneth galbraith ‘a nuclear war does not defend a country and it does not defend a system …not even the most accomplished ideologue will be able to tell the difference between the ashes of capitalism and the ashes of communism.’ peah: the book highlights two of our greatest social problems: changing the way we relate to the planet and to one another and confronting how we use technology for the benefit of both humankind and the planet. how to translate theory into practice? lueddeke: several years ago, marco lambertini, executive director at wwf, made clear why there has to be a major societal transformation. as one example, he observed that ‘in less than two human generations, population sizes of vertebrate species have dropped by half.’ further, he reminded us: ‘these are the living forms that constitute the fabric of the ecosystems which sustain life on earth and the barometer of what we are doing to our planet, our only home.’ he also warned that ‘we ignore their decline at our peril.’ echoing the book’s main theme, he also emphasised the need for ‘unity around a common cause, ’ collaboration, and leadership ‘to start thinking globally and to stop behaving as if we have a limitless world.’ in the intervening five years since the wwf report was published, too few leaders – g7 (france, united states, united kingdom, germany, japan, italy, canada [ russia suspended] and e7 (emerging – china, india, brazil, mexico, russia, indonesia and turkey) have listened. given the available evidence today (e.g., the un biodiversity report published in may 2019!), there is now, unquestionably, a pressing need to re-orient society towards a sustainable future. the challenge is to shift our perspective from two-dimensional to three-dimensional, ‘orbital’ thinking, as nasa international space station astronaut col ron garan contends –‘bringing to the forefront the longterm and global effects of every decision.’ peah: relevantly, you maintain in the book that two fundamental changes are necessary if we – and all other species – are to survive in the coming decades. tell us more, please, around these changes. lueddeke: in terms of sustainability we are challenged to make a fundamental mind shift – adopt a new worldview – to ensure our needs as human beings are compatible with the needs of our outer world – our ecosystem. education is key in this regard as are global/national/local policies and strategies that underpin ohwb and the sdgs. secondly, we must ensure that technology / ai is used only for peaceful purposes and in support of the health and well-being of all species and the planet. the dangers of techno warfare and genetically engineered viruses are all too real and we must learn from history. the late physicist, stephen hawking, said it best ‘we are all different we all share the human spirit’ but ‘unless crucial societal transformations occur, including the prevention of nuclear war, global warming and genetically engineered viruses – the shelf life of homo sapiens could be extremely short.’ lueddeke gr. survival: one health, one planet, one future. interview by daniele dionisio. seejph 2019, posted: 16 december 2019. doi 10.4119/seejph-3231 p a g e 5 | 7 the battle between technology and humanity may yet become our greatest threat. as we head further into a techno-driven society – age of quantum computers (where computations can be done in minutes vs 10,000 years on today’s supercomputers), there is a real danger that we become increasingly dehumanised rather than as klaus schwab, executive chair of the world economic forum, aspired, that we refocus on becoming ‘better humans.’ peah: summarised in *ten propositions for global sustainability*(ch. 12), the volume calls for the one health and wellbeing concept to become the cornerstone of our educational systems and societal institutions – helping to create – in keeping with the un 2030 global goals – a more “just, sustainable and peaceful world.” can you detail about the propositions in their connection with the one health and wellbeing concept? lueddeke: two of the main recommendations of survival is that the one health & well-being concept should become the cornerstone of our educational systems and society at large and that ohwb principles and approach should underpin the un-2030 sustainable development goals. the propositions cut across socioeconomic, geopolitical and environmental lines. the need for a paradigm shift and peaceful use of technology have already been mentioned. others relate to migration, genuine collaboration among government, business, civil society, and actively promoting ‘the values of equality, democracy, tolerance and respect.’ the need for global discussion on these and other propositions seems essential. the un could be best placed to lead on the initiative perhaps supported by higher education institutions (universities, colleges, etc) of which there are about 26,000 impacting on the lives of millions. to raise awareness across education systems and communities, the one health education task force along with a global planning tea mare evolving an international one health for one planet education initiative (1 hope). anyone interested in joining a working group can sign up https://tinyurl.com/y2ux5b5g peah: proposition 10, inter alia, focuses on reforming the un security council established right after wwii (1946).what does this mean? lueddeke: well, the unsc was formed after wwii (1946) consisting of 5 permanent members (us, china, russia, uk, france), while in 2019, the most densely populated regions with the greatest poverty and conflicts – africa (c. 1.2 bill), india (c.1.3 bill), se asia (c. 600 mill), middle east (c. 400 mill) – c. 50 % [3.5 bill out of c 7.7 bill] – are not permanently represented. shifting to regional (6) representation (vs countries) would clearly be in the best interest of the world given the need for global accountability and sustainability. unsc members should also beheld globally accountable by key stakeholders – government, business, civil society – for their role in maintaining world peace and security – based on a genuine commitment to shared people and planet values. the question is how we can achieve these ends when forces are pushing the world in the opposite direction. surely, these decision-makers also have children and grand-children and would like to see them thrive in a better world where hopes and dreams can be realised. https://www.un.org/sustainabledevelopment/sustainable-development-goals/ https://www.un.org/sustainabledevelopment/sustainable-development-goals/ https://myemail.constantcontact.com/one-health-education---updates-and-expansion-exploration.html?soid=1121110857318&aid=wt811s7nkn0 https://tinyurl.com/y2ux5b5g lueddeke gr. survival: one health, one planet, one future. interview by daniele dionisio. seejph 2019, posted: 16 december 2019. doi 10.4119/seejph-3231 p a g e 6 | 7 peah: as for the range of key topics covered in the book? lueddeke: this is my third book this decade and in a way represents a personal journey of discovery trying to understand the world and healthcare – first from a more narrow humancentric medical education perspective (medical education for the 21st century), moving to the wider public health horizon and recognising the limitations of my assumptions (global population health &well-being in the 21st century) to pulling various strands together in survival: one health, one planet, one future. i don’t think i could have written the latter without the former. the new publication is really a building block of personal knowledge acquisition tinged by personal and professional experience in canada and the uk plus other countries. peah: as reported ‘…the sub-discipline that has perhaps come closest to integrating other disciplines, including medicine and environmental science, is public health. in survival: one health, one planet, one future, george r. lueddeke, the chair of the one health education task force, shows how public health can be incorporated into a wide range of fields to address individual, population, and ecosystem health…’with respect to this, kindly let us know more. lueddeke: this quote appears in one of the on-line book reviews and comes from a world economic forum / political syndicate on-line article, “economics can no longer ignore the earth’s natural boundaries,” written by erik berglof at the london school of economics. three key messages are that 1) economists have treated inequality too narrowly and that income disparities within countries are caused mainly by global financial forces rather than local labourmarket conditions; 2) policies are required to make society more sustainable; and 3) a new field of planetary social science is needed to bring together ‘different perspectives, conceptual frameworks, and analytical tools.’ he affirms that public health is closest to integrating other disciplines and refers to survival: one health, one planet, one future, and ‘how public health can be incorporated into a wide range of fields to address individual, population, and ecosystem health.’ survival concludes with a discussion on the leadership role that generation z – those – the ‘fixers’ born in the mid-90s – need to play in the decades that lie ahead. they are becoming the face of the planet and are much more tolerant of others and thrive on collaboration. recalling the eloquent words of civil rights leader martin luther king jr, are certainly far from silent ‘about things that matter.’ their voices must be heard across the globe as their future depends on decisions we make today! peah: your insightful answers best enhance the book. so compounded, the volume is of great interest to policy-makers, multi-professional practitioners, academics, students across all disciplines and concerned members of the general public – especially the younger generation – in both developed and developing nations. for many reviewers to date, your book is indeed a wake-up call which needs to be heard “loud and clear” globally. just echoing a recent endorsement by tracy collins, founder at the island retreat, county cork, ireland ‘… when we accept that humankind is part of something bigger, then the world will be a better place. our natural world is not there to provide us with https://www.weforum.org/agenda/2019/08/building-a-truly-sustainable-global-economy-heres-how/; https://www.routledge.com/survival-one-health-one-planet-one-future/lueddeke/p/book/9781138334953 https://www.routledge.com/survival-one-health-one-planet-one-future/lueddeke/p/book/9781138334953 https://www.routledge.com/survival-one-health-one-planet-one-future/lueddeke/p/book/9781138334953 https://www.routledge.com/survival-one-health-one-planet-one-future/lueddeke/p/book/9781138334953 lueddeke gr. survival: one health, one planet, one future. interview by daniele dionisio. seejph 2019, posted: 16 december 2019. doi 10.4119/seejph-3231 p a g e 7 | 7 unlimited resources…it really is time to start learning to respect it. thank you george r. lueddeke for being a voice of reason in a world of chaos!’ ___________________________________________________________________________ © 2019 daniele dionisio; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 1 | 14 original research childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study phoebe w. hwang1, cristiano dos santos gomes2, mohammad auais3, kathryn l. braun1, catherine m. pirkle1 1 office of public health studies, university of hawaii at mānoa, hawaii, usa; 2 federal university of rio grande do norte, natal, brazil; 3 school of rehabilitation therapy, queen’s university, ontario, canada. corresponding author: phoebe w. hwang address: 1960 east west road, biomedical sciences bldg #d104t, honolulu, hawaii 96822; telephone: (808) 232-3223; e-mail: pwnhwang@hawaii.edu hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 2 | 14 abstract aim: the purpose is to examine the relationship between childhood adversity and leisure time physical activity (ltpa) among community-dwelling older adults from high and middle-income sites. methods: cross-sectional analysis of 2012 data from older adult ages 64-75 years old from kingston, canada; st. hyacinthe, canada; tirana, albania; manizales, colombia; and natal, brazil. principal exposure variables were childhood social and economic adversity. covariates included participant age, sex, income, and educational attainment. outcome variables were ltpa and leisure time sports activity (ltsa). results: high-income sites had higher ltpa prevalence than middle-income sites. females were less likely to engage in ltpa compared to males in tirana (or:0.53, 95%ci:0.30-0.94), but were more likely to engage in ltpa in manizales (or:2.54, 95%ci:1.54-4.18). low education was less likely than high education to engage in ltpa in kingston (or:0.38, 95%ci:0.19-0.73) and natal (or: 0.52, 95%ci:0.28-0.97). low income was less likely than high income to engage in ltpa in st. hyacinthe (or: 0.42, 95%ci:0.20-0.89) and manizales (or:0.33, 95%ci:0.16-0.55). in tirana, low income was more likely than high income to engage in ltpa (or:5.27, 95%ci:2.06-13.51). conclusions: childhood economic and social adversity were not significantly associated with ltpa. sex, income, and education were associated with older adult pa engagement, however the direction of the association varied by site location. this suggests that the paradigms surrounding pa behavior may vary from city to city. understanding the site-specific risk factors to pa engagement may better inform clinical recommendations and public health approaches to increase pa engagement among older adults across the globe. keywords: childhood adversity, gerontology, global health, physical activity. conflicts of interest: none declared. hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 3 | 14 introduction physical activity (pa) is protective against chronic diseases and delays the onset of agerelated health complications (1). leisure time physical activity (ltpa) in particular is more effective in improving overall health than transportation, occupational, and sport-related pa among older adults. unfortunately, the amount of ltpa decreases as age increases (2). a large portion of pa literature explores individual level theories of pa behavior change, such as self-efficacy theory and the transtheoretical model, or individual-microenvironment level theories, such as the social cognitive model (3). consequently, there is no shortage of behavior-based interventions directed to increase older adult pa. whether home, group, or educational-based, evaluations of these interventions have come to the same conclusion: individual behavior reinforcement strategies alone are not effective in maintaining older adult pa behavior (4). etiological studies applying a life course perspective may be informative for interventions aimed in improving pa (2). among the many exposures life course researchers have examined, early-life exposures appear the most cogently popular. studies have shown that early life exposures and socio-demographic characteristics affect an individual’s health behaviors and outcomes. gender, social and material adversity, and living in a disadvantaged neighborhood are all documented to influence overall health during adulthood (5,6). these findings suggest that early childhood events may have long-term consequences on health behaviors and that pa behaviors may have roots situated in early life circumstances. this study focused on community dwelling older adults of diverse socioeconomic status and global settings, recruited as part of the international mobility in aging study (imias). the objective is to examine the relationship between childhood adversity, and self-reported pa behaviors. since early-life adversity negatively impacts many later life health behaviors, the authors hypothesize that childhood adversity is associated with lower levels of older adult pa behavior. previous early life adversity studies that utilize a life course model were unable to examine crosssocietal influences on behaviors due to sample homogeneity. cross-societal investigations may provide insights on the contribution of broad social structures to pa behaviors, which in turn, may improve interventions geared at individual behavior change. methods site location descriptions imias is a longitudinal study focused on older adult health. baseline data were obtained in 2012, with follow-up collections in 2014 and 2016 (7). data were community samples collected from five distinct study sites: kingston and st. hyacinthe, canada; tirana, albania; natal, brazil; and manizales, colombia. the entire sample size is 2002 (roughly 200 men and 200 women from each site), which is large enough to examine how childhood adversity influences later life physical activity behavior. population socioeconomic, cultural, and religious demographics within each study site are relatively homogenous, whereas between sites there is substantial heterogeneity in socio-demographic characteristics. this give us a broad spectrum of different life exposures and health outcomes, thus providing a comprehensive picture of life course exposures and later life health outcomes across the globe. for a detailed description on hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 4 | 14 site locations and study, please refer to gomez et al (7). population and data collection participants of this study are male and female community-dwelling older adults age 65-74 years. at canadian sites, university ethics committees did not allow researchers to recruit potential participants directly. family physicians sent letters of invitation to potential participants that invited them to contact a field coordinator for further information regarding the study. participants were recruited from health center registries in tirana, natal, and manizales. a random sample of potential participants was drawn from health center registries, and these individuals were recruited directly by interviewers. interviewers were trained with a standardized protocol. comparisons of recruited participants to census data suggest samples are representative of the towns/cities from which they were recruited (7). individuals who had four or more errors on leganes cognitive test orientation scale (8) were excluded from the study. low scores indicated inability to complete study procedures. recruitment continued until about 400 responses were obtained in each locale. exposure childhood adversity was measured using a series of retrospective questions on events that occurred within the first 15 years of the participants’ life. imias survey questions regarding childhood adversity were from the survey on health and well-being elders (sabe study) (9,10), and the canadian community health survey (cchs) (11). the events were: death of parent, parental substance abuse, parental divorce, witnessing physical violence in the family, low economic status, having been hungry, having been physically abused, and parental unemployment. members of the imias team previously performed an exploratory factor analysis on these indicators to yield two categories: economic adversity (low economic status, hunger, and parental unemployment), and social adversity (parental substance abuse, witnessing family physical violence, having been physically abused) (12). adversity summary scores of economic and social adversity were recoded into two variables with binary responses—having experienced adversity (having experienced >0 of the indicators listed above) in childhood and no adversity experiences in childhood (having experienced none of the indicators listed above). covariates education, income, age, and sex were chosen as covariates based on research into the social determinants of health (13). education was previously trichotomized into three categories: illiterate/primary school only, secondary schooling, and post-secondary schooling. analyses indicated insufficient variability within sites for comparison across sites. to allow for comparisons across sites, total years of education was split categorically into tertiles of high, medium, and low education by site to obtain a variable called “relative education”. thus, it is possible for a participant to have high educational attainment relative to his/her community, but medium or low attainment compared to another site in imias. sex is an interviewer reported categorical variable (male/female). age is a self-reported continuous variable re-coded into a binary categorical variable (64-69/70-75 years). income is a self-reported continuous variable of annual income recoded into an ordinal variable (poor/middle/high) based on site-specific hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 5 | 14 poverty thresholds (7). site location is based on the location of data collection. outcomes the outcomes for this study were ltpa and ltsa. ltpa was defined as leisure time activity that involved bodily movement produced by large skeletal muscles that require energy expenditure (14). ltsa was defined as any reported leisure time activity that is considered an official event in the olympics (15). ltsa is a subset of ltpa. participants were asked to report any leisure time activities and to specify those activities. responses were categorized into yes or no ltpa or ltsa based on the definitions above. statistical analysis bivariate analyses were performed using pearson’s chi-squared test for categorical data in order to assess potential differences in proportions between different groups. assumptions were met for all comparisons. the exposures and covariates listed above were tested as correlates to ltpa and ltsa behavior using logistic regression. preliminary analysis demonstrated a strong site-specific interaction with the outcome variables childhood social and economic adversities. this was expected given the substantial economic and societal differences between the sites. therefore, this study focuses on the effect modification per site and analyses were stratified by site to highlight the different relationships. please refer to the imias cohort profile for additional information regarding study sites (7). all regression models statistically adjusted for age, educational attainment, current income, sex, and site location. stata/se 14.0 was used to conduct the analyses. results the prevalence of ltpa and ltsa engagement by site is displayed in table 1. kingston (68.1%) and st. hyacinthe (51.4%) had higher prevalence of ltpa compared to tirana (17.5%), manizales (27.3%), and natal (22.6%). similar patterns were also observed in ltsa. of all the participants, 36.7% in kingston, 31.7% in st. hyacinthe, 4.1% in tirana, 5.7% in manizales, and 5.5% in natal engaged in ltsa. table 1. proportion of participants reporting leisure time physical and sports activity engagement by site kingston (n=398) st. hyacinthe (n=401) tirana (n=394) manizales (n=407) natal (n=402) ltpa engagement, n (%)* 68.1% 51.4% 17.5% 27.3% 22.6% ltsa engagement, n (%)† 36.7% 31.7% 4.1% 5.7% 5.5% missing data: kingston=24; st. hyacinthe= 46; tirana= 7; manizales= 10. *ltpa = activity done for leisure that results in energy expenditure by major skeletal muscles. †ltsa = activity done for leisure that requires physical exertion and skill for competition. table 2 summarizes socio-demographic characteristics and adversity. in manizales, compared to men, women were significantly more likely to report ltpa engagement (33.8% versus 21.9%). at both canadian sites, those with higher levels of education were significantly more likely to report ltpa compared to those with medium and low site-specific education levels. in kingston for example, 81.8% of highly educated participants report ltpa compared to 63.5% of those with low education. it should be hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 6 | 14 noted, however, that even low educated participants from kingston and st. hyacinthe reported more ltpa than any educational category at the middle-income sites. income was significantly associated with ltpa engagement in st. hyacinthe, tirana, and manizales. however, the nature of these associations varied by site. in both st. hyacinthe and manizales, high income participants were more likely to report ltpa engagement (67.4% and 41.7%, respectively), compared to poor income participants (47.2% and 23.2%, respectively). the opposite was true in tirana. poor income participants were more likely to report ltpa engagement (32.6%) compared to high income (10.6%). in tirana, 21.3% of participants who experienced childhood economic adversity engaged in ltpa compared to 13.3% of those who didn’t experience childhood economic adversity. table 2. summary of leisure time physical activity engagement (ltpa)‡ by participant socio-demographic characteristics and childhood adversity, according to site ltpa engagement kingston (n=398) st. hyacinthe (n=401) tirana (n=394) manizales (n=407) natal (n=402) sex (%) male 76.6% 59.9% 21.7% 21.9%† 24.0% female 68.7% 56.4% 14.3% 33.8% 21.4% age in years (%) 64 to 69 72.4% 59.5% 17.1% 26.9% 24.2% 70 to 74 72.6% 55.5% 18.7% 29.2% 20.9% education (%)¶ low 63.5%† 50.0%† 17.9% 26.1% 16.7%† medium 76.5% 61.3% 18.3% 23.2% 24.5% high 81.8% 66.1% 17.0% 35.9% 19.0% income (%) poor 64.4% 47.2%* 32.6%* 23.2%† 12.1% middle 72.9% 66.4% 19.0% 28.07% 21.0% high 74.5% 67.4% 10.6% 41.7% 27.6% childhood economic adversity (%)§ yes 71.7% 55.0% 21.3%† 28.9% 22.0% no 72.7% 59.7% 13.3% 27.4% 22.0% childhood social adversity (%)ii yes 74.7% 55.0% 21.7% 27.7% 26.2% no 71.6% 59.1% 17.0% 28.2% 21.4% pearson’s chi-square analysis was used to test for association of categories within sites *p<0.001 †p<0.05 ‡leisure time physical activity is defined as activity done for leisure that results in energy expenditure by major skeletal muscles. §childhood economic adversity is defined as having experienced poor economic status, hunger, or parental unemployment. iichildhood social adversity is defined as having experienced parental substance abuse, family physical violence, or physical abuse. ¶education calculated from total years of education categorized by site-specific tertiles hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 7 | 14 table 3 summarizes socio-demographic characteristics and adversity by ltsa engagement. men were significantly more likely to report ltsa engagement in kingston (49.3%), st. hyacinthe (43.1%), and tirana (7.1%) compared to women (29.8%, 29.3%, and 1.5%, respectively). the younger age group (43.8%) was significantly more likely to engage in ltsa compared to the older age group (32.9%) only in kingston. in manizales, high education and high income were significantly associated with ltsa engagement. in tirana, presence of childhood economic adversity was significantly associated with ltsa engagement. in natal, presence of childhood social adversity was significantly associated with ltsa. table 3. summary of leisure time sport activity engagement (ltsa)‡ by participant sociodemographic characteristics and childhood adversity, according to site ltsa engagement kingston (n=398) st. hyacinthe (n=401) tirana (n=394) manizales (n=407) natal (n=402) sex (%) male 49.3%* 43.1%† 7.1%† 6.1% 6.8% female 29.8% 29.3% 1.5% 5.5% 4.3% age in years (%) 64 to 69 43.8%† 35.3% 3.6% 7.1% 6.5% 70 to 74 32.93% 36.7% 4.7% 4.3% 4.3% education (%)¶ low 33.9% 34.5% 5.2% 4.9%† 5.1% medium 43.1% 33.1% 3.9% 2.9% 5.8% high 39.4% 39.1% 3.0% 10.3% 5.8% income (%) poor 34.0% 32.0% 5.2% 4.9%† 5.1% middle 45.9% 36.6% 3.9% 2.9% 5.8% high 39.4% 40.2% 3.0% 10.3% 5.6% childhood economic adversity (%)§ yes 44.2% 34.9% 6.3%† 5.4% 4.6% no 36.8% 36.3% 1.2% 6.09% 7.1% childhood social adversity (%)ii yes 35.8% 34.1% 5.8% 2.1% 9.4%† no 40.3% 36.4% 3.8% 7.0% 4.1% pearson’s chi-square analysis was used to test for association of categories within sites. * p<0.001 † p<0.05 ‡ leisure time sport activity is defined as activity done for leisure that requires physical exertion and skill for competition. § childhood economic adversity is defined as having experienced poor economic status, hunger, or parental unemployment. ii childhood social adversity is defined as having experienced parental substance abuse, family physical violence, or physical abused ¶ education calculated from total years of education categorized by site-specific tertiles tables 4 and 5 summarize the results of the multivariate models. childhood social and economic adversities were not significantly associated with ltpa engagement in all sites. in kingston, participants with lower education were less likely to engage in ltpa (or:0.38, 95%ci:0.19-0.73) compared to high education. in st. hyacinthe, poor income participants were less likely to engage hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 8 | 14 in ltpa (or:0.42, 95%ci:0.20-0.89) compared to high income. the opposite relationship was observed in tirana. poor (or:5.27, 95%ci:2.06-13.51) and middle income (or:2.44, 95%ci:1.20-4.99) participants were more likely to engage in ltpa compared to high income. in manizales, women were more likely to engage in ltpa compared to men (or:2.54, 95%ci:1.54-4.18). also, poor (or:0.33, 95%ci:0.16-0.65) and medium income participants (or:0.46, 95%ci:0.23-0.92) were less likely to engage in ltpa compared to high income participants from this site. in natal, participants with low education were also less likely to engage in ltpa compared to high education (or:0.52, 95%ci0.28-0.97). for ltsa in natal, participants who experienced childhood social adversity were more likely to engage in ltsa compared to those who did not (or:3.31, 95%ci:1.31-8.41). females were less likely to engage in ltsa compared to males in kingston (or:0.40, 95%ci:0.250.65) and tirana (or:0.17, 95%ci:0.040.64). in manizales, participants with medium level education were less likely to engage in ltsa compared to high level (or:0.25, 95%ci:0.10-0.82). in natal, middle income participants were less likely to engage in ltsa compared to high income (or:0.29, 95% ci:0.10-0.82). table 4. association of participant socio-demographic characteristics and childhood adversity measures with self-reported ltpa†,‡ kingston (n=398) st. hyacinthe (n=401) tirana (n=394) manizales (n=407) natal (n=402) or 95% ci or 95% ci or 95% ci or 95% ci or 95% ci sex male 1.00 1.00 1.00 1.00 1.00 female 0.74 0.44-1.23 1.24 0.74-2.05 0.53* 0.30-0.94 2.54* 1.54-4.18 0.99 0.60-1.65 age (years) 64 to 69 1.00 1.00 1.00 1.00 1.00 70 to 74 1.18 0.72-1.95 0.89 0.56-1.43 0.91 0.53-1.58 1.08 0.68-1.70 0.81 0.50-1.31 education¶ low 0.38* 0.19-0.73 0.78 0.80 0.38-1.71 0.83 0.44-1.54 0.52* 0.28-0.97 medium 0.88 0.43-1.78 1.05 0.55-2.00 0.83 0.41-1.69 0.65 0.36-1.19 0.85 0.47-1.52 high 1.00 1.00 1.00 1.00 1.00 income poor 0.82 0.40-1.67 0.42* 0.20-0.89 5.27* 2.06-13.51 0.33* 0.16-0.65 0.35 0.11-1.10 middle 1.31 0.72-2.39 0.95 0.49-1.83 2.44* 1.20-4.99 0.46* 0.23-0.92 0.76 0.44-1.31 high 1.00 1.00 1.00 1.00 1.00 childhood econo mic adversity§ yes 0.96 0.56-1.64 0.86 0.53-1.39 1.65 0.92-2.93 1.29 0.79-2.09 1.19 0.71-1.99 no 1.00 1.00 1.00 1.00 1.00 childhood social adversityii yes 1.42 0.78-2.56 1.08 0.63-1.85 0.93 0.47-1.87 0.90 0.52-1.56 1.43 0.84-2.45 no 1.00 1.00 1.00 1.00 1.00 *p<0.05 †leisure time physical activity is defined as activity done for leisure that results in energy expenditure by major skeletal muscles. ‡logistic regression models have been adjusted for age, sex, education, and income. §childhood economic adversity is defined as having experienced poor economic status, hunger, or parental unemployment. iichildhood social adversity is defined as having experienced parental substance abuse, family physical violence, or physical abuse ¶education calculated from total years of education categorized by site-specific tertiles hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 9 | 14 table 5. association of participant socio-demographic characteristics and childhood adversity measures with self-reported ltsa†,‡ kingston (n=398) st. hyacinthe (n=401) tirana (n=394) manizales (n=407) natal (n=402) or 95% ci or 95% ci or 95% ci or 95% ci or 95% ci sex male 1.00 1.00 1.00 1.00 1.00 female 0.40* 0.25-0.65 0.65 0.39-1.08 0.17* 0.04-0.64 1.09 0.44-2.67 0.70 0.27-1.85 age (years) 64 to 69 1.00 1.00 1.00 1.00 1.00 70 to 74 0.64 0.40-1.02 1.14 0.71-1.83 1.04 0.36-2.97 0.59 0.24-1.46 0.64 0.25-1.60 education¶ low 0.89 0.49-1.61 0.95 0.51-1.75 2.05 0.46-9.10 0.54 0.17-1.69 1.56 0.48-5.10 medium 1.62 0.90-2.93 1.17 0.62-2.19 1.28 0.29-5.65 0.25* 0.07-0.87 1.44 0.46-4.54 high 1.00 1.00 1.00 1.00 1.00 income poor 1.01 0.50-2.05 0.59 0.28-1.24 3.88 0.79-10.07 0.65 0.18-2.36 0.53 0.10-2.69 middle 1.21 0.69-2.10 0.84 0.44-1.59 1.37 0.37-5.03 1.42 0.44-4.58 0.29* 0.10-0.82 high 1.00 1.00 1.00 1.00 1.00 childhood econo mic adversity§ yes 1.62 0.98-2.66 0.88 0.54-1.43 4.35 0.94-20.13 1.31 0.50-3.39 0.60 0.24-1.51 no 1.00 1.00 1.00 1.00 1.00 childhood social adversityii yes 0.78 0.46-1.34 1.10 0.64-1.92 0.76 0.22-2.69 0.24 0.5-1.10 3.31* 1.31-8.41 no 1.00 1.00 1.00 1.00 1.00 *p<0.05 †leisure time physical activity is defined as activity done for leisure that results in energy expenditure by major skeletal muscles. ‡logistic regression models have been adjusted for age, sex, education, and income. §childhood economic adversity is defined as having experienced poor economic status, hunger, or parental unemployment. iichildhood social adversity is defined as having experienced parental substance abuse, family physical violence, or physical abuse. ¶education calculated from total years of education categorized by site-specific tertiles. discussion this study examined the relationship between childhood adversity, occurring before 15 years of age, and self-reported later life pa behaviors among community-dwelling older adults from diverse global settings. this study hypothesized that since previous imias studies demonstrated a strong association between childhood adversity and older adult physical performance, there must also be a relationship between childhood adversity and physical activity behavior. however, findings from these studies demonstrated that childhood social adversity was associated with self-reported ltpa only in tirana and natal, and childhood economic adversity was not associated with pa engagement at all. as expected, sex, income and education were associated with older adult pa engagement, however the direction of the association varied by site location. this suggests that the paradigms surrounding pa behavior may vary, possibly depending on geographical, cultural, social, and/or historical influences. thus, the risk factors associated with low pa engagement differ from city to city. understanding the site-specific risk factors to pa hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 10 | 14 engagement may better inform clinical recommendations and public health approaches to increase pa engagement among older adults across the globe. childhood adversity and physical activity behavior in a previous imias study, the presence of social and economic childhood adversity was associated with poor physical performance. however, the mechanisms of this relationship were unexplored. since physical activity is commonly associated with good physical performance (16), we hypothesized that low physical activity engagement may partially explain the association observed by sousa et al. contrary to our hypotheses, self-reported childhood adversity experiences did not correlate strongly with ltpa/ltsa engagement among older adults. moreover, the nature of the association differed from what we hypothesized. in tirana, self-reported childhood economic adversity was marginally associated with both ltpa/ltsa engagement. while not statistically significant, participants in tirana who reported childhood economic adversity had 4.35 times the odds of reporting ltsa engagement. in natal, reporting childhood social adversity was also associated with ltsa. there is no doubt that early life adversity is associated to poor health behaviors and health outcomes in later life. therefore, it was puzzling to find that early life adversity did not correlate strongly with ltpa/ltsa. unfortunately, there is currently no literature that examines the relationship between childhood adversity and later life physical activity behaviors to which we can compare this study. our current results suggest that physical activity behavior may not explain the relationship between early life adversity and physical performance. one possible explanation for our contrary findings may be selective survival, since data were collected only among older adults aged 65-74 (17), and the average life expectancies at birth between the sampled sites varied greatly. for example, in 1960, the life expectancy at birth in brazil was 54.7 years, whereas canada’s average life expectancy was 71.13 years old (18). therefore, those in brazil who survived until study recruitment reflect the survivors of their birth cohort. selective survival has been observed in previous studies where the differences in health and mortality between groups of high and low socioeconomic statuses decline as age increases (19). in fact, a study conducted in israel found that older adults who survived past 61 years old have higher community resilience scores compared to the younger population, indicating that healthy older adults have a better ability to alleviate the detrimental effects of adverse events (20). this may explain why childhood adversity was associated with physical activity engagement in the middle income sites. those who managed to overcome childhood adversity and live past the average life expectancy of their cohort may have distinctively different behaviors from those who did not survive. site-specific influences on physical activity behavior overall, childhood adversity did not correlate as strongly to ltpa/ltsa as compared to the other socio-demographic factors that were observed in this study. ltpa/ltsa engagement was notably greater in high income (kingston, st. hyacinthe) compared to middle-income sites (tirana, manizales, natal). these results were consistent with a study that analyzed physical activity trends using data from the world health organization. among adults aged 15 years and over, brazil, hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 11 | 14 colombia, and albania’s physical inactivity rates were higher than canada’s (21). additionally, the authors found that ltpa increased as occupational pa decreased over time in high-income countries. the same analysis could not be done with low and middle-income countries because these data were not available (21). our study is one of the first to estimate ltpa prevalence in community dwelling older adults from middle-income settings. the observed associations between socio-demographic factors and reported pa behavior varied notably by study site as well. the relationships between ltpa/ltsa engagement and socio-demographic variables may be dependent on site-specific norms. for example, income was significantly associated with ltpa engagement in st. hyacinthe, tirana, and manizales, but not in a consistent direction. in tirana, poor income participants were five times more likely to engage in ltpa compared to high income participants, whereas in st. hyacinthe, poor income participants were less likely to engage in ltpa compared to high income. our study further justifies that social norms may influence pa behaviors. similar results can be found within the united states (22), and high-income east asian countries (23). however, to the authors’ knowledge, no studies have identified cross-societal differences of factors associated to ltpa engagement across study sites of varying income categorization. ltpa versus ltsa this paper examined pa behavior by type— ltpa and ltsa. ltsa is a subcategory of ltpa. it can be said that all ltsa is considered ltpa, but not all ltpa is considered ltsa. ltsa have a set of rules and goals to train and excel in specific athletic skills. moreover, ltsa in general, has a more competitive edge (24). in this study, sex was a significant correlate to ltsa engagement for all sites except natal. males were more likely to engage in ltsa compared to females. yet, sex was not significantly associated to ltpa. results from this study were congruent to other studies that examined sex differences in pa behaviors. in the united states, females are less likely to engage in vigorous pa from adolescence to adulthood (2). among college attending young adults, females were less likely to engage in sports compared to males (25). historical and anthropological studies suggest that males experience an evolutionary history of physical competition for courtship and warfare more often than females (26). further, men are more likely to engage in extreme physical competitive aggression compared to women (27). understanding how sex is correlated with physical activity type preference may give us insight on the social norms of pa, and guide sex-specific pa intervention design. limitations although the large gap between middle and high-income sites clearly shows a difference in pa engagement prevalence, bivariate sitespecific analyses that examine the correlates to pa engagement may have been underpowered as very few participants from middle income sites reported ltsa engagement, and relatively few reported ltpa engagement. a second limitation to this study is that the ltpa/ltsa measure used has not been previously validated. however, widely used ltpa measurement tools such as godin leisure time questionnaire, international physical activity questionnaire, and sedentary behavior questionnaire have been only validated with populations aged 18 to 69 years old, just missing the older adult population. hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 12 | 14 further, pilot studies were previously conducted to validate the ipaq in santa cruz, brazil, using accelerometers. results showed that ipaq had poor validity (28); therefore, it was not considered for this study. lastly, since this is a secondary data analysis, sample size could not be determined a priori. thus, the sample size may not be powered for this particular analysis. however, given the richness of the data, it allows us to deeply examine the multiple factors involved in the life course. conclusions since the 1990’s, there has been a progress in research that examines environment-level factors correlates and causes of pa. unfortunately, many studies focused only on high-income countries (29). as the world ages, and the global burden of non-communicable diseases increase, health behaviors such as pa are becoming more relevant in lower-income settings. several studies have shown a link between childhood adversity at adult pa behavior, but have not followed the participants into older adulthood (30). this study is one of the few that makes cross-societal inferences on the effects of childhood 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original work is properly cited. https://papyrus.bib.umontreal.ca/xmlui/handle/1866/7133 https://papyrus.bib.umontreal.ca/xmlui/handle/1866/7133 marstein e, babich sm. global health in transition: the coming of neoliberalism (original research). seejph 2018, posted: 04 january 2018. doi 10.4119/unibi/seejph-2018-179 1 original research global health in transition: the coming of neoliberalism egil marstein 1 , suzanne m. babich 1 1 department of health policy and management, richard m. fairbanks school of public health, indiana university, indianapolis, usa. corresponding author: egil marstein, phd department of health policy and management, richard m. fairbanks school of public health, indiana university; address: health sciences building (rg), 1050 wishard blvd. floor 5, indianapolis in 46202-2872, usa; telephone: 317-274-3850; email: egmars@iu.edu marstein e, babich sm. global health in transition: the coming of neoliberalism (original research). seejph 2018, posted: 04 january 2018. doi 10.4119/unibi/seejph-2018-179 2 abstract global health as a transnational, intergovernmental, value-based initiative led by the world health organization (who), working toward improving health and achieving equity in health for all people worldwide, has for years yielded to a growing reliance on corporate-led solutions. private organizations, non-governmental organizations (ngo), religious and other philanthropic and charitable organizations, increasingly serve a dominant role in setting the global health agenda. short-term success in combating epidemics and in the provision of funding for project-based initiatives appeals to supporters of marketization of health services. for 30 years, a neoliberal paradigm has dominated the international po litical economy and hence the governance of global health. a utilitarian logic or the ethics of consequentialism have attained prominence under such banners as effective altruism or venture philanthropy. this contrasts with the merits and relevance of deontological ethics in which rules and moral duty are central. this paper seeks to explain how neo-liberalism became a governing precept and paradigm for global health governance. a priority is to unmask terms and precepts serving as ethos or moral character for corporate actions that benefit vested stakeholders. keywords: global health governance, global health leadership, neoliberalism. conflicts of interest: none. marstein e, babich sm. global health in transition: the coming of neoliberalism (original research). seejph 2018, posted: 04 january 2018. doi 10.4119/unibi/seejph-2018-179 3 a new look at global health global health has generally been perceived as a universal call to assist developing nations mediate health disparities and inequities in access to health services. today, its transnational, institution-based foundation appears to be weakening. this is taking place at a time when we see an historic wave of migration, with refugees challenging the political will of sanctuary countries. the mass influx of refugees into european union (eu) member countries dramatizes and confirms this. some of the wealthiest regions of the world seem both unprepared and even hostile to the millions of multiethnic migrants seeking shelter (1). the humanitarian crisis appears endless, as politicians debate durable solutions to limit immigration, placing millions of people in limbo. sounding the alarm are barbara adams and jens martens stating that: “while global economic, social and ecological crises have intensified in recent years, the ability of states and multilateral organizations to tackle these crises appears to have diminished” (2). opinions on public health policy, global health initiatives and the potential for intergovernmental programs to “improve health and achieve equity in health for all people worldwide” vary within and between nations (3). achieving consensus on an approach will require reconciling divergent views and policies. however, the first step requires a discussion that is conceptual and philosophical in nature. a value-based challenge the global disarray in managing the migration crisis demonstrates the lack of a universal understanding of the underlying global health policy precept. to remedy this, it is important to explain the relevance of conceptual terms that in turn help to explain political actions governing national health, safety and security. for example, the migration crisis is said to constitute a fiscal uncertainty, motivating policy makers to safeguard national welfare state schemes, of which public health is a critical part. consequently, immigration policies of many countries have become more restrictive (2). another term refers to “the issue of the humanitarian border” (4). this concept invites a common agreement on the ethical issues surrounding global health initiatives. a humanitarian intervention, for example, may be initiated that would safeguard people from the consequences of a state failing to provide adequate protection and relief for its citizens (5). failure of the state to act in this case could incite a challenge to the political order of the countries involved. an intriguing new issue is the arrival of wealthy philanthropists and their foundations subscribing to venture philanthropy. venture-based philanthropy or effective altruism is a term coined by the australian professor peter singer (6). singer is credited with producing a canonical text outlining applied ethics employing principles of utilitarianism to resolve moral disagreements. singer’s concept encourages individuals to act in a way that brings about the greatest positive impact, based upon their empirical monetary values, distinguishing effective altruism from traditional altruism or charity. with regards to international relations and intergovernmental institutions, terms and concepts and their etymology play key roles in setting the agenda for global health. contributors to the lancet have claimed global health to be poorly defined but frequently referenced (3). authors tried to provide insights into the interpretations of terms and their conceptual relevance, suggesting key competencies for improved scholarship and practice. follow-up articles have sought to distinguish between national, international and global health. academia has fallen short of initiating a discourse necessary to understand the origins and current status of the conceptual debate and its implications for global health practice. https://en.wikipedia.org/wiki/altruism https://en.wikipedia.org/wiki/charity_(practice) marstein e, babich sm. global health in transition: the coming of neoliberalism (original research). seejph 2018, posted: 04 january 2018. doi 10.4119/unibi/seejph-2018-179 4 underscoring this, beaglehole and bonita point out that “without an accepted definition of global health, it will be difficult to agree on what global health is trying to achieve and how progress will be made and monitored” (7). in pursuing the semantic connections, the recent migration crisis, and the topics of climate change, the economic, food and energy crises all illuminate the need for different relief approaches supported by a common vision for global health. the avenue to conceptual clarity is broadened when mcinnes and lee revitalize the concept of social constructivism (8). mcinnes and lee draw on alfred schultz’s sociology of knowledge and durkheim’s concept of institutions when interpreting the relationship between human thoughts in a social context and the effects these ideas have on society. their argument is that varied positions on global health emerge as a product of different values and interests. following the fusion of schultz and durkheim´s theories, priorities of nations emerge as social facts reflecting “the power of ideas rather than an independent understanding based on objective observations of the world”. the concept of social constructivism is linked to jürgen habermas’s theory of communicative action, bringing in the eurocentric bias rooted in occidental rationalism (9). recognizing the ills and problems of the world is thus rooted in a weaker notion of rationality. any problem of universality is thus a cognitive cultural phenomenon. in historical and normative terms, mark nichter sees global health as the purview of our thinking about global health responsibility and our future roles in it (10). international health was largely limited to programs funded by bilateral aid, a few foundations, and the world health organization (who). now, health problems, issues, and concerns that transcend national boundaries are being influenced by circumstances or experiences in other countries, best addressed by cooperative actions and solutions (11). nichter offers an answer to the conceptual challenge in his quest for semantic universalism. global health should represent “collaborative transnational research and action for promoting health for all” (10). using a similar catchall tenet, beaglehole and bonita propose that global health should build on national public health efforts, whether population-wide or individually based actions, across all sectors, not just the health sector (7). though they may not fully diffuse the potential for cognitive bias, these broad concepts may be better than the rest for fostering cooperative efforts to resolve the global health challenges of the day. the “globalization” of global health given the diversity of opinions and the scope of resources involved, the issue of governance is paramount in effectively addressing issues of global health. given the range of current public and private stakeholders, in addition to those historically established, the locus of authority takes on special significance. the prominence of new global health actors and their divergent interests creates significant conflicts with the priorities of public institutions. acknowledging the influence of new and resourceful stakeholders, kay and williams have created a definition of global health governance to represent “any means or mechanism used by various public and private actors, acting at sub-national, national and international levels, that seek to control, regulate or ameliorate this global system of disease” (12). hence, with the appearance of multinational corporations, ngos, philanthropic and other nongovernmental organizations merging with intergovernmental institutions, the global health agenda has become linked to international relations. this broadening of the global health reach relates to the expansion of globalism where economic liberalism facilitates and impacts its governance. marstein e, babich sm. global health in transition: the coming of neoliberalism (original research). seejph 2018, posted: 04 january 2018. doi 10.4119/unibi/seejph-2018-179 5 kaye and williams challenge the view that global health is just a discrete area of activity driven by biomedicine and public health objectives. their work attests to the centrality of global economic institutions having created a particular neoliberal modality of global health governance inviting public and private international interests. mcinnes and leesee global health as having graduated to a broadened position in response to real world developments (13). global health has moved from a focus on technical competencies toward a more politicized view of relationships between growing numbers of stakeholders. clearly, the potential consequences of this fragmentation of actors and issues create a demand for coordination between nation-states and the increased number of non-state participants. to develop new forms of networking and governance, the reconciliation of interests and progress toward a common cause require a deeper understanding of stakeholders’ motives and the required means. reaching this common vision is particularly difficult given the influx of dominating private donors acting independently and governed by the precepts of venture philanthropy. in the ensuing discourse, we must scrutinize how public policies at local and intergovernmental levels have come to reflect revived liberal – or so-called neo-liberal – ideas. the orthodoxy of liberalism as a political philosophy, liberalism in its classical sense is associated with principles of individual freedom, such as freedom of speech, freedom of religion, civil rights, secular government and gender equality. as an ideology, it represents a set of ethical ideals, principles or even a social movement explaining how a society should work. as such, liberalism, in a contemporary fashion, functions as a political blueprint for social order. the modern intellectual history of liberalism dates back to the age of enlightenment. several principles critical to today’s understanding of neo-liberalism were debated as they pertained to economic policies of the day. proponents such as hugo grotius (1583-1645) and john locke (1632-1704) introduced the concept of social contract in which life, liberty and property were subject to governance. opposing this was thomas hobbes (1588-1679) arguing that individuals’ actions should be balanced only by their own consciences. locke and grotius warned that a state of nature, if unchecked, would eventually require individuals to act in abidance with a law of nature, ensuring a minimum of security, rights and liberty. the french philosopher, jean-jaques rousseau (1712-1778), balanced the state of nature through his social contract theory, introducing the notion of popular sovereignty, rejecting hobbes’s notion of individual sovereignty. here pierre-joseph proudhon (1809-1865) warned of a surrender of sovereignty: people should coexist in a state of nature, refraining from coercing or governing each other. everyone should have complete sovereignty over themselves. proudhon and other 19 th century philosophers such as david ricardo, thomas malthus, adam smith and james mill inspired precepts of economic liberalism or classical economics. common ideological ground was established with classical liberalism, conceptually transposing into today’s political neo-liberal tenets of privatization, deregulation, free trade, and reductions in government spending. per rosseau’s social contract theory, continental europe saw more than one hundred years of social welfare state program expansions. social insurance schemes of chancellor otto von bismarck and germany were introduced in the 1880s and 1890s, partly a result of escalating labor unrest but also an effort to build a strong and durable nation in an age of geo-political conflicts. https://en.wikipedia.org/wiki/ideal_(ethics) https://en.wikipedia.org/wiki/social_movement https://en.wikipedia.org/wiki/privatisation https://en.wikipedia.org/wiki/deregulation https://en.wikipedia.org/wiki/free_trade https://en.wikipedia.org/wiki/government_spending marstein e, babich sm. global health in transition: the coming of neoliberalism (original research). seejph 2018, posted: 04 january 2018. doi 10.4119/unibi/seejph-2018-179 6 the national insurance bill of 1911 in the uk, the social insurance law in 1928 in france, and the 1983 french free medical assistance program are three examples of such outcomes. pierre rosanvallon referred to this as the state being the “institutionalizer of the social”. in other words, the state began to be seen as an agency of social solidarity working to correct inequalities and increasingly intervening in aspects of everyday life, such as education, housing and transportation (14). these ideas mirrored those of the enlightenment, particularly as argued by john lock, jean j. rosseau, françois-marie arouet (voltaire) and charles montesquieu. after wwii, the uk developed a social welfare system, the hallmark being the introduction in 1948 of the national health service (nhs), a public health system that became the model for evolving social democracies throughout europe. inspired by economists such as john m. keynes and later the post-keynesian economics of john kenneth galbraith, their socioeconomic tenets promoted an active and comprehensive state governing to secure fair trade practices and workers’ social welfare. classical keynesian economics (as opposed to the later and much debated post/neo-keynesian economics) served as the standard economic model in developed nations during the latter part of the great depression, world war ii, and the postwar economic expansion (1945–1973). the most prominent of social reforms of its time, however, was the nhs. at the time, it was considered “the most civilized step by any country”, with universal health coverage, comprehensive and free at the point of delivery (15). the emergence of neoliberalism how neoliberal philosophies came into being as a dominating policy precept and governance model in global health may best be rationalized by studying the public policy reform agenda in the u.s., china and western europe over the past 40 years. the american professor of anthropology, david harvey, points to 1978–1980 as a revolutionary turning point in the world’s social and economic history. ronald regan was elected u.s. president, serving from1981 to 1989. only one year earlier, paul volcker took command of the u.s. federal reserve (1979-1987) and within a few months dramatically changed u.s. monetary policy. across the atlantic, margaret thatcher, england’s prime minister fro m 1979 to1990, advanced economic and social practices that deemed human well being could best be advanced by liberating individual entrepreneurial skills within an institutional freedom characterized by strong private property rights, free markets and free trade (16). the precept was clear. both thatcher and regan moved quickly to curb the power of unions, deregulate industry, agriculture and resource development while liberating the powers of finance. according to harvey, if markets did not exist in areas such as land, water, education, health care, social security and environmental pollution, then they had to be created, if necessary by the state. state intervention was kept to a minimum. so, too, began the process of deconstruction of the public health models in europe, models largely vested in universalistic principles. again, according to harvey the theoretical precept for neoliberalism emerged from a small and exclusive group of passionate advocates of the austrian political philosopher friedrich von hayek and the american economist milton friedman. neoliberal doctrines, as they emerged, were deeply opposed to state intervention. awarding the swedish national bank´s prize in economics sciences in memory of alfred nobel (often erroneously referred to as the nobel prize in economics) to both hayek (1974) and friedman (1976), though both controversial at the time, gave credence to the doctrines they professed. almost all countries, from those newly created after the collapse of the soviet union, to old-style social https://en.wikipedia.org/wiki/developed_nations https://en.wikipedia.org/wiki/great_depression https://en.wikipedia.org/wiki/world_war_ii https://en.wikipedia.org/wiki/post-world_war_ii_economic_expansion https://en.wikipedia.org/wiki/post-world_war_ii_economic_expansion marstein e, babich sm. global health in transition: the coming of neoliberalism (original research). seejph 2018, posted: 04 january 2018. doi 10.4119/unibi/seejph-2018-179 7 democracies such as the nordic countries, have since aligned their public policies, particularly within the public health under the health and social care act, which served to dismantle the constitutional basis of the nhs, making way for a market-driven system of health care. on the international scene, institutions such as the international monetary fund (imf), the world bank and the world trade organization encouraged and facilitated neoliberal measures through lending policies, making neoliberalism the hegemonic model. to conclude, neoliberalism has become the orthodoxy of global health. the implications for policy and practice should have prominence in discussions that seek to find effective and sustainable solutions to the world’s most critical and complex public health challenges. references 1. glasas ri. americas vital interest in global health. perspectives from the fogarty international center. institute of medicine; 24 march, 2008. 2. adams b, martens j. fit for whose purpose? private funding and corporate influence in the united nations. global policy forum/global policy watch; 27 july, 2015. 3. kopland jp, bond tc, merson mh, reddy ks, rodriguez mh, sewankambo nk et al. towards a common definition of global health. lancet 2009;9679:1993-5. 4. williams jm. from humanitarian exceptionalism to contingent care: care and enforcement at the humanitarian border. political geography, 2015;47:11-20. 5. brown bs. humanitarian intervention at a crossroad. william & mary law review 2000;41(5/6). 6. singer. p. practical ethics (3 rd ed.) melbourne: cambridge university press; 2011. 7. beaglehole r, bonita r. what is global health? global health action 2010;3. 8. mcinnes c, lee k. global health and international relations. john wiley & sons; 2012. 9. delanty g. habermas and occidental rationalism: the politics of identity, social learning, and the cultural limits of moral universalism. sociological theory 1997;15:30-59. 10. nichter m. global health: why cultural perceptions, social representations, and biopolitics matter. human ecology 2009;37:669-70. 11. the institute of medicine, board on international health. americas vital interest in global health. protecting our people, enhancing our economy, and advancing our international interests; 1997. 12. kay a. williams od (ed.). global health governance: crisis, institutions and political economy. palgrave mcmillan, uk; 2009. 13. mcinnes cj, lee, k. global health & international relations, cambridge; polity press; 2012. 14. rosanvallon p. the society of equals, cambridge, mass, harvard university press; 2013. 15. people’s health movement. global health watch # 4. alternative health report. london: zed books; 2014 (p. 96). 16. harvey d. a brief history of neoliberalism. new york: oxford university press; 2005. ______________________________________________________________________________________ © 2018 marstein et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. chernyavskiy v, mikhailova j. russia: a key partner in the northern dimension partnership (editorial). seejph 2019, posted: 10 may 2019. doi 10.4119/unibi/seejph-2019-217 page 1 of 5 editorial russia: a key partner in the northern dimension partnership valery chernyavskiy1, julia mikhailova1 1federal research institute for health organization and informatics of the russian ministry of health, moscow, russian federation. corresponding author: dr. valery chernyavskiy phd, mph, dr.h.c., deputy head of the unit for coordination of the northern dimension partnership of public health and social well-being (ndphs),federal research institute for health organization and informatics of the russian ministry of health; address: 11, dobrolubova str. moscow, 127254, russian federation; e-mail: vch@mednet.ru. chernyavskiy v, mikhailova j. russia: a key partner in the northern dimension partnership (editorial). seejph 2019, posted: 10 may 2019. doi 10.4119/unibi/seejph-2019-217 page 2 of 5 nearly thirty years after the breakdown of the soviet union (ussr) in 1991, the countries of the former ussr that emerged from it still face a multitude of challenges including the need to reorganise the health services, their structure, budgeting, staffing, and quality. the soviet system, despite its many and profound flaws, represented also very real achievements (1-3). it provided a basis for community health activities including mandatory immunization and periodic health checks and it fostered a generation committed to solidarity in the provision of health care aiming at universal coverage and equitable access. despite the enormous challenges facing the country today, the belief in a health system centred on need rather than the ability to pay remains intact. however, the russian federation by far the biggest successor state of the former ussr carries most of the advantages as well as disadvantages of the soviet past (4). today, we observe a growing awareness of the necessity to increase the efficiency of the health system and a real desire to enhance user satisfaction in russia. these concerns coupled with recognition of the need to address issues of sustainability have prompted a major reform of the health system centred on appropriate financing mechanisms: funding which previously came from general taxation has shifted in part to a social insurance system and it is this shift which provides the fundament for the health reform process of the russian federation (5,6). two additional problems add to the need for change:  there is a major impact of environmental pollution on the health of the population, to a considerable degree caused by the historical break-down of central regulation and enforcement of health and safety standards in the nineties which allowed the industry to produce without regard to air and water pollution.  equally worrying is the unhealthy behaviour of russian citizens especially with regard to the high alcohol and cigarette consumption and poor nutritional status, i.e. high levels of energy intake from fat instead of vegetables and fruits (7). the subsequent deterioration of major health indicators foresees a long-term rise of morbidity and mortality of the present generations and correspondingly a very high burden of disease to be tackled by the health system. therefore, today, one of the key areas of work of the ministry of health of the russian federation is to strengthen the cooperation with experts from other countries in order to set up channels for exchange of knowledge and experience between health professionals, politicians and decision-makers (8). the northern dimension partnership on public health and social well-being (ndphs) as a cooperative effort of ten governments (estonia, finland, iceland, germany, latvia, lithuania, norway, poland, russian federation and sweden), the european commission and eight international organisations was formally established at a ministerial-level meeting on 27 october, 2003. since then, the northern dimension is steadily on track to reduce the preventable years of life lost in their respective populations and the difference between the member countries with reference to the sustainable development goals 2030 and the european union strategy for the baltic sea region 2020. from the very beginning, the russian federation has been actively involved in the cooperative work of the ndphs. summing up the contributions of the russian federation from 2003 until 2018, chernyavskiy v, mikhailova j. russia: a key partner in the northern dimension partnership (editorial). seejph 2019, posted: 10 may 2019. doi 10.4119/unibi/seejph-2019-217 page 3 of 5 the following three periods can be differentiated (9). i.the period from 2003 to 2009 this was the period of foundation of the partnership, the searching for its purpose and place in the international, as well as regional agenda of public health and social well-being. at the various international platforms, russia actively participated in discussions about the feasibility, goals, status, and mission of the new international network for regional cooperation at the northern dimension area. ii.the period from 2010 to 2014 during this period, the general goal of the partnership was determined, the first strategy was adopted (but, still, without an action plan), and objectives were defined. in accordance with the general goal of the partnership, two priority areas were identified: to reduce the spread of major communicable diseases and to prevent lifestyle related non-communicable diseases; to enhance peoples’ levels of social well-being and to promote socially rewarding lifestyles. to implement actions in these directions, terms of reference were developed and four expert groups were created, in which international experts from the ten partner countries including russia worked together. this period allowed the partner countries to outline common problems in health and to define mechanisms of interaction and cooperation. during 2010-2011, the partnership worked under the chairmanship of the russian federation. in this period, activities related to new challenges in the health of all partner countries were integrated: population aging, issues of prevention and control of non-communicable diseases including cardiovascular diseases and tumours as the main causes of mortality, the growth of resistance of microorganisms to antibacterial drugs, the increasing relevance of primary health care as an accessible, comprehensive, and highquality, component of the health sector. during this period, a ndphs secretariat with legal capacity was established, which is currently located in stockholm, sweden. iii.the period from 2015 to 2018 a new ndphs strategy 2020 was developed and, corresponding to its objectives, an action plan was adopted, as well as terms of reference and tasks of the meanwhile six expert groups were established. the new ndphs mission was formulated as an innovative regional cooperation network, making a significant contribution to improving the health and social well-being of the population in the northern dimension area. the current ndphs strategy 2020 is defined as a guiding tool to assist the partner countries and organizations in their joint efforts to achieve improvements in selected priority areas and to strengthen the recognition of health and social well-being on the political agenda in the northern dimension area and the russian federation, as well as ensuring greater stakeholder commitment to include aspects of health and quality of life in the process of developing national policies. it is important to note the increasing relevance of the political components during this most recent period: inclusion of the north-west federal district of the russian federation into the zone of activity and responsibility of the russian federation in the ndphs (until 2014 only the region of kaliningrad participated in ndphs activities). to determine the current problems in the health and healthcare of the north-west federal district, the federal research institute of health organization and chernyavskiy v, mikhailova j. russia: a key partner in the northern dimension partnership (editorial). seejph 2019, posted: 10 may 2019. doi 10.4119/unibi/seejph-2019-217 page 4 of 5 informatics of the ministry of health of the russian federation carried out extensive work on assessing the health of the population and the capacity of the health care organization in the region. the new policy of the northern dimension placed a strong emphasis on cooperation between the european union and russia with full participation of iceland and norway in matters relating to the northern dimension region. the russian federation has been actively involved in the ndphs from the beginning (that is 15 years ago) in all areas of the partnership. it should be emphasized that russian experts are actively promoting many aspects of health and health care presented and discussed in the expert groups and transfer the insights gained into the national strategic documents for further development of the health system in russia. ndphs now is at the stage of preparation the new strategy 2025 based on the national priorities of the partners. in parallel, the president of russia signed the decree “on the national goals and strategic objectives of the development of the russian federation for the period up to 2024”. based on the analysis of global and national trends and conditions in the years to come, the new policy indicates the trajectory of economic, social, and technological break-through, sustainable growth of well-being and competitiveness of individuals and the society as a whole on social and economic development. at this historical turning point, it is expected that the european union will likewise renew its strategy for the baltic sea region (eu-sbsr) including a reevaluation of the financial investment in order to combine all efforts in the region efficiently. the complex but steady progress during 15 years shows that international cooperation at expert level may be slow but in the long run can become effective. the well-resourced northern and western countries and the european union should realise their strategic interest in the unique platform of the northern dimension partnership on public health and social well-being. conflicts of interest: none. references 1. tchernyavskii v. research on public health in transitional russia. understanding and orientating national health systems. proceedings of the 3rd ficosser general conference helsinki, 1995; p. 271-8. 2. public health in russia. international handbook of public health. editors: klaus hurrelmann, ulrich laaser. greenwood press, westport, connecticut, usa, 1996; p. 297-315. 3. lessof s, chernyavskiy v. health care systems in transition: russian federation. who, regional office for europe, copenhagen; 1998. 4. tchernyvskii v. health and health care in the russian federation. in: “the cost of reform: the social aspect of transitional economies” (editors: jones jf, kumssa a). nova science publishers, inc., huntington. new york, 2000; p. 89-101. 5. problems of russian mortality, its consequences and priorities for actions (editors: starodubov vi, mikhailova yu v, ivanova ae). moscow, 2006. 6. the health of the population of russia in the social context of the 90s: problems and prospects (editors: starodubov vi, mikhailova yv, ivanov ae). moscow, 2003. chernyavskiy v, mikhailova j. russia: a key partner in the northern dimension partnership (editorial). seejph 2019, posted: 10 may 2019. doi 10.4119/unibi/seejph-2019-217 page 5 of 5 7. stanley j. tillinghast, valery e. tchernjavskii. building health promotion into health care reform in russia. journal of public health medicine vol.16, no 4, december 1996; p. 473-7. 8. chernyavskiy v. modern approaches in the implementation of international projects for the prevention and treatment of socially significant diseases (hiv, tuberculosis and malaria). materials of the 8th russian forum with international participation: “children’s health: prevention and treatment of socially significant diseases”. st. petersburg, 2014; p. 2716. 9. mikhailova yv, andreeva om, chernyavskiy v. work of the russian federation within ndphs in 20032018; may 2019. ______________________________________________________________________________________ © 2019 chernyavskiy et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. caushaj k, czabanowska k, roshi e, muja h, burazeri g. leadership competencies among male health professionals in a western balkan country (original research). seejph 2019, posted: 26 april 2019. doi 10.4119/unibi/seejph-2019-213 page 1 of 9 original research leadership competencies among male health professionals in a western balkan country klevis caushaj1,2, katarzyna czabanowska1,3, enver roshi4, herion muja4, genc burazeri1,4 1 department of international health, school caphri (care and public health research institute), maastricht university, maastricht, the netherlands; 2 american hospital, tirana, albania; 3 institute of public health, faculty of health sciences, jagiellonian university, krakow, poland; 4 department of public health, faculty of medicine, university of medicine, tirana, albania. corresponding author: katarzyna czabanowska, phd; department of international health, maastricht university, faculty of health, medicine and life sciences, school caphri, maastricht, the netherlands; email: kasia.czabanowska@maastrichtuniversity.nl caushaj k, czabanowska k, roshi e, muja h, burazeri g. leadership competencies among male health professionals in a western balkan country (original research). seejph 2019, posted: 26 april 2019. doi 10.4119/unibi/seejph-2019-213 page 2 of 9 abstract aim: our objective was to assess the current and the required level of leadership competencies among male health professionals in albania, a country which is characterized by an intensive process of emigration of the health workforce in the past few decades. methods: this was a cross-sectional study carried out in albania in june-november 2018 including a nationwide representative sample of 132 male health professionals working at different health institutions at both central and local level in albania (mean age: 41.4±10.1 years; overall response rate: 88%). a structured 52-item questionnaire was administered to all male health professionals aiming at self-assessing the current level and the required (necessary) level of leadership competencies for their actual job positions. answers for each item of the instrument ranged from 1 (“minimal competency level”) to 5 (“maximal competency level”). an overall summary score (range: 52-260) and a subscale summary score for each domain were calculated for both the current and the required leadership competency levels. paired sample t-test was used to compare the overall mean scores and the subscale mean scores of the current level and the required level of leadership competencies among male health professionals. results: mean value of the overall summary score of the instrument was lower for the current leadership competency level compared with the required leadership competency level (137.6±8.7 vs. 140.7±21.2, respectively; p=0.02). mean difference between the required and the current level of leadership competencies was higher for male health professionals working in top managerial positions and those working in urban areas of albania. conclusion: this study informs about the current and the required level of leadership competencies among male health professionals in albania, a transitional country in the western balkans. policymakers and decision-makers in albania and other countries in the european region should be aware of the existing gap between the required and the current level of leadership competencies among health professionals operating at all levels. keywords: albania, competency level, male health professionals, public health leadership, western balkans. conflicts of interest: none. caushaj k, czabanowska k, roshi e, muja h, burazeri g. leadership competencies among male health professionals in a western balkan country (original research). seejph 2019, posted: 26 april 2019. doi 10.4119/unibi/seejph-2019-213 page 3 of 9 introduction several competency frameworks have been established in the past decades in order to assess public health leadership and medical leadership competencies in different countries (1-4). all of these instruments consist of the core principles and concepts of leadership (5,6). however, most of the existing frameworks assessing leadership competencies in the field of medicine and public health are quite broad and non-specific enough. as a matter of fact, such general frameworks do not allow for an appropriate assessment of the level of leadership competencies, as a major requirement for modification and finetuning of the educational curriculum and training models for public health professionals (7). based on these considerations, in the past few years, it has been successfully developed a new and more specific public health leadership competency framework aiming at promoting considerably the competency-based european public health leadership curriculum (7). this competency framework was part of the “leaders for european public health (lephie) erasmus multilateral curriculum development project”, which was supported by the european union lifelong learning programme (7). this framework has been already adapted and used in the albanian context (8,9). albania is a post-communist country in the western balkans, which has experienced a rapid demographic and epidemiological transition in the past few decades (10). currently, non-communicable diseases (ncds) and its associated risk factors constitute the highest burden of disease in albania (10). hence, according to the estimates of the global burden of disease, the crude mortality rate from the overall ncds in albania in 2016 was about 731 (95%ci=646-804) deaths per 100,000 population (11). almost 94% of albanian people died from ncds in 2016 (11). furthermore, about 84% of the overall disease burden in 2016 was attributed to the ncds. for the same year, the burden of ncds was estimated at about 22,260 (95%ci=19,380-25,280) dalys per 100,000 (11). a whole range of risk factors are currently contributing to the ncd situation in albania. yet, the top three leading factors responsible for the disease burden in the albanian population include the arterial hypertension, nutritional-related risks and smoking (11). the albanian health system is currently facing a multitude of challenges including the sufficiency and sustainability of health financing mechanisms in line with the ongoing reforms in all sectors (12). furthermore, out-of-pocket payments still constitute almost half of the overall health expenditure in albania and bear significant impoverishing effects upon the poorest and vulnerable and marginalized population categories. also, human resources for health is another issue which currently represents a tremendous challenge (12) given the unabated brain drain from albania to the western countries, mainly to germany which has become particularly attractive in the past few years for young physicians and nurses. in the context of an intensive process of emigration of the health workforce in the past few years, our aim was to assess the current and the required leadership competency level of male health professionals in albania, using an internationally valid instrument, which has been already applied in albanian settings (8,9). methods a cross-sectional study was carried out in albania in june-november 2018 including a nationwide representative sample of 132 male health professionals working at different health institutions pertinent to caushaj k, czabanowska k, roshi e, muja h, burazeri g. leadership competencies among male health professionals in a western balkan country (original research). seejph 2019, posted: 26 april 2019. doi 10.4119/unibi/seejph-2019-213 page 4 of 9 both the central level (institute of public health, regional health directorates, university hospital centre “mother teresa”, and health insurance fund) and local level (primary health care services, and regional hospitals). initially, 150 male health professionals were targeted for recruitment; of these, 18 individuals did not participate. hence, the final study sample consisted of 132 male health professionals, with an overall response rate of: 132/150=88%. a structured questionnaire was administered to all male health professionals included in this survey. the questionnaire aimed at self-assessing the current level of leadership competencies and the required (necessary) level of leadership competencies based on the actual job position of health professionals. the questionnaire included 52 items categorized into the following eight competency domains (subscales) (7): i) systems thinking; ii) political leadership; iii) collaborative leadership: building and leading interdisciplinary teams; iv) leadership and communication; v) leading change; vi) emotional intelligence and leadership in team-based organizations; vii) leadership, organizational learning and development, and; viii) ethics and professionalism. possible answers for each item of each domain/subscale of the leadership instrument ranged from 1 (“minimal competency level”) to 5 (“maximal competency level”). an overall summary score (range: 52-260) and a subscale summary score for each domain were calculated for both, the current level of competencies and the required level of competencies. furthermore, the gap between the required (necessary) and the current level of leadership competencies was calculated for each participant, as a difference between the summary score of the required level and the current level of leadership competencies. of note, the leadership instrument was validated since 2014 in a sample of health professionals operating in tirana (8) and, after the respective cross-cultural adaptation, this tool was subsequently administered to a nationwide sample of male and female health professionals in albania (9). in addition to the leadership competency level, the structured questionnaire inquired about some basic demographic data (age of male health professionals and workplace: urban areas vs. rural areas); work experience (expressed in full years); main degree obtained (health sciences including medicine, public health, nursing, pharmacy, or dentistry vs. other degrees including economics, social sciences, law, engineering, or other disciplines; this variable was dichotomized in the analysis into: health sciences vs. other diploma); and the current job position (trichotomized in the analysis into: high, middle and low managerial level). this study was approved by the department of public health, faculty of medicine, university of medicine, tirana, albania. the distribution of age and working experience among male health professionals included in this study was presented by use of the measures of central tendency and dispersion (mean values and standard deviations). on the other hand, absolute numbers and their respective percentages were employed for presentation of the distribution of workplace (urban vs. rural areas), main degree obtained (health sciences vs. other degrees) and the job position (top, middle and low managerial positions) of health professionals. cronbach’s alpha was employed to assess the internal consistency for both the current level and the required level of leadership caushaj k, czabanowska k, roshi e, muja h, burazeri g. leadership competencies among male health professionals in a western balkan country (original research). seejph 2019, posted: 26 april 2019. doi 10.4119/unibi/seejph-2019-213 page 5 of 9 competencies (13). conversely, paired sample t-test was used to compare the overall mean scores and the subscale mean scores of the current level of competencies and the required level of competencies among male health professionals included in this survey. a p-value of ≤0.05 was considered as statistically significant. all statistical analyses were performed by use of the statistical package for social sciences (spss, version 19.0). results mean age in this nationwide representative sample of male health professionals (n=132) was 41.4±10.1 years (table 1). in turn, mean working experience was 14.8±9.4 years. about 71% of study participants were working in urban areas of albania, whereas the remaining 29% were operating in rural areas (mainly in tirana, but also in the other districts of albania). about 87% of participants had obtained their main degree in health sciences (including medicine, public health, nursing, pharmacy, or dentistry), whereas further 13% had obtained their main degree in other fields (including economics, social sciences, law, engineering, or other disciplines). regarding job position, about 34% of health professionals were operating in high managerial positions; 44% in middle managerial positions; and the remaining 22% were working in low managerial positions (table 1). table 1. demographic factors and characteristics of the workplace in a nationwide representative sample of 132 male health professionals in albania, in 2018 numerical variables mean standard deviation age (years) 41.4 10.1 working experience (years) 14.8 9.4 categorical variables number percentage place of work: urban areas rural areas total 94 38 132 71.2 28.8 100.0 diploma (main degree): health sciences other degrees 115 17 87.1 12.9 job position: high managerial level middle managerial level low managerial level 45 58 29 34.1 43.9 22.0 the internal consistency of the overall scale of the leadership instrument (52 items) was cronbach’s alpha=0.87 for the current competency level and cronbach’s alpha=0.95 for the required competency level (table 2). for the current competency level, cronbach’s alpha was the lowest for the “ethics and professionalism” domain (0.50) and the “leadership, organizational learning and development” subscale (0.51) and the highest for the “political leadership” caushaj k, czabanowska k, roshi e, muja h, burazeri g. leadership competencies among male health professionals in a western balkan country (original research). seejph 2019, posted: 26 april 2019. doi 10.4119/unibi/seejph-2019-213 page 6 of 9 domain (0.93) followed by the “collaborative leadership” subscale (0.89). likewise, for the required competency level, cronbach’s alpha was the lowest for the “ethics and professionalism” domain (0.67) and the highest for the “political leadership” subscale (0.90) and the “collaborative leadership” subscale (0.86). overall, cronbach’s alpha was higher for five of the domains of the required competency level compared with the current competency level. table 2. internal consistency of the leadership competency instrument in a nationwide sample of male health professionals in albania in 2018 (n=132) domain (subscale) cronbach’s alpha current competency level required competency level overall scale (52 items) 0.87 0.95 systems thinking (7 items) 0.69 0.75 political leadership (8 items) 0.93 0.90 collaborative leadership: building and leading interdisciplinary teams (5 items) 0.89 0.86 leadership and communication (7 items) 0.56 0.84 leading change (6 items) 0.65 0.76 emotional intelligence and leadership in team-based organizations (6 items) 0.82 0.81 leadership, organizational learning and development (7 items) 0.51 0.75 ethics and professionalism (6 items) 0.50 0.67 table 3 presents mean summary scores of each domain of the leadership instrument for both the current and the required competency level. mean value of the overall summary score for the 52 items of the instrument was somehow lower for the current competency level compared with the required competency level (137.6±8.7 vs. 140.7±21.2, respectively; p=0.02). most of the subscales’ scores were significantly higher for the required competency level than for the current competency level, except for the “emotional intelligence and leadership in team-based organisations” and “leading change” domains. conversely, mean scores of the “ethics and professionalism” subscale were similar for the current and the required leadership competency level (table 3). table 3. summary scores of the overall scale and subscales for the current and the required leadership competency level of albanian male health professionals in 2018 (n=132) domain (subscale) mean values ± standard deviations p-value* current competency level required competency level overall scale (52 items) 137.6±8.7 140.7±21.2 0.019 systems thinking (7 items) 20.8±1.7 21.9±3.2 0.004 political leadership (8 items) 19.5±4.7 20.2±5.0 0.001 collaborative leadership: building and 11.4±3.0 12.6±3.5 <0.001 caushaj k, czabanowska k, roshi e, muja h, burazeri g. leadership competencies among male health professionals in a western balkan country (original research). seejph 2019, posted: 26 april 2019. doi 10.4119/unibi/seejph-2019-213 page 7 of 9 leading interdisciplinary teams (5 items) leadership and communication (7 items) 16.2±2.1 17.4±3.9 <0.001 leading change (6 items) 17.5±2.2 16.8±3.1 0.005 emotional intelligence and leadership in team-based organizations (6 items) 18.4±2.4 16.9±3.3 <0.001 leadership, organizational learning and development (7 items) 16.3±2.0 17.5±3.3 <0.001 ethics and professionalism (6 items) 17.5±2.0 17.6±2.6 0.603 * paired sample t-test. the gap of leadership competency level (mean difference between the required and the current level of competencies) was higher for male health professionals working in top managerial positions (mean difference: 4.1) compared to those operating in middle managerial positions (mean difference: 3.2) and, particularly, individuals working in low managerial positions (mean difference: 1.5). furthermore, the gap in leadership competencies was higher among health professionals working in urban areas compared with their rural counterparts (mean differences: 3.6 vs. 2.0, respectively) [data not shown in the tables]. discussion main findings of the actual study consist of a higher self-perceived level of the required (necessary) leadership competencies than the current (existing) level of leadership competencies in this nationwide representative sample of male health professionals in transitional albania. this finding resembles a previous report which consisted of application of the same instrument in a nationwide representative sample of male and female health professionals in albania in 2014 (9). the internationally valid instrument for assessment of leadership competencies in the current study had an overall reasonable internal consistency, particularly for the required (necessary) leadership competency level. this was also the case in the previous study conducted in 2014 (9). interestingly, the mean difference between the required and the current level of leadership competencies was higher for male health professionals working in top managerial positions. this finding points to the urgent need for specific leadership training of public health professionals operating in key managerial positions in albania. furthermore, the mean difference between the required and the current level of leadership competencies was higher for male health professionals working in urban areas of albania. this finding is somehow intuitive considering the pressure and demands for high-quality services in urban areas, especially in large cities of albania (particularly in tirana). in the previous study, which was conducted in albania in 2014 employing the same measuring instrument (7,9), there were included 162 men aged 44.9±10.6 years and 105 women aged 44.4±9.9 years (9). in this sex-pooled sample of male and female health professionals in albania surveyed in 2014, the mean value of the overall summary score for the 52 items of the leadership instrument was 138.4±11.2 for the current leadership competency level compared with 159.7±25.3 for the required leadership competency level (p<0.001) (9). also, most of the subscales’ caushaj k, czabanowska k, roshi e, muja h, burazeri g. leadership competencies among male health professionals in a western balkan country (original research). seejph 2019, posted: 26 april 2019. doi 10.4119/unibi/seejph-2019-213 page 8 of 9 scores of the leadership instrument in the study conducted in 2014 were significantly higher for the required than for the current leadership competency level (9), a finding which is somehow similar to our current study conducted in 2018. competencies in the area of public health leadership are considered essential components for the performance and ongoing activities of health professionals at all levels of health care services in a wide range of settings and organizational structures (14). as described elsewhere, developing effective leadership is vital in most of the european countries given the considerable financial pressures of the public health systems and their need to deliver more services in line with declining resources and financial constrains (15). in the context of albania, the curriculum of both undergraduate and postgraduate public health programs does not adequately promote leadership skills and competencies for future health professionals (9). however, a similar trend is observed in many other countries where teaching of leadership is still not common in public health training programmes (14,15). this is especially the case in countries experiencing intensive public health reforms including albania. hence, there is an urgent call for a considerable investment in leadership training for public health professionals worldwide (16). this study may have several limitations including the study design, sampling strategy and the information obtained. regarding the possibility of selection bias, a nationwide representative sample of male health professionals was included, which is comforting. concerning the instruments of data collection, this study used an internationally standardized instrument (7), which had been previously validated in albania (8) and subsequently applied to a larger sample of health professionals (9). overall, the instrument used for the measurement of leadership competencies indicated good internal consistency. nevertheless, the internal consistency was not high enough for some subscales of, particularly, the current leadership competency level. regarding the possibility of information bias, there is no reason to assume differential reporting in the actual or the required levels of leadership competencies among male professionals involved in this study. nonetheless, the possibility of information bias cannot be entirely excluded, as it is never the case with this type of surveys. finally, findings from cross-sectional studies are not assumed to be causal and should be interpreted with caution. in conclusion, regardless of its potential limitations, this study provides recent information about the current and the required level of leadership competencies among male health professionals in transitional albania, based on an internationally valid instrument, which has been previously validated and administered in albanian settings. as convincingly argued (7,9), application of this useful instrument enables the recognition of possible gaps in the level of existing leadership competencies and the required (necessary) level of leadership competencies, which will eventually inform the public health curricula about necessary content adjustments. therefore, policymakers and decision-makers in albania and other countries in the european region should be aware of the existing gap between the required and the current level of leadership competencies among health professionals operating at all levels. caushaj k, czabanowska k, roshi e, muja h, burazeri g. leadership competencies among male 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commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed?term=czabanowska%20k%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=smith%20t%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=k%c3%b6nings%20kd%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=sumskas%20l%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=otok%20r%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=bjegovic-mikanovic%20v%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=bjegovic-mikanovic%20v%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=brand%20h%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed/24121098 http://www.ncbi.nlm.nih.gov/pubmed/24121098 http://doi.org/10.4119/unibi/seejph-2015-51 http://doi.org/10.4119/unibi/seejph-2015-51 http://www.ncbi.nlm.nih.gov/pubmed/?term=czabanowska%20k%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=rethmeier%20ka%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=lueddeke%20g%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=smith%20t%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=malho%20a%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=otok%20r%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=otok%20r%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=stankunas%20m%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=czabanowska%20k%5bauthor%5d&cauthor=true&cauthor_uid=23399070 http://www.ncbi.nlm.nih.gov/pubmed/?term=smith%20t%5bauthor%5d&cauthor=true&cauthor_uid=23399070 http://www.ncbi.nlm.nih.gov/pubmed/?term=stankunas%20m%5bauthor%5d&cauthor=true&cauthor_uid=23399070 http://www.ncbi.nlm.nih.gov/pubmed/?term=stankunas%20m%5bauthor%5d&cauthor=true&cauthor_uid=23399070 http://www.ncbi.nlm.nih.gov/pubmed/?term=avery%20m%5bauthor%5d&cauthor=true&cauthor_uid=23399070 http://www.ncbi.nlm.nih.gov/pubmed/?term=otok%20r%5bauthor%5d&cauthor=true&cauthor_uid=23399070 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 1 original research from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003 aloysius p. taylor1 1 affiliation: independent consultant corresponding author:aloysius p. taylor address: monrovia, liberia e-mail: aloysiustaylor@hotmail.com mailto:aloysiustaylor@hotmail.com� taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 2 abstract aim:to explore the experience of fighters disabled during the liberian civil war; what they did and what was done to them; and what happened after their demobilization. methods:six focus group discussions were organized in monrovia, the capital of liberia, with 50 invalid veterans aged 10 to 25 at their entrance into the war and eightwomen wounded, although civilians, sampled as in convenience. in addition,sevenkey-informant interviews took place. all encounters were agreeably taped, transcribed and summarized under the items of the discussion guide. results:most ex-combatants joined the fighting to protect themselves and their families who were targeted by rebel fighters or joined to revenge the killing of close family members by fighters from all sides including government soldiers. nearly all the former fighters interviewed expressed their desire to be trained in various areas of life skills. a vast majority of the ex-combatants are living from begging in the streets.those from factions feel that government cares for former regular soldiers and discriminates those from other warring factions. the lack of housing for ex-combatants with war related infirmities is of paramount concern to them. they feel that the post-war reintegration program did not achieve its objectives. in the communities, they are stigmatized, blamed as the ones who brought suffering to their own people. the key informants are calling for establishment of trust fund for survivors of the civil war who are disabled. recommendations: establishment of a trust fund for survivors of the civil war who are disabled; reform of the national bureau of veteran affairs to include the disabled ex combatants of all former warring factions; erection as planned of the proposed veterans hospital; a national census of disabled ex-combatants and war victims. keywords:civil war, demobilization, disabled combatants, liberia, reconciliation. conflicts of interest:none. acknowledgements: this study has been conducted with service providers in mind, based on the social, economic and health status of the former fighters who were wounded and made disabled by the liberian civil war. first and foremost, many thanks go to professor dr. ulrich laaser who took special interest in the disabled former combatants to the extent that he contributed the financial resources to enable the conduct of this study. he also encouraged colleagues of his to assist the research team implement. prominent among this is dr. moses galakpai who provided technical support to the research team and roosevelt mccaco who in his free time took care of the financial management. we appreciate the work of the research team members who made valuable contributions to the development of the documents leading to the completion of the study. special recognition goes to mr. richard duo of the amputees football club for his coordinating role in facilitating the key informant and focus group interviews. funding: private. taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 3 foreword the civil conflict has been over for nearly as many years as it lasted. the scars however are as visible today as were the horrible episodes of atrocities that characterized life during the war years. the wrecked economy of liberia following the onset of the civil war, gross human rights violations, involvement of child soldiers and use of harmful substances by both armed fighters and civilians are all hallmarks of the liberian civil war. thousands of young people who were active members in the numerous fighting forces got maimed and are today disabled for various causes. what is true for nearly all of them is the fact that they are living under difficult circumstances no jobs, no housing, and no sustainable care. with no preparation to face the harsh post conflict and post ebola environment in liberia, the disabled ex combatants deserve attention that will give them hope, attention that will harness their potentials not only for sustaining themselves but for promoting peace in the nation. this publication, though conducted in only one of the 15 counties of liberia, contributes to the knowledge needed for the attainment of a better living condition for disabled ex-combatants as well as promoting sustainable peace in liberia. dr. moses kortyassahgalakpai former deputy minister of health republic of liberia taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 4 introduction liberia, to mean „land of the free‟, was founded by freed american slaves who were sponsored to settle in africa as early as 1822. annexation of land from the indigenous tribes enabled the country to be formed until statehood was declared 1847. the lack of full integration of the indigenes was the main trigger for the civil war beginning on christmas eve in1989 (1). the large number of young people exposed to arms and use of harmful substances constitutes a significant risk for the sustainability of peace in the country.the idea to undertaking this explorative study into their feelings and experience comes from the general observation of the appalling conditions of disabled veterans. unable to earn a living due to the lack of skills compounded by the fact that they have lost parts of their bodies, the former combatants are in serious need of assistance which is not forthcoming. not only are the disabled ex-combatants unable to provide daily food for themselves, but they are under incessant barrage of accusations of bringing suffering to their people. such stance inhibits a free flow of material assistance to them as well as social acceptance (2). therefore this investigation attempts to documentfrom their own wordsthe past and present experience of former fighters who were disabled and traumatized during the civil war in liberia including a selected number of civilian women wounded. in addition key informants have been interviewedand asked for their analysis and recommendations. methods study population the qualitative studytook place inmontserrado county which includes the capital monrovia with more than a million inhabitants, about a quarter of liberia‟s entire population. the respondents were recruited by non-probability sampling as in convenience between march 29 and may 3, 2017 through the amputees football club in monrovia (4) and consisted of two categories of respondents: the first comprised of five focus groups of ten former combatants each, together 50participants who were disabled as a result of their participation in the fighting. these persons were from various fighting forces including those from the national army. additionally, there were eight women who received their disabilities from bullets and bombs even though they were civilians; some were targeted while others were accidental.the selection process did not allow anyone to attend more than one focus group. focus group discussions the study relied on a participatory approach and semi-structured narrative format.the discussion guide for the focus groups,taking about three hours,comprised a set of nine questions, assembled by four experts three liberian and one european familiar with the setting. the questions were introduced to the focus groups by a moderator: 1) why and for which faction (out of eight) did you join the fight? 2) what was your rank and war-name and what weapons did you use? 3) what made you brave and how did you get wounded? 4) did you commit atrocities yourself? 5) did you meet later your comrades or your victims? 6) what is your experience with the demobilization program after the war ended? 7) where and how do you live now and how are you received by the community? 8) are you satisfied with your living conditions and what are your expectations? 9) how did you as a women experience the civil war?voices of female survivors. taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 5 key-informant interviews the seven key informants contacted had witnessed events during the civil war and were knowledgeable about former fighters and the programs initiated for their return to civilian life. they saw what happened or took part in what happened such as rendering social, relief or medical services to the population affected by the war. these included stakeholders and others such as project officers, focal point persons in security sector institutions, community leaders, and relevant government personnel. although they were professionals in their own right, some of them were seen as rebel supporters because they operated in particular geographic locations controlled by warring factions. seven such persons were interviewed on issues surrounding the following topics: 1) the disarmament, demobilization, rehabilitation and reintegration program (ddrr) 2) key challenges facing ex-combatants 3) strategic recommendations information processing all encounters were agreeably taped, transcribed and summarized under the items of the discussion guide by a team of liberians under the guidance of the author. results i. the focus group interviews (fdg) characterization of the participants most of the discussants were young school-going children, when the war started. however, as the war progressed educational institutions in the war-affected areas were shut down, leaving thousands of idle youths susceptible to align themselves as child soldiers, boys and also girls (5),with the warring faction that was present in their areas of domicile. 1) why and for which fraction did you join the fight? for most, as seen from their age profile, serving in the military was never then thought of. the discussants disclosed that the war was brought home when they witnessed the gruesome murder and mutilation of their relatives, the personal pain inflicted on them by those bearing arms whether government troops or members of opposing warring factions, the looting of their family‟s properties or just the excitement of being with members of their age group, all thatserved according to them as motivating factors to become fighters themselves. a couple of others were forcefully recruited and others joined because they were used as porters of ammunition and goods for the men at arms.defections from the national army became commonplace joining one of the rebel factions (see box), some related to ethnical or religious background. their allegiance to the armed group to which they belonged became stronger than the bond with their families and socio-cultural institutions that nurtured them and that they once respected. 2) what was your rank and war name and what weapons did you use? in order to persuade their men to obey their authority, those in command assigned meaningless ranks to fighters under their command. such arbitrary ranks gave them an air of greatness. additionally, there was no previous training to back the ranks. the discussants informed that rebel training sometimes lasted for only two months. examples of these fake ranks given by the discussants are: field commander, full colonel, general, captain, brigadier general, lt. colonel, major, chief of staff. taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 6 war-names or nicknames played an important role in the behavior of the individual combatant and how he/she was perceived by comrades and commanders. besides being used as a means to motivate combatants into action, nicknames served to conceal the real identity of the fighter. nicknames were also used to promote certain behavior of the fighter. for example, “dog killer” could mean killer of the enemy (the dog). someone bearing such nick name would live to prove that he is a killer of the enemy. similar other nicknames of discussants were: major danger, super killer, no ma no pa. the discussants indicated that they used various weapons during the course of the war. the predominant one was the kalashnikov (ak47 and others in the series). the combatants used the guns to exploit the civilians in their controlled areas, a major factor for the mass exodus of people out of the country. the proliferation of small arms in all areas controlled by warring factions made the entire country unsafe at the time especially that the combatants according to them served as the “justice systems” in their controlled areas. many of these weapons were traded among warring factions as some combatants switched sides or needed money. however, heavier weapons fielded were more supervised by those in command. 3) what made you brave and how did you get wounded? myths and rumors surrounding the composition of rebel fighting forces and their use of mystic powers coupled with the government‟s mismanagement of the war, greatly aided the demoralization of the better trained government troops to the point of stimulating mass defections.the rapid advance of rebel forces mainly rested on the highly motivated youths most of whom were given drugs and other substances to influence their behavior, giving them a false sense of invincibility. some others mentioned the use of drugs and strong alcoholic drinks given them by their commanders as sources of their bravery. some wore amulets on their necks and “hands for protection” against bullets. a discussant explained that he was given a talisman belt to wear around his waist which could hold him tight and become very hot when enemies were around. these good luck charms turned up to be fake; many fighters died or got wounded due to their belief in these charms. other reasons cited as sources of their bravery are as follows: • colleagues made me brave • afl distributed the new testament bible • god and the arm given to me • the gun gave me power • the urge to revenge for the killing of relatives military groups named by participants as their own ones: armed forces of liberia (afl) • lofa defense force (ldf) • liberians united for reconciliation and democracy (lurd) • national patriotic front of liberia (npfl) o independent national patriotic front of liberia (inpfl) o national patriotic front of liberia-central revolutionary council (npfl-crc) • united liberation movement of liberia for democracy(ulimo) o united liberation movement of liberia for democracy-johnson faction (ulimo-j) united liberation movement of liberia for democracy-kromah faction (ulimo-k) https://en.wikipedia.org/wiki/armed_forces_of_liberia� https://en.wikipedia.org/wiki/lofa_defense_force� https://en.wikipedia.org/wiki/liberians_united_for_reconciliation_and_democracy� https://en.wikipedia.org/wiki/national_patriotic_front_of_liberia� https://en.wikipedia.org/wiki/independent_national_patriotic_front_of_liberia� https://en.wikipedia.org/wiki/national_patriotic_front_of_liberia-central_revolutionary_council� https://en.wikipedia.org/wiki/united_liberation_movement_of_liberia_for_democracy� https://en.wikipedia.org/wiki/united_liberation_movement_of_liberia_for_democracy-johnson_faction� https://en.wikipedia.org/wiki/united_liberation_movement_of_liberia_for_democracy-kromah_faction� https://en.wikipedia.org/wiki/united_liberation_movement_of_liberia_for_democracy-kromah_faction� https://en.wikipedia.org/wiki/united_liberation_movement_of_liberia_for_democracy-kromah_faction� taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 7 • american war movies • family members were not around, so fear left me when i joined. the discussants narrated various ways in which they received wounds which led to their disability today. to wit: • mistake from friendly forces • enemy fire, on the frontline • aerial bombardment by alpha jet • personal mistake handling grenade • fell in enemy ambush. some of the other causes of wounds which resulted into amputation of limbs are directly reflective of the low level of training of the fighters as regards safe handling of weapons. 4) did you commit atrocities yourself? discussants admitted that they also committed atrocities in response to what others did to them and their people. they said that they killed and raped in revenge for what was done to their family members or relatives. they informed that they saw wickedness in the extremes such disembowelling of pregnant women and using their intestines to intimidate other people at checkpoints. the discussants said that they burned houses and other peoples‟ properties because of anger. the discussants also admitted to beating people, looting goods and killing domesticated animals. asked if they have any regrets for also committing crimes against others, a few said they do regret but most of them said no, as they were under the influence of drugs or were forced by their commanders. one discussant said that he did not do anything to anyone but only killed enemies on the battlefield. 5) did you meet later your comrades or your victims? the participants said that they sometimes see their colleagues and those who commanded them during the war, most of them in same impoverished conditions as they are and sometimes even worse. these past commanders, they said, sometimes even asked for help from the disabled ex-combatants in this study: “our former commanders feel more frustrated than us, because they have no more power to do anything or command other people to do something for them”. some met also their victims and begged them to forgive, others saw them on the street but were not given a chance to talk to them or even beaten in revenge. 6) what is your experience with the demobilization program after the war ended? the most contentious issue reference the transition from active combatants to civilian life was the liberia disarmament, demobilization, rehabilitation and reintegration program (ddrr) up to 2009. nearly all of the discussants were not pleased with how it was handled. the vocational training to which some went was rather too short. they informed that they were promised packages at the end of the training which many of them did not receive. they said that their names were written down to be contacted when the packages were reading and up till now nothing has been done. a discussant informed that he entered the ddrr program and spent five days and afterwards used his id (identification) card to enter a vocational institution where he spent nine months, graduating with a certificate but the tools given him and his colleagues did not match the certificate. a few others admitted that they sold their id cards for money.according to discussants who fought for the warring factions, they are dissatisfied over how the government did not arrange a better package as that made for the regular soldiers when in their opinion all of them had served their country. • usd 150 was given to rebel fighters as a one-shot resettlement package taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 8 • government of liberia soldiers were given usd540 and also benefited from appropriate pension arrangement. 7) where and how do you live now and how are you received by the community? most of the disabled ex-combatants congregated in monrovia and its immediate environs for fear of reprisal as stigma against them in their original communities is described as high. most of them are blamed for the atrocities and the sufferings that the civilian population had to endure during the civil war. as a result the furthest distance from the city centre where most disabled are living turned out to becareysburg and gardnersville whereas the heaviest concentration is in paynesville, all less than 50 km away. the discussants were frankto also admitthat they wereashamed toreturn to their original places of residence. furthermore the high cost of rent, distance from their usual places of street begging and the fact that there are some people in their original locals who want them to die, were cited as compelling reason for finding new places to live.many of the fighters refused to go home even up to today. some participants were received well by their families but were rejected by their communities. one discussant said that his parents and other family members cried upon seeing him and later encouraged him not to harm himself. another discussant said that reception was good at first after ddrr but when the money they received from the ddrr was exhausted he was thrown out. yet another informed that he had a girl pregnant for him at time of disarmament but right after his money was finished too, she left him and said that the pregnancy was not his. the psychological anguish and social marginalization ex-combatants have been subjected to have led some of them to attempt suicide. the suicidal inclinations among freshly-wounded ex-combatants were motivated by feelings of being useless after losing limbs, ashamed of their conditions, thinking that they would be rejected by women, being mocked by children or just share embarrassment at the disability. asked why they did not carry out their desire to commit suicide after all, they gave the following reasons: • another disabled friend encouraged me not to kill myself • i made my own decision not to kill myself • nurses at the hospital talked to me and promised me “false legs” after one year. as a result of all these inconveniences, they move in groups and sleep in makeshift huts and market places where the night will find them after a hectic day of begging for alms from humanitarians in the street corners and in front of supermarkets and other public places. taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 9 figure 1. disabled war combatants 1017 8) are you satisfied with your living conditions and what are your expectations? the overwhelming majority of discussants indicated they are not satisfied with their present conditions, both physical and economic. however, they do accept the fact that their physical conditions in the given situation cannot be reversed, so they must live with it. they stated that “no one can be satisfied with this kind of condition, there is nothing we can do” (picture). all the respondents felt that the ddrr was hastily planed and haphazardly implemented and that the implementation period of less than 3 years was grossly inadequate. those who were enlisted in skills training programs were given 6 months to complete the training. they expected the program to last much longer to allow them acquire the knowledge and skills that are marketable. they expected the ddrr to provide free medical care and “we need housing and education for our children as well as jobs to move us from begging in the streets. we also need training to become peace ambassadors to reconcile our country and prevent war”. 9) how did you as a women experience the civil war?voices of female survivors “my son and his friend were hit when they went in our yard to get water from the well. i took them both to jfk hospital and when i went to front street, i was hit too and my hand got broken. i was assisted by government security and icrc; the ministry of finance gave me money to attend to my injury.” “i was a student in grade seven in 1996 when i got shot entering into my own father‟s house. the boy who shot me did it intentionally; five persons were also fired, 2 survived. i used tube for one year eight months.” “i got hit also in 1996. they took me to redemption hospital. one ecowas man helped me and carried me to ghana. i waited 9 month to remove the bullets. i lost one hand and foot.” “i made many attempts to kill myself, each time i tried to do so someone would interrupt.” “i did not go to school. i went to do business, when i got shot at the age of 23, only my mother stood by me, my boyfriend ran away.” “i have had two children since my injury. one is going to school.” “i am making and selling hand bags, neck ties, etc. don bosco taught me.” taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 10 “particles are still in my body; they can be removed but someone has to foot the bill.” “we need help. the government is not focused on the disabled.” “we need micro-loan, wheel chairs and all disabled materials” ii. perspectives of key informants during the study a number of key informants knowledgeable about the former fighters and the programs initiated for their return to civilian life were identified and interviewed. their perspectives have been summarized below. among the views expressed by all key informants is the fact that there was not a dependable exit strategy for the thousands of ex-fighters especially those who be invalids from the war. it is not surprising therefore that disabled ex-combatants are finding it difficult to survive today. having gained nothing from the war, physically impaired and not receiving any subsistence from government or other humanitarian organizations, the disabled ex-combatants civilians are the true victims of the liberian civil war. the key informants feel that for all practical purposes the ex-combatants are marginalized by the government of liberia and rejected by the larger society. 1) the disarmament, demobilization, rehabilitation and reintegration program (ddrr): all the key informants dubbed the ddrr program as a long-term failure exercise, not only because of its failure to retrieve all the weapons from the ex-combatants but its inability to implement a program for providing sustainable basis for marketable life skills. they were unanimous on their fact that the ddrr program also lacked credible trauma healing offering as well as the availability of psychosocial counselling. it is the view of some key informants that the major reason standing in the way of true reintegration of ex-combatants is that the ddrr only put a quick-fix program that did little to prepare the ex-fighters for the life they were destined to face after disarmament. 2) challenges facing ex-combatants: the current state of the disabled ex-combatants is appalling, their dependency on handouts to feed themselves and their dependents not guaranteed from day to day; hopelessness is written in their faces, said one key informant. their presence in the streets begging for livelihood reminds those who carry hurt in their hearts from the civil war. the informants generally believe that the provision of housing for disabled ex-combatants will not only dignify them and restore their self-esteem, but it will be easier to control or maintain them in any skilled training program that they may hereafter be given. they recommend skills training need assessment among disabled ex-combatants before any such training is initiated for them unlike the approach employed during the ddrr. a key informant who happens to be a medical doctor confided that some of those who sustained bullets wounds in their bodies need follow-up treatment but they lack the means. if their exit strategy had been thoroughly planned, a referral program could have been in place to address such persons‟ conditions.the need for access to free health care was discussed and emphasized. summary of some major findings • most ex-combatants joined the fighting to protect themselves and their families who were targeted by rebel fighters • others joined to revenge the killing of close family members by fighters from all sides including government soldiers • some ex-combatants joined the fighting because they were tired of carrying looted materials or taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 11 3) strategic recommendations the ex-combatants, especially those who are disabled and had come from the warring factions, are no longer in the mathematics associated with post-war assistance to fighters. the national bureau of veterans affairs caters exclusively to former armed forces of liberia (afl) fighters. there is no provision for free medical service. the afl still maintains a medical unit but does not have the mandate to give free treatment to disabled ex-fighters. an elaborate plan for the construction of a veterans hospital never got off the blueprint. aside from their inability to provide basic needs for themselves, disabled ex-combatants as well as their civilian victims need support to upkeep and educate their children. the need for conducting a census of those who became disabled by the war, ex-combatants as well as their victims, was underscored. women in this category were in significant number and are grappling with life‟s challenges. their leadership is calling for reparation for these innocent people and they have been advocating for this since the days of the trc, the truth and reconciliation commission, enacted by the parliament in 2005 but nothing has materialized. some disabled could be trained to perform a variety of tasks for their sustenance and for the promotion of national peace and security. they could be prepared to serve as receptionists, ticket sellers for the lma, the liberia marketing association, at city parking services, car washers and the like. discussion and recommendations certainly an explorative investigation as presented here does not allow generalizingthe results. however even the limited information collected indicates a major deficit in dealing with the sequelae of the liberian civil war. the hardship imposed on the disabled by the very nature of their disabilities is exacerbated by the lack of opportunities for gainful employment to match their various forms of disabilities and skills, the uncertain source of daily meal and sometimes hostile attitude from some of the community members. this investigation,however underlines the need to execute a more representative study including ammunition for fighters through long distances • nearly all the former fighters interviewed expressed their desire to be trained in several areas of life skills • a vast majority of the ex-combatants are living from begging in the streets. • several ex-combatants are concerned about the education of their children and are asking for educational support for them • ex-combatants want to serve as peace ambassadors and are requesting to be trained to serve as counsellors for other youths to deter them from engaging in violent activities and prevent war in this nation • those from factions feel that government cares for former afl soldiers and discriminates those from other warring factions • the lack of housing for ex-combatants with war related infirmities is of paramount concern to them • the ex-combatants feel that the ddrr program did not achieve its objectives because it was poorly planned and implemented in the rush • in the communities, they are stigmatized. they are blamed as people who brought suffering to their own people. • they are denied job opportunities even when the job requires only elementary school knowledge • they are discriminated against even by taxicabs especially if they carry crutches. • the key informants are calling for establishment of trust fund for survivors of the civil war who are disabled. taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 12 the disabled war veterans as well as their victims, a study which would allow representative data and their advanced qualitative and quantitative analysis. the present publication can only serve as a trigger. nevertheless the findings of the study demonstrate that the ex-combatants of the civil war and even more the disabled civilian victims are forgotten not only by the government of liberia, but also by aid agencies. the post-war status of the ex-combatants was not factored into the transitional arrangements such as the ddrr program for the combatants‟ return to civilian lifeconfirming an earlier analysis of 2007 (6). if government and the nation at large continue to ignore the plight of these sizable population groups, the security of the nation will remain fragile(7) and national reconciliation will be elusive and unachievable. it is therefore recommended with priority that: • the government of liberia revisits or reforms the national bureau of veteran affairs to include the disabled ex-combatants of all former warring factions. • the proposed veterans hospital be erected as planned to cater to the health needs of active service personnel, veterans of the civil war and disabled ex-combatants of former warring factions for whom no health service is available. while this is being done, it is recommended that the mandate of the afl medical unit be expanded to provide free medical service to the disabled ex-fighters and war victims. • a national census of disabled ex-combatants is executed, an imperative about peace building in the aftermath of the civil crisis. this exercise would provide a thorough needs assessment that will put into place client-responsive actions that promote peace building, reconciliation and inclusiveness of those who are disabled by the war either during active combat or civilians as a result of inadvertent explosions and wanton acts of cruelty (8). • arrangements be made for a minimal (financial) survival package for each disabled ex combatant which can enable them to afford at least a meal a day so that they will be able to contribute to national peace and reconciliation efforts. furthermore it is highly recommended that: • some low cost housing arrangement be put into place for all disabled victims of the war. • carefully designedlife skills training programs that are effective and efficient to make ex combatants marketable or capable of sustaining themselves instead of begging in the streets. • continued education programs for ex-combatants who have dropped out of school due to lack of support and are desirous of learning be established. • scholarship programs and tuition support for children of war victimsare put in place. references 1. gerdes f. civil war and state formation, the political economy of war and peace in liberia. campus frankfurt/new york; 2013. 2. lord je, stein ma: peacebuilding and reintegrating ex-combatants with disabilities. the international journal of human rightsvol. 19/3,2015. http://www.tandfonline.com/doi/full/10.1080/13642987.2015.1031515?src=recsys. 3. harrell mc, bradley ma. data collection methods semi-structured interviews and focus groups. rand corporation: santa monica, ca: 2009. http://www.rand.org/content/dam/rand/pubs/technical_reports/2009/rand_tr718.p df. 4. bloomfield s. liberia's amputee footballers: from civil war to african champions their injuries are a painful reminder of a bitter conflict, but this football team is http://www.tandfonline.com/doi/full/10.1080/13642987.2015.1031515?src=recsys� http://www.tandfonline.com/doi/full/10.1080/13642987.2015.1031515?src=recsys� http://www.tandfonline.com/doi/full/10.1080/13642987.2015.1031515?src=recsys� http://www.rand.org/content/dam/rand/pubs/technical_reports/2009/rand_tr718.p� http://www.rand.org/content/dam/rand/pubs/technical_reports/2009/rand_tr718.p� http://www.rand.org/content/dam/rand/pubs/technical_reports/2009/rand_tr718.p� taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 13 bringing pride to the country. the observer, 10 january 2010. https://www.theguardian.com/sport/2010/jan/10/liberia-amputee-football. 5. international labour office, programme on crisis response and reconstruction:red shoes experiences of girl-combatants in liberia. report coordinated by irma specht, geneva; 2017. http://www.ilo.org/wcmsp5/groups/public/@ed_emp/@emp_ent/@ifp_crisis/docume nts/publication/wcms_116435.pdf. 6. jennings km.the struggle to satisfy: ddr through the eyes of ex-combatants in liberia. international peacekeepingvol. 14/2,2007. http://www.tandfonline.com/doi/full/10.1080/13533310601150800?scroll=top&need access=true. 7. wiegink n.former military networks a threat to peace? the demobilisation and remobilization of renamo in central mozambique. stability: international journal of security and development. 4/1, 2015; p.art. 56. doi: http://doi.org/10.5334/sta.gk. 8. johnson k, asher j, rosborough s, raja a, panjabi r, beadling c, lawry l. association of combatant status and sexual violence with health and mental health outcomes in post-conflictliberia. jama 2008;300:676-90. doi: 10.1001/jama.300.6.676. © 2017 taylor; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.theguardian.com/sport/2010/jan/10/liberia-amputee-football� http://www.theguardian.com/sport/2010/jan/10/liberia-amputee-football� http://www.ilo.org/wcmsp5/groups/public/%40ed_emp/%40emp_ent/%40ifp_crisis/docume� http://www.ilo.org/wcmsp5/groups/public/%40ed_emp/%40emp_ent/%40ifp_crisis/docume� http://www.ilo.org/wcmsp5/groups/public/%40ed_emp/%40emp_ent/%40ifp_crisis/docume� http://www.tandfonline.com/doi/full/10.1080/13533310601150800?scroll=top&amp;need� http://www.tandfonline.com/doi/full/10.1080/13533310601150800?scroll=top&amp;need� http://www.tandfonline.com/doi/full/10.1080/13533310601150800?scroll=top&amp;need� http://doi.org/10.5334/sta.gk� https://www.ncbi.nlm.nih.gov/pubmed/?term=johnson%20k%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=johnson%20k%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=rosborough%20s%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=raja%20a%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=raja%20a%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=raja%20a%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=beadling%20c%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=beadling%20c%5bauthor%5d&amp;cauthor=true&amp;cauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/18698066� http://creativecommons.org/licenses/by/3.0)� original research aloysius p. taylor1 1 affiliation: independent consultant abstract conflicts of interest:none. foreword introduction methods study population focus group discussions key-informant interviews information processing results the focus group interviews (fdg) figure 1. disabled war combatants 1017 perspectives of key informants discussion and recommendations references lueddeke g. toward holistic governance in an interdependent world (editorial). seejph 2017, posted: 26 november 2017. doi 10.4119/unibi/seejph-2017-176 1 editorial toward holistic governance in an interdependent world george r. lueddeke1 1 one health education task force. corresponding author: george r. lueddeke, chair, one health education task force; address: 9 lakeland gardens, southampton, hampshire, so40 4xg, united kingdom; email: glueddeke@aol.com lueddeke g. toward holistic governance in an interdependent world (editorial). seejph 2017, posted: 26 november 2017. doi 10.4119/unibi/seejph-2017-176 2 in an informative piece, ‘what do we mean by governance?’ (1), anna bruce-lockhart, editor at the world economic forum, cuts through a lot of the ‘buzzwords’ that are used to describe governance. she refers to governance in its ‘purest form’, that is ‘the structures and decisionmaking processes that allow a state, organization or group of people to conduct affairs’ and applies the term to organisations, such as the international monetary fund, the world bank and the united nations (un) that ‘have an authority that is recognized in the world’. in a business context, the label generally refers to how companies regulate themselves and contribute to the regulation of global frameworks. referencing the australian audit office, she shares the view that good governance is about openness, transparency, integrity, effective collaboration, and performance orientation. she emphasises that it is a central concept that applies to most areas and levels of human activity, and includes human rights, freedom of speech, economic transactions on a worldwide basis, full access to the internet, and to financial markets. unfortunately, however, given the risks facing us categorised as global warming, global divides, global security, global instability, and global health (2), few might question her conclusion: ‘global regimes are experiencing an erosion of authority in the face of intensifying threats’. more might agree that as things stand “textbook” political governance is generally not working on the global, regional and national stage anymore. on many counts, it is a failing concept.as edward lucas, former editor of the economist, points out, ‘the brexit vote and donald trump’s election in the us both stem from a widespread feeling that the system no longer works properly. in the advanced industrialised world, two thirds of the population, or 580 million people saw their incomes before taxpayer-financed top-ups stagnate or fall between 2004 and 2014. between 1993 and 2005 that figure was only 10 million (3). professor ian goldin at oxford martin school in his book “divided nations: why global governance is failing, andwhat we can do about it” (4), highlights that one of the main reasons why we are failing ‘to manage global issues’-migration, climate change, cybersecurity etc. alongside their preventionis that global institutions, such as the un as well as most other ones, have not kept pace with ‘their growing complexity and danger’ and as a result are no longer fit for purpose. the author puts forth that we need ‘a fundamental rethink of the way we approach global governance’. in his view governance is failing in global institutions because their power or authority is ‘circumscribed by its members.’ in other words, as we have seen time and time again in the un security council member allegiance is generally not to the unto which they all belong but to their respective nation-states. to make these institutions work for the benefit of the world or region would mean ceding powers to them, which as history has shown is highly unlikely. the difficult question, then, is howself-interests and cooperation for the common good can be reconciled? one option for professor goldin is to view sovereignty in a different light –‘to imagine a world where sovereignty is not just about preventing but also about enabling. if we redefine sovereignty, to look beyond coercion and exclusion but also consider cooperation and inclusion, it no longer makes sense as something one can monopolize’. a hallmark of the seventeen un -2030 sustainable development goals (5) with which most are now familiar,is their interconnectedness and interdependency-as examples, climate, health, food production, peace, education, prosperity, security and that progressing the goals and targets could be optimised by “building co-operative organisations out of self-interested components”. this fundamental principle underpinning the un-2030 agenda and the sdgs could apply equally well to other issues of global governance (trade, migration, conflicts), that is, ensuring that interactions and negotiations take a more holistic approach tackling https://www.weforum.org/agenda/authors/anna-bruce-lockhart� lueddeke g. toward holistic governance in an interdependent world (editorial). seejph 2017, posted: 26 november 2017. doi 10.4119/unibi/seejph-2017-176 3 complementary global issues so that what one nation may lose on one issue (e.g., migration), it can gain on another, rather than dealing with only one hurdle at a time often leading to an unsatisfactory outcome or at best a stalemate (6). streamlining the committee structures of many organisations (e.g., un, eu) could be a useful first step to dealing with multi-faceted issues or problems, arriving at more realistic outcomes while also saving time especially if a horizontal management structure is put in place, providing ‘a balanced equilibrium between bottom-up initiative and top-down support’ (7). while research into distinctive areas of knowledge continues to be vital in gaining a better understanding of the world we inhabit, it has also been the cause of fragmentation, competition and tensions (6). the differentiation of school subjects and medical specialisations (over 100 in us) are examples of how society has tried to cope with the everincreasing range, complexity and depth of knowledge integral to the planet and our relationship to it. one estimate is that knowledge is now doubling every twelve months and may soon do so every month. reductionism and silo approaches to tackling global issues as applied in the 19th and 20th centuries persist (e.g., ebola crisis) but no longer work when we know, as example, that the drought in california is linked to deforestation in the amazon rainforest and that unregulated migration to europe is related to political hegemony, ideological extremism, climate change, food insecurity, education, unemployment and regional conflicts.the separation of ecology, democracy, social justice, prosperity and peace and the impact these have on the health and well-being of people and the planet can no longer be justified and neither can effective governance that underpin these factors. rather than focusing strictly on human dimensions governance is tasked with taking a broader perspective considering the interplay between humans, animals, plants and the environment. the concept is known as one health (8,9) and has been taken on board by many organisations globally – the world medical association, the world veterinary association, the interaction council, made up of former heads of state and ministers, the oecd, and the cdc, among many others (9). the pressing need to adopt the concept and collaborative approach is exemplified by the devastation in syria: not only did it lead to the destruction of a society – over 500,000 lives half children needlessly lost along with countless farm animals and poisoned land but it also impacted severely on the constituents that make life possible in the first place -undermining biodiversity and the ecological systems in general. while agreeing with the attributes about ‘good governance, identified earlier (1), perhaps consideration might also be given to another,that is, recognising that ‘governance’ has a higher purpose the sustainability of people and planet. achieving this aim would require adoption of a new worldview to ensure that our needs as human beings are compatible with the needs of our ecosystem upon which all life and our activities depend (10). embracing the mantra ‘one health in all policies’ (6) could be a timely and ground-breaking first step toward realising the ‘governance’ we need. conflicts of interest: none. references 1. bruce-lockhart a. what do we mean by governance? https://www.weforum.org/agenda/2016/02/what-is-governance-and-why-does-itmatter/ (accessed: 26 february, 2016). 2. laaser u. a plea for good global governance. front public health 2015;3:46. doi: 10.3389/fpubh.2015.00046. lueddeke g. toward holistic governance in an interdependent world (editorial). seejph 2017, posted: 26 november 2017. doi 10.4119/unibi/seejph-2017-176 4 3. lucas e. it’s not only mugabe who has failed his people. the times (comment, p. 31); november 17, 2017. 4. goldin i. divided nations. why global governance is failing, andwhat we can do about it. oxford: oxford university press; 2013. 5. united nations. sustainable development knowledge platform. https://sustainabledevelopment.un.org/sdgs (accessed: 23 november, 2017). 6. lueddeke g. global population health and well-being. toward new paradigms, policy andpractice. new york: springer publishing company; 2016. 7. laaser u, dorey s, nurse j. a plea for global health action bottom-up. front public health 2016;4:241. doi: 10.3389/fpubh.2016.00241. 8. one health commission (ohc). mission. https://www.onehealthcommission.org (accessed: 23 november, 2017). 9. lueddeke g. achieving the un-2030 global goals for a sustainable future through one health principles and practice. 2nd global conference on one health. world veterinary association and the world medical association in association with the japan veterinary association and the japan medical association, kitakyushu city, japan; 10-11 nov 2016. 10. lueddeke g. toward a new worldview: one health, one planet, one future (in progress). ______________________________________________________________________________________ © 2017 lueddeke; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://urldefense.proofpoint.com/v2/url?u=https-3a__www.onehealthcommission.org_&d=dwmfaq&c=wo-rgvefibhhbzq3fl85hq&r=_gxceyeg6oihqft2wjoavyynkncfvlge7x4oso4jwxa&m=zaq1qmq5d6z5alwirzbi6bdag7codkthgtx9c-fhsd4&s=1mwq7emxydkru5t0xvp29bvnurut72vdjj3cuk4z2om&e=� in an informative piece, ‘what do we mean by governance?’ (1), anna bruce-lockhart, editor at the world economic forum, cuts through a lot of the ‘buzzwords’ that are used to describe governance. she refers to governance in its ‘purest form’, that is ... she emphasises that it is a central concept that applies to most areas and levels of human activity, and includes human rights, freedom of speech, economic transactions on a worldwide basis, full access to the internet, and to financial markets. unfor... more might agree that as things stand “textbook” political governance is generally not working on the global, regional and national stage anymore. on many counts, it is a failing concept.as edward lucas, former editor of the economist, points out, ‘th... professor ian goldin at oxford martin school in his book “divided nations: why global governance is failing, andwhat we can do about it” (4), highlights that one of the main reasons why we are failing ‘to manage global issues’-migration, climate chang... the author puts forth that we need ‘a fundamental rethink of the way we approach global governance’. in his view governance is failing in global institutions because their power or authority is ‘circumscribed by its members.’ in other words, as we hav... one option for professor goldin is to view sovereignty in a different light –‘to imagine a world where sovereignty is not just about preventing but also about enabling. if we redefine sovereignty, to look beyond coercion and exclusion but also conside... a hallmark of the seventeen un -2030 sustainable development goals (5) with which most are now familiar,is their interconnectedness and interdependency-as examples, climate, health, food production, peace, education, prosperity, security and that pr... this fundamental principle underpinning the un-2030 agenda and the sdgs could apply equally well to other issues of global governance (trade, migration, conflicts), that is, ensuring that interactions and negotiations take a more holistic approach tac... while research into distinctive areas of knowledge continues to be vital in gaining a better understanding of the world we inhabit, it has also been the cause of fragmentation, competition and tensions (6). the differentiation of school subjects and m... reductionism and silo approaches to tackling global issues as applied in the 19th and 20th centuries persist (e.g., ebola crisis) but no longer work when we know, as example, that the drought in california is linked to deforestation in the amazon rain... rather than focusing strictly on human dimensions governance is tasked with taking a broader perspective considering the interplay between humans, animals, plants and the environment. the concept is known as one health (8,9) and has been taken on boar... the pressing need to adopt the concept and collaborative approach is exemplified by the devastation in syria: not only did it lead to the destruction of a society – over 500,000 lives half children needlessly lost along with countless farm animals... while agreeing with the attributes about ‘good governance, identified earlier (1), perhaps consideration might also be given to another,that is, recognising that ‘governance’ has a higher purpose the sustainability of people and planet. achieving th... references bruce-lockhart a. what do we mean by governance? https://www.weforum.org/agenda/2016/02/what-is-governance-and-why-does-it-matter/ (accessed: 26 february, 2016). laaser u. a plea for good global governance. front public health 2015;3:46. doi: 10.3389/fpubh.2015.00046. lucas e. it’s not only mugabe who has failed his people. the times (comment, p. 31); november 17, 2017. goldin i. divided nations. why global governance is failing, andwhat we can do about it. oxford: oxford university press; 2013. united nations. sustainable development knowledge platform. https://sustainabledevelopment.un.org/sdgs (accessed: 23 november, 2017). lueddeke g. global population health and well-being. toward new paradigms, policy andpractice. new york: springer publishing company; 2016. laaser u, dorey s, nurse j. a plea for global health action bottom-up. front public health 2016;4:241. doi: 10.3389/fpubh.2016.00241. one health commission (ohc). mission. https://www.onehealthcommission.org (accessed: 23 november, 2017). lueddeke g. achieving the un-2030 global goals for a sustainable future through one health principles and practice. 2nd global conference on one health. world veterinary association and the world medical association in association with the japan veter... lueddeke g. toward a new worldview: one health, one planet, one future (in progress). petrela k, roshi m, laaser u, burazeri g. survey exploring the opinion of corresponding authors of articles published in the south eastern european journal of public health during 2014-2021 (short report). seejph 2021, posted: 09 july 2021. doi: 10.11576/seejph-4585 p a g e 1 | 6 short report survey exploring the opinion of corresponding authors of articles published in the south eastern european journal of public health during 2014-2021 kreshnik petrela1, meri roshi1, ulrich laaser1, genc burazeri1 1 south eastern european journal of public health. corresponding author: prof. dr. med. ulrich laaser dtm&h, mph; faculty of health sciences, bielefeld university address: pob 10 01 31, d-33501 bielefeld, germany; e-mail: ulrich.laaser@uni-bielefeld.de mailto:ulrich.laaser@uni-bielefeld.de petrela k, roshi m, laaser u, burazeri g. survey exploring the opinion of corresponding authors of articles published in the south eastern european journal of public health during 2014-2021 (short report). seejph 2021, posted: 09 july 2021. doi: 10.11576/seejph-4585 p a g e 2 | 6 abstract the aim of this survey was to assess the intentions of corresponding authors for publishing again in the south eastern european journal of public health (seejph), the aspects that they like most about the journal, and things which can be improved by seejph in order to be more attractive to potential contributors. a three-item questionnaire was sent out by email to all corresponding authors (n=89) who published in the 16 volumes of the seejph journal between 2014 and 2021. among 84 eligible corresponding authors, we collected 26 answers, or 31%. there were generally favourable and constructive comments, which is encouraging. the wide array of countries of the corresponding authors represents the successful global orientation of seejph. also, more than half of all related articles are classified as original papers, and the average of four authors per represented paper is satisfying. furthermore, all corresponding authors would publish again in seejph (“definitely”, or “probably”), and their numbers are almost equally distributed throughout 2014-2021. keywords: author survey, corresponding author, scientific journal, south eastern european journal of public health (seejph). acknowledgments: we express our gratitude to our publisher dr. hans jacobs, sebastian wolf, and all our supporters in the university of bielefeld/germany, our boards of editors, and our authors, friends, and colleagues. petrela k, roshi m, laaser u, burazeri g. survey exploring the opinion of corresponding authors of articles published in the south eastern european journal of public health during 2014-2021 (short report). seejph 2021, posted: 09 july 2021. doi: 10.11576/seejph-4585 p a g e 3 | 6 introduction in the past few years, there is evidence of an intensive proliferation and competition of many online scientific journals including also health sciences (1). hence, perceptions and practices of researchers regarding the current state of play and the future of scholarly publishing is important to be assessed and is actually subject to ongoing research (2). in 2014, the first volume of a new open access journal was published by jacobs company (3). the south eastern european journal of public health (seejph) is an open access international peer-reviewed journal involving all areas of the health sciences and public health (4). seejph welcomes submissions of scientists, researchers, and practitioners from all over the world, but particularly pertinent to transition countries (4). after six years of release of the journal, we aimed at exploring the opinions of all corresponding authors of the articles published in seejph. more specifically, we aimed at assessing the intentions of corresponding authors for publishing again in seejph, the aspects that they liked most about the journal, and things which can be improved by the journal in order to be more attractive to potential contributors. methods a three-item questionnaire was sent out by email twice (in february and april 2021) to all corresponding authors (n=89) who published in the 16 volumes of the seejph journal between 2014 and 2021. two emails of corresponding authors turned out to be not functional, whereas one of the corresponding authors was deceased. in addition, two other corresponding authors (co-authors of this short report) were excluded from the current analysis. overall, among 84 eligible corresponding authors, we collected 26 answers, or 31% (the complete excel database is annexed). results addressees responded from the following countries: albania, croatia, england, ethiopia, germany, ghana, greece, india, ireland, italy, ivory coast, kosovo, netherlands, north macedonia, poland, serbia, sweden. out of the represented publications, 14 studies (53.8%) were classified as original articles. the other 12 papers are distributed between reviews (n=3), reports (n=4), case studies (n=2), commentaries (n=1), and editorials (n=2). altogether, 104 scientists co-authored these papers, i.e. on average 4 authors per publication. the 26 corresponding authors participated during the period 2014-2021 in 10 additional articles, a total of 36 papers distributed over the years almost evenly with 6 publications in 2017, 2019, and 2020, and a minimum of 3 in 2015 and 2 in 2021 (only the first volume of the two planned in 2021). we addressed the corresponding authors per email as follows: “you have published in the south eastern european journal of public health (seejph) as the corresponding author. to develop the journal, we would like to ask you three short questions about your experience with seejph (please send your short answers as a reply to this email to kreshnikp@gmail.com):” question 1: would you publish again in seejph? (a. definitely, b. probably, c. unlikely, d. no) regarding the answers: 22 or 84.6% of the corresponding authors answered “definitely” and 4 authors answered “probably”. mailto:kreshnikp@gmail.com) petrela k, roshi m, laaser u, burazeri g. survey exploring the opinion of corresponding authors of articles published in the south eastern european journal of public health during 2014-2021 (short report). seejph 2021, posted: 09 july 2021. doi: 10.11576/seejph-4585 p a g e 4 | 6 question 2: what did you like about seejph (free wording)? answers (the favorable core terms underlined and listed in alphabetical order) include: open access; coverage of balkan (2 times); public health content; reasonable cost; format; innovative (new ideas); excellent organization; orientation; fast and helpful peer-review (19 times); global perspective; good quality; global readership; serious and correct; supportive; registered in scopus. question 3: what should be improved in seejph (free wording)? answers (core terms underlined and listed in alphabetical order) include: technical improvement of layout (2 times), copyediting (1 time), and website (4 times); orcid numbers; inform mainstream providers and provide volumes free of charge e.g. to elsevier, academic search ultimate, sciencedirect, emerald insight, proquest etc.; register with pubmed/medline; link to services (public health, medicine, health promotion, ministries of health); use of social media; more special volumes; more volumes per year. discussion the generally favorable and constructive comments are encouraging. the wide array of countries of the corresponding authors represents the successful global orientation of seejph. also, more than half of all related articles are classified as original papers, and the average of four authors per represented paper is satisfying given the widespread misuse of co-authorships (5). furthermore, all corresponding authors would publish again in seejph, definitely or probably, and their numbers are almost equally distributed throughout the years 2014-2021. most importantly, quality, organization, and fast peer-review are perceived as very positive, especially the fast and supportive peer review at the top with 19 out of 26 possible judgments (only one author perceived a delayed peer-review process). even more critical, and the primary purpose of the survey, are the suggestions for possible improvements: proactive information of mainstream providers, intensified use of social media, more publications per year (three or four partly special volumes per year), linkage to orcid, and improvement of the website layout and copyediting (together, seven times, or 26.9%). references 1. gasparyan ay, yessirkepov m, voronov aa, maksaev aa, kitas gd. article-level metrics. j korean med sci 2021;36:e74. doi: 10.3346/jkms.2021.36.e74. 2. gupta l, gasparyan ay, zimba o, misra dp. scholarly publishing and journal targeting in the time of the coronavirus disease 2019 (covid 19) pandemic: a cross-sectional survey of rheumatologists and other specialists. rheumatol int 2020;40:2023-30. doi: 10.1007/s00296-02004718-x. 3. the south eastern european journal of public health (seejph), published by jacobs verlag, hellweg 72, d-32791 lage, germany. 4. holst j, breckenkamp j, burazeri g, martinmoreno jm, schröder-bäck p, laaser u. five years of the south eastern european journal of public health (seejph): focusing on health systems in transition and global health. seejph 2018 (vol x). doi: 10.4119/seejph-1870. petrela k, roshi m, laaser u, burazeri g. survey exploring the opinion of corresponding authors of articles published in the south eastern european journal of public health during 2014-2021 (short report). seejph 2021, posted: 09 july 2021. doi: 10.11576/seejph-4585 p a g e 5 | 6 © 2021 petrela et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 5. zimba o, gasparyan ay. scientific authorship: a primer for researchers.reumatologia 2020;58:345-9. doi: 10.5114/reum.2020.101999. __________________________________________________________________________ petrela k, roshi m, laaser u, burazeri g. survey exploring the opinion of corresponding authors of articles published in the south eastern european journal of public health during 2014-2021 (short report). seejph 2021, posted: 09 july 2021. doi: 10.11576/seejph-4585 p a g e 6 | 6 annex. detailed answers of all corresponding authors who participated in the survey (excel database) the excel file is attached to this pdf. health development program for students at dormitories pilot scheme assessment sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 1 original research pilot scheme assessment: health development program for students at dormitories hulya sirin 1 , emine fusun karasahin 2 , basak tezel 1 , sema ozbas 1 , bekir keskinkilic 1 , secil ozkan 3 1 general directorate of public health, ankara, turkey; 2 erzurum provincial health directorate, erzurum, turkey; 3 gazi university, school of medicine, department of public health, ankara, turkey. corresponding author: emine fusun karasahin md, public health specialist, vice president. erzurum provincial health directorate, turkey; address: hastaneler cad. lapasa mah. no. 23, 25000, yakutiye, erzurum, turkey; telephone: +90442238 51 00; email: fusuncivil@gmail.com mailto:fusuncivil@gmail.com sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 2 abstract aim: this study, conducted in turkey, aims to increase the practicability of health counselling and protective services offered to young people in the long term. in the short term, it is aimed to determine health counselling needs of students at dormitories and it might enlighten researchers working in this field. methods: a pilot questionnaire, developed in order to determine health needs of students staying at dormitories, was conducted in two dormitories in ankara. focus group interviews were done, also. after that, in nine dormitories from nine provinces from all over the turkey, questionnaire and health screening tests were applied to 5,852 volunteers. results: the common topics for both sexes which students would like to receive counselling are nutrition and anxiety about exams. conclusion: as a result of the study, service has been planned for the identified needs of the students. keywords: counselling, dormitory, health, student, turkey, university. conflicts of interest: none. sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 3 introduction young population (aged 10-24 years) constituted 25% of the world population, 17% of the european population and 26% of the turkish population in 2013. years at university make up a new period in which important changes occur in the lives of this great population, considered to be a social and biologic transition. this period in which adolescence connects to adulthood and which includes a dynamic development and growth, requires careful research as it corresponds to the last stage of adolescence (1,2). those living at dormitories among university students constitute a group which has different social and emotional characteristics and which should be considered in terms of their needs and problems. these people generally stay far from home for the first time, need to cope with new situations without experience and support of their parents and are responsible for their health and lifestyle besides many other responsibilities. young adults develop behaviours to be conveyed to their adulthood or affect their health during this period. moreover, there are different lifestyles and challenging living conditions in the social area at university. many students adopt unhealthy behaviours and habits including malnutrition, smoking, physical inactivity, unsafe sex due to changes in their accustomed living conditions and patterns of education (3-6). the world health organization reported life quality of an individual depends on their own behaviours and lifestyles by 60%. many studies report health improving behaviours reduce the risk of diseases and death rate. many effects of health risk factors can be prevented by determining and changing unhealthy behaviours. a good health improving behaviour depends on living habits developed in the early period. considering “health in youth”, it should be noted that young people not only need to stay away from diseases physically and mentally, but also need to access necessary information and services to ensure this. for health of future generations, it is very important to understand, monitor, evaluate health behaviour tendencies and offer counselling to ensure adoption of a healthy lifestyle. unfortunately, information about health improving counselling services offered to young people at dormitories is limited in the literature (7-11). those in economically disadvantaged condition among students at universities in turkey mostly stat at state dormitories called “yurtkur" operating under the ministry of youth and sports, where our study was conducted. students live in high capacity rooms, at least 4 beds, use common bathrooms, toilettes and dining halls at these dormitories. this provides limited facilities to meet their personal needs. in our country, primary health care is offered in the family medicine system. although every citizen has a family physician according to registered address, students living away from their families generally have their physicians in the city of their families (as they do not transfer their registration). “youth counselling and health service centres" have been established to ensure young people benefit more from primary health care as they need a special treatment due to their age. these centres offer counselling services, training and information, diagnosis and treatment, referral to reference centres for adolescence at the primary care. the number of applications to these centres gradually decreased over the years. this study, conducted under the light of these conditions, aims at practicability of healthy counselling and protective services offered to this age group in the system. in the short term, it helps researchers try to determine health counselling needs of students at dormitories. methods operations to execute a program to promote health of students at dormitories began in january 2014. pilot schemes were implemented in 2 dormitories in ankara to provide a basis sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 4 for the scheme by the turkish public health institution department of child and adolescent health. after preliminary trial of the questionnaire, the questionnaire was applied to 26 males and 51 females in these 2 dormitories and a focus group interview was made with the dormitory managers. the results of the questionnaire and focus group interviews were shared at meetings held with the credit and dormitories institution (yurtkur) representatives, turkish public hospitals agency, general directorate of health promotion and cities where the pilot scheme would be implemented and the framework of the study were determined. health managers from 9 cities where 9 dormitories selected to implement the pilot practice on january 17 and february 4, 2014 were informed about the study in ankara and city plans were arranged. the project was initiated to implement the pilot practice in ankara, antalya, balikesir, diyarbakır, erzurum, istanbul, izmir, tekirdag and trabzon cities. as the sole purpose was to provide data for the program to be developed, these cities were selected randomly based on their sizes irrespective of representation of all students. there were approximately 4 million 300 thousand university students at 170 universities in our country as of 2013. according to yurtkur data, 365 dormitories in 81 cities, 145 districts and 2 points abroad offer service with a bed capacity of 310,000. eighteen thousand and fifty four students staying at dormitories were informed about general health, eye, teeth, skin and oral health, and the students were applied eye (2,351 students, 13.2%), teeth (3,410 students, 18.9%) and skin (2,130 students, 11.8%) screening on voluntary basis. the 14 item questionnaire developed to determine definitive characteristics of the students in the study was applied under supervision to 5,852 students (32.4%) who volunteered for participation (table 1). table 1. dormitories in the study, occupancy rates and rate of participation in the questionnaire name of province capacity survey participation percent * percent † female male total antalya 1,968 1,135 3,071 120 3.9 2.1 ankara 2,976 2,976 260 8.7 4.4 diyarbakır 1,020 1,020 494 48.4 8.4 i̇stanbul 1,072 536 1,608 725 45.1 12.4 i̇zmir 1,932 1,932 853 44.2 14.6 trabzon 2,611 2,611 1301 49.8 22.2 erzurum 1,500 1,500 352 23.5 6.0 balıkesir 1,136 888 2,024 1211 59.8 20.7 tekirdağ 696 616 1,312 536 40.9 9.2 (9 provinces 9 dormitories) 8,503 9,583 18,054 5,852 32.4 100.0 * row percentages. † column percentages. sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 5 the following findings were obtained from the pilot scheme conducted at 2 dormitories: • the top three health services requested by students are eye, teeth and skin health services. • the top topics they request counselling for are in the following order: – adequate and balanced nutrition – personal hygiene – anxiety about exams – anger management – healthy life habits – smoking, alcohol and drug use • students want to receive these counselling services especially from counsellors and medical personnel • information about hygiene and protective health services • psychosocial service personnel taking part in training of young people • visual based training about adequate and balanced nutrition, smoking, alcohol and drug abuse and sexually transmitted infections • separate planning for counselling and health service for male and female students • provide immediate and efficient information at periods of certain diseases (flu, measles etc.) • providing information about sleep problems • training about breathing exercises, methods of coping with stress the study protocol was approved by the gazi university ethics committee. the data used for this study do not include any identifiable personal information, and informed consent was waived by the committee. data was entered in the statistics package program and was analyzed with the same program. categorical variables were presented in figure and percentage and continuous ones were presented in mean ± standard deviation and median (min, max). chi-square, chi-square for trend tests and kruskal-wallis test were used. statistical significance level was determined as p≤0.05. results basing on the initial findings obtained from the pilot scheme, 5,852 students at dormitories accepted to take part in the questionnaire and/or screening. moreover, 8,000 students received training in conference forms about screened diseases (findings, clinics, etc.) and requested subjects. the screening results were shown in table 2. for female students, the mean age is 21.59 ± 1.99 and the median is 21 (16-41), the mean length is 163.72 ± 5.81 cm and the median is 164 (143 – 189) cm, the mean weight is 57.56 ± 8.45 kg and the median is 56 (37 – 110) kg, the body mass index mean is 21.46 ± 2.89 kg/m 2 and the median is 21.1(14.3 – 38.1) kg/m 2 ; for male students, the mean age is 21.85 ± 2.26 and the median is 22 (16 – 42), the mean length is 176.97 ± 6.41 cm and the median is 177 (152 – 197) cm, the mean weight is 74.07 ± 11.56 kg and the median is 73 (49 – 138) kg, the body mass index mean is 23.62 ± 3.28 kg/m 2 and the median is 23.4 (16.7 – 45.1) kg/m 2 . when distribution of body mass indexes of students was compared, the body mass indexes of male students were statistically significantly higher than female students (p<0.001). in all students, underweight rate was 9.8% (13.6% in girls; 3.6% in boys), normal weight rate was sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 6 73.5%, overweight rate was 14.3% (9.7% in girls; 23.8% in boys) and obesity rate was 2.4% (1.4% in girls; 4.5% in boys). the largest part of the students have stayed at dormitories for 1-3 years and the number of students staying in the same room is 3 for females and 4 and more for females for the highest level. table 2. pathologies identified in examined students the number of students diagnosed with pathologies the number of students who received a prescription the number of students referred to hospitals the number of students who received a recommendation eye diseases screening findings (n=2351) wink problems 595 64 315 190 eyelid diseases 31 5 5 17 eye infection 113 35 12 68 cross eye 15 1 3 6 other 278 65 64 136 total 1032 170 399 417 skin diseases screening findings (n=2130) allergic skin diseases 99 30 25 38 fungi 56 28 19 16 acne vulgaris 490 113 251 155 other 281 55 113 147 total 926 226 408 356 oral and dental diseases screening findings (n=3410) gingiva diseases 430 46 128 378 rate of decayed teeth 753 30 478 169 rate of filling 474 0 139 148 students with permanent teeth extracted 266 0 108 90 malocclusion and orthodontic disorders 99 0 55 61 other 94 1 10 13 total 2116 77 918 859 eight percent of the students have a chronic disease and 11.3% use regular medication. considering chronic diseases and regular medication intake by the time at the dormitory, there is not any significant difference in chronic disease frequency but the frequency of regular medication increases significantly with increased time at the dormitory (p=0.016). about 80% of the students are registered at a family physician. the highest frequency of application to a health centre is 1-11 months and it is generally less for male students. female and male students, who do regular sports, in other words 3 times a week or more, are less than 10%. sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 7 considering use of alcohol, male students are ahead of female students (9%-22%) and the largest group in all students reported to use alcohol once a month or less (about 75%). drug abuse was reported by 15 students out of 3823 students who answered this question (2 females 13 males). the frequency of use decreases significantly with increased time at the dormitory in the trend analysis (p=0.003). smoking is available in 37% of females and 63% of males (table 3). the frequency of smoking decreases significantly with increased time at the dormitory in the trend analysis (p=0.02). female students have been smoking for 3.6 ± 2.2 years and male students have been smoking for 4.2 ± 2.6 years. considering amount of smoking, females smoke 0.8 ± 0.4 and males smoke 1.0 ± 0.3 packages of cigarettes a day. table 3. distribution of certain characteristics and habits of students by gender females males n percent * n percent * total † p time at dormitory (n=3826) less than 1 year 566 61.4 356 38.6 24.1 0.002 1-3 years 1040 61.6 647 38.4 44.1 3-5 years 688 68.1 323 31.9 26.4 more than 5 years 121 58.7 85 41.3 5.4 number of students in the room (n=3821) 1 6 75.0 2 25.0 0.2 0.001 2 138 93.2 10 6.8 3.9 3 2008 77.9 570 22.1 67.5 4 and more 266 24.5 821 75.5 28.4 chronic disease (n=3008) yes 199 82.9 41 17.1 8.0 0.361 no 2228 80.5 540 19.5 92.0 regular medication intake (n=3837) yes 263 60.7 170 39.3 11.3 0.254 no 2163 63.5 1241 36.5 88.7 registry at the family physician (n=3757) yes 2022 65.2 1078 34.8 82.5 0.001 no 376 57.2 281 42.8 17.5 frequency of application to a medical centre (n=3808) less than 1 month 222 69.6 97 30.4 8.4 0.001 1-11 months 1460 65.9 755 34.1 58.2 1-3 years 528 59.0 367 41.0 23.5 more than 3 years 200 52.8 179 47.2 10.0 regular sports (n=3835) yes 449 47.7 493 52.3 24.6 0.001 no 1976 68.3 917 31.7 75.4 frequency of sports (n=3845) rarely (once a 2115 62.6 1263 37.4 87.9 0.006 sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 8 month or less) less than once a month-three weeks 57 64.0 32 36.0 2.3 1-2 times a week 45 59.2 31 40.8 2.0 3-4 times a week 147 67.7 70 32.3 5.6 everyday 67 78.8 18 21.2 2.2 alcohol use (n=3813) yes 218 41.8 304 58.2 13.7 0.001 no 2198 66.8 1093 33.2 86.3 frequency of alcohol use (n=263) rarely (once a month or less) 140 71.4 56 28.6 74.5 0.011 once a month-three weeks 32 66.7 16 33.3 18.3 twice a week and more 10 52.6 9 47.4 7.2 drug abuse (n=3823) yes 2 13.3 13 86.7 0.4 0.001 no 2418 63.5 1390 36.5 99.6 smoking (n=3841) yes 221 37.3 371 62.7 15.4 0.001 no 2208 68.0 1041 32.0 84.6 * row percentages. † column percentages. the top 5 topics for which female students would like to receive counseling are respectively nutrition, menstrual hygiene, communication in the family, anxiety about exams and personal hygiene. the top 5 topics for which male students would like to receive counseling are respectively nutrition, physical activity, healthy living habits, anger management and anxiety about exams (figure 1). considering change of request for counselling by the time at the dormitory, while demand for menstrual hygiene, anger management and anxiety about exams increases significantly with time (respectively, p=0.001; p=0.001, p=0.032); demand for personal hygiene, healthy living habits, physical activity and reproduction system habits significantly decreased with increased time (respectively, p=0.001; p=0.004; p=0.001; p=0.010). no significant change was observed in demand for other counselling topics (p>0.05). sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 9 figure 1. topics for which students would like to receive counseling based on gender 27.3 48.7 54.5 22.5 15.8 11.3 13.7 25.6 8.8 7.6 10.4 40.4 9.2 8.5 14.4 21.8 12.6 22 7.1 39.6 16.6 6.9 37.6 24.4 30.1 12.4 12.7 7.2 8.5 5.8 5.9 13.9 12.2 9.1 22.3 15.9 10.6 11.4 5.4 21.6 0 10 20 30 40 50 60 70 80 90 100 personal hygiene menstrual hygiene adequate and balanced nutrition healthy living habits physical activity tobacco, alcohol, drug abuse internet addiction reproductive system std reproductive health family relations family communication set limits peer relations anger management coping skills neglect violence explotation exam anxiety girl boy % discussion although the young population is generally considered to be "healthy", it constitutes 15% of the total disease burden in the world and about 1 million young people die of preventable reasons every year. of the deaths at early ages in adults, 70% depends on gender discrimination and habits adopted in adolescence including smoking, malnutrition and risky sexual behaviours (12). a study conducted at a university in turkey reported that half of 183 students had decayed teeth, one fourth had lost a tooth and more than half had filling in their teeth (13). this study reports that almost one fourth of the students had decayed teeth, one tenth had filling in their teeth and about 8% lost a tooth. although the oral-dental health screening results in this study are lower than those of the study conducted in 2012-2013 academic year, these rates are considered to be very high for young population with a long life expectancy. it is required to continue with these scans considering the results of the screening. a study conducted with the students at dormitories at alexandria university reported 6.5% of chronic disease or disability frequency in students (3). our study reported a chronic disease frequency of 8.0% in the students and this frequency does not vary depending on time at dormitories and causes significantly more frequent medication intake (47.7% vs. 6.1%) in this group. sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 10 a study conducted in a middle east country, egypt, reported that 33.8% of the university students were physically inactive and 25.3% were overweight (3). studies conducted in far east countries, thailand, china and japan reported a frequency of overweight between 2.9% 16%. bmi mean of male students was significantly higher than females in all studies (5,14,15). fifty-one percent of the students at dormitories at canada nova scotia university reported sports activities for less than three times a week and more than half were determined to be at normal weight limits (4). considering europe, a study conducted in germany reported more than half of the students were normal and 6.5% were overweight and only one fifth reported they did not engage in sports activities (16). a study made with university student in germany, poland and bulgaria reported that more than half of the participants were normal weight and the overweight frequency was 11.6% (10). a study made with university students from 23 different countries reported that more than three fourths of the students were normal weight (17). a study made with 233 university students in turkey in 2009 reported that one fifth of the students did not exercise and more than half were reported to exercise for 2-3 days a week or more (18). although over weight/obesity prevalence in our students was 16.7%, unfortunately, three fourths reported not to engage in sports and almost 90% of the students engaged in sports once a month or less. a study in egypt reported that 17.5% of male students smoked and 4.0% used drugs (3). a study conducted at helwan university in egypt reported that the frequency of currently smoking students was 8.6% (19). a study made to determine water pipe smoking prevalence of 1,454 students at 3 universities in 2008 in jordan reported a smoking prevalence of 30.7% (20). a study made with 355 students in total with 215 students staying at dormitories at 2 male medical faculties in iran in 2014 reported smoking, alcohol and drug abuse frequencies of 3.9%, 10.1% and 19.4% respectively (21). a study made in canada reported that 14.3% of the students at dormitories smoked (4). it was reported that out of 17,591 students at 152 universities studied in 2010 in usa, 16.8% were currently smoking and 34.6% reported to have smoked before (22). a study conducted in uk reported a smoking frequency of 15.9% in 937 students (23). a study made at 3 universities in germany, poland and bulgaria reported that 19.3% of the students smoked (10). a study conducted in germany, out of 650 students, 24.5% smoked and 88.5% used alcohol (16). a study conducted at linköping university in sweden reviewed alcohol consumption of 1,297 students and reported that 91% consumed alcohol in the last 3 months (24). another study made with 572 students in turkey reported that none of the participants used drug and almost all of them reported they never tried (98.4%) (25). this study determined smoking frequency as 15.4% and the frequency decreased to 12.7% with increased time at the dormitory. while the frequency of the students using alcohol is 13.7%, no significant change was obtained by years, the frequency of drug abuse is 0.4% and a significant decrease was obtained by years. it is considered that statements of alcohol and drug abuse can be low due to prohibition of substance use and hesitations about profiling. a study which evaluated health behaviours and health development needs of 650 students in germany reported that more than half of the students cared for their health and tried to be on a healthy diet. more than half of the students reported they would attend health oriented group programs, especially sports, relaxation and stress management programs and one fourth reported they would attend healthy nutrition and health classes. about one fourth of sirin h, karasahin ef, tezel b, ozbas s, keskinkilic b, ozkan s. pilot scheme assessment: health development program for students at dormitories (original research). seejph 2018, posted: 02 may 2018 . doi 10.4119/unibi/seejph-2018-186 11 students said they were interested in counselling about stress management and one fifth in nutrition and reproductive health (16). almost half of the students at canada nova scotia university reported they would attend stress management training (4). a study made in china in 2001-2002 academic years reported that almost half of the students would like to receive training about healthy nutrition (15). in our study, students reported they would like to have training about hygiene, healthy nutrition, physical activity and healthy living habits. recent studies on health of the young population indicate that a more holistic approach to the youth would prove to be more efficient rather than focusing on a single problematic behaviour and reducing specific risks. therefore, the young population needs programs which support healthy development. the purpose of this program is to support healthy psychological and social development and growth and to increase individual endurance. moreover, it is recommended to ensure that the young individual "adopts life skills". therefore, it would be ensured that the young individual undertakes responsibility for making healthy decisions, resisting negative pressures and avoiding risky behaviours (5,21). who determined obesity, physical inactivity and alcohol use and smoking as the risk factors of chronic diseases. our study clearly demonstrates the need for “healthy development” counselling for the young population to struggle with chronic diseases which are the main medical problem of our century, for which risk factors are evaluated in the study. risks can be prevented and a bright future can be ensured for the young population with a healthy living culture to be developed accordingly. this requirement has already reflected on demands of the young population and they reported they would like to have this kind of counselling. as a result of the study, service has been planned for the identified needs of the students. activities have been initiated to spread this study to cover all students at dormitories and dormitories have been put to contact with “youth counselling and medical care centres”. systems have started to be developed to increase use of primary health services by dormitory students. 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p. alcohol use among university students in sweden measured by anelectronic screening instrument. bmc public health 2009;9:229. doi:10.1186/1471-2458-9-229. 25. sungu h. attitudes towards substance addiction: a study of turkish university students. educ res rev 2015;10:1015-22. ______________________________________________________________________________________ © 2018 sirin h, et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 1 short report socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania manushaqe rustani-batku1, ali tonuzi2 1 primary health care center no. 2, tirana, albania; 2 university hospital center “mother teresa”, tirana, albania. corresponding author: dr. manushaqe rustani-batku, primary health care center no. 2, tirana; address: rr. “arkitekt kasemi”, 51, tirana, albania; telephone: +355682359312; email: manushaqebatku@yahoo.com http://wikimapia.org/street/16408710/sq/rruga-arkitekt-kasemi� rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 2 abstract aim: the aim of our study was to assess the distribution of socio-demographic factors and the clinical profile of individuals diagnosed with retinal vein occlusion (rvo) in albania, a former communist country in south-eastern europe which has been undergoing a rapid transition in the past decades. methods: this study was carried out in 2013-2016 at the primary health care centre no. 2 in tirana municipality, which is the capital of albania. during this timeframe, on the whole, 44 patients were diagnosed with rvo at this primary health care centre (17 women and 27 men; overall mean age: 69.5±11.5 years). the diagnosis of rvo was based on signs and symptoms indicating a quick reduction of the sight (vision), fundoscopy, fluorescein angiography and the optical coherence tomography. data on socio-demographic factors and clinical characteristics were also gathered for each study participant. results: the prevalence of glaucoma was considerably higher in men than in women (67% vs. 24%, respectively, p=0.01). diabetic retinopathy was somehow more prevalent in women than in men (18% vs. 11%, respectively), whereas an opposite finding was noted for the presence of hypertensive retinopathy (6% vs. 11%, respectively). the prevalence of cataract was higher in female patients compared with their male counterparts (18% vs. 7%, respectively, p=0.36). both macular oedema and papillary oedema were almost equally distributed in men and in women (22% vs. 18% and 4% vs. 6%, respectively). all female patients had comorbid conditions compared to 85% of their male counterparts (p=0.15). the prevalence of hypertension was almost identical in both sexes (52% in men vs. 53% in women), whereas the prevalence of diabetes was somehow higher in men than in women (26% vs. 18%, respectively). conclusion: this is one of the very few studies informing about the distribution of sociodemographic factors and selected clinical characteristics of individuals diagnosed with rvo in transitional albania. keywords: albania, clinical profile, ophthalmology, retinal vein occlusion, sociodemographic factors. conflicts of interest: none. rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 3 introduction retinal vein occlusion (rvo) is a major reason for severe ocular impairment and blindness (1,2). the available evidence, based on many studies carried out in different countries of the world, indicates that rvo is linked to an increased risk of cardiovascular disease, especially hypertension, diabetes mellitus, and coronary artery disease (3-5). the incidence and prevalence of rvo is substantially higher among older people, notwithstanding the fact that this condition is a frequent cause of painless visual loss also in middle-aged individuals (6-8). data from the global burden of disease (gbd) 2010 study indicate that albania is the only country in the south-eastern european region that has experienced an increase in the mortality rate from ischemic heart disease and cerebrovascular diseases in the past two decades (9), exhibiting an early evolutionary stage of the coronary epidemic, which was evident many decades ago in the western countries (10). indeed, ischemic heart disease and cerebrovascular disease were among the highest ranking causes regarding the number of years of life lost due to premature mortality in albania in 2010 (9). furthermore, the burden of diabetes mellitus has almost doubled in albania in both sexes in the past two decades (10). in males, there was an increase of 96% in disability-adjusted life years (dalys) from diabetes, whereas in females this increase was 85%. overall, the sex-pooled proportional dalys for diabetes in albania in 2010 increased 50% compared with 1990 (9). currently, there is evidence of a gradual increase in the diabetes burden which is also due to improvements in the accessibility of health care (that is adequate registration and management of all cases with diabetes) coupled with a steady increase in the ageing population (which, in turn, is associated with an increase in the prevalence of diabetes) (10). yet, data on the prevalence and determinants of rvo in albania are scarce. indeed, to date, there are no scientific papers available providing evidence about the magnitude and occurrence of rvo in the population of albania. in this context, the aim of our study was to assess the distribution of socio-demographic factors and the clinical profile of individuals diagnosed with rvo in albania, a former communist country in south-eastern europe which has been undergoing a rapid transition in the past decades. methods a case-series study was carried out at the primary health care centre no. 2 in tirana municipality during the time period 2013-2016. overall, the number of patients diagnosed with rvo in this health centre during the study period was 44. of these, 27 (61%) patients were males and 17 (39%) were females. on the whole, mean age of the patients was 69.5±11.5 years (with a range from 42 years to 93 years). median age was 70.5 years (interquartile range: 60.3-77.8 years). the diagnosis of rvo was based on the following criteria: i) signs and symptoms indicating a quick decrease and reduction of the unilateral sight; ii) fundoscopy, a conventional examination technique of the fundus employed at the primary health care services in albania (a procedure which indicates the retinal veins that are dilated or tortuous, as well as the retinal haemorrhages); iii) fluorescein angiography, which was the main examination procedure in this study, and; iv) the optical coherence tomography (oct). furthermore, information about selected clinical characteristics of each patient diagnosed with rvo was gathered. more specifically, the clinical information for all the patients diagnosed with rvo included the presence of glaucoma (yes vs. no), the type of glaucoma (open angle, closed angle, secondary, or absolute glaucoma), presence of diabetic rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 4 retinopathy, hypertensive retinopathy, cataract, macular oedema, papillary oedema, or comorbidity (all dichotomized into: yes vs. no), as well as the type of comorbidity (hypertension, diabetes, or both conditions). information on socio-demographic characteristics was also collected based on a structured interview. more specifically, for each patient it was gathered information on demographic factors (age and sex) and selected socio-economic characteristics [place of residence (dichotomized into: urban vs. rural areas) and employment status (trichotomized into: employed, unemployed, retired)]. the study was approved by the faculty of medicine in tirana and all patients who agreed to participate in this study gave their informed consent. mean values and the respective standard deviations were calculated for the age of the overall sample of study participants, as well as separately in men and in women. conversely, absolute numbers and their respective percentages were calculated for the other sociodemographic factors (place of residence and employment status) and all the clinical characteristics of the patients. mann-whitney u-test was used to compare the age between male and female patients diagnosed with rvo. on the other hand, fisher’s exact test was used to assess sex-differences in the distribution of the other socio-demographic factors (see table 1) and all the clinical characteristics in the sample of patients included in this study (table 2). a p-value of ≤0.05 was considered as statistically significant in all ca ses. statistical package for social sciences (spss, version 17.0) was used for all the statistical analyses. results the distribution of socio-demographic characteristics of the patients included in this study is presented in table 1. mean age in men was 71.1±10.9 years, whereas in women it was 67.0±12.4 years. yet, there was no evidence of a significant sex-difference in the mean age of the patients included in this study (mann-whitney u-test: p=0.27). about 19% of male patients and 29% of females were residing in rural areas, without evidence of a sex-difference though (p=0.47). similarly, there was no evidence of a statistically significant difference in the distribution of employment status between genders, regardless of a higher rate of unemployment in women compared to men (29% vs. 15%, respectively, p=0.51) [table 1]. table 1. socio-demographic characteristics of a sample of patients diagnosed with rvo during 2013-2016 in tirana, albania variable men (n=27) women (n=17) p * total (n=44) age (in years) [mean±sd] 71.1±10.9 67.0±12.4 0.272 69.5±11.5 place of residence [n (column %)] urban areas rural areas 22 (81.5) 5 (18.5) 12 (70.6) 5 (29.4) 0.473 34 (77.3) 10 (22.7) employment status [n (column %)] employed unemployed retired 2 (7.4) 4 (14.8) 21 (77.8) 1 (5.9) 5 (29.4) 11 (64.7) 0.505 3 (6.8) 9 (20.5) 32 (72.7) * mann-whitney u-test was used for the comparison of age between men and women, whereas fisher’s exact test was used to test sex-differences regarding the distribution of place of residence and employment status. rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 5 the distribution of selected clinical characteristics of the patients included in this study is presented in table 2. the prevalence of glaucoma was considerably and significantly higher in men than in women (67% vs. 24%, respectively, p=0.01). absolute glaucoma was found in 26% of men, but only in 6% of women, notwithstanding the lack of a statistically significant sex-difference in the distribution of glaucoma types (p=0.26), possibly due to the modest sample sizes. diabetic retinopathy was somehow more prevalent in women than in men (18% vs. 11%, respectively), whereas an opposite finding was noted for the presence of hypertensive retinopathy (6% vs. 11%, respectively). yet, none of these differences was statistically significant. the prevalence of cataract was higher in female patients compared with their male counterparts (18% vs. 7%, respectively), regardless of the lack of statistical significance (p=0.36). both macular oedema and papillary oedema were almost equally distributed in men and in women (22% vs. 18% and 4% vs. 6%, respectively). table 2. distribution of clinical characteristics in a sample of patients diagnosed with rvo during 2013-2016 in tirana, albania clinical characteristic men (n=27) women (n=17) p † total (n=44) glaucoma: no yes 9 (33.3)* 18 (66.7) 13 (76.5) 4 (23.5) 0.012 22 (50.0) 22 (50.0) glaucoma type: open angle closed angle secondary absolute 5 (18.5) 4 (14.8) 11 (40.7) 7 (25.9) 5 (29.4) 5 (29.4) 6 (35.3) 1 (5.9) 0.261 10 (22.7) 9 (20.5) 17 (38.6) 8 (18.2) diabetic retinopathy: no yes 24 (88.9) 3 (11.1) 14 (82.4) 3 (17.6) 0.662 38 (86.4) 6 (13.6) hypertensive retinopathy: no yes 24 (88.9) 3 (11.1) 16 (94.1) 1 (5.9) 0.999 40 (90.9) 4 (9.1) cataract: no yes 25 (92.6) 2 (7.4) 14 (82.4) 3 (17.6) 0.359 39 (88.6) 5 (11.4) macular oedema: no yes 21 (77.8) 6 (22.2) 14 (82.4) 3 (17.6) 0.999 35 (79.5) 9 (20.5) papillary oedema: no yes 26 (96.3) 1 (3.7) 16 (94.1) 1 (5.9) 0.999 42 (95.5) 2 (4.5) comorbidity: no yes 4 (14.8) 23 (85.2) 0 (-) 17 (100.0) 0.147 4 (9.1) 40 (90.9) type of comorbidity: hypertension diabetes both 14 (51.9) 7 (25.9) 6 (22.2) 9 (52.9) 3 (17.6) 5 (29.4) 0.761 23 (52.3) 10 (22.7) 11 (25.0) rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 6 * absolute numbers and the respective column percentages (in parentheses). † fisher’s exact test was employed to test sex-differences regarding the distribution of all clinical characteristics presented in the table. all female patients had comorbid conditions compared to 85% of their male counterparts (p=0.15). the prevalence of hypertension was almost identical in both sexes (52% in men vs. 53% in women), whereas the prevalence of diabetes was somehow higher in men than in women (26% vs. 18%, respectively) [table 2]. discussion this study provides evidence about the distribution of socio-demographic factors and the clinical profile of individuals diagnosed with rvo at primary health care services in tirana, the capital and the largest city in post-communist albania. essentially, the main findings of this study consist of a higher prevalence of glaucoma, hypertensive retinopathy and diabetes in men than in women. on the other hand, women exhibited a higher prevalence of diabetic retinopathy, cataract and comorbid conditions. it should be noted that there are no previous studies describing the socio-demographic factors and clinical characteristics of albanian patients with rvo. the incidence and prevalence of rvo will increase steadily in albania in line with the population aging. thus, according to the last census conducted by the albanian institute of statistics in 2011, the proportion of individuals aged 65 years and over increased to 11% (11). this gradual increase of the older population bears important implications for the heath care sector including also provision of more specialized care against visual impairment. several systemic risk factors for rvo are also associated with arterial thromboembolic events including myocardial infarction and cerebrovascular disease (12,13). from this perspective, it has been shown that the retinal blood vessels exhibit similar anatomic features and physiologic characteristics with cerebral vessels (1,14). based on this evidence, it has been convincingly argued that there might be an association between rvo and myocardial infarction and cerebrovascular disease occurrence (1,14). our study may have several potential limitations due to the sample size and, particularly, sample representativeness. from this point of view, the number of individuals involved in this study was small and was confined only to one of the eleven primary health care centres of the municipality of tirana. in addition, some individuals suffering from rvo might have not preferred to seek care in primary health services. instead, some patients might have preferred more specialized care which is available at the university clinic of ophthalmology as a part of the university hospital centre “mother teresa”, the only public hospital in tirana. also, some patients might have used private ophthalmology clinics which may currently provide better care in albania. based on these considerations, the representativeness of our study sample may be questionable and, therefore, our findings should not be generalized to the general population of tirana and the overall population of albania. instead, findings of this study should be interpreted with extreme caution. on the other hand, the diagnosis of patients with rvo in our study was based on standardized and valid instruments, similar to studies conducted elsewhere. nonetheless, we cannot entirely exclude the possibility of information bias related to socio-demographic data, in particular regarding the employment status of study participants. rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 7 in conclusion, notwithstanding some possible limitations, this study offers useful information about the distribution of socio-demographic factors and the clinical profile of primary health care users diagnosed with rvo in transitional albania, an under-researched setting. population-based studies should be carried out in the future in 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(http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.ncbi.nlm.nih.gov/pubmed/?term=zhong%20c%5bauthor%5d&cauthor=true&cauthor_uid=26922716� https://www.ncbi.nlm.nih.gov/pubmed/?term=you%20s%5bauthor%5d&cauthor=true&cauthor_uid=26922716� https://www.ncbi.nlm.nih.gov/pubmed/?term=zhong%20x%5bauthor%5d&cauthor=true&cauthor_uid=26922716� https://www.ncbi.nlm.nih.gov/pubmed/?term=chen%20gc%5bauthor%5d&cauthor=true&cauthor_uid=26922716� https://www.ncbi.nlm.nih.gov/pubmed/?term=xu%20t%5bauthor%5d&cauthor=true&cauthor_uid=26922716� https://www.ncbi.nlm.nih.gov/pubmed/?term=zhang%20y%5bauthor%5d&cauthor=true&cauthor_uid=26922716� https://www.ncbi.nlm.nih.gov/pubmed/?term=retinal+vein+occlusion+and+risk+of+cerebrovascular+disease+and+myocardial+infarction%3a+a+meta-analysis+of+cohort+studies� 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https://www.ncbi.nlm.nih.gov/pubmed/?term=elkind%20ms%5bauthor%5d&cauthor=true&cauthor_uid=9932614� https://www.ncbi.nlm.nih.gov/pubmed/?term=sacco%20rl%5bauthor%5d&cauthor=true&cauthor_uid=9932614� gutema k, mariam dh. does health sector aid matter? evidence from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 1 original research does health sector aid matter? evidence from time-series data analysis in ethiopia keneni gutema 1 , damen haile mariam 2 1 college of medicine and health sciences, hawassa university, hawassa, ethiopia; 2 school of public health, addis ababa university, addis ababa, ethiopia; corresponding author: prof. damen haile mariam, addis ababa university; address: p. o. box 11950, addis ababa, ethiopia; telephone: +251911228981; email: damen_h@hotmail.com gutema k, mariam dh. does health sector aid matter? evidence from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 2 abstract aims: development assistance for health is an important part of financing health care in developing countries. in spite of the increasing volumes in absolute terms in development assistance for health, there are controversies on their effect on health outcomes. therefore, this study aims to analyze the effect of development assistance for health on health status in ethiopia. methods: using dynamic time series analytic approach for the period 1978-2013, this paper examines whether development assistance for health has contributed for health status change in ethiopia. while life expectancy at birth was used as a measure of health status, vector error correction model was used for the analysis. results: development assistance for health expenditure (lagged one and two years) had a significant positive effect on life expectancy at birth in ethiopia. other things being equal, a 1% increase in per capita development assistance for health leads to 0.026 years improvement in life expectancy at birth (p<0.001) in the immediate year following the period of assistance, and 0.008 years (p=0.025) in the immediate two years following the provision of assistance. conclusion: this study indicates that, seemingly, development assistance for health has significant favourable effect in improving health status in ethiopia. the policy implication of this finding is development assistance for the health should continue as an interim means to an end. keywords: development assistance, health financing, health status, infant mortality rate, life expectancy. conflicts of interest: none. gutema k, mariam dh. does health sector aid matter? evidence from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 3 introduction there is paucity of evidence on the effects of development assistance on health outcomes in developing countries. within the limited literature on the issue, there is disagreement on its effect. some researchers argue that health specific aid leads to improved health outcomes in developing countries by relaxing resource constraints and directly improving health service delivery (1-3). in line with this, levine (1) argues that health is an area where development assistance is likely to show positive changes, as preventive and promotive health activities are directly related to the better health outcomes. the empirical studies by mishra and newhouse, and ebeke and drabo (2,3) also report strong positive effect of health aid on health outcomes in improving infant mortality rate and access to health care for the treatment of fever and diarrhoea respectively in developing countries. chauvet, gubert and mesple-somps (4), who analyzed the respective impact of aid and remittances on infant and child mortality rates with a panel data from 1987 to 2004, also reported results suggesting a positive effect of health aid on health outcomes. similarly, gormanee, girma, and morrissey reported that aggregate aid improves health status by decreasing infant mortality in least developed countries (5). on the contrary, some other scholars argue that there is no reliable evidence supporting the claimed positive effect of health aid on health outcomes (6,7). williamson (6), for example, looked into the impact of foreign aid commitments by donor to health sector using a panel set of 208 developed and developing countries with data from 1973 to 2004 and found no significant impact of health sector aid on a variety of health outcome indicators (including infant mortality and life expectancy at birth). similarly, wilson (7), using panel data of 96 countries with high mortality during 1975-2005, tested the relationship between development assistance for health and a recipient country’s infant mortality rate (imr). his empirical analysis suggests that development assistance for health has no effect on infant mortality at the country level. although sub-saharan africa including ethiopia is among the largest recipients of development assistance (8), the relationship between such assistance and health outcomes has not been properly investigated. ethiopia has been receiving increased inflow of development assistance following its implementation of the health sector development plan (hsdp) (9). during 2009 and 2010, the country received the second highest volume of average development assistance in absolute terms among 24 low and lower-middle income countries, while in 2011, it was the first recipient among these countries (10). as a result, the country’s national health account (nha) show development assistance as contributing to 50% of the general health care spending in the year 2010-2011, up from 40% during 2007-2008 (11). parallel to the increase in development assistance, health outcomes in the country have also shown noticeable changes during the last two and half decades (11,12).under-five mortality rate (u5mr) is reduced by two thirds between 1990 and 2015, and the country has achieved mdg4 two years before the target year (11-13). the ethiopian demographic and health survey (edhs) reports of 2000, 2005 and 2011 also show declining trends in both u5mr and imr (14-16), even though changes in neonatal mortality rate were not as impressive (14-16). in this context, the present study aimed to explore whether the aforementioned improvements in health outcomes are partly attributed to an increase in inflow of development assistance. gutema k, mariam dh. does health sector aid matter? evidence from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 4 methods the theoretical model using dynamic time series analytic approach, the effect of development assistance on health status in ethiopia was examined for the period of 1978-2013. the year 1978 is considered as an initial period for the study as there is a dearth of data for the period prior to that. it also seems reasonable to use 1978 as an initial period since it is also the historical period for the declaration of primary health care (17). the year 2013 was taken as the last period since it is for this period that comprehensive data could be secured. life expectancy at birth (leb) is used as a measure of health status as it has long been used in other studies for this purpose (18). data sources data for the analysis were obtained from world development indicators (wdi) (19), africa development indicators (adi) (20), as well as from ethiopian ministry of finance and economic development (21,22) and central statistical agency (23). variables the dependent variable used was life expectancy at birth (leb). leb is the average equivalent number of years of full health that a new-born could expect to live, if he or she were to pass through life subject to the age-specific death rates and average age-specific levels of health states for a given period. this indicator is preferred as it is also used as a measure of health status in most other studies used for comparison (6,18). moreover, it exhibits a stationary pattern after differencing, a basic requirement for time series analysis (24,25). the independent variables used include: development assistance for health expenditure (dahe) refers to health expenditure that originates from external sources. per capita dahe in usd was used for the current analysis; public health expenditure excluding dahe (phe dah): was used as a control variable, and represents recurrent and capital spending from government (central and local) budgets, other than dahe. a per capita phe dah in usd is used. this variable is considered since health expenditures from local sources is among the factors known to influence health status of populations; gdp per capita (gdpp) is gross domestic product divided by mid-year population; total female enrolment in primary education (femed) percentage of the female population of official primary education age. the choice of this variable is by evidence of an earlier finding that when women are educated, they become aware of issues related to health development at household level, such as, nutrition, immunization, health seeking behaviour (26,27); femed can exceed 100% due to the inclusion of over-aged and under-aged students because of early or late school entrance and grade repetition, however, it can provide a valid evidence. the choice was made as this was the only alternative education indicator found for the sampled year; and population ages 15 to 64 (pop) percentage of the total population in the age group 15 to 64years. gutema k, mariam dh. does health sector aid matter? evidence from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 5 statistical analysis tests for stationarity and long-run equilibrium before the exploration of the presence of long-run equilibrium relationship between development assistance for health and life expectancy at birth, two tests were performed to ensure the stationarity of the variables in question. the results of the adf and philips-perron test have guaranteed that the estimated variables are integrated of order one (after first differencing). furthermore, the presence of long run equilibrium relationship between the two variables in the regression was examined through the multivariate johansen-juseliusco-integration test which ascertained the existence of convergence between the long run equilibrium and the short run dynamics of the variables under study. furthermore, to examine the effects of development assistance on health outcomes, the vector error correction model was used. the model, besides including time dependency between the variables of interest and allowing for stochastic trends, it uses long-run equilibrium relationships through co-integration. furthermore, johansen’s approach was used to estimate the cointegrating relations and the other parameters in the model (25,28,29). based on previous studies (30,31), the implicit function for our model can be expressed as:           txtxtxtyft n ,...,,1y 21  .......................................................................(1) where ‘n’ is the number of explanatory variables. by taking the derivative of both sides of the equation, the following is obtained:                               )2....(....................'1dydy :,,..2,1y1arg yarg1dydy 1 0 0 1 0 tyorty ty tx fwheretf tx tdx t aswrittenrebecanwhichnjandtontyofeffectinalmisf tontxofeffectinalmisfwheretftdxft jj j jj n j j j j jj n j jj         furthermore, under the assumptions of the constant j  ’s , one can integrate both sides of the equation, and get:       )3(ln1yy 3 1     n j jj txtt where 0 f and 3  is a constant term. having in place the theoretical frame work, the empirical estimation equations for the study can be specified as: leb=β0+ 𝛽1tln dahe+𝛽2tlngdpp+ 𝛽3tphe dah + 𝛽4t femed+ pop+ εt …........….(4) where: leb = health outcome as measured by life expectancy at birth dahe = development assistance for health expenditure per capita (in current usd) phe dah= public health expenditure other than dah in per capita (in current usd) gdpp= gross domestic product per capita (in current usd) gutema k, mariam dh. does health sector aid matter? evidence from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 6 predfem = total female enrolment in primary education pop = population ages 15 to 64 εt = stochastic disturbance term to capture omitted variables t = 1, 2, 3….36 and βs are the parameters to be estimated. to analyze the association between dahe and leb, the stationarity of each series was tested using an econometric analysis. the test used for this purpose is the standard augmented dickey fuller (adf) and philips-perron test. this test helps to avoid the spurious results that would make the estimate biased and inconsistent (24,32). results descriptive results as shown in table 1, mean (±sd) of leb and per capita dahe during the period of the study (1978-2013) were 51(6.44) and 1.73(2.61) respectively. during the same period of study, the range was between 43.67 and 63.62 for leb and 0.05 and 9.06 for dahe. table 1. health and the related indicators summary statistics, ethiopia, 1978-2013 variables definitions observed mean sd min max leb life expectancy at birth (years) 36 51.069 6.437 43.674 63.617 dahe development assistance for health expenditure (usd per capita per year 36 1.727 2.612 0.050 9.057 gdpp gross domestic product per capita per year 36 218.916 96.336 111.531 502.597 phe dah public health expenditure other than dahe 36 1.619 1.660 0.140 6.580 femed percentage of female secondary school enrolment ratio (control variable) 36 46.157 27.585 13.906 100.546 pop total population aged 15 to 64 years (control variable) 36 3.06e+07 9940617 1.80e+07 5.10e+07 figure 1 illustrates trends in leb and dahe in ethiopia during the study period of time. the country has experienced a steady increase in leb, along with a growth (with some variation) in level of development assistance for health. gutema k, mariam dh. does health sector aid matter? evidence from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 7 figure 1. trends in life expectancy at birth (leb) and development assistance for health expenditure (dahe) in ethiopia (1978-2013) the other way of looking in to this is by plotting a local polynomial smoothing curve that gives a more insight to the change of leb and dahe. figure 2 below shows that dahe is increasingly effective in continuously and steadily increasing leb. figure 2. a plot of local polynomial smooth curve of life expectance on development assistance for health per capita (1978-2013) 0 2 4 6 8 1 0 d a h e 4 5 5 0 5 5 6 0 6 5 l e b 1980 1990 2000 2010 2020 year leb dahe 45 50 55 60 65 leb 0 2 4 6 8 10 dahe in current usd per capita gutema k, mariam dh. does health sector aid matter? evidence from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 8 results from error correction model (ecm) once the presence of stationarity and co-integration of the series between the variables in the regression model was established, an error correction model (ecm) was fitted to estimate the relationship between the variables. as can be seen in table 2, the effect of development assistance for health on life expectancy is positive and significant – a 1% increase in development assistance for health leads to an approximate nine days increase in life expectancy (p<0.001). similarly, the analysis results suggest that there is a statistically significant positive association between level of development assistance for health during previous two periods and life expectance a 1 % increase in development assistance for health during previous two periods leads to three days increase in life expectancy (p=0.025). table 2. ecm estimation results, ethiopia, 1978-2013 variables coefficient standard error t-values probability ect-1 -0.011 0.001 -9.070 <0.001 leb ld. 1.822 0.039 46.870 <0.001 leb l2d. -1.080 0.052 -20.930 <0.001 lndahe ld. 0.026 0.004 6.160 <0.001 lndahe l2d. 0.008 0.004 2.240 0.025 lngdpp ld. 0.083 0.023 3.600 <0.001 lngdppl2d. 0.086 0.024 3.620 <0.001 phe dah ld. 0.004 0.003 1.390 0.166 † phe dah l2d. 0.008 0.003 2.480 0.013 † predf ld. -0.0004 0.001 -0.770 0.442 predf l2d. -0.0002 0.001 -0.360 0.715 lnpopd. 2.056 1.279 1.610 0.108 * lnpop2d. -2.459 0.958 -2.570 0.010 * _cons 0.863 0.085 10.200 <0.001 * indicates that the joint effect is insignificant. † indicates that the joint effect significant. public health expenditure other than development assistance during the immediate two previous periods is also positively and significantly associated with life expectancy at birth(p=0.013), indicating a 1% increase in general public health expenditure during the immediate two previous years can lead to three days of improvement in current life expectancy at birth. the association between gdpp and leb is also found to be statistically significant (p<0.001) and positive, both during the immediate one and two previous years. a 1% increase in gdpp improves the current level of leb approximately by 1 month. furthermore, the analysis shows that that the relationship between femed and leb is negative but insignificant. the association of population aged 15-64 years and leb portrays a mixed result. it is positive and insignificant during the immediate previous one year and negative and significant during the immediate previous two periods. however, the joint effect of this variable on leb is found to be insignificant. gutema k, mariam dh. does health sector aid matter? evidence from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 9 discussion the analysis of data under the current study proceeded by testing for stationarity of each series as is common in time series data analysis. all the included variables (leb, dahe gdpp, dahe dah,femed and pop) were undergone the standard augmented dickey fuller (adf) and philips-perron test to avoid the spurious results that would make the estimate biased and inconsistent (24,32). this study explored the association between life expectancy at birth (leb) and development assistance for the health sector (dahe) in ethiopia using a sample of 36 observations(years: 1978-2013). accordingly, the effect of dahe, the variable of interest in this study, is found to have a significant long run influence on the health status of the population in ethiopia. as the result suggests, the coefficient of ect-1 has the correct negative sign and is statistically significant (p=0.001) implying that about 1.1% of the disequilibrium in the previous year (year t1) in leb are corrected in the current year period. likewise, the immediate one and two prior year of dahe has shown to have a significant positive effect on leb. consequently, other things being equal, an increase of dahe by 1% leads to an improvement in life expectancy at birth by about 0.026 years which is 0.312 month, approximately 10 days (p=0.000). in the immediate year following the period, and 0.008 years or approximately 3 days following the immediate two years period (p=0.025). the short run effect of the result is greater than the findings of bendavid & bhattacharya who studied on 140 aidrecipient countries between 1974 and 2010reports change of leb to dah as 0.02 month (33). while the period is more or less similar, the applied methodology in their study is panel approach (time series cross section). therefore, the observed difference might be an account of methodological difference as this study is country specific, a country with higher inflow of dah and better performance history in health indicators. similarly, the result is higher than another cross country study report of leb elasticity to dahe in ssa, which is 0.005 year (34). here again the difference might be an account of better performances in ethiopia’s health care system in utilizing dah. as shown earlier, ethiopia is a country with high inflow of dah with the expectation of high performance in the health outcome. therefore, according to the current finding, an increase of dah has been resulted in an increased life expectancy, even better than that of the average ssa. in ethiopia, phc at peripheral level, where most of dah is changed in to the actual consumers service is widely exercised by innovative programme, a deployment of health extension workers and this might have been an account for the significant effect and difference observed in the current study (35,36). similarly, the elasticity estimates of the current result is slightly higher than the country specific study conducted in pakistan (37), that reported 0.024 for the elasticity estimate of leb with regard to government health expenditure. again, it seems that the per capita dahe drives more leb in ethiopia than in pakistan, consonance with the previous stated studies because of the fact that the pakistan study is total public expenditure. on the other hand, the current findings contradicts previous conclusions that claim health aid has no effect in developing countries (6,7). it seems that the effect of the rest of public health expenditure which is in fact domestic funding for health expenditure in the country, has also exhibited more effect in explaining leb than that of an average ssa do. holding all others constant, a per capita change in the rest of public health expenditure in the year immediately preceding the period improves leb by about 0.008 year. this result is higher compared to one cross-country study conducted for ssa, which estimates 0.003 (34).this might be an attribute of the policy commitment in the country to implement gutema k, mariam dh. does health sector aid matter? evidence from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 10 phc. with regard to the remaining control variables, starting first by considering the gdp, per capita gdp has got a positive significant effect on leb and this finding is consistent with results reported elsewhere (27,38). this is expected, because as income increases, one would expect the standards of living of the people to improve, meaning that people will have access to better education, health care, housing, etc. reduced mortality and ultimately an increased life expectancy. in the present study, the relationship between female education and health status showed an unexpected (but not significant) effect, which might be due to possible autocorrelation with the lagged variable for life expectancy. finally, the association of population aged 15-64 years and leb portrays a mixed result. it is positive, insignificant during the immediate previous one year, negative, and significant during the immediate previous two periods. however, the joint effect of this variable on leb is found to be insignificant. while the positive association is as expected (because this age group is the productive age group that could possibly maximizes health production), the negative sign on leb during the immediate previous two years might be due to the same age groups’ prone to hiv/aids that might have led to increased mortality as is a known disease burden in ssa including ethiopia (37). in this study, it would have been better had more control variables like environmental sanitation and safe water supplies were considered as these factors are known variables to explain health status in developing countries. however, both variables were not included in the data, because first, there is no adequate data series prior to 1990 for both variables. second, the available national health account report, a report from where dahe originates and considered in this study, indicates that health expenditure includes spending on both core and health-related activities such as drinking water and environmental health spending (11). similarly, consideration of education indicators like net enrolment and school years would have been better but the data are highly deficient for the sampled year. in addition, health professionals to population ratio and governance are other indicators one would expect to be included. however, all health facility performance related activities is largely an attribute of recurrent and capital health expenditure (39) that is already captured in the study. for instance, hiring health workers and paying their salaries holds the highest proportion of recurrent expenditure, that if considered with health expenditures, lead to a possible higher multi-collinearity among the variables. governance related variables where other explanatory variables that would have been included at national level. however, the dearth of national data for the sampled period of years has limited the inclusion. similarly, the proxies used in measuring health outcomes are not exhaustive; especially, morbidity and disability data were not captured. while these limitations may be the bases for future research, the result of the current analysis verified that development assistance for health has favourable effect in improving health status in ethiopia. the policy implication of the current findings is that development assistance for health is essential component in improving health status in the country and should continue as an interim necessity means to an end. gutema k, mariam dh. does health sector aid matter? evidence from 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from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 13 39. ministry of health, ethiopia fdre. health & health related indicators, 1998-2005. addis ababa; fmoh, 1999-2007. ______________________________________________________________________________________ © 2018 gutema k et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 1 original research factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria david ayobami adewole1, temitope ilori2 1department of health policy and management, college of medicine, university of ibadan, nigeria; 2family medicine unit, department of community medicine, college of medicine, university of ibadan, nigeria; corresponding author: david ayobami adewole; address: department of health policy and management, college of medicine, university of ibadan, nigeria; telephone: +234 8034052838; email: ayodadewole@yahoo.com mailto:ayodadewole@yahoo.com adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 2 abstract aims: factors that influence the personal choice of a health care facility among health care consumers vary. currently, what influences the choice of health facilities among enrollees under the national health insurance scheme (nhis) is not known. this study aimed to assess what influences the choice of facilities in the nhis of nigeria. methods: this was a descriptive cross-sectional study conducted among enrollees in selected nhis facilities in the 11 local government areas (lgas) of ibadan, nigeria. a total of 432 enrollees were selected and were interviewed. a who-usaid semi-structured intervieweradministered questionnaire was used to obtain relevant data. data collection was between october and december 2019. data were analyzed using stata version 12.0 (α =0.05). results: at unadjusted or, older respondents (or 3.24, ci = 2.52-4.18, p = <0.0001), and those who had attained the tertiary level of education (or 3.30, ci 2.57-4.23, p <0.0001) were more likely to make a personal choice of health care facilities. a similar pattern was observed among respondents who were in the high socioeconomic group (or 4.10, ci 3.015.59, p = <0.0001). however, at adjusted or, only high socio-economic status was a predictor of personal choice of health care facility (or 1.92, ci 1.21-3.05, p = 0.005). conclusion: this study is suggestive that a need for and the ability to afford the cost of care influence the choice of health facilities. policies that promote health literacy in the general populace will enhance the capability of individuals to make a personal choice of health facilities. stakeholders should prioritize this for policy. recommended citation: david a. adewole, temitope ilori. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria keywords: choice, national health insurance scheme, personal, health facility, enrolees acknowledgments: the authors wish to acknowledge study participants for permission to interview them in the course of the data collection of this study. authors' contributions: david adewole conceived and designed the study. temitope ilori did data collection and analysis. both authors contributed equally to the manuscript write-up. the two authors also read through the manuscript draft the second time and agreed to the final manuscript. conflict of interests: none declared. adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 3 introduction while some studies suggest that patients actively choose healthcare facilities evidenced by a significant level of health literacy (1), a substantial proportion of patients do not consider the choice to be very important (2). many factors have been ascribed to influence the choice of healthcare facilities. reliance on physician advice/referrals, advice of friends and relatives, and patronizing the nearest health care facilities are some of the means of choosing health care facilities. socio-demographic factors such as age, sex, educational status and socioeconomic status, cost of care, the severity of illness, existence of multiple morbidities/comorbidity, and past experiences with a facility all influence choice in different ways. cost of care and the ability to pay to play a role in the active choice of facilities (3). however, for those who are on a health care plan, the cost of care may not necessarily be an incentive in the choice of a preferred health care facility as health insurance organizations partly determine the facilities that are available to patients (4). the national health insurance scheme (nhis) of nigeria is a social health insurance program established in the year 2005. currently, the total population coverage is 4 million lives, of which the formal sector constitutes 64% compared with the informal sector. major stakeholders in the scheme are the nhis (government) officials, which provide policy guidelines, the health maintenance organizations (hmos) who are the insurers, and health care providers. by the act that established the scheme, enrolment in the scheme is voluntary. a principal enrollee is entitled to register a spouse and four children below the age of eighteen years under the scheme. the principal enrollee chooses a health care facility to receive care (5). presently, it’s not clear what factors influence the choice of health care facilities among enrollees in the scheme. the present study aimed to determine this. findings would be useful to understand better the level of health literacy of enrollees under the scheme. this will provide an avenue to addressing any existing deficiency in the process of choice of facilities. this could serve as a guide in similar schemes and settings. methods study design and area: this is a descriptive cross-sectional study. it was conducted in the 11 local government areas (lgas) of ibadan, nigeria. the 11 lgas were made up of 5 urban and 6 semi-urban areas. the semi-urban lgas formed an outer ring of the inner 5 lgas (6). the estimated population of the 11 lgas was about 3 million based on the projection using the figure from the 2006 nigeria population census as the base year (7). there were several health care facilities at the primary, secondary, and tertiary care levels in the study area. sample size estimation in this study, factors that influence the choice of health care facilities are the main outcome variable. satisfaction with services is known to influence the choice of facilities, the proportion of the enrollees who were satisfied with the choice of a facility in a previous study in nigeria was 40.7% (8). using the leslie-kish formula, (9) calculated minimum sample size was 420. sampling strategy: a list of all health care facilities within the study area (11 lgas); primary, secondary, and tertiary care level facilities was obtained from the oyo state ministry of health. next, a list of all nhis accredited facilities within the study area was obtained from the nhis office in ibadan. for the choice of enrolees, eleven (11) nhis accredited health facilities, one (1) facility in adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 4 each of the 11 lgas were selected by simple random sampling. the selected facilities were visited and the number of enrollees in each of these facilities was verified. proportional allocation of the estimated sample size (420) was done based on the number of enrollees across the selected nhis accredited facilities. profile of selected facilities there are three levels of care in the health system of nigeria. these are the primary, secondary, and tertiary levels. the primary is the first level of care and entry point of individuals to the health system. the secondary serves as the referral centre for the primary, while the tertiary is the referral centre for the secondary level. the secondary provides general medical and laboratory services, as well as specialized health services, such as surgery, pediatrics, obstetrics, and gynecology to patients referred from the primary health care level, and this is generally uniform. ownership of these facilities cuts across the private and the public (government). ownership in the private sector is either private profit-based or non-for-profit faith-based organizations (10). in the nhis arrangement, the primary level of care is not engaged to provide services. there is only one (1) tertiary level facility within the study area. only the secondary and the tertiary levels do. in this study, only the secondary level of care facilities was selected. due to the small number (only one [1] in the study area) compared to nhis accredited secondary health care facilities, and also because of better infrastructural facilities and human resources availability compared to secondary health care facilities, the only available tertiary health care facility in the study area was not selected. all faith-based health care facilities in the study area (three – 3) were however purposefully selected into the study, while others (non-faith-based private) were selected using stratified systematic sampling to allow for a representation method of sampling. participants’ selection a list of nhis enrolees waiting to receive care in the outpatient unit of a selected health facility was obtained from the medical records department of the facility. eligible individuals were the principal enrolees or spouses (excluding dependents under the age of 18 years) and had enrolled in the facility for at least one year before the commencement of the study. this was to increase the possibility that study participants had an appreciable level of interaction with the health system under the scheme that will enable appropriate responses from them (8). among this population, enrollees who began using the selected facilities before the commencement of the health insurance scheme, as well as enrollees who were health care workers in these facilities were excluded from the study. a sampling frame was generated, a sampling interval was determined, and systematic random sampling was used to select eligible participants. systematic sampling was chosen because it eliminates the phenomenon of clustered selection and a low probability of data contamination. the disadvantage of using a systematic sampling technique is noted and is considered a study limitation. the hospital card numbers of the enrollees who were interviewed were documented and kept safe. data collection selected enrolees (n = 420) in the selected nhis accredited health facilities were interviewed with the aid of an adapted whousaid demographic and health survey semi-structured interviewer-administered questionnaire (united states agency for international development. the demographic and health surveys). enrolees who had earlier been interviewed during the study but came back to the clinic for care adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 5 were deliberately identified and excluded. this was done so as not to interview such individuals a second time, and it was carried out by cross-checking the hospital number of the prospective interviewee (enrolee) in the list of hospital numbers that were earlier documented for safekeeping. this exercise was repeated daily until the allocated number of enrollees in each of the facilities was interviewed. quantitative data analysis choice of health care facilities was categorized into personal and choice-based on advice. while personal choice is the one made by the individual enrolee, a choice based on advice was the one made with the assistance of other individuals and entities such as friends and colleagues, referral physicians, family members, and insurers. quantitative data were analyzed using stata. a chisquare test was used to determine the association between socio-demographic characteristics and the choice of health care facility. following this, statistically significant variables (α = 5%) were entered into multiple logistic regression models to determine the strength of association between the dependent and independent variables (predictors). results the data as shown in table 1 depicts that more than three-quarters, 331(76.6%) of the respondents were at least 35 years of age. about three-fifths, 263 (60.9%) of the respondents were females, while 344 (79.6%) had tertiary level of education, 319 (73.8%) were civil servants. those who were in the high socio-economic status were more, 255(59.0%) compared to those who were in the low group. about one-third of 134 (31.0%) claimed to have multiple morbidities, and 219 (67.4%) sought information about the quality of service in the facility before enrolment. almost three-quarters, 320 (74.1%) of the study participants claimed to have personally chosen health care facilities where current care is received under the scheme. the total number of respondents eventually interviewed was 432 (2.8% above the minimum estimated sample size). table 1: sociodemographic characteristics of respondents socio-demographic characteristics frequency n = 432 percent age group < 35 years 101 23.4 35 and above 331 76.6 sex male 169 39.1 female 263 60.9 marital status married 415 96.1 others 17 3.9 level of education less than tertiary 88 20.4 tertiary 344 79.6 adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 6 table 2 below shows the distribution of respondents by socio-demographic characteristics and by sector. the majority, 319 (73.8%) were civil servants. overall, on the choice of health care facilities, the proportion of those who made a personal choice of facilities among civil servants compared with those who were from the private sector was much higher. however, this was not statistically significant: χ2 = 0.06, p = 0.94. however, choice of facilities was significant across age groups, χ2 28.33, p <0.001, level of education χ2 10.6, p = 0.001, and status of co-morbidities χ2 12.2 p <0.001. table 2: distribution of respondents by socio-demographic characteristics and by place of work socio-demographic characteristics public n(%) private n(%) χ2 (p-value) age group 28.33(<0.001) < 35 years 54 (53.5) 47(46.5) 35 and above 265(80.1) 66(19.9) sex 2.1 (0.11) male 132(78.1) 37(21.9) female 187(71.1) 76(28.9) marital status married 305(73.5) 110(26.5) others 14(82.4) 3(17.6) level of education 10.6 (0.001) less than tertiary 53(60.2) 35(39.8) tertiary 266(77.3) 78(22.7) socio-economic status 0.13(0.71) low 129(72.9) 48(27.1) occupation civil servant 319 73.8 private 113 26.2 socio-economic status low 177 41.0 high 255 59.0 presence of multiple morbidities absent 298 69.0 present 134 31.0 prior information about quality of care in facility yes 291 67.4 no 141 32.6 method of choice of facility personal choice 320 74.1 choice based on advice 112 25.9 adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 7 high 190(74.5) 65(25.5) presence of multiple morbidities 12.2 (<0.001) absent 235(78.9) 63(21.1) present 84(62.7) 50(37.3) prior information about quality of care in facility 0.01(0.98) yes 215(73.9) 76(26.1) no 104(73.8) 37(26.2) method of choice of facility 0.06 (0.94) personal choice 236(73.8) 84(26.2) choice based on advice 83(74.1) 29(25.9) table 3 below shows the pattern of choice of health care facilities among nhis enrollees. generally, respondents claimed the health care facilities where they enrolled for care under the scheme were chosen by personal choice. however, older respondents, married individuals, and those who attained a tertiary level of education were significantly more likely to do so than their respective counterparts ( 2  4.11, p = 0.043; 2  6.73, p = 0.01; 2  6.27, p = 0.012) respectively. also, choice of health care facilities was statistically significant among respondents who were in high socioeconomic status compared with those who were in the low group, ( 2  12.94, p = <0.00001) and as well among those who had multiple morbidities compared with those who were otherwise ( 2  4.30, p = 0.038). table 3: percentage distribution of the enrolees according to choice of health care facilities by socio-demographic characteristics personal choice choice based on advice total 2  p-value socio-demographic characteristics age group 4.11** 0.043 < 35 years 67(66.34) 34(33.66) 101 35 and above 253(76.44) 78(23.56) 331 sex 0.034 0.855 male 126(74.56) 43(25.44) 169 female 194(73.76) 69(26.24) 263 marital status 6.73*** 0.01 married 312(75.18) 103(24.82) 415 others 8(47.06) 9(52.94) 17 level of education 6.27** 0.012 less than tertiary 56(63.64) 32(36.36) 88 tertiary 264(76.74) 80(23.26) 344 occupation 0.0055 0.941 civil servant 236(73.98) 83(26.02) 319 private 84(74.34) 29(25.66) 113 adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 8 at adjusted or, while the presence of multiple morbidities was weakly significantly associated with a personal choice of health care facility (or 1.63, ci 0.97-2.74, p = 0.063, being in the high socio-economic class was highly significantly associated with a personal choice of health care facility (or 1.92, ci 1.21-3.05, p = 0.005). table 4 (below). table 4: logistics regression model of predictors of personal choice of facilities among respondents socio-economic status 12.94*** <0.00001 low 115(64.97) 62(35.03) 177 high 205(80.39) 50(19.61) 255 multiple morbidities absent 212(71.14) 86(28.86) 298 4.30** 0.038 present 108(80.6) 26(19.4) 134 information on quality 0.69 0.405 yes 212(72.85) 79(27.15) 291 no 108(76.60) 33(23.40) 141 closer facility 2.01 0.157 yes 115(78.23) 32(21.77) 147 no 205(71.93) 80(28.07) 285 socio-demographic characteristics unadjusted or adjusted or or 95% c.i p-value or 95% c.i p-value age group < 35 years (ref.) 35 and above 3.24*** 2.52-4.18 <0.0001 1.56 0.89-2.73 0.123 sex male 2.93*** 2.07-4.14 <0.0001 0.88 0.56-1.40 0.601 female (ref.) marital status married 3.03*** 2.42-3.78 <0.0001 0.86 0.42-1.79 0.691 others (ref.) level of education less than tertiary (ref.) tertiary 3.30*** 2.57-4.23 <0.0001 1.47 0.88-2.48 0.145 occupation civil servant (ref.) private 2.90*** 1.90-4.42 <0.0001 1.08 0.63-1.84 0.781 socio-economic status low (ref.) high 4.10*** 3.01-5.59 <0.0001 1.92*** 1.21-3.05 0.005 multiple morbidities adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 9 discussion the older age group respondents were more than double the younger ones. this is at variance with the 2013 ndhs and other reports that the age distribution of nigeria population and similar other countries in the sub-saharan african countries (ssa) characteristically have (5, 11, 12). the observation in this study may be partly due to a long embargo on employment in the formal sector that has resulted in the population of the current formal sector employees, the majority of whom constituted the study respondents, has grown to older age without a concomitant younger population for a gradual replacement. another factor could be that the study population (nhis enrolees) was restricted to a select privileged few unlike if the selection were to be from a more representative general population. however, the population distribution of respondents by sex and by enrolment under the nhis, and by marital status reflects the latest ndhs reports (11, 13). the higher proportion of female respondents may be a reflection of the known better health-seeking behaviour among women compared to that of men (14). it is an expected observation that the majority of the respondents’ attained tertiary level education as enrollees under the nhis are mainly individuals in the formal sector employment of the federal government of nigeria (5). in this study, respondents who were civil servants were almost three times those who were from the private sector. this is in order with credible sources that only a handful of the present enrollees under the nhis were voluntary/private contributors (5, 15). this is also similar to the general pattern observed in some other countries, such as in ghana (16) and kenya, in these countries as it is common in other poor developing ssa countries, the design of social health insurance schemes tends to be unfavourable for the informal sector population who, compared with those in the formal sector, are usually burdened with low and inconsistent income (4). as a result, the majority of the people in this category are compelled to pay health care costs through of pocket method which is associated with the inequity of access to health care and poor health outcomes (17). contextually designed strategies to addressing these challenges will assist in turning around the picture and minimize the likely inequity of access among the informal sector population. several factors interplay differently in different health situations in the same individual to influence the choice of health care facilities. these factors cut across both the consumer and facility sides of the health care market. literature on the choice of health care facilities generally agrees that health care consumers hardly make an active choice of facilities/facilities (2), and, that they more often than do not consider the choice of health facilities to be important. as a result, consumers mostly rely absent (ref.) present 4.30*** 2.71-6.37 <0.0001 1.63* 0.97-2.74 0.063 prior information about quality of care in facility yes (ref.) no 3.27*** 2.22-4.83 <0.0001 1.12 0.69-1.82 0.642 knowledge of nhis facility closer to residence yes 3.59*** 2.43-5.32 <0.0001 1.21 0.75-1.98 0.432 no (ref.) adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 10 on the assistance of others for the choice of health facilities (2, 18). for that purpose, friends, family members, and general practitioners are the usual sources of influence (18, 19). in addition to these, the presence or absence of a health insurance policy also influences the choice of facilities since in most cases, insurers determine the specific facilities that are available to health care consumers (2, 20). in addition, a knowledge of the quality of the care, (21) and the dimensions of care, functional and technical (22) available in health care facilities play a role in the choice of health facilities especially when individuals are well informed about such (1). health care consumers’ attributes such as age, sex, marital status, level of education, and type of occupation are also some of the factors that influence the choice of facilities (2, 20). others are the socio-economic status as well as the presence or absence of comorbidities and perceived severity of illness in individuals (23, 24). there are contrary opinions about the younger age group, while some claimed that this group of people make an active choice of facilities, (2), some are of the contrary view, and that passive choice is more common among them (20, 25). female sex was reported to be associated with passive choice in a previous study in nigeria (26). highly educated individuals and those in the high socioeconomic group have been reported to be more likely to actively choose health care facilities (24, 27). in this study, the personal choice of health care facilities was more likely with more vulnerable individuals such as being married, older individuals, and the presence of multiple morbidities. findings from previous studies corroborate these findings that this category of people is less likely to tolerate the risk of uncertainties and thus, are less favourably disposed to accepting the choice of health care facilities through a third party (2, 20, 23, 28). also, the acquisition of tertiary education and being in the high socio-economic class was associated with the active choice of health care facilities. in this environment, the tertiary level of education is a factor of employment in the formal sector (civil service), who characteristically enjoy a consistent and higher level of income compared with those in the informal sector (4). the synergy of higher income and education could be a strong factor in exposure to better access to beneficial health-related information. this inadvertently enhances the health literacy of such individuals and the tendencies to obtain, process, and compare different health care facilities and services while making a choice (1). it is noteworthy that, when health care consumers have the privilege to choose health care facilities and insurers, it encourages healthy competition, which in turn enhances efficient delivery of quality health services (2, 18, 29, 30). however, of all the factors associated with a personal choice of health facility, high socio-economic status and the presence of multiple morbidities had more influence in the choice of health facilities. it should be noted that the number of those who claimed personal choice of a health facility was almost three times the number of those who claimed a choice based on advice. this finding was in disagreement with the generally held pattern of passive selection of health care facilities by the majority of consumers compared to a few who do active selection (2, 18, 19). again, high socioeconomic class and level of education among the respondents in this study could be contributory factors. in conclusion, this study shows that various socio-demographic factors influence the choice of health facilities among individuals. however, a need for and the ability to afford the cost of care influences the choice of health facilities the most, as demonstrated by the presence of multiple morbidities and a high socio-economic class. it should also noteworthy that the majority made a personal choice of health facilities. this may not be unconnected with a high level of general literacy which may have had a direct impact adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 11 on health literacy. stakeholders should note this for policy purposes. as an emphasis on the benefits of 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(accessed 2019 january 21). available from: https://projects.worldbank.org/en/projects-operations/project-detail/p163969?lang=en. (accessed: april 25, 2021). ___________________________________________________________________ https://www.ncbi.nlm.nih.gov/pubmed/?term=patterns+of+hiv%2c+tb%2c+and+non-communicable+disease+multi-morbidity+in+peri-urban+south+africa-a+cross+sectional+study. https://www.ncbi.nlm.nih.gov/pubmed/?term=a+cross-sectional+and+spatial+analysis+of+the+prevalence+of+multimorbidity+and+its+association+with+socioeconomic+disadvantage+in+south+africa%3a+a+comparison+between+2008+and+2012. https://projects.worldbank.org/en/projects-operations/project-detail/p163969?lang=en https://projects.worldbank.org/en/projects-operations/project-detail/p163969?lang=en https://projects.worldbank.org/en/projects-operations/project-detail/p163969?lang=en https://projects.worldbank.org/en/projects-operations/project-detail/p163969?lang=en laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 1 review article the rise and fall of the “massively open online courses” wolfram laaser 1 1 self-employed consultant and external staff member of wwedu/austria, germany. corresponding author: dr. wolfram laaser address: milly-steger-str. 1, d-58093 hagen, germany; e-mail: wolframlaaser@googlemail.com laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 2 abstract the paper summarizes the actual debate about “massive open online courses” (mooc), a concept that swept over like a “tsunami” to european educators and universities since its first development in 2008. the definition of the so-called moocs, also referred to as a “disruptive educational innovation”, however, is not very precise and has led to some irritations and scepticism. therefore, the ideas moocs rely on, will be described and the pedagogical and technological background will be explained by detailed descriptions of concrete examples. after setting the scene, the factors responsible for the initial hype about moocs will be analyzed as well as the upcoming criticism raised against the arguments of the mooc proponents. the model of the gartner hype cycle serves as a useful illustration of the ups and downs of expectations related to the introduction of educational innovations. the discussion will be supplemented by a brief flash back on prior developments in distance education. furthermore, some recent empirical data retrieved from google trends are presented to underline that moocs are already on the descent. finally, the conditions for a survival of some specific applications of moocs at “the plateau of the cycle of expectations” will be outlined. in conclusion, moocs seem to have promoted, especially in the us, the use of online teaching and learning as well as the reflection about open educational resources. however, the blurred definition of the term mooc combined with exaggerated expectations turned down the initial hype about a “disruptive innovative concept of teaching and learning” to a more modest consideration of its potential. keywords: connectivism, hype cycle, massive open online courses, mooc, online learning. conflict of interest: none. laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 3 definition and origin of “massively open online course” (mooc) mooc stands for “massively open online course”. hence, there are four criteria: massive, open, online and course. it all began with the offers of two young canadian researchers, who tutored in 2008 a course about “connectivism and connectivist knowledge” at manitoba university. the young researchers were george siemens and steven downes, both not having a phd at that time with a very mixed study background, but often called the founders of moocs. however, two other researchers namely david wiley and alec couros were a little bit faster in running an mooc (1). the idea was to supply the students with the basic framework for the course and then lead from behind. the students were not confined to a prescribed online learning platform; they were encouraged to figure out what environment suited them. some spanish-speaking students even created places in “second life”, a virtual world, where they could hold discussions in their own language. the course, called “connectivism and connectivist knowledge”, ended up attracting about 2,300 non-paying, non-credit students in addition to the 25 students who took it for credit through the university of manitoba. the learning theory that pretends to back up their approach was called “connectivism” and is described by siemens (2) as being composed by the following key features:  learning and knowledge rest in diversity of opinions.  learning is a process of connecting specialized nodes or information sources.  learning may reside in non-human appliances.  the capacity to know more is more critical than what is currently known.  nurturing and maintaining connections is needed to facilitate continual learning.  the ability to see connections between fields, ideas, and concepts is a core skill. however, to call connectivism a “learning theory” has been criticised by many researchers as not fulfilling the requirements of a learning theory and for neglecting the work of previous scientists (3-6). different types of moocs the connectivist background of moocs disappeared to some extent when in 2011 a second type of mooc emerged, namely the xmoocs. these courses were primarily based on interactive media, such as lectures, videos and text. the xmoocs adopted a more behaviourist pedagogical approach, with the emphasis on individual learning, rather than on learning through peers. a number of companies were launched in the us to run xmoocs, such as: udacity, edx and coursera. the courses tend to be offered by prestigious institutions, such as harvard and stanford. the emphasis is on delivery of content via professors from these institutions (7). actually, there are different types of moocs and a number of additional abbreviating letters. to make a difference, the connective moocs were called then cmoocs. if moocs are imbedded into traditional classroom activities in a blended learning mode, the respective moocs are labelled bmoocs, which increases the variety of the “mooc alphabet”, but not the clarity of the meaning of mooc. figure 1 summarizes the mooc types, however, without reference to the blended settings. in the meantime, a new variant came from harvard university: spocs (small, private online courses). the different concepts of moocs mentioned are not clearly defined and overlap to a great extent with both, traditional terminology of distance education and definition of teaching environments in classroom-based conventional teaching. laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 4 similar to the invention of the new theory of learning “connectivism”, the concept of moocs created a lot of repercussions in academic debates. before going into details, the pedagogical concepts and technical settings of past moocs will be briefly described. figure 1. different types of moocs (source: delta initiative: evolutioncombine20120927) pedagogical settings of cmoocs in 2012, the university of frankfurt ran one of the first moocs in germany about “trends in eteaching” (8,9). the participation was free of charge and all interested participants were admitted. at the beginning of each two weeks, interval participants could listen to a video streaming lecture of one hour duration with subsequent discussion. to prepare for the expert lectures, participants received some bibliographic references related to the respective topics. as the mooc was not part of an academic curriculum, participants could ask at the end of the course for badges that characterize their contribution and role across the entire course. three types of badges were available: observer (following discussions and video lectures), commentator (giving at least three comments related to different topics by blog, video, audio, or other media), and curator (contributing significantly to the organization and content production of the course, e.g. summing up discussions, leading subgroups etc.) (9). an example of detailed differentiation of badges is shown in figure 2. mozilla offers also workflows to design individual digital badges (10). except of the certification by badges, no exams could be taken during or at the end of the mooc. participants were asked to aggregate the content offered, to remix information, to contribute by writing down own ideas and to share their knowledge. they could use the tools of their own personal learning environment such as blogs, wikis, twitter posts, or facebook. the organizers summarized the main discussion threads at the end of the two weeks rhythm and let students access them via the course website. laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 5 figure 2. example of badge design (source: http://beuthbadges.files.wordpress.com/2012/12/ple-badges1.png?w=560&h=930) (modified by: wolfram laaser) technical requirements of cmoocs which are the technical requirements to run this type of comic, which kind of programs support students and organizers in their activities to create, to certify, to assess, to collaborate, to deploy and to analyze? in a slideshare presentation of the software used in his mooc, downes listed the following software components (11):  a course wiki on the project website provided general information about participation, topics and other general issues.  a course blog (to motivate discussion and give additional inputs by the tutors).  a moodle forum (to run common discussions).  pageflakes (to add widgets for rss (rich site summary) feeds to a web page).  elluminate (group video conferencing tool).  ustream (live streaming of contributions).  twitter (to tweet with an identifying course tag).  grsshopper (harvesting content input coming from rss feeds).  ltc (language translation software). furthermore, students could subscribe to a newsletter with rss feed and use additional software for infographics (e.g. wordle), formation of working groups (google groups), storytelling (word of mouth), music integrator (orchard), virtual worlds (second life), social bookmarking, tags (11), or to create student‟s blogs (wordpress). this selection of software tools is based on available tools during the years of running the course in 2007-2008. laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 6 currently, in many cases, different tools can be used for the various purposes mentioned (12). comparing cmoocs with xmoocs among the most active mooc providers today is coursera, a start-up that offers some 200 online courses to 1.5 million students. it does so by providing a technical platform to 33 educational institutions, including the university of pennsylvania. according to daphne koller, “coursera is still a hugely interactive experience in terms of working with the material, which is not just video. there are a lot of exercises and assessments. furthermore, an educational community is created based on students interacting with each other.” (13). however, when the author (wl) picked just randomly an economics course offered by columbia university via coursera to look at the course description with respect to pedagogical design, it was found to resemble a traditional distance education course. the course description says: “the class will consist of lecture videos, shot live in the classroom but then edited down into digestible segments, with integrated quiz questions and animated slide videos added. there will also be weekly quizzes and a final exam.” (14). but, there is no mention of interaction with teachers or tutors. the only difference is that anybody is admitted; there is no fee and that there is no recognized degree available. usually, only short courses on relatively specific topics are offered. they have to be selected independently of any curriculum. just some general remarks about necessary pre-knowledge are mentioned. daphne koller (coursera), continuing her interview responses, states: “i think that it‟s wonderful for students around the world to have access to content from those universities as well. this arrangement between institutions provides economies of scale, since a single platform is an expensive and complicated thing to develop. we have almost 200 courses right now and more coming up on this hub. that‟s why we have 1.5 million students, and the population is growing.” (13). opposing to the setting of the xmoocs, one of the cmooc protagonists, downes, commented on xmoocs as follows: “look what they‟ve done to my mooc: as deployed by commercial providers they resemble television shows or digital textbooks with – at best – an online quiz component.” (15). the hype about moocs so, why those types of course setting became so popular and much discussed during the last six years? there are a number of reasons to explain this phenomenon. first of all, the young researchers did not hesitate to give a label in abbreviated form to their experiment “massively open online courses” equal to mooc to make it sound already a widely known course concept. abbreviations are known for chatting among young people and tend to hide a clear definition of what the terms exactly mean, e.g. elearning, and mlearning. furthermore, they related their concept to another newly invented label called “connectivism”, which they claimed to offer a learning theory for the 21 st century. buzz words are mostly part of a marketing strategy. by contrast, the effort to ground the concept and theoretical background on prior research is kept quite limited. a second important factor might be the proximity to the spread of the open educational resources movement, as moocs are actually free of matriculation fees and open to anybody regardless of the academic background. thus, at the same time it shares the problem of covering costs with the open educational resources. as a third point, movements such as the “edupunk” and “do it yourself university” (16), or “p2p university”(17) can be mentioned. all these ideas claim that peers learn best from laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 7 each-other according to their specific interests and needs. the expert teacher becomes obsolete (18). a fourth argument lies in the economic interests of multinationals to market educational content to a worldwide audience. multinationals try to overcome cultural and national borders by introducing their courses at zero prices in an initial phase. therefore, it is not surprising that mooc development was supported by the us and canadian government as well as by organizations like bill gates and linda gates foundation or the hewlett packard foundation. another interesting source of hidden revenue is the selling of student data to advertising companies or potential employers (19). finally, as economic pressure and new models of education are bringing competition to the traditional models of higher education, institutions are looking for ways to control costs while still providing a high quality of service. hence, participating in accreditation of moocs as part of their curriculum, economic cost reductions are expected. the necessity to economize resources on a worldwide level is also stressed by m. waldrop (20): “bricks-and-mortar campuses are unlikely to keep up with the demand for advanced education: according to one widely quoted calculation, the world would have to construct more than four new 30,000-student universities per week to accommodate the children who will reach enrolment age by 2025, let alone the millions of adults looking for further education or career training. colleges and universities are also under tremendous financial pressure, especially in the us, where rocketing tuition fees and ever-expanding student debts have resulted in a backlash from politicians, parents and students demanding to know what their money is going towards”. expectations and forecasts “moocs have gained public awareness with a ferocity not seen for some time. worldrenowned universities, as well as innovative start-ups such as udacity jumped into the marketplace with huge splashes, and have garnered a tremendous amount of attention and imitation. designed to provide high quality online learning, offered to people regardless of their location or educational background, moocs have been met with enthusiasm because of their potential to reach a previously unimaginable number of learners. the notion of thousands and even tens of thousands of students participating in a single course, working at their own pace, relying on their own style of learning, and assessing each other‟s progress has changed the landscape of online learning. this statement was given under the heading: “moocs on the move: how coursera is disrupting the traditional classroom” (13). though the term mooc was hardly a thought bubble for the new media consortium (nmc) during the discussions in 2012, the opinion of the experts changed already in their 2013 report (21). in the horizon report 2013, it is assumed that the time for global adoption of moocs in higher education (20% of all national educational institutions) will be a year or less (20). however, the methodology of the nmc horizon reports and the yearly revisions of previous forecasts have been heavily criticized by jon baggaley (3,4). the british open university suggested in its innovation report a timeframe of one to two years (22). other forecasters were more cautious and commented more in detail the factors that influence medium term trends (23). hence, are we in the rising part of the hype cycle? norway, recently announced proudly a national initiative for mooc development to promote online education and to develop a national mooc platform (24). laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 8 critical views about moocs g. siemens according to parr 2013 (15) believes that attitudes towards moocs are in a period of flux and that criticism is mounting because of what he calls the “biggest failing of the big mooc providers”; from this point of view, they are simply repackaging what is already known rather than encouraging creativity and innovation: “there has been a growing backlash against moocs over the past year. if 2012 was the „year of the mooc‟, 2013 is shaping up as the „year of the anti-mooc.‟ schulmeister, a german pedagogue, after participation in several xmoocs summed up the following critical points (19):  lack of feedback and low interaction.  high drop-out rates.  no reliable checking of learning outcomes and peer reviews.  many different subjects, but no curriculum. to these points, the information overload in terms of quality and structure might be added especially for cmoocs. it is not really surprising that nmc experts did not provide correct orientations of future mooc perspectives. according to a study of the babson survey research group (25), only a very small segment of higher education institutions in the us are now experimenting with moocs with a somewhat larger number in the planning stages. most institutions remain undecided. according to them, only 2.6% of higher education institutions in the us currently have a mooc, and another 9.4% which report moocs are in the planning stages. the majority of institutions (55.4%) report they are still undecided about moocs, while less than one-third (32.7%) state that they have no plans for an mooc. academic leaders are not concerned about mooc instruction being accepted in the workplace, but do have concerns that credentials for mooc completion will cause confusion about higher education degrees (problem of recognizing badges). in a recent paper, the conference of german university‟s rectors stressed, that the use of external mooc platforms may reduce the “visibility” of the educational institution and that the fragmentation of educational offers could lead to a “mac donaldization” of teaching (26). though, no clear cut position is taken, mainly “pros” and “cons” are discussed. as a final quotation we will mention sebastian thrun, who, after his first optimism about the tremendous enrolment rates for his udacity course on “artificial intelligence” states later with resignation: “we were on the front pages of newspapers and magazines, and at the same time, i was realizing, we don‟t educate people as others wished, or as i wished. we have a lousy product.” (27). since udacity was one of the first mooc companies, and sebastian thrun its founder, his admission came as a shock. it signalled the decline of the mooc empire: from 2012 when the new york times declared it “the year of the mooc” to now, when its very champions, who had built their reputation and companies around the theory that free, huge, online college classes were the way to fix education, were conceding failure. thrun retained that moocs were a bad product because less than ten percent of the mooc students managed to complete each class. “how can classes revolutionize education if no one is finishing them?”. the first hype about moocs is somehow difficult to follow as in pedagogical terms the early application of televised courses 30 years back in the us did not differ much from today‟s xmoocs. about that time, the author of this paper wrote, that “in 1984, the national technological university began to offer courses for upgrading engineers. a consortium of 22 universities distributed their courses through the system. classes are given as live lectures by staff of the associated universities in especially equipped classrooms and transmitted via satellite. the student at his workplace has options to pose questions via direct http://www.nytimes.com/2012/11/04/education/edlife/massive-open-online-courses-are-multiplying-at-a-rapid-pace.html?pagewanted=all&_r=0 laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 9 telephone links.” (28). the question remains whether moocs represent really a disruptive innovation (see also 29). so, is the position of moocs on the hype cycle rather like the one indicated in figure 3? figure 3. the tentative position of moocs in the hype cycle if we use the frequency of searches in google as an indicator using google trends, we can observe that the interest in moocs started in germany with a delay compared to the us and after reaching its highest values declines faster than in the us. the interest in moocs in general seems to be still declining in contrast to all exaggerated expectations and forecasts. remaining perspectives of moocs there are a number of aspects relevant for the future survival and usefulness of moocs. first of all, an economic solution has to be found to finance moocs if they are offered free of charge. however this is a problem that moocs have in common with any open educational resource. as our economic system is based on private property rights, it will always be difficult to offer private goods for free, or as the american economist milton friedman expressed: “there is nothing like a free lunch”. so far, several business models have been developed to charge not the course, but the connected services or certifications (coursera charges now for the certificate). udacity will charge in the future for tutoring support. the remaining possibilities are the financing by donations or membership contributions. “obviously, if sustainable models for the support of open content initiatives cannot be found in the relatively near future, most are doomed to be left by the wayside when their initial funding ceases.” (30). laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 10 figures 4a and b. frequency of searches in google trends in the us and germany, generated in june 2014 laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 11 secondly, the unique possibility to dispose about “big data” by using moocs is of great relevance to research projects. moocs represent by their huge international clientele a fantastic field for research studies such as learning analytics, collaboration formats and automated support of large student numbers, spontaneous formation of groups and communities of practice, behaviour of peers in online environments and analysis of intercultural communication patterns. actual research experiences and best practise “in and around moocs” are presented in a special edition of elearning papers (31). another relevant source for mooc research are the proceedings of the european mooc stakeholder summit 2014 (32). research topics dealt with are models, built to forecast drop-out rates, eye tracking studies, or analysis of video usage and design patterns. to date, moocs have been offered usually for small courses with special content areas selected. in the future, complete degree courses will be probably offered and this will be affordable mainly for institutions that can invest huge amounts of money in attractive course presentation and marketing. this holds primarily true for xmoocs. the future of cmoocs seems to be even more uncertain, but future developments might show up new ways to teach specific subjects to huge and extremely heterogeneous groups of learners. annex baggaley j. running a mooc. https://www.youtube.com/user/jonbaggaley/videos/ (accessed: november 9, 2014). references 1. rodriguez co. moocs and the ai-stanford like courses: two successful and distinct course formats for massive open online courses. eurodl, 2002. 2. siemens g. connectivism: learning theory for the digital age, elearning space. 2004: http://www.elearnspace.org/articles/connectivism.htm (accessed: november 05, 2014). 3. baggaley j. when prophecy fails. distance education 2013;34:119-28. 4. baggaley j. moocs: digesting the facts. distance education 2014;35:159-63. doi 10.1080/01587919.2014.919710. 5. zapata ros m. teorías y modelos sobre el aprendizaje en entornos conectados y ubicuos. bases para un nuevo modelo teórico a partir de una visión critica del “conectivismo”. 2012. e-prints 17463/1: 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28. laaser w. effective methods for meeting student needs in telecommunicationssupported distance education: some lessons from experience. in: tutoring and monitoring facilities for european open learning. whiting j, bell da (eds.). amsterdam, 1987. p. 98. 29. kolovich s. the mooc „revolution‟ may not be as disruptive as some had imagined. the chronicle of higher education, 2013. 30. wiley d, gurrell s. a decade of development. open learning: the journal of open, distance and e-learning 2009;24:11-21. 31. elearning papers. in and around moocs. special edition, 2014, vol. 37. 32. kress u, kloos cd (eds.). emoocs. proceedings of the european mooc stakeholder summit, 2014: http://www.emoocs2014.eu/sites/default/files/proceedings-moocs-summit-2014.pdf (accessed: november 07, 2014). ___________________________________________________________ © 2014 laaser; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 1 review article governance and management of health care institutions in serbia: an overview of recent developments vesna bjegovic-mikanovic 1 1 faculty of medicine, belgrade university, belgrade, serbia. corresponding author: prof. vesna bjegovic-mikanovic, md, msc, phd; address: dr subotica 15, 11000 belgrade, serbia; email: bjegov@med.bg.ac.rs mailto:bjegov@med.bg.ac.rs bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 2 abstract in order to promote awareness of factors that affect social services, their quality, effectiveness and coverage, the term “governance” is frequently used. however, there is no agreement on definitions, frameworks and how it relates to the health sector. in this overview, two interrelated processes in serbia will be analyzed: governance and management at the macro-, meso-, and micro level. key messages are as follows: i) continue decentralization and support to an effective national decision-making body (health council of serbia) with all relevant stakeholders; ii) reduce the well-known implementation gap and agree on a binding time frame for reforms, and; iii) establish obligatory schemes for education and training of managers and support sustainability of state institutional capacity to teach, train and advise on a scientific basis. keywords: governance, health sector, management, serbia. conflict of interest: none. bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 3 introduction governance and management of health care institutions encompass a series of regulatory measures undertaken for planning, organizing, functioning and evaluation of all the numerous and interrelated system elements by which the set objectives are brought into effect (1). although it is considered as a multidimensional and interdependent process, there are differences between governance and management. how to apply in particular the term “governance” to the health sector? in order to promote awareness of factors that affect social services, their quality, effectiveness and coverage, the term “governance” is frequently used. however, there is no agreement on definitions, frameworks and how it relates to the health sector (2). in general, governance relates to decisions on the framework that defines expectations, grants power, or verifies performance. the debate over this terminology began in the early nineties when the world bank defined governance as: “the exercise of political authority and the use of institutional resources to manage society’s problems and affairs” (3). in recent years, the avenues towards effective governance are described in more detail: good governance in health systems promotes efficient delivery of health services. critical are appropriate standards, incentives, information, and accountabilities, which induce high performance from public providers (4). the united nations led a debate on the understanding of good governance. referring to the world bank definition, good governance entails sound public sector management (efficiency, effectiveness, and economy), accountability, exchange and the free flow of information (transparency), and a legal framework for development (justice, respect for human rights and liberties) (5). who summarizes it as follows: “the leadership and governance of health systems, also called stewardship, is arguably the most complex but critical building block of any health system. it is about the role of the government in health and its relation to other actors whose activities impact on health. this involves overseeing and guiding the whole health system, private as well as public, to protect the public interest. it requires both political and technical action because it involves reconciling competing demands for limited resources, in changing circumstances” (6). governance represents the owners, or the interest group of people, who represent an organization or any institution (7,8). the governing body, on the other hand, appoints personnel for the (executive) management. while governance is relevant for the vision of an organization, and translation of the vision into policy, management is related to making decisions for implementing the policies. governance also includes the relationships among the many players involved (the stakeholders) and the corporate goals. the principal players include the shareholders, the board of directors, and the management. other stakeholders include employees, suppliers, customers, regulators, the social environment and the community as a whole. management comes only second to the governing body, and it is bound to strive as per the wishes of the governing body. aim of this review in this overview, two interrelated processes in serbia will be analyzed: governance and management. to summarize the terminology, which will be used in the overview, as an official translation from serbian, “macro,” “meso” and “micro” levels are discussed. at the “macro” level, (usually at the state level) governance of health care system in serbia is performed by government, ministry of health and republic fund of health insurance. in addition, some governance functions in serbia (without kosovo and metohija) are also at the level of (9,10): bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 4  autonomous province of vojvodina and its six cities and 39 municipalities; governing bodies are “province government of vojvodina”, “province secretariat for health social policy and demography” and “province fund of health insurance”.  city of belgrade and its 17 municipalities; governing bodies are “city council with the mayor, deputy mayor and members” and “city secretariat for health care”, and 23 cities (including those in vojvodina with its 28 urban municipalities) and 150 municipalities (including those in vojvodina); governing bodies are the city and municipality authorities. at the “meso” level (at the facility/institutional level), governance is performed by the managerial board of each facility/institution (in serbian: “upravni odbor”). also, some governance functions with very weakly defined tor (terms of references) at the institutional level are performed by the supervisory board (in serbian: “nadzorni odbor”). at the “meso” level management is performed by the director and his/her management team. at the “micro” level, we can observe only management processes. a framework for assessing governance and management of health institutions in serbia is based on a set of criteria to cover assessment of institutional, financial and accountability arrangements, together with decision-making capacity and responsibility during the last decade (11,12). besides the “macro” level determining the basic structure, organization and finance of all publicly owned health institutions in the serbian context, this overview particularly deals with the description of the “meso” level: the functions/responsibilities of health managers at primary, secondary and tertiary care level of organization (see figure 1). however, the “micro” level dealing with operational management of staff and services inside the organization is also highlighted. this overview is prepared based on the following sources of information (data):  published health policy and legal documents in serbia, health legislation and guidelines from the ministry of health (moh), published papers in the serbian and international health management literature, internationally funded project reports (eu and wb projects’ reports dealing with health management, financing (capitation), quality improvement and local governance), health management conferences in the country and the region, training curricula and programmes of work;  published general health statistics, national electronic databases and who/eurostat database for comparison, and;  results of national survey of all health institutions’ directors and matron nurses done by the health council of serbia in 2010 and 2011. i. governance and management at macro level the essential characteristics of the external environment in which today’s governance and management of health service organizations in serbia are taking place include population aging, costly medical technologies, lifestyle intervention, and advance health promotion and prevention. also, the health care system, as in some other transitional countries, is faced with ethical and economic crises of unpredictable outcome. political, social and, predominantly, professional groups attempt to introduce changes in health legislation and functioning of health service organization, however, with variable success. at the macro level of governance, the most important was the adoption of the health policy document (13) by the serbian government. no similar document has ever been adopted in serbia, hence the process of bringing health in serbia closer to the relevant policy of the bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 5 european union was at this moment initiated. the health policy document defined the main directions of development of the health care system. as such, it was essential as a foundation of laws and bylaws conducive to the reforms of the health care system, including governance and management at all levels. according to this document, the reform of the health care system in serbia, being a continuous process of the transition of the entire socio-economic system, presupposes the implementation of the following goals of the health policy: a) safeguarding and improving the status of health of the population in serbia and strengthening of the health potential of the nation; b) a just and equal accessibility to health care for all the citizens of serbia and improvement of the health care for vulnerable populations; c) putting the beneficiaries (patients) into the centre of the health care system; d) sustainability of the health care system while ensuring transparency and a selective decentralization in the field of resource management, and diversification of sources and methods of financing; e) improvement in functionality, efficiency and quality of the health care system and definition of specialized national programs to advance human resources, corporate networks, technologies, and provision of medical supplies; f) defining the role of private sector in provision of medical services to the population; g) improvement of the human resources for health care. however, more than a decade after the adoption of this document, achievements of the health policy proves still to be variable in the sense of governance and implementation, due to the lack of specific objectives and priorities adopted by all parties. in practice, the implementation of the proposed framework of health policy of serbia presupposes consensus thereon of all the key actors in the health care system (beneficiaries, providers of services and mediators in the provision of health care – health insurance and ministry). following the adoption of the new system laws in 2005 (health care law and health insurance law), intended decentralization has been considered to play a major role in the portfolio of possible activities to improve governance and management of health care organizations in serbia. the actual organizational structure of the health care system in serbia as a framework for governance and management at “macro level” is presented in figure 1. serbia, as other parts of former yugoslavia, inherited a centralized state health system financed by compulsory health insurance contributions. the system was intended to provide access to comprehensive health services for all citizens with an extensive network of health institutions. at the end of 2013, the publicly owned health care system in serbia employed 112.202 persons in a total of 354 institutions (14). currently, in serbia, looking at the governance at “macro” level as the process by which authority is exercised, still many functions related to strategic directions/planning, legislation, and financing are at the national – republic level (ministry of health and health insurance fund, see figure 1). however, with the beginning of the process of decentralization, important players at “macro level” could also be seen at vojvodina province level, within its provincial secretariat for health care, social policy and demography (15), city belgrade secretariat for health care (16), and the respective provincial health insurance agency (17). social care for health at the level of an autonomous province, a municipality, or a city, includes measures for the provision and implementation of health care according to the interest of the citizens in the territory, as follows (article 13 of health care law) (18): bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 6 i. monitoring of the state of health of the population and the operation of the health service in their respective territories, as well as looking after the implementation of the established priorities in health care; ii. creating of conditions for accessibility and equal use of the primary health care in their respective territories; iii. coordination, encouraging, organization, and targeting of the implementation of health care, which is exercised by the activity of the authorities of the local self-government units, citizens, enterprises, social, educational, and other facilities and other organizations; iv. planning and implementation of own program(s) for preservation and protection of health from polluted environment, which is caused by noxious and hazardous matters in air, water, and soil, disposal of waste matters, hazardous chemicals, sources of ionizing and non-ionizing radiation, noise and vibrations in their respective territories, as well as by carrying out systematic tests of victuals, items of general use, mineral drinking waters, drinking water, and other waters used for production and processing of foodstuffs, and sanitary and hygienic and recreational requirements, for the purpose of establishing their sanitary and hygienic condition and the specified quality; v. providing of the funds for assuming of the foundation rights to the health care facilities it is the founder of in compliance with the law and with the plan of the network of health care facilities, and which includes construction, maintenance, and equipping of health care facilities, and/or capital investment, capital-current maintenance of premises, medical and non-medical equipment and means of transport, equipment in the area of integrated healthcare information system, as well as for other liabilities specified by the law and by the articles of association; vi. cooperation with humanitarian and professional organizations, unions and partnerships, in the affairs of health care development. decentralization implies a transfer of authority and competencies, as well as responsibilities from higher to lower levels. the transfer of authority from the central administration to smaller and local communities does not necessarily deprive the central government from all authority and power. the central administration should retain some control along with essential tasks in the sense of governance, such as legislative, financial, and regulatory duties. any excess, whether it refers to total centralization or total decentralization, can harm the health care process (19). in the health insurance act of 2005 (articles 208 et seq.), the serbian government (20) admitted that the reorganization of the serbian health care system has to take into account the following key issues: “the compulsory health insurance is provided and implemented by the republic fund of health insurance, with its official seat in belgrade” (article 208), and: “the republic fund is managed by the insured that are equally represented in the board of directors of the republic fund in proportion to the type and number of the insured established by this act” (article 209). according to the serbian legislation, health care facilities with funds in state ownership (hereinafter referred to as: state owned health care facility) are funded in accordance with the plan of the network of health care facilities, which is adopted by the government. health care facilities that provide emergency medical care, supply of blood and blood derivative products, taking, keeping, and transplantation of organs and parts of human body, production of serums and vaccines and patho-anatomical and autopsy activity, as well as the healthcare activity in the area of public health, shall be funded exclusively in state ownership. bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 7 figure 1. organizational structure of the health care system in serbia institutes institutes of public health general hospitals private specialist practices primary health care centers “dz” private general offices of physicians private pharmacies health stations health ambulances clinical centers clinical hospital centers special hospitals professional commissions republic government health insurance fund health council ministry of health f in a n ci n g p o li cy republic parliament pharmacies clinics, institutes ethical board otherwise, health care facilities can be established by legal or natural persons at any level. the complex interrelationships between the macro-, meso-, and micro level are illustrated in figures 2 and 3. however, governance at the level of municipalities predominantly has been exercised only regarding appointments of the directors, deputy director, the members of the management board (board of directors), and the supervisory board of health care institutions, at the same time with low capacity/competencies to exercise the decision making process at the local level and use responsibilities in the decision making space. execution of financial functions at the local/municipality level could be observed within some municipalities and their annual programme budget planning, which engages resources mainly to meet infrastructure needs of primary health care at the local level. besides the adopted law on local self-governance (23) which is providing decision space for local authorities to exercise more responsibility in governance at the local level, decision capacity stays limited. therefore, the main objective of the recent international projects, such as: dils – “delivery of improved local services” [managed by ministries of health, education, labour and social policies (24)] and “support to local self-government in decentralization” [managed by standing conference of towns and municipalities (25)] are meant to increase decision capacity of multidisciplinary teams at municipality level, both in governance and management. bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 8 figure 2. overview of the governance process source: original copy from: lewis w, pettersson g. governance in health care delivery: raising performance. policy research working paper 5074. washington: the world bank development economics department & human development department 2009 (21). figure 3. the long and short routes of accountability source: world bank. world development report 2004: making services work for poor people, washington, dc: world bank 2004 (22). bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 9 several factors contributed to this type of evolvement of governance at “macro” level. firstly, serbia is still in economic crisis, inherited from the past and aggravated by the world economic crisis. the poor performance of economy has a deep negative impact on the social sectors, including the health sector. political involvement at almost all administrative levels has also affected in a negative way the proper governance and management of the health system. it induced changes in the human resources structure (especially top managers) affecting the continuity of governance at “macro” level and strategic thinking (26,27). besides financial and legislative problems, many other weaknesses in the area of organization and functioning of the health care sector are present at “macro” level governance:  rigid normative regulation of the health care system;  centralized and bureaucratized management with limited autonomy of managers lacking necessary management skills;  still not fully developed and operational health information system and up-to-date information as basis for decision-making processes;  undeveloped “market” in the health sector with deprivation of private health care providers and still “passive” approach to privatization in the health care system;  development of health facilities beyond economic possibilities, their duplication, lack of coordination of activities according to levels of health care organization, poor maintenance of equipment and buildings, lack of sufficient operational budgets;  low professional satisfaction of health workers caused by low salaries with the consequence of bad motivation for providing efficient and quality health services;  dehumanised relationships between medical personnel and patients followed by absence of citizens’ responsibility for their own health;  curative orientation of the health care system with priority in development of secondary (hospital) and tertiary (sub-specialized) levels of care, despite formal support to primary health care orientation;  unrealistic objectives for prevention with formal and non-effective programs and activities in health promotion despite widespread risk behaviour and numerous environmental hazards;  lasting postponement of implementation of legal and administrative decisions, with lack of swaps (sector wide approaches) as necessary for development and implementation of regulations connected to the authority of other ministries, such as those dealing with economic affairs and regional development. however, certain achievements of “macro” level governance during the last decade have to be acknowledged, such as the introduction of the health council of serbia as advisory body to the ministry of health, development of a transparent process for continuous quality improvement in health care and the agency for accreditation, trying out new payment mechanisms in primary health care (“performance-based payment” as a step towards capitation), preparation for more efficient financing of hospitals by development of a drg system, and the like. ii. governance and management at meso-level institutional arrangements a review of health service legislation and the regulatory environment related to governance and health management shows weak areas that should be addressed and opportunities that bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 10 exist to make governance and management the mainstay of health sector reform in serbia. contrary to a typical business organization, the authority structure in managing a health services organization is divided among three authority and responsibility centres: board of directors, doctors, and administration represented by the director and his management team (28,29). the managerial board is legally responsible for the organization as a whole, including provision of health care, public relations and assistance in supply of resources for its functioning. if basic social roles of a health service are under consideration, it is the managerial board that most commonly reflects the profile of the community and its health services organization. it means that the former consists of delegates from various social groups of certain educational level and experience and in this way is executing governance at the “meso” level. doctors, comprising a medical board, but others as well, have a powerful role in management, since they are hold responsible for the majority of cost rendering decisions made. administration, composed of director, heads of departments and chiefs of assisting services, is the third and last authority centre in managing health services organizations, responsible for operational management. the authority and responsibility structure in managing the health services organization in serbia is defined in the health care law and bylaws together with the role and current and expected function of health managers at “meso” level. according to the health care law (article 130), a typical health care organization in serbia has the following management structure: the director, the managerial board (corresponding to the board of directors), and the supervisory board. it may also have a deputy director, who is appointed and relieved under the same conditions and according to the same procedure, which is specified for appointment and relieving of the director of the health care organization. the director, deputy director, the members of the management board, and the supervisory board of health care organisations are appointed and relieved by the founder. as an example, the director, deputy director, the members of the management board, and the supervisory board of an institute, clinic, institute, and clinical center, or the health care of employees institute of the ministry of interior affairs, the founder of which is the republic, are appointed and relieved by the government. the director, deputy director, the members of the management board, and the supervisory board of health care facilities the founder of which is the republic, except for the specifically mentioned institutions, are appointed and relieved by the minister. the director of a health care facility is appointed on the basis of a vacancy publicly announced by the management board of the health care organisation. the management board of a health care organization makes selection of the candidate and submits the proposal to the founder, which then makes the appointment. however, should the management board of a health care organization fail to elect the candidate for the director of the health care facility, or should the founder of a health care facility fail to appoint the director of the health care facility, in accordance with the provisions of the law, the founder shall appoint the acting director for a period of six months. in practice, it was not unusual that “acting director” stays for couple of years; whereas the law (article 135) also prescribed criteria for appointment, as well as conditions in which the director of a health care organization should be replaced. furthermore, the same health care law defines responsibilities and duties of the respective managerial bodies. the director is organizing the work and managing the process of work, representing and acting as proxy of the health care facility and is responsible for the legality of work of health care facility. in this way, contrary to established theory and practice, it seems that in serbia the director has also some governance function. if the director does not bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 11 have medical university qualifications, the deputy, or assistant director shall be responsible for the professional and medical work of the health care facility. the director shall submit to the management board a written quarterly, and/or six-monthly report about the business operations of the health care organization. the director shall attend the meetings and participate in the work of the management board, without the right to vote. contrary to the position of the director, the law does not prescribe such detailed instructions as regards who should be appointed for management board and supervisory board. it is only stated (article 137) that the management board in primary health care centres dz, pharmacies, institutes (see table 1 for details), and the national public health institute have five members of whom two members are from the health care organization, and three members are the representatives of the founder, whereas the management board in a hospital, clinic, institute, clinical hospital, and clinical centre has seven members of whom three members are from the health care facility, and four members are the representatives of the founder. responsibilities of the management board are the following: i) adopt the articles of association of the health care organization with the approval of the founder; ii) adopt other bylaws of the organization in compliance with the law; iii) decide on the business operations of the health care organization; iv) adopt the program of work and development; v) adopt financial plan and annual statement of account of the health care organization in compliance with the law; vi) adopt annual report on the work and business operations of the health care organization; vii) decide on the use of resources of the health care organization, in compliance with the law; viii) announce vacancy and implement the procedure of election of the candidates for performing the function of the director; ix) administer other affairs specified by the law and the articles of the association. a supervisory body as the third centre of authority is appointed in a similar way as the management board (with three members for less complex health care organizations and five for those at secondary and tertiary level of organization). contrary to the management board, the law does not prescribe in detail responsibilities of the supervisory board, except for the following (article 138): “the supervisory board of health care organization shall exercise supervision over the work and business operations of a health care organization”. in practice, such formula is producing a rather passive role for this body. a recent survey of all directors of health care organizations conducted by the health council of serbia in 2010 and 2011, pointed to some general and some specific characteristics of management at “meso-level”. the study used a questionnaire designed on the basis of similar studies in serbia, which comprises five groups of questions: general characteristics that define the manager profile, the problems of management, assessment of the importance of motivational factors, carrying out the management goals and self-evaluation of managerial skills. according to this survey, the managers of health care organizations in serbia are mostly experienced specialists, slightly more often males than females, who usually have some form of management education (table 1). in comparison with the period of the nineties, the structure of health organizations’ managers in serbia improved in terms of management training and gender sensitivity. bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 12 table 1. general profile of directors of health care organizations in serbia characteristics directors of outpatient institutions (n=140) directors of hospital institutions (n=90) p number percent number percent gender 0.032 male 76 54.3 61 68.5 female 64 45.7 28 31.5 age (years) 0.033 <35 3 2.1 1 1.1 35-45 14 10 11 12.5 46-55 92 65.7 42 45.7 56-65 31 22.1 34 38.6 occupation <0.001 physician with specialization 104 76.3 87 96.7 physician without specialization 6 4.3 0 0 dentist 8 5.7 0 0 pharmacists 19 13.6 1 1.1 economists, lawyers, other 3 2.1 2 2.2 working experience 0.135 up to 15 8 5.9 7 8.1 15-19 21 15.4 7 8.1 20-24 44 32.4 20 23.3 25-29 38 27.9 27 31.4 over 30 25 18.4 25 29.1 managerial experience (years) 0.265 <1 21 15.2 7 8 1-2 43 31.2 28 31.8 3-4 25 18.1 10 11.4 5-6 18 13 14 15.9 7-9 24 17.4 23 26.1 over 10 7 5.1 6 6.8 education in management 0.047 yes 110 79.1 60 67.4 no 29 20.9 29 32.6 type of education 0.212 self-empowerment 13 11.2 12 18.2 courses 73 62.9 43 65.2 master programmes 30 25.9 11 16.7 satisfaction with social status 0.959 very satisfied 99 70.7 65 72.2 moderate satisfaction 35 25 21 23.3 not satisfied 6 4.3 4 4.4 member of a political party 0.003 yes 85 63 37 42.5 no 50 37 50 57.5 source: health council of serbia survey of directors of health care organizations 2010-2011 (30). a situation analysis performed within a recent eu project found that given the opportunity, some health workers would choose management roles in the health services. they may also choose project-based work with international organisations and ngos, and when the funding for such projects ends may seek to return to the health services in management positions. bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 13 there are also managers in legal services, human resources, utilities management and other professional categories. the issues of general management and non-medically trained managers are complex and have not yet been addressed in serbia as a debate about health management has only recently started. the need for new management skills is being partially met by existing institutions and universities, on the job training, projects funded by international organisations and ngos, and, in a very limited way, education programmes by newly emerging private providers. a large boost is required to create a cadre of managers who can bring about change in the health services. responsibilities of managers in serbia will request change with decentralisation, requiring more knowledge and skills at municipal level. private/public partnerships are likely to develop within the next five years, requiring more skills in contracting out. as of now, there is no clear career structure or progression pathway for health managers. however, this is likely to be mapped out within the next five years and will increase demand for formal training and accredited courses. it is expected that the old style bureaucratic and very hierarchical structure will change and for this managers with change management skills will be required. the following have been identified by key informants as priority areas for the introduction of change management: team working will enable a more effective approach to cross-disciplinary tasks. better use of information technology is likely to produce information that is more relevant to decision-making. financial tracking will shift to output-based methods and efficiency will be measurable. individual accountability, currently weak, will be required to increase; there will be a shift to benchmarking rather than a reliance on blame and, therefore, criteria for positive results will become more transparent and measurable. transparency in decision making and better planning and consultation processes. prioritizing of scarce resources while protecting access to services for the poor and uninsured. project management skills will be applied within the health service. there will be a shift from development support from the international community towards loans and credits; managers who understand how to use such funds will be required. there will also be a shift towards contracting out services. increased individual accountability and managers who understand client-focused services will be required. this will require a cadre of managers with a very new set of skills. by producing large numbers of change managers it is also expected that they will be able to support each other in a system that is currently quite hostile to change. this has been a positive experience from the ear funded and carl bro implemented project, where team-based working and problem solving has also provided professional support for the managers involved. there is a frequently expressed belief in the health services that hospital management is very different to general management of other organizations. there is likely to be little acceptance of general managers in the health system; actually, this has not been tried out in serbia to date, but it should not be excluded. there is also a practice that amongst health professionals, only senior specialist doctors have the authority required for senior management and leadership positions in the health services; again, this should be questioned and tested (27). bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 14 financial arrangements besides the main financial arrangements in serbia and implementation of ongoing changes in the financial management system, particular attention is given to the managerial aspects of decision making related to capital investment, adjustment of capital and operational expenses and ability to incur debt, sometimes considered by managers (directors and management teams) as deficit carried over from the last fiscal year and due to introduction of a new budget system for reporting based on the new law on budget system, which is ongoing from 2009 and adopted in the serbian parliament each year (31). according to real practice examples, strengths and weaknesses are obvious in planning and reporting on institutional financial flows. typically, the managerial board (“upravni odbor”) is responsible for the adoption of financial reports and annual budget plans at the beginning of each calendar year, after which a report and a plan is processed to the republic fund of health insurance for approval and serves as a base for contracting with the health care organization. those institutions which have also financing directly through the republic budget (such as institutes of public health) are obliged to send their plan of activities including a budget in the foregoing calendar year for the next calendar year. although it should be activity-based costing, very often the correlation between activities and budget lines is not clear and visible. examples from practice indicate that the managerial board (“upravni odbor”) does not have always direct responsibilities in financial arrangements, as sometimes changes in contractual agreements with the republic fund of health insurance, as well as with the ministry of health during the year are reported by directors only post factum. this is also an indication of the relatively weak role (responsibility) of the managerial board within health care organizations of serbia regarding governance. accountability arrangements health managers are not defined as a separate profession in serbia. senior staff in the health services has management functions and responsibilities, and these are noted under the health law of 2005 and under various other procedural documents in the legislation. with very few exceptions, senior health services managers in the country are doctors, there is more variety at middle management level, although the two levels have not till now been clearly defined. in the study of managing health services organizations in serbia over the last decade, apart from the triple power and authority distribution between management and supervisory board, administrative director with his collegiums, workforce particularly doctors, specific accountability and responsibilities include the following: accountability and responsibility for the patient, above all, within the scope of modern medicine and health promotion movement, with provision of the best possible health care, with minimal costs. only recently in serbia within the development of different patient ngo’s; accountability is increasing in this regard, apart also from recently established the socalled “protector” of patients’ rights in each institution. reports about patients’ complaints are regularly presented both to directors and managerial boards. however, regular monitoring during five years within the reporting about quality indicators has pointed to a low level of complaints and consequently few actions by management for corrections; accountability and responsibility for the employed workforce by recognizing their sensible requirements for safety in terms of wages, appropriate working conditions, bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 15 promotions, but also identifying their fears caused by uncertainty regarding positive effects of their work (outcomes concerning the treated patients’ health). usually, this is exercised through trade unions, sometimes several per one health care organization; accountability and responsibility for a financier and different social groups (donors, sponsors) supplying resources for functioning of the institution; accountability and responsibility for the community (public) in determining means for meeting the population health care needs, and; accountability and responsibility for oneself by making efforts to perfect one’s knowledge and skills related to management as well as readiness to make effective responses under conditions of continuing changes and threats. the national survey of directors is offering assessment of the last bullet point referring to managerial skills (table 2). there are no differences between outpatient and hospital managers in this regard, however, this is a very subjective assessment indicating surprisingly high competences, which should be further investigated and verified. table 2. self-assessment of managerial skills (on a 5-point scale) skill directors of outpatient institutions (n=140) directors of hospital institutions (n=90) p average sd average sd evidence based situation analysis 4.39 0.862 4.37 0.788 0.859 application of swot analysis 3.59 1.293 3.42 1.277 0.350 development of mission and vision 4.20 1.052 4.30 0.866 0.450 development of flow-charts for specific work process 3.28 1.227 3.25 1.199 0.833 development of smart objectives 3.57 1.290 3.39 1.216 0.322 development of diagrams 3.15 1.321 3.10 1.234 0.805 development of wbs 3.46 1.332 3.23 1.180 0.217 assessment of employees 4.26 0.930 4.17 0.865 0.476 public relations skills 4.30 0.852 4.25 0.918 0.700 change management skills 4.29 0.862 4.30 0.714 0.944 project management skills 4.26 0.864 4.33 0.769 0.536 conducting effective meeting 4.45 0.704 4.54 0.724 0.374 searching through internet 4.14 0.928 4.17 0.950 0.811 communications with employees 4.60 0.560 4.51 0.642 0.222 fund raising and donor searching 4.10 1.046 3.84 1.127 0.087 source: health council of serbia survey of directors of health care organizations 2010-2011 (30). decision-making capacity versus responsibility this section is based mainly on the national health management survey executed among directors of health care institutions and matron nurses. there are few exclusive health service managers, as it is an insecure profession. often doctors take up a management role but continue to wear their “clinical hats” and keep a base in their clinical work. this gives them a safety net in the event that they do not keep their management posts, the most senior of which are subject to political appointment. according to the national survey results in serbia, priority objectives for managers are: improving health care quality, increasing patient bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 16 satisfaction and professional development, as well as improving employee satisfaction and work organization (table 3). significant differences were found between managers of primary healthcare organizations and hospitals: outpatient facilities’ managers are much more likely to improve in the areas of management, are significantly more often members of a political party and more frequently state that the problem of management is the lack of coordination in health care institutions. the major objectives for hospital managers are familiarizing new employees with the work process, introducing new technologies and developing scientific research. table 3. assessment of importance of institutional objectives by directors (on a 10-point scale) objective directors of outpatient institutions (n=140) directors of hospital institutions (n=90) p average sd average sd improvement of work organization 73.17 26.59 78.30 21.88 0.132 decreasing of operational costs 63.31 31.10 64.77 31.28 0.733 increasing staff satisfaction 76.26 23.38 75.17 24.82 0.740 increasing consumer satisfaction 79.14 22.89 80.80 24.08 0.603 multidisciplinary team work 69.78 26.80 74.89 24.02 0.148 empowering of newly employed staff 57.55 30.30 65.34 26.78 0.050 continuing education 78.06 23.68 77.84 25.12 0.948 introduction of new technologies 71.09 28.40 78.60 24.02 0.042 research and development 52.07 33.61 68.50 32.20 0.001 source: health council of serbia survey of directors of health care organizations 2010-2011 (30). considering the main player in the setting of institutional objectives, the situation is very interesting pointing to very low authority of managerial boards in this process, which is mainly governance function. according to the national survey conducted in 2010-2011, the situation is as follows:  ministry of health 7.4%  director alone 2,6%  director after discussion with collaborators and staff 65,7%  management team and its discussion 22,6%  other players 0.4%  without answer 1,3% managerial problems (table 4) are grouped into factors, based on which it is possible to define future interventions such as improvement of work organization and coordination, control systems and working discipline. strategic management comprises drafting, implementing, and evaluating cross-functional decisions that enable an organization to achieve its long-term objectives together with solving strategic and operational daily problems of management. in this process, a strategic plan is laid out that encompasses the organization’s mission, vision, objectives, and action plans aimed at achieving these objectives. bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 17 table 4. assessment of management problems (on a 4-point scale) type of problems directors of outpatient institutions (n=140) directors of hospital institutions (n=90) p prosečna vrednost sd prosečna vrednost sd planning 2.78 0.942 2.65 0.871 0.314 work organization 2.79 0.832 2.72 0.750 0.514 coordination of services 3.17 0.731 2.85 0.847 0.003 replacement of staff 2.75 0.884 2.63 0.949 0.363 professional development 3.06 0.923 2.93 0.997 0.329 procurement of equipment 2.09 1.062 1.84 0.931 0.067 keeping of equipment 2.39 1.036 2.21 0.935 0.199 financing 1.86 0.938 1.76 0.905 0.413 system of control 2.90 0.851 2.84 0.838 0.589 information system 2.46 0.992 2.38 1.053 0.598 working discipline 2.96 0.734 2.80 0.733 0.108 cooperation with ministry of health 2.80 1.105 2.87 1.120 0.664 cooperation with health insurance fund 2.70 1.057 2.63 1.083 0.658 source: health council of serbia survey of directors of health care organizations 2010-2011 (30). a recent study of 40 hospital management teams in serbia proved capacity of managers who are trained to improve strategic management competences and accept clear responsibility in strategic management. during the workshop done with the same 40 general hospitals managers they did a swot analysis and possible strategic options for development of their organizations. examples are presented in table 5. continuing education on health care management is being offered in serbia at an increasing scale, in response to the health care system’s well-known deficits. recently, at the belgrade school of medicine, a postgraduate master’s program in health care management was established. however, in serbia, such programs have been evaluated very rarely if at all. exceptions are the results of the training programme for hospital and primary health care managers, offered by the centre school of public health and management in belgrade, with providing evidence, for the first time in serbia, of effective support to the directing managerial teams with respect to their strategic planning abilities. during those studies, the measurement and evaluation of hospital performance were recognized as essential, partly as a consequence of the recently established reporting system of quality indicators and partly due to recognition of the usefulness for benchmarking. only a few stakeholders, e.g., the ministry of health, the republic health insurance fund, and project agencies, were considered relevant for the hospitals. those key partners directly affect hospital services and financial flows and, therefore, were highly correlated to hospital managers’ ability to plan strategically. this demonstrates that the managerial teams were predominantly oriented toward the fulfilment of legal obligations and contracts. the second independent component was a detailed analysis of the internal environment (staff, their training and development, management, information system, equipment, customers and their satisfaction, and kind and quality of health services). the hospital’s internal environment was included in the government’s health reform initiatives (32). in serbia, defining a hospital’s mission, vision, action plan, and especially its bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 18 smart objectives (33) seems to be dependent on the political environment and the existing legislation. table 5. strategic management thinking in serbian general hospitals example of vision and mission statement: “we are here to provide optimal methods in health care services with respect to the demands of our patients and to apply new technological accomplishments for the faster and more efficient treatment of our customers.” examples of goals: development of quality and efficiency of health care services establishing new diagnostic and therapeutic methods implementation of procedures for ambulatory surgery examples of strengths: highly educated staff introduction of clinical guidelines renovation of some parts of our facilities good relationship with the media examples of weaknesses: medical staff holding second jobs in private practice medical equipment out of date low motivation of staff negative financial balance examples of opportunities: rationing of hospital staff and facilities support from the local community and from ngos participation in international projects examples of threats: lack of treatment standards and protocols high number of refugees and internally displaced people lack of effective gatekeeper function in primary health care proposals of strategic options comparative advantage (strength/opportunity): widen the spectrum of services to gain additional income investment/divestment (weakness/opportunity): promotion of cooperation with local authorities mobilisation (strength/threat): improvement of communication with customers damage control (weakness/threat) note: the teams could not or did not want to imagine this scenario source: workshop with 40 general hospital teams done in 2009 by the school of public health and health management university of belgrade, within an eu project (see also terzic-supic et al. (32). in order to increase further management capacity to deal with management problems, numerous training have been organized since 2007 supported by several projects which resulted in the development of strategic plans: “capacity building of hospital management teams”, supported by eu project (result: 40 hospitals developed strategic plans); “programme for management development in primary health care institutions of belgrade” project funded by the city secretariat of health care belgrade, 2007-2009 (result: 14 primary health care centres in belgrade developed strategic plans); working group of serbian basic health project – ministry of health (wb) – education of 7 primary health care managers (result: 9 primary health care centres in belgrade developed strategic plans); “politics of primary health care in balkans”, project managed by cida (result: 7 primary health care centres developed strategic plans); bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 19 “support to the implementation of capitation payment in primary health care in serbia”, eu financed and managed project (result: 29 primary health care centres developed strategic plans); dils – “delivery of improved local services” (managed by piu of ministries of health, education, labour and social policies (result: 28 primary health care centres developed strategic plans). looking at primary health care organizations up to 2012, in total, 78 out of 157 have developed strategic plans based on this capacity building (predominantly with the support of the school of public health and management, faculty of medicine, university of belgrade). in addition, strategic plans for capacity building of management teams in primary health care as support to the new method of payment of providers in primary health care are developed since 2010. it is also proven (34-37) that the training courses offered to management teams in serbia by the centre school of public health and management in belgrade had positive effects on the teams’ ability to formulate their organizational mission and vision, strategic objectives, and action plan as learning outcomes and to implement monitoring and adjustment of their strategies. nevertheless, the research evidences in serbia also demonstrates that improving strategic planning practices can be effective, but many health care organizations have difficulties in translating their strategic plan into actions that result in successful performance. iii. management at micro-level as physicians and to a lesser extend nurses regularly execute management functions at micro-level, it is of great relevance for a smooth operation of services as well as for the satisfaction of patients and staff, that these functions are not only performed with good will but also with knowledge and skills. the example of gaps in management competence before and after training for physicians and nurses illustrated in figures 4 and 5 highlight a key problem at the micro-level: training! female managers in our studies, here following santric-milicevic (36), developed higher competency levels after training in communication skills and problem solving. managers rated assessing performance of higher importance, while chief nurses emphasized the importance of leading. before training, the estimated competency gap was generally the highest in assessing performance, followed by team building and planning and priority setting. terzic et al. (35) came to similar conclusions but added the analysis of predictors: “the biggest improvement was in the following skills: organizing daily activities, motivating and guiding others, supervising the work of others, group discussion, and situation analysis. the least improved skills were: applying creative techniques, working well with peers, professional self-development, written communication, and operational planning. identified predictors of improvement were: shorter years of managerial experience, type of manager, type of profession, and recognizing the importance of the managerial skills in oral communication, evidence-based decision making, and supervising the work of others.” bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 20 figure 4. core management competences of top managers (physicians): competence gap before and after training (the confetti pattern of radar indicates the area of improvement after training) source: santric milicevic m, bjegovic-mikanovic v, terzic-supic z, vasic v. competencies gap of management teams in primary health care. the european journal of public health 2011; 21(2):247-53 (36). figure 5. core management competences of chief nurses: competence gap before and after training (the confetti pattern of radar indicates the area of improvement after training) source: santric milicevic m, bjegovic-mikanovic v, terzic-supic z, vasic v. competencies gap of management teams in primary health care. the european journal of public health 2011; 21(2):247-53 (36). bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 21 challenges and recommendations for possible improvements of governance and management of health care institutions in serbia challenges ahead for the governance and management of health institutions in serbia are derived from the situation analysis and recommendations are made based on actual examples of good practices in europe and the world and in the light of management opportunities/threats and strengths/weaknesses in serbia. the serbian health system is by tradition highly centralized. however, providing health services of high quality on a regular basis requires a high degree of complexity and interaction between various levels of management and different stakeholders. keeping all relevant decisions at the national level and organizing complex tasks centrally cannot be perceived without establishing a highly trained, numerous and well-paid central bureaucracy. this does not seem to be a realistic option for serbia and many other countries as well. therefore, the issue of far reaching and effective decentralization is on the table which at the same time introduces a certain degree of competition between service institutions. the term “horizontal, not vertical management” has been introduced in this context. however, each country coming from a specific historical background has to find its own way forward. the concept of decentralization according to bossert (38-41) comprises three elements at the macro-level, namely allowing for “decentralist decision space”, “corresponding institutional capacity”, and “local accountability” (towards the community). at the managerial meso-level this has to be translated into operational planning, budgeting, human resources management, and service organization, where this last element is considered to be a matter of the microlevel. in order to strive for the implementation of this concept in serbia, the following activities are recommended to be carried out timely and successfully: macro-level: i. the ministry of health should revise the valid legislation allowing for a stepwise transfer of more decision making powers within a limited time period to the “decentralist level”, defined as municipality authorities. ii. the republic fund of health insurance is to become fully independent and has likewise to defer financial powers to the lower levels – branches. however, there should be a compensation mechanism between poorer and richer municipalities in serbia, maybe supported from tax money allocated by the budget or by the ministry of finance, or through the ministry of health. iii. the service facilities (hospitals and others) within a district (= region = “okrug”) negotiate their service profile and budget directly with the local partners – the branch of the republic fund of health and municipal authority. iv. insured patients can select a chosen physician wherever they want. v. in order to harmonise the various elements of the health system in terms of a horizontal management, a national decision making body composed of the hif and the representation of the service providers together with the professional chambers should meet chaired by the ministry of health in order to adapt permanently the governance. the package of basic health services is to be defined at this level, as well as the care to be provided to uninsured persons. vi. the number of institutional managers required nationwide has to be determined and trained accordingly in postgraduate programmes for public health and management bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 22 (based on defined competences required to provide good performance). otherwise, they will not be able to make use of the larger decision space provided. vii. likewise, short-courses in community health management for mandated civil servants and politicians at the community level should be regularly offered. meso-level: i. standard models of terms of references for all management staff categories have to be developed and harmonised to correspond to the new legislation and practice in educational sector and linked to corresponding programmes of continuous professional development (cpd) offered by the four serbian medical/health faculties in close cooperation with the faculties of management and organization. ii. satisfaction of patients and employees which is measured by standard instruments every year at the institutional level should be improved both in the way of assessment and tools for improvement. iii. development of a guideline on change management and decentralist accountability towards the local elected community representatives. iv. promotion of the employment of non-medical managers and managers coming from non-medical environments. micro-level: i. allowance of intra-institutional opportunities for increased decision space of staff, especially nurses, and encouragement of training options up to postgraduate levels. ii. regular negotiations with the trade union representatives to agree on payment schemes which correspond to the qualification and position of staff, especially nurses. key messages  continue decentralization and support to an effective national decision making body (health council of serbia) with all relevant stakeholders.  reduce the well-known implementation gap and agree on a binding time frame for reforms.  establish obligatory schemes for education and training of managers and support sustainability of state institutional capacity to teach, train and advise on a scientific basis. references 1. world bank. world development report 2004: making services work for poor people, washington, dc: world bank, 2004. 2. savedoff wd. governance in the health sector: a strategy for measuring determinants and performance. policy research working paper 5655. washington d.c: the world bank, human development network office of the chief economist: may 2011. 3. world bank. managing development the governance dimension. washington 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bossert t. decentralisation of health system: decision space, innovations and performance: boston: harvard university, 1997. bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 25 39. bossert t, baernighausen t, mitchell a, bowser d. assessing financing, education and management for strategic planning for human resources in health: geneva: who, 2007. 40. brune n, bossert t. building social capital in post-conflict communities: evidence from nicaragua. soc sci med 2009;68:885-93. 41. bossert tj, mitchel ad. health sector decentralisation and local decision-making: decision space, institutional capacities and accountability in pakistan. soc sci med 2011;72:39-48. ___________________________________________________________ © 2016 bjegovic-mikanovic; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. jovanovic d, jankovic j, mirilovic n. socio-demographic inequalities in satisfaction with primary health care and utilization of chosen doctors’ services: a cross-sectional study (original research). seejph 2020, posted: 11 february 2020. doi: 10.4119/seejph-3311 p a g e 1 | 12 original research socio-demographic inequalities in satisfaction with primary health care and utilization of chosen doctors’ services: a cross-sectional study dragana jovanovic1, janko jankovic2, nikola mirilovic3 1 department of social medicine with informatics, primary health center valjevo, valjevo, serbia; 2 institute of social medicine, faculty of medicine, university of belgrade, belgrade, serbia; 3 zemun gymnasium, zemun, serbia. corresponding author: prof. janko jankovic, md, phd; address: institute of social medicine, faculty of medicine, university of belgrade, dr subotica 15, 11000 belgrade, serbia; telephone: +381 11 2643 830; fax: +381 11 2659 533; e-mail: drjankojankovic@yahoo.com jovanovic d, jankovic j, mirilovic n. socio-demographic inequalities in satisfaction with primary health care and utilization of chosen doctors’ services: a cross-sectional study (original research). seejph 2020, posted: 11 february 2020. doi: 10.4119/seejph-3311 p a g e 2 | 12 abstract aim: the aim of the study was to examine socio-demographic inequalities in user satisfaction with phc and utilization of chosen doctors’ services. methods: this cross-sectional study was conducted in 2016 among 232 respondents who participated in phc user satisfaction survey in phc center valjevo, serbia. inclusion criteria were an age of at least 20 years, sufficient skills of serbian language to fill in questionnaires and consent to participation. two hundreds and six patients completed an anonymous questionnaire about the user satisfaction with phc. results: the chosen doctor was seven times more often visited by the elderly (or=7.03) and almost three times more often by the middle-aged (or=2.66) compared to the youngest category of respondents. those with low education and poor financial status of the household visited a doctor four (or=4.14) and almost nine times (or=8.66) more often, respectively, compared to those with high education and good socioeconomic status. a statistically significant higher level of phc satisfaction was recorded in the rural population (p<0.001) and among respondents with poor socioeconomic status of the household (p=0.014). conclusion: the chosen doctor was more frequently visited by respondents with low education and those with poor socioeconomic status of the household, while a higher degree of satisfaction with phc was recorded in the rural population as well as in those with poor socioeconomic status of the household. keywords: cross-sectional study, inequalities, primary health care, serbia, service utilization, user satisfaction. conflicts of interest: none declared. jovanovic d, jankovic j, mirilovic n. socio-demographic inequalities in satisfaction with primary health care and utilization of chosen doctors’ services: a cross-sectional study (original research). seejph 2020, posted: 11 february 2020. doi: 10.4119/seejph-3311 p a g e 3 | 12 introduction health inequalities are "systematic differences in health or distribution of health resources between different population groups" and mainly produced by different socio-demographic determinants such as education, material status, employment, gender, type of settlement, age and ethnicity (1). sociodemographic inequalities in health pose a major challenge for health policy makers in a country because they are unfair, unjust and avoidable. they are also a persistent and widespread public health problem, both in the countries of the european region and worldwide (2,3). serbia is no exception in this respect, as the presence of health inequalities between different population groups (4), as well as in the domicile population has been documented (5-7). primary health care (phc) represents the first contact and entry into a country's health system and most health problems that occur in the population have been addressed at the phc level (8). a good phc system in a country ensures a more equitable distribution of health services and better health outcomes for the entire population (9) and this can be to some extent done by continuous testing and analysis of user satisfaction as a valid and comprehensive indicator of quality in health care (10,11). satisfaction with phc is the users’ response to provided primary care services and also implies users’ attitude towards the doctor, other healthcare personnel, and health care system in general (12-14). it is natural for different persons to have different perceptions and experiences regarding provided health services, relationship with physicians and other healthcare personnel, availability of health care and other quality indicators (14). data from 2013 serbian health survey (15) showed that 53.8% of citizens were satisfied with public health services. the less educated, the poorest, as well as the residents of rural settlements were the most satisfied with the provided health care services. speaking about utilization of health care it refers to obtain the necessary services from the health service in the form of contact. more illustratively, it is the point where patients' needs meet the health care system and are satisfied (16). one measure of phc use is the average number of visits to chosen physician per capita per year. according to the latest health survey of the serbian population (15), approximately two thirds of the population aged 14 years and older (65.5%) visited the chosen doctor or pediatrician in 2013. each adult visited its chosen physician 4.8 times in average (17). despite the fact that serbia has a comprehensive universal health care system with free access to primary care services, inequalities in the utilization of health care services are present (6,15). men and women belonging to the poor and men with lower education were less likely to visit general practitioners (gps), regardless of their health status (6). the aim of the study is to examine the influence of demographic (gender, age, type of settlement) and socioeconomic determinants of health (education, socioeconomic status of the household) on the users’ satisfaction with phc and the utilization of chosen doctors’ services. methods study population and setting the cross-sectional study was conducted in the primary health care center valjevo, serbia. a total of 232 patients were enrolled during a 6-week period in june and july 2016. the sample size was calculated based on the number of total and first visits in the previous year. assuming a standard error of 2%, the minimum sample size was 180 patients. to allow for no respondents at least 200 patients were enrolled. to diminish selection bias, patients were selected consecutively from the medical charts of patients waiting to be seen. inclusion criteria were an age of at least 20 years, sufficient skills of serbian language to fill in questionnaires and consent to participation. we excluded patients coming to the practice only for picking up a prescription, who did not aim to see the physician, or who needed immediate emergency care. all eligible consecutive patients visiting the primary health care center valjevo and its branches in brankovina and gola glava were informed about the purpose of the study and invited to participate. written informed consent was obtained from all participants prior to beginning the testing. the study was approved by the ethical board of primary health care center valjevo, serbia (number of approval: dz-01-1656/1, date of approval 8 june 2016). research instrument the user satisfaction with the primary health care (phc) was examined according to the professionalmethodological manual from the institute of public health of serbia (iphs) “dr. milan jovanovic batut” (18). a modified anonymous questionnaire about the user satisfaction of the work of the general medicine department was used. the validity and reliability of the questionnaire was tested during the prior study conducted in valjevo (19). the original questionnaire was slightly shortened in order to achieve higher consistency, to avoid asking similar questions, and with the goal of an easier, faster and more effective jovanovic d, jankovic j, mirilovic n. socio-demographic inequalities in satisfaction with primary health care and utilization of chosen doctors’ services: a cross-sectional study (original research). seejph 2020, posted: 11 february 2020. doi: 10.4119/seejph-3311 p a g e 4 | 12 filling out of the questionnaire by the respondents. the original questionnaire about user satisfaction was constructed based on the questionnaire recommended by who for the evaluation of the use, availability, coordination and comprehensiveness of the health care. at the consensus workshop in 2009, the iphs questionnaire was adapted for chosen doctors in serbia (13). the users of valjevo primary health care center services, as well as the ambulance services in brankovina and gola glava, were given anonymous questionnaires upon completing their visit to the chosen doctor. the respondents were filling them out on their own, consulting with the interviewers only about the questions they were not sure about. upon completion of the questionnaires, they were put in the sealed boxes, so the total anonymity was guaranteed. variables the demographic determinants used in this study were: age, sex (male and female), and type of settlement (urban and rural). the age was categorized into three age groups: 20 to 39, 40 to 64, and 65+ years. the socio-economic characteristics were the level of education and self-assessed socioeconomic status of the household. education was defined as low, middle and high, while self-assessed socioeconomic status as poor, average and good. the outcome variables selected in the present study were the number of visits to a chosen doctor per year and the customer satisfaction with the primary health care. the number of visits was dichotomized into two categories: up to 5 visits to the doctor per year and 5 or more visits in the same period. for items "skipped check-ups due to financial constraints" and "wait too long for check-up" two answers were offered: yes or no. to examine patient satisfaction with the nurses and doctors in phc we were interested to know how they felt about the following statements: "nurses at the counter are kind", "nurses at the interventions are kind", "nurses offer all information", "doctor is familiar with the previous diseases", "doctor takes enough time for conversation", and "doctor gives clear explanations about the diseases and the medicines" (the offered answers were: yes, partly and no). the general assessment of customer satisfaction with the primary health care was grouped into three categories: satisfied, partly satisfied and unsatisfied. statistical analysis the data was analyzed using the methods of descriptive statistics, as well as bivariate and multivariate linear and logistical regression analysis. to find statistically significant differences between socio-demographic (sex, age, type of settlement, level of education and self-assessed socioeconomic status of the household) and outcome variables, the chi-squared test was used. bivariate and multivariate logistic regression analyses were performed to estimate the association between the use of chosen doctors’ services and socio-demographic variables. to assess the association between user satisfaction with the primary health care and socio-demographic variables, methods of bivariate and multivariate linear regression analyses were used. the results of logistic regression analyses were reported with odds ratios (ors) and 95% cis, and with unstandardized regression coefficients (b) and probability in linear models. statistical significance was set at 2-sided p<0.05. all statistical analyses were performed using the statistical ibm package spss v.20.0 (spss inc., chicago, illinois, usa). results of the 232 enrolled primary care patients, 206 completed the questionnaire, yielding a response rate of 88.8%. out of 206 patients, 135 (65.5%) patients were from the urban area and 71 (34.5%) from the rural area. most of the patients were woman (54.9%). the mean age of the patients was 54.5 years (sd = 17.0; age range 20 to 86 years). 26 patients (most of them from the youngest age group and from the urban area) refused to participate, typically because of lack of time or unwillingness to fill in the questionnaire. distribution of socio-demographic characteristics and user satisfaction indicators with the primary health care by type of settlement is shown in table 1. the largest percentage of respondents belonged to the middle age group (45.8%), finished middle education (51.0%) and rated their socioeconomic status as average (52.9%). slightly over a half of patients (54.7%) visited their chosen doctor five and more times per year, and most of them did not skip their check-ups due to financial constraints (80.1%). more than one-third of patients (37.4%) were not satisfied with the kindness of the nurses at the counter, 14.1% considered that the doctor was not familiar with their previous diseases, and 17.0% stated that the doctor did not take enough time for conversation with the patient. more than half of the respondents (55.1%) were satisfied with the primary health care, while approximately every eighth respondent was unsatisfied (12.7%). concerning type of settlement, people residing in rural area were older (45%), with low education (52.2%), and with an average socioeconomic status (53.5%), whilst urban jovanovic d, jankovic j, mirilovic n. socio-demographic inequalities in satisfaction with primary health care and utilization of chosen doctors’ services: a cross-sectional study (original research). seejph 2020, posted: 11 february 2020. doi: 10.4119/seejph-3311 p a g e 5 | 12 respondents were mainly with middle educational attainment (56.3%). around two-thirds (66.2%) of the respondents from the rural area visited their chosen doctor five or more times per year, compared to 48.5% of those in the urban area. rural patients compared with their urban counterparts had lower level of “waiting too long for check-up”, and higher levels of “nurses at the counter and at the interventions are kind”, “information provided by nurses”, “doctors being familiar with the previous diseases”, “doctor taking enough time for conversation” and “doctor providing clear explanations about the diseases and the medicines”. a general satisfaction with the primary health care was expressed by 78.8% patients from the rural area, and 42.2% from the urban area. table 1. distribution of socio-demographic characteristics and user satisfaction indicators with primary health care by type of settlement variables total (206) urban (135) rural (71) p* n % n % n % age categories 20 – 39 40 – 64 65+ 46 94 66 22.0 45.8 32.2 37 64 34 27.4 47.4 25.2 9 30 32 12.7 42.3 45.0 0.005 sex male female 93 113 45.1 54.9 62 73 45.9 54.1 31 40 43.7 56.3 0.756 education high middle low 33 105 68 16.0 51.0 33.0 28 76 31 20.7 56.3 23.0 5 29 37 7.0 40.8 52.2 <0.001 socioeconomic status of the household good average poor 70 109 27 34.0 52.9 13.1 46 71 18 34.1 52.6 13.3 24 38 9 33.8 53.5 12.7 0.988 number of visits to a chosen doctor per year < 5 ≥ 5 92 111 45.3 54.7 68 64 51.5 48.5 24 47 33.8 66.2 0.016 skipped check-ups due to financial constraints yes no 41 165 19.9 80.1 31 104 23.0 77.0 10 61 14.1 85.9 0.313 wait too long for check-up yes no 110 96 53.4 46.6 85 50 63.0 37.0 25 46 35.2 64.8 <0.001 nurses at the counter are kind yes partly no 83 46 77 40.3 22.3 37.4 50 30 55 37.0 22.2 40.8 51 16 4 71.9 22.5 5.6 <0.001 nurses at the interventions are kind yes partly 92 58 44.9 28.3 55 44 41.0 32.9 54 14 76.1 19.7 <0.001 jovanovic d, jankovic j, mirilovic n. socio-demographic inequalities in satisfaction with primary health care and utilization of chosen doctors’ services: a cross-sectional study (original research). seejph 2020, posted: 11 february 2020. doi: 10.4119/seejph-3311 p a g e 6 | 12 no 55 26.8 35 26.1 3 4.2 nurses offer all information yes partly no 84 55 66 41.0 26.8 32.2 49 40 45 36.6 29.9 33.6 49 15 7 69.0 21.1 9.9 <0.001 doctor is familiar with the previous diseases yes partly no 125 52 29 60.7 25.2 14.1 73 40 22 54.1 29.6 16.3 52 12 7 73.2 16.9 9.9 0.028 doctor takes enough time for conversation yes partly no 102 69 35 49.5 33.5 17.0 52 53 30 38.5 39.3 22.2 50 16 5 70.4 22.6 7.0 <0.001 doctor gives clear explanations about the diseases and the medicines yes partly no 109 60 37 52.9 29.1 18.0 58 47 30 43.0 34.8 22.2 51 13 7 71.8 18.3 9.9 <0.001 customer satisfaction with the primary health care satisfied partly satisfied unsatisfied 113 66 26 55.1 32.2 12.7 57 55 23 42.2 40.8 17.0 56 12 3 78.8 16.9 4.2 <0.001 * χ2 test. the distribution of user satisfaction with the primary health care and visits to the chosen doctor per year by socio-demographic variables is shown in table 2. the oldest users were the most satisfied ones (65.2%), compared to the middle-aged (57.5%) and the youngest (34.1%). in the rural type of settlement, patients were more satisfied (78.8%) compared to those from the urban area (42.2%). there were no statistically significant differences in user satisfaction according to education and socioeconomic status of respondents. regarding visits to the chosen doctor, respondents with low education (83.2%), the poorest (88.5%), the elderly (78.5%) and those from the rural area (66.2%) visited their doctor more frequently, that is five and more times in the year preceding the survey. jovanovic d, jankovic j, mirilovic n. socio-demographic inequalities in satisfaction with primary health care and utilization of chosen doctors’ services: a cross-sectional study (original research). seejph 2020, posted: 11 february 2020. doi: 10.4119/seejph-3311 p a g e 7 | 12 table 2. distribution of user satisfaction with primary health care and visits to the chosen doctor per year by socio-demographic variables variables level of satisfaction number of visits to the chosen doctor (per year) unsatisfied partly satisfied satisfied p* < 5 ≥ 5 p* n (%) n (%) n (%) n (%) n (%) age categories 20 – 39 40 – 64 65+ 7 (14.9) 10 (10.7) 9 (13.6) 24 (51.1) 30 (31.9) 14 (21.2) 16 (34.1) 54 (57.5) 43 (65.2) 0.015 36 (78.3) 43 (46.2) 14 (21.5) 10 (21.7) 50 (53.8) 51 (78.5) <0.001 sex male female 15 (16.2) 11 ( 9.6) 31 (33.3) 36 (32.5) 47 (50.6) 66 (57.9) 0.323 45 (48.9) 48 (42.9) 47 (51.1) 64 (57.1) 0.349 type of settlement urban rural 23 (17.0) 3 (4.2) 55 (40.8) 12 (16.9) 57 (42.2) 56 (78.8) <0.001 69 (51.9) 24 (33.8) 64 (48.1) 47 (66.2) 0.016 education high middle low 5 (15.2) 11 (10.4) 10 (14.7) 11 (33.3) 42 (39.6) 15 (22.1) 17 (51.6) 53 (50.0) 43 (63.3) 0.218 22 (66.7) 60 (58.3) 11 (16.2) 11 (33.3) 43 (41.7) 57 (83.2) <0.001 socioeconomic status of the household good average poor 6 (8.4) 16 (14.7) 4 (14.80) 19 (26.8) 37 (33.9) 12 (44.4) 46 (64.8) 56 (51.4) 11 (40.70) 0.175 46 (64.8) 44 (41.1) 3 (11.5) 25 (35.2) 63 (58.9) 23 (88.5) <0.001 * χ2 test. the results of the bivariate and multivariate logistical regression analyses related to the correlation between socio-demographic variables and visits to the chosen doctor per year are shown in table 3. the oldest respondents visited their doctor seven times more (or = 7.03), while those in the age group between 40 and 64 years did it about three times more (or = 2.66) than the youngest ones. the respondents with a low education had four times more visits to the doctor per year (or = 4.14) compared to those with high education, while patients with poor self-assessed socioeconomic status of the household used their doctors' services almost nine times more (or = 8.66) than those with a good socioeconomic status. the results of the bivariate and multivariate linear regression analyses related to the correlation between user satisfaction with primary health care and sociodemographic characteristics are presented in table 4. the respondents from the rural area were more satisfied with primary health care (p<0.001), as well as those with the poor socioeconomic status of the household (p=0.014). jovanovic d, jankovic j, mirilovic n. socio-demographic inequalities in satisfaction with primary health care and utilization of chosen doctors’ services: a cross-sectional study (original research). seejph 2020, posted: 11 february 2020. doi: 10.4119/seejph-3311 p a g e 8 | 12 table 3. odds-ratios (ors) and 95% confidence intervals (cis) for the number of visits to the chosen doctor per year by socio-demographic characteristics variables n % or (95% ci) blr mlr age categories 20 – 39 40 – 64 65+ 45 93 65 22.2 45.8 32.0 1.00 4.07 (1.81-9.17) 12.75 (5.09-31.95) 1.00 2.66 (1.11-6.36) 7.03 (2.56-19.34) sex male female 92 111 45.3 54.7 1.00 1.30 (0.75-2.27) 1.00 1.33 (0.68-2.59) type of settlement urban rural 132 71 65.0 35.0 1.00 2.08 (1.14-3.79) 1.00 1.27 (0.61-2.66) education high middle low 33 102 68 16.3 50.2 33.5 1.00 1.46 (0.64-3.32) 10.36 (3.93-27.33) 1.00 1.22 (0.48-3.07) 4.14 (1.36-12.61) socioeconomic status of the household good average poor 70 107 26 34.5 52.7 12.8 1.00 2.58 (1.38-4.80) 13.80 (3.77-50.57) 1.00 2.27 (1.10-4.67) 8.66 (2.06-36.37) blr – bivariate logistic regression; mlr – multivariate logistic regression; referent category – number of visits to the chosen doctor (up to 5 per year). table 4. the relationship between the level of user satisfaction with primary health care and sociodemographic characteristics – results of linear regression analyses variables bivariate multivariate b*(p) b*(p) age 0.150 (0.025) 0.107 (0.111) sex 0.143 (0.150) 0.146 (0.114) type of settlement 0.495 (<0.001) 0.458 (<0.001) education 0.065 (0.368) -0.011 (0.889) socioeconomic status of the household -0.169 (0.025) -0.185 (0.014) *unstandardized regression coefficient referent category – unsatisfied with primary health care. jovanovic d, jankovic j, mirilovic n. socio-demographic inequalities in satisfaction with primary health care and utilization of chosen doctors’ services: a cross-sectional study (original research). seejph 2020, posted: 11 february 2020. doi: 10.4119/seejph-3311 p a g e 9 | 12 discussion socio-demographic inequalities in the utilization of chosen doctors’ services our results showed significant inequalities in the utilization of chosen doctors’ services. respondents aged 65 and over visited their doctor seven times, while middle-aged patients (40-64 years) did it three times more frequently than the youngest (20-39 years), which may be explained by the increased needs of the elderly for health services within the natural process of aging and its biological manifestations. more frequent visits to gps by older patients have been linked to their rather poor health, as shown by a systematic review of european studies from uk, sweden, germany, denmark, italy, and slovenia (20). the authors concluded that the main reason that older people are more likely to use phc services is their real need for medical treatment. respondents with a low level of education in this study were four times more likely to visit their physician than those with university degree, which is in line with the results of the 2013 serbian health survey (15) showing that 71.9% people (aged 14 years and more) with the lowest educational attainment visited a gp general practitioner or pediatrician in the year preceding the survey. our finding is also in accordance with the studies conducted in sweden (21) and denmark (22) which showed a significant negative correlation between the level of education and the number of visits to the gp, indicating that a higher level of education was associated with fewer visits to phc. research by chinese authors (23) showed that lower level of education as well as poorer socioeconomic status also implied lower health literacy rate, which might explain the more frequent visits of this population to the chosen doctor. namely, due to low health literacy, the population does not distinguish serious from ordinary health problems, and minor health problems are often the reason why they go to the doctor. conversely, more educated respondents have more capacity (cognitive, communicative), they are better informed and make more effective decisions for their health, reflecting their high health literacy rate (24). accordingly, they visit a doctor less frequently. the poor, and thus the low-educated, in serbia had a significantly higher prevalence of chronic diseases than the rich (7). this implies their greater health care needs, and might explain the more frequent utilization of the chosen doctors’ services in our study. the results of this study also showed that people with poor financial status of the household visited their doctor almost nine times more per year (or = 8.66) compared to better-off. this result is in contrast to the 2006 serbian health survey and study by janković et al. (7), according to which gps were less frequently visited by poor people and those with lower educational attainment (7,25), but in agreement with the last national health survey conducted in 2013, in which the least educated and the poorest population had the highest percentage of visits to the gp (15). the use of gps services in bosnia and herzegovina was much lower for the uninsured, who are most often unemployed and most likely to be poorer, than for the insured (26). also, in montenegro, access to phc health services is lower for people with lower household incomes and mainly for roma population (27). the prevalence of chronic diseases is higher among the poor population in serbia and they also have a high risk of infectious diseases, lower life expectancy at birth, high prevalence of smoking, alcohol and drugs, as well as a higher incidence of mental health problems (5,28). more health problems imply greater need for health care, which is the reason why the poor in our study used more frequently the services of their chosen doctor. this practice is in line with the health insurance law that made phc more accessible to certain groups in the republic of serbia (29), that is, socially disadvantaged groups are exempted from paying official out-of-pocket payments (30). in this way, phc has become more economically accessible to them, which is confirmed by the greater number of their visits to the chosen physician. socio-demographic inequalities in user satisfaction with phc the results of our study regarding the association of socio-demographic variables with user satisfaction showed a significantly higher degree of satisfaction with phc in rural areas (p<0.001) and among respondents who self-assessed their socioeconomic status as poor (p=0.014). regarding type of settlement our findings are in accordance with 2013 serbian health survey (15) where the most satisfied people with state health services were those from rural areas. higher satisfaction with the phc as a whole among respondents who live in rural area could be explained by their better scoring in the items (indicators) of partial satisfaction (such as waiting time and doctorpatient interaction), but also by their lower health expectations related to the fact that the population with a low level of education and, consequently, poorer health literacy lives in the rural area. often, these individuals do not recognize or minimize their health jovanovic d, jankovic j, mirilovic n. socio-demographic inequalities in satisfaction with primary health care and utilization of chosen doctors’ services: a cross-sectional study (original research). seejph 2020, posted: 11 february 2020. doi: 10.4119/seejph-3311 p a g e 10 | 12 problems because they are not sufficiently aware of their own health needs. also, there is a lack of knowledge about patients’ rights, as well as obligations in the health care system (31). for this reason, they are satisfied with basic health services such as medical check-up and/or prescribing medicines while preventive services such as influenza vaccination or screening for early detection of colon cancer made them more than satisfied. if we take into account that there are exempt from official payments on the basis of legal regulations (29), their satisfaction becomes easy to explain, even rational. a study of user satisfaction conducted in croatia (10) showed results opposite to ours, that is, respondents in rural settlements were less satisfied with phc compared to those in urban and suburban settlements. the reasons for this were non-respect of working hours by healthcare professionals and dissatisfaction with the manner in which patients' confidential information was stored. a cross-sectional study from germany (32) also showed that respondents from rural areas were less satisfied with phc and the reason was lower accessibility of phc to them. the higher level of satisfaction with the phc among people with poor socioeconomic status of the household, recorded in our paper, was also found in a study conducted in spain (33). a possible explanation might be high expectations of wealthier users, whose unmet health needs lead to dissatisfaction. on contrary, the results of the study by vojvodić et al. (34) showed that people with estimated good socioeconomic status were significantly more satisfied with phc (84.9%), and this is probably due to their general satisfaction with socio-economic status and life. study limitations this research has some limitations. a methodological weakness of this study is a relatively small sample size which made the study results difficult to generalize for all outpatient service consumers. also, some study participants were not willing to respond. age, gender and socioeconomic differences of eligible patients refusing participation were not documented consistently and we have not all data for few nonrespondents. yet, given the low non-response-rate of about 11%, it is very unlikely that study participants are a strongly biased sample. also, the cross-sectional study design does not allow us to establish causal relationships among variables. we measured users’ utilization of chosen doctors’ services and satisfaction with phc during a single visit, and so were unable to examine outcomes longitudinally. one of the limitations is patient subjectivity in response ,which is not avoidable and is present in all similar studies. conclusion taking into consideration all limitations, this study showed the presence of inequalities in the utilization of chosen doctors’ services as well as in the satisfaction with phc. the chosen doctor was more frequently visited by respondents with low education and those with poor socioeconomic status of the household, while a higher degree of satisfaction with phc was recorded in the rural population as well as in those with poor socioeconomic status of the household. more research on larger samples is needed. references 1. marmot m. social determinants of health inequalities. lancet 2005;365:1099-104. 2. acheson d. independent inquiry into inequalities in health: report. hm stationery office; 1998. 3. sigriest j. social variations in health expectancy in europe. in: an esf scientific programme 1999–2003. 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___________________________________________________________ © 2020 jovanovic et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://doiserbia.nb.rs/phd/fulltext/bg20121226jankovic.pdf http://doiserbia.nb.rs/phd/fulltext/bg20121226jankovic.pdf http://doiserbia.nb.rs/phd/fulltext/bg20121226jankovic.pdf https://www.ncbi.nlm.nih.gov/pubmed/29262798 https://www.ncbi.nlm.nih.gov/pubmed/25748498 jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 1 original research pharmaceutical expenditure changes in serbia and greece during the global economic recession mihajlo b. jakovljevic 1 , kyriakos souliotis 2,3 1 health economics and pharmacoeconomics, faculty of medical sciences, university of kragujevac, kragujevac, serbia; 2 university of peloponnese, corinth, greece; 3 the centre for health services research, medical school, university of athens, greece. corresponding author: mihajlo (michael) jakovljevic, md, phd, head of graduate health economics & pharmacoeconomics curricula, faculty of medical sciences, university of kragujevac; address: svetozara markovica 69, 34000 kragujevac, serbia; telephone: +38134306800 (ext. 223); email: sidartagothama@gmail.com jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 2 abstract aim: clarity on health expenditures is essential for the timely identification of risks that jeopardize the democratic provision of health services and the credibility of health insurance systems. furthermore, observing health outcomes with geographical scope is essential for making multilateral associations. this study aimed at conveying information on the variability of important economic parameters of the health sector of serbia and greece from 2007 to 2012, when the most serious financial crisis in the post-war economic history hit the global economy. methods: exchange rates, purchase-power-parities (ppp) and price indices were used for the bilateral review of health and pharmaceutical expenditure dynamics during 2007-2012. prescription and dispensing changes were also studied taking into account the anatomical therapeutic chemical (atc) structure of drugs consumed. results: greece was forced to cut down its total health care and pharmaceutical expenditure and mainly its out-of-pocket payments were more seriously affected by the recession. surprisingly, emerging market of serbia, although severely damaged by global recession, succeeded to maintain 19% growth of its per capita health expenditure and even 25% increase of its per capita spending on pharmaceuticals. innovative pharmaceuticals showed an upward trend in both countries. conclusions: these two countries might serve as an example of two distinct pathways of mature and emerging health care markets during financial constraints caused by global recession. our findings show that producing disease-based feedback, in the long run, may empower the assessment of the return on investment on medical technology and healthcare systems’ cost-effectiveness. keywords: economic crisis, expenditure, greece, pharmaceutical global recession, serbia. conflict of interest: none. source of funding: the ministry of education, science and technological development of the republic of serbia has funded this study through grant: oi 175014. in any case, publication of results of this study was not contingent on ministry’s censorship or approval. jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 3 introduction studying the cost of services in healthcare over multiple periods is a challenging task taking into account the coalescence of explicit and implicit parameters of change in the service products provided; namely, the changes in the commodities’ price and quality (1). pharmaceutical care is, ‘par excellence’, a dynamic part of health sector. firstly, pharmaceutical products are dominated by continual change due to the unstoppable technological improvement; secondly, the public sector has a role of payer and hence the power to regulate market prices. financial fluctuations can thus act as tidal waves affecting providers, users and, ultimately, the population’s health. the following paragraphs attempt to delineate key changes in the serbian and greek healthcare sector covering the period from 2007 onwards, when the global economy was hit by the most serious financial crisis in the post-war economic history (2). serbia, the largest market of the western balkans region, has experienced bold growth of domestic public and private health care sector. its total health expenditure grew from 7.7% of gdp in 2000 to 10.5% in 2009, well above the eu average. its total public health expenditure increased enormously (from €1,175 million in 2004 to €1,847 million in 2012). at the same time, public spending on pharmaceuticals doubled, reaching a level of €742 million (3). unfortunately, like all the surrounding balkan and eastern european transitional post-socialist markets, the serbian health system suffered heavily from several consecutive waves of global recession. after sustaining these impacts and introducing severe cost-cutting policies (some of which introduced only recently in 2014), the national market of serbia began its slow recovery. the greek health sector experienced a period of significant growth during the first decade of the millennium, with a total health expenditure rising from 8.7% of gdp in 2003 to 10% in 2009, which was above the eu average (4). this growth was very pronounced particularly in the pharmaceutical sector where total expenditure more than doubled during the same period (from €3.2 billion in 2003 to €6.6 in 2009), rising from 1.9% to 2.8% of the gdp, with more than 78% being public expenditure (5). specifically, public pharmaceutical expenditure increased by €0.5 billion per year between 2004 and 2009, reaching €5.2 billion in 2009 (4). yet, following the signing of the memorandum of understanding (mou) (6) in 2010, a series of extraordinary cost-containment measures and structural reforms were imposed on the greek health sector, and on the pharmaceutical sector in particular, a sector regarded as a major contributor to both the deficit and the public debt due to the excessive public spending resulting from lack of control over both volume and cost of prescribing. thus, since may 2010, the pharmaceutical sector has been placed at the centre of fiscal consolidation, becoming one of the key areas of intervention in order to reduce public pharmaceutical expenditure to 1% of gdp, thereby approaching the european average (7). as a result, public pharmaceutical expenditure has dropped by 44% between 2009 and 2012, reaching €2.8 billion and corresponding to 1.5% of the gdp in 2012 (iobe, 2014). methods setting serbian and greek national pharmaceutical sectors assessments grounded in official data released by the respective national medicines’ agencies and national health insurance funds. jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 4 study design consisted of a retrospective database analysis conducted from the first party payer’s perspective with a six-year long time horizon. health outcomes regarding values, prices and the quality of the services provided were observed for serbia and greece. the time domain of the analysis covers the time interval 2007-2012. any information fissures caused by lack of data in health accounts are glossed over by more recent data. differences in price levels between the two countries are measured with the official exchange rates into us dollars. the purchasing power parity (ppp) was additionally used as a real expenditure change survey tool (8). the presented ppps are in 2011 us dollars (9). the price index of the comparative price level (cpl) was also computed according to the algebraic expression shown below (10): cpl = rateexchange ppp the relevant outcomes are presented in table 1. other measures of bilateral comparability are also included in table 1, such as the gdp and the gdp per capita which are based on ppps in us dollars. population magnitudes as the size of the population, the percentage of people aged 65 and over, and the crude birth and death rates per 1000 people are also appended. table 1. basic macroeconomic and demographic magnitudes in serbia and greece in 2012/2013 economy serbia greece gross national income (ppp billions us$, 2012) 82.6 290.3 gross national income per capita (ppp us$, 2012) 11 430 26 170 indices ppp* (1 us$=1.000) 37.29 0.69 exchange rate (1 us$=1.000) 73.34 0.72 cpl price index (us prices=100) 16.22 37.00 demographics resident population (millions, 2013) 7.3 11.3 population ≥65 years (%, 2013) 14 20 crude death rate per 1000 people (2012) 14 11 crude birth rate per 1000 people (2012) 9 9 unemployment % of total labour force (2008-2012) 24 24 * sources: 2014 world development indicators. 2014 international bank for reconstruction and development, the world bank purchasing power parities and the real size of world economies. a comprehensive report of the 2011 international comparison program. 2015 international bank for reconstruction and development, the world bank. table 2 includes health expenditure values and changes based on ppps. annual percentage changes depicted in the last column of the table are yielded according to the harmonic mean of annual changes within the period 2007-2012. national total and pharmaceutical health expenditure per capita trends in serbia and greece during 2007-2012 are analytically presented (in ppp$ values) in figure 1. jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 5 national health expenditures as percentage of gdp in serbia and greece during the period 2007-2012 are also depicted in figure 2. table 2. health expenditure values and their increase: serbia and greece, 2007-2012 healthcare outcome 2007 2012 change (%) annual change (%) health expenditure per capita, ppp$ serbia 1 047 1 250 19.39 3.44 health expenditure per capita, ppp$ greece 2 727 2 346 -13.95 -3.28 health expenditure, private (% of gdp) serbia 4 4 1.62 0.28 health expenditure, private (% of gdp) greece 4 3 -16.39 -3.88 health expenditure, private (% of total health expenditure -the) serbia 39 39 0.55 0.10 health expenditure, private (% of total health expenditure-the) greece 37 32 -11.53 -2.84 health expenditure, public (% of gdp) serbia 6 6 0.72 0.12 health expenditure, public (% of gdp) greece 6 6 7.09 1.06 health expenditure, public (% of government expenditure) serbia 14 13 -3.37 -0.72 health expenditure, public (% of government expenditure) greece 12 11 -7.10 -1.56 health expenditure, public (% of total health expenditure) serbia 61 61 -0.34 -0.07 health expenditure, public (% of total health expenditure) greece 60 68 13.32 2.42 health expenditure, total (% of gdp) serbia 10 10 1.07 0.19 health expenditure, total (% of gdp) greece 10 9 -5.50 -1.20 health expenditure, total (current us$, millions) serbia 4 035 4 030 -0.13 -1.00 health expenditure, total (current us$) greece 29 964 23 080 -22.97 -5.58 pharmaceutical expenditure per capita, ppp$ serbia 305 382 * 25.25 0.64 pharmaceutical expenditure per capita, ppp$ greece 676 673 * -0.44 -1.16 * sources: data from database: health nutrition and population statistics. the world bank. 2011. who global health expenditure database 2007–2012 and european health for all database (hfa-db) 2007–2012. tables 3 and 4 illustrate respectively the maximum and minimum absolute changes in the available outcomes of the two countries’ pharmaceutical sector, classified according to the atc4 level of the anatomical therapeutic chemical classification system of drugs (11). direct bilateral ppp comparisons were conducted for the gdp per capita and the pharmaceutical expenditure per capita, simplifying the paasche price index. in the algebraic expression (2), serbia is the base country and the pgs expresses greece’s “p” values (i.e., the p.c. gdp or the p.c. pharmaceutical expenditure) in serbian terms. “s” and “g” initials denote “serbia” and “greece”, respectively, and “q” is the general population of greece. pgs = σpgqg / σpsqg (2) jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 6 jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 7 figure 1. national total and pharmaceutical health expenditure trends in serbia and greece during the period 2007-2012 (expressed in current ppp $ per capita) * source: who global health expenditure database 2007-2012 and european health for all database (hfa-db) 2007-2012. figure 2. national health expenditure trends in serbia and greece during the period 2007-2012 (expressed as a percentage of disposable gross domestic product, gdp) jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 8 * source: who global health expenditure database 2007-2012 and european health for all database (hfa-db) 2007-2012. table 3. top 20 atc drug classes based on turnover growth, 2007-2012 atc classes serbia * atc classes greece † c09ba ace inhibitors and diuretics € 2 246 511 l01xc monoclonal antibodies € 11 287 179 l01xc monoclonal antibodies € 1 890 961 l01xe protein kinase inhibitors € 9 001 287 b01ac platelet aggregation inhibitors excluding heparin € 1 662 525 l04ab tumor necrosis factor alpha (tnf-α) inhibitors € 8 711 090 c10aa hmg coa reductase inhibitors € 1 560 979 l04aa selective immunosuppressants € 4 954 700 r03ak adrenergics in combination with corticosteroids or other drugs, excl. anticholinergics € 1 430 330 l02bx other hormone antagonists and related agents € 4 405 048 c09ca angiotensin ii antagonists, plain € 1 180 464 l04ax other immunosuppressants € 4 155 810 l01xe protein kinase inhibitors € 1 000 095 s01la antineovascularisation agents € 3 530 581 a10ad insulins and analogues for injection, intermediateor long-acting combined with fastacting € 863 908 l04ac interleukin inhibitors € 2 756 671 c07ab beta blocking agents, selective € 789 919 a16ab enzymes € 2 440 854 v08ab water-soluble, nephrotropic, low osmolar x-ray contrast media € 635 129 j05ab nucleosides and nucleotides excluding reverse transcriptase inhibitors € 2 396 560 n04bc dopamine agonists € 600 260 b03xa other antianemic preparations € 2 354 249 g04ca alpha-adrenoreceptor antagonists € 589 965 c01eb other cardiac preparations € 2 238 049 j05ar antivirals for treatment of hiv infections, combinations € 581 846 c09dx angiotensin ii antagonists, other combinations € 2 001 835 n02be anilides € 562 326 a10bd combinations of oral blood glucose lowering drugs € 1 902 922 c05ba heparins or heparinoids for topical use € 541 038 r03dx other systemic drugs for obstructive airway diseases € 1 760 418 l01cd taxanes € 493 830 l01xx other antineoplastic agents € 1 758 626 n06da anticholinesterases € 438 968 b01ae direct thrombin inhibitors € 1 606 684 g04be drugs used in erectile dysfunction € 432 442 l01ba folic acid analogues € 1 597 243 r01aa sympathomimetics, plain € 418 995 l03aa colony stimulating factors € 1 411 531 a10ba biguanides € 415 132 l01bc pyrimidine analogues € 1 368 591 * sources: medicines and medicinal device agency of serbia annual reports on turnover and consumption of pharmaceuticals; national health insurance fund of serbia. jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 9 † greek national organisation for health care services provision-eopyy. jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 10 table 4. bottom 20 atc drug classes based on turnover growth 2007-2012 atc classes serbia * atc classes greece † c09aa ace inhibitors, plain -€ 1 643 854 c10aa hmg coa reductase inhibitors -€ 31 679 014 g03ga gonadotropins -€ 1 330 919 c09da angiotensin ii antagonists and diuretics -€ 13 420 269 j01fa macrolides -€ 1 197 082 b01ac platelet aggregation inhibitors excluding heparin -€ 8 526 396 j01dd third-generation cephalosporins -€ 1 059 188 c09ca angiotensin ii antagonists, plain -€ 7 929 987 m01ab acetic acid derivatives and related substances -€ 1 040 177 n03ax other antiepileptics -€ 7 071 604 c01da organic nitrates -€ 935 780 a02bc proton pump inhibitors -€ 6 745 836 a02ba h2-receptor antagonists -€ 896 631 n06ab selective serotonin reuptake inhibitors -€ 6 399 987 m01ae propionic acid derivatives -€ 846 670 n06da anticholinesterases -€ 5 199 056 j01db first-generation cephalosporins -€ 691 096 n05ax other antipsychotics -€ 5 119 251 l01cb podophyllotoxin derivatives -€ 577 411 m05ba bisphosphonates -€ 4 794 650 b03xa other antianemic preparations -€ 566 477 c08ca dihydropyridine derivatives -€ 4 165 272 c04ad purine derivatives -€ 563 692 n06ax other antidepressants -€ 3 810 668 l04aa selective immunosuppressants -€ 438 147 c09aa ace inhibitors, plain -€ 3 275 530 j01ca penicillins with extended spectrum -€ 433 257 r03dc leukotriene receptor antagonists -€ 3 182 560 j01dc second-generation cephalosporins -€ 417 805 n05ah diazepines, oxazepines, thiazepines and oxepines -€ 2 894 838 b05ba solutions for parenteral nutrition -€ 390 852 a10bg thiazolidinediones -€ 2 860 150 r03ac selective beta-2adrenoreceptor agonists -€ 376 303 r03ba glucocorticoids -€ 2 455 708 j01cr combinations of penicillins, including betalactamase inhibitors -€ 374 335 c09ba ace inhibitors and diuretics -€ 2 195 843 r03da xanthines -€ 340 329 a10bb sulfonamides, urea derivatives -€ 2 137 085 b05aa blood substitutes and plasma protein fractions -€ 328 794 l02bg aromatase inhibitors -€ 2 007 464 * sources: medicines and medicinal device agency of serbia annual reports on turnover and consumption of pharmaceuticals; national health insurance fund of serbia. jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 11 † greek national organisation for health care services provision-eopyy (estimations based on 2010-2012 data). results aside from minor differences in their aging populations, serbia and greece were spending similar amounts on health as percentage of the gdp, in the beginning of the recession. the recession, however, resulted in decreases in the amounts allocated for health in both countries, with greece reducing mainly its private expenditure on health (from 37% to 32% of the). in per capita terms, pharmaceutical expenditure recorded bold 25% growth in serbia, whereas marginal decreases (0.4%) were jotted down for greece, during the recession. greece’s more intense recession effects on the pharmaceutical sector were also reflected on the values of the pgs price index. greece’s p.c. gdp in ppp$ was 2.29 times the p.c. gdp of serbia in 2012 (pgs = 26,170/11,430). similarly, the pharmaceutical expenditure per capita of greece was 2.22 times the pharmaceutical expenditure per capita of serbia in 2007 (pgs = 676/305), whereas in 2012 it reduced to 1.76 (pgs = 673/382). the pharmaceutical market internal structure of prescription and sales has in some cases moved in the same direction in the two countries. specifically, within some therapeutic categories, pharmaceutical expenditure continued to grow despite the depression. these categories included the l01xc monoclonal antibodies, the l01xe protein-kinase inhibitors, the a10b blood glucose lowering drugs, excluding insulins and the j05a direct acting antiviral drugs. continuing rise of share of innovative biological medicines is evident despite the financial constraints. few important differences in adaptive responses to the economic crisis induced weaknesses were noticed between emerging and mature health market. while health expenditure per capita (ppp$) in serbia still succeeded to grow for 19.4%, the greek one felt almost 14% during these six years. the total health expenditure (the) in serbia decreased marginally by 0.13%, whereas during the same time, the greek the fell abruptly by even 23%. health expenditure percentage of gdp in serbia grew 1% while greek one decreased almost 5.5%. a similar pattern was noticed with private health care expenditure expressed either as percentage of the or gdp: the greek one decreased by 16.4% and 12% respectively, while serbian private health expenditure recorded minor growth in crisis’ years. governmental share of health expenditure has fallen dramatically in both countries although more prominently in greece. opposed to all the aforementioned recessional changes, public health expenditure was rising much faster in greece compared to serbia both on grounds of gdp proportion and the proportion which reached 13.3% increase. at the same time, in serbia, these values were slightly up and down, but only marginally (see table 2). discussion to date, all countries of the broader south eastern europe have found themselves in different stages of profound demographic transition outsourcing from increased longevity and falling fertility rates (12). greece’s population is ageing faster considering its lower crude death rates and its higher proportion of old ages in the general population. population aging in serbia has deep historical roots and is likely to pose severe challenge on the national health system financing in the upcoming decades (13). this inevitable demographic change will be shaping growing needs for pharmaceuticals and the landscape of their consumption in both countries in the long run. jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 12 observing much shorter time horizon of six recent years of global economic recession, emerging serbian pharmaceutical market has undergone complex changes in terms of valuebased medicines prescription and dispensing. regardless of significant difficulties and slower growth, national public expenditure on pharmaceuticals has doubled since 2004. innovative cardiovascular, anti-diabetic agents, combined adrenergic and corticosteroid preparations and targeted immunotherapies dominated the landscape. economic crisis induced package of policy measures provided temporary relief for the ongoing financial difficulties. nevertheless, shortages of pharmaceuticals continued to occur more frequently compared to the period before 2008. these shortages occasionally refer even to the essential medicines and are primarily caused by the substantial public debt toward major multinational pharma companies supplying the eastern european markets. contemporary market access and reimbursement policies by regional authorities in most of balkans peninsula limit patient access to the expensive innovative medicines to narrowly defined diagnoses related groups (14). it is essential to be aware of the boomerang effect created by these restrictive policies. individuals, who are denied primary care preventive or screening services, ultimately end up in late severe stages of illness requiring expensive and complex inpatient treatment. a higher presence of clinically evolved conditions in transitional eastern european countries has already been proven in the case of copd (15), alcohol abuse (16) and cancer (17). these health system inefficiencies inherited from the socialist era create significant costs to the system, as well as worse health outcomes. high consumption of medicines indicated to treat some of key “prosperity” diseases such as diabetes (18), copd, risky pregnancies (19,20), addiction disorders, hepatitis (21) and cancer (22) serves as the evidence of such vulnerabilities within the system (20). these major illnesses should also present core targets for more responsible, evidence-based national resource allocation strategies (23). in greece, the pharmaceutical industry has traditionally represented an important sector of the economy and has been a major employer in the production, research and development, as well as distribution wholesale and retail. however, the greek pharmaceutical market has been long characterized by significant overspending (24), with public pharmaceutical expenditure reaching unprecedented levels in 2009 and thus being blamed as one of the main contributors of public deficit and debt. between 1990 and 2010, the applied pharmaceutical policy has focused mostly on price regulations in order to control expenditure, while no real effort was made to contain the volume of prescribed medicines, determined by the prescribing habits of physicians and by patients’ demand (25,26). as a result, public pharmaceutical expenditure continued to rise during this period, while the introduction of measures such as pharmaceutical pricing according to the lowest ex-factory european price and the positive list, had only a temporary effect on reducing expenditure, ultimately leading to the replacement of old products with new, more expensive ones and to the switching to more expensive medicines of the same therapeutic category (27,28). in light of the above and in the context of fiscal consolidation, a comprehensive health care reform was implemented after the signing of the mou in 2010 and is still on-going, aiming, among other things, to reduce waste, control expenditure and increase the accountability and efficiency of the greek pharmaceutical sector. the mou defined a number of costcontainment measures that had to be implemented within very tight timelines, targeting the reduction of both cost and volume of prescribed medicines. these measures included interim flat decreases of pharmaceutical prices, a new pharmaceutical pricing system according to jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 13 which prices are determined based on the average of the three lowest prices in the eu-27, introduction of positive, negative and over-thecounter (otc) medication lists, reduction in the profit margins of pharmacists and wholesalers, collection of rebate and claw-back from pharmaceutical companies, changes in the distribution of high-cost medicines, increase in the use of generics in the national health system, introduction of electronic prescriptions for medicines, publication of clinical guidelines and prescribing protocols, as well as monitoring of physicians’ prescribing habits (29). following the implementation of the mou, the greek government has primarily focused on applying cost-containment measures such as flat decreases of pharmaceutical prices and the collection of the rebates from pharmaceutical companies in order to achieve a fast reduction of pharmaceutical expenditure, while the measures and structural reforms aiming at the rationalization of the prescribing behaviour of physicians, such as e-prescribing and monitoring of physicians’ behaviour progressed at a slower pace. by 2012, public pharmaceutical expenditure shrunk by 44% since 2009, reaching 1.5% of gdp, while in 2013 it was reduced to €2.4 billion (53% decrease). the recent changes in pharmaceutical policy which have been implemented in greece in the context of its economic adjustment program have created turmoil in the pharmaceutical sector challenging its growth prospects and its long-term sustainability, thus resulting in instability in the market. this led to temporary drug shortages, hampering access to timely and effective therapy for the patients (30). at the same time, the policy of continuous reductions in pharmaceutical expenditure after a certain level and the substantial downsizing of the market, led to significant losses in public income resulting from the layoffs in the pharmaceutical sector and the subsequent lost of tax revenues and social contributions from pharmaceutical companies and pharmacies. the above demonstrate that even though in 2010 there was a real, urgent need for rationalization of the greek pharmaceutical market and for the implementation of a number of structural reforms, currently, several years after the eruption of the fiscal crisis and while the health care reform is still on-going, there is a need to adopt a more multi-factorial approach in policy-making, i.e., an approach which will account for the potential impact of applied policies on: i) patient access; ii) insurance contributions, employment and gdp, as well as; iii) the benefits brought by the strengthening of scientific research and development, when estimating the net financial result of these policies. conclusions these two countries might serve as an example of two distinct pathways of mature and emerging health care markets during financial constraints caused by global recession. apart from the ostensible differences in their composition of health and pharmaceutical expenditure, serbia and greece both cut down on their pharmaceutical expenditure during the financial crisis, even though greece was more seriously affected by the recession. surprisingly, the emerging market of serbia, although severely damaged by the global recession, succeeded to maintain 19% growth of its per capita health expenditure and even 25% increase of its per capita spending on pharmaceuticals. the recession left unaffected certain pharmaceutical expenditure trends in both countries dictating inelastic areas in the curve of pharmaceutical needs. specifically, an increasing expenditure was documented for the l01xc monoclonal antibodies, the l01xe proteinkinase inhibitors, the a10b blood glucose lowering drugs, excluding insulins and the j05a direct acting antiviral drugs. jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 14 the current results show that studies in the direction of producing disease-based feedback could empower the assessment of return on investment on medical technology, enhance the process of pharmaceutical expenditure estimations, predictions and projections and, in the long run, increase health outcomes’ predictability and the european healthcare systems’ costeffectiveness. jakovljevic mb, souliotis k. pharmaceutical 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http://dx.doi.org/10.1136/bmj.c3043. 30. souliotis k. quality in healthcare and the contribution of patient and public involvement: talking the talk and walking the walk? health expect 2015;18:1-2. ___________________________________________________________ © 2016 jakovljevic et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 1 original research enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania herion muja1,2, genc burazeri1,2, peter schröder-bäck1, helmut brand1 1department of international health, school caphri, care and public health research institute, maastricht university, maastricht, the netherlands; 2 institute of public health, tirana, albania. corresponding author: herion muja, md; address: rr. “aleksander moisiu”, no. 88, tirana, albania; telephone: +355672315056; email: herionmuja@gmail.com http://doi.org/10.4119/unibi/seejph-2017-143 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 2 abstract to inform policymakers well, there is a need to promote different types of health examination surveys as additional sources of valuable information which, otherwise, would not be available through routine/administrative statistics. this is especially important for former communist countries of south eastern europe including albania, where the existing health information system (his) is weak. among many efforts to strengthen the his in albania, there is currently a commitment to undertake a second round of a nationwide demographic and health survey (dhs). this survey will involve a nationwide representative sample of about 17,000 private households, where all women aged 15-59 years and their respective partners will be interviewed and examined. externally, the upcoming albanian dhs will contribute to the european union accession requirements regarding provision of standardized and valid health information. furthermore, the dhs will considerably enhance the core functions of the albanian health system in line with the who recommendations. internally, the dhs will promote societal participation and responsibility in transitional albania. importantly, the forthcoming survey will promote good governance including transparency, accountability and health system responsiveness. also, the dhs will allow for collection of internationally valid and standardized baseline sociodemographic and health information for: assessment of future national trends; monitoring and evaluation of health programs and interventions; evidencing health disparities and inequities; and cross-national comparisons between albania and different countries of the european region. ultimately, findings of the dhs will enable rational decision-making and evidencebased policy formulation in albania including appropriate planning, prioritization and sound resource allocation. however, transfer of the information collected and implementation in public health policies and interventional programs is rather challenging for most of the countries, particularly for transitional post-communist countries of south eastern europe including albania. keywords: albania, demographic and health survey (dhs), health examination survey, health information system, health interview survey, health system governance. conflicts of interest: none. http://doi.org/10.4119/unibi/seejph-2017-143 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 3 the need to strengthen health information systems a “health information system” (his) is conventionally defined as a system which collects, stores, processes, conducts analysis, disseminates and communicates all the information related to the health status of the population and the activities and performance of health institutions and other health-related organizations (1). from this point of view, a suitable and well-designed his incorporates data generated from routine information systems, disease surveillance systems, but also laboratory information systems, hospital and primary care administration systems, as well as human resource management information systems (1,2). the ultimate goal of a well-functioning his is a continuous and synchronized endeavor to gather, process, report and use health information and the knowledge generated for the good governance of health systems; in other words: influence policy and decision-making, design activities and programs which eventually improve the health outcomes of the population, but also contribute to more efficient use of (often limited) resources (1,3,4). at the same time, the evidence generated from his may suggest the need for further research in certain areas (1,5). nevertheless, a major prerequisite for a good health system governance consists of a wide array of valid and reliable data, which are not often available from a traditional (routine) or administrative his (2,6).therefore, there is a clear need to promote different types of health examination surveys and health interview surveys as valuable sources for generation of additional health information which, otherwise, would not be available based on routine/administrative statistics. this is important in any health care system, where reforms are underway constantly (7). health examination surveys and health interview surveys issues related to the quality of life of individuals, patient satisfaction of health care delivery, knowledge, attitudes, perceptions, or beliefs of individuals, as well as health literacy levels in general are all important components which should be measured at a population level in order to design and tailor health strategies and policies accordingly (1,3). from this perspective, health examination surveys are a powerful tool which enrich a certain his and provide useful clues about the health status of populations, quality of life, as well as access, utilization and satisfaction with health care services. in this framework, the european health examination surveys (ehes: http://www.ehes.info/) and the european health interview surveys (ehis: http://ec.europa.eu/eurostat/web/microdata/european-health-interview-survey) constitute two major exercises which are carried out in most countries of the european union (eu). indeed, health examination surveys and health interview surveys are conducted periodically in most of the eu countries generating important evidence about the magnitude and distribution of selected ill-health conditions and health determinants at a population level. based on the unique value of health examination surveys and health interview surveys, there is a clear call for undertaking a similar exercise also in transitional former communist countries of south eastern europe including albania. country profile: albania after the collapse of the communist regime in early 1990s, albania has undergone significant political, social and economic changes striving towards a market-oriented economy (8). nevertheless, the particularly rapid transition from state-enforced collectivism towards a capitalistic system was associated with poverty, high unemployment rates, financial loss and social mobility, and massive emigration (9). at the same time, however, the transition period in albania was associated with increased personal and religious freedom in a predominantly muslim secular society (8,10). all these features continue to spot albania as a distinctive http://doi.org/10.4119/unibi/seejph-2017-143 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 4 country in europe, notwithstanding the similarities in many characteristics with other transitional countries in the western balkans and beyond. the health care sector has suffered substantially during the transition period and there has been a significant change in the epidemiological profile of the population in the past few decades with a remarkable transition towards non-communicable diseases (ncds) (11,12). indeed, there is a tremendous increase in the total burden of ncds in albania including heart disease, cancer, lung and liver diseases, and diabetes (11,12). against this background, there is an urgent need for an integrated approach for both prevention and improvement of health care in order to face the high burden of ncds in transitional albania (12). in any case, the existing his in albania has insufficient routine health data for a valid and reliable analysis of disease trends and the associated risk factors. the first round of a nationwide demographic and health survey (dhs) in albania was conducted in 2008-2009 (13). almost ten years later, there is currently an urgent need to carry out a second dhs round which would generate valuable information regarding selected key socio-demographic characteristics and health data of the albanian population, which are otherwise not available based on routine/administrative statistics. not only that with new data new needs for priorities in the health system governance can be identified, but the changes and potential effects of health policy decision-making of the last years can be measured too. the albanian demographic and health survey (dhs) 2017-2018 among many efforts to strengthen the his in albania, there is currently a commitment to undertake a second round of a nationwide dhs. the upcoming round of dhs in albania will be implemented by the national institute of public health and the institute of statistics with technical support from the us-based company icf international (https://www.icf.com/). funding has been already provided by the swiss cooperation and the united nation agencies operating in albania. the dhs will involve a nationwide representative sample of about 17,000 private households. all women aged 15-59 years and their respective husbands/partners living permanently in the selected households or present in the household on the night before the survey visit will be eligible to be interviewed in the dhs. the specific objectives of the dhs will be to: i) collect data at a national, regional and local level which will allow the calculation of key demographic rates; ii) analyze the direct and indirect factors which determine the level and trends of fertility and abortion in albania; iii) measure the level of contraceptive knowledge and practice of albanian men and women; iv) collect data on family health including immunization coverage among children, prevalence of most common diseases among children under five and maternity care indicators; v) collect data on infant and child mortality and maternal mortality; vi) obtain data on child feeding practices including breastfeeding, collect anthropometric measures to use in assessing the nutritional status of children including anemia testing; vii) measure the knowledge and attitudes of women and men about sexually transmitted diseases and hiv/aids; viii) assess key conventional risk factors for ncds in albanian men and women aged 15-59 years including dietary patterns and nutritional habits, smoking status, alcohol consumption, physical activity, systolic and diastolic blood pressure, and measurement of anthropometric indices (height and weight, as well as waist and hip circumferences). the data collected will be scientifically analyzed and scientific reports and policy briefs will be subsequently written and disseminated for a wide audience including health professionals, social workers, policymakers and decision-makers, as well as the general public. in addition, http://doi.org/10.4119/unibi/seejph-2017-143 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 5 the open data source approach will enable secondary (in-depth) analysis to all interested researchers and scientists all over the world. contribution of the demographic and health survey (dhs) to health system governance in albania table 1 presents the potential contribution of the upcoming albanian dhs at different levels (international, national, regional, and local level), recognizing that different actors of health system governance which are located at different levels, yet, interact with each-other (14,15). selected potential contributing characteristics (features) include different dimensions pertinent to both, the international environment and cooperation, as well as the internal (national) situation/circumstances. table 1. international relevance and contribution of the “albanian demographic and health survey 2017-18” to governance processes at national, regional and local levels international relevance characteristic description european union fulfillment of accession requirements, and contribution to the “europeanization” process of albania world health organization (who) strengthening of the core functions of the health system (in line with the who recommendations) national (central) government characteristic description democracy a good exercise for strengthening societal participation and responsibility governance enhancing good governance: transparency, accountability and responsiveness informing policy prioritization, evidence-based planning and allocation of resources research strengthening research capacities at a national level national data collection of (good quality) nationwide representative health data national disparities evidencing overall (national) disparities in terms of place of residence (urban vs. rural areas), ethnicity, minorities, vulnerable subgroups, socioeconomic categories, as well as sexand-age group differences baseline national data useful baseline data for assessing national trends over time, as well as monitoring and evaluation of nationwide health programs and interventions cross-country comparisons use of internationally valid/standardized instruments will eventually enable cross-national comparisons with the neighboring countries and beyond regional level: interface between the central and the local government characteristic description research strengthening research capacities at a regional level regional data collection of sub-national data regional disparities evidencing sub-national (regional) health disparities and inequities baseline regional data baseline data for assessing regional trends, as well as monitoring and evaluation of regional health initiatives, programs and interventions local government characteristic description research strengthening research capacities at a local level local data collection of health data at a local level local disparities evidencing local health disparities and inequities individual-based data potential for intervention (treatment and counseling of people in need) baseline local data baseline data for assessing local trends, as well as monitoring and evaluation of interventions implemented at a local level http://doi.org/10.4119/unibi/seejph-2017-143 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 6 regarding the international environment, the upcoming albanian dhs will significantly contribute in terms of fulfillment of accession requirements to the eu related to provision of standardized and valid health information/data. on the other hand, the dhs will also contribute considerably to the enhancement of the core functions of the albanian health system in line with the who recommendations (16). according to who, four vital functions of health systems include provision of health care services, resource generation, financing, and stewardship (16).the upcoming survey will support most of these core functions in the context of a particularly rapid process of transformation and reform of the albanian health system. as for the internal environment, at a central (national) level, the dhs will be an important exercise for strengthening societal participation and responsibility, which is fundamental given the low participation rates and societal contribution in post-communist countries such as albania. from a governmental point of view (4), the forthcoming survey is expected to promote good governance in terms of transparency, accountability and health system responsiveness. conversely, the dhs exercise will considerably strengthen national research capacities in albania. the survey will be conducted in close collaboration with the university of medicine, tirana, and other scientific and research institutions in albania which will help to further strengthen the epidemiological and the overall capacities of the albanian research community. furthermore, the dhs will allow for collection of nationwide high-quality information including a wide array of demographic and socioeconomic characteristics and valuable health data. such data will provide useful baseline information for assessment of national trends in the future, as well as monitoring and evaluation of nationwide health programs and health interventions. in addition, this baseline information will evidence national disparities and inequities regarding the place of residence (urban vs. rural areas), ethnicity groups and minorities, vulnerable/marginalized segments, socioeconomic disadvantaged categories, as well as sexand-age group health differences. at the same time, employment of standardized and internationally valid instruments for data collection will allow for cross-national comparisons between albania and different countries of the european region. ultimately, at a central (national) level, findings of the dhs will enable rational decision-making and evidence-based policy formulation in albania including appropriate planning, prioritization and sound resource allocation. at a lower level, the dhs exercise will help to strengthen research capacities and collaboration at a regional level. this will be an important added value given the new administrative/territorial reform which was fairly recently implemented in albania. in addition, availability of health data at a regional level will help to tailor regional policies in accordance with the epidemiological profile and health problems of the respective population groups, as well as monitoring and evaluation of different interventions and programs implemented at a regional level. at the lowest (i.e., local) level, the dhs will similarly but even more specifically contribute to evidence-based policy formulation and rational decision-making at a local/community level. likewise, the survey will contribute to the enhancement of research capacities at a local level, which will be particularly valuable for many under-resourced communities in albania characterized by limited and not properly trained research personnel. it should be noted that, for the first time ever, the upcoming dhs round will be a unique opportunity to collect representative data at the lowest administrative level in albania. also, importantly, the survey will offer a unique opportunity for intervention regarding potential treatment and especially counseling of individuals in need, particularly those who, for different reasons, have limited access to health care services, such as the case of roma community (17). http://doi.org/10.4119/unibi/seejph-2017-143 https://en.wikipedia.org/wiki/health_care_provider muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 7 conclusion the upcoming dhs round will be a unique opportunity for albania for strengthening research capacities at a national and local level. in addition, the dhs will provide valuable baseline evidence highlighting regional disparities and subgroup inequities which are assumed to have been rapidly increasing given the rapid political and socioeconomic transition of albania in the past three decades. furthermore, this survey will offer an opportunity for evidence-based policy formulation in albania. overall, the dhs exercise will be an important tool for strengthening the core functions of the albanian health system contributing also to the europeanization process and accession to the eu. however, transfer of the information collected and implementation in public health policies and interventional programs is rather challenging for most of the countries, particularly for transitional postcommunist countries of south eastern europe including albania. references 1. world health organization. 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2015;119:1636-44. 16. world health organization. world health report 2000 – health systems: improving performance. geneva, switzerland, 2000. http://www.who.int/whr/2000/en/index.html (accessed: 14 march, 2017). 17. de graaf p, rotar pavlič d, zelko e, vintges m, willems s, hanssens l. primary care for the roma in europe: position paper of the european forum for primary care. zdr varst 2016;55:218-24. ______________________________________________________________________________________ © 2017 muja et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://doi.org/10.4119/unibi/seejph-2017-143 http://www.ncbi.nlm.nih.gov/pubmed/?term=kuhlmann%20e%5bauthor%5d&cauthor=true&cauthor_uid=26321192 http://www.ncbi.nlm.nih.gov/pubmed/?term=larsen%20c%5bauthor%5d&cauthor=true&cauthor_uid=26321192 http://www.ncbi.nlm.nih.gov/pubmed/26321192 http://www.who.int/whr/2000/en/index.html https://www.ncbi.nlm.nih.gov/pubmed/?term=de%20graaf%20p%5bauthor%5d&cauthor=true&cauthor_uid=27703542 https://www.ncbi.nlm.nih.gov/pubmed/?term=rotar%20pavli%c4%8d%20d%5bauthor%5d&cauthor=true&cauthor_uid=27703542 https://www.ncbi.nlm.nih.gov/pubmed/?term=zelko%20e%5bauthor%5d&cauthor=true&cauthor_uid=27703542 https://www.ncbi.nlm.nih.gov/pubmed/?term=vintges%20m%5bauthor%5d&cauthor=true&cauthor_uid=27703542 https://www.ncbi.nlm.nih.gov/pubmed/?term=willems%20s%5bauthor%5d&cauthor=true&cauthor_uid=27703542 https://www.ncbi.nlm.nih.gov/pubmed/?term=hanssens%20l%5bauthor%5d&cauthor=true&cauthor_uid=27703542 https://www.ncbi.nlm.nih.gov/pubmed/?term=zdrav+var+2016%3b+55(3)%3a+218-224 grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 1 | 14 original research national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study thomas grochtdreis1,2, peter schröder-bäck3,4, niels harenberg2, stefan görres2, nynke de jong5 1 department of health economics and health services research, hamburg center for health economics, university medical center hamburg-eppendorf, hamburg, germany; 2 institute for public health and nursing science, university of bremen, bremen, germany; 3 department of international health, care and public health research institute (caphri), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 4 faculty for human and health sciences, university of bremen, bremen, germany; 5 department of educational development and research, school of health professions education (she), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands. corresponding author: dr. thomas grochtdreis; address: department of health economics and health services research, hamburg center for health economics, university medical center hamburg-eppendorf, martinistr. 52, 20246 hamburg, germany; telephone: +49 (0)40 7410-52405; e-mail: t.grochtdreis@uke.de grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 2 | 14 abstract aim: this study aimed to explore the german nurses’ perceptions of their knowledge, roles and experience in the field of national preparedness and emergency response. methods: an exploratory qualitative design was used with open-ended questions during semistructured interviews with qualified nurses currently working in hospitals. the setting of the study consisted of wards of different hospitals in three northern federal states of germany. the data analysis was done by summarizing analysis of the contents. from a convenient sample of n=31 hospitals, n=13 nurses were included in the study. results: the median age of the participants was 45 years and 38% were female. within the three professional socialization fields, knowledge, roles and experience, 17 themes were clustered. conclusion: within the themes of knowledge, role and experience in national disaster preparedness and emergency response, similarities and differences were explored in comparison to international literature. keywords: disaster management, disaster planning, disasters, emergencies, emergency preparedness, experience, knowledge, nurses, qualitative research, roles. source of funding: this study did not receive any form of financial or other support. acknowledgements: we would like to thank the nurses who participated in this study. we would also like to thank the nursing managers of the hospitals, the head of the departments and the head nurses for approaching their employees and colleagues. conflict of interest: none declared grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 3 | 14 introduction disasters have always been a challenge and disasters are to happen all over the world, including europe and germany. in the future, disasters will be likely to happen again all over the world. the situation in germany may serve as an example for other european countries, when reviewing european disasters in past years and comparing the preceding situation to the current health and climatic situation. a concrete current example is the covid-19 pandemic that lead to disasters globally, including europe. nurses already play a central role in disaster preparedness and management, as well as in emergency response, in many countries all over the world (1). all nurses, regardless of their level of professionalization, need to receive disaster preparedness education in their undergraduate and continuous nursing education, in order to have a great pool of nurses during a disaster. in germany, the law on health care explicitly mentions that the training of nurses has to qualify to be actively involved in disaster preparedness and emergency response (2). however, involvement in disaster preparedness and emergency response is neither a particular part of the formal qualification nor the regular professional practice of nurses in germany (3). care providers are considered important protagonists of disaster preparedness and emergency response (4). in the literature, an essential role is allotted to nurses for integrating communicating efforts and for having role competencies in disaster preparation (5). nurses are able to reduce premature death, impaired quality of life, and altered health status, which can be caused by disasters (5). health care professionals, including nurses, are feeling responsible for responding to disasters. however, nurses’ intention to respond to disasters, the needs of nurses who respond to disasters and other health emergencies, as well as the influence of the nursing shortage and the lack of education preparing nurses for disaster response are scarcely known (6). in order to prepare for emergency response, education within the field of disaster nursing is essential. in the usa, before 2001, few nurses received any formal education in the areas of emergency preparedness or disaster response, unless they served in the military, worked as pre-hospital providers, were employed in a hospital emergency department, or participated in humanitarian disaster relief work (7). occasionally, disaster nursing education is seldom provided at the basic nursing education level (8). it has become apparent, that there is a distinct need for disaster nursing curricula and for preparation of nursing faculty members to teach disaster nursing in order to adequately prepare nursing students for possible disaster situations in future (9). according to the world health organization and the international council of nurses, nurses, as the largest group of health care practitioners, need to develop competencies in disaster response and recovery, but training is often fragmented or not available (10). in order to understand the essence of national disaster preparedness and emergency response for and of nurses as well as the meaning they give to this topic in germany, the following research questions were formulated for providing nursing practice and nursing research with valuable information: ‘how do german nurses perceive the educational system in the field of disaster nursing?’, ‘how do german nurses describe their role in the field of national preparedness and emer grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 4 | 14 gency response?’ as well as ‘what is the experience of german nurses in the field of national preparedness and emergency response?’. therefore, the aim of this study was to explore the knowledge, role and experience in national disaster preparedness and emergency response of german nurses. methods an exploratory qualitative design was used with open-ended questions during semistructured interviews with qualified nurses currently working in hospitals. research design the field of nursing care might be well described by lived experiences of nurses working in this field. in order to reach insight in these lived experiences, a careful description of ordinary conscious experience of everyday life is necessary. based on the pre-formulated research aim, it was essential to identify preconceived beliefs and opinions to bracket out any presuppositions to confront the data in pure form (11). for not violating the inductive assumption of qualitative research, theory was used to focus the inquiry and to give it boundaries for comparison in facilitating the development of the theoretical or conceptual outcomes. this means that the conceptual framework of this research was used as a template, with which results will be compared and contrasted (figure 1) (12). the conceptual framework consists of the three relevant fields of professional socialization: knowledge, roles and experience (13). according to the conceptual framework, knowledge in disaster nursing supports necessary roles during a disaster and having roles during a disaster leads to experience. based on a literature review, sub-topics for each field have been identified (14). basic interpretivist research was followed, in fact to gather qualitative data and to analyse their content in a way that experiences, as well as perceived general roles, tasks and responsibilities as well as knowledge of nurses in the topic under research can be best described and interpreted. figure 1. conceptual framework [based on: grochtdreis et al. (14)] grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 5 | 14 setting and sample the setting of the research was different wards of hospitals in three northern federal states of germany (bremen, hamburg, lower saxony). based on experience, for gathering enough data for a sufficient analysis, at least twelve qualified nurses were considered to participate in the study. in order to have a comparable gender distribution between the participants and qualified nurses in general, at least two male nurses were considered to take part in the research. in germany, approximately 14% of qualified nurses were male in the year 2010 (15) and it was anticipated that the interpretation of experience of men and women is somehow different. eligible participants were qualified nurses currently working in the field of nursing care. furthermore, it was anticipated to select participants with different lengths of work experiences. the participants were not selected randomly, since it was more important to select people who will make good informants. good informants were defined as knowledgeable, articulate, reflective, and willing to talk at length with the researcher (11). the basic approach of the sampling was a convenient approach, based on a volunteer sample out of all hospitals. the volunteer sample was put together from nursing managers of cooperating hospitals. in total, a convenient sample of n=31 hospitals was asked for participation. of those, n=4 hospitals provided access towards potential participants (n=5 hospitals were willing to participate, n=9 hospitals were unwilling to participate, n=13 hospitals did not respond). finally, n=13 nurses were included in the study. data collection in order to elicit data in the study, nurses working in hospitals were asked identical open-ended questions during an interview. the specific questions were developed out of a literature review on nurses’ roles, knowledge and experience in national disaster preparedness and emergency response (14). based on relevant topics extracted from the literature review, a semi-structured interview guideline with open-ended questions was developed and pretested (11,16,17). during the interviews (male interviewer, tg), it was given as much time as needed to narrate to the questions of the interview guideline. all interviews were audio taped with a digital recording device and transcribed using the computer software f4 (dr. dresing & pehl gmbh, germany) (18). ethical considerations the ethical review committee of university of bremen ascertained no reason for an objection of the study. all interviewees gave written informed consent. a description of the purpose of the study was made available during recruitment, reiterated in writing within the consent form and verbally before each interview. withdrawal of consent without personal consequence was possible at any time point and participants were aware of their freedom. confidentiality of participation was secured and participants were made aware of the anonymization of personal information. data analysis the data analysis was accomplished by using summarizing analysis of the contents of semi-structured interviews using mayring’s method (tg) (19). therefore, the interviews have been open coded as a first step, using the computer software maxqda 11 (verbigmbh, germany) (20,21). out of these coded text parts paraphrases have been created. in a next step, these paraphrases were abstracted. synonymous paraphrases were grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 6 | 14 deleted. these two last steps were repeated until a satisfactory level of abstraction was reached (19). based on these abstracted statements, themes were developed, which were validated by the original text passages. all analyses were based on texts in its original language, translation into english took place while the first abstraction of paraphrases. as all interviews were conducted in german, presentation of original quotations in the results was waived. results participant characteristics characteristics of the participants are presented in table 1. the median age was 45 years (interquartile range 5) and 38% were female. the specialty areas of nurses were emergency care (n=5), intensive care (n=4), internal medicine (n=3) and orthopaedics (n=1). the median practical nursing experience was 21 years (interquartile range 9). the majority of participants (n=11) reported one or two job specializations, including specialization as head nurse (n=8) as well as in anaesthesia care and intensive care (n=5). participation in disaster nursing-related continuing education programs was reported by five participants with a mean participation number of six education programs. volunteer involvement in an aid organization was reported by two participants. disaster preparedness and knowledge within the first professional socialization field, knowledge, seven themes were clustered (table 2). table 1. participant characteristics (n=13) characteristics median (iqr) n (%)** age: years 45 (5) work experience: years 21 (9) female sex 5 (38.5) specialty area emergency care 5 (38.5) intensive care 4 (30.8) internal medicine 3 (23.1) orthopaedics 1 (7.7) job specialisation* head nurse 8 (61.5) anaesthesia care and intensive care 5 (38.5) disaster-related continuing education 5 (38.5) volunteer involvement: n (%) 2 (15.4) iqr: interquartile range *multiple response allowed **absolute numbers and their respective percentages (in parentheses) grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 7 | 14 table 2. identified themes of relevant topics topic themes (i) disaster preparedness and knowledge of german nurses definition of a disaster knowledge and skills undergraduate nursing education continuing education programs disaster drills willingness to help disaster preparedness (ii) roles of german nurses during emergency response general roles of nurses expectations of society and the hospital role conflicts assignments of medical tasks special roles during a pandemic influenza (iii) disaster experiences of german nurses work environment nursing care feelings burdens and stressors call of duty impacts a dominant definition of a disaster was that disasters are man-made and technical. furthermore, terror attacks, meteorological and natural disasters as well as biological and chemical disasters were described as possible disaster sub-groups. a majority of participants defined a disaster as a mass casualty incident, which is hardly controllable without external assistance and accompanied by severe personal and material damage. alternatively, disasters were defined as a situation with a large number of affected and/or killed people as well as an unpredictable, sudden and challenging event, lasting for a longer time. knowledge and skills were perceived as highly necessary regarding disasters. knowledge about the hospital emergency action plan and the corresponding roles during a disaster was considered essential. additionally, knowing the hospital structures such as the hospital alarm system, the triage system and the supplies maintenance as well as knowing the federal state law for disaster control and about the duty to report to work were assumed important. emotional skills, communicative and organizational skills, and professional skills were considered important for disaster preparedness. according to the participants, undergraduate nursing education did not address disaster nursing, yet emergency care and trauma care nursing has been addressed. however, communicative and organizational skills as well as certain professional skills are well trained in undergraduate nursing education. a future need for an explicit disaster nursing education for undergraduate nurses was addressed. a need for nurses to be continuously educated and trained in disaster nursing has been made clear. a minority of participants affirmed that training and education in disaster nursing would be existent in their own hospital. the plurality of the participants stated that disaster drills had not been performed in their hospitals yet. however, nearly every partici grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 8 | 14 pant saw advantages in regular and mandatory disaster drills, such as experiencing disasters in hospitals, recognizing roles and emotions during a disaster and practising and optimizing alerting, assembly, the hospital emergency action plan, communications and triage. willingness to help during a disaster was taken for granted and as an ethical obligation by almost all participants. willingness and unwillingness to help were influenced by several factors, such as preparedness, prior disaster experience, the scope and type of the disaster or being personally affected by a disaster. professional disaster preparedness was perceived by barely half of participants, as they already had training in psychosocial emergency care, long-term caring experience or knowledge of the hospital emergency action plan and medical care. furthermore, aspects of disaster preparedness were receiving regular education in disaster management and knowing the own roles during a disaster. half of the participants felt personally prepared, due to volunteer activity in a disaster relief organisation, knowledge about behaviour during disasters or information of the own family. roles during emergency response within the second professional socialization field, roles, five themes were clustered (table 2). most of the participants defined the following general roles during disasters: patient care, assistance during triage, on-scene command, setting priorities, communication, public relations, clearing of space for additional patients, recruitment and deployment of personnel. according to the participants, patient care will be reduced to psychological care and emergency care. according to the majority of the participants, nurses are expected by society and the hospital to be willing to help and to stay able to cope during a disaster. furthermore, nurses are expected to be prepared, knowledgeable and skilled and to give quick and high quality aid. in particular, the hospital was believed to expect professional care, psychological care, organizational capabilities, teamwork, courage and versatility during a disaster. participants identified conflicts between their professional and private, either when they would be personally hit by a disaster or when they were single parents, have an infant or were responsible for the care of relatives. the assignment of medical tasks, such as triage or tracheal intubation, was perceived as “realistic” by the majority of participants. however, others stated that they could not imagine performing medical tasks, such as diagnosis or the administration of drugs, during a disaster. for the case of a pandemic influenza, participants identified that nurses were responsible for infection protection, hygiene, disinfection and of the correct use of personal protective equipment. furthermore, nurses needed information about the course of epidemics, conduct case investigations and educate colleagues, patients and relatives about epidemics in order to calm their fears. disaster experiences within the third professional socialization field, experience, five themes were clustered (table 2). almost all participants described a (potential) work environment in hospital during a disaster as being tense, chaotic, rushed, panicky as well as crowded with patients and relatives. moreover, a disaster was described an exceptional situation for a hospital, accompanied grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 9 | 14 by an overwhelmed capacity. the work environment was also described as being disturbed by the military or the press. nursing care was described as possible to a limited extend and controlled by priorities. according to the participants, different nursing tasks were attributed to different groups of nurses during a disaster (table 3). participants described six domains of feelings they may experience during a disaster: excessive demands, fear and panic, feeling of horror, feeling of terror, feeling of incapability, as well as positive feelings, such as feeling of security and a good feeling of being able to help. furthermore, the larger part of the participants agreed that disasters are or might be physically and psychically burdensome. nurses described four domains of disaster burdens: disgusting conditions, work environment-related burdens, care-related burdens and disaster impact-related burdens. the majority of the participants took it for granted to get to the hospital and to work beyond regular working hours when they would be called for duty during a disaster. in addition, there was almost no doubts that other nurses would get to the hospital, as well. table 3. nursing tasks during disasters for different groups of nurses groups of nurses nursing tasks and characteristics nurses in general be on call for duty during a disaster perform delegated medical tasks support each other and work together high flexibility ready to work for extended periods of time emergency nurses triage emergency care dependent on triage section clinical nurses expansion of capacity by discharging patients assurance of the availability of supplies assurance of the availability of medicines and medical equipment professional care for present and additional patients head nurses ensure readiness of nurses organisation and decision-making deploy nurses according to their qualifications a specific part of the participants considered debriefing and giving feedback to the team after a disaster important in order to identify needs of colleagues. in addition, the evaluation of the disaster response and the processing of problems were considered important. the following professional impacts of a disaster were described: disaster experience, improving skills and knowledge as well as identification with the team and as a nurse. the following personal impacts of a disaster were described: strengthening personality, achievement of success, gratitude for life, nevertheless, also not wanting to experience another disaster anymore. discussion participants of the study were able to find definitions of disasters corresponding to the definition of centre for research on the epidemiology of disasters (22). both definitions emphasized unpredictability, the sudden onset and the great personal and material damage. it is noteworthy that participants of the grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 10 | 14 current study mentioned that disasters are challenging local capacity, but not overwhelming it. another study about nurses’ perception of disaster identified similar attributes to disasters as the current study (e.g. being unpredictable, sudden, unexpected or unpreventable) (1). existing disaster nursing curricula set other priorities for education and training than the participants of the current study (23,24). those curricula did not address the topics duty to work and hospital structures. however, there is strong consent in the need for disaster nursing undergraduate nursing education and continuing education programs among the current study and international studies (1,25-28). in the literature, regular and mandatory disaster drills were demanded (29,30), as they were expected to improve emergency response capabilities (31-33). according to international studies, requirements for disaster preparedness were pre-registering in a disaster registry, having experience in disaster nursing and continuingly taking part in trainings and drills (1,31,33-37). indeed, those requirements were in line with requirements stated in the current study. the requirements for personal disaster preparedness, however, deviated largely. in the literature, for instance, the following requirements were described: having a go-pack containing essential personal supplies, preparing and protecting the family and having a personal plan for times of disaster (31,32,34,37-40). however, the majority of the nurses who participated in the current study did not feel personally prepared. and those who did, thought they were personally prepared, if they merely informed their families about their role in hospital during a disaster. for personal and professional preparedness and in order to raise willingness to respond, nurses need to pack their essential personal supplies standing by for emergencies, need to know that their families are protected and need to be registered in a disaster registry as well as know their relevant disaster plan. a personal disaster plan will help to arrange personal matters when responding to a disaster. in contrast to the responses of the participants of current study, it has been occasionally described in international studies that nurses will definitely be assigned medical tasks (34,41). furthermore, different roles special roles during a pandemic influenza, such as contact tracing, engaging in surveillance and reporting, collecting specimens or administering immunizations, were described elsewhere (32). the disaster experiences described, for instance the descriptions of the (potential) work environment during a disaster, were in line with descriptions from other studies (33,42,43). however, potentially hazardous work environments due to inferred security or potentially lethal situations were not described by any participant of the current study (33). no other study did describe feelings potentially experienced during a disaster, as the current study did. one study described guilt when taking leave, concern about causing pain to patients, being overwhelmed by the tragedy, disgust and distress as feelings of nurses experienced during a disaster. other studies described fear, stress and confusion (34), uncertainty, hopelessness, abandonment (44) and vulnerability (45) as feelings of nurses experienced during a disaster. the participants of the current study described disgusting conditions as a dominant domain of burdens and stressors during a disaster. in the literature, however, excessive demands (e.g., due to lack of satisfaction of basic needs, due to decline of infrastructure) were the dominantly represented domain of grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 11 | 14 burdens and stressors during a disaster (33,44-49). in the aftermath of a disaster, both, positive and negative consequences of disaster experiences, such as improvement of professional competency and rethinking of the commitment to nursing, play an important role in the current study as well as in the international literature (50). limitations of the study first, the gathering of qualitative data and the analysis of their content were based on texts in its original language to best describe and interpret their content. translation of descriptions and interpretations of the content might have leaded to a distortion or transformation of their true meaning. second, this study is not representative of the german nursing population, but it explored the field of the role, experience and knowledge in national disaster preparedness and emergency response. the results of this study may not be representative for healthcare systems and educational systems in other countries. last, different from expectation, a majority of nurses who participated in the study were male. it is possible that experiences of women were not adequately reflected. furthermore, participant characteristics have to be distinguished for its overly large number of nursing specialists in emergency care and intensive care. conclusion the results of this exploratory qualitative study implied similarities but also differences in the knowledge, role and experience in national disaster preparedness and emergency response of german nurses, compared to other countries. there is a need of further research in order to further explore the knowledge, role and experience in a broader sample of nurses in germany. the results of this explorative qualitative study can be used to design a national survey with representative samples in order to expand and validate its findings. nurses need to get involved in all aspects of disaster management and need to receive proper education and training. it is imperative that nurses know about their duties and their roles, especially within the execution of medical tasks, before and during disasters and epidemics. hospitals and federal states of germany need to organize regular and mandatory disaster drills for nurses. nurses themselves need to get informed about their possibilities for personal and professional disaster preparedness. close attention is needed on ethical aspects and the assumption of responsibility by nurses during disasters. it is necessary that nurses know about feelings which can be created during disasters and have coping strategies for stressful and burdensome situations, which are applicable in exceptional circumstances and in the aftermath, as well. hospitals and the federal state offices for civil protection and disaster control need to be aware that not every nurse will anticipate getting to the hospital and having longer working hours during a disaster for self-evident. references 1. fung wmo, lai kyc, loke ay. nurses' perception of disaster: implications for disaster nursing curriculum. j clin nurs 2009;18:3165-71. 2. bundesministerium der 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matern child nurs 2008;33:249-57. 49. o'sullivan tl, amaratunga c, phillips kp, corneil w, o'connor e, lemyre l, et al. if schools are closed, who will watch our kids? family caregiving and other sources of role conflict among nurses during large-scale outbreaks. prehosp disaster med 2009;24:321-5. 50. shih fj, liao yc, chan sm, duh br, gau ml. the impact of the 9-21 earthquake experiences of taiwanese nurses as rescuers. soc sci med 2002;55:659-72. ________________________________________________________________________ © 2020 grochtdreis et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ylli a, jurgutis a, burazeri g, bejtja g, artykova n, sentell t. preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt (original research). seejph 2021, posted: 17 april 2021. doi: 10.11576/seejph-4352 p a g e 1 | 10 original research preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt alban ylli1,2, arnoldas jurgutis3, genc burazeri1, gazmend bejtja4, nazira artykova4, tetine sentell5 1 faculty of medicine, university of medicine, tirana, albania; 2 institute of public health, tirana, albania; 3 world health organization, european centre for primary health care, almaty, kazakhstan; 4 world health organization, office in albania, tirana, albania. 5 university of hawai‘i at mānoa, usa. corresponding author: alban ylli, md, phd; address: faculty of medicine, rr. “dibres”, no. 371, tirana, albania; telephone: 355672052674; email: albanylli@yahoo.co.uk mailto:albanylli@yahoo.co.uk ylli a, jurgutis a, burazeri g, bejtja g, artykova n, sentell t. preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt (original research). seejph 2021, posted: xx april 2021. doi: p a g e 2 | 10 abstract non-communicable diseases (ncds) in albania are increasing, yet the country has a low number of outpatient visits per inhabitant per year. a primary health care (phc) based programme of medical check-ups, with a focus on prevention, was set up in the country in 2015 aiming to address this issue, among others. this manuscript describes the development and status of the programme at key time points after its implementation, and considers some of its outcomes. the current analysis was based on data gathered from the check-up programme information system and the registry of diseases at phc centres, and guided by the european framework for action on integrated health services delivery. based on phc registered cases, a 13% and 34% increase in the prevalence of elevated blood pressure and diabetes were observed in 2015 respectively, following the introduction of the check-up programme compared to the previous year. three years after implementation, about 60% of the population aged 35–70 years old had used the programme at least once, with 61% of the total 954 667 visits provided to women. overall, the check-up programme in albania has identified a substantial number of new cases of ncd as well as their associated risk factors in its population. the early detection of ncds is expected to contribute to the prevention of complications, premature mortality and their associated costs. albanian politicians and decision-makers should regularly revise and introduce appropriate changes to the check-up programme in the future. in particular, the issue of sustainability and longterm resource mobilization is of particular concern and warrants careful consideration. keywords: albania, check-up programme, prevention, primary health care. conflict of interests: none declared. ylli a, jurgutis a, burazeri g, bejtja g, artykova n, sentell t. preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt (original research). seejph 2021, posted: xx april 2021. doi: p a g e 3 | 10 background in albania, non-communicable diseases (ncds) are estimated to account for 89% of all deaths, with cardiovascular diseases accounting for 57%, cancer 20%, chronic respiratory diseases 3%, diabetes 1% and other ncds 12% (1). the probability of dying between the age of 30 and 70 years old from a ncd in albania is 17% (1), and ncds as a percentage of total disability-adjusted lifeyears (dalys) increased considerably from 67% in 2000 to 80% in 2012 (2). furthermore, lifestyle factors account for more than 70% of the total disease burden in albania. during the past two decades, the total mortality rate related to being overweight or obese has more than doubled, and the death rate from ischaemic heart disease and diabetes have more than doubled and tripled respectively (3). despite the increases in ncds in albania, the country was reported as having the fewest outpatient visits per inhabitant per year out of the eight countries in south-eastern europe in 2013, at 2.5 per inhabitant per year, with the average in the who european region at 7.5 (2). this low attendance rate, and consequent delays in addressing health problems, were assumed to be a result of the lack of state funded health care, low population coverage of health insurance and high out-of-pocket payments, which comprised 55% of the total albanian national expenditure on health in 2014 (4,5). in response to these issues, the government of albania, in addition to introducing national intersectoral policies targeting the determinants of ncds, developed and implemented a national medical check-up programme in 2015, aiming to improve the early detection and management of ncds, and to increase access to and trust in the primary health care (phc) sector (6-8). the objective of this study was to describe the development and status of the programme at key time points after its implementation, and to quantify some of its outcomes. methods and approach each of the following factors were initially assessed: the scope/selection of services for the check up programme; the system’s delivery capacities; design of patient pathways; organization of providers at the phc centres; screening management; and the mechanisms in place to ensure performance improvement. subsequently, the outcomes and impact of the programme were analysed by focusing on indicators such as the early detection of health conditions/metabolic risk factors and changes in the registered prevalence of ncds as a result of the programme. two main data sources were used in our analysis: the checkup programme documentation and information system and the registry of diseases at phc centres. the check-up programme information system, managed by the ministry of health and social protection (mhsp), is a fully computerized case-based registry, which employs a state-of-the-art bi (business intelligence) system and provides timely information about the result of each patient visit. the registry of diseases, which was set up twelve years ago, contains all prevalent cases of disease diagnosed by a general practitioner (gp) and confirmed by a specialist, within a phc centre’s catchment area. each phc centre reports the data periodically to the compulsory health insurance fund (chif) and the aggregated database is shared with the institute of public health. along with the check-up information system, these registries are considered reliable sources of information as they have frequently (i.e., every three months updated core documentation and are also periodically checked by chif supervisors. the current analysis and presentation of findings were guided by the principles put forward by the european framework for action on integrated health services delivery and its approach to transforming the delivery of health services (9). it ylli a, jurgutis a, burazeri g, bejtja g, artykova n, sentell t. preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt (original research). seejph 2021, posted: xx april 2021. doi: p a g e 4 | 10 includes among others the people-centred approach, which recognizes that before people become patients, they need to be informed and empowered in promoting and protecting their own health. results and discussion scope of the check-up programme based on the changing health needs of the population resulting from the increasing burden of ncds, the albanian government put forward a national health programme with the primary goal of increasing life expectancy by preventing premature deaths. following international evidence on the role of phc in addressing ncd-related health needs, the government put priority on improving phc performance. during 2013/2014 the government conducted detailed preparatory work before launching a primarily preventive programme in 2015 officially named the essential medical evaluation, but announced under the logo ‘how are you?’ for all albanian citizens aged 40–65 years. this was initially set to run over three years, but has subsequently been expanded until 2024. in addition, the target age group was expanded to cover all citizens between 35–70 years at the end of 2016. the size of the initial target group in 2015 was around 1 160 000 inhabitants, which constituted 41% of the total resident population in albania. the programme, considered by the government as a major step towards universal health coverage, targeted all albanian residents regardless of their insurance status. the scope of the programme was to assess health status of eligible individuals on a yearly basis in six priority areas highlighted as high priority by the albanian institute of public health (10) and included several tests (such as blood sugar level and lipid profile, as well as assessment of other key cardiovascular risk factors) to be performed throughout the target population (table 1). table 1. tests provided in six priority areas of the check-up programme (source: reference number 10) areas tests risk factors tobacco use harmful use of alcohol unhealthy diet physical inactivity hypertension blood pressure measurement diabetes fasting plasma glucose test glucose tolerance test (2-hour plasma glucose) cardiovascular risk score (systematic coronary risk evaluation) family history ecg mental health and depression patient health questionnaire key laboratory tests complete blood count complete urine analysis faecal occult blood test liver enzymes: aspartate aminotransferase and alanine aminotransferase blood lipid analysis creatinine and urea (since 2016) ylli a, jurgutis a, burazeri g, bejtja g, artykova n, sentell t. preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt (original research). seejph 2021, posted: xx april 2021. doi: p a g e 5 | 10 the included screening tests were more comprehensive than those previously available in phc services in albania (notably the inclusion of laboratory tests) (11), and went beyond evidence-informed recommendations to include areas of priority to the government, including liver enzymes tests, electrocardiogram (ecg) etc. (10,12,13). furthermore, at the end of 2016, in addition to expanding the age group eligible for screening, the government increased the scope of the check-up programme by increasing the number of laboratory tests, (creatinine and urea tests were added). as of yet, there have been no attempts to reduce the frequency of some of the current tests, despite evidence to do so, but there is a willingness to consider the inclusion of cervical and breast cancer screening as recommended by who (12), although this has yet to be implemented. capacity for implementing the check-up programme the mhsp and chif implemented the programme through a contract with an external company, which was responsible for purchasing and maintaining equipment and the information technology system in all 380 albanian phc centres, training the staff involved in the screening, transporting samples, organizing mobile units to provide screening in remote areas and carrying out all laboratory tests. the government-funded phc centres were themselves obliged to provide: (i) suitable premises for receiving people coming for a check-up; (ii) a list of the people eligible for screening in their designated catchment area; (iii) a computer for registering and transferring data; (iv) maintaining equipment provided by the contractor; and (v) nurses responsible for check-ups. larger phc centres appointed nurses solely responsible for the check-ups, whereas smaller phc centres usually just expanded the role of the family nurse. this was reflected in higher attendance rates in larger phc centres due to their larger capacity, whereas smaller centres encountered several challenges in conducting the programme tasks. all phc doctors and nurses responsible for check-up processes were trained for the task and equipped with an accompanying manual (14) and clinical algorithms, both of which provided guidance on when further investigations and referrals were recommended. preventive check-up procedures, referrals and follow-ups the mhsp clearly defined the processes for the check-ups. all necessary steps involved, as well as the responsibilities of the contractor, phc centre and secondary health care consultants were clearly stated in a written manual. the check-up appointment itself consisted of an initial briefing on the programme by the nurse, followed by the completion of questionnaires on behavioural risk factors, body mass index calculations based on measured weight and height, an ecg, and the taking of blood samples. laboratory tests were collected by the contractor on a daily basis. if behavioural risk factors were identified, the patient received a brief intervention consisting of advice and guidance by the nurse. in addition to the 380 phc centres, mobile units visited 35 remote villages with limited health services, twice a year. the contractor provided the laboratory tests results to each phc centre and, in case of abnormalities, the stationed gp provided health advice and suitable prescriptions, or referred the patient to a secondary health care clinic, following the well-defined clinical pathways. a check-up programme referral guaranteed free and easy access to secondary health care regardless of the patient’s insurance status, with short waiting times to see a consulting ylli a, jurgutis a, burazeri g, bejtja g, artykova n, sentell t. preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt (original research). seejph 2021, posted: xx april 2021. doi: p a g e 6 | 10 specialist and for any necessary further clinical investigations, as confirmed elsewhere (15). the check-up process was deemed completed after the gp sent the contractor a report with the results of the check-up describing any identified or suspected clinical conditions. these reports were filed before any feedback from subsequent specialists and therefore rarely included a final clinical diagnosis. if the person did not require a referral to a gp, the report was filed by the nurse. identification of new cases and changes in registered morbidity the analysis of check-up programme data determined the extent to which check-ups identified new cases of ncds, and risk factors associated with ncds, but also the number of referrals to a specialist. in 2016, of the 329 576 people that underwent a check-up in albania, 36% had elevated blood pressure (systolic at 140 mmhg or higher and/or diastolic at 95 mmhg or higher); 21% were suspected of having depression; 15% had blood glucose levels higher than 5.5 mmol/l; 9% higher than 7.0 mmol/l; and 1% had a positive faecal occult blood test (table 2). table 2. distribution of selected medical conditions among 329,576 individuals undergoing a medical check-up in albania in 2016 condition number percentage percentage not previously aware of their condition depression 69211 21% 76% high blood pressure 118647 36% 49% high blood glucose 49436 15% 42% positive occult blood in faeces 2637 0.8% 99% in 2016, there were 39 213 referrals to specialists as a result of the check-ups, although there is no data regarding follow-ups and final diagnoses. a large proportion of people identified as having a medical problem as a result of the check-up had not previously been aware of their condition, with 49% unaware of their high blood pressure status and 42% unaware of their diabetic status in 2016. according to the phc registries, there was a marked increase in the prevalence of diabetes mellitus, depression and arterial hypertension (34%, 30% and 13% respectively) following the introduction of the check-up programme in 2015 compared to the previous year (fig. 1). previous annual increases had only been at around 1% for diabetes, hypertension and depression. despite the observed increase in the prevalence of phc registered hypertension, the overall prevalence actually remained low compared to the expected population levels based on who ncd country profiles in 2014, where more than 36% of the population (over 25 years old) had hypertension (3,9). almost three years after the introduction of the check-up programme, at the end of 2017, the prevalence of phc registered arterial hypertension was only 15%. similarly, the registered prevalence of diabetes mellitus was lower than expected at 3.8%. it seems that program has yet to diagnose and register all cases of hypertension and diabetes in community. ylli a, jurgutis a, burazeri g, bejtja g, artykova n, sentell t. preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt (original research). seejph 2021, posted: xx april 2021. doi: p a g e 7 | 10 figure 1. number of cases of hypertension, diabetes and depression in ncd registries of phc centres, from 2011-2017 f outcomes and impact up until february 2018, 54% of all 954 667 check-up visits were carried out in rural areas, which was a strong point of the programme, as one of its objectives was to tackle geographical differences in accessing phc. it is also worth noting the gender difference in the programme participation, with 61.3% of the check-ups provided to women, in line with the fact that programme compliance was lowest among younger middle-aged men (aged 35–44 years), an issue that deserves future attention. beyond informing and managing patients suspected of having a ncd, the check-up programme also brought about a number of key changes in the albanian health sector: (i) it changed traditional attitudes that health services should only be used for perceived and disturbing health problems, with healthy people now attending check-ups aimed at the prevention and early detection of severe health problems, as described elsewhere (16); (ii) it increased trust and utilization of phc services; and (iii) it increased the accessibility of health services for socially disadvantaged population groups, although more data are needed to confirm the extent of this (17). the perception among health professionals was that albanian population place a higher value on objective measurements of health, such as laboratory and diagnostic tests, over questionnaires for assessment of behaviour risk factors (16). therefore, in order to make the intervention more attractive and to increase participation, more laboratory tests were included in the check-up programme in 2016. overall, the check-up programme raised the awareness of the population for the need of preventive check-ups, with 60% of the people eligible for the checkups attending at least once in the period march 2015–march 2018. about half of the people screened in 2015 attended a second check-up in 2016. data on check-ups from the first quarter of 2017 indicated that about one third of the eligible population participated in the check-up programme for the first time, one third for the second time and one 229.519 231.396 233.71 236.047 267.28 269.077 281.857 45.606 48.05 48.53 48.966 65.55 71.414 72.926 7.614 7.489 7.564 7.64 9.905 10.154 10.448 0 50 100 150 200 250 300 2011 2012 2013 2014 2015 2016 2017 n um be r o f c as es (t ho us nd s) year hbp diabetes depression ylli a, jurgutis a, burazeri g, bejtja g, artykova n, sentell t. preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt (original research). seejph 2021, posted: xx april 2021. doi: p a g e 8 | 10 third of them for the third time. the phc centres were encouraged to invite eligible individuals through all channels they considered appropriate. this included both advertising campaigns and individual letters sent out to each subject, but some barriers still remain both in communication logistics between phc centres and their communities, and in the low awareness of the importance of the check-up programme in certain population groups, especially young males in the cities. only 8% of the young middle age (35–44 years) urban male population responded to the invitation. this low level of attendance may reflect different priorities in this population than preventive health, a concern in men’s health (18). it may also reflect challenges in accepting a shift from the more traditional role of the albanian phc services, which focused on illness and maternal and child health. hence, the programme still needs to be adapted to the needs and preferences of the male population, especially given that a higher prevalence of several ncds and their risk factors are expected among men. at the end of 2016, the government extended the check-up programme and from the beginning of 2017 free phc visits for the entire population, covering all health conditions, were introduced, along with easy access to specialized services, targeting this overall aim of providing universal health coverage. conclusions the check-up programme has been an important intervention in strengthening the phc service in albania. it has helped improve access to, and build more awareness about preventive care among the albanian population. there is a general consensus among professionals that the program has created the basis for better service attendance and improved health seeking behaviour in albanian adults, as well as restoring trust and communication between health professionals and communities (16). yet, there are areas to be addressed within the programme in the future. notably, the programme needs to focus on encouraging men to also attend check-ups, and needs to assess potential differences in participation rates between different socioeconomic population subgroups. this information is currently not available. overall, the check-up programme in albania has identified a substantial number of new cases of ncds and risk factors associated with chronic disease. the early detection of a ncd is expected to reduce the development of related complications, as well as premature mortality rates, which in turn should reduce the associated costs. however, policy makers need to continue to support and shift more resources to phc services to cover the increase in workload for phc gps and nurses. to ensure the effectiveness of the check-up programme and improvements in the overall health status of the population, however, it is not sufficient to have a well-funded check-up programme if it is based in the framework of low-resource phc facilities, with a limited capacity for the follow-up and management of patients with ncds. the check-up programme needs to be accompanied by a more advanced primary health care model that would include ncd management by well-trained family doctors and phc nurses, supported by other members of a multidisciplinary team (for example psychologists, health educators, public health specialists), as required. in addition, the programme should be further optimized by revising the scope of tests, the targeted age groups, and the frequency of the tests according to age and health status. for example, a number of tests including in the check-up programme, including ecg, liver enzyme tests and complete urine analysis, among others, have not been shown to be effective in population based screening (19), and should therefore only be used for opportunistic ylli a, jurgutis a, burazeri g, bejtja g, artykova n, sentell t. preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt (original research). seejph 2021, posted: xx april 2021. doi: p a g e 9 | 10 screening of patients at risk for a particular disease. this would optimize resources within the programme potentially allowing for the introduction of other evidence-based tests, including the screening of some cancers, as well as the better follow up of detected cases. overall, a better financial optimization is required to encompass both the costs of further investigation and specialist consultations, which are currently covered by health insurance, in addition to the cost of the check-ups. the check-up programme has also helped raise the professional profile of phc nurses, by transferring to them some essential tasks previously carried out by physicians. the check-up programme could gradually introduce phc nurses responsible for a particular district, so that every individual would receive a more comprehensive service from their own nurse, including check-ups, behaviour change counselling, and followups for patients with ncds. such a model should be supported by clear clinical guidelines and should include some form of both performance measurement and accountability for health personnel – along with supporting incentives (for example the revision of remuneration schemes) – with patients reaping the benefits. user-friendly and culturallysensitive information campaigns aimed at all levels of society each at an individual, family, and community-based level will be important for the future of the programme. in addition, measures to enhance the responsibility of citizens themselves to participate in the checkup programme should be gradually introduced, and incentives towards this aim need to be considered. in conclusion, the current case study is an example of how a country in the who european region with limited resources was able to make prompt resource mobilization and to strengthen the role of phc in ncd control. however, albanian politicians and decision-makers need to be able to regularly revise and introduce appropriate changes to the check-up programme in the future. in particular, the issue of sustainability and long-term resource mobilization is of particular concern and deserves careful consideration. references 1. world health organization. noncommunicable diseases country profiles 2018. country profile for albania. geneva: who; 2018. available from: http://www.who.int/nmh/countries/2018/alb_en.pdf (accessed: november 21, 2020). 2. world health organization. european health for all database. copenhagen: who regional office for europe; 2017. available from: https://gateway.euro.who.int/en/hfaexplorer (accessed: november 29, 2020). 3. institute of public health. national health report. tirana, albania; 2014. 4. world health organization. albania: scoping mission on phc needs assessment. copenhagen: who regional office for europe; 2014. 5. world bank. albania: world bank group partnership program snapshot. washington (dc): world bank; 2014. 6. national programme for prevention and control of ncds in albania 2016–2020. tirana and copenhagen: ministry of health of albania and who regional office for europe; 2017. 7. ministry of health and social protection of the republic of albania. albanian national health strategy 2016–2020. tirana, albania; 2016. ylli a, jurgutis a, burazeri g, bejtja g, artykova n, sentell t. preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt (original research). seejph 2021, posted: xx april 2021. doi: p a g e 10 | 10 © 2021 ylli et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 8. health insurance fund. focus magazine 2015;31. available from: http://www.fsdksh.com.al/images/stories/publikimet/revista/revista_fokus_dhjetor/draft_fokus_shqip_18_dhjetor.pdf (accessed: may 29, 2020). 9. world health organization. strengthening people-centred health systems in the who european region: framework for action on integrated health services delivery. copenhagen: who regional office for europe; 2016. available from: http://www.euro.who.int/__data/assets/pdf_file/0004/315787/66wd15e_ ffa_ihsd_160535.pdf?ua=1 (accessed: november 21, 2020). 10. world health organization. assessment report on implementation of the screening programme “primary care for citizens aged 40–65 in albania”. copenhagen: who regional office for europe; 2015. 11. ministry of health of albania. the basic package of primary health care services. tirana, albania; 2009. 12. world health organization. evaluation of screening in albania. copenhagen: who regional office for europe; 2016. 13. ylli a, xinxo s, lakrori j. parandalimi i semundjeve kardiovaskulare ne kujdesin paresor. [in albanian]. institute of public health; 2015. 14. ministry of health of albania. healthy, we are all equal. primary care for citizens aged 40–65. checkup programme manual. tirana, albania; 2013. 15. health consumer powerhouse. euro health consumer index, 2016. available from: https://healthpowerhouse.com/media/ehci-2016/ehci2016-report.pdf (accessed: june 20, 2020). 16. sentell tl, ylli a, pirkle cm, qirjako g, xinxo s. promoting a culture of prevention in albania: the "si je?" program. prev sci 2021;22:2939. doi: 10.1007/s11121-018-09675. 17. arora vs, kühlbrandt c, mckee m. albania: an examination of unmet health needs as perceived by roma in central and eastern europe. eur j public health 2016;26:737-42. 18. editorial. raising the profile of men's health. lancet 2019;394:1779. doi: https://doi.org/10.1016/s01406736(19)32759-x. 19. us preventive services task force. available from: https://www.uspreventiveservicestaskforce.org/browserec/index (accessed: november 21, 2020). ____________________________________________________________________________ http://www.fsdksh.com.al/images/stories/publikimet/revista/revista_fokus_dhjetor/draft_fokus_shqip_18_dhjetor.pdf http://www.fsdksh.com.al/images/stories/publikimet/revista/revista_fokus_dhjetor/draft_fokus_shqip_18_dhjetor.pdf http://www.fsdksh.com.al/images/stories/publikimet/revista/revista_fokus_dhjetor/draft_fokus_shqip_18_dhjetor.pdf http://www.fsdksh.com.al/images/stories/publikimet/revista/revista_fokus_dhjetor/draft_fokus_shqip_18_dhjetor.pdf http://www.fsdksh.com.al/images/stories/publikimet/revista/revista_fokus_dhjetor/draft_fokus_shqip_18_dhjetor.pdf https://doi.org/10.1016/s0140-6736(19)32759-x https://doi.org/10.1016/s0140-6736(19)32759-x mone, i, kraja b, hyska g, burazeri g. chocolate intake is associated with a lower body mass index in adult men and women in transitional albania (original research). seejph 2021, posted: 02 april 2021. doi : 10.11576/seejph-4297 p a g e 1 | 9 original research chocolate intake is associated with a lower body mass index in adult men and women in transitional albania iris mone1,2, bledar kraja1,2, jolanda hyska1, genc burazeri1,3 1 university of medicine, tirana, albania; 2 university hospital center mother theresa, tirana, albania; 3 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands. corresponding author: iris mone, md, phd address: rr. “dibrës”, no. 371, tirana, albania telephone: +355692149301; e-mail: iris_mone@yahoo.com acknowledgments: genc burazeri was a recipient of an irma milstein international fellowship at the hebrew university–hadassah school of public health and community medicine, jerusalem, israel, which provided support for the study. mone, i, kraja b, hyska g, burazeri g. chocolate intake is associated with a lower body mass index in adult men and women in transitional albania (original research). seejph 2021, posted: 02 april 2021. doi : 10.11576/seejph-4297 p a g e 2 | 9 abstract aim: in light of the controversial evidence regarding health effects of chocolate intake, we aimed to assess its association with body mass index (bmi) among adult individuals in albania, a transitional post-communist country in south eastern europe which has traditionally employed a mediterranean dietary pattern. methods: a cross-sectional study was conducted in 2003-2006 involving a population-based sample of 737 tirana residents aged 35-74 years (469 men, 268 women; overall response: 70%). of these, 565 individuals (373 men and 192 women) provided data on chocolate intake and anthropometrics (77% of the sample). a 105-item food frequency questionnaire, including chocolate consumption, was administered to all individuals. nine categories were used to assess the average frequency of intake of each food item in the past 12 months. in the analysis, chocolate intake was dichotomized into: consumption of <1/month vs. ≥1/month. a physical examination included measurement of weight and height. furthermore, information on socio-demographic characteristics and classical risk factors was collected. multivariable-adjusted general linear model was used to calculate the mean bmi values by chocolate intake groupings. results: upon simultaneous adjustment for socio-demographic characteristics, classical risk factors and nutritional factors, there was an inverse association between bmi and chocolate intake in both sexes (sex-pooled mean bmi: 26.1 among participants who consumed chocolate <1/month vs. 27.0 in those with an intake of ≥1/month; p<0.001). conclusions: this study points to a beneficial effect of moderate chocolate intake on lowering bmi, which deserves further vigorous investigation and replication in prospective studies in albania and other populations. keywords: albania, body mass index, chocolate, cross-sectional study, epidemiology. mone, i, kraja b, hyska g, burazeri g. chocolate intake is associated with a lower body mass index in adult men and women in transitional albania (original research). seejph 2021, posted: 02 april 2021. doi : 10.11576/seejph-4297 p a g e 3 | 9 introduction chocolate is a typical sweet food that evokes ambivalent feelings: pleasure as the result of its taste, flavor and appearance, and concerns as the results of its content with high sugar and calorie (1). therefore, previous epidemiological studies have observed healthy and unhealthy effects of chocolate intake. several studies have reported a positive link between frequent chocolate intake and a lower body mass index (bmi) (2,3), or a reduction in the risk of cardio-metabolic disorders (4) and diabetes (5). furthermore, chocolate consumption has been linked to beneficial effects on human health and diseases (6) including cardiovascular health (7,8) blood pressure and vascular function (9). however, a cross-sectional study reported a positive association between chocolate intake and bmi in a dose-response pattern (10). hence, according to this report, the positive relationship between chocolate intake and a lower body mass was evident only among participants with preexisting serious obesityrelated illness (10). also, a meta-analysis of 10 observational studies concluded that the evidences on the association between chocolate intake and cvd risk need to be confirm in further studies (11). in light of the controversial evidence regarding health effects of chocolate intake, we aimed to assess its association with bmi among adult individuals of both sexes in albania, a transitional post-communist country in south eastern europe which has traditionally employed a mediterranean dietary pattern. methods a cross-sectional study involving a representative sample of 35-74-year-old residents of tirana, the albanian capital, was conducted in 2003-2006 (12). study population and sampling the sample consisted of an age-and-sexstratified random sample from the adult population of the tirana municipality, as registered in the albanian census of april 2001. we sampled a total of 1200 individuals, 720 men and 480 women (12). of the estimated 1046 subjects (644 men and 402 women) who met the eligibility criteria (12), 737 individuals participated in the study (469 men, 268 women; overall response: 70%). data collection a semi-quantitative food frequency questionnaire (ffq), consisting of 105 food items including chocolate consumption, was administered to all individuals (13). participants were asked to indicate how often, on average, they had eaten specified amounts of each food item in the past 12 months. nine categories were used to assess the average frequency of intake of each food item: <1/month, 1-3/month, 1/week, 2-4/week, 56/week, 1/day, 2-3/day, 4-5/day, and >6/day. in the analysis, chocolate intake was dichotomized into: consumption of <1/month vs. ≥1/month. microdiet, version 2 (downlee systems limited, uk, 2005) was employed to calculate for each food item the daily calorie intake. the respective values for all 105 food items were added up in order to get a summary score for each participant (13) for the total daily calorie intake expressed in kcal, protein, fat and carbohydrate (in the analysis, all expressed as percentage of total calorie intake) and sfa, mufa, pufa and trans fatty acid intake (in the analysis, all expressed as g/daily calories*100). in addition, information on socio-demographic characteristics (age and educational level) and classical risk factors (physical exercise and alcohol intake) was collected for each participant. furthermore, a physical examination included measurement of weight and height (based on which we calculated the mone, i, kraja b, hyska g, burazeri g. chocolate intake is associated with a lower body mass index in adult men and women in transitional albania (original research). seejph 2021, posted: 02 april 2021. doi : 10.11576/seejph-4297 p a g e 4 | 9 body mass index [bmi]: kg/m2) and waist and hip circumferences (based on which we calculated the waist-to-hip ratio [w/h]) (12). the study was approved by the albanian committee of medical ethics. participants gave written consent after being informed about the aims and procedures of the study. statistical analysis the statistical analysis included 565 individuals (373 men and 192 women) for whom data on chocolate intake and anthropometric measurements were available (565/737=77% of the overall sample of study participants). general linear model was used to assess the association between chocolate consumption and socio-demographic characteristics (age and education) and behavioral factors (exercise, alcohol intake, bmi, w/h and nutrients), separately in men and women. age-adjusted mean values and their respective 95% confidence intervals (95%cis) were calculated for each covariate by the two categories of chocolate intake (<1/month vs. ≥1/month). subsequently, multivariable-adjusted (footnote to table 2) mean bmi values and their respective 95%cis were calculated by the two categories of chocolate intake (<1/month vs. ≥1/month), separately in men and women. spss (statistical package for social sciences, version 19.0), was used for all the statistical analyses. results mean age was significantly higher among women who reported chocolate intake at least once per month compared with their counterparts who consumed chocolate <1/month (56 years vs. 50 years, respectively; p<0.001) – a finding which was not evident in men (table 1, upper panel). mean educational level was not significantly different between the two groups distinguished by frequency of chocolate intake in either sex. a similar finding was evident for alcohol intake, notwithstanding the particularly low consumption of alcohol among women. conversely, in both sexes, participants who reported chocolate consumption of ≥1/month were more physically active than individuals who reported a chocolate intake of <1/month (in men: 201 kcal vs. 87 kcal, respectively, p<0.001; in women: 164 kcal vs. 95 kcal, respectively, p<0.001). furthermore, mean bmi was considerably lower among participants who consumed chocolate ≥1/month than those who consumed chocolate <1/month (in men: 26 vs. 28, respectively, p<0.001; in women: 25 vs. 27, respectively; p<0.001). in men only, mean w/h was significantly lower among participants who reported a chocolate intake ≥1/month compared with individuals who consumed chocolate <1/month (0.93 vs. 0.95, respectively; p<0.001). in both sexes, the total calorie intake was significantly higher among individuals who consumed chocolate ≥1/month than those who consumed chocolate <1/month (table 1, lower panel). in men only, a higher chocolate intake was related to a lower protein (as percentage of total calories), whereas in women only a higher chocolate consumption was associated with higher total fats. in men, a higher chocolate intake was related to higher total carbohydrates, whereas in women there was evidence of the opposite. in both sexes, pufa level (g/daily calories) was significantly higher among participants who consumed chocolate ≥1/month than those who consumed chocolate <1/month. in women only, mufa level was higher in participants with a higher chocolate consumption. on the other hand, in men only, there was evidence of a higher level of trans fatty acids in those who consumed chocolate ≥1/month compared to those who consumed chocolate <1/month. mone, i, kraja b, hyska g, burazeri g. chocolate intake is associated with a lower body mass index in adult men and women in transitional albania (original research). seejph 2021, posted: 02 april 2021. doi : 10.11576/seejph-4297 p a g e 5 | 9 table 1. association of chocolate intake with socio-demographic characteristics, conventional risk factors and nutrient intake in a population-based sample of albanian adults; age-adjusted mean values from general linear models upper panel: socio-demographic and classical risk factors men (n=373) women (n=192) n* mean 95%ci p n* mean 95%ci p age (years): <1/month ≥1/month 146 227 52.1 51.8 50.5-53.7 50.5-53.1 0.742 74 118 55.7 50.0 53.3-58.0 48.2-51.9 <0.001 education (years): <1/month ≥1/month 146 226 11.8 11.2 11.3-12.4 10.7-11.6 0.060 72 118 10.9 10.6 10.1-11.8 9.9-11.2 0.514 alcohol intake (drinks/week): <1/month ≥1/month 146 226 3.6 4.4 2.4-4.8 3.4-5.4 0.320 73 118 0.8 0.6 0.2-1.3 0.2-1.1 0.657 physical exercise (kcal): <1/month ≥1/month 146 225 86.8 201.5 69.5-104.1 187.5-215.4 <0.001 71 117 94.7 164.4 76.1-113.4 150.0-178.7 <0.001 bmi: <1/month ≥1/month 146 226 28.0 25.8 27.5-28.5 25.4-26.2 <0.001 74 118 27.1 24.7 26.3-27.9 24.0-25.3 <0.001 w/h: <1/month ≥1/month 146 226 0.95 0.93 0.94-0.95 0.92-0.94 <0.001 74 118 0.87 0.86 0.86-0.88 0.85-0.87 0.139 lower panel: nutrients men women n* mean 95%ci p n mean 95%ci p total calorie intake (kcal): <1/month ≥1/month 146 227 2909 3186 2824-2996 3117-3255 <0.001 74 118 2431 2711 2333-2529 2634-2788 <0.001 total proteins (% of calories): <1/month ≥1/month 146 227 17.9 16.8 17.6-18.2 16.6-17.1 <0.001 74 118 17.7 17.6 17.4-18.0 17.4-17.9 0.670 total fats (% of calories): <1/month ≥1/month 147 227 35.1 35.5 34.5-35.6 35.0-35.9 0.281 74 118 38.3 39.8 37.6-39.0 39.3-40.4 0.001 total carbohydrates (% of calories): <1/month ≥1/month 146 227 47.4 48.2 46.8-48.1 47.7-48.7 0.053 74 118 46.1 44.7 45.3-46.9 44.1-45.4 0.013 sfa (g/daily calories*100): <1/month ≥1/month 146 227 1.34 1.32 1.32-1.36 1.30-1.34 0.231 74 118 1.43 1.47 1.40-1.46 1.45-1.49 0.038 mufa (g/daily calories*100): <1/month ≥1/month 146 227 1.48 1.50 1.45-1.51 1.48-1.52 0.395 74 118 1.65 1.71 1.60-1.69 1.68-1.75 0.018 pufa (g/daily calories*100): <1/month ≥1/month 146 227 0.76 0.83 0.74-0.78 0.81-0.85 <0.001 74 118 0.86 0.94 0.83-0.90 0.91-0.96 0.002 trans (g/daily calories*100): <1/month ≥1/month 146 227 0.022 0.024 0.021-0.023 0.023-0.025 0.003 74 118 0.025 0.025 0.024-0.027 0.023-0.026 0.378 * discrepancies in the totals are due to missing covariate values. mone, i, kraja b, hyska g, burazeri g. chocolate intake is associated with a lower body mass index in adult men and women in transitional albania (original research). seejph 2021, posted: 02 april 2021. doi : 10.11576/seejph-4297 p a g e 6 | 9 in crude/unadjusted models (table 2, model 1), mean bmi was substantially lower among participants who consumed chocolate ≥1/month compared to those who consumed chocolate <1/month (sex-pooled mean bmi: 25.3 vs. 27.5, respectively; p<0.001). adjustment for age (model 2) did not affect the findings (sex-pooled mean bmi: 25.2 vs. 27.5, respectively; p<0.001). table 2. association of chocolate intake with bmi; unadjusted and multivariable-adjusted mean bmi values by sex model men (n=373) women (n=192) overall (n=565)* mean 95%ci p mean 95%ci p mean 95%ci p model 1†: <1/month ≥1/month 27.98 25.79 27.4728.49 25.3826.21 <0.001 26.94 24.77 26.1227.76 24.1225.42 <0.001 27.46 25.28 27.0227.91 24.9225.64 <0.001 model 2‡: <1/month ≥1/month 27.99 25.79 27.4828.50 25.3826.20 <0.001 27.10 24.67 26.2727.94 24.0225.33 <0.001 27.52 25.23 27.0827.97 24.8925.61 <0.001 model 3¶: <1/month ≥1/month 27.00 26.41 26.5827.42 26.0826.74 0.046 26.47 24.86 25.8327.11 24.3925.34 <0.001 27.04 26.13 26.6627.41 25.8426.43 <0.001 * adjusted for sex. † model 1: crude/unadjusted models. ‡ model 2: adjusted for age. ¶ model 3: adjusted for age, education, exercise, alcohol intake and w/h, total calorie intake, protein, fat and carbohydrate (all expressed as percentage of total calorie intake) and sfa, mufa, pufa and trans fatty acid intake (all expressed as g/daily calories*100). upon simultaneous adjustment for all covariates (model 3), the inverse association between bmi and chocolate intake was attenuated but nevertheless remained statistically significant in both sexes (sex-pooled mean bmi: 26.1 vs. 27.0, respectively; p<0.001). discussion we found a strong inverse relationship between frequency of chocolate intake and bmi, which was consistent in both sexes and persisted upon adjustment for a wide array of socio-demographic characteristics and behavioral factors including nutrient intake as assessed by a detailed ffq. the results of the present study are comparable with a previous study conducted by golomb et al. (2), which examined the crosssectional relationship of chocolate intake and bmi among american adults. they reported that chocolate consumption frequency is linked to lower bmi in unadjusted model (p=0.008) and in adjusted models adding age, sex, activity, saturated fats, fruit and vegeta mone, i, kraja b, hyska g, burazeri g. chocolate intake is associated with a lower body mass index in adult men and women in transitional albania (original research). seejph 2021, posted: 02 april 2021. doi : 10.11576/seejph-4297 p a g e 7 | 9 bles, mood and calories (p=0.001). also, another study found that high chocolate consumption was associated with lower bmi, body fat and waist circumference in young people regardless of different confounders (age, sex, total energy, saturated fats, fruit and vegetable, and physical activity) (3). one possible explanation for these findings is due to the fact that the caloric components as well as the other biologically active components of the food could influence bmi. hence, the observed inverse association between chocolate consumption and bmi may relate to the effects of other biologically active components of chocolate such as flavanols including catechin, epicatechin, and procyanidins which have a variety of beneficial physiologic actions (6). flovanols promote the release of nitric oxide which has been shown to increase oxidation of fatty acids and glucose in skeletal muscle, inhibits fat synthesis in adipose tissue, and stimulates lipolysis in adipocytes (6). the netherlands cohort study after 14 years of follow-up reported that women with the highest dietary intake of total flavonols had significantly lower increases in bmi than women with the lowest intake, over time (0.41 and 0.91, respectively; p<0.05), suggesting a favorable effect of dietary flavanols intake on maintaining of body weight (14). additionally, animal studies have shown that dietary flovanols intake may possibly reduce weight gain through effects of epicatechin and catechin on target tissues (15,16). epicatechin improves the mitochondrial content, structure and function as well as capillarity of skeletal muscle (15), whereas catechin increases energy expenditure, decreases fatty acid synthase levels in adipose tissue and inhibits adipocyte differentiation (16). another explanation for the observed findings may relate to the effect of chocolate consumption on appetite and satiety. massolt et al. have shown that chocolate eating and smelling both could reduce appetite (17) whereas in a randomized, controlled study, tey et al. demonstrated that chocolate consumption could decrease satiety (18). these findings suggest that chocolate consumption may aid for weight maintenance as a result of early termination of food intake. the main advantages of this study are its community-based design which included men and women from general population of albania and use of a validated questionnaire for assessment of nutrient intake and physical activity. the ffq we used for measurement of dietary patterns was customized to the albanian context and previously validated in a small sample of albanian adults of both sexes. seemingly, there is no plausible reason to assume differential reporting among participants distinguished by socioeconomic characteristics or bmi groupings. nevertheless, we cannot entirely exclude the possibility of information bias. our study has other limitations. the response rate raises the possibility of selection bias. male non-respondents, in addition to being older than participants, were more likely to be retired; however, exclusion of retirees from the analysis did not affect the magnitude of the association. in women, respondents and non-respondents were more similar. if non-response among thinner individuals was associated with higher chocolate intake, this could attenuate the findings. conversely, if obese individuals who did not respond tended to employ a higher chocolate consumption, this could spuriously strengthen the findings, but would be unlikely to rule out the entire association. also, importantly, the data included in this analysis are old. in conclusion, our findings point to a beneficial effect of moderate chocolate intake on lowering the body mass, which deserves further vigorous investigation and replication in mone, i, kraja b, hyska g, burazeri g. chocolate intake is associated with a lower body mass index in adult men and women in transitional albania (original research). seejph 2021, posted: 02 april 2021. doi : 10.11576/seejph-4297 p a g e 8 | 9 prospective studies in albania and other populations. conflicts of interest: none declared. references 1. roeline g. kuijer, jessica a. boyce. chocolate cake. guilt or celebration? 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(-)-epicatechin enhances fatigue resistance and oxidative capacity in mouse muscle. j physiol 2011;589(pt 18):4615-31. 16. wolfram s, raederstorff d, wang y, et al. teavigo (epigallocatechin mone, i, kraja b, hyska g, burazeri g. chocolate intake is associated with a lower body mass index in adult men and women in transitional albania (original research). seejph 2021, posted: 02 april 2021. doi : 10.11576/seejph-4297 p a g e 9 | 9 © 2021 mone et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. gallate) supplementation prevents obesity in rodents by reducing adipose tissue mass. ann nutr metab 2005;49:54–63. 17. massolt et, van haard pm, rehfeld jf, posthuma ef, van der veer e, and schweitzer dh. appetite suppression through smelling of dark chocolate correlates with changes in ghrelin in young women. regul pept 2010;161:81–6. 18. siew ling tey, rachel c brown, andrew r gray, alexandra w chisholm, conor m delahunty. long-term consumption of high energy-dense snack foods on sensoryspecific satiety and intake. am j clin nutr 2012;95:1038–47. ____________________________________________________________________________ raport hyska j, mersini e, mone, i, bushi e, sadiku e, hoti k, bregu a. assessment of knowledge, attitudes and practices about public health nutrition among students of the university of medicine in tirana, albania (original research). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-01. 1 original research assessment of knowledge, attitudes and practices about public health nutrition among students of the university of medicine in tirana, albania jolanda hyska1,2, ehadu mersini1, iris mone2, entela bushi1, edite sadiku2, kliti hoti2, arjan bregu1 1 institute of public health, tirana, albania; 2 university of medicine, tirana, albania. corresponding author: jolanda hyska, md, phd, institute of public health; address: rr. “aleksander moisiu”, no. 88, tirana, albania; telephone: +355672052972; email: lhyska@yahoo.it hyska j, mersini e, mone, i, bushi e, sadiku e, hoti k, bregu a. assessment of knowledge, attitudes and practices about public health nutrition among students of the university of medicine in tirana, albania (original research). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-01. 2 abstract aim: the aim of this survey was twofold: (i): to assess medical students’ knowledge, attitudes and practices regarding nutrition in general, in order to identify their level of competences in the field of nutrition which will be useful in their future role of providers/health care professionals, and; (ii) to assess the knowledge, attitudes and practices regarding the discipline of public health nutrition in order to identify the needs for improving the curriculum of this subject in all the branches of the university of medicine in tirana. methods: a cross-sectional study was conducted in june-july 2013 including a representative sample of 347 students at the university of medicine in tirana, albania (61% females and 39% males; overall mean age: 23±2 years; response rate: 87%). a nutritional questionnaire, adopted according to the models used in previous international studies, was used to assess the level of knowledge, attitudes and practices among the university students. results: overall, about one third of the students was not satisfied with the quality and quantity of nutritional education and demanded a more scientifically rigorous curriculum. in general, students’ knowledge about infant feeding practices was adequate. however, there were gaps in the students’ knowledge regarding the commencement of breastfeeding, or the duration of exclusive breast-feeding. furthermore, there was evidence of an insufficient level of knowledge among students regarding diet and nutrition in general and their health impact, especially on development and prevention of chronic diseases. conclusion: this survey identified significant gaps in the current curriculum of public health nutrition at the university of medicine in tirana. our findings suggest the need for intervention programs to improve both the quantitative and the qualitative aspects of nutrition curricula in all the branches of the university of medicine tirana, in accordance with the professional expectations of this teaching institution, as well as the urge for a movement towards a more integrated curriculum and problem-based learning approach. keywords: albania, diet, knowledge, nutrition, students, university of medicine. hyska j, mersini e, mone, i, bushi e, sadiku e, hoti k, bregu a. assessment of knowledge, attitudes and practices about public health nutrition among students of the university of medicine in tirana, albania (original research). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-01. 3 introduction it is argued that the amount of nutritional education in the teaching curricula of different medical schools remains inadequate and does not meet the needs of this important area of health sciences (1,2). hence, many studies show that family physicians generally have little training in nutrition (3-5). furthermore, several studies have shown that the vast majority of medical students and incoming interns are dissatisfied with their education in medical nutrition and feel unprepared to counsel patients on nutritional topics (6-8). therefore, it is largely recognized that there is a critical need for improvements of teaching programs related to nutrition in medical schools and public health schools along with an increased education of the general population at large (9-11). public health nutrition is a discipline introduced already in all branches of the university of medicine in tirana, the albanian capital. however, there is no scientific evidence regarding the level of attitudes and knowledge in this field among the students at all levels and branches of this teaching institution in tirana, which is the only medical university in albania. in this context, the aim of this survey was twofold: (i): to assess medical students’ knowledge, attitudes and practices regarding nutrition in general, in order to identify their level of competences in the field of nutrition which will be useful in their future role of providers/health care professionals, and; (ii) to assess the knowledge, attitudes and practices regarding the discipline of public health nutrition in order to identify the needs for improving the curriculum of this subject in all the branches of the university of medicine in tirana. methods a cross-sectional study was conducted in june-july 2013 including a representative sample of 347 students at the university of medicine in tirana, the capital of albania. study population the study population consisted of a simple random sample of 347 students (out of 400 invited; response rate: 86.7%) of the university of medicine in tirana pertinent to the following branches: medicine (26.8%), nursing (32.9%), pharmacy (21.9%) and dentistry (18.4%). the sampling frame consisted of a list of all students who had undertaken a course on public health nutrition (280 medical students; 110 dentistry students; 108 pharmacy students; 312 nursing students). the response rate was somehow lower among the medical students (81.5%) compared with students from the other branches. on the other hand, the overall response rate was similar among male and female students. data collection a nutritional questionnaire, adopted according to the models used in previous international studies, was used to assess the level of knowledge, attitudes and practices among the university students. the first part of the questionnaire concerned the attitudes of the students about nutritional education in their respective faculties/schools. the attitudes were measured by means of an indicative scale from 1 to 5 regarding students’ concordance with several statements (1= strongly disagree; 5= strongly agree) (7). the second part of the questionnaire concerned the level of knowledge of the students about nutrition in general (4,5). hyska j, mersini e, mone, i, bushi e, sadiku e, hoti k, bregu a. assessment of knowledge, attitudes and practices about public health nutrition among students of the university of medicine in tirana, albania (original research). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-01. 4 data analysis spss (statistical package for social sciences) version 19.0 was used for data analysis. data were presented as frequency tables (for categorical variables) and as measures of central tendency (mean scores) [for numerical variables]. results overall, the survey sample included 136 (39.2%) male students and 211 (60.8%) female students (overall mean age: 22.8±2.1 years). students’ attitudes about their education in the discipline of nutrition overall, the students were somewhat satisfied with the quantity (mean score: 3.3; range from 1 [lowest] to 5 [highest]) and quality (mean score: 3.2) of the nutritional education in the course of their studies (table 1). students reported that more time should have been dedicated to the topic of nutrition at the university of medicine in tirana (overall mean score: 3.5), especially including more material relevant to the personal health and wellbeing (mean score: 3.8). conversely, students were quite neutral regarding the scientific rigor of the teaching curriculum (overall mean score: 2.9). table 1. students’ attitudes about their education in the discipline of nutrition students’ attitudes total (n=347) medicine (n=93) dentistry (n=64) pharmacy (n=76) nursing (n=114) i am satisfied with the quantity of my nutrition education. 3.26 2.69 2.81 3.47 3.83 i am satisfied with the quality of my nutrition education. 3.18 2.71 2.84 3.22 3.71 my medical school nutrition curriculum should have had more time specifically dedicated to the topic of nutrition (independent of organ system-based studies). 3.46 3.67 3.42 3.70 3.17 my medical school nutrition curriculum should have had more nutrition content formally integrated into the organ system-based courses. 3.38 3.91 3.36 3.21 3.07 my medical school nutrition curriculum should have included more online materials available for independent study. 2.90 3.32 2.52 3.05 2.67 my medical school nutrition curriculum should have included more material relevant to my personal health and wellbeing. 3.80 4.31 3.81 3.37 3.68 my medical school nutrition curriculum should have been more scientifically rigorous. 2.89 3.32 3.39 2.58 2.46 students of the faculty of medicine were the most unsatisfied group with regard to the quantity (mean score: 2.7) and quality (mean score: 2.7) of the information obtained in the nutrition course, considering that: • more time should be dedicated to the topic of nutrition in the course of their studies (mean score: 3.7); • more nutrition content should be formally integrated into the organ system-based courses (mean score: 3.9); • the curriculum should include more material relevant to personal health and well-being (4.3); hyska j, mersini e, mone, i, bushi e, sadiku e, hoti k, bregu a. assessment of knowledge, attitudes and practices about public health nutrition among students of the university of medicine in tirana, albania (original research). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-01. 5 • in addition, medical students felt that the teaching curriculum should be more scientifically rigorous (mean score: 3.3) [table 1]. however, almost similar attitudes were encountered among the students of the faculty of dentistry, but their mean scores were slightly higher compared to the students of the faculty of medicine. unlike the students of the faculty of medicine and dentistry, students of the faculty of pharmacy appeared to be more satisfied with the quantity (mean score: 3.5) and the quality (mean score: 3.2) of the nutritional education; nonetheless, they considered that more time should be dedicated to the topic of nutrition in the course curriculum (mean score: 3.7), but were generally satisfied regarding the scientific rigor of nutrition curriculum (mean score: 2.6). conversely, students of the faculty of nursing were the most satisfied group with regard to the quantity (mean score: 3.8) and quality (mean score: 3.7) of the nutritional education in their branch. their most obvious demand, however, was that more material relevant to personal health and wellbeing should be included in the teaching curriculum (mean score: 3.7) [table 1]. overall, about one third of the students was not satisfied with the quality and quantity of nutritional education and demanded a more scientifically rigorous curriculum. three out of four students demanded a more practical and useful curriculum regarding personal health and well-being; more than half of the students demanded an integrated curriculum into the organ system-based; and half of the students suggested that more time should be dedicated to the teaching curriculum independent of organ system-based studies (table 1). students’ knowledge about infant feeding practices overall, the level of students’ knowledge about infant feeding practices was satisfactory, as the percentage of correct answers for every question was in the range from 70%-92% (table 2). table 2. students’ knowledge on infant feeding practices item correct wrong don’t know according to who, the optimal duration for breastfeeding an infant is a minimum of twelve months. 71.8% 21.3% 6.9% infant formula contains all ingredients found in human breast milk. 1.4% 97.1% 1.4% infants consuming breast milk have fewer ear infections than infants consuming formula. 91.9% 4.6% 3.5% the percentage of wrong answers was higher among the students of the faculty of pharmacy, followed by the students of the faculty of dentistry (29.7% and 7.8% respectively). about 82% of the students knew “the most appropriate age to introduce other foods in the infant’s diet”, whereas one out of three students of the faculty of dentistry gave a wrong answer (data not shown). regarding the “commencement of breastfeeding”, 70% of the students did not know the recommended initiation of breastfeeding, which was especially apparent for students of the faculty of nursing and medicine (80% and 76%, respectively), although the nutrition curriculum of these two faculties regarding infant feeding practices is much more expanded than the other two faculties (data not shown in the tables). most of the students (about 77%) stated that exclusive breast feeding is important because “breast milk is the ideal food”, 10% of the students considered that “breastfeeding creates a hyska j, mersini e, mone, i, bushi e, sadiku e, hoti k, bregu a. assessment of knowledge, attitudes and practices about public health nutrition among students of the university of medicine in tirana, albania (original research). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-01. 6 physical/spiritual bond between mother and baby”, and 9% of the students believed that “breastfeeding protects the mother from pregnancy”. regarding the duration of exclusive breastfeeding, the opinion of the students was divided between the period of 6-9 months, and only 1.3% of the students considered that “breastfeeding should not be extended more than 1 month” (not shown). students’ knowledge on the health impact of diet and nutrients regarding the questions that aimed at assessing the students’ general knowledge about the health impact of diet and nutrients, students of the faculty of medicine, generally, exhibited the highest level of knowledge compared to the other branches (table 3). especially, medical students reported correctly on the following: “the nutrient that helps prevent thrombosis” (100%); “the nutrient closely related to the prevention of neural tube defects” (97%); “zinc is not an antioxidant” (87%); and “potassium has protective effect against hypertension” (75%). however, none of them knew that “excess proteins promote loss of ca”; “albanians are advised not to consume more than 30% fat” (8%); and “fruits and vegetables have a preventive role in the development of some types of cancer” (10%) [table 3]. table 3. students’ knowledge about diet and health item total* medicine* dentistry* pharmacy* nursing* a nutrient believed to help prevent thrombosis is: omega-3 fat 100 28.1 50 28.9 excess of which nutrient may increase body calcium loss? proteins 0 4.7 7.9 14 what is the type of dietary fiber helpful in lowering the blood cholesterol level? soluble fiber 67.7 42.2 28.9 15.8 the major type of fat in olive oil: monounsaturated fat 54.8 31.2 22.4 16.7 compared with unprocessed vegetable oil, hydrogenated fats contain: more trans fats 37.6 9.4 42.1 16.7 the nutrient is protective against hypertension potassium 75.3 14.1 44.7 45.6 if a person habitually consumes 10 tablets a day of vitamin mineral supplements, which nutrient is least likely to cause toxicity vitamin e 66.7 21.9 39.5 24.6 the most concentrated source of vitamin b12 is meat 43 6.2 18.4 31.6 which substance raises the blood hdlcholesterol level alcohol 41.9 9.4 17.1 22.8 nutrition recommendations for albanian recommends that the diet should contain the following percentage of energy as fat under 30% of daily energy 7.5 9.4 25 21.9 nutritional recommendations for albanian recommends that the diet should contain the following type and percentage of salt no more than 6 g iodized salt 44.1 3.1 19.7 37.7 a type of food believed to have a preventive effect on varioustypes of cancer is fruits and vegetables 9.7 34.4 57.9 41.2 the number of kilocalories in one gram of fat is 9 kkal 100 96.9 96.1 94.7 which of the following is not an antioxidant nutrient zinc 86 46.9 80.3 48.2 the nutrient strongly associated with the prevention of neural tube defects is folate 96.8 73.4 77.6 71.1 * percentages of correct answers. hyska j, mersini e, mone, i, bushi e, sadiku e, hoti k, bregu a. assessment of knowledge, attitudes and practices about public health nutrition among students of the university of medicine in tirana, albania (original research). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-01. 7 discussion our findings indicate that students of the university of medicine in tirana are not sufficiently satisfied with the quantity and quality of the knowledge obtained on public health nutrition, demanding more time to be dedicated to the topic of nutrition in the undergraduate curriculum including especially more material relevant to personal health and wellbeing. such requirements and demands were more pronounced among students of the faculty of medicine and dentistry. students’ knowledge about infant feeding practices were relatively satisfactory among the students of the faculty of medicine, and less so among students of the other faculties. however, there were also apparent gaps in the knowledge of medical students regarding the commencement of breastfeeding, or the duration of exclusive breastfeeding. our findings in this regard are compatible with previous reports from studies conducted elsewhere (12-14). regarding students’ general knowledge about diet and its impact on the development or prevention and treatment of diseases, especially of chronic diseases, it was often encountered an overrated concept about the role/influence of the dietary fat and individual health, suggesting insufficient knowledge among students regarding the specific role and impact of carbohydrates and proteins. similar findings have been previously reported in the uk (13,14), canada (15,16) and the usa (17). on the other hand, students included in the current survey did not have updated information regarding the “albanian recommendations for a healthy nutrition”, which points to the need for case-based teaching, and updated scientific rigor. overall, the current survey identified gaps in the current curriculum of public health nutrition which suggests the need for appropriate changes and amendments to the curriculum in all the branches of the university of medicine in tirana (general medicine, public health, nursing, pharmacy and dentistry). from this perspective, our study provides useful baseline information which should be eventually used to close the knowledge and competence gaps in the current teaching and training programs offered by the university of medicine in tirana. in addition, the assessment of knowledge, attitudes and practices of the students on nutritional aspects in general is a basic precondition for understanding their competences and roles as future health care providers and health professionals, hence, evaluating healthy nutrition as an important element in the prevention and treatment of a number of non-communicable diseases which are currently highly prevalent in albania (5,18). from this point of view, our study makes a useful contribution in the albanian context. in conclusion, our study suggests the need for intervention programs to improve both the quantitative and the qualitative aspects of nutrition curricula in all the branches of the university of medicine tirana, in accordance with the professional expectations of this teaching institution, as well as the urge for a movement towards a more integrated curriculum and problem-based learning approach. acknowledgements this survey was supported by the world health organization (tirana office and the office for europe) in the framework of the joint program of nutrition “reducing malnutrition among children”, funded by the spanish millennium development goals. conflicts of interest: none declared. references 1. adams km, kohlmeier m, zeisel sh. nutrition education in u.s. medical schools: latest update of a national survey. acad med 2010;85:1537-42. hyska j, mersini e, mone, i, bushi e, sadiku e, hoti k, bregu a. assessment of knowledge, attitudes and practices about public health nutrition among students of the university of medicine in tirana, albania (original research). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-01. 8 2. torti fm, adams km, edwards lj, lindell kc, zeisel sh. survey of nutrition education in u.s. medical schools – an instructor-based analysis. med educ online 2001;6:8. 3. vetter ml, herring sj, sood m, shah nr, kalet al. what do resident physicians know about nutrition? an evaluation of attitudes, self-perceived proficiency and knowledge. j am coll nutr 2008;27:287-98. 4. temple nj. survey of nutrition knowledge of canadian physicians. athabasca university, alberta, canada. j am coll nutr 1999;18:26-9. 5. hyska j, bushi e, luzati a, bizhga j. nutritional knowledge of primary care physicians in tirana, albania. medicus 2012; vol xvii:200-206. available from: http://www.medalb.com/gazeta/medicus17.pdf (accessed: january 05, 2014). 6. spencer eh, frank e, elon lk, hertzberg vs, serdula mk, galuska da. predictors of nutrition counseling behaviors and attitudes in us medical students. am j clin nutr 2006;84:655-62. 7. walsh co, ziniel si, delichatsios hk, ludwig ds. nutrition attitudes and knowledge in medical students after completion of an integrated nutrition curriculum compared to a dedicated nutrition curriculum: a quasi-experimental study. bmc med educ 2011;11:58. doi: 10.1186/1472-6920-11-58. 8. weinsier rl, boker jr, feldman eb, read ms, brooks cm. nutrition knowledge of senior medical students: a collaborative study of southeastern medical schools. am j clin nutr 1986;43:959-68. 9. makowske m, feinman rd. nutrition education: a questionnaire for assessment and teaching. nutr j 2005;4:2. doi: 10.1186/1475-2891-4-2. 10. cooksey k, kohlmeier m, plaisted c, adams k, zeisel sh. getting nutrition education into medical schools: a computer-based approach. am j clin nutr 2000;72(3 suppl):868s-876s. 11. lo c. integrating nutrition as a theme throughout the medical school curriculum. am j clin nutr 2000;72(3 suppl):882s-889s. 12. ray s, udumyan r, rajput-ray m, thompson b, lodge km, douglas p, et al. evaluation of a novel nutrition education intervention for medical students from across england. bmj open 2012;2:e000417. doi: 10.1136/bmjopen-2011-000417. 13. kafatos a. is clinical nutrition teaching needed in medical schools? ann nutr metab 2009;54:129-30. 14. nightingale jm, reeves j. knowledge about the assessment and management of undernutrition: a pilot questionnaire in a uk teaching hospital. clin nutr 1999;18:23-7. 15. adams km, kohlmeier m, powell m, et al. invited review: nutrition in medicine: nutrition education for medical students and residents. nutr clin pract 2010;25:471-80. 16. collier r. canadian medical students want more nutrition instruction. cmaj 2009;181:133-4. 17. frantz dj, munroe c, mcclave sa, et al. current perception of nutrition education in u.s. medical schools. curr gastroenterol rep 2011;13:4. 18. burazeri g, kark jd. hostility and acute coronary syndrome in a transitional postcommunist muslim country: a population-based study in tirana, albania. eur j public health 2011;21:469-76. ___________________________________________________________ © 2014 hyska et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed/10067655 http://www.medalb.com/gazeta/medicus17.pdf http://www.ncbi.nlm.nih.gov/pubmed?term=ray%20s%5bauthor%5d&cauthor=true&cauthor_uid=22327628 http://www.ncbi.nlm.nih.gov/pubmed?term=udumyan%20r%5bauthor%5d&cauthor=true&cauthor_uid=22327628 http://www.ncbi.nlm.nih.gov/pubmed?term=rajput-ray%20m%5bauthor%5d&cauthor=true&cauthor_uid=22327628 http://www.ncbi.nlm.nih.gov/pubmed?term=thompson%20b%5bauthor%5d&cauthor=true&cauthor_uid=22327628 http://www.ncbi.nlm.nih.gov/pubmed?term=lodge%20km%5bauthor%5d&cauthor=true&cauthor_uid=22327628 http://www.ncbi.nlm.nih.gov/pubmed?term=douglas%20p%5bauthor%5d&cauthor=true&cauthor_uid=22327628 http://www.ncbi.nlm.nih.gov/pubmed/?term=sumantra+ray%2c+ruzan+udumyan%2c+minha+rajput-ray%2c+ben+thompson http://www.nutritionj.com/sfx_links?ui=1475-2891-4-2&bibl=b1� http://www.biomedcentral.com/sfx_links?ui=1472-6920-11-58&bibl=b14� http://www.biomedcentral.com/sfx_links?ui=1472-6920-11-58&bibl=b13� http://www.nutritionj.com/sfx_links?ui=1475-2891-4-2&bibl=b2� bozikov j. european and north american schools of public health – establishment, growth, differences and similarities (editorial). seejph 2016, posted: 03 june 2016. doi : 10.4119/unibi/seejph-2016-119 1 review article european and north american schools of public health – establishment, growth, differences and similarities jadranka bozikov 1 1 andrija stampar school of public health, school of medicine, university of zagreb, zagreb, croatia. corresponding author: jadranka bozikov, phd address: andrija stampar school of public health, rockefeller st. 4, zagreb, croatia; telephone: +38514590101; e-mail: jbozikov@snz.hr conflicts of interest: none. acknowledgements: the author is grateful to the editor prof. ulrich laaser for the encouragement and corrections. mailto:jbozikov@snz.hr bozikov j. european and north american schools of public health – establishment, growth, differences and similarities (editorial). seejph 2016, posted: 03 june 2016. doi : 10.4119/unibi/seejph-2016-119 2 abstract unlike european schools of public health, whose development was primarily influenced by the medical profession and was linked to the healthcare system, north american schools of public health operate as independent academic institutions engaged in research and education of public health specialists. while public health has been recognised as a distinctive profession in usa and canada for almost a century, in many european countries it is not recognized as such and, accordingly, there are no well-defined job positions for graduates. similarities and differences between the european and american schools of public health are reviewed and the importance of classification of core competences, responsibilities and scope of knowledge required for public health practice was pointed out as a prerequisite for accreditation of study curricula. for the professionalization of public health in europe further efforts are needed. keywords: competency-based education, public health, public health students, schools of public health. bozikov j. european and north american schools of public health – establishment, growth, differences and similarities (editorial). seejph 2016, posted: 03 june 2016. doi : 10.4119/unibi/seejph-2016-119 3 origins of the schools of public health schools of public health (sphs) operate either as independent institutions or as constituents of academic institutions, and vary widely in their foundation patterns, in particular if comparing north american sphs against those established in great britain and europe. the eldest institutions of this kind, those established in great britain, have evolved from various charity organisations primarily founded for provision of healthcare to seafarers and ship crews affected by numerous communicable diseases, in particular those contracted in the tropics. these institutions began to offer systematic education of healthcare professionals (mainly those willing to practice overseas), while the research conducted under their roofs was primarily focused on the pathology of tropical diseases. the london school of hygiene and tropical medicine (lshtm) and the liverpool school of tropical medicine (lstm), both founded at the very end of 19 th century (in 1899 and 1898, respectively), were not only the oldest schools of tropical medicine in the world but also leading institutions of this kind until today, well-known due to their educational excellence and scientific breakthroughs (1,2). however, the european continent accommodated only a few sphs prior to the world war two and two types of sphs have profiled – those operating under the wings of the ministries of health that are actually the constituents of public (state-governed) healthcare system involved in public health (health-related) research and education, and those operating under the wings of medical schools/universities (as their constituents or departments like for instance, department of hygiene or social medicine department or, more recently, public health or healthcare management departments, as typical examples). regardless of their status (healthcare facility, or an academic institution or department), the european sphs were dominated by medical profession from the very start, gradually also affiliating experts of other backgrounds as necessary due to the multidisciplinary nature of public health. as opposed to that, the north american model of public health education is unique due to the fact that american sphs operate independently from the healthcare system. namely, in the times of rapid industrialisation and urban growth, witnessed in the second half of the 19 th century when numerous cities were afflicted with major disease outbreaks including cholera and typhoid, city health offices or, more precisely, utility and healthcare services, were established across the us, especially in cities where, among other things, clean water supply and drainage systems of indisputable importance for the prevention of communicable diseases were established. however, this course of events facilitated the struggle for supremacy between experts of medical and non-medical profile. it is astonishing that the american public health association, established in new york by a small group of enthusiasts, was founded as early as in 1872. within this context, the key role was played by the rockefeller foundation under which the rockefeller sanitary commission for the eradication of hookworm disease started to operate as early as in 1909. the commission was established owing to the initial one million-donation and was led by wickliffe rose, a professor of history and philosophy (3). the famous flexner report released in 1910 served as the basis for the substantial reform of medical education, resulting in the cessation of operation of numerous schools of medicine in the usa and canada and the improved quality of medical tuition (4). the report set new, higher medical education standards. about the same time, in october 1914, the education board of the rockefeller foundation organised the new york conference, which further propelled the discussion on, and contributed to, the defining of tasks, responsibilities and scopes of knowledge and expertise required for public health practice. the initial ideas were further elaborated by william welch and wickliffe rose, the authors of the famous welch bozikov j. european and north american schools of public health – establishment, growth, differences and similarities (editorial). seejph 2016, posted: 03 june 2016. doi : 10.4119/unibi/seejph-2016-119 4 rose report, actually compiled in two versions and released in 1915 (5). the report became the symbol and the blueprint of evidence-based education underpinning the new profession that requires well-defined competencies. growth of sphs and their associations public health as a distinctive profession and the first sphs, operating as independent academic institutions (optionally, but not necessarily, under the wings of the universities) were established across the us, a number of them thereby being supported by the rockefeller foundation. w. welch was elected the first dean of the renowned johns hopkins school of public health (originally named the johns hopkins school of hygiene and public health, established in 1916). this school served as the model institution and several sphs were established soon after under the wings of the columbia, harvard, yale and other universities. welch was already well-known as one of the “big four” founding professors at the johns hopkins hospital established earlier (in 1889) and also the first dean of its affiliated johns hopkins school of medicine (he was pathologist and bacteriologist) (6). in 1953, the us sphs united into an organisation named the association of schools of public health (asph), currently joined by approximately 50 members and referred to as the association of schools and programs of public health (aspph). before the world war two, the “old continent” accommodated only a few sphs (excluding the institutes of hygiene that were founded in european capitals already in the 19 th and at the beginning of the 20 th century as health administrative, but not academic institutions, although often involved in teaching). one of the first schools of this kind that followed into the footsteps of the lshtm and the lstm was the school of public health in zagreb, ceremonially opened on october 3 rd , 1927. the credit for this development goes to dr andrija stampar and the rockefeller foundation that granted funds for the construction and equipping of the school’s building. in the subsequent course, the national school of public health was established in athens in 1929, followed by the ankara school of public health, founded in 1936. contrary to the american model of education, until late 1960s, in the majority of european countries one could opt for public health as a narrow field of expertise only as medical specialization although there were models of postgraduate programmes tailored for experts of various background, both medical and non-medical, mainly those already engaged in the health segment, the showcases hereby being the andrija stampar school of public health in zagreb and ehesp school of public health in rennes (today’s ehesp école des hautes études en santé publique was established in 1945 by the french government under the name ensp école des hautes études en santé publique). since, and especially after 1990s, new sphs were established either as independent high schools or faculties under the wings of universities offering professional (mainly master and post-master) degrees in health sciences (showcase is the faculty of health sciences, university of bielefeld, germany). the association of european sphs was established in 1966 in response to the initiative of who regional office for europe. the association was first given the french name and acronym airesspe – association des institutions responsables d’un enseignement supérieur en santépublique et des écoles de sp en europe, which was later changed into aspher association of schools of public health in the european region. aspher has tripled its membership during 50 years of continuing growth, which is described in more detail in this issue of seejph (7). bozikov j. european and north american schools of public health – establishment, growth, differences and similarities (editorial). seejph 2016, posted: 03 june 2016. doi : 10.4119/unibi/seejph-2016-119 5 upon the implementation of the bologna process, a number of european countries have virtually been flooded with undergraduate and graduate public health study programmes proposed and introduced, but regrettably often lacking clearly defined competencies and, unlike the us, clearly defined labour market prospects and career advancement paths. bottom-line, for almost a century, public health has been recognised as a distinctive profession both by the us and canada, a great importance thereby being given to the accreditation of the study curricula. aspph membership is allowed only to the institutions of merit, which have satisfied stringent accreditation criteria. however, it should be pointed out that aspph can be joined only by institutions that have passed the accreditation procedure entrusted with the special agency operating under the wing of the council on education of public health (the ceph), while schools having their study curricula not yet accredited may join the association only as associated members, provided that the accreditation procedure is already set in motion. from the past to the present developments one of the founding fathers of the european union, jean monnet has stated that: “nothing is possible without man, nothing is sustainable without institutions”. associations of sphs, established in europe and north america long time ago were drivers for promotion of public health education, research and service and, warranty, of high quality educational standards. aspher celebrates its half a century-long establishment in 2016. the association primarily embraces schools or departments of public health established in countries belonging to the who-euro, and has only recently opened to associated members beyond the european region. aspher membership reached 110 members in terms of schools or departments of public health established in 43 countries of the who european region, spanning from iceland to the west to kazakhstan to the east, and from norway to the north to israel to the south. on top of that, some of the schools from other continents (australia, canada, mexico, lebanon and syria) are affiliated with the association as associated members (8). aspher became a respectable european organisation in public health workforce development and collaborates with who as well as with other european and international organizations and associations such as the european public health association (eupha), the world federation of public health associations (wfpha), the european public health alliance (epha), the european health management association (ehma), the eurohealthnet (ehn) and many others. despite different patterns of establishment, sphs from both sides of the atlantic ocean have currently a lot in common; one can say they are converging having in mind that sphs in europe are currently academic institutions with multi-professional faculty. many new sphs were established after 1990 in central and eastern european (cee) countries, as well as in the newly independent states formed after dissolution of ussr. besides education and training of health professionals, sphs have the mission to inform and support the planning, development and evaluation of public health interventions, programmes and policies coming from both, governmental and non-governmental sector. in 1995, evelyne de leeuw, at that time secretary-general of apsher, published an excellent article in the lancet based on a survey performed three years earlier encompassing 54 sphs in europe in which she labelled eight types of sphs (9). two types were found to be most common in cee countries: (i) sph within medical university, and; (ii) sph which is a branch of the ministry of health (moh), while other types were more typical for western europe: (iii) sph within medical school; (iv) university (multi-school) based programme bozikov j. european and north american schools of public health – establishment, growth, differences and similarities (editorial). seejph 2016, posted: 03 june 2016. doi : 10.4119/unibi/seejph-2016-119 designated by moh, and; (v) an independent research and training institution within the university (what is in fact an equivalent of the accredited sph in us). some sphs in cee countries, particularly the newly establishing ones, were in transition towards the last type (us-type sph). it seemed that the european scene of public health education had been changing but cee countries showed to be polarized: in some countries us-type sphs had been established, whereas in the others even the new initiatives were based at the training under the umbrella of mohs, likely due to historical reasons as it was stated in the conclusion (9). twenty years later, the situation is very much the same and public health as a profession is still struggling for recognition not only in cee countries, but also in some western european countries. besides the need for integration of academic and field activities already in the educational environment, i.e. establishment of us-like academic institutions granting bachelor and/or master degrees and not only postgraduate ones, another issue is essential: availability of well-defined jobs for graduates. in many european countries, both in western and eastern europe, it is difficult to change patterns according to which job posts are defined and made available. that is why in some countries (e.g., in albania), newly established higher education programmes in public health were abolished due to non-employability of graduates, while in others after many years of successful training within a common postgraduate msc study programme in public health and epidemiology that was open to multi-professional student body (e.g., to candidates with medical as well as different non medical background), separated programmes have been currently introduced (e.g., in croatia): public health medicine as mandatory part of medical specialization (i.e. for mds only) and specialized postgraduate programme in public health designed for other professionals, mainly those already employed in the health sector or engaged in governmental or local authorities or ngos. this programme started at the andrija stampar school of public health already in 1947 followed by the opening of similar programmes in other public health disciplines: occupational medicine in 1949, mother and child care in 1953, environmental health in 1954, school medicine and hygiene in 1955, sports medicine in 1965, and two programmes started in 1984 (gerontology and medical informatics). besides these postgraduate study programmes that led to msc degree, there were two other tracks opened to mds only (family medicine introduced in 1960 and medical microbiology introduced in 1961). while some of the mentioned programmes were designed as a mandatory part of medical specialist training and enrolled exclusively mds, some others used to mix students of different backgrounds or had two or more tracks (e.g. public health and epidemiology, school medicine and hygiene, environmental health, sports medicine) and students had the option to write a thesis and earn an msc degree or to complete only the study and exams as mandatory part of medical specialization. the last two programmes were aimed for a mixed student body. all mentioned programmes were terminated in 1998 while since than there are no msc programmes anymore in croatia and two types of postgraduate programmes were put in place instead: phd study programmes as the third cycle of higher education and postgraduate specialized programmes. the later programmes are designed either as part of organized education within medical specializations or for other professionals (market-oriented) looking for expertize in a narrow field and mag. univ. degree. in many european countries, public health professionals are still trained at postgraduate level only in schools or departments of public health located within medical school/university, in educational structures of type 1 or 2 described in (9). in some other countries professionals of different backgrounds (e.g. lawyers, social workers or economists) are undergoing training in public health in institutions under the responsibility and management 6 bozikov j. european and north american schools of public health – establishment, growth, differences and similarities (editorial). seejph 2016, posted: 03 june 2016. doi : 10.4119/unibi/seejph-2016-119 7 of national health authorities, i.e. in type 5 sphs according to the referred classification. the best examples for these two forms of postgraduate training institutions were until recently two of the aspher’s founding schools, andrija stampar school of public health belonging to the school of medicine university of zagreb and the french ensp in rennes that was transformed by the public health act in 2004 into ehesp in order to provide france with an outstanding, internationally recognized sph. besides many programmes leading to civil service executive degrees for students previously recruited by government departments or local authorities as well as professional development programmes, the school offers a full range of programmes leading to academic degrees covering all three cycles (bachelor, master and phd) for international students (10). there is evidence that it is possible to build educational structures for education and training of master level public health professionals but they are not sustainable without the changes of labour market. it seems that unlike the west of europe, its east still lacks well-defined job posts for public health graduates unless they have another previously acquired “traditional” qualification. there are even worse examples: more than ten years after the majority of higher education programmes were split into two cycles (bachelor and master) with the bologna reform of higher education in croatia, we are still lacking job positions for those with bachelor degrees and more than 90% of them are continuing their studies for master degree in the same field. moreover, not only that bologna reform seems to be unnecessary, but we are already witnessing demands and examples of a backward process at the university of zagreb: integration of two cycles split previously at the time of bologna process “passion”. bottom-line, well-defined qualification standards linked to well-defined learning outcomes within the national qualification frameworks and in accordance with the european qualification framework are prerequisites for the creation of jobs, but the policy makers should take into account that changes in job definitions should be made and the labour market must be prepared in order to ensure employability of graduates. this is a necessary prerequisite for sustainability of higher education programmes but also could give an impetus to the professionalization of public health and further advancement of public health education, training, and practice. in previous issues of this journal current state of public health profession has already been described by czabanowska et al. (11) followed by an excellent apology towards formulation of a code of conduct for the european public health profession formulated by laaser and schröder-bäck (12). there are no contradictions in the fact that the profession includes, besides those graduated in public health, also members of different other professions – which also have their own values and conducts. in addition to the adherence to ethical principles of public health practice like the ones proposed by the american public health leadership society already in 2002, the european added dimension and values need to be included and obeyed such as solidarity, equity, efficiency and respect for autonomy. the way towards the european treasury of public health competences/operations and accreditation criteria the consensus on core competency model for master’s degree in public health was reached within the aspph at the beginning of the 21 st century (13). on the other side of the atlantic ocean, similar efforts were already under way. in cooperation with the open society institute (osi) public health program, apsher started a project entitled “quality development of public health teaching programmes in central and eastern europe” in the year 2000 aimed bozikov j. european and north american schools of public health – establishment, growth, differences and similarities (editorial). seejph 2016, posted: 03 june 2016. doi : 10.4119/unibi/seejph-2016-119 8 for the quality improvement of public health education in cee countries through review of their teaching programmes by the evaluators coming from the more developed european schools (14). results of this five-year project were already available and lessons learned when the programme targeted towards the european core competences started in the year 2006 and involved public health teachers, scientists and practitioners from aspher member schools in the discussion leading to the first and second list of competences (15,16). it was the base for further discussions taking into account different perspectives of teachers and practitioners, as well as the diversity of public health functions across europe and between different levels of education what resulted in the third edition of aspher’s list of competences in 2011 (17-20). finally, aspher’s lists of competences were widely recognized and endorsed as the basis for public health education by all european who member states at the regional committee for europe sixty-second session in september 2012 and included in the who european action plan for strengthening public heath capacities and services (21,22). moreover, in 2013, who europe delegated the responsibility to aspher for leading its working group concerning the assurance of a sufficient and competent public health workforce (essential public health operation [epho] no. 7). despite aspher’s and other institutions’ efforts, the educational capacity in the european region is still far from being sufficient if compared to aspired us levels (23). as public health opportunities and threats are increasingly global, higher education institutions in europe as well as in other regions have to look beyond national and even regional boundaries and participate in global networks for education, research and practice (24). aspher leaders planned and completed the survey aimed to assess the desired levels of performance by different categories of potential employers of graduates. compared to the ranking obtained from member schools, ranks were lower. it means that schools need to reconsider priorities and questions the competences’ level (i.e. learning outcomes) of their graduates in accordance with the expectations and needs of their potential employers (25). aspher made also efforts to establish criteria for accreditation of programmes in public health that ended in the establishment of the agency for public health education accreditation (aphea) launched in 2011 which has already accredited some aspher members (26,27). conclusions north american sphs operate as independent academic institutions engaged in research and education of public health specialists and public health has been recognised as a distinctive profession both by the us and canada for almost a century. in contrary, the development of the european sphs was primarily influenced by the medical profession and linked to the healthcare system. recent developments at both sides of the atlantic ocean seems to be converging towards an academic type of sph offering all three cycles of study programmes with a great importance given to the accreditation of the study curricula. the design/redesign of any study curriculum for education and training of professionals must be based on well-defined and work-related set of competences in accordance with the employers’ needs. the accreditation criteria for higher education programmes are carefully prepared and formal accreditation procedures exist not only at national, but also at international level. bozikov j. european and north american schools of public health – establishment, growth, differences and similarities (editorial). seejph 2016, posted: 03 june 2016. doi : 10.4119/unibi/seejph-2016-119 9 public health workforce in europe consists of members of different professions working under the same roof and accepting the public health professional identity by obeying not only common ethical values, but also the values determined by the european heritage. the code of conduct for the european public health profession must include european added values and is considered as an amalgam for the public health professionalization. references 1. london school of hygiene & tropical medicine. introducing our school. http://www.lshtm.ac.uk/aboutus/introducing/index.html (accessed: april 13, 2016). 2. liverpool school of tropical medicine. history. http://www.lstmed.ac.uk/about/history (accessed: april 13, 2016). 3. rockefeller foundation. 100 years of the rockefeller foundation. rockefeller 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health 2015;25:1112-6. © 2016 bozikov; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.aspher.org/european-public-healthhttp://www.euro.who.int/__data/assets/pdf_file/0005/171770/rc62wd12rev1-eng.pdf?ua=1 http://www.euro.who.int/__data/assets/pdf_file/0005/171770/rc62wd12rev1-eng.pdf?ua=1 http://aphea.net/ http://creativecommons.org/licenses/by/3.0) selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 1 original research discrimination of elderly patients in the health care system of lithuania kristina selli 1 , kasia czabanowska 2,3 , lina danusevičienė 1 , rūta butkevičienė 1 , ramunė jurkuvienė 1 , judy overall 4 1 faculty of public health, lithuanian university of health sciences, kaunas, lithuania; 2 department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 3 faculty of health sciences, jagiellonian university, krakow, poland; 4 fairbanks school of public health, indiana university, indianapolis, indiana, usa. corresponding author: assist. kristina selli, llm, department of health management, faculty of public health, lithuanian university of health sciences; address: a. mickevičiaus g. 9, kaunas, lt-44307, lithuania; telephone: +37067172620; e-mail: kristina.selli@gmail.com selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 2 abstract aim: this study aimed to explore and describe the barriers that elderly lithuanians experience with respect to going to court or other institutions to defend their right not to be discriminated regarding medical care. methods: we used a mixed methods approach due to the scarcity of information in lithuania. first, the review of laws was done using the e-tar database and court cases were searched using the e-teismai database followed by policy analysis. additional sources of information were identified searching google scholar and pubmed, as well as google for grey literature. the keywords used were: ageism in patient care, discrimination against elderly, elderly and health (english and lithuanian: 2000-2015). secondly, we conducted indepth individual interviews with 27 clients of newly-established integrated home care services: 13 elderly patients, and 14 informal caregivers. results: this study identified five groups of barriers explaining why lithuanian elderly are hesitant to fight discrimination in the health system. the results of the study disclose the following barriers that the elderly in lithuania face: i) the lack of recognition of the phenomenon of discrimination against the elderly in patient care; ii) the lack of information for complaining and the fear of consequences of complaining; iii) the deficiencies and uncertainties of laws and regulations devoted to discrimination; iv) the high level of burden of proof in court cases and lack of good practices; v) the lack of a patient (human) rightsbased approach in all policies and in education as well as the lack of intersectoral work. conclusions: this study disclosed the need to: encourage training of legists and lawyers in expanding knowledge and skills in human rights in patient care; encourage training of health care professionals – the burden of leadership for this has to be assumed by universities and public health professionals; incorporate a new article in the „law on the rights of patients and compensation for the damage to their health‟, clearly stating where to complain in case of discrimination; create a webpage and brochures with readable and understandable information for elderly persons and their families and caregivers; establish legal consultation and mediation cabinets in health care facilities; establish an older persons‟ rights protection service under the ministry of social security and labour in close cooperation with the ministry of health; promote sustainable results by incorporating a human rights-based approach regarding elderly persons in all policies. keywords: aging, discrimination against elderly patients, human rights, legislation, lithuania, patient care. acknowledgements the research was inspired by the scholars program of the association of schools of public health in the european region, human rights in patient care core network (aspher hrpc). the purpose of the scholars program is to foster research and publication on human rights in patient care (available at: http://cop.health-rights.org/scholars and http://eurpub.oxfordjournals.org/content/24/suppl_2/cku151.111). we thank prof. ulrich laaser, faculty of health sciences, bielefeld, germany, for the extensive support and careful editing. conflicts of interest: none. selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 3 introduction although ageism, i.e. stereotyping and discriminating against individuals or groups on the basis of their age, has been described already since 1969 by robert neil butler (1), it is still prevalent, and in some societies even growing (2). roots of ageism are gerontophobia and the fear of death, which are deeply embedded in people‟s minds. discrimination against the elderly exists in all spheres of life and in patient care as well (3,4). discrimination against the elderly in patient care combines two main actions: discriminating behaviour on the ground of a patient‟s age and the lack of „good behaviour‟ by someone who has a duty and responsibility for patients in the health context. this type of discriminating behaviour may occur when professional health care providers are not educated enough to question their own personal culture, views or attitudes (subjective causes), or when the state violates the legallyrecognized human rights principles by creating discriminatory policies. in one of the interviews, an over-80-year-old man said “it surprised me how children and young people show love and respect for the elderly in their family and yet disrespect and ignore the elderly outside” (5). this „outside‟ can be a hospital, hospice or elderly home or system of laws. french researchers herr et al. (6) disclosed that „socioeconomic position influenced the risk of having unmet health care needs, but the main risk factors identified were advanced age and homebound status.<...> the oldest-olds are the most affected by unmet health care needs‟. the united nations special rapporteur believes „…that the promotion and protection of human rights of older persons is not only in the interest of senior persons, but should also be of concern to everyone, because every person ages‟ (7). europe is aging and lithuania is aging twice as fast as europe on the whole (8). the main causes are low birth and high emigration rates of younger lithuanians. at the beginning of 2015, the population of lithuania was 2.9 million, including more than 650,000 (or 22.3%) of pension-age individuals (work according to a moving age-scale in 2015 ends at 61,4 years of age for women and 63,2 for men) (9). the elderly have become a significant part of society, but this does not mean in any way that they have become a privileged part of society. europe, including lithuania, has clear legal protection a convention for children (10), but does not have a convention for older persons. both are vulnerable groups and need more protection than the working age subgroup of the population. elderly are only covered indirectly, e.g. by the european charter of patients‟ rights (11), or the council of europe in its convention for the protection of human rights and dignity of the human being (12). policy makers do not seem to be very interested in an additional document specifying the elderly person‟s rights (13), but it is time to connect patient care and public health law with a human rights-based approach. according to gostin (14): “…public health law is the study of the legal powers and duties of the state, to assure the conditions for people to be healthy. the prime objective of public health law is to pursue the highest possible level of physical and mental health in the population, consistent with the values of social justice”. according to the eurobarometer survey, “discrimination eu 2012”, discrimination against old age and disability is very frequent in lithuania, respectively 59% and 45% percent (15). lithuanian research reveals a deep and ingrained discrimination in all fields of life, especially in the labour market (16). although discrimination of elderly occurs also in patient care in lithuania (17,18) there is lack of multi-facetted and comprehensive research showing how widespread the discrimination of elderly in fact is. discrimination in patient care in lithuania resembles the allegory about the three wise monkeys that hear, see, and speak no evil. but in real life an older person faces many discriminating phrases like: „what do you expect at your age?‟; „you don‟t need breast at your age‟; „come on, pensioners can wait‟…and „never tell the ambulance operator your real age, they will not hurry‟. given this situation, questions selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 4 remain as to why lithuanian elderly do not use institutions or courts to insist on their rights. after all, health issues are the most pertinent to survival. “ageist attitudes are not only hurtful; they are harmful<…> the fact is that older people get sick from disease, not old age‟ (19). „the right to health requires that facilities, goods, and services be available, accessible, acceptable, and of quality” (20). this is not only the question of a patient‟s right to health, but of the person‟s human rights per se. the research question has derived from the description of the situation in lithuania and the aim of the research was to identify the barriers preventing elderly patients from filing legal action against experienced discrimination which could be successful and, even more, would indicate the magnitude of the problem. methods in this study two main methods were employed. firstly, a review of the legislation using the e-tar database (21). court cases were searched employing the e-teismai database (22) followed by policy analysis. furthermore, google scholar and pubmed and, for grey literature, google were screened. the following key words and terms were used: „ageism in patient care‟, „discrimination against elderly‟, „elderly and health‟ (all in english and lithuanian: 2000-2015). secondly, in-depth individual interviews with elderly patients and their family members (informal care givers) were conducted to answer questions like: what is your current health care situation? what difficulties do you face concerning health care? what actions do you think you could take in order to change the situation and to receive proper medical care? the answers were analysed with the research focus on how discriminating behaviour towards elderly patients manifests in patients‟ everyday day life, and what do patients and their caregivers think of taking legal action to protect their rights of access to and receipt of proper medical care. the targeted sample of informants was the users of the newly-implemented integrated home care services from ten lithuanian municipalities (out of 21 municipalities where the services were started). the users were chosen according to their availability for an interview on the day that the interviewer was visiting the municipality. overall, 34 patients and their care-givers were visited, but seven patients were not interviewed because they were younger than 65 years. the final sample comprised 13 patients and 14 family members. the patients were present during the interview, but seven of them were not contributing significantly because of having difficulties to express their thoughts. all informants (including the family members) were older than 65 years. the elderly patients had chronic conditions and required long-term care around-the-clock. the informal caregivers were nine daughters or daughters-in-law, and five spouses (four wives and one husband). although the intention of interviewing family members was to hear about the person they take care of, the result always was that the carers additionally volunteered to provide information about their own experience in health care as patients. the interviews focused on informants‟ experiences, perceptions, and opinions concerning medical care services. all interviews were conducted by a team of authors (ld, rj, rb). the interviews took place in patients‟ homes and lasted 60-90 minutes each. all interviews were tape-recorded (audio) with the informants‟ consent, both the patient and the family member. all three interviewers/authors repeatedly read the material, selected, and coded the „meaning units‟ related to the manifestation of discriminating behaviour by health care providers and the opinions of taking legal action to protect the elderly persons‟ rights to proper medical care. the main categories were developed and reached by the team of authors after thorough discussion. selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 5 definitions: discrimination: i) the unjust or prejudicial treatment of different categories of people, especially on the grounds of race, age, or sex (23), or ii) any distinction, exclusion or preference that has the effect of nullifying or impairing equal enjoyment of rights (who) (24). the study was conducted in accordance with the declaration of helsinki (25). results examination of the lithuanian legal framework and the court practice and litigation procedure i) article 29 of the lithuanian constitution does not mention age specifically but is inclusive in regard to equality of all persons under the law and non-restriction of rights of human beings and contains a limited list of categories of persons whose rights cannot be restricted or to whom special privileges cannot be granted on specific grounds: “all persons shall be equal before the law, the court, and other state institutions and officials. the rights of the human being may not be restricted, nor may he be granted any privileges on the ground of gender, race, nationality, language, origin, social status, belief, convictions, or views” (26). ii) the main law, “law on the rights of patients and compensation for the damage to their health” (27), which describes different patient rights and establishes a particular institution to which to complain (article 23), does not mention any institution which has the authority to solve disputes regarding discrimination in lithuania. iii) the law, „law on equal treatment‟ (28), which sets up the categories of discrimination and empowers the ombudsperson to investigate alleged instances of discrimination, does not define describe discrimination in health care – whereas discrimination in the education system or labour marked is clearly mentioned. iv) regarding court practice and litigation procedure as of now (early 2016) there are no cases in the lithuanian supreme court and other courts‟ records. in 2015, lithuania still did not have an effective procedure or best practice in formulating court suits linked to discrimination of elderly persons in the delivery of patient care (29). it seems that the majority of lithuanian elderly do not use legal means. v) there is a lack of complaints in the office of the equal opportunities ombudsperson in spite of the provision 13 of the european charter of patients‟ rights is the „right to complain‟ (11). in lithuania, on 1 january 2005, a new law on equal treatment came into force, guaranteeing the right to file complaints to the equal opportunities ombudsman in cases of discrimination on grounds of age, sexual orientation, disability, race and ethnic origin, religion or beliefs (30). the ombudsman is a pre-litigation body in lithuania for discrimination cases. until now, the ombudsman service had only one case regarding age discrimination in health preventive programs (31). an analysis of the webpage of the ombudsman service revealed that almost all information, complaints and researches are devoted to age discrimination in the labour market. vi) in 2015, lithuania created an „inter-institutional operations plan for promotion of nondiscrimination‟ for the period 2015-2020, the main aim of which is to raise public awareness and foster respect for human beings. the plan recognized: “lithuanian public awareness is still too low, only a small proportion of the population knows where to go for fighting discrimination” (32). the same is demonstrated in our findings. in interviews, „i do not know what to do‟ was repeated in almost all conversations. furthermore, in the action plan there are lots of general and specific steps and recommendations to act in fighting age discrimination; but this does not ensure that educational activities will reach those persons selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 6 who discriminate against the elderly in patient care. this type of discrimination is not mentioned in the action plan, and among actors (implementing authorities) there is no inclusion of the ministry of health. implementing authorities are: ministry of social security and labor, ministry of education and science and ombudsman. vii) there is a lack of institutions and organizations that provide legal help for elderly persons in resolving disputes and defending their rights in health care facilities. we did not find elder law clinics or older persons‟ rights protection services. viii) there is a shortage of easy, understandable, and easily-obtainable information for elderly persons regarding their rights. we did not find web pages or specialized easily understandable, and obtainable information for elderly. to prove discrimination against elderly in legal cases is often challenging: a citation of the chief of the lithuanian supreme court in 2007 may serve: “there is no racial discrimination in lithuania, <…> there are some complaints for some not-equal treatment in other spheres, but then proceedings are completed and discrimination is not proven” (33). analysis of the interviews the initial idea of the study was to gather information from elderly patients who were most in need of care as they required long-term care around-the-clock. however, what the family members provided as their experience of taking care and of being patients themselves, broadened the scope of the study. thus, information about discrimination not only of the bedridden people, but also of healthier old people was gathered. in spite of all the interviewees reporting their experience as patients, the research team will further on call the two groups “patients” and “informal caregivers” according to their social roles. as concerns the discrimination because of age, there was no difference between the two groups found in what they were telling about themselves as patients, therefore, the findings about ageism are presented for both groups together. the analysis of the interviews with patients and their informal caregivers revealed manifestation of discrimination due to age. older persons very often confronted with violation of their rights as a human and as a patient to receive health care services and proper treatment. they often were ignored and were not treated seriously. their right to information was violated and their right of participation in the process of decision making regarding to their own health situation was ignored. an older person with special needs (overweight) was left without appropriate care, because hospitals and elderly homes are poorly equipped and do not even have simple hoists. the detailed manifestation of discrimination and ageist behaviour revealed in the interviews is presented in table 1. table 1. ageist behaviour and manifestation of discrimination ageist behaviour manifestation of discrimination violation of the patients‟ rights to health care because of their age "the nurse is talking [to me, the caregiver] on a phone: „87 years old! and you want our doctor to pay a home visit to such a patient!? no, he [doctor] won‟t come. and it‟s illegal for me to provide infusion therapy without a prescription of the doctor.‟ and what should i do?" (daughter, 67 years old, site 1). violation of the patients‟ rights to the information because of their age “nobody really cares to explain to you in what case you are eligible for rehabilitation services. the doctor says „you are too old to understand‟” (spouse, 82 years old, site 1). selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 7 ignored or not taken seriously because of their age “i am not able to talk with the doctor about my mother‟s condition. when i go for a consultation i get the only answer „such an age [94 years old]!‟ she even said to me, „in your seventies you want to be healthy?‟ and i got so angry at that moment. our town is small; we know each other. she is only several years younger than i am and she thinks that she is young! i tell her about my condition and she is not even listening. i never get any prescription. if not for our pharmacist, my mother would have been dead. my mother had a very bad erysipelas. and only the pharmacist told me that there is a special antibiotic, but the doctors usually do not prescribe it. i went to the doctor and insisted that she give the prescription for this medication. she was very unpleasant, but gave the prescription. and my mother got better straight away. but if i did not know about this type of medication, i would have never got it.” (daughter, 70 years old, site 6). the system serves only the interests of the system when the client is old, overweight and has special health problems “the family doctor did not even come and look at her [mother]. <…> she said she has too many patients registered! then she [doctor] wrote a referral to a hospital for treatment without seeing her. she [mother] did feel very bad, she was coughing up to suffocation. and my mom, she weighs 120 kg. <…> we went [to the hospital] to look for an illness in the lungs, and ended up in vilnius [the capital] to do a computer tomography of the intestines, because they came up with an idea that there is a tumour in the intestines. but nobody hospitalized her, and the night was approaching! so i called the nurse of the integrated care team at 8.30 pm: “what should i do? nobody hospitalizes us. and how am i supposed to take my bedridden mother who weighs 120 kg home?” everything went on through the phone: send her, bring her, go… the nurse somehow arranged that an ambulance brought us back from vilnius, so we were finally back in a district hospital at 2.30 am. and here again i hear: “we are not going to hospitalize her; she is old and her condition is too severe.” and they sent us back home. and i think to myself, what i should do now? my mother was dragged around through half of lithuania and now i have her back at home with the inflammation of the lungs on my own” (daughter, 65 years old, site 2) when the patient is old, the doctor is reluctant to visit that patient with acute disease at home. “<...> in april it happened that the doctor refused to visit my wife. over the weekend my wife had gotten even worse. on monday i went to [our] ambulatory centre to ask for a doctor‟s visit. and there i was told that “today we do not have any times free for registration; for tomorrow we also cannot register. and from the first of may our doctor leaves for the holiday”. it felt like a mockery. and in the cases of acute conditions they [personnel of primary health care centre] have to take the patient in without any registration. in the waiting room there were no patients at all. then i asked, “maybe now she [doctor] could come and examine her [my wife]? we live so close, just across the street. it would take only a few minutes to come and examine.” and her answer was, “no, i cannot leave the ambulatory“. and at the same time there were two nurses there sitting. you realize how it is? they do not care about old patients. what should we do? the fever was very high. i called for an ambulance. the ambulance took her to the hospital. and there in the hospital, she, having pneumonia and high fever, had to stay in the corridor on a transfer trolley for almost over twenty-four hours. the hospital could not refuse to selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 8 take her in with high fever… ” ( spouse, 78 years old, site 1) how do the older persons deal with the experience of ageist behaviour? as findings reveal, in most cases the older persons recognize ageist behaviour, but do not perceive it as a violation of their rights. instead of trying to change anything, the people use emotional coping and remain with the feeling of helplessness. the findings disclosed that older persons face certain barriers that prevail on taking legal action in order to protect their rights to proper medical care. among the barriers were internal barriers, health limitations, readiness and willingness of legal representatives to identify ageist and discriminatory behaviour and to represent the older person in a legal action based upon the discrimination (table 2). table 2. barriers in taking legal actions to protect the rights of older persons to proper care barriers description of the barrier health state limitations “…at this age you are not supposed to go to fight in the courts. [in order] to go to the court and to fight you ought to have good health and a lot of strength.” (woman, 75 years old, site 1). prolonged court processes “you need help here and now and not at the time when the process will be over and the court will decide. people might be in the suit for years there, and what result does it give? <...> and on the other hand, the winning of the court after half of a year or a year might be too late. by that time my husband or i myself might be below ground.” (spouse, 70 years old, site 4). “there were two court processes [about using the handicapped spouses‟ money for nursing]. the procedure seems quite simple, but it took half a year <...> and you have to live now, to buy medications and nursing items now. you have to live your life now.” (spouse 78 years old, site 1) the lack of positive experience in dealing with the courts “the old person has no chance to win the court. in our courts the justice is on the side of the one who has more money. it is as simple as that…” (man, 77 years old, site 2) “... i had already gone through the court in order to get the permission to use her money for her care. after her stroke she is not able to go to the bank or to sign [documents]. her speech is limited. <...> there were two court processes. the procedure seems quite simple, but it took a half of a year <...> and you have to live now, to buy medications and nursing items now. you have to live life now. and what the result was: the decision that i can take from her account only 1400 euro even though at the time i had already spent over 1700 euro just for her medications. if you want more money, you have to appeal to the court from the very beginning again. and they questioned my daughter and my son, and they both [daughter and son] were not against it. but still such decision.” (spouse, 82 years old, site 1) the lack of special knowledge “if you want to fight for justice in the court, you have to have selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 9 knowledge. these things are not for an old person.” (woman, 71 years old, site 2). need of other resources “you need somebody who could drive you to the court. and not once, but constantly through all the procedure. and at the moment i feel lucky that my daughter and son-in-law drive me to the doctor or to the shop, or to the church. and you would additionally ask to drive to the court? everybody is busy with their own affairs and duties.” (women, 74 years old, site 5). the lack of recognition of the discrimination even by lawyers “and regarding the court… now i think to myself. my son-in-law is a lawyer. and he has never mentioned the possibility of the court. he knew our situation in details; he saw everything. apparently he really knows that the court cannot help there. and he is really good at those things...” (spouse, 76 years old, site 10) inner barriers and fear of consequences to be left without any care researcher: “have you ever thought of looking for justice [regarding being discriminated by the doctor] or looking for another doctor?” “i have never thought about it... and when i think now, i realise that i would never do it. i would really feel uncomfortable regarding the doctor. i know her and she knows our family for so many years. and you are used to her and she knows all my health problems. somehow you cannot go into the conflict [with the doctor]” (spouse, 76 years old, site 10). “if you start to conflict, you may stay without any help. and what should one do in such an age and health condition. you completely depend on the doctor. she prescribes medications… and in our ambulatory she is the only doctor.” (woman, 78 years old, site 9). the lack of a patient (human) rights-based approach in all policies, lack of education, and the lack of intersectoral work “...i could not imagine that it would be hard to take care of your own mother? she raised us, so can't i now take care of her? it is five years now [since then]. <...> she cries day and night: mum, mum. you don't get if she has pain, or not. this cry, it seems i will get crazy. when i cannot bear it anymore, i go out, walk around with my head in my arms, and come back. i used to hire people [to nurse] <...> but nobody wants to stay with such a hard patient. they stay for a month and leave. where haven't i looked for help? <...> the answer was that we understand that it is hard for you, but it is your mother and you have to take care of her.” (daughter, 66 years old, caregiver of 91yearold mother, site 8). for the caregivers, taking care itself is already a huge emotional and physical overload. “well, when i get tired at night, i think to myself sometimes, “god, oh, god”... [...] the nursing is very difficult. you cannot leave anywhere. i step out, sit on a bench for a while and back into the house. oh, and i go to the shop. i long for the fresh air… he is sick for 8 years already. you can imagine what it means to stay with a patient for so many years” [she is moved and gets tearful, cannot talk for some time] (spouse, 74, site 16). it can be rewarding experience when you help, but there is ample research about caregivers feeling depression, somatic disorders and the like (35,36). when somebody is discriminated and does not receive proper medical care, s/he can already feel disappointed and rejected. selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 10 when you additionally do not get help with the one you take care of, the helplessness that you feel is double, because you have to see the suffering of a person close to you. the question “and what should i do?” without finding appropriate answer and with the feeling of helplessness was very often on the lips of the caregivers in the study. some participants of the study had interesting suggestions regarding how the situation could be changed to a less-ageist attitude. one of them suggested that the problem was that the fight against ageist behaviour was seen as a private matter and it has to be made into a public one. moreover, because of their homebound, bedridden situation the people are not able to take proper care of themselves; therefore it is improbable that they would additionally fight against discrimination. as concerns the carers, having to deal with the situation where the sick relative totally depends on you made them learn a lot about nursing, filling appropriate documents, achieving that help is provided and this round-the-clock job without holidays often left them exhausted, was causing health problems, and did not allow to fight for change against discrimination: there were other, more urgent problems at hand and not enough resources to deal with everything. even people with political positions could not achieve change in patient-care, in spite of writing about the situation extensively (rūta vanagaitė, active politician: she used her position in parliament to change the situation of people, who are dependent and need home care. she iniciated discussions on the topic and raised the problems in media. even wrote a book. vanagaitė r. pareigos metas [time of duty], 2014 [in lithuanian]). therefore it came as a natural suggestion, that there is a need for professionals such as social workers, who would be legally entitled to act against discrimination based on age: “i think that an older person has to have a legal representative such as a social worker. the social worker could present cases of violation of the rights of an older person. social workers should be entitled to file a suit to the court when an older person is left without care or when a patient has to take care of another patient at home without formal support and without proper attention of doctor and nurse in such cases like my situation was [when i was caring for my late husband]. me, with a heart pacemaker, had to take care of my bedridden husband for over three months. i had to wash him, to lift him, and day and night to nurse him on my own. after such an intensive care i walked wobbling. thanks god, he died in time” (78 years old women, site 5). summary of the empirical findings i) discrimination is not perceived as such and often is considered a lack of attention. ii) the fear to lose doctors‟ friendly support dominates, especially in rural areas, were only one doctor works. iii) there is no elderly-orientated or easily-operational legal information that clearly states steps to fight discrimination in patient care. iv) there is a lack of confidence in justice, courts, and institutions. v) the results of the study disclose the following barriers which the elderly in lithuania face: a) lack of recognition of the phenomenon of discrimination against the elderly in patient care; b) lack of information for complaining and fear of consequences of complaining; c) deficiencies and uncertainties of laws and regulations devoted to discrimination; d) a high level of burden of proof in court cases and lack of good practices; e) lack of a patient (human) rights-based approach in all policies and in education as well as the lack of intersectoral work. discussion selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 11 while other authors (35) often discuss how to fight hidden discrimination, we found it necessary to speak about open discrimination of elderly patients. the review of court cases, and more specifically interviews disclosed that the phenomenon of discrimination is neither perceived nor recognized. on the contrary, findings show that wide and open discrimination against elderly persons is manifest in patient care. in line with discussion by williams in „age discrimination in the delivery of health care services to our elders‟ (36), we found that the main barrier to changing practice still is the lack of recognition. in regard to the second important barrier, the lack of information and fear of consequences, clough and brazier asked similar questions in their work „never too old for health and human rights?‟(35). they cite barriers in the context of the united kingdom: the elderly patients “may not complain because of a fear of consequences, for example, that they will be evicted from their care home if they do, may not complain because they lack confidence, may feel they are „just making a fuss‟, may find there is a lack of accessible complaints, mechanisms or information about how to complain, may have particular communications/language difficulties or may face limited access to legal aid providers or be limited by the scope of legal aid, or may be put off by complex legal procedures such as conditional fee arrangements” (35). this comes close to our empirical findings: the lack of information and especially the fear of consequences are additional major barriers in lithuania. differently from the uk context, the fear of consequences can be explained in lithuania by „renter mentality and conformity that are lingering of soviet society mentality” (37) because the older generations in lithuania lived during the soviet period (1940-1990). we found that elderly persons do not trust courts and they do not see any possible real way to change the system. they do not know who can help them or who can inform them. they need health care now, not after long-lasting, expensive litigation. they believe that a doctor is the only person who could help them and that is why they do not want to risk losing their doctor‟s favour. the third barrier in lithuania is the deficiencies and uncertainties of laws and regulations devoted to discrimination. in this study we found that in 2004, when entering the european union (eu), lithuania changed or supplemented laws according to eu requirements. in most laws, non-discriminatory sentences were added. however, the implementation of laws, in general, is a real issue. perhaps it is due to a lack of brave and new practice for forming decisions of the lithuanian supreme court. lithuanian laws should be written more clearly; their examination revealed a lack of precise articles in two basic laws (27,28) that should indicate the way for complains and, ultimately, the constitution of lithuania does not pay attention to age discrimination at all. in line with the european union agency for fundamental rights finding that „interviews with legal experts, equality bodies and health ombudsmen indicate that proving that a discriminatory act has taken place is often challenging for plaintiffs and their lawyers (38), we found that the lack of court cases is the result of the difficulty to prove discrimination, and vice versa the difficulty of the burden of proof is the result of the absence of successful litigation. there is one possible solution: in lithuanian civil law court cases, the aim of averment is a court‟s reasonable belief of existence or non-existence of certain circumstances (art.176) (39). that is why anti-discriminatory policies could educate judges to see discrimination more often. also more frequent complaints (starting with civil cases) would slowly change the practice and burden of proving in civil and administrative cases (including ombudsman‟s procedures). finally, a change in policy regarding a human rights approach influencing education and fostering intersectoral coordination and cooperation in terms of health in all policies would selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 12 accelerate the already visible slow movement forward as regards the european context. tonio borg, ex-eu commissioner for health, said: “i believe health is for all. everybody should have access to good quality healthcare regardless of gender, age, race, and sexual orientation, type of condition, social status, education, or country of residence. for this to become reality, we need to fight discrimination in health” (40). unfortunately, the new lithuanian action plan for “healthy aging” (32) that derived from the strategy and action plan of healthy aging in europe, 2012-2020 (41) interprets „healthy aging‟ from a nonhuman rights perspective and is in itself discriminatory. its main focus is to inspire the elderly to be active, as a cause of healthy living, not as a consequence of healthy living. there is a policy deficiency regarding a non-active, almost-disabled or very old person who cannot be active. lithuanian „healthy aging‟ itself has to tackle discrimination and health inequalities in its approach and focus more on „strengthening health systems, in order to increase older people‟s access to affordable, high-quality health and social services‟ (41). one of the reasons for the incomplete implementation of human rights in elderly patient care is likely the non-binding character of many conventions and charters instead of binding legislation. the european charter of patients‟ rights of 2002 (4) contains 14 provisions, the second being the „right of access‟: „the health services must guarantee equal access to everyone, without discriminating on basis of financial resources, place of residence, kind of illness or time of access to services‟. it seems that lithuanian lawmakers are afraid of the word „guarantee‟ and its consequences, especially when the talk is about financial resources. this can be illustrated by the words of the secretary-general to the un general assembly: “older persons suffer discrimination in health care and tend to be overlooked in health policies, programmes and resource allocation” (42). or by the research, where aleksandrova investigating the question of financial resource allocation in her study „should age be a criterion for the allocation of health resources?‟ (43) gives different arguments „for‟ and „against‟ focusing on the usefulness of the elderly. the universal declaration on bioethics and human rights of 2005 is not legally binding either, but has expedient content such as its article 11: „no individual or group should be discriminated against or stigmatized on any grounds, in violation of human dignity, human rights and fundamental freedoms‟ (44). even binding instruments, as the international covenant on economic, social and cultural rights with its article 12 „the states parties to the present covenant (e.g. lithuania) recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health‟ do not change the situation. the crucial point, however, is the lack of successful practice in the european court of human rights (echr) (34). examples of echr cases show that lithuania has no strong outside incentive or rather pressure, different from the period of accession to the eu in 2004. the fear of sanctions/consequences for not complying with the acquis communeautaire was a powerful incentive. but later, in 2005, the protocol 12 to the european convention on human rights – devoted to the extension of prohibition of discrimination – was not signed by lithuania (45). the americas likely will become the first region in the world to have an instrument for the promotion and protection of the rights of older persons (46). if it is ratified, the member states will “adopt and strengthen such legislative, administrative, judicial, budgetary, and other measures as may be necessary to give effect to and raise awareness of the rights recognised in the present convention, including adequate access to justice, in order to ensure differentiated and preferential treatment for older persons in all areas” (47). this is a good example setting standards for a stronger legislation. selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 13 most barriers not only in lithuania seem to be concerned with policy. now it is time to ask about the place of elderly people in public health policy. first, there is an “inner level” question: what person is able to notice the discrimination and the barriers? answer: a person who is trained to notice. our study revealed a big gap between the occurrence of discrimination and fighting that discrimination in the health system. we agree with the statement by bjegovic-mikanovic et al. that: „…public health education needs to include a wider range of health-related professionals including: managers, health promotion specialists, health economists, lawyers and pharmacists. <…> investing in a multidisciplinary public health workforce is a prerequisite for current challenges‟ (48). secondly, there is an “external level” question. when asking how/where can the barriers be removed, we find that in a state, where there are appropriate and enforceable instruments and an older person-friendly scene in which to enforce them. historically, from the ancient times it was a taboo to complain about the doctor‟s work; it appears that it is still a taboo to complain about human rights violations. the state must improve the legal basis and have a strong will to help improve and protect older persons‟ rights in all spheres. thirdly, there is a question dealing with information and leadership. the need for a workforce that is educated in the needs and rights of elderly persons (lawyers, judges, health care providers, politicians, and even the church clerks) is obvious. these professionals need multidisciplinary knowledge in order to think “out of the box”. good practices from other countries for elderly legal consultation can be used, for example elder law clinics (49) and „ehelp‟ as a compilation of useful information (50). the burden of leadership is to make this a reality that belongs to everyone. however, we are aware of the limitations of our research. the narrative literature review was performed in order to show the need to solve the problem of discrimination and because of scarcity of prior research in lithuania. however, a systematic review of good practice abroad might have yielded more specific evidence. also a bigger sample size might have allowed comparing the group of patients with the caregivers. nevertheless even our small study reveals serious violations of elderly patients‟ rights and should arose the attention of politicians, stakeholders and professionals and help to initiate further studies to analyse the quantity and quality of human rights neglect in elderly patient care. conclusions in spite of the obvious limitations of our study, we were able to identify three main barriers that blockade improvements in elderly patient care:  recognition of open and hidden discrimination of elderly patients.  lack of information and fear of consequences experienced by patients and caregivers facing discrimination and considering complaint.  deficient non-binding legislation and court practice. in consequence this study disclosed the need to:  encourage training of health care professionals. the burden of leadership has to be assumed by universities and public health professionals;  encourage training of legists and lawyers in expanding knowledge and skills in human rights in patient care;  incorporate a new article in the „law on the rights of patients and compensation for the damage to their health‟, clearly stating where to complain in case of discrimination;  create a web page and brochures with readable and understandable information for elderly persons and their families and caregivers; selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 14  establish legal consultation and mediation cabinets in health care facilities;  establish an older persons‟ rights protection service under the ministry of social security and labor in close cooperation with the ministry of health;  promote sustainable results by incorporating a human rights-based approach regarding elderly persons in all policies. selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system 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2006. http://unesdoc.unesco.org/images/0014/001461/146180e.pdf (accessed: november 1, 2015). 45. european convention of human rights, protocol 12. http://www.echr.coe.int/documents/convention_eng.pdf (accessed: november 1, 2015). 46. the global alliance for the rights of older people: http://www.rightsofolderpeople.org/inter-american-convention-on-protecting-thehuman-rights-of-older-persons/ (accessed march 6, 2016). http://www.lat.lt/lt/naujienos/pranesimai/705.html http://www.echr.coe.int/documents/fs_elderly_eng.pdf http://scholarship.law.marquette.edu/elders/vol11/iss1/3 http://fra.europa.eu/sites/default/files/inequalities-discrimination-healthcare_en.pdf http://fra.europa.eu/sites/default/files/inequalities-discrimination-healthcare_en.pdf https://www.e-tar.lt/portal/en/legalact/tar.2e7c18f61454 https://www.e-tar.lt/portal/en/legalact/tar.2e7c18f61454 http://ec.europa.eu/health/newsletter/115/newsletter_en.htm http://www.euro.who.int/__data/assets/pdf_file/0008/175544/rc62wd10rev1-eng.pdf http://www.euro.who.int/__data/assets/pdf_file/0008/175544/rc62wd10rev1-eng.pdf http://www.ohchr.org/en/issues/olderpersons/pages/olderpersonsindex.aspx http://www.kwnc.edu.mo/journal/fulltext/mjn_2004_vol3_1/mjn_2004_vol3_no1_47.pdf http://www.kwnc.edu.mo/journal/fulltext/mjn_2004_vol3_1/mjn_2004_vol3_no1_47.pdf http://unesdoc.unesco.org/images/0014/001461/146180e.pdf http://www.echr.coe.int/documents/convention_eng.pdf http://www.rightsofolderpeople.org/inter-american-convention-on-protecting-the-human-rights-of-older-persons/ http://www.rightsofolderpeople.org/inter-american-convention-on-protecting-the-human-rights-of-older-persons/ selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 18 47. organization of american states. inter-american convention on protecting the human rights of older persons; 2015. https://www.oas.org/en/media_center/press_release.asp?scodigo=e-198/15 (accessed: november 1, 2015). 48. bjegovic-mikanovic v, czabanowska k, flahault a, otok r, shortell s, wisbaum w, laaser u. policy summary 10: addressing needs in the public health workforce in europe. european observatory on health systems and policies, who-euro: copenhagen, denmark; 2014. http://www.euro.who.int/__data/assets/pdf_file/0003/248304/addressing-needs-inthe-public-health-workforce-in-europe.pdf?ua=1 (accessed: november 1, 2015). 49. elder law clinic. wake forest university, usa. http://elderclinic.law.wfu.edu/resources/basic-n-c-information/ (accessed: november 1, 2015). 50. aging and adult services. salt lake city, utah, usa. http://www.hsdaas.utah.gov/ (accessed: november 1, 2015). __________________________________________________________ © 2016 selli et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://scm.oas.org/idms/redirectpage.aspx?class=ag/doc.&classnum=5493&lang=e http://scm.oas.org/idms/redirectpage.aspx?class=ag/doc.&classnum=5493&lang=e https://www.oas.org/en/media_center/press_release.asp?scodigo=e-198/15 http://www.euro.who.int/__data/assets/pdf_file/0003/248304/addressing-needs-in-the-public-health-workforce-in-europe.pdf?ua=1 http://www.euro.who.int/__data/assets/pdf_file/0003/248304/addressing-needs-in-the-public-health-workforce-in-europe.pdf?ua=1 http://elder-clinic.law.wfu.edu/resources/basic-n-c-information/ http://elder-clinic.law.wfu.edu/resources/basic-n-c-information/ http://www.hsdaas.utah.gov/ levett j. first half century of the association of schools of public health in the european region (editorial). seejph 2016, posted: 20 april 2016. doi: 10.4119/unibi/seejph-2016-113 1 editorial first half century of the association of schools of public health in the european region jeffrey levett 1 1 the national school of public health, athens, greece. corresponding author: prof. dr. jeffrey levett, national school of public health; address: ilia rogakou 2, athens, 106 72, greece; telephone: +302103641607; email: jeffrey.levett@gmail.com levett j. first half century of the association of schools of public health in the european region (editorial). seejph 2016, posted: 20 april 2016. doi: 10.4119/unibi/seejph-2016-113 2 this year, the association of schools of public health in the european region (aspher) reaches 50 years [1966-2016] and is engaged in celebration. its significant achievements on the european stage will appear in the anniversary book and tell much of its exciting story (1). the official ceremony will take place in athens, greece 25-27 may 2016 with an opening event in the acropolis museum. the celebration is hosted by the hellenic school, an institution finally launched in 1929, following heroic efforts of greek pioneers in malaria and after a bizarre pandemic of dengue fever and a little known, unique and short-lived revolution in public health, which hiccoughed its way into history (2-5). one powerful driving force was ludwik rajchman of the league of nations who described the health situation in greece as being “worse than in brazil”. aspher’s contemporary vision is expressed in its 2020 strategy, enunciated into five specific strategic objectives that reflect educational quality, research capacity and global governance. these are pivotal to present and future population health challenges and have been elaborated in a spirit of collaboration and solidarity and in concert with the international community. one fundamental goal is the continued improvement of competency training of the european workforce. appropriately trained public health practitioners are an effective link to crisis intervention such as in the current refugee crisis. aspher is a natural link and think tank for europe and can provide insights into paths towards solution for the current and horrendous set of european problems. in 1992, with the support of who-euro [jo asval, m. barberro] and the european commission, dgv [david hunter, jos draijer], a turbulent general assembly was hosted by the hellenic school. it received support from the rockefeller and goulandri foundations and from hellenic ministries of health, education and culture [melina mecouri]. in athens, i) a balkan forum for public health was conducted and facilitated eastern european schools to become a greater force within aspher thus fulfilling the aim of its first secretary-general, teodor gjurgjevic, zagreb [1968] who travelled unsuccessfully to moscow, to encourage membership; ii) aspher outlined its response to article 154 of the maastricht treaty, and; iii) an award named for andrija stampar got underway, which this year goes to richard horton, editor of the lancet (6). public health is a paradoxical entity spurned when things go well, called back by society when things fall apart. it is an essential function of society; an organized and systematic concoction for dealing with unpleasant surprises. it is an invigorating interdisciplinary cocktail, which like women’s domestic work, does not fit well into the economist’s equations of development or into business or market models. public health is an anti-hero, not unlike don quixote who tilted at windmills and hucklebury finn who knew hell awaited him, after he helped the escape from slavery. like huck and the don, public health has a nobility of spirit and purpose, wanting to right wrongs. like a woman spurned, it can take disastrous revenge when rejected by the community or by the state. think of ebola [africa]; lead in flint [usa]. social sensitivity to deprivation and the organization of public health in response to dismal outcomes from environmental miasma are both constructs and products of the enlightenment (7). its thinkers aimed to improve living conditions of the population impacted by the industrial revolution and urbanization. they embraced such powerful thoughts as: “there but for the grace of god go i, do onto others as you would have them do onto you and that the reduction of mortality had an economic value to society”. nevertheless, the danger still exists that the ship of state is operating with an insufficient ratio of lifeboats to passengers while avoidable death climbs (8). levett j. first half century of the association of schools of public health in the european region (editorial). seejph 2016, posted: 20 april 2016. doi: 10.4119/unibi/seejph-2016-113 3 aspher’s homunculus-logo depicts both heart and brain, thus echoing the ancient maxim of “healthy in body, healthy in mind”, for the individual, the community and the body politic. perhaps we should listen more to female voices; hygiene, daughter of asclepius, goddess symbol of public health; peitho goddess of persuasion. linguistically, public health suggests political tension and ideological divisions. it is a strange couplet from which the polar “public-private” surfaces. etymologically, idiocy-idiot derives from the greek word private and health lacks importance until lost. at this time of humanitarian crisis in europe, aspher calls for greater tolerance of diversity; color, creed, opinion nurtured within cultures of peace and science and within a framework of equality. public health policy must be equal in complexity to the current problem space; refugee waves, austerity measures, terrorism. it must demonstrate flexibility in approach and draw upon alternative but convergent conceptualizations as either in terms of reducing vulnerability or in terms of resilience building. as we step into the future we may be faced by health indicator decline and health determinant disasters. aspher’s 50 year legacy must be seen as a vital contributor to socio-economic progress, a bulwark against health damage and a pillar for our common european future. we say that investing in schools of public health is a good thing! schools of public health do make a difference (9)! no better gift can come from the political world than greater recognition of schools and institutions of public health in tandem with the ascendancy of public health up the political agenda. from athens, aspher’s thoughts and concerns go out to all victims of abominable terrorist attacks, those suffering the consequences of austerity and to the plight of being a refugee. we must resist the dastardly and merciless acts of terrorism and mount a more effective response to population deprivation and environmental dangers and not permit them to derail europe. with pride we draw attention to our appealing association aspher as it reaches a half century, while simultaneously, appealing to the european world of politics to make more room for public health. references 1. foldspang a, müller-nordhorn j, bjegovic-mikanovic v, otok r (eds.). fifty years of professional public health workforce development. aspher’s 50 th anniversary book. brussels: association of schools of public health in the european region, 2016 [in press]. 2. mandyla m, tsiamis c, kousounis a, petridou e. pioneers in the anti-malaria battle in greece (1900-1930). gesnerus 2011;68:180-97. 3. levett j. the athens school: lighthouse of greek public health. www.kastaniotis.com (greek only). 4. giannuli d. repeated disappointment: the rockefeller foundation and the reform of the greek public health system, 1929-1940. bull hist med 1988;72:47-72. 5. scientific foundations of public health policy in europe. editors: laaser u, de leeuw e, stock c. juventa verlag weinheim and munchen; 1995. 6. aspher. welcome to athens. http://www.aspher.org/articles,4,20.html http://www.kastaniotis.com/ http://www.aspher.org/articles,4,20.html levett j. first half century of the association of schools of public health in the european region (editorial). seejph 2016, posted: 20 april 2016. doi: 10.4119/unibi/seejph-2016-113 4 7. levett j. disaster press: public health enlightenment, greece: from the athens to the hellenic national school of public health. sunday, 20 november 2011. http://nrdisaster.blogspot.gr/2011/11/public-health-enlightenment-greece.html (accessed: april 21, 2016). 8. levett j. disaster press: blunders without apology, mistakes and their excuses. thursday, 31 march 2016. http://nrdisaster.blogspot.gr/2016/03/blunders-withoutapology-mistakes-and.html (accessed: april 21, 2016). 9. de leeuw e. european schools of public health in state of flux. lancet 1995;345:1158-60. ___________________________________________________________ © 2016 levett; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://nrdisaster.blogspot.gr/2016/03/blunders-without-apology-mistakes-and.html. http://nrdisaster.blogspot.gr/2016/03/blunders-without-apology-mistakes-and.html. siepmann i, chen t, andelic p. how can we champion young women working in public health? (viewpoint). seejph 2021, posted: 10 may 2021. doi: 10.11576/seejph-4424 viewpoint how can we champion young women working in public health? ines siepmann1,2, tara chen2,3, petra andelic1,2 1 faculty of health, medicine, and life sciences, maastricht university, the netherlands; 2 young professionals programme, association of schools of public health in the european region (aspher), brussels, belgium; 3 department of social work, tzu-chi university, hualien, taiwan. corresponding author: ines siepmann address: faculty of health, medicine, and life sciences, maastricht university, the netherlands; email: i.siepmann@student.maastrichtuniversity.nl siepmann i, chen t, andelic p. how can we champion young women working in public health? (viewpoint). seejph 2021, posted: 10 may 2021. doi: 10.11576/seejph-4424 women, especially early in their careers, have been systematically excluded from public health leadership positions, only holding 25% of the leading roles despite compromising 70% of the workforce (1). they face difficulties in entering the field, ensuring a work life balance, and receiving adequate support. this disparity has been highlighted during the covid-19 pandemic, in which the public health workforce (phwf) has been placed at the forefront of the crisis response. this spotlight on public health has demonstrated the gaps within the system, namely the inability to respond to current and future public health demands and to adapt to constantly changing environments. the failures of public health systems have been in part attributed to the fact that the phwf, particularly its leaders, have not been adequately supported and strengthened, resulting in a homogeneous, nonrepresentative workforce (2). a revitalized phwf is urgently needed. the new workforce must address the nonrepresentative nature of current leaders and support individuals and organizations ready to champion a new era of public health. “champions” themselves are described as engaging, innovative individuals who are passionate, persistent, persuasive, and influential (3). the combination of these values is critical for effective public health leadership, and is associated with improved population health and well-being. these characteristics in a woman, however, can be seen as disruptive, loud, assertive and emotional. this viewpoint discusses how this and additional barriers impact young women from entering the field, achieving a work life balance, and receiving adequate support. it provides key takeaways based off of these observations, and demands institutional change for the betterment of individual and population health. entering the public health field the demographics of the public health workforce are largely unexplored. in a field intended to be diverse and representative of the public, this is a large oversight. diversity and inclusion in public health is tied to better health outcomes, which is simultaneously the goal of public health (4). data often showcases gender distribution for healthcare practitioners such as physicians and nurses, but data collection does not extend to public health practitioners and students. the majority of educational institutions do not collect demographic data regarding students or faculty, and organisations are even less likely to collect and share data (5). for those that do, the gender gap remains, with women being underrepresented in higher positions (6). this knowledge gap demonstrates an early stage ignorance of the disparities present within public health. by not knowing who chooses to enter the public health field and why, barriers that individuals might face when considering entering the field are ignored. generally, public health leaders are not visible to the public. this is exacerbated for young women, as they see few female leaders in the field. it is essential to be exposed to people they can identify with in a leadership position to consequently see a potential future for themselves. as a result, the field would be richer through a more diverse representation, knowledge and leadership traits (1). achieving a work-life balance the challenge of championing young women does not end just by breaking the barrier of entering into the workforce. it transitions to the next question of “what now?”. with the pressures of today’s society and health needs, the public health workforce is faced with the conundrum of balancing a high, active engagement in their work with family and personal life. https://www.zotero.org/google-docs/?7r5ol2 https://www.zotero.org/google-docs/?utee1q https://www.zotero.org/google-docs/?qzwliv https://www.zotero.org/google-docs/?zxxmkr https://www.zotero.org/google-docs/?gefnue https://www.zotero.org/google-docs/?y19gkk https://www.zotero.org/google-docs/?uapt63 siepmann i, chen t, andelic p. how can we champion young women working in public health? (viewpoint). seejph 2021, posted: 10 may 2021. doi: 10.11576/seejph-4424 women are expected to take on multiple roles in life, such as a homemaker and a working woman, as well as maintaining strong social networks. research findings continuously emphasize that women are paid less for doing the same work, that being a ‘working mother’ has made it harder for women to advance in their job or career, that work conditions are designed for men, and that woman face additional pressures to being a good parent and friend compared to men (7). these imbalances warrant stress, and are linked to unwanted health issues. the high expectations can be intimidating and alienating for young women trying to advocate for themselves in the public health workforce (8). receiving adequate support once a young woman has entered the phwf, she is faced not only with high professional and personal expectations, but also with the limitations of our current mentorship system. very few programmes and organizations, both academic and in industry, have established cohesive mentoring frameworks. public health organizations are underfunded and under resourced, with limited time to develop robust mentorship systems. genuine, bidirectional inclusion of young people is necessary for better health programmes and subsequent outcomes (9). however, mentorship is hard to come by, due to the high pressures of academia and silos between private and public sectors. above all, opportunities are not casually offered to young mentees. academia and research follow a publish-orperish system, which has resulted in a culture of selfishness and gender disparity. women are significantly underrepresented in scholarly journals (10); this is particularly damaging in a field such as public health, which thrives off of multidisciplinary, relational work. by building a workforce in which the members are competing to be seen, it limits its own ability to effectively teach and collaborate in the workforce. the culture also disproportionately impacts women, who due to other responsibilities, may not be as able to compete for recognition. the essence of female empowerment lies in increasing female representation in the organization’s social order to bring forth the idea that this is possible. female leaders in health systems have a common element in their careers: a strong social network early on that helped them develop confidence and credibility (11). to advance in the career, a robust professional social network is necessary. today’s next generation is suffering from a high impact, fast-paced global environment. these high demands as a young woman in public health challenges the notions of being a visible part of the workforce in demanding situations. key takeaways the public health infrastructure needs strengthening to be gender responsive. to do so, women, particularly young women, must be more intentionally welcomed into the field and given the opportunity to reach their full potential in leadership roles. the demographics of the public health workforce are not established and female leaders are not clearly visible to the public. to address this gap, public health educators, practitioners, and leaders need to consider how public health organisations function and recruit at all levels, from initial visibility of the field, to opportunities and support once women have entered. gender transformative policies need to be created and adopted to push the health sector to empower women and girls. public health must: ● have representative leadership, including women and young people ● recognize the barriers to entry for young women, including workplace https://www.zotero.org/google-docs/?gyxzra https://www.zotero.org/google-docs/?wp3g4l https://www.zotero.org/google-docs/?zykj8k https://www.zotero.org/google-docs/?rvmihx https://www.zotero.org/google-docs/?flsocf siepmann i, chen t, andelic p. how can we champion young women working in public health? (viewpoint). seejph 2021, posted: 10 may 2021. doi: 10.11576/seejph-4424 demands and availability of role models ● bolster mentorship and support networks, particularly for young women to highlight women empowerment ● support career advancement and gender parity in leadership positions providing equal and equitable opportunities for young women working in public health is essential to achieve the necessary strengthening of the public health infrastructure. making overdue changes to systemically gender biased and discriminatory infrastructures is crucial for the future of public health, and will strengthen public health’s post-pandemic response. conflict of interest: none declared. acknowledgements: we would like to thank kasia czabanowska and lisa wandschneider for their thoughtful feedback. references 1. who. delivered by women, led by men: a gender and equity analysis of the global health and social workforce [internet]. world health organization; 2019 [cited 2021 may 6]. (human resources for health observer issue 24). available from: http://www.who.int/hrh/resources/he alth-observer24/en/. 2. treviño‐reyna g, czabanowska k, haque s, plepys cm, magaña l, middleton j. employment outcomes and job satisfaction of international public health professionals: what lessons for public health and covid19 pandemic preparedness? employment outcomes of public health graduates. int j health plann manage. 2021 april 4. doi: https://doi.org/10.1002/hpm.3140. 3. fhi360. engaging innovative advocates as public health champions [internet]. 2010. available from: https://www.fhi360.org/sites/default/f iles/media/documents/engaginginnovative-advocates-as-publichealth-champions.pdf. 4. kalina p. challenges to diversity and inclusion in health care. hum resour manag res. 2018;8(3):45–8. doi: https://doi.org/10.5923/j.hrmr.201808 03.01. 5. claeys-kulik a-l, jørgensen te, stöber h. diversity, equity and inclusion in european higher education institutions [internet]. 2019. available from: https://eua.eu/downloads/publications /web_diversity%20equity%20and%2 0inclusion%20in%20european%20hi gher%20education%20institutions.pd f. 6. statistikportal. geschlechterbezogene hochschuldaten nrw [internet]. 2021. available from: https://www.gender-statistikportalhochschulen.nrw.de/start. 7. poduval j, poduval m. working mothers: how much working, how much mothers, and where is the womanhood? 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(viewpoint). seejph 2021, posted: 10 may 2021. doi: 10.11576/seejph-4424 © 2021 siepmann et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 2019 oct 1;3(10):673–5. doi: https://doi.org/10.1016/s23524642(19)30247-0. 10. west jd, jacquet j, king mm, correll sj, bergstrom ct. the role of gender in scholarly authorship. hadany l, editor. plos one. 2013 jul 22;8(7):e66212. doi: 10.1371/journal.pone.0066212. 11. javadi d, vega j, etienne c, wandira s, doyle y, nishtar s. women who lead: successes and challenges of five health leaders. health syst reform. 2016 jul 2;2(3):229–40. doi: https://doi.org/10.1080/23288604.201 6.1225471. _________________________________________________________________________________________ https://www.zotero.org/google-docs/?8kbwo1 https://doi.org/10.1016/s2352-4642(19)30247-0 https://doi.org/10.1016/s2352-4642(19)30247-0 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://dx.doi.org/10.1371%2fjournal.pone.0066212 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://doi.org/10.1080/23288604.2016.1225471 https://doi.org/10.1080/23288604.2016.1225471 bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 1 of 17 review article maternal and new-born health policy indicators for low-resourced countries: the example of liberia vesna bjegovic-mikanovic1, raphael broniatowski2, stephen byepu3, ulrich laaser4 1 belgrade university, faculty of medicine, centre school of public health and management, serbia; 2 epos health management, bad homburg, germany; 3 inha university, incheon, korea and monrovia, liberia; 4 faculty of health sciences, university of bielefeld, germany. corresponding author: prof. vesna bjegovic-mikanovic, md, msc, phd; address: university of belgrade, faculty of medicine, centre school of public health and management, dr subotica 15, 11000 belgrade, serbia; telephone: +381112643830; e-mail: vesna.bjegovic-mikanovic@med.bg.ac.rs mailto:bjegov@med.bg.ac.rs bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 2 of 17 abstract aim: over the past two decades, two catastrophic events caused a steep decline in health services in liberia: the long-lasting civil war (1989-2003) and the weak response of the health system to the ebola viral disease (evd) outbreak (2013-2015). in early 2015 the liberian government reacted and developed a strategic health policy framework. this paper reviews that framework with a focus on maternal and newborn health. methods: the study is designed as a narrative review executed during the second half of 2017 in monrovia. it takes advantage of triangulation, derived from recent international and national documents, relevant literature, and available information from primary and secondary sources and databases. results: in 2015 the severely compromised health system infrastructure included lack of functional refrigerators, low availability of vaccines and child immunization guidelines, high stock-out rates, and an absence of the cold chain minimum requirements in 46% of health facilities. the public health workforce on payroll during 2014/15 included only 117 physicians. skilled birth attendance as an indicator of maternal health services performance was 61%. presently, approximately 4.5 women die each day in liberia due to complications of pregnancy, delivery, and during the post-partum period, equalling about 1,100 women per 100,000 live births. of particular note is the adolescent birth rate of 147 per 1000 women aged 15-19 years, three times higher than the world average of 44. additionally, with a neonatal mortality rate of 19.2 neonatal deaths per 1,000 live births, liberia stands higher than the world average as well. the high mortality rates are caused by multiple factors, including a delay in recognition of complications and the need for medical care, the time it takes to reach a health facility due to a lack of suitable roads and transportation, and a delay in receiving competent care in the health facilities. conclusions: the fact that performance is above average for some indicators and far below for other points to unexplained discrepancies and a mismatch of international and national definitions or validity of data. therefore, it is recommended to concentrate on the core of tracer indicators adopted at the global level for universal health coverage and the sustainable development goals to enable a permanent update of relevant information for policymaking and adjustment. at present all health policy documents miss a thorough application of the smart objectives (specific, measurable, attainable, relevant and timely), notably missing in most documents are realistic and detailed budgeting and obligatory timelines for set targets. keywords: health system, liberia, maternal and newborn health, maternal mortality, policies, strategies. bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 3 of 17 introduction the liberian population is comprised of the descendants of the immigration from the united states in the early 19th century and of 17 major tribal affiliations. half of the population lives in urban areas (1), the majority being christians, a minority of about one-tenth are muslims. the civil war from 1989 to 2003 generated a death toll of about 18% of the population of 4.5 million and nearly one million displaced persons (2). living standards dropped considerably also as a consequence of the weak response of the health system to the subsequent outbreak of ebola viral disease (evd) 2013-2015 (3). accordingly resources for health services missed the so-called abuja target of 15% (4) by 2.6 percentage points. a restart and overhaul of the health system became mandatory. health system oriented towards women and children obtained particular attention of the liberian government (5). the “global strategy for women’s, children’s and adolescents’ health” (2016-2030) (6) in the context of the agenda for sustainable development (7) identify 9 areas for ‘reproductive, maternal, newborn, children, and adolescent health’ (rmncah) policies, calling on governmental initiatives and country leadership, financing for health, health system resilience, individual potential, community engagement, multi-sector action, humanitarian and fragile settings, research and innovation, and accountability for results, resources and rights. similarly, universal health coverage identifies availability, accessibility, acceptability, and quality of services (8). these target areas for rmncah are of similar priority for almost all countries in the economic community of west african states (ecowas) as recently analyzed (9). our narrative review investigates maternal and new-born health policies. also, review addresses the basic components of reproductive health specific for liberia as an example for other low-resourced countries especially in west-africa: fertility (actual bearing of live offspring), safe motherhood (pregnancy and delivery without risk for own life and child's life), family planning, prevention of unwanted pregnancies and abortions, as well as characteristic diseases for women in their reproductive age. methods we make use of a combination of quantitative and qualitative methodologies. a participatory process involving governmental stakeholders through several interviews was particularly helpful and supportive in ensuring that issues were explored across sectors to provide a holistic understanding of the situation. also, the paper takes advantage of triangulation based on national and international sources and publications as well as on data and documents of the government of liberia predominantly the ministry of health and the liberia institute of statistics and geo-information services. we employ further the current methodology proposed by the maternal mortality estimation inter-agency group (mmeig) (10). the main framework of analysis is following steps of the policy cycle (11) as necessary, moving towards universal health coverage. all actual policy documents are analyzed looking at 1) agenda-setting with problem definition and situation analysis, 2) policy formulation with goals and objectives, 3) implementation by government action and 4) monitoring/evaluation with revised agenda setting. bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 4 of 17 results 1) review of health policy documents related to maternal & new-born health (mnh) the key documents in this context are the “investment plan for building a resilient health system 2015-2021” (12)in line with the “national health and social welfare policy and plan 2011–2021” (13). also, recently the ministry of health (moh) in cooperation with national and international partners drafted and endorsed a document, the “investment case for reproductive, maternal, neonatal, child and adolescent health 2016-2020” (14) aiming to support high impact intervention for improving mnh (maternal and newborn health). we have retrieved in total 28 policy documents, which all involve maternal and new-born health, either as a general or specific priority health problem under concern and in need for accelerated action (table 1), as maternal mortality in liberia is among the highest worldwide being 1,072/100,000 live-births during the seven years preceding the 2013 ldhs (15). according to the 2007 ldhs, maternal mortality was even slightly less than today being 994/100,000 (16). approximately 4.5 women die each day in liberia due to complications of pregnancy, delivery, and during the postpartum period (17), equalling about 11 women for every 1,000 live births. table 1. liberian policy documents embracing mnh no title of the policy document time frame source (internet pages or references) 1 national health and social welfare policy and plan  national health and social welfare policy  national health and social welfare plan 2011-2021 http://moh.gov.lr/category/policies/ 2 national health and social welfare financing policy and plan 2011-2021 http://moh.gov.lr/category/policies/ 3 national human resources policy and plan for health and social welfare 2011-2021 http://moh.gov.lr/category/policies/ 4 national health and social welfare decentralization policy and strategy 2011-2021 not online 5 investment plan for building a resilient health system 2015-2021 http://moh.gov.lr/cabinet-endorses-investmentplan-for-building-a-resilient-health-system/ 6 investment case for reproductive, maternal, new-born, child, and adolescent health 2016-2020 http://www.globalfinancingfacility.org/sites/gff _new/files/documents/liberia%20rmncah% 20investment%20case%202016%20%202020.pdf 7 liberia community health road map 2014-2017 not online 8 revised national community health services strategic plan 2016-2021 not online 9 national policy and strategic plan on health promotion 2016-2021 http://www.afro.who.int/en/liberia/liberiapublications.html 10 national hiv & aids strategic plan 2015-2020 http://www.nacliberia.org/doc/liberia%20nsp %2020152020%20final%20_authorized_%20ok.pdf 11 national malaria control program. malaria communication strategy 2016-2020 http://www.thehealthcompass.org/sites/default/f iles/project_examples/liberia%20nmcs%2020 16-2020.pdf 12 national leprosy and tuberculosis strategic 2014-2018 http://www.lcm.org.lr/doc/tb%20and%20lepr http://moh.gov.lr/category/policies/ http://moh.gov.lr/category/policies/ http://www.afro.who.int/en/liberia/liberia-publications.html http://www.afro.who.int/en/liberia/liberia-publications.html http://www.nacliberia.org/doc/liberia%20nsp%202015-2020%20final%20_authorized_%20ok.pdf http://www.nacliberia.org/doc/liberia%20nsp%202015-2020%20final%20_authorized_%20ok.pdf http://www.nacliberia.org/doc/liberia%20nsp%202015-2020%20final%20_authorized_%20ok.pdf http://www.thehealthcompass.org/sites/default/files/project_examples/liberia%20nmcs%202016-2020.pdf http://www.thehealthcompass.org/sites/default/files/project_examples/liberia%20nmcs%202016-2020.pdf http://www.thehealthcompass.org/sites/default/files/project_examples/liberia%20nmcs%202016-2020.pdf http://www.lcm.org.lr/doc/tb%20and%20leprosy%20strategic%20plan%202014-2018%20consolidated%20(1)%20(1).pdf bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 5 of 17 plan osy%20strategic%20plan%2020142018%20consolidated%20(1)%20(1).pdf 13 the national traditional medicine policy and strategy (2015-2019) 2015-2019 http://moh.gov.lr/category/policies/ 14 strategic plan for integrated case management of neglected tropical diseases (ntds) 2016-2020 not online 15 consolidated operational plan (fy 2016/17) 2016-2017 http://moh.gov.lr/wpcontent/uploads/2017/04/operational-plan_fy17_-martin.pdf and: http://www.seejph.com/public/books/consolidat ed_operational_plan_2016-17.pdf 16 joint annual health sector review report 2016. 2016 http://www.seejph.com/public/books/joint_ann ual_health_sector_review_report_2016.pdf 17 family planning 2020 commitment 2011-2020 http://ec2-54-210-230-186.compute1.amazonaws.com/wpcontent/uploads/2016/10/govt.-of-liberiafp2020-commitment-2012.pdf 18 national gender policy 2010-2020 2010-2020 http://www.africanchildforum.org/clr/policy%2 0per%20country/liberia/liberia_gender_2009_e n.pdf 19 national therapeutic guidelines for liberia and essential medicine list 2011 ongoing https://www.medbox.org/countries/nationaltherapeutic-guidelines-for-liberia-and-essentialmedicines-list/preview?q= 20 essential package of health services (ephs) 2011 ongoing http://apps.who.int/medicinedocs/documents/s1 9420en/s19420en.pdf 21 road map for accelerating the reduction of maternal and new-born morbidity and mortality in liberia (2011-2015)(18) 2011-2015 ministry of health and social welfare, republic of liberia. roadmap for accelerating the reduction of maternal and new-born mortality 2011-2015 (an updated version of the original publication in 2007). monrovia, liberia: ministry of health, 2011. 22 accelerated action plan to reduce maternal and neonatal mortality 2012-2016 (19) 2012-2016 ministry of health and social welfare, family health division. accelerated action plan to reduce maternal and neonatal mortality. monrovia, liberia: ministry of health and social welfare, 2012 july. 23 the national roadmap for maternal mortality reduction “the reach every pregnant woman (rep) strategy” 2007 http://apps.who.int/pmnch/media/events/2013/li beria_mnh_roadmap.pdf 24 national strategy for child survival in liberia 2008-2011 http://liberiamohsw.org/policies%20&%20plans /national%20strategy%20for%20child%20sur vival.pdf 25 national sexual & reproductive health policy 2010 http://liberiamohsw.org/policies%20&%20plans /national%20sexual%20&%20reproductive%2 0health%20policy.pdf 26 poverty reduction strategy 2008 http://www.emansion.gov.lr/doc/final%20prs. pdf 27 national policy and strategic plan on integrated vector management 2012-2017 http://pdf.usaid.gov/pdf_docs/pa00j21w.pdf 28 liberia health system assessment (20) 2015 ministry of health, republic of liberia. liberia health system assessment. monrovia, liberia: ministry of health, 2015. http://www.lcm.org.lr/doc/tb%20and%20leprosy%20strategic%20plan%202014-2018%20consolidated%20(1)%20(1).pdf http://www.lcm.org.lr/doc/tb%20and%20leprosy%20strategic%20plan%202014-2018%20consolidated%20(1)%20(1).pdf http://moh.gov.lr/category/policies/ http://ec2-54-210-230-186.compute-1.amazonaws.com/wp-content/uploads/2016/10/govt.-of-liberia-fp2020-commitment-2012.pdf http://ec2-54-210-230-186.compute-1.amazonaws.com/wp-content/uploads/2016/10/govt.-of-liberia-fp2020-commitment-2012.pdf http://ec2-54-210-230-186.compute-1.amazonaws.com/wp-content/uploads/2016/10/govt.-of-liberia-fp2020-commitment-2012.pdf http://ec2-54-210-230-186.compute-1.amazonaws.com/wp-content/uploads/2016/10/govt.-of-liberia-fp2020-commitment-2012.pdf http://www.africanchildforum.org/clr/policy%20per%20country/liberia/liberia_gender_2009_en.pdf http://www.africanchildforum.org/clr/policy%20per%20country/liberia/liberia_gender_2009_en.pdf http://www.africanchildforum.org/clr/policy%20per%20country/liberia/liberia_gender_2009_en.pdf https://www.medbox.org/countries/national-therapeutic-guidelines-for-liberia-and-essential-medicines-list/preview?q https://www.medbox.org/countries/national-therapeutic-guidelines-for-liberia-and-essential-medicines-list/preview?q https://www.medbox.org/countries/national-therapeutic-guidelines-for-liberia-and-essential-medicines-list/preview?q http://apps.who.int/pmnch/media/events/2013/liberia_mnh_roadmap.pdf http://apps.who.int/pmnch/media/events/2013/liberia_mnh_roadmap.pdf http://liberiamohsw.org/policies%20&%20plans/national%20strategy%20for%20child%20survival.pdf http://liberiamohsw.org/policies%20&%20plans/national%20strategy%20for%20child%20survival.pdf http://liberiamohsw.org/policies%20&%20plans/national%20strategy%20for%20child%20survival.pdf http://www.emansion.gov.lr/doc/final%20prs.pdf http://www.emansion.gov.lr/doc/final%20prs.pdf bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 6 of 17 the most recent situation analysis is presented in the “liberia service availability and readiness assessment and quality of care report (sara and qoc)” (21), while the most recent documents covering mnh policy implementation are the “joint annual health sector review report 2016” (22) and the “consolidated operational plan (fy 2016/17)” (23). the most important of the documents listed in table 1 is the investment plan (number 5) for the period 2015-2021 making use of the more recent data of the dhs 2013. the political decision-maker drafting it employed the mdg targets and indicators (24) but not yet the more recent sdg indicators (25). the method of stating targets is not explained, in spite of the recommendation to tailor targets towards local context and embrace a more realistic approach. as an example, liberian policymakers envisioned a goal to reduce maternal mortality by three quarters between 1990 and 2015 as set in mdg-5. that would be equal to looking at the upper bound level in 1990 (figure 1 below) – 1,980 maternal deaths to be reduced to 495 per 100,000 live-births in 2015, which is at the same time close to the national target of 497 maternal deaths per 100,000 live-births set as a desirable goal only for 2021. due to such weaknesses and inconsistencies, it may be assumed that the selection of liberian objectives and targets in these documents often have been set at random. such assumption is mirrored in the recent mgds assessments (26) that criticize too ambitious mdgs, which do not take into account infrastructure and health system capacity in general, which is a strong request of the global strategy for women’s, children’s and adolescents’ health (2016-2030) (27-29). to enhance increased investment into health systems of resource-limited countries, ihp+ has been transformed into the international health partnership for universal health coverage (uhc) 2030, based on the 2005 paris declaration on aid effectiveness and the 2011 busan partnership agreement(30).during the first meeting of the uhc-2030 working group in march 2017 (31), the main focus was on low and middle-income countries facing many threats to their health systems including decrease in the external financial support. liberia potentially faces similar threats in the near future but joined ihp+ only in march 2016, however, a significant amount of donor support (about 75%) (32) remains off-budget with various parallel implementation arrangements. nevertheless, progress is visible in spite of the recent ebola crisis (2014/15), mainly due to the efforts of the liberian government to implement an essential package of health services (ephs) since 2011 (33,34). 2) analysis of maternal and neonatal mortality looking at time trends, from 1985 to 2015 (figure 1), the period of the first civil war (1989-1996) was when maternal mortality experienced a peak. in 1994 mortality ratios were 1,890 deaths per 100,000 livebirths (with the upper bound of 2,470 and a lower bound of 1,320). after a significant recovery, the second civil war (1999-2003) again caused a negligence to mnh and retardation of improvement. today liberian reproductive women have a 3 times higher chance than the average global population of women to experience premature death due to complications during pregnancy, delivery, and the postpartum period. between 2000 and 2015, the global maternal mortality ratio, or a number of maternal deaths per 100,000 live births, declined by 37 percent to an estimated ratio of 216 per 100,000 live births in 2015. in liberia maternal bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 7 of 17 mortality in the same period declined by 43% from 1,270 to an estimated ratio of 725 per 100,000 live births in 2015, indicating considerable improvement since the civil wars ended, although still higher than the global average. the national data based on the dhss published in 2008 and 2013 represent maternal mortality during the 7 preceding years. the main reason for differences is insufficient death statistics in liberia, with many failing to register the majority of causes of deaths in the population. the liberian moh information summarises: “the liberian public health law of 1976 mandates the moh to register all deaths within 24 hours. as a result of inadequate access, the coverage of registration has always been below 5% annually. death certificates are usually processed in liberia with the intent to obtain insurance benefits, to settle inheritance issues and not as a requirement for burial and documentation of the cause of death.” (35).as an example: in 2013, only 659 deaths were registered according to the rules. figure 1. maternal mortality ratio in liberia (9,15) data on maternal mortality presented in figure 1 are obtained from databases maintained by the who, undp, unicef, and world bank group. some of the earlier policy documents stated several reasons for high maternal mortality rates mainly related to the insufficient quantity and quality of the liberian human resources for health and health facilities’ performance (36). some of the problems cited were an inadequate number of skilled human resources for health in general and of experienced,skilled birth attendants specifically also inadequate emergency obstetric and new-born care services, inadequate referral mechanisms, inadequate essential drugs, equipment, and supplies were cited. the major non health factors include a lack of clearly defined community referral, lack of health financing mechanisms, and socio-cultural 994 1072 0 500 1000 1500 2000 2500 1 9 8 5 1 9 8 6 1 9 8 7 1 9 8 8 1 9 8 9 1 9 9 0 1 9 9 1 1 9 9 2 1 9 9 3 1 9 9 4 1 9 9 5 1 9 9 6 1 9 9 7 1 9 9 8 1 9 9 9 2 0 0 0 2 0 0 1 2 0 0 2 2 0 0 3 2 0 0 4 2 0 0 5 2 0 0 6 2 0 0 7 2 0 0 8 2 0 0 9 2 0 1 0 2 0 1 1 2 0 1 2 2 0 1 3 2 0 1 4 2 0 1 5 2 0 1 6 lower bound (80% ui) point estimate upper bound (50% ui) ldhs bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 8 of 17 inequities. there are significant delays which also contribute to maternal and newborn mortality: delays in recognition of danger signs and making the decision to seek health care, delays in reaching a health facility via an insufficient road system (37), and delays in receiving care at the health facility. consequentially, the leading causes of maternal deaths are haemorrhage (25%) and hypertension (16%) followed by sepsis and abortion (each 10%). the next important indicator of mnh in the sdg framework is neonatal mortality. with 24.1 neonates’ deaths up to 28 days per 1,000 live-births, liberia is still above the world average (19.2 per 1,000 livebirths). however, the historical decrease in neonatal mortality is significant (figure 2). the main causes of neonatal deaths are preterm birth complications (10%) and intrapartum related events: asphyxia (9%), and sepsis (8%). figure 2. neonatal mortality rate in liberia (15,38) 48.3 47 46.1 45 43.8 43.3 42.5 41.9 40.7 39.1 37.3 35.5 33.8 32.1 30.6 29.1 27.5 26.2 24.8 23.4 22.1 20.8 19.5 18.6 17.6 16.7 57 55.5 54.3 52.9 52 51.1 50.3 49.1 47.4 45.6 43.7 41.7 39.7 37.9 36.2 34.5 32.9 31.3 29.9 28.6 27.6 26.8 26 25.3 24.7 24.1 66.9 65.4 63.8 62.4 61 59.7 58.6 57 55.1 52.9 50.8 48.4 46.3 44.2 42.2 40.4 38.7 37.1 35.7 34.8 34.2 34.1 34.1 34.4 34.5 34.8 0 10 20 30 40 50 60 70 80 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 lower median upper per 1,000 live-births years legend: lower, median and upper refer to the lower, median and upper bound of a 90% uncertainty interval. despite these results, policymakers should carefully consider whether the relatively low neonatal mortality could be due to the insufficient liberian deaths registration (potential entrap of under-registration). the framework for sdg monitoring includes 27 indicators for monitoring of bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 9 of 17 sdg-3 (“ensure healthy lives and promote well-being for all at all ages”), out of which a group of 16 indicatorsis directly related to health status (39). though all indirectly are relevant for mnh, a particularly important indicator, within sdg-3, is the adolescent birth rate per 1,000 women aged 15-19 years. the main rationale for the recognition of this indicator is: “preventing unintended pregnancy and reducing adolescent childbearing through universal access to sexual and reproductive health-care services are critical to further advances in the health of women, children, and adolescents. childbearing in adolescence has steadily declined in almost all regions, but wide disparities persist: in 2015, the birth rate among adolescent girls aged 15 to 19 ranged from 7 births per 1,000 girls in eastern asia to 102 births per 1,000 girls in sub-saharan africa” (40). in liberia, this rate was even higher in 2015 and also higher than in ecowas and the african region. with 147 adolescent girls per 1,000 aged 15-19 years who gave birth to a baby, liberian female population is at 3 times higher risk in this regard than the world average (44.1 per 1,000) (41). 3) status of health services the second group of relevant indicators for the situation analysis of mnh in relation to sdg-3 is related to health system strengthening. these indicators refer to health system structure, quality, and effectiveness of performance, which holds a prominent place in the situation analyses of many liberian health policy documents. the investment plan for building a resilient health system (2015-2021) has been marked already as one of the best health policy documents in liberia. following this report (3), the public health workforce on payroll, during 2014/15, included only 117 physicians, 436 physician assistants, 2,137 nurses (rn/lpn), and 659 midwives (1.2 per 10,000 population). also 2,856 trained traditional midwives (ttm) are listed. ttms belong to the corpus of 8,052 community health volunteers (based on the 2013 mapping exercise). today, health workers’ density varies significantly between counties in liberia, the lowest being in nimba and the highest in bomi. though improvement in quantity is visible from 2010 to 2015, still numbers are far below the levels proposed by who to avoid critical shortage: 23 health workers per 10,000 are considered as necessary to secure essential maternal and child health services to the entire population (42).the roadmap for scaling up human resources for improved health service delivery in the african region 2012-2025 has determined the same threshold (43). skilled health professionals’ density is 25 per 10,000 globally, but in liberia almost nine times less (2.9 per 10,000). the difference stems partly from different definitions of a skilled health professional, and consequently, different counting in who and national statistics. for international comparison, who includes as skilled health professionals only the following: nurses, midwives and physicians (44). there liberia with 2.9/1.000 is the fourth to last place in the ecowas community and much below its nationally calculated average of 6.4/1.000 of skilled health professionals. maternal health services performance assessed by the proportion of births attended by skilled health personnel in liberia at 61% is better than the ecowas average of 57% and the average of the african region. according to these statistics, liberia still performs at a lower level than the global average where 3 out of 4 births (73%) were assisted by skilled health-care personnel in 2015. performance is above average for some bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 10 of 17 indicators and far below for others (e.g., maternal vs. neo-natal mortality), the disparity points to unexplained discrepancies and mismatch of international and national definitions or validity of data. for example a comparison of maternal and neonatal mortality throughout historical periods in liberia is misleading: researchers and authors of ldhs-2013 (page 285) (45) have rightfully warned that comparison is possible only with ldhs-2007, due to the fact that methods of estimates were significantly changed in 2007 and cannot serve for comparison with previous surveys – lsdh-1999/2000. furthermore, the interpretation of indicators does not account for the fact that ldhs provides direct estimates of maternal mortality for the seven years preceding each survey. finally, a tracer indicator, relevant for mnh and sdg-3, may serve to describe the status of the liberian health system and its infrastructure best: “infants receiving three doses of hepatitis b vaccine”. in liberia, only 50% of children received the vaccination in 2014 (46) (ecowas average 78%). such situation is well explained in a national situation analysis (47) as a consequence of the evd crisis (with declines not only of immunizations but also all other mnh services). the recent sara report (48) clarifies the situation by severely compromised health system infrastructure: lack of functional refrigerators, low availability of vaccines and child immunization guidelines, high stock-out rates, and absence of the cold chain minimum requirements in even 46% health facilities. 13% are also without direct access to water, 43% without incinerator, and 45% without regular electricity. discussion a main observation with regard to this policy analysis is that significant weaknesses of the national policy documents derive from missing links between objectives, realistic and measurable targets, activities with a quantifiable input, precise and controlled timelines for their implementation, and appropriate reliable budgetary allocation (49). an example of necessary links is given in figure 3. furthermore, liberia (in spite of the country’s low capacity) could use available opportunities to improve the insufficient registration of birth and death events. an immediate option is provided by the multiple indicator cluster survey (mics), organized and funded by unicef. preparation for the mics 6 is ongoing in many countries (50), while liberia implemented only the first round in 1995, with only three counties at the time (montserrado, parts of margibi and bassa) though with 60% of the total liberian population living in the same areas) (51). mics is a valuable data source covering the reproductive health of women, health outcomes for children and adolescents, child mortality, education, water, and sanitation. bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 11 of 17 figure 3. the complex linkage between a health problem, its determinants, areas of intervention, the regulatory framework and smart activities organise all donor conference/ compact upgrade facilities and replace outdated equipment curriculum update increasing study places supervised fieldwork guaranty 24/7 secure reimbursement reliable salaries and incentives reconsider ttm role and reduce waiting time accreditation of colleges/ schools obligatory ce for midwifery employing sufficient midwifery staff secure emonc services at all levels high maternal mortality staff quantity and qualification low connectivity, lack of (solar) electricity and tape water insufficient transport capacity & lack of maternal waiting homes availability of staff at point of access motivation of midwifery staff health problem: the maternal mortality rate in liberia was 1072/100,000 life-births in 2013. potential intervention areas determinants health problem regulatory changes smart activities developing workforce for maternal health planning workforce for maternal health define ce courses based on the model healthy plan-ittm of cdc atlanta. a final evaluation will only be possible upon completion of all planned activities in 2021. liberian moh policymakers should consider more closely (during monitoring activities) the international developments, which received a final endorsement in 2017. the universal health coverage (uhc) indicators for the sustainable development goals (sdgs) monitoring framework have been agreed on march 13, 2017 (52). the global indicator framework has been formally adopted by the united nations general assembly through the united nations economic and social council and will be instrumental for the national and international monitoring, evaluation,and comparison of achievements. particularly relevant for liberia is the sdg index, with tracer indicators that serve both for health workforce and health services’ monitoring. the index comprises only 12 indicators and serves for both national and international comparisons. the latest examples of such utilization can be found in the global strategy on human resources for health – workforce 2030 and the global strategy for women’s, children’s and adolescents’ health (2016-2030). conclusions and recommendations there are well-developed strategies in almost all health areas,but most of them are missing defined action plans with publicized targets following smart principles, therefore correspondingly there bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 12 of 17 is a severe gap in implementation. also, data used should be referenced, crosschecked, and critically evaluated regarding reliability and validity. it is recommended to go beyond simple presentation and analyze differences in outcomes for statistical significance, including multiple regressions to identify significant determinants of health outcomes. analyses and the discussion of their results should always be compared to west african, african, and global parameters, not restricted to the national perspective. for intra-national comparisons, the same data sources have to be used as otherwise comparability and conclusions are jeopardized. it is further recommended to initiate as soon as possible a process of developing new health policy documents in liberia for implementation after 2021 by moh stakeholders, involving inter-sectoral representation and independent expertise. a multidisciplinary team of health policymakers should analyze opportunities and strengths, based on existing national development plans (especially the liberia agenda for transformation: steps towards liberia rising 2030 (53)). the main intention is to have health policy documents fitting the local context and the new movement towards sdgs, strictly applying smart principles, especially obligatory timelines and budgetary allocation as a key element of the smart principle in realistic planning. acknowledging the local context, already now a first step could be the revision of the national health and social welfare decentralization policy and strategy:  development of a roadmap 2030 for the sdgs, which will allow for implementation and monitoring after 2021 (providing transparency of fragmented implementation and a database of ongoing projects in counties) is one of the immediate tasks for the liberian moh.  strengthening of policy planning at the county level is also a priority in policy formulation, preferably by using one of the proven models for programme planning, such as healthy plan-ittm by cdc (atlanta).  invited international expertise should be given full access to data, and technical assistance should have access (observer status) to policy meetings like the health sector coordination committee (hscc) and the pool-fund meetings (as otherwise a lateral and vertical information exchange within the moh is severely inhibited). derived from liberian health policy documents, the situation analysis, and the literature review, the following areas may be prioritized regarding mnh services (54):  ensure timely, equitable, respectful, evidence-based, and safe maternal– perinatal health care, delivered through context-appropriate implementation strategies;  build linkages within and between maternal–perinatal and other healthcare services to address the increasing diversity of the burden of poor maternal health;  increase the resilience and strength of health systems by optimizing the health workforce and improving facility capability;  guarantee sustainable financing for maternal–perinatal health; and  accelerate progress through evidence, advocacy, and accountability by: developing improved metrics, and support implementation research to promote accountable, evidencebased maternal health care and bjegovic-mikanovic v, broniatowski r, byepu s, laaser u. maternal and new-born health policy indicators for low-resourced countries: the example of liberia (review article). seejph 2019, posted: 19 august 2019. doi 10.4119/unibi/seejph-2019-221 page 13 of 17 translating evidence into action through effective advocacy and accountability for maternal health. finally, there is a significant opportunity for liberia and all african countries to make use of the new who leadership and dr. tedros adhanom ghebreyesus, who director-general, who recently pointed out (55): “universal health coverage is ultimately a political choice. it is the responsibility of every country and national government to pursue it. countries have unique needs, and tailored political negotiations will determine domestic resource mobilisation. who will catalyse proactive engagement and advocacy with global, regional, and national political structures and leaders including heads of state and national parliaments”. conflict of interest: none declared. ethical approval: not required as this paper does not contain any studies with human participants or animals performed by any of the authors. funding: this work has been done in the framework of project funding by the european commission: technical assistance to support the implementation of the national health plan and the roadmap for the reduction of maternal mortality in liberia (fed/2014/351/044). acknowledgments: the authors are grateful to the ministry of health of the republic of liberia, to richard gargli and roosevelt mccaco in monrovia for their help in identifying the relevant publications, and to nelson chase for english editing. references 1. lisgis. republic of liberia 2008 population and housing census. analytic report on population size and composition. monrovia, liberia: liberia institute of statistics and geoinformation services 2011. available from: https://www.lisgis.net/pg_img/populatio n%20size%20210512.pdf (accessed: august 15, 2019). 2. ministry of health and social welfare, republic of liberia. national health and social welfare policy and plan 2011-2021. monrovia, liberia: ministry of health and social welfare, 2010. available from: http://moh.gov.lr/documents/policy/201 9/national-health-policy-and-plan-20072011/ (accessed: august 15, 2019). 3. ministry of health, republic of liberia. 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(editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 1 global health competences revised shortlist for a global public health curriculum (16 august 2018) the aspher working group on education for global public health edited by ulrich laaser correspondence: prof. dr. med. ulrich laaser dtm&h, mph section of international public health (s-iph) faculty of health sciences, university of bielefeld pob 10 01 31, d-33501 bielefeld e-mail: ulrich.laaser@uni-bielefeld.de; laaseru@gmail.com the 1st edition of the global public health curriculum has been published in the south eastern european journal of public health, end of 2016 as a special volume (editors ulrich laaser & florida beluli) at: http://www.seejph.com/index.php/seejph/article/view/106/82. the curriculum targets the postgraduate education and training of public health professionals including their continued professional development (cpd). however, specific competences for the curricular modules remained to be identified in a more systematic approach. a first comprehensive draft version of related competences has been published in february 2018 (laaser u, editor: the global public health curriculum: specific global health competences. seejph 2018, vol. 9. doi 10.4119/unibi/seejph-2018-180). the two main categories for the grouping of required competences have been adopted from a. foldspang (public health core competences for essential public health operations, volume 3, aspher 2016 at: http://aspher.org/download/76/booklet-competencesephosvolume-3.pdf): 1.0 the public health professional shall know and understand: 2.0 the public health professional shall be able to: in this 2nd edition we aim at a more operational shortlist of 15 most relevant competences extracted from the 1st edition and based on additional comments from authors of the modules of the global public health curriculum. the rationale behind this approach is that a minimum of 5 competences in each category can be expected to differentiate sufficiently and a maximum of 15 competences in total might have a realistic chance to be remembered and introduced into regular teaching. for relevant literature please refer to the 1st edition. as in the meantime the sustainable development goals (sdg) are operational we included also an additional section (numbered as 2.9b). additional information on a pilot-survey: in the context of preparing the 2nd edition we also run a pilot-survey on the use of the global health modules as published at: http://www.seejph.com/index.php/seejph/article/view/106/82. eleven schools and departments of public health (sdph) from 8 out of 19 european countries (42%) returned the questionnaire with the following results: mailto:ulrich.laaser@uni-bielefeld.de mailto:laaseru@gmail.com http://www.seejph.com/index.php/seejph/article/view/106/82 http://doi.org/10.4119/unibi/seejph-2017-180 http://aspher.org/download/76/booklet-competencesephos-volume-3.pdf http://aspher.org/download/76/booklet-competencesephos-volume-3.pdf http://www.seejph.com/index.php/seejph/article/view/106/82 laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 2 out of the 11 participating sdph 6 have a separate module on global health, 5 of them as obligatory module with teaching hours between 13 and 240 per year, mainly lectures and small group work. 7 sdph have global health content in other modules (out of them 3 with no separate module); 6 institutions publish on global health, 7 participate in projects, mainly on education or research, 4 cooperate with other sdph and 3 are member of a global health organisation. although in no way representative it is of interest that the analytical modules (r 2.0 ff.) got in general considerably better rankings in terms of their relevance than the interventive modules (r 3.0 ff.). participants of the pilot study: genc burazeri, ansgar gerhardus, jouni j. k. jaakkola & timo hugg, mihail kochubovski, anneli milen &mikko perkio, elpida pavi, oliver razum & alexander kraemer, gabriela scintee, mindaugas stankūnas, vesna velikj stefanovska, lijana zaletel kragelj. special thanks go to assistant professor liang-yin hsu, tzu chi university, hualien, taiwan for providing global public health expertise. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 3 r 2.1 demographic challenges (charles surjadi, luka kovacic1, muzaffar malik) there is growing interest in demography, among the public, politicians, and professionals: “demographic change” has become the subject of debates in many developed and developing countries. this is because it impacts on all aspects of people`s life, social relations, economy, and culture. the world population will continue to grow in the 21st century, but at a slower rate compared to the recent past. the annual growth rate reached its peak in the late 1960s, when it was at 2% and above. better health, economic and social conditions resulted in longer life and an ageing population. it is projected that by 2025 more than 20% of europeans will be 65 or over. better living conditions in cities lead to higher urbanization, more than 55% of the world’s population residing in urban areas in 2015. 1.0 the public health professional shall know and understand: 1.1 the definitions of demography, aging, social status, and urbanisation. 1.2 the major determinants of population dynamics. 1.3 the five stages of the global transition model. 1.4 the global distribution of major diseases according to climate, gender and age, social status and culture. 1.5 major environmental effects of urbanization. 2.0 the public health professional shall be able to: 2.1 develop specific population projections and identify their determinants. 2.2 identify the problems accruing from population growth, aging, and urbanisation. 2.3 apply the six determinants of active aging according to the who policy framework to selected populations/countries. 2.4 design realistic improvements of slums and informal settlements. 2.5 develop interventions in interdisciplinary and multi-professional environments. r 2.2 burden of disease (milena santric-milicevic, zorica terzic-supic) health systems today face challenges in the management of available resources. the implemented set of interventions and the criteria used for resource allocation are publicly debated. during reforms and in particular due to tough squeezing of resources, it is crucial to understand a proposed health plan and to have it supported by the public, health professionals, policy makers from other relevant sectors and international community. however, data on health and mortality in populations are not as comprehensive and consistent nor relevant as professionals require, rather are fragmentary and sometimes heterogeneous. the framework of burden of disease and injury study provides information and tools for integration, validation, exploration, and distribution of consistent and comparative descriptors of the burden of diseases, injuries and attributed risk factors, over time and across different health systems. as of 1992, when the first global burden of 1 see obituary at: http://www.seejph.com/index.php/seejph/article/view/19/17 http://www.seejph.com/index.php/seejph/article/view/19/17 laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 4 diseases study was executed, many national burden of disease studies have been undertaken and this framework is currently refining and updating. 1.0 the public health professional shall know and understand: 1.1 health data sources and tools; data integration analysis and reporting. 1.2 surveillance of health system performance. 1.3 identification and monitoring of health hazards; occupational health protection; food safety; road safety. 1.4 primary prevention; secondary prevention; tertiary/quaternary prevention; social support. 1.5 economic assessment (e.g. cost-effectiveness analysis) of different healthcare procedures or programmes. 1.6 setting a national research agenda. 1.7 advocacy for public health improvement. 2.0 a public health student should be able to: 2.1 explore global health data sources and understand the limitations of these data. 2.2 identify the composite health measures and their use for health program monitoring, evaluation and priority setting. 2.3 examine the major categories of morbidity and mortality used by the world health organization (who) and institute of health metrics and evaluation ihme (communicable and parasitic diseases, maternal, perinatal and childhood conditions, and nutritional deficiencies, non-communicable conditions importance and injuries). 2.4 describe the concept of premature mortality including age, sex and cause specific mortality rates, life expectancy and years of life lost (yll). 2.5 demonstrate knowledge of the major global causes of morbidity and health risks, by describing the concepts of years lived with disability (yld) and disability adjusted life-year (daly). 2.6 describe the relative importance of each global burden of disease (gbd) category, how the leading gbd diagnoses (15 causes) within each category vary by age, gender and time, and explain potential contributors to the observed variations. 2.7 explain how life expectancy, yld, yll and daly may be used to make general health comparisons within and/or between countries and who regions, and between high, middle and low-income regions, and draw implications for policy and practice. r 2.3 environmental health (dragan gjorgjev, fimka tozija) the concept of limits of growth – how far we can go? the ecological concept of health, ecological public health – reshaping the conditions for good health. from demographic to democratic transitions to be addressed by public health; different dpseea models of environmental health assessment – conceptual framework of environmental health wellbeing. environmental and climate change (cc), burden of diseases (daly, yll). environment and health inequalities. environment and health risk assessment studies. environmental health indicators to assess health effects of climate change – threats to be reduced and opportunities to be adopted. importance of the intersectoral work. vulnerability, mitigation, and adaptation of the health sector. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 5 1.0 the public health professional shall know and understand: 1.1 the basic concept of relationships between ecosystem, environmental degradation, pollution, and human health. 1.2 the dependence of human health on local and global ecological systems and the context of policies, practices and beliefs required to address global environmental changes (such as climate change, biodiversity loss and resource depletion). 1.3 the impact of major driving forces like industrialization, transport, rapid population growth and of unsustainable and inequitable consumption on important resources essential to human health including air, water, sanitation, food supply and living/housing and know how these resources vary across world regions. 1.4 the interactions between inadequate clean water supplies and good sanitation and diarrheal and parasitic diseases. 1.5 the effects of air pollution on acute and chronic lung, cardiovascular disease and other systems diseases. 2.0 the public health professional shall be able to: 2.1 use an ecological public health model within a specific social-economic context to discuss how global forces impact health aiming to improve the promotion of health and management of environment and health risks and effects. 2.2 applying the basic methods for environment and health impact assessment (ehia) 2.3 analyse the relationship between the availability of adequate nutrition, potable water, and sanitation and the risk of communicable and non-communicable diseases. 2.4 analyse the relationship between environmental pollution and cancers (air pollution, radon and lung cancer; benzene and leukaemia etc.). 2.5 communicate the environment and health risks and inform the public how the driving forces like globalisation and others affects environment and health inequalities within and between countries. 2.6 develop the skills to provide evidence based support to policy makers in order to mitigate the effects of global environmental change on health. r 2.4 global migration and migrant health (muhammad wasif alam, vesna bjegovic-mikanovic) nowadays, global migration is considered even more important than in the past. the main reason for that is the number of migrants, which is steadily increasing at the end of the 20th century and will continue to grow in the twenty-first. in general, migrants are supposed to have bad opportunities for health as a consequence of their migrant status. the most important issue in analytical models for the health effects of migration is the type of migration – whether it is voluntary, involuntary, or irregular migration. usually, migration brings improvement in social well-being and health. the wide variety of health conditions and consequences is associated with the profile of the mobile population: “what migrants bring, what they find, and what they build in the host country”. many authors stress three temporal and successive phases associated with individual movements: the pre-departure phase, the journey phase, and the post-journey phase. though different in many ways they suffer from globally dominant health problems: tuberculosis, trauma/rape/torture/ptsd, hiv/aids, cardiovascular disease etc. prevention of the public health consequences is laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 6 particularly relevant and important among the migrant. a clear strategy at the local, regional, and international levels is needed for efficient interventions. there is a human right of migrants to be treated properly if necessary. 1.0 the public health professional shall know and understand: 1.1 the concept of a pandemic and how global commerce and travel contribute to the spread of pandemics. 1.2 the epidemiology of global migration. 1.3 the interplay between national and international conflict, interpersonal violence, and health as well as the direct and indirect threats to both individual and population. 1.4 health threats posed by violent conflict and natural disaster, and ways in which such threats may extend beyond the borders of the country directly affected. 1.5 the health challenges (including accessing healthcare) that refugees, asylum seekers and other migrants are faced with during life in their country of origin. 2.0 the public health professional shall be able to: 2.1 analyse the health risks related to migration, with emphasis on the potential risks and appropriate resources. 2.2 consider the utility and limitations of common infection control and public health measures in dealing with local or global outbreaks. 2.3 control outbreaks of communicable diseases such as measles in a context of local and international populations with varying levels of immunization. 2.4 liaise with local or regional public health authorities and be aware of national and international public health organizations responsible for issuing health advisory recommendations. 2.5 analyse general trends and influences in the global availability and movement of health workers. 2.6 regard the impact on health of cross-border flows, including international trade, information and communications technology, and health worker migration. r 2.5 social determinants of health inequalities (janko jankovic) the largest contribution to health inequalities both within and between countries around the world is attributable to the social circumstances in which people live and work, i.e. to the social determinants of health. educational attainment, income, occupational category and social class are probably the most often used indicators of current socioeconomic status in studies on social inequalities in health which present differences in health that are unnecessary, avoidable, unfair and unjust. they are also systematic (not distributed randomly) and socially produced and therefore modifiable. the fairest way to combat against social inequalities in health is to improve the health of the most disadvantaged faster than that among the rich. 1.0 the public health professional shall know and understand: 1.1 that health is not only a medical, but also a social issue. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 7 1.2 the major social determinants of health and their impact on differences in life expectancy, major causes of morbidity and mortality and access to healthcare between and within countries (topics include absolute and relative poverty, income, education, employment status, social gradient, gender, ethnicity and other social determinants). 1.3 the relationship between health and social determinants of health, and how social determinants vary across world regions. 1.4 how social determinants operates at different levels (individual, household, community, national and international). 1.5 the relationship between health, human rights, and global inequities. 2.0 the public health professional shall be able to: 2.1 define health inequity and health inequalities. 2.2 demonstrate how one can inform policy makers about the importance of addressing health inequalities, and advocate for strategies to address health inequalities at a local, national or international level. 2.3 describe major public health efforts to reduce disparities in global health (such as sustainable development goals, europe 2020 and health 2020). 2.4 analyse local, national or international interventions to address health determinants such as strategies to engage marginalized and vulnerable populations in making decisions that affect their health and well-being. 2.5 analyse distribution of resources to meet the health needs of marginalized and vulnerable groups. 2.6 advance strategic thinking on tackling health inequalities. r 2.6 gender and health (bosiljka djikanovic) while sex in genetically and biologically determined, gender is socially constructed identity that shapes many aspects of person’s functioning and has implications on health as well. there are historically present gender disparities that are related to the power, decision making, and different societal expectations of women and men. although gender norms and values are deeply rooted in the culture, they are not fixed and unchangeable. they might evolve over time and may vary substantially in different environments. gender analysis aims to identify gender differences that will inform actions to address gender inequality. gender mainstreaming in medical education is important for eliminating gender biases in existing routines of health professionals. 1.0 the public health professional shall know and understand: 1.1 the basic differences between sex and gender and their overall importance on health. 1.2 how different levels of development of civil society and human rights affect identification and respect of gender differences. 1.3 the factors that influence construction of gender identity, and the impact of gender identity on achieving full potentials for health, including an access to health promotion and disease prevention. 1.4 the historical perspective of gender differences and their impact on social functioning and health 1.5 the relationship between sex and other mediating factors with different health outcomes. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 8 1.6 how gender affects different risk-taking behaviours and other mediating factors of the importance for disease prevention, treatment and rehabilitation. 1.7 how transgender identity is associated with different health outcomes. 2.0 the public health professional shall be able to: 2.1 elaborate on differences and interrelationship between sex, gender and health, and corresponding challenges that appear at primary, secondary and tertiary level of prevention. 2.2 identify windows of opportunities in public health for addressing gender differences that have an impact on health. 2.3. use different tools and mechanisms that better recognise, identify and articulate gender differences in health-related matters. 2.4. conduct proper gender analysis in order to identify gender inequities and gender inequalities that exist in certain communities and societies, with the relevance for health. 2.5 apply gender mainstreaming, as a process of assessing implications for women and men of any planned action, including legislation, policies or programs, in any area, and at all levels. 2.6 apply gender mainstreaming as an integral part of the design, implementation, monitoring and evaluation of policies and programs in all political, economic and societal spheres, so that women and men benefit equally. 2.7 propose set of actions that would overcome gender gap in achieving the fullest potential for health. r 2.7 structural and social violence (fimka tozija) theoretical and conceptual basis is provided for understanding structural and social violence, collective violence and armed conflicts as a public health problem: definitions, typology, burden, context, root causes and risk factors, public health approach, structural interventions and multilevel prevention. general overview of public health approach, ecological model and human rights approach is presented. the module also explains the impact of structural and social violence on health, human rights, the role of the health sector, and suggests a number of practical approaches for prevention and policy intervention. 1.0 the public health professional shall know and understand: 1.1 the theoretical and conceptual basis of structural and social violence, and armed conflicts as a public health problem: definitions, typology, burden and context. 1.2 root causes and risk factors for structural and social violence. 1.3 the main analytical methods and tools for structural and social violence: public health approach, ecological model and human rights approach as defined by the who. 1.4 the impact of structural and social violence on health and human rights. 1.5 the role of the health sector for prevention of structural and social violence. 1.6 health in all policies and evidence-based multilevel prevention programmes for structural and social violence. 1.7 practical approaches for prevention and policy intervention for structural and social violence prevention and the impact of resilient factors on structural and social violence prevention. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 9 2.0 the public health professional shall be able to: 2.1 apply analytical tools for structural and social violence: public health approach and ecological method. 2.2 determine the magnitude, burden and economic consequences of structural and social violence applying who methodology. 2.3 identify root causes and risk factors for structural and social violence at different levels and compare in different countries. 2.4 do case problem analysis and review of evidence-based multilevel prevention measures for structural and social violence. 2.5 translate knowledge in practice consider and apply successful practices from other countries for structural and social violence. 2.6 develop sustainable multilevel prevention programs for structural and social violence. 2.7 identify resilient factors to strengthen community capabilities, and contribute to reduction of structural and social violence. r 2.8 disaster preparedness (elisaveta stikova) the disaster and emergency preparedness and response core competences were created to establish a common performance goal for the public health preparedness workforce. this goal is defined as the ability to proficiently perform assigned prevention, preparedness, response, and recovery role(s) in accordance with established national, state, and local health security and public health policies, laws, and systems. much of an individual's ability to meet this performance goal is based on competences acquired from three sources: foundational public health competences, generic health security or emergency core competences, and position-specific or professional competences. 1.0 the public health professional shall know and understand: 1.1 the main definitions of disaster and emergencies (similarities and differences); role of hazard and vulnerability in disaster occurrence. 1.2 the aim of the disaster/emergency management and main components of the disaster’s management cycle. 1.3 the basic principles for development of disaster preparedness and importance of the appropriate risk assessment analysis. 1.4 the importance and the scope of the preparedness plan for the protection of the critical infrastructure, across the ten community’s essential sectors. 1.5 the specificity of the public health emergency preparedness plan and importance of the early warning and surveillance systems as key elements for assessing of the state of emergency. 1.6 the opportunities for using a combined remote sensing technology, geographic information systems (gis), spatial statistical techniques and mathematical models which can help in modelling of the dispersion of the harmful agent and exposure of the population to the harmful agent. 1.7 being familiar with the structure and components of the hospital preparedness plan and infrastructure safety. 2.0 the public health professional shall be able to: laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 10 2.1 demonstrate operational skills to use administrative measures, to implement strategies, and to improve coping capacities in order to lessen the adverse impacts of hazards and to minimize the opportunity for development of disaster. 2.2 apply analytical tools and to perform early and initial risk assessment. 2.3 design a specific preparedness plan for the protection and strengthen the resilience of the critical infrastructure of the community, across the ten essential sectors. 2.4 develop the government preparedness actions grouped into five general categories: planning, resources and equipment, exercise, training and statutory authority. 2.5 identify the 15 public health and health-care preparedness capabilities as the basis for state and local public health and health-care preparedness. 2.6 develop an emergency response plan (erp) and associated early warning and surveillance functions, training and exercises using an “all-hazard/whole-health” approach applicable in public health emergency. 2.7 to communicate and manage the need for use of the public national/international network of public health laboratories for rapid detection and identification of unknown agents and/or confirmation of known agents. 2.8 develop hospital preparedness plan taking into account such factors as the appropriateness and adequacy of physical facilities, organizational structures, human resources, and communication systems. r 2.9a millennium and sustainable development goals (marta lomazzi) the millennium development goals (mdgs) are eight international development goals to be achieved by 2015 addressing extreme poverty, hunger, maternal and child mortality, communicable disease, education, gender equality and women empowerment, environmental sustainability and the global partnership. most activities worldwide have focused on maternal and child health as well as communicable diseases, while less attention has been addressed to environmental sustainability and the development of a global partnership. in 2015, numerous targets have been at least partially attained. however, some goals have not been achieved, particularly in the poorest regions, due to different challenges. the post-2015 agenda is now set. the new goals, the sustainable development goals (sdg), reflect today’s geopolitical, economic and social situation and adopt an all-inclusive, intersectoral and accountable approach. 1.0 the public health professionals shall know and understand: 1.1 what are the millennium development goals, including targets and indicators? 1.2 achievements and failures of mdgs at global, regional and national levels. 1.3 mdgs and inequalities: how and where the goals have or not reduced inequalities and disparities. 1.4 the impact of the mdgs in shaping the public health agenda 2000-2015, mobilizing the public health community and in revitalizing the development aid. 1.5 how progresses have been measured and evaluated. availability and accountability of data on mdgs achievements and failures. 1.6 whether and how mdgs have impacted local and global governance, policies set-up and education approaches. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 11 1.7 the basic concepts underlying the subsequent sdgs. 2.0 the public health professional shall be able to: 2.1 demonstrate a basic understanding of the relationship between mdgs, health, economic growth and governance. 2.2 understand the tools and reports used to evaluate mdgs and make a critical reading of the results and articles. this should include also analysis and critical evaluation of the impact of donors in shaping the agenda and achieving the targets. 2.3 compare the results of the mdgs to the intended achievements of the sdgs at local, regional and global level. 2.4 identify root causes and facilitators that impacted most the failure or achievements of mdgs. 2.5 translate knowledge in practice consider and apply successful practices from effective mdgs and early sdgs activities that can be applied in other contexts. 2.6 identify methods for assuring health sector programme sustainability and apply them to model implementation. 2.9b the un-2030 sustainable development goals (george lueddeke) following the millennium summit of the united nations in 2000, the adoption of the united nations (un) millennium declaration by 189 nations, including the eight millennium development goals (mdgs), was hailed as a unique achievement in international development.1 although the mdgs raised the profile of global health, particularly in low and middle-income countries, underpinned by the urgent need to address poverty worldwide, progress was uneven both between and within countries.1 with over one billion people, africa is a case in point. aside from children completing a full course in primary school and achieving gender equality in primary school, none of the twelve main targets set for ss africa has been met. a key reason suggested for this lack of progress was that the mdgs fell far short in terms of addressing the broader concept of development encapsulated in the millennium declaration, which included human rights, equity, democracy, and governance.2 on 25 september 2015, 193 member states of the united nations general assembly ratified the un 2030 sustainable development goals (sdgs) or un -2030 global goals, as they are also called.3 extending the breadth and depth of the mdgs dramatically, the sdgs, as shown in figure 2.9.1, are ‘a universal call to action to end poverty, protect the planet and ensure that all people enjoy peace and prosperity.3 framing the sdgs involved the largest consultatory process within the history of the un with contributions from more than a million people and an ‘expert group’ of over 3000 participants from over a hundred countries and six continents. the 17 sdgs are intended to be ‘integrated and indivisible, global in nature and universally applicable’ while ‘respecting national policies and priorities’3 and officially came into force in january 2016. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 12 figure 2.9.1: the un -2030 sustainable development goals4 the sdgs provide a synthesis of major global issues and place collaborative partnerships (#17) at the centre of strategic implementation strategies. given the state of the planet, their adoption could not come too soon as, according to marco lambertini, director general of wwf international, transformative change is now imperative challenging global leaders to respond to three main questions5:  ‘what kind of future are we heading toward?  what kind of future do we want?’  ‘can we justify eroding our natural capital and allocating nature’s resources so inequitably?’ his concerns go beyond the immediate un -2030 global goals and demand finding, first and foremost, a lasting ‘unity around a common cause.’5,6 his message is intended for the public, private and civil society sectors and implores these stakeholders to be proactive, to “pull together in a bold and coordinated effort,” for “heads of state” to think globally; businesses and consumers, ‘to stop behaving as if live in a limitless world’ – before facing inevitable and potentially disastrous consequences. the three un historical milestones in 2015 the addis ababa conference, the un-2030 sdgs and the paris climate accord7 represent major un achievements although translating the vision and the goals into viable policies and enabling strategies, nationally and locally “on the ground”, presents considerable hurdles.6,7 social, political and economic dichotomies remain and finding “middle ground,” without sacrificing basic values and principles, of all stakeholders will be key to their success. the new goals, the sustainable development goals (sdg), reflect today’s geopolitical, economic and social situation and adopt an all-inclusive, inter-sectoral and accountable approach.6 1.0 the public health professionals shall know and understand: 1.1 the achievements and failures of mdgs at global, regional and national levels. 1.2 mdgs and inequalities: how and where the goals have or not reduced inequalities and disparities. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 13 1.3 the impact of the mdgs in shaping the public health agenda 2000-2015, mobilizing the public health community and in revitalizing the development aid. 1.4 beginning with the rio+20 conference the future we want, describe the process (e.g., “global conversations, world survey) leading up to the un 2030 sustainable development goals and how it differed from the mdgs. 1.5 the 17 goals and targets agreed by the un general assembly in 2015 and the indicators8 identified to date. 2.0 the public health professional shall be able to: 2.1 understand the tools and reports used to evaluate the sdgs and make a critical reading of the results and articles. this should include also analysis and critical evaluation of the impact of donors in shaping the agenda and achieving the targets. 2.2 determine the impact to date of the sdgs at local, regional and global levels. 2.3 identify the roles played by various un groups responsible for implementing the sdgs the un general assembly, the economic and social council , the united nations high-level political forum on sustainable development (hlpf), division for sustainable development goals (un-desa), the united nations development program (undp).9 2.4 determine extent to which your country is involved with advancing the sdgs and progress to date. 2.5 examine how the implementation of the sdgs could be informed and strengthened by the one health and well-being concept and approach.6 2.6 translate knowledge in practice consider and apply successful practices from effective sdgs activities that can be applied in other contexts. develop preventive programs on that basis. 2.7 identify methods for assuring prevention program sustainability. 2.8 explore how public health professionals might play a much more pivotal role –locally, regionally, nationally and globally in the implementation of the sdgs.6,7 references2 2 references: (1) united nations. the millennium development goals report 2015. available at: http://www.un.org/millenniumgoals/2015_mdg_report/pdf/mdg%202015%20rev%20(july%201).pdf (2) lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights. available at: http://www.seejph.com/index.php/seejph/article/view/42 (3) united nations. transforming our world: the 2030 agenda for sustainable development. available at: https://sustainabledevelopment.un.org/post2015/transformingourworld (4) united nations. sustainable development goals. available at: https://www.un.org/sustainabledevelopment/sustainable-development-goals/ (5) wwf. living planet index 2014. available at: https://www.wwf.or.jp/activities/data/wwf_lpr_2014.pdf (6) lueddeke g. survival: one health, one planet, one future. london: routledge; 2019. (available at: https://www.crcpress.com/survival-one-health-one-planet-onefuture/lueddeke/p/book/9781138334953) (7) lueddeke g .global population health and well-being. toward new paradigms, policy and practice. new york: springer publications; 2016. (8) united nations. sdg indicators. available at: https://unstats.un.org/sdgs/indicators/indicators-list/ (9)united nations. sustainable development. knowledge platform. available at: https://sustainabledevelopment.un.org/ https://sustainabledevelopment.un.org/index.php?menu=1298 https://www.un.org/ecosoc/en/ http://www.un.org/millenniumgoals/2015_mdg_report/pdf/mdg%202015%20rev%20(july%201).pdf http://www.seejph.com/index.php/seejph/article/view/42 https://sustainabledevelopment.un.org/post2015/transformingourworld https://www.un.org/sustainabledevelopment/sustainable-development-goals/ https://www.wwf.or.jp/activities/data/wwf_lpr_2014.pdf https://www.crcpress.com/survival-one-health-one-planet-one-future/lueddeke/p/book/9781138334953 https://www.crcpress.com/survival-one-health-one-planet-one-future/lueddeke/p/book/9781138334953 https://unstats.un.org/sdgs/indicators/indicators-list/ laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 14 r 2.10 health and wellbeing (francesco lietz) teach a man to fish and you feed him for a lifetime” they say: promoting well-being is not so distant a concept from teaching how to fish, since high levels of well-being are correlated to a reduction of diseases and mental disorders, and vice versa. well-being can be studied at two different levels: internal/subjective, whose measures rely on how a respondent places him or herself on a scale; or external/objective, measured through demographics and material conditions. the promotion of well-being has been indicated by the united nations as one of the 17 sustainable development global goals sdg 3) to be achieved over the next 15 years. in order to face this workload public health professionals with the ability to think globally and act locally are needed. 1.0 the public health professional shall know and understand: 1.1 main concepts of well-being, happiness, quality of life, wealth, and life satisfaction. 1.2 main determinants of well-being: from the definitions to the potential applications in programs and interventions. 1.3 the optimal research tools for well-being in the different cultures and the different life stages. 1.4 the application of the theory in the context of the sustainable development goals. 1.5 the different strategies of the health sector to implement well-being programs and initiatives. 1.6 how to predict future pathways of well-being at regional and national levels. 2.0 the public health professional shall be able to: 2.1 choose the best measurement tools for well-being according to the environment’s requests. 2.2 take into account the importance of cross-culturalism and different population groups in well-being assessment. 2.3 optimize the process of communicating knowledge in the scientific environment. 2.4 taking under consideration the multidimensional aspect of well-being when developing prevention programmes. 2.5 anticipate future trends in order to assure programme sustainability. 2.6 implement concepts to empower the stakeholder at all levels so that they can strengthen community capabilities. r 2.11 the global financial crisis and health (helmut wenzel) the economic situation influences the health status of a population in many ways. the financial crisis has now given greater weight on an old debate about the financial sustainability of health systems in europe. drivers of health expenditures will be critically analysed. the vulnerability of public budgets and its consequences for health budgets is depicted. the toolset of politics, and policies applied by policy-makers will be analysed. managed care approaches are presented and evaluated. 1.0 the public health professional shall know and understand: laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 15 1.1 the interdependencies of health and national economies at times of global market and global competition. 1.2 the relationship between unemployment, unsecure living conditions and related health problems. 1.3 the constraints of financing and setting up health budgets and measures to cope with discrepancy between needs and financial power. 1.4 the main drivers of health care demand and the arguments of changing demand of health care by quantity and quality. 1.5 the operation and financing of health care systems with respect to their underlying national premises (beveridge, bismarck etc.). 1.6 managed care and integrated care approaches, their organisational structures and their opportunities to improve cooperation and increase efficiency of provision of care. 2.0 the public health professional shall be able to: 2.1 critically analyse health care systems and their connected budgeting processes 2.2 apply knowledge and skills needed for recommending a redesign of selected health care systems. 2.3 apply analytical tools to identify particularly vulnerable areas of health care in a constrained environment such as neonatal medical care. 2.4 identify imbalances in care delivery like the affordability of out-of-pocket purchased medicines among the elderly and retired citizens. 2.5 identify imbalances in access to the most expensive medical technologies such as targeted biologicals indicated in cancer and autoimmune diseases, radiation therapy; various implantbased interventional radiology, orthopaedic and cardiovascular surgical procedures. 2.6 to understand the relevance of catastrophic household expenditure imposed by illness among the world’s poor residing in low and middle income countries (increased vulnerability during crisis evidenced). 2.7 review the literature and design a case study for analysing the impact of the crises on health outcomes, based on secondary statistics. r 3.1 global governance of population health and well-being (george lueddeke) strengthening the health of populations and the health systems requires a “glocal” perspective being aware of the essential role of governments and to consider the adoption of a new mindset in meeting global challenges to planet health and well-being, applying, where appropriate and feasible, the ‘one world, one health’ concept. furthermore, there is the need for a new form of global governance that is ‘fit for the 21st century’ and is able to effectively respond to unprecedented environmental, societal, economic and geopolitical hurdles and lead the way to a safer, fairer and equitable future for all. 1.0 the public health professional shall know and understand: 1.1 how global trends in public health practice, in commerce and in culture contribute to health and the quality and availability of health services locally and internationally. 1.2 the role of key actors in global health including the world health organization, united laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 16 nations, world bank, multilateral and bilateral organisations, foundations, non-governmental organisations (ngos); and their interactions, power, governance and different approaches to global health. 1.3 how global actors provide resources, funding and direction for health practice and research locally and globally, and the effects that this has on individual and population health. 1.4 how global funding mechanisms can influence the design and outcome of research strategies and policies, and how policies made at a global or national level can impact on health at a local level. 1.5 different national models for public and/or private provision of health services and their impact on the health of the population and individuals. 1.6 how globalisation and trade including trade agreements affect availability of public health services and commodities such as patented or essential medicines. 1.7 the barriers to recruitment, training and retention of human resources in underserved areas such as rural, inner-city and indigenous communities within highand low-income countries. 2.0 the public health professional shall be able to: 2.1 promote the function/intention of the sdgs and identify health-related objectives, including: 1. reduce child mortality; 2. improve maternal health; 3. eradicate extreme poverty and hunger; 4. combat hiv/aids, malaria, tuberculosis and other diseases. 2.2 critically comment on policies with respect to impact on health equity and social justice. 2.3 explain the advantages of collaborating and partnering and to select, recruit, and work with a diverse range of global health stakeholders to advance research, policy, and practice goals, and to foster open dialogue and effective communication. 2.4 identify barriers to appropriate prevention and treatment in low-resource settings and publicise especially the effect of distance and inadequate infrastructure (roads, facilities) on the delivery of health services. 2.5 develop health service delivery strategies in low-resource settings, especially the role of community-based health services and primary care models taking into consideration the benefits and disadvantages of horizontal and vertical implementation strategies. 2.6 advise on the impact of trade regulations on health, for example through impact on access to clean water, taxation, tobacco use, alcohol and fast-food consumption, antibiotic use and health service provision. 2.7 advocate for effective systems to facilitate global responses to international health emergencies, including timely, well-supported and appropriate movement of health professionals across borders during and after the event. 2.8 participate in responsible social media use to promote health locally, nationally or globally, informed by an understanding of how telecommunications influence global and local health. r 3.2 health programme management (christopher potter) health development interventions are described as falling under four modalities: personnel, projects, programmes and policy reform initiatives underpinned by new financial support mechanisms, particularly sector-wide approaches (swaps). these modalities are briefly analysed to provide an introduction to readers about how and why such interventions are used, and their strengths and weaknesses. it is emphasised that the modalities are not hard laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 17 and fast entities but frequently overlap. indeed one of the problems facing those designing and implementing interventions is the fuzzy nature of many management terms. such issues as vertical and horizontal programme design and the transaction costs to governments who have to deal with many donors in an often relatively short-term and fragmentary manner are considered. swaps are considered as one way of dealing with some of these issues but it is noted that as many other non-state stakeholders, including industrial and commercial interests, have entered the health development arena, the possible, although contended advantages, of swaps have been compromised. finally, it is recognised that the public health challenges and their socio-political and economic contexts facing poorer countries are ever changing, so finding effective ways to deliver health development to the world’s most needy will also be an on-going challenge. 1.0 the public health professional shall know and understand: 1.1 to participate effectively in the world of actual global health care development. 1.2 the key expressions widely used within international health development activities such as “project” and “project management”, “programme,” including “vertical” and “horizontal” programmes, and “log-frame” among others. 1.3 common management techniques related to project design, monitoring and evaluation, and different approaches for activities with which they are engaged. 1.4 the action and interaction of the various development agencies and other stakeholders active within applied health development activities. 1.5 the concerns that underpin attempts at health sector reform, and the importance socioeconomic drivers that mean more nuanced approaches must be used in different locations. 2.0 the public health professional shall be able to: 2.1 work efficiently within health development environments carrying out such activities as bidding for projects, designing project implementation and appreciating the needs of different stakeholders, including political and commercial actors. 2.2 apply scientific evidence throughout program planning, implementation, and evaluation. 2.3 design program work plans based on logic models. 2.4 develop proposals to secure donor and stakeholder support. 2.5 plan evidence-based interventions to meet internationally established health targets. 2.6 develop monitoring and evaluation frameworks to assess programmes. 2.7 develop context-specific implementation strategies for scaling up best-practice interventions. r 3.3 civil society organisations in health (motasem hamdan) the role of the civil society for health is increasingly recognized, mainly due to the historical development of non-governmental organizations. their role in health and social development as well as in global scale is nowadays indispensable. there should be, however, a regulating framework or code of conduct. 1.0. the public health professional shall know and understand: 1.1 the concepts of civil society organizations. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 18 1.2 the historical development and the roots of ngos work. 1.3 the types, features of ngos and area of activity in different countries. 1.4 the methods of funding ngos. 1.5 the role of ngos in health system development, health policy, and health research. 1.6 the challenges of regulating and coordinating the work of ngos. 2.0 the public health professional shall be able to: 2.1 to analyze the impact of ngos on health, and health care systems. 2.2 to identify measures to enhance accountability and regulate the work of ngos. 2.3 to apply analytical tools to understand the coordination and harmonization of the work of the civil society organizations to national health priorities. 2.4 help to assure the capacity of the government to control the work of ngos based on regular full reporting. 2.5 apply mechanisms to provide, prolong or deny the permission for ngos to work in the country. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 19 r 3.4 universal health coverage (jose m. martin-moreno, meggan harris) nearly half of all countries worldwide are pursuing policies to achieve universal health coverage. this undertaking has the potential to improve health indicators dramatically, contributing to human development and more generally to global equity. however, the path towards uhc is often rocky, and every country must work to channel resources, adapt existing institutions and build health system capacity in order to accomplish its goals. global health advocates must understand what elements contribute to the success of uhc strategies, as well as how to measure real progress, so that they will be prepared to substantially contribute to policies in their own country or worldwide. 1.0. the public health professional shall know and understand: 1.1 the concepts and the rationale of universal health coverage (uhc) and its linkage with health financing and public-private partnership for health. 1.2 the roles and contributions of the private sector, communities, and the traditional medicine in promoting and sustaining uhc. 1.3 the political, social, economic and technical aspects of the health financing transition. 1.4 specific reasons for slow and stagnating progress in uhc. 1.5 the role of international cooperation in implementing uhc successfully. 2.0 the public health professional shall be able to: 2.1 advocate in favour of uhc strategies in health policies and programmes at global, regional, and national levels. 2.2 assess progress towards uhc employing a standardised methodology. 2.4 bring national and international partners together to advance the implementation of uhc. 2.3 enhance critical and strategic thinking when designing a uhc programme, both in a national context and as part of an external development strategy. 2.5 secure the sustainability of uhc implementation by highest level political and legal approval. r 3.5 public health leadership in a globalised world (katarzyna czabanowska, tony smith, kenneth a. rethmeier) leadership is a well-known concept within organisational science, public health leadership has still not been well-defined. a recent who report acknowledges that contemporary health improvement is more complex than ever before and requires leadership that is “more fluid, multilevel, multi-stakeholder and adaptive” rather than of a traditional command and control management variety. today’s public health professionals therefore need to be able to lead in contexts where there is considerable uncertainty and ambiguity, and where there is often imperfect evidence and an absence of agreement about both the precise nature of the problem and the solutions to it. the impact of the evolving growth of the eu and its impact on the potential mobility of healthcare professionals to re-locate across many geographic regions has left, in some communities, a gap in the resources of seasoned healthcare leaders. while this trend opens new opportunities for emerging young healthcare professionals to take on greater roles guiding their healthcare systems, it has also produced a significant need for high quality leadership development educational needs. there is a need to discuss and laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 20 provide professional development with a concentration on the vital role of leadership and governance play in public health globally. indeed, the presence of competent leaders is crucial to achieve progress in the field. a number of studies have identified the capability of effective leaders in dealing with the complexity of introducing new innovations or evidencebased practice more successfully. 1.0 the public health professional shall know and understand: 1.1 to demonstrate diplomacy and build trust with community partners. 1.2 to communicate joint lessons learned to community partners and global constituencies. 1.3 to exhibit inter-professional values and communication skills that demonstrate respect for, and awareness of, the unique cultures, values, roles/responsibilities and expertise represented by other professionals and groups that work in global health. 1.4 to apply leadership that support collaborative practice and team effectiveness. 2.0 the public health professional shall be able to3: 2.1 communicate in a credible and effective way: expresses oneself clearly in conversations and interactions with others; listens actively. 2.2 to produce effective written communications and ensures that information is shared. positive: speaks and writes clearly, adapting communication style and content so they are appropriate to the needs of the intended audience conveys information and opinions in a structured and credible way encourages others to share their views; takes time to understand and consider these views ensures that messages have been heard and understood keeps others informed of key and relevant issues negative: does not share useful information with others does little to facilitate open communication interrupts or argues with others rather than listening uses jargon inappropriately in interaction with others lacks coherence in structure of oral and written communications; overlooks key points 2.3 to produce and deliver quality results; is action oriented and committed to achieving outcomes. positive: demonstrates a systematic and efficient approach to work produces high-quality results and workable solutions that meet client needs monitors own progress against objectives and takes any corrective actions necessary acts without being prompted and makes things happen; handles problems effectively takes responsibility for own work sees tasks through to completion negative: focuses on the trivial at the expense of more important issues provides solutions that are inappropriate or in conflict with other needs. 3 for this section on public health leadership the positive/negative categorization otherwise not employed has been kept as an interesting example of future conceptual improvement of competence development. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 21 focuses on process rather than on outcomes delivers incomplete, incorrect or inaccurate work fails to monitor progress towards goals; fails to respect deadlines delays decisions and actions 2.4 to succeed as an effective and efficient health system manager positive: personal qualities (leadership): manages ambiguity and pressure in a self-reflective way. uses criticism as a development opportunity. seeks opportunities for continuous learning and professional growth. works productively in an environment where clear information or direction is not always available remains productive when under pressure stays positive in the face of challenges and recovers quickly from setbacks uses constructive criticism to improve performance shows willingness to learn from previous experience and mistakes, and applies lessons to improve performance seeks feedback to improve skills, knowledge and performance negative: demonstrates helplessness when confronted with ambiguous situations demonstrates a lack of emotional control during difficult situations reacts in a hostile and overly defensive way to constructive criticism fails to make use of opportunities to fill knowledge and skills gaps consistently demonstrates the same behaviour despite being given feedback to change transfers own stress or pressure to others r 3.6 public health ethics (alexandra jovic-vranes) the basic concept of public health ethics covers principles and values that support an ethical approach to public health practice and provide examples of some of the complex areas which those practicing, analysing, and planning the health of populations have to navigate; a code of ethics is the first explicit statement of ethical principles inherent to public health. 1.0 the public health professional shall know and understand: 1.1 how to identify an ethical issue and the principles of ethical decision-making. 1.2 the various conceptions of human rights, including those of the community. 1.3 basic ethical concepts such as justice, virtue and human rights. 1.4 the tension between rights of individuals and community health, and the relevance of consent at the individual and group level. 1.6 the ethical value the public health community gives to prevention. 1.7 how to build and maintain public trust. 2.0 the public health professional shall be able to: 2.1 consider the values of diverse stakeholders when conducting needs assessments and evaluations. 2.2 recognise the ways that advocacy and empowerment can be done. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 22 2.3 represent the needs and perspectives of all relative stakeholders with particular attention to the disenfranchised 2.4 identify the range of options for obtaining consent at the individual and group level 2.5 discern the risks and benefits of not acting quickly or not acting at all. 2.6 determine the range of appropriate actions for addressing unethical behaviour. 2.7 identify interests and conflicts of interest between potential partners. r 3.7 the global public health workforce (milena santric-milicevic, vesna bjegovic-mikanovic, muhammad wasiful alam) the progress of health sciences and technological innovations including modern medicine and health care technologies has increased our expectations for quality of life and health care. that has influenced the public health vision, the scope of public health interventions, and the composition of public health workforce. the outline the text includes description of the current situation of the public health workforce globally; future needs assessment; public health workforce challenges and mitigation globally. it underscores the demand for valid, reliable data sources and tools for mobilization of capacities of skilled public health staff in order to appropriately address global health challenges. 1.0 the public health professional shall know and understand: 1.1 health data sources and tools; data integration analysis and reporting; 1.2 surveillance of health system performance; 1.3 identification and monitoring of health hazards; occupational health protection; food safety; road safety; 1.4 primary prevention; secondary prevention; tertiary/quaternary prevention; social support; 1.5 economic assessment (e.g. cost-effectiveness analysis) of different healthcare procedures or programmes. 1.6 setting a national research agenda; 1.7 advocacy for public health improvement 2.0 the public health professional should be able to: 2.1 explore global health data sources and understand the limitations of these data. 2.2 identify the composite health measures and their use for health program monitoring, evaluation and priority setting. 2.3 examine the major categories of morbidity and mortality used by the world health organization (who) and institute of health metrics and evaluation ihme (communicable and parasitic diseases, maternal, perinatal and childhood conditions, and nutritional deficiencies, non-communicable conditions importance and injuries) 2.4 describe the concept of premature mortality including age, sex and cause specific mortality rates, life expectancy and years of life lost (yll). 2.5 demonstrate knowledge of the major global causes of morbidity and health risks, by describing the concepts of years lived with disability (yld) and disability adjusted life-year (daly). 2.6 describe the relative importance of each global burden of disease (gbd) category, how the leading gbd diagnoses (15 causes) within each category vary by age, gender and time, and explain potential contributors to the observed variations. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 23 2.7 explain how life expectancy, yld, yll and daly may be used to make general health comparisons within and/or between countries and who regions, and between high, middle and low-income regions, and draw implications for policy and practice. r 3.8 education and training of professionals for global public health (suzanne babich, egil marstein) by addressing the critical need for public health education and training within the global health workforce, we have in this program an opportunity to contribute substantially to efforts to improve the health of people worldwide through improved project management and resource application. topics introduced and discussed address the complexities of working with country specific agents, organizational representatives and formal and informal stakeholders who may influence the outcome of global health operations. 1.0 the public health professional shall know and understand: 1.1 key concepts related to stakeholder theory: how political, organizational and socioeconomic conditions affect critical operational premises in the governance of global health. 1.2 complexities associated with working with country specific agents: appreciate the makeup and workings of context specific forces as these impact global health initiatives; e.g. (i) identify key stakeholders and their impacts on health governance and leadership; (ii) evaluate culture-specific traits relevant for the professions, teams and organizational processes; (iii) analyze institutional governance as it applies to fieldwork planning and program execution; and (iv) recognize the dynamics of the global health field and how this needs be incorporated in operational strategies and actions. 1.3 principles of project management and resource application 1.4 how global health initiatives are financed through international aid 1.5 international standards for health program performance evaluation 2.0 the public health professional should be able to: 2.1 critique policies with respect to impact on health equity and social justice 2.2 describe the roles and relationships of the entities influencing global health 2.3 analyze the impact of transnational movements on population health 2.4 analyze context-specific policy making processes that impact health 2.5 describe the interrelationship of foreign policy and health diplomacy 2.6 conduct a situation analysis across a range of cultural, economic, and health contexts r 3.9 blended learning (željka stamenkovic, suzanne babic) blended learning is an educational model with great potential to increase student learning outcomes and to create new roles for teachers. in its basic and simplest definition, blended learning is an instructional methodology, a teaching and learning approach that combines face-to-face classroom methods with online activities. as a cost-effective way to overcome the issue of overcrowded classrooms, blended learning adds flexibility for students and offers a convenient alternative to learning. but it has quickly become much more than that. institutions with blended learning models may also choose to reallocate resources to boost laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 24 student achievement outcomes. the question of how to blend face-to-face and online instruction effectively is one of the most important we can consider as we move into the future. 1.0 the public health professional shall know and understand: 1.1 main concept of blended learning and 4 basic blended learning models: (1) rotation model, (2) flex model, (3) a la carte model and (4) enriched virtual model. 1.2 the differences between blended learning models and when each model should be applied. 1.3 how to integrate face-to-face and online learning in order to improve the learning outcomes. 1.4 how to implement and successfully accomplished blended learning process. 1.5 the main drivers of blended learning. 1.6 the advantages and disadvantages of blended learning for teachers. 1.7 the advantages and disadvantages of blended learning for students. 1.8 how global trends in technology may affect blended learning in public health. 2.0 the public health professional shall be able to: 2.1 use the technology tools and resources in order to support blended learning. 2.2 work in different environments and have the flexible time schedule. 2.3 know when blended learning is the best choice for the particular course. 2.4 design a successful blended learning strategy and identify methods for assuring successfully accomplished blended learning process. 2.5 target learning opportunities and act as a learning facilitator. 2.6 constantly support students who are learning different things, at different paces, through different approaches. r 3.10 global health law (joaquin cayon) transnational public health problems have been traditionally addressed through international health law whose proper implementation faces two important handicaps: the absence of an international authority that can enforce it, and the absence of a comprehensive concept. despite this, international agreements and treaties are among the most important intermediate public health goods because they provide a legal foundation for many other intermediate products with global public health benefits. nowadays, according to the emergence of the idea of global public health, a new concept -“global health law”has been born. there is an important distinction between international health law and global health law. international health law connotes a more traditional approach derived from rules governing relations among states. on the other hand, global health law is developing an international structure based on the world as a community, not just a collection of nations. there is also an important international trend leaded by some prestigious scholars who have urged adoption of a legally binding global health treaty: a framework convention on global health grounded in the right to health. in this context, an interdisciplinary approach to global public health inevitably requires the study of global health law for any healthcare professional. it is undoubtedly necessary to study and analyse the emergence and development of global health law just because it arises as an important tool to address the phenomenon of laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 25 globalization of health. in this regard, the future of global public health is directly dependent on the strength of global health law understood in a comprehensive way. 1.0 the public health professional shall know and understand: 1.1 theoretical and conceptual basis of global health law. 1.2 the rationale of studying global health law. 1.3 the increasingly interactive relationship between global health law and global public health. 1.4 the role of global health law as an important tool to deal with the phenomenon of globalization of health. 1.5 differences between international health law, global health law and global health jurisprudence. 1.6 how global health diplomacy brings together the disciplines of public health, international law and economics and focuses on negotiations that manage the global policy environment for health. 1.7 how international trade law, international labour law and international humanitarian law impact on national health systems. 2.0 the public health professional shall be able to: 2.1 demonstrate a basic understanding of the relationship between global health law and global public health. 2.2 develop skills for critical analysis of legal data and health information. 2.3 develop critical thinking skills and explore critically health systems from a legalnormative perspective. 2.4 do literature review and critical reading for globalization of health and the role of law. 2.5 identify the main international treaties on communicable disease control, world trade, environmental protection and working conditions that impact on public health. 2.6 employ a comprehensive and multidisciplinary approach for the analysis of the role of global law as a determinant of health. 2.7 compare differences between national and international legal framework on public health and develop proposals to improve health legislation both at national and international level. 2.8 identify key points to be included in a future global framework on public health. r 3.11 human rights and health (fiona haigh) human rights and health are intrinsically linked. health policies and practice can impact positively or negatively on rights and in turn human rights infringements and enhancements can influence health. increasingly human rights based approaches are being used to strengthen public health policies and programmes and as a powerful tool to advocate for the action on the social determinants of health. 1.0 the public health professional shall know and understand: 1.1 the key human rights concepts and the un treaty system. 1.2 the relationship between health and human rights. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 26 1.3 how social, economic, political and cultural factors may affect an individual’s or community’s right to health services (e.g. availability, accessibility, affordability, and quality). 1.4 the rationale for using human rights based approaches to health. 1.5 the relevance of human rights to global public health. 1.6 the key values in population ethics and the limitations of the utilitarian principle. in the implementation of public health programmes. the public health professional shall be able to: 2.1 analyse the right to health and how this right is defined under international agreements such as the united nations’ universal declaration of human rights or the declaration of alma-ata. 2.2 introduce the main objective of policies and programmes with regard to the fulfilment of human rights. 2.3 to identify rights holders and duty bearers, and the capacities of rights holders to make claims on duty bearers to meet their obligations. 2.4 operationalise in public health programmes the principles of population ethics as there are e.g. solidarity, equity, efficiency, respect for autonomy, and justice. 2.5 initiate collaborative efforts of multiple disciplines working locally, nationally, and globally, to achieve the best health and well-being. r 3.12 global financial management for health (ulrich laaser) world population growth takes place predominantly in the poor countries of the south whereas most of the resources are available in the north. the economic inequalities are related to key health indicators. although official development assistance (oda) and development assistance for health (dha) grew considerable during the last decade the objective of 0.7% of the northern gdp to be transferred to the south has not been reached by far. in order to correct the main weaknesses the international community agreed on the socalled paris indicators but failed the set timelines. the underlying reasons may be sought in the fragmentation and incoherence of international financial assistance. 1.0 the public health professional shall know and understand: 1.1 the major social and economic determinants of health and their effects on the access to and quality of health services and on differences in morbidity and mortality between and within countries. 1.2 the deeper reasons for the gap in wealth between the south and the north corresponding to vast disparities in standards of living, health, and opportunities. 1.3 the structures of international financial management in the health sector and their terminology as for example oda and dah 1.4 the five principles of the paris declaration on aid effectiveness and the results of the subsequent conferences. 1.5 the key global strategies to reduce the north-south gap including sdg 3. 1.6 how to analyse the critical aspects of loans to developing countries regarding intergenerational effects, and monetary back flows to the donors for experts and equipment. laaser u. (editor) the global public health curriculum – revised shortlist of specific global health competences (short reports). seejph 2018, posted: 10 september 2018. doi 10.4119/unibi/seejph-2018-199 27 2.0 the public health professional shall be able to: 2.1 analyse the underlying reasons for the failure in efficiently organizing international assistance as there is the extreme fragmentation and therefore ineffectiveness of international aid, and the insufficient coordinating capacities and competences in the national ministries of health making it difficult to secure ownership. 2.2 follow up and promote the latest evaluation of the paris indicators. 2.3 argue and act against imbalances in oda and dah due to political and economic interests of the donor countries. 2.4 design global, regional, national and local structures, organisational principles and mechanisms to improve and sustain global health and well-being, including universal health coverage. 2.5 work in a constructive and contributing way in the environment of a sector-wide approach or pool-funding. 2.6 contribute to the management of a medium term expenditure framework and to the improvement of debt and debt relief management (national health accounts, nha). 2.7 promote a code of ethics for ngos taking into consideration their increasing relevance in channelling aid to developing countries. © 2018 laaser u (ed.); this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 1 of 16 original research digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health coverage jameel ismail ahmad1, murtala jibril2, barroon isma’eel ahmad3, abdurrahman suleiman4, nasir sani inuwa5, abdullahi garba ali6, salihu ibrahim ismail7 1. department of surgery, faculty of clinical sciences, bayero university kano/ aminu kano teaching hospital, kano, nigeria. 2. department of pharmacology and therapeutics, faculty of pharmaceutical sciences, bayero university, kano, nigeria 3. department of computer science, ahmadu bello university, zaria, nigeria 4. hubuk technology, zoo road, kano, nigeria 5. first monument city bank (fcmb), nigeria. 6. faculty of computer science and information technology, bayero university, kano, nigeria. 7. department of biochemistry, federal university dutse, jigawa state, nigeria corresponding author: jameel ismail ahmad mbbs, fwacs, mba; address: department of surgery, faculty of clinical sciences, bayero university kano, aminu kano teaching hospital, kano, nigeria; email: iajameel@yahoo.com ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 2 of 16 abstract introduction: the covid-19 pandemic highlighted the need for evolving an integrated healthcare ecosystem that will connect patients to digital and home healthcare to achieve universal health coverage. the survey aims to assess perceptions and preferences about digital and home healthcare services and develop an integrated healthcare ecosystem. methods: a survey of 254 nigerians was conducted to assess their awareness, preferences, and willingness to pay for digital and home healthcare services using electronic questionnaires, and the data were analysed using spss 16.0. results: males constituted 70.9%, and 61.4% were aged ≤35 years. two-third were clients, and a third were healthcare providers. although about 71% patronized public hospitals, there was poor satisfaction (31.7%) than those attending private hospitals that were more satisfied. the male gender, private hospital utilization, and age of ≤35 years were associated with the satisfaction with or 1.19 (95% ci 0.69-2.05), or 1.22 (95% ci 0.73-2.04), and or 2.41 (95% ci 1.384.20) respectively. thirty minutes was the acceptable delay in receiving care by most respondents. only 39.4% were aware of digital health, and 52.8% were aware of home healthcare. male gender was associated with dh awareness, while being a healthcare provider was associated with both dh and home healthcare awareness. the respondents' median amount was willing to pay for dh and hh respondents is $1.64 $6.56 and $3.28 – $6.56, respectively. conclusion: in response to the survey result, we designed an integrated hospital, digital, and home healthcare project named edokta, to leapfrog the attainment of universal health coverage in nigeria. keywords: digital health, home healthcare, universal health coverage, healthcare ecosystem ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 3 of 16 introduction nigeria is the most populous country in africa and is poised to become the third most populous in the world by 2050 (1). poverty, inequality, and poor access to health have kept the citizens' life expectancy low. the nigerian healthcare system is bedeviled with a lack of human resources, infrastructural and system challenges, which threaten the attainment of universal health coverage (uhc). to ameliorate that, nigeria developed a national health information communication technology (ict) strategic framework 2015-2020 with the vision: "by 2020 health ict will help enable and deliver universal health coverage in nigeria" (2). this strategic framework provides for the identification, prioritization, and application of appropriate icts that can strengthen the national health system. poor implementation of the framework led to poor results by 2020. one of the most essential strategies for improving the provision of quality health care to attain uhc in resource-constrained settings is the effective utilization of digital health (dh). digital health is defined as a system that connects and empowers people and populations to manage health and wellness, augmented by accessible and supportive provider teams working within flexible, integrated and interoperable, and digitally-enabled care environments that strategically leverage digital tools, technologies, and services to transform care delivery (3). it is also defined as the application of ict to advance health services delivery." the term dh is also used interchangeably with ehealth. the world health assembly (wha) recognized the role of dh in healthcare delivery in resolution wha 58.28 (2005): "ehealth is the cost-effective and secure use of ict in support of health and health-related fields including healthcare services, health surveillance, health literature, and health education, knowledge and research. mhealth is a subset of ehealth and involves providing health services and information via mobile technologies such as mobile phones, tablet computers, and personal digital assistants. dh is a tool for the achievement of goal 3 of the sustainable development goals by 2030, which is to "ensure healthy lives and promote well-being for all at all ages," particularly its article 8 to "achieve universal health coverage (uhc)" in ensuring people access quality healthcare without falling into financial catastrophes (4,5). the role of dh cut across healthcare financing, health service delivery, human resources training, health system support, and health information system. despite these potentials, dh implementation has taken a slow course, especially in many african countries. some of the challenges hampering its scaleup in many developing countries are issues bordering on usability, technology integration and interoperability, data security, and privacy, reliability, network access, affordability, acceptability, illiteracy, funding, trained human capacity, policy, and regulation (6,7). the application of dh in africa has gained momentum over the past decade, essentially due to the digital revolution brought about by the increasing penetration of mobile technology and internet use, which stood at 80.8% and 25.1% as of 2018. this is further enhanced by the proliferation of affordable smartphones, particularly from china (5). these factors have afforded a great opportunity, which could improve the ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 4 of 16 smooth launching of various dh platforms, but there is a need to understand enablers for their effective utilization. a feasibility survey was conducted to develop a sustainable dh platform that will facilitate the attainment of sdgs. the objectives of the study are to assess the respondents' perceptions about conventional hospital-based care; set awareness and preferences of dh and home healthcare; determine the willingness to pay for dh and hh services; and then develop an integrated healthcare ecosystem that will incorporate hospital-based, digital and home healthcare services to achieve uhc. methods an online survey to assess the awareness, preferences, and willingness to pay for nigerians' dh and home healthcare services was conducted in december 2019 electronically using google forms. (8) the data was automatically received, and a microsoft excel spreadsheet version of the data was generated. the data was then transferred and analysed using statistical product and service solutions (spss) 16.0. basic information, perceptions, and awareness of hospital based, digital, and home healthcare and their association to age, sex, status, and hospital being utilized was analyzed. results two hundred and fifty-four (254) respondents electronically filled the online questionnaire representing a response rate of 84.7%. the respondents include those living in all 36 states and the capital of nigeria. however, 69.7% were living in kano state. males constituted 70.9%, while 61.4% and 38.6% were aged ≤35 years and >35 years, respectively. the respondents include civil servants (40.2%), medical doctors (31.5%), traders/businesspersons (8.3%) and 11.4% were unemployed. others include other health workers, bankers, engineers, and software developers. healthcare providers constituted 36.2%, while clients were 63.8%. (table 1) table 1: respondents’ baseline characteristics over-all percentage % (n=254) age (years) ≤35 61.4(156) >35 38.6(98) sex female 29.1(74) male 70.9(180) status clients 63.8(162) providers 36.2(92) hospital being utilised private 28.7(73) ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 5 of 16 public hospitals were the most utilized by 71.3% of the respondents. the level of satisfaction is better with the private hospitals as 60.3% of the respondents were satisfied in contrast to only 31.7% who were satisfied with the public hospitals. younger age ≤35 years, male gender, and private hospital patronage were associated with reasonable satisfaction with or 1.22 (95% ci 0.73-2.04), or 1.19 (95% ci 0.69-2.05), and or 2.41 (95% ci 1.38-4.20) respectively. only a quarter of the respondents considered lack of trained staff, while delay in receiving care and poor staff attitude featured prominently by 74% and 63% of the respondents. lack of feedback from hospitals and health workers and lack of quality branded drugs are reasons for dissatisfaction by nearly a third of the respondents. thirty minutes was the acceptable delay in receiving care when sought for by 80% of the respondents. the dh awareness of the respondents was relatively low (39.4%) and male gender and being a healthcare provider associated with the awareness or 1.40 (95% ci 0.80-2.47) and or 1.40 (95% ci 0.83-2.36) (table 2). virtual booking for medical consultation, health education, and remote patient monitoring was the commonest dh services needed (figure 1). nearly two-thirds of the respondents preferred online dh services over mobile dh services, and 90.9% use android phones, while 8.3% use ios phones. more than half (52.8%) of the respondents were aware of home healthcare services which were significantly associated with respondents' status as healthcare providers, or 3.25 (95% ci 1.90-5.60) (table 3). approximately three-quarters (74.8%) of respondents believe it was operational, and 93.3% were willing to utilize the services. the home healthcare (hh) services needed include home consultation (81.3%), home delivery of purchased drugs (66.3%), and simple investigations (64.7%). other services include sample collection and delivery of results and nursing care. public 71.3(181) type of phone used ios 8.3(21) others 0.8(2) ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 6 of 16 figure 1: preferred digital health services by the respondents table 2: awareness of digital health and home healthcare digital health home healthcare awar e n=10 0 unaware n=154 or (95% ci) p-value awar e n=13 4 unaware n=120 or (95% ci) pval ue age (years) ≤35 57 99 0.74 (0.44-1.23) 0.291 78 78 0.75 (0.45-1.25) 0.3 02 >35 43 55 56 42 sex male 75 105 1.40 (0.80-2.47) 0.261 94 86 0.93 (0.54-1.60) 0.8 90 female 25 49 40 34 status provider 41 51 1.40 (0.80-2.47) 0.230 65 27 3.25 (1.90-5.60) 0.0 00 client 59 103 69 93 hospital patronized private 25 48 0.74 (0.42-1.30) 0.322 26 47 0.37 (0.21-0.66) 0.0 01 public 75 106 108 73 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% booking for medical consultation digital medical consultation digital health education remote patients monitoring ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 7 of 16 there is a remarkable willingness to pay for the dh and hh services. the median amounts the respondents were willing to pay for the digital booking for consultation, digital booking and physical consultation, digital booking and virtual consultation, and digital health education were $3.28 ($4.92), $6.56 ($6.56), $6.56 ($13.12) and $1.64 ($5.90) respectively. the median amounts (and interquartile range) the respondents were willing to pay for a home consultation, simple investigations, sample collection/results delivery, nursing care, and pharmaceuticals delivery were $6.56 ($13.12), $3.28 ($4.92), $3.28 ($4.92), $6.56 ($6.56) and $4.92 ($6.56) respectively. (table 3). table 3: willingness to pay for digital and home healthcare services in usd digital health services booking booking and physical consultation booking and remote consultation health education median (interquartile range) $ 3.28 (4.92) 6.56 (6.56) 6.56 (13.12) 1.64 (5.90) mean (sd)/$ 5.75 (±7.12) 8.98 (±9.06) 8.62 (±8.82) 5.60 (±21.90) home health services consultation basic investigations sample taking and results delivery nursing care pharmaceuticals delivery median (interquartile range) $ 6.56 (13.12) 3.28 (4.92) 3.28 (4.92) 6.56 (6.56) 4.92 (6.56) mean (sd)/$ 9.58 (±9.83) 6.76 (±32.05) 5.61 (±5.14) 8.64 (±12.03) 7.58 (±10.60) those younger than ≤35 years were more to pay a higher amount for digital booking, digital booking and physical consultation and health education with or:1.39, or:1.05, and or:1.38, respectively. at the same time, those patronizing private hospitals were more willing to pay for the digital booking and health education. females and those patronizing private hospitals were more willing to pay higher for all types of home healthcare services. at the same time, those older than 35 years were more willing to pay higher amounts for a home consultation, sample collection and results of delivery, nursing care, and pharmaceutical products. compared with the clients' willingness to pay for the services, healthcare providers were more willing to pay higher for all digital and home healthcare ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 8 of 16 services. (table 4). the healthcare providers' willingness to pay higher was more when the services involve consultation such as digital booking and physical consultation, digital booking and remote consultation and home consultation with or 2.31 (95% ci 1.363.91), or 2.21 (95% ci 1.30-3.78 ) and or 2.29 (95% ci 1.36-3.89) respectively. table 4: respondents willingness to pay higher than medium (wtph) and willingness to pay the medium and lower (wtpl) between healthcare providers and clients digital health services booking booking and physical consultation booking and remote consultation health education wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) providers 39(53) 1.51 (0.892.57) 46(46) 2.31 (1.36-3.91) 43(49) 2.21 (1.30-3.78) 43(49) 1.07 (0.641.79) clients 53(109) 1.00 49(113) 1.00 46(116) 1.00 73(89) 1.00 home healthcare services consultation basic investigations sample taking and results delivery nursing care pharmaceuticals delivery wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) providers 54(38) 2.29 (1.363.89) 46(46) 1.95 (1.153.28) 54(38) 1.49 (0.892.50) 41(51) 1.44 (0.862.43) 52(40) 1.12 (0.671.88) clients 62(100) 1.00 55(107) 1.00 79(83) 1.00 58(104) 1.00 87(75) 1.00 discussion the nigerian healthcare industry is pluralistically shared by the public and private sectors. although the public sector owns about 66% of the health facilities in nigeria, the private sector accounts for 70-75% of the total health expenditure (9). the public healthcare system is organized into primary comprising of primary healthcare services at the rural and community level, secondary consisting of general and specialist hospitals, and tertiary healthcare having the teaching hospitals and specialized medical centers. the private hospitals and clinics contribute significantly to nigeria's healthcare delivery all over the country (10). the healthcare budget is abysmally low as only 3.6% of nigeria's gdp was ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 9 of 16 spent on health, which translates to $14.6 billion in 2016. there is a considerable healthcare infrastructural gap and a massive brain drain of healthcare workers (11). it is estimated that about 3,000 new medical doctors are registered in nigeria annually. currently, nearly 2,000 doctors migrate from nigeria to other countries yearly, leaving a net of 1000 doctors and further widening doctors' deficit to about 260,000. nigerians spend an average of $1 billion on medical tourism annually abroad. nigeria has five hospital beds per 10,000 population (9,12). public hospitals' patronage remains high, with 71% of the respondents despite its poor satisfaction level (32%) when compared to private hospitals likely due to affordability factors. there is a higher satisfaction level (60%) among those who patronize private hospitals. there is evident worsening satisfaction of hospital services over the years compared to kano reports a decade ago by iliyasu et al. when the satisfaction level was 83% (13). the satisfaction level is lower than reports from different parts of nigeria and ethiopia (14–19). this could be attributable to infrastructural and personnel deficits despite an increasing population, bureaucracy, and ongoing disruption of healthcare services due to industrial actions by health workers. based on the perceived reasons for dissatisfaction, any intervention that will shorten the duration to receiving care within the first 30 minutes, teach an empathic and memorable staff attitude, provide access to quality drugs and ensure appropriate feedback will significantly improve clients' satisfaction. there is a need to enhance the satisfaction level, especially to the older respondents and females. the differential satisfaction between the public and private hospitals calls for studying and emulating the delivery of services in private hospitals so that the public hospitals could equally improve the satisfaction. digital health and home healthcare have the potential of filling these gaps. digital technology can facilitate healthcare delivery at different levels (system, center, professional and patient levels). supply chain management and an integrated platform for booking and payment can be facilitated at the system level. at the same time, the availability of remote patient monitoring and remote diagnostics can be improved at the center level. similarly, education/training and data collection and reporting will be relevant at an individual professional level. at the same time, health and wellness information and medical advice will affect patients' levels (20). the world health organization (who) classified dh interventions into interventions for clients, interventions for healthcare providers, interventions for a health system or resources management, and interventions for data services (21). dh improves access to health, quality of care and reduces healthcare costs through many applications that can contribute to sustainable development goals. these applications include electronic health records (ehr), telemedicine/telehealth, mhealth, elearning, the connection of medical devices via the internet of things (iot), and personal health using wearable devices (20,22,23). there is an unprecedented rise in teledensity, internet penetration, and social media usage globally, but more phenomenal in africa. there are 1.049 billion mobile users, 473 million internet users, and 216 million active social media users, representing 80%, 36%, and 17% pene ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 10 of 16 tration in africa (24). the available dh services in africa include mhealth, social media, telemedicine/telehealth, elearning, ehr, and big data analytics in order of preference (4,5). nigeria is strategically located to benefit from the digital economy. it accounts for about 47% of the west african population, and a half (about 100 million) of its population is under 30 years and is leading the continent in the economy (25). the country is also experiencing this trend of increasing mobile, internet, and social media penetration. according to the nigerian communications commission (ncc), the number of mobile phone subscriptions in nigeria was 176, 897, 879 (92.7% teledensity), while internet subscriptions were 122, 975, 740 (56% penetration) as of august 2019 (26). the number of smartphone users in nigeria is estimated to be 36 million (18.37% penetration). this could be attributed to an influx of low-priced smartphones (the average cost of smartphones decreased from $216 in 2014 to $95 in 2018). there are 24 million (12% penetration) social media users, and in 2018, 44% and 4% of mobile users use 3g and 4g technology, respectively, and the number keeps increasing (26,27). despite these potentials, nigeria was ranked 143rd among 176 countries on the ict development index (idd) in 2017. it did not feature among the top 16 countries on the ehealth priority ranking of sub-saharan african countries and is ranked 15th among the top 17 countries on the ehealth regulating readiness index. this is due to barriers such as infrastructure and device access challenges, funding, human resources capacity, and policies and government leadership (28,29). to establish sustainable digital health and other digital services, there is a need to build critical digital pillars such as digital infrastructure, digital platforms, digital financial services, digital entrepreneurship, and digital skills and literacy (25). covid-19 has brought the role of telehealth during the pandemic and beyond all over the world to the fore. mckinsey conducted covid-19 consumer surveys in april and may 2020, which showed an apparent increase in the adoption of telehealth services in the usa. telehealth usage was 11% in 2019, which increased, and 76% were interested in using telehealth with a 50-175 times increase in the number of telehealth visits and 80 new telehealth services approved by the centers of medicare and medicaid. precovid-19, the total annual revenue of telehealth players was estimated at $3 billion and postulated that up to $250 billion of current us healthcare spending could be virtualized (30,31). the dh awareness of the respondents was low (39.4%), even though this level of awareness could have improved after the covid-19 pandemic when some dh services were used to provide virtual medical care. the result calls for creating more awareness amongst females and clients. access to booking for consultation is a challenge, especially for rural dwellers. a window for remote booking for a medical consultation is needed, as indicated by the respondents, in addition to virtual medical consultation, health education, and remote patient monitoring. the preference for online over mobile dh services point to an interesting scenario despite mobile technology penetration being better than internet penetration. this and the preponderance of android phones should guide any dh platforms in software development and technology deployment. currently, most ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 11 of 16 home healthcare services are offered at the individual and informal level, and there is a need to coordinate the services to ensure quality, reliability, and interoperability with other dh services. home antenatal care, immunizations, management of chronic diseases including hiv-aids are low-hanging fruits to consider for hhs. there is a need for a massive hhs awareness campaign targeted at clients and those patronizing private hospitals. our findings show that there is a notable willingness to pay for the dh and hhs. although the amount the respondents were willing to pay for both services in this study seems low, it is significant when related to the prevailing minimum wage of $50 per month. it might increase after experiencing their value and advantages. the potential early adopters of dh with the willingness to pay higher will be the healthcare providers, younger clients, and those patronizing private hospitals and should be the first marketing targets. gradual engagement of older respondents and public health users will expand the dh market base. females will likely adopt hhs early, especially since they attend hospitals more frequently to seek care for themselves or their children and hence face the challenges more. healthcare providers' willingness to pay higher for the digital and healthcare services could likely be due to their exposure to healthcare delivery and challenges, bias because they were potential beneficiaries for the payment, and possible higher disposable income than the clients. in response to the above data, a team (comprising two medical specialists, a biochemist, three it experts, and a financial expert) developed an integrated (hospital-based, digital, and home healthcare) healthcare ecosystem and named it edokta. it was designed to provide hospital-based care, telemedical care, home healthcare, diagnostic and pharmaceutical services, remote patient monitoring, health education, medical education, and universal medical identity services. it is aimed at removing barriers to accessing healthcare by providing virtual access to healthcare providers using mobile and internet technology for personalized, seamless, and quality care by patients and expand the providers' customer base and returns. the critical disruptions are the local content via the inclusion of local languages and the onestop health solution nature of our services. it has a potential for facilitating dh innovations such as drones (for delivery of medical supplies to difficult terrains), big data (for managed care, disease prediction, and more accurate treatment), artificial intelligence-ai (for workflow management, precision in diagnosis and treatment aid) and iot (for remote patients monitoring). some of our key partners include specialists, hospitals, diagnostic centers, pharmaceutical shops, mobile telecommunication companies, governments, and non-governmental agencies. the telemedicine software is developed, and more than 1,000 patients benefit from free consultation during the covid-19 lockdown. the entire edokta project will be launched in may 2021. conslusion the digital and home healthcare ecosystem is a new frontier for healthcare globally and is gradually being applied in africa especially following the covid-19 pandemic. ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 12 of 16 the growing dissatisfaction with the current hospital-based healthcare system, the massive health workers' brain drain, and the unequal distribution of health personnel and infrastructure threaten the attainment of universal health coverage in nigeria and thus pave the way for introducing dh and home healthcare services. our attempt at translating dh and home healthcare survey to real life (edokta) is on the verge of debuting, gal vanizing the triple helix collaboration between government, research institutes, and industry to develop a sustainable healthcare ecosystem by utilizing digital technology to leapfrog the attainment of uhc in africa. acknowledgement i, jameel ismail ahmad, acknowledge the mentorship offered to me by professor modest mulenga, chair of the tdr joint coordinating board. references 1. united nations. world population prospects 2019 highlights [internet]. newyork; 2019. available from: https:/population.un.org/wup/publications/files/wup 2018-key facts.pdf 2. federal ministry of health. national health ict strategic framework: 2015-2020 [internet]. 2016. available from: https://www.who.int/goe/policies/nigeria_health.pdf?ua=1 3. himss unveils the digital health indicator to measure health system progress toward a digital health 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2019. available from: https://www.google.com/search?q=n igerian+digital+economy+diagnostic+report+2019+world+bank&rlz =1c1okwm_enng893ng893&oq =nigerian+digital+economy+diagnostic+report+2019+world+bank&aqs =chrome..69i57.23968j0j7&sourceid =chrome&ie=utf-8# 26. nigerian communications commission. industry statistics [internet]. [cited 2019 jul 19]. available from: https://www.ncc.gov.ng/statistics-reports/industry-overview 27. kolawole o. nigeria mobile report 2019 [internet]. 2019 [cited 2020 nov 17]. available from: https://www.jumia.com.ng/sp-mobile-report/ 28. ict development index 2017 [internet]. 2018. available from: https://www.itu.int/net4/itud/idi/2017/index.html 29. strategic partnership digital africa. digital health ecosystem for african countries: a guide for public and private actors for establishing holistic digital health ecosystems in africa [internet]. 2018. available from: https://www.bmz.de/en/publications/topics/health/materilie345_digital_health_africa.pdf 30. united states agency for international development. trends in digital health in africa : 2016;(september):1–7. available from: http://www.africanstrategies4health.org/uploads/1/3/5/3/13538666/trends_in_di gital_health_in_africa_brief_final.pdf ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 15 of 16 © 2021 ahmad; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 31. bestsennyy o, gilbert g, harris a, rost j. telehealth: a quarter-trillion-dollar post-covid-19 reality? mckinsey company publ may [internet]. 2020;29. available from: https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality __________________________________________________________________________ ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 16 of 16 fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 1 | 15 original research voluntary blood donation promotion in haute matsiatra region of madagascar jocia fenomanana1, heritiana gisèle ramaminiaina1, fidiniaina mamy randriatsarafara2, zely arivelo randriamanantany3 1service laboratoire chu andrainjato fianarantsoa 301 madagascar; 2département de santé publique université d’antananarivo ; 3direction de la transfusion sanguine tananarive madagascar and direction générale de fourniture des soins ministère de la santé publique madagascar ; corresponding author: jocia fenomanana; address: service laboratoire chu andrainjato fianarantsoa 301 madagascar ; e-mail: jfenomanana@yahoo.fr mailto:jfenomanana@yahoo.fr fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 2 | 15 abstract aims: access to sufficient, secure supplies of blood and safe transfusion services is an essential part of any strong health system. the haute matsiatra region has a need for blood and blood products that exceeds current availability (only 7% of needs are met). the aim of this study ls to assess community knowledge, attitude, and practice regarding voluntary blood donation in order to identify the obstacles. methods: we have conducted a community-based cross-sectional study from 26th to 31th july 2019 within a sample of 300 subjects using a structured questionnaire and face-to-face interview. data were analyzed using r software version 4.0.2. results: all participants were unanimous about vital role of blood so that 62.3% were willing to donate blood but only 13% have ever donated blood. the majority of respondents (60.0%) had never heard sensitization about blood donation. the reason for non-donation were related to fears of needlestick injuries during the blood collect (38.3%), fear of blood borne diseases (17%), the lack of sensitization (6%). there was a positive significant relationship between level of education and willingness to donate blood (p-value <0, 05). the likelihood of blood donation was found to be higher among male participant 28 (71.8%) p<0.05, and among >45 years group (21.4 %) p= 0.03. among those who ever donated blood, only 37 (26.6%) of them have received sensitization about donation. conclusion: there is growing interest in blood donation among the population. activities to promote blood volunteer donation should take into account the demotivating reasons for blood donation. source of funding : none conflict of interest statement: the authors report no conflicts of interest in this work. authors’ contributions : all authors contributed toward data analysis, drafting and critically revising the paper and agree to be accountable for all aspects of the work. acknowledgments : we thank all those who, directly or indirectly, have contributed to this publication. fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 3 | 15 introduction access to sufficient, secure supplies of blood and safe transfusion services is an essential part of any strong health system (1). blood transfusions contribute for saving patients whose lives are at risk. they can help patients who have a life-threatening disease, complications during pregnancy and childbirth, severe trauma, surgical procedures. they are also regularly used for patients with hematologic disease such as sickle cell disease, thalassemia and hemophilia (2). despite advanced research, there is currently no substitute for human blood (3). according to the world health organization (who), about 118.5 million blood donations are collected around the world, in which 40% are collected in high-income countries, home to 16% of the world’s population (4). unpaid voluntary donors have the lowest rates of transfusion-associated infections and are the ideal population from which to recruit donors as bloods are given for genuine altruistic reasons. voluntary donors do not have any reason to give false information about lifestyle factors which might place them at risk of transmitting infectious agents. there is therefore a reduced risk of obtaining blood during the 'window' period of hiv infection (5). the who’s goal is to obtain for each country all their respective blood supplies through voluntary unpaid donors, in accordance with the art 28.72 of world health assembly adopted resolution in 1975 (6). in madagascar, the blood donation rate in 2013 was 1.0 unit per 1000 inhabitants. among all donors, only 18.6% are voluntary non remunerated (7). the region of haute matsiatra, in particular, has a need for blood and blood products that exceeds current availability (only 7 % of needs are met). the voluntary blood donor insufficiency is a major challenge in this area even if information about donation is offered regularly (16.41% in 2019: haute matsiatra region blood bank, unpublished data, 2019). replacement blood donors recruited by families are the major source of blood in this region. this situation contributes to the persistent high mortality rates associated with potentially reversible conditions such as haemorrhage and anaemia. factors affecting blood donation often vary in various populations (8) (9). therefore, better understanding on the level of community knowledge, attitude, and the practice of donors may help to strengthen the blood donation program in this area. in order to identify obstacles to blood donation among the population of haute matsiatra region, we have conducted a preliminary survey that aim to assess knowledge, attitude, and practice towards blood donation and its associated factors. methods we implemented a cross-sectional community-based study in the haute matsiatra region. haute matsiatra is located at 400km from the capital city of madagascar. based on malagasy population and housing census 2019 estimation, the total population of this region was estimated 1 447 296 inhabitants, 189 879 of which are urban populations (10). multi-stage sampling technique was used to in order to recruit the study participants. on the first stage, 6 fokontany (equivalent of village) were selected from the total of 50 of the region by lottery method. we used then a systematic random sampling technique to select 50 households per fokontany. to select one study participant per household we employed a lottery method. study population: all adults aged 18 65 years residing in haute matsiatra region were the source population. they were selected by multi-stage sampling technique and lived in the study area for at least six months fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 4 | 15 were included. sample size determination: we calculated the sample size with a single population proportion formula using 95 % ci and 5 % margin of error. the sample size was found to be n=300 after considering a 1.69 % non-response rate. data processing and analysis: malagasy structured questionnaire was used to collect the data at each selected household. the tools were developed after reviewing of relevant literatures and adapted to the context of the study area (11). information on the sociodemographic characteristics (15 questions), knowledge (9 questions), attitude (17 questions), and practice-related questions (12 questions) on blood donation were included. then, separated face to face interview from questionnaire data were entered into r software version 4.0.2 for univariate and multivariate analysis. ethical considerations: the study was approved by an ethics committee. written informed consent was obtained from all the study participants. they were adequately preinformed of the aim and the implication of the study and were told about their right to refuse or withdraw their verbal consent to participate in the research. confidentiality of information was kept including omitting personal identifiers such as the name of the respondent. results sociodemographic characteristics: from the calculated 305 sample size, 5 subjects recruited was not related to the sample size, 300 participants were involved in the study. a total of 122 (40.7%) participants were in the age group of 18-25 years, more than half 167 (55.7%) were females and 175 (58.3%) were married (table 1). table 1: sociodemographic characteristics of the study participants (n=300) variables frequency n=300 percentage (%) age group in years 18-25) 122 40,7 26-35) 82 27,3 36-45) 40 13,3 > 45 56 18,7 gender female 167 55.7 male 133 44.3 marital status married 175 58,3 single 104 34,7 separated 11 3,7 widowed 10 3,3 religion christian 298 99.3 other 2 0.7 fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 5 | 15 *tertiary sector: commerce, administration, transport, financial and real estate activities, business and personal services, education, health and social work knowledge about voluntary blood donation the majority of respondents 180 (60.0%) had never heard sensitization about blood donation. mass media was the main source of information of 186 (62.7%) participants. among the 300 study participants, 263 (87.7%) were affirmed that blood transfusion “can save life”. only 13 (4.4%) study participants had the right answers concerning minimum criteria for blood donation (age 18-65 years, weight above 45kg, basic good health). two hundred eighty-seven (95.7%) participants replied that hospital is the only site of blood collection. digestive hemorrhage, anemia, accident were the main cited indications of blood transfusion, 69 (23%) participants didn’t have any idea. two hundred and ten participants (70.0%) replied that donating blood advantages were “to save life”, “to benefit from free analysis”12 (4.0%), “to earn money”6 (2%). cited disadvantages were 55 (18.4%) “fear of degraded health after donation”, 6 (2.0%) “fear of acquired diseases”, 4 (1.3%) “fear of bloodborne disease”, 3 (1.0%) “fear of anemia”, 1 (0.3%) “fear of sudden death after donation” (table 2). table 2: knowledge about voluntary blood donation (n=300) variables frequency n=300 percentage (%) main cited indications of blood donation digestive hemorrage 96 32.0 anemia 53 17.7 bleeding 44 14.7 accident injuries 17 5.6 delivery 9 3.0 surgical intervention 12 4.0 do not have any idea 69 23.0 main cited advantages of blood donation educational status illiterate 15 5 elementary education 101 33.7 secondary education 111 37.0 graduated education 73 24.3 occupation sector primary 152 50.7 secundary 37 12.3 tertiary* 111 37.0 fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 6 | 15 satisfaction saving life 210 70.0 to ameliorate health 47 15.7 benefit from free analysis 12 4.0 to earn money 6 2.0 no advantages 25 8.3 main cited disadvantages of blood donation degraded health after donation 55 18.4 risk of acquired diseases 6 2.0 blood born infections 4 1.3 anemia 3 1.0 sudden death after donation 1 0.3 no disadvantages 214 71.3 do not have any idea 17 5.7 attitude toward voluntary blood donation among respondents, 153 (51%) of them approve of voluntary blood donation but only 49 (16.3%) showed their willingness to donate blood in the future if needed (table 3). the likelihood of favorable attitudes towards blood donation was higher among male gender (36.3% p<0.05), those who attended secondary school (28 % p<0.005). media user had higher chance of having favorable attitude compared to other source of information user (42% p<0.05). about 34.3% of those who had previous sensitization had favorable attitude towards blood donation (table 4). table 3: study participants’ attitude toward voluntary blood donation (n=300) variables frequency n=300 percentage (%) do you approuve of voluntary blood donation? approve 153 51.0 strongly approve 111 37.0 disapprove 18 6.0 i do not know 18 6.0 have you ever been sollicited for blood donation ? yes 49 16.3 no 251 83.7 are you motivated to donate blood for a relative if there is need? yes 243 81.0 no 57 19.0 what reasons could motivate you to blood donation ? fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 7 | 15 to benefif from free blood tests 121 40.3 fear of not receiving blood when need 88 29.3 to earn money 65 21.7 to save life 17 5.7 for the maintenance of good health 9 3.0 table 4: factors associated with the attitudes towards blood donation among participants (n=300) variables attitude to donate blood pvalue favorable % unfavorable % age 0.02 18-25) 88 29.33 34 11.34 26-35) 48 16.00 34 11.34 36-45) 20 6.66 20 6.66 > 45 ans 31 10.34 25 8.33 gender 0.29 male 109 36.33 58 19.33 female 78 26.00 55 18.34 occupation sector 0.00 primary 67 22.33 85 28.34 secundary 31 10.33 6 2.00 tertiary 89 29.66 22 7.34 marital status 0.00 married 90 30.00 85 28.34 single 83 27.67 21 7.00 widowed 8 2.67 2 0.66 separated 6 2.00 5 1.66 educational status 0.00 illiterate 2 0.66 13 4.34 elementary education 35 11.66 66 22.00 secondary education 84 28.00 27 9.00 undergraduate education 66 22.00 7 2.34 source of information 0.00 media 126 42.00 60 20.00 medecin 33 11.00 4 1.34 community worker 19 6.33 37 12.34 fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 8 | 15 friends 5 1.66 5 1.66 other 4 1.33 7 2.34 previous sensitization 0.00 yes 103 34.33 36 12.00 no 84 28.00 77 25.67 the mainly cited barriers for blood donation related to fears of needlestick injuries during the blood collect (38.3%), fear of blood-born diseases (17%), and lack of sensitization (6%) (figure 1). figure 1: main cited barriers for blood donation (n=300) practice of blood donation and its associated factors total number of participants who have already practiced blood donation was 39 (13 %) from which 22 (56.4 %), 11 (28.2 %), 3 (3%) and 3 (7.7%) have donated respectively once, two, three and more than 3 times. the reasons for donation were to save relative’s life 22 (56.4 %), moral duty 7(17.9 %), due to efficient sensitization 6 (15.4 %), to save other peoples’ lives 4 (10.3%). overall, the majority were satisfied with the blood collection session, 6 among 39 felt not reassured. significant factors associated to blood donation was age group >35 years (41.4 %): p= 0.02, male gender, marital status (married status has positive influence). participants having secondary school level education were more likely (22/39) to donate blood compared to those who have a high degree education: p=0.04. among those who ever donated blood, majority 37 (34.3%) of them have received general sensitization before donation: p0.02 (table 5). 0 5 10 15 20 25 30 35 40 percentage… fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 9 | 15 table 5: factors associated with practice of blood donation among participants. (n=300) variables have already donated blood pvalue yes % no % age 0.03 18-25) 9 7.4 113 92.6 26-35) 10 12.2 72 87.8 36-45) 8 20.0 32 80 > 45 ans 12 21.4 44 78.6 gender 0.0004 male 28 21.1 105 78.9 female 11 6.60 156 93.4 marital status 0.07 married 27 15.4 148 84.6 single 8 7.7 96 92.3 widowed 3 30 7 70 separated 1 9.1 10 90.9 educationalstatus 0.04 illiterate 0 0 15 100 elementary education 10 9.9 91 90.1 secondary education 22 19.8 89 80.2 undergraduate education 7 9.6 66 90.4 source of information 0.01 media 29 15.6 157 84.4 medecin 3 8.1 34 91.9 communityworker 5 8.9 51 91.11 friends 0 0 10 100 others 0 0 11 100 previous sensitization 0.02 yes 37 34.3 102 65.7 no 2 28.00 159 72 discussion in this study, the overall level of knowledge (about minimum criteria for blood donation) towards blood donation was found to be much lower than a community based study conducted in the debre markos town of ethiopia (56.5%) (12), in the city of mekelle (49 %) (13), and another study, conducted among fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 10 | 15 students of health science in addis ababa (83 %)(14). the difference in socio-economic status and in educational status of population might explain the discrepancy with the above findings. this is possible, ‘because more educated people might be in a better position to access the media and availability of awareness creation at primary and secondary school and higher educational institutions’ (12). moreover, the majority of respondents had never heard any sensitization about blood donation before the study. partly, this might be explained by the limitations of awareness campaigns on addressing the intended goals. in addition to individual factors, the characteristics of the collection site fixed or mobile are important in explaining variation in donor behavior. satisfaction with the blood bank opening hours, collection site type, the traveled distance to the medical examination site and blood collection, represent important clues for blood bank policies and interventions to improve donor motivation (15). television and the internet are the most effective tools for promotion and recruitment for blood donation in guangzhou china (16). social media have become the second most important motivation reason to recruit voluntary donor beside relatives and friends. in the study area, facebook is the preferred social media to transmit and receive information about the blood donation process, however, access to internet is still limited compared with mass media and is not used sufficiently for awareness campaigns. for repeat donors, experience of the last donation process plays a key role, the more it is positive, the more it is motivating for the future (17). some participants are scared of what they regard as side effects of blood donation. as per a nigerian study, 36·1% of university graduated donors believe that they can contract human immunodeficiency virus (hiv) and/or hepatitis infection from blood donation (18). it highlights the fact that knowledge of blood donation is an essential prerequisite before voluntary blood donation, and it is an important tool for avoiding fear and building positive attitude. creating awareness on the general public regarding hiv, hbsag and hcv transmission and prevention should be strengthened (19). the overall intention of respondents to donate blood voluntarily can be due to the malagasy culture (the “fihavanana”) of sustaining social relationships and being generous to help anytime anywhere. the findings of this study are consistent with studies across the world, which found overall positive attitudes towards blood donation among respondents(20), (21), (14), (22), (23). findings were lower in other studies conducted in karachi (42%) (23), mekelle (61 %) (13) and addis ababa (68 %) due to cultural differences (14). regarding factors affecting blood donation, a range of socio-demographic, organizational, physiological and psychological may influence people's willingness to donate blood (24). in the current study, factor significantly associated to favorable attitude for blood donation were age group, male gender, media and previous sensitization. young participants were indeed significantly associated with favorable attitude for voluntary blood donation. this could be due to a large proportion of young adult’s state that they are able and willing to donate blood compared with elder one (25). it was also noted that male gender was significantly favorable to blood donation compared with female which is consistent with overall studies across the world (26). this could be in congruent to cultural belief that male is better and stronger to take responsibility than female. also, women have to face many different temporary restrictions for blood donation because of the menstrual cycle or lactation period (27, 28). herein, most of donors were satisfied with previous blood collection expe fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 11 | 15 rience and felt reassured. personal blood-donation experience (quality of donor reception, pleasant medical staff, good atmosphere during donation, organization of blood collecting and processing facilities, perceived physical, psychological and social impact) was indeed cited as a significant predictor of behavioral intentions to donate blood. in fact, occurrence of positive experience may make blood donation less frightening and perhaps even attractive. one of the most important incentive for being a donor was also the direct approach by another donor (29). concerning the frequently cited motivation for blood donation, altruism was not highlighted for males compared with females, but was combined with 'warm glow' in novice males (30). in a sample of primary healthcare users in a brazilian municipality, fear of blood, vasovagal reactions, and lack of knowledge regarding the donation process were revealed as important barriers to the decision to donate blood (26). the study showed that some of the participants had a history of blood donation which are not permanent as of now. people donate when there is a need related to family member, not because there is need of safe blood in the community. that could be due to the lack of social marketing toward blood donation and periodic sensitization in the study area. according to the study results, the greatest barrier that prevents people from donating blood were fear of needles, degraded health, physical weakness, bloodborne disease, lack of sensitization. while lack of time and fear of blood donation were the main barriers in saudi arabia and some developing countries (30). the findings of this study were different to those barriers reported in gangzhou china which was self‐ perception of poor health (33·1%) (16). in a brazilian study, fear of blood, injections or vasovagal reactions, and a lack of knowledge of the donation process were revealed as important barriers to the decision to donate blood (28). in a qualitative investigation of indian non-donors living in england, lack of awareness and accessibility were prominent barriers; in contrast, there was a strong preference for donated blood to be distributed within the family, as opposed to unknown recipients (30). globally, ‘the greatest barrier that prevents people from donating is a lack of convenience and a lack of knowledge of the importance of donating’ (5, 8). it suggests that an intensive blood donation campaign should be promoted. this would allow people to be well informed, changing the positive attitude of saving life through blood donation to a regular practice. recommendations it is vital to consider, in the light of the predicted shortages in blood supply, methods to maximize donation rates. as per who criteria, availability of blood in a country for transfusion should be indicated by 10 blood donations at least per 1000 population (4). in madagascar, the number of whole blood donations per 1000 population was less than 5 which remains too low to cover the blood requirements. donations by repeat voluntary non-remunerated blood donor is 13% (4). promotion of blood voluntary donation should take into account the demotivating reasons for blood donation which calls governmental commitment and required the need to improve research evidence in this area of practice. particularly, the existence of a data collection and reporting system is an important element of a well-managed nationally coordinated blood transfusion programme. adequate national data on blood availability and safety allow the area to set priorities and to further strengthen the blood system. it would be suitable to readjust the strategies for implementing the national blood transfusion policy based on the results of the target population survey. it is then necessary to convince non-donors and retain regular volunteer fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 12 | 15 donors. consequently, we suggest the following changes: awareness campaigns should focus on strategies to unlock obstacles to donation and insisting on common misconceptions about blood (the belief to a high risk to get infected through the process of donation, blood banks sell donated blood to patients, blood donation believed to cause physical weakness). some information has to be clarified (the donation process does not spend more than one hours, menstruation is just a temporary contraindication of blood donation). number of mobile collections should be increased to be closer to volunteers (lack of time is sometimes cited as obstacle). use of radio spots, tv spots, telephone messages, leaflets, the press or banners on the internet, can serve as very good advertising media. guarantee an excellent reception and collection session to avoid negative perception about blood donation process promotion of research in the field of «knowledge, attitude and practice towards blood donation », « donor sources of motivation », « blood donation experience ». in fact, having an adequate data on blood availability, safety and a feed-back from donors allow the area to set priorities and to further strengthen the regional blood system. training of medical staff (quality of reception, humanization of care, confidence in donors) implementation of educational programs in terms of educational sessions, media presentations, brochures distribution, and raising awareness of students on 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of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 15 | 15 © 2021 fenomanana et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. __________________________________________________________________________ malik ks, adoubi a, kouadio k, kouamé j, hounsa a, sackou j. overweight and obesity among women living in peri-urban areas in west africa (original research). seejph 2019, posted: 09 september 2019. doi 10.4119/unibi/seejph-2019-222 1 original research overweight and obesity among women living in peri-urban areas in west africa koussoh simone malik1, anicet adoubi2, kouamékouadio3, jérôme kouamé4, annita hounsa4, julie sackou4 1 cardiology unit, national institute of public health, abidjan, côte d’ivoire; 2 medical sciences training and research unit, cardiology department, university of bouaké, bouaké, côte d’ivoire; 3 eco epidemiology unit, department of environmental health, institut pasteur of côte d’ivoire, abidjan, côte d’ivoire; 4 department of public health, hydrology and toxicology, training and research unit of pharmaceutical and biological sciences, félix houphouët boigny university, abidjan, côte d’ivoire. corresponding author: malik koussoh simone; address: cardiology unit, national institute of public health of côte d’ivoire, bp v 47 abidjan, côte d’ivoire. telephone: +225-01-24-61-25; e-mail:simone.malik@medecins.ci mailto:simone.malik@medecins.ci malik ks, adoubi a, kouadio k, kouamé j, hounsa a, sackou j. overweight and obesity among women living in peri-urban areas in west africa (original research). seejph 2019, posted: 09 september 2019. doi 10.4119/unibi/seejph-2019-222 2 abstract aim: this study assessed selected correlates of overweight and obesity among women in a sub-urban population of abidjan, côte d’ivoire. methods: a cross-sectional study was conducted during april-may, 2014 in abobo-anonkoi 3, a peri-urban city of abidjan in côte d’ivoire. women of 18 years and older healthy in appearance were randomly recruited from households. overweight and obesity were measured by bmi respectively greater or equal to 25 and 30 kg/m2. abdominal obesity was defined by waist to hip ratio greater or equal to 0.80. the level of physical activity was evaluated by the ipaq questionnaire and the blood pressure according to the criteria of the jnc7 report. a regression analysis of the associated factors with overweight and obesity (age, marital status, level of study, level of physical activity, blood pressure, and socioeconomic status) was carried out. results: we visited 486 households in which 398 women were approached and 327 agreed to participate in the survey. the average age was 35.25 ± 12.4 years. the prevalence of overweight was 27.2% and that of obesity was 19.6%; 72.2%of women had abdominal obesity. the prevalence of abdominal obesity was 90.6% among obese people. age (p=0.006), marital status (p=0.002) and blood pressure (p=0.004) were significantly associated with obesity. with regard to abdominal obesity, there was a significant association of educational level in addition to the above factors. conclusion: overweight and obesity are a reality in this population of côte d’ivoire and about one in five people are affected by the scourge of obesity. keywords: abdominal obesity, africa, central obesity, overweight, women. malik ks, adoubi a, kouadio k, kouamé j, hounsa a, sackou j. overweight and obesity among women living in peri-urban areas in west africa (original research). seejph 2019, posted: 09 september 2019. doi 10.4119/unibi/seejph-2019-222 3 introduction in 2016, more than 1.9 billion adults, 18 years and older, were overweight and these over 650 million were obese (1) projections show that by 2030, about 2.16 billion adults will be overweight and 1.12 billion adults will be obese (2). the global prevalence estimate showed that the proportion of obese adults rose from 28.8% in 1980 to 36.9% in 2013 among men and from 29.8% to 38% among women (3). these increases have been observed in both developed and developing countries (3). in africa, in 2008, 26.9% of the adult population was overweight or obese (4). overweight and obesity are risk factors for chronic diseases such as cardiovascular disease, diabetes and some cancers (5). certain events in women's lives (childbirth, menopause) could promote the development of obesity (6). thus, several studies on obesity conducted both in developed countries and in africa, particularly in urban areas, have established that the prevalence of obesity was often higher among women (7-10). obesity affects women more often than men (11). in côte d'ivoire, the world health organization steps survey (measures of risk factors for chronic diseases) revealed a prevalence of overweight and obesity of 32.2% among the adult population in 2005 in the lagoon region, in the south of the country, which includes the city of abidjan (8). the same study confirmed a higher prevalence of overweight and obesity among women of 37.6% compared to 24.6% among men. the 2011 2012 demographic and health survey in côte d'ivoire reported an overweight prevalence of 19% and obesity of 6.6% among women of reproductive age (10). in these studies conducted in côte d'ivoire, the factors associated with overweight and obesity in women have been underresearched in the peri-urban environment. this environment is at the junction of urban and rural areas, it is distinct from these two areas in relation to eating habits (12). it is also an important place for epidemiological, demographic, social and nutritional transition (2). however, demographic, social, epidemiological and nutritional transitions are inseparable (11,13). the corollary of this transition in the field of nutrition is the substitution of problems of overweight and obesity for problems of nutritional deficiencies (13). thus, one marker of the ongoing nutritional transition is the increase in obesity (11). diet is the leading cause of overweight and obesity (11). what factors other than diet are associated with overweight and obesity in women in this particular space that is the peri-urban environment? to answer this question, we conducted a study to determine the prevalence and factors associated with overweight and obesity in women. methods framework of the study this survey was conducted in the autonomous district of abidjan. it was carried out in households in the anonkoi 3 district located in the municipality of abobo, which is the second most populated municipality in the autonomous district of abidjan after yopougon, with a density of 167 inhabitants per square kilometre (14). the autonomous district of abidjan is located in the lagoons region in the south of côte d'ivoire (15). type and period of study this was a cross-sectional study conducted from 24 april to 23 may 2014. the sample size was calculated using the formula: n = p (1-p) z2/i2 with n: sample size; p: prevalence of overweight and obesity 32.2%; z=1.96 for a 5% risk of error and i: accuracy (5%). malik ks, adoubi a, kouadio k, kouamé j, hounsa a, sackou j. overweight and obesity among women living in peri-urban areas in west africa (original research). seejph 2019, posted: 09 september 2019. doi 10.4119/unibi/seejph-2019-222 4 the sample size calculated was 336. considering a response rate of 80%, the minimum sample size was 420. sampling strategy the neighbourhood of anonkoi 3 is a village in the commune of abidjan. in this neighbourhood households are not numbered. in the general census of the population in 1998, the neighbourhood had 474 households (16). however during a comprehensive study in this area, sackou kouakou et al. identified 668 households (14). therefore, we conducted a random sample, we calculated a sampling interval of two (668/336 = 1.98). we considered household no. 1 the first household found when we had access to the area, and we visited one in two households. population the study included all women 18 years of age and older who were not in bed and were present at the time of the survey. women who were pregnant or breastfeeding were not included. in each household visited, the woman aged 18 and over present was selected. in the presence of more than one woman 18 years of age or older, only one was randomly selected. data collection data collection was based on a pre-tested questionnaire with the free and informed consent of the person selected (written or oral consent). overweight and obesity were defined from the quételet body mass index (17).overweight is defined as having a bmi greater than or equal to 25 and lower than 30 kg/m2; obesity is defined as having a bmi greater than or equal to 30. height was measured by a tape measure and weight by a camry® brand scale model scal160 that can support up to 160 kg. abdominal obesity was measured by a tape measure and defined as a waist circumference (wc) to hip circumference (th) ratio greater than 0.80 (18). the level of physical activity was assessed by the ipaq questionnaire which defined 3 categories of persons: category 1 (inactive or insufficiently active) category 2 (sufficiently active) category 3 (very active). blood pressure (bp) was measured with an omron electronic blood pressure monitor with an arm cuff after five minutes rest. women with systolic blood pressure greater or equal to 140 mmhg and/or diastolic blood pressure greater or equal to 90 mmhg with or without treatment were considered to have high blood pressure. systolic blood pressure below 90 mmhg and/or diastolic blood pressure below 60 mmhg were considered low blood pressure. the level of education was categorized into four (no education, primary level, secondary level and higher level) (19). the socioeconomic level was assessed by the poverty score or wealth index calculated on the basis of asset ownership. the wealth index was calculated using data on the ownership of assets selected by a household (e.g. televisions, bicycles, cars, materials used for housing construction, types of access to water and sanitation). the relative wealth scale was then classified into five categories (poorest, poor, middle, rich and richest) according to the quintile of the sample (19). other factors associated with overweight and obesity that were collected were age andmarital status. ethical considerations survey participants were informed of the reasons for the study. they all have accepted to fill out a personal identification form and submit to taking the settings. their free and informed consent was obtained before the investigation began. they were free to withdraw from the investigation at any time without prejudice. the data were collected anonymously. malik ks, adoubi a, kouadio k, kouamé j, hounsa a, sackou j. overweight and obesity among women living in peri-urban areas in west africa (original research). seejph 2019, posted: 09 september 2019. doi 10.4119/unibi/seejph-2019-222 5 data analysis the data were entered on the epi data software (version 3.1) and analyzed with the spss software (version 22.0). the quantitative variable bmi was transformed into a categorical variable with 4 modalities: lean, bmi less than 18.5; normal, bmi between 18.5 and 24.9; overweight, bmi between 25 and 29.9 and obese, bmi greater than or equal to 30. the ratio tt/th has been transformed into a binary variable (less than 0.80: no; greater or equal to 0.80: yes). the search of factors associated with bmi was done in two stages. first, we performed a univariate analysis using the pearson khi two test at the 0.05 significance level.in this analysis, bmi was considered as a qualitative variable with four modalities (skinny, normal weight, overweight and obesity). then, the variables having a value less than 0.05 p were included in a logistic regression model. for regression model, bmi (the dependent variable) has been categorized into two modalities (obesity / non-obesity). the non-obesity modality resulted from the combination of skinny, normal and overweight modalities. the adjusted odds ratio and the confidence intervals at 95% were calculated. results four hundred and eighty-six (486) households were visited. in 88 households there was no woman and in 398 households there was at least one woman aged 18 and over whom we approached. among them, 46 did not meet the inclusion criteria (29 were pregnant and 17 were bedridden). finally, 327 agreed to participate in the survey. the response rate was 93%. the average age was 35.25 years and the standard deviation was 12.40 years. the participation rate was 67.3%. the overall prevalence of overweight and obesity was 46.8%. the prevalence of overweight was 27.2% (89 women) and 64 women were obese (19.6%). table 1 presents the socio-demographic characteristics and association between women's bmi and the analyzed different factors. about 2 in 5 women had no education and just over 20% had only primary education. almost 3 out of 5 women were married. the prevalence of high blood pressure was 26%. very active women represented less than 2% of our study population. in this environment, the poor and the poorest represented nearly 60% of the population. the association between body mass index and age was significant. indeed, overweight and obesity were observed mainly between 30 and 45 years of age (54.68% obese, p=0.006). a significant association was also found between body mass index and marital status. married women were more overweight and obese (p=0.002). in addition, overweight and obese women had higher blood pressure (p=0.004). the factors involved in obesity are presented in table 2. according to our study, the factor involved in the onset of obesity is age. the 30-45 age group is three times more likely to be obese than other age groups. malik ks, adoubi a, kouadio k, kouamé j, hounsa a, sackou j. overweight and obesity among women living in peri-urban areas in west africa (original research). seejph 2019, posted: 09 september 2019. doi 10.4119/unibi/seejph-2019-222 6 table 1. socio-demographic characteristics and association between women's bmi and the analyzed different factors in anonkoi 3 variable number (%) n=327 (100 %) skinny n=18 (5.50%) normal n=156 (47.71%) overweight n=89 (2.21%) obese n=64 (19.57%) p age (years) 15-30 31-45 >45 128 (39.14) 129 (39.45) 70 (21.41) 8(44.45) 4(22.23) 6(33.33) 76 (48.72) 52 (33.33) 28(17.95) 29 (32.58) 38 (42.70) 22 (24.72) 15 (23.44) 35 (54.68) 14 (21.88) 0.006 marital status married single and widows 184 (56.27) 143 (43.73) 8(44.45) 10(55.55) 73 (46.79) 83 (53.21) 61 (68.54) 28 (31.46) 42 (65.63) 22 (34.37) 0.002 level of study none primary secondary higher 127 (38.84) 68 (20.8) 106 (32.41) 26 (7.95) 12 (66.67) 2 (11.11) 3 (16.67) 1 (5.55) 51 (32.69) 30 (19.23) 59 (37.82) 16 (10.26) 39 (43.82) 22 (24.72) 25 (28.09) 3 (3.37) 25 (39.06) 14 (21.88) 19 (29.68) 6 (9.38) 0.106 level of physical activity inactive active very active 170 (51.99) 151 (46,18) 6 (1.83) 10 (55.56) 7 (38.88) 1 (5.56) 77 (49.36) 77 (49.36) 2 (1.28) 46 (51.68) 41 (46.07) 2 (2.25) 37 (57.81) 26 (40.63) 1 (1.56) 0.761 blood pressure high normal low 85 (26.0) 188 (57.49) 54 (16.51) 4 (22.23) 6 (33.33) 8 (44.44) 33 (21.15) 96 (61.54) 27 (17.31) 23 (25.84) 55 (61.80) 11 (12.36) 25 (39.06) 31 (48.44) 8 (12.50) 0.004 socioeconomic situation very poor poor middle income rich very rich 61 (18.65) 127 (38.84) 88 (26.91) 33 (10.10) 18 (5.5) 6 (33.33) 8 (44.44) 3 (16.67) 1 (5.56) 0 (0.0) 28 (17.95) 62 (39.74) 42 (26.92) 19 (12.18) 5 (3.21) 15 (16.85) 31 (34.83) 28 (31.46) 8 (9.00) 7 (7.86) 12 (18.75) 26 (40.62) 15 (23.44) 5 (7.81) 6 (9.38) 0.51 table 2. relationship between the analyzed factors and the risk of being obese in anonkoi 3 independent variables n obesity (%) no obesity (%) adjusted or 95%ci age group 15 – 30 128 15 (23.44) 113 (42.97) 1.00 reference 30 – 45 129 35 (54.68) 94 (35.74) 2.80 1.44-5.44 45 – 60 70 14 (21.88) 56 (21.29) 1.88 0.84-4.16 marital status married 184 42 (65.63) 142(54.00) 1.62 0.91-2.87 single and widow 143 22 (34.37) 121(46.00) 1.00 reference blood pressure high bp 85 25 (39.06) 60(22.81) 2.39 0.98-5.79 normal bp 188 31 (48.44) 157(59.70) 1.13 0.48-2.64 low bp 54 8 (12.50) 46 (17.49) 1.00 reference or: odds ratio; ci: confidence interval; 1: reference category. malik ks, adoubi a, kouadio k, kouamé j, hounsa a, sackou j. overweight and obesity among women living in peri-urban areas in west africa (original research). seejph 2019, posted: 09 september 2019. doi 10.4119/unibi/seejph-2019-222 7 the prevalence of abdominal obesity was 90.6% among obese people. the different associations between abdominal obesity and factors are presented in table 3. the association between abdominal obesity and age was significant. indeed, abdominal obesity was observed in the 30-45 and 4560 age groups (p=0.001). the 30-45 age group is three times more likely to have abdominal obesity than the 15-30 age group. similarly, the 45-60 age group is four and a half times more likely to have abdominal obesity than the 15-30 age group. this abdominal obesity was also higher among women with no education and those with only primary education (p=0.004). thus, women with no education and those with primary education are three times more likely to have abdominal obesity than those with higher education. abdominal obesity was also higher in married women (p=0.002) and those with high blood pressure (p<103). married women are twice as likely to have abdominal obesity as those without a partner. women with high blood pressure are five times more likely to have abdominal obesity than women without high blood pressure. table 3. association between abdominal obesity among women (n=327) and the analyzed different factors in anonkoi 3 abdominal obesity or 95%ci p no n=91 n (%) yes n=236 n (%) age group 15 – 30 55(60.44) 73(30.93) 1.00 reference <0.001 30 – 45 26(28.57) 103(43.65) 2.98 1.71-5.19 45 – 60 10(10.99) 60(25.42) 4.52 2.12-9.62 level of study none 27(29.67) 100(42.37) 2.72 1.11-6.59 0.004 primary 13(14.29) 55(23.31) 3.10 1.15-8.31 secondary 40(43.95) 66(27.96) 1.21 0.50-2.89 higher 11(12.09) 15(6.36) 1.00 reference marital status married 39(42.86) 145(61.44) 2.12 1.30-3.47 0.002 single and widows 52(57.14) 91(38.56) 1.00 reference blood pressure (bp) high bp normal bp low bp 10(10.99) 59(64.84) 22(24.17) 75(31.78) 129(54.66) 32(13.56) 5.15 1.50 1.00 2.19-12.11 0.802.80 reference <0.001 or: odds ratio; ci: confidence interval; 1: reference category. discussion in our study, almost half of the women were overweight, about 20% of whom were obese. this prevalence shows that one in five women is at risk of developing a cardiovascular pathology, as some authors confirm. these reported that women are becoming increasingly at risk for non-communicable diseases or associated comorbidities including hypertension, diabetes, cancer and stroke (20). this obesity was related to various factors including age (between 30 and 45 years), marriage and high blood pressure. the active 30-45 age group is the obese age malik ks, adoubi a, kouadio k, kouamé j, hounsa a, sackou j. overweight and obesity among women living in peri-urban areas in west africa (original research). seejph 2019, posted: 09 september 2019. doi 10.4119/unibi/seejph-2019-222 8 group. these young adults are thus at higher risk of developing cardiovascular disease and dying prematurely, posing a serious threat to the economies of countries in sub-saharan africa (21,22). the prevalence of overweight and obesity increases steadily with age in developing countries (9,23). some studies in nigeria, cameroon and togo found an association between age and obesity later (after 40 years) than found in our study (9,23,24). the association between marital status and obesity can be explained by the fact that people after marriage have less physical activity, change their diet and may be less concerned about their weight (25). this is the observation in african society where culture considers that being overweight is a sign of material ease (19). the prevalence of overweight and obesity is high in peri-urban areas, in the middle of the epidemiological transition. this high prevalence could be explained by the culture and lifestyles of our population. indeed, in developing countries there is a shift from a low-fat diet and a physically active life to a diet richer in saturated animal fat and a sedentary lifestyle (2). overweight and obesity are no longer only predominant in high socioeconomic backgrounds, but this burden in developing countries is shifting to low socioeconomic groups and particularly to women (26). our work confirms the relationship between obesity and high blood pressure (27). high blood pressure is more frequent in obese subjects and hypertensive subjects develop overweight more easily. this epidemiological observation explains the link between high blood pressure and obesity. in addition, obesity potentiates the presence and severity of other cardiovascular risk factors (28). an excess weight of 10 kg is associated with an increase of 3 mmhg in systolic blood pressure and 2.3 mmhg in diastolic blood pressure. in anonkoi 3, the prevalence of abdominal obesity was also high (near ¾ of our total population and almost all obese women). waist circumference is a simple indicator of excess abdominal fat in adults. excess abdominal fat is associated, independently of bmi, with the development of metabolic and vascular complications of obesity (24,27). indeed, abdominal obesity, a toxic form of obesity, is a complex dysmetabolic state at the origin of a profound disorder of blood pressure, vascular endothelium and energy homeostasis. thus, at equivalent bmi, subjects with abdominal obesity develop more cardiovascular complications. beyond weight, the type of obesity has an even greater influence on the prognosis of patients (28). our study found that women with no education and those with only primary education are more overweight or obese. the lower the level of education, the higher the prevalence of obesity. in recent years, obesity rates have increased in all education groups, but more rapidly among less educated women (29). according to the centre de recherche pour l'étude et l'observation des conditions de vie (crédoc), those who have a healthy diet (more fruits and vegetables, higher nutrient intakes, better food indices) are those who have higher degrees. they are more interested in the links between nutrition and health (30). however, some studies have reported that women with a high level of education were more overweight or obese (25). study limitations however, we noted some limitations in our study. the number of study participants was lower than the anticipated sample size. this is partly due to the fact that in more than 10% of households, there were no women. moreover, we considered as married women, all women legally married or living in a couple. as far as parity is malik ks, adoubi a, kouadio k, kouamé j, hounsa a, sackou j. overweight and obesity among women living in peri-urban areas in west africa (original research). seejph 2019, posted: 09 september 2019. doi 10.4119/unibi/seejph-2019-222 9 concerned, it has not been sought. we considered snacking as diet data. in addition, it is a cross-sectional study over a relatively short period and for which there could be bias in the design. these biases could be related to the nonrepresentativeness of the sample, the mode of selection of households and women in households. we did not take into account the number of women eligible for the survey in each household visited, we limited ourselves to choosing a single woman. also, information on sociodemographic characteristics, level of physical activity and snacking were assessed using self-reporting which is a source of information bias. conclusion the prevalence of overweight and obesity is high among women in peri-urban areas. this obesity particularly affects young, married women with no education or primary education. our study shows the need for urgent intervention targeted at women with information, education and communication (iec). it is important to fight against this obesity through awareness sessions for women on the consequences of obesity, education sessions and management of this scourge during home visits. conflicts of interest: none declared. acknowledgments: the authors would like to thank the ngo asapsu (urban health self-promotion association) for its contribution during the investigation. we would like to thank also the staff member of the department of public health, hydrology and toxicology, training and research unit of pharmaceutical and biological sciences. references 1. world health organisation. obesity and overweight. available from: https://www.who.int/news-room/factsheets/detail/obesity-and-overweight (accessed: july 23, 2019). 2. popkin bm, adair ls, ng sw. global nutrition transition and the pandemic of obesity in developing countries. nutr rev2012;70:3-21. 3. ng m, fleming t, robinson m, thomson b, graetz n, margono c, et al. global, regional and national prevalence of overweight and obesity in children and adults 1980-2013: a systematic analysis. lancet 2014;384:766-81. 4. yatsuya h, li y, hilawe eh, ota a, wang c, chiang c, et al. global trend in overweight and obesity and its association with cardiovascular disease incidence. circ j 2014;78:2807-18. 5. correia j, pataky z, golay a. comprendrel’obésitéen afrique: poids du développementet des représentations. rev med suisse 2014;6 [in french]. 6. hauhouot-attoungbré ml, yayo es, konan jl, koné f, siara e, monnet d. fattening diet and metabolic syndrome in ivory coast. ann biolclin (paris) 2013;71:207-10. 7. inserm, 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2000:252. 18. krotkiewski m, björntorp p, sjöström l, smith u. impact of obesity on metabolism in men and women. importance of regional adipose tissue distribution. j clin invest 1983;72:1150-62. 19. neupane s, prakash kc, doku dt. overweight and obesity among women: analysis of demographic and health survey data from 32 subsaharan african countries. bmc public health 2016;16:30. 20. paul e, mtumwa ah, ntwenya je, vuai sah. disparities in risk factors associated with obesity between zanzibar and tanzania mainland among women of reproductive age based on the 2010 tdhs. j obes2016;2016:10. 21. murray cjl, vos t, lozano r, naghavi m, flaxman ad, michaud c, et al. disability-adjusted life years (dalys) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the global burden of disease study 2010. lancet 2012;380:2197-223. 22. abegunde do, mathers cd, adam t, ortegon m, strong k. the burden and costs of chronic diseases in lowincome and middle-income countries. lancet 2007;370:1929-38. 23. fouda a, lemogoum d, owona manga j, il dissongo j, tobbit r, ngounoumoyo df, et al. epidémiologie de l’obésitéen milieu du travail à douala, cameroun. rev med brux 2012;33:131-7 [in french]. 24. pessinaba s, yayehd k, pio m, baragou r, afassinou y, tchérou t, et al. l’obésitéen consultation cardiologique à lomé: prévalence et facteurs de risque cardiovasculaireassociés étude chez 1200 patients. pan afr med j 2012;12:99 [in french]. 25. tzotzas t, vlahavas g, papadopoulou sk, kapantais e, kaklamanou d, hassapidou m. marital status and educational level associated to obesity in greek adults: data from the national malik ks, adoubi a, kouadio k, kouamé j, hounsa a, sackou j. overweight and obesity among women living in peri-urban areas in west africa (original research). seejph 2019, posted: 09 september 2019. doi 10.4119/unibi/seejph-2019-222 11 epidemiological survey. bmc public health 2010;10:732. 26. monteiro ca, conde wl, popkin bm. the burden of disease fromundernutrition and overnutrition in countries undergoing rapid nutrition transition: a view from brazil. am j public health 2004;94:433-4. 27. ahaneku gi, osuji cu, anisiuba bc, ikeh vo, oguejiofor oc, ahaneku je. evaluation of blood pressure and indices of obesity in a typical rural community in eastern nigeria. ann afr med 2011;10:120-6. 28. pathak a, galinier m, senard j-m. obésitéet maladies cardiovasculaires: physiopathologie, comorbidités et effet de laperte de poids. mt cardio 2007;3:187-92 [in french]. 29. ogden cl, carroll md, mcdowell ma, flegal km. obesity and socioeconomic status in adults: united states, 2005-2008. nchs data brief 2010;51:1-8. 30. recoursf,hébel p, chamaret c. les populationsmodestesont-ellesune alimentation déséquilibrée? paris: credoc (cahiers de recherche); 2006:113 [in french]. ______________________________________________________________________________________ ©2019 malik et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. jarke h, džindo a, jakob l. healthcare access in bosnia and herzegovina in the light of european union accession efforts (review article). seejph 2019, posted: 27 march 2019. doi 10.4119/unibi/seejph-2019-210 r e v i e w a r t i c l e healthcare access in bosnia and herzegovina in the light of european union accession efforts hannes jarke1, amra džindo2, lea jakob3 1 department of international health, school caphri, care and public health research institute, maastricht university, maastricht, the netherlands; 2 department of psychology, university of sarajevo, bosnia and herzegovina; 3 assessment systems international, prague, czech republic. corresponding author: hannes jarke address: maastricht university, po box 616, 6200 md maastricht, the netherlands; email: hannes.jarke@pscholars.org abstract european union (eu) member states are bound to ensure accessible, good quality healthcare for all of their citizens. in 2018, bosnia and herzegovina has been named as a candidate for accession to eu membership as part of the “strategy for the western balkans”. this scoping review identifies healthcare access issues in the country, aiming to inform policy-makers of challenges that may be faced in a possible membership application process and beyond. while the country has seemingly improved citizens’ healthcare access—as measured by the healthcare access and quality index—various specific problems remain unresolved. the main barrier to equal access appears to lie in the division of the healthcare system between the federation of bosnia and herzegovina, the republika srpska, and the brcko district, which also influences medicine availability and pricing. although not necessarily systematic, studies further report distance from healthcare providers, alleged widespread corruption, discrimination of minorities and vulnerable populations, as well as vaccination gaps as problems in healthcare access for specific groups. while certainly not easy to realise, this scoping review concludes that possible solutions could include efforts to unify the healthcare and pricing system, and the implementation of the world health organization’s essential medicines list, as well as investigating and tackling corruption and stigma issues. keywords: bosnia and herzegovina, european union membership, healthcare access, healthcare access and quality index, inequality. conflicts of interest: none. jarke h, džindo a, jakob l. healthcare access in bosnia and herzegovina in the light of european union accession efforts (review article). seejph 2019, posted: 27 march 2019. doi 10.4119/unibi/seejph-2019-210 introduction in february 2018, the european commission (ec) announced their “strategy for the western balkans” (1), featuring the discussion of a possible future european union (eu) membership for bosnia and herzegovina (b&h). since the treaty of the functioning of the european union (tfeu) entered into force in 2009, one of the eu’s key objectives is a high level of human health protection (2) with the aim to provide eu citizens access to good quality healthcare and a wide range of evidence-based treatments. however, healthcare access has been named as one of the biggest problems in the healthcare system of b&h (3). bosnia & herzegovina: history and numbers b&h is located on the balkan peninsula in south-eastern europe, with an overall population of 3,507,017inhabitants, and a gdp of 18.055 billion us$ (4). the country declared independence in 1992— during the breakdown of yugoslavia—but subsequently fell into a state of civil war and is still heavily affected by its aftermath, which included large-scale war crimes. the country features a very heterogeneous population (see figure 1 please note that this data is referring to the federation of b&h [fbh], not the whole country). people who have fled the war and have returned afterwards face additional difficulties: returned men are more likely to be unemployed than those who stayed, while formerly displaced women are dropping out of the labour force more often than others of the same sex (5), and all groups are more vulnerable to corruption than those who stayed (6). the organisation of healthcare is split between the fbh, republika srpska (rs), ten autonomous cantons, and the brcko district (bd) which makes it a heterogeneous structure split into 13 components (8). similarly, drug prescription systems are different between three entities (9). figure 1. ethnicities in the federation of bosnia and herzegovina (7) jarke h, džindo a, jakob l. healthcare access in bosnia and herzegovina in the light of european union accession efforts (review article). seejph 2019, posted: 27 march 2019. doi 10.4119/unibi/seejph-2019-210 figure 2. main stakeholders for drug prescription in the healthcare system of b&h [source: adapted from guzvic et al. (9)] while the peace treaty has been in effect for more than two decades, not all laws are in accordance with the conditions outlined in it. long-term health consequences of deteriorated living standards, high unemployment, and economic insecurity include post-traumatic stress disorder (ptsd) and impaired psychological wellbeing, not only among patients but also among their treating physicians (10). likewise, adverse childhood experiences appear to be more common than in the eu likely fostered by the post-war environment. a study on 400 hospital patients between 18 and 24 years of age found that 48.7% of respondents had experienced at least one form of childhood adversity and the results “demonstrated associations between adverse experiences in childhood and the probability of engaging in health risk behaviour” (11). this environment and the often-related financial hardships further reduce access to healthcare (12). other specific health challenges are physical war injuries. since the beginning of the war, close to 8,000 landmine victims have been reported (13). b&h remains one of the most landmine infested countries in the european region. while most victims die instantly, survivors often have to undergo amputations, great physical pain, long hospitalisation periods, and can develop anxiety and/or depression. data on patient safety in hospitals is scarce, but initial research found anecdotal evidence for an overall low perceived safety in three hospitals (14). a table containing the available health indicators can be found in the accompanying online repository (https://osf.io/axty3/). access to health services; inequities, and inequalities access to health services and healthcare is imperative for a healthy society. eu member states “have a clear mandate to ensure equitable access to high-quality health services for everyone living in their countries” (15). the exph clarifies that unmet healthcare needs should be addressed by allocating an appropriate amount of resources towards them. in that jarke h, džindo a, jakob l. healthcare access in bosnia and herzegovina in the light of european union accession efforts (review article). seejph 2019, posted: 27 march 2019. doi 10.4119/unibi/seejph-2019-210 sense, proper access to healthcare features the following eight characteristics: ● financial resources are linked to health needs ● services are affordable for everyone ● services are relevant, appropriate, and cost-effective ● facilities are within easy reach ● there are enough health workers, with the right skills, in the right place ● quality medicine and medical devices are available at fair prices ● people can use services when they need them ● services are acceptable to everyone this paper seeks to examine the status of healthcare access in the general population and vulnerable groups in b&h. areas for improvement are identified, so that they may inform further specific research and recommendations for the ec as outlined in art. 168 (2) in the tfeu should an accession process be put into motion. to do this, the countryand region-specific healthcare access problems are identified, inequities and inequalities are investigated, and compared to eu expectations (exph recommendations related to results can be found at: https://osf.io/zsq23). methods given the urgency of the issue, a scoping review was deemed to be the most fitting approach to identify healthcare access issues in b&h. while not fully exhaustive, scoping reviews allow for a faster (compared to systematic reviews) summary and dissemination of research findings, as well as the identification of research gaps (16), especially when the aim is to map broad topics. it has been argued that while there is no universally accepted precise definition of scoping reviews, their flexibility allows for the inclusion of more diverse evidence—such as grey literature— and therefore yields great potential to inform practice, policy, education, and further research into specific aspects (17). an iterative approach based on a framework by arksey and o’malley (18) was employed. to identify relevant studies, pubmed was searched first, but this endeavour showed only limited results. a search in google scholar revealed a much greater amount of hits, but also clearly showed a massive number of unrelated results. the full number of results using [“healthcare access” and “bosnia”] (n = 384), and an arbitrary number of results using [healthcare access and bosnia] (n = 250 out of 16,100) were scanned and included if relevant. based on these results, the identified topics were then again used in pubmed searches. lastly, databases in bosnian and croatian language were searched for healthcare access issues in b&h to include local research and grey literature. for a detailed overview of search strings and results, please see https://osf.io/yn6ed/. a total of 14 scientific papers and policy documents were included in the full evidence review, based on the criterion that they investigate a healthcare access issue related to one or more populations in b&h. results are portrayed in a narrative structure. whenever possible, the investigated studies are also compared to the overall ratings of the healthcare access and quality index (haq) which is based on data from the global burden of diseases, injuries, and risk factors study 2015 (gbd) (19), building on six factors: i. health expenditure per capita ii. hospital beds (per 1000 inhabitants) iii. universal health coverage tracer index of 11 interventions iv. physicians, nurses, and midwives (per 1000 inhabitants) v. proportion of population with formal health coverage vi. coverage index of three primary health-care interventions to calculate the haq, these were combined into a scale from 1 (lowest access jarke h, džindo a, jakob l. healthcare access in bosnia and herzegovina in the light of european union accession efforts (review article). seejph 2019, posted: 27 march 2019. doi 10.4119/unibi/seejph-2019-210 and quality) to 100 (highest possible access and quality) and measured per state and globally. results overall healthcare access and quality score the haq is generally improving globally and has even slightly improved in b&h during the war. it, therefore, may appear as if the war has hindered the development of overall access, but not thrown it back. however, the haq should not be taken as an indicator of equal healthcare access during 1990 and 1995, but merely interpreted as that the six outlined factors were invested in. when the war ended in 1995, b&h had an overall haq of 62.1 (compared to 60.9 in 1990) and has since constantly improved, up to a level of 78.2 in 2015 (19). the highest score was in diphtheria [100] and the lowest in adverse effects of medical treatments [45]. for comparison: b&h’s eu neighbour croatia had an overall haq of 70.4 in 1995 and improved to 81.6 in 2015. access to healthcare in bosnia & herzegovina the haq may only serve as a point of reference for specific problems in order to check whether improving one of the six factors could serve as a starting point in solving the problem. in 2006, the uptake of basic healthcare insurance in b&h—which covers medical services at an appointed general practitioner or through specialist recommendation, as well as specific drug prescriptions—was 84%, ranging from 63% in hercegbosanski kanton to 93% in sarajevo kanton, leaving around 380,000 citizens uninsured (20). coverage of basic healthcare for women in fbh and rs is lacking for 13–16% of the population, with the number rising up to 60% in roma women (21). in general, roma women, impoverished women, individuals living in rural areas, and people with disabilities have been found to have the lowest rates of healthcare coverage. a low number of available gynaecologist practices and a lack of basic information about the process of acquiring health insurance are further hindering equal healthcare access. employers do not always contribute regularly to workers healthcare schemes. this affected 27% of employees in 2015 in rs, with 16% receiving no payments at all towards their healthcare plan (21). regional inequalities in health care access and provisions the division of the healthcare system between fbh, rs, and bd likely poses the greatest challenge in providing equal healthcare and healthcare access to citizens of b&h. health policy making already proves to be extremely difficult because of a decentralised system and a large variety of decision makers in multiple regions (9). this also influences health technology assessment (hta), which is needed to ensure that proper technology and methodology for screenings, diagnoses, and treatments are available. while hta has been recognised in legislation, it has still not been introduced in full capacity due to lack of experts and education, and resistance from within the political environment (9). drug prescription and reimbursement are decentralised and differ between regions, leading to discrepancies in pricing (figure 2). this causes an inequity regarding access to essential medicines, with prescribed drugs being 20% more expensive on average in rs compared to fbh (22). the highest price difference was found for atorvastatin—used in the treatment of dyslipidaemia and prevention of cardiovascular disease—which is 39% more expensive in rs than in the fbh. in general, prices in bd are 14% lower, compared to fbh. prices and reimbursement for drugs also vary between cantons. neighbours divided by a simple jarke h, džindo a, jakob l. healthcare access in bosnia and herzegovina in the light of european union accession efforts (review article). seejph 2019, posted: 27 march 2019. doi 10.4119/unibi/seejph-2019-210 canton border may have different access to prescriptions and reimbursements. access to crucial medicine is further hindered by the limited number of drugs included on the fbh’s list of basic medicines (fbl). compared to the who’ essential medicines list (eml) it is not a sufficient list of important drugs which should be reimbursed (23). considering the scarce financial resources, the authors of the comparison conclude that the government should rather rely on the established, evidence informed eml. one example where this kind of inequity apparently has grave consequences is cancer treatment. kurtovic-kozaric et al. (24) claim that cancer patients in b&h either never receive the accurate therapy because it is missing from the list of government-reimbursed drugs, or they are put on a waiting list for one of the nine available drugs which are reimbursed still causing a delay in treatment, with some treatments supposedly not available at all. unmet healthcare needs long distance to the nearest primary healthcare provider is problematic for citizens in various regions (3). about a quarter of the inhabitants live 1.5–5 kilometres away from their nearest place of primary health care and 22% live more than 5 kilometres away (20). this further disadvantages vulnerable populations, such as children, the elderly, or individuals with chronic ailments, who may be in special need of timely treatment or regular checkups (21). rural areas also lack dental care specialists, compared to urban areas. mandic dokic (21) found that individuals with lower comprehension of written materials—with illiteracy being unequally distributed by gender (5.32% in men versus 0.93% in women)—face a barrier in understanding medical conditions or treatment information written at a level too complex for them to understand. healthcare access inequities and inequalities are often found for specific groups, especially minorities. in b&h, the number of sinti and roma is estimated to be around 35,000–40,000 (25). they are 2– 3 times more likely to report unmet health needs compared to non-roma living nearby, especially when uninsured (26). even when adjusted for “variation in gender, age, marital status, employment status, education, number of chronic conditions, health insurance status and geographical proximity to medical provider” (26) they are more likely to report unmet health needs in b&h specifically (odds ratio [or]=1.44 adjusted for the aforementioned factors, or=1.95 unadjusted). the authors call for increased inclusion of roma in the system and highlight the need for a detailed assessment of their needs within and outside of the health system. one of these unmet health needs is a gap in vaccination. an investigation (27) found that in central and eastern europe, “roma children have a lower probability of being vaccinated compared to non-roma ([or]= 0.325). the odds of being vaccinated for a roma child is 33.9% to that of a non-roma child for dpt [diphtheria, pertussis, tetanus], 34.4% for polio, 38.6% for mmr [measles, mumps, rubella] and 45.7% for bcg [tuberculosis]” (27). by comparing the means of vaccination coverage, the authors show that in b&h, the proportion of roma children having received any vaccination is 14.8% lower compared to non-roma. they are lower specifically by 21.2% for bcg vaccine, 35.3% for polio vaccine, 33.9% for dpt vaccine, and 35.8% for mmr vaccine. this is especially worrying, as roma tend to live in closed groups, making them less protected by the overall population’s herd immunity. the factors leading to low vaccination levels are relatively unknown but are likely related to a lack of access to healthcare in general, low level of education, and discrimination. jarke h, džindo a, jakob l. healthcare access in bosnia and herzegovina in the light of european union accession efforts (review article). seejph 2019, posted: 27 march 2019. doi 10.4119/unibi/seejph-2019-210 financial barriers in healthcare access people formerly displaced through the war may return to their home country to find the healthcare system not to be welcoming. a series of semi-structured interviews conducted among 33 refugees who returned to b&h after long-term residence in denmark provides an insight into their perception of the healthcare system (6). interviewees reported widespread corruption and added that it influenced them even more negatively than it does people who stayed. results indicate that corrupt physicians ask for larger bribes from returnees than from other citizens, facilitating a barrier to accessing various forms of healthcare. the situation is even worse for people suffering from chronic illnesses, as they are in need of frequent care. focus group interviews with returnees (28) found that healthcare quality in general was perceived as extremely low, going as far as to state that “[n]one of the participants could see any bright future in the healthcare system” (28). while the authors suggest that educational activities for healthcare professionals—teaching them how to meet the needs of returned migrants—are needed, success is questionable in the light of the apparent existence of widespread corruption. one public opinion survey (3) found that many people believed that corruption occurs in hospitals (77% agreed), health centres (68%), and outpatient clinics (60%). homoand bisexual men are reportedly facing barriers in obtaining healthcare. qualitative data obtained from 12 in-depth interviews suggests that stigmatisation, discrimination, prejudice, and inequities this group faces in bosnian & herzegovinian society extends to the healthcare sector (29). while further, quantitative, investigation is needed to estimate the extent of this situation, stojisavljevic and her colleagues (29) highlight the need for both educational trainings of professionals, as well as structural reform. this article features additional materials hosted on the open science framework at https://osf.io/z8sd3/. discussion the most important task goal b&h appears to be fostering re-unification of citizens and the healthcare system, whereas the latter is probably not possible without the former. if equity and equality in healthcare access ought to be improved as outlined by the exph (12), it is imperative that more treatments are made available and that they are available to all citizens, with medicine equally prescribed and reimbursed. a big step is an ordinance announced in january 2017 (30) by the agency for medicinal products and medical devices, which is supposed to harmonise medication prices. however, its implementation has been described as insufficient and hindered by bureaucracy (3). equity will also probably face a greater setback if b&h joined the eu: should the b&h health system stay similar to how it is now, some citizens are likely to choose medical travel to meet their health needs an option that is, however, too expensive for most citizens. while directive 2011/24/eu (31) constitutes a great opportunity to receive treatment which is not available in one’s own country, it is unlikely that—given the low income and overall gdp in b&h compared to the eu average—the majority of citizens will be able to profit from it. one straightforward option to work towards healthcare access equity would be to replace the national or regional medicine lists with the who’s eml and to adjust reimbursement schemes accordingly. if all three regions were to adopt the eml, this might also speed up the process of building a more unified healthcare and reimbursement system in general. another possibly beneficial innovation is telemedicine. while it is currently only being adapted slowly in b&h, naser et al. jarke h, džindo a, jakob l. healthcare access in bosnia and herzegovina in the light of european union accession efforts (review article). seejph 2019, posted: 27 march 2019. doi 10.4119/unibi/seejph-2019-210 (32) outline its potential, both in educating young professionals, as well as in treatment. however, the authors also note that its implementation is heavily reliant on investments in infrastructure and equipment, as well as a positive political climate welcoming it. while this seems highly ambitious, especially vulnerable groups could gain access to physicians of their choice more easily. should b&h continue in its accession plans, the way will be a long one—especially in healthcare— and will likely require some societal changes first. while many have called for more educational and change programmes, clear ideas on how these could look like or could be implemented are missing. as a scoping review, this investigation has a number of limitations by default. as it is supposed to serve as an overview of issues to address, there is no guarantee that it exhaustively covers all healthcare access issues in the country. the strength of evidence varies and is rather weak for certain areas; for example, while the vaccination gap in roma is rather well researched—and immediate, specific action may be recommended—especially qualitative evidence for discrimination and bribery—although definitely issues to be investigated—are hard to quantify and their actual spread hard to know. further, there is no indication to the extent of publication bias regarding the topic. in conclusion, both, the eu and b&h politics appear to be in need of addressing a multitude of healthcare access issues and establish solutions before accession seems sensible for both sides with regard to the goals set out by the exph. should they succeed in this, however, citizens in b&h may be able to benefit from better access 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for medicinal products and medical devices. official gazette 3/17. 2017 march. 31. parliament directive 2011/24/eu of 9 march 2011 on the application of patients’ rights in cross-border healthcare. 32. naser n, tandir s, begic e. telemedicine in cardiology perspectives in bosnia and herzegovina. acta inform med 2017;25:263. ______________________________________________________________________________________ © 2019 jarke et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 1 short report the global public health curriculum: specific global health competences edited by ulrich laaser version i (1 february 2018) correspondence: prof. dr. med. ulrich laaser dtm&h, mph section of international public health (s-iph) faculty of health sciences, university of bielefeld pob 10 01 31, d-33501 bielefeld e-mail: ulrich.laaser@uni-bielefeld.de; laaseru@gmail.com the 2nd edition of the global public health curriculum has been published in the south eastern european journal of public health, end of 2016 as a special volume (editors ulrich laaser & florida beluli) at: http://www.seejph.com/index.php/seejph/article/view/106/82. the curriculum targets the postgraduate education and training of public health professionals including their continued professional development (cpd). however, specific competences for the curricular modules remained to be identified in a more systematic approach. to that end from the international literature the following references have been used as a general orientation: a) armed forces medical college (afmc) resource group, ghec committee, india: global health essential core competencies. at: https://lane.stanford.edu/portals/ihealthpdfs/basiccore_competencies_final2010.pdf b) dias m. et al.: global health competencies for uk health professionals. technical report · september 2015. at: http://www.researchgate.net/publication/283086441 c) association of schools and programs of public health (aspph): the global health competency model. at: www.aspph.org/educate/models/masters-global-health/ d) world health organisation (who): who global competency model. at: www.who.int/employment/competencies/who_competencies_en.pdf e) jogerst k et al.: identifying interprofessional global health competencies for 21st century. at: https://www.cfhi.org/sites/files/files/pages/global_health_competencies_article.pdf mailto:ulrich.laaser@uni-bielefeld.de� mailto:laaseru@gmail.com� http://www.seejph.com/index.php/seejph/article/view/106/82� https://lane.stanford.edu/portals/ihealth-pdfs/basiccore_competencies_final2010.pdf� https://lane.stanford.edu/portals/ihealth-pdfs/basiccore_competencies_final2010.pdf� http://www.researchgate.net/publication/283086441� http://www.aspph.org/educate/models/masters-global-health/� http://www.who.int/employment/competencies/who_competencies_en.pdf� https://www.cfhi.org/sites/files/files/pages/global_health_competencies_article.pdf� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 2 an overview of the published modules is available in the background section of the curriculum as an introductory module (numbered r1.1): 1.0 background 1.1 introduction (ulrich laaser) 1.2 global public health functions and services: the history (ehud miron) 1.3 global public health definitions and challenges (joanna nurse) 2.0 global health challenges 2.1 demographic challenges (charles surjadi et al.) 2.2 burden of disease (milena santric-milicevic et al.) 2.3 environmental health and climate change (dragan gjorgjev et al.) 2.4 global migration and migrant health (m. wasif alam et al.) 2.5 social determinants of health inequalities (janko jankovic) 2.6 gender and health (bosiljka djikanovic) 2.7 structural and social violence (fimka tosija) 2.8 disaster preparedness (elisaveta stikova) 2.9 millennium development goals (marta lomazzi) 2.10 health and wellbeing (francesco lietz) 2.11global financial crisis and health (helmut wenzel) 3.0 governance of global public health 3.1 global governance of population health and well-being (george lueddeke) 3.2 health programme management (christopher potter) 3.3 role of the civil society in health (motasem hamdan) 3.4 universal health coverage (jose moreno et al.) 3.5 public health leadership in a globalised world (katarzyna czabanowska et al.) 3.6 public health ethics (alexandra jovic-vranes) 3.7 the global public health workforce (milena santric-milicevic et al.) 3.8 education and training of professionals for global public health (suzanne babic et al.) 3.9 blended learning (željka stamenkovic-nikolic et al.) 3.10 global health law (joaquin cayon) 3.11 human rights and health (fiona haigh) 3.12 global financial management for health (ulrich laaser) 4.0 going global (ulrich laaser) the two main categories for the grouping of essential competences have been adopted from a. foldspang (public health core competences for essential public health operations, volume 3, aspher 2016 at: http://aspher.org/download/76/booklet-competencesephosvolume-3.pdf): 1.0 the public health professional shall know and understand: 2.0 the public health professional shall be able to: for these two categories competences have been drafted more or less detailed in this first version for all modules by the authors in sections r 2.0 on global health challenges and r http://aspher.org/download/76/booklet-competencesephos-volume-3.pdf� http://aspher.org/download/76/booklet-competencesephos-volume-3.pdf� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 3 3.0 on governance of global public health. sections 1.0 (background) and 4.0 (going global) are of a different character and in principle allow only for the first category, therefore not included here. in some sections below additional references have been indicated by the authors. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 4 r 2.1 demographic challenges (charles surjadi, luka kovacic1 health systems today face challenges in the management of available resources. the implemented set of interventions and the criteria used for resource allocation are publicly debated. during reforms and in particular due to tough squeezing of resources, it is crucial to understand a proposed health plan and to have it supported by the public, health professionals, policy makers from other relevant sectors and international community. however, data on health and mortality in populations are not as comprehensive and consistent nor relevant as professionals require, rather are fragmentary and sometimes heterogeneous. the framework of burden of disease and injury study provides information and tools for integration, validation, exploration, and distribution of consistent and , muzaffar malik) there is growing interest in demography, among the public, politicians, and professionals: “demographic change” has become the subject of debates in many developed and developing countries. this is because it impacts on all aspects of people`s life, social relations, economy, and culture. the world population will continue to grow in the 21st century, but at a slower rate compared to the recent past. the annual growth rate reached its peak in the late 1960s, when it was at 2% and above. better health, economic and social conditions resulted in longer life and an ageing population. it is projected that by 2025 more than 20% of europeans will be 65 or over. better living conditions in cities lead to higher urbanization, more than 55% of the world’s population residing in urban areas in 2015. 1.0 the public health professional shall know and understand: 1.1 the definitions of demography, aging, social status, and urbanisation. 1.2 the major determinants of population dynamics. 1.3 the five stages of the global transition model 1.4 the global distribution of major diseases according to climate, gender and age, social status and culture. 1.5 major environmental effects of urbanization 2.0 the public health professional shall be able to: 2.1 develop specific population projections and identify their determinants. 2.2 identify the problems accruing from population growth, aging, and urbanisation. 2.3 apply the six determinants of active aging according to the who policy framework to selected populations/countries 2.4 design realistic improvements of slums and informal settlements r 2.2 burden of disease (milena santric-milicevic, zorica terzic-supic) 1 see obituary at: http://www.seejph.com/index.php/seejph/article/view/19/17 http://www.seejph.com/index.php/seejph/article/view/19/17� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 5 comparative descriptors of the burden of diseases, injuries and attributed risk factors, over time and across different health systems. as of 1992, when the first global burden of diseases study was executed, many national burden of disease studies have been undertaken and this framework is currently refining and updating. 1.0 the public health professional shall know and understand2 2 taken from reference (1), p. 36 ff.: 1a1, 1a2, 1a4; 1b1-3, 1b7-14; 1c3, 1d2.3-1d2.5, 1d3-5; 2a1; 3b5, 3b6; 3c2,3e2, 5a, 5b, 5c, 5d, 10a,10b,10c,10e,10d; : 1.1 health data sources and tools; surveillance of population health and disease programmes; surveillance of health system performance; data integration analysis and reporting; 1.2 identification and monitoring of health hazards; occupational health protection; food safety; road safety; 1.3 primary prevention; secondary prevention; tertiary/quaternary prevention; social support; 1.4 setting a national research agenda; capacity-building; coordination of research activities; dissemination and knowledge brokering 2.0 a public health student should be able to: 2.1 efficiently access global health data from sources such as the who global burden of disease measures and understand the limitations of these data. 2.2 identify the composite measures of morbidity and mortality and their roles and limitations for health program monitoring, evaluation and priority setting. 2.3 examine the major categories of morbidity and mortality used by the world health organization (who) and institute of health metrics and evaluation ihme (communicable and parasitic diseases, maternal, perinatal and childhood conditions, and nutritional deficiencies, non-communicable conditions importance and injuries) 2.4 describe the concept of premature mortality including age, sex and cause specific mortality rates, life expectancy and years of life lost (yll). this will involve the ability to undertake calculation of indicators such as under 5 mortality rate, maternal mortality and hiv/aids mortality rates and yll due to selected causes of deaths in a target population. 2.5 demonstrate knowledge of the major global causes of morbidity and health risks, by describing the concepts of years lived with disability (yld) and disability adjusted life-year (daly). 2.6 describe how the relative importance of each category, and of the leading diagnoses (15 causes) within each category, vary by age, gender and time, and explain potential contributors to the observed variations. 2.7 explain how life expectancy, yld, yll and daly may be used to make general health comparisons within and/or between countries and who regions, and between high, middle and low-income regions, and draw implications for policy and practice. 2.8 perform a health economic assessment (e.g. cost-effectiveness analysis) for different procedures or programmes. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 6 additional reference: foldspang, a. on behalf of aspher: from potential to action, public health core competences for essential public health operations (edition for comments). volume 2, brussels: may 2016. at: http://www.aspher.org/download/75/booklet-competencesephosvolume-2.pdf r 2.3 environmental health (dragan gjorgjev, fimka tozija) the concept of limits of growth – how far we can go? the ecological concept of health, ecological public health – reshaping the conditions for good health. from demographic to democratic transitions to be addressed by public health; different dpseea models of environmental health assessment – conceptual framework of environmental health wellbeing. environmental and climate change (cc), burden of diseases (daly, yll). environment and health inequalities. environment and health risk assessment studies. environmental health indicators to assess health effects of climate change – threats to be reduced and opportunities to be adopted. importance of the intersectoral work. vulnerability, mitigation, and adaptation of the health sector. 1.0 the public health professional shall know and understand: 1.1 the basic concept of relationships between ecosystem, environmental degradation, pollution, and human health. 1.2 the dependence of human health on local and global ecological systems and the context of policies, practices and beliefs required to address global environmental changes (such as climate change, biodiversity loss and resource depletion). 1.3 the impact of major driving forces like industrialization, transport , rapid population growth and of unsustainable and inequitable consumption on important resources essential to human health including air, water, sanitation, food supply and living/housing and know how these resources vary across world regions. 2.0 the public health professional shall be able to: 2.1 use an ecological public health model within a specific social-economic context to discuss how global forces impact health aiming to improve the promotion of health and management of environment and health risks and effects. 2.2 applying the basic methods for environment and health impact assessment (ehia) 2.3 analyse the effects of air pollution on acute and chronic lung, cardiovascular disease and other systems diseases 2.4 analyse the interactions between inadequate clean water supplies and good sanitation and diarrheal and parasitic diseases. 2.5 analyse the relationship between the availability of adequate nutrition, potable water and sanitation and risk of communicable and chronic diseases. http://www.aspher.org/download/75/booklet-competencesephos-volume-2.pdf� http://www.aspher.org/download/75/booklet-competencesephos-volume-2.pdf� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 7 2.6 analyse the relationship between environmental pollution and cancers (air pollution, radon and lung cancer; benzene and leukaemia etc.). 2.7 analyse the relationship between climate change and human health. 2.8 communicate the environment and health risks and inform the public how the driving forces like globalisation and others affects environment and health inequalities within and between countries. 2.9 develop the skills to provide evidence based support to policy makers in order to mitigate the effects of global environmental change on health. r 2.4 global migration and migrant health (muhammad wasif alam, vesna bjegovic-mikanovic) nowadays, global migration is considered even more important than in the past. the main reason for that is the number of migrants, which is steadily increasing at the end of the 20th century and will continue to grow in the twenty-first. in general, migrants are supposed to have bad opportunities for health as a consequence of their migrant status. the most important issue in analytical models for the health effects of migration is the type of migration – whether it is voluntary, involuntary, or irregular migration. usually, migration does not bring improvement in social well-being and health. the wide variety of health conditions and consequences is associated with the profile of the mobile population: “what migrants bring, what they find, and what they build in the host country”. many authors stress three temporal and successive phases associated with individual movements: the predeparture phase, the journey phase, and the post-journey phase. though different in many ways they suffer from globally dominant health problems: tuberculosis, trauma/rape/torture/ptsd, hiv/aids, cardiovascular disease etc. prevention of the public health consequences is particularly relevant and important among the migrants and classified in three levels: primary, secondary, and tertiary. a clear strategy at the local, regional, and international levels is needed for efficient interventions. there is human right of migrants to be treated properly. 1.0 the public health professional shall know and understand: 1.1 the concept of a pandemic and how global commerce and travel contribute to the spread of pandemics. 1.2 the interplay between national and international conflict, interpersonal violence, and health as well as the direct and indirect threats to both individual and population. 1.3 health threats posed by violent conflict and natural disaster, and ways in which such threats may extend beyond the borders of the country directly affected. 1.4 the health challenges (including accessing healthcare) that refugees, asylum seekers and other migrants are faced with during life in their country of origin. 2.0 the public health professional shall be able to: laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 8 2.1 analyse the health risks related to migration, with emphasis on the potential risks and appropriate resources. 2.2 consider the utility and limitations of common infection control and public health measures in dealing with local or global outbreaks. 2.3 control outbreaks of communicable diseases such as measles in a context of local and international populations with varying levels of immunization. 2.4 liaise with local or regional public health authorities and be aware of national and international public health organizations responsible for issuing health advisory recommendations. 2.5 analyse general trends and influences in the global availability and movement of health workers. 2.6 regard the impact on health of cross-border flows, including international trade, information and communications technology, and health worker migration. r 2.5 social determinants of health inequalities (janko jankovic) the largest contribution to health inequalities both within and between countries around the world is attributable to the social circumstances in which people live and work, i.e. to the social determinants of health. educational attainment, income, occupational category and social class are probably the most often used indicators of current socioeconomic status in studies on social inequalities in health which present differences in health that are unnecessary, avoidable, unfair and unjust. they are also systematic (not distributed randomly) and socially produced and therefore modifiable. the fairest way to combat against social inequalities in health is to improve the health of the most disadvantaged faster than that among the rich. 1.0 the public health professional shall know and understand: 1.1 the relationship between health and social determinants of health, and how social determinants vary across world regions. 1.2 the major social determinants of health and their impact on differences in life expectancy, major causes of morbidity and mortality and access to healthcare between and within countries (topics include absolute and relative poverty, income, education, employment status, social gradient, gender, ethnicity and other social determinants). 1.3 the relationship between health, human rights, and global inequities. 2.0 the public health professional shall be able to: 2.1 define health inequity and health inequalities. 2.2 demonstrate how one can inform policy makers about the importance of addressing health inequalities, and advocate for strategies to address health inequalities at a local, national or international level. 2.3 describe major public health efforts to reduce disparities in global health (such as sustainable development goals, europe 2020 and health 2020). laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 9 2.4 analyse local, national or international interventions to address health determinants such as strategies to engage marginalized and vulnerable populations in making decisions that affect their health and well-being. 2.5 analyse distribution of resources to meet the health needs of marginalized and vulnerable groups. r 2.6 gender and health (bosiljka djikanovic) while sex in genetically and biologically determined, gender is socially constructed identity that shapes many aspects of person’s functioning and has implications on health as well. there are historically present gender disparities that are related to the power, decision making, and different societal expectations of women and men. although gender norms and values are deeply rooted in the culture, they are not fixed and unchangeable. they might evolve over time and may vary substantially in different environments. gender analysis aims to identify gender differences that will inform actions to address gender inequality. gender mainstreaming in medical education is important for eliminating gender biases in existing routines of health professionals. 1.0 the public health professional shall know and understand: 1.1 the basic differences between sex and gender and their overall importance on health. 1.2 how different levels of development of civil society and human rights affect identification and respect of gender differences. 1.3 the factors that influence construction of gender identity, and the impact of gender identity on achieving full potentials for health, including an access to health promotion and disease prevention. 1.4 the historical perspective of gender differences and their impact on social functioning and health 1.5 the relationship between sex and other mediating factors with different health outcomes. 1.6 how gender affects different risk-taking behaviours and other mediating factors of the importance for disease prevention, treatment and rehabilitation. 1.7 how transgender identity is associated with different health outcomes. 2.0 the public health professional shall be able to: 2.1 elaborate on differences and interrelationship between sex, gender and health, and corresponding challenges that appear at primary, secondary and tertiary level of prevention. 2.2 identify windows of opportunities in public health for addressing gender differences that have an impact on health. 2.3. use different tools and mechanisms that better recognise, identify and articulate gender differences in health-related matters. 2.4. conduct proper gender analysis in order to identify gender inequities and gender inequalities that exist in certain communities and societies, with the relevance for health. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 10 2.5 apply gender mainstreaming, as a process of assessing implications for women and men of any planned action, including legislation, policies or programs, in any area, and at all levels. 2.6 apply gender mainstreaming as an integral part of the design, implementation, monitoring and evaluation of policies and programs in all political, economic and societal spheres, so that women and men benefit equally. 2.7 propose set of actions that would overcome gender gap in achieving the fullest potential for health. r 2.7 structural and social violence (fimka tozija) theoretical and conceptual basis is provided for understanding structural and social violence, collective violence and armed conflicts as a public health problem: definitions, typology, burden, context, root causes and risk factors, public health approach, structural interventions and multilevel prevention. general overview of public health approach, ecological model and human rights approach is presented. the module also explains the impact of structural and social violence on health, human rights, the role of the health sector, and suggests a number of practical approaches for prevention and policy intervention. 1.0 the public health professional shall know and understand: 1.1 the main concepts of structural and social violence, collective violence and armed conflicts, human rights, public health approach, structural interventions and multilevel prevention. 1.2 the theoretical and conceptual basis of structural and social violence, and armed conflicts as a public health problem: definitions, typology, burden and context. 1.3 root causes and risk factors for structural and social violence. 1.4 the main analytical methods and tools for structural and social violence: public health approach, ecological model and human rights approach as defined by the who. 1.5 the impact of structural and social violence on health and human rights. 1.6 the role of the health sector for prevention of structural and social violence. 1.7 evidence-based multilevel prevention programmes for structural and social violence. 1.8 health in all policies for prevention of structural and social violence. 1.9 practical approaches for prevention and policy intervention for structural and social violence prevention. 1.10 the impact of resilient factors on structural and social violence prevention. 2.0 the public health professional shall be able to: 2.1 demonstrate a basic understanding of the relationship between health, human rights and structural and social violence. 2.2 apply analytical tools for structural and social violence: public health approach and ecological method. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 11 2.3 determine the magnitude, burden and economic consequences of structural and social violence applying who methodology. 2.4 identify root causes and risk factors for structural and social violence at different levels and compare in different countries. 2.5 perform literature review and critical reading for structural and social violence. 2.6 do case problem analysis and review of evidence-based multilevel prevention measures for structural and social violence. 2.7 translate knowledge in practice consider and apply successful practices from other countries for structural and social violence. 2.8 develop multilevel prevention programs for structural and social violence. 2.9 identify methods for assuring prevention program sustainability. 2.10 identify resilient factors to strengthen community capabilities, and contribute to reduction of structural and social violence. additional references: foldspang a, otok r, czabanowska k, bjegovic-mikanovic v. developing the public health workforce in europe: the european public health reference framework (ephrf): it’s council and online repository. concepts and policy brief. brussels: aspher, 2014. available from: http://www.aspher.org/download/27/ephrf_concept_and_policy_brief.pdf (accessed 21st december 2016). who. global strategy on human resources for health: workforce 2030. geneva: health workforce department 2016. available from: http://www.who.int/hrh/resources/pub_globstrathrh-2030/en/ (accessed 21st december 2016). background reading: eu joint action on health workforce planning & forecasting. http://healthworkforce.eu/ (accessed 19th december 2016). who. models and tools for health workforce planning and projections. geneva: who press 2010 teach-vip 2 users’ manual training, educating and advancing collaboration in health on violence and injury. geneva: vip department 2012. r 2.8 disaster preparedness (elisaveta stikova) the disaster and emergency preparedness and response core competences were created to establish a common performance goal for the public health preparedness workforce. this goal is defined as the ability to proficiently perform assigned prevention, preparedness, response, and recovery role(s) in accordance with established national, state, and local health security and public health policies, laws, and systems. much of an individual's ability to meet this performance goal is based on competences acquired from three sources: foundational public health competences, generic health security or emergency core competences, and position-specific or professional competences. 1.0 the public health professional shall know and understand: http://www.aspher.org/download/27/ephrf_concept_and_policy_brief.pdf� http://www.who.int/hrh/resources/pub_globstrathrh-2030/en/� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 12 1.1 the main definitions of disaster and emergencies (similarities and differences); role of the hazard and vulnerability in disaster occurrence. 1.2 the theoretical and conceptual basis of single and compound disaster, measurement of the consequences and threshold level of the responsibilities of the local/national/international communities in the scope of the required resources for planning and response during the local or state-wide incident, disaster, and crisis. 1.3 the aim of the disaster/emergency management and main components of the disaster’s management cycle 1.4 the basic principles for development of disaster preparedness and importance of the appropriate risk assessment analysis 1.5 the differences of the generic preparedness i.e. “all-hazard” and “specific” hazard’s related preparedness process 1.6 the importance and the scope of the preparedness plan for the protection and of the critical infrastructure, across the ten community’s essential sectors 1.7 the meaning and main components of the governmental, population/individuals and business preparedness planning activities 1.8 the definition of public health emergency and importance of appropriate public health emergency preparedness in the scope of the public health emergency functions 1.9 the specificity of the public health emergency preparedness plan and importance of the early warning and surveillance systems as a key elements for assessing of the state of emergency 1.10 the opportunities for using a combined remote sensing technology, geographic information systems (gis), spatial statistical techniques and mathematical models which can help in modelling of the dispersion of the harmful agent and exposure of the population to the harmful agent. 1.11 the use of the new rapid detection and identification of unknown agents or confirmation of known agents that can cause disaster. 1.12 being familiar with the structure and component of the hospital preparedness plan and infrastructure safety. 2.0 the public health professional shall be able to: 2.1 apply the activities which are necessary for ensuring an effective disaster management in a pre-event (disaster mitigation) and in a post-event (disaster response) period, aiming to ensure an appropriate (pre-event) and effective (post-event). 2.2 demonstrate basic understandings of disaster preparedness as a most effective disaster mitigation process. 2.3 demonstrate operational skills to use administrative measures, to implement strategies, and to improve coping capacities in order to lessen the adverse impacts of hazards and to minimize the opportunity for development of disaster. 2.4 apply analytical tools and to perform early and initial risk assessment. 2.5 do specific preparedness plan for the protection and strengthen the resilience of the critical infrastructure of the community, across the ten essential sectors. 2.6 develop the government preparedness actions grouped into five general categories: planning, resources and equipment, exercise, training and statutory authority. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 13 2.7 determine the differences of the public health functions in the prevention/mitigation and preparedness phases during public health emergencies. 2.8 identify the 15 public health and health-care preparedness capabilities, divided in six core groups, as the basis for state and local public health and health-care preparedness. 2.9 develop an emergency response plan (erp) and associated early warning and surveillance functions, training and exercises using an “all-hazard/whole-health” approach applicable in public health emergency. 2.10 know to use of remote sensing technology, geographic information systems (gis), spatial statistical techniques and mathematical models for modelling of the dispersion of the harmful agent and modelling of the exposure of the population to the harmful agent. 2.11 be able to communicate and manage the need for use of the public national/international network of public health laboratories for rapid detection and identification of unknown agents and/or confirmation of known agents 2.12 know to develop hospital preparedness plan taking into account such factors as the appropriateness and adequacy of physical facilities, organizational structures, human resources, and communication systems. background reading: council on linkages between academia and public health practice. core competencies for public health professionals. at: http://www.phf.org/resourcestools/pages/core_public_health_competencies.aspx centers for disease control and prevention, centers for disease control and prevention. public health preparedness capabilities: national standards for state and local planning. atlanta, ga: centers for disease control and prevention. 2011 subbarao i, lyznicki jm, hsu eb, gebbie km, markenson d, barzansky b, armstrong jh, cassimatis eg, coule pl, dallas ce, king rv. a consensus-based educational framework and competency set for the discipline of disaster medicine and public health preparedness. disaster medicine and public health preparedness. 2008 mar 1;2(01):57-68. r 2.9 millennium and sustainable development goals (marta lomazzi) the millennium development goals (mdgs) are eight international development goals to be achieved by 2015 addressing extreme poverty, hunger, maternal and child mortality, communicable disease, education, gender equality and women empowerment, environmental sustainability and the global partnership. most activities worldwide have focused on maternal and child health as well as communicable diseases, while less attention has been addressed to environmental sustainability and the development of a global partnership. in 2015, numerous targets have been at least partially attained. however, some goals have not been achieved, particularly in the poorest regions, due to different challenges. the post-2015 agenda is now set. the new goals, the sustainable development goals (sdg), reflect today’s geopolitical, economic and social situation and adopt an all-inclusive, intersectoral and accountable approach. http://www.phf.org/resourcestools/pages/core_public_health_competencies.aspx� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 14 1.0 the public health professionals shall know and understand: 1.1 what are the millennium development goals, including targets and indicators? 1.2 achievements and failures of mdgs at global, regional and national levels. 1.3 mdgs and inequalities: how and where the goals have or not reduced inequalities and disparities. 1.4 the impact of the mdgs in shaping the public health agenda 2000-2015, mobilizing the public health community and in revitalizing the development aid. 1.5 how progresses have been measured and evaluated. availability and accountability of data on mdgs achievements and failures. 1.6 whether and how mdgs have impacted local and global governance, policies set-up and education approaches. 2.0 the public health professional shall be able to: 2.1 demonstrate a basic understanding of the relationship between mdgs, health, economic growth and governance. 2.2 understand the tools and reports used to evaluate mdgs and make a critical reading of the results and articles. this should include also analysis and critical evaluation of the impact of donors in shaping the agenda and achieving the targets. 2.3 determine the impact of mdgs at local, regional and global level. 2.4 identify root causes and facilitators that impacted most the failure or achievements of mdgs. 2.5 translate knowledge in practice consider and apply successful practices from effective mdgs activities that can be applied in other contexts. develop preventive programs on that basis. 2.6 identify methods for assuring prevention program sustainability. additional references: un the millennium development goals report 2015 http://www.un.org/millenniumgoals/2015_mdg_report/pdf/mdg%202015%20rev%20%28 july%201%29.pdf health in 2015: from mdgs to sdgs http://www.who.int/gho/publications/mdgs-sdgs/en/ lomazzi, m., et al., mdgs – a public health professional’s perspective from 71 countries. journal of public health policy, 2013. 34(1): p. e1-e22. lomazi, marta; borisch bettina; laaser, ulrich. the millennium development goals: experiences, achievements and what’s next. global health action, [s.l.], v. 7, feb. 2014. issn 1654-9880. r 2.10 health and wellbeing (francesco lietz) teach a man to fish and you feed him for a lifetime” they say: promoting well-being is not so distant a concept from teaching how to fish, since high levels of well-being are correlated to a http://www.un.org/millenniumgoals/2015_mdg_report/pdf/mdg%202015%20rev%20%28july%201%29.pdf� http://www.un.org/millenniumgoals/2015_mdg_report/pdf/mdg%202015%20rev%20%28july%201%29.pdf� http://www.who.int/gho/publications/mdgs-sdgs/en/� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 15 reduction of diseases and mental disorders, and vice versa. well-being can be studied at two different levels: internal/subjective; whose measures rely on how a respondent places him or herself on a scale; or external/objective; measured through demographics and material conditions. the promotion of well-being has been indicated by the united nations as one of the 17 sustainable development global goals sdg 3) to be achieved over the next 15 years. in order to face this workload public health professionals with the ability to think globally and act locally are needed. 1.0 the public health professional shall know and understand: 1.1 main concepts of well-being, happiness, quality of life, wealth, and life satisfaction. 1.2 main determinants of well-being: from the definitions to the potential applications in programs and interventions. 1.3 the historical background of the well-being’s study. 1.4 the difference between the eudaimonic and the hedonic approach. 1.5 the optimal research tools for well-being in the different cultures and the different life stages. 1.6) the application of the theory in the context of the sustainable development goals. 1.7 the different strategies of the health sector to implement well-being programs and initiatives. 1.8 the latest evidence about well-being from different theoretical perspectives. 1.9 how to predict future pathways of well-being on regional and national plan. 1.10 how can the different trajectories of well-being’s determinants influence the health dynamics of a population? 2.0 the public health professional shall be able to: 2.1 effectively differentiate well-being from other similar concepts, such as happiness and quality of life. 2.2 choose the best measurement tools according the environment’s requests. 2.3 looking at the literature in order to determine the quality of well-being at every given moment. 2.4 understand the importance of cross-culturalism and different population groups in wellbeing assessment. 2.5 analytically review the literature. 2.6 react on the base of the researches’ results. 2.7 optimize the process of communication knowledge in the scientific environment. 2.8 taking under consideration the multidimensional aspect of well-being when developing prevention programs. 2.9 anticipate future trends in order to assure program sustainability. 2.10 empower the stakeholder at all levels so that they can strengthen community capabilities. additional references: laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 16 centers for disease control and prevention. well-being concepts. available from: https://www.cdc.gov/hrqol/wellbeing.htm (accessed 28th february 2017). dodge r, daly ap, huyton j, sanders ld. the challenge of defining wellbeing. international journal of wellbeing. 2012 aug 29;2(3). oecd. oecd guidelines on measuring subjective well-being. paris: oecd, 2013. helliwell jf, layard r, sachs j. world happiness report 2015. new york: sustainable development solutions network, 2015. sustainable development goals. goal 3: ensure healthy lives and promote well-being for all at all ages. available from: https://sustainabledevelopment.un.org/sdg3 (accessed 28th february 2017). background reading: oecd. measuring well-being and progress. available from: http://www.oecd.org/std/measuring%20well-being%20and%20progress%20brochure.pdf (accessed 28th february 2017). oecd. compendium of oecd well-being indicators. available from: https://www.oecd.org/std/47917288.pdf (accessed 28th february 2017). topp cw, østergaard sd, søndergaard s, bech p. the who-5 well-being index: a systematic review of the literature. psychotherapy and psychosomatics. 2015 mar 28;84(3):167-76. r 2.11 the global financial crisis and health (helmut wenzel) the economic situation influences the health status of a population in many ways. the financial crisis has now given greater weight on an old debate about the financial sustainability of health systems in europe. drivers of health expenditures will be critically analysed. the vulnerability of public budgets and its consequences for health budgets is depicted. the toolset of politics, and policies applied by policy-makers will be analysed. managed care approaches are presented and evaluated. 1.0 the public health professional shall know and understand: 1.1 the interdepencies of health and “structural determinants of health” 1.2 the principles of the global financial market 1.3 the interdependencies of health and national economies at times of global market and global competition 1.4 the impact of competitive production processes at times of a global market on worker’s health. e.g., the place of production heavily depends on the local production cost. 1.5 the relationship between unemployment, unsecure living conditions and related health problems 1.6 how fragile national economies cause falling budgets on all levels of a country 1.7 the interdependencies of national budgets and allocation of resources on health budgets 1.8 the financing gaps of health care and its possible causes laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 17 1.9 the constraints of financing and setting up health budgets 1.10 understand the various policy measures to cope with decreasing budgets 1.11 common measures to cope with discrepancy between needs and financial power 1.12the interdependencies of the financial crisis and economic crises in a global market and its dynamic nature 1.13 the concept of financial market and “frozen market” leading to shortage in the real economy 1.14 the four channels through which the “disease” spreads 1.15 the reasons of changing demand of health care by quantity and quality 1.16 the main drivers of health care demand 1.17 the operation and financing of health care systems with respect to their underlying national premises (beveridge, bismarckian etc.). 1.18 the advantages and disadvantages of the various national concepts to organise health care systems 1.19 approaches to improve health care efficiency and sustainable financing 1.20 managed care approaches, their organisational structures and their operations 1.21 integrated care approaches and their opportunities to improve cooperation and increase efficiency of provision of care 2.0 the public health professional shall be able to: 2.1 demonstrate a basic understanding of the relationship between global economy and health 2.2 critically analyse health care systems and their connected budgeting processes 2.3 apply knowledge and skills needed for recommending a redesigning of health care systems 2.4 apply analytical tools to identify particularly vulnerable areas of health care in constrained environment such as neonatal medical care 2.5 identify imbalances in care delivery like the affordability of out-of-pocket purchased medicines among the elderly and retired citizens 2.6 identify imbalances in access to the most expensive medical technologies such as targeted biologicals indicated in cancer and autoimmune diseases, radiation therapy; various implantbased interventional radiology, orthopaedic and cardiovascular surgical procedures 2.7 to understand the relevance of catastrophic household expenditure imposed by illness among the world’s poor residing in low and middle income countries (increased vulnerability during crisis evidenced) 2.8 review the literature and design a case study for analysing the impact of the crises on health outcomes, based on secondary statistics. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 18 r 3.1 global governance of population health and well-being (george lueddeke) strengthening the health of populations and the health systems requires a “glocal” perspective being aware of the essential role of governments and to consider the adoption of a new mindset in meeting global challenges to planet health and well-being, applying, where appropriate and feasible, the ‘one world, one health’ concept. furthermore, there is the need for a new form of global governance that is ‘fit for the 21st century’ and is able to effectively respond to unprecedented environmental, societal, economic and geopolitical hurdles and lead the way to a safer, fairer and equitable future for all. 1.0 the public health professional shall know and understand: 1.1 how global trends in public health practice, commerce and culture contribute to health and the quality and availability of health services locally and internationally. 1.2 the role of key actors in global health including the world health organization, united nations, world bank, multilateral and bilateral organisations, foundations, nongovernmental organisations (ngos); and their interactions, power, governance and different approaches to global health (for example, emergency aid versus long term development and horizontal versus vertical approaches: horizontal approach addressing a range of diseases and determinants of health, e.g. comprehensive primary care, versus a vertical approach focusing on one disease, e.g. a disease-specific immunization programme). 1.3 how global actors provide resources, funding and direction for health practice and research locally and globally, and the effects that this has on individual and population health. 1.4 how global funding mechanisms can influence the design and outcome of research strategies and policies, and how policies made at a global or national level can impact on health at a local level. 2.0 the public health professional shall be able to: 2.1 describe different national models for public and/or private provision of health services and their impact on the health of the population and individuals. 2.2 give examples of how globalization and trade including trade agreements affect availability of public health services and commodities such as patented or essential medicines. 2.3 promote the function/intention of the sdgs and identify health-related objectives, including: 1. reduce child mortality 2. improve maternal health 3. eradicate extreme poverty and hunger 4. combat hiv/aids, malaria, tuberculosis and other diseases 2.4 critically comment on policies with respect to impact on health equity and social justice. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 19 2.5 explain the advantages of collaborating and partnering and to select, recruit, and work with a diverse range of global health stakeholders to advance research, policy, and practice goals, and to foster open dialogue and effective communication. 2.6 identify barriers to health and health services in low resource settings locally and internationally. 2.7 describe barriers to recruitment, training and retention of human resources in underserved areas such as rural, inner-city and indigenous communities within highand low-income countries. 2.8 analyse the effect of distance and inadequate infrastructure on the delivery of health services (effects of travel costs, poor roads, lack of mailing address or phone system, lack of medicines, inadequate staffing, and inadequate and unreliable laboratory and diagnostic support). 2.9 identify barriers to appropriate prevention and treatment programs in low-resource settings (low literacy and health literacy, user fees, lack of health insurance, costs of medicines and treatments, therapies and procedures, advanced presentation of disease, lack of provider access to management guidelines and training including continuing professional development, concerns regarding quality of care, real or perceived, cultural barriers to care, underutilization of existing resources, issues facing scaling up and implementation of successful programs). 2.10 develop health service delivery strategies in low-resource settings, especially the role of community-based health services and primary care models. 2.11 differentiate between and highlight the benefits and disadvantages of horizontal and vertical implementation strategies. 2.12 refer to the essential medicines list and its role in ensuring access to standardized, effective treatments. 2.13 explain how international policies affect health locally, for example policies relating to global markets in healthcare (such as the pharmaceutical industry) and global resources for health (such as medications and transplant organs). 2.14 advise on the impact of trade regulations on health, for example through impact on access to clean water, taxation, tobacco use, alcohol and fast-food consumption, antibiotic use and health service provision. 2.15 propose how countries may work together to address shared health burdens or threats such as pandemics and natural disasters. 2.16 give examples how health can be a shared goal in conflict resolution and peace promotion at a local, regional, national and international level and investigate why governments may have competing aims regarding military and health intervention in conflict settings. 2.17 advocate for global trade regulations that promote public health, for example in relation to tobacco, fast-food and alcohol. 2.18 identify a organisation’s emergency response plans (including pandemic preparedness) and attend local emergency preparedness training to learn about your role during an international health emergency. 2.19 advocate for effective systems to facilitate global responses to international health emergencies, including timely, well-supported and appropriate movement of health professionals across borders during and after the event. 2.20 participate in responsible social media use to promote health locally or globally, informed by an understanding of how telecommunications influence global and local health laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 20 (for example by making health information available globally, and by enabling transnational advocacy about health issues). 2.21 exhibit interpersonal communication skills that demonstrate respect for other perspectives and cultures. r 3.2 health programme management (christopher potter) health development interventions are described as falling under four modalities: personnel, projects, programmes and policy reform initiatives underpinned by new financial support mechanisms, particularly sector-wide approaches (swaps). these modalities are briefly analysed to provide an introduction to readers about how and why such interventions are used, and their strengths and weaknesses. it is emphasised that the modalities are not hard and fast entities but frequently overlap. indeed one of the problems facing those designing and implementing interventions is the fuzzy nature of many management terms. such issues as vertical and horizontal programme design and the transaction costs to governments who have to deal with many donors in an often relatively short-term and fragmentary manner are considered. swaps are considered as one way of dealing with some of these issues but it is noted that as many other non-state stakeholders, including industrial and commercial interests, have entered the health development arena, the possible, although contended advantages, of swaps have been compromised. finally, it is recognised that the public health challenges and their socio-political and economic contexts facing poorer countries are ever changing, so finding effective ways to deliver health development to the world’s most needy will also be an on-going challenge. 1.0 the public health professional shall know and understand: 1.1 project management techniques throughout program planning, implementation, and evaluation. 1.2 the use of the terms project and programme in the context of public health interventions. 1.3 how skills/tools such as project management and log-frames can be used to improve the effectiveness of interventions. 1.4 key concepts of health policy reforms and effective interventions e.g. sip and swap 1.5 appreciate a range of interventions to promote public health improvements in disadvantaged countries. 2.0 the public health professional shall be able to: 2.1 apply scientific evidence throughout program planning, implementation, and evaluation. 2.2 design program work plans based on logic models. 2.3 develop proposals to secure donor and stakeholder support. 2.4 plan evidence-based interventions to meet internationally established health targets. 2.5 develop monitoring and evaluation frameworks to assess programs. 2.6 develop context-specific implementation strategies for scaling up best-practice interventions. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 21 2.7 plan, implement, and evaluate an evidence-based programme. r 3.3 civil society organisations in health (motasem hamdan) the role of the civil society for health is increasingly recognized, mainly due to the historical development of non-governmental organizations. their role in health and social development as well as in global scale is nowadays indispensable. there should be, however, a regulating framework or code of conduct. 1.0. the public health professional shall know and understand: 1.1 the concepts of civil society organizations. 1.2 the historical development and the roots of ngos work. 1.3 the types, features of ngos and area of activity in different countries. 1.4 the methods of funding ngos. 1.5 the role of ngos in health system development, health policy, and health research. 1.6 the challenges of regulating and coordinating the work of ngos. 2.0 the public health professional shall be able to: 2.1 to analyze the impact of ngos on health, and health care systems. 2.2 to identify measures to enhance accountability and regulate the work of ngos. 2.3 to apply analytical tools to understand the coordination and harmonization of the work of the civil society organizations to national health priorities. r 3.4 universal health coverage (jose m. martin-moreno, meggan harris) nearly half of all countries worldwide are pursuing policies to achieve universal health coverage. this undertaking has the potential to improve health indicators dramatically, contributing to human development and more generally to global equity. however, the path towards uhc is often rocky, and every country must work to channel resources, adapt existing institutions and build health system capacity in order to accomplish its goals. global health advocates must understand what elements contribute to the success of uhc strategies, as well as how to measure real progress, so that they will be prepared to substantially contribute to policies in their own country or worldwide. 1.0. the public health professional shall know and understand: 1.1 the concepts and the rationale of universal health coverage (uhc) and its linkage with health financing and public-private partnership for health. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 22 1.2 the roles and contributions of the private sector, communities, and the traditional medicine in promoting and sustaining uhc. 1.3 the political, social, economic and technical aspects of the health financing transition. 2.0 the public health professional shall be able to: 2.1 advocate in favour of uhc strategies in health policies and programmes at global, regional, and national levels. 2.2 assess progress towards uhc. 2.3 advance critical and strategic thinking when designing a uhc programme, both in a national context and as part of an external development strategy. r 3.5 public health leadership in a globalised world (katarzyna czabanowska, tony smith, kenneth a. rethmeier) leadership is a well-known concept within organisational science, public health leadership has still not been well-defined. a recent who report acknowledges that contemporary health improvement is more complex than ever before and requires leadership that is “more fluid, multilevel, multi-stakeholder and adaptive” rather than of a traditional command and control management variety. today’s public health professionals therefore need to be able to lead in contexts where there is considerable uncertainty and ambiguity, and where there is often imperfect evidence and an absence of agreement about both the precise nature of the problem and the solutions to it. the impact of the evolving growth of the eu and its impact on the potential mobility of healthcare professionals to re-locate across many geographic regions has left, in some communities, a gap in the resources of seasoned healthcare leaders. while this trend opens new opportunities for emerging young healthcare professionals to take on greater roles guiding their healthcare systems, it has also produced a significant need for high quality leadership development educational needs. there is a need to discuss and provide professional development with a concentration on the vital role of leadership and governance play in public health globally. indeed, the presence of competent leaders is crucial to achieve progress in the field. a number of studies have identified the capability of effective leaders in dealing with the complexity of introducing new innovations or evidencebased practice more successfully. 1.0 the public health professional shall know and understand: 1.1 to demonstrate diplomacy and build trust with community partners. 1.2 to communicate joint lessons learned to community partners and global constituencies. 1.3 to exhibit inter-professional values and communication skills that demonstrate respect for, and awareness of, the unique cultures, values, roles/responsibilities and expertise represented by other professionals and groups that work in global health. 1.4 to apply leadership practices that support collaborative practice and team effectiveness. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 23 2.0 the public health professional shall be able to: 2.1 communicate in a credible and effective way: expresses oneself clearly in conversations and interactions with others; listens actively. 2.2 to produce effective written communications and ensures that information is shared. positive: speaks and writes clearly, adapting communication style and content so they are appropriate to the needs of the intended audience conveys information and opinions in a structured and credible way encourages others to share their views; takes time to understand and consider these views ensures that messages have been heard and understood keeps others informed of key and relevant issues negative: does not share useful information with others does little to facilitate open communication interrupts or argues with others rather than listening uses jargon inappropriately in interaction with others lacks coherence in structure of oral and written communications; overlooks key points 2.3 to produce and deliver quality results; is action oriented and committed to achieving outcomes. positive: demonstrates a systematic and efficient approach to work produces high-quality results and workable solutions that meet client needs monitors own progress against objectives and takes any corrective actions necessary acts without being prompted and makes things happen; handles problems effectively takes responsibility for own work sees tasks through to completion negative: focuses on the trivial at the expense of more important issues provides solutions that are inappropriate or in conflict with other needs. focuses on process rather than on outcomes delivers incomplete, incorrect or inaccurate work fails to monitor progress towards goals; fails to respect deadlines delays decisions and actions 2.4 to succeed as an effective and efficient health system manager positive: personal qualities (leadership): manages ambiguity and pressure in a self-reflective way. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 24 uses criticism as a development opportunity. seeks opportunities for continuous learning and professional growth. works productively in an environment where clear information or direction is not always available remains productive when under pressure stays positive in the face of challenges and recovers quickly from setbacks uses constructive criticism to improve performance shows willingness to learn from previous experience and mistakes, and applies lessons to improve performance seeks feedback to improve skills, knowledge and performance negative: demonstrates helplessness when confronted with ambiguous situations demonstrates a lack of emotional control during difficult situations reacts in a hostile and overly defensive way to constructive criticism fails to make use of opportunities to fill knowledge and skills gaps consistently demonstrates the same behaviour despite being given feedback to change transfers own stress or pressure to others r 3.6 public health ethics (alexandra jovic-vranes) the basic concept of public health ethics covers principles and values that support an ethical approach to public health practice and provide examples of some of the complex areas which those practicing, analysing, and planning the health of populations have to navigate; a code of ethics is the first explicit statement of ethical principles inherent to public health. 1.0 the public health professional shall know and understand: 1.1 the ability to identify an ethical issue. 1.2 ethical decision-making. 1.3 understanding the full spectrum of the determinants of health. 1.4 understanding basic ethical concepts such as justice, virtue, and human rights. 1.5building and maintaining public trust. 2.0 the public health professional shall be able to: 2.1 recognizes the ethical value the public health community gives to prevention 2.2 considers the full spectrum of the determinants of health 2.3 identifies the range of options for interventions that correspond to the full spectrum of determinants of health 2.4 recognizes the tension between community health and rights of individuals 2.5 identifies the various conceptions of human rights, including those of the community 2.6 defines the legal authority of public health agencies laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 25 2.7 considers the values of diverse stakeholders when conducting needs assessments and evaluations 2.8 recognizes the ways that advocacy and empowerment can be done 2.9 represents the needs and perspectives of all relative stakeholders with particular attention to the disenfranchised 2.10 describes issues of access and barriers to public health services 2.11 recognizes the ethical priority the public health community gives to the health of the disenfranchised 2.12 determines research priorities with an understanding of areas of the community that have been underserved 2.13 specifies the meaning of consent at the individual and group level 2.14 identifies the range of options for obtaining consent at the individual and group level 2.15 recalls historical abuses of informed consent 2.16 discerns the risk and benefits of not acting quickly or not acting at all 2.17 identifies the range of options for responding to unethical practices observed outside of one’s realm of responsibility 2.18 recognizes that legal rules can fall short of the ethically required action 2.19 describes the full spectrum of the determinants of health 2.20 identifies best practices for achieving a particular health objective 2.21 discerns and applies different methods of maintaining confidentiality 2.22 describes the potential harms and benefits of giving information about individuals and communities while maintaining confidentiality 2.23 identifies specific circumstances when maintaining trust may justify with holding or delaying the communication of information 2.24 identifies best practices for one’s areas of responsibility and action 2.25 determines the range of appropriate actions for addressing unethical behavior 2.26 identifies interests and conflicts of interest between potential partners 2.27 articulates how public trust is built or undermined by partner collaboration 2.28 establishes transparency about collaborations to maintain public accountability additional references: 1) thomas j. skills for the ethical practice of public health. washington dc: public health leadership society; 2004; available at: http://phls.org/cmsuploads/skills-for-the-ethicalpractice-of-public-health-68547.pdf. background reading: 1) lee lm, wright b, semaan s. expected ethical competencies of public health professionals and graduate curricula in accredited schools of public health in north america. am j public health. 2013 may; 103(5): 938–942. 2) bernheim rg, nieburg p, bonnie jr. ethics and practice of public health. in goodman ar (editor) law in public health practice. 2nd edition. oxford university press, 2007: 110135. lee lm. public health ethical theory: review and path to convergence. j law med ethics. 2012;40(1):85–98. http://phls.org/cmsuploads/skills-for-the-ethical-practice-of-public-health-68547.pdf� http://phls.org/cmsuploads/skills-for-the-ethical-practice-of-public-health-68547.pdf� https://www.ncbi.nlm.nih.gov/pubmed/?term=lee%20lm%5bauthor%5d&cauthor=true&cauthor_uid=22994177� https://www.ncbi.nlm.nih.gov/pubmed/?term=wright%20b%5bauthor%5d&cauthor=true&cauthor_uid=22994177� https://www.ncbi.nlm.nih.gov/pubmed/?term=semaan%20s%5bauthor%5d&cauthor=true&cauthor_uid=22994177� https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3698833/� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 26 r 3.7 the global public health workforce3 3 see also reference (1), p. 36 ff.: 1a1,3,4; 1b,c,d; 2a4; 2b7-9; 2c2; 3a7, 3b3; 3c2; 3d3; 4a,b; 5a,d; 6a; 6b2-5; 6c; 7a; 7b, 7c; 7d; 8 a; 8b; (milena santric-milicevic, vesna bjegovic-mikanovic, muhammad wasiful alam) the progress of health sciences and technological innovations including modern medicine and health care technologies has increased our expectations for quality of life and health care. that has influenced the public health vision, the scope of public health interventions, and the composition of public health workforce. the outline the text includes description of the current situation of the public health workforce globally; future needs assessment; public health workforce challenges and mitigation globally. it underscores the demand for valid, reliable data sources and tools for mobilization of capacities of skilled public health staff in order to appropriately address global health challenges. 1.0 the public health professional shall know and understand: 1.1 the concepts of public health and public health workforce, including barriers and limitations of their application in the practice. 1.2 10 essential public health functions (services, operations) and the global framework for public health functions (see: wfpha. “a global charter for the public’s health” and related documents at https://www.wfpha.org/charter/the-charter). 1.3 the roles and responsibilities of public health professionals and wider public health workforce at the global, regional, national and local level. 1.4 the 6 ‘action fields’ of a comprehensive hrh action framework of the management systems of human resources for global public health : (1) hr management systems (2) leadership/governance, (3) partnership (4) finance, (5) education, and (6) policy and 4 phases (situation analysis, planning, implementation and monitoring, evaluation and research). 1.5 how global factors and country context influence the functioning of public health systems and the work of public health professionals. 1.6 how global trends in epidemiology, environmental change, economy, technology and medicines development, and resource availability may affect public health services supply and demand within and between countries. 1.7 methods and tools used for workforce planning in public health. 1.8 how decisions are made about workforce resource allocation in the context of local and global resource constraints and the contribution of economic evaluations and populationbased needs assessments to such decisions. 1.9 in the context of resource limitation, especially workforce, how best to identify key partners and work effectively and efficiently with the stake holders. 2.0 the public health professional should be able to: laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 27 2.1 efficiently access global health workforce data from national and international sources such as the who global health observatory (gho) data and understand the limitations of these data. 2.2 identify and compare services delivered by the public health professionals across countries and the alignment with public health priorities. 2.3 undertake the public health workforce analysis using the 6 action fields and 4 phases. 2.4 examine the major governance and organizational structures and mechanisms for provision of public health services nationally and internationally. 2.5 examine the drivers of health worker migration, and the impacts of such migration on health systems, as well as the wellbeing of health professionals and health service users. 2.6 consider successful practices from other health systems to improve national public health services equity, efficiency, access, quality applied to address global public health challenges. 2.7 identify and compare public health workforce planning and development systems across countries. 2.8 use methods for assessing the public health workforce requirements (services and capacities) locally and globally. 2.9design sustainable workforce development strategies for resource-limited settings. additional references: foldspang, a. on behalf of aspher: from potential to action, public health core competences for essential public health operations (edition for comments). volume 2, brussels: may 2016. at: http://www.aspher.org/download/75/booklet-competencesephosvolume-2.pdf foldspang, a. on behalf of aspher: public health core competences for essential public health operations. volume 3, brussels 2016. at: http://aspher.org/download/76/bookletcompetencesephos-volume-3.pdf r 3.8 education and training of professionals for global public health (suzanne babich, egil marstein) by addressing the critical need for public health education and training within the global health workforce, we have in this program an opportunity to contribute substantially to efforts to improve the health of people worldwide through improved project management and resource application. topics introduced and discussed address the complexities of working with country specific agents, organizational representatives and formal and informal stakeholders who may influence the outcome of global health operations. 1.0 the public health professional shall know and understand: 1.1 key concepts related to stakeholder theory: how political, organizational and socioeconomic conditions affect critical operational premises in the governance of global health. http://www.aspher.org/download/75/booklet-competencesephos-volume-2.pdf� http://www.aspher.org/download/75/booklet-competencesephos-volume-2.pdf� http://aspher.org/download/76/booklet-competencesephos-volume-3.pdf� http://aspher.org/download/76/booklet-competencesephos-volume-3.pdf� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 28 complexities associated with working with country specific agents: appreciate the makeup and workings of context specific forces as these impact global health initiatives; e.g. (i) identify key stakeholders and their impacts on health governance and leadership; (ii) evaluate culture-specific traits relevant for the professions, teams and organizational processes; (iii) analyze institutional governance as it applies to fieldwork planning and program execution; and (iv) recognize the dynamics of the global health field and how this needs be incorporated in operational strategies and actions. 1.3 principles of project management and resource application 1.4 how global health initiatives are financed through international aid 1.5 international standards for health program performance evaluation 2.0 the public health professional should be able to: 2.1 critique policies with respect to impact on health equity and social justice 2.2 describe the roles and relationships of the entities influencing global health 2.3 analyze the impact of transnational movements on population health 2.4 analyze context-specific policy making processes that impact health 2.5 describe the interrelationship of foreign policy and health diplomacy 2.6 conduct a situation analysis across a range of cultural, economic, and health contexts 2.4 analyze context-specific policy making processes that impact health 2.5 describe the interrelationship of foreign policy and health diplomacy 2.6 conduct a situation analysis across a range of cultural, economic, and health contexts r 3.9 blended learning (željka stamenkovic, suzanne babic) blended learning is an educational model with great potential to increase student learning outcomes and to create new roles for teachers. in this course you will learn about and then develop tools to build your own blended learning programme. 1.0 the public health professional shall know and understand: 1.1 main concept of blended learning and 4 basic blended learning models: (1) rotation model, (2) flex model, (3) a la carte model and (4) enriched virtual model. 1.2 the differences between blended learning models and when each model should be applied. 1.3 how to integrate face-to-face and online learning in order to improve the learning outcomes. 1.4 how to implement blended learning and successfully accomplished blended learning process. 1.5 the main drivers of blended learning. 1.6 the advantages and disadvantages of blended learning for teachers. 1.7 the advantages and disadvantages of blended learning for students. 1.8 how global trends in technology may affect blended learning in public health in the future. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 29 2.0 the public health professional shall be able to: 2.1 use the technology tools and resources in order to support blended learning. 2.2 work in different environments and have the flexible time schedule. 2.3 know when blended learning is the best choice for the particular course. 2.4 design a successful blended learning strategy and identify methods for assuring successfully accomplished blended learning process. 2.5 target learning opportunities. 2.6 act as a learning facilitator. 2.7 constantly support students who are learning different things, at different paces, through different approaches. 2.8 participate in students’ process of learning. additional references: bonk cj, graham cr (eds.) (2005). handbook of blended learning: global perspectives, local designs. san francisco, ca: pfeiffer publishing. carman jm (2005). blended learning design: five key ingredients. agilant learning. donoghue f (2011). the strength of online learning. the chronicle of higher education. http://chronicle.com/blogs/innovations/the-strengths-of-online-learning/29849 (accessed on december 31, 2016). friesen, n. (2012). report: defining blended learning. http://learningspaces.org/papers/defining_blended_learning_nf.pdf (accessed on december 31, 2016). kelly r (2012). blended learning: integrating online and f2f. online classroom 12: 1,3. lephie. leaders for european public health. http://www.lephie.eu (accessed on december 31, 2016). u.s. department of education, office of planning, evaluation, and policy development, evaluation of evidence-based practices in online learning: a meta-analysis and review of online learning studies, washington, d.c., 2010. r 3.10 global health law (joaquin cayon) transnational public health problems have been traditionally addressed through international health law whose proper implementation faces two important handicaps: the absence of an international authority that can enforce it, and the absence of a comprehensive concept. despite this, international agreements and treaties are among the most important intermediate public health goods because they provide a legal foundation for many other intermediate products with global public health benefits. nowadays, according to the emergence of the idea of global public health, a new concept -“global health law”has been born. there is an important distinction between international health law and global health law. international health law connotes a more traditional approach derived from rules governing relations among states. on the other hand, global health law is developing an international structure based on the world as a community, not just a collection of nations. there is also an http://chronicle.com/blogs/innovations/the-strengths-of-online-learning/29849� http://learningspaces.org/papers/defining_blended_learning_nf.pdf� http://www.lephie.eu/lephie_repository.html� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 30 important international trend leaded by some prestigious scholars who have urged adoption of a legally binding global health treaty: a framework convention on global health grounded in the right to health. in this context, an interdisciplinary approach to global public health inevitably requires the study of global health law for any healthcare professional. it is undoubtedly necessary to study and analyse the emergence and development of global health law just because it arises as an important tool to address the phenomenon of globalization of health. in this regard, the future of global public health is directly dependent on the strength of global health law understood in a comprehensive way. 1.0 the public health professional shall know and understand: 1.1 theoretical and conceptual basis of global health law. 1.2 the rationale of studying global health law. 1.3 the increasingly interactive relationship between global health law and global public health. 1.4 the role of global health law as an important tool to deal with the phenomenon of globalization of health. 1.5 differences between international health law, global health law and global health jurisprudence. 1.6 how global health diplomacy brings together the disciplines of public health, international law and economics and focuses on negotiations that manage the global policy environment for health. 1.7 how international trade law, international labour law and international humanitarian law impact on national health systems. 1.8 how the human rights approach constitutes an important strategy for challenging globalization's effects. 1.9 the connection between the prevention principle to sustainable development and international legal obligations regarding cross-border pollution. 1.10the challenge of a legally binding global health framework convention grounded in the right to health. 2.0 the public health professional shall be able to: 2.1 demonstrate a basic understanding of the relationship between global health law and global public health. 2.2 develop skills for critical analysis of legal data and health information. 2.3 develop critical thinking skills and explore critically health systems from a legalnormative perspective. 2.4 do literature review and critical reading for globalization of health and the role of law. 2.5 identify the main international treaties on communicable disease control, world trade, environmental protection and working conditions that impact on public health. 2.6 employ a comprehensive and multidisciplinary approach for the analysis of the role of global law as a determinant of health. 2.7 identify key points to be included in a future global framework on public health. 2.8 identify human rights and public health issues involved and affected by international treaties. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 31 2.9 compare differences between national and international legal framework on public health and develop proposals to improve health legislation both at national and international level. 2.10 apply basic legal tools for developing, exploring, and evaluating global health initiatives. additional references: ablah e (2014): improving global health education: development of a global health competency model. at: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3945704/ berkman be, rothemberg kh (2012): teaching health law, j law med ethics 40(1):14753. mcneill ransom m (2016): public health law competency model: version 1.0. at: https://www.cdc.gov/phlp/docs/phlcm-v1.pdf rowthorn v, olsen j (2014): all together now: developing a team competency domain for global health education, j law med ethics 42 (4): 550-63. r 3.11 human rights and health (fiona haigh) human rights and health are intrinsically linked. health policies and practice can impact positively or negatively on rights and in turn human rights infringements and enhancements can influence health. increasingly human rights based approaches are being used to strengthen public health policies and programs and as a powerful tool to advocate for the action on the social determinants of health. 1.0 the public health professional shall know and understand: 1.1 the key human rights concepts and the un treaty system. 1.2 the relationship between health and human rights. 1.3 how social, economic, political and cultural factors may affect an individual’s or community’s right to health services (e.g. availability, accessibility, affordability, and quality). 1.4 the rationale for using human rights based approaches to health. 1.5 the relevance of human rights to global public health. the public health professional shall be able to: 2.1 analyse the right to health and how this right is defined under international agreements such as the united nations’ universal declaration of human rights or the declaration of alma-ata. 2.2 introduce the main objective of policies and programmes with regard to the fulfilment of human rights. 2.3 to identify rights holders and duty bearers, and the capacities of rights holders to make claims on duty bearers to meet their obligations. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3945704/� https://www.cdc.gov/phlp/docs/phlcm-v1.pdf� laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 32 r 3.12 global financial management for health (ulrich laaser) world population growth takes place predominantly in the poor countries of the south whereas most of the resources are available in the north. the economic inequalities are related to key health indicators. although official development assistance (oda) and development assistance for health (dha) grew considerable during the last decade the objective of 0.7% of the northern gdp to be transferred to the south has not been reached by far. in order to correct the main weaknesses the international community agreed on the socalled paris indicators but failed the set timelines. the underlying reasons may be sought in the fragmentation and incoherence of international financial assistance. 1.0 the public health professional shall know and understand: 1.1 the major social and economic determinants of health and their effects on the access to and quality of health services and on differences in morbidity and mortality between and within countries. 1.2 the deeper reasons for the gap in wealth between the south and the north corresponding to vast disparities in standards of living, health, and opportunities. 1.3 the structures of international financial management in the health sector. 1.4 the main terminologies of oda and dah. 1.5 the five principles of the paris declaration on aid effectiveness and the results of the subsequent conferences. 1.6 the key global strategies to reduce the north-south gap including sdg 3. 1.7 how to analyse the critical aspects of loans to developing countries regarding intergenerational effects, and monetary back flows to the donors for experts and equipment. 1.8 why capacity strengthening means sharing knowledge, skills, and resources for enhancing global public health programs, infrastructure, and workforce to address current and future global public health needs. 1.9 why assistance to developing countries is increasingly considered a moral obligation, although more often declared in resolutions than in deeds. 2.0 the public health professional shall be able to: 2.1 consider the underlying reasons for the failure in efficiently organizing international assistance as there is the extreme fragmentation and therefore ineffectiveness of international aid, and the insufficient coordinating capacities and competences in the national ministries of health making it difficult to secure ownership. 2.2 identify the deficits of global governance and to implement interim strategies to strengthen regional collaboration. 2.3 follow up and promote the latest evaluation of the paris indicators. 2.4 advocate effectively for an increase in oda to reach 0.7% of gdp of donor countries and for an increasing share of dah. 2.5 argue and act against imbalances in oda and dah due to political and economic interests of the donor countries. laaser u. (editor) the global public health curriculum specific global health competences (short reports). seejph 2018, posted: 06 february 2018. doi 10.4119/unibi/seejph-2018-180 33 2.6 design global, regional, national and local structures, organisational principles and mechanisms to improve and sustain global health and well-being, including universal health coverage. 2.7 work in a constructive and contributing way in the environment of a sector-wide approach or pool-funding. 2.8 contribute to the management of a medium term expenditure framework and help to establish nhas. 2.9 contribute to the improvement of debt and debt relief management as important steps towards addressing the massive inequalities that currently deform global relationships and enable debtor countries to make a fresh start towards genuine social and economic development. 2.10 promote a code of ethics for ngos taking into consideration their increasing relevance in channelling aid to developing countries. 2.11 conduct a situation analysis across a range of cultural, economic, and health contexts. 2.12 develop a network of international health professionals for enhancement of professional work in areas of mutual interest. ablah e (2014): improving global health education: development of a global health competency model. at: berkman be, rothemberg kh (2012): teaching health law, j law med ethics 40(1):147-53. holst j. designing germany’s new global health strategy: some important recommendations (editorial). seejph 2019, posted: 02 april 2019. doi 10.4119/unibi/seejph-2019-211 page 1 of 7 e d i t o r i a l designing germany’s new global health strategy: some important recommendations jens holst1, on behalf of the german platform for global health 1 department of nursing and health sciences, fulda university of applied sciences, fulda, germany. corresponding author: jens holst, fulda university of applied sciences; address: leipziger strasse 123, d-36037 fulda, germany; telephone +496619640643; email: jens.holst@pg.hs-fulda.de holst j. designing germany’s new global health strategy: some important recommendations (editorial). seejph 2019, posted: 02 april 2019. doi 10.4119/unibi/seejph-2019-211 page 2 of 7 introduction the german government is currently preparing a new global-health concept. this is remarkable only five years after the adoption of the first national concept as an important step towards a coherent globalhealth policy (1). public-health experts had warned at the time that the 2013 strategy might fail to make a consolidated contribution to solving global health challenges. they identified important gaps, particularly in the areas of non-medical determinants of health, national and global inequity, and universal health coverage for migrants, refugees and sans papiers, as well as in the effective and transparent inter-ministerial institutionalisation of german global health policies and universal health coverage (2). for the re-launching of the global health strategy paper, the federal government organised two preparatory meetings with civil society and invited different actors to elaborate their priority recommendations. in the context of the participatory process initiated by the government, the german platform for global health (dpgg), an association of trade unions, nongovernmental organisations and researchers, now highlights a series of recommendations which will be crucial for making an effective and convincing contribution to the global health agenda. in particular, germany’s growing role as global-health actor (3) calls for a balanced, multidisciplinary, coherent and problemoriented policy for contributing to significant and sustained improvement in people’s health worldwide. based on inputs from a broad array of areas of expertise, the platform aims to emphasise the importance of the social determinants of health and disease in both the national and international health debate (4). in today's globalised world, the key conditions of people's well-being and health are no longer steerable and modifiable at the national level alone. a comprehensive approach has to acknowledge that global health starts at home. hence, the platform strives to bridge the divide between national and global health policies. starting from this understanding, the german platform for global health has developed the following key recommendations for the new german global-health strategy. equal health opportunities worldwide health is both a precious resource and a human right. all over the world, health opportunities depend far more on social conditions and social status than on individual health behaviours. people with lower education and income fall ill and die earlier than members of the upper socioeconomic class (5,6). this is not due to higher barriers to access to medical care, because even comprehensive social protection systems such as those in france, germany, the netherlands or the united kingdom do not alter the fact that life expectancy for the poorest quintile is shorter by many years, on average, than for the richest 20 percent of the population (7). these disparities in the health and life chances of people in germany, europe and world-wide are not ordained by nature but caused by social conditions and can therefore be influenced by political measures. responsible global health policies must strive to reduce these inequalities. however, as in most countries, the healthpolicy debate in germany is almost exclusively concerned with the scope and organisation of the health-care system, with financial contributions and the payment of health-care providers. restricting health and illness to individual self-responsibility is the wrong way to go and heightens inequalities rather than reducing them. often the causes of disease are primarily addressed as individual risk factors, while little attention is paid to the most harmful factors, the social, environmental, structural holst j. designing germany’s new global health strategy: some important recommendations (editorial). seejph 2019, posted: 02 april 2019. doi 10.4119/unibi/seejph-2019-211 page 3 of 7 and political determinants of health and disease. the forthcoming global health strategy of the german federal government should thus also highlight the creation and promotion of healthy living and environmental conditions at local, national and global levels. a healthpromoting policy must not only ensure good care in the event of illness, but above all create conditions that enable a healthy life. in any case, the health-care system can only contribute a small part to overcoming health inequalities. health policy must be cross-sectoral and target all areas that directly or indirectly affect people's wellbeing and health. who therefore calls for a coherent approach at various policy levels (health in all policies) involving government actors, business, civil society and global organisations (8). if it wants to contribute effectively to improving the health of the world's population, the federal government's global health strategy must also provide policy impact assessment tools; that is, approaches to review all policy areas for their social, environmental and, most importantly, health impacts. this is the only way to prevent regulations, projects and measures from having a negative impact on human health. the global health strategy should therefore:  create conditions that enable a healthy life;  reduce health inequalities;  pursue a health-in-all approach;  subject measures in all policy areas to a health impact assessment. social security for all especially in the countries of the global south, but also in the rich countries of the north, globalisation measures such as structural adjustment policies, public austerity programmes and privatisation have put pressure on or even dismantled public social security systems (9). in the case of illness, unemployment and disability, people must be able to build on reliable social protection systems. without overcoming social insecurity and hardship, the fundamental rights, opportunities for realisation and ultimately the freedom of the people are not guaranteed. universal social protection in the event of illness is not a mere economic cost factor, but the basis for individual and economic development and social welfare (10). the sustainable development goals (sdgs) also oblige germany to offer social protection to all people living in the country (11). this means making social benefits fully available to asylum seekers, non-working eu citizens and all people without a regular residence permit. at the global level, there must be a special emphasis on strengthening social protection systems, especially in the poor countries of the south. therefore, a country’s global health strategy must always include universal health coverage as well as more extensive social protection – both in that country and elsewhere in the world. but even strengthening health and social systems through international cooperation will not be sufficient in itself. the sustainable improvement of the social condition of all people on earth requires fair use of national resources, economic participation as well as financial support of poor societies and their people. the global health strategy should therefore include the following elements:  ensuring the universal right to social protection and mitigation of social risks;  developing social security systems worldwide with sustainable and solidarity-based financing, including access to guaranteed social benefits for all people living in germany;  establishing a global financial equalisation fund for social benefits, and particularly social protection in case of illness. holst j. designing germany’s new global health strategy: some important recommendations (editorial). seejph 2019, posted: 02 april 2019. doi 10.4119/unibi/seejph-2019-211 page 4 of 7 decent and healthy work adequate protection of the life and health of the working population, as well as social security to safeguard minimum income and comprehensive medical care, have long been central objectives of the international community. however, globalisation is increasingly putting pressure on labour standards worldwide and making their enforcement more difficult (12,13). wellbeing and health opportunities of the working population are often subordinated to the pursuit of growth and profit. even worse is the situation for the unemployed, who face a significantly higher risk of illness and death (14), for about 20 million people obliged to work as forced labourers, and over 200 million working children worldwide (15). therefore, a global health strategy should also include actions to reduce relevant detrimental risk factors for health, such as job insecurity, precarious employment, poor working conditions and lack of social protection for the unemployed. in today's global economic order, low wage levels, savings on health and safety protection in the workplace, flexible and hence unstable employment conditions, and weak trade unions or none at all, are considered positive business-location factors. until the logic of short-term profit maximisation and growth at any price can be reversed, equity in health remains unattainable. the global health strategy of the federal government must not only consider the working conditions of people all over the globe, but also the responsibility of german and international companies. those who are serious about better global health have to demand responsible, democratic governance of the global economy which respects economic, social, environmental and health aspects and reconciles different interests. the global health strategy should therefore include the following:  ensuring the fundamental right to work and adequate remuneration;  compliance with ilo health and safety regulations and eliminating hazardous working conditions worldwide;  greater focus of the global economy on societal, environmental and health criteria. climate change and health climate change threatens the very foundations of human life on the planet and is considered the greatest health threat in the 21st century (16). air pollution is one of the leading causes of illness and death worldwide (17,18); global warming and climate-related environmental damage endanger the basic conditions for health and well-being and are threatening to undermine the health improvements of recent decades. comprehensive, determined and quick action is needed to keep the consequences of global warming under control. environmental pollution and climate change have a direct and indirect health impact (19). given the potentially existential threat to our civilisation and human health from environmental degradation, climate change and health should be cornerstones of any global health strategy. effective climate protection is active health protection that goes beyond merely strengthening resilience. the global health strategy should therefore:  call for a rapid transition to a carbonneutral economy and society by means of emissions reductions, adequate taxation of fossil fuels and reduction of subsidies, which are harmful to the environment or the environment;  seek to use the additional funds for climate change and health;  financially and technologically support poorer countries to avoid development pathways based on environmental degradation and fossil energy generation;  understand global health as the health of human civilisation and its natural holst j. designing germany’s new global health strategy: some important recommendations (editorial). seejph 2019, posted: 02 april 2019. doi 10.4119/unibi/seejph-2019-211 page 5 of 7 resources. health: human right in public responsibility “everyone has the right to a standard of living adequate for the health and wellbeing of himself and of his family, including food, clothing, housing and medical care and necessary social services”, states the 1948 universal declaration of human rights (20). the 1966 social pact of the united nations establishes "the right of everyone to the enjoyment of the highest attainable standard of physical and mental health" and further specifies the “steps to be taken by the states parties to the present covenant to achieve the full realization of this right” (21). the world health organization also explicitly makes governments responsible for the state of health of the population (22). although civil society involvement is important, states should not shift that responsibility to them. despite these and other internationally binding rules, the implementation of the right to health remains a global challenge. privatisations and public-private partnerships (ppps), praised as a solution for tight budgets, are now showing undesirable effects such as rising consumer prices, lack of control over the use of public funds, and growing social and health inequalities (23,24). these consequences of the narrow business logic of marketoriented reforms have underlined the necessity and significance of social services in the general public interest, both in germany and in other countries of the world. without preserving and strengthening public social responsibility, the right to health remains unattainable. it is first and foremost the duty of states to ensure the social and institutional framework, bear responsibility for unimpeded access to care for all and reduce health inequalities. while the german global health strategy should involve civil society, it also has to emphasise the mandatory role of the public sector in providing services in the general public interest, health care and social security. conclusions the german government is currently preparing a new global health strategy, to be published in 2019. the former strategy from 2103 had received criticism for the inadequate consideration of non-medical determinants of health and insufficient political coherence. as social, political and economic determinants are highly relevant for population health, the new strategy will have to strive for increased political and inter-sectoral coherence which is indispensable for promoting equal opportunities and reducing inequalities in and between countries. for effectively improving global health, the german government will have to emphasise multilateral strategies and the crucial role of the public sector. the new global-health strategy needs to provide proof of germany’s commitment to reduce social and health inequalities, to support health system strengthening and universal health coverage, to promote decent work and healthy labour conditions, to fulfil its climate targets, and to enforce the right to health. conflicts of interest: none. holst j. designing germany’s new global health strategy: some important recommendations (editorial). seejph 2019, posted: 02 april 2019. doi 10.4119/unibi/seejph-2019-211 page 6 of 7 references 1. bundesministerium für gesundheit. shaping global health – taking joint action – embracing responsibility. the federal government's strategy paper. https://www.bundesgesundheitsminister ium.de/fileadmin/dateien/5_publikation en/gesundheit/broschueren/screen_glo bale_gesundheitspolitik_engl.pdf (accessed: march 28, 2018). 2. bozorgmehr k, bruchhausen w, hein w, et al. germany and global health: an unfinished agenda? lancet 2013;382:1702-3. 3. kickbusch i, franz c, holzscheiter a et al. germany’s expanding role in global health. lancet 2017;390:898-912. 4. dpgg. deutsche plattform für globale gesundheit – basispapier. http://plattformglobalegesundheit.de/wp -content/uploads/2015/07/plattformfuer-globale-gesundheit.pdf (accessed: march 27, 2019). 5. beckfield j, olafsdottir s. health inequalities in global context. am behav sci 2013;57:1014-39. 6. marmot m. social justice, epidemiology and health inequalities. eur j epidemiol 32:537-46. 7. mackenbach j, kulhánová i, artnik b et al. changes in mortality inequalities over two decades: register based study of european countries. bmj 2916;353:i1732. 8. who. health in all policies: helsinki statement. framework for country action: http://www.who.int/iris/bitstream/10665 /112636/1/9789241506908_eng.pdf (accessed: march 28, 2019). 9. labonté r, stuckler d. the rise of neoliberalism: how bad economics imperils health and what to do about it. j epidemiol community health 2015;70:312-8. 10. jamison d, summers l, alleyne g et al. global health 2035: a world converging within a generation. lancet 2013;382:1898-955. 11. united nations. sustainable development goals. https://www.un.org/sustainabledevelop ment/sustainable-development-goals (accessed: march 18, 2019). 12. freeman b. the new global labor market. focus (university of wisconsin–madison) 26:1–6. https://www.irp.wisc.edu/publications/ focus/pdfs/foc261a.pdf (accessed: march 23, 2019). 13. reddy n. challenges of decent work in the globalising world. ind j lab econ 2005;48:3-17. 14. clemens t, popham f, boyle p. what is the effect of unemployment on allcause mortality? a cohort study using propensity score matching. eur j public health 2015;25:115-21. 15. international labor organization. global estimates of modern slavery. forced labour and forced marriage. http://www.ilo.org/wcmsp5/groups/pub lic/---dgreports/--dcomm/documents/publication/wcms_ 575479.pdf (accessed: march 23, 2019). 16. watts n, adger wn, agnolucci p, et al. health and climate change: policy responses to protect public health. lancet 2015;386:1861-914. 17. world health organization. 7 million deaths annually linked to air pollution. cent eur j public health 2014;22:53,59. 18. mannucci pm, franchini m. health effects of ambient air pollution in developing countries. int j environ res public health 2017;14:1048. 19. who. global health risks. mortality and burden of disease attributable to selected major risks: http://apps.who.int/iris/bitstream/handl e/10665/44203/9789241563871_eng.p df (accessed: march 23, 201). holst j. designing germany’s new global health strategy: some important recommendations (editorial). seejph 2019, posted: 02 april 2019. doi 10.4119/unibi/seejph-2019-211 page 7 of 7 20. un. universal declaration of human rights preamble. preamble, art. 25. https://www.ohchr.org/en/udhr/doc uments/udhr_translations/eng.pdf (accessed: march 28, 2019). 21. un. international convenant on economic, social and cultural rights. adopted by the general assembly resolution 2200 (xxi) of december 1966. preamble, art. 12. http://www.undocuments.net/icescr.htm (accessed: march 28, 2019). 22. gostin l, heywood m, ooms g,grover a, røttingen ja, chenguang w. national and global responsibilities for health. bull world health organ2010;88:719-719a. 23. brenck a, beckers t, heinrich m, von hirschhausen c. public-private partnerships in new eu member countries of central and eastern europe: an economic analysis with case studies from the highway sector. eib papers 2005;10:82–112: https://tudresden.de/bu/wirtschaft/ee2/ressource n/dateien/dateien/ordner_publikationen /wp_psm_08_brenck_beckers_heinrich _hirschhausen_2005_ppp_eastern_euro pe.pdf (accessed: march 26, 2019). 24. languille s. public private partnerships in education and health in the global south: a literature review. j int compar soc pol 2017;32:142-65. ______________________________________________________________________________________ © 2019 holst; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.ncbi.nlm.nih.gov/pubmed/?term=grover%20a%5bauthor%5d&cauthor=true&cauthor_uid=20931051 https://www.ncbi.nlm.nih.gov/pubmed/?term=r%c3%b8ttingen%20ja%5bauthor%5d&cauthor=true&cauthor_uid=20931051 https://www.ncbi.nlm.nih.gov/pubmed/?term=chenguang%20w%5bauthor%5d&cauthor=true&cauthor_uid=20931051 https://www.ncbi.nlm.nih.gov/pubmed/?term=chenguang%20w%5bauthor%5d&cauthor=true&cauthor_uid=20931051 burazeri g, roshi m, laaser u. (editorial). seejph 2021, posted: 11 november 2021. doi: 10.11576/seejph-4882 editorial the editors of the south eastern european journal of public health (seejph) proudly present a collection of papers authored by young african scientists in honor of dr. hideyo noguchi (1876‒1928), the famous japanese bacteriologist (see the introductory editorial information). although the publication is in english, it also collects contributions from several francophone countries in subsaharan africa. as the authors may go for the hideyo noguchi competition, we did not modify the submitted papers’ content to not interfere with the selection process. however, we invite minor corrections e.g. of misspellings etc. if later detected. we are, nevertheless, highly impressed by the quality, engagement, and originality of the contributions examining the status of universal health coverage in one of the most disadvantaged regions of the world, with insufficient health infrastructure and investment, aggravated by the permanent outmigration of qualified personnel and the current covid19 pandemic. the editors are very grateful for the permanent and effective support of prof. flavia senkubuge, chair who/afro african advisory committee on research and development and president colleges of medicine of south africa, vice-president african federation of public health associations. genc burazeri meri roshi ulrich laaser executive director technical editor board of editors laaser u, schröder-bäck p. towards a code of conduct for the european public health profession! (short report). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-88 1 short report towards a code of conduct for the european public health profession! ulrich laaser1, peter schröder-bäck2,3 1 faculty of health sciences, university of bielefeld, bielefeld, germany; 2 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life science, maastricht university, maastricht, the netherlands; 3 faculty of human and health sciences, university of bremen, bremen, germany. corresponding author: dr. peter schröder-bäck address: postbus 616, 6200 md maastricht, the netherlands e-mail: peter.schroder@maastrichtuniversity.nl conflicts of interest: none. laaser u, schröder-bäck p. towards a code of conduct for the european public health profession! (short report). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-88 2 introduction is the group of public health professionals consistent of other professions such as physicians, nurses, social workers and the like, or should public health professionals define themselves as a distinct profession in their own rights? as of today, in europe, public health professionals do not build an own profession. czabanowska et al. (1) define and promote in this journal the formalization of the public health profession, based on the criteria which – following macdonald (2) – differentiate a profession from an occupation. these criteria include adherence to a code of conduct and altruistic service. from an ethical point of view, both elements are essentially related and both are reflected in the most famous example of a code for a health profession: the ancient hippocratic oath (3). for a public health profession we can draw only partly on the oath as public health deals with populations – not with individual patients – and, therefore, requires population ethics, not medical or bio-ethics, the latter well accepted since the 1980s at least (4). population ethics what is particularly relevant when we take a social or population ethics point of view? following e.g. laaser (5) financial means are in principle never sufficient because the health of population groups is always subject to potential improvement. therefore, efficiency or cost-effectiveness of interventions gains ethical relevance as resources can be spent only once, and are then not available for alternative use. for this reason, population ethics often adhere to the utilitarian principle. however, it is normatively important to amend the utilitarian calculus, namely that the ‘pursuit of happiness’ for the greatest number must not be achieved by reducing the benefit of any single individual (6). given the specific prevailing european value tradition of solidarity (7), an additional amendment may be considered namely, that differences between population groups should not increase by any public health measure but be minimized wherever possible. another deontological limitation of the utilitarian principle is the respect for the autonomy of persons and their rights (8). in addition, a fundamental moral issue remains in that all decisions on population health level are based on probabilities and statistical lives (9), making possible technologies of assessing interventions – and promoting the giving or withholding of interventions – based on utilitarian cost-effectiveness rationales (10). the utilitarian principle, its ethical limitations and practicability for public health decision-making requires a continuous public health ethics discourse (11). which principles could nevertheless be identified guiding a public health profession in its decisions on the population’s health? summarising the ethical literature, schröder-bäck et al. (12) proposed seven mid-level principles to be considered: maleficence, beneficence, health maximisation, efficiency, respect for autonomy, justice, and proportionality. laaser et al. (13) proposed with reference to a specific european heritage the following principles: solidarity, efficiency, participation, equity, subsidiarity, sustainability, reconciliation, and evidence, underlining in addition the component of empathy/altruism which is of essential relevance in the individual physician-patient relationship, as well as in the professional-population realm. with regard to a european dimension, the european commission published council conclusions (14) manifesting four overarching principles: equity, universality, access to good quality of care, and solidarity – critically discussed by schröder-bäck et al. (15). from this short account it seems that, in spite of different terminologies used, the following four values can be considered as core for a european framework: solidarity, equity, efficiency and respect for autonomy. the access to good quality of care describes only one of the preconditions of health and can be hardly considered as an ethical principle. laaser u, schröder-bäck p. towards a code of conduct for the european public health profession! (short report). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-88 3 a professional code? can we build a professional code on this value account? various aspects are published in volume 36 of the public health reviews (16). in its recommendation on good governance in health systems (17) in 2010, the council of europe promotes codes of conduct for stakeholders in the health sector including effective mechanisms for enforcement and specific clauses on conflict of interest. in 2002, the american public health leadership society published twelve principles of the ethical practice of public health (18) [table 1]. table 1. principles of the ethical practice of public health no. principle 1 public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes. 2 public health should achieve community health in a way that respects the rights of individuals in the community. 3 public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members. 4 public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all. 5 public health should seek the information needed to implement effective policies and programs that protect and promote health. 6 public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation. 7 public health institutions should act in a timely manner on the information they have within the resources and the mandate given to them by the public. 8 public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community. 9 public health programs and policies should be implemented in a manner that most enhances the physical and social environment. 10 public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others. 11 public health institutions should ensure the professional competence of their employees. 12 public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness. even though the values we mentioned and affirmed above are somewhat reflected in the code of the leadership society, values that seem particularly important for a european perspective on public health – namely solidarity and equity – are not explicitly mentioned. according to prainsack & buyx (19), often they are even referred to as opposed to the american thinking. prainsack & buyx define solidarity as shared practices reflecting a collective commitment to carry costs (financial, social, emotional, or otherwise) to assist others. also, the term equity has a long european tradition and has likewise a moral dimension. inequity refers to differences which are unnecessary and avoidable but, in addition, are also considered unfair and unjust (20). we propose herewith that solidarity and equity are core values that have to be reflected in a european version of a code of conduct for public health professionals, operating in a laaser u, schröder-bäck p. towards a code of conduct for the european public health profession! (short report). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-88 4 framework that is also guided by the principles of efficiency and respect for autonomy. with a transnational perspective, verkerk & lindemann (21) call in addition for more justice of resource sharing on a global scale, whereas stapleton et al. (22) talk already about a global ethics. these values would reflect a specific european value dimension in public health conduct. but, what does this mean? if we assume – what we do – that a code of conduct is important to function as an explicit normative compass for public health and to help building the public health profession for europe, then such a code of conduct should be formulated and it will help to further professionalization of public health. professionalization of public health is important to advance public health education, training, and practice. in our opinion, there is no contradiction that the profession of public health consists of members of different other professions – which also have their own values and conducts. yet, if professions work under the roof of public health, the pillars – the core values – of the house that is built are the common denominators. making the guiding norms and values explicit is important for the self-definition of the professional field/profession and giving guidance in pursuing a fair and respectful improvement of population health. references 1. czabanowska k, laaser u, stjernberg l. shaping and authorising a public health profession. seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-23. 2. macdonald km. the sociology of the professions. london: sage publications, 1999. 3. available in the original version at: https://www.nlm.nih.gov/hmd/greek/greek_oath.html, and in one of the modern adaptations at: http://guides.library.jhu.edu/c.php?g=202502&p=1335759 (both accessed: september 5, 2015). 4. beauchamp tl, childress jf. principles of biomedical ethics. 6th edition. oxford university press: new york, 2009. 5. laaser u. health, economics and ethical reasoning. j publ hlth (springer) 2005;13:229-30. 6. rawls j. theory of justice. harvard university press, 1971. 7. laaser u, bjegovic-mikanovic v, lueddeke g. epilogue: global health, governance, and education. in: lueddeke g (ed.) global population health and well-being in the 21st century – towards new paradigms, policy, and practice. springer: new york, 2015. 8. sass hm. introduction: the principle of solidarity in health care policy. j med philos 1992;17:367-70. 9. cohen ig, daniels n, eyal n. identified versus statistical lives: an interdisciplinary perspective (front matter and introduction). oxford university press, 2015. available at: http://ssrn.com/abstract=2571392 (accessed: september 10, 2015). 10. laaser u. ethical approach in good governance of health systems. moldovan journal of health sciences 2015;4:66-72. 11. schröder-bäck p, maeckelberghe e, royo-bordonada má. the ethics effect. seejph 2014, posted: 23 september 2014. doi 10.12908/seejph-2014-31. 12. schröder-bäck p, duncan p, sherlaw w, brall c, czabanowska k. teaching seven principles for public health ethics: towards a curriculum for a short course on ethics in public health programmes. bmc medical ethics 2014;15:73. doi:10.1186/14726939-15-73. laaser u, schröder-bäck p. towards a code of conduct for the european public health profession! (short report). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-88 5 13. laaser u, donev d, bjegovic v, sarolli y. public health and peace. croat med j 2002;43:107-13. 14. council of the european union. council conclusions on equity and health in all policies: solidarity in health. 3019th employment, social policy, health and consumer affairs council meeting. brussels: 8 june 2010. available at: http://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/lsa/114994.pdf (accessed: september 10, 2015). 15. schröder-bäck p, clemens t, michelsen k, schulte in den bäumen t, sørensen c, borrett g, brand h. public health ethical perspectives on the values of the european commission’s white paper “together for health”. cent eur j public health 2012;20:95-100. 16. chambaud l, tulchinsky t (eds.). ethics. public health reviews 2015;36. available at: http://www.publichealthreviews.net/ (accessed: september 10, 2015). 17. council of europe. recommendation cm/rec(2010)6 of the committee of ministers to member states on good governance in health systems. 18. public health leadership society (phls). principles of the ethical practice of public health, version 2.2.2002. available at: http://nnphi.org/uploads/media_items/principles-of-the-ethical-practice-of-publichealth-brochure.original.pdf (accessed: september 5, 2015). 19. prainsack b, buyx a. solidarity: reflections on an emerging concept in bioethics. nuffield council on bioethics (ncob): november 2011; isbn: 978-1-904384-25-0. available at: http://nuffieldbioethics.org/wpcontent/uploads/2014/07/solidarity_report_final.pdf (accessed: september 10, 2015). 20. whitehead m. the concepts and principles of equity and health. european health for all series no. 1. who europa: copenhagen 1985 (eur/icp/rpd 414 7734r). available at: http://publicaciones.ops.org.ar/publicaciones/piezas%20comunicacionales/cursodds/ cursoeng/textos%20completos/the%20concepts%20and%20principles%20of%20equ ity%20and%20health.pdf (accessed: september 10, 2015). 21. verkerk ma, lindemann h. theoretical resources for a globalised bioethics. j med ethics 2011;37:92-6. 22. stapleton g, schroeder-baeck p, laaser u, meershoek a, popa d. global health ethics: an introduction to prominent theories and relevant topics. glob health action 2014;7: 23569. doi: 10.3402/gha.v7.23569. ___________________________________________________________ © 2016 laaser et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/lsa/114994.pdf http://www.publichealthreviews.net/ http://nnphi.org/uploads/media_items/principles-of-the-ethical-practice-of-public-health-brochure.original.pdf http://nnphi.org/uploads/media_items/principles-of-the-ethical-practice-of-public-health-brochure.original.pdf http://nuffieldbioethics.org/wp-content/uploads/2014/07/solidarity_report_final.pdf http://nuffieldbioethics.org/wp-content/uploads/2014/07/solidarity_report_final.pdf hoxha r, kosevska e, berisha m, ramadani n, jerliu n, zhjeqi v, gashi s. predictive factors for patient satisfaction in public and private hospitals in kosovo (original research). seejph 2019, posted: 08 october 2019. doi 10.4119/seejph-2362 page 1 of 9 original research predictive factors for patient satisfaction in public and private hospitals in kosovo rina hoxha1,2, elena kosevska3, merita berisha1,2, naser ramadani1,2, naim jerliu1,2, valbona zhjeqi1,2, sanije gashi1,2 1 national institute of public health of kosovo, prishtina, kosovo; 2 university of prishtina “hasan prishtina”, faculty of medicine, prishtina, kosovo; 3 institute of public health, faculty of medicine, skopje, republic of north macedonia. corresponding author: merita berisha, md, phd; address: national institute of public health of kosovo, nn. prishtina 10000, kosovo; telephone: +38344238136; e-mail: merita.berisha@uni-pr.edu abstract aim: the objective of this study was to assess predictive factors for patient satisfaction with healthcare services as a measure of the quality of hospital care in public and private hospitals in kosovo. methods: a cross-sectional study was conducted in kosovo during 2015-2016 including a representative sample of 2585 patients older than 18 years [1010 (48.6%) males and 1069 (51.4%) females from public hospitals; and 240 (47.4%) males and 266 (52.6%) females from private hospitals]. patient satisfaction dimensions such as satisfaction with medical care, nursing care, organization, and overall impression were the main variables measured. a riskadjusted multivariate analysis was applied. results: multiple linear regression analysis revealed as independent significant predictors of the total satisfaction of patients from public hospitals the following factors: age, length of stay in hospital in days, education, payment for additional analyzes during hospitalization and buying medications for hospital treatment. these five independent significant predictors accounted for 7.3% of the change in the total patients’ satisfaction (stepwise method r2 = 0.073). conversely, there were only four predictors of the total satisfaction of patients from private hospitals: length of stay in hospital in days, number of hospitalizations in the last 12 months, paying for hospitalization, and cost of hospitalization exceeds received services. only the variables “length of hospital stay” together with “cost of hospitalization exceeds received services” as independent predictors, explained 5.3% of the variability of total satisfaction. conclusion: structural and qualitative characteristics of hospitals have a significant impact on patients’ satisfaction. age, length of stay, education, payment for additional analyzes during hospitalization and the cost of hospitalization in public hospitals and length of stay, paying for hospitalization, and cost of hospitalization in private hospitals are useful predictors for total satisfaction of patients in kosovo. keywords: kosovo, predictors of patient satisfaction, public and private hospitals. mailto:merita.berisha@uni-pr.edu hoxha r, kosevska e, berisha m, ramadani n, jerliu n, zhjeqi v, gashi s. predictive factors for patient satisfaction in public and private hospitals in kosovo (original research). seejph 2019, posted: 08 october 2019. doi 10.4119/seejph-2362 page 2 of 9 introduction around the world, hospitals appear to gradually focus on their strategies of service quality. patient satisfaction is best understood as a multi-attribute model with completely different aspects of care decisive overall satisfaction. lower performance on an attribute creates much more dissatisfaction than the satisfaction generated by higher performance on another attribute, negative performance is more determinant in satisfaction than positive performance (1). patient satisfaction will offer valuable and distinctive insights into daily medical care and is widely accepted as a freelance dimension of quality of care as a result of an analysis of patient satisfaction includes “internal” (inward-looking) aspects of hospital care, which regularly stay unrecorded, like communica tion, fellow feeling or interaction (2,3-5). however, various studies and systematic reviews demonstrate a correlation between subjective patient perspective and clinical safety and effectiveness, and that they demonstrate that patient satisfaction reflects totally different dimensions of quality of care (3,6-12). thus, it comes as no surprise that the activity of patient satisfaction is usually used as a tool to enhance the quality of care (8,12). international studies additionally counsel that inprogress analysis and publication of patient surveys could complement public reportage on clinical outcomes and method quality to help patients in selecting a hospital and serve to enhance the standard of medical care on a long-run basis (7,8). research on health system satisfaction has known ways to boost health, scale back prices and implement reform (13). the lack of a solid abstract basis and an identical mensuration tool for client satisfaction has crystal rectifier over the past ten years to a proliferation of surveys that focus solely on patient expertise. i.e. aspects of the caring expertise like waiting time, quality of basic amenities, and communication with health care suppliers all facilitate tangible quality improvement priorities. according the idea of un agency, within the future measures of patient expertise, meant to capture the “responsiveness” of the health system (14), seemingly to receive even larger attention as physicians and hospitals return underneath growing pressure to enhance the standard of care, enhance patient safety and lower the value of services. health system responsiveness specifically refers to the manner and surroundings during which individuals are treated once seeking health care. hospitals have dominantly specialized in health care provision to fulfill, maintain and promote people's health desires of a community (15). within a study (16) has been found that private hospitals have higher name and image in the eyes of patients, and are far better than public ones in terms of service quality, giving importance to patients' satisfaction and physical look of the hospital buildings. several studies highlighted that the factors who influence patients’ satisfaction with attention services are classified into 2 broad categories: provider-related and patient-related (17,18). socioeconomic characteristics have impacted patients satisfaction. within the most systematic reviews (18) are found that providers’ ability, social skills and facility characteristics (e.g. physical surroundings, sort and level of the facility) were absolutely related to patients’ satisfaction. patient-related characteristics, for instance, gender, age, race, socioeconomic standing, health standing, and expectation were weak and inconsistent predictors of patients’ satisfaction. many studies additionally highlighted what proportion of patient’s hoxha r, kosevska e, berisha m, ramadani n, jerliu n, zhjeqi v, gashi s. predictive factors for patient satisfaction in public and private hospitals in kosovo (original research). seejph 2019, posted: 08 october 2019. doi 10.4119/seejph-2362 page 3 of 9 perceptions of care and actual aid experiences contribute to overall patients’ satisfaction level (17-19). the purpose of this study was to analyze the predictive factors for patient satisfaction in public and private hospitals in kosovo. methods a cross-sectional study was implemented for nine months in the period 2015-2016 in kosovo. the study sample consisted of 2585 patients randomly selected (i.e., the sample was representative of the population of kosovo for the level of significance of 95% and a confidence interval of ±5%). the main criteria for selecting patients were to be older than 18 years and to be hospitalized at the moment of study implementation. the study covered patients from all public and private hospitals in kosovo. after information related to study and confidentiality aspects, the participants were asked for oral consent. the ethical committee of niph kosovo approved the study. we used a standardized questionnaire (queensland, australia 2004) (20), translated into the albanian language and after piloting adapted to the national needs. a few questions were excluded and several other items were added to the final version of the study questionnaire. all six sections of the questionnaire covered 55 questions (first visit-5, before admission-3, admission-8, hospital stay-24, hospital environment -8 and discharged-7). possible answers were on a six-point likert scale (excellent, very good, good, fair, poor, and not sure), with lower scores corresponding to higher satisfaction. participants had the option to fulfill the questionnaire by themselves or to ask for assistance from the field researchers. statistical analysis data was statistically analyzed in spss software package, version 22.0 for windows (spss, chicago, il, usa). the qualitative series were processed by determining the coefficient of relations, proportions, and rates, and were shown as absolute and relative numbers. quantitative series were analyzed with measures of central tendency (average, median), as well as with dispersion measures (standard deviation, standard error). internal consistency on a set of questions was examined by cronbach’s аlpha. the mann-whitney u test was used to compare differences between two independent groups when the dependent variable was continuous, but not normally distributed. pearson’s chi-square test was used to determine the association between certain attributive dichotomies. a two-sided analysis with a significance level of p<0.05 was used to determine the statistical significance. results a total of 2585 hospitalized patients were involved in this study. reliability analysis for the items included exhibited a cronbach’s аlpha=0.872 (cronbach’s alpha based on standardized items: 0.874; n=55). there were 2079 patients from public hospitals: 1010 (48.58%) males and 1069 (51.42%) females; and 506 patients from private hospitals: 240 (47.43%) males and 266 (52.57%) females. no significant association was found between gender and the type of the hospital (pearson chisquare=0.6527; df=1; p=0.4191). mean age of public patients was 44.67±16.49 with median iqr=45 (30-56), and of private patients it was 42.71±15.76 with median iqr=42 (29-54), with significant differences in mean age between the two groups (mann-whitney u test: z=2.516; p=0.0119), implying a significantly lower age of patients from private hospitals. from rural areas, there were 995 (47.45%) of public hospital patients and 158 (31.11%) of private hospital patients, with two times significantly more patients from rural areas in public hospitals compared to private ones hoxha r, kosevska e, berisha m, ramadani n, jerliu n, zhjeqi v, gashi s. predictive factors for patient satisfaction in public and private hospitals in kosovo (original research). seejph 2019, posted: 08 october 2019. doi 10.4119/seejph-2362 page 4 of 9 [or=2.001 (1.63 – 2.46) 99% ci]. public and private hospital patients with high education were 497 (24.13%) vs. 206 (40.79%); with college degree there were 565 (27.43%) vs. 31 (6.14%); with elementary school there were 495 (24.03%) vs. 31 (6.14%); and with no education there were 81 (3.93%) vs. 6 (1.19%). there was a significant difference between patients from public and private hospitals in terms of individual overall satisfaction for each of the analyzed aspects (first visit, acceptance, stay, physical environment and output) with significantly greater satisfaction of patients from private hospitals. among the public hospital patients, for p<0.05, significant differences in the total satisfaction score were found related to reason for admission, number of hospitalizations in the last 12 months, education, payment for additional analysis while in hospital, cost of hospitalization exceeds received services, buying medication for hospital treatment, age, and length of hospital stay (enter method r2=0.076) (table 1). with multiple linear regression analysis (table 2), as independent significant predictors of the total satisfaction of patients from public hospitals, there were confirmed five factors: age, length of stay in hospital in days, education, payment for additional analyzes during hospitalization and buying medications for hospital treatment. these five independent significant predictors explained 7.3% of the changes in the total patients’ satisfaction (stepwise method r2 = 0.073). only the variables “pay for additional analysis during hospitalization”, together with “buying medications for hospital treatment”, as independent predictors, explained 4.1% of the variability of total satisfaction. table 1. binary linear regression total satisfaction score related to selected parameters parameters satisfaction score (public) satisfaction score (private) mean sd p mean sd p reason for admission surgical 2.358584 0.524215 kruskal-wallis test: h=18.451 p=0.0004** 1.528748 0.429106 kruskal-wallis test: h=50.001 p=0.0001** medical 2.325146 0.545558 1.921032 0.399125 maternity 2.507780 0.729963 1.669437 0.515809 emergency 2.253506 0.543969 1.686018 0.208065 transferred from another hospital yes 1.632222 0.200030 mann-whitney u test: z=-0.886 p=0.375 1.377778 0.452155 mann-whitney u test: z=-0.979 p=0.327 no 1.648361 0.469240 1.529697 0.521974 number of hospitalizations in the last 12 months one 2.310388 0.570299 kruskal-wallis test: h=10.658 p=0.005** 1.607373 0.438166 kruskal-wallis test: h=30.869 p=0.0001** two 2.413505 0.513785 1.841548 0.425020 ≥ three 2.337081 0.649830 1.481222 0.522291 gender male 2.338796 0.515792 mann-whitney u test: z=-0.174 p=0.862 1.602579 0.353156 mann-whitney u test: z=-1.039 p=0.298 female 2.347288 0.609724 1.686032 0.524438 place of living urban 2.359672 0.569754 mann-whitney u test: z=0.385 p=0.862 1.654048 0.424239 mann-whitney u test: z=1.523 p=0.128 rural 2.327131 0.557364 1.630998 0.516661 level of education hoxha r, kosevska e, berisha m, ramadani n, jerliu n, zhjeqi v, gashi s. predictive factors for patient satisfaction in public and private hospitals in kosovo (original research). seejph 2019, posted: 08 october 2019. doi 10.4119/seejph-2362 page 5 of 9 no education 2.179574 0.798358 kruskal-wallis test: h=21.758 p=0.0006** 1.318492 0.343095 kruskal-wallis test: h=46.714 p=0.0001** partly elementary 2.206693 0.634021 1.365179 0.215593 elementary 2.354832 0.577412 1.914056 0.480274 secondary 2.302739 0.565943 1.556413 0.423172 college 2.395024 0.526674 1.832815 0.410434 high 2.399455 0.511615 1.571029 0.456809 paying for hospitalization yes 2.347518 0.591523 mann-whitney u test: z=0.901 p=0.368 1.561964 0.398229 mann-whitney u test: z=-8.561 p=0.0001** no 2.339965 0.539951 2.169494 0.426998 paying for additional analysis while in hospital yes 2.428653 0.546035 mann-whitney u test: z=7.734 p=0.0001** 1.819382 0.591600 mann-whitney u test: z=-2.777 p=0.005** no 2.180322 0.563681 1.588795 0.380680 paid price for hospitalization is more than received services yes 2.458014 0.556340 kruskal-wallis test: h=49.759 p=0.0001** 1.650059 0.409010 kruskal-wallis test: h=2.956 p=0.228 no 2.229283 0.539610 1.602356 0.427372 don’t know 2.416133 0.575153 1.683548 0.557070 buying medication for hospital treatment yes 2.391366 0.567563 mann-whitney u test: z=-5.336 p=0.0001** 1.406746 0.331941 mann-whitney u test: z=1.081 p=0.279 no 2.169203 0.516799 1.651445 0.454457 cost of hospitalization exceeds received services yes 2.401185 0.551062 kruskal-wallis test: h=3.265 p=0.195 1.567328 0.371254 kruskal-wallis test: h=11.495 p=0.003** no 2.321112 0.525140 1.804324 0.619753 don’t know 2.341440 0.608008 1.741223 0.471197 length of hospital stay days spearman rank order correlation: r=-0.127* spearman rank order correlation: r=0.118* age years spearman rank order correlation: r=-0.147* spearman rank order correlation: r=0.037 * significant for p<0.05. ** significant for p<0.01. among the private hospital patients, for p<0.05, significant differences in total satisfaction score were found related to reason for admission, number of hospitalizations in the last 12 months, education, paying for hospitalization, payment for additional analysis while in hospital, cost of hospitalization exceeds received services, and length of hospital stay (table 1) (enter method r2=0.073) (table 2). hoxha r, kosevska e, berisha m, ramadani n, jerliu n, zhjeqi v, gashi s. predictive factors for patient satisfaction in public and private hospitals in kosovo (original research). seejph 2019, posted: 08 october 2019. doi 10.4119/seejph-2362 page 6 of 9 table 2. multiple linear regression – independent predictors for total satisfaction in public hospitals independent variable non-standardized coefficient standardized coefficient t sig. 95% ci for b b std. error beta upper level lower level (constant) 2.635 .119 22.087 .000 2.401 2.869 reason for admission (.012) .019 (.019) (.628) .530 (.048) .025 hospitalizations in the last 12 months .029 .024 .037 1.227 .220 (.017) .076 age .015 .003 .132 4.377 .000 .008 .022 length of hospital stay (.004) .001 (.100) (3.219) .001 (.006) (.001) level of education .035 .012 .087 2.868 .004 .011 .058 payment for additional analyzes (.156) .037 (.132) (4.251) .000 (.229) (.084) cost of hospitalization exceeds received services .022 .022 .029 .961 .337 (.023) .066 buying medication for hospital treatment (.191) .043 (.137) (4.476) .000 (.274) (.107) r=0.275 r2=0.076 f=11.362 p=0.0001 dependent variable=satisfaction score table 3. multiple linear regression – independent predictors for total satisfaction in private hospitals independent variable non-standardized coefficient standardized coefficient t sig. 95% ci for b b std. error beta upper level lower level (constant) 1.953 .107 18.272 .000 1.743 2.163 reason for admission .021 .018 .033 1.167 .243 (.014) .057 hospitalizations in the last 12 months .063 .026 .070 2.445 .015 .012 .113 length of hospital stay .021 .004 .150 5.367 .000 .013 .028 level of education (.010) .012 (.023) (.833) .405 (.034) .014 paying for hospitalisation .144 .039 .104 3.662 .000 .067 .221 payment for additional analyzes .011 .026 .012 .440 .660 (.039) .062 cost of hospitalization exceeds received services (.200) .029 (.191) (6.807) .000 (.257) (.142) r=0.269 r2=0.073 f=13.797 p=0.0001 dependent variable=satisfaction score. hoxha r, kosevska e, berisha m, ramadani n, jerliu n, zhjeqi v, gashi s. predictive factors for patient satisfaction in public and private hospitals in kosovo (original research). seejph 2019, posted: 08 october 2019. doi 10.4119/seejph-2362 page 7 of 9 with multiple linear regression analysis (table 3), as independent significant predictors of the total satisfaction of patients from private hospitals, there were confirmed only four factors: length of stay in hospital in days, number of hospitalizations in the last 12 months, paying for hospitalization, and cost of hospitalization exceeds received services. these four independent significant predictors accounted for 7.1% of the changes in total patient satisfaction (stepwise method r2 = 0.071). only the variables “length of hospital stay” together with “cost of hospitalization exceeds received services”, as independent predictors, explained 5.3% of the variability of total satisfaction. discussion this study has clearly demonstrated that there is a significant difference between patients from public and private hospitals in terms of individual overall satisfaction for each of the analyzed aspects (first visit, acceptance, stay, physical environment and output) with significantly greater satisfaction of patients from private hospitals. this finding is quite comparable to other studies (19,21,22). in this study, it is evident that age is a predictor factor, by increase of age, patients' satisfaction increases too regarding quality of health care, similar to other studies, older patients tended to have higher satisfaction scores (23-26). whereas for education as predictor factor, correlation is negative, with increase of education level, patient satisfaction decreases, similar to other studies (23). the findings from our study show that the length of stay in the hospital could determine significantly the overall patient satisfaction, similar to study conducted in japan (27). the longer the length of stay in the hospital generates lower patient satisfaction on specific domains such as comfort, visiting, and cleanliness, which seemed logical, as in other studies (28). an inverse correlation between inpatient satisfaction and length of stay was seen in other studies (29). as independent significant predictors of the total satisfaction of patients from public hospitals, we confirmed only five: payment for additional analyzes during hospitalization and buying medications for hospital treatment. main predictors in private hospitals are payment for hospitalization, and cost of hospitalization. predictors of the total satisfaction of patients from private hospitals, we confirmed only four: length of stay in hospital in days, number of hospitalizations in the last 12 months, paying for hospitalization, and cost of hospitalization exceeds received services. in the case of private physicians, the performance fell short of expectations, thus generating dissatisfaction (30). in conclusion, the structural and qualitative characteristics of hospitals have a significant impact on patient satisfaction. age, length of stay, education, payment for additional analyzes during hospitalization and the cost of hospitalization in public hospitals and length of stay, paying for hospitalization, and cost of hospitalization in private hospitals are predictor factors for total satisfaction of patients. conflicts of interest: none. hoxha r, kosevska e, berisha m, ramadani n, jerliu n, zhjeqi v, gashi s. predictive factors for patient satisfaction in public and private hospitals in kosovo (original research). seejph 2019, posted: 08 october 2019. doi 10.4119/seejph-2362 page 8 of 9 references 1. otani k, harris le, tierney wm. a paradigm shift in patient satisfaction assessment. med care res rev 2003;60:347-65. 2. doyle c, lennox l, bell d. a systematic review of evidence on the links between patient experience and clinical safety and effectiveness. bmj open 2013;3:e001570. 3. manary mp, boulding w, staelin r, glickman sw. the patient experience and health outcomes. n engl j 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than younger patients?. j gen intern med 2003;18:23-30. 27. tokunaga j, imanaka y. influence of length of stay on patient satisfaction with hospital care in japan. int j qual health c 2002;14:493-502. 28. thi pl, briancon s, empereur f, guillemin f. factors determining inpatient satisfaction with care. soc sci med 2002;54:493-504. 29. vovos tj, ryan sp, hong cs, howell cb, risoli tj, attarian de, et al. predicting inpatient dissatisfaction following total joint arthroplasty: an analysis of 3,593 hospital consumer assessment of healthcare providers and systems survey responses. j arthroplasty 2019;34:824-33. doi: 10.1016/j.arth.2019.01.008. 30. naidu a. factors affecting patient satisfaction and healthcare quality. int j health care qual assur 2009;22:36681. doi: 10.1108/09526860910964834. ___________________________________________________________ © 2019 hoxha et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.pc.gov.au/research/supporting/patient-satisfaction/patientsatisfaction.pdf https://www.pc.gov.au/research/supporting/patient-satisfaction/patientsatisfaction.pdf https://www.pc.gov.au/research/supporting/patient-satisfaction/patientsatisfaction.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4565136/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4565136/ https://dx.doi.org/10.4102%2fphcfm.v4i1.384 https://www.ncbi.nlm.nih.gov/pubmed/?term=vovos%20tj%5bauthor%5d&cauthor=true&cauthor_uid=30777630 https://www.ncbi.nlm.nih.gov/pubmed/?term=ryan%20sp%5bauthor%5d&cauthor=true&cauthor_uid=30777630 https://www.ncbi.nlm.nih.gov/pubmed/?term=hong%20cs%5bauthor%5d&cauthor=true&cauthor_uid=30777630 https://www.ncbi.nlm.nih.gov/pubmed/?term=howell%20cb%5bauthor%5d&cauthor=true&cauthor_uid=30777630 https://www.ncbi.nlm.nih.gov/pubmed/?term=howell%20cb%5bauthor%5d&cauthor=true&cauthor_uid=30777630 https://www.ncbi.nlm.nih.gov/pubmed/?term=risoli%20tj%20jr%5bauthor%5d&cauthor=true&cauthor_uid=30777630 https://www.ncbi.nlm.nih.gov/pubmed/?term=attarian%20de%5bauthor%5d&cauthor=true&cauthor_uid=30777630 https://www.ncbi.nlm.nih.gov/pubmed/?term=seyler%20tm%5bauthor%5d&cauthor=true&cauthor_uid=30777630 https://www.ncbi.nlm.nih.gov/pubmed/30777630 https://www.ncbi.nlm.nih.gov/pubmed/30777630 ohia c, ongolo-zogo p, fawole oi. digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare pro viders (review article). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4381 p a g e 1 | 11 digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare providers chinenyenwa ohia1, pierre ongolo-zogo2, olufunmilayo ibitola fawole3 1 department of environmental health sciences, university of ibadan, faculty of public health, college of medicine, university of ibadan, nigeria; 2 agrégé des facultés de médecine fmsb, université de yaoundé 1, cameroon; 3 department of epidemiology and medical statistics, faculty of public health, college of med icine, university of ibadan, nigeria; corresponding author: ohia chinenyenwa m.d.; address: department of environmental health sciences, faculty of public health, college of medicine, university of ibadan; email: ohiacmd@gmail.com; phone: +234 703 831 8289 review article mailto:ohiacmd@gmail.com ohia ch, ongolo-zogo p, fawole oi. digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare pro viders (review article). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4381 p a g e 2 | 11 abstract in tandem with the current drive to achieve the sdg 2030 goals, the universal health coverage (uhc) is been projected as a strong propelling strategy with key indicators, all aimed at achiev ing universal access to health services without having to endure financial difficulties in individ ual countries. currently, africa is lagging in meeting the targets of the uhc with between 5% 25% coverage across countries. adoption of new innovations are critical for the actualization of universal health coverage in africa. digital health technology offers one of such novel approaches to providing quality healthcare services and can help countries achieve the universal health coverage targets. it has been suggested that digital health provides an opportunity to overcome the longstanding prob lems of inefficiency of health information gathering, sharing, and access. in addition, literature is already replete with various factors that can aid countries to achieve uhc and one of such fac tors is the urgency of generating valid and quality evidence to inform decision-making. although the primary health care remains at the core of the achievement of universal health coverage, the utilization of digital health technologies remains very poor at the grassroots in af rica and this poses a huge barrier to effectiveness and quality of healthcare delivery. given the foregoing, it is obvious that there is an urgent need to understand the landscapes, issues and bar riers to utilization of digital health at the primary health care levels. however, there remains a paucity of data to support evidence-based decision making about full implementation of digital health services across the continent while also taking into cognisance the peculiarities of individ ual countries. hence, there is a critical need to determine the current levels of knowledge, skills, attitude, prac tice and readiness to adopt digital health in service delivery by healthcare workers at the primary health care levels across the continent. the generation of such data from major stakeholders such as health workers and health managers, providers among others will provide important evi dence needed for attaining optimal utilization of digital health in the context of health for all. summarily, a clear understanding of the contextual and implementation bottlenecks highlighted from such assessment(s), especially as it relates to individual african countries, will go a long way to guide decisions to address the low utilization of digital health technologies in health ser vices delivery in africa. keywords: digital health technologies, willingness to adopt, primary healthcare providers, universal health coverage, africa. source of funding this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. acknowledgement the authors acknowledge the support of the department of environmental health sciences, uni versity of ibadan and contributions of prof. g.r.e. e ana, prof. m.k.c. sridhar, dr. e.c. uwalaka, dr. o.t. okareh and dr. o.m. morakinyo, in the writing of this paper. we also thank the world health organisation (who) for the technical support and the publishing of this manuscript. ohia ch, ongolo-zogo p, fawole oi. digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare pro viders (review article). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4381 p a g e 3 | 11 co is supported by consortium for advanced research training in africa (carta) which is funded by the carnegie corporation of new york (grant no--b 8606.r02), sida (grant no:54100029), the deltas africa initiative (grant no: 107768/z/15/z). conflict of interest statement the authors declare that they have no known competing financial interests or personal relation ships that could have influenced the writing of this paper. author contributions co: conceptualization; co, po and of: writingoriginal draft preparation, co, po and of: writingreviewing and editing. ohia ch, ongolo-zogo p, fawole oi. digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare pro viders (review article). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4381 p a g e 4 | 11 introduction the universal health coverage (uhc) target is a strategic ambition with an overarching goal that all individuals and communities re ceive universal access to good quality health services without having to endure pain and fi nancial difficulties [1-3]. in tandem with the sdg-2030 goals these ‘coverage’ refers to an array of services encompassing promotion, prevention, treatment, rehabilitation and pal liation, particularly the health-related goals of the sdgs [3]. uhc is widely recognised as a priority track to aid and accelerate the achievement of the sdg-2030 goals and consequently three key indicators for the achievement of uhc have been defined: (1) equity in access to health ser vices (those who need health services irrespective of whether they can or cannot af ford them should receive them); (2) quality of healthcare services (health services should be good enough to improve the health status of those receiv ing them); and (3) financial risk protection (the guarantee that health service costs do not expose people to financial problems) [4,5]. several factors can help countries to move to wards the achievement of the uhc goal and literature is already replete with suggestions of possible factors that can propel countries towards achieving uhc. one of such factors is the urgency of generating valid and quality evidence to inform decision-making. all these factors are important for all stages of the uhc process including the exploration, development and sustenance of interven tionsincluding novel strategies such as utili zation of digital health information technol ogyat the primary healthcare level. the aim of this paper is to enumerate and de scribe barriers identified from available liter ature as limiting the adoption of digital health information technology among pri mary healthcare providers and proffer the way forward to enhance adoption in order to ultimately propel the african continent to wards the actualization of the uhc targets. method a preliminary search of literature was con ducted to determine the need for the study. this was important and helped to refine the initial broad concept of digital health and gave clarity and objectivity to the choice of topic. then literature searches of electronic databases (pubmed, medline and google scholar) were carried out from may through november, 2020. in addition, the snowball ing technique of literature search was em ployed and this involved searches through the references of relevant published articles that were retrieved from the electronic databases. keywords used in the search included ‘digi tal health technologies’ or ‘mobile health’ and ‘willingness to adopt’ and ‘barriers to adoption’, ‘primary healthcare’ and ‘univer sal health coverage’. the inclusion criterion was that published articles should be pub lished in english. furthermore, articles not related to the aim of the study topic were ex cluded. figure 1further describes the stages of the literature search process that was un dertaken during this review. ohia ch, ongolo-zogo p, fawole oi. digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare pro viders (review article). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4381 p a g e 5 | 11 figure 1: stages of the literature search process discussion factors limiting the actualization of uni versal health coverage (uhc) targets in africa currently, africa is lagging in meeting the targets of the uhc with between 5% -25% coverage across countries. several barriers limit the actualization of the targets of the uhc in africa. these barriers are far reach ing and include high operational and finan cial costs required for the expansion of health service access to areas or communities cur rently lacking access [6]; paucity of data due to lack of appropriate researches [5]; exten sively weak health systems; poor infrastruc ture; inefficient transport; inadequate physi cal access to several communities due to in accessible, difficult topography, insecurity; and sociocultural barriers [7]. these barriers limit the potential of current approaches to health service delivery and may in the long run hinder the achievement of the uhc tar gets given the realities on ground. this is worrisome especially in the face of dwindling economic capabilities of these african na tions and the prevailing political and social environments. it is imperative to begin to consider new paradigm shifts and innova tions in the achievement of the uhc targets in africa for the ultimate actualization of the ohia ch, ongolo-zogo p, fawole oi. digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare pro viders (review article). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4381 p a g e 6 | 11 sdgs goals. hence, adoption of new innova tions is key for the actualization of universal health coverage in africa. digital health technology: a novel ap proach to delivering quality healthcare services and achieving the uhc targets in africa digital health technology offers one of such novel approaches to providing quality healthcare services and can help countries achieve the universal health coverage tar gets [7]. it has been suggested that digital health provides an opportunity to overcome the longstanding problems of inefficiency of health information gathering, sharing, and ac cess [5]. digital health information technol ogy is a term synonymous to mobile health (mhealth) or ehealth. this refers to a broad range of information and communication technologies that are used to gather, collate, transmit, display and store patient data [8 10]. the world health organisation (who) defines digital health as the use of mobile tel ecommunications and multimedia technolo gies to address health-associated issues within health service delivery and public health systems [11]. this concept encom passes a range of technologies, products and services comprising but not limited to medi cal devices, tele-monitoring instruments and devices, remote mobile health technologies, cloud-based services in addition to assistant and sensor technologies [12]. digital health information technology has the potential to enhance the quality, efficiency of health ser vice delivery for improved results, client safety and may possibly reduce healthcare delivery costs in resource poor settings as prevalent in africa. [13,14]. digital health approach finds application in several spheres of health service delivery including patient data management (e-health records), health information and services provision via mo bile technology (mhealth), remote services (telemedicine/telehealth), health knowledge learning and management [7]. application of digital health information technology ensures the prompt deployment of health information and thereby enhances accessibility of health services by all stake holders including patients, health service pro viders and relevant agencies of government. also, it can reduce medical mistakes, costs, and paperwork associated with medical ser vice delivery. this subsequently increases ef ficiency, quality of health service delivery while enhancing the empowerment of pa tients and healthcare providers including cli nicians [15]. the various applications of dig ital health have shown its potential for use in promoting individual health and public health at large. furthermore, these technologies can improve efficiency of health care services; reduce cost of health services delivery [16]; enhance the dynamism and timeliness of de cision making by expediting speedy trans mission of real time public health infor mation; and enhance the monitoring and evaluation capacity of the health system in general. this provides ample opportunity for enhanced planning, organization, and man agement of health services at all levels in cluding the primary health care level. how ever, in spite of the potential benefits of the digital health information technology, adop tion is a huge challenge especially in low and middle income countries including africa. this has greatly limited the utilization of the technology in health care service delivery. it is therefore imperative to identify the obsta cles to the adoption of digital health infor mation technology among relevant stake holders across levels in the health care ser vice delivery network especially at the pri mary healthcare level. ohia ch, ongolo-zogo p, fawole oi. digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare pro viders (review article). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4381 p a g e 7 | 11 barriers to adoption of digital health in formation technology among primary healthcare providers. a key impediment to adoption of digital health information technology in resource low communities is low level of technology knowledge and limited accessibility to tech nological devices. a study conducted in iran found that the level of technology literacy was poor; utilization of these technologies among health care personnel was limited [17]. in addition, computer possession and use among health care professionals and stu dents were low [17]. this may be due lack of structured trainings and limited access to technological devices such as computer in these settings [17]. despite the fact that ma jority of the respondents owned a computer, only a few number of them had acceptable skills and practice habits. another study in nigeria reported that just 18.9% of health personnel and medical students had good knowledge of computer while 58.8% had av erage knowledge and 22.3% revealed poor knowledge [18]. similarly, mohammed et al. [19] reported that only 33.7% of health work ers had sufficient knowledge of computer or other digital devices. in more developed countries the case is different, as 57.91% of health personnel were well-informed about digital information technologies including use of computers in india [20]. and majority (82%) of health workers in countries like po land were knowledgeable about the concept of telemedicine [21]. studies have shown that digital knowledge and experience of healthcare personnel have considerable im pact on their readiness, perception, attitude, and probability of adopting and utilizing these health technology applications in prac tice [22,23]. healthcare professionals with sufficient and requisite information technol ogy knowledge and experience are likely to have better and positive disposition towards the utilization of new innovations like digital health technology applications. thus the need to focus on developing context-specific training on digital health in order to fill the knowledge gap. another barrier to adoption is the low level of acceptance of the innova tion in most of low and middle income coun tries [14]. these maybe due to the fact that very few healthcare workers know and un derstand the enormous benefits of digital health information technology [24] in provid ing prompt and efficient services at any level of the healthcare system. resistance to the use of digital health technologies from healthcare professionals may be due to low level of digital literacy and limited skill in the use of digital health technology applications [25]. in addition, absence of motivation, poor organizational and management level poli cies also pose very formidable barriers to the adoption and utilization of these technologies [26]. poor technology infrastructure in rela tion to hardware, software, and networking facilities is also a main obstacle to healthcare personnel’s decision to embrace e-health technology applications [2529]. this is due to the fact that most digital infrastructure pro jects in countries have previously been run as pilot projects resulting in duplication of ef forts and technologies with little or no focus on sustainability [7, 26]. another salient lim itation to adoption in low and middle income countries (lmics) is monetary barriers espe cially with respect to budgeting and funding [26,30-32]. although the level of funding varies across countries, however most devel oping countries allocate very little funding for the health sector which are mostly lower than the world health organization (who) benchmark, that requires countries to appor tion at least 13 percent of their annual budg etary spending to the health sector. this makes funding of such investments such as digital health grossly inadequate in develop ing countries when compared to more devel oped countries. ohia ch, ongolo-zogo p, fawole oi. digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare pro viders (review article). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4381 p a g e 8 | 11 administrative issues including political will and bureaucracy related to organizational and management policies go a long way to deter mine the level of adoption of these technolo gies [33]. these could pose very formidable barriers to the efficiency of the implementa tion of these technologies at all levels of health service delivery. security barriers re lated to privacy and trust arise both among healthcare workers and patients [26]. this could be due to prevalent myths and socio cultural beliefs especially in african coun tries with the potential to negatively impact decisions when contemplating the adoption and utilization of digital health technology. although evident in most of the barriers dis cussed, it is important to consider human re source barriers distinctly in addressing the is sue of technology adoption. this is important especially in relation to individual attitude, readiness and belief of the overarching goal and benefits of digital health technologies. this has significant influence on the individ ual’s intention to adopt and use available dig ital health technology applications. table 1 provides a summary of barriers identified from available literature in the field. table 1: identified barriers to adoption and utilization of digital health information tech nology applications in most of low and middle income countries. s/n identified barriers to adoption references 1. low level of technology knowledge and limited accessibility to technological devices. 17-21 2. low level of acceptance of the innovation in most of low and middle income countries 14, 24.25 3. low level of digital literacy and limited skills in the utilization of digital health infor mation technology applications in most of low and middle income countries 21-23, 25 4. poor technology infrastructure in relation to hardware, software, and networking faci lities 7, 25-29 5. absence of motivation, poor organisational and management level policies to drive adoption of novel interventions at the primary healthcare level 26 6. monetary barriers especially with respect to budgeting and funding 26, 30-32 7. administrative issues including political will and bureaucracy related to organizatio nal and management policies 33 8. security barriers related to privacy and trust arise both among healthcare workers and patients 26 9. human resource barriers distinctly in addressing the issue of technology adoption 17-21, 25,26 way forward to enhance adoption of digi tal health information technology among primary healthcare providers. there is an urgent and critical need to deter mine the current levels of knowledge, atti tude, practice and readiness to adopt digital health in service delivery by healthcare work ers especially at the primary health care lev els across the continent. a mixed study approach including a longitu dinal study is recommended to enable the col lection of quality information. the genera tion of such data from major stakeholders such as health workers and health managers, providers among others will provide im portant evidence needed for attaining optimal utilization of digital health in the context of health for all. in addition, the deployment of ohia ch, ongolo-zogo p, fawole oi. digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare pro viders (review article). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4381 p a g e 9 | 11 context-specific digital health information technologies is essential in african countries, if the full potentials of the strategy are to be realized. it is also important to evaluate the outcomes, effect and cost effectiveness of proposed models of digital health alongside the development of clear sustainable funding models with contextual relevance to target countries. the need for community and stakeholder engagement, mobilization and education cannot be over-emphasised as ena blers and drivers of dynamic participation in digital health initiatives and activities at the primary care level in african countries. hence, policy and public health interventions such as creation of awareness and promotion of use of digital health will go a long way to enhance its integration into the mainstream healthcare system in countries. conclusion the primary health care remains at the cen tre of the actualization of universal health coverage and digital health technologies have huge potential to enhance service deliv ery and access to health with minimal finan cial burden to both individuals, communities and nations. however, the utilization of digi tal health technologies remains very meagre at the grassroots in africa and this poses im mense impediments to the efficiency and quality of healthcare delivery. in addition, there remains a paucity of data to support ev idence-based decision making about full im plementation of digital health services across the continent; aside from the reality of the in herent peculiarities of individual countries. this paper has identified some of the barriers to adoption of digital health approach in lmics especially in africa and posits that there is an urgent need to understand the con textual and political landscapes, issues and barriers to the utilization of digital health at the primary health care levels. in addition, some recommendations have been proffered as the way forward is sought to improve adoption level of digital health in africa. summarily, a clear understanding of the con textual and implementation bottlenecks high lighted from such assessment(s), especially as it relates to individual african countries, will go a long way to guide decisions to ad dress the low utilization of digital health tech nologies in health services delivery in africa. 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acceptance and use of in formation technology: extending the unified theory of acceptance and use of technology. mis quarterly 2012; 36(1):425_478. 23. kabashiki ir, moneke ni. the im pact of the use of health information http://www.who.int/ehealth/en/ ohia ch, ongolo-zogo p, fawole oi. digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare pro viders (review article). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4381 p a g e 11 | 11 and communication technology on health care delivery in manitoba, canada. journal of hospital admin istration 2014; 3(6):8_19 doi 10.5430/jha.v3n6p8. 24. adebayo kj, ofoegbu eo. issues on e-health adoption in nigeria. interna tional journal of modern education and computer science 2014; 6(9):36_46 doi 10.5815/ijmecs.2014.09.06. 25. quaglio g, schellekens a, blankers m, hoch e, karapiperis t, esposito g, brand h,nutt d, kiefer f. a brief outline of the use of new technologies for treating substance use disorders in the european union. european ad diction research 2017; 23:177_181 doi 10.1159/000478904. 26. zayyad and toycan factors affecting sustainable adoption of e-health tech nology in developing countries: an exploratory survey of nigerian hospi tals from the perspective of healthcare professionals peerj, 2018. doi 10.7717/peerj.4436 27. qureshi qa, shah b, najeebullah gm, nawaz a, miankhel ak, chishti ka, qureshi na. infrastructural bar riers to e-health implementation in developing countries. european jour nal of sustainable development 2013; 2(1):163_170 doi 10.14207/ejsd.2013.v2n1p163. 28. zhu, k., kraemer, k.l., & xu, s. the process of innovation assimilation by firms in different countries: a technol ogy diffusion perspective on e-busi ness. management science, 2006; 52(10), 1557-1576 29. ismail, n.i., abdullah, n.h., shamsudin, a., & ariffin, n.a.n. implementation differences of hospi tal information system (his) in ma laysian public hospitals. international journal of social science and hu manity 2013; 3(2), 115. 30. obansa saj, orimisan a. health care financing in nigeria: prospects and challenges. mediterranean journal of social sciences 2013; 4(1):221_236 doi 10.5901/mjss.2013.v4n1p221. 31. eneji ma, juliana dv, onabe bj. health care expenditure, health status and national productivity in nigeria (1999_2012). journal of economics and international finance 2013; 5(7):258_272 doi 10.5897/jeif2013.0523. 32. sulaiman, h. healthcare information systems assimilation: the malay sian experience. 2011. rmit univer sity. 33. hossein ahmadi, leila shahmoradi, farahnaz sadoughi, azadeh bashiri, mehrbakhsh nilashi, abbas sheikhtaheri, sarminah samad, oth man ibrahim. a narrative literature review on the impact of organiza tional context perspective on innova tive health technology adoption. journal of soft computing and deci sion support systems 2018; 5:(4): 1 12. © 2021 ohia et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0) chinenyenwa ohia1, pierre ongolo-zogo2, olufunmilayo ibitola fawole3 source of funding acknowledgement introduction method figure 1: stages of the literature search process factors limiting the actualization of universal health coverage (uhc) targets in africa digital health technology: a novel approach to delivering quality healthcare services and achieving the uhc targets in africa barriers to adoption of digital health information technology among primary healthcare providers. table 1: identified barriers to adoption and utilization of digital health information technology applications in most of low and middle income countries. conclusion references lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 1 review article preparing society to create the world we need through “one health” education report of a global survey and web conference on “one health” k-12 education, 18 november 2016 george r. lueddeke1, gretchen e. kaufman1, joann m. lindenmayer2, cheryl m. stroud2 1 one health education task force; 2 one health commission. corresponding author: george r. lueddeke, co-chair, one health education task force; address: 9 lakeland gardens, southampton, hampshire, so40 4xg, united kingdom; email: glueddeke@aol.com http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 2 abstract aims: a previous concept paper published in this journal (1), and a press release in june 2016 (2), focused on the importance of raising awareness about the un-2030 sustainable development goals (sdgs) (3) and, in particular, developing a better understanding about the critical need to ensure the sustainability of people and the planet in this decade and beyond through education. the one health education task force (ohetf), led by one health commission (4) in association with the one health initiative (5) agreed to conduct an online survey and conference in the fall of 2016 to engage interested colleagues in a discussion about the possible application of one health in k-12 (or equivalent) educational settings. method: the survey instrument, reviewed by a panel of experts (below), was conducted in september and october 2016 and focused on basic concepts, values and principles associated with one health and well-being. input was sought on the various ways that one health intersects with the un sustainable development goals and how they might work together toward common objectives. questions also explored ‘why, how, and where’ one health could be incorporated into k-12 curricula, and who should be involved in creating this new curriculum. results and conclusions: overall, there was general consensus that this initiative could make a significant contribution to implementing the sdgs3 through the one health spectrum as well as the priorities and major challenges that would be encountered in moving this initiative forward. five strategies were presented for embedding the sdgs and one health through curriculum innovation from early years to tertiary education and beyond. importantly, a “community of practice” model was put forward as a means to support and promote the sdg goals through one health teaching and learning in a meaningful and supportive way for the benefit of all involved. a subsequent conference in november 2016 provided an opportunity to present the results of the survey and conduct a more in depth discussion about potential curriculum development designs, possible project funding sources, and implementation challenges. keywords: education, one health, global health. conflicts of interest: none. acknowledgements: the organizers would like to thank the members of the one health educationtask force for their contributions to the conference and survey development including, lee willingham and tammi kracek from the one health commission and representatives from the one health initiative autonomous pro bono team: bruce kaplan, laura kahn, lisa conti and tom monath. we are also grateful for the invaluable assistance from peter costa, associate executive director for the one health commission, in organizing and moderating the on-line conference. in addition we would like to thank the following reviewers who assisted in the development of the online survey: muhammad wasif alam, dubai health authority-head quarter, uae; stephen dorey, commonwealth secretariat, uk; jim herrington, university of north carolina at chapel hill, usa; getnet mitike, senior public health consultant, ethiopia; heather k. moberly; dorothy g. whitley texas a&m university, usa; joanna nurse, commonwealth secretariat, uk; christopher w. olsen, university of wisconsin-madison, usa; richard seifman, capacity plusintrahealth international, usa; neil squires, public health england, uk; erica wheeler, paho/who, barbados. http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 http://www.seejph.com/index.php/seejph/article/view/122 https://www.onehealthcommission.org/documents/filelibrary/commission_news/press_releases/61016__oh_education_press_releasefi_f7644a48f9910.pdf https://sustainabledevelopment.un.org/post2015/transformingourworld https://sustainabledevelopment.un.org/post2015/transformingourworld https://www.onehealthcommission.org/ https://www.onehealthcommission.org/ http://www.onehealthinitiative.com/ http://www.onehealthinitiative.com/ http://www.onehealthinitiative.com/ http://www.onehealthcommission.org/ lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 3 introduction the one health concept is rightly gaining timely support and momentum worldwide as we are all becoming increasingly aware that humans, animals, plants and the environment must be in much better balance or harmony to ensure the present and future of our planet. it is gradually becoming clear that to realise or indeed re-capture this state of equilibrium, one health and well-being must be at the heart of socioeconomic, environmental and geopolitical decisionmaking at global, regional, national and local levels, thereby informing, as the commonwealth secretariat health and education unit (comsec heu) posits governance, knowledge development, capacity building and advocacy (6). over the past 18 months or so, and in line with the un-2030 global goals (3) (or sustainable development goals-sdgs) agreed late 2015, that embraced a broad notion of sustainable development – how all things are interconnected – climate, energy, water, food, education -we have been researching and developing ideas on how the one health task force might support sustainability of the planet and people. our deliberations led us to the fundamental question of how we might address perhaps the most important social problem of our time, that is, ‘how to change the way humans relate to the planet and each other to ensure a more sustainable future for all life.’ (2) our unanimous conclusion is that learning about ‘one health and well-being’ needs to play a much greater role in the education of our children and younger generation as well as society in general. to these ends, we developed position papers, issued a press release (2) in june 2016, to which many webinar attendees responded, followed by an on-line survey in septemberoctober to solicit wider input on one health education. the survey thus informed an online one health education conference on november 18, 2016 (7). the main purpose of the webinar was to share and build on the survey findings with a view to informing a ‘robust’ one health education project funding proposal. a vital consideration governing the proposal was the potential of raising awareness about the social determinants of human-animal-environment interactions as well as the limitations presented by an unbridled human population expansion in the face of finite natural resources. many of the task force discussions reminded us that while we are advancing scientifically and technologically, we are also faced with a huge ingenuity gap – that is finding answers to unprecedented social problems that on many days seem to overwhelm us – climate change, health and food security, armed conflicts, ideological extremism, economic uncertainty, global inequalities, inequities and imbalances, to name a few. the ebola crisis especially caught the world’s attention in this regard. there are no easy answers. but encouraging young people to gain a better understanding of the planet we all share and need to sustain, along with our individual responsibilities to each other, and learning not only ‘to do things better’ but also, perhaps most importantly , ‘to do better things’ through collaboration and education, must surely be part of the way forward. underpinning our resolve to engage children and young adults in the pursuit of achieving the un-2030 global goals through education and the one health education initiative (ohei) is captured in the recently published book, global population health and well-being in the 21st century (8). a recurring theme in the publication is that achieving the 17 sdgs and targets requires a fundamental paradigm or mind-shift in the coming decades: moving us from a view that sees the world as ‘a place primarily for humans and without limits’ to one that views the world holistically, ensuring it is fit for purpose in the long run for humans, animals, plants and the environment or our ecosystem. one health provides us with the ‘unity around a common cause’ (9) toward which all of us need to aspire and which we believe is fundamental to building the world we need. http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 file:///c:/users/george/downloads/:%20https:/drive.google.com/file/d/0b8wr6920su0arhlyd0pdoerlajq/view file:///c:/users/george/downloads/:%20https:/drive.google.com/file/d/0b8wr6920su0arhlyd0pdoerlajq/view http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 4 summary of online one health education survey results the purpose of the one health education online survey was to elucidate concepts, values and principles that respondents associated with one health, and to begin to define how the one health concept might be operationalized in k-12 schools. invitations to participate in the survey were sent to individuals that had previously expressed interest in the one health k-12 education initiative expressed through presentations, in response to the published concept note and a press release, and through individual conversations. seventy-six people responded to one or more questions on the survey. of the 52 (68.4%) respondents who answered the question about highest level of education attained, 31 held one or more doctoral-level (18 phd, 9 dvm, 4 md, 1 jd), 14 held master’s-level, and 7 held bachelor’s-level degrees. of the 53 (69.7%) respondents who answered the question about country where they worked, 21 answered usa, 15 europe (including 6 in the uk), 10 africa, 5 asia or southeast asia, 1 south america, and 1 answered middle east. one health concepts, values and principles words that respondents most commonly cited were “health” and the health domains (human, animal, environment/ecosystem/ecology). respondents also cited words that represented common ground among one health disciplines, e.g., inter-, coop-, collab-, coor-, integ-, uni and holi-. “sustain” and “educ-“ were mentioned frequently, as were “diseand “zoo-.” respondents preferred the venn diagram and triad representations of one health by far over other representations. values most commonly cited as most essential to one health are sustainability, cooperation, diversity/biodiversity and responsibility, leadership and understanding. innovation was also noted. the type of sustainability judged to be the most important type by far was ecologic sustainability, economic and cultural/social only moderately so. a high degree of agreement (>90%) was given to the following statements: “the health of humans, other animal species and plants cannot be separated,” and “environment includes both natural and built environments.” more than 80% of respondents agreed that “humans have a moral imperative to address one health challenges,” and “one health should be practiced so that there is no net (ecosystem) loss of biological diversity.” more than two-thirds of respondents agreed with all other statements except “when you optimize health for one species, health for others is marginalized or eliminated.” this implies that the health of species is inter-related and should not be viewed as mutually exclusive. the factors contributing most to current one health problems are compartmentalization of health services and policies, lack of knowledge/understanding, lack of funding streams that encourage collaboration and provide support for one health initiatives, poverty-distribution of wealth-inequity, overemphasis of treatment of individuals (human and animal) at the expense of preventive medicine and population health, political systems that support individual/corporate interests above all else, and overemphasis of human health at the expense of animal/environmental health. other factors mentioned were that one health was too veterinary-centric and that there was a need to acknowledge differences between the developed and developing world. one health education and the sdgs respondents related k-12 education most closely to sdg 3 (ensure healthy lives and promote well-being for all ages). also related, although slightly less so, were sdg 14 (conserve and sustainably use the oceans, seas and marine resources for sustainable development), sdg 15 http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 5 (protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification and halt and reverse land degradation and halt biodiversity loss), sdg 6 (ensure availability and sustainable management of water and sanitation for all), and sdg 2 (end hunger, achieve food security and improved nutrition and promote sustainable agriculture). other sustainability goals not included in the 17 sdgs included improving animal welfare, developing sustainable strategies for control of feral animals, invasive species and pests (to humans), moving to clean energy sources, developing new tools for impact assessment, and promoting greater intake of locally raised foods. operationalizing one health education in k-12 why? long-term outcomes of a one health-themed curriculum included products (trained educators, better policies and decisions, multidisciplinary approaches to risk, sustainable environment/ecosystems/communities, successful adaptation to climate change, new disciplines, better communication, reduction of the gender gap, more recycling, project design competitions), changes in attitudes and behaviors, more and better engagement as citizens with policy and as consumers, and better health and greater awareness of human populations relationship with the planet and its inhabitants. a number of people anticipated that systems/interdisciplinary thinking would be an outcome. what? students should be exposed to all concepts listed, although personal responsibility (how individual actions impact one health) and respect for natural systems and human responsibility for planetary health were the most important, followed by environmental contexts of one health issues and corporate, political and societal responsibility (how their actions impact one health). one person noted that equity and social justice was important, as was the moral imperative of viewing nature as equally important as humanity. students in one health-themed educational programs should learn collaboration, interdisciplinary thinking, systems-thinking, problem-solving and team-building skills. entrepreneurship, environmental ethics were also noted. one person remarked that “in my opinion, students in one health must, before anything else, gain the ability to immediately look for solutions from all media when facing a problem that requires a more complex approach. basically questioning themselves -what would an engineer/medic/chemist/vet/etc. do when faced with the current problem?” how? challenges most commonly cited that could be used to illustrate one health in k-12 education were diseases (vector-borne, zoonotic, food-born), food security, antimicrobial resistance, environmental pollution (of air, water, soil), climate change and loss of biodiversity/disruption of ecosystem services. where? college and university students are the groups most exposed at present to one health concepts (although fewer than 20% of respondents believed they were exposed at all). fewer than five percent of respondents believed that students at all other levels of education are exposed to these concepts. respondents believed that at levels below college/university, it’s most important to introduce one health concepts to students at all educational levels, although it’s most important in high/secondary schools and slightly less so in middle schools. http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 6 one health-themed curricula should be piloted in publicly-funded schools and in colleges or universities. one person suggested piloting one health education in religious classrooms because a lot of teaching goes on there from k-12 (nb: makes sense as long as pope francis is in charge!). virtual classrooms were also noted. barriers and challenges to piloting and scaling up the main barrier to incorporating a oh-themed program into k-12 education is constraints posed by the current educational system, including lack of knowledge and understanding on the part of teachers and the public, the need for adequate teacher training, rigid limits posed by established curricula, government objectives, and the requirement for standardized testing. also noted were overloaded curricula, lack of adequate resources (validated k-12 curricula, infrastructure, access to the internet and it, materials such as case studies, activities, textbooks, pedagogical methods and tools), and inertia of current educational systems and their representatives. many respondents stated that one health is complex, requires simplification, and concrete and practical examples to make it more easily understood. major logistical challenges to scaling-up a k-12 one health curriculum to a global stage that respondents anticipated were lack of funding and resources (it, infrastructure, human resources, content, simulation exercises, alternate delivery platforms), constraints posed by current educational systems (different education systems/formats/settings, teacher training, limitations imposed by pre-existing curriculum requirements, need for tailored education to different contexts, underserved areas sustainable funding), and cultural and language differences. one person noted the need to first measure the added value of pilot projects before scaling up. who? the most common educational stakeholder sector that should be represented in developing the concept of a one health-themed education initiative into a successfully-funded proposal included various members of educational systems (teachers and educators at all levels (including university) of public and private sector, educational/instructional/ curriculum designers, school administrators, teacher associations, teacher training institutions, teachers unions, and educational researchers). government was also mentioned frequently. interesting suggestions included church schools, where a great deal of education takes place, parents and students, and publishers of textbooks. funding organizations that might support implementation of a one health-themed education initiative included government sectors (education, development, health), various private foundations (wellcome trust, melinda & bill gates foundation, soros foundation, the josiah macy jr. foundation, rockefeller foundation, skoll foundation, the global fund, the foundation for international medical education and research), international nongovernmental organizations such as those originating in the eu and the un, and banks such as the world bank. also mentioned were the european social fund, the network: towards unity for health, the european horizon 2020 program, and the global partnership for education. other comments and suggestions worthy of mention were:  a one health curriculum has to be content rich and ‘not just another vague thing' about relationships and collaboration, and that it needs to address critical problems like climate change, agricultural intensification, comparative medicine, environmental health threats.  consider strengthening and using innovative on-line teaching, flipped class room, take advantage of existing educative one health tools (mooc on one health, environment challenges, etc.), and create new ones. http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 http://macyfoundation.org/ http://macyfoundation.org/ lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 7  the biggest challenge we face in implementing a one health curriculum at a global stage is the lack of a major driving force in one health. although we are trying our best as one health clusters, we need to have a major support from a so called "poster boy", something that will catalyze our efforts.  one-health should be a process that start at pre-primary level to change mind-sets, although there should be entry-levels at all phases for those who were not exposed from the start. it will be beneficial if the one-health principles thinking can be incorporated as it relates to different subject streams (e.g. economics, social science, and others).  we need to understand that we, as individuals, are not quite the center of the universe and that our actions, even though they may not bring us much benefit/losses, surely can influence everyone around us.  this is an extremely important project at a very volatile time in our world. education is the key to supporting and delivering the un 2030 sdgs. strategies for k-12 one health curriculum innovation this segment of the conference presented some of the ways that the one health education task force has considered to utilize one health concepts in curriculum development for k-12 classroom applications. feedback from the participants was requested and additional ideas that might be considered for the program and funding proposal were encouraged. we have explored the following five potential options to consider for our proposal: curriculum innovation grants for educators, curriculum development workshops for teachers, teacher training programs, a one health education network, and an on-line knowledgebase of one health curriculum materials. we understand that there are different needs among various educational systems and across countries around the world, so the options presented below are not mutually exclusive and we could consider one or any combination of these within the larger project. i) curriculum innovation grants for educators the initial idea that we explored was a program that would offer grants to teachers to develop and implement a one health focused curriculum at their school that meets specific criteria and objectives set by the one health education task force. we are attracted to this idea because we understand that teachers themselves know best how to reach their students, what curricular designs work within their institutions and grade levels, and what tools are most effective at reaching outcomes. in addition, by engaging teachers directly and offering opportunities for innovation, we feel that other teachers would be more likely to adopt and share successful methods among themselves, either thru example and their existing networks, or with formal mentoring. this program would offer competitive innovation curriculum development grants to teachers or teams of educators on an annual basis. the focus of this program could be open ended or could involve a changing one health theme each year to ensure diversity of topics. applicants would be asked to meet very specific guidelines that target values, skills and knowledge criteria using one health approaches. these guidelines would be developed by the one health education task force and would be informed by wider conversations with the one health global community, including the survey recently conducted. proposals would need to emphasize interdisciplinary engagement as a fundamental tenet of one health principles. as time goes by, successful methods and curricula would be shared through the proposed oh education network and knowledgebase described below and would not be limited only to participants in the program. http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 8 ii) curriculum development workshops for teachers we have received feedback that some teachers would never have the time to devote to curriculum development themselves. some have also expressed concern that they do not know the subject area well enough to be able to write a curriculum or innovate very effectively along one health lines. in response, we decided we needed to create an opportunity for motivated teachers to learn more about one health and receive some direct assistance in creating one health themed curricula. we are proposing to do this through a series of summer workshops, which would include summer salary for participants. this would be an annual opportunity and could again be open ended or focused on changing themes or topics. workshops would involve participation by “experts” in one health, depending on the topics selected, and would also include curriculum development professionals to assist teachers in classroom applications. the workshops would emphasize innovative learning methods that target one health values, skills and knowledge criteria as described above and would provide an important networking opportunity for sharing and mentoring between teachers and experts. iii) teacher training programs a third concept that we are proposing is to work with teaching training programs already in existence that are interested in building one health approaches into their training programs. this approach would involve new teachers in the process of curriculum development and could be implemented through specific courses or teaching modules. by working with teaching training programs we would be creating opportunities for innovation from the ground up which may provide greater opportunity for broad integration of one health values across subjects. in this environment, we would also be in a good position to inculcate one health skills and knowledge in teachers during a critical period in their own development as educators. this approach would also ensure that appropriate regional programming is being developed that best meet the needs of local education systems and would maximize benefits and outcomes which may not be otherwise adaptable from a more universal, less regional approach. it was suggested that we think about promoting this opportunity to make sure teachers that need it to take advantage of it. this could be done by developing introductory one health presentations and using social media to reach a broad audience. the example of an ivsa program was given where they are “developing a one health presentation to school children on veterinary public health, one health and explaining the diversity and active contribution of vets and medics to the human-animal-environment interface. we plan to distribute it to our member organisations in over 60 countries and translate it to at least 2/3 languages for teachers to use. we hope to use social media to spread the word, to students will promote or present this workshop to communities, to families and then to schoolsto encompass student centred learning (bhavisha patel).” iv) one health education network the creation of a one health education network will be critical to global adoption of any curriculum innovation that results from this initiative. we feel that it would be very valuable to foster mentorship and sharing among project participants and provide opportunities for others outside the project to benefit from the teaching expertise that develops as a result of this initiative. over several years this could develop into a robust and supportive cohort of one health educators around the globe and provide the best mechanism for achieving sustainable development goals globally through one health. http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 9 the ohe network would provide a directory of one health educators, facilitate communication between educators with social networking tools, and facilitate mentorship connections between educators and one health experts. the network could act as a platform for organizing meetings and presentations, and would facilitate collaboration on future projects. importantly, the network could become self-sustaining simply through the interest and enthusiasm of the participants and provide longevity to the investment of this project for years to come. v) on-line knowledge base of one health curriculum materials finally, we want to openly share the products of any of these curriculum development programs as we start a movement and inspire teachers around the world to adopt one health principles in their teaching. we propose to build an open access technology platform for sharing curriculum that will serve as a repository for products of any grants or workshop programs developed through this initiative. sharing outwardly to the world would provide an opportunity for feedback and dialogue to improve these products and encourage, in an organic way, the transition of more curriculum to include one health principles. over time, this knowledgebase could also link to or include contributions from outside this project and broaden the impact and engagement for one health themed educational initiatives that furthers our global objective for achieving sustainable development goals through one health themed education. above are the five main programs we have focused on to date and we encourage feedback and input from a broader audience. there are many details to work out, and the scale of these programs is still undetermined. what follows is a summary of the participant suggestions and calls for clarification concerning the strategies presented. first and foremost we would like to clarify that the scope of this project is intended to be global. while initial implementation of pilot projects may precede full globe reach, the pilot projects would likely include a diversity of sites. the exact structure or timeline has not yet been determined. the different nature of various education systems around the world and even within a country like the us was brought up as a challenge. within the us, there is a great deal of variation and level of influence between state agencies and the federal government through the department of education. some states may be more receptive than others to the type of curriculum initiative we are proposing. we hoped that the first option which asks for teachers themselves to come forward, would take care of some of this diversity. teachers would presumably be proposing curriculum development that would work within their own context. the great differences between developed educational systems and developing educational systems will also be a challenge and may require two different efforts or pathways. some clarification about who will make up the group of “one health” experts to participate will be needed, especially since there are no specific well defined criteria for a one health expert, or any standardized system for accreditation or academic degree existing today. we are specifically look for content experts to provide necessary knowledge and resources, as well as curriculum development experts, and the specific qualifying criteria that defines a participating “expert” still needs to be worked out. an excellent suggestion was made to consider including parents in grants or workshops to help bridge the resource gap in some low-income schools where parent leaders play an important volunteer role. engaging with parents may also promote greater acceptance with the community outside the school. the concept of a “community of practice” approach was mentioned as a model for the knowledgebase as well as the network. one way to do this might be to target a specific group of people involved in middle and high school education and connect them with existing experts http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 10 or groups that might have resource materials to provide, such as the oie. we would very much like these two programs, the knowledgebase and the network, to operate as a community of practice in one health education. one significant outcome will a one health education foundational body of work that currently does not exist. another mentorship model to consider would be the twinning model, used in the usaid emerging pandemic threats program and others to share between developed and developing educational systems or institutions. there were a couple of cautionary remarks to conclude this section. first of all, considering the large scope of programs and challenges for implementation, there was some concern about staff time and capacity necessary to follow through with this initiative and a need to establish realistic priorities. we are very aware of this and will be considering these questions as we approach funders and develop a timeline. lastly, beware of the top down approach being proposed by our group of one health champions. this will not work without active engagement with k-12 education partners. we have discussed this at length and have been struggling to find the appropriate enthusiastic partners. we welcome any good ideas or introductions to institutions or people that we can draw in to this initiative that will provide the appropriate input. dr. lueddeke will provide more detail on our potential partners defined to date. funding considerations for a one health education initiative this segment of the conference focused on three main funding considerations: i) linking un 2030 sustainable development goals to one health education initiatives (10); ii) supporting projects through existing development mechanisms; iii) possible funding sources. a key argument for project funding decisions was that the one health concept and approach need to be considered as a lens or filter for shaping global policy and strategy regardless of the sdg goals and targets being evolved and implemented, including k-12+ education (fig.1). and, while the habitat iii the new urban agenda (11) agreed in october 2016 is a highly commendable achievement, according to a word search, the 19 documents failed to mention terms or explanatory paragraphs/recommendations related as planet, one health, conservation, animals, epidemic, root causes, overcrowding, inequities, automation, eco footprint, infectious disease, non-communicable disease and only singularly cited the words prevention, healthy lifestyles, ageing population, mental health. more than 70 % of the world’s 9 billion population will be living in cities by 2050 or before. one health crosses all discipline boundaries, and it is important that the project planners identify and collaborate across existing networks, as shown in fig. 2. consideration to seeking funding from multiple funding sources might also be appropriate (e.g., bill and melinda gates foundation, un agencies (e.g., undp, unesco), rockefeller foundation, macarthur foundation, the uk department for international development, and welcome trust). several avenues will be pursued in the next few months, including making personal contact with potential partners or collaborators. http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 https://www2.habitat3.org/bitcache/99d99fbd0824de50214e99f864459d8081a9be00?vid=591155&disposition=inline&op=view lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 11 figure 1. linking un 2030-global goals to k-12 one health and well-being education figure 2. global networks (selected) global networks: united nations 193 members states -2 observer states who collaborating centers (>700) world bank global learning development network (>120 institutions – 80 countries) the commonwealth (52 nations) the european union (27 nations) http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 12 further to a question about identifying good partners, it is recognised that a traditional top down approach is not likely to work in this situation. an example of behaviour change that worked well in the u.s. in 70s and 80s is recycling, a local, bottom up endeavour. interestingly, it was young people (children) being inspired by teachers that made the recycling movement happen in the u.s. we should be concerned about strictly advocating a top down approach for k-12 one health education. a successful approach has to start more locally, but be guided by national aspirations or goals. local and national interests should be working in tandem. in the u.s. and the u.k. there has been very little discussion so far about the sustainability development goals. we must draw on expertise locally and find support nationally to enable action groups. we like to think of the dual concepts of one health and ‘well-being’. one health is beyond any political or health system. it’s really saying here is our planet, a very small planet, and we have got to keep it healthy regardless of how we are living our lives. it is probably the only non-divisive concept that we have right now. the un development program folks have done a fairly good job with disseminating information. but, if the un had incorporated one health a year or so ago, we would be further along. meeting the needs of the diverse global community although we believe there exists one health core values, principles and concepts, we recognize that operationalizing one health in primary and secondary schools must recognize and appreciate educational, cultural and social differences among countries and educational systems. therefore, no one model or curriculum will fit all situations. how then, can we begin to frame a proposal that honours one health core values, principles and concepts, but is flexible enough to be adapted for diverse circumstances? a point well-taken from the survey is that a validated one health curriculum does not exist. for that reason, any attempt to propose one must include a pilot phase from which one could learn valuable lessons related to adoption, implementation, and evaluation of a curriculum before it could be modified and scaled up in one or more systems. therefore, a successful proposal will focus on pilot studies in one or more education systems (to be defined), but at the same time, it must include metrics that could be used to judge whether or not here is evidence that scaling up and/or out is feasible and of value. various models have been used to pilot educational interventions, even those that encompass one health, in colleges and universities and in the health workforce. historically these have been piloted in one or more systems that are not linked, but in the last decade a twinning model has gained interest and acceptance. this model links two or more educational systems that, at its best, involves equal partners that each learn from the other; it can, however, evolve to a mentor-mentee situation whereby one partner assumes most of the responsibility and the other partner(s) assume lesser, more receptive roles. there may be other models of which we are not yet aware, and we look to others to suggest them. twinning and other models have been implemented at various scales from local to national systems. participants seconded the idea of a proposal that takes a twinning approach and starts at the local level, with curricula that are meaningful to local communities and that involve parents, community members and students alike as teachers and learners. it would be instructive to apply twinning between a higher income and a lower income country, as is being done at a university level, and to look for points of alignment and difference. the proposal may want to http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 13 consider adopting a term other than ‘twinning,” which is so closely associated with universitylevel activities and is, as was pointed out, often interpreted by higher income countries as “the world is here for us to remodel.” building on responses to the survey, participants suggested that there is a need for concrete yet simple to grasp examples illustrative of one health. if one health is ultimately about changing behaviours, previous successful examples of changing public behaviours such as recycling (which was started by teachers and taken home to parents and communities by students) and smoking cessation (for which youtube videos, cartoons and other popular media presentations have been developed and widely disseminated) might offer valuable lessons for how to accomplish behaviour change, but they must be grounded in one health principles and guided by local customs and beliefs. a proposal would have to involve social scientists, particularly those with expertise in behaviour change and public health. if messages were meaningful and easy to grasp they could be taken to households with the support of government and international organizations. the first nine months of a child’s life is critical to her/his perception of the environment as friendly or hostile, and having a ‘village’ teach one health to young children could well establish a ‘the environment is friendly’ mindset (see the foundation vie’s 1001 critical days of development, also the first five initiative in california). work on empowering girls is being conducted by the university of wisconsin in ghana and could illustrate successful implementation of this approach. a recent teachertraining workshop using student-centred active approaches was very well received by teachers who are used to the ‘sage on the stage’ approach so common in many countries. and, rather than importing more new material into already packed curricula, a proposal could instead strengthen existing curricula, for example, by supporting teachers to adapt current material using more ‘hands-on’ learning with the natural world that incorporate ethics of how we view and treat each other, animals and the environment. a third option would be to develop ‘scaffolding’ lessons that integrate existing curricula across disciplines and grade levels. scaling up and out presumes some early measures of success, but the goal of a one health curriculum is to change behaviours. because this is a long-term outcome, it cannot be used to judge the success of a one health project in the short term. one suggestion was the level of involvement of a community could be used as an early indicator of success for a pilot project . another metric being used in ghana is the degree to which students who experience the curriculum in schools take that learning home to educate their parents, although the cultural appropriateness of children teaching adults has to be considered. successful pilot projects would be shared widely, thereby developing a “community of practice” that would reflect the common goals of one health teaching and learning and the richness of its adaptations. open panel discussion in this section we discussed additional questions and received numerous suggestions that are not included in the sections above. the topic of curriculum design was raised. we purposely do not want to prescribe what any given curriculum would look like, whether that be modules, week-long units, individual lectures or a scaffold of modules across grade levels and across subjects. we want to encourage innovation in curriculum design and pedagogy as much as possible and are hoping that educators would develop curricula together to produce integrated learning designs preferably to create modules that fit into an existing science class for example. programs that cut across courses and grades would be optimal. incentivizing collaborations and trans-disciplinary teambased curricula was suggested, over didactic ‘preaching’. curricula should incorporate issues http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 14 based, inquiry based, problem based, small group based methods that focus on real issues, because our challenges today do cross disciplines. another suggestion was made to organize content around broad categories made up of a series of small modules or easy to digest, bite-sized pieces. this can be particularly important where language might be a challenge. the reference was made to experience in ghana in the one health and girls empowerment program with junior and senior high school girls. in those workshops they found that in addition to ‘content’ that the teachers loved learning about student-centred active teaching approaches that they had never been exposed to. they need to see other ways to teach. there are likely some other good programs already on the ground that we could learn from. several examples of these were mentioned including:  an 8-12 grade curriculum for veterinary science and one health science in the state of texas (try contacting dr. heather simmons);  a new mooc addressing one health that will be available through coursera (https://www.coursera.org/) in spring 2017;  a university of washington "conservation biology & global health" 3 day curriculum for high school students;  the california state first five initiative;  examples of twinning as a collaborative development and support mechanism (e.g. usaid emerging pandemic threats program). however we proceed, the idea of piloting programs in different regions was felt to be important along with the willingness to be flexible and respond to community and cultural diversity in different parts of the world. some discussion centred on the topic of behaviour change. it will be important to include social scientists on the development team that have expertise in this area. one of our challenges is the goal of changing the mindset. 97% of world health funds are going toward treatment of disease and only 3% goes to prevention. this is from a global budget of $7.7 trillion us dollars. because one health is all about prevention strategies, initiatives like the ghsa should be interested. it was suggested that there may be lessons learned from experiences in developing countries with hiv behaviour change programs, particularly how to reach communities. several participants stressed that one of the best ways to gain support for a new program and improve the possibility of success is to make sure there is a link with communities beyond the classroom, with the caveat that we need to be sensitive about the cultural appropriateness of kids teaching adults. another potential ally could be the network of school nurses, a group that is greatly under-utilized and under-appreciated. if appropriately empowered, they could be a valuable asset. in any event we will need good partners in the k-12 system before moving forward since a top down approach will likely not work here. some discussion came up on the topic of finding funding for educational initiatives. it was suggested that it might be helpful to look at the portfolios of the various donors (e.g. usaid, dfid, multilateral and regional banks, etc.) to look for compatible interests in education. it can be very challenging to get an innovative, technical assistance grant. reference was made to experience in a new regional project in west africa called the regional disease surveillance systems enhancement project, a huge world bank project that handles 15 countries in w africa with ohahu and who that involved several hundred million dollars. another suggestion was to explore existing zoonotic disease initiatives, such as predict or the global health security agenda (ghsa). http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 15 some other potential funding sources mentioned include: skoll, ford, rockefeller, gates, the instituyo alana in sao paulo brazil, african union/ecowas. in some cases, appealing directly to ministries of education or health might find support for being the first one to institute something truly innovative (e.g. island nations like fiji and seychelles). conclusion we assumed that most people attending this conference (10) do support the idea of k-12 one health education. perhaps attendees, like us, are driven by the need to examine what is currently being done (in education) and to postulate what we need to be doing differently to prepare future generations. there are some attempts being made globally for one health education at the graduate and professional education levels. but that is too late to significantly affect behaviours and in still attitudes of open collaboration and interactions. by then young people are already in their academic silos. we are very concerned about current attitudes toward our human place on the planet. in this conference we have outlined some tangible, programmatic models that could be used in young children and expanded to a global community of practice to improve things for future generations. the un sustainable development goals are a wonderful target to aim for globally. but there is currently no mechanism to unite and implement them. one health thinking and acting can do that. indeed, one health is a pathway not only to the un sdgs and planetary health, but also to global security. health and well-being are profoundly embedded in and dependent on global government stabilities. as the last 10-15 years have shown, it can be very difficult to introduce one health concepts to already established systems. but k-12 children will be our future global leaders. how do we help them understand the severity of what is going on right now in the world? what is restraining us from doing new things like taking one health education and concepts to young children? we need to change today’s mindset/paradigm of using up our global resources without regard for the health and well-being of our planet because future generations will depend on mother earth. how do we get individuals, governments and corporate bodies to think more holistically and sustainably about the health and well-being of people, animals and the planet? there is much work to do to make one health the default way of doing business around the world. children and one health can be our ‘ray of hope’ for the future. references 1. lueddeke g, kaufman g, kahn l, krecek r, willingham a, stroud c, et al. preparing society to create the world we need through ‘one health’ education. seejph 2016;6. doi 10.4119/unibi/seejph-2016-122. 2. lueddeke g, stroud c. preparing society to create the world we need through ‘one health’ education! (press release). one health commission. available at: https://www.onehealthcommission.org/documents/filelibrary/commission_news/press _releases/61016__oh_education_press_releasefi_f7644a48f9910.pdf (accessed: march 20, 2017). 3. united nations. united nations. transforming our world: the 2030 agenda for sustainable development. available at: https://sustainabledevelopment.un.org/post2015/transformingourworld (accessed: march 20, 2017). http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2016-122 https://www.onehealthcommission.org/documents/filelibrary/commission_news/press_releases/61016__oh_education_press_releasefi_f7644a48f9910.pdf https://www.onehealthcommission.org/documents/filelibrary/commission_news/press_releases/61016__oh_education_press_releasefi_f7644a48f9910.pdf https://sustainabledevelopment.un.org/post2015/transformingourworld lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 16 4. one health commission (ohc). (2017). mission. available at: https://www.onehealthcommission.org/en/why_one_health/ohc_mission/ (accessed: march 20, 2017). 5. one health initiative (ohi). mission statement. available at: http://www.onehealthinitiative.com/mission.php (accessed: march 20, 2017). 6. the commonwealth secretariat (health and education unit). advancing sustainable social development through lifelong learning and well-being for all. available at: https://drive.google.com/file/d/0b8wr6920su0arhlyd0pdoerlajq/view (accessed: march 20, 2017). 7. one health commission. one health education conference. available at: https://www.onehealthcommission.org/en/eventscalendar/one_health_education_onlin e_conference/ (accessed: march 20, 2017). 8. lueddeke g. global population health and well-being in the 21st century: toward new paradigms, policy and practice. new york: springer publication; 2016. available at: http://www.springerpub.com/global-population-health-and-well-beingin-the-21st-century-toward-new-paradigms-policy-and-practice.html (accessed: march 20, 2017). 9. wwf international. living planet report 2014. available at: https://www.wwf.or.jp/activities/lib/lpr/wwf_lpr_2014.pdf (accessed: march 20, 2017). 10. lueddeke g. the un-2030 sustainable development goals and the one health concept: a case for synergistic collaboration towards a common cause. world medicine journal, vol. 62, 2016: 162-167. available at: http://lab.arstubiedriba.lv/wmj/vol62/december-2016/#page=44 (accessed: march 20, 2017). 11. un news centre. habitat iii: un conference agrees new urban development agenda creating sustainable, equitable cities for all. available at: http://www.un.org/apps/news/story.asp?newsid=55360#.wo3xddqrjkg (accessed: march 20, 2017). http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 https://www.onehealthcommission.org/en/why_one_health/ohc_mission/ http://www.onehealthinitiative.com/mission.php https://drive.google.com/file/d/0b8wr6920su0arhlyd0pdoerlajq/view https://www.onehealthcommission.org/en/eventscalendar/one_health_education_online_conference/ https://www.onehealthcommission.org/en/eventscalendar/one_health_education_online_conference/ http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html https://www.wwf.or.jp/activities/lib/lpr/wwf_lpr_2014.pdf http://lab.arstubiedriba.lv/wmj/vol62/december-2016/#page=44 http://www.un.org/apps/news/story.asp?newsid=55360#.wo3xddqrjkg lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 17 appendix i – participants in the one health education conference and survey (respondents to the survey who identified themselves included) james akpablie claire b. andreasen, iowa state university, college of veterinary medicine olutayo babalobi, one health nigeria christopher birt isabelle bolon bonnie buntain, university of arizona, school of veterinary medicine bill burdick peter cowen, north carolina state university stephen dorey, commonwealth secretariat, health and education unit eliudi eliakimu nirmal kumar ganguly, national institute of immunology, department of biotechnology, india julie gerland, noble institution for environmental peace, chief un representative aja godwin ralf graves michael huang lai jiang, institute of tropical medicine, belgium bruce kaplan, one health initiative getnet mitike kassie gretchen kaufman, one health education task force ulrich laaser sultana ladhani, commonwealth secretariat zohar lederman, national university singapore joann lindenmayer, one health commission jill lueddeke george lueddeke, one health education task force pamela luna donald noah, one health center, director martha nowak, kansas state university, olathe chris olsen, university of wisconsin olajide olutayo amina osman, commonwealth secretariat, health and education unit steven a. osofsky, cornell university bhavisha patel nikola piesinger, mission rabies, uk, education officer kristen pogreba-brown peter rabinowitz, university of washington vickie ramirez, university of washington ralph richardson, kansas state university, olathe, dean/ceo raphael ruiz de castaneda, institute of global health, oh unit, geneva laura schoenle richard seifman sara stone alexandru supeanu, one health romania http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 18 appendix ii – survey instrument the following survey was conducted by the one health education task force between october 16, 2016 and december 10, 2016 utilizing the survey monkey ® web based platform. introduction: the goal of this survey is to collect views on the importance of one health in preparation for an online pre-proposal conference scheduled for mid-november. survey feedback will help us define the parameters and design of a global one health-themed educational funding initiative, spearheaded by the one health commission in association with the one health initiative. the proposed project focuses on the development and support of one health (and well-being) curriculum materials, involving primarily k-12* teaching staff and education providers. the survey will help to identify ways of addressing challenges to successfully implement a number of pilot projects on a global scale. subsequent educational initiatives will address post-secondary and professional education. the survey will take approximately 20 minutes to complete. the survey employs the one health commission definition of one health: “one health is the collaborative effort of multiple health science professions, together with their related disciplines and institutions – working locally, nationally, and globally – to attain optimal health for people, domestic animals, wildlife, plants, and our environment.” *“k-12” is defined as organized pre-primary through secondary school education. we acknowledge that this is not uniform terminology around the world, but will use this term for convenience. survey questions objective 1: identifying complex issues/examples that can be used to address the drivers of one health challenges and can lead to sustainable solutions. 1) list 5 words that immediately come to mind when you think of one health (open question): 2) please rank the following types of sustainability from 1-5 in terms of their importance to one health (1=most important and 5=least important) a. ecological b. economic c. cultural/social d. ethical e. justicial (of or relating to justice, as opposed to judicial) 3) list 3-5 one health challenges that could be used to illustrate the need for a one health approach. include no more than one zoonotic disease. 4) please choose what you believe are the 5 most important contributing factors to the development of one health challenges (not limited to disease transmission) that should be considered in developing preventive policies or sustainable solutions or those challenges: a) lack of knowledge/understanding b) lack of methods and tools to investigate complex problems c) lack of uniform standards for information management and sharing d) compartmentalization of health services and policies e) lack of funding streams that encourage collaboration and provide support for one health initiatives f) overemphasis of treatment of individuals (human and animal) at the expense of preventive medicine and population health http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 19 g) overemphasis of human health at the expense of animal and environmental health h) human population growth and development i) poverty, distribution of wealth, inequity j) political systems that support individual/corporate interests above all else k) globalization in the absence of global standards of practice l) short-term decision/policy horizons m) over-exploitation of natural resources n) tribalism o) climate change p) otheropen ended objective 2: meeting the un sustainable development goals thru one health-themed education (http://www.un.org/sustainable-deevelopment-goals/). 5) how well do you think a one health-themed k-12 education program relates to each of the following sdgs (1=not at all related and 5=highly related)? a) end poverty in all its forms everywhere b) end hunger, achieve food security and improved nutrition and promote sustainable agriculture c) ensure health lives and promote well-being for all at all ages d) insure equitable and inclusive quality education and promote lifelong learning opportunities for all e) achieve gender equality and empower all women and girls f) ensure availability and sustainable management of water and sanitation for all g) ensure access to affordable, reliable, sustainable and modern energy for all h) promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all i) build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation j) reduce inequality within and among countries k) make cities and human settlements inclusive, safe, resilient and sustainable l) ensure sustainable consumption and production patterns m) take urgent action to combat climate change and its impacts n) conserve and sustainably use the oceans, seas and marine resources for sustainable development o) protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification and halt and reverse land degradation and halt biodiversity loss p) promote peaceful and inclusive societies for sustainable development, provide access to justice for all, and build effective and accountable, inclusive institutions at all levels q) strengthen the means of implementation and revitalize the global partnership for sustainable development 6) are there other sustainability goals that you think should be included (open-ended): objective 3: identifying values and principles that underlie a global one health approach towards health and well-being for the planet. http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 20 7) which one of the following graphical representations best captures the values and principles of one health? f) none of the representations are satisfactory 8) which of the following values do you think are essential to the application of one health? (please select all that apply)  balance  community  compassion  competence  compromise  cooperation  diversity/biodiversity  empathy  experience  freedom  growth  humility  integrity  justice/fairness  leadership  mindfulness  reason  resilience  respect  responsibility  rigor  self-awareness  sustainability  synergy  tolerance  transparency  understanding  vision  other (open ended) 9) to what degree do you agree with each of the following statements as it relates to one health, where 1=strongly disagree and 5=strongly agree? a) when you optimize health for one species, health for others is marginalized or eliminated. b) one health should be practiced so that there is no net (ecosystem) loss of biological diversity. c) the health of humans, other animal species and plants cannot be separated. http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 21 d) one health recognizes the intrinsic value of life on earth (plants, animals, microbes) regardless of a direct benefit to humans. e) “environment” includes natural and built environments. f) one health embraces the value of social interaction as a critical component of health and well-being. g) humans have a moral imperative to address one health challenges. h) ecological, economic, social/cultural, ethical and justicial sustainability are equally important for one health. i) the world health organization defines “health” as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” this definition also applies to other animals and ecosystems. j) other (open ended). objective 4: designing a global one health-themed k-12 educational program that supports innovation by educators and learners. 10) in your experience, to what extent are students currently exposed to concepts related to one health (including well-being) where 1=not at all exposed and 5=highly exposed? a) pre-primary education b) primary education secondary education c) college and university education d) adult education e) other (open ended) 11) how important is it that students are introduced to one health concepts in the educational curriculum at the following educational levels, where 1=not at all important and 5=highly important? a) pre-primary school b) primary school c) middle school d) high school 12) in what types of schools would you pilot a one health-themed curriculum, understanding that not all school types are found in every country (please select all that apply)? a) publicly-funded schools b) privately-funded schools c) magnet schools d) charter schools e) independent schools f) home school networks g) extra-curricular education (after school) h) summer school or camps i) colleges or universities j) other (open ended) 13) what broad-based skills should students learn through a one healththemed educational program (please select any that apply)? a) collaboration b) communication to diverse audiences c) concept mapping d) conservation http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 22 e) experimental design/methods/inquiry f) goal-setting g) interdisciplinary thinking h) leadership i) problem-solving j) systems thinking k) team-building l) other (open ended) 14) to what extent should students be exposed to the following concepts in a one healththemed educational program, where 1=not at all exposed and 5=highly exposed? a) role of natural and built environments in human and animal health and well-being b) respect for natural systems and human responsibility for planetary health c) the connection between well-being and mental/physical health d) personal responsibility – how individual actions impact one health e) corporate, political and societal responsibility – how their actions impact one health f) climate change and health of the planet g) environmental contexts of one health issues h) staying healthy and making good choices for the environment i) “cradle-to-grave” thinking j) other (open ended) 15) in your opinion, what are 3 main barriers to incorporating a one health-themed program in k-12 education in your country (open ended)? 16) what do you believe should be some long term outcomes (how might it change the knowledge, understanding, attitudes or behaviors of students) of a one health-themed curriculum (open ended)? objective 5: identifying challenges that must be addressed for a proposal to be funded 17) what educational stakeholder sectors (e.g. state, private, other) should be represented in developing the concept of a one health-themed education initiative into a successfullyfunded proposal (open ended)? 18) please suggest up to 3 funding organizations that might support implementation of a one health -themed education initiative (open ended). 19) please list up to 3 major logistical challenges to scaling up a k-12 one health curriculum to a global stage (open ended)? 20) please provide any other comments or suggestions (open ended). __________________________________________________________ © 2017 lueddeke et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 analysis of the liberian health policy kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 1 original article the status of health services in the 15 counties of liberia roland y. kesselly 1 , nuaker k. kwenah 1 , ernest gonyon 1 , stephen byepu 2 , luke bawo 1 , george jacobs 1 , justin korvayan 1 , melanie s. graeser 1 , moses kortoyassah galakpai 3 , sandford wesseh 1 , ulrich laaser 4 1 ministry of health, monrovia, liberia; 2 inha university, incheon, korea; 3 epos, bad homburg, germany; 4 university of bielefeld, germany. corresponding author: prof. dr. med. ulrich laaser dtm&h, mph address: university of bielefeld, faculty of health sciences, pob 10 01 31, d 33501 bielefeld, germany; email: ulrich.laaser@uni-bielefeld.de kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 2 abstract aim: liberia, situated at the west african coast, is composed of 15 counties with an economic gradient steeply decreasing from the northwest to the southeast. health-related activities by government action in the 15 counties concentrate on the areas of family planning, antenatal and delivery care, as well as immunization, health workforce and infrastructure. the differences in this regard between the 15 liberian counties will be reviewed. methods: a narrative review is employed, making use of the recent international and national documents, relevant literature and available information from the following primary and secondary sources and databases. results: the results point to gross differences between the 15 counties of liberia in terms of health service provision. the overall readiness based on defined indicators for all 701 facilities was 59% with a range between facilities at the level of counties of 50% to 65%; for family planning services 88% (range 65% – 100%); for antenatal care 62% (range 55% – 100%); for immunization coverage 76% (range 66% – 86%). the health workforce of liberia comprises 11.8 health workers per 10.000 population, who target is 23, the counties range from 8.0 to 15.7. similarly, according to who standards, there should be 2 health facilities per 10.000 inhabitants, liberia comes up to 1.9 however the counties range from 1.1 – 3.0 per 10.000. conclusions: it is obvious that across almost all areas of women and child health and health services in general there exist large differences between counties, which points to considerable health inequities in this country. the government of liberia should consider reallocating the available resources per number of population instead of accepting historical developments, however with a correction factor in favour of disadvantaged regions and population groups. keywords: africa, health services, liberia, narrative review. conflict of interest: none. acknowledgements: the authors are grateful to richard gargli and roosevelt mccaco in monrovia, liberia for their help in identifying the relevant publications. kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 3 introduction liberia is one of the smaller west african countries, situated at the atlantic coast with a rainy season of approximately 6 months from mid-march to mid-october. together with the neighbouring countries sierra leone and guinea liberia experienced in 2014/15 the devastating effects of the ebola epidemic. the 4.5 million inhabitants – descendants of liberated american slaves with a majority indigenous tribal populations – are concentrated with more than 1 million in the capital monrovia in the central county of montserrado. there are 15 more or less populated counties with an economic gradient decreasing from the northwest to the southeast. with this paper we refer to the 2005 paris declaration on aid effectiveness and the 2011 busan partnership agreement (1) as well as the international health partnership for universal health coverage (uhc) 2030 (2). coverage of essential health services according to uhc relates to 4 categories: 1) reproductive, maternal, newborn and child health, 2) infectious diseases, 3) noncommunicable diseases, and 4) service capacity and access to services. the index of uhc presents an average coverage for 16 tracer indicators across the four categories, adjusted for coverage of the most disadvantaged population (3). during the first meeting of the uhc-2030 working group in march 2017 (4), the main focus was on low and middle-income countries facing ―a number of critical pressures on their health systems‖. some of these are particularly salient for countries that are currently or will soon be ―transitioning to much lower levels of external financial support‖. in preparation of the aforementioned situation, the ministry of health of liberia has established a health sector coordinating committee serving as a regulator to the already established pool fund with five donors since 2008. nevertheless, a significant amount of donor support which constitutes about 75% (5) remains off-budget with various parallel implementation arrangements. in our review, we focus on the intra-country differences of health services between the 15 liberian counties. methods the authors employed a narrative review, making use of the recent international and national documents, relevant literature and available information from the following primary and secondary sources and databases: a) published liberian documents including policies, strategies, plans, programs and reviews of the ministry of health and government of liberia; the most recent situation analysis is presented in the ―liberia service availability and readiness assessment and quality of care report (sara and qoc) (6), while the most recent documents covering mnh policy implementation are the ―joint annual health sector review report 2016‖(7) and the ―consolidated operational plan (fy 2016/17)‖(8). b) publications in the area of routine health statistics including population census and household surveys developed by the liberia institute of statistics and geo-information services with partners (2008 population and housing census, liberia demographic and health survey 2000, 2007, 2013), national e-databases with administrative data of liberia health information management system (dhis2) and international e-databases (who, unicef, unfpa, world bank group and the united nations population division, un inter-agency group for child mortality estimation) for purpose of comparison; kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 4 c) published reviews, scientific and professional articles on liberian maternal and new-born health in international journals, national surveys and project reports of international organizations (who, eu, world bank, unicef, unfpa) that deal with issues of women‘s and new-born health in liberia. results demonstration how resilience can be built after health crises like the ebola epidemic has been recently presented in several scientific papers (9-11). however, the purpose of the liberian actions in the field of health is to monitor progress throughout the implementation period of defined activities and achievements, following expressions in the investment plan (12). the purpose is described as building a resilient health system through: (a) improved access to safe and quality health services, (b) health emergency risk management, and (c) enabling environment and restoring trust. general services availability and readiness in 2016, based on the who sara report (6) encompasses assessment of basic amenities, basic equipment, and standard precautions for infectious disease prevention, diagnostics, and essential medicines by involving particular tracer items. the overall readiness to provide general health services in 701 facilities was 59%, while the best situation at the national level was found for basic equipment (77%), followed by standard precautions for prevention of infections (73%), basic amenities (57%), essential medicines (44%), and availability of diagnostics (42%). however, liberia‘s 15 counties differ significantly in their capacity to deliver basic health services (figure 1). the worst situation regarding general service readiness is found in bassa, maryland and sinoe (each county with only half of facilities ready to perform a comprehensive basic health services). the best situation is found in grand cape (65% readiness for general services), followed by bomi (64%), rivercess and grand kru (each 62%). diagnostics, which has included availability of 8 tracer items, (among them malaria and hiv diagnostic capacity, urine test for pregnancy), was the worst in maryland (only 24% of facilities were ready), followed by sinoe (27%) and bassa (readiness was 29%). nevertheless, it is worthwhile to mention that tracer items for malaria diagnostics were mostly present – in average in 88% of facilities with the least readiness interestingly in montserrado (51%). the uhc approach (13) embraces the following 4 core groups of indicators: 1. reproductive and newborn health (indicators adopted in liberia for family planning, four or more visits for antenatal care, skilled birth attendance and coverage of pregnant women with ipt). with regard to family planning, now in liberia defined as ‗number of total couple year protection (all methods), the indicator should be redefined according to the uhc approach as: ‗proportion of married or in union women of reproductive age who have their need for family planning satisfied with modern methods‘. kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 5 figure 1. general service availability and readiness (as percentage) in liberian counties (in total 701 health facilities were assessed) source of data: ministry of health, republic of liberia. liberia service availability and readiness assessment (sara) and quality of care report, 2016: pages 137-138. 2. child immunization (in liberia: ‗fully immunized infants‘). the corresponding uhc indicator is defined as: ‗dtp3 immunization coverage among 1-year olds‘. 3. infectious disease (in liberia: ‗antiretroviral therapy (art) for hiv positive pregnant women‘ and ‗tuberculosis (tb) detection rate‘. instead more appropriate: ‗utilization of tb treatment‘. 4. major social determinants of the population‘s health status as e.g. improved water sources and improved sanitary facilities. looking at these indicators planned to measure implementation throughout national health policies, it is not possible to track all tracer indicators and to calculate the index of uhc. nevertheless, international, as well as national databases contain values for the main indicators of relevance. the following sections describe availability and readiness for selected health services with a focus on the uhc priority of mother and new-born health (mnh): 81 75 77 86 69 79 74 7779 77 71 89 70 80 88 0 10 20 30 40 50 60 70 80 90 100 bomi bong bassa grand cape mount grand gedeh grand kru lofa margibimaryland montserr ado nimba rivercess sinoe river gee gbarpolu basic amenities basic equipment standard precautions diagnostics essential medicines kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 6 1) family planning despite 88% of health facilities are offering family planning services, still there are significant disparities in the availability between counties (figure 2). astonishingly, this service is more available in rural than in urban areas (97% versus 70%) and significantly more in government/ public facilities (97%) in comparison to private (62%) and mission/faith based facilities (60%). family planning readiness, in general 73%, is less present measured by availability of particular tracers: guidelines, check-lists, trained staff, and different modern methods of contraception. a particularly small number of facilities, only 14%, indicated to have at least one trained staff in the past two years for application of family planning counseling. figure 2. family planning – availability and readiness of services in counties as percentage (701 health facilities) source: ministry of health, republic of liberia. liberia service availability and readiness assessment (sara)and quality of care report, 2016: pages 143-144. 2) antenatal care: the next important uhc tracer indicator is antenatal and delivery care (14). routine antenatal care (anc) is clearly important for the health of the mother and her baby, but it also provides an important access point to the health-care system for pregnant women, and may include vaccination against tetanus, screening and treatment for high blood pressure, diabetes, anaemia, hiv, malaria and sexually transmitted diseases, dissemination of information on topics such as postpartum contraception and breastfeeding, and ultimately linkage to care during delivery. based on the sara assessment in 2016 liberia, in average, is doing well with 90% of facilities offering antenatal care, while 6 counties (bassa, grand cape, grand kru, rivercess, river gee, and gbarpolu) reported that all facilities are performing antenatal services and almost all have 84 79 80 74 70 81 80 7876 64 68 81 67 72 75 0 10 20 30 40 50 60 70 80 90 100 bomi bong grand bassa grand cape mount grand gedeh grand kru lofa margibimaryland montserrado nimba rivercess sinoe river gee gbarpolu facilities offering family planning family planning readiness kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 7 tracer items available: iron and folic acid supplementation, intermittent preventive therapy, tetanus toxoid vaccination, and monitoring for hypertensive disorders of pregnancy (figure3). figure 3. availability and readiness of antenatal care services in counties as percentage (701 health facilities) source: ministry of health, republic of liberia. liberia service availability and readiness assessment (sara) and quality of care report, 2016: pages 149-150. geographical location is also a factor with one third of world‘s countries having anc4 coverage at least 20% higher in urban than rural areas. in liberia the situation is, according to the recent assessment in 2016, opposite: 75% of urban facilities are offering antenatal care in contrast to 98% of rural facilities. even more: the most urbanized environment in liberia – montserrado county has the least availability and readiness of antenatal services (70% and 55% respectively). in general, the readiness in other areas expressed as availability of staff, guidelines, equipment, diagnostics, and medicines and commodities is considerably less. at the national level 62% of facilities are not fully ready to deliver antenatal care, predominantly due to the lack of diagnostics (only 27% of facilities are ready regarding diagnostics) followed by staff and guidelines (40% answered positively) (6). tracer items in diagnostics, which are the most problematic and contribute to the low readiness, were: haemoglobin test (available only in 12% of facilities) and urine dipstick protein test (availability of 42%). similar to the family planning services – low presence of continuing professional development (cpd) of staff is contributing to lower readiness of antenatal health services. only 15% of facilities had at least one trained staff in the two past years for antenatal care. so far, it seems that the availability of a well trained workforce in this field is still insufficient. 72 61 66 53 68 70 67 6769 55 57 75 62 62 60 0 10 20 30 40 50 60 70 80 90 100 bomi bong grand bassa grand cape mount grand gedeh grand kru lofa margibimaryland montserrado nimba rivercess sinoe river gee gbarpolu availability readiness score kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 8 3) immunization of children universal immunization is a core of one of uhc‘s objectives, and a key focus of global initiatives. notably, the global vaccine action plan (gvap) 2011–2020, which aims to achieve at least 90% national coverage by 2020 and at least 80% vaccination coverage in every district or equivalent administrative unit for all vaccines in national immunization programs is yet to reach the full target as planned. according to the sara report (6), liberia still did not reach this threshold with an average 82% of health facilities offering child immunization and an average readiness score of 76% of facilities out of 701. while in international statistics immunization coverage is at the level of 52% for liberia in 2015, the national figure for the same year is above 60%. such discrepancies can be a consequence of different definition of indicators or quality of the data. nevertheless, moh is reporting decrease in immunization for the two years stricken with evd (15). the investment plan has a target of 91% fully immunized infants and the real progress will be monitored during the population survey dhs 2018. only five counties (bomi, bong, rivercess, sinoe and gbarpolu) have readiness scores proposed as threshold in the uhc approach above 80% although all counties, except one, have health facilities stated to offer child immunization in average above 80%. extreme outlier is the highly populated montserrado county, where only 54% out of 261 health facilities offer immunization services with a readiness score of 70%. their readiness score encompasses (1) staff and guidelines, (2) equipment, and (3) medicines and commodities. one of the possible reasons could be the generally lower commitment to child immunization services in urban counties (only 61% are offering this service with 71% readiness). the same is the case regarding low immunization services offered by mission/ faith based health facilities, ngo/notfor-profit and particularly private-for-profit health facilities – possibly because they are more clinically oriented. while government/public facilities are offering immunization service in 95% of cases, private-for-profit institutions are doing so only in 47% of 235 registered facilities. regarding readiness score counties are more equalized (reaching from 66% to 86%) (figure 4). figure 4. availability and readiness of child immunization services in counties as percentage (701 health facilities) kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 9 source: ministry of health, republic of liberia. liberia service availability and readiness assessment (sara) and quality of care report, 2016. pages 147-148. the infrastructure regarding workforce, facilities and equipment is analysed in the following sections 5-7. 5) health workforce the investment plan 2015-2021 placed the health workforce as the first investment area: ―to build a fit-for-purpose productive and motivated health workforce that equitably and optimally delivers quality services‖ (16). despite, the pull of human resources for health was heavily hit by the ebola crisis, when 372 health workers obtained the disease and even 184 died (as of april 08 2015)(17), following the 2015/2016 health workforce census, the total number of health workers of 16,064(18) have exceeded the number projected in the national health and social welfare plan 2011-2021(19) and the national human resources policy and plan for health and social welfare 20112021(20), which aimed at 15,626 in 2021 for the population projected to be 4,555,985 in the same year. however, the actual composition of workforce does not follow the same positive path. if we look exclusively at the physician, physician assistants, registered nurses, certified midwifes and nursemidwifes, we would expect to see following the cited plans – more than 6,294 health workers and not as in reality only 4,756 of them placed on the governments payroll. that means, liberia still has to cover a 24% deficit of the nationally projected number of the core health workforce. the biggest deficit is with physician assistants, liberia is still missing 48% of the projected number for 2021, followed by physicians with deficit of 44%. the least deficit is with registered nurses, certified midwifes and nurse-midwifes – 20%. 81 80 66 79 73 75 75 79 75 70 73 86 82 75 84 0 10 20 30 40 50 60 70 80 90 100 bomi bong grand bassa grand cape mount grand gedeh grand kru lofa margibimaryland montserrado nimba rivercess sinoe river gee gbarpolu availability readiness score kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 10 if we look at the who‘s threshold of 23 health workers per 10,000 population, then liberia would need to speed up to reach the total number of 10,479 core health workforce. in other words, still 55% of health workforce is missing in comparison to the who threshold. achieving the sdg threshold of 44.5 per 10.000 would be even more unlikely. the global strategy on human resources for health ―workforce 2030‖ underlines the required progress towards uhc by strengthening health workforce (21). at the same time, inequitable distribution per 15 counties is remarkable and fluctuation of workforce is significant from year to year (figure 5). commitment to strengthen workforce for health in liberia by increasing investment through country resources is remarkable looking at the staff on payroll. the percentage of health workers placed on the national budget payroll increased from 58% in 2015 to 68% (7,214 out of 10,672 employed in governmental/ public health facilities) in 2016. kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 11 figure 5. density of health workforce by counties – health professionals per 10,000 population data sources merged: 1. ministry of health, republic of liberia. investment plan for building a resilient health system 2015 to 2021. monrovia, liberia: ministry of health, 2015. pages 8-35. 2. ministry of health republic of liberia. joint annual health sector review report 2016. . monrovia, liberia: ministry of health, 2016. page 44. available from: http://www.seejph.com/public/books/joint_annual_health_sector_review_report_2016.pdf [cited 2017 july 30] 6) construction of health facilities while lack of access to health services continues to be of major concern and central tenet of uhc, in many parts of the world, there are several forms of barriers, the most obvious being the lack of quality health services; but there are also obstacles such as a deficit of numbers of health facilities and distance to the nearest one (22). the who global threshold for health facilities is 2 per 10,000 population, while there is no set target for the indicator ―percentage of population living within 5 kilometres from nearest health facility‖ (national target for 2021 in liberia is 85%). figure 6 presents the density of public and private health facilities per 10,000 population. though, mal-distribution of health facilities by counties is still obvious, even six counties exceeded who threshold of 2 per 10,000 already in 2015, and the same situation appeared in 2016: sinoe, grand kru, rivercess, river gee, bomi and grand cape. in comparison to 2015, critical shortage of health facilities has decreased, however still three counties – bong, nimba and grand bassa have extremely low health facilities‘ density being <1.5 per 10,000 population. 15.7 14.9 12.3 12.2 11.5 11.4 11.3 11.2 9.9 9.9 9.5 9.4 9.2 8.5 8 11.8 8.6 6.3 14 23 0 5 10 15 20 25 2016 2015 2010 kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 12 kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 13 figure 6. health facilities’ density per 10,000 population by counties sources: 1. ministry of health, republic of liberia. investment plan for building a resilient health system 2015 to 2021. monrovia, liberia: ministry of health, 2015: page 7. available from: http://moh.gov.lr/cabinet-endorses-investment-plan-for-building-a-resilient-healthsystem/ [cited 2017 mar 17] 2. ministry of health republic of liberia. joint annual health sector review report 2016. . monrovia, liberia: ministry of health, 2016. page 54. available from: http://www.seejph.com/public/books/joint_annual_health_sector_review_report_2016.pdf [cited 2017 july 30] one example is county nimba. the projected figure of 70 public health facilities is not enough to reach a density of 2 per 10,000 population; in fact it would be necessary to have 121 facilities in this county. as of 2016, nimba has 68 public and private health facilities and therefore still 53 functional health institutions are missing in order to reach who‘s threshold. in 2011, moh reported 550 opened health facilities (378 public and 172 private) (23), while in the 2016 health sector performance report 727 health facilities were listed (out of 701 directly assessed: 437 public; 216 private-for-profit and 48 private-not-for-profit – together 264) (24). whereas in 2011, liberian health policy set out a projection of 543 public health facilities to be reached up to 2021with reference to the who‘s threshold of 2 functional health facilities per 10,000 population liberia would need a total of 911 health facilities serving the projected number of population being 4,555,985 in 2021. in conclusion liberia needs in addition to the 543 public facilities projected by gol and the 264 private ones, pre-existing in 2011 a number of 211 additional facilities, either public or private. 7) availability of equipment 2.8 2.5 2.2 2.2 2.5 2.2 1.9 1.7 1.4 1.2 1.5 1 1.2 1.1 1.6 3 2.9 2.3 2.3 2.2 2.2 1.9 1.8 1.6 1.6 1.6 1.2 1.2 1.1 1.9 2 0 0.5 1 1.5 2 2.5 3 3.5 2015 2016 kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 14 at this stage of implementation, the envisioned inventory of equipment and a comprehensive maintenance plan for facilities and equipment are still missing. with significant differences between counties, basic equipment is ready in 77% of 701 health facilities, however only 19% of facilities have all items (adult and child scale, thermometer, stethoscope, blood pressure apparatus, light source). while margibi and montserrado have problems with child scales, dramatic problems with light sources are reported in five counties which have less than 20% of facilities with permanent electricity: maryland, sinoe, river gee, grand kru and grand gedeh (6). discussion in spite of the described deficits liberia‘s position with regard to the 15 west-african countries is acceptable for a country after civil war and ebola epidemic (25). the health related sdg index for liberia is 33 i.e. the 9 th position where niger is the 15 th with a value of 23 and neighbouring sierra leone 13 th with 27. ghana takes the 2 nd position with 43 and capo verde islands the first with 53 (26). although the validity of the data used here may be questioned to some degree it is obvious that across almost all areas of women and child health and health services in general considerable differences between counties can be identified (even with regard to basic immunizations) which points to considerable health inequities in this country. the most impressive ones are demonstrated in figures 5 and 6 regarding the density of staff – ranging in 2016 from 8.0 to 15.7 and facilities per population ranging the same year from 1.1 to 3.0 per 10.000 population. whereas the national average of the number of facilities is close to the who recommendation of 2.0 facilities per 10.000 population, the number of staff in average is far below i.e. 11.8 vs. 23.0 with an interim goal of 14 per 10.000 in 2021 (7). nevertheless, the recent health workforce census has identified once more the low motivation of health workers and their deep frustration regarding financial incentives together with insufficient possibilities for professional development (27). this demonstrates very clearly that investments should go with priority into education and continuing training of qualified staff, paid regularly and reliably, especially registered midwifes (28). furthermore the poor infrastructure in liberia (lack of roads, electricity, water and sanitation) and the devastating economic situation appear to be the main threats to the health system in general (personal communications). in addition to the availability of sufficient health facilities, their staffing and quality of services, also accessibility in terms of distances and road quality are of highest relevance. the investment plan 2015-2021 set a percentage of population living within 5 km from the nearest health facility (approximately within one hour of walking distance). in 2016 71% of all liberian citizens have access within 5 kilometers of their place of living. nevertheless, liberia is yet to reach the nationally projected target of 85%. in addition, there are significant disparities across counties, with gbarpolu having only 32% of population with nearby access and montserrado with 96% respectively (29). in order to obtain more reliable estimates of the main health indicators across the liberian health sector, the government of liberia is preparing in collaboration with international partners -the next generation of demographic and health surveys together with the population census for the year 2018. kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 15 conclusions the ministry of health has the responsibility to take care of effective extension of coverage of health services to the entire population in liberia. one key instrument is transparent investment, i.e. timely and accurate reporting of local and international donor agencies including implementing partners and correspondingly to reallocate the available resources per number of population instead of accepting historical developments, however with a correction factor in favour of disadvantaged regions and population groups. references 1. world health organization. tracking universal health coverage: first global monitoring report. geneva: who, 2015. 2. international health partnership for uhc 2030. available from: https://www.internationalhealthpartnership.net/en/ (accessed: april 29, 2017). 3. world health organization. global tracking uhc report. geneva: world health organization and world bank 2016. 4. first meeting of uhc2030 working group on sustainability, transition from aid and health system strengthening. available from: https://www.internationalhealthpartnership.net/en/news-videos/article/first-meeting-ofuhc2030-working-group-on-sustainability-transition-from-aid-and-health-systemstrengthening-401839/ (accessed: april 29, 2017). 5. international health partnership for uhc 2030. available from: http://www.nationalplanningcycles.org/planning-cycle/lbr/ (accessed: april 29, 2017). 6. ministry of health. liberia service availability and readiness assessment (sara) and quality of care report. monrovia, liberia: ministry of health, 2016 oct. 7. ministry of health. joint annual health sector review report 2016. national health sector investment plan for building a resilient health system. monrovia, liberia: ministry of health, 2016 nov. 8. ministry of health, republic of liberia. consolidated operational plan (fy 2016/17). monrovia, liberia: ministry of health, 2016 sept. 9. kruk me, ling ej, bitton a, cammett m, cavanaugh k, chopra m, et al. building resilient health systems: a proposal for a resilience index. bmj 2017;357:j2323. doi: 10.1136/bmj.j2323. 10. luckow pw, kenny a, white e, ballard m, dorr l, erlandson k, et al. implementation research on community health workers‘ provision of maternal and child health services in rural liberia. bull world health organ 2017;95:113-20. doi: http://dx.doi.org/10.2471/blt.16.175513 11. shoman h, karafillakis e, rawaf s. the link between the west african ebola outbreak and health systems in guinea, liberia and sierra leone: a systematic review. global health 2017;13:1. doi 10.1186/s12992-016-0224-2. 12. ministry of health, republic of liberia. investment plan for building a resilient health system 2015 to 2021. monrovia, liberia: ministry of health, 2015:35. kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 16 13. world health organization. universal health coverage data portal. available from: http://apps.who.int/gho/cabinet/uhc.jsp (accessed: july 29, 2017). 14. who, wb. tracking universal health coverage. first global monitoring report. geneva: who department of health statistics and information systems 2015. 15. ministry of health, republic of liberia. health annual report 2015. monrovia, liberia: ministry of health, 2015. 16. ministry of health, republic of liberia. investment plan for building a resilient health system 2015 to 2021. monrovia, liberia: ministry of health, 2015:8-35. 17. un economic and social council. progress towards sustainable development goals. report of the secretary general. e/2016/75. available from: http://undocs.org/e/2016/75 (accessed: july 29, 2017). 18. ministry of health republic of liberia. joint annual health sector review report 2016. monrovia, liberia: ministry of health, 2016:43-50. available from: http://www.seejph.com/public/books/joint_annual_health_sector_review_report_2016 .pdf (accessed: july 30, 2017). 19. ministry of health and social welfare, republic of liberia. national health and social welfare policy and plan 2011-2021. monrovia, liberia: ministry of health and social welfare, 2010:59-61. available from: http://moh.gov.lr/category/policies/ (accessed: july 30, 2017). 20. ministry of health and social welfare, republic of liberia. national human resources policy and plan for health and social welfare 2011-2021. monrovia, liberia: ministry of health and social welfare, 2010:59-61. available from: http://moh.gov.lr/category/policies/ (accessed: july 30, 2017). 21. who. global strategy on human resources for health: workforce 2030. geneva: who document production services, 2016. available from: http://apps.who.int/iris/bitstream/10665/250368/1/9789241511131-eng.pdf?ua=1 (accessed: july 31, 2017). 22. who, wb. tracking universal health coverage. first global monitoring report. geneva: world health organization. available from: http://www.who.int/healthinfo/universal_health_coverage/report/2015/en/ (accessed: july 31, 2017). 23. ministry of health and social welfare, republic of liberia. national human resources policy and plan for health and social welfare 2011-2021. monrovia, liberia: ministry of health and social welfare, 2010: 7. available from: http://moh.gov.lr/category/policies/ (accessed: july 30, 2017). 24. ministry of health republic of liberia. joint annual health sector review report 2016. monrovia, liberia: ministry of health, 2016:53. available from: http://www.seejph.com/public/books/joint_annual_health_sector_review_report_2016 .pdf (accessed: july 31, 2017). 25. taylor a. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003. seejph 2017;8. doi 10.4119/unibi/seejph-2017-155. http://undocs.org/e/2016/75 kesselly ry, kwenah nk, gonyon e, byepu s, bawo l, jacobs g, korvayan j, graeser ms, galakpai mk, wesseh s, laaser u. the status of health services in the 15 counties of liberia (original article). seejph 2018, posted: 14june 2018. doi 10.4119/unibi/seejph-2018-190 17 26. gdb 2015 sdg collaborators. measuring the health related sustainable development goals in 188 countries: a baseline analysis from the global burden of disease study 2015. lancet 2016;388:1813-50. 27. ministry of health republic of liberia. joint annual health sector review report 2016. monrovia, liberia: ministry of health, 2016:48. available from: http://www.seejph.com/public/books/joint_annual_health_sector_review_report_2016 .pdf (accessed: july 31, 2017). 28. michel-schuldt m, dayon mb, klar rt, subah m, king-lincoln e, kpangbala-flomo c, et al. continuous professional development of liberia's midwifery workforce—a coordinated multi-stakeholder approach. midwifery 2018;62:77-80. 29. ministry of health republic of liberia. joint annual health sector review report 2016. monrovia, liberia: ministry of health, 2016:52. available from: http://www.seejph.com/public/books/joint_annual_health_sector_review_report_2016 .pdf (accessed: july 30, 2017). ______________________________________________________________________________________ © 2018 kesselly et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. public health perspective levett j. albanian castles in defence of balkan public health (public health perspective). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-06. 1 public health perspective albanian castles in defence of balkan public health jeffrey levett1 1 the national school of public health, athens, greece. corresponding author: prof. dr. jeffrey levett, national school of public health; address: ilia rogakou 2, athens 106 72, greece; telephone: +302103641607; email: jeffrey.levett@gmail.com levett j. albanian castles in defence of balkan public health (public health perspective). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-06. 2 public health is a rare lamp that can push back the dark shadows of vulnerability, misfortune and poverty in our increasingly complex world. in the balkans (south eastern europe, see) its wick must be turned up and its bright flame lengthened. political support can provide oil to fuel its lamp. health diplomacy and the principles of human security can be useful tools (1,2). when the political will falters or is subverted health damage may result. the world health organization (who) and the council of europe called attention to the growth of population vulnerability and the declining health status in the balkans. together and within the context of the stability pact, they targeted social cohesion. one outcome was the dubrovnik pledge, a political agreement that made a commitment to regional health development by meeting the health needs of vulnerable populations. country projects relating for example to infectious diseases (albania), nutrition (serbia), mental health (bih) and emergency medical services (fyrom) were additional outcomes. another outcome was the network for public health for southeast europe (ph-see) (3). this network has an impressive list of publications covering a wide range of subject materials and books for students and has addressed the development of schools of public health and the need for a health curriculum for peace (4). most recently it launched this journal, the south eastern european journal of public health (seejph). the value system of public health is succinctly and differently expressed in the skopje declaration, for peace, public health and human rights (5) another outcome of the ph-see network. it was later adopted by the world federation of public health associations. in words and spirit of the skopje declaration our actions must “build a better balkan world, closer to the human heart’s desire”. public health emphasizes a cybernetic or systems principle: its improvement must be addressed using strategies and action plans that are multidimensional, interdisciplinary and strongly backed by adequate human resources, by considerable ingenuity and with policy instruments commensurate to the same level of complexity of the problem space. training for competence improvement of public health professionals and the strengthening of schools of public health is a regional priority embedded in the same principle. throughout the region the role of knowledge for development is being vigorously debated (6). the emergence of a balkan research culture will depend upon abundant light and enlightenment. progress in public health will depend on the existence of more autonomous institutions for research and education, mechanisms for accreditation and evaluation, which can include scientific journals, such as this one as well as competence to innovate and implement and direct education towards human development. a place in the new world will depend on science, truth and reconciliation as well as a rightful place for the balkans in europe. development must be inseparable from socio-economic reform, target better wages, housing, living and working conditions and promote health security, which equates to “freedom from want and freedom from fear” (7). by use of metaphor, we can say that the regional intellectual capacity of public health is expressed and in the launch of the seejph, much akin to a line of new albanian castles (from lezha to shkodra), which can stem the tide of greed and corruption and pave a way for regional health development by building on what went before. the seejph is a new vehicle for discussion and debate. it can help institutional renewal of public health, give a boost to investment in training for competence, promote levett j. albanian castles in defence of balkan public health (public health perspective). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-06. 3 policy implementation and the design of multidimensional action plans to ensure human safety and health protection. it must be prepared to break down academic barriers and build the public health community of the balkans. it should be positively viewed and strongly supported as a channel for change promotion. asclepios and his disciple hippocrates, father of western medicine, acted as change agents when they proclaimed: “we have an opinion, let’s discuss it, if the evidence warrants, let’s change it”. today we have evidence-based medicine, health technology assessment and frequently modified or changed clinical guidelines. half of what is true today will be questioned in the next few years. can we predict which half? do we have such good discriminators? a competent seejph can help. public health training has become less fragmented and now presents a more uniform profile. this process was aided by the establishment in the balkans of the association of schools of public health in the european region (aspher, zagreb, 1968) as a contact point, then as a hub for informational exchanges between related schools and institutions. aspher is a network of expertise whose functional links integrate training, science and public health policy and promote cooperation in europe and between regions and continents. over the past three decades the balkan region has courted disaster (8), suffered from economic sanctions, political upheavals, radioactive fallout (chernobyl), armed conflict, wars (bosnia and kosovo), socioeconomic disaster and ecological calamity as well as earthquakes, floods and most recently a creeping health disaster in greece of uncertain dynamics, a result of austerity measures imposed by the government, in response to the global financial crisis (9). in 2005, i suggested that “within an enlarging and safer europe, the language of health is key to a better future…. without adequate socio-economic management, population vulnerability can trigger a creeping social disaster” (10). where cultures, religions, and national languages come together as in the balkans, public health can be the common denominator for development. i have also argued that the region’s best future is its organization without borders and within a single european space (this was implicit in the apt phrase of the late tony judt: “border breaking, community making”). the outcome of any complex activity is hard if not impossible to predict. all we can hope for is that ingenuity and leadership will prevail, that balkan governments will provide public health governance within a competent infrastructure capable of monitoring success and failure and with effective corrective mechanisms for the righting of wrongs. in the balkans let’s now hope for frequent, significant ups with fewer, smaller downs. development of schools of public health, journals such as this and the recent return of the presidency of aspher, albeit temporarily to the region where it was born (see) are some significant ups (professor vesna begovic, serbia assumed the aspher presidency in 2013). let’s hope that a new moment for regional public health has come. if the balkans makes it in public health, it will make it in europe! failing to manage the health of the balkan region can have serious consequences for europe (11,12). europe without its cradle will not sleep well. endnote: the title is a tribute to extensive activities between greece and albania, conducted by the athens school of public health sponsored by the greek ministry of health. it gave the writer opportunities to mentor students, visit castles and archaeological sites, interact with many directors of the institute of public health, tirana, several ngo’s and hospitals, university staff, members of levett j. albanian castles in defence of balkan public health (public health perspective). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-06. 4 parliament as well as health ministers, two who the writer interacted with in prizren and belgrade and one who was honored by the school. projects were conducted throughout albania one funded through phare. the athens school is one of two schools inaugurated by eleftherios venizelos (1919, 1929). he initiated a short-lived revolution in public health, with the help of the international community. the school conducted the first balkan public health forum when the creation of schools in albania and serbia were also discussed (1992). references 1. togo t, levett j. health diplomacy as an aid to human security, 12th world congress on public health, istanbul, wfpha, 2009. 2. declaration on implementation of the human security concept in the balkan region. sixth ecpd conference, national and inter-ethnic reconciliation, religious tolerance and human security in the balkans, brioni island, croatia, 2011. 3. founded by ulrich laaser (bielefeld) and luka kovacic (zagreb) in 2000: forum for public health in south eastern europe (ph-see): programmes for training and research in public health. available from: http://www.snz.unizg.hr/ph-see/index.htm (accessed: january 11, 2014). 4. levett j. contributing to balkan public health: a school for skopje. croat med j 2002;43:117-25. 5. donev d, laaser u, levett j. south eastern european conference on public health and peace. skopje declaration on public health, peace & human rights, december 2001. croat med j 2002;43:105-6. 6. new knowledge for new development. skopje, manu, 7 october 2013, ecpd web-page. 7. undp principle on human security 1994, human security report 2012. 8. levett j, mavrokefalos p. disaster’s imprint on balkan region health, id: 44, 18th world congress on disaster and emergency medicine, manchester uk. may 2013. 9. levett j. from cradle of european civilization to grave austerity: does greece face a creeping health disaster? prehosp disaster med. 2013;28:1-2. 10. levett j, kyriopoulos j. public health in the balkan region: one school’s experience. eur j public health 2005;15:97-9. 11. stoianovich t. balkan worlds: the first and last europe. armonk, new york, and london, england: m.e. sharpe, 1994. 12. stavrianos ls. the balkans since 1453. new york: holt, rinehart, 1958. ___________________________________________________________ © 2014 levett; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed?term=donev%20d%5bauthor%5d&cauthor=true&cauthor_uid=11885032 http://www.ncbi.nlm.nih.gov/pubmed?term=laaser%20u%5bauthor%5d&cauthor=true&cauthor_uid=11885032 http://www.ncbi.nlm.nih.gov/pubmed?term=levett%20j%5bauthor%5d&cauthor=true&cauthor_uid=11885032 http://www.ncbi.nlm.nih.gov/pubmed?term=south%20eastern%20european%20conference%20on%20public%20health%20and%20peace%5bcorporate%20author%5d http://www.ncbi.nlm.nih.gov/pubmed?term=south%20eastern%20european%20conference%20on%20public%20health%20and%20peace%5bcorporate%20author%5d http://www.ncbi.nlm.nih.gov/pubmed/11885032 disaster nursing grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 1 review article nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review thomas grochtdreis 1,2 , nynke de jong 3 , niels harenberg 2 , stefan görres 2 , peter schröder-bäck 4,5 1 department of health economics and health services research, hamburg centre for health economics, university medical centre hamburg-eppendorf, hamburg, germany; 2 institute for public health and nursing science, university of bremen, bremen, germany; 3 department of educational development and research, school of health professions education, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 4 department of international health, caphri school for public health and primary care, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 5 faculty for human and health sciences, university of bremen, bremen, germany. corresponding author: thomas grochtdreis, department of health economics and health services research, hamburg centre for health economics, university medical centre hamburg-eppendorf; address: martinistr. 52, 20246 hamburg, germany; telephone: +49407410-52405; email: t.grochtdreis@uke.de grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 2 abstract aim: nurses play a central role in disaster preparedness and management, as well as in emergency response, in many countries over the world. care in a disaster environment is different from day-to-day nursing care and nurses have special needs during a disaster. however, disaster nursing education is seldom provided and a lack of curricula exists in many countries around the world. the aim of this literature review is to provide an overview of nurses‟ roles, knowledge and experience in national disaster preparedness and emergency response. methods: an electronic search was conducted using multiple literature databases. all items were included, regardless of the publication year. all abstracts were screened for relevance and a synthesis of evidence of relevant articles was undertaken. relevant information was extracted, summarized and categorized. out of 432 reviewed references, information of 68 articles was included in this review. results: the sub-themes of the first main theme (a) roles of nurses during emergency response include the expectations of the hospital and the public, general and special roles of nurses, assignments of medical tasks, special role during a pandemic influenza, role conflicts during a disaster, willingness to respond to a disaster. for (b) disaster preparedness knowledge of nurses, the corresponding sub-themes include the definition of a disaster, core competencies and curriculum, undergraduate nursing education and continuing education programs, disaster drills, training and exercises, preparedness. the sub-themes for the last theme (c) disaster experiences of nurses include the work environment, nursing care, feelings, stressors, willingness to respond as well as lessons learned and impacts. conclusion: there is consensus in the literature that nurses are key players in emergency response. however, no clear mandate for nurses exists concerning their tasks during a disaster. for a nurse, to be able to respond to a disaster, personal and professional preparedness, in terms of education and training, are central. the framework of disaster nursing competencies of the who and icn, broken down into national core competencies, will serve as a sufficient complement to the knowledge and skills of nurses already acquired through basic nursing curricula. during and after a disaster, attention should be applied to the work environment, feelings and stressors of nurses, not only to raise the willingness to respond to a disaster. where non-existent, national directives and concepts for disaster nursing should be developed and nurses should be aware of their duties. nursing educators should prepare nurses for disasters, by adjusting the curricula and by meeting the increased need for education and training in disaster nursing for all groups of nurses. the appropriateness of theoretical and practical preparation of disaster nursing competencies in undergraduate nursing courses and continuing education programmes should be evaluated. keywords: disasters, disaster planning, emergencies, emergency preparedness, nurses. conflicts of interest: thomas grochtdreis is a member of the german red cross and vice president of the german red cross youth. the other authors do not declare any conflicts of interest. grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 3 introduction disasters are defined by the centre for research on the epidemiology of disasters (cred) as “a situation or event, which overwhelms local capacity, necessitating a request to a national or international level for external assistance; an unforeseen and often sudden event that causes great damage, destruction and human suffering” (1). disasters are classified as natural, biological, geophysical, climatological, hydrological, meteorological, and technological (2). recent examples of major disasters are the earthquake in haiti in 2010 as an example of a natural disaster and the earthquake followed by a tsunami and the nuclear catastrophe in japan in 2011 as an example of a mixed natural and manmade disaster. within the countries of western europe, more than five million people have been affected by a variety of disaster types (e.g., 4,295,600 people affected by storms, 684,492 by floods, and 816 by epidemics) in the last 20 years. within this timeframe, 8,835 people were injured and 38,643 people were killed (3). in order to master a huge number of affected people due to a disaster within a short period, it is important to have well trained first-response personnel or volunteers. here, an essential role is allotted to nurses for integrating communicating efforts across these protagonists and for having role competencies in disaster preparation. it is quite probable that at some time in the future, nurses may be called upon to respond to a mass casualty event or disaster outside of the hospitals. therefore, a need for nurses, who are well trained and prepared, arises on a national as well as on an international level (4). referring to the conditions in the usa, four strengths of nurses, which are key to a central role in disaster preparedness and management, as well as in emergency response, can be stated (5): (i) nurses are team players and work effectively in interdisciplinary teams needed in disaster situations; (ii) nurses have been advocates for primary, secondary, and tertiary prevention, which means that nurses can play key roles at the forefront in disaster prevention, preparedness, response, recovery, and evaluation; (iii) nurses historically integrate the psychological, social support, and family-oriented aspects of care with psychological needs of patients/clients; and (iv) nurses are available and practicing across the spectrum of health care delivery system settings and can be mobilized rapidly if necessary. however, approximately two out of five health care professionals would not respond during health emergencies. the nurses‟ intention to respond to disasters, the needs of nurses who respond to disasters and other health emergencies, and as well as the influence of the nursing shortage and the lack of education preparing nurses for disaster response are important issues which need to be approached (6). concerning the anticipated needs of nurses during a disaster, giarratano, orlando and savage (7) report that during a disaster nurses have to live through the uncertainty of the situation and have to be prepared to adapt to the needs that arise in both patient care and selfpreservation situations. in order to prepare for emergency response, education within the field of disaster nursing is essential. disaster nursing curricula and preparation of nursing faculty members are distinctly needed to teach disaster nursing in order to prepare nursing students for possible disaster situations adequately in future (6). extensive work towards a comprehensive list of core competencies has been done by the who and icn in their framework of disaster nursing competencies (8). pang, chan and cheng (9) suggest that this framework should equip nurses with similar competencies from around the world while giving attention to local applications. grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 4 there is no comprehensive review covering all relevant fields of professional socialization: role, knowledge and experience. recent reviews do concentrate on either the nurses‟ disaster preparedness, or the response of nurses working during a bioterrorism event (10). the aim of this literature review is to provide an overview of the nurses‟ role, knowledge and experience in national disaster preparedness and emergency response within the international scientific literature. methods search strategy a database search was conducted during september-november 2012 using cinahl (ebsco), pubmed, cochrane library, and carelit. a search strategy was used utilizing the terms „disaster‟ and „nursing‟ as keyword searches or subject headings, where applicable. all study designs as well as expert opinions were included in the review. inclusion criteria were the existence of a relevant abstract on the role, knowledge and experience in the field of disaster nursing. all results, independent of their publication year and country of publication, written in english or german language, were included. selection criteria in total, 503 articles were identified within the databases; out of these, 71 appeared in more than one database. the abstracts of all included literature (432 references) were scanned for their relevance on the topic. articles were excluded if they definitely lacked relevance, meaning that the topic of disaster nursing did not appear at all (242 references). as a second step, the articles, which were deemed relevant (190 references), were evaluated in-depth by the first author by initial reading and appraising the relevance in relation to the aim of the literature review. articles were excluded if they failed to address nurses‟ role, knowledge or experience in national disaster preparedness and emergency response in their full text (103 references) or if they were not available for evaluation (19 references) resulting in 68 included references. a flow chart of the selection process is presented in figure 1. figure 1. flow chart of the selection process grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 5 data analysis as articles differed in their (study) design, no meta-analysis was possible. therefore, synthesis of the written evidence was undertaken. categories for analysis, which were predefined through the aim of this literature review, included: (a) roles of nurses during emergency response, (b) disaster preparedness knowledge of nurses and (c) disaster experiences of nurses. for each category, sub-themes were determined out of the different focuses of the articles on disaster nursing (11). for each article, the narratives about a particular sub-theme were extracted. the narratives were paraphrased and generalized, where possible. results in total, 68 relevant sources were identified from the literature search. the majority of the studies were descriptive (40%), or expert opinions/case reports (40%). furthermore, 15% of the studies were qualitative and correlational studies, whereas 3% were systematic reviews. the three categories, according to which the articles where analysed, represented also the most important themes: (a) roles of nurses during emergency response, (b) disaster preparedness knowledge of nurses and (c) disaster experiences of nurses. most of the articles on disaster nursing were drafted in north america. in europe, no articles concerning disaster experiences of nurses had been published. below, each theme is divided into paragraphs, which are equivalent to the determined sub-themes. roles of nurses during emergency response the six identified sub-themes include expectations of the public and the hospital, general and special roles of nurses, assignments of medical tasks, special role during a pandemic influenza and biological terrorism, role conflicts during a disaster and willingness to respond to a disaster. expectations of the public and the hospital: the public expects that nurses are prepared at a personal and professional level and that they have procedures in place, which enable them to carelit: n=34 cochrane: n=2 cinahl: n=297 n=190 abstract not relevant: n=242 double: n=71 n=68 article not relevant: n=103 no full text available: n=19 pubmed: n=170 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 6 serve in an emergency (12). reinforcing, the public has a right to expect effective response from healthcare professional, including nurses (13). moreover, it is anticipated from the hospitals that nurses know before a disaster what will be expected from them in such a situation, what tasks will have to be fulfilled and who is authorized to issue directives towards them and many employees in hospitals do not know what their role during a disaster will be (14). in order to develop or to optimize the field of disaster nursing nationwide, it is proposed to develop a national committee to help define the discipline, build disaster curricula, and to set disaster competencies. furthermore, nurses need to participate in disaster preparedness planning to become familiar with their responsibilities in disaster situations (15). general and special roles of nurses: in general, nurses will have to provide care in a very different context than in their usual practice during disasters (16,17). further, it is imperative that nurses are able to continue working to provide care to additional patients (18). different authors acknowledge that nurses are key players in emergency response (15,17-22). in other words, it can be determined that nurses are in a natural position to assist in a disaster (23), they are the most vital resources in dealing with disasters (24), they have been part of disaster response as long as nurses have existed, nurses will continue to be key players (20) and when nurses are not involved yet in the aspects of disaster care, the involvement should become mandatory (25). particularly, nurses working in disaster-prone areas need to know their professional role in a disaster (26). not every nurse is expected to fulfil any assigned role, and special roles before, during and after a disaster are assigned to nurses with different qualifications (table 1). table 1. general and special roles of nurses groups of persons role description nurses meeting surge capacity needs (20) conducting surveillance in the field dispensing mass medication or vaccination in shelters staffing information hotlines in departments of health admitting patients in hospitals nurses within hospitals (20,27) identify signs and symptoms of injuries and exposures work in a disciplined team follow clear lines of communication perform according their assigned role directions and responsibilities nurses in general (28-30) establish disaster plans train responders coordinate the disaster response provision of care for disaster victims support and protect others from health hazards make life-and-death decisions and decisions about prioritization nursing executives (31) preserve open lines of communication ensure the quality of patient care, provide current education influence policy and political decisions provide security for staff, patients and families. public health nurses (20) screening administer first aid and psychosocial support implement infection control procedures and monitoring assignments of medical tasks: during a disaster, nurses are expected to be able to fulfil the role of a medical practitioner in some ways. this role can be described as outside of the normal scope of nursing practice, their knowledge or their abilities (32). nevertheless, it is imgrochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 7 perative that nurses are trained in disaster medicine in order to be assigned to medical tasks in emergency response (30). the task of triaging patients as an assigned medical task is figured prominently in the literature (19,29,32). special role during a pandemic influenza and biological terrorism: the tasks during epidemic situations are contact tracing, conducting case investigations, engaging in surveillance and reporting, collecting specimens, administering immunizations and educating the community (20). furthermore, in hospital settings, it is expected from nurses to be able to identify, manage and treat infectious outbreaks (32). role conflicts during a disaster and willingness to respond to a disaster: nurses might have conflicts between their professional, their private and their community role, respectively (33). nurses might be therefore less willing to respond to work during a disaster. other reasons influencing the willingness to respond are low baseline knowledge, low perception of personal safety, and low perception of clinical competence (34). it is also stated that these factors will lead to a shortage of nurses to provide care during a disaster. nurses not responding to a disaster describe having feelings of guilt towards their jobs and co-workers, recognizing the impact of their decision. on the other hand, it is also possible that nurses maintain being able to respond to disasters beyond normal working hours (33). disaster preparedness and knowledge of nurses the six identified sub-themes include definition of a disaster, core competencies and curriculum, undergraduate nursing education and continuing education programs, disaster drills, training and exercises, as well as preparedness. definition of a disaster: it is acknowledged that nurses might perceive a disaster differently than described from official definitions and classifications such as the one of the cred (1,2). in a study by fung et al. (29), nurses described their perception of a disaster in a fourfold manner. most of the nurses attributed specific characteristics to disasters. exemplarily, these characteristics are being unpredictable, sudden, unexpected or unpreventable, being out of control and not manageable, urgent response, horrible crisis or unknown disease with no treatment available. another way of describing a disaster is by impact, as for example: large numbers of victims, damage to the environment, adverse psychological effects, loss of family, and serious consequences. moreover, disasters were described as demanding emergency services and care. examples are being in need for immediate medical attention, a challenge to professional services or requiring extensive work force to cope. only few nurses described disasters in a way a definition would do: epidemics, accidents, terrorist attacks, natural disasters, extreme weather and war. core competencies and curriculum: for preparedness purposes, it is very important to have core competencies for education and training as well as for the effectiveness and efficiency of response during a disaster (35). the identification of core competencies and knowledge needed to help and protect self and others during a disaster is an important first step to qualify nurses for disaster response (20,35). weiner (36) refers to the core competencies defined by the nursing education preparedness education coalition (nepec) (table 2). when comparing knowledge and experiences underpinning these competencies with nursing practice, it can be concluded that many of them are basic to a nursing curriculum (35). furthermore, others claim that nurses already possess the skills enabling them to respond to a disaster. these are purported to be the values of human caring, creativity, the ability to improvise, communication and management skills (20,23). on the other hand, usher and mayner (22) state that working in an emergency department or a similar area is (still) not good enough to meet the grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 8 required competencies to respond to a disaster. others claim that nurses working in acute care already have specific disaster nursing core competencies (28). some authors annotate that the area of disaster nursing is underrepresented or lacking in undergraduate nursing curricula, nurses and nurse practitioners are not able to meet required disaster nursing competencies and that it is urgent to include content in order to enable nurses to respond in times of disasters (6,12,15,17). nursing educators are hold accountable to preparing nurses for disasters, for example by adjusting the curricula and by meeting the increased need for education and training in disaster nursing for all groups of nurses (6,17,37). concerning a disaster curriculum, lund et al. (30) propose seven modules for a comprehensive nursing curriculum to address chemical and biological warfare (table 2). elsewhere, such a training of specialized skills and knowledge is criticized because they are unlikely to be retained until an opportunity to use them is afforded (38). others propose educational components that are more medically oriented (table 2) (14,24). undergraduate nursing education and continuing education programs: the fields of undergraduate education and continuing education programmes for nurses are widely discussed in the literature. because nurses have to be aware of disasters and be prepared for them, it is imperative that disaster management and nursing contents and experience are integrated into undergraduate nursing and continuing education programme curricula (15,17,22,24,35,3941). it has to be acknowledged that all nurses, irrespective of being educated and trained or not, may be called during a disaster and therefore, all nurses must have a minimal knowledge and skills for appropriateness of their response (17,26,29,35). education is critical to the feeling of safety and competence as well as the willingness to participate in an emergency (32,34), but it needs to be tailored according to the specific needs of the location such as capacity and expected role of nurses (16). for australia, usher and mayner (22) state that the theoretical and practical preparation of disaster nursing competencies in undergraduate nursing courses are inadequate or only little is known about the inclusion and that professional development opportunities are needed. one possibility for an adequate provision of knowledge and skills required in a disaster could be the collaboration and sharing of knowledge between nursing schools and the military medical communities as well as other trained medical professionals, for example volunteers from the red cross or red crescent and other medical response teams (17). another effective strategy might be the dissemination of information and educational materials related to disasters (18). it is central that nurses receive education which is specific to their actual knowledge and skills in order to not duplicate efforts or miss important content because the more advanced nurses are, concerning both experience and knowledge, the more likely they are to implement advanced disaster nursing (15,32,35). disaster drills, training and exercises: drills and training play also an important role for disaster preparedness. it is concluded, that intensive training and periodical drill programs simulating hospitals‟ emergency plans will improve capabilities of nurses for emergency response (15,20,21,31,42,43). all nurses are recommended to participate in periodic emergency response drills and disaster training, and nursing schools should collaborate with the local ems to give their students a disaster field experience and to expedite teamwork between first responders and first receivers, because during a disaster an enormous pool of nurses will be needed (20,21,23,25,35). further reasons for participating in and specific issues for disaster training are described in table 3. others contrarily describe specific medical tasks and conclude that these tasks should be tailored to the nurses‟ background knowledge and clinical experience (13,16). grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 9 with any disaster training, a broad range of topics should be covered in order to prepare nurses to function in disasters due to any hazard and settings other than their work settings (41). goodhue et al. (21) conclude that having disaster training, besides having a specified role in the workplace disaster plan, is the most easily modifiable variable with the most impact on increasing the likelihood of response in the event of a disaster. preparedness: disaster preparedness of nurses is pivotal to the ability and capacity to respond as well as the delivery of effective disaster response (6,18,24,33). there are two ways of viewing preparedness, personal preparedness and professional preparedness. special attention is given to bioterrorism preparedness, because being especially prepared for bioterrorism and thus infectious disease emergencies, has a positive impact on patients, families and the nurses themselves, for example by preventing a secondary spread (18,45). furthermore, bioterrorism preparedness readies nurses for other disasters, because the skills and response actions are the same and misconceptions can be prevented (46). due to this importance, bioterrorism preparedness should be part of continuing education and nursing school curricula (18,43). other special fields where preparedness is necessary are described in table 4. grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 10 table 2. core competencies and disaster curriculum description contents core competencies defined by the nursing emergency preparedness education coalition (nepec) (36) protect self and others from harm participate in a multidisciplinary, coordinated response communicate in a professional manner recognize disaster situations and potential for mass casualty events seek additional information and resources needed to manage the event recognize your roles and limitations in disaster response efforts cope with challenges that occur in disaster situations define terms relative to disaster management response discuss ethical issues related to mass casualty events describe community health issues related to mass casualty events already existing specific disaster nursing core competencies of nurses working in acute care (28,41) triage securing of personnel, supplies and equipment recordkeeping patient transport decontamination patient management of specific illnesses and injuries patient management of special needs population evacuation development of disaster plans ethics response to stress reactions disaster curriculum modules of lund et al. (30) anatomy of a disaster epidemiology of disaster disaster planning communications in disaster introduction to disaster medicine introduction to pathophysiology of disaster the disaster response nursing curriculum to address chemical and biological warfare (40) introduction to biological and chemical terrorism surveillance systems for bioterrorism identification of agencies communication response systems biological and chemical agents of concern mass immunization decontamination and mass triage therapy and pharmacology psychosocial effects of terrorism nursing leadership during emergencies medically oriented educational components (14,24) first aid basic life support advanced cardiovascular life support infection control field triage pre-hospital trauma life support advanced trauma care nursing post-traumatic psychological care peri-trauma counselling grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 11 table 3. reasons for participating and specific issues for disaster training description contents reasons for participating in disaster training (10,13,15,18,21,24,26,27) test and maintain disaster preparedness create awareness for disasters in general create awareness for physical and mental limits increase personal safety increase confidence in disaster management minimize emotional and psychological trauma specific issues for disaster training (38,43,44) triage mass casualty management (bio-) terrorism preparedness communications command and control interagency cooperation waste management decontamination personal protection specific medical tasks (13,16) cardiopulmonary resuscitation central venous catheter insertion trauma care table 4. personal and professional disaster preparedness description contents personal preparedness (15,18-20,27,47) go-pack containing essential personal supplies preparing and protecting the family personal plan for times of disaster knowing employment contract statement about obligation to report to duty during a disaster professional preparedness (15,19,26,27,29,47) pre-registering in a disaster registry developing and knowing disaster plans assembling emergency supplies studying evacuation or shelter options ongoing training and drills experience in disaster nursing special fields of disaster preparedness (33,34,40) bioterrorism disasters involving special need populations chemical or radiation disasters according to al khalaileh et al. (15), jordanian nurses consider themselves being weakly to moderately prepared for a disaster and think that additional training would be beneficial. the same issues are made out for hong kong nurses and the existence of a lack of understanding their preparedness needs with regard to disaster is concluded (24,29). being prepared for a disaster as a nurse might maximise safe conditions, decrease vulnerability and minimise risk to individuals during a disaster (12). disaster experiences of nurses the six identified sub-themes are work environment, nursing care, feelings, stressors, and willingness to respond to disasters and to treat patients as well as lessons learned and impacts. grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 12 work environment: nurses will experience challenging working conditions, an environment of fear and difficult infection control requirement conditions during a bioterrorist event (10). nurses believe that during a disaster will be a chaotic clinical environment without a clear chain of command, with insufficient protective equipment and little freedom to leave (47). manley et al. (38) assume, even if hospitals are well prepared, that during a disaster will be chaos, inadequate resources, deaths and injuries, confusion and contention over who is in command, lapses in security and breakdowns in communication. during a disaster, problems concerning organizational and social supports caused by challenges with care for children, elderly or pets during prolonged shifts and quarantine might also prevail (48). nursing care: nursing care during a disaster is a special type of care because of the exceptional situation and the change of routine. during a disaster, care is provided by an interdependent team of nurses, clinicians and ems professionals, each playing unique roles (41). thus, nurses especially feel as advocates for their patients, especially those who are frightened or most vulnerable, and their merits of caring and unity are the most appreciated aspects of their rescue experience, reinforced through communal sprit with their colleagues and the feeling of being rewarded by the victims (7,27). nurses are confronted with conflicts and ethical issues when working during a disaster. because of increased staff requirement and the allocation of resources nurses come into conflict with the delivery of dependent care (27,48). other challenges for nurses are the identification of unfamiliar infectious agents, long working hours, limited supplies, unfamiliar environments, provision of care to infected patients, or fear of infection (10). chaffee (49) concludes that tasks like triage, quarantine and mandatory administration of medication might be ethically challenging during a disaster. if uncertainty of the conditions worsens, nurses might experience discouragement and fear (7). feelings: on the one hand, nurses feel guilty when taking leave, are concerned about causing pain and distress to their patients, are overwhelmed by the scale of the tragedy, feel disgusted or distressed at the nature of the injuries and the scale of the suffering or felt apprehensive about being able to cope. on the other hand, nurses also feel excited and challenged by what they have to do, or feel to be valued as much-needed colleague (50). anger towards people in authority, because of the expectation to fulfil the duty to care, is another feeling described by nurses (7). fear, anxiety, stress and confusion are perceived to be felt in the event of bioterrorism. fears might arouse in consequence of the possibility of acquiring a lethal disease from exposure to an infectious agent, transmitting an infectious agent to other patients or the family, lack of knowledge about disease agents, isolation procedures, and access to content resources (47). other feelings might be uncertainty, hopelessness, or abandonment related to the issue of chaos in general and evacuation in special (7). stressors: there is a widespread assumption that nurses “by virtue of their training and personality traits are relatively impervious to the effects of distressing experiences”, such as disasters (50). newer studies disqualify this assumption, because for example, the work of nurses can be compromised when a lack of adequate rest, poor nutrition, erratic eating patterns and insufficient fluid intake prevails (26). other stressors might be information and work overload, crisis, confusion, uncertainty, chaos, disruption of services, casualties, or distractions with crowds and media, decline of infrastructure, limited medical supplies and loss of electricity and potable water (7,25,31,47,48). moreover, poor knowledge and working skills, combined with a heavy workload and lack of equipment, leads to emotional distress during a disaster (25). a disaster can also lead to personal trauma because of the experienced loss of homes, workplaces, and close relationships as well as suffering or dying patients (7). willingness to respond to a disaster and to treat patients: main issues related to a reduced willingness to treat patients during an epidemic include having a high level of concern about grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 13 an infection and lack of medical knowledge (46). during a disaster, nurses will have the same vulnerability to property damage, injury or displacement, will have fear and concern about own and family‟s safety and will, therefore, have to make a decision whether to report to work or to care for oneself, one‟s family, or personal property (49). other reasons for unwillingness to respond to a disaster are responsibilities to children or elderly, a second job, transportation issues or obligations to care for a pet (49). goodhue et al. (21) found out in their study that less than one third of paediatric nurse practitioners would definitely respond during a disaster. one result of the study of o‟boyle et al. (47) is that many nurses would leave hospitals or would not report for work when a bio-terroristic event occurred. not all nurses will be willing to respond to chemical, biological or radiological disasters, because of personal risk and not all nurses will be able to respond because of the unavailability of personal protective equipment (33). in order to raise the willingness to respond to a disaster, nurses need to be educated on what the hospital expects from them and what the implications of certain choices of not responding to work will be (49). other factors might be: knowing that family members are safe and provided for, having a home disaster plan, having disaster training, having an assigned role in the workplace disaster plan and prior disaster experience (21). lessons learned and consequences: based on experience, often lessons learned and consequences for the future are stated. ammartyothin et al. (42) conclude that medical personnel, such as volunteers, should be incorporated into the organic medical staff during a disaster as well as that communication systems are important for disaster management and have to withstand the actual event and the unavoidable. as a health institution, it is important to find out about the nurses‟ determinants of reporting for work when a disaster strikes in order to be better prepared (46). during a disaster, it is imperative, that food, water and a place to sleep or a quiet area are available for continued functioning of nurses. in order to ensure an effective response, nurses need to build functional partnerships with physicians, to support one another and to express a sense of responsibility and empathy for colleagues and patients (7,25,39). for future disaster responses, the performance of nurses during a disaster needs to be evaluated and the most frequently used skills need to be identified for further training (13). discussion concerning the general role of nurses in disasters, different attributions are observed. on the one hand, there is international consensus that nurses are key players in emergency response is somehow contemporary. on the other hand, it does not seem finally clear which expectations are cherished towards nurses. is it only the continuation of the provision of care in different circumstances or is the assumption of medical tasks, in fact? of course, not every nurse needs to be able to fulfil every role, but medical tasks during a disaster might be mandatory to undertake. it does not become finally clear from the literature review which medical tasks most certainly are needed in general and particularly for specific disasters. moreover, heterogeneity about the field of application of nurses exists in the literature. in some it is described, that nurses will work on-site of the disaster area in others nurses will be deployed in their own hospital or in a hospital in the proximity of the disaster area and yet in others nurses will work in the community. these heterogeneities surely are due to the different healthcare systems and professional qualifications in the different countries, a diversity that is remains unanswered in this review. however, it seems convincing that preparedness for a disaster as well as an effective response are expectations of the public towards nurses in all countries. special attention is given to the roles of nurses before and during a pandemic influenza and biological terrorism. nurses have a share in the identification, management and treatment of grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 14 infectious outbreaks. again, the specific tasks during such an event are dependent on the professional education of the nurses. the professional roles during a disaster might be in conflict with the personal duties in the family and in the community. such conflicts can undermine supply of work force during a disaster immensely. the definition of disaster is perceived differently by nurses than from the officially used definitions. officially used definitions mainly focus on the cause of a disaster. thereby, the passage between a mass casualty event and a disaster is fluent. for nurses, a disaster is mainly considered through the impact it has for their daily work, the persons who they care for and their own life. thus, the unpredictability and suddenness as well as the number of victims, their injuries and clinical picture play a greater role in the perceptions of nurses. furthermore, terrorism does not explicitly appear in the disaster classification of the cred; yet, nurses do think that terrorism might be a threat for their country (2). in order to be prepared for a disaster, it is important to define core competencies applicable to the different professional qualifications of nurses. a comprehensive list might be the who and icn in their framework of disaster nursing competencies (8). this supranational framework has to be broken down into national core competencies for nurses and a list of competencies for undergraduate and continuous nursing education, at the end, because it may very well be the case that some knowledge and skills acquired through basic nursing curricula already equip nurses for disaster response. on the other hand, some disaster nursing competencies might be highly specialized, and thus uncommon in practise as well as unlikely to be retained. thereby, a careful choice between specialization and generalization of skills and knowledge for undergraduate and continuous nursing education should be made. both, undergraduate education and continuing education programmes have to raise awareness and preparedness for a disaster adequately. by tailoring education to the local needs, such as the likelihood of specific disasters or existing disaster plans, and the needs of the nurses, such as the requirements for general disaster management knowledge or specialized medical skills, all nurses should be able to respond to a disaster appropriately. it remains unclear which strategy for the education of nurses in disaster management is the most effective. the collaboration with medical communities and other medical response teams, as well as the dissemination of information materials on the topic seem to be promising, not only for education but also for drills and training. emergency response drills and disaster training are important elements of individually and professionally preparing nurses for disaster and evaluating existing disaster plans. again, emergency response drills and disaster training need to be tailored according to the local needs and the needs of the nurses, leading to an improvement of the nurses‟ willingness to respond to a disaster and the response as such. being prepared for a disaster as a nurse means being personally and professionally prepared. nurses are considered to be personally prepared, when they are able to protect their family as well as when they know their obligation to report to duty during a disaster and have all their essential personal supplies standing by. professional preparedness of nurses means the registration in a relevant disaster registry, knowing the disaster plans and being trained. furthermore, special preparedness is needed for nurses‟ working areas with special needs populations and specific disaster types. the work environment of a nurse during a disaster will likely be challenging and chaotic. nurses need to know beforehand what they might expect; therefore, preparing them through education and training is essential. furthermore, a need for a good disaster plan, where chains of command and effective alternatives in communication are described, arises considering the high possibility of an adverse work environment. for nurses, it has to be clear, that care durgrochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 15 ing a disaster differs from the routine work. interdependence in a team will become even more important as well as advocacy for patients, the allocation of resources and ethically challenging decisions (for example, during triage). during a disaster, negative feelings, such as guiltiness, disgust, anger or fear, are dominant in descriptions of nurses‟ experiences, besides positive feelings of excitement or being challenged. no information is given on the impacts of those feelings on working capacity and mental health. nurses also experience specific stressors during a disaster, likely leading to emotional distress and possibly to personal trauma. these stressors can either have a personal character, such as uncertainty about the safety of the family or themselves, an organizational character, such as being cut-off from support sources, and an occupational character, such as hazards, lack of equipment or high workload. the willingness to respond to a disaster is dependent on the level of concern, responsibilities and the medical knowledge of nurses. concern may exist for example due to property damage or own and family‟s safety, responsibilities may be towards children, elderly or another employer. it is important that nurses are educated and trained on the expectations of the hospitals and that they have their own disaster plan. disaster experiences importantly should lead to impacts for the future, the so-called lessons learned. often, these lessons learned refer to optimizing communication systems, nurses‟ determinants of reporting for work, controlling the hospital environment during a disaster and the knowledge and skills of nurses. nurses themselves will acquire experience, and might rethink their commitment to nursing. in summary, it can be stated that, after a disaster is, with all probability, before a disaster and it is therefore inevitable to prepare anew. conclusions and implications it seems self-evident that nurses are key players in emergency response. in order to prepare nurses for disasters, clear roles should be defined according to the professional education of the nurses, which should be communicated beforehand. these roles of nurses during a disaster should be realistic in relation to their skills and practical experiences. in order to raise the availability of nurses during a disaster, roles should be adjusted to each nurses‟ personal duties in the family and in the community, in the best case. roles should also be tailored according to the characteristics of the different disaster types, with special attention to pandemic influenza and biological terrorism. in order to satisfy public expectations towards nurses, national directives and concepts for disaster nursing should be developed, where nonexistent, and nurses have to be called attention to their duties. moreover, distinctions towards roles of physicians and nurses during a disaster are needed in order to define the medical tasks of nurses clearly, which have to be trained and performed during a disaster. existent definitions of disasters seem not to be appropriate for the working environment of nurses. defining disasters out of the experience of nurses could help to give a better understanding for such a sweeping event. a definition from the perspective of a nurse could be an unpredictable, sudden event that is hardly but urgently manageable with serious consequences to the population and environment demanding an extensive need for professional health services personnel. in order to develop national disaster nursing core competencies, the framework of disaster nursing competencies from the who and icn (8) should be interpreted for the needs of each professional group of nurses. national disaster nursing core competencies then should be adjusted to the demands formulated in the undergraduate nursing curricula in order to meet the national criteria. nurses should receive education and training tailored to the local needs and their actual competencies. collaboration with relevant national institutions and organizagrochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 16 tions is indicated for making education and training in disaster nursing more efficient, precisely if nursing educators are not knowledgeable in the field of disaster nursing. for personal and professional preparedness and in order to raise willingness to respond, nurses need to pack their essential personal supplies standing by for emergencies, need to know that their families are protected and need to be registered in a disaster registry as well as know their relevant disaster plan. a personal disaster plan will help to arrange personal matters when responding to a disaster. in order to counteract the high possibility of challenging and chaotic working conditions during a disaster, nurses need to be prepared for many situations and hospitals need to develop or improve their disaster plans. it has to become a given for every nurse, that nursing care during a disaster will change from its routine way, including all consequences, such as the allocation of resources. not much is known about the feelings of nurses responding to a disaster and their resistance to stressors. in order to be able raise the willingness to work in a disaster, it is imperative that possible distressing situations during a disaster are identified and reduced, and nurses become prepared for coping. it is central to learn from a disaster experience and to prepare anew. not only will the optimizing of processes during a disaster written down in a disaster plan have to be evaluated, but the performance of the nurses who were on duty and the reasons of the nonperformance of the nurses who were not able or not willing to respond to the disaster, as well. an overview of the implications and the relevance to nursing practice, nursing education and research is presented in table 5. table 5. relevance to nursing practice, nursing education and research relevance to nursing practice: all nurses, regardless of their professionalization, need to receive disaster preparedness education in their undergraduate and continuous nursing education, in order to have a great pool of nurses during a disaster. all nurses should periodically take part in emergency response drills and disaster training in order to be prepared for disasters. for being prepared for a disaster and willing to respond, nurses need to be personally and professionally prepared. a personal disaster plan will help to arrange personal matters. hospitals need to have a disaster plan, wherein chains of commands, alternative communications and task descriptions for groups of nurses during disasters are described. during a disaster, the routine way of nursing care changes and nurses need to be prepared to make ethically challenging decisions. relevance to nursing education and research: nursing educators should prepare nurses for disasters, by adjusting the curricula and by meeting the increased need for education and training in disaster nursing for all groups of nurses. nursing research should find definitions of disasters appropriate for the working environment of nurses. research should be done in order to review the appropriateness of theoretical and practical preparation of disaster nursing competencies in undergraduate nursing courses and continuing education programmes. disaster preparedness of nurses needs to be 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universal health coverage in africa: relevance of telemedicine and mobile clinics oluwakorede joshua adedeji1, yusuf olalekan babatunde1, abdulmumin damilola ibrahim1, yusuff adebayo adebisi2,3, don eliseo lucero-prisno iii3 1 faculty of pharmaceutical sciences, university of ilorin, ilorin, nigeria 2 faculty of pharmacy, university of ibadan, ibadan, nigeria 3 global health focus africa corresponding author: oluwakorede adedeji; address: faculty of pharmaceutical sciences, university of ilorin, ilorin, nigeria; email: oluwakorede2017@gmail.com mailto:oluwakorede2017@gmail.com adedeji oj, babatunde yo, ibrahim ad, adebisi ya, lucero-prisno iii de. towards universal health coverage in africa: relevance of telemedicine and mobile clinics (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4448 2 | p a g e abstract access to essential healthcare services is limited in africa, resulting in preventable mortalities. telemedicine, which can be defined as the use of information and communication technologies in the delivery of healthcare services, is applied in various fields of medicine and at multiple times. some telemedicine projects have been implemented in different african countries. some successes were recorded, as well as failures. despite challenges, such as high cost, that inhibit telemedicine coverage, telemedicine still presents excellent opportunities in increasing access to basic healthcare and expert services. mobile clinics provide the opportunity to expand access to health services across a region. they can be implemented as an extension of fixed1hospitals that are often situated away from remote villages, serve in the heart of communities, and aid in preventive screenings and epidemiological monitoring. africa has limited resources but leveraging these existing resources most cost-effectively is key to achieving universal health coverage in the region. keywords: universal health coverage, telemedicine, information and communication technology, mobile clinic, africa source of funding: none conflicting interest: the authors declare no conflict of interest. authors' contributions: oluwakorede joshua adedeji conceptualized the study. oluwakorede joshua adedeji, yusuf olalekan babatunde and abdulmumin damilola ibrahim acquired, analysed and interpreted the data for the work. yusuff adebayo adebisi and don eliseo lucero-prisno iii revised it critically for important intellectual content. all authors agree to be accountable for all aspects of the work in ensuring that all questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. adedeji oj, babatunde yo, ibrahim ad, adebisi ya, lucero-prisno iii de. towards universal health coverage in africa: relevance of telemedicine and mobile clinics (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4448 3 | p a g e introduction accessibility to basic promotive, preventive, curative, rehabilitative, and palliative health services of adequate quality without incurring financial hardship encompasses the concept of universal health coverage (1). universal health coverage (uhc) enables all population members to easily obtain primary health services without being pushed to poverty or debt. health is a fundamental right of all, and access to it should not be difficult or impossible for anyone. globally, about 100 million people are pushed into extreme poverty because they have to pay for healthcare (2). this is particularly worse in africa as 11 million africans are pushed to poverty each year due to out-of-pocket expenditure (3). uhc is not just about health financing. it encompasses all other components, such as health technologies, health service delivery, health workforce, health facilities and communication networks, information systems, quality assurance mechanisms, governance, and legislation (2). several african nations are moving slowly towards universal health coverage (4), but particular challenges threaten the actualization of the "health for all" reality. such challenges include the lack of political commitment, lack of coherent health financing policies, weak health systems, and weak information systems to monitor uhc progress (1). africa harbours over 90% of global malaria cases (5), almost two-thirds of the global total of new hiv cases (6), and over 25% of tuberculosis deaths (7). many deaths can be prevented and reduced with effective health coverage in the region. attaining the third sustainable development goal (good health and wellbeing for all) requires country-specific actions towards achieving universal health coverage (1). each country's ability to translate plans and policies into concrete actions will determine the reduction in mortality rates and overall wellness of the population, thus affecting the level of growth. this paper aims to elucidate the roles and relevance of the dual implementation of telemedicine and mobile clinics as a tool for ensuring adequate health coverage in africa. telemedicine, or telehealth, can be referred to as "the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for the diagnosis, treatment, and prevention of diseases and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities" (8). the use of telemedicine can be classified as either clinical (diagnostic and therapeutic), educational or administrative (9). mobile clinics are an essential part of the health system that can help deliver basic health services to remote areas (10) predominantly rural communities that lack access to health centres. they are instrumental in accessing vulnerable populations (10). mobile clinics contain necessary equipment for temporary treatment of patients in critical situations and can help increase access to essential health services (11). implementation of telemedicine and mobile clinics provide significant advantages and challenges that inhibit full implementation and utilisation, especially in the african region. however, the dual performance may provide substantial benefits and increased access to health services of sufficient quality. this paper assesses the impact of existing telehealth platforms and mobile clinics and the effect of a dual implementation. method we conducted a narrative review of published articles on telemedicine and mobile clinics in africa. search for relevant medical literature in biomedical databases (google scholar and pubmed) was con adedeji oj, babatunde yo, ibrahim ad, adebisi ya, lucero-prisno iii de. towards universal health coverage in africa: relevance of telemedicine and mobile clinics (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4448 4 | p a g e ducted using the following key terms: "telemedicine", "mobile clinics", "africa", "telehealth", "electronic health", "ehealth" and "e-health". papers were selected based on the country (only african countries were selected), quality, and relevance to the scope of the study by reviewing their abstract and title. we also used supplementary references listed under the papers. implemented telemedicine projects in africa were selected and analysed for successes and/or reasons for failures. results in the use of telecommunication technologies to advance citizens' health and wellbeing in the state, africa is still in its infancy compared to developed countries; nevertheless, various telemedicine projects have been implemented in different african countries, as seen in table 1. these telemedicine projects were implemented for various purposes across different countries, and some successes were recorded for some projects while some other projects might have failed. table 1: various telemedicine projects and approaches and impact towards achieving universal health coverage in africa authors telemedicine project country roles and impact on healthcare towards uhc lessons antoine geissbuhler et al [22] keneyan blown mali (2001) tele-education for physicians and students and teleconsultation to follow up with patients operated in geneva and returned to mali. improved education of physicians for better healthcare delivery and post-discharge care is enhanced. problems identified include poor internet connectivity and poor infrastructure required to support telemedicine coverage t. mpunga et al. [28] static-image telepathology program at butaro cancer centre of excellence rwanda (2013) the use of static-imaging telepathology enhanced the diagnosis and interpretation of specimen samples and, overall, improved care and diagnosis for cancer patients in the country. limited bandwidth and internet instability limited the choice for dynamic real-time readings. also, the varying time zones serve as a limitation to synchronous communication. n.d montgmorey et al. [29] clinicopathologic conferences between clinicians and pathologists in kamuzu central hospital (kch) and pathologists in the university of north carolina, chapel hill (unc) malawi (2011) improved diagnosis of lymphoproliferative disorder in resource-limited settings on a modest investment and a collaborative academic environment for malawian pathologists. telemedicine can play an influential role in advancing care to millions while leveraging on existing resources and investment. maurice mars [19] drug resource enhancement against aids and malnutrition (dream) project tanzania, malawi, mozambique telecardiology training, the establishment of telecardiology centres, and remote reporting of ecgs from italy. telemedicine can cut across different countries and thus facilitate intercultural and international collaboration. cheick-oumar bagayoko et al [31] equi-reshus mali (2011) task shifting of medical imaging in obstetrics and the use of telemedicine for training and networking of health adedeji oj, babatunde yo, ibrahim ad, adebisi ya, lucero-prisno iii de. towards universal health coverage in africa: relevance of telemedicine and mobile clinics (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4448 5 | p a g e cardiology in remote locations and provision of cme (continuing medical education) professionals can help reduce the isolation of these professionals working in remote areas. cheick-oumar bagayoko et al [32] réseau afrique francophone de télémédecine (raft) project madagascar, rwanda, mali, morocco, mauritania, etc. distance learning, teleconsultations, and digital collaboration within africa and between africa and europe. the development of large-scale telemedicine projects involves the inclusion of participating countries in the development of the project. discussion overview of telemedicine coverage and application to various fields of medicine the use of information and communication technologies (ict) in healthcare has gained ground. its application spans radiology, especially teleradiology, i.e., using ict to transmit radiographic images from one location to another, usually for diagnosis and interpretation (12, 13). teleradiology often involves a store-and-forward or asynchronous form of telemedicine. the patient data is generated, stored, and transmitted to a receiver which responds at a later time (13). in psychiatry, telepsychiatry is used to diagnose, educate, treat, consult, transfer medical data, research, and other healthcare activities between a patient and the healthcare provider (14). telepsychiatry usually involves real-time or synchronous communication between the patient and a healthcare provider in which both individuals at either end of the communication link are simultaneously present and actively engaged ); dermatology (teledermatology includes both store-and-forward communication and real-time synchronous communication between patient and clinician (15).); pathology (telepathology (13)the application of telecommunication technologies in microscopic imaging and pathology (16)), etc. the use of telemedicine in real-time video consultations with off-site specialists cuts across various fields such as oncology, rheumatology, etc.(17); thus, almost every area in medicine has a potential telemedicine application. telemedicine also plays vital roles in managing chronic illnesses, emergency and trauma care, medication prescribing, counselling, stroke intervention, and post-discharge coordination (17). pharmacy practice is not left out in the application of telemedicine. the use of telemedicine can provide great advantages in remote dispensing and supervision in community pharmacies. use of mobile clinics mobile health clinics are designed from vans, trucks, or buses and, depending on use, are fitted with equipment and facilities essential in carrying out the design purpose. mobile clinics are used for various purposes in emergency cases, primary healthcare delivery, preventive screenings, etc. carried out by quite a small number of healthcare professionals. in humanitarian emergencies, mobile clinics are often common in delivering health services (24). in the united states of america, mobile health clinics serve an essential role in providing healthcare to vulnerable populations (25). the use of mobile health clinics for primary healthcare delivery is not quite established in africa. globally, more than half of the world's population lives in urban areas. however, in africa, about 57% in rural areas (26). among these countries, about 41% in lower-middle-income-countries and 32% in low-income countries live in urban areas. due to the presence of most hospitals adedeji oj, babatunde yo, ibrahim ad, adebisi ya, lucero-prisno iii de. towards universal health coverage in africa: relevance of telemedicine and mobile clinics (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4448 6 | p a g e in the cities, the use of mobile clinics presents an effective framework for health delivery to those in need in these rural areas.the ratios of the number of hospital beds to the population in most african countries is quite low and below standard values with most african countries having less than 15 beds per 10,000 population (27) and most of these beds often remain inaccessible to the majority of the population. the adoption of mobile clinics may present great benefits in eradicating preventable endemic diseases such as malaria and reducing the high mortality rate that results from such diseases in the region. mobile clinics have also been used for massive immunization programmes and ante-natal care. mobile clinics might even reduce the high mortality rate associated with the region due to certain factors such as the absence of a health professional at the time of child delivery, probably as a result of distance from hospitals. the accessibility of mobile clinics to rural and vulnerable communities greatly benefits attaining uhc in africa. stakeholders involved in the implementation of a possible framework modern telemedicine systems and mobile clinics involve a wide range of stakeholders, each having their responsibility. the key stakeholders that have important roles for successfully implementing telemedicine and mobile clinics include system designers and developers, (33) healthcare professionals like physicians, nurses, pharmacists, and community healthcare professionals (34). also, internet service providers, information technology support staff, policymakers, and end-users (35) have essential roles to play to get the required satisfaction from telemedicine projects. a proper evaluation of telemedicine and mobile clinics is essential to convince various stakeholders of its importance and as a means to come to a rational implementation in various health sectors across african countries. there is a need to establish roles of additional stakeholders that could be an important addition to the novel telemedicine and mobile clinics systems to achieve equal access to health by everyone everywhere in africa. the central role of nurses can be seen in telemedicine systems adopted in-home care settings, where patients have to be introduced to the use of new technology and empowered to perform self-management. moreover, nurses are often responsible for daily patient control through remote monitoring systems (36). also, pharmacists are increasingly acquiring a front-line role in many public health initiatives (37), (38) with the possibility of being supported by teleconsultation when needed. implementation of telemedicine and mobile clinics as a means to achieve universal health coverage in africa requires a multidisciplinary approach. firstly, the core of any telemedicine intervention would be technology. technical issues like quality, robustness need to be taken into account and integral to any telemedicine implementation. given the complexity and novelty of telemedicine applications, appropriate training to relevant stakeholders regarding the use is necessary for a successful implementation. secondly, acceptance by the users (patients and healthcare providers) is required. the users must be satisfied with the system operation and effectiveness. therefore, as suggested by berg (39), users should be involved in the early stages of the development process. thirdly, implementing telemedicine and mobile clinics will influence the financial situations of various parties in the health sector (40). the telemedicine financing will be different from the normal non-telemedicine (traditional) approach, affecting the distribution of cost and revenue amongst stakeholders. therefore, there is a need to design a sustainable business model so that all participants benefit from telemedicine. finally, there have been discussions on telemedicine systems' legal and ethical impli adedeji oj, babatunde yo, ibrahim ad, adebisi ya, lucero-prisno iii de. towards universal health coverage in africa: relevance of telemedicine and mobile clinics (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4448 7 | p a g e cations on different levels (i.e. international, national, regional) by regulatory bodies (41). commonly needed policies are related to the protection of the patient's privacy and the patient's safety. moreover, there is a need for standards to ensure the conformance of telemedicine implementations at (42) the technical level and (43) the organizational level; to guarantee the quality of the telemedicine development (44) effects of single and dual implementation of telemedicine and mobile clinics in africa ensuring successful implementation of telemedicine requires satisfying the following factors: governance, policy or strategy, scientific development and evaluation (13). an international collaboration between participating countries in a telemedicine project to stipulate guidelines and conduct that regulate the utilisation of the project is necessary for governance to ensure smooth implementation. since many telemedicine projects cut across state borders, the promulgation of guidelines can help harmonize country practices. most countries in the african region do not have a defined policy or strategy for achieving telemedicine (13), hence the low coverage in the region. as seen from other telemedicine projects in various institutions and countries, the effects of telemedicine in africa are diverse. in some projects, telemedicine enhances access to specialty services from experts. some other projects improve diagnostic services and reduce the time often spent in obtaining diagnostic results. furthermore, telemedicine has been of great advantage in enhancing interprofessional collaboration, networking and reducing isolation of professionals working in remote areas (31). despite the immense advantages telemedicine presents to numerous fields particularly in reducing the burden of distance and travel, some projects are often short-lived. improving the chances of success of a telemedicine project involves careful planning based on local resources and community setting, observing the results produced, expanding on evidence-based effectiveness, and ensuring adaptability to the local region. there is no "one-size-fits-all" strategy in achieving universal health coverage (45), every country needs to adopt a policy or strategy that achieves the best results. despite the need for the variability of approach to ensure adaptability to the region, the influence of telemedicine cuts across various processes. it can be modified to adapt to the needs of a region, state, or country. telemedicine, as a means to strengthen and support the healthcare system in africa, and not as a separate entity or competitor to the existing means of healthcare, can help improve healthcare coverage and maximise the use of existing resources either among clinicians and healthcare providers or between patients and healthcare providers. the use of mobile clinics successfully reaches vulnerable populations (10), especially in remote communities, offering urgent and emergency care reduces barriers to healthcare such as transportation, time and complexity and providing preventive services and screenings (25). mobile clinics can be implemented and utilised in catering to a particular region or location. an effective model involves dividing a state into regions and assigning a mobile clinic to each region. even in urban slums, mobile clinics may even provide health services to urban residents who may not afford the expenses of a hospital. a dual implementation of telemedicine and mobile clinics in africa combines the advantages and strengths of each approach while minimising their challenges. for example, mobile clinics present the disadvantage of isolation of health professionals, telemedicine can help bridge that gap and provide a medium for collaboration and connection with other health professionals. telemedicine presents a disadvantage of adedeji oj, babatunde yo, ibrahim ad, adebisi ya, lucero-prisno iii de. towards universal health coverage in africa: relevance of telemedicine and mobile clinics (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4448 8 | p a g e limited infrastructure such as mobile sensors and appropriate camera technology for data collection from patients. mobile clinics can serve as a point of collection of patient information such as blood pressure, body temperature, and other vitals that may be needed to provide a clinical diagnosis. the concept of a dual implementation of telemedicine and mobile clinics is not new in africa, similar projects like "the virtual doctor project" in zambia (46) aim to take medical expertise to remote locations, hence, reshaping and improving primary healthcare for all (46). a powerful combination of telemedicine and mobile clinics can endeavour to provide services to communities where neither the infrastructure nor health facilities exist (46). limitations the study focused more on the implementation and responsibilities of relevant stakeholders in telemedicine systems and less on mobile clinics. they were very few interventions of mobile clinics in african countries. recommendations the emergence of telemedicine and mobile clinics should be seen as an opportunity to renew knowledge for medical policy-making and actions in response to the need to improve health care services for rural and remote communities. additional stakeholders to the already considered patient and physician also need to be factored in the implementation of telemedicine and mobile clinic projects: nurses, pharmacists, knowledge engineers, hardware vendors, communication service providers. it is recommended to have a quantitative study on the general public's perspective so that more factors relating to the perception of the public are uncovered and any issues are addressed in the planning and development of telemedicine projects. stakeholders need to be made aware of standardized project management practices after evaluation. this will contribute to overall improvements in planning, managing, organizing, sustaining, and monitoring of telemedicine and mobile clinics. business models need to be adapted in the national context for successfully implementing telemedicine systems. this is to avoid any financial situations amongst certain stakeholders in terms of the distribution of cost and revenue. more research and studies are needed to be conducted on how the incorporation of mobile clinics can be a great step to achieve universal health coverage in africa. conclusion innovative approaches such as telemedicine and mobile clinics can speed up the attainment of universal health coverage in africa (47). a combination of telemedicine tools and mobile clinics in africa will allow the most remote and vulnerable populations to receive quality care while strengthening health systems across the continent. implementing these approaches, on the other hand, is not without challenges. successful implementation of these initiatives will require that the african health and ict stakeholders embrace the transformative capacity they offer (47). some of the challenges and barriers facing the implementation include an inadequate legal framework, capacity for addressing ethical issues, unreliable infrastructure, long-term feasibility, and funding (10),(47). if these challenges are addressed and stringent measures put in place, these initiatives will go a long way in achieving uhc. references 1. world health organization (who), african union (au). universal health coverage in africa: from concept to action. 1st african ministers of health meeting convened by who and au (2014). adedeji oj, babatunde yo, ibrahim ad, adebisi ya, lucero-prisno iii de. towards universal health coverage in africa: relevance of telemedicine and mobile clinics (review article). seejph 2021, posted: 18 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(http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 46. e.n. mupela, p. mustarde, h.l. jones. telemedicine in primary health: the virtual doctor project zambia. philosophy, ethics, and humanities in medicine. 6.1 (2011): 9. 47. olu oo, muneene d, bataringaya je, nahimana mr, ba h, turgeon y, karamagi hc, dovlo d. how can digital health contribute to sustainable attainment of universal health coverage in africa? a perspective. frontiers in public health. 2019;7:341. ______________________________________________________________________ houghton f, o’doherty d, mcinerney d, duncan b. anti-tobacco text warnings in italy: geography, language, and south tyrol (short report). seejph 2019, posted: 21 may 2019. doi 10.4119/unibi/seejph-2019-218 page 1 of 4 short report anti-tobacco text warnings in italy: geography, language and south tyrol frank houghton1, diane o’doherty1, derek mcinerney2, bruce duncan3 1 department of applied social sciences, limerick institute of technology, moylish, limerick, ireland; 2 department of sport, limerick institute of technology, moylish, limerick, ireland; 3 hauora tairawhiti, gisborne, new zealand. corresponding author: frank houghton, phd, mphe, ma, msc, director healr research group; department of applied social sciences, limerick institute of technology, limerick, ireland; telephone: +353-87-7101346; email: frank.houghton@lit.ie houghton f, o’doherty d, mcinerney d, duncan b. anti-tobacco text warnings in italy: geography, language, and south tyrol (short report). seejph 2019, posted: 21 may 2019. doi 10.4119/unibi/seejph-2019-218 page 2 of 4 the global death toll from tobacco is now estimated to be in excess of 6 million annually, with projections of this burden reaching 8 million by 2030 (1). the impact of smoking on morbidity is equally alarming, as well as it having a significant adverse impact on individual and family finances. focusing on italy, the tobacco atlas notes that 28.3% of men aged 15 and over, and 19.7% of women of a similar age smoke (2). the annual death-toll of 93,300 from tobacco-induced illness, and an economic cost of 26041 million euro. although smoking is not highly regulated in italy (2), under european union legislation all tobacco products sold there carry mandated combined graphical and text warnings. an example of one of the current italian cancer warnings contained on cigarette packets is given in figure 1a. as the one official language of the italian state, it is perhaps no surprise that this warning is written in italian. however, this one-size-fits-all approach glosses over important linguistic differences within italy, most notably in relation to south tyrol (südtirol [german] / alto adige [italian]) in the northeast of the country. previously part of the austro-hungarian empire, the south tyrol region was annexed by italy following the end of world war one. although german speaking, the region was subject to a policy of italianization and italian inmigration during the fascist era under mussolini. although agreement on a solution was reached between hitler and mussolini, de facto annexation of the region by occupying german forces occurred after italy surrendered and then joined the allies in world war ii. in 1946 italy and austria signed the paris treaty which secured cultural, economic and linguistic rights for the region. fifteen years later this treaty had still not been enacted, which led to a campaign of violence in support of the rights of the german speaking population. this culminated in debates in the un and ultimately the 1972 second autonomy statute, known as the ‘package’. this agreement officially ended the dispute between austria and italy over the status of south tyrol in 1992. this agreement created an autonomous zone in south tyrol and contained over 130 measures designed to safeguard the germanspeaking minority there (3). the south tyrol population is 511,750, the majority of which is (62.3%; 314,604) german speaking (italian census, 2011). less than a quarter of the population (23.4%; 118,120) speak italian, with the third recognized linguistic group, ladin speakers, constituting just 4.1% (20,548) of the populace. these statistics are important because emerging evidence from anti-smoking research in ireland (4) supports basic marketing communication theory which stresses the importance of language ability and preference in health warnings, as well as the need for ease and speed in health communications. under primary and secondary elements of the ‘package’ the south tyrol rgion already has a legal remit in relation to matters of language, health and public health. the south tyrol region therefore should strongly consider legislation to require either bilingual (german then italian), or preferably trilingual antismoking text warnings (german then italian, followed by ladin). south tyrol would then join other areas within the eu with more than one language in its combined graphical anti-smoking warnings. such linguistic diversity is currently reflected in the anti-smoking warnings in the five countries that are officially bilingual (malta [see figure 1b), ireland, finland, cyprus, & luxembourg) and belgium which is officially trilingual (see figure 1c). houghton f, o’doherty d, mcinerney d, duncan b. anti-tobacco text warnings in italy: geography, language, and south tyrol (short report). seejph 2019, posted: 21 may 2019. doi 10.4119/unibi/seejph-2019-218 page 3 of 4 the relatively small population of south tyrol is not a reason to justify continuing with an ‘italian only’ approach on the combined text and graphic warnings. the population of the region is considerably larger than that of malta (approximately 430,000), an eu state with its own unique requirements in antismoking warnings. as can be seen from figure 1b current maltese legislation requires warnings in both english and maltese (5). figure 1. examples of current anti-smoking combined graphic and text warnings from italy, malta & belgium 1aitalian warning 1bmaltese warning 1cbelgium warning it is easy to overlook the importance of text warnings in an era of graphic pictorial warnings. however, evidence suggests that text based warnings are still an important element of health education and in some ways may be more influential than graphic warnings (6-8). it is also notable, as noar et al. point out, that if one assumes an average consumption of 20 cigarettes per day for a year, this equals a total of 7,300 potential opportunities to view the combined text and graphic warnings annually (9). this form of direct marketing to smokers therefore may achieve incomparable penetration to the target audience. the damage wrought by smoking is such that continuing with a generic italian only approach is no longer acceptable. every effort must be taken to reduce smoking using a multiplicity of approaches. this proposal has two crucial factors in its favour. most importantly, the population in south tyrol, like those elsewhere within the eu, are familiar with, and largely accepting of, combined text and graphic anti-smoking warnings. as such this initiative is largely a fine-tuning of current protections, rather than a new development. therefore it is unlikely to encounter significant opposition, and given the strength of feeling towards language exhibited by the german-speaking population of south tyrol, may well be welcomed. an additional advantage of this approach is that the cost of this intervention is borne solely by the tobacco producers. this development therefore is attractive to regulators and policy makers operating in fiscally constrained environments. conflicts of interest: none. houghton f, o’doherty d, mcinerney d, duncan b. anti-tobacco text warnings in italy: geography, language, and south tyrol (short report). seejph 2019, posted: 21 may 2019. doi 10.4119/unibi/seejph-2019-218 page 4 of 4 references 1. world health organisation. who report on the global tobacco epidemic, 2011. geneva: world health organisation; 2011. 2. italy | tobacco atlas [internet]. tobacco atlas. 2018 [cited: 5 november 2018]. https://tobaccoatlas.org/country/italy/ (accessed: 13 may 2019). 3. alcock a. from tragedy to triumph: the german language in south tyrol, 1922-2000. in: hogan-brun g, ed. by. national varieties of german outside germany: a european perspective. bern, switzerland: peter lang; 2000. p. 161-94. 4. o’doherty d, houghton f, mcinerney d. tobacco control in ireland: how effective are dual health warnings on tobacco packaging? tob prev cessat 2018; 4(supplement):a72. doi: https://doi.org/10.18332/tpc/90316. 5. o’doherty d, houghton f, mcinerney d. asleep at the helm? language and malta's new combined tobacco control warnings. public health 2018;163:1557. 6. pepper jk, cameron ld, reiter pl, mcree, a-l, brewer nt. nonsmoking male adolescents’ reactions to cigarette warnings. plos one 2013;8:e65533. doi: 10.1371/journal.pone.0065533. 7. sabbane li, lowrey tm, chebat j. the effectiveness of cigarette warning label threats on nonsmoking adolescents. j consum aff 2009;43:332-45. 8. evans at, peters f, shoben ab, meilleur lr, klein eg, tompkins mk, et al. cigarette graphic warning labels are not created equal: they can increase or decrease smokers’ quit intentions relative to text-only warnings. nicotine tob res 2017;19:1155-62. 9. noar sm, hall mg, francis db, ribisl km, pepper jk, brewer nt. pictorial cigarette pack warnings: a metaanalysis of experimental studies. tob control 2016;25:341-54. ______________________________________________________________________________________ © 2019 houghton et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ministry of health consolidated work plan 2016/17 ministry of health republic of liberia consolidated operational plan fy 2016/17 september 2016 ministry of health consolidated work plan 2016/17 2 foreword liberia emerged out of 14 years (1989-2003) of brutal conflict that ravaged gains made in every sector of the society. with one decade of relative peace and stability, liberia restored health services and started making enormous strives in childhood mortality reduction, decline in aids related deaths and expansion of health services. unfortunately, in 2014, the country was hit with an incomparable ebola outbreak that shattered gains in health status, social values and the economy. the impact of the evd outbreak was very grave, affecting households’ income, health status and food security. the crisis depleted the health workforce, led to low utilization of health services and desertion of health facilities by service providers. the economic forecast shows that the outbreak is draining the finances of governments—increasing national deficits due to additional expenditures incurred during the evd crisis amidst drastic shortfalls in domestic revenue. the ministry of health in 2007 developed a post conflict policy and strategic plan that guided the health sector into restoration and recovery for five years (2007-2011). the five years plan were revised to ten years with new strategies to maintain gains and further improve health outcomes. the 2011-2021 national health plan was launched in 2011 and implemented until 2014 when ebola exposed the health systems vulnerabilities. in order to address the health systems fragilities, the health sector investment plan was formulated to drive responsiveness and resiliency in the sector. the investment plan has nine vital areas for improving the sector effectiveness, efficiency, and resilience. it is my conviction that despite the colossal challenges we have to surmount in the health sector to attain the health related sustainable development goals (sdgs) and resiliency, i am confident that the fy 2016/17 operational will be instrumental in translating the strategic priorities of the health sector recovery and development as stipulated in the investment plan (2015-2021) into concrete actions. i trust that partnership will take us to alignment and harmonization, and make the operational plan a reality. i am pleased to express my deep appreciation and sincere gratitude to all stakeholders, partners, and moh staff that contributed technical and financial support in the development of the operational plan 2016/17. dr. bernice dahn md, mph, flcp minister of health ministry of health consolidated work plan 2016/17 3 acknowledgement the annual operational plan is the road map for the implementation of the post evd recovery plan and the health sector investment plan for building a resilient health system. the overall objective of the plan is to ensure a functional and resilient health system that guarantees its population an effective and equitable health. the plan is a consolidation of both central and county levels work plans. the ministry of health is pleased to recognize the effort of all of those who contributed to the development of the fy 2016/17 annual operational plan. special thanks are extended to members of the county health teams, moh departments, programs and divisions for their contributions towards the formulation of the annual operational plan. without their involvement, the consolidated operational plan would not have been finalized. the moh is grateful to the world health organization for providing financial and technical support for the orientation and training workshops for county health teams and partner and the elaboration of the annual consolidated operational plan together with epos eu ta. special gratitude is extended to usaid (fara project) for providing funds for the county level planning process. we want to express our appreciation to all ngos, un agencies for technical support and county officials that participated in the planning exercise. your participation and contributions have made this document useful and inclusive. it is our hope and aspiration that the annual operational plan will be used as the health sector development agenda for fy 2016/17 at all levels to build a system that is responsive, effective and resilient. let us solicit the financial and technical resources to implement this operational plan together. ministry of health consolidated work plan 2016/17 4 table of contents 1.0 introduction ......................................................................................................................6 1.1 background ................................................................................................................................... 6 1.2 health sector governance and management ................................................................................ 6 2.0 planning cycle and processes ..........................................................................................8 2.1 planning objectives ....................................................................................................................... 8 2.2 planning process ........................................................................................................................... 8 3.0 situational analysis and performance fy 2015/16 ...................................................... 10 3.1 situational analysis ........................................................................................................... 10 3.2 performance fy 2015/16 ................................................................................................... 11 4.0 operational plan 2016/17 ................................................................................................ 12 4.1 health infrastructure ................................................................................................................. 12 4.2 human resources for health ...................................................................................................... 13 4.3 health care financing ................................................................................................................. 14 4.4 emergency preparedness and response (epr) .............................................................................. 14 4.5 health service delivery and quality of care ................................................................................ 17 4.6 drugs and supply chain management ......................................................................................... 31 4.7 health information systems, m&e and research ........................................................................ 32 4.8 community engagement .............................................................................................................. 34 4.9 leadership and governance ......................................................................................................... 34 5.0 costing and budgeting .................................................................................................... 35 5.1 national budget................................................................................................................... 36 6.0 monitoring and review of investment plan ................................................................ 36 annexes ............................................................................................................................................ annex a: health infrastructure needs fy 2016/17 ......................................................... 37 annex b: supply chain fy 2016/17 activities ............................................................................................ 38 annex c: health sector performance framework ................................................................................... 38 annex d: county level performance framework ..................................................................................... 40 ministry of health consolidated work plan 2016/17 5 abbreviations cha community health assistant chw community health worker csa civil service agency evd ebola virus disease epr emergency preparedness response epi expanded program on immunization fara fixed amount reimbursement arrangement fhd family health division fy fiscal year hr human resources hf health facility his health information system hmer health information system, monitoring and evaluation and research hmis health management information system m&e monitoring and evaluation mfdp ministry of finance and development planning moh ministry of health nacp national aids & stds control program nds national drug osc one stop center op operational plan sop standard operating procedure ttms trained traditional midwives ministry of health consolidated work plan 2016/17 6 1.0 introduction 1.1 background the 10-year strategic plan (2011–2021) and the post ebola crisis national investment plan (2015–2021), provide an overall guide and orientation, while the instrument that is required to ensure that the strategy is implemented is the operational plan (op). the health sector recognizes its inherent health system challenges and weaknesses that were further amplified by the impact of the ebola crisis. the operational plan is the annual roadmap to implement the national investment plan (2015-2021). the op provides priorities activities and establishes targets that are linked to budget, which is funded through a combination of known domestic and external resources. it was formulated based on county and central levels consultations with various stakeholders. in view of the national investment plan, the current operational plan, while focusing on safe and quality health services, recognizes the need to invest on key support components of the health system that enable service provision and fosters donor coordination and alignment at decentralized and central levels of the health system. the process of planning has also taken account of existing capacity and resources through integrating the contributions of most development partners into a consistent framework, both in terms of financial and of technical assistance. the plan intends to address issues related to recovery through phased or incremental changes but in an equitable and sustainable manner. furthermore, the recovery phase of the operational plan goes beyond the hardware required to include the regulatory and implementation capacity building components. moreover, products of the annual plan consist of aligning available funding with planned activities, resources, and service delivery targets. 1.2 health sector governance and management the liberian government comprises three separate branches, the executive, judiciary, and house of representatives and the senate. administratively, the country is divided into 15 counties and 73 political districts. the country is however demarcated into 89 health districts for operational purposes. the superintendents are the heads of the counties. the superintendents and other county functionaries (district commissioners, paramount chiefs, clan chiefs, city majors and town chiefs) are appointed by the president. with the wave of reforms in governance, the superintendents and other government functionaries in the future are likely to be elected by the people if the local government act now before the ministry of health consolidated work plan 2016/17 7 house is passed into law. in the draft act, the county structure consists of 9 departments. the county health team becomes a department of health. 1.2.1 structure of ministry of health the minister of health is appointed by the president and is not a member of the house of representatives or of the senate. the minister is assisted by four deputies manning the following departments: health services; planning, policy and development; administration, and public health recently included out of the aches of the ebola crisis. there are several assistant ministers heading bureaus and managers heading divisions and vertical programs such as the national tb & leprosy control program (ntlcp), the national aids & stds control program (nacp), etc. there are four levels of supervision: (i) central level, which includes departments, programs, divisions and units, (ii) county level, hospitals and lower level health units, (iii) district level, and (iv) community based health services. the county health services and community health services units of the ministry of health have been established to provide direct support to the counties and community based services, respectively. while systems for supervision and monitoring exist, there are enormous challenges. the fiscal year plan is to redress issues of the essential services and other components of the investment plan. strong involvement and engagement of communities and their representatives are expected to play a critical role in the management and monitoring of the operational plan at all levels of the health system. minister department of health services bureau of curative services 15 county health and social welfare teams bureau of preventive services national programs (e.g., tb, epi, malaria, etc department of planning and statistics bureau of planning and policy bureau of vital statistics department of administration bureau of fiscal affairs bureau of administration department of public health minister department of health services bureau of curative services 15 county health and social welfare teams bureau of preventive services national programs (e.g., tb, epi, malaria, etc department of planning, policy and development bureau of planning and policy bureau of vital statistics department of administration bureau of fiscal affairs bureau of administration department of public health ministry of health consolidated work plan 2016/17 8 2.0 planning cycle and processes 2.1 planning objectives the overall objectives of the operational plan are to ensure a functional and resilient health system that guarantees its population an effective and equitable health. the operational plan however, is to enhance implementation of the investment plan for recovery and resilience through coherent planning and budgeting at different levels of the health care delivery and management systems. the specific objectives are as follows: 1. identify and measure needs, 2. map available resources (hr, infrastructure and financial); 3. establish baselines and set targets for the priority activities of the recovery of the investment plan; 4. prioritize activities for implementation of programs and delivery of services during the fiscal year; and 5. develop a harmonized and integrated annual plan in line with the investment plan (2015-2021). 6. the expected results of the annual operational plan, 2016/2017 1. annual health sector plans for 15 counties, 2. a consolidated national integrated annual plan fy 2016/217 2.2 planning process in 2014, the ministry of health with support from its development partners reviewed the implementation of its 10-year national health plan and strategy (2011-2021) and developed a post evd response national health investment plan and strategy (2015-2021) aimed at restoring health care services and to incrementally enhance resilience and health security in the health services delivery system. one fiscal year of implementing this resilience strategy elapsed at the close of the fy 2015/16. to operationalize the national health investment plan (2015-2021) the department of planning, research & human development is mandated to specify the investment plan into core and comprehensive operational plans at community, health facility, county, and national levels. the process involves the provision of technical support for the development of each county’s operational plan from the levels of the community to health facility including the districts that culminated into the counties’ operational plans for the ensuing fiscal year. the central level support by extension is also aimed at building the capacities of counties in planning, budgeting, data analyses and service delivery target setting. ministry of health consolidated work plan 2016/17 9 additionally, the county planning process is comprehensive and entails the review of counties performance over the preceding fiscal year with an assessment of the previous plan to inform the development of the ensuing fiscal year. coupled with this, the process also includes the customization of the planning tools, templates and developing national targets while at the same time aligning activities and resources at the county level with all implementing partners providing services at all levels within the counties (community, facility district, and county). the process of producing the ministry of health’s consolidated operational plan follows its planning cycle aligned with that of the government of liberia. it begins with the situational analysis, followed by the priority settings, options appraisal, programming and monitoring and evaluation. moreover, it focuses on possible health system diagnosis, including bottleneck analysis, the enabling environment at operational levels that follows the select of appropriate target setting and integration of resources and activities mappings to ensure the harmonization and alignment at county and national levels. the process follows a consultative and participatory process to ensure that all key stakeholders are involved. the activities and steps that follow are conducted both at county and national levels to facilitate the development of the consolidated national health operational plan. step 1: compile and share operational planning tools, guides, and reference documents: a. all key documents to be used in the process are collected, compiled and distributed to all relevant stakeholders at county and national levels; b. existing moh operational planning guides and revised tools are adapted to respond to the needs of the planning exercises. step 2: prepare and orientate technical working groups consisting of moh health managers and partners for the operational planning exercise: a. set national targets that aligned with the national health investment plan; b. conduct activity and resource mapping (local, government, donors and partners); c. adapt planning tools and guides to inform planning at all levels; d. identify national and county teams and technical assistance to support the operational planning process and plan orientation sessions e. hold central and county levels operational planning orientation sessions step 3: assess and mobilize resources, both on and off budget at all levels of the health system step 4: develop operational plans at various levels (facility, district, county and central levels) ministry of health consolidated work plan 2016/17 10 a. update county situational analyses with improved data/information; b. establish targets for main service delivery components aligned with the national indicative targets; c. identify priority strategies/actions to achieve targets; d. analyze health service delivery systemic components (human resources for health, financing, infrastructure, supply chain) and set objectives; e. estimate resource requirements to implement planned priority interventions f. establish objectives, activities and funding step 5: finalize, consolidate, and implement national health operational plan (the consolidated plan guides the sector for the ensuing fiscal year) a. policy and planning unit collaborates with central moh departments, divisions, units and programs to develop central level plans; a. operational plans get reviewed and feed backs provided until plans meet the standards and deliverables; b. the policy and planning unit coordinates with technical team to consolidate national health operational plan for dissemination and consequent implementation 3.0 situational analysis and performance fy 2015/16 3.1 situational analysis in 2015, the health sector led by the moh developed a post evd recovery plan and an investment plan to restore basic health service and build a health care delivery system that is resilient. the investment plan identified nine (9) critical health system areas for investment that will drive the system to be more responsive, efficient and resilient. there are currently, 727 health facilities in liberia of which 64% are public. these facilities provide 71% of liberians geographical access within 1 hour of walking distance or within 5km of walking distance. though nationally, 29% of the population lacks physical access to health care, 20% (3 out 15) of the counties have over 50% of their population living beyond 5km or 1hour walking distance within reach of a health facility. the 2013 liberia demographic and health survey results revealed that 65% of households do not drive by cars but walk to health facilities in case of need. the 2016 health workforce census results show that 35% of health facilities lack electricity while 32% do not have water supplies. the health workforce census documented 16,064 health workers of which 10,672 are within the employed of the moh. one-third of the public health workers are clinical and their distribution is skewed towards urban areas. there acute shortage of critical health workers such as physicians, midwives, lab technicians and specialist doctors (ie: surgeons, pediatricians, psychiatrics, etc). ministry of health consolidated work plan 2016/17 11 drugs and medical supplies is an essential component of the health system. however, this area is characterized by irregular supply of drugs and medical supplies, limited number of personnel, (pharmacists), to prescribe, quantify and dispense medicines to patients. due to inadequate budgetary allocation to procure and distribute drugs and medical supplies, patients are often given prescription to buy unavailable essential medicines. monitoring, supervision and mentoring has been weak and irregular. furthermore, the capacity of the hmis is still inadequate for example data collection and timely reporting from the service delivery sites have remained incomplete and less integrated. information use culture at the collection and intermediate aggregation levels has remained weak. the utilization of health services in liberia is poor due to limited access and/or poor quality of health services and patients and providers’ relationship. in 2015/16, utilization rate was 1.06, which is only 21% of the optimal utilization rate (5.0). antenatal care (4 visits) was 57.5% and only one-third of postnatal mothers received care. half (51%) of the pregnant women delivered in health facilities and 60% of children under age one were fully immunized with all basic vaccines. 3.2 performance fy 2015/16 the health sector performance was appalling in 2014 due to the devastation caused by evd in the country. however, during the restoration and recovery stages of the investment plan (2015), basic health services were restored and utilization increased. the sector has made progress since the cessation of the evd crisis, although few of the health service delivery targets were not achieved. table 3.1 presents service delivery summary accomplishments. on the other hand, hmis report submission increased from 70% in 2014 to 78% in 2015/16 and timeliness improved from 41% to 57% over the same period. the proportion of health facilities with basic utilities (ie: water and electricity) increased from 55% in 2014 to 66% (hr census 2016). table 3.1: health service delivery indicators, targets and achievement in fy 2015/16 # health service delivery indicators baseline targets fy 2015/16 achievement 1 % of children under 1yr fully immunized 46% 64% 60% 2 penta -3 63% 75% 65% 3 measles 58% 64% 64% 4 anc 1st visits 61% 75% 75% ministry of health consolidated work plan 2016/17 12 5 anc 4th visits and more 46% 51% 58% 6 institutional delivery 40% 45% 52% 7 % of deliveries by skilled birth attendants 39% 42% 51% 8 % of pregnant women receiving second dose iptp 39% 44% 41% 9 % of postnatal mothers that received pnc 29% 34% 33% the number of health facilities providing health services increased by 71 from 2014 – 2015 (656 in 2014 to 727 in 2015). additionally, the public health workforce increased from 10,052 in 2014 to 10,673 in 2016. the number of health workers placed on government of liberia payroll increased from 5,920 in 2014 to 7,214 in 2016. 4.0 operational plan 2016/17 4.1 health infrastructure health infrastructure is the second priority pillar of the health sector investment plan that allows access to health care. expanding access to quality health care through the construction, renovation and improvement of health facilities is critical for reaching the 1.2 million liberians that are derived of basic health services. investment in this pillar is enormous and requires both domestic and external resources. objective: to increase physical access to the ephs services. to accomplish this objective, ten major activities have been earmarked for the fiscal year 2016/17 excluding the national drug service warehouse and the health workers housing unit projects. below is the list of the 2016/17 planned activities: central level activities 1. construct national drug depot (nds warehouse) 2. assess and complete 16 abandoned clinics 3. build 168 staff housing units county level activities 1. construct 29 primary clinics 2. construct 47 maternal waiting homes 3. construct 41 incinerators 4. construct 34 triages ministry of health consolidated work plan 2016/17 13 5. fence 52 health facilities including phebe hospital 6. construct 26 clinics laboratory 7. build 17 district health teams’ offices 8. renovate 20 health facilities annex a provides a table depicting major infrastructure activities by county as recorded in their operational plan. the table precludes national level activities. 4.2 human resources for health objective: build a fit for purpose productive and motivated health workforce that equitably and optimally delivers quality services target 1: to ensure the recruitment of needs-based health workforce central level activities 1. conduct health workforce hiring plan to address priority gaps in the health workforce model required for the restoration of essential health services. 2. create 5,000 payroll slots (2015-2016/phase 3. expand payroll slots in relation to needs-based workforce (2016 and beyond) target 2: eliminate fragmentation and inefficiencies in the remuneration payment process and establish platforms for timely, efficient and transparent bank and mobile money transfer systems. central level activities 1. hold consultative meeting with civil service agency and ministry of finance and development planning to establish a singular payroll system. 2. moh and mofdp establish and validate mobile money accounts for salary disbursement of salaries and manage queries and complaints. 3. moh, csa and technical assistance costs to develop remuneration packages options analysis and proposal. 4. explore remuneration package chws county level activities target: ensure the availability of adequate health workforce with inclusive capacity building, supervision and performance appraisal systems at county level. 1. recruit clinical and non-clinical staffers at facility, district and county levels 2. conduct in-service infection prevention and control at county levels 3. ensure county, district and facility levels staffers supervision, appraisal monitoring and performance ministry of health consolidated work plan 2016/17 14 4. conduct evidence-based capacity building sessions for staffers at county, district and facility levels 4.3 health care financing objective: establish sustainable health financing systems that will ensure sufficient and predictable resource generation, risk pooling mechanisms and strategic purchasing of services. implementation of the below noted activities will require collaboration between all health financing functions within the ministry of health and partners, specifically the health financing unit (planning department), office of financial management (administration department), the performance-based financing unit (health services department), fara management office and pool fund management office. central level activities 1. evaluate effectiveness of pbf in liberia to date-full impact evaluation study depending on available resources and feasibility-swot analysis 2. finalize fiscal space analysis and disseminate by end of fy 2016/ 2017 3. finalize resource allocation formula in consultation with stakeholders and apply to fy 2017/18 budget 4. train selected staffers of 15 chts in planning, costing and budgeting (activity based costing) 5. finalize legal proceedings and legislate liberia health equity fund (lhef) act 6. conduct publicity and advocacy in 4 counties on revolving drug fund (rdf) and lhef county level activities 1. support county level capacity building in financial management and auditing 2. develop strategy to mobilize domestic resources and ensure financial sustainability to support county level operational plan 3. establish fixed assets management systems at county level 4. provide short term financial management training for financial officers at county level 4.4 disease prevention and control objective: strengthen national core capacities in compliance with international health regulation (2005) requirements capable to timely detect, investigate and response to epidemic prone diseases and other health related events. central level activities ministry of health consolidated work plan 2016/17 15 1. train and deploy 2000 community health assistants to implement cebs 2. finalize idsr technical guidelines and other relevant operational tool (reporting forms, cebs manual, health facility sop on idsr, maternal death sop, etc) 3. reproduce and distribute training modules and simulation tools for poe 4. develop and disseminate monthly idsr dash board 5. produce and disseminate weekly and quarterly epidemiological bulletin 6. establish functional idsr situational awareness rooms in 16 eocs (national and 15 counties) 7. conduct annual idsr/ihr program implementation review meetings 8. develop national risk communication plan for public health events 9. conduct external assessment of ihr core capacities 10. conduct health risk and vulnerability assessment /mapping 11. develop risk communication operational plan 12. produce and air prevention messages using local radio (idsr jingles, drama, etc) 13. print and disseminate surveillance reporting forms to all levels 14. print and disseminate patient care report form for 100 ambulances 15. print and disseminate idsr technical guidelines to 1,000 health facilities 16. print and disseminate cebs manual to all 1,000 facilities and poes 17. print and disseminate idsr strategic plan to all counties and district offices 18. print and disseminate 100 ambulance guidelines 19. print and disseminate national and county epr plans 20. print and disseminate relevant sops, ems protocol and guidelines 21. print and disseminate job aides: cebs, clinical 22. develop, reproduce, and disseminate idsr priority disease media kits to media houses. specific objective 1: improve idsr data and specimen management, biosafety regulations, ensure interoperability with dsis activities 1. provide logistical support to 3 laboratories 2. validate, reproduce and disseminate national public health lab strategic plan (2017 2022) 3. procure idsr lab. sample collection kits for peripheral health facilities 4. train and mentor idsr focal persons at national, county, district and health facilities 5. scale up idsr surveillance (edews) implementation in 11 counties 6. improve rapid sharing of public health and scientific information and data 7. purchase and distribute reagents, lab supplies, and equipment cholera, lassa fever, yellow fever, evd, measles, shigella, rabies, afp (support transportation and sample referral) ministry of health consolidated work plan 2016/17 16 specific objective 2: strengthen emergency preparedness and response and enhance crosssector coordination and collaboration 1. establish, train and deploy rapid response teams (rrt) at national, county and district levels. 2. support rrt simulation activities across target levels 3. support internal functionality of ph emergency operation centers to coordinate the epidemic preparedness and response at national and county levels (stationeries, fuel, internet connectivity) 4. develop national and county specific epr and disease specific contingency plans 5. work with partners to provide counties emergency contingency fund 6. procure and deploy preparedness stocks in all counties for all priority public health events: cholera, evd, rabies, bloody diarrhea, lassa fever, yellow fever, meningitis 7. conduct midterm review and update of national and county specific epidemic preparedness and response plans specific objective 3: institutional support, capacity building, advocacy, and communication. project coordination, fiduciary management, monitoring and evaluation, data generation, and knowledge management central level activities 1. provide credentialing and capacity building in surveillance staff, including field epidemiology laboratory training programs (feltp-frontline: 3 months; intermediate9 moths; and advance-masters)), and phd programs targeting hospital, chos, national staff, cso, moa, 2. work with the pre-service institutions (medical and para-medical) to build hr instructional capacity and strengthen curriculum 3. train dsos in dead body swabbing and safe specimen collection, packaging and transport 4. support short course (international) in emergency management/ims for all incident command managers at national and county levels 5. train 3 national, 15 counties and 92 district rrts 6. train 15 county health promotion focal persons in risk/outbreak communication 7. cross border coordination meeting at all levels 8. provide incentives for dso county level activities 1. train traditional healers in community case definition of priority diseases 2. provide refresher training on idsr for health facility staff 3. conduct weekly surveillance coordination meeting 4. conduct rrt refresher training for surveillance team 5. refresher training to all hcw on ipc standard precautions ministry of health consolidated work plan 2016/17 17 6. conduct quarterly mentorship on ipc standard precautions 7. supply facilities with iec/bcc materials 8. to conduct health talk using available iec/bcc materials 9. conduct epidemiological investigation of rumors/suspected disease of epidemic potential 10. conduct edews supervision 11. establish data storage for surveillance 12. continue community events based surveillance 13. ensure the supply of ppe for epr purpose 14. establish facilities epr team and conduct in-service training 15. liaise with county health team to provide the updated epr plan to the district and health facilities. 16. work with county pharmacist to supply and maintain the minimum stock of epr supply at all levels 17. work with partner to provide logistic supports (fuel & stationaries) for district epr activities. 18. provide communication equipment (phones, vhf radio etc) for surveillance activities 19. review idsr plan every 6 months to evaluate and improve the performance of surveillance and response systems and provide feedback within and across levels of the health system 4.5 health service delivery and quality of care 4.5.1 improve health of mothers, and newborns services objective: to improve availability and readiness of quality of and demand for maternal, newborn, adolescent and reproductive health services to improve access and coverage. target 1: improve coverage of family planning with couple year of protection in all the 15 counties. central level activities 1. conduct mapping of community based family planning distributors 2. train/refresh cbd to scale up distribution points 3. provide rh commodity storage boxes (wooden) for community based distributors 4. conduct post partum family planning training 5. conduct training/refresher to strengthen and scale up epi/fp integration in all fifteen counties 6. support provision of iucd insertion kits to health care facilities 7. provide financial support for nds for quarterly supply of rh commodities ministry of health consolidated work plan 2016/17 18 8. provide support for printing of revised family planning strategy 9. review, print and disseminate to operationalize the family planning road map 10. support development of messages, radio talk show, jingles/dramas to educate on the side-effects of family planning commodity to reduce myths 11. provide vehicle to support rmncah supportive 12. provide maintenance for vehicles 13. support 1 ta for rh commodities quantification 14. procure 1 laptop for data management (ppmr) at fhd level 15. print and disseminate mother and child health cards to the 15 counties 16. conduct quarterly mentoring in all counties county level activities 1. provide motivational package for gchvs providing cbd services 2. provide logistical support for mentors to implement fp activities at health facility and community levels 3. establish/reactivate condom distribution points in 300 communities 4. implement providers initiated counseling on family planning in all routine health services at all levels 5. identify and train cbd to pilot community depo/injectable administration in three counties 6. integrated family planning, epi, and mch outreach target 2: coverage to basic and comprehensive emergency obstetric and neonatal care (emonc) and essential maternal and newborn care increased in nine counties (health centers and hospitals) central level activities 1. conduct refresher training and tot in blss/emonc quarterly 2. review and consolidate 15 county rh supervisors and partners work plans and consolidate fy 2016/17 3. ensure a sufficient and reliable supply of safe blood for cemonc 4. build new clinics and upgrade select clinics to health centers to improve access to care. 5. deploy community base certified midwives to underserved areas to care for women without access to facilities. county level activities 1. the fhd will review, revise and print the midwifery constitution and disseminate copies to all facilities and stakeholders. 2. validation, printing and dissemination of standards for midwifery practice will be done including monitoring of its use. ministry of health consolidated work plan 2016/17 19 3. fhd will provide support for strengthening implementation of safe delivery services under the national health policy & plan related to maternal, newborn and child health through promotion of delivery kits to facilities. 4. conduct emergency obstetrics and neonatal care (emonc) training basic and comprehensive to nurses and midwives in 6 counties. target 6: strengthen national capacity to address gender-based violence using a multi-sectoral approach and the provision of high quality services to survivors. central level activities 1. support to the 12 existing one stop centers (osc) 2. procure and distribute rape treatment (pep/kit3) 3. provide transportation incentive for osc personnel 4. refurbish two additional oscs in two counties (lofa and nimba) 5. train clinical staff in the management of gbv/sgbv 6. produce medical reporting form-10000 copies 7. supervise and mentor staff at all oscs county level activity 1. implement, supervise and monitor performance target 7: prevention, management and control of pmtct strengthened at national and county level central level activities 1. provide program management, strengthened coordination and collaboration 2. provide on-site training in adherence counseling skills and ensure acceptance attitude for knowing your hiv status for pregnant women. 3. train service providers on option b+, ttms/tba, mother peers, and exposed infants for pcr county level activities 1. provide hiv care, treatment and support services (antiretroviral therapy art) for hiv positive pregnant women and children 2. strengthen and provide mother to mother peer support services (preventing lost to follow-up) father and adolescent 3. provide supportive supervision, on-site mentoring and ensure data accuracy 4. strengthen community based organizations and structures to provide community awareness, sensitization and mobilization on emtct/pediatric and adolescent hiv target 8: improving health and education with emphasis on reduced maternal and child mortality and education achievement services and as well enhanced ministry of health consolidated work plan 2016/17 20 national capacity for treatment and social reintegration of obstetric fistula. central level activities 1. produce 25 copies magazines of fistula survivors success stories 2. provide support for surgical outreach in hard-to-reach counties 3. maintain fistula facilities and services (including patients feeding, laundry services, cleaning) 4. provide salary payment for project staff 5. provide support to operational activities county level activity 1. implement robust mobilization campaigns in 3 hard-to-reach counties 4.5.2 improve child health objective: to improve availability and readiness of child health services to improve access and coverage target 1: reviewed and revised the national child survival strategy (20082011) central level activities 1. undertake comprehensive assessment of process actors and context 2. define goals and priorities 3. validate a national policy target 2: minimum 75% of the monthly target of children under 1 year in all counties vaccinated by august 2015 (for all antigens to achieve 85%), central level activities 1. provide quarterly financial support to 534 hf for outreach vaccination teams for 12 months @ us50.00 2. conduct refresher training on immunization in practice 3. tot for 45 counties participants, 15 national, 6 facilitators 4. conduct quarterly periodic intensification of routine immunization (piri) in all counties 5. conduct national micro-planning exercise 6. implement urban immunization strategy 7. support social mobilization and communication for urban immunization with montserrado county 8. support the development/production of messages 9. procure 100 motorbikes for integrated outreach services ministry of health consolidated work plan 2016/17 21 10. conduct quarterly cold chain and vaccine management monitoring & supervision visits 11. produce, printing and distribution of epi monitoring tools (i.e. child health cards, ledgers, tally booklets, monitoring charts, summary forms and job-aids) 12. train cco and csfp on equipment maintenance and vaccine management 13. procure bundle vaccines and other supplies. 14. distribute bundle vaccines to county depots. county level activities 1. periodic intensification of routine immunization (piri), round 3 2. continue regular immunization with outreach services 3. training for hf personnel on immunization in practice (iip) 4. conduct quarterly monitoring and supportive supervision to district and hfs (provide us$150/month for 12 months), target 3: at least 85% of all 15 counties will attain all epi surveillance indicators by december 2016 central level activities 1. provide regular logistics support and equipment for the conduct of active surveillance activities at counties and districts, 2. support outbreak investigation and response 3. procure data management and ict equipment (e.g. lap top, back-up, antivirus, etc) for county and national levels 4. provide financial support for ncc, nec, and npec activities 5. conduct quarterly surveillance visits to rotavirus sentinel site at redemption hospital 6. develop immunization supply chain (iscm) sops 7. procure and install continuous temperature monitoring device at epi regional cold stores 8. conduct temperature mapping study of cold/freezer rooms at national and regional stores; and temperature monitoring study in vaccine supply chain in accordance with who protocol. 9. conduct cold chain inventory assessment and develop equipment replacement plan 10. procure fuel for county generators 11. procure fuel for county vehicles for vaccine distribution 12. provide financial support to procure immunization supplies and spare parts for motorcycles maintenance for district & hf 150 @ $20/month 13. support running and maintenance of central and 2 regional cold room 14. procure one 4 x 4 utility truck for delivery of assorted immunization supplies and one refrigerated truck for vaccine transportation; three toyota 4x4 pick-up and one 4x4 nissan jeep ministry of health consolidated work plan 2016/17 22 county level activities 1. intensify and strengthen afp surveillance nationwide 2. conduct epi biannual surveillance supervisory visits to priority sites 3. conduct regular quarterly cross border meeting on immunization activities objective: to ensure that at least 90% of all epi data (i.e. absolute numbers & coverage rates) from health facilities are verified by the end of the year. target 4: immunization data quality improved from 85% to 95% completion, by the end 2015. central level activities 1. train health workers (chdd, csfp, data manager & cco) on district vaccination data monitoring tool (dvd-mt) from all counties, 2. conduct quarterly data harmonization and validation. 3. reinforce and recognize good practices publically county level activities 1. conduct independent integrated supportive supervision to districts, and health facilities 2. monthly meetings with chdcc 3. improve documentation and timely reporting to the central level 4. enhance stakeholder coordination at county and below, on monthly and quarterly bases target 5: at least 95% of all 554 hfs have bundle vaccines and supplies available with functional cold chain equipment at all times central level activities 1. forecast and procure bundle vaccines 2. expand cold chain thru the procurement and installation of additional solar direct drive (sdd), wicr, refrigerators, cold boxes, etc. target 6: central and 15 county program management improved central level activities 1. build capacity of county and health facility epi management team 2. conduct mid-term and end of period programme evaluation and planning county level activities 1. train community and health facility managers on basics of health services planning and monitoring ministry of health consolidated work plan 2016/17 23 2. undertake regular supportive supervision 3. facilitate and support stakeholder coordination at health facility and community levels 4. provide timely feedback 4.5.3 community health services objective: strengthen community based health services to improve access and coverage of essential services for communities and families that reside beyond 5 km. target 1: establish support systems to strengthen implementation of quality services (hr, m&e, supply chain and operations, supervision, performance and quality improvement) central level activities 1. develop, define, standardize and validate minimum set of indicators (including community births and deaths) in collaboration with programs 2. develop, field test and finalize data collection and reporting tools for chas and chsss 3. develop cbis database and modules in affiliated systems (ihris, lmis, dhis2, etc) 4. develop sops for cbis data management (data reporting, analysis, use and feedback) and integration with other systems including cebs, lmis, ihris, etc) 5. hold validation workshop for cbis tools and sops 6. print and supply monitoring & evaluation materials (including cbis sops, indicator guidelines/definitions, data collection and reporting forms to counties and health facilities) 7. conduct training and roll-out of cbis at in all 15 counties 8. carry out bi-annual joint coaching & mentoring visits to cha implementation sites target 2: recruitment & training of 2000 chas, 300 chsss and 100 master trainers central level activities 1. develop and validate training modules and guideline 2. facilitate and hire master trainers 3. train hss from the 15 counties 4. train chas 5. deploy and manage work of chas 6. develop supervision checklist and train chss 7. print curriculum, training sops, job aids, tools, and training materials ministry of health consolidated work plan 2016/17 24 target 3: strengthen national advocacy, coordination, partnerships, and leadership at all levels central level activities 1. launch community health assistant program at national level 2. develop a dissemination guide and fact sheet for dissemination at county and local level 3. print policy, strategic plan, implementation guide for dissemination, 4. conduct dissemination workshops & tool kit orientation (implementation guide, tors, recruitment guidelines, etc.) for revised community health services policy & strategic plan and launch cha program in all counties 5. establish and hold monthly coordination meeting for community health partners, chaired by director of chsd 6. organize & host annual review of the community health program county level activities 1. establish county and health facility coordination mechanisms among implementing entities, 2. strengthen health facility boards 3. support chas and health facility health workers integrate advocacy and social mobilization, 4. supervise implementation at community and health facility 5. undertake bimonthly monitoring and review at health facility and community level 6. organize biannual review at county level 4.5.4 improve coverage of health related nutrition services objective: strengthen integration and analysis of nutrition program information and surveillance system. central level activities 1. collect and collate monthly nutrition information not included in the current hmis using moh endorsed nutrition reporting tools 2. organize monthly forums to discuss and address bottlenecks identified in the nutrition program 3. support development and dissemination of quarterly nutrition dashboard county level activity 1. organize monthly forums to discuss and address bottlenecks identified in the nutrition program ministry of health consolidated work plan 2016/17 25 4.5.5 improve mental health services objective 1: enhance the capacity of the national health coordination unit, thereby improving mechanisms for coordination, collaboration and monitoring all mental health related activities by june 2017. target 1: capacity of the national health coordination unit built thereby improving mechanisms for coordination, collaboration and monitoring all mental health related activities. county level activities 1. print the updated national mental health policy & strategic plan to include implementation framework and county specific plan. 2. ensure the provision of additional one 4x4 vehicle to capacitate mental health unit to conduct supervision and other mental health activities 3. conduct quarterly national mental health & psychosocial coordination meeting 4. support to evd survivors to be able to communicate the challenges and tell their stories through individual advocacy, and participatory research through photo voice programs 5. to conduct rapid situation analysis & strengthen mental health data reporting/recording systems integrated with existing hmis and other information management systems as well as, designing software/ database for mental health information system objective 2: increase the clinical capacity of mental health professional target 2: additional 1500 phc workers trained central level activities 1. revise the national mental health policy and update the strategic plan with cost, specification of county level structure and an overall timeframe 2. ensure that all county referral hospitals are well prepared with trained phc workers with mhgap-ig materials to host mentally ill patients 3. print and distribute 500 copies of the validated mhgap materials and launch 4. institute supervision mechanisms to follow up on mhgap trainees 5. increase in the # of mental health clinicians county level activities 1. conduct in service training at the primary care level for additional 1500 phc workers using mhgap materials by dec. 15, 2016 2. conduct training for new cadre of the mental health clinicians (child & adolescent) ministry of health consolidated work plan 2016/17 26 objective 3: advocacy and awareness of mental health issues through celebration of mental health illness reduced misconceptions, common fears to reduce stigma and discrimination for people living with mental illnesses, substance use disorders and epilepsy. target 3: five key mental health days celebrated and advocacy meetings held (both among health workers and populous) county level activities 1. celebrate key mental health days such as world mental health day, world epilepsy day, world drug day, world children mental health day and work with resources in the community (e.g. chws, religious leaders & traditional healers) to raise awareness on mental, neurological and substance abuse disorders and to identify and refer clients 2. mental health unit (mhu) to undertake mental health promotion activities 3. mhu to celebrate international children mh day 4. mhu and dea to celebrate world drug day 5. celebrate international mental health day and work with structures in community (eg chws, religious leaders & traditional healers) to raise awareness on mental, neurological and substance abuse disorders and to identify and refer clients 6. conduct additional community healing dialogue for 1,500 evd affected survivors, family and community members 7. raise awareness on mental illnesses, substance use disorders and epilepsy (radio advent, unmil & elbs) objective 4: to improve the accessibility and availability of quality mental health treatment and services including epilepsy and substance abuse disorders management of all persons at all levels of the health care provision. ensure the improvement, accessibility, availability, distribution and utilization of cost effective psychotropic medications. target 4: accessibility and availability of quality mental health treatment and services improved this should include improvement of epilepsy and substance abuse disorders management of all persons at all levels of the health care provision. county level activities 1. advocate for uninterrupted drug supply chain of essential medicines for mental and neurological disorders to be captured on the national essential medicines list 2. conduct regular supportive supervision and monitor available stocks of psychotropic medication and mental health services at each level of service provision ministry of health consolidated work plan 2016/17 27 3. mhu to work with supply chain management unit (scmu) with forecasting and quantification tools for mental and neurological health care products at national and county levels. 4. mhu to work with scmu in strengthening procurement and the distribution based on needs and request 5. provide mhpss to children affected by evd in 15 counties 6. mental health unit to work with lmhra to regulate, evaluate and register of essential medicines for mental and neurological disorders 7. establish mechanisms to support to evd survivors to be able to communicate the challenges and tell their stories through individual advocacy, and participatory research through photo voice programs remain available 8. conduct psychotropic drugs monthly inventory from 15 counties county level activities 1. conduct independent integrated supportive supervision to districts, and health facilities 2. monthly meetings with chdcc 3. improve documentation and timely reporting to the central level 4. enhance stakeholder coordination at county and below, on monthly and quarterly bases 4.5.6 improve hygiene & environmental services objective: to improve accessibility to, quality of hygiene and environmental determinants of health and related services. target 1: increase hygiene awareness and ensure access to acceptable sanitation with 200 households trigger clts, 50% access to sanitation and 35% practice improved hygiene central level activities 1. develop/produce and disseminate national hygiene promotion guidelines 2. revise clts guidelines strengthen national capacity to manage clts 3. increase access to clts triggering and odf monitoring, capacity building of ntcu staff, re-activation of csc, 12 routines monitoring of clts 4.5.7 county health services objective: to strengthen structures for partnership & coordination at cht and central levels. ministry of health consolidated work plan 2016/17 28 target: structures for coordination and partnership revitalized and monitored central level activities 1. attend monthly prison health coordination meetings to strengthen collaboration 2. develop county heath team partners data base and update to ensure proper coordination and partnership county level activities 1. review and harmonize program work plans for implementation at county levels 2. coordinate with qmu, chts and secondary pbf hospitals to establish qi committees 3. attend monthly prison health coordination meetings to strengthen collaboration 4. develop county heath team partners data base and update to ensure proper coordination and partnership specific objective 2: to ensure implementation of the ephs target 1: routine use of the ephs for health service implemented central level activities 1. support the implementation of ephs package 2. receive all requests including liquidation from chts, pass requests to appropriate unit and ensure prompt action is taken county level activities 1. monitor and evaluate primary health care activities in the county specific objective 3: to strengthen systems through capacity building activities at central mohsw and county levels target 1: systems for capacity building activities are strengthened at central moshw and county levels central level activities 1. work closely with contracting-in coordinator to finalize capacity building 2. provide supportive guidance on the design and implementation of cb activities within the counties county level activities 1. provide supportive guidance on the design and implementation of cb activities within the counties 2. monitor the implementation of cb plan ministry of health consolidated work plan 2016/17 29 specific objective 4: to improve prison health activities and ensure that prisons are provided with quality health care within the 15 counties target 1: prison health activities are improved central level activities 1. conduct quarterly monitoring visits for protection officers & health workers in 15 counties 2. provide essential hygienic materials for inmates county level activity 1. provide essential hygienic materials for inmates specific objective 5: to strengthen contracting mechanisms for the delivery of the ephs target 1: harmonization of contracting mechanisms central level activities 1. organize meeting with all donors’/fund holders for the implementation of various contract schemes 2. standardize all contracting mechanisms approach 3. develop zero draft of the contracting guidelines and tool 4. pretesting of the zero draft of the contracting guidelines and tool 5. validation of revised contracting-in guidelines and tool 6. conduct end of contracts performance appraisal for all contracts county level activities 1. conduct readiness assessment for county to be contracted in 2. conduct training for chts on the guidelines and tool 3. capacity building mentoring and coaching for contracting-in 4. quarterly monitoring of county readiness for contracting 5. conduct end of contracts performance appraisal for all contracts 4.5.8 national health promotion specific objective 1: improved coordination among major stakeholders in promoting healthy practices by the end of 2016 target 1: health promotion policy, strategic plan and communication strategy finalized, validated, printed and disseminated central level activities ministry of health consolidated work plan 2016/17 30 1. complete and validate health promotion policy, strategic plan and communication strategy, 2. develop and disseminate health promotion policy briefs and conduct policy dissemination events at the county level. 3. develop national emergency risk communication strategy 4. initiate partner mapping in all counties 5. establish health promotion technical working groups at county and district levels 6. conduct joint assessment on risk communication capacity 7. training of ecap2 ngo network on health messaging using lla training methodology 8. initiate bio-safety and traffic health hazard awareness and sensitization 9. assessment on knowledge on cervical cancer and rota vaccine (diarrhea vaccine) 10. development of messages and materials to create awareness and sensitize the general public for all vaccine preventable diseases 11. under the leadership of the hptwg/messages and materials development (mmd) working group, draft and disseminate rmnch message guide. 12. development of messages and materials to create awareness and sensitize the general public to prevent stigmatization of ebola survivors 13. review and revise pretest questionnaire for message and materials development 14. identify, recruit and train volunteers for pretesting of messages and materials 15. introduction of hpv vaccine and rota vaccine launching nation wide campaign on healthy life brand and airing of radio spots to increase demand of and utilization of health services county level activities 1. initiate partner mapping in all counties 2. awareness campaign on non communication disease in all 15 counties 3. development of messages and materials to create awareness and sensitize the general public to prevent stigmatization of ebola survivors 4. introduction of hpv vaccine and rota vaccine specific objective 2: strengthen and sustain community engagement, to identify health needs and take actions target 1: community stakeholders will be aware and sensitized to disseminate information to community members central level activities 1. dialogue with community stakeholders (chiefs, religious, traditional, youths leaders and women groups 2. radio distance learning program to enable chvs to implement more effective health promotion and social mobilization activities leading to improved health practices and return to rmnch services ministry of health consolidated work plan 2016/17 31 3. continue the orientation of select chvs and their supervisors on the community engagement tool, bridges of hope 4. training of 1,500 chcs on health messaging and community health risk reduction plan county level activity 1. dialogue with community stakeholders (chiefs, religious, traditional, youths leaders and women groups specific objective 3: empower media to inform and educate the public to promote healthy life style by the end of 2016 central level activities 1. strengthen partnership with media in health promotion activities 2. conduct radio/tv shows, print news letter and provide information to the public 3. continue and maintain the dey say rumor tracker system, expand network of users, conduct roundtables with local media, orient chws and chvs to dey say use, mentor journalists on the use of dey say 4. establish resource center/ documentation 4.6 drugs and supply chain management drugs and medical supplies is an essential component of the investment plan for building a resilient health care in liberia. this pillar is under-funded, with insufficient capacity to effectively deliver and maintain commodities and supplies at the service delivery levels. these factors result in frequent stock out, distribution of prescriptions to patients and low utilization of health services. objective: to put in place a cost-effective and efficient supply chain management systems for essential medicines and supplies, including ppes. to achieve this objective, 18 major activities have been earmarked for the fiscal year 2016/17. below is the list of the 2016/17 planned activities: central level activities 1. develop and decentralize lmis 2. evaluate interim approach 3. distribute drug and medical supplies from nds 4. assess drug national and counties drug depots 5. conduct six counties drug depots (lofa, grand kru, sinoe, bomi, grand bassa and grand cape mt) 6. build drug shelves in 350 health facilities and at supply chain offices ministry of health consolidated work plan 2016/17 32 7. de-junk and incinerate health facilities and depots expire drugs 8. automate the lmis into the general hmis of the moh 9. procure ict equipment (laps, desktops, scanners, printers, etc) 10. train supply chain officers and program managers on reporting, supervision, monitoring, quantification and supply chain management 11. dispose of expired pharmaceuticals and medical equipment without harming the environment and the community 12. procure drugs and medical supplies 13. procure motorcycles a for supply chain officers 14. procure vehicles for county pharmacists 15. train dispenser on rational use of drugs and supply chain management 16. conduct quarterly monitoring and audit county level activities 1. conduct last mile drug and medical supplies distribution 2. procure lab reagent 3. conduct quarterly monitoring and supervision 4. procure essential drugs and medical supplies 4.7 health information systems, m&e and research health information system, research and m&e are the fulcrum for the evidence-based management that the ministry of health subscribes to. the his, m&e and research units have set objectives and earmarked key activities that are geared towards strengthening data collection, information generation and inquiry to support management decision making, implementation tracking and performance monitoring. the objectives and key activities include: objective: strengthen m&e, research and his capacity and coordination to ensure a functional m&e system with harmonized data sources that meets all stakeholders’ needs. central level activities 1. hold monthly hmer technical working groups with all national programs and technical partners 2. hold quarterly hmer coordination committee meeting with senior moh manager and representative of donor institutions. 3. map key partners for research, local and international to identify opportunities for collaboration and support for research 4. train county m&e staff in monitoring and evaluation concept and practices for effective m&e at the lower levels ministry of health consolidated work plan 2016/17 33 5. train county and district health teams on data use in ongoing management decision making 6. mentor county health m&e team to master core m&e skills and execute their functions with efficiency and effectiveness, and transfer skills down to the district levels 7. train district health team on data validation, analysis and interpretation 8. decentralize dhis-2 to district levels on an incremental basis as district health teams developed. 9. produce and disseminate revised national m&e policy and strategy 10. validate, produce and disseminate moh indicator reference book to all stakeholders including the chts and districts offices. 11. mobilize resources for logistics to facilitate core m&e activities to the decentralized levels 12. develop unique code for id for every health facility in collaboration with key stakeholders including lisgis and liberia medical and dental council. 13. produce master facility registry capturing all health facilities in the country indicating their facility types and gps coordinates. 14. work towards the development of the seven sub-information systems on an incremental basic with standards and capabilities to interoperate and exchange data 15. train 20 health managers on research methodologies, analysis and report writing. 16. train 15 health managers on the use of statistical packages and technical writing skills 17. establish health research repository 18. produce quarterly dashboard and scorecards using selected core indicators to measure moh’s overall and key programs performance 19. produce quality of performance report to inform management on some of the factors influencing and or impeding progress on service delivery, quality of care, and health system strengthening; and to document those enablers, challenges, lessons, and good practices to inform remedial management actions. 20. conduct quarterly verification of implementation and monitoring visits to counties monitor counties’ implementation of the nhpp as expressed in their annual operational plan, looking at chts, facilities and communities as well a ngo partners’ activities. 21. county m&e teams to conduct routine data verification, monitoring and m&e supervision to the districts and facilities levels 22. county m&e to produce quarterly reports to inform chts of their performances as well as central moh on where each county stand on progress towards their annual targets and activities plan. 23. conduct annual nation review of the health system to take stock of performance for the year in review and fine-tune operation plan for the following year. 24. conduct quarterly review at central to look at output and assess progress towards national annual target and key investment activities ministry of health consolidated work plan 2016/17 34 25. county conduct quarterly data and performance review meetings involving facilities, districts and local authorities to discuss success and failures and look at assess strategies against challenges 4.8 community engagement objective: strengthen community awareness on health risks and their engagement and linkages with the health system. central level activities 1. develop community engagement policy and strategy 2. conduct stakeholders’ orientation on community engagement policy and strategy county level activities 1. engage ttms to refer pregnant women from communities to health facilities 2. conduct awareness and public education on ena by ttms and gchvs 3. support gchvs/cha to deliver integrated community health services 4. conduct monthly meeting with chdc to take ownership of health facilities 5. conduct idsr refresher training for gchvs, ttms and community leaders in community event based surveillance 4.9 leadership and governance objective: strengthen governance, leadership and management capacities at all levels to implement the national and county plans. central level activities 1. finalize and validate the ministry of health organizational structure 2. finalize the organizational structure of the chts 3. develop, review and validate county health boards mandate, membership and tors (operational manual) 4. establish, finalize and validate organizational structures of dhts 5. reactivate /establish district health boards 6. review and align the ministry of health decentralization policy and strategy to the national health investment plan (2016-2021) 7. print and disseminate the revised national health sector decentralization policy & plan (2016-2021) target 1: 15 county annual plans and the consolidated national plan 2016/17 with an effective feedback mechanism from the central to counties, districts, and communities are developed. ministry of health consolidated work plan 2016/17 35 1. develop standardized guides and tools for formulating the annual operational plan. 2. apply a bottom up approach to develop annual operation plans for the district and counties with the participation of all stakeholders 3. facilitate and conduct horizontal plan for the central moh and a consolidated annual plan for the whole health sector for the fiscal year county level activities 1. conduct quarterly county health board meetings 2. orientate county health board members on their roles and responsibilities (csh) 3. conduct quarterly district health coordination meetings 4. conduct bi-annual county review meeting with (csh) in collaboration with partners 5. conduct quarterly health board meeting 6. organize chc meetings and disseminate revised community health policy 7. training of communities leaders and oics on the ephs components 8. conduct monthly meeting with gchvs and ttms in the communities 9. train dht on supervision and reporting 10. refresher training for oic, cm, registrar, and dispenser on data management 11. work through the district superintendent/commissioner to establish district health committees 12. conduct bi-annual operational plan review meeting to review the county work plan, identify progress, gaps and address the gaps 13. work with dhts to engage community leadership on taking ownership of health facilities 5.0 costing and budgeting the amount of us$ 149.89 million is required to fully implement the fy 2016/17 operational plan of the national investment plan for building a resilient health system. the moh financing unit conducted a resource mapping within the sector and has identified us$ 251,513,495 as commitment from the government of liberia (us$ 72, million) and partners (us$ 179.45 million) for the fiscal year. table 5.1: estimated budget and committed resources by investment areas # investment pillars estimated cost committed partners & donors resources 1 fit for purpose motivated workforce 21.3 million 2 re-engineer health infrastructure 10.9 million emergency preparedness and ministry of health consolidated work plan 2016/17 36 3 response 29.7 million 4 health care financing 3.8 million 5 quality of health services 57.2 million 6 drugs and medical supplies 13.9 million 7 comprehensive information system and research 0.387 million 8 leadership and governance 11.3 million 9 community engagement 1.4 million total us$ us$ 149.89 million 5.1 national budget the approved fy 2016/17 national health sector budget is us$ 72 million of which the ministry of health has us$ 57 million. the budget will be used to fund activities in the operational plan at the national, county, district and health facility levels. below is a description of the draft health sector fy 2016/17 budget. table 5.2 : health sector government draft budget fy 2016/17 health sector expending entities fy 2016/17 budget ministry of health 57,126,248 john f. kennedy medical center 6,295,156 phebe hospital and school of nursing 2,130,956 liberia institute of bio-medical research 487,778 liberia board for nursing and midwifery 188,628 liberia pharmacy board 189,938 liberia medical and dental council 387,358 liberia college of physician and surgeons 1,117,500 liberia medical and health products regulation 458,079 national aids commission 844,367 jackson f. doe hospital 2,835,468 total budget 72,061,476 6.0 monitoring and review of investment plan this operational health plan will be monitored using the performance framework available in annex c. the list of core output and short term outcome indicators contained in the framework will be used to track performance at every level of the health system. the performance framework will guide all stakeholders including partners to monitor and review the health system for the fiscal year. district and facility teams will focus on service delivery and community engagement indicators, while county and central levels will focus on indicators in their monitoring and reviews. ministry of health consolidated work plan 2016/17 37 reviews will take place quarterly and annually. at the decentralized level, review will be done quarterly involving service providers, health managers and local authorities. this quarterly review will look back at performance over the previous three months at the end of the quarters. it will focus on successes and failures, weakness and strengths, good practices and learn lessons to improve results in the subsequent quarters. at the central level, quarterly review will be done looking at performance on the core list of indicators and the implementation of central level planned activities and achievement of key deliverables in the investment plan. at the end on the fiscal year, a comprehensive review will be done using a mixed of methodologies and gauge the sector’s performance for the fiscal year ended. outcomes of the review will form the agenda for the annual health review conference of all stakeholders in the sector. this annual meeting will take place preferably in october will document progress towards 2021 and re-align the moh priorities towards achievements of the milestones set forth in the national health plan and the investment plan for building a resilient health plan. annex c presents national and county levels performance framework. annex a: health infrastructure needs fy 2016/17 # county clinic maternal home staff quarter dht /cht office lab incinerators fence hf triag e cost 1 bomi 2 22 22 2 bong 5 127,200 3 gbarpolu 2 3 7 3 4 6 5 8 4 grand bassa 4 21 20 8 22 10 775,150 5 grand cape mt 2 1 2 192,950 6 grand gedeh 4 4 3 149,400 7 grand kru 10 1 2 8 lofa 10 9 margibi 10 maryland 11 montserrado 5 7 1 8 2 12 nimba 2 10 7 8 18 13 rivercess 3 6 14 river gee 6 1 12 15 sinoe 7 2 5 2 775,600 total 39 47 69 17 26 41 52 34 2,020,300 ministry of health consolidated work plan 2016/17 38 annex b: supply chain fy 2016/17 activities # activity cost 1 develop and decentralize lmis 100,000 2 evaluate interim approach 27,700 3 distribute drug and medical supplies from nds 200,000 4 assess drug national and counties drug depots 20,000 5 conduct six counties drug depots (lofa, grand kru, sinoe, bomi, grand bassa and grand cape mt) 900,000 6 build drug shelves in 350 health facilities and at supply chain offices 245,000 7 de-junk and incinerate health facilities and depots expire drugs 200,000 8 automate the lmis into the general hmis of the moh 350,000 9 procure ict equipment (laps, desktops, scanners, printers, etc) 100,000 10 train supply chain officers and program managers on reporting, supervision, monitoring, quantification and supply chain management 100,000 11 dispose expired pharmaceuticals and medical equipment without harming the environment and the community 150,000 12 conduct last mile drug distribution 250,000 13 procure drugs and medical supplies 3,000,000 14 procure lab reagent 100,000 15 conduct quarterly monitoring and audit 200,000 16 procure motorcycles a for supply chain officers 70,000 17 procure vehicles for county pharmacists 525,000 18 train dispenser on rational use of drugs and supply chain management 100,000 total 6,637,700 annex c: health sector performance framework no. indicators baseline 2015/2016 baseline year data sources target fy 2016/17 1 percentage of pregnant mothers attending 4 anc visits 50% 2015/16 hmis 76% 2 percentage of pregnant mothers receiving ipt-2 37% 2015/16 hmis 60% 3 percentage of hiv positive pregnant women initiated on arv prophylaxis or art to reduce the risk of mtct tbd hmis 60% ministry of health consolidated work plan 2016/17 39 4 percentage of deliveries attended by skilled personnel 50% 2015/16 hmis 72% 5 percentage of infants fully immunized 52% 2015/16 hmis 75% 6 percentage of children zero to five months of age exclusively breast fed tbd tbd 7 tb case detection rate (all forms) 56% 2015/16 hmis 75% 8 proportion of children one year old immunized against measles 63% 2015/16 hmis 70 9 treatment success rate among smear positive tb cases (under directly observed treatment short course) 72% 2015/16 hmis 85 10 % of health facilities meeting minimum ipc standards tbd qu 100% 11 percentage of population living within 5 km from the nearest health facility 71% 2013 dhs 80% 12 functional health facilities per 10,000 population 1.8 2016 hr census 2 13 percentage of health facilities with all utilities, ready to provide services (water, electricity) 64% 2016 sara 80% 14 number of counties with funded outbreak preparedness and response plans non funded 90% 15 number of counties reporting event based surveillance data 100% 2016 dcp weekly epi report 100% 16 percentage of health facilities with no stock-outs of tracer drugs at any given time (amoxicillin, cotrimoxazole, paracetamol, ors, iron folate, act, fp commodity) tbd sata 85% 17 opd consultations per inhabitant per year 1.08 2016 hmis 2.0 18 skilled health workforce (physicians, nurses, midwives, physician assistants) per 1,000 persons 4,756 2016 hr census 11.0 19 proportion of health facilities with at least two skilled health workers na n/a 20 proportion of health workers on government payroll 6,272 2015/16 gol payroll n/a 21 timeliness of hmis reports quarterly 2016 hmis 75% 22 proportion of facilities that submitted hmis reports 2016 hmis 75% 23 per capita public health expenditure in usd us$ 11.23 2015 moh ar us$70 24 public expenditure in health as % of total public expenditure us$ 12.4 2015 moh ar 15% ministry of health consolidated work plan 2016/17 40 annex d: county level performance framework # county anc 4 visits iptp2 institutional delivery baselines targets baselines targets baselines targets 1 bomi 77% 85% 47% 55% 57% 62% 2 bong 77% 79% 73% 79% 78% 80% 3 gbarpolu 33% 48% 23% 53% 29% 41% 4 grand bassa 67% 70% 41% 55% 52% 60% 5 grand cape mt 47% 52% 35% 46% 46% 50% 6 grand gedeh 67% 70% 41% 55% 52% 60% 7 grand kru 8 lofa 9 margibi 49% 0% 37% 0% 42% 0% 10 maryland 11 montserrado 44% 45% 22% 25% 24% 30% 12 nimba 44% 85% 40% 70% 46% 80% 13 rivercess 14 river gee 15 sinoe 73% 78% 53% 62% 61% 66% national 50% 76% 37% 60% 50% 72% # county delivery by sba fully immunized penta-3 baselines targets baselines targets baselines targets 1 bomi 57 62 71 91 76 82 2 bong 57 62 71 91 76 82 3 gbarpolu 29 41 0 0 82 94 4 grand bassa 44 50 43 50 57 60 5 grand cape mt 46 50 55 60 74 78 6 grand gedeh 44% 50% 43% 50% 57% 60% 7 grand kru 8 lofa 9 margibi 42% 0% 71% 0% 82% 0% 10 maryland 11 montserrado 24% 30% 53% 60% 62% 68% 12 nimba 46% 80% 40% 13 rivercess 14 river gee 15 sinoe 61% 66% 68% 76% 92% 94% national 50% 72% 52% 75% ministry of health consolidated work plan 2016/17 41 # county measles hmis reporting rate hmis reporting timeliness baselines targets baselines targets baselines targets 1 bomi 66% 70% 100% 100% 100% 100% 2 bong 95% 96% 100% 100% 100% 100% 3 gbarpolu 63% 79% 100% 100% 100% 100% 4 grand bassa 69% 75% 93% 100% 97% 100% 5 grand cape mt 60% 60% 94% 100% 97% 100% 6 grand gedeh 48% 54% 93% 100% 93% 100% 7 grand kru 8 lofa 9 margibi 73% 10 maryland 11 montserrado 60% 68% 12 nimba 68% 70% 80% 90% 80% 90% 13 rivercess 63% 65% 100% 100% 100% 100% 14 river gee 15 sinoe 85% 90% 100% 100% 100% 100% national 63% 70% 75% 75% # county pnc within 2 wks utilization rate anc 1st visits baselines targets baselines targets baselines targets 1 bomi 56% 60% 86% 90% 2 bong 46% 50% 86% 90% 3 gbarpolu 20% 40% 41% 59% 4 grand bassa 33% 40% 80% 89% 5 grand cape mt 56% 60% 71% 75% 6 grand gedeh 37% 40% 70% 75% 7 grand kru 8 lofa 9 margibi 10 maryland 11 montserrado 28% 30% 90% 90% 12 nimba 78% 80% 94% 96% 13 rivercess 34% 40% 73% 75% 14 river gee 15 sinoe 45% 49% 79% 85% national bozikov j. half century of the association of schools of public health in the european region: a significant contribution to public health education (editorial). seejph 2016, posted: 23 april 2016. doi: 10.4119/unibi/seejph-2016-115 1 editorial half century of the association of schools of public health in the european region: a significant contribution to public health education jadranka bozikov 1 1 andrija stampar school of public health, school of medicine, university of zagreb, zagreb, croatia. corresponding author: jadranka bozikov, phd address: andrija stampar school of public health, rockefeller st. 4, zagreb, croatia; telephone: +38514590101; e-mail: jbozikov@snz.hr conflicts of interest: the author is the director of the andrija stampar school of public health in zagreb, croatia, which is one of the founding members of aspher. mailto:jbozikov@snz.hr bozikov j. half century of the association of schools of public health in the european region: a significant contribution to public health education (editorial). seejph 2016, posted: 23 april 2016. doi: 10.4119/unibi/seejph-2016-115 2 abstract the association of institutions responsible for advanced teaching in public health and of schools of public health in europe was established in 1966. it was in response to the initiative of the world health organization (who) regional office for europe as part of a worldwide initiative to set up regional associations of schools in every who region as a channel for initiating innovative policies. the organisation’s name was later changed into association of schools of public health in the european region (aspher). aspher has established a tradition in terms of an annual award named andrija stampar, which has become a prestigious european reward for merits in public health. a significant contribution to public health education has been made during half century and the association is today stronger than ever before. keywords: association of schools of public health in the european region (aspher), public health education, public health teaching. bozikov j. half century of the association of schools of public health in the european region: a significant contribution to public health education (editorial). seejph 2016, posted: 23 april 2016. doi: 10.4119/unibi/seejph-2016-115 3 establishment and early years in response to the world health organization (who) euro initiative, representatives of the leading schools of public health (or hygiene) including the schools for tropical medicine (and, in addition, the institutes of hygiene/healthcare) gathered together at meetings held between 1964 and 1966 in rennes (december 14-18, 1964), lisbon (february 14-16, 1966) and ankara (october 17-21, 1966). already in 1964, professor sénécal from the school of medicine in rennes was appointed to draft the statutes based on the statues of several international associations and taking into account specificities of the “old continent” and suggestions from representatives of the schools. the statutes were unanimously adopted at the meeting in ankara on the 20 th of october, 1966. the organisation was first given the french name and acronym (airesspe – association des institutions responsables d’un enseignement supérieur en santé publique et des écoles de sp en europe) and later (in 1973) the association’s name was changed into aspher (association of schools of public health in the european region). the history of the association has been already described (1-3). the article 24 of the statutes stated that its text, written in english, french and russian (the working languages of the who regional office for europe), was to be deposited in the archives of the who regional office in copenhagen accompanied with versions in spanish (also, official and working language of who euro) and german. an interim committee was elected with the task of carrying out the decisions of the ankara symposium and to convening the first general assembly of the newly established association. prof. dr. hans harmsen from hamburg was elected as president, dr. frans doeleman from leiden as vicepresident and prof. dr. jean-simon cayla as the secretary-general of the interim committee (4, preface, pp. 1-3). the statutes were signed by the president, vice-president and two rapporteurs (professor jean sénécal and dr stuart w. hinds) and it was later approved and published in english, french and russian in the bulletin no. 1-2 together with the list of member institutions with full addresses and phone numbers, delegate name and his/her alternate representing the respective member according to the article 6 of the statutes (4,5). the author of this article, currently acting in the capacity of director of the andrija stampar school of public health, takes pride from the fact that our institution hosted the first general assembly of the newly-established organisation, convened in 1968 (figure 1), on the occasion of which the statutes were approved and dr. jean-simon cayla, the director of the ėcole nationale de la santé publique (ensp; today’s ehesp) established in rennes, was elected as president; dr. christian lucasse, representing the koninklijke instituut voor de tropen (royal tropical institute from amsterdam) was elected as vice-president; whereas dr. teodor gjurgjevic, acting in the capacity of the administrative secretary of the andrija stampar school of public health, was elected as secretary-general. prior to that, dr. gjurgjevic was personal secretary of andrija stampar himself. at the time of the first general assembly, the director of the school was professor branko kesic, while prof. fedor valic was the third one who contributed significantly to the airesspe’s foundation acting in the capacity of the delegate. it was decided that a seat of the newly established organization would be at the school in zagreb as long as dr gjurgjevic was secretarygeneral. the bulletin of the association was launched and the first two double-issues were published during 1969 (no. 1-2 and no. 3-4) bringing in printed form records of all sessions thanks to the efforts of the secretary-general who wrote the respective prefaces too (4,5). according to the published lists of the members, the association counted 33 members at the time of its first general assembly and it reached 40 members by the end of 1969. interesting to mention, those 40 members represented the following 16 countries: algeria [1], belgium bozikov j. half century of the association of schools of public health in the european region: a significant contribution to public health education (editorial). seejph 2016, posted: 23 april 2016. doi: 10.4119/unibi/seejph-2016-115 4 [5], france [5], germany [2], greece [1], hungary [1], ireland [1], italy [4], portugal [1], the netherlands [6], spain [1], sweden [1], czechoslovakia [1], turkey [3], uk [4] and yugoslavia [3], where number of members is denoted in squared parentheses including one french institute that already in 1969 announced an intention to withdraw from membership (4,5). figure 1. participants of the first aspher general assembly, convened from october 7-12, 1968, in front of the andrija stampar school of public health in zagreb, croatia the school of public health in zagreb was established in 1927 by funds of the rockefeller foundation and the efforts of dr. andrija stampar as one of the oldest schools of public health in europe. at the ceremonial opening of the school’s building which took place on october 3 , 1927, speeches were delivered by the representatives of rockefeller foundation (selskar m. gunn), the league of nations (dr. ludwig rajchman and prof. léon bernard), as well as by many others including the representatives of the institutes of hygiene from warsaw, prague and budapest. the school became part of the zagreb university school of medicine after world war ii under the directorship of andrija stampar who also chaired the department of hygiene and social medicine. at the same time, stampar was preparing the constitutions and other documents for the establishment of the world health organization, chaired the interim commission and was elected by the virtue of acclamation as the president of its first assembly convened in geneva. “he was not only a founding father of the latter organization, but also one of its most stalwart bulwarks during the first and formative decade of its existence” wrote who director-general dr. mg candau in his letter to contribute as a foreword of the publication of selected papers by andrija stampar in 1965 (6). the school proudly took stampar’s name after he passed away in 1958. bozikov j. half century of the association of schools of public health in the european region: a significant contribution to public health education (editorial). seejph 2016, posted: 23 april 2016. doi: 10.4119/unibi/seejph-2016-115 5 dr. teodor gjurjevic (1909-1976) was an interesting person: educated in law in zagreb and later in international affairs in paris and haag, he was a polyglot fluent in several foreign languages (he used to speak and write in english, french, german and italian and spoke polish, russian and spanish). he had pursued the path of the career diplomat already before world war ii and was a holder of two phd degrees, one in law obtained at the university of zagreb in 1933 and the second in humanities from the university of oxford in 1956. he was an employee of the zagreb school of public health since january 1, 1948 till his death on march 20, 1976 with a 3-year break (in 1954-1957) which he used for preparation of the phd dissertation at the faculty of modern history, university of oxford (7). dr. gjurgjevic had every intention to evoke the interest of sphs established in the east europe and encourage them to join the association; to that goal, he even travelled to moscow, but was unsuccessful. moreover, in aspher written history it reads: “dr. gjurgjevic had a fatal heart attack whilst visiting libya in the pursuit of his heroic efforts to set up a world federation of schools of public health”, while in official documents it is stated that he died on 20 march 1976 in zagreb (1,7). ever since the foundation day, aspher has regularly organised its annual conferences. from 2008 on, these annual conferences have been organised in collaboration with the european public health association (eupha) and have run under the name european public health conference (eph). on top of the eph attendance, the school principals get to meet once more on the occasion of the deans’ and directors’ retreat (d&d retreat), also organised on an annual basis. since 2014, when zagreb had the privilege to host the d&d retreat, the event has become even more important, given that within its frame the annual session of the general assembly, earlier convened on the occasion of the annual conference, takes place. the prestigious andrija stampar medal aspher has made it its tradition to present an accolade (a medal) in memory of andrija stampar; the medal became a reality in 1992 and has been awarded annually since 1993 to the key opinion leaders in recognition of their international-scale achievements in the field of public health. the andrija stampar medal has become the most prestigious european award presented in recognition of one’s achievements in public health leadership and education. the credit for introducing this accolade and making it a tradition should go to prof. jeffrey levett from athens, who presided over the association in the 1992-1993 timeframe, and to his successor, prof. ulrich laaser from bielefeld, who had acted in the capacity of aspher president when it was coined and firstly awarded during the 15 th aspher annual conference held in bielefeld, germany, from november 28 to december 2, 1993. on one side of the medal, the name of the association and its logo can be found, while on the edge of its other side the following words, allegedly spoken by dr. andrija stampar, are embossed: “public health investment harvests rich rewards”. in the centre of the medal, the name of the medallist is engraved (figure 2). the awardee is selected by the aspher executive committee, and the award is presented on the occasion of the ceremony organised during the aspher annual conference. the ceremony includes the laudatio to the awardee delivered by a prominent figure, followed by the “thank you” speech given by the awardee. the very first awardee was dr. léo kaprio, who euro regional director emeritus at the time (who regional director 1966-1985), whereas the laudatio speech was delivered by prof. jeffrey levett, the dean of the athens school of public health (figure 3). it is worth mentioning that dr. kaprio, representing the world health organization in his address given at the first general assembly convened in zagreb in 1968, stated the following: “this bozikov j. half century of the association of schools of public health in the european region: a significant contribution to public health education (editorial). seejph 2016, posted: 23 april 2016. doi: 10.4119/unibi/seejph-2016-115 6 general assembly of your association can be an important milestone along the road to further progress in european public health” (4, pp 35-39). the list of the medallists, the pertaining conference venues and the names of the laudatio speakers are available at aspher’s website (8). figure 2. the andrija stampar medal * * in order to express her gratitude for the medal awarded to her in november 2011, dr zsuzsanna jakab, the who regional director for europe, gave a thank you speech in words most carefully selected which was recorded and made available through the who website (9); who regional director also took the opportunity to proudly advertise her medal awardee achievement while presenting her annual report during the 62nd session of the who regional committee convened at malta on september 10th, 2012 (10, slide 12). bozikov j. half century of the association of schools of public health in the european region: a significant contribution to public health education (editorial). seejph 2016, posted: 23 april 2016. doi: 10.4119/unibi/seejph-2016-115 7 figure 3. ceremony of the first andrija stampar medal * * the very first stampar medal award ceremony was held during the xv aspher annual conference held in bielefeld from november 28 to december 2, 1993. from left to the right: prof. ulrich laaser, aspher president, evelyne de leeuw, aspher secretary-general, awardee dr. léo kaprio accompanied by mrs. kaprio and prof. jeffrey levett, aspher immediate past-president who delivered the laudatio speech (courtesy of aspher). congratulations and best wishes for a productive and prosperous future currently, aspher has reached 110 members in terms of schools or departments of public health established in 43 countries of the who european region and, on top of that, some of the schools from other continents (australia, canada, mexico, lebanon and syria) are affiliated with the organization as “associated members” (11). this year aspher is celebrating the 50 th anniversary and the schools’ heads will meet end of may 2016 in athens, where deans’ and directors’ retreat together with the general assembly is hosted by the national school of public health under the aegis of the hellenic ministry of health (12). the fiftieth anniversary book with member schools’ profiles is already in press (13). congratulations! long live and best wishes for a successful and prosperous next 50 years! bozikov j. half century of the association of schools of public health in the european region: a significant contribution to public health education (editorial). seejph 2016, posted: 23 april 2016. doi: 10.4119/unibi/seejph-2016-115 8 references 1. landheer t, macara aw. the history of aspher 1968-1993. http://aspher.org/download/24/the_history_of_aspher_by_awmacara_and_tlandheer.pdf (accessed: march 10, 2016). 2. foldspang a, louvet t, normand c, sitko s (editors). 40 aspher anniversary 1966-2006. anniversary book. aspher series no. 1. st maurice: aspher, 2006. http://aspher.org/download/23/aspher_40_anniversary_book.pdf (accessed: march 10, 2016). 3. levett j. from leo kaprio to julio frenk – two decades of aspher's andrija stampar award. the tribute to the ever current štampar. malta, october 10, 2012. http://aspher.org/mod/file/download.php?file_guid=9548 (accessed: march 10, 2016). 4. airesspe. bulletin no 1-2, zagreb: airesspe, 1969, 139 pages. 5. airesspe. bulletin no 3-4, zagreb: airesspe, 1969, 171 pages. 6. grmek md (editor). serving the cause of public health. selected papers of andrija stampar. zagreb: andrija stampar school of public health, medical faculty, university of zagreb, 1966. p. 5 7. kovacic l. [dr teodor gjurgjevic, lawyer, diplomat, polyglot, and the collaborator of andrija stampar]. acta med hist adriat 2015; 13(suppl. 1); 21-30. http://hrcak.srce.hr/file/218055 (accessed: march 10, 2016). 8. aspher. andrija stampar medal. http://www.aspher.org/andrija-stampar-medal.html (accessed: march 10, 2016). 9. jakab z. speech “on accepting the andrija stampar medal from the association of schools of public health in the european region”. copenhagen, november 10, 2011. http://www.euro.who.int/en/who-we-are/regional-director/speeches-and-presentations-byyear/2011/speech-on-accepting-the-andrija-stampar-medal-from-the-association-of-schools-ofpublic-health-in-the-european-region 10. jakab z. report on the work of the regional office. malta, september 10, 2012. http://www.slideshare.net/slideshow/embed_code/14232316?rel=0# (accessed: march 10, 2016). 11. aspher. members. available at: http://www.aspher.org/members.html (accessed: march 10, 2016). 12. levett j. athens aspher celebration, 25-27 may, 2016 blog 2. http://www.aspher.org/articles,21.html (accessed: march 10, 2016). 13. foldspang a, müller-nordhorn j, bjegovic-mikanovic v, otok r (editors). fifty years of professional public health workforce development. aspher’s 50th anniversary book. brussels: aspher, 2016 [in press]. ___________________________________________________________ © 2016 bozikov; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://aspher.org/download/24/the_history_of_aspher_by_awmacara_and_tlandheer.pdf http://aspher.org/download/23/aspher_40_anniversary_book.pdf http://aspher.org/mod/file/download.php?file_guid=9548 http://hrcak.srce.hr/file/218055 http://www.aspher.org/andrija-stampar-medal.html http://www.slideshare.net/slideshow/embed_code/14232316?rel=0 http://www.aspher.org/members.html http://www.aspher.org/articles,21.html surjadi c, jani d, langoday uy. geriatric curriculum at faculties of medicine in indonesia (case study). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-195 1 case study geriatric curriculum at faculties of medicine in indonesia charles surjadi 1 , dwi jani 1 , ursula yunita langoday 1 1 department of public health and preventive medicine, faculty of medicine, university atma jaya, jakarta, indonesia. corresponding author: prof. charles surjadi address: faculty medicine atmajaya university jl pluit raya no. 2, floor 4, room 413, jakarta 14350 indonesia; email: kotasehat@hotmail.com mailto:kotasehat@hotmail.com surjadi c, jani d, langoday uy. geriatric curriculum at faculties of medicine in indonesia (case study). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-195 2 abstract aim: in indonesia, the elderly population is growing rapidly and will comprise 35 million in 2035. the aim of this study was to assess how geriatric training is organised in medical faculties in indonesia. methods: in 2017, we asked through questionnaires the vice deans of the faculties of medicine about their perceptions towards health and ageing and how they organized the geriatric training in their respective schools. overall, we obtained data from 32 out of 71 (45.1%) faculties of medicine. results: all respondents perceived geriatrics as an important issue for faculties of medicine. only 12 (37.5%) faculties employ geriatric specialists, 28 (87.5%) teach geriatrics at the undergraduate level, and 12 (40.6%) at postgraduate level, whereas 4 (12.5%) universities teach at specialty level. conversely, at undergraduate level, only 18 (64.2%) faculties include the ‘geriatric giants’, and 5 (17.8%) include ageism. there are 13 (46.4%) geriatric classes implemented through skill laboratories, 5 (17.8%) through geriatric policlinics, and 4 (14.3%) through geriatric wards. conclusion: attention to geriatric training among medical schools in indonesia has to be improved. at national level, there should be a more specific formulation of geriatric competencies and how they can be operationalised. geriatric training is recommended to prepare lecturers in medical faculties. related to the content of aging curriculum, geriatric issues, attitudes towards aging, and ageism should be addressed. keywords: faculty of medicine, geriatric competency, indonesia, teaching geriatrics. conflict of interest: none. surjadi c, jani d, langoday uy. geriatric curriculum at faculties of medicine in indonesia (case study). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-195 3 introduction in indonesia, better health, due to improved economic and social conditions, has resulted in longer life and in consequence an ageing population. in 2010, there were 18.1 million elderly people (>60 years) in indonesia. in the year 2035, this number is predicted to be around 48.2 million or, 15.8% of the overall population (1). the world health organization (who) strongly advocates for all future medical doctors the need to be well-trained in caring of older people (2). currently, students need to acquire knowledge about how to treat older people from an interdisciplinary point of view (2). issues regarding education on geriatrics and the related competencies are also the concern of medical associations such as the society for family physicians and the association of gerontology higher education (aghe), while the association of international gerontology and geriatrics (iagg) pays more attention to specific themes as e.g. the relationship between generations, but also on advanced teaching methods (3-9). on the other hand, who develops manuals for primary care facilities which provide friendly services for the elderly (10). our aim was to assess how geriatric training is organised in medical faculties in indonesia. more specifically, we asked the vice deans of academic affairs pertinent to the faculties of medicine in indonesia about the way they organise training on geriatrics in their respective schools. methods based on the list of addresses and emails from deans’ offices and the ministry of education, we sent a questionnaire by post, email, and by phone to secretariats of the vice deans for key academic affairs of all medical faculties in indonesia. the questionnaire developed for this study consists of two main instruments. the general questionnaire inquired about characteristics of the persons completing the questionnaire (including information on sex, education, age and belonging to the medical profession or not). the specific questionnaire included questions regarding their perception of problems concerning the health of elderly people, whether they have taught geriatrics at undergraduate and postgraduate level and how they organised this training. the 6-pages questionnaire included some open-ended options and had already been tried out at the dean’s office of atma jaya university and at the neurological department and internal medicine department there by lecturers responsible for geriatric topics to look for inconsistencies and problems of understanding. based on this validation exercise, some revisions were done to make the questionnaire simpler and easier to be answered. for the current study, descriptive statistics are presented. results we were able to get data from 32 out of 71 (45.1 %) faculties of medicine in indonesia (table 1). all respondents perceived geriatrics as an important issue for the faculties of medicine. only 12 (37.5 %) faculties employ geriatric specialists, and 22 (68.8%) suggested that geriatrics should be integrated into the specialisation for internal medicine; 10 (31.3%) faculties consider that geriatrics is a discipline which needs participation from other medical disciplines. at present, 28 (87.5%) faculties teach geriatric topics at the undergraduate level but only 13 (40.6 %) schools teach this discipline at the doctoral level. surjadi c, jani d, langoday uy. geriatric curriculum at faculties of medicine in indonesia (case study). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-195 4 table 1. geriatric training at the faculties of medicine in indonesia (n=32) variable number percentage perceived geriatrics should get attention in the medical faculty 32 100.0 employed a geriatric specialist 12 37.5 geriatrics should be integrated into the department of internal medicine 22 68.8 geriatrics need participation of other disciplines 10 31.3 training at undergraduate level 28 87.5 training at doctoral level 13 40.6 training at specialty level 4 12.5 for the undergraduate level, we asked whether the faculties have a specific objective related to geriatric training. overall, there are 9 (32.1 %) schools which have developed a proper syllabus (table 2). related to specific issues of ageing, there are only 18 (64.3%) schools which include the ‘geriatric giants’, 5 (17.8%) include ageism and attitudes towards aging. in relation to the method of teaching geriatrics there are 13 (46.4%) classes supported by skill laboratories, 5 (17.8 %) through outpatient geriatric clinics, and 4 (14.3%) through geriatric wards. table 2. teaching geriatrics at the undergraduate level of medicine in indonesia (n=28) present situation number percentage there is a syllabus on geriatrics 9 32.1 ‘geriatric giants’ have been taught 18 64.3 ageism has been taught 5 17.9 geriatrics include education in skill laboratories 13 46.4 have a geriatric policlinic 5 17.8 have a geriatric ward 4 14.3 discussion in indonesia, at the national level, there are few standard sets of competencies for medical doctors, e.g. for dentists formulated in 2012 by the indonesian medical council (11). geriatrics are not specifically mentioned although students should be able to solve those problems of old age as part of their skills. curricula in indonesia should be focused around the four pillars of learning i) learning to know, ii) learning to do, iii) learning to live together, and iv) learning to be. in an inputprocess-outcomes framework, curricular content, textbooks, and learning materials are among the major teaching inputs as a dimension of quality education (12). however, a policy framework is needed that encourages geriatric training formats but is missing in indonesia. examples of structured training and corresponding sets of competencies can be found in the international literature e.g. in canada (4), the united states (13), or taiwan (14): taiwanese educators have developed and implemented several methods in the framework of a national project for excellence in geriatric care education:  curricula development for innovative teaching and learning consisting of a) curriculum development and goals b) curricula content and certification, for undergraduate as well as for postgraduate programmes. surjadi c, jani d, langoday uy. geriatric curriculum at faculties of medicine in indonesia (case study). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-195 5  excellence in teaching and learning: a) problem-based learning, b) geriatric care practicum, c) research practicum, d) learning by visiting rounds. in summary, it is recommended to include into the formal training by a gerontologist a clerkship in geriatrics which has to be supported at the national, the faculty and the individual level through national guidelines. in some american faculties of medicine, blended learning has been introduced with web-based modules, interactive videogames, and face to face learning such as ward rounds, case conferences, meet the team, community practice through nursing home and home visits (13). in the united states it is recommended that nine or more geriatric physicians are employed at a faculty of medicine; this criterion was met in 30% of medical schools in 2000 and in 49% in 2010. the main topics taught included geriatric syndromes and geriatric assessment (15). minimum geriatric competencies for medical students are presented in table 3. four criteria were used as guiding principles: i) competencies should focus on issues that really matter to health outcomes of elderly people. ii) competencies should be discussed before the start of one’s internship. iii) the total number of content domains and competencies should be limited, with no more than 5-8 domains, and no more than 3-5 competencies in each. iv) the competencies should be similar to quality indicators in that they are the ‘floor’ behaviours and could be taught and evaluated at any medical school (16). table 3. minimum geriatric competencies for medical students world geriatric and gerontology association (17) canada (3) united states (16) 1. medication management 2. cognitive and behavioural disorders 3. self care capacity 4. falls, balance, gait disorders 5. health care planning and promotion 6. atypical presentation of disease 7. palliative care 8. hospital care for elders 1. cognitive impairment 2. functional impairment 3. falls balance and gate disorder 4. medication management 5. biological of aging and atypical presentation of diseases 6. adverse event 7. urinary incontinence 8. transition of care 9. health care planning 1. medication management 2. cognitive and behavioural disorders 3. self care capacity 4. falls, balance, gait disorders 5. health care planning and promotion 6. atypical presentation of disease 7. palliative care 8. hospital care for elders conclusion attention of geriatric training among medical schools in indonesia should be improved. at national level there should be a more specific formulation on geriatric competency and how it could be implemented. also, there should be advocacy and awareness campaigns. geriatric training in medical faculties should include lectures and practical sessions. related to the content of geriatric curricula, topics on ‘geriatric giant’, attitudes towards aging and ageism should be addressed. surjadi c, jani d, langoday uy. geriatric curriculum at faculties of medicine in indonesia (case study). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-195 6 references 1. united nations population fund (unfpa) indonesia. indonesia on the threshold of population ageing. monograph series no. 1, july 2014. 2. keller i, makipaa a, kalenscher t, kalache a. global survey on geriatrics in the medical curriculum. geneva, world health organization; 2002. 3. williams bc, warshaw g, fabiny ar, lundebjerg n, medina-walpole a, et al. medicine in the 21 st century: recommended essential geriatrics competencies for internal medicine and family medicine residents. j grad med educ 2010;2:373-83. 4. parmar j. core competencies in the care of older persons for canadian medical students. can geriatr j 2009;12. 5. aghe. november 2014. gerontology competencies for under graduate and graduate education. http://www.aghe.org/images/aghe/competencies/gerontology_competencies.pdf (accessed: july 20, 2018). 6. gordon a. british geriatrics society recommended curriculum in geriatric medicine for medical undergraduates, 2013. british geriatrics society; 2013. http://www.bgs.org.uk/pdf_cms/trainees/2013_undergrad_med_curriculum.docx (accessed: july 20, 2018). 7. just jm, schulz c, bongartz m, schnell mw. palliative care for the elderly developing a curriculum for nursing and medical students. bmc geriatrics 2010;10:66. 8. olson t, stoehr j, shukla a, moreau t. a needs assessment of geriatric curriculum in physician assistant education. perspect phys assist educ 2003;14:208-13. 9. igenbergs e, deutsch t, frese t, sandholzer h. geriatric assessment in undergraduate geriatric education a structured interpretation guide improves the quantity and accuracy of the results: a cohort comparison. bmc med educ 2013;13:116. 10. strano-paul l. effective teaching methods for geriatric competencies. geront geriat educ 2011;32:342-9. 11. indonesia medical council. indonesia dental professional education standard. jakarta 2012. 12. unesco 2004. efa global monitoring report. paris: unesco press; 2005. 13. g duque, o demontiero. evaluation of a blended learning model in geriatric medicine a succesfull learning experiences to medical students austral j ageing 2013;32:103-9. 14. lee m-c, yen c-h, ho rfc, wang c-c, tang y-j, liao w-c, et al. national project for excellence in geriatric care education—a comprehensive, innovative and practical program for undergraduate and graduate students in taiwan. j clin gerontol geriatr 2010;1:12-6. 15. meteos-nozal j c-ja, ribera casado jm. a systematic review of surveys on undergraduate teaching of geriatrics in medical schools in the xxi century. eur geriat med 2014;5:119-24. 16. leipzig rm, granville l, simpson d, anderson mb, sauvigné k, soriano rp. keeping granny safe on july 1: a consensus on minimum geriatrics competencies for graduating medical students. acad med 2009;84:604-10. http://www.aghe.org/images/aghe/competencies/gerontology_competencies.pdf surjadi c, jani d, langoday uy. geriatric curriculum at faculties of medicine in indonesia (case study). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-195 7 17. association of american medical colleges/john a. hartford foundation, inc. july 2007 consensus conference on competencies in geriatrics education. acad med 2009;84:604-10. ______________________________________________________________________________________ © 2018 surjadi et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. kollcaku j, kollcaku a. correlates of rheumatoid arthritis among women in albania (original research). seejph 2016, posted: 29 august 2016. doi 10.4119/unibi/seejph-2016-127 1 original research correlates of rheumatoid arthritis among women in albania julia kollcaku1, artur kollcaku2 1 ambulatory health service, polyclinic no. 3, tirana, albania; 2 rheumatology service, university hospital center “mother teresa”, tirana, albania. corresponding author: julia kollcaku, md; address: polyclinic no. 3, rr. “qemal stafa”, tirana, albania; telephone: 00355674039706; e-mail: artur_kollcaku@yahoo.com mailto:g@yahoo.com� kollcaku j, kollcaku a. correlates of rheumatoid arthritis among women in albania (original research). seejph 2016, posted: 29 august 2016. doi 10.4119/unibi/seejph-2016-127 2 abstract aim: our aim was to assess the association of rheumatoid arthritis with socio-demographic characteristics and lifestyle factors among women in transitional albania. methods: a cross-sectional study was carried out in 2012-2013 including a sample of 2198 women aged 30 years and above who attended the rheumatology services at primary health care clinics in tirana municipality (mean age: 60.2±9.7 years; overall response rate: 95%). the diagnosis of rheumatoid arthritis was based on the american college of rheumatology/european league against rheumatism (acr/eular) 2010 criteria. in addition, a structured questionnaire was administered to all study participants including information on demographic and socioeconomic characteristics and behavioral factors. binary logistic regression was used to assess the association of rheumatoid arthritis with covariates. results: overall, 437 (19.9%) women were diagnosed with rheumatoid arthritis (both incident and prevalent cases). in multivariable-adjusted models, rheumatoid arthritis was positively and significantly related to older age (or=1.8, 95%ci=1.3-2.6), a lower educational attainment (or=1.4, 95%ci=1.1-1.9), smoking (or=1.5, 95%ci=1.1-2.0), alcohol intake (or=1.9, 95%ci=1.2-3.1) and overweight and obesity (or=1.5, 95%ci=1.22.0 and or=1.6, 95%ci=1.2-2.0, respectively). conclusion: this study provides useful evidence about selected correlates of rheumatoid arthritis among women attending specialized primary health care services in albania. health professionals and policymakers in albania should be aware of the magnitude and consequences of this chronic condition in the adult population. keywords: albania, behavioral factors, rheumatoid arthritis, socio-demographic factors, western balkans. conflicts of interest: none. kollcaku j, kollcaku a. correlates of rheumatoid arthritis among women in albania (original research). seejph 2016, posted: 29 august 2016. doi 10.4119/unibi/seejph-2016-127 3 introduction rheumatoid arthritis is currently considered a clinical syndrome across several disease subsets (1), involving inflammatory flows (2), leading to an ultimate common pathway in which persistent synovial inflammation and associated damage to articular cartilage and underlying bone are present (3). overproduction of the tumor necrosis factor is the principal inflammatory process in the pathophysiology of the rheumatoid arthritis (1,4). this leads to overproduction of many cytokines such as interleukin 6, which causes persistent inflammation and joint destruction (1,5). regarding the etiology, genetic factors account for about 50% of the risk of developing rheumatoid arthritis (6,7). these factors are primarily related to either autoantibody-positive disease (acpa-positive) or acpa-negative disease (1). as for the lifestyle factors, smoking is considered the main environmental risk factor (1,8), doubling the risk for development of rheumatoid arthritis (9). rheumatoid arthritis affects 0.5%-1.0% of adults in developed countries (1). women are three times more affected than men (1). however, the prevalence of this condition is positively related to age in both men and women (1). in women, hormonal factors play an additional role as the prevalence of rheumatoid arthritis is highest among individuals over 65 years (10). regarding the incidence of rheumatoid arthritis in developed countries, it varies from 5 to 50 cases per 100,000 adults (11). on the other hand, the prevalence of rheumatoid arthritis displays significant geographical variations (12). the prevalence of this condition is higher in northern europe and north america compared to developing countries (13). such geographical variations have been linked both to different genetic inclinations as well as to different environmental factors which expose individuals from different regions to different levels of risk for rheumatoid arthritis (1). the information about rheumatoid arthritis in former communist countries of the western balkans including albania is scarce. in general, the burden of musculoskeletal disorders has increased in albania in the past few decades (14). the proportion of musculoskeletal disorders comprised only 8.5% of the total burden of disease in albania in 1990, whereas in 2010 it increased to 11.0% (14). there is evidence of a steeper increase in women than in men (3.7% vs. 2.0%, respectively) (14). in this context, the aim of our study was to assess the association of rheumatoid arthritis with demographic and socioeconomic characteristics and lifestyle/behavioral factors among women attending specialized primary health care services in transitional albania. methods this was a cross-sectional study which was carried out in 2012-2013. study population this study included a sample of 2198 women aged 30 years and over who attended the rheumatology services at primary health care clinics in tirana municipality. beforehand, the required sample size was estimated at 1870 women in order to obtain sufficient cases of rheumatoid arthritis among women who attended the rheumatology services in different polyclinics of tirana. in order to increase the study power and account for potential nonresponse, we decided to include 2500 consecutive women aged ≥30 years who attended t he rheumatology services. of these, 198 women were ineligible (too sick to participate), whereas 104 further women refused to participate. the final study sample consisted of 2198 eligible women who agreed to participate (overall response rate: 2198/2302=95%). of 2198 kollcaku j, kollcaku a. correlates of rheumatoid arthritis among women in albania (original research). seejph 2016, posted: 29 august 2016. doi 10.4119/unibi/seejph-2016-127 4 women who participated in the study, 437 (19.9%) were diagnosed with rheumatoid arthritis (both incident and prevalent cases). data collection the diagnosis of rheumatoid arthritis was based on the american college of rheumatology/european league against rheumatism (acr/eular) 2010 criteria (15). these criteria consist of joint involvement, serology, acute-phase reactants and duration of symptoms (15). in addition, a structured questionnaire was administered to all study participants including information on selected demographic and socioeconomic characteristics and lifestyle/behavioral factors. socio-demographic factors included age (which in the analysis was dichotomized into: ≤50 years vs. >50 years), marital status (dichotomiz ed into: married vs. not married), employment status (employed and/or retired vs. unemployed) and educational attainment (trichotomized into: low, middle and high). conversely, lifestyle/behavioral factors included smoking, alcohol intake, coffee consumption and tea consumption – all dichotomized into: no vs. yes), as well as the body mass index (bmi, trichotomized into: <25, 25-29.9 and ≥30). statistical analysis independent samples t-test was used to compare the mean ages between women with and without rheumatoid arthritis. conversely, fisher’s exact test was used to compare the distribution of socio-economic characteristics and behavioral factors between women with and without rheumatoid arthritis. on the other hand, binary logistic regression was used to assess the association of rheumatoid arthritis (outcome variable) with socio-economic characteristics and behavioral factors (independent variables). initially, crude (unadjusted) odds ratios (ors) and their respective 95% confidence intervals (95%cis) were calculated. subsequently, multivariable-adjusted models controlling simultaneously for all covariates were run. multivariable-adjusted ors and their respective 95%cis were calculated. in all cases, a p-value of ≤0.05 was considered as statistically significant. statistical package for social sciences (spss, version 15.0) was used for all the statistical analyses. results overall, mean age of study participants was 60.2±9.7 years; median age was 60.0 years (interquartile range: 54.0-67.0 years). on the other hand, the age range was 30-92 years. women diagnosed with rheumatoid arthritis were older than those without rheumatoid arthritis (mean age: 62.0±9.8 years vs. 59.8±9.7 years, respectively; p<0.001) [not shown in the tables]. the distribution of socio-demographic characteristics and lifestyle/behavioral factors of women by rheumatoid arthritis status is presented in table 1. as expected, the proportion of older individuals (over 50 years of age) was higher among women with rheumatoid arthritis compared with their counterparts without this condition (91% vs. 85%, respectively, p<0.001). the proportion of a lower educational level was more prevalent in women with rheumatoid arthritis than in those without rheumatoid arthritis (20% vs. 16%, respectively, p=0.02). conversely, no differences were evident for marital status or employment between the two groups of women. regarding behavioral factors, the prevalence of smoking and alcohol intake were significantly higher in women with rheumatoid arthritis than in those without rheumatoid arthritis (for smoking: 15% vs. 11%, respectively, p=0.02; for alcohol consumption: 7% vs. 4%, respectively, p=0.01). similarly, the prevalence of coffee kollcaku j, kollcaku a. correlates of rheumatoid arthritis among women in albania (original research). seejph 2016, posted: 29 august 2016. doi 10.4119/unibi/seejph-2016-127 5 consumption was higher among women with rheumatoid arthritis, but this finding was not statistically significant. the prevalence of tea consumption was similar in the two groupings. on the other hand, the prevalence of overweight and obesity were significantly higher in women with rheumatoid arthritis compared with those without this chronic condition (for overweight: 35% vs. 29%, respectively, whereas for obesity: 30% vs. 25%, respectively; overall p<0.001) [table 1]. table 1. distribution of socio-demographic characteristics and lifestyle/behavioral factors in a sample of albanian women by rheumatoid arthritis status variable total (n=2198) rheumatoid arthritis (n=437) no rheumatoid arthritis (n=1761) p † age-group: ≤50 years >50 years 298 (13.6)* 1900 (86.4) 37 (8.5) 400 (91.5) 261 (14.8) 1500 (85.2) <0.001 employment: employed and/or retired unemployed 1746 (79.4) 452 (20.6) 342 (78.3) 95 (21.7) 1404 (79.7) 357 (20.3) 0.509 marital status: married not married 1793 (81.6) 405 (18.4) 363 (83.1) 74 (16.9) 1430 (81.2) 331 (18.8) 0.408 educational level: low middle/high 364 (16.6) 1834 (83.4) 89 (20.4) 348 (79.6) 275 (15.6) 1486 (84.4) 0.021 smoking: no yes 1947 (88.6) 251 (11.4) 372 (85.1) 65 (14.9) 1575 (89.4) 186 (10.6) 0.015 alcohol intake: no yes 2105 (95.8) 93 (4.2) 407 (93.1) 30 (6.9) 1698 (96.4) 63 (3.6) 0.005 coffee consumption: no yes 758 (34.5) 1440 (65.5) 136 (31.1) 301 (68.9) 622 (35.3) 1139 (64.7) 0.103 tea consumption: no yes 1200 (54.6) 998 (45.4) 242 (55.4) 195 (44.6) 958 (54.4) 803 (45.6) 0.747 bmi: normal weight overweight obesity 971 (44.2) 655 (29.8) 572 (26.0) 155 (35.5) 151 (34.6) 131 (30.0) 816 (46.3) 504 (28.6) 441 (25.0) <0.001 * absolute numbers and their respective column percentages (in parentheses). † p-values from fisher’s exact test. table 2 presents the association of rheumatoid arthritis with demographic and socioeconomic characteristics and behavioral factors. in crude (unadjusted) models, there was a positive association of rheumatoid arthritis with older age (or=1.9, 95%ci=1.3-2.7), a lower educational attainment (or=1.4, 95%ci=1.1-1.8), smoking (or=1.5, 95%ci=1.1-2.0), alcohol intake (or=2.0, 95%ci=1.3-3.1) and overweight and obesity (or=1.5, 95%ci=1.22.0 and or=1.6, 95%ci=1.3-2.3, respectively). furthermore, there was a weak and kollcaku j, kollcaku a. correlates of rheumatoid arthritis among women in albania (original research). seejph 2016, posted: 29 august 2016. doi 10.4119/unibi/seejph-2016-127 6 borderline statistically significant relationship with coffee consumption (or=1.2, 95%ci=1.0-1.5). on the other hand, there was no association with employment, marital status, or tea consumption. table 2. association of rheumatoid arthritis with socio-demographic characteristics and lifestyle factors variable crude (unadjusted) models multivariable-adjusted models or (95%ci)* p* or (95%ci)* p* age-group: ≤50 years >50 years 1.00 (reference) 1.88 (1.31-2.70) 0.001 1.00 (reference) 1.82 (1.26-2.62) 0.001 employment: employed and/or retired unemployed 1.00 (reference) 1.09 (0.85-1.41) 0.497 1.00 (reference) 1.08 (0.84-1.43) 0.522 marital status: married not married 1.00 (reference) 0.88 (0.67-1.16) 0.369 1.00 (reference) 0.94 (0.71-1.24) 0.654 educational level: middle/high low 1.00 (reference) 1.38 (1.06-1.80) 0.017 1.00 (reference) 1.44 (1.10-1.89) 0.008 smoking: no yes 1.00 (reference) 1.48 (1.09-2.01) 0.012 1.00 (reference) 1.46 (1.07-2.00) 0.017 alcohol intake: no yes 1.00 (reference) 1.99 (1.27-3.11) 0.003 1.00 (reference) 1.93 (1.22-3.05) 0.005 coffee consumption: no yes 1.00 (reference) 1.21 (0.97-1.51) 0.099 1.00 (reference) 1.16 (0.92-1.46) 0.210 tea consumption: no yes 1.00 (reference) 0.96 (0.78-1.19) 0.714 1.00 (reference) 0.92 (0.74-1.14) 0.421 bmi: normal weight overweight obesity 1.00 (reference) 1.54 (1.23-2.02) 1.59 (1.29-2.28) <0.001 (2)† 0.001 <0.001 1.00 (reference) 1.53 (1.18-1.98) 1.57 (1.22-2.02) <0.001 (2)† 0.001 <0.001 * odds ratios (or: rheumatoid arthritis vs. no rheumatoid arthritis), 95% confidence intervals (95%cis) and p-values from binary logistic regression. † overall p-value and degrees of freedom (in parentheses). upon multivariable-adjustment for all covariates entered simultaneously into the logistic regression models, rheumatoid arthritis was positively and significantly related to older age (or=1.8, 95%ci=1.3-2.6), a lower educational attainment (or=1.4, 95%ci=1.1-1.9), smoking (or=1.5, 95%ci=1.1-2.0), alcohol intake (or=1.9, 95%ci=1.2-3.1) and overweight and obesity (or=1.5, 95%ci=1.2-2.0 and or=1.6, 95%ci=1.2-2.0, respectively) [table 2]. discussion kollcaku j, kollcaku a. correlates of rheumatoid arthritis among women in albania (original research). seejph 2016, posted: 29 august 2016. doi 10.4119/unibi/seejph-2016-127 7 this study provides evidence on selected socio-demographic and lifestyle correlates of rheumatoid arthritis among women seeking specialized primary health care in postcommunist albania. older age, low education, smoking, alcohol intake and overweight and obesity were strong and significant “predictors” of rheumatoid arthritis in this sample of adult women in albania. the positive association of rheumatoid arthritis with age which was found in our study is in line with several previous reports (1). on the other hand, the positive relationship with a lower educational attainment is appealing and deserves further investigation in populationbased samples. regarding the environmental factors, we found that, in multivariable-adjusted models, smoking was related to a 50% increase in the risk of rheumatoid arthritis. several studies have indicated that smoking is the main environmental risk factor which increases twice the risk of developing rheumatoid arthritis (9). it has been demonstrated that the effect of smoking is confined to patients with acpa-positive disease (8). nonetheless, at a population level, the risk associated with smoking is quite low and has limited clinical relevance regardless of the pathogenetic importance of this factor (1). in our study, we found a positive relationship between rheumatoid arthritis and alcohol consumption. the risk in women who reported to consume alcohol was about 90% higher than in those who did not report alcohol intake. this finding is generally compatible with previous studies conducted elsewhere (1,16). other potential environmental risk factors for development of rheumatoid arthritis may include coffee intake, vitamin d status, and oral contraceptive use (1,16). we did not assess the effect of vitamin d, or oral contraceptive use, but found a weak and borderline significant relationship with coffee consumption in unadjusted logistic regression models only. in any case, smoking excluded, the effect of environmental factors in the risk of rheumatoid arthritis is controversial (1). at present, there are many unresolved difficulties for individuals suffering from rheumatoid arthritis. yet, the constant introduction of innovative and ground-breaking treatments can overcome many of these difficulties and challenges (1). one of the main requirements involves the characterization of disease subsets in individuals with early onset of rheumatoid arthritis in order to target intensive treatment regimens for those who need them most and are also likely to respond (1). from this perspective, it is suggested that that the new direction of treatment and management of rheumatoid arthritis should be towards short intensive therapeutic courses that result in remission instead of the traditional approach which consist of long-term suppressive treatment strategies (1). this study may have several limitations. the study sample may not be representative of all women who attend rheumatology services at the primary health care level in tirana. nonetheless, we included consecutive women who fulfilled the eligibility criteria in order to ensure, to the extent possible, a representative sample of female primary health care users seeking rheumatology services in tirana municipality. yet, as our study was conducted in tirana only, the sample may not be necessarily representative of all the albanian women. assessment of rheumatoid arthritis was based on the acr/eular 2010 criteria (15), which is reassuring. however, the information related to lifestyle/behavioral factors of women included in this study may have been biased in the context of a traditional and patriarchal society such as albania. notwithstanding this possibility, there is no plausible reason to assume different reporting of behavioral factors in women with and without rheumatoid arthritis. kollcaku j, kollcaku a. correlates of rheumatoid arthritis among women in albania (original research). seejph 2016, posted: 29 august 2016. doi 10.4119/unibi/seejph-2016-127 8 in conclusion, this study provides useful information about important correlates of rheumatoid arthritis among women 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criteria: an american college of https://www.ncbi.nlm.nih.gov/pubmed/?term=funovits%20j%5bauthor%5d&cauthor=true&cauthor_uid=20872595� https://www.ncbi.nlm.nih.gov/pubmed/?term=felson%20dt%5bauthor%5d&cauthor=true&cauthor_uid=20872595� https://www.ncbi.nlm.nih.gov/pubmed/?term=bingham%20co%203rd%5bauthor%5d&cauthor=true&cauthor_uid=20872595� kollcaku j, kollcaku a. correlates of rheumatoid arthritis among women in albania (original research). seejph 2016, posted: 29 august 2016. doi 10.4119/unibi/seejph-2016-127 9 rheumatology/european league against rheumatism collaborative initiative. arthritis rheum 2010;62:256981. 16. liao kp, alfredsson l, karlson ew. environmental influences on risk for rheumatoid arthritis. curr opin rheumatol 2009;21:279-83. __________________________________________________________ © 2016 kollcaku et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1 request for the retraction of the manuscript “public health in kosovo after five difficult years of independence” (review article). seejph 2013 by authors jerliu n, ramadani n, mone i, brand h. slavenka jankovic, co-editor, seejph dear executive editor, i have read carefully the manuscripts published in the first issue of the seejph. as a co-editor of the seejph, i have to request the retraction of the review article: “public health in kosovo 1 after five difficult years of independence” by authors jerliu n, ramadani n, mone i, brand h. this manuscript does not fulfil neither criteria for a review paper nor for any other type of scientific manuscripts that the seejph publishes, as outlined in the seejph authors’ instructions. according to the checklist for review papers (please see below) none of the several basic criteria was observed. criteria for review articles article: “public health in kosovo * after five difficult years of independence“ criterium observed (yes/no) review articles are an attempt to summarize the current state of understanding on a topic. they analyze or discuss research previously published…they come in the form of systematic reviews and literature reviews and are a form of secondary literature (1). no the paper reports on demographic and socioeconomic indicators, health profile, lifestyle factors, health reforms and health financing in kosovo using official data from the agency of statistics kosovo, the ministry of health kosovo, the world bank, the iph kosovo, etc. a systematic review is a review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research, and to collect and analyze data from the studies that are included in the review (2). no a review article is written about other articles, and does not report original research of its own. review articles draw upon the articles that they review to suggest new research directions, to strengthen support for existing theories and/or identify patterns among existing research studies (3). no reviews should stimulate thinking and further reading indicating other sources of information (3). no the review should include a broad update of recent developments (from the past 3-5 years) and their likely public health or clinical applications in primary and secondary care (4). no review articles provide an extensive overview of the existing literature on a topic (they should include a number of relevant references, mainly original research papers and reviews (up to 50 references according to seejph instruction for authors) (3-5). no there are only 10 references in the reference list (only four are original papers). half of all references (2,3,5,8,10) are incomplete (without url and the dates of access that is not in line with the seejph authors’ instructions). 1 this designation is without prejudice to positions on status, and is in line with unscr 1244 and the icj opinion on the kosovo declaration of independence: (http://ec.europa.eu/enlargement/countries/detailed-country-information/kosovo/ (accessed april 17, 2014). http://en.wikipedia.org/wiki/systematic_review http://en.wikipedia.org/wiki/literature_reviews http://en.wikipedia.org/wiki/secondary_literature http://en.wikipedia.org/wiki/kosovo_status_process http://en.wikipedia.org/wiki/united_nations_security_council_resolution_1244 http://en.wikipedia.org/wiki/international_court_of_justice_advisory_opinion_on_kosovo%27s_declaration_of_independence http://en.wikipedia.org/wiki/international_court_of_justice_advisory_opinion_on_kosovo%27s_declaration_of_independence 2 references 1. english encyclopedia. review article. http://www.encyclo.co.uk/define/review%20article (accessed: april 17, 2014). 2. moher d, liberati a, tetzlaff j, altman dg, the prisma group. preferred reporting items for systematic reviews and meta-analyses: the prisma statement. bmj 2009;339:b2535, doi: 10.1136/bmj.b2535. 3. american public university system. a review article: http://apus.libanswers.com/a.php?qid=153014 (accessed: april 17, 2014). 4. seejph. authors’ instructions: http://www.seejph.com/instructions-for-authors/ (accessed: april 17, 2014). 5. day ra, gastel b. how to write and publish a scientific paper. 7 th edition. oxford: greenwood press, 2011. http://www.encyclo.co.uk/define/review%20article http://www.bmj.com/cgi/content/full/339/jul21_1/b2535?view=long&pmid=19622551 http://www.bmj.com/cgi/content/full/339/jul21_1/b2535?view=long&pmid=19622551 http://apus.libanswers.com/a.php?qid=153014 http://www.seejph.com/instructions-for-authors/ lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 1 review article preparing society to create the world we need through “one health” education report of a global survey and web conference on “one health” k-12 education, 18 november 2016 george r. lueddeke1, gretchen e. kaufman1, joann m. lindenmayer2, cheryl m. stroud2 1 one health education task force; 2 one health commission. corresponding author: george r. lueddeke, co-chair, one health education task force; address: 9 lakeland gardens, southampton, hampshire, so40 4xg, united kingdom; email: glueddeke@aol.com http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 2 abstract aims: a previous concept paper published in this journal (1), and a press release in june 2016 (2), focused on the importance of raising awareness about the un-2030 sustainable development goals (sdgs) (3) and, in particular, developing a better understanding about the critical need to ensure the sustainability of people and the planet in this decade and beyond through education. the one health education task force (ohetf), led by one health commission (4) in association with the one health initiative (5) agreed to conduct an online survey and conference in the fall of 2016 to engage interested colleagues in a discussion about the possible application of one health in k-12 (or equivalent) educational settings. method: the survey instrument, reviewed by a panel of experts (below), was conducted in september and october 2016 and focused on basic concepts, values and principles associated with one health and well-being. input was sought on the various ways that one health intersects with the un sustainable development goals and how they might work together toward common objectives. questions also explored ‘why, how, and where’ one health could be incorporated into k-12 curricula, and who should be involved in creating this new curriculum. results and conclusions: overall, there was general consensus that this initiative could make a significant contribution to implementing the sdgs3 through the one health spectrum as well as the priorities and major challenges that would be encountered in moving this initiative forward. five strategies were presented for embedding the sdgs and one health through curriculum innovation from early years to tertiary education and beyond. importantly, a “community of practice” model was put forward as a means to support and promote the sdg goals through one health teaching and learning in a meaningful and supportive way for the benefit of all involved. a subsequent conference in november 2016 provided an opportunity to present the results of the survey and conduct a more in depth discussion about potential curriculum development designs, possible project funding sources, and implementation challenges. keywords: education, one health, global health. conflicts of interest: none. acknowledgements: the organizers would like to thank the members of the one health educationtask force for their contributions to the conference and survey development including, lee willingham and tammi kracek from the one health commission and representatives from the one health initiative autonomous pro bono team: bruce kaplan, laura kahn, lisa conti and tom monath. we are also grateful for the invaluable assistance from peter costa, associate executive director for the one health commission, in organizing and moderating the on-line conference. in addition we would like to thank the following reviewers who assisted in the development of the online survey: muhammad wasif alam, dubai health authority-head quarter, uae; stephen dorey, commonwealth secretariat, uk; jim herrington, university of north carolina at chapel hill, usa; getnet mitike, senior public health consultant, ethiopia; heather k. moberly; dorothy g. whitley texas a&m university, usa; joanna nurse, commonwealth secretariat, uk; christopher w. olsen, university of wisconsin-madison, usa; richard seifman, capacity plusintrahealth international, usa; neil squires, public health england, uk; erica wheeler, paho/who, barbados. http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 http://www.seejph.com/index.php/seejph/article/view/122 https://www.onehealthcommission.org/documents/filelibrary/commission_news/press_releases/61016__oh_education_press_releasefi_f7644a48f9910.pdf https://sustainabledevelopment.un.org/post2015/transformingourworld https://sustainabledevelopment.un.org/post2015/transformingourworld https://www.onehealthcommission.org/ https://www.onehealthcommission.org/ http://www.onehealthinitiative.com/ http://www.onehealthinitiative.com/ http://www.onehealthinitiative.com/ http://www.onehealthcommission.org/ lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 3 introduction the one health concept is rightly gaining timely support and momentum worldwide as we are all becoming increasingly aware that humans, animals, plants and the environment must be in much better balance or harmony to ensure the present and future of our planet. it is gradually becoming clear that to realise or indeed re-capture this state of equilibrium, one health and well-being must be at the heart of socioeconomic, environmental and geopolitical decisionmaking at global, regional, national and local levels, thereby informing, as the commonwealth secretariat health and education unit (comsec heu) posits governance, knowledge development, capacity building and advocacy (6). over the past 18 months or so, and in line with the un-2030 global goals (3) (or sustainable development goals-sdgs) agreed late 2015, that embraced a broad notion of sustainable development – how all things are interconnected – climate, energy, water, food, education -we have been researching and developing ideas on how the one health task force might support sustainability of the planet and people. our deliberations led us to the fundamental question of how we might address perhaps the most important social problem of our time, that is, ‘how to change the way humans relate to the planet and each other to ensure a more sustainable future for all life.’ (2) our unanimous conclusion is that learning about ‘one health and well-being’ needs to play a much greater role in the education of our children and younger generation as well as society in general. to these ends, we developed position papers, issued a press release (2) in june 2016, to which many webinar attendees responded, followed by an on-line survey in septemberoctober to solicit wider input on one health education. the survey thus informed an online one health education conference on november 18, 2016 (7). the main purpose of the webinar was to share and build on the survey findings with a view to informing a ‘robust’ one health education project funding proposal. a vital consideration governing the proposal was the potential of raising awareness about the social determinants of human-animal-environment interactions as well as the limitations presented by an unbridled human population expansion in the face of finite natural resources. many of the task force discussions reminded us that while we are advancing scientifically and technologically, we are also faced with a huge ingenuity gap – that is finding answers to unprecedented social problems that on many days seem to overwhelm us – climate change, health and food security, armed conflicts, ideological extremism, economic uncertainty, global inequalities, inequities and imbalances, to name a few. the ebola crisis especially caught the world’s attention in this regard. there are no easy answers. but encouraging young people to gain a better understanding of the planet we all share and need to sustain, along with our individual responsibilities to each other, and learning not only ‘to do things better’ but also, perhaps most importantly , ‘to do better things’ through collaboration and education, must surely be part of the way forward. underpinning our resolve to engage children and young adults in the pursuit of achieving the un-2030 global goals through education and the one health education initiative (ohei) is captured in the recently published book, global population health and well-being in the 21st century (8). a recurring theme in the publication is that achieving the 17 sdgs and targets requires a fundamental paradigm or mind-shift in the coming decades: moving us from a view that sees the world as ‘a place primarily for humans and without limits’ to one that views the world holistically, ensuring it is fit for purpose in the long run for humans, animals, plants and the environment or our ecosystem. one health provides us with the ‘unity around a common cause’ (9) toward which all of us need to aspire and which we believe is fundamental to building the world we need. http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 file:///c:/users/george/downloads/:%20https:/drive.google.com/file/d/0b8wr6920su0arhlyd0pdoerlajq/view file:///c:/users/george/downloads/:%20https:/drive.google.com/file/d/0b8wr6920su0arhlyd0pdoerlajq/view http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 4 summary of online one health education survey results the purpose of the one health education online survey was to elucidate concepts, values and principles that respondents associated with one health, and to begin to define how the one health concept might be operationalized in k-12 schools. invitations to participate in the survey were sent to individuals that had previously expressed interest in the one health k-12 education initiative expressed through presentations, in response to the published concept note and a press release, and through individual conversations. seventy-six people responded to one or more questions on the survey. of the 52 (68.4%) respondents who answered the question about highest level of education attained, 31 held one or more doctoral-level (18 phd, 9 dvm, 4 md, 1 jd), 14 held master’s-level, and 7 held bachelor’s-level degrees. of the 53 (69.7%) respondents who answered the question about country where they worked, 21 answered usa, 15 europe (including 6 in the uk), 10 africa, 5 asia or southeast asia, 1 south america, and 1 answered middle east. one health concepts, values and principles words that respondents most commonly cited were “health” and the health domains (human, animal, environment/ecosystem/ecology). respondents also cited words that represented common ground among one health disciplines, e.g., inter-, coop-, collab-, coor-, integ-, uni and holi-. “sustain” and “educ-“ were mentioned frequently, as were “diseand “zoo-.” respondents preferred the venn diagram and triad representations of one health by far over other representations. values most commonly cited as most essential to one health are sustainability, cooperation, diversity/biodiversity and responsibility, leadership and understanding. innovation was also noted. the type of sustainability judged to be the most important type by far was ecologic sustainability, economic and cultural/social only moderately so. a high degree of agreement (>90%) was given to the following statements: “the health of humans, other animal species and plants cannot be separated,” and “environment includes both natural and built environments.” more than 80% of respondents agreed that “humans have a moral imperative to address one health challenges,” and “one health should be practiced so that there is no net (ecosystem) loss of biological diversity.” more than two-thirds of respondents agreed with all other statements except “when you optimize health for one species, health for others is marginalized or eliminated.” this implies that the health of species is inter-related and should not be viewed as mutually exclusive. the factors contributing most to current one health problems are compartmentalization of health services and policies, lack of knowledge/understanding, lack of funding streams that encourage collaboration and provide support for one health initiatives, poverty-distribution of wealth-inequity, overemphasis of treatment of individuals (human and animal) at the expense of preventive medicine and population health, political systems that support individual/corporate interests above all else, and overemphasis of human health at the expense of animal/environmental health. other factors mentioned were that one health was too veterinary-centric and that there was a need to acknowledge differences between the developed and developing world. one health education and the sdgs respondents related k-12 education most closely to sdg 3 (ensure healthy lives and promote well-being for all ages). also related, although slightly less so, were sdg 14 (conserve and sustainably use the oceans, seas and marine resources for sustainable development), sdg 15 http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 5 (protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification and halt and reverse land degradation and halt biodiversity loss), sdg 6 (ensure availability and sustainable management of water and sanitation for all), and sdg 2 (end hunger, achieve food security and improved nutrition and promote sustainable agriculture). other sustainability goals not included in the 17 sdgs included improving animal welfare, developing sustainable strategies for control of feral animals, invasive species and pests (to humans), moving to clean energy sources, developing new tools for impact assessment, and promoting greater intake of locally raised foods. operationalizing one health education in k-12 why? long-term outcomes of a one health-themed curriculum included products (trained educators, better policies and decisions, multidisciplinary approaches to risk, sustainable environment/ecosystems/communities, successful adaptation to climate change, new disciplines, better communication, reduction of the gender gap, more recycling, project design competitions), changes in attitudes and behaviors, more and better engagement as citizens with policy and as consumers, and better health and greater awareness of human populations relationship with the planet and its inhabitants. a number of people anticipated that systems/interdisciplinary thinking would be an outcome. what? students should be exposed to all concepts listed, although personal responsibility (how individual actions impact one health) and respect for natural systems and human responsibility for planetary health were the most important, followed by environmental contexts of one health issues and corporate, political and societal responsibility (how their actions impact one health). one person noted that equity and social justice was important, as was the moral imperative of viewing nature as equally important as humanity. students in one health-themed educational programs should learn collaboration, interdisciplinary thinking, systems-thinking, problem-solving and team-building skills. entrepreneurship, environmental ethics were also noted. one person remarked that “in my opinion, students in one health must, before anything else, gain the ability to immediately look for solutions from all media when facing a problem that requires a more complex approach. basically questioning themselves -what would an engineer/medic/chemist/vet/etc. do when faced with the current problem?” how? challenges most commonly cited that could be used to illustrate one health in k-12 education were diseases (vector-borne, zoonotic, food-born), food security, antimicrobial resistance, environmental pollution (of air, water, soil), climate change and loss of biodiversity/disruption of ecosystem services. where? college and university students are the groups most exposed at present to one health concepts (although fewer than 20% of respondents believed they were exposed at all). fewer than five percent of respondents believed that students at all other levels of education are exposed to these concepts. respondents believed that at levels below college/university, it’s most important to introduce one health concepts to students at all educational levels, although it’s most important in high/secondary schools and slightly less so in middle schools. http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 6 one health-themed curricula should be piloted in publicly-funded schools and in colleges or universities. one person suggested piloting one health education in religious classrooms because a lot of teaching goes on there from k-12 (nb: makes sense as long as pope francis is in charge!). virtual classrooms were also noted. barriers and challenges to piloting and scaling up the main barrier to incorporating a oh-themed program into k-12 education is constraints posed by the current educational system, including lack of knowledge and understanding on the part of teachers and the public, the need for adequate teacher training, rigid limits posed by established curricula, government objectives, and the requirement for standardized testing. also noted were overloaded curricula, lack of adequate resources (validated k-12 curricula, infrastructure, access to the internet and it, materials such as case studies, activities, textbooks, pedagogical methods and tools), and inertia of current educational systems and their representatives. many respondents stated that one health is complex, requires simplification, and concrete and practical examples to make it more easily understood. major logistical challenges to scaling-up a k-12 one health curriculum to a global stage that respondents anticipated were lack of funding and resources (it, infrastructure, human resources, content, simulation exercises, alternate delivery platforms), constraints posed by current educational systems (different education systems/formats/settings, teacher training, limitations imposed by pre-existing curriculum requirements, need for tailored education to different contexts, underserved areas sustainable funding), and cultural and language differences. one person noted the need to first measure the added value of pilot projects before scaling up. who? the most common educational stakeholder sector that should be represented in developing the concept of a one health-themed education initiative into a successfully-funded proposal included various members of educational systems (teachers and educators at all levels (including university) of public and private sector, educational/instructional/ curriculum designers, school administrators, teacher associations, teacher training institutions, teachers unions, and educational researchers). government was also mentioned frequently. interesting suggestions included church schools, where a great deal of education takes place, parents and students, and publishers of textbooks. funding organizations that might support implementation of a one health-themed education initiative included government sectors (education, development, health), various private foundations (wellcome trust, melinda & bill gates foundation, soros foundation, the josiah macy jr. foundation, rockefeller foundation, skoll foundation, the global fund, the foundation for international medical education and research), international nongovernmental organizations such as those originating in the eu and the un, and banks such as the world bank. also mentioned were the european social fund, the network: towards unity for health, the european horizon 2020 program, and the global partnership for education. other comments and suggestions worthy of mention were:  a one health curriculum has to be content rich and ‘not just another vague thing' about relationships and collaboration, and that it needs to address critical problems like climate change, agricultural intensification, comparative medicine, environmental health threats.  consider strengthening and using innovative on-line teaching, flipped class room, take advantage of existing educative one health tools (mooc on one health, environment challenges, etc.), and create new ones. http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 http://macyfoundation.org/ http://macyfoundation.org/ lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 7  the biggest challenge we face in implementing a one health curriculum at a global stage is the lack of a major driving force in one health. although we are trying our best as one health clusters, we need to have a major support from a so called "poster boy", something that will catalyze our efforts.  one-health should be a process that start at pre-primary level to change mind-sets, although there should be entry-levels at all phases for those who were not exposed from the start. it will be beneficial if the one-health principles thinking can be incorporated as it relates to different subject streams (e.g. economics, social science, and others).  we need to understand that we, as individuals, are not quite the center of the universe and that our actions, even though they may not bring us much benefit/losses, surely can influence everyone around us.  this is an extremely important project at a very volatile time in our world. education is the key to supporting and delivering the un 2030 sdgs. strategies for k-12 one health curriculum innovation this segment of the conference presented some of the ways that the one health education task force has considered to utilize one health concepts in curriculum development for k-12 classroom applications. feedback from the participants was requested and additional ideas that might be considered for the program and funding proposal were encouraged. we have explored the following five potential options to consider for our proposal: curriculum innovation grants for educators, curriculum development workshops for teachers, teacher training programs, a one health education network, and an on-line knowledgebase of one health curriculum materials. we understand that there are different needs among various educational systems and across countries around the world, so the options presented below are not mutually exclusive and we could consider one or any combination of these within the larger project. i) curriculum innovation grants for educators the initial idea that we explored was a program that would offer grants to teachers to develop and implement a one health focused curriculum at their school that meets specific criteria and objectives set by the one health education task force. we are attracted to this idea because we understand that teachers themselves know best how to reach their students, what curricular designs work within their institutions and grade levels, and what tools are most effective at reaching outcomes. in addition, by engaging teachers directly and offering opportunities for innovation, we feel that other teachers would be more likely to adopt and share successful methods among themselves, either thru example and their existing networks, or with formal mentoring. this program would offer competitive innovation curriculum development grants to teachers or teams of educators on an annual basis. the focus of this program could be open ended or could involve a changing one health theme each year to ensure diversity of topics. applicants would be asked to meet very specific guidelines that target values, skills and knowledge criteria using one health approaches. these guidelines would be developed by the one health education task force and would be informed by wider conversations with the one health global community, including the survey recently conducted. proposals would need to emphasize interdisciplinary engagement as a fundamental tenet of one health principles. as time goes by, successful methods and curricula would be shared through the proposed oh education network and knowledgebase described below and would not be limited only to participants in the program. http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 8 ii) curriculum development workshops for teachers we have received feedback that some teachers would never have the time to devote to curriculum development themselves. some have also expressed concern that they do not know the subject area well enough to be able to write a curriculum or innovate very effectively along one health lines. in response, we decided we needed to create an opportunity for motivated teachers to learn more about one health and receive some direct assistance in creating one health themed curricula. we are proposing to do this through a series of summer workshops, which would include summer salary for participants. this would be an annual opportunity and could again be open ended or focused on changing themes or topics. workshops would involve participation by “experts” in one health, depending on the topics selected, and would also include curriculum development professionals to assist teachers in classroom applications. the workshops would emphasize innovative learning methods that target one health values, skills and knowledge criteria as described above and would provide an important networking opportunity for sharing and mentoring between teachers and experts. iii) teacher training programs a third concept that we are proposing is to work with teaching training programs already in existence that are interested in building one health approaches into their training programs. this approach would involve new teachers in the process of curriculum development and could be implemented through specific courses or teaching modules. by working with teaching training programs we would be creating opportunities for innovation from the ground up which may provide greater opportunity for broad integration of one health values across subjects. in this environment, we would also be in a good position to inculcate one health skills and knowledge in teachers during a critical period in their own development as educators. this approach would also ensure that appropriate regional programming is being developed that best meet the needs of local education systems and would maximize benefits and outcomes which may not be otherwise adaptable from a more universal, less regional approach. it was suggested that we think about promoting this opportunity to make sure teachers that need it to take advantage of it. this could be done by developing introductory one health presentations and using social media to reach a broad audience. the example of an ivsa program was given where they are “developing a one health presentation to school children on veterinary public health, one health and explaining the diversity and active contribution of vets and medics to the human-animal-environment interface. we plan to distribute it to our member organisations in over 60 countries and translate it to at least 2/3 languages for teachers to use. we hope to use social media to spread the word, to students will promote or present this workshop to communities, to families and then to schoolsto encompass student centred learning (bhavisha patel).” iv) one health education network the creation of a one health education network will be critical to global adoption of any curriculum innovation that results from this initiative. we feel that it would be very valuable to foster mentorship and sharing among project participants and provide opportunities for others outside the project to benefit from the teaching expertise that develops as a result of this initiative. over several years this could develop into a robust and supportive cohort of one health educators around the globe and provide the best mechanism for achieving sustainable development goals globally through one health. http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 9 the ohe network would provide a directory of one health educators, facilitate communication between educators with social networking tools, and facilitate mentorship connections between educators and one health experts. the network could act as a platform for organizing meetings and presentations, and would facilitate collaboration on future projects. importantly, the network could become self-sustaining simply through the interest and enthusiasm of the participants and provide longevity to the investment of this project for years to come. v) on-line knowledge base of one health curriculum materials finally, we want to openly share the products of any of these curriculum development programs as we start a movement and inspire teachers around the world to adopt one health principles in their teaching. we propose to build an open access technology platform for sharing curriculum that will serve as a repository for products of any grants or workshop programs developed through this initiative. sharing outwardly to the world would provide an opportunity for feedback and dialogue to improve these products and encourage, in an organic way, the transition of more curriculum to include one health principles. over time, this knowledgebase could also link to or include contributions from outside this project and broaden the impact and engagement for one health themed educational initiatives that furthers our global objective for achieving sustainable development goals through one health themed education. above are the five main programs we have focused on to date and we encourage feedback and input from a broader audience. there are many details to work out, and the scale of these programs is still undetermined. what follows is a summary of the participant suggestions and calls for clarification concerning the strategies presented. first and foremost we would like to clarify that the scope of this project is intended to be global. while initial implementation of pilot projects may precede full globe reach, the pilot projects would likely include a diversity of sites. the exact structure or timeline has not yet been determined. the different nature of various education systems around the world and even within a country like the us was brought up as a challenge. within the us, there is a great deal of variation and level of influence between state agencies and the federal government through the department of education. some states may be more receptive than others to the type of curriculum initiative we are proposing. we hoped that the first option which asks for teachers themselves to come forward, would take care of some of this diversity. teachers would presumably be proposing curriculum development that would work within their own context. the great differences between developed educational systems and developing educational systems will also be a challenge and may require two different efforts or pathways. some clarification about who will make up the group of “one health” experts to participate will be needed, especially since there are no specific well defined criteria for a one health expert, or any standardized system for accreditation or academic degree existing today. we are specifically look for content experts to provide necessary knowledge and resources, as well as curriculum development experts, and the specific qualifying criteria that defines a participating “expert” still needs to be worked out. an excellent suggestion was made to consider including parents in grants or workshops to help bridge the resource gap in some low-income schools where parent leaders play an important volunteer role. engaging with parents may also promote greater acceptance with the community outside the school. the concept of a “community of practice” approach was mentioned as a model for the knowledgebase as well as the network. one way to do this might be to target a specific group of people involved in middle and high school education and connect them with existing experts http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 10 or groups that might have resource materials to provide, such as the oie. we would very much like these two programs, the knowledgebase and the network, to operate as a community of practice in one health education. one significant outcome will a one health education foundational body of work that currently does not exist. another mentorship model to consider would be the twinning model, used in the usaid emerging pandemic threats program and others to share between developed and developing educational systems or institutions. there were a couple of cautionary remarks to conclude this section. first of all, considering the large scope of programs and challenges for implementation, there was some concern about staff time and capacity necessary to follow through with this initiative and a need to establish realistic priorities. we are very aware of this and will be considering these questions as we approach funders and develop a timeline. lastly, beware of the top down approach being proposed by our group of one health champions. this will not work without active engagement with k-12 education partners. we have discussed this at length and have been struggling to find the appropriate enthusiastic partners. we welcome any good ideas or introductions to institutions or people that we can draw in to this initiative that will provide the appropriate input. dr. lueddeke will provide more detail on our potential partners defined to date. funding considerations for a one health education initiative this segment of the conference focused on three main funding considerations: i) linking un 2030 sustainable development goals to one health education initiatives (10); ii) supporting projects through existing development mechanisms; iii) possible funding sources. a key argument for project funding decisions was that the one health concept and approach need to be considered as a lens or filter for shaping global policy and strategy regardless of the sdg goals and targets being evolved and implemented, including k-12+ education (fig.1). and, while the habitat iii the new urban agenda (11) agreed in october 2016 is a highly commendable achievement, according to a word search, the 19 documents failed to mention terms or explanatory paragraphs/recommendations related as planet, one health, conservation, animals, epidemic, root causes, overcrowding, inequities, automation, eco footprint, infectious disease, non-communicable disease and only singularly cited the words prevention, healthy lifestyles, ageing population, mental health. more than 70 % of the world’s 9 billion population will be living in cities by 2050 or before. one health crosses all discipline boundaries, and it is important that the project planners identify and collaborate across existing networks, as shown in fig. 2. consideration to seeking funding from multiple funding sources might also be appropriate (e.g., bill and melinda gates foundation, un agencies (e.g., undp, unesco), rockefeller foundation, macarthur foundation, the uk department for international development, and welcome trust). several avenues will be pursued in the next few months, including making personal contact with potential partners or collaborators. http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 https://www2.habitat3.org/bitcache/99d99fbd0824de50214e99f864459d8081a9be00?vid=591155&disposition=inline&op=view lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 11 figure 1. linking un 2030-global goals to k-12 one health and well-being education figure 2. global networks (selected) global networks: united nations 193 members states -2 observer states who collaborating centers (>700) world bank global learning development network (>120 institutions – 80 countries) the commonwealth (52 nations) the european union (27 nations) http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 12 further to a question about identifying good partners, it is recognised that a traditional top down approach is not likely to work in this situation. an example of behaviour change that worked well in the u.s. in 70s and 80s is recycling, a local, bottom up endeavour. interestingly, it was young people (children) being inspired by teachers that made the recycling movement happen in the u.s. we should be concerned about strictly advocating a top down approach for k-12 one health education. a successful approach has to start more locally, but be guided by national aspirations or goals. local and national interests should be working in tandem. in the u.s. and the u.k. there has been very little discussion so far about the sustainability development goals. we must draw on expertise locally and find support nationally to enable action groups. we like to think of the dual concepts of one health and ‘well-being’. one health is beyond any political or health system. it’s really saying here is our planet, a very small planet, and we have got to keep it healthy regardless of how we are living our lives. it is probably the only non-divisive concept that we have right now. the un development program folks have done a fairly good job with disseminating information. but, if the un had incorporated one health a year or so ago, we would be further along. meeting the needs of the diverse global community although we believe there exists one health core values, principles and concepts, we recognize that operationalizing one health in primary and secondary schools must recognize and appreciate educational, cultural and social differences among countries and educational systems. therefore, no one model or curriculum will fit all situations. how then, can we begin to frame a proposal that honours one health core values, principles and concepts, but is flexible enough to be adapted for diverse circumstances? a point well-taken from the survey is that a validated one health curriculum does not exist. for that reason, any attempt to propose one must include a pilot phase from which one could learn valuable lessons related to adoption, implementation, and evaluation of a curriculum before it could be modified and scaled up in one or more systems. therefore, a successful proposal will focus on pilot studies in one or more education systems (to be defined), but at the same time, it must include metrics that could be used to judge whether or not here is evidence that scaling up and/or out is feasible and of value. various models have been used to pilot educational interventions, even those that encompass one health, in colleges and universities and in the health workforce. historically these have been piloted in one or more systems that are not linked, but in the last decade a twinning model has gained interest and acceptance. this model links two or more educational systems that, at its best, involves equal partners that each learn from the other; it can, however, evolve to a mentor-mentee situation whereby one partner assumes most of the responsibility and the other partner(s) assume lesser, more receptive roles. there may be other models of which we are not yet aware, and we look to others to suggest them. twinning and other models have been implemented at various scales from local to national systems. participants seconded the idea of a proposal that takes a twinning approach and starts at the local level, with curricula that are meaningful to local communities and that involve parents, community members and students alike as teachers and learners. it would be instructive to apply twinning between a higher income and a lower income country, as is being done at a university level, and to look for points of alignment and difference. the proposal may want to http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 13 consider adopting a term other than ‘twinning,” which is so closely associated with universitylevel activities and is, as was pointed out, often interpreted by higher income countries as “the world is here for us to remodel.” building on responses to the survey, participants suggested that there is a need for concrete yet simple to grasp examples illustrative of one health. if one health is ultimately about changing behaviours, previous successful examples of changing public behaviours such as recycling (which was started by teachers and taken home to parents and communities by students) and smoking cessation (for which youtube videos, cartoons and other popular media presentations have been developed and widely disseminated) might offer valuable lessons for how to accomplish behaviour change, but they must be grounded in one health principles and guided by local customs and beliefs. a proposal would have to involve social scientists, particularly those with expertise in behaviour change and public health. if messages were meaningful and easy to grasp they could be taken to households with the support of government and international organizations. the first nine months of a child’s life is critical to her/his perception of the environment as friendly or hostile, and having a ‘village’ teach one health to young children could well establish a ‘the environment is friendly’ mindset (see the foundation vie’s 1001 critical days of development, also the first five initiative in california). work on empowering girls is being conducted by the university of wisconsin in ghana and could illustrate successful implementation of this approach. a recent teachertraining workshop using student-centred active approaches was very well received by teachers who are used to the ‘sage on the stage’ approach so common in many countries. and, rather than importing more new material into already packed curricula, a proposal could instead strengthen existing curricula, for example, by supporting teachers to adapt current material using more ‘hands-on’ learning with the natural world that incorporate ethics of how we view and treat each other, animals and the environment. a third option would be to develop ‘scaffolding’ lessons that integrate existing curricula across disciplines and grade levels. scaling up and out presumes some early measures of success, but the goal of a one health curriculum is to change behaviours. because this is a long-term outcome, it cannot be used to judge the success of a one health project in the short term. one suggestion was the level of involvement of a community could be used as an early indicator of success for a pilot project . another metric being used in ghana is the degree to which students who experience the curriculum in schools take that learning home to educate their parents, although the cultural appropriateness of children teaching adults has to be considered. successful pilot projects would be shared widely, thereby developing a “community of practice” that would reflect the common goals of one health teaching and learning and the richness of its adaptations. open panel discussion in this section we discussed additional questions and received numerous suggestions that are not included in the sections above. the topic of curriculum design was raised. we purposely do not want to prescribe what any given curriculum would look like, whether that be modules, week-long units, individual lectures or a scaffold of modules across grade levels and across subjects. we want to encourage innovation in curriculum design and pedagogy as much as possible and are hoping that educators would develop curricula together to produce integrated learning designs preferably to create modules that fit into an existing science class for example. programs that cut across courses and grades would be optimal. incentivizing collaborations and trans-disciplinary teambased curricula was suggested, over didactic ‘preaching’. curricula should incorporate issues http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 14 based, inquiry based, problem based, small group based methods that focus on real issues, because our challenges today do cross disciplines. another suggestion was made to organize content around broad categories made up of a series of small modules or easy to digest, bite-sized pieces. this can be particularly important where language might be a challenge. the reference was made to experience in ghana in the one health and girls empowerment program with junior and senior high school girls. in those workshops they found that in addition to ‘content’ that the teachers loved learning about student-centred active teaching approaches that they had never been exposed to. they need to see other ways to teach. there are likely some other good programs already on the ground that we could learn from. several examples of these were mentioned including:  an 8-12 grade curriculum for veterinary science and one health science in the state of texas (try contacting dr. heather simmons);  a new mooc addressing one health that will be available through coursera (https://www.coursera.org/) in spring 2017;  a university of washington "conservation biology & global health" 3 day curriculum for high school students;  the california state first five initiative;  examples of twinning as a collaborative development and support mechanism (e.g. usaid emerging pandemic threats program). however we proceed, the idea of piloting programs in different regions was felt to be important along with the willingness to be flexible and respond to community and cultural diversity in different parts of the world. some discussion centred on the topic of behaviour change. it will be important to include social scientists on the development team that have expertise in this area. one of our challenges is the goal of changing the mindset. 97% of world health funds are going toward treatment of disease and only 3% goes to prevention. this is from a global budget of $7.7 trillion us dollars. because one health is all about prevention strategies, initiatives like the ghsa should be interested. it was suggested that there may be lessons learned from experiences in developing countries with hiv behaviour change programs, particularly how to reach communities. several participants stressed that one of the best ways to gain support for a new program and improve the possibility of success is to make sure there is a link with communities beyond the classroom, with the caveat that we need to be sensitive about the cultural appropriateness of kids teaching adults. another potential ally could be the network of school nurses, a group that is greatly under-utilized and under-appreciated. if appropriately empowered, they could be a valuable asset. in any event we will need good partners in the k-12 system before moving forward since a top down approach will likely not work here. some discussion came up on the topic of finding funding for educational initiatives. it was suggested that it might be helpful to look at the portfolios of the various donors (e.g. usaid, dfid, multilateral and regional banks, etc.) to look for compatible interests in education. it can be very challenging to get an innovative, technical assistance grant. reference was made to experience in a new regional project in west africa called the regional disease surveillance systems enhancement project, a huge world bank project that handles 15 countries in w africa with ohahu and who that involved several hundred million dollars. another suggestion was to explore existing zoonotic disease initiatives, such as predict or the global health security agenda (ghsa). http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 15 some other potential funding sources mentioned include: skoll, ford, rockefeller, gates, the instituyo alana in sao paulo brazil, african union/ecowas. in some cases, appealing directly to ministries of education or health might find support for being the first one to institute something truly innovative (e.g. island nations like fiji and seychelles). conclusion we assumed that most people attending this conference (10) do support the idea of k-12 one health education. perhaps attendees, like us, are driven by the need to examine what is currently being done (in education) and to postulate what we need to be doing differently to prepare future generations. there are some attempts being made globally for one health education at the graduate and professional education levels. but that is too late to significantly affect behaviours and in still attitudes of open collaboration and interactions. by then young people are already in their academic silos. we are very concerned about current attitudes toward our human place on the planet. in this conference we have outlined some tangible, programmatic models that could be used in young children and expanded to a global community of practice to improve things for future generations. the un sustainable development goals are a wonderful target to aim for globally. but there is currently no mechanism to unite and implement them. one health thinking and acting can do that. indeed, one health is a pathway not only to the un sdgs and planetary health, but also to global security. health and well-being are profoundly embedded in and dependent on global government stabilities. as the last 10-15 years have shown, it can be very difficult to introduce one health concepts to already established systems. but k-12 children will be our future global leaders. how do we help them understand the severity of what is going on right now in the world? what is restraining us from doing new things like taking one health education and concepts to young children? we need to change today’s mindset/paradigm of using up our global resources without regard for the health and well-being of our planet because future generations will depend on mother earth. how do we get individuals, governments and corporate bodies to think more holistically and sustainably about the health and well-being of people, animals and the planet? there is much work to do to make one health the default way of doing business around the world. children and one health can be our ‘ray of hope’ for the future. references 1. lueddeke g, kaufman g, kahn l, krecek r, willingham a, stroud c, et al. preparing society to create the world we need through ‘one health’ education. seejph 2016;6. doi 10.4119/unibi/seejph-2016-122. 2. lueddeke g, stroud c. preparing society to create the world we need through ‘one health’ education! (press release). one health commission. available at: https://www.onehealthcommission.org/documents/filelibrary/commission_news/press _releases/61016__oh_education_press_releasefi_f7644a48f9910.pdf (accessed: march 20, 2017). 3. united nations. united nations. transforming our world: the 2030 agenda for sustainable development. available at: https://sustainabledevelopment.un.org/post2015/transformingourworld (accessed: march 20, 2017). http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2016-122 https://www.onehealthcommission.org/documents/filelibrary/commission_news/press_releases/61016__oh_education_press_releasefi_f7644a48f9910.pdf https://www.onehealthcommission.org/documents/filelibrary/commission_news/press_releases/61016__oh_education_press_releasefi_f7644a48f9910.pdf https://sustainabledevelopment.un.org/post2015/transformingourworld lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 16 4. one health commission (ohc). (2017). mission. available at: https://www.onehealthcommission.org/en/why_one_health/ohc_mission/ (accessed: march 20, 2017). 5. one health initiative (ohi). mission statement. available at: http://www.onehealthinitiative.com/mission.php (accessed: march 20, 2017). 6. the commonwealth secretariat (health and education unit). advancing sustainable social development through lifelong learning and well-being for all. available at: https://drive.google.com/file/d/0b8wr6920su0arhlyd0pdoerlajq/view (accessed: march 20, 2017). 7. one health commission. one health education conference. available at: https://www.onehealthcommission.org/en/eventscalendar/one_health_education_onlin e_conference/ (accessed: march 20, 2017). 8. lueddeke g. global population health and well-being in the 21st century: toward new paradigms, policy and practice. new york: springer publication; 2016. available at: http://www.springerpub.com/global-population-health-and-well-beingin-the-21st-century-toward-new-paradigms-policy-and-practice.html (accessed: march 20, 2017). 9. wwf international. living planet report 2014. available at: https://www.wwf.or.jp/activities/lib/lpr/wwf_lpr_2014.pdf (accessed: march 20, 2017). 10. lueddeke g. the un-2030 sustainable development goals and the one health concept: a case for synergistic collaboration towards a common cause. world medicine journal, vol. 62, 2016: 162-167. available at: http://lab.arstubiedriba.lv/wmj/vol62/december-2016/#page=44 (accessed: march 20, 2017). 11. un news centre. habitat iii: un conference agrees new urban development agenda creating sustainable, equitable cities for all. available at: http://www.un.org/apps/news/story.asp?newsid=55360#.wo3xddqrjkg (accessed: march 20, 2017). http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 https://www.onehealthcommission.org/en/why_one_health/ohc_mission/ http://www.onehealthinitiative.com/mission.php https://drive.google.com/file/d/0b8wr6920su0arhlyd0pdoerlajq/view https://www.onehealthcommission.org/en/eventscalendar/one_health_education_online_conference/ https://www.onehealthcommission.org/en/eventscalendar/one_health_education_online_conference/ http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html https://www.wwf.or.jp/activities/lib/lpr/wwf_lpr_2014.pdf http://lab.arstubiedriba.lv/wmj/vol62/december-2016/#page=44 http://www.un.org/apps/news/story.asp?newsid=55360#.wo3xddqrjkg lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 17 appendix i – participants in the one health education conference and survey (respondents to the survey who identified themselves included) james akpablie claire b. andreasen, iowa state university, college of veterinary medicine olutayo babalobi, one health nigeria christopher birt isabelle bolon bonnie buntain, university of arizona, school of veterinary medicine bill burdick peter cowen, north carolina state university stephen dorey, commonwealth secretariat, health and education unit eliudi eliakimu nirmal kumar ganguly, national institute of immunology, department of biotechnology, india julie gerland, noble institution for environmental peace, chief un representative aja godwin ralf graves michael huang lai jiang, institute of tropical medicine, belgium bruce kaplan, one health initiative getnet mitike kassie gretchen kaufman, one health education task force ulrich laaser sultana ladhani, commonwealth secretariat zohar lederman, national university singapore joann lindenmayer, one health commission jill lueddeke george lueddeke, one health education task force pamela luna donald noah, one health center, director martha nowak, kansas state university, olathe chris olsen, university of wisconsin olajide olutayo amina osman, commonwealth secretariat, health and education unit steven a. osofsky, cornell university bhavisha patel nikola piesinger, mission rabies, uk, education officer kristen pogreba-brown peter rabinowitz, university of washington vickie ramirez, university of washington ralph richardson, kansas state university, olathe, dean/ceo raphael ruiz de castaneda, institute of global health, oh unit, geneva laura schoenle richard seifman sara stone alexandru supeanu, one health romania http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 18 appendix ii – survey instrument the following survey was conducted by the one health education task force between october 16, 2016 and december 10, 2016 utilizing the survey monkey ® web based platform. introduction: the goal of this survey is to collect views on the importance of one health in preparation for an online pre-proposal conference scheduled for mid-november. survey feedback will help us define the parameters and design of a global one health-themed educational funding initiative, spearheaded by the one health commission in association with the one health initiative. the proposed project focuses on the development and support of one health (and well-being) curriculum materials, involving primarily k-12* teaching staff and education providers. the survey will help to identify ways of addressing challenges to successfully implement a number of pilot projects on a global scale. subsequent educational initiatives will address post-secondary and professional education. the survey will take approximately 20 minutes to complete. the survey employs the one health commission definition of one health: “one health is the collaborative effort of multiple health science professions, together with their related disciplines and institutions – working locally, nationally, and globally – to attain optimal health for people, domestic animals, wildlife, plants, and our environment.” *“k-12” is defined as organized pre-primary through secondary school education. we acknowledge that this is not uniform terminology around the world, but will use this term for convenience. survey questions objective 1: identifying complex issues/examples that can be used to address the drivers of one health challenges and can lead to sustainable solutions. 1) list 5 words that immediately come to mind when you think of one health (open question): 2) please rank the following types of sustainability from 1-5 in terms of their importance to one health (1=most important and 5=least important) a. ecological b. economic c. cultural/social d. ethical e. justicial (of or relating to justice, as opposed to judicial) 3) list 3-5 one health challenges that could be used to illustrate the need for a one health approach. include no more than one zoonotic disease. 4) please choose what you believe are the 5 most important contributing factors to the development of one health challenges (not limited to disease transmission) that should be considered in developing preventive policies or sustainable solutions or those challenges: a) lack of knowledge/understanding b) lack of methods and tools to investigate complex problems c) lack of uniform standards for information management and sharing d) compartmentalization of health services and policies e) lack of funding streams that encourage collaboration and provide support for one health initiatives f) overemphasis of treatment of individuals (human and animal) at the expense of preventive medicine and population health http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 19 g) overemphasis of human health at the expense of animal and environmental health h) human population growth and development i) poverty, distribution of wealth, inequity j) political systems that support individual/corporate interests above all else k) globalization in the absence of global standards of practice l) short-term decision/policy horizons m) over-exploitation of natural resources n) tribalism o) climate change p) otheropen ended objective 2: meeting the un sustainable development goals thru one health-themed education (http://www.un.org/sustainable-deevelopment-goals/). 5) how well do you think a one health-themed k-12 education program relates to each of the following sdgs (1=not at all related and 5=highly related)? a) end poverty in all its forms everywhere b) end hunger, achieve food security and improved nutrition and promote sustainable agriculture c) ensure health lives and promote well-being for all at all ages d) insure equitable and inclusive quality education and promote lifelong learning opportunities for all e) achieve gender equality and empower all women and girls f) ensure availability and sustainable management of water and sanitation for all g) ensure access to affordable, reliable, sustainable and modern energy for all h) promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all i) build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation j) reduce inequality within and among countries k) make cities and human settlements inclusive, safe, resilient and sustainable l) ensure sustainable consumption and production patterns m) take urgent action to combat climate change and its impacts n) conserve and sustainably use the oceans, seas and marine resources for sustainable development o) protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification and halt and reverse land degradation and halt biodiversity loss p) promote peaceful and inclusive societies for sustainable development, provide access to justice for all, and build effective and accountable, inclusive institutions at all levels q) strengthen the means of implementation and revitalize the global partnership for sustainable development 6) are there other sustainability goals that you think should be included (open-ended): objective 3: identifying values and principles that underlie a global one health approach towards health and well-being for the planet. http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 20 7) which one of the following graphical representations best captures the values and principles of one health? f) none of the representations are satisfactory 8) which of the following values do you think are essential to the application of one health? (please select all that apply)  balance  community  compassion  competence  compromise  cooperation  diversity/biodiversity  empathy  experience  freedom  growth  humility  integrity  justice/fairness  leadership  mindfulness  reason  resilience  respect  responsibility  rigor  self-awareness  sustainability  synergy  tolerance  transparency  understanding  vision  other (open ended) 9) to what degree do you agree with each of the following statements as it relates to one health, where 1=strongly disagree and 5=strongly agree? a) when you optimize health for one species, health for others is marginalized or eliminated. b) one health should be practiced so that there is no net (ecosystem) loss of biological diversity. c) the health of humans, other animal species and plants cannot be separated. http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 21 d) one health recognizes the intrinsic value of life on earth (plants, animals, microbes) regardless of a direct benefit to humans. e) “environment” includes natural and built environments. f) one health embraces the value of social interaction as a critical component of health and well-being. g) humans have a moral imperative to address one health challenges. h) ecological, economic, social/cultural, ethical and justicial sustainability are equally important for one health. i) the world health organization defines “health” as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” this definition also applies to other animals and ecosystems. j) other (open ended). objective 4: designing a global one health-themed k-12 educational program that supports innovation by educators and learners. 10) in your experience, to what extent are students currently exposed to concepts related to one health (including well-being) where 1=not at all exposed and 5=highly exposed? a) pre-primary education b) primary education secondary education c) college and university education d) adult education e) other (open ended) 11) how important is it that students are introduced to one health concepts in the educational curriculum at the following educational levels, where 1=not at all important and 5=highly important? a) pre-primary school b) primary school c) middle school d) high school 12) in what types of schools would you pilot a one health-themed curriculum, understanding that not all school types are found in every country (please select all that apply)? a) publicly-funded schools b) privately-funded schools c) magnet schools d) charter schools e) independent schools f) home school networks g) extra-curricular education (after school) h) summer school or camps i) colleges or universities j) other (open ended) 13) what broad-based skills should students learn through a one healththemed educational program (please select any that apply)? a) collaboration b) communication to diverse audiences c) concept mapping d) conservation http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph2017-142 22 e) experimental design/methods/inquiry f) goal-setting g) interdisciplinary thinking h) leadership i) problem-solving j) systems thinking k) team-building l) other (open ended) 14) to what extent should students be exposed to the following concepts in a one healththemed educational program, where 1=not at all exposed and 5=highly exposed? a) role of natural and built environments in human and animal health and well-being b) respect for natural systems and human responsibility for planetary health c) the connection between well-being and mental/physical health d) personal responsibility – how individual actions impact one health e) corporate, political and societal responsibility – how their actions impact one health f) climate change and health of the planet g) environmental contexts of one health issues h) staying healthy and making good choices for the environment i) “cradle-to-grave” thinking j) other (open ended) 15) in your opinion, what are 3 main barriers to incorporating a one health-themed program in k-12 education in your country (open ended)? 16) what do you believe should be some long term outcomes (how might it change the knowledge, understanding, attitudes or behaviors of students) of a one health-themed curriculum (open ended)? objective 5: identifying challenges that must be addressed for a proposal to be funded 17) what educational stakeholder sectors (e.g. state, private, other) should be represented in developing the concept of a one health-themed education initiative into a successfullyfunded proposal (open ended)? 18) please suggest up to 3 funding organizations that might support implementation of a one health -themed education initiative (open ended). 19) please list up to 3 major logistical challenges to scaling up a k-12 one health curriculum to a global stage (open ended)? 20) please provide any other comments or suggestions (open ended). __________________________________________________________ © 2017 lueddeke et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://doi.org/10.4119/unibi/seejph-2017-142 http://doi.org/10.4119/unibi/seejph-2017-142 roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 1 | 13 review article pharmaceutical policies in post-communist albania: progress and challenges toward european union membership dajana roshi1,2*, eni tresa1,3*, alessandra lafranconi1, genc burazeri1,3, katarzyna czabanowska1,4, helmut brand1 1 department of international health, school caphri (care and public health research institute), maastricht university, maastricht, the netherlands; 2 national agency for drugs and medical devices, tirana, albania; 3 department of public health, faculty of medicine, university of medicine, tirana, albania; 4 institute of public health, faculty of health sciences, jagiellonian university, krakow, poland. * these authors contributed equally. corresponding author: dajana roshi, msc; address: national agency for drugs and medical devices, dibra street no. 359/1, tirana, albania; telephone: 0035569565614; e-mail: dajana.roshi@maastrichtuniversity.nl roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 2 | 13 abstract aim: shifting from a communist regime to a democratic system has affected health system fundamentally in most of the western balkan countries including albania. albania became a european union (eu) candidate country in 2014. since then, one of the main concerns has been to approximate the legislation with the eu framework. the aim of this paper is to review the evolvement of pharmaceutical legislation in albania and challenges toward achieving full approximation to the eu’s respective legislation. methods: we used qualitative techniques, especially means of conventional content analysis and two sources to collection data. first, we consulted the albania’s national publications office webpage and analysed all available legislation regarding “pharmacy”, “medicine” and “pharmaceutical products” from 1994 to 2021. then, we analysed the national integration plans that have been published by the government of albania from 2014 to 2021. results: the decrease of the price margin system goes in parallel with the increase of the pharmaceutical expenditure, including out-of-pocket expenditure on medicines and lack of adequate and sensitive reimbursement policies. the main pillars of the pharmaceutical sector in albania are well-covered legally but not fully in concordance with the eu framework. conclusion: there is a need to foster laws implementation that regulate the opening of pharmacies; a detailed regulation on pharmacovigilance; and a regulation on medicinal products for paediatric use. also, the existing legal framework should be aligned with the european one. medicine pricing methods should go in the same line with the decrease of out-of-pocket expenditure. keywords: albania, european union membership, legislation, pharmaceutical policies. roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 3 | 13 introduction the western balkan countries (wb) – albania, bosnia and herzegovina, republic of north macedonia, kosovo, montenegro and serbia – are facing a formidable array of challenges such as demographic, socio-economic and legislative (1). beside the complex past, wb aspirate to join the european union (eu) (2). albania is a eu candidate country since june 2014 and, from march 2020, the eu opened the accession negotiations with albania (3). the process of european integration is followed by “construction, diffusion and implementation of formal and informal rules, procedures, policy paradigms, styles, ’ways of doing things,’ and shared beliefs and norms which are first defined and consolidated in the eu policy process and then incorporated in the logic of domestic discourse, identities, political structures and public policy”, known as europeanization process (4). the albanian health system is mainly public, and the state provides the majority of services regarding promotion, prevention, diagnosis, and treatment of diseases (1). the private sector covers mostly the pharmaceutical and dental services, and some specialized diagnostic services (5). never the less, the europeanization process in expected to influence health sector and contribute to protection of health, safety and economic interests of consumers (6). in this regard, the government has started to align the pharmaceutical legislation and practices with the eu respective directives including measures to simplify the medicine registration, licensing of professionals and pharmacies, price controls and reimbursement of drugs and implication of ethical standards (7). the process of europeanization of medicines regulations “involves harmonization and mutual recognition of regulatory decision making as well as the transfer of some authority from member states to supranational eu regulatory agencies” (8). however, there are differences in the way the countries approach new pharmaceutical legislation including how various stakeholders are involved in policy making and how easy it is for the country to implement the new legislative changes (9). the national european integration plans (nip) have been regularly published and updated since 2014 aiming at description of achievements and setting new objectives (10). in this regard, the pharmaceutical policies have been changing, as it is shown in the nip and the official publications centre (from 1994 to 2014) (10,11). these changes are reflected in the law on medicines and pharmaceutical services, clinical trials, medicine pricing, reimbursement policies, the list of over the counter medicines/ medicines given without prescription (otc), and the pharmaceutical education, laws that regulate the most important parts of the pharmaceutical field in albania (11). in the same time, the number of the pharmacies in albania has been increasing from year 1993 to year 2014 (from 1,097 pharmacies in 1994 to 1,600 pharmacies in 2014) (7,12). however, there is not a clear picture of the pharmaceutical legislative development in albania fostered by the europeanization process. the aim of this review is to explore how the pharmaceutical legislation of albania has evolved from 1994 to 2021 and where does it stand toward achieving the full approximation to the eu respective legislation. methods this study is based on qualitative research techniques, especially means of content analysis. we used two sources to collect data. first, we consulted the albania’s national publications office webpage and analysed all roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 4 | 13 available legislation regarding “pharmacy”, “medicine” and “pharmaceutical products” from 1994 to 2021 (11). the second source of data were national integration plans (nip) that have been published by the government of albania from 2014 to 2021 (10). in both cases we included in the analysis the laws and chapters that contained the words “pharmacy”, “pharmaceuticals”, “price”, “medicine”, “out of pocket”. all consulted documents are available at appendix 1. then, we used conventional content analysis to group the data and identify the “coding categories directly from the text data” (13). each nip has 33 chapters that cover different areas. the chapter which covers pharmaceutical issues and medicines is chapter 28 on “consumer and health protection”. all data are presented in the results section based on four categories we identified through content analysis: sale at distance and pharmaceutical indicators; pricing policy and pharmaceutical expenditure; clinical trials; marketing authorization, distribution and storage practices. results and discussion the law on medicines and pharmaceutical service has changed many times from 1994 to 2014. the latest published version (the 2014 one) is the most compatible to the respective eu directive (directive 2001/83) (8,9). however, when comparing the eu pharmaceutical legal framework to the albanian one, it results that the albanian legal framework lacks many regulations such as the one on pharmacovigilance and the regulation on medicinal products for paediatric use. sale at distance and pharmaceutical indicators after the fall of the communist regime (in 1991), various reforms took place in albania such as the permission of private service providers to operate, decentralization of primary care management, the privatization of the pharmaceutical and dentistry sectors, and the founding of the health insurance institute (16). data shows that the number of pharmacies has been increasing from 1994 to 2014 (table 1) (7,12). this might be related to the opening of pharmaceutical private universities since 2003 which resulted to a higher number of pharmacists graduated annually in albania (17–19). even though, the government started to apply the professional state exam (to control the number and professional quality of pharmacist who graduated), the number pharmacists licenced annually continued to increase (11). the increased number of pharmacies is not proportional with the total population (table 1). table 1. pharmaceutical indicators (7,12,20–22) indicator 1990 2003 2005 last year available number of pharmacies (total) 1097 1000 1600 (2014) pharmacists per 100000 inhabitants 36.37 35.28 38.3 108.4 (2018) pharmacists graduated per 100000 inhabitants 0.7 1.2 2.8 3.5 (2013) roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 5 | 13 only the pharmacies that plan to have a contract with the compulsory health care insurance fund (chif) must fulfil some conditions before opening the pharmacy (23). as per the albanian legislation, a pharmacy that signs a contract with the with the chif for the first time should, be at least 50 meter square, at least 150 meter linear away from an existing pharmacy and in a distance at least 30 meter from the health care centre (23). the law on medicines and pharmaceutical service of 2004 specified that: the pharmacies could be opened in urban areas in a distance lower than 150 meters from each other, depending from population density (one pharmacy for 3000 inhabitants), but the legislations on distance is not in force anymore (compared to the actual law of 2014) (11). pharmacies are periodically controlled/inspected by the national agency for drugs and medical devices and chif (the regional branch and national office in case the pharmacy has a contract with this institution), by the order of pharmacist and the tax administration office (tao). all these institutions inspect the pharmacies regarding the conditions on storing the medicines; the order/timeline in which they keep the prescriptions; if they give any non-over the counter (otc) without prescription; if they sell medicines that do not have a marketing authorization (contraband medicine); if they store the expired medicines in a non-separate area inside the pharmacy; if the number of the reimbursed medicines is the same with the one shown in the electronic prescription system (only for the pharmacies with a contract with chif); if they give a coupon after each sale; or/and if the employed pharmacists are licensed (11,14). a yearly report from the state central inspectorate mentions that in 2017 were inspected and controlled 424 subjects out of which 352 were pharmacies and pharmaceutical agencies and 48 were pharmaceutical distributors or importing warehouses. in this regard, 25 administrative measures were taken (24). in 2018, the same report showed that out of 603 controlled subjects, 592 were pharmacies and pharmaceutical agencies, 11 were pharmaceutical distributors or importing warehouses, 14 inspections for expired medicines upon request of the subjects themselves and one inspection in collaboration with the state policy (sector against economic and financial crime). overall, 182 administrative measures were taken (25). the european directive (2001/83) specifies the sale at distance to the public (15). in this regard, taking in consideration the existing albanian law on medicines and pharmaceutical service 105/2014, the selling of medicines at distance to the public is difficult to be monitored (14). pricing policy and pharmaceutical expenditure medicine pricing in albania is done by an official committee assigned by the minister of health (19). this committee aims at achieving a lower price of the medicines regardless the quality. the committee uses a specific formula and the reference price to calculated the medicine price (20). the pricing policy since 2014 is as follows: i) the medicine reference price for albania should be the lowest among: the wholesale prices in the reference countries. the retail price the medicine has in its origin place. roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 6 | 13 the price that the medicine has had in the last 12 months of import (11). ii) the generic medicine price should be 80% of the patent medicine price registered in the national agency for drugs and medical devices. in case the patent medicine does not have a marketing authorization in albania, then its price in the origin place should be taken into consideration (19). iii) the retail selling price of the medicine should be the same with the price of the medicine in the origin place (19). in the meantime, the price margin has changed – table 2 shows the price margins during the period 2005-2006. table 2. regressive margin system for medicines in albania [source: imasheva & seiter, 2008 (7)] type of medicines importer and wholesale margin retail margin most expensive 8% 15% moderately expensive 10% 20% non-expensive 15% 30% least expensive 18% 33% the purpose of such regressive price margin is to reduce the incentive for pharmacists to recommend expensive, branded medicines over cheaper generics (7). until 2015, the price margin system has changed by decreasing the wholesale and retail margin (11). the decision no.143 date 18.02.2015 stated that the margin of the wholesale margin should be 11% (divided 8% for the importer and 3% for the distributor) and 25% for the retail seller (25% of the price that the medicine has once distributed to the pharmacy) (11). since 2015, in wb a lot of attention has been devoted to pharmaceuticals, which have become one of the largest and fastest growing components of health expenditure (26). the national health strategy nhs aims at increasing of the medicine quality, safety and affordability in accordance with the european standards (27). this is planned to be achieved by: reducing the prices and improving access through a progressive expansion of the reimbursable medicine list. registration of medical devices. establishing a tracking system to maintain, strengthen and ensure quality during all phases: production, import, distribution and sale at the final point. achieving quality on pharmaceutical service available throughout the country. strengthening the national agency for drugs and medical devices (27). table 3 indicates that the pharmaceutical expenditure as part of the total health expenditure has been increasing. it indicates a considerable out of pocket expense on medicines and also lack of reimbursement policies. roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 7 | 13 table 3. pharmaceutical expenditure in albania (28) pharmaceutical expenditure as a proportion of total health expenditure 1993 (earliest year available) 2007 (last year available) 23% 28% in albania, annual expenditures on reimbursed medicines increased from all 3.5 billion in 2007 to all 8.4 billion in 2013, due to a variety of reasons such as: expansion of the health insurance scheme, reimbursement of innovative medicines, the tendency of the physicians to prescribe expensive therapies, lack of rules and regulations controlling this sector, and lack of significant policy for using generic medicines as substitutes for expensive products with the same active substances (26). a study conducted on the affordability of healthcare payments in albania showed that the average nominal annual amount spent out of pocket per person increased with 37%, from 2009 to 2015 with an annual average growth rate over 5% (29). some of the main issues that come out of the nip, are: the health sector remains a major challenge; new initiatives aim significant changes in health care financing systems and achieving universal coverage of ongoing initiatives. new programs for periodic population examinations will improve disease prevention. introduction of universal coverage system is expected to improve the health care system and the provision of health services. (appendix1) the national medicine control strategy 2018–2022 is envisaged for approval in the last quarter of 2018. (the nips of 2018-2020). the national health strategy 20162020 was approved in may 2017 and aims to achieve universal healthcare coverage. (the nips of 2019-2021). in terms of public health, significant progress needs to be made to implement the policy framework and ensure health care coverage for all in albania. regarding medical devices, law 89/2014 "on medical devices" has been revised pursuant to the european regulation on medical devices. the revision of the law was made following the process of approximation of albanian legislation with the european one and aims to increase safety during the use of medical devices after their placement on the market and increase access for patients. (the nips of 2021-2023) (11). the national health strategy (nhs) cites that the medicine market in albania is wellregulated, while medicines and pharmaceutical services are offered by the private sector (27). the legislation, is progressively improved in line with the eu directives (27). the national agency for drugs and medical devices has been established in 2014, before it was known as the national centre of drug control (27). in order to increase the access to safe medicines and reduce their financial burden, in 2015 a series of medicines were traded at prices around 30% cheaper compared to 2013. also, the list of essential medicines has been updated with 200 new medicines compared to 2013, while the list of reimbursable medicines was updated with about 80 new medicines (27). in the last two years, cytostatic medicines are doubled, while medical materials for cardiology have increased by 50% (27). roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 8 | 13 clinical trials clinical trials have been a specific chapter of the albanian law on medicines since 1994 and later 2004 (11). in march 2018 for the first time the order on approving the guidelines for clinical trials was published (30). this regulation is nearly harmonized with the eu directive 2001/20 on the approximation of the laws, regulations and administrative provisions of the member states in relation to the implementation of good clinical practice during the conduct of clinical trials on medicinal products for human use (30). the european commission directive 2005/28/ec of 8 april 2005 on laying down principles and detailed guidelines for good clinical practice (including investigational medicinal products for human use, the requirements for authorization of the manufacturing or importation of such products) is far more detailed than the before mentioned albanian ordinance on guidelines on conducting clinical trials (31). therefore, this part of the pharmaceutical legislation lacks detailed regulation on conducting clinical trials. marketing authorization, distribution and storage practices regarding the granting of marketing authorization for medicines for human use, the procedure is nearly the same as in the eu (11). there is also a specific regulation on granting the marketing authorization for medicines for human use in albania, decision no.299 dated 08.04.2015 on the approval of the regulation on granting the medicines marketing authorization (11). until 2018, no specific regulation existed in albania on distribution and storage practice, although this chapter was part of the law on medicines on pharmaceutical service 105/2014 (14,32). this law states that a regulation regarding the good distribution and storage practices should be approved by the minister of health and should be obligatory for the importers, exporters, pharmaceutical distributors, pharmacies and pharmaceutical agencies (14). in the law 105/2014, existed an administrative offense for each pharmacy that did not comply with the foreseen practices, even though such regulation was not in place yet (14). such issues were solved out in 2018, when the regulation on distribution and storage practice was implemented for the first time (32). this ordinance was based on the european medicines agency’s scientific guidelines on the quality of human medicines; regulation (ec) no 726/2004 of the european parliament; world health organization technical report series, no. 908, 2003, guide to good storage practices for pharmaceuticals; us pharmacopoeia 1079, good storage and distribution practices; guidelines of 5 nov ec ember 2013 on good distribution practice of medicinal products for human use (2013/c 343/01); guidelines for the storage of essential medicines and other health commodities 2003; and pharmaceutical inspection co-operation scheme (pic/s) guide to good distribution practice for medicinal products (32). conclusion in conclusion, the main pillars of the pharmaceutical sector in albania are well-covered legally but not fully in concordance with the eu framework. there is a need to reinforce the laws that regulate the opening of pharmacies; a detailed regulation on supervising and controlling the online sale of medicines and taking administrative measures where appropriate; a regulation on implementing the track and trace system of medicines. there is no regulation regarding pharmacovigilance in albania. also, unlike the eu, in albania, there is no regulation on medicinal products for paediatric use. roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 9 | 13 conflicts of interest: none. references 1. sanfey p, milatovic j, kresic a. how the western balkans can catch up. european bank for reconstruction and development, 2016: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3119685 (accessed: 17.05.2021). 2. stanek p, wach k, ambroziak a, et al. conceptualizing europeanization: theoretical approaches and research designs. in: stanek p, wach k, editors. europeanization processes from the mesoeconomic perspective: industries and policies. krakow: krakow university of economics, 2015: 11-20. 3. delegation of the european union to albania: https://eeas.europa.eu/delegations/albania_en/6953/albania and the eu (accessed: 17.05.2021). 4. featherstone k, radaelli c. the politics of europeanization. new york: oxford university press, 2003. 5. institute of statistics. albania demographic health survey 2017-18: https://dhsprogram.com/pubs/pdf/fr348/fr348.pd f (accessed: 17.05.2021). 6. altenstetter c, permanand g. eu regulation of medical devices and pharmaceuticals in comparative perspective. rev policy res 2007;24:385405. 7. imasheva a, seiter a. health nutrition and population paper, the pharmaceutical sector of the western balkan countries. washington d.c: the world bank, 2008: https://openknowledge.worldbank.org /bitstream/handle/10986/13736/428270wp01no0p 1lsinwesternbalkansdp.pdf?sequence=1&isallowed=y (accessed: 17.05.2021). 8. abraham j, lewis g. europeanization of medicines regulation. in: abraham j, smith hl, editors. regulation of the pharmaceutical industry. london: palgrave macmillan, 2003: 4281. 9. borup r, traulsen jm, kaae s. regulatory capture in pharmaceutical policy making: the case of national medicine agencies related to the eu falsified medicines directive. pharmaceut med 2019;33:199-207. 10. ministria e puneve te jashtme integrimi i republikës së shqipërisë në bashkimin europian: http://integrimine-be.punetejashtme.gov.al/anetaresimi-ne-be/plani-kombetar-i-integrimit-pkie/ (accessed: 15.05.2021) (albanian). 11. qëndra e botimeve zyrtare: https://qbz.gov.al/ (accessed: 15.05.2021) (albanian). 12. voncina l, sallaku j. republic of albania, technical assistance review of albanian pharmaceutical policy. tirana: ministry of health, 2014. 13. hsieh hf, shannon s. three approaches to qualitative content analysis. qual health res 2005;15:127788. 14. kuvendi i shqipërisë: https://www.parlament.al/files/integrimi/ligj_nr_105_dt_31_7_2014_1 8582_12.pdf (accessed: 15.05.2021) (albanian). 15. official journal of the european communities directive 2001/83: roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 10 | 13 https://eur-lex.europa.eu/legal-content/en/txt/pdf/?uri=celex:320 01l0083&from=fr (accessed: 16.05.2021). 16. gabrani j, schindler c, wyss k. perspectives of public and private primary healthcare users in two regions of albania on non-clinical quality of care. j prim care community health 2020;11:1-3. 17. aldent university, history. https://ual.edu.al/ual.edu.al/rrethnesh/historiku/. 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https://eur-lex.europa.eu/eli/dir/2005/28/oj (accessed: 15.05.2021). 32. urdhri i farmacistëve të shqipërisë prakikat e ruajtjes dhe shpërndarjes së mirë të barnave: https://www.ufsh.org.al/content/uploads/2018/nov/9/rregullore-mbipraktikat-e-ruajtjes-dhe-shprndarjess-mir-t-barnave.pdf (accessed: 30.03.2021) (albanian). ______________________________________________________________________________ © 2021 roshi et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 12 | 13 appendix 1. list of consulted legislation, directives and orders no. the consulted legislation link last accessed 1 law nr.10 171, date 22.10.2009 on regulated professions in republic of albania https://www.arsimi.gov.al/wp-content/uploads/2017/10/ligj_nr_10_171_p rr.pdf 16.05.2021 2 law of medicine and pharmaceutical services 2004 https://qbz.gov.al/eli/ligj/2004/11/2 5/9323/25d3c84f-e0ad-4a23-980cd948f6c7a430;q=299 17.05.2021 3 decision no. 781, date 14.11.2007 on “technical functional characteristics of fiscal equipment; integrated computerized system for periodic and automatic transferring of financial declarations; communication system on procedure and documentation for its approval; and the criteria for the equipment authorized from the authorized companies for offering fiscal equipment. https://qbz.gov.al/preview/302da00f-7476-47a5-a2d7c583698f8c4e/cons/20181031 15.05.2021 4 law no. 10 383, date 24.2.2011 on compulsory health insurance in republic of albania https://qbz.gov.al/preview/1af1180f-c82e-4ec7-b37b9904e9aab976/cons/20170211 17.05.2021 5 order no.645 date 01.10.2014 on establishment and operation of the commission on medicine pricing https://qbz.gov.al/eli/vendim/2014/ 10/01/645/c05dd224-5c03-40ba99d9-0dc03882fa1c 17.05.2021 6 order no.143 date 18.02.2015 on designation of trade and fabrication margins of medicines https://qbz.gov.al/eli/vendim/2015/ 02/18/143/6d99b717-9493-41aeb77a-8ff1edc5ff63 17.05.2021 7 law on medicine and pharmaceutical services 1994 https://qbz.gov.al/eli/ligj/1994/04/2 0/7815/6103b566-80d1-4ccc-a6a99a67dcbc8559;q=299 15.05.2021 8 order no 299 on “on approving the regulation on granting the medicines marketing authorization and their classification on the republic of albania” https://qbz.gov.al/eli/vendim/2015/ 04/08/299/60e02154-8b2b-49eaaa45-6e3e1e849892;q=299 16.05.2021 9 national health strategy 2016-2020 https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/albania/draft_strategt_albania_2016-2020.pdf 16.05.2021 https://www.arsimi.gov.al/wp-content/uploads/2017/10/ligj_nr_10_171_prr.pdf https://www.arsimi.gov.al/wp-content/uploads/2017/10/ligj_nr_10_171_prr.pdf https://www.arsimi.gov.al/wp-content/uploads/2017/10/ligj_nr_10_171_prr.pdf https://www.arsimi.gov.al/wp-content/uploads/2017/10/ligj_nr_10_171_prr.pdf https://qbz.gov.al/eli/ligj/2004/11/25/9323/25d3c84f-e0ad-4a23-980c-d948f6c7a430;q=299 https://qbz.gov.al/eli/ligj/2004/11/25/9323/25d3c84f-e0ad-4a23-980c-d948f6c7a430;q=299 https://qbz.gov.al/eli/ligj/2004/11/25/9323/25d3c84f-e0ad-4a23-980c-d948f6c7a430;q=299 https://qbz.gov.al/preview/302da00f-7476-47a5-a2d7-c583698f8c4e/cons/20181031 https://qbz.gov.al/preview/302da00f-7476-47a5-a2d7-c583698f8c4e/cons/20181031 https://qbz.gov.al/preview/302da00f-7476-47a5-a2d7-c583698f8c4e/cons/20181031 https://qbz.gov.al/preview/1af1180f-c82e-4ec7-b37b-9904e9aab976/cons/20170211 https://qbz.gov.al/preview/1af1180f-c82e-4ec7-b37b-9904e9aab976/cons/20170211 https://qbz.gov.al/preview/1af1180f-c82e-4ec7-b37b-9904e9aab976/cons/20170211 https://qbz.gov.al/eli/vendim/2014/10/01/645/c05dd224-5c03-40ba-99d9-0dc03882fa1c https://qbz.gov.al/eli/vendim/2014/10/01/645/c05dd224-5c03-40ba-99d9-0dc03882fa1c https://qbz.gov.al/eli/vendim/2014/10/01/645/c05dd224-5c03-40ba-99d9-0dc03882fa1c https://qbz.gov.al/eli/vendim/2015/02/18/143/6d99b717-9493-41ae-b77a-8ff1edc5ff63 https://qbz.gov.al/eli/vendim/2015/02/18/143/6d99b717-9493-41ae-b77a-8ff1edc5ff63 https://qbz.gov.al/eli/vendim/2015/02/18/143/6d99b717-9493-41ae-b77a-8ff1edc5ff63 https://qbz.gov.al/eli/ligj/1994/04/20/7815/6103b566-80d1-4ccc-a6a9-9a67dcbc8559;q=299 https://qbz.gov.al/eli/ligj/1994/04/20/7815/6103b566-80d1-4ccc-a6a9-9a67dcbc8559;q=299 https://qbz.gov.al/eli/ligj/1994/04/20/7815/6103b566-80d1-4ccc-a6a9-9a67dcbc8559;q=299 https://qbz.gov.al/eli/vendim/2015/04/08/299/60e02154-8b2b-49ea-aa45-6e3e1e849892;q=299 https://qbz.gov.al/eli/vendim/2015/04/08/299/60e02154-8b2b-49ea-aa45-6e3e1e849892;q=299 https://qbz.gov.al/eli/vendim/2015/04/08/299/60e02154-8b2b-49ea-aa45-6e3e1e849892;q=299 https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/albania/draft_strategt_albania_2016-2020.pdf https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/albania/draft_strategt_albania_2016-2020.pdf https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/albania/draft_strategt_albania_2016-2020.pdf https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/albania/draft_strategt_albania_2016-2020.pdf https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/albania/draft_strategt_albania_2016-2020.pdf roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 13 | 13 10 national european integration plan 20142020 http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2014-2020.pdf 14.15.2021 11 national european integration plan 20152020 http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2015-2020.pdf 16.05.2021 12 national european integration plan 20162020 http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2016-2020.pdf 16.05.2021 13 national european integration plan 20172020 http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2017-2020.pdf 17.05.2021 14 national european integration plan 20182020 http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2018-2020.pdf 15.05.2021 15 national european integration plan 20192021 http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2019-2021.pdf 15.05.2021 16 national european integration plan 20212023 https://qbz.gov.al/eli/vendim/2021/ 02/17/90/b8a74244-4688-4227bfb6-f75c873a5708;q=plani kombëtar 16.052021 17 directive 2001/83 of the european parliament and of the council of 6 november 2001 on the community code relating to medicinal products for human use https://eur-lex.europa.eu/legal-content/en/all/?uri=celex%3a320 01l0083 17.05.2021 18 commission directive 2005/28/ec of 8 april 2005 laying down principles and detailed guidelines for good clinical practice as regards investigational medicinal products for human use, as well as the requirements for authorisation of the manufacturing or importation of such products https://eur-lex.europa.eu/legal-content/en/txt/?uri=celex%3a32 005l0028 16.05.2021 19 directive 2001/20/ec of the european parliament and of the council of 4 april 2001 on the approximation of the laws, regulations and administrative provisions of the member states relating to the implementation of good clinical practice in the conduct of clinical trials on medicinal products for human use https://ec.europa.eu/health/sites/health/files/files /eudralex/vol1/dir_2001_20/dir_2001_20_en.pdf 17.05.2021 http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2014-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2014-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2014-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2015-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2015-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2015-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2016-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2016-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2016-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2017-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2017-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2017-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2018-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2018-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2018-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2019-2021.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2019-2021.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2019-2021.pdf https://qbz.gov.al/eli/vendim/2021/02/17/90/b8a74244-4688-4227-bfb6-f75c873a5708;q=plani%20kombëtar https://qbz.gov.al/eli/vendim/2021/02/17/90/b8a74244-4688-4227-bfb6-f75c873a5708;q=plani%20kombëtar https://qbz.gov.al/eli/vendim/2021/02/17/90/b8a74244-4688-4227-bfb6-f75c873a5708;q=plani%20kombëtar https://qbz.gov.al/eli/vendim/2021/02/17/90/b8a74244-4688-4227-bfb6-f75c873a5708;q=plani%20kombëtar https://eur-lex.europa.eu/legal-content/en/all/?uri=celex%3a32001l0083 https://eur-lex.europa.eu/legal-content/en/all/?uri=celex%3a32001l0083 https://eur-lex.europa.eu/legal-content/en/all/?uri=celex%3a32001l0083 https://eur-lex.europa.eu/legal-content/en/txt/?uri=celex%3a32005l0028 https://eur-lex.europa.eu/legal-content/en/txt/?uri=celex%3a32005l0028 https://eur-lex.europa.eu/legal-content/en/txt/?uri=celex%3a32005l0028 https://ec.europa.eu/health/sites/health/files/files/eudralex/vol-1/dir_2001_20/dir_2001_20_en.pdf https://ec.europa.eu/health/sites/health/files/files/eudralex/vol-1/dir_2001_20/dir_2001_20_en.pdf https://ec.europa.eu/health/sites/health/files/files/eudralex/vol-1/dir_2001_20/dir_2001_20_en.pdf https://ec.europa.eu/health/sites/health/files/files/eudralex/vol-1/dir_2001_20/dir_2001_20_en.pdf von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 1 original research developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania per m. von groote 1-3 , gabi m. comanescu 4 , claudia ungureanu 4 , jerome e. bickenbach 1,2 , john n. lavis 5 1 department of health sciences and health policy, university of lucerne, lucerne, switzerland; 2 swiss paraplegic research, nottwil, switzerland; 3 institute of social and preventive medicine (ispm), university of bern, bern, switzerland; 4 motivation romania foundation, ilfov county, romania; 5 mcmaster health forum, centre for health economics and policy analysis, department of clinical epidemiology and biostatistics, and department of political science, mcmaster university, hamilton, on, canada. corresponding author: per m. von groote, institute of social and preventive medicine (ispm), university of bern; address: mittelstrasse 43, 3012 bern, switzerland; telephone: +41316313076; email: per.vongroote@gmail.com von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 2 abstract aim: the world health organization (who) publishes a large number of health reports every year, containing recommendations to overcome societal and system barrier challenges toward targeting unmet health needs. one such report, the international perspectives on spinal cord injury (ipsci), specifically describes the situation of persons with spinal cord injury. against this backdrop, the question arises about how these recommendations can be incorporated into an implementation strategy. therefore, the aim of this paper is to describe a phased process of developing an implementation strategy for a who public health report with ipsci serving as a case example. methods: the process to develop the implementation strategy consisted of specific phases each employing particular mechanisms. the preparatory phase was composed of a group discussion to select development mechanisms. the implementation strategy development phase comprised focus-group interviews, as well as of a stakeholder dialogue. thematic content analysis was applied to qualitative data. results: the group discussion led to selection of specific development mechanisms. the focus group mechanism allowed key stakeholders to openly discuss implementation goals and processesand impacted the selection of the core implementation group members and the focus of the stakeholder dialogue (sd) discussion.the sd was instrumental in developing a specific implementation strategy based on the report‟s recommendations. the strategy consisted of a detailed implementation plan, provisions to coordinate an implementation group and expert guidance. conclusion: the findings from the current study can inform the ongoing development of systematic, evidence-informed, participatory and stakeholder-driven processes for the development of implementation strategies for recommendations from who public health reports. keywords: implementation, implementation framework, implementation principles, implementation plan, implementation strategy, romania, world health organization (who). conflict of interest: none. funding statement: the project received funds from the swiss-romanian cooperation programme as part of swiss contribution to the enlarged eu. acknowledgements: the authors would like to thank jan d. reinhardt and dimitrios skempes for their conceptual feedback in drafting the manuscript. von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 3 introduction unmet health needs of people with disabilities due to barriers to healthcare services can pose a considerable challenge and an unnecessary burden for people in their everyday lives (1). these problems are often worsened by ineffective and unresponsive social and educational systems, as can be the case in many former soviet states in eastern europe. in romania, for instance, the employment rate of people with disabilities is only 15.5% and a high number of children with disabilities are not registered in any form of education (2).the situation is very similar in hungary or bulgaria where the lack of active labour market measures in combination with the reduction in the level of disability benefits with the aim to incentivise disabled persons to seek a job lead to an increasing poverty risk (3). disability pensions and welfare benefits are generally below the level of a basic income and pay for people with disabilities on the free market far below the minimum wage. disability status is still defined on the basis of medical diagnosis with no individual functional capacity or needs assessment for social inclusion and participation. this invariable leads to further dependency on the state disability pension system. the united nations (un) convention on the rights of persons with disabilities (crpd), as the guiding international human rights document, mandates that signatory states comply with international standards of inclusion and full participation of people with disabilities in all major life areas and in particular to ensure access to life-improving provisions such as assistive technologies and medical rehabilitation (4). despite recent adoption of new national disability strategies, “romania is far from being an inclusive country for people with disabilities”. major challenges remain, spanning from finding a tool for monitoring the implementation of the measures proposed as well as “shifting the perspective of the public system to internalising the principles of the crpd in all areas, including education, access to work and independent living”. the world health organization (who), as the un specialized agency for health, issues several health policy reports every year that formulate health policy and system recommendations toward meeting these goals. in late 2013, the who launched one such public health report, entitled the international perspectives on spinal cord injury (ipsci) (5). following the example of the world report on disability (wrd), launched two years before, ipsci describes the situation of persons with spinal cord injury (sci) around the world, and in particular, highlights the barriers they face in accessing health and rehabilitation services, education, employment, and support services, and, most importantly, proposes ways to overcome these barriers (1,5). the report‟s policy recommendations follow directly from the human rights provisions set out in the crpd, and include technical recommendations, such as prescribing particular types of health care, assistive technology or other technical accommodations or modifications to the environment. early on, the question arose on how the globally formulated public health recommendations from such a who report can be translated to an implementation strategy for a specific, national context. the implementation of these evidence-based recommendations is a challenge, since international public health reports can call for sweeping changes and innovation across several policy areas beyond the health sector. in addition, policy decision makers, systems and service administrators are under pressure to make reliable and evidence-based decisions under considerable constraints (6). these may often include lack of technical expertise to von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 4 translate global public health recommendations to national contexts, lack of access to implementation relevant information or expertise, and minimal cross-sectoral collaboration. finally, a dialogue mechanism needs to be in place so that civil society and other groups affected by policy changes are consulted and empowered to participate in policy development processes. to benefit these audiences, this paper will introduce an easy-to-use approach to planning implementation of public health recommendations. this is in addition timely and strategically relevant to service managers as „the lack of sufficient specific evidence on how to implement specific policies and interventions in specific contexts to reduce health inequities creates policy confusion and partly explains the lack of progress on health inequalities‟ (7). therefore, this paper aims to describe a phased process of developing an implementation strategy for a who public health report with a focus on specific development mechanisms. we hypothesized that a practical, nationally applicable implementation strategy based on the recommendations of a who public health report can be developed using distinct participatory, stakeholder driven, expert guided and evidence-informed mechanisms. the work described in the present paper was part of efforts by a partnership between the motivation romania foundation (mrf) and swiss paraplegic research (spf) to support the implementation of the ipsci report in romania. the preparation of a competitive grant application in the third quarter of 2012 marked the starting point for the joint romanian-swiss project work, which was guided by an international implementation expert until the end of the study in may 2015. methods the implementation strategy development process consisted of two phases (box 1 presents a glossary of terms). box 1. glossary of implementation research terms [based on (10)] implementation strategy a set of implementation activities or interventions described in a central implementation plan or guideline, to work in combination, and administered by a coordinated group of implementers. implementation strategy development mechanism specific tools used to conceptualize, inform or frame, and draft an implementation strategy. multiple mechanism coordinated among each other form an implementation strategy development process. implementation activity actions taken or interventions performed through which inputs, such as funds, technical assistance and other types of resources are mobilized to produce specific outputs. in the context of this research the mechanisms for the development of the implementation strategy are also activities or interventions toward implementation. output the (tangible) products, capital goods and services, which result from an implementation activity. impact positive and negative, medium-term and long-term effects on the individual, organizational and systems level produced by an implementation activity, directly or indirectly, intended or unintended. in the context of this research, the impact includes the effect that mechanisms for implementation strategy development can have on their own or in combination as a process. von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 5 the preparatory phase was composed of group discussions by the research project team. the implementation strategy development phase comprised focus group interviews (fg) of people with sci, policy makers, system and service developers and managers, and representatives of non-governmental organizations (ngo); as well as of a stakeholder dialogue (sd) with participants from the same pool of fg participants from romania and an international implementation expert. this approach is based on the methodology of expert panel guided and scientific evidence informed consensus processes such as in the development of the who functioning and health classifications and sci research strategies (8,9). table 1 provides an overview of the preparatory and strategy development phases, respective input, corresponding mechanisms, and anticipated output. they are described in more detail in the following sections. table 1. implementation strategy development phases, their input, corresponding mechanisms, and anticipated output phase input mechanism anticipated output preparatory phase conceptual implementation framework guiding implementation planning principles group discussion of research project team selection of mechanisms to develop the implementation strategy and to monitoring and evaluate its application implementation strategy development phase information on ipsci report content and main topics, background information to sci in the romanian context focus group interviews collection of national context specific implementation goals, stakeholders, and possible implementation processes to inform the sd summary results of the focus group interviews conceptual paper on implementation (framework and tools) (15) stakeholder dialogue (sd) documentation of implementation goals, related activities, barriers and facilitators to implementation, and next steps per stakeholder preparatory phase who has been criticized in the past for the lack of implementation guidance in the reports it develops (11). the ipsci report itself only gives general implementation considerations, a common gap even in technical who guidelines, as reported in a review by wang et al. (12). who acknowledges this challenge and has, for example, called on researchers to document and share their experiences of implementation efforts (13). in research on health equity, where it is increasingly recognized that there is a need to expand the knowledge base toward actual implementation of solutions, a similar call has been voiced (7). when seeking implementation guidance in who‟s work, however, there are a variety of frameworks and strategies that could be used to support implementation, but only some aspects of these are suited to the case of a complex report like ipsci that covers such a broad spectrum of technical recommendations and normative principles targeted at policymakers. the who‟s „knowledge translation on ageing and health‟ framework and guide to implementation research has identified key conceptual considerations (14). the who sponsored von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 6 evidence-informed policy networks (evipnet), and particularly its use of evidence briefs and policy dialogues to inform policy development and implementation, as well as the support tools used to inform evipnet‟s approaches, offer a variety of useful practical mechanisms. aspects of evipnet‟s approach have been used by a research group from australia as part of their effort to devise a national sci research strategy (9). four team members, consulted by an international implementation expert, entered into a group discussion to select mechanisms to develop the implementation strategy, and to monitor and evaluate its application, to be added to the grant protocol. for the group discussion the team were provided with two sources of information. first, a previous scoping review of implementation science by the research team leader that, among other things, captures elements of the frameworks discussed above suitable for implementing a public health report (15). this review presented, along with a synthesis of central elements of a conceptual implementation framework, a set of implementation strategy development criteria for public health reports such as the ipsci. secondly, the group was provided with a set of guiding implementation strategy development principles(see box 2).the development of principles was based on a review of relevant documents including, but not limited to, peer reviewed articles from implementation science and policy implementation (16-21), innovation and organizational change research (22), and theories of deliberation (23), communication (24), and facilitation (25). box 2. guiding principles for the development of an implementation strategy participatory and inclusive active and meaningful involvement of those most affected by intended change or innovation in implementation planning, goal setting, administration and evaluation. deliberative encouraging the judgment-free exchange of different and potentially conflicting views. consensus-oriented seeking agreement on key features of implementation such as options to target the problem. ethical soundness adherence to basic ethical principles and human rights standards such as confidentiality of information, anonymity, informed consent and intellectual property rights. external control and evaluation independent review or control entity outside of the project such as a funding agency or ethics review committee. procedural evaluation evaluation at specific time points during processes. summative evaluation evaluation at the close of processes. team-based approach collaboration of multiple members of the research team in all phases of the project including conceptualization, planning, administration, analysis and reporting. ownership facilitating and building on the buy-in of key stakeholders to be drivers of change. transparency making information on project background, aims, funding and outcomes accessible to all involved stakeholders. research integrity and quality ensure trustworthiness of research results through adoption of standard criteria for the collection and analysis of data. von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 7 finally, as shown in table 2 with corresponding implementation strategy development criteria and guiding implementation strategy development principles, the following development mechanisms were selected: focus group interviews, a stakeholder dialogue, and monitoring and evaluation surveys. the rationale behind choosing these mechanisms is described briefly in the next section followed by a detailed presentation of the mechanisms within their development phase. the piloting of the strategy and its monitoring and evaluation organized in a third phase is not part of this paper and is described in more detail elsewhere (26) table 2. implementation strategy development criteria, corresponding mechanisms, guiding principles, and anticipated output implementation strategy development criteria(15) corresponding mechanism guiding principles anticipated output multi-stakeholder involvement (practitioners, consumers, policy makers) in identifying the nationally applicable implementation goals on the basis of the recommendations made […] focus group interviews participatory and inclusive; ethical soundness collection national context specific implementation goals, stakeholders, and possible implementation processes to inform the sd consensus-based national implementation strategy development including indicators with implementation experts and implementers for better buy-in stakeholder dialogue; revision process participatory and inclusive; deliberative; consensus oriented; ethical soundness documentation of implementation goals, related activities, barriers and facilitators to implementation, and next steps per stakeholder piloting of the implementation strategy including the collection of qualitative and quantitative process and output data pilot phase including revision of data collection mechanism (surveys) based on external expert review; half yearly review by funder; core implementation group as implementers; procedural evaluation; external control and evaluation; participatory and inclusive; team-based approach ownership comprehensive data on implementation activities; data on effect of strategy development process on implementation activities. evaluation and publication of results data analysis plan; team based data extraction, coding and interpretation of data; summative evaluation of project and report to funder; summative evaluation of implementation plan; preparation of scientific manuscript team-based approach; summative evaluation; transparency; ethical soundness; research integrity and quality project reports and peer reviewed publications von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 8 the focus group interview mechanism was chosen in order to bring together multiple romanian stakeholders so that they could bring out their insights into the development of an implementation strategy for ipsci in romania and make it easier for them to identify implementation goals and priorities. focus group interviews can be effective in encouraging an open exchange of ideas and concepts, to prioritize issues and reach consensus and is generally thought to trigger inputs through group discussion, inputs that might not be identified as relevant by respondents in single interviews (27). the focus group interview method has been widely used in social science research and it has been accepted as a method in implementation research in health (28,29). the stakeholder dialogue mechanism was chosen with the aim to bring together stakeholders to discuss the development of the ipsci implementation strategy for romania in a structured and focused meeting atmosphere. also, participants of the dialogue were to be encouraged to plan and lead implementation activities themselves as a core implementation group. stakeholder (or deliberative) dialogues (sd) originated in deliberative democratic theory but have since found application in many fields as practical tools to allow decision makers to consider ways to tackle complex issues taking a variety of views into account (23). the mechanism has been defined as a process that „convenes policymakers, stakeholders and researchers to deliberate about a policy issue, and […] ideally informed by a pre-circulated brief and organized to allow for a full airing of participants‟ tacit knowledge and real-world views and experiences (30). sd have been recognized as an innovative knowledge-sharing mechanism and has been applied in implementation science, health policy and health services research (31,32). implementation strategy development phase focus group interviews content development: the focus group materials were jointly developed by two research project team members and reviewed by a third. the materials consisted of an introductory text to the situation of people with sci in romania and the ipsci report, and a statement of confidentiality that opened the sessions; open ended questions based on the central elements of the comprehensive implementation framework (15) and central ipsci topics; a participant recruitment scheme for the recruitment of interviewees; and a self-administered pre-meeting survey to be sent to potential participants for group composition planning. central ipsci topics were: data and information about sci; prevention (primary) of sci; sci health care and rehabilitation; health systems and assistive technology for sci; attitudes, assistance and support; environmental barriers; education and employment. the participant recruitment scheme‟s purpose was to define central characteristics of suitable participants to reach heterogeneity in group composition, and describe the process of identification, discussion and invitation of focus group participants, and to also help identify people within the focus group candidate pool as participants to the later stakeholder dialogue. participants recruitment: participants were purposefully selected from known contacts of the romanian project partner and its network. they were contacted in writing by romanian project team members and followed up on with phone calls. 11 people with sci and 16 policy makers, systems and service developers or administrators, and representatives from ngos and think tanks were successfully recruited. setup and design: standard focus group operational guidelines were used (27,28). one focus group of people with sci, and two with the remaining participants were formed to increase von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 9 the likelihood that participants would feel comfortable to speak freely within a group of peers and reflect the perception of differing experience based on the information from the short survey (28). overall, group heterogeneity was reached. a moderator guided through the session, assisted by a local host, posed the questions and encouraged group interaction. simultaneous translation was available during the interviews. after an introduction to sci in romania and the ipsci report the central ipsci topics were handed out participants were first asked to choose and rank three topics they would want policy and decision makers to target in romania and explain why. subsequent questions asked about possible processes to target these topics, participants of such processes, role of people with sci, and monitoring and outcome indicators. data collection and analysis: participant observation notes were made by the focus group assistant and moderator. the sessions were audio-recorded, the data were transcribed verbatim, translated, and translations checked by a second researcher and spot-checked by a third one. an iterative thematic data analysis and manual extraction of meaningful concepts was performed (33). frequency and intensity counts were conducted for the ranking of the ipsci central topics in each fg group (27,33). a summary of results for each fg was compiled into short reports including the ranking and verbatim quotes by participants to inform the implementation strategy development during the stakeholder dialogue. stakeholder dialogue the mcmaster health forum stakeholder dialogue format was used as a guide to develop the stakeholder dialogue (34). development and participant recruitment: the sd development was led by one researcher, assisted by the romanian project partner and consulted by an international implementation expert. participants were purposefully selected and recruited from the focus group candidate pool based on the participant recruitment scheme by mailing and follow-up phone calls. materials (scientific paper on implementation, icf case studies, agenda, consent form) were jointly selected or developed by the project team. setup and design: participants to the three-day meeting were seven mid to high level romanian disability experts from the private and government sector, two international health policy and implementation science experts, one facilitator and one assistant took part in the meeting. one participant from romania with a sci participated and four other participants had first-hand research or service development and management experience in the field of sci. two participants were directly involved in the original development of the ipsci report. the appropriate use of research evidence was ensured by distributing the scientific paper on implementation and the ipsci report before and again during the meeting, and by a discussion during the sd on the kind and levels of evidence the report‟s recommendations are based on and in what form these are expressed. focus group reports, icf case studies (35), and the ipsci recommendations translated into romanian were distributed as well as examples of implementation tools and materials discussed during the meeting. a facilitator with in-depth knowledge of the ipsci report moderated the discussion (encouraging even participation, in-depth discussion; summarizing findings to assist in targeting open questions; documentation of results in living documents). two translators provided simultaneous translations and precautions were made to counterbalance effects on the flow and precision of the discussion (hand signalling, restriction of lengthy inputs, allowing translations to be completed, reiteration of arguments by facilitator). the chatham house rule was applied to encourage free expression of views. von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 10 after a deliberation about the implementation themes and goals based on focus group results, expert opinions and guided by the essential implementation components (15) the discussion turned to issues drafted into separate documents during the consultation(the problem, options to target problems, facilitators and barriers to implementation per stakeholder group, and next steps for each stakeholder present). participants were encouraged to suggest implementation activities they could lead in romania themselves and in partnership with others. participants were from then on defined as a core implementation group. results documentation and follow-up: audio recordings were made and notes taken by the meeting assistant. after the meeting final revisions were made of the documents developed during the sd in an online finalization process (three rounds) by participants. clarifications were sought in the form of exact wording of alternative text, arguments for changing the text or extending the document, and any additional, freely accessible information necessary. finally, an implementation plan was drafted by participants detailing the implementation activities based on these sd documents developed during the sd and finalized in the follow-up, which then marked the start of implementation activities. data collection and analysis: audio recordings and hand notes were used to check and supplement completeness of documents developed during the sd and help verify participant observations discussed after the meeting between project members. an iterative thematic data analysis and manual extraction of meaningful concepts was performed of hand notes summarizing the discussions. results the administration of the implementation strategy development process produced results thematically summarized in a structured, narrative report. these results need to be seen in context of the boundaries of the study setting and particularly that of the people involved. the focus group interviews represent the true voice of those most affected, conveying real world challenges people with sci face in romania. beyond that, the identification of relevant issues came from participants representing a cross-section of romanian civil society in the field of disability including from ngo‟s, think tanks and universities as well as health and social system and service administers as discussants of the remaining focus groups and specifically the sd. focus group the analysis of the focus group discussions revealed detailed information on the situation of people with sci in romania, including the definition of specific barriers and facilitators they face, as well as implementation considerations. the voices of people with sci were evenly represented (fg1: 11 participants and 63 responses) in comparison to those of the non-disabled experts (fg 2&3: 16 participants and 62 responses). all three fgs provided a clear rating of their three top priority topics for change (table 3). von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 11 table 3. ranking of the main ipsci themes by fg participants rank fg 1 fg 2 fg 3 1 st : education and employment education and employment education and employment 2 nd : health systems and assistive technology for sci health systems and assistive technology for sci health systems and assistive technology for sci 3 rd : sci health care and rehabilitation attitudes, assistance and support attitudes, assistance and support the reasons given for the ranking of topics were the same themes highlighted by the participants toward challenges people with sci face in romania and toward possible solutions to target these. the most salient of these themes were: attitudes of individual groups and the influence these have on change, portrayed as playing an important role in terms of self-awareness and awareness of others, such as teachers, physicians or decision makers; education meaning both educating and awareness raising of others about sci as stated by one participant, “it’s important to educate people to perceive us as we are, to consider us equal, not different”, and also in terms of knowledge and skills development of people with sci, as expressed clearly by another participant: “for me, a proper recovery process means that somebody in my situation taught me to do things”; lack of assistive technology and importance of availability and training to social participation in combination with the inaccessible environment in romania further hindering mobility and participation: “it does not matter if you have an appropriate wheelchair if you cannot use it because of an inaccessible environment, and, on the other side, it is useless to benefit from an accessible environment if you do not own a wheelchair because it might take years to get one”; poor state of social services and need to shift from medical to a social model of service provision; importance of employment as a great influence on social participation; cross-cutting and multi-facetted nature of issues, especially in terms of accessibility of the environmental most often as a pre-requisite to education and employment opportunities and the accessibility to rehabilitation programs. all three fgs presented a broad range of stakeholders that should be involved in implementation, ranging from policy (e.g. ministries of health, employment and education) to practice (e.g. physicians, teachers), and equally valued the importance of people with sci being involved at key stages of implementation. they are even perceived as being the best drivers of change, as one participant from fg1 pointed out, “neither the ngos in bucharest, nor the media will promote best our rights”. in terms of implementation processes to be considered, dissemination efforts such as distribution of ipsci copies to educational facilities or government bodies, or in the form of media campaigns were named in all three fgs. the stakeholder dialogue as a specific mechanism to involve people with sci and politicians so they receive first-hand accounts by people affected was brought up in fg1. in terms of tools, the use of the ipsci report and its recommendations was suggested to be used along with the crpd to submit official complaints to authorities in violation of rights of persons with disabilities and to inform the assessments of pwd by local authorities. von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 12 when discussing how to monitor implementation the issue of missing data and lack of appropriate data collection tools was named as a major problem (fg 2&3). where participants in fg1 emphasized the need to include pwd in monitoring and of independent, uncorrupted monitors, fg3 stressed the need for monitoring authority‟s collaboration on disability issues and that indicators should be based on the principles promoted by the crpd. stakeholder dialogue the dialogue started with discussing the main challenges in terms of sci and disability in romania based on the fg results. major issues voiced were the lack of cross-sectoral and inter-professional communication; the general lack of data and collaboration in terms of data collection; the lack of suitable regulations or provisions and generally of enforcement of accessibility standards; the small number of rehabilitation centres, of qualified staff and technical expertise in health and allied professionals; lack of vocational services including a comprehensive needs assessment; attitudes of employers as well as the resistance to change in the sci community due to fear of loss of benefits; lack of unity and initiative in the disability community. based on this discussion and the fg results, the group agreed to focus their attention and further deliberation on three broad headings: medical rehabilitation and follow up in the community, independent living, and employment & inclusive education overlapping with three out of four top priority topics for change ranked by the fgs (education & employment; health systems and assistive technology for sci; sci health care and rehabilitation). the dialogue group then used live documents on screen discussing each recommendation‟s applicability to the romanian context, positioning it under the three broad headings, reformulating the recommendations to context specific problem statements, and then defined options to target these. based on this review, participants then turned to suggesting implementation goals to target, specific implementation considerations, and concrete implementation activities. goals (g) suggested included:g1. raising awareness in the government to disseminate ipsci and information on sci; g2. presenting specific ipsci recommendations to policy decision makers; g3. raising the awareness of pwd; g4. improving access of pwsci to employment opportunities; g5. improving access of pwsci to medical rehabilitation services; g6. improving independence of pwsci; g7. introducing sci specific rehabilitation knowledge to romanian professionals; g8. improving inter-professional communication; g9. showing the benefits of a bio-psychosocial assessment and rehabilitation management approach; g10. developing an ipsci implementation plan; and g11. creating a multi-stakeholder working group with a concrete calendar of events. specific implementation considerations (ic) voiced were: ic1. to involve pwd as implementers; ic 2. use one group of pwd as symbolic case to trigger change; ic3. deliver technical training to professionals; ic 4. using existing foreign guidelines as examples; ic5. to start efforts in own organizations and networks; and ic6. to lead coordinated efforts such as to jointly consult the government on bio-psychosocial orientation of the disability assessment and provision of services. the group went on to formulate the following activities based on the expressed implementation goals and considerations:  development of a joint position paper defining goals and covering topics such as the employment quota system and highlighting a cost-benefit and business case to the human rights approach (g1&2; ic2, ic6)  icf workshops (g8&9; ic2-4) von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 13  icf conference (g1, g7-9;ic2)  employment service for pwsci (g3, g4, g6; ic5)  wheelchairs caravan to provide personalized mobility equipment, adaptations and repairs, together with independent living training (g3, g4, g6; ic1, ic5)  implementation of the icf into mrf rehabilitation as a good practice example (g1, g8, g9; ic 2-5);  sci rehabilitation guideline for romania (g7-9;ic3&4)  emergency help telephone line for people with sci (g3, g5&6; ic2)  translation of the full ipsci report into romanian (g1-3, g7-9; ic2, ic4) finally, participants came to an agreement to pursue these jointly devised implementation activities as a core implementation group, centrally coordination by the local romanian ngo as leader, and on next steps toward completion of the sd documents in online review cycles toward final development of an implementation plan. the implementation strategy at the core of the strategy was the implementation plan with the implementation activities to be administered (appendix 1). participants of the sd and two additional disability experts from romania who could not join the meeting agreed to work together as a core implementation group in implementing pre-defined and coordinated activities of the implementation plan and report back to the implementation leader to document progress. the implementation leader was to serve as a central communication and coordination hub for all implementers, contact international content experts on the use of the icf and the ipsci report to assist implementers in preparing and executing their activities, and link implementers within the core group to assist in activities if needed. the implementation group planned to meet in person or by teleconference regularly over the course of the one-year implementation period to discuss progress, challenges and ways to overcome these. discussion the main findings of the study can be summarized in terms of issues identified in the fg and sd relevant to challenges people face in romania and toward the implementation of recommendations to target these; the benefits of applying the described process; and contextual implications of the experiences gathered. first, the fgs and sd identified as main issues the attitudes of individual groups and selfawareness, education meaning both educating and awareness raising of others, the lack of assistive technology in combination with an inaccessible environment as major barrier, the general lack of appropriate health, education and employment systems and services. the cross-cutting nature of these issues call for developing solutions involving abroad range of stakeholders using mechanisms such as the sd and ipsci and the crpd as tools. secondly, this study showed that the described evidence-informed, stakeholder-driven and participatory process facilitated the development of an implementation strategy for a who health report. the process enabled the development of an implementation plan and the establishment of a core implementation group to carry out the implementation strategy. specifically, the fgs affected the selection of the core implementation group members and the focus of the sd discussion. insights from the focus group interviews in terms of who should be involved and what implementation should focus on further informed the discussion of implementation themes and goals during the sd itself. this was most apparent in implevon groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 14 mentation approaches or topics named in the fgs that were later part of the discussion in the sd or were even incorporated into the implementation plan. the mechanisms for developing the implementation strategy can themselves be characterized as implementation interventions, since they engaged key stakeholders, informed the process and educated the stakeholders into jointly taking actions. in this sense, standard implementation outcome variables used in implementation research (29) show the appropriateness of the mechanisms, and the fact that in this setting and with this target audience it was possible to successfully engage participants to contribute to the development of the implementation strategy. the mechanisms were also feasible, since they could be carried out in the settings and the way intended. the criterion of fidelity was satisfied as the mechanisms were implemented as designed by the research team. the intended coverage of stakeholder representativeness was achieved. also, process costs were sufficiently covered by the project grant. furthermore, network ties introduced or reaffirmed in the form of the core implementation group in combination with the implementation information embedded show signs of sustainability. finally, these results also have implications for the participation of civil society actors in the development of policies that influence them. this study has shown how the participatory process of issue identification, discussion and development of possible solutions served to actively engage civil society representatives and empower them in their crucial role in policy development and promotion of fundamental rights. in times of both legal and practical restrictions, these experiences will likely become ever more important (36). findings in relation to other studies the present study is also novel in its focused attempt at developing an implementation strategy for a who health report and thus limiting points of comparison to other studies. in a synthesis of guideline development and implementation advice towards the development of a checklist for implementation planning gagliardi and colleagues found overall „no evidence on the effectiveness of planning steps or considerations‟ in respect to planning for implementation of guidelines, arguing further that „the impact of forming an implementation team or developing an implementation plan on the conduct and outcomes of implementation planning is a logistical consideration‟ (18). however, results of the present case show that conceptualizing and planning corresponding development mechanisms involves more than just logistical considerations. guiding principles and characteristics of the present development process are however also reflected in other research. single guidelines and studies highlight the value of considering and assessing stakeholder needs and preferences through observations or focus groups (3739); forming an implementation team from the start including a wide range of stakeholders; and one or more knowledge translation experts (37-39)when planning for guideline implementation. all of these steps have also been proven to be useful in the present study. implications for health policy report development and implementation two implications for policy can be derived from these observations. first, comprehensive planning of implementation should begin alongside the development of the health policy report so as to realize the full potential of the implementation content or innovation being proposed. in an ideal world, the development team should not only be assisted by public relations or media specialists but also by implementation experts. early involvement of stakeholder groups through advisory structures is a common feature of the development of health policy report. a stronger and more immediate involvement of these stakeholders -in the von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 15 form of an implementation working group -should be part of the planning for publication and dissemination processes, including the process of applying for funding and developing a detailed implementation strategy using the mechanisms studied here. in essence, the developed public health report or guideline should include implementation advice (12,40). secondly, the nature of the mechanisms used here depended on the fact that the participants were not only knowledgeable in the overlapping areas of health, disability and sci, but they were also relevant stakeholders. the openness of decisionand policymakers and their availability ensured a timely, easily accessible, and evidence-appraised input through mechanisms such as the sd. much can be gained from such purposely planned approaches for implementation planning of health policy report recommendations. implications for future research the boundaries of this study leave unanswered questions for future research: how far does the context-specific environment impact on the implementation planning in terms of planning (feasibility), execution (barriers and facilitators) and outcomes? it is important to stress that the original intent of this study was to demonstrate the application of the mechanisms in the romanian context. future research is needed to test the transferability of the underlying theoretical framework and the application of the mechanisms in different contexts and countries similar to recent examples from the field and expand this research by an outcome or impact evaluation (17,41). strengths and limitations of the approach the approaches‟ strengths lie in the adherence to the guiding implementation strategy development principles set out at the beginning of the preparatory phase. specifically, the process was evidence-informed as it included scientific evidence summarized in key documents introduced to the preparatory and strategy development phase. the process was participatory and stakeholder driven involving people with sci, disability experts and policy makers from romania in every phase. furthermore, this study was a theoretically grounded, multi-method explorative effort. namely, in its design, the study was based on a theoretical framework derived from a scoping review and involved key informants and experts in its review. also, transparency was achieved by describing details of the mechanism selection, data collection, and the researcher‟s level of involvement. the studies‟ focus on civil society representatives as key participants to the fgs and sd, however, and the representativeness and completeness of what is a much more complex picture of societal and system interactions constitutes important limitations to the study. the involvement of policy decision-makers would have helped to solve the policy puzzle. in addition, the present case was a small-scale pragmatic study that took place in a naturally occurring (authentic) societal and policy environment with complex circumstance out of control of the researchers with methodological challenges to any study (42). this naturally limits the explanatory power of results and also their transferability to other contexts. also, it needs to be mentioned that the lead author fulfilled a dual role of moderator and observer. however, precautions were taken in the form of note taking by meeting assistants and discussion of observations after interactions to prevent this impacting the overall results. conclusion the findings from the current study can inform the ongoing development of systematic, evidence-informed, participatory and stakeholder driven processes for the development of imvon groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 16 plementation strategies for recommendations from who public health reports. given limitations of this study in terms of scope and focus, the study does support the conclusion that a strong conceptualization and careful consideration of contextual factors needs to inform the refinement and application of this process in other european or global scenarios. references 1. world health organization, world bank. world report on disability. geneva: who; 2011. 2. tudose e, căloiu o. european semester 2016/2017 country fiche on disability. romania. leeds; 2017. 3. the academic network of european disability experts (aned) 2018.http://www.disability-europe.net (accessed: 23 february, 2018). 4. united nations. convention on the rights of persons with disabilities. resolution 61/106. new york, ny: united nations; 2006. 5. world health organization, international spinal cord society. 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development manual instructions for generating implementation advice. implement science 2012;7:67. 41. haynes a, brennan s, carter s, o‟connor d, schneider ch, turner t, et al. protocol for the process evaluation of a complex intervention designed to increase the use of research in health policy and program organisations (the spirit study). implementation science 2014;9:1-12. 42. nilsen p, ståhl c, roback k, cairney p. never the twain shall meet? a comparison of implementation science and policy implementation research. implement science 2013;8:63. ______________________________________________________________________________________ © 2018 von groote et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 19 appendix 1. implementation plan action context, venue or event date & place relation to another event or initiative activity leader contributor from core group target audience tools & materials to be used ipsci link i presentations (n=6) ipsci presentation national conference of medical expertise and work capacity rehabilitation,evolution of invalidity in romania march, bucharest core implementation group member medical rehabilitation and work capacity specialists presentation; conference program book 1, 3 ipsci presentation debate on international day of health, organised by institute for human rights (irdo) april, bucharest national health day core implementation group member irdo, health ministry, parliament members, nongovernmental organizations (ngo) website 3, 6 ipsci presentation and mrf research report promotion (life in an wheelchair) seminar, ministry of labour, family and social protection may, bucharest technical assistance grant to support disability and development core implementation group leader core implementation group members ministry of labour, family and social protection ipsci presentation, research reports 6 ipsci presentation and mrf research report promotion (life in an wheelchair) workshop, ministry of labour, family and social protection may, bucharest technical assistance grant to support disability and development core implementation group member core implementation group members ministry of labour, family and social protection ipsci presentation, research reports 1-6 ipsci presentation and mrf research report promotion (life in an wheelchair) meeting with persons with disabilities committee may-june, prahova prahova directorate core implementation group leader disability experts, ngos ipsci presentation, research reports 6 three ipsci presentations national congress of medical rehabilitation september, sibiu core implementation group member core implementation group leader medical rehabilitation and allied health ipsci presentation, conference 1, 3 von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 20 action context, venue or event date & place relation to another event or initiative activity leader contributor from core group target audience tools & materials to be used ipsci link i professionals program book publications (n=4) translation of ipsci full report into romanian publication of romanian ipsci version januarydecember ipsci implementation core implementation group leader core implementation group members broad range of policy makers, civil society and people with sci ipsci full report 7 drafting of article on ipsci publication in the romanian institute for human rights (irdo) magazine june-july, nationwide debate on international day of health, organized by irdo core implementation group member irdo, health ministry, parliament members, ngos magazine article 3, 6 6 drafting of article on ipsci publication in magazine of national institute of medical expertise and work capacity november, nationwide conference of national institute of medical expertise and work capacity core implementation group member medical rehabilitation and work capacity specialists ipsci full report, group position paper 1, 3 ipsci report and group position paper dissemination dissemination by the national authority for the protection of child rights and adoption (anpdca) octoberdecember, nationwide anpdca core implementation group member anpdc evaluation services ipsci report, group position paper 1-6 development(n=5) website development accessibility map ongoing usaid project wheels of change core implementation group leader people with sci, wheelchair users, ngos website 2, 4 evaluation evaluating costs of rehabilitation services in hospitals, for introducing home rehabilitation may, bucharest in coordination with national who office core implementation group member core implementation group member health system and service providers, ministry of health, who hospital documentation and reports, ipsci report 1, 6 von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 21 action context, venue or event date & place relation to another event or initiative activity leader contributor from core group target audience tools & materials to be used ipsci link i proposal development proposal for department of teacher training (dppd, anpdca) for sci statistics in romania may-june, bucharest core implementation group leader core implementation group member dppd, anpdca proposal document, ipsci report 6 elaborating, signing and disseminating group statement ipsci implementation may – september, bucharest core implementation group member core implementation group members irdo, ministry of health, parliament members, ngos sd documents 1-6 development of sci rehabilitation guideline ipsci implementation in romanian medical rehabilitation system maydecember, sibiu core implementation group member core implementation group members rehabilitation medicine, other medical specialties, and allied health professions ipsci, international medical guidelines 1 training (n=9) delivery of trainings 4 icf trainings for disability professionals using sci and ipsci themes as cases in point may-june, bucharest; september, sibiu; october, bacău; november, brașov project look at abilities, forget incapacity core implementation group leader core implementation group members disability professionals ipsci presentation, handouts, website 1, 3 delivery of training independent living training camps july, varatec project usaid wheels of change core implementation group leader people with sci working tools based on icf, camp materials 2, 3, 5 delivery of training who accredited courses regarding adequate evaluation and september, bucharest project usaid wheelchair access to educacore implementation group leader wheelchair service personnel ipsci presentation, handouts, website 1, 3 von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 22 action context, venue or event date & place relation to another event or initiative activity leader contributor from core group target audience tools & materials to be used ipsci link i prescription of wheelchairs tion, services and community for wheelchair users delivery of training camp for educational inclusion september, bucharest project access core implementation group leader pupils with disabilities, teachers, parents presentations, handouts, website 2, 3, 5 delivery of training who accredited courses regarding adequate evaluation and prescription of wheelchairs september project vodafone mobile for good core implementation group leader core implementation group member rehabilitation specialists and allied health professionals ipsci presentation, handouts, website 1, 3 delivery of training who accredited courses regarding adequate evaluation and prescription of wheelchairs october & december, bucharest project access core implementation group leader rehabilitation system and service managers ipsci presentation, handouts, website 1, 3 development and delivery of training training on revised legislation for disabled children and icf-cy octobermarch, bucharest department of teacher training, national authority for child protection (dppd, anpdca) core implementation group member anpdca evaluation services icf training materials, website, ipsci report 1-6 development and delivery of training independent living training to be jointly developed and delivered by government authorities octoberdecember, bucharest anpdc, ngos federations core implementation group member ngos website, handouts 1-6 delivery of training seminar take part! in schools where pupils with disabilities learn november, bucharest project access core implementation group leader pupils with disabilities, teachers, presentations, handouts 2, 3 von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 23 action context, venue or event date & place relation to another event or initiative activity leader contributor from core group target audience tools & materials to be used ipsci link i parents service (n=8) development and delivery of service creation emergency call centre for people with sci including software and relevant sci information; equipping and training 10 hospitals sites mai december, nationwide project vodafone mobile for good core implementation group leader core implementation group member 10 neurology hospitals/ rehabilitation centres software, tablets, telephones 1, 2, 3, 6 delivery of service home care services for people with sci and otherfor wheelchair users maydecember project access core implementation group leader people with sci working tools based on icf 1, 2 delivery of service psychological support groups to empower people with sci to take part in social activities and to finding jobs maydecember project access & wheels of change core implementation group leader people with sci working tools based on icf 2, 5 delivery of service mobility caravan to provide personalized mobility equipment, adaptations and repairs, together with independent living training juneseptembre, varatec, tulcea, constanta, alba project vodafone mobility caravan core implementation group leader people with sci wheelchairs caravan vehicle; working tools based on icf 2, 3 delivery of service icf based rehabilitation assessment service for wheelchair users at main project partner julydecember project look at abilities, forget incapacity core implementation group leader people with sci working tools based on icf 2, 5 delivery of service employment services september november esf financed project motivation for occupation core implementation group leader people with disabilities working tools based on icf 2, 5 von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 24 action context, venue or event date & place relation to another event or initiative activity leader contributor from core group target audience tools & materials to be used ipsci link i delivery of service wheelchair services ongoing core implementation group leader people with sci, wheelchair users working tools based on icf 2, 5 delivery of service service of assisted transportation ongoing project access core implementation group leader people with sci, wheelchair users working tools based on icf 2, 4 consultation (n=3) consultancy and promotion on disability data collection meeting at the romanian ministry of labour, family, social protection and elderly may-june 2014 core implementation group leader core implementation group members government authorities responsible for data collection and maintenance position paper, ipsci report 6 consultancy and promotion on the use of the icf and ipsci meetings with representatives of the general directorate of social assistance and child protection may-june, prohava prohava directorate; core implementation group leader disabilities experts from government and civil society project presentation 1-6 consultancy and promotion on the use of the icf and ipsci meeting with stakeholders as part of government lead working group june technical assistance grant to support disability and development core implementation group leader core implementation group members disabilities experts from government and civil society project presentation 1-6 conference (n=1) organization and hosting of conference scientific conference look at abilities, forget incapacity 25-26 september project look at abilities, forget incapacity core implementation group leader core implementation group members disabilities experts from government and civil society, health prowebsite, handout, presentation 1-6 von groote pm, comanescu gm, ungureanu c, bickenbach je, lavis jn. developing an implementation strategy for a world health organization public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2018, posted: 26 february 2018. doi 10.4119/unibi/seejph-2018-183 25 action context, venue or event date & place relation to another event or initiative activity leader contributor from core group target audience tools & materials to be used ipsci link i fessionals event (n=4) organization of swimming event sport events for persons with/without disabilities may, bucharest project vodafone mobility caravan core implementation group leader people with sci, sports persons with disabilities website, social media 2, 3 organization of wheelchair sport demonstrations wheelchair sport demonstrations june, september, november, nationwide project access core implementation group leader pupils, teachers, trainers, people with sci website, social media 2, 3 organization of basketball event sport events for persons with/without disabilities october, bucharest project vodafone mobility caravan core implementation group leader people with sci, sports persons with disabilities website, social media 2, 3 organization of national television disability gala annual persons with disabilities gala november, bucharest project look at abilities, forget incapacity core implementation group leader core implementation group members persons with disabilities, tv audience tv, website, social media 2, 3,4, 5 i ipsci recommendations: 1. improve health sector response to spinal cord injury; 2. empower people with spinal cord injury and their families; 3. challenge negative attitudes to people with spinal cord injury; 4. ensure that buildings, transport and information are accessible; 5. support employment and self-employment; 6. promote appropriate research and data collection; 7. implement recommendations. laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 1 original research a code of ethical conduct for the public health profession ulrich laaser1,2, peter schröder-bäck3,4 eliudi eliakimu5, katarzyna czabanowska3,6, the one health global think-tank for sustainable health & well-being (ghw-2030)7 1 faculty of health sciences, university of bielefeld, bielefeld, germany; 2 institute of social medicine and school of public health and management, faculty of medicine, university of belgrade, belgrade, serbia; 3 department of international health, care and public health research institute (caphri), faculty of health, medicine and life science, maastricht university, maastricht, the netherlands; 4 faculty of human and health sciences, university of bremen, bremen, germany; 5 health services inspectorate and quality assurance section, health quality assurance division, ministry of health, community development, gender, elderly and children, dar es salaam, tanzania; 6faculty of health sciences, medical college, jagiellonian university, krakow, poland 7 george lueddeke, think-tank convenor/chair; southampton, united kingdom; membership of the “one health global think-tank for sustainable health & well-being (ghw 2030)”: moaz abdelwadoud, ibukun adepoju, muhammad mahmood afzal, muhammad wasif alam, john ashton, vesna bjegovic-mikanovic, bettina borisch, genc burazeri, sara carr, lisa conti, katarzyna czabanowska, eliudi eliakimu, kira fortune, luis galvão, iman hakim, n.k. ganguly, joshua godwin, james herington, tomiko hokama, howard hu, ehimario igumbor, paul johnstone, mitike getnet kassie, laura kahn, bruce kaplan, gretchen kaufman, daniella kingsley, ulrich laaser, joann lindenmayer, george lueddeke, qingyue meng, jay maddock, john middleton, geoff mccoll, thomas monath, joanna nurse, robert otok, giovanni piumatti, srinath reddy, helena ribeiro, barbara rimer, gautam saha, flavia senkubuge, neil squires, cheryl stroud, charles surjadi, john woodall. corresponding author: prof. dr. med. ulrich laaser dtm&h, mph section of international public health (s-iph) faculty of health sciences, university of bielefeld e-mail: ulrich.laaser@uni-bielefeld.de laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 2 abstract aim: agreeing on a code of ethical conduct is an essential step in the formation and definition of a public health profession in its own right. in this paper we attempt to identify a limited number of key ethical principles to be reflected as professional guidance. methods: we used a consensus building approach based on narrative review of pivotal literature and theoretical argumentation in search for corresponding terms and in a second step attempted to align them to a limited number of key values. the resulting draft code of ethical conduct was validated employing a framework of the council of europe and reviewed in two quasi delphi rounds by members of a global think tank. results: the alignment exercise demonstrated the acceptability of five preselected key principles: solidarity, equity, efficiency, respect for autonomy, and justice whereas three additional principles were identified during the discussion rounds: common good, stewardship, and keeping promises. conclusions: in the context of emerging and re-emerging diseases as well as increase in lifestyle-related diseases, the proposed code of ethical conduct may serve as a mirror which public health professionals will use to design and implement public health interventions. future public health professional chambers or an analogous structure should become responsible for the acknowledgement and enforcement of the code. keywords: code of ethics, moral obligations, principle-based ethics, professional standards, public health profession, population ethics, societal responsibility, utilitarian ethics. conflicts of interest: none. acknowledgements: the authors express their gratitude to george lueddeke who helped initiate the “one health global think-tank for sustainable health & well-being (ghw 2030)” and chairs it since. special thanks go to think tank members muhammad mahmood afzal, muhammad wasif alam, mitike getnet kassie, and joann lindenmayer for their extensive review and comments which were of invaluable help. laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 3 introduction the implementation of public health interventions raises ethical issues which require public health professionals to address them. the awareness of the ethical dimension of public health activities has given rise to the relevance of public health ethics, which meagher and lee refer to as “a subspecialty of bioethics” (1), and kass refers to as a “subfield of bioethics” (2). several authors have noted the importance of ethics for public health (3, 4), and public health professionals training (5). for example, ethical issues in public health also feature prominently in the efforts to control emerging infectious diseases at the population level (6, 7), which necessitated the world health organisation (who) to issue guidance on how to deal with ethical issues in infectious diseases control (8). also, the efforts to address antimicrobial resistance (amr) have raised a number of ethical questions (9). in a systematic review by klingler et al., they have identified a comprehensive catalogue of ethically relevant conditions (10). thus in order to address the ethical issues arising from public health practice and research, it has been noted that there is a need to establish a public health ethics framework and a code of conduct for public health professionals, as well as to train public health professionals in population ethics (11). several frameworks for public health ethics have been documented (2, 12-15); among them, marckmann et al. (12) have provided detailed reasoning on application in the field practice. however, a gap remains: the development of a code of ethics and professional conduct in the field of public health or in short: a code of ethical conduct for the public health profession. in a recent introductory paper, laaser and schröder-bäck (16) outlined the reasoning why a code of conduct is an essential step in the formation and definition of a public health profession in its own right at the national as well as the european level and with relevance to a global dimension. the european directive on the recognition of professional qualifications 2005/36/ec (17) acknowledges as regulated professions in the health sector only physicians, nurses, dentists, midwifes, and pharmacists. the amendment eight years later in directive 2013/55/eu opens the door to include additional professions when it refers to a ‘broader context of the european workforce for health’ (18) which should then include for example veterinarians given their high relevance for people’s health. in most of the european countries, public health professionals are not formally organised as an autonomous profession in its own right – as for example it is the case in the united kingdom (19) – and do not adhere to an agreed code of conduct (20). however, the “good public health practice framework published 2016 by the uk faculty of public health 2016 (21) constitutes rather – as the title says – a guide for ethical practice which may be derived from overarching principles as discussed in this paper. although there are organisations of schools of public health (22) and public health associations (23) as well as other associations related to areas of public health relevance, agreement on a code of conduct as one precondition for the formalisation and integration of a public health profession has not been promoted as necessary. the american public health leadership society (24) described the rationale for an ethical code of conduct in 2002 as: “…a code of ethics thus serves as a goal to guide public health institutions and practitioners and as a standard to which they can be held accountable”. the statement goes further beyond public health professionals to include institutions that are involved in public health to abide to ethical conduct. however, as a first attempt this did not initiate a lasting debate and the recent volume of the public health reviews on ethics in public health (25) touches the topic only indirectly. laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 4 in the introductory paper referred to above (16), laaser and schröder-bäck discussed the limitations of the often dominant utilitarian principle in population ethics. the utilitarian principle says that the moral worth of an action or inaction lies in the consequences that follow. an action (or inaction) is good if it maximises the good for a maximum of people and is better in this regard than any alternative action. intrinsic values – such as respecting persons or dignity – do not exist in utilitarian thinking. instead of applying the utilitarian principle, the authors propose “...that solidarity and equity are core values that have to be reflected in a european version of a code of conduct for public health professionals… also guided by the principles of efficiency and respect for autonomy”. as an additional principle they discuss justice, especially for resource sharing on a global scale. although these five principles reflect the european heritage, the authors underline the increasingly global dimension of the public’s health (26, 27, 28) and therefore of a public health profession welldefined by the same principles (29, 30). methods we used a consensus building approach based on narrative review of literature and theoretical argumentation: we 1) argued the proposed five core ethical principles from the theoretical standpoint using a narrative review of selected publications in the field and trying to be as comprehensive as possible and relevant; 2) extracted and confirmed the five core principles as essential values for public health professionals and institutions in an “overlapping consensus” based on several rounds of discussion among authors, then translated the core principles into a draft code of ethical conduct making use of ‘mapping the terrain’ as proposed by childress et al. (31); 3) validated the draft employing the ‘general framework for codes of conduct in the health sector’ adopted by the council of europe in 2010 (32); and finally, 4) sent out the resulting draft for comments in two quasi delphi rounds conducted by the global think tank ghw-2030 (33). the comments from members of the global think tank in round one have to a large degree been integrated by the authors. the second round revealed support in formulating the conclusions and recommendations and the approval of the second draft. results review of the literature with regard to corresponding terms table 1 presents the selected and scrutinised papers related to principles and norms regarding public health ethics. we carefully aligned and synthesised theoretical frameworks to find the best fit between them. the draft ethical code the identified literature revealed its best fit with the five core values identified earlier (16): solidarity, equity, efficiency, respect for autonomy and justice. three additional principles were identified in the alignment exercise, which are: common (public) good, stewardship, and keeping promises and commitments. in the following we explain their core normative meaning. solidarity laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 5 solidarity is a value that increases in significance in the health realm. whereas in the conclusions of the council of the european union (38) solidarity was solely defined as being closely “linked to the financial arrangement of our national health systems and the need to ensure accessibility to all”, the normative scope, its relevance and meaning for public health gets more and more developed during the last years. a recent report of the nuffield council on bioethics defines solidarity as a concept that “signifies shared practices reflecting a collective commitment to carry ‘costs’ (financial, social, emotional or otherwise) to assist others.” (41). ter meulen (42) emphasises that solidarity is more than respecting each other and assuming liberal negative rights of freedom but that positive relations among human beings should be in the forefront, next to rights and duties. he formulates: “health care policies and arrangements should go beyond merely meeting needs and rights, by exploring how people’s personal dignity and sense of belonging can be sustained within relations of recognition, reciprocity and support”. from these essential cornerstones defining solidarity, one can conclude that the value of solidarity acknowledges that human beings should not forget that they are united, bond to other humans by virtue of humanity. from this also follows the duty for mutual support and the strengthening of relations among human beings should therefore be in the forefront of public health practice. equity also “equity” is one of the core values that are discussed in public health. the european union defines equity in health simply as relating “to equal access according to need, regardless of ethnicity, gender, age, social status or ability to pay” (council of the european union 2006 (38)). however, equity is also the normative reminder that health inequalities have to be in the focus of all public health action if considered to be unjust and unfair (43), foremost all those which refer to religion, race, gender identity etc. efficiency despite the last values that focus on rights and stress the moral importance of every one, the value of “efficiency” stems from another philosophical school but the rights-based approach. “efficiency” follows more utilitarian thinking inclined to maximize the positive outcome with a minimum of resources. this economic reasoning has a value also from a moral perspective because it reminds public health professionals that one has to be careful when dealing with scarce resources. scarce resources should be invested wisely to have the best health effect and economic evaluations are therefore important for public health. for instance, in some circumstances such as in the area of hiv/aids, there are challenging questions on how to allocate resources in an ethically acceptable and efficient way between preventive and curative demands (39) or between different health programmes. also, in the example of antimicrobial resistance, the allocation of resources may require reprioritisation from other areas and sectors outside health in order to gather enough funding to support containment of the epidemic (9). laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 6 table 1. review of ethical principles and terminologies with relevance to public health sources of ethical principles and terminologies for public health ethical principles proposed for public health attempted alignment of ethical principles for public health professionals world health organisation [2016] (8) justice equity transparency inclusiveness/ community engagement accountability oversight utility proportionality efficiency respect of persons (autonomy, informed consent, privacy confidentiality) liberty solidarity reciprocity solidarity reciprocity community engagement equity utility efficiency liberty respect of persons (autonomy, informed consent, privacy confidentiality) proportionality justice transparency inclusiveness/ community engagement accountability oversight core ethical principles solidarity equity efficiency respect for autonomy justice littmann and viens [2015] (9) justice distributive fairness effectiveness reciprocity stewardship citizen obligations to self educate citizens obligations not to infect others citizen involvement in responsibility citizen obligations and actions solidarity public engagement reciprocity distributive fairness effectiveness responsibility priority setting and resource allocation risk information sharing justice distributive fairness health justice trust public engagement distribution of research outcomes laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 7 sources of ethical principles and terminologies for public health ethical principles proposed for public health attempted alignment of ethical principles for public health professionals lobbying risk information sharing distribution of research outcomes public engagement solidarity reciprocity health justice common good trust royo-bordonada and roman-maestre [2015] (11) autonomy solidarity transparency pluralism community perspectives rights of individuals common good partnerships (public-private partnerships) collection and use of data (information) solidarity partnerships (public-private partnerships) information (collection and use of data) resource allocation autonomy rights of individuals pluralism community perspectives core ethical principles solidarity equity efficiency respect for autonomy justice marckmann g et al. [2015] (12) maximizing health benefits preventing harm respecting autonomy equity efficiency compensatory justice transparency participation justification equity compensatory justice maximizing health benefits efficiency respect for autonomy justice participation justification transparency consistency laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 8 sources of ethical principles and terminologies for public health ethical principles proposed for public health attempted alignment of ethical principles for public health professionals consistency justification participation ortmann le et al. [2016] (13) utility equity justice reciprocity solidarity privacy confidentiality keeping promises effectiveness proportionality necessity least infringement public justification solidarity reciprocity necessity equity effectiveness utility privacy least infringement confidentiality proportionality justice public justification public health leadership society [2002] (24) information collaboration respect for individual rights diversity incorporation confidentiality collaboration information respect for individual rights, confidentiality diversity incorporation information core ethical principles solidarity equity efficiency respect for autonomy justice schröder-bäck p et al. [2014] (34) maleficence beneficence health-maximisation efficiency respect for autonomy justice proportionality justice justice efficiency health maximisation respect for autonomy proportionality justice laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 9 sources of ethical principles and terminologies for public health ethical principles proposed for public health attempted alignment of ethical principles for public health professionals laaser u et al. [2002] (35) solidarity equity efficiency sustainability participation subsidiarity reconciliation evidence empathy/altruism solidarity empathy/ altruism equity subsidiarity efficiency sustainability evidence reconciliation participation sustainability institute for global ethics [n.d.] (36) competence honesty responsibility respect fairness compassion compassion competence responsibility respect honesty fairness council of the european union [2006](38) equity universality solidarity solidarity universality equity world health organisation [2015] (39) equity solidarity social justice reciprocity trust individual liberty versus broader societal concerns public good distributive justice solidarity reciprocity equity allocating scarce resources individual liberty versus broader societal concerns distributive justice social justice trust core ethical principles solidarity equity efficiency respect for autonomy justice coughlin sts [2008] minimizing possible harms solidarity/social effectiveness least infringement treating others fairly laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 10 sources of ethical principles and terminologies for public health ethical principles proposed for public health attempted alignment of ethical principles for public health professionals (40) treating others (current & future generations) fairly sustainability solidarity/social cohesion precautionary principle utility public justification least infringement necessity proportionality efficiency effectiveness building and maintaining public trust transparency (speaking honestly and truthfully) keeping promises and commitments protecting privacy and confidentiality procedural justice (participation of the public and the participation of affected parties) cohesion necessity efficiency sustainability utility protecting privacy and confidentiality proportionality (minimising possible harms) procedural justice (participation of the public and the participation of affected parties) building and maintaining public trust transparency public justification core ethical principles (summarised): * additional ethical principles remaining after the attempted alignment (bold in the table) are: solidarity (reciprocity) equity efficiency (utility, effectiveness) respect for autonomy (respect for individual and community, justice (public justification) laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 11 sources of ethical principles and terminologies for public health ethical principles proposed for public health attempted alignment of ethical principles for public health professionals • common (public) good • stewardship • keeping promises and commitments privacy, confidentiality, least infringement) laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 12 respect for autonomy economic evaluation and utilitarian thinking have to be hold in check by the rights-reflecting values equity, justice and also respect for autonomy. the normative core of the latter value is to re-iterate and focus what also is reflected in justice and equity: every person has autonomy and thus the capacity to make own decisions (for children or other persons unable to consent, parents or guardians take this role). respect for autonomy thus reminds public health professionals to obtain informed consent of persons who are subject to health interventions but also stresses that persons have a dignity that must not be comprised. this value warns of stigmatisation and instrumentalisation of persons for the benefit of others. if the autonomy of persons is comprised, this has at least the strong burden of proof that such an autonomy limiting behaviour is justifiable. however, respecting the autonomy of everyone not only means “to back off” and respect the liberty of a decision of persons. rather, o’neill (44) reminds the public health community that respecting autonomy can also refer to a duty, e.g. to participate in health interventions like immunisation campaigns to achieve herd immunity. littman and viens (9) in this context have noted that in order to address antimicrobial resistance “citizens have obligations to educate themselves, obligation of not to infect others, and obligation to lobby for support from political leaders and industries.” there might be examples where the infringement of a will of a person can be justified. the use of spillover effects of an intervention as a basis to restrict autonomy of an individual has been well explained by royo-bordonada and roman-maestre (11, pp. 12 of 15): “…among public health officials, there is a political component in the form of the health authority, with legal capacity in certain instances, to take action targeted at the individual or the environment. this capacity to restrict the autonomy of the individual can … come to be justified on the basis of the externalities, positive or negative, induced by the intervention in third parties”. an example could be to restrict the free movement of people with infectious diseases if their free movement could lead to severe infections of others. justice when can we consider something as being unjust and unfair? a benchmark for justice theories in health is the work of norman daniels. daniels (2008 (45)) follows his teacher rawls in the assumption that public institutions are obliged to promote fair equality of opportunity for everyone. public institutions and resources should be organized in such a way that every person can participate in society – to take public offices but also to have resources to live a good life (which is not further specified). daniels continues the rawlsian approach by claiming that health significantly contributes to the opportunity range that people are having. and, as a consequence, justice requires to protect health and to meet health needs of every person. following the philosopher boorse (46), daniels also has a clear idea of what health means in this context: species typical normal functioning according to the functioning of others in the same (e.g., age) reference class. thus, for public health professionals, justice understood in this way should remind them of including everyone to benefit from health and thus getting fair equality of opportunity in life when the social and other determinants of health (incl. access to health care) do not support this goal for everyone. the concept of distributive fairness includes also the important question of how findings from scientific research are distributed since research evidence is key for an informed laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 13 decision-making in public health. for instance, the tension in resource allocation between prevention and treatment in hiv and aids services can better be solved if decision makers know the evidence that treatment helps to minimize the risk of transmission, therefore, we can take treatment as part of prevention. in this way, the evidence for treatment as prevention can assist in distributive justice in resource allocation in hiv/aids between preventive and curative interventions. also, by sharing research results, it will help communities to understand the value of interventions being implemented in public health and hence be more willing to support them. however, justice could also extend to include unproportionate focus on resource driven health programmes versus “other” public health calamities with significant impact. a key message to public health professionals is that distribution of research outcomes should be tailored to the audience, i.e., to the ordinary citizens; message should be prepared in simple, non-technical terms to ensure that it is clearly understood. the core principle of justice and its emphasis on transparency, inclusiveness, and community engagement provides an opportunity for people of different culture, values, and beliefs to participate in assembling public support. “lessons from the human genome project – ethical, legal, and social implications program” (1) indicate that engaging the public in an informed discussion aiming at reaching agreement on a particular public health intervention, can help to get support of the population or community. additional principles from table 1, three additional principles have emerged, namely: protection of common (public) good; stewardship; and keeping promises and commitments. common (public) good this principle focuses on the need to protect things that are shared by all for the benefit of all people in the community, population or a nation. in economic theories the characteristics of a “public good” are those of being “non-excludable” and “nonrivalrous”. this means that all people can benefit from the good, no one is (or can be excluded), and use of the common good does not diminish the good. the “common (public) good” has close links to communitarian theories of public health ethics (47). this also requires public health professionals to be able to solve ethical conflicts between the protection of public good and human rights of individuals within a particular community or population (48). knowing that priority is on preservation of common good should be the bottom-line for a public health professional when implementing an intervention that encroaches on individual’s rights and freedom. if a public health professional decides to focus on rights of individuals alone at the expense of a common good, this may put the whole community or population at risk. also, the principle requires the public health professional to be informed by scientific evidence while making decisions about a particular intervention. stewardship this normative value insists that public health professionals have a stewardship role, which means that they have to put the health of the population as their number one priority (37). in other words, the stewardship role of public health professionals makes them responsible for the health of the entire population. as stewards, public health professionals must have a vision for the health of the people they serve. this brings to them a need for using scientific information to analyse situation and design laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 14 (jointly with the population) appropriate interventions. also, public health professionals must build skills to engage the population and to reach consensus on public health interventions that will help to solve a problem at hand. if a public health professional behaves as a “good steward”, then all stakeholders will likely support the implementation of public health interventions. to this end, public health professionals must be able to communicate effectively all the interventions as well as research findings to the population. laws, regulations, and other tools for governance arrangements are part and parcel of the stewardship role. therefore, public health professionals in fulfilling their stewardship role should be able to participate in setting regulations and bylaws and support the populations to comply with in order to flourish healthy lives. keeping promises this principle calls for public health professionals to hold themselves responsible on the promises and commitments they make. it should be understood by the professionals that commitment to improve and preserve the health of the population they serve is central to their duties. when a planned intervention is to be implemented in a particular community, it is the responsibility of the public health professional to ensure that the promise is achieved in a transparent manner and that the resources earmarked for the intervention are used as planned. these three additional principles underline the relevance of operational ethical competence and are constitutive elements of public health professionalism. validating the draft code of conduct for validation we found most suitable the general framework for codes of conduct in the health sector, approved by the council of europe in 2010 (32). in table 2 we attempt to show that the core ethical principles we identified can be aligned to a large degree with the framework adopted by the council of europe. table 2. general framework for codes of conduct in the health sector of the council of europe (complete version in annex 1) main areas subareas selected examples corresponding core principle 4. areas to be regulated by a code of conduct in the health sector a. good professional practice i. respect for the dignity of people (employees…) ii. honesty and confidentiality … iv. use of the best scientific evidence … vi. compliance with regulations and legislation vii. awareness of the needs, demands and expectations of the population … 2.4 2.4 2.3 2.5 2.2 laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 15 b. use of resources of the service/system i. cost-effectiveness… ii. avoiding using public resources for private gain iii. prevention of fraud and corruption 2.3 2.5 2.5 c. handling of conflict of interests… i. economic: weighing between health benefits and economic gains on one side and individual gains (employment, etc.) (45). ii. non-economic: managing relationships with health authorities and other government officials (11, 45). 2.6.1 d. proper access, sharing and use of information … ii. duty to disclose all relevant information… … 2.4; 2.5 e. handling of gifts and benefits i. existence of an explicit policy concerning gifts … 2.5 f. research-related topics … ii. truthful claims of research potential … iv.* feedback to study populations on the results v.* research outcomes as part of public good need to be shared in order to facilitate evidence-based decisions. 2.4 2.4 2.5 g. relationships with other actors in the health sector … vii.* collaboration between public health professionals, communities and public health institutions. 2.1 2.6.1 h. good corporate governance of health institutions/services/centres i. issues of multiculturalism, tolerance and respect … ii.* participation in humanitarian activities 2.4 2.1 2.6.2 5. enforcement of the code of conduct a. recognition of violations b. composition of the body responsible for dealing with enforcement c. transparency of procedures and public scrutiny d. complaints system e.* use of nudging techniques in design of public health interventions (46). this emphasis is based on the consideration that public health professionals need to balance application of nudging and strict prohibition. 2.5 2.5 2.5 2.5 2.3 2.6.2 2.5 6. updating, a. process of development of 2.6.1 laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 16 monitoring and development of the code of conduct codes of conducts: initiative, ownership, legitimacy b. comprehensiveness c. limitations of codes of conduct d. codes of conduct and legislation 2.6.2 2.6.3 * amended by e. eliakimu. results of two quasi delphi rounds the final outcome of our integrating consensus oriented approach is summarised in table 3. laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 17 table 3. the aligned code of ethical conduct for the public health profession preamble: the public health profession is defined inter alia by an adopted set of principles guiding the ethical conduct of its members. these principles form a normative core of the profession. public health professionals should orient their conduct – their doing and omission – according to the following norms and values. in case of conflict of these values, professionals accept a burden of proof to argue the ethically best acceptable solution for their conduct while taking the normative guidance of all these norms and values into account. core ethical principles short characterisation taken from section 2.1-2.5 above 2.1 solidarity solidarity signifies shared practices reflecting a collective commitment to carry ‘costs’ together to assist others. human beings are united in the fact that they are bond to other humans by virtue of humanity. from this also follows the duty for mutual support for every human being. the strengthening of relations among human beings should therefore be in the forefront of public health. 2.2 equity equity is relating to equal access according to need, regardless of ethnicity, gender, age, social status or ability to pay. health inequities considered to be unjust and unfair have to be in the focus of all public health actions. 2.3 efficiency maximisation of the positive outcome with a minimum of resources, i.e., scarce resources should be invested wisely to have the best health effect. 2.4 respect for autonomy economic evaluation and utilitarian thinking have to be hold in check by the rights-reflecting values equity, justice and also respect for autonomy. persons have a dignity that must not be comprised. 2.5 justice public institutions and public health professionals are obliged to promote fair equality of opportunity for everyone. this principle also encompasses distributive justice on research, i.e. to consider how findings from scientific research are distributed. operational ethics short characterisation taken from section 2.6.1 2.6.3 above 2.6.1 common (public) good this principle focuses on the need to protect things that are shared by all for the benefit of all. public health professionals must be able to solve ethical conflicts between the protection of public good and human rights of individuals. knowing that priority is on preservation of common good should be the bottom-line for a public health professional. 2.6.2 stewardship stewardship makes public health professionals responsible for the health of the entire population. they have to build skills to engage the population and to reach consensus on public health interventions that will help to solve a problem at hand. they should also support the citizens to comply with various laws and regulations governing public health issues. 2.6.3 keeping promises this principle calls for public health professionals to hold themselves responsible for the promises and commitments they make. promoting and preserving the health of the population they serve is central to their duties. discussion the proposed code of ethical conduct for the public health profession hopefully will become relevant in global and not just in european contexts. for example anderson et al. (51) have highlighted a global health ethics in addressing the challenge of maternal and neonatal mortality. the identified principles make a significant contribution to the newer related field of “global health ethics”, which has been shown to adopt almost similar values but operates at or requires actions at global level (52). principles include equity, justice, laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 18 autonomy, human rights, application of scientific research, as well as related virtues such as compassion, trustworthiness, integrity, and conscientiousness. the world health organisation in its key document on global health ethics has identified three ethical challenges that closely relate to these principles: first – “… to specify the actions that wealthier countries should take, as a matter of global justice and solidarity, to promote global health equity”; second – “… is related to cultural relativity. it is sometimes asked whether ethical standards are universal, given that different people in different countries may hold different values or place different weights on common values; third concerns international research, especially when investigators from wealthy countries conduct research in impoverished settings where participants are especially vulnerable or where language and cultural barriers make informed consent difficult.”(39, pp. 19-20) the implementation of the code of ethical conduct for the public health profession, supports public health professionals addressing the ethical questions and dilemmas for the benefit of population health. ethical principles including equity, social justice, national and individual autonomy, transparency, accountability, open communication, trust, mutual respect, development of servant leadership are characterised as globally relevant to meet the global challenges. also, solidarity, stewardship, production of global public goods, and management of externalities across countries, have been shown to be the “essential functions of the global health system” (53). the role of human rights in health links both, public and global health ethics. to this end supporting, protecting and respecting human rights is essential both to public health ethics (54) and to global health ethics (55). however, e.g. out of fifty-five finalized project proposals identified in the second public health programme (2008-2013) of the european commission only ‘equity’ and ‘efficiency’ were explicitly considered in eighteen projects and four projects respectively while solidarity was only discussed in one project (56). limitations the limitations of our approach to public health or population ethics are obvious. firstly, the selected literature may not be comprehensive respectively the balance between the relevance of publications and preferences of the authoring team may be biased by prejudice. secondly our attempt to align relevant terms in the literature (see table 1) may similarly be biased by our prejudices, although our intensive discussions during the last year hopefully have minimised the effect of personal preferences. thirdly, the terminology in the subject area has not finally matured leaving boundaries foggy and allow for undefined overlaps taking the example of public health vs. population health and global public health vs. global health where the latter terms include individual health predominantly subject of clinical medicine and the former terms are restricting to public health services and thereby to the multitude of public health professions working in the public health services (physicians, economists, sociologists to name a few). the authors of this paper however, do not consider public health ethics as a subspecialty (1) or a subfield (2) of bioethics. although there are norms and values shared in bioethics and public health ethics, the latter has a basic normative orientation towards the good of the public and populations, whereas bioethics was designed for the clinical context of the patient-physician encounter (57). laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 19 fourth, we embrace a public health ethics perspective but the purpose of this paper is to narrow it down to a code of ethical conduct to guide multi-disciplinary public health professionals in their operations and to help defining a distinct profession targeting population health rather than individual health (16). this may imply the partly loss of a comprehensive picture, however, an elaborate guide or code would not serve the needs of the public health practitioner in the field. insofar, we adopted a somewhat different strategy focussing on a smaller but comprehensive set of core principles (see table 3 above) relevant to public health ethics rather than prescribing a lengthy set of concrete rules (like e.g. 21, 24). fifth, trying to be focused we did not elaborate on applications in the various fields of public health relevance as for example natural or man-made disasters and the resulting emergency state (58) which relates especially to the principle of solidarity, or the issue of universal health coverage (59) which requires the consideration of justice. sixth, the focus on populations leaves out personal conscience and self-determination values (60) or virtues (61, 62), most important being honesty and trustworthiness, integrity and excellence. finally, in light of the sustainable development goals, sdgs (33) and the case for people and planetary sustainability becoming increasingly more urgent, it seems timely, although beyond the scope of this paper, to reflect on aligning the proposed ethical principles with the attainment of the sdgs, and for public health to adopt a wider perspective that underpins a one health concept, that is, to encourage the collaborative efforts of multiple disciplines working locally, nationally, and globally, to achieve the best health (and well-being) for people, animals and our environment (63-66). conclusions and recommendations the prospects of the code of ethical conduct proposed here are related to its acknowledgement and enforcement which likely in the future can be done effectively only by own professional chambers or other suitable bodies for public health, not by common medical chambers as of now. the authors therefore urge public health professionals to use the proposed code of ethical conduct with its eight principles to guide them in pursuing their work so as to assure that citizens are living healthy. given the current context in which we experience emerging and re-emerging diseases, as well as the epidemic of lifestyle-related diseases; and also that research and public (health) institutions and their actors are threatened by populist politics and anti-factual movements (67), the proposed code of ethical conduct should be used to guide the design and implementation of public health interventions including research, the training of public health professionals, their professional acting, and last not least the acknowledgement of a public health profession in its own right. references 1. meagher km, lee lm. integrating public health and deliberative public bioethics: lessons from the human genome project ethical, legal, and social implications program. public health rep 2016;131:44-51. 2. kass ne. public health ethics: from foundations and frameworks to justice and global public health. j law med ethics 2004;32:232-42. 3. coleman ch, bouesseau mc, reis a. the contribution of ethics to 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http://www.springerpub.com/global-population-health-and-wellbeing-in-the-21st-century-toward-new-paradigms-policy-and-practice.html (accessed: 5 may, 2017). laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 25 annex 1. general framework for codes of conduct in the health sector of the council of europe (29) 1. introduction 2. values and ethical references 3. legal framework of reference 4. example of areas to be regulated by a code of conduct in the health sector nb. not all areas are applicable to all situations. the order of the items does not reflect priority ranking. the list is non-exhaustive and the items are for illustrative purposes only. a. good professional practice i. respect for the dignity of people (employees, patients, customers) ii. honesty and confidentiality iii. keeping up-to-date professional competence iv. use of the best scientific evidence v. compliance with accepted standards vi. compliance with regulations and legislation vii. awareness of the needs, demands and expectations of the population, patients and customers viii. co-operation with colleagues ix. spirit of moderation, reconciliation, tolerance and appeasement b. use of resources of the service/system i. cost-effectiveness practice in the use of resources ii. avoiding using public resources for private gain iii. prevention of fraud and corruption c. handling of conflict of interests in the best interest of patients and population, whether i. economic, or ii. non-economic d. proper access, sharing and use of information i. research of any information necessary for decision making ii. duty to disclose all relevant information to the public and authorities iii. duty to provide information to patients with respect to their needs and preferences e. handling of gifts and benefits i. existence of an explicit policy concerning gifts ii. transparency regarding gifts received from interested parties f. research-related topics i. clinical trials (helsinki declaration) ii. truthful claims of research potential iii. patient consent with full disclosure of risks g. relationships with other actors in the health sector i. colleagues and other health professionals ii. patients and their families iii. insurers, third-party payers laaser u, schröder-bäck p, eliakimu e, czabanowska k, the one health global think-tank for sustainable health & well-being (ghw-2030). a code of ethical conduct for the public health profession (original research). seejph 2017, posted: 01 december 2017. doi 10.4119/unibi/seejph-2017-177 26 iv. health-related industries (pharmaceutical, food, advertisement, cosmetic, medical devices, etc.), and other interest groups v. government officers of health and other sectors (police) vi. patients and self-help organisations, ngos, etc. vii. media h. good corporate governance of health institutions/services/centres i. issues of multiculturalism, tolerance and respect 5. enforcement of the code of conduct a. recognition of violations b. composition of the body responsible for dealing with enforcement c. transparency of procedures and public scrutiny d. complaints system 6. updating, monitoring and development of the code of conduct a. process of development of codes of conducts: initiative, ownership, legitimacy b. comprehensiveness c. limitations of codes of conduct d. codes of conduct and legislation ______________________________________________________________________________________ © 2017 laaser et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. the uk faculty of public health. www.fph.org.uk/ (accessed: 19 february, 2016). macassa g. integrated corporate social responsibility and human resources management for stakeholders health promotion (short report). seejph 2019, posted: 14 october 2019. doi 10.4119/seejph-2373 1 short report integrated corporate social responsibility and human resources management for stakeholders health promotion gloria macassa1 1department of public health and sports science, university of gävle, sweden. corresponding author: gloria macassa, md; address: department of public health and sports science, university of gävle, se-801 76, gävle, sweden; telephone: +4626648228; e-mail: gloria.macassa@hig.se abstract in the past decade, there has been an argument for the inclusion of corporate social responsibility (csr) in models and business strategies. however, the conversion of csr strategy into actual managerial practices and outcome values remains an issue of ongoing debate as well an important challenge for business organizations. furthermore, still is very little discussion on how business will influence stakeholder’s health promotion and surrounding environment as means to help address society’s most pressing challenges. this paper discusses the potential of public health literacy in advancing stakeholders’ health promotion beyond the workplace. the discussion argues that integrating corporate social responsibility (csr) and human resources management (hrm) is an effective strategy to achieve social sustainability in organizations in which stakeholders’ health and well-being are important components. this short report describes an integrated csr-hrm and describes how it can facilitate public health literacy. in the era of sustainable development, there is a need to discuss how business organizations can strategize to enhance internal and external stakeholders’ health and wellbeing. keywords: corporate social responsibility, human resources management, public health literacy, stakeholders’ health. macassa g. integrated corporate social responsibility and human resources management for stakeholders health promotion (short report). seejph 2019, posted: 14 october 2019. doi 10.4119/seejph-2373 2 the corporate social responsibility– human resources management nexus background in the past decade, there has been an argument for the inclusion of corporate social responsibility (csr) in models and business strategies (1-3). however, as suggested by jamali et al. (1), the conversion of csr strategy into actual managerial practices and outcome values remains an ongoing challenge for many organizations (1). various authors argue that human resources management (hrm) can provide interesting and dynamic support to csr strategy design, implementation, and delivery (1-3). although the definition of csr has been debated (4-9), there is agreement about its implementation and delivery. this short report defines csr as the social obligation of business enterprises to impact society beyond pure profit maximization (1,10) through an institutionalized responsive approach translated into and aligned with managerial practices, including human resource management (1,11). with that approach, csr can be seen as a planned process with strategic applications and links to the organization’s mission and core competences (12-14).several works have highlighted how csr can increase organizational performance (15) through generating a sense of belonging and commitment among stakeholders (16,17). in addition to the evidence for csr’s beneficial effects on employees (18), the main argument here is that hrm could provide a managerial framework to support organizational efforts to translate csr strategies into practical managerial actions and outcomes, especially within the internal organizational environment (2,19,20). similar to csr, hrm has been defined different ways, especially as it has evolved over time (21,22). there are also international differences in its definitions. for instance, kaufman argues that in the dominant american model, hrm is considered both a function and a process, thus making it difficult to disentangle from general management activities (23). in this short report i follow watson (24) in defining hrm as ‘institutions, discourses and practices focused on the management of people within an employment relationship enacted through networks comprising multiple public and private actors’. this definition allows us to understand hrm beyond its functional aspects, to consider both micro and macro levels of the phenomenon, and to expand the employer–worker dyad to include multiple institutions and stakeholders (24). hrm is seen to have capabilities and expertise in executing organizational strategies, participating in change management support and facilitation, and enhancing managerial efficiency and responsibility for learning, training, and development programmes to help to integrate csr into an organization’s culture. what makes its role all the more interesting and promising is that hrm is increasingly considered responsible not only for humanistic and social concerns, but also for adding value in a broader business sense (25,26). hrm is expected to reach out to communities and society in general as well as to have an important role in the search for sustainable organizations (22). in addition, hrm has the potential to target sustainability at the dual dimension of work and home, as well as contribute to responsible leadership (rl) within organizations. this type of leadership is known to transcend the traditional binary leadership-employee relationship to emphasize multiple leader-stakeholder relationships, paying attention to all stakeholders as well as the environment. hrm can help to create a win–win environment for business organizations macassa g. integrated corporate social responsibility and human resources management for stakeholders health promotion (short report). seejph 2019, posted: 14 october 2019. doi 10.4119/seejph-2373 3 and their multiple stakeholders (internal and external) through better alignment with the organization’s mission and strategic direction (27,28). hrm thus appears to be well positioned to be more involved in helping firms to amplify their csr efforts and achieve worthwhile and substantive outcome values (3). integrated human csr-hrm for stakeholders’ health promotion: the role of public health literacy socially responsible hrm, csr, and promotion of stakeholder’s health should be seen through the lens of stakeholder theory, in which the essence of business lies primarily in building and creating value for all stakeholders, internal and external (29,30). this theory helps to explain why is beneficial to integrate csr with business management to advance the health and well-being of all stakeholders within and beyond the workplace (31). csr is thus considered to be a process in which business organizations integrate social, ethical, environmental, and human rights and consumer concerns across its operations in order to maximize value for owners, stakeholders, and the broader society as well as identify, prevent, and mitigate potential adverse consequences on the environment (1,8,10). for instance, the introduction of socially responsible elements to daily management has been argued to legitimize companies’ activities vis-à-vis the groups with which they interact: shareholders, partners, suppliers, customers, public institutions, nongovernmental organizations, employees, and society in general (32,33). from a health promotion perspective, this integration could be an important vehicle for disseminating strategies that support sustainable population health (34). i argue that csr-hrm can be used within enterprises to implement stakeholders’ literacy in health and well-being in both the workplace and the larger society. contrary to individual health literacy (which is a predictor to individual health outcomes), public health literacy is defined as the public’s ability to make sound health decisions in the context of everyday life-at home, in the community, at the workplace, in the health care system, at the market place, and in the political arena (34). for instance, linking csr and health literacy can encourage both business and civic engagement in health, thus creating a reciprocal responsibility to create workplaces in which employees can obtain the information they need to understand and act on both individual and public health concerns (35). sorensen et al. argue that health literacy could benefit csr through widening opportunities to promote new partnerships and resources for its progress (35). they also suggest that business can play an important role in spreading health literacy not only among employees, but also in society (35). health literacy is important to business in ensuring the availability of a healthy workforce and its long-term sustainability, well-being, and performance (35,36). health literacy in the workplace can also be both a catalyst for a long-term return on investment and a way for companies to educate their workforce on the importance of societal well-being and sustainability (37). because public health literacy can be embedded in the company’s strategic csr-hrm, it can boost employees’ knowledge and motivate them to make decisions important to their health, the working environment, and the health and well-being of others (including the natural environment). burmeister argues that modern companies cannot operate without considering the social consequences of their actions (38). advancing public health literacy as a corporate strategic choice can fit the dynamic change from an add-on csr to a built-in csr, where social considerations are integrated into strategies and macassa g. integrated corporate social responsibility and human resources management for stakeholders health promotion (short report). seejph 2019, posted: 14 october 2019. doi 10.4119/seejph-2373 4 operations. it can also stimulate the shift form value protection to value creation (including social value), with a focus on innovation and competitive advantage rather than risk and reputation management (38,39). using the csr-hrm nexus to enhance public health literacy and stakeholders’ health and well-being may not necessarily require additional resources from businesses. instead, it might be accomplished using already available tools and past efforts, but now coordinated with 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health-literacy – a strategic asset for corporate social responsibility in europe. j health commun 2011;16 suppl 3:322-7. doi: 10.1080/10810730.2011.606072. 37. larsen ak, holterman a, mortensen os, punnett l, rod mh, jorgensen mb. organizing workplace health literacy to reduce musculoskeletal pain and consequences. bmc nurs 2015;14:46. 38. burmeister k. megatrends and the future of corporate social responsibility. forum csr international 2008;1:16-7. 39. maanavilija l. csr in europe. a look back and into the future. forum csr international 2010;1:76-7. ___________________________________________________________ © 2019 macassa; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://ilcuk.org.uk/wp-content/uploads/2018/10/navigatinghealth.pdf https://ilcuk.org.uk/wp-content/uploads/2018/10/navigatinghealth.pdf https://ilcuk.org.uk/wp-content/uploads/2018/10/navigatinghealth.pdf https://www.ncbi.nlm.nih.gov/pubmed/21951261 https://www.ncbi.nlm.nih.gov/pubmed/21951261 laaser w, exeni c. introduction of digital technologies in education concepts and experiences (review article). seejph 2019, posted: 06 june 2019. doi 10.4119/unibi/seejph-2019-220 page 1 of 10 review article introduction of digital technologies in education concepts and experiences wolfram laaser1, cecilia exeni2 1 ex fernuniversität, hagen, germany; 2 national university, cordoba, argentina. corresponding author: dr. wolfram laaser; address: milly-steger-str. 1, d-58093 hagen, germany; e-mail: wolframlaaaser@gmail.com abstract during the last decades technologies of information and communication technologies made a lot of progress, which increased the quantity and quality of distance education programs and the upcoming blended learning models. however, some basic difficulties in defining meaningful terms instead of buzzwords, often used in the present debate, will be discussed to raise consciousness of the rather vague terminology. the progress of digital technologies offered also a chance for better inclusion of disadvantaged parts of the population. the focus lies on the young generation of school attendants and how technology-oriented programs can provide better inclusion. we put a regional focus on development in latin america. to highlight some of the issues discussed before, we will present a detailed case study about the argentinean project “conectarigualdad”. we have also added a brief comparison with some other latin american initiatives. summarizing we list considerations for a successful inclusive application of digital technologies in education. keywords: argentina, conectarigualdad, digital, digitalization, digital technology, inclusion, netbooks, one laptop per child. conflicts of interest: none. mailto:wolframlaaaser@gmail.com laaser w, exeni c. introduction of digital technologies in education concepts and experiences (review article). seejph 2019, posted: 06 june 2019. doi 10.4119/unibi/seejph-2019-220 page 2 of 10 introduction during the last decades, information and communication technologies advanced at a fast rate and impacted on education, especially on distance education, both, in a qualitative and in a quantitative way. the range of options of how to introduce and apply the new technologies in online distance education were manifold. the recently upcoming format, called moocs (massive open online courses) is an example. moocs give open access to knowledge of well-known universities at zero or at least low cost, without asking for any necessary certificate about prior qualification. moocs range from free of charge short online courses with massive enrolment up to offers of complete online master degree course. some moocs are directed to an open non-expert general public, e.g. a mooc for integration of refugees, others are directed to the higher education segment. the structure then will be more curriculum bound. many moocs form part of continuous adult education or are applied in enterprises for “training on the job”. moocs attracted students from all over the globe. the first moocs started in canada with a constructivist studentcentred approach. later some well-known us american universities took over and changed moocs to a behaviouristic model. the open courses demonstrated their impact on distance learning by use of online pre-recorded video lectures instead of printed study units and multiplechoice tests instead of written or oral exams. however, the video presentation format was simple and the assessment and evaluation not very profound (1). today, moocs are offered by many national universities from all over the world. however, they represent only a small part compared to the total number of traditional courses. in this context we could observe nevertheless some changes of educational practices, though, even today we still find educational practices which emulate traditional classroom teaching approaches while applying new web-based technologies. however, more relevant is the stepwise upsurge of a pedagogy with tics. new affordances for teachers and students are required. a prominent example is the tepac (technological pedagogical content knowledge) model which describes the necessary qualifications, teachers must acquire to make meaningful use of the new technological devices. the concept has been developed during the years 2006 to 2009 at michigan state university (2). figure 1. tpak model (source: google images) with respect to students’ affordances bates postulates: “in order to develop the skills students need in the 21st century, we need to focus more on skills development than on the transmission of content. online learning can focus better on the development of soft skills, such as communication and knowledge management. everything on the internet is a potential study material” (3). a detailed example of the expected advances to be laaser w, exeni c. introduction of digital technologies in education concepts and experiences (review article). seejph 2019, posted: 06 june 2019. doi 10.4119/unibi/seejph-2019-220 page 3 of 10 achieved with the use of computers in schools is the expectation that the 1112years old kids should acquire the following abilities:  creativity and innovation  communication and collaboration  search and information management  critical thinking  problem solving  decision taking and being a digital citizen at the same time, technological tools have been developing according to the needs of these educational processes and the advancement of digital technologies. likewise, we have a variety of virtual platforms, educational portals, repositories, libraries with e-books, virtual labs, etc. accordingly, there has been a paradigmatic shift in the design and delivery of educational materials. at present, distance learning uses multimedia and interactive technologies, for example: animated graphs, simulators, educational video games, streamed podcasts and vodcasts, etc. deficiencies in the definition of some related concepts with the changes towards a digital environment, new concepts emerged with labels such as “digitization”, “digital school”, “university of the future”, “education for the digital century”, “intelligent learning” or “algorithmic learning”, to describe the introduction and/or application of technologies in education. the denomination of these terms is often sketchy but not very succinct. the word “digital”, for example, refers in mathematics to the representation of analogous information by a combination of the digits 1 and 0. digitization then is the process of transforming analogous information into its digital form. what then is a “digital school or university?” basically, the digitization in the educational field is seen as a process of transformation towards implementation of digital technologies in teaching and learning. but this transformation is more complex and not exclusively a technical problem. consequently, segura, quinteros & mon (4) confirm that the “digital university” is a social and material reality and is the product of the complex relationships that are established. digital is an adjective that no longer describes almost anything in the current university. many of the concepts used today refer to technologies as drivers of teaching and learning processes. people share beliefs that using the latest new technology is the most important way to modernize education and will solve most educational problems, ignoring the necessity of teachers who can work with digital tools and/or develop lesson plans or school projects. this perception is backed by companies who market the digital equipment and the respective software and thereby push the sale of their products. audrey watters calls it the “silicon valley” ideology: “educational technology is, after all, a series of practices itself-it is not just the hardware or software. ed tech carries with it ideologies and ideas” (5) and in another blog post she wrote: “the tech sector does love stories-grand narratives and make-believes and mythologies about revolution and disruption and innovation” (6). however, the way people accept, use and handle learning technologies is crucial in determining the success or failure of the introduction of new technologies. that is why we think, it is important to highlight how digital technologies can or should be implemented in the public educational sector. laaser w, exeni c. introduction of digital technologies in education concepts and experiences (review article). seejph 2019, posted: 06 june 2019. doi 10.4119/unibi/seejph-2019-220 page 4 of 10 new generation features information and communication technologies were created mainly for the private consumer market or business and not for educational use. however, they were very quickly adopted by the new generations who gave the mother uses: fun, games, socialization, informal learning, etc. in 2001 marc prensky (7) revolutionized the perspective on the relationship between the different generations and ict with the concepts “digital natives” and “digital immigrants”. a series of studies and research focus on the numerous and complex facets that link children and young people with ict education, such as: changes in social dynamics, the relocation of content, the new meaning of the learning process and schools, the connotation of technologies. for this reason, the works of emilia ferreiro (8) [“nuevastecnologías y escritura” -new technologies and writing], together with dussel [“aprender y enseñaren la cultura digital”learning and teaching in digital culture-], morduchowicz [“los adolescentes y las redessociales” -adolescents and social networks-] martin barbero [“estallido de losrelatos y pluralización de las lecturas” outbreak of the stories and pluralization of the readings-], virdo (los “neonativosdigitales” -the digital “neonatives”-]and sibilia [“la intimidadcomoespectáculo” -the intimacy as spectacle-], among others, tackle the conflicts and frictions that today marks the education of children and young people. today we know that ict increases the flow of personal interactions constantly, creates new bounds with knowledge and is used to legitimize ideological frameworks. it has a market and symbolic value that determines positions in indifferent social strata. that is why those who do not have access to digital technologies are excluded. silvia bacher (9) says: “the informational society brings a new social conception, where the disconnected (homeless children, teachers who do not feel safe in front of their students or seniors who do not access ict) are at risk of being segregated or even more to become live witnesses of a never greater deepening of already existing exclusions. today it is not possible to speak of a digital divide but of digital gaps framed by social gaps.” many students do not have access to the technologies, but it does not imply that they have a way of building knowledge determined by the logic of the screens, because that is the current reference today. emilia ferreiro (8) argues that those who are twenty-five years old or older did the trip from the notebooks to the screens and those who are younger are doing a reverse tour. the researcher also emphasizes the different organizations of technology and of the book industry, and analyses today’s school, in which the adults, as seldom times in history, can recognize a students’ specific knowledge and can learn from them (8). the “conectarigualdad” program (connecting equality) the context the significant impact, that involves the use of ict makes it part of the educational goals for 2021 (10) proposed by the organization of ibero-american states (ois). specifically, goal number 5 establishes the use of these in classroom practices, affirms the potential of ict in education and states: “it is not limited to the digital literacy of the population. it is also expected that these can be introduced across the teaching-learning process, facilitating the creation of modern skills and improving the educational laaser w, exeni c. introduction of digital technologies in education concepts and experiences (review article). seejph 2019, posted: 06 june 2019. doi 10.4119/unibi/seejph-2019-220 page 5 of 10 achievement of the scholar”. from the adhesion to the educational goals for 2021, several latin american countries implemented educational programs with ict, based on the negroponte model “one laptop per child”. the argentine program is in this line one of these programs. objectives and implementation in argentina, the national education act no. 26206 (10) is sanctioned. this law puts the focus on social inclusion and human rights. this framework establishes the use of ict in the classrooms. this is explained in article 100: the national executive branch, through the ministry of education, science and technology, will set the policy and develop educational options based on the use of information and communication technologies and the mass media of social communication, collaborative with the fulfilment of the purposes and objectives of this law (p. 20). accordingly, with this law, the “conectarigualdad” program was created with the purpose of implementing a digital inclusion policy that enhanced public school and reduced the digital, educational and social gaps in argentina. figure 2. conectar igualdad reaches the most vulnerable sectors (source: google images) the program focused on two lines of action:  deliver netbooks to students and teachers of middle school, high school, college (associate degree) and special education 1 to 1 (“one laptop per child”);  to train teachers in the pedagogical use of ict and to guide them in their classroom practices while using netbooks. equipment the implementation of the program began with building “technological floors” in each school. each one had a school server which was connected to each of the netbooks. each netbook was delivered to teachers and students of that school. it also disposed of a school network through a switch and access points placed in each of the classrooms. five million netbooks were delivered during five years of the program. two years later the “digital elementary” program was added. this program also provided netbooks to schools, but in the format of “mobile digital classrooms”. these included: 30 laaser w, exeni c. introduction of digital technologies in education concepts and experiences (review article). seejph 2019, posted: 06 june 2019. doi 10.4119/unibi/seejph-2019-220 page 6 of 10 netbooks, an interactive digital whiteboard, a projector, a router, a server and a cart to transport equipment. training and guidance education with technologies has many epistemological perspectives. considering the articulation between the specificities of each science and the inclusion of ict, unprecedented specializations were done in the field of education, communication and educational technology to be able to address them. for the netbooks, help desks were provided with software and educational materials according to each of the recipients. even today it is possible to find on the web and download the “teacher’s desk”, the “student’s desk”, the “student desk for ese (exceptional students education)”, etc. in addition, many multimedia educational materials have been developed and were available in different formats and platforms. for example, television channels such as “paka-paka” and “encuentro”, the first directed to early childhood and the second to audiovisual educational and cultural topics. in addition, the official educational portals, such as connect, educ.ar and digital elementary are accessible. at the same time, "huayra" gnu/linux was developed, an operating system for the argentine educational community based on debian. this operating system had applications, suggested by teachers and was constantly renewed. the netbooks carried two operating systems “huayra” and windows. the pros and cons of the “conectarigualdad” program over the course of its few years, the program has received both criticism as well as positive comments. detractors argue that no improvement in educational quality was visible. they also emphasized the fact that students use netbooks to connect to social networks and video games. those in favour of “conectarigualdad” said that the program improves learning and that the school does not consider in the classrooms. also, it evaluates the quality of education from paradigms that do not contemplate the ways that new generations are learning. the emphasis of the criticism was on the school, however the main objective of the program was to promote the inclusion of those more vulnerable social sectors that otherwise would not have had access to a computer with all that what it socially means. the criticism, based on the helpless, argue that “the poor need to cover basic needs: food, medicine, a home, etc.”. now, it is precisely about the consumption of “superficial” goods where the processes of distinction and classism are established in stratified societies such as ours. perhaps what irritates the people about the “conectarigualdad” program is that they are granted free goods that are expensive and could be used as signs of distinction by the dominant classes (12). laaser w, exeni c. introduction of digital technologies in education concepts and experiences (review article). seejph 2019, posted: 06 june 2019. doi 10.4119/unibi/seejph-2019-220 page 7 of 10 figure 3. drone and robot model of the “aprender conectados” (learning connected) program (source: ministry of education, argentina) the “conectarigualdad” program was disabled and in its replacement, “aprender conectados” (learn connected) was created. this new program changes the target and puts focus on competitiveness, innovation and digital inclusion. for their implementation, they take the existing equipment in the schools (that “conectarigualdad” left) and distribute robots and drones with different degree of complexity to kids, aged eight years or more. for about 30 students five items are at their disposal. the delivery of these resources has not been well received by the teachers. they argue that they cannot do very much. once students learn to program robots and drones, which they do quickly, the resource loses its educational function, unlike computers that have a lot more possibilities. in this regard, da porta (13) says: “the bombastic release of ‘aprender conectados’ put the emphasis on the promises and illusions of technology, it makes evident the rejection of an equal social policy that even with its issues was able to articulate school and educational rights as a chance to jump the deep gap in inequality.” comparative evaluation of similar programs in mexico and uruguay the literature about the effectiveness of delivering free computers to schools is quite limited. one reason may have been that projects have been used to increase political prestige and were losing support from the next government. in latin america, uruguay was a forerunner with the plan ‘ceibal’ as a partner in negropontes “one laptop per child” campaign. mexico followed next with the “@aprende” project, which was set up to create an internet platform with support material for using technology at school or at the university, and the micompumxprogram for introducing computers to basic schools. the following tables show some facts about these programs. laaser w, exeni c. introduction of digital technologies in education concepts and experiences (review article). seejph 2019, posted: 06 june 2019. doi 10.4119/unibi/seejph-2019-220 page 8 of 10 table 1. comparison of national programs program number of computers delivered program coverage number of trained teachers evaluation plan ceibal (uruguay) 2003 1.000,000computers have been delivered 99% of students with laptops and 99% of schools with online access 4000 teachers trained under this program it has been possible to universalize access to computers for homes with school-age children. likewise, the public school has become the axis of digital experience. micompumx (mexico) 240.000 computers delivered the pilot program was implemented in three states: colima, sonora and tabasco from 2009 to 2012 a total of 11.060 teachers have been trained. currently, there are no data on the results of the project or associated initiatives. all these actions are in the process of development and implementation. conectarigualdad (argentina) in 2004 100 % of the students have a computer. it is a total of 4.979.682 99,5 % covered 600.000 teachers trained it is said that there were changes in the way of teaching and the program promotes horizontal communication to improve the teacher/student relationship and to make students more active. the acceptance of the programs will be increased if the characteristics of the target groups are analysed before the program starts. for example:  some of the students, who received a laptop had no or deficient internet connection;  down loading of files was too slow;  the technical support was not sufficiently qualified;  teachers were not willing to spend extra time;  the training sessions were too short;  the quality of the teaching content was not well integrated with the curriculum. an important factor for success is a highspeed network infrastructure and wellstructured web-portals that contain free downloadable content as well as uploading of user created content. however, perhaps most important is the motivation of teachers to make creative use of digital facilities. it is interesting to state that there are few research papers that are checking the efficiency and sustainability of the huge latin american national programs, which aim at reduced exclusion from educational options and to raise the level of computer literacy by introduction of teaching and learning with digital technologies. however, the programs have their own dynamics and are changing and adjusted continuously. the answers given today will be different tomorrow. conclusion finally, we can conclude that the delivery of netbooks to the students and, by extension to their families was the right decision to take to increase inclusion and to reduce the digital gap. while schools should not follow the logic of the consumer market, when it comes to thinking about the incorporation laaser w, exeni c. introduction of digital technologies in education concepts and experiences (review article). seejph 2019, posted: 06 june 2019. doi 10.4119/unibi/seejph-2019-220 page 9 of 10 of technologies in educational processes, an important point to consider is the updating of technologies and their consequences in the social dynamics. today, young people weigh and value mobile devices over other technological artefacts. with this tool they communicate, fall in love, and have fun, play, do banking, work, report and study. for both private and public uses they found only one technology. in perspective, questions remain, how will education with technologies be in a not too distant future? what new concepts will emerge? what new tools will determine the social inclusion of young generations? who will determine the educational paradigms: teachers or the consumer market of technologies? references 1. laaser w, tolozaea. the changing role of the educational video in higher distance education. irrodl 2017;18.available at: https://files.eric.ed.gov/fulltext/ej1138780 .pdf (accessed: may 20, 2019). 2. koehler mj, mishra p. what is technological pedagogical content knowledge? cite 2009;9:60-70. https://www.researchgate.net/publicatio n/241616400_what_is_technological_ pedagogical_content_knowledge (accessed: may 20, 2019). 3. bates aw. online learning and disruptive change at the uk open university 2018. may 2: 2018. https://www.tonybates.ca/2018/05/02/o nline-learning-and-disruptive-changeat-the-uk-open-university/ (accessed: may 22, 2019). 4. segura j, quinteros l, mon f. towards ubersity? conflicts and contradictions of the digital university. ried 2018;21:51-68. doi: http://dx.doi.org/10.5944/ried.21.2.2066 9 5. watters a. 2015 trends. retrieved from:http://hackeducation.com/2017/12/ 20/top-ed-tech-trends-robots-kids (accessed: may 20, 2019). 6. watters a. the tech sector does love stories – grand narratives and makebelieves and mythologies about revolution and disruption and innovation. http://hackeducation.com/2018/04/26/cu ny-gc (accessed: may 20, 2019). 7. prensky m. digital natives, digital immigrants. by marc prensky. on the horizon. mcb university press 2001; 9, 5 (accessed may 20, 2019). 8. ferreiro e. presentación de cátedra emilia ferreiro. universidad nacional de rosario. https://www.youtube.com/watch?v=q8 c-v8owork (accessed: may 20, 2019). 9. bacher s. la infancia, ¿conectada? la nación, revista. http://silviabacher.com.ar/articulo3/ (accessed: may 20, 2019). 10. inter-american children’s institute and organization of ibero-american states. agreement of cooperation (2019). http://iin.oea.org/pdf-iin/informe90/en/agreement_cooperation_iin_o ei.pdf (accessed: may 20, 2019). 11. library of congress argentina: constitutional right to an education law 26,206 on national education, adopted on dec. 14, 2006. https://www.loc.gov/law/help/constitut ional-right-to-aneducation/argentina.php (accessed: may 20, 2019). 12. larghi b. selogio de unfracaso. la dimension simbólicadel programa conectarigualdad. (praise of a “failure”: the symbolic dimension of laaser w, exeni c. introduction of digital technologies in education concepts and experiences (review article). seejph 2019, posted: 06 june 2019. doi 10.4119/unibi/seejph-2019-220 page 10 of 10 the conectarigualdad program). juv;2016:10. 13. da porta e. aprender conectados o cómoborrar la igualdad pordecreto. conversaciones necesarias entre educación, cultura y política. https://conversacionesnecesarias.org/2 018/05/11/aprender-conectados-ocomo-borrar-la-igualdad-pordecreto/ (accessed: may 20, 2019). ______________________________________________________________________________________ © 2019 laaser et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 1 of 16 original research digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health coverage jameel ismail ahmad1, murtala jibril2, barroon isma’eel ahmad3, abdurrahman suleiman4, nasir sani inuwa5, abdullahi garba ali6, salihu ibrahim ismail7 1. department of surgery, faculty of clinical sciences, bayero university kano/ aminu kano teaching hospital, kano, nigeria. 2. department of pharmacology and therapeutics, faculty of pharmaceutical sciences, bayero university, kano, nigeria 3. department of computer science, ahmadu bello university, zaria, nigeria 4. hubuk technology, zoo road, kano, nigeria 5. first monument city bank (fcmb), nigeria. 6. faculty of computer science and information technology, bayero university, kano, nigeria. 7. department of biochemistry, federal university dutse, jigawa state, nigeria corresponding author: jameel ismail ahmad mbbs, fwacs, mba; address: department of surgery, faculty of clinical sciences, bayero university kano, aminu kano teaching hospital, kano, nigeria; email: iajameel@yahoo.com ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 2 of 16 abstract introduction: the covid-19 pandemic highlighted the need for evolving an integrated healthcare ecosystem that will connect patients to digital and home healthcare to achieve universal health coverage. the survey aims to assess perceptions and preferences about digital and home healthcare services and develop an integrated healthcare ecosystem. methods: a survey of 254 nigerians was conducted to assess their awareness, preferences, and willingness to pay for digital and home healthcare services using electronic questionnaires, and the data were analysed using spss 16.0. results: males constituted 70.9%, and 61.4% were aged ≤35 years. two-third were clients, and a third were healthcare providers. although about 71% patronized public hospitals, there was poor satisfaction (31.7%) than those attending private hospitals that were more satisfied. the male gender, private hospital utilization, and age of ≤35 years were associated with the satisfaction with or 1.19 (95% ci 0.69-2.05), or 1.22 (95% ci 0.73-2.04), and or 2.41 (95% ci 1.384.20) respectively. thirty minutes was the acceptable delay in receiving care by most respondents. only 39.4% were aware of digital health, and 52.8% were aware of home healthcare. male gender was associated with dh awareness, while being a healthcare provider was associated with both dh and home healthcare awareness. the respondents' median amount was willing to pay for dh and hh respondents is $1.64 $6.56 and $3.28 – $6.56, respectively. conclusion: in response to the survey result, we designed an integrated hospital, digital, and home healthcare project named edokta, to leapfrog the attainment of universal health coverage in nigeria. keywords: digital health, home healthcare, universal health coverage, healthcare ecosystem ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 3 of 16 introduction nigeria is the most populous country in africa and is poised to become the third most populous in the world by 2050 (1). poverty, inequality, and poor access to health have kept the citizens' life expectancy low. the nigerian healthcare system is bedeviled with a lack of human resources, infrastructural and system challenges, which threaten the attainment of universal health coverage (uhc). to ameliorate that, nigeria developed a national health information communication technology (ict) strategic framework 2015-2020 with the vision: "by 2020 health ict will help enable and deliver universal health coverage in nigeria" (2). this strategic framework provides for the identification, prioritization, and application of appropriate icts that can strengthen the national health system. poor implementation of the framework led to poor results by 2020. one of the most essential strategies for improving the provision of quality health care to attain uhc in resource-constrained settings is the effective utilization of digital health (dh). digital health is defined as a system that connects and empowers people and populations to manage health and wellness, augmented by accessible and supportive provider teams working within flexible, integrated and interoperable, and digitally-enabled care environments that strategically leverage digital tools, technologies, and services to transform care delivery (3). it is also defined as the application of ict to advance health services delivery." the term dh is also used interchangeably with ehealth. the world health assembly (wha) recognized the role of dh in healthcare delivery in resolution wha 58.28 (2005): "ehealth is the cost-effective and secure use of ict in support of health and health-related fields including healthcare services, health surveillance, health literature, and health education, knowledge and research. mhealth is a subset of ehealth and involves providing health services and information via mobile technologies such as mobile phones, tablet computers, and personal digital assistants. dh is a tool for the achievement of goal 3 of the sustainable development goals by 2030, which is to "ensure healthy lives and promote well-being for all at all ages," particularly its article 8 to "achieve universal health coverage (uhc)" in ensuring people access quality healthcare without falling into financial catastrophes (4,5). the role of dh cut across healthcare financing, health service delivery, human resources training, health system support, and health information system. despite these potentials, dh implementation has taken a slow course, especially in many african countries. some of the challenges hampering its scaleup in many developing countries are issues bordering on usability, technology integration and interoperability, data security, and privacy, reliability, network access, affordability, acceptability, illiteracy, funding, trained human capacity, policy, and regulation (6,7). the application of dh in africa has gained momentum over the past decade, essentially due to the digital revolution brought about by the increasing penetration of mobile technology and internet use, which stood at 80.8% and 25.1% as of 2018. this is further enhanced by the proliferation of affordable smartphones, particularly from china (5). these factors have afforded a great opportunity, which could improve the ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 4 of 16 smooth launching of various dh platforms, but there is a need to understand enablers for their effective utilization. a feasibility survey was conducted to develop a sustainable dh platform that will facilitate the attainment of sdgs. the objectives of the study are to assess the respondents' perceptions about conventional hospital-based care; set awareness and preferences of dh and home healthcare; determine the willingness to pay for dh and hh services; and then develop an integrated healthcare ecosystem that will incorporate hospital-based, digital and home healthcare services to achieve uhc. methods an online survey to assess the awareness, preferences, and willingness to pay for nigerians' dh and home healthcare services was conducted in december 2019 electronically using google forms. (8) the data was automatically received, and a microsoft excel spreadsheet version of the data was generated. the data was then transferred and analysed using statistical product and service solutions (spss) 16.0. basic information, perceptions, and awareness of hospital based, digital, and home healthcare and their association to age, sex, status, and hospital being utilized was analyzed. results two hundred and fifty-four (254) respondents electronically filled the online questionnaire representing a response rate of 84.7%. the respondents include those living in all 36 states and the capital of nigeria. however, 69.7% were living in kano state. males constituted 70.9%, while 61.4% and 38.6% were aged ≤35 years and >35 years, respectively. the respondents include civil servants (40.2%), medical doctors (31.5%), traders/businesspersons (8.3%) and 11.4% were unemployed. others include other health workers, bankers, engineers, and software developers. healthcare providers constituted 36.2%, while clients were 63.8%. (table 1) table 1: respondents’ baseline characteristics over-all percentage % (n=254) age (years) ≤35 61.4(156) >35 38.6(98) sex female 29.1(74) male 70.9(180) status clients 63.8(162) providers 36.2(92) hospital being utilised private 28.7(73) ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 5 of 16 public hospitals were the most utilized by 71.3% of the respondents. the level of satisfaction is better with the private hospitals as 60.3% of the respondents were satisfied in contrast to only 31.7% who were satisfied with the public hospitals. younger age ≤35 years, male gender, and private hospital patronage were associated with reasonable satisfaction with or 1.22 (95% ci 0.73-2.04), or 1.19 (95% ci 0.69-2.05), and or 2.41 (95% ci 1.38-4.20) respectively. only a quarter of the respondents considered lack of trained staff, while delay in receiving care and poor staff attitude featured prominently by 74% and 63% of the respondents. lack of feedback from hospitals and health workers and lack of quality branded drugs are reasons for dissatisfaction by nearly a third of the respondents. thirty minutes was the acceptable delay in receiving care when sought for by 80% of the respondents. the dh awareness of the respondents was relatively low (39.4%) and male gender and being a healthcare provider associated with the awareness or 1.40 (95% ci 0.80-2.47) and or 1.40 (95% ci 0.83-2.36) (table 2). virtual booking for medical consultation, health education, and remote patient monitoring was the commonest dh services needed (figure 1). nearly two-thirds of the respondents preferred online dh services over mobile dh services, and 90.9% use android phones, while 8.3% use ios phones. more than half (52.8%) of the respondents were aware of home healthcare services which were significantly associated with respondents' status as healthcare providers, or 3.25 (95% ci 1.90-5.60) (table 3). approximately three-quarters (74.8%) of respondents believe it was operational, and 93.3% were willing to utilize the services. the home healthcare (hh) services needed include home consultation (81.3%), home delivery of purchased drugs (66.3%), and simple investigations (64.7%). other services include sample collection and delivery of results and nursing care. public 71.3(181) type of phone used ios 8.3(21) others 0.8(2) ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 6 of 16 figure 1: preferred digital health services by the respondents table 2: awareness of digital health and home healthcare digital health home healthcare awar e n=10 0 unaware n=154 or (95% ci) p-value awar e n=13 4 unaware n=120 or (95% ci) pval ue age (years) ≤35 57 99 0.74 (0.44-1.23) 0.291 78 78 0.75 (0.45-1.25) 0.3 02 >35 43 55 56 42 sex male 75 105 1.40 (0.80-2.47) 0.261 94 86 0.93 (0.54-1.60) 0.8 90 female 25 49 40 34 status provider 41 51 1.40 (0.80-2.47) 0.230 65 27 3.25 (1.90-5.60) 0.0 00 client 59 103 69 93 hospital patronized private 25 48 0.74 (0.42-1.30) 0.322 26 47 0.37 (0.21-0.66) 0.0 01 public 75 106 108 73 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% booking for medical consultation digital medical consultation digital health education remote patients monitoring ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 7 of 16 there is a remarkable willingness to pay for the dh and hh services. the median amounts the respondents were willing to pay for the digital booking for consultation, digital booking and physical consultation, digital booking and virtual consultation, and digital health education were $3.28 ($4.92), $6.56 ($6.56), $6.56 ($13.12) and $1.64 ($5.90) respectively. the median amounts (and interquartile range) the respondents were willing to pay for a home consultation, simple investigations, sample collection/results delivery, nursing care, and pharmaceuticals delivery were $6.56 ($13.12), $3.28 ($4.92), $3.28 ($4.92), $6.56 ($6.56) and $4.92 ($6.56) respectively. (table 3). table 3: willingness to pay for digital and home healthcare services in usd digital health services booking booking and physical consultation booking and remote consultation health education median (interquartile range) $ 3.28 (4.92) 6.56 (6.56) 6.56 (13.12) 1.64 (5.90) mean (sd)/$ 5.75 (±7.12) 8.98 (±9.06) 8.62 (±8.82) 5.60 (±21.90) home health services consultation basic investigations sample taking and results delivery nursing care pharmaceuticals delivery median (interquartile range) $ 6.56 (13.12) 3.28 (4.92) 3.28 (4.92) 6.56 (6.56) 4.92 (6.56) mean (sd)/$ 9.58 (±9.83) 6.76 (±32.05) 5.61 (±5.14) 8.64 (±12.03) 7.58 (±10.60) those younger than ≤35 years were more to pay a higher amount for digital booking, digital booking and physical consultation and health education with or:1.39, or:1.05, and or:1.38, respectively. at the same time, those patronizing private hospitals were more willing to pay for the digital booking and health education. females and those patronizing private hospitals were more willing to pay higher for all types of home healthcare services. at the same time, those older than 35 years were more willing to pay higher amounts for a home consultation, sample collection and results of delivery, nursing care, and pharmaceutical products. compared with the clients' willingness to pay for the services, healthcare providers were more willing to pay higher for all digital and home healthcare ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 8 of 16 services. (table 4). the healthcare providers' willingness to pay higher was more when the services involve consultation such as digital booking and physical consultation, digital booking and remote consultation and home consultation with or 2.31 (95% ci 1.363.91), or 2.21 (95% ci 1.30-3.78 ) and or 2.29 (95% ci 1.36-3.89) respectively. table 4: respondents willingness to pay higher than medium (wtph) and willingness to pay the medium and lower (wtpl) between healthcare providers and clients digital health services booking booking and physical consultation booking and remote consultation health education wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) providers 39(53) 1.51 (0.892.57) 46(46) 2.31 (1.36-3.91) 43(49) 2.21 (1.30-3.78) 43(49) 1.07 (0.641.79) clients 53(109) 1.00 49(113) 1.00 46(116) 1.00 73(89) 1.00 home healthcare services consultation basic investigations sample taking and results delivery nursing care pharmaceuticals delivery wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) providers 54(38) 2.29 (1.363.89) 46(46) 1.95 (1.153.28) 54(38) 1.49 (0.892.50) 41(51) 1.44 (0.862.43) 52(40) 1.12 (0.671.88) clients 62(100) 1.00 55(107) 1.00 79(83) 1.00 58(104) 1.00 87(75) 1.00 discussion the nigerian healthcare industry is pluralistically shared by the public and private sectors. although the public sector owns about 66% of the health facilities in nigeria, the private sector accounts for 70-75% of the total health expenditure (9). the public healthcare system is organized into primary comprising of primary healthcare services at the rural and community level, secondary consisting of general and specialist hospitals, and tertiary healthcare having the teaching hospitals and specialized medical centers. the private hospitals and clinics contribute significantly to nigeria's healthcare delivery all over the country (10). the healthcare budget is abysmally low as only 3.6% of nigeria's gdp was ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 9 of 16 spent on health, which translates to $14.6 billion in 2016. there is a considerable healthcare infrastructural gap and a massive brain drain of healthcare workers (11). it is estimated that about 3,000 new medical doctors are registered in nigeria annually. currently, nearly 2,000 doctors migrate from nigeria to other countries yearly, leaving a net of 1000 doctors and further widening doctors' deficit to about 260,000. nigerians spend an average of $1 billion on medical tourism annually abroad. nigeria has five hospital beds per 10,000 population (9,12). public hospitals' patronage remains high, with 71% of the respondents despite its poor satisfaction level (32%) when compared to private hospitals likely due to affordability factors. there is a higher satisfaction level (60%) among those who patronize private hospitals. there is evident worsening satisfaction of hospital services over the years compared to kano reports a decade ago by iliyasu et al. when the satisfaction level was 83% (13). the satisfaction level is lower than reports from different parts of nigeria and ethiopia (14–19). this could be attributable to infrastructural and personnel deficits despite an increasing population, bureaucracy, and ongoing disruption of healthcare services due to industrial actions by health workers. based on the perceived reasons for dissatisfaction, any intervention that will shorten the duration to receiving care within the first 30 minutes, teach an empathic and memorable staff attitude, provide access to quality drugs and ensure appropriate feedback will significantly improve clients' satisfaction. there is a need to enhance the satisfaction level, especially to the older respondents and females. the differential satisfaction between the public and private hospitals calls for studying and emulating the delivery of services in private hospitals so that the public hospitals could equally improve the satisfaction. digital health and home healthcare have the potential of filling these gaps. digital technology can facilitate healthcare delivery at different levels (system, center, professional and patient levels). supply chain management and an integrated platform for booking and payment can be facilitated at the system level. at the same time, the availability of remote patient monitoring and remote diagnostics can be improved at the center level. similarly, education/training and data collection and reporting will be relevant at an individual professional level. at the same time, health and wellness information and medical advice will affect patients' levels (20). the world health organization (who) classified dh interventions into interventions for clients, interventions for healthcare providers, interventions for a health system or resources management, and interventions for data services (21). dh improves access to health, quality of care and reduces healthcare costs through many applications that can contribute to sustainable development goals. these applications include electronic health records (ehr), telemedicine/telehealth, mhealth, elearning, the connection of medical devices via the internet of things (iot), and personal health using wearable devices (20,22,23). there is an unprecedented rise in teledensity, internet penetration, and social media usage globally, but more phenomenal in africa. there are 1.049 billion mobile users, 473 million internet users, and 216 million active social media users, representing 80%, 36%, and 17% pene ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 10 of 16 tration in africa (24). the available dh services in africa include mhealth, social media, telemedicine/telehealth, elearning, ehr, and big data analytics in order of preference (4,5). nigeria is strategically located to benefit from the digital economy. it accounts for about 47% of the west african population, and a half (about 100 million) of its population is under 30 years and is leading the continent in the economy (25). the country is also experiencing this trend of increasing mobile, internet, and social media penetration. according to the nigerian communications commission (ncc), the number of mobile phone subscriptions in nigeria was 176, 897, 879 (92.7% teledensity), while internet subscriptions were 122, 975, 740 (56% penetration) as of august 2019 (26). the number of smartphone users in nigeria is estimated to be 36 million (18.37% penetration). this could be attributed to an influx of low-priced smartphones (the average cost of smartphones decreased from $216 in 2014 to $95 in 2018). there are 24 million (12% penetration) social media users, and in 2018, 44% and 4% of mobile users use 3g and 4g technology, respectively, and the number keeps increasing (26,27). despite these potentials, nigeria was ranked 143rd among 176 countries on the ict development index (idd) in 2017. it did not feature among the top 16 countries on the ehealth priority ranking of sub-saharan african countries and is ranked 15th among the top 17 countries on the ehealth regulating readiness index. this is due to barriers such as infrastructure and device access challenges, funding, human resources capacity, and policies and government leadership (28,29). to establish sustainable digital health and other digital services, there is a need to build critical digital pillars such as digital infrastructure, digital platforms, digital financial services, digital entrepreneurship, and digital skills and literacy (25). covid-19 has brought the role of telehealth during the pandemic and beyond all over the world to the fore. mckinsey conducted covid-19 consumer surveys in april and may 2020, which showed an apparent increase in the adoption of telehealth services in the usa. telehealth usage was 11% in 2019, which increased, and 76% were interested in using telehealth with a 50-175 times increase in the number of telehealth visits and 80 new telehealth services approved by the centers of medicare and medicaid. precovid-19, the total annual revenue of telehealth players was estimated at $3 billion and postulated that up to $250 billion of current us healthcare spending could be virtualized (30,31). the dh awareness of the respondents was low (39.4%), even though this level of awareness could have improved after the covid-19 pandemic when some dh services were used to provide virtual medical care. the result calls for creating more awareness amongst females and clients. access to booking for consultation is a challenge, especially for rural dwellers. a window for remote booking for a medical consultation is needed, as indicated by the respondents, in addition to virtual medical consultation, health education, and remote patient monitoring. the preference for online over mobile dh services point to an interesting scenario despite mobile technology penetration being better than internet penetration. this and the preponderance of android phones should guide any dh platforms in software development and technology deployment. currently, most ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 11 of 16 home healthcare services are offered at the individual and informal level, and there is a need to coordinate the services to ensure quality, reliability, and interoperability with other dh services. home antenatal care, immunizations, management of chronic diseases including hiv-aids are low-hanging fruits to consider for hhs. there is a need for a massive hhs awareness campaign targeted at clients and those patronizing private hospitals. our findings show that there is a notable willingness to pay for the dh and hhs. although the amount the respondents were willing to pay for both services in this study seems low, it is significant when related to the prevailing minimum wage of $50 per month. it might increase after experiencing their value and advantages. the potential early adopters of dh with the willingness to pay higher will be the healthcare providers, younger clients, and those patronizing private hospitals and should be the first marketing targets. gradual engagement of older respondents and public health users will expand the dh market base. females will likely adopt hhs early, especially since they attend hospitals more frequently to seek care for themselves or their children and hence face the challenges more. healthcare providers' willingness to pay higher for the digital and healthcare services could likely be due to their exposure to healthcare delivery and challenges, bias because they were potential beneficiaries for the payment, and possible higher disposable income than the clients. in response to the above data, a team (comprising two medical specialists, a biochemist, three it experts, and a financial expert) developed an integrated (hospital-based, digital, and home healthcare) healthcare ecosystem and named it edokta. it was designed to provide hospital-based care, telemedical care, home healthcare, diagnostic and pharmaceutical services, remote patient monitoring, health education, medical education, and universal medical identity services. it is aimed at removing barriers to accessing healthcare by providing virtual access to healthcare providers using mobile and internet technology for personalized, seamless, and quality care by patients and expand the providers' customer base and returns. the critical disruptions are the local content via the inclusion of local languages and the onestop health solution nature of our services. it has a potential for facilitating dh innovations such as drones (for delivery of medical supplies to difficult terrains), big data (for managed care, disease prediction, and more accurate treatment), artificial intelligence-ai (for workflow management, precision in diagnosis and treatment aid) and iot (for remote patients monitoring). some of our key partners include specialists, hospitals, diagnostic centers, pharmaceutical shops, mobile telecommunication companies, governments, and non-governmental agencies. the telemedicine software is developed, and more than 1,000 patients benefit from free consultation during the covid-19 lockdown. the entire edokta project will be launched in may 2021. conslusion the digital and home healthcare ecosystem is a new frontier for healthcare globally and is gradually being applied in africa especially following the covid-19 pandemic. ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 12 of 16 the growing dissatisfaction with the current hospital-based healthcare system, the massive health workers' brain drain, and the unequal distribution of health personnel and infrastructure threaten the attainment of universal health coverage in nigeria and thus pave the way for introducing dh and home healthcare services. our attempt at translating dh and home healthcare survey to real life (edokta) is on the verge of debuting, gal vanizing the triple helix collaboration between government, research institutes, and industry to develop a sustainable healthcare ecosystem by utilizing digital technology to leapfrog the attainment of uhc in africa. acknowledgement i, jameel ismail ahmad, acknowledge the mentorship offered to me by professor modest mulenga, chair of the tdr joint coordinating board. references 1. united nations. world population prospects 2019 highlights [internet]. newyork; 2019. available from: https:/population.un.org/wup/publications/files/wup 2018-key facts.pdf 2. federal ministry of health. national health ict strategic framework: 2015-2020 [internet]. 2016. available from: https://www.who.int/goe/policies/nigeria_health.pdf?ua=1 3. himss unveils the digital health indicator to measure health system progress toward a digital health 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[cited 2020 nov 21]. available from: https://www.himss.org/news/himssunveils-digital-health-indicatormeasure-health-system-progress-toward-digitalhealth?_ga=2.187911660.512109590 .16059468541216353937.1605946854 4. tran ngoc c, bigirimana n, muneene d, bataringaya je, barango p, eskandar h, et al. conclusions of the digital health hub of the transform africa summit (2018): strong government leadership and public-private-partnerships are key prerequisites for sustainable scale up of digital health in africa. bmc proc [internet]. 2018 aug 15;12(s11):17. available from: https://bmcproc.biomedcentral.com/articles/10.1186/s12919-018-0156-3 5. w h o global observatory for ehealth. global diffusion of ehealth: making universal health coverage achievable: report of the third global survey on ehealth [internet]. world health organization; 2016. available from: https://www.who.int/goe/publications/global_diffusion/en/ 6. sam ajadi. digital health a health system strengthening tool for developing countries [internet]. 2020. available from: www.gsma.com/mobilefordevelopment 7. nsor-anabiah s, udunwa u ms. review of the prospects and challenges ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 13 of 16 of mhealth implementation in developing countries. int j appl eng res. 2019;14(12):2897–903. 8. googleform questionnaire. available from: https://docs.google.com/forms/d/e/1f aipqlsflnezi0yt_v_87zftbmmz7mvkr2zftwfvrlxm94yalpdoba/viewform?usp=sf_link 9. corporation if. the role of the private sector in expanding health access to the base of the pyramid. 2010; 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available from: https://healthmarketinnovations.org/sites/default/files/chmi 21. world health organization. classification of digital health interventions [internet]. 2018. available from: https://www.who.int/reproductivehealth/publications/mhealth/classification-digital-health-interventions/en/ 22. olu oo, muneene d, bataringaya je, nahimana m-r, ba h, turgeon y, et al. how can digital health contribute to sustainable attainment of universal health coverage in africa? a perspective. front public heal. 2019;7:341. 23. fowkes j, fross c, gilbert g, harris a. virtual health : a look at the next frontier of care delivery. mckinsey insights [internet]. 2020;(exhibit 1):1–11. available from: https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/virtual-health-alook-at-the-next-frontier-of-care-delivery#%0ahttps://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/virtual-health-a-look-at-the-n 24. kemp s. digital 2019: global internet use accelerates [internet]. 2019 [cited 2020 nov 17]. available from: https://wearesocial.com/blog/2019/01/digital-2019global-internet-use-accelerates 25. nigeria digital economy diagnostic report [internet]. washington, dc; 2019. available from: https://www.google.com/search?q=n igerian+digital+economy+diagnostic+report+2019+world+bank&rlz =1c1okwm_enng893ng893&oq =nigerian+digital+economy+diagnostic+report+2019+world+bank&aqs =chrome..69i57.23968j0j7&sourceid =chrome&ie=utf-8# 26. nigerian communications commission. industry statistics [internet]. [cited 2019 jul 19]. available from: https://www.ncc.gov.ng/statistics-reports/industry-overview 27. kolawole o. nigeria mobile report 2019 [internet]. 2019 [cited 2020 nov 17]. available from: https://www.jumia.com.ng/sp-mobile-report/ 28. ict development index 2017 [internet]. 2018. available from: https://www.itu.int/net4/itud/idi/2017/index.html 29. strategic partnership digital africa. digital health ecosystem for african countries: a guide for public and private actors for establishing holistic digital health ecosystems in africa [internet]. 2018. available from: https://www.bmz.de/en/publications/topics/health/materilie345_digital_health_africa.pdf 30. united states agency for international development. trends in digital health in africa : 2016;(september):1–7. available from: http://www.africanstrategies4health.org/uploads/1/3/5/3/13538666/trends_in_di gital_health_in_africa_brief_final.pdf ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 15 of 16 © 2021 ahmad; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 31. bestsennyy o, gilbert g, harris a, rost j. telehealth: a quarter-trillion-dollar post-covid-19 reality? mckinsey company publ may [internet]. 2020;29. available from: https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality __________________________________________________________________________ ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 16 of 16 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 1 original research evaluation of an implementation strategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania per m. von groote1-3, dimitrios skempes1,2, jerome e. bickenbach1,2 1department of health sciences and health policy, university of lucerne, lucerne, switzerland; 2swiss paraplegic research, nottwil, switzerland; 3institute of social and preventive medicine (ispm), university of bern, bern, switzerland corresponding author: per m. von groote, institute of social and preventive medicine (ispm), university of bern; address: finkenhubelweg 11, ch-3012, bern, switzerland; e-mail: per.vongroote@gmail.com von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 2 abstract aim: this paper aims to evaluate a strategy for the implementation of public health policy recommendations from the world health organization’s (who) report “international perspectives on spinal cord injury” in romania. more specifically, it seeks to: a) evaluate implementation actions with a focus on a number of people reached and status of completion at 12 months follow-up; b) describe implementation activities undertaken in the course of one year, and; c) evaluate perceived barriers and facilitators of implementation at 12 months follow-up. methods: a cross-sectional design was adopted with two surveys administered in 2014/15 among key implementers in romania. the questionnaires contained open-ended, multiple choice and 5-point likert scale questions. results on the implementation status, implementation activities performed and self-reported barriers and facilitators were analysed and reported using descriptive statistics. results: implementation completion rate was 75%, with 4390 persons directly or indirectly benefiting from the implementation-related activities listed in the final implementation plan reporting. a broad range of implementation experiences was reported. most common activity types were delivery of services, technical trainings, implementation coordination and development meetings. most useful tools and processes were the romanian language version summary of the report, educational meetings, and local consensuses processes. reported outcomes included the direct output produced, evidence of services provided, and individual or organizational level impact. most barriers were named for the policymakers and academia as stakeholder groups and most facilitating influences for the private sector, with dependence of policymakers on constituency interest scoring highest barrier and the general availability of european commission and european structural funds highest facilitator. conclusion: the surveys proved to be both feasible and useful tools to expand our understanding of implementation and to supplement the more standard used implementation strategies at country level. keywords: implementation, implementation strategy, public health report, spinal cord injury, world health organization. conflicts of interest: none. funding statement: the project received funds from the swiss-romanian cooperation programme as part of swiss contribution to the enlarged eu. acknowledgments: the authors would specifically like to thank dr. cristina ehrmannbostan for her continuous support in analysing the data and preparing display items, and dr. jan d. reinhardt for his conceptual feedback in drafting the manuscript. von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 3 introduction although spinal cord injury (sci) is a low-incident condition, it can be devastating and costly in both human and social terms (1). sci can occur as a consequence of trauma, infection, inflammation, degeneration, tumour, or another disease and often results in a significant decline of physical capacity (2). sci a principal cause of permanent disability has become a significant concern for public health mainly because it places substantial socioeconomic burden on affected individuals and their families, communities and the healthcare system (3). it is considered a particularly pervasive stressor as people who sustain these injuries experience profound alterations in almost all aspects of their life (4). however, many of the difficulties experienced by people with sci do not result from the condition itself, but from inadequate medical care and rehabilitation services, and from barriers in the physical, social and policy environments (5). implementation of measures aiming at removing barriers to access to healthcare and enhancing the effectiveness of rehabilitation and community reintegration is therefore imperative (1). to help propel the implementation of evidence-informed health care and policy for people with sci forward, the world health organization (who) in collaboration with the international spinal cord society in 2013 published a global report titled “international perspectives on spinal cord injury” (ipsci) (6). the report assembles and summarizes the best available scientific evidence and information on spinal cord injury together with the lived experience of people with spinal cord injury and makes recommendations for actions that are consistent with the aspirations for inclusion and participation as expressed in the united nations convention on the rights of persons with disabilities (crpd) (1). the crpd (7) reaffirms the universal human rights and fundamental freedoms of all people with disabilities and calls upon states to secure and promote their inclusion and participation in all aspects of civil, social, economic and community life. notably, the treaty marks a paradigm shift in understanding disability as the result of physical and social barriers interacting with impairments and health states in a way that deprives people of equal opportunities for societal participation. this view implies that multiple systems and stakeholders from health to social and employment sectors must undertake coordinated actions to translate the normative recommendations of international law into concrete benefits for those living with disability (8). for this reason, the who has recognized the necessity to strengthen governments’ capacities in implementing their legal obligations through evidence based programmatic guidance, including guidance on policy implementation. indeed, while the convention is among the “most significant policy catalysts” for disability policy at the global level, nonetheless, “the most significant implementation constraints are at the national level” (7,9). to investigate all aspects of implementation, including activities used to put interventions or innovations into practice and contextual factors that influence these activities, one can look toward implementation research (10). this discipline offers insights for selecting evidenceinformed policies and interventions, identifying how to implement these in the disability context across populations and resources, and evaluating outcomes. in implementation research, widespread development of programmatic instruments and innovative tools promises to expedite policy implementation in various contexts. these tools are to a large extent tailored to specific purposes and contexts and have limited prospects for large-scale or long-term prospective testing (11). it is now well-established, however, that the transfer of knowledge to support implementation is more complex than it usually appears and is more difficult in the trans-disciplinary domain of public health policy (12,13). pragmatically, there is no “one-size-fits all” health policy and it would be naive to expect von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 4 implementation tools to work across different domains of public health policy, from clinical care guidelines to policy recommendations of international public health organizations. generally, the who’s effort to strengthen health policy implementation research and practice has been led by the alliance for health policy and systems research with its international academic and civil society partners network (14).the alliance highlights the value in documenting and analysing implementation experiences and sharing lessons for unravelling the otherwise invisible facets of the complex process of policy implementation and allowing implementing agents, facilitators and ‘champions’ to better understand their practice and realize their roles by reframing their perspective and refocusing their expectations. this will lead to better judgments about whether a particular strategy works or is relevant to other circumstances and situations, leading to measurable improvements in efficient health systems (15). in light of this, the objective of this paper is to evaluate an implementation strategy for the who ipsci report in romania. the context the research project was led by a partnership between a romanian non-governmental organization dedicated to delivering health and social services to people with disabilities and a swiss health research institute specialized in sci. the partnership organized the development of a strategy to implement the ipsci report in romania in august 2012. the strategy consisted of a set of implementation actions or interventions described in a central implementation plan, to work in combination, and administered by a coordinated group of implementers. the resulting implementation activities that are evaluated in the present paper started in march 2014 and lasted for 12 months. implementation research is by definition a participatory, stakeholder-driven and evidenceinformed process (10). adopting this approach is particularly important in disability research as persons with disabilities have long been denied equal voice in research and policy processes due to power asymmetries and misallocation of technical and financial resources. in this project, the participatory process of developing the implementation strategy and its evaluation involved three main phases: the preparatory phase, the implementation strategy development phase, and the monitoring and evaluation phase. the preparatory phase consisted of a group discussion by the research project team to identify and select mechanisms to develop the strategy. the implementation strategy development phase encompassed focus group interviews (fg) of people with sci, policy makers, system and service developers and managers, and representatives of ngos to elicit insights into key implementation considerations, a stakeholder dialogue (sd) with participants from the same pool of fg participants from romania and international experts to develop an implementation strategy, including the use of tools and processes. the development process was informed by a conceptual framework and guiding principles which have been previously developed by the authors (16). the monitoring and evaluation phase included surveys administered over the course of one year to monitor implementation activities by a core implementation group and evaluate the strategy. the question was now, what actually happened on the ground during 12 months of implementation and in how far the development process infused implementation activities that were successful. more specifically, this paper seeks to: a) evaluate implementation actions with a focus on the number of people reached and the status of completion at 12 months follow-up; b) describe implementation activities undertaken in the course of one year; and c) evaluate perceived barriers and facilitators of implementation at 12 months follow-up. von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 5 methods due to the lack of validated instruments to measure activities using the conceptual implementation framework, and given the research aim of focusing on the tools developed during the sd and documenting their use in implementation activities undertaken, new and fit-for-purpose survey questions were developed by the research project team. as a result, two surveys were developed in the preparatory phase and finalized after the implementation strategy development phase: first, the online report card survey to document implementation activities throughout the course of one year, and second a one year sd follow-up survey to capture implementation experiences such as perceived barriers and facilitators, among others. in addition, the implementation plan was used as a basis for the summative evaluation of activities at 12 months after the start of implementation. surveys development: the online report card survey questions were first developed by the lead author along the central elements of the comprehensive implementation framework and based on insights from the fgs and sd (16). the survey was independently reviewed by an implementation science expert and an expert on rehabilitation systems and services from the research project team. the survey was tested by a third health scientist who was not involved in the project. the questions were revised based on feedback. the one year sd follow-up survey questions were developed based on the online survey and on first screening of response data to its questions. this survey was reviewed by two team members and reviewer comments were incorporated in the revision. setup and design: the surveys were self-administered, with both quantitative and qualitative data elements. they contained both open-ended questions and questions with predefined response options ranging from yes/no (‘did the activity take place in relation to another event or initiative?’) to five-level psychometric scales (‘what tools were used during the implementation activity and how useful where they?’ – ‘very useful’ to ‘not at all useful’). both surveys were administered in english. the online survey was administered beginning after the sd in four waves from march 2014 until february 2015 capturing implementation activities during 3-month reporting periods each. it took approximately 20 minutes to complete each time. the sd followup survey was a one time, one year follow up survey to the sd. components: the online survey was composed of nine personal and demographic questions followed by 26 questions categorized by the essential implementation components asking, among others, about the kind of implementation activity, relation to the three central themes identified during the sd (medical rehabilitation and follow up in the community, independent living, employment and inclusive education), tools used including those introduced during the sd, processes followed, relation of activity to ipsci recommendation, and perceived receptiveness of audience. in the one year sd follow-up survey participants were asked to judge the extent (0 -5 likert scale) of hindering and facilitating influence attributes or factors of stakeholder groups had on implementation. these attributes had been jointly identified during the sd and were now being evaluated based on 12 months of implementation experience. participant recruitment: participants included a convenience sample of ten residents of romania, seven who had participated in the sd and three from the focus groups. as described elsewhere, participants of the sd and focus groups had been recruited on a participant roster developed by the researchers to maximize heterogeneity and representativeness. all participants were given an information sheet about the survey and asked to sign a consent form. von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 6 data analysis: qualitative survey data from open-ended questions were content-analysed by two researchers. the specificity and intensity of responses were determined by means of a thematic, open and selective description of meaningful concepts and themes using sentences as units of analysis (17,18). categories were then produced using inductive reasoning. conversely, descriptive statistics of quantitative data, such as frequency distributions, were carried out. implementation plan during the sd, five documents were developed that separately described problems related to the three central themes identified during the sd (i.e., sci medical rehabilitation and follow up in the community, independent living, employment and inclusive education), options to target these problems, facilitators and barriers by stakeholder groups, and next steps. these documents then served as a baseline analysis for the development of the implementation plan. the final evaluation of the plan was based on the categories ‘number of people reached’ and ‘status’ defined as either ‘completed’ or ‘incomplete’ at 12 months implementation by the core implementation group. results implementation plan the implementation plan listed 40potential actions in the categories presentations, publications, report development activities, trainings, services, consultations, conferences, and social events. actions planned included, among others: the development of a group statement based on ipsci recommendations, which was disseminated among key stakeholders; a 2-day scientific conference held in bucharest; a disability gala that was broadcasted on national television; an emergency call centre for persons with sci; an sci rehabilitation guide; and a meeting with high ranking government officials. of those listed, 29 actions were rated as “completed” and 11 as “incomplete” (75% completion rate). those listed as incomplete included also activities already planned or still in progress at 12 months. in total, 4390 persons had directly or indirectly benefited from the implementation related activities listed in the final implementation plan reporting. they were either active participants in activities, such as trainings, or the audience of oral presentations. implementation activities captured although the response rate dropped in the online report card survey, all ten participants responded at least, and often more than, once over the course of the year (10, 8, 3, 4 at time points 14). the one year sd follow up survey to the same pool of core implementers had a response rate of 9/10, one survey was returned incomplete. overall, respondents seemed to have understood the questions well, as the large majority of open responses were clear and to the point intended. no respondent reported technical problems accessing the online survey platform or the paper based questionnaires. one respondent reported language difficulties and was assisted by a colleague. the online report card survey captured 36 (14, 12, 5, 5 in time points one to four) implementation activities overall. table 1 provides an overview of these implementation activities. von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 7 table 1. implementation activities reported implementation activities (number of reports: 36) type of activity percent (number) delivery of social support services 30.5% (11) icf training 19.4% (7) implementation coordination and development meeting 19.4% (7) icf implementation in support services 5.6% (2) oral presentation 5.6% (2) dissemination through personal communication 2.8% (1) expert workshop 2.8% (1) guideline development 2.8% (1) organizing a scientific conference 2.8% (1) review of current state and report development 2.8% (1) stakeholder meeting 2.8% (1) workshop at scientific conference 2.8% (1) venue or setting percent (number) within an organization 36.1% (13) workshop by invitation only 33.3% (12) meeting by invitation 27.8% (10) during a scientific conference 8.3% (3) other 8.3% (3) within government ministry 2.8% (1) link to other activity percent (number) yes 61.1% (22) no 38.9% (14) implementation goal percent (number) delivery of workshop 22.2% (8) development implementation content and/or group 19.4% (7) promotion or dissemination of implementation content 13.9% (5) professionalization of services 11.1% (4) social reintegration of wheelchair users 8.3% (3) implement specialized knowledge 8.3% (3) improve independence of people with sci 5.6% (2) increase awareness 5.6% (2) improve services and procedures 2.8% (1) raising level of acceptance and self-competence in pwsci 2.8% (1) influencing the revision of disability assessment 2.8% (1) publish report 2.8% (1) organizing a conference 2.8% (1) influence administration of existing services 2.8% (1) delivery of products and services 2.8% (1) main implementation theme percent (number) independent living 55.6% (20) medical rehabilitation and follow up in the community 27.8% (10) employment & inclusive education 16.7% (6) target audience percent (number) people with disabilities 50% (18) disability professionals 33.3% (12) representatives of government and public authorities 33.3% (12) civil society 22.2% (8) health professionals 19.4% (7) students 11.1% (4) family members of people with disabilities 8.3% (3) implementers, implementation and human rights experts 8.3% (3) von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 8 pupils and teachers 8.3% (3) support service professional 8.3% (3) representatives of international organizations 2.8% (1) link with ipsci recommendation percent (number) 2. empower people with spinal cord injury and their families 30.6% (11) 3. challenge negative attitudes to people with spinal cord injury 19.4% (7) 7. implement recommendations 19.4% (7) 1. improve health sector response to spinal cord injury 11.1% (4) 5. support employment and self-employment 11.1% (4) 6. promote appropriate research and data collection 5.6% (2) 4. ensure that buildings, transport and information are accessible 2.8% (1) use of materials and content percent (number) icf case studies (distributed) 69.4% (25) facilitators 66.7% (24) barriers 63.9% (23) the problem 50% (18) the options 50% (18) next steps 50% (18) scientific paper on implementation (distributed) 27.8% (10) other 16.7% (6) adaption of content to local context percent (number) no, the documents were used as they are 36.1% (13) yes, they were translated further 36.1% (13) yes, they were shortened 13.9% (5) other 13.9% (5) yes, they were rearranged 11.1% (4) yes, they were rewritten 11.1% (4) not applicable 5.6% (2) monitoring tools percent (number) longitudinal patient or recipient documentation 30.6% (11) outcome questionnaire 22.2% (8) activity documentation 8.3% (3) group discussion 2.8% (1) mapping of documents 2.8% (1) testimonials 2.8% (1) no monitoring of activities 30.6% (11) receptiveness of audience percent (number) in favour 66.7% (24) slightly in favour 30.6% (11) neither in favour nor against 2.7% (1) implementation activities respondents participated in most were by a large margin social support services (31%), followed by icf trainings and implementation coordination and development meetings (both 20%). the majority of implementation activities took place within an organization (34%) and participation was by invitation in 63% of activities. about two thirds of activities were related to other events or projects (63%). asked to state the explicit goal of the implementation activity they were part of, respondents named the delivery of a workshop or training (n=8) most often, followed by the development of implementation content and / or forming an implementation group (n=5), the promotion or dissemination of implementation content (n=4), and professionalization of services (n=4). in terms of goals targeting the person level, improving independence of people with sci (n=2), social reintegration of wheelchair users (n=2), their participation in services (n=3), and raising the level of acceptance and self-competence in people with sci (n=1) were named. von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 9 respondents were also asked to what main implementation theme, identified during the sd as main focus of implementation efforts, the activities related to. in 56% of cases and by a large margin these were related to the theme independent living. in addition, implementation activities mainly related to the ipsci recommendation empower people with spinal cord injury and their families (31%). the recommendation challenge negative attitudes to people with spinal cord injury (20%) and implement recommendations scored both second highest. key messages of activities were directed at raising awareness toward problems people with sci face in terms of accessibility barriers, poor health, denial of rights, and social exclusion. these messages highlighted an inclusive and rights based approach (obstacles can be overcome and people live independently with the right supports; people with disabilities should be socially and financially independent; people with disabilities have rights they should access). further key messages targeted the system and service level, calling for an improvement of medical sci rehabilitation, provision of services based on the icf approach, and stating that better access to at and mobility training improves the lives of people with disabilities and the elderly. in addition, employment services should consider all abilities of people with sci also in relation to their functioning capacity in a specific environment and not only assessed from a medical point of view. finally, key messages toward implementation stated that successful implementation of ipsci recommendations would first require a rethinking of legislation and policies on disability in line with crpd, and that it necessitates joint action by key experts, sustained by policy. the main target audience of activities were people with disabilities followed by disability professionals and representatives from government and public authorities. out of the seven total documents created or introduced during the sd, the icf case studies and the facilitators’ document were used most often. in 73% of cases respondents had adapted these documents to the local context, mostly by translation (36%). in terms of processes or techniques used and their usefulness (figure 1), respondents found in61% of their activities elements of educational meetings or teachings (of health professionals, government employees, people with sci and families) either fairly useful or very useful as well as local consensus processes (meeting to discuss and agree on implementation goals, steps, etc.) in 47% of cases. tools rated most useful during implementation activities (figure2) were the ipsci summary in romanian (83% of cases), the ipsci full report in english (61%), the icf and own documents or media (53%). other, very specific who media was in the majority of cases not used. twenty-five out of 36 activities were monitored. about 97% of the target audience reported to have been in favour or slightly in favour (0-5 likert scale) of the implementation activities. asked to describe the main outcomes of their activities, respondents named direct output produced, evidence of services provided, and individual or organizational level impact. activity related output included the development of and promotion of implementation content (n=11), such as an implementation plan, technical information, or a journal article. also, the organization of an expert group to develop an implementation plan was highlighted as one such direct output. evidence of service provision (n=13) included the recruitment of clients and services delivered (registration, assessment, program development, training). in addition, some activities were evaluated by participants (n=3) leading to sum scores of how far training participant’s expectations were met. individual level impact (n=23) was reported as knowledge gain or change of perspective and awareness in the target audiences, including a better understanding of rehabilitation von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 10 objectives, outcomes and problems by health professionals. furthermore, specific skills were acquired by the target audience, their independence improved, and their activity and social participation increased. finally, one respondent named improved working procedures and working tools used within the target organization as a direct organizational level impact (n=1). during the sd participants had listed most anticipated barriers for the stakeholder group policy makers and ngo. figure 1. implementation techniques and their perceived usefulness by number of cases von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 11 figure 2. implementation tools and their perceived usefulness by number of cases respondents also rated the extent of hindering and facilitating factors by stakeholders had on implementation during the last 12 months (figure 3). these factors had been jointly formulated during the sd and listed most barriers for the policy maker and academia stakeholder group (6 & 4) and most facilitating influences for the private sector (4). only nine out 26 factors had been rated of no influence and all as either of large or very large influence. the dependence of policy makers on constituency interest scored as highest barrier and the general availability of european commission and european structural funds highest facilitator, possibly counterbalancing the general lack of funds and resources as general barrier. von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 12 figure 3. perceived barriers and facilitators by stakeholder group and in general terms legend: ac academia; dpo – disabled people’s organization; ggeneral; ngo – nongovernmental organizations; pm – policy makers; ps – private sector; sci – people with sci; spp service and product providers. von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 13 discussion summary of main results when summarizing the main results of the surveys it is important to note that multiple and different kinds of implementation activities were undertaken over the course of the monitoring period. these were to a very large extent completed (75%) and had involved over 4000 people. the activities produced direct output, evidence of services provided, and indications of individual or organizational level impact. on closer examination patterns become apparent in the data. a majority of activities were concerned with the delivery of social support services, icf trainings, and implementation coordination and development meetings. these activities mostly took place within an organization, by invitation and related to other events or projects. consequently, goals were largely related to improving independence of people with sci, the delivery of workshops or trainings, and development of implementation content or formation of an implementation group. subsequently, activities largely related to the overall theme of independent living with key messages of the need for awareness raising, improvement of service provision, and the necessity to coordinate implementation efforts. evenly matched are the target audiences - people with disabilities, disability professionals and representatives from government and public authorities. the most useful processes were educational meetings or teachings and local consensus processes. most notably in terms of tool usefulness is that the ipsci summary in romanian, the ipsci full report in english, the icf and their own documents and media scored most useful, while who media products were least used or useful. although these tools had been introduced during the sd, implementers resorted to using tools that were more linguistically accessible or their own tools. an additional indication that language accessibility is an important issue is the fact that in one third of cases sd documents were translated for further use in implementation. finally, the implementers rated substantial hindering and facilitating influences stakeholder groups had on their implementation efforts. lessons learned beyond offering insights into actual implementation experiences, we can draw three lessons from the experience that can help in the development and application of an implementation strategy for a who public health report. first, we can see that the overall implementation strategy worked in terms of pre-defining activities in a plan and coordinating the implementation groups’ efforts. this was apparent in activity achievement as documented in the implementation plan and established through implementation content and group development meetings as documented in the monitoring survey. secondly, results indicate that the process of developing the implementation strategy had a positive impact of building the team for the core implementation group, ownership and participation, as well as on focus and the continuation of efforts, and, lastly, on implementation outcomes. finally, the monitoring mechanism drafted during the implementation strategy development process is feasible, faithful and useful as the surveys were able to display the broad range of implementation experiences with their many facets. this fact underscores the usefulness of the underlying conceptual implementation framework used to map out the survey questions across core implementation components toward planning, administering and monitoring implementation (16). von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 14 however, the surveys could also benefit from a closer alignment with recently developed surveys in similar contexts (19,20). in particular, this would mean adding survey questions within the online report card survey assessing the specific impacts the process to develop the strategy had, similar to those survey cycles used in stakeholder dialogue researched by boyko and colleagues (21). overall, survey design, analysis and interpretation can be standardized by further application in similar case studies to improve data quality. results in light of research in the field waltz and colleagues as part of the expert recommendations for implementing change (eric) study recruited a panel of experts in implementation science to sort 73 implementation strategies and to rate their relative importance and feasibility. the ratings reflect similar processes identified in the present case as the most important and feasible, for instance, identifying barriers and facilitators to implementation, developing stakeholder interrelationships, training and educating stakeholders, and engaging consumers (22). furthermore, participatory implementation strategy development mechanisms create strong coherence in the implementation group and a shared sense of commitment greatly benefiting outcomes. findings from the international consortium project ‘equitable’ of two european and four african countries highlight very similar lessons learned when developing and implementing a joint project (23). likewise, identifying implementers during strategy implementation in terms of professional knowledge, involvement in issue, networks, ability to influence, and interpersonal competencies will benefit implementation processes (24,25). finally, drawing on standard outcome variables proposed for implementation outcome research (26) this study shows that the following are the most relevant: reach in terms of the number of people directly or indirectly involved throughout romania; adoption and fidelity in terms of level of activity completion; perceived usefulness of implementation tools and processes; and signs of sustainability in terms of technical expertise introduced to services on the ground. limitations and implications for future research in the present case, much of the implementation success must be attributed to the core implementation group and the influence the individual implementers had in their respective organizations (27). this is particularly evident in the role of main project partners and their effective interplay. although the core implementation group members were selected from the pool of focus group and sd participants who in turn were invited based on a detailed participants’ recruitment scheme to reach heterogeneity in group composition, the group constitutes a small convenience sample lacking representativeness. this limits the generalisability of results. expanding on the number of implementers involved will increase reach and generalisability of results. however, inclusion of participants from one particular country only will always introduce a cultural bias. respondents could have over or underrated specific elements or tools of implementation that are either lacking in their country or are in general under prioritized. in effect, what was accomplished here is a pilot of two surveys that are innovative in their own right and fill an important gap in the toolset of implementation research. subsequent research using these, or modified versions of these surveys also in other contexts and countries will help to refine the methodology and strengthen the survey approach. another limitation might be the reporting bias of the implementers. the implementers might have felt obliged to report favourably on implementation interventions within the realm of their own organizations, although specific precautions were made in term of anonymity of responses and disclosure of implementation group composition. it must be kept in mind, however, that the concern here is not so much the accuracy of the reporting, as the selfvon groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 15 awareness of the implementers of what they have committed themselves to do. it is extremely difficult to avoid self-serving responses in this context, and independent verification of these results would go far beyond this study. when it comes to evaluation, defining appropriate impact indicators at the start of the project will help measure implementation outcomes and impact in wider contexts in addition to the project-related process and output indicators (28,29). context data and information on stakeholder influences on implementation could be set in reference to network analysis as it has been applied in health systems research (11,30). conclusion as who’s alliance for health policy and systems research has made clear, any effort to strengthen health policy implementation research and practice depends on clear documentation and analysis of the experience of implementers ‘on the ground’. agents, facilitators and other implementation ‘champions’ have always been the engine of implementation, and it is crucial to understand their motivations, experiences, and selfperception of their implementation roles. in this paper we have presented one important method for achieving this, in the form of 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distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. evaluation of an implementation strategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania abstract introduction methods results discussion conclusion "сhallenges(approaches to)forinternational standards application inhealth south eastern european journal of public health volume viii, 2017 genc burazeri, ulrich laaser, jürgen breckenkamp, jose m. martin-moreno, peter schröder-bäck(eds.) jacobs verlag south eastern european journal of public health genc burazeri, ulrich laaser, jürgen breckenkamp jose m. martin-moreno, peter schröder-bäck. executive editor genc burazeri (tirana, albania and maastricht, the netherlands) faculty of medicine rr. “dibres”, no. 371 tirana, albania phone: 0035/5672071652 skype: genc.burazeri assistant executive editor kreshnik petrela, institute of public health, rr. “a.moisiu” nr. 80, tirane, albania technical editor florida beluli institute of public health, rr. “a.moisiu” nr. 80, tirane, albania editors jürgen breckenkamp, faculty of health sciences, university of bielefeld, germany (2016). genc burazeri, faculty of medicine, tirana, albania and department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands (2013). ulrich laaser, faculty of health sciences, university of bielefeld, germany (2013). jose m. martin-moreno, school of public health, valencia, spain (2013). peter schröder-bäck, department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands (2014). regional editors suzanne m. babich, associate dean of global health and professor, health policy and management, at the indiana university richard m. fairbanks school of public health in indianapolis, indiana, usa, for north america. samir n. banoob, president, intenational health mangement, tampa, florida, usa, for the middle east. jadranka bozikov, department for medical statistics, epidemiology and medical informatics, andrija stampar school of public health, school of medicine, university of zagreb, zagreb, croatia evelyne de leeuw, free lance health consultant, sydney, australia, for the western pacific region. damen haile mariam, university of addis ababa, ethiopia, for the african region. charles surjadi, faculty of medicine, atmajaya university, jakarta, indonesia, for the south east asian region. fimka tozija institute of social medicine, faculty of medicine, university “ss cyril and methodius”, skopje, macedonia, for south eastern europe. laura magana valladares, secretaria académica, instituto nacional de salud pública, mexico, mexico, for latin america. advisory editorial board tewabech bishaw, african federation of public health associations (afpha), addis ababa, ethiopia. helmut brand, department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands. patricia brownell, fordham university, new york city, new york, usa. franco cavallo, department of public health and paediatrics, school of medicine, university of torino, torino, italy. doncho donev, institute of social medicine, faculty of medicine, university “ss cyril and methodius”, skopje, macedonia. mariana dyakova, university of warwick, faculty of public health, united kingdom. florentina furtunescu, department of public health and management, university of medicine and pharmacy "carol davila", bucharest, romania. andrej grjibovski, norwegian institute of public health, oslo, norway and school of public health, arkhangelsk, russia motasem hamdan, school of public health, al-quds university, east jerusalem, palestine. mihajlo jakovljevic, faculty of medical sciences, university of kragujevac, kragujevac, serbia. aleksandra jovic-vranes, institute of social medicine, medical faculty, belgrade university, serbia. ilona kickbusch, graduate institute of international and development studies, geneva, switzerland. mihali kokeny, free lance consultant, budapest, hungary. dominique kondji, cameroon public health association, douala, cameroon. giuseppe la torre, department of public health and infectious diseases, university sapienza, rome, italy. oleg lozan, school of public health management, chisinau, moldova. george lueddeke, consultant in higher and medical education, southampton, united kingdom. izet masic, university of sarajevo, sarajevo, bosnia and herzegovina. martin mckee, london school of hygiene and tropical medicine, london, united kingdom. bernhard merkel, visiting research fellow, london school of hygiene and tropical medicine, london, uk. naser ramadani, institute of public health, prishtina, kosovo. enver roshi, school of public health, university of medicine, tirana, albania. maria ruseva, south east european health network (seehn), sofia, bulgaria. theodore tulchinsky, hadassah–braun school of public health and community medicine, jerusalem, israel. lijana zaletel-kragelj, faculty of medicine, university of ljubljana, ljubljana, slovenia. publisher dr. hans jacobs (lage, germany) editorial office jacobs verlag hellweg 72 d 32791 lage germany email phone: 0049/5232/979043 fax: 0049/05232/979045 mailto:info@jacobs-verlag.de� seejph south eastern european journal of public health www.seejph.com/ volume viii, 2017 genc burazeri, ulrich laaser, jürgen breckenkamp, jose m. martin-moreno, peter schröder-bäck (eds.) publisher: jacobs/germany issn 2197-5248 jacobs verlag http://www.seejph.com/� issn2197-5248 doi 10.4119/unibi/seejph-2017-175 bibliographic information published by die deutschebibliothek. die deutsche bibliothek lists this publication in the deutsche nationalbibliografie; detailed bibliographic data is available on the internet at http://dnb.ddb.de south eastern european journal of public health (open access journal) copyright 2016 by jacobs publishing company hellweg 72, 32791 lage, germany copyright cover picture: wordpress foundation: http://wordpressfoundation.org/gnu general public license http://dnb.ddb.de/� http://wordpressfoundation.org/gnu� table of contents page editorial reflections on the liberian civil war, 1989-2003 1-3 ulrich laaser original research introduction of the european union case definitions to primary care physicians has improved the quality 4-12 of communicable diseases notification in tuzla, bosnia and herzegovina martin rusnak, predrag duric, denisa jakubcova, viera rusnakova, amina obradovic-balihodzic enhancing health system’s governance through demographic and health surveys in transitional 13-20 european countries: the example of albania herion muja, genc burazeri, peter schröder-bäck, helmut brand evaluation of an implementation strategy for a world health organization (who) public health report: 21-37 the implementation of the international perspectives on spinal cord injury (ipsci) in romania per m. von groote, dimitrios skempes, jerome e. bickenbach the dutch long-term care reform: moral conflicts in executing the social support act 2015 38-56 wesley jongen, peter schröder-bäck, jos mga schols from their own words: an explorative qualitative study on the experience of combatants 57-69 disabled in the liberian civil war,1989-2003 aloysius p. taylor review articles preparing society to create the world we need through“one health”education 70-91 george r. lueddeke, gretchen e. kaufman, joann m. lindenmayer, cheryl m. stroud approaches to the international standards application in healthcare and public health in 92-103 different countries vitaliy sarancha, vadym sulyma, nenad pros, ksenija vitale letters to editor high level communiqué from the interaction council 104-106 george lueddeke laaseru. reflections on the liberian civil war, 1989-2003 (editorial). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-154 1 editorial reflections on the liberian civil war, 1989-2003 ulrich laaser1 1 faculty of health sciences, university of bielefeld,bielefeld, germany. corresponding author: ulrich laaser address: faculty of health sciences, university of bielefeld, pob 10 01 31, d-33501, bielefeld, germany; e-mail: ulrich.laaser@uni-bielefeld.de conflicts of interest: none. mailto:ulrich.laaser@uni-bielefeld.de� laaseru. reflections on the liberian civil war, 1989-2003 (editorial). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-154 2 the generation which experienced war in europe – world war ii – is passing away and with it those who can tell ‘in their own words’ from war experience and trauma. on the other hand accelerating globalization confronts us with a series of armed conflicts all over the world. the civil war in liberia was one of these. all of the possible fuelling factors were brought to bear on it: ethnic differences, economic domination by a ruling class the progeny of the freed slaves in 1822, and the long litany of misrule by various administrations crowned by the execution of predominantly people of american descent in the 1980 coup d’état, all set the stage for a final showdown. the conflict involved eight armed factions fighting for dominance and lasted with a short interruption from 1989 to 2003. whereas, for example in germany, there is an abundance of literature describing and analyzing personal and social experience during the war[for example translated into english (1)]; it is not so in liberia. the veterans of the various rebel groups and even former members of the regular army usually live in very poor conditions and those invalidated populate begging the streets. furthermore there are thousands of civil victims and especially an estimated 10-15% of the female population raped, more than half a million (out of a population of about four million at the time) were killed (2) and close to one million dislocated. although people have generally enjoyed peace in liberia for over a decade by now that peace can still be described as fragile. every year one can observe signs of simmering instability when ex-combatants make threats on radio and in newspapers that they will disturb the peace in the country for claims of perceived benefits they have against the government in concert with left behind widows and children and their disabled comrades. the condition of those who are physically or mentally disabled is appalling, the standard of living at the edge as usually there is no income; the acquisition of a daily meal becomes a problem. they are considered by the national community to be responsible for the atrocities and the suffering of the civilian people although they were often in the child and adolescent age when entering the armed factions, hardly mature enough to discern between what was right and what was wrong to do even in a war situation (3). different from the reaction on the ebola epidemic (4) which posed a threat to themselves, the international community has rarely taken notice of the victims of the civil war in liberia and few people seem to be concerned about the abundance of psychiatric disease including posttraumatic stress disorder. even less realized is the threat of further social disruption as any organized reconciliation process involving ex-combatants is missing. documented experience in europe and notably germany shows war traumata handed over through several generations, from the parents experiencing war to their children and even grand-children, a threat for social stability and cohesion: ‘because of the war my parents simply did not experience that the world is a safe place where one can feel well and protected. and exactly the same feeling i ascertained in myself although there was no external inducement’ [own translation (1)]. to listen to the ostracized invalids from the civil war and take note of what they have to say is the aim of the explorative study by aloysius taylor hoping to initiate public discussion aimed at healing the liberian society. references 1. bodes. the forgotten generation – the war children break their silence. klett cotta, stuttgart; 2004. https://www.sabine-bode-koeln.de/war-children/the-forgotten generation/. 2. edgertonrb. africa’s armies: from honor to infamy. amazon; 2004. https://www.amazon.co.uk/africas-armies-infamy-robert-edgerton/dp/0813342775. https://www.sabine-bode-koeln.de/war-children/the-forgotten-generation/� https://www.amazon.co.uk/africas-armies-infamy-robert-edgerton/dp/0813342775� laaseru. reflections on the liberian civil war, 1989-2003 (editorial). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-154 3 3. kokulofasuekoi j. a journalist’s photo diary. auto-publication, date unknown, monrovia, liberia. https://www.barnesandnoble.com/w/rape-loot-murder-james kokulo-fasuekoi/1105497189?ean=9781468591620. 4. gostin lo, lucey d, phelan a. the ebola epidemic: a global health emergency. jama 2014;312:1095-6. © 2017 laaser; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.barnesandnoble.com/w/rape-loot-murder-james-kokulo-fasuekoi/1105497189?ean=9781468591620� http://jamanetwork.com/searchresults?author=alexandra%2bphelan&amp;amp%3bq=alexandra%2bphelan� http://creativecommons.org/licenses/by/3.0)� 4 rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 original research introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina martin rusnak1, predrag duric2, denisa jakubcova1, viera rusnakova1, amina obradovic-balihodzic3 1 department of public health, faculty of health sciences and social work, trnava university in trnava, slovakia; 2 institute for global health and development, queen margaret university, edinburgh, uk; 3 institute for public health of canton sarajevo, sarajevo, bosnia and herzegovina. corresponding author: prof. martin rusnak; address: trnava university in trnava, faculty of health sciences and social work, department of public health, univerzitnenamestie 1, 918 43 trnava, slovakia; telephone: +421335939495; e-mail: rusnakm@truni.sk mailto:rusnakm@truni.sk� 5 rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 abstract aim: the public health reform ii project was implemented in bosnia and herzegovina from december 2011 to december 2013 and was funded by the european union aid schema. the principal aim of the project was to strengthen public health services in the country through improved control of public health threats. workshops for primary care physicians were provided to improve the situation and increase communicable diseases notification rates in eight selected primary care centres. they were followed with visits from the project’s implementing team to verify the effects of trainings. methods: the quality of notifications from physicians in tuzla region was compared before and after the workshop. the timeliness was used as an indicator of quality. medians of timeliness before and after the training were compared by use of wilcoxon test, whereas the averages of timeliness were compared by use of the t-test. results: there were 980 reported cases, 80% before the training and 20% after the training. a lower median of timeliness for all the reported cases after the training was statistically significant compared to the median value before the training. a similar picture was revealed for specific diseases i.e. tuberculosis and enteritis, not so for scarlet fever and scabies. conclusion: the significant reduction in time response between the first symptoms and disease diagnosis indicates the positive impact of the training program in tuzla. hence, primary care physicians provided better quality of reported data after the training course. keywords: bosnia and herzegovina, communicable diseases notification, surveillance, timeliness, tuzla. conflicts of interest: none. acknowledgements: the authors are grateful to all primary care physicians and epidemiologists for their interest in training topics and to the management teams of health care centres for their close cooperation. funding: the data used for this study were collected within the public health reform ii project in bosnia and herzegovina. the project was funded by the european union (eu) as a part of the instrument for pre-accession assistance (ipa). the project was implemented by the consortium comprising the ceu consulting gmbh, wien, austria and diadikasia, athens, greece. 6 rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 introduction surveillance on communicable diseases is defined as an ongoing, systematic collection, analysis, interpretation and dissemination of infectious disease data for public health action (1,2). effective surveillance provides information on infections that are the most important causes of illness, disability and death, populations at risk, outbreaks, demands on health care services and effectiveness of control programs so priorities for prevention activities can be determined (3,4). the primary aim of infectious diseases surveillance is to eliminate and eradicate disease incidence with two core functions: early warning system for outbreaks and early response to disease occurrence, known also as epidemiological intelligence. an early warning and response system for the prevention and control of communicable diseases is essential for ensuring public health at the regional, national and global levels. recent cases of severe acute respiratory syndrome, avian influenza, haemorrhagic fevers and especially the threats arising from the possibility of misuse of biological and chemical agents demonstrate the need for an effective system of surveillance and early warning at national level providing a higher data structure (5 7). the structure of surveillance system is based on the existing legislation, goals and priorities, implementation strategies, identification of stakeholders and their mutual connections, networks and partnerships and also capacity for disease diagnosis. primary care physicians or general practitioners who provide the first contact with a patient play a crucial role in the system. the surveillance system relies on the detection of communicable disease in the patients and disease notification (8-10). the project public health reform ii (europe aid/128400/c/ser/ba)was implemented in bosnia and herzegovina from december 2011 till december 2013 and was funded by the european union aid schema. its principal aim was to strengthen public health services in the country through improved control of public health threats. one of the three components of the project dealt with enhancing and improving assessment of global public health and the system of communicable diseases notification. based on an interest from regional public health authorities, eight of them were selected to participate in some workshops. interviews with general practitioners in each region were taken during the initial phase of the activities. professionals who were interviewed indicated the following challenges for the surveillance system they contribute to: the list of mandatory notified diseases too long, clear case definitions and rationale for surveillance missing, mixture of case-based (11) and syndromic surveillance (12), lack of capacity for cases confirmation and a low level of communication among all surveillance stakeholders. the interview findings led to organization of workshops for primary care physicians in eight primary health care centres during march 2013. the aim was to improve the situation and increase notification rates. it was expected that acquiring deeper insights into the role of disease notification would lead to an increased effectiveness of the surveillance system. outcomes from the effort to improve the quality of notifications in the region of tuzla are reported in this paper. physicians from the county were invited in cooperation with the local public health office and notifications were stored in electronic format. this set-up of the endeavour was uniformly repeated across all the eight regions of bosnia and herzegovina. 7 rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 methods study design the study was designed with the aim of revealing potential effects of updating primary care physicians with details of surveillance. thus, a cohort of primary care physicians was used to follow the effects. selection of participants was on the basis of interest. no attempts to randomize were undertaken. the project collected baseline data on notification from the database maintained by the tuzla epidemiologists for year 2012 up to february 2013. the workshop was carried in march 2013. the project attempted to keep contact with participants by email and by personal visits. data from the same source were collected until october 2013. there were 20 participants at the first workshop. estimating the proportion from the total of those who serve the region was not possible because of the lack of data. however, the total number of general practitioners listed in 2014 was 378 physicians (13) as our participants were mostly from offices within the city of tuzla. our estimate is based on the average number of citizens per general practitioners (gps) in the region which is 1263 inhabitants per gp. tuzla has 120441 inhabitants according to the census from 2013, which results in about 95 general practitioners in the city. hence, participation in the workshop represents approximately 21% of all primary care physicians in tuzla. workshop the workshop started with an introduction of aims and expected outcomes. assessment of knowledge on surveillance, disease reporting and attitudes to disease notification followed. principles of communicable disease surveillance and use of case definitions with emphasis on importance of surveillance, techniques, categories and use of the eu case definitions were presented by the project. following discussion dealt with everyday problems and opinions on the system of surveillance as well as the use of the eu case definitions. at the end of the workshop each participant received a copy of the eu case definitions, translated into the local language. local management of primary health care centres and people from epidemiology department were also invited to participate as observers. all data were anonymised and no ethical considerations were identified. data processing the timeliness for notifications obtained from primary care physicians in the town of tuzla was compared before and after the workshop. the timeliness was used as an indicator of quality, as it reflects the speed between steps in a public health surveillance system (14). we chose the following definition of timeliness out of several options: “average time interval between date of onset and date of notification by general practitioners/hospital (by disease, region and surveillance unit). it means time interval between the first symptoms of diseases and reporting”, as defined by the ecdc (15). timeliness was computed from dates stated in individual notifications separately for those noted before and after the workshop. the file was sorted based on the icd-10 diagnosis stated by the physician notifying the case and laboratory confirmation. timeliness was computed for all the diagnoses as well as selected icds for tuberculosis (a15), scarlet fever (a38), enteritis (a09) and scabies (b86). differences in medians before and after the workshop were compared by use of the two-sample wilcoxon rank sum test and signed rank tests and the average values were compared by the two-sample independent t-test from the r project (16), with a level of statistical significance set at p≤0.05. 8 rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 results as table 1 illustrates, the sample comprised 980 reported cases, 784 (80%) were before the training and 196 (20%) were reported after the workshop. in total, 147 primary care physicians reported syndromic diagnosis of a communicable disease case (140 before the workshop and 69 after the workshop). table 1. timeliness for notified cases before and after the workshop total sample sample total before after p-value total cases 980 784 196 median 1 6 1 0.030* average 12 20.2 9.2 0.039† maximum 152 152 133 minimum 0 0 0 tuberculosis sample total before after p-value total cases 159 99 60 median 58 60 13 0.014* average 57.1 57.6 27 0.019† maximum 152 152 133 minimum 0 0 0 enteritis (a09) sample total before after p-value total cases 132 86 46 median 2 3 2 0.035* average 3.7 3.2 2.7 0.065† maximum 41 41 23 minimum 0 0 0 scarlet fever (a38) sample total before after p-value total cases 33 17 16 median 0 1 0 0.487* average 1.8 1.6 1.5 0.611† maximum 13 13 13 minimum 0 0 0 scabies (b86) sample total before after p-value total cases 98 71 27 median 0 1 0 0.512* average 1.7 3.9 2.7 0.481† maximum 37 37 13 minimum 0 0 0 *p-values from wilcoxon test. †p-values from t-test. the difference in medians of timeliness for the total sample (table 1) indicates a reduction from 6 days to 1 day following the workshop; the average of the indicator was reduced to one half. the difference was statistically significant for both the median value (p=0.03) and the mean value (p=0.04). the reduction for notified cases of tuberculosis was more pronounced. it 9 rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 went down from a median of 60 days to 13 days (p=0.01), whereas the mean from 57.6 days to 27.0 days and this difference was statistically significant too (p=0.02). the median of timeliness notification for enteritis cases was significantly lowered after the workshop from 3 days to 2 days and this difference was statistically significant (p=0.03). furthermore, this difference was also evident in the comparison of mean values. there were no significant differences in both median and mean values in the timeliness for scarlet fever and scabies before and after the workshop (table 1). discussion the surveillance system in bosnia and herzegovina suffered after the war. it is not stabilized yet, experiencing lack of funds, and it is both organizationally as well as politically divided. it is run on a regional basis, where all primary care physicians are legally required to notify cases based on syndromic diagnosis. such a system is characterized by underreporting due to lack of responsibility and weak supervision from authorities. nevertheless, some authors have demonstrated positive effects of an information campaign on improved notifications in a province of vojvodina, serbia (17) where public health services operate in a similar environment to bosnia and herzegovina. this project in bosnia and herzegovina aimed to increase syndromic notification rates through focused workshops as an example for regional epidemiologists how to continue with improving quality of the surveillance. however, we are aware that the quality consists of a multidimensional character and the timeliness is only one of them. thus, using it for a proxy of quality has its limitations. timeliness of a surveillance system depends on a number of factors and its assessment should include a consideration of how the data will be used and is specific for individual diseases under surveillance (3,18). other indicators of timeliness are also available, such as the average time interval between the date of outbreak notification and the date of the first investigation or proportion of outbreaks notified within 48 hours of detection and the like. obtaining a comprehensive assessment of surveillance quality requires considering more attributes, such as sensitivity, representativeness, usefulness, simplicity, acceptability and flexibility (15,19). therefore, even so, this report demonstrates a significant reduction in notification time between syndromic diagnosis and notifications, and the quality improvement was achieved incompletely. another opened question is whether or not achievements are to be sustained. nevertheless, the changes in notifications were observed after the workshops, based on a follow-up evaluation. our findings are congruent with similar studies where timeliness of disease notification was also followed and reported, before and after some type of intervention with a main aim to reduce time response between two steps in the process of reporting. implementation of electronic laboratory reporting resulted in reducing the median of timeliness to 20 days versus 25 days for non-electronic laboratory reporting (20). another study has demonstrated reduced median of timeliness for notifications by 17 days from the year 2000 to 2006 with a higher rate of notification completeness (21). the importance of increased interaction between primary care physicians and surveillance professionals in notifying communicable diseases was demonstrated in our study, as well. providing case definitions from the eu and along with the local ones was appreciated and probably contributed to improved notification rates. the fact that standard case definition is a premise for data quality and validity (22) was reconfirmed with similar studies reported (23,24), where increased dedication to reporting with data qualitytimeliness and completeness was observed. there are factors which are beyond the influence of physicians, such as patient’s awareness of symptoms, patient’s search for medical care, capacity for case confirmation, 10 rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 reporting of laboratory test results back to the physician and to other surveillance stakeholders and public health agencies, which limit the validity of interpretation of the findings, too. another limitation stems from the limited time of the study, where 80% of cases were reported before the workshop and 20% of cases were notified after the workshop. another serious limitation of this study stems from the design used. given the specific audience we worked with, namely general practitioners from various parts of the administrative area, the selection of the study participants was "on the basis of interest". as an europeaid project we had no other choice. therefore, the results based on such constrained participation should not be utilized with valid statistical inference on the level of population. the sample representativeness may seriously affect the generalizability (external validity) of the findings. nevertheless, the study was intended to be more of a pilot nature, demonstrating the feasibility of monitoring the quality of the surveillance system. communicable disease surveillance is the first step towards prevention and it is one of the most important tools used in public health. the surveillance system should be regularly evaluated in terms of usefulness and quality by defined standards and recommendations. in this report, we shared results of the surveillance system evaluation in tuzla, bosnia and herzegovina by using one of quality standardstimeliness of disease notification before the training and after the training. this study underlined the importance and effectiveness of increased communication and feedback procedures between primary care physicians and surveillance professionals, use of standard case definition and surveillance evaluation. the identified outcomes of evaluation should be the basis for setting priorities and activities to improve the quality and effectiveness of the surveillance system. references 1. world health organization. communicable disease surveillance and response systems. geneva, switzerland; 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2004;36:865-72. 22. jajosky ra, groseclose s. evaluation of reporting timeliness of public health surveillance systems for infectious diseases. bmc public health 2004;4:29. 23. turnberg w, daniell w, duchin j. notifiable infectious disease reporting awareness among physicians and registered nurses in primary care and emergency department settings. am j infect control 2010;38:410-13. 24. keramarou m, evans mr. completeness of infectious disease notification in the united kingdom: a systematic review. j infect 2012;64:555-64. http://www.episouthnetwork.org/sites/default/files/meeting_report_ebs_march_2013_final.pdf� http://www.zzjzfbih.ba/wp-content/uploads/2009/02/zdravstveno-statisticki-godisnjak-fbih-20121.pdf� http://ecdc.europa.eu/en/publications/publications/data-quality-monitoring-surveillance-system-evaluation-sept-2014.pdf� http://www.r-project.org/� 12 rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 © 2017 rusnak; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0)� 13 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 original research enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania herion muja1,2, genc burazeri1,2, peter schröder-bäck1, helmut brand1 1department of international health, school caphri, care and public health research institute, maastricht university, maastricht, the netherlands; 2 institute of public health, tirana, albania. corresponding author: herion muja, md; address: rr. “aleksander moisiu”, no. 88, tirana, albania; telephone: +355672315056; email: herionmuja@gmail.com http://doi.org/10.4119/unibi/seejph-2017-143� mailto:herionmuja@gmail.com� 14 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 abstract to inform policymakers well, there is a need to promote different types of health examination surveys as additional sources of valuable information which, otherwise, would not be available through routine/administrative statistics. this is especially important for former communist countries of south eastern europe including albania, where the existing health information system (his) is weak. among many efforts to strengthen the his in albania, there is currently a commitment to undertake a second round of a nationwide demographic and health survey (dhs). this survey will involve a nationwide representative sample of about 17,000 private households, where all women aged 15-59 years and their respective partners will be interviewed and examined. externally, the upcoming albanian dhs will contribute to the european union accession requirements regarding provision of standardized and valid health information. furthermore, the dhs will considerably enhance the core functions of the albanian health system in line with the who recommendations. internally, the dhs will promote societal participation and responsibility in transitional albania. importantly, the forthcoming survey will promote good governance including transparency, accountability and health system responsiveness. also, the dhs will allow for collection of internationally valid and standardized baseline socio demographic and health information for: assessment of future national trends; monitoring and evaluation of health programs and interventions; evidencing health disparities and inequities; and cross-national comparisons between albania and different countries of the european region. ultimately, findings of the dhs will enable rational decision-making and evidence based policy formulation in albania including appropriate planning, prioritization and sound resource allocation. however, transfer of the information collected and implementation in public health policies and interventional programs is rather challenging for most of the countries, particularly for transitional post-communist countries of south eastern europe including albania. keywords: albania, demographic and health survey (dhs), health examination survey, health information system, health interview survey, health system governance. conflicts of interest: none. http://doi.org/10.4119/unibi/seejph-2017-143� 15 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 the need to strengthen health information systems a “health information system” (his) is conventionally defined as a system which collects, stores, processes, conducts analysis, disseminates and communicates all the information related to the health status of the population and the activities and performance of health institutions and other health-related organizations (1). from this point of view, a suitable and well-designed his incorporates data generated from routine information systems, disease surveillance systems, but also laboratory information systems, hospital and primary care administration systems, as well as human resource management information systems (1,2). the ultimate goal of a well-functioning his is a continuous and synchronized endeavor to gather, process, report and use health information and the knowledge generated for the good governance of health systems; in other words: influence policy and decision-making, design activities and programs which eventually improve the health outcomes of the population, but also contribute to more efficient use of (often limited) resources (1,3,4). at the same time, the evidence generated from his may suggest the need for further research in certain areas (1,5). nevertheless, a major prerequisite for a good health system governance consists of a wide array of valid and reliable data, which are not often available from a traditional (routine) or administrative his (2,6).therefore, there is a clear need to promote different types of health examination surveys and health interview surveys as valuable sources for generation of additional health information which, otherwise, would not be available based on routine/administrative statistics. this is important in any health care system, where reforms are underway constantly (7). health examination surveys and health interview surveys issues related to the quality of life of individuals, patient satisfaction of health care delivery, knowledge, attitudes, perceptions, or beliefs of individuals, as well as health literacy levels in general are all important components which should be measured at a population level in order to design and tailor health strategies and policies accordingly (1,3). from this perspective, health examination surveys are a powerful tool which enrich a certain his and provide useful clues about the health status of populations, quality of life, as well as access, utilization and satisfaction with health care services. in this framework, the european health examination surveys (ehes: http://www.ehes.info/) and the european health interview surveys (ehis: http://ec.europa.eu/eurostat/web/microdata/european-health-interview-survey) constitute two major exercises which are carried out in most countries of the european union (eu). indeed, health examination surveys and health interview surveys are conducted periodically in most of the eu countries generating important evidence about the magnitude and distribution of selected ill-health conditions and health determinants at a population level. based on the unique value of health examination surveys and health interview surveys, there is a clear call for undertaking a similar exercise also in transitional former communist countries of south eastern europe including albania. country profile: albania after the collapse of the communist regime in early 1990s, albania has undergone significant political, social and economic changes striving towards a market-oriented economy (8). nevertheless, the particularly rapid transition from state-enforced collectivism towards a capitalistic system was associated with poverty, high unemployment rates, financial loss and social mobility, and massive emigration (9). at the same time, however, the transition period in albania was associated with increased personal and religious freedom in a predominantly muslim secular society (8,10). all these features continue to spot albania as a distinctive http://doi.org/10.4119/unibi/seejph-2017-143� http://www.ehes.info/)� http://ec.europa.eu/eurostat/web/microdata/european-health-interview-survey)� 16 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 country in europe, notwithstanding the similarities in many characteristics with other transitional countries in the western balkans and beyond. the health care sector has suffered substantially during the transition period and there has been a significant change in the epidemiological profile of the population in the past few decades with a remarkable transition towards non-communicable diseases (ncds) (11,12). indeed, there is a tremendous increase in the total burden of ncds in albania including heart disease, cancer, lung and liver diseases, and diabetes (11,12). against this background, there is an urgent need for an integrated approach for both prevention and improvement of health care in order to face the high burden of ncds in transitional albania (12). in any case, the existing his in albania has insufficient routine health data for a valid and reliable analysis of disease trends and the associated risk factors. the first round of a nationwide demographic and health survey (dhs) in albania was conducted in 2008-2009 (13). almost ten years later, there is currently an urgent need to carry out a second dhs round which would generate valuable information regarding selected key socio-demographic characteristics and health data of the albanian population, which are otherwise not available based on routine/administrative statistics. not only that with new data new needs for priorities in the health system governance can be identified, but the changes and potential effects of health policy decision-making of the last years can be measured too. the albanian demographic and health survey (dhs) 2017-2018 among many efforts to strengthen the his in albania, there is currently a commitment to undertake a second round of a nationwide dhs. the upcoming round of dhs in albania will be implemented by the national institute of public health and the institute of statistics with technical support from the us-based company icf international (https://www.icf.com/). funding has been already provided by the swiss cooperation and the united nation agencies operating in albania. the dhs will involve a nationwide representative sample of about 17,000 private households. all women aged 15-59 years and their respective husbands/partners living permanently in the selected households or present in the household on the night before the survey visit will be eligible to be interviewed in the dhs. the specific objectives of the dhs will be to: i) collect data at a national, regional and local level which will allow the calculation of key demographic rates; ii) analyze the direct and indirect factors which determine the level and trends of fertility and abortion in albania; iii) measure the level of contraceptive knowledge and practice of albanian men and women; iv) collect data on family health including immunization coverage among children, prevalence of most common diseases among children under five and maternity care indicators; v) collect data on infant and child mortality and maternal mortality; vi) obtain data on child feeding practices including breastfeeding, collect anthropometric measures to use in assessing the nutritional status of children including anemia testing; vii) measure the knowledge and attitudes of women and men about sexually transmitted diseases and hiv/aids; viii) assess key conventional risk factors for ncds in albanian men and women aged 15-59 years including dietary patterns and nutritional habits, smoking status, alcohol consumption, physical activity, systolic and diastolic blood pressure, and measurement of anthropometric indices (height and weight, as well as waist and hip circumferences). the data collected will be scientifically analyzed and scientific reports and policy briefs will be subsequently written and disseminated for a wide audience including health professionals, social workers, policymakers and decision-makers, as well as the general public. in addition, http://doi.org/10.4119/unibi/seejph-2017-143� http://www.icf.com/)� 17 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 the open data source approach will enable secondary (in-depth) analysis to all interested researchers and scientists all over the world. contribution of the demographic and health survey (dhs) to health system governance in albania table 1 presents the potential contribution of the upcoming albanian dhs at different levels (international, national, regional, and local level), recognizing that different actors of health system governance which are located at different levels, yet, interact with each-other (14,15). selected potential contributing characteristics (features) include different dimensions pertinent to both, the international environment and cooperation, as well as the internal (national) situation/circumstances. table 1. international relevance and contribution of the “albanian demographic and health survey 2017-18” to governance processes at national, regional and local levels international relevance characteristic description european union fulfillment of accession requirements, and contribution to the “europeanization” process of albania world health organization (who) strengthening of the core functions of the health system (in line with the who recommendations) national (central) government characteristic description democracy a good exercise for strengthening societal participation and responsibility governance enhancing good governance: transparency, accountability and responsiveness informing policy prioritization, evidence-based planning and allocation of resources research strengthening research capacities at a national level national data collection of (good quality) nationwide representative health data evidencing overall (national) disparities in terms of place of residence national disparities (urban vs. rural areas), ethnicity, minorities, vulnerable subgroups, socioeconomic categories, as well as sexand-age group differences useful baseline data for assessing national trends over time, as well as baseline national data cross-country comparisons monitoring and evaluation of nationwide health programs and interventions use of internationally valid/standardized instruments will eventually enable cross-national comparisons with the neighboring countries and beyond regional level: interface between the central and the local government characteristic description research strengthening research capacities at a regional level regional data collection of sub-national data regional disparities evidencing sub-national (regional) health disparities and inequities baseline regional data baseline data for assessing regional trends, as well as monitoring and evaluation of regional health initiatives, programs andinterventions local government characteristic description research strengthening research capacities at a local level local data collection of health data at a local level local disparities evidencing local health disparities and inequities individual-based data potential for intervention (treatment and counseling of people in need) baseline local data baseline data for assessing local trends, as well as monitoring and evaluation of interventions implemented at a local level http://doi.org/10.4119/unibi/seejph-2017-143� 18 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 regarding the international environment, the upcoming albanian dhs will significantly contribute in terms of fulfillment of accession requirements to the eu related to provision of standardized and valid health information/data. on the other hand, the dhs will also contribute considerably to the enhancement of the core functions of the albanian health system in line with the who recommendations (16). according to who, four vital functions of health systems include provision of health care services, resource generation, financing, and stewardship (16).the upcoming survey will support most of these core functions in the context of a particularly rapid process of transformation and reform of the albanian health system. as for the internal environment, at a central (national) level, the dhs will be an important exercise for strengthening societal participation and responsibility, which is fundamental given the low participation rates and societal contribution in post-communist countries such as albania. from a governmental point of view (4), the forthcoming survey is expected to promote good governance in terms of transparency, accountability and health system responsiveness. conversely, the dhs exercise will considerably strengthen national research capacities in albania. the survey will be conducted in close collaboration with the university of medicine, tirana, and other scientific and research institutions in albania which will help to further strengthen the epidemiological and the overall capacities of the albanian research community. furthermore, the dhs will allow for collection of nationwide high-quality information including a wide array of demographic and socioeconomic characteristics and valuable health data. such data will provide useful baseline information for assessment of national trends in the future, as well as monitoring and evaluation of nationwide health programs and health interventions. in addition, this baseline information will evidence national disparities and inequities regarding the place of residence (urban vs. rural areas), ethnicity groups and minorities, vulnerable/marginalized segments, socioeconomic disadvantaged categories, as well as sexand-age group health differences. at the same time, employment of standardized and internationally valid instruments for data collection will allow for cross-national comparisons between albania and different countries of the european region. ultimately, at a central (national) level, findings of the dhs will enable rational decision-making and evidence-based policy formulation in albania including appropriate planning, prioritization and sound resource allocation. at a lower level, the dhs exercise will help to strengthen research capacities and collaboration at a regional level. this will be an important added value given the new administrative/territorial reform which was fairly recently implemented in albania. in addition, availability of health data at a regional level will help to tailor regional policies in accordance with the epidemiological profile and health problems of the respective population groups, as well as monitoring and evaluation of different interventions and programs implemented at a regional level. at the lowest (i.e., local) level, the dhs will similarly but even more specifically contribute to evidence-based policy formulation and rational decision-making at a local/community level. likewise, the survey will contribute to the enhancement of research capacities at a local level, which will be particularly valuable for many under-resourced communities in albania characterized by limited and not properly trained research personnel. it should be noted that, for the first time ever, the upcoming dhs round will be a unique opportunity to collect representative data at the lowest administrative level in albania. also, importantly, the survey will offer a unique opportunity for intervention regarding potential treatment and especially counseling of individuals in need, particularly those who, for different reasons, have limited access to health care services, such as the case of roma community (17). http://doi.org/10.4119/unibi/seejph-2017-143� https://en.wikipedia.org/wiki/health_care_provider� 19 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 conclusion the upcoming dhs round will be a unique opportunity for albania for strengthening research capacities at a national and local level. in addition, the dhs will provide valuable baseline evidence highlighting regional disparities and subgroup inequities which are assumed to have been rapidly increasing given the rapid political and socioeconomic transition of albania in the past three decades. furthermore, this survey will offer an opportunity for evidence-based policy formulation in albania. overall, the dhs exercise will be an important tool for strengthening the core functions of the albanian health system contributing also to the europeanization process and accession to the eu. however, transfer of the information collected and implementation in public health policies and interventional programs is rather challenging for most of the countries, 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d, zelko e, vintges m, willems s, hanssens l. primary care for the roma in europe: position paper of the european forum for primary care. zdr varst 2016;55:218-24. © 2017 muja et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://doi.org/10.4119/unibi/seejph-2017-143� http://www.ncbi.nlm.nih.gov/pubmed/?term=kuhlmann%20e%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26321192� http://www.ncbi.nlm.nih.gov/pubmed/?term=kuhlmann%20e%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26321192� http://www.ncbi.nlm.nih.gov/pubmed/26321192� http://www.who.int/whr/2000/en/index.html� https://www.ncbi.nlm.nih.gov/pubmed/?term=de%20graaf%20p%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=27703542� 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http://creativecommons.org/licenses/by/3.0)� 21 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 original research evaluation of an implementation strategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania per m. von groote1-3, dimitrios skempes1,2, jerome e. bickenbach1,2 1department of health sciences and health policy, university of lucerne, lucerne, switzerland; 2swiss paraplegic research, nottwil, switzerland; 3institute of social and preventive medicine (ispm), university of bern, bern, switzerland corresponding author: per m. von groote, institute of social and preventive medicine (ispm), university of bern; address: finkenhubelweg 11, ch-3012, bern, switzerland; e-mail: per.vongroote@gmail.com mailto:per.vongroote@gmail.com� 22 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 abstract aim: this paper aims to evaluate a strategy for the implementation of public health policy recommendations from the world health organization’s (who) report “international perspectives on spinal cord injury” in romania. more specifically, it seeks to: a) evaluate implementation actions with a focus on a number of people reached and status of completion at 12 months follow-up; b) describe implementation activities undertaken in the course of one year, and; c) evaluate perceived barriers and facilitators of implementation at 12 months follow-up. methods: a cross-sectional design was adopted with two surveys administered in 2014/15 among key implementers in romania. the questionnaires contained open-ended, multiple choice and 5-point likert scale questions. results on the implementation status, implementation activities performed and self-reported barriers and facilitators were analysed and reported using descriptive statistics. results: implementation completion rate was 75%, with 4390 persons directly or indirectly benefiting from the implementation-related activities listed in the final implementation plan reporting. a broad range of implementation experiences was reported. most common activity types were delivery of services, technical trainings, implementation coordination and development meetings. most useful tools and processes were the romanian language version summary of the report, educational meetings, and local consensuses processes. reported outcomes included the direct output produced, evidence of services provided, and individual or organizational level impact. most barriers were named for the policymakers and academia as stakeholder groups and most facilitating influences for the private sector, with dependence of policymakers on constituency interest scoring highest barrier and the general availability of european commission and european structural funds highest facilitator. conclusion: the surveys proved to be both feasible and useful tools to expand our understanding of implementation and to supplement the more standard used implementation strategies at country level. keywords: implementation, implementation strategy, public health report, spinal cord injury, world health organization. conflicts of interest: none. funding statement: the project received funds from the swiss-romanian cooperation programme as part of swiss contribution to the enlarged eu. acknowledgments: the authors would specifically like to thank dr. cristina ehrmann bostan for her continuous support in analysing the data and preparing display items, and dr. jan d. reinhardt for his conceptual feedback in drafting the manuscript. 23 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 introduction although spinal cord injury (sci) is a low-incident condition, it can be devastating and costly in both human and social terms (1). sci can occur as a consequence of trauma, infection, inflammation, degeneration, tumour, or another disease and often results in a significant decline of physical capacity (2). sci a principal cause of permanent disability has become a significant concern for public health mainly because it places substantial socioeconomic burden on affected individuals and their families, communities and the healthcare system (3). it is considered a particularly pervasive stressor as people who sustain these injuries experience profound alterations in almost all aspects of their life (4). however, many of the difficulties experienced by people with sci do not result from the condition itself, but from inadequate medical care and rehabilitation services, and from barriers in the physical, social and policy environments (5). implementation of measures aiming at removing barriers to access to healthcare and enhancing the effectiveness of rehabilitation and community reintegration is therefore imperative (1). to help propel the implementation of evidence-informed health care and policy for people with sci forward, the world health organization (who) in collaboration with the international spinal cord society in 2013 published a global report titled “international perspectives on spinal cord injury” (ipsci) (6). the report assembles and summarizes the best available scientific evidence and information on spinal cord injury together with the lived experience of people with spinal cord injury and makes recommendations for actions that are consistent with the aspirations for inclusion and participation as expressed in the united nations convention on the rights of persons with disabilities (crpd) (1). the crpd (7) reaffirms the universal human rights and fundamental freedoms of all people with disabilities and calls upon states to secure and promote their inclusion and participation in all aspects of civil, social, economic and community life. notably, the treaty marks a paradigm shift in understanding disability as the result of physical and social barriers interacting with impairments and health states in a way that deprives people of equal opportunities for societal participation. this view implies that multiple systems and stakeholders from health to social and employment sectors must undertake coordinated actions to translate the normative recommendations of international law into concrete benefits for those living with disability (8). for this reason, the who has recognized the necessity to strengthen governments’ capacities in implementing their legal obligations through evidence based programmatic guidance, including guidance on policy implementation. indeed, while the convention is among the “most significant policy catalysts” for disability policy at the global level, nonetheless, “the most significant implementation constraints are at the national level” (7,9). to investigate all aspects of implementation, including activities used to put interventions or innovations into practice and contextual factors that influence these activities, one can look toward implementation research (10). this discipline offers insights for selecting evidence informed policies and interventions, identifying how to implement these in the disability context across populations and resources, and evaluating outcomes. in implementation research, widespread development of programmatic instruments and innovative tools promises to expedite policy implementation in various contexts. these tools are to a large extent tailored to specific purposes and contexts and have limited prospects for large-scale or long-term prospective testing (11). it is now well-established, however, that the transfer of knowledge to support implementation is more complex than it usually appears and is more difficult in the trans-disciplinary domain of public health policy (12,13). pragmatically, there is no “one-size-fits all” health policy and it would be naive to expect 24 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 implementation tools to work across different domains of public health policy, from clinical care guidelines to policy recommendations of international public health organizations. generally, the who’s effort to strengthen health policy implementation research and practice has been led by the alliance for health policy and systems research with its international academic and civil society partners network (14).the alliance highlights the value in documenting and analysing implementation experiences and sharing lessons for unravelling the otherwise invisible facets of the complex process of policy implementation and allowing implementing agents, facilitators and ‘champions’ to better understand their practice and realize their roles by reframing their perspective and refocusing their expectations. this will lead to better judgments about whether a particular strategy works or is relevant to other circumstances and situations, leading to measurable improvements in efficient health systems (15). in light of this, the objective of this paper is to evaluate an implementation strategy for the who ipsci report in romania. the context the research project was led by a partnership between a romanian non-governmental organization dedicated to delivering health and social services to people with disabilities and a swiss health research institute specialized in sci. the partnership organized the development of a strategy to implement the ipsci report in romania in august 2012. the strategy consisted of a set of implementation actions or interventions described in a central implementation plan, to work in combination, and administered by a coordinated group of implementers. the resulting implementation activities that are evaluated in the present paper started in march 2014 and lasted for 12 months. implementation research is by definition a participatory, stakeholder-driven and evidence informed process (10). adopting this approach is particularly important in disability research as persons with disabilities have long been denied equal voice in research and policy processes due to power asymmetries and misallocation of technical and financial resources. in this project, the participatory process of developing the implementation strategy and its evaluation involved three main phases: the preparatory phase, the implementation strategy development phase, and the monitoring and evaluation phase. the preparatory phase consisted of a group discussion by the research project team to identify and select mechanisms to develop the strategy. the implementation strategy development phase encompassed focus group interviews (fg) of people with sci, policy makers, system and service developers and managers, and representatives of ngos to elicit insights into key implementation considerations, a stakeholder dialogue (sd) with participants from the same pool of fg participants from romania and international experts to develop an implementation strategy, including the use of tools and processes. the development process was informed by a conceptual framework and guiding principles which have been previously developed by the authors (16). the monitoring and evaluation phase included surveys administered over the course of one year to monitor implementation activities by a core implementation group and evaluate the strategy. the question was now, what actually happened on the ground during 12 months of implementation and in how far the development process infused implementation activities that were successful. more specifically, this paper seeks to: a) evaluate implementation actions with a focus on the number of people reached and the status of completion at 12 months follow-up; b) describe implementation activities undertaken in the course of one year; and c) evaluate perceived barriers and facilitators of implementation at 12 months follow-up. 25 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 methods due to the lack of validated instruments to measure activities using the conceptual implementation framework, and given the research aim of focusing on the tools developed during the sd and documenting their use in implementation activities undertaken, new and fit-for-purpose survey questions were developed by the research project team. as a result, two surveys were developed in the preparatory phase and finalized after the implementation strategy development phase: first, the online report card survey to document implementation activities throughout the course of one year, and second a one year sd follow-up survey to capture implementation experiences such as perceived barriers and facilitators, among others. in addition, the implementation plan was used as a basis for the summative evaluation of activities at 12 months after the start of implementation. surveys development: the online report card survey questions were first developed by the lead author along the central elements of the comprehensive implementation framework and based on insights from the fgs and sd (16). the survey was independently reviewed by an implementation science expert and an expert on rehabilitation systems and services from the research project team. the survey was tested by a third health scientist who was not involved in the project. the questions were revised based on feedback. the one year sd follow-up survey questions were developed based on the online survey and on first screening of response data to its questions. this survey was reviewed by two team members and reviewer comments were incorporated in the revision. setup and design: the surveys were self-administered, with both quantitative and qualitative data elements. they contained both open-ended questions and questions with predefined response options ranging from yes/no (‘did the activity take place in relation to another event or initiative?’) to five-level psychometric scales (‘what tools were used during the implementation activity and how useful where they?’ – ‘very useful’ to ‘not at all useful’). both surveys were administered in english. the online survey was administered beginning after the sd in four waves from march 2014 until february 2015 capturing implementation activities during 3-month reporting periods each. it took approximately 20 minutes to complete each time. the sd followup survey was a one time, one year follow up survey to the sd. components: the online survey was composed of nine personal and demographic questions followed by 26 questions categorized by the essential implementation components asking, among others, about the kind of implementation activity, relation to the three central themes identified during the sd (medical rehabilitation and follow up in the community, independent living, employment and inclusive education), tools used including those introduced during the sd, processes followed, relation of activity to ipsci recommendation, and perceived receptiveness of audience. in the one year sd follow-up survey participants were asked to judge the extent (0 -5 likert scale) of hindering and facilitating influence attributes or factors of stakeholder groups had on implementation. these attributes had been jointly identified during the sd and were now being evaluated based on 12 months of implementation experience. participant recruitment: participants included a convenience sample of ten residents of romania, seven who had participated in the sd and three from the focus groups. as described elsewhere, participants of the sd and focus groups had been recruited on a participant roster developed by the researchers to maximize heterogeneity and representativeness. all participants were given an information sheet about the survey and asked to sign a consent form. 26 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 data analysis: qualitative survey data from open-ended questions were content-analysed by two researchers. the specificity and intensity of responses were determined by means of a thematic, open and selective description of meaningful concepts and themes using sentences as units of analysis (17,18). categories were then produced using inductive reasoning. conversely, descriptive statistics of quantitative data, such as frequency distributions, were carried out. implementation plan during the sd, five documents were developed that separately described problems related to the three central themes identified during the sd (i.e., sci medical rehabilitation and follow up in the community, independent living, employment and inclusive education), options to target these problems, facilitators and barriers by stakeholder groups, and next steps. these documents then served as a baseline analysis for the development of the implementation plan. the final evaluation of the plan was based on the categories ‘number of people reached’ and ‘status’ defined as either ‘completed’ or ‘incomplete’ at 12 months implementation by the core implementation group. results implementation plan the implementation plan listed 40potential actions in the categories presentations, publications, report development activities, trainings, services, consultations, conferences, and social events. actions planned included, among others: the development of a group statement based on ipsci recommendations, which was disseminated among key stakeholders; a 2-day scientific conference held in bucharest; a disability gala that was broadcasted on national television; an emergency call centre for persons with sci; an sci rehabilitation guide; and a meeting with high ranking government officials. of those listed, 29 actions were rated as “completed” and 11 as “incomplete” (75% completion rate). those listed as incomplete included also activities already planned or still in progress at 12 months. in total, 4390 persons had directly or indirectly benefited from the implementation related activities listed in the final implementation plan reporting. they were either active participants in activities, such as trainings, or the audience of oral presentations. implementation activities captured although the response rate dropped in the online report card survey, all ten participants responded at least, and often more than, once over the course of the year (10, 8, 3, 4 at time points 14). the one year sd follow up survey to the same pool of core implementers had a response rate of 9/10, one survey was returned incomplete. overall, respondents seemed to have understood the questions well, as the large majority of open responses were clear and to the point intended. no respondent reported technical problems accessing the online survey platform or the paper based questionnaires. one respondent reported language difficulties and was assisted by a colleague. the online report card survey captured 36 (14, 12, 5, 5 in time points one to four) implementation activities overall. table 1 provides an overview of these implementation activities. 27 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 table 1. implementation activities reported implementation activities (number of repor ts: 36) type of activity percent (number) delivery of social support services 30.5% (11) icf training 19.4% (7) implementation coordination and development meeting 19.4% (7) icf implementation in support services 5.6% (2) oral presentation 5.6% (2) dissemination through personal communication 2.8% (1) expert workshop 2.8% (1) guideline development 2.8% (1) organizing a scientific conference 2.8% (1) review of current state and report development 2.8% (1) stakeholder meeting 2.8% (1) workshop at scientific conference 2.8% (1) venue or setting percent (number) within an organization 36.1% (13) workshop by invitation only 33.3% (12) meeting by invitation 27.8% (10) during a scientific conference 8.3% (3) other 8.3% (3) within government ministry 2.8% (1) link to other activity percent (number) yes 61.1% (22) no 38.9% (14) implementation goal percent (number) delivery of workshop 22.2% (8) development implementation content and/or group 19.4% (7) promotion or dissemination of implementation content 13.9% (5) professionalization of services 11.1% (4) social reintegration of wheelchair users 8.3% (3) implement specialized knowledge 8.3% (3) improve independence of people with sci 5.6% (2) increase awareness 5.6% (2) improve services and procedures 2.8% (1) raising level of acceptance and self-competence in pwsci 2.8% (1) influencing the revision of disability assessment 2.8% (1) publish report 2.8% (1) organizing a conference 2.8% (1) influence administration of existing services 2.8% (1) delivery of products and services 2.8% (1) main implementation theme percent (number) independent living 55.6% (20) medical rehabilitation and follow up in the community 27.8% (10) employment & inclusive education 16.7% (6) target audience percent (number) people with disabilities 50% (18) disability professionals 33.3% (12) representatives of government and public authorities 33.3% (12) civil society 22.2% (8) health professionals 19.4% (7) students 11.1% (4) family members of people with disabilities 8.3% (3) implementers, implementation and human rights experts 8.3% (3) 28 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 pupils and teachers 8.3% (3) support service professional 8.3% (3) representatives of international organizations 2.8% (1) link with ipsci recommendation percent (number) 2. empower people with spinal cord injury and their families 30.6% (11) 3. challenge negative attitudes to people with spinal cord injury 19.4% (7) 7. implement recommendations 19.4% (7) 1. improve health sector response to spinal cord injury 11.1% (4) 5. support employment and self-employment 11.1% (4) 6. promote appropriate research and data collection 5.6% (2) use of materials and content 4. ensure that buildings, transport and information are accessible 2.8% (1) percent (number) icf case studies (distributed) 69.4% (25) facilitators 66.7% (24) barriers 63.9% (23) the problem 50% (18) the options 50% (18) next steps 50% (18) scientific paper on implementation (distributed) 27.8% (10) other 16.7% (6) adaption of content to local context percent (number) no, the documents were used as they are 36.1% (13) yes, they were translated further 36.1% (13) yes, they were shortened 13.9% (5) other 13.9% (5) yes, they were rearranged 11.1% (4) yes, they were rewritten 11.1% (4) not applicable 5.6% (2) monitoring tools percent (number) longitudinal patient or recipient documentation 30.6% (11) outcome questionnaire 22.2% (8) activity documentation 8.3% (3) group discussion 2.8% (1) mapping of documents 2.8% (1) testimonials 2.8% (1) no monitoring of activities 30.6% (11) receptiveness of audience percent (number) in favour 66.7% (24) slightly in favour 30.6% (11) neither in favour nor against 2.7% (1) implementation activities respondents participated in most were by a large margin social support services (31%), followed by icf trainings and implementation coordination and development meetings (both 20%). the majority of implementation activities took place within an organization (34%) and participation was by invitation in 63% of activities. about two thirds of activities were related to other events or projects (63%). asked to state the explicit goal of the implementation activity they were part of, respondents named the delivery of a workshop or training (n=8) most often, followed by the development of implementation content and / or forming an implementation group (n=5), the promotion or dissemination of implementation content (n=4), and professionalization of services (n=4). in terms of goals targeting the person level, improving independence of people with sci (n=2), social reintegration of wheelchair users (n=2), their participation in services (n=3), and raising the level of acceptance and self-competence in people with sci (n=1) were named. 29 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 respondents were also asked to what main implementation theme, identified during the sd as main focus of implementation efforts, the activities related to. in 56% of cases and by a large margin these were related to the theme independent living. in addition, implementation activities mainly related to the ipsci recommendation empower people with spinal cord injury and their families (31%). the recommendation challenge negative attitudes to people with spinal cord injury (20%) and implement recommendations scored both second highest. key messages of activities were directed at raising awareness toward problems people with sci face in terms of accessibility barriers, poor health, denial of rights, and social exclusion. these messages highlighted an inclusive and rights based approach (obstacles can be overcome and people live independently with the right supports; people with disabilities should be socially and financially independent; people with disabilities have rights they should access). further key messages targeted the system and service level, calling for an improvement of medical sci rehabilitation, provision of services based on the icf approach, and stating that better access to at and mobility training improves the lives of people with disabilities and the elderly. in addition, employment services should consider all abilities of people with sci also in relation to their functioning capacity in a specific environment and not only assessed from a medical point of view. finally, key messages toward implementation stated that successful implementation of ipsci recommendations would first require a rethinking of legislation and policies on disability in line with crpd, and that it necessitates joint action by key experts, sustained by policy. the main target audience of activities were people with disabilities followed by disability professionals and representatives from government and public authorities. out of the seven total documents created or introduced during the sd, the icf case studies and the facilitators’ document were used most often. in 73% of cases respondents had adapted these documents to the local context, mostly by translation (36%). in terms of processes or techniques used and their usefulness (figure 1), respondents found in61% of their activities elements of educational meetings or teachings (of health professionals, government employees, people with sci and families) either fairly useful or very useful as well as local consensus processes (meeting to discuss and agree on implementation goals, steps, etc.) in 47% of cases. tools rated most useful during implementation activities (figure2) were the ipsci summary in romanian (83% of cases), the ipsci full report in english (61%), the icf and own documents or media (53%). other, very specific who media was in the majority of cases not used. twenty-five out of 36 activities were monitored. about 97% of the target audience reported to have been in favour or slightly in favour (0-5 likert scale) of the implementation activities. asked to describe the main outcomes of their activities, respondents named direct output produced, evidence of services provided, and individual or organizational level impact. activity related output included the development of and promotion of implementation content (n=11), such as an implementation plan, technical information, or a journal article. also, the organization of an expert group to develop an implementation plan was highlighted as one such direct output. evidence of service provision (n=13) included the recruitment of clients and services delivered (registration, assessment, program development, training). in addition, some activities were evaluated by participants (n=3) leading to sum scores of how far training participant’s expectations were met. individual level impact (n=23) was reported as knowledge gain or change of perspective and awareness in the target audiences, including a better understanding of rehabilitation 30 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 objectives, outcomes and problems by health professionals. furthermore, specific skills were acquired by the target audience, their independence improved, and their activity and social participation increased. finally, one respondent named improved working procedures and working tools used within the target organization as a direct organizational level impact (n=1). during the sd participants had listed most anticipated barriers for the stakeholder group policy makers and ngo. figure 1. implementation techniques and their perceived usefulness by number of cases 31 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 figure 2. implementation tools and their perceived usefulness by number of cases respondents also rated the extent of hindering and facilitating factors by stakeholders had on implementation during the last 12 months (figure 3). these factors had been jointly formulated during the sd and listed most barriers for the policy maker and academia stakeholder group (6 & 4) and most facilitating influences for the private sector (4). only nine out 26 factors had been rated of no influence and all as either of large or very large influence. the dependence of policy makers on constituency interest scored as highest barrier and the general availability of european commission and european structural funds highest facilitator, possibly counterbalancing the general lack of funds and resources as general barrier. 32 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 figure 3. perceived barriers and facilitators by stakeholder group and in general terms legend: ac academia; dpo – disabled people’s organization; ggeneral; ngo – non governmental organizations; pm – policy makers; ps – private sector; sci – people with sci; spp service and product providers. 33 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 discussion summary of main results when summarizing the main results of the surveys it is important to note that multiple and different kinds of implementation activities were undertaken over the course of the monitoring period. these were to a very large extent completed (75%) and had involved over 4000 people. the activities produced direct output, evidence of services provided, and indications of individual or organizational level impact. on closer examination patterns become apparent in the data. a majority of activities were concerned with the delivery of social support services, icf trainings, and implementation coordination and development meetings. these activities mostly took place within an organization, by invitation and related to other events or projects. consequently, goals were largely related to improving independence of people with sci, the delivery of workshops or trainings, and development of implementation content or formation of an implementation group. subsequently, activities largely related to the overall theme of independent living with key messages of the need for awareness raising, improvement of service provision, and the necessity to coordinate implementation efforts. evenly matched are the target audiences - people with disabilities, disability professionals and representatives from government and public authorities. the most useful processes were educational meetings or teachings and local consensus processes. most notably in terms of tool usefulness is that the ipsci summary in romanian, the ipsci full report in english, the icf and their own documents and media scored most useful, while who media products were least used or useful. although these tools had been introduced during the sd, implementers resorted to using tools that were more linguistically accessible or their own tools. an additional indication that language accessibility is an important issue is the fact that in one third of cases sd documents were translated for further use in implementation. finally, the implementers rated substantial hindering and facilitating influences stakeholder groups had on their implementation efforts. lessons learned beyond offering insights into actual implementation experiences, we can draw three lessons from the experience that can help in the development and application of an implementation strategy for a who public health report. first, we can see that the overall implementation strategy worked in terms of pre-defining activities in a plan and coordinating the implementation groups’ efforts. this was apparent in activity achievement as documented in the implementation plan and established through implementation content and group development meetings as documented in the monitoring survey. secondly, results indicate that the process of developing the implementation strategy had a positive impact of building the team for the core implementation group, ownership and participation, as well as on focus and the continuation of efforts, and, lastly, on implementation outcomes. finally, the monitoring mechanism drafted during the implementation strategy development process is feasible, faithful and useful as the surveys were able to display the broad range of implementation experiences with their many facets. this fact underscores the usefulness of the underlying conceptual implementation framework used to map out the survey questions across core implementation components toward planning, administering and monitoring implementation (16). 34 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 however, the surveys could also benefit from a closer alignment with recently developed surveys in similar contexts (19,20). in particular, this would mean adding survey questions within the online report card survey assessing the specific impacts the process to develop the strategy had, similar to those survey cycles used in stakeholder dialogue researched by boyko and colleagues (21). overall, survey design, analysis and interpretation can be standardized by further application in similar case studies to improve data quality. results in light of research in the field waltz and colleagues as part of the expert recommendations for implementing change (eric) study recruited a panel of experts in implementation science to sort 73 implementation strategies and to rate their relative importance and feasibility. the ratings reflect similar processes identified in the present case as the most important and feasible, for instance, identifying barriers and facilitators to implementation, developing stakeholder interrelationships, training and educating stakeholders, and engaging consumers (22). furthermore, participatory implementation strategy development mechanisms create strong coherence in the implementation group and a shared sense of commitment greatly benefiting outcomes. findings from the international consortium project ‘equitable’ of two european and four african countries highlight very similar lessons learned when developing and implementing a joint project (23). likewise, identifying implementers during strategy implementation in terms of professional knowledge, involvement in issue, networks, ability to influence, and interpersonal competencies will benefit implementation processes (24,25). finally, drawing on standard outcome variables proposed for implementation outcome research (26) this study shows that the following are the most relevant: reach in terms of the number of people directly or indirectly involved throughout romania; adoption and fidelity in terms of level of activity completion; perceived usefulness of implementation tools and processes; and signs of sustainability in terms of technical expertise introduced to services on the ground. limitations and implications for future research in the present case, much of the implementation success must be attributed to the core implementation group and the influence the individual implementers had in their respective organizations (27). this is particularly evident in the role of main project partners and their effective interplay. although the core implementation group members were selected from the pool of focus group and sd participants who in turn were invited based on a detailed participants’ recruitment scheme to reach heterogeneity in group composition, the group constitutes a small convenience sample lacking representativeness. this limits the generalisability of results. expanding on the number of implementers involved will increase reach and generalisability of results. however, inclusion of participants from one particular country only will always introduce a cultural bias. respondents could have over or underrated specific elements or tools of implementation that are either lacking in their country or are in general under prioritized. in effect, what was accomplished here is a pilot of two surveys that are innovative in their own right and fill an important gap in the toolset of implementation research. subsequent research using these, or modified versions of these surveys also in other contexts and countries will help to refine the methodology and strengthen the survey approach. another limitation might be the reporting bias of the implementers. the implementers might have felt obliged to report favourably on implementation interventions within the realm of their own organizations, although specific precautions were made in term of anonymity of responses and disclosure of implementation group composition. it must be kept in mind, however, that the concern here is not so much the accuracy of the reporting, as the self 35 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 awareness of the implementers of what they have committed themselves to do. it is extremely difficult to avoid self-serving responses in this context, and independent verification of these results would go far beyond this study. when it comes to evaluation, defining appropriate impact indicators at the start of the project will help measure implementation outcomes and impact in wider contexts in addition to the project-related process and output indicators (28,29). context data and information on stakeholder influences on implementation could be set in reference to network analysis as it has been applied in health systems research (11,30). conclusion as who’s alliance for health policy and systems research has made clear, any effort to strengthen health policy implementation research and practice depends on clear documentation and analysis of the experience of implementers ‘on the ground’. agents, facilitators and other implementation ‘champions’ have always been the engine of implementation, and it is crucial to understand their motivations, experiences, and self perception of their implementation roles. in this paper we have presented one important method for achieving this, in the form of surveys used to evaluate an implementation strategy for the who ipsci report in romania. despite limitations in this study – described above – it is clear from this initial, piloting of the surveys that they are both feasible and extremely useful tools to supplement the more standard used implementation strategies at country level. references 1. world health organization, international spinal cord society. international perspectives on spinal cord injury. geneva: who; 2013. 2. kirshblum sc, burns sp, biering-sorensen f, donovan w, graves de, jha a, et al. international standards for neurological classification of spinal cord injury (revised 2011). j spinal cord med 2011;34:535-46. 3. weerts e, wyndaele jj. accessibility to spinal cord injury care worldwide, the need for poverty reduction. spinal cord 2011;49:767. 4. post mw, van leeuwen cm. psychosocial issues in spinal cord injury, a review. spinal cord 2012;50:382-9. 5. von groote pm, shakespeare t, officer a. prevention of spinal cord injury. inj prev 2014;20:72. 6. biering-sorensen f, brown dj, officer a, shakespeare t, von groote p, wyndaele jj. ipsci, a who and iscos collaboration report. spinal cord 2014;52:87. 7. united nations. convention 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al. learning from doing the equitable project, content, context, process, and impact of a multi country research project on vulnerable populations in africa. afr j dis 2014;3:1-12. 24. greenhalgh t, robert g, macfarlane f, bate p, kyriakidou o. diffusion of innovations in service organizations, systematic review and recommendations. milbank q 2004;82:581-629. 25. newman j, cherney a, head bw. policy capacity and evidence-based policy in the public service. public management review 2016:1-20. 26. world health organization (who). a guide to implementation research in the prevention and control of noncommunicable diseases. geneva: who, 2016. 27. hupe p. what happens on the ground, persistent issues in implementation research. publ pol adm 2014;29:164-82. 28. fretheim a, oxman ad, lavis jn, lewin s. support tools for evidence-informed policymaking in health 18, planning monitoring and evaluation of policies. health res policy syst 2009;7:s1-s18. 29. oxman ad, bjorndal a, becerra-posada f, gibson m, block ma, haines a, et al. a framework for mandatory impact evaluation to ensure well informed public policy decisions. lancet 2010;375:427-31. 30. blanchet k, james p. how to do (or not to do), a social network analysis in health systems research. health policy plan 2012;27:438-46. http://www.who.int/alliance-hpsr/en/(accessed� 37 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 © 2017 von groote et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0)� 38 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 original research the dutch long-term care reform: moral conflicts in executing the social support act 2015 wesley jongen1, peter schröder-bäck1, jos mga schols2 1 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, the netherlands; 2 department of health services research and department of family medicine, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, the netherlands. corresponding author: wesley jongen, phd, department of international health, maastricht university; address: po box 616, 6200 md, maastricht, the netherlands; telephone: +31433882204; email: w.jongen@maastrichtuniversity.nl mailto:w.jongen@maastrichtuniversity.nl� 39 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 abstract on 1 january 2015, a new long-term care reform entered into force in the netherlands, entailing amongst others a decentralization of long-term care responsibilities from the national government to the municipalities by means of a new law: the social support act 2015. given the often disputed nature of the reform, being characterized on the one hand by severe budget cuts and on the other hand by a normative reorientation towards a participation society, this article examines to what extent municipalities in the netherlands take (potential) moral conflicts into account in their execution of the social support act 2015. in doing so, the article applies a ‘coherentist’ approach (consisting of both rights-based and consequentialist strands of ethical reasoning), thereby putting six ethical principles at the core (non-maleficence & beneficence, social beneficence, respect for autonomy, social justice, efficiency and proportionality). it is argued that while municipalities are indeed aware of (potential) moral conflicts, the nature of the new law itself leaves insufficient room for municipalities to act in a sufficiently proactive and supportive/empowering manner on these challenges. keywords: ethical reasoning, long-term care reform, moral conflicts, the netherlands. conflicts of interest: none. 40 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 introduction background in 2006, the council of the european union made reference to “a set of values that are shared across europe” in its ‘council conclusions on common values and principles in european health systems’ (1). the council conclusions stipulate that “[t]he health systems of the european union are a central part of europe's high levels of social protection, and contribute to social cohesion and social justice as well as to sustainable development. the overarching values of universality, access to good quality care, equity, and solidarity have been widely accepted in the work of the different eu institutions” (1). this set of values was subsequently reinforced a year later in the european commission’s ‘white paper together for health: a strategic approach for the eu 2008-2013’ (2), comprising the eu’s health strategy supporting the overall ‘europe 2020’ strategy (3). the healthcare sector, and more specifically the long-term care sector, has always been a source for ethical debate. typical ethical issues (or moral conflicts) in long-term care decision-making include the debate on whether we should only look at people’s deficits or also to their rest capacities (4),“the nature and significance of the elder's diminished capacity for self-care and independent living”, the question “whether an older adult should continue to live at home”, “the obligation of the elder to recognize and respect the limits that family members may justifiably set on their care giving responsibilities”, a loss of autonomy “when the decision is made to change either the elder’s place of living or support services” and “the balance to be struck between independence and safety” (5). however, as argued by ranci and pavolini (6), “[o]ver the past two decades, many changes have happened to the social welfare policies of various industrial countries. citizens have seen their pensions, unemployment benefits, and general healthcare policies shrink as ‘belt tightening’ measures are enforced”. at the same time, ranci and pavolini (6) argue, “long term care has seen a general growth in public financing, an expansion of beneficiaries, and, more generally, an attempt to define larger social responsibilities and related social rights”. consequently, pavolini and ranci (7) conclude that “[f]aced with the problems associated with an ageing society, many european countries have adopted innovative policies to achieve a better balance between the need to expand social care and the imperative to curb public spending”. the adoption of such innovative policies is referred to here as reforms in long term care policies. the unfold of long-term care reforms even seems to be exacerbated in the aftermath of the 2008 economic crisis, when many european countries introduced austerity measures that in many cases appeared to have adverse effects on health systems and/or social determinants of health (8-12). moreover, schröder-bäck et al. argue that “[t]he current protracted economic crisis is giving rise to the scarcity of public health resources in europe. in response to budgetary pressures and the eurozone public debt crisis, decision makers resort to a short term solution: the introduction of austerity measures in diverse policy fields. health and social policy tend to be easy targets in this regard, and budget cuts often include a reduction of healthcare expenditure or social welfare benefits” (13). jongen et al. (14) add to this that “this crisis has had a much more direct and short-term influence on the quality of countries’ long-term care system than more gradual developments such as population aging and declining workforces, mainly due to austerity measures being the result of, or being accelerated by, this crisis”. also the council conclusions make reference to this changing context of many european countries’ long-term care system, by stating that “[i]t is an essential feature of all our systems that we aim to make them financially sustainable in a way which safeguards these values into the future” (1). moreover, the document stresses patient empowerment, by stating that “[a]ll 41 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 eu health systems aim to be patient-centred. this means they aim to involve patients in their treatment, to be transparent with them, and to offer them choices where this is possible, e.g. a choice between different health care service providers” (1). at the same time, the council conclusions acknowledge that “[d]emographic challenges and new medical technologies can give rise to difficult questions (of ethics and affordability), which all eu member states must answer. […] all systems have to deal with the challenge of prioritising health care in a way that balances the needs of individual patients with the financial resources available to treat the whole population” (1). although sharing some characteristics, every long-term care reform is embedded within peculiar national traditions and is therefore unique. this is true all the more for the latest dutch long-term care reform, that entered into force on 1 january 2015, and which can be considered as the latest major step in a more all-encompassing ‘market-oriented reform’ of the dutch healthcare system in general. the 2015 reform can be characterized as having a “hybrid structure” (15), characterized, on the one hand, by a “reign in expenditure growth to safeguard the fiscal sustainability of ltc” (16), and on the other hand by a “multiplicity of regulations to safeguard public values” (15). more concretely, as argued by maarse and jeurissen (16), the 2015 long-term care reform consists of four interrelated pillars: expenditure cuts, a shift from residential to non-residential care, decentralization of non residential care (implying a transfer of responsibilities in that policy domain from the national government to the municipalities), and a normative reorientation. the latter refers to the notion that “[u]niversal access and solidarity in ltc-financing can only be upheld as its normative cornerstone, if people, where possible, take on more individual and social responsibility. the underlying policy assumption is that various social care services may be provided by family members and local community networks” (16). indeed, a general shift in focus from formal care provision to informal care provision is added by jongen et al. (17) as a key element of the 2015 dutch long-term care reform. it is, however, exactly this normative reorientation, and its underlying assumption of an increased informal care provision, that is often disputed. as argued by maarse and jeurissen (16): “an important line of criticism is not only that informal care is already provided at a large scale, but also that the potential of ‘unexplored’ informal care is overestimated. furthermore, the negative externalities for caregivers who deliver informal care are underestimated”. moreover, while residential care remains under the responsibility of the national government after the entry into force of the 2015 long-term care reform, and a large part of non-residential care came under the responsibility of the health insurers, it is the municipalities that became under the social support act 2015 (ssc 2015) [in dutch: wet maatschappelijkeondersteuning (wmo) 2015] responsible for particularly those parts of non-residential care dealing with support directed towards the social participation of people with severe limitations (in the wordings of the official legal text of the social support act 2015 (authors’ own translation): “people with disabilities, chronic mental or psychosocial problems”), as well as with support for informal caregivers (17). indeed, the official legal text of the social support act 2015 stipulates that “citizens who themselves or together with people in their immediate environment are not sufficiently self-sufficient or insufficiently able to participate [in society], must be able to rely on organized support by the government” (authors’ own translation). however, municipalities have a large discretion in making this obligation to provide support concrete (the so-called ‘postcode [zip code] rationing’), which may lead to unequal access to long-term care in different municipalities (16). literature research so far, the academic literature has not extensively scrutinized the potential moral conflicts resulting from the implementation of the social support act 2015, and is more about 42 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 organization and logistics than about ethics. the available literature either touches upon mere elements of an all-encompassing ethical debate, or upon the perspective of specific groups. as an example of the former, van der aa et al. (18) consider the presumed impact of the 2015 long-term care reform on such elements as good quality of care and solidarity. van der aa et al. argue that the above-mentioned ‘zip code rationing’ might well lead to differences between municipalities in the degree of solidarity as perceived by citizens (‘zip code solidarity’). furthermore, van der aa et al. argue that it should not be taken for granted that municipalities, by simply making an efficiency move, can guarantee an equal level of care quality with the decreased budget they are faced with for executing their new long-term care tasks. next, grootegoed and tonkens (19) consider the impact of the dutch shift in focus from formal to informal care provision on such elements as respect for autonomy or human dignity and argue that “the turn to voluntarism does not always prompt recognition of the needs and autonomy of vulnerable citizens” and furthermore that “the virtues of voluntarism may be overstated by policy makers and that the bases of recognition should be reconsidered as welfare states implement reform”. examples of literature focusing on the perspective of specific groups include the articles by dwarswaard et al. (20) and dwarswaard and van de bovenkamp (21) on, respectively, self-management support considered from the perspective of patients and the ethical dilemmas faced by nurses in providing self-management support (whereby self-management is defined as “the involvement of patients in their own care process” (21), and in that way relates to the above-mentioned notion of individual responsibility). study objectives and research questions no comprehensive ethical approach towards the impact of the social support act 2015, however, appears yet to exist. the current study intends to fill in this gap, by answering the following research question: to what extent did/do municipalities in the netherlands take potential moral conflicts into account when implementing and executing the social support act 2015? as the core of the 2015 dutch long-term care reform is characterized by, on the one hand, severe budget cuts, and, on the other hand, by a normative reorientation towards a participation society wherein people are expected to take on more individual and social responsibility (16,17), we additionally formulated the following sub-research questions: 1. how do municipalities divide scarce resources in the social domain in a fair way?; 2. how do municipalities empower citizens towards a participation society? in answering both research questions we consider the potential moral conflicts experienced by municipalities, as executers of the social support act 2015, with regard to those entitled (or proclaim to be entitled) to receive support on the basis of the social support act 2015, as well as with regard to relatives providing informal care to the previous group. despite the fact that the nature, as well as corresponding reforms, of individual countries’ long-term care systems differ, the systematic approach of assessing moral conflicts resulting from the introduction of new long term policies as applied in this study could also be transferred to other countries were long term care reforms are being implemented. at the same time, several policy lessons could be derived from the experiences of dutch municipalities with the 2015 long-term care reform. methods research method and study design to answer our research question, a mixed-method research approach was chosen. first, a document analysis was conducted, in order to explore if, and to what extent, ethical values and principles are literally incorporated in the legal text of the social support act 2015. for 43 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 this analysis we only considered the primary source (the legal text itself) and no other, secondary documents (such as municipal policy documents). second, policy advisors (responsible for the long-term care policy domain) of all 390 dutch municipalities were invited to complete anonline survey. henceforth, no sampling technique had to be applied, although of course we had to compile a mail distribution listconsisting of either the general e mail addresses of municipalities, or the e-mail addresses of the specific departments the intended policy advisors are working. in some smaller municipalities these policy advisors were not only responsible for the long-term care policy domain, but for the whole social domain (next to the long-term care decentralization, municipalities were simultaneously also faced withdecentralizations in the field of youth care and in the field of labor participation of people with an occupationaldisability); in large municipalities more than one person might be responsible for the long-term care policy domain. however, in our explanatory notes we specifically asked to forward our demand to one of the intended policy advisors, in order to avoid multiple respondents from the same municipality. the reason for choosing policy advisors, instead of politicians, had to do with the potential political bias that politicians might have with regard to the topic of this study. indeed, the potential ethical implications surrounding the long-term care decentralization constitutes a politically sensitive issue in many municipalities, as clearly came to the forefront in one of the two test-interviews, which was conducted with the major of a municipality (the other test-interview was conducted with a professor of old age medicine). moreover, while each municipality also has several so called ‘social support act consultants’ [in dutch: wmoconsulenten], who do the actual fieldwork, implying the one-to-one contact with individual (potential) clients, these employees are believed to lack an overarching helicopter view. in principle, participation in the online survey was anonymous, except when a respondent declared to be willing to participate in an in-depth telephonic interview. these in-depth interviews constituted the third step in our mixed-method research approach, and were intended to expand on the survey, instead of asking new questions. anonymity of these respondents has been guaranteed by omitting persons’ and municipalities’ names here. theoretical framework and conceptual model for the analysis of the potential moral conflicts surrounding the implementation and execution of the social support act 2015, we applied a ‘coherentist’ approach(consisting of both rights-based and consequentialist strands of ethical reasoning) as offered by schröder bäck et al. (22), thereby putting six ethical principles at the core that are considered to capture the specificities of the current study (non-maleficence & beneficence, health maximisation / social beneficence, respect for autonomy, social justice, efficiency and proportionality). taking into account the variety of seemingly similar concepts such as ‘ethical dilemmas’, ‘moral conflicts’, ‘moral dilemmas’, et cetera, it should however first be clarified which definition is applied in this study and what is meant with it. given the heavily-loaded connotation of the term ‘ethical dilemma’, we prefer the term ‘moral conflict’ here. subsequently, based on the stanford encyclopaedia of philosophy (23), we define a ‘moral conflict’ as follows: a moral conflict appears if one thinks one has good moral reasons to do one thing, but also good moral reasons to not do it, or do something that is in conflict with it. so either decision is not perfect. or, in other words: a moral conflict arises if the moral norms and values we would like to follow guide us to conflicting/opposing actions. a coherentist ethical approach, then, implies that an ethical analysis “should be based on a variety of plausible norms and values” and that none of the traditional ethical approaches is therefore superior to the other (22). instead, they all contribute important moral insights. schröder-bäck et al. (22) add to this that “their norms do weigh prima facie the same and need to be plausibly unfolded and specified in a given setting. when they are contextualised 44 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 and specified they develop their normative weight and power”. this prima facie status of the ethical principles thus “supports the process of careful ethical deliberation and reflection”. moreover, specifying the more ‘overarching’ ethical approaches into a concise set of ethical principles is considered as a useful, practical, tool for medical and public health ethics (24). each of these six principles will be discussed in detail in the following. non-maleficence and beneficence: non-maleficence implies that “a healthcare professional should act in such a way that he or she does no harm, even if her patient or client requests this” (25). beneficence is connected to non-maleficence, the only difference being that non maleficence involves the omission of harmful action and beneficence actively contributes to the well-being of others (25). because of their intimate connection, both principles are considered under one heading here. considering the overarching approaches to ethical reasoning as mentioned above, the principles of non-maleficenceand beneficencecorrespond to the ‘do no harm’ principle under the consequentialist approach to ethical reasoning. health maximisation / social beneficence: although in the literature one can find either of these terms, we refer to social beneficence as the norm that says that it is a moral goal to improve the wellbeing of people on an aggregated population level. social beneficence resembles in a significant way the consequentialist principle of utilitarianism. utilitarianism is the ethical theory that requests from an action or omission to be in such a way that the maximization of best consequences would follow. respect for autonomy: the ‘respect for autonomy’ principle implies a tempering of the “paternalistic benevolence contained in the principles of non-maleficence and beneficence” (25). in that way, the ‘respect for autonomy’ principle is closely related to the ‘human dignity’ principle under the rights-based approach to ethical reasoning. moreover, without taking into account the ‘respect for autonomy’ principle, it would under the principle of health maximisation / social beneficence alone be allowed “to use individuals (or whole groups) for other than their own ends and even sacrifice them if only this provided a greater net benefit, i.e. maximised health” (24). social justice: the principle of (social) justice as referred to under the rights-based approach to ethical reasoningcan be considered another side constraint to the principle of health maximisation / social beneficence. as schröder-bäck et al. (24) put it: “it does not only matter to enhance the net-benefit; it also matters how the benefits and burdens are distributed”. moreover, this also includes “a fair distribution of health outcomes in societies, which is often discussed in terms of public health as ‘health equity’” (25), which is considered by daniels as a matter of fairness and justice (26). in fact, the principle of ‘equity’ constitutes the core of the values of the ‘council conclusions on common values and principles in european health systems’. as schröder-bäck et al. (22) put it: “the other three overarching values can be conceptualised as specifications of equity (and of social justice). access to good quality of care and universality can be seen as a reiteration of the core demands of equity and justice”, while “solidarity is seen as a characteristic that describes the willingness of members of communities to be committed to the principle of justice or to each other”. in short, one could argue thus that “[j]ustice approaches in health care often demand nothing more than universal access to good quality care” (22). or, as the world health organization (who) puts it: “universal health coverage (uhc) is defined as ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship” (27). efficiency: efficiency requires the efficient use and distribution of scarce health resources (24). 45 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 proportionality:the principle of proportionality, finally, emphasizes that it is “essential to show that the probable public health benefits outweigh the infringed general moral considerations. all of the positive features and benefits must be balanced against the negative features and effects“ (24). in their ‘ethical criteria for immunization programmes’, verweij and dawson (28) combine the principles of efficiency and proportionality under one heading, by stating that a “programme’s burden/benefit ratio should be favourable in comparison with alternative […] options”. data collection for the document analysis, we specifically considered the presence of the values as stipulated by the ‘council conclusions on common values and principles in european union health systems’, as well as the six ethical principles elaborated on above. next, for the survey and in-depth interviews, these principles have been broken down into representative survey/interview questions, allowing for a structured and comparative analysis of potential moral conflicts. schröder-bäck et al. (25) applied a similar approach within the context of developing a curriculum for a short course on ethics in public health programmes, by suggesting a checklist consisting of several questions around each of the ethical principles they applied in their study (largely comparable to the six principles as applied in the current study). with the respective author of that study, one question for each of the above six principles was chosen, adapting them to the specificities of the current study, and translated into dutch (see table 1 for the final survey/interview questions). the reason for choosing merely one question per category had to do with the practical limitations of using open-ended questions in an online survey: based on andrews (29) as well as on two test-interviews we conducted, the response rate to open-ended survey questions is considered to be substantially lower than in the case of closed-ended survey questions, especially when the number of questions would be too high. the questions covering each of the six ethical principles were preceded by a general question on the identification of potential moral conflicts (intended to trigger respondents, before directing them into the six predefined categories), and followed by two general questions on the way (if applicable) municipalities deal with the identified moral conflicts. data analysis the document analysis implied a scrutinization of the presence (or non-presence) of the values and principles elaborated on abovein the legal text of the social support act 2015, either in terms of a literal incorporationin the legal text, or in terms of indirect referrals to the respective values and principles. the data of the surveys and interviews were analysed through the application of a directed approach to qualitative content analysis (30). we chose for this approach, as it allows for an analysis that “starts with a theory or relevant research findings as guidance for initial codes” (30). in that way, we were enabled to directly apply our theoretical framework of ethical reasoning in the interpretation and categorisation of the research data, with the six predefined ethical principles as initial coding categories. within each of these categories, we clustered the respondents’ answers in ‘dominant responseclusters’ as a way of quantifying to some extent our qualitative survey results. this approach allowed for an organized inclusion of the main results in this article. obviously, qualitative results can never completely be quantified, as each specific answer remains unique. therefore, in order to add some extra weight to our results, we included direct respondents’ quotes to several of the dominant response clusters. 46 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 table 1. survey/interview questions q1: according to you,what are the most important moral conflicts (if any) your municipality has been faced with in the context of implementing and executing the social support act 2015? ethical principles original selected ‘check marks’(25) adapted questions ethical principle 1: non-maleficence & beneficence ethical principle 2: health maximization / social beneficence ethical principle 3: efficiency ethical principle 4: respect for autonomy ethical principle 5: (social) justice ethical principle 6: overall, for both non-maleficence and beneficence, is it possible to assess whether more benefit than harm is produced by intervening (or not intervening) and, if so, on what side (benefit or harm) does the equation finally fall? does it [the proposed intervention] have a sustainable, long-term effect on the public’s health? awareness of scarcity of public money; saved money can be used for other goods and services. does the intervention promote the exercise of autonomy? does the intervention promote rather than endanger fair (and real) equality of opportunity and participation in social action? q2: according to you, will more people (both care recipients as informal caregivers) have advantage or disadvantage as a result of the introduction of the social support act 2015? how do these advantages and disadvantages look like? q3: according to you, will the social support act 2015 have a sustainable, long-term, effect on the quality of life of the entire (older) population? q4: according to you, how does your municipality deal with the availability of the scarce resources that are available for the social support act 2015? q5: according to you, does the social support act 2015 provide sufficient opportunity for people’s freedom of choice with regard to the care and support they wish to receive (and the way how they receive it)? q6: according to you, do people under the social support act 2015 have an equal opportunity to live their lives the way they want (or, in other words: is the freedom of choice as mentioned in the previous question also practically possible for every person)? q7: according to you, will costs proportionality are costs and utility proportional? and utility under the social support act 2015 be proportional? q8: according to you, how does your municipality deal with the moral conflicts as identified under part 1? or, in other words: what are your municipality’s solutions to these moral conflicts? q9: according to you, are there, for your municipality, alternative ways of executing the social support act 2015, that will lead to less moral conflicts? part 1: identifying potential moral conflicts part 2: dealing with moral conflicts 47 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 results document analysis in terms of the values as stipulated by the ‘council conclusions on common values and principles in european union health systems’, the legal text of the social support act 2015 only literally makes reference to the value of ‘access to good quality care’, although quality of care should be understood here as ‘good quality of (social) support’. indeed, as was explained in the previous chapter, the dutch long-term care system is, as of 1 january 2015, divided into three laws, of which the social support act 2015 constitutes the one mainly dealing with social types of care (directed at increasing or maintaining the self-sufficiency and social participation of vulnerable citizens) instead of traditional healthcare. the municipalities’ responsibility under this law can therefore best be understood as providing adequate social support services instead of providing actual healthcare services. nevertheless, this focus on social types of care instead of traditional types of healthcare, or on ‘well-being’ instead of ‘health’ as a desired outcome of support, does not imply that the social support act 2015 should not be based on certain key ethical values or principles. also the council conclusions (1) go further than traditional healthcare, by implying that “[t]he health systems of the european union are a central part of europe's high levels of social protection, and contribute to social cohesion and social justice as well as to sustainable development”. with regard to good quality of social support, then, article 2.1.1 of the social support act 2015 stipulates that “[t]he municipal council is responsible for the quality and continuity of services” (authors’ own translation), while article 3.1 continues by stating that “[t]he provider shall ensure the provision of good quality services” (authors’ own translation). services either refer here to ‘general services’ (in dutch: algemenevoorzieningen), or to ‘customized services’ (in dutch: maatwerkvoorzieningen). the latter, subsequently, is defined in the legal text as a “range of services, tools, home adaptations and other measures, tailored to the needs, personal characteristics and capabilities of a person” (authors’ own translation). solidarity is by definition an important component of this law, and is referred to in the first sentence of the legal text, which points out that “citizens bear a personal responsibility for the way they organize their lives and participate in society, and that may be expected of citizens to support each other in doing so to the best of their ability” (authors’ own translation). the values of universality and the, more overarching, value of equity (being part of the principle of social justice in our theoretical framework) are indirectly referred to in the introduction of the legal text by stating that “citizens who themselves or together with people in their immediate environment are not sufficiently self-sufficient or insufficiently able to participate [in society], must be able to rely on organized support by the government” (authors’ own translation). as a result of the limited literal inclusion of these ethical values, it is not surprising that the more specified ethical principles derived from these values are hardly included in literal terms in the legal text neither. the only exception here is the ‘respect for autonomy’ principle, that could be derived from the wording of article 2.1.2 (4.c), which stipulates that municipalities in their social support policy should specifically take the freedom of choice into account of those citizens that are entitled to customized support services. survey and interviews having considered the literal inclusion of the ethical values and principles in the legal text of the social support act 2015, a next step in our research process was to examine to what extent municipal policy advisors consider the execution of the social support act 2015 to be in compliance with the six ethical principles as applied in this study. in totality 70 policy advisors completed the survey, constituting 18 per cent of dutch municipalities. in total, ten 48 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 of these respondents also appeared to be willing to participate in an in-depth interview. the results of the surveys and in-depth interviews are described question by question in the followingsection and discussed simultaneously (as the in-depth interviews were intended to expand on the survey results instead of asking new questions).given the number of respondents, only those answers that most frequently resulted from our analysis (the ‘dominant response clusters’ mentioned above) are discussed here. the direct respondents’ quotes that are included are believed to represent the respective cluster best and are the authors’ own translations from dutch to english. question 1 (general identification of moral conflicts). although not all respondents confirmed the existence of moral conflicts with regard to the implementation and execution of the social support act 2015, most respondents did identify one or more moral conflicts. in general, our respondents identified threetypes ofmoral conflicts. first, the conflict of adhering to the social support act’s underlying theory of moving towards a participation society vs. the limited budget and time-frame that is offered to municipalities for supporting this change process. indeed, the theoretical idea of moving towards a society wherein citizens take up more individual and social responsibility and where care and support is provided on a customized basis and closer to home, is considered by many as a positive normative development. however, the severe budget cuts that accompany the long-term care decentralization (expected to lead to budgetary shortfalls), as well as the rapidity of the reform process, hamper municipalities’ opportunities for supporting this development. or, as one respondent put it: “pragmatism prevails over quality demands”. second, respondents identified the conflict of how to efficiently coordinate responsibilities between the three different long-term care acts. the fact that municipalities under the long-term care reform only got responsibility for parts of the long-term care sector might lead to unclarity and confusion, not the least among (potential) recipients of care/support, regarding under which act one is entitled to care/support. moreover, some respondents indicated that an insufficient coordination between the three laws sometimes results in a lack of incentives among municipalities to invest in prevention and informal care support, as the financial benefits of these investments might not be evident for the ‘own law’, but only for the ‘other laws’. the third moral conflict identified relates to the correct assessment of citizens’ self-sufficiency and their ability to social participation vs. their care/support needs and the urge to empowerment. the fact that municipalities have a large policy discretion in executing their responsibilities under the social support act 2015 even complicates this point, as similar situations might well lead to different assessments in different municipalities. particularly difficult, then, is how to justify these differences to citizens. question 2 (ethical principle 1: non-maleficence and beneficence). most respondents appeared to have a rather neutral stance when it comes to assessing the non-maleficence and beneficence of the social support act 2015, arguing that the act leads to advantages for some and disadvantages for others, especially on the short-term. or, as one respondent put it: “it depends on the individual perception of people whether they experience the introduction of the new social support act as an advantage or a disadvantage”. moreover, getting used to a new situation always takes time, especially for those citizens that were already entitled to care or support under the pre-2015 situation. advantages primarily include the provision of customized care closer to home, in line with people’s specific living conditions, instead of standard care provisions like in the pre-2015 situation. disadvantages primarily include the, already above-mentioned, high degree of policy discretion of municipalities regarding their allocation of support measures—which tends to lead to perceptions of ‘unfairness’ or ‘subjectivity’ among citizens—, a lower level of formal care provision as experienced by individual citizens and consequently the increasing burden on informal caregivers. 49 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 question 3 (ethical principle 2: health maximization / social beneficence). the decreasing level of formal care provision can also be considered as a disadvantage on a societal level, when considering the more long-term expected consequences of the implementation of the social support act 2015. at the same time, a decreasing level of formal care provision is not considered by all respondents as a disadvantageous development. as one respondent put it: “if we execute it [the social support act 2015] well, this will increase quality of life. however, this also entails that we should carefully deal with informal caregivers”. one of the more long-term advantages is indeed believed to be the creation of a better awareness and appreciation among citizens about care in general, as a result of the diminishing resources for formal care provision, leading to a more inclusive society—characterized by the emergence of a new quality of life—wherein people have a better esteem of their own possibilities as well as a better appreciation of each other. at the same time, many respondents pointed out that this ‘emergence of a new quality of life’ is not so much due to the social support act 2015 (or the long-term care reform in general), but more to overarching trends such as demographical developments (people get older and older), technological developments in healthcare (which facilitate people in achieving a decent quality of life) and changing ways of thinking about care in general (such as other perspectives on civic engagement and patient empowerment). as one respondent put it: “the quality of life has always had a different standard than the generation before”. or, as another respondent put it: “laws don’t have an influence on quality of life”. question 4 (ethical principle 3: respect for autonomy). respect for autonomy was considered by most respondents as being sufficiently covered by the social support act 2015, specifically through the inclusion of the freedom of choice as mentioned under article 2.1.2 of the social support act 2015. concretely, the freedom of choice as referred to in article 2.1.2 implies either the choice between several by the municipality selected providers (when one is entitled to customized care services) or a fully open choice (when one is entitled to a personal budget). yet, respondents did put several remarks to this freedom of choice. first, due to the large discretion municipalities have in executing the social support act 2015, the interpretation of freedom of choice differs between municipalities (indeed, some municipalities offer a larger selection of providers than others). as one respondent put it: “the new social support act isn’t designed as to ‘support wishes’, nor as a ‘right to support’. therefore, there is a strong dependence on supplemental local rules”. second, in practice, freedom of choice is not always considered as an added value by people, especially by vulnerable people that are often just looking for good quality support. as one respondent put it: “for that [freedom of choice] there is little attention among people. moreover, it is questionable whether that is actually needed; people merely want good quality care instead of freedom of choice” (author’s own translation). question 5 (ethical principle 4: social justice). in line with the previous question, the question about social justice was basically about people’s capabilities of making use of their right to freedom of choice. answers to this question were divided. on the one hand, many respondents considered the majority of people that are entitled to support under the social support act 2015 to be indeed capable of making use of their right to freedom of choice. moreover, when necessary, support is offered to clients by the municipality. as one respondent put it: “the municipality is actively cooperating with ‘client supporters’ to facilitate people as good as possible in their freedom of choice” (these ‘client supporters’ are people that work independently from the municipality). on the other hand, other respondents emphasized that not everyone, especially vulnerable groups in society, are capable of applying their freedom of choice, neither has everyone a social network at her/his disposal to support them in doing so. moreover, freedom of choice depends to some extent on people’s 50 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 own resources. indeed, under the social support act 2015, the own financial contributions people are expected to pay for the care/support they receive have grown as compared to the pre-2015 situation, which might lead to the avoidance of care/support (31). as a result, respondents argue, differences in society grow when it comes to the possibility of people to make use of their freedom of choice under the social support act 2015. as one respondent put it: “a barrier to care is created, that leads to a split in society: if you have money you can buy care yourself; if you little money you’ll have to do it with a stripped care system”. question 6 (ethical principle 5: efficiency). with regard to the allocation of scarce resources, respondents’ views could be divided into three main groups. one part considered the budget available for the execution of their long-term care responsibilities, which was substantially lowered as compared to the pre-2015 situation, to be leading in the allocation of resources, implying that care/support demands are (according to these respondents) considered more critically—on the basis of stricter indications—as compared to the pre-2015 situation. as one respondent put it: “the resources are distributed as indicated by the national government”. moreover, some municipalities try to focus on general (collective) support services instead of on customized (individual) support services in order to remain within their budgetary margins. a second groups considered demand to be key in decision-making, implying that as much as possible is done to do what is necessary, at least for the most vulnerable groups. in case of shortages, solutions are (according to these respondents) considered to be the appeal to general municipal resources or the transfer of resources from other policy domains within the municipality. indeed, many municipalities are currently searching for more integral ways of working between the different parts of the social domain within their municipality (17). one respondent formulated it as follows: “it starts with the client and we do what is necessary; many roads lead to rome”. a third, though smaller, group took a more neutral stance and considered the underlying idea of the long-term care reform (truly progressing towards a participation society) to be key in decision-making, implying that ‘new’, ‘creative’, or ‘innovative’ solutions have to be sought in balancing between a limited budget and the existing (or even growing) care/support demand. one respondent covered this point by stating that we should “learn people how to fish instead of supplying the fish”. apart from an increased focus on prevention (e.g. by supporting, or cooperating with, citizens’ initiatives and/or informal care organizations), it remains however unclear what is exactly meant by ‘innovative solutions’. question 7 (ethical principle 6: proportionality). next, respondents were asked whether they think the social support act 2015 can be considered as a proportionate measure for the goals it intends to pursue. in general, respondents considered this proportionality indeed to be present, thereby primarily making the comparison to the pre-2015 situation, which was considered by many as ‘unfair’ and ‘untenable’ due to the often exaggerated care demands of people (the so-called ‘claim-mentality’). or, in the words of one respondent: “a greater reliance on an own network / own resources will eventually replace the claim-mentality (‘i am entitled to’) and thus be cheaper”.another group of respondents considered the underlying idea of the decentralization (providing care and support on a customized basis and closer to home) as a positive normative development, while being worried about the budget cuts that accompanied the decentralization. as one respondent put it: “there will only be a balance in case of sufficient budget and autonomy for municipalities”. for this group of respondents, the social support act 2015 is considered to be putting a disproportionate burden on society. for part of this latter group, this disproportionality is likely to reduce in the longer-term, due to a gradually reducing ‘claim-mentality’ within society. for another part, however, the reduction of long-term care costs in the longer-term will not be the result of a more efficient provision of long-term care, but will simply be the result of the mere fact 51 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 of less available financial resources (and thus less possibilities), leading logically to less expenses in the long-term care sector. question 8 (dealing with moral conflicts). the last two questions of the survey referred to the way municipalities deal with the identified moral conflicts. in general, most respondents pointed to the importance of communication and transparency here. on the basis of regular deliberations, meetings and conversations with both care/support providers, surrounding municipalities, care/support recipients and their informal caregivers, and other stakeholders, the execution of the social support act 2015 is evaluated regularly and adapted where necessary. moreover, although the large discretion that municipalities have in assessing citizens’ care/support needs is considered by many citizens as unfair or subjective (as we mentioned before), the best way of dealing with this discretion according to our respondents is to critically assess each individual situation in-depth, offer customized support where possible, be open and transparent towards care/support recipients and their informal caregivers, and thoroughly explain the choices made where necessary. as one respondent captured it: “continue discussions, while in the meantime also ensuring that the necessary care delivery continues”. question 9 (dealing with moral conflicts: alternatives). subsequently, respondents were asked whether they foresaw alternatives with regard to the execution of municipalities’ long term care responsibilities. many pointed to the unlikelihood of such an option, as the social support act 2015 is an established fact by law. others argued that neither option would be perfect and that turning to an alternative law now would be going back to square one. most respondents, however, interpreted this question not so much in terms of alternatives to the social support act 2015 in itself, but in terms of possible alternatives in the execution of this law. most of these respondents pointed to the potential release of more financial resources by the national government. at the same time, respondents acknowledged that although the availability of more financial resources would make life easier, it would not dissolve moral conflicts. a second alternative would be a clearer delineation between (or integration of) the different long-term care acts. respondents argued for example that it would have made more sense if the complete package of non-residential care services was put under responsibility of either the municipalities, or the health insurers. currently, the majority of non-residential care services is under responsibility of the health insurers, and only a small part under responsibility of the municipalities. finally, respondents pointed to the need for more innovative and unorthodox solutions, arguing that the social support act 2015 is not an aim in itself, but a means to deliver good care/support. or, as one respondent put it: “every law has an article 5”, implying that governments should sometimes turn a blind eye in the execution of policies. discussion principal findings and conclusions the aim of this study has been to examine to what extent municipalities in the netherlands take/took potential moral conflicts into account when implementing and executing the social support act 2015. we intend to answer our research question by relating the results corresponding to each of the six principles of our theoretical framework back to the coherentist approach of ethical reasoning this framework was based on. as was mentioned before, the coherentist approach is based on two main strands of ethical reasoning, being the ‘rights-based approach’ and the ‘consequentialist approach’. within a consequentialist approach, “actions are judged for their outcome and overall produced value” (22). this approach is basically founded on such principles as ‘health maximisation’ and ‘do no harm’ (22), corresponding to the principles of non-maleficence & beneficence and social 52 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 beneficence in our theoretical framework. in a public health context a consequentialist approach to ethical reasoning implies that health should be maximised, “as long as health maximisation is not endangering the maximisation of the overall utility of people” (22). as was described in the previous chapter, most of our respondents appeared to have a rather neutral stance with regard to assessing the non-maleficence and beneficence of the social support act 2015, emphasizing that it depends to a large extent on the individual perception of people whether they experience the introduction of the new social support act as an advantage or a disadvantage. with regard to social beneficence we found that, despite worries about the decreasing level of formal care provision, most respondents considered the creation of a better awareness and appreciation among citizens about care in general to be one of the more long-term advantages of the social support act 2015. at the same time there are also doubts about the impact that a law can have on such developments as new ways of thinking about long-term care (referred to above as a ‘normative reorientation’ towards long-term care). indeed, concepts such as the concept of ‘positive health’ as developed by huber et al. (4) are gaining importance within the healthcare sector.the conceptof ‘positive health’ considers health as “the ability to adapt and to self manage” (4) instead of considering it under the traditional who definition as “a state of complete physical, mental and social well being and not merely the absence of disease or infirmity” (32). a rights-based approach is basically founded on such principles as ‘human dignity’ and ‘justice’, corresponding to the principles of respect for autonomy and social justice of our theoretical framework, and claims that “persons have rights to fair equality of opportunity” (22). in a public health context this implies that people have a right to (equal opportunity) “to receive appropriate healthcare and live in environments in which social determinants of health are distributed in a fair way” (22). as we saw in the previous chapter, most respondents considered respect for autonomy to be sufficiently covered by the social support act 2015, mainly by its emphasis on freedom of choice. at the same time, however, our respondents pointed out that exactly freedom of choice is something that is not always of added value in a context wherein people are often just looking for good quality support. moreover, while social justice (people’s capabilities of making use of their right to freedom of choice) was considered to be sufficiently present for the majority of people, it is also exactly this point that respondents appeared to be most worried about in light of the social support act 2015, especially when applying it to vulnerable groups in society. indeed, the legal text of the social support act 2015 hardly stresses the importance of such notions as ‘equity’, one of the core underlying values of the principle of social justice. although the legal text stipulates that “citizens who themselves or together with people in their immediate environment are not sufficiently self-sufficient or insufficiently able to participate [in society], must be able to rely on organized support by the government”, it remains unclear when exactly someone is ‘insufficiently self-sufficient’, ‘insufficiently able to participate in society’, and (in case someone is entitled to support) when one is entitled to ‘general services’ and when to ‘customized services’. indeed, as was argued by maarse and jeurissen (16), municipalities actually have a large policy discretion with regard to the allocation of support measures (the so-called ‘zip code rationing’), which may lead to unequal access to long-term care. in fact, this point was one of the three main moral conflicts as identified by our respondents under question 1 of the survey. moreover, as argued by van der aa et al. (18), with the advent of the social support act 2015 a shift can be witnessed from a ‘right to care’ to a ‘right to customized support’. next, although solidarity is by definition an important component of the social support act 2015, the act foresees a shift from formal to informal solidarity (18). it remains, however, doubtful how much can be expected of this informal solidarity. as maarse and jeurissen (16) already pointed out, “the potential of 53 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 ‘unexplored’ informal care is overestimated. furthermore, the negative externalities for caregivers who deliver intense informal care are underestimated”. finally, the legal text of the social support act 2015 stipulates that “it is desirable to set new rules, in order to bring citizens’ rights and duties more in line with each other” (authors’ own translation), which tends to imply a decreasing government responsibility for citizens’ rights to equality of opportunities regarding access to good quality care/support. our first sub-research question was specifically directed towards the way municipalities divide scarce resources in the social domain in a fair way. as we saw in the previous chapter, our respondents’ views towards principles of efficiency and proportionality were quite divergent. on the one hand, the availability of less public resources for long-term care and the higher own financial contributions people are expected to pay for the care/support they receive might eventually lead to a more conscious use of care (and in that way contribute to the normative reorientation of creating a true participation society). on the other hand, however, these developmentsmight unconsciously lead to the creation of an access barrier to care (especially for the less affluent in society) or to the avoidance of necessary care. in fact, the conflict of adhering to the social support act’s underlying theory of moving towards a participation society while at the same time having to deal with the limited budget and time frame that is offered to municipalities for supporting this change process was one of the three main moral conflicts as identified by our respondents under question 1 of the survey. moreover, within the context of the social support act 2015 ‘efficiency’ might primarily be understood as a way of justifying the budget cuts that accompanied the long-term care decentralization, instead of as a moral obligation to efficiently use scarce health resources. at least part of the solution to the dilemma of how municipalities then can divide scarce resources in the social domain in a fair way might be provided by the ‘accountability for reasonableness’ approach of procedural justice by daniels and sabin (33), which offers a “minimum ethical standard in times of economic downturn characterized by scarcity of resources and when not all needs are being satisfied” (13). the accountability for reasonableness approach requires certain conditions to be met in order for a process of allocating scarce healthcare resources to be ‘fair’: the process (including the reasoning behind it) has to be transparent to the public, the reasons by which decisions were made have to be relevant, and it should be possible to revise any decision in case of new evidence or arguments (13). these conditions are quite in line with our results under question 8 (dealing with moral conflicts), emphasizing the importance of communication and transparency in the process of dealing with moral conflicts (such as the division of scarce resources). finally, in order to answer our second sub-research question (regarding the way municipalities empower citizens towards a participation society), it has to be determined how the kind of efficiency goals as discussed under the previous sub-question can be reconciled with moving towards a participation society; or, in other words, does the latter lead to the former, or does the former require the latter? is thus “participation” a good value or a fig leaf or metaphor for a liberalist mindset? we argue that although participation is an intended goal of the social support act 2015, citizens are insufficiently supported to achieve that participation. as we argued before, ‘support’ under the social support act 2015 is intended to be limited to those citizens who themselves or together with people in their immediate environment are not sufficiently self-sufficient or insufficiently able to participate. or, as maarse and jeurissen (16) put it: “the wmo 2015 gives applicants a right to publicly funded support if they cannot run a household on their ownand/or participate in social life”. however, proactively supporting citizens towards the initial goal of creating a participation society (e.g. by focusing on preventive measures), is much less pronounced in the legal text of the social support act 2015. article 2.1.2 (c, d and e)points in general terms at, 54 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 respectively, the early determination of citizens’ support needs, the prevention of citizens’ reliance on support, and the provision of general support services (provided without the prior examination of the recipient’s need, characteristics and capabilities). however, how to achieve these points is left to the municipalities’ discretion. in the same vein, article 2.1.2b points out that “the different categories of informal caregivers should be enabled as much as possible to perform their duties as informal caregiver” (authors’ own translation), but this point is not specified in the remainder of the legal text. this point is therefore, we argue, much less concrete as compared to the old 2007 social support act (under which municipalities where merely responsible for domestic help), where support for informal caregivers was concretized in such sub-themes as information, advice, emotional support, education, practical support, respite care, financial support and material support. at the same time, this high degree of policy discretionfor municipalities under the 2015 social support act gives room for ‘innovative and unorthodox solutions’, as was indicated by several of our respondents, although this may require the availability of more financial resources and/or a clearer delineation between (or integration of) the different long-term care acts (the latter being one of the three main moral conflicts as identified by our respondents under question 1 of the survey). coming back to our main research question (“to what extent did/do municipalities in the netherlands take potential moral conflicts into account when implementing and executing the social support act 2015?”), we conclude by arguing that while municipalities are indeed aware of (potential) moral conflicts, the nature of the new law itself leaves insufficient room for municipalities to act in a sufficiently proactive and supportive/empowering manner on these challenges, as well as on the long-term aim of the social support act 2015 of achieving a true participation society. the reasoning behind this argumentation is that although the new law appears to emphasise such ethical principles as social beneficence and respect for autonomy, the lack of emphasis on notions of social justice threatens to impede the effectuation of the intended goals in practice. moreover, the social support act 2015 seems to be mainly directed towards achieving a certain outcome (the maximisation of social beneficence through the creation of a participation society), instead of stipulating how that outcome should exactly be achieved in a fair manner. as such, the social support act 2015 insufficiently seems to provide equality of opportunity with regard to long-term care access, both between citizens within the same municipality, as (and perhaps especially) between different municipalities. at the more short-term, taking into account a minimum set of ethical principles allows for the allocation of (seemingly scarce) resources that is, at the least, as fair as possible. study strengths and limitations and suggestions for further research the principle strength of this study has been the application of a broad ethical approach towards scrutinizing a new, and still sensitive, policy responsibility of dutch municipalities. we have shown that taking into account a minimum set of ethical principles, raises awareness of (potential) moral conflicts within the context of the new social support act. being aware of such conflicts, at its turn, helps in executing the new responsibilities under the social support act in an appropriate manner (or in justifying decisions towards citizens) and gives room for municipalities to act in a as proactively as possible manner on the challengesresulting from these new responsibilities. next, the fact that all dutch municipalities were invited to participate in our study led to a reasonable response rate, in terms of reaching a saturation point in our data analysis. at the same time, the limited response rate to the invitation for a telephonic interview might have led to a certain selection bias, as not all respondents have given the same level of in-depth explanation to their survey answers. moreover, it might have been valuable if additional questions were added to the in 55 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 depth interviews, although also the semi-structured character of these interviews already 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permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://plato.stanford.edu/archives/fall2014/entries/moral-dilemmas/� http://www.who.int/health_financing/universal_coverage_definition/en/� http://www.binnenlandsbestuur.nl/sociaal/nieuws/kwart-zorggebruikers-mijdt-dure-� http://www.who.int/governance/eb/who_constitution_en.pdf� http://creativecommons.org/licenses/by/3.0)� 57 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 original research from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003 aloysius p. taylor1 1 affiliation: independent consultant corresponding author:aloysius p. taylor address: monrovia, liberia e-mail: aloysiustaylor@hotmail.com mailto:aloysiustaylor@hotmail.com� 58 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 abstract aim:to explore the experience of fighters disabled during the liberian civil war; what they did and what was done to them; and what happened after their demobilization. methods:six focus group discussions were organized in monrovia, the capital of liberia, with 50 invalid veterans aged 10 to 25 at their entrance into the war and eightwomen wounded, although civilians, sampled as in convenience. in addition,sevenkey-informant interviews took place. all encounters were agreeably taped, transcribed and summarized under the items of the discussion guide. results:most ex-combatants joined the fighting to protect themselves and their families who were targeted by rebel fighters or joined to revenge the killing of close family members by fighters from all sides including government soldiers. nearly all the former fighters interviewed expressed their desire to be trained in various areas of life skills. a vast majority of the ex-combatants are living from begging in the streets.those from factions feel that government cares for former regular soldiers and discriminates those from other warring factions. the lack of housing for ex-combatants with war related infirmities is of paramount concern to them. they feel that the post-war reintegration program did not achieve its objectives. in the communities, they are stigmatized, blamed as the ones who brought suffering to their own people. the key informants are calling for establishment of trust fund for survivors of the civil war who are disabled. recommendations: establishment of a trust fund for survivors of the civil war who are disabled; reform of the national bureau of veteran affairs to include the disabled ex combatants of all former warring factions; erection as planned of the proposed veterans hospital; a national census of disabled ex-combatants and war victims. keywords:civil war, demobilization, disabled combatants, liberia, reconciliation. conflicts of interest:none. acknowledgements: this study has been conducted with service providers in mind, based on the social, economic and health status of the former fighters who were wounded and made disabled by the liberian civil war. first and foremost, many thanks go to professor dr. ulrich laaser who took special interest in the disabled former combatants to the extent that he contributed the financial resources to enable the conduct of this study. he also encouraged colleagues of his to assist the research team implement. prominent among this is dr. moses galakpai who provided technical support to the research team and roosevelt mccaco who in his free time took care of the financial management. we appreciate the work of the research team members who made valuable contributions to the development of the documents leading to the completion of the study. special recognition goes to mr. richard duo of the amputees football club for his coordinating role in facilitating the key informant and focus group interviews. funding: private. 59 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 foreword the civil conflict has been over for nearly as many years as it lasted. the scars however are as visible today as were the horrible episodes of atrocities that characterized life during the war years. the wrecked economy of liberia following the onset of the civil war, gross human rights violations, involvement of child soldiers and use of harmful substances by both armed fighters and civilians are all hallmarks of the liberian civil war. thousands of young people who were active members in the numerous fighting forces got maimed and are today disabled for various causes. what is true for nearly all of them is the fact that they are living under difficult circumstances no jobs, no housing, and no sustainable care. with no preparation to face the harsh post conflict and post ebola environment in liberia, the disabled ex combatants deserve attention that will give them hope, attention that will harness their potentials not only for sustaining themselves but for promoting peace in the nation. this publication, though conducted in only one of the 15 counties of liberia, contributes to the knowledge needed for the attainment of a better living condition for disabled ex-combatants as well as promoting sustainable peace in liberia. dr. moses kortyassahgalakpai former deputy minister of health republic of liberia 60 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 introduction liberia, to mean „land of the free ‟, was founded by freed american slaves who were sponsored to settle in africa as early as 1822. annexation of land from the indigenous tribes enabled the country to be formed until statehood was declared 1847. the lack of full integration of the indigenes was the main trigger for the civil war beginning on christmas eve in1989 (1). the large number of young people exposed to arms and use of harmful substances constitutes a significant risk for the sustainability of peace in the country.the idea to undertaking this explorative study into their feelings and experience comes from the general observation of the appalling conditions of disabled veterans. unable to earn a living due to the lack of skills compounded by the fact that they have lost parts of their bodies, the former combatants are in serious need of assistance which is not forthcoming. not only are the disabled ex-combatants unable to provide daily food for themselves, but they are under incessant barrage of accusations of bringing suffering to their people. such stance inhibits a free flow of material assistance to them as well as social acceptance (2). therefore this investigation attempts to documentfrom their own wordsthe past and present experience of former fighters who were disabled and traumatized during the civil war in liberia including a selected number of civilian women wounded. in addition key informants have been interviewedand asked for their analysis and recommendations. methods study population the qualitative studytook place inmontserrado county which includes the capital monrovia with more than a million inhabitants, about a quarter of libe‟risa entire population. the respondents were recruited by non-probability sampling as in convenience between march 29 and may 3, 2017 through the amputees football club in monrovia (4) and consisted of two categories of respondents: the first comprised of five focus groups of ten former combatants each, together 50participants who were disabled as a result of their participation in the fighting. these persons were from various fighting forces including those from the national army. additionally, there were eight women who received their disabilities from bullets and bombs even though they were civilians; some were targeted while others were accidental.the selection process did not allow anyone to attend more than one focus group. focus group discussions the study relied on a participatory approach and semi-structured narrative format.the discussion guide for the focus groups,taking about three hours,comprised a set of nine questions, assembled by four experts three liberian and one european familiar with the setting. the questions were introduced to the focus groups by amoderator: 1) why and for which faction (out of eight) did you join the fight? 2) what was your rank and war-name and what weapons did you use? 3) what made you brave and how did you get wounded? 4) did you commit atrocities yourself? 5) did you meet later your comrades or your victims? 6) what is your experience with the demobilization program after the war ended? 7) where and how do you live now and how are you received by thecommunity? 8) are you satisfied with your living conditions and what are your expectations? 9) how did you as a women experience the civil war?voices of female survivors. 61 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 key-informant interviews the seven key informants contacted had witnessed events during the civil war and were knowledgeable about former fighters and the programs initiated for their return to civilian life. they saw what happened or took part in what happened such as rendering social, relief or medical services to the population affected by the war. these included stakeholders and others such as project officers, focal point persons in security sector institutions, community leaders, and relevant government personnel. although they were professionals in their own right, some of them were seen as rebel supporters because they operated in particular geographic locations controlled by warring factions. seven such persons were interviewed on issues surrounding the following topics: 1) the disarmament, demobilization, rehabilitation and reintegration program (ddrr) 2) key challenges facing ex-combatants 3) strategic recommendations information processing all encounters were agreeably taped, transcribed and summarized under the items of the discussion guide by a team of liberians under the guidance of the author. results i. the focus group interviews (fdg) characterization of the participants most of the discussants were young school-going children, when the war started. however, as the war progressed educational institutions in the war-affected areas were shut down, leaving thousands of idle youths susceptible to align themselves as child soldiers, boys and also girls (5),with the warring faction that was present in their areas of domicile. 1) why and for which fraction did you join the fight? for most, as seen from their age profile, serving in the military was never then thought of. the discussants disclosed that the war was brought home when they witnessed the gruesome murder and mutilation of their relatives, the personal pain inflicted on them by those bearing arms whether government troops or members of opposing warring factions, the looting of their family‟s properties or just the excitement of being with members of their age group, all thatserved according to them as motivating factors to become fighters themselves. a couple of others were forcefully recruited and others joined because they were used as porters of ammunition and goods for the men at arms.defections from the national army became commonplace joining one of the rebel factions (see box), some related to ethnical or religious background. their allegiance to the armed group to which they belonged became stronger than the bond with their families and socio-cultural institutions that nurtured them and that they once respected. 2) what was your rank and war name and what weapons did you use? in order to persuade their men to obey their authority, those in command assigned meaningless ranks to fighters under their command. such arbitrary ranks gave them an air of greatness. additionally, there was no previous training to back the ranks. the discussants informed that rebel training sometimes lasted for only two months. examples of these fake ranks given by the discussants are: field commander, full colonel, general, captain, brigadier general, lt. colonel, major, chief of staff. 62 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 war-names or nicknames played an important role in the behavior of the individual combatant and how he/she was perceived by comrades and commanders. besides being used as a means to motivate combatants into action, nicknames served to conceal the real identity of the fighter. nicknames were also used to promote certain behavior of the fighter. for example, “dog killer” could mean killer of the enemy (the dog). someone bearing such nick name would live to prove that he is a killer of the enemy. similar other nicknames of discussants were: major danger, super killer, no ma no pa. the discussants indicated that they used various weapons during the course of the war. the predominant one was the kalashnikov (ak47 and others in the series). the combatants used the guns to exploit the civilians in their controlled areas, a major factor for the mass exodus of people out of the country. the proliferation of small arms in all areas controlled by warring factions made the entire country unsafe at the time especially that the combatants according to them served as the “justice systems” in their controlled areas. many of these weapons were traded among warring factions as some combatants switched sides or needed money. however, heavier weapons fielded were more supervised by those in command. 3) what made you brave and how did you get wounded? myths and rumors surrounding the composition of rebel fighting forces and their use of mystic powers coupled with the governmen ‟ts mismanagement of the war, greatly aided the demoralization of the better trained government troops to the point of stimulating mass defections.the rapid advance of rebel forces mainly rested on the highly motivated youths most of whom were given drugs and other substances to influence their behavior, giving them a false sense of invincibility. some others mentioned the use of drugs and strong alcoholic drinks given them by their commanders as sources of their bravery. some wore amulets on their necks and “hands for protection” against bullets. a discussant explained that he was given a talisman belt to wear around his waist which could hold him tight and become very hot when enemies were around. these good luck charms turned up to be fake; many fighters died or got wounded due to their belief in these charms. other reasons cited as sources of their bravery are as follows: • colleagues made me brave • afl distributed the new testament bible • god and the arm given to me • the gun gave me power • the urge to revenge for the killing of relatives military groups named by participants as their own ones: armed forces of liberia (afl) • lofa defense force (ldf) • liberians united for reconciliation and democracy (lurd) • national patriotic front of liberia (npfl) o independent national patriotic front of liberia (inpfl) o national patriotic front of liberia-central revolutionary council (npfl-crc) • united liberation movement of liberia for democracy(ulimo) o united liberation movement of liberia for democracy-johnson faction (ulimo-j) united liberation movement of liberia for democracy-kromah faction (ulimo-k) https://en.wikipedia.org/wiki/armed_forces_of_liberia� https://en.wikipedia.org/wiki/lofa_defense_force� https://en.wikipedia.org/wiki/liberians_united_for_reconciliation_and_democracy� https://en.wikipedia.org/wiki/national_patriotic_front_of_liberia� https://en.wikipedia.org/wiki/independent_national_patriotic_front_of_liberia� https://en.wikipedia.org/wiki/national_patriotic_front_of_liberia-central_revolutionary_council� https://en.wikipedia.org/wiki/united_liberation_movement_of_liberia_for_democracy� https://en.wikipedia.org/wiki/united_liberation_movement_of_liberia_for_democracy-johnson_faction� https://en.wikipedia.org/wiki/united_liberation_movement_of_liberia_for_democracy-kromah_faction� https://en.wikipedia.org/wiki/united_liberation_movement_of_liberia_for_democracy-kromah_faction� https://en.wikipedia.org/wiki/united_liberation_movement_of_liberia_for_democracy-kromah_faction� 63 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 • american war movies • family members were not around, so fear left me when i joined. the discussants narrated various ways in which they received wounds which led to their disability today. to wit: • mistake from friendly forces • enemy fire, on the frontline • aerial bombardment by alpha jet • personal mistake handling grenade • fell in enemy ambush. some of the other causes of wounds which resulted into amputation of limbs are directly reflective of the low level of training of the fighters as regards safe handling of weapons. 4) did you commit atrocities yourself? discussants admitted that they also committed atrocities in response to what others did to them and their people. they said that they killed and raped in revenge for what was done to their family members or relatives. they informed that they saw wickedness in the extremes such disembowelling of pregnant women and using their intestines to intimidate other people at checkpoints. the discussants said that they burned houses and other peop‟lepsroperties because of anger. the discussants also admitted to beating people, looting goods and killing domesticated animals. asked if they have any regrets for also committing crimes against others, a few said they do regret but most of them said no, as they were under the influence of drugs or were forced by their commanders. one discussant said that he did not do anything to anyone but only killed enemies on the battlefield. 5) did you meet later your comrades or your victims? the participants said that they sometimes see their colleagues and those who commanded them during the war, most of them in same impoverished conditions as they are and sometimes even worse. these past commanders, they said, sometimes even asked for help from the disabled ex-combatants in this study: “our former commanders feel more frustrated than us, because they have no more power to do anything or command other people to do something for them”. some met also their victims and begged them to forgive, others saw them on the street but were not given a chance to talk to them or even beaten in revenge. 6) what is your experience with the demobilization program after the war ended? the most contentious issue reference the transition from active combatants to civilian life was the liberia disarmament, demobilization, rehabilitation and reintegration program (ddrr) up to 2009. nearly all of the discussants were not pleased with how it was handled. the vocational training to which some went was rather too short. they informed that they were promised packages at the end of the training which many of them did not receive. they said that their names were written down to be contacted when the packages were reading and up till now nothing has been done. a discussant informed that he entered the ddrr program and spent five days and afterwards used his id (identification) card to enter a vocational institution where he spent nine months, graduating with a certificate but the tools given him and his colleagues did not match the certificate. a few others admitted that they sold their id cards for money.according to discussants who fought for the warring factions, they are dissatisfied over how the government did not arrange a better package as that made for the regular soldiers when in their opinion all of them had served their country. • usd 150 was given to rebel fighters as a one-shot resettlement package 64 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 • government of liberia soldiers were given usd540 and also benefited from appropriate pension arrangement. 7) where and how do you live now and how are you received by the community? most of the disabled ex-combatants congregated in monrovia and its immediate environs for fear of reprisal as stigma against them in their original communities is described as high. most of them are blamed for the atrocities and the sufferings that the civilian population had to endure during the civil war. as a result the furthest distance from the city centre where most disabled are living turned out to becareysburg and gardnersville whereas the heaviest concentration is in paynesville, all less than 50 km away. the discussants were frankto also admitthat they wereashamed toreturn to their original places of residence. furthermore the high cost of rent, distance from their usual places of street begging and the fact that there are some people in their original locals who want them to die, were cited as compelling reason for finding new places to live.many of the fighters refused to go home even up to today. some participants were received well by their families but were rejected by their communities. one discussant said that his parents and other family members cried upon seeing him and later encouraged him not to harm himself. another discussant said that reception was good at first after ddrr but when the money they received from the ddrr was exhausted he was thrown out. yet another informed that he had a girl pregnant for him at time of disarmament but right after his money was finished too, she left him and said that the pregnancy was not his. the psychological anguish and social marginalization ex-combatants have been subjected to have led some of them to attempt suicide. the suicidal inclinations among freshly-wounded ex-combatants were motivated by feelings of being useless after losing limbs, ashamed of their conditions, thinking that they would be rejected by women, being mocked by children or just share embarrassment at the disability. asked why they did not carry out their desire to commit suicide after all, they gave the following reasons: • another disabled friend encouraged me not to kill myself • i made my own decision not to kill myself • nurses at the hospital talked to me and promised me “false legs” after one year. as a result of all these inconveniences, they move in groups and sleep in makeshift huts and market places where the night will find them after a hectic day of begging for alms from humanitarians in the street corners and in front of supermarkets and other public places. 65 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 figure 1. disabled war combatants 1017 8) are you satisfied with your living conditions and what are your expectations? the overwhelming majority of discussants indicated they are not satisfied with their present conditions, both physical and economic. however, they do accept the fact that their physical conditions in the given situation cannot be reversed, so they must live with it. they stated that “no one can be satisfied with this kind of condition, there is nothing we can do” (picture). all the respondents felt that the ddrr was hastily planed and haphazardly implemented and that the implementation period of less than 3 years was grossly inadequate. those who were enlisted in skills training programs were given 6 months to complete the training. they expected the program to last much longer to allow them acquire the knowledge and skills that are marketable. they expected the ddrr to provide free medical care and “we need housing and education for our children as well as jobs to move us from begging in the streets. we also need training to become peace ambassadors to reconcile our country and prevent war”. 9) how did you as a women experience the civil war?voices of female survivors “my son and his friend were hit when they went in our yard to get water from the well. i took them both to jfk hospital and when i went to front street, i was hit too and my hand got broken. i was assisted by government security and icrc; the ministry of finance gave me money to attend to my injury.” “i was a student in grade seven in 1996 when i got shot entering into my own father‟s house. the boy who shot me did it intentionally; five persons were also fired, 2 survived. i used tube for one year eight months.” “i got hit also in 1996. they took me to redemption hospital. one ecowas man helped me and carried me to ghana. i waited 9 month to remove the bullets. i lost one hand and foot.” “i made many attempts to kill myself, each time i tried to do so someone would interrupt.” “i did not go to school. i went to do business, when i got shot at the age of 23, only my mother stood by me, my boyfriend ran away.” “i have had two children since my injury. one is going to school.” “i am making and selling hand bags, neck ties, etc. don bosco taught me.” 66 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 “particles are still in my body; they can be removed but someone has to foot the bill.” “we need help. the government is not focused on the disabled.” “we need micro-loan, wheel chairs and all disabled materials” ii. perspectives of key informants during the study a number of key informants knowledgeable about the former fighters and the programs initiated for their return to civilian life were identified and interviewed. their perspectives have been summarized below. among the views expressed by all key informants is the fact that there was not a dependable exit strategy for the thousands of ex-fighters especially those who be invalids from the war. it is not surprising therefore that disabled ex-combatants are finding it difficult to survive today. having gained nothing from the war, physically impaired and not receiving any subsistence from government or other humanitarian organizations, the disabled ex-combatants civilians are the true victims of the liberian civil war. the key informants feel that for all practical purposes the ex-combatants are marginalized by the government of liberia and rejected by the larger society. 1) the disarmament, demobilization, rehabilitation and reintegration program (ddrr): all the key informants dubbed the ddrr program as a long-term failure exercise, not only because of its failure to retrieve all the weapons from the ex-combatants but its inability to implement a program for providing sustainable basis for marketable life skills. they were unanimous on their fact that the ddrr program also lacked credible trauma healing offering as well as the availability of psychosocial counselling. it is the view of some key informants that the major reason standing in the way of true reintegration of ex-combatants is that the ddrr only put a quick-fix program that did little to prepare the ex-fighters for the life they were destined to face after disarmament. 2) challenges facing ex-combatants: the current state of the disabled ex-combatants is appalling, their dependency on handouts to feed themselves and their dependents not guaranteed from day to day; hopelessness is written in their faces, said one key informant. their presence in the streets begging for livelihood reminds those who carry hurt in their hearts from the civil war. the informants generally believe that the provision of housing for disabled ex-combatants will not only dignify them and restore their self-esteem, but it will be easier to control or maintain them in any skilled training program that they may hereafter be given. they recommend skills training need assessment among disabled ex-combatants before any such training is initiated for them unlike the approach employed during the ddrr. a key informant who happens to be a medical doctor confided that some of those who sustained bullets wounds in their bodies need follow-up treatment but they lack the means. if their exit strategy had been thoroughly planned, a referral program could have been in place to address such persons‟ conditions.the need for access to free health care was discussed and emphasized. summary of some major findings • most ex-combatants joined the fighting to protect themselves and their families who were targeted by rebel fighters • others joined to revenge the killing of close family members by fighters from all sides including government soldiers • some ex-combatants joined the fighting because they were tired of carrying looted materials or 67 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 3) strategic recommendations the ex-combatants, especially those who are disabled and had come from the warring factions, are no longer in the mathematics associated with post-war assistance to fighters. the national bureau of veterans affairs caters exclusively to former armed forces of liberia (afl) fighters. there is no provision for free medical service. the afl still maintains a medical unit but does not have the mandate to give free treatment to disabled ex-fighters. an elaborate plan for the construction of a veterans hospital never got off the blueprint. aside from their inability to provide basic needs for themselves, disabled ex-combatants as well as their civilian victims need support to upkeep and educate their children. the need for conducting a census of those who became disabled by the war, ex-combatants as well as their victims, was underscored. women in this category were in significant number and are grappling with life‟s challenges. their leadership is calling for reparation for these innocent people and they have been advocating for this since the days of the trc, the truth and reconciliation commission, enacted by the parliament in 2005 but nothing has materialized. some disabled could be trained to perform a variety of tasks for their sustenance and for the promotion of national peace and security. they could be prepared to serve as receptionists, ticket sellers for the lma, the liberia marketing association, at city parking services, car washers and the like. discussion and recommendations certainly an explorative investigation as presented here does not allow generalizingthe results. however even the limited information collected indicates a major deficit in dealing with the sequelae of the liberian civil war. the hardship imposed on the disabled by the very nature of their disabilities is exacerbated by the lack of opportunities for gainful employment to match their various forms of disabilities and skills, the uncertain source of daily meal and sometimes hostile attitude from some of the community members. this investigation,however underlines the need to execute a more representativestudy including ammunition for fighters through long distances • nearly all the former fighters interviewed expressed their desire to be trained in several areas of life skills • a vast majority of the ex-combatants are living from begging in thestreets. • several ex-combatants are concerned about the education of their children and are asking for educational support for them • ex-combatants want to serve as peace ambassadors and are requesting to be trained to serve as counsellors for other youths to deter them from engaging in violent activities and prevent war in this nation • those from factions feel that government cares for former afl soldiers and discriminates those from other warring factions • the lack of housing for ex-combatants with war related infirmities is of paramount concern to them • the ex-combatants feel that the ddrr program did not achieve its objectives because it was poorly planned and implemented in the rush • in the communities, they are stigmatized. they are blamed as people who brought suffering to their own people. • they are denied job opportunities even when the job requires only elementary school knowledge • they are discriminated against even by taxicabs especially if they carrycrutches. • the key informants are calling for establishment of trust fund for survivors of the civil war who are disabled. 68 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 the disabled war veterans as well as their victims, a study which would allow representative data and their advanced qualitative and quantitative analysis. the present publication can only serve as a trigger. nevertheless the findings of the study demonstrate that the ex-combatants of the civil war and even more the disabled civilian victims are forgotten not only by the government of liberia, but also by aid agencies. the post-war status of the ex-combatants was not factored into the transitional arrangements such as the ddrr program for the combatan‟tsreturn to civilian lifeconfirming an earlier analysis of 2007 (6). if government and the nation at large continue to ignore the plight of these sizable population groups, the security of the nation will remain fragile(7) and national reconciliation will be elusive and unachievable. it is therefore recommended with priority that: • the government of liberia revisits or reforms the national bureau of veteran affairs to include the disabled ex-combatants of all former warring factions. • the proposed veterans hospital be erected as planned to cater to the health needs of active service personnel, veterans of the civil war and disabled ex-combatants of former warring factions for whom no health service is available. while this is being done, it is recommended that the mandate of the afl medical unit be expanded to provide free medical service to the disabled ex-fighters and war victims. • a national census of disabled ex-combatants is executed, an imperative about peace building in the aftermath of the civil crisis. this exercise would provide a thorough needs assessment that will put into place client-responsive actions that promote peace building, reconciliation and inclusiveness of those who are disabled by the war either during active combat or civilians as a result of inadvertent explosions and wanton acts of cruelty (8). • arrangements be made for a minimal (financial) survival package for each disabled ex combatant which can enable them to afford at least a meal a day so that they will be able to contribute to national peace and reconciliation efforts. furthermore it is highly recommended that: • some low cost housing arrangement be put into place for all disabled victims of the war. • carefully designedlife skills training programs that are effective and efficient to make ex combatants marketable or capable of sustaining themselves instead of begging in thestreets. • continued education programs for ex-combatants who have dropped out of school due to lack of support and are desirous of learning be established. • scholarship programs and tuition support for children of war victimsare put in place. references 1. gerdes f. civil war and state formation, the political economy of war and peace in liberia. campus frankfurt/new york; 2013. 2. lord je, stein ma: peacebuilding and reintegrating ex-combatants withdisabilities. the international journal of human rightsvol. 19/3,2015. http://www.tandfonline.com/doi/full/10.1080/13642987.2015.1031515?src=recsys. 3. harrell mc, bradley ma. data collection methods semi-structured interviews and focus groups. rand corporation: santa monica, ca: 2009. http://www.rand.org/content/dam/rand/pubs/technical_reports/2009/rand_tr718.p df. 4. bloomfield s. liberia's amputee footballers: from civil war to african champions their injuries are a painful reminder of a bitter conflict, but this football team is http://www.tandfonline.com/doi/full/10.1080/13642987.2015.1031515?src=recsys� http://www.rand.org/content/dam/rand/pubs/technical_reports/2009/rand_tr718.p� http://www.rand.org/content/dam/rand/pubs/technical_reports/2009/rand_tr718.p� http://www.rand.org/content/dam/rand/pubs/technical_reports/2009/rand_tr718.p� 69 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 bringing pride to the country. the observer, 10 january 2010. https://www.theguardian.com/sport/2010/jan/10/liberia-amputee-football. 5. international labour office, programme on crisis response and reconstruction:red shoes experiences of girl-combatants in liberia. report coordinated by irma specht, geneva; 2017. http://www.ilo.org/wcmsp5/groups/public/@ed_emp/@emp_ent/@ifp_crisis/docume nts/publication/wcms_116435.pdf. 6. jennings km.the struggle to satisfy: ddr through the eyes of ex-combatants in liberia. international peacekeepingvol. 14/2,2007. http://www.tandfonline.com/doi/full/10.1080/13533310601150800?scroll=top&need access=true. 7. wiegink n.former military networks a threat to peace? the demobilisation and remobilization of renamo in central mozambique. stability: international journal of security and development. 4/1, 2015; p.art. 56. doi: http://doi.org/10.5334/sta.gk. 8. johnson k, asher j, rosborough s, raja a, panjabi r, beadling c, lawry l. association of combatant status and sexual violence with health and mentalhealth outcomes in post-conflictliberia. jama 2008;300:676-90. doi: 10.1001/jama.300.6.676. © 2017 taylor; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.theguardian.com/sport/2010/jan/10/liberia-amputee-football� http://www.theguardian.com/sport/2010/jan/10/liberia-amputee-football� http://www.theguardian.com/sport/2010/jan/10/liberia-amputee-football� http://www.ilo.org/wcmsp5/groups/public/%40ed_emp/%40emp_ent/%40ifp_crisis/docume� http://www.tandfonline.com/doi/full/10.1080/13533310601150800?scroll=top&amp;amp%3bamp%3bneed� http://doi.org/10.5334/sta.gk� https://www.ncbi.nlm.nih.gov/pubmed/?term=johnson%20k%5bauthor%5d&amp;amp%3bamp%3bcauthor=true&amp;amp%3bamp%3bcauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=johnson%20k%5bauthor%5d&amp;amp%3bamp%3bcauthor=true&amp;amp%3bamp%3bcauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=rosborough%20s%5bauthor%5d&amp;amp%3bamp%3bcauthor=true&amp;amp%3bamp%3bcauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=raja%20a%5bauthor%5d&amp;amp%3bamp%3bcauthor=true&amp;amp%3bamp%3bcauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=raja%20a%5bauthor%5d&amp;amp%3bamp%3bcauthor=true&amp;amp%3bamp%3bcauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=beadling%20c%5bauthor%5d&amp;amp%3bamp%3bcauthor=true&amp;amp%3bamp%3bcauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/18698066� http://creativecommons.org/licenses/by/3.0)� 70 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 review article preparing society to create the world we need through “one health” education report of a global survey and web conference on “one health” k-12 education, 18 november 2016 george r. lueddeke1, gretchen e. kaufman1, joann m. lindenmayer2, cheryl m. stroud2 1 one health education task force; 2 one health commission. corresponding author: george r. lueddeke, co-chair, one health education task force; address: 9 lakeland gardens, southampton, hampshire, so40 4xg, united kingdom; email: glueddeke@aol.com http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� mailto:glueddeke@aol.com� 71 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 abstract aims: a previous concept paper published in this journal (1), and a press release in june 2016 (2), focused on the importance of raising awareness about the un-2030 sustainable development goals (sdgs) (3) and, in particular, developing a better understanding about the critical need to ensure the sustainability of people and the planet in this decade and beyond through education. the one health education task force (ohetf), led by one health commission (4) in association with the one health initiative (5) agreed to conduct an online survey and conference in the fall of 2016 to engage interested colleagues in a discussion about the possible application of one health in k-12 (or equivalent) educational settings. method: the survey instrument, reviewed by a panel of experts (below), was conducted in september and october 2016 and focused on basic concepts, values and principles associated with one health and well-being. input was sought on the various ways that one health intersects with the un sustainable development goals and how they might work together toward common objectives. questions also explored ‘why, how, and where’ one health could be incorporated into k-12 curricula, and who should be involved in creating this new curriculum. results and conclusions: overall, there was general consensus that this initiative could make a significant contribution to implementing the sdgs3 through the one health spectrum as well as the priorities and major challenges that would be encountered in moving this initiative forward. five strategies were presented for embedding the sdgs and one health through curriculum innovation from early years to tertiary education and beyond. importantly, a “community of practice” model was put forward as a means to support and promote the sdg goals through one health teaching and learning in a meaningful and supportive way for the benefit of all involved. a subsequent conference in november 2016 provided an opportunity to present the results of the survey and conduct a more in depth discussion about potential curriculum development designs, possible project funding sources, and implementation challenges. keywords: education, one health, global health. conflicts of interest: none. acknowledgements: the organizers would like to thank the members of the one health educationtask force for their contributions to the conference and survey development including, lee willingham and tammi kracek from the one health commission and representatives from the one health initiative autonomous pro bono team: bruce kaplan, laura kahn, lisa conti and tom monath. we are also grateful for the invaluable assistance from peter costa, associate executive director for the one health commission, in organizing and moderating the on-line conference. in addition we would like to thank the following reviewers who assisted in the development of the online survey: muhammad wasif alam, dubai health authority-head quarter, uae; stephen dorey, commonwealth secretariat, uk; jim herrington, university of north carolina at chapel hill, usa; getnet mitike, senior public health consultant, ethiopia; heather k. moberly; dorothy g. whitley texas a&m university, usa; joanna nurse, commonwealth secretariat, uk; christopher w. olsen, university of wisconsin-madison, usa; richard seifman, capacity plusintrahealth international, usa; neil squires, public health england, uk; erica wheeler, paho/who, barbados. http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� http://www.seejph.com/index.php/seejph/article/view/122� https://www.onehealthcommission.org/documents/filelibrary/commission_news/press_releases/61016__oh_education_press_releasefi_f7644a48f9910.pdf� https://sustainabledevelopment.un.org/post2015/transformingourworld� https://sustainabledevelopment.un.org/post2015/transformingourworld� https://www.onehealthcommission.org/� https://www.onehealthcommission.org/� http://www.onehealthinitiative.com/� http://www.onehealthinitiative.com/� http://www.onehealthinitiative.com/� http://www.onehealthcommission.org/� 72 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 introduction the one health concept is rightly gaining timely support and momentum worldwide as we are all becoming increasingly aware that humans, animals, plants and the environment must be in much better balance or harmony to ensure the present and future of our planet. it is gradually becoming clear that to realise or indeed re-capture this state of equilibrium, one health and well-being must be at the heart of socioeconomic, environmental and geopolitical decision making at global, regional, national and local levels, thereby informing, as the commonwealth secretariat health and education unit (comsec heu) posits governance, knowledge development, capacity building and advocacy (6). over the past 18 months or so, and in line with the un-2030 global goals (3) (or sustainable development goals-sdgs) agreed late 2015, that embraced a broad notion of sustainable development – how all things are interconnected – climate, energy, water, food, education -we have been researching and developing ideas on how the one health task force might support sustainability of the planet and people. our deliberations led us to the fundamental question of how we might address perhaps the most important social problem of our time, that is, ‘how to change the way humans relate to the planet and each other to ensure a more sustainable future for all life.’ (2) our unanimous conclusion is that learning about ‘one health and well-being’ needs to play a much greater role in the education of our children and younger generation as well as society in general. to these ends, we developed position papers, issued a press release (2) in june 2016, to which many webinar attendees responded, followed by an on-line survey in september october to solicit wider input on one health education. the survey thus informed an online one health education conference on november 18, 2016 (7). the main purpose of the webinar was to share and build on the survey findings with a view to informing a ‘robust’ one health education project funding proposal. a vital consideration governing the proposal was the potential of raising awareness about the social determinants of human-animal-environment interactions as well as the limitations presented by an unbridled human population expansion in the face of finite natural resources. many of the task force discussions reminded us that while we are advancing scientifically and technologically, we are also faced with a huge ingenuity gap – that is finding answers to unprecedented social problems that on many days seem to overwhelm us – climate change, health and food security, armed conflicts, ideological extremism, economic uncertainty, global inequalities, inequities and imbalances, to name a few. the ebola crisis especially caught the world’s attention in this regard. there are no easy answers. but encouraging young people to gain a better understanding of the planet we all share and need to sustain, along with our individual responsibilities to each other, and learning not only ‘to do things better’ but also, perhaps most importantly , ‘to do better things’ through collaboration and education, must surely be part of the way forward. underpinning our resolve to engage children and young adults in the pursuit of achieving the un-2030 global goals through education and the one health education initiative (ohei) is captured in the recently published book, global population health and well-being in the 21st century (8). a recurring theme in the publication is that achieving the 17 sdgs and targets requires a fundamental paradigm or mind-shift in the coming decades: moving us from a view that sees the world as ‘a place primarily for humans and without limits’ to one that views the world holistically, ensuring it is fit for purpose in the long run for humans, animals, plants and the environment or our ecosystem. one health provides us with the ‘unity around a common cause’ (9) toward which all of us need to aspire and which we believe is fundamental to building the world we need. http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html� http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html� 73 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 summary of online one health education survey results the purpose of the one health education online survey was to elucidate concepts, values and principles that respondents associated with one health, and to begin to define how the one health concept might be operationalized in k-12 schools. invitations to participate in the survey were sent to individuals that had previously expressed interest in the one health k-12 education initiative expressed through presentations, in response to the published concept note and a press release, and through individual conversations. seventy-six people responded to one or more questions on the survey. of the 52 (68.4%) respondents who answered the question about highest level of education attained, 31 held one or more doctoral-level (18 phd, 9 dvm, 4 md, 1 jd), 14 held master’s-level, and 7 held bachelor’s-level degrees. of the 53 (69.7%) respondents who answered the question about country where they worked, 21 answered usa, 15 europe (including 6 in the uk), 10 africa, 5 asia or southeast asia, 1 south america, and 1 answered middle east. one health concepts, values and principles words that respondents most commonly cited were “health” and the health domains (human, animal, environment/ecosystem/ecology). respondents also cited words that represented common ground among one health disciplines, e.g., inter-, coop-, collab-, coor-, integ-, uni and holi-. “sustain” and “educ-“ were mentioned frequently, as were “diseand “zoo-.” respondents preferred the venn diagram and triad representations of one health by far over other representations. values most commonly cited as most essential to one health are sustainability, cooperation, diversity/biodiversity and responsibility, leadership and understanding. innovation was also noted. the type of sustainability judged to be the most important type by far was ecologic sustainability, economic and cultural/social only moderately so. a high degree of agreement (>90%) was given to the following statements: “the health of humans, other animal species and plants cannot be separated,” and “environment includes both natural and built environments.” more than 80% of respondents agreed that “humans have a moral imperative to address one health challenges,” and “one health should be practiced so that there is no net (ecosystem) loss of biological diversity.” more than two-thirds of respondents agreed with all other statements except “when you optimize health for one species, health for others is marginalized or eliminated.” this implies that the health of species is inter-related and should not be viewed as mutually exclusive. the factors contributing most to current one health problems are compartmentalization of health services and policies, lack of knowledge/understanding, lack of funding streams that encourage collaboration and provide support for one health initiatives, poverty-distribution of wealth-inequity, overemphasis of treatment of individuals (human and animal) at the expense of preventive medicine and population health, political systems that support individual/corporate interests above all else, and overemphasis of human health at the expense of animal/environmental health. other factors mentioned were that one health was too veterinary-centric and that there was a need to acknowledge differences between the developed and developing world. one health education and the sdgs respondents related k-12 education most closely to sdg 3 (ensure healthy lives and promote well-being for all ages). also related, although slightly less so, were sdg 14 (conserve and sustainably use the oceans, seas and marine resources for sustainable development), sdg 15 http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 74 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 (protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification and halt and reverse land degradation and halt biodiversity loss), sdg 6 (ensure availability and sustainable management of water and sanitation for all), and sdg 2 (end hunger, achieve food security and improved nutrition and promote sustainable agriculture). other sustainability goals not included in the 17 sdgs included improving animal welfare, developing sustainable strategies for control of feral animals, invasive species and pests (to humans), moving to clean energy sources, developing new tools for impact assessment, and promoting greater intake of locally raised foods. operationalizing one health education in k-12 why? long-term outcomes of a one health-themed curriculum included products (trained educators, better policies and decisions, multidisciplinary approaches to risk, sustainable environment/ecosystems/communities, successful adaptation to climate change, new disciplines, better communication, reduction of the gender gap, more recycling, project design competitions), changes in attitudes and behaviors, more and better engagement as citizens with policy and as consumers, and better health and greater awareness of human populations relationship with the planet and its inhabitants. a number of people anticipated that systems/interdisciplinary thinking would be an outcome. what? students should be exposed to all concepts listed, although personal responsibility (how individual actions impact one health) and respect for natural systems and human responsibility for planetary health were the most important, followed by environmental contexts of one health issues and corporate, political and societal responsibility (how their actions impact one health). one person noted that equity and social justice was important, as was the moral imperative of viewing nature as equally important as humanity. students in one health-themed educational programs should learn collaboration, interdisciplinary thinking, systems-thinking, problem-solving and team-building skills. entrepreneurship, environmental ethics were also noted. one person remarked that “in my opinion, students in one health must, before anything else, gain the ability to immediately look for solutions from all media when facing a problem that requires a more complex approach. basically questioning themselves -what would an engineer/medic/chemist/vet/etc. do when faced with the current problem?” how? challenges most commonly cited that could be used to illustrate one health in k-12 education were diseases (vector-borne, zoonotic, food-born), food security, antimicrobial resistance, environmental pollution (of air, water, soil), climate change and loss of biodiversity/disruption of ecosystem services. where? college and university students are the groups most exposed at present to one health concepts (although fewer than 20% of respondents believed they were exposed at all). fewer than five percent of respondents believed that students at all other levels of education are exposed to these concepts. respondents believed that at levels below college/university, it’s most important to introduce one health concepts to students at all educational levels, although it’s most important in high/secondary schools and slightly less so in middle schools. http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 75 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 one health-themed curricula should be piloted in publicly-funded schools and in colleges or universities. one person suggested piloting one health education in religious classrooms because a lot of teaching goes on there from k-12 (nb: makes sense as long as pope francis is in charge!). virtual classrooms were also noted. barriers and challenges to piloting and scaling up the main barrier to incorporating a oh-themed program into k-12 education is constraints posed by the current educational system, including lack of knowledge and understanding on the part of teachers and the public, the need for adequate teacher training, rigid limits posed by established curricula, government objectives, and the requirement for standardized testing. also noted were overloaded curricula, lack of adequate resources (validated k-12 curricula, infrastructure, access to the internet and it, materials such as case studies, activities, textbooks, pedagogical methods and tools), and inertia of current educational systems and their representatives. many respondents stated that one health is complex, requires simplification, and concrete and practical examples to make it more easily understood. major logistical challenges to scaling-up a k-12 one health curriculum to a global stage that respondents anticipated were lack of funding and resources (it, infrastructure, human resources, content, simulation exercises, alternate delivery platforms), constraints posed by current educational systems (different education systems/formats/settings, teacher training, limitations imposed by pre-existing curriculum requirements, need for tailored education to different contexts, underserved areas sustainable funding), and cultural and language differences. one person noted the need to first measure the added value of pilot projects before scaling up. who? the most common educational stakeholder sector that should be represented in developing the concept of a one health-themed education initiative into a successfully-funded proposal included various members of educational systems (teachers and educators at all levels (including university) of public and private sector, educational/instructional/ curriculum designers, school administrators, teacher associations, teacher training institutions, teachers unions, and educational researchers). government was also mentioned frequently. interesting suggestions included church schools, where a great deal of education takes place, parents and students, and publishers of textbooks. funding organizations that might support implementation of a one health-themed education initiative included government sectors (education, development, health), various private foundations (wellcome trust, melinda & bill gates foundation, soros foundation, the josiah macy jr. foundation, rockefeller foundation, skoll foundation, the global fund, the foundation for international medical education and research), international nongovernmental organizations such as those originating in the eu and the un, and banks such as the world bank. also mentioned were the european social fund, the network: towards unity for health, the european horizon 2020 program, and the global partnership for education. other comments and suggestions worthy of mention were: • a one health curriculum has to be content rich and ‘not just another vague thing' about relationships and collaboration, and that it needs to address critical problems like climate change, agricultural intensification, comparative medicine, environmental health threats. • consider strengthening and using innovative on-line teaching, flipped class room, take advantage of existing educative one health tools (mooc on one health, environment challenges, etc.), and create new ones. http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� http://macyfoundation.org/� http://macyfoundation.org/� 76 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 • the biggest challenge we face in implementing a one health curriculum at a global stage is the lack of a major driving force in one health. although we are trying our best as one health clusters, we need to have a major support from a so called "poster boy", something that will catalyze our efforts. • one-health should be a process that start at pre-primary level to change mind-sets, although there should be entry-levels at all phases for those who were not exposed from the start. it will be beneficial if the one-health principles thinking can be incorporated as it relates to different subject streams (e.g. economics, social science, and others). • we need to understand that we, as individuals, are not quite the center of the universe and that our actions, even though they may not bring us much benefit/losses, surely can influence everyone around us. • this is an extremely important project at a very volatile time in our world. education is the key to supporting and delivering the un 2030 sdgs. strategies for k-12 one health curriculum innovation this segment of the conference presented some of the ways that the one health education task force has considered to utilize one health concepts in curriculum development for k-12 classroom applications. feedback from the participants was requested and additional ideas that might be considered for the program and funding proposal were encouraged. we have explored the following five potential options to consider for our proposal: curriculum innovation grants for educators, curriculum development workshops for teachers, teacher training programs, a one health education network, and an on-line knowledgebase of one health curriculum materials. we understand that there are different needs among various educational systems and across countries around the world, so the options presented below are not mutually exclusive and we could consider one or any combination of these within the larger project. i) curriculum innovation grants for educators the initial idea that we explored was a program that would offer grants to teachers to develop and implement a one health focused curriculum at their school that meets specific criteria and objectives set by the one health education task force. we are attracted to this idea because we understand that teachers themselves know best how to reach their students, what curricular designs work within their institutions and grade levels, and what tools are most effective at reaching outcomes. in addition, by engaging teachers directly and offering opportunities for innovation, we feel that other teachers would be more likely to adopt and share successful methods among themselves, either thru example and their existing networks, or with formal mentoring. this program would offer competitive innovation curriculum development grants to teachers or teams of educators on an annual basis. the focus of this program could be open ended or could involve a changing one health theme each year to ensure diversity of topics. applicants would be asked to meet very specific guidelines that target values, skills and knowledge criteria using one health approaches. these guidelines would be developed by the one health education task force and would be informed by wider conversations with the one health global community, including the survey recently conducted. proposals would need to emphasize interdisciplinary engagement as a fundamental tenet of one health principles. as time goes by, successful methods and curricula would be shared through the proposed oh education network and knowledgebase described below and would not be limited only to participants in the program. http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 77 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 ii) curriculum development workshops for teachers we have received feedback that some teachers would never have the time to devote to curriculum development themselves. some have also expressed concern that they do not know the subject area well enough to be able to write a curriculum or innovate very effectively along one health lines. in response, we decided we needed to create an opportunity for motivated teachers to learn more about one health and receive some direct assistance in creating one health themed curricula. we are proposing to do this through a series of summer workshops, which would include summer salary for participants. this would be an annual opportunity and could again be open ended or focused on changing themes or topics. workshops would involve participation by “experts” in one health, depending on the topics selected, and would also include curriculum development professionals to assist teachers in classroom applications. the workshops would emphasize innovative learning methods that target one health values, skills and knowledge criteria as described above and would provide an important networking opportunity for sharing and mentoring between teachers and experts. iii) teacher training programs a third concept that we are proposing is to work with teaching training programs already in existence that are interested in building one health approaches into their training programs. this approach would involve new teachers in the process of curriculum development and could be implemented through specific courses or teaching modules. by working with teaching training programs we would be creating opportunities for innovation from the ground up which may provide greater opportunity for broad integration of one health values across subjects. in this environment, we would also be in a good position to inculcate one health skills and knowledge in teachers during a critical period in their own development as educators. this approach would also ensure that appropriate regional programming is being developed that best meet the needs of local education systems and would maximize benefits and outcomes which may not be otherwise adaptable from a more universal, less regional approach. it was suggested that we think about promoting this opportunity to make sure teachers that need it to take advantage of it. this could be done by developing introductory one health presentations and using social media to reach a broad audience. the example of an ivsa program was given where they are “developing a one health presentation to school children on veterinary public health, one health and explaining the diversity and active contribution of vets and medics to the human-animal-environment interface. we plan to distribute it to our member organisations in over 60 countries and translate it to at least 2/3 languages for teachers to use. we hope to use social media to spread the word, to students will promote or present this workshop to communities, to families and then to schoolsto encompass student centred learning (bhavisha patel).” iv) one health education network the creation of a one health education network will be critical to global adoption of any curriculum innovation that results from this initiative. we feel that it would be very valuable to foster mentorship and sharing among project participants and provide opportunities for others outside the project to benefit from the teaching expertise that develops as a result of this initiative. over several years this could develop into a robust and supportive cohort of one health educators around the globe and provide the best mechanism for achieving sustainable development goals globally through one health. http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 78 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 the ohe network would provide a directory of one health educators, facilitate communication between educators with social networking tools, and facilitate mentorship connections between educators and one health experts. the network could act as a platform for organizing meetings and presentations, and would facilitate collaboration on future projects. importantly, the network could become self-sustaining simply through the interest and enthusiasm of the participants and provide longevity to the investment of this project for years to come. v) on-line knowledge base of one health curriculum materials finally, we want to openly share the products of any of these curriculum development programs as we start a movement and inspire teachers around the world to adopt one health principles in their teaching. we propose to build an open access technology platform for sharing curriculum that will serve as a repository for products of any grants or workshop programs developed through this initiative. sharing outwardly to the world would provide an opportunity for feedback and dialogue to improve these products and encourage, in an organic way, the transition of more curriculum to include one health principles. over time, this knowledgebase could also link to or include contributions from outside this project and broaden the impact and engagement for one health themed educational initiatives that furthers our global objective for achieving sustainable development goals through one health themed education. above are the five main programs we have focused on to date and we encourage feedback and input from a broader audience. there are many details to work out, and the scale of these programs is still undetermined. what follows is a summary of the participant suggestions and calls for clarification concerning the strategies presented. first and foremost we would like to clarify that the scope of this project is intended to be global. while initial implementation of pilot projects may precede full globe reach, the pilot projects would likely include a diversity of sites. the exact structure or timeline has not yet been determined. the different nature of various education systems around the world and even within a country like the us was brought up as a challenge. within the us, there is a great deal of variation and level of influence between state agencies and the federal government through the department of education. some states may be more receptive than others to the type of curriculum initiative we are proposing. we hoped that the first option which asks for teachers themselves to come forward, would take care of some of this diversity. teachers would presumably be proposing curriculum development that would work within their own context. the great differences between developed educational systems and developing educational systems will also be a challenge and may require two different efforts or pathways. some clarification about who will make up the group of “one health” experts to participate will be needed, especially since there are no specific well defined criteria for a one health expert, or any standardized system for accreditation or academic degree existing today. we are specifically look for content experts to provide necessary knowledge and resources, as well as curriculum development experts, and the specific qualifying criteria that defines a participating “expert” still needs to be worked out. an excellent suggestion was made to consider including parents in grants or workshops to help bridge the resource gap in some low-income schools where parent leaders play an important volunteer role. engaging with parents may also promote greater acceptance with the community outside the school. the concept of a “community of practice” approach was mentioned as a model for the knowledgebase as well as the network. one way to do this might be to target a specific group of people involved in middle and high school education and connect them with existing experts http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 79 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 or groups that might have resource materials to provide, such as the oie. we would very much like these two programs, the knowledgebase and the network, to operate as a community of practice in one health education. one significant outcome will a one health education foundational body of work that currently does not exist. another mentorship model to consider would be the twinning model, used in the usaid emerging pandemic threats program and others to share between developed and developing educational systems or institutions. there were a couple of cautionary remarks to conclude this section. first of all, considering the large scope of programs and challenges for implementation, there was some concern about staff time and capacity necessary to follow through with this initiative and a need to establish realistic priorities. we are very aware of this and will be considering these questions as we approach funders and develop a timeline. lastly, beware of the top down approach being proposed by our group of one health champions. this will not work without active engagement with k-12 education partners. we have discussed this at length and have been struggling to find the appropriate enthusiastic partners. we welcome any good ideas or introductions to institutions or people that we can draw in to this initiative that will provide the appropriate input. dr. lueddeke will provide more detail on our potential partners defined to date. funding considerations for a one health education initiative this segment of the conference focused on three main funding considerations: i) linking un 2030 sustainable development goals to one health education initiatives (10); ii) supporting projects through existing development mechanisms; iii) possible funding sources. a key argument for project funding decisions was that the one health concept and approach need to be considered as a lens or filter for shaping global policy and strategy regardless of the sdg goals and targets being evolved and implemented, including k-12+ education (fig.1). and, while the habitat iii the new urban agenda (11) agreed in october 2016 is a highly commendable achievement, according to a word search, the 19 documents failed to mention terms or explanatory paragraphs/recommendations related as planet, one health, conservation, animals, epidemic, root causes, overcrowding, inequities, automation, eco footprint, infectious disease, non-communicable disease and only singularly cited the words prevention, healthy lifestyles, ageing population, mental health. more than 70 % of the world’s 9 billion population will be living in cities by 2050 or before. one health crosses all discipline boundaries, and it is important that the project planners identify and collaborate across existing networks, as shown in fig. 2. consideration to seeking funding from multiple funding sources might also be appropriate (e.g., bill and melinda gates foundation, un agencies (e.g., undp, unesco), rockefeller foundation, macarthur foundation, the uk department for international development, and welcome trust). several avenues will be pursued in the next few months, including making personal contact with potential partners or collaborators. http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� https://www2.habitat3.org/bitcache/99d99fbd0824de50214e99f864459d8081a9be00?vid=591155&amp;amp%3bdisposition=inline&amp;amp%3bop=view� 80 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 figure 1. linking un 2030-global goals to k-12 one health and well-being education figure 2. global networks (selected) global networks: united nations 193 members states -2 observer states who collaborating centers (>700) world bank global learning development network (>120 institutions – 80 countries) the commonwealth (52 nations) the european union (27 nations) http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 81 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 further to a question about identifying good partners, it is recognised that a traditional top down approach is not likely to work in this situation. an example of behaviour change that worked well in the u.s. in 70s and 80s is recycling, a local, bottom up endeavour. interestingly, it was young people (children) being inspired by teachers that made the recycling movement happen in the u.s. we should be concerned about strictly advocating a top down approach for k-12 one health education. a successful approach has to start more locally, but be guided by national aspirations or goals. local and national interests should be working in tandem. in the and the u.k. there has been very little discussion so far about the sustainability development goals. we must draw on expertise locally and find support nationally to enable action groups. we like to think of the dual concepts of one health and ‘well-being’. one health is beyond any political or health system. it’s really saying here is our planet, a very small planet, and we have got to keep it healthy regardless of how we are living our lives. it is probably the only non-divisive concept that we have right now. the un development program folks have done a fairly good job with disseminating information. but, if the un had incorporated one health a year or so ago, we would be further along. meeting the needs of the diverse global community although we believe there exists one health core values, principles and concepts, we recognize that operationalizing one health in primary and secondary schools must recognize and appreciate educational, cultural and social differences among countries and educational systems. therefore, no one model or curriculum will fit all situations. how then, can we begin to frame a proposal that honours one health core values, principles and concepts, but is flexible enough to be adapted for diverse circumstances? a point well-taken from the survey is that a validated one health curriculum does not exist. for that reason, any attempt to propose one must include a pilot phase from which one could learn valuable lessons related to adoption, implementation, and evaluation of a curriculum before it could be modified and scaled up in one or more systems. therefore, a successful proposal will focus on pilot studies in one or more education systems (to be defined), but at the same time, it must include metrics that could be used to judge whether or not here is evidence that scaling up and/or out is feasible and of value. various models have been used to pilot educational interventions, even those that encompass one health, in colleges and universities and in the health workforce. historically these have been piloted in one or more systems that are not linked, but in the last decade a twinning model has gained interest and acceptance. this model links two or more educational systems that, at its best, involves equal partners that each learn from the other; it can, however, evolve to a mentor-mentee situation whereby one partner assumes most of the responsibility and the other partner(s) assume lesser, more receptive roles. there may be other models of which we are not yet aware, and we look to others to suggest them. twinning and other models have been implemented at various scales from local to national systems. participants seconded the idea of a proposal that takes a twinning approach and starts at the local level, with curricula that are meaningful to local communities and that involve parents, community members and students alike as teachers and learners. it would be instructive to apply twinning between a higher income and a lower income country, as is being done at a university level, and to look for points of alignment and difference. the proposal may want to http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 82 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 consider adopting a term other than ‘twinning,” which is so closely associated with university level activities and is, as was pointed out, often interpreted by higher income countries as “the world is here for us to remodel.” building on responses to the survey, participants suggested that there is a need for concrete yet simple to grasp examples illustrative of one health. if one health is ultimately about changing behaviours, previous successful examples of changing public behaviours such as recycling (which was started by teachers and taken home to parents and communities by students) and smoking cessation (for which youtube videos, cartoons and other popular media presentations have been developed and widely disseminated) might offer valuable lessons for how to accomplish behaviour change, but they must be grounded in one health principles and guided by local customs and beliefs. a proposal would have to involve social scientists, particularly those with expertise in behaviour change and public health. if messages were meaningful and easy to grasp they could be taken to households with the support of government and international organizations. the first nine months of a child’s life is critical to her/his perception of the environment as friendly or hostile, and having a ‘village’ teach one health to young children could well establish a ‘the environment is friendly’ mindset (see the foundation vie’s 1001 critical days of development, also the first five initiative in california). work on empowering girls is being conducted by the university of wisconsin in ghana and could illustrate successful implementation of this approach. a recent teacher training workshop using student-centred active approaches was very well received by teachers who are used to the ‘sage on the stage’ approach so common in many countries. and, rather than importing more new material into already packed curricula, a proposal could instead strengthen existing curricula, for example, by supporting teachers to adapt current material using more ‘hands-on’ learning with the natural world that incorporate ethics of how we view and treat each other, animals and the environment. a third option would be to develop ‘scaffolding’ lessons that integrate existing curricula across disciplines and grade levels. scaling up and out presumes some early measures of success, but the goal of a one health curriculum is to change behaviours. because this is a long-term outcome, it cannot be used to judge the success of a one health project in the short term. one suggestion was the level of involvement of a community could be used as an early indicator of success for a pilot project. another metric being used in ghana is the degree to which students who experience the curriculum in schools take that learning home to educate their parents, although the cultural appropriateness of children teaching adults has to be considered. successful pilot projects would be shared widely, thereby developing a “community of practice” that would reflect the common goals of one health teaching and learning and the richness of its adaptations. open panel discussion in this section we discussed additional questions and received numerous suggestions that are not included in the sections above. the topic of curriculum design was raised. we purposely do not want to prescribe what any given curriculum would look like, whether that be modules, week-long units, individual lectures or a scaffold of modules across grade levels and across subjects. we want to encourage innovation in curriculum design and pedagogy as much as possible and are hoping that educators would develop curricula together to produce integrated learning designs preferably to create modules that fit into an existing science class for example. programs that cut across courses and grades would be optimal. incentivizing collaborations and trans-disciplinary team based curricula was suggested, over didactic ‘preaching’. curricula should incorporate issues http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 83 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 based, inquiry based, problem based, small group based methods that focus on real issues, because our challenges today do cross disciplines. another suggestion was made to organize content around broad categories made up of a series of small modules or easy to digest, bite-sized pieces. this can be particularly important where language might be a challenge. the reference was made to experience in ghana in the one health and girls empowerment program with junior and senior high school girls. in those workshops they found that in addition to ‘content’ that the teachers loved learning about student-centred active teaching approaches that they had never been exposed to. they need to see other ways to teach. there are likely some other good programs already on the ground that we could learn from. several examples of these were mentioned including: • an 8-12 grade curriculum for veterinary science and one health science in the state of texas (try contacting dr. heather simmons); • a new mooc addressing one health that will be available through coursera (https://www.coursera.org/) in spring 2017; • a university of washington "conservation biology & global health" 3 day curriculum for high school students; • the california state first five initiative; • examples of twinning as a collaborative development and support mechanism (e.g. usaid emerging pandemic threats program). however we proceed, the idea of piloting programs in different regions was felt to be important along with the willingness to be flexible and respond to community and cultural diversity in different parts of the world. some discussion centred on the topic of behaviour change. it will be important to include social scientists on the development team that have expertise in this area. one of our challenges is the goal of changing the mindset. 97% of world health funds are going toward treatment of disease and only 3% goes to prevention. this is from a global budget of $7.7 trillion us dollars. because one health is all about prevention strategies, initiatives like the ghsa should be interested. it was suggested that there may be lessons learned from experiences in developing countries with hiv behaviour change programs, particularly how to reach communities. several participants stressed that one of the best ways to gain support for a new program and improve the possibility of success is to make sure there is a link with communities beyond the classroom, with the caveat that we need to be sensitive about the cultural appropriateness of kids teaching adults. another potential ally could be the network of school nurses, a group that is greatly under-utilized and under-appreciated. if appropriately empowered, they could be a valuable asset. in any event we will need good partners in the k-12 system before moving forward since a top down approach will likely not work here. some discussion came up on the topic of finding funding for educational initiatives. it was suggested that it might be helpful to look at the portfolios of the various donors (e.g. usaid, dfid, multilateral and regional banks, etc.) to look for compatible interests in education. it can be very challenging to get an innovative, technical assistance grant. reference was made to experience in a new regional project in west africa called the regional disease surveillance systems enhancement project, a huge world bank project that handles 15 countries in w africa with ohahu and who that involved several hundred million dollars. another suggestion was to explore existing zoonotic disease initiatives, such as predict or the global health security agenda (ghsa). http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� http://www.coursera.org/)� http://www.coursera.org/)� http://www.coursera.org/)� 84 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 some other potential funding sources mentioned include: skoll, ford, rockefeller, gates, the instituyo alana in sao paulo brazil, african union/ecowas. in some cases, appealing directly to ministries of education or health might find support for being the first one to institute something truly innovative (e.g. island nations like fiji and seychelles). conclusion we assumed that most people attending this conference (10) do support the idea of k-12 one health education. perhaps attendees, like us, are driven by the need to examine what is currently being done (in education) and to postulate what we need to be doing differently to prepare future generations. there are some attempts being made globally for one health education at the graduate and professional education levels. but that is too late to significantly affect behaviours and in still attitudes of open collaboration and interactions. by then young people are already in their academic silos. we are very concerned about current attitudes toward our human place on the planet. in this conference we have outlined some tangible, programmatic models that could be used in young children and expanded to a global community of practice to improve things for future generations. the un sustainable development goals are a wonderful target to aim for globally. but there is currently no mechanism to unite and implement them. one health thinking and acting can do that. indeed, one health is a pathway not only to the un sdgs and planetary health, but also to global security. health and well-being are profoundly embedded in and dependent on global government stabilities. as the last 10-15 years have shown, it can be very difficult to introduce one health concepts to already established systems. but k-12 children will be our future global leaders. how do we help them understand the severity of what is going on right now in the world? what is restraining us from doing new things like taking one health education and concepts to young children? we need to change today’s mindset/paradigm of using up our global resources without regard for the health and well-being of our planet because future generations will depend on mother earth. how do we get individuals, governments and corporate bodies to think more holistically and sustainably about the health and well-being of people, animals and the planet? there is much work to do to make one health the default way of doing business around the world. children and one health can be our ‘ray of hope’ for the future. references 1. lueddeke g, kaufman g, kahn l, krecek r, willingham a, stroud c, et al. preparing society to create the world we need through ‘one health’ education. seejph 2016;6. doi 10.4119/unibi/seejph-2016-122. 2. lueddeke g, stroud c. preparing society to create the world we need through ‘one health’ education! (press release). one health commission. available at: https://www.onehealthcommission.org/documents/filelibrary/commission_news/press _releases/61016 oh_education_press_releasefi_f7644a48f9910.pdf (accessed: march 20, 2017). 3. united nations. united nations. transforming our world: the 2030 agenda for sustainable development. available at: https://sustainabledevelopment.un.org/post2015/transformingourworld (accessed: march 20, 2017). http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2016-122� https://www.onehealthcommission.org/documents/filelibrary/commission_news/press_releases/61016__oh_education_press_releasefi_f7644a48f9910.pdf� https://www.onehealthcommission.org/documents/filelibrary/commission_news/press_releases/61016__oh_education_press_releasefi_f7644a48f9910.pdf� https://sustainabledevelopment.un.org/post2015/transformingourworld� 85 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 4. one health commission (ohc). (2017). mission. available at: https://www.onehealthcommission.org/en/why_one_health/ohc_mission/ (accessed: march 20, 2017). 5. one health initiative (ohi). mission statement. available at: http://www.onehealthinitiative.com/mission.php (accessed: march 20, 2017). 6. the commonwealth secretariat (health and education unit). advancingsustainable social development through lifelong learning and well-being for all. available at: https://drive.google.com/file/d/0b8wr6920su0arhlyd0pdoerlajq/view (accessed: march 20, 2017). 7. one health commission. one health education conference. available at: https://www.onehealthcommission.org/en/eventscalendar/one_health_education_onlin e_conference/ (accessed: march 20, 2017). 8. lueddeke g. global population health and well-being in the 21st century: toward new paradigms, policy and practice. new york: springer publication; 2016. available at: http://www.springerpub.com/global-population-health-and-well-being in-the-21st-century-toward-new-paradigms-policy-and-practice.html (accessed: march 20, 2017). 9. wwf international. living planet report 2014. available at: https://www.wwf.or.jp/activities/lib/lpr/wwf_lpr_2014.pdf (accessed: march 20, 2017). 10. lueddeke g. the un-2030 sustainable development goals and the one health concept: a case for synergistic collaboration towards a common cause. world medicine journal, vol. 62, 2016: 162-167. available at: http://lab.arstubiedriba.lv/wmj/vol62/december-2016/#page=44 (accessed: march 20, 2017). 11. un news centre. habitat iii: un conference agrees new urban development agenda creating sustainable, equitable cities for all. available at: http://www.un.org/apps/news/story.asp?newsid=55360#.wo3xddqrjkg (accessed: march 20, 2017). http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� https://www.onehealthcommission.org/en/why_one_health/ohc_mission/� http://www.onehealthinitiative.com/mission.php� https://drive.google.com/file/d/0b8wr6920su0arhlyd0pdoerlajq/view� https://www.onehealthcommission.org/en/eventscalendar/one_health_education_online_conference/� http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html� https://www.wwf.or.jp/activities/lib/lpr/wwf_lpr_2014.pdf� https://www.wwf.or.jp/activities/lib/lpr/wwf_lpr_2014.pdf� https://www.wwf.or.jp/activities/lib/lpr/wwf_lpr_2014.pdf� http://lab.arstubiedriba.lv/wmj/vol62/december-2016/#page%3d44� http://www.un.org/apps/news/story.asp?newsid=55360&amp;amp%3b.wo3xddqrjkg� 86 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 appendix i – participants in the one health education conference and survey (respondents to the survey who identified themselves included) james akpablie claire b. andreasen, iowa state university, college of veterinary medicine olutayo babalobi, one health nigeria christopher birt isabelle bolon bonnie buntain, university of arizona, school of veterinary medicine bill burdick peter cowen, north carolina state university stephen dorey, commonwealth secretariat, health and education unit eliudi eliakimu nirmal kumar ganguly, national institute of immunology, department of biotechnology, india julie gerland, noble institution for environmental peace, chief un representative aja godwin ralf graves michael huang lai jiang, institute of tropical medicine, belgium bruce kaplan, one health initiative getnet mitike kassie gretchen kaufman, one health education task force ulrich laaser sultana ladhani, commonwealth secretariat zohar lederman, national university singapore joann lindenmayer, one health commission jill lueddeke george lueddeke, one health education task force pamela luna donald noah, one health center, director martha nowak, kansas state university, olathe chris olsen, university of wisconsin olajide olutayo amina osman, commonwealth secretariat, health and education unit steven a. osofsky, cornell university bhavisha patel nikola piesinger, mission rabies, uk, education officer kristen pogreba-brown peter rabinowitz, university of washington vickie ramirez, university of washington ralph richardson, kansas state university, olathe, dean/ceo raphael ruiz de castaneda, institute of global health, oh unit, geneva laura schoenle richard seifman sara stone alexandru supeanu, one health romania http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 87 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 appendix ii – survey instrument the following survey was conducted by the one health education task force between october 16, 2016 and december 10, 2016 utilizing the survey monkey ® web based platform. introduction: the goal of this survey is to collect views on the importance of one health in preparation for an online pre-proposal conference scheduled for mid-november. survey feedback will help us define the parameters and design of a global one health-themed educational funding initiative, spearheaded by the one health commission in association with the one health initiative. the proposed project focuses on the development and support of one health (and well-being) curriculum materials, involving primarily k-12* teaching staff and education providers. the survey will help to identify ways of addressing challenges to successfully implement a number of pilot projects on a global scale. subsequent educational initiatives will address post-secondary and professional education. the survey will take approximately 20 minutes to complete. the survey employs the one health commission definition of one health: “one health is the collaborative effort of multiple health science professions, together with their related disciplines and institutions – working locally, nationally, and globally – to attain optimal health for people, domestic animals, wildlife, plants, and our environment.” *“k-12” is defined as organized pre-primary through secondary school education. we acknowledge that this is not uniform terminology around the world, but will use this term for convenience. survey questions objective 1: identifying complex issues/examples that can be used to address the drivers of one health challenges and can lead to sustainable solutions. 1) list 5 words that immediately come to mind when you think of one health (open question): 2) please rank the following types of sustainability from 1-5 in terms of their importance to one health (1=most important and 5=least important) a. ecological b. economic c. cultural/social d. ethical e. justicial (of or relating to justice, as opposed to judicial) 3) list 3-5 one health challenges that could be used to illustrate the need for a one health approach. include no more than one zoonotic disease. 4) please choose what you believe are the 5 most important contributing factors to the development of one health challenges (not limited to disease transmission) that should be considered in developing preventive policies or sustainable solutions or those challenges: a) lack of knowledge/understanding b) lack of methods and tools to investigate complex problems c) lack of uniform standards for information management and sharing d) compartmentalization of health services and policies e) lack of funding streams that encourage collaboration and provide support for one health initiatives f) overemphasis of treatment of individuals (human and animal) at the expense of preventive medicine and population health http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 88 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 g) overemphasis of human health at the expense of animal and environmental health h) human population growth and development i) poverty, distribution of wealth, inequity j) political systems that support individual/corporate interests above all else k) globalization in the absence of global standards of practice l) short-term decision/policy horizons m) over-exploitation of natural resources n) tribalism o) climate change p) otheropen ended objective 2: meeting the un sustainable development goals thru one health-themed education (http://www.un.org/sustainable-deevelopment-goals/). 5) how well do you think a one health-themed k-12 education program relates to each of the following sdgs (1=not at all related and 5=highly related)? a) end poverty in all its forms everywhere b) end hunger, achieve food security and improved nutrition and promote sustainable agriculture c) ensure health lives and promote well-being for all at all ages d) insure equitable and inclusive quality education and promote lifelong learning opportunities for all e) achieve gender equality and empower all women and girls f) ensure availability and sustainable management of water and sanitation for all g) ensure access to affordable, reliable, sustainable and modern energy for all h) promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all i) build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation j) reduce inequality within and among countries k) make cities and human settlements inclusive, safe, resilient and sustainable l) ensure sustainable consumption and production patterns m) take urgent action to combat climate change and its impacts n) conserve and sustainably use the oceans, seas and marine resources for sustainable development o) protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification and halt and reverse land degradation and halt biodiversity loss p) promote peaceful and inclusive societies for sustainable development, provide access to justice for all, and build effective and accountable, inclusive institutions at all levels q) strengthen the means of implementation and revitalize the global partnership for sustainable development 6) are there other sustainability goals that you think should be included (open-ended): objective 3: identifying values and principles that underlie a global one health approach towards health and well-being for the planet. http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� http://www.un.org/sustainable-deevelopment-goals/)� 89 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 7) which one of the following graphical representations best captures the valuesand principles of one health? f) none of the representations are satisfactory 8) which of the following values do you think are essential to the application of one health? (please select all that apply) • balance • community • compassion • competence • compromise • cooperation • diversity/biodiversity • empathy • experience • freedom • growth • humility • integrity • justice/fairness • leadership • mindfulness • reason • resilience • respect • responsibility • rigor • self-awareness • sustainability • synergy • tolerance • transparency • understanding • vision • other (open ended) 9) to what degree do you agree with each of the following statements as it relates to one health, where 1=strongly disagree and 5=strongly agree? a) when you optimize health for one species, health for others is marginalized or eliminated. b) one health should be practiced so that there is no net (ecosystem) loss of biological diversity. c) the health of humans, other animal species and plants cannot be separated. http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 90 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 d) one health recognizes the intrinsic value of life on earth (plants, animals, microbes) regardless of a direct benefit to humans. e) “environment” includes natural and built environments. f) one health embraces the value of social interaction as a critical component of health and well-being. g) humans have a moral imperative to address one health challenges. h) ecological, economic, social/cultural, ethical and justicial sustainability are equally important for one health. i) the world health organization defines “health” as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” this definition also applies to other animals and ecosystems. j) other (open ended). objective 4: designing a global one health-themed k-12 educational program that supports innovation by educators and learners. 10) in your experience, to what extent are students currently exposed to concepts related to one health (including well-being) where 1=not at all exposed and 5=highly exposed? a) pre-primary education b) primary education secondary education c) college and university education d) adult education e) other (open ended) 11) how important is it that students are introduced to one health concepts in the educational curriculum at the following educational levels, where 1=not at all important and 5=highly important? a) pre-primary school b) primary school c) middle school d) high school 12) in what types of schools would you pilot a one health-themed curriculum, understanding that not all school types are found in every country (please select all that apply)? a) publicly-funded schools b) privately-funded schools c) magnet schools d) charter schools e) independent schools f) home school networks g) extra-curricular education (after school) h) summer school or camps i) colleges or universities j) other (open ended) 13) what broad-based skills should students learn through a one healththemed educational program (please select any that apply)? a) collaboration b) communication to diverse audiences c) concept mapping d) conservation http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 91 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 e) experimental design/methods/inquiry f) goal-setting g) interdisciplinary thinking h) leadership i) problem-solving j) systems thinking k) team-building l) other (open ended) 14) to what extent should students be exposed to the following concepts in a one health themed educational program, where 1=not at all exposed and 5=highly exposed? a) role of natural and built environments in human and animal health and well-being b) respect for natural systems and human responsibility for planetary health c) the connection between well-being and mental/physical health d) personal responsibility – how individual actions impact one health e) corporate, political and societal responsibility – how their actions impact one health f) climate change and health of the planet g) environmental contexts of one health issues h) staying healthy and making good choices for the environment i) “cradle-to-grave” thinking j) other (open ended) 15) in your opinion, what are 3 main barriers to incorporating a one health-themed program in k-12 education in your country (open ended)? 16) what do you believe should be some long term outcomes (how might it change the knowledge, understanding, attitudes or behaviors of students) of a one health-themed curriculum (open ended)? objective 5: identifying challenges that must be addressed for a proposal to be funded 17) what educational stakeholder sectors (e.g. state, private, other) should be represented in developing the concept of a one health-themed education initiative into a successfully funded proposal (open ended)? 18) please suggest up to 3 funding organizations that might support implementation of a one health -themed education initiative (open ended). 19) please list up to 3 major logistical challenges to scaling up a k-12 one health curriculum to a global stage (open ended)? 20) please provide any other comments or suggestions (open ended). © 2017 lueddeke et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� http://creativecommons.org/licenses/by/3.0)� 92 sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 review article approaches to the international standards application in healthcare and public health in different countries vitaliy sarancha1, vadym sulyma2, nenad pros3, ksenija vitale1 1 school of public health “a. stampar”, medical school, university of zagreb, zagreb, croatia; 2 department of traumatology, ivano frankivsk national medical university, ivano – frankivsk, ukraine; 3 quality management department, pastor tva jsc, croatia. corresponding author: vitaliy sarancha, md; address: 4 rockefeller st., zagreb 10000, croatia; email: saranchavi@gmail.com mailto:saranchavi@gmail.com� 93 sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 abstract as a result of consequent development, and guided by an increasing demand of different types of the organizations regarding structured management, the system of standardization has been established. the idea behind standardization is adjusting the characteristics of a product, process or a production cycle to make them consistent and in line with the rules regarding what is proper and acceptable. the “standard” is a document that specifies such established set of criteria covering a broad range of topics and applicable to commissioners of health, specialists in primary care, public health staff, and social care providers, as well as the local authorities and service users. health products, ranging from medical devices and health informatics to traditional medicines and unconventional healing tools are all in the focus of standards’ application. different countries have their own quality management traditions based on their history, mentality, socio-economic environment and the local regulations. taking into consideration that community social system organization and the quality of social infrastructure are the main foundations of social relations and future prosperity, here we review the existing standardization environment in the health sector in different countries, both developed and those on a convergence path. we focused on standardization environment in the united states of america, great britain, germany, ukraine, russian federation, croatia and albania. in order to simplify comprehension, we also demonstrate the algorithm of standardization, as well as the opportunities for application of the international standards in healthcare and public health. keywords: healthcare, international standards, public health. conflicts of interest: none. 94 sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 introduction first traces of quality development appeared more than four thousand years bc, at the time when commodity barter had been replaced by the development of trade among greek, roman, egyptian, arab and phoenician traders (1). artisans described to their suppliers, by experience, using simple words, what kinds of materials they preferred. this was common practice, since the craftsmen had no tools to measure the composition, strength, chemical or physical characteristics of a given material. industrial revolution contributed to the development of product specification (2). manufacturers began issuing precise descriptions of materials and processing methods in order to ensure that supplies met certain quality criteria (3). thus, producers were obliged to take samples from each batch, which was then subjected to tests determining its elasticity, tensile strength, etc. when the first factories were established, requirements for a higher degree of order, greater focus on precision and monitoring quality control of a product were introduced. evolving through different stages, beginning with the 'division of labour' in the late 1700s until the beginning of the 20th century, the scope of activities from the beginning of a production cycle to the final phase led to the occurrence of the first model-based managerial approach (4). when the demands of tasks became too complex basic managerial principles, such as planning, execution, monitoring, controlling, completion and improvement were implemented (5). therefore, to form a structurally oriented organization, systematic quality control became a necessity. later on, such quality patterns and models became generally accepted and are today known as the standards. in the modern society, social infrastructure quality is the main foundation of social relations and future prosperity, thus the purpose of this article is to review the existing standardization environment in the health sector in different countries, both developed and those on a convergence path; as well as to demonstrate a common algorithm for standardization and the opportunities for the application of international standards in healthcare and public health. definition and different types of standards the idea behind standardization is adjusting the characteristics of a product, process or a production cycle as to make them consistent and in line with the rules regarding what is proper and acceptable. standard is a document that specifies such established set of criteria. more than 21000 international standards covering almost all aspects of human activity, including healthcare, have been published since february 1947, when the delegates from 25 countries met at the institution of civil engineers in london and founded the international organization for standardization (iso). today, it encompasses 162 member countries and more than 238 technical committees taking care of the development of standards (6). after the foundation of the european union a network of new institutions, such as the european standardization organizations (esos) consisting of 33 european countries, and cen the european committee for standardization, has been established. cen together with the european committee for electro-technical standardization (cenelec) and the european telecommunications standards institute (etsi) are officially recognized by the european union and by the european free trade association to be responsible for developing voluntary standards on the european level (7). regarding various products, materials, services and processes, cen provides a platform for the european norms (ens) development (8). en is to be implemented on a national level by being given the status of a national standard, and by withdrawing any conflicting national standards used previously. therefore, the european standard becomes a national standard in each of the 33 cen-cenelec member countries once adopted by the national body (9). for example, croatia after entering eu had to harmonize the local hrns (croatian norms) to conform to the ens. 95 sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 standardization process the functional diagram (figure 1) introduces an 11-step assessment construct having been passed by any organization in attempt to obtain a particular certificate. figure 1. the 11-step assessment construct that an organization needs to go through in order to obtain a certificate (source: sarancha v, nenad pros 2016) formalization of workflow, introduction, implementation and staff training policies, guidlines, summaries, process diagrams, etc., ... manuals, procedures, instructions, check lists, etc., ... no document is valid yes ready for use document training confirmation record internal audit record, report nonconformities revealed notes, records yes no yes system is adjusted no audit by the certification body client report nonconformities revaled notes, records yes no yes system is adjusted no 2. introduction of norm general requirements 4. documentation set design 6. implementation and staff training 5. acceptance and authorization of the documentation system 3. establishment of company policy, responsibilities assingment, processes definition 11. document of conformity 10. corrective actions 9. external audit 8. corrective actions 7. internal audit documents in use 1. analisys of actual working conditions and workflow 96 sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 certification body is a third party auditing firm that assesses organization against a specific international standard. taking into account a huge amount of relevant documents and the complexity of the procedures, it is important to correctly identify the procedure required for the certification process at the beginning. approaches in different countries different countries have their own quality management traditions based on their history, mentality, socio-economic environment and the local regulations (10,11). this otherness is fundamental when considering well-developed countries such as the usa, germany and great britain in comparison with the converging countries of eastern and south-east europe (12,13). thereby, the usa has developed a quality infrastructure and there are many organizations that provide accreditation services covering various aspects of healthcare and public health. some of them include the accreditation association for ambulatory health care (14), the community health accreditation partner, the joint commission and the accreditation commission for health care, the american accreditation council, and the healthcare quality association on accreditation (15). one of the main acknowledged bodies in healthcare is the national association for healthcare quality (nahq). it certifies professionals in healthcare awarding the certified professional in healthcare quality (cphq). cphq plays an important role in clinical outcomes, reliability and financial stability of the healthcare organizations. the key elements of their knowledge refer to information management, measurement and analytics, quality measurement and improvements as well as planning, implementation, evaluation, training, strategic and operational tasks concerning patient safety. in great britain, the national standards body is bsi group (16). one of the outstanding resulting documents created by a group of representatives from bsi to help organizations put in place occupational health and safety performance is the occupational health and safety assessment series 18000 (ohsas) with its next revision ohsas 18002 which was accepted as a standard. in the updated edition “health” component was given greater emphasis and current version became more closely aligned with the structures of iso 9000 and iso 14000. thereby organizations could more easily adopt ohsas alongside the existing management systems (17). another institution is the united kingdom accreditation forum or ukaf. founded in 1998 by a group of leading healthcare accreditation organizations, nowadays ukaf is an umbrella structure for organizations providing healthcare accreditation. it operates with an interest in developing assessment and accreditation programmes in healthcare and public health (18). the national institute for health and care excellence (nice) provides guidance and contains governance information, publications, and policies concerning healthcare. it collaborates with the public health institutions, social care professionals and service users, and it also designs concise sets of statements and guidelines to drive measurable quality improvements within a particular area of healthcare (19). furthermore, there is a supervisory structure in the uk called the professional standards authority. this body is responsible for overseeing the uk’s nine health and care professional regulatory bodies (20). referring to the topics that focus on the subject it is important to mention the united kingdom accreditation service (ukas), the national health service (nhs), the department of health, etc. in germany, as a result of agreement with the german federal government, the national standards body is the german institute for standardization (din). its experts administer about 29,500 standards and it was one of the first well-structured certification institutions in europe. din remains the competent authority in respect to the technical issues and widely known specifications for products and materials. the accreditation body for the federal republic of germany is dakks. it has a special health/forensics division, which among other tasks attests third-party certification bodies taking care of healthcare, forensic medicine, medical laboratory 97 sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 diagnostics and medical devices. the german worker’s welfare association (awo) also plays an important role. together with iso they have formed an effective tandem that ensures quality in awo rehabilitation facilities and health organizations. the model combines requirements of iso 9001 with those of awo quality and risk assessment guidelines. consequently, quality of a particular facility is measured by the care provided, the organization structure and the satisfaction of patients and residents. in addition, important requirements for patient safety are formulated by a german initiative called the german coalition for patient safety. it provides a basis in processing the audits that are conducted in the client’s premises, with the aim of providing the client with a feedback regarding the degree of implementation of the quality dimension of “patient safety”, e.g. regarding a particular healthcare system unit. speaking of developed economies, it can be concluded that as of today standardization has taken a strong position. in our opinion this is due to understanding by the managers of its effectiveness, as well as the level of comfort regarding integration of standards, clear description of the processes and therefore adherence to the relevant rules and procedures. in spite of positive sides of standardization, we have to understand that human factor in healthcare should also be taken into account, which means inapplicability of one approach only, the engineering approach to the human being as a mechanism. in comparison with the quality management systems present in the developed countries, ukraine has relatively unbalanced quality infrastructure. it bears elements of the former ussr standardizing paradigm that has to be re-evaluated, updated and adapted to suit the existing economic and social environment. there are state and industry branch systems of standardization in ukraine (21). the state branch includes the ukrainian scientific research institute of standardization certification and informatics, and the ukrainian state research and production centre of standardization, metrology and certification (22,23). the most flexible are the service standards departments and the industrial standards departments. state social standards in the health sector are regulated by the ukrainian law “fundamentals of ukraine on healthcare” (24). since ukraine has become a participant of the euro integration process, the reform on the adaptation of local standards to the european and international norms has been significantly accelerated (25). the main principles are shown in the “national strategy on reforming the healthcare system in ukraine” which has been accepted for implementation in the period from 2015 – 2020 (26). more often, private clinics and research centres all over the country engage certification bodies to perform an external audit with the aim of meeting international quality requirements. standardization in russian federation is based on gosts. the word gost (russian: гост) is an acronym for “государственный стандарт” which means the national standard. there is a set of technical norms maintained by the euro-asian council for standardization, metrology and certification (easc) (27). one of the steps towards the standardization is by issuing the ordinance of the ministry of health “on the introduction of standardization into healthcare” (28). there are also many national programmes and ordinances in russia dealing with the implementation of particular standards in public health (29). the problem in russia is actually in hyper-regulation as regards the standardization. numerous ordinances, guidelines and procedures on one hand, and a lack of specific implementation mechanisms on the other hand causes confusion and regress with regard to the harmonization of national standards with their international counterparts. thus, the organization for economic co-operation and development (oecd) series on principles of good laboratory practice (glp) currently operates with gost r53434-2009 “principles of good laboratory practice” together with the support of other 14 interstate standards which have already been successfully implemented. in croatia, accreditation is provided only by the croatian accreditation agency (haa) which is a national accreditation body that complies with the requirements of the international and european standard for accreditation bodies adopted in the republic of 98 sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 croatia as the croatian standard hrn en iso/iec 17011: 2005. the haa is a member of the international laboratory accreditation cooperation (ilac) and the european co operation for accreditation (ea). the ilac is an international organization for accreditation bodies operating in accordance with iso/iec 17011 and involved in the accreditation of conformity assessment bodies including calibration laboratories (using iso/iec 17025), testing laboratories (using iso/iec 17025), medical testing laboratories (using iso 15189) and inspection bodies (using iso/iec 17020). the ea is an association of national accreditation bodies in europe which are officially recognised by their national governments to assess and verify (in line with the international standards) the organizations that carry out evaluation services such as certification, verification, inspection, testing and calibration (also known as conformity assessment services). on the other hand there are agencies in croatia dealing with quality control issues on the national level. thus, the agency for quality and accreditation in health care is an authority whose competence refers to quality improvement in healthcare services and social care, as well as medical technology assessment according to the corresponding law (official gazette of the republic of croatia 124/11) (30). targeted assistance in further development of quality infrastructure in croatia has been successfully implemented by the joint research centre of the european commission with amended action programmes such as cards croatia project on the “development of national metrology, standardization, conformity assessment and accreditation system” (31). other institutions that cope with quality paradigm introduction into the croatian healthcare and public health system are andrija stampar school of public health and the european society of quality in healthcare (32). according to the 2009 ministry of health national background report “health in albania”, the country has performed very well in sustaining high rates of economic recovery after the financial collapse of 1997 (33). quality assurance of health systems has been outlined as a priority in primary healthcare reform: a pilot project to provide evidence for health policy (34). the national agencies are empowered by the government to be responsible for accreditation of hospitals and licensing medical personnel. albania maintains the initiatives and continuous a dialog with the public institutions such as the institute of public health, private laboratories and clinics as well as with the international ngos, who, unicef, wb and usaid regarding a more active participation of the country in the international activities of the quality system implementation (35). international quality bodies are successfully co-operating with the aim to internationalize standardizing efforts in healthcare. one of such example is the international society for quality in health care (isqua). it is a parent institution for bodies providing international healthcare accreditation. isqua provides services in guidance to health professionals, providers, researchers, agencies, policy makers and consumers as to achieve excellence in healthcare delivery to the public and to continuously improve the quality of care (36). among others, quality bodies working on the international level are astm international (37), the international accreditation forum (iaf) (38), and the council for health service accreditation of southern africa (39), the quality management institute, etc. quality paradigm implementation in healthcare and public health standards cover a broad range of topics and are applicable to commissioners of health, specialists in primary care, public health staff, and social care providers as well as the local authorities and service users. health products, ranging from medical devices and health informatics to traditional medicines and unconventional healing tools are all in the focus of standards application (40). standards are designed to establish patterns of quality and performance including the measures to protect and improve the safety of patients, to promote a culture of continual improvement, support efficient exchange of information and data protection while benefiting the environment. depending on the scope of responsibilities and http://www.european-accreditation.org/brochure/ea-slides-rev24-02-17� http://www.european-accreditation.org/brochure/ea-slides-rev24-02-17� 99 sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 areas of activity every organization is able to voluntarily choose among the standards it wishes to implement. iso has created about 1200 health standards that are grouped in families. some of them, such as environmental management iso 14000, occupational health and safety ohsas 18000, guidance on social responsibility iso 26000, environmental management 14000 are featured as widely applicable to public health and healthcare. a family contains a number of standards, each focusing on different aspects of a corresponding topic. according to 2012 iso press release the most commonly used standard is quality management standard iso 9001 (belongs to iso 9000 quality management systems). due to its generic basis, it is applicable to all types of organizations. it enables a company to develop a quality management system (qms) which implies the introduction of quality planning, quality assurance, quality control and quality improvement, and it is a perfect tool to measure the fundamental way of developing health services. iso 9001 has been updated and together with the cooperation for transparency and quality (ktq) for hospitals became the most acknowledged “brand” for quality recognition in healthcare. ktq certification is aimed at hospitals, medical practitioners and institutions, rehabilitation centres, nursing homes, hospices, and emergency medical services. it shows that the focus is primarily on patient satisfaction, from the preparation of the patient’s stay until his discharge. a good example of such practical application of quality management in a combined clinic is perfectly demonstrated in the article by eckert h. and schulze u., (2004) (41). iso 13485:2016 – medical devices, is also a useful standard. it is designed to define the requirements of quality management system with the aim of demonstrating a company’s ability to provide medical devices and related services that meet the clients’ and regulatory requirements. together with en 15224:2012 certification of quality management systems in healthcare, with its emphasis on the hospital process and risk management, both standards become strong indicators of quality level of care provided at an institution. the best way to find a relative iso standard is to search through the work of a particular iso technical committee (tc) on the iso web page, as follows: tc 76, transfusion, infusion and injection, and blood processing equipment for medical and pharmaceutical use; tc 84, devices for administration of medicinal products and intravascular catheters; tc 94, personal safety protective clothing and equipment; tc 106, dentistry; tc 121, anaesthetic and respiratory equipment; tc 150, implants for surgery; tc 157, contraceptives/sti; tc 168, prosthetics and orthotics; tc 170, surgical instruments; tc 172, optics and photonics; tc 173, assistive products for persons with disability; tc 181, safety of toys; tc 194, biological evaluation of medical devices; tc 198, sterilization of healthcare products; tc 210, quality management and corresponding general aspects for medical devices; tc 212, clinical laboratory testing and in vitro diagnostic test systems; tc 215, health informatics; tc 249, traditional chinese medicine; iso/pc 283, occupational health and safety management systems. challenges, opportunities and benefits twenty-first century and the globalization bring new challenges to the organizations exposed to the global market. with a drastic number of competitors, growing demands of consumers and legislators, quality requirements of goods and services together with a lack of resources are constantly increasing (42). be it in environmental protection, in the food industry or public health objective testing and calibration play a notable role. assessments ensure that tested products, methods, services or systems are reliable with regard to their quality and safety, that they correspond to the technical criteria and conform with the characteristics, guidelines, and laws. observational findings indicate that nowadays oecd countries have a relatively developed infrastructure of standards implementation in almost all segments 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public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 healthcare is one of the world’s largest and fastest-growing sectors of the society. in 2009 about 12.4% of gross domestic product of oecd was spent on healthcare. these countries are the basis for research and development, as well as the improvement of international standardization environment. on the other hand, studies have shown that south european countries together with ukraine and russia are, in the long run, heading towards the social paradigm shift and understanding of standardization principles. most frequently cited problems refer to failure of recognizing positive effects of a systematic approach, financial means, long waiting lists, systematic delays in first aid providers, lack of competent staff due to “brain-drain” and insufficient organizations’ preparedness for the implementation of structural changes at all levels. some health centres, clinics and hospitals are funded by the state or county budget revenues (beveridge’s model) or partly from social insurance contributions deducted from the citizens’ wages (bismarck model), and consequently do not recognize the need to increase the level of quality, responsibility and international standards compliance (43). in addition, high payroll taxes in eastern and south european countries are discouraging formal employment, dampening labour demand and increasing employment in the informal sector (44). a study published in british medical journal estimates that medical errors are the third leading cause of death in the united states, that caused a quarter-million fatalities in 2013 alone (45). it obviously means that the reduction of risks of all kinds is also an important problem that needs to be resolved (46). despite relatively well-structured lex artis in standardizing processes, its efficiency in many cases remains controversial. sometimes, due to enormous amount of paperwork and bureaucracy, standardization can become a nuisance causing waste of time and human resources. combination of all these factors, together with the unfair competition, weak governance and corruption may cause unwillingness towards continuous improvement which is the ultimate precondition for an efficient functioning of standardization in healthcare and public health (47). public health and healthcare are vital and sensitive issues, and their importance pervades all aspects of social life due to their medical, social, political, ethical, business, and financial ramifications. looking into the future, it is impossible to predict exactly how our world is going evolve, but current trends suggest that together with climate change, migration, urbanization, a growing and ageing population, poverty, emerging diseases, food and water shortages and a lack of access to health services, the future of health sector appears to be complicated. new fields of expertise such as medical tourism are on the rise (48). they create a pool of migrating specialists whose services and reliability need to be properly examined and permanently reviewed. in our opinion standardization is a step-by-step process that requires commitment and cooperation of all parties. it may flow both in the bottom-up and in the top-down directions. the key element of this evolutionary process is the end-user of services the patient, in whose best interest the described changes should be made. the patient, service provider, health insurance officer, public health institution, legislative body all of them form an integral network of relationships and responsibility. therefore, awareness regarding the benefits of the standardization process and full understanding of its stages, by those included, are key factors in the overall success of its implementation. quality management systems based on the international standards should be a strategic decision of the national public health institutions in an attempt to meet long-term strategic goals. if an organization wishes to use one of the worldwide-recognized norms it has to ensure its adherence to best practices in everything it is involved in (49). it also includes the mapping processes, setting performance targets and making sure that it continually improves and meets the goals of shareholders, clients, and patients. regular audit processes and subsequent annual assessments meet the needs of health service providers, patients, in this way guaranteeing the quality of services and achieving maximum results. in this way, the standardization creates powerful tools in order to fine-tune the performance and manage the risks while operating in 10 sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 more efficient ways that allow time and capacity for innovation and 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(original in russian). russian entrepreneurship (journal), 2006;8:148-52. 30. mittermayer r, huic m, mestrovic j. quality of healthcare, accreditation of health activities holders and assessment of health technologies in croatia: the role of the agency for quality and accreditation in healthcare. acta med croatica 2010;64:425 34. 31. european commission, joint research centre, nikola poposki, ani todorova, lutgart van nevel. development of national metrology, standardisation, conformity assessment and accreditation system in croatia, 3rd interim report: cards 2004: croatia, project no 116536: 2008. 32. džakula a, sagan a, pavic n, loncarek k, sekelj-kauzlaric k. health system review. health syst transit 2014;16. 33. nuri b. in: tragakes e (ed). heath care systems in transition: albania. copenhagen, european observatory on health care systems; 2002:4. 34. cook m, mceuen m, valdelin j. primary health care reform in albania. bethesda, md: the partners for health reformplus project, abt associates inc. february 2005. 35. hajdini g. the institute of public health in albania: institutional learning survey. j health edu res dev 2015;3:148. doi:10.4172/2380-5439.1000148. 36. the international society for quality in health care. available at: http://www.isqua.org/who-we-are/isqua-mission (accessed: march 6, 2017). 37. astm international. astm standards for healthcare services, products and technology, 2014. available at: www.astm.org (accessed: march 6, 2017). 38. the international accreditation forum (iaf). the iaf multilateral recognition arrangement (mla). brochure. iaf b2 1/2012. 39. the council for health service accreditation of southern africa. available at: http://www.cohsasa.co.za/mission-vision-values (accessed: march 6, 2017). 40. who press. who global health expenditure atlas; 2012. isbn 9789241504447. 41. eckert h, schulze u. quality management in a combined clinic the quality http://www.orderline.dh.gov.uk/� http://www.orderline.dh.gov.uk/� http://www.orderline.dh.gov.uk/� http://sips.gov.ua/en/laws_special_6� http://www.ctmed.ru/dicom_hl7/mz12_98.html� http://bookshop.europa.eu/en/european-commission-cbalokabstp1saaaejgiky4e5k/� http://bookshop.europa.eu/en/joint-research-centre-cblqgkabstejaaaaejaouy4e5k/� http://bookshop.europa.eu/en/search/filter?searchparameter=%26%40queryterm%3d%2a%26author%3dnikola%2bpoposki� http://bookshop.europa.eu/en/search/filter?searchparameter=%26%40queryterm%3d%2a%26author%3dani%2btodorova� http://bookshop.europa.eu/en/search/filter?searchparameter=%26%40queryterm%3d%2a%26author%3dani%2btodorova� http://bookshop.europa.eu/en/search/filter?searchparameter=%26%40queryterm%3d%2a%26author%3dani%2btodorova� http://bookshop.europa.eu/en/search/filter?searchparameter=%26%40queryterm%3d%2a%26author%3dani%2btodorova� http://bookshop.europa.eu/en/search/filter?searchparameter=%26%40queryterm%3d%2a%26author%3dlutgart%2bvan%2bnevel� http://bookshop.europa.eu/en/search/filter?searchparameter=%26%40queryterm%3d%2a%26author%3dlutgart%2bvan%2bnevel� http://www.isqua.org/who-we-are/isqua-mission� http://www.astm.org/� http://www.cohsasa.co.za/mission-vision-values� http://www.cohsasa.co.za/mission-vision-values� http://www.cohsasa.co.za/mission-vision-values� http://www.ncbi.nlm.nih.gov/pubmed/?term=eckert%20h%255bauthor%255d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=15202041� http://www.ncbi.nlm.nih.gov/pubmed/?term=schulze%20u%255bauthor%255d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=15202041� 10 sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 management system according to din en iso 9001 of the the german association of spa accommodation resorts e. v. (vdkb). (original in german). rehabilitation (stuttg) 2004;43:166-73. 42. berger s. how we compete: what companies around the world are doing to make it in today’s global economy, random house, new york; 2006. 43. kutzin j. bismarck vs. beveridge: is there increasing convergence between health financing systems? 1st annual meeting of sbo network on health expenditure 21-22, oecd. who, paris, 2011. 44. hazans m. informal workers across europe: evidence from 30 countries. the institute for the study of labor (iza). discussion paper no. 5871: 2011. 45. makary ma, daniel m. medical error the third leading cause of death in the us. bmj 2016;353. doi: http://dx.doi.org/10.1136/bmj.i2139. 2016. 46. european commission. occupational health and safety risks in the health sector. guide to prevention and good practice. available at: http://ec.europa.eu/progress (accessed: march 6, 2017). 47. mayberry rm, nicewander da, qin h, ballard dj. improving quality and reducing inequities: a challenge in achieving best care. proc (bayl univ med cent) 2006;19:103-18. 48. medical tourism magazine. faq concerning the medical tourism, sept-oct 2009. 49. lee dh. implementation of quality programs in healthcare organizations. service business 2012;6:387-404. © 2017 sarancha et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://dx.doi.org/10.1136/bmj.i2139� http://ec.europa.eu/progress� http://www.ncbi.nlm.nih.gov/pubmed/?term=mayberry%20rm%255bauth%255d� http://www.ncbi.nlm.nih.gov/pubmed/?term=nicewander%20da%255bauth%255d� http://www.ncbi.nlm.nih.gov/pubmed/?term=qin%20h%255bauth%255d� http://www.ncbi.nlm.nih.gov/pubmed/?term=ballard%20dj%255bauth%255d� http://link.springer.com/journal/11628� http://creativecommons.org/licenses/by/3.0)� 10 lueddeke g. high level communiqué from the interaction council(letter to editors). seejph 2017, posted: 07 july 2017. doi: 10.4119/unibi/seejph-2017-146 letter to editors high level communiqué from the interaction council george lueddeke1 1 consultant in higher and medical education, united kingdom. corresponding author: george r. lueddeke, co-chair, one health education task force; address: 9 lakeland gardens, southampton, hampshire, so40 4xg, united kingdom; email: glueddeke@aol.com mailto:glueddeke@aol.com� 10 lueddeke g. high level communiqué from the interaction council(letter to editors). seejph 2017, posted: 07 july 2017. doi: 10.4119/unibi/seejph-2017-146 dear colleagues, here is a link to a copy of a high level communiqué from the interactioncouncil that may also be of interest to seejph readers. as you may be aware, the council brings together former world leaders (heads of government and senior officials) and focuses on issues related, among others, to global security and has been examining the role of health security over the last few years. at this year’s meeting (30-31 may), co-chaired by he obasanjo from nigeria and he bertie ahern from ireland, the session on planetary health, coordinated by professor john wyn owen, resulted in the endorsement of the “dublin charter for one health”. dr joanna nurse presented on the policy implications of planetary and one health in this session and is tasked by the interaction council with advancing the one health charter in collaboration with key partners. below is a summary of the main actions in the charter for one health that may in due course help to inform trans-disciplinary research, education and practice at national, regional and global levels with a view to sustaining people and planet health and well-being. your comments on how best to advance these key areas are requested-i.e. please let us know what is already happening, gaps and suggestions for how to advance the following: 1. strengthening multi-sector solutions for the sdgs the one health approach has the potential to act as a unifying theme; 2. resilience to emerging threats -including amr, disease outbreaks, climate change and environmental impacts; 3. mainstreaming one health within public health systems for uhc -including environmental health; 4. strengthen one health governance mechanisms for systems reform; 5. building leadership for one health for future generations; 6. establish an independent accountability mechanism for advancing action on one health. please send your comment to glueddeke@aol.com by 10 july. many thanks and best wishes! george lueddeke phd chair, one health education task force the one health commission in association with the one health initiative convenor/chair, one health global think tank for sustainable health & well-being 2030 consultant in higher and medical education southampton, united kingdom linked-in connection: http://www.linkedin.com/pub/dr-george-lueddeke/42/4b0/401 * link to the one health initiative news item: http://www.onehealthinitiative.com/news.php?query=interaction+council+issues+%91the +dublin+charter+for+one+health%92+communiqu%e9 http://interactioncouncil.org/final-communiqu-53� http://interactioncouncil.org/final-communiqu-53� mailto:glueddeke@aol.com� https://www.onehealthcommission.org/� http://www.onehealthinitiative.com/� http://www.seejph.com/index.php/seejph/article/view/114� http://www.linkedin.com/pub/dr-george-lueddeke/42/4b0/401� http://www.onehealthinitiative.com/news.php?query=interaction%2bcouncil%2bissues%2b%91the� 10 lueddeke g. high level communiqué from the interaction council(letter to editors). seejph 2017, posted: 07 july 2017. doi: 10.4119/unibi/seejph-2017-146 link to a one health primary to tertiary education article and proposal supporting the sdgs and one health: http://africahealthnews.com/development-project-proposal-supporting sustainable-future-people-planet/. conflicts of interest: none. © 2017 lueddeke et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://africahealthnews.com/development-project-proposal-supporting-sustainable-future-people-planet/� http://africahealthnews.com/development-project-proposal-supporting-sustainable-future-people-planet/� http://creativecommons.org/licenses/by/3.0)� jacobs verlag executive editor assistant executive editor editors regional editors advisory editorial board publisher table of contents editorial reflections on the liberian civil war, 1989-2003 conflicts of interest: none. references original research abstract conflicts of interest: none. introduction methods study design workshop data processing results table 1. timeliness for notified cases before and after the workshop discussion references original research abstract conflicts of interest: none. health examination surveys and health interview surveys country profile: albania the albanian demographic and health survey (dhs) 2017-2018 contribution of the demographic and health survey (dhs) to health system governance in albania conclusion references original research abstract conflicts of interest: none. introduction the context methods surveys implementation plan results implementation plan implementation activities captured discussion summary of main results lessons learned results in light of research in the field limitations and implications for future research conclusion references original research the dutch long-term care reform: moral conflicts in executing the social support act 2015 abstract conflicts of interest: none. background literature research study objectives and research questions methods research method and study design theoretical framework and conceptual model data collection data analysis results document analysis survey and interviews discussion principal findings and conclusions study strengths and limitations and suggestions for further research references original research abstract conflicts of interest:none. foreword introduction methods study population focus group discussions key-informant interviews information processing results the focus group interviews (fdg) figure 1. disabled war combatants 1017 perspectives of key informants discussion and recommendations references review article preparing society to create the world we need through “one health” education report of a global survey and web conference on “one health” k-12 education, 18 november 2016 abstract conflicts of interest: none. introduction summary of online one health education survey results one health concepts, values and principles one health education and the sdgs operationalizing one health education in k-12 strategies for k-12 one health curriculum innovation curriculum innovation grants for educators curriculum development workshops for teachers teacher training programs one health education network on-line knowledge base of one health curriculum materials funding considerations for a one health education initiative figure 1. linking un 2030-global goals to k-12 one health and well-being education meeting the needs of the diverse global community open panel discussion conclusion references appendix ii – survey instrument survey questions objective 1: identifying complex issues/examples that can be used to address the drivers of one health challenges and can lead to sustainable solutions. objective 3: identifying values and principles that underlie a global one health approach towards health and well-being for the planet. objective 4: designing a global one health-themed k-12 educational program that supports innovation by educators and learners. objective 5: identifying challenges that must be addressed for a proposal to be funded review article vitaliy sarancha1, vadym sulyma2, nenad pros3, ksenija vitale1 abstract conflicts of interest: none. definition and different types of standards standardization process approaches in different countries quality paradigm implementation in healthcare and public health challenges, opportunities and benefits references letter to editors conflicts of interest: none. marstein e, babich sm. the corporatization of global health: the impact of neoliberalism (original research). seejph 2018, posted: 14 june 2018. doi 10.4119/unibi/seejph-2018-191 original research the corporatization of global health: the impact of neoliberalism egil marstein 1 , suzanne m. babich 1 1 department of health policy and management, richard m. fairbanks school of public health, indiana university, indianapolis, usa. corresponding author: egil marstein, phd department of health policy and management, richard m. fairbanks school of public health, indiana university; address: health sciences building (rg), 1050 wishard blvd. floor 5, indianapolis in 462022872, usa; telephone: 317-274-3850; email: egmars@iu.edu marstein e, babich sm. the corporatization of global health: the impact of neoliberalism (original research). seejph 2018, posted: 14 june 2018. doi 10.4119/unibi/seejph-2018-191 abstract concomitant with the emergence of a neoliberal precept for global health is the decline in support for publicly funded programs working to alleviate health disparities in poor countries. an unequivocal faith in the privatization and marketization of public health services is evident in current day national policy reforms. commodification of health services is perceived as a cureall. privatization of global health initiatives contrasts with the past institutional paradigm. corporate and philanthropic power trumps intergovernmental governance. the epistemological precept is clear: global health is best served with mandated private initiatives. powerful foundations cause critical shifts in the balance of power among stakeholders and become preeminent players in global health policy agenda formation. the ethics of consequentialism have attained current day prominence. this contrasts with the merits and relevancy of deontological ethics in which rules and moral duty are central. in this paper, authors make a case for contesting the ethos of effective altruism or venture philanthropy, suggesting that this approach keeps nations and people from recognizing the oppressive nature of neoliberalism as a governing precept for global health. keywords: global health governance, global health leadership, venture philanthropy. conflicts of interest: none. marstein e, babich sm. the corporatization of global health: the impact of neoliberalism (original research). seejph 2018, posted: 14 june 2018. doi 10.4119/unibi/seejph-2018-191 the oligarchs of philanthropy over the past forty years of expanding globalization, waves of deregulation and privatization have facilitated the power of private actors. in a 2015 global policy forum (gpf) report, jens martens and karolin seitz highlighted widespread concern over the power exerted by the philanthropies of corporations, foundations, non-governmental organizations (ngos) and charitable organizations (1). transnational corporations – companies operating in multiple countries – exert significant influence within the global economic system, gaining political clout in the process. the gfp reports equate “big philanthropy” with “big business” in their expanding influence on global development policies through grant-making, personal networking and active advocacy. the report points to the need for a renewed political discourse that carefully scrutinizes the impact of these ngos on the global health policy agenda. it underscores the need to fully analyze the risks and consequences of letting organizations such as the bill & melinda gates foundation (gates foundation) and the rockefeller foundation shape the priorities of health programs in developing countries. in the first half of the last century, the rockefeller foundation was particularly influential in shaping the discourse on global health and building the institutional structure of global health governance (1). since the turn of the millennium, however, the gates foundation has become the leading actor. in 2012 and 2013, the amount spent by the gates foundation on global health was equal to one half of the total budget of the world health organization (who) (gates foundation: u.s. $1.98 billion; who: us$ 3.96 billion). the gates foundation demonstrates a strong preference for measures based on a biomedical view of public health and clearly embraces the application of innovations and new technologies. this is true despite the fact that in the beginning of the 20th century, public health improvements were mainly achieved through improvements in social conditions, such as hygiene, nutrition, improved housing and education. martens and seitz have suggested that the gates foundation approach to tackling global health challenges is disease-specific, using vertical health inventions through vaccines in lieu of a horizontal and holistic approach through overall health system strengthening. grants made by the gates foundation are earmarked or limited to specific program areas. this prompted former who director general margaret chan to state at the time that: “my budget is highly earmarked, so it is driven by what i call donor interests” (1). the who is the foremost proponent and caretaker of global health initiatives. it was founded in 1948 as part of the united nations (un) to act as “the directing and coordinating authority on international health work” (2). with the arrival of new and powerful actors in the global health arena its importance has steadily dwindled. these new actors dispose of significant resources made available by a wide range of private contributors and corporate philanthropy. the growing importance of private contributions coincides with a decreasing assessed contribution support provided by member states (who). assessed contributions are non-earmarked contributions, whereas voluntary contributions come from private organizations or public institutions and are earmarked for special programs, with donor conditions attached. earmarked contributions undermine the who’s capacity to remain true to its original role as a global health authority to direct and coordinate international health work (2). the arrival of modern philanthropy the history of modern philanthropy can be traced to the early 19th century in the united states. motivated primarily as a way to shield private and corporate fortune from taxation and to gain prestige and political influence, wealthy individuals such as john d. rockefeller (1913) and marstein e, babich sm. the corporatization of global health: the impact of neoliberalism (original research). seejph 2018, posted: 14 june 2018. doi 10.4119/unibi/seejph-2018-191 andrew carnegie (1911) set up the first charitable foundations. in the 1930s, increased income and estate taxes in the u.s. led to further proliferation of u.s. foundations set up by wealthy individuals, most notably by industrialists such as w. k. kellogg and henry ford, creating the most influential foundations with global reach and foundation-supported programs established all over the world (2). beyond charitable philanthropic foundations, the number of nongovernmental organizations has proliferated. the term ngo entered common usage through the un charter at the end of the world war ii (ww ii). prior to that, missionary groups, religious orders, and scientific societies engaged in activities crossing continents (3). whatever the motivation, the population of charitable foundations in the form of ngos alone now numbers 20,000 globally (3). criticism of the expanding influence and power of ngos is mounting. issa g. shivji argues that the sharp rise in the number and power of ngos is due to the neoliberal paradigm and does not purely represent altruistic objectives (4). shivji criticizes ngos for aiming to change the world without understanding it and warns that they perpetuate imperial, north-south relationships. james pfeiffer points to the fact that over the last decade, ngos (in mozambique) have fragmented the local health system, undermined local control of health programs, and contributed to growing local social inequality (5). in the geo-political scope, ngos have been criticized for representing an extension of the regular foreign-policy instruments of some western countries and groups of countries. according to michael bond, "most large ngos are striving to make their aid provisions more sustainable. however, some, “mostly in the us, are still exporting the ideologies of their backers."(6). viera pawliková -vilhanová has traced the evolution of ngos in africa , suggesting that their roles represent a continuation of the work of their predecessors, the missionaries and voluntary organizations that cooperated in europe’s colonization of africa. the author further maintains that the work of ngos today undermines the efforts of african people to emancipate themselves from economic, social and political oppression. development ngos have become part of the neoliberal system that has resulted in widespread impoverishment and loss of the authority of african states to determine their own agendas. ngos could, and some do, play a role in supporting an emancipatory agenda in africa, but that involves abandoning the role of missionary by disengaging from paternalistic roles in development initiatives (7). efforts to shape stakeholder interests into a uniform global health agenda have led to a recommendation to give intergovernmental institutions such as the who a greater diplomatic role, working with nations and philanthropic elites, ngos and international corporations (7). this could strengthen international cooperation and create needed synergies for confronting global health challenges. who director general gro harlem brundtland (1998-2003) is credited with first proposing that the who take on this political role. dr. brundtland advocated a normative dimension in global health. the approach emphasized the goal of a healthier world rather than serving a realpolitik line advancing individual state and institutional interests. from the who’s original position of promoting health as a human right, the organization has taken on a technocratic approach, prioritizing disease control. consequently, there is less emphasis on governance issues focusing on social control and the reallocation of resources. a significant factor associated with this policy has been a subscription to economic efficiency as espoused by the powerful foundations promoting their brands of venture philanthropy. the tenet has been to accept a reduced role for the state and intergovernmental institutions when faced with global health challenges. in this way, the system has enabled private organizations to assume a greater role in setting priorities and controlling project governance. https://en.wikipedia.org/wiki/issa_g._shivji https://en.wikipedia.org/wiki/neoliberal https://en.wikipedia.org/wiki/imperialism marstein e, babich sm. the corporatization of global health: the impact of neoliberalism (original research). seejph 2018, posted: 14 june 2018. doi 10.4119/unibi/seejph-2018-191 challenges the proliferation of neoliberalism has, according to global health watch # 4, produced a “global health crisis” in crafting a new global health agenda (8). as the scope of global health challenges grows, so does the call for comprehensive measures to alleviate immediate crises of disease and hunger. equally important is the need for strong governance institutions to strengthen public health programs and to ensure the capacity to meet future health challenges. to succeed, transnational preparedness will be necessary and attainable only through joint and transparent initiatives focusing on long term and comprehensive priorities. meanwhile there are power struggles underway between intergovernmental institutions with authorities mandated to act on behalf of a global consensus and the emerging corporate/philanthropic initiatives capable of thwarting any institutional momentum. non-bona fide actors are rendering intergovernmental institutions significantly weaker in their efforts to carry out their mandated roles of “directing and coordinating authority on international health work” (2). dominant philanthropic foundations have succeeded in creating a web of corporate, public and private actors working in unison and acting authoritatively relative to public governance. succumbing to this corporatization of global health, the who collaborates with powerful philanthropic foundations targeting specific projects, most commonly vaccine programs. the price paid is the relinquishing of global health governance to project organizations that do not answer to any national or international authorities with regard to priorities, transparency or any considerations relative to recipient countries. through a process of transforming global health into a neoliberal policy framework, it has brought about a refeudalization of global health. the community of nations comprising the who has abandoned moral and ethical ideals in favour of practical realities. in “the structure of scientific revolutions” (9), thomas kuhn paraphrased the old greek concept of paradigm, originally meaning a model or a pattern that the demiurge (the god) used when creating the cosmos, and thus offered a way to interpret the world. in more modern terms, kuhn describes a scientific paradigm as a universally recognized achievement that, for a time, provides a framework for solutions for a community of practitioners. the idea that a current paradigm represents the only conceivable reality works to protect the paradigm from being undermined. kuhn’s thesis may be considered relevant in light of the current neoliberal scheme in global health. corporate oligarchs seem currently secure in their capacities to enforce their desired objectives. the paradigm of neoliberalism seems unassailable, as its popularity is embedded in public health governance in national, international and intergovernmental organizations. generally, the greatest barrier to any paradigm shift is the inability or refusal of the public to see beyond the current model of thinking. opposition to neoliberalism appears to be insignificant, considering the present day scope of application. economic models promoting commodification and marketization of what were previously considered public goods and services are secure. global trade agreements facilitated by financing institutions such as the world bank, the international monetary fund (imf) and the european central bank (eub) enhance globalization, capital accumulation and the reconstituting of social class structures. reversing this embodiment of ideology, social construction of knowledge and related, powerful institutions today seems incomprehensible. marstein e, babich sm. the corporatization of global health: the impact of neoliberalism (original research). seejph 2018, posted: 14 june 2018. doi 10.4119/unibi/seejph-2018-191 a way forward? kuhn described the possibility for movements that could lead to a paradigm shift, an overthrow of an incumbent paradigm. in his classic book, “the structure of scientific revolutions” (9), kuhn concludes that, “the successive transition from one paradigm to another via revolution is the usual developmental pattern of mature science” (9). neoliberalism’s history vested in social philosophy and economic liberalism may hardly be termed a mature “science”. even metaphysics lost its significance with the arrival of the enlightenment, setting the stage for scientific revolutions. paradoxically, one may perceive hope for a paradigm shift or, in what foucault termed an epistemological shift, confronting a paradigm in the perspective of competing worldviews. the french philosopher michel foucault (1926-1984) employed the old greek term episteme and discourse, in a highly specialized sense, in his work, “the order of things” (10). an episteme referred to the historical a priori that grounds knowledge and its discourses. it represents the condition of their possibility within a particular epoch. herein lies hope for a paradigm shift, where foucault´s model of discourse may be applied to contest the current day epistemology and challenge the feudal order of global health. jeremy shiffman outlines such an approach, drawing on the theory of social constructivism (11). shiffman suggests that the rise and fall of a global health issue may have less to do with how “important” it is in any objective sense, and more to do with how supporters of the issue come to understand and portray its importance: “the rise, persistence and decline of a global health issue may best be explained by the way in which its policy community the network of individuals and organizations concerned with the problem comes to understand and portray the issue and establishes institutions that can sustain this portrayal” (11). beliefs and activities are best understood from the perspective of cultural origin. berger and luckman, suggest an explanation to aid in understanding the popularity of neoliberalism today when viewed in the context of global health. the qualitative understanding of society is a social construction of reality and a function of a cognitive bias. knowledge is socially constructed, as are ideologies, subjecting populations to norms and controlling their lives and institutions. michelle foucault´s perspectives of power and, particularly the power of profession, are a reminder of the role that power plays in the discourse of society. in much of his work, foucault’s thesis was that any dominant ideology serves the interest of the ruling class (10). in linking this latter precept of power to his thesis of modern medicine, foucault viewed the power and accomplishments of modern medicine as an epistemological shift ascribed to the consequence of the modern medical clinic manifested in its institutional power. it is perhaps a novel proposal of this paper to equate foucault’s thesis to the significance of modern day institutions such as the imf, the world bank and the world trade organization serving in empowerment capacities for neoliberalism. following foucault’s thesis, only the process of philosophical reasoning could generate an epistemological shift, thereby displacing the neoliberal paradigm and its governing precepts of global health. in what foucault labels discursive formations, a humanistically inspired exchange of views could be contrasted with corporate vested neoliberalism. this may ultimately displace the prevailing attachment to the governance of global health initiatives by corporate and philanthropic elites. it holds the promise of bringing about the re-emergence of global health governance vested in the transnational consensus of elected representatives. it increases the likelihood of global health policies and programs designed in the public interest, with resources https://en.wikipedia.org/wiki/discourse https://en.wikipedia.org/wiki/the_order_of_things https://en.wikipedia.org/wiki/a_priori_and_a_posteriori https://en.wikipedia.org/wiki/discourse https://en.wikipedia.org/wiki/condition_of_possibility marstein e, babich sm. the corporatization of global health: the impact of neoliberalism (original research). seejph 2018, posted: 14 june 2018. doi 10.4119/unibi/seejph-2018-191 directed to those initiatives of greatest priority to ensure improved health and health equity for all people worldwide. the implications for global public health practice are profound. the way forward must begin with broad, inclusive philosophical reasoning, discourse and debate about the role of corporate philanthropy and the ethics of treating health services as commodities. conclusion and implications for practice the obstacles to advancing global health in the best long-term public interests are not only related to accessing and prioritizing resources. they include disputes about ideologies, philosophies and competing vested interests. the commodification and marketization of health services, interventions and technologies attract powerful corporate actors capable of circumventing intergovernmental institutions and any other public governance initiative that poses a threat. the current situation highlights how the concepts of effective altruism, corporate philanthropy and the practice of utilitarianism sideline public institutions to bring about local and national autonomy. decades of neoliberal measures vested in the governing policies of developed countries encourage public-private partnerships that escalate the dominating role of the private sector. discussions and debates that critically analyze the impact of neoliberalism may seem unrealistic, considering how entrenched the precept of economic liberalism is around the world. it is embedded in the charters of international trade policies enforced by institutions such as the world bank, the imf and the world trade organization, with the supportive groundwork of the oecd. this union between the corporate world and a public sector vested in neoliberal dogma illustrates the need for powerful, transformative actions that can bring about change. the thomas kuhn theory of scientific revolutions is salient. replacement of the existing paradigm will require bold, determined efforts. a discursive formation to reach consensus is a necessary first step. references 1. martens j, seitz k. philanthropic power and development: who shapes the agenda? bischöfliches hilfswerk misereor, germany; 2015. 2. adams b, martens j. fit for whose purpose? private funding and corporate influence in the united nations. global policy forum, new york; 2015:59. 3. davis t. ngo’s: a long and turbulent history. the global journal 2013;15. 4. shivji ig. silences in ngo discourse: the role and future of ngos in africa. networks for social justice. nairobi & oxford; 2007. 5. pfeiffer j. ngos and primary health care in mozambique: the need for a new model of collaboration. soc sci med 2003;56:725-38. 6. bond ms. the backlash against ngos. prospect, april 2000; issue no. 51. 7. pawlikova-vilhanova v. christian missions in africa and their role in the transformation of african societies. j asian afr stud 2007;16:249-60. 8. people’s health movement, medact, medico international, third world network, health action international and alames. global health watch 4: an alternative world health report, zed books ltd; 2014. 9. kuhn t. the structure of scientific revolutions, university of chicago press; 1962. 10. foucault m. the order of things: an archaeology of the human sciences, (1966) (english ed. 1970). tavistock publications, uk; 1970. marstein e, babich sm. the corporatization of global health: the impact of neoliberalism (original research). seejph 2018, posted: 14 june 2018. doi 10.4119/unibi/seejph-2018-191 11. shiffman j. a social explanation for the rise and fall of global health issues. bull world health organ 2009;87:608-13. ______________________________________________________________________________________ © 2018 marstein et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 1 | 12 original research contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. nathalie ambounda ledaga 1, robertine mamche 1, sylvain honore woromogo 1, jesse saint saba antaon 1, fatou sow saar 2 1interstate centre for higher public health education in central africa (ciespac), brazzaville, congo. 2 director of the gender and family institute dakar, senegal. corresponding author: nathalie ambounda ledaga; address: interstate centre for higher public health education in central africa (ciespac), brazzaville, congo; e-mail: ledagan@yahoo.com mailto:ledagan@yahoo.com ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 2 | 12 abstract aims: this study aims to assess the knowledge of people from central africa about universal health coverage and show the contribution of information-education-communication for its adoption. methods: a cross-sectional analytical study across 4 of 6 central african countries was conducted. independent variables are sociodemographic characteristics. dependent variables are knowledge about information-education-communication and universal health coverage. the questionnaire was disseminated by whatsapp images or word file or copy/paste of the text and send to the contacted and trained focal points. from the smartphone, the filmed or transferred data were entered into a cspro 5.0 input form. mean score calculations and odd ratio with 95 % confidence interval for p < 0.005 were used to make associations. results: the universal health coverage had never been heard of by 56.3% of the participants. the universal health coverage was defined as health insurance by (43.9%), free care (30.3%). respondents with secondary and higher education are more likely to have heard of the uhc than respondents with no education or those with elementary education [or = 2.95 (1.01-8.64), p = 0.021] and [or = 4.27 (1.50 – 12.16), p = 0.002] respectively. conclusion: 9.3% of the economic and monetary community of central africa (cemac) population is aware of the universal health coverage; 89.4% of these accept universal health coverage in their country, and 87.4% of them think that the information education communication could enable better adherence to the universal health communication. implemention of universal health coverage for the general population and adoption of information-education-communication to promote universal health coverage and pool efforts and affiliation procedures in the cemac zone is very important. keywords : universal health, coverage, central africa ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 3 | 12 introduction according to who's definition, universal health coverage (uhc) is achieved when ‘all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship’ (1, 2). universal health coverage « is driving the global health agenda; it is embedded in the sustainable development goals (sdgs) and is now designated by an official united nations uhc day on december 12. ‘although many sub-saharan african countries have made efforts to provide universal health coverage for their citizens, several of these initiatives have achieved little success’ (3,4). local health authorities need guidance on how they can set fair and sustainable priorities (5,6). ‘progressive realisation is invoked as the guiding principle for countries on their own path to uhc and achievement of the sdg health targets. it refers to the governmental obligations to immediately and progressively move towards the full realisation of uhc, recognising the constraints imposed by limited available resources’ (7). information-education-communication (iec) is a process for individuals, communities and societies to develop communication strategies to promote health-promoting behaviour (8). africa's population is young and the burden of non-communicable and communicable diseases is a double burden, the lack of health knowledge could become a triple burden if nothing is done for iec to move towards disease-related communication for development and universal health coverage to prevent, detect and treat diseases early and cheaply (9, 10). within the economic and monetary community of central africa (cemac) countries, university health coverage seems to be unknown to the population despite the commitments made by the states to move towards it (11-14). the objective of this work was to study the contribution of iec in the adoption of universal health coverage by the populations in the cemac zone in 2020. methods study design: this was a cross-sectional, analytical, interventional study conducted from july 15 to july 30 2020 in the major cities of the cemac countries as cameroon, central african republic (car), congo, gabon, equatorial guinea (eg) and chad. study population: residents of the cemac countries, whose general population is estimated at 55 781 513, constituted the target population studied (15). residents under 15 years of age and those who refused to answer the questionnaire were not included. sampling: probabilistic and exhaustive type of sampling was chosen. the sample size, to ensure representativeness, was calculated using daniel schwartz's formula (16): n= p(1-p)(z(α/2) ) 2/ i², where n is the minimum sample size, p is the prevalence of uhc in africa (50%), z(α/2) = is the confidence level of the study at risk α = 95%, i.e. 1.96, i is the accepted printing error on either side of the result, i.e. 5%. we obtained n = 403. sample size by country : the general population by country was 23 779 022 (cameroon), 5 745 135 (car), 5 279 517 (congo), 2 074 656 (gabon), 2 015 334 (eg) and 15 162 044 (chad). to obtain the sample per country, we used the following formula n = (country population x 403) / general population for the 6 countries. thus, we obtained 182 for cameroon, 42 for car, 40 for ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 4 | 12 congo, 16 for gabon, 15 for eg and 110 for chad. data collection tool and collection procedure: we used a questionnaire with two sections, a definition and concepts. the questionnaire was disseminated by whatsapp images or word file or copy/paste of the text and send to the contacted and trained focal points. through relationships with ngos adolescence et santé, exit gate from gabon, whatapps contacts were made in the capitals of the countries; volunteer interviewers were trained and deployed in the city respecting the barrier gestures also those who could fill in numerically did so. in the end, there was one principal interviewer in each country except cameroon where there were two. the questionnaires were filled in and collected in the community face to face in focus groups of less than 5 people and through the whatsapp network on the questionnaire sent online. for the digital responses, questionnaires were sent by whatsapp to the country correspondents who collected the responses via whatsapp before transmitting them via the same channel or internet. variables independent variables : sociodemographic characteristics (age, gender, level of education, marital status, occupation. dependent variables : knowledge of iec and uhc, attitudes towards iec and uhc, adoption of iec and uhc. data entry and analysis: from the smarthphone, the filmed or transferred data were entered into a cspro 5.0 input form, imported and analysed using spss. mean score calculations and or with 95 % ci for p < 0.05 were used to make associations. ethical considerations: requests for authorisation were sent to the ministries of health of the 6 countries with acknowledgement of receipt. informed consent file submitted to participants who read and agreed before participating in the interview. results a total of 403 questionnaires, of which 100 were on hard paper and 303 on digital, were submitted and transferred to the population. only 302 responded, i.e. a participation rate of 74.94% (302/403). out of 6 countries, 4 returned the questionnaires. cameroonian participation represented 37.7%, congolese 34.2%, gabonese 18.5% and central african 9.6% (table 1). sociodemographic characteristics : the mean age was 31.29 ± 10.74 years. the 2534 age group accounted for 39.1%; the 15-24 and 35-44 age groups for 29.1 and 18.9% respectively. the female and male sex represented 46% and 54% respectively, sex ratio: 1.17 (163/139). higher education was found in 52% of the participants. the marital status revealed 65.9% of single people. unemployed participants represented 47.7% (table 1). ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 5 | 12 table 1. sociodemographic characteristics of participants variables number percentage (%) country participation rates cameroon 114 37.7 central african republic (rca) 56 18.5 congo 103 34.2 gabon 29 9.6 age (years) : mean/sd 31.29 (10.74); min/max 15/74 15-24 88 29.1 25-34 175 58.0 45-54 39 12.9 sex sex ratio : 1.17 female 139 46.0 male 163 54.0 education no education 22 7.3 primary 21 7.0 secondary 101 33.4 university 158 52.3 marital status single 199 65.9 married 86 28.5 divorced 14 4.6 widowed 3 1.0 sector of activities public 51 16.9 private 64 21.1 liberal 38 12.6 without 149 49.4 knowledge of uhc and iec: the uhc had never been heard of by 56.3% of the participants. the information sources mentioned by the participants were television (25.8%) and social networks (28%). the uhc was defined as health insurance by (43.9%), free care (30.3%) participants. the concept of iec was not known by 63.6% of participants. social networks, health structures and television represented 24.1%, 24.1% and 15.7% respectively. the participants who acknowledged not having received iec on uhc represented 59.3% (table 2). ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 6 | 12 table 2. knowledge of participants about uhc and iec knowledge number percentage n = 302 % have you heard about uhc ? yes 132 43.7 no 170 56.3 what is the uhc ? health insurance 58 43.9 mutual insurance 4 3.0 free care 40 30.3 dont’t know 24 18.2 other 3 2.3 not specified 3 2.3 you heard through which channel? tv 34 25.8 radio 18 13.6 social networks 37 28.0 health structure 20 15.2 other 18 13.6 not specified 5 3.8 have you heard about iec ? yes 108 35.7 no 192 63.6 not specified 2 0.7 you heard through which channel? tv 17 15.7 radio 16 14.8 social networks 26 24.1 health structure 26 24.1 other 22 20.4 not specified 1 0.9 was there an iec on uhc? yes 39 36.1 no 64 59.3 not specified 5 4.6 ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 7 | 12 attitudes towards the iec and uhc: the uhc was accepted in their country by 89.4% of participants; 81.8% were willing to enrol and 88.4% accepted the iec on uhc. participants without uhc represented 89.4%; of the 9.3% with insurance 42.9% had full coverage (table 3). the origin of the uhc fund was not known for 28.8%. 80.5% of the participants were willing to practice iec. iec on uhc does not exist in their country according to 55.6% of the participants. 87.4% of the participants felt that uhc is necessary for the population; 74.8% had not been trained on iec and 87.4% thought that iec can improve adherence to uhc. table 3. attitudes of participants towards uhc and iec attitudes number percentage n =302 % do you agree with the uhc in your country ? yes 270 89.4 no 30 9.9 not specified 2 0.7 are you ready to subscribe to the uhc ? yes 247 81.8 no 55 18.2 would you accept the iec on uhc ? yes 267 88.4 no 29 9.6 not specified 6 2.0 have you subscribed to an uhc ? yes 28 9.3 no 270 89.4 not specified 4 1.3 if yes total or partial ? total 2 7.1 partial 12 42.9 not specified 14 50.0 are you willing to practice iec ? yes 243 80.5 no 56 18.5 not specified 3 1.0 in your country has there been iec on uhc ? yes 30 9.9 enough 23 7.6 not enough 78 25.8 no 168 55.6 not specified 3 1.1 ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 8 | 12 have you ever been trained on iec ? yes 75 24.8 no 226 74.8 not specified 1 0.4 does iec lead to better adherence to uhc ? yes 264 87.4 no 36 11.9 not specified 2 0.7 influences of socio-demographic factors on the level of knowledge: respondents with secondary and higher education are more likely to have heard of the uhc than respondents with no education or those with elementary education [or = 2.95 (1.01-8.64), p = 0.021] and [or = 4.27 (1.50 – 12.16), p = 0.002] respectively. public, private and liberal sector workers are more likely to have heard of the uhc than non-employees [or = 8.67 (4.26-17.66), p < 0.001], [or = 2.39 (1.29 – 4.44), p = 0.00] and [or = 2.34 (1.11 4.91), p = 0.013] respectively. workers are more likely to have heard of the iec than non-workers (table 4). table 4. influences of sociodemographic factors on the level of knowledge sociodemographic factors yes no or (95% ci) p knowledge: heard about uhc education without education 05 17 primary 9 12 2.55 (0.68 – 9.54) 0.090 secondary 47 54 2.95 (1.01 – 8.64) 0.021 university 88 70 4.27 (1.50 12.16) 0.002 sector of activities public 42 14 8.67 (4.26 – 17.66) < 0.001 private 29 35 2.39 (1.29 – 4.44) 0.003 liberal 17 21 2.34 (1.11 – 4.91) 0.013 without 37 107 144 (100) knowledge: heard about iec sector of activities public 30 26 2.89 (1.53 – 5.48) < 0.001 private 28 36 1.95 (1.06 – 3.60) 0.017 liberal 21 17 3.10 (1.49 – 6.47) 0.001 without 41 103 143 (100) ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 9 | 12 discussion the most represented age group was 25-34. the young african population may explain the predominant age ranges. more than half of our respondents were men and university education was more represented as well as the private sector of activity. the period of containment may explain the higher participation rate of men as they are more out of the home and also as workers in the private sectors have many more work constraints than those in the public sector. knowledge: we assessed participants' knowledge of universal health coverage and iec and the ways in which they acquired this knowledge. more than half of the participants had never heard of universal health coverage and the concept of iec, although we found that more than half of the respondents were employees or had attended university. our findings clearly show the low level of knowledge and perception of universal health coverage among the urban population of the cemac zone countries. taking into account the expectations of the populations of the districts of certain countries, which notably show that ‘respondents seek improvements in the quality of care, community engagement activities, expansion of the range of services to include emergency referral services, and enhancement of clinical health insurance coverage to include preventive health services’ (17), it is important for the countries of the cemac zone to initiate perspectives aimed at strengthening the implementation of the uhc by taking into account the actions recommended by the who and certain studies (7,18). the case of nepal and ghana which illustrates the role and contribution of community health worker counseling family is prominent (8, 19, 20, 21). almost half of the respondents defined the uhc as health insurance. one of the paths for strengthening the practice of uhc is therefore health insurance. in the cemac zone, only gabon has adopted this policy; countries are encouraged to have their population subscribe to health insurance, considering that the role of insurance in the achievement of universal coverage within a developing country context has been demonstrated (22) as well as that of the iec (18, 23). health services are expected to play an important role in the implementation of the uhc as more than half of the respondents mentioned these health services. finally, we noted that knowledge of the uhc and iec is related to the respondents' level of education as well as their business sector. cemac member states are encouraged to use different methods to sensitise the population on the uhc as we have noted that correspondents have mentioned social networks and television as the main sources of information on the uhc. it can be seen today that there is an increase in the number of people using social networks and television as sources of information. attitudes : the uhc was accepted in their country by 89.4% of participants; 81.8% were willing to enrol and 88.4% accepted the iec on uhc. we noticed that people are willing to embrace the uhc and the concept of iec, which many have found to be innovative. governments can build on this to boost the uhc. but before that it would be useful to go through a situational analysis at different levels of the community and business sector as proposed by some studies (7,18). study limitations : for this study, covid-19 imposed digital communication and this ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 10 | 12 seemed to be little used by the populations for the surveys; the high penetration rates and costs of the internet seemed to reduce the enthusiasm of the investigators and the surveyed population. the spanish language in malabo obstructed the data collection process. in ndjamena, the investigator did not adopt the digital tool. the rainy season in bangui and the expensive and poorly penetrating internet were reported by the investigator to explain the low participation rate. conclusions less than 10%of the cemac population is aware of the uhc; 89.4% of them accept universal health coverage in their country and 87.4% of them think that the iec could enable better adherence to the uhc. only 30% have an uhc. in view of these results, the following suggestions are proposed to the cemac states: implemention of uhc for the general population, adoption of iec as a means of promoting uhc and to pool efforts and affiliation procedures in the cemac zone is very important. references 1. verrecchia r, thompson r, yates r. universal health coverage and public health : a truly sustainable approach. lancet 2019 ; 4(1) : e10-e11 2. who. what is health financing for universal health coverage ? geneva : world health organization. http://www.who.int/health_financial/universal_coverage_definition (accessed april 04 2021) 3. mclntyre d, garshong b, mtei g, meheus f, thiede m, akazili j, ally m, aikins m, mulligan ja, goudge j. beyong fragmentation and towards universal coverage : insights from ghana, south africa and the united republic of tanzania. bull world health organ 2008 ; 86(11) :871-6 4. chukwuemeka au. challenges toward achieving universal health coverage in ghana, kenya, nigeria, and tanzania. int j health plann manage 2018 ; 33(4) : 794-805 5. jansen mpm, bijlmakers l, baltussen r, rouwette ea, broekhuizen h. a sustainable apporach to universal health coverage. lancet glob health 2019 ; 7(8) : e1013 6. sakolsatayadorn p, chan m. breaking down the barriers to universal health coverage. bull world health organ 2017 ; 95(2) :86 7. who consultative group on equity and universal health coverage. making fair choices on the path to uhc. geneva 2016 8. schwarz r, thapa a, sharma s, kalaunee sp. at a crossroads : how can nepal enhance its community health care system to achieve sustainable development goal 3 and universal health coverage ? j glob health 2020 ; 10(1) :010309 9. sanofi [internet]. the rise and rise of chronic diseases in africa. 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address: rr. “dibres”, no. 371, tirana, albania; telephone: +355692492756; email: nadacomo@yahoo.com çomo n, meta e, qato m, gjermeni n, kolovani e, pipero p, harxhi a, kraja d. overview on epidemiological and clinical manifestation of covid-19 in albanian adults (original research). seejph 2022, posted: june 2022. doi: 10.11576/seejph-5626 p a g e 2 | 11 abstract on march 9, 2020 the first two cases of sars-cov-2 were identified and hospitalized in albania. in this paper we present a retrospective analysis of 3000 consecutive covid-19 confirmed cases in albanian adults admitted at the infectious diseases service which includes three tertiary care wards, part of tirana university hospital center “mother teresa”. the period included in this analysis is from march 2020 – april 30, 2021. the paper provides a general overview including demographic distribution, symptomatic diversity and clinical signs manifested among cases, as well as the association observed with underlying pathologies. the analysis included 1944 males and 1056 females. overall, the age groups included range from 15 to 99 years (median 65 years; mean value 63.4±13.4 years). there were no statistically significant age differences between males and females (mean ages were: 63.5±13.1 in females and 63.3±13.5 in males; median ages were: 64 years in females and 65 years in males; p=0.67). there was evidence of a statistically significant difference between sexes regarding the presence of symptoms, which were more predominant in males (p<0.001). on the whole, we observed 19 cases with specific signs and symptoms, most of them (82.9%) among patients who reported the presence of such symptoms 5-14 days before hospitalization. the comorbidities encountered were ranked according to systems and organs, classifying them in 22 categories, among which the most frequent were hypertension (52%) and diabetes mellitus (26.4%). age was a strong risk factor for severe illness, complications, and death. analyzing symptom onset with total symptoms and comorbidities, it showed that some patients were affected for many days with few symptoms and few comorbidities. it seems they started as mild cases for many days unpredictably precipitating. there were also a few cases with many comorbidities, but a few symptoms upon hospital admission. keywords: adults, albania, clinical manifestations, covid-19, epidemiology. conflicts of interest: none declared. çomo n, meta e, qato m, gjermeni n, kolovani e, pipero p, harxhi a, kraja d. overview on epidemiological and clinical manifestation of covid-19 in albanian adults (original research). seejph 2022, posted: june 2022. doi: 10.11576/seejph-5626 p a g e 3 | 11 introduction it’s the second year of the pandemic, from the identification of the first cases of sarscov-2 in wuhan, hubei province of china, characterized by acute respiratory syndrome and silent hypoxemia (1-3). this new clinical syndrome was similar to sars cov and mers but with faster and much more contagious designation named covid-19. on march 11, 2020 who declared a global pandemic situation, of which our country was a part. on march 9, 2020 the first 2 cases of sars-cov-2 were identified in albania and hospitalized in infectious diseases (id) service of uhc tirana. the id service was adapted to receive patients with covid-19. from the identification and hospitalization of the first two cases and so far in this service that includes 3 covid hospitals, over 8000 patients have been hospitalized (4). facing a new syndrome in our country not encountered before with similar forms sars cov and mers, based on the initial media data or the first articles on it that focused on symptoms such as fever, dry cough, dyspnea, asthenia; we focused on each of the signs and symptoms referred by the patient, the variety of clinical forms, concomitant diseases clinical forms that appear. in the first 12 weeks, cases were hospitalized with positive rt-pcr of mild forms to severe in order to receive early medical treatment and limit the spread of the virus, through negativity in the hospital and then "self-isolation" after discharge for up to 14 days (3). as the months went by and the progressive increase of cases and the emergence of new genetic variants of covid19 we encountered as a result a wider spectrum of clinical forms, the severity of the presentation and the most affected age groups. the purpose of this study is to present a general overview of covid-19 in albanian adults including demographic distribution, symptomatic diversity and clinical signs manifested, the association with accompanying pathologies. methods we conducted a descriptive retrospective analysis of 3000 consecutive covid-19 confirmed cases hospitalized in infectious diseases hospital service which include three hospitals, part of tirana university hospital center ‘mother teresa’. all three hospitals are tertiary care institutions. cases were admitted in hospital from march 2020 to april 2021. study inclusion was based on the hospital admission criteria consisting of proved cases of non-pediatric age. covid hospitals in tirana, the capital, were the same and admissions are representative of the pandemic characteristics because there were no different filters accepting patients. demographics, symptoms and comorbidities were analyzed through counting and descriptive statistics as frequencies (and percentages) and mean and standard deviation were calculated. data were elaborated through ibm® spss® statistics 26 software (5). results based on gender; females were n=1056 (35.2%), mean (sd): 63.5±13.1 years; males were n=1944 (64.8%) mean (sd): 63.3±13.5 years. there was statistically significant difference between sexes, p<0.001 (table 1 and figure 1). epidemiological aspects: in 3,000 cases with a range from 15 years to 99 years, mean (sd) was 63.4±13.4 years, p= 0.667 (table 1). çomo n, meta e, qato m, gjermeni n, kolovani e, pipero p, harxhi a, kraja d. overview on epidemiological and clinical manifestation of covid-19 in albanian adults (original research). seejph 2022, posted: june 2022. doi: 10.11576/seejph-5626 p a g e 4 | 11 table 1. distribution of participants by age-group age group number percentage 15-19 4 0.1% 20-29 43 1.4% 30-39 150 5.0% 40-49 246 8.2% 50-59 554 18.5% 60-69 945 31.5% 70-79 760 25.3% over 80 298 9.9% total 3000 100.0% figure 1. distribution of particiaptns by gender and age-group based on the place of residence, the highest frequency was encountered in tirana, the capital city of albania (n=1348, 44.9%), due to the higher population density and testing capacities in the capital; uhc serves at the same time as a secondary and tertiary center for the capital in contrast to the districts, as well as in contrast to the regional hospitals are expected to be cases of larger age groups, and with higher gravity. clinical aspects: we identified 19 clinical signs and symptoms referring from the day of onset to the hospitalization (presented in table 2). çomo n, meta e, qato m, gjermeni n, kolovani e, pipero p, harxhi a, kraja d. overview on epidemiological and clinical manifestation of covid-19 in albanian adults (original research). seejph 2022, posted: june 2022. doi: 10.11576/seejph-5626 p a g e 5 | 11 table 2. clinical signs and symptoms frequency percent 1. sore throat 723 24.1 2. syncope 18 .6 3. weakness 2959 98.6 4. headache 1452 48.4 5. mialgia 2166 72.2 6. arthralgia 2090 69.7 7. anosmia 1553 51.8 8. anorexia 1483 49.4 9. sweats 2188 72.9 10. vomiting 332 11.1 11. diarrhea 505 16.8 12. dyspnea 2645 88.2 13. cough 2469 82.3 14. dry mouth 9 .3 15. thirst 4 .1 16. poliuria 3 .1 17. chest pain 974 32.5 18. paleness 2591 86.4 19. face congestion 72 2.4 20. fever 2769 92.3 among the most common signs and symptoms there were weakness 98.6%, fever 92.3%, paleness 86.4%, dyspnea 88.2%, cough 82.3%, myalgia 72.2%, sweats 72.9%, arthralgia 69.7%. we also monitored symptoms such as heart rate (hr), respiratory rate (rr), oxygen saturation level and at the time of hospitalization in 3000 patients were encountered (hr) with a range 19-170 and mean (sd) of 86.2±14.3; rr with a range 39 and mean (sd) of 20.8±3.3; and oxygen saturation level with a range 40-99 and mean (sd) of 82.7±11.1 (table 3). table 3. heart rate, respiratory rate and oxygen saturation level parameter n minimum maximum median mean std. deviation heart rate (/min.) 3000 19 170 85.0 86.2 14.3 respiratory rate (/min.) 3000 10 49 20.0 20.8 3.3 sato2 lying position 3000 40 99 84.0 82.7 11.1 çomo n, meta e, qato m, gjermeni n, kolovani e, pipero p, harxhi a, kraja d. overview on epidemiological and clinical manifestation of covid-19 in albanian adults (original research). seejph 2022, posted: june 2022. doi: 10.11576/seejph-5626 p a g e 6 | 11 most symptoms and signs were observed in 82.9% of patients who showed symptoms from 5-14 days before hospitalization (figure 2). figure 2. day of the symptoms onset we also analyzed the number of symptoms per patient, we identified that the predominant cases were 7-11 signs and symptoms. there was a significant positive correlation between the onset of symptoms and the total number of symptoms n=3000, r = 0.161, p <0.001 (figure 3). figure 3. number of sings and symptoms çomo n, meta e, qato m, gjermeni n, kolovani e, pipero p, harxhi a, kraja d. overview on epidemiological and clinical manifestation of covid-19 in albanian adults (original research). seejph 2022, posted: june 2022. doi: 10.11576/seejph-5626 p a g e 7 | 11 table 4. number of sings and symptoms percentile value 25 6.00 50 8.00 75 10.00 we categorized the concomitant diseases encountered according to the systems and organs and the frequency of occurrence (table 5). table 5. comorbidity diseases frequency percent dm cat. 791 26.4 hta cat. 1559 52.0 thyroid disorders cat. 55 1.8 ckd cat. 159 5.3 neoplasms cat. 78 2.6 obesity cat. 36 1.2 diseases of the respiratory system cat. 116 3.9 cardiac diseases cat. 77 2.6 cardiac arrhythmia’s cat. 74 2.5 post myocardial infarction cat. 16 .5 chf cat. 73 2.4 ischemic heart disease cat. 30 1.0 prostate cancer cat. 77 2.6 rheumatic & dermatologic cat. 57 1.9 post stroke cat. 40 1.3 hematological diseases cat. 31 1.0 diseases of the nervous system cat. 48 1.6 infectious diseases cat. 22 .7 mental disorders cat. 32 1.1 diseases of the digestive system cat. 17 .6 thrombosis cat. 8 .3 other health conditions cat. 32 1.1 in 36.3% of cases there were no comorbidity diseases up to 0.1% with 6 comorbidity pathologies (figure 4). çomo n, meta e, qato m, gjermeni n, kolovani e, pipero p, harxhi a, kraja d. overview on epidemiological and clinical manifestation of covid-19 in albanian adults (original research). seejph 2022, posted: june 2022. doi: 10.11576/seejph-5626 p a g e 8 | 11 figure 4. comorbidities in the study population the comorbidities encountered are ranked according to systems and organs, classifying them in 22 categories, among which the most frequent were hta 52% and dm 26.4%. from statistical analysis the onset of symptoms depends on age but not on gender and comorbidities. from the regression it was seen that the onset of symptoms “agerelated comorbidities were introduced into the regression model; their onset is significantly p = 0.004 for age but the onset of symptoms has nothing to do with comorbidities p = 0.229. another correlation we analyzed consisting of the frequency of symptoms according to comorbidities, patients with connective/dermatological and digestive tissue diseases had an average of 8.7 signs and symptoms, followed by the respiratory system with 8.4 and at a lower heart rate and those of the nervous system with 7.1. to assess the impact of age, sex, comorbidities and the total number of symptoms on the time of symptoms onset, a multivariate model was constructed and analyzed (table 6). table 6. multiple linear regression model unstandardized coefficients standardized coefficients t sig. 95.0% confidence interval for b model b std. error beta lower bound upper bound age .016 .006 .054 2.848 .004 .005 .027 sex -.248 .151 -.030 -1.643 .100 -.543 .048 comorbidites -.107 .089 -.023 -1.203 .229 -.282 .067 total symptoms .246 .027 .162 9.014 .000 .193 .300 çomo n, meta e, qato m, gjermeni n, kolovani e, pipero p, harxhi a, kraja d. overview on epidemiological and clinical manifestation of covid-19 in albanian adults (original research). seejph 2022, posted: june 2022. doi: 10.11576/seejph-5626 p a g e 9 | 11 discussion in our study conducted in albania, the most affected age group was between 50-79 years (comprising 75% of the overall number of participants). there was evidence of a more prevalent moderate type of disease with an increase in the age of the affected patients with sars cov 2. on the other hand, the age group over 80 years was less prevalent compared to some studies in other countries, because albania is characterized by a young population and social centers and asylums are in smaller numbers which explains the lower exposure of older people in albania (1-3,7). furthermore, in our study there was evidence of male predomination (with 64.8% of the cases). we distinguished a variety of 20 symptoms; their manifestation varied from 1-30 days, with greater predominance in the number between the day 5-11 before hospitalization. in the analysis made on their number for each patient, the most predominant ones had 7-11 symptoms. age is a strong risk factor for severe illness, complications, and death (15-17). in our study, the most frequent underlying diseases included hypertension and diabetes mellitus (52% and 26.4%, respectively). our detailed analysis indicated also the time when the symptoms started among patients affected (14-25). prediction of symptoms onset (days) was run through multiple linear regression controlling for age, sex and comorbidities. variables in equation significantly predicted symptom onset f(4, 2995) = 22.669, p<0.001. age significantly added to prediction (p=0.004) while comorbidities (p=0.229) and sex (p=0.100) did not. analyzing symptom onset with total symptoms and comorbidities indicated that some patients were affected for many days with few symptoms and few comorbidities. it seems they started as mild cases for many days unpredictably precipitating. there were also a few cases with many comorbidities, but a few symptoms upon hospital admission. in conclusion, this study provides useful evidence about covid-19 in albanian adults including its demographic distribution, symptomatic diversity and the clinical signs manifested. references 1. center for disease control and prevention. coronavirus disease 2019 (covid-19). 2020. available from: https://www.cdc.gov/coronavirus/20 19-ncov/symptomstesting/symptoms.html (accessed: march 20, 2020). 2. world health organization. coronavirus disease 2019 (covid19) situation report – 46. 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anymedium, provided the original work is properly cited. https://doi.org/10.1101/2020.03.17.20037572 https://doi.org/10.1101/2020.03.17.20037572 https://covid19-surveillance-report.ecdc.europa.eu/archive-covid19-reports/index.html https://covid19-surveillance-report.ecdc.europa.eu/archive-covid19-reports/index.html https://covid19-surveillance-report.ecdc.europa.eu/archive-covid19-reports/index.html https://covid19-surveillance-report.ecdc.europa.eu/archive-covid19-reports/index.html senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 1 review article the emerging public health legislation in ukraine iryna senyuta1 1 danylo halytskyi lviv national medical university, lviv, ukraine. corresponding author: assoc. prof. iryna senyuta, ph.d. in law, head of the department of medical law of the danylo halytskyi lviv national medical university; address: solodova street 10, 79010, lviv, ukraine; email: prlawlab@uk.net senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 2 abstract as ukraine has started the legal process for a public health legislation, this narrative review attempts to: i) characterize recent legal acts (which are current as well as drafts) and international standards in the sphere of public health; ii) analyze the definitions of public health legally relevant to ukraine, in particular: public health and public health protection; iii) discuss related definitions relevant to the health sector; iv) characterize the main subjects tasked to protect public health; v) and clarify the necessary educational innovations, which are the basis in the preparation of human resources for an efficient implementation of the public health concept. after referring to the current legislative process and a discussion of some of the concepts and terminologies available in the literature, the following understanding of the terminology is proposed here: i) ‘public health’ should be understood as mental and physical health of the population in a certain territory, determined by the best achievable demographic indicators, characterized by decreasing morbidity and mortality and increasing the potential to lead an active and long life; ii) the term ‘public health protection’ (or, ‘protection of public health’) should address a system of measures which are aimed at prevention and control of morbidity, optimization of demographic indicators, promoting a value-oriented state policy, securing biological and genetic safety and relying on joint societal efforts. it is essential that the implementation of a public health law is underpinned by adapting the postgraduate educational system to the new challenges in ukraine. keywords: health care, multiprofessionality, public health, public health protection, ukraine. conflicts of interest: none. acknowledgements: the author expresses her cordial gratitude to prof. ulrich laaser, faculty of health sciences, bielefeld, germany, for his valuable comments and input. senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 3 introduction ukraine entered an active process to integrate public health into the national health system as part of the wide spectrum of transformations of all ukrainian systems. the “embryo” of public health has a long national history. in the historical context, it is worth paying attention to the state sanitary-epidemiological service, which was responsible for protection of public health and had two main functions, i.e. control of communicable diseases and environmental protection (monitoring the quality of water, air, soil and food) (1). scholars, who worked on various aspects of public health development in ukraine include y. bazylevych, i. gryga, n. chala, v. moskalenko, v. lekhan, v. rudiy and others. in particular i. gryga researched the issue of public health funding in ukraine and proved the idea of introducing official patient payments in ukraine in order to avoid informal or quasiofficial payments (2). the system of state bodies responsible for public health protection was the focus of interest of v. lekhan and v. rudiy (1). this process started to actively develop when ukraine signed the association agreement with the european union in 2014 (3). the article 426 of chapter 22 of the association agreement foresees that the parties shall develop their cooperation in the field of public health, to raise the level of public health safety and protection of human health as a precondition for sustainable development and economic growth. a conceptual provision of the association agreement within its chapter 22 is the “health in all policies” approach. hence, public health and health care should be a starting point for the state authorities to develop policies benefitting their population, since human wellbeing constitutes the core of any health system. correspondingly, the article 3 of the constitution of ukraine states that an individual, his or her life and health, honour and dignity, inviolability and security shall be recognized in ukraine as the highest social value. value-oriented law-making foresees the satisfaction of universal human needs and interests and it creates a relevant social toolset to meet these objectives. in the philosophical-legal interpretation, a value means objects, phenomena, social processes and their features, which are treated by a human being as those, which satisfy his or her social needs, interests, desires and which he or she involves to one’s sphere of life activity (4). public health is a collective good, which has an individual value effect – human health. in this paper i try to elucidate some aspects of the formation and development of the public health concept as a national ukrainian paradigm; to clarify the terminological framework as a basis for the creation of the forthcoming public health legislation; to define public health in the ukrainian environment and characterize the main educational innovations to support the preparation of well-trained human resources. in order to achieve these objectives the following is required: i) to characterize recent legal acts (which are current as well as drafts) and international standards in the sphere of public health; ii) to analyze the definitions of public health legally relevant to ukraine, in particular: public health and public health protection; iii) to discuss related definitions relevant to the health sector; iv) to characterize the main subjects tasked to protect public health; v) and to clarify the necessary educational innovations, which are the basis in the preparation of human resources for an efficient implementation of the public health concept. recent legal initiatives in ukraine currently, the establishment of an effective public health system is one of the priorities of the ukrainian ministry of health (3). in a strategic document of the world health organization (who) regional office for europe, issued in 2012: “health 2020: a european policy framework supporting action across government and society for health and well-being” (5), it senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 4 is noted that “...all 53 member states in the who european region have agreed on a new common policy framework – health 2020. their shared goals are to “significantly improve the health and well-being of populations, reduce health inequalities, strengthen public health and ensure people-centred health systems that are universal, equitable, sustainable and of high quality”. recommendations of the parliamentary hearings on the topic: “on health care reform in ukraine” of 21 april 2016 (6), which is currently the sole strategic document for the envisaged transformations of the health system, also encompasses the public health sector. the ‘recommendations’ define the list of tasks of the state bodies with regard to public health, including: • development and approval of the concept of the public health system reform; • preparation of a draft-law on the public health system in ukraine; hence, the government started coordinating a process aiming at the legal foundation of a national system of public health, which should include the following elements: • a modern system of epidemiologic surveillance of communicable diseases; • a modern system of epidemiologic surveillance of non-communicable diseases; • creating a system of public health, which is based on the principle “ukraine 80+”. for the first time the principle “ukraine 80+” was mentioned in the agenda of the head of the committee on health of the verkhovna rada of ukraine, namely professor o. bogomolets (“health care reform: 25 steps to happiness”). in order to implement this principle it was foreseen that there should be developed such a system of public health which would secure an increase in life expectancy of the ukrainian people. however, this principle was not further legally established in order to be implemented, except for some initial measures of organizational character, in particular official meetings with the european union representatives. subsequently, the “concept of public health system development in ukraine” (7) (hereinafter – the “concept”) and the draft “law on principles of state policy of health care” (8) (hereinafter the “draft law”) have been issued. for the first time, the draft concept foresees the definition of the term ‘system of public health’, which is a set of instruments, procedures and measures, which are implemented by state and non-state institutions in order to strengthen the health of the population, prevent disease, support an active aging, and promote a healthy lifestyle, as a joint effort of the whole society. the draft law attempts to provide a legal definition of the public health notion as a set of activities aiming at the maintenance and strengthening of the health of the population and increasing life expectancy. the state agencies and the bodies of local self-government are responsible for the organization of these societal efforts. definitions of public health legally relevant to ukraine since the legal framework for a system of public health is under consideration, the terminology and meaning of the central term ‘public health’ has to be thoroughly examined. there are many scientific and legal definitions of this term. therefore, a comparative discussion has to be conducted with regard to terms and concepts relevant to the health system. one of the oldest definitions has been formulated by charles-edward winslow in 1920: “public health refers to the science and art of preventing disease, prolonging life and promoting health through organized efforts and informed choices of society, organizations, public and private, communities and individuals” (9). according to the who definition in 1978 (10): “public health is the science and art of preventing disease, prolonging life and https://en.wikipedia.org/wiki/health� senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 5 promoting mental and physical health and efficiency through organized community efforts for the sanitation of the environment, the control of communicable infections, the education of the individual in personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of social machinery to ensure to every individual a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity”. the dimension of health according to who refers to “...a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. also, this understanding of public health incorporates the interdisciplinary approaches of epidemiology, biostatistics, community health, behavioural health, health economics, health management, health policy, health insurance, mental health, and occupational health as important subfields. however, probably, the most common definition has been coined by donald acheson in 1988 (11): “public health is the science and art of preventing disease, prolonging life and promoting health through organised efforts of society”. in contrast, in john last’s famous dictionary of public health in 2006 (12), it reads as follows: “the mission of public health is to protect, preserve and promote the health of the public. public health is the art and science of promoting and protecting good health, preventing disease, disability, and premature death, restoring health when it is impaired, and maximizing the quality of life when health cannot be restored. public health requires collective action by society; collaborative teamwork involving physicians, nurses, engineers, environmental scientists, health educators, social workers, nutritionists, administrators, and other specialized professional and technical workers; and an effective partnership with all levels of government”. ukrainian laws in force do not foresee a legal definition of the term public health; the above mentioned draft legal acts do that for the first time. it is worth paying attention to the legislation of other countries, which have special laws with a relevant legal glossary. for instance, the article 3 of the ‘law of georgia on public health’ of 27 june 2007 (13) provides a definition of the term ‘protection of public health’ as a set of measures aimed at improving the health of the population, prevention and monitoring of diseases. the article 1 of the ‘law on public health’ of the kyrgyz republic of 25 june 2009 (14) defines ‘public health’ as the health of the population or certain groups and communities defined by a geographic, social or another characteristic, which is evaluated by demographic indicators, characteristics of physical development, morbidity and disability, whereas ‘public health protection’ is defined as a system of measures, directed at the protection of public health, prevention of diseases, prolongation of life and strengthening of human health owing to organizational efforts of all parties, the population, public and private organizations, communities and individuals. these two examples demonstrate that the respective legislators have adapted elements from the aforementioned definitions which are deemed relevant in their national contexts. related definitions relevant to the health sector however, terminological problems can easily occur importing and translating terms during the process of their adaptation to national legal systems. for example, in chapter 22 of the association agreement (3), the term ‘public health’ is used solely to define the name of the chapter but in the text of the agreement the term ‘health care’ is used, which has a different meaning underlining individual health rather than population health. https://en.wikipedia.org/wiki/interdisciplinary� https://en.wikipedia.org/wiki/epidemiology� https://en.wikipedia.org/wiki/biostatistics� https://en.wikipedia.org/wiki/community_health� https://en.wikipedia.org/wiki/behavioral_health� https://en.wikipedia.org/wiki/health_economics� https://en.wikipedia.org/wiki/public_policy� https://en.wikipedia.org/wiki/insurance_medicine� https://en.wikipedia.org/wiki/occupational_safety_and_health� senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 6 taking into consideration the definitions of public health discussed so far, it is worthwhile to relate the term ‘public health’ to other terms in the field of health care and identify its place in the relevant system. especially relevant for the ukrainian legislatory process is the understanding of public health as the health of the population impacted by activities which are not restricted to the public sector – a common misunderstanding of the terminology. therefore, we propose to consider in addition the term “public health protection” which denotes the set of activities to be performed not only by the public services in order to achieve the best possible public health (health of the population) as a vision and objective. also, verweij and dawson (15) for example argue that the term ‘public health’ combines two words, each of which can be ambiguous and that among the many definitions of public health, the word “public” has two general interpretations. in a straightforward interpretation, “public” is an aggregate concept and is equated with the “population”. in this meaning, “public health” refers to the state of population’s health in general or a certain population group. the second interpretation of “public” is in terms of “collective action”, which has the goal to protect and promote a population’s health alongside efforts to prevent diseases. although historically, the same term “public health” was used in both meanings to characterize the state of the population in general and to define joint measures, which have to be taken in order to protect and improve such health (16). in the ukrainian context, it seems preferable to apply two different terms: “public health” – to define a state of health of the population and “public health protection (or: “protection of public health” – to describe collective measures. however, most scholars agree that the essence of public health is the prevention of diseases, in order to maintain and strengthen both individual and collective (population’s) health (17). with reference to the above considerations, in the ukrainian legislatory process, the following understanding of the terminology should be adopted: • public health is understood as mental and physical health of the population in a certain territory, determined by the best achievable demographic indicators, characterized by decreasing morbidity and mortality and increasing the potential to lead an active and long life. • under the term ‘public health protection’ (or, ‘protection of ‘public health’) we understand a system of measures, which are aimed at prevention and control of morbidity, optimization of demographic indicators, promoting a value-oriented state policy, securing biological and genetic safety and relying on joint societal efforts. according to article 3 of the law of ukraine on: “principles of ukrainian health care legislation” (18), medical care is the activity of the professionally trained medical workers, aimed at prophylaxis, diagnosis, treatment and rehabilitation pertinent to diseases, injuries, intoxications and pathological conditions, as well as pregnancy and childbirth. consequently, the complexity of public health’s legal nature is caused by its multidisciplinary character, which generates the following formula: “medical care” and “public health protection” are partially overlapping in the area of prophylaxis. at the same time, both terms are part of the umbrella term ‘health care’. hence, both terms are within the realm of ‘health care’. the term ‘medical care’ by its content is narrower than ‘public health protection’, since providing equal access to effective and high quality medical care is only one of the functions of the protection of public health. on this basis, the main functions of the protection of public health include: • monitoring: evaluation, analysis, and comparison of the state of health of the population in order to identify the existing problems and develop priorities. senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 7 • control: provision of biological and genetic security, decreasing the morbidity level. • prevention: prophylaxis of diseases and formation of a healthy lifestyle of the population. • strategy and coordination: formation of the state and local policy on the basis of “health in all policies”. • communication: interaction of different subjects in terms of implementing the values of public health protection into social and state life. • medical: securing equal access of the population in general and each person in particular to high-quality and effective medical services. • integration: consolidation of the national and international efforts aimed at the protection of public health. public health service according to paragraph 1.2 of the concept (7), the key central body of executive power, which is responsible for the management of public health system, is the ministry of health of ukraine. the department of public health as a structural subdivision is targeted at securing proper management of the public health system. in order to implement policy and provide services in the sphere of public health at the national level, on 31 may 2016, the government established a state institution “centre of public health of the ministry of public health of ukraine” (hereinafter – the centre). according to its charter, the centre is a scientific and practical institution of medical profile, which fulfils the following functions: ensure the permanent strengthening of the population’s health; carrying out social and hygienic monitoring of diseases; epidemiological supervision and biological security; conducting the group and population oriented prophylaxis of morbidity; combating epidemics; and execute the strategic management of all public health issues. at the regional level, it is foreseen to create regional centres of public health. at the level of districts and cities, the provision of public health services will be coordinated by a public health specialist (epidemiologist) of the regional centre who will be appointed to a certain territory. the concept also envisages that family doctors, mid-level medical personnel and representatives of the civil society should be involved in public health services. preparing human resources for the implementation of the upcoming public health legislation when creating a new structure no less important are the human resources, which will be the element of the system that takes responsibility to implement a state policy in the sphere of public health. an important step in area of education was made after the resolution of the cabinet of ministers of ukraine passed on 23 november 2016. according to this resolution, a new specialty labelled “public health” was added to the list of fields of knowledge and specialties, according to which, persons who receive higher education, are trained. this step became a foundation for the implementation of bachelor and master programs on public health. consequently, this new sector will promote the professionalization of the public health workforce. currently, in ukraine, schools of public health are being actively established and these schools will be the major centres responsible for educating the new generation of public health professionals. on the one hand, according to the multidisciplinary character of public health, specialists can be trained after different undergraduate studies (bachelor programs) and, on the other hand, training of professionals is conducted with a focus on different competencies, which are necessary for the public health sphere (for instance, with a legal specialization). senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 8 one of the examples of innovations in the sphere of education includes the departments of medical law, which were established within medical schools. these departments are to provide advanced training for health care managers and physicians. therefore, they should be involved in the training of public health professionals, especially for those who are going to specialise on legal issues of public health. in this respect, the example of the department of medical law of the danylo halytskyi lviv national medical university is of interest, which became already an associated member of aspher (19). at this department, a postgraduate course on medical law has been established targeting physicians, health care managers, and lawyers. in addition, this department has implemented other innovative educational programs, among them for example “leadership in the sphere of health care, human rights and public health law”, focusing on an advanced training of health care managers and comprising 78 hours, including lectures, practical classes and individual work. conclusions the legislative initiative to formulate a public health law for ukraine requires a careful analysis of the concepts and the term ‘public health’ and the pre-existing services and service providers in ukraine. after referring to the current legislative process and a discussion of some of the concepts and terminologies available in the literature, the following understanding of the terminology is proposed here: • ‘public health’ should be understood as mental and physical health of the population in a certain territory, determined by the best achievable demographic indicators, characterized by decreasing morbidity and mortality and increasing the potential to lead an active and long life. • the term ‘public health protection’ (or, ‘protection of public health’) should address a system of measures which are aimed at prevention and control of morbidity, optimization of demographic indicators, promoting a value-oriented state policy, securing biological and genetic safety and relying on joint societal efforts. it is essential that the implementation of a public health law is underpinned by 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which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 1 | p a g e c original research improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria prince agwu1,5, obinna onwujekwe 2,5, benjamin uzochukwu3,5, modest mulenga4 1 department of social work, university of nigeria, nsukka, enugu, nigeria; 2 department of health administration and management, college of medicine, university of nigeria, enugu campus, enugu, nigeria; 3 department of community medicine, college of medicine, university of nigeria, enugu campus, enugu, nigeria; 4 tropical diseases research centre, zambia; 5 health policy research group, college of medicine, university of nigeria enugu campus, enugu, nigeria; corresponding author: prince agwu; department of social work, university of nigeria, nsukka campus, nigeria; postal code: 410001; email: prince.agwu@unn.edu.ng; mailto:prince.agwu@unn.edu.ng agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 2 | p a g e abstract background: availability of health services at the primary healthcare (phc) level is crucial to the achievement of universal health coverage (uhc). however, insecurity of phc facilities inspires unavailability of health services. from perspectives of primary health service providers, we examined the effects of insecurity at rural and urban phc facilities in enugu, nigeria. methodology: the study adopts a qualitative method using in-depth interviews and non-participant observation. the study sites were eight (8) phc facilities (rural/urban) that were purposively selected. the first author interacted with the health workers and made extensive observations on infrastructure, policing, and other security gaps affecting the facilities. findings: while health workers wish to provide services as stipulated, the fear of getting hurt or losing their properties to hoodlums scares them, especially during the dusk hours. owing to infrastructure deficits and lack of security personnel, incidents of losing phones, stolen babies and facility items/consumables, and patients being attacked were said to be recurring. the absence of power supply during the dusk hours tend to heighten their fears, hence health workers close before it gets dark, not minding the consequences on health service users. conclusion: the issue of insecurity of lives of both the health workers and their clients is paramount to the optimal use of services in the phc facilities. insecurity is a priority concern for the health workers, and if not addressed could cause them to completely shun working in certain areas, or shun their jobs completely, with dire consequences for the achievement of uhc. keywords: primary healthcare, insecurity, community policing, universal health coverage, absenteeism agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 3 | p a g e introduction the bedrock of achieving universal health coverage (uhc) is primary healthcare [1]. this was subsequently validated in what has come to be known as the “declaration of astana” [2]. primary healthcare has the advantage of geographical spread and affordability. it covers remote regions and mostly accessed by the lowand middle-income class. in nigeria, there is a phc facility in every “ward” (the least seat of government’s administration just below the local government) [3,4]. hence, it seems that the availability component of uhc is somewhat addressed, especially in terms of presence. however, presence of healthcare facilities seems not to translate into the dispensation of health services round the clock, where patients can access and get quality health services at any time. the absence of health workers in phc facilities is documented in literature, alongside several drivers [5]. insecurity of lives and properties in phc facilities is listed among the drivers. unfortunately, this issue is underexplored in literature, whereas it forms a cardinal reason for health workers’ presence at work and efficiency, especially during dusk hours. it is also implicated in the safety of the properties of the phc facilities, as well as the lives of health service users. thus, this paper is poised to address the insecurity of phc facilities in nigeria within the context of achieving uhc by 2030. the foundations of uhc are anchored on the availability of health services and prevention of financial hardship while accessing health services. uhc service coverage index ranks nigeria on a score of 39, where the highest score is ≥80 [6]. this indicates how far nigeria is away from attaining uhc. an intersection of several factors could account for nigeria’s slow pace toward uhc, of which the closure of health facilities at crucial periods ranks highly. it is a known fact that nigeria faces a myriad of insecurity issues across its geopolitical zones. cases of insurgency, farmers-herders rivalry, kidnapping, banditry, and armed robbery make the daily news headlines [7,8]. these security lapses have occasioned calls for community policing, which means that communities should devise their means of securing themselves while partnering with the mainstream security agents. fortunately, the national primary healthcare development agency (nphcda) states how compulsory it is for phc facilities to be secured, including the employment of security personnel [4]. the local governments with oversights from the state governments employ phc workers. disappointedly, they make no vacancies for security personnel. the police force which should be an instrument of security within the state is never assigned to phc facilities, while they could be assigned to protect some private citizens [7]. thus, phc facilities are forced to rely on voluntary and community-provided security guards. in a study by okoli et al. which involved several states in nigeria, the ward development commission (wdc) in anambra state was the only wdc that helped phc facilities to recruit security staff [9]. although, the recruited security staff were not strong enough, which could be attributed to deficiencies in age (older adults) and equipment. several studies highlight the presence of key security infrastructure (perimeter fence and lighting at nights), and human security as motivators for health workers to attend work, especially at nights [10,11,12,13]. unfortunately, these infrastructures are found lacking across most phc facilities in nigeria. a study by christian aid uk on phc facilities in abuja, reveals that just 24.7% of the facilities have a perimeter fence, while virtually all do not have active security guards [14]. properly illuminated facilities will at least give a feeling of safety and capable of putting away hoodlums since they could be easily spotted. agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 4 | p a g e unfortunately, studies reveal an acute shortage of power supply across phc facilities in nigeria, causing them to rely on carbon-emitting kerosene lanterns and petrolpowered generators that are disastrous to the environment or illumination from their phones or electricity-rechargeable lanterns, even when electricity is also a problem [12,13]. in some other study, alternative sources of power supply, especially petrolpowered generators and kerosene lanterns could be too expensive to maintain by the health workers, since they need to service the generators and also purchase petrol and kerosene for the generators and lanterns respectively [15]. their inabilities to meet up with such demand justifies leaving the facilities before it gets dark, citing the need to save their lives and those of the service users who could be attacked in the course of visiting the facilities [16]. in onwujekwe et al, some cases of health service users visiting facilities at nights and meeting no one are highlighted [5]. some of the cases highlight mortality scenarios as consequence. yet the health workers feel that saving their lives by leaving insecure facilities before dusk, is the best decision to make. given these series of security setbacks marring the efficiency of phc facilities, this study reflects through the rational choice theory. the theory as designed by george homans, fundamentally asserts that human actions are often premeditated to maximise benefits over losses [17]. health workers could consider it rational when they rather choose to save their lives and those of health service users by vacating facilities before the times when they are prone to be at risk. this seems a rational choice, but it is at the expense of health service delivery, and further stalling the achievement of uhc. therefore, closing the security gaps informing the said rational choice of abandoning facilities for safety reasons is important. the dearth of literature on the physical security of phc facilities inspires the need to ascertain the relationship such gap shares with the achievement of uhc. much seems to have been done on the financial security of service users and uhc. so, it makes sense to consider their physical security as well. therefore, our study objectives include: (a) to examine the state of security of phc facilities in enugu; (b) to determine the influence insecurity of phc facilities exercises on uhc; (c) to reveal grassroots generated solutions to insecurity of phc facilities in enugu state and possible implications. methods study area the study was conducted in enugu state, southeast nigeria. the state’s population predominantly comprises the igbo ethnic group and christians. enugu state has 17 local government areas (lgas), of which 14 of them are categorized as rural, and the rest 3 as urban. the population in enugu state is at 3.3 million with an annual growth rate of 2.59% [18]. about 35% of the 1,050 phc facilities in the state are public [19]. the state of security of phc facilities in southeast nigeria is discussed in etiaba et al., as suboptimal, deeply characterized by the absence of security personnel, perimeter fence, and poor infrastructure, which heighten fear during dusk hours and force the closure of facilities within such times [27]. a preliminary investigation into the state of security of phc facilities in six distinct lgas of enugu state different from those the authors have selected describes it as a “sorry condition” [28]. in addition, crime statistics in enugu state for 2017 is 2,171; 12,408 for abia; 1,623 for imo; 4,214 for ebonyi and 1,888 for anambra [8]. these five states make up the southeast region and are barely far apart with porous land borders. this means that possible infiltration of criminal elements from one state into another is quite high. therefore, the demand for vigilance and carefulness across the region cannot be overstated. agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 5 | p a g e sampling procedure the purposive sampling technique was used in selecting 8 facilities across enugu east senatorial district that lacked perimeter fence, security personnel or both. to select the 8 facilities, two lgas, nkanu west and enugu north lgas were selected and allotted 4 facilities each. enugu north was chosen because it is the hub of enugu urban, and will naturally have higher levels of crime occurrences. this is corroborated by anumba et al., who stated that enugu urban and surrounding lgas, of which nkanu west is among the closest, are endemic areas for restiveness and crime [26]. however, while nkanu west represented the rural lgas, enugu north was selected to represent urban lgas (see figure 1 for a representation of the study locations and selected facilities). of the 4 facilities selected in nkanu west, 2 had no perimeter fence and none had designated security personnel. the absence of perimeter fence for phc facilities is prevalent in rural areas. in contrast, all 4 facilities in enugu north had perimeter fence, as expected. however, none of the selected facilities in the urban lga had an employed security guard. the rationale behind picking facilities with and without perimeter fence is to identify implications for differences in security experiences. the health workers that participated in an in-depth conversation with the investigator were selected based on their availability at the health facilities at the time the researcher visited. the study was not designed to have any specific number of respondents, but to use non-participant observation and conversations with available health workers to unravel the state of security of these facilities and the implications for healthcare. figure 1: geographical information of selected facilities agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 6 | p a g e data collection a mix of non-participant observation and key informant interviews (kii) was used to collect data for this study. the investigator (first author) visited all 8 facilities within one month (june 2020). this happened during the first and second phases of easing lockdown for covid-19 pandemic in nigeria which commenced in may 2020. however, the investigator took steps to ensure safety by facemask wearing, using a private vehicle to avoid contacts, minimal close interaction with persons at facilities, had provision for extra facemasks to be given to those he interacted with, maintaining appropriate physical distancing at each point, and effective hand sanitizing when necessary. a checklist for observation was drawn by the authors to include the presence of perimeter fence, security guards and state of power supply. the investigator took extensive notes of what he observed on the spot, after introducing himself to the health worker(s) on the ground as a researcher and orally seeking their permission to proceed with the study. permission was swiftly granted owing to a working relationship the investigator shares with most phc facilities in the state. for coherence, the notes were structured to follow three key themes of (a) state of security of the facilities (b) implications for availability of health service delivery, and (c) what the grassroots are doing to secure themselves amidst weak or no intervention from the government, which we describe as horizontal-level solutions. to understand in-depth the security situation of the facilities, available health workers provided more insights. the insights were recorded with an android phone following acknowledgement by the health workers. those that interacted with the investigator were promised confidentiality and anonymity. ethical approval ethical approval was granted by the health research ethics committee of the university of nigeria teaching hospital, itukuozalla. approval no: nhrec/05/01/2008bfwa00002458-irb00002323). data analysis a phenomenological process to data analysis was applied, which implies constructing field experiences and responses into thematic meanings [20]. observations and narratives were reviewed and categorized under three thematic categories: (1) the state of security of the facilities; (2) implications for healthcare and uhc; (3) horizontal solutions. in line with padgett’s recommended observer triangulation and peer debriefing in strengthening qualitative studies [21], the thematically arranged observations and narratives were individually reviewed among the researchers. they were also handed to two peers within the fields of community health and social determinants of health to validate appropriateness. their comments benefitted the quality of the research reporting. results results are presented in three themes. the first examines the state of security of the facilities. the second considers the security concerns and influence exercised on healthcare and uhc. while the third provides horizontal-level solutions. security of phc facilities in enugu state of the eight facilities visited, six of them were fenced with functional gates. the agbani phc facility shares a compound with a police station. there were mixed reactions to the security from the police. the facility also has a perimeter fence. this was the only facility the investigator visited and got checked before entering. although, he was somewhat asked by one of the police agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 7 | p a g e officers to offer money, which he refused. a health worker in the facility said – “as you can see, we are together with the police and should be secured, but patients sometimes avoid coming to the facility because the police are here”. the rest facilities had no one who monitors anyone at the entrance. the gates and perimeter fence tend to have no security implication during the day since anyone could get into the facilities unchecked. the health workers on duty receive persons who get into the facilities, and sometimes, they could be unaware of who gets into the facility or goes out. well, we don’t have any security guard here. i get busy and sometimes, cannot tell who is coming or leaving. it is worse during immunization or antenatal when we attend to too many persons. it is not safe, but we depend on god. my colleague’s phone was stolen the other day and we could not trace who stole it (health worker, asata health centre). the narrative above is not farfetched from the experience across other facilities, except the one in agbani. such loosed security experience during the day could be instructive of what could happen at nights. a few narratives below explain further: we only have our volunteer worker living here. we don’t live here because the accommodation is small, and it could be scary at nights. the volunteer worker is usually scared to open the gate for anyone who knocks at night because you cannot tell if it is a pregnant mother or a criminal. the other day, she was taking care of a woman who went into labour, i think around 11 pm or 12 am […] on entering her room, a thief was in it. she fought with him, but the thief overpowered her and took her phone and money. thank god she was not raped […] she screamed, but no one could come to help her. even the patient and her husband had to first secure themselves. you have seen how quiet this place is […] (health worker, new haven health centre). i was delivering a woman of her baby one night. thieves broke into the facility. they robbed me and robbed the woman even while in labour. they took our phones and money. it was so terrible that night (health worker, asata health centre). a health worker in akegbe ugwu facility reported that the power-generator set they got from a programme – partnership for transformation of health systems (paths 1) was stolen. in nkanu west, the facilities except for agbani phc facility mentioned losing a few items like foodstuff, fridge, etc., to thieves. these concerns of robbery attacks and theft caused some facilities to shut down before it gets dark, health workers could stay back in fear or liaise with local and neighbouring security agents. on the issue of power supply, it is common knowledge that illumination enhances security. being off the grid is common among phc facilities, for the reason that they might lack the wherewithal to pay bills. the investigator only met two facilities with power supply (ngwo and new haven phc facilities) while on ground, and both are in the urban area, even though ngwo can be considered semi-urban. however, health workers in these facilities mentioned that the power supply is not steady and they cannot consistently fund alternative sources. what it means is that they rely on kerosene or rechargeable lanterns to function when no power and when it is dark. for the phc facilities in the rural zone, power supply remains in hopes. the respondents said that most and if not all the attacks that they have experienced and heard, happened during the dark hours, and in the absence of power. a health worker from amodu phc facility said, “if we have a big security light in front of our facility which constantly shines when it is dark, it will help chase away hoodlums because they know they can easily be seen”. other facilities with power agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 8 | p a g e supply (although the investigator met them without power) but still had issues with steadiness are akegbe ugwu phc, amodu phc, agbani phc, and asata phc. see table 1 for a complete mapping of the security features of the selected facilities and evaluation of security risks. table 1: selected phc facilities from nkanu west and enugu north lgas, security features and evaluation facilities perimeter fence stand-by security personnel power supply alternative source of power supply risk level nkanu west akegbe ugwu phc yes no yes (unsteady) no amodu phc no no yes (unsteady) no amagu phc no no no no agbani phc yes yes (although it shares a compound with the police, security is still challenging) yes (unsteady) no enugu north new haven phc yes no yes (unsteady) no ngwohilltop phc yes yes (just night) yes (unsteady) yes (but lacks fund to consistently run it) coal camp phc no no no no asata phc yes no yes (unsteady) no source: authors’ compilation legend: red – high-level risk; yellow – mid-level risk; green – no risk insecurity in phc facilities and implications for healthcare and uhc everyone who gives and receives health services wants to be safe while doing so. on the contrary, this is not the case across the visited phc facilities, as both health workers and health service users are unsatisfied with the security level, but ngwo-hilltop phc. in the coal camp facility, although agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 9 | p a g e it is fenced, it is still accessed by cult groups. the cultists come around the facility to smoke marijuana. they threaten the health workers at times and steal items from the facility. the health worker that was engaged said both patients and health workers are usually scared when the cultists are around the facility, and they get disturbed by the smell of the smoked marijuana. she also mentioned that it affects the inflow of patients they receive. a sad story of a stolen baby was reported. […] our patients could be scared and even us health workers. we fear what might happen to us. some patients have stopped coming here. i am even scared of coming to work at night. there is this story that a baby was stolen from this facility by hoodlums. the community people are still scared of that till today (health worker, coal camp health centre). a major concern the health workers expressed is that of closing the facilities during unsafe periods or refusing to open the facility for anyone in such times. on some occasions, their choices to stay safe affected healthcare seekers. a volunteer health worker recounted her experience: i have been reported to the oic severally that i locked out persons who came to use our health centre. some of them are pregnant women. this facility has been robbed during such odd hours. i am a young girl, and i do not want to be attacked or raped. that is why i stopped opening the gate when it is so late, especially during midnights. most times, i am the only one staying here (health worker, akegbe ugwu health centre). […] anyone who wants to come to this facility for the first time, especially at night, will be discouraged for the sake of the fear that it is not fenced and no security personnel. i live here, and i get scared, even with the neighbourhood watchmen around. sometimes, they might not be close to the facility because they move around […] so, you can imagine what patients will think about when coming here, especially the first-time patients who are not aware that the neighbourhood security watchmen can sometimes be of help (health worker, amodu health centre). finally, a health worker from asata health centre made mention of what the appalling news of robbery could cause. she pitiably said: the woman that was in labour who was robbed went to tell some persons what happened to her. for a while, we hardly got patients visiting at nights […] i can’t tell how they might have survived, especially those that could go into labour within such dangerous times. maybe, they might have gone to private facilities or the enugu state teaching hospital. at least those are usually secured (health worker, asata health centre). horizontal solutions to insecurity in phc facilities aside from the phc facility in agbani, the rest facilities tried to device some ways to secure themselves. some of them were beneficial and those that concern locking up facilities during dusk kept the health workers safe but deprived service users of health services. for ngwo-hilltop health centre, the head of the facility privately employed the services of a man within the 50s to help secure the facility during dusk. according to a narrative from a health worker, the employed security personnel has a main job he does during the day and reports to the facility by the late evening hours to commence his security job. he is paid n5000 ($12). for the efficacy of his service, see quote below: […] he uses a very big torch to flash around […] because of his presence, the volunteer health workers who stay in the facility feel comfortable at nights. they don’t need to attend to the gate when someone agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 10 | p a g e comes late at night. he attends to them, and verifies, before allowing the person in. patients do not have any need to be scared again […] (health worker, ngwo-hilltop health centre) in amodu health centre, there is an understanding between the facility and the neighbourhood security watch. fortunately, they have an office not so far from the facility. amidst the fears the health workers cite because of the poorly protected facility, they tend to feel a sense of hope that the neighbourhood security watch could come to their rescue if it matters. the phone contacts of key members of the security outfit are with the health workers residing in the facility. one of the health workers narrates her experience: one day, i was here at night and i sighted herdsmen. you know how herdsmen have been terrorizing the country. so, i immediately put a call across to one of the neighbourhood security men. not so long they landed at the facility and the herdsmen had to leave the area (health worker, amodu health centre). lastly, the health facilities in new haven and amagu tend to share a similar experience concerning the provision of security for their facilities. it deals with leveraging the security apparatus of neighbours who are elites. for instance, the facility in amagu is close to the chief of the community. what they have been able to do is to request that the security of the palace equally puts an eye on their facility. fortunately, the chief approved the request. the facility in new haven shares a fence with a catholic priest. they have been able to also reach a similar bargain. discussion a vital part of the uhc is to guarantee improved access to health facilities which seems suboptimal in the study area, especially during dusk hours. scholars in health systems have at different times researched and communicated findings on how access to health services can be improved. in all, a missing agenda evident because of paucity in literature is the subject of physical security of health facilities. it is common sense that no stakeholder in the giving and receiving ends of health services would want to lose his or her life to insecurity. much of financial security as a strong component of uhc is discussed extensively in literature. yet on second thought, there could be a spillover of the effects of poor physical security into financial security while accessing healthcare. we have seen how a finding in this study implied that closure of the phc facility for security concerns forced service users into considering private facilities and higher-level hospitals where the cost of healthcare is higher. these are some concerns raised in onwujekwe et al. about the need to keep phc facilities open and health workers present to effectively dispense health services [5]. efforts are made in terms of seeking to optimize human resources for primary healthcare, but they have largely focused on mainstream health services [22,23]. the neglect of the security apparatus of the primary healthcare stands remarkably high chances of causing losses to the gains from the other areas of human resources for health. three vital elements this study has identified that will boost the security of phc facilities in nigeria are perimeter fence, power supply (especially during dusk), and competent security personnel. we found a huge security gap across the studied phc facilities, which mirrors the likelihood of similar experiences all over phc facilities in nigeria. the studied facilities were lacking at least two of the vital security elements, and in some cases, all three. we discovered that a facility that shares a common compound with the nigeria police force (npf) could not boast with the expected security they should enjoy from such a privilege. rather, findings agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 11 | p a g e showed that patients avoided the facility because of the presence of the police, which could be in connection with the corrupt attitudes of most police officers in nigeria and the grave disregard of the citizens they are meant to protect. nigeria’s police force is among the five worst-performing on the globe [29]. as a result of these gaps, theft, high profile stealing of properties and even babies, harassment, and attacks on health workers and patients were reported. an investigative report by onyeji and a study from etiaba et al revealed the neglect of phc facilities in nigeria, strongly maintaining that most phc facilities are unsafe for health workers and patients [11,24]. we discovered that these concerns of insecurity were prevalent when it gets dark. this could be the pointer toward the fact that the health workers held nothing back when stating the crucial importance of power supply. they were of the view that illumination will help drive away the hoodlums. unfortunately, they neither had a stable power supply nor the resources to maintain alternative sources. we recorded cases of petrol-powered generators donated to phc facilities being stolen. such generators as explained to the investigator are of big sizes. if such can be taken away from the facility without any attempt to apprehend the culprit, it reveals how terrible the security condition of the facilities must be. as a result of poor power condition in these facilities, kerosene lanterns are mostly used, especially, since you even need power supply to charge the rechargeable lanterns. okoye et al propose the need for off-grid solutions to the power concerns of phc facilities [13]. this could form a programmatic option for the government and donors, since most of the facilities are currently off-grid because they lack the wherewithal to regularly pay light bills. with poor power condition across the phc facilities, added to the absence of perimeter fence and competent security guard, health workers and patients try to be rational about their safety. at times, it could entail shutting down facilities at dangerous times or the patronage of more secured facilities for a higher fee. although this is not good for uhc, health workers and patients might consider such choice as the best option to take. this aligns with the rational choice theory [17]. therefore, efforts must be made to address the rational justifications that are tantamount to the achievement of uhc. this is crucial, given that primary healthcare is the cornerstone to achieving uhc [1]. one major observation in this study is that the facilities with “no risk” or “mid-level risk” were seen to have more patients than those with “high-level risk” (refer to table 1). since the investigator did not stay in any of the facilities late into the nights, it was vivid from activities during the day hours that facilities with some security sense fared better in patronage than those without any security sense. this is irrespective of geographical location because the investigator also discovered that rural and semi-urban facilities like akegbeugwu and ngwo-hilltop phcs respectively, were seen to have more patronage than coal camp phc facility which is located at the heart of enugu urban. again, it could be that health service consumers continue patronage with phc facilities or any other facility that guarantee their security during odd hours. it is especially a case for pregnant women, nursing mothers or accident victims who could be in urgent need of health services. thus, these categories of service users are more likely to go back to those facilities that attended to them during distress, and importantly, under safe conditions. this explains why urban phc facilities like the one in coal camp which is centrally and strategically located, records poor patronage even during the day. in all, while vertical interventions such as providing in a standard manner the three key security elements would radically change the security face of phc facilities, in the meantime agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 12 | p a g e some horizontal strategies have been applied with evidence to show effectiveness. although, some of these horizontal strategies could mean that health workers spend out of their poor salaries or device informal patterns of charges on health service users to provide these security elements. such could be demotivating and could affect job satisfaction, as well as encourage corruption. for instance, engaging a willing fellow ready to offer security services to the facility only during dusk at a relatively affordable fee was applied by one of the facilities. though, there is the concern that he might not be as active as he should, given his age, and the stress of shuttling between the security job at night and his primary job during the day. other approaches we found included discussing with the elites around the facility to permit their security personnel to have an eye on the facility and leveraging the services of neighbourhood security watch. in conclusion, the security of phc facilities strongly connects with the availability of health services which enhances access and utilization that are key to the tenets of uhc. this study has brought to the fore a less researched subject, yet a vital component that will improve the safety of health providers and consumers at any time within the facility. safety will improve efficient service delivery and healthcare-seeking. this will scale up the pace of nigeria towards uhc. our study has also brought to the table the need to reform the nigeria police force, perhaps its members could at some point be deployed to man the security of phcs. interestingly, president muhammadu buhari’s agenda captures security [25]. therefore, addressing insecurity across health facilities will be vital. it will be interesting to replicate this study in other geopolitical zones since crime statistics across the geopolitical zones vary. also, it will be good to give patients the chance to speak on this subject. these two recommendations for further research are the limitations of our study. references 1. who (2017a). from primary 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(2019). sorry condition of primary health care facilities in enugu state as government promises to overhaul the system. retrieved from http://radionigeriaenugu.com/all-news/localnews/sorry-condition-of-primaryhealth-care-facilities-in-enugustate-as-government-promises-tooverhaul-the-system/ 29. international police science association (2016). world internal security & police index. retrieved from http://www.ipsa-police.org/images/uploaded/pdf%20file/wispi%20report.pdf. https://www.premiumtimesng.com/news/headlines/252694-investigation-terrible-state-nigerias-primary-healthcare-centres-part-two.html https://www.premiumtimesng.com/news/headlines/252694-investigation-terrible-state-nigerias-primary-healthcare-centres-part-two.html https://www.premiumtimesng.com/news/headlines/252694-investigation-terrible-state-nigerias-primary-healthcare-centres-part-two.html https://www.premiumtimesng.com/news/headlines/252694-investigation-terrible-state-nigerias-primary-healthcare-centres-part-two.html https://www.premiumtimesng.com/news/headlines/252694-investigation-terrible-state-nigerias-primary-healthcare-centres-part-two.html hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 1 review article effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. salisu hassan1, jamila aliyu mohammed2 1centre of excellence for development communication department of theatre and performing arts ahmadu bello university zaria kaduna state nigeria 2 centre of excellence for development communication department of theatre and performing arts ahmadu bello university zaria kaduna state nigeria corresponding author: salisu hassan; address: media and public relations division, national health insurance scheme damaturu, yobe state nigeria; email: salisu2015.sh@gmail.com mailto:salisu2015.sh@gmail.com hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 2 abstract national health insurance scheme (nhis) designed various social health insurance programmes to achieve universal coverage in healthcare delivery in the country. the scheme is adjudged to have failed to achieve its primary objective, especially in the informal sector, due to communication lapses. this study has employed an integrative literature review method to appraise the principles underlying effective health communication, the communication approaches of the nhis, and recommended plausible alternatives. media integration, advocacy campaign, social media, domestications of icts, communication in multiple languages, and active involvement of communities in the programme were found to imbibe some practical communication principles that can help improve communications to a target audience. keywords: nhis, social health insurance, effective communication approaches, universal health coverage hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 3 introduction increasing access to healthcare remains pivotal to the improvement of healthcare and the attainment of sustainable development goals (sdgs) in nigeria. more importantly, the need to provide health services to vulnerable groups such as pregnant women and children under five and those in hard-to-reach communities remains a herculean task for health stakeholders to address. universal health coverage (uhc) can be achieved through the effective implementation of social health insurance. health care coverage is adjudged to be an essential block of sustainable development, and it is a vital index for measuring the growth of a nation. one of the important duties of government is to provide the masses access to basic healthcare and protection from catastrophic health expenditures (1). however, financial constraints often limit the ability of the government to provide healthcare for all using government funding. many responsible governments consequently embrace social health insurance as a governance responsibility to provide quality and affordable healthcare. apart from quality and affordability, healthcare also needs to have universal coverage to boost accessibility (2). universal health coverage refers to a healthcare system in which all people who need health services can receive them without undue financial hardship (3). many authors have described social health insurance as ideal for quality, affordable and accessible healthcare for the masses (4,5). because of these qualities, social health insurance (shi) is becoming a more popular option in providing healthcare, particularly in developing countries where it is challenging to sustain the taxbased or out-of-pocket pay-based health financing options. nigeria is one of the developing countries that have embraced the social health insurance scheme. nigeria christened her shi designed to ensure universal health coverage. this study problematizes the extant communication approaches the national health insurance system (nhis) of nigeria deploys in communicating health. it appraises the methods used by the nhis vis-à-vis its reach to vulnerable groups in hard-to-reach communities in nigeria. before delving into the communication approaches deployed by the nhis, it is imperative to provide some core conceptual principles of nhis in nigeria to its citizenry, particularly the less privileged. social health insurance provides the opportunity for those who cannot afford out-of-pocket payment to access quality healthcare through various health insurance programmes. this also saves the government from having to go borrowing above her means to finance humongous healthcare needs. national health insurance scheme in perspective to achieve universal health coverage, the national health insurance scheme (nhis)was established in nigeria by act 35 of the nigerian1999 constitution (now cited as nhis act cap 42 lnf,2004) with a mandate to promote, regulate and administer the effective implementation of social health insurance programme to ensure easy access to quality and affordable health services to all nigerians. the nhis has a presidential mandate for achieving universal health coverage. this is to be achieved through various programmes designed to target different social-economic groupings in the country. it is believed that for the presidential mandate of universal health coverage to be achieved, the nhis must extend the deliverables of social health insurance to the informal sector (comprising over 75% of the total nigerian population). to give mobility to its term of hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 4 reference, the nhis, over the years, has developed various programmes to cater to the diverse health demands of vulnerable groups, community-based organizations, permanently disabled, tertiary institutions, and the formal sector (6). the spirit of these programmes was to reach people in rural and urban centres and get them to enroll in the scheme. nevertheless, these programmatic efforts met low enrolments in many parts of the country, especially in the informal sector (7). as many studies have shown, the root of this challenge is traceable to the communication strategy employed by the scheme. nhis focuses more on conventional media in its communication (8). the level of active community involvement in the various programmes of the scheme was also low (7). other factors that limited high enrolment in social health insurance programmes have been found to include misconceptions and the lack of consumers' understanding about the concept, underlying principles, and the benefits of the schemes (9). specifically, authors have identified that ineffective communication is one of the impediments to the success of health insurance more significantly, the informal sector. (9,10). reasons for non-patronage of social health insurance programmes have also been tied to ignorance of their processes, operations, and benefits attached to participation (11). hence, there is the need to adopt effective communication approaches that would help increase enrollment rate into the nhis programmes and engender active community involvement to enable the scheme to attain its mandate for achieving universal health coverage. methods the study has employed an integrative literature review method to appraise the various issues in the study. both online and offline literature were reviewed, critiqued, and synthesized. both qualitative and quantitative data were used to establish a position in this study. for this study, about 108 publications were consulted. the information obtained was also used to support the evidence found in the review by using descriptive statistics. results principles of effective health communication towards ensuring that health communications are effective, the who(2017)developed six principles to guide health communicators. the principles demand that health communications are accessible, actionable, credible (trusted), relevant, timely, and understandable (12). in nigeria, these principles have mostly found relevance in the formal sector. at the rural and, in some cases, periurban centres, none of these principles can be said to apply. this may be because nhis messages are arguably communicated in english language even though most rural or peri-urban centres are speech communities of diverse indigenous languages. furthermore, the messages shared, where they managed to be communicated in indigenous languages, does not engage people and set them to take action. the messages are passive with no channel ensuring instantaneous feedback. accessibility, being the first point of call, constitutes its own problem. studies have shown that, despite the numerous campaigns to create awareness about health insurance scheme in the country, many people are still not aware that such scheme exists. other studies revealed that many people who are aware do not have an appreciable level of information on the scheme's modus operandi, thereby stifling possible interest in the hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 5 scheme. therefore, there is a gap in communication about the scheme. authors have blamed the communication gap on the accessibility of media through which information about the health insurance schemes is disseminated. social health insurance is often communicated through the mainstream media like radio and television. radio is very well accessible to many people, particularly in northern nigeria. still, the energy crisis facing the country limits the potential of radio as an effective medium of disseminating useful information about the programme. television as the only medium of information dissemination about health insurance cannot provide a much-desired result. to pass the accessibility test, communications about health insurance need to go beyond the mass media. one of the delimitations with conventional media is that its feedback mechanism is neither non-existent nor not pulsating enough to propel the critical population to action. the goal of the nhis messages on radio or television is basically to inform, not to share. this is problematic because the awareness does not translate to action. the who (2017) recommended that communicators identify all available channels and map their capacities to reach priority audiences. the organization advises that communicators use the right mix of media to help empower audiences with the information they need to make informed decisions. using the right mix of media tends to improve accessibility to information about social health insurance (12). who's recommendation is instructive in that communication should involve both conventional and unconventional communication tools to facilitate participatory change. empowerment comes through active participation. from active participation, the target audience learns and makes an informed decision to impact or change their lives. so far, the nhis has not used or exhausted indigenous media in communicating its key messages. the use of indigenous media tools is arguably, almost non-existent on the fringes of nigerian communities. next to accessible is 'actionable' on the who's effective communication principles list. actionable communication is communication designed to increase audience engagement and motivation to take action (13). to be successful, communicators must understand the target audience's knowledge, attitudes, and behaviours to create messages that address barriers and encourage the audience to take action (12). in nigeria, the vulnerable groups who are the prime target of the programme are often very attached to their culture and religion. in other words, the audience's knowledge, attitudes, and behaviours are assumed to have been shaped by their culture. communications that will elicit the emotion and action of these people may, therefore, need to take cognizance of their culture (14). this aspect of the core principle is crucial. where there are cultural or religious myths against some aspects of nhis practices, as it is evident in some parts of nigeria, only actionable messages can transform attitudes. this is where peoplecentric and direct engagement with communities is beneficial. drama, as well as other theatrical performances, has proven to be helpful in this regard. however, the nhis has not explored this option enough in rural communities and for the target population to bring about sustainable health practice. another principle of effective communication is credibility. for instance, contributory health insurance programme, as the name indicates, requires participatory funding from the audience. for them to be committed to contributing their meager financial resource to the scheme, the scheme has to be perceived or known to be credible. transparency is key to credibility; thus, communicators must be hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 6 transparent in their dealings with the audience. therefore, communications aimed at encouraging participation in social health insurance need to emphasize the scheme's credibility by citing authoritative sources, showing verifiable case studies and perhaps, having a timeline for the measure of progress. 'relevance' is another principle of effective communication. according to who (2017), to be relevant, contacts must help audiences see the health information, advice, or guidance as applicable to them, their families, or others they care about. relevant communications are essential towards the personalization of benefits derivable from participating in shi. when the audience can identify with the problem that shi is trying to solve and see the benefits as applicable to them, they would more likely embrace the scheme. to make relevant communication, who recommends knowing the background of the audience and their concerns, attitudes, and behavior. apart from the need for communication to be accessible, actionable, credible, and relevant, it also needs to be timely. it is essential to make information, advice, and guidance available conveniently, so audiences have the information they need when they need it to make appropriate health decisions (12). wrong timing can cause communication to become irrelevant to the audience's needs. once the relevance quality is lost, the communication becomes useless, leading to resource wastage. communications have to be delivered timely so that the audience can have enough time to evaluate and or assimilate inherent information and decide to act on it. finally, health communication also needs to be understandable. making communications understandable is particularly important given that target audiences are people who may not individually afford to finance their healthcare needs. most of these people belong to the vulnerable group who are educationally disadvantaged. hassan and adie(2018) stated that the imperativeness of health insurance, primarily for vulnerable groups, may not be appreciated without considering the state of human capital development in the country. table 1: nhis application of the principle of effective health communication principle of health communication literature consulted frequency percentage accessible 10 yes no 6 5 54.54 45.45 actionable 11 yes no 6 5 54.54 45.45 credible 11 yes no 7 4 63.63 36.36 relevant 11 yes no 8 3 72.72 27.27 timely 11 yes no 6 5 54.54 45.45 understandable 11 yes no 7 4 63.63 36.36 hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 7 given that human capital development (education) is low, particularly in northern nigeria, technical jargon that impedes understanding needs to be avoided, or better, translated into memorable indigenous jargon that the people can relate to. technical terms in communication need to be simplified and presented clearly. anything that can serve as noise should be preconceived, identified, and avoided (11). when the audience fails to understand communication, counterproductive misinformation can occur (15). having appraised the principles/qualities that can make health insurance communication effective, it is plausible to evaluate the approaches used in the shi communication in nigeria to recommend a better option. communication approaches of the national health insurance scheme many studies have established that the communication approaches of nhis and by extension, the informal sector have not been very effective (11, 10, 16). hassan and adie (2018) warned that the communication lapses could have dire consequences on the programme's overall success. hassan (2010) reported that the nhis communication approaches had been mainly either proactive or reactive since inception. nhis communications have been less interactive (17). according to joseph & chukwuemeka (2016), proactive communication allows an organisation to seize control of the public relations messages presented to the public (14). it enables communicators to preempt response through careful evaluation (18). reactive public relations or communication is usually impromptu and can be less thoughtful and compelling. according to hassan (2010), reactive communication stems from anger, fear, resentment, and uncertainty(17). this type of communication can be counterproductive, causing new problems while trying to solve existing ones(19). of the three communication approaches, the interactive is considered more appropriate in disseminating information about health insurance schemes (19,20). interactive communication involves engaging the stakeholders through various interactive methods such as participatory learning and action (pla) tools, workshops, and storytelling. the predominant use of either proactive or reactive communication approaches by nhis has not yielded noticeable positive results in the informal sector (17), hence the need to try interactive communication to disseminate information about the programme. table 2: shows the nature of the use of the three communication approaches by nhis. communication approaches consulted literature frequency percentage proactive 13 yes no 8 5 61.53 38.46 reactive 13 yes no 7 6 53.84 interactive 13 yes no 6 7 46.15 53.84 hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 8 considerations of alternative communication model for nhis to make nhis messages interactive, there is a need to consider applied interactional methodologies. baezconde-garbanati et al.(2014) recommended using various media combinations and testing what works and what does not(21). besides, hamel (2010) has shown that combining interpersonal, folk, and mass media would enhance the communication of nhis in nigeria (22). dauda mani (in hassan 2019) commented that: fusion between local indigenous media and the mainstream media would be in no small measure contributed toward adequate awareness creation and provision of health insurance knowledge to the local communities. integration of media and what steve abah calls "methodological conversation" approaches tend to create more awareness about the nhis and instigate the critical population to action. conversational tools like pla, fgds, drama-in-education (die), theatre for development (tfd), and other applied methodologies can stimulate serious advocacy campaigns targeting critical stakeholders. methodological conversation advocates for a synergy between the sciences, social sciences and humanities, to address community-centered interventions. the term is used to describe a synergizing process and interface between (tfd and pla) to engage local communities in a constructive process of social change. it is premised on the agglutination or convergence of ideas, principles, and approaches to produce a common goal. hence, interactive tools such as live or playback theatre can be viable instruments across disciplines. medical or scientific interventions can be re-enacted or performed for easy comprehension. for example, as seen in ahmadu bello university, the department of community medicine can partner with the theatre and performing arts department to organize medical community outreaches where all the intended health messages are communicated using the performing arts. those mentioned above can provide avenues to sensitize people and subsequent follow-up of policymakers and other stakeholders to arouse their interest to get them committed. when nhis engages in constant advocacy, the scheme would have an opportunity to carry information, education, and communication (iec) materials which can be essential for creating awareness, motivating people, and promoting desired changes in behavior while educating and informing people. abosede (2003) stated that advocacy materials carry messages easily understood, remembered, and retained for future use. this aligns with the 'understandable' and 'actionable' principles of effective communication highlighted by the who (2017). continuous social mobilization extensive social mobilizations contribute to awareness and knowledge creation but also helps in motivating and encouraging the community members to act positively. traditional religious leaders, ngos, and health workers could be turned to mobilizers of the community on the programme (7). one tool that has proven to be effective in social mobilization is the theatre. many empirical case studies and workshops, such as the samaru project and the community theatre engagements of the department of theatre and perfuming arts of ahmadu bello university zaria, have achieved many results (hassan, 2019). one way theatre has succeeded as a tool for social mobilization and communication is a mass appeal and the use of local or indigenous idiolects to communicate health messages. rather than run a commentary or health talk, the health messages are dramatized and acted before the local audience. the hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 9 community people are asked to dialogue on the outcome of the drama or what they have watched. this tool is engaging. it draws the target people into the performance as events in their lives, health behaviour, and practices are acted before them. this way, they can see themselves being played out for what or who they are. as deployed by the university department, the tool is even more stimulating as members of the community often take roles in the performance or story told by them and acted by them. effective utilization of social media a report from hassan (2019) indicates that the nhis utilization of social media channels was below average compared to the other channels of communication, such as radio, television, newspapers, etc. though social media falls within the scope of the new media and targets elites, it can improve 'accessibility' to information about the shi, particularly among the educated youths who are internet-inclined. hence there is a need for more utilization of social media such as youtube, facebook, instagram, etc., to reach more people, particularly those that are information technology compliant. again, using social media goes beyond uploading videos or writing health messages. it also involves identifying catch-nets to draw or attract young people. in this regard, high or pop music can be potent. more, urban legends or celebrities with mass online followership can also be branded as nhis ambassadors and made for sharing useful health messages to their online followers. domestication of information and communication technologies (icts) icts can be utilised to reach people in the community efficiently. icts can also help enrollers to become more involved in their own decisions. small handsets can be tailored to provide various services to rural areas by using the available icts. for this to work, locally-made applications should be developed to make enrolment less difficult so much so that anyone can register at every where or point in time. using a multi-lingual approach in communicating the various nhis programmes using appropriate language plays a vital role in reaching the enrollees. inegbedion (2015) indicates that english was the dominant language being used by nhis in communication with the general public (10). hence, there is the need to use various significant languages spoken in the country to reach people, especially those in rural areas. jegede (2010) advocated for using local languages to enable the development partners to implement their programmes (23) fully. according to adewole and osungbade (2016), using a multilingual approach can rapidly facilitate the nhis program's implementation. emphasis on behavior change communication bcc is a research-based consultative process of addressing knowledge, attitude, and practice by identifying, analyzing, and segmenting audience and participants in programmes (24). nhis should emphasize communication that would change the negative perception and misunderstanding of people about health insurance. hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 10 table 3: further confirmation of the level of effectiveness of the highlighted communication approaches above that can be used towards achieving universal health coverage through social health insurance. communication approaches literature consulted frequency percentage media integration 15 yes no 14 1 93.33 6.66 continues social mobilization 13 yes no 11 2 84.61 18.16 utilization of social media 11 yes no 9 3 81.81 27.27 demonstration of icts 10 yes no 8 2 80 20 multi-lingual approach 8 yes no 7 1 87.50 12.50 emphasis on behavior change communication 14 yes no 12 2 85.71 14.28 active community involvement 13 yes no 12 1 92.30 7.69 active community involvement studies (odeyemi, 2014; carrin et al., 2005) suggest that when communities are actively involved during the implementation of any development programme, the sustainability of that programme would be high. this follows the findings of ihidero and hassan (2019), which observes that true empowerment comes when community people actively participate in their own development affairs. nhis as a development-oriented scheme should, therefore, be able to adequately involve the communities in its various activities to enable it communicated its various programmes to target enrollees (25, 16, 2). discussion in its effort to communicate its various programmes to achieve universal health coverage, we found that national health insurance scheme has applied the six principles of effective health communication given by who (2017) to some degree. table 1 further confirmed how the health communication principles were applied to communicate social health insurance. in table 1, 54.54% of the literature consulted ensures that nhis has followed the principle of "accessibility" in communicating its programme. also, another hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 11 54.54% of the literatures consulted confirms that the nhis has followed the principle of "actionably" while 63.63% of the literature affirm the application of "credibility" and also 72.72% affirms the principle of "relevance". however, 54.54% of the nhis communication to the audience has confirmed" timely" and 63.63% confirmed the principle of "understandable". evidence from this study established that the national health insurance scheme's existing communication approaches are proactive and reactive than interactive. the literature further indicated that an interactive communication approach would be needed for nhis to ensure the achievements of universal health coverage in the country. table 2 in this study confirms 61.53% of the literature and documents consulted approved that nhis has been applying a proactive approach in communicating its various programmes and activities. also, 53.84% of the consulted literature and records show that the nhis communication approach is reactive. and lastly, 46.15% of the consulted evidence provided that the nhis communication approach is interactive. the study recommends that various media for communicating health insurance effectively was found in the study. hence, a fusion between mass media, inter-personal and folk media would be a viable option for sharing health insurance to achieve universal health coverage. table 3 also shows that 93.33% of the literature and documents have confirmed that media integration would enhance health insurance communication in nigeria. however, it was also observed that continuous social mobilization as a communication approach would create awareness and enhance the knowledge of the health insurance enrollees. about 84.61% of the literature consulted showed that continuous social mobilization would facilitate the awareness and knowledge creation of health insurance customers in such a way that they would be able to take positive action toward the programme. this study also found that effective utilization of social media would provide access to information to the social health insurance enrollees in nigeria. about 81.61% of the sources confirm that if social media is effectively utilized for communicating health insurance, there is a more favorable result. moreover, it was observed that the domestication of information and communication technologies can enhance the promotion of health insurance in such a way that it would facilitate the attainment of universal health coverage in the country. in about 80% of the literature verified, it was found that if icts are carefully domesticated, this will facilitate the promotion of various health insurance programmes. in this study, however, it was found that most of the contents of communication materials and programmes of the national health insurance scheme are in the english language, neglecting the other indigenous languages. hence, about 87.59% of the consulted literature recomme nded that using indigenous language in communicating health insurance would motivate people to act positively towards the programme. reports in this study have shown that people have different cultural and religious perceptions of social health insurance. because of these different perceptions and attitudes, there is the need of more emphasis on behaviour change communication by the nhis. about 85.71% of the literature consulted has provide the need for a national health insurance scheme to focus more on behavioral change communication to change the negative perception of people towards the scheme's programmes and activities. lastly, it was observed that active involvement of the hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 12 indigenous communities during the planning and the implementation of the nhis programmes and activities would encourage ownership and sustainability. about 92.3% of the literature consulted have shown the need for active community involvement to ensure adequate coverage of social health insurance in rural areas. without active community involvement achieving universal health coverage through health insurance would be very difficult. conclusion nhis has designed various social health insurance programmes to ensure the universal coverage of healthcare in nigeria. despite the multiple approaches put in place by nhis to reach the nigerians and create awareness about the scheme, many nigerians are not aware of the programme or do not fully understand the operational guidelines due to the excessive conventionalization of its communication tools and channels. to find an effective communication approach that can help improve awareness and participation, this study reviewed relevant literature and suggested alternative communication tools that can help the nhis achieve its mandate. a review of principles underlying effective communication was done, and communication approaches with qualities that can help improve social health insurance were identified. media integration, advocacy campaign, the use of social media, domestication of icts, communication in multiple languages, emphasis on behaviour change communication and active community involvement were found to imbibe some of the effective communication principles and are therefore recommended towards effective communication that would facilitate the universal health coverage in nigeria. importantly, there is a need for more empirical studies on nhis that draws from or uses multi-disciplinary analytic approaches. current accessible literature on nhis is mainly within the disciplines of medical sciences and social sciences. worse, the methodological approaches to such literature are mostly stand-alone and mostly depend on numbers instead of a well-triangulated outcome that shows actionable results achieved through collective community action. empirical studies should quantify data and emphasize the process of engaging the community because therein lies development and the global call for convergence in terms of methodology. acknowledgments first and foremost, my gratitude goes to the who regional office for africa the organizer of hideyo noguchi african prize for sponsoring this work. i am also using this medium to appreciate dr. dorcas kamuya of kemri welcome trust, kenya for her wonderful mentorship throughout this work . i am very grateful to dr. jamila aliyu mohammed of centre of excellence for development communication, abu zaria nigeria, for assisting me with some of the literatures as well as helping me in editing this work to ensure it's better shape. last but not the least i am very grateful to mr. victor osae ihiedero of the department of theatre and performing arts, abu zaria for his advice to ensure the success of this work. hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. 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"community-driven development at the heart of 26. sustainable agriculture: an assessment of fadama ii intervention in kajuru lga, kaduna state otukpa: a journal of the faculty of humanities and social sciences, federal university otuoke. vol.1. nos. 1 &2. ___________________________________________________________________________________ orellana garcía lpo, kaur k, brand h, schröder-bäck p. scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 (original research). seejph 2021, posted: 06 april 2021. doi: 10.11576/seejph-4312 p a g e 1 | 11 c original research scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 laura patricia orellana garcía1, kiranjeet kaur2, helmut brand1,3, peter schröder-bäck1 1 department of international health, care and public health research institute (caphri), maastricht university, the netherlands; 2 chitkara school of health sciences, chitkara university, punjab, india; 3 prasanna school of public health, manipal academy of higher education, manipal, india. corresponding author: laura patricia orellana garcía; address: department of international health, maastricht university, duboisdomein 30, 6229 gt, maastricht, the netherlands; email: l.orellanagarcia@student.maastrichtuniversity.nl orellana garcía lpo, kaur k, brand h, schröder-bäck p. scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 (original research). seejph 2021, posted: 06 april 2021. doi: 10.11576/seejph-4312 p a g e 2 | 11 abstract aim: antimicrobial resistance (amr) is one of the major health challenges of the future, but the concrete impact of counteracting measures is still unclear. to study possible outcomes within the european union, a scenario analysis for the year 2050 was performed on the possible influence of the european commission (ec). methods: scenario planning and development of strategies based on different scenarios. results: rational use of antimicrobials in animals and humans, surveillance and monitoring, new antimicrobial therapies, travel and globalization, exposure to the environment, and awareness were recognized as the main driving elements. four scenarios were developed: an efficient and implicated ec sorts out amr; an implicated but unsuccessful ec withstands amr; amr is managed regardless of the ec disinterest; and a neutral and inefficient ec fails to manage amr. conclusion: all the strategies developed on the basis of the four scenarios probe for an increase in european union's dedication to achieve positive outcomes. these include the development of effective legislation and international coordination. keywords: antimicrobial resistance, european commission, one health, scenario planning, strategies. acknowledgment: peter schröder-bäck, helmut brand and kiranjeet kaur’s contribution is cofunded through a grant of the european commission within the erasmus+ programme (project: prevent it. project reference: 598515-epp-1-2018-1-in-eppka2-cbhe-jp). conflict of interests: none declared. orellana garcía lpo, kaur k, brand h, schröder-bäck p. scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 (original research). seejph 2021, posted: 06 april 2021. doi: 10.11576/seejph-4312 p a g e 3 | 11 introduction since time immemorial, mankind has struggled with the control of infectious diseases which are one of the leading causes of death worldwide (1). the covid-19 pandemic has brought infectious diseases as top priority on the global health agenda, but in general, most of the infections are caused by non-viral agents the bacteria. luckily, the development of antimicrobial agents has remarkably helped for treating these infectious diseases: antimicrobials can kill or inhibit the growth of bacteria by disrupting one or more of their essential functions. however, the indiscriminate and prolific use of antibiotics ensued a selection pressure that led to the emergence of “antibiotic resistant” organisms, resulting in antimicrobial resistance (amr) (2). it has become a major problem given the slow pace at which new antibiotics are discovered (3). effective antimicrobial drugs are especially needed for preventive and curative measures such as ensuring complex procedures (surgeries, cancer treatment, transplants) or protecting patients from fatal diseases (2,4). in 2019, amr has been named as one of the top ten threats to global health by the world health organization (who) (5). apprehensions are rampant that amr may follow similar patterns as seen in case of epidemic outbreaks developing into pandemics (6). amr associated burden can be described as its impact on health or on the economy (7). at present, amr is estimated to cause 700,000 deaths in the world per year and a cumulative loss of over 88 trillion euros by 2050 (2,8). hence, global efforts have been organized to face this challenge. the 2015-who global action plan and 2016-united nations political declaration on amr are some of the latest undertaken actions worldwide (9). in the european union (eu) 25,000 patients die annually and 1.5 billion euros are expended each year due to amr (8). consequently, the eu reinforced the 2001 community strategy against amr through the 2011 commission action plan. with its “one health” approach, this action plan addresses amr in humans and animals. based on previous approaches, the european commission (ec) also developed guidelines for the prudent use of antimicrobials in human health (9). amr prevention is also a topic for research and educational projects of the ec, as for example the prevent it project (risk management and prevention of antibiotics resistance) that established a collaboration between european and indian universities and ngos for mutual learning (10). to introduce policy interventions, evaluations of amr burden are performed through morbidity/mortality and economic indicators (11). nevertheless, these indicators are the result of amr rather than the factors which currently influence it. thus, to ascertain the best approaches in the eu, it is imperative to acknowledge the factors that will influence amr by 2050. the present paper aims to determine the driving forces of amr and establish useful strategies through the development of a series of scenarios. these scenarios will concern the influence of the eu in combating amr by the year 2050. methods scenario planning is a technique used for anticipating alternative futures. it was originally founded by economic experts to predict large-scale changes. in fact, it is particularly convenient in circumstances with high uncertainty. this method is progressively expanding in the public health sector since it takes apart the complexity of most public health concerns (12). accordingly, scenario planning was employed in this study to address amr intricacy and enhancing key strategies from the eu perspective. moreover, this method has been applied successfully in the context of eu policies earlier as well. for in orellana garcía lpo, kaur k, brand h, schröder-bäck p. scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 (original research). seejph 2021, posted: 06 april 2021. doi: 10.11576/seejph-4312 p a g e 4 | 11 stance, the white paper on the future of europe shows five scenarios for how europe could evolve by 2025 (13). to execute scenario planning, the process described by neiner et al (12) was followed. according to the authors, four steps are needed to develop scenario planning in public health: (i) define the sense of purpose; (ii) understand driving forces, key patterns and trends; (iii) develop scenario plots; and (iv) plot strategy, rehearse and converse. briefly, first of all a relevant objective needs to be established to define the sense of purpose. in this matter, the impact of amr on public health was considered, as it has motivated the need for action (14). after all, the ec has recognized amr threat and works closely with who and other partners to accomplish amr global action plan (15). besides, it aims the eu to set best example globally (16). secondly, predetermined and unpredictable forces shaping the objective need to be determined. for this purpose, a literature review was carried out. as a result, key factors, previous actions and current involvement of the eu in amr were exposed. next, alternative futures ought to be developed in conformity with the forces formerly established. hereby, four scenarios were developed based on amr progress and ec support considering the factors ascertained from the literature review. lastly, valuable strategies should be settled irrespective of the scenario contemplated. and so, these strategies were ultimately included and argued in the discussion section (12). results driving forces, key patterns and trends the development of resistance basically involves three major determinants: humans, animals, and the environment. resistant bacteria arising in humans, animals, or the environment may spread from one to the other, and from one place to another. it spans inappropriate antibiotic prescription, uncontrolled over-the-counter sale of antibiotics, disproportionate use of antibiotics in the food for animals (e.g. livestock, aquatic, pets), and poor sanitation and hygiene (17). of these, the rational use of antibiotics has a major influence on amr outcomes. common infections such as cold, flu are responsible for the majority of antibiotic prescriptions, however in reality, most of these infections are caused by viral agents against which antibiotics are ineffective (18). the use of antibiotics in these cases is not appropriate, rather it enhances the risk of amr. antibiotics also prevail as a prophylactic measure for minimizing the consequence of poor farming conditions and as a growth accelerator (18). to prevent misuse, the eu has published guidelines for the prudent use of antimicrobials (19). in this regard, the european parliament and the council of the eu issued the eu 2019/6 regulation that prohibits the use of antimicrobial as prophylactic agent or growth promoter in animals (20). rational use of antibiotics is a predetermined force since it has become a priority for health professionals (21). surveillance and monitoring are key elements of national action plans on amr (18). for instance, at eu level, several agencies are involved in amr surveillance: the european centre for disease prevention and control (ecdc), the european medicines agency (ema), and the european food safety agency (efsa). basically, ecdc is responsible for coordinating two surveillance networks (ears-net and esac-net), while ema and efsa publish annual reports on amr (18). these are predetermined forces since these agencies are expected to continue with their responsibilities. public awareness is another key element in combating amr. the results of price et al (22) substantiated poor understanding of orellana garcía lpo, kaur k, brand h, schröder-bäck p. scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 (original research). seejph 2021, posted: 06 april 2021. doi: 10.11576/seejph-4312 p a g e 5 | 11 amr in the general population. as a matter of fact, the 2018 eurobarometer indicated 57% of europeans were uninformed that antibiotics are ineffective against viruses (18). this unawareness endorses antibiotics’ misuse and so amr. hence, ecdc established the european antibiotic awareness day (eaad) which aims to support the correct use of antibiotics through national campaigns (16). though raising amr awareness perhaps entail a predictable force, its effectiveness is certainly unpredictable. the discovery of new antimicrobials and diagnostic techniques will significantly impact amr (23), therefore more investment is needed in basic science (18). for this reason, one of the main pillars of one health action plan focus on boosting research, development and innovation (9). in this regard, the eu is developing in coordination with industry for development of new antibacterial agents under the combacte-magnet project (24). despite the investment, it is unpredictable when new antimicrobials will be ready and if so, what will be their efficacy against amr strains. the relevance of the interaction between chemicals (antimicrobials, heavy metals, and biocides) and pathways (industrial wastewater, animal manure) has also been emphasized in contributing to the spread of amr. it seems that strict environmental regulations are needed in the development of amr national action plans (25). the eu acknowledges that strong evidence is needed to counteract the incomprehension of the environment role in amr. to fill this knowledge gap, specific actions (such as strengthening the role of the scientific committee on health and environmental risks (scher) on amr matters) have been included in the eu one health action plan (9). despite the ec engagement in the environmental area, the success of this approach is yet unpredictable. lastly, travel and globalization have allowed newer opportunities for cross-transmission of amr (23). visitors from developed countries such as usa often show colonization or infections with kpc-, vim-, oxa-48and especially ndm-producing enterobacteriaceae, upon travel to countries such as greece, israel, turkey and morocco and the indian subcontinent (26). amongst various categories of visits, medical tourism is specifically linked to the spread of amr. people from developed countries usually undergo several types of surgical procedures in developing countries such as india and china due to relatively low treatment costs and shorter waiting times for surgeries. travel and globalization are unpredictable driving forces since their course and trends are likely uncertain. scenario plots four scenario plots have been developed, based on the anticipated futures resulting from amr progress and ec support. the different scenario plots are presented in table 1 and 2. the first two scenarios (‘an efficient and implicated ec sorts out amr’ and ‘an implicated but unsuccessful ec withstands amr’) assumed a strong ec involvement, whereas in the last two (amr is managed regardless of the ec disinterest and a neutral and inefficient ec fails to manage amr) indicates that there is no engagement of the ec to encounter amr. despite the level of support provided by the ec, in the first and third scenario (an efficient and implicated ec sorts out amr and amr is managed regardless of the ec disinterest) it is assumed amr has been addressed appropriately. on the contrary, the second and fourth scenario (an implicated but unsuccessful ec withstands amr and a neutral and inefficient ec fails to manage amr) assumed an inefficient management of amr. orellana garcía lpo, kaur k, brand h, schröder-bäck p. scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 (original research). seejph 2021, posted: 06 april 2021. doi: 10.11576/seejph-4312 p a g e 6 | 11 table 1. scenario planning for amr in view of the ec table 2. scenario planning for amr in view of the ec an efficient and implicated ec sorts out amr an implicated but unsuccessful ec withstands amr amr is managed regardless of the ec disinterest a neutral and inefficient ec fails to manage amr u n p r e d ic ta b le f o r c e s a m r a w a r e n e ss the ec encouraged ms to raise effective awareness among the population through the increase of national campaigns. people are conscious of the use of antibiotics and follow accurately healthcare professionals’ instructions. the ec supported ms in developing multiple national campaigns to raise amr mindfulness. even so, the interventions did not have the desired impact and the public still use antimicrobials indiscriminately. the ec did not encourage ms to increase the number of national campaigns to raise amr awareness. however, the general public is more conscious about the amr problem and they use antibiotics less indiscriminately, although misuse still exists. the ec failed to encourage and support ms to raise amr awareness through sufficient and effective national campaigns. citizens misuse antibiotics which have increased the number of resistant pathogens. an efficient and implicated ec sorts out amr an implicated but unsuccessful ec withstands amr amr is managed regardless of the ec disinterest a neutral and inefficient ec fails to manage amr p r e d e te r m in e d f o r c e s r a ti o n a l u se i n a n im a ls a n d h u m a n s the ec extended the guidelines and introduced stricter measures regarding the use of antimicrobials. the broad use of antimicrobials decreased and they are uniquely provided when indicated in guidelines. the ec extended the guidelines and introduced stricter measures for antimicrobials use. still, professionals do not follow the guidelines and measures established. antimicrobials are used irrationally which has resulted in an increase of amr. the ec did not extend the guidelines and measures regarding the use of antimicrobials. despite this, professionals are following outdated guidelines. amr has slightly increased but not as much as it was expected. the ec did not extend the guidelines and measures regarding the use of antimicrobials. besides, professionals are not following the guidelines and measures. s u r v e il la n c e a n d m o n it o r in g surveillance and evaluation of amr have been performed correctly. useful information has been gathered which allowed to develop appropriate strategies to confront amr. surveillance and evaluation of amr have been performed correctly and more agencies have been involved to complete this task. despite the information gathered, it has not been used appropriately to developed useful strategies to approach amr. surveillance and evaluation of amr have failed to provide useful information. however, policymakers have been able to use the little information gathered to improve some strategies and developed useful interventions. surveillance and evaluation of amr have failed to provide useful information. the ec has lost interest in monitoring amr, there is no pressure from the european parliament or the ec. the real status of the amr situation is not known. orellana garcía lpo, kaur k, brand h, schröder-bäck p. scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 (original research). seejph 2021, posted: 06 april 2021. doi: 10.11576/seejph-4312 p a g e 7 | 11 n e w a n ti m ic r o b ia l th e r a p ie s the ec has constantly been investing in amr research. the investment has provided good results, new antibiotics have been discovered and new diagnostic technologies developed. amr exists but there are effective resources to deal with it. the ec has constantly been investing in amr research. however, the development of new antimicrobials and diagnostics has not improved considerably. new advances have been made but not sufficiently to solve the problem. the ec decreased the investment in research in amr. the development of new therapies and diagnostics has slowed down. despite this, new technologies developed for other health problems have been useful to deal with amr and reduce its impact. the ec stopped the investment in research, and no new development has been achieved. old antimicrobials are still used as first and second-line treatments. health professionals have to deal with new amr pathogens. a m r e x p o su r e t o t h e e n v ir o n m e n t the ec has been working to involve environmental regulators in amr national action plans. also, their coordination with stakeholders has improved. the degradation of antimicrobials in wastewater is strictly controlled and treated. no antimicrobials are released to the environment. the ec has been working to get environmental regulators to be more involved in amr national action plans. however, their coordination with stakeholders is still insufficient. new regulations are considered to be implemented regarding wastewater, but no steady action has been yet taken. the ec did not boost the involvement of environmental regulators in amr national action plans. nonetheless, there is coordination between environmental regulators and other stakeholders. they achieved to develop strategies to minimize amr impact in the environment. the ec did not boost the involvement and coordination between environmental regulators and stakeholders. national action plans did not include amr's impact on the environment. antimicrobials are constantly released to the environment since there is no regulation to control it. t r a v e l a n d g lo b a li z a ti o n tourism increased in the last years. the ec has been working to endorse early screening and control measures to tourist arriving from amr endemic areas. these measures have been successfully applied and so, fewer amr pathogens have been spread. the ec encouraged new control measures and provided additional guidance on early screening for tourists returning from amr endemic areas, yet they were not strongly followed, and several amr strains have been locally spread. the ec has not considered the need of new guidelines regarding early detection or additional measures in tourists. nonetheless, healthcare professionals have been able to detect certain carriers and limit the spread of imported amr strains. there ec ignored tourism as a amr threat and consequently, no measures have been considered nor proposed to supervise the transit of tourist arriving from amr endemic areas. this situation has boosted the spread of amr strains to different regions. discussion the ongoing covid-19 pandemic has taught us a big lesson that how devastating nontreatable infectious diseases can be (27). on similar league, amr bears the proficiency of attacking us as an epidemic or pandemic. an estimate by who suggests that approximately 10 million deaths will happen due to amr by 2050. although just a forecast, some of the scenarios described could be associated with this number of deaths. to decrease the odds of these deaths becoming a reality, actions must be taken on priority. therefore, the potential influence of driving forces has been described in the scenario orellana garcía lpo, kaur k, brand h, schröder-bäck p. scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 (original research). seejph 2021, posted: 06 april 2021. doi: 10.11576/seejph-4312 p a g e 8 | 11 plots to better understand the ways to combat amr. encouraging legislators to introduce standards and procedures to assure sensible use of antimicrobials will be useful (19). antibiotics could be restricted with a similar approach narcotics and psychotropics are controlled (regulated by the single convention on narcotic drugs of 1961 and the convention on psychotropic substances of 1971). the development of these “antibiotic conventions” could shift the prescription of antibiotics as a first-line treatment to every possible infection. nevertheless, to achieve this type of covenant a high level of international agreement is required. stakeholders would clearly benefit from this consensus and of these, society also plays a fundamental role. public awareness is an influential factor on amr. thus, further efforts should be considered to increase population’s consciousness about amr threat: diversification of amr campaigns in diverse channels such as tv, radio, or social media that could successfully raise public awareness. in light of newer antibiotics, the development of effective antibiotics against resistant strains is the need of the hour. a fixed amount of money provided by the ec to industry could be established as funding to foster new antibiotics discoveries. promoting partnership with industries will also improve the likelihood of developing better diagnostics to determine the etiologic agents of the diseases and, consequently, prescribe antibiotics only when necessary. likewise, the use of artificial intelligence in amr surveillance and monitoring would allow to analyze existing data more precisely and consequently improve outcomes through strategies adapted to each circumstance. tourism also represents a relevant threat to the spread of amr strains: tourists may acquire amr pathogens in their journeys and subsequently spread them in their country of origin. early detection of carriers and control measures, in combination with international cooperation are strategies which could be beneficial, if they are successfully applied (23,28). on the other hand, it is necessary to emphasize the connection between amr and the environment. on this ground, legal measures could be established to control wastewater treatment, followed by regular inspections to assure that legislation is properly applied. in general, the strategies developed from each scenario imply that the outcomes would likely be beneficial if there is an increase of commitment and coordination between stakeholders, especially from the ec. some of the strategies established have been compared with conventions already applied to other health challenges, such as the psychotropic and narcotic drug conventions. nonetheless, to achieve these methods, further collaboration and coordination are needed not only among member states but also at international level. the eu-india collaboration contributing to this global perspective (10). the global position also emphasizes the important role the eu plays in this global health challenge and the advantageous outcomes that could be achieved if the eu is fully involved in slowing down amr. on the other hand, the results have shown that the ec could address the driving forces of surveillance and monitoring, environmental amr, treatment innovation, and tourism by introducing new legislation. eu legislation can have a significant impact, not only within the member states but also outside its borders. in fact, the eu is currently endorsing amr measures in third countries through different actions, like promoting amr-related standards in its bilateral free trade agreements (ftas) (9). these actions underpin the role of the eu as a global actor in the orellana garcía lpo, kaur k, brand h, schröder-bäck p. scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 (original research). seejph 2021, posted: 06 april 2021. doi: 10.11576/seejph-4312 p a g e 9 | 11 amr challenge and highlights, again, the importance of developing and reinforcing international collaboration. limitations: the initial inquiry necessary for determining the trends and driving forces was not based on a systematic literature review. scenario planning is a method based on assumptions and therefore subject to bias, yet the non-systematic research of driving forces increases the risk of bias. besides, some of the driving forces, though acknowledged, were not included in the scenario planning as per the scope of this paper. for instance, the use of vaccination has shown positive effects in reducing amr, although its success has been historically under-recognized so far (29). lastly, the mutual influence between driving forces were not considered since none of the driving forces would uniquely impact amr but also influence one another. therefore, further scenarios and strategies should be developed in the future, including additional driving forces along with their reciprocal interaction/s. references 1. devasahayam g, scheld wm, hoffman ps. newer antibacterial drugs for a new century. expert opin investig drugs 2010;19:215-34. 2. european commission. a european one health action plan against antimicrobial resistance (amr). 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schröder-bäck p. scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 (original research). seejph 2021, posted: 06 april 2021. doi: 10.11576/seejph-4312 p a g e 11 | 11 © 2021 orellana garcía et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 27. clark a, jit m, warren-gash c, guthrie b, wang hh, mercer sw, et al. global, regional, and national estimates of the population at increased risk of severe covid-19 due to underlying health conditions in 2020: a modelling study. lancet glob health 2020;8:e1003-17. 28. macpherson dw, gushulak bd, baine wb, bala s, gubbins po, holtom p, et al. population mobility, globalization, and antimicrobial drug resistance. emerg infect dis 2009;15:1727-31. 29. jansen ku, knirsch c, anderson as. the role of vaccines in preventing bacterial antimicrobial resistance. nat med 2018;24:10-9. ____________________________________________________________________________ spallek j, breckenkamp j, kraywinkel k, schwabe w, krieg v, greiner w, damm o, razum o. need for nursing care support in cancer patients: registry-linkage study in germany (original article). seejph 2018, posted: 19 october 2018. doi 10.4119/unibi/seejph-2018-204 page 1 of 10 o r i gi n a l a r t i c l e need for nursing care support in cancer patients: registrylinkage study in germany jacob spallek1,2*, jürgen breckenkamp1*, klaus kraywinkel3,4, wolfgang schwabe5, volker krieg3, wolfgang greiner6, oliver damm6, oliver razum1 abstract aim: in germany, very little is known about the need for assistance and nursing care support among cancer patients after hospitalization. the aim of this study was to describe nursing care support for cancer patients and to analyse whether these patients need more care assistance than other persons in need for care. methods: this was a registry linkage study conducted in 2011. cases were identified from the population-based cancer registry for the muenster district in north-western germany and in factually anonymised form linked by a semi-automatic probabilistic procedure (the standard procedure of the cancer registry) with medical examination records of patients applying for assistance and nursing care support from the regional statutory health insurance. the application records of 4,029 patients with colon, breast and prostate cancer were compared to a reference group of 13,104 non-cancer patients. results: in only 41.7% of colon, 45.8% of breast and 37.4% of prostate cancer patients was the malignancy the main underlying diagnostic cause for the application of assistance and nursing care. these patients were on average younger (mean age 71.1 vs. 76.8 years) than the non-cancer reference group, required higher levels of support (79.5 vs. 58.1% “considerable” or higher level care need) and their applications were less likely to be rejected (odds ratios [ors] 0.26, 0.28, and 0.31, respectively). by contrast, the proportion of successful applications and the level of support granted did not differ between multimorbid cancer patients with other main diagnoses as compared to non-cancer applicants. conclusion: patients with colon, breast or prostate cancer do not need per se more nursing care than non-cancer patients. only if cancer is the main underlying diagnosis for nursing care support, higher levels of support are needed. keywords: cancer patients, germany, nursing care. 1 department of epidemiology and international public health, school of public health, bielefeld university, bielefeld, germany; 2 department of public health, brandenburg university of technology cottbus-senftenberg, senftenberg, germany; 3 epidemiologic cancer registry nrw ggmbh, münster, germany; 4 german centre for cancer registry data, robert koch-institute, berlin, germany; 5 medical service of the health insurance westphalia-lippe, administrative centre, münster, germany; 6 department of health economics and health care management, school of public health bielefeld university, bielefeld, germany. *j. spallek and j. breckenkamp contributed equally to this paper. corresponding author: dr. jürgen breckenkamp, department of epidemiology and international public health, school of public health, bielefeld university; address: d-33615 bielefeld, germany; telephone: +49(0)521-106 3803; e-mail: juergen.breckenkamp@uni-bielefeld.de mailto:juergen.breckenkamp@uni-bielefeld.de spallek j, breckenkamp j, kraywinkel k, schwabe w, krieg v, greiner w, damm o, razum o. need for nursing care support in cancer patients: registry-linkage study in germany (original article). seejph 2018, posted: 08 october 2018. doi 10.4119/unibi/seejph-2018-204 page 2 of 10 introduction the population in germany, like in other industrialized countries, is ageing. consequently, the burden of disease due to chronic conditions such as cancer is increasing.improved early detection and medical care result in longer survival of cancer patients (1).cancer survivors not only require in-hospital or ambulatory medical treatment but they may also need assistance and nursing care, either permanently or during certain periods in the course of their disease. internationally the access to, the implication for and the coordination of care after treatment for cancer is a subject of research (2). geriatric assessment (3), the use of care plans (4) and their improvement (5) as well as the use of multidisciplinary teams are discussed as ways to improve care (6). in germany, depending on the individual need (determined by the type of disease, stage of disease and age of the patient) and on the personal financial resources, the patient or his/her family are entitled to apply for support from the statutory health insurances’ nursing care provision program (gesetzliche pflegeversicherung). this insurance covers about 70.5 million of the 80 million people residing in germany (all those insured in the compulsory health insurance). after applying for support, the medical service of the health insurance (medizinischer dienst der kranken-versicherung, mdk) will entrust trained medical personal with conducting a standardized assessment of the actual need of home nursing care in order to assess the eligibility for support and the type of support granted (financial, ambulatory nursing care, or institutional care) (7).the medical assessment results as well as information on the type of support granted are stored in regional databases maintained by the mdk. the mdk databases contain one main and one concomitant diagnosis underlying the need for nursing care support. thus, older and multimorbid patients, even if they are cancer survivors and have been granted nursing care support, may not be registered as cancer cases in the mdk database. hence, with this database alone, it is not possible to assess the level of nursing care support that cancer patients require relative to non-cancer patients. the complementing information may be retrieved from population-based cancer registries, which, however, usually do not contain information on nursing care (8). therefore, very little is known about the need for nursing care support of cancer survivors after hospitalization in germany. this study aims to describe nursing care support for cancer patients and to analyse whether these patients need more care assistance than other persons in need for care. all requirements of the german data protection act and the responsible ethical committee were adhered to. methods the study was conducted in the muenster district in the north-west of germany with a population of about 2.6 million persons in 2011. the epidemiologic cancer registry for the muenster district (ekr) registers all cancer cases, with a completeness of recording of more than 95% and a proportion of death certificate only cases of about 7% (9). the number of incident cancer diagnoses in the muenster district is about 13,000 per year (10). data of the regional mdk of westphalialippe (mdk-wl) were used to determine the need for and the type of nursing care support granted in the period of 2004 to 2008. the mdk-wl maintains a quasi-complete database of all claims for nursing care in westphalialippe (7). westphalia-lippe comprises three of the five districts of north rhinewestphalia (nrw), among them the district of muenster. in this district, about 73,000 persons received support for nursing care in 2009, corresponding to 2,810 cases per 100,000 inhabitants (11). spallek j, breckenkamp j, kraywinkel k, schwabe w, krieg v, greiner w, damm o, razum o. need for nursing care support in cancer patients: registry-linkage study in germany (original article). seejph 2018, posted: 08 october 2018. doi 10.4119/unibi/seejph-2018-204 page 3 of 10 as described elsewhere, records of the ekr and the mdk were pseudonymised and linked using a semi-automatic probabilistic procedure in accordance with the cancer registry act of nrw (12). the resulting database contained detailed information about cancer cases (site, time of diagnosis, etc.) as well as their need for nursing care and the type of nursing care granted by the mdk. about 18,900 cancer cases could be identified in the ekr who had at least one medical examination recorded in the mdk database. a reference group of patients with no records in the ekr was drawn from the mdk database for comparison (about 21,400 non-cancer patients). we used temporary record numbers to identify the patients not registered in the cancer registry and to draw the reference group. in cases of changes in the need for nursing care (or appeals against the mdk’s decision), a follow-up medical examination is conducted. here, data of the first mdk follow-up examination is used to assess nursing care needs in relation to disease progress. the analysis was restricted to cancer of the breast, colon and prostate (icd10 c-18, icd10 c-50, icd10 c-61, total n= 4,029), the most frequent malignancies. a cancer record in the ekr and the main diagnosis leading to nursing care in the mdk database were used to define three subgroups: i) cancer according to ekr (yes) and to main diagnosis in the mdk (yes): n=1,707 patients; ii) cancer according to ekr (yes) but not to mdk (no): n=2,322 patients, and; iii) ekr (no) and mdk (no): n=13,104 patients (reference group). due to the small number of patients (n=181) the fourth group (no/yes) was not considered. the age range was restricted to 38-95 years, so that groups of equal age are compared. the outcome of interest was the “need for nursing care support” as assessed by mdk in the medical examination. it was defined according to the german nursing act in five levels (0 to 3+)[box 1]. descriptive analyses compared groups with regard to baseline characteristics and levels of need. logistic regression models were used to adjust dichotomous outcomes for age (in years) and sex (colon cancer only). analyses were performed with sas 9.2. results age and sex distribution of patients who applied for nursing care are shown in table 1, stratified by cancer case status in the ekr and the mdk database. cancer patients with cancer as main diagnosis justifying nursing care (group 1) were about eight years younger than cancer patients whose need for nursing care was justified by another condition (group 2) and patients with main diagnoses other than cancer (group 3, reference). differences by sex were fairly small, although statistically significant. in more than 50% of mdk patients who suffered from colon, breast or prostate cancer, cancer was not the main diagnosis leading to nursing care (table 2). nursing care level between 20.5% (group 1) and 41.9% (group 3) of mdk patients did not fulfil the criteria to receive nursing care support according to the first mdk medical examination. spallek j, breckenkamp j, kraywinkel k, schwabe w, krieg v, greiner w, damm o, razum o. need for nursing care support in cancer patients: registry-linkage study in germany (original article). seejph 2018, posted: 08 october 2018. doi 10.4119/unibi/seejph-2018-204 page 4 of 10 textbox 1: levels of need for nursing care support adapted from [8] -level 0: no need of nursing care support the need for nursing care is below the threshold of 90 minutes/day on average (see level 1 below), so no support is granted. -level 1: considerable need for nursing care support need for assistance is required at least once a day and covers at least two activities in one or more areas of basic care (body care, feeding and mobility). in addition, domestic help is required several times a week.the weekly expenditure of time is at least 90minutes/day on average, with more than 45 minutes for basic care. -level 2: extensive need for nursing care support need for assistance in basic care (body care, feeding and mobility) is required at least three times daily at different times of the day. in addition, domestic help is required several times a week.the weekly expenditure of time is at least 3 hours/day on average, with more than 2 hours for basic care. -level 3: very extensive need for nursing care support there is need for assistance in basic care around the clock, also at night. in addition, domestic help is required several times a week.the weekly expenditure of time is at least 5 hours/day on average, with more than 4 hours for basic care. -level 3+: “härtefall” if the conditions of level 3 are satisfied and there is an unusually high or intensive need of assistance, the hardship regulation with higher payments can be applied. nursing care support was more often granted (nursing care level 1 and higher) in mdk patients in whom cancer was the main diagnosis justifying nursing care support (group 1). for cancer patients who had another main diagnosis that justified nursing care support (group 2), the rejection rate was considerably higher than in group 1, but similar to patients without cancer (group 3). table 1. age and sex of mdk patients grouped by cancer case status in cancer registry (ekr) and mdk database (cancer cases in groups 1 and 2 restricted to colon, breast and prostate cancer) variable group 1 *(ekr yes/ mdk yes) group 2 †(ekr yes/ mdk no) group 3 ‡(ekr no/ mdk no) p age mean ±sd 71.1±11.0 79.2±8.0 76.8±11.1 <0.001median 73 80 79 range 38-95 38-95 38-95 sex male n, (%) 623 (36.5) 920 (39.6) 4.320 (33.0) <0.001female n, (%) 1,084 (63.5) 1.402 (60.4) 8.784 (67.0) total 1,707 (100) 2,322 (100) 13,104 (100) * cancer case in ekr + cancer is main diagnosis justifying nursing care also if nursing care is not granted (level 0). † cancer case in ekr + cancer is not main diagnosis justifying nursing care also if nursing care is not granted (level 0). ‡ non-cancer case in ekr + cancer is not main diagnosis justifying nursing care also if nursing care is not granted (level 0), reference. patients in group 1 also needed extensive nursing care of level 2 or level 3 (including level 3+) more frequently than patients in the other groups (table 3). spallek j, breckenkamp j, kraywinkel k, schwabe w, krieg v, greiner w, damm o, razum o. need for nursing care support in cancer patients: registry-linkage study in germany (original article). seejph 2018, posted: 08 october 2018. doi 10.4119/unibi/seejph-2018-204 page 5 of 10 of all persons registered in the ekr applying for nursing care support (groups 1 and 2) a need for nursing care support (level 1 and higher) was confirmed at the first medical examination in 69.2 % of colon cancer patients (mean age: 77.1 years), 65.1 % of breast cancer patients (mean age: 73.4 years), and 72.4 % of prostate cancer patients (mean age 76.4 years) (table 3). table 2. age distribution of mdk patients stratified by cancer location, grouped by cancer case status in cancer registry (ekr) and mdk database group 1 *yes/ mdk yes)(ekr group 2 †(ekr yes/ mdk no) group ‡(ekr no/ mdk no) icd10 c-18: n, (%) (cancer of the colon) 483 (41.7) 675 (58.3) mean(±sd) age females 75.1±10.0 82.0±7.0 78.6±10.3 mean(±sd) age males 70.6±10.5 77.8±7.8 73.2±11.8 icd10 c-50: n, (%) (female breast cancer) 811 (45.8) 958 (54.2) mean(±sd) age females 68.4±12.2 79.1±8.9 78.6±10.3 icd10 c-61: n, (%) (cancer of prostate) 413 (37.4) 689 (62.6) mean(±sd) age males 73.8±7.7 77.9±6.9 73.2±11.8 *cancer case in ekr + cancer is main diagnosis justifying nursing care also if nursing care is not granted (level 0). † cancer case in ekr + cancer is not main diagnosis justifying nursing care also if nursing care is not granted (level 0). ‡ non-cancer case in ekr + cancer is not main diagnosis justifying nursing care also if nursing care is not granted (level 0), reference. to assess what determines the chances of nursing care support being refused by mdk, we calculated odds ratios separately for the three cancer types (table 4). the reference was group 3 (table 4). the chance of receiving no support (level 0) was statistically significantly lower when cancer was the main diagnosis justifying nursing care, irrespective of the type of cancer (or=0.26-0.31). table 3. nursing care level of mdk patients as per first medical examination by cancer case status in cancer registry (ekr) and mdk database (cancer cases in groups 1 and 2 restricted to colon, breast and prostate cancer) group 1 (ekr yes/ mdk yes)* group 2 (ekr yes/ mdk no)* group 3 (ekr no/ mdkno)* nursing care level as per first medical opinion (n, %) level 0 (no support) 350 (20.5) 928 (40.0) 5.492 (41.9) level 1 and higher 1.357 (79.5) 1.394 (60.0) 7.612 (58.1) level 1† 673 (49.6) 1.065 (76.4) 5.741 (75.4) level 2 614 (45.3) 310 (22.2) 1.711 (22.5) level 3‡ 70 (5.1) 19 (1.4) 160 (2.1) * see footnotes to table 1. †subgroups with level 1, 2 and 3 add up to 100% (as do level 0 plus “level 1 and higher”). ‡ includes level 3+ cases. spallek j, breckenkamp j, kraywinkel k, schwabe w, krieg v, greiner w, damm o, razum o. need for nursing care support in cancer patients: registry-linkage study in germany (original article). seejph 2018, posted: 08 october 2018. doi 10.4119/unibi/seejph-2018-202 page 6 of 10 by contrast, cancer patients who had another main diagnosis justifying their nursing care need (group 2) had equally high chances of refusal as the cancer-free reference group 3. table 4. chance of receiving no nursing care support (level 0) among mdk patients by type of cancer, adjusted for age (breast and prostate cancer) and for age and sex (colon cancer), by cancer case status in cancer registry (ekr) and mdk database group 1 (ekr yes/ mdk yes)* group 2 (ekr yes/ mdk no)* group 3 (ekr no/ mdk no)* n or [95% ci] n or [95% ci] n or cancer of colon level 0 92 0.28 [0.22-0.36] 265 1.01 [0.86-1.18] 5,492 1.00 (ref.) level 1 and higher 391 410 7,612 female breast cancer level 0 201 0.31 [0.26-0.37] 416 1.00 [0.87-1.14] 3,848 1.00 (ref.) level 1 and higher 610 542 4,936 cancer of prostate level 0 57 0.26 [0.20-0.35] 247 1.12 [0.94-1.33] 1,644 1.00 (ref.) level 1 and higher 356 442 2,676 * see footnotes to table 1. disease progression the number of patients in our dataset with a second medical examination was limited (see numbers in table 5). an increase in the need for nursing care support over time is evident, which is compatible with a progression of the malignancy. the strongest increment in terms of a need for level 2 or higher care was found in patients from group 1. for example, 11% of colon cancer patients were in level 2+ at the first examination. this increased to almost 52% at the second examination, a far larger increase than in the non-cancer reference group (12% to 39%). the difference between mean ages (as estimated from the mean ages in table 5) is smallest in group 1, suggesting a shorter time-span between first and second medical examination. discussion in this population of patients with colon, breast or prostate cancer who had applied for nursing care support (groups 1+2), the malignant disease was in less than half of the cases the underlying justification for support being granted (group 1). in other words, more than every second cancer patient (group 2) had another underlying diagnosis that was the main reason for nursing care support. the mean age of the cancer patients was high, so the combination of cancer with one or more other (presumably chronic) conditions reflects the well-known multimorbidity of the elderly in germany (13-15). studies analyzing german claims data indicate that the most common conditions in multimorbid patients are hypertension, lipid metabolism disorders, chronic low back pain diabetes spallek j, breckenkamp j, kraywinkel k, schwabe w, krieg v, greiner w, damm o, razum o. need for nursing care support in cancer patients: registry-linkage study in germany (original article). seejph 2018, posted: 08 october 2018. doi 10.4119/unibi/seejph-2018-204 page 7 of 10 table 5. changes from first to second medical examination to establish level of nursing care support among mdk patients, by cancer case status in cancer registry (ekr) and mdk database group 1 (ekr yes/ mdk yes)* group 2 (ekr yes/ mdk no)* group 3 (ekr no/ mdk no)* level n % n % n % cancer of colon 234 5,205 first medical examination 0 23.8 32.9 32.9 1 65.3 55.1 54.8 2+ 10.9 12.0 12.4 mean age 74.3 79.9 77.0 second med. examination 0 20.8 26.5 25.6 1 27.7 33.3 35.7 2+ 51.5 40.2 38.7 mean age 74.8 80.7 77.7 female breast cancer 194 354 3,506 first med. examination 0 22.7 39.8 34.3 1 88.0 87.8 82.7 2+ 12.0 12.2 17.3 mean age 69.9 79.5 78.6 second med. examination 0 19.6 25.7 26.7 1 39.7 49.1 47.8 2+ 60.3 51.0 52.2 mean age 70.4 80.2 79.4 cancer of prostate 108 262 1699 first med. examination 0 15.7 29.8 29.8 1 84.6 83.7 79.5 2+ 15.4 16.3 20.5 mean age 73.0 78.0 73.5 second med. examination 0 13.0 21.0 24.3 1 25.5 46.9 48.4 2+ 74.5 53.1 51.6 mean age 73.5 78.9 74.2 * see footnotes to table 1. mellitus, osteoarthritis and chronic ischemic heart disease (16,17). these often occur in dyads or triads together with cancer. accordingly, diseases other than cancer are the major reasons for claiming nursing care support in germany: psychological and behavioural disorders take first place (18) while cancer ranges at the fifth rank (19). our study shows, however, that if cancer was the diagnosis justifying nursing care support (patient group 1), then the probability of actually being granted support was significantly higher than in the reference group of non-cancer patients. despite having greater need for care support, cancer patients in group 1 were significantly younger than patients in the other groups (more than 10 years in case of breast cancer). it can be concluded that there is a group of cancer patients who apparently is more severely ill and in need of nursing care support relatively early in life (group 1); and a second, older group of cancer first med. examination first med. examination spallek j, breckenkamp j, kraywinkel k, schwabe w, krieg v, greiner w, damm o, razum o. need for nursing care support in cancer patients: registry-linkage study in germany (original article). seejph 2018, posted: 08 october 2018. doi 10.4119/unibi/seejph-2018-204 page 8 of 10 patients who is multimorbid and in whom cancer survivorship is a concomitant condition of less severity (group 2). the need for nursing care support of the latter group is not substantially different from that of non-cancer patients (group 3). our findings regarding the temporal development of the need for support seem to support this interpretation. second medical examinations were conducted sooner in patients from group 1 than in the other two patient groups, indicating that the course of disease in this group was more severe requiring reassessment of the condition. also, the proportion of patients being upgraded to higher levels of support was substantially higher in group 1 than in the other groups, despite younger age and earlier reassessment. while this might reflect a comparatively quick worsening of health among this group of cancer patients, differences in mean age could also partly be an effect of a higher case fatality rate in group 1. discussions in other countries highlight unmet needs of cancer patients, often calling for specialised oncology nursing in hospital and nursing home care (2,22-23). hansen et al. (20) reported an association of unmet needs with health-related quality of live. according to puts et al. (21) the most common needs are psychological and physical needs as well as needs for information. another focus is on improvement and coordination of nursing care (2-6). salz and baxi (5) assume that patients with serious health problems will benefit most from care coordination. though the system of nursing care support in germany is different from systems in other countries, our findings confirm among cancer specific care needs patients. comparative studies should establish how the different systems are performing, relative to each other. -strengths: firstly, the medical examinations from mdk are performed by experts following highly standardized procedures, so information about need for nursing care and the underlying main diagnosis is reliable. secondly, the completeness of data in the cancer registry and mdk databases is high. about 95% of cancer cases are registered. about 94% of persons in the study population are insured in the compulsory nursing care insurance, so all their claims for nursing care are registered by the mdk. thirdly, the results of our study are representative for the study region of muenster district. as muenster is a typical west german district with rural and urban areas, the findings may be generally indicative of needs of the population in the western part of germany. fourthly, we could combine administrative with medical data, thus obtaining information that is not available in single databases such as claims data (16,17). to achieve this, we had to solve a methodological problem, namely linking routine data while maintaining data protection. there is no system of unique national identification numbers (24) that would allow a simple linkage of routine health data from different sources (25) in germany, as in case of countries like canada or the united kingdom. we overcame this problem by developing an approach using pseudonymisation of personal identifiers, data encryption and probabilistic record linkage (17). -limitations: only information available in the datasets of mdk and the cancer registry could be used. as complete data could only be obtained from one region, the number of cancer cases was sufficiently large to analyze only the three most common cancer diagnoses. data on follow-up (second medical examination) was limited and this may compromise the interpretation of findings on the progression of nursing care needs. also, deaths are documented in the cancer registry but not by the mdk database, which could bias comparisons between cancer and non-cancer patients. studies with larger study populations and spallek j, breckenkamp j, kraywinkel k, schwabe w, krieg v, greiner w, damm o, razum o. need for nursing care support in cancer patients: registry-linkage study in germany (original article). seejph 2018, posted: 08 october 2018. doi 10.4119/unibi/seejph-2018-204 page 9 of 10 preferably a prospective design could help to analyse the need for nursing care among other cancer diagnoses and to obtain more reliable data about the progression of nursing care needs of cancer patients. enrolling incident cancer cases prospectively would also allow estimating the proportion of cancer patients applying for nursing care support. however, until sufficient patient-years among elderly people have been accrued in large cohortstudies, registry-based studies such as ours are needed to fill the gap. conclusion patients applying for nursing care support because of colon, breast or prostate cancer needed higher levels of support in spite of being younger than non-cancer patients (reference group). also, their condition seems to deteriorate faster as they are reexamined after shorter time periods. multimorbid cancer survivor patients, in references 1. brenner h. long-term survival rates of cancer patients achieved by the end of the 20th century: a period analysis. lancet 2002;360:1131-5. 2. cockle-hearne j, charnay-sonnek f, denis l, fairbanks he, kelly d, kav s, et al. the impact of supportive nursing care on the needs of men with prostate cancer: a study across seven european countries. brit j cancer 2013;109:2121-30. 3. magnuson a, allore h, cohen hj, mohile sg, williams gr, chapman a, et al. geriatric assessment with management in cancer care: current evidence and potential mechanisms for future research. j geriatr oncol 2016;7:242-8. 4. guerard ej, nightingale g, bellizzi k, burhenn p, rosko a, artz as, et al. survivorship care for older adults with cancer: u 13 conference report. j geriatr oncol 2016;7:305-12. 5. salz t, baxi s. moving survivorship care plans forward: focus on care coordination. cancer med 2016;5:1717-22. 6. karnakiis t, gattás-vernaglia if, saraiva md, gil-junior la, kanaji al, jacob-filho w. the geriatrician’s perspective on practical aspects of the multidisciplinary care of older adults with cancer. j geriatr oncol 2016;7:341-5. 7. medizinischer dienst der krankenversicherung westfalen-lippe. wir über uns – aufgaben und leistungen. available from: whom cancer was not the main reason for their application for nursing care support, did not differ from the reference group in most parameters. conflict of interest: none. authors’ contribution js and or conceived the study. kk, ws, jb, and vk provided the data and prepared the datasets. jb, kk, vk and js performed the data analysis. jb, js and or wrote the first draft of the manuscript. all authors contributed to discussion of the results and revised the manuscript. all authors have read and approved the final manuscript. acknowledgements funded by german cancer aid (“deutsche krebshilfe”, project number 108232). the study sponsor had no involvement in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. we acknowledge support for the article processing charge by the deutsche forschungsgemeinschaft and the open access publication fund of bielefeld university. 8. robert koch-institut und die gesellschaft der epidemiologischen krebsregister (eds). krebs in deutschland 2005/2006. häufigkeiten und trends. berlin; 2010. 9. gekid. cancer in germany, incidence and trends. saarbrücken, gekid; 2006. available from: http://www.ekr.med.unierlangen.de/gekid/doc/kid2006.pdf (accessed: july 30, 2018). 10. ekr epidemiologisches krebsregister für den regierungsbezirk münster (eds.). krebserkrankungen im regierungsbezirk münster, band 3. bericht für die jahre 1998 – 2002. münster, ekr; 2004. 11. landeszentrum gesundheit nordrheinwestfalen. indikatoren der ländergesundheitsberichterstattung. indikator 3.49_01, jahr 2009. available from: http://www.lzg.gc.nrw.de/00indi/0data/03/html/030 4901052009.html (accessed: july 30, 2018). 12. breckenkamp j, spallek j, kraywinkel k, krieg v, schwabe w, greiner w, et al. abgleich von verwaltungsdaten des medizinischen dienstes der krankenversicherung mit krebsregisterdaten. das gesundheitswesen 2012;74:e52-60. spallek j, breckenkamp j, kraywinkel k, schwabe w, krieg v, greiner w, damm o, razum o. need for nursing care support in cancer patients: registry-linkage study in germany (original article). seejph 2018, posted: 08 october 2018. doi 10.4119/unibi/seejph-2018-204 page 10 of 10 13. sgb §15; sozialgesetzbuch (sgb), elftes buch (xi) – soziale pflegeversicherung. artikel 1 des gesetzes vom 26. mai 1994. §15 stufen der pflegebedürftigkeit. available from: http://www.gesetze-iminternet.de/sgb_11/__15.html (accessed: july 30, 2018). 14. kirchberger i, meisinger c, heier m, zimmermann ak, thorand b, autenrieth cs, et al. patterns of multimorbidity in the aged population. results from the kora-age study. plos one 2012;7:1. 15. fuchs j, busch m, lange c, scheidt-nave c. prevalence and patterns of morbidity among adults in germany. results of the german telephone health interview survey german health update (geda) 2009. bundesgesundheitsblatt gesundheitsforschung gesundheitsschutz 2012;55:576-8. 16. van den bussche h, koller d, kolonko t, hansen h, wegscheider k, glaeske g, et al. which chronic diseases and disease combinations are specific to multimorbidity in the elderly? results of a claims data based cross-sectional study in germany. bmc public health 2011;11:101. 17. schäfer i. does multimorbidity influence the occurrence rates of chronic conditions? a claims data based comparison of expected and observed prevalence rates. plos one 2012;7:e45390. 18. wagner a, fleer b. pflegebericht des medizinischen dienstes 2006. medizinischer dienst des spitzenverbandes bund der krankenkassen e.v. essen; 2007. 19. wagner a, brucker u. pflegebericht des medizinischen dienstes 2001-2002. medizinischer dienst des spitzenverbandes bund der krankenkassen e.v. essen; 2003. 20. hansen dg, larsen pv, holm lv, rottmann n, bergholdt sh, søndergaard j. association between unmet needs and quality of life of cancer patients: a population-based study. acta oncol 2013;52:391-9. 21. puts mte, papoutsis a, springall e, tourangeau ae. a systematic review of unmet needs of newly diagnosed older cancer patients undergoing active cancer treatment. support care canser 2012;20:1377-94. 22. maguire r, papadopoulou c, kotronoulas g, simpson mf, mcphelim j, irvine l. a systematic review of supportive care needs of people living with lung cancer. eur j oncol nurs 2013;17:449-64. 23. fennell ml. nursing homes and cancer care. health serv res 2009;44:6. 24. nitsch d, morton s, de stavola b, clark h, leon da. how good is probabilistic record linkage to reconstruct reproductive histories?results from the aberdeen children of the 1950s study. bmc med res methodol 2006;6:15. 25. ronellenfitsch u, kyobutungi c, becher h, razum o. large-scale, population-based epidemiological studies with record linkage can be done in germany. eur j epidemiol 2004;19:1073-4. © 2018 spallek et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. czabanowska k, cichowska myrup a, aleksandrova o. women leadership for public health: the added value and needs of women driving public health system reform in ukraine (case study). seejph 2018, posted:20 september 2018. doi 10.4119/unibi/seejph-2018-200 1 case study women leadership for public health: the added value and needs of women driving public health system reform in ukraine katarzyna czabanowska1,2, anna cichowska myrup3, olga aleksandrova4 1 department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 2 institute of public health, faculty of health sciences, jagiellonian university, krakow, poland. 3 division of health systems and public health, world health organization regional office for europe, copenhagen, denmark. 4 world health organization country office, kyiv, ukraine. corresponding author: katarzyna czabanowska, maastricht university; address: duboisdomein 30, 6229 gt maastricht, the netherlands; telephone: +31433881592; email: kasia.czabanowska@maastrichtuniversity.nl czabanowska k, cichowska myrup a, aleksandrova o. women leadership for public health: the added value and needs of women driving public health system reform in ukraine (case study). seejph 2018, posted:20 september 2018. doi 10.4119/unibi/seejph-2018-200 2 abstract the ukrainian health care system is undergoing reforms. although women constitute a driving force in the ukrainian health system transformation, their economic and decisionmaking participation remains extremely low. the existence of barriers such as: work/life balance, gender bias, stereotypes, lack of confidence, lack of mentoring, and lack of adequate networking and equal access to opportunities prevent women from reaching high leadership positions. with the aim to empower the current and future female public health leaders, the ministry of health of ukraine and who held a seminar entitled “women’s leadership in public health” in kyiv on 16-18 may 2017. the seminar was based on the assumption that contemporary public health demands require a more inclusive and less hierarchical style of leadership – focused on developing and working with stakeholder networks. such a leadership style is more effective in achieving public health goals. the international, interdisciplinary and inter-professional faculty engaged in the interactive meaning making around such topics as: the self-assessment of leadership competencies, public health leadership, leadership theories, system thinking, dealing with interests, power and stakeholders, barriers to women leadership and methods to address them, special leadership tools for women empowerment and leading change, communication and impact. strengthening health systems for better health was the red thread throughout the whole seminar. keywords: leadership, public health, ukraine, women. conflict of interest: none. acknowledgements: the authors would like to acknowledge the contributions and participation in the course and its development of: taru koivisto, ministry of of social affairs and health, finland, valia kalaitzi, mendor publishers, greece, aasa nihlen, who, denmark, dr. olena hankivsky, institute for intersectionality research and policy at simon fraser university, canada. the support and commitment of dr oksana syvak, the former deputy minister of health in ukraine, dr. marthe everard, who representative and head of country office to ukraine, oleksandr martynenko, project officer, who country office in ukraine, polina adamovych, technical assistant, who country office in ukraine, is highly appreciated. funding: the seminar was supported by the swiss agency for development and cooperation. czabanowska k, cichowska myrup a, aleksandrova o. women leadership for public health: the added value and needs of women driving public health system reform in ukraine (case study). seejph 2018, posted:20 september 2018. doi 10.4119/unibi/seejph-2018-200 3 introduction the ukrainian health care system is undergoing through reforms. one of the main objectives of the new reforms is the shift towards a policy of strengthening and maintaining health and preventing diseases through the life-course. women constitute a driving force in the ukrainian health system transformation however, according to the global gender gap report by the world economic forum (1), ukraine ranks 64th in terms of women’s income level, 22ndin terms of women’s education and 34thon economic participation and opportunities. women's participation in decision-making remains extremely low. women hold only 12% of seats in the parliament and make 11% of the cabinet of ministers. the european parliament stated that gender mainstreaming constitutes an essential factor for the achievement of a sustainable and inclusive society (2) and smart, sustainable and inclusive growth require higher gender equality scores (3). the united nations (un) included gender equality and the empowerment of women in its sustainable development goals (sgds) (goal no 5) for the 2030 agenda. both global gender gap report (1) and eu progress report (2012) (4) examine barriers existing in relation to women leadership such as work/life balance, gender bias and stereotypes, lack of confidence, lack of mentoring, and lack of adequate networking and equal access to opportunities. the recent publication of the world bank on gender assessment in ukraine (5) pointed out clear misbalances such as: male domination at the top managerial positions, political representation and decision making, persistent ‘glass ceiling’ in access to chief executive positions in public administration, stereotypes traditional roles of men and women, lower wages and devaluated social prestige often associated with female economic activity, vulnerability at the labour market and poverty risks, prevalent part-time employment, unequal income opportunities, limited access to business activities and financial resource, public tolerance to spousal violence, gender-based violence and trafficking to name a few. with the aim to empower and support the development of current and future female leaders who drive public health reform, the ministry of health of ukraine held a seminar entitled “women’s leadership in public health” in kyiv on 16-18 may 2017. it organized the seminar with technical support from who, contributions from the association of schools of public health in the european region (aspher) and maastricht university, the netherlands, and financial support from the swiss agency for development and cooperation. the seminar was delivered in the context of the implementation of the who european action plan to strengthen public health services and capacities and the who strategy on women’s health and well-being in the who european region. the seminar contributed directly to the implementation of the sdgs by developing a workforce with 21st century public health competencies. the seminar concept, mission, objectives and content the seminar was based on the assumption that contemporary public health demands a more inclusive, less hierarchical style of leadership – focused on developing and working with stakeholder networks to be effective in achieving public health goals (6,7). public health leaders “must be the transcendent, collaborative “servant leaders” (8) able to: articulate shared values, acknowledge the unfamiliarity, ambiguity, and paradox, combine administrative excellence with a strong sense of professional commitment (8), show passion, drive and perseverance in leading for change. the concept of the seminar was linked to the merizow’s transformative learning theory (9), according to which learning is “…the process by which we transform our taken-for-granted czabanowska k, cichowska myrup a, aleksandrova o. women leadership for public health: the added value and needs of women driving public health system reform in ukraine (case study). seejph 2018, posted:20 september 2018. doi 10.4119/unibi/seejph-2018-200 4 frames of reference (meaning perspectives, habits of mind, mind sets) to make them more inclusive, open, emotionally capable of change, and reflective so that they may generate beliefs and opinions that will prove more true or justified to guide action.” (9). the seminar was competency-based, structured around modern leadership theories especially suited to develop women leaders, reflecting real life experiences of role-models. it included the topics identified through research and local needs analysis. the seminar was supported by the executive coaching provided to the participants with the objective to develop, enhance and build personal leadership attributes for the successful career and growth in health care environment and develop the ability to set individual career goals to the benefit of population heath outcomes. the main topics included: self-assessment of leadership competencies, public health leadership and leadership theories, system thinking, dealing with interests, power and stakeholders, barriers to women leadership and methods to address them, special leadership tools for women empowerment and leading change, communication and impact. strengthening health systems for better health was the red thread throughout the whole seminar. the content was presented during the two and a half day training which included interactive lectures, discussions, group work and experiential learning. the core of the programme was reinforced with the leadership development life stories from female health professional leaders trainers and participants five lecturers and trainers came from various professional fields: policy, academia, public health practice, government and business. they also came from different countries to assure variety of perspectives and experience. they represented: the netherlands, greece, sweden, finland, canada and ukraine. the lead trainer was responsible for the design, main content, cohesion and coaching whereas other trainers presented specific topics and illustrations from their public health practice as well as their leadership development stories. all presenters engaged in the discussion with the participants. the consecutive high quality professional translation was provided which allowed for good communication and satisfaction from the learning and teaching experience. there were 22 participating women leaders who were carefully selected by the ministry of health in ukraine based on their role or potential new position in relation to the introduction of public health reforms. the women came from different regions of ukraine and represented a range of organisations which are vital in the change process including the ministry of health of ukraine, public health centre of the ministry of health of ukraine, regional health centres and hospitals, non-governmental organizations, and the like. evaluation method in order to gather the feedback from the participants we used a short open-ended questionnaire addressing the following dimensions: usefulness of the seminar for the public health reform and for personal development, satisfaction with the content, form and instructors, the highlights of the course and areas for improvement, further needs concerning a follow-up on women leadership in public health training and specific areas which the participants would like to cover. we also gave space for personal reflections about the course. 14 out of 22 participants filled in the questionnaires and five shared their observations faceto-face with the course leader with a help of a professional interpreter. the atmosphere was open and relaxed, building on trust and opinion sharing. the evaluation was carried out after the course and before the individual coaching sessions. the feedback on coaching was czabanowska k, cichowska myrup a, aleksandrova o. women leadership for public health: the added value and needs of women driving public health system reform in ukraine (case study). seejph 2018, posted:20 september 2018. doi 10.4119/unibi/seejph-2018-200 5 obtained in a follow-up conversation after the coaching sessions. the evaluation forms were filled in ukrainian language. the anonymity of responses was assured. the collected data was translated into english, analysed and synthesized according to the leading questions. next conventional content analysis was used (10) to develop categories and arrange the data around them. the five categories include: opinions about the course, aspects of special value, satisfaction with the trainer, areas for improvement and further training needs. feedback from the participants opinions about the course it was the first seminar about the leadership in public health for women. all the respondents were “100% positive” and found the seminar of high quality, extremely useful both form and content wise. it was very interesting, helpful, informative, comprehensive and consistent. the participants felt that “…three days passed with one breath”. new theories and different leadership tools that can be used at work in the field of public health combined with the leader experience of the participants helped them structure all previously gained knowledge. the participating women leaders had a unique opportunity to do self-assessment and selfappraise their leadership qualities which help them reveal the strong and weaker sides and discuss the ways to improve them as well as see themselves from the leadership prospective. they also valued learning about emotional intelligence and how to manage emotions “…i have a desire to invite the psychologist to work with us at the hospital...”. this helped them also understand why the authoritarian style is not the best approach especially when you work in an interdisciplinary team or if you are newly appointed to lead a department. the participants stated that owing to this training they realized that the inner power of women is able to move or change things which may seem unchangeable. they especially valued familiarity and open communication with other women leaders and professional trainers who provided useful information and tips for troubleshooting the situational problems and barriers. moreover, the experience of getting to know the colleagues from other regions who are inspired, fulfilled, beautiful women striving to use their skills as well as spiritual and cultural values for the general development of the country was very powerful. the presence, facilitation and sharing of experience of the international faculty was greatly appreciated. “…it showed the openness of the world towards my country ukraine from a different perspective”. aspects of special value the participants especially valued some specific aspects of the training. these included: the scientific evidence on which the public health leadership course for women was based, realizing the added value of women power in leading people regardless of age and position, systematically presented content, examples from personal lives of trainers and coaches which allowed for making comparisons with their own life experiences, possibility to improve oneself, importance of developing the vision and understanding what kind of a leader you want to be. “the value for me personally is that i realized my personal complexes, my claims toward myself which i have in my thoughts that i shouldn’t have”. the new theories of leadership, practical exercises on system thinking using a ”red ribbon” (a role play illustrating system thinking using a red ribbon to connect the elements of a system) and “thinking hats” (the de bono “six thinking hats”) technique provided the information that a woman-leader needs at work. “when i return to work, i will try to put into practice all gained knowledge and skills and will put special attention to my personal qualities”. http://context.reverso.net/%d0%bf%d0%b5%d1%80%d0%b5%d0%b2%d0%be%d0%b4/%d0%b0%d0%bd%d0%b3%d0%bb%d0%b8%d0%b9%d1%81%d0%ba%d0%b8%d0%b9-%d1%80%d1%83%d1%81%d1%81%d0%ba%d0%b8%d0%b9/authoritarian http://context.reverso.net/%d0%bf%d0%b5%d1%80%d0%b5%d0%b2%d0%be%d0%b4/%d0%b0%d0%bd%d0%b3%d0%bb%d0%b8%d0%b9%d1%81%d0%ba%d0%b8%d0%b9-%d1%80%d1%83%d1%81%d1%81%d0%ba%d0%b8%d0%b9/scientific+evidence czabanowska k, cichowska myrup a, aleksandrova o. women leadership for public health: the added value and needs of women driving public health system reform in ukraine (case study). seejph 2018, posted:20 september 2018. doi 10.4119/unibi/seejph-2018-200 6 satisfaction with the trainers the participants were very satisfied with the speakers’ performance. the presenters and trainers were pleasant, open-minded, attracted their attention, very outspoken, showing excellent knowledge of the subject matter and professionalism, they served as examples or role-models. “i realized how to work on myself to become better and on what to work on concerning my personality.” the combination of women`s stories from real life or previous experience, attractive way of presenting the material, availability and genuine interest to answer the questions were inspirational. the trainers were open to dialogue and able to merge with the participants due to their high level of qualification, commitment to the job, high motivation, integrity and gratitude. each speaker was an individuality holding their own position in the society and their own positive world view. their honesty, openness and equal attention to all the participants greatly contributed to the satisfaction from the course. on the whole “….everything was good, time flew fast and the emotions were running high, it was generally hard to say goodbye to them. i love them. good luck to them”. areas for improvement although everything was interesting and highly satisfactory, the participants identified some areas which might be improved in the future courses. they would generally welcome more time to get to know each other better, to have more possibility for discussions and communication with the speakers as well as time to solve some situational problems from their individual professional practice, using real-life examples and getting feedback on them from other colleagues. they would also appreciate more situational games, exercises and active group work like the ones with the “ribbon” and “hats” and have more space to delve into the emotional intelligence topic and more life stories or research on women leaders in medical sphere even if it means inviting more teachers. further training needs there was a strong conviction that the course on women leadership in public health needs to be continued in the context of theoretical knowledge and extended practical application with mentoring and coaching. the participants would be interested in getting more acquainted with such topics as: emotional intelligence, communication and social marketing, theory of negotiations, general management and time management to become more efficient and effective, short, consistent personal coaching, how to develop as a future leader and practical application of women leadership in public health practice including the dress code and personal preparedness for a role as a woman leader, leading change in the organisation, how to create a successful and effective team for a new public health centre in the region. they would also like to learn and practice how to lead public health system transformation in ukraine, how to collaborate with different sectors and stakeholders for the benefit of public health reform, how to use evidence for informed decision making, how to practically apply women leadership competences in specific public health practice and importantly how to reach a high level position “i have my personal need to get a high level job: just give me an opportunity and i will turn the world.” the list of needs is long which shows that there is a great need for such a training especially for women. the course on women leadership for public health in ukraine was a small drop filling a huge niche which is open. the participating women would like to be informed and invited for similar events in the future. some of them would like to be involved and collaborate with who in preparing future programmes to assure the inclusion of current and real issues of concern in ukraine. czabanowska k, cichowska myrup a, aleksandrova o. women leadership for public health: the added value and needs of women driving public health system reform in ukraine (case study). seejph 2018, posted:20 september 2018. doi 10.4119/unibi/seejph-2018-200 7 concluding remarks and recommendations the initiative proved to be empowering not only for the participants of the seminar but also for the trainers who were able to challenge their own frames of reference and show the added value of women leadership in times of transformation in the context of ukrainian health care and public health reforms. the women leaders from different regions of ukraine had a unique opportunity to build social capital around women leadership and develop their own professional public health network which, in order to be sustainable, needs further support and more focused and in-depth training. this initiative has further provided evidence of the need for practical, context-specific development of female public health leaders in ukraine. the programme will benefit from developing trainers and mentors from among the participants who can replicate the training model to meet the need of women working in the field of health in ukraine. references 1. world economic forum. the global gender gap report 2016. p. v. http://www3.weforum.org/docs/gggr16/wef_global_gender_gap_report_2016.p df (accessed: 10 june, 2017). 2. report on women’s careers in science and universities, and glass ceiling encountered, european parliament, 2014. 3. gender equality index 2015 − measuring gender equality in the european union 2005-2012. european institute for gender equality; 2015. 4. european commission. directorate-general for justice. women in economic decision-making in the eu: progress report, 2012, publications office of the european union. http://ec.europa.eu/justice/gender-equality/files/women-onboards_en.pdf (accessed: 12 june, 2017). 5. world bank. country gender assessment for ukraine 2016. world bank, kiev; 2016. https://openknowledge.worldbank.org/handle/10986/24976 license: cc by 3.0 igo. 6. day m, shickle d, smith k, zakariasen k, oliver t, moskol j. time for heroes: public health leadership in the 21st century. lancet 2012;380:1205-6. 7. czabanowska k, rethmeier ka, lueddeke g, smith t, malho a, otok r, stankunas m. public health in the 21st century: “working differently means leading and learning differently” (a qualitative study based on interviews with european public health leaders). eur j public health 2014;24:1047-52. 8. koh h. leadership in public health. j cancer educ 2009;24:s11-8. 9. mezirow j. & associates. learning as transformation, critical perspectives on a theory in progress. san francisco: jossey-bass inc; 2000. 10. hsieh hf, shannon se. three approaches to qualitative content analysis. qual health res 2005;15:1277-88. ______________________________________________________________________________________ © 2018 czabanowska et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. laaseru. reflections on the liberian civil war, 1989-2003 (editorial). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-154 1 editorial reflections on the liberian civil war, 1989-2003 ulrich laaser 1 1 faculty of health sciences, university of bielefeld,bielefeld, germany. corresponding author: ulrich laaser address: faculty of health sciences, university of bielefeld, pob 10 01 31, d-33501, bielefeld, germany; e-mail: ulrich.laaser@uni-bielefeld.de conflicts of interest: none. laaseru. reflections on the liberian civil war, 1989-2003 (editorial). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-154 2 the generation which experienced war in europe – world war ii – is passing away and with it those who can tell ‘in their own words’ from war experience and trauma. on the other hand accelerating globalization confronts us with a series of armed conflicts all over the world. the civil war in liberia was one of these. all of the possible fuelling factors were brought to bear on it: ethnic differences, economic domination by a ruling class the progeny of the freed slaves in 1822, and the long litany of misrule by various administrations crowned by the execution of predominantly people of american descent in the 1980 coup d’état, all set the stage for a final showdown. the conflict involved eight armed factions fighting for dominance and lasted with a short interruption from 1989 to 2003. whereas, for example in germany, there is an abundance of literature describing and analyzing personal and social experience during the war[for example translated into english (1)]; it is not so in liberia. the veterans of the various rebel groups and even former members of the regular army usually live in very poor conditions and those invalidated populate begging the streets. furthermore there are thousands of civil victims and especially an estimated 10-15% of the female population raped, more than half a million (out of a population of about four million at the time) were killed (2) and close to one million dislocated. although people have generally enjoyed peace in liberia for over a decade by now that peace can still be described as fragile. every year one can observe signs of simmering instability when ex-combatants make threats on radio and in newspapers that they will disturb the peace in the country for claims of perceived benefits they have against the government in concert with left behind widows and children and their disabled comrades. the condition of those who are physically or mentally disabled is appalling, the standard of living at the edge as usually there is no income; the acquisition of a daily meal becomes a problem. they are considered by the national community to be responsible for the atrocities and the suffering of the civilian people although they were often in the child and adolescent age when entering the armed factions, hardly mature enough to discern between what was right and what was wrong to do even in a war situation (3). different from the reaction on the ebola epidemic (4) which posed a threat to themselves, the international community has rarely taken notice of the victims of the civil war in liberia and few people seem to be concerned about the abundance of psychiatric disease including posttraumatic stress disorder. even less realized is the threat of further social disruption as any organized reconciliation processinvolving ex-combatants is missing. documented experience in europe and notably germany shows war traumata handed over through several generations, from the parents experiencing war to their children and even grand-children, a threat for social stability and cohesion: ‘because of the war my parents simply did not experience that the world is a safe place where one can feel well and protected. and exactly the same feeling i ascertained in myself although there was no external inducement’ [own translation (1)]. to listen to the ostracized invalids from the civil war and take note of what they have to say is the aim of theexplorative study by aloysius taylor hoping to initiate public discussion aimed at healing the liberian society. references 1. bodes. the forgotten generation – the war children break their silence. klettcotta, stuttgart; 2004. https://www.sabine-bode-koeln.de/war-children/the-forgottengeneration/. 2. edgertonrb. africa’s armies: from honor to infamy. amazon; 2004. https://www.amazon.co.uk/africas-armies-infamy-robert-edgerton/dp/0813342775. https://www.sabine-bode-koeln.de/war-children/the-forgotten-generation/ https://www.sabine-bode-koeln.de/war-children/the-forgotten-generation/ https://www.amazon.co.uk/africas-armies-infamy-robert-edgerton/dp/0813342775 laaseru. reflections on the liberian civil war, 1989-2003 (editorial). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-154 3 3. kokulofasuekoi j. a journalist’s photo diary. auto-publication, date unknown, monrovia, liberia. https://www.barnesandnoble.com/w/rape-loot-murder-jameskokulo-fasuekoi/1105497189?ean=9781468591620. 4. gostin lo, lucey d, phelan a. the ebola epidemic: a global health emergency. jama 2014;312:1095-6. __________________________________________________________ © 2017 laaser; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.barnesandnoble.com/w/rape-loot-murder-james-kokulo-fasuekoi/1105497189?ean=9781468591620 https://www.barnesandnoble.com/w/rape-loot-murder-james-kokulo-fasuekoi/1105497189?ean=9781468591620 http://jamanetwork.com/searchresults?author=alexandra+phelan&q=alexandra+phelan 1 south eastern european journal of public health volume iv, 2015 editors: genc burazeri, ulrich laaser, jose m. martin-moreno,peter schröder bäck jacobs verlag south eastern european journal of public health volume iv, 2015 genc burazeri, ulrich laaser, jose m. martin-moreno, peter schröder-bäck executive editor genc burazeri (tirana, albania and maastricht, the netherlands) faculty of medicine rr. “dibres”, no. 371 tirana albania phone: 0035/5672071652 e-mail:gburazeri@yahoo.com skype: genc.burazeri assistant executive editors ms. florida beluli dr. ervin toci mr. kreshnik petrela editors genc burazeri (tirana, albania and maastricht, the netherlands) ulrich laaser (bielefeld, germany) jose martin-moreno (valencia, spain) peter schröder-bäck (maastricht, thenetherlands) regional editors samir banoob (tampa, florida, usa) for the middle east evelyne de leeuw (sydney, australia) for the western pacific region damen haile mariam (addis ababa, ethiopia) for the african region charles surjadi (jakarta, indonesia) for the south east asian region laura magana valladares (mexico, mexico) for latin america advisory editorial board tewabech bishaw, african federation of public health associations (afpha) (addisababa, ethiopia) helmut brand (maastricht, the netherlands) patricia brownell (new york, usa) franco cavallo (torino, italy) doncho donev (skopje, fyr macedonia) mariana dyakova (sofia, bulgaria and warwick, united kingdom) florentina furtunescu (bucharest, romania) andrej grjibovski (oslo, norway & arkhangelsk, russia) motasem hamdan (al quds, occupied palestinian territories) mihajlo jakovljevic (kragujevac, serbia) aleksandra jovic-vranes (belgrade, serbia) ilona kickbusch (geneva, switzerland) mihali kokeny (budapest, hungary) dominique kondji (douala, cameroon) giuseppe la torre (rome, italy) oleg lozan (chisinau, moldova) george lueddeke (southampton, united kingdom) jelena marinkovic (belgrade, serbia) izet masic (sarajevo, bosnia-herzegovina) martin mckee (london, united kingdom) bernhard merkel (brussels, belgium) naser ramadani (prishtina, kosovo) enver roshi (tirana, albania) maria ruseva, south east european health network (seehn) (sofia,bulgaria) fimka tozija (skopje, fyrmacedonia) theodore tulchinsky (jerusalem, israel) lijana zaletel-kragelj (ljubljana,slovenia) mailto:gburazeri@yahoo.com mailto:gburazeri@yahoo.com mailto:gburazeri@yahoo.com mailto:gburazeri@yahoo.com publisher dr. hans jacobs (lage, germany) editorial office jacobs verlag hellweg 72 d 32791 lage germany e-mail: info@jacobs-verlag.de phone: 0049/5232/979043 fax: 0049/05232/979045 value added tax identification number/umsatzsteueridentitätsnummer: de 177 865 481 instructions to authors http://www.seejph.com/instructions-to-authors mailto:info@jacobs-verlag.de mailto:info@jacobs-verlag.de http://www.seejph.com/instructions-to-authors south eastern european journal of public health volume iv, 2015 genc burazeri, ulrich laaser, jose m. martin-moreno, peter schröder-bäck jacobs verlag issn 2197-5248 doi 10.12908/seejph-2014-54 bibliographic information published by die deutschebibliothek. die deutsche bibliothek lists this publication in the deutsche nationalbibliografie;detailed bibliographic data is available on the internet at http://dnb.ddb.de south eastern european journal of public health (open access journal) copyright 2015 by jacobs publishing company hellweg 72, 32791 lage, germany copyright cover picture: wordpress foundation:http://wordpressfoundation.org/ gnu general public license http://dnb.ddb.de/ http://wordpressfoundation.org/ table ofcontents editorial page ehealth and m-health: great potentials for health and wellbeing, but also 1-7 for harmonization and european integration in health jadranka bozikov original research piloting an advanced methodology to analyse health care policynetworks: the 8-21 example of belgrade, serbia helmut wenzel, vesna bjegovic-mikanovic, ulrichlaaser estimating health impacts and economic costs of air pollution in the republic of 22-29 macedonia craig meisner, dragan gjorgjev, fimkatozija health and health status of children in serbia and the desired millennium 30-38 development goals aleksandra jovic-vranes, vesnabjegovic-mikanovic adverse effects of maternal age, weight and smoking during pregnancy in pleven, 39-48 bulgaria mariela kamburova, petkana angelova hristova, stela ludmilova georgieva, azhar khan lifestyle correlates of low bone mineral density in albanianwomen 49-57 artur kollcaku, julia kollcaku, valbona duraj, teuta backa, argjendtafaj public expenditure and drug policies in bulgaria in 2014 58-65 toni yonkov vekov, silviyaaleksandrova-yankulovska reaction to political and socioeconomic transition and self-perceived health 66-75 status in the adult population of gjilan region, kosovo musa qazimi, luljeta cakerri, zejdush tahiri, genc burazeri http://www.seejph.com/e-health-and-m-health-great-potentials-for-health-and-wellbeing-but-also-for-harmonization-and-european-integration-in-health/ http://www.seejph.com/e-health-and-m-health-great-potentials-for-health-and-wellbeing-but-also-for-harmonization-and-european-integration-in-health/ http://www.seejph.com/e-health-and-m-health-great-potentials-for-health-and-wellbeing-but-also-for-harmonization-and-european-integration-in-health/ commentary a growing competence: the unfinished story of the european unionhealth policy 7680 bernard merkel obituary professor luka kovacic, md, phd 80-85 bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph 2014-53 1 editorial ehealth and m-health: great potentials for health and wellbeing, butalso for harmonization and european integration inhealth jadranka bozikov 1 1 department for medical statistics, epidemiology and medical informatics, andrija stampar school of public health, school of medicine, university of zagreb, zagreb,croatia. corresponding author: jadranka bozikov, phd address: andrija stampar school of public health, rockefeller st. 4, zagreb, croatia; telephone: +38514590101; e-mail: jbozikov@snz.hr conflicts of interest: none. mailto:jbozikov@snz.hr bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph 2014-53 2 health has never been an european union (eu) priority like agriculture, research, ecology or food safety and still remains to be first of all, if not exclusively, the responsibility of member states (ms). from the eu perspective, health is the crosscutting policy sector dominated by many other policies, especially by the ―hard law‖ regulations of the internal market. in the preceding two volumes, the south eastern european journal of public health (seejph) published an admirable lengthy article by hans stein and equally splendid supplemented commentary by bernard merkel recounting and evaluating developments of the eu‘s health policy from the 1992 maastricht treaty (and even from earlier) to the present-day state and future perspectives (1,2). although health still has very weak basis in the eu legislation, it has evolved from ―non-topic‖ into a key area of the eu economic policy (1), but despite a growing competence ―the unfinished story of the eu health policy” is slowly moving from declarative to operational phase in developing framework for circulation of health goods and related items within europe and beyond (2). in his commentary, dr merkel has summarized changes in treaties and other regulations from 1971 (directive on pharmaceuticals and regulation on coordination of social security systems providing rights to health care to workers in other ec countries) through the following milestones: (i) the article 129 of the maastricht treaty that for the first time introduced health although in a very weak manner; (ii) the 1997 treaty of amsterdam that extended the public health article and introduced the new one (article 152) including for the first time a few specific areas related to blood and organs, some veterinary and phytosanitary areas and other things, and; (iii) finally, the 2007 lisbon treaty with inclusion of medicinal products and medical devices but also incorporating the charter of fundamental rights of the eu including the right to access health care (preventive and curative, article 35 of the charter)(3). having in mind also the common currency introduced and spreading since 1999, the conclusion that single market will finally have an impact on health and health policy stands up. on the other hand, charter of fundamental rights of the eu (proclaimed in the year 2000 but being put in the new legal environment since it became formally binding by the lisbon treaty in 2009) has declared in its article 35 in addition that ―a high level of human health protection shall be ensured in the definition and implementation of all union policies and activities‖ prior than this principle became known as health in all policies (hiap) during the finish eu presidency in 2006. according to what has been mentioned above, population health and organization of health system (including health insurance) has always been and remains a national responsibility. at the same time, the eu member states (as well as accession candidates and potential candidates) were shaping their health policies, implementing activities and monitoring systems directed by recognized international organizations such as who and oecd (and, more recently, the eu) and also used their support in responding to health threats from communicable diseases and disasters, as well as in combating the growing burden of non-communicablediseases. finally, single market principles are going to enter health sector somehow through ―back door‖ via instruments such as directive 2011/24/eu on the application of patients‘ rights in cross-border healthcare that came into force on 25 th october 2013 (4), up to now without a great success, but with potential to improve access to healthcare services and harmonize their quality within the eu member states and push them to cooperate closer in establishing of health networks in order to meet patients‘ expectations. another very important opportunity for european integration is influencing and penetrating health sector from a much broader perspective of fast developing communication technologies. bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph 2014-53 3 a digital agenda for europe initiative was selected as one of the seven flagship initiatives supposed to be crucial for obtaining the targets of europe 2020 strategy for smart, sustainable and inclusive growth (5). the adoption of europe 2020 strategy in 2010 was followed by ―e health action plan 2012-2020‖ (6), a new one after the previous adopted in 2004 (7), and ―a digital single market strategy‖ for europe which was adopted in may 2015 after the new european commission elected in 2014 set up ten priority policy areas in its agenda for jobs, growth, fairness and democratic change including the priority to create ―a connected digital single market‖ listed as no. 2 priority by jean-claude juncker in his opening statement speech before the european parliament delivered on the 15 th of july 2014 (8,9). it is expected that the creation of digital single market will enable the creation of new jobs, notably for younger job seekers, and a vibrant knowledge-based society. enhancement of the use of digital technologies and online services was proclaimed as a horizontal policy, covering all sectors of the economy, as well as the public sector including health, and common european data protection rules were seen as a necessary prerequisite. facts about the ―digital agenda for europe initiative and digital single market (dsm) strategy‖ are available at the respective web-site (10), where we can also find new information and follow developments and public consultations on selected topics ofinterest. the ―digital agenda for europe initiative‖ proposes to better exploit the potential of information and communication technologies (icts) in order to foster innovation, economic growth and progress. it consists of the following sevenpillars: i. digital single market ii. interoperability & standards iii. trust & security iv. fast and ultra-fast internetaccess v. research and innovation vi. enhancing digital literacy, skills andinclusion vii. ict-enabled benefits for eu society a ―digital single market‖ (dsm) is one in which the free movement of persons, services and capital is ensured and where individuals and businesses can seamlessly access and exercise online activities under conditions of fair competition, and a high level of consumer and personal data protection, irrespective of their nationality or place ofresidence. at (10) we can find definitions of e-health and m-health as well as information on what is going on in digital society including the public consultations launched on respectivetopics. information and communication technology for health and wellbeing (e-health) is becoming increasingly important to deliver top-quality care to european citizens and includes informatisation of health care systems at all levels (from local through institutional and regional to european and global level including use of tele-consultations and telemedicine. mobile health (m-health) is a sub-segment of e-health and covers medical and public health practice supported by mobile devices. it especially includes the use of mobile communication devices for health and wellbeing services and information purposes, as well as mobile health applications. particularly important are policies for healthy and active ageing with help of ict and use of mobile applications for health and wellbeing including home care monitoring devices (wired and mobile). there are already more than 100,000 applications for health, fitness and wellbeing obtainable for different mobile platforms, the majority of which are designed for apple ios and android smart phones. bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph 2014-53 4 the european commission often consults with stakeholders on a number of subjects and such consultations can be found on the pages of digital agenda for europe (10). the commission launched a public consultation on the green paper on mobile health (11) on 10th of april2014. the green paper on mobile health covered broad scope of m-health potential for both, healthcare and market. main potential for healthcare are seen in (i) increased prevention and quality of life approach, (ii) more efficient and sustainable healthcare, and (iii) more empowered patients. having in mind that the healthcare systems‘ organization is a national competence green paper focused on cross-border european-wide issues and on possible coordinated actions at eu level that could contribute to the scale-up of m-health in europe by putting 11 issues atstake: 1. data protection, including security of healthdata 2. big data 3. state of play on the applicable eu legal framework 4. patient safety and transparency ofinformation 5. m-health role in healthcare systems and equalaccess 6. interoperability 7. reimbursement models 8. liability 9. research and innovation in m-health 10. international cooperation 11. access of web entrepreneurs to the m-healthmarket the commission also published a staff working document on the existing eu legal framework applicable to lifestyle and wellbeing apps, aiming at providing simple guidance to application developers on eu legislation in the field (12) and invited the views of stakeholderslike:  regional and national authorities e.g. health ministries, authorities dealing withmedical devices/data protection  health professionals, carers, health practitioners, medicalassociations  consumers, users of m-health apps, patients and theirassociations  web entrepreneurs  app developers and app stores  manufacturers of mobile devices  insurance agencies  sports centres, health clubs, and the like. consultation was open for more than three months during which stakeholders responded to 23 questions on a wide range of themes: data protection, legal framework, patient safety and transparency of information, m-health role in healthcare systems and equal access, interoperability, reimbursement models, liability, research & innovation, international cooperation and web entrepreneurs‘ market access. a total of 211 responses were received and summarized in the published report (13). besides the great potential for health and wellbeing, there are some concerns, as well. the safety of mobile health solutions (and of some lifestyle and wellbeing applications, too) is a main cause for concern, explaining the potential lack of trust. there are reports pointing out that some solutions do not function as expected, and may not have been properly tested or in some cases may even endanger people‘s safety. that is why on both sides of the atlantic, regulations for medical devices including software applications are established and continuously updated (14-16). it is beyond the scope of this article to discuss the importance bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph 2014-53 5 and the need of certification of e-health and m-health devices and software, but health professionals must carefully take this issue into account and stick to guidelines and recommendations issued by regulatory agencies and bodies as thosecited. undoubtedly, e-health and m-health have a large potential for health and wellbeing through empowering of patients and enabling them to take responsibility for their own health while reducing the ever-growing healthcare costs. at the same time, health professionals and students need to be educated and trained to evaluate such applications or at least to take into account their limitations. my personal experience has shown that medical students are capable to test m health applications and understand the need for validation and certification of such applications. they successfully prepared a seminar in medical informatics using their own smart phones. within the same course students received assignments to read, understand and present eu directives, charters and other documents (e.g. 3,4,6,11,14,16) in order to become acquainted with the european integration in health. health systems in the eu are facing the common challenge of a rise in chronic diseases as a consequence of our increasingly ageing population. vytenis andriukaitis, the eu commissioner for health and food safety, entitled his column in august 2015 issue of the european journal of public health ―how the ehealth can help with europe‘s chronic diseases epidemic‖ (17). quotes from this article are presented below: ―as a former medical doctor, i am fascinated with innovative solutions that are part of today‟s medical toolbox. i would like to highlight ehealth in particular. the more i learn about ehealth, the more convinced i am that it can enable better health, better and safer care for citizens and more efficient and sustainable healthcare systems. ehealth and mhealth can deliver more tailormade, „citizen-centric‟ care, more targeted and effective therapies, andhelp reduce medical errors.” good to hear that ehealth network has adopted the guidelines on electronic prescriptions needed for their cross-border exchange and progress ininteroperability: “although the deployment of ehealth is the responsibility of member states, the eu adds value in many ways. the ehealth network set up under the cross-border health care directive provides a forum for cooperation, support and guidance for speeding up the broad use of ehealth services and solutions. facilitating interoperability and safe and efficient handling of electronic health data across national and organizational boundaries is a key issue. the ehealth network has already adopted guidelines on cross-border exchange of patient summaries and prescriptions. these guidelines encourage the adoption of ehealth applications at national level.” guidelines on eprescriptions dataset adopted by ehealth network (18) are intended to be complementary to the commission implementing directive 2012/52/eu of 20 december 2012 laying down measures to facilitate the validation of medical prescriptions issued in another member state (19), but also as another document for implementation in the nearfuture. references 1. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives. seejph 2014; posted: 23 december 2014. doi 10.12908/seejph-2014-36. 2. merkel b. a growing competence: the unfinished story of the european union health policy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-2014 49. 3. charter of the fundamental rights of the european union. (2000/c 364/01). available at: http://www.europarl.europa.eu/charter/pdf/text_en.pdf (accessed: september 29,2015). http://www.europarl.europa.eu/charter/pdf/text_en.pdf bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph 2014-53 6 4. directive 2011/24/eu of the european parliament and of the council of 9 march 2011 on the application of patients‘ rights in cross-border healthcare. available at: http://eur lex.europa.eu/lexuriserv/lexuriserv.do?uri=oj:l:2011:088:0045:0065:en:pdf (accessed: september 29, 2015). 5. europe 2020 a strategy for smart, sustainable and inclusive growth. available at: http://eur-lex.europa.eu/legal-content/en/txt/pdf/?uri=celex:52010dc2020 (accessed: september 29, 2015). 6. e-health action plan 2012-2020 innovative healthcare for the 21st century. available at: http://ec.europa.eu/health/ehealth/docs/com_2012_736_en.pdf (accessed: september 29, 2015). 7. e-health making healthcare better for european citizens: an action plan for a europeane health area. available at: http://eur lex.europa.eu/lexuriserv/lexuriserv.do?uri=com:2004:0356:fin:en:pdf (accessed: september 29, 2015). 8. a digital single market strategy for europe. available at: http://ec.europa.eu/priorities/digital-single-market/docs/dsm-communication_en.pdf (accessed: september 29, 2015). 9. juncker jc. a new start for europe: my agenda for jobs, growth, fairness and democratic change. political guidelines for the next european commission, july 15, 2014, strasbourg. available at: http://ec.europa.eu/priorities/docs/pg_en.pdf (accessed: september 29,2015). 10. digital agenda for europe. a europe 2020 initiative. available at: https://ec.europa.eu/digital-agenda/en/digital-agenda-europe-2020-strategy(accessed: october 02, 2015). 11. green paper on mobile health (―mhealth‖). available at: https://ec.europa.eu/digital agenda/news-redirect/15512 (accessed: october 02, 2015). 12. commission staff working document on the existing eu legal framework applicable to lifestyle and wellbeing apps. accompanying the document green paper on mobile health (―mhealth‖). available at: http://ec.europa.eu/newsroom/dae/document.cfm?doc_id=5146 (accessed: october 02, 2015). 13. summary report on the public consultation on the green paper on mobile health. available at: http://ec.europa.eu/newsroom/dae/document.cfm?doc_id=8382 (accessed: october 02, 2015). 14. fda. mobile medical applications. guidance for industry and food and drug administration staff. document issued on february 9, 2015. available at: http://www.fda.gov/downloads/medicaldevices/.../ucm263366.pdf (accessed: september 29, 2015). 15. fda. medical devices data systems, medical image storage devices, and medicalimage communications devices. guidance for industry and food and drug administration staff. document issued on february 9, 2015. available at: http://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidancedocu ments/ucm401996.pdf (accessed: september 29, 2015). 16. ec. dg health and consumer. guidelines on the qualification and classification of stand alone software used in healthcare within the regulatory framework of medical devices (meddev 2.1/6 january 2012). available at: http://ec.europa.eu/health/medical devices/files/meddev/2_1_6_ol_en.pdf (accessed: september 29, 2015). 17. andriukaitis v. how ehealth can help with europe's chronic diseases epidemic. eur j public health 2015;25:748-50. http://eur-lex.europa.eu/lexuriserv/lexuriserv.do?uri=oj%3al%3a2011%3a088%3a0045%3a0065%3aen%3apdf http://eur-lex.europa.eu/lexuriserv/lexuriserv.do?uri=oj%3al%3a2011%3a088%3a0045%3a0065%3aen%3apdf http://eur-lex.europa.eu/legal-content/en/txt/pdf/?uri=celex%3a52010dc2020&amp;amp%3bamp%3bamp%3bamp%3bfrom=hr http://ec.europa.eu/health/ehealth/docs/com_2012_736_en.pdf http://eur-/ http://ec.europa.eu/priorities/digital-single-market/docs/dsm-communication_en.pdf http://ec.europa.eu/priorities/docs/pg_en.pdf https://ec.europa.eu/digital-agenda/en/digital-agenda-europe-2020-strategy%20(2 https://ec.europa.eu/digital-agenda/news-redirect/15512 https://ec.europa.eu/digital-agenda/news-redirect/15512 http://ec.europa.eu/newsroom/dae/document.cfm?doc_id=5146 http://ec.europa.eu/newsroom/dae/document.cfm?doc_id=8382 http://www.fda.gov/downloads/medicaldevices/.../ucm263366.pdf http://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidancedocu http://ec.europa.eu/health/medicalbozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph 2014-53 7 18. guidelines on eprescriptions dataset for electronic exchange under cross-borderdirective 2011/24/eu. release 1. adopted by ehealth network. available at: http://ec.europa.eu/health/ehealth/docs/eprescription_guidelines_en.pdf (accessed: september 29, 2015). 19. commission implementing directive 2012/52/eu of 20 december 2012 laying down measures to facilitate the recognition of medical prescriptions issued in another member state. available at: http://ec.europa.eu/health/cross_border_care/docs/impl_directive_presciptions_2012_en.pdf (accessed: september 29, 2015). © 2015 bozikov; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://ec.europa.eu/health/ehealth/docs/eprescription_guidelines_en.pdf http://ec.europa.eu/health/cross_border_care/docs/impl_directive_presciptions_2012_en.pdf http://creativecommons.org/licenses/by/3.0) 8 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 original research piloting an advanced methodology to analyse health care policynetworks: the example of belgrade, serbia helmut wenzel 1 , vesna bjegovic-mikanovic 2 , ulrichlaaser 3 1 health economic consultant; 2 institute of social medicine, faculty of medicine, university of belgrade,serbia; 3 section of international health, faculty of health sciences, university of bielefeld, ger many. corresponding author: helmut wenzel, m.a.s. address: d78464 konstanz,germany; e-mail: hkwen@aol.com mailto:hkwen@aol.com 9 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 abstract aim: political decisions usually emerge from the competing interests of politicians, voters, and special interest groups. we investigated the applicability of an advanced methodological concept to determine whether certain institutional positions in a cooperating network have influence on the decision-making procedures. to that end, we made use of the institutional network of relevant health care and health governance institutions, concentrated in belgrade, serbia. methods: we used a principal component analysis (pca) based on a combination of meas ures for centrality in order to evaluate the positions of 25 players in belgrade‟s institutional network. their directed links were determined by a simulated position approach employing the authors‟ long-term involvement. software packages used consisted of visone 2.9, ucinet 6, and keyplayer 1.44. results: in our analysis, the network density score in belgrade was 71%. the pca revealed two dimensions: control and attractiveness. the ministry of health exerted the highest level of control but displayed a low attractiveness in terms of receiving links from important play ers. the national health insurance fund had less control capacity but a high attractiveness. the national institute of public health‟s position was characterized by a low control capacity and high attractiveness, whereas the national drug agency, the national health council, and non-governmental organisations were no prominentplayers. conclusions: the advanced methodologies used here to analyse the health care policy net work in belgrade provided consistent results indicating that the intended decentralization of the health care network in belgrade may be incomplete, still with low participation of civil society representatives. with the present study we set the stage for a broad-range survey based data collection applying the methodology piloted inbelgrade. keywords: belgrade‟s health care policy network, policy analysis, serbia, social network analysis, sources of power. conflicts of interest: none. acknowledgments: this work was supported by the ministry of science and technological development, republic of serbia, contract no. 175042. 10 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 introduction political decisions are not primarily the result of scientific (rational) problem solving like e.g. the illustration of the policy cycle suggests (1,2). the decisions usually will emerge from the competing interests of politicians, voters, and special interest groups. the policy literature considers this issue and suggests a variety of frameworks and analytic models for policy analysis (3). the spectrum ranges from the rather normative scientific problem solving ap proach to a more „incrementalistic‟ way (4). lindblom even calls it „muddling through‟ (5) and finally to the paradigm of „bounded rationality‟ (6,7). analyzing decision outcomes (policies) has to consider the specific organisational structure (policy) and the initiated proc esses (politics), comparable to donabedian‟s concept of structure and process as a prerequi site of outcome quality (8). related questions are: how will political decision processes pos sibly influence policy-making (6)? do certain individual or institutional positions in a coop erating network have more or less influence on the decision-makingprocedures? to explore the complex governmental portfolio of resources, hood et al. (9,10) propose a classification scheme, which gets to the point with only four important sources of power: nodality, authority, treasure and organisation. they state that nodality denotes the property of being in the middle of an information or social network (10). a high degree of nodality gives a player a strategic position from which he allocates information, and which enables him to draw in information. authority is the formal and legitimate official power (11). that is the formal power to demand, forbid, guarantee, and arbitrate. treasure gives the government the ability to exchange goods, using the coin of money or something that has a money-like property. finally, organisation gives to a government the physical ability to act directly, us ing its own forces (10). with the serbian health insurance act of 2005 (12) the serbian government aimed at reo rienting the health care system and transform it into a more decentralised organisation. these changes would hopefully offer to the insured population an opportunity for a greater self management. as most of the relevant institutions are concentrated in the serbian capital bel grade, we used this example to investigate the applicability of the aforementioned methodo logical concept. with the disclosure of the players‟ nodalities that make up belgrade‟s health care policy network, we envisaged to analyse to which degree the decentralisation of decision making has progressed since the legislation of 2005, extending our preliminary analysis (13). with the present step we focus on institutional players and their nodality only, without con sideration of potentially influential individual players. the analysis of belgrade‟s health pol icy network is a pilot project appropriate for testing the feasibility of a countrywide survey. this analysis was based on a questionnairesurvey. methods to break down the abstract notion of power and influence, different paradigms were used in sociology and political science: reputation approach, decision approach, or position approach (14). for a critical review of the approaches see domhoff (14). in our understanding, influen tial actors can be best described by the position approach, i.e. a policy network. a policy network is described by its various players public as well as non-governmental their for mal and informal connections and the specific boundary of the network under consideration. the links between the players are likely to be understood as communication channels for the exchange of information, expertise, trust and other policy resources (15). depending on the scientific disciplines, e.g. coming from community power research (14), or systems thinking (16,17), various technical approaches and measures have been used to identify, describe and 11 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 analyse formal or informal networks within organisations. necessary data can be collected by means of survey (questionnaires, interviews), observations, or by analysing secondary data. for economic reasons, a heuristic procedure as outlined e.g. by vester (16) or bryson (18) was applied and possible actors [so-called boundary specification (19, p. 77)] were enume rated in a brainstorming session listed in a ―cross-impact matrix‖ of influences (16, p. 188). finally, the strength and direction of their connections was estimated (16, p. 188) by the au thors for the purpose of this methodological study. these are ―soft data‖ (16, p. 22), but nev ertheless they are based on experience, knowledge of the health care system and observa tions. as newman points out, collecting data by directly questioning participants (or, players) does not necessarily provide a higher accuracy and is also a laborious endeavour (20). for visualisation of the network and a more in-depth analysis, we recurred to the analytic tools of social network analysis (sna). the concept of nodality corresponds well with the measures used in sna and, basically, two viewpoints are possible: primarily focusing on a specific player (ego-centred) only, and analysing and evaluating the network as a whole, taking all connections and all players into account (socio-centred)(13). on a socio-centred level, the network structure can be described by measuring density and centralization. centralization is defined as the variation in the centrality scores of the nodes or players in the network. this variation shows the extent to which there is a centre i.e., very central players and a periphery i.e., players with very low centrality scores (21). density is a basic network property that reflects the overall intensity of the connected players: the more connected the network, the greater its density. a dense network is one where a lot of activity or a large number of strong ties exist among its members (22). on an ego-centred (individual) level, we focused on the players‟ importance. importance reflects the visibility to other net work members (23) and is broken down into indices like influence andprestige. measures of centrality the concept of centrality is a crucial aspect when representing policy networks (24). central ity measures will identify the most prominent players. these are the players who are exten sively involved in relationships with other network members (25) without necessarily dis criminating between formal or informal links (depending on the data collection approach). the most frequently centrality measures used include degree centrality, betweenness central ity, and closeness centrality. they reflect the view that information is transferred along the shortest pathways (26). degree centrality is an indicator of expertise and is measured by the sum of all other players who are directly connected to a specific player (25). asymmetric networks are particular in that the distinction between indegree-centrality and outdegree-centrality has to be taken into account (13). players receiving many ties (indegree) have a high prestige (23). players with a high flow of outgoing connections (outdegree) are able to exchange with many others, or at least make others aware of their views (13). this means that players with a high outdegree centrality are said to be influential players(27). betweenness centrality counts how many times a player connects other players, who other wise would not be able to reach one-another (25). it measures the potential for control, be cause a player who shows a high betweenness degree will be able to operate as a gatekeeper by controlling the flow of resources between the other nodes that are connected through him (25) on shortest paths (28). 12 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 closeness centrality is based on the concept of distance. a player who is close to all others in the network, e.g. having a distance of no more than one, is not dependent on any other to reach everyone in the network (25). closeness centrality measures independence or efficiency (25). in the context of sna, efficiency means that the higher the closeness centrality of a node, the shorter is its average distance to any other node, thus indicating a better position for spreading information (29). further centrality measures are hub function and authority. in directed networks, players that have important resources should get a high centrality score too. newman defines it as fol lows: “authorities are nodes that contain useful information on a topic of interest; hubs are nodes that tell us where the best authorities are to be found” (30, p. 179). in the framework of sna, formal authority has to be differentiated from informal authority (11). hubs are en ablers of effective knowledge transfer (31, p. 225). a high hub player points to many impor tant authorities (high outdegree) whereas a high authority player receives ties from many im portant hubs (high outdegree). they can effectively connect different sub-groups of the net work and facilitate knowledge flows; removing them from the network can lead to its frag mentation (31, p. 225). study setting for investigating the applicability of the methodological concept we chose a position ap proach as it best describes the potential of power and influence, combined with a heuristic data collection. to that end, the authors all well informed about the serbian health care sys tem and the situation in belgrade listed 25 players, identified the links between the players and the perceived strength of their relationship together in an open process. as pointed out earlier (13), the links can point in one direction only (unidirectional), or include both direc tions (bidirectional). the strength of the relationship was rated on a scale ranging from 0 to 4. very weak links with a value of 1 were put on a level with 0 for ―no link‖ (13). the rating of the links reflects the averaged assessment of the authors. the resulting ―cross-impact matrix‖ was exported to visone 2.9 (15) for further analysis. in some cases where the analytic toolset of visone 2.9 did not provide the calculation of specific indices, we used ucinet 6 (32), and keyplayer1.44 (33) instead. to visualise the analytical findings in an easily understandable format, we chose the design of a target diagram, which is also a built-in feature of visone 2.9. in this diagram, the 25 players (nodes) are placed according to their scores. this means that the player with the high est score is positioned in the centre of the diagram; the others, according to their decreasing scores, are moved toward the periphery of the structure, correspondingly. to ensure a largely undisturbed view, the authors of visone 2.9 applied a specialized layout algorithm that aims at minimizing entanglement by reducing the number of crossing lines and occlusions deter mine the angular location. the different score levels are displayed as thin concentric circles. this allows comparing the scores of the players easily, without looking at the output table (15, p. 17). brandes et al. (15) successfully used these diagrams to analyse local health poli cies and the underlying structure of the various players, e.g. to disclose the differences in the local drug policy of two german municipalities and the networks of players that form the basis of the policy making. furthermore, to facilitate an overall perspective (holistic view) of the indices applied, we merged the results with the help of a principle component analysis (pca) diagram. pca is a multivariate data analysis method which is used to reduce complex ity by transforming a set of possibly correlated variables into a set of uncorrelated variables, 13 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 ., principal components (34,35). this approach explains best the variance of data and helps to reveal the internal structure of the data. results the network matrix was composed by 25 players and 158 directed and valued links or con nections as determined for the purpose of this methodological study by the authors. the network density was calculated as 71% realized links out of all possible ones. a density greater than 50% is considered high (36). therefore, we assumed here that the players in bel grade were well connected. for valued networks (see figure 1), the centralization score has to be calculated separately for outdegree and indegree centrality. the outdegree score here was 46.3% of all possible connections, whereas the indegree score was 19.1% (calculated with ucinet 6). this would disclose a distinct centralisation. however, the range of outdegree scores was larger than that of indegree scores, and the players showed a higher variability. the coefficient of variation was 93% for outdegree and 54% for indegree centrality, indicat ing that the network was less homogeneous with regard to outdegree centrality, or influence (27). the possible influence of the players in the network varied largely, i.e., the positional advantages were rather unequallydistributed. the most important players – identified in terms of degree centrality (figure 1a and table 1) were the national health insurance fund [1], the ministry of health [15], the national government [14], and the medical faculty, belgrade [22]. the health insurance fund [1] received most of the strongest [blue] links. the players with the highest indegree centrality or 14 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 prestige were the clinical hospital centres, belgrade [8], the institute of public health, bel grade [4], the national health insurance fund [1], and the clinical hospital centre of the republic [7]. players with the highest outdegree centrality or influence were the national government [14], the ministry of health [15], the medical faculty, belgrade [22], the state revisor [18], and the national health insurance fund [1]. table 1. ranking of players by centralityindices (based on percentages – for the numeric codes, see table 3 in theannex) indices of centrality degree centrality indegree centrality outdegree centrality betweenness closeness hub function authority 1 8 14 8 14 14 3 15 4 15 15 15 15 8 14 1 22 22 18 18 4 22 7 18 7 22 1 7 7 3 1 19 19 22 23 8 5 17 1 7 17 1 18 6 7 20 1 20 25 5 23 20 11 20 7 9 4 25 19 23 23 11 2 17 9 11 5 17 19 10 19 15 23 6 11 5 15 20 23 8 9 16 23 6 23 2 5 23 8 8 23 6 10 16 18 10 10 5 11 22 9 12 3 9 13 3 12 6 17 9 16 17 23 19 10 3 23 6 16 9 13 4 4 21 2 19 25 17 2 10 12 4 12 2 11 12 2 5 23 22 10 20 21 14 6 21 20 12 16 23 16 2 12 11 16 21 3 21 4 3 21 13 18 25 25 25 25 18 21 14 13 13 13 13 14 with respect to the betweenness centrality, the clinical hospital centres, belgrade [8] were the most central players. the ministry of health [15], the medical faculty, belgrade [22], the clinical hospital centre of serbia [7], and the serbian physicians society [19] seemed to be very close to each-other, but located more to the margin. players with a high degree of close ness were the national government [14], the ministry of health [15], the state revisor [18], the medical faculty, belgrade [22], and the serbian physicians society [19]. the picture changed when we looked at hub functions. as pointed out, hubs are enablers of effective knowledge transfer, they can effectively connect different sub-groups of the network and facilitate knowledge flows; removing them from the network can lead to its fragmentation (31, p. 225). considering the hub function, the national government [14] was in the most 15 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 favourable position (see figure 1b), followed by the ministry of health [15]. the national health insurance fund [1] moved more to the periphery indicating a loss of importance for knowledge transfer. the state revisor [18] and the mof budget inspection [17] also moved more to the centre of the diagram. as hannemann and riddle note, the question of how structural positioning implicates power is still a matter of research and debate (34). to reduce the complexity, eventually sort out redundant information and get an integral view, we applied pca which is displayed in table 2 and figure 2. table 2. contribution of centrality measures to the dimensions of the pca(percentages) centrality measures d1 (control) d2 (attractiveness) degree 22.645 3.186 indegree 0.159 40.837 outdegree 22.820 3.876 betweenness 12.246 7.907 closeness 19.822 3.205 hub function 21.654 3.607 authority 0.654 37.381 the pca provides evidence of two dimensions (figure 2); they explain 88.81% of the data. the first dimension consists of degree, outdegree, closeness, and hub function. the second dimension consists of indegree and authority. the first dimension d1 represents the capacity for ―control‖; the second dimension d2 depicts what we called―attractiveness‖. the main players: the ministry of health [15] apart from the formal aspect i.e. legal author ity and organisation was highly ranked on the first dimension of control. on the second di mension of attractiveness, it was ranked just above the average. this picture was confirmed in the classification by hub function and authority. the ministry of health was a hub as well as an authority in this analysis, whereas the hub feature was more pronounced. this would mean that it was connected to many popular players and received links from important play ers. the national government [14] was likewise highly ranked on the first dimension, but showed the lowest score on the second dimension. this means that control was high but the attractiveness was low. on the other hand, the national government [14] was also a hub, which means that it was connected to many very important players, and its influence might be based on this feature, primarily. the national health insurance fund [1] showed less poten tial of control [first dimension] than the ministry of health [15], but had a higher score on the attractiveness axis [second dimension]. the national health insurance fund [1] was a hub and an authority too. the hub score was lower than that of the ministry of health or the na tional government, but its authority score was very pronounced. this means, its authority feature receiving links from important players – in our pilot study was moreimportant. according to this analysis, effective decentralisation would require more autonomy for insti tutions like the national institute of public health [3], the national drug agency [10], the national health council [13], and non-governmental organisations [21], all ranking with the exception of the national institute of public health [3] towards the end in table 1 and low on both dimensions in figure 2. but, also the chambers of health professionals [11, 12] could play a more important role as well as the trade unions [20] and the branches of the na tional health insurance fund [2]. 16 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 figure 2. the position of players by twodimensions legend: the yellow triangles mark the national government and the ministry of health; the green diamonds signify the players focussed in the analysis; the blue circles represent the remaining players. for the numeric codes, see table 3 in theannex. the national institute of public health [3] ranked below average on the first dimension (con trol) and was positioned above average on the second dimension (attractiveness) that is play ers were seeking contact. its high authority score confirmed this, but as a hub it ranked very low (table 1). according to borgatti, such players are primarily mediators(37). discussion it is a widespread view in the literature that no single or generally accepted method for mea suring decentralization exists (38); there are many different definitions, understandings of the concepts and diverse measurement instruments (39). thus, measuring centralization or decen tralization is mostly based on analyzing the financial autonomy or regulatory mechanisms (39,40). independent of the underlying ―intellectual tradition‖ (41), disciplinary and language differences, and the way the various indices were constructed, these approaches focus on formal aspects. informal ways of influence and power are not taken into account. however, these informal relationships may superimpose the formal balance of power, supporting or even hindering structural changes or specific policy-making, and possibly will underestimate the real balance of power. the concept of nodalities, used here, is based on relationships (links). these links cannot only indicate subordination but can also stand for information observations (axes d1 and d2: 88.81 %) after varimaxrotation 2.5 2 8 1.5 7 1 4 3 24 1 25 0.5 6 9 5 15 0 2 23 10 19 22 -0.5 13 12 11 1720 -1 16 21 -1.5 18 -2 14 -2.5 -2 -1.5 -1 -0.5 0 0.5 1 1.5 2 d1 control (55.4%) 2.5 d 2 a tt r a c ti v it y ( 3 3 .4 % ) 17 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 channels. insofar, mapping the nodalities, is complementary to the approaches mentioned above and will round off the picture. compared to other european countries, serbia is among the most centralized systems (42). it ranks second on a list of thirteen countries (38). the analysis of the degree and appropriate ness of decentralization, however, is not an end in itself. it is a means to achieve a broader spectrum of goals (43) or, more generally speaking, it is an important component of good governance (38). very often it is emphasized that decentralization is a very significant step in promoting democracy (44,45). with decentralization essential goals should be achieved, such as effectiveness and efficiency, fairness, quality, financial responsibility, and respect for local preferences (43,45). decentralization is one of the most important issues on the agenda of health care reform in many countries. however, there is little information from research that can show the likely correlation between the degree of centralization and health outcomes, i.e. the health of the population (40). furthermore, observations and case studies indicate that, if inadequately planned, and implemented, i.e. too rapidly or inconsistently, decentralization can have serious consequences on the provision of health services to the population (43). for that reason, appropriate planning, and considering corresponding experiences in other coun tries, may prevent disappointment and slow-down of processes. decentralization also will shift the role of the ministry of health, from direct management and decision making toward formulating health care policies, technical counselling and assistance, as well as monitoring and evaluation of programmes andactivities. decentralization represents the transfer of authority and responsibility for public functions from the central to subordinate levels and/or to the private sector (43,45). the essential task, then, is to define the adequate level of decentralization (45) by entities, i.e., regions, districts, and municipalities, and by appropriate forms of bureaucratic autonomy, i.e. deconcentration, delegation, and devolution. any consideration on whether decentralization is necessary and how much will be feasible has to undergo a detailed examination in the context of a (rational) organisational structure (46); this is very often perceived a common place, and ignored with associated consequences. certain aspects of decentralization deserve closer attention. for example, the possibility of local authorities to adapt to local conditions should be carefully balanced against a common vision and the goals of the health care system (4). for this reason, the policy of decentralization should include mechanisms of coordination, since the local political interests grow as more responsibilities are transferred to that level (47). furthermore, decentralization bears the risk of fragmenting responsibility for different types of health care (specialist hospitals, general hospitals, primary care etc.) between the levels of regional and municipal government (43). in this context, it is indicative that the coordinative and integra tive potential of the national health council of serbia [13] seemingly is not used. this body could include non-governmental organisations [21] in the field of health, as well as trade union representatives from the most important health institutions. the limitations of our approach relate to its validity and reliability. a valid model has to be isomorphic, thus representing a true picture of the system to be modelled. the level of iso morphism can be disclosed in analogy to the revision of „validity of structure and processes‟ (48), or „expert concurrence‟ (49). however, in this study the boundaries and the linksremain to be crosschecked as a next research step, especially as the present dataset relies only on the author‟s evaluation of the situation. missing data, i.e., the absence of players and/or links can also have an important impact (50,51) on the „application validity‟. another criticism that raised concerns relates to the shortest paths-based measures as they do not take intoaccount 18 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 diffusion along non-shortest paths (52). however, the modelling algorithms used here are consistent with validated standard computersoftware. in order to challenge the appropriate level and structure of a health care system and to control any process of reorganisation, it is essential to be fully familiar with the positive interaction of the various players. in this context, it is an important cornerstone to know the nodality of the health care network, in our example that of belgrade hosting most of the national health institutions. the network depicted would also provide a basis for what-if-scenarios to antici pate the likely effects of intended changes. furthermore, the methodology used for the net work and its description, which examines the system from a relatively high level (bird‟s eye view), can be adapted to specific decision-making situations, and tailored to support specific planning processes. conclusion the advanced methodologies used here to analyse the health care policy network in belgrade deliver consistent results indicating that the intended decentralization of the health care net work in belgrade may be incomplete, still with low participation of civil society representa tives. with the present study we hope to prepare for a broad-range survey-based data collec tion and to apply the methodology piloted in belgrade. references 1. bridgman p, davis g. what use is a policy cycle? plenty, if the aim is clear. austj pub admin 2003;62:98-102. 2. may jv, wildavsky ab. the policy cycle. beverly hills, sage publications;1978. 3. parag y. a system perspective for policy analysis and understanding: the policy process networks. systemist 2006;28:212-24. 4. hayes mt. incrementalism and public policy. new york ny u.a, longman; 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2013. p. 24-43. 52. borgatti sp. centrality and network flow. social networks2005;27:55-71. annex table 3. list of players and their correspondingcodes work code full name 1 national health insurance fund 2 nhif, belgrade branch 3 national institute of publichealth 4 institute of public health, belgrade 5 secretary for health, belgrade 6 primary health care centres (17),belgrade 7 clinical hospital centre of serbia 8 clinical hospital centres (4),belgrade 9 national accreditationagency 10 national drug agency 11 national chambers of healthprofessionals 12 chambers of health professionals, belgradebranches 13 national health council 14 national government 15 ministry of health 16 ministry of finance 17 mof budget inspection 18 state revisor 19 serbian physicians society 20 trade unions 21 non-governmental organisations 22 medical faculty, belgrade 23 council of the medical faculty,belgrade 24 special hospitals, belgrade 25 tertiary medical institutes,belgrade © 2015 wenzel et al; this is an open access article distributed under the terms of the creative commons attri bution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited. http://creativecommons.org/licenses/by/3.0) 22 meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in therepublic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 original research estimating health impacts and economic costs of air pollutioninthe republic of macedonia craig meisner 1 , dragan gjorgjev 2,3 , fimka tozija 2,3 1 the world bank, washington, dc, usa; 2 institute of public health, skopje, republic of macedonia 3 medical faculty, skopje, republic of macedonia corresponding author: craig meisner, senior environmental economist, the world bank, msn mc7-720; address: 1818 h street, nw, washington, dc 20433, usa; telephone: 202-473-6852; e-mail: cmeisner@worldbank.org mailto:cmeisner@worldbank.org 23 meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in therepublic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 abstract aim: this paper assesses the magnitude of health impacts and economic costs of fine particulate matter (pm) air pollution in the republic of macedonia. methods: ambient pm10 and pm2.5 monitoring data were combined with population characteristics and exposure-response functions to calculate the incidence of several health end-points known to be highly influenced by air pollution. health impacts were converted to disability-adjusted life years (dalys) and then translated into economic terms using three valuation approaches to form lower and higher bounds: the (adjusted) human capital approach (hca), value of a statistical life (vsl) and the coi (cost ofillness). results: fine particulate matter frequently exceeds daily and annual limit values and influences a person‟s day-to-day health and their ability to work. converting lost years of life and disabilities into dalys these health effects represent an annual economic cost of approximately €253 million or 3.2% of gdp (midpoint estimate). premature death accounts for over 90% of the total health burden since this represents a loss of total life-long income. a reduction of even 1μg/m 3 in ambient pm10 or pm2.5 would imply 195 fewer deaths and represent an economic savings of €34 million per year in reduced health costs. conclusion: interventions that reduce ambient pm10 or pm2.5 have significant economic savings in both the short and long run. currently, these benefits (costs) are „hidden‟ due to the lack of information linking air quality and health outcomes and translating this into economic terms. policymakers seeking ways to improve the public‟s health and lessen the burden on the health system could focus on a narrow set of air pollution sources to achieve these goals. keywords: air pollution, health and economic costs, particulatematter. conflicts of interest: none. acknowledgements: the authors would like to first acknowledge the financial support of the green growth and climate change analytic and advisory support program launched in 2011, with funding support from the world bank and the governments of norway and sweden. we would also like to thank our local macedonian counterparts at the institute of public health and the ministry of environment and physical planning for their willingness to collect and share data. we would also like to thank the finnish meteorological institute (fmi) for their guidance and suggestions on earlier drafts of this work. fmi is currently working with the moepp in strengthening their air quality monitoring network through an eu-sponsored twinning project. 24 meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in therepublic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 introduction according to the global burden of disease (2010) estimates (1), the crude mortality rate from ambient particulate matter (pm) pollution in macedonia was 80.6 deaths per 100,000 in 2010. in comparable neighboring states such as serbia, it was 71.8 deaths per 100,000; in croatia it was 69.4 per 100,000; in hungary 92.0 per 100,000; and 70 per 100,000 in slovakia. the total disability-adjusted life years (dalys) attributable to pm were about 1,480 per 100,000 in macedonia (but, up to 1,600 in hungary) (1). the main sources of this ambient condition were the use of solid fuel for heating households in the winter, as well as the impact of industry and traffic. uncontrolled urbanization is also a significant source of particulate matter. in 2009, an average annual concentration of 90µg/m 3 was registered in skopje. compounding the situation, poor air circulation is another reason why the capital city of skopje has one of the worse air conditions inwinter. air pollution is also significant throughout the european region, with only nine of the 34 member states reporting pm10 levels below the annual who air quality guideline (aqg) of 20μg/m 3 . almost 83% of the population in these cities is exposed to pm10 levels exceeding the aqg levels(2). results from a recent project improving knowledge and communication for decision-making on air pollution and health in europe (aphekom), which uses a traditional health impact assessment method, indicated that average life expectancy in the most polluted cities could be increased by approximately 20 months if long-term pm2.5 concentrations were reduced to who guidelines (3). one recent study in macedonia found that an increase of pm10 by 10μg/m 3 above the daily maximum permitted level (50μg/m 3 ) was associated with a 12% increase in cardiovascular disease(2). methods to estimate the health impacts and economic costs of air pollution, the approach required overlaying data from multiple sources. the method used ambient air quality data [information received from the ministry of environment and physical planning (moepp)] for pm10 and pm2.5, health statistics – annual deaths by disease type; frequency of chronic bronchitis, asthma, infant mortality; and health cost data (information received from the institute of public health and health insurance fund), exposure-response functions from health studies (information from international and local literature) and population characteristics – age groups, gender, urban/rural population (information from the state statistics bureau). these data were combined for a municipal (city) levelanalysis. the approach to estimating health impacts and economic costs encompassed fivesteps:  collection of monitored, ambient concentration data on pm10 and pm2.5  calculation of exposed population  exposure-response functions  calculation of physical health impacts (mortality, morbidity,dalys)  monetizing health impacts collection of monitored data on fine particulatematter currently, the ministry of environment and physical planning (moepp) has a network of 19 automatic monitoring stations: seven in skopje, two in bitola, two in veles and one in kicevo, kumanovo, kocani, tetovo, kavadarci, village lazaropole, and two near the okta oil refinery (near the villages of miladinovci and mrsevci). stations measure so2, no2, co, pm10, pm2.5, ozone, benzene, toluene, ethyl benzene and btx – although some stations do not measure all pollutants [monitored pm2.5 measurements began in november, 2011 in 25 meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in therepublic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 karpos and centar. in cases where pm2.5 is not actually monitored, observed pm10 is adjusted by the ratio pm2.5/pm10. the ratio, based on recent observations, is estimated at in the case of macedonia; and is within ranges found in other international studies. see ostro (4) for a discussion]. this information is available electronically through their air quality portal (available at: http://airquality.moepp.gov.mk/?lang=en). calculation of exposed population population information for 2010 was used focusing on the working population as well as vulnerable segments of society (for example, those under the age of five or older than 65 are considered more vulnerable to the effects of air pollution – that is more prone to develop acute or chronic respiratory ailments). exposure-response functions the selection of exposure-response functions was based on epidemiological research between pm10 and pm2.5 and mortality and morbidity. for mortality, exposure-response functions for long-term exposure to pm2.5 were (4): relative risks (rr) were calculatedas: cardiopulmonary (cp) mortality: rr =[(x+1)/(x0 +1)] 0.15515 lung cancer (lc) mortality: rr = exp[0.23218 (x-x0)] alri mortality in under-five children: rr = exp[0.00166 (x-x0)] with: x = current annual average pm2.5 concentration for cp and lc among adults, and pm10 concentrations for alri among children and x0 = target or baselinepm2.5 concentration. information on the crude death rate (cdr), cp, lc and alri data were used to set the mortality baseline. for morbidity, exposure-response coefficients (annual cases per 100,000 population) for pm10 from ostro (4,5) and abbey et al. (6) were applied. ostro (4) reflects a review of worldwide studies, and abbey et al., (6) provides estimates of chronic bronchitis associated with particulates (pm10). a baseline for pm concentrations a baseline level (natural background concentration) for pm2.5 = 7.5 µg/m 3 , as suggested by ostro (4), was used (some argue that the baseline should be set at zero since the literature does not support the existence of a concentration level of which there are no observable effects. however a baseline of zero is not realistic since natural background concentrations hover between 10-15 μg/m 3 in macedonia – and one would only look at investments which could reduce ambient concentrations to this level (i.e. at least from a benefit-cost standpoint of weighing alternativeinvestments). given a pm2.5/pm10 ratio of 0.71 using observations in macedonia, the baseline level for pm10 is 10.6 µg/m 3 . these baseline concentrations were applied to both large and medium/small urban areas. calculation of physical health impacts (mortality, morbidity, dalys) using the population information and the exposure-response functions, mortality and morbidity impacts were calculated through the conversion of impacts to dalys (dalys = sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability). the daly method weights illnesses by severity: a mild illness or disability (e.g. morbidity effects) represents a small fraction of a daly and a severe illness represents a larger fraction (e.g. mortality = 1 daly). weights used in this context were adapted from larsen (7) and are presented in table 1. http://airquality.moepp.gov.mk/?lang=en) 26 meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in therepublic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 table 1. estimated health impacts of air pollution, urban and rural,2010 (source: world bank, 2012) health impacts dalys /10,000 cases cp mortality(pm2.5) 80,000 lc mortality (pm2.5) 80,000 alri mortality (pm10) 340,000 chronic bronchitis (pm10) 22,000 hospital admissions(pm10) 160 emergency room visits (pm10) 45 restricted activity days(pm10) 3 lower respiratory illness in children(pm10) 65 respiratory symptoms (pm10) 0.75 total monetizing health impacts to create a set of bounds three alternative valuation approaches were used: the (adjusted) human capital approach (hca) [the adjusted version avoids the issue of assigning a value of zero to the lives of the retired and the disabled since the traditional approach is based on foregone earnings. it avoids this issue by assigning the same value – per capita gdp – to a year of life lost by all persons, regardless of age], value of a statistical life (vsl) and the coi (cost of illness). the hca estimates the indirect cost of productivity loss through the value of an individual‟s future earnings. thus, one daly corresponds to one person‟s contribution to production, or gdp per capita. this method provides a realistic lower bound for the loss of one daly. the vsl measures the willingness-to-pay (wtp) to avoid death – using actual behavior on the tradeoffs between risks and money. the vsl is calculated by dividing the marginal wtp to reduce the risk of death by the size of the risk reduction. measured this way, the value of one daly corresponds to the vsl divided by the number of discounted years lost because of death. the vsl typically forms an upper bound measure of health damages. the coi approach estimates the direct treatment costs associated to different health end-points (e.g. hospitalization, restricted activity days, and doctor visits). mortality was valued using hca as a lower bound and the vsl as an upper bound. for morbidity effects the coi was estimated as a lower bound and willingness-to-pay to avoid a case of illness was applied as a higher bound of cost (wtp was assumed to be two times thecoi). results air quality data support the finding that particulate matter is one of the most serious concerns in the country. ambient pm10 concentrations frequently exceeded the eu standard of 40μg/m 3 over the years (figure 1). using information on ambient pm10 and pm2.5 in conjunction with the methods outlined above, it is estimated that in macedonia 1,350 deaths occur annually from cardiopulmonary disease and lung cancer (table 2). these deaths are considered „premature‟ in the sense that air pollution contributed to their early demise – since many factors actually influence a persons‟ lifespan (e.g. smoking, exposure to the outdoors, job, etc.). particulate matter can also influence a person‟s day-to-day health and their ability to work. in 2011, levels of pm10 and pm2.5 were primarily responsible for 485 new cases of chronic bronchitis, 770 hospital admissions, and 15,200 emergency visits. 27 meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in therepublic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 figure 1. annual average pm10 concentration at each automatic monitoring stationin μg/m 3 (source: ministry of environment and physical planning, 2012) what do these translate to in terms of a total cost to society? converting lost years of life and disabilities to dalys (or disability-adjusted life years) these health effects represent an annual economic cost of €253 million or 3.2% of gdp (table 2). note that premature death accounts for over 90% of the total health cost since the loss of life is a loss of total (future) income. people also suffer from the day-to-day consequences of respiratory diseases. it is estimated that several thousand work-years are lost annually from chronic bronchitis, asthma, hospital admissions and days of restricted activity. these estimates are consistent with other recent studies – such as kosovo where annual deaths were estimated to be in the range of 805-861 from cardiovascular disease and lung cancer (8). it should be noted that our estimates are mid-points (middle) with lower and higher ranges reflecting different assumptions made on the pm2.5/pm10 ratio and the population‟s exposure to airpollution. what are the potential benefits of reducing particulate matter? if macedonia were to lower pm10 and pm2.5 to eu limit values this would avoid over 800 deaths and thousands of days in lost productivity – representing a health cost savings of €151 million per year (table 3). a reduction of even 1μg/m 3 in ambient pm10 and pm2.5 would result in 195 fewer deaths (1,648 fewer dalys) and imply an economic savings of €34 million per year in reduced health costs. skopje bitola veles tetovo kumanovo kavadarci kocani kicevo rural eu std p m 1 0 c o n c e n tr a ti o n ( u g / m 3 ) 28 meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in therepublic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 10 2.5 10 2.5 10 2.5 table 2. number of annual cases, dalys per year and economic cost in millioneuros, 2011 (source: authors’ calculations) health impact annual cases * total daly per year s annual economic cost (€ million) cardiopulmonary & lung cancer mortality(pm2.5) 1,351 10,809 232.0 alri † mortality(pm10) 1 17 0.1 chronic bronchitis (pm10) 485 1,066 3.0 hospital admissions(pm10) 770 12 0.4 emergency room visits(pm10) 15,200 68 0.9 restricted activity days(pm10) 3,213,000 964 8.6 lower respiratory illness in children(pm10) 22,400 146 1.5 respiratory symptoms(pm10) 10,197,000 765 6.8 total 13,847 253.3 * mid-point estimates using a baseline for pm = 15 µg/m 3 and pm = 7.5 µg/m 3 † alri: acute lower respiratoryinfections. table 3. the potential health ‘savings’ associated with reductions in pm10 and pm2.5 (€ million) [source: authors’ calculations] level of reduction in ambient pm10 and pm2.5(μg/m 3 ) * reduced dalys annual health savings (€ million) 0 0 0.0 1 1,648 34.1 5 4,894 98.9 10 6,636 133.6 15 8,059 161.5 20 9,275 184.9 eu standards met † 7,840 151.5 * example reductions were equally applied to both pm and pm at the same time. † pm = 40 µg/m 3 and pm = 20 µg/m 3 . discussion there is significant evidence of the effects of short-term exposure to pm10 on respiratory health, but for mortality, and especially as a consequence of long-term exposure, pm2.5 is a more robust risk factor than the coarse part of pm10 (particles in the 2.5–10 μm range). all cause daily mortality is estimated to increase by 0.2 0.6% per 10 μg/m 3 of pm10 (9). furthermore, it has been estimated that exposure to pm2.5 reduces life expectancyby about months on average in the european region. results from the study ―improving knowledge and communication for decision-making on air pollution and health in europe‖ (aphekom), which uses traditional health impact assessment methods, indicates that average life expectancy in the most polluted cities could increase by approximately 20 months if long term pm2.5 concentrations were reduced to who annual guidelines (10). monitored pm10 and pm2.5 concentrations have repeatedly exceeded eu standards in republic of macedonia and have contributed to short-term and chronic respiratory disease. this study estimated an annual (mid-point) loss of approximately 1,350 lives with thousands of lost-productive days, indirectly costing the economy up wa rds of €253 million or 3.2% of gdp in 2011. the specific exposure-response functions used in this study were 29 meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in therepublic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 borrowed from the international literature – however the orders of magnitude have been shown to be robust in many developing country applications after adjusting for local conditions(4,5,7,8). from a policy standpoint, it is important to note that these estimated costs are generally ―hidden‖ since they are not normally quantified, and benchmarked to the value of economic activity that generated the pollution (i.e. gdp). likewise the distribution of this burden is shared between the general public and the health care system – so total costs are not transparent. the results should motivate policy makers to be more focused on preventative measures, among them, local green options to reduce particulate matter including energy efficiency, fuel switching and the adoption of cleaner technologies. the benefits from such actions should find their way into the benefit-cost analysis of associated investments since the health ―savings‖ could offset theinvestment costs of greeninginterventions. references 1. institute for health metrics and evaluation. global burden of disease, 2010. http://www.healthdata.org/search-gbd-data?s (accessed: february 2, 2015). 2. kochubovski m, kendrovski v. monitoring of the ambient air quality (pm10) in skopje and evaluation of the health effects in 2010. jepe 2012;13:789-96. 3. world health organization (who). who air quality guidelines, particulate matter, ozone, nitrogen dioxide and sulphur oxide; geneva, switzerland; 2006. 4. ostro b. outdoor air pollution assessing the environmental burden of disease at national and local levels. environmental burden of disease, series no. 5, geneva: who; 2004 (62p). 5. ostro b. estimating the health effects of air pollution: a method with an application to jakarta. policy research working paper no. 1301, washington, d.c.: the world bank; 1994. 6. abbey de, lebowitz md, mills pk, petersen ff, beeson wl, burchette rj. long term ambient concentrations of particulates and oxidants and development of chronic disease in a cohort of nonsmoking california residents. inhal toxicol 1995;7:19-34. 7. larsen b. colombia. cost of environmental damage: a socio-economic and environmental health risk assessment. final report prepared for the ministryof environment, housing and land development of republic of colombia; 2004. 8. world bank. kosovo country environmental analysis: cost assessment of environmental degradation, institutional review, and public environmental expenditure review, washington, dc. the world bank; 2012. http://documents.worldbank.org/curated/en/2013/01/17485553/kosovo-country environmental-analysis-kosovo-country-environmental-analysis-cea (accessed: february 2, 2015). 9. samoli e, peng r, ramsay t, pipikou m, touloumi g, dominici f, et al. acute effects of ambient particulate matter on mortality in europe and north america: results from the aphena study. environ health perspect 2008;116:1480-6. 10. world health organization (who) – regional office for europe. health effects of particulate matter: policy implications for countries in eastern europe, caucasus and central asia. copenhagen, denmark; 2013. © 2015 meisner et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.healthdata.org/search-gbd-data?s http://documents.worldbank.org/curated/en/2013/01/17485553/kosovo-countryhttp://creativecommons.org/licenses/by/3.0) 30 jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 original research health and health status of children in serbia and thedesired millennium development goals aleksandra jovic-vranes 1 , vesna bjegovic-mikanovic 1 1 institute of social medicine, medical faculty, belgrade university,serbia. corresponding author: aleksandra jovic-vranes, belgrade university, serbia; address: dr subotica 15, 1100 belgrade,serbia; telephone: +381112643830; e-mail: aljvranes@yahoo.co.uk mailto:aljvranes@yahoo.co.uk 31 jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 abstract aim: children represent the future, and ensuring their healthy growth and development should be a prime concern of all societies. better health for all children is one of the leading objectives of the national plan of action for children and a key element of the tailored millennium development goals forserbia. methods: our analysis was based on relevant literature and available information from the primary and secondary sources and databases. we analyzed health status of children that can be illustrated by indicators of child and infant mortality, morbidity, and nutritional status. results: there has been a significant reduction in the mortality rates at the national level, particularly with regard to infants and children under five years of age. however, the current mortality rate of roma children is still three times as high as the millennium goal set at the national level for serbia. most deaths of children under the age of five are due to preterm birth complications, congenital anomalies, birth asphyxia and trauma, pneumonia and sepsis. the rate of malnourished children among the poor and in roma settlements is twice as high as in the general population of serbian children. a growing number of obese children was also noted in the roma population. conclusion: political awareness, commitment and leadership are required to ensure that child health receives receive the attention and the resources needed to accelerate the progress of serbia. keywords: children, health status, millennium development goals,serbia. conflicts of interest: none. 32 jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 introduction a comprehensive understanding of the children‘s and women‘s health as a state of complete physical, mental and social wellbeing (1) is essential to the health of current and future generations. almost every culture holds that a society has a responsibility to ensure a nearly equal start in life for children, which implies developing their full health potential (2). however, there are still significant ethnical and regional differences that need to be considered while developing the global health policy framework. the differences in people health are determined by their exposures to health risks, which are, in turn, the social determinants of health (3). the prevention of disease requires overall investment in the social determinants of health and reduction of inequalities and unfairness inhealth. the foundations for adult health and, indeed, the health of future generations are laid in early childhood and even before birth. therefore, better health for all children is one of the leading objectives of the national plan of action for children (4) and a key element of the tailored millennium development goals forserbia. progress in the reduction of child mortality is one of the leading public health challenges in all countries (1). reducing child mortality is also one of the millennium development goals, and the first of the total of 27 goals adopted at the world summit for children. it has also been incorporated into many national plans of action for children. in spite of major improvements, national reports on progress in attaining the millennium development goals, even in countries in which child mortality has been reduced by two thirds on the average, highlight that the problem is still present in rural areas, among people living below the accepted poverty line and – as regards southeastern europe – in particular, among roma subpopulations (1,5). child mortality due to preventable causes is further compounded by poverty, unfavorable living conditions, low educational level of mothers, social exclusion, neglect, violence against children and insufficiently accessible antenatal and postnatal health care (6,7). deaths among children under the age of five years represent one of the most serious challenges currently faced by the international community. to address this challenge, it is necessary to measure accurately the levels and causes of mortality among this population group (8). major causes of under-five mortality remain the same globally; their relative importance varies across regions of the world. while in low-income countries infectious diseases account for a large proportion of under-five deaths, the main killers of children in high-income countries are non-communicable diseases such as congenital anomalies, prematurity, injuries and birth asphyxia (9). monitoring of the nutritional status plays an important role in the analysis of the health of children, particularly when health risks and preventive actions need to be assessed and considered. irregular and insufficient nutrition during infancy and later can significantly impair the growth and development of children and have adverse health effects (physical fitness, mental functions, immune system). at the same time, excessive food intake and an imbalanced diet may also result in obesity and negative health consequences (10). the aim of our study was to analyze children mortality rates in serbia, leading causes of death, differences in mortality rates between the average population of children and roma children and diet and nutritional status of children under the age of fiveyears. 33 jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 methods this situation analysis has been done on the basis of relevant literature and available information from the following primary and secondary sources anddatabases: published documents including strategies, policies, programs, plans, laws and other regulations of the government of the republic of serbia, health regulations and guidelines of the ministry of health, published reviews, scientific and professional articles on health and health status of the serbian population in national and international journals, national surveys and project reports of international organizations (unicef, who, eu, world bank) that deal with issues of children‘s and women‘s health in serbia; publications in the area of routine health statistics, national e-databases (institute of public health of serbia, dr. milan ―jovanović batut‖, statistical office of the republic of serbia and international e-databases (who/eurostat) for comparison purposes. this statistical information often is only available in aggregated sets of data which do not allow for detailed analyses. health outcomes and health status of children are illustrated by the following indicators: infant mortality rate (deaths of children in the first year of life), perinatal mortality rate (fetal deaths from the 22 nd week of gestation or achieved 1000g in intrauterine development and deaths by the seventh day of life), neonatal mortality rate (deaths in the first 27 days of life only), and morality of children under five years of age (deaths before children turn five years); morbidity, nutritional status and comparisons with relevant national and international benchmarks and objectives. a special focus was placed on disparities and social inequalities in health among population groups within serbia, which are considered unfair, unjust, avoidable and unnecessary. the results were presented in tables andgraphs. results in serbia, there has been a significant reduction in the mortality rates at the national level, particularly with regard to infants and children under five (figure 1), while the reduction of the mortality rate in the prenatal period was somewhat morelimited. figure 1. children mortality rates in serbia: situation analysis and the desired millennium goal by 2015 i-infant mortality rate; ii-perinatal mortalityrate; iii-neonatal mortalityrate; iv-children under 5-yearmortalityrate. 14 12.7 12 10.6 11.2 10 8.0 9.3 9.2 8.8 7.7 8 7.1 6.3 6.5 5.8 6 4.5 4.7 5 4 3 2 0 i ii iii iv 2000 2005 2011 mdg 2015. 34 jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 mortality among roma children remains high, the rate has almost halved over the last five years bringing the number closer to the national millennium goal of reducing roma under-five child mortality to 14 and infant mortality to 12. however, the current mortality rate of roma children is still three times as high as the millennium goal set at the national level for serbia (figure2). figure 2. differences in mortality rates between the average population of childrenand roma children in 2005 and 2010 in serbia figure 3 presents the leading causes of death in serbian children under-five years. most deaths of under-five children are due to preterm birth complications, congenital anomalies, birth asphyxia and trauma, pneumonia andsepsis. figure 3. distribution of the leading causes of death of children under-five inserbia 35 roma children rate per 1000 livebirths roma children2 30 29 2015: mdg for roma children 25.9 2005: averagepopulation 25 2010:averagepopulation 20 2015: mdg for serbia 15 14 15 14 12 10 9.2 8 7.9 6.7 4.5 5 5 0 roma settlements infantmortality serbia roma settlements under 5 yearsmortality serbia 45 41 40 36 35 36 32 35 consequences of pre-termbirth 31 30 30 31 congenitalanoma 29 30 28 25 otherdiseases 20 asfixiaduringbirth 15 pneumonia injuries 10 7 6 6 6 6 5 sepsis 5 4 4 5 4 3 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 35 jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 the indicators of diet and nutritional status of children under-five years of age are presented in table 1. the rate of malnourished children among the poor and in roma settlements is twice as high as in the general population of serbian children. surprisingly, a growing number of obese children were also noted in the roma population, from 6.7% to 12.8%, which points to irregular nutrition. the corresponding millennium development goal in serbia aims to bring the share of obese children down to 9.1% by 2015. breastfeeding habits have not substantially changed, except in the roma population where the number of exclusive breastfeeding up to the age of six months has decreased. the rate of exclusive breastfeeding is still only half of the desired millennium development goal in serbia (30% of exclusively breastfed children from birth until the six month ofage). table 1. diet and nutritional status of children under five years of age in 2005 and 2010 in serbia indicator serbia the poor roma settlements mdg 2005 2010 2005 2010 2005 2010 2015 live births with low birthweight 4.9 4.8 8.6 8.3 9.3 10.2 percent of children first breastfed within a day after birth 68.8 61.9 71.7 69.1 72.5 70.3 percent of children with exclusive breastfeeding for the first sixmonth 14.9 13.7 15.4 19.5 18.0 9.1 30.0 percent of children 6-23 months who receive the minimum number ofmeals na 84.3 na 80.0 na 71.9 prevalence of malnourishment among children under-five (body weight for the given height ≤2sd) 3.2 2.3 3.8 5.2 4.1 5.2 prevalence of obesity among children under-five (body weight for the given height ≤2sd) 15.6 12.7 15.5 12.5 6.7 12.8 9.1 discussion this situation analysis covers the health status of serbian children that can be illustrated by indicators of child and infant mortality, morbidity and nutritional status which are compared with relevant national and international benchmarks and objectives. a special focus was placed on disparities and social inequalities in health among population groups within serbia, which are considered unfair, unjust, avoidable and unnecessary since they open a systematic burden on vulnerable population groups. it is believed that the unfair differences in health of children result from social structures and political, economic and legal relations: they are derived from the system, and are result of the social system (so that they can be changed) and they are unjust (11). marmot insists that they are not a natural phenomenon by any means; instead, they are a combination of poor conditions and low standards of living, poverty, risky life-styles, social exclusion, scarcely formulated, inappropriate health programs and sometimes toxic national and local policies(12). infant mortality is generally regarded as a basic indicator of population health and a measure of long-term consequences of perinatal events. this parameter is particularly 36 jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 important for monitoring and assessing health outcomes in high risk groups such as pre-term children and children with developmental difficulties. trends show that serbia has made significant progress towards the millennium development goal relating to infant mortality (13,14). an analysis of routine statistical data, although infant mortality is still above the european union–27 average (for example, in 2010, the eu-27 infant mortality average was 4.1 vs. 6.7 in serbia), suggests that serbia may achieve the proposed national millennium goals in 2015: an infant mortality rate of 4.5 and an under-five mortality rate of 5 per 1000 live births. earlier comparisons of infant mortality revealed rates in serbia two times higher than the eu rates, but this difference has been substantially reduced to date (15,16). recent studies conducted by unicef and other organizations indicate that the majority of the roma population face social disadvantage and exclusion, and most of them live in poverty (17). many roma individuals are also unemployed, have limited education, as well as insufficient access to information, which combined with a lack of trust in institutions often prevent them from using healthcare services in case of need. the multiple indicator cluster surveys (mics), which have been conducted periodically in serbia since 1996 with the help of unicef, have been extremely valuable in gaining a better understanding of the challenges involved. from 2005, these surveys have provided assessments of child mortality in the roma population using the brass method for estimating child mortality taking into account the risk of death to which the children are exposed to (18). although mortality among roma children remains high, the rate has almost halved over the last five years bringing the number closer to the national millennium goal of reducing roma under-five child mortality to 14, and infant mortality to 12. however, the current mortality rate of roma children is still three times as high as the millennium goal set at the national level for serbia (15). according to the world health organization, most deaths of children under the age of five years are due to a small number of diseases and conditions. forty-three per cent of these deaths occur among babies aged 0-28 days (newborns) and are mainly due to preterm birth complications, birth asphyxia and trauma, and sepsis. after the first 28 days until the age of five years, the majority of deaths are attributable to infectious diseases such as pneumonia (22%), diarrhoeal diseases (15%), malaria (12%) and hiv/aids (3%)(8,9). while international efforts to address mortality among children under the age of five have resulted in significant reductions globally, persistent inequities between and within countries exist. these are not only driven by poverty, but are intrinsically linked to social exclusion and discrimination. therefore, continued efforts to eliminate under-five mortality must take into consideration both direct causes and underlying determinants. this requires a comprehensive and holistic approach,which must explicitly recognize human rights‘ standards as essential and integral elements. also, poor nutritional status in children is strongly correlated with vulnerability to diseases, delayed physical and mental development, and an increased risk ofdying. while, between 1990 and 2011, the proportion of children under the age of five years who were underweight declined by 36%, under-nutrition is still estimated to be associated with 45% of child deaths worldwide. in 2011, there were 165 million children under the age of five years who were stunted, and 52 million who were wasted (10,19,20). low birth weight is closely associated with increased risks of neonatal mortality, cognitive problems and chronic diseases in later life (20). our 37 jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 analysis shows that the national average share of live births with low birth weight (under 2,500 grams) has remained constant in serbia in the last decade. the share of low birth weight is significantly higher for roma and poorchildren. more preventive approaches and consistent efforts for improvement are needed in serbia, to ensure that child health receives the attention and resources needed and secure the benefits that children and familiesrequire. identifying the health outcomes that matter most for the children, and set out the contribution that each part of the health system needs to make in order that desired health outcomes are achieved, would be an effective way to reachprogress. reference 1. who constitution. http://www.who.int/governance/eb/who_constitution_en.pdf (accessed: may 16, 2015). 2. barros fc, victora cg, scherpbier r, gwatkin d. socioeconomic inequities in the health and nutrition of children in low/middle income countries. rev saude publica 2010;44:1-16. 3. marmot m, allen j, bell r, bloomer e, goldblatt p; consortium for the european review of social determinants of health and the health divide. who european review of social determinants of health and the health divide. lancet 2012;380:1011-29. doi: 10.1016/s0140-6736(12)61228-84. 4. government of serbia. national plan of action for children in serbia. http://www.arhiva.serbia.gov.rs (accessed: may 16,2015). 5. unicef (un inter-agency group for child mortality estimation). levels and trends in child mortality. report 2012. new york: unicef headquarters, 2012. 6. parekh n, rose t. 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inequities in health: levelling up. copenhagen: who regional office for europe; 2006. 12. marmot m. global action on social determinants of health. bull world health org 2011;89:702. http://www.who.int/governance/eb/who_constitution_en.pdf http://www.arhiva.serbia.gov.rs/ http://www.childinfo.org/files/mics4_serbia_finalreport_eng.pdf http://www.who.int/healthinfo/statistics/indunder5mortality/en/ http://www.ncbi.nlm.nih.gov/pubmed/?term=black%20re%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=23746772 http://www.ncbi.nlm.nih.gov/pubmed/?term=victora%20cg%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=23746772 http://www.ncbi.nlm.nih.gov/pubmed/?term=walker%20sp%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=23746772 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izjzs; 2012. 15. vlada republike srbije. nacionalni milenijumski ciljevi razvoja u republici srbiji. beograd vs; 2006. 16. vlada republike srbije. progres u realizaciji milenijumskih ciljeva razvoja u republici srbiji. beograd: vs i undp; 2009. 17. unicef. serbia. multiple indicator cluster survey 2005. monitoring the situation of children and women. belgrade: unicef belgrade; 2007. 18. unicef. srbija. istraživanje višestrukih pokazatelja 2010. praćenje stanja i položaja dece i žena. beograd: unicef beograd; 2012. 19. united nations children‘s fund/world health organization/world bank. levels and trends in child malnutrition: report 2012; 2012. http://www.who.int/nutgrowthdb/jme_unicef_who_wb.pdf (accessed: may 16, 2015). 20. united nations children‘s fund/world health organization. low birth weight: country, regional, and global estimates. unicef: new york; 2004. © 2015 jovic-vranes et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited. http://www.who.int/nutgrowthdb/jme_unicef_who_wb.pdf http://creativecommons.org/licenses/by/3.0) 39 kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 original research adverse effects of maternal age, weight and smoking during pregnancyin pleven, bulgaria mariela stefanova kamburova 1 , petkana angelova hristova 1 , stelaludmilova georgieva 1 , azhar khan 1 1 department of public health sciences, faculty of public health, medical university, pleven, bulgaria. corresponding author: dr. mariela kamburova, medical university, pleven; address: 1, st. kliment ohridski, str, pleven, 5800, bulgaria telephone: +359887636599; email: mariela_kamburova@yahoo.com mailto:mariela_kamburova@yahoo.com 40 kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 abstract aim: this paper aims to study the relationship between mothers‘ age, body mass index (bmi), gestational weight gain (gwg) and smoking and the risk for premature birth in pleven, bulgaria. methods: a case-control study was conducted in pleven in 2007. the study was comprehensive for all premature children (n=58) and representative for full-term infants (n=192, or 10.4% of all of the 1827 full-term children) born in 2007 at the university hospital of pleven and resident in the city of pleven. retrospective data on determinants under study were collected from all the mothers included in this study(n=250). results: mothers of premature children were more likely to be above 35 years old (27.6%), with a bmi ≥25 kg/m² (23.1%), gwg below the recommended value (38.5%) and to smoke during pregnancy (37.9%). the odds of being a smoker during pregnancy were five times higher among mothers with low birth weight (lbw) newborns compared with their counterparts with normal birth weight newborns (or=5.1, 95%ci=2.4-10.6). there was a positive association between bmi and lbw in infants whose mothers were overweight (or=2.1, 95%ci=1.0-4.0). the risk of lbw increased when gwg was less than recommended (or=1.8, 95%ci=1.0-3.1). conclusion: our results indicate that pre-pregnancy bmi ≥25 kg/m², less than recommended gwg and smoking during pregnancy are risk factors for premature birth in pleven region. findings from this study suggest the need for active health and educational actions by health professionals in order to avoid premature births inbulgaria. keywords: bulgaria, lifestyle, pleven, premature birth, riskfactors. conflicts of interest: none. acknowledgements: the authors are very grateful to the staff of the obstetric clinic at university hospital in pleven, bulgaria, for their continuous support for the whole duration of this study. 41 kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 introduction premature birth (pb) is a major public health problem worldwide (1). furthermore, pb is rated as one of the most important single causes of the global burden of diseases in neonatal period (2). it is associated with increased infant mortality, short and long-term negative effects on health and additional costly care needs(3). the interest of researchers in personal characteristics and lifestyle factors of the mothers is due to the fact that they are modifiable and they affect the incidence of premature birth. the challenge is to accurately measure the impact of these factors because of their complexity (4). several studies have shown young maternal age as a significant risk factor for premature birth (5,6). it has not been established with certainty yet, whether this risk is associated primarily with the biological immaturity of young mothers, or an increased incidence of certain risk factors associated with socioeconomic status such as age-appropriate educational level, parity, smoking status, prenatal care utilization and poverty status (7,8). women over the age of 35 years are also at increased risk of pre-term birth. astolfi and zonta (2002) found a 64% increase in the probability of giving premature birth for women over 35 years after controlling for educational status, birth order, and sex of the newborns(9). low or high pre-pregnancy body mass index (bmi) and inadequate or excess gestational weight gain (gwg) are linked to an increased risk of adverse neonatal outcomes (10,11). the weight of a woman before the pregnancy is related to her diet, quantity and quality of food (4). studies have shown that low weight of women before pregnancy is associated with an increased risk of preterm birth (12). campbell et al. (2012) found a link between low pre pregnancy bmi and the birth of a premature baby, with a relative risk of >2.5 (6). a study conducted in 2010 in bulgaria on the role of some risk factors for preterm birth failed to establish a statistically significant difference in the weight of women bearing preterm children and those with to term births (13). smoking is defined as one of the most common and preventable causes of adverse outcomes of pregnancy (14,15). many chemicals in maternal smoking pass from the pregnant woman to the fetus through the placenta (16). smoking is associated with placental abruption and inadequate weight gain during pregnancy, but this relationship with the birth of a premature baby is not conclusive and is not proven in all studies. the probable reason for this is that the impact of smoking depends on its duration and intensity, and decreases in women who stop smoking at the beginning of pregnancy (17). some studies have found a strong causal association between smoking and pb of a child (18). a large number of studies have found a moderate influence of smoking in relation to pb of a baby(14,16,17). bulgaria is a country that is characterized by one of the highest indicators of age-specific fertility rate (above 40 per 1000) in europe in the age-group 15-20 years, which is a risk factor for giving birth to a premature baby (19). according to manolova (2004), 42.3% of women in bulgaria smoked during pregnancy (20). however, prematurity as a public health issue has not been subject to scientific inquiry in bulgaria in the past two decades. yet, there are a small number of scientific publications in terms of risk factors for pb in bulgarian children (21). in this context, there is a need to determine the lifestyle characteristics of mothers as important factors for pb in bulgaria. this paper aims at studying the relationship between mothers‘ age, bmi, gwg and smoking during pregnancy and the risk for pb in the city of pleven, bulgaria. we hypothesized a positive association between pb and younger or older age and smoking habits of the mothers. furthermore, we assumed a positive link between low bmi and low weight gain during pregnancy andpb. 42 kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 methods study design a case-control study was carried out in 2007 in the city of pleven, bulgaria. pleven is a typical township, located in central north bulgaria. at the beginning of the study (in 2007) the size of the population of the city was 139,573 people. in the same year, the birth rate was 8.96‰. maternal care was carried out only by the university hospital. there were 2004 children born at the university hospital, of whom, 1981 were live births. the proportion of preterm infants among all live births was 7.7%. study population the anticipated sample size for inclusion in this study consisted of 250 newborns. the study was comprehensive for all premature children (n=58) and representative for full-term infants (192, or 10.4% of all 1827 full-term children) born in 2007 at the university hospital of pleven and resident in the city of pleven. cases: 58 premature infants weighing 2500 g or less at birth. their gestational age was 37 weeks or less, and they resided in pleven. controls: 192 term infants who were matched to premature infants by date of birth. they were selected randomly among preterm children born on the same date. they weighed more than 2500 g. their gestational age was more than 37 weeks and they also resided inpleven. data collection document analysis: the information on birth weight, gestational age and home addresses of newborns was derived from medical records in a neonatal clinic at the university hospital pleven. interview: the information for mother‘s age, weight of women before the pregnancy, weight gain during pregnancy and smoking habits was gathered retrospectively by interviewing mothers during home visits. such information was not available in the records of mothers in the obstetrics ward, and not all women retained documents from antenatal visits. special questionnaires were designed for the purpose of the study. they were part of a larger study on risk factors for premature birth in the region of pleven, bulgaria. the questionnaire used for the documents‘ analysis contained 39 questions, four of which were related to demographic and socio-economic status of the mother. the questionnaire for the interview comprised 92 questions, nine of which were about the lifestyle factors of the mother. for the validation of the questionnaires, a pilot study was conducted. before and after the pilot study questionnaires were discussed and approved by experts, pediatricians, obstetricians and public health professionals. all included mothers answered the questionnaire in the process of an interview. all data in this study were based on women‘s reports during the surveyinterviews. ethical considerations the study was conducted under the supervision of the chair of the irb (institutional review board). the right of privacy of the studied subjects was guaranteed. only the leading investigator had access to the identifying information. mothers expressed their free will for participation and signed an informed consent before theinterview. outcomes we studied two outcomes: preterm birth (pb<37 weeks completed gestation and birth weight <2500 g) and low birth weight (lbw: birth weight <2500g). 43 kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 determinants age of the mothers was determined as: ≤24 years, 25-29 years, 30-34 years and ≥35 years. pre-pregnancy bmi was categorized according to the world health organization (who) as either being underweight (bmi<18.5kg/m²), normal weight (18.5≤ bmi≤ 24.9), overweight (25≤bmi≤29.9), or obese(bmi≥30). we utilized the 2009 institute of medicine guidelines on gwg to categorize women‘s weight gain for their bmi as below, within, or above the recommended value(22). smoking during pregnancy was determined based on the question “did you smoke during pregnancy?”. women who responded “yes” or “rarely” were categorized as ―regular smokers‖ and ―occasionalsmokers‖. statistical analysis the survey data was processed with the statistical software packages spss (statistical package for social sciences), version 11.5, statgraphics and excel forwindows. the results were described using tables. percentages were used to report the observed distribution of age of the mothers, bmi, gwg, smoking during pregnancy and other maternal characteristics. parametric tests for hypotheses testing at normal and near to normal distribution of cases: t test, anova with post hoc tests (lsd, tukey, scheffe, bonferroni, newman-keuls, duncan) and nonparametric tests in other than normal distribution of cases pearson χ²-test, mann-whitney, kruskal-wallis h-test were applied. regression models for modeling and predicting of correlations and multiple logistic regression analyses controlled for covariates estimated the odds ratios with 95% confidence intervals of pb and lbw wereused. using multivariable linear regression we assessed the relationships of studied determinants with outcomes (pb, lbw). odds ratios (or) were calculated to determine the effect of the age, weight and smoking during pregnancy, as factors for pretermbirth. in all cases, a value of p≤0.05 was considered as statisticallysignificant. results table 1 presents the distribution of basic characteristics of the participants by pb status. the distribution of maternal characteristics varied across mothers with pb and termbirth. overall, 17.2% of women were above 35 years old. the share of older mothers was two times higher among those with pb compared to women with term-birth. overall, 23.3% of women were underweight and 12.5% were either overweight or obese. the proportion of overweight was more than two times higher among mothers with pb (19.2%) compared to mothers with term-birth (9.6%). around half (48.8%) of women gained above than the recommended weight for their bmi and a quarter (24.6%) gained less than the recommended weight. about 39% of women with pb compared to 21% of mothers with term-birth gained less than the recommended weight. smoking was reported by 38% of women: 16% of them were regular smokers and 22% occasional smokers. the proportion of mothers with pb who smoked (38%) was about four times higher compared to smoking women with term-birth(10%). compared to mothers with term-born infants, mothers of premature children were more likely to be above 35 years (27.6%), have a bmi≥25 (23,1%), have a gwg below the recommended value (38.5%), smoke during pregnancy (37.9%) and deliver pb children after the third delivery (17.2%). significant differences among mothers with pb were identified for maternal age, pre-pregnancy bmi, gwg, maternal smoking during pregnancy and birth order. conversely, there was no significant difference between groups with regard to their income level. 44 kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 table 1. distribution of maternalcharacteristics characteristics all wome (n=250) n mothers with premature birth (n=58) mothers with term p birth (n=192) maternal age ≤24 years 25.8 10.4 30.5 0.001 25-29 years 27.4 37.9 24.2 0.049 30-34 years 29.1 24.1 30.5 ns ≥35 years 17.2 27.6 14.8 0.047 pre-pregnancy bmi <18.5 kg/m 2 23.3 15.4 25.5 ns 18.5-24.9 kg/m 2 64.2 61.5 64.9 ns 25.0-29.9 kg/m 2 11.7 19.2 9.6 ns ≥30 kg/m 2 0.8 3.9 gestational weight gain <recommended 24.6 38.5 20.7 0.010 = recommended 26.7 26.9 26.6 ns > recommended 48.8 34.6 52.7 0.020 smoking during pregnancy regularly 16.1 37.9 9.5 0.001 occasionally 21.8 10.3 25.3 0.002 no 62.1 51.8 65.2 ns per capita income lowest (0-125 euro) 36.0 41.4 34.4 ns middle (126-250 euro) 46.4 41.4 47.9 ns highest (>250 euro) 17.6 17.2 17.7 ns birth order 1 52.4 41.4 55.8 0.050 2-3 41.2 41.4 41.1 ns ≥4 6.4 17.2 3.1 0.005 table 2. maternal characteristics correlated with normal birth-weight and low birth-weight(g) linear regression logistic regression characteristics all (n=250) low birth weight (n=58) normal birth weight (n=192) low birth weight p mean±se p mean±se p mean±se p or (95%ci) maternal age 25-29 3120±85 2297±45 3491±46 reference ≤24 3219±69 ns 2256±47 ns 3318±62 ns 0.22 (0.08-0.58) 0.001 30-34 3168±71 ns 2361±43 ns 3318±53 ns 0.50 (0.23-0.99) 0.048 ≥35 2790±127 0.007 1876±88 0.001 3312±71 0.005 1.19 (0.54-2,65) 0.600 pre-pregnancy bmi 18.5-24.9 3185±59 2149±90 3427±41 reference <18.5 3124±72 ns 2163±72 ns 3284±56 ns 0.64 (0.27-1.48) 0.280 25.0-29.9 2844±101 0.040 2296±45 ns 3148±96 0.001 2.12 (1.02-4.03) 0.049 ≥30 * 2400±0 0.010 2400±0 ns gestational weightgain = recommended 3158±84 2300±44 3347±64 reference <recommended 2955±74 0.020 2307±40 ns 3287±61 ns 1.83 (1.04-3.08) 0.048 > recommended 3191±66 ns 1971±146 0.002 3402±46 ns 0.65 (0.30-1.41) 0.270 smoking duringpregnancy no 3192±60 2065±92 3437±40 reference regularly 2666±72 0.001 2328±29 0.030 3080±86 0.001 5.05 (2.41-10.58) 0.001 occasionally 3162±66 ns 2333±58 ns 3265±58 0.001 0.52 (0.20–1.32) 0.160 * only two children weighing 2400 g were born from mothers with bmi≥30. 45 kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 table 2 shows that maternal age at delivery, gwg and smoking during pregnancy were significantly associated with lbw. mothers who smoked regularly had a significant fivefold increase in lbw risk compared with nonsmoking mothers (or=5.05, 95%ci=2.41-10.58, p=0.001). the association between bmi and lbw was evident among infants whose mothers‘ were overweight (or=2.12, 95%ci=1.02=4.03, p=0.049). we did not assess obesity as a risk factor for lbw, because there were no mothers of children with normal birth weight who had a bmi≥30. the risk of lbw increased when gwg was less than the recommended value (or=1.83, 95%ci=1.04 3.08, p=0.048). age of the mothers upon delivery less than 24 years (or=0.22, 95%ci=0.080.58, p=0.001) and between 30-34 years (or=0.50, 95%ci=0.23-0.99, p=0.048) was found as a protective factor for lbw. table 3 shows the results of fitting a multiple linear regression model to describe the relationship between prematurity and three independent variables: pre-pregnancy bmi, gwg and maternal age. the model explains 93% of the variability inpb. the equation of the fitted model was as follows: pb = 87.6117*bmi + 41.0981*gwg + 9.6293*maternal age table 3. multiple regression analysis: pre-pregnancy bmi, gwg and maternal age correlated with premature birth dependent variable: premature birth parameter estimate standard error t statistic p pre-pregnancy bmi 87.6117 12.4486 7.03787 0.001 gestational weight gain 41.0981 7.13523 5.75988 0.001 maternal age 19.6293 8.4454 2.32426 0.021 analysis of variance source sum of squares df mean square f-ratio p-value model 2.30485e9 3 7.68283e8 0.001 residual 1.70403e8 235 725119.0 total 2.47525e9 238 r-squared = 93.1157 %; r-squared (adjusted for d.f.) = 93.0571 %; standard error of est. = 851.539; mean absolute error = 646.141; durbin-watson statistic =1.04712. discussion this study provides useful evidence about pb and lbw in the region of pleven, bulgaria. our results indicate that pre-pregnancy bmi, gwg related with personal bmi and smoking during pregnancy are important characteristics for pb in thispopulation. the age of the mother is essential for normal pregnancy and delivery with a favorable outcome. from a biological point of view, the best age for childbirth is 20-29 years (8). the average age of women in our study was 26.3±5.8 years which was non-significantly lower than the average age for childbirth established in bulgaria (27.9 years of age) (23) and also lower than that established by yankova and dimitrov (2010) who stated an average age of 28 years at birth (24). the results for more than a twofold increased risk of premature birth to mothers aged under 20 years were reported by branum and schoendorf in 2005 (25). the association between the risk of a preterm labor and mother‘s age is reported to be inverse (21,26), but we did not establish this. we found the age of the mothers at delivery less than 34 years as a protective factor for lbw. 46 kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 we did not find a significant difference between the mean weight of mothers of premature (55 kg) and to term infants (54 kg) before pregnancy. we found a more than two times higher risk for lbw among mothers with pre-pregnancy bmi 25.0-29.9 kg/m², but there was no effect found of pre-pregnancy bmi<18.5 kg/m². the results of our study are compatible with the findings of a recent meta-analysis on the existence of a weak association or lack of association between low bmi before pregnancy and the birth of a premature baby(27). according to our results, the probability of giving birth to a premature baby in women who have had gwg less than recommended is around two times higher compared with mothers with recommended gwg. the insufficient weight gain during pregnancy increases the risk of having a premature baby, especially amongst women with low bmi before pregnancy: rr=1.5-2.5 (27). our results are similar to those of schieve la et al. (2000), who found out a three times higher risk of giving birth to a premature baby in women with a normal bmi, but not enough weight gain during pregnancy compared with women of normal weight and with adequate weight gain during pregnancy(28). our results concerning smoking during pregnancy (around 40% of all mothers) are close to a previous study from bulgaria conducted by manolova (2004), which reported that about 42% of all women smoked during the whole pregnancy (20). yet, the proportion of smoking mothers in our study was higher than a previous study conducted in bulgaria in 2007, which reported a prevalence of 33% (23). smoking is regarded as one of the most common and preventable causes of poor pregnancy outcomes (17). there is variability in the reported results for the relationship between smoking and pb, but a large number of studies establish an rr=1.2-1.5 when daily consumption of cigarettes is 10-20, and an rr=1.5-2.0 when more than 20 cigarettes are smoked per day. the same results were obtained by andriani and kuo for smoking mothers who lived in urban areas (17). our survey revealed a greater than fivefold increase in the risk of lbw among mothers who smoked during pregnancy, a finding which is in line with previous reports about the influence of smoking on the pb risk(14,17). study limitations this study may have several limitations. firstly, reports of the characteristics of mothers were retrospective after the child was born. additionally, self-reported data on bmi, gwg and smoking are highly correlated with pb and lbw, but they tend to underestimate these measures. women who smoked were categorized into three groups based on qualitative variables, and not according to the number of cigarettes smoked per day. the dissemination of information on adverse outcomes of smoking may have discouraged some mothers from disclosing it. secondly, because the place of study was an urban area we did not find enough mothers less than 19 years old. the result was that we did not establish the association between young maternal age and pb. thirdly, we utilized the institute of medicine guidelines to categorize women‘s weight gain as below, within, or above recommended value (22), which maybe is not appropriate for bulgaria, but there are no other recommendations to be used. finally, we excluded from the analysis some women with either missing information on the principal determinants of interest (age, bmi, gwg, smoking), or missing information on gestational age and birth weight (needed for outcome variables), but the number of missing values was small. 47 kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 obviously, there is a need for prospective studies from the registration of the pregnancy, in pleven and in other regions of bulgaria, in which such data should be collected in a standardized manner and the number of mothers and their children should be higher. conclusion our results confirm our research hypothesis that pre-pregnancy bmi>25 kg/m², less than recommended gwg related with their personal bmi and smoking during pregnancy arerisk factors for pb. age of the mothers at delivery <34 years was a protective factor for lbw. this analysis was part of a study on the risk factors for pb and their impact on development and health status of children <3 years in bulgaria. our findings highlight the public health importance of promoting a healthy lifestyle of mothers in order to reduce the level of pb in bulgaria. references 1. blencove h, cousens s, oestergaard m, chou d, moller ab, narwal r, et al. national, regional and worldwide estimates of preterm birth in the year 2010 with time trends for selected countries since 1990: a systematic analysis and implications. lancet 2012;379:2162-72. 2. wang h, liddell ca, coates mm, mooney md, levitz ce, 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under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited. http://www.ncbi.nlm.nih.gov/pubmed/?term=sijtsma%20a%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24510962 http://www.ncbi.nlm.nih.gov/pubmed/?term=sauer%20pj%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24510962 http://www.ncbi.nlm.nih.gov/pubmed/?term=land%20ja%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24510962 http://www.nsi.bg/ http://www.ncbi.nlm.nih.gov/pubmed/?term=laopaiboon%20m%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24641534 http://www.ncbi.nlm.nih.gov/pubmed/?term=lumbiganon%20p%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24641534 http://www.ncbi.nlm.nih.gov/pubmed/?term=zhang%20j%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24641534 http://creativecommons.org/licenses/by/3.0) 49 kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 original research lifestyle correlates of low bone mineral density in albanianwomen artur kollcaku 1 , julia kollcaku², valbona duraj 1 , teuta backa 1 , argjendtafaj 1 1 rheumatology service, university hospital center ―mother teresa‖, tirana, albania; ² ambulatory health service, polyclinic, tirana, albania. corresponding author: dr. artur kollcaku address: rr. ―dibres‖, no. 371, tirana, albania; telephone: +355674039706; e-mail: artur_kollcaku@yahoo.com mailto:artur_kollcaku@yahoo.com 50 kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 abstract aim: the aim of this study was to assess the association of lifestyle/behavioral factors with low bone mineral density in albanian women, a transitional country in the western balkans. methods: a cross-sectional study was conducted in tirana city in 2010 including a population-based sample of 549 women aged 35 years and above (response rate: 92%). low bone mineral density (osteopenia and/or osteoporosis defined as a bone mineral density t score less than -1) was assessed with a bone ultrasound device which is simple and easy to use for screening of bone mineral density in population-based studies. binary logistic regression was used to determine the relationship of low bone mineral density with behavioral factors in this studypopulation. results: the prevalence of low bone mineral density in this study population was 28.4% (156/549). in multivariable-adjusted logistic regression models, low bone mineral density was positively associated with smoking (or=4.1, 95%ci=2.2-7.4) and coffee consumption (or=2.3, 95%ci=1.3-4.1), but inversely related to overweight and obesity (or=0.4, 95%ci=0.2-0.7 and or=0.3, 95%ci=0.2-0.6, respectively). conclusion: this study offers useful evidence about the lifestyle/behavioral determinants of low bone mineral density among women in this transitional south eastern european population. health professionals and policymakers in albania should be aware of the major behavioral factors which increase the risk of low bone mineral density in order to provide correct treatment and control of this condition in the generalpopulation. keywords: albania, bone mineral density, bone ultrasound, bone ultrasound device, osteopenia, osteoporosis, tirana. conflicts of interest: none. 51 kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 introduction low bone mineral density, especially osteoporosis, is characterized by excessive skeletal fragility and susceptibility to trauma fracture (1), particularly among older individuals (2,3). conventionally, low bone mineral density includes osteopenia and osteoporosis. osteopenia is deemed as en initial step of osteoporosis notwithstanding the fact that not every person with osteopenia may inevitably experience osteoporosis (4-6). as a rule of thumb, osteopenia is defined as a bone mineral density t-score lower than -1.0 and greater than -2.5 (7). on the other hand, osteoporosis is defined as a bone mineral density t-score of -2.5 or lower (7). it is important to note that osteopenia is an indication of normal aging, as opposed to osteoporosis which is evident in pathologic aging(1,5). the prevalence of low mineral bone density, especially osteoporosis, increases with age (2,3,8). furthermore, the prevalence of osteoporosis is higher in women, especially after menopause (1,8,9). in addition, unhealthy behavioral patterns consisting of smoking, excessive alcohol consumption and physical inactivity increase the risk of low bone mineral density and/or exacerbate the conditions of osteopenia and osteoporosis (5,10,11). on the other hand, body weight has been shown to exert a beneficial effect on increasing bone mass which, in turn, reduces the risk of osteoporosis (1). furthermore, fat mass has been described as a protective factor against osteoporosis in several studies conducted worldwide (12-14). however, the findings related to excessive fat mass are not consistent and several other studies have reported that it may not protect against decreases in bone mass(15-17). the assessment of bone mineral density is typically done with dual x-ray absorptiometry (dexa) procedure (18). at the same time, assessment of bone mineral density can be also performed with portable scanners using ultrasound, and portable machines can measure density in the heel (19,20). as a matter of fact, quantitative ultrasound is currently used worldwide due to its low cost, simplicity of performance, mobility and due to the lack of ionizing radiation (19). after the fall of the communist regime in 1990, albania, a transitional country in the western balkans, has been characterized by a particularly difficult political and socioeconomic situation associated with periodic civil unrests and high rates of unemployment(21). according to a recent report, the burden of musculoskeletal disorders has increased in albania in the past two decades (22). the overall share of musculoskeletal disorders accounted for 8.5% of the total burden of disease in 1990, whereas in 2010 it amounted to 11.0% (22,23). there is evidence of a stronger increase in females than in males. in both sexes, there was a similar moderate yet steady increase from 1990-2005 (22,23). subsequently, there was a steeper increase in females, but a smaller increase in males, which additionally accentuated the excess burden of disease explained by the musculoskeletal disorders in females compared to males (22). the burden of musculoskeletal disorders in albania was similar to most of the countries in south eastern european (see) region in both 1990 and 2010 (22,23). in 2010, the share of musculoskeletal disorders was 11.0% of the total burden of disease in several see countries including albania. essentially, musculoskeletal disorders are said to have increased in albania probably due to a higher accessibility to the health care services in addition to the ageing pattern of the albanian population (22). to date though, data on the prevalence and determinants of osteopenia and osteoporosis in the albanian population is scarce. in this framework, the aim of our study was to assess the lifestyle/behavioral correlates of low bone mineral density (osteopenia and/or osteoporosis) in tirana city, the capital of albania, a transitional country in the western balkans http://en.wikipedia.org/wiki/osteoporosis http://en.wikipedia.org/wiki/bone_mineral_density#t-score http://en.wikipedia.org/wiki/aging http://en.wikipedia.org/wiki/osteoporosis http://en.wikipedia.org/wiki/dual_energy_x-ray_absorptiometry 52 kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 characterized by an intensive process of urbanization and internal migration of the population in the past twenty five years. methods a cross-sectional study was conducted in 2010 including a population-based sample of women aged 35 years and above residing in tirana city, the capital of albania. regarding the sample size, a minimum of 540 women was estimated as the minimal number required for inclusion in this study. in order to account for potential non-response, we decided to invite 600 women to participate in our study. the inclusion criteria consisted of women aged 35 years and above residing in tirana city. of 600 eligible individuals invited to take part in this study, 549 women agreed to participate (mean age: 55.6±9.1 years; response rate: 92%). the bone mineral density among study participants was assessed with a bone ultrasound device which is simple and easy to use for screening of bone mineral density in population based studies (19,20). from this point of view, ultrasound is considered as a quick, cheap and non-radiating device for assessing bone quality (19,20). low bone mineral density was defined as a bone mineral density t-score less than -1 that is osteopenia and/or osteoporosis. the physical examination included also measurement of height and weight for all study participants based on which body mass index (bmi) was calculated (kg/m 2 ) and categorized in the analysis into normal weight (bmi≤25 kg/m 2 ), overweight (bmi: 25.1-29.9 kg/m 2 ) and obesity (bmi≥30 kg/m 2 ). the other lifestyle/behavioral factors were assessed through an interviewer-administered structured questionnaire including information on smoking habits (dichotomized in the analysis into: yes vs. no), alcohol intake (yes vs. no), coffee consumption (yes vs. no) and tea consumption (yes vs. no). demographic and socioeconomic data (age, marital status, educational level and employment status of study participants) were also collected for all women included in thisstudy. binary logistic regression was used to assess the association of low bone mineral density (outcome variable) with lifestyle/behavioral factors (independent variables). initially, crude (unadjusted) odds ratios (ors) and their respective 95% confidence intervals (95%cis) were calculated. next, all the lifestyle factors (smoking, alcohol intake, coffee and tea consumption and bmi) together with demographic and socioeconomic characteristics (age, marital status, educational level and employment status) were entered simultaneously into the logistic regression models. multivariable-adjusted ors and their respective 95%cis were calculated. in all cases, a p-value of ≤0.05 was considered as statistically significant. statistical package for social sciences (spss, version 15.0) was used for all the statisticalanalyses. results the prevalence of low bone mineral density (osteopenia and/or osteoporosis) in this study population was 156/549=28.4% (table 1). the prevalence of smoking was significantly higher in women with low bone mineral density compared with those with normal bone mineral density (25.6% vs. 8.7%, respectively; p<0.001). there were no differences regarding the prevalence of alcoholintake. the prevalence of both coffee consumption and tea consumption was significantly higher in women with low bone mineral density than in those with normal bone mineral density (83.3% vs. 68.2%, p<0.001 and 53.8% vs. 41.2%, p=0.005, respectively). 53 kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 on the other hand, the prevalence of both overweight and obesity was significantly lower in women with low bone mineral density compared with women with normal bone mineral density (30.8% vs. 40.2% and 23.7% vs. 32.2%, respectively; overall p<0.001) (table1). table 1. distribution of lifestyle/behavioral factors in a sample of albanian womenby bone mineral density status variable total normal bone mineral low bone mineral † (n=549) density (n=393) density (n=156) smoking: no 475 (86.5) * 359 (91.3) 116 (74.4) <0.001 yes 74 (13.5) 34 (8.7) 40 (25.6) alcohol intake: no 514 (93.8) 369 (93.9) 145 (93.5) 0.508 yes 34 (6.2) 24 (6.1) 10 (6.5) coffee consumption: no 151 (27.5) 125 (31.8) 26 (16.7) <0.001 yes 398 (72.5) 268 (68.2) 130 (83.3) tea consumption: no 303 (55.2) 231 (58.8) 72 (46.2) 0.005 yes 246 (44.8) 162 (41.2) 84 (53.8) bmi: normal weight 179 (32.7) 108 (27.6) 71 (45.5) overweight 205 (37.5) 157 (40.2) 48 (30.8) obesity 163 (29.8) 126 (32.2) 37 (23.7) * absolute numbers and their respective column percentages (in parentheses). † p-values from fisher‘s exact test. table 2 presents the association of low bone mineral density with lifestyle factors of the women included in this study. in crude (unadjusted) logistic regression models, there was evidence of a strong and statistically significant association of low bone mineral density with smoking (or=3.6, 95%ci=2.2-6.0), but not alcohol intake (or=1.1, 95%ci=0.5-2.3). on the other hand, there was a strong association of low bone mineral density with coffee consumption (or=2.3, 95%ci=1.5-3.7) and tea consumption (or=1.7, 95%ci=1.2-2.4). on the contrary, the odds of overweight and obesity were lower among women with a low bone mineral density compared with their counterparts with normal bone mineral density (or=0.5, 95%ci=0.3-0.7 and or=0.4, 95%ci=0.3-0.7, respectively). in multivariable-adjusted logistic regression models, low bone mineral density was positively associated with smoking (or=4.1, 95%ci=2.2-7.4), coffee consumption (or=2.3, 95%ci=1.3-4.1) and (non-significantly) with tea consumption (or=1.4, 95%ci=0.9-2.2), but inversely related to overweight and obesity (or=0.4, 95%ci=0.2-0.7 and or=0.3, 95%ci=0.2-0.6, respectively) (table 2). 54 kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 table 2. association of low bone mineral density with lifestyle/behavioral factorsamong women in tirana, albania variable crude (unadjusted models) multivariable-adjustedmodels or (95%ci) * p * or (95%ci) * p * smoking: no 1.00 (reference) <0.001 1.00 (reference) <0.001 yes 3.64 (2.20-6.02) 4.07 (2.23-7.40) alcohol intake: no 1.00 (reference) 0.880 1.00 (reference) 0.478 yes 1.06 (0.49-2.27) 0.73 (0.30-1.75) coffee consumption: no 1.00 (reference) <0.001 1.00 (reference) 0.003 yes 2.33 (1.46-3.74) 2.33 (1.34-4.07) tea consumption: no 1.00 (reference) 0.008 1.00 (reference) 0.134 yes 1.66 (1.15-2.42) 1.40 (0.90-2.16) bmi: <0.001 (2) † <0.001 (2) † normal weight 1.00 (reference) 1.00 (reference) overweight 0.47 (0.30-0.72) 0.001 0.39 (0.23-0.65) <0.001 obesity 0.45 (0.28-0.72) 0.001 0.32 (0.18-0.55) <0.001 * odds ratios (or: low bone mineral density vs. normal bone mineral density), 95% confidence intervals (95%cis) and p-values from binary logistic regression. besides the variables presented in the table, multivariable-adjusted models were additionally controlled for age, marital status, employment status and educationallevel. † overall p-value and degrees of freedom (inparentheses). discussion this study including a representative sample of women residing in tirana – the capital city of transitional albania which was the most isolated country in europe during the communist regime – offers useful evidence about selected lifestyle/behavioral predictors of low bone mineral density (osteopenia and osteoporosis) in the adult female population. smoking and coffee consumption were positively associated, whereas overweight and obesity were inversely related to osteopenia and osteoporosis in this sample of albanian women, after controlling for other lifestyle factors and several demographic and socioeconomic characteristics. our findings related to a positive association between low bone mineral density with smoking and coffee consumption are in line with previous reports from the international literature (5). in our study, the association of osteopenia and osteoporosis with coffee consumption was strong and remained unaffected upon simultaneous adjustment for a wide array of covariates including alcohol intake and tea consumption. furthermore, the positive relationship with smoking was even stronger after multivariable adjustment for other behavioral characteristics. in our study, overweight and obesity were strong correlates of osteopenia and osteoporosis. the negative association of overweight and obesity with low bone mineral density was accentuated in multivariable-adjusted logistic regression models. our findings regarding body mass are compatible with several reports from the international literature (1,24). from this point of view, higher body weight or higher bmi is known to be a protective factor against bone loss in both men and women worldwide (1,24-26). nevertheless, overweight and 55 kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 obesity are related to a gain in fat mass as well as an increase in lean mass. therefore, identification of the specific roles that fat mass itself plays in bone mass regulation is important to establish the clinical implications of osteoporosis (24). several studies have indicated that both fat mass and lean mass can lead to an increase in bone mass which, in turn, reduces the risk of osteoporosis (13,24). on the other hand, according to some other studies, fat mass has a negative effect on bone mass after controlling for body weight (1,27). importantly, regarding total fat mass, subcutaneous fat has been reported to be beneficial for bone mass, whereas visceral fat has negative effects(24,28). this study may have some limitations. notwithstanding the representativeness of the sample of women included in this study, the possibility of selection bias, at least to some extent, may be an issue which cannot be completely excluded. in any case, tirana women are not assumed to represent the overall albanian women and, hence, findings from this study cannot be generalized to the overall female population in albania. in our survey, we employed a standardized and internationally valid instrument for assessment of low bone mineral density in population-based studies. furthermore, findings from the quantitative ultrasound measurements of bone mineral density correlate well with the dual energy x-ray absorptiometry (dxa) (19), which is one of the most widely validated tools for measurement of bmd in clinical practice (18). on the other hand, the lifestyle/behavioral data collected through the interview may have been subject to information bias. this may be the case of smoking, alcohol intake, as well as coffee and tea consumption. seemingly though, there is no plausible explanation of a differential reporting of lifestyle factors between women distinguished by the presence of osteopenia and/or osteoporosis in our study. conversely, measurement of height and weight provides little grounds for biased estimates of overweight and obesity in our study sample. in conclusion, our study provides important evidence about the lifestyle/behavioral determinants of low bone mineral density in tirana, the capital city of albania. smoking and coffee consumption were significant predictors of low bone mineral density (osteopenia and osteoporosis) in this study sample of tirana women. future studies in albania should assess the magnitude and distribution of osteopenia and osteoporosis in population-based samples of the general population. references 1. zhao lj, jiang h, papasian cj, maulik d, drees b, hamilton j, deng hw. correlation of obesity and osteoporosis: effect of fat mass on the determination of osteoporosis. j bone miner res 2008;23:17-29. 2. melton lj iii. adverse outcomes of osteoporotic fractures in the general population. j bone miner res 2003;18:1139-41. 3. melton lj iii. the prevalence of osteoporosis: gender and racial comparison. calcif tissue int 2001;69:179-81. 4. world health organization. who scientific group on the assessment of osteoporosis at primary health care level. summary meeting report; 2004. 5. leslie wd, morin sn. osteoporosis epidemiology 2013: implications for diagnosis, risk assessment, and treatment. curr opin rheumatol 2014;26:440-6. 6. consensus development conference. diagnosis, prophylaxis, and treatment of osteoporosis. am j med 1993;94:646-50. 7. international osteoporosis federation. available at: http://www.iofbonehealth.org/ (accessed: april 15, 2015). http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=zhao%20lj%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=17784844 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=jiang%20h%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=17784844 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=papasian%20cj%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=17784844 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10.12908/seejph-2014-46 8. el-heis ma, al-kamil ea, kheirallah ka, al-shatnawi tn, gharaibia m, al mnayyis a. factors associated with osteoporosis among a sample of jordanian women referred for investigation for osteoporosis. east mediterr health j 2013;19:459-64. 9. spencer h, kramer l. nih consensus conference: osteoporosis. factors contributing to osteoporosis. j nutr 1986;116:316-9. 10. duncan cs, blimkie cj, cowell ct, burke st, briody jn, howman-giles r. bone mineral density in adolescent female athletes: relationship to exercise type and muscle strength. med sci sports exerc 2002;34:286-94. 11. kohrt wm, bloomfield sa, little kd, nelson me, yingling vr. american college of sports medicine position stand: physical activity and bone health. med sci sports exerc 2004;36:1985-96. 12. reid ir, ames r, evans mc, sharpe s, gamble g, france jt, lim tm, cundy tf. determinants of total body and regional bone mineral density in normal postmenopausal women—a key role for fat mass. j clin endocrinol metab 1992;75:45-51. 13. khosla s, atkinson ej, riggs bl, melton lj iii. relationship between body composition and bone mass in women. j bone miner res 1996;11:857-63. 14. douchi t, yamamoto s, oki t, maruta k, kuwahata r, nagata y. relationship between body fat distribution and bone mineral density in premenopausal japanese women. obstet gynecol 2000;95:722-5. 15. de laet c, kanis ja, oden a, johanson h, johnell o, delmas p, eisman ja, kroger h, fujiwara s, garnero p, mccloskey ev, mellstrom d, melton lj iii, meunier pj, pols ha, reeve j, silman a, tenenhouse a. body mass index as a predictor of fracture risk: a meta-analysis. osteoporos int2005;16:1330-8. 16. hsu yh, venners sa, terwedow ha, feng y, niu t, li z, laird n, brain jd, cummings sr, bouxsein ml, rosen cj, xu x. relation of body composition, fat mass, and serum lipids to osteoporotic fractures and bone mineral density in chinese men and women. am j clin nutr 2006;83:146-54. 17. janicka a, wren ta, sanchez mm, dorey f, kim ps, mittelman sd, gilsanz v. fat mass is not beneficial to bone in adolescents and young adults. j clin endocrinol metab 2007;92:143-7. 18. cummings sr, bates d, black dm. clinical use of bone densitometry: scientific review. jama 2002;288:1889-97. 19. trimpou p, bosaeus i, bengtsson ba, landin-wilhelmsen k. high correlation between quantitative ultrasound and dxa during 7 years of follow-up. eur j radiol 2010;73:360-4. 20. saadi hf, reed rl, carter ao, qazaq hs, al-suhaili ar. bone density estimates and risk factors for osteoporosis in young women. east mediterr health j 2001;7:730 7. 21. burazeri g, kark jd. hostility and acute coronary syndrome in a transitional post communist muslim country: a population-based study in tirana, albania. eur j public health 2011;21:469-76. 22. albanian institute of public health. national health report: health status of the albanian population. tirana, albania, 2014. http://www.ishp.gov.al/wp content/uploads/2015/01/health-report-english-version.pdf (accessed: april 15, 2015). http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=el-heis%20ma%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24617125 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=al-kamil%20ea%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24617125 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=kheirallah%20ka%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24617125 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=al-shatnawi%20tn%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24617125 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=gharaibia%20m%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24617125 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http://www.ncbi.nlm.nih.gov/pubmed?term=black%20dm%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=12377088 http://www.ncbi.nlm.nih.gov/pubmed/12377088 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=trimpou%20p%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=19135327 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=bosaeus%20i%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=19135327 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=bengtsson%20ba%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=19135327 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=landin-wilhelmsen%20k%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=19135327 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/19135327 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=saadi%20hf%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=15332772 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=reed%20rl%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=15332772 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=carter%20ao%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=15332772 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=qazaq%20hs%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=15332772 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=al-suhaili%20ar%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=15332772 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/15332772 http://www.ishp.gov.al/wp57 kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 23. institute for health metrics and evaluation (ihme). global burden of disease database. seattle, wa: ihme, university of washington, 2014. http://www.healthdata.org (accessed: april 15, 2015). 24. kim jh, choi hj, kim mj, shin cs, cho nh. fat mass is negatively associated with bone mineral content in koreans. osteoporos int 2012;23:2009-16. 25. ravn p, cizza g, bjarnason nh, thompson d, daley m, wasnich rd, et al. low body mass index is an important risk factor for low bone mass and increased bone loss in early postmenopausal women. early postmenopausal intervention cohort (epic) study group. j bone miner res 1999;14:1622-7. 26. reid ir. relationships among body mass, its components, and bone. bone 2002;31:547-55. 27. zhao lj, liu yj, liu py, hamilton j, recker rr, deng hw. relationship of obesity with osteoporosis. j clin endocrinol metab 2007;92:1640-6. 28. gilsanz v, chalfant j, mo ao, lee dc, dorey fj, mittelman sd. reciprocal relations of subcutaneous and visceral fat to bone structure and strength. j clin endocrinol metab 2009;94:3387-93. © 2015 kollcaku et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.healthdata.org/ http://creativecommons.org/licenses/by/3.0) 58 vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi10.12908/seejph-2014-48 original research public expenditure and drug policies in bulgaria in2014 toni yonkov vekov 1 , silviya aleksandrova-yankulovska 1 1 department of medical ethics, management of health care and informationtechnology, faculty of public health, medical university –pleven. corresponding author: prof. toni yonkov vekov, medical university,pleven; address: 1 sv kliment ohridski st., 5800 pleven,bulgaria; telephone: +35929625454; e-mail: t.vekov.mu.pleven@abv.bg mailto:t.vekov.mu.pleven@abv.bg 59 vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi10.12908/seejph-2014-48 abstract aim: the objective of this study was to provide an analysis of the factors which have a significant impact on the growth of public expenditure on medical products inbulgaria. methods: this research work consists of a critical analysis of the data reported by the national health insurance fund in bulgaria on the stability of the healthcare insurance model and the implementation of the budget for 2014. results: the results from the current analysis indicate that the growth of public expenditure is directly proportional to the number of reimbursed medical products and that the pattern of prescriptions including the innovative medical products mainly for the treatment of oncological and rare diseases has a significant impact onit. conclusion: the reasons for the increase of public expenditure in bulgaria include the non transparent decisions in pricing and reimbursement of the products, the lack of guidelines for presenting pharmacological evidence and the lack of legislatively-defined drug policies for the management and control of the patterns of medicalprescriptions. key words: bulgaria, drug policies, reimbursement, publicexpenditure. conflicts of interest: none. 60 vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi10.12908/seejph-2014-48 introduction healthcare in the european union (eu) countries including bulgaria is funded by the healthcare systems and/or through general taxation. the main objective of the healthcare systems is the protection of public health, based on the principles of solidarity and universal access. the drug policy in every country is part of the healthcare policy and adopts the same objectives and principles (1). the expenses on medical products are an important component of the healthcare budgets of all the eu member states. there is an increasing necessity to limit the escalating expenses on healthcare including those on medical products, as well as the effective spending of the financial resources (2). the good european practice on drug policy implies the determining of positive drug lists (pdl) provided by the healthcare system, and the regulation of the drug prices in a certain order. the main focus of the approaches to drug policies includes the rational use of medical products, which contributes to the control of public expenditure (3). considering the fiscal impact of the economical and financial crisis, as well as the expected healthcare expenses for the aging population, these policies are of an increasing interest to the institutions which pay for the public expenses in healthcare (4). the contemporary views of the european healthcare policies are that through the correct regulation of the pharmaceutical markets economies can be achieved, without having an impact on the provision of care (5). the drug policy in bulgaria is legally established by the ministry of health and practically applied by the national council on prices and reimbursement of medical products (ncprmp). this is the authority which regulates the prices and makes decisions regarding the reimbursement of the medical products with public funds. the control on prices is based on external and internal reference pricing and regressive margins for distributors and pharmacies. the reimbursing decisions are formally based on pharmaco-economic valuations, but the experts‘ reports are not available to the public and the objectivity of these decisions cannot be established. in this context, the aim of this study was to analyze the public fund expenses on medical products in bulgaria in 2014 in order to determine the impact of the legislative approaches to drug policies and their possible impact on public health. methods this article is a critical analysis of data from the report of the national health insurance fund (nhif) in bulgaria on the stability of the healthcare insurance model and the implementation of the budget for 2014 (6). a commentary is provided concerning the existing prescribing patterns, national policies for the inclusion of medical products in pdl and their impact on the increasing public expenses. a detailed analysis of the expenses by disease groups and the pattern for the prescription of medicines is also provided. all graphs and tables included in this article are created on the basis of the data derived from the report of the nhif in bulgaria on the stability of the healthcare insurance model and the implementation of the budget for the year 2014 (6). the difference of costs and amount of reimbursed products in the pdl for the period under investigation is presented as a percentage and is calculated with a mathematical method based on the determination of proportionalitycoefficients. when trying to predict the future value, one follows the following basicidea: future value = present value + change from this idea, we obtain a differential, or a difference equation by notingthat: 61 vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi10.12908/seejph-2014-48 change = future value – present value the growth of public expenses is influenced by a number of factors discussed in the report of the nhif in bulgaria on the stability of the healthcare insurance model and the implementation of the budget for 2014 (6). all prices are given in bgn with current exchange rates of: 1.95583 bgn = 1 eur. results the review of the development of the pdl in bulgaria in the past three years (2011-2014) from the viewpoint of quantitative indicators shows a big volume (1997 medical products) and a list with frequent changes (every 15 days). in 2011, the pdl included 1382 medical products, in 2012 it included 1673 products, and in 2014 there were 1997 products. during this three-year period, the number of reimbursed medical products increased by 45%. the proportion of public expenditure and the number of reimbursed medical products is presented in figure 1. the established relationship is directly proportional, whereas the cost of public expenses increased by 25%. figure 1. reimbursed medicines for home treatment and the cost of public expenses (bothin bgn) in bulgaria; data for 2014 consists of estimates (source: nhif report for june2014) the other factor which has a marked impact on public expenditure is the pattern of prescription of the medical products. the presented results (figure 2) of the average cost of public expenditure for the treatment of non-insulin diabetes in 2013 are indicative – the cost of the expense differs doubly in the various regions, considering that the list of the medical products, their prices and the reimbursed amounts are the same for all the regions of bulgaria. the different cost of public expenses in the various regions of bulgaria directly depends on the level of prescribing of dpp-4 inhibitors and glp-1 receptor antagonists. these are the two groups of innovative medical products for the oral therapy of diabetes, which are rather recommended as a second and a third line of treatment, due to unclear data for the long-term cost effectiveness and doubts about the safety profile(7). cost 600 quantity 2000 550 500 1500 450 400 1000 2011 2012 2013 2014 n u m b e r n u m b e r 62 vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi10.12908/seejph-2014-48 figure 2. average cost per patient (in bgn) for the treatment of non-insulin dependentdiabetes in bulgaria in 2013 (source: nhif report for june2014) the analysis of public expenses by groups of diseases outlines the clear tendencies for an abrupt increase in the expenses for the treatment of rare diseases and oncologicaldiseases. the expenses for the treatment of rare diseases increased by 36% in 2013 compared to 2012 and reached 59 million bgn, which constitutes 10.7% of all public expenses for medical products (table 1). this points to a pronounced imbalance of solidarity in the insurance system, because these public costs are absorbed by only 0.15% of the insured individuals. at the same time, public expenses for socially significant diseases such as the cardiovascular disease, diseases of the neural system and diseases of other systems are decreasing (6). these results are an expression of the flaws in the drug policy, part of which are the application of internal reference pricing without a system for the control of medical prescriptions (8), the lack of transparency in the decisions on pricing and reimbursement, based on an expert evaluation of pharmaco-economical evidence, the lack of a defined limit of public expenses for one gained quality-adjusted life year (qaly), and the like(9). table 1. expenses for the treatment of rare diseases in2013 (source: nhif report for june 2014) disease public expense average annual cost number of per patient in bgn patients haemophilus 20 009 544 5290 3783 beta-thalassemia 8 323 230 3692 2254 gaucher disease 8 196 183 32 795 250 blonhopulmonal dysplasia 4 245 087 2828 1501 mukopolizaharoidosis 3 294 574 68 637 48 hereditary amyloidosis with neuropathy 1 625 885 27 098 60 pompe disease 477 953 47 795 10 700 600 500 400 300 200 100 0 rousse gabrovo sliven bourgas smolyan average cost vratsa shoumen silistra haskovo pernik n u m b e r 63 vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi10.12908/seejph-2014-48 the analysis of the expenses on the medical therapy for oncological diseases, paid outside the cost of clinical pathways emphasizes several mainfacts:  the expanding of the indications for innovative medicines, mainly for monoclonal antibodies and tyrosine kinase inhibitors. however, there is no data on the evaluation of the efficacy, benefits and costs of the newindications.  the addition of monoclonal antibodies to the target therapies, which increases the cost of the therapy more than 30 times, while the benefits, expressed as final health outcomes, are minimal. the willingness of society to pay such a high price for the gain of a qaly remainsuncertain.  the inclusion of new international non-proprietary names in the pdl without a clear evaluation of their differential cost-effectiveness as compared to the existing therapies. as a result of all these factors, the public expenditure on oncological medical products significantlyexceeded the settled budgets for the past years, as indicated in table 2. table 2. expenses of the medical therapy for oncological diseases, paid outside the costs of clinical pathways (source: report on the implementation of the budget of nhif,2013-2014) year ye ar 2013 2014 budget in bgn 90 000 000 145 000 000 public expenditure in bgn 172 443 480 203 472 732 * relative share of the overspending (%) 91,60 40,30 * data for 2014 consists of estimates. discussion several main factors have been identified which have an impact on the annuallyincreasing public expenses on medical products in bulgaria:  non-transparent decisions for the inclusion of medical products in the pdl with unclear cost-effectiveness compared to the existing drug alternatives. there is no data on the recommendations of ncprmp for the pharmaceutical industry and set out denials for reimbursement justified by the lack of sufficient evidence of effectiveness and/or high prices. the practice in the economically developed countries is different. for example, the committee for the evaluation of medicinal products in canada refused to reimburse pemetrexed for the treatment of malignant pleural mesothelioma, because the product does not provide added value for the price difference compared to the existing alternatives (10). another canadian solution sets to reimburse sunitinib for the treatment of metastatic renal cell carcinoma only after negotiating the price because of poor cost effectiveness, despite the improved efficacy over the existing therapeutic alternatives. many similar negative decisions regarding the reimbursement of medical products for a specific diagnosis can be found in the scientific literature. their aim is both to facilitate the access of patients to therapies which give them additional therapeutic value and use, as well as to protect patients from health risks connected to severe adverse drug reactions (11,12). 64 vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi10.12908/seejph-2014-48  the lack of legally defined public expenditure related to one gained qaly. this is a widely used instrument for limiting public expenditure and for the control of the innovative medical therapies (13).  lack of legal control on the patterns of prescribing medicines. the eu states have a number of measures in working order for improving the patterns of prescribing medicines. most often they entail the monitoring of the prescriptions, recommendations and guidelines of advisory/obligatory nature regarding the prescriptions, including the requirements to prescribe an international non-proprietary name, a maximum limit on the prescribed medicines, prescription quotas, financial incentives, as well as educational and informational approaches(14-16). the aim of all enumerated policies is to promote the rational use of medical products for the benefit of public health. the combinations of diverse measures, as electronic monitoring in prescription and in guidelines, connected with electronic systems which support the process of decision-making and give feedback to the physician, are an effective way to improve the patterns in prescribing medicines (17). in addition, educational and informational instruments should be activated. the prescription of international non-proprietary names and prescription quotas, if possible in combination with target budgets and financial incentives, seem to be effective tools for the purpose of regulating public expenditure. conclusion the effectiveness of public expenditure in bulgaria will improve when it becomes the main objective in medical policy, i.e., when medical therapies are evaluated in a real and transparent way as a ratio of expenses and use as compared to the existing alternatives. it is necessary that the first steps are aimed at developing 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http://www.ncbi.nlm.nih.gov/pubmed/23996108 http://onlinelibrary.wiley.com/doi/10.1002/hec.v22.7/issuetoc http://www/ http://www.ncbi.nlm.nih.gov/pubmed/?term=von%20der%20schulenburg%20f%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=22828053 http://www.ncbi.nlm.nih.gov/pubmed/?term=vandoros%20s%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=22828053 http://www.ncbi.nlm.nih.gov/pubmed/?term=kanavos%20p%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=22828053 http://creativecommons.org/licenses/by/3.0) 66 qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and self perceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi10.12908/seejph-2014-50 original research reaction to political and socioeconomic transition and self-perceived health status in the adult population of gjilan region,kosovo musa qazimi 1 , luljeta cakerri 2 , zejdush tahiri 2 , gencburazeri 3 1 principal family medicine centre, gjilan,kosovo; 2 faculty of medicine, tirana university, tirana,albania; 3 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands. corresponding author: dr. musa qazimi address: rr. ―avdulla tahiri‖, p.n. 60000, gjilan, kosovo telephone: +381280323066; e-mail: micro_dental@hotmail.com mailto:micro_dental@hotmail.com 67 qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and self perceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi10.12908/seejph-2014-50 abstract aim: the objective of our study was to assess the association of reaction to political and socioeconomic transition with self-perceived general health status in adult men and women in a region of kosovo, a post-war country in the western balkans which has proclaimed independence in 2008. methods: this was a cross-sectional study carried out in gjilan region of kosovo in 2014, including a representative sample of 867 primary health care users aged ≥35 years (419 men aged 54.3±10.9 years and 448 women aged 54.0±10.1 years; overall response rate: 87%). reaction to political and socioeconomic aspects of transition was assessed by a three-item scale (trichotomized in the analysis into positive attitude, intermediate attitude, and negative attitude towards transition), which was previously used in the neighbouring albania. self reported health status was measured on a 5-point scale which was dichotomized in the analysis into ―good‖ vs. ―poor‖ health. demographic and socioeconomic data were also collected. binary logistic regression was used to assess the association of reaction to transition with self-rated health status. results: in crude/unadjusted models, negative attitude to transition was a ―strong‖ predictor of poor self-perceived health (or=2.5, 95%ci=1.7-3.8). upon multivariable adjustment for all the demographic factors and socioeconomic characteristics, the association was attenuated and was only borderline statistically significant (or=1.6, 95%ci=1.0-2.6,p=0.07). conclusion: our findings indicate an important association between reaction to transition and self-perceived health status in the adult population of the newly independent kosovo. policymakers and decision-makers in post-war countries such as kosovo should be aware of the health effects of attitudes towards political and socioeconomic aspects of transition, which is seemingly an important psychosocialfactor. keywords: attitude to transition, gjilan, kosovo, psychosocial factors, reaction to transition, self-perceived health, self-ratedhealth. conflicts of interest: none. 68 qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and self perceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi10.12908/seejph-2014-50 introduction in several post-communist countries including russia, negative attitudes towards the political transition and socioeconomic reforms have been linked to poor self-perceived health among adult men and women (1,2). similarly, a negative or a pessimistic reaction to transition has been more recently linked to development of acute coronary syndrome in albania (3), a country which shares the same language and culture with the nowadays republic of kosovo. according to this previous study conducted in albania, a plausible mechanism linking pessimism, or negative attitude with excess coronary risk was deemed the stressor effect of inadequate coping with change in this transitional society(3). nonetheless, the evidence from many former communist countries of southeast europe, including kosovo, is scarce. after a long war against serbia and its proclaimed independence in 2008, kosovo has been undergoing a very difficult process of political and socioeconomic transition (4) associated with a particularly high unemployment rate and a rather poor socioeconomic situation of the general population (5), which leads to an intensive process of emigration to different european union countries and beyond (6). given this particularly difficult socioeconomic situation, the attitudes and perceptions of the adult population in kosovo towards the political reforms and socioeconomic aspects of transition are considered to have been negatively affected notwithstanding the lack of systematic documentation (6). as a matter of fact, regardless of its natural resources, kosovo is one of the poorest countries in europe (4-6). current evidence suggests an increase in the morbidity and mortality rates from non-communicable diseases in adult men and women in kosovo (7,8), which is explained by an increase in unhealthy behaviours (9) and presumably psychosocial factors (9). according to a recent review, alongside with unhealthy lifestyle including dietary patterns and physical inactivity, unfavourable socioeconomic and psychosocial conditions are considered as important determinants of the excess morbidity and mortality from chronic diseases in kosovo including diabetes and cardiovascular diseases (9). notably, it has been argued that changes in behavioural patterns may have unevenly affected different population subgroups, especially the vulnerable and the marginalized categories who are unable to cope with the dramatic changes of the rapid transition occurring in post-communist societies including kosovo (6,9,10). nonetheless, the negative health effects of psychosocial factors in the adult population of kosovo have not been scientifically documented todate. in this context, our aim was to determine the association of reaction to political and socioeconomic aspects of transition with self-perceived general health status among adult men and women in a region of post-war kosovo. based on a previous report from albania (3), we hypothesized a negative health effect of pessimistic attitudes towards transition, suggesting inadequate coping with change, independent of (or, mediated through) demographic factors and socioeconomic characteristics. methods this was a cross-sectional study which was carried out in gjilan region, kosovo, in 2014. study population this study included a representative sample of primary health care users of both sexes aged 35 years and above. a minimum of 740 individuals was required for participation in this study, based on the initial sample size calculations. nevertheless, it was decided to invite 1000 individuals in order to increase the study power accounting also for non-response. therefore, 1000 consecutive primary health care users aged 35 years and above who were resident in gjilan region were invited to participate in thisstudy. 69 qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and self perceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi10.12908/seejph-2014-50 of 1000 individuals who were invited to participate, 62 primary health care users were ineligible (individuals aged <35 years and/or very sick to participate), whereas 71 individuals refused to participate. hence, the final study population included 867 individuals (419 men and 448 women) with an overall mean age of 54.2±10.5 years (54.3±10.9 years in men and 54.0±10.1 years in women). the overall response rate in this study was:867/1000=87%. data collection a structured questionnaire was administered to all participants including information on demographic and socioeconomic characteristics, reaction to political and socioeconomic transition in kosovo and self-perceived healthstatus. reaction to political and socioeconomic aspects of transition among study participants was assessed by a three-item scale which was previously used in the neighbouring albania (3). this scale employed in albania was adapted from an instrument originally used in russia (1,2,11). in the current study conducted in kosovo, all participants were asked to rate their agreement/disagreement about the following three statements: a) “overall, the current economic system in kosovo is better than the old system” [range from 0 (strongly agree) to 3 (strongly disagree)]; b) “the transition toward the new system in kosovo is difficult; however, it’s worthwhile in view of the forthcoming prosperity” [range from 0 (strongly agree) to 3 (strongly disagree)], and; c) “compared with the previous system, most of the people in kosovo are poorer now” [range from 0 (strongly disagree) to 3 (strongly agree)]. a summary score was calculated for each individual (referred to as ―overall reaction to transition‖) ranging from 0 (most positive or optimistic attitude towards political and socioeconomic aspects of transition) to 9 (most negative or pessimistic reaction to transition). cronbach‘s alpha of the three-item scale in our study conducted in kosovo was 0.94, which was slightly lower than a previous study conducted in albania (3). in the statistical analysis, the summary score of attitudes to transition was categorized into three groups [positive attitude (score: 0-3), intermediate attitude (score: 4-6), and negative attitude (score:7-9)]. in addition, all participants were asked to rate their general health status: “overall, during the past year, how would you rate your general health status: excellent, very good, good, poor, or very poor?”. in the analysis, the self-perceived health status was dichotomized into: ―good‖ vs. ―poor‖. demographic factors included age of study participants (in the analysis grouped into: 35-44 years, 45-54 years, 55-64 years and ≥65 years), sex and marital status (in the analysis, dichotomized into: married vs. not married), whereas socioeconomic characteristics consisted of educational attainment (categorized into: low, middle and high), employment status (trichotomized into: employed, unemployed and retired), income level (categorized into: low, middle and high) and social status (similarly trichotomized into: low, middle andhigh). statistical analysis measures of central tendency [mean values (± standard deviations) and median values (with their respective interquartile ranges iqr)] were used to describe the distribution of reaction to transition scores separately in male and female study participants. on the other hand, the distribution of different categories of the reaction to transition scores (positive, intermediate and negative) was expressed in absolute numbers together with their respective percentages separately in men and in women. chi-square test was used to assess the crude (unadjusted) association of reaction to transition scores (trichotomized into: positive, intermediate, negative) with the socio-demographic characteristics and self-perceived health status of studyparticipants. 70 qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and self perceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi10.12908/seejph-2014-50 conversely, binary logistic regression was used to assess the crude (unadjusted) and subsequently the multivariable-adjusted associations of self-reported health status (outcome variable dichotomized into: ―good‖ vs. ―poor‖ health status) and reaction to transition (independent variable) of study participants. initially, crude (unadjusted) odds ratios (ors) and their respective 95% confidence intervals (95%cis) were calculated. next, the logistic regression models were adjusted for age of participants. subsequently, the other demographic factors (sex and marital status) were entered simultaneously into the logistic regression models. finally, socioeconomic characteristics (educational attainment, employment status, income level and social status) were entered simultaneously into the logistic regression models. in all logistic regression models, the self-perceived health status was the outcome variable and reaction to transition (introduced in three categories: positive, intermediate and negative) was the main independent variable. multivariable-adjusted ors and their respective 95%cis were calculated. hosmer-lemeshow test was used to assess the overall goodness-of fit of the logistic regression models (12). in all cases, a p-value of ≤0.05 was considered as statistical significant. statistical package for social sciences (spss, version 17.0) was used for all the statisticalanalyses. results overall mean (sd) summary score of reaction to transition was 4.2±2.8 (4.1±2.8 in men and 4.2±2.7 in women) [table 1]. furthermore, median (iqr) was quite similar in men and in women [sex-pooled median (iqr): 3.0 (3.0)]. overall, 494 (57%) of participants reported a positive attitude towards the political and socioeconomic transition in kosovo, as opposed to 181 (21%) of individuals who had a negative reaction to transition. the negative attitude to transition was higher in men than in women (23% vs. 19%, respectively) [table 1]. table 1. distribution of reaction to political and socioeconomic transition scores ina representative sample of primary health care users in gjilan region, kosovo, in2014 reaction to transitionscore men (n=419) women (n=448) total (n=867) mean (standard deviation) 4.1±2.8 4.2±2.7 4.2±2.8 median (interquartilerange) 3.0 (4.0) 3.0 (3.0) 3.0 (3.0) positive (score: 0-3) 243 (58.0) 251 (56.0) 494 (57.0) intermediate (score: 4-6) 79 (18.9) 113 (25.2) 192 (22.1) negative (score: 7-9) 97 (23.2) 84 (18.8) 181 (20.9) table 2 presents the distribution of demographic factors, socioeconomic characteristics and self-perceived health status by reaction to transition scores (trichotomized into: positive, intermediate and negative scores) among study participants. as noted above, the prevalence of negative attitudes to transition was significantly higher in men compared to women (p=0.05). furthermore, older individuals (65 years and above) displayed the most negative (pessimistic) attitudes to transition compared with their younger counterparts (p<0.001). similarly, the prevalence of a negative reaction to transition was the highest among the retirees (p<0.001), given the aging of this population subgroup. there was no significant association with marital status. remarkably, low-educated participants had a significantly higher prevalence of negative attitudes to transition compared with their highly educated counterparts (40% vs. 7%, respectively, p<0.001). likewise, albeit with smaller differences, low-income individuals and those with a lower social status displayed a higher prevalence of negative reaction to transition compared to high-income participants (33% vs. 18%, 71 qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and self perceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi10.12908/seejph-2014-50 respectively, p<0.001), and individuals with a higher social status (29% vs. 12%, respectively, p<0.001). participants with a poor self-perceived health status had a significantly higher prevalence of negative reaction to political and socioeconomic transition compared with individuals who reported a good health status (34% vs. 18%, respectively, p<0.001) [table 2]. it should be noted that, on the whole, there were 696 (80.5%) participants who reported a ―good‖ health status compared with 169 (19.5%) individuals who perceived their health status as ―poor‖. table 2. distribution of socio-demographic characteristics and self-perceived health statusby reaction to transition scores in the study population(n=867) variable positive (score =494] : 0-3) [n intermediate (score: 4-6) [n=192] (sco negative 181] p † sex: men 243 (58.0) * 79 (18.9) 97 (23.2) women 251 (56.0) 113 (25.2) 84 (18.8) age-group: 35-44 years 132 (69.8) 37 (19.6) 20 (10.6) 45-54 years 171 (68.7) 56 (22.5) 22 (8.8) <0.001 55-64 years 131 (52.8) 59 (23.8) 58 (23.4) ≥65 years 60 (33.1) 40 (22.1) 81 (44.8) employment: employed 272 (71.0) 78 (20.4) 33 (8.6) unemployed 129 (62.0) 52 (25.0) 27 (13.0) retired 93 (33.8) 62 (22.5) 120 (43.6) marital status: not married 63 (49.2) 31 (24.2) 34 (26.6) married 431 (58.4) 161 (21.8) 146 (19.8) educational level: low 101 (30.5) 96 (29.0) 134 (40.5) middle 246 (69.9) 73 (20.7) 33 (9.4) high 145 (80.1) 23 (12.7) 13 (7.2) income level: low 46 (35.7) 40 (31.0) 43 (33.3) middle 118 (47.0) 85 (33.9) 48 (19.1) high 330 (68.2) 66 (13.6) 88 (18.2) social status: low 40 (40.0) 31 (31.0) 29 (29.0) middle 318 (55.4) 128 (22.3) 128 (22.3) high 136 (71.6) 32 (16.8) 22 (11.6) self-perceived health: good 416 (59.8) 158 (22.7) 122 (17.5) poor 78 (46.2) 33 (19.5) 58 (34.3) * absolute numbers and their respective row percentages (in parentheses). discrepancies in the totals are due to the missingvalues. † p-values from the chi-squaretest. table 3 presents the association of reaction to transition with self-perceived health status of study participants. in crude (unadjusted) logistic regression models (model 1), there was 6 72 qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and self perceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi10.12908/seejph-2014-50 evidence of a strong positive association between negative reaction to transition and poor self-rated health: or(negative vs. positive scores)=2.5, 95%ci=1.7-3.8. adjustment for age (model 2) attenuated the findings (or=1.8, 95%ci=1.2-2.8). additional adjustment for sex and marital status (model 3) did not affect the findings (or=1.8, 95%ci=1.2-2.8). further adjustment for socioeconomic characteristics including education, employment, income level and social status (model 4) attenuated the strength of the association which, in fully-adjusted models, was only borderline statistically significant (or=1.6, 95%ci=1.0-2.6,p=0.07). on the other hand, there was no difference in the odds of self-perceived health status between participants with intermediate scores and those with positive scores of reaction to transition, even in crude (unadjusted) logistic regression models (table 3, models 1-4). table 3. association of reaction to transition with self-perceived health status in a representative sample of primary health care users in gjilan region,kosovo model or * 95%ci * p * model 1 † <0.001 (2) ‡ positive attitude (score:0-3) 1.00 reference intermediate attitude (score:4-6) 1.11 0.71-1.74 0.636 negative attitude (score: 7-9) 2.54 1.71-3.76 <0.001 model 2 ¶ 0.014 (2) positive attitude (score:0-3) 1.00 reference intermediate attitude (score:4-6) 0.99 0.63-1.56 0.958 negative attitude (score: 7-9) 1.81 1.18-2.78 0.007 model 3 § 0.011 (2) positive attitude (score:0-3) 1.00 reference intermediate attitude (score:4-6) 0.97 0.62-1.53 0.897 negative attitude (score: 7-9) 1.84 1.20-2.83 0.005 model 4 ** 0.079 (2) positive attitude (score:0-3) 1.00 reference intermediate attitude (score:4-6) 0.88 0.54-1.43 0.605 negative attitude (score: 7-9) 1.58 0.96-2.61 0.072 * oddsratios (or: ―poor health‖ vs. ―good health‖), 95% confidence intervals (95%cis) and p-values from binary logisticregression. † model 1: crude (unadjusted). ‡ overall p-value and degrees of freedom(inparentheses). ¶ model 2: adjusted for age (35-44 years, 45-54 years, 55-64 years and ≥65 years). § model 3: adjusted for age, sex (men vs. women) and marital status (married vs. unmarried). ** model 4: adjusted for age, sex, marital status, educational level (low, middle, high), employment status (employed, unemployed, retired), income level (low, middle, high) and social status (low, middle, high). discussion the main finding of this study consists of a positive association of pessimistic reaction towards political reforms and socioeconomic transition with poor self-rated health among adult men and women in post-war kosovo, a country characterized by dramatic and rapid changes in the past few years. the association of poor self-perceived health with negative reaction to transition was strong, but upon multivariable adjustment for a wide array of demographic and socioeconomic characteristics the relationship was only borderline 73 qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and self perceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi10.12908/seejph-2014-50 statistically significant. our findings are largely compatible with previous reports from former communist countries including russia (1,2,11) and albania(3). overall, the prevalence of negative reaction (score 0-3) towards socioeconomic aspects of transition in our study population was 21%, which is higher than a previous study carried out in albania which reported a sex-pooled prevalence of 13% (3). nevertheless, the prevalence of pessimistic reaction in our sample is much lower than in russia, where 49% of a representative sample of the adult population reported a nostalgic reaction to political and socioeconomic changes (disapproving the new system and approving the old system) according to a previous study (2). it should be pointed out that, in russia, it was considered that the attitudes towards the political and socioeconomic reforms in 1990s were significantly more negative than in other post-communist countries in europe(2,3). in our study, there was no evidence of a graded relationship with pessimistic or negative attitudes to transition. hence, the association was evident only between negative vs. positive attitude groups, with no differences between neutral (intermediate) and positive attitude categories (table 3). on the other hand, a previous study conducted in albania reported a graded relationship between acute coronary syndrome and negative attitudes towards socioeconomic transition consistent in both sexes and irrespective of demographic and socioeconomic characteristics and a wide range of conventional risk factors(3). potential mechanisms of psychosocial factors including reaction towards political and socioeconomic aspects of transition have been suggested to operate either directly through the neuro-endocrine system (13), or indirectly through induction of unhealthy behaviour such as smoking, excessive alcohol consumption, unhealthy diet and sedentary lifestyle (3,13). furthermore, regarding the negative effect of psychosocial factors on cardiovascular risk, it has been suggested that psychological distress may act chronically through pathological modifications of the cardiovascular system, such as changes in lipid profile and elevation of arterial blood pressure (3,14). in our study, the mechanism of excess self-perceived poor health among pessimists may be related to poor adaptation to critical circumstances associated with the particularly rapid transition in kosovo, as suggested by previous research on this field (3), where obvious differences in coping strategies between optimists and pessimists have been convincingly demonstrated (3,15,16). conversely, negative reaction towards political and socioeconomic aspects of transition may also serve as a marker of depression (17,18), which may lead to poor health status ingeneral. this study may suffer from several limitations including its design, representativeness of the study population and the possibility of information bias. firstly, findings from cross-sectional studies do not imply causality and, therefore, future prospective studies should robustly assess and establish the directionality of the relationship between self-reported health status and attitudes to political and socioeconomic transition in kosovo and other transitional settings. secondly, we cannot exclude the possibility of selection bias in our study sample notwithstanding the inclusion of a fairly large sample of consecutive primary health care users of both sexes in gjilan region. in addition, we obtained a very high response rate (87%), which is reassuring. yet, we cannot generalize our findings to the general adult population of gjilan region given the fact that our study population was confined merely to primary health users. more importantly, findings from this study cannot be generalized to the overall adult population of kosovo, as our survey was conducted only in gjilan region. thirdly, the instrument used for measurement of reaction to transition may be subject to information bias, regardless of the fact that this tool was previously validated in albania (3). in our study population, the measuring instrument of reaction to transition exhibited a very 74 qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and self perceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi10.12908/seejph-2014-50 high internal consistency and discriminated well between population subgroups distinguished in their educational attainment, income level and social status – similar to previous reports including the neighbouring albania(3). in conclusion, regardless of these potential limitations, our findings indicate an important association between reaction to transition and self-perceived health status in the adult men and women of post-war kosovo. health professionals and policymakers in developing countries and transitional populations should be aware of the negative health effects of psychosocial factors including also the general 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http://www.ncbi.nlm.nih.gov/pubmed/?term=weintraub%20jk%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=2926629 http://www.ncbi.nlm.nih.gov/pubmed/2926629 http://www.ncbi.nlm.nih.gov/pubmed/?term=kubzansky%20ld%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=15953792 http://www.ncbi.nlm.nih.gov/pubmed/?term=davidson%20kw%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=15953792 http://www.ncbi.nlm.nih.gov/pubmed/?term=rozanski%20a%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=15953792 http://www.ncbi.nlm.nih.gov/pubmed/?term=the%2bclinical%2bimpact%2bof%2bnegative%2bpsychological%2bstates%3a%2bexpanding%2bthe%2bspectrum%2bof%2brisk%2bfor%2bcoronary%2bartery%2bdisease http://creativecommons.org/licenses/by/3.0) 76 merkel b. a growing competence: the unfinished story of the european union healthpolicy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-2014-49 commentary a growing competence: the unfinished story of the european unionhealth policy bernard merkel 1 1 visiting research fellow, london school of hygiene and tropical medicine, london, uk. corresponding author: dr. bernard merkel address: dg sante, european commission, brussels; email: merkebe@gmail.com mailto:merkebe@gmail.com 77 merkel b. a growing competence: the unfinished story of the european union healthpolicy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-2014-49 a few months ago, the south eastern european journal of public health (seejph) published a lengthy article by hans stein on the importance of the maastricht treaty of 1992 and how the european union (eu) health policy has developed since then (1). undoubtedly, dr. stein made a major contribution to this story himself and in his paper he sets out his own viewpoint on key events and trends, offering us a wealth of historical detail and many real insights. but, like all good commentators who try to condense and make sense of a tortuous and convoluted sequence of events spanning more than two decades and involving very many players, he inevitably omits parts of the story, and his interpretations can sometimes give rise to more questions than answers. in this review, i will entirely leave aside his general discussion of the overall evolution of the eu and its future prospects, and instead concentrate on a few specific points about the development of eu health policy to date. it is a truism, and the beginning of perceived wisdom on the history of eu health policy, that the maastricht treaty introduced the first explicit ec (european community) legal competence for public health, devoting an article to it (article 129). it is also true, as dr. stein mentions, that there was much health-related activity in the ec well before the advent of the maastricht treaty. such actions, in fact, go back many years. for instance, there was an ec directive on pharmaceuticals in 1971 and in the same year a regulation on coordination of social security systems providing rights to health care to workers in other ec countries. moreover, various public health programmes on cancer, aids and drugs also predate maastricht. yet, article 129 represented the first explicit framework for public health. however, dr stein makes the more interesting point that this competence was “often but never substantially changed in the subsequent treaties”. and, again, “the main components of article 129 were slightly reworded in the following treaties, but essentially are still valid”. in saying this he is implying that it was and remains after several treaty changes, a very weak competence which results from the “defensive and negative position of ms” (eu member states) and reflects their position “to keep the eu as far away as possible from influencing their health policy”. there is no doubt that the health ministries of the older ms, and most, if not all, of the newer ones, have never wanted the eu to tell them how to run their healthcare systems, or to subsume their health policies into an eu-wide policy as has been done in areas such as trade or agriculture. and it is certainly the case, as dr. stein emphasizes, that the article 129 competence is a weak one – as well as being veryill-defined. but, this raises some furtherissues. as he says, it was ms, not the commission or the european parliament, that dominated the process of negotiating and agreeing the maastricht treaty. the question then must arise of why did these very ms decide to put into the treaty a new competence in public health at all if they did not want the ec (eu as it has become) to do anything of significance in this field? later in his paper, dr. stein quotes approvingly from an article by scott greer who says that article 129 “was the harbinger of more effective promotion of health issues within eu policymaking. in time, however, the internal market and the single currency have had the biggest health consequences”. and then, dr. stein adds the interesting comment that: “this was not really what the ms had in mind when they established a specific eu public health mandate”. of course, in 1992, the ms could not really have been thinking about the impact of the single currency which was not introduced until 1999! it is true that the treaty did set out some clear steps towards achieving an economic and monetary union. but, it seems far 78 merkel b. a growing competence: the unfinished story of the european union healthpolicy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-2014-49 fetched, to say the least, to suppose that those involved in designing a new public health competence would have given any thought to the potential impact on health of such a theoretical eventuality. similarly, how likely is it that many of them were envisaging the creation of some kind of protective instrument to counter the single market‘s potential impact on public health? this may have been on the mind of one influential player: hans stein, at least according to what he wrote in an article some years later (2). in this he states that: “single market regulations are sure to have an impact on health and health policy.....the full consequences of the internal market in the field of health and health care are as yet unknown. to analyse, to support or to counteract them can be done effectively only on an euscale”. but, it is doubtful that others were so far-sighted. moreover, if ms had really wanted to establish a health competence that could act as a bastion to promote and defend the interests of public health against the possible negative consequences of the single market, why did they make the public health competence so feeble that it ‗is the weakest legal base possible‘? what seems more plausible is that ms (most of them in any case) saw some advantages in european cooperation in some health areas either where they faced common health problems such as aids, and tobacco, and on some apparently non-contentious topics, such as improving health information, and health education, where they could exchange experience and expertise. in doing so it is arguable that they were trying to achieve two objectives: first to show that the ec was not just about markets and economics but could play a valuable role in other policy spheres. this indeed was a general underlying thread of the maastricht treaty. it is noteworthy in this context that article 129 is sandwiched by two rather similar articles, 128 on culture, and 129a on consumer protection. the second aim could be seen as being perhaps a more cynical one: it was to give the ec a formal competence to take some actions in health, which they had in any case been doing for some time in fields such as cancer,aids and drugs, while reducing the potential for any future action in areas where ms did not wish to see ec involvement by defining the scope of the ec‘s public health activities and explicitly limiting its competence in this field. this view was common among commission officials involved in health policy, including this reviewer, who expressed it in an article in 1995 (3). a second contestable point is the claim that the treaty competence on public health has remained essentially the same over the last two decades. on the face of it, this cannot really be the case. indeed what is particularly striking about this competence is how greatly the legal provisions have changed from treaty to treaty. unlike many other policy areas where the treaty provisions have remained largely unchanged, the wording about health has been greatly amended and the provisions have become more and moredetailed. in the treaty of amsterdam of 1997, for example, the public health article (article 129 of the maastricht treaty) was significantly lengthened and the new article (article 152), among other things, included for the first time the power to make binding eu legislation in a few specific areas, in relation to blood and organs, and in some veterinary and phytosanitary areas. a quick look at the current health article, (article 168 of the lisbon treaty) will show that it is again substantially different from the ones agreed in previous treaties, as well as being very much longer. the areas of binding legislative powers introduced in 1997 are retained and there is a further one: medicinal products and medical devices, additionally, the scope for taking legal measures is increased, and now also includes cross-border threats tohealth, 79 merkel b. a growing competence: the unfinished story of the european union healthpolicy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-2014-49 tobacco and alcohol; and the article includes soft law provisions similar to those of the so called ‗open method of coordination‘ used in social and employment policy. the article also concedes for the first time that the eu in the framework of its public health competence may have a role in relation to health services, saying that the eu: “shall in particular encourage co-operation between the ms to improve the complementarity of their health services in cross-border areas”. finally, of course, in addition to article 168, the treaty of lisbon also incorporates the charter of fundamental rights of the eu. article 35 of this promulgates a right in respect of health care: “everyone has the right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices. a high level of human health protection shall be ensured in the definition and implementation of all the union’s policies and activities”. hence, clearly, the eu‘s legal competence has considerably evolved since the maastricht treaty. but perhaps dr. stein is making a deeper point, that regardless of the specific textual amendments in successive treaties, the underlying scope of and limitations on the eu‘s public health competence have not fundamentally changed. there is some strength in this argument. but the position is not as clear-cut as he maintains. the first point to be considered is similar to the one we have made in connection with the article 129 of the maastricht treaty. if ms wanted to preserve the eu‘s public health power weak and nebulous, why did they not simply keep it as it was? why did they keep changing it (and adding to it!) in each treaty revision? we can advance several reasons. first, there was never unanimity among the ms about the extent of the eu‘s role in public health, and in fact a diminishing degree of consensus as more ms joined the eu. some of them, notably the newer ms, actively welcomed a greater eu involvement not only in developing national public health policies but even in respect of the functioning of their healthsystems. second, the treaty reformulations represent (to some extent) responses to developments in europe and beyond. gradually, even against their basic instincts, most, if not all, ms came to appreciate that the eu could be of use in helping tackle some health problems that would be difficult to deal with by individual countries acting separately. these include forexample  responding effectively to health threats from communicable diseases and man-made and natural disasters,  tackling various health determinants,  developing a framework for regulating health goods and related items that circulatein europe, and  responding to global health problems. thirdly, the ms were not negotiating in a vacuum; they had to take into account public opinion and, in particular, the views of the other eu institutions, notably the european parliament (ep) and the commission which both pressed at various points for the eu to be given additional powers in particular health fields. in relation to the maastricht treaty, for example, the commission may have had a limited role in the actual negotiations, but it made proposals for what it wanted to see, it liaised with ms about how texts were worded and certainly followed the negotiations extremely closely. the final draft of the new public health article therefore came as no surprise to the commission. and directly after the treaty had been ratified on 1 november 1993, it published a detailed communication setting out how it intended to implement the new provisions (4). similarly the ep played a very forceful role in the bse crisis which led both to a substantial shake–up in the organization of the commission services to separate agriculture from food safety and also to pressure to 80 strengthen the treaty provisions on the protection of public health. this resulted in the inclusion in article 152 of the amsterdam treaty of provisions allowing for binding measures to be taken in the veterinary and phytosanitary fields in relation to public health, and the extension of the overall scope of ec public health action to “preventing human illness and diseases, and obviating sources of danger to human health”. certainly, dr. stein is right in his contention that the health ministries of many ms have never been the warmest advocates of increasing eu competence in health. yet despite this the fact remains that it has increased, is increasing and seems likely to continue to increase. paradoxically, it is arguable that the prime movers of this growth in eu power have not generally been those in the health field, but rather those in charge of other policy areas who have never been so zealous about national prerogatives in relation to health. decades ago it was heads of government who pushed for action on the single market which led ultimately led to eu action on pharmaceuticals, mutual recognition of health professionals and reciprocity of health insurance coverage. later those same heads of government called for eu action on cancer and aids. in the last few years it has again been heads of government and finance ministers who have set up a new eu system of economic governance which has led to direct interventions in ms‘s budgetary and economic policies and through those means intrusion into their national health care policies. today, as part of this system, we have an eu instrument, the semester, which enables the eu to give every ms specific (non-binding but very influential) recommendations on the main issues confronting their healthcare systems, their health spending and the reforms they shouldmake. we have obviously travelled a very long way indeed from the arguments about whether the eu had a significant role in public health policy, let alone that it could have anything to do with the functioning of national health systems. dr. stein has written a thought provoking article which helps us to trace the path that has been followed and offers us some pointers to what may come in the future for european health policy. as he wrote in 1995: ―it may take some time, but i have little doubt that when the range of possibilities inherent in the new treaty provisions are really used, their impact on public health will be greater than anybody expects today” (5). now, twenty years and several treaties later, we can see just how prescient he was. references 1. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives. seejph 2014; posted: 23 december 2014. doi 10.12908/seejph-2014-36. 2. stein h. experiences of the german presidency: small steps towards integrating public health. eurohealth 1995;1:19-20. 3. merkel b. the public health competence of the european community. eurohealth 1995;1:21-2. 4. european commission. communication on the framework for action in the field of public health. com(93)559 final. 5. stein h. experiences of the german presidency: small steps towards integrating public health. eurohealth 1995;1:19-20. © 2015 merkel; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited. http://creativecommons.org/licenses/by/3.0) 81 obituary luka kovacic the editors of the south eastern european journal of public health express their deepest sorrow about the death of one of our most prominent members of the editorial board, professor luka kovačic, founder of the stability pact‘s forum for public health in south eastern europe (fph-see) in 2000/2001 and strong supporter of the creation of this journal. genc burazeri (tirana, albania and maastricht, the netherlands) ulrich laaser (bielefeld, germany) jose martin-moreno (valencia, spain) peter schröder-bäck (maastricht, the netherlands) obituary professor luka kovačic, md,phd professor luka kovačic, md, phd, specialist in social medicine and organization of health care, retired full professor of the school of medicine, university of zagreb, passed away on 21 april 2015 fatigued by incurable malignant disease. luka kovačic was born on 13 october 1940 in a small town đurđevac some 100 km north of zagreb in the area called podravina, where he attended primary school and finished gymnasium in koprivnica. he graduated from the school of medicine in zagreb in 1965, and after a few years of medical practice he joined the andrija štampar school of public health which is a part of the school of medicine, university of zagreb. there he spent practically his entire working lifetime. he earned both, msc and phd degrees from the university of zagreb, school of medicine in 1972 and 1983. in his academic career he advanced from the assistant position at the chair for hygiene, social medicine, and epidemiology through positions as assistant professor (1984) and associate professor (1988) to full professorship (2003). he completed the specialization in social medicine and organization of health care successfully in 1974. he was also trained in sweden (1964), scotland (1966), usa (1968 and 1971, when he was trained in public health, epidemiology and research methods at the johns hopkins school of hygiene and public health in baltimore), finland (university of kuopio, 1977) and alma-ata (who training in planning and management in 1985). he paid study visits or served as a consultant in the uk, the ussr, kazakhstan, sudan, cameroon, india, iran (undp), nigeria (who) and elsewhere. at the andrija štampar school of public health he used to held numerous posts and responsibilities: he was a head of the department for hygiene, social medicine and epidemiology 1993-1997 and after its dissolution in three smaller departments in 1997 he continued to chair the department for social medicine and organization of health care; he was deputy coordinator from 1984 and coordinator 1997-2000 of the who collaborating centre for primary health care. he served as an assistant to the director and deputy director (1984-2004) and finally as the director of the school from 2004 till his retirement in2006. he served firstly as the coordinator and later as director (1990-1996) of the international 9-week course "planning and management of primary health care in developing countries" which was 82 held 16 times between 1978 and 1996 at the andrija štampar school of public health with the support of the government of the netherlands and had altogether more than 350 participants coming from 66 countries. luka kovacic was active member of the croatian medical association, president of its section for social medicine and organization of health care (1978-1986). later the section changed its name into the society for public health with him as president (1986-1999). his activities and duties were so numerous, both within his institution and in the broader croatian and international context, that we mentioned only those mostly pronounced or internationally visible. luka was a gifted and dedicated teacher, mentor of six msc theses and one phd dissertation as well as altogether more than 200 diploma works for medical and nursing students at the school of medicine and school of applied health sciences. he was principal investigator in many domestic projects and played a leading role in several international projects and networks. he actively participated in the work of the european network of districts "tipping the balance toward primary health care" (ttb) from 1987, being also its chairman of the board and president of the assembly from 1997 to 2005, and the coordinator of the whole network and the project "ttb second decennial survey of the health needs and health care for older people in europe", which was implemented in five european countries including croatia in 2005-2006. he was also a member of the european society for public health and its scientific committee since2000. the cooperation between the school of public health, university of bielefeld and public health academic institutions in ten south eastern european (see) countries started in the year 2000 under his able leadership together with professor ulrich laaser, supported by the stability pact for south eastern europe. professor luka kovačic contributed enormously to the establishment of the forum for public health in south eastern europe (fph-see) as a network of academic institutions, aiming at the reestablishment of professional cooperation between public health teachers and professionals in see. as the result of this cooperation six book volumes were prepared and published between 2004 and 2010 encompassing altogether more than 4300 pages, containing some 250 teaching modules authored by more than 200 authors. among them professor kovačič co-edited the volume “management in health care practice” and authored four modulestherein. luka kovačic was retired less than 9 years ago but he continued to be active and involved in teaching, especially in postgraduate specialist programmes and the phd programme "medicine and health sciences" where he coordinated courses in research methods in public health also at the school of applied health sciences in zagreb he taught several subjects and mentored diploma works. he was a full member of the croatian academy of medical sciences where he chaired the college of public health and participated in the work of the committee for food and the committee for telemedicine to which he was previously president during two terms. professor luka kovačic has published almost 200 scientific and professional articles and edited several books, among them also a textbook in social medicine. he coordinated a number of national and international projects and networks, and has organized numerous national and international conferences in the field of public health and health careorganization. condolence arrived to family kovačic and his colleagues from many institutions and individuals not only from croatia but also from abroad, especially from colleagues from the south eastern european countries. their words once again proved not only how much professor kovačic was respected as an expert, but also how he was appreciated and loved as a co-worker, colleague and teacher. professor luka kovačic will remain in our memory forever as a creative and responsible teacher, an excellent organizer, a competent expert, but above all as a colleague and a friend always ready 83 to assume obligations and help others, a modest and friendly man. a number of colleagues, former students, associates and friends from all over croatia together with those coming from neighbouring countries joined his beloved ones, his wife marija, sons mladen and damir, brother, daughters in law and four lovely grandchildren at his funeral as well as at the commemoration held in the andrija štampar school of public health on may 12 to pay a tribute to a conscientious and gifted teacher, diligent and organized scientists but above all to the dear colleague, a man who did not have and could not have enemies, because he was gentle and always ready to help, both students and colleagues. only ten days after luka passed away the global public health curriculum was published in the south eastern european journal of public health (seejph) including two modules (2.1 and 2.8) he authored. so it happened that his last two teaching texts appeared in seejph, let there be glory and praises to lukakovačic! may he rest in peace! on behalf of the andrija štampar school of public health, school of medicine, university of zagreb prof. jadranka bozikov selected papers of professor luka kovacic: 1. schach e, bice tw, haythrone df, kovačic l, matthews vl, paganini jm, rabin dv. methodologic results of the who/international collaborative study of medical care utilization. milbank memorial fund quaerterly 1972;5:65-80. 2. kovačic l. dogovaranje pregleda i posjeta. *appointment system in health care+. lijec vjesn 1979;101:120-1. 3. kovačic l & al. dogovaranje pregleda u primarnoj zdravstvenoj zaštiti. *appointment system in primary health care]. zagreb: jugoslavenska medicinska naklada; 1979. 97 pp. 4. lemkau pv, kulčar ž, kesid b, kovačic l. selected aspects of the epidemiology of psychoses in croatia. am j epid 1980;112:661-74. 5. kovačic l, stipanov i. optimal development and utilization of primary health care in zadar. european journal of public health 1992;2:212-4. 6. kovačic l, šošid z. organization of health care in croatia: needs and priorities. croatian med j 1998;39:249-55. 7. kovačic l, lončarid s, paladino j, kern j. the croatian telemedicine. in: hasman et al. (eds). medical infobahn for europe. proceedings of mie 2000 and gmds 2000. ios press vol 77: 1146-50. 8. heslin jm, soveri pj, vinoy jb, lyons ra, buttanshaw ac, kovačic l, daley ja, gonzalo e. health status and service utilisation of older people in different european countries. scan j prim health care2001;19:218-22. 9. kovačic l, laaser u. public health training and research collaboration in south eastern europe. medicinski arhiv2001;55:13-5. 10. laaser u, kovačic l, editors.the reconstruction of public health training in south eastern europe. lage: hans jacobs editing company; 2001. 104 pp. (international public health working papers ; 4) 11. lang s, kovačic l, sogoric s, brborovic o. challenge of goodness iii: public health facing war. croat med j 2002;43:156-65 12. babid-banaszak a, kovačic l, kovačevid l, vuletid g, mujkid a, ebling z. impact of war on 84 health related quality of life in croatia: population study. croat med j 2002; 43:396-402. 13. ivekovid h, božikov j, mladinid-vulid d, ebling z, kern j, kovačic l. electronic health center (ehc): integration of continuing medical education, information and communication for general practitioners. stud health technol inform 2002;90:788-92. 14. ebling z, kovačic l, šerid v, santo t, gmajnid r, kraljik n, lončar j. traheal, bronhial and lung cancer prevention in the osijek municipality. med fam croat 2003; 11 (1-2):15. 15. gazdek d, kovačic l. navika pušenja djelatnika u zdravstvu koprivničko-križevačke županije – usporedna studija 1998. i 2002. [smoking habits among health staff in the county of koprivnica-krizevci--comparative study 1998 and 2002]. lijec vjesn2004;126:6-10. 16. vrca botica m, kovačic l, kujundžid tiljak m, katid m, botica i, rapid m, novakovid d, lovasid s. frequent attenders in family practice in croatia: retrospective study. croat med j. 2004;45:620-4. 17. vrca botica m, kovačic l, kujundžid tiljak m, katid m, botica i, rapid m, novakovid d, lovasid s. frequent attenders in family practice in croatia: retrospective study. croat med j. 2004; 45:620-4. 18. kovačic l, božikov j. master programs in public health – dilemmas and challenges. european phd programmes in biomedicine and health sciences. proceedings of the european conference on harmonisation of phd programmes in biomedicine and health sciences zagreb, croatia, april 24 and 25, 2004. zagreb: medical school, 2004; 52-4. 19. bjegovid v, kovačic l, laaser u. the challenge of public health transition in south eastern europe. journal of public health2006;14:184-9. 20. kovačic l, gazdek d, samardžid s. hrvatska zdravstvena anketa: pušenje *croatian health survey: cigarette smoking]. acta med croatica2007;61:281-5. 21. kovačic l, zaletel kragelj l (eds.). management in health care practice. lage: hans jacobs verlag; 2008. 22. majnarid-trtica lj, vitale b, kovačic l, martinis m. trends and challenges in preventive medicine in european union countries. comment on the state in croatia. period biol. 2009;111:5-12. 23. kovačic l, laaser u. ten years of public health training and research collaboration in south eastern europe (ph-see). snz.hr2010;1(1):53-4. 24. tomek-roksandid s, tomasovid mrčela n, kovačic l, šostar z. kardiovaskularno zdravlje, prehrana i prehrambeni unos soli kod starijih osoba. [cardiovascular health, diet and salt in the elderly]. acta med croatica2010;64:151-7. 25. vadla d, božikov j kovačic l. differences in health status and well-being of the elderly in three croatian districts. eur j public health 2011; 21(suppl 1):156. 26. vadla d, božikov j, akerström b, cheung wy, kovačic l, mašanovid m, merilainen s, mihel s, nummelin-niemi h, stefanaki in, stencrantz b. differences in healthcare service utilisation in elderly, registered in eight districts of five european countries. scand j public health. 2011; 39, 3:272-9. 27. zaletel kragelj l, kovačic l, bjegovid v, božikov j, burazeri g, donev d, galan a, georgieva l, pavlekovid g, scintea sg, bardhele d, laaser u. the use and exchange of teaching modules published in the series of handbooks prepared within the frame of the „forum for public health in south-eastern europe“ network. zdrav var 2012; 51:237-250. 28. keenan s, hammond j, leeks d, šogorid s, kovačic l, džakula a, ganzleben c, guarinoni m, belin a. food safety and public health situation in croatia. european parliament, directorate general for internal policies, brussels, october 2012 (monograph, 66 pages). available at: http://www.europarl.europa.eu/studies 29. polid-vižintin m, tomasovid-mrčela n, kovačic l. mortalitet od cirkulacijskih bolesti i zlodudnih novotvorina u gradu zagrebu u osoba mlađih od 65 godina – stanje za uzbunu? [mortality rates of circulatory system diseases and malignant neoplasms in zagreb population younger than sixty-five – call for alarm?] acta med croatica. 2012: 66: 357-64. 30. vadla d, božikov j, kovačic l. are the untreated anxiety and depression in elderly http://www.europarl.europa.eu/studies 85 unrecognized sources of increased healthcare utilisation? eur j public health 2012; 22(suppl. 2):212-3. 31. bralic i, tahirovic h, matanid d, vrdoljak o, stojanovid-špehar s, kovačic v, blažekovid milakovid s. association of early menarche age and overweight/obesity. j pediatr endocrinol metab.2012;25(1-2):57-62. 32. vadla d, božikov j, blažekovid-milakovid s, kovačic l. anksioznost i depresivnost u starijih osoba pojavnost i povezanost s korištenjem zdravstvene zaštite. *anxiety and depression in elderly prevalence and association with health care]. lijec vjesn. 2013; 135:134-8. 33. vrcid keglevid m, kovačic l, pavlekovid g. assessing primary care in croatia: could it be moved forward? coll. antropol. 2014; 38(suppl. 2):3–9. 34. bendekovid z, šimid d, gladovid a, kovačic l. changes in the organizational structure of public health nurse service in the republic of croatia 1995 to 2012. coll antropol. 2014; 38(suppl. 2):85-9. 35. šimid d, bendekovid z, gladovid a, kovačic l. did the structure of work in the public health nurse service of the republic of croatia change in the period 1995-2012? coll antropol. 2014; 38(suppl 2):91-5. 36. kostanjšek d, topolovec nižetid v, razum z, kovačic l. getting some insight into the home care nursing service in croatia. coll antropol. 2014; 38(suppl2):97-103. 37. kovačic l, malik m. n2.1 demographic challenges, population growth, ageing, and urbanization. seejph 2015; available at: http://www.seejph.com/n-2-1-demographic challenges-population-growth-aging-and-urbanisation/ 38. kovačic l. n2.8 disaster preparedness. seejph 2015; available at: http://www.seejph.com/n 2-8-kovacic-disaster-preparedness-150322/ http://www.ncbi.nlm.nih.gov/pubmed/23898693 http://www.seejph.com/n-2-1-demographichttp://www.seejph.com/n jacobs verlag laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 1 editorial comment launch of the ‘one health global think-tank for sustainable health & well-being’ – 2030 (ghw-2030) the adoption of the 17 sustainable development goals (sdgs) by the un general assembly in september 2015 opens a new era for global, regional, national and local initiatives to ensure the well-being and sustainability of the planet and people (1). the south eastern european journal of public health (seejph) published several papers (volumes 2,3,5) on the un global goals (2, 3, 4). in addition, prof ulrich laaser and prof vesna bjegovic mikanovic established together with dr george lueddeke a global think-tank on „global health, governance, and education‟ (5) to help inform the writing of the epilogue of dr lueddeke‟s recent book entitled global population health and well-being in the 21 st century – towards new paradigms, policy, and practice (6). in continuation of this process we worked with dr. joanna nurse, head of the commonwealth* secretariat health and education unit (heu) (7, 8) and collectively founded the „one health global think tank for sustainable health & well-being – 2030‟ (ghw-2030). a synopsis of the think-tank‟s remit and membership is set out below. the summary is followed by a background paper outlining the ghw-2030 rationales, particularly in light of the un 2030 agenda for sustainable development (9), and the pressing need to incorporate holistic one world, one health values, principles and practice (10, 11) as these relate to environmental, social, economic and geopolitical spheres with a view to guiding associated frameworks (12, 13), policies and enabling strategies. a listing of current ghw-2030 members and affiliations is also provided. for the ghw-2030, april 2016 professor ulrich laaser, international public health, university of bielefeld, bielefeld, germany (ulrich.laaser@uni-bielefeld.de) dr george lueddeke, think-tank convenor/chair; southampton, united kingdom (glueddeke@aol.com) dr joanna nurse, head, commonwealth secretariat health and education unit (heu), london, united kingdom (j.nurse@commonwealth.int) * the commonwealth is a voluntary association of 53 independent and equal sovereign states. it is home to 2.2 billion citizens, of which over 60% are under the age of 30” (7). laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 2 references (1) united nations. sustainable development goals, sustainable development knowledge platform, 2016. available at: https://sustainabledevelopment.un.org/sdgs (2) burazerii g, laaser u, jose m. martin-moreno jm, schröder-bäck p (eds.) complete issue. seejph 2014, vol.2: availableat:http://www.seejph.com/index.php/seejph/article/view/2/ (3) burazeri g, laaser u, martin-moreno jm, schröder-bäck p (eds.) complete issue. seejph 2015, vol.3: available at: http://www.seejph.com/index.php/seejph/article/view/3/ (4) burazeri g, laaser u, martin-moreno jm, schröder-bäck p (eds.) complete issue. seejph 2016, vol.5: available at: http://www.seejph.com/index.php/seejph/article/view/3/ (5) laaser u, bjegovic-mikanovic v, lueddeke g. et al. epilogue. in: lueddeke g. global population health and well-being in the 21st century: toward new paradigms, policy, and practice. springer publishing, new york; 2016. (6) lueddeke g. global population health and well-being in the 21 st century: toward new paradigms, policy and change. springer publishing; new york; 2016. available at: http://www.springerpub.com/global-population-health-and-well-beingin-the-21st-century-toward-new-paradigms-policy-and-practice.html. (7) the commonwealth secretariat. about us: the commonwealth; 2016. available at: http://thecommonwealth.org/about-us. (8) the commonwealth secretariat. promoting sustainable social development and well-being for all: an overview of the commonwealth secretariat‟s health and education unit. available at: file:///c:/users/george/downloads/health_and_education_unit_brochure.pdf (9) united nations. transforming our world: the 2030 agenda for sustainable development; 2016. available at: https://sustainabledevelopment.un.org/post2015/transformingourworld (10) one health commission. ohc mission; 2016. available at: https://www.onehealthcommission.org/en/why_one_health/ohc_mission/ (11) one health initiative. mission statement;2016. available at: http://www.onehealthinitiative.com/mission.php https://www.thecommonwealth-healthhub.net/ (12) nurse j. a health systems policy framework for the commonwealth to support the sustainable delivery of universal health coverage (uhc). commonwealth secretariat, health and education unit, london uk; 2015. (13) lueddeke g. achieving the un-2030 sustainable development goals through the „one world, one health‟ concept, oxford public health; 2016. available at: https://issuu.com/oxfordpublichealth/docs/oxph_magazine_issue_4_apr2016/37?e=19 297810/34461022 copyright (c) 2016 ulrich laaser, george r. lueddeke, joanna nurse http://www.seejph.com/index.php/seejph/article/view/3/ http://www.seejph.com/index.php/seejph/article/view/3/ http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html http://thecommonwealth.org/about-us https://www.onehealthcommission.org/en/why_one_health/ohc_mission/ http://www.onehealthinitiative.com/mission.php https://www.thecommonwealth-healthhub.net/ https://issuu.com/oxfordpublichealth/docs/oxph_magazine_issue_4_apr2016/37?e=19297810/34461022 https://issuu.com/oxfordpublichealth/docs/oxph_magazine_issue_4_apr2016/37?e=19297810/34461022 laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 3 the one health global think tank for sustainable health & well-being – 2030 (ghw-2030) purpose, rationales, and guidance synopsis purpose to bring together global multi-sectoral and multi-disciplinary thought leaders to articulate and advocate for sustainable „planet and people‟ health and well-being. mission and method the central mission of the ghw-2030 multi-sectoral think tank is to contribute to the implementation of the un sustainable development goals (sdgs) by working toward achieving the education and health goals in cooperation with the commonwealth secretariat using an international interdisciplinary/multidisciplinary/transdisciplinary global one health approach. a major focus of the think tank will be on the health and well-being – physical, emotional, aspirational – of children and young people particularly as these relate to their personal security, physical and emotional well-being, education and employment and the sustainability of life on the planet. referencing contemporary and future-oriented developments, the activities of think tank members include:  analysing root causes with regard to key issues in environmental, social, economic and geopolitical arenas, particularly in relation to „well-being‟ goals, targets and indicators underpinning the un 2030 agenda for sustainable development;  considering and assessing future risks, such as egocentrism, demographic shifts, environmental, and public one health challenges generally – human, animal, plant, environmental – and identifying potential solutions at local, national, regional and global levels;  exploring creative and innovative approaches for informing global and national policy directions, including a „global framework for public health systems and services‟ (see background paper below, fig 4) .  publishing and disseminating knowledge and evidence-based papers articles (possibly informed by recognised research tools (e.g., cdc-authored community guide) or interviews in a creative and sustained fashion;  producing short summaries of policy options and recommendations for policy-makers and planners;  stimulating public online discussions as well as potential consortial activities, including social media; and  contributing to decision-making and policy development (government and nongovernmental) to enhance sustainable „health and well-being‟ at local, national, regional and global levels, involving existing and potential mechanisms for transformative enabling action. laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 4 in addition, along with others, think tank members will have the opportunity to engage in high level on-line policy discussions on the commonwealth secretariat‟s health and education unit hubs as well as contribute to a range of policy briefs which target policy makers and planners on key global health issues. (health:<healthhub@commonwealth.int> education:<eduhub@commonwealth.int>) terms of reference the overall aim of ghw-2030 is to explore and present evidence-based and refreshing or creative solutions through theme papers / interviews that impact on well-being or quality of life (human, animal, plant, environmental) and that go beyond silo thinking and conventional political interventions. think tank reviews will be undertaken annually with agendas set out by the secretariat and will be reported to the commonwealth secretariat health and education unit seeking its guidance for dissemination and implementation.  papers may originate with any member of the think tank and will be considered a „draft‟ subject to reviews of think tank members.  contributions from trans-disciplinary and/or multi-sectoral „primary‟ sources are essential;  the draft papers will be reviewed first by the secretariat and subsequently circulated to other members for comments through three review rounds.  draft papers should be restricted to significant contemporary global issues (e.g., involuntary migration, food safety and security, unemployment/underemployment, national governance, armed conflict, small island health, climate change, social instability, public health emergencies caused by infectious diseases such as the ebola and the zika virus, urban violence and crime).  the papers should be about 1500-2500 words in length, excluding references.  each paper should culminate with recommendations in terms of addressing the issue(s).  comments will be returned to originating author(s) for integration of feedback.  final papers will be disseminated, first, to all think tank members and, secondly, they will be submitted for consideration to global/public/clinical health and social care journals* and other fora (e.g., social media), to reach a wider audience.  up to six papers will be reviewed annually, involving on-line meetings, as required, and agreed through final on-line approval meetings of all members. organisation for the time being the group will function in association with the commonwealth secretariat health and education unit (heu), facilitated by its on-line health and education hubs. links to other think tanks or working groups addressing similar concerns will be developed wherever possible. mailto:healthhub@commonwealth.int mailto:eduhub@commonwealth.int laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 5 membership and affiliations think tank members (two year renewable term) involve those who helped to draft the epilogue „global health, education and governance,‟ for the book, global population health and well-being in the 21 st century: toward new paradigm, policy and practice and others working in diverse capacities in such areas as education, politics, health, research, journalism, economics, civil service, business, law, to name several fields. recommended affiliations include leading organisations focusing on global / national health and well-being. secretariat professor ulrich laaser, [dr. med, dtm&h, mph], international public health, university of bielefeld, bielefeld, germany (ulrich.laaser@uni-bielefeld.de) dr george lueddeke [ba, otc, med, phd] / ghw-2030 convenor/chair; consultant in higher & medical education, southampton, united kingdom (glueddeke@aol.com) dr joanna nurse, [bm, mph, msc. ffph], head, commonwealth secretariat health and education unit (heu), london, united kingdom (j.nurse@commonwealth.int) laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 6 the one health global think-tank for sustainable health & well-being -2030 (ghw-2030) purpose, rationales, and guidance the 21 st century has been marked by a rapidly accelerating globalization of cultures, religions, trade, and also of conflict. correspondingly recognition of global threats is rising with regard to environmental degradation, social divides and resulting civil war, enforced migration, and terrorism. taken together, it has become clear that global and regional governmental structures are struggling to cope effectively with emerging challenges to peace, security, basic human rights and planetary imbalances. the eight millennium development goals (mdgs) as a global average – have made considerable progress in several key areas, including increasing the net enrolment rate in primary school education in developing regions from 83 per cent in 2000 to 91 per cent in 2015 and raising official development assistance (oda) from developed countries by 66 per cent in real terms between 2000 and 2014, reaching $135.2 billion (1). however, progress has been uneven. as one example, poverty reduction, „which has declined significantly over the last two decades‟ (1) is partly due to the overachievement of countries like china and cannot be generalised across other – especially low income countries (2). and, while initiatives appear to be promising across the other seven mdgs, many targets remain unfulfilled and many more have emerged or have deepened since the mdg inception in 2000 (3). to cite a few specific examples: across 53 nations and about 2.5 billion people in the commonwealth nations „there are still approximately 23 million primary-aged children out of school‟ and „just over a third (8.5 million) are known to have access to anti-retroviral therapy‟ for those living with hiv/aids. moreover, given global socioeconomic and political polarizations, „the radicalization of young people and the underachievement of boys are emerging as challenges‟ (4). addressing the global life-threatening issues, as ban ki-moon un secretary-general highlights in the mdg final report, requires „targeted interventions, sound strategies, adequate resources and political will.‟ what has been demonstrated throughout the mdg initiative, he concludes in the introduction to the mdg final report, is that „even the poorest countries can make dramatic and unprecedented progress‟ (1). for the secretary-general the most important factor is „to tackle root causes and do more to integrate the economic, social and environmental dimensions of sustainable development,‟ thereby working toward resolving the „uneven achievements and shortfalls in many areas‟. the recently agreed un addis ababa action agenda (5), the 2030 agenda for sustainable development (6), including the 17 sustainable development goals (figure 1), as well as the framework convention on climate change (7) may be timely and catalytical in underpinning the establishment of the think tank, elaborated in the terms of reference (p. 4) laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 7 the sustainable development goals (sdgs) (2016-2030) by agreeing to the 17 sdgs on 25 september 2015 (6), the 193 member states of the un general assembly resolved to:  end poverty and hunger everywhere;  combat inequalities within and among countries;  build peaceful, just and inclusive societies;  protect human rights and promote gender equality and the empowerment of women and girls; and  ensure the lasting protection of the planet and its natural resources (6). figure 1: visual representation of the overarching elements of the sdgs source: commonwealth secretariat, health and education unit, 2015 (4) inherent in the un final report transforming our world: the 2030 agenda for sustainable development (6) are fundamental principles and values that inter alia include  adopting an overarching approach that fully integrates the social, economic and environmental dimensions of sustainable development;  committing to the intent of „leaving no one behind‟ and reflecting universality through all goals;  placing people and the planet at the centre at global, regional, national and local levels; and laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 8  supporting development cooperation commitments and means of implementation (moi) that consider finance, trade, technology, capacity-building, policy and institutional coherence, data and monitoring and multi stakeholder partnerships . jeff waage and christopher yap (editors) of thinking beyond sectors for sustainable development (figure 2) (8) grouped the sdgs into three main concentric circles and categories: natural environment, infrastructure and wellbeing , underpinned by sdg 17 which cuts across all sdgs (6). each sdg has specific targets with performance indicators, which are currently under development and are „expected to be adopted by the un economic and social council (ecosoc) and the un general assembly (unga), „preferably in june 2016‟ (9). figure 2: framework for examining interactions between sustainable development goals. (goal 17 is excluded from this framework because it is an overarching goal.) march 2016. laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 9 environmental-social sustainability and prospects for individual ‘well-being’ the central concerns of the 2030 agenda lie with ensuring sustainability of the natural environment, infrastructure while globally meeting basic human needs in order to safeguard and promote societal and individual well-being. the authors of „a vision for human well-being: transition to social sustainability‟ (10) emphasise the value of “living in ways that can be sustained because they are healthy and satisfying for people and communities.” in short, they posit that “while environmental sustainability examines living within the limits of the natural world”, social sustainability requires providing for material, social and emotional needs, avoiding behaviours that result in poor health, emotional distress and conflict, and ensuring that we do not destroy the social structures (such as families and communities), cultural values, knowledge systems and human diversity that contribute to a vibrant and thriving human community. as the authors make clear, „key components of human well-being are dependent on well-functioning ecosystems and the biosphere” and “conversely, maintaining a healthy environment and making the transition to environmental sustainability requires human societies that function well.‟ another important working hypothesis put forth is that „healthy, happy individuals with a strong sense of place, identity and hope for the future are more likely to make protection of their environment a priority‟. in this regard, a useful definition of “well-being” comes from the uk department of health which in the report confident communities, brighter futures. a framework for developing well-being‟ (11) defined „well-being‟ as „a positive state of mind and body, feeling safe and able to cope, with a sense of connection with people, communities, and the wider environment‟. according to the report, promoting mental health and well-being can be enhanced by a number of strategies or initiatives especially those that • use a life course approach to ensure a positive start in life and healthy adult and older years. with such an approach, people develop and share skills to continue learning and have positive social relationships throughout life. • build strength, safety and resilience: address inequalities and ensure safety and security at individual, relationship, community and environmental levels. • develop sustainable, connected communities: create socially inclusive communities that promote social networks and environmental engagement . • integrate physical and mental health: develop a holistic view of well-being that encompasses both physical and mental health, reduce health-risk behaviour and promote physical activity. oecd’s ‘better life’ index: an illusionary measure for the 21 st century? the comprehensive and informative global/national/regional oecd‟s better life index (12,13) indicates that australia is the „#1 place to live if all factors or criteria housing, income, jobs, community, education, environment, governance, health, life satisfaction, safety and work-life balance were treated with equal importance.‟ laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 10 figure 3: oecd better life index source: oecd, 2014 however, while „the overall level of health and wellbeing of australians is relatively high compared with other countries,‟ (14) the graph and findings may be somewhat illusory and may fall short in terms of representing a true picture of individual well-being on national scales where „there are significant disparities in the health outcomes of different populations‟ impacting mostly on the poor, the marginalised, the disadvantaged and increasingly the desperate as the european migration crisis makes clear. many past and present reviews of well-being have been and continue to be based on gross domestic product (gdp) per capita. while gdp as an average measure is “a good proxy for well-being,‟ it „ignores the asymmetrical distribution of wealth in a country‟ (10) and continues to correlate wealth and well-being as complementary and generally benign measures. research tells us that „happiness is not always closely associated with income or other objective indicators of well-being such as physical health.‟ in fact, amartya sen, acclaimed philosopher and proponent of social justice has argued that what is most important is to provide „the freedoms and capabilities that allow each person to achieve what will contribute to his or her own well-being,‟ (15) which may place less value on material wealth and shift from economic focus toward „equality in social relations, social trust in most other people, and degree of democracy; and safety of the area in which one lives‟ (10, 16). highlighting that „evidence about well-being comes from several different standpoints,‟ dr piumatti from the university of belgrade (17) reminds us that „economists laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 11 and psychologists are improving the measures of subjective well-being‟ (18) and that „questions about the influence of different determinants of psychological well-being are also being raised” (19). more specifically, he observes that researchers agree on the fact that individuals have different sources of well-being at different stages in their lives. for example, career and educational goals are highly relevant for people across the globe, particularly for young people who are transitioning into work. failing to meet one’s personal goals can result in disappointment and lower levels of well-being (20). accordingly, in order to contribute moving the measurement of subjective well being from a primarily academic activity to the sphere of official statistic and to raise awareness on this topic, we need to build bridges across disciplines. indeed, many new dimensions have already been absorbed by this field: nutritionists cooperate on defining the field of nutritional well-being (21), sociologists utilize the definition of community well-being (22), while other scientists analyze well-being in different age groups (23, 24). these works also represent a reflection of the complex and contested nature of well-being. moreover, it is noteworthy that while the meaning and application of „well-being‟ as a social construct may differ, viewed historically, „human‟ well-being has been largely defined in physical terms enabled through wealth creation and made possible especially in the past century through advancements in technology and science. in this respect well-being has become synonymous with a substantial rise in the standard of living for about a fifth of the world population totalling close to 7.4 billion at the moment. but economic growth has come at a steep price: first, it has promulgated a rather narrow – consumption –drivenconcept of „well-being‟ that is human ego-centric (vs animal, environmental – eco-centric) affecting the potential prosperity of only about 20 per cent of the human population coupled with huge losses in other species and biodiversity. and, secondly, it has created modern lifestyles that are arguably incongruous with our genetic evolution and are fast becoming a major societal dilemma affecting individuals from all groups regardless of background and increasingly all nations, high and low incomes (25, 26). as one example, considering the limitations of figure 3, obesity rates in australia are climbing faster than anywhere else in the world with about 5 million australians classified as obese (27) out of close to 24 million people. these trends are equally disturbing in the uk where, for example, a study predicts that „by 2035, 39 per cent of the population will be classed as obese, 33 per cent will be overweight and only 28 per cent will be of healthy weight or less, on current trends. (28). even close to half the staff in the uk national health service, the largest employer in the uk, –about 700,000are estimated to be overweight or obese (29). china is also experiencing a similar crisis. according to a study by the university of washington‟s institute for health metrics and evaluation, „the country is now no. 2 for obesity, with its number of obese residents outstripped only by the u.s. its obesity rate has skyrocketed over the last three decades, resulting in 46 million obese chinese adults and 300 million who are overweight (30). similarly, obesity appears to spreading across india, where its „economic boom has been accompanied by a meteoric increase in the number of people with diabetes – and those at risk for the disease. prevalence rates are up to 20% in some cities, and recent figures showed surprisingly increased rates in rural areas.‟ there are now over ‟65.1 million people with the disease, compared to 50.8 million in 2010‟ (31). http://online.wsj.com/articles/nearly-30-of-world-population-is-overweight-1401365395 http://online.wsj.com/articles/nearly-30-of-world-population-is-overweight-1401365395 laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 12 a study by the university of washington‟s institute for health metrics and evaluation focused on south asians and is generalizable to all nations trying to find a way forward to unhealthy and often unhappy lifestyles. perhaps unsurprisingly their report concluded that obesity „is primarily driven by nutrition, lifestyle and demographic transitions, increasingly faulty diets and physical inactivity, in the background of genetic predisposition‟ (32). another worrying trend likely intensified by modernism relates to mental health. research in australia found that „one in four young australians currently has a mental health condition‟ and „a quarter of young australians say they are unhappy with their lives‟ (14). these changes are also evidenced in levels of unhappiness in children in the uk, where a helpline study comparing reasons why children call childline from 1986 to the present, found that one in eight calls are now primarily related to feelings of loneliness and low self-esteem rather than sexual abuse and pregnancy which was the case 30 years ago. helpline concludes that „the pressures of modern life are „creating a generation of children plagued by low-level mental health problems,‟ causing stress attributable largely to „social media „and cyberbullying (33). exacerbating the difficulty of finding solutions in the uk and likely in other high and moderate income nations is the low priority that seems to be ascribed to mental health. as one example, the uk medical research council „spent less than 3 per cent of its budget on mental health last year,‟ (34) and local councils „spend only 1 per cent of the annual budget on mental health‟ with some spending „nothing on preventing mental illness‟ (35). nationally only £3.3 billion are allocated to public health out of a total nhs budget of about £116 billion, that is, around 3 per cent, considering that „annual cost from days at work lost and under-employment along with care and treatment is estimated at £105 billion‟ alone (34). most health funds globally are spent on treatment of physical health, not prevention of mental illness and ensuring well-being, despite non-communicable diseases, including a dramatic rise in depression, anxiety disorders, self-harming –especially among adolescents now accounting for c. 70 per cent of all mortalities and morbidities worldwide. perhaps dr stan kutcher from dalhousie university in nova scotia, canada, echoes the feelings of many distressed parents across the globe querying „why mental health services waited until young people reached crisis point before stepping in,‟ when „oncologists did not wait until a cancer was in stage 4 before treating it‟ (36). as a grieving father noted, giving young individuals who are mentally ill a „strip of pills‟ and „website names‟ is not the answer and more funded, collaborative and focused social research and system reform are urgently required (36). at the extreme opposite end of the figure 2 „well-being‟ spectrum are the non-oecd millions of children and young adults who are presently displaced or caught in conflict and war zones. syria is a cruel example of „social breakdown‟ as intolerable as any in preceding wars, reflected starkly in the unicef report, „committing to child survival: a promise renewed progress report 2015‟ (37) and reminding us that „in „2015 an estimated 5.9 million children will have died before turning 5 – and children under 5 from the poorest households are twice as likely to die as those from the richest.‟ further, the authors acknowledge „the cost of inaction at moral, economic and societal levels is too high,‟ and unquestionably must be viewed as one of the most important priorities for the united nations development program (undp) and those responsible for implementing the sdgs globally (38). laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 13 re-focusing on social and individual well-being in the 21 st century rogers et al (10) conclude their article by highlighting that unlike the natural sciences where there is general consensus „on the urgent need to reduce carbon emissions,‟ recently translated into a worldwide agreement at the paris climate conference, social science research still has a considerable distance to travel before nations agree to „replace the consumer culture with something more supportive of human and social and emotional needs…‟ in this regard, while tackling poverty, inequalities and „promoting peaceful, just and inclusive societies‟, our biggest challenge in this decade and beyond may be no longer defining “success and happiness” solely “in terms of material wealth” but accepting that “human happiness and well-being can continue to grow without exceeding sustainability limits and planetary boundaries‟ (10). writing in the times, in a piece entitled, „the search for happiness is all greek to me,‟ science correspondent oliver moody laments that “moral philosophy has all but vacated the public sphere over the last century, and, while we might blame practitioners for walling themselves up in a labyrinth of obscurities”, the truth may be “that the rest of the world is too busy upgrading its iphones and filling its tax returns to listen”. the writer‟s main point is that our seemingly „busy‟ lives make “all of us poorer” and “without a common idea of neither happiness nor “even the means to come up with one” (39). his conclusion may be confirmed by on-going deliberations that involve the draft sdg indicators by hundreds of dedicated stakeholders. the sdg indicators are certainly pointing in the right direction (9), but, by and large, the emphasis is still primarily on „conventional growth, competitiveness and personal gain‟ not on „promoting sustainable social development and well-being for all‟ (10). in short, there is little evidence that the sdgs will lead to diminishing „inequalities within and between societies‟ along with developing „economic and political policies and institutions that serve human well-being in all its dimensions.‟ the un decision to establish a ten-member group to support the technology facilitation mechanism (tfm), as part of the addis ababa action agenda (aaaa) for the period 2016-2017 to promote „technology initiatives‟ is an important step (40). it is also telling. the decision does little to respond to „the imperatives of human rights and the values of humanity and solidarity‟ (40). as success of the un 2030 agenda for sustainable development (6) depends arguably more on human than technological systems and factors, as the 20 th century and this century have already painfully demonstrated, would it not make sense to establish a parallel, authoritative „mechanism‟ for achieving humanitarian ends that value „consensus and common action, mutual respect, inclusiveness, transparency, accountability, legitimacy and responsiveness‟? (4). moody appears to be entirely justified in reminding us that it is really time „to tell us why we‟re wrong‟and the urgency „to show us a better way‟ (39). it is against this broad background that we have established the „one health global think tank for sustainable health and well-being – 2030‟ and agreed its overall rationales and guidelines. laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 14 the one health global think-tank for sustainable health & well-being -2030 (ghw-2030) purpose to bring together global multi-sectoral and multi-disciplinary thought leaders to articulate and advocate for sustainable „planet and people‟ health and well-being. mission and method the central mission of the ghw-2030 multi-sectoral think tank is to contribute to the implementation of the un sustainable development goals (sdgs) by working toward achieving the education and health goals in cooperation with the commonwealth secretariat using an international interdisciplinary/multidisciplinary/transdisciplinary “one health” approach. a major focus of the think tank will be on the health and well-being – physical, emotional, aspirational – of children and young people particularly as these relate to their personal security, physical and emotional well-being, education and employment and the sustainability of life on the planet. referencing contemporary and future-oriented developments, the activities of think tank members include:  analysing root causes with regard to key issues in environmental, social, economic and geopolitical arenas, particularly in relation to „well-being‟ goals, targets and indicators underpinning the un 2030 agenda for sustainable development;  considering and assessing future risks, such as egocentrism, demographic shifts, environmental, and public one health challenges generally – human, animal, plant, environmental – and identifying potential solutions at local, national, regional and global levels;  exploring creative and innovative approaches for informing global and national policy directions, including a „global framework for public health systems and services‟ (fig 4);  publishing and disseminating knowledge and evidence-based papers or articles* (possibly informed by recognised research tools (e.g., cdc-authored community guide) or interviews in a creative and sustained fashion;  producing short summaries of policy options and recommendations for policy-makers and planners;  stimulating public online discussions as well as potential consortial activities, including social media; and  contributing to decision-making and policy development (government and nongovernmental) to enhance sustainable „health and well-being‟ at local, national, regional and global levels, involving existing and potential mechanisms for transformative enabling action. laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 15 figure 4: public health systems and services source: commonwealth secretariat, health and education unit, 2015 (33) *potential journals (others to be added depending on theme or author preference) american journal of preventive medicine, american journal of public health, bulletin of the world health organisation, american journal of tropical medicine and hygiene, ecology letters, european journal of public health, global journal of interdisciplinary social sciences, health affairs, infection ecology and epidemiology, international journal of one health, international journal of public health, journal of the american medical association, journal of american public health, journal of international humanitarian action, journal of the veterinary medical association, journal of the united nations, lancet global health, one health journal (sweden), oxford public health magazine, plos one, south eastern european journal of public health, trends in ecology and evolution, vectorborne and zoonotic diseases, veterinary sciences (switzerland), world bank research observer…. laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 16 in addition, along with others, think tank members will have the opportunity to engage in high level on-line policy discussions on the commonwealth secretariat‟s health and education unit hubs as well as contribute to a range of policy briefs which target policy makers and planners on key global health issues (4). (health:<healthhub@commonwealth.int>( education:<eduhub@commonwealth.int>) the „one world, one health‟ concept refers to „a worldwide strategy for expanding interdisciplinary collaboration and communication in all aspects of health for humans, animals and the environment‟ (42). according to the one health initiative (ohi), „the synergism achieved will advance health care for the 21st century and beyond by accelerating biomedical research discoveries, enhancing public health efficacy, expeditiously expanding the scientific knowledge base, and improving public health education and health care.‟ the global one health commission (43) asserts that these aims can be greatly facilitated by: • connecting one health stakeholders • creating strategic networks / partnerships • educating about one health issues to support a paradigm shift in information sharing, active health interventions, collaborations, and demonstration projects. it is anticipated that „when properly implemented, the one health concept will help protect and save untold millions of lives in our present and future generations‟ (42). public health is the fundamental bridge or key coordinating mechanism to „improve health outcomes and well-being of humans, animals and plants and to promote environmental resilience…‟ (43). immediate catalysts the ghw-2030 think tank has developed based on the experience with the international group of advisors contributing to the final chapter of george lueddeke‟s book, global population health and well-being in the 21 st century – toward new paradigms, policy, and practice (25). the intention is to make use of this network of excellence and create a permanent structure inviting additional experts to work on topics of global health and wellbeing relevance. more particularly, the impetus for establishing the think tank is based on recommendations contained in the book‟s epilogue, which highlights recommendations for global decision makers, including the need to consider ‘the creation of a collective public or population health and well-being vision underpinned by global social justice, formalized structures of regional health and well-being‟; and transforming „traditional health & and social care education and training through innovative practice, focusing on prevention and health promotion’ (44). mailto:healthhub@commonwealth.int mailto:eduhub@commonwealth.int laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 17 supporting the latter, the association of schools of public health in the european region (aspher) has already recently underlined this essential in its global charter (45) and in its strategy 2020 (46). similarly, the world federation of public health associations (wfpha) has prepared “a global charter for the public‟s health: the public health system: role, functions, competencies and education requirements” (47) (in print), and the framework of a global strategic network for public health education and training has been outlined by professor vesna bjegovic-mikanovic, aspher president, et al (48). . organisation for the time being the group will function in association with the commonwealth secretariat health and education unit (heu), facilitated by its on-line health and education hubs. links to other think tanks or working groups addressing similar concerns will be developed wherever possible. membership and affiliations think tank members (two year renewable term) involve those who helped to draft the epilogue „global health, education and governance,‟ for the book, global population health and well-being in the 21 st century: toward new paradigm, policy and practice* (25) and others working in diverse capacities in such areas as education, politics, health, research, journalism, economics, civil service, business, law, to name several fields. affiliations include leading organisations focusing on global / national health and well-being. additional affiliations a number of key organizations have joined the think-tank. additional members are being sought representing inter alia: american public health association (apha), asia pacific academic consortium for public health (apacph), earth institute (tei), european public health association (eupha), global health council (ghc), india public health association (ipha), international association of public health institutes (ianph), rockefeller foundation (rf), united nations – undp, unesco, un foundation, world bank group (wbg), world health organisation (who), world veterinary association (wva), world medical association (wma). secretariat professor ulrich laaser, international public health, university of bielefeld, bielefeld, germany (ulrich.laaser@unibielefeld.de) dr george lueddeke, think-tank convenor/chair; southampton, united kingdom (glueddeke@aol.com) dr joanna nurse, head, commonwealth secretariat health and education unit (heu), london, united kingdom (j.nurse@commonwealth.int) laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 18 references (1) united nations. the millennium development goals report 2015. summary. available at: http://www.un.org/millenniumgoals/2015_mdg_report/pdf/mdg%202015%20summary% 20web_english.pdf. 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7/2014 . available at: http://www.globalhealthaction.net/index.php/gha/issue/current copyright (c) 2016 ulrich laaser, george r. lueddeke, joanna nurse laaser et al. for the ghw-2030; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://unictz.org/2016/02/01/secretary-general-appoints-a-10-member-group-to-support-the-technology-facilitation-mechanism/ http://unictz.org/2016/02/01/secretary-general-appoints-a-10-member-group-to-support-the-technology-facilitation-mechanism/ http://www.globalpolicywatch.org/blog/2015/07/16/civil-society-response-agenda-financing-development/ http://www.globalpolicywatch.org/blog/2015/07/16/civil-society-response-agenda-financing-development/ http://www.onehealthinitiative.com/mission.php https://www.onehealthcommission.org/en/why_one_health/ohc_mission/ http://aspher.org/pg/file/read/370940/the-global-dimension-of-education-and-training-for-public-health-in-the-21st-century-in-europe-and-in-the-world http://aspher.org/pg/file/read/370940/the-global-dimension-of-education-and-training-for-public-health-in-the-21st-century-in-europe-and-in-the-world http://aspher.org/download/20/aspher2020_outline-aga2015.pdf http://www.wfpha.org/about-wfpha http://www.globalhealthaction.net/index.php/gha/issue/current laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 21 the one health global think-tank for sustainable health & well-being -2030 (ghw-2030) (members as of 14.05.16) name affiliation e-mail country 1. dr. ibukun adepoju phd fellow, vriej university, amsterdam ladeadepoju@yahoo.com nigeria/neth erlands 2. dr. muhammad mahmood afzal ret'd global health workforce alliance, world health organization (ghwa/who), geneva, switzerland. chairman/chief editor, 'global health & medicine' magazine. drmmafzal@yahoo.com lahore, pakistan 3. dr. muhammad wasif alam director, public health and safety department, dubai health authority head quarter. malam@dha.gov.ae, wasifsuper@juno.com dubai , united arab emirates 4. prof john ashton president, uk faculty of public health . president@fph.org.uk uk 5. prof vesna bjegovicmikanovic vice dean of the faculty of medicine, university of belgrade. past president of the association of schools of public health in the european region (aspher). bjegov@med.bg.ac.rs vesna.bjegovic@aspher.org republic of serbia 6. prof bettina borisch director of the geneva office, world federation of public health associations. bettina.borisch@unige.ch switzerland 7. prof genc burazeri deputy director of the national institute of public health (albania).visiting lecturer at maastricht university; ;executive editor, south eastern european journal of public health. gburazeri@yahoo.com> albania 8. dr. sara carr clinical psychology, university of southampton. sara.carr4@nhs.net uk 9. dr. lisa conti deputy commissioner and chief science officer at florida department of agriculture and consumer services. lisa.conti@freshfromflorida.com u.s. 10. dr. katarzyna czabanowska dept of international health, faculty of health, medicine and life sciences, caphri school of public health & primary care (maastricht university) . kasia.czabanowska@maastrichtuniversit y.nl the netherlands, 11. dr. eliudi eliakimu assistant director health services inspectorate and quality assurance, health quality assurance division, ministry of health, community development, gender, elderly and children, dar es salaam eliakimueliudi@yahoo.co.uk eliakimueliudi@gmail.com tanzania 12. dr. kira fortune advisor, determinants of health (paho/who) fortunek@paho.org denmark 13. dr. luis galvão regional manager, sustainable development and environmental health (paho/who) galvaolu@paho.org brazil 14. dr. iman hakim dean of the university of arizona mel and enid zuckerman college of public health. ihakim@email.arizona.edu varelal@email.arizona.edu u.s. 15. prof n.k. ganguly former director general, indian council of medical research (icmr). coordinator and chair, policy center for biomedical research (pcbr), translational health science & technology institute (thsti). nkganguly@nii.ac.in india 16. prof joshua godwin international association of health care joshua@medicalscs.co.uk uk mailto:malam@dha.gov.ae mailto:wasifsuper@juno.com mailto:president@fph.org mailto:bjegov@med.bg.ac.rs mailto:vesna.bjegovic@aspher.org mailto:bettina.borisch@unige.ch mailto:gburazeri@yahoo.com mailto:ihakim@email.arizona.edu mailto:varelal@email.arizona.edu mailto:nkganguly@nii.ac.in mailto:joshua@medicalscs.co.uk laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 22 professionals (iahcp) joshuagodwin414@ymail.com 17. prof. james herington department of health behavior and executive director, gillings global gateway.™ unc gillings school of global public health . jimhsph@email.unc.edu u.s. 18. prof. tomiko hokama emeritus professor. executive vice president, university of the ryukyus. former president of asia pacific academic consortium for public health, (apacph). b987390@med.u-ryukyu.ac.jp japan 19. dr. howard hu dean, dalla lana school of public health, university of toronto. professor of environmental health, epidemiology and global health. professor of medicine. howard.hu@utoronto.ca canada 20. prof. ehimario igumbor extraordinary associate professor of public health, school of public health, university of the western cape, bellville, cape town, south africa. eigumbor@uwc.ac.za s. africa 21. prof. paul johnstone regional director for the north of england (public health england) paul.johnstone@phe.gov.uk uk 22. dr gretchen kaufman co-chair, education task force (one health commission). adjunct faculty, paul g. allen school for global animal health, washington state university.adjunct faculty, tufts center for conservation medicine, tufts university.co-founder and associate director, veterinary initiative for endangered wildlife. gkaufman10@gmail.com u.s. 23. dr. bruce kaplan co-founder, global one health initiative team; manager/editor, one health initiative website; former cdc eis officer and usda/fsis food safety staff officer; small animal veterinary medicine practitioner; retired bkapdvm@verizon.net u.s. 24. dr. laura kahn research scholar with the program on science and global security, princeton u. co-founder, global one health initiative (ohi). lkahn@princeton.edu u.s. 25. prof daniella kingsley international association of health care professionals (iahcp) daniella@iahcp.org.uk uk 26. prof ulrich laaser (secretariat) section of international public health (siph), faculty of health sciences, university of bielefeld. past president of the world federation of public health associations (wfpha). past president of the association of schools of public health in the european region (aspher). ulrich.laaser@uni-bielefeld.de germany 27. dr. george lueddeke (secretariat/convenor/chair) consultant education advisor, higher & medical education. co-chair, one health education task force. glueddeke@aol.com uk 28. dr. joann lindenmayer chair, one health commission (ohc) senior manager of disaster operations, humane society international jlindenmayer@hsi.org u.s. 29. prof qingyue meng professor in health economics and policy. dean of peking university school of public health. executive director of peking universitychina center for health development studies. qmeng@bjmu.edu.cn china mailto:joshuagodwin414@ymail.com mailto:jimhsph@email.unc.edu mailto:paul.johnstone@phe.gov.uk mailto:daniella@iahcp.org.uk mailto:glueddeke@aol.com laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 23 30. dr. jay maddock association of schools and programs of public health (aspph). dean of the texas a&m health science center, school of public health. maddock@tamhsc.edu kmanry@srph.tamhsc.edu u.s. 31. dr. john middleton vice president, uk faculty of public health. president-elect uk faculty of public health. honorary professor, wolverhampton university johnmiddleton@phonecoop.coop uk 32. prof getnet mitike professor of public health, addis ababa university, college of health sciences, school of public health getnetmk@gmail.com ethiopia 33. prof. geoff mccoll dean of medical education and training, university of melbourne; director of the medical journal of australia gjmccoll@unimelb.edu.au australia 34. dr. thomas monath chief scientific and chief operations officer of bioprotection systems corporation. tmonath@linkp.com u.s. 35. dr. joanna nurse (secretariat) head, commonwealth secretariat health and education unit. j.nurse@commonwealth.int jonurse66@hotmail.com m.mulholland@commonwealth.int uk 36. mr. robert otok executive director, association of schools of public health in the european region (aspher). robert.otok@aspher.org belgium 37. dr. giovanni piumatti universityof belgrade, school of public health. giovanni.piumatti@gmail.com italy 38. prof. k. srinath reddy president, public health foundation of india. ksrinath.reddy@phfi.org india 39. prof helena ribeiro former dean of the school of public health at the university of são paulo, lena@usp.br brazil 40. prof . barbara rimer dean, university of north carolina (unc) gillingsschool of global public health. brimer@unc.edu usa 41. dr. flavia senkubuge public health medicine specialist (university of pretoria). vice-president african federation of public health associations. junior vice-president of the colleges of medicine of south africa. flavia.senkubuge@up.ac.za s. africa, 42. dr. neil squires chair of global health (uk public health foundation ). neil.squires@phe.gov.uk uk 43. dr. cheryl stroud executive director, one health commission cstroud@onehealthcommission.org u.s. 44. prof charles surjadi chief technical advisor, indonesian epidemiology network. atmajaya faculty of medicine, djakarta. kotasehat@hotmail.com indonesia 45. dr. moaz abdel wadoud doctor of public health in health management and policy, college of public health, university of kentucky. previous associate researcher of public health, theodor bilharz research institute, ministry of scientific research, egypt. drmoaz@windowslive.com egypt 46. dr. john “jack” woodall professor and director (retd.), nucleus for the investigation of emerging infectious diseases at the institute of medical biochemistry, center for health sciences, federal university of rio de janeiro, brazil. co-founder and associate editor of jackwoodall13@gmail.com u.s. mailto:maddock@tamhsc.edu mailto:kmanry@srph.tamhsc.edu mailto:johnmiddleton@phonecoop.coop mailto:professor%20of%20medical%20education%20and%20training,%20univerity%20of%20melbourne,%20%20and%20director%20of%20the medical%20journal%20of%20australia,%20.ccoll@unimelb.edu.au mailto:professor%20of%20medical%20education%20and%20training,%20univerity%20of%20melbourne,%20%20and%20director%20of%20the medical%20journal%20of%20australia,%20.ccoll@unimelb.edu.au mailto:professor%20of%20medical%20education%20and%20training,%20univerity%20of%20melbourne,%20%20and%20director%20of%20the medical%20journal%20of%20australia,%20.ccoll@unimelb.edu.au mailto:jonurse66@hotmail.com mailto:m.mulholland@commonwealth.int mailto:robert.otok@aspher.org https://www.linkedin.com/company/595282?trk=prof-0-ovw-curr_pos https://www.linkedin.com/company/595282?trk=prof-0-ovw-curr_pos mailto:ksrinath.reddy@phfi.org mailto:flavia.senkubuge@up.ac.za#_blank mailto:neil.squires@phe.gov.uk http://www.linkedin.com/search?search=&company=indonesian+epidemiology+network&sortcriteria=r&keepfacets=true&trk=prof-exp-company-name http://www.linkedin.com/search?search=&company=indonesian+epidemiology+network&sortcriteria=r&keepfacets=true&trk=prof-exp-company-name http://www.linkedin.com/search?search=&company=atmajaya+faculty+of+medicine&sortcriteria=r&keepfacets=true&trk=prof-0-ovw-curr_pos http://www.linkedin.com/search?search=&company=atmajaya+faculty+of+medicine&sortcriteria=r&keepfacets=true&trk=prof-0-ovw-curr_pos mailto:kotasehat@hotmail.com mailto:jackwoodall13@gmail.com laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 24 promed. member of one health initiative autonomous team. stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 1 | 14 original research two sides of a broken medal: disease prevention and health promotion in schools of public health zeljka stamenkovic1, helmut wenzel2, janko jankovic1, vesna bjegovic-mikanovic3 1 university of belgrade, faculty of medicine, institute of social medicine, belgrade, serbia; 2 independent consultant, konstanz, germany; 3 university of belgrade, faculty of medicine, centre school of public health and management, belgrade, serbia. corresponding author: željka stamenković address: dr subotica 15, 11000 belgrade, serbia telephone: +381 11 2643 830; fax: +381 11 2659 533; e-mail: zeljka.stamenkovic@med.bg.ac.rs stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 2 | 14 abstract aim: disease prevention and health promotion are closely related through the lifestyle concept and teaching modules on them should be a part of the postgraduate curriculum of every school of public health (sph) in the european region and beyond. we aimed to determine to which degree the european sph offer modules on disease prevention and health promotion in their postgraduate programs, but also the delay in full implementation for the target year 2030 that has been set at 100% for all sphs. methods: the association of schools of public health in the european region (aspher) conducted two surveys on the activities of its members in 2011 and 2015/16. a group of 48 sph responded in both surveys. questions were related to the content offered by sphs, the types of teaching methods that are in use and presentations of the modules at social networks. results: for both modules, the 2nd survey in 2015/16 shows slightly less positive results as compared to the 1st survey in 2011 (72.9% vs. 77.1% and 81.3% v. 87.5%). the only exception is the use of social media which increased for disease prevention from 20.8% to 37.5% of all sph and for health promotion from 22.9% to 39.6%. referring to the set target of 100%, delays between 4 and 13.5 years accumulate for the target year 2030. conclusion: with the exception of the use of social media, progress towards 2030 is slow or even negative. serious efforts have to be made by aspher to revert this process. keywords: disease prevention, european region, health promotion, schools of public health. acknowledgments: the authors would like to thank all members of aspher for their commitment in responding to the survey questionnaire and providing examples of good practices in education, training and research for public health. conflict of interest: none declared. stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 3 | 14 introduction health promotion and disease prevention are closely related through the lifestyle concept and can be considered as two sides of the same medal. whereas research in the field of prevention tries to analyze, detect and modify risk factors which may with a certain probability lead to disease, in the field of health promotion efforts are made to find out how to change risky lifestyles, at the individual as well as at the community level by identifying upstream system determinants as codified in the ottawa charter (1) and their impact on health defined in health in all policies (2). the ottawa charter recognized the need to reorient the health system towards health promotion and disease prevention with a focus on environments and policies that can make the healthy choice the easy choice (1). recent global policy priorities of the united nations have given further impetus to health promotion and to an increased focus on equity in prevention. the most prominent global policy includes sustainable development goals 2030 with its focus on equity – ensuring that ‘no one is left behind’ (3). except for ottawa charter where the concept of health promotion is elaborated, who defined 10 main categories of essential public health operations (ephos), out of which "health promotion including action to address social determinants and health inequity and disease prevention, including early detection of illness" represent two core services delivery of ephos (4,5). additionally, health promotion, health protection and disease prevention is one of the 6 main chapters of aspher’s european list of public health generic core competences for the public health professional (6). in this regard, health promotion and disease prevention are an essential composite of any bachelor or master program in public health. all european schools of public health (sph) should offer these two modules in their programs with a focus on modifiable risk factors. there are two interrelated modern risk behaviors, the sedentary lifestyle and, usually associated, the intake of high caloric food and alcoholic beverages which both lead to overweight and elevated levels of blood pressure and cholesterol as well to diabetes mellitus, often accompanied by smoking as a key risk factor for lung cancer and cardiovascular diseases (7). on the other hand, physical inactivity and eating habits are the leading modifiable risk factors (8,9). the individual consequences in terms of reduced quality of life can be considerable (10) but also the socioeconomic costs constitute a heavy economic burden for the population (11). thus, health is more than an individual concern. a public health educational capacity in european countries significantly increased during the last decades and manifests itself in a growing membership (schools and university departments of public health) of the association of schools of public health in the european region (aspher): during 2006–2016, from 69 to 112 institutional members situated all over europe (12). there are numerous public health programs offered across europe. the most frequent include bachelor and master’s programs in comprehensive public health. also, together with programs for specialization in public health for physicians and nurses, continuing education supporting the process of lifelong learning, they form a relevant background for shaping a generalist professional, accredited and authorized in comprehensive public health (12-14). however, if we focus on the two priority fields of health promotion and disease prevention, the broader corresponding modular concepts on teaching and training can be described as a framework for two standard training modules (15): stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 4 | 14 health promotion. scholars will be prepared to design, implement and evaluate health promotion programs at all levels from local to international. health promotion is fundamental to public health and forms an integral part of all public health activities. scholars will review the development of health promotion, studying key documents such as the ottawa charter, jakarta declaration and related international statements. both the theoretical and practical aspects of health promotion will be examined, exploring different models of health and methods of achieving behaviour change on a population and individual basis. detailed competency profiles have been published for disease prevention and health promotion by the aspher (6) and for health promotion by the international union for health promotion and education (iuhpe) (16). disease prevention. scholars will be introduced to the basic principles, methods and application of screening in early detection and prevention of disease. they will be taught to calculate basic parameters of screening tests: sensitivity, specificity, positive and negative predictive values. also, they will be introduced to take into account the ethical and economic aspects of screening, as well as the planning and organization of screening programs. special attention will be paid to the assessment of the effectiveness of screening, such as randomized controlled trials, prospective cohort and case-control studies. economic evaluation methods, such as cost-effectiveness-analysis, cost-utilityanalysis, cost-benefit-analysis, and technology assessment tools are available (6). study objectives in this paper, we attempt to analyze: 1. to which degree the european sphs offer modules on disease prevention and health promotion in their postgraduate master-programs; 2. the distribution of different types of teaching methods that are in use for modules on disease prevention and health promotion; and 3. the delays in the implementation of disease prevention and health promotion teaching modules. methods research design and study population aspher conducted two methodologically equal studies on the activities of sphs in the european region between january 2015 and march 2016 (survey ii (17)) and in 2011 (survey i (13)). between two surveys, the membership of aspher increased from 80 to 96 members with approximately the same percentage participating, 66 (82.5%) in 2011 and 78 (81.3%) in 2015/16. however, this analysis focused on the 48 sphs which responded in both surveys. data collection the online questionnaire for survey ii was made available by aspher with a few modifications vs. the one used in survey i. questions were related to the content areas offered by sphs, the types of teaching methods that are in use (% of hours approximately spent per method) and presentations of the offered modules at social networks. data analysis the statistical analyses were done using the methods of descriptive and analytical statistics. in descriptive data analysis, absolute numbers and percentages were used. graphs and tables were used to display data. to determine delays in the implementation of the respective teaching modules we used a gap stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 5 | 14 analysis according to the united nations development program (18). the data analysis was done with tibco software (19). results the comparison of the frequency of teaching modules on disease prevention and health promotion in the aspher surveys of 2011 and 2015/16 is shown in table 1. the second survey (2015/16) showed slightly less positive results as compared to the first survey (2011) regarding both programs (table 1). while in 2015/16 there were 35 sphs that tough disease prevention, in 2011, 37 sphs offered this module (table 1 a). the same pattern has been observed regarding health promotion module that was offered by 39 sphs in 2015/16 vs. 42 sphs in 2011 (table 1 b). table 1. comparison of the frequency of modules on disease prevention and health promotion in the aspher surveys of 2011 and 2015/16 a. comparison i: frequency in dp module in both surveys second survey 2015/16; disease prevention ii yes no sum first survey 2011 disease prevention i yes 27 (56.3) 10 (20.8) 37 (77.1) no 8 (16.7) 3 (06.3) 11 (22.9) sum 35 (72.9) 13 (27.1) 48 (100.0) b. comparison ii: frequency in hp module in both surveys second survey 2015/16; health promotion ii yes no sum first survey 2011 health promotion i yes 35 (72.9) 7 (14.6) 42 (87.5) no 4 (08.3) 2 (04.2) 6 (12.5) sum 39 (81.3) 9 (18.8) 48 (100.0) c. comparison iii: frequency of both modules in 2011 survey first survey 2011; health promotion i yes no sum first survey 2011 disease prevention i yes 37 (77.1) 0 (00.0) 37 (77.1) no 5 (10.4) 6 (12.5) 11 (22.9) sum 42 (87.5) 6 (12.5) 48 (100.0) d. comparison iv: frequency of both modules in 2015/16 second survey 2015/16; health promotion ii yes no sum second survey 2015/16 disease prevention ii yes 32 (66.7) 3 (06.3) 35 (72.9) no 7 (14.6) 6 (12.5) 13 (27.1) sum 39 (81.3) 9 (18.8) 48 (100.0) stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 6 | 14 frequency of modules for disease prevention and health promotion in surveys i and ii (n=48) is presented in figure 1. out of the 48 sphs in this analysis, 11 sphs in the first and 16 sphs in the second survey did not indicate to teach both subjects (“either/or” plus “none”). while disease prevention was taught by 27 sphs in 2011 and 2015/16, health promotion was offered as a teaching program in 35 sphs in both survey years (figure 1). figure 1. frequency of modules for disease prevention (dp) and health promotion (hp) in surveys i and ii (n=48) dp i & dp ii = disease prevention in survey i & ii hp i & hp ii = health promotion in survey i & ii dp i & hp i = disease prevention & health promotion in survey i dp ii & hp ii = disease prevention & health promotion in survey ii the proportion of methods in teaching and training for disease prevention and health promotion programs are shown in table 2 and figure 2. all methods of teaching and training were more prevalent for health promotion program than disease prevention programs. however, when comparing survey i (2011) and survey ii (2015/16) for both programs, significantly lower participation of all forms of teaching methods was observed in the latter year. the exception is the presentations of programs at social networks which increased almost double for both programs (disease prevention: from 20.8% to 37.5%; health promotion: from 22.9% to 39.6%). 27 35 37 32 18 11 5 10 3 2 6 6 dp i & dp ii hp i & hp ii dp i & hp i dp ii & hp ii both either/or none stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 7 | 14 table 2. methods in teaching and training for disease prevention and health promotion disease prevention health promotion teaching methods survey i survey ii survey i survey ii lectures 37 (77.1) 29 (60.4) 42 (87.5) 31 (64.6) small group work 37 (77.1) 30 (62.5) 41 (85.4) 33 (68.8) practice training 33 (68.8) 25 (52.1) 38 (79.2) 26 (54.2) fieldwork 25 (52.1) 21 (43.8) 28 (58.3) 23 (47.9) social networks 10 (20.8) 18 (37.5) 11 (22.9) 19 (39.6) figure 2. methods in teaching and training for disease prevention and health promotion (n=48) the results of the gap analysis for disease prevention and health promotion programs towards the target years 2020 and 2030 are shown in table 3. the target set at 100% in 2030 requests all 48 sph to offer both modules in 2030 the latest. this allows to determine the time gap, i.e. the time remaining to achieve the agreed target of 100% earlier or with delay, based on the progress made between 2011 and 2015/16. 37 29 42 31 37 30 41 33 33 25 38 2625 21 28 23 10 18 11 19 disease prevention survey i disease prevention survey ii health promotion survey i health promotion survey ii lectures small group work practice training field work social networking stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 8 | 14 table 3. gap analysis for disease prevention and health promotion of 48 sph in the european region towards the 100% target for the years 2020 and 2030 target: 48 sph offer programs on disease prevention and health promotion latest in 2020 resp. 2030 2011 2015/16 time gap to the year 2020 target time gap to the year 2030 target disease prevention 37 35 -5.6/-1.13 -7.5/-0.50 health promotion 42 39 -8.5/-1.70 -13.5/-0.90 both programs together 37 32 -8.1/-1.62 -12.6/-0.84 both programs either/or 42 42 -4.0/-0.80 4.0/-0.27 social networks in prevention 10 18 -2.1/-0.42 0/0 social networks in promotion 11 19 -2.1/-0.41 +0.1/+0.01 however, we found a considerable delay between 2.1 and 8.5 years for 2020 because of the negative trend between 2011 and 2015/16 between 4 and 13.5 years accumulating for 2030. the same tendency we find for the training/teaching methods with regard to lecturers, small group work, practice training and fieldwork (data not shown in the table). the only exception of these trends is the use of social networks with a much smaller delay of only 2.1 years for 2020 and achievement in time for 2030. discussion this study provided valuable information on to which degree the european sphs offer modules on disease prevention and health promotion in their postgraduate programs including continuing education and to comparable analysis of the results from two surveys conducted in 2011 and 2015/16. however, the results are disappointing. there is a significant decline in the number of sphs that offer these modules. also, the proportion of all teaching methods such as lectures, small group works and practical works for these two modules has been decreased. since noncommunicable diseases are substantially preventable and investment in the prevention of risk factors and health promotion could benefit the whole population, the central question is why the decline happened in 5-years period and why it is important to put disease prevention and health promotion in the focus of curricula for future ph professionals. one of the possible explanations lies in the fact that there is not a clear distinction between disease prevention and health promotion. although the core competencies for health promotion and disease prevention have been elaborated during the last decade and published in who european action plan for strengthening public health capacities and services (4,5) and aspher’s european stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 9 | 14 list of public health generic core competences for the public health professional (6), these two programs interrelate so it might be possible that students learn about both within one program. a small number of sphs that offer programs on health promotion and disease prevention might be a reflection of the lack of investment in the necessary health promotion and primary prevention systems at a global level which has been recognized by the international union for health promotion and education (iuhpe) (20). big community trials on health promotion and primary prevention have shown to effect upon non-communicable diseases at the population level (21). these successes should have been reflected in postgraduate education. as werkhoven et al. stated, perceptions held or acquired during tertiary study can influence health promotion students’ interactions with their future clientele and their long-term sustainability as health promotion practitioners (22). since current trends in the field of health promotion and disease prevention emphasize community-based programs employing multiple interventions as the main strategy for achieving population-level change in risk behaviors and health, the focus should be on a communityand population-based approach representing a shift in emphasis from individually focused explanations of health behavior to ones that encompass social and environmental influences (23, 24). this paper focuses on postgraduate education including continuing education where the latter is especially important to close deficits in primary health care provision. only a minority of primary health care physicians understands health promotion as an integral part of practice (25). also, the european union sees both subjects interlinked (26,27), but to transfer the community dimension into primary health care may prove extremely difficult as leppin et al. concluded from their study in southeast minnesota: primary care and community-based programs exist in disconnected worlds (28). by transferring the community dimension to primary health care, most of the activity falls within the role of health professionals and health-care providers in primary care which could be an additional burden (29). a more optimistic analysis is presented by march et al. after review of 39 health-promoting community interventions concluding that nevertheless there is lack of evidence on many community interventions in primary health care (30). however, in western countries, there are many primary care-based chronic diseases intervention studies that confirm positive effects (31,32) which encourage us to achieve the best possible effects on population health. the systematic review of health promotion and disease prevention strategies in some curricula revealed that the inclusion of health promotion and disease prevention programs varied considerably, but was strongest in programs claiming social accountability and responding to medical education standards of the more influential regulators (33). this is a pattern that should be applied at the postgraduate level as well. although the contribution of medical education to improvements in health care and the health of populations is difficult to measure, examples are demonstrating that investment in these programs brings benefits to the population. as such, north karelia project is a classic example of a big community trail that has shown the feasibility of interventions at the community level and with a specific focus in preventing ncds especially cardiovascular diseases (34). similar programs were conducted the united states leading to a significant decrease in blood pressure levels and improvement in blood pressure management (32). stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 10 | 14 since physical inactivity, unhealthy diet, and harmful use of alcohol are the common risk factors for ncds such as hypertension, cardiovascular diseases, and cancers, with all these projects the focus has shifted from cardiovascular disease prevention to ncd prevention due to the similarity in risk factors. the overwhelmingly disappointing results of our study concerning the expected progress in teaching and training identified in the european region can be described as the two sides of a medal but unfortunately, the one with cracks. not only the number of schools that offer these programs decrease but the proportion of teaching methods of the respective modules is unsatisfactory. however, the increase of social networks for program presentation is visible as a bright side of the unexpectedly discouraging results but still could be better. after finishing the first survey, the authors identified lack of modernity regarding continuing education (13,35) as a potential space for improvement. since the use of social networks has been almost doubled for both modules, these results could be viewed as a shift from traditional to modern technological advances. further, it represents a ground for the future use of social networks not only for the presentations of programs but for the full process of learning and teaching. with technology advancements, it seems that traditional ways of learning are likely to be replaced with blended or online learning. it is important to highlight some limitations of the study. at the time of the second survey in 2015/6 aspher had 96 members out of which only 48 or 50.0% could be subjected to our analysis therefore results may be less representative. also, the study design is limited by potential bias because the quality of answers to the questionnaire could not be controlled. in addition, the two surveys have been conducted five and ten years ago, respectively and may not provide an accurate picture of aspher’s institutional membership as of today in 2021. however, there is no indication that the picture changed considerably in the last five years. to stimulate improvement, it may be preferable to assume an estimated straight trend of development. also, the two subjects may overlap to some degree in the practice of lecturing which could be the reason for a more favorable picture then analyzed here. the projected progress towards achievement of the sdgs in 2030 as calculated on the basis of the years 2011 and 2016 seems to be too slow in many areas: in the delay of up to 13.5 years. only for achieving targets for presentation at social networks for both programs, a significant delay is observed in all program areas. the long time passed since the collection of information in the field remains the main limitation for identification of the causal factors responsible for the slow progress during the period between the two surveys. a future study in 2021 focusing on the progress and innovations would be of a great interest. in survey ii several proposals for improvement have been made (17) out of which the following may relate especially to teaching health promotion and to some degree also disease prevention and may partly be implemented since: 1) to correspond adequately to the comprehensive character of the key topics in public health it is certainly advisable to move towards a mix of modular transversal courses and schedule an increased number of hours for learning in small groups and/or extend field practice, especially in remote rural or disadvantaged urban areas. this move is expected to be accelerated by the coronavirus pandemic in 2020. stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 11 | 14 2) to provide knowledge and experience in the cultural dimension of health and train intensively communication skills and how to interact with the general public. 3) to interact with the policymaking process at the local and national level in order to overcome resistance on the side of governments to implement health policies in collaboration with the researchers. conclusion the study clearly indicates the significant decline in the number of sphs that offer disease prevention and health promotion modules. the share of all teaching methods such as lectures, small 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national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 1 | 16 review article national health systems strengthening as the primary strategy to achieve universal health coverage in african countries yasir ahmed mohammed elhadi 1,2, yusuff adebayo adebisi 3, uchechukwu victor abel 3, ekpoh mfonobong daniel 4, ashraf zaghloul 1, don eliseo lucero-prisno iii 5 1department of health administration and behavioral sciences, high institute of public health, alexandria university, alexandria, egypt 2department of public health, medical research office, sudanese medical research association. khartoum, sudan 3faculty of pharmacy, university of ibadan, ibadan, nigeria 4faculty of pharmaceutical sciences, university of port harcourt, nigeria 5founder and managing director, global health focus africa corresponding author: yasir ahmed mohammed elhadi; address: high institute of public health 165 el horreya avenue 21561 alexandria, egypt; email: hiph.yelhadi@alexu.edu.eg author's contribution: yasir elhadi developed the concept for this paper and wrote the first draft. yasir elhadi, yusuff adebisi, uchechukwu abel and ekpoh mfonobong assisted in data search and draft of the manuscript with important contribution from ashraf zaghloul and don lucero-prisno iii in writing reviewing and editing. mailto:hiph.yelhadi@alexu.edu.eg elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 2 | 16 abstract africa is the second largest continent and has its socioeconomic and health peculiarities. countries are faced with varying challenges towards its universal health coverage (uhc) achievement and hence the region requires health system reforms to drive equitable and balanced medical services to its populace. the main objectives of the paper were to explore the complexities of the african health systems, subsequently highlighting major challenges to uhc and to provide a framework for strategic approaches to health system strengthening to ensure realization of uhc. information presented in this paper was collected from published literature and reports on rwanda, kenya, nigeria, tanzania, ghana, tunisia, democratic republic of congo, zambia, egypt and south africa, amidst other african countries. the published literature points to the presence of a somewhat slow progress towards uhc or at least an existent knowledge of it. however, common challenges faced can be grouped into 1) financial constraints which include low levels of government expenditure on health and increased out-of-pocket percentages, (2) lack of coverage of key services which includes majorly immunization rates and existence of health insurance for citizens, (3) input constraints ranging from drug availability to skilled healthcare workforce, information and research and (4) lack of political support and commitment towards universal health coverage. to overcome the above-stated constraints, two broad groups of interventions were identified; general interventions largely focusing on reprioritization of health budget, quality and improved services, equipped facilities and efficient social protection systems; and specific interventions which emphasizes the importance of eliminating shortage of health workers, ensuring availability of essential medicines/ products, embracing decentralization at supply chain management, validating data/ information system and advocacy for impactful health education/promotion. although there will be strength and weakness for whatever reforms adopted, implementation is totally contextual and contingent upon countries' specific health system bottlenecks. keywords: universal health coverage, health system strengthening, africa, framework, health sector reform. sources of funding none conflicts of interest the authors declare no conflict of interest acknowledgement we would like to thank dr. augustinoting mayai for assistance and mentorship elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 3 | 16 introduction the world health organization's (who) definition of universal health coverage is "all people have access to services and do not suffer financial hardship paying for them" (page ix) (1). the need to build consensus on the definition of uhc is crucial for setting priorities, polices and budgeting changes needed to realize uhc (2). the principle of universal health coverage aims at ensuring equitable and efficient access to health services. therefore, it has become priority objective and major goal of health reform in many countries (3). health system reform interventions are complex in nature depending on a country's individual context and system bottlenecks, these interventions take place at different levels in the health system. achievement of uhc through continued health systems reform in african countries is, therefore, the most promising strategy. the experience of different countries in implementing uhc strategies has revealed successful lessons and pitfalls to avoid in ensuring the progress towards universal health coverage (4). the health system strengthening (hss) initiatives are usually composed of multiple strategies designed to work at different levels and components of the health system (1). recognizing complex interconnections and interactions of combined strategies, health planners and policy makers should account for proper coordination between the intervening links and pay more attention in designing specific interventions (4). many health system frameworks have been developed to focus on strengthening health systems to improve health outcomes. the available frameworks differ in conceptualising health systems' functions, which directly influence strategies and policies (5). this review aims to evaluate progress towards uhc and introduce holistic approaches to strengthening health systems in 10 african countries (rwanda, kenya, nigeria, tanzania, ghana, tunisia, democratic republic of congo, zambia, egypt and south africa) by using who health system framework. methods this is a review study on health systems strengthening strategies and progress towards universal health coverage in 10 african countries (rwanda, kenya, nigeria, tanzania, ghana, tunisia, democratic republic of congo, zambia, egypt, and south africa). reviews of published articles and official reports were used to gather information on progress toward universal health coverage in studied african countries and key challenges in african health system components. the search was done on 13th to 19th july 2020 using pubmed, medline, and scopus electronic databases and public search engines such as google scholar and google. the relevant keywords used in the search consisted of phrases considered by the authors to describe targeted information about service delivery, health workforce density and distribution in african countries, health financing, leadership and governance, health information systems and research, and health systems strengthening strategies and interventions. search query was adapted to the specific needs of each database. search phrases used were "healthcare services delivery in africa", "health workforce density in africa", "health financing in african countries", and "health information systems in africa", "health system strengthening strategies", "universal health coverage in africa". additionally, latest published reports of the who, world bank and fmoh on rwanda, kenya, nigeria, tanzania, ghana, tunisia, elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 4 | 16 democratic republic of congo, zambia, egypt and south africa were also reviewed to provide in depth analysis of health systems problems and impediments to uhc in each country. finally, the authors provide a framework for health systems strengthening in the african region, general and specific interventions to overcome the reported health systems bottlenecks and constraints to uhc in the african countries based on evidence-based guidelines and lesson learned from previous countries' experience. results progress toward uhc in african countries the uhc monitoring framework developed by the world bank and the who focuses on the coverage of critical services, population coverage, and financial protection (6). our analysis of the extent of service coverage included maternal health-related indicators, access to essential hiv/aids services, and childcare interventions, amongst others. most of the interventions related to maternal health have improved in the last couple of decades in these selected countries; antenatal care visit (at least 4) has increased by about 40% between 2004 and 2014, and the proportion of birth attended by skilled health personnel has improved by about 10% in the last decade coming up to 2014. the most rapid improvement has been the change in the coverage of insecticide-treated bed nets for children increasing on average by about 15% per year between 2006 and 2014. prior studies show notable variation in antiretroviral therapy (art) coverage among people with hiv eligible for art ranging from 17% in north africa to 54% in esa in the year 2016 (7). the coverage of diphtheria-tetanus toxoid (dtp3) vaccination has seen an increase over the period except for five countries (benin botswana, equatorial guinea, kenya, and south africa), among which equatorial guinea is the only one with a 35% coverage rate (7). health financing total health expenditure in the region has grown over the last two decades. (8) shows the trend of total health expenditure for the african region over a period of 9 years. we see that more countries have been increasing expenditures on health over this period although the rates vary among the countries. for example, information from the 2010 world health report (9) indicates that rwanda more than doubled its per capita expenditure on health over a period of 10 years, with a large part of this increase attributed to external funds (9). however, three countries have remained below the expenditure level of us$ 20 per capita, with thirty countries persistently spending over us$ 44 per capita over the same period. in 14 of the 47 countries included in the above analysis, the level of funding for health was below the minimum level of us$ 44 per capita recommended for 2009 by the high level task force on innovative international financing for health systems (8). information and research low investment in data management infrastructure shows that priority is not given to health research and data, which are crucial for sustainable development. consequently, several functions. hence, several functions of the health research systems are either non-existent or weak. furthermore, the research elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 5 | 16 arena in the african region is characterized by a multiplicity of externally driven agendas, dispersed efforts, and unclear results in relation to impact on priority health problems. in addition, although publications have increased by 10.3% each year in recent years, this has not translated into the conversion of evidence to policy and calls for more to be done (10). health workforce statistics as at 2016 show that twenty-five percent of doctors, and five percent of nurses trained in africa are currently working in developed countries. this brain drain has resulted in a shortfall of over 1.5 million health workers in the region (11). table 1 shows the health workforce density of ten countries in the region. “the health sector in rwanda has pioneered task-shifting by transferring agency for many clinical decisions and activities to nurses and community health workers” (12). however, a persistent shortage of adequately trained health professionals poses a major barrier to scaling up the availability and quality of specialized care. in 2016, nearly 70% of the health workforce was composed of nurses and midwives. the density of doctors, nurses and midwives per 1,000 population is estimated to be 1.01, 108% increase since 2005, rwanda still falls far below the minimum level recommended by the who of 2.3 providers per 1000 population (13). in nigeria, the health workforce density is estimated at 1.95 per 1000 population (14) as at 2016. table 1: density of doctors, nurses and midwives per 1,000 population in the 10 african countries source: world bank data. country density of doctors per 1,000 population nurses & midwives per 1,000 population ghana (2017) 0.18 4.2 rwanda (2017) 0.13 1.2 nigeria (2018) 0.38 1.2 kenya (2018) 0.16 1.2 drc (2016) 0.07 1.1 tanzania (2016) 0.01 0.6 zambia (2018) 1.2 1.3 south africa (2017) 0.9 1.3 egypt (2018) 0.5 1.9 tunisia (2017) 1.3 2.5 elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 6 | 16 lessons learned from previous countries' experience and major barriers to uhc despite the great diversity of african countries, many of them are facing common challenges; these can be grouped into financial constraints, coverage of key services and input's constraints. the key financial constraints are low levels of government expenditure on health and overall expenditure on health. among ten countries studied in the region, it was shown that seven of which allocated less than 5% of the gross domestic product (gdp) as expenditure on health in 2017. the average government expenditure on health as a percentage of the gross domestic profit (gdp) was 4.75% ranging from 3.2% in ghana to 8.11% in south africa. government spending on health as a percentage of total government spending varied, from a low of 3.3% in drc to a high of 13.63% in tunisia. government spending on health as a percentage of total health spending appears to be decreasing moderately over the past decade for countries, rwanda and tanzania, whereas south africa maintained a relatively stable share while egypt and kenya experienced an increase in 2017 (15). rwanda appears to be the most advanced country in africa regarding universal coverage. the country has achieved 96.15% coverage in health insurance as of 2011, with a 95% utilization rate (16). out of pocket expenditure as a percentage of total health expenditure was as low as 6.25% in 2017 (18). the world health organization states that it is very difficult to achieve uhc if out-ofpocket (oop) as a percentage of total health spending is equal or greater than 30%. the who defines households with catastrophic health expenditure (che) as a household with a total oop health payment equal to or exceeding 40% of a household's capacity to pay. a non-poor household is impoverished by health payments when it gets poor below the poverty line after paying for health services (17, 19) the share of oop as a percentage of total health spending ranged from a low of 6.25% in rwanda to a high of 77.22% in nigeria in 2017. in 2013, south africa had a rate of 39%, in zambia it was 11% in 2014, 18% for tanzania in 2009, drc was 45% in 2015, kenya was 22% in 2013, ghana was 12% in 2006, no data was available for egypt, tunisia for recent years (18). households covered under health insurance, engaged in mutual health organizations, or an informal social safety network have a reduced risk of catastrophic spending (20, 21) as informal financing mechanisms through mutual organizations, “informal groups and merry go rounds unlike formal health insurance is observed to reduce the risk of che” (22). in certain cases, health insurance, however, is not a significant determinant, as for instance, in kenya, where it only covers a small proportion of households and only inpatient services (23). for coverage of key services for uhc, a key indicator is immunization rates. as (8) shows, dtp3 immunization coverage among children ages 12-23 months has decreased roughly in ghana, rwanda, tanzania, south africa, egypt, tunisia, increased sharply in kenya and steeply in drc in the most recent years. in general, rates have fluctuated in all these countries in the last decades with a relatively constant rate in nigeria from (2017-2018). tanzania consistently has the highest vaccination rates of 98% and above during this period, followed by ghana, rwanda and tunisia at 97%, the countries with working national or community-based insurance schemes in africa. governments have used different methods to expand coverage for health services for some vulnerable groups; countries such as ghana, rwanda have exemption guidelines within the health financing framework that target poor and vul elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 7 | 16 nerable groups. however, many of these targeted services are not within the reach of the poor and, as a result, many are not covered by health insurance schemes. of the selected countries, rwanda is the only one with wide coverage of the poor (24). the "ubudeheprogramme" in rwanda has been proven effective in identifying those most in need of exemptions under the cbhi. tanzania and kenya have no specific exemption guidelines for the poor, but some waivers are given to patients in tanzania who are assessed to be too poor to pay their bills. in ghana, after almost twelve years of introducing national health insurance less than 40% of the population is covered by the scheme and less than 2% of them make up the poor. input's constraint comprises of the availability of drugs, human resources, data collection, and skilled workforce. insufficient healthcare providers and unequal distribution of health professionals continue to remain significant problems in the african countries (table 1). the ratio of doctors ranged from one doctor per100, 000 populations in tanzania, to 130 doctors per 100,000 populations in tunisia. in all the african countries, there were more nurses and midwives than doctors in the population. the shortage of health workers in sub-saharan africa (ssa) is due majorly to high attrition rates and the inability to produce and recruit the appropriate cadres of health workers (25–28). in 2015 fifteen countries in ssa had developed the human resource for health (hrh) policy and strategic areas that all the hrh plans included were the scaling up of the education and training process of health worker. earlier in 2012, rwanda announced collaboration between the u.s., rwandan governments and 1https://hms.harvard.edu/news/how-rwanda-dramatically-expanding-its-health-workforce 25 leading u.s. academic institutions in fulfillment of their hrh plans. $150 million program launched in kigali. under the program, each year more than 100 american health care professionals from medicine, nursing and midwifery, dentistry and health management work in rwanda alongside rwandan faculty to build residency programs, strengthen instruction quality and substantially increase the output of new health workers. rwanda's example and the human resources for health program in particular, have the potential to transform global health by serving as a model for any country that wants to increase the efficiency of foreign aid and improve the health of its people.1 the major challenges and barriers toward uhc can also be contextualized in each of the african countries included in this study. ghana was the first country in africa to finance its national health insurance scheme with revenue from a value-added tax (vat), this means that revenue can benefit from its economic growth (29). however, ghana stills struggles with how to attain universal population coverage under this scheme as it currently has active coverage around 40 % of the population (30). from 2010 to 2012, public and external assistance declined, while the share of private expenditure (mostly out-ofpocket payments) tripled, indicating an increased financial strain on its citizens (6). in rwanda, inadequacy in the health workforce and insufficient funds has hindered access to health services for some 80 per cent of the population thereby hindering progress toward uhc for the population. the ratio of doctors to population in rwanda is amongst the lowest in africa (13 doctors for every 100,000 population, 2017). although this deficit in health workers i.e. doctors, nurses https://hms.harvard.edu/news/how-rwanda-dramatically-expanding-its-health-workforce https://hms.harvard.edu/news/how-rwanda-dramatically-expanding-its-health-workforce elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 8 | 16 and midwives “was partly compensated by the large number of chws who visit people's houses to monitor health events and suggest early intervention”, improvements are needed for effective and timely access to health care in rwanda. furthermore “in addition to the insufficient number of skilled health workers, capacity building is needed for health workers and managers. distribution of health workers across regions has to be made more equitable, especially between urban and rural areas. cbhi's low contribution rates have resulted in hospitals bearing large debts and patients having to buy drugs themselves from pharmacies without reimbursement”. (31). in nigeria, one of the main challenges that have affected its attainment of uhc is inadequate government health financing and budgetary allocations to the health sector. the government is yet to commit to adequate health financing and budgetary provisions for the health of nigerians. out‐of‐pocket payments estimated at 77% as at 2017 (6) is said to be the most common source of health‐care financing in nigeria. similarly, since the nhis (national health insurance scheme) was launched in 2005, only the contributions from government (employer) are still largely available to fund the contributory social health insurance scheme. in kenya, the main problem is simply a shortage of government budgetary resources for health care in relation to increasing demand and need for care. the effect of the budgetary shortfall is seen in the deterioration in the quality and effectiveness of publicly provided health services (32). “in addition to an absolute shortage of resources going into the health sector, patterns of spending in most countries cause or reflect an inequitable and inefficient allocation of inputs and services. the clearest example of this is the concentration of government resources in large, urban hospitals. on average, people who live in urban areas have higher incomes than those in rural areas, yet the urban bias in government health spending means that the costs of gaining access to good quality care are highest for the most remote, and usually poorest, groups of the population” (33). in the drc, with less than 10% of the urban population covered by formal health insurance programs and even less for the rural population ensures that the national health system heavily relies on households' direct contributions. thereby, the financial risk incurred by the households in the region increases, which serves as the biggest barrier to achieving uhc (34).i n zambia, although zambian governments have increased and continue to increase domestic funding for the country's health services, the health system as a whole is subsidized by foreign donor funds and that funding is decreasing since 2010 following the global financial crisis. also, changes in the composition and concentrations of the national population have also led to an increase in chronic non-communicable diseases (35). health system strengthening framework for african countries it is not acceptable that some members of society should face death, disability, ill health, or impoverishment for reasons that could be addressed at limited cost” (36). the need for a clear health system strengthening guide has recently grown, especially among stakeholders working at the country level. with many available competing frameworks health planners and policy makers often encounter conceptual confusion, which hinders them from properly defining and describing their health system functions; and accordingly designing and implementing the suitable interventions. efforts have been continuously directed to address this confusion through conversion of elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 9 | 16 multiple frameworks to revitalize available strengthening approaches (37). the access, bottlenecks, costs, and equity (abce) project, led by institute for health metrics and evaluation (ihme) and country collaborators in ghana, kenya, uganda, and zambia, is an example of the kind of comprehensive and detailed assessment that is a top priority to health policymaking and resource allocation – and which rarely occurs because health system functions worldwide are complex and multidimensional (38). developing of strong health financing system is a main goal for all african countries. according to the world bank classifications most of african countries ranked in area of lowand middle-income countries, so shortage of funds for health in these countries and insufficient investments in the health sector is critical challenges to enhancing health outcomes in africa. world health organization highlights three main policies that aim to strengthen the financial health system in africa; aligning budget resources and health priorities; closing the gap between health budget allocation and expenditure; maximizing uhc performance with the money available (39). community-based health planning and service approach one of the best approaches in increasing community commitments towards health system strengthening, enhancing equitable access, delivery of primary health care, and resource mobilizations (40). table 2 below summarizes main bottlenecks (problems) of health system components in the african region with related strengthening strategies. table 2: health system strengthening framework for african countries health system component current problems strengthening strategies health financing reliance on out-of-pocket payments. lack of investment in health sector and overdependence on funds from foreign donors. increase social insurance schemes, encourage progressive taxation, reprioritize government budgets to reduce impoverishment and give money to health. internal assessment of country's revenue modalities/ matched funding. strengthen domestic mechanisms for prepaid funding. workforce workforce shortage and unequal distribution at sub-national level. increase support and facilitate medical education. engage informal community health workers. redistribution of human resources throughout rural areas. leadership/governance graft and corruption. politicians appointed as health ministers and not health experts. populist decision making and not based on science. poor/lack of evidence-based enacted policies appoint professional managers. train them in good governance, transparency and accountability. implement properly laws on graft and corruption. utilization of technical expert in evidence-based policy making. elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 10 | 16 discussion selection, implementing and monitoring of health system strengthening strategies relative prioritization debate in selecting specific strategies for a particular context has always been evolving among global health stakeholder, heath planners and policy makers. complexity of interconnection in intervening links directly influence relative importance of one strategy over the other (5). however, assessment and proper identification of key bottlenecks in health system ensure selection of the most appropriate strategies. achieving universal health coverage despite the diversity of needs and contextual factors in african region requires adopting holistic and combined approaches to guide health system strengthening initiatives. these approaches fall into two recommended strategic domains; general and specific interventions of health system strengthening. general interventions as shown in table 3, these include evidencebased strengthening strategies (41 43) to expand dimensions of universal health coverage in terms of cost coverage, service coverage, and population coverage. table 3: general strategies for health systems strengthening with major strengths and weaknesses. uhc dimension strategies of hss strength weakness cost coverage increasing funds through efficient revenue collection and reprioritization of government budgets to give more money to the health sector. support public, private and social insurance schemes. eliminate corruption with healthcare system. decrease out of pocket payments and reduce financial hardship. may impact the overall government budget. service delivery unequal distribution of health facilities between urban and rural areas unnecessary medical tourism. build new facilities, partner with civil society organizations (cso), properly maximize international collaborations and improve quality of services for underserved populations through effective primary health care. build infrastructure, equipped to competing standards, expand and ensure sufficient services provision. medical products, vaccines and technologies medicine, medical supplies and supply chain shortages. decrease organizational barriers and introduce more decentralization at supply chain management. information system lack of surveillance systems, knowledge and expertise of it. absence of proper data management and transfer systems. no technical knowledge. build data accountability systems and provide scientific and technical support. deliberately work with research institutes to encourage researchers. elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 11 | 16 service coverage increase provision of health services in term of number and type of services. introduce new health technology based on the need of specific population. monitor quality of services through implementing of quality assurance and quality assessment programs. increase the overall patient satisfaction. may decrease the cost coverage unless additional resources were generated. population coverage redistribution of health care facilities and health workers. construction of localized health care facilities. reduce geographic barriers to access to health services. if disadvantaged and underserved population were not identified properly lead to inefficient use of resources. specific interventions shown in table 4 these strategies are designed mainly to target specific problems that directly impact health system performance, with proper identification and removal of key bottlenecks in the health system and focus mainly on the quality of service provision to underserved and disadvantaged populations. table 4: specific strategies for health systems strengthening with major strengths and weaknesses. health system problem/system bottleneck specific strategies strength weakness health workers shortage increase support and facilitate medical education. engage informal community health workers. redistribution of human resources throughout rural areas. increased competency and skills of staff. build engagement with localized communities. ensure equitable access to good quality health services. some system constrains may limit the implementation of these strategies. elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 12 | 16 supply chain bottlenecks decrease organizational barriers and introduce more decentralization at supply chain management. design alternative supply chains for specific areas based on the specific need of disadvantaged population. increase system responsiveness to supply shortages. ensure delivery of products. unless designed, implemented and monitored properly may lead to inefficient use of resources medicines and medical products shortage reassessment of national priority to select most appropriate products. efficient use of resources and avoid catastrophic impact of life saving health products. unless designed, implemented and monitored properly may lead to inefficient use of resources data unavailability design and implement data accountability system and information-based health centers ensure proper identification of disadvantaged population and their needs. may be limited by environmental constrains. insufficient health education design national health campaigns about country specific disease burden. increase awareness of community and compliance with health advisor. may deplete available human resources for health. implementation of strengthening strategy requires framework that accounts for potential interaction and contextual constrains within the health system. based on previous experience of african countries, strengthening should be considered a continuous learning process; also, adjustment of contextual factors is crucial to ensure effectiveness of interventions (44). engagement of the private sector and public-private partnerships when implementing strengthening initiatives through african countries is strongly recommended (45). however, there is need for effective approaches for monitoring quality of health services provided by the private sector (46-48). conclusion and recommendations uhc is a good economic investment, and we believe the african region has great potential in achieving quality, affordable and equitable healthcare for its populace if the right interventions are made. to stay committed to uhc, it is important that african countries implement country-led strategies/ interventions to better reform their health systems. to overcome the above-stated constraints, two broad groups of interventions are recommended; general interventions largely focused on reprioritization of budget, quality and improved services, equipped facilities and efficient social protection systems; and elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 13 | 16 specific interventions which emphasizes the importance of eliminating shortage of health workers, ensuring availability of essential 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'who | improving health system efficiency', who, 2016. 44. f. c. rwabukwisi et al., 'health system strengthening: a qualitative evaluation of implementation experience and lessons learned across five african countries', bmc health serv. res., vol. 17, p. 826, dec. 2017, doi: 10.1186/s12913-017-2662-9. elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 16 | 16 © 2021 elhadi et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 45. b. mcpake and k. hanson, 'managing the public–private mix to achieve universal health coverage', the lancet, vol. 388, no. 10044. lancet publishing group, pp. 622– 630, 06-aug-2016, doi: 10.1016/s01406736(16)00344-5. 46. d. montagu and c. goodman, 'prohibit, constrain, encourage, or purchase: how should we engage with the private healthcare sector?', the lancet, vol. 388, no. 10044. lancet publishing group, pp. 613– 621, 06-aug-2016, doi: 10.1016/s01406736(16)30242-2. 47. r. morgan, t. ensor, and h. waters, 'performance of private sector health care: implications for universal health coverage', the lancet, vol. 388, no. 10044. lancet publishing group, pp. 606–612, 06-aug2016, doi: 10.1016/s0140-6736(16)00343-3. 48. adebisi ya, umah jo, olaoye oc, alaran aj, sina-odunsi ab, et al. assessment of health budgetary allocation and expenditure toward achieving universal health coverage in nigeria, int j health life sci. online ahead of print ; in press(in press):e102552. doi: 10.5812/ijhls.102552. __________________________________________________________________________ amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 1 | p a g e c review article post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa mcking i. amedari 1, ifunanya carista ejidike 2 1department of preventive and community dentistry, obafemi awolowo university teaching hospitals complex, ile-ife, osun state, nigeria; 2access to medicine foundation, amsterdam netherlands; corresponding author: dr. mcking i. amedari bds, mph; department of preventive and community dentistry, obafemi awolowo university teaching hospitals complex, ile-ife, osun state, nigeria; email: mckingamedari@yahoo.com mailto:mckingamedari@yahoo.com amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 2 | p a g e abstract aim: to analyse options for maximising the capacity of human resources for health to achieve universal health coverage (uhc) in africa. methods: articles were retrieved from a pubmed search and additional snowballing was conducted to provide other relevant sources. further utilizations were made of campbell's modified framework of the human resources for health (hrh) and universal health coverage with the who labour market dynamics framework for universal health coverage. four sub-themes viz improved hrh performance, labour market factors, rural health workers retention factors, and information technology factors were analysed. results: labour market factors such as the dynamics of demand and supply of health workers determine the availability of health workers. supportive supervision enables the health workers to improve in their performance and enhance optimised utilisation of available resources. this supervision can be more effective by complementing it with tools such as information technology that focus on improving the quality of health care, considering the growth in the number of internet and broadband users in the continent. conclusion: expanding the training opportunities for health workers and also increasing the funding to human resources for health are useful policy options to consider. cost-effective approaches such as a focus on community health committees which stimulate the demand for health services in rural communities to tackle the disproportionate distribution of health workers should be considered in the context of the uncertain economic aftermath of the covid-19 outbreak. keywords: covid-19, human resources for health, supportive supervision, market factors, information technology. sources of funding nil acknowledgement we express profound gratitude to prof flavia senkubuge for providing technical help and writing assistance during the preparation of this manuscript. we also appreciate dr. aborisade adetayo for assisting with editing of the manuscript. conflicts of interest the authors declare no conflict of interest. author contributions mia drafted the entire manuscript. ice provided a critical review and made substantial contributions to the design of the manuscript. amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 3 | p a g e introduction africa is inundated with a dual burden of diseases (1). communicable diseases are more prevalent on the african continent than elsewhere, and it is mainly linked with extreme poverty and the poor living conditions that many experience (1). non-communicable diseases (ncds) are also on the rise, especially among poorer communities: its under-reporting, however, makes the spectrum complicated to detect and treat. in countries like namibia, seychelles, and mauritius, 50% of deaths among adults are attributable to ncds (1,2). the covid-19 outbreak has exacerbated poor health outcomes in badly affected countries on the continent culminating in rising cases of ncd related morbidities and mortalities (3). this invariably overburdens health systems that are previously struggling to respond to health needs and further weakens the capacity of human resources to play a central role in mounting a robust response to the emerging health problems in the context of an epidemiologic and demographic transition (1,4). it has become imperative that "adequate, skilled, well trained and motivated" human resources for health is needed in the trajectory towards universal health coverage (4). many countries in africa face socio-economic challenges, with constraints on their fiscal space and limited government expenditure on health (5). some countries are only just emerging from conflict situations or security challenges, or natural disasters that impose specific limitations on the healthcare worker's availability. the number of healthcare workers present at the health centres and the actual number needed at these facilities is customarily imbalanced and although there have been attempts at planning workforce using epidemiological and demographic surveys, not much more attention has been given to the evolving market factors that also influence this situation (6,7). the shortage of health workers is a global challenge, but this is more prevalent in africa with its perilous shortages projected to be up to 6 million health workers by 2030 (7). this shortage becomes glaring in the context of the rural-urban disproportionate health worker distribution despite a larger population size in rural communities (8). beyond availability, possession of adequate competency, motivation to deliver quality health services provided in a culturally acceptable way as well as an equitable distribution of health workers are necessary considerations for effective coverage of the health system (7). community health workers remain an integral part of the workforce in rural communities and have to deal with multifarious tasks and poor remuneration in carrying out their duties. nevertheless, with attention to supportive supervision, it is suggested that this will enhance the motivation and the performance of these workers and also improve the quality of health care (9). additionally, investment in innovative technologies for health systems has also been suggested as a cost-effective solution to challenges such as lack of trainers or quality guidance for the workers in the frontline (10). while the focus is on human resources for health, implementation and contextual factors limit interventions to improve health outcomes in africa. this review seeks to analyse options for maximising human resources for health to achieve universal health coverage in africa. methods the review uses themes from the campbell's modified framework of the human resources for health (hrh) and universal health coverage (uhc) with the who labour market dynamics framework for universal health coverage presented in the who global strategy for workforce towards uhc in 2030. by focusing on the common difficulties that affect health amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 4 | p a g e worker training, retention, performance and quality of service provision according to the hrh strategy document (7), sub-themes were purposively determined to guide the analysis in this review. these include labour market and the availability of health workers, retention of health workers in the rural areas, training (supportive supervision) and information technology to improve performance. a detailed search was next conducted utilizing the pubmed database. this database was selected because it comprises the largest collection of peer-reviewed articles globally. there are over 30 million citations on the database and fulltext contents are linked with it. the search was guided by the four study sub-themes and conducted using several keywords including: "market forces", "market factors" "human resource for health", "hrh", "africa", "retention", "communities", "rural", "supportive supervision", "quality", "health care", "universal health coverage"," uhc", "information technology", appropriate boolean terms "and" "or" were utilized to facilitate the search. no date filter was used and relevant articles to the topic were selected from a large pool of 173 articles at the first search. (please refer to appendix). targeted snowballing from the list of references was also conducted to complement the list of scientific publications used, following the guidance of: figure 1. human resources for health and effective coverage (campbell et al, 2013 as cited by (7): p.11); figure 2. who labour market dynamics. (sousa a, scheffler m r, nyoni j, et al, 2013 as cited by (7): p. 13). results the results will be presented considering, the main factors influencing the availability, accessibility, acceptability, and overall quality of hrh divided into four umbrella factors or subthemes namely, labour market factors, rural health workers retention factors, health workers obligatory education and supportive supervision factors and information technology factors. furthermore, these four factors are underpinned by financial, professional, infrastructural, and procedural support, see figure 3 in the appendix. labour market factors attention should be focused on the health worker preferences and the dynamic labour market (6). health workers may be interested in alternative positions or may emigrate against the health care needs that require their availability. furthermore, there is an imbalance between the supply (health workers available) and the demand for health workers (health workers hired) resulting in either inefficiency of government spending or under-employment (6). the labour market in the health sector is determined by the interactions between the supply and the demand for health workers. the demand for health workers has hinged on the government, private or external donor readiness to pay (hire) health workers (6). this is a function of the flexibility of spending or the fiscal space from which health care expenses can be determined. notably, per capita income and health worker density are both lowest in africa compared to other continents (5,7,11). supply of health workers, on the other hand, depends on the emoluments and upon other socio-economic, political and demographic factors. an analysis of these market conditions is necessary to guide policymaking concerning human resources for health towards achieving universal health coverage. policies can be directed towards the increase of training opportunities for health workers when the challenge is supply related or towards increased government allocation of funds for the health workforce in when the challenge is demand related. additionally, a more comprehensive approach will be a bidirectional policy inclination (6). amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 5 | p a g e while the two options require major government spending to increase the availability of hrh, many african countries lack the capacity for flexible expenditure (5). a pragmatic way is to invest in more cost-effective spending such as funding community-based health workers. this category of health workers requires training of shorter duration and lower financial investment. they also play a prominent role in stimulating demand for health services in rural areas, expanding coverage of health services and improving health outcomes in neglected communities. this has been exemplified in countries like ethiopia and niger where constraining macroeconomic conditions informed this approach. similarly, this category of health workers are shown to be more readily retained in underserved areas and not as easily affected by the conditions of the labour market in the health sector (6, 11, 12). furthermore, wage bills can influence health workforce availability or the attractiveness of the health sector to unemployed health workers. government wage bill policies have been implemented in some african countries such as rwanda, kenya and zambia. vujicic et al. (13) studied the consequences of the bill on the health workforce of these countries with mixed outcomes. expansion of the health workforce occurred in rwanda while the wages were maintained. in zambia however, challenges with occupying budgeted posts were identified as the obstacle to expansion and in kenya reduction of the wage bill prevented the growth of the workforce. in ghana, government spending on the public sector wage bill increased from 3.6 in 2000 to 6.7% in 2008, while the health sector wage bill rose as a percentage of the total wage bill from 9% to 15% (14). although with minor changes, in monetary terms, the public spending on health increased. during the same period, while the wage bill increased by 5 times the health sector workforce increased substantially. with a largely decentralized health workforce to regions and districts, the resource allocation was channeled to districts, subdistricts and community-based committees and funding increased by 10%, while allo cation to tertiary hospitals dropped by 3% (14). rural health workers retention factors the disproportionate distribution of health care workers between rural and urban areas despite a majority of the population residing in rural communities, results in higher mortality rates from these remote and rural areas. this leaves many residents seeking primary care and overcrowding the health centres in urban areas (8). this inefficient delivery of health care causes skilled workers to be underutilized and consequently overburdened; this could also be complicated by emigration of these workers for a more rewarding income package. against this backdrop, the who provided evidence-based recommendations to improve retention of health workers in rural communities (8). these include a focus on training (enrolling students with a background in the rural communities), regulation (such as ensuring a required posting in rural and remote areas) and providing enabling incentives in the form of financial and/or professional support (8,15). in nigeria, recruitment at the primary health centre (phc) is at the call of the local government (for junior workers) and the state government (senior cadres). due to this form of governance, health worker attrition is highest at the phc and unlike the doctors and nurses, only the community health workers are readily available at the phcs (16). in zambia, hrh decentralization was also recommended for easy resource allocation to enable task shifting for essential service provision where trained professionals are unavailable (15). community health committees which are recognized in the national health policy, along with the phcs form an amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 6 | p a g e extra tier of governance that plays a key role in the retention of health workers at the phc in nigeria. these committees are made up of key persons in the community such as teachers, religious leaders and other respectable persons in the community. they support the retention of health workers by intervening when salaries to health workers are delayed or not paid and also provide social and financial support of these workers in rural communities. the resurgent awareness of the role of community health committees in retaining health workers in rural communities calls for policies that reinforces the establishment of these committees. the government and policy analysts should consider the role of community engagements such as educating the workers on their various roles to adequately uphold the provision for the scheme. notably, also, community engagements through the community health committee offer various incentives for retention of worker with or without financial investment (16). in zambia, the ministry of health introduced strategies to facilitate retention of health workers at rural communities (15). these incentives included adjunct allowances such as on-call allowances, hardship allowance, retention allowances etc. however, there was no relationship between these strategies and the worker’s desire to remain in the sector. thus, it was recommended that strategies that enable the health workers to perceive and understand the context and the characteristics of working in the facilities should be implemented. similarly, updating the financial incentives in line with the realities of inflation as it affects the cost of living should be considered for the different training duration, working hours or level of experience (15). implementation of the who recommendations on retention of health workers in rural communities requires contextualization according to individual country’s need. south africa contextualized it’s strategies to deal with a hrh crisis. in the aspect of education, it focused on training health workers in underserved communities, it also developed a social accountability framework to better respond to the communities need. other strategies included having students trained from communities where the need is greatest as well as using target community health and social needs to guide education (17). health workers obligatory education and supportive supervision factors at the heart of achieving universal health coverage is the certainty of quality of healthcare. clients are not willing to utilize healthcare in situations where the services are poor, hindering realistic achievement of uhc. and in some situations where the health service is still utilized, the health outcomes are also undermined. there are few, sufficiently trained and motivated health care staff with the requisite resources to offer essential health care in many african countries which: this culminates in poor quality of care (18,19). continuous professional development (cpd) has been identified as a means of maintaining knowledge capacity through ‘on the job’ training of nurses and midwives to function competently and attain universal health coverage (20). about 70% of the anglophone countries (n=21) including nigeria and ghana and only rwanda among francophone countries (n=20) have demonstrated evidence of mandatory cpd being operational. these programs are run by the nursing councils and the health professional councils. through this obligatory system of education, targeting global health indicators such as hiv is made possible vis the who afro region dictating licensure from specific cpd modules. also, some countries require cpd points to ensure license renewal on an annual basis. nevertheless, only 10 member states in the who-afroregion make cpd a mandatory program to complete, and there is still a shortage of nurses as well as a lack of interest among amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 7 | p a g e nurses which slows the movement towards uhc and sdg attainment in the region (20). supportive supervision is a process that promotes quality at all levels of the health system by strengthening relationships within the system, focusing on the identification and the resolution of problems. it also helps to optimize the allocation of resources'. (9: p.989) it involves enabling the health workers to always get better at the performance of their work in a nonforceful but respectful manner through supervisory visits (21). a reported increase in the proportion of health workers (community health workers), improved quality of care and sustained performance as a result of supportive supervision has been documented in the literature (22). in a systematic review of supportive supervision carried out on phc workers in low and in middleincome countries in africa, it was revealed that efficiency, quality of care, motivation and job satisfaction were positively influenced (22). critical to the improved motivation and performance was an open twoway communication and feedbacks, a fervent team spirit and the development of mutual trust between the supervisor(s) and the health worker(s) (22). the performance of community health workers is a function of the interaction with the complex health system, and it may also be influenced by intrinsic factors such as the personality of an individual. a supportive environment is thus needed to enable these health workers to play their roles as agents of social change. this implies a need to be skilled in building confidence, solving problems and communicating well with the immediate community (23). perceptibly, the higher-level health workers do not regard the inputs or efforts of these community health workers, hence organizing joint training sessions of the higher-level health workers and the community health workers aids in building better relationships between both categories. the supervisors also need to be trained about the significant roles community health workers play in strengthening the relationship with the community and its people. management and technical skills should be inculcated into the training. likewise, team building activities should be included in the training of supervisors to reduce the social distance between the supervisor and the community health workers; this will result in better relationships and an overall better performance. the community will more likely recognize the community health worker due to better supervision occurring within the health sector (23). to make supportive supervision more effective renggli et al. (19). in their tanzanian study described the effectiveness of an electronic tool to improve the quality of health care (etiqh). it was found that across different contexts in tanzania, the quality standard of primary health care was improved, and it was demonstrated to have shown a direct impact on the overall quality of care that was obtained. with strong supervision, a 'virtuous cycle' is built. there is an increase in community health worker's confidence, more cohesion between all cadres of health workers, a sense of inclusion with the health system and recognition by the community, as well as an effective referral system (22). supportive supervision, however, is not without its problems. these include the propensity for diverting attention to quantity rather than quality, also supervisory visits may be fragmented, infrequent, and inconsistent. a gap also often exists between what is known and what is done. there is often no ownership of quality development activities at the facility level without feedback on this development up to the council level as described in countries like tanzania. similarly, supervision could be de-motivating when carried out with fault-finding and can be irregularly executed. weak supervisions can also lead to a 'vicious' cycle of neglect among the health workers, absence of technical assistance, weak referral of patients and bad treatments (19, 24). amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 8 | p a g e information technology factors between 2007 and 2011, the number of subscribers for mobile broadband in developing countries rose astronomically to 458 million from 43 million, representing over 10-fold increase in the number of users (10). this implies more users of mobile devices, as well as increased access to the internet. the internet and mobile devices are also fast becoming essential tools for the health professionals in urban and rural communities. the use of mobile devices to practice medicine and public health has facilitated services in the difficult terrains and geographically inaccessible areas in developing countries. the adoption of this technology has been proposed to limit the rural health worker isolation that is usually experienced, and a study revealed that mobile dependent technologies are gradually being embraced by the health workers. it is transformative and can bridge the existing gap in human resources for health accessibility and acceptability (10). information technology can be utilized to support communication between the health providers and the clients as well as enable the capacity building of the health worker which engenders more demand for a high quality of care from the community. health workers are usually exposed to standard educators through webcasting, recording, and video conferencing. this mode of training is shown to be more cost-effective compared to educational programs held face to face. it is not considered an alternative to face-to-face education, rather it aids in reducing the challenges faced by this traditional method. it has been reported that presenting educational content and gaining competency is the goal of an educational strategy and when complemented by information technology, this goal can be essentially achieved (10). in a study on a post-conflict setting on the utilization of information technology for the retention of health workers, there was a positive perception about information technology among health worker(s) even in a setting where the applications of information technology were rare and remote. thus, there is a need to increase investments in information and technology, mobilise health workers and train the workers on the use of information technology for the delivery of health services (25). additionally, studies have proposed that information technology can serve as a major boost to health worker retention apart from other traditional strategies for retention (25,26). despite the general benefits of information technology, there are barriers to its implementation. these barriers include unreliable internet connection, unstable power supply, lack of knowledge on information technology, expensive access to computers and lack of effective policies on information technology (25). other barriers include cultural barriers and deficient interoperability between technologies and platforms (10). in addressing some of these challenges, interventions on information technology should be prioritized especially at post-conflict settings as well as for rural communities. computers are not indispensable, as smartphones can be provided for health workers in the rural communities which are useful in accessing health information and communication with professional colleagues. incentives might be required to enable health workers to accept information technology and overcome their reluctance with the approach. similarly, the collaboration between relevant ministries such as information, finance, education and health are important to develop a synergy and proper coordination of information technology use among health workers (10, 25). discussion and conclusions the post-covid-19 agenda must include human resources for health as a key critical component. human resources for health forms an essential component of any health system. yet this component of the health amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 9 | p a g e system is faced with immense crisis that borders on the shortage, maldistribution, and performance. market factors such as demand and supply issues, wage bill incre ments as well as socioeconomic factors play a role in influencing human resources availability. existing rural-urban inequalities create a disproportionate distribution of health workers in the african region which demands steps to ensure health workers are retained especially in rural communities and post-conflict communities. considering the limited fiscal space and constrained macro-economic environment in many african countries, cost-effective interventions should be adopted to ensure the sustenance in the delivery of quality health care in the remote and inaccessible areas. thus, approaches that utilize the services of community health workers who play a crucial role in stimulating demand for health care should be applied. the duration of training is shorter, they can be recruited from communities with highest health need, they form a pragmatic alternative to higher earning and higher cadres of health workers and are usually closer to the members of the community. supervision of these health workers is a vital part of the promotion of the delivery of quality health services. by focusing on the virtuous cycle created by strong supervision of community health workers, a cohesive and confident health workforce with a strong connection with the community is built and inherent in this approach is health system strengthening. embracing information technology also presents an effective means of maximizing human resources for universal health coverage. by multi-stakeholder collaboration, the challenges with the use of technology can be overcome and technology can be utilized to prevent the isolation of health workers in remote areas, encourage their retention at rural communities, facilitate their training and interaction with other health professionals. policy formulation should, therefore, focus on market factors that influence health worker retention, as well as developing sustainable supportive supervision of community health workers and the establishment of pathways for utilizing information technology as leverages in the trajectory towards universal health coverage in africa. recommendations 1. financial support: the need to improve financial investment in education and training of health workers cannot be overemphasized. more attention should be given to the provision of incentives for health workers in remote and largely inaccessible areas. 2. professional support: a broader view into health worker demand and the availability of health workers to deliver the needed services especially in the context of a post-covid19 era reveals the need for the delivery of essential health services through delegated roles in form of task shifting with a combination supportive supervision to maximize the performance. 3. infrastructural support: considering the growth in the number of users of mobile technology on the continent and the benefit it brings to the health system, efforts should be directed at removing the outlined barriers such as unstable internet and irregular power supply to aid its proper functioning in maximizing hrh capacity. 4. procedural support: an improved understanding of the contextual factors that influence retention of health workers especially at remote and rural communities is expedient for the decision-makers and government stakeholders in health. there is an urgent need to correct negative amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 10 | p a g e trends leading to health worker attrition especially at the lower tiers of governance in member states' health systems. references 1. narayan k, donnenfeld z. envisioning a healthy future: africa’s shifting burden of disease. african futures paper. iss. 2016. available from: https://media.africaportal.org/documents/african_futures18.pdf. (accessed: october 10, 2020). 2. world health organisation. available from: https://www.who.int/nmh/ncdtools/who-regionsafrican/en/(accessed: october 10, 2020). 3. mbunge e. effects of covid-19 in south african health system and society: an explanatory study. diabetes metab syndr clin res rev. 2020. available from: https://www.sciencedirect.com/scie nce/article/abs/pii/s1871402120303 696?via%3dihub (accessed: october 10, 2020). 4. mozart s, marie-paule k, ruediger k, et al. human resources for universal health coverage: from evidence to policy and action. bull world health organ 2013: available from: https://www.who.int/bulletin/volum es/91/11/13-131110.pdf (accessed : july 18, 2020). 5. world health organisation;2017.available from: https://www.who.int/healthtopics/health-accounts/#tab=tab_1 (accessed: july 18, 2020). 6. mcpake b, maeda a, correia araújo e, et al. why do health labour market forces matter? bull world heal organ; 2013. available from: https://www.who.int/bulletin/volum es/91/11/13-118794.pdf (accessed july 18, 2020). 7. world health organisation.; 2016. available from: http://www.who.int/hrh/resources/p (accessed july 18, 2020). 8. buchan j, couper id, tangcharoensathien v, et al. early implementation of who recommendations for the retention of health workers in remote and rural areas. bull world heal organ. ;2013 ;91:834–840. 9. kok mc, dé rique valliè res f, tulloch o, et al. does supportive supervision enhance community health worker motivation? a mixedmethods study in four african countries. health policy plan. 2018;33:988–998. 10. bollinger r, chang l, jafari r, et al. leveraging information technology to bridge the health workforce gap . bull world heal organ.2013;91:890–892. 11. wakabi w. extension workers drive ethiopia’s primary health care. lancet. 2008; 372: 880-880. 12. amouzou a, habi o, bensaïd k. reduction in child mortality in niger: a countdown to 2015 country case study. lancet. 2012;380(9848):1169–1178. 13. vujicic m, ohiri k, sparkes s. working in health : financing and managing the public sector health workforce. washinghton, dc: world bank publications;2009. 14. ebenezer a, christopher hh, agnes s, et al. toward interventions in human resources for health in ghana: evidence for health workforce planning and results. washinghton, dc: world bank; 2013. https://media.africaportal.org/documents/african_futures18.pdf https://media.africaportal.org/documents/african_futures18.pdf https://media.africaportal.org/documents/african_futures18.pdf https://ideas.repec.org/b/wbk/wbpubs/2621.html https://ideas.repec.org/b/wbk/wbpubs/2621.html https://ideas.repec.org/b/wbk/wbpubs/2621.html https://ideas.repec.org/s/wbk/wbpubs.html amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 11 | p a g e 15. goma fm, murphy gt, mackenzie a, et al. evaluation of recruitment and retention strategies for health workers in rural zambia. hum resour health. 2014. available from: https://human-resourceshealth.biomedcentral.com/articles/1 0.1186/1478-4491-12-s1-s1 ub_globstrathrh-2030/en/ (accessed :july 18, 2020). 16. abimbola s, olanipekun t, igbokwe u, et al. how decentralisation influences the retention of primary health care workers in rural nigeria. glob health action 03 may 2015. available from:https://www.tandfonline.com/ doi/full/10.3402/gha.v8.26616 (accessed july 18, 2020). 17. world health organisation; 2010 available from: https://apps.who.int/iris/bitstream/h andle/10665/44369/9789241564014 _eng.pdf?sequence=1 (accessed: july 18, 2020). 18. johnson mc, schellekens o, stewart j, et al. safecare: an innovative approach for improving quality through standards, benchmarking, and improvement in low-and middle-income countries. jt comm j qual patient saf; 2016 ;42(8):350-360. 19. renggli s, mayumana i, mboya d, charles c, mshana c, kessy f, et al. towards improved health service quality in tanzania: contribution of a supportive supervision approach to increased quality of primary healthcare. bmc health serv res. 2019; 19(1):848-864 20. baloyi ob, jarvis ma. continuing professional development status in the world health organisation, afro-region member states. int. j. africa nurs. sci.2020 jan 1;13:100258. 21. world health organisation;2008. available from: https://www.who.int/immunization/ documents/mlm/en/ (accessed :july 18, 2020). 22. snowdon da, leggat sg, taylor nf. does clinical supervision of healthcare professionals improve effectiveness of care and patient experience? a systematic review. bmc health serv res. 2017;17:786-797. 23. kok mc, broerse jew, theobald s, et al. performance of community health workers: situating their intermediary position within complex adaptive health systems [internet]. vol. 15, hum. resour. health.2017;15(1):59-66 24. ludwick t, turyakira e, kyomuhangi t, manalili k, robinson s, brenner jl. supportive supervision and constructive relationships with healthcare workers support chw performance: use of a qualitative framework to evaluate chw programming in uganda. hum resour health. 2018. available from: https: https://human-resourceshealth.biomedcentral.com/articles/1 0.1186/s12960-018-0272-1 (accessed:july 18, 2020). 25. yagos wo, tabo olok g, ovuga e. use of information and communication technology and retention of health workers in rural post-war conflict northern uganda: findings from a qualitative study. bmc med inform decis mak. 2017;17(1):1-7 26. mbemba g, gagnon mp, paré g, interventions for supporting nurse retention in rural and remote areas: an umbrella review. hum resour health.; 2013. available from: https://human-resourceshealth.biomedcentral.com/articles/1 amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 12 | p a g e © 2021 mcking et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 0.1186/1478-4491-11-44 (accessed :july 18, 2020). ____________________________________________________________ amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 13 | p a g e quality of hrh service utilization acceptability of hrh acceptability to hrh availability of hrh theoretical coverage by ‘availability’ of health workforce effective coverage gap population + health needs: who is provided effective coverage? appendix overview of article selection because no date filter was initially used at the first search, a total of 173 articles emerged. this was via the use of keywords and bolean terms on pubmed as stated in the main text. the titles and abstracts of these publications were next evaluated for suitability based on the two guiding frameworks: the human resource for health and effective coverage and the who labour market dynamics. the number of articles were thus reduced to 40 articles for consideration. selection criteria was then determined. these included publications not older than 20 years, who bulletins and publications and a targeted snow balling from key who articles on the themes. this was independently agreed upon by the two authors, mia and ice. consequently, this led to a final selection of 22 articles used for the review. figure 1. human resources for health and effective coverage amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 14 | p a g e figure 2. who: labour market dynamics economy, population, and broader societal drivers education sector labour market dynamics education in health education in other fields pool of qualified health workers* abroad employed unemployed out of labour force health care sector** other sectors h ig h s ch o o l health workforce equipped to deliver quality health service u n iv e rs a l h e a lt h c o v e ra g e w it h s a fe , e ff e ct iv e , p e rs o n ce n tr e d h e a lt h s e rv ic e s. policies on production  on infrastructure and material  on enrolment  on selecting students  on teaching staff policies to address inflows and outflows  to address migration and emigration  to attract unemployed health workers  to bring healthy workers back into the health care sector policies to address maldistribution and insuffciencies to improve productivity and performance to improve skill mix composition. to retain health workers in underserved areas policies to regulate the private sector  to manage dual practice  to improve quality of training  to enhance service delivery migration amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 15 | p a g e amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 16 | p a g e figure 3. factors influencing the maximizing of human resources for health towards universal health coverage in africa.  labour market factors  rural health workers retention factors  health workers supportive supervision factors  information technology factors 4 main hrh factors in africa these 4 main factors affect hrh  hrh availability  hrh accessibility,  hrh acceptability,  overall hrh quality financial support | professional support | infrastructural support |procedural support these factors are underpinned by  information technology factors mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 1 original research performance of the public health care sector in the republic of macedonia lolita mitevska 1 , manuela sofia stanculescu 2 , elisaveta stikova 3 1 national institute of transfusion medicine-skopje, r. macedonia; 2 research institute for quality of life, romanian academy of science, romania; 3 university “ss. ciryl & methodius”, medical faculty, institute of public health, skopje, republic of macedonia. corresponding author: prof. elisaveta stikova, university “ss. ciryl & methodius”, medical faculty, institute of public health, skopje, republic of macedonia; address: 50 divizija no 6, 1000 skopje, r of macedonia; telephone: +38970230183; e-mail: estikova@ukim.edu.mk mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 2 abstract aim: healthcare authorities constantly search for new approaches of assessing the performance of the health sector. comparative studies help for improvements in healthcare by learning from each-other. our aim was to assess the performance of the public healthcare system in the republic of macedonia, through the analysis of preparedness of institutions to fulfill the population‟s healthcare needs and expectations. methods: this study had a regional character. the national research team interviewed 175 randomly selected participants from macedonia. the research was performed in the period march 2012 – march 2013. for the research purposes there were used especially designed questionnaires for cancer, stroke, myocardial infarction, diabetes mellitus and injuries. for assessment of the performances, the appropriate techniques were developed. results: macedonians consider public healthcare system as being medium-good in all aspects: accessibility, availability, quality of health care services and population‟s confidence. the knowledgeable observers (n=125) believe that state-of-the-art treatment exist all over the country (“yes”: 33.6% and “rather yes”: 44.8%). they believe that the services are accessible to everybody, free of major charges (“yes”: 31.2% and “rather yes”: 45.6%). the individual witnesses (n=50) argued toward lack of pharmacies and proper medicines in rural areas, with a gap between the availability and quality of services in rural vs. urban areas. conclusion: the future goals for macedonia include better public healthcare financing, cost definition of health packages, improved disease prevention and effective human resources. keywords: assessment of services, availability, public healthcare system, quality of care. conflicts of interest: none. mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 3 introduction health authorities are in constant search for systematic ways and new approaches of assessing the performance of the health sector at national, or cross-national level. main arguments for the necessity of measurement include identification of the quality of healthcare service delivery, support for design of the health sector reforms, improvement of healthcare system and production of better outcomes for the patients and payers. the healthcare performance can be followed and measured by different indicators, such are: life expectancy, morbidity, or mortality. there are many determinants of health that have influence on the health status of the population, but are not considered as direct indicators (1). the performance assessment can be defined as comparing or measuring deviations of observed clinical practice from recommended practice. this assessment may range from a formal in-depth evaluation process to a much less elaborate simple review of practice. the most common performance assessment methods are: (i) audits/audit groups, (ii) peer-review groups, and (iii) practice visits (2,3). noncommunicable diseases (ncd), principally cardiovascular diseases (cvd), diabetes mellitus (dm), cancer, and chronic respiratory diseases, are the most common diseases which have caused million deaths worldwide. the scientists predict an increased number of deaths from noncommunicable diseases that are projected to further 17% over the next 10 years (4). republic of macedonia is not different in disease prevalence values compared with other european or neighboring countries. according to the data from the national public health institute in the republic of macedonia, in the year 2011, the most frequent diseases for which the patients had received treatments at out-patient services were: cardiovascular diseases (23.6%), respiratory diseases (18.2%), diseases of the muscular-skeletal system (7.7%), diseases of digestive system (7.2%), and diseases of the endocrine system (7.1%), out of 2695233 registered cases (5). for the same year, the total number of hospitalized patients was 253906 (6), out of which for: cancer 33836 (13.3%), endocrinology system diseases 6422 (2.5%) patients, musculoskeletal system diseases 11150 (4.4%), cardio-vascular diseases 38133 (15.0%) and for injuries 12955 (5.1%). the republic of macedonia has a compulsory health insurance system that provides universal health coverage for the whole population. the goal of the health sector reform in republic of macedonia is the creation of a system that is aligned to the needs of the population, which can operate efficiently within the resources available. the government and the ministry of health provide the legal framework for operation and stewardship and the health insurance fund (hif) is responsible for the collection of contributions, allocation of funds and the supervision and contracting of providers. in the year 2002, the hif has started contracting the private primary health care facilities (family doctors or general practitioners-gps), introducing a capitation-based payment system. the medical examinations by the gps are provided free of charge for all citizens. the population participates in covering the health expenditures by paying some amount of money which is calculated from hif special scales and generally is 20% of the total costs of health services. this practice was changed and even improved in the year 2012, by introduction of a law for health protection (7). free-of-charge healthcare services receive all patients with monthly salary lower than the average official salary for the previous year. from co-payments are excluded blood donors, children with special needs, persons under permanent social care, patients in mental institutions and mentally retired abandoned persons. mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 4 all citizens that do not have regular health insurance (for example: stateless persons and social care recipients), are subsidized by the state budget (8). in the year 2010, general government expenditure on health as a percentage of total government expenditure was 12.9%. the total expenditure on health (ppp in us$) in the same year was 791 $ per capita, which increased from 423 $ in the year 1995. the healthcare system in the republic of macedonia is organized at three levels: primary, secondary and tertiary level. some of these services are part only of the public healthcare sector, whereas some other services are provided in public and private healthcare facilities. in the year 2011, there were 3375 at primary level and 386 at secondary level private healthcare practices that had contracts with hif. the total number of hospital beds in 2012 was 9076, or 4.4 beds per 1000 inhabitants (9). the hospital services are organized in: 14 general hospitals, 13 special hospitals, 30 university clinics and 19 other clinical hospitals, centers and units (9). in this framework, the objective of this study was to assess the performance of the public healthcare system in the republic of macedonia, through the analysis of the expected (stateof-art treatment) and actual public health care of the patients. methods the performance of the public health care system in the republic of macedonia was analyzed trough assessment of the access of the population to health care services developed by wismar et al. (10), where “the state-of-the-art” of the healthcare system is defined as: diagnosis, treatment and recovery, which are accessible to every citizen covered by a health insurance, free of major additional charges. accessibility of the health care system is defined as “a measure of the proportion of the population that reaches appropriate health services”. the assessment of the expected and actual performances of public health care system was based on the data collected from 175 interviewed respondents: 125 knowledgeable observers (family physicians and medical specialists in hospitals or emergency centers), and 50 individual witnesses (patients or their family members who were diagnosed during the period between the 1 st of january 2010 to the 31 st of december 2011). the structured interviews were performed for those two groups of the study participants, using ten different questionnaires tailored according to the five selected health problems/diseases: cancer, stroke, myocardial infarction, diabetes mellitus (type ii) and injuries. the selection of these health problems/diseases was due to the fact that they represent the major causes of death in the country and require different approaches in the health care response (emergency versus longterm monitoring and care). we combined two different sampling methods: selective expert sampling for knowledgeable observers and non-probability convenience sampling method for the individual witnesses. the field work was carried out in the period from march 2012 to march 2013. the data obtained through interviews with knowledgeable observers and individual witnesses, for each of the five selected health problems, was organized and analyzed in relation to an adjusted 6-access-steps model based on the following sequence of themes: the extent to which the national benefit packages cover diagnostic, treatment, monitoring and rehabilitation in the specific health problem; the extent to which payments, co-payments, and out-of-pocket expenditure are involved and threaten equity of access; geographical access and availability of services; availability of public and private health-care providers; waiting lists and other aspects of system organization that can result in barriers to the health care access; and groups with limited access and risk factors related to the specific health problems. the expected performance of the health care system was assessed by measurement of four dimensions of the health care system: accessibility, availability, quality of health-care mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 5 services and the population‟s confidence in the public health system, based on the opinion of the knowledgeable observers. assessment for each dimension was made using the likert scale from 1 („very poor‟) to 5 („very good‟). results were presented as the average of the scored values for each dimension. for measurement of the general assessment of the health system, the opinions on the four dimensions were aggregated into a dominant opinion index, using the method basically developed by hofstede in 1980 (11) and the formula: (p-n) * (t-nr)*100/t*t, where p – positive answers („very good‟ or „good‟), n – negative („very poor‟ or „poor‟), nr – neutral or non-response, and t – total number of variables. this type of index varies between -100 (generalized negative attitude) and 100 (generalized positive attitude toward the issue). for assessment of the actual performance of the public health care system, the analysis of the opinions/experience of the individual witnesses and knowledgeable experts was made with a focus on the history of the health problem. the main focus was on the factors hampering the access to the health care system, as essential elements for the assessment of the actual performance of the public health care system. results health status of the population in macedonia shows many different characteristics and tendency, caused by economic, political, socio-demographic changes, as well as health care reforms which have been in process in the past 20 years. figure 1 presents the standardized death rate (sdr) of five health problems: malignant, cerebrovascular and ischemic heart diseases, diabetes and injuries in the period 1990-2010 (12). sdr of malignant neoplasms shows higher rate and increasing trends in the republic of macedonia, compared with the eu and the european region countries. hence, the sdrs of cerebrovascular diseases and diabetes are 3.5 times higher in macedonia than in the eu countries and much higher than in the countries of the european region. sdr of cerebrovascular diseases follows the similar trend as in the other european countries, but the sdr of injuries is two times lower than in the european countries. in the current research, all respondents were divided into two groups: individual witnesses (n=50) and knowledgeable observer (n=125). their distribution is presented in map 1. the demographic characteristics of the individual witnesses that have participated in the study are presented in table 1. the dominant characteristics of the respondents from the group of the individual witnesses included: patients (64%) that live in a large urban residency (48%), pensioners (34%), with high school level of education (54%) and middle income (38%). the characteristics of the knowledgeable observers are presented in table 2. according to demographic data, the dominant group of respondents from knowledgeable observers consisted of doctors (34.4% gps and 31.2% specialists), males (58.4%) that live in a large urban residency (66.4%), with a mean age of 43.3 years. the results of the assessment of the performance of public health care system in the country are presented in table 3. knowledgeable observers consider the health system as being medium/good in all four dimensions: accessibility, availability, quality of healthcare service and the population‟s confidence in the public health system, with an average score of 3.5. the scores vary from 3.4 points for the population confidence to 3.7 points for the availability of the services. the biggest part of respondents from the group of the knowledgeable observers believes that state-of-the-art treatment exists all over the country (“yes”: 33.6% and “rather yes”: 44.8%) and that they are accessible to everyone free of major charges (“yes”: 31.2% and “rather yes”: mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 6 45.6%). yet, health professionals from rural areas tend to assess the system performance with lower remarks. at the level of the overall sample, the dominant opinion index about the health care services showed an average value of 34 points in a scale from -100 to +100. this index had very little variations from 38 for diabetes mellitus, 37 for injuries, 35 for stroke and myocardial infarction, but it was significantly lowest for cancer, with only 23 points. these findings are shown in figure 2. figure 1. sdr for selected diseases in the republic of macedonia during 1990-2010 130 140 150 160 170 180 190 200 210 1990 2000 2010 mkd* european region eu sdr, malignant neoplasms, all ages, per 100 000 0 50 100 150 200 250 1990 2000 2010 mkd* european region eu sdr, cerebrovascular diseases, all ages, per 100 000 10 15 20 25 30 35 40 1990 2000 2010 mkd* european region eu sdr, diabetes, all ages, per 100 000 20 30 40 50 60 70 80 90 100 1990 2000 2010 mkd* european region eu sdr, external causes of injury and poisoning, all ages, per 100 000 10 20 30 40 50 60 70 1990 2000 2010 mkd* european region eu sdr, ischaemic heart disease, 0–64, per 100 000 mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 7 map 1. distribution of respondents table 1. demographic characteristic of individual witnesses variable category number percent type of respondent patients 32 64 family member 18 36 residence large urban 24 48 small urban 14 28 rural 12 24 ethnicity macedonian 37 74 albanian 11 22 other (roma, serbian) 2 4 age (average) cancer 54.9 ? stroke 65.3 ? aim 53.8 ? injuries 43 ? dm 61.6 ? employment status manager 1 2 clerical staff 6 12 non-manual worker 5 10 manual worker 11 22 pensioner 17 34 student 3 6 housewife or inactive 7 14 level of education none 3 6 elementary 10 20 high school 27 54 college or more 10 20 income low 10 20 middle low 13 26 middle 19 38 middle high 6 12 high 2 4 x knowledgeable observers  individual witnesses mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 8 table 2. demographic characteristic of knowledgeable observers variable category number percent type of respondent general practitioners 43 34.4 specialist doctors 39 31.2 representatives of regional or national directions of public health 7 5.6 hospital representatives 11 8.8 emergency centers representatives, 3 2.4 representatives of ngos active in the field 2 1.6 representatives of patient organizations 3 2.4 other 17 13.6 residency large urban 83 66.4 small urban 32 25.6 rural 10 8 age (average) 43.3 (min=24; max=67) gender male 73 58.4 female 52 41.6 figure 2. the value of the dominant opinion index -150 -100 -50 0 50 100 150 dominant opinion index min max average diabetes injuries infarction stroke cancer mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 9 table 3. assessment of the performance of public health care system in the republic of macedonia assessment of public health performance category number percent score (1-5) availability of health care services very poor 0 poor 11 8.8 medium 43 34.4 good 48 38.4 very good 23 18.4 average score 3.7 quality of health-care services very poor 1 0.8 poor 11 8.8 medium 52 41.6 good 44 35.2 very good 17 13.6 average score 3.5 population’s confidence in the public health-care system very poor 3 2.4 poor 14 11.2 medium 52 41.6 good 40 32 very good 16 12.8 average score 3.4 health-care services are accessible to any person who needs them, regardless their economic situation very poor 8 6.4 poor 16 12.8 medium 32 25.6 good 37 29.6 very good 32 25.6 average score 3.5 state-of-art treatment (of the respective health problem) is available? yes 42 33.6 rather yes 56 44.8 no 6 4.8 rather no 21 16.8 is the state-of-the-art treatment (including diagnostics, monitoring etc.) accessible to everybody, which means free of major charges? yes 39 31.2 rather yes 57 45.6 no 6 4.8 rather no 23 18.4 dominant opinion index (overall) 34 when analyzing which group of knowledgeable observers are most satisfied, it is remarkable to note that physicians (general practitioners and specialists) are the most satisfied observers, with a score on the dominant opinion index of 40 points, despite the ngo and representatives of the patients‟ organizations who are the least satisfied observers (approaching to the 0 point on the scale). however, it should be emphasized that the simple size and the profile of the observers influenced on the observed results of this research work. regarding the assessment of the actual performance of the public health care system, table 4 provides descriptions about the main barriers of access to services in macedonia. mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 10 table 4. main access barriers in public health care of the five selected health problems access barriers 1 2 3 4 5 iw ko iw ko iw ko iw ko iw ko delayed first contact with a doctor x x x x x poor knowledge and low level of prevention and information of population x x x x x doctor or medical services are not available in some areas x x x x x x diseases‟ related services are available only in some areas x x x rehabilitation units/ services are not available/enough in some areas x x pharmacies are not available in some areas x x x emergency services are not available in some areas or are underdeveloped x x x x x transport services are underdeveloped or too costly x the waiting time for being received by a specialist is very long x x x the waiting time for getting medication is very long x x the waiting time for rehabilitation services is very long x x lack of trust in doctors, nurses or medical staff x x x lack of interest or unprofessionalism of the doctor or medical staff x x x lack of humanness of the staff x x lack of money to pay the doctor x x lack of money to pay the needed tests lack of money for out-of-pocket payments x low quality and effectiveness of medical services x x x x x x x x high costs of medication x x x x x x x poor equipment of public clinics/hospitals x x x x x x lack of accessibility and continuity of care x x specialists of certain subspecialties are missing or insufficient legend: 1 = infarction; 2 = stroke; 3 = cancer; 4 = injuries; 5 = diabetes iw = individual witnesses; ko = knowledgeable observers there are four major aspects of the health care system that are major barriers in accessing state-of-the-art treatment, for all the selected health problems:  low quality and effectiveness of medical services; mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 11  high cost of medication;  poor equipment of public health care clinics/hospitals, and;  availability of doctors and medical services. additionally, the respondents gave high priority to the poor knowledge and the low level of information and the lack of preventive health-related behavior; availability of emergency services and lack of trust in medical staff and their unprofessionalism as possible barriers hampering state-of-the-art treatment of the patients. the respondents in this study confirmed a delayed first contact with a doctor in four of the analyzed diseases (myocardial infarction and stroke from knowledgeable observers, cancer and diabetes from individual witnesses), as well as unavailability of healthcare services in some areas (for stroke and cancer) and long waiting time for specialized care (myocardial infarction and cancer). more than 70% of participants in the study referred to a low quality of medical services, high cost of medication and poor equipment of public clinics and hospitals. despite these remarks, macedonian citizens showed a high level of trust in doctors. the trust in medical doctors or nurses in this study was pointed out for cancer (knowledgeable observers) and injuries (individual witnesses and knowledgeable observers). discussion considering the health challenges that are facing all countries in the southeastern european (see) region, a comparative qualitative study about assessment of the performance of the public health care system was performed in 2013, with participation of eight countries. this paper is focused on the research results obtained in the republic of macedonia. the main idea was to compare the actual level of health care delivery in comparison with the highest, “state-of-the-art” diagnosis, treatment and recovery, related to five deadliest health problems in the country: myocardial infarctions, stroke, cancer, diabetes mellitus type 2 and injuries. the results of the study showed that health professionals consider the macedonian health care system as being “medium/good” with no significant variations in the accessibility, availability, quality of health care service and the population‟s confidence. the overall performance of the health care system was similarly assessed as “good” with no significant differences for different health care problems/diseases. regarding the opinions of study participants, low quality and effectiveness of medical services, high cost of medication and uncommon preventive health related behavior were pointed out as the main barriers in delivery of the state-of-the-art health care treatment. there is a lot of information about the risk factors for non-communicable diseases and preventive measures in the country, but apparently they do not reach the needs and expectation of the citizens, even though the gps are obliged to make regular preventive examinations among the population, according to the national preventive programs. the strategic objective to the ministry of health (2010-2014) aimed to provide healthcare services for the population with good quality, improved availability and accessibility, as well as better primary health care services for the population (13). there are a lot activities that are conducted to meet this goal (including provision of new equipment, education of medical staff, preventive programs and the like). in 2011, the ministry of health started a project for public procurement of new equipment. with a budget of 70 million euros, there were provided over 609 new sophisticated medical devices. the research that was performed in macedonia (in may, 2012) with 531 respondents, showed that citizens expect better behavior of the medical staff, shorter waiting time for medical examination or diagnostic procedures and better hygiene (14). mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 12 in comparison with the results from the other seven countries included in the research comparative study, macedonia shares the same situation as the other see countries, where poverty, financial and geographical barriers are major factors that lead to a lack of access. in most of the countries (especially in moldova, bulgaria and kosovo), out-of-pocket payments constitute more than 40% of the total payments for health care services, in contrast with the responses from participants in macedonia, where out-of-pocket payments as a barrier is mentioned only for cancer. however, the performance of the public health care system in macedonia has differences compared with other see countries, from the point of view of knowledgeable observers, because the knowledgeable observers from croatia, montenegro and serbia tend to assess their health systems in positive terms. on the other side, representatives of romania, moldova and kosovo are rather critical in evaluating their health systems. bulgarians and macedonians consider their health systems as being “medium-good” in all respects. macedonian citizens showed a high level of trust in doctors, similar to the results from the whole study, where from a total number of 845 respondents, 70.8% reported trust in doctors, 21.4 % did not, and the remaining 7.8% were neutral (15). the future reforms in health policies in the republic of macedonia, as well as in other see countries should be oriented toward six major goals (15,16): the need to better define, and evaluate the costs of benefit packages: all eight countries provide, by national laws, comprehensive packages of health-care services. none of the studied health systems has the capacity to ensure the universal provision of such services. the need to develop prevention services: the community nursing system, considered to be the most powerful “equalizer” in the health system is still largely unutilized in most of see countries. despite efforts to develop primary care, access to adequate and holistic community, health care remains a challenge for certain segments of the population (low-income groups, residents of rural areas and small towns, rom, and the like). the need to develop rehabilitation, palliative and long-term care services: palliative, long-term and rehabilitation care are not sufficiently developed as parts of the healthcare systems in the region. most long-term care is provided in the family, and there are few resources available for informal cares. the need to improve the financing of the public health care systems: public health-care systems in the region are under-financed, primarily as a result of fiscal constraints. hence, political will is a major factor for improving the performance of public health care systems. the need for an effective human resource policy in health: in nearly all countries included in this survey, the availability of all types of medical professionals is far below the european average. shortages of some specialties and skills are also reported in the studied countries such as croatia, macedonia, kosovo and moldova, and are not necessarily related to health professional mobility. the need to address informal payments in the public health care system: the study showed that informal payments still represent an access barrier to state-of-the-art treatment, in particular in relation to chronic diseases. informal payments primarily represent a response to the poor capacity of the public health-care system to provide adequate access to basic services. in conclusion, over the last ten years, many efforts have been undertaken to establish a common conceptual framework for health system performance assessment which is defined mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 13 as the way how the individuals/patients are treated encompassing the notion of the patients‟ experience. measuring of the health care performances is a key tool in aiding decision makers to describe, analyze, compare and improve the delivery and outcomes achieved by health care systems (17). this study applied the method of measuring qualitative parameters received by structured interview to quantitative indicators. the results from the first research study performed in the country show that macedonians consider their health systems as being “medium-good” in all respects. the research methodology used in this paper has the potential to extend the applied methods to the large population taking into consideration other socioeconomic characteristics (income, education, cultural influences and the like). it would help to obtain stronger scientific evidence on health care system performances and to foster the development of measuring tools of its components. 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analysis of the financial literacy survey in romania and recommendation. comprehensive report prepared for world bank. institute for the study of the quality of life. bucharest; 2010. 17. murray cj, evans d. health systems performance assessment. office of health economics; 2006. __________________________________________________________ © 2016 mitevska et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. £ rip £ rip £ rip making a difference: investing in sustainable health and well-being for the people of wales executive summary 2016 scho ol £ rip isbn 978-1-910768-32-7 © 2016 public health wales nhs trust material contained in this document may be reproduced under the terms of the open government licence (ogl) www.nationalarchives.gov.uk/doc/open-government-licence/version/3/ provided it is done so accurately and is not used in a misleading context. acknowledgement to public health wales nhs trust to be stated. copyright in the typographical arrangement, design and layout belongs to public health wales nhs trust. design: jenney creative www.jenneycreative.co.uk about this report this report offers research evidence and expert opinion in support of preventing ill health and reducing inequalities to achieve a sustainable economy, thriving society and optimum health and well-being for the present and future generations in wales. public health wales has developed this report as part of its mission to protect, improve and promote the health and well-being of the people in wales and reduce health inequalities. the report also reflects public health wales’ responsibility to inform, support and advocate for wider health policy and cross-sector approaches and interventions offering benefits to the people, health system, society and the economy. the report has been informed by: ■ research evidence ■ professional guidance and expertise in public health, policy, social studies, equity and economics ■ welsh priorities for health and wellbeing ■ current welsh policy and health context the report consists of three parts published separately: 1 making a difference: investing in sustainable health and well-being for the people of wales executive summary (this document); 2 making a difference: investing in sustainable health and well-being for the people of wales – supporting evidence; and 3 series of 8 infographics focusing on key health challenges for wales and suggested evidence-based solutions. this is not an exhaustive public health review but presents selected summarised research evidence, data and contextual information available at the time of the report development. http://www.nationalarchives.gov.uk/doc/open-government-licence/version/3/ http://www.jenneycreative.co.uk 1 making a difference: investing in sustainable health and well-being for the people of wales executive summary we have made great strides in improving the health of the population. we are living longer, fewer of us are dying from infections and chronic diseases and we have better health services. however, we still face significant challenges in how we reduce the poverty and health inequalities that exist in some parts of wales. we also face challenges in how to support better our growing older population to stay healthy and independent for as long as possible; how to best prevent and manage chronic conditions and how to prepare ourselves and manage new epidemics and global threats to our security. this is also set within an environment of fiscal and economic challenges that require us to shift, even more so, to a more informed and targeted approach to investing in what will have the maximum impact to improve health and well-being and enable health, wealth and growth to thrive in wales. now we know more than ever that prevention saves lives and money and brings multiple benefits to the people, communities and the economy – this is a significant opportunity for us. an extensive body of evidence already exists to support the types of interventions and policies which address the root causes of ill health and inequalities and lead to better mental, physical and social well-being together with enhancing resilience, employment and growth. this report provides the most up-to-date supporting research and expertise on effective and sustainable solutions that are worth investing in to optimise health in wales. now is the time to act together. through a systems approach sharing our collective assets, following the principles of sustainability and prudent healthcare and complying with our unique legislation, the well-being of future generations (wales) act, we have the opportunity and responsibility to work united across sectors and organisations. it is essential to listen to and empower our people and to appreciate the assets of our communities, allowing them an equal part in all decisions and plans for their life, health and happiness. with this timely report, public health wales would like to be part of the solution, to inform and support decisions and policies and to join an allwales commitment and action to make a positive change towards a healthier, happier and more sustainable future for our people in wales. dr tracey cooper chief executive, public health wales foreword the momentum is accelerating to focus our efforts on making a difference to the health and well-being of the present and future generations living and working in wales. public health wales 2 authors and contributors the development of this report has been led by mariana dyakova*. it has been written by mariana dyakova*, teri knight** and sian price** with the help of sumina azam*, elodie besnier*, alisha davies*, nathan lester**, isabel puscas** and malcolm ward*. mark a bellis* and chrissie pickin** provided advice and guidance for the development of the report. high level expert group we are grateful to the national and international experts in public health, policy, social studies, equity and economics who met in january 2016 to discuss key messages and recommendations and to advise on the report structure and contents. they also provided additional evidence and feedback during the report development. eva elliott, cardiff institute of society, health and wellbeing (cishew), cardiff university school of social sciences robin ireland, health equalities group marcus longley, welsh institute for health and social care, university of south wales martin o’neill, cardiff institute of society, health and wellbeing (cishew), cardiff university school of social sciences john wyn owen, bevan commission aaron reeves, london school of economics and political science sarah simpson, equiact ted schrecker, centre for public policy and health, durham university stephen wright, independent consultant in health economics acknowledgements many thanks for providing additional evidence and comments to: julie bishop, huw brunt, nicola gordon, ashley gould, christian heathcote-elliott, rosemary fox, ciaran humphreys, dyfed huws, adam jones, angela jones, craig jones, sarah jones, carolyn lester, sue mably, tracy price, richard roberts, janine roderick, quentin sandifer, rob sage, hannah show, josie smith, robert smith, daniel thomas, angela tinkler and holly walsh from public health wales as well as to phill chick, abertawe bro morgannwg university health board; stephen macey, ash wales and clare bambra, durham university. *policy, research and international development and **health and wellbeing directorates, public health wales making a difference: investing in sustainable health and well-being for the people of wales 3 we know the economic, social and natural environment in which we grow up, live and work is a major determinant of our health and well-being and that of our children – directly, and through the ways in which we are living. there is strong evidence to support a preventative approach prevention removing the causes of poor health and inequalities (rather than addressing the consequences) offers good value for money. preventive policies and interventions save lives, money and improve peoples’ mental, physical and social well-being. they show both short and long-term benefits far beyond the health system across communities, society and the economy. wales is in a unique position to make a difference a favourable legislation and policy context, with the groundbreaking well-being of future generations (wales) act 2015, presents key opportunities to work differently across sectors and with communities to address the increasing health, social and economic challenges in a more effective and sustainable way. why now? the public health offer for wales current globalisation and demographic trends, the rising human and financial costs of illness and inequalities in health, and the ever more limited economic and natural resources threaten sustainability, and the health and well-being of the people living and working in wales. a change in the status quo is urgently needed with new, more effective and efficient solutions informed by evidence, expertise and sound judgement, to address the challenges of the current austerity climate and to achieve future health and economic gains for wales. public health can be a part of the answer together with public policy and public financing. who needs to act? public health wales suggests three priority areas for preventive action: 1 building resilience across the lifecourse and settings 2 addressing harmful behaviours and protecting health 3 addressing wider economic, social and environmental determinants of health ■ decision-makers and policy-makers in national and local governmental roles ■ senior leaders across all public services, those with public health responsibilities, planners and managers ■ all professionals whose role has an impact on people’s health and well-being ■ local communities, third sector and private organisations achieving sustainable health and well-being for the people in wales is everybody’s business. it requires dialogue, shared responsibility and agreement on harnessing action and investment between: public health wales 4 public health wales has defined three priority areas for action (figure. 1) where challenges and health needs in wales are growing and costeffective preventive interventions exist. these areas are interrelated and interdependent, sharing common determinants and solutions. solutions are enabled by the unique well-being of future generations (wales) act1 and its sustainable development principle2 as well as other legislation and approaches, such as the social services and well-being (wales) act3, the active travel (wales) act4, the prudent healthcare principles5 and the concept of systems working (building partnerships and synergies across sectors and stakeholders). the on-going devolution process has the potential to bring more positive developments and unlock key levers (e.g. taxation) to reduce inequalities and benefit people’s well-being. the public health offer for wales figure 1. priority areas for action, enabled by systems working, legislation and key principles enabling legislation systems working addressing wider economic, social and environmental determinants of health prevention long-term view integration collaboration involvement sustainable development principle prudent healthcare principles reduce variation only do what is needed greatest need first co-production do no harm only do what only you can do use evidence 1 http://gov.wales/topics/people-and-communities/people/future-generations-act/?lang=en 2 http://thewaleswewant.co.uk/ 3 http://gov.wales/topics/health/socialcare/act/?lang=en 4 http://gov.wales/legislation/programme/assemblybills/active-travel-act/?lang=en 5 http://www.prudenthealthcare.org.uk/ addressing harmful behaviours and protecting health building resilience across the life-course and settings http://gov.wales/topics/people-and-communities/people/future-generations-act/?lang=en http://thewaleswewant.co.uk/ http://gov.wales/topics/health/socialcare/act/?lang=en http://gov.wales/legislation/programme/assemblybills/active-travel-act/?lang=en http://www.prudenthealthcare.org.uk/ making a difference: investing in sustainable health and well-being for the people of wales 5 for each priority area a summary of key messages is presented, supported by examples from the evidence. more detailed information and references are provided in the supporting evidence document. ensuring good maternal health and a safe and caring environment for children, as well as reducing poverty and deprivation, are essential for a good start in life. deaths among infants (0-28 days) in the most deprived areas in wales are one and a half times more than those in the least deprived. what works? investing in early years6 universal (population wide) interventions along with additional resource proportionate to need for vulnerable children is cost-effective and essential to ensure a healthy and productive wales. investing in targeted interventions and universal child care and paid parental leave could help address as much as £72 billion worth of the cost of social problems such as crime, mental ill health, family breakdown, drug abuse and obesity for wales7. mental ill health is associated with worse physical health, increased health risk behaviours, poor education and unemployment. it accounts for a substantial burden of ill health and disability in wales with high costs to the nhs, the society and the economy. inequality is a key determinant of mental ill health and mental ill health leads to further inequality. in wales, 24% of those who are long term unemployed or have never worked, report a mental health condition compared with 9% of adults in managerial and professional groups. early life experiences, such as bullying or abuse, may have long-term consequences for the development of children and young people, with associated costs to society and public services. in wales, in 2013/14, over a third of pupils reported bullying at school in the previous two months. priority areas for preventive action building resilience across the life-course and settings in wales, 13% of adults reported a mental health condition in 2015 compared to 9% in 2003/4. the estimated cost of mental ill health to society is £7.2 billion per year. the most potential for action is in the first 1000 days from conception to the second birthday. in wales, adverse childhood experiences (aces), such as child maltreatment and/or living in a household affected by parental separation, domestic violence, mental ill health, alcohol, drug abuse or the incarceration of a parent, are associated with: over ½ of the violence and drugs abuse over of teenage pregnancies nearly ¼ of current adult smoking 1. ensuring a good start in life for all 2. promoting mental wellbeing and preventing mental ill health 6 early years defined as 0 to 7 years of age 7 estimated from uk data on unadjusted per capita basis public health wales 6 what works? investing to increase access to early intervention mental health services could lead to considerable savings for other public services. interventions for children and young people, especially the most vulnerable, could lead to long-term savings by reducing the risk of health and social problems and by improving employment prospects. ‘best buys’8 to prevent mental ill health can include interventions and policies to support parents and young children; to improve workplaces; to change lifestyles; to provide social support and to support communities through environmental improvements. violence is a major cause of poor physical and mental health. it impacts on society, the health service and the wider economy. violence affects deprived communities the most. according to the welsh aces survey, 16% of participants reported witnessing domestic violence and abuse; 17% experienced physical abuse and 10% sexual abuse, while they were growing up. admission to hospital for assaults is 3.7 times more likely in the most deprived areas compared to the least deprived areas in wales. what works? reducing violence and abuse could result in substantial savings to health and social care. effective interventions include focusing on children and young people; preventing domestic violence, abuse and violence against women; reducing harmful use of alcohol; and multi-agency approaches. implementing the nice9 guidance on domestic violence and abuse could save £4,700 per month per person on longer-term costs associated with treating and supporting someone experiencing post-traumatic stress disorder as a result of violence and abuse. in wales, domestic violence and abuse costs public services £303.5 million per year. human and emotional costs are an additional £523 million. preventing adverse childhood experiences (aces) and improving resilience and protective factors for children could reduce acts of violence in adults by 60%. anti-bullying interventions in schools can return £15 for every £1 spent; parenting programmes to prevent conduct disorder return £8 over six years for every £1 invested. 3. preventing violence and abuse 8 taking into account cost effectiveness, implementation costs and feasibility 9 uk national institute for health and care excellence improving mental health in the workplace, including prevention and early identification of problems, could produce annual savings of £250,607 for an organisation with 1000 employees. making a difference: investing in sustainable health and well-being for the people of wales 7 smoking is the largest single preventable cause of ill health and death in wales with high costs to the nhs, society and the economy. childhood exposure to tobacco smoke is of specific concern. two in three smokers start before the age of 18 years; one in five children aged 10-11 years are exposed to second hand smoke. deprivation is a risk factor for smoking. in wales, nearly 1/3 of the people in the most deprived fifth of the population smoke (29%), compared to 11% in the least deprived fifth. the health of babies born into lower income households is disproportionately affected by second hand smoke. what works? cost-effective interventions to reduce smoking include enforcing bans on tobacco advertising; raising taxes on tobacco; offering counselling to smokers and others. helping smokers to quit could reduce healthcare costs. each 25 year old smoker who cuts down on smoking would save the nhs in wales £882 over the course of their lifetime, and this would increase to £1,592 if they quit. in wales, 1 in 5 adults smoke causing 18% of adult deaths and costs of £386 million per year to the nhs and £791 million per year to the overall economy. 4. reducing prevalence of smoking 5. reducing prevalence of alcohol misuse alcohol misuse remains a major threat to public health in wales. it is a major cause of death and illness with high costs to the nhs, society and the economy. alcohol is associated with more than 6000 cases of domestic violence and more than £1 billion cost of harm to society each year. heavy drinking increases the risk of unemployment and could account for more than 800,000 working days lost due to absences from work10 and nearly 1 million working days lost due to job loss and reduced employment opportunities in wales. alcohol hurts the poorest the most. alcohol related deaths are more in the most deprived areas in wales. what works? “best buys”11 to reduce alcohol misuse include interventions and policies, such as a minimum unit price (mup) of 50 pence/unit; limiting availability (i.e. reducing outlet density, hours and days of sale); and better control of advertising. brief motivational interviewing in primary care is a cost-effective intervention. every £1 spent on motivational interviewing and supportive networks for people with alcohol dependence returns £5 to the public sector in reduced health, social care and criminal justice costs. 10 estimated from uk data on unadjusted per capita basis 11 taking into account cost effectiveness, implementation costs and feasibility addressing harmful behaviours and protecting health public health wales 8 scho ol many people in wales are not physically active12 enough to protect their health. the burden of physical inactivity is rising13 with significant costs to the health system and the wider economy. physical inactivity is related to social disadvantage. in wales, 40% of adults in the most deprived fifth reported physical activity for less than 30 minutes in the previous week, compared with 23% in the least deprived fifth. increasing physical activity can: improve physical and mental well-being; help prevent and manage many illnesses; and reduce the risk of early death. what works? “best buys”14 to increase physical activity include interventions and policies, such as mass media campaigns; active transport strategies i.e. moving from driving to walking or cycling, promoting physical activity in work places, schools and communities, and providing advice and support in primary care. primary care brief interventions are more cost-effective than prescribing drugs to lower cholesterol levels. over half of welsh adults and a large proportion of children are overweight or obese13. the burden of overweight and obesity is rising with significant costs to the health system and the economy. overweight and obesity are related to social disadvantage. what works? “best buys”14 to reduce levels of unhealthy diet include interventions and policies, such as restricting the marketing of unhealthy food and beverages to children; raising public awareness of healthy diets; increased taxes of unhealthy foods; promoting healthy eating in schools and workplaces and providing counselling in primary care. introducing a 10% tax on sugar sweetened drinks elsewhere resulted in decrease in drinks purchased by an average of 6% and by 9% in more deprived households. offering counselling to obese people in primary care could provide an additional 5,700 years of life in good health per year in wales15. increasing cycling and walking in urban areas could save £0.9 billion for the nhs in wales over 20 years16. if rates of overweight and obesity continue to rise, by 2050, this will cost the nhs in wales £465 million per year, with a cost to society and the economy of £2.4 billion. each year physical inactivity costs £51 million to the nhs and £314 million to the overall economy in wales. 6. promoting physical activity 7. promoting healthy diet and preventing obesity in wales, 28.4% of children in the most deprived areas are overweight or obese, compared to 20.9% in the least deprived areas. 12 physically active for 150 minutes or more a week. 13 for ‘overweight’ and ‘obesity’ definitions, see supporting evidence document 14 taking into account cost effectiveness, implementation costs and feasibility 15 estimated from england and wales data on unadjusted per capita basis scho ol making a difference: investing in sustainable health and well-being for the people of wales 9 infectious diseases are still a major health and economic burden in wales. rates of hiv and other sexually transmitted and some bloodborne infections are increasing. the estimated hiv-related life time costs for diagnosed individuals ranges between £280,000 and £360,000 in the uk. each unplanned hospital admission for flu treatment was estimated to cost the nhs between £347 and £774. inequalities exist for some communicable diseases. 60% of tuberculosis cases are found in people in black and other minority ethnic groups. cancer is a major cause of ill health and premature death in wales with the number of new cases continuing to rise both in men and women. deprivation is linked to poorer uptake of all adult screening programmes. for 2014/15, bowel screening uptake in wales was 41.5% in the most deprived areas compared to 57.1% in the least deprived areas. the uptake of abdominal aortic aneurysm screening was lower in men living in the most deprived areas (67.7%) compared to men living in the least deprived areas (79.5%). what works? vaccination provides a return on investment. the estimated cost of measles treatment was between £159 and £356 per case, while the cost of measles vaccination and control ranged from £0.13 to £0.74 per person in 2003 across europe. early diagnosis of infections saves lives and costs. if 1% of patients with hiv are diagnosed at an earlier stage of disease this could save around £12,114 a year for men who have sex with men and £15,143 a year for black africans in wales16. cancer screening can be cost-effective and early identification could lead to patients living longer and to fewer hospital emergency admissions and diagnostic tests. if the proportion of cancer diagnosed at early stages increased by 10% between 7000 and 9000 more people would survive cancer for 5 years in the uk. colorectal cancer alone accounted for 1,327 new cases and 528 deaths in men and 1,008 new cases and 399 deaths in women in 2014 in wales. the total number of new cases of any cancer in 2014 was 19,118, a 14% increase since 2005. the number of new hiv diagnoses reported from across wales has increased since 2012, with the highest annual number in the last 15 years in 2014 (189 new cases). 8. protection from disease and early identification 16 estimated from england and wales data on unadjusted per capita basis £1.35 would be returned for every £1 spent on targeted flu vaccination. savings would increase to £12 per vaccination when health care workers are included. public health wales 10 economic and social inequalities persist in wales with multi-generational negative impacts on health and wellbeing, triggering and sustaining health inequalities, unhealthy behaviours and influencing future generations and their life prospects. children from disadvantaged households die more often than average as babies and are more likely to have lower income or live in poverty as adults, thus perpetuating a vicious circle. a greater proportion of adults in the most deprived areas of wales die as a result of smoking and alcohol misuse compared to those in the least deprived areas. social inequality is a barrier to sustainable growth. the detrimental effects of austerity are felt greatest by those less resilient; such as those with less economic security or poor physical and mental health. babies living in fuel poor homes (cold and damp) are more likely (by 30%) to be admitted to hospital or to attend primary care. what works? tackling the causes of social and economic inequalities that drive health inequalities is likely to be most effective. this may include interventions to ensure a living wage, reduce unemployment, improve the physical environment and provide universal services (accessible to all) while also investing additionally to support vulnerable groups. a living wage is associated with improvements in life expectancy, mental health, alcohol consumption, and a fall in mortality. preventing ill health across the population is generally more effective at reducing health inequalities than a focus on clinical interventions. minimum unit pricing for alcohol reduces alcohol consumption among the lowest income group by 6% and reduces mortality among the heavy drinkers in routine/manual occupations by 8%. investing in insulation and heating to address cold and damp housing could return savings of nearly £35 million for the nhs in wales17. treating public finances as a public health issue could mitigate austerity measures, i.e. monitoring the impact of all economic and welfare reforms on the public services and public health. this could be done through using health impact assessment18. addressing wider economic, social and environmental determinants of health 9. reducing economic and social inequalities and mitigating austerity estimated costs of inequalities to the welsh economy are £1.8 to £1.9 billion per year due to productivity losses and £1.1 to £1.8 billion per year due to welfare payments and lost taxes17. 17 estimated from england and wales data on unadjusted per capita basis 18 assessing systematically the potential influences of policies, plans and projects in different non health sectors on health and well-being almost a quarter (20-25%) of the deaths among unemployed people over the 10 years following the loss of job could be prevented if they were employed. £ rip 11 environmental risks include occupational risks, urban outdoor air pollution, unsafe water, indoor smoke from solid fuels, lead exposure and global climate change. a triple jeopardy of air pollution, impaired health and social deprivation could increase ill health, disabilities and death disproportionately between and within regions in wales. breathing polluted air causes premature death. it increases the risk from heart disease, stroke, respiratory disease and lung cancer and imposes a considerable cost to society. poor quality housing, including issues such as mould, poor warmth and energy efficiency, infestations, second-hand smoke, overcrowding, noise, lack of green space and toxins, is linked to physical and mental ill health. it impacts the individual, as well as costs to the individual, society and the nhs in terms of associated higher crime, unemployment and treatment costs. injury is a leading cause of death and disability in wales. what works? although there are serious gaps in the economic evidence due to the complexity of environmental hazards and long lag of visible effect (i.e. disease), the world health organisation suggests approaches with health, social, economic and environmental benefits. these are shown to be cost-effective with potential returns on investment and include active transport, safe green spaces, low emission zones, speed management, heat wave plans, chemical regulation and removal of lead and mercury. introducing a traffic congestion charge in london has resulted in 9% reduction in bronchiolitis (lung condition) hospital stays. investing in housing improvements provides a cost-effective way of preventing ill health and reducing health inequalities. it could lead to less time off from school or work, increased use of the home for study and leisure, and improved relationships between household members. 10. ensuring safe and health promoting natural and built environment in wales, around 1,320 deaths and 13,549 years of life are lost due to small particles in the air. the financial, individual and societal costs of air pollution are estimated at nearly £1 billion per year 19. 1100 deaths, 42,000 in-patient admissions and 445,000 emergency department attendances were due to injuries in 2009 in wales. making a difference: investing in sustainable health and well-being for the people of wales 19 estimated from uk data on unadjusted per capita basis £ rip public health wales 12 the unique welsh policy context, especially the well-being of future generations (wales) act 2015, has the potential to enable positive change and secure sustainable solutions for the present and future generations. the five sustainable development principles, agreed with the welsh population are: prevention, long-term view, integration, collaboration and involvement. they are in part complemented by the four prudent healthcare principles: ‘do no harm and only do what’s needed’, ‘coproduction’, ‘reduce inappropriate variation and use evidence’ and ‘care for those with the greatest health need first’. a key enabler for all health interventions is ‘systems working’ to improve the public’s health, i.e. taking a whole systems approach which aligns public policies, financial flows and accountability with local public, private and third sector delivery and shared outcomes. a collaborative approach with an emphasis on prevention and public health will help address the current and future health, social and economic challenges in wales. drawing on recommendations from national and international experts in public health and policy, social studies, equity and economics, we have brought together recommendations on how to embed these principles into practice. enabling principles 1 prevention invest in preventive interventions which are based on evidence and offer value for money. this report has highlighted potential ‘solutions’ and approaches in some key public health areas. 2 long-term view adopt a long-term investment and prioritisation framework (on national and local level) to protect, improve and promote the health and well-being of people and communities in wales. 3 integration utilise health impact assessment across welsh government, local government and the public sector in order to consider the impact of any decision and intervention on health, well-being and inequalities, i.e. assessing the potential influences of policies, plans and projects in different non health sectors. 4 collaboration and ‘systems working’ working in partnership and synergy across sectors on national and local level, including governmental, public, private and third sector organisations. 5 involvement and ‘co-production’ ensure communities and people in wales are given a voice, involved in decisions about their health and well-being and listened to through ‘knowledge forums’ to facilitate the engagement of the public, professionals, policy makers and academic experts. 6 minimise and mitigate harms to health ensure impacts on health, well-being and equity are known and harms are minimised and mitigated through adopting a ‘health in all policies’ approach across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts, to improve population health and health equity. 7 reduce variation and address the greatest population health need first ensure a ‘proportionate universalism’ approach, i.e. all decisions and interventions which benefit health and well-being are implemented for all people but delivered at scale proportionate to need. about us public health wales exists to protect and improve health and wellbeing and reduce health inequalities for people in wales. we are part of the nhs and report to the minister for health and social services in the welsh government. our vision is for a healthier, happier and fairer wales. we work locally, nationally and, with partners, across communities in the following areas: health protection – providing information and advice and taking action to protect people from communicable disease and environmental hazards. microbiology – providing a network of microbiology services which support the diagnosis and management of infectious diseases. screening – providing screening programmes which assist the early detection, prevention and treatment of disease. nhs quality improvement and patient safety – providing the nhs with information, advice and support to improve patient outcomes. primary, community and integrated care – strengthening its public health impact through policy, commissioning, planning and service delivery. safeguarding – providing expertise and strategic advice to help safeguard children and vulnerable adults. health intelligence – providing public health data analysis, evidence finding and knowledge management. policy, research and international development – influencing policy, supporting research and contributing to international health development. health improvement – working across agencies and providing population services to improve health and reduce health inequalities. further information web: www.publichealthwales.org email: generalenquiries@wales.nhs.uk twitter: @publichealthw facebook: www.facebook.com/#!/publichealthwales http://www.publichealthwales.org mailto:generalenquiries@wales.nhs.uk http://www.facebook.com/#!/publichealthwales public health wales hadyn ellis building maindy road cathays cardiff cf24 4hq tel: 02921 841 933 this report, including the executive summary, supporting evidence and infographics can be found on the public health wales website www.publichealthwales.wales.nhs.uk £ rip http://www.publichealthwales.wales.nhs.uk holst j, breckenkamp j, burazeri g, martin-moreno jm, schröder-bäck p, laaser u. five years of the south eastern european journal of public health (seejph): focusing on health systems in transition and global health [editorial]. seejph 2018, posted: 24 september 2018. doi 10.4119/unibi/seejph-2018-201 1 editorial five years of the south eastern european journal of public health (seejph): focusing on health systems in transition and global health jens holst1, jürgen breckenkamp1, genc burazeri1, jose m. martin-moreno1, peter schröder-bäck1, ulrich laaser1 1 editors, south eastern european journal of public health (seejph). corresponding author: ulrich laaser section of international public health, faculty of health sciences bsph, university of bielefeld, germany; address: pob 10 01 31, d-33501 bielefeld, germany; email: ulrich.laaser@uni-bielefeld.de mailto:ulrich.laaser@uni-bielefeld.de holst j, breckenkamp j, burazeri g, martin-moreno jm, schröder-bäck p, laaser u. five years of the south eastern european journal of public health (seejph): focusing on health systems in transition and global health [editorial]. seejph 2018, posted: 24 september 2018. doi 10.4119/unibi/seejph-2018-201 2 five years ago, in the spring of 2014, the first volume of a new open access journal was published by jacobs company (1). it was conceptualized in the framework of the european stability pact for south eastern europe, financed until 2010 by the german academic exchange service. yet, by that time, the project had supported the creation of schools of public health and public health training programmes in albania, bulgaria, moldova, romania, serbia, and slovenia, complementing the andrija stampar school of public health in zagreb, croatia, the oldest institution for teaching, research, and practice of public health in the region (since 1927). the south eastern european journal of public health (seejph) is an open access international peer-reviewed journal involving all areas of the health sciences and public health. seejph welcomes submissions of scientists, researchers, and practitioners from all over the world, but particularly pertinent to transition countries. in their introductory editorial, the editors wrote that: “the need for scientific journals such as seejph springs from the peculiar geopolitical history of the region. during the late 1980s and early 1990s, the disintegration of the communist regimes in most of south eastern europe hastened the collapse or at least enormous challenges in the economies of the region” (2). since then, the journal steadily widened its array with a focus on the southern and eastern regions of the world which are currently experiencing a process of transition similar to south eastern europe. as a consequence, we appointed regional editors for each of the world health organization (who) regions of africa, the americas, europe, south east asia, western pacific, and logically paying tribute to the genesis of the journal within south eastern europe (3). as the global dimension of the journal gained weight, the editors invited professor jens holst as coeditor and chair of the regional editorial group, taking office with this tenth issue of the journal. in this context, we are determined to widen the field of interest beyond a historical national or local vision of public health to a global health perspective which, of course, in our understanding, has increasingly developed from a kind of cosmopolitan cousin into an overarching concept in the globalised world. current trends in global health include demographic and epidemiological transitions, the changing burden of disease, climate change, and the increasing awareness of both national and global disparities in health. the most frequently cited definition was crafted by jeffrey koplan and colleagues in 2009: “global health emphasises transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care” (4). the concept of ‘global’ in global health goes beyond its geographic meaning. like international health, global health links to health equity and cross-border solidarity. apart from this, global health considers health from a human-rights perspective and as an explicitly social, economic, and political issue anywhere in the world (5). in this understanding, the editors perceive ‘public’ in the journal title as ‘global’ health. likewise, the term ‘south eastern european’ is not limited to its geographic meaning, but rather refers to the global south and some parts of the east in a developing world. starting with its 10th edition, seejph will put a major focus on global health challenges and cover health issues that transcend national boundaries calling for action in the various sectors, which determine people’s health. holst j, breckenkamp j, burazeri g, martin-moreno jm, schröder-bäck p, laaser u. five years of the south eastern european journal of public health (seejph): focusing on health systems in transition and global health [editorial]. seejph 2018, posted: 24 september 2018. doi 10.4119/unibi/seejph-2018-201 3 we believe that the challenges we are experiencing in this historical moment deserve such a commitment and we thank you in advance for your support to this initiative. references 1) the south eastern european journal of public health (seejph), published by jacobs verlag, hellweg 72, d-32791 lage, germany. 2) burazeri g, jankovic s, laaser u, martin-moreno j. south eastern european journal of public health: a new international online journal. seejph 2015, vol. 1. doi 10.4119/unibi/seejph-2014-21. 3) seejph, about: http://www.seejph.com/index.php/seejph/pages/view/editorialteam. 4) koplan jp, bond tc, mersonmh, reddy ks, rodriguez mh, sewankambo nk, wasserheit jn, for the consortium of universities for global health executive board. towards a common definition of global health. lancet 2009;373:1993-5. 5) bozorgmehr k. rethinking the ‘global’ in global health: a dialectic approach. global health 2010;6:19. doi: 10.1186/1744-8603-6-19. ______________________________________________________________________________________ © 2018 holst j, et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. karma e, gashi s. technical efficiency of kosovo public hospitals (original research). seejph 2022, posted: 27 july 2022. doi: 10.11576/seejph-5771 p a g e 1 | 11 original research technical efficiency of kosovo public hospitals emiljan karma phd1, dr. silvana gashi 2 1 research centre on developing economies, faculty of economic, political and social sciences, catholic university our lady of good counsel, tirana, albania 2 management department, faculty of business, university “aleksandër moisiu”, durrës, albania corresponding author: emiljan karma, phd. address: univ. katolik zoja e keshillit te mire, rruga d. hoxha, 23, tirana (albania) telephone: 00355695639061 email: e.karma@unizkm.al karma e, gashi s. technical efficiency of kosovo public hospitals (original research). seejph 2022, posted: 27 july 2022. doi: 10.11576/seejph-5771 p a g e 2 | 11 abstract aim: the goal of this paper is to evaluate the technical efficiency of kosovo public hospitals and to propose ways to improve the situation. methods: an input-oriented data envelopment analysis model with a constant return to scale was applied for a 3-year period from 2018 to 2020. input variables of number of beds, number of specialists and how they are used to produce outputs of inpatient discharges and surgical operations, are examined. results: the analysis highlights the marked hospital technical inefficiencies. this study clearly points out the greater attention of public healthcare institutions toward production efficiency. results illustrate that at least half of kosovo public hospitals operate inefficiently compared to their counterparts. inefficient, compared to efficient hospitals, on average utilize at least (depending on scenarios analysed) 30% more beds and specialists. conclusions: the resources available for public health services in kosovo are the lowest in europe and the challenge remains to secure financial resources and use them effectively. the study illustrates that most of kosovo public hospitals run inefficiently. productivity is low, efficiency needs to be improved, especially in terms of introducing modern treatment methods such as daycare. based on this research, it seems advisable to decrease the number of beds while rationalizing the number of specialized physicians with respect to the special requirements of therapeutic and diagnostic processes in the individual hospitals. keywords: dea, efficiency; kosovo, public health; tobit regression. karma e, gashi s. technical efficiency of kosovo public hospitals (original research). seejph 2022, posted: 27 july 2022. doi: 10.11576/seejph-5771 p a g e 3 | 11 introduction healthcare services in kosovo are provided through a network of health institutions organized at three levels: primary(kpsh), secondary(kdsh) and tertiary level (ktsh). healthcare services are organized and provided by healthcare providers such as hospital services, home health care services and emergency ones. these services are provided in public and private health institutions. based on the law on health 04 / l-125 (1), the ministry regulates, supervises, and controls the health care implementation in public and private institutions at all three levels of health care. the resources available for public health services in kosovo are the lowest in europe and the challenge remains to secure financial resources and use them effectively (2). over the past decade, kosovo has experienced a rise in health care spending. during the 11-year period covering 2010 to 2021, kosovo's per capita health care spending (in u.s. dollars) increased 1,9 times from $49 in 2010 to $141 in 2021 (3,4). kosovo’s total health expenditure, as a percentage of gross domestic product, rose from 1.6% in 2010 to 3.5% in 2021 (3,4). this study on the health system of kosovo seeks to identify the technical inefficiencies present in public hospitals in kosovo considering the necessary interventions to improve cost – effectiveness. hospitals are the key resource units in a health care system. they consume the majority of a country's health expenditures, and the important role they play in the delivery of health care services place them at the root of many pressing issues. because of their importance, hospitals strongly influence their health care system's efficiency (5). performance in the production theory refers to an optimal combination of inputs to achieve maximum outputs, thereby reducing waste (6). regarding efficiency, we refer to the way that public hospitals allocate (allocative efficiency) and utilize their inputs (productive efficiency) to produce outputs in terms of specialized services. efficiency refers to the use of an input to generate output; previously defined as the output-toinput ratio, such as cost per unit or production per hour of labour (7). literature (8 10) has shown that a traditional method (ratio analysis) is not relevant in measuring the overall performance of a dmu (decision making unit). ratios are based on a single input and single output and measure the performance on a single indicator, which does not serve the purpose of measuring the hospital efficiency. the modern efficiency method can be extended to more inputs and outputs and can be used to measure the dmus performance. the study proposes relative effectiveness as a metric that can be used relatively to assess the success of dmus in terms of social and financial aspects. to our knowledge, this is the first study that directly investigates the kosovo public hospitals’ efficiency using a nonparametric method like dea. there are studies that use the traditional method (parametric and ratio analysis) in evaluating indirectly but partially the efficiency in health care institutions. lleshi (11) conducted a study using the parametric model to evaluate the quality assurance concerning the quality based management system. bytyqi et al. (12) use a quantitative approach, with an explorative-descriptive design to examine the leadership profile and quality in primary, secondary and tertiary public health institutions in kosovo. tahiri et al. (13) conducted a study using the traditional method to evaluate the patient satisfaction with the primary health care service in gjilan region, kosovo. hoxha et al. (14) conducted a study using multiple linear regression analysis to assess predictive factors for patient satisfaction with healthcare services as a measure of the quality of hospital care in public and private hospitals in kosovo. kosovo agency of statistics (15-17) periodically reports the efficiency indicators of public hospitals activity in kosovo (indicators which are based on a single input and single output). karma e, gashi s. technical efficiency of kosovo public hospitals (original research). seejph 2022, posted: 27 july 2022. doi: 10.11576/seejph-5771 p a g e 4 | 11 methods the evaluation of health services has been addressed by a number of authors worldwide. multi-criteria methods are widely used for the evaluation as tools that are able to assess the efficiency of inputs and show the opportunities for the improvement of inefficient units, but also to identify exemplary units. one of the tools able to determine the rate of technical efficiency of production units is the data envelopment analysis (dea) model. dea is a non-parametric method that evaluates the relative technical efficiency of decision-making units (dmus) in terms of input / output combination. dea analyzes the efficiency with which dmu (in this study, hospital) uses inputs to produce its outputs. this method identifies the optimal input/output combination and represents it with the "best practice frontier," or data envelope. dmus that compose this frontier are assigned an efficiency score of one and are technically efficient relative to their peers (18). all other dmus are assigned a score of between less than one, but greater than zero (18,19). the first dea model was formulated in the study published by charnes, cooper, rhodes (20). this model is based on the assumption of constant returns to scale and maximizes the efficiency of the evaluated production unit under the condition that the efficiency of all other units is less than or equal to one. the modelling of technical efficiency was performed using the inputoriented model that expects that inefficient units should reduce their inputs with respect to the outputs attained. however, it is also a well-known fact that reductions in key human resources (physicians, general nurses, and midwives) have a negative impact on the quality of the services provided in both public health and social services (21,22). the two basic dea models are the ccr model of charnes, cooper, rhodes (20) and the bcc model of banker, charnes, cooper (23). ccr assesses technical efficiency under a constant return to scale (crs) condition (20). considering that this is often not the case, banker et al. (23) introduced the variable return to scale (vrs) condition, so that an institution will be compared to a similarly sized institution that has similar return to scale (24). in the basic dea model, there are two approaches that can be used, the input-oriented approach, which maximizes proportional input reduction by holding outputs constant, and the output-oriented approach, which maximizes proportional output increase while keeping inputs constant (20). our analysis only uses the input-oriented approach with its crs model: θ * =min 𝜃𝑘 , subject to ∑ 𝜆𝑗 𝑛 𝑗=1 𝑦𝑟𝑗 ≤ 𝑦𝑟𝑘 𝑟 = 1, 2, … , 𝑠 ∑ 𝜆𝑗 𝑛 𝑗=1 𝑥𝑖𝑗 ≥ θ * 𝑥𝑖𝑘 𝑖 = 1, 2, … , 𝑚 𝜆𝑗 ≥ 0 ∀ 𝑗 = 1, 2, … , 𝑛 dea show an exponential growth in its use in academic research over the last forty years (25). technical efficiency is analysed in two stages. first, we calculated the relative technical efficiency using the basic outline of the input-oriented dea model with crs (constant returns to scale). in the second stage, a regression analysis is performed to relate efficiency scores to contextual factors for investigating their influence on the relative efficiency in the provision of hospital services. the karma e, gashi s. technical efficiency of kosovo public hospitals (original research). seejph 2022, posted: 27 july 2022. doi: 10.11576/seejph-5771 p a g e 5 | 11 description of the production units evaluated public hospitals (dmus), the inputs and outputs, and evaluation models are specified below. statistical analyses are performed using stata 16 software. dmus in the context of the health system as of 31 december 2020, a total of 8 public hospitals operated in kosovo, with a total capacity of 3872 beds: university clinical centre kosovo (qkuk) and seven public hospitals (regional hospitals). according to the ministry of health (26), the expenses of public health for inpatient and outpatient care in secondary and tertiary health care providers increased during the period 2010 – 2018 (passing from 45% to 70% of the kosovo health budget). the hospital network comprises both public and private hospitals, while public hospitals are unambiguously dominant. significant changes implemented in the last 20 years were aimed at making the public health system more efficient, whether from the perspective of the hospitals’ operation or in terms of hospital care funding changes. although much was accomplished, reforms largely failed due to the discrepancy between the identification of internal needs and external priorities that drove health reform process (world bank and other donors). secondly, the weak state capacities and the political instability contributed to slowing down the implementation of reforms (2). this research focuses on public hospitals that provide comprehensive acute inpatient care. inputs and outputs there is no clear guideline on how to select among a variety of indicators. the articles specified below demonstrate the combination input/output changes in various studies. medarević et al. (27) conducted a study to evaluate the efficiency and productivity of public hospitals in serbia between 2015 – 2019. their method was the input – oriented method and the proposed dea model comprises the number of beds, the number of health workers (without physicians), the total number of physicians. the output variables included the number of inpatient episodes and the number of outpatient episodes. torabipur et al. (28) aimed to measure the hospital productivity using a cross sectional study in which the panel data comprised a 4-year period from 2007 to 2010. the input measures included are the number of nurses, number of beds and number of physicians. the output measures included are number of the outpatients and inpatients, average of hospital stay, and number of surgeries. kundurjiev et al. (29) focused on the efficiency in healthcare and especially technical efficiency in psychiatric hospital care. the proposed dea model includes as inputs hospital beds, physicians, nurses, and as outputs inpatients and bed – days. pirani et al. (30) focused on the evaluation of the efficiency of public hospitals between 2012 and 2016. their method was the output-oriented dea model positing variable returns to scale, while the input variables comprised the number of hospital admissions, the number of nurses, and the number of available beds. the output variables included the average length of stay and the bed turnover interval. ghahremanloo et al. (31) point to the importance of performance evaluation as a relevant tool for hospital management. the proposed dea model includes the evaluation of the overall hospital efficiency. the model’s input indicators comprise the number of healthcare professionals, the number of other staff, and the number of beds. the output indicators include the bed occupancy rate and the bed turnover rate. varabyova et al. (32) focused their research on applying the non-parametric methods (such as dea and fdh) to evaluate certain italian and german hospitals. their input indicators were the number of beds, the number of physicians and the number of https://pubmed.ncbi.nlm.nih.gov/?term=medarevi%c4%87%20a%5bauthor%5d karma e, gashi s. technical efficiency of kosovo public hospitals (original research). seejph 2022, posted: 27 july 2022. doi: 10.11576/seejph-5771 p a g e 6 | 11 nurses (the personnel data are specified in a full-time equivalent), while the output indicators were the selected inpatient adjusted and day cases. however, to use dea correctly, the number of dmus must be high enough: the larger the number of variables used, the larger the number of dmus (33). given that the number of dmus in kosovo is only eight, two inputs indicators and two output indicators were chosen to fulfil the objective of the article. secondly, after conducting a review of the available literature (34, 35) we decided to use these inputs and outputs: x1 number of hospital beds available in public hospitals (input); x2 – number of specialized physicians (input); y1 – number of hospitalized patients by year (output); y2 – number of surgeries by year (output). the performance estimation of efficiency according to the dea model is implemented using four specific models. the first two models contain two outputs and one input and estimate the efficiency with constant returns to scale (crs) method. these models are indicated as x1crs (x1; y1-y2) and x2-crs (x2; y1 – y2). consequently, the partial efficiency is estimated from the perspective of the individual inputs (x1, x2). the other two models contain two inputs and one output and estimate the efficiency with crs method. these models are indicated as y1crs (x1-x2; y1) and y2-crs (x1-x2; y2). consequently, the partial efficiency is estimated from the perspective of the individual outputs (y1, y2). results the distribution of the results between the individual inefficiency levels (mild, moderate, strong) confirms that models x1 crs attain the worst results, while the best results are attained by y1 – crs. of the 8 general hospitals included in the study, the average efficiency rate fluctuates from 70% to 91% depending on the model applied. according to this analysis, the best performance, in all models, is obtained by the public hospital of vushtrri. on the other side, considering these input – output indicators, the worst performance is obtained by the public hospital of gjilan. dmus efficiency ranking, the means of input and output variables, for both efficient and inefficient hospitals, are presented in table 1. table 1. hospital efficiency results dmu efficiency ranking (by model) x1 crs x2 crs y1 crs y2 crs prizren 4 1 1 2 peje 6 4 5 5 gjilan 8 7 7 8 vushtrri 1 1 1 1 mitrovice 2 6 1 4 gjakove 6 1 1 7 ferizaj 3 8 8 6 qkuk 5 5 6 3 the efficiency rate of 8 general hospitals by models mean 0,70 0,87 0,91 0,72 mean (%) 70 87 91 72 st. deviation 0,17 0,24 0,33 0,48 efficient hospitals are using fewer inputs to produce more outputs compared to inefficient hospitals. the extent of the inefficiency changes according to the karma e, gashi s. technical efficiency of kosovo public hospitals (original research). seejph 2022, posted: 27 july 2022. doi: 10.11576/seejph-5771 p a g e 7 | 11 models used. the presence of inefficiencies indicates that a hospital has excess inputs or insufficient outputs compared to those hospitals on the efficiency frontier. the distribution of dmus based on the efficiency score is presented in figure 1. for the efficiency comparison over time, a mann-whitney test is used (36-39). this non-parametric test identifies whether the efficiency scores from one year to another have a significant difference. following the results (see table 2), we can conclude that there are no significant differences in all models with the exception of model y2 – crs: in this case, it can be seen a statistically significant efficiency improvement during 2019 and 2020 compared with the year 2018. the selected tobit model (40, 41) for explaining the observed hospital inefficiencies contains the following variables: hospital size (size), average length of stay (alos) and bed occupancy rate (bor). the tobit model was performed for the four scenarios (x1-crs; x2-crs; y1-crs; y2-crs). table 2. results of the mann – whitney test (year efficiency comparison). x1 crs x2 crs y1 crs y2 crs 18/19 18/20 19/20 18/19 18/20 19/20 18/19 18/20 19/20 18/19 18/20 19/20 u value 15,5 15 24 20 28 27 19 27 25 11.5 12 30 z – value -1,68 -1,73 -0,78 -1,2 -0,36 0,47 -1,31 -0,47 0,68 -2,1 -2,04 0,15 p value 0,09 0,08 0,43 0,23 0,71 0,63 0,19 0,64 0,49 0,04* 0,04* 0,87 note: p* = 0.05 (significance level) table 3 presents the tobit regression model results. results from the regression analysis indicate that the coefficient for bed occupancy rate has a positive coefficient in all efficiency models indicating that the higher the bed occupancy rate the higher the efficiency score (in x1 – crs model, 1% increase in bed occupancy rate increases the 1 3 4 1 2 1 3 1 2 3 1 5 3 1 1 0 1 2 3 4 5 6 7 8 9 x1 crs x2 crs y1 crs y2 crs figure 1. distribution of dmus by efficiency score efficiency mild inefficiency moderate inefficiency strong inefficiency note: [0-0,5[ score: strong-inefficiency; [0,5 – 0,7[ score: moderate inefficiency; [0,7-0,99[ mild-inefficiency; [1] score: efficiency karma e, gashi s. technical efficiency of kosovo public hospitals (original research). seejph 2022, posted: 27 july 2022. doi: 10.11576/seejph-5771 p a g e 8 | 11 efficiency score by 0,0143054 all other factors remaining constant. the score coefficient is statistically significant at the 1% level). the coefficient for the hospital size is positive in all efficiency models but significant only for x2 – crs and y1 – crs models. the coefficient for alos has a negative and significant coefficient in all models indicating that the higher the average length of stay the lower the technical efficiency score. table 3. results of tobit model efficiency model variable coefficient t p > |t| x1 crs size -0,0082051 -0,50 0,640 bor 0,0143054 22.99 0,000** alos -0,1625514 -15.23 0,000** cons 0,6849855 20.51 0,000** sigma .0094139 **p < 0,01 *p < 0,05 n. observations 8 lr chi2 45,13 prob > chi2 0,0000 log likelihood 25,973067 pseudo r2 -6,6161 x2 crs size 0,5481224 4,07 0,010* bor 0,0204997 4,04 0,010* alos -0,2820566 -3,24 0,023* cons 0,7138949 2,62 0,047* sigma 0,0767903 **p < 0,01 *p < 0,05 n. observations 8 lr chi2 10,06 prob > chi2 0,018 log likelihood 9,1819099 pseudo r2 -1.2127 y1 crs size 0,3574446 3,48 0,018* bor 0,0125095 3,23 0,023* alos 0,2419334 -3,64 0,015* cons 1,115265 5,36 0,003** sigma 0,00586798 **p < 0,01 *p < 0,05 n. observations 8 lr chi2 8,39 prob > chi2 0,0387 log likelihood 11,33377 pseudo r2 -0,5873 y2 crs size 0,2358457 2,35 0,065 bor 0,0244741 6,48 0.001** alos 0,1787922 -2,76 0,040* cons 0,1009707 0,50 0,640 sigma 0,0571663 **p < 0,01 *p < 0,05 n. observations 8 lr chi2 16,24 prob > chi2 0,0010 log likelihood 11,542818 pseudo r2 -2,3711 karma e, gashi s. technical efficiency of kosovo public hospitals (original research). seejph 2022, posted: 27 july 2022. doi: 10.11576/seejph-5771 p a g e 9 | 11 discussion this study is one of the first attempts at analyzing technical the efficiencies of public hospitals in kosovo by using dea methodology. the study illustrates that the large majority of kosovo public hospitals run inefficiently. these results are not surprising and are further support of the conventional beliefs that the kosovo health and hospital systems are not effective and efficient (42). because the hospital system is the largest component of the health system, it can be said that to a great degree, the efficiency of the hospital system determines the health system efficiency. as shown in table 1, inputs are wasted and not utilized in the production of hospital services. the above results may indicate—within the context of the evaluation logic according to the input-oriented dea model—those inefficient hospitals should primarily consider reducing the number of beds and secondly discuss the number of specialized physicians. however, this recommendation must be considered individually in the hospital conditions, especially those showing an extensive inefficiency degree, even if this includes at least 50% of all the public hospitals. the evaluation of the technical efficiency results according to hospital size shows that big hospitals are not necessarily the leaders within the set analysed (e.g., the hospital of vushtrri is a small structure with only 63 beds.). based on this research, it seems advisable to decrease the number of beds while rationalizing the number of specialized physicians with respect to the special requirements of therapeutic and diagnostic processes in individual hospitals. in the case of physicians, any interference in 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(with a summary in english) 39. grosskopf s, valdmanis v. measuring hospital performance. a nonparametric approach. journal of health economics 1987; 6:89-107. 40. chilingerian ja. evaluating physician efficiency in hospitals: a multivariate analysis of best practices. european journal of operational research 1995;80:548-74. 41. amore md, murtinu s. tobit models in strategy research: critical issues and applications. global strategy journal 2021;11:331-55. 42. qosaj fa, froeschl g, berisha m, bellaqa b, holle r. catastrophic expenditures, and impoverishment due to out‑of‑pocket health payments in kosovo. cost effectiveness and resource allocation 2018; 16:1-12. __________________________________________________________________________________________ © 2022 karma et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.researchgate.net/journal/engineering-management-in-production-and-services-2543-912x https://www.researchgate.net/journal/engineering-management-in-production-and-services-2543-912x gutema k, mariam dh. does health sector aid matter? evidence from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 1 original research does health sector aid matter? evidence from time-series data analysis in ethiopia keneni gutema 1 , damen haile mariam 2 1 college of medicine and health sciences, hawassa university, hawassa, ethiopia; 2 school of public health, addis ababa university, addis ababa, ethiopia; corresponding author: prof. damen haile mariam, addis ababa university; address: p. o. box 11950, addis ababa, ethiopia; telephone: +251911228981; email: damen_h@hotmail.com gutema k, mariam dh. does health sector aid matter? evidence from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 2 abstract aims: development assistance for health is an important part of financing health care in developing countries. in spite of the increasing volumes in absolute terms in development assistance for health, there are controversies on their effect on health outcomes. therefore, this study aims to analyze the effect of development assistance for health on health status in ethiopia. methods: using dynamic time series analytic approach for the period 1978-2013, this paper examines whether development assistance for health has contributed for health status change in ethiopia. while life expectancy at birth was used as a measure of health status, vector error correction model was used for the analysis. results: development assistance for health expenditure (lagged one and two years) had a significant positive effect on life expectancy at birth in ethiopia. other things being equal, a 1% increase in per capita development assistance for health leads to 0.026 years improvement in life expectancy at birth (p<0.001) in the immediate year following the period of assistance, and 0.008 years (p=0.025) in the immediate two years following the provision of assistance. conclusion: this study indicates that, seemingly, development assistance for health has significant favourable effect in improving health status in ethiopia. the policy implication of this finding is development assistance for the health should continue as an interim means to an end. keywords: development assistance, health financing, health status, infant mortality rate, life expectancy. conflicts of interest: none. gutema k, mariam dh. does health sector aid matter? evidence from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 3 introduction there is paucity of evidence on the effects of development assistance on health outcomes in developing countries. within the limited literature on the issue, there is disagreement on its effect. some researchers argue that health specific aid leads to improved health outcomes in developing countries by relaxing resource constraints and directly improving health service delivery (1-3). in line with this, levine (1) argues that health is an area where development assistance is likely to show positive changes, as preventive and promotive health activities are directly related to the better health outcomes. the empirical studies by mishra and newhouse, and ebeke and drabo (2,3) also report strong positive effect of health aid on health outcomes in improving infant mortality rate and access to health care for the treatment of fever and diarrhoea respectively in developing countries. chauvet, gubert and mesple-somps (4), who analyzed the respective impact of aid and remittances on infant and child mortality rates with a panel data from 1987 to 2004, also reported results suggesting a positive effect of health aid on health outcomes. similarly, gormanee, girma, and morrissey reported that aggregate aid improves health status by decreasing infant mortality in least developed countries (5). on the contrary, some other scholars argue that there is no reliable evidence supporting the claimed positive effect of health aid on health outcomes (6,7). williamson (6), for example, looked into the impact of foreign aid commitments by donor to health sector using a panel set of 208 developed and developing countries with data from 1973 to 2004 and found no significant impact of health sector aid on a variety of health outcome indicators (including infant mortality and life expectancy at birth). similarly, wilson (7), using panel data of 96 countries with high mortality during 1975-2005, tested the relationship between development assistance for health and a recipient country’s infant mortality rate (imr). his empirical analysis suggests that development assistance for health has no effect on infant mortality at the country level. although sub-saharan africa including ethiopia is among the largest recipients of development assistance (8), the relationship between such assistance and health outcomes has not been properly investigated. ethiopia has been receiving increased inflow of development assistance following its implementation of the health sector development plan (hsdp) (9). during 2009 and 2010, the country received the second highest volume of average development assistance in absolute terms among 24 low and lower-middle income countries, while in 2011, it was the first recipient among these countries (10). as a result, the country’s national health account (nha) show development assistance as contributing to 50% of the general health care spending in the year 2010-2011, up from 40% during 2007-2008 (11). parallel to the increase in development assistance, health outcomes in the country have also shown noticeable changes during the last two and half decades (11,12).under-five mortality rate (u5mr) is reduced by two thirds between 1990 and 2015, and the country has achieved mdg4 two years before the target year (11-13). the ethiopian demographic and health survey (edhs) reports of 2000, 2005 and 2011 also show declining trends in both u5mr and imr (14-16), even though changes in neonatal mortality rate were not as impressive (14-16). in this context, the present study aimed to explore whether the aforementioned improvements in health outcomes are partly attributed to an increase in inflow of development assistance. gutema k, mariam dh. does health sector aid matter? evidence from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 4 methods the theoretical model using dynamic time series analytic approach, the effect of development assistance on health status in ethiopia was examined for the period of 1978-2013. the year 1978 is considered as an initial period for the study as there is a dearth of data for the period prior to that. it also seems reasonable to use 1978 as an initial period since it is also the historical period for the declaration of primary health care (17). the year 2013 was taken as the last period since it is for this period that comprehensive data could be secured. life expectancy at birth (leb) is used as a measure of health status as it has long been used in other studies for this purpose (18). data sources data for the analysis were obtained from world development indicators (wdi) (19), africa development indicators (adi) (20), as well as from ethiopian ministry of finance and economic development (21,22) and central statistical agency (23). variables the dependent variable used was life expectancy at birth (leb). leb is the average equivalent number of years of full health that a new-born could expect to live, if he or she were to pass through life subject to the age-specific death rates and average age-specific levels of health states for a given period. this indicator is preferred as it is also used as a measure of health status in most other studies used for comparison (6,18). moreover, it exhibits a stationary pattern after differencing, a basic requirement for time series analysis (24,25). the independent variables used include: development assistance for health expenditure (dahe) refers to health expenditure that originates from external sources. per capita dahe in usd was used for the current analysis; public health expenditure excluding dahe (phe dah): was used as a control variable, and represents recurrent and capital spending from government (central and local) budgets, other than dahe. a per capita phe dah in usd is used. this variable is considered since health expenditures from local sources is among the factors known to influence health status of populations; gdp per capita (gdpp) is gross domestic product divided by mid-year population; total female enrolment in primary education (femed) percentage of the female population of official primary education age. the choice of this variable is by evidence of an earlier finding that when women are educated, they become aware of issues related to health development at household level, such as, nutrition, immunization, health seeking behaviour (26,27); femed can exceed 100% due to the inclusion of over-aged and under-aged students because of early or late school entrance and grade repetition, however, it can provide a valid evidence. the choice was made as this was the only alternative education indicator found for the sampled year; and population ages 15 to 64 (pop) percentage of the total population in the age group 15 to 64years. gutema k, mariam dh. does health sector aid matter? evidence from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 5 statistical analysis tests for stationarity and long-run equilibrium before the exploration of the presence of long-run equilibrium relationship between development assistance for health and life expectancy at birth, two tests were performed to ensure the stationarity of the variables in question. the results of the adf and philips-perron test have guaranteed that the estimated variables are integrated of order one (after first differencing). furthermore, the presence of long run equilibrium relationship between the two variables in the regression was examined through the multivariate johansen-juseliusco-integration test which ascertained the existence of convergence between the long run equilibrium and the short run dynamics of the variables under study. furthermore, to examine the effects of development assistance on health outcomes, the vector error correction model was used. the model, besides including time dependency between the variables of interest and allowing for stochastic trends, it uses long-run equilibrium relationships through co-integration. furthermore, johansen’s approach was used to estimate the cointegrating relations and the other parameters in the model (25,28,29). based on previous studies (30,31), the implicit function for our model can be expressed as:           txtxtxtyft n ,...,,1y 21  .......................................................................(1) where ‘n’ is the number of explanatory variables. by taking the derivative of both sides of the equation, the following is obtained:                               )2....(....................'1dydy :,,..2,1y1arg yarg1dydy 1 0 0 1 0 tyorty ty tx fwheretf tx tdx t aswrittenrebecanwhichnjandtontyofeffectinalmisf tontxofeffectinalmisfwheretftdxft jj j jj n j j j j jj n j jj         furthermore, under the assumptions of the constant j  ’s , one can integrate both sides of the equation, and get:       )3(ln1yy 3 1     n j jj txtt where 0 f and 3  is a constant term. having in place the theoretical frame work, the empirical estimation equations for the study can be specified as: leb=β0+ 𝛽1tln dahe+𝛽2tlngdpp+ 𝛽3tphe dah + 𝛽4t femed+ pop+ εt …........….(4) where: leb = health outcome as measured by life expectancy at birth dahe = development assistance for health expenditure per capita (in current usd) phe dah= public health expenditure other than dah in per capita (in current usd) gdpp= gross domestic product per capita (in current usd) gutema k, mariam dh. does health sector aid matter? evidence from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 6 predfem = total female enrolment in primary education pop = population ages 15 to 64 εt = stochastic disturbance term to capture omitted variables t = 1, 2, 3….36 and βs are the parameters to be estimated. to analyze the association between dahe and leb, the stationarity of each series was tested using an econometric analysis. the test used for this purpose is the standard augmented dickey fuller (adf) and philips-perron test. this test helps to avoid the spurious results that would make the estimate biased and inconsistent (24,32). results descriptive results as shown in table 1, mean (±sd) of leb and per capita dahe during the period of the study (1978-2013) were 51(6.44) and 1.73(2.61) respectively. during the same period of study, the range was between 43.67 and 63.62 for leb and 0.05 and 9.06 for dahe. table 1. health and the related indicators summary statistics, ethiopia, 1978-2013 variables definitions observed mean sd min max leb life expectancy at birth (years) 36 51.069 6.437 43.674 63.617 dahe development assistance for health expenditure (usd per capita per year 36 1.727 2.612 0.050 9.057 gdpp gross domestic product per capita per year 36 218.916 96.336 111.531 502.597 phe dah public health expenditure other than dahe 36 1.619 1.660 0.140 6.580 femed percentage of female secondary school enrolment ratio (control variable) 36 46.157 27.585 13.906 100.546 pop total population aged 15 to 64 years (control variable) 36 3.06e+07 9940617 1.80e+07 5.10e+07 figure 1 illustrates trends in leb and dahe in ethiopia during the study period of time. the country has experienced a steady increase in leb, along with a growth (with some variation) in level of development assistance for health. gutema k, mariam dh. does health sector aid matter? evidence from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 7 figure 1. trends in life expectancy at birth (leb) and development assistance for health expenditure (dahe) in ethiopia (1978-2013) the other way of looking in to this is by plotting a local polynomial smoothing curve that gives a more insight to the change of leb and dahe. figure 2 below shows that dahe is increasingly effective in continuously and steadily increasing leb. figure 2. a plot of local polynomial smooth curve of life expectance on development assistance for health per capita (1978-2013) 0 2 4 6 8 1 0 d a h e 4 5 5 0 5 5 6 0 6 5 l e b 1980 1990 2000 2010 2020 year leb dahe 45 50 55 60 65 leb 0 2 4 6 8 10 dahe in current usd per capita gutema k, mariam dh. does health sector aid matter? evidence from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 8 results from error correction model (ecm) once the presence of stationarity and co-integration of the series between the variables in the regression model was established, an error correction model (ecm) was fitted to estimate the relationship between the variables. as can be seen in table 2, the effect of development assistance for health on life expectancy is positive and significant – a 1% increase in development assistance for health leads to an approximate nine days increase in life expectancy (p<0.001). similarly, the analysis results suggest that there is a statistically significant positive association between level of development assistance for health during previous two periods and life expectance a 1 % increase in development assistance for health during previous two periods leads to three days increase in life expectancy (p=0.025). table 2. ecm estimation results, ethiopia, 1978-2013 variables coefficient standard error t-values probability ect-1 -0.011 0.001 -9.070 <0.001 leb ld. 1.822 0.039 46.870 <0.001 leb l2d. -1.080 0.052 -20.930 <0.001 lndahe ld. 0.026 0.004 6.160 <0.001 lndahe l2d. 0.008 0.004 2.240 0.025 lngdpp ld. 0.083 0.023 3.600 <0.001 lngdppl2d. 0.086 0.024 3.620 <0.001 phe dah ld. 0.004 0.003 1.390 0.166 † phe dah l2d. 0.008 0.003 2.480 0.013 † predf ld. -0.0004 0.001 -0.770 0.442 predf l2d. -0.0002 0.001 -0.360 0.715 lnpopd. 2.056 1.279 1.610 0.108 * lnpop2d. -2.459 0.958 -2.570 0.010 * _cons 0.863 0.085 10.200 <0.001 * indicates that the joint effect is insignificant. † indicates that the joint effect significant. public health expenditure other than development assistance during the immediate two previous periods is also positively and significantly associated with life expectancy at birth(p=0.013), indicating a 1% increase in general public health expenditure during the immediate two previous years can lead to three days of improvement in current life expectancy at birth. the association between gdpp and leb is also found to be statistically significant (p<0.001) and positive, both during the immediate one and two previous years. a 1% increase in gdpp improves the current level of leb approximately by 1 month. furthermore, the analysis shows that that the relationship between femed and leb is negative but insignificant. the association of population aged 15-64 years and leb portrays a mixed result. it is positive and insignificant during the immediate previous one year and negative and significant during the immediate previous two periods. however, the joint effect of this variable on leb is found to be insignificant. gutema k, mariam dh. does health sector aid matter? evidence from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 9 discussion the analysis of data under the current study proceeded by testing for stationarity of each series as is common in time series data analysis. all the included variables (leb, dahe gdpp, dahe dah,femed and pop) were undergone the standard augmented dickey fuller (adf) and philips-perron test to avoid the spurious results that would make the estimate biased and inconsistent (24,32). this study explored the association between life expectancy at birth (leb) and development assistance for the health sector (dahe) in ethiopia using a sample of 36 observations(years: 1978-2013). accordingly, the effect of dahe, the variable of interest in this study, is found to have a significant long run influence on the health status of the population in ethiopia. as the result suggests, the coefficient of ect-1 has the correct negative sign and is statistically significant (p=0.001) implying that about 1.1% of the disequilibrium in the previous year (year t1) in leb are corrected in the current year period. likewise, the immediate one and two prior year of dahe has shown to have a significant positive effect on leb. consequently, other things being equal, an increase of dahe by 1% leads to an improvement in life expectancy at birth by about 0.026 years which is 0.312 month, approximately 10 days (p=0.000). in the immediate year following the period, and 0.008 years or approximately 3 days following the immediate two years period (p=0.025). the short run effect of the result is greater than the findings of bendavid & bhattacharya who studied on 140 aidrecipient countries between 1974 and 2010reports change of leb to dah as 0.02 month (33). while the period is more or less similar, the applied methodology in their study is panel approach (time series cross section). therefore, the observed difference might be an account of methodological difference as this study is country specific, a country with higher inflow of dah and better performance history in health indicators. similarly, the result is higher than another cross country study report of leb elasticity to dahe in ssa, which is 0.005 year (34). here again the difference might be an account of better performances in ethiopia’s health care system in utilizing dah. as shown earlier, ethiopia is a country with high inflow of dah with the expectation of high performance in the health outcome. therefore, according to the current finding, an increase of dah has been resulted in an increased life expectancy, even better than that of the average ssa. in ethiopia, phc at peripheral level, where most of dah is changed in to the actual consumers service is widely exercised by innovative programme, a deployment of health extension workers and this might have been an account for the significant effect and difference observed in the current study (35,36). similarly, the elasticity estimates of the current result is slightly higher than the country specific study conducted in pakistan (37), that reported 0.024 for the elasticity estimate of leb with regard to government health expenditure. again, it seems that the per capita dahe drives more leb in ethiopia than in pakistan, consonance with the previous stated studies because of the fact that the pakistan study is total public expenditure. on the other hand, the current findings contradicts previous conclusions that claim health aid has no effect in developing countries (6,7). it seems that the effect of the rest of public health expenditure which is in fact domestic funding for health expenditure in the country, has also exhibited more effect in explaining leb than that of an average ssa do. holding all others constant, a per capita change in the rest of public health expenditure in the year immediately preceding the period improves leb by about 0.008 year. this result is higher compared to one cross-country study conducted for ssa, which estimates 0.003 (34).this might be an attribute of the policy commitment in the country to implement gutema k, mariam dh. does health sector aid matter? evidence from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 10 phc. with regard to the remaining control variables, starting first by considering the gdp, per capita gdp has got a positive significant effect on leb and this finding is consistent with results reported elsewhere (27,38). this is expected, because as income increases, one would expect the standards of living of the people to improve, meaning that people will have access to better education, health care, housing, etc. reduced mortality and ultimately an increased life expectancy. in the present study, the relationship between female education and health status showed an unexpected (but not significant) effect, which might be due to possible autocorrelation with the lagged variable for life expectancy. finally, the association of population aged 15-64 years and leb portrays a mixed result. it is positive, insignificant during the immediate previous one year, negative, and significant during the immediate previous two periods. however, the joint effect of this variable on leb is found to be insignificant. while the positive association is as expected (because this age group is the productive age group that could possibly maximizes health production), the negative sign on leb during the immediate previous two years might be due to the same age groups’ prone to hiv/aids that might have led to increased mortality as is a known disease burden in ssa including ethiopia (37). in this study, it would have been better had more control variables like environmental sanitation and safe water supplies were considered as these factors are known variables to explain health status in developing countries. however, both variables were not included in the data, because first, there is no adequate data series prior to 1990 for both variables. second, the available national health account report, a report from where dahe originates and considered in this study, indicates that health expenditure includes spending on both core and health-related activities such as drinking water and environmental health spending (11). similarly, consideration of education indicators like net enrolment and school years would have been better but the data are highly deficient for the sampled year. in addition, health professionals to population ratio and governance are other indicators one would expect to be included. however, all health facility performance related activities is largely an attribute of recurrent and capital health expenditure (39) that is already captured in the study. for instance, hiring health workers and paying their salaries holds the highest proportion of recurrent expenditure, that if considered with health expenditures, lead to a possible higher multi-collinearity among the variables. governance related variables where other explanatory variables that would have been included at national level. however, the dearth of national data for the sampled period of years has limited the inclusion. similarly, the proxies used in measuring health outcomes are not exhaustive; especially, morbidity and disability data were not captured. while these limitations may be the bases for future research, the result of the current analysis verified that development assistance for health has favourable effect in improving health status in ethiopia. the policy implication of the current findings is that development assistance for health is essential component in improving health status in the country and should continue as an interim necessity means to an end. gutema k, mariam dh. does health sector aid matter? 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from time-series data analysis in ethiopia (original research). seejph 2018, posted: 04 april 2018. doi 10.4119/unibi/seejph-2018-184 13 39. ministry of health, ethiopia fdre. health & health related indicators, 1998-2005. addis ababa; fmoh, 1999-2007. ______________________________________________________________________________________ © 2018 gutema k et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. cela d, abilaliaj v, shpuza a. nonoperative management for major blunt hepatic trauma in a 3-yearold child (case report). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5925 p a g e 1 | 6 case study nonoperative management for major blunt hepatic trauma in a 3-year-old child dritan cela1, valmira abilaliaj1, aldo shpuza2 1 department of surgery, university trauma hospital, tirana, albania; 2 department of public health, faculty of medicine, university of medicine, tirana, albania. corresponding author: dritan cela, md university trauma hospital, tirana, albania telephone: +355674939333; email: dritan.cela@yahoo.com cela d, abilaliaj v, shpuza a. nonoperative management for major blunt hepatic trauma in a 3-yearold child (case report). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5925 p a g e 2 | 6 abstract introduction: based on hemodynamic stability, non-operative management of lowand highgrade liver injury is the first treatment choice over surgical treatment. small clinics are still preferring primary operative approach instead of nonoperative one. presentation of the case: we are presenting a case (3-year-old male child) of nonoperative treatment of a grade iv blunt liver trauma (lacero-contusive injury of v, vi and vii segments) with massive hemoperitoneum. the patient was put into a conservative treatment with antibiotics, fluids and ½ unit of blood. the results of computed tomography showed significant amounts of perihepatic and periileal fluid between the bowels and in the douglas pouch, which persisted for five days. laboratory alterations of serum glutamic pyruvic transaminase, serum glutamic-oxaloacetic transaminase, and total bilirubin reached their maximum values on third day, persisting in decline until fifth day and returned to normal after tenth day. the hospital stay was 11 days, the length of time necessary for the complete conservatory treatment and full recovery of the trauma. discussion: more than 80%-90% of liver injuries are managed with nonoperative intervention. early and late complication can be managed by interventional radiology procedures when it is possible. success rate of conservative treatment is over 80%. conclusion: if no other abdominal injuries are evident and patient is hemodynamically stable nonoperative management for major blunt hepatic trauma in children is the best choice of treatment. keywords: nonoperative, hepatic trauma, hospital stay cela d, abilaliaj v, shpuza a. nonoperative management for major blunt hepatic trauma in a 3-yearold child (case report). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5925 p a g e 3 | 6 introduction operative management of severe blunt liver trauma (as the abdominal organ most commonly injured) is often associated with significant morbidity and mortality (1). despite the difficulty of choosing the right management, nonoperative management of blunt liver injury is currently the treatment modality of choice for hemodynamically stable patients, regardless of the degree of injury or age of the patient (2). thus, even in paediatric age, surgical interventions for liver injuries are almost history (3). the choice of trauma management is facilitated when the environment offers clinical monitoring and serial exam capabilities and an operating room available for emergency laparotomy (2,4). university trauma hospital is the only centre providing tertiary healthcare in trauma management, so it offers all of the aforementioned capabilities. in this context, a presentation of a case with major blunt liver trauma under non-operatory hospital management conditions was presented. presentation of the case a 3-year-old male child was presented in severe condition in the emergency department of the university trauma hospital, tirana, albania, after a car accident. after the emergency ultrasound was performed, at the time of admission, a considerable amount of perihepatic and periilenal fluid was found between the bowels and in the douglas pouch. according to laboratory tests, the results showed relevant values: white blood cells (wbc) 18.5k/ul, haematocrit (hct) 27%, red blood cells (rbc) 3.200 000, haemoglobin (hb) 9.2 g/dl, serum glutamic pyruvic transaminase (sgpt) 198u/l, serum glutamic-oxaloacetic transaminase (sgot) 178u/l, and total bilirubin 1.40mg/dl. regarding hemodynamic, the parameters appear to be stabilized: arterial pressure 100/60 mm hg, v=136 min, and oxygen saturation (sat o2) 99%. abdominal computed tomography (ct) reinforces the findings of considerable abdominal perihepatic and periilenal fluid between the bowels and in the douglas pouch, with a large contusion area of segments v-vi-vii of the liver (image 1). the patient was put into a conservative treatment with antibiotics, fluids and ½ unit of blood. image 1:ct image, day 1 cela d, abilaliaj v, shpuza a. nonoperative management for major blunt hepatic trauma in a 3-yearold child (case report). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5925 p a g e 4 | 6 after two days, the patient presented with flatulence and painful abdomen. however, the patient continued to have a stable hemodynamic status, while laboratory values are presented as follows: total bilirubin 2.4, sgpt 1490 u/l, sgot 1400 u/l, amylase 17 u/l, lipase 7 u/l, wbc 15.2, rbc 3.800 000 and hb 10.4. in this context, a contrast-enhanced ct of the abdomen was performed, the findings of which showed significant amounts of perihepatic and periileal fluid between the bowels and in the douglas pouch. no active bleeding and no other obvious damage in the abdomen were observed (image 2). image 2: ct image, day 2 after the third day, the clinical condition remained the same, with the patient having also a sub-febrile temperature of 38 degrees celsius and the laboratory alterations persisted with the following values: total bilirubin 8.7, direct bilirubin 5.1, sgpt 2240 u/l, sgot 198000 u/l, amylase 17 u/l, lipase 7 u/l, wbc 18.2, rbc 3.900 000, and hb 11.0. during the ultrasound, a diminutive quantity of perihepatic and perilenal blood were observed, with a minimum of liquid in morison, and a considerable amount between the bowels and in the douglas pouch. after the fifth day, the patient was cannulated, active and fed enterally. the temperature was 37.5 degrees celsius, the hemodynamic remained stable and laboratory values began to drop to the following values: creatinine 0.37mg/dl, total bilirubin 5.2, direct bilirubin 3.0, sgpt 1710 u/l, sgot 16440 u/l, amylase 23u/l, lipase 8 u/l, wbc 15.2, rbc 3.800 000, and hb 10.4 in the i/v contrast ct abdomen, a small amount of liquid was found between the bowels and in the douglas pouch and also a minimum of bilateral pleural liquid (image 3). cela d, abilaliaj v, shpuza a. nonoperative management for major blunt hepatic trauma in a 3-yearold child (case report). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5925 p a g e 5 | 6 image 3: ct image, day 5 after the tenth day, the patient was afebrile, without clinical complaints. nutrition was enteral, laboratory results returned to normal, and imaging tests indicated that there was no free fluid in the abdomen. the hospital stay was 11 days, the length of time necessary for the complete conservatory treatment of the hepatic trauma and full recovery. discussion the most common cause of traumatic liver damage identified in some studies was car accidents (5,6). this factor may be the ethology of injury even in children, as is the case in our study. studies have demonstrated that severe liver injury (grade iii, iv and v) is associated with increased morbidity and mortality (7). the 3-year-old patient had a grade iv blunt liver trauma (lacero-contusive injury of v, vi and vii segments) with massive hemoperitoneum and severe clinical condition. it has been demonstrated that nearly 80% of patients with liver injury are successfully treated with conservative management (8). in this context, the patient was treated conservatively and, after 11 days in hospital, was able to recover completely. the study of approximately 40,000 patients with liver injury from 405 trauma centres showed that the likelihood of operative therapy for successful treatment of complicated liver trauma was less than 40% (9). thus, contrary to the surgical treatment’s choice, on the side of old scholar surgeons in particular in small clinics, the basis of modern nonoperative management is based on the patient's stable hemodynamic. the main potential drawbacks of non-surgical care in managing blunt liver injury may be delayed bleeding and the omission of related injuries that require surgery (10). by providing the right environment that offers clinical follow-up and the possibility of rapid interventions through interventional radiology of possible complications, nonoperative management remains an effective solution even for major blunt hepatic trauma in children. cela d, abilaliaj v, shpuza a. nonoperative management for major blunt hepatic trauma in a 3-yearold child (case report). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5925 p a g e 6 | 6 conclusion if no other abdominal injuries are evident and patient is hemodynamically stable nonoperative management for major blunt hepatic trauma in children is the best choice of treatment. follow-up in appropriate hospital conditions enables the full recovery of the patient and the reduction of hospital stay. references 1. croce ma, fabian tc, menke pg, waddle-smith l, minard g, kudsk ka, et al. nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients. results of a prospective trial. ann surg. 1995 jun;221(6):744–55. 2. stassen na, bhullar i, cheng jd, crandall m, friese r, guillamondegui o, et al. nonoperative management of blunt hepatic injury: an eastern association for the surgery of trauma practice management guideline. j trauma acute care surg. 2012 nov;73(5 suppl 4):s288-293. 3. koyama t, skattum j, engelsen p, eken t, gaarder c, naess pa. surgical intervention for paediatric liver injuries is almost history a 12-year cohort from a major scandinavian trauma centre. scandinavian journal of trauma, resuscitation and emergency medicine. 2016 nov 29;24(1):139. 4. alonso m, brathwaite c, garcia v, patterson l, scherer t, stafford p, et al. practice management guidelines for the nonoperative management of blunt injury to the liver and spleen. 2003;32. 5. park kb, you dd, hong th, heo jm, won ys. comparison between operative versus non-operative management of traumatic liver injury. korean j hepatobiliary pancreat surg. 2015 aug;19(3):103–8. 6. scollay jm, beard d, smith r, mckeown d, garden oj, parks r. eleven years of liver trauma: the scottish experience. world j surg. 2005 jun;29(6):744–9. 7. zago tm, tavares pereira bm, araujo calderan tr, godinho m, nascimento b, fraga gp. nonoperative management for patients with grade iv blunt hepatic trauma. world journal of emergency surgery. 2012 aug 22;7(1):s8. 8. raza m, abbas y, devi v, prasad kvs, rizk kn, nair pp. non operative management of abdominal trauma – a 10 years review. world journal of emergency surgery. 2013 apr 5;8(1):14. 9. yu wy, li qj, gong jp. treatment strategy for hepatic trauma. chin j traumatol. 2016 jun;19(3):168–71. 10.norrman g, tingstedt b, ekelund m, andersson r. non-operative management of blunt liver trauma: feasible and safe also in centres with a low trauma incidence. hpb (oxford). 2009 feb;11(1):50–6. __________________________________________________________________________________________ © 2022 cela et al; this is an open access article distributed under the terms of the creative commons attribution license (http:// creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 1 review article a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level beatrice scholtes1, peter schröder-bäck1, morag mackay2, joanne vincenten2, helmut brand1 1 department of international health, maastricht university, maastricht, the netherlands; 2 european child safety alliance, birmingham, united kingdom. corresponding author: beatrice scholtes, department of international health, caphri; address: maastricht university, po box 616, 6200 md maastricht, the netherlands; telephone: +31433881710; fax: +31433884172; email: beatrice.scholtes@maastrichtuniversity.nl scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 2 abstract aim: risk factors for child injury are multi-faceted. social, environmental and economic factors place responsibility for prevention upon many stakeholders across traditional sectors such as health, justice, environment and education. multi-sectoral collaboration for injury prevention is thus essential. in addition, co-benefits due to injury prevention initiatives exist. however, multi-sectoral collaboration is often difficult to establish and maintain. we present an applied approach for practitioners and policy makers at the local level to use to explore and address the multi-sectoral nature of child injury. methods: we combined elements of the haddon matrix and the lens and telescope model, to develop a new approach for practitioners and policy makers at the local level. results: the approach offers the opportunity for diverse sectors at the local level to work together to identify their role in child injury prevention. based on ecological injury prevention and life-course epidemiology it encourages multi-disciplinary team building from the outset. the process has three phases: first, visualising the multi-sectoral responsibilities for child injury prevention in the local area; second, demonstrating the need for multi-sectoral collaboration and helping plan prevention activities together; and third, visualising potential co-benefits to other sectors and age groups that may arise from child injury prevention initiatives. conclusion: the approach and process encourages inter-sectoral collaboration for child injury prevention at the local level. it is a useful addition for child injury prevention at the local level, however testing the practicality of the approach in a real-world setting, and refinement of the process would improve it further. keywords: co-benefits, inter-sectoral collaboration, prevention and control, wounds and injuries. scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 3 introduction it is far from trivial to reiterate how devastating child injury is to the individual, family and society. among the measurable costs, are loss of life, long and short-term disability, psychological consequences, and financial costs (1). in addition, child injury remains the leading cause of death and a major cause of disability for children aged 5–19 in the european region (2). despite this varied and heavy burden, funding for prevention is comparatively low (3), and capacity and leadership resources, in terms of adequate numbers of personnel and availability of the relevant skills set, are limited (4). the determinants of child injury are multiple, broad, and not limited to the health sector (2,5). thus, in order to efficiently direct and fund child injury prevention, one must account for the cross-cutting, multi-sectoral determinants that result from a complex interplay between human factors and those in the physical and socio-cultural environments. since the multiple determinants of child injury cannot be addressed by the health sector alone, a whole-of-government approach is required—vertically, from international politics to local decision makers, and horizontally, across policy fields such as health, transport, housing, justice and education. preventive action must also work across society, employing a whole-of-society approach engaging actors and stakeholders within government, civil society, and the private sector (2,6). though inter-sectoral co-operation is essential, it is notoriously challenging (7,8). it is often difficult to engage relevant stakeholders and maintain their co-operation throughout the process from policy making through to implementation and evaluation. additionally, the complexity of government systems, where roles and responsibilities are divided into traditional silos (e.g., health, transport, education), and where responsibility and power are split between national, regional and local levels, can further hinder cooperation (9). thus, due to its complexity, child injury is one of the so-called ‘wicked’ problems of public health (7). however, its cross-cutting nature offers broad scope for interventions to result in or contribute to multi-sectoral co-benefits (10). in this paper we focus on the role of regional or local level decision makers and propose a model to facilitate the decision making process for the cross cutting issue of child injury prevention. existing models for injury prevention several models to guide injury prevention have been proposed, including those addressing the multiple determinants of injury (11,12) intervention planning (13,14) and inter-sectoral collaboration (15). these models provide useful theoretical frameworks to address injuries and their prevention. however, they do not address the specific nature of child injury and in some cases may be challenging for use at the local level. child injury prevention requires specific, directed attention. children participate in environments largely designed for adults where their physical and cognitive characteristics make them more vulnerable to injury. physical and cognitive developmental stages precipitate different periods of injury susceptibility. age is therefore an important factor in child injury prevention and models used must have the flexibility to address this heterogeneous group. children are also highly dependent upon the care and protection of adults, so factors affecting an adult’s capacity to supervise children can directly affect them (16,17). general injury prevention initiatives, designed for adults, do not always protect children to the same extent (18,19). in terms of governance for child injury prevention, a lack of leadership and capacity at the national level such as dedicated government departments or ministries or a lack of a specific scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 4 focal point within key departments for child safety has been identified (20). it is likely that if this is the situation at the national level that there is an even greater potential for lack of capacity at the regional or local level where much decision making for health lies (21). to our knowledge, no existing model or approach adequately addresses child injury, while simultaneously providing a practical, multi-sectoral process for practitioners and policy makers at the local level to use to guide prevention efforts. in order to adequately assess the specificities of child injury and its cross-cutting nature, as well as incorporate the potential co-benefits into prevention planning, practitioners and policy makers should be able to: • examine the issue and visualise the multi-sectoral responsibilities for child injury prevention in the local area • demonstrate the need for inter-sectoral collaboration and collective planning of prevention activities • identify the scope for co-benefits for other sectors, age groups or health issues arising from child injury prevention initiatives in this paper we propose a model based upon aspects of the haddon matrix (22) and the lens and telescope model (23) providing a practical approach and process to meet these requirements for the local level. the local level child injury prevention assessment approach the traditional haddon matrix depicts a time element in the first dimension (vertical axis), dividing factors associated with what haddon termed the pre-event, event and post-event phases of an injury event. in the second dimension (horizontal axis), of the simplest form of the matrix, are the three vertices of the epidemiological triangle the host (human), the agent (vehicle/vector) and the environment, with environment often divided into social and physical. the haddon matrix fits well into the traditional public health approach of primary, secondary and tertiary prevention and has been used to explore a variety of aspects of the public health process for injury prevention including assessing risk factors (5,24), identifying preventive strategies and assisting the decision making process (13) and for public health readiness and planning (25,26). the traditional, nine cell, haddon matrix maybe less suited to child injury prevention due to the separation between environment, host and agent. children’s dependence upon adult supervision to secure their environment and their lack of control over the environment is difficult to capture in this version of the haddon matrix. therefore, when developing our approach, we sub-divided the columns, host and agent into factors for human, social and physical environment. this allows the table to capture more detail that maybe particularly relevant for preventing child injury such as factors affecting parental supervision. the temporal element of injury prevention is well represented in the haddon matrix, however circumstances preceding the injury are limited to the pre-event phase. this makes it difficult to differentiate between long standing risk factors such as socio-economic status, and short-term factors such as bad lighting. a further reality of child injury is that the determinants of injury change with age. the inclusion of the life course approach developed in the lens and telescope model (23) is intended to provide a visual cue regarding the needs of the different age groups, encouraging one to think of enduring injury determinants such as socio-economic status and parental factors. the life course aspect of our tool is divided into five specific age groups relevant to child injury, 0-1, 2-4, 5-9, 10-14, and 15-19; with general phases for the foetal phase, adulthood, previous and the next generation. the slices representing age get larger towards older age groups to illustrate the breadth of influence preventive measures could have. scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 5 the resulting approach (figure 1) can be used to examine a specific injury event (e.g., a specific car pedestrian collision) or a group of injuries (e.g., child pedestrian injuries). further, in order to include and examine all relevant factors, the matrix (or matrices, if a separate matrix is needed to provide more space) should be completed with factors relevant to each affected person in the injury event. for example, in the case of a car – pedestrian collision, a matrix should be completed accommodating the perspectives of the injured child, the driver, passengers in the car and any other relevant people. figure 1. local level child injury prevention assessment approach using the local level child injury prevention assessment approach and process the approach and resulting process are intended for use by practitioners and policy makers at the local or regional level. they can be used in three ways: first, to examine and visualise the multi-sectoral responsibilities for child injury prevention in the local area; second, to demonstrate the need for inter-sectoral collaboration and collective planning of prevention activities and third to identify the scope for co-benefits for other sectors, age groups or health issues arising from child injury prevention initiatives. phase one – examining the issue and visualising multi-sectoral responsibilities the approach and process are designed for use in a collaborative setting from the outset. relevant partners and stakeholders from multiple sectors should contribute throughout the process to map each of the factors that contribute (or could contribute) to the injury event for each person involved in the injury. in line with concepts of life-course epidemiology, the factors should not be confined to the moment the injury occurred but should also include preexisting factors. the process of eliciting each of these factors aims first, to draw all of the stakeholders together to come to a common understanding of the problem and potential scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 6 solutions (7) and second, to identify the many sectors implicated within child injury prevention. phase two demonstrating the need for multi-sectoral cooperation once factors and involvement of sectors coming out of the injury analysis are identified, users can reflect on them and propose specific evidence based interventions and policies that address these factors and identify the appropriate sectors that would need to be involved. these specifics can then be used to make the case for investment and/or engage additional stakeholders. the integrated life course approach serves as a prompt to ensure age is being taken into consideration as interventions are considered. potential interventions can then be inserted into an empty matrix in the same way as the factors were placed in phase one. phase three – visualising the scope for co-benefits the third phase is designed to help identify potential co-benefits of child injury prevention strategies for other age-groups and issues within and outside the health sector. co-benefits can be achieved as a result of child injury prevention measures in three ways. first are the physical, economic and societal benefits for the child, family and community as a result of a reduction in intentional and unintentional injury (1,3). second are co-benefits for the target population or other groups arising as a result of injury prevention initiatives (e.g., the health benefits of swimming lessons or environmental and health benefits of a safer walking environment in terms of a reduction in car use); these are not dependent upon a reduction in injury incidence but are derived from the intervention itself. third are co-benefits for other groups that can be achieved as a result of the implementation of injury prevention strategies (e.g., providing training and employment to distributers of safety equipment). by reflecting on the age group segments of the approach, users are encouraged to consider the impact on other age-groups and identify which groups might directly and indirectly benefit from child injury prevention interventions and elaborate on these co-benefits. for example, an intervention to improve the walkability of an area surrounding a school would directly benefit age groups 5-9, 10-14 and 15-19 years, but may also benefit the elderly population of that area by providing a safer walking environment. discussion much responsibility for injury prevention lies with local practitioners and policy makers in terms of choice of intervention and process of implementation. however, for complex ‘wicked’ problems such as child injury, the key stakeholders at the local level are often unaware of their responsibilities for public health and the potential impact of their participation (27). local government officials have been found to lack awareness of the link between health and non-health sectors, and their experience of inter-sectoral collaboration is often limited (8). a key determinant of success for inter-sectoral collaboration, is the development of a multi-disciplinary team of multiple stakeholders (28,29) to first reach a common understanding of the problem and then, on that basis, to collaboratively design evidence based interventions that are specific and relevant to the needs of the target population (7). a significant difference between our approach and process and other existing models for child injury prevention is its interactive and collaborative nature. our approach provides a practical framework to engage diverse stakeholders from the outset. it has been designed to provide a comprehensive approach to child injury prevention in a simple (and familiar) format to maximise output at the local level of governance. the exercise of mapping factors using a matrix that addresses the specific physical and social environments for host and agent scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 7 separately helps identify the potential involvement for many sectors and the identification of roles and responsibilities as interventions are selected. a limitation of this approach is that it is unable to quantify the comparative or cumulative impact of the identified risk factors in the local setting. local knowledge of their relative importance in the target setting is therefore required to weight them appropriately, in terms of importance and prevalence, and to develop a suitable intervention. additionally, the approach does not help planners/researchers identify what interventions or policies are already in place or how to choose an intervention. however the third dimension of the haddon matrix as proposed by runyan (13) could be used in conjunction with this model to aid intervention choice. the opportunity to identify the potential co-benefits of injury prevention initiatives offered by this approach is particularly important in the context of advocacy and efforts to secure funds for prevention activities. a lack of funding is a common barrier to adoption and implementation of public health interventions, particularly for complex or wicked problems. (8) if co-benefits of prevention activities outside the target group or injury domain can be demonstrated, the chances of securing funding may be higher, particularly if the co-benefit addresses a priority area (e.g., obesity or healthy ageing). our proposed approach and process provide a way of demonstrating the interconnectivity between sectors and therefore the secondary impact child injury prevention strategies may have beyond childhood or outside the injury domain. however, it must be noted that when identifying co-benefits this approach does not offer any quantification of economical or health benefits associated with a given strategy. the use of a life course model is a central element of our approach. there are several advantages to this: first, it emphasises the importance of a child’s age for injury susceptibility and acts as a lens through which to consider relevant factors, particularly when looking at an overall injury issue (e.g., child drowning); second, it accommodates age in the design or choice of preventive interventions; third, it allows analysis of risk factors related to parents or carers and underlying causes; and, fourth, it provides a frame to reflect upon potential cobenefits for other age groups arising from child injury prevention interventions. additionally, some interventions in child injury prevention include longer timeframes between intervention implementation and results, especially when addressing the more complex risk factors such as substance abuse and mental health. these are often incompatible with the short-term pressures on policy makers (30). visualisation of co-benefits using a lifecourse approach could provide policy makers with solid arguments for the implementation of such interventions. conclusion this approach and three phase process to child injury prevention, based on combining haddon’s matrix with a life course model facilitates stakeholders identification of risk factors and solutions across policy sectors. when done collectively, engaging multiple stakeholders, it should result in a better understanding of the multi-sectoral nature of child injury prevention and the potential roles and responsibilities for the stakeholders at the local area. this, in turn, should assist in the planning of tailored inter-sectoral child injury prevention activities. further the broadened frame helps identify potential co-benefits across sectors, within and outside the injury domain, which may assist in gaining support for child injury prevention. this approach and process have been designed to provide a practical and user-friendly methodology to address the inter-sectoral issue of child injury prevention at the local level. scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 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2008;23:318-27. ___________________________________________________________ © 2014 scholtes et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 1 of 21 review article data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion tetine sentell1, saionara maria aires da câmara2, alban ylli3, maria p. velez4, marlos r. domingues5, diego g. bassani6, mary guo1, catherine m. pirkle1 1 office of public health studies, honolulu, hawaii, usa; 2 faculty of health sciences of trairi, federal university of rio grande do norte, santa cruz, brazil; 3 department of epidemiology and health systems, institute of public health, tirana, albania; 4 departments of obstetrics and gynaecology & public health sciences, queen’s university, kingston general hospital, ontario, canada; 5 postgraduate programme in physical education, federal university of pelotas, pelotas, brazil; 6 department of paediatrics, faculty of medicine & dalla lana school of public health university of toronto, toronto, canada. corresponding author: tetine sentell, phd; address: office of public health studies, 1960 east-west road, biomed t102, honolulu, hi 96822, usa; telephone: +18089565781; email: tsentell@hawaii.edu sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 2 of 21 abstract adolescent health is a major global priority. yet, as recently described by the world health organization (who), increased recognition of the importance of adolescent health rarely transforms into action. one challenge is lack of data, particularly on adolescent fertility. adolescent pregnancy and childbirth are widespread and affect lifetime health and social outcomes of women, men, and families. other important components of adolescent fertility include abortion, miscarriage, and stillbirth. access to reliable, consistently-collected data to understand the scope and complexity of adolescent fertility is critical for designing strong research, developing meaningful policies, building effective programs, and evaluating success in these domains. vital surveillance data can be challenging to obtain in general, and particularly in lowand middle-income countries and other under-resourced settings (including rural and indigenous communities in high-income countries). definitions also vary, making comparisons over time and across locations challenging. informed by the adolescence and motherhood research project in brazil and considering relevance to the southern eastern european (see) context, this article focuses on challenges in surveillance data for adolescent fertility for middleincome countries. specifically, we review the literature to: (1) discuss the importance of understanding adolescent fertility generally, and (2) highlight relevant challenges and complexity in collecting adolescent fertility data, then we (3) consider implications of data gaps on this topic for selected middle-income countries in latin america and see, and (4) propose next steps to improve adolescent fertility data for evidence-based health promotion in the middle-income country context. keywords: adolescent health, fertility, health promotion, surveillance. conflicts of interest: none. funding: this work was supported by the fogarty international center of the national institutes of health under award number r21 tw010466. the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. we thank the participants of the “supporting maternal health across the life-course: improving the evidence base to inform policy and practice” meeting in honolulu, hi august 2018 for their insights. sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 3 of 21 introduction adolescent health is a major global priority, particularly in the lowand middle-income countries where 90% of the 1.2 billion adolescents (aged 10-19 years) globally live, comprising over 20% of the total population in some countries (1,2). recent work highlights the urgent need for comprehensive, integrated, and sustained investment in adolescent health (3-5). this can reap immediate rewards, and pay dividends into adult health and future generations (3-5). a major challenge towards this goal is access to reliable surveillance data, which is critical to designing effective policies, programs, and research and then evaluating their impacts across populations (2-5). data gaps may be one critical reason why the growing recognition of the importance of adolescent health has not transformed into sufficient research, policy, and action (2-5). data limitations can be a specific problem in understanding adolescent fertility patterns, trends, and outcomes (6-13). adolescent pregnancy and childbirth are widespread and affect lifetime health and social outcomes of women, men, and families (6-9). other important components of adolescent fertility include abortion, miscarriage, and stillbirth (14-16). data on these topics can be challenging to obtain given the considerable stigma, measurement complexities, and cultural, demographic, and legal variation across regions and countries (6-16). there is also considerable overlap and variation in the terminology used to describe aspects and outcomes of adolescent fertility (6-13). (for clarity, table 1 describes key terminology as used in this article.) informed by the adolescence and motherhood research (amor) project in brazil (17) and considering the relevance to the southern eastern european (see) region, this article reviews the literature to: (1) discuss the importance of understanding adolescent fertility generally, and (2) highlight relevant challenges and complexity in collecting adolescent fertility data, then (3) considers implications of these data gaps for selected middle-income countries (mic) specifically in latin america and see, and (4) proposes next steps to improve adolescent fertility data for evidence-based health promotion in the mic context. table 1. key terminology as used in this article term this article adolescent fertility we use this term in a general sense to cover any pregnancyrelated experience among those 10-19 years of age, including live birth, abortion, stillbirth, or miscarriage. the live birth could lead to parenting or to adoption. this can include multiple pregnancies during this time of life. adolescent pregnancy the terms describes a specific physiological state of pregnancy among those 10-19 years of age. includes pregnancies ending in births, but also miscarriage and abortion*. adolescent live birth the term describes a specific outcome from an adolescent pregnancy among women, specifically the outcome of delivering a living child among those 10-19 years of age†. adolescent parenting this term describes one outcome that might follow a live birth. in contrast to the other definitions that apply to sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 4 of 21 women only, this term applies to both men and women. * http://origin.who.int/healthinfo/indicators/2015/chi_2015_37_fertility_adolescent.pdf. † https://data.worldbank.org/indicator/sp.ado.tfrt. section 1: importance of understanding adolescent fertility patterns and trends three major health risks stem from adolescent fertility. first, pregnancy during adolescence is associated with increased risk of maternal death and disability across a variety of outcomes, with unsafe abortion as one of the foremost contributors (14,16,1822). legal and social restrictions on access to safe abortion prompt adolescents to resort to procedures administered by unskilled providers and/or in unsafe conditions (14,16,20,21). secondly, pregnancy and delivery during adolescence is associated with elevated risks of respiratory diseases, birth trauma, and bearing premature newborns with low birth weight (22). finally, adolescent pregnancies are correlated with long-term consequences for the mother, including cardiovascular disease, mobility limitations, incontinence, and chronic pain (23,24). there are also social consequences. adolescent pregnancies, particularly those resulting in a child, may cause women to miss important life opportunities by dropping out of school and earning less over their lifetimes (1,2,25). adolescent childbearing can also perpetuate intergenerational poverty through successive waves of adolescent mothers (26,27). it is additionally associated with interpersonal violence and contributes to higher risks of experiencing violence, with a number of negative impacts (28). understanding the patterns of adolescent fertility globally and within specific populations is thus vital for regional, national, and international public health. this is particularly true as the critical role of adolescence on health outcomes across the lifespan is increasingly recognized. as highlighted by vinter et al (2015): “adolescence is second only to fetal and infant life in the rapidity of growth and pervasiveness of change across body systems” (29). section 2: adolescent fertility data gaps and challenges for mic despite the critical importance of this topic, finding relevant data can be challenging and/or have hidden complexities that obscures patterns, trends, and outcomes. others have documented critical gaps in adolescent fertility data surveillance and management (3,4,6,7,14,30). besides adolescent fertility, many other relevant metrics and measures exist around other aspects of adolescent reproductive health (1-8,30). some relevant examples include: adolescent abortion rate; adolescent marriage rate; access to contraception; use of contraception; use of modern contraception, a sdg (sustainable development goals) target goal for those 15-49 years (31); planning status of adolescent pregnancy (intended, mistimed, unwanted); age at the time of the last pregnancy under 20; age at the time of the first pregnancy; marital status during adolescent pregnancy; and fertility preferences of currently married teenage women (want a child now, within a year, 2 years, later). other important, related topics include sexual exploitation, sexual preferences, gender identity, sexually transmitted diseases (1-8,30). these sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 5 of 21 measures share many of the same challenges described in this article but are beyond the scope to discuss in detail. we highlight some issues with relevance to mic. research. first, it is important to note that research on adolescent health generally lags behind research in both child and adult health (1). this may help explain why the decrease in global burden of disease as measured in disability-adjusted life years for adolescents was less than the decrease for adults (3) and why adolescent health gains have been less than those for children (5). indicators. there are many relevant indicators in adolescent fertility, which are vital health indicators (30). for instance, rate of adolescent live birth is one of the 12 headline indicators proposed by the lancet commission on adolescent health and wellbeing and one of 13 global health target measures for the 2030 sdg (11,31). a recent paper by azzopardi et al (2019) provided definitive estimates across many nations for these sdg indicators, including adolescent live birth, and gave a cumulative accounting of 11.7 million live births to adolescents between 15–19 years old in 2016 worldwide (3). while rates of adolescent live birth are decreasing in most countries, patterns vary considerably (3). for instance, albania was one of only ten countries with an increase in the rate of adolescent live birth between 1990 and 2016 (3). it is important to note the complexity in the measure of adolescent live birth, including how “adolescent” is defined (11). in the azzopardi et al (2019) paper, the sdg “annual birth rate per 1000 adolescents aged 10-19 years” metric was measured by “live births per 1000 adolescents in females aged 15-19 years” (3). of course, across the 10-19 age range many pregnancies occurred that did not result in a live birth, which can have health consequences and are thus also important to measure. table 2 shows in detail three of the most common ways that relevant constructs in adolescent fertility are actually measured in surveillance, providing calculations for the measure, and targeted critiques for these metrics (adolescent fertility rate, adolescent pregnancy, and adolescent girl pregnancy) (30). comparative data. comparative data is important to understand regional differences and cumulative global needs, which necessitate similar time frames and harmonized data (14). adolescent health data in mic can be found through national and cross-national surveillance systems. many mic publish their own vital statistics reports, but the quality of civil registration and vital statistics systems vary, even across mic (32). many mic also participate in cross-country surveillance systems toward global consensus indicators, including the demographic and health survey (dhs), the multiple indicator cluster survey (mics), and reproductive health survey (rhs) (3336). these are administered by national health systems in conjunction with usaid (dhs & rhs) and unicef (mics) (3336). they use similar definitions of adolescent fertility, and often, have been administered consistently for many years. international comparison information for adolescent fertility and related measures are also compiled into databases by major organizations, including the united nations (un) (37), the world bank (38), and the global health data exchange (39). major international efforts generate point estimates sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 6 of 21 for country-level comparisons, allowing for cumulative global calculations for key indicators (3,14,21,33,40). table 2. selected definitions for adolescent fertility measures* source indicator name(s) calculation comments numerator comments denominator u n f p a adolescent birth rate adolescent fertility rate age-specific fertility rate number of live births to women 15-19 years / total number of women 15 to 19 years excludes very young adolescents (10-14-yearolds) excludes miscarriages, stillbirths, and abortions. measure of adolescent childbearing, not pregnancy requires vital statistics for denominator, which can be challenging in very low income settings assumption that all women 15-19 years are at risk of pregnancy and thus, presumably that all women in this age group have already hit puberty. this may not be the case in communities with elevated malnutrition or illness that affect pubertal timing. u n f p a adolescent pregnancy number of women aged 20-24 that had a live birth before the age of 18 / total number of women aged 20 to 24 excludes miscarriages, stillbirths, and abortions. measure of adolescent childbearing, not pregnancy excludes those who died prior to adulthood, such as those who died in childbirth and/or those living in violent communities. may underestimate adolescent pregnancy/childbirth in the most disadvantaged areas. requires vital statistics for denominator, which can be challenging in very low income settings u n f p a adolescent girl pregnancy number of women aged 20-24 that had a live birth before the age of 15 / total number of women aged 20 to 24 excludes miscarriages, stillbirths, and abortions. measure of adolescent girl childbearing, not pregnancy similar to above. the issue of deaths before reaching 2024 is particularly problematic in this group because of the very high risk of maternal mortality in lowincome settings, among adolescents having children. * loaiza e, liang m. (2013). adolescent pregnancy: a review of the evidence. new york, ny: unfpa. these readily available metrics are valuable, and provide vital comparative data, but as in the live birth example above, in the background is variation and complexity. many mic have incomplete data for adolescent reproductive health outcomes and/or contextual variables (income inequality, social determinants of health) to better understand variation, patterns, and reasons for those outcomes (12,13). the dhs, mics, and rhs are not completed yearly, and some countries have not done them recently or at all. for instance, brazil has not completed a post-2000 dhs (41). sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 7 of 21 countries, who have cost sharing for these surveys, have autonomy to add questions and determine sampling frames, which may vary. for instance, many locations did not include unmarried adolescents in questions about sexual activity, use of contraception, or childbearing intentions in past dhs; this continues in a few dhs programs (33,36). additionally, while many global health indicators seem straightforward when presented in tables comparing outcomes across countries, plotted in useful maps (41) or included in sophisticated data visualizations (43), they are often obtained from very complex statistical models, different time periods, and/or may have missing data generated through sophisticated algorithms (3,14,19,33). in some cases, cross-national comparisons are created where at least some studies have national data extrapolated from smaller studies (14,19). these estimates often do not provide region or focal population specific statistics, which can vary in critical ways within a country. whatever the indicator, there can be incentives to suppress data for political reasons (5), making the data unreliable in ways that will not be visible in public reports or comparisons. stigma. there are also critical gaps in adolescent fertility data due to underreporting (6). many adolescents do not want to admit to sexual behavior. these actions and consequences are stigmatized and can be illegal, particularly induced abortion. the implications of these issues for data quality vary by country, and by context within countries (6). school-based youth risk behavior surveys may omit sensitive questions due to stigma and discomfort, exclude younger adolescents, and miss those who are not attending school, but who are particularly vulnerable (44). informed consent at this age can be complex and parents may refuse to let their children participate in health surveys that include these issues. missing populations. many major yearly public health surveillance instruments (e.g., brfss in the us) exclude those younger than 18 as primary respondents. as in school-based settings, adolescent sexuality questions may be deemed too sensitive (or unreliable) for proxy respondents. population-based telephone surveys may also miss vulnerable communities, including refugee, migrant, homeless and street youth (6,7). school-based surveys miss students who have left school, including those who did so because they are parenting. thus, many critical communities related to adolescent fertility are excluded from surveillance. there is also a lack of attention to adolescent male fathers. this is problematic because many assume parenting roles and after doing so, like their female counterparts, become adversely impacted. for example, younger age at birth of first child in men, as well as women, has been associated with greater risk of cardivascular disease (45). however, global data is insufficient on the quantity of adolescent pregnancies fathered by those 10-19 themselves. some dhs programs do not survey adolescent men at all (46). adolescents less than 15 years of age. adolescents younger than 15 are often left out of measurement for fertility issues. for instance, much dhs data uses the 15-19 age category to determine adolescent births, excluding the very young and high-risk births. this is a problem because younger girls generally have more complications sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 8 of 21 with pregnancy and childbirth versus older ones (44,46). repeat births. limited guidance exists on repeat birth, especially rapid repeat pregnancy (within 2 years of the index pregnancy). data on this is particularly limited in mic, but evidence from higherincome settings indicate that rapid, unwanted repeat pregnancies are relatively common among adolescents (9). disaggregated data. there is a critical need to disaggregate data by community, vulnerability, and narrower age groups to identify true needs and risks (6). for instance, while adolescent health data is typically aggregated for 15-19-year-olds in many mic, the pregnancy rate is higher among 18-19-yearolds than among 15-17year-olds (14). abortions, miscarriages, and stillbirths. especially given that a large percentage of adolescent pregnancies are unwanted or unintended (82% in a us study) (14), not all adolescent pregnancies end in a live birth. while birth data are generally complete, collection and evaluation of abortion data and estimation of miscarriages globally and by country are limited (14). miscarriage among adolescents may go unrecognized (14). stillbirths, a major issue in many mic, can be hard to definitively quantify (47,48). these issues can vary greatly by location and reporting laws (voluntary or required, sanctions), and the role of the public and private health sectors; where abortion is legally or logistically restricted may be both the least likely to have relatable data on abortion as well as most likely to have unsafe abortions (14,16,20,21). abortion policies can vary greatly in a short time period, impacting data reporting patterns, validity, and completeness over time (14). in places were abortion is illegal, there are clandestine clinics unknown to the health system and that do not provide information to national registries or researchers resulting in underestimates of true prevalence. cross-sectional data. the cross-sectional nature of data typically collected on adolescent fertility also impacts research into the consequences of adolescent pregnancy or related issues, as socioeconomic characteristics are measured at the time of the survey, not at birth or during pregnancy (49). in retrospective surveys, a woman’s situation may have changed considerably. she may have experienced a socioeconomic downturn subsequent to the delivery; for instance, some adolescents are kicked out of their homes if they become pregnant. cohort effects can also be an issue; yet, little longitudinal research exists on this topic, especially from large, cross-cultural populations (50). good sexual health. most adolescent fertility surveillance metrics focus on risk and danger (pregnancy, sexually transmitted disease), treating all adolescent sexuality as negative (51,52). we know little about childbearing desires (6) or positive sexual health. in some communities, childbearing and marriage at this age are common and surveillance systems might build distrust by taking a completely negative perspective on this issue (7,53). consequences of these gaps and challenges. many adolescent pregnancies and the negative consequences are preventable, but inconsistent and unreliable sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 9 of 21 data can make it hard to design effective solutions across all populations. ignoring inequality between specific groups can hide critical disparities, including a fundamental cause of intergenerational cycles of poverty. there can be considerable variation in data quality across regions within countries, across countries, and across regional groupings of countries. this adds complexity (not always acknowledged) to international comparisons, and makesevidence-based policy and the evaluation of those policies challenging (4,5,54,55). yet, better surveillance may bring unwelcome or unexpected findings as key metrics may increase, impacting funding priorities or political momentum. without meaningful, nuanced, consistent data, including data sensitive to subtle and incremental change, it is challenging to design programs, policies, and research to address adolescent fertility issues and hard to measure intervention effects (49). section 3: data challenges in the mic context we now specifically consider these adolescent reproductive health data challenges from experiences in the amor project in a latin america context, followed by a consideration of these issues in the see context. the adolescence and motherhood research (amor) project. the amor project (17) is a research initiative with two complementary study aims of improving quantitative health research capacity in a low-income rural area of northeast brazil, while completing a pilot project towards the long-term objective of building sustainable infrastructure for research to elucidate pathways between adolescent childbirth and adverse health conditions across the lifecourse (23). as part of this study, a pilot cohort of adolescents, pregnant for the first time, was recruited in the first trimester of pregnancy and followed over time. measurement/regional data. brazil is a large mic with substantial socioeconomic regional divides. many states in northeast brazil, such as rio grande do norte, rank last for income, education and social services, while other states in the south of the country, such as são paulo, are relatively well off (56). in brazil, the national information system on live births (sinasc), implemented gradually in all states since 1990 (57), receives live birth information from all maternity hospitals and other health units. although there is increasing coverage of sinasc across the states, scale-up has occurred differentially across brazil. for example, it was estimated that the coverage rate of sinasc reached almost 100% for the south, southeast and midwest regions in 2011, but it was between 70-90% for most of the poorer northern and northeastern states (58). although sinasc provides useful data about rates of live birth for women of specific age-groups and regions over the years, incomplete data in some registers, particularly in the less advantaged regions, and the lack of information about miscarriages or abortions, limits its use for the understanding of adolescent pregnancies. the brazilian institutes of geography and statistics (ibge) performs a demographic census in brazil every decade and provide information about adolescent childbirth rates, but its use is limited given the large time lag between surveys. during the years between the censuses, the ibge performs an annual national household sample survey. sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 10 of 21 however, because data is collected on a sample of households for each state, information about the levels and patterns of adolescent fertility, as well as any spatial disaggregation generated by such estimates are limited by small sample sizes. moreover, questions about adolescent fertility are directed only for girls aged 15 or older. study recruitment. planning the amor project recruitment was difficult due to such data gaps. our target sample included adolescents in the first pregnancy aged between 13-18 years-old from the trairi region of the rio grande do norte state. using information from sinasc, we identified the number of live births from adolescents in the target towns during the previous years, but the data regarding adolescents from 13-18 years were aggregated into the 10-19-year age group. in particular, the number of adolescent pregancies increases dramatically when age 19 is included, showing the importance of relevant data disagregation. once the project was underway, we also needed adolescent birth rate for our focal location to understand the scope, representation, and success of our study recruitment. again, aggregated information by age groups from sinasc prevented us from being able to do these estimates. we also were unable to estimate miscarriages, which were not included in the sinasc data, but were ultimately seen in 8% of our adolescent sample after baseline evaluation. latin america context. regional relevance and knowledge are important for consideration of these data gaps in brazil. adolescent fertility rates in the who latin american and caribbean region are the second highest in the world, much higher than in other regions with similar levels of development (49). while total fertility has dropped in recent decades, adolescent fertility rates have dropped much less sharply (46). the high rates of adolescent fertility can be seen in the latin american table 3. table 3. adolescent birth rate (births per 1,000 women ages 15-19) available by selected countries in latin america and south eastern europe by source* indicator latin america examples south eastern european examples notes brazil colombia honduras albania romania serbia azzopardi et al, 2019, lancet article (data from 2016) † 66.8 41.6 72.6 21.8 32.2 16.1 data is “birth rate (live births per 1000 population per year) in females aged 15–19 years.” representing sdg metric: “annual birth rate per 1000 adolescents aged 10–19 years.” world bank database adolescent fertility rates (data from 2016) ‡ 62.7 49.5 72.1 20.7 33.7 19.3 yearly adolescent fertility rate since 1960 by countries with regional benchmarks. adolescent birth rate map 65 85 99 18 36 22 map with comparisons by countries. per sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 11 of 21 adolescent health unicef ¶ website “most recent estimates for each country taken from 2015 update for the mdg database: adolescent birth rate (unfpa/un population division).” united nations age-specific fertility rates (2010-2015)§ 67.0 57.7 77.8 20.7 36.4 21.0 5-year average agespecific fertility rates from 1950-1955 with regional benchmarks. who adolescent birth rate by who region, 20052016** 60.8 71.6 101.0 18.9 35.3 16.4 data visualization with comparisons by countries within who regions and global and regional benchmarks. demographic and health survey (dhs)†† (date of most recent dhs included on website) 87.9 (1996) 85.1 (2010) 99.0 (2011) 19.6 (2008) n/a n/a adolescent birth rate information by country. subnational information available by income quartiles and rural/urban. * as shown by source as of march 15, 2019. † azzopardi ps, hearps sjc, francis kl, et al. progress in adolescent health and wellbeing: tracking 12 headline indicators for 195 countries and territories, 1990–2016. lancet 2019; published online march 12. http://dx.doi.org/10.1016/s0140-6736(18)32427-9. ‡ sp.ado.tfrt from world bank website downloaded https://data.worldbank.org/indicator/sp.ado.tfrt 3.14.2019. ¶ https://data.unicef.org/topic/maternal-health/adolescent-health/ -adolescent birth rate by country (number of annual births per 1000 adolescents aged 15-19). . § https://population.un.org/wpp/download/standard/fertility/ fert/7: age-specific fertility rates by region, subregion and country, 1950-2100 (births per 1,000 women). ** http://apps.who.int/gho/data/node.sdg.3-7-viz-2?lang=en sdg target 3.7 world health statistics data visualizations dashboard sdg target 3.7 | sexual and reproductive health; adolescent birth. †† http://apps.who.int/gho/data/view.main.vurbadobirthtotv adolescent birth rate data by country; per website: last updated: 2016-03-23. though abortion and contraception are heavily restricted in this region, many occur nonetheless, often unsafely (46,49,59). adolescent fertility is considered to be high with little use of modern contraceptives; there are an estimated 600,000 unplanned pregnancies in adolescents, and about half of women giving birth for the first time are in their teens (50). many latin american nations have adolescent pregnancy and health inequalities by population or region, but these disparities are hidden by aggregated national-level data (46). genderbased violence is a significant problem in latin america, though sexual coercion and abuse from adult males are not reliably or consistently recorded in adolescent health surveillance data (46). examples. to demonstrate an example of the general data complexity mentioned in section 2 applied to the latin american context, table 3 provides comparative data specifically for one metric (adolescent fertility rate) for three latin american http://apps.who.int/gho/data/node.sdg.3-7-viz-2?lang=en sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 12 of 21 countries (brazil, colombia, and honduras) taken from current online resources or recent, influential publications from reliable sources. data is also provided for three see countries (albania, romania, and serbia). this table demonstrates inconsistent results, timing differences of data collection, and the importance of these issues on demonstrated trends. while some variation is to be expected over time, there are large differences across measures. for instance, measures for honduras vary from 72.1 to over 100 per 1000 women. table 4 summarizes some key challenges in the latin america context in adolescent fertility surveillance. table 4. some important data gaps by region for south eastern europe and latin america location what is missing for surveillance? context specific challenges specific areas in the country where there are data gaps and challenges s o u th e a st e rn e u ro p e e x a m p le s pregnancies teen pregnancies which end in abortion adolescent births outside the marriage teen pregnancies which end in miscarriages despite some standardized instruments there are differences in indicators used to monitor the problem. different indicators used by eu (eurostat) and un dhs is not carried out by all see countries. it is not planned for the future and needs to be substituted by good surveillance data important discrepancies especially in abortion rates among surveillance and dhs/rhs. limited studies in serbia, bulgaria and albania show very high risk among roma population compared to general. most surveillance data do not allow specific monitoring of this ethnic group. l a ti n a m e ri c a n e x a m p le s data about abortion: according to the most recent estimate, about 99% of abortions in colombia are performed outside the law (impossible to obtain direct data about these) data on interpersonal violence in pregnancy information relevant to infectious diseases such as zika, which may have influenced abortions stillbirths abortion in brazil and colombia are legal only in very specific circumstances. in colombia this includes the following circumstances since 2006: the continuation of the pregnancy constitutes a danger to the life or health of the mother; the existence of life-threatening fetal malformations; the pregnancy is the result of rape, non-consensual artificial insemination or incest. vulnerability is hidden and patterns of risk or illness may not reflect facts. northeastern brazil has lower surveillance, with relevance to adolescence and motherhood research study planning and recruitment evaluation, and to other studies on similar populations. while the rich in many latin american countries may have access to abortions, this is not the case for the poor. thus, more cases of microcephaly may have occurred from zika that were not reported as those who were rich could have received abortions that were never recorded. this can impact regional estimates as well as surveillance generally. southern eastern european context. the see region is mostly made of mic transitioning from ex-communist societies to european union (eu) associates, including albania, bosnia and herzegovina, bulgaria, croatia, northern macedonia, moldavia, montenegro, romania, serbia, and ukraine. this context has both similar and unique adolescent reproductive health data gaps to those discussed above (60,61). these sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 13 of 21 countries have a very different historical and economic background from the latin american context. while this region has some of the lowest rates of adolescent-girl pregnancies among all lmic (31), rates remain higher than the eu average. some eastern european eu members in the see region, notably romania and bulgaria, have high rates of adolescent pregnancy relative to peer states (62). also, although the see region is rated relatively high in terms of equality as measured by gini index, the trends of ‘adolescent-girl pregnancies’ rates are disproportionally unfavorable among the poorest (31,62,63). usage rates of contraceptive methods, including modern methods, remain very low in see (63). abortion has dropped significantly in the region, since the 1990s, but reliance on abortion as a means of fertility control remains high in some countries (62,63). variation and measurement challenges are demonstrated in table 3 for the see counties. misinterpretation of indicators or gaps in data can cause significant inconsistencies in reporting of adolescent fertility rates across sources for the same country in the region (63,64). when comparing adolescent fertility rates among see countries, albania appears to be the only one showing a reverse of the general decreasing trend during the last decade. romania has one of the highest adolescent birth rates in the region. the three major surveillance instruments (dhs, rhs, and mics) have been implemented in albania, in consecutive rounds, with the most recent published on december 2018. the latest dhs or rhs reports from other see countries are from more than 10 years ago. besides the metrics in table 3, albania also has official administrative data from birth registration. accordingly, the adolescent fertility rate is 15.96 (65), considerably lower than estimates from other surveybased surveillance sources. according to some estimations, romania has one of the highest “young adolescent” birth rates in the world (14). data from the 2005 romanian rhs, which could be outdated, show regional variation with the rate of young adolescent births per 1000 to be 10 in urban areas compared to 46 in rural areas (66). similarly, some data from the serbian mics 2014 allows detailed analyses of adolescent fertility indicators among roma settlements where rates are exceptionally high compared to general population (67,68). in some roma settlements, 32.8% of adolescents are having children (23.8% given birth; 9% pregnant) (68). as in latin america, most see lack reliable country-level data on abortion (14). when they do, the data conflict. for instance, 2017 albanian estimates of the adolescent abortion rate were 2.1 per 1000 live births among those 15-19 years from abortion surveillance data (69), while an estimate based on dhs is lower at 1 per 1000 women for those 15-19 years (70). data from romania is from 2005, which estimates the adolescent abortion rate (for three years prior to survey) at 10 per 1000 women 15-19 years, which is a decrease from 26 per 1000 women 15-19 in the rhs 2000. one additional interesting issue is that this region is defined differently by various international organizations (60,61). many other locations have similar benchmark/comparator issues. table 4 also summarizes some key challenges for see region in adolescent fertility surveillance. sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 14 of 21 section 4: ideas for solutions and conversations in order to design targeted interventions to improve adolescent health, there is a need to better understand data and needs around critical metrics of relevance to these population groups. darroch et al (6) provide some excellent solutions. these include: using creative analyses of existing data to consider reporting by those over 15 of their experiences before 15, though this is subject to limitations in report and recollection, particularly over time; broadening existing national surveillance to better include excluded groups (younger women, nevermarried women); and creating focused, youth-targeted surveys especially including vulnerable communities. harmonized data systems also are needed with consensus/standardization of various instruments used in various mic, with buyin from relevant organizations, including who, unicef, unfpa, world bank, usaid, and eurostat (1,71-73). shared goals (such as sdg targets) can provide momentum to achieve these goals. indeed, there are critical new movements towards health data collaboratives (1,71-73), though these have many challenges (74,75). engaging the health system may help fill in some data gaps, such as increasing the stimuli for the health units/ providers to provide the information properly, to fill out the forms, making them understand its importance or giving some credits for who does. this should be a priority especially in countries where population surveys have failed to overcome stigma and produced lower rates than surveillance systems. other options include using specific studies to represent larger regions, but these do not solve issues where there is no data or where it has critical gaps for underreported or missing groups. in fact, this could obscure these issues even more dramatically. also, for better data, more longitudinal studies are needed with data about teen pregnancy and the consequences over time, physically, emotionally, and situationally. one way to address these issues is to have conversations across settings. we invite interested readers with similar, or different, challenges to share their concerns to be compiled in future work. the survey will be open from april 1, 2019 to january 1, 2020: http://hawaiidphs.co1.qualtrics.com/jfe/form /sv_7utmvpgifhiq5kj. conclusions adolescent health is increasingly recognized as a major global priority, necessitating comprehensive, integrated, and sustained investment to allow this population to achieve their full potential and most optimal wellbeing (1,3). this investment can reap rewards. as the lancet commission on adolescent health and wellbeing highlighted, this time period is foundational to physical, cognitive, emotional, social, and economic resources, concluding that: “investments in adolescent health and wellbeing bring benefits today, for decades to come, and for the next generation” (5). variation in the measures, and the absence of other important metrics, may contribute to misleading conclusions about who is at risk, trends in rates, and the success or lack thereof of interventions. with improved collection of this health data, governments are better equipped and informed to prioritize health challenges, develop policies, deploy resources, and measure success (6,7,73-77). in the absence of this information, it is challenging to develop appropriate adolescent reproductive health programs and interventions. sentell t, câmara sma, ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 15 of 21 while this paper focused on adolescent pregnancy, these data collection challenges could be relevant to many other adolescent health issues that are preventable but also neglected, such as mental health, drug abuse, intentional and unintentional injuries, or sexually transmitted infections (2). other sexual and reproductive health problems, including hiv/aids, remain a major concern for adolescent health, particularly in some regions. collecting substance use data and adolescent violence have related issues and also relationships with adolescent sexual choices 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ylli a, velez m, domingues mr, bassani dg, et al. data gaps in adolescent fertility surveillance in middle-income countries in latin america and south eastern europe: barriers to evidence-based health promotion (review article). seejph 2019, posted: 30 april 2019. doi 10.4119/unibi/seejph-2019-214 page 21 of 21 ______________________________________________________________________________________ © 2019 sentell et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. hoti a, gashi e, kraja f, sallaku a. association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania (original research). seejph 2018, posted: 01 january 2018. doi 10.4119/unibi/seejph-2018-178 1 original research association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania adrian hoti1, edmond gashi1, fationa kraja1, agim sallaku1 1 oncology service, university hospital centre “mother teresa”, tirana, albania. corresponding author: dr. adrian hoti address: rr. “dibres”, no. 370, tirana, albania; telephone: +355672024078; e-mail: dr.ahoti@yahoo.com mailto:dr.ahoti@yahoo.com� hoti a, gashi e, kraja f, sallaku a. association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania (original research). seejph 2018, posted: 01 january 2018. doi 10.4119/unibi/seejph-2018-178 2 abstract aim: the aim of our study was to assess the association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca15-3) with socio-demographic factors and metastases site in women diagnosed with metastatic breast cancer in post-communist albania. methods: a case-series study was carried out during the period january 2010 – september 2017 including 110 female patients diagnosed with breast cancer with metastases at the oncology service of the university hospital centre “mother teresa” in tirana, the albanian capital. of these, 57 (51.8%) patients had evidence of hepatic metastases, whereas the reaming 53 (48.2%) patients had metastases in the bones and/or in the lungs. cea and ca153 were measured at the time of diagnosis for all study participants. in addition, information on socio-demographic factors was collected. general linear model was used to assess the relationship of cea and ca15-3 with covariates. results: there was evidence of a significant correlation between cea and ca15-3 levels (spearman’s rho=0.59, p<0.001). upon simultaneous adjustment for all covariates, mean values of cea and ca15-3 were significantly higher in patients with metastases in the bones and/or in the lungs compared with their counterparts with metastases in the liver. also, ca15-3 levels were significantly higher in younger patients compared with their older counterparts. conclusion: this study provides valuable evidence on selected correlates of cea and ca153 in albanian female patients diagnosed with metastatic breast cancer. oncologists and other health professionals in albania, as well as decision-makers and policymakers should be aware of the burden and risk factors of breast cancer among women in this transitional society. keywords: albania, bone metastases, breast cancer, cancer antigen 15-3 (ca15-3), carcinoembryonic antigen (cea), hepatic metastases, lung metastases, oncology, tumours, tumour markers. conflicts of interest: none. hoti a, gashi e, kraja f, sallaku a. association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania (original research). seejph 2018, posted: 01 january 2018. doi 10.4119/unibi/seejph-2018-178 3 introduction breast cancer is a serious issue and an important public health problem in all countries worldwide. it has been convincingly documented that breast cancer leads to death of more women than any other type of malignant tumours (1). a recent systematic review reported that, at a global scale, breast cancer is the most frequently diagnosed cancer and the leading cause of cancer mortality among women (1). it has been reported that the incidence of breast cancer increases by 5% each year in lowand middle-income countries representing an increasingly urgent public health problem in these countries, similar to the situation observed in higher income countries (1-3). many studies on this matter have addressed several risk characteristics (etiological factors) for breast cancer including reproductive characteristics, growth, obesity, and postmenopausal hormones (1,4). nonetheless, these putative etiological factors are responsible only for a small proportion of breast cancer risk (1,4). the prognosis of breast cancer depends on a wide range of factors and circumstances including tumour biology, histology, peritumoural vascular invasion, tumour size, lymph node involvement, receptor status and presence of distant metastasis (5). furthermore, it has been indicated that the skeleton is the most frequent site of metastasis in breast cancer patients (5). cancer antigen 15-3 (ca15-3) and, to a lesser degree, carcinoembryonic antigen (cea) are the tumour markers most strongly related to recurrence in asymptomatic breast cancer patients (6,7). yet, these antigens lack specificity, and the american society of clinical oncology (asco) does not recommend their use in routine follow-up of patients treated for breast cancer (8). in addition, it has been argued that an increase in these tumour markers does not predict the number of involved sites or their localization (9). according to the global burden of disease (gbd) study, the mortality rate from breast cancer in albania was estimated at 15.2 deaths per 100,000 females in the year 2016 (10). on the other hand, for the same year, the disability-adjusted life years (dalys) for breast cancer were estimated at about 441 per 100,000 (10). according to the gbd estimates, there has been a steady increase in the mortality rate and the burden of breast cancer in albanian women for the period 1990-2010, which was followed by a plateau during the past few years (10). however, the validity of such estimates is questionable and open to criticism. on the other hand, according to the most recent world health organization (who) report released in 2017 (11), the estimated breast cancer incidence in females in albania is 30.8 per 100,000 population. the who european region average is 106.7 per 100,000 population, which is substantially higher than in albania. as a matter of fact, the incidence rate of breast cancer in albanian females is lower than in all countries of the south eastern european region. the highest incidence rate in this region is evident in slovenia (125.0 per 100,000 population) followed by croatia (116.1 per 100,000 population) and montenegro (114.9 per 100,000 population) (11). in any case, to date, the available scientific evidence about the burden of breast cancer in the general female population in albania is scarce. likewise, there are no scientific reports about the main risk factors or determinants related to breast cancer occurrence among albanian females during the transition period in the past two decades. in this framework, the aim of this study was to assess the association between cea and ca15-3 with socio-demographic factors and metastases site in women diagnosed with metastatic breast cancer in post-communist albania, a country characterized by a particularly rapid transition towards a market-oriented economy which is associated with tremendous changes also in lifestyle patterns of the adult population. hoti a, gashi e, kraja f, sallaku a. association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania (original research). seejph 2018, posted: 01 january 2018. doi 10.4119/unibi/seejph-2018-178 4 methods a case-series study was carried out in tirana during the period january 2010 – september 2017. this study involved 110 female patients diagnosed with breast cancer with metastases at the oncology service of the university hospital centre “mother teresa” in tirana, the albanian capital city. the different sites of metastases were dichotomized in the current analysis into: liver metastases vs. bones and/or lungs metastases. cea and ca15-3 levels were measured for each study participant at the time of diagnosis. in addition, a structured questionnaire was administered to all the female patients in order to collect information on socio-demographic characteristics including age (which in the analysis was dichotomized into: ≤50 years vs. ≥51 years) , district of current residence (dichotomized into: tirana vs. other districts of albania), place of residence (urban areas vs. rural areas), educational attainment (trichotomised in the analysis into: 0-8 years, 9-12 years and ≥13 years of formal schooling), economic level (also trichotomised into: low, middle, high) and employment status (nominal variable: employed, unemployed, retired). spearman’s correlation coefficients were used to assess the association between cea, ca153, age, and educational attainment (introduced as the number of years of formal schooling). on the other hand, general linear model was employed to assess the associations of cea and ca15-3 with socio-demographic characteristic and metastases site of female patients diagnosed with metastatic breast cancer. from a methodological point of view, the general linear model procedure provides regression analysis and analysis of variance for one dependent variable by one or more factors (referred to as variables). using the general linear model procedures one can test the null hypothesis about the effects of other variables on the means of various groupings of a single dependent variable. in the current analysis, this feature of the general linear model was used in order to compare the mean values of cea and ca15-3 by different categories of socio-demographic factors (age-group: ≤50 years vs. ≥51 years; district of residence: tirana vs. other districts of albania; place of residence: urban vs. rural areas; educational level: 0-8, 9-12, ≥13 years; economic lev el: low, middle, high; employment status: employed, unemployed, retired) and metastases site (liver vs. bones and/or lungs). initially, age-adjusted mean values and their respective 95% confidence intervals (95%cis) were calculated. subsequently, multivariable-adjusted (simultaneous adjustment for: age-group, district of residence, place of residence, educational attainment, income level, employment status and metastases site) mean values and their respective 95%cis were calculated. spss (statistical package for social sciences, version 17.0), was used for all the statistical analyses. results overall, mean age of the study population was 57.1±11.9 years (median age: 57.5 years; interquartile range: 48.0-66.0 years; age range: 26-83 years). of 110 women included in this study, 57 (51.8%) patients had evidence of hepatic metastases, whereas the reaming 53 (48.2%) patients had metastases in the bones and/or in the lungs. on the whole, 38% of participants had a low educational level; about 32% reported a low economic level; and 36% of participants were unemployed (data not shown in the tables). table 1 presents the distribution of cea and ca15-3 levels in the sample of female patients with breast cancer included in this study. hoti a, gashi e, kraja f, sallaku a. association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania (original research). seejph 2018, posted: 01 january 2018. doi 10.4119/unibi/seejph-2018-178 5 mean (sd) value of cea was 19.1±23.9 ng/ml (median value: 12.9 ng/ml; interquartile range: 4.7-22.1 ng/ml). on the other hand, mean (sd) value of ca15-3 was 167.2±205.2 u/ml (median value: 94.7 u/ml; interquartile range: 27.5-219.5 u/ml). of note, both cea and ca15-3 values displayed a highly skewed distribution as evidenced in table 1 by their respective measures of dispersion (that is standard deviation). table 1. distribution of cea and ca15-3 in the study population parameter cea (ng/ml) ca15-3 (u/ml) mean (±sd) 19.1±23.9 167.2±205.2 median (iqr) 12.9 (4.7-22.1) 94.7 (27.5-219.5) range 1.7-133.2 6.1-1026.0 there was evidence of a significant correlation between cea and ca15-3 levels (spearman’s rho=0.59, p<0.001) [table 2]. furthermore, there was evidence of a significant inverse linear association between ca15-3 and age (rho= 0.43, p<0.001), but a positive relationship with education which was only borderline statistically significant (rho=0.42, p=0.1). interestingly, there was a significant inverse correlation between age and educational attainment (rho= -0.52, p=0.02). table 2. correlational matrix of cea, ca15-3 and socio-demographic characteristics variable cea ca15-3 age ca15-3 0.59 (<0.001)* age -0.04 (0.704) -0.43 (<0.001) years of formal schooling 0.36 (0.109) 0.42 (0.097) -0.51 (0.023) * spearman’s correlation coefficients and their respective p-values (in parentheses). table 3 presents the association between cea and socio-demographic characteristics and metastases site. in age-adjusted general linear models, there was evidence of a borderline statistically significant association of cea with age-group (mean cea level was higher among younger participants) and district of residence (mean cea level was lower among tirana residents). furthermore, mean cea level was higher among the low-educated female patients compared with their high-educated counterparts (overall p=0.06). in particular, mean cea level was considerably higher in patients with metastases in the bones and/or lungs compared with those with metastases in the liver (27.2 ng/ml vs. 13.5 ng/ml, respectively; p<0.01). upon simultaneous adjustment for all covariates, there was no evidence of significant associations of cea with any socio-demographic factors, whereas the strong and significant relationship with metastases site persisted (mean cea level was 24.5 ng/ml in patients with bones and/or lungs metastases compared with 11.9 ng/ml in those with liver metastases; p<0.01). hoti a, gashi e, kraja f, sallaku a. association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania (original research). seejph 2018, posted: 01 january 2018. doi 10.4119/unibi/seejph-2018-178 6 table 3. association of cea with socio-demographic characteristics and metastases site; ageadjusted and multivariable-adjusted mean values from the general linear model * this model was simultaneously adjusted for age-group (≤50 years vs. ≥51 years), district of residence (tirana vs. other districts of albania), place of residence (urban vs. rural areas), educational level (0-8, 9-12, ≥13 years), economic level (low, middle, high), employment status (employed, unemployed, retired) and metastases site (liver vs. bones and/or lungs). † overall p-values and degrees of freedom (in parentheses). table 4 presents the association between ca15-3 and socio-demographic characteristics and metastases site. in age-adjusted general linear models, there was an inverse and statistically significant association of ca15-3 with the age and educational attainment of study participants (mean cea level was higher among the younger and the low-educated individuals). in addition, mean ca15-3 level was significantly higher in patients with metastases in the bones and/or lungs compared with those with metastases in the liver (235.7 u/ml vs. 150.4 u/ml, respectively; p<0.01). in multivariable-adjusted general linear models, there was evidence of a significant association of ca15-3 with the age-group (mean level was 246.6 u/ml in younger patients compared with 84.9 u/ml of their older counterparts; p<0.01) and metastases site (mean level was 203.6 u/ml in patients with bones and/or lungs metastases compared with 128.0 u/ml in those with liver metastases; p=0.04) [table 4]. variable age-adjusted multivariable-adjusted* mean 95% ci p mean 95% ci p age-group: ≤50 years ≥51 years 24.3 16.0 17.0-31.6 10.4-21.7 0.081 20.7 15.7 10.9-30.4 8.8-22.6 0.401 district of residence: tirana other districts 18.7 21.2 11.3-26.0 15.2-27.1 0.072 15.6 20.8 7.3-23.8 13.8-27.8 0.267 place of residence: urban areas rural areas 17.9 23.8 12.1-23.7 16.5-31.1 0.206 17.4 18.9 10.3-24.5 10.5-27.4 0.759 education: 0-8 years 9-12 years ≥13 years 26.4 18.3 11.2 19.1-33.7 11.7-24.9 0.3-22.2 0.056 (2)† 0.068 0.615 24.6 18.1 11.9 15.2-33.9 5.0-31.3 0.5-23.3 0.247 (2) 0.268 0.877 economic level: low middle high 24.7 18.1 16.2 16.8-32.7 12.0-24.3 2.8-29.6 0.363 (2) 0.628 0.991 18.8 17.8 18.0 8.4-29.2 8.1-27.5 2.6-33.3 0.991 (2) 0.994 0.997 employment status: employed unemployed retired 20.9 21.7 16.8 12.7-29.1 14.1-29.3 7.0-26.7 0.716 (2) 0.913 0.805 21.3 18.8 14.4 12.9-29.7 10.4-27.3 3.4-25.4 0.607 (2) 0.691 0.846 site of metastases: liver bones and/or lungs 13.5 27.2 7.4-19.6 20.9-33.5 0.002 11.9 24.5 4.3-19.6 16.9-32.0 0.008 hoti a, gashi e, kraja f, sallaku a. association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania (original research). seejph 2018, posted: 01 january 2018. doi 10.4119/unibi/seejph-2018-178 7 table 4. association of ca15-3 with socio-demographic characteristics and metastases site; ageadjusted and multivariable-adjusted mean values from the general linear model * this model was simultaneously adjusted for age-group (≤50 years vs. ≥51 years), district of residence (tirana vs. other districts of albania), place of residence (urban vs. rural areas), educational level (0-8, 9-12, ≥13 years), economic level (low, middle, high), employment status (employed, unemployed, retired) and metastases site (liver vs. bones and/or lungs). † overall p-values and degrees of freedom (in parentheses). variable age-adjusted multivariable-adjusted* mean 95% ci p mean 95% ci p age-group: ≤50 years ≥51 years 289.9 94.2 233.3-346.4 50.6-137.8 <0.001 246.6 84.9 170.1-323.1 31.2-138.7 0.001 district of residence: tirana other districts 188.7 194.2 131.9-245.5 148.2-240.3 0.881 153.9 177.8 89.1-218.7 123.1-232.3 0.519 place of residence: urban areas rural areas 177.8 214.9 132.9-222.7 158.4-271.4 0.303 161.7 169.9 106.1-217.3 103.6-236.1 0.834 education: 0-8 years 9-12 years ≥13 years 235.6 184.6 113.5 179.5-291.7 133.8-235.5 29.3-197.6 0.055 (2)† 0.052 0.388 220.2 150.8 126.4 146.9-293.6 47.8-253.7 37.1-215.6 0.249 (2) 0.314 0.982 economic level: low middle high 219.9 186.8 129.6 158.8-281.1 139.7-234.0 26.2-233.1 0.323 (2) 0.360 0.672 171.2 194.2 132.0 89.7-252.8 118.2-270.1 11.7-252.2 0.733 (2) 0.926 0.818 employment status: employed unemployed retired 197.1 207.1 163.0 134.0-260.1 148.3-265.9 87.3-238.7 0.637 (2) 0.893 0.719 189.8 177.5 130.1 124.3-255.2 111.3-243.7 43.8-216.5 0.506 (2) 0.620 0.680 site of metastases: liver bones and/or lungs 150.4 235.7 102.5-198.4 186.6-284.8 0.014 128.0 203.6 68.0-188.0 144.7-262.5 0.039 hoti a, gashi e, kraja f, sallaku a. association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania (original research). seejph 2018, posted: 01 january 2018. doi 10.4119/unibi/seejph-2018-178 8 discussion main findings of the current analysis include a higher mean value of both cea and ca15-3 levels in albanian female patients with breast cancer metastases in the bones and/or lungs compared with their counterparts with metastases in the liver. furthermore, mean ca15-3 level was considerably higher in the younger patients. there was a significant linear association between cea and ca15-3 levels. it should be noted that the current analysis of both cea and ca15-3 values relates to the time of diagnosis and not the subsequent treatment which certainly causes alterations of the cea and ca15-3 values. breast cancer is the most frequent cancer in women from western countries (9) and it is increasing in lowand middle-income countries as well (1-3). in western countries, the incidence of breast cancer has progressively increased in the past 30 years, whereas the specific mortality rate is relatively stable (9,12). it has been argued that this is a result of both extensive screening and great therapeutic strides (9,13). in the current study conducted in tirana, two important tumour markers were measured in all study participants at the time of diagnosis. however, to date, measurement of ca15-3 and cea serum levels are not recommended in the follow-up of breast cancer, in light of their lack of specificity (9,14). yet, some previous studies have indicated that the likelihood of discovering recurrence of breast cancer is influenced by the ca15-3 serum level and its doubling time (15,16). the current analysis may have some limitations related to the inclusion of study participants and the data collection procedures. regarding the possibility of selection bias, it should be noted that this study involved all patients with metastatic breast cancer diagnosed and treated over a seven-year period at the oncology service of the university hospital centre “mother teresa”, which is currently the only tertiary care institution in albania. based on this fact, the oncology service of the university hospital centre “mother teresa” in tirana is the only public institution in albania offering specialized services and most of the albanian female patients are assumed to be diagnosed with breast cancer and subsequently treated in this medical centre. therefore, the female patients included in our analysis comprise a representative sample of breast cancer patients for the whole period study period. as for the possibility of information bias, the diagnosis of breast cancer and the location of metastases were based on the best clinical protocols and contemporary examination techniques used in other countries. in any case, we cannot entirely exclude the possibility of information bias at least for the socio-demographic information which was collected through interviews. yes, seemingly, there is no plausible reason to assume a differential reporting of sociodemographic factors between women with different clinical characteristics or stage of disease progression. in conclusion, this study provides valuable evidence on selected correlates of cea and ca15-3 levels in albanian female patients diagnosed with metastatic breast cancer. oncologists and other health professionals in albania, as well as decision-makers and policymakers should be aware of the burden and risk factors of breast cancer among women in this transitional society. hoti a, gashi e, kraja f, sallaku a. association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania (original research). seejph 2018, posted: 01 january 2018. doi 10.4119/unibi/seejph-2018-178 9 references 1. lu c, sun h, huang j, yin s, hou w, zhang j, et al. long-term sleep duration as a risk factor for breast cancer: evidence from a systematic review and doseresponse meta-analysis. biomed res int 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https://www.ncbi.nlm.nih.gov/pubmed/?term=domper%20m%5bauthor%5d&cauthor=true&cauthor_uid=12114874� https://www.ncbi.nlm.nih.gov/pubmed/?term=ruiz%20g%5bauthor%5d&cauthor=true&cauthor_uid=12114874� https://www.ncbi.nlm.nih.gov/pubmed/?term=montz%20r%5bauthor%5d&cauthor=true&cauthor_uid=12114874� https://www.ncbi.nlm.nih.gov/pubmed/?term=carreras%20jl%5bauthor%5d&cauthor=true&cauthor_uid=12114874� https://www.ncbi.nlm.nih.gov/pubmed/?term=heutte%20n%5bauthor%5d&cauthor=true&cauthor_uid=17325589� https://www.ncbi.nlm.nih.gov/pubmed/?term=delozier%20t%5bauthor%5d&cauthor=true&cauthor_uid=17325589� https://www.ncbi.nlm.nih.gov/pubmed/?term=hardouin%20a%5bauthor%5d&cauthor=true&cauthor_uid=17325589� https://www.ncbi.nlm.nih.gov/pubmed/?term=bardet%20s%5bauthor%5d&cauthor=true&cauthor_uid=17325589� hoti a, gashi e, kraja f, sallaku a. association of carcinoembryonic antigen (cea) and cancer antigen 15-3 (ca 15-3) with socio-demographic factors and metastases site in women with metastatic breast cancer in albania (original research). seejph 2018, posted: 01 january 2018. doi 10.4119/unibi/seejph-2018-178 10 ______________________________________________________________________________________ © 2018 hoti et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 1 review article ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy christiane wiskow 1 , maria ruseva 2 , ulrich laaser 3 1 sectoral policies department, international labour office, geneva, switzerland; 2 executive committee, south eastern europe health network, skopje, fyr macedonia (republic of macedonia) and management board, international health partnerships association, sofia, bulgaria; 3 section of international public health, faculty of health sciences, university of bielefeld, bielefeld, germany and member, international health partnerships association, sofia, bulgaria. corresponding author: maria ruseva, md, international expert, public health member, executive committee, see health network (seehn) and founding member, international health partnerships association (ihpa); address: bellmansgade 23, 7 tv. 2100 copenhagen ø, denmark; telephone: +4539186929; e-mail: rusevamaria33@gmail.com wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 2 abstract aim: regional collaboration has continuously contributed to the development of public health in the south eastern europe (see) region since 2000 when the public health collaboration in see (ph-see) was initiated. this article looks into two frameworks for regional collaboration in the area of public health: a framework developed in 2004 by a network of public health professionals and academics, and another one developed by the see health network as integral part of the see 2020 strategy on jobs and prosperity in a european perspective, adopted in 2013. it compares the commonalities and differences of the two frameworks; considers what is still valid and relevant after ten years and which new features have emerged in the new strategy. methods: a literature review was carried out and a qualitative analysis was applied for the comparison of the two frameworks. results: notwithstanding the time gap of nearly ten years, the commonalities between the two regional health strategies are significant. major consistent goals include: improving equity in health; strengthening human resources for health; improving intersectoral cooperation and governance. the differences between the two regional strategies, including issues around social participation and regional health information systems, are partially due to their different development context. cross-border policies and quality management have emerged as new or more pronounced topics in the see 2020 strategy’s health dimension. conclusions: many aspects addressed in the 2004 framework are pertinent with regard to the see 2020 health dimension and remain relevant in the current context. the integration of health as part of the economic see 2020 strategy reflects a significant paradigm shift and important step forward for public health. keywords: public health strategy, regional collaboration, socioeconomic development. conflicts of interest: none. disclaimer: the main author of this article is a health sector specialist at the sectoral policies department of the international labour office, geneva. the views expressed in this article are those of the author and do not necessarily reflect the views of the international labour organization. wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 3 introduction in november 2013, ministers of economy of seven south eastern european (see) transition economies signed the see 2020 strategy on jobs and prosperity in a european perspective (hereafter see 2020 strategy, or strategy). the see 2020 strategy aims at socio-economic growth and underlines the importance of the european union (eu) perspective for the see region. it provides a framework for regional cooperation in specific political and economic areas with the purpose to assist governments in the achievement of common national goals. the development of the strategy has revealed a high level between regional and national agendas (1,2). while the focus of the strategy is primarily on advancing the economic development of its members, health constitutes an integral part of this strategy. as highlighted by the see health network (seehn), this is an innovative aspect reflecting a paradigm shift in recognizing that health contributes to socioeconomic growth rather than constituting just a burdening cost factor (3,4). the seehn has been mandated to assist in the implementation of the health dimension of the see 2020 strategy (5). in the context of another network, the public health collaboration in see (ph-see), a framework for a regional public health strategy had been developed and suggested as early as in 2004 (6). this article looks into two frameworks for regional collaboration in the area of public health: one framework developed in 2004 by public health professionals and academics, and another one developed by the seehn as integral part of the see 2020 strategy. it compares the commonalities and differences of the two frameworks; considers what is still valid and relevant after ten years and which new features emerged in the new strategy. it is based on a literature review and applied qualitative analysis for the comparison. background information during the past three decades, the see countries have experienced dramatic changes through the disintegration of the communist systems and the subsequent rapid transition to marketoriented economies. this shift had social and cultural implications for the societies, marked by increasing poverty, high unemployment, massive emigration, and financial downturn, further aggravated by a devastating war. as a consequence, the burden of disease in many see countries has been – and continues to be – higher than in western european highincome countries despite varieties in the region (7-9). the eu-initiated stability pact for the see (1999-2008) 1 included two major health programmes under the social cohesion pillar that resulted in two distinct public health networks, operating at political and professional levels:  the see health network (seehn), established in 2001, brought together the ministries of health of nine see countries 2 and other experts, and has since acted as an intergovernmental forum and legal platform implementing regional collaboration on health systems and public health at political level. in 2010, the see health network took ownership for the regional collaboration on health and development under the regional 1 the eu was the main initiator of the stability pact for the see. over 60 partners provided funding for the activities and programmes under the stability pact, including the wb, ebrd, ceb, coe, all un organizations and many bilateral donor countries. all health actions were financially and technically supported by ten bilateral donor countries, coe, ceb and who europe. 2 albania, bosnia and herzegovina, bulgaria, croatia, the former yugoslav republic (fyr) of macedonia (republic of macedonia), republic of moldova, montenegro, romania and the republic of serbia. israel joined seehn in 2011 as the tenth member country. wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 4 cooperation council (10), the successor of the stability pact since 2008 (11). its institutions include regional health development centres in each of its ten member states and a network of over 300 experts, with a secretariat based in skopje, fyr macedonia (12). it is one of the over 60 see regional initiatives under the broad political framework of the see regional cooperation process and the regional cooperation council.  at the academic and technical level, the public health collaboration in see (ph-see), funded by the german stability pact (2000-2008), brought together universities and institutes of public health of see countries and partner universities from european countries to develop programmes for training and research in public health and assist in the establishment of schools of public health. following the end of the stability pact, in 2008, ph-see transformed into the forum for public health in see (fph-see), a nongovernmental and non-profit consortium of public health institutions in the see region. as an affiliate of the european public health association (eupha) it aims at exchange of experience, mutual support, and common activities for a new public health (13). both networks continue to be active; it is noteworthy that they share the vision and mission to promote peace, reconciliation, and health through regional collaboration in public health. as pointed out by ruseva et al. (14), both networks together enhanced public health as a common denominator of both a political and an academic movement to improve the health and wellbeing of the see populations. the seehn achievements are numerous with significant impact on health policies, spanning the areas of mental health, non-communicable and communicable diseases, healthy aging, antibiotic resistance, organ donor and transplant medicine, blood safety, accreditation and quality improvement of health services, health workforce, and public health services. at the academic level, the ph-see by 2008 had produced six volumes of teaching materials (3500 pages), a shortlist of health indicators; organized more than 25 conferences and summer schools; and had assisted in the establishment of new schools of public health in belgrade, bucharest, chisinau, novi sad, pleven, skopje, sofia, tirana, and varna. as a lesson learnt from the seehn, ruseva et al. conclude that a network approach constitutes an added value for the region with view to the small size of most of see countries. the regional collaboration network amplifies their influence and power at international levels, as they speak with one voice; moreover, collaboration between various stakeholders has enabled the countries to rapidly resort to their respective networks to mobilize assistance in emergency events, such as the floods in 2014 (14). development of a regional public health strategy framework in 2004 3 in 2004, the public health collaboration in see programme (ph-see) (13) brought together public health professionals from seven see countries and other european countries 4 in a seminar that served as a forum for the development process of the regional strategy framework. the seminar built on previous work in the region and followed a participatory approach in several steps. hence, based on the existing national health strategies at that time, the participants jointly elaborated a situation analysis with regard to public health in the see 3 this section draws on reference no. 6: framework for a common regional public health strategy of south eastern europe, in: scintee sg and galan a (eds.). public health strategies: a tool for regional development – a handbook for teachers, researchers and public health professionals. lage: hans jacobs publishing company, 2005. 4 36 public health experts from albania; bulgaria; croatia; fyr macedonia; romania; serbia and montenegro; and slovenia; five public health experts from denmark, germany, switzerland and the uk. wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 5 region, selected priorities for a regional framework, formulated major goals and developed an operational action plan. a methodological combination of the swot 5 analysis and the nominal group technique was selected for the framework development. both methods are recognized in supporting decision-making and problem solving processes, by applying heuristic reasoning for advancing analysis and decision-making. being primarily intuitive and judgemental rather than mechanistic and measurable (15), these methods nevertheless follow rigorously disciplined regulations. in regional development as well as in strategic planning, the use of heuristic reasoning is well-established. situation analysis of public health in the see region in 2004 the situation analysis using the swot methodology aimed at describing the external and internal environment of public health in the see region and facilitating the choice of strategic options. strengths the countries in the see region could build on a strong tradition and history in public health. namely, the management of communicable diseases in conjunction with the sanitary control of water supplies and food safety had the potential for further development at regional level. the traditional system of family physicians and the focus on maternal and child health were highly relevant with regard to international trends in health. this was backed by already existing legislation and regulations like the laws on surveillance of communicable diseases, food safety and healthy nutrition, environmental health, occupational health, school children health, immunization and the like. routine health data collection was maintained in most countries. the existing public health infrastructure consisting of professionals, inspectorates and national institutes of public health represented a solid base both at country and regional levels. in 2004, a core group of public health professionals with international training and connections provided quality input into projects and institutions. nearly all countries in central and eastern europe had mature education and training systems (15), although the see region could build only on a selected number of schools of public health, such as the andrija stampar school in zagreb, croatia with its long tradition. professional associations and non-governmental organizations (ngo) reflected the continuing cooperation and communication and represented a means for empowerment of public health. national public health associations and schools of public health had been founded in romania, serbia, moldova, fyr macedonia, bulgaria and albania in recent years with the support of the open society foundations and the german funded stability pact. weaknesses weaknesses within public health in see countries were observed in the areas of legislation, organization, financing, health promotion, health information system, human resources, education and training, and ethical issues. the health sector reforms during the transition period brought about rapid changes of legislation. in addition, the unstable political situation often led to the disruption of development processes in public health, and as a consequence resulted in a lack of persistent vision and policy. at the same time, the slow transition from a centralized structure to 5 swot analysis is a structured planning process that assesses strengths, weaknesses, opportunities and threats with regard to the internal and external environment of a project or business. wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 6 decentralised systems reflected a form of inflexibility stemming from former systems. additionally, poor vertical and horizontal communication impeded the advancement of new structures and initiatives. community involvement in health development tended to be neglected. overall, the efficiency of the health information systems was questioned, as was the quality and the effective use of health information. the health financing was perceived to be insufficient. of concern were also the inappropriate allocation of funds and the low effectiveness in spending, enhanced by a lack of control mechanisms. corruption was a significant worry, as it was contributing to increasing inequalities in health care. inappropriate salaries and lack of incentives were also weakening the delivery of public health services through demotivated health personnel. furthermore, the lack of professional and social recognition and the missing formal inclusion in decision-making processes demotivated the public health professionals. at that time, a critical mass of well-trained public health professionals was not built yet and a clear shortage of management skills in public health was observed. opportunities in contrast to the 1990s, in 2004, the see region was characterized by a climate of opening and cooperation between the countries. the dubrovnik pledge of 2001 (16) had marked a firm political commitment to regional health development. the political and technical cooperation had been institutionalised in the “see health network” as the main political body for providing leadership and sustaining ownership of the countries and implementing concerted action in defined areas of mutual interest. 6 there was an enhanced trend to increased professional cooperation within and between the see countries, facilitated and sustained by the establishment of institutionalized structures, such as the seehn and the phsee networks. political changes and increasing foreign investment targeting the socio-economic development in see countries also opened opportunities for public health initiatives. a number of international agreements and regional declarations constituted important reference points for a regional public health strategy, including the united nations (un) millennium development goals (mdgs) (17). the european public health policies provided a frame for harmonizing see approaches and alignment with the european standards, including the who health 21 strategy (18); the ljubljana charter on reforming health care, 1996 (19); and the eu public health programme (20-22). other relevant international declarations were the who ottawa charter concerning health promotion and the verona initiative advocating for multi-sectoral investment in health (23). the development of information technology (it) offered new opportunities in terms of facilitating better access to the international body of knowledge in public health for professionals and politicians in the region, helping to exchange information and improving equal access to new databases, journals and other up-to-date information. the emerging national public health strategies demonstrated the relevance of a regional approach as they provided evidence on the numerous common problems and challenges that 6 in 2004, the see health network consisted of over 200 members, including representatives of nine see beneficiary countries, ten donor and neighbour countries and representatives of international organizations, such as who regional office for europe, the council of europe (coe) and the council of europe development bank (ceb). the political body of representatives of the ministers of health, called the national health coordinators of the see countries, acted as the steering committee for implementing the dubrovnik pledge. wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 7 most see countries faced. for addressing those, a regional framework through setting of goals of mutual interest, joining forces through cooperation and information exchange was considered beneficial for advancing public health in the see region. threats at the same time, political, security and socioeconomic instability in the region and at country level was perceived as a major constraint on the way forward. particularly, the political instability was of concern as every electoral mandate came along with changes in governmental strategies, institutions and agencies with effects on legislation and financing mechanisms. the lack of continuity in management, legal framework and allocation of resources throughout and across different political cycles were challenging the development of sustainable public health strategies. competing and conflicting interests of the different political groups also meant a threat to the thorough development of a long-term public health policy. despite the stability pact efforts in the follow-up of the dubrovnik pledge, the see countries at that time felt that the international community had paid limited attention to the reform of the health systems in see and health had been excluded as a regional priority in the frame of the eu cards programme (24). primary concern among the consequences of the socioeconomic instability was the high turnover of health professionals. furthermore, the lack of recognition of public health professionals compared to clinical medical staff, in terms of identity, social status and public image, hindered the evolution of public health within the health system. strategic choice and recommendations the mapping of interactions between the external and the internal environment suggested the choice of the comparative advantage strategy that matched the strengths in the public health field in see with the external opportunities. building on the potentials did not mean losing reality out of sight: maximising the strengths implied overcoming the weaknesses for a stronger position to take opportunities offered by the external environment. in this understanding, a set of key messages and recommendations were formulated:  a key priority in the see region was the reduction of health inequalities within and between the countries with a view to further socioeconomic stabilization of the region and a better use of external opportunities.  improved community involvement and social participation in the decision-making process in health activities would be important with a view to meeting the expectations of the population and making the public health strategy socially and culturally acceptable.  intersectoral collaboration (vertical and horizontal) would be indispensable for integrating public health in the agenda of all economic sectors and overall politics. it would also help to resolve competing interests in national coalitions and international partnerships.  the willingness of joining the eu could be the engine for economical and social development. the public health field should take advantage of the requirements to adapt to eu standards and regulations in order to improve legislation, professional regulations and harmonize public health practices.  regional cooperation would contribute to improving the capability of attracting international funding for multi-national projects. joining forces in obtaining international wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 8 investments in public health research, capacity building and improving infrastructure could help to mitigate the weak financing of public health in the region.  the sustainable development of a public health workforce was necessary to strengthen public health aspects in health reform and health policies. capacity building should include management of health systems and better use of existing resources.  an improved status of public health professionals would enhance their active involvement in policy development and decision making processes, thus ensuring the integration of public health knowledge and the use of data for evidence based policymaking processes. this could be operationalized in strengthening or establishing national public health associations and forming a regional umbrella organization.  professional collaboration in the form of networks would help in capacity building across see countries through mutual exchange of information and experiences and the sharing of successful national projects throughout the region. the results of the situation analysis and the recommendations informed the priority setting process for public health goals in the region. the final priorities were formulated as goals, framing the regional public health strategy. this framework of strategic goals was translated into an action plan by setting operational objectives, specifying activities, timeframe, deliverables, outcomes, indicators, and analysing potential partners, resources and risks. the see regional public health strategy framework (2004) five strategic goals build the overall framework for action to address public health priorities at a regional level (box 1). an initial five-year period for implementation was established (2005-2010). the regional strategy framework aims to complement the national public health strategies. in addition to the countries’ strategies, it provides a framework for addressing common health challenges in the region, contributing to the harmonization of public health policies between the countries and the approximation to european standards. box 1. overview of the strategic goals and objectives of the draft of see regional public health strategy framework (2004) [source: scintee sg and galan a (eds.) (2005). public health strategies: a tool for regional development, page 629] see regional public health strategy framework, 2005-2010 goals and objectives goal 1 improving equity in health 1.1: targeting vulnerable groups 1.2: ensuring adequate and safe living conditions goal 2 strengthening social participation 2.1: mapping social participation opportunities and initiatives 2.2: awareness rising and empowerment of the public 2.3: developing mechanisms to involve civil society in decision making processes goal 3 strengthening human resources in public health 3.1: ensuring sustainable development of human resources 3.2: enhancing regional professional collaboration goal 4 improving regional public health information and knowledge 4.1: establishing a regional public health information system 4.2: developing mechanisms for reporting and analysis at regional level 4.3: improving the level of public health knowledge among three key groups: the professionals, the decision-makers and the public goal 5 establishing intersectoral cooperation 5.1:establishing involvement in programmes of non-health sectors 5.2:introducing intersectoral research wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 9 see 2020 strategy – the health dimension (2013) the see 2020 strategy pursues a holistic approach of development (1, page 4). it features health as integral part of the overall socioeconomic development. the strategy aims to achieve three overall economic targets 7 building on a structure of five pillars (integrated growth, smart growth, sustainable growth, inclusive growth and governance for growth), with pillar specific targets and a set of 16 dimensions. health and employment form the two priority dimensions under the pillar inclusive growth as they were identified as the most urgent topics to be addressed and there are expectations of significant return of efforts in terms of social development. the employment dimension appears more prominent compared to the health dimension, which may reflect on the importance of employment in the strategy, as well as the commitment to create one million new jobs in the see region by 2020. yet, the inter-linkages of the employment and the health dimensions become apparent in two key goals of the strategy: fighting poverty through job creation and fighting health inequalities with a focus on low-income and vulnerable groups. the aim is to ensure that everybody benefits from growth through reduction of poverty, improved health and wellbeing, and greater social cohesion. the see 2020 labour market policies focus on the flexicurity approach to be implemented through comprehensive lifelong learning strategies, effective active labour market policies and modern social security systems (1, pages 28 & 50). according to the european commission, flexicurity is an integrated strategy that attempts to reconcile employers’ needs for a flexible workforce (flexibility) with workers’ needs for security (25). the see 2020 actions refer to the four components of flexicurity approaches: flexible and secure contractual arrangements and work organisations, both from the perspective of the employer and the employee; active labour market policies that help workers to cope with rapid changes, unemployment, reintegration and transitions to new jobs; lifelong learning systems to ensure the continuous adaptability and employability of all workers, and to enable firms to keep up productivity levels; and modern social security systems which provide adequate income support and facilitate labour market mobility (26). effective social security can be achieved through comprehensive social protection floors. this approach comprises an integrated set of social policies designed to guarantee income security and access to essential social services for all, with a focus on vulnerable groups and protecting and empowering people across the life cycle (27). social protection floors, as defined by the international labour organization (ilo), are nationally defined sets of basic social security guarantees that ensure that all in need have, as a minimum, access to essential health care and to basic income security that together secure effective access to goods and social services. the concept is part of a two-dimensional strategy aimed at the rapid implementation of national social protection floors in line with the ilo social protection floors recommendation, 2012 (no. 202), and the progressive achievement of higher levels of protection within comprehensive social security systems according to the ilo social security (minimum standards) convention, 1952 (no 102) (28). robust social protection floors are important particularly with view to the demographic transition in the see region posing challenges for both the employment and the health dimension. accelerated population aging has been observed in the region throughout the past six decades, with an increased median age, rising life expectancies and a simultaneous fall of fertility rates by more than half 7 short version: (i) increase see average gdp per capita relative to the eu average; (ii) boost total see trade in goods and services; (iii) reduce see trade deficit (1, page 5). wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 10 (from 3.55 children per childbearing woman in 1950 to 1.49 in 2010). the percentage of population aged 65 or older has doubled in the same period (from 7 to 14 per cent) as well as the old-age dependency ratio (from 10.6 to 20.9). the effect of the demographic transition on health systems consists of an increasing demand through more old-age related health care needs; the employment dimension will have to address the increasing gaps in labour, while social security systems have to struggle with the decrease of the potential support ratio. the countries in the see region will have to respond to these developments with complex and integrated socioeconomic and health policies (29). the see health network has developed the health dimension for the see 2020 strategy (12). this section of the see 2020 strategy has been based on the seehn policies expressed in the skopje (2005) and banja luka (2011) pledges, the findings and recommendations of four seehn studies (3,4,30,31), the national health and health systems policies, strategies and action plans of all seehn member states and, finally, on their cross-country analysis. a brief description of the situation within the see 2020 acknowledges the significant progress in health care in the region while pointing to several challenges. among the common health challenges identified in the region, inequalities within and between countries are a priority concern. health systems in the region have been described as still being inefficient with common weaknesses including the lack of effective access to health services; inadequate financing of health systems, but also inefficient use of available resources; fragmentation of health services; deficiencies in quality of care; inefficient management; low capacities of the health workforce and significant internal and international migration. in terms of public health needs, the burden of non-communicable diseases also suggests a lack of effective health promotion policies and preventive health services (1, page 27). in order to achieve the set objective of improving health and wellbeing of all people living in the see region, four key strategy actions have been set: i) strengthen the delivery of universal and high-quality health-promoting services. policies for improving the health status focus on low-income and vulnerable groups. ii) strengthen and improve the intersectoral governance of the health sector at all levels, including the health information structure and enhancing regional information exchange. iii) harmonise public health and public health services legislation, standards and procedures across countries in the region. this includes developing mutual recognition and trust to enable the creation of a free trade area from a public health perspective. iv) strengthen human resources in the health sector, harmonise qualifications of health professionals in the see region and monitor health workforce mobility. table 1 summarizes the objective, key strategy actions and activities, projects or instruments for implementation of the see 2020 health dimension. the responsible actors for implementation of the health dimension consist of the ministries of health at national level and the see health network at regional level. wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 11 table 1. overview of the see 2020 strategy, dimension health (source: regional cooperation council. see 2020 strategy, pages 28-29 and 50-51) objective: improve health and wellbeing of all those living in the see region timeframe 1. strengthen the delivery of universal and high-quality health-promoting services at all levels of care  adopt and implement a regional model for delivery of universal and high-quality health, promoting services at all levels of care with an emphasis on a strong primary care sector for improving the health gain in the see region, with a particular focus on low-income and vulnerable groups;  develop a baseline cross-country study on the efficiency of health systems and services;  update current health service legislation and regulations related to health care, disease prevention, health promotion and patient safety;  develop and implement quality improvement mechanisms;  introduce efficient monitoring and evaluation mechanisms in the region’s health systems to improve transparency and accountability. 2015–16 2. strengthen and improve the intersectoral governance of the health sector at all regional levels. adopt regional exchange mechanism for sharing experiences and good practices  strengthen health institutions and improve the intersectoral governance of the health sector at national, regional and community levels following the health in all policy (hiap) approach; and including capacity building for health information infrastructure and introducing ehealth;  adopt a regional information exchange mechanism for sharing experiences and good practices in cross-border public health, health care and mobility of health workforce;  review the current networks of health institutions and develop reform strategies;  review and update the existing health legislation in order to introduce hiap and hia;  implement best practice from eu countries when introducing mechanisms for the intersectoral governance of health; 2015–16 3. harmonise the cross-border public health legislation and enable a free trade area from a public health perspective  adopt multilateral and bilateral agreements to harmonise the cross-border public health and public health services legislation, standards, procedures and develop mutual recognition and trust to enable the creation of a free trade area from a public health perspective;  develop mutually agreed regional public health cross-border standards and procedures;  develop and launch an see regional information database on cross-border public health issues and best practice. 2020 4. adopt multilateral and bilateral agreements to strengthen human resources for health, harmonise and mutually recognize health professionals’ qualifications  adopt multilateral and bilateral agreements to strengthen human resources for health, harmonise and mutually recognise health professionals’ qualifications and monitor the human resources for health and their mobility;  review the current situation on forecasting and planning in respect of the health workforce, as well as on harmonising and mutually recognising the qualifications and mobility of health professionals;  establish a permanent see forum for health education institutions;  establish a regional masters programme for public health based on eu public health curricula. 2016 discussion notwithstanding the time gap of nearly ten years and the different context of their development histories, the commonalities between the two regional health strategies described above are significant. this may be owing to the common spirit in which they have been created with shared values of equity, social justice, and health as a human right as wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 12 underlying principles. another reason emerges when comparing the two situation analyses pointing to a number of persisting common problems and weaknesses, including health inequalities within countries and across the region as a primary concern. the aim to address these problems being the basis for the selection of strategic goals and implementation action may explain some of the similarities between the two strategies. in 2004, the experts of ph-see were convinced that a regional public health framework would underscore the critical role of public health for the socioeconomic development and its implementation would help enhancing social stability and peace in the region. while in 2004 it was acknowledged that the health of populations was an important factor in economic development (18,32), the potential of public health as active supporter remained underestimated. similarly, in the context of see 2020, the seehn refers to health and wellbeing as a determinant as well as a contributor to peace and economic development (12). the integration of health as part of the economic growth strategy see 2020 reflects indeed an important paradigm shift towards the full recognition of health as a contributor to economic growth as highlighted by seehn (5). both regional strategies underline the commitment to eu and who regional office for europe policies in the area of health as well as the intention to complement national health policies and support the collaboration between countries in the region to address issues of mutual interest in national health policies aiming for harmonization of policies and standards. regardless the differences in structure and wording, both strategies are consistent in the majority of their goals and strategy actions. major consistent objectives include: i) improving equity in health with a focus on vulnerable and low-income groups, hence improving health for all; ii) strengthening human resources for health and public health, respectively; iii) strengthening and improving intersectoral cooperation and governance. within those consistent goals, partially different priorities and approaches reflect the timegap and the variety of contexts. i) improving equity in health in 2004, reducing inequalities in health and in access to quality health care within and between the countries in the region was a top priority. at that time, political changes, economic breakdowns and war had resulted in the deterioration of the overall population health status, affecting most the vulnerable groups. a special challenge for some see countries in that period was the situation of internally displaced persons and refugees; those living in conflict areas under the stress of insecurity and violent threats; and those considered as ethnic minorities. these groups were considered vulnerable in terms of social exclusion and deprivation from resources influencing health such as income, education and healthy living conditions. despite the progress made to date, health inequalities within and between the countries remain of high concern; assisting governments in reducing poverty and health inequalities is the declared aim of the see 2020 inclusive growth pillar. the health objective in this regard is to ensure universal quality health services focusing on access for vulnerable groups. ii) strengthening the health workforce the concern of insufficient numbers and capacities of the health workforce has been addressed in both strategies, regardless of different perspectives. the ph-see framework emphasized the strengthening of the public health workforce capacities and status within the overall health workforce. in 2004, the emergence of the holistic approach to public health wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 13 was not mirrored in the public health workforce in see. the existing body of knowledge, institutions and professionals focused on the bio-medical aspects of public health and was complemented by the existing expertise in social medicine; however, the need for integrative approaches and inter-professional collaboration was evident. in the context of see 2020, low capacities of the health workforce have been indicated as one of the persisting weaknesses. under the objective of strengthening the health workforce, the cross-border aspect is emphasized. mobility has been mentioned in the 2004 framework strategy, but the emphasis of this aspect in see 2020 reflects the current situation characterized by significant international migration of health workers. general trends of health professional mobility flows from eastern to western europe have been persisting throughout the past decade with peaks following the eu enlargement, though at more moderate levels than expected, and with varying magnitude across countries depending on their health labour markets (33,34). on the one hand, health professional mobility is being facilitated in the context of eu policies, through harmonization and mutual recognition of qualifications; on the other hand, the intention is to improve the management of the mobility through monitoring and bilateral and multi-lateral agreements to mitigate adverse effects of outflows from vulnerable health systems that already experience workforce shortages as well as protecting migrant health workers. both regional public health strategies commonly aim for enhancing the regional professional collaboration in the area of education through harmonisation of curricula and a common forum of health education institutions. see 2020 further aims at establishing a regional public health masters programme based on the eu public health curricula. here is certainly an opportunity for enhanced collaboration between the two networks fph-see and seehn as most of the see countries have already implemented the three cycles of the bologna process including master programmes in public health. both strategies focus on the qualification and performance aspects regarding the health workforce while the importance of employment opportunities and decent working conditions in the health sector have been mentioned only marginally. yet, health provider performance and quality of care are linked with enabling and supportive work environments (35). in the context of the see 2020 strategy, the health sector is also economically important in terms of its potential for employment creation, with a view to the increasing demand for health services in times of demographic transition. iii) improving intersectoral collaboration the progress made in the past ten years is particularly evident in the aspect of achieving the integration of health across all sectors. intersectoral collaboration has become more commonly accepted with the appearance of the health impact assessment in the context of the health promotion movement. while the 2004 strategy framework (modestly) aimed at establishing the involvement of public health in the programmes of non-health sectors, the see 2020 aims to implement the integrative approach of “health in all policies” (hiap). in 2004, there was already recognition that most of the determinants of health were outside the sphere of influence of the health sector. however, at that time, the awareness of health impact of actions undertaken in other sectors was limited and neglected in practice in the see region. regular and institutionalized mechanisms of intersectoral cooperation needed to be developed and established in the region in order to promote the protection of health. such integrative and intersectoral approach, while recognized and promoted since the alma ata declaration on primary health care (in 1978) has only later been labelled as “health in all policies” (hiap), more specifically in the eu during the second finnish eu presidency in 2006 (36). in parallel, methods of health impact assessment (hia) have been developed and wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 14 implemented. furthermore, the who europe framework health policy “health 2020” develops and recommends the whole-of-government and whole-of-society approaches that were endorsed by all ten seehn members states during the who europe regional committee session in 2012 in malta (37). the see 2020 strategy takes advantage of these developments and includes in their objectives to “review and update the existing legislation in order to introduce hiap and hia” (table 1, action 2). hiap and hia reflect the important influence of health within the policies of other sectors in the overall see 2020 strategy and offers new opportunities for public health intersectoral collaboration. seehn has been mandated to monitor the health impact of the see 2020 implementation and has ensured that health targets and indicators incorporate prevention and health promotion within the hiap approach, social determinants of health and inequalities (5). in addition to the obvious commonalities, there are also apparent differences between the two strategies that are reflected in a number of objectives and issues without matching counterparts. nevertheless, some of those aspects can be found as elements or indirect intentions in the other strategy.  social participation the 2004 framework for a regional public health strategy emphasized the importance of strengthening social participation in public health and in decision-making processes. it referred to the alma ata declaration on primary health care (phc; 1978) and the health for all strategy (hfa; 1981) policies promoting public participation in health policy development. it further pointed to the responsibility and accountability of all as a prerequisite for sustainable health development, which required the involvement of all stakeholders in health policy and action, including communities. the concept of social dialogue had been suggested as a means for inclusive development processes in the health sector (38). the emphasis of social participation in the 2004 framework strategy may be explained by the historical context and situation at that time, influenced by the aftermaths of a war and in light of the political and socioeconomic instabilities in transition countries. developing trust between people and nations was seen as a priority at a time when see countries were perceived as fragile and the rapid changes involved socio-cultural incoherence. nevertheless, while social or community participation is not explicitly mentioned in the see 2020 health dimension, it emphasizes primary health care and seeks to improve transparency and accountability. both aspects take into account the community level and population interface with the health service delivery, with the aim to build up resilient communities.  regional public health information improving regional public health information and knowledge was one of the priorities and strategic goals in the 2004 framework strategy as well as one of the seven objectives of the seehn dubrovnik pledge. the health information systems at that time were considered inefficient and compounded by the ineffective use of the information in shaping health policies. the set objectives included establishing a regional public health information system and developing mechanisms for reporting and analysis at regional level with a view to improving the level of public health knowledge among professionals, decision-makers and the public. the objective referred to the dubrovnik pledge with its commitment to “establish regional networks and systems for the collection and exchange of social and health information” (16). within the see 2020 health dimension, information systems appear less prominently and in a different way. a reference is found under the objective of cross-border harmonization where the “development and launch of a see regional information database on cross-border public health issues and best practice” is one of the planned activities (table wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 15 1, action 3). while the establishment of health information systems in the see region has advanced following the commitment of the dubrovnik pledge, it is still “work in progress”. thus, strengthening health information systems in the see region continues to be an important priority, as recognized by the ad-hoc meeting of the see ministers of health, 22 june 2015, in belgrade, serbia (39).  cross – border public health the see 2020 strategy includes cross-border public health as a new aspect that is not reflected in the 2004 framework. the strategy action aims at harmonizing cross-border public health legislation and to enable a free trade area from a public health perspective (table 1, action 3). to this end, multilateral and bilateral agreements shall help in harmonizing standards and procedures and, moreover, in the development of mutual recognition and trust to enable a public health free trade area. in 2004, the idea of a see regional free trade area was not foreseen given the instable situation in the region at that time.  quality improvement see 2020 explicitly addresses quality improvement of health services delivery. it aims at exploring the efficiency of health systems with a baseline study and establishing a sustainable quality management system. the aspect of quality management is missing in the 2004 strategy while it implicitly forms an underlying principle. conclusions despite the time lag of nearly ten years, the commonalities of the two strategies for regional public health collaboration are significant. many aspects addressed in the 2004 framework are pertinent with regard to the see 2020 health dimension; therefore, the main parts of the 2004 framework strategy are still relevant in the current context. the differences between the two regional strategies are partially due to the different development context, not only in terms of the different situations in the see region in 2004 and 2013, respectively, but also in terms of different angles: the 2004 framework strategy was developed from within the health system perspective by public health professionals, whereas the see 2020 strategy has been developed at a political level and 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access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 1 original research global health in foreign policy in south africa – evidence from state actors moeketsi modisenyane 1, flavia senkubuge1, stephen jh hendricks1 1 school of health policy and systems, faculty of health sciences, university of pretoria, south africa. corresponding author: moeketsi modisenyane bsc, bed, msc, mph; address: school of health policy and systems, faculty of health sciences, university of pretoria, south africa; telephone: +27123958833/4; e-mail: modisem44@gmail.com modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 2 abstract aim: there are currently debates about why south africa integrates global health into its foreign policy agendas. this study aimed at exploring motivation and interests’ south african policy actors pursue to advance global health and the processes that lead to such integration. methods: the study utilized a mixed-method design from a sample of state policy actors at the national department of health of south africa. participants were selected purposively and had experience of more than three years participating in various international health activities. all participants completed semi-structured questionnaires. quantitative data was analysed to determine frequencies and transcribed text was analyzed using qualitative content analysis. results: a total of 40 people were invited, of whom 35 agreed to participate. of the respondents, 89.7% (n=32) strongly argued that health should facilitate ‘free movement of people, goods and services’. majority (79.0%, n= 29) agreed that ‘development and equality’ are the main elements of foreign policy. of the respondents, majority 77.1% (n=27) agreed that ‘moral and human rights’ are the main elements of foreign policy. furthermore, 82.8% (n=29) agreed that the country should advance ‘africa regionalism and south-south cooperation’ and 85.7% (n=30) strongly argued for a ‘whole-government approach’ in addressing global health challenges. ‘hiv/aids’ and ‘access to medicines agenda’ were the main policy issues advanced. the main domestic factors shaping south africa’s involvement in global health were its ‘political leadership’ and ‘capacity of negotiators’. conclusion: it is evident that within south africa, state policy actors are largely concerned with promoting global health interest as a normative value and a goal of foreign policy, namely, human dignity and development cooperation. furthermore, south africa drives its global health through building coalition with other state and non-state actors such as civil society. hiv/aids, as a policy issue, presents a potential entry point for engagement in global health diplomacy. keywords: diplomacy, foreign policy, global health, global health diplomacy, south africa. conflicts of interest: none. acknowledgment: national department of health, south africa. modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 3 introduction global health diplomacy (ghd) has dramatically increased in the recent years in global health and international relations (1,2). amid this enthusiasm, it is apparent that the concept of ghd is an emerging concept, with new evidence and debates emerging but with clearly diverse and sometimes poorly clarified meanings ascribed to the terms (3,4). in addition, rapid increase in the number of state and non-state actors in global health is an important development. however, the main challenge for governments and non-state organizations is to develop a multisectoral and coherent approach to overcome fragmented policies (5). while the global health practitioners have welcomed this elevated political priority, there have been questions and debates about why and how south africa has conceptualized and contributed to global health diplomacy. furthermore, there has been less examination of why south africa incorporates global health into its foreign policy agenda since 1994 elections. this then raises the question: why south africa incorporates global health into its foreign policy? therefore, these questions, and the broader issue of understanding the relationship between global health and foreign policy in south africa are the focus of this study. along this pathway, the study explored in-depth information on the views of senior state policy actors with the intention of generating new explanations or theory to account for pattern of such health influenced behaviour. as such, deductive process from existing knowledge and theory will be followed which would then be further tested and refined. furthermore, the study explored the strategies, policy issues, domestic factors and diplomatic practices that would shape south africa’s involvement in global health. several authors have tried to introduce frameworks to analyse the relationship between global health and foreign policy. whichever framework of ghd is used, most of the authors have agreed that no single policy framework offers a fully comprehensive description or understanding of the integration of global health into foreign policy as each answers somewhat different questions. furthermore, some authors indicated that there are differing arguments between and within these policy frames, while others are overlapping, and can also be contradictory. in this study, labonte and gagnon framework was used to better explain why south africa incorporates global health into its foreign policy agenda. labonte and gagnon (2010) use the deductive approach using six policy frames, namely: security; development; global public good; trade; human rights and ethical/moral reasoning (6). therefore, this paper, using the framework developed by labonte and gagnon’s health and foreign policy conceptualizations, contributes to this goal by reviewing health in foreign policy through an empirical research case study of south africa. methods participants the study utilized a mixed-method design including both qualitative and quantitative methods (7). a cross-sectional study was conducted amongst state policy actors at the national department of health (ndoh), in pretoria, the capital city of south africa. purposeful sampling (8) was used to identify and recruit interviewees based on relevant peerreviewed or grey literature, as well as the lead author’s professional networks in global health and development. we then employed snowball sampling to enrol additional interviewees until we achieved theoretical saturation, that is, until successive interviews produced no new concepts. participants eligible for in-depth interviews were key informants who had extensive experience in international negotiations for improved access to medicines in each of the three cases. inclusion criteria consisted of key informants who had extensive experience and skills modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 4 (such as more than five years) in participating in international negotiations, which include bilateral, regional and multilateral activities and more than five years working in the health sector. key informants not meeting the above inclusion criteria were excluded. the reason for using semi-structured interviews was to help to reduce bias, sequence, clarity and face validity (9). the need for ‘extra’ sampling arose during the process of interviewing and preliminary theorizing or analysis. the total of eligible participants was 40, and 35 individuals participated in the study giving a response rate of 87.5%. all participants completed a semi-structured questionnaire. nevertheless, the study sample in general was limited by the number of state policy actors who normally participate in international health activities, especially in multilateral negotiations. participants provided written informed consent. the items in the questionnaire were adapted from the previously published instrument used by labonte (6,10). however, the questionnaire was adapted to fit south african context and discussed thoroughly until a consensus was reached, based on agreed criteria. in order to improve clarity, the questionnaire was pilot-tested amongst three state policy actors within the ndoh representing different areas. this pilot test provided the opportunity to refine the questions for clarity and local adaptation. data collection data for this study was gathered by using a self-administered semi-structured questionnaire. the closed questions provided an assessment of views and perspectives of state policy actors regarding what interests south africa pursue when it engages in global health issues. the first five items provided socio-economic indicators of the respondents, namely: ranks; gender; health programme or service responsible for; experience working in health sector; and experience in participating in global health activities. the following 14 items were scored on a five-point likert scale anchored at 5 as strongly agreed and 1 as strongly disagreed, with a mid-point for unsure. the structure of each question was in the following form: ‘the main motivation and/or interests used to justify why health should be a prominent element of foreign policy is that health is a global public good’. for these 14 items, participants were asked to provide a detailed narrative explanation or provide examples. by use of written individual narratives to explain their views, this process provided a validity check and complemented the findings. one item asked participants to identify the biggest challenges that south africa face in fulfilling its commitment to global health. procedures in the first stage of data collection, a semi-structured self-administered survey was given to 40 state policy actors within the ndoh who had participated in global health negotiations in various global health forums. all the potential participants were approached, and were asked if they were willing to participate in the study. in addition, the questionnaire was also given two present and previous health attachés who were willing to participate in the study. the questionnaires were delivered during lunch breaks and all potential participants were explained the purpose of the study and were asked about their willingness to participate. a register was made to record the number of questionnaires issued out. in case where participants were not in the office or were absent, appointments were made for a follow-up visit. the second stage of data collection included a review of published literature and reports on why south africa incorporates global health into its foreign policy agenda. searches were modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 5 conducted in numerous databases (pubmed, medline, social science citation index and science direct), selecting articles and reports that either directly addressed the relationship between global health and foreign policy, or were case studies of an interaction between global health and one or more of the six dimensions of foreign policy in south african context. quantitative data was entered anonymously into the database. the data editing and data capturing on spreadsheet were initially done on site by the research team as soon as the completed questionnaires became available. double data entry and validation was done by two operators at the university of pretoria using the statistical package epi-info, version 13. in the case of qualitative data from both the primary (questionnaire) and the secondary sources, the data were transcribed into microsoft word, and initial notes were written which were used during the coding cycle. the process, settings, events, as well as discussions with respondents were all meticulously recorded. the study received ethical approval from the research and ethics committee of the university of pretoria and the ndoh of south africa. in addition, participants provided informed consent to participate in the study. analysis quantitative data was exported using start transfer and analysis was done using the statistical package stata (version 12). following cleaning of the data, variables were recorded. the main outcome measure was successful participation in global health diplomacy. descriptive statistical analysis was used to compute frequency distributions and sample characteristics in order to summarize and describe data in a concise form. in the case of qualitative variables emanating from survey questionnaire, published literature and government reports on global health and foreign policy, data was analyzed for content (9). all the texts were read several times and were labelled with codes to conceptualize and categorize the respondents’ experiences. codes sharing communalities were grouped into sub-categories, which later supported the construction of categories. analysis was done concurrently with data collection, making interpretations and preliminary reports on ongoing basis. the explanations given by participants in the survey questionnaire illuminated the experiences, perspectives and views of state policy actors. a ‘thick description’ of both participants and document quotes were presented throughout the results section to contribute to the trustworthiness of the research (9). the study used a combination of emerging codes and those that fitted already predetermined codes. secondary sources were also used to support and give context to the findings. the analysis was characterized by constant comparison of the sub-categories and categories with the original text to ensure that the interpretations were grounded in the data (9). limitations a limitation is that it was not possible to examine all papers across a broad range of public health, political science and international relations literature dealing with the understanding of international networks’ ghd processes. thus, this study is not a comprehensive review of every published article related to this subject; rather, this study sought key literature that illuminates the relationship between global health and foreign policy. furthermore, this study did not interview all possible key informants. in addition, there was a potential for selection bias resulting from the purposive sampling and initial selection of documents to be analyzed. in an attempt to mitigate or overcome this problem, we expanded the analysis to examine documents from other sources. furthermore, there was a high rate of responsiveness of many modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 6 potential respondents who had knowledge and experiences in participating in negotiations for integration of health into foreign policy in south africa. the responses from the questionnaire served as a useful purpose of validating the data from the published literature and reports, and acted as a control mechanism to test the validity of the findings. results a total of 35 state policy actors completed the questionnaire, providing their views about why south africa incorporates global health into its foreign policy agendas. the response rate was 87.5%. table 1 presents the socio-demographic characteristics of the study participants. of the 35 respondents, 54.3% (n=19) were female; 45.7% (n=16) were at post level 13 (directors); 48.6% (n=17) had more than 15 years experience working in health sector; and 34.3% (n= 12) had between 5 to 10 years experience participating in global health activities. table 1. socio-demographic characteristics of study participants variable number percentage gender: male female total 16 19 35 45.7 54.3 100.0 rank: post level 15 post level 14 post level 13 post level 12 or below 2 6 16 11 5.7 17.1 45.7 31.4 experience in the health sector: >15 years 10-15 years 5-9 years <5 years 17 8 8 2 48.6 22.9 22.9 5.7 experience in the health sector: >15 years 10-15 years 5-9 years 3-4 years 6 7 12 10 17.1 20.0 34.3 28.6 analysis of the quantitative and qualitative data from the questionnaire and published literature resulted in 16 categories that correspond to four content areas, namely: motivations and interests used to advance global health agenda; strategies and approaches used to advance global health; domestic factors affecting south africa’s participation in global health discourse and policy issue(s) to be advanced in global health. motivations and interests used to advance global health agenda the responses are shown in table 2. of the respondents, the majority 89.7% (n=32) agreed that health is a global public good. conversely, only 42.8% (n=15) agreed that health is part of global security concerns. however, a significant number of respondents, 34.3% (n=12) disagreed that security concerns is the main motivation why health is an element of foreign policy. of the respondents, 45.9% (n=16) agreed that trade and economic interest are the modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 7 main elements of foreign policy. of the respondents, majority agreed 79.0% (n=29) that development assistance for health is the main element of foreign policy. furthermore, the majority 77.1% (n=27) agreed that human rights and ethical/moral reasoning are main elements of foreign policy. modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 8 table 2. motivation and interest used to advance global health variable number percentage global public good: strongly disagree disagree not sure agree strongly agree 0 0 3 8 24 8.6 22.9 68.6 security argument: strongly disagree disagree not sure agree strongly agree 0 12 8 6 9 34.3 22.9 17.1 25.7 trade and economic interest: strongly disagree disagree not sure agree strongly agree 4 8 7 9 7 11.4 22.9 20.0 25.7 20.0 development agenda: strongly disagree disagree not sure agree strongly agree 1 1 5 11 17 2.9 2.9 14.3 31.4 48.6 human rights and moral reasoning: strongly disagree disagree not sure agree strongly agree 0 2 6 11 16 5.7 17.1 31.4 45.7 in order to complement the quantitative results presented above, the qualitative analysis of the narratives from the semi-structured questionnaires, published literature and government reports regarding why health is a prominent element of foreign policy in south africa, post 1994, resulted in the following categories: free movement of people, goods and services most of the respondents believe that due to globalization, health is becoming a global public good, as indicated below: ‘globalization and movement of people into the country and out of the country due to country to country interactions, asylum seeking activities, wars that cause people to be displaced, health tourism, sports. people movement and goods may result in transfer of disease pathogens from country to country’ [respondent no 25]. human security and better health for all modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 9 most respondents have argued strongly on focusing on human security, safety and protection of the individuals more than the state security, as indicated below: ‘public health issues goes beyond bioterrorism and outbreaks of influenza. public health is about addressing inequalities and social determinants of health and therefore must be an important element of all foreign policy. health has no geographic border, it affect all people, everywhere’ [respondent no 8]. however, some respondents are of the view that acute outbreak of infectious diseases such as sars and h1n1, threaten the citizens and security of the country. as a result, there is a need to establish effective cross border disease control and management, as indicated below: ‘the world we live in has become highly permeable and an attack on one nation has got a ripple effect in term of other nations. this was evident during the h1n1 influenza outbreak’ [respondent no 26]. socio-economic development and equality most of the respondents have argued strongly that trade and commerce should not lead to reduction of the fundamental rights to health and dignity, as indicated below: ‘the issue of trade and socio-economic interest should not be at the centre stage undermining people’s rights to health and dignity’ [respondent no 26]. some of the responses from state policy actors clearly indicate tensions in the trade-andhealth relationships due to conflict between economic interests and global health goals, as indicated below: ‘again, although this is a realistic and driving force for many countries’ foreign policy, it would be better if this was discounted, but that would be regarded as naïve’ [respondent 20]. development, equality and solidarity most respondents have argued that south africa’s engagements in global health should lead to the advancement of developmental health agenda and equality, located within african solidarity, as indicated below: ‘sa in line with its foreign policy has always prioritized development and equality, such as making spaces available for training of students from sadc, assist other countries such as drc, rwanda during humanitarian situation’ [respondent no 28]. furthermore, most respondents are of the view that south africa should strengthen its international cooperation and developmental assistance, and also address issues of poverty and underdevelopment, as indicated below: ‘consolidation of the african agenda is key to the rsa’ foreign policy. to this end, the goal of this priority is for the continent to be able to resolve conflicts and building of an environment in which socio-economic development can flourish’ [respondent no 3]. rights-based structural cooperation most respondents argued that south africa’s engagements in global health should be framed within human rights, morality and democratic principles, as indicated below: ‘(sa) constitution, align with it. regional perspective in terms of our moral and human right standing in the africa continent’ [respondent no 23]. the review of the available published literature highlighted the need for south africa to use its role of peace making and institutions building in africa, as part of its continent’s renewal and advancement of interest of the developing countries (11). the literature also revealed that south africa should use its moral power, its own struggle for democracy, commitment to promoting human rights, and multilateral focus, to leverage its own sovereignty and that of weaker states, especially in the areas of access to medicines and migration of health modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 10 professionals (12). many authors argue that south africa needs a stronger and focused foreign and global health policies (12,13). this focused global health policy can include the identification of strategic global health priorities, greater institutional co-operation with agencies dealing with health and foreign policy; and the need for south africa to develop a stronger leadership role in the african continent on global health. strategies and approaches used to advance global health the responses are shown in table 3. of the respondents, majority 82.8% (n=29) agreed that south africa build coalition with other countries. table 3. strategies, approaches and domestic factors used to advance global health variable number percentage coalitions with other countries: strongly disagree disagree not sure agree strongly agree 0 3 3 13 16 8.6 8.6 37.1 45.7 capacity building for actors or negotiators: strongly disagree disagree not sure agree strongly agree 11 12 11 1 0 31.4 34.3 31.4 2.8 role of other ministries: strongly disagree disagree not sure agree strongly agree 0 0 5 13 17 14.3 37.1 48.6 role of academia and private sector: strongly disagree disagree not sure agree strongly agree 0 0 2 15 18 5.7 42.9 51.4 role of civil society: strongly disagree disagree not sure agree strongly agree 1 2 1 14 17 2.9 5.7 2.8 40.0 48.6 domestic factors: strongly disagree disagree not sure agree 1 1 9 10 2.9 2.9 25.7 28.6 modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 11 strongly agree 14 40.0 however, 65.7% (n=23) said that there is no national programme for capacity building for south african actors or negotiators on global health issues. of the respondents, 85.7% (n=30) agreed that other ministries have a role to play in addressing global health challenges. of the respondents, 94.3% (n=33) agreed that academia and private sector have a role to play in addressing global health challenges. of the respondents, 88.6% (n=31) agreed that civil society have a role to play in addressing global health challenges. to complement the quantitative results shown above, the qualitative analysis of narratives from the semi-structured questionnaires and available literature regarding strategies and approaches used to advance south africa’s involvement in global health, post 1994, resulted in the following categories: whole-government approach most respondents argued that south africa’s engagement in global health should include consistency of purpose across all government sectors, as indicated below: ‘health needs a “whole government approach”. this is very well illustrated with regards to ncds, where we need changes in eating, behavior, physical activity, etc. we cannot achieve this without changing pricing of health, foods, involvement of schools, sport, transport, etc.’ [respondent no 14]. role of non-state actors most respondents argued that south africa’s engagements in global health should use the soft power of non-state actors such as civil society, academia and private sector as a global health policy instrument, as indicated below: ‘… for example the ncd alliance played a prominent role in advocating for the unea political declaration on ncds and gave perspectives of users and experts, which was critical to the final declaration’ [respondent no 14]. african regionalism most respondents argued that south africa’s engagements in global health should be framed within africa’s socio-economic development agenda, as indicated below: ‘consolidation of the african agenda is key to the rsa’ foreign policy. to this end, the goal of this priority is for the continent to be able to resolve conflicts and building of an environment in which socio-economic development can flourish’ [respondent 3]. south-south cooperation most respondents argued that south africa’s engagements in global health should aim at advancing development socio-economic development within the developing world, as indicated below: ‘ … ibsa promotes south-south cooperation and build consensus on issues of increasingly trade opportunities amongst the three countries as well as exchange of information, technology and skills to complement each other’s strengths’ [respondent 3]. the review of the available literature highlighted that non-state actors, including civil society, universities and other academic institutions, as well as private cooperation, have contributed to the advancement of global health goals (11,12). for example, south african health activists community like treatment action campaign (tac) and cosatu, in consultation with transnational activism networks in the global south, have advocated for a broader access to affordable medicines, especially arvs. furthermore, the country was successful in modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 12 building strategic alliances with countries such as brazil, during negotiations of 2001 doha declaration on the agreement on trade related aspects of intellectual property rights (trips). modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 13 domestic factors affecting south africa’s involvement in global health the responses are shown in table 3. of the respondents, majority 68.6% (n=24) agreed that south africa’s newly assertive foreign policy and global health remains constrained by its domestic challenges. furthermore, 65.7% (n=23) indicated that south africa has no capacity building programme for its actors or negotiators. the qualitative analysis of narratives from the semi-structured questionnaires and the available literature regarding domestic factors affecting south africa’s involvement in global health, post 1994, resulted in the following categories:  high disease burden: most respondents argued that south africa’s engagements in global health should be framed within south africa disease burden or challenges, as indicated below: ‘rsa is faced with quadruple diseases that impact immensely on the economy and this is compounded by the hr scarce to meet the health needs of the people’ [respondent no 6].  political leadership: most respondents argued that south africa’s engagements in global health are shaped by the leadership that was provided recently, especially in the area of hiv and aids and recently in non-communicable diseases, as indicated below: ‘hct (hiv/aids counseling and treatment) campaign initiated by the minister of health has drawn interest globally and regionally and has had a positive influence in the global agenda’ [respondent no 8]. ‘in the past decade sa has taken a particular leadership role in hiv and aids, mdgs and now recently in ncds. also in tobacco framework and now alcohol related harm’ [respondent 14].  moderate resources: most respondents argued that south africa’s engagements in global health have been shaped by its moderate resources, especially its scientific skills, r&d and private sector, as indicated below: ‘our technical and expert knowledge will be our entry into new market in africa, south americas and asia. with expansion in develop countries to assist with global financial crises’ [respondent 30].  capacity of negotiators: most respondents indicated that there is no health diplomacy training programme for actors or negotiators, as indicated below: ‘available programmes are not specific for health, but assist in orientating health actors, like the orientation programme for ambassadors by dirco’ [respondent no 11]. the review of the literature clearly indicated that despite south africa’s increasing participation in global health discourse, it is facing several constraints in implementing its global health initiatives. these constraints are found in south africa’s socio-economic challenges and institutional capacity (13). the country faces challenges of high unemployment, poverty and inequality. on health, the country face quadruple burden of diseases, due to hiv and aids and tb, an increasing burden of chronic diseases, high rates of interpersonal violence and injuries (14). this has limited south africa’s scope and influence of its global health assistance programme. that said, literature has also highlighted that south africa has had broad influence and has provided leadership on global health, especially in terms of clinical research, advocacy and policy (15). the literature also indicated that south africa’s weak institutional capacity of its negotiators is another major challenge to its ability to deliver a robust global health policy befitting its modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 14 newly enhanced global standing. nonetheless, south african actors or key negotiators have played significant role in major negotiations, such as during negotiations of trips agreement, who fctc tobacco control and who code for ethical recruitment of health professionals. during these negotiations, south africa has demonstrated its ability to play a leadership role in the south, as a facilitator and a bridge-builder between north and south. policy issue(s) to be advanced in global health  access to medicine agenda: most respondents argued that south africa’s success in global health diplomacy has been achieved within access to medicines control, especially in ensuring availability arvs to all, as indicated below: ‘sa realizes that it will not be able to provide medical care to all unless it assists in bringing prices of medicine down. it therefore collaborate(s) with other countries and strategizes how best this can be done’ [respondent no 14].  hiv/aids: most respondents argued that south africa’s success in global health diplomacy has been achieved within area of hiv and aids, as indicated below: ‘without sa’s interventions on issues such as hiv, the world would not have moved to where it currently is’ [respondent 14].  tobacco control: most respondents argued that south africa’s success in global health diplomacy has also been achieved within the who’s fctc, as indicated below: ‘fctc is a(n) excellent example where we were proactive & prepared & followed through with active … actions & perseverance & purpose!’ [respondent no 20]. ‘sa was one of the first few countries to ratify the who fctc’ [respondent no 8]. the literature review highlighted that, given that nearly six million south african are hivpositive, the country can take up the global leadership on hiv and aids (11). the notion of niche or focused diplomacy brings the identification of ‘transnational issue networks’ that can be used to advocate for improved health outcomes (12). in addition, south africa need to use its bridge-builder and facilitation ability, to explore closer multilateral ties with brazil (via ibsa) to seek to advancement of a shared health goals (11,12,16). discussion findings from the current study reveal that south africa’s participation in global health discourse is limited by its domestic health challenges. the findings confirm other studies in that south africa is faced with challenges of epidemics such as hiv/aids and tb, an increasing burden of chronic diseases including obesity, and high rates of interpersonal violence and injuries (11). behind these epidemics, there is the continuing mortality of mothers, babies and children, which still primarily affects the poorest families. hence, the findings of the study are in line with results of other studies which have demonstrated that south africa has understandably chosen to prioritize domestic health over global health (11). the findings of this study are also in line with other studies in that south africa should use a human rights framework to position its approach to health diplomacy (11,12). south african government has used its human rights emphasis to champion for increase access to antiretroviral drugs in order to provide universal treatment to all hiv-positive people. however, studies have also revealed that south africa has experienced a palpable tension between the politics of solidarity and sovereignty on the one hand and human rights on the other, as evidenced in its voting patterns on zimbabwe to libya in the un security council and aids denialism (17). modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 15 this study, consistent with other studies, confirms that overemphasis on health security overshadow the opportunity to use health as a constructive and novel perspective to shape international, transnational and global action (17,18). the findings support other studies in that the governance of health threats should be about the search for equity, justice and well being, other than the current perspective of protection of international commerce from a freeriding epidemics (11,19). the findings of this study are also consistent with other studies in that some state policy actors still tend to focus on “high politics” of health issues, rather than on “low politics” in which health issues are seen as a reflection of human dignity (11,19). the findings of this study are consistent with many other studies that have argued that south africa should explicitly pursue issues of poverty and equality within its global health agendas and debates (11,19). furthermore, studies have highlighted that south africa’s attention on global health diplomacy should focus on global trade, as ‘trade and health linkage highlights the new prominence of health within foreign policy’ (20). the findings of this study are consistent with other studies and reports that have reported that south africa does allocate limited resources to health assistance through multilateral agencies, bilateral channels and other south-south partnerships (15,21). the findings suggest that south africa can play a more transformative role, through providing focused technical assistance for health projects, supplying medical goods and services to very poor countries in its immediate geographic neighborhood. for example, south africa has provided funding to seychelles for infrastructure rehabilitation and republic of guinea to boost rice production (21). the findings of this study are consistent with other studies in that the contribution of nonstate actors, including civil society, universities and other academic institutions, as well as private cooperation, is an important development in the advancement of global health goals (11,15). for example, south african health activists community like treatment action campaign (tac), in consultation with transnational activism networks in the global south, have advocated for broader access to affordable arvs and health care services in south africa and developing countries.15 this study is consistent with other studies, in that south africa as an emerging middle income country, should prioritize its global health efforts (17). south africa should avoid using rhetoric or ineffectual diplomacy, and try to be all and do all for everyone. for example, brazil used focused diplomacy in areas of antiretroviral drugs, using health rights framework, while cuba and china used medical diplomacy to achieve their foreign policy goals (22,23). therefore, given the current burden of diseases, south africa can use its hiv and aids diplomacy as a project of emancipating and transformation, rather than an affirmation of the world as it is (15). lastly, this study found that there is no formal training programme for actors and diplomats on global health diplomacy in south africa. other studies have also indicated the need for the development of a training programme on global health diplomacy (24,25). all these studies have clearly indicated that for health to be a sustainable lens for foreign policy thinking and agenda setting, it must be mainstreamed into the training of diplomats and health officials. this finding therefore highlights the need for south africa to take a lead in training of diplomats and health officials within the country and in the africa region. conclusion this study has showed that south africa has a limited engagement in global health diplomacy. south africa is still inward focused, and that its domestic challenges (such as especially the burden of hiv/aids and tb) will drive its engagement internationally. modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 16 furthermore, due to its domestic challenges, south africa has not taken a regional leadership role in global health diplomacy. south africa’s economic diplomacy can presents a potential entry point for engagements in global health diplomacy. non-state actors might also push the government to be more actively engage in global health diplomacy. it is therefore south africa’s approach to hiv/aids and tobacco control which might position it for engagement and a leadership role internationally. therefore, in order to take its rightful leadership role, south africa need to develop a focused global health strategy and take a lead in the training of diplomats and health officials within the country and for the africa region. references 1. kickbusch i. global health diplomacy: how foreign policy can influence health. british medical journal 2011;342:d3154. doi: 10.1136/bmj.d3154. 2. chan m, gahr s, kouchner b. editorial: foreign policy and global public health: working together towards common goals. bulletin of the world health organization 2008;86:498. 3. lee k, smith r. what is ‘global health diplomacy’? a conceptual review. glob health gov 2011;1:1-12. 4. feldbaum h, michaud j. health diplomacy and enduring relevance of foreign policy interests. plos medicine 2010;7:1-6. 5. frenk j, moon s. governance challenges in global health. n engl j med 2013;368:936-42. 6. labonte r, gagnon ml. framing health and foreign policy: lessons for global health diplomacy. global health 2010;6:14. 7. greswell jw. research design: qualitative and quantitative approaches. thousand oaks, ca: sage; 1995. 8. kvale s. interviews: an introduction to qualitative research interviewing. london: sage; 1996. 9. liamputton p. qualitative data analysis: conceptual and practical considerations. health promot j austr 2009;20:133-9. 10. lee k, chagas l, novotny t. brazil and the framework convention on tobacco control: global health diplomacy as soft power. plos medicine 2010;7:e1000232. doi:10.1371/journal.pmed.1000232. 11. fourie p. turning the dread into capital. south africa’s aids diplomacy. center for strategic and international studies. washington, dc; 2012. 12. landsberg c, monyae d. south africa’s foreign policy: carving a global niche. south african journal of international affairs 2006;13:131-45. 13. south african government. national development plan: 2030. http://www.poa.gov.za/news/documents/npc%20development%20plan%20vision %202030%20-lo-res.pdf (accessed august 13, 2016). 14. chorpa m, lawn je, sanders d, et al. achieving the health millennium development goals for south africa: challenges and priorities. lancet 2009;374:1023-31. 15. global health strategies initiatives (ghsi). how the brics are reshaping global health and development, ghsi; 2012. 16. alden c, vieira ma. the new diplomacy of the south: south africa, brazil, india and trilateralism. third world quarterly 2005;26:1077-95. 17. loewenson r, modisenyane m, pearcey m. concepts in and perspectives on global health diplomacy. interim working paper. equinet discussion paper 96; 2013. javascript:void(0); javascript:void(0); modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 17 18. bond k. commentary: health security or health diplomacy? motivation beyond semantic analysis to strengthen health systems and global cooperation. health policy plan 2008;23:376-8. doi: 10.1093/heapol/czn031. 19. amorim c, douste-blazy p, wirayuda h, et al. oslo ministerial declaration-global health: a pressing foreign policy issue of our time. lancet 2007;2:1-6. 20. drager n, fidler dp. foreign policy, trade and health: at the cutting edge of global health diplomacy. bull world health organ 2007;85:162. 21. south africa. department of international relations and cooperation. report on the african renaissance and international cooperation fund 2009/10. http://www.dirco.gov.za/department/report_2009-2010/annualreportarf2009-2010.pdf (accessed august 13, 2016). 22. nunn a, da fonsecab e, gruskind s. changing global essential medicines norms to improve access to aids treatment: lessons from brazil. glob public health 2009;4:131-49. doi: 10.1080/17441690802684067 23. wang k. the experience of chinese physicians in the national health diplomacy programme deployed to sudan. glob public health 2011;7:196-211. 24. kickbusch i, siberschmidt g, buss p. global health diplomacy: the need for new perspectives, strategic approaches and skills in global health. bull world health organ 2007;85:857-61. 25. kickbusch i, novotny te, drager n, silberschmidt g, alcazar s. global health diplomacy: training across disciplines. bull world health organ 2007;85:971-3. __________________________________________________________ © 2016 modisenyane et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed/?term=silberschmidt%20g%5bauthor%5d&cauthor=true&cauthor_uid=18278266 http://www.ncbi.nlm.nih.gov/pubmed/?term=alcazar%20s%5bauthor%5d&cauthor=true&cauthor_uid=18278266 kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-135 1 short report protecting the planet and sustainable development laura h. kahn1 1program on science and global security, woodrow wilson school of public and international affairs, princeton university, new jersey, usa. corresponding author: laura h. kahn, md, mph, mpp, woodrow wilson school of public and international affairs, princeton university; address: 221 nassau street, 2nd floor, princeton, new jersey 08542, usa; telephone: 609 258 6763; email: lkahn@princeton.edu mailto:lkahn@princeton.edu� kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-135 2 abstract the united nations has made a commitment for sustainable development. an important component of this is a healthy environment. but what exactly is a healthy environment? environmental health specialists typically focus on occupational exposures in workers; the field mainly addresses the abiotic (i.e. non-living) aspects of environments. ecosystem health addresses biotic (i.e. living) aspects of environments. merging these two realms is essential for sustainable development but will be challenging because the fields are so different. the united nations, individual countries, and schools of public health could do much to help merge these realms by implementing environmental/ecosystem health into their missions and curriculums. keywords: ecosystem, healthy environment, planet, sustainable development. conflicts of interest: none. kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-135 3 expanding the definition of environmental health the definition of environmental health must be expanded. the twenty-first century presents many challenges to global health. a growing human population, estimated to reach approximately 9 billion by 2050 if estimated growth rates continue, will require food, water, and other natural resources to survive. meeting humanity’s demands for natural resources threatens the environment including worsening deforestation, land degradation and contamination, water contamination, diminishing biodiversity, and spreading vector-borne and other zoonotic diseases. a warming climate with extreme weather conditions including drought and floods threatens agriculture and food security, the foundation of civilization. in the midst of all of these developments, a healthy environment seems almost impossible. but, the need for a healthy environment is imperative for life to continue, and the need to educate the next generation on the importance of sustainable development in a habitable world is essential (1,2). the question is:“what exactly is a healthy environment and how should it be defined?” the national environmental health association (neha) defines environmental health as “the science and practice of preventing human injury and illness and promoting well-being by identifying and evaluating environmental sources and hazardous agents and limiting exposures to hazardous physical, chemical, and biological agents in air, water, soil, food and other environmental media or settings that may adversely affect human health”(3). this definition focuses primarily on the hazards that affect humans. from a one health perspective, however, it leaves out animals and the environment, itself. one health is the concept that human, animal, and environmental health are linked, and because they are linked, complex subjects such as emerging diseases, food safety and security, antimicrobial resistance, and waterborne illnesses must be examined and addressed in an interdisciplinary, holistic way. the term is relatively new, but the concept is ancient. nevertheless, environmental health has been difficult to integrate into one health for a variety of reasons. first, those who work on environmental health, such as occupational and environmental physicians, nurses, and environmental health specialists, focus their work primarily on abiotic (i.e. non-living) contaminants, pesticides, and toxic waste exposures in occupational settings that affect workers. while this is extremely important, it is not the only aspect of what constitutes a healthy environment. ecosystem health focuses on the biotic (i.e. living) components of an environment and their interactions. many scientists and other professionals from a variety of academic disciplines work on ecosystem health such as wildlife veterinarians, biologists, geologists, ecologists, plant pathologists and others. they study the web of life, complex interactions between many interconnecting systems. man-made alterations to entire ecosystems have many consequences, both intentional and unintentional, potentially harming the health of current and future generations (4). environmental/ecosystem health would address the inter-action between the biotic (i.e. living) and abiotic components of environments and ecosystems. unchecked development, including the destruction of ecosystems for agricultural or other purposes, potentially jeopardizes the health of regions, including the health of animals and humans. the challenge is integrating both the environmental and ecosystem health realms into a unified field that incorporates the one health paradigm. a new inclusive term should be developed to reflect the expanded mandate. efforts are underway to establish new integrated environmental/ecosystem health fields. one is called “planetary health” (5). advocates for planetary health seek to educate a new cadre of individuals (6). the challenge with this strategy is that it focuses primarily on humans and the kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-134 environment, minimizing the importance of animal health and zoonotic diseases. also, planetary health is a broad, general term; it’s not entirely clear what exactly its practitioners would do, or who would hire them. one health recognizes the vast breadth of knowledge and skills needed for human, animal, and environmental/ecosystem health and seeks to increase communication and collaboration between medical, veterinary medical, and public health professionals and scientists to achieve these goals. a global international body and environmental protection a global, coordinating international body must be in charge of environmental monitoring and protection. currently, there is no united nations environmental protection organization, but there is an environment programme that was established in 1972 with the mission to promote wise use of the environment and assess global trends (7). for the fiscal year 2014-2015, its total planned budget, from voluntary contributions from member states, was approximately $619 million, which was a 134 percent increase from the previous fiscal year(8). to put this budget into perspective, the world health organization’s budget for 2014-2015 was almost $4 billion (9) (who has an environmental health section that addresses sanitation and water and air pollution but not necessarily ecosystems). the 2014-2015 budget for the food and agriculture organization (fao) was approximately $2 billion (10). fao focuses primarily on food safety and security. in contrast, the 2014-2015 budget for the world organization for animal health (oie) was €22 million (approximately $17.2 million in 2014 usd) (11,12). the oie’s mission is to ensure healthy food animals for food safety. vast disparities in international funding between human, animal, and environmental health makes implementing a global one health strategy extremely difficult, if not impossible. if world leaders were serious about protecting the environment/ecosystems of the planet, they should consider establishing a world environment/ecosystem protection organization with a mandate to examine and address environmental/ecosystem alterations and their resulting outcomes; the organization should have a budget at least comparable to the fao, and it should have enough power to influence nations to act in the best interest of humanity to ensure planetary habitability and survival. countries’ commitments countries must make commitments to study and protect their environments/ecosystems. analogous to the international level, many nations such as the u.s., allocate little for analyzing, managing, and protecting their environments/ecosystems. in the u.s., responsibilities for environmental/ecosystem health are split between government agencies, which can dilute the overall effectiveness of efforts. the u.s. department of the interior oversees the u.s. fish and wildlife service, which has the responsibility to manage biological resources and enforce laws like the marine mammal protection act and the endangered species act (13). in the fiscal year 2012, its budget was $1.48 billion, a two percent decrease from the previous year (14). the environmental protection agency (epa), established in 1970 because of public concern about environmental pollution, conducts monitoring, standard-setting, research, and enforcement activities to protect the public from environmental contaminants, toxic wastes, and other health hazards (15). in the fiscal year 2015, its budget was $7.89 billion, a 4 percent decrease from the fiscal year 2014 (16). president donald trump has vowed to eviscerate, and possibly eliminate, the epa (17). the us geological survey, under the aegis of the department of the interior, was created in 1879 to provide scientific information to understand the earth and to manage the nation’s water, biological, energy, and mineral resources in order to protect life (18). the usgs 4 kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-134 5 monitors, collects, and analyzes data concerning natural resources. they provide scientific information to policy makers, planners, and others (18). in the fiscal year 2012, the u.s. fish and wildlife service’s budget was approximately $ 1.48 billion, an approximate 2 percent decrease from the previous year (19). these entities do work together, but funding is tight, and efforts might not necessarily be coordinated. the trump administration and the republican-controlled congress threaten to undo many of the conservation and environmental/ecosystem protection efforts over the past sixty years (20). the role of schools of public health schools of public health should offer interdisciplinary courses in conjunction with geological sciences and agriculture and forestry on environmental and ecosystem health, sustainable agriculture and biodiversity, food safety and security, water management and others. schools of public health traditionally teach subjects such as biostatistics, epidemiology, health policy and management, socio-medical sciences, population and family health, and environmental health. environmental health concentrates primarily on reducing carcinogens, toxic waste exposures, and other harmful chemicals. however, the health threats we face in the 21st century extend well beyond traditional public health subject areas. massive waste production from megacities and large animal production facilities threatens water and land quality as run-off from sludge seeps into soils and groundwater. sanitation and hygiene will become one of the most important fields of public health, particularly in an era of worsening antimicrobial resistance. preventing disease by lowering microbial burdens must be a global priority. contaminated land and water contributes to food and water-borne illnesses. severe droughts, floods, and unpredictable weather threaten food security as well as food safety. arthropod-borne diseases are spreading, and will continue to do so with on-going deforestation, upending delicate ecosystems. the curricula of schools of public health need to change to meet the challenges of the 21st century. much more emphasis should be given to emerging zoonotic diseases, entomology, parasitology, virology, and bacteriology. food safety and security should to be taught along with sanitation and hygiene, environmental and ecosystem health, climate and health. one health policy should be taught to examine the intersection between public health, agriculture, and environmental/ecosystem health. the importance of agriculture is rarely discussed outside of agriculture and animal husbandry courses. this must change. with worsening climate change, agriculture will be threatened in unprecedented ways. food security and its impact on civil society will be an increasingly important subject in the decades ahead. one health education should be team-based (analogous to business schools) and should be focused on researching and analyzing national and international government infrastructures relevant to human, animal, and environmental health. most health policy courses focus on healthcare delivery such as in hospitals and clinics. health insurance coverage is another common area of study. but, policy education must be expanded to examine the larger issues such as biodefense, food safety and security, and disaster preparedness. the world needs creative thinkers and problem solves who can conduct fieldwork projects at local, regional, national, and international levels to improve global one health. conclusion in conclusion, environmental/ecosystem health must be better defined to meet the challenges of the 21st century. expanding human populations, deforestation, land degradation, water contamination, massive human and animal manure production, crumbling sanitation kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-134 6 infrastructures, the growth of megacities, diminishing biodiversity, food safety and security, agriculture and animal husbandry, emerging zoonotic diseases are all tied together and adversely impact the world’s environments/ecosystems, and ultimately, global health. these subjects must be examined and taught using an integrated one health framework to adequately understand and address them. united nations member states have already made a commitment for sustainable development. at a united nations sustainable development summit meeting in september 2015, world leaders adopted 17 sustainable development goals for the 2030 agenda for sustainable development. world leaders recognize the importance of setting goals for leaving future generations a habitable planet. expanding the definition of environmental health to include ecosystems and integrating it into a holistic, interdisciplinary one health framework would be an important first step forward. references 1. laaser u, lueddeke g, nurse j. launch of the ‘one health global think-tank for sustainable health & well-being’—2030 (ghw-2030). seejph 2016, vol. 6. doi 10.4119/unibi/seejph-2016-114. 2. lueddeke g, kaufman g, kahn l, krecek r, willingham a, stroud c, lindenmayer j, kaplan b, conti l, monath t, woodall j. preparing society to create the world we need through ‘one health’ education. seejph 2016, vol. 6. doi 10.4119/unibi/seejph-2016-122. 3. national environmental health association. about neha. definitions of environmental health. http://www.neha.org/about-neha/definitions-environmental health (accessed: december 7, 2016). 4. myers ss, gaffikin l, golden cd, et al. human health impacts of ecosystem alteration. pnas 2013;110: 18753-60. http://www.pnas.org/content/110/47/18753.full. 5. horton r, lo s. planetary health: a new science for exceptional action. the lancet 2015;386:1921-2. 6. planetary health alliance. why a planetary health alliance? http://planetaryhealthalliance.org/why-planetary-health-alliance (accessed: december 12, 2016). 7. united nations environmental programme. about. http://web.unep.org/about/ (accessed: december 12, 2016). 8. united nations environmental programme annual report. https://wedocs.unep.org/bitstream/handle/20.500.11822/7544/ unep_2015_annual_report-2016unep-annualreport-2015 en.pdf.pdf?sequence=8&isallowed=y (pages 56-7) (accessed: december 12, 2016). 9. world health organization. about. resources. http://www.who.int/about/resources_planning/a66_r2_en.pdf (accessed: december 14, 2016). 10. un food and agriculture organization. conference. fao 2014 audited accounts. http://www.fao.org/3/a-mo335e.pdf (page 7) (accessed: december 14, 2016). 11. world organization for animal health. http://www.oie.int/fileadmin/vademecum/pdf/rapport%20annuel/en_annualr eport_2014_lr.pdf (page 9) (accessed: december 14, 2016). 12. u.s. internal revenue service. yearly average currency exchange rates. https://www.irs.gov/individuals/international-taxpayers/yearly-average-currency exchange-rates (1 euro equals 0.784 dollars) (accessed: december 14, 2016). http://www.neha.org/about-neha/definitions-environmental-� http://www.pnas.org/content/110/47/18753.full� http://planetaryhealthalliance.org/why-planetary-health-alliance� http://web.unep.org/about/� http://www.who.int/about/resources_planning/a66_r2_en.pdf� http://www.fao.org/3/a-mo335e.pdf� http://www.oie.int/fileadmin/vademecum/pdf/rapport%20annuel/en_annualr� http://www.irs.gov/individuals/international-taxpayers/yearly-average-currency-� kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-134 7 13. u.s. department of the interior. fish and wildlife service. about the u.s. fish and wildlife service. https://www.fws.gov/help/about_us.html (accessed: december 15, 2016). 14. u.s. fish and wildlife service fy 2013 budget justification. https://www.fws.gov/budget/2013/pdf%20files%20fy%202013%20greenbook/3. %20budget%20at%20a%20glance.pdf (accessed: december 15, 2016). 15. u.s. environmental protection agency. epa history. https://www.epa.gov/history (accessed: december 15, 2016). 16. u.s. environmental protection agency. fy 2015. a budget in brief. https://www.epa.gov/sites/production/files/2014-03/documents/fy15_bib.pdf (accessed: december 19, 2016). 17. fountain h. “trump’s climate contrarian: myron ebell takes on the e.p.a.” new york times. nov. 11, 2016 (http://www.nytimes.com/2016/11/12/science/myron ebell-trump-epa.html) (accessed: december 19, 2016). 18. u.s. geological survey. who we are. https://www.usgs.gov/about/about-us/who-we are (accessed: december 19, 2016). 19. u.s. department of the interior. fish and wildlife service. budget at a glance. https://www.fws.gov/budget/2013/pdf%20files%20fy%202013%20greenbook/3. %20budget%20at%20a%20glance.pdf (accessed: december 19, 2016). 20. harvey c. these are the two environmental rules the republican congress is trying to kill first. washington post. january 17, 2017 https://www.washingtonpost.com/news/energy-environment/wp/2017/01/17/these are-the-two-environmental-rules-the-republican-congress-is-trying-to-kill first/?utm_term=.1f64715c54af (accessed: february 2, 2017). © 2017kahn; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.fws.gov/help/about_us.html� http://www.fws.gov/budget/2013/pdf%20files%20fy%202013%20greenbook/3� http://www.epa.gov/history� http://www.epa.gov/sites/production/files/2014-03/documents/fy15_bib.pdf� http://www.nytimes.com/2016/11/12/science/myron-� http://www.usgs.gov/about/about-us/who-we-� http://www.fws.gov/budget/2013/pdf%20files%20fy%202013%20greenbook/3� http://www.washingtonpost.com/news/energy-environment/wp/2017/01/17/these-� http://creativecommons.org/licenses/by/3.0)� short report laura h. kahn1 abstract conflicts of interest: none. a global international body and environmental protection countries’ commitments the role of schools of public health conclusion references adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 1 | p a g e c original research pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3-year post implementation evaluation david ayobami adewole1, temitope ilori2, wuraola ladepo1, olusola augustus akande3, ganiyu owolabi3 1 department of health policy and management, college of medicine, university of ibadan, nigeria; 2 family medicine unit, department of community medicine, college of medicine, university of ibadan, nigeria; 3 oyo state health insurance agency, ministry of health, secretariat, ibadan, nigeria. corresponding author: david ayobami adewole; address: department of health policy and management, college of medicine, university of ibadan, nigeria; telephone: +234 8034052838; email: ayodadewole@yahoo.com mailto:ayodadewole@yahoo.com adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 2 | p a g e abstract aims: social health insurance scheme is capable of minimizing inequity of access to health services, and thereby enhance an improvement in population health outcomes. recently the national health insurance scheme (nhis) of nigeria decentralized its management to the subnational levels, thus the emergence of state health insurance schemes (shis). the shis of oyo state nigeria started operations about three years ago (june 2017). there is limited/sparse evidence on the performance of the scheme since its inception. therefore, the aim of this study was to assess the scheme’s level of population coverage in the first three years of implementation. the findings will also provide an evidence base to inform the repositioning of the scheme for improved performance and enable it achieve the purpose of its establishment. methods: service data from the server of oyo shis were downloaded, collated and analyzed with excel software. data extraction, cleaning and analysis covered a period of three months (september – october, 2020). descriptive statistics were used to summarise the data. population coverage distributions were expressed as frequency and percentages. frequency tables and graphs were generated to disaggregate the findings. results: since inception, the population coverage of the scheme has remained low at less than 1% of the total population of the state over the past three years. this trend is depicted across the various sociodemographic sections of the population. conclusion: stakeholders in the oyo state shis need to re-strategize to reposition the scheme for an accelerated population coverage as a proxy for performance assessment. keywords: beneficiaries, coverage, national health insurance scheme, oyo state, population coverage, state supported social health insurance programme. acknowledgements: authors wish to acknowledge oyo state health insurance agency for the permission to make use of the data and to submit the manuscript for publication. we authors would like to sincerely acknowledge the contributions of prof. charles wiysonge and that of dr. chukwudi nnaji for the comprehensive review and suggestions made on this manuscript. many thanks. authors' contributions: david adewole conceived and designed the study. wuraola ladepo and temitope ilori did data collection and analysis. adewole, owolabi and akande contributed equally to the manuscript write up. all authors read through the manuscript draft the second time. all authors agreed to the final manuscript. conflict of interests: none declared. adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 3 | p a g e introduction different countries the world over had attained universal health coverage (uhc) within different time duration (1). while it has taken countries like germany and some other western european countries about a century to achieve uhc, some other countries in recent times especially in the asian blocks have done tremendously achieving same within a period of a few decades (1,2). encouraging reports about the speed of achieving uhc were also documented in many latin american countries especially brazil, costa rica, cuba, and argentina among others (3). similar achievements have been reported in some african countries like rwanda (4-6) and ghana (4,7). for reasons of equity of access to available health care services and to accelerate the achievement of uhc, some countries in africa, asia and latin america have made significant strides towards achieving uhc. these countries have engaged all levels of health care delivery especially the primary health care level facilities as service providers in their health system reforms especially the social health insurance schemes (3). challenges with social health insurance schemes in many of the ssa countries include poverty, low level of awareness, superstitious belief, poor technical skills of the personnel in the industry (8), and inability to differentiate it from other pre-existing microfinance schemes among others (9). uptake of health insurance have been found to be more likely among those who are more likely to need health care services more such as married individuals, the elderly and those with chronic illnesses (10). the poor population health indices common in developing countries is majorly as a result of inequity of access to available health care (11-13). however, when it is efficiently managed, social health insurance scheme is capable of minimizing inequity of access to health services, and thereby enhance an improvement in population health outcomes (3,4,8,14). following almost two decades of efforts to achieve universal health coverage (uhc) through the national health insurance scheme (nhis) of nigeria (15), and not satisfied with the achievement made by the nhis in terms of population coverage so far, the national council on health (nch) and other stakeholders in the health system of nigeria approved the establishment of the state supported social health insurance programme (sship) in the year 2015. this is a form of decentralization of the nhis to the sub-national governments, that is, the states. it was the belief that this reform will bring about the necessary sense of ownership and commitment to the prepayment system for health among stakeholders in these states and thus enhance a steady progress of the scheme to achieving uhc (16). stakeholders were optimistic that decentralization of prepayment scheme will provide the necessary impetus for the state stakeholders to design a sustainable prepayment scheme. with this, the sub-national levels of government, that is, the 36 states (including the federal capital territory, fct) were empowered to design, implement and manage a form of social health insurance scheme for people in the respective states of the country. statutorily, the nhis provides technical and some level of financial support to the states operating their own sship. findings from a commissioned report on the scheme shows that oyo (state) sship commenced operations in the year 2017, following the recommendation of a planning and design committee whose membership consisted of stakeholders from the state ministry of health, the nhis, private and public health care providers (including pharmacists and laboratory scientists), academics, and the health maintenance organizations. the report further shows that just before the commencement of its operations, a public hearing on it held whereby members of the public and committee on health of the house adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 4 | p a g e of representatives of oyo state held a town hall meeting with the purpose of having contributions from all stakeholders. the meeting aimed to social market and enhance the acceptance of the scheme among potential beneficiaries (17). the sship aimed to achieve uhc through a state-wide implementation strategy partnering with both the public and private health care facilities in all the lgas of the state. the bill that established oyshia was signed into law 2016, however, implementation of the scheme commenced in 2017 (18). generally, with a lower level of awareness (19) and poor financial capacity to pay premiums (8), social health insurance schemes have been reported to favour the rich majorly (20), while the informal sector population tends to be poorly represented (21). there was no comprehensive assessment of the performance of the scheme since inception. the only information about the scheme was a one year post-implementation report. the report only assessed the level of awareness of the populace about the scheme and as well as available service providers (17). prior this study, there was no report on the performance and coverage of the scheme among socio-demographic and geographical divides. this study was conducted as a means of assessing the level of and implementation mechanisms of the scheme. findings will assist in identifying gaps and areas of success. this information will assist in taking appropriate steps where and when necessary to ensure the scheme is kept on track to achieving its objectives. it will also be useful to similar settings making efforts to achieve universal health coverage for their populations. methods study design/area this is a descriptive cross-sectional study. it was carried out in oyo state, one of the 6 states in the southwest geo-political zone of nigeria. the capital of the state is ibadan, a city of about 150km northeast of lagos, the former capital of nigeria. currently, the estimated population of the state is 7.6 million people, with male to female ratio almost of equal proportion. the state has 33 local government areas (lgas), with varying population sizes. typical of developing country, the state has a much larger informal population compared with those in the formal or organized private sector. more of the people lives in the rural areas (22). data collection and analysis with the permission of oyshia, data on monthly enrolment in the state’s health insurance scheme were downloaded from the scheme’s website. the agency’s data bank on enrolees is built as information on new enrolees is collected at registration. this is a continuous process across all designated registration points in the state. data collected are uploaded into the agency’s website as and when due. collected data were analysed to suite the purpose of the study. downloading of data from the website and subsequent analyses were accomplished over a period of three months (may-july, 2020). data were used to plot a graph-displaying pattern of enrolment in the scheme by month over a period 36 months (july 2017 – june 2020) (fig. 1). other relevant charts were produced from the data. a map of oyo state showing all the lgas and the proportion of enrolees in the scheme by lga was also produced. the data were publicly available online. there was no need for ethical approval for this study because secondary data of all enrolees in the health insurance scheme of the state were used. there were no exclusion criteria. results figure 1 below shows the pattern of enrolment in the health insurance scheme over a period of three years since inception (june 2017 – july 2020) with a common pattern of periods of increased enrolment followed by decline in enrolment in the scheme. this pattern is uniform for the three-year period. adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 5 | p a g e figure 1. secular trend of enrolment in oyshi scheme in first 3 years of operation figure 2 (and appendix 1) shows the spatial distribution of the lgas in the state and the proportion of uptake of health insurance against the total population is as displayed in the map. the highest proportion of those who enrolled in the scheme in any of the lgas was found in two lgas (ibadan northwest and lagelu) and were not higher than 2% of the total population in each of these two lgas. in total, less than 1% of the current total population of oyo state was covered, only two lgas, ibarapa north 8 (0.04%) and olorunsogo 71 (0.14%) recorded an increase in the total number of enrolees over the three-year period, while 29,726 (35.0%) of the total population ever registered in the state had dropped out of the scheme. figure 2. geographical pattern of enrolment in oyshi scheme by lga adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 6 | p a g e figure 3 below shows the pattern of enrolment by age group. enrolees in the age group between 20 and 59 years had the highest proportion of those currently registered 55,119 (100%). of this age group, those in the 40-59 years were more, 40,010 (72.6%) compared with those between 20 and 39 years 12,774 (23.2%). individuals who were 80 years and above 25(0.05%) were the least group represented. figure 3. pattern of enrolment in oysh scheme by age group figure 4 below shows that almost twothirds 33,644 (61.0%) of the total currently enrolled individuals were females compared to males 21,475 (38.9%). figure 4. pattern of enrolment in oysh scheme by sex adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 7 | p a g e almost all enrolees reported been married individuals, 51,098 (92.7%) compared with singles who were much less in number 3,960 (7.2%) (appendix ii). in the three-year period of the scheme, 84,845 individuals have ever registered. however, as at the end of the first three years (june 2020), the number of enrolees on the scheme was 55,119. thus, individuals who have dropped out of the scheme was 29,726 (35.0%) (appendix iii). of the total enrolees, individuals from the civil service of oyo state had the highest number 51,585 (93.5%). the least was among the organized private sector, 809 (1.5%) (appendix iv). discussion the state social health insurance scheme having enrolment service points in all the lgas in the state is an encouraging development. however, the population coverage in the last three years has remained extremely low at less than one percent of the total population. the scenario is worsened by a drop out at over one-third of the original enrolment figure. an encouraging development in the scheme is having enrolment centres in all the lgas which have provided equal opportunity for the citizens in the state to enjoy the benefit associated with membership of the scheme. this pattern of start-up is also capable of an accelerated population coverage with the foci of enrolment eventually coalescing with time. it would also avoid the political insinuation that some lgas were better favoured than others which could arise if some lgas were selected as pilot sites. it has also avoided unnecessary schism in existing cooperation needed for growth and development in the state. however, it should be noted that generally, the rate of enrolment in the scheme across the lgas and the state as a whole was quite slow. studies have shown different periods of achieving universal health coverage (uhc) in different countries (1,2). in western european countries such as germany and other developed economies where prepayment schemes for health are well established, it has been reported that attainment of uhc took an average of a century in countries like belgium and germany, (1). however, some other countries especially in latin america such as costa rica and brazil (3) and as well as japan and republic of korea in asia (1) were able to achieve uhc in less than half of a century. it has been reported that the average period to attain between 60-80% population coverage is 9 years post implementation of a social health insurance scheme (2). in this study, and using available data, the rate of population coverage is estimated at 18,373 per year. assuming a static population, it would take more than four centuries to cover the present population of oyo state [7,690,472]. nevertheless, the population will not remain static. this analysis should be a startling reality and for the stakeholders in the state’s health insurance industry as well as actors in relevant other sectors, to re-strategize for the achievement of uhc in reasonably good period. awareness creation, education about the mechanisms of operation of a social health insurance scheme has been found to improve uptake in some other settings (19). other efforts to overcome the common challenges in the uptake of a social health insurance scheme in developing countries of the saa has been suggested (23). however, it is certain that the solution should be a multi-pronged approach. this study shows that the working age population group had the highest representation in the scheme. this may not be farfetched as the scheme is mandatory for civil servants. again, the lower proportion of other age groups who were obviously not likely to be employees of the government would be more of the difficulty to enrol those who are in the informal sector as there was no register for those outside of the formal government employment for reason of retirement or for any other reason. capturing population group in the informal adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 8 | p a g e sector for mandatory health insurance is one of the common challenges faced by prepayment schemes in developing countries (8). it should also be noted that the lower proportion of those in the twenties and late thirties may have to do with the current present prevailing age structure in the civil service of oyo state. however, further studies are necessary to clarify this observation. the same explanation goes for the higher proportion of females than males in the study. individuals who are more likely to need health care services such as married, the elderly, women and those who are chronically ill have been identified to have better disposition to register in a health insurance scheme (10). this may suffice to explain the higher proportion of married people and women in this study. however, the lower proportion of elderly people as against the observed norm could be due to other reasons such as inability to pay premium, lack of an efficient platform to pay premium, poor understanding of the mechanisms of operation of the scheme or lack of awareness of the existence of the scheme. this study could not establish any of the suggested reasons. it would require further research efforts, particularly qualitative studies to clarify. this study also observed that more than one-third of the total number of enrolees have dropped out of the scheme. this should be a cause for concern. factors of disincentive in a health insurance scheme have been linked to what could breach the trust of people such as poor attitude of health care personnel in the facilities, lack of drugs, equipment and personnel and other factors that could cause dissatisfaction in health care (24). none of these factors could be proven in this study because secondary data were used. it is desirable to know for certainty what could have been the reasons for this observation. studies to unravel the cause(s) will go a long way in the efforts to achieving uhc for the scheme. this study attempts to assess the performance of a state health insurance scheme using the extent of population coverage as a proxy. it has chosen to make use of the enrolment pattern across the sectors of the civil service, organized private sector and the informal population group. based on available data on these three sectors, it could, with caution, conclude that the performance of the scheme is generally very low for the following reasons. first, the scheme is compulsory for civil servants, thus the high proportion of this group could not be said to be because of civil servants’ satisfaction with the scheme but rather is more like a compulsion. secondly, informal sector population is known to be the larger sector than any other sector in developing countries (8). therefore, a smaller proportion of the informal sector in the enrolment status under this scheme is a point to the fact of the scheme’s low performance than otherwise. stakeholders in the health insurance industry in oyo state definitely have a big task to make the scheme achieve a uhc in the state. concerted efforts and re-strategizing are needed. limitation/recommendation this study made use of secondary data. therefore, individuals could not be interviewed to enable an in-depth knowledge of the factors that may have contributed to or caused the study findings. this is a call for further studies that will need primary data and involve individual as study participants to enable a more robust assessment of the scheme. in conclusion, this study has shown that the population coverage of the present social health insurance scheme in oyo state is poor and as it is presently, it is not likely to reduce inequity of access to health care. strategies for achieving sustainable uhc in oyo state and in similar other settings in the african region must target specific population groups such as the elderly and those in the informal sector. associated adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 9 | p a g e challenges that serve as barriers with enrolment in prepayment schemes and access to available health services under it should be appropriately and specifically addressed. references 1. carrin g, james c. social health insurance: key factors affecting the transition towards universal coverage. int soc secur rev 2005;58:45-64. 2. carrin g, james c, adelhardt m, doetinchem o, eriki p, hassan m, et al. health financing reform in kenya assessing the social health insurance proposal. s afr med j 2007;97:130-5. 3. atun r, de andrade lo, almeida g, cotlear d, dmytraczenko t, frenz p, et al. health-system reform and universal health coverage in latin america. lancet 2015;385:1230-47. 4. lagomarsino g, garabrant a, adyas a, muga r, otoo n. moving towards universal health coverage: health insurance reforms in nine developing countries in africa and asia. 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health policy 2011;99:193-202. 22. national population commission nigeria. national demographic and health survey 2013. abuja, nigeria; 2013. available from: https://dhsprogram.com/publication s/publication-fr293-dhs-finalreports.cfm (accessed: july 21, 2017). 23. adewole da. understanding the concept of health insurance: an innovative social marketing tool. j public health afr 2018;9:739. 24. carrin g. social health insurance in developing countries: a continuing challenge. int soc secur rev 2002;55:57-69. __________________________________________________________________________________________ https://oyostate.gov.ng/about-oyo-state/ https://oyostate.gov.ng/about-oyo-state/ https://dhsprogram.com/publications/publication-fr293-dhs-final-reports.cfm https://dhsprogram.com/publications/publication-fr293-dhs-final-reports.cfm https://dhsprogram.com/publications/publication-fr293-dhs-final-reports.cfm adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 11 | p a g e appendix 1. pattern of enrolment and drop out in the scheme by lga lga number ever registered in scheme current population coverage projected pop @ 2.7% annual increase % current pop. covered % dropped out of ever registered afijio 856 847 182,150 0.465001 9 (0.011) akinyele 5,855 2,529 291,876 0.866464 3326 (0.56) atiba 1,963 968 231,843 0.417524 995 (0.50) atisbo 737 727 151,532 0.479767 10 (0.014) egbeda 4,470 3,064 390,860 0.783912 1406 (0.31) ibadan north east 3,083 1,105 456,730 0.241937 1978 (0.64) ibadan north 7,839 6,088 424,588 1.433861 1751 (0.22) ibadan north west 10,878 4,663 212,252 2.196917 6215 (0.57) ibadan south east 2,505 369 367,178 0.100496 2136 (0.85) ibadan south west 8,282 5,354 390,109 1.372437 2928 (0.35) ibarapa central 1,889 1,820 142,269 1.279267 69 (0.04) ibarapa east 566 549 161,477 0.339986 17(0.03) ibarapa north 184 192 138,204 0.138925 8(0.04) ido 3,674 1,805 143,432 1.258436 1869 (0.50) irepo 542 467 167,069 0.279525 75 (0.14) iseyin 1,753 1,615 352,243 0.45849 138 (0.08) itesiwaju 478 470 175,545 0.267738 8 (0.02) iwajowa 692 691 141,723 0.487571 1 (0.001) kajola 1,166 1,152 276,328 0.416896 14 (0.01) lagelu 7,313 4,576 204,127 2.241742 2737 (0.37) ogbomoso north 2,876 2,580 274,028 0.94151 296 (0.10) ogbomoso south 3,032 2,571 138,322 1.858706 461 (0.15) ogooluwa 96 69 89,843 0.076801 27 (0.28) olorunsogo 499 570 112,085 0.508543 71(0.14) oluyole 3,503 1,736 280,369 0.619184 1767 (0.5)) onaara 3,606 2,381 365,957 0.650623 1225 (0.33) orelope 902 875 143,318 0.61053 27 (0.02) oriire 51 38 205,884 0.018457 13 (0.25) oyo east 1,148 1,030 171,003 0.602329 118 (0.10) oyo west 2,310 2,251 188,038 1.197098 59 (0.02) saki east 1,549 1,510 150,143 1.005708 39 (0.02) saki west 439 394 376,563 0.104631 45 (0.10) surulere 109 63 193,387 0.032577 46(0.42) total 84845 55119 7,690,472 0.716718 29,726(35.0) total ever registered total currently registered total population oyo state proportion currently of registered in oyo state adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 12 | p a g e appendix ii. pattern of enrolment in oysh scheme by marital status appendix iii. discontinuity with membership of oyshi scheme among enrolees adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 13 | p a g e appendix iv. enrolment pattern in the oyshi scheme by sector "сhallenges(approaches to)forinternational standards application inhealth sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 1 review article approaches to the international standards application in healthcare and public health in different countries vitaliy sarancha1, vadym sulyma2, nenad pros3, ksenija vitale1 1 school of public health “a. stampar”, medical school, university of zagreb, zagreb, croatia; 2 department of traumatology, ivano frankivsk national medical university, ivano – frankivsk, ukraine; 3 quality management department, pastor tva jsc, croatia. corresponding author: vitaliy sarancha, md; address: 4 rockefeller st., zagreb 10000, croatia; email: saranchavi@gmail.com mailto:saranchavi@gmail.com� sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 2 abstract as a result of consequent development, and guided by an increasing demand of different types of the organizations regarding structured management, the system of standardization has been established. the idea behind standardization is adjusting the characteristics of a product, process or a production cycle to make them consistent and in line with the rules regarding what is proper and acceptable. the “standard” is a document that specifies such established set of criteria covering a broad range of topics and applicable to commissioners of health, specialists in primary care, public health staff, and social care providers, as well as the local authorities and service users. health products, ranging from medical devices and health informatics to traditional medicines and unconventional healing tools are all in the focus of standards’ application. different countries have their own quality management traditions based on their history, mentality, socio-economic environment and the local regulations. taking into consideration that community social system organization and the quality of social infrastructure are the main foundations of social relations and future prosperity, here we review the existing standardization environment in the health sector in different countries, both developed and those on a convergence path. we focused on standardization environment in the united states of america, great britain, germany, ukraine, russian federation, croatia and albania. in order to simplify comprehension, we also demonstrate the algorithm of standardization, as well as the opportunities for application of the international standards in healthcare and public health. keywords: healthcare, international standards, public health. conflicts of interest: none. sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 3 introduction first traces of quality development appeared more than four thousand years bc, at the time when commodity barter had been replaced by the development of trade among greek, roman, egyptian, arab and phoenician traders (1). artisans described to their suppliers, by experience, using simple words, what kinds of materials they preferred. this was common practice, since the craftsmen had no tools to measure the composition, strength, chemical or physical characteristics of a given material. industrial revolution contributed to the development of product specification (2). manufacturers began issuing precise descriptions of materials and processing methods in order to ensure that supplies met certain quality criteria (3). thus, producers were obliged to take samples from each batch, which was then subjected to tests determining its elasticity, tensile strength, etc. when the first factories were established, requirements for a higher degree of order, greater focus on precision and monitoring quality control of a product were introduced. evolving through different stages, beginning with the 'division of labour' in the late 1700s until the beginning of the 20th century, the scope of activities from the beginning of a production cycle to the final phase led to the occurrence of the first model-based managerial approach (4). when the demands of tasks became too complex basic managerial principles, such as planning, execution, monitoring, controlling, completion and improvement were implemented (5). therefore, to form a structurally oriented organization, systematic quality control became a necessity. later on, such quality patterns and models became generally accepted and are today known as the standards. in the modern society, social infrastructure quality is the main foundation of social relations and future prosperity, thus the purpose of this article is to review the existing standardization environment in the health sector in different countries, both developed and those on a convergence path; as well as to demonstrate a common algorithm for standardization and the opportunities for the application of international standards in healthcare and public health. definition and different types of standards the idea behind standardization is adjusting the characteristics of a product, process or a production cycle as to make them consistent and in line with the rules regarding what is proper and acceptable. standard is a document that specifies such established set of criteria. more than 21000 international standards covering almost all aspects of human activity, including healthcare, have been published since february 1947, when the delegates from 25 countries met at the institution of civil engineers in london and founded the international organization for standardization (iso). today, it encompasses 162 member countries and more than 238 technical committees taking care of the development of standards (6). after the foundation of the european union a network of new institutions, such as the european standardization organizations (esos) consisting of 33 european countries, and cen the european committee for standardization, has been established. cen together with the european committee for electro-technical standardization (cenelec) and the european telecommunications standards institute (etsi) are officially recognized by the european union and by the european free trade association to be responsible for developing voluntary standards on the european level (7). regarding various products, materials, services and processes, cen provides a platform for the european norms (ens) development (8). en is to be implemented on a national level by being given the status of a national standard, and by withdrawing any conflicting national standards used previously. therefore, the european standard becomes a national standard in each of the 33 cen-cenelec member countries once adopted by the national body (9). for example, croatia after entering eu had to harmonize the local hrns (croatian norms) to conform to the ens. sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 4 standardization process the functional diagram (figure 1) introduces an 11-step assessment construct having been passed by any organization in attempt to obtain a particular certificate. figure 1. the 11-step assessment construct that an organization needs to go through in order to obtain a certificate (source: sarancha v, nenad pros 2016) formalization of workflow, introduction, implementation and staff training internal audit audit by the certification body 1. analisys of actual working conditions and workflow manuals, procedures, instructions, check lists, etc., ... 2. introduction of norm general requirements 3. establishment of company policy, responsibilities assingment, processes definition 4. documentation set design document is valid 5. acceptance and authorization of the documentation system ready for use documentyesno policies, guidlines, summaries, process diagrams, etc., ... 6. implementation and staff training training confirmation record nonconformities revealed 7. internal audit record, report 8. corrective actions no yes notes, records documents in use system is adjustedyes no nonconformities revaled 10. corrective actions notes, records yes 11. document of conformity no 9. external audit system is adjusted noyes client report sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 5 certification body is a third party auditing firm that assesses organization against a specific international standard. taking into account a huge amount of relevant documents and the complexity of the procedures, it is important to correctly identify the procedure required for the certification process at the beginning. approaches in different countries different countries have their own quality management traditions based on their history, mentality, socio-economic environment and the local regulations (10,11). this otherness is fundamental when considering well-developed countries such as the usa, germany and great britain in comparison with the converging countries of eastern and south-east europe (12,13). thereby, the usa has developed a quality infrastructure and there are many organizations that provide accreditation services covering various aspects of healthcare and public health. some of them include the accreditation association for ambulatory health care (14), the community health accreditation partner, the joint commission and the accreditation commission for health care, the american accreditation council, and the healthcare quality association on accreditation (15). one of the main acknowledged bodies in healthcare is the national association for healthcare quality (nahq). it certifies professionals in healthcare awarding the certified professional in healthcare quality (cphq). cphq plays an important role in clinical outcomes, reliability and financial stability of the healthcare organizations. the key elements of their knowledge refer to information management, measurement and analytics, quality measurement and improvements as well as planning, implementation, evaluation, training, strategic and operational tasks concerning patient safety. in great britain, the national standards body is bsi group (16). one of the outstanding resulting documents created by a group of representatives from bsi to help organizations put in place occupational health and safety performance is the occupational health and safety assessment series 18000 (ohsas) with its next revision ohsas 18002 which was accepted as a standard. in the updated edition “health” component was given greater emphasis and current version became more closely aligned with the structures of iso 9000 and iso 14000. thereby organizations could more easily adopt ohsas alongside the existing management systems (17). another institution is the united kingdom accreditation forum or ukaf. founded in 1998 by a group of leading healthcare accreditation organizations, nowadays ukaf is an umbrella structure for organizations providing healthcare accreditation. it operates with an interest in developing assessment and accreditation programmes in healthcare and public health (18). the national institute for health and care excellence (nice) provides guidance and contains governance information, publications, and policies concerning healthcare. it collaborates with the public health institutions, social care professionals and service users, and it also designs concise sets of statements and guidelines to drive measurable quality improvements within a particular area of healthcare (19). furthermore, there is a supervisory structure in the uk called the professional standards authority. this body is responsible for overseeing the uk’s nine health and care professional regulatory bodies (20). referring to the topics that focus on the subject it is important to mention the united kingdom accreditation service (ukas), the national health service (nhs), the department of health, etc. in germany, as a result of agreement with the german federal government, the national standards body is the german institute for standardization (din). its experts administer about 29,500 standards and it was one of the first well-structured certification institutions in europe. din remains the competent authority in respect to the technical issues and widely known specifications for products and materials. the accreditation body for the federal republic of germany is dakks. it has a special health/forensics division, which among other tasks attests third-party certification bodies taking care of healthcare, forensic medicine, medical laboratory sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 6 diagnostics and medical devices. the german worker’s welfare association (awo) also plays an important role. together with iso they have formed an effective tandem that ensures quality in awo rehabilitation facilities and health organizations. the model combines requirements of iso 9001 with those of awo quality and risk assessment guidelines. consequently, quality of a particular facility is measured by the care provided, the organization structure and the satisfaction of patients and residents. in addition, important requirements for patient safety are formulated by a german initiative called the german coalition for patient safety. it provides a basis in processing the audits that are conducted in the client’s premises, with the aim of providing the client with a feedback regarding the degree of implementation of the quality dimension of “patient safety”, e.g. regarding a particular healthcare system unit. speaking of developed economies, it can be concluded that as of today standardization has taken a strong position. in our opinion this is due to understanding by the managers of its effectiveness, as well as the level of comfort regarding integration of standards, clear description of the processes and therefore adherence to the relevant rules and procedures. in spite of positive sides of standardization, we have to understand that human factor in healthcare should also be taken into account, which means inapplicability of one approach only, the engineering approach to the human being as a mechanism. in comparison with the quality management systems present in the developed countries, ukraine has relatively unbalanced quality infrastructure. it bears elements of the former ussr standardizing paradigm that has to be re-evaluated, updated and adapted to suit the existing economic and social environment. there are state and industry branch systems of standardization in ukraine (21). the state branch includes the ukrainian scientific research institute of standardization certification and informatics, and the ukrainian state research and production centre of standardization, metrology and certification (22,23). the most flexible are the service standards departments and the industrial standards departments. state social standards in the health sector are regulated by the ukrainian law “fundamentals of ukraine on healthcare” (24). since ukraine has become a participant of the eurointegration process, the reform on the adaptation of local standards to the european and international norms has been significantly accelerated (25). the main principles are shown in the “national strategy on reforming the healthcare system in ukraine” which has been accepted for implementation in the period from 2015 – 2020 (26). more often, private clinics and research centres all over the country engage certification bodies to perform an external audit with the aim of meeting international quality requirements. standardization in russian federation is based on gosts. the word gost (russian: гост) is an acronym for “государственный стандарт” which means the national standard. there is a set of technical norms maintained by the euro-asian council for standardization, metrology and certification (easc) (27). one of the steps towards the standardization is by issuing the ordinance of the ministry of health “on the introduction of standardization into healthcare” (28). there are also many national programmes and ordinances in russia dealing with the implementation of particular standards in public health (29). the problem in russia is actually in hyper-regulation as regards the standardization. numerous ordinances, guidelines and procedures on one hand, and a lack of specific implementation mechanisms on the other hand causes confusion and regress with regard to the harmonization of national standards with their international counterparts. thus, the organization for economic co-operation and development (oecd) series on principles of good laboratory practice (glp) currently operates with gost r53434-2009 “principles of good laboratory practice” together with the support of other 14 interstate standards which have already been successfully implemented. in croatia, accreditation is provided only by the croatian accreditation agency (haa) which is a national accreditation body that complies with the requirements of the international and european standard for accreditation bodies adopted in the republic of sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 7 croatia as the croatian standard hrn en iso/iec 17011: 2005. the haa is a member of the international laboratory accreditation cooperation (ilac) and the european cooperation for accreditation (ea). the ilac is an international organization for accreditation bodies operating in accordance with iso/iec 17011 and involved in the accreditation of conformity assessment bodies including calibration laboratories (using iso/iec 17025), testing laboratories (using iso/iec 17025), medical testing laboratories (using iso 15189) and inspection bodies (using iso/iec 17020). the ea is an association of national accreditation bodies in europe which are officially recognised by their national governments to assess and verify (in line with the international standards) the organizations that carry out evaluation services such as certification, verification, inspection, testing and calibration (also known as conformity assessment services). on the other hand there are agencies in croatia dealing with quality control issues on the national level. thus, the agency for quality and accreditation in health care is an authority whose competence refers to quality improvement in healthcare services and social care, as well as medical technology assessment according to the corresponding law (official gazette of the republic of croatia 124/11) (30). targeted assistance in further development of quality infrastructure in croatia has been successfully implemented by the joint research centre of the european commission with amended action programmes such as cards croatia project on the “development of national metrology, standardization, conformity assessment and accreditation system” (31). other institutions that cope with quality paradigm introduction into the croatian healthcare and public health system are andrija stampar school of public health and the european society of quality in healthcare (32). according to the 2009 ministry of health national background report “health in albania”, the country has performed very well in sustaining high rates of economic recovery after the financial collapse of 1997 (33). quality assurance of health systems has been outlined as a priority in primary healthcare reform: a pilot project to provide evidence for health policy (34). the national agencies are empowered by the government to be responsible for accreditation of hospitals and licensing medical personnel. albania maintains the initiatives and continuous a dialog with the public institutions such as the institute of public health, private laboratories and clinics as well as with the international ngos, who, unicef, wb and usaid regarding a more active participation of the country in the international activities of the quality system implementation (35). international quality bodies are successfully co-operating with the aim to internationalize standardizing efforts in healthcare. one of such example is the international society for quality in health care (isqua). it is a parent institution for bodies providing international healthcare accreditation. isqua provides services in guidance to health professionals, providers, researchers, agencies, policy makers and consumers as to achieve excellence in healthcare delivery to the public and to continuously improve the quality of care (36). among others, quality bodies working on the international level are astm international (37), the international accreditation forum (iaf) (38), and the council for health service accreditation of southern africa (39), the quality management institute, etc. quality paradigm implementation in healthcare and public health standards cover a broad range of topics and are applicable to commissioners of health, specialists in primary care, public health staff, and social care providers as well as the local authorities and service users. health products, ranging from medical devices and health informatics to traditional medicines and unconventional healing tools are all in the focus of standards application (40). standards are designed to establish patterns of quality and performance including the measures to protect and improve the safety of patients, to promote a culture of continual improvement, support efficient exchange of information and data protection while benefiting the environment. depending on the scope of responsibilities and http://www.european-accreditation.org/brochure/ea-slides-rev24-02-17� http://www.european-accreditation.org/brochure/ea-slides-rev24-02-17� sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 8 areas of activity every organization is able to voluntarily choose among the standards it wishes to implement. iso has created about 1200 health standards that are grouped in families. some of them, such as environmental management iso 14000, occupational health and safety ohsas 18000, guidance on social responsibility iso 26000, environmental management 14000 are featured as widely applicable to public health and healthcare. a family contains a number of standards, each focusing on different aspects of a corresponding topic. according to 2012 iso press release the most commonly used standard is quality management standard iso 9001 (belongs to iso 9000 quality management systems). due to its generic basis, it is applicable to all types of organizations. it enables a company to develop a quality management system (qms) which implies the introduction of quality planning, quality assurance, quality control and quality improvement, and it is a perfect tool to measure the fundamental way of developing health services. iso 9001 has been updated and together with the cooperation for transparency and quality (ktq) for hospitals became the most acknowledged “brand” for quality recognition in healthcare. ktq certification is aimed at hospitals, medical practitioners and institutions, rehabilitation centres, nursing homes, hospices, and emergency medical services. it shows that the focus is primarily on patient satisfaction, from the preparation of the patient’s stay until his discharge. a good example of such practical application of quality management in a combined clinic is perfectly demonstrated in the article by eckert h. and schulze u., (2004) (41). iso 13485:2016 – medical devices, is also a useful standard. it is designed to define the requirements of quality management system with the aim of demonstrating a company’s ability to provide medical devices and related services that meet the clients’ and regulatory requirements. together with en 15224:2012 certification of quality management systems in healthcare, with its emphasis on the hospital process and risk management, both standards become strong indicators of quality level of care provided at an institution. the best way to find a relative iso standard is to search through the work of a particular iso technical committee (tc) on the iso web page, as follows: tc 76, transfusion, infusion and injection, and blood processing equipment for medical and pharmaceutical use; tc 84, devices for administration of medicinal products and intravascular catheters; tc 94, personal safety protective clothing and equipment; tc 106, dentistry; tc 121, anaesthetic and respiratory equipment; tc 150, implants for surgery; tc 157, contraceptives/sti; tc 168, prosthetics and orthotics; tc 170, surgical instruments; tc 172, optics and photonics; tc 173, assistive products for persons with disability; tc 181, safety of toys; tc 194, biological evaluation of medical devices; tc 198, sterilization of healthcare products; tc 210, quality management and corresponding general aspects for medical devices; tc 212, clinical laboratory testing and in vitro diagnostic test systems; tc 215, health informatics; tc 249, traditional chinese medicine; iso/pc 283, occupational health and safety management systems. challenges, opportunities and benefits twenty-first century and the globalization bring new challenges to the organizations exposed to the global market. with a drastic number of competitors, growing demands of consumers and legislators, quality requirements of goods and services together with a lack of resources are constantly increasing (42). be it in environmental protection, in the food industry or public health objective testing and calibration play a notable role. assessments ensure that tested products, methods, services or systems are reliable with regard to their quality and safety, that they correspond to the technical criteria and conform with the characteristics, guidelines, and laws. observational findings 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http://www.iso.org/iso/home/standards_development/list_of_iso_technical_committees/iso_technical_committee.htm?commid=4857129� sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 9 healthcare is one of the world’s largest and fastest-growing sectors of the society. in 2009 about 12.4% of gross domestic product of oecd was spent on healthcare. these countries are the basis for research and development, as well as the improvement of international standardization environment. on the other hand, studies have shown that south european countries together with ukraine and russia are, in the long run, heading towards the social paradigm shift and understanding of standardization principles. most frequently cited problems refer to failure of recognizing positive effects of a systematic approach, financial means, long waiting lists, systematic delays in first aid providers, lack of competent staff due to “brain-drain” and insufficient organizations’ preparedness for the implementation of structural changes at all levels. some health centres, clinics and hospitals are funded by the state or county budget revenues (beveridge’s model) or partly from social insurance contributions deducted from the citizens’ wages (bismarck model), and consequently do not recognize the need to increase the level of quality, responsibility and international standards compliance (43). in addition, high payroll taxes in eastern and south european countries are discouraging formal employment, dampening labour demand and increasing employment in the informal sector (44). a study published in british medical journal estimates that medical errors are the third leading cause of death in the united states, that caused a quarter-million fatalities in 2013 alone (45). it obviously means that the reduction of risks of all kinds is also an important problem that needs to be resolved (46). despite relatively well-structured lex artis in standardizing processes, its efficiency in many cases remains controversial. sometimes, due to enormous amount of paperwork and bureaucracy, standardization can become a nuisance causing waste of time and human resources. combination of all these factors, together with the unfair competition, weak governance and corruption may cause unwillingness towards continuous improvement which is the ultimate precondition for an efficient functioning of standardization in healthcare and public health (47). public health and healthcare are vital and sensitive issues, and their importance pervades all aspects of social life due to their medical, social, political, ethical, business, and financial ramifications. looking into the future, it is impossible to predict exactly how our world is going evolve, but current trends suggest that together with climate change, migration, urbanization, a growing and ageing population, poverty, emerging diseases, food and water shortages and a lack of access to health services, the future of health sector appears to be complicated. new fields of expertise such as medical tourism are on the rise (48). they create a pool of migrating specialists whose services and reliability need to be properly examined and permanently reviewed. in our opinion standardization is a step-by-step process that requires commitment and cooperation of all parties. it may flow both in the bottom-up and in the top-down directions. the key element of this evolutionary process is the end-user of services the patient, in whose best interest the described changes should be made. the patient, service provider, health insurance officer, public health institution, legislative body all of them form an integral network of relationships and responsibility. therefore, awareness regarding the benefits of the standardization process and full understanding of its stages, by those included, are key factors in the overall success of its implementation. quality management systems based on the international standards should be a strategic decision of the national public health institutions in an attempt to meet long-term strategic goals. if an organization wishes to use one of the worldwide-recognized norms it has to ensure its adherence to best practices in everything it is involved in (49). it also includes the mapping processes, setting performance targets and making sure that it continually improves and meets the goals of shareholders, clients, and patients. regular audit processes and subsequent annual assessments meet the needs of health service providers, patients, in this way guaranteeing the quality of services and achieving maximum results. in this way, the standardization creates powerful tools in order to fine-tune the performance and manage the risks while operating in sarancha v, sulyma v, pros n, vitale k. approaches to the 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(original in german). rehabilitation (stuttg) 2004;43:166-73. 42. berger s. how we compete: what companies around the world are doing to make it in today’s global economy, random house, new york; 2006. 43. kutzin j. bismarck vs. beveridge: is there increasing convergence between health financing systems? 1st annual meeting of sbo network on health expenditure 21-22, oecd. who, paris, 2011. 44. hazans m. informal workers across europe: evidence from 30 countries. the institute for the study of labor (iza). discussion paper no. 5871: 2011. 45. makary ma, daniel m. medical error the third leading cause of death in the us. bmj 2016;353. doi: http://dx.doi.org/10.1136/bmj.i2139. 2016. 46. european commission. occupational health and safety risks in the health sector. guide to prevention and good practice. available at: http://ec.europa.eu/progress (accessed: march 6, 2017). 47. mayberry rm, nicewander da, qin h, ballard dj. improving quality and reducing inequities: a challenge in achieving best care. proc (bayl univ med cent) 2006;19:103-18. 48. medical tourism magazine. faq concerning the medical tourism, sept-oct 2009. 49. lee dh. implementation of quality programs in healthcare organizations. service business 2012;6:387-404. __________________________________________________________ © 2017 sarancha et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://ec.europa.eu/progress� http://www.ncbi.nlm.nih.gov/pubmed/?term=mayberry%20rm%255bauth%255d� http://www.ncbi.nlm.nih.gov/pubmed/?term=nicewander%20da%255bauth%255d� http://www.ncbi.nlm.nih.gov/pubmed/?term=qin%20h%255bauth%255d� http://www.ncbi.nlm.nih.gov/pubmed/?term=ballard%20dj%255bauth%255d� http://link.springer.com/journal/11628� http://link.springer.com/journal/11628� http://link.springer.com/journal/11628� mayberry rm, nicewander da, qin h, ballard dj. improving quality and reducing inequities: a challenge in achieving best care. proc (bayl univ med cent) 2006;19:103-18. book review global population health and well-being in the 21st century: toward new paradigms, policy and practice (springer publishing, new york, 2016) author: george r lueddeke phd a must read for public health, clinical, and social care students, teachers, and practitioners alike, including case studies to provide a thorough and up-to-date account of the past, present, and future of global public health. dr lueddeke effectively highlights the ingenuity gap between today’s wicked problems and their potential solutions, with a timely emphasis on the concepts of ‘planetary health’ and ‘integrative ecological public health’. following on from the four “waves” of public health interventions in developed nations, including water/sanitation (first), medical and scientific breakthroughs (second), the welfare state and social security (third), and the current focus on systems thinking, risk factors, and lifestyle (fourth), there is now an emerging need for the “fifth wave” interventions that require complex adaptive systems thinking. dr lueddeke presents a manifesto for collective public health action through the ‘one health’ movement, recognising the inter-dependencies in the health of people, other animals and the environment we live in. one of the main aims of the book is to support the implementation of the un 2030 agenda for sustainable development, including the 17 sustainable development goals (sdgs). this book describes part of the solution being the development of an effective public health workforce through innovations in education and training, offering a proposal for centers of one health excellence (cohe) worldwide. our mission at oxford public health is aligned closely with many of the compelling concepts in this very informative and groundbreaking read. dr behrooz behbod, mb chb msc scd mfph founder, oxford public health ltd www.oxfordpublichealth.com http://www.oxfordpublichealth.com/ kamberi h, jerliu n, kamberi s, berisha i. knowledge about breastfeeding of children 0-6 months among mothers attending hospital services in kosovo (original article). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-196 1 original article knowledge about breastfeeding of children 0-6 months among mothers attending hospital services in kosovo haxhi kamberi 1,2 , naim jerliu 3,4 , safete kamberi 5 , idriz berisha 2 1 regional hospital “isa grezda”, gjakove, republic of kosovo; 2 faculty of medicine, university of gjakova, gjakove, republic of kosovo; 3 faculty of medicine, university of prishtina, prishtina, republic of kosovo; 4 national institute of public health of kosovo, prishtina, republic of kosovo; 5 regional centre of public health, gjakove, republic of kosovo. corresponding author: naim jerliu, md, phd, national institute of public health of kosovo and faculty of medicine, university of prishtina, prishtina, kosovo; address: rr. “instituti shendetesor”, 10000, prishtina, republic of kosovo; telephone: +38138541432; e-mail: naim.jerliu@uni-pr.edu mailto:naim.jerliu@uni-pr.edu kamberi h, jerliu n, kamberi s, berisha i. knowledge about breastfeeding of children 0-6 months among mothers attending hospital services in kosovo (original article). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-196 2 abstract aim: the aim of this study was to assess the level of knowledge and socio-demographic correlates of breastfeeding of children aged 0-6 months among mothers with young children in post-war kosovo. methods: a cross-sectional study was conducted in kosovo during the period december 2017 – february 2018 including a representative sample of 201 mothers (aged 29.4±6.0 years) with young children attending hospital services. in addition to socio-demographic data, a structured 13-item questionnaire inquiring about breastfeeding of children aged 0-6 months was administered to all women. a summary score was calculated for all 13 items related to women’s knowledge on breastfeeding (0 denoting incorrect answers to all 13 items, and 13 denoting correct answers to all 13 questions). general linear model was used to assess the association between summary score of the knowledge about breastfeeding and sociodemographic characteristics of the women. results: mean summary score of the 13 items related to knowledge about breastfeeding was 10.3±1.9; median score was 11 (interquartile range: 9-12). in multivariable-adjusted models, the mean summary score of knowledge about breastfeeding of children 0-6 months was slightly but non-significantly higher among “older” women, those residing in urban areas, highly educated women, those currently employed, and women with a higher income level. conclusion: generally, the level of knowledge about breastfeeding of children aged 0-6 months was satisfactory among mothers with young children included in this survey in kosovo. furthermore, there were seemingly no significant socio-demographic differences in the level of knowledge about breastfeeding of young infants among women in this study carried out in kosovo. keywords: breastfeeding, children 0-6 months, knowledge, mothers, kosovo, women. kamberi h, jerliu n, kamberi s, berisha i. knowledge about breastfeeding of children 0-6 months among mothers attending hospital services in kosovo (original article). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-196 3 introduction breastfeeding of newborns is very important and it significantly decreases the risk of neonatal complications (1), respiratory diseases and other diseases of young infants, as convincingly demonstrated in the vast international scientific literature (2-5). based on the considerable empirical evidence about the benefits of breastfeeding to both the mother and the baby, the world health organization (who) has recommended a two-year breastfeeding approach (6). more specifically, who has recommended exclusive breastfeeding for the first six months of life, with more than eight times breastfeeding of the baby per day in the first three months of a newborn’s life (6). however, a wide range of factors may influence the breastfeeding rates in different countries including maternal characteristics (7,8) and socioeconomic status of the families (9), different health issues and problems of the newborns (10), several psychosocial factors involved (11), as well as different ethnic and cultural norms pertinent to various countries and populations worldwide (8,12). after the war and the liberation from the serbian regime in 1999 and almost a decade under united nations administration, kosovo underwent an intensive process of transformation to an independent state, which was formally proclaimed in 2008. hence, kosovo is the newest country in europe with the youngest population of the continent (mean age of the kosovo population has been reported at about 27 years) (13). in kosovo, infant mortality rate is one of the highest in the who european region (17.1 deaths per 1000 live births in the year 2011) (13). similarly, maternal mortality rate is also high (7.2 deaths per 100.000 in 2011) (13). the available evidence, albeit not well-documented, suggests a relatively higher breastfeeding rate in kosovo compared with the other european countries. however, to date, the evidence about the level of knowledge, attitudes and practices related to breastfeeding of kosovo mothers with infants and young children is scarce. in this context, the aim of this study was to assess the level of knowledge and sociodemographic correlates of breastfeeding of children aged 0-6 months among mothers with young children in kosovo. methods a cross-sectional study was conducted in kosovo during the period december 2017 – february 2018. the study was carried out in four regions of the republic of kosovo including peja, gjakova, prizren and prishtina. a representative sample of 201 mothers with young children attending hospital services was included in this survey (overall, 92 women from rural areas and 109 women from urban areas). a structured 13-item questionnaire inquiring about breastfeeding of children aged 0-6 months was administered to all women (all 13 questions are presented in table 2). in the analysis, answers to each of the 13 items were dichotomized into: correct vs. incorrect. a summary score was calculated for all 13 items of the questionnaire (0 denoting incorrect answers to all 13 items, and 13 denoting correct answers to all 13 questions). in addition, data on demographic factors (age and place of residence) and socioeconomic characteristics (educational level, employment status, and self-perceived income) were collected for all study participants. the study was approved from the board of the national institute of public health of the republic of kosovo. fisher’s exact test was used to compare differences in socio-demographic characteristics (age, education, employment and income) between women residing in urban areas and their counterparts pertinent to rural areas. furthermore, fisher’s exact test was employed to kamberi h, jerliu n, kamberi s, berisha i. knowledge about breastfeeding of children 0-6 months among mothers attending hospital services in kosovo (original article). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-196 4 compare differences for each of the 13 items related to mothers’ knowledge about breastfeeding of children aged 0-6 months between urban and rural residents. on the other hand, general linear model was used to assess the association between summary score of the knowledge (13 items) about breastfeeding and socio-demographic characteristics of the women. initially, crude (unadjusted) mean values, their respective 95% confidence intervals (95%cis) and p-values were calculated. subsequently, multivariable-adjusted models were run adjusting simultaneously for all socio-demographic factors of the women (age-group, place of residence, educational attainment, employment status and income level). multivariable-adjusted mean values, their respective 95%cis and p-values were calculated. in all cases, a p-value ≤0.05 was considered as statistically significant. statistical package for social sciences (spss< version 19.0) was used for all the statistical analyses. results mean age (±sd) of women included in this study was 29.4±6.0 years; median age was 28 years (interquartile range: 25-33 years); the age range was: 17-48 years (data not shown in the tables). the distribution of demographic and socioeconomic characteristics of study participants by their place of residence is presented in table 1. overall, 40% of women were 30 years or older. compared to their rural counterparts, women residing in urban areas had a higher educational level (45% in urban areas vs. 24% in rural areas; p<0.01), a higher employment rate (48% in urban areas vs. 20% in rural areas; p<0.01) and a higher income level (a low income was reported only among 4% of urban women compared to 15% of women residing in rural areas; p=0.02). mean age was similar among women residing in urban areas and those pertinent to rural areas (29.7 years vs. 29.1 years, respectively; data not shown). table 1. demographic and socioeconomic characteristics in a sample of mothers with young children attending hospital services in kosovo, in 2017-2018 demographic and socioeconomic characteristics total (n=201) rural (n=92) urban (n=109) p-value † age-group: <30 years ≥30 years 120 (59.7) * 81 (40.3) 56 (60.9) 36 (39.1) 64 (58.7) 45 (41.3) 0.775 educational level: low middle high 46 (22.9) 84 (41.8) 71 (35.3) 31 (33.7) 39 (42.4) 22 (23.9) 15 (13.8) 45 (41.3) 49 (45.0) 0.001 employment status: employed unemployed 70 (34.8) 131 (65.2) 18 (19.6) 74 (80.4) 52 (47.7) 57 (52.3) <0.001 income level: low middle high 18 (9.0) 177 (88.1) 6 (3.0) 14 (15.2) 76 (82.6) 2 (2.2) 4 (3.7) 101 (92.7) 4 (3.7) 0.015 * numbers and column percentages (in parenthesis). † p-values from fisher’s exact test. the correct knowledge about a wide array of breastfeeding aspects of children 0-6 months among women residing in urban and rural areas is presented in table 2. for most of the items there were no significant differences by place of residence of study participants. overall, kamberi h, jerliu n, kamberi s, berisha i. knowledge about breastfeeding of children 0-6 months among mothers attending hospital services in kosovo (original article). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-196 5 almost all women (99%) knew correctly that breast milk is the best type of milk for feeding children aged 0-6 months. about 85% of the women correctly reported that newborns should be breastfed immediately after birth, and 77% of the women stated that newborns should be breastfed as frequently as needed. furthermore, about 63% of the women correctly stated that colostrum is very useful for the newborn. about three-quarters of the women correctly identified the duration of a normal breastfeeding session. the vast majority of the women (93%) correctly reported that breastfeeding improves the immune system of the newborn; 89% of the mothers stated that breastfeeding improves the mother-child emotional bond; and 88% of the women correctly knew that a newborn is properly fed when he/she attaches well the nipples and grasps a large portion of breast’s aureole. conversely, only 40% of the women correctly knew that breastfeeding reduces mother’s weight gained during pregnancy (47% of urban women vs. only 33% of rural women; p=0.05). a higher proportion of urban residents correctly knew that breastfeeding reduces the neonatal jaundice (76% vs. 60% among rural residents; p=0.02). similarly, a higher proportion of urban residents correctly knew that newborns who gain weight, have wet dippers and sleep well have received sufficient breast milk (95% vs. 87% among rural residents; p=0.04). on the other hand, there were no differences regarding the correct knowledge about bottlefeeding (overall, 78% of the women correctly reported that bottle-feeding should not be used for breastfed children 0-6 months), or complementary feeding (overall, 86% of the women correctly reported that, besides breastfeeding, children should start the complementary feeding six months after birth) [table 2]. table 2. knowledge about breastfeeding of children aged 0-6 months in a sample of mothers with young children attending hospital services in kosovo knowledge about breastfeeding of children 0-6 months total (n=201) rural (n=92) urban (n=109) p-value ‡ 1. which type of milk is the best for your child? breast milk * other (formula, etc.) 199 (99.0) † 2 (1.0) 90 (97.8) 2 (2.2) 109 (100.0) 0 (-) 0.208 2. when should the newborn be breastfed? immediately after birth * at least 4 hours after birth 170 (84.6) 31 (15.4) 78 (84.8) 14 (15.2) 92 (84.4) 17 (15.6) 0.999 3. is colostrum useful for the newborn? very useful * little or no useful at all 127 (63.2) 74 (36.8) 57 (62.0) 35 (38.0) 70 (64.2) 39 (35.8) 0.770 4. how many times should the newborn be breastfed? every time he/she needs * each 4 hours or longer 155 (77.1) 46 (22.9) 74 (80.4) 18 (19.6) 81 (74.3) 28 (25.7) 0.318 5. how long does a breastfeeding session last? 10-15 minutes * other 149 (74.1) 52 (25.9) 68 (73.9) 24 (26.1) 81 (74.3) 28 (25.7) 0.999 6. does breastfeeding improves the immune system of the newborn? yes * little or not at all 187 (93.0) 14 (7.0) 85 (92.4) 7 (7.6) 102 (93.6) 7 (6.4) 0.786 7. does breastfeeding influence the 0.111 kamberi h, jerliu n, kamberi s, berisha i. knowledge about breastfeeding of children 0-6 months among mothers attending hospital services in kosovo (original article). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-196 6 mother-and-child emotional bond? yes * little or not at all 179 (89.1) 22 (10.9) 78 (84.4) 14 (15.2) 101 (92.7) 8 (7.3) 8. does breastfeeding reduce the neonatal jaundice? yes * no 138 (68.7) 63 (31.3) 55 (59.8) 37 (40.2) 83 (76.1) 26 (23.9) 0.015 9. does breastfeeding reduce mother’s weight gained during pregnancy? yes * little or not at all 81 (40.3) 120 (59.7) 30 (32.6) 62 (67.4) 51 (46.8) 58 (53.2) 0.045 10. if the newborn attaches well the nipples and grasps a large portion of breast’s aureole, then: the newborn will be properly fed * the newborn should be repositioned or will not be properly fed 176 (87.6) 25 (12.4) 79 (85.9) 13 (14.1) 97 (89.0) 12 (11.0) 0.527 11. if the newborn gains weight, has wet dippers and sleeps well, then: he/she takes sufficient breast milk * he/she does not take sufficient breast milk, or is ill 184 (91.5) 17 (8.5) 80 (87.0) 12 (13.0) 104 (95.4) 5 (4.6) 0.041 12. should bottle-feeding be used for breastfed children 0-6 months? no * yes 156 (77.6) 45 (22.4) 75 (81.5) 17 (18.5) 81 (74.3) 28 (25.7) 0.239 13. besides breastfeeding, when should the newborn start the complementary feeding? 6 months after birth * other 172 (85.6) 29 (14.4) 78 (84.8) 14 (15.2) 94 (86.2) 15 (13.8) 0.841 * correct answer. † numbers and column percentages (in parenthesis). ‡ p-values from fisher’s exact test. a summary score was calculated for all 13 items displayed in table 2 regarding the correct level of knowledge of women about breastfeeding of children aged 0-6 months (a summary score of 0 denoting incorrect answers to all 13 items, and a summary score of 13 denoting correct answers to all 13 questions). mean summary score of the 13 knowledge items was 10.3±1.9; median score was 11 (interquartile range: 9-12); the range of the scores was: 1 (only one correct answer) to 13 (all 13 correct answers) [data not shown in the tables]. table 3 presents the association of summary score of knowledge about breastfeeding and demographic and socioeconomic characteristics of the women. in crude (unadjusted) general linear models, the mean summary score of the 13 knowledge items was (non-significantly) higher among older women, those residing in urban areas, highly educated women and those currently employed. women with a higher income level had a significantly higher mean summary score of the knowledge items compared with lowincome women (11.0 vs. 9.3, respectively, p=0.05). kamberi h, jerliu n, kamberi s, berisha i. knowledge about breastfeeding of children 0-6 months among mothers attending hospital services in kosovo (original article). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-196 7 in multivariable-adjusted models, there was evidence of the same findings compared with the unadjusted estimates. hence, mean summary score of knowledge about breastfeeding of children 0-6 months was (non-significantly) higher among older women, those residing in urban areas, highly educated women, those currently employed and women with a higher income level. table 3. association of the summary score of knowledge about breastfeeding and demographic and socioeconomic characteristics of the women; mean values from the general linear model socio-demographic characteristics unadjusted models multivariable-adjusted models mean * 95%ci p mean * 95%ci p age-group: <30 years ≥30 years 10.2 10.5 9.8-10.5 10.1-10.9 0.272 10.1 10.4 9.5-10.8 9.7-11.1 0.298 place of residence: rural areas urban areas 10.1 10.5 9.7-10.5 10.2-10.9 0.105 10.1 10.4 9.5-10.8 9.7-11.1 0.363 educational level: low middle high 9.9 10.3 10.5 9.4-10.5 9.9-10.8 10.1-11.2 0.344 (2) † 0.242 0.815 reference 10.1 10.3 10.5 9.3-10.9 9.5-11.3 9.7-11.6 0.596 (2) 0.867 0.444 reference employment status: unemployed employed 10.1 10.6 9.8-10.5 10.2-11.3 0.186 10.2 10.4 9.4-10.8 9.6-11.1 0.648 income level: low middle high 9.3 10.4 11.0 8.4-9.8 10.1-10.7 9.9-12.5 0.04 (2) 0.045 0.441 reference 9.4 10.4 11.0 8.5-10.4 10.1-10.7 9.4-12.6 0.120 (2) 0.098 0.447 reference * range of the summary score from 0 (all 13 incorrect answers) to 13 (all 13 correct answers). † overall p-values and degrees of freedom (in parentheses). there was evidence of a weak and non-significant linear association between the summary score of knowledge about breastfeeding and age of the women (spearman’s rho=0.11, p=0.14), but a borderline statistically significant correlation with the number of births (spearman’s rho=0.13, p=0.06) [data not shown]. discussion the main finding of this study consists of a quite satisfactory level of knowledge about breastfeeding of children aged 0-6 months among mothers attending hospital services in kosovo. in addition to the general level of knowledge, on the face of it, there were no significant demographic or socio-economic differences in the level of knowledge about breastfeeding of young infants among women in kosovo. indeed, in multivariable-adjusted general linear models (controlling simultaneously for key socio-demographic factors) there was no evidence of any statistically significant differences in the level of knowledge about breastfeeding of children aged 0-6 months among various categories and subgroups of women differentiated in terms of age-group, place of residence, educational attainment, employment status, or income level. such findings are quite appealing, but they should be interpreted with extreme caution due to the small sample size included in the current study. hence, findings from this report deserve further rigorous investigation and replication in more robust and larger studies. kamberi h, jerliu n, kamberi s, berisha i. knowledge about breastfeeding of children 0-6 months among mothers attending hospital services in kosovo (original article). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-196 8 to the best of our knowledge, there are no previous similar studies conducted in kosovo in order to compare our findings. on the other hand, a previous cross-sectional study conducted in kosovo in 2013 has assessed women’s knowledge and practices of complementary feeding from 28 cities, towns and villages across kosovo, including a sample of 492 mothers with infants aged 6-24 months (14). according to this report, about 88% of the women included in the study reported good knowledge of complementary feeding, whereas only about 38% of them employed good practices regarding time for starting complementary feeding (14). in addition, an association between maternal knowledge about complementary feeding and educational level was reported from this study (14). the current study conducted in kosovo revealed that the majority of the women included in the survey had good knowledge about breastfeeding of children aged 0-6 months. similar to the evidence obtained in previous studies conducted elsewhere, most of the mothers included in this study in kosovo correctly reported that breastfeeding promotes mother-baby emotional bonding (8,15,16), and the fact that breastfeeding in the early period can help reduce jaundice (8,17,18). nonetheless, there are several imitations of the current study including the size and representativeness of the study population involved, the possibility of information bias and the study design. the sample size included in this study (n=201) was not large, an issue which might have jeopardized the power of the study for detecting small differences in the level of knowledge about breastfeeding among women pertinent to different sociodemographic categories. more importantly, although the sample was meant to be representative to kosovo women with young children, the hospital-based selection approach does not allow generalization of the survey findings to all women in kosovo. at best, findings from the current analysis may be generalized only to women who attend hospital services in this transitional country. the instrument for data collection was based on a simple and standardized tool which has been largely employed in similar studies in many countries worldwide (8). yet, regardless of the lack of any evidence obtained, the possibility of differential reporting between groups of women pertinent to different socio-demographic categories cannot be completely excluded. finally, as this was a cross-sectional study, findings should be interpreted with caution and replicated and confirmed in future larger prospective studies. regardless of these potential limitations, this study provides useful evidence about the level of knowledge and socio-demographic correlates of breastfeeding of children aged 0-6 months among mothers with young children in kosovo. findings of this study should inform policy and shape future interventions and programs aiming at improving mother and child health status and health care services in kosovo. references 1. furman l, minch nm, hack m. breastfeeding of very low birth weight. j hum lact 1998;14:29-34. 2. akobeng ak, ramanan av, buchan i, heller rf. effect of breast feeding on risk of coeliac disease: a systematic review and meta-analysis of observational studies. arch dis child 2006;91:39-43. 3. chantry cj, howard cr, auinger p. full breastfeeding duration and associated decrease in respiratory tract infection in us children. pediatrics 2006;117:425-32. 4. cushing ah, samet jm, lambert we, skipper bj, hunt wc, young sa, mclaren lc: breastfeeding reduces risk of respiratory illness in infants. am j epidemiol 1998;147:863-70. kamberi h, jerliu n, kamberi s, berisha i. knowledge about breastfeeding of children 0-6 months among mothers attending hospital services in kosovo (original article). seejph 2018, posted: 30 july 2018. doi 10.4119/unibi/seejph-2018-196 9 5. lópez-alarcón m, villalpando s, fajardo a. breast-feeding lowers the frequency and duration of acute respiratory infection and diarrhea in infants under six months of age. j nutr 1997;127:436-43. 6. world health organization (who). the global strategy for infant and young child feeding. geneva: who; 2003. http://whqlibdoc.who.int/publications/2003/9241562218.pdf (accessed: 24 july, 2018). 7. bertino e, varalda a, magnetti f, di nicola p, cester e, occhi l, perathoner c, soldi a, prandi g. is breastfeeding duration influenced by maternal attitude and knowledge? a longitudinal study during the first year of life. j matern fetal neonatal med 2012;25:32-6. 8. mbada ce, olowookere ae, faronbi jo, oyinlola-aromolaran fc, faremi fa, ogundele ao, et al. knowledge, attitude and techniques of breastfeeding among nigerian mothers from a semi-urban community. bmc research notes 2013;6:552. 9. flacking r, nyqvist kh, ewald u. effects of socioeconomic status on breastfeeding duration in mothers of preterm and term infants. eur j public health 2007;17:579-84. 10. narayan s, natarajan n, bawa ks. maternal and neonatal factors adversely affecting breastfeeding in the perinatal period. mjafi 2005;61:216-9. 11. kronborg h, vaeth m. the influence of psychosocial factors on the duration of breastfeeding. scand j public health 2004;32:210-6. 12. christopher k. breastfeeding perceptions and attitudes: the effect of race/ethnicity and cultural background. soc today 2012;10:2. 13. jerliu n, toçi e, burazeri g, ramadani n, brand h. socioeconomic conditions of elderly people in kosovo: a cross-sectional study. bmc public health 2012;12:512. 14. berisha m, ramadani n, hoxha r, gashi s, zhjeqi v, zajmi d, begolli i. knowledge, attitudes and practices of mothers in kosova about complementary feeding for infant and children 6-24 months. med arch 2017;71:37-41. 15. klaus mh, kennell jh, klaus ph. bonding: building the foundations of secure attachment and independence. in reading, mass. addison-wesley publishing; 1995. 16. uvnäs-moberg k, eriksson m. breastfeeding: physiological, endocrine and behavioural adaptations caused by oxytocin and local neurogenic activity in the nipple and mammary gland. acta paediatr 1996;85:525-30. 17. maisels mj, vain n, acquavita am, de blanco nv, cohen a, digregorio j. the effect of breast-feeding frequency on serum bilirubin levels. am j obstet gynecol 1994;170:880-3. 18. lin yy, tsao p-n, hsieh w-s, chen c-y, chou h-c. the impact of breastfeeding on early neonatal jaundice. clin neonatol 2008;15:31-5. ______________________________________________________________________________________ © 2018 kamberi et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed?term=jerliu%20n%5bauthor%5d&cauthor=true&cauthor_uid=22776197 http://www.ncbi.nlm.nih.gov/pubmed?term=to%c3%a7i%20e%5bauthor%5d&cauthor=true&cauthor_uid=22776197 http://www.ncbi.nlm.nih.gov/pubmed?term=burazeri%20g%5bauthor%5d&cauthor=true&cauthor_uid=22776197 http://www.ncbi.nlm.nih.gov/pubmed?term=ramadani%20n%5bauthor%5d&cauthor=true&cauthor_uid=22776197 http://www.ncbi.nlm.nih.gov/pubmed?term=brand%20h%5bauthor%5d&cauthor=true&cauthor_uid=22776197 http://www.ncbi.nlm.nih.gov/pubmed/22776197 lueddeke g. preparing society to create the world we need through ‘one health’ education’ (commentary). seejph 2016, posted: 04 june 2016. doi: 10.4119/unibi/seejph-2016-122 1 commentary preparing society to create the world we need through ‘one health’ education george r. lueddeke 1,2 , gretchen e. kaufman 1,2 , laura h. kahn 1,3 , rosina c. krecek 1,2 , a. lee willingham 1,2 , cheryl m. stroud 1,2 , joann m. lindenmayer 1,2 , bruce kaplan 1,3 , lisa a. conti 3 , thomas p. monath 3 , john (jack) woodall 3 1 one health education task force; 2 one health commission; 3 one health initiative. corresponding author: george r lueddeke, med, phd, co-chair, one health education task force. consultant education advisor in higher and medical education. address: 9 lakeland gardens, southampton, hampshire, so40 4xg, united kingdom. email: glueddeke@aol.com contributing authors: 1,2 gretchen e. kaufman, dvm. co-chair, one health education task force. adjunct faculty (paul g. allen school for global animal health, washington state university, tufts center for conservation medicine, tufts university). co-founder and associate director,veterinary initiative for endangered wildlife. e-mail: gkaufman10@gmail.com 1,3 laura h. kahn, md, mph, mpp. co-founder, global one health initiative team. research scholar program on science and global security, woodrow wilson school of public and international affairs, princeton university. columnist, bulletin of the atomic scientists http://www.thebulletin.org. e-mail: lkahn@princeton.edu. 1,2 rosina c. krecek, frssaf, bs, ms, phd, map.interim assistant dean of one health, office of the dean . visiting professor, department of veterinary pathobiology,college of veterinary medicine & biomedical sciences. texas a&m university, texas, usa. visiting professor, university of johannesburg, south africa. e-mail: tkrecek@cvm.tamu.edu. 1,2 a. lee willingham, bsc, dvm, phd. associate dean for research and postgraduate studies. director of one health center for zoonoses and tropical veterinary medicine. professor of one health. institutional officer, ross university school of veterinary medicine, st kitts and nevis, west indies. e-mail: awillingham@rossu.edu. 2 cheryl m. stroud, dvm, phd. executive director, one health commission. previous chair of north carolina one health collaborative. e-mail: cstroud@onehealthcommission.org. 2 joann m. lindenmayer, dvm, mph. chair, board of directors, one health commission. senior manager of disaster operations and director, haiti program. department of companion animals and engagement, humane society international. e-mail: jlindenmayer@hsi.org 3 bruce kaplan, dvm. co-founder,global one health initiative team. manager/editor, one health initiative website. former cdc eis officer and usda/fsis food safety staff officer. small animal veterinary medicine practitioner; retired. e-mail:bkapdvm@verizon.net. 3 lisa a. conti, dvm, mph. member of one health initiative autonomous team deputy commissioner and chief science officer at florida department of agriculture and consumer. e-mail: lxc2001@gmail.com. 3 thomas p. monath, md. member of one health initiative autonomous team . chief scientific and chief operations officer of bioprotection systems corporation. e-mail: tmonath@linkp.com 3 john woodall, phd. member of one health initiative autonomous team. professor and director (retd.), nucleus for the investigation of emerging infectious diseases at the institute of medical biochemistry, center for health sciences, federal university of rio de janeiro, brazil. co-founder and associate editor of promed. e-mail: jackwoodall13@gmail.com. mailto:glueddeke@aol.com mailto:gkaufman10@gmail.com http://www.thebulletin.org/ mailto:lkahn@princeton.edu mailto:tkrecek@cvm.tamu.edu mailto:awillingham@rossu.edu mailto:cstroud@onehealthcommission.org mailto:jlindenmayer@hsi.org mailto:bkapdvm@verizon.net mailto:lxc2001@gmail.com mailto:tmonath@linkp.com mailto:jackwoodall13@gmail.com lueddeke g. preparing society to create the world we need through ‘one health’ education’ (commentary). seejph 2016, posted: 04 june 2016. doi: 10.4119/unibi/seejph-2016-122 2 abstract: growing concerns about a threatened environment, conflicts, inequities, poverty, ideological extremes, and consumerism are all indicative of a pressing need to reflect on the global status quo and to find constructive and long-term, sustainable strategies for planet and people. the need to give the younger generation “a better deal” for helping to shape a sustainable world has been embraced by the global one health commission (ohc) in association with the one health initiative (ohi). envisioning a program that provides funding for national and global one health-themed educational projects, one health leaders in collaboration with partners call for collective action by legislators, public / private educators, and public health professionals to support the development and implementation of progressive and comprehensive global one health learning opportunities. one health (and well-being) projects led by teachers who want to make a difference could begin in primary/secondary schools and extend through graduate and professional education. the overall intent of the concept paper is to raise awareness about the urgent need for the development and to explore the concept further through a small pre-project proposal conference (possibly off and/or on line) with a view to fleshing out a strong plan to fund the envisioned global learning program. keywords: global health, planetary health, health education conflicts of interest: none. lueddeke g. preparing society to create the world we need through ‘one health’ education’ (commentary). seejph 2016, posted: 04 june 2016. doi: 10.4119/unibi/seejph-2016-122 3 human existence is deeply embedded in the natural world and the survival of all species, including our own, is wholly dependent on a healthy planet. but the health of our planet is in serious trouble. attempts by scientists, technical professionals, and policymakers to understand and solve many of the problems being confronted today have been fragmented, short-sighted and outpaced by the rate at which the world changes and catastrophic events occur (1). time is running short. as one example, data from the living planet index should “make us stop and think” (2): …in less than two human generations, population sizes of vertebrate species have dropped by half. these are the living forms that constitute the fabric of the ecosystems which sustain life on earth and the barometer of what we are doing to our planet, our only home. global inequities, conflicts and modernity impacting on the human dimension are equally and deeply worrying. in both low and high income nations growing concerns about poverty, ideological extremes, consumerism, and associated consequences are all indicative of a pressing need to reflect on the global status quo and to find constructive and long-term, sustainable strategies for both planet and people. 1 in this regard it is becoming increasingly clear that realigning our relationship with the planet and ourselves rests not with individuals or groups who follow their own narrow self-interests – corporate, political, ideological but with people who value collaborative approaches to these challenges and who embrace a bolder, broader more hopeful scope of human existence within a sustainable world. the “tragedy of the commons” (3) must become the „promise of the commons.‟ recognizing that species‟ interdependencies are rooted in the sanctity of life, we are tasked to ensure that the health and well-being of the planet must become the norm, not the exception, worldwide. in educating for a sustainable future: a transdisciplinary vision for concerted action (4), unesco highlighted that “education is the most effective means that society possesses for confronting the challenges of the future.” the significance of this resolve was also captured in the un‟s earth charter, which emphasized the importance of integrating into “education and life-long learning the knowledge, values, and skills needed for a sustainable way of life (principle 9)” (5). more recently, the un 2030-sustainable development goals (sdgs) reinforce this principle, declaring that by 2030: all learners acquire knowledge and skills needed to promote sustainable development, including among others through education for sustainable development and sustainable lifestyles, human rights, gender equality, promotion of a culture of peace and non violence, global citizenship, and appreciation of cultural diversity and of culture’s contribution to sustainable development (sdg 4) (6). the need to give the younger generation „a better deal‟ for helping to shape a sustainable world has been embraced by the global one health commission (ohc) (7) [in association with the one health initiative (8)]. we believe the best opportunity to achieve meaningful societal change and prepare future leaders to create a healthier world must be seized early on in children‟s lives as they form fundamental views of their places on the planet and carry those views forward into adulthood. the ohc [and partners] calls for collective action by legislators, public and private educators, and public health professionals to support the development and implementation of progressive and comprehensive global one health learning opportunities beginning in primary/secondary schools and extending through graduate and professional education. we envision a program that provides funding for national and global one health-themed educational initiatives that focus on the formation of:  basic values and responsibilities with respect to “the community of life” (5); lueddeke g. preparing society to create the world we need through ‘one health’ education’ (commentary). seejph 2016, posted: 04 june 2016. doi: 10.4119/unibi/seejph-2016-122 4  knowledge with respect to the interconnectedness of life on our planet;  real world application skills underpinned by interdisciplinary teamwork, creativity and group problem-solving; and  a global network of one health education providers who are committed to supporting learners and teachers in their quest to realize a more sustainable world. addressing these aims on national and global scales and linking the sdgs (6) to the one health concept/approach (9) is crucial. today “73 million young people are looking for work and many more are trapped in exploitative jobs” and “more than two and a half million more children in affluent countries” have fallen “into poverty, bringing the total above 76 million” (10). policymakers cannot ignore the connection between their plight and the world in which they live, that is, recognizing the interdependency of human, animal and environmental health and well-being. our argument is unequivocal: one health must extend to all living things implicit in the world health organization definition “good health is a state of complete physical, social and mental well-being” (11). to this end, we energetically assert that our proposed one health educational initiative is a fundamental step toward preparing the next generation of global citizens and visionary leaders to help shape the healthy, peaceful and sustainable world that we so vitally need (1,6)! references 1. lueddeke g. global population health and well-being in the 21st century: toward new paradigms, policy and practice. retrieved 2016, from: http://www.springerpub.com/global population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and practice.html. 2. world wildlife fund (wwf). living planet report 2014. retrieved 2014, from: wwf: http://wwf.panda.org/about_our_earth/all_publications/living_planet_report/. 3. hardin g. the tragedy of the commons. science 162: 1243–1248; 1968. 4. unesco. transdisciplinary vision for concerted action. retrieved 2014, from: http://unesdoc.unesco.org/images/0011/001106/110686eo.pdf. 5. unesco. the earth charter. retrieved 2016, from: http://www.unesco.org/education/tlsf/mods/theme_a/img/02_earthcharter.pdf 6. united nations. transforming our world: the 2030 agenda for sustainable development. retrieved 2015, from: https://sustainabledevelopment.un.org/post2015/transformingourworld. 7. one health commission (ohc). mission. retrieved 2016, from ohc home page: https://www.onehealthcommission.org/en/why_one_health/mission goals/ 8. one health initiative (ohi). mission statement. retrieved 2016, from ohi home page: http://www.onehealthinitiative.com/mission.php. 9. lueddeke g. achieving the un-2030 sustainable development goals through the „one world, one health‟ concept. retrieved 2016, from: https://www.onehealthcommission.org/documents/news/mar_25_2016_r_one_health_article_u s_9942316cb5117.pdf . 10. united nations. climate change and sustainability key to future development agenda, says former un official. retrieved 2015, from: http://www.un.org/apps/news/story.asp?newsid=50165#.vwuvqjwrjkg. 11. world health organization. trade, foreign policy, diplomacy and health. retrieved 2016, from http://www.who.int/trade/glossary/story046/en/. © 2016 lueddeke et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html http://wwf.panda.org/about_our_earth/all_publications/living_planet_report/ http://unesdoc.unesco.org/images/0011/001106/110686eo.pdf http://www.unesco.org/education/tlsf/mods/theme_a/img/02_earthcharter.pdf https://sustainabledevelopment.un.org/post2015/transformingourworld https://www.onehealthcommission.org/en/why_one_health/mission__goals/ http://www.onehealthinitiative.com/mission.php https://www.onehealthcommission.org/documents/news/mar_25_2016_r_one_health_article_us_9942316cb5117.pdf https://www.onehealthcommission.org/documents/news/mar_25_2016_r_one_health_article_us_9942316cb5117.pdf http://www.un.org/apps/news/story.asp?newsid=50165&amp;.vwuvqjwrjkg http://www.who.int/trade/glossary/story046/en/ http://creativecommons.org/licenses/by/3.0) msokwa r. improving access to health services in malawi (original research). seejph 2021, posted: 26 april 2021. doi : 10.11576/seejph-4383 p a g e 1 | 9 original research improving access to health services in malawi robert msokwa1 1 dedza district hospital, ministry of health, malawi; corresponding author: robert msokwa (bsc, mbbs college of medicine); address: dedza district hospital, ministry of health, malawi; email: m201650043380@stud.medcol.mw mailto:m201650043380@stud.medcol.mw msokwa r. improving access to health services in malawi (original research). seejph 2021, posted: 26 april 2021. doi : 10.11576/seejph-4383 p a g e 2 | 9 . abstract background: timely access to health care can substantially reduce mortality. the united nations sustainable development goal 3, target eight recommends provision of quality care to all must include usually underserved groups by 2030. universal access to healthcare remains unavailable particularly in rural areas, due to a shortage of labor, a lack of basic health-facility infrastructure, poor management practices, and insufficient financing in malawi, universal access to healthcare remains unavailable particularly in rural areas, however, no data is available from villagers themselves on improving access to health services. the aim of the study was to find ways of improving access to health services in malawi with focus on people staying in rural areas. methods: quantitative cross-sectional study. simple random sampling. face to face interview was conducted. results: the survey included 126 people, 97(77%) were women and 29 (23%) were men. 52 % participants were farmers, 7% of participants were employed, and 5% attainted tertiary education. common barriers to access health services which participants (35%) mentioned were lack of drugs and medical equipment, shortage of health personnel (25%), another 25% complained of long distance to nearest health facility. 10 % of participants fail to access health services due to poor design of hospitals and 5% failed to access health services due to rudeness of health workers. accessibility of health services in malawi can be improved by increasing number of clinics which was suggested by 28% of participants, 25% of study participants suggested training more health workers, 23% suggested of setting up of community fund to transport patients in cases of emergency, 20% of participants suggested of introducing mobile clinics and 4% suggested of designing of tricycle to be used for transport in rural areas. conclusion: access to health services in malawi can be achieved by training more health workers, introducing community funds, empowering local people to own the health facilities, increasing number of health facilities, designing tricycle which could travel in rural areas and improve drug supply and quality of medical equipment through increased funding from central government keywords: world health organization, health care workers, united nations, tuberculosis, acquired immune deficiency syndrome, human immune virus, christian health association of malawi, barriers, health services, health care access, sub-saharan africa msokwa r. improving access to health services in malawi (original research). seejph 2021, posted: 26 april 2021. doi : 10.11576/seejph-4383 p a g e 3 | 9 introduction ‘universal health coverage is defined as ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation, and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user the financial hardship’ (1). the united nation through sustainable development goal 3 recommends universal access to health services. this translates equal access to health services no matter you are rich or poor. every human being has a right to life by having access to universal health services [2]. nobody must die due to failure to access health services. death may only occur after doctors have tried all means to save life, but all available interventions have failed. according to the united nations (un) sustainable development goal 3, target eight, recommends ‘the provision of quality care to all must include underserved groups’, however studies had unveiled that most countries do not meet the world body recommendations. at least half of the world’s population does not get essential health services (3). according to a new report from the world bank and who, each year 100 million of people are being pushed into poverty extreme because they must pay for health care out of their own pockets, forcing them to survive on just $1.90 or less a day. ‘currently, 800 million people spend at least 10 percent of their household budgets on health expenses for themselves, a sick child or other family member’ (3). other continents are better in terms of access to health services as compared to africa. in africa, accessibility and coverage of essential health services are very low (4). ‘physical access to emergency hospital care provided by the public sector in africa remains poor and varies substantially within and between countries’ (5). africa accounts for almost half of the world’s deaths of children under five and has the highest maternal mortality rate, hiv /aids, tb, and malaria (7). people in sub-saharan africa have the worst health on the average in the world. it has only 3% of the world health workers [6].three countries (malawi, the philippines, and tanzania) saw deteriorations in both service coverage and financial protection (7). malawi as one of sub-saharan countries, health care provision is difficult because the population is largely rural, and 15 percent of malawians were unable to attend to their medical-health needs (8). malawi health care is also dispersed across the country. according to usaid report 2019, malawi has a high unmet need for family planning services (26%), with acute needs among young people [9]. in malawi almost one million people live with hiv, and about 34,000 new cases every year, 37 percent of malawian children suffer from chronic malnutrition and a large of malaria cases with an ‘incidence rate of 332 cases annually per every 1,000 people and approximately 4.8 million episodes of malaria per year. over a third of established positions in the health sector are vacant and there is a perpetual shortage of qualified health workers in facilities across the country’ (8). universal access to healthcare remains unavailable particularly in rural areas, due to a shortage of labor, a lack of basic health-facility infrastructure, poor management practices, and insufficient financing (7). methods the study design was a quantitative crosssectional study, and the study setting was chitipa, dedza and mangochi districts in malawi. the study was conducted between march and july 2020.the sampling strategy was simple random sampling. people who met the preferred age group were interviewed. the sample size was determined by msokwa r. improving access to health services in malawi (original research). seejph 2021, posted: 26 april 2021. doi : 10.11576/seejph-4383 p a g e 4 | 9 assessing the number table of numbers was used in coming up with sample size. from population of three hundred twenty five people in three selected areas, a sample had 126 participants for ±7% precision level and confidence level was 95% and p<0.5. about thirty-one patients were selected from chitipa, forty-eight were selected from dedza and ninety-five patients were selected from mangochi. local people aged between 18 years and above who use health services participated in the study. data was collected using a structured questionnaire with close – ended questions was formulated in english. questions which were in cooperated in the questionnaire answer objectives of the study that was mainly focused on accessing universal health services in malawi.there after each participant was interviewed using a questionnaire. three clerks were trained to collect the data. data management included questionnaires being collected from study participants were checked for mistakes. thereafter it was transported in a locked brief case to the house of the researcher. upon arrival at home, it was kept safely and locked in drawer to prevent access by other people. to ease entry in the computer, coding was done to all questions on a questionnaire. after finishing coding, the data was entered in the computer using excel database. data analysis data analysis was done using computer aided programs such as microsoft excel and epi info tables, pie charts and bar graphs were constructed using excel. ethical consideration consent was obtained from the district commissioner, institutional research team, traditional authority and village leader before conducting the study. consent was also be obtained from participants. participants names were not indicated on the questionnaire. results the study was conducted in chitipa, dedza and mangochi districts in malawi. a total of 126 participants were interviewed in rural health centers. the target population are people aged 18 years and above (table: 1). the majority of the participants (43%) were within the age group of 23-33 years, 1% of participants were in 83-93 age range. most women (77%) participated in the study. 80% of the participants were married and 12% were single. 56% of the participants had attained primary education and 2% were illiterate. 52% of participants were farmers and 3% earn their living by doing business. 27% of study participants were c.c.a.p. members and 2% were muslims. malawians have several barriers to access health services (figure 1) according to the study findings; 35% of study participants said that lack of drugs and medical equipment was a barrier to access health services while 25% of participants said that shortage of health care workers was a barrier to access health services. participants proposed several methods of improving accessing to health services in their respective areas (figure 2); 28% participants suggested that increasing number of clinics can improve access to health services which is seconded by 25% participants who suggested that by training more health care workers could improve access to health services. table 1: social demographic characteristics of the study population msokwa r. improving access to health services in malawi (original research). seejph 2021, posted: 26 april 2021. doi : 10.11576/seejph-4383 p a g e 5 | 9 characteristics variable number (n=126) percent age sex female 97 77% male 29 23% age group 18-23 34 27% 23-33 54 43% 33-43 20 16% 43-53 4 3% 53-63 5 4% 63-73 6 5% 73-83 1 1% 83-93 2 1% marital status married 101 80% single 15 12% divorced 5 4% windowed 5 4% education level primary 71 56% secondary 47 37% tertiary 6 5% illiterate 2 2% occupation employed 2 7% business 1 3% farmer 16 52% others 12 39% religion c.c.a.p. 34 27% catholic 26 21% pentecostal 14 11% muslim 3 2% others 49 39% figure 1: common barriers to seek universal health services msokwa r. improving access to health services in malawi (original research). seejph 2021, posted: 26 april 2021. doi : 10.11576/seejph-4383 p a g e 6 | 9 figure 2: methods of improving health services to people discussion the universal declaration of human rights of the united nations states in article 3 that everyone has the right to life, liberty, and security of person (12). every human being at some point in his/her journey become sick., to restore normal human health some health 25% 35% 5% 25% 10% 0% 5% 10% 15% 20% 25% 30% 35% 40% barriers to seek health services 4% 25% 23% 20% 28% methods of improving health services tricycle train more health workers community fund mobile clinics introduction increasing numberr of clinics msokwa r. improving access to health services in malawi (original research). seejph 2021, posted: 26 april 2021. doi : 10.11576/seejph-4383 p a g e 7 | 9 conditions requires to seek health services failing to do so result into loss of life. therefore, access to health services is a human right. contrary to united nations recommendation, the study carried out in some parts of malawi had revealed that people do not have access to right to health services. the study (figure 1) has found several factors hindering people to access health services. in the study, 35% of participants fail to access health services due to lack of drugs and medical equipment. malawi as developing country does not have sophisticated equipment to diagnose some diseases. currently there is only one magnetic resonance imaging (mri) for imaging brain tumors). there is no radiotherapy facility for cancer patients. as result some patients become disappointed with this and never return to the hospital for the second time when they are sick. the study findings correlate with usaid report for 2019 which stated that malawi has poor health services due to poor health financing although percentages were not mentioned [9]. however, a study conducted by institute of public opinion and governance (7) found that 29% of malawians cited the absence of necessary treatment as a reason for being unable to attend to their medical services which a bit lower than in our study. the difference may be due to the target population interviewed. the study had revealed the second barrier to access health services in malawi as lack of health workers which was at 25%. usaid global health for 2019 reported similar results. ‘over a third of established positions in the health sector are vacant and there is a perpetual shortage of qualified health workers in facilities’ across malawi (8). long distance of travel to visit the nearest is another barrier to seek health services which also at 25%. most health facilities are dispersed especially in rural. a study conducted in malawi by institute of public opinion and governance in 2016 reported similar findings. another study conducted by lancet global health across africa revealed that hospitals in the continent are dispersed and people take long time to access health services to the nearest hospital. the investigator was interested in approaches of improving universal access to health services. formulation of solutions for access to health services depends on the problems identified. different countries have different barriers for access to health services. in the study conducted in malawi by the researcher (figure 2), participants came with several solutions of improving access to health services. the majority (28%) of participants suggested that access to health services can be improved by increasing number health facilities such as clinics in locations where people stay. most participants said that health services must be brought closer to end users. the government must allocate more money to build health facilities according to the abuja declaration (10) and world bank report of 2018 [11]. the study agrees with world bank, global health report for 2018 (13) which recommends at least 15% budget allocation to the health sector. another group of participants (25%) suggested training of more health workers to work in hospitals could solve the problem. by training more health workers, will result improving quality of health services. the world bank report for 2018 also recommends improving quality health services as one way of improving access to health services. some participants (20%) reported introduction of mobile clinics can improve access to health services. mobile clinics can help to screen some diseases, provision of primary health care, and manage conditions associated with the elderly. halina et al. (14) also recommends improving primary health care as one way to improve access to health services. furthermore, universal health services can be improved by protecting all people from pandemics (12). msokwa r. improving access to health services in malawi (original research). seejph 2021, posted: 26 april 2021. doi : 10.11576/seejph-4383 p a g e 8 | 9 conclusion the study found that common barriers to access universal health services are lack of drugs and medical equipment, long distance of health facilities from residential areas of patients, and shortage of health workers. access to health services can be improved by improving drugs supplies, building more hospitals, empowering communities to own health facilities and training more health workers. references 1. who, "universal health coverage," 4 may 2020. (online). available: https://www.who.int/healthsystems/universal_health_coverage/en/. (accessed 31 july 2020). 2. un, "the universal declaration of human rights," united nations, new york, 1948. 3. w. &. w. bank, "tracking universal health coverage," world health organization, geneva, 2015. 4. m. yoshizu, "half the world lacks access to essential health services, 100 million still pushed into extreme poverty because of health expenses," who news letter, tokyo, 2017. 5. s. yaya, "universal health coverage and facilitation of equitable access to care in africa," front global health, vol. 7, no. 02, p. 3, 2019. 6. l. g. health, "access to emergency hospital care provided by the public sector in sub-saharan africa in 2015: a geocoded inventory and spatial analysis," lancet global health, vol. 6, no. 3, p. 4, 2018. 7. w. b. -ifc, "health and education," 16 june 2020. (online). available: https://www.ifc.org/wps/wcm/connect/region__ext_content/ifc_external_corporate_site/sub-saharan+africa/priorities/health+and+education/. (accessed 31 july 2020). 8. i. o. p. o. a. governance, "the local governance permonce index(lgpi) in malawi: selected findings on health," univesity of gothenburg, 2017. 9. usaid, "improving the health status of malawians in targeted districts," 19 november 2019. (online). available: https://www.usaid.gov/malawi/global-health. (accessed 25 july 2020). 10. a. &who, "abuja declaration: ten years on," 2011. (online). available: https://www.who.int/healthsystems/publications/abuja_declaration/en/e abuja declaration: ten years on. (accessed 29 july 2020). 11. w. bank, "lack of health a waste human capital.:5 ways to achieve universal access to health services by 2030," world bank, new york, 2018. 12. a. f. d. s. n. rozita halina tun hussein, "opinion: 5 ways to make progress towards universal health coverage," devex, 12 december 2017. (online). available: https://www.devex.com/news/opinion-5-ways-to-make-progress-towards-universal-health-coverage91726. (accessed 25 july 2020). 13. s. n. adam wagstaff &, "a comprehensive assessment of universal health coverage in 111 countries: a retrospective observational study," lancet global health, vol. 8, no. 1, p. 13, 2019. 14. p. k. trani jean-francois, "assessment of progress towards universal msokwa r. improving access to health services in malawi (original research). seejph 2021, posted: 26 april 2021. doi : 10.11576/seejph-4383 p a g e 9 | 9 © 2021 msokwa et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. health coverage for people with disabilities in afghanistan: a multilevel analysis of repeated cross-sectional surveys," lancet global health, vol. 14, no. 6, 2017. ____________________________________________________________________________ bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph2014-53 1 editorial e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health jadranka bozikov 1 1 department for medical statistics, epidemiology and medical informatics, andrija stampar school of public health, school of medicine, university of zagreb, zagreb, croatia. corresponding author: jadranka bozikov, phd address: andrija stampar school of public health, rockefeller st. 4, zagreb, croatia; telephone: +38514590101; e-mail: jbozikov@snz.hr conflicts of interest: none. bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph2014-53 2 health has never been an european union (eu) priority like agriculture, research, ecology or food safety and still remains to be first of all, if not exclusively, the responsibility of member states (ms). from the eu perspective, health is the crosscutting policy sector dominated by many other policies, especially by the “hard law” regulations of the internal market. in the preceding two volumes, the south eastern european journal of public health (seejph) published an admirable lengthy article by hans stein and equally splendid supplemented commentary by bernard merkel recounting and evaluating developments of the eu’s health policy from the 1992 maastricht treaty (and even from earlier) to the present-day state and future perspectives (1,2). although health still has very weak basis in the eu legislation, it has evolved from “non-topic” into a key area of the eu economic policy (1), but despite a growing competence “the unfinished story of the eu health policy” is slowly moving from declarative to operational phase in developing framework for circulation of health goods and related items within europe and beyond (2). in his commentary, dr merkel has summarized changes in treaties and other regulations from 1971 (directive on pharmaceuticals and regulation on coordination of social security systems providing rights to health care to workers in other ec countries) through the following milestones: (i) the article 129 of the maastricht treaty that for the first time introduced health although in a very weak manner; (ii) the 1997 treaty of amsterdam that extended the public health article and introduced the new one (article 152) including for the first time a few specific areas related to blood and organs, some veterinary and phytosanitary areas and other things, and; (iii) finally, the 2007 lisbon treaty with inclusion of medicinal products and medical devices but also incorporating the charter of fundamental rights of the eu including the right to access health care (preventive and curative, article 35 of the charter) (3). having in mind also the common currency introduced and spreading since 1999, the conclusion that single market will finally have an impact on health and health policy stands up. on the other hand, charter of fundamental rights of the eu (proclaimed in the year 2000 but being put in the new legal environment since it became formally binding by the lisbon treaty in 2009) has declared in its article 35 in addition that “a high level of human health protection shall be ensured in the definition and implementation of all union policies and activities” prior than this principle became known as health in all policies (hiap) during the finish eu presidency in 2006. according to what has been mentioned above, population health and organization of health system (including health insurance) has always been and remains a national responsibility. at the same time, the eu member states (as well as accession candidates and potential candidates) were shaping their health policies, implementing activities and monitoring systems directed by recognized international organizations such as who and oecd (and, more recently, the eu) and also used their support in responding to health threats from communicable diseases and disasters, as well as in combating the growing burden of non-communicable diseases. finally, single market principles are going to enter health sector somehow through “backdoor” via instruments such as directive 2011/24/eu on the application of patients’ rights in cross-border healthcare that came into force on 25 th october 2013 (4), up to now without a great success, but with potential to improve access to healthcare services and harmonize their quality within the eu member states and push them to cooperate closer in establishing of health networks in order to meet patients’ expectations. another very important opportunity for european integration is influencing and penetrating health sector from a much broader perspective of fast developing communication technologies. bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph2014-53 3 a digital agenda for europe initiative was selected as one of the seven flagship initiatives supposed to be crucial for obtaining the targets of europe 2020 strategy for smart, sustainable and inclusive growth (5). the adoption of europe 2020 strategy in 2010 was followed by “ehealth action plan 2012-2020” (6), a new one after the previous adopted in 2004 (7), and “a digital single market strategy” for europe which was adopted in may 2015 after the new european commission elected in 2014 set up ten priority policy areas in its agenda for jobs, growth, fairness and democratic change including the priority to create “a connected digital single market” listed as no. 2 priority by jean-claude juncker in his opening statement speech before the european parliament delivered on the 15 th of july 2014 (8,9). it is expected that the creation of digital single market will enable the creation of new jobs, notably for younger jobseekers, and a vibrant knowledge-based society. enhancement of the use of digital technologies and online services was proclaimed as a horizontal policy, covering all sectors of the economy, as well as the public sector including health, and common european data protection rules were seen as a necessary prerequisite. facts about the “digital agenda for europe initiative and digital single market (dsm) strategy” are available at the respective web-site (10), where we can also find new information and follow developments and public consultations on selected topics of interest. the “digital agenda for europe initiative” proposes to better exploit the potential of information and communication technologies (icts) in order to foster innovation, economic growth and progress. it consists of the following seven pillars: i. digital single market ii. interoperability & standards iii. trust & security iv. fast and ultra-fast internet access v. research and innovation vi. enhancing digital literacy, skills and inclusion vii. ict-enabled benefits for eu society a “digital single market” (dsm) is one in which the free movement of persons, services and capital is ensured and where individuals and businesses can seamlessly access and exercise online activities under conditions of fair competition, and a high level of consumer and personal data protection, irrespective of their nationality or place of residence. at (10) we can find definitions of e-health and m-health as well as information on what is going on in digital society including the public consultations launched on respective topics. information and communication technology for health and wellbeing (e-health) is becoming increasingly important to deliver top-quality care to european citizens and includes informatisation of health care systems at all levels (from local through institutional and regional to european and global level including use of tele-consultations and telemedicine. mobile health (m-health) is a sub-segment of e-health and covers medical and public health practice supported by mobile devices. it especially includes the use of mobile communication devices for health and wellbeing services and information purposes, as well as mobile health applications. particularly important are policies for healthy and active ageing with help of ict and use of mobile applications for health and wellbeing including home care monitoring devices (wired and mobile). there are already more than 100,000 applications for health, fitness and wellbeing obtainable for different mobile platforms, the majority of which are designed for apple ios and android smart phones. bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph2014-53 4 the european commission often consults with stakeholders on a number of subjects and such consultations can be found on the pages of digital agenda for europe (10). the commission launched a public consultation on the green paper on mobile health (11) on 10th of april 2014. the green paper on mobile health covered broad scope of m-health potential for both, healthcare and market. main potential for healthcare are seen in (i) increased prevention and quality of life approach, (ii) more efficient and sustainable healthcare, and (iii) more empowered patients. having in mind that the healthcare systems’ organization is a national competence green paper focused on cross-border european-wide issues and on possible coordinated actions at eu level that could contribute to the scale-up of m-health in europe by putting 11 issues at stake: 1. data protection, including security of health data 2. big data 3. state of play on the applicable eu legal framework 4. patient safety and transparency of information 5. m-health role in healthcare systems and equal access 6. interoperability 7. reimbursement models 8. liability 9. research and innovation in m-health 10. international cooperation 11. access of web entrepreneurs to the m-health market the commission also published a staff working document on the existing eu legal framework applicable to lifestyle and wellbeing apps, aiming at providing simple guidance to application developers on eu legislation in the field (12) and invited the views of stakeholders like:  regional and national authorities e.g. health ministries, authorities dealing with medical devices/data protection  health professionals, carers, health practitioners, medical associations  consumers, users of m-health apps, patients and their associations  web entrepreneurs  app developers and app stores  manufacturers of mobile devices  insurance agencies  sports centres, health clubs, and the like. consultation was open for more than three months during which stakeholders responded to 23 questions on a wide range of themes: data protection, legal framework, patient safety and transparency of information, m-health role in healthcare systems and equal access, interoperability, reimbursement models, liability, research & innovation, international cooperation and web entrepreneurs’ market access. a total of 211 responses were received and summarized in the published report (13). besides the great potential for health and wellbeing, there are some concerns, as well. the safety of mobile health solutions (and of some lifestyle and wellbeing applications, too) is a main cause for concern, explaining the potential lack of trust. there are reports pointing out that some solutions do not function as expected, and may not have been properly tested or in some cases may even endanger people’s safety. that is why on both sides of the atlantic, regulations for medical devices including software applications are established and continuously updated (14-16). it is beyond the scope of this article to discuss the importance bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph2014-53 5 and the need of certification of e-health and m-health devices and software, but health professionals must carefully take this issue into account and stick to guidelines and recommendations issued by regulatory agencies and bodies as those cited. undoubtedly, e-health and m-health have a large potential for health and wellbeing through empowering of patients and enabling them to take responsibility for their own health while reducing the ever-growing healthcare costs. at the same time, health professionals and students need to be educated and trained to evaluate such applications or at least to take into account their limitations. my personal experience has shown that medical students are capable to test m-health applications and understand the need for validation and certification of such applications. they successfully prepared a seminar in medical informatics using their own smart phones. within the same course students received assignments to read, understand and present eu directives, charters and other documents (e.g. 3,4,6,11,14,16) in order to become acquainted with the european integration in health. health systems in the eu are facing the common challenge of a rise in chronic diseases as a consequence of our increasingly ageing population. vytenis andriukaitis, the eu commissioner for health and food safety, entitled his column in august 2015 issue of the european journal of public health “how the ehealth can help with europe’s chronic diseases epidemic” (17). quotes from this article are presented below: “as a former medical doctor, i am fascinated with innovative solutions that are part of today‟s medical toolbox. i would like to highlight ehealth in particular. the more i learn about ehealth, the more convinced i am that it can enable better health, better and safer care for citizens and more efficient and sustainable healthcare systems. ehealth and mhealth can deliver more tailormade, „citizen-centric‟ care, more targeted and effective therapies, and help reduce medical errors.” good to hear that ehealth network has adopted the guidelines on electronic prescriptions needed for their cross-border exchange and progress in interoperability: “although the deployment of ehealth is the responsibility of member states, the eu adds value in many ways. the ehealth network set up under the cross-border health care directive provides a forum for cooperation, support and guidance for speeding up the broad use of ehealth services and solutions. facilitating interoperability and safe and efficient handling of electronic health data across national and organizational boundaries is a key issue. the ehealth network has already adopted guidelines on cross-border exchange of patient summaries and prescriptions. these guidelines encourage the adoption of ehealth applications at national level.” guidelines on eprescriptions dataset adopted by ehealth network (18) are intended to be complementary to the commission implementing directive 2012/52/eu of 20 december 2012 laying down measures to facilitate the validation of medical prescriptions issued in another member state (19), but also as another document for implementation in the near future. references 1. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives. seejph 2014; posted: 23 december 2014. doi 10.12908/seejph-2014-36. 2. merkel b. a growing competence: the unfinished story of the european union health policy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-201449. 3. charter of the fundamental rights of the european union. (2000/c 364/01). available at: http://www.europarl.europa.eu/charter/pdf/text_en.pdf (accessed: september 29, 2015). http://www.europarl.europa.eu/charter/pdf/text_en.pdf bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph2014-53 6 4. directive 2011/24/eu of the european parliament and of the council of 9 march 2011 on the application of patients’ rights in cross-border healthcare. available at: http://eurlex.europa.eu/lexuriserv/lexuriserv.do?uri=oj:l:2011:088:0045:0065:en:pdf (accessed: september 29, 2015). 5. europe 2020 a strategy for smart, sustainable and inclusive growth. available at: http://eur-lex.europa.eu/legal-content/en/txt/pdf/?uri=celex:52010dc2020 (accessed: september 29, 2015). 6. e-health action plan 2012-2020 innovative healthcare for the 21st century. available at: http://ec.europa.eu/health/ehealth/docs/com_2012_736_en.pdf (accessed: september 29, 2015). 7. e-health making healthcare better for european citizens: an action plan for a european ehealth area. available at: http://eurlex.europa.eu/lexuriserv/lexuriserv.do?uri=com:2004:0356:fin:en:pdf (accessed: september 29, 2015). 8. a digital single market strategy for europe. available at: http://ec.europa.eu/priorities/digital-single-market/docs/dsm-communication_en.pdf (accessed: september 29, 2015). 9. juncker jc. a new start for europe: my agenda for jobs, growth, fairness and democratic change. political guidelines for the next european commission, july 15, 2014, strasbourg. available at: http://ec.europa.eu/priorities/docs/pg_en.pdf (accessed: september 29, 2015). 10. digital agenda for europe. a europe 2020 initiative. available at: https://ec.europa.eu/digital-agenda/en/digital-agenda-europe-2020-strategy (accessed: october 02, 2015). 11. green paper on mobile health (“mhealth”). available at: https://ec.europa.eu/digitalagenda/news-redirect/15512 (accessed: october 02, 2015). 12. commission staff working document on the existing eu legal framework applicable to lifestyle and wellbeing apps. accompanying the document green paper on mobile health (“mhealth”). available at: http://ec.europa.eu/newsroom/dae/document.cfm?doc_id=5146 (accessed: october 02, 2015). 13. summary report on the public consultation on the green paper on mobile health. available at: http://ec.europa.eu/newsroom/dae/document.cfm?doc_id=8382 (accessed: october 02, 2015). 14. fda. mobile medical applications. guidance for industry and food and drug administration staff. document issued on february 9, 2015. available at: http://www.fda.gov/downloads/medicaldevices/.../ucm263366.pdf (accessed: september 29, 2015). 15. fda. medical devices data systems, medical image storage devices, and medical image communications devices. guidance for industry and food and drug administration staff. document issued on february 9, 2015. available at: http://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidancedocu ments/ucm401996.pdf (accessed: september 29, 2015). 16. ec. dg health and consumer. guidelines on the qualification and classification of standalone software used in healthcare within the regulatory framework of medical devices (meddev 2.1/6 january 2012). available at: http://ec.europa.eu/health/medicaldevices/files/meddev/2_1_6_ol_en.pdf (accessed: september 29, 2015). 17. andriukaitis v. how ehealth can help with europe's chronic diseases epidemic. eur j public health 2015;25:748-50. http://eur-lex.europa.eu/lexuriserv/lexuriserv.do?uri=oj:l:2011:088:0045:0065:en:pdf http://eur-lex.europa.eu/lexuriserv/lexuriserv.do?uri=oj:l:2011:088:0045:0065:en:pdf http://eur-lex.europa.eu/legal-content/en/txt/pdf/?uri=celex:52010dc2020&from=hr http://ec.europa.eu/health/ehealth/docs/com_2012_736_en.pdf http://ec.europa.eu/priorities/digital-single-market/docs/dsm-communication_en.pdf http://ec.europa.eu/priorities/docs/pg_en.pdf https://ec.europa.eu/digital-agenda/en/digital-agenda-europe-2020-strategy%20(2 https://ec.europa.eu/digital-agenda/news-redirect/15512 https://ec.europa.eu/digital-agenda/news-redirect/15512 http://ec.europa.eu/newsroom/dae/document.cfm?doc_id=5146 http://ec.europa.eu/newsroom/dae/document.cfm?doc_id=8382 http://www.fda.gov/downloads/medicaldevices/.../ucm263366.pdf bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph2014-53 7 18. guidelines on eprescriptions dataset for electronic exchange under cross-border directive 2011/24/eu. release 1. adopted by ehealth network. available at: http://ec.europa.eu/health/ehealth/docs/eprescription_guidelines_en.pdf (accessed: september 29, 2015). 19. commission implementing directive 2012/52/eu of 20 december 2012 laying down measures to facilitate the recognition of medical prescriptions issued in another member state. available at: http://ec.europa.eu/health/cross_border_care/docs/impl_directive_presciptions_2012_en.pdf (accessed: september 29, 2015). ___________________________________________________________ © 2015 bozikov; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://ec.europa.eu/health/ehealth/docs/eprescription_guidelines_en.pdf brauneis s, sorrentino e, di lisa v, galluccio g, piras b, carella f, et al. assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy (original research). seejph 2021, posted: 17 march 2021. doi: 10.11576/seejph4240 p a g e 1 | 13 original research assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy stefano brauneis1, enza sorrentino1, vincenza di lisa1, gabriella galluccio1, barbara piras2, francesca carella3, edoardo palozzi3, carmela generali3, simona maggiacomo3, silvia d’aurelio3, insa backhaus3, filippo la torre4, ciro villani5, giuseppe la torre3 1 pain center, "policlinico umberto i” hospital, sapienza university of rome, rome, italy; 2 casilino hospital, rome, italy; 3 department of public health and infectious diseases, sapienza university of rome, rome; 4 surgical sciences and emergency department, policlinico umberto i/sapienza university of rome, rome, italy; 5 department of orthopaedic and traumatology, policlinico umberto i hospital sapienza university of rome, rome, italy. correspondending author: prof. giuseppe la torre; address: piazzale aldo moro 5 – 00185, rome, italy; telephone: +39(0)649694308/+39(0)649970978; email: giuseppe.latorre@uniroma1.it brauneis s, sorrentino e, di lisa v, galluccio g, piras b, carella f, et al. assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy (original research). seejph 2021, posted: 17 march 2021. doi: 10.11576/seejph4240 p a g e 2 | 13 abstract aim: the aim of this study was to assess the prevalence of low back pain (lbp) among health professionals and the possible risk factors. methods: the study was carried out from april 2018 to october 2018 among all health workers of the orthopaedic clinic and the emergency department of “policlinico umberto i” in rome. lbp was assessed using the nordic questionnaire musculoskeletal disorders in the section on lumbar pain. the type of physical activity carried out as prevention was investigated by use of the international physical activity questionnaires. the overall state of health and lifestyle was determined by the short form 12-item health survey. job satisfaction and perceived work stress were assessed through the 15-questions of karasek’s questionnaire. the intensity of the low back pain was assessed using a numerical rating scale. a univariate analysis was conducted to assess the associations between socio-demographic and working variables. multiple logistic regression models were used to assess independent correlates of lbp. results: one hundred thirteen subjects were enrolled, 52 women and 61 men. the annual periodprevalence of lumbar musculoskeletal disorder was found on 79.6% of participants with lbp. mean value evidence of nrs was 2.66. the highest lbp risk over the 12 months was found in groups with high job demand (or = 1.18; 95%ci: 1.01 – 1.38), low decision-making opportunities (for decision latitude or = 0.87; (0-76 – 1.0), and low levels of physical activity (or = 0.75; 95%ci: 0.64 – 0.89). conclusion: the working environment is a potential risk factor for the development of lbp and is suitable for prevention programmes. the protective effect of physical activity and work-related stress management indicate room for improvements for the prevention of lbp in these hcws. keywords: health workers, low back pain, occupational low back pain, operating room health professionals, prevention. conflicts of interest: none declared. brauneis s, sorrentino e, di lisa v, galluccio g, piras b, carella f, et al. assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy (original research). seejph 2021, posted: 17 march 2021. doi: 10.11576/seejph4240 p a g e 3 | 13 introduction low back pain’s incidence in adult population is 10-30% every year and the lifetime prevalence in adults is as high as 65-80% in usa (1,2). people in working age, from 26 to 60 years, are affected by low back pain at least once in their lifetime (3). occupational low back pain (lbp) has become an emerging health issue in recent years (4,5). in italy a review found that lbp prevalence in healthcare workers varied from 33% to 86% (6). among health care workers, nurses and surgeons are the working categories with the highest risk of experiencing pain related to musculoskeletal disorders (msds) during their working life. this risk is related to a broad range of factors such as incorrect postures, exposure to heavy physical loads, muscle strain, whole-body vibrations (wbv), patient treatment activities (3,7-10) and may affect the ability and the efficiency of health care workers in the performance of their tasks (10). awkward postures, carrying and repositioning patients, prolonged standing, and working without sufficient breaks represent risk factors for the developing of lbp in nurses (11). among physicians the prevalence of lbp is higher among surgeons (37%) than other specialties (9,12,13). the inappropriate positioning, posture during surgery, and prolonged standing are possible cause (14,15). persistent low back pain comes along with several consequences and can cause temporary work disability with sick leave (16). work-related msds are the number one cause of absenteeism among the health care workers. the us department of labor estimates that msds are the cause of 62% of all worker injuries and 32% of missed days from work, and an estimated economic impact of $13 to $20 billion every year (9). it is essential to promote new prevention programmes based on vocational training and physical activity to provide benefits and reduce the incidence of lbp in these professional categories since it’s been demonstrated that muscle strength is a protective factor against physical fatigue and msds (12,17). due to the prolonged activity and the burden of workload on spine and shoulders of operating room health workers, as detected during the occupational health visit, the aim of the study was to assess the prevalence of lbp related to the work activity in a group of health workers, from the orthopaedic clinic and the emergency department, and the associated risk factors. methods this observational study was led by the pain therapy center “enzo borzomati” – hub lazio region, in collaboration with occupational medicine and medical radiation protection service of the university hospital "umberto i" in rome. approval to conduct this study was obtained from the ethical committee of our university hospital (5030/18). all study participants gave informed written consent and the research was conducted in accordance with the helsinki declaration. data were collected from april 2018 to october 2018 among health workers of the orthopaedic clinic and the emergency department of “policlinico umberto i” in rome participation in the study was voluntary and anonymous. setting and population all healthcare professionals who were working in the operational unit of orthopaedic surgery and emergency department (dea) at brauneis s, sorrentino e, di lisa v, galluccio g, piras b, carella f, et al. assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy (original research). seejph 2021, posted: 17 march 2021. doi: 10.11576/seejph4240 p a g e 4 | 13 the “policlinico umberto i” in rome (italy) were invited to participate. they were approached by telephone and an appointment for the interview was fixed. admission criteria: i) healthcare professionals in the operational unit of orthopaedic surgery and emergency surgery; ii) candidates of both sexes and over the age of 18 and under 70 years old. exclusion criteria: i) participants in other studies; ii) subjects with serious local or systemic physical occurring pathologies that can interfere in the investigator’s judgment with pain assessment; iii) subjects with recent surgical procedure. data collection data were collected using standardised validated questionnaires in italian. the presence of low back pain was assessed using the italian version of the nordic questionnaire musculoskeletal disorders in the section on lumbar pain (18,19). the type and quality of physical activity carried out as prevention and/or therapy has been investigated with international physical activity questionnaires (ipaq) (20,21). the overall state of health and lifestyle was determined by short form 12-item health survey (sf-12 standard v1) (22-23). job satisfaction and perceived work stress were assessed through the 15-questions karasek questionnaire (24). the intensity of the low back pain was assessed using a numerical rating scale (nrs) (25). statistical analysis quantitative and qualitative variables were examined and their frequency was calculated: years of work, years of work in the company ("policlinico umberto i" university hospital in rome), type of permanent/occasional contract with continuous/split hours and fixed/rotation on several shifts. particular attention was paid to the body mass index (bmi, calculated considering the weight and height of the subject under examination) and the hours of work spent standing or sitting. a univariate analysis was conducted to assess the association between socio-demographic factors and working variables with the following variables derived from the nordic questionnaire musculoskeletal disorders: have you ever had low back pain disorders in the last few months? during the last 12 months, have your musculoskeletal disorders ever prevented you from performing your normal activities both at home and outside? have these disorders manifested themselves in the last seven days? have you ever had any lower back problems in your life? have you ever suffered any lower back trauma as a result of an injury? logistic regression models have been built for the variables “lumbar pain in the last 12 months” and “lumbar pain in the last 7 days” in order to verify the associated variables with a multiple regression approach. we built full model and stepwise models with a backward elimination procedure. the results are presented as odd ratio (or) and 95% confidence interval (95%ci). goodness of fit of the models was assesses using the hosmerlemeshow test. the level of significance was set at p≤0.05. the spss statistical package, version 25.0, was used. results one hundred thirteenhealth professionals (response rate 100%) completed the study. contingency tables have been elaborated to describe and analyse the relationships between two or more variables and to define the frequency tables, the results of which have brauneis s, sorrentino e, di lisa v, galluccio g, piras b, carella f, et al. assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy (original research). seejph 2021, posted: 17 march 2021. doi: 10.11576/seejph4240 p a g e 5 | 13 been graphically represented by histogram, box-plot, dot-plot. socio-demographic and clinical data were obtained by the nordic questionnaire musculoskeletal disorders, in relation to the lumbar section, which were identified as quantitative and qualitative variables associated with lbp. 52 women (46%) and 61 men (54%), were enrolled, aged between 26 and 68 years (average age = 42.76 years, st. dev. = 12; median = 44 years; mode = 29 years). participants were divided into different groups on the basis of qualification and recoded as follows: specialist medical surgeon: no. 18/113 15.9%; specialist medical personnel: n° 33/113 29.2%; nursing staff: no. 49/113 (4 nursing coordinators, 44 nurses) 43.4%; technical operator (ot): n° 7/113 6.2%; socio-medical caregiver (in italian medical system distinguished in two professional figures having ass and oss as acronyms) and technical caregiver (in italian medical acronyms ota): n° 6/85 (3ass, 2oss, 1ota) 5.3%. table 1 shows the characteristics of the study participants. out of 113 subjects examined: 111 subjects have permanent employment and only 2 occasional; 107 subjects have a full-time job and 6 subjects have a part-time job; 14 subjects work the morning shift, 39 in the morning and afternoon, 36 work the multishift rotation. table 1. characteristics of the study participants variable n (%) or median (range) gender female male 52 (53.8) 61 (68.9) age 44 (26 – 68) years of work 11.4 (0.3 – 40.3) hours of work standing up 6 (3-10) hours of work sitting 1.5 (0-20) continuous working hours no yes 12 (66.7) 101 (61.4) job role nurses other health professions technicians doctors in training structured doctors 49 (51) 6 (83.3) 7 (57.1) 33 (66.7) 18 (77.8) bmi (body mass index) 24 (18.1 – 36.2) met (metabolic equivalent of task) 3483 (0 – 79140) pcs (physical component summary) 49.5 (24.5 – 63.7) mcs (mental component summary) 46.4 (20.1 – 62.8) low back pain lifetime in the last 12 months in the last week 99 (87.6) 90 (79.6) 43 (38.1) decision latitude 68 (52 90) job demand 35(25 – 48) job strain 0.82 (0.49 – 1.29) brauneis s, sorrentino e, di lisa v, galluccio g, piras b, carella f, et al. assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy (original research). seejph 2021, posted: 17 march 2021. doi: 10.11576/seejph4240 p a g e 6 | 13 based on the analysed data, it was possible to calculate the prevalence of lbp with time intervals of one week, one year, over a lifetime and the percentage of subjects who have never had lbp experience. subsequently, the annual periodic prevalence of lumbar musculoskeletal disorder was quantified on the total of 79.6% of subjects with lbp. the intensity of lumbar pain in the last 7 days was evaluated using the numerical rating scale (nrs) with a mean value evidence, on a scale from 0 to 10, of 2.66. a predictive factor for persistent low back pain seems to be the presence of neuropathy in the lower limbs, with an incidence of 11.7% on the lifetime prevalence of lbp (table 2). table 2. lumbar pain in the last 12 months variable no yes p gender female male 9 (17.3) 14 (23) 43 (82.7) 47 (77) 0.458 age 47 (27 – 68) 43.5 (26 64) 0.343 years of work 10 (0.3 – 40) 12 (0.3 – 40.3 0.795 continuous working hours no yes 5 (41.7) 18 (17.8) 7 (58.3) 83 (82.2) 0.05 job role nurses other health professions technicians doctors in training structured doctors 12 (24.5) 1 (16.7) 1 (14.3) 6 (18.2) 3 (16.7) 37 (75.5) 5 (83.3) 6 (85.7) 27 (81.8) 15 (83.3) 0.914 bmi 23.4 (18.1 – 36.2) 24 (18.2 – 36.2) 0.559 job strain 0.79 (0.59 – 1.01) 0.82 (0.49 – 1.29) 0.290 met 2670 (495 17790) 3483 (0 79140) 0.392 mcs 48.3 (20.6 – 58.8) 48.8 (22.1 – 63.9) 0.746 pcs 55 (34.1 – 63.3) 50.6 (23.8 – 61.2) < 0.001 legend: bmi= body mass index; met = metabolic equivalent of task; mcs =mental component summary; pcs =physical component summary the 15-question karasek questionnaire provided data on psychosocial conditions at work and perceived work stress, i.e. it was possible to assess the worker's autonomy in making decisions concerning his or her job. this model suggests that the relationship between high job demand (job demand, jd) and low decision-making freedom (decision latitude, dl) defines a condition of "job strain" or "perceived job stress", which can explain the levels of chronic stress and the increased risk in this case of manifesting lbp (table 3). the two main working dimensions (jd vs dl) are considered independent variables and placed on orthogonal axes. the job demand refers to the work effort required, in terms of: work rhythms; taxing nature of the organization; number of working hours; any inconsistent requests. decision latitude, on the other hand, is defined by two components: skill discretion; brauneis s, sorrentino e, di lisa v, galluccio g, piras b, carella f, et al. assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy (original research). seejph 2021, posted: 17 march 2021. doi: 10.11576/seejph4240 p a g e 7 | 13 decision authority. on the one hand, the first identifies conditions characterized by the possibility to learn new things, the degree of repetitiveness of tasks and the opportunity to enhance one's skills; on the other hand, the second basically identifies the level of control of the individual on the planning and organization of work. table 3. lumbar pain in the last 7 days variable no yes p gender female male 28 (53.8) 42 (68.9) 24 (46.2) 19 (31.1) 0.102 age 47 (27 – 68) 43.5 (26 64) 0.993 years of work 10 (0.3 – 40) 12 (0.3 – 40.3 0.599 continuous working hours no yes 8 (66.7) 62 (61.4) 4 (33.3) 39 (38.6) 0.722 job role nurses other health professions technicians doctors in training structured doctors 25 (51) 5 (83.3) 4 (57.1) 22 (66.7) 14 (77.8) 24 (49) 1 (16.7) 3 (42.9) 11 (33.3) 4 (22.2) 0.204 bmi 23.4 (18.1 – 36.2) 24 (18.2 – 36.2) 0.316 job strain 0.79 (0.59 – 1.01) 0.82 (0.49 – 1.28) 0.562 met 2670 (495 17790) 3483 (0 79140) 0.224 mcs 48.3 (20.6 – 58.8) 48.8 (22.1 – 63.9) 0.668 pcs 55 (34.1 – 63.3) 50.6 (23.8 – 61.2) 0.001 legend: bmi= body mass index; met = metabolic equivalent of task; mcs =mental component summary; pcs =physical component summary through this tool it was possible to identify the classic four working conditions, defined as: high strain, high demand with low freedom of decision; passive, low demand with low decision making (work that does not encourage individual skills with marked levels of dissatisfaction); active, high demand with high decision (job with a high degree of learning and responsibility); low strain, low demand with high decision (optimal work situation, in which the individual can manage his working time independently). in accordance with this model and by including the most significant variables, including the task performed, the highest lbp risk over the 12 months was found in groups with high labour demand and low decision-making opportunities, represented in this case by health care personnel in training. the information on the physical activity performed was obtained by using the short form of the international physical activity questionnaire (ipaq), in which weekly frequency and average duration of physical activity (intense, moderate, walking) are required, regardless of whether during work or leisure time, and the number of hours per day spent sitting. in addition, to assess the degree of physical activity exercised and classify it as good / moderate / poor, the ipaq uses mets (metabolic equivalent of task), which have a different value depending on the effort brauneis s, sorrentino e, di lisa v, galluccio g, piras b, carella f, et al. assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy (original research). seejph 2021, posted: 17 march 2021. doi: 10.11576/seejph4240 p a g e 8 | 13 practiced, allowing to add up activities of different intensity. by combining the main characteristics in a multivariate analysis and recoding the data for the task performed, the results show that ass+oss+ota staff practice a good level of physical activity and are less at risk of developing lbp in the last 12 months. through the summary of the scores obtained from the 12 questions of the short form health survey (sf-12 standard v1 questionnaire), the general state of health was investigated using two synthetic indices, the physical component summary (pcs) for the physical state and the mental component summary (mcs) for the mental state. the values of the synthetic indices vary, on the observed sample, from 23.8 to 63.3 for the pcs and from 20.59 to 60.15 for the mcs index, indicating that their growth indicates better psychophysical health conditions (table 1). considering qualitative and quantitative variables and sample averages, the most relevant data acquired from all the questionnaires (gender, age, years of work, years of work in the company, days worked per week, continuous working hours, broken hours, daily standing hours, daily sitting hours, role, bmi, pcs, mcs, mets, job demand and decision latitude) were associated with the incidence of lumbar pain in the last 12 months and the last 7 days (tables 2 and 3). there are significant variables associated with lumbar pain over the last 12 months: continuous working hours (p = 0.05); high pcs scores, in protective terms (the higher the pcs level, the lower the probability of having had lumbar pain in the last 12 months). the only variable associated with lumbar pain in the last 7 days was pcs, with higher values of pcs indicating a protective effect. the multivariate analysis shows different results for the two dependent variables (table 4). firstly, lumbar pain in the last 12 months is directly associated with years of work (or = 1.16) and job demand (or = 1.18), and inversely associated with age (or = 0.81), decision latitude (or = 0.87) and pcs (or = 0.75). on the other hand, lumbar pain in the last 7 days is directly associated to being a nurse (or = 2.55) and inversely associated pcs (or = 0.91). table 4. results of the multiple logistic regression analyses. dependent variables: lumbar pain in the last 12 months lumbar pain in the last week variable lumbar pain in the last 12 months lumbar pain in the last 7 days full model backward elimination model full model backward elimination model gender female male (ref.) 1.66 (0.30 – 9.31) 1 0.73 (0.21 – 2.49) 1 age 0.80 (0.69 – 0.92) 0.81 (0.71 – 0.92) 0.94 (0.85 – 1.04) years of work 1.21 (1.04 – 1.41) 1.16 (1.03 – 1.32) 1.01 (0.92 – 1.10) continuous working hours yes no (ref.) 0.20 (0.04 – 1.03) 1 0.17 (0.04 – 0.81) 1 0.89 (0.23 – 3.41) 1 job role nurses doctors 0.60 (0.06 – 6.08) 0.95 (0.09 – 9.8) 1 3.37 (0.69 – 16.4) 1.28 (0.22 – 7.21) 1 2.55 (1.0 – 6.49) 1 brauneis s, sorrentino e, di lisa v, galluccio g, piras b, carella f, et al. assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy (original research). seejph 2021, posted: 17 march 2021. doi: 10.11576/seejph4240 p a g e 9 | 13 other health professions (ref.) bmi (body mass index) 0.84 (0.69 – 1.03) 0.98 (0.84 – 1.13) job demand 1.19 (1.01 – 1.40) 1.18 (1.01 – 1.38) 0.98 (0.87 – 1.10) decision latitude 0.86 (0.733 – 1.01) 0.87 (0-76 – 1.0) 1.02 (0.92 – 1.12) met 1.001 (0.99 – 1.003) 1.002 (1.00 – 1.003) 1.002 (1.00 – 1.003) mcs 1.07 (0.99 – 1.16) 0.99 (0.94 – 1.05) pcs 0.74 (0.62 – 0.88) 0.75 (0.64 – 0.89) 0.91 (0.85 – 0.97) 0.91 (0.86 – 0.96) discussion lbp is a very common health problem. in this study we found that in hcws that work in operating theatre have a prevalence of lbp of almost 80% and 38%, in the last year and the last week, respectively. results show that 14 out of 113 candidates (12.4% of the total) had never experienced lumbar pain in their lifetime, while 99 (87.6%) had experienced lbp at least once in their life. these data do not differ from what is stated in scientific literature (26-27). based on the data we can assume that: lbp’s incidence shows peaks in particular age groups characterized by intense work activity (28 to 32 yearsold and 40 to 45 years-old). there is no significant difference in lbp’s incidence between male and female population. high bmis are statistically associated with lbp. a sedentary lifestyle and low physical activity levels are risk factors and aggravating factors for lbp. an adequate muscle mass tone significantly reduces lbp’s occurrence. excessive working hours, especially with insufficient recovery time between activities, increase the incidence of lbp. lbp’s incidence is lower in nurses and higher in trainees, mainly because of the above-average number of continuous working hours for trainees. a high physical effort and an excessive mechanical load or an inadequacy of the load in relation to the physical competence of the subject increase the risk of experimenting lbp. the etiopathogenesis of lumbar pain therefore involves countless variables, including biophysical factors, genetic factors, psychological factors, social factors and comorbidities (1,2). most surgeons are usually subjected to physical and mental stress and suffer from msds (physical fatigue, stiffness and pain) involving different body areas, arising during or after surgery (17). there is an association between risk factors and musculoskeletal disorders most frequently due to static positions and extreme postures that require sustained effort in the absence of breaks or with inadequate recovery timing between surgeries (28). each surgical specialty has its own ergonomic characteristics (position and height of the operating table, position of monitors, design of laparoscopic instrument handles, etc.) and this evidence suggests that particular groups of surgeons may be at higher risk of having symptoms related to their profession. in addition, the affected body area varies according to the surgical specialty (29-31). previous works show that many health care workers complain of generalized pain (17.2%) and physical fatigue (36.2%) and experience msds more than once in their working life. the areas of the body most affected brauneis s, sorrentino e, di lisa v, galluccio g, piras b, carella f, et al. assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy (original research). seejph 2021, posted: 17 march 2021. doi: 10.11576/seejph4240 p a g e 10 | 13 by skeletal muscle disorders, in descending order of incidence, are (32,33): lumbar region of the spine (66.9%); cervical area of the spine (with associated headache) (65.4%); dorsal area of the spine (22.4%); lower extremities (leg and foot) (12.1%); wrist and right hand (8.6%); shoulder and right arm (8.6%). many health professionals report that pain, particularly lbp, interferes with quality of life, mental and physical health, quality of sleep and social relationships (34). persistent low back pain comes along with several consequences and can cause temporary work disability with sick leave. moreover, recurrent or persistent musculoskeletal disorders may affect the ability and efficiency of the surgeon to perform his or her work by encouraging him or her to favour the open surgical approach rather than minimally invasive surgery (mis) and/or to reduce the number of procedures or to discontinue surgery early (15, 35). from the prevention point of view, one of the most interesting results seems to be the protective effect on both dependent variables of the physical composite score, indicating that hcws involved in operating room are a perfect target of preventive programs based on regular physical activity. this result is supported by a recent systematic review and meta-analysis of rcts focused on prevention of lbp that indicates physical exercise as a protective factor against the risk of episodic lbp and sick leave due to lbp in general population (36). physical activity programs among professional health care workers could be recommended in order to prevent lbp, and this activity could be intended as part of a disability management program (15,17,37-39). another interesting point from a public health perspective is related to the association between job demand and decision latitude (as indicators of work-related stress) and lbp. our results are in agreement with those coming from the scarce literature on this issue on hcws (40,41), but according to our knowledge it is the first study that demonstrates the association between work-related stress items and lbp in operating room hcws. some limitations in this study must be acknowledged. first of all, the study carried out has a cross-sectional design, and the casual relationship between risk or protective factors and lbp cannot be completely clear. another possible limitation could be related to the settings involved, in terms of external validity. we involved only two settings (orthopedics and emergency room) and the validity of the results can be considered for these. we cannot be sure to 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2 international health partnerships association, member, scientific advisory committee; 3 international health partnerships association, member, management board. corresponding author: dr. maria ruseva, member, management board, international health partnerships association; address: bellmansgade 23, 7 tv., copenhagen 2100, denmark telephone: +45 22 500 664; e-mail: rusevamaria33@gmail.com alderslade r, fawcett-henesy a, ruseva m. on the perspectives of public health and what ihpa can contribute to its advancement in practice (editorial). seejph 2018, posted: 07 july 2018. doi10.4119/unibi/seejph-2018194 2 today’s health challenges are formidable. they include patterns of behaviour leading to increased mortality and morbidity from noncommunicable diseases; the rapid spread of infectious pathogens and the potential for global pandemics; national disasters, conflicts and mass population movements; antimicrobial resistance; urbanization, and the health impacts of climate change and environmental pollution. the sustainable development goals (sdgs) (1), the health 2020 european health policy framework (2), and the european action plan for the strengthening of public health capacities and services (eap-phs) (3) all make clear that development programmes should aim to improve health and well-being equitably. this means that government priorities, policies, and budgets should be health orientated, based on health impact assessment, and focused on sustainability. to achieve this, governments require a national health policy that emphasizes a multisectoral approach across all their actions and the whole of society. a focus is needed on “upstream” determinants of health if better outcomes and reduced inequities are to be realised. this needs an interconnected, horizontal and networked system of governance which is open, collaborative and consensual. public health practitioners should be able to work with complexity and to speak the language of other sectors and share their agendas. to respond to this new environment, eap-phs is a main pillar of health 2020. the ten essential public health operations (ephos), provide a common frame for the member states (below). they deal comprehensively with genetic, political, social and economic, environmental, commercial, cultural and health system determinants. the essential public health operations for europe (4) 1. surveillance of population health and well-being 2. monitoring and response to health hazards and emergencies 3. health protection including environmental, occupational, food safety and others 4. health promotion including action to address social determinants and health inequity 5. disease prevention, including early detection of illness 6. assuring governance for health and well-being 7. assuring a sufficient and competent public health workforce 8. assuring sustainable organizational structures and financing 9. advocacy, communication and social mobilization for health 10. advancing public health research to inform policy and practice today’s public health practice needs to tackle inequalities, promote equity in health, and work across sectors. modern public health needs to work in a horizontal and distributed way, identifying matters of public health concern which are ever changing. in particular, the european public health workforce needs substantial development in capacities and skills. while much progress has been made in countries with the implementation of the eap-phs and the ephos, facilitated by the who european regional office, the full potential of public health strengthening has certainly not yet been realised. with this in mind, in 2014 the international health partnerships’ association, (ihpa – www.ihpa.eu), was established to aim for a worldwide society where everyone lives in healthy alderslade r, fawcett-henesy a, ruseva m. on the perspectives of public health and what ihpa can contribute to its advancement in practice (editorial). seejph 2018, posted: 07 july 2018. doi10.4119/unibi/seejph-2018194 3 communities and the benefit of good health is equally accessible to all. the ihpa and its members are driven by this view of public health, using their expertise to promote and protect health and well-being, preventing ill-health and prolonging life, through the organized efforts of societies, of professionals, leaders and community-based groups. the ihpa members believe those who have the least deserve our best; hence it has a stubborn insistence that tomorrow’s world must be better than today’s. ihpa is committed to acknowledging diversity, equity, and inclusion. the association believes in the need for health improvement through the reduction of inequalities and inequities in health, better housing and access to employment. it understands the underlying causes of disparity and the way those factors influence all of us, as well as the communities we serve. it recognizes the role of the state, and the underlying socio-economic and wider determinants of health and disease. it has a deep understanding of the responsibility of individuals in their lifestyle choices, and the need for population surveillance and monitoring of specific diseases and risk factors. there have been many resounding statements and manifesto pledges – and broken promises. ihpa aims to give those pledges reality by achieving change for the public good. at the strategic level, ihpa advises public and private healthcare companies, government and international organizations about their business plans, strategies and policies. ihpa also works at local levels, where it believes that important improvements may often best be made. our work is centred on evidence, health intelligence and evaluation which we use to understand and promote better health and better value health care. ihpa, a non-governmental organization, works with governments and others to promote the right to health for all, to strengthen health systems and develop strategies that promote health, prevent disease and encourage healthy lifestyles. it seeks international contacts, partnerships with other organizations, assists its members and performs and supports research and development in its field. since its onset, the ihpa has placed all its capacities and services in support of european countries by working with and for the who regional office for europe on public health services, prevention and control of noncommunicable diseases, health promotion, and migration. ihpa has also worked with and for the see health network, a multi-governmental platform and organization of nine countries in south east europe. the efforts of the see governments and health sectors will be supported by the ihpa which has a wealth of capacities needed to support countries at national, community and grass-roots levels. on 1 st -2 nd april 2017, the ministers of the see health network and their international partners held their 4 th ministerial forum in chisinau, the republic of moldova (v). as a result, the fourth ministerial pledge was adopted, committing the nine countries to cooperate and work jointly towards achieving the sustainable development goals 2030 of the united nations, by implementing the newest european and global policies and best practices. implementing the policies to achieve the sdgs 2030 requires strong health systems and public health services. ihpa will join forces with the national public health and other health institutions as it is only through networking and learning from each other that practical results will be achieved. conflicts of interest: none. alderslade r, fawcett-henesy a, ruseva m. on the perspectives of public health and what ihpa can contribute to its advancement in practice (editorial). seejph 2018, posted: 07 july 2018. doi10.4119/unibi/seejph-2018194 4 references 1. https://sustainabledevelopment.un.org/post2015/transformingourworld (accessed: july 04, 2018). 2. the european health policy framework “health 2020” ,who europe, 2013. http://www.euro.who.int/__data/assets/pdf_file/0011/199532/health2020-long.pdf (accessed: july 04, 2018). 3. european action plan for strengthening public health capacities and services, who europe, 2012. http://www.euro.who.int/__data/assets/pdf_file/0005/171770/rc62wd12rev1-eng.pdf (accessed: july 04, 2018). 4. the 10 essential public health operations (epho) for europe were endorsed by all 53 european member states’ ministers of health during the 62 nd session of the who europe regional committee. http://www.euro.who.int/en/health-topics/health-systems/publichealth-services/policy/the-10-essential-public-health-operations (accessed: july 04, 2018). 5. report of the fourth south-eastern europe health ministerial forum on “health, well-being and prosperity in south-eastern europe by 2030 in the context of the 2030 agenda for sustainable development”. http://seehn.org/report-of-the-fourth-south-eastern-europehealth-ministerial-forum-on-health-well-being-and-prosperity-in-south-eastern-europeby-2030-in-the-context-of-the-2030-agenda-for-sustainable-dev/ (accessed: july 04, 2018). ______________________________________________________________________________________ © 2018 alderslade et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. brownell p. future directions for research on neglect, abuse and violence against older women (editorial). seejph 2019, posted: 19 february 2019. doi 10.4119/unibi/seejph-2019-205 page 1 of 8 e d i t o r i a l future directions for research on neglect, abuse and violence against older women patricia brownell1 1 fordham university, new york city, new york, usa. corresponding author: patricia brownell, phd, lmsw – associate professor emerita of social service, fordham university, new york city, new york, usa. brownell p. future directions for research on neglect, abuse and violence against older women (editorial). seejph 2019, posted: 19 february 2019. doi 10.4119/unibi/seejph-2019-205 page 2 of 8 the elder abuse field has developed significantly since its inception as a field of practice along with gerontology in the 1970s. research on elder abuse evolved later, stimulated by the work of the late rosalie wolf, considered a founder of the elder mistreatment field (1). much of this work has been interdisciplinary, with medicine, law, nursing, psychiatry and social work collaborating, as well as sociology. as a result, important research initiatives have significantly broadened our understanding of prevalence, and other dimensions of elder abuse, within aging and vulnerable adult frameworks. however, some aspects of elder abuse remain underdeveloped and open for further exploration. feminist perspective/domestic violence much work still needs to be done to bring elder abuse into the domestic violence field. feminist scholars particularly in the disciplines of sociology, social work and psychology in the 1980s and 1990s began to consider elder abuse within a feminist perspective (2). some limited intervention research on elder abuse in this frame was initiated (3,4). feminist gerontology has also been developing as a perspective (5). coming out of social gerontology and critical theory, this perspective seeks to focus on gender relations in gerontology and builds on the pioneering work of mary brickerjenkins and feminist social work practice (6). bringing elder abuse within the domestic violence framework has resulted in increased understanding of why older women have been invisible as victims and survivors of intimate partner abuse (7). some novel research methodologies have emerged from the european union (8) and the world health organization (9) in examining prevalence of abuse experienced by older women. another direction that has yet to be fully explored in the elder abuse literature with respect to older women and abuse is that of the application of complex trauma to an understanding of neglect, abuse and violence against women in later life (1015). life course perspective bringing a life course trauma-focused perspective may also address another gap in the literature on older women and abuse: the failure of gerontology and the vulnerable adult fields to focus on older women and abuse in spite of evidence that abuse is more prevalent for women of all ages, compared with men; and the failure of the domestic violence field to include women above the age of 49 in prevalence studies and to relegate older women in an “other” category (susan b. somers, president, international network for the prevention of elder abuse, personal communication, january 5, 2019). to place elder abuse within the field of family violence, we need to move beyond a siloed approach to understanding abuse only as child abuse (vulnerable dependent) and spouse/partner abuse (reproductive age women as victims/survivors). these siloes when applied to elder abuse have resulted in a misunderstanding of older adults as frail care dependent victims or as experiencing negligible intimate partner violence in later life. it has also obscured an identified risk factor in elder abuse: abuse experienced earlier in the lifespan of elder abuse victims (16). trauma-informed care only very recently has trauma been considered a factor in elder abuse (14,17). social work is a leading profession that has placed trauma-focused care as a practice model in the fields of child abuse and spouse/partner abuse. however, the medical model dominating elder abuse has resulted in a lack of understanding of the role of trauma in elder abuse. both feminist gerontology and a life course brownell p. future directions for research on neglect, abuse and violence against older women (editorial). seejph 2019, posted: 19 february 2019. doi 10.4119/unibi/seejph-2019-205 page 3 of 8 perspective require a feminist perspective and an understanding of domestic violence as part of the life course. while theory has laggedobservation, a growing body of research has identified a correlation between abuse early in the lifespan and elder abuse (16,18). this required challenging the ageist bias in the field of domestic violence, as well as the wellmeaning but misguided effort to address a perceived sexist bias in gerontology research by applying a gender neutral lens (19). practitioners and researchers are beginning to develop and assess trauma-focused interventions and care. among promising models include psycho-educational support groups, groups promoting spirituality among older women who have experienced familial abuse, and interventions intended to target depression and abuse (4,20,21). acknowledgement of trauma as a central factor in abuse for girls and women of all ages not only provides an explanatory framework for what has been identified as a risk factor for elder abuse, experiencing abuse as a child, but can also provide a practice framework for interventions across the lifespan. it also has the potential for integrating older women into a life course perspective on neglect, abuse and violence against girls and women: older women are too often relegated to an “other” category as though old age renders older women gender neutral (see susan b. somers, above). interventions for children who have experienced abuse, as well as younger women who are victims of domestic violence, may mitigate against vulnerability to abuse in later life as older women. also, interest in unresolved trauma in later life has led to models of intervention that can begin to address late life trauma or earlier unresolved trauma. theoretical advances in understanding neglect, abuse and violence across the life course the field of elder abuse research has been hampered by lack of a unifying theory that explains abuse of older adults in domestic settings (22). this is also the case for understanding neglect, abuse and violence against older women from a life course perspective, and in explaining how abuse experienced in childhood can be a risk factor for abuse in later life. an understanding of trauma across the life course provides one framework for conceptually linking abuse experienced earlier in life to risk of late life abuse (23). research has found that the effects of childhood trauma may persist or surface intermittently with mental or physical effects that include continued revictimization (24). early life trauma has been associated with later life physical and mental health problems; in addition, the broad scope of early traumatic experience is also evident in risk behavior studies. one comprehensive literature review found that the correlates and consequences of childhood trauma on later life consequences is compelling (25). the effects of early trauma can be life-course persistent and negatively affect the wellbeing of individuals, families and communities. understanding this from a life course perspective can help to identify multiple points of intervention, with trauma-informed research and practice models. childhood trauma effects can persist into old age (26). the adverse childhood experiences (ace) study conducted by kaiser permanente in california has found that the more adverse experiences subjects reported experienced in childhood, the more difficulties they reported encountering in later life (27). in addition, brownell p. future directions for research on neglect, abuse and violence against older women (editorial). seejph 2019, posted: 19 february 2019. doi 10.4119/unibi/seejph-2019-205 page 4 of 8 older women who report interpersonal violence earlier in their lives experience adverse cumulative emotional and health symptoms that affect wellbeing later in life (28,29). lifetime prevalence of gender-based violence in women and the relationship with mental disorder and psychosocial functioning is often overlooked in prevalence studies of neglect, abuse and violence against older women (30). survey questions about interpersonal abuse within the past year or even five years might lead to misleading conclusions that older women experience minimal if any genderbased violence compared to younger ones, when in fact abuse experienced earlier in life can continue to be vividly experienced in late life as well. complex trauma and relevance to abuse in later life individuals with a history of interpersonal trauma rarely experience only a single traumatic event, and may have experienced exposure to sustained, repeated or multiple traumas: this has been proposed to lead to a complex symptom presentation that includes not only posttraumatic stress symptoms but also those predominately in affective and interpersonal domains (31). this is known as complex trauma, a type of trauma that occurs repeatedly and cumulatively and within specific relationships and contexts (32). while initially thought to be related to child abuse, including child sexual abuse, the expanded understanding now extends to all forms of domestic violence, including emotional abuse, and attachment trauma occurring with the context of family and other intimate relationships over extended periods of time (33,34). while complex trauma (developmental disorder for children) has been proposed as a diagnostic category for the dsm-5, to date it has not been accepted as a distinct diagnostic category (35). the 11th revision to the world health organization’s international classification of diseases (icd-11) does include complex post traumatic stress disorder (cptsd) as a diagnostic category distinct from ptsd (36). the icd-11 cptsd includes not only the three symptom clusters associated with ptsd (re-experiencing the trauma in the here and now; avoidance of traumatic reminders; and a persistent sense of current threat manifested by exaggerated startle and hypervigilance) but in addition three additional clusters, identified as disturbances in self-organization. these include affective dysregulation; negative self-concept; and disturbances in relationships (37). the basis of the concept of complex (developmental) trauma is attachment theory, originally formulated by bowlby (38). other clinicians and theorists began to examine the developmental timing of trauma exposure and emotional dysregulation in adulthood (39,40), the impact of the developmental timing of trauma exposure on ptsd symptoms and psychosocial functioning among older adults (10), and the relationship between childhood trauma and complex posttraumatic stress disorder symptoms in older adults (15). with a theoretical basis for understanding complex trauma from a developmental perspective, researchers and practitioners have begun to understand the links between childhood experiences of interpersonal trauma and abuse with experiences across the lifespan, including old age (14,17,31). as this understanding developed, intervention strategies evolved with gerontologists taking the lead in implementing and evaluating them (20). in addition, translational collaborations between researchers and clinicians have resulted in formulating clinical applications of the attachment framework (13) as well as designing phase-oriented clinical interventions (41). brownell p. future directions for research on neglect, abuse and violence against older women (editorial). seejph 2019, posted: 19 february 2019. doi 10.4119/unibi/seejph-2019-205 page 5 of 8 interventions for later life interpersonal victimization related to lifetime trauma history necessarily require cognitive capacity, access to treatment modalities with skilled practitioners, and motivation on the part of the victim, and may also require access to safe living alternatives and other community and social supports (42). cultural beliefs about the role of girls and women within the family, as well as perceived responsibilities of older mothers toward impaired adult children who are abusive (43,44), are salient, even without past histories of abuse. abuse of older women with dementia and/or severe physical care needs, particularly within care settings, requires different intervention strategies targeted to institutional or criminal justice remedies (45). however, for cognitively unimpaired victims living in the community who are struggling to resolve chronic abuse particularly as perpetrated by family members or trusted others, and who disclose a history of abuse as children and young adults, trauma focused interventions may be indicated. conclusion chronic interpersonal abuse experienced earlier in life, particularly if not within an enabling environment and if left unaddressed and unresolved, may predispose some victims to continued trauma during their lives, according to trauma-informed researchers (16,18). adoption of a public health framework to address trauma can assist researchers, practitioners and policy makers to develop a theoretically informed multi-faceted prevention and intervention strategy to address what is known as complex trauma (14). recently evolved methodologies for assessing, measuring (46,47) and treating this in older adults, including older adult victims of abuse, are beginning to make this feasible. conflicts of interest: none. references 1. bonnie rj, wallace rb. elder mistreatment: abuse, neglect, and exploitation in an aging america. washington dc: the national academies press; 2003. 2. nerenberg l. a feminist perspective on gender and elder abuse: a review of the literature; 2002. https://ncea.acl.gov/resources/docs/arch ive/feminist-perspective-ea-2002.pdf (accessed: september 24, 2018). 3. vinton l. a model collaborative project toward making domestic violence centers elder ready. violence against women 2003;9:1504-13. 4. brownell p, heiser d. psychoeducational support groups for older women victims of family mistreatment: a pilot study. j gerontol soc work 2006;46:145-60. 5. hooyman n, browne cv, ray r, richardson v. feminist gerontology and the life course. gerontol geriatr educ 2002;22:3-26. 6. bricker-jenkins m, hooyman nr (eds.). not for women only: social work practice for a feminist future. silver spring, md.: national association of social workers; 1986. 7. crockett c, brandl b, dabby fc. survivors in the margins: the invisibility of violence against older women. j elder abuse negl 2015;27:291-302. 8. luoma ml, koivusilta m, lang g, enzenhofer e, de donder l, verté d, et al. prevalence study of abuse and violence against older women: results of a multi-cultural survey in austria, belgium, finland, lithuania, and portugal (european report of the avow project). finland: national brownell p. future directions for research on neglect, abuse and violence against older women (editorial). seejph 2019, posted: 19 february 2019. doi 10.4119/unibi/seejph-2019-205 page 6 of 8 institute of health and welfare (thl); 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2019. 43. smith jr. expanding constructions of elder abuse and neglect: older mothers’ subjective experiences. j elder abuse negl 2015;27:32855. 44. smith jr. listening to older adult parents of adult children with mental illness. j fam soc work 2012;15:126-140. 45. ramsey-klawsnik h, teaster pb, mendiondo ms, marcum jl, abner el. sexual predators who target elders: findings from the first national study of sexual abuse in nursing homes. j elder abuse negl 2008;20:353-76. 46. elhai jd, gray mj, kashdan tb, franklin cl.which instruments are most commonly used to assess traumatic event exposure and posttraumatic effects: a survey of traumatic stress professionals. j trauma stress 2005;18:541-5. 47. widom cs, dutton ma, czaja sj, dumont ka. development and validation of a new instrument to assess lifetime trauma and victimization history. j trauma stress 2005;18:519-31. © 2019 brownell; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. seasonal variations in emergency department visits of schizophrenic patients in sofia spasova z. seasonal variations of schizophrenic patients in emergency departments in sofia, bulgaria (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-07. 1 original research seasonal variations of schizophrenic patients in emergency departments in sofia, bulgaria zornitsa spasova1 1 department of health policy analysis, national center of public health and analysis. corresponding author: zornitsa spasova, national center of public health and analysis; address: 15 acad. ivan geshov blvd, sofia 1431, bulgaria; telephone: +35928056381; e-mail: z.spassova@ncpha.government.bg mailto:z.spassova@ncpha.government.bg spasova z. seasonal variations of schizophrenic patients in emergency departments in sofia, bulgaria (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-07. 2 abstract aim: the purpose of this study was to reveal the seasonal distribution of emergency department visits of schizophrenic patients in sofia, bulgaria. methods: we collected daily data for visits of patients with schizophrenia, schizotypal and delusional disorders in the emergency center of the regional dispenser for mental disorders in the city of sofia for the period 1998-2003. the total number of emergency visits was 5723 (mean daily visits: 5.04±2.4). t-test was used to compare the monthly and seasonal distribution of visits. results: the season with the highest levels of emergency visits was summer, and the lowest levels were observed in winter (p<0.0001). spring and autumn had intermediate values close to the mean value, and significantly differentiated from winter values. the month with the highest admission rates was september, followed by may and the three summer’s months. the lowest levels were observed in december, october and january, with statistically significant differences observed between the values of all the three months. differences between july values compared with december and october values were significant, but not with january values. conclusion: the study showed significant seasonal and monthly differences in emergency schizophrenics’ visits. the data confirm the outcome of similar studies conducted in countries with temperate climate in the northern hemisphere. these results could prove useful for psychiatrists, public health specialists, and governmental authorities dealing with team planning and prevention programs in the field of psychiatry. keywords: month, schizophrenia, season. spasova z. seasonal variations of schizophrenic patients in emergency departments in sofia, bulgaria (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-07. 3 introduction schizophrenia is a mental disorder characterized by enormous societal and economic costs due to the extensive therapeutic care and loss of economic productivity, as well as personal suffering and stigma which often affect the patient and his/her family for most of the patient’s life. as for schizophrenia patients, there is still no cure, the research of etiologic factors, particularly environmental ones that could be avoided and used in effective prevention programs, is essential (1). many studies have demonstrated evidence of seasonal patterns in the incidence of psychotic disorders, and schizophrenia in particular. it is known since the time of esquirol (1838) that the number of patients admitted in mental hospitals increases in summer months and decreases in winter (1). most of the studies for seasonal distribution of hospital admissions in schizophrenia also report summer peaks (2,3), some of these for female patients only (4). shiloh et al. (5) conducted research on admissions of schizophrenia and schizoaffective disorder patients to tel-aviv’s seven public psychiatric hospitals during 11 consecutive years. they found that the mean monthly admission rates are significantly higher during the summer (for schizophrenia patients) and fall (for schizoaffective patients). clarke et al. (6) studied first admissions for the diagnosis of schizophrenia, citing april and october as peak months. in a few publications (7-10), no significant difference between admissions in various seasons was observed. eastwood and stiasny (7) failed to replicate the summer peak in the admissions for schizophrenia in ontario, canada. partonen and lonnqvist (8), in a study of 295 schizophrenic patients, also reported no significant seasonal variation of admission with schizophrenia (cited by 9). de graaf et al. (11) did not find seasonal variations for schizophrenia. the authors concluded there are only limited seasonal variations in mental disorders in general population studies, at least in countries with a mild maritime climate. it is interesting that while most of the studies conducted in the northern hemisphere found summer peaks in hospital admissions for schizophrenia, results from three studies in the southern hemisphere show converse results – winter peaks (9,12,13). owеns and mcgorry (13) analyzed data for six years and found that only male cases of schizophrenia showed a significant seasonal distribution in the dates of onset of symptoms, with a peak in august. the other two studies: davies et al. (12) in first episode schizophrenia (strongly visible for the males, but the pattern for females also displayed annual periodicity) in queensland, australia and daniels et al. (9) in male patients with schizoaffective disorder in tasmania also showed austral winter peaks in admission data. while the problem of seasonal admissions of patients with schizophrenia has been widely discussed in western europe, america and australia, in eastern europe it has been neglected. in this region, we are only familiar with research conducted in poland by kotsur and gurski, where the authors confirmed the presence of seasonality in admission of schizophrenic patients (14). we are not aware of any published research on this subject in bulgaria, which makes the present study important as a contribution to the scientific literature on the problem in the country and in the south east europe (see) region. its findings could also raise the awareness of the problem of health care management for psychiatric patients in see countries besides bulgaria. the aim of the present research was to study the seasonal distribution of emergency department visits (not planned visits) of schizophrenic patients in the city of sofia, bulgaria (42°40' north latitude, 23°18' east longitude). methods we collected daily data for visits of patients with schizophrenia, schizotypal and delusional disorders (f20-f29, icd-10) in the emergency center of the regional dispenser for mental disorders in the city of sofia for the period 1 january 1998 – 30 june 2003. the total number of emergency visits of schizophrenic patients was 5723 (mean daily visits: x =5.04, σ=2.4). the total number of spasova z. seasonal variations of schizophrenic patients in emergency departments in sofia, bulgaria (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-07. 4 analyzed days was 1135 (data was missing for a part of the period). data was categorized by months and then by meteorological seasons – the winter season defined as december, january and february; the spring season as march, april and may; the summer season as the months of june, july and august; and the autumn (fall) season as the months of september, october and november. because of missing information for some of the days during the period, the mean daily (not monthly) values were calculated for the particular month and season, and then the values were compared by using t-test. mathematically, this method could be used by application of the following formula: 2 2 2 1 2 1 21 nn xx t σσ + − = where, 1x and 2x are the mean arithmetic values of the two samples, σ1 and σ2 are the dispersions of the two samples, and n1 and n2 are the numbers of the two samples. results obtained by t-test were compared with table values, which show the probability connected with the zero-hypothesis. for this purpose, the degrees of freedom are calculated using the following formula: 221 −+= nnk the calculated value of the degree of freedom was subsequently compared with the table critical value. if the t-test value is lower or equivalent to the critical value, then it is accepted that there are occasional differences between the two samples. if the t-test value is higher than the critical value it is accepted that the differences between the two samples are statistically significant, thus rejecting the zero-hypothesis. results the season with the highest levels of emergency visits was summer ( x =5.44) and the lowest levels were observed in winter ( x = 4.63) (figure 1), with statistically significant differences between these two seasons (t= 4.12*, p<0.0001) (table 1). spring and autumn had intermediate values close to the mean value (respectively, 5.15 and 5.02). spring and autumn values also significantly differentiated from winter values (t=2.78*, p=0.006 and t=2.07*, p=0.035, respectively) (figure 1). table 1. comparative analysis of the mean seasonal visits of schizophrenic patients in the emergency department of the regional dispenser for mental disorders in sofia, bulgaria, january 1998-june 2003 season winter spring summer autumn winter spring 2.78* summer 4.12* 1.36 autumn 2.07* 0.63 1.95 * the quotients marked with an asterisk are statistically significant (p<0.05). spasova z. seasonal variations of schizophrenic patients in emergency departments in sofia, bulgaria (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-07. 5 figure 1. seasonal patterns of admissions of schizophrenic patients in the emergency center of the regional dispanser for mental disorders in the city of sofia 4.63 5.15 5.44 5.02 4.2 4.4 4.6 4.8 5.0 5.2 5.4 5.6 winter spring summer autumn m ea n da ily a dm is si on n um be r the month with the highest admission levels was september ( x = 5.79), followed by may ( x = 5.63), and the summer months (august, june and july). the lowest levels were observed during the cold months: december ( x = 4.22), followed by october ( x = 4.58), and january ( x = 4.71) (figure 2). figure 2. monthly distribution of visits of schizophrenic patients in the emergency center of the regional dispenser in sofia 0 1 2 3 4 5 6 january february march april may june july august september october november december spasova z. seasonal variations of schizophrenic patients in emergency departments in sofia, bulgaria (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-07. 6 statistically significant differences were observed between the values of all the three months, with the highest levels compared with the three months with the lowest levels. differences between july values compared with december and october values were significant, but not with january values (table 2). table 2. comparative analysis of the mean monthly visits of patients with schizophrenia in the emergency department of the regional dispenser for mental disorders in sofia, bulgaria, january 1998 – june 2003 month jan feb march april may june july aug sept oct nov dec january february 1.07 march 0.61 0.35 april 0.78 0.29 0.09 may 2.76* 1.7 1.95 1.99* june 2.28* 1.22 1.5 1.51 0.47 july 1.86 0.78 1.06 1.05 0.97 0.5 august 2.51* 1.52 1.77 1.79 0.09 0.35 0.83 september 3.04* 2.03* 2.25* 2.3* 0.38 0.84 1.34 0.47 october 0.42 1.33 0.92 1.08 2.84* 2.41* 2.02* 2.62* 3.1* november 0.59 0.44 0.06 0.16 2.11* 1.64 1.19 1.91 2.41* 0.91 december 1.8 2.64* 2.11* 2.4* 4.1* 3.67* 3.35* 3.8* 4.3* 1.14 2.2* * the quotients marked with an asterisk are statistically significant (p<0.05). discussion the results obtained in this study confirm the presence of seasonality in the emergency visits of schizophrenic patients in sofia. our findings confirm many of the studies conducted in the northern hemisphere (summer peak) in countries with continental tempеrate climate (3,4,6). with respect to the factors responsible for the summer excess of admissions, myers and davies (15) have suggested a rise in ambient temperature; parker and walter (16), the increasing luminance; and carney et al. (17), the length of day. social factors, such as summer holidays, “are unlikely to have an effect” (4). some publications confirm a straight relationship between the ambient temperature and hospital admissions of patients with diagnosis schizophrenia. such a relationship was found by gupta and murray (18) and faust (19). hansen et al. investigated the effect of heat waves on mental health in australia (temperate climate) and found that hospital admissions were increased by 7.3% during heat waves. mortalities attributed to mental disorders also increased during heat waves in the age group of 65-74 years and in persons with schizophrenia (20). shiloh et al. (5) concluded that the mean rates of monthly admissions of patients with schizophrenia correlate with the maximum mean monthly environment temperature (r=0.35). they connect the admission rates with the higher summer temperatures, and conclude that “persistent high environmental temperature may be a contributing factor for psychotic exacerbation in schizophrenia patients and their consequent admission to mental hospitals”. in previous research (21) using the present data, we also found a positive straight relationship between mean ambient temperature and the emergency visits of schizophrenic patients in sofia. the analysis of the observed relationship is somehow complicated because of many uncertainties coming from the etiology of the mental disorders. from a physiological point of view, there are still not firm conclusions about the reasons for the outcome of these disorders in psychiatry, and spasova z. seasonal variations of schizophrenic patients in emergency departments in sofia, bulgaria (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-07. 7 many theories try to explain these uncertainties. yet, some conclusions could be made from a theoretical point of view and the literature review. since we have been interested in the effect of meteorological factors on the mental crises manifesting, comparatively most important is the theory connected with the fundamental physiological processes in the cerebral cortex – as we are interested in the changeable side of environmental factors influencing the damaged human psyche. first, the russian scientist pavlov developed on a theoretical level his hypothesis in relation to the concept of the so-called “patho-dynamical structures” (“sick point”). the patho-dynamical structure is characterized by a change in the ratio between the basic neural processes – excitement and suppression, which leads itself to the development of phase states. depending on the structures involved in the pathological process, the external manifestations of the disorders are different (22). with respect to schizophrenia, strategic guidance for the interpretation of the impact of the ambient temperature on the occurrence of mental crisis could be made by applying the theory of pavlov. according to him, the main emphasis should be placed on spilled retention, which covers the cortex and sometimes spread on the sub-cortex and brain stem departments, as well as the transition between wakefulness and sleep phases. the main reason for the increased retention of hemispheres in schizophrenia, the russian scientist sees, is the weakness of the nervous system, when multiple stimuli from the environment are super strong, causing over the limit detention. such detention in some departments of the brain can lead to release and positive induction of others, and ultimately to a distortion of the interaction of brain structures, such as the relationship between signaling systems, bark and under-bark (cited by 22). considering that the ambient temperature has a direct impact on the physiological processes in humans by thermo-receptors, it could be expected that its impact will play the role of these super strong as – pavlov calls them – stimuli. they act as stressors on the body – especially the nervous system – and consequently, in combination with other stimuli (predominantly of the social character), lead to disturbance of the balance and induce psychological crisis. conclusion our study shows significant seasonal and monthly differences in emergency visits of schizophrenia patients. the results confirm the outcome of many other studies conducted in countries with temperate climate in the northern hemisphere. results from this study could be useful for psychiatrists and medical staff working in emergency centers and mental health hospitals, public health specialists and governmental authorities dealing with team planning and prevention programs in the field of psychiatry. 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creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed/?term=singh%20gp%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=chavan%20bs%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=arun%20p%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=sidana%20a%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed?term=davies%20g%5bauthor%5d&cauthor=true&cauthor_uid=10728722 http://www.ncbi.nlm.nih.gov/pubmed?term=ahmad%20f%5bauthor%5d&cauthor=true&cauthor_uid=10728722 http://www.ncbi.nlm.nih.gov/pubmed?term=chant%20d%5bauthor%5d&cauthor=true&cauthor_uid=10728722 http://www.ncbi.nlm.nih.gov/pubmed/10728722## rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 1 | 19 review article hepatitis c in several risk groups: literature review albiona rashiti-bytyçi1, naser ramadani1,2, ariana kalaveshi1,2, sefedin muçaj1,2, luljeta gashi1, premtim rashiti2 1 national institute of public health in kosovo, prishtina, kosovo; 2 university of prishtina “hasan prishtina”, prishtina, kosovo. corresponding author: prof. dr. naser ramadani, md, phd, mphe, cmis, cieh; address: rr. nëna tereze p.n., rrethi i spitalit, 10.000, prishtina, kosovo; telephone: +38338551431; email: naser.ramadani@uni-pr.edu rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 2 | 19 abstract aim: the objective of this study was to assess the distribution of hepatitis c in selected risk groups such as haemodialysis patients, pregnant women, healthcare workers, hiv-hcv co-infected patients, patients with mental health diseases and piercing and tattoo procedures. furthermore, it aimed at evidencing common transmitting routes and highlighting the importance of preventive measures among these groups. methods: the literature review was conducted using online databases (medline) with search query involving the keyword “hepatitis c” in conjunction with keywords describing risk groups such as "dialysis", or "haemodialysis", or "pregnancy", or "pregnant", or "mental health", or "tattoo", or "piercing", or "hiv", or "health professionals”. results: after assessing all the retrieved publications, 39 of them were considered for inclusion: 17 on haemodialysis patients, 7 on pregnant women, 8 on hiv-hcv co-infection and 7 publications on health professionals, patients of mental health wards and piercing and tattoo procedures. the high rate of hepatitis c is still a high problem and in some cases it is considered as a new issue, as in the case of pregnancy. some of the transmission routes have been identified earlier, such as the hiv-hcv co-infection but some, such as piercing and tattoo, are becoming new transmission routes. health professionals are still identified as high risk group while mental health patients are a potentially high risk group. conclusion: even though some patients are routinely screened for hepatitis c, there are indications for performing such a routine test in other groups. in almost all of the risk groups, it is advocated to use stricter preventive measures and to disseminate knowledge on risks of hepatitis c. keywords: haemodialysis, healthcare workers, hepatitis c, human immunodeficiency virus, mental health diseases, piercing and tattoo, pregnancy. conflict of interest: none declared. rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 3 | 19 introduction hepatitis c, as a liver infection, is caused by the hepatitis c virus (hcv), blood borne virus. the virus can cause both acute and chronic hepatitis, ranging in severity from a mild illness lasting a few weeks to a serious, lifelong illness. approximately 60%-80% of infected people may progress to chronic liver disease and 20% of them will develop cirrhosis (1). according to who, globally, an estimated 71 million people have chronic hepatitis c infection (2). an estimated 3.5 million people in the united states have chronic hepatitis c (3). globally, morbidity and mortality from hepatitis c virus infection (hcv) is increasing. according to estimation from recent studies, more than 185 million people around the world are infected with hepatitis c virus (1). total global prevalence of hcv is 2.5%, varying from 2.9% in africa to 1.3% in america, with global viremic rate 67% (118.9 million hcvrna positive cases), varying from 64.4% in asia to 74.8% in australasia (4). in europe, the prevalence of hepatitis c (hcv) is estimated to be around 1.7% and includes 13 million cases, the lowest prevalence (0.9%) is reported in western europe (except some rural regions in south of italy and greece) and the highest prevalence in central europe (3.1%) specifically in romania and russia (5). according to estimation from global burden of disease study, deaths rate from hepatitis c was 333000 in 1990, 499000 in 2010 and 704000 in 2013 (6). these cases of deaths are result of complications from hcv, including liver cirrhosis, hepatocellular carcinoma and liver failure (7). the following groups are at increased risk for hcv infection:  current or former injection drug users;  chronic haemodialysis patients;  people with known exposures to hcv, such as (health care workers after needle sticks involving hcv-positive blood, recipients of blood or organs from a donor who tested hcvpositive);  people with hiv infection;  children born to hcv-positive mothers;  patients of mental health wards and also were at risk:  recipients of clotting factor concentrates made before 1987, when less advanced methods for manufacturing those products were used;  recipients of blood transfusions or solid organ transplants prior 1992, before better testing of blood donors became available (8); conversely, the transmission routes and epidemiology include:  intravenous drug use;  non-intravenous recreational drug exposure;  healthcare procedures;  accidental exposure;  mother to child vertical transmission;  sexual exposure etc. (8). methods search and study identification the aim of the study was to identify, through literature review, studies addressing the following: cases of hepatitis c, most common transmitting route, the importance of preventive measures, among several risk groups such as: haemodialysis patients, pregnant women, healthcare rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 4 | 19 workers, hiv-hcv co-infected patients, patients with mental health diseases and practitioners of piercing and tattoo. articles published were identified by literature survey in online database medline through pubmed interface, using keywords: "hepatitis c" and ("dialysis" or "haemodialysis" or "pregnancy" or "pregnant" or "mental health" or "psychiatry" or "tattoo" or "piercing" or "hiv" or "health professionals" or "health workers"). from the search query, 1788 publications were identified and from these only original publications were included. the following data were excluded from our analysis: data with unclear definition of hcv infection, duplicated data, all short communications or reviews. next, the remaining 688 publications were selected and after removing publications without abstract, there were left 617 of them. after reading abstracts of 617 publications we selected 150 publications that fulfilled our research interests. all 150 publications were studied and publications that dealt with detailed treatments, or included other groups of interests were excluded. finally, we selected 39 publications for analysing and presenting their results, as presented in figure 1. figure 1. search and study identification rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 5 | 19 overview of the results after a full text screening, as presented in figure 2, a total of 39 articles were considered for inclusion: 17 on haemodialysis patients, 7 on pregnant women, 8 on hiv-hcv coinfection and in total 7 publications on health professionals, patients of mental health wards and piercing and tattoo procedures. in following sections, each group will be discussed and in the end of each section, a short conclusion will be presented. figure 2. publications with hcv data by risk groups results on haemodialysis / hcv from 17 publications on hcv and haemodialysis, 10 of the publications included on their results prevalence of hcv on haemodialysis centres, while 7 other publications included on their result other findings or association of hcv with other factors. for hcv, prevalence estimates that were considered representative for haemodialysis centres were available for 10 countries as presented in table 1. a prospective study conducted in japan in 2016 (9) included 41 haemodialysis centres, with total of 2986 haemodialysis patients. the aim of the study was to screen for hcv antibody, and hcv rna, but as well to determine genotype of hepatitis c and the treatment of hcv patients. in its findings, authors have reported that 5.02% of patients were hcv ab positive and from this number 72.31% were hcv rna positive. another interesting conclusion of the study, was that 62.1% of tested patients were hcv genotype 1 and that the combined therapy of daclatasvir and asunaprevir was effective at hcv positive patients in haemodialysis. another study performed in japan, but this time a retrospective one (10), included 3064 patients on haemodialysis. the aim of the study was to find the association of hepatitis c virus infection with the prognosis of chronic haemodialysis patients. the results of the study suggested that of those patients, 14.0% were hcv rna positive, while 2.4% were hbsag positive and 0.3% were double positive. also in the study, it was reported that by 2010, 49% of haemodialysis patients were deceased. from that percentage, 60% of them were hcv rna positive, and 47% hcv rna negative. a prospective study was con17 7 8 3 2 2 0 2 4 6 8 10 12 14 16 18 rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 6 | 19 ducted in brazil (11) that included 798 haemodialysis patients, with the aim of determination of prevalence of hcv infection and genotypes in patients undergoing haemodialysis. the study found that performing elisa test, 8.4% of the patients resulted hcv positive, while 86.1% of them had determined viral genotype 1 and 11.6% determined genotype 2 and 2.3% determined genotype 3. one of the suggestions of the authors was to strengthen the control strategies for hepatitis c in haemodialysis centres. a cross-sectional study conducted in china in 2013 (12), included 2120 patients on haemodialysis and 409 patient partners. this study investigated the prevalence and risk factors of hcv and hbv infection and the distribution of hcv genotypes among haemodialysis patients and their spouses. authors findings were that 6.1% of the patients were anti-hcv positive, 4.6% of them were hcv rna and 7.0% of them resulted in hbsag positive. regarding the prevalence of their partners, it resulted that 0.5% of them were anti-hcv positive, while 0.2% rna hcv positive and 4.2% hbsag positive. some of the risk factors that authors have mentioned were: the duration of dialysis and blood transfusion. the predominant genotype was 1b with 89% while 2a had 7.7% and genotype 3a, 3b, 6a each by1.1%. authors’ suggestion, due to the persistence of nosocomial infection, were strict infection control measures to be strengthened with the aim of reducing the transmission of hcv. another prospective study, that involved 170 patients on haemodialysis, was performed in us (13), with the aim to overview the incidence and preventive measures for hcv in the haemodialysis centre. the study resulted in finding 5.4% new hcv cases, from which 4 cases were genotype 1a, 2 cases of genotype 1b. the other 37.6% of old cases, 29 cases were genotype 1a, 16 cases were genotype 1b, and 2 cases were genotype 3a. cross sectional survey in sudan included 353 patients of haemodialysis, aiming to determine the seroprevalence and risk factors for hepatitis c and hepatitis b in their dialysis centres (14). their finding resulted in 16 cases that were hbsag positive and 30 cases that were anti-hcv positive. the long duration of dialysis and surgical intervention, were most common risk factors, related to infection. in the middle east, authors (15) conducted a prospective investigation, to find the impact of an identical isolation policy on incidence of nosocomial hcv infection in haemodialysis centre. study was conducted in two phases, phase one involving 189 patients and phase two involving 198 patients affected of haemodialysis. their study resulted in finding 83 (43.9%) phase one patients with anti hcv positive, while the remaining 106 (56.1%) patients resulted as anti hcv negative. an interesting fact is the correlation between hcv positivity and the dialytic age (of 83 patients who had positive results for antihcv antibodies had a mean dialytic age of 48.5 ± 14.2 months, compared with 25.0 ± 8.6 months among the 106 anti-hcv-negative patients). in phase ii, they had similar results, 85 (42.9%) of 198 patients had antihcv positive results, and 113 (57.1%) continued to have a negative status for anti-hcv antibodies. interesting relation between phase one and two is the addition of two new anti-hcv positive cases (none of them belonging to the added 9 after phase one), that occurred over 12 months of study period, leading to an hcv seroconversion rate of 1.01% per year (15). netherlands conducted a nationwide prospective study on the prevalence and incidence of hepatitis c virus infections among dialysis patients in 1996 (16). in 34 haemodialysis centres, a total of 2281 patients were included, dividing the research into two phases: the first phase with 2281 patients – where the hcv rna positive rate was 2.9%, and the second phase after one rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 7 | 19 year with the sample of 2286 patients, where 3.4% of the cases were hcv rna positive. main risk factors were also identified by the study, and those being: haemodialysis before 1992, kidney transplantation before 1994, birth in other countries, and receiving dialysis abroad during vacations. another cross sectional study was conducted in canada, aiming to study hepatitis c prevalence and risk factors in dialysis population, with 336 patients included in the study (17). the study resulted in finding that prevalence of antihcv antibody was 6.5% (22/336), 77.2% (17/22) of cases that were anti-hcv positive resulted hcv rna positive. another prospective study was conducted with 128 patients in usa, with findings of 25% of them positive hcv eia (18), but tests were not specific because in 6 cases it was detected and resulted negative, which speaks about past infection. it is known that pcr remains the only reliable test to determine the presence of the virus. table 1. hepatitis c in haemodialysis centres paper year country study design study sample laboratory tests hcv ab positive hcv rna positive (9) 2016 japan prospective 2986 hcv antibody, hcv rna 5.02% from total of hcv ab positive cases, 72.31% were hcv rna positive (10) 2010 japan retrospective 3064 hcv rna / 14.00% (11) 2013 brazil prospective 798 hcv antibody 8.40% / (12) 2013 china cross-sectional 2120 hcv antibody, hcv rna 6.10% from total of hcv ab positive cases 4.6% were hcv rna positive; (13) 2009 usa prospective 170 hcv rna / 5.4% new hcv cases and 37.6% older hcv cases (14) 2010 sudan crosssectional 353 hcv antibody 8.50% / (15) 2003 arabia retrospective and prospective 189 hcv antibody phase i, 43.9% phase ii, 42.9% / (16) 1996 netherlands prospective 2281 (phase i) 2286 (phase ii) hcv rna / first phase 2.9%; second phase 3.4% (17) 1997 canada crosssectional 336 hcv antibody, hcv rna 6.5% hcv from total of hcv ab positive cases 77.2% were rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 8 | 19 hcv rna positive (18) 1998 usa prospective 128 hcv antibody 25% / in relation to haemodialysis patients, some other studies were conducted to find the connection between haemodialysis patients and hcv and other risk factors. since that connection is believed to be of importance, findings of those studies are briefly presented in the following paragraphs. one of the studies investigated bleeding epidemic that has erupted on september-october 2013, in haemodialysis unit in vietnam, involving 119 patients with 9 positive hcv cases and 9 positive hbv cases. authors found that hcv prevalence in the epidemic was 6%, which is 7.5 times higher than in the vast population of vietnam (19). another retrospective study conducted in usa found correlation between hcv and hepatocellular carcinoma (hcc), when checking 32860 hcv cases, that resulted in 262 cases with hcc (20). hcc was 12 times more common in cases of cirrhosis, 3 times more frequent in cases of alcohol consumption and 1.3 times higher in cases of diabetes, with the likelihood of hcc increasing with age. another correlation, this time linear, between incidence and prevalence, was found in a study in france, concluding that doubling the value of p(c) doubles the incidence of cases with hepatitis c (21). a prospective study conducted in spain, found initial prevalence (p <0.0001) and time (p <0.0001) emerging as independent variables associated with the decrease of hcv prevalence (22). authors of another study, conducted in france, found that hcv seroconversion was associated with the number of hemodialysis sessions undergone on a machine shared with or in the same room as a patient who was anti-hcv (genotype 2a/2c) positive (23). a cross sectional study in usa found by using multivariate logistic regression analysis, that the longer duration of receiving dialysis associated with a history of intravenous drug use, were the only risk factors that remained independently associated with hcv seropositivity (24). authors of a study in france found that overall, hcv rna became undetectable in 16 patients (69.6%) 1 month after starting ifn-a therapy and in 21 patients (91.3%) at the end of treatment (25). results on pregnancy /hcv conducting the literature review, 7 studies that presented a relation between hcv infection and pregnancy were included, as shown in table 2. a research conducted in pakistan (26), enrolled 119 cases of pregnant women with hcv positive, and 238 control cases, from the total of 5621 pregnant women, of whom 5339 were screened. their result showed that iatrogenic exposure (health care injections, hospitalizations and pregnancies) are the major risk factors for transmission of hcv among pregnant women. therefore, the authors call for strengthening the prevention aspect of the hepatitis control program to focus on behaviour change for reducing injection reuse and overuse. a study in the usa, which included 1013 obstetric patients identified that use of intravenous drugs resulted as the fastest risk factor (27) in hcv. authors emphasize that the epidemiologic data are consistent with sexual and parenteral modes of transmission, however, according to them routine screening for hepatitis c is not advocated. another study in the usa, with 599 pregnant hospitalised women, identified rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 9 | 19 4.3% were hcv positive, from which 3 positive hiv cases, and 2 of them had coinfection with hepatitis c. another correlation between hepatitis b and hepatitis c, resulted in 1 coinfection from 5 cases with hepatitis b (28). another study in italy, reported that hcv transmission was higher in mothers with fluctuating alt levels (31/154; 20.1%) when compared with mothers with normal alt levels (35/292; 12%). the hcv transmission was the highest in the group of mothers with constantly raised alt levels (8/31; 25.8%) (29). vertical transmission of hcv was investigated in three studies. the first study (30), had as a subject 2447 hcv pregnant women, from whom 78 women (3.2%) were anti-hcv positive, 60 women (2.5% or 77% of all cases of positive anti-hcv) were positive hcv-rnas. regarding the newborns, 60 of them (50%) remained hcvrna negative, throughout 22 of them (36.7%) were rna-hcv positive in one case and 8 of them (13.3%) were rna-hcv positive at least in the two following tests and only 2 children (3.3%) remained positive rna-hcv, testing after 8 to 24 months (30). the second vertical transmission study was conducted in ireland with 36 hcv pregnant women (31). from the study resulted that all 36 cases were positive when tested with elisa and 26 women (76%) were pcr positive for hcv genotype 1. in terms of vertical transmission only one child resulted positive when tested with pcr hcv (31). the third study conducted with 3712 pregnant women, resulted in 35 (0.94%) women that were antihcv positive and out of this number 20 women (57%) were hcv rna positive (32). the vertical transmission rate was 5%, where only one new-born of 29 of maternal rna hcvs positive resulted hcv rna even after 12 months of birth that speaks for hcv persistent infection (32). table 2. hepatitis c related to pregnancy paper year country study design study sample laboratory tests results (26) 2006 pakistan case control 5339 elisa hcv 119 (2%) were hcv positive (27) 1992 usa prospective 1005 hcv antibody 2.28% (n = 23) were hcv positive (28) 1994 usa prospective 599 elisa hcv 4.3% were hcv positive (29) 2006 italy case control 74 hcv rna transmitting mothers and 403 hcvrna not transmitting hcv rna, alt hcv transmission was higher in mothers with fluctuating alt levels (31/154; 20.1%) when compared with mothers with normal alt levels (35/292; 12%) (30) 1997 italy prospective 78 hcv positive anti-hcv, hcv rna 8 of 60 (13.3%) infants born to hcv-rna positive mothers acquired hcv infection, but only 2 (3.3%) were still infected by the end of follow-up. (31) 2001 ireland retrospective 36 women with hcv elisa hcv. hcv rna the 36 cases were positive elisa and 26 (76%) were pcr positive for hcv genotype 1b. in terms of rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 10 | 19 vertical transmission only one child resulted positive pcr hcv. (32) 1996 germany prospective 3712 pregnant women anti-hcv, hcv rna out of 3712 women, 35 (0.94%) were anti-hcv positive and out of this number 20 (57%) were hcv rna positive. the vertical transmission rate was 5%. results on hiv / hcv coinfection regarding the relation between the hcv and hiv, a number of research papers, presented in table 3, discussed the coinfection, while proving unfortunately that the problem is on the rise. the first study reviewed, was a prospective study performed in ghana, where from 1520 hiv infected cases, hcv rna test was performed in all hbsag positive subjects (n=236) and a random subset of hbsag negative subjects (n=172), which resulted in 4 positive cases (3 cases of genotype 2 and 1 case of genotype 1). from these four infected cases surgical procedures and blood transfusion procedure was reported as an important risk factor for hcv infection (33). in 2018, a study in spain was performed including 322 patients with hepatocellular carcinoma in patients with hiv/hcv coinfection (34). the study aimed finding the relationship between the use of antiviral agents and the risk of hcc in hiv/hepatitis c coinfected patients. as a result, 42 (13%) of patients occurred after sustained virological response. it is interesting to mention that after using direct antiviral agents in hiv/hcv coinfected patients, the frequency of hepatocellular carcinoma was not increased. a study conducted in canada between 2005 and 2015, examined the relationship between hiv-seropositivity and having access to a physician for regular hcv care (35). in total, 1627 hcv-positive cases were eligible for analysis; from whom 582 (35.8%) were hivpositive at baseline and 31 (1.9%) became hiv-positive during follow-up. their results demonstrated a positive relationship between hiv-seropositivity and having access to a physician for regular hcv care, which is partially explained through increased frequency of engagement in health care (35). in 11 european countries, data were used for performing retrospective and cross sectional study with 229 hcv / hiv cases of children and young adults (36). that resulted in 63% of cases that were infected with hepatitis c vertically, 7% of them were infected with hepatitis c as nosocomial infection, 17% with drug use and 13% of them has no data about the way of infection. study also reveals that among infected patients with hepatitis c, a high number of patients with progressive liver disease was present, so it suggests the importance of improving monitoring procedures and offering earlier hcv proper treatment (36). a study in 9 emergency units in england, in 2014, during “going viral” campaign, 7807 patients were tested (37). that resulted in 39 hcv infected persons (15 newly diagnosed), 17 hiv infected persons (six newly diagnosed), and 15 hbv infected persons (11 newly diagnosed). it also revealed that those aged 25–54 years had the highest prevalence: 2.46% for hcv, 1.36% for hiv and 1.09% for hbv. another study performed with 4950 participants in some regions in china resulted with hiv and hcv prevalence of yanyuan county were 0.06% and 0.15%, respectively. hcv prevalence of muli county was 0.06% hcv and none was found to be hiv positive (38). another important finding from this survey was that hiv epidemics has not spread from high risk groups to the general population. a systematic review and meta-analyses of 10 studies (39), 2382 infants, were included in rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 11 | 19 an analysis of hcv-infected mothers (defined by anti-hcv and antibody assays) with and without concomitant hiv infection. the risk estimate of hcv vertical transmission was 2.82 from anti-hcv positive/hiv positive co-infected mothers compared with antihcv positive/ hiv negative mothers. this finding revealed that the risk of hcv vertical transmission is higher in infants born to hiv co-infected mothers. rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 12 | 19 table 3. hiv – hcv coinfection paper year country study design study sample laboratory tests results (33) 2014 ghana prospective study from 1520 infected hiv, all hbsag-positive subjects (n = 236) and a random subset of hbsag-negative subject (n = 172) were screened for hcv rna hcv rna 4 positive cases (34) 2018 spain prospective study 322 hcc cases in hiv/hcv co-infected patients n/a after svr 42 cases (13%) (35) 20052015 canada prospective cohort 1627 hcv positive cases hcv rna, hiv test 582 (35.8%) were hiv-positive at baseline; and 31 (1.9%) became hivpositive during follow-up (36) 2016 11 european countries retrospective cross sectional 229 children and young adults with hiv/hcv hcv rna, hiv rna 63% of cases infected with hepatitis c vertically, 7% infected with hepatitis c as nosocomial infection, 17% drug use and 13% no data (37) 2014 england prospective 9 units of emergency departments (7807 patients) hivag/ab, hbsag, hcv ab 39 hcv infections (15 newly diagnosed), 17 hiv infections (six newly diagnosed), and 15 hbv infections (11 newly diagnosed). (38) 2011 china randomised prospective 4950 participant elisa hiv, elisa hcv hiv and hcv prevalence of yanyuan county were 0.06% and 0.15%, respectively. hcv prevalence of muli county was 0.06% hcv and none was found to be hiv positive (39) 2003 usa a systematic review 2382 infants from hcv infected mothers hiv rna, hcv rna risk estimate of hcv vertical transmission was 2.82 from anti-hcv+/ hiv+ co-infected mothers compared with antihcv+/hiv-mothers (40) 2014 usa review of recommendations / / / rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 13 | 19 results on health workers, tattoo and piercing procedures, patients of mental units / hcv three of seven studies involved in the survey and presented in table 4, revealed that health practitioners are the major risk group of getting hcv while giving care to their positive hcv patients. study on health care professionals approach to patients with hepatitis c revealed that during treatment they use stricter measures to protect themselves from infection (40). in the study, a questionnaire was sent to 3675 health professionals and in the end 1347 completed questionnaires were taken for analysis. as a final result, the study suggests that focusing education strategies on changing health practitioners’ attitudes toward people with hepatitis c, injecting drug users, and infection control guidelines rather than concentrating solely on medical information might ultimately improve patient care. another study conducted in usa, revealed that hiv and hcv infection was transmitted to health care workers from nursing home patients, when they dealt with these infections through non-intact skin exposure. in these cases, the infection may have been prevented by consistent, unfailing use of barrier preventive measures (41). in italy the research that was performed in 9 haemodialysis centres with 1002 patients for detecting infection with hepatitis b, hepatitis c and hiv, resulted with prevalence of hbsag in patients of 5.1%; hcv antibody 39.4%; antibodies to hiv 0.1%. another important result in this study emphasized that health professionals in haemodialytic centres has 4000 and 8000 times lower for hiv than for hepatitis b and hepatitis c, respectively (42). regarding the relation of hcv with mental illness, in the review are included two studies. the first study, with 293 veterans with hcv positive, resulted with 93% of the participants had at least one psychiatric problem and 73% had more than 2 mental disorders (43). the authors concluded that the routine screening for underlying psychiatric and substance use disorders and early treatment intervention before initiating antiviral therapy is essential. another study with 931 patients with mental illness, revealed that among this group there is a high number of infected persons with hiv, hepatitis b and hepatitis c 3.1% with hiv, 23.4% cases with hepatitis b and 19.6% cases with hcv (44). a big problem, authors found, is the large number of undetected cases with hepatitis c, and delay in detection is related to treatment delay and also might be a source of infection to others. regarding the relation of hcv and tattooing or piercing procedures, two studies are included. the first study, of 10 case-control studies, 6 reported no increased risk of hcv infection from tattooing when they controlled for injected drug use and other risk behaviours, and 2 studies reported a 2–3 times higher risk for hcv infection when the tattoo was received in nonprofessional settings (45). another study about knowledge of tattoo practitioners about hcv and transmission revealed that from 35 employees, 34 were aware of guidelines and body piercing (46). the average number of piercing procedures during the week was 5.5. study showed that body-piercing practitioners had inadequate training, and lacked knowledge and understanding of hcv transmission, infection control, and universal precautions. as a conclusion health care practitioners are in high risk for getting hcv infection from infected patients, so they should stricter measures. also it was identified high rate of hcv infection among patient with mental health diseases, and large number of undetected cases, that is a sign for occurring epidemics inside mental health wards. another conclusion related to piercing and tattoo procedures revealed that risk of hcv infection is significant among risk groups. also lack of knowledge about hcv transmission among rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 14 | 19 body piercing and tattoo practitioners could be a risk factor on rise. table 4. hepatitis c related to health care practitioners, mental disease patients, tattoo and piercing procedures paper study group year country study design results (41) health professionals 2006 australia analytic cross sectional study focusing education strategies on changing health practitioners’ attitudes toward people with hepatitis c, injecting drug users, and infection control guidelines (42) health professionals 2003 usa case report hiv and hcv transmission from the patient to the hcw appears to have occurred through non-intact skin exposure (43) health professionals 1993 italy prospective the risk of acquiring infection was calculated to be 8000 times lower for hiv than for hepatitis c. (44) mental health patients 2005 usa prospective 93% of the patients had a current or past history of at least 1 psychiatric disorder, and 73% had ⩾2 disorders (45) mental health patients 2001 usa prospective prevalence rates of hbv (23.4%) and hcv (19.6%) were approximately 5 and 11 times the overall estimated population rates for these infections, respectively (46) tattoo and piercing procedures 2015 usa meta –analyse risk of hcv infection is significant, especially among high-risk groups (adjusted odds ratio, 2.0–3.6), when tattoos are applied in prison settings or by friends (47) tattoo and piercing procedures 2003 australia cross sectional survey body piercing practitioners had inadequate training, and lacked knowledge and understanding of hcv transmission, infection control, and universal precautions discussion as for the first part of the research on haemodialysis, presented in table 1, most of the studies were of prospective nature, indicating the importance of following up the relations between the haemodialysis and hcv. less than half of the studies had a bigger sample than 1000 patients. the timing of haemodialysis and the risk of infection with hepatitis c virus appear to be in the right proportion, as the years of haemodialysis increase and the risk of acquiring hepatitis c infection increases. the laboratory tests in almost all of the studies, included hcv antibody and/or hcv rna but considering that hcv rna test is more expensive, in developing countries like sudan, only the hcv antibody test rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 15 | 19 was conducted, which can’t differentiate between an active infection versus a chronic or previously acquired infection. but, still the hcv antibody test, can provide an overview of the infected population with hepatitis c. this is also confirmed by the results of three studies (9,12,17) where over 70% of hcv ab positive cases were found to be hcv rna positive. generally, most of the studies suggest stronger preventive measures and stronger infection control strategies on haemodialysis centres. the second part of the research, dealing with relation between hepatitis c and pregnancy, presented in table 2, most of the studies were of prospective nature. injections (intravenous drugs) and hospitalization were identified as most common pathways of infection of pregnant women with hcv. other studies focused on vertical transmission, identified that new-borns were infected with hcv. these results emphasise the importance of routine screening for hcv during pregnancy. the part of the research dealing with hepatitis c and hiv co-infection, identified several publications, where most of them conducted prospective studies. the laboratory tests included hcv rna and hiv test. several studies call for routine screening in order to find out if they are infected but as well to offer earlier and proper treatment. the last part of the research included health care practitioners, mental health patients and tattoo and piercing procedures. according to the publications, health care practitioners are in high risk for getting hcv infection, from infected patients, so they should use stricter measures. also, a high rate of hcv infection among patient with mental health diseases was observed, and large number of undetected cases, that is a sign for occurring epidemics inside mental health wards. meanwhile, related to piercing and tattoo procedures, research revealed that risk of hcv infection is significant among risk groups. also lack of knowledge about hcv transmission among body piercing and tattoo practitioners could be a risk factor on the rise. conclusion after discussing the most important aspects presented in all 39 papers, the authors’ viewpoints are as follows: the most common test used to identify hepatitis c is hcv rna, even though as an expensive test, sometimes elisa / hcv antibody test can provide a valuable overview on infection. most of the studies were of prospective nature, indicating the importance of following up the disease. almost every study suggests stronger preventive measures and stronger control on haemodialysis centres. unfortunately, the hepatitis c incidence is on the rise. in line with these viewpoints, it is of paramount importance to emphasize that the routine screening can be life changing in finding out new cases and educating the population about the importance of preventive measures, as well as the early treatment. references 1. mohd hanafiah k, groeger j, flaxman ad, wiersma st. global epidemiology of hepatitis c virus infection: new estimates of age-specific antibody to hcv seroprevalence. hepatology 2013;57:1333-42. 2. world health organization. hepatitis c. available from: https://www.who.int/newsroom/fact-sheets/detail/hepatitis-c (accessed: november 18, 2020). 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the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina martin rusnak1, predrag duric2, denisa jakubcova1, viera rusnakova1, amina obradovic-balihodzic3 1 department of public health, faculty of health sciences and social work, trnava university in trnava, slovakia; 2 institute for global health and development, queen margaret university, edinburgh, uk; 3 institute for public health of canton sarajevo, sarajevo, bosnia and herzegovina. corresponding author: prof. martin rusnak; address: trnava university in trnava, faculty of health sciences and social work, department of public health, univerzitnenamestie 1, 918 43 trnava, slovakia; telephone: +421335939495; e-mail: rusnakm@truni.sk rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 2 abstract aim: the public health reform ii project was implemented in bosnia and herzegovina from december 2011 to december 2013 and was funded by the european union aid schema. the principal aim of the project was to strengthen public health services in the country through improved control of public health threats. workshops for primary care physicians were provided to improve the situation and increase communicable diseases notification rates in eight selected primary care centres. they were followed with visits from the project’s implementing team to verify the effects of trainings. methods: the quality of notifications from physicians in tuzla region was compared before and after the workshop. the timeliness was used as an indicator of quality. medians of timeliness before and after the training were compared by use of wilcoxon test, whereas the averages of timeliness were compared by use of the t-test. results: there were 980 reported cases, 80% before the training and 20% after the training. a lower median of timeliness for all the reported cases after the training was statistically significant compared to the median value before the training. a similar picture was revealed for specific diseases i.e. tuberculosis and enteritis, not so for scarlet fever and scabies. conclusion: the significant reduction in time response between the first symptoms and disease diagnosis indicates the positive impact of the training program in tuzla. hence, primary care physicians provided better quality of reported data after the training course. keywords: bosnia and herzegovina, communicable diseases notification, surveillance, timeliness, tuzla. conflicts of interest: none. acknowledgements: the authors are grateful to all primary care physicians and epidemiologists for their interest in training topics and to the management teams of health care centres for their close cooperation. funding: the data used for this study were collected within the public health reform ii project in bosnia and herzegovina. the project was funded by the european union (eu) as a part of the instrument for pre-accession assistance (ipa). the project was implemented by the consortium comprising the ceu consulting gmbh, wien, austria and diadikasia, athens, greece. rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 3 introduction surveillance on communicable diseases is defined as an ongoing, systematic collection, analysis, interpretation and dissemination of infectious disease data for public health action (1,2). effective surveillance provides information on infections that are the most important causes of illness, disability and death, populations at risk, outbreaks, demands on health care services and effectiveness of control programs so priorities for prevention activities can be determined (3,4). the primary aim of infectious diseases surveillance is to eliminate and eradicate disease incidence with two core functions: early warning system for outbreaks and early response to disease occurrence, known also as epidemiological intelligence. an early warning and response system for the prevention and control of communicable diseases is essential for ensuring public health at the regional, national and global levels. recent cases of severe acute respiratory syndrome, avian influenza, haemorrhagic fevers and especially the threats arising from the possibility of misuse of biological and chemical agents demonstrate the need for an effective system of surveillance and early warning at national level providing a higher data structure (57). the structure of surveillance system is based on the existing legislation, goals and priorities, implementation strategies, identification of stakeholders and their mutual connections, networks and partnerships and also capacity for disease diagnosis. primary care physicians or general practitioners who provide the first contact with a patient play a crucial role in the system. the surveillance system relies on the detection of communicable disease in the patients and disease notification (8-10). the project public health reform ii (europe aid/128400/c/ser/ba)was implemented in bosnia and herzegovina from december 2011 till december 2013 and was funded by the european union aid schema. its principal aim was to strengthen public health services in the country through improved control of public health threats. one of the three components of the project dealt with enhancing and improving assessment of global public health and the system of communicable diseases notification. based on an interest from regional public health authorities, eight of them were selected to participate in some workshops. interviews with general practitioners in each region were taken during the initial phase of the activities. professionals who were interviewed indicated the following challenges for the surveillance system they contribute to: the list of mandatory notified diseases too long, clear case definitions and rationale for surveillance missing, mixture of case-based (11) and syndromic surveillance (12), lack of capacity for cases confirmation and a low level of communication among all surveillance stakeholders. the interview findings led to organization of workshops for primary care physicians in eight primary health care centres during march 2013. the aim was to improve the situation and increase notification rates. it was expected that acquiring deeper insights into the role of disease notification would lead to an increased effectiveness of the surveillance system. outcomes from the effort to improve the quality of notifications in the region of tuzla are reported in this paper. physicians from the county were invited in cooperation with the local public health office and notifications were stored in electronic format. this set-up of the endeavour was uniformly repeated across all the eight regions of bosnia and herzegovina. rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 4 methods study design the study was designed with the aim of revealing potential effects of updating primary care physicians with details of surveillance. thus, a cohort of primary care physicians was used to follow the effects. selection of participants was on the basis of interest. no attempts to randomize were undertaken. the project collected baseline data on notification from the database maintained by the tuzla epidemiologists for year 2012 up to february 2013. the workshop was carried in march 2013. the project attempted to keep contact with participants by email and by personal visits. data from the same source were collected until october 2013. there were 20 participants at the first workshop. estimating the proportion from the total of those who serve the region was not possible because of the lack of data. however, the total number of general practitioners listed in 2014 was 378 physicians (13) as our participants were mostly from offices within the city of tuzla. our estimate is based on the average number of citizens per general practitioners (gps) in the region which is 1263 inhabitants per gp. tuzla has 120441 inhabitants according to the census from 2013, which results in about 95 general practitioners in the city. hence, participation in the workshop represents approximately 21% of all primary care physicians in tuzla. workshop the workshop started with an introduction of aims and expected outcomes. assessment of knowledge on surveillance, disease reporting and attitudes to disease notification followed. principles of communicable disease surveillance and use of case definitions with emphasis on importance of surveillance, techniques, categories and use of the eu case definitions were presented by the project. following discussion dealt with everyday problems and opinions on the system of surveillance as well as the use of the eu case definitions. at the end of the workshop each participant received a copy of the eu case definitions, translated into the local language. local management of primary health care centres and people from epidemiology department were also invited to participate as observers. all data were anonymised and no ethical considerations were identified. data processing the timeliness for notifications obtained from primary care physicians in the town of tuzla was compared before and after the workshop. the timeliness was used as an indicator of quality, as it reflects the speed between steps in a public health surveillance system (14). we chose the following definition of timeliness out of several options: “average time interval between date of onset and date of notification by general practitioners/hospital (by disease, region and surveillance unit). it means time interval between the first symptoms of diseases and reporting”, as defined by the ecdc (15). timeliness was computed from dates stated in individual notifications separately for those noted before and after the workshop. the file was sorted based on the icd-10 diagnosis stated by the physician notifying the case and laboratory confirmation. timeliness was computed for all the diagnoses as well as selected icds for tuberculosis (a15), scarlet fever (a38), enteritis (a09) and scabies (b86). differences in medians before and after the workshop were compared by use of the two-sample wilcoxon rank sum test and signed rank tests and the average values were compared by the two-sample independent t-test from the r project (16), with a level of statistical significance set at p≤0.05. rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 5 results as table 1 illustrates, the sample comprised 980 reported cases, 784 (80%) were before the training and 196 (20%) were reported after the workshop. in total, 147 primary care physicians reported syndromic diagnosis of a communicable disease case (140 before the workshop and 69 after the workshop). table 1. timeliness for notified cases before and after the workshop total sample sample total before after p-value total cases 980 784 196 median 1 6 1 0.030* average 12 20.2 9.2 0.039† maximum minimum 152 0 152 0 133 0 tuberculosis sample total before after p-value total cases 159 99 60 median 58 60 13 0.014* average 57.1 57.6 27 0.019† maximum minimum 152 0 152 0 133 0 enteritis (a09) sample total before after p-value total cases 132 86 46 median 2 3 2 0.035* average 3.7 3.2 2.7 0.065† maximum minimum 41 0 41 0 23 0 scarlet fever (a38) sample total before after p-value total cases 33 17 16 median 0 1 0 0.487* average 1.8 1.6 1.5 0.611† maximum minimum 13 0 13 0 13 0 scabies (b86) sample total before after p-value total cases 98 71 27 median 0 1 0 0.512* average 1.7 3.9 2.7 0.481† maximum minimum 37 0 37 0 13 0 *p-values from wilcoxon test. †p-values from t-test. the difference in medians of timeliness for the total sample (table 1) indicates a reduction from 6 days to 1 day following the workshop; the average of the indicator was reduced to one half. the difference was statistically significant for both the median value (p=0.03) and the mean value (p=0.04). the reduction for notified cases of tuberculosis was more pronounced. it rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 6 went down from a median of 60 days to 13 days (p=0.01), whereas the mean from 57.6 days to 27.0 days and this difference was statistically significant too (p=0.02). the median of timeliness notification for enteritis cases was significantly lowered after the workshop from 3 days to 2 days and this difference was statistically significant (p=0.03). furthermore, this difference was also evident in the comparison of mean values. there were no significant differences in both median and mean values in the timeliness for scarlet fever and scabies before and after the workshop (table 1). discussion the surveillance system in bosnia and herzegovina suffered after the war. it is not stabilized yet, experiencing lack of funds, and it is both organizationally as well as politically divided. it is run on a regional basis, where all primary care physicians are legally required to notify cases based on syndromic diagnosis. such a system is characterized by underreporting due to lack of responsibility and weak supervision from authorities. nevertheless, some authors have demonstrated positive effects of an information campaign on improved notifications in a province of vojvodina, serbia (17) where public health services operate in a similar environment to bosnia and herzegovina. this project in bosnia and herzegovina aimed to increase syndromic notification rates through focused workshops as an example for regional epidemiologists how to continue with improving quality of the surveillance. however, we are aware that the quality consists of a multidimensional character and the timeliness is only one of them. thus, using it for a proxy of quality has its limitations. timeliness of a surveillance system depends on a number of factors and its assessment should include a consideration of how the data will be used and is specific for individual diseases under surveillance (3,18). other indicators of timeliness are also available, such as the average time interval between the date of outbreak notification and the date of the first investigation or proportion of outbreaks notified within 48 hours of detection and the like. obtaining a comprehensive assessment of surveillance quality requires considering more attributes, such as sensitivity, representativeness, usefulness, simplicity, acceptability and flexibility (15,19). therefore, even so, this report demonstrates a significant reduction in notification time between syndromic diagnosis and notifications, and the quality improvement was achieved incompletely. another opened question is whether or not achievements are to be sustained. nevertheless, the changes in notifications were observed after the workshops, based on a follow-up evaluation. our findings are congruent with similar studies where timeliness of disease notification was also followed and reported, before and after some type of intervention with a main aim to reduce time response between two steps in the process of reporting. implementation of electronic laboratory reporting resulted in reducing the median of timeliness to 20 days versus 25 days for non-electronic laboratory reporting (20). another study has demonstrated reduced median of timeliness for notifications by 17 days from the year 2000 to 2006 with a higher rate of notification completeness (21). the importance of increased interaction between primary care physicians and surveillance professionals in notifying communicable diseases was demonstrated in our study, as well. providing case definitions from the eu and along with the local ones was appreciated and probably contributed to improved notification rates. the fact that standard case definition is a premise for data quality and validity (22) was reconfirmed with similar studies reported (23,24), where increased dedication to reporting with data qualitytimeliness and completeness was observed. there are factors which are beyond the influence of physicians, such as patient’s awareness of symptoms, patient’s search for medical care, capacity for case confirmation, rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 7 reporting of laboratory test results back to the physician and to other surveillance stakeholders and public health agencies, which limit the validity of interpretation of the findings, too. another limitation stems from the limited time of the study, where 80% of cases were reported before the workshop and 20% of cases were notified after the workshop. another serious limitation of this study stems from the design used. given the specific audience we worked with, namely general practitioners from various parts of the administrative area, the selection of the study participants was "on the basis of interest". as an europeaid project we had no other choice. therefore, the results based on such constrained participation should not be utilized with valid statistical inference on the level of population. the sample representativeness may seriously affect the generalizability (external validity) of the findings. nevertheless, the study was intended to be more of a pilot nature, demonstrating the feasibility of monitoring the quality of the surveillance system. communicable disease surveillance is the first step towards prevention and it is one of the most important tools used in public health. the surveillance system should be regularly evaluated in terms of usefulness and quality by defined standards and recommendations. in this report, we shared results of the surveillance system evaluation in tuzla, bosnia and herzegovina by using one of quality standardstimeliness of disease notification before the training and after the training. this study underlined the importance and effectiveness of increased communication and feedback procedures between primary care physicians and surveillance professionals, use of standard case definition and surveillance evaluation. the identified outcomes of evaluation should be the basis for setting priorities and activities to improve the quality and effectiveness of the surveillance system. references 1. world health organization. communicable disease surveillance and response systems. geneva, switzerland; 2006. http://www.who.int/csr/resources/publications/surveillance/who_cds_epr_lyo_2006 _2.pdf (accessed: 29 march, 2017). 2. world health organization. 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grabowska k, ekdahl k. implementing a public web based gis service for feedback of surveillance data on communicable diseases in sweden. bmc infect dis 2004;4:17. http://www.who.int/csr/resources/publications/surveillance/who_cds_epr_lyo_2006_2.pdf http://www.who.int/csr/resources/publications/surveillance/who_cds_epr_lyo_2006_2.pdf http://www.who.int/csr/resources/publications/surveillance/whocdscsrisr992.pdf http://ecdc.europa.eu/en/activities/surveillance/pages/surveillance_objectives.aspx rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 8 8. jamison dt, breman jg, measham ar, alleyne g, claeson m, evans db, et al. disease control priorities in developing countries, 2nd edition. washington dc: world bank; 2006. 9. baker mg, fidler dp. global public health surveillance under new international health regulations. emerg infect dis2011;7:1058-63. 10. souty c. improving disease incidence estimates in primary care surveillance systems. popul health metr 2014;19:12. 11. who. who technical consultation on event-based surveillancemeeting report. lyon: france; 2013. http://www.episouthnetwork.org/sites/default/files/meeting_report_ebs_march_2013_fina l.pdf (accessed: 29 march, 2017). 12. henning, kj. what is syndromic surveillance. mmwr morb mortal wkly rep 2004;53:7-11. 13. institute for public health fb& h. health statistics annual federation of bosnia and herzegovina. sarajevo; 2013. http://www.zzjzfbih.ba/wpcontent/uploads/2009/02/zdravstveno-statisticki-godisnjak-fbih-20121.pdf (accessed: 29 march, 2017). 14. thackers sb, stroup df. future directions for comprehensive public health surveillance and health information systems in the united states. am j epidemiol 1994;140:383-97. 15. european centre for disease control and prevention. data quality monitoring and surveillance system evaluation – a handbook of methods and applications. stockholm, sweden; 2014. http://ecdc.europa.eu/en/publications/publications/data-qualitymonitoring-surveillance-system-evaluation-sept-2014.pdf (accessed: 29 march, 2017). 16. the r project for statistical computing. vienna, austria.http://www.r-project.org/ (accessed: 29 march, 2017). 17. duric p, ilic s. quality of infectious diseases surveillance in primary health care. sri lank j infect dis 2012;2:37-46. 18. yoo hs, park o, park hk, leeeg, jeong ek, lee jk, et al. timeliness of national notifiable diseases surveillance system in korea: a cross-sectional study. bmc public health 2009;9:93. 19. buehler jw, hopkins sr, overhage jm, sosin dmt. framework for evaluating public health surveillance systems for early detection of outbreaks: recommendations from the cdc working group. mmwr recomm rep 2004;53:1-11. 20. samoff e, fangman mt, fleischauer at, waller ae, macdonald pd. improvements in timeliness resulting from implementation of electronic laboratory reporting and an electronic disease surveillance system. public health rep 2013;128:393-8. 21. jansonn a. timeliness of case reporting in the swedish statutory surveillance of communicable diseases 1998-2002. scand j infect dis 2004;36:865-72. 22. jajosky ra, groseclose s. evaluation of reporting timeliness of public health surveillance systems for infectious diseases. bmc public health 2004;4:29. 23. turnberg w, daniell w, duchin j. notifiable infectious disease reporting awareness among physicians and registered nurses in primary care and emergency department settings. am j infect control 2010;38:410-13. 24. keramarou m, evans mr. completeness of infectious disease notification in the united kingdom: a systematic review. j infect 2012;64:555-64. ______________________________________________________________________________________ http://www.episouthnetwork.org/sites/default/files/meeting_report_ebs_march_2013_final.pdf http://www.episouthnetwork.org/sites/default/files/meeting_report_ebs_march_2013_final.pdf http://www.zzjzfbih.ba/wp-content/uploads/2009/02/zdravstveno-statisticki-godisnjak-fbih-20121.pdf http://www.zzjzfbih.ba/wp-content/uploads/2009/02/zdravstveno-statisticki-godisnjak-fbih-20121.pdf http://ecdc.europa.eu/en/publications/publications/data-quality-monitoring-surveillance-system-evaluation-sept-2014.pdf http://ecdc.europa.eu/en/publications/publications/data-quality-monitoring-surveillance-system-evaluation-sept-2014.pdf http://www.r-project.org/ rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 9 © 2017 rusnak; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. burazeri g. mortality reduction in the russian federation: significant progress contrary to western beliefs (editorial). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3130 p a g e 1 | 3 editorial mortality reduction in the russian federation: significant progress contrary to western beliefs genc burazeri1,2 1department of public health, faculty of medicine, university of medicine, tirana, albania; 2department of international health, school caphri (care and public health research institute), maastricht university, maastricht, the netherlands. corresponding author: genc burazeri, md, phd; address: university of medicine, rr. “dibres”, no. 371, tirana, albania; email: genc.burazeri@maastrichtuniversity.nl burazeri g. mortality reduction in the russian federation: significant progress contrary to western beliefs (editorial). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3130 p a g e 2 | 3 the south eastern european journal of public health (seejph) continuously and successfully widens its global outreach especially to the southern and eastern world. hence, especially in the past years, seejph has placed a major focus on global health challenges and has covered health issues that transcend national boundaries calling for action in the various sectors, which determine the health of populations worldwide (1). however, the biggest and most important neighbour in the european region, the russian federation, is connected with western and south eastern europe through only a few channels. one of them is the technical cooperation in the framework of the northern dimension partnerships which includes the european union (eu) member states around the baltic sea and russia as a whole through its bordering north-west district including petersburg and kaliningrad (2). the eu and the russian federation contribute financially in similar dimensions. the paper published by chernyavskiy et al. in the current issue of seejph shows that the russian federation has made a considerable progress in the reduction of premature mortality, contrary to western expectations (3). the detailed and robust analysis presented in this article indicates a remarkable reduction of premature years of life lost (pyll) for the period 20032013 which, assuming the same pace of progress, will eventually lead into a “positive gap ratio” for the year 2020 and subsequently in 2030. of note, a positive gap ratio indicates an “on track” status for achievement of the respective sustainable development goal (sdg) target (4). interestingly, a comparison of regions of north-western russia and neighbouring european countries confirmed that the higher the mortality levels the stronger the contribution of avoidable causes. thus, on average, mortality reduction levels amounted to 50% in north-western russia, suggesting an impressive progress. among other things, this progress is due to increasing investments of the russian government in the last decade, which have largely focused on the renovation of old health care facilities including purchasing of modern medical equipment for diagnosis and treatment of a wide range of medical conditions (5). notwithstanding the importance of the healthcare investments in mortality reduction, this is however not the main contributor of the observed health improvements. based on these considerations, it is from our point of view extremely important to keep communication channels open between the eu member states and the russian federation, at least at the professional and technical level. from this perspective, the paper by chernyavskiy et al. (3) is timely and very relevant, providing a significant contribution on the understating of the health status progress and achievements observed in the russian federation in the past decades. burazeri g. mortality reduction in the russian federation: significant progress contrary to western beliefs (editorial). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3130 p a g e 3 | 3 references 1. jens holst, breckenkamp j, burazeri, martin-moreno jm, schröder-bäck p, laaser u. five years of the south eastern european journal of public health (seejph): focusing on health systems in transition and global health. seejph 2018; vol x. doi: https://doi.org/10.4119/seejph1870. 2. the northern dimension. https://eeas.europa.eu/diplomaticnetwork/northern-dimension_en (accessed: october 24, 2019). 3. chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovicmikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being. seejph 2019; vol xii. doi 10.4119/seejph-3129 4. bjegovic-mikanovic v, salem za, breckenkamp j, wenzel h, broniatowski r, nelson c, vukovic d, laaser u. a gap analysis of sdg 3 and mdg 4/5 mortality health targets in the six arabic countries of north africa: egypt, libya, tunisia, algeria, morocco, and mauritania. lib j med 2019:14/1. https://doi.org/10.1080/19932820.2019. 1607698 (accessed: october 24, 2019). 5. chernyavskiy v, mikhailova j. russia: a key partner in the northern dimension partnership. seejph 2019; vol xii. doi: 10.4119/unibi/seejph-2019-217. _________________________________________________________________________ © 2019 burazeri; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://doi.org/10.4119/seejph-1870 https://doi.org/10.4119/seejph-1870 oduor k, ogweno s, ajwang’ d, okinyi n. incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach (review). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4317 1 | p a g e c review article incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach kevin oduor1, stephen ogweno1, danor ajwang’2, nyawade okinyi2 1 stowelink, nairobi, kenya; 2 plan international corresponding author: mr. kevin oduor address: nairobi, p.o. box 43844-00100, kenya email: oduorkevin@stowelink.com oduor k, ogweno s, ajwang’ d, okinyi n. incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach (review). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4317 2 | p a g e abstract mhealth is the use of mobile and wireless devices to improve health outcomes, healthcare services, and health research. an estimated 68% of the world’s population own mobile phones, with kenya having approximately 80% of mobile phone penetration. this makes it feasible to accelerate the uptake of mhealth interventions to improve health services delivery. while some evidence has shown how various forms of mhealth interventions have been used to transform health services, health outcomes, and health research in kenya and globally, many remain largely anecdotal or undocumented. this paper examines the various forms of mhealth interventions that have been incorporated into kenya’s health infrastructure, and their effectiveness in improving health services delivery in kenya. a systematic review of peer-reviewed articles, policy briefs, and credible materials published on mhealth have shown that mhealth has succeeded in the health infrastructure such as in collecting and transferring health and patient data, remote diagnosis, treatment, and patient follow-up. the paper also examines the barriers around the uptake of mhealth interventions and recommends how these interventions can be integrated into kenya’s health infrastructure. even though there is every reason to believe that mhealth can allow limited resource settings to “leapfrog” over more advanced settings in using mobile technologies to improve health services delivery, mhealth is not a panacea. there are limited will and resources to scale up and integrate mhealth into the health infrastructure with attempted integration met with a negative attitude from the strained health workforce who still view mhealth as additional work, among other challenges. despite the challenges, there may be an opportunity for kenya’s government to leverage mobile and wireless devices to improve the delivery of health services to areas that were previously unreachable, thereby fast-tracking its commitment to achieving universal health coverage. keywords: ehealth, health systems, mhealth, mobile phones, telemedicine, universal health coverage. conflict of interest: none declared. oduor k, ogweno s, ajwang’ d, okinyi n. incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach (review). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4317 3 | p a g e introduction background of the study the world health organization states that universal health coverage (uhc) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship (1). uhc has continued to gain momentum even as nations around the world move towards protecting their citizens against financial hardships in accessing health care. kenya has shown great commitment towards achieving uhc with president uhuru kenyatta including it in his big four agenda (2). uhc has been piloted in kisumu, isiolo, nyeri and makueni counties of kenya to inform the uptake and the metrics for upscaling (3). but even as uhc is being implemented, one of the questions that linger is how kenya can leverage the huge mobile phones penetration which stands at an estimated 80 % (4) to accelerate the achievement of uhc. reliable studies on mhealth around the world strongly suggest that mobile phones can be used for instantaneous access, for direct communication and for prompt transfer of health information (5). mobile technologies are currently being used to monitor patient’s adherence to treatments such as tb using apps (6), for patient’s communication, to improved access to health services and diagnosis and for management of chronic diseases (7). with evidence of mhealth success around the world, kenya too is at a vantage position to reap the benefits that come with its huge mobile phone subscriptions. but even as research in this field is growing day by day, information is still limited as to the impact of mhealth interventions at scale (8). as such, a thorough systematic review of the available evidence was greatly warranted to inform the parameters of integrating mhealth, especially during this period when the call to achieve universal health coverage is beckoning. to this end, the objective of this study was to conduct a systematic review that established how mhealth intervention could be incorporated into kenya’s health infrastructure to augment universal health coverage. statement of the problem experts are in agreement that mobile health technologies hold great opportunity to revamp the health care industry (9) while addressing the inequalities that have remained so prevalent in kenya. however, even with the huge mobile penetration for kenya to leverage on in accelerating uhc, implementing the mobile health technologies requires more than purchasing a gadget and using them for health. available studies are only providing evidence of the potential benefits that mhealth offers and not necessarily the implementation matrix (8). though the field of mhealth is rapidly emerging, there is little evidence as to the impact of mhealth when rolled on a large scale and especially in achieving the muchdesired universal health coverage. furthermore, uhc in kenya continues to grapple with inadequate service delivery 2 years after the kenyan government ambitious plan to improve access to health care (10). as such, this systematic review is greatly warranted to inform on how mhealth can be integrated into kenya’s health infrastructure to augment universal health coverage and subsequently improve service delivery. justification of the study this review is particularly important at this time when the call to hasten the achievement of universal health coverage is emphasized. the aim of this review is to provide evidenced based recommendations on how mhealth technologies can improve service delivery and fast-track the achieve oduor k, ogweno s, ajwang’ d, okinyi n. incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach (review). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4317 4 | p a g e ment of uhc. moreover, findings from this study will help in augmenting universal health coverage to reduce the burden of delivering health in the long term. and since the field of mhealth is rapidly evolving (11), research in this area is needed to inform the impact it has at scale and the strategies for integration. it will also inform the policy around mhealth by bringing together lessons learned while incorporating mhealth in kenya. objectives of the study the purpose of this study is to systematically review the mhealth interventions in kenya and establish how they can be incorporated into kenya’s health infrastructure to augment universal health coverage. specific objectives 1. examine the various forms of mhealth interventions incorporated into kenya’s health infrastructure. 2. assess the effectiveness of mhealth interventions in improving health services delivery in kenya. 3. establish the challenges facing the uptake of mhealth interventions in kenya. 4. determine ways in which mhealth interventions can be integrated into kenya’s health infrastructure. research questions 1. in what forms have mhealth interventions been incorporated into kenya’s health infrastructure? 2. have mhealth interventions been effective in improving health services delivery in kenya? 3. what have been the challenges facing the uptake of mhealth interventions in kenya? 4. in what ways can mhealth interventions be integrated into kenya’s health infrastructure? methodology this review followed the preferred reporting items for systematic reviews checklist. the search criterion was derived from the review’s objectives and the search done on cinahl and pubmed. to ensure the search was contextual, exhaustive terms including mhealth, text messaging, kenya, and low-middle income countries were used. similarly, the search was limited to studies conducted around health between 2010-2020 that meet the expected threshold of validity and reliability. these studies were in english language. four authors thoroughly reviewed the articles and their abstracts to establish if they were aligned to the objectives. the articles were cross verified for rigor, authority, and relevance before being subjected to review. inclusion & exclusion criteria the review was conducted using a common search methodology. the reviewed studies and citations were assigned to reviewers before they could be confirmed for review. the review articles and citation conformed with the inclusion and exclusion criteria below:  recent i.e., 2010-2020.  relevant i.e., ehealth and mhealth.  quality of evidence (from reputable journals i.e., pubmed eanso frontiers and hindawi)  geographical context i.e., low-middle income settings. data extraction and quality assessment two authors conducted data extraction following an agreed format and criteria. the findings of were then reviewed by two other senior authors. in the data extraction process, journal, study design, country of implementation, main findings, forms of mhealth intervention, challenges facing mhealth interventions, impact and effectiveness of mhealth interventions and oduor k, ogweno s, ajwang’ d, okinyi n. incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach (review). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4317 5 | p a g e mhealth interventions scale up. to assess the methodological correctness, the reviews were evaluated using the measurement tool to assess systematic review (amstar). results the search strategy identified 41,047 citations which were both peer-reviewed and non-peer-reviewed (see figure 1). an additional 25 publications were retrieved through hand searches of blogs from web searches, institutions websites, and from appropriate documents. when we applied the filter to focus on kenya, we got 142 citations on mhealth and 12 publications from the hand search. the researchers then applied the filter of time to look at research from 10 years ago and 139 citations from research and 8 the hand searchers emerged. the final filtering criteria involved reviewing original randomized controlled research and previous systematic reviews which led to a total of 27 papers of interest for review in addition to the 8 other citations from searches. finally, researchers met to review the remaining documents and settled on reviewing 24 total research citations and 5 hand searched citations bringing the total of reviewed articles to 29. figure 1: review strategy, authors synthesis oduor k, ogweno s, ajwang’ d, okinyi n. incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach (review). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4317 6 | p a g e forms of mhealth interventions in the health care system mhealth interventions have taken many forms addressing various needs in the health care delivery system. according to world health organization (12), mhealth interventions have taken the following forms i.e., health call centers, emergency toll-free telephone services, mobile telemedicine, health surveys, surveillance, awareness-raising, and decision support systems. call centers, sms and mobile apps are the most common forms of implementing mhealth interventions in the country with sms being used most predominantly (13-16). most mhealth interventions are implemented in nairobi county with about 37 counties in kenya having at least one mhealth intervention working in the health system (13). mhealth interventions in the form of mobile apps are also mostly found in cities where there is access to good internet connectivity and higher phone penetration while sms and call centers generally are found in both cities and rural areas (13). of the 29 mhealth citations reviewed, findings indicate that only 3 projects have been scaled nationally and with one project relying on the use of mobile money systems to achieve its objectives (17,18). most mhealth interventions in kenya focus majorly on hiv aids, maternal and child health and malaria (7). these interventions are provided from both private and government service providers including non-governmental organizations like pham access, safaricom and ampath bringing mhealth solution ranging from sms daily reminders, hiv drugs compliance programmes and even medical insurance and telemedicine (9). a review of the study conducted by vedanthan et al. reveals that community health workers used smartphones to improve linkages to hypertension care (14). however, this study concluded that the strategy has to combine a tailored behavioral communication and mhealth (14). effectiveness of mhealth interventions in service delivery mhealth interventions have shown success in achieving their intended outcomes. from the reviewed citations, mhealth showed success in achieving retention in care (16), behavior change (19) cultural change and adaptation of new health-friendly behavior (15), maternal and child health improvements (20). indeed, mhealth interventions have managed to achieve effectiveness at a small scale. most mhealth interventions have not been able to successfully scale up nationally to augment health delivery at a national level (13). in terms of cost effectiveness, of all the citations that were reviewed in this study, only two research did a cost-benefit analysis indicating that sms use for mhealth was a cheap and cost-effective way of achieving certain health outcomes. text messaging was found to be 35% less expensive compare to the control group through reduction in the workforce involved such as research assistants, wages, salaries required, and communication costs (5,21). in assessing the effectiveness of text messaging in clinical outcomes, the citations reviewed revealed that there is positive outcome demonstrated with moderatequality evidence of greater improvement in the symptoms score compared to the control group (mean difference 0.36, 95% ci 0.56 to -0.17) (5). similarly, a review of this citation further revealed that there are increased hospital visits for those in the sms group compared to the control group. there is also reduction in number of days in hospitalization and reported better symptom control using spirometry transmission to health caregiver via sms and cell/telephone counseling (5). further, out of all the citations reviewed, two reviews yielded that oduor k, ogweno s, ajwang’ d, okinyi n. incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach (review). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4317 7 | p a g e mobile technology led to fewer symptoms being reported for congestive heart failure (5,22). a randomized control study on cellphone counseling in kisumu, kenya, showed that there was higher retention in the intervention arm than the control arm during delivery (16). the retention rate in the intervention arm was reported to be at 95.2% while that of the control arm was recorded as 77.7%. the 6 weeks postpartum was at 93.9% for the interventional arm and 72.9% for the control arm (16). overall, despite the many mhealth interventions currently happening in the country, very few interventions have been evaluated and very few have been research based making it difficult to track overall effectiveness of mhealth interventions (13). challenges facing mhealth interventions together with the potential impact that comes with mhealth intervention, there are myriad of challenges hovering around their implementation. gurupur & wan in their systematic review indicates that usability is a challenge to mhealth implementation (23). in considering the use of mobile health technologies in providing feedback for researchers, the review submits that issues of efficacy, effectiveness and satisfaction with which users can achieve specific goals are concerns of usability. in reviewing the study by gurupur & wan, we found out that usability has several components which includes learnability, efficiency, memorability, and satisfaction (23). a study by kariuki & okanda (24) on the adoption of mhealth and usability challenges in kenya also seem to have the same argument as that of gurupur & wan. the issue of usability is highlighted in the kimmnchip m-health application. the application was in english language hence the users who did not understand the language found it difficult to use it. further, the study submits that the interoperability was also a challenge as the web interface did not suit every device. the display was rather disfigured and difficult to use (24). the weltel intervention in kenya and canada also revealed some of the challenges facing mhealth interventions. in reviewing their study, bardosh et al reveals that juggling different interest, establishing the most appropriate financing pathways, maintaining network growth and “packaging” the intervention for impact and relevance is a challenge both in canada and kenya where the intervention is implemented (15). implementing mhealth technologies require more than just procuring the gadgets and using them. there are legal formalities that must be followed to approve their application (25). in reviewing the article by ryan (25), it is quite evident that incorporating mobile health solutions into the larger health infrastructure calls for its implementation to be harmonized in order to remove potential inequalities that may come with it. in the view of the aforementioned, the long and bureaucratic process that involves the approval of its application is poised to cause considerable timeline challenges (25). apart from the regulation challenges, security concerns also present another challenge that policymakers are grappling with. from the report submitted by elliot (26), itis evident that over 400 million people are using different forms of mobile health technologies. with this huge number, a single flaw in the system can render the data available to hackers or malware. the flaw also leads to the breach of the healthcare data (27). furthermore, mhealth has received a major blow even as critics suggest that without proper guidelines, mhealth intervention can infringe on patient’s data safety. this is a widespread concern especially in the context of electronic health records (27). still on the issue of data safety, review of the systematic review by gurupur & wan reveals that there is inherent problem with cloud computingstorage of data in unknown locations (23). this poses a significant threat to data and can be accessed by unauthorized persons. oduor k, ogweno s, ajwang’ d, okinyi n. incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach (review). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4317 8 | p a g e atun et al., indicate that apart from problems with cloud computing, data can also suffer risk of storage in non-secure locations (28). mhealth integration into kenya’s health infrastructure our focus in this systematic review was to determine how mhealth can be integrated into kenya’s health infrastructure to augment universal health coverage. we were concerned about how such integration can improve service delivery and in turn, fast track the achievement of universal health coverage. in our reviewed citations, we found out that mhealth integration is possible due to the increased smartphone penetration in kenya (24). in this study, the authors accessed the cost of accessing uzazi poa web application in terms of internet bundles. the accumulative percentage of 100% of the respondents submitted that access to mhealth application was not expensive and they would adopt it at will (24). the authors are in agreement that this was attributed to the prototype being developed using light graphics which ensure prompt transmission of data from the server to the mobile phone of the user (24). in light of the above, one thing that becomes clear is the issue of usability. for mhealth intervention to be fully optimized in kenya, the different forms of mhealth interventions must ensure efficiency which is a component of usability (23). universal health coverage as defined by who seeks to alleviate financial hardships in accessing health care services (1) meaning that mhealth intervention must be as efficient as possible. with the huge mobile penetration in kenya, addressing the usability concerns opens a pathway for mhealth integration into the larger health care infrastructure. four of the studies reviewed pointed out to the issue of an effective regulatory framework to be developed to inform the implementation of mhealth solutions (13-16,29). the ministry of health in kenya has the obligation of implementing mhealth committee or governing body because the field of technology and mhealth is ever-changing (29). it is paramount that the ministry of health set specific groups to keep up to date with new development in regard to how mobile technologies can be used to fasttrack achievement of universal health coverage. a proper regulatory framework will help in data security and the protection of individual information. similarly, integrating mhealth intervention into kenya’s health infrastructure will require more than just having a governing body. a study on the integration of mhealth in low-middle income settings suggests that governments should produce mhealth strategy and forge partnerships with ngos implementing mhealth solutions. this partnership enhances reporting and effectiveness more so because the government is involved and has systems to accept mhealth technologies (29,30). the issue of small mhealth project reaching to scale in kenya can also be made possible if the ministry of health consider endorsement of mhealth technologies as providing an acceptable standard of care (30). changamka’s linda jamii health insurance programme financed through a partnership between the kenyan government and safaricom is an example of how endorsement is critical for adoption and integration (29). again, for mhealth to be fully integrated into kenya’s health infrastructure to augment uhc, there is a growing body of need for investment in technology and infrastructure (13). the increased mobile penetration in kenya is not a coverup for internet connectivity. it is important that the government focus on increasing cellular and data coverage and increase data speed and transmission even in most remote parts of the country (13). while at it, app developers also have the responsibility of developing applications that are efficient and can fit oduor k, ogweno s, ajwang’ d, okinyi n. incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach (review). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4317 9 | p a g e well into kenya’s technological infrastructure (28). if mhealth solutions are going to fast-track the achievement of uhc, then it is only making sense if they are feasible and can be integrated into health infrastructure without major bottlenecks. coming back on the issue of usability, mhealth interventions must be continually evaluated and reassessed to sidestep the potential problems when the intervention reaches scale (28,29). discussion this systematic review was set out to identify mhealth interventions in kenya and how mhealth could be integrated into the health system to facilitate and enhance health service delivery with the aim of augmenting universal health coverage in the country. the authors used various approaches to ensure they extensively review existing projects which fit the research criterion. the analysis of the various works in the mhealth sector revealed strong points to which mhealth interventions have indeed improved health service delivery. mhealth interventions have proven effective in achieving various health objectives necessary for the achievement of universal health coverage including improving health literacy (13), improving compliance to medication (7), enhancing positive behavior change (14,15,19), improving access to health (14,20) and improving health financing and mobile health insurance (29). in the analysis, it was also noted that mhealth interventions are a feasible way of improving service delivery (24) due to the supportive environment that the country has, which includes being one of the highest internet connection subscription rates (31), and the demographic advantage as the country mostly consists of mostly the younger population with median age being 20 years (32). finally, one of the biggest factors in the mhealth interventions that have the potential to support and highly improve service delivery and universal health coverage is the availability of the various forms of mhealth interventions that have been adopted and implemented in various parts of the country with success (13-16). the various forms of mhealth interventions make it very possible to fast track the achievement of universal health coverage. some of the identified challenges and limitations in the mhealth interventions included the scalability factor (13). most mhealth interventions are implemented regionally and have not been able to scale up to various parts of the country. another challenge identified was lack of a national governing body for mhealth interventions (29). most mhealth interventions have been developed by private entities and until very recently, there was nobody in the government charged with streamlining mhealth interventions in the country. finally, the biggest limitation of this research was the fact that there is a huge gap in mhealth research. despite the numerous interventions, very few have actually been documented and even fewer have been evaluated through research (13). conclusion in conclusion, this review confirms that there has been indeed a lot of mhealth interventions in kenya, and mhealth is rapidly catching up and improving with the improved mobile internet penetration. there has been a lot of successful mhealth interventions in the country both locally and nationally. the adaptation of mhealth has been shown through research to greatly improve health service delivery and achieve various health objectives. despite the increased developments in the mhealth space, there has been significant challenges including around perceptions, usability, interoperability, funding, and scalability. but since we are just in the beginning stages of mhealth interventions in the country and the region, these challenges are definitely expected. owing to the findings of in this oduor k, ogweno s, ajwang’ d, okinyi n. incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach (review). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4317 10 | p a g e review, and the existing evidence and future trends, it is the researcher’s opinion that mhealth indeed has the potential to improve health service delivery and as a result, augment universal health coverage not only in kenya but also around the world. recommendations this review recommends the following: 1. in kenya and even globally, more research needs to be undertaken to meas ure effectiveness and impact of already existing mhealth interventions. 2. mhealth interventions 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(n.d.). retrieved august 01, 2020. available from https://www.worldometers.info/world-population/kenyapopulation/ (accessed: january 15, 2021). macassa g. responsible leadership styles and promotion of stakeholders’ health (short report). seejph 2019, posted: 07 march 2019. doi 10.4119/unibi/seejph-2019-207 page 1 of 5 s h o r t r e po r t responsible leadership styles and promotion of stakeholders’ health gloria macassa1 1department of public health and sports science, university of gävle, sweden. corresponding author: gloria macassa, md, professor of public health and epidemiology, department of public health and sports science, university of gävle, sweden; address: se-801 76, gävle, sweden; telephone: +4626648228; email: gloria.macassa@hig.se. macassa g. responsible leadership styles and promotion of stakeholders’ health (short report). seejph 2019, posted: 07 march 2019. doi 10.4119/unibi/seejph-2019-207 page 2 of 5 abstract the aim of this short report is to stimulate a conversation on the potential role to be played by responsible leadership in promoting the health and well-being of stakeholders (employees and society at large). the report first describes responsible leadership styles and then briefly discusses the potential connection with health promotion within the lens of the wider determinants of health and intersectorial collaboration. integrative responsible leadership and health promotion share a common vision: to alter the economic, environmental, and social contexts in which decisions relating to health and wellbeing are made, thus affecting health equity. keywords: health promotion; responsible leadership, stakeholders, sustainable development goals. conflicts of interest: none. macassa g. responsible leadership styles and promotion of stakeholders’ health (short report). seejph 2019, posted: 07 march 2019. doi 10.4119/unibi/seejph-2019-207 page 3 of 5 responsible leadership responsible leadership (rl) is a relational process between leaders and stakeholders aimed at establishing accountability in matters pertaining to organizational value creation (1). pless et al. define leadership style as an observable behaviour that reflects different degrees of such accountability in executive actions and discussions (2), and argue that this behaviour could be evaluated by other people like subordinates (who are classical followers, peers, and external constituencies) (2). this short report looks at rl styles and examines how they can influence health promotion through corporate social responsibility (csr) strategies and processes in the organization. this approach to rl is supported by doh and quigley’s understanding of rl behaviour, which they see as going beyond “doing no harm” to contributing to value creation in relation to multiple bottom lines (3). according to maak et al. (1) there are two rl behaviours with two distinct leadership styles: instrumental and integrative. instrumental rl is centred on driving business, with a strategic focus on business performance (1) and less attention paid to non-core business issues (2). this style entails a personalized vision based on the achievement of organizational goals such as maximization of profits, growth, and dominance over the competition (1). instrumental rl is also associated with weaker interactions with stakeholders, mostly based on key business stakeholders, employees, governments, and investors. regarding relations with internal stakeholders (employees), instrumental rl is suggested to lead by objectives, setting high performance goals as well as focusing on managing employees’ performance and excellence to meet the defined goals (2). relations with external stakeholders are suggested to come through economic means-end relationships (4) or beneficial in terms of power, or through relations with governments, legislation or media (for urgency issues). instrumental leaders are rational, as they search for information about selected societal issues that they see as providing business benefits (2,4). in contrast to this, an integrative rl style is characterised by a balanced approach towards value creation, leading the business towards societal as well as business objectives (the so-called “double-bottomline”) (1). integrative responsible leaders use communication and vision statements as an active leadership tool to convey positive messages regarding societal impact, taking boundary-spanning roles and connecting with a large range of stakeholders (1,4).these leaders are connected to external constituencies, governments, and investors as well as being facilitators of collaboration between stakeholders from different sectors and industries. they can also facilitate inclusive processes in decision making, use moral reasoning and often make pro-social choices (1). the two leadership styles are summarised in table 1. can responsible leaders contribute to public health promotion? according to the world health organization (who), health promotion is the process of enabling people to increase control over and improve their health (5). health promotion moves beyond the focus on individual behaviours towards a wide range of social, economic, and environmental interventions. it is strictly linked to the determinants of health and well-being which are known to be the conditions in which people are born, grow, live, work, and age. these conditions determine people’s chances for good health, and are sometimes called “the causes of the causes” (6). there is now a broader consensus that health is linked not only to behaviour or risk exposure, but also to how social and economic structures shape the health of the populations globally. macassa g. responsible leadership styles and promotion of stakeholders’ health (short report). seejph 2019, posted: 07 march 2019. doi 10.4119/unibi/seejph-2019-207 page 4 of 5 table 1. responsible leadership styles behavioural characteristics instrumental leader integrative leader vision personalized socialized focus of business leadership/value creation leading business with a focus on the financial bottom-line leading business with a focus on dual-bottom-line approach to leading leading by objective setting leading by mobilizing stakeholders stakeholders relations/scope of interaction low degree of interconnectedness boundary setting reactive narrow focus on powerful and urgent stakeholders high degree of interconnectedness boundary spanning proactive broader focus on all legitimate stakeholders decision making process/ applied logic/justification of choices exclusive economic cost – benefit logic business case justification inclusive pro-social cost logic logic of appropriateness source: adapted from maak et al 2016 (1). i argue that responsible leaders, especially those with an integrative behaviour style, will be more likely to advance csr strategies and processes that are inclusive and that involve collaboration with other stakeholders, in order to improve people’s health beyond the workplace. this inclusiveness and collaboration, which is a common feature of integrative responsible leaders, is very important in health promotion and is referred to as “intersectorial collaboration” (7). since its conception, health promotion was always thought to advance intersectorial collaboration beyond the health sector in pursuit of improving human health (5). this view was that by creating partnerships with sectors beyond the health sector, countries could better address the underlying causes of the conditions that create ill health, and especially health inequalities (7). business organizations, through their integrative responsible leaders, can help improve population health by collaborating in addressing the social determinants of health (e.g., tackling environmental, economic, social and health challenges) between and within countries in the era of sustainable development goals (sdgs). for instance, macassa and colleagues viewed responsible leaders as posited to achieve mutually shared objectives (for internal and external stakeholders) based on a vision of business as a force of good for the many, and not only for shareholders and managers (8). it is argued that health promotion offers a great opportunity and means to achieve the sdgs by equipping and empowering individuals and communities and by promoting inclusive models of governance via advocating health policies and environments (9,10). the sdgs are the foundation for supporting global health and international development work in the years to come. csr strategies promoted throughout integrative rl and health promotion share a common vision; that is, to alter the economic, environmental, and social contexts in which decisions relating to health and well-being are made, thus affecting health equity. macassa g. responsible leadership styles and promotion of stakeholders’ health (short report). seejph 2019, posted: 07 march 2019. doi 10.4119/unibi/seejph-2019-207 page 5 of 5 references 1. maak t, pless nm, voegtlin c. business statesman or shareholder advocate? ceo responsible leadership styles and the micro-foundations of political csr. j manag stud 2016;53:463-93. 2. pless n, maak t, waldmand, wang d. development of a measure of responsible leadership. acad manag proceed 2014;1:12973. 3. doh jp, quigley nr. responsible leadership and stakeholder management: influence pathways and organizational outcomes. acad manag perspect 2014;28:255-74. 4. hahn t, pless l, pinkse j, figge, f. cognitive frames in corporate sustainability: managerial sensemaking with paradoxical and business cases frames. acad manag rev 2014;39:46378. 5. world health organization.the ottawa charter for health promotion. geneva: world health organization; 1986. http://www.who.int/healthpromotion/co nferences/previous/ottawa/en/ (accessed: 12 february 2019). 6. world health organization commission on the social determinants of health (who csdh). closing the gap in a generation. health equity through action on the social determinants of health. geneva: world health organization; 2008. https://www.who.int/social_determinant s/thecommission/finalreport/en/ (accessed:14 february 2019) 7. corbin jh. health promotion, partnership and intersectorial collaboration. health promot int 2017;32:923-9. 8. macassa g, francisco jc, mcgrath c. corporate social responsibility and population health. health sj. 2017;11:5:528. 9. spencer g, corbin jh, miedema e. sustainable development goals for health promotion. health promot int 2018. doi: 10.1093/heapro/day036. 10. fortune k, becerra-posada f, buss p, galvao lac, contreras a, murphy m, et al. health promotion and the agenda for sustainable development, who region of the americas. bull world health organ 2018;96:621-6. _____________________________________________________________________________________ © 2019 macassa; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.who.int/healthpromotion/conferences/previous/ottawa/en/ http://www.who.int/healthpromotion/conferences/previous/ottawa/en/ https://www.who.int/social_determinants/thecommission/finalreport/en/ https://www.who.int/social_determinants/thecommission/finalreport/en/ review of biographical lexicon of public health by izet masic, 410 pages ,2015 avicena, sarajevo (isbn 978-9958-720-60-4) at the occasion of the 70th anniversary of the publication of “medical archives”, its readers should be informed of the availability of a new book by its prolific editor professor izet masic. he just published the first biographical lexicon in the field of public health. it includes about 750 names in alphabetical order. this work is an original contribution to the history and to the state of the art in public health. it describes the life and work of prominent contributors to the wide field of population based health improvement, disease prevention and community care. these biographies cover all five continents with personal stories about the development of public health in 50 nations and through international cooperation. the main usefulness of this work is to provide a large set of references to professionals all over the world. in addition, professor masic wrote in his book a comprehensive preface that clarifies the meaning of the terms lexicon and biography. he also described historical milestones in the concepts of social medicine, statistical analysis, epidemiologic studies, communicable diseases prevention, chronic diseases epidemiology, health services organization, health economics, medical record linkage, health informatics, quality of care indicators, health policies, social coverage, risks factors intervention trials, as well as key-role players in the former years for the advances in these various areas. the specific contribution of south east european countries is particularly well described. it adds knowledge for the public health scientists from other european countries and from other continents. as underlined by the author, this lexicon might require a constant updating. even if this first edition contains worldwide biographies of a very large number of developers for many aspects of public health, some names might be missing and could be added in a second edition. another point that might be taken into account is a more standardized presentation of some biographies. it is not always possible to obtain enough information on date of birth, nationality and the original character of the contribution of each person listed. finally, after closing the book, i wondered if we could not have a dream for a longer term future edition: to obtain an index of the specific areas of public health in which each name listed in the lexicon has mainly contributed. this might remain a dream, because requiring an enormous work. such a suggestion only indicates that this publication is an important input to the not always well understood and regularly renewing field of public health. izet masic gives to his readers not only information that was missing. he stimulates his readers to help him to go further in his way. francis roger france, md, ms, phd professor emeritus of the university of louvain, belgium book review global population health and well-being in the 21st century: toward new paradigms, policy and practice (springer publishing, new york, 2016) author: george r lueddeke phd a must read for public health, clinical, and social care students, teachers, and practitioners alike, including case studies to provide a thorough and up-to-date account of the past, present, and future of global public health. dr lueddeke effectively highlights the ingenuity gap between today’s wicked problems and their potential solutions, with a timely emphasis on the concepts of ‘planetary health’ and ‘integrative ecological public health’. following on from the four “waves” of public health interventions in developed nations, including water/sanitation (first), medical and scientific breakthroughs (second), the welfare state and social security (third), and the current focus on systems thinking, risk factors, and lifestyle (fourth), there is now an emerging need for the “fifth wave” interventions that require complex adaptive systems thinking. dr lueddeke presents a manifesto for collective public health action through the ‘one health’ movement, recognising the inter-dependencies in the health of people, other animals and the environment we live in. one of the main aims of the book is to support the implementation of the un 2030 agenda for sustainable development, including the 17 sustainable development goals (sdgs). this book describes part of the solution being the development of an effective public health workforce through innovations in education and training, offering a proposal for centers of one health excellence (cohe) worldwide. our mission at oxford public health is aligned closely with many of the compelling concepts in this very informative and groundbreaking read. dr behrooz behbod, mb chb msc scd mfph founder, oxford public health ltd www.oxfordpublichealth.com http://www.oxfordpublichealth.com/ dyakova m, drew c, wright n, clarke a, rees k. systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease: cochrane systematic review protocol (short report). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-02. 1 short report systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease: cochrane systematic review protocol mariana dyakova1, christian drew1, nicola wright2, aileen clarke1, karen rees1 1health sciences, warwick medical school, university of warwick, united kingdom; 2 public health, communities group, warwickshire county council, united kingdom. corresponding author: dr mariana dyakova, division of health sciences, warwick medical school, university of warwick; address: medical school building, gibbet hill campus, coventry, cv4 7al, england, united kingdom; email: m.dyakova@warwick.ac.uk dyakova m, drew c, wright n, clarke a, rees k. systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease: cochrane systematic review protocol (short report). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-02. 2 abstract a large number of people, considered at increased risk of vascular disease, remain unidentified, untreated and not reached by lifestyle advice or intervention, despite public health and clinical efforts. this has prompted the initiation of national screening/systematic risk assessment programmes for vascular disease in healthy populations. these exist in addition to the more ad hoc opportunistic risk assessment initiatives undertaken worldwide. there is currently not enough indisputable evidence either showing clear clinical or economic benefits of systematic screening-like programmes over opportunistic risk assessment of cardiovascular disease (cvd) in primary care. we present the rationale and methodology of a cochrane systematic review, assessing the effectiveness, costs and adverse effects of systematic risk assessment compared to opportunistic risk assessment for the primary prevention of cvd. keywords: cardiovascular disease, cochrane systematic review protocol, risk assessment. dyakova m, drew c, wright n, clarke a, rees k. systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease: cochrane systematic review protocol (short report). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-02. 3 introduction description of the condition many risk factors contribute to the development of cardiovascular disease (cvd), most of which are related to lifestyle, such as physical inactivity, smoking and unhealthy diet (1). in more than 90% of cases, the risk of a first heart attack is related to nine potentially modifiable risk factors (2): smoking/tobacco use; poor diet; high blood cholesterol; high blood pressure; insufficient physical activity; overweight/obesity; diabetes; psychosocial stress and excess alcohol consumption. the combined effect of different coexisting cardiovascular risk factors determines the total or global risk of developing cvd. many people are unaware of their risk status and total risk assessment is potentially useful for finding high-risk individuals and guiding clinical decisions (3). such a risk stratification approach is particularly suitable to settings with limited resources (1). short emphasises that there is no advantage in assessment, without the ability to intervene and to make changes to lower that risk (4). efficient and effective means of identifying high-risk individuals and then providing the support to enable them to modify their lifestyles requires a delivery system which gives priority to preventive services rather than focusing on treatment (5). description of the intervention the main objectives of a risk assessment are to assess health status, to estimate health risk, and to inform and provide feedback to participants in order to reduce health risks (6). systematic risk assessment systematic risk assessment (sra) for primary prevention of cvd is defined here as a screening-like programme, involving a pre-determined process for selection of people, who are systematically invited to attend a cvd health check in a primary care or similar setting. the selection, invitation and follow-up processes are determined in advance, for example specific inclusion/ exclusion criteria; a unified method of invitation, such as letter/birthday card/phone call; and there is a system for providing feedback or referral. such a programme is repeated at pre-defined intervals, for example every five or ten years. the assessment process includes finding out and measuring risk factors as well as estimating the total (global) cvd risk, using a specific risk scoring tool. the target population for such systematic risk assessment includes healthy individuals (not previously diagnosed with cvd but may already have been diagnosed with one or more cvd risk factors). similarly to other screening programmes, sra can be realised in two ways: population (universal/mass), including the general population in a certain age group with no regard to any underlying risk factors; high-risk targeted to a specific group of individuals, considered potentially to be at increased risk of cvd due to some pre-existing risk factors. opportunistic risk assessment opportunistic risk assessment (ora) for primary prevention of cvd is defined here as occurring sporadically in a primary setting, including primary care, pharmacy chains, supermarket chains, food companies, occupational health departments or small businesses. the range of such activities varies from no cvd risk assessment at all (no risk factors are measured/no total risk is scored in healthy individuals); through random (opportunistic) risk assessment in patients attending primary care for another reason; to incentivised case-finding, for example through the quality and outcomes framework for uk general practitioners (7). dyakova m, drew c, wright n, clarke a, rees k. systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease: cochrane systematic review protocol (short report). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-02. 4 how the intervention might work according to the nhs health checks programme (8), a standard assessment, based on simple questions and measurements to identify the risk of coronary heart disease (chd), stroke, diabetes and kidney disease, would be effective. after assessing the levels of the main risk factors and the total cvd risk, a follow-up is organised with an individually tailored assessment, setting out the person’s level of vascular risk and what steps they could take to reduce it. modelling work around the health checks approach has predicted that it would deliver significant benefits for the uk population: preventing at least 9500 heart attacks and strokes a year (2000 of which would be fatal); preventing at least 4000 people a year from developing diabetes; and detecting diabetes or kidney disease at least a year earlier for 25,000 people. it has predicted high levels of both clinical and cost-effectiveness against a range of assumptions when this approach is applied to all those aged 40 to 74 years (9). recent research suggests that targeting high-risk individuals (high risk based sra) rather than mass population screening is a preferred route (10,11). lawson identified that 16 people were needed to be screened, following the population approach, to identify one individual at high risk of cvd, costing gbp 370 per high-risk person. the alternative, e.g. targeted screening of deprived communities, estimated that only six people would need to be assessed for the identification of one high risk individual, reducing the costs to gbp 141 per positive identification. jackson et al identify that a screening programme targeted at individuals with likely or known cvd risk factors would be preferable from a cost-effectiveness point of view (12). previous research (13) suggests that when a population screening programme is undertaken, there is a persistent level of non-attendance and that whilst cardiac risk score for nonattenders is similar to those who attended, non-attenders have significantly more risk behaviours such as smoking. population-based (universal) risk assessment every five years was found to be cost-effective when compared with no screening; however a cost-analysis was not conducted on whether universal risk assessment would remain cost-effective when compared to targeted high-risk screening. objective: the primary objective of this review is to assess the effectiveness, costs and adverse effects of sra compared to ora for the primary prevention of cvd. methods types of studies: randomised controlled trials (rcts). types of participants: healthy adults (18 years old or over) from the general population, including those at moderate to high risk of cvd. intervention: sra for primary prevention of cvd, defined as a screening-like programme, involving a predetermined selection process of people, systematically invited to attend a cvd health check in a primary care or similar setting, assessing at least two of the following risk factors: • blood pressure (systolic and/or diastolic) or lipid profile (total cholesterol, ldl, ldl/hdl); and • any other modifiable risk factor (smoking, weight, diet, exercise, alcohol, stress). dyakova m, drew c, wright n, clarke a, rees k. systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease: cochrane systematic review protocol (short report). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-02. 5 control: ora for primary prevention of cvd, defined as a range of activities, occurring sporadically in any primary setting from no risk assessment at all to incentivised case finding. outcome measures primary outcomes • all-cause mortality; • cardiovascular mortality; • non-fatal endpoints, including chd, mi, cabg, ptca, stroke, transitory ischaemic attack (tia) and peripheral artery disease. secondary outcomes • cvd major risk factors: blood pressure, lipid levels, type 2 diabetes; • intermediate (programme) outcomes (if reported): attendance rates (number of individuals who came for examination); case finding rates (number of high-risk individuals, identified by the health check); acceptability and participants’ satisfaction; and follow-up rates (number of cases who were followed with some intervention in primary and secondary care); • costs; • adverse effects. search methods for identification of studies electronic searches the following electronic databases were searched: • the cochrane library (including the cochrane central register of controlled trials (central) and nhs centre for reviews and dissemination (crd) databases: health technology assessment (hta), database of abstracts of reviews of effects (dare) and nhs economic evaluation database (need); • medline (ovid); • embase (ovid); • science citation index expanded (sci-expanded), social sciences citation index (ssci), conference proceedings citation index science (cpci-s) on web of science; • amed allied and complementary medicine database. we will use medical subject headings (mesh) or equivalent and text word terms. we will design searches in accordance with the cochrane heart group methods and guidance. we will impose no language restrictions. searching other resources open grey for grey literature; meta-register of controlled trials (m-rct) (www.controlledtrials.com/mrct); clinicaltrials.gov (www.clinicaltrials.gov) and who international clinical trials registry platform (ictrp) (http://apps.who.int/trialsearch/). data collection and analysis data collection and analysis is realised through: selection of studies; data extraction and management; assessment of risk of bias in included studies; measures of treatment effect; assessment of heterogeneity; subgroup analysis, if sufficient studies are found. dyakova m, drew c, wright n, clarke a, rees k. systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease: cochrane systematic review protocol (short report). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-02. 6 we will also examine the effects of the intervention design (setting, personnel involved, invitation and follow-up system). we will carry out sensitivity analyses excluding studies with a high risk of bias. if there are sufficient trials, we will undertake assessment of funnel plots and tests of asymmetry (14) to assess possible publication bias. acknowledgment this protocol is published in full in the cochrane library (dyakova m, drew c, wright n, clarke a, rees k. systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease (protocol). cochrane database of systematic reviews 2013, issue 2. art. no.: cd010411. doi: 10.1002/14651858.cd010411) funding source: this project is funded by the national institute for health research. department of health disclaimer: the views and opinions expressed therein are those of the authors and do not necessarily reflect those of the nihr, nhs or the department of health. conflicts of interest: none declared. references 1. who. integrated management of cardiovascular risk. report of a who meeting, 9-12 july 2002. geneva: who, 2002. media centre: cardiovascular diseases (cvds). available from: http://www.who.int/mediacentre/factsheets/fs317/en/index.html (accessed 29 march 2013). 2. yusuf s, hawken s, unpuu t, dans t, avezum a, lanas f, et al. effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the interheart study): case control study. the lancet 2004;364:937–52. 3. tunstall-pedoe h (ed). monica monograph and multimedia sourcebook. world’s largest study of heart disease, stroke, risk factors and population trends 1979-2002. geneva: who, 2003. 4. short r. putting vascular disease management into practice. bath: medical management services, 2009. 5. bernard sl, lux l, lohr kn (rti international). qquipp: healthcare delivery models for prevention of cardiovascular disease (cvd). london: the health foundation, 2009. 6. national patient safety agency, nhs. healthcare risk assessment made easy. london: npsa, 2007:3–12. available from: http://www.nrls.npsa.nhs.uk/resources/?entryid45=59825 (accessed 5 september 2013). 7. nice. about the quality and outcomes framework (qof). available from: http://www.nice.org.uk/aboutnice/qof/qof.jsp (accessed 2 september 2013). 8. department of health. putting prevention first. vascular checks: risk assessment and management. impact assessment. london: department of health, 2008. 9. department of health. economic modelling for vascular checks. london: department of health, 2008. 10. chamnan p, simmons r, khaw k, wareham n, griffin s. estimating the population impact of screening strategies for identifying and treating people at high risk of cardiovascular disease: modelling study. bmj 2010;340:c1693. dyakova m, drew c, wright n, clarke a, rees k. systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease: cochrane systematic review protocol (short report). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-02. 7 11. lawson k, fenwick e, pell ach, pell j. comparison of mass and targeted screening strategies for cardiovascular risk: simulation of the effectiveness, cost-effectiveness and coverage using a cross-sectional survey of 3921 people. heart 2010;96(3):208–12. 12. jackson r, wells s, rodgers a. will screening individuals at high risk of cardiovascular events deliver large benefits? bmj 2008;337:a1371. 13. wood d, kinmontha a, daviesa g, yarwooda j, thompsona s, pykea s, et al. randomised controlled trial evaluating cardiovascular screening and intervention in general practice: principal results of british family heart study. bmj 1994;308:313. 14. egger m, davey smith g, schneider m, minder c. bias in meta-analysis detected by a simple graphical test. bmj 1997;315:629–34. ___________________________________________________________ © 2014 dyakova et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 1 review article a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level beatrice scholtes1, peter schröder-bäck1, morag mackay2, joanne vincenten2, helmut brand1 1 department of international health, maastricht university, maastricht, the netherlands; 2 european child safety alliance, birmingham, united kingdom. corresponding author: beatrice scholtes, department of international health, caphri; address: maastricht university, po box 616, 6200 md maastricht, the netherlands; telephone: +31433881710; fax: +31433884172; email: beatrice.scholtes@maastrichtuniversity.nl scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 2 abstract aim: risk factors for child injury are multi-faceted. social, environmental and economic factors place responsibility for prevention upon many stakeholders across traditional sectors such as health, justice, environment and education. multi-sectoral collaboration for injury prevention is thus essential. in addition, co-benefits due to injury prevention initiatives exist. however, multi-sectoral collaboration is often difficult to establish and maintain. we present an applied approach for practitioners and policy makers at the local level to use to explore and address the multi-sectoral nature of child injury. methods: we combined elements of the haddon matrix and the lens and telescope model, to develop a new approach for practitioners and policy makers at the local level. results: the approach offers the opportunity for diverse sectors at the local level to work together to identify their role in child injury prevention. based on ecological injury prevention and life-course epidemiology it encourages multi-disciplinary team building from the outset. the process has three phases: first, visualising the multi-sectoral responsibilities for child injury prevention in the local area; second, demonstrating the need for multi-sectoral collaboration and helping plan prevention activities together; and third, visualising potential co-benefits to other sectors and age groups that may arise from child injury prevention initiatives. conclusion: the approach and process encourages inter-sectoral collaboration for child injury prevention at the local level. it is a useful addition for child injury prevention at the local level, however testing the practicality of the approach in a real-world setting, and refinement of the process would improve it further. keywords: co-benefits, inter-sectoral collaboration, prevention and control, wounds and injuries. scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 3 introduction it is far from trivial to reiterate how devastating child injury is to the individual, family and society. among the measurable costs, are loss of life, long and short-term disability, psychological consequences, and financial costs (1). in addition, child injury remains the leading cause of death and a major cause of disability for children aged 5–19 in the european region (2). despite this varied and heavy burden, funding for prevention is comparatively low (3), and capacity and leadership resources, in terms of adequate numbers of personnel and availability of the relevant skills set, are limited (4). the determinants of child injury are multiple, broad, and not limited to the health sector (2,5). thus, in order to efficiently direct and fund child injury prevention, one must account for the cross-cutting, multi-sectoral determinants that result from a complex interplay between human factors and those in the physical and socio-cultural environments. since the multiple determinants of child injury cannot be addressed by the health sector alone, a whole-of-government approach is required—vertically, from international politics to local decision makers, and horizontally, across policy fields such as health, transport, housing, justice and education. preventive action must also work across society, employing a whole-of-society approach engaging actors and stakeholders within government, civil society, and the private sector (2,6). though inter-sectoral co-operation is essential, it is notoriously challenging (7,8). it is often difficult to engage relevant stakeholders and maintain their co-operation throughout the process from policy making through to implementation and evaluation. additionally, the complexity of government systems, where roles and responsibilities are divided into traditional silos (e.g., health, transport, education), and where responsibility and power are split between national, regional and local levels, can further hinder cooperation (9). thus, due to its complexity, child injury is one of the so-called ‘wicked’ problems of public health (7). however, its cross-cutting nature offers broad scope for interventions to result in or contribute to multi-sectoral co-benefits (10). in this paper we focus on the role of regional or local level decision makers and propose a model to facilitate the decision making process for the cross cutting issue of child injury prevention. existing models for injury prevention several models to guide injury prevention have been proposed, including those addressing the multiple determinants of injury (11,12) intervention planning (13,14) and inter-sectoral collaboration (15). these models provide useful theoretical frameworks to address injuries and their prevention. however, they do not address the specific nature of child injury and in some cases may be challenging for use at the local level. child injury prevention requires specific, directed attention. children participate in environments largely designed for adults where their physical and cognitive characteristics make them more vulnerable to injury. physical and cognitive developmental stages precipitate different periods of injury susceptibility. age is therefore an important factor in child injury prevention and models used must have the flexibility to address this heterogeneous group. children are also highly dependent upon the care and protection of adults, so factors affecting an adult’s capacity to supervise children can directly affect them (16,17). general injury prevention initiatives, designed for adults, do not always protect children to the same extent (18,19). in terms of governance for child injury prevention, a lack of leadership and capacity at the national level such as dedicated government departments or ministries or a lack of a specific scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 4 focal point within key departments for child safety has been identified (20). it is likely that if this is the situation at the national level that there is an even greater potential for lack of capacity at the regional or local level where much decision making for health lies (21). to our knowledge, no existing model or approach adequately addresses child injury, while simultaneously providing a practical, multi-sectoral process for practitioners and policy makers at the local level to use to guide prevention efforts. in order to adequately assess the specificities of child injury and its cross-cutting nature, as well as incorporate the potential co-benefits into prevention planning, practitioners and policy makers should be able to: • examine the issue and visualise the multi-sectoral responsibilities for child injury prevention in the local area • demonstrate the need for inter-sectoral collaboration and collective planning of prevention activities • identify the scope for co-benefits for other sectors, age groups or health issues arising from child injury prevention initiatives in this paper we propose a model based upon aspects of the haddon matrix (22) and the lens and telescope model (23) providing a practical approach and process to meet these requirements for the local level. the local level child injury prevention assessment approach the traditional haddon matrix depicts a time element in the first dimension (vertical axis), dividing factors associated with what haddon termed the pre-event, event and post-event phases of an injury event. in the second dimension (horizontal axis), of the simplest form of the matrix, are the three vertices of the epidemiological triangle the host (human), the agent (vehicle/vector) and the environment, with environment often divided into social and physical. the haddon matrix fits well into the traditional public health approach of primary, secondary and tertiary prevention and has been used to explore a variety of aspects of the public health process for injury prevention including assessing risk factors (5,24), identifying preventive strategies and assisting the decision making process (13) and for public health readiness and planning (25,26). the traditional, nine cell, haddon matrix maybe less suited to child injury prevention due to the separation between environment, host and agent. children’s dependence upon adult supervision to secure their environment and their lack of control over the environment is difficult to capture in this version of the haddon matrix. therefore, when developing our approach, we sub-divided the columns, host and agent into factors for human, social and physical environment. this allows the table to capture more detail that maybe particularly relevant for preventing child injury such as factors affecting parental supervision. the temporal element of injury prevention is well represented in the haddon matrix, however circumstances preceding the injury are limited to the pre-event phase. this makes it difficult to differentiate between long standing risk factors such as socio-economic status, and short-term factors such as bad lighting. a further reality of child injury is that the determinants of injury change with age. the inclusion of the life course approach developed in the lens and telescope model (23) is intended to provide a visual cue regarding the needs of the different age groups, encouraging one to think of enduring injury determinants such as socio-economic status and parental factors. the life course aspect of our tool is divided into five specific age groups relevant to child injury, 0-1, 2-4, 5-9, 10-14, and 15-19; with general phases for the foetal phase, adulthood, previous and the next generation. the slices representing age get larger towards older age groups to illustrate the breadth of influence preventive measures could have. scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 5 the resulting approach (figure 1) can be used to examine a specific injury event (e.g., a specific car pedestrian collision) or a group of injuries (e.g., child pedestrian injuries). further, in order to include and examine all relevant factors, the matrix (or matrices, if a separate matrix is needed to provide more space) should be completed with factors relevant to each affected person in the injury event. for example, in the case of a car – pedestrian collision, a matrix should be completed accommodating the perspectives of the injured child, the driver, passengers in the car and any other relevant people. figure 1. local level child injury prevention assessment approach using the local level child injury prevention assessment approach and process the approach and resulting process are intended for use by practitioners and policy makers at the local or regional level. they can be used in three ways: first, to examine and visualise the multi-sectoral responsibilities for child injury prevention in the local area; second, to demonstrate the need for inter-sectoral collaboration and collective planning of prevention activities and third to identify the scope for co-benefits for other sectors, age groups or health issues arising from child injury prevention initiatives. phase one – examining the issue and visualising multi-sectoral responsibilities the approach and process are designed for use in a collaborative setting from the outset. relevant partners and stakeholders from multiple sectors should contribute throughout the process to map each of the factors that contribute (or could contribute) to the injury event for each person involved in the injury. in line with concepts of life-course epidemiology, the factors should not be confined to the moment the injury occurred but should also include preexisting factors. the process of eliciting each of these factors aims first, to draw all of the stakeholders together to come to a common understanding of the problem and potential scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 6 solutions (7) and second, to identify the many sectors implicated within child injury prevention. phase two demonstrating the need for multi-sectoral cooperation once factors and involvement of sectors coming out of the injury analysis are identified, users can reflect on them and propose specific evidence based interventions and policies that address these factors and identify the appropriate sectors that would need to be involved. these specifics can then be used to make the case for investment and/or engage additional stakeholders. the integrated life course approach serves as a prompt to ensure age is being taken into consideration as interventions are considered. potential interventions can then be inserted into an empty matrix in the same way as the factors were placed in phase one. phase three – visualising the scope for co-benefits the third phase is designed to help identify potential co-benefits of child injury prevention strategies for other age-groups and issues within and outside the health sector. co-benefits can be achieved as a result of child injury prevention measures in three ways. first are the physical, economic and societal benefits for the child, family and community as a result of a reduction in intentional and unintentional injury (1,3). second are co-benefits for the target population or other groups arising as a result of injury prevention initiatives (e.g., the health benefits of swimming lessons or environmental and health benefits of a safer walking environment in terms of a reduction in car use); these are not dependent upon a reduction in injury incidence but are derived from the intervention itself. third are co-benefits for other groups that can be achieved as a result of the implementation of injury prevention strategies (e.g., providing training and employment to distributers of safety equipment). by reflecting on the age group segments of the approach, users are encouraged to consider the impact on other age-groups and identify which groups might directly and indirectly benefit from child injury prevention interventions and elaborate on these co-benefits. for example, an intervention to improve the walkability of an area surrounding a school would directly benefit age groups 5-9, 10-14 and 15-19 years, but may also benefit the elderly population of that area by providing a safer walking environment. discussion much responsibility for injury prevention lies with local practitioners and policy makers in terms of choice of intervention and process of implementation. however, for complex ‘wicked’ problems such as child injury, the key stakeholders at the local level are often unaware of their responsibilities for public health and the potential impact of their participation (27). local government officials have been found to lack awareness of the link between health and non-health sectors, and their experience of inter-sectoral collaboration is often limited (8). a key determinant of success for inter-sectoral collaboration, is the development of a multi-disciplinary team of multiple stakeholders (28,29) to first reach a common understanding of the problem and then, on that basis, to collaboratively design evidence based interventions that are specific and relevant to the needs of the target population (7). a significant difference between our approach and process and other existing models for child injury prevention is its interactive and collaborative nature. our approach provides a practical framework to engage diverse stakeholders from the outset. it has been designed to provide a comprehensive approach to child injury prevention in a simple (and familiar) format to maximise output at the local level of governance. the exercise of mapping factors using a matrix that addresses the specific physical and social environments for host and agent scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 7 separately helps identify the potential involvement for many sectors and the identification of roles and responsibilities as interventions are selected. a limitation of this approach is that it is unable to quantify the comparative or cumulative impact of the identified risk factors in the local setting. local knowledge of their relative importance in the target setting is therefore required to weight them appropriately, in terms of importance and prevalence, and to develop a suitable intervention. additionally, the approach does not help planners/researchers identify what interventions or policies are already in place or how to choose an intervention. however the third dimension of the haddon matrix as proposed by runyan (13) could be used in conjunction with this model to aid intervention choice. the opportunity to identify the potential co-benefits of injury prevention initiatives offered by this approach is particularly important in the context of advocacy and efforts to secure funds for prevention activities. a lack of funding is a common barrier to adoption and implementation of public health interventions, particularly for complex or wicked problems. (8) if co-benefits of prevention activities outside the target group or injury domain can be demonstrated, the chances of securing funding may be higher, particularly if the co-benefit addresses a priority area (e.g., obesity or healthy ageing). our proposed approach and process provide a way of demonstrating the interconnectivity between sectors and therefore the secondary impact child injury prevention strategies may have beyond childhood or outside the injury domain. however, it must be noted that when identifying co-benefits this approach does not offer any quantification of economical or health benefits associated with a given strategy. the use of a life course model is a central element of our approach. there are several advantages to this: first, it emphasises the importance of a child’s age for injury susceptibility and acts as a lens through which to consider relevant factors, particularly when looking at an overall injury issue (e.g., child drowning); second, it accommodates age in the design or choice of preventive interventions; third, it allows analysis of risk factors related to parents or carers and underlying causes; and, fourth, it provides a frame to reflect upon potential cobenefits for other age groups arising from child injury prevention interventions. additionally, some interventions in child injury prevention include longer timeframes between intervention implementation and results, especially when addressing the more complex risk factors such as substance abuse and mental health. these are often incompatible with the short-term pressures on policy makers (30). visualisation of co-benefits using a lifecourse approach could provide policy makers with solid arguments for the implementation of such interventions. conclusion this approach and three phase process to child injury prevention, based on combining haddon’s matrix with a life course model facilitates stakeholders identification of risk factors and solutions across policy sectors. when done collectively, engaging multiple stakeholders, it should result in a better understanding of the multi-sectoral nature of child injury prevention and the potential roles and responsibilities for the stakeholders at the local area. this, in turn, should assist in the planning of tailored inter-sectoral child injury prevention activities. further the broadened frame helps identify potential co-benefits across sectors, within and outside the injury domain, which may assist in gaining support for child injury prevention. this approach and process have been designed to provide a practical and user-friendly methodology to address the inter-sectoral issue of child injury prevention at the local level. scholtes b, schröder-bäck p, mackay m, vincenten j, brand h. a practical and applied approach to assessing the cross cutting nature of child injury prevention as a basis for policy making at the local level (review article). seejph 2014, posted: 22 february 2014. doi 10.12908/seejph-2014-08. 8 however it is yet to be tested in a real world setting and a study of its efficiency would be a useful addition to this research. acknowledgments: the authors would like to thank members of the european child safety alliance and the tactics scientific committee for input into early discussions. competing interests: none. funding: this paper is based on work conducted under the tactics project, which receives funding from the european union, in the framework of the health programme. contributorship: bs developed the idea for the approach and process and all authors contributed to the design. bs led the drafting of the paper and all authors were involved in revising it and approving the final version. references 1. lyons ra, finch cf, mcclure r, van b, ed, macey s. the injury list of all deficits (load) framework conceptualising the full range of deficits and adverse outcomes following injury and violence. int j inj contr saf promot 2010;17:145-59. 2. sethi d, towner e, vincenten j. 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matrix to public health readiness and response planning. environ health perspect 2005;113:561-6. 26. brand h, schroder p, davies jk et al. reference frameworks for the health management of measles, breast cancer and diabetes (type ii). cent eur j public health 2006;14:39-45. 27. hendriks am, jansen mwj, gubbels js, vries nkd. proposing a conceptual framework for integrated local public health policy, applied to childhood obesity-the behavior change ball. implement sci 2013;8. 28. axelsson r, axelsson sb. integration and collaboration in public health—a conceptual framework. int j health plann mgmt 2006;21:75-88. 29. warner m, gould n. integrating health in all policies at the local level: using network governance to create ‘virtual reorganization by design’. in: kickbusch i, editor. policy innovation for health. springer; 2009. p. 125-63. 30. exworthy m. policy to tackle the social determinants of health: using conceptual models to understand the policy process. health policy plann 2008;23:318-27. ___________________________________________________________ © 2014 scholtes et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 1 | 13 original research norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics peter schröder-bäck1, claire van duin1, caroline brall1,2, beatrice scholtes1,3, farhangtahzib4, elsmaeckelberghe5 1department of international health, school caphri (care and public health research institute), maastricht university, the netherlands; 2health ethics and policy lab, department of health sciences and technology, swiss federal institute of technology eth zurich, switzerland; 3department of public health sciences, university of liege, belgium; 4uk faculty for public health, london, united kingdom; 5university of groningen, institute for medical education, university medical center groningen, the netherlands. corresponding author: peter schröder-bäck address: maastricht university, po box 616, 6200 md maastricht, the netherlands; email: peter.schroder@maastrichtuniversity.nl schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 2 | 13 abstract this paper draws attention to the translation of ethical norms between the theoretical discourses of philosophers and practical discourses in public health. it is suggested that five levels can be identified describing categories of a transferral process of ethical norms – a process we will refer hereto as “translational ethics”. the aim of the described process is to generate understanding regarding how ethical norms come into public health policy documents and are eventually referred to in practice. categorizing several levels can show how ethical-philosophical concepts such as norms are transforming in meaning and scope. by subdividing the model to five levels, it is suggested that ethical concepts reduce their “content thickness” and complexity and trade this in for practicability and potential consensus in public health discourses from level to level. the model presented here is illustrated by showing how the philosophical-ethical terms “autonomy”, “dignity”, and “justice” are used at different levels of the translation process, from kant’s and rawls’ theories (level 1) to, in this example, who reports and communications (levels 4 and 5). a central role is seen for what is called “applied ethics” (level 3). keywords: ethics, practice, public health, theory, translation. conflicts of interest: none. schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 3 | 13 background there is growing interest in public health ethics as a distinct discipline from clinical ethics and critical to consideration of population health issues (1). as highlighted by michael marmot there is an urgent need to create better understanding between philosophers, the health community and the real world (2). he has lamented, at times, the contemptuous approach of some philosophers, not considering real life concerns and not engaging with nonphilosophers. these philosophers are often engaged in highly theoretical discussions, even in multidisciplinary gatherings. such issues are relevant since public health prides itself in evidence based knowledge and there is a question as to why evidence often does not translate into public health practice. it has been suggested that evidence is generated within a deliberate exchange process between scientists and practitioners, and that it is essential to take values, resources and interests of the different parties into account (3). consequently, consideration of ethical norms and values should be seen as a critical part of the translation process (4). this is more than just linking the philosophical ivory tower approach of academics with the practical world of practitioners but rather also appreciating the language, purpose and nature of philosophy and public health, and their essential roles for effective scholarship and practice. to give an example, ethical norms, such as “autonomy” and “justice”, are often mentioned in public health policy and practice discourses. when these normative concepts are used, public health practitioners probably understand them differently to – but not necessarily incompatibly with – philosophers. this presumed discrepancy leads to the question: how can one relate the ethical concepts in practice to their philosophical background theories? this paper provides a description of the potential pathway between the ivory tower and practice using case studies of some specific conceptual issues used in theoretical, policy and practical discourses. translation and transferral in medicine the term “translational research” or “translational medicine” is well established, generally referring to the translation of scientific research to clinical practice, a process often called “from bench to bedside” [e.g. (5)]. however, translation of knowledge does not only take place in sciences and medicine. ethical concepts also undergo a translation– from philosophical theory to, in this example, public health policy and practice. in the following discussion we focus on the translation of philosophical work into public health practice. the term “translational ethics” is relatively new. even though ethical concepts are frequently “transferred” or “translated” – both etymologically meaning “to carry over” – between and across different domains, there is scarce academic scholarship regarding the issue (6-8). unlike language translation it is not the name of the concept that is translated, but its specific content that is made applicable for practice: the meaning and scope of philosophical concepts is explained and made usable for – or “carried over” to – contexts of professional practice in a process that we can term “translation”. the metaphor “translation” is also used as a reference for other areas of “translational research”, as mentioned above, when one refers to the transferral of basic scientific knowledge (the laboratory “bench”) to the more applicable and practical use of the knowledge (the clinical practice at the “bedside”). in this discourse, however, the concepts sometimes schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 4 | 13 change in scope and meaning so that we consider the term “translation” to be appropriate. this translational process is by no means meant to be a one-way street (6). indeed practical discourses can initiate or inform developments in philosophical theory as well. however, in this paper – as a starting point – we focus on the translation of philosophical knowledge to public health practice. translational processes to give an example of the translational process, the concepts “autonomy” and “dignity” shall be mentioned. these concepts have been philosophically elaborated upon by the renowned eighteenth century philosopher immanuel kant. however, for him these concepts had a different meaning than they do for the public health practitioner who is, for example, considering the autonomy or dignity of a child and her parents who refuse immunization. even without knowing the precise philosophical aspects of the concept of “autonomy”, at least through common, every day or professional language, the physician possesses a normative understanding of the concept that usually derives from kant’s (and others’) conception of it. a normative appreciation of autonomy may lead the physician to accept a patient’s decision. another example is how public health practitioners formulate in the context of childhood immunization that […] the impulse to maximize benefit for the highest number of people is counterbalanced by the kantian threshold of a categorical imperative […] that preserves individual autonomy and emphasizes ideas such as informed consent” (9). however, this formulated kantian “side constraint” may not be as readily accepted by a more theoretically informed philosophical argumentation, such as that offered by the philosopher and kant scholar onora o’neill. in her argumentation, kantian autonomy may even put moral obligations on parents to have their child immunized for the sake of protecting the autonomy of others (10). this is not to say – and not the question of this paper – that either salmon and omer or o’neill are right in the interpretation of kant. it is to demonstrate that the understanding of both is significantly different even though both relate back to kant. indeed, autonomy is an ethical concept with a long standing philosophical tradition and strong and “content thick” background theories from which it has evolved (11). “content thick” means the involvement of sophisticated philosophical substantiation and differentiation, perhaps including explicit consideration of other philosophical fields, such as from epistemology or metaphysics. nevertheless, a public health practitioner is not (necessarily) aware of ethical theories behind this term when using it, even if he or she refers back to kant explicitly, as the example of salmon and olmer (9) – who claim that kantian autonomy is incompatible with involuntary immunization – shows. so, how does the practitioner come to use an ethical concept? it is the thesis of this paper that ethical concepts move from the “philosophical ivory tower” to – in this case – public health “practice” (including policy making and research). this happens while practitioners have, or display, only common knowledge of the philosophical backgrounds of the ethical concepts they are normatively applying. thus we suggest that if we could reconstruct the patterns of translation of meaning of the term “autonomy” from kant to the practitioners’ use of this concept, we could help to facilitate communication among the stakeholders involved in the normative elaboration and development of public schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 5 | 13 health. the aim of this paper is thus to propose a heuristic model for discussion and to stimulate scholarship on the translation of ethical terms for practice. towards a heuristic model the development of such a model draws on some assumptions of the philosophy and sociology of science in the tradition of thomas kuhn (12) and ludwik fleck (13). the concept held in common among these authors and underpinning the proposed model is that scientists and practitioners live and act in their respective paradigms and communities, which are partly constituent by their use of language. thus, for members of one community to understand members of other communities, care needs to be taken to ensure that their lexicon is the same. moreover, concepts should be made commensurable – meaning that the sense of a common concept or term is comparable in different discourses. however, this is not easy since the extension of concepts and their meanings can change. the model proposed here raises awareness of this challenge. the “content thickness” of elaborated philosophical concepts is relevant for practice, for example, to achieve a differentiated and critical understanding of terms, similarly “content-thinness” has some virtues. “content thin” concepts are more acceptable in pluralistic societies and policy making (because the concept could derive from and stand for many background theories and worldviews). practitioners can agree on the normative concept first – and then elaborate upon what this means exactly by referring back to elaborations and theories of earlier levels of the translational process. it is the assumption of the model proposed here that normative concepts have legitimacy and specific roles in each of these communities – be it in the philosophical ivory tower or in practice. yet, when “carrying over” or “handing over” the normative concept like a baton, even though the concept still looks the same, its meaning has often changed. a heuristic and descriptive model of translational ethics the proposed model consists office levels. these levels range – analogous to the concept of “from bench to bedside” – from the philosophical ivory tower (level one) to public health practice (levels four and five). normative concepts such as ethical principles are complex and “content thick” on a philosophical level and, in practice, are more “content thin”. thus, the model focuses upon the transformative journey that ethical concepts make from the ivory tower to practice. in the following section we describe the different levels of the model by using different examples: the strongly related concepts of autonomy, dignity, and justice and specifications of these. we illustrate levels 4 and 5 using the example of the who report on “health systems performance” from 2000 (14). level one: abstract and ideal philosophical theory the first level of the model refers to philosophical works that are often the foundation for normative ethical concepts. using the examples of autonomy, dignity and justice, one can refer to the works of immanuel kant. in his discussion of these concepts, kant already uses examples, such as the murderer at the door to whom one may not lie, even to protect an innocent friend– yet, they remain very abstract, often counterintuitive in the modern world. kant’s discussions would be too abstract and somewhat unconvincing if one were to apply them directly to public health practice. schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 6 | 13 furthermore, he also includes complex and controversial metaphysical concepts in his argumentation– such as the claim that a person as “homo noumenon” bears human dignity (15) – that are unsuitable for public health practices, as we have argued elsewhere (16). in fact, theories at this level often integrate a rich and wide scholarship of other areas of philosophy – including ontology, epistemology and metaphysics. john rawls (in 1971) in his theory of justice as fairness (17), has also drawn on kant’s insights. rawls’ theory also remains abstract in many regards, for instance due to his use of hypothetical models such as the contractarian approach to justify his concept of justice and the difficulties associated with the applicability of the concept to everyday concrete problems. in fact, rawls’ account has been considered an “ideal” theory (18). thus, we would consider this level as representing ideal theory; meaning that it abstracts from concrete real-world practice and conditions (7, p. 210). similarly, rawls is criticized by amartya sen for dealing with the design of “ideal” institutions (19, p. 15ff), as opposed to institutions that function in the real-world. marmot has highlighted that nonphilosophers are not familiar with complex philosophical concepts and that many think that “rawls were to do with building sites” (2), given that the british english word for “screw anchor” is “rawl plug”. level two: non-ideal theory for a field of practice the second level covers ethical theories that are already more concrete with regard to the field of practice in question, and are developed based on empiric knowledge of that setting. theorists build a theory for a concrete context referring to and basing it on level one theories such as rawls and kant. theorists from this level include figures such as health justice theorist norman daniels who developed a theory based on rawls’ basic ideas (20); or the philosopher madison powers and the bioethicist and public health researcher ruth faden, with their work on social justice (21). while developing, in their view, a sound theory of health justice, they also claim to develop a decided non-ideal theory. powers and faden (21) criticize rawls’ assumption of equality of persons in a hypothetical situation. instead, they look at real world inequalities and work on criteria of why these inequalities matter. however, without rawls’ ideal theory of justice (and indirectly kant’s concept of dignity) their own theory would probably not have been developed. despite this very theoretical difference between levels one and two, the intention to be more practical on level two and to try to deliver real world solutions for public health makes a significant difference. yet, both daniels and powers and fadens’ theoretical approaches, explicitly draw on level one theories, criticize them and dialectically develop their own, more accessible, level two theories for philosophers and practitioners. level two academic scholarship is often made more practical by collaborations between philosophers and public health scientists (e.g. daniels, kennedy and kawachi (22), powers and faden (21)). on level two, interdisciplinary perspectives and collaboration become more relevant. here, the aim is, as o’neill formulates it (23), to give more ethical substantial input to applied ethical debates, leading us to the next level. level three: applied ethics level three represents what is often called “applied ethics”, meaning that concepts and theories from previous levels are “applied” to concrete practical problems to receive schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 7 | 13 normative guidance – but this is also an area where normative convictions and judgements could be inductively connected to ethical theory. level three discourses are often initiated by practitioners. they look for interdisciplinary discourses with ethicists to find criteria or even solutions to moral questions. public health practitioners at this level are positive about the powers (and limits) of philosophical ethics, as they are often already ethically informed or educated. ethicists, when working on these issues – often in interdisciplinary teams or even commissions, like the nuffield council on bioethics and its report on public health ethics (24) – try to use generally understandable references of ethical theories. at level three the works of applied ethics such as the influential work of philosophers beauchamp and childress (25) is very prevalent. in their four-principle approach for biomedical ethics, they also refer to “autonomy” and “justice”. beauchamp and childress explain the background concepts of their principles such as “autonomy” and” justice” – making reference to level two and level one theories and approaches. in the context of “autonomy” for instance, they combine kantian ideas of autonomy and the related concept of dignity with other relevant philosophies (most notably the related concept of “liberty” of john stuart mill). yet, they explain this overlap so broadly and generally that practitioners can understand and apply the principles. this might mean a loss of theoretical complexity and content thickness (even though beauchamp and childress would argue that they have a unifying background theory of coherentism and might claim their work to be on level two). for the sake of being interdisciplinary, pluralistically communicable, agreeable and helpful as tools and criteria for decision making this is understandable and in fact very helpful. of course, as the example of beauchamp and childress shows, philosophers can work on different levels and levels should not be identified with persons. a good example is philosophers who engage in level one scholarship but also write on applied ethics or work in interdisciplinary ethics commissions (such as e.g. tom beauchamp, a renowned hume scholar). level four: applied ethics in practice the normative concepts used at level four mainly refer to literature from level three. authors of arguments using the terms “respect for dignity” or “autonomy” refer to the works of theorists such as beauchamp and childress. they understand these terms rudimentarily (in a philosophical sense). they are not (as) aware of the background theories. in this translation process the “content thickness” and depth of the norms are further lost, yet, these criteria help to make normative arguments around the acceptability of public health interventions. representatives of these levels would be public health researchers or practitioners aware of moral problems. they are also aware of these being norms and concepts coming from a rich ethical discourse. normative tools – including codes of conduct – that are established to guide practical conduct (1) arguably also belong to this level, or between levels three and four. the example we use to explain this level and level five is the use of ethical norms in a framework for health systems performance assessment developed for and used by the world health organization. the initial framework was developed by christopher murray and julio frenk and was improved and adopted for use in “the world health report 2000”. with their framework for health systems performance assessment, murray and frenk schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 8 | 13 aim to advise decision makers (26,27). in other words, their work should be of very practical use. within their framework, they formulate “health system goals”. the main goals are “health”, “responsiveness” and “fair financing and financial risk protection”. these goals are to be measured in health systems performance and efficiency assessments. “responsiveness” has two dimensions. the second one is “client orientation”, the first one, upon which we focus, is “respect for persons”. of the several sub-components, the first three explicitly use ethical norms and can be closely related to the philosophy of autonomy and dignity: “respect for the dignity of the person” as the first sub-component forbids instrumentalisation of persons. as they formulate, it is important to show “respect for the autonomy of the individual to make choices about his/her own health. individuals, when competent, or their agents, should have the right to choose what interventions they do and do not receive” (26). they further talk of “respect for confidentiality” (26). in referring to these ethical norms and applying them to their context, murray and frenk formulate precisely in the language of applied ethics and refer to 18 sources, many of which are works in applied ethics (level three), including beauchamp and childress. the third goal “fair financing and financial risk protection” makes explicit reference to the concept of fairness (related to the concept of justice). here they reference work by the philosopher daniels and colleagues where they apply his theory to concrete health care issues (28). here again it can be seen that normative arguments are clearly made, using ethical norms without going back to “content thick” theories of level one. level 5: reference to ethical-normative concepts in practice on the final level, practitioners use ethical concepts as normative terms without making any reference to theories of ethics or applied ethics (levels one -three). no explicit elaboration of the normative concepts can be found at level four. at this point these concepts have only a rudimentary link with the concepts of levels one and two. nevertheless, a certain normative essence is encapsulated. to illustrate this, we look at how “the world health report 2000” was further condensed and “translated” for practice and the public by an accompanying message from the former who director general, gro harlem brundtland, and by the press release of the who. gro harlem brundtland’s statement opens the report as a “message from the director-general”. brundtland starts by asking two (of three) questions relating explicitly to ethical concepts “what makes for a good health system? what makes a health system fair?” she continues by saying that it is the task of the who and of such a report to help all stakeholders “to reach a balanced judgment” (29, p. vii). moreover, she makes reference to values and norms we are already familiar with from level four, the framework paper by murray and frenk (26). she continues with stating the ethically relevant part: the goals of health systems “are concerned with fairness in the way people pay for health care, and with how systems respond to people’s expectations with regard to how they are treated. where health and responsiveness are concerned, achieving a high average level is not good enough: the goals of a health system must also include reducing inequalities in ways that improve the situation of the worst-off.” according to these (normative, ethics based) considerations, health system performance is schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 9 | 13 measured to give policy-makers information to act on. additionally, the translational function of journalism is considered by formulating a press release. in this press release, there are direct quotes by the director general but also by murray, frenk and others. the press release additionally refers to the ethical concepts and norms. it mentions “injustice” and treating with “respect”. however, it also refers to the main categories and components of the performance index “responsiveness” and “fairness of financial contribution”. the aspect of “responsiveness” based on the ethical norms is now concisely summarized as “respect for persons (including dignity, confidentiality and autonomy of individuals and families to decide about their own health)”. in the press – e.g. in the new york times (30)– the ethical concepts are even less prevalent. formerly used foundational norms such as “respect” and “dignity” are not used any longer, only the term “fairness” related to the measurements. in other words, the explicit ethical norms are even further in the background. yet, one could trace “fairness” back – translated through the levels – to rawls’ level one explication. discussion philosophers often develop their normative concepts and ideal theories without considering real world practice. public health practitioners, on the other hand, often refer to normative ethical concepts without explaining their specific meaning or referring to underlying ethical theories (and possible normative ambiguities). in many cases, practitioners use these norms because they are “common sense” or belong to the “common morality”, yet, in their normative explication they can generally be traced back to philosophical theories that substantiate the norms’ normative content. this paper explores how these norms make their way into the language of practitioners (e.g. health policy documents). it is the thesis of this paper that there is a translational process in the background through which the norms in practices are also connected to (underlying, foundational) ethical theories. the paper proposes a model with several levels highlighting how this translational process occurs. the model is intended to heuristically describe how ethical norms are used (and translated) between scholarship (levels one – three) and practice (levels four and five). whereas in public health the use of schematic models is widely accepted, even though models are always a simplification and models like the ‘policy action cycle’ are by no means meant to be exhaustive or static, this seems less common in ethics. we are aware that the differentiation between the levels can be debated and concepts like “applied ethics” are contested in philosophy, yet we deem such a model a heuristic starting point for discourses aiming to better connect philosophical theory to public health practice. in this model we observe what we call the inverse relationship thesis which is visualized in figure 1. on the one side (on level one), there is content thickness and complex original philosophical thought with regard to theory building in the foreground. on the other side (levels four and five) there is public health practice. here the content thickness and complexity of the normative concepts proportionally decreases while there is an increase of applicability and suitability for practice. in other words, we formulate the thesis that there is an inverse relationship between content thicknesses and practicability. in public health practice there are also often inherent unsaid value judgements which are made around content “thickness” and “thinness” and their suitability to practice and the issue of practice schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 10 | 13 is important in terms of generating knowledge and interdisciplinary research and practice. the developed model has several limitations that point in the direction of a need for further scholarship and development on this topic. the five levels have blurred boundaries and partly overlap (for example, the rich work of beauchamp and childress could be considered to be both level two and three). demarcations between these categories and levels are difficult to set. in fact, one could argue that there could be more or fewer categories and one would probably also find good reasons for these changes. having five levels, however, also makes visible the central role of applied ethics as an intermediary and interface between the academic and the practical world. we believe that such a model helps raising awareness that different discourses on ethical norms are taking place and that a “translation” process exists. awareness of this process is important to improve communication and ultimately to elaborate better arguments, consequently also improving public health practice. figure 1. the translational process of ethical norms: the relation of content thickness and suitability for use in practice applied ethics interdisciplinary discourses (level 3) (normative) practice public health practice (levels 4-5) complex theories philosophical discourses (levels 1 and 2) content thickness (suitability for) use & communication in practice schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 11 | 13 lastly, we have suggested that there is a linear, top-down direction of travel from level one to level five. despite this not (necessarily or always) being a linear process – where levels can be jumped or individuals can work on several levels at the same time – the process works in several directions (6,31). it can work its way backwards – more practical levels inspiring more philosophical levels. and, of course, practical levels can request from multiple philosophical levels to reflect on implications of the use and meaning of normative concepts. for instance, discussions on the concept of autonomy in the philosophical levels can be prompted and inspired by problems arising on the work floor in the practical levels. to illustrate, certain groups can be encountered to whom autonomy and informed consent cannot be readily applied, such as young children or patients with alzheimer`s disease. in such cases, it can be helpful to have discussions in the philosophical levels on the meaning and applicability of autonomy in different contexts (31). conclusion there seem to be transferral or transformative processes, here referred to as translational processes, of ethical concepts from the “philosophical ivory tower” to public health practice – and vice versa. the model presented here describes that a norm reduces philosophical-theoretical “content thickness” and complexity to become more applicable in practice and, in the other direction, that norms from practice are connected to ethical theories. awareness of these translational processes can ultimately help to improve the moral foundation of public health practice and critically inform practice of norms and values. more research would be helpful to validate this model, identify and discuss more examples of translational ethics as modelled here, and to investigate the relationships between the different levels. furthermore, attention needs to be given to the practical consequences of our model. references 1. laaser u, schröder-bäck p, eliakimu e, czabanowska k. thinktank for sustainable health & wellbeing (ghw-2030). a code of ethical conduct for the public health profession. seejph 2017;9. doi 10.4119/unibi/seejph-2017-177. 2. marmot m. foreword. in: sridhar venkatpuram, health justice: an argument from the capabilities approach. wiley, 2011. 3. gerhardus a. evidence in 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nuffield council on bioethics. public health: ethical issues. london: nuffield council on bioethics; 2007. 25. beauchamp t, childress j. principles of biomedical ethics. 5th edition. new york: oxford university press; 2001. 26. murray c, frenk j. a who framework for health systems performance assessment. technical document [internet]. world health organisation. available from: http://apps.who.int/iris/handle/10665 /66267 (accessed: march 10, 2019). 27. murray c, frenk. a framework for assessing the performance of health systems. bull world health organ2000;78:717-31. 28. daniels n, light d, caplan r. benchmarks of fairness for health care reform. new york: oxford university press; 1996. 29. brundtland gh. message from the director-general. in: who (editor) the world health report 2000 schröder-bäck p, van duin c, brall c, scholtes b, tahzib f, maeckelberghe e. norms in and between the philosophical ivory tower and public health practice: a heuristic model of translational ethics (original research). seejph 2019, posted: 16 april 2019. doi 10.4119/unibi/seejph-2019-212 p a g e 13 | 13 health systems: improving performance. geneva, who: vii-x. 30. hilts p. europeans perform highest in ranking of world health. new york times, 2000 june 21 [internet]. available from: http://www.nytimes.com/2000/06/21 /world/europeans-perform-highestin-ranking-of-world-health.html (accessed: march 10, 2019). 31. van duin c. evaluation of amodel of translational ethics. maastricht university, bachelor thesis; 2016. ___________________________________________________________ © 2019 schröder-bäck et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. . http://www.nytimes.com/2000/06/21/world/europeans-perform-highest-in-ranking-of-world-health.html http://www.nytimes.com/2000/06/21/world/europeans-perform-highest-in-ranking-of-world-health.html http://www.nytimes.com/2000/06/21/world/europeans-perform-highest-in-ranking-of-world-health.html collaku l, resuli m, gjermeni i, tase m. evidence of a higher burden of multimorbidity among female patients in albania (original research). seejph 2018, posted: 10 april 2018. doi 10.4119/unibi/seejph-2018-185 1 original research evidence of a higher burden of multimorbidity among female patients in albania ledio collaku 1 , margarita resuli 1 , ilir gjermeni 1 , mihal tase 1 1 internal medicine and hypertension service, university hospital center ―mother teresa‖, tirana, albania. corresponding author: dr. ledio collaku address: rr. ―dibres‖, no. 370, tirana, albania; e-mail: collaku_l@yahoo.com collaku l, resuli m, gjermeni i, tase m. evidence of a higher burden of multimorbidity among female patients in albania (original research). seejph 2018, posted: 10 april 2018. doi 10.4119/unibi/seejph-2018-185 2 abstract aim: the purpose of this study was to assess sex-differences in the prevalence of multimorbidity and the number of comorbid conditions among hospitalized patients in tirana, the capital of albania, a transitional country in southeastern europe. methods: the current study was a case-series, which was carried out in the period august 2013–june 2014. overall, 974 patients were enrolled (46.6% men with a mean age of 61.2±13.8 years, and 53.4% women with a mean age of 61.3±13.1 years), who were admitted at the service of internal medicine and hypertension, university hospital center ―mother teresa‖ in tirana. a comprehensive clinical profile was assembled for all patients in addition to socio-demographic data and information on lifestyle factors. general linear model was used to assess the association between multimorbidity (total number of diseases/conditions) and sex of the patients, controlling for socio-demographic characteristics and lifestyle factors. results: in crude (unadjusted) models and in age-adjusted models, female patients had a higher mean value of diseases/conditions compared to males (for both: 4.4 vs. 4.1, respectively, p=0.03). likewise, upon adjustment for all socio-demographic characteristics, the mean number of disease/conditions was significantly higher in female patients compared to their male counterparts (4.2 vs. 3.9, respectively; p=0.03). after additional adjustment for lifestyle factors, the association between sex and number diseases/conditions was not significant anymore (p=0.16), notwithstanding the evidence of a higher mean value in women compared to men (4.2 vs. 4.0). conclusion: current evidence from transitional albania suggests a higher burden of multimorbidity among female patients compared to males, which is a cause of concern. these findings should raise the awareness of health professionals and particularly policymakers and decision-makers in order to address gender issues and inequity gaps in health outcomes and burden of disease of the albanian population. keywords: albania, female patients, internal medicine, male patients, multimorbidity, patients, sex. conflicts of interest: none. collaku l, resuli m, gjermeni i, tase m. evidence of a higher burden of multimorbidity among female patients in albania (original research). seejph 2018, posted: 10 april 2018. doi 10.4119/unibi/seejph-2018-185 3 introduction the burden of non-communicable diseases and the burden of multimorbidity has increased in albania in the past few decades (1,2), a process which is also in line with an increase in life expectancy and continuous aging of the albanian population (3). regarding the major causes of mortality, the ischemic heart disease was the top cause of death in the albanian population in 2016, followed by cerebrovascular disease and lung cancer (1). notably, only during the past decade, there has been an increase of about 19% in the mortality rate attributable to the ischemic heart disease and/or lung cancer, and an increase of about 10% due to cerebrovascular disease in albania (1). in addition, in the past decade, there has been an increase of about 20% of other cardiovascular diseases, and an increase of 11% of the chronic obstructive pulmonary disease (1). it is assumed that a large share of especially the older albanian population suffer from multimorbidity and comorbidty (2,4). in terms of premature mortality, in the past decade, there has been a considerable increase (about 49%) in the mortality rate due to alzheimer disease in albania, followed by lung cancer (11%) and ischemic heart disease (6%). also, the burden of cerebrovascular disease in albania has increased by about 41% in the past decade (1). the five main risk factors contributing to the overall burden of disease (death and disability combined) in albania in 2016 consisted of high blood pressure, dietary risks, tobacco smoking, high body mass index, and high total cholesterol level (1). multimorbidity is conventionally considered as the presence of several diseases or conditions in a single individual or patient (5). in the contemporary clinical practice there are other important constructs including comorbidity (presence of other diseases/conditions along with a main pathology), morbidity burden (referring to the overall impact of various disease or conditions in a single patient), or disease complexity (referring not only to the presence of various disease/conditions in a single patient, but also to the severity and duration of each condition) (5). in all cases though, these classifications are largely based on considerations from medical doctors and other health professionals, but not necessarily on self-reports, or feelings and perceptions of patients suffering from several diseases (either in the framework of multimorbidity or comorbidity situations) (6). notwithstanding the lack of proper evidence and scientific documentation, the burden of multimorbidity is high in the albanian adult population, especially in the elderly people category (4). anecdotic evidence suggests a higher burden of multimorbidity among older women than in men, which may be partly explained by a higher life expectancy among albanian females compared to their male counterparts (3,4). yet, to date, scientific reports about the burden and impact of multimorbidity and comorbidity in albanian patients are scant. in this framework, the aim of the current study was to assess sex-differences in the prevalence of multimorbidity and the number of comorbid conditions among hospitalized patients in tirana, the capital of albania, a transitional country in southeastern europe. methods the current study consisted of a case-series design. this study was carried out between august 2013 and june 2014. during this period of time, there were recruited 974 patients admitted at the service of internal medicine and hypertension, university hospital center ―mother teresa‖ in tirana, which is the capital city of albania. of the 974 patients recruited in this study, 46.6% were men and 53.4% were women. for all the patients included in this study, it was performed a whole range of clinical examinations including assessment of the main disease, presence of comorbid conditions, hematological parameters, lipid profile, as well as other clinical examinations. collaku l, resuli m, gjermeni i, tase m. evidence of a higher burden of multimorbidity among female patients in albania (original research). seejph 2018, posted: 10 april 2018. doi 10.4119/unibi/seejph-2018-185 4 in addition, a structured questionnaire was administered to all the patients aiming at collecting useful information about their socio-demographic characteristics and lifestyle factors. the socio-demographic information included age (which was dichotomized in the analysis into: ≤60 years vs. ≥61 years), current place of residence (which was also dichotomized in the analysis into: tirana vs. other districts of albania) and current employment status (trichotomized in the analysis into: employed, unemployed, retired). on the other hand, the lifestyle (behavioral) factors consisted of tobacco smoking and alcohol consumption (in the analysis, these two variables were dichotomized into: yes vs. no). fisher’s exact test was used to assess the differences between male and female patients regarding the prevalence of multimorbidity (ranging from presence of at least two diseases/conditions up to ten diseases/conditions). spearman’s correlation coefficient (rho) was used to assess the linear association between the number of disease/conditions and age of the patients, number of their hospitalizations, and the length (duration) for the current hospitalization episode. conversely, general linear model was employed to assess the association between multimorbidity (total number of diseases/conditions) and sex of the patients included in this study. initially, crude (unadjusted) mean values, their 95% confidence intervals (95%cis) and p-values were calculated. next, general linear models were adjusted for the age of study participants. subsequently, general linear models were adjusted for all socio-demographic characteristics of the patients (age, current place of residence and current employment status). finally, general linear models were additionally adjusted for lifestyle/behavioral factors (smoking and alcohol consumption). multivariable-adjusted mean values, their 95%cis and p-values were calculated. all statistical analyses were performed with the statistical package for social sciences (spss for windows, version 19.0). results overall, mean age among patients included in this study was 61.3±13.1 years (median age: 62 years; interquartile range: 71-53=18 years). mean age was similar in male and female patients. around 54% of the patients were ≥61 years old; about 38% of participants were residing in tirana; and about 46% of the patients were currently employed. overall, the prevalence of smoking was 16%, whereas the prevalence of alcohol consumption was 9% (data not shown in the tables). table 1 presents the distribution of multimorbidity (total number of diseases) by sex of the patients included in this study. overall, about 96% of the patients had at least two diseases/conditions; 89% had at least three conditions; 76% had at least four conditions; 60% had at least five conditions; 42% had at least six conditions; 28% had at least seven conditions; 18% had at least eight conditions; 12% had at least nine conditions; and about 6% of the patients had at least ten diseases (conditions). as for sex-differences, there was a significant difference only for the presence of at least five or six conditions (p=0.04 and p<0.01, respectively) with men exhibiting a higher prevalence than women. conversely, there were no sex-differences for the other combinations. as a matter of fact, looking at the two extremes, the prevalence of at least two diseases/conditions (95% in men 96% in women) and the prevalence of at least ten diseases/conditions (5.5% in men 5.6% in women) were very similar in both sexes (table 1). collaku l, resuli m, gjermeni i, tase m. evidence of a higher burden of multimorbidity among female patients in albania (original research). seejph 2018, posted: 10 april 2018. doi 10.4119/unibi/seejph-2018-185 5 table 1. distribution of patients according to the number of diseases and sex number of diseases total (n=974) men (n=454) women (n=520) p † two diseases: no yes 41 (4.2) * 933 (95.8) 21 (4.6) 433 (95.4) 20 (3.8) 500 (96.2) 0.632 three diseases: no yes 112 (11.5) 862 (88.5) 51 (11.2) 403 (88.8) 61 (11.7) 459 (88.3) 0.841 four diseases: no yes 237 (24.3) 737 (75.7) 105 (23.1) 349 (76.9) 132 (25.4) 388 (74.6) 0.454 five diseases: no yes 388 (39.8) 586 (60.2) 165 (36.3) 289 (63.7) 223 (42.9) 297 (57.1) 0.042 six diseases: no yes 568 (58.3) 406 (41.7) 237 (52.2) 217 (47.8) 331 (63.7) 189 (36.3) <0.001 seven diseases: no yes 698 (71.7) 276 (28.3) 312 (68.7) 142 (31.3) 386 (74.2) 134 (25.8) 0.064 eight diseases: no yes 795 (81.6) 179 (18.4) 360 (79.3) 94 (20.7) 435 (83.7) 85 (16.3) 0.082 nine diseases: no yes 861 (88.4) 113 (11.6) 395 (87.0) 59 (13.0) 466 (89.6) 54 (10.4) 0.229 ten diseases: no yes 920 (94.5) 54 (5.5) 429 (94.5) 25 (5.5) 491 (94.4) 29 (5.6) 0.998 * absolute numbers and column percentages (in parentheses). † p-values from fisher’s exact test. there was evidence of a significant correlation between the number diseases/conditions and age of the patients (spearman’s rho=0.35, p<0.01), number hospitalizations (rho=0.15, p<0.01) and length of stay for the current hospitalization episode (rho=0.21, p<0.01) [data not shown]. table 2 presents the association between multimorbidity (number of diseases/conditions) with sex of the patients included in the study. in crude (unadjusted) models (model 1), there was evidence of a significant relationship with sex, with women displaying a higher mean value of diseases/conditions compared to men (about 4.4 vs. 4.1, p=0.03). similar findings were evident after adjustment for age of the patients (model 2): mean value of diseases/conditions was about 4.4 in women, whereas in men it was 4.1 (p=0.03). likewise, upon adjustment for all socio-demographic characteristics (model 3), the mean number of diseases/conditions was significantly higher in female patients compared to their male counterparts (4.2 vs. 3.9, respectively; p=0.03). however, after additional adjustment for lifestyle/behavioral factors (smoking and alcohol consumption) of study participants, the association between sex and number diseases/conditions was not significant anymore collaku l, resuli m, gjermeni i, tase m. evidence of a higher burden of multimorbidity among female patients in albania (original research). seejph 2018, posted: 10 april 2018. doi 10.4119/unibi/seejph-2018-185 6 (p=0.16), notwithstanding the evidence of a higher mean value in women compared to men (4.2 vs. 4.0) [table 2, model 4]. table 2. association of multimorbidity with sex of the patients; mean values, 95% confidence intervals (95%cis) and p-values from the general linear models model men women p mean 95%ci mean 95%ci model 1 * 4.11 3.91-4.30 4.43 4.22-4.64 0.028 model 2 † 4.06 3.87-4.25 4.37 4.16-4.57 0.029 model 3 ‡ 3.89 3.62-4.17 4.20 3.91-4.49 0.031 model 4 § 4.01 3.63-4.37 4.21 3.88-4.56 0.158 * crude (unadjusted) models. † age-adjusted models. ‡ adjusted for all socio-demographic characteristics (age, place of residence and employment status). § adjusted also for lifestyle/behavioral factors (smoking and alcohol consumption). discussion the main findings of this study consist of a significantly higher mean value of diseases among albania female patients compared to their male counterparts, e finding which was evident irrespective of several demographic and socio-economic characteristics. hence, female patients appeared to experience a higher burden of multimorbidity, which is a cause of concern pointing to a significant gender issue and health inequity gap in the context of transitional albania. nonetheless, the sex-difference in the burden of multimorbidity disappeared upon additional adjustment for lifestyle/behavioral factors including tobacco smoking and alcohol consumption. on the face of it, smoking and harmful alcohol consumption account for a considerable share of multimorbidity and comorbidity in albanian males, which goes in line with a previous report (4). currently, at a global scale, there is a great interest from health professionals, policymakers and decision-makers concerning the impact of comorbidity and multimorbidity on a whole range of clinical outcomes including mortality, health-related quality of life, physical functioning, and quality of health care services (5,7-9). as a matter of fact, healthcare systems worldwide are currently dealing with an increasing demand for provision of effective and efficient medical services for patients with evidence of multimorbidity and comorbidity (8). the burden of multimorbidity has a negative impact on the health status of the populations worldwide, but it also bears an enormous cost for the health care sectors and societies at large (8,10,11). indeed, patients with several diseases/conditions experience not only a higher mortality rate (12), but also require more frequent hospitalization episodes with a longer duration (length of stay) for each hospitalization episode (12,13). the current study may suffer from several drawbacks which may have stemmed from patients’ recruitment and the information gathering. as for study population representativeness, this study involved all consecutive hospitalized patients with evidence of multimorbidity over a certain period of time. all patients enrolled in the current study were admitted at the service of internal medicine and hypertension of the university hospital center ―mother teresa‖ in tirana which, to date, is the only tertiary care facility in albania. therefore, it is likely that most of the adult patients with evidence of multimorbidity are collaku l, resuli m, gjermeni i, tase m. evidence of a higher burden of multimorbidity among female patients in albania (original research). seejph 2018, posted: 10 april 2018. doi 10.4119/unibi/seejph-2018-185 7 hospitalized in this very university hospital center in tirana, which is specialized and in title of providing this type of qualified medical services. from this point of view, the sample of patients included in this study may be largely representative of the overall albanian adult patients with presence of multimorbidity requiring hospitalization. nonetheless, the sample of patients involved is representative only for the duration of the recruitment process that is the period of time over which this study was carried out. in addition, the diagnosis of different diseases and various conditions was based on contemporary guidelines and clinical protocols which consist of recent examination techniques and procedures employed also in other research and medical centers in different countries worldwide. yet, the information about demographic and socioeconomic characteristics, as well as about behavioral factors was collected through interviews and, therefore, it is not possible to completely exclude the possibility of information bias for these factors which were based on patients’ self-reports. notwithstanding these considerations, there is no evidence supporting a differential reporting of socio-demographic characteristics and lifestyle factors between male and female patients with presence of multimorbidity. comparison of morbidity trends including multimorbidity and comorbidity during the past decades in albania is very important because it provides valuable information for health professionals, and especially for policymakers and decision-makers who are involved particularly in the fight against non-communicable diseases, which are currently rising in albania, likewise the situation evidenced in most of the countries of the european region (14). in conclusion, this study informs about the sex-differences of multimorbidity among hospitalized patients in tirana, the albanian capital. our findings demonstrate that the burden of multimorbidity is higher in women than in men in this transitional society, which is a cause of concern. therefore, these findings should raise the awareness of health professionals and particularly policymakers and decision-makers in order to address gender issues and inequity gaps in health outcomes and the burden of disease in the albanian population. references 1. institute for health metrics and evaluation (ihme). country profile: albania. seattle, wa: ihme, university of washington; 2018. http://www.healthdata.org/albania?language=41 (accessed: april 05, 2018). 2. albanian institute of public health. national health report: health status of the albanian population. tirana, albania; 2014. 3. institute of statistics, albania. women and men in albania, 2017. available at: http://www.instat.gov.al/media/2316/burrat_dhe_grat__ne_shqiperi_2017_libri.pdf (accessed: april 04, 2018). 4. institute for health metrics and evaluation (ihme). global burden of disease database. seattle, wa: ihme, university of washington; 2014. http://www.healthdata.org (accessed: march 28, 2018). 5. valderas jm, starfield b, sibbald b, salisbury c, roland m. defining comorbidity: implications for understanding health and health services. ann fam med 2009;7:357-63. 6. bayliss ea, edwards ae, steiner jf, main ds. processes of care desired by elderly patients with multimorbidities. fam pract 2008;25:287-93. 7. smith sm, soubhi h, fortin m, hudon c, o’dowd t. managing patients with multimorbidity: systematic review of interventions in primary care and community settings. bmj 2012;345:e5205. https://www.ncbi.nlm.nih.gov/pubmed/?term=sibbald%20b%5bauthor%5d&cauthor=true&cauthor_uid=19597174 https://www.ncbi.nlm.nih.gov/pubmed/?term=salisbury%20c%5bauthor%5d&cauthor=true&cauthor_uid=19597174 https://www.ncbi.nlm.nih.gov/pubmed/?term=roland%20m%5bauthor%5d&cauthor=true&cauthor_uid=19597174 https://www.ncbi.nlm.nih.gov/pubmed/19597174 https://www.ncbi.nlm.nih.gov/pubmed/19597174 https://www.ncbi.nlm.nih.gov/pubmed/19597174 https://www.ncbi.nlm.nih.gov/pubmed/?term=smith%20sm%5bauthor%5d&cauthor=true&cauthor_uid=22945950 https://www.ncbi.nlm.nih.gov/pubmed/?term=soubhi%20h%5bauthor%5d&cauthor=true&cauthor_uid=22945950 https://www.ncbi.nlm.nih.gov/pubmed/?term=fortin%20m%5bauthor%5d&cauthor=true&cauthor_uid=22945950 https://www.ncbi.nlm.nih.gov/pubmed/?term=hudon%20c%5bauthor%5d&cauthor=true&cauthor_uid=22945950 https://www.ncbi.nlm.nih.gov/pubmed/?term=o%27dowd%20t%5bauthor%5d&cauthor=true&cauthor_uid=22945950 https://www.ncbi.nlm.nih.gov/pubmed/?term=managing+patients+with+multimorbidity%3a+systematic+review+of+interventions+in+primary+care+and+community+settings collaku l, resuli m, gjermeni i, tase m. evidence of a higher burden of multimorbidity among female patients in albania (original research). seejph 2018, posted: 10 april 2018. doi 10.4119/unibi/seejph-2018-185 8 8. fortin m, soubhi h, hudon c, bayliss ea, van den akker m. multimorbidity’s many challenges. bmj 2007;334:1016-7. 9. ritchie c. health care quality and multimorbidity: the jury is still out. med care 2007;45:477-9. 10. marengoni a, angleman s, melis r, mangialasche f, karp a, garmen a, et al. aging with multimorbidity: a systematic review of the literature. ageing res rev 2011;10:430-9. 11. taylor aw, price k, gill tk, adams r, pilkington r, carrangis n, et al. multimorbidity—not just an older person’s issue. results from an australian biomedical study. bmc public health 2010;10:718. 12. menotti a, mulder i, nissinen a, giampaoli s, feskens ej, kromhout d. prevalence of morbidity and multimorbidity in elderly male populations and their impact on 10year all-cause mortality: the fine study (finland, italy, netherlands, elderly). j clin epidemiol 2001;54:680-6. 13. vogeli c, shields ae, lee ta, gibson tb, marder wd, weiss kb, et al. multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. j gen intern med 2007;22(suppl 3):391-5. 14. world health organization. core health indicators in the who european region. copenhagen, denmark; 2017. ______________________________________________________________________________________ © 2018 collaku et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. an empirical study into factors that influence e-learning adoption by medical students in uae (original research), posted:29 september 2022. doi: 10.11576/seejph-5902 original research an empirical study into factors that influence e-learning adoption by medical students in uae afrah alsharafi1 1. faculty of business and law, the british university in dubai, uae corresponding author: afrah alsharafi faculty of business and law, the british university in dubai, uae 21002516@student.buid.ac.ae an empirical study into factors that influence e-learning adoption by medical students in uae (original research), posted:29 september 2022. doi: 10.11576/seejph-5902 abstract aim: the global higher education sector has shown an inclination towards the adoption of technology-based learning for introducing innovation in teaching and learning activities. however, this e-learning environment can only be effective if students have positive perceptions of e-learning. hence, educational personnel is required to consider how students perceive this concept. this research intends to serve this purpose by identifying factors affecting students' acceptance of e-learning as well as their intention toward the use of e-learning for their learning activities. methods: the technology acceptance model (tam) was used in this re-search to formulate a theoretical framework. this research will employ online questionnaires as a data collection tool while the international students enrolled at united arab emirates universities will serve as study participants. results: the research outcomes indicated the most crucial role played by the predictors of “accessibility" “perceived enjoyment", “social influence”, “perceived usefulness”, and "perceived ease of use" in shaping students’ intention to resort to e-learning platforms for learning purposes. conclusion: the research indicated that the extended tam model is applicable in the uae educational context. the research outcomes also showed the possibility for policymakers in the educational sector to make effective use of e-learning platforms both as a technological solution and as an e-learning platform to support distance learning. the research also highlights the practical implications for the concerned educational developers in the educational sector to help them develop and apply a competent e-learning system. keywords: e-learning; higher education; international students; uae. acknowledgment: this work is a part of a project undertaken at the british university in dubai conflicts of interest: none declared. an empirical study into factors that influence e-learning adoption by medical students in uae (original research), posted:29 september 2022. doi: 10.11576/seejph-5902 introduction innovation has introduced the use and application of digital technologies in all walks of life particularly the digital learning and teaching processes. the global higher education sector has shown an inclination towards the adoption of technology-based learning for introducing innovation in teaching and learning activities. in this innovative world, student needs are also evolving and the educational sector specifically the academic institutions have to keep pace with these developments through continuous modification of their courses and mode of education delivery. presently, the educational sector is shifting towards elearning as a new mode of education delivery to cater to the needs of distant students. due to the extraordinary benefits of e-learning like lower cost, ease of use, and flexibility, the global education system is showing an inclination towards the integration of elearning as part of their teaching and learning strategy. e-learning adoption is being observed in various higher education institutions to offer better learning experience to students in the form of easy accessibility free from temporal and spatial limitations. the uae government’s commitment to promote online learning and distance education is evident from its implementation of e-learning as part of their innovation-promoting campaign in education sector. the concept of distant learning gained popularity in march 2020 during the spread of covid-19 when learning from home was applied by all higher edu-cation institutions and schools across the uae. as part of this movement, training programs were conducted to equip school teachers with the essential knowledge of using distance learning programs effectively. private schools were also encouraged to apply individual distance learning system for supporting the learning and teaching activities during the pandemic. the smart learning plat-forms were also initiated by the uae government. the teachers using distant learning programs for conducting classes were provided with guidelines by the uae government for proper supervision of their students’ behavior. the uae government ensured easy internet accessibility to all the students across the country. in this regard, remote areas with low or no internet connectivity were provided with free-of-cost satellite broadband services. moreover, students were also provided with free-of-cost home internet connection. the uae is committed to implement the e-learning system in all educational institutes in the country due to the strategic significance of such systems in accomplishment of the uaes in-novation-promotion campaign. e-learning systems allow easy access to learning activities by greater number of students besides facilitating the delivery of professional education leading to higher rate of qualification and attracting students beyond the traditional area of student influx. e-learning supports innovative teaching and learning process by revolutionizing the education sector through the modification of traditional education systems and methods as indicated in earlier studies. eventually, educational and learning system yields better quality. other benefits offered by e-learning system are improvement in educational curriculum and reputation of the institute, cam-pus space utilization and optimization of resources for better learning; e-learning encourages the enrolment of greater number of students leading to higher student diversity and higher income (1). but, adoption of elearning systems is not as easy as it seems. it involves various obstacles, such as improper infrastructure (2), inadequate ict support (3) and public fear and reluctance towards adoption of technology (4) among others. even the institutions fear the adoption of technology and are reluctant to switch to e an empirical study into factors that influence e-learning adoption by medical students in uae (original research), posted:29 september 2022. doi: 10.11576/seejph-5902 learning and prefer to adopt a middle way method of blended learning; in this method, e-learning tools are employed to complement the traditional classes instead of fully replacing them with online learning methods (1). positive student perception and expectations about e-learning are extremely important for the successful implementation of e-learning and development of e-learning environment. however, students’ perceptions about e-learning and the factors that motivate e-learning adoption among international student community have been fully ignored. fortunately, this study identified the factors influencing intention of students studying in higher education institutes towards using e-learning system. these factors were “accessibility", “perceived enjoyment", and “social influence”. moreover, the effect of each of these factors on international students’ perception and intention to accept the elearning platforms were also discussed. according to the literature, there is limited empirical research on how e-learning is utilized in the uae institutions and limited awareness of the factors that influence students' actual use. in the perspective of methodology, most technological acceptance researches asses, theoretical models, using the “structural equation modeling (plssem)” technique. as a result, there are two folds to this study. to begin, tam (5) and external variables were combined to assess students' actual use of e-learning. second, employing the pls-sem tool, verify the constructed theoretical model. this study starts with the literature review of the selected studies related to e-learning systems. in the next step, hypotheses are developed. after this, an ex-planation of the method is given. in the end, the study present the results and discussion, elaborates the limitations and offers recommendations for future re-search. literature review distance learning has become much convenient in the previous 10 years with the introduction of world wide web, or web which serves as a platform for con-ducting online teaching and learning activities for distant students. web is assessed by a number of users at the same time for communication and collaboration purposes; it is also accessed by many learners to obtain information. learners also get a chance to use various learning tools available on the internet for acquiring new knowledge or exploit the available knowledge. various terms associated with internet and webbased teaching and learning activities are web-based learning, e-learning and online learning among others. e-learning is a virtual classroom where different learners and teachers located remotely use inter-net for developing a connection with each other and conduct teaching and learning activities. internet acts as a mode of imparting education to students. internet allows students to involve in repetitive learning activities and access course materials irrespective of the time and place constraints (6). internet acts as a life-saver for students of all ages and levels who do not have physical access to educational centers or educational content to acquire advanced degrees otherwise. besides the educational purposes, there has been an inclination towards implementing e-learning for commercial purposes (6). e-learning has helped the educational sector specifically the higher education and corporate training institutes to overcome the obstacles experienced in learning and teaching activities (6). this situation calls for more research on e-learning which is become one of the most important developments in is industry due to the present situation where physical classes have been abandoned due to covid-19. e-learning research is essential for allowing schools and higher education institutes and students to understand this an empirical study into factors that influence e-learning adoption by medical students in uae (original research), posted:29 september 2022. doi: 10.11576/seejph-5902 technology and make best use of it while conducting e-learning courses (7). proper knowledge and implementation of e-learning in the current knowledge-based economy allows financial institutes and organizations to gain information and exploit the available information to outshine their competitors. the learning environment in organizations is also being incorporated with e-learning technology for equipping the workers with latest information and proper training. however, it must be comprehended that student acceptance of the technology is critical factor for effective implementation of online learning in educational institutes. students are the ones who are exposed to technology use in learning activities on daily basis, therefore their acceptance behavior towards that technology is extremely important to consider. before taking any decision about incorporating technology in learning processes or bringing about a change in learning behavior, students’ disposition and acceptance to adopt the change must be taken into account. the empirical evidence also depicted that user acceptance was imperative for effective implementation of technology (8). re-searchers have shown keen interest in identifying factors affecting the acceptance of information technology; in this regard, they have formulated and tested many relevant models like the “theory of reasoned action (tra)” (9) and the “technology acceptance model (tam)” (10). out of all these models, the most effective one is known to be tam since it has been validated, executed and simulated extensively and is also found to be much robust and predicative than other models (11). tam has been formulated on the basis of technology adoption literature and is a significant innovation in the domain of is. this research mainly intends to investigate the factors that affect the acceptance of elearning by students studying in higher education institutes. the research specifically focuses on how “perceived usefulness and perceived ease of use” are affected by the elearning external factors of “accessibility", “perceived enjoyment", and “social influence”. additionally, the impact of these factors on students' intention to-wards adoption of e-learning is studied. this research contributes to the domain of elearning by allowing the formulation of effective e-learning programs and conducting e-learning courses. the conceptual model and hypotheses 3.1 accessibility (acs) alshammari et al (12) defines system accessibility as the degree of ease of student access to e-learning system and the degree of student’s adoption of this system for continued learning. students find the elearning system as easy to use if the elearning system offers accessibility to them (13). it has been indicated by (14), that “perceived ease of use” associated with a website expresses its system accessibility. additionally, (15,16) also conveyed the idea that perceived ease of use of e-learning system is significantly dependent on the accessibility of that system. previous research showed same outcomes about the significant effect of perceived accessibility of an e-learning system on both its “perceived ease of use” (17) and “perceived usefulness” (18). an easily accessible e-learning sys-tem sounds more appealing to the student as the student perceives such a system to offer more usefulness and greater ease of use (15,16). thus, it is hypothesized that: h1a: accessibility (acs) has a significant influence on perceived usefulness (pu). h1b: accessibility (acs) has a significant influence on perceived ease of use (peou). an empirical study into factors that influence e-learning adoption by medical students in uae (original research), posted:29 september 2022. doi: 10.11576/seejph-5902 3.2 perceived enjoyment (pe) another intrinsic variable of ‘enjoyment’ was investigated by many researchers due to its significant relevance to technologyacceptance studies. enjoyment associated with the use of a new system has a positive influence on user perception (19). when a new system feels enjoyable, the user automatically ignores the complexities experienced during its use and perceives it to be convenient and easy-to-use (20). thus, the factor of perceived enjoyment in using elearning systems has a positive effect on elearning adoption or acceptance. similarly, previous research revealed that like any technology, for e-learning systems, perceived ease of use (21–23) and perceived usefulness (21–23) significantly de-pends on the user perception about the enjoyment offered by the e-learning sys-tem. an enjoyable e-learning system sounds more appealing to the student as the student perceives such a system to offer more usefulness and greater ease of use (6). as a result, we obtain two hypotheses: h2a: perceived enjoyment (pe) has a significant influence on perceived usefullness (pu). h2b: perceived enjoyment (pe) has a significant influence on perceived ease of use (peou). 3.3 social influence (sol) social influence is defined as the perception of influential people regarding the use of a system (24). sometimes, people’s decision to adopt or use a system is based on this social influence which means that they are willing to adopt a sys-tem to follow others and not because of their personal beliefs or emotions (25). a number of research works have investigated the impact of subjective norms on the adoption or acceptance of e-learning. (22) also revealed a significant association of subjective norm with the “perceived usefulness” of an e-learning system (22,23,26) and “perceived ease of use” (22,23,26,27). hence the hypothesis giv-en below is postulated: h3a: social influence (sol) has a significant influence on perceived usefulness (pu). h3b: social influence (sol) has a significant influence on the perceived ease of use (peou). 3.4 the technology acceptance model (tam) the “perceived usefulness and perceived ease of use” lead to the acceptance of new technology. the users’ behavioral intention to use a technology is also significantly dependent on the “perceived ease of use and perceived usefulness”; this has been indicated in tam as well as relevant studies. perceived ease of use depicts the degree of willingness of a user towards the adaption to a new technology (5). a significant association between the two aspects of “perceived ease of use (peou) and perceived usefulness (pu)” was revealed in previous research works (28–30). moreover, the two aspects of the “behavioral intention to use elearning system (iu) and perceived ease of use (peou)” were also found to have a positive direct and indirect link. a corresponding finding by (31) indicates that the user’s intention to employ an e-learning system and to show direct and indirect willingness to accept and adjust to such a system is affected by “perceived usefulness (pu)”. another study revealed a significant positive association be-tween “perceived usefulness (pu) and intention to use the elearning system (iu)” (32,33). hence, this research identifies that iu, pu and peou are positively linked. the relevant literature was reviewed leading to postulation of the hypotheses stated below: an empirical study into factors that influence e-learning adoption by medical students in uae (original research), posted:29 september 2022. doi: 10.11576/seejph-5902 h4. perceived ease of use (peou) has a positive effect on the perceived usefulness (pu). h5. perceived usefulness (pu) positively affects the intention of international student to accept an e-learning platforms (bi). h6. perceived ease of use (peou) positively affects the intention of international student to accept an e-learning platforms (bi) figure 1 illustrates that these hypotheses are employed to propose the research model. a structural equation model is developed on the basis of the theoretical model and is subsequently tested. fig. 1. theoretical framework. research methodology data collection the data collection for this study was conducted throughout the month of november 2021. an online survey was used as a data collection instrument. the international students studying in public or private universities in the uae were selected as the study participants. besides appealing the tourists from around the world, the uae has also been the center of attention for students worldwide to pursue their education and career. the abu dhabi and dubai are the two most significant destinations that house most of the higher education institutions in the uae. the web link of the survey was sent to the respondents through college website. this survey was then filled by the respondents. the link also contained a cover letter that elaborated the survey objectives; the cover letter also affirmed that the identities and personal data of the study participants will be kept confidential and not publicized. the cover letter also gave indications about how long will it take to complete the research. in this research, the traditional face-to face physical classroom settings were used; however, the college used the online platforms like college website, teachers’ blog and school intranet to give students the access to course materials uploaded online. the students were asked to obtain the study material available online before each class through their pcs or through the computers at the college laboratory. findings and discussionhypothesis testing using sem-pls the partial least squares-structural equation modeling (pls-sem) was used to analyze the data for this research with the assistance of smartpls v.3.2.7 software. the collected data was evaluated using a two-step assessment approach that included a structural model and a measurement model. pls-sem was used for this research for a myriad of purposes. primarily, pls-sem is thought to be the ideal option when the goal an empirical study into factors that influence e-learning adoption by medical students in uae (original research), posted:29 september 2022. doi: 10.11576/seejph-5902 of the study is to develop an established notion. second, the pls-sem may be used to effectively manage exploratory research with complex models. third, rather than breaking the model into bits, pls-sem analyses the entire model as a single entity. pls-sem, which delivers accurate computations sequentially, provides concurrent analysis for both measurement and structural model. the structural equation model was used in conjunction with smart pls and maximum likelihood estimation to determine the interdependence of several structural model theoretical constructs. table 1 shows the beta (β) values, t-values, and p-values for each of the hypotheses made using the pls-sem technique predicated on the obtained findings. all the hypotheses were strongly supported by all the researchers. the empirical data supported hypotheses h1a, h1b, h2a, h2b, h3a, h3b, h4, h5, and h6 relying on the data analysis. table 1. hypotheses-testing of the research model (significant at p** < = 0.01, p* < 0.05). h relationship path t-value p-value direction decision h1a acs -> pu 0.352 3.066 0.035 positive supported* h1b acs -> peou 0.617 15.485 0.000 positive supported** h2a pe -> pu 0.359 12.572 0.000 positive supported** h2b pe -> peou 0.587 17.815 0.002 positive supported** h3a sol -> pu 0.665 13.876 0.001 positive supported** h3b sol -> peou 0.632 9.154 0.003 positive supported** h4 peou -> pu 0.354 10.362 0.005 positive supported** h5 pu -> bi 0.458 3.426 0.033 positive supported* h6 peou -> bi 0.725 16.630 0.000 positive supported** conclusion this study intends to extract the factors influencing the perception of the international students about the adoption of electronic learning (e-learning) for their educational activities. the research model will be proposed and the hypothesis for testing the behavioral intention of learners to use e-learning platforms will be postulated on the basis of data analysis results. the research applies structure equation modeling (pls-sem) for evaluation of research hypotheses. it is found that the behavioral intention of students to use e-learning platforms is positively influenced by the factors of “accessibility" “perceived enjoyment", “social influence”, “perceived usefulness”, and "perceived ease of use". the study also suggested that e-learning systems hold significance and are considered as competent online learning platforms by students. an empirical study 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understanding the impact of social media practices on e-learning systems acceptance. 2019; _________________________________________________________________________ kamberi h, tanushi v, kadrija m, kamberi s, jerliu n. level of satisfaction and socio-demographic correlates among users of primary health care services in kosovo (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5922 p a g e 1 | 9 original research level of satisfaction and socio-demographic correlates among users of primary health care services in kosovo haxhi kamberi1,2, vanesa tanushi2, muhamet kadrija2,3, safete kamberi4, naim jerliu5,6 1 regional hospital “isa grezda”, gjakova, kosovo; 2 faculty of medicine, university of gjakova “fehmi agani”, gjakova, kosovo; 3 family medicine center, gjakova, kosovo; 4 center of public health, gjakova, kosovo 5 national institute of public health of kosovo, prishtina, kosovo; 6 faculty of medicine, university of prishtina “hasan prishtina”, prishtina, kosovo. corresponding author: naim jerliu, md, phd, faculty of medicine “hasan prishtina”, university of prishtina & national institute of public health of kosovo, prishtina, kosovo address: national institute of public health of kosovo, str. instituti shëndetësor, 10000, prishtina, kosovo telephone: +38338541432; email: naim.jerliu@uni-pr.edu kamberi h, tanushi v, kadrija m, kamberi s, jerliu n. level of satisfaction and socio-demographic correlates among users of primary health care services in kosovo (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5922 p a g e 2 | 9 abstract aim: the aim of this study was to assess the level and socio-demographic correlates of satisfaction with services among adult primary health care users in kosovo. methods: a cross-sectional study was conducted in kosovo during the period may-june 2022 including a representative sample of 510 adult users (238 men and 272 women) of primary health care services in kosovo (mean age: 44.6±19.2 years). in addition to socio-demographic data, a structured 23-item questionnaire aiming at assessing the level of satisfaction with primary health care services was administered to all participants (each item ranging from 1 [high] to 5 [low]). a summary score was calculated for all 23 items related to satisfaction level ranging from 23 (the highest satisfaction level) to 115 (the lowest satisfaction level). general linear model was used to assess the association between the summary score of satisfaction level with primary health care services and socio-demographic factors of study participants. results: mean summary score of the 23 items related to the satisfaction level with primary health care services was 49.8±13.0; median score was 49 (interquartile range: 41-57). in multivariable-adjusted models, the level of satisfaction with primary health care services was significantly higher among participants with a lower educational attainment, individuals with e lower income level, and ethnic albanian participants. conclusion: this study identified important socio-demographic correlates of the level of satisfaction with primary health care services in the adult population of kosovo. findings from this study should raise the awareness of policymakers and decision-makers in kosovo and elsewhere in order to improve the quality of primary health care services. keywords: epidemiology, kosovo, patients, primary health care, satisfaction, socioeconomic factors, users of services. kamberi h, tanushi v, kadrija m, kamberi s, jerliu n. level of satisfaction and socio-demographic correlates among users of primary health care services in kosovo (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5922 p a g e 3 | 9 introduction almost 15 years after declaring its independence, kosovo is still undergoing a difficult political and socioeconomic transition, striving for wider recognition in the international arena and aspiring to join european union in due time. according to the world bank data (1), life expectancy in kosovo in 2020 was 71 years (74 years in women and 69 years in men), which is substantially lower than the national report of about 76 years (which is related to a significant under-registration of deaths) (2). crude death rate in kosovo is 8 per 1,000 population, whereas crude birth rate is 15 per 1,000 people. in turn, fertility rate is 1.9 births per woman of childbearing age (3). similar to most of the central and eastern european countries, kosovo has experienced a development of health care reform that shifted its semashko health care system established during the communist era, towards social health insurance (4). primary health care services in kosovo are regulated, somehow well-organized and standardized in all communes. in 2021, overall, there were registered about 3.2 million visits at primary health care services (5), which exhibits a decreasing trend from the previous year (2020) which registered more than 4 million primary health care visits (6). the current scientific evidence about the level and determinants of satisfaction with primary health care services in kosovo is scarce. at an international level, assessment of satisfaction level among users of healthcare service is considered an essential part of the overall assessment of health care services regarding quality and health care system responsiveness (7,8). despite the wide range of the level of satisfaction with healthcare services, three key individual determinants of satisfaction have been consistently reported from previous studies conducted internationally: expectations, health status and socio-demographic characteristics (9). the associations of users’ satisfaction with age, health status and education are usually fairly consistent, whereas the relationship between satisfaction and gender has been reported to be somehow inconsistent (10). in this context, the aim of this study was to assess the level of satisfaction and selected socio-economic correlates among adult primary healthcare users in kosovo. we hypothesized a higher level of satisfaction among younger participants, male individuals, and higher socioeconomic status participants. methods a cross-sectional study was conducted in kosovo during the period may-june 2022 in a sample of primary healthcare users. the study was carried out in three regions of kosovo: gjakova, peje, and prizren, which constitute some of the main regions of the republic of kosovo. a representative sample of individuals attending primary healthcare services in the regions of gjakova, peje and prizren was included in this survey. more specifically, the study population consisted of a random sample of 510 adult individuals (91% response rate; 238 men and 272 women – all 18 years and above) attending different primary healthcare centres/facilities in the aforementioned three regions of kosovo. a structured 23-item questionnaire (11) inquiring about the level of satisfaction with primary healthcare services was administered to all study participants. assessment of satisfaction level consisted of the 23-item europep instrument (11). this instrument has been previously validated in the adult population of kosovo (12). kamberi h, tanushi v, kadrija m, kamberi s, jerliu n. level of satisfaction and socio-demographic correlates among users of primary health care services in kosovo (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5922 p a g e 4 | 9 a summary score was calculated for all 23 items related to the level of satisfaction with primary healthcare services ranging from 23 (highest level of satisfaction) to 115 (lowest level of satisfaction with primary healthcare services). furthermore, information about demographic factors (age, sex, ethnicity, marital status and place of residence) and socioeconomic characteristics (employment status, educational attainment and income level) were gathered for all study participants. the study was approved by the ethics commission and council of the faculty of medicine, university of gjakova. fisher’s exact test was used to compare differences in socio-demographic factors (age, place of residence, marital status, ethnicity, employment status, educational attainment and income level) between male and female participants. conversely, general linear model was used to assess the association between the summary score of the satisfaction level with primary healthcare services (23-item instrument) and socio-demographic factors of study participants. firstly, crude (unadjusted) mean values, their respective 95% confidence intervals (95%cis) and p-values were calculated. secondly, multivariable-adjusted models were run controlling simultaneously for all socio-demographic factors of study participants (age, sex, ethnicity, place of residence, employment, educational attainment and income level). multivariableadjusted mean values, their respective 95%cis and p-values were calculated. a p-value ≤0.05 was considered as statistically significant in all cases. statistical package for social sciences (spss, version 19.0) was used for all the statistical analyses. results mean age (±sd) of participants included in this study was 44.6±19.2 years; median age was 44 years (interquartile range: 27-59 years); the age range was: 18-88 years (not shown in the tables). table 1 presents the distribution of sociodemographic factors of study participants (n=510), separately in men and in women. overall, about 32% of individuals were aged ≤30 years, whereas 38% of participants were 51 years and above. about 50% of participants resided in rural areas, whereas about 90% were ethnic albanians. about 62% of individuals were currently married (which was more prevalent in men than in women, p=0.01). only half of study participants (51%) were currently employed (62% in men vs. 40% in women, p<0.01). around 41% of individuals had a low educational attainment (≤8 years of formal schooling), whereas 26% of them had a high educational level (with significant gender differences: p=0.01). on the whole, 49% of individuals had a lowincome level, whereas only about 7% of participants reported a high-income level. there were no statistically significant differences in the distribution of the other socio-demographic characteristics between men and women included in the study (table 1). a summary score was calculated for all 23 items of the satisfaction level with primary healthcare services ranging from 23 (indicating the highest level of satisfaction with primary healthcare services) to 115 (indicating the lowest level of satisfaction with primary healthcare services). mean summary score of the 23 item-instrument of the level of satisfaction with primary healthcare services was 49.8±13.0; median kamberi h, tanushi v, kadrija m, kamberi s, jerliu n. level of satisfaction and socio-demographic correlates among users of primary health care services in kosovo (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5922 p a g e 5 | 9 score was 49 (interquartile range: 41-57) [data not shown in the tables]. table 1. socio-demographic factors in a sample of primary health users in kosovo in 2022 (n=510) socio-demographic factors total (n=510) men (n=238) women (n=272) p † age-group: ≤30 years 31-50 years ≥51 years 164 (32.2)* 154 (30.2) 192 (37.6) 65 (27.3) 74 (31.1) 99 (41.6) 99 (36.4) 80 (29.4) 93 (34.2) 0.073 place of residence: urban areas rural areas 254 (49.8) 256 (50.2) 111 (46.6) 127 (53.4) 143 (52.6) 129 (47.4) 0.106 region: peje prizren gjakove 146 (28.6) 176 (34.5) 188 (36.9) 68 (28.6) 83 (34.9) 87 (36.6) 78 (28.7) 93 (34.2) 101 (37.1) 0.986 ethnicity: other albanian 50 (9.8) 460 (90.2) 22 (9.2) 216 (90.8) 28 (10.3) 244 (89.7) 0.403 marital status: other married 191 (37.5) 319 (62.5) 76 (31.9) 162 (68.1) 115 (42.3) 157 (57.7) 0.010 educational level: low middle high 209 (41.0) 167 (32.7) 134 (26.3) 91 (38.2) 94 (39.5) 53 (22.3) 118 (43.4) 73 (26.8) 81 (29.8) 0.008 employment status: employed unemployed retired 257 (50.5) 157 (30.8) 95 (18.7) 147 (62.0) 49 (20.7) 41 (17.3) 110 (40.4) 108 (39.7) 54 (19.9) <0.001 income level: low middle high 250 (49.1) 226 (44.4) 33 (6.5) 124 (52.3) 101 (42.6) 12 (5.1) 126 (46.3) 125 (46.0) 21 (7.7) 0.269 * numbers and column percentages (in parenthesis). † p-values from fisher’s exact test. table 2 presents the association between summary score of satisfaction level with primary healthcare services and sociodemographic factors of study participants. in crude (unadjusted) general linear models, the mean summary score of the 23-item kamberi h, tanushi v, kadrija m, kamberi s, jerliu n. level of satisfaction and socio-demographic correlates among users of primary health care services in kosovo (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5922 p a g e 6 | 9 instrument measuring the level of satisfaction with primary healthcare services was significantly higher among ethnic albanians compared to other ethnic groups: 49.3 vs. 54.8, respectively (p=0.01). furthermore, the level of satisfaction with primary healthcare services was higher among low-income participants compared to their high-income counterparts (47.5 vs. 54.9, respectively), and among low-educated individuals compared to highly educated participants (49.2 vs. 51.9). conversely, there were no differences in summary scores of the level of satisfaction with primary healthcare services between male and female participants, urban and rural residents, or between different age-groups of individuals included in this study. table 2. association between the level of satisfaction with primary healthcare services and socio-demographic factors – results from the general linear models socio-demographic factors unadjusted models multivariable-adjusted models mean* 95%ci p mean 95%ci p sex: women men 49.8 49.8 48.1-51.5 48.2-51.3 0.952 53.1 53.7 50.6-55.7 50.9-56.5 0.624 age-group: ≤30 years 31-50 years ≥51 years 50.0 49.6 49.8 48.0-52.0 47.5-51.7 47.9-51.7 0.963 (2)† 0.914 0.862 reference 53.7 52.7 53.9 50.6-56.8 49.7-55.7 51.0-56.9 0.699 (2) 0.874 0.442 reference ethnicity: albanian other groups 49.3 54.8 48.1-50.5 51.0-58.6 0.007 51.2 55.7 49.2-53.2 51.7-59.6 0.032 place of residence: urban areas rural areas 49.8 49.8 48.2-51.5 48.2-51.4 0.985 53.3 53.6 50.7-55.9 50.9-56.2 0.832 educational level: low middle high 49.2 48.9 51.9 47.5-51.0 46.9-50.9 49.6-54.1 0.111 (2) 0.073 0.054 reference 51.9 52.2 56.2 49.3-54.6 49.2-55.1 52.9-59.5 0. 019 (2) 0.012 0.011 reference employment: employed unemployed retired 50.4 49.0 49.7 48.7-51.9 47.0-51.1 47.0-52.4 0.610 (2) 0.681 0.703 reference 53.7 52.7 53.9 51.2-56.3 49.7-55.7 50.1-57.6 0.742 (2) 0.941 0.577 reference income level: low middle high 47.5 51.7 54.9 45.6-49.1 50.0-53.4 50.3-59.5 <0.001 (2) 0.003 0.196 reference 49.3 54.2 56.7 46.8-51.8 51.7-56.8 52.0-61.5 <0.001 (2) 0.004 0.321 reference * range of the summary score from 23 (the highest level of satisfaction) to 115 (the lowest level of satisfaction with primary healthcare services). † overall p-values and degrees of freedom (in parentheses). kamberi h, tanushi v, kadrija m, kamberi s, jerliu n. level of satisfaction and socio-demographic correlates among users of primary health care services in kosovo (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5922 p a g e 7 | 9 in multivariable-adjusted models, the significant association with ethnicity persisted strongly, with ethnic albanians exhibiting a significantly higher satisfaction level with primary healthcare services compared with the other ethnic groups, whereas the association with educational attainment was accentuated. in brief, upon simultaneous multivariable adjustment for all socio-demographic characteristics, mean summary score of satisfaction level with primary healthcare services was significantly higher among: low-educated individuals compared to highly educated participants (51.9 vs. 56.2, respectively); in low-income participants compared to high-income individuals (49.3 vs. 56.7, respectively); and ethnic albanian participants compared to other ethnic groups (51.2 vs. 55.7, respectively) [table 2]. discussion the main finding of this study consists of a remarkably significant relationship between satisfaction level with primary healthcare services and selected key socio-demographic characteristics including educational attainment, income level, and ethnicity. the associations with these three characteristics persisted upon adjustment for several other key socio-demographic factors including age, gender, place of residence, and employment status. our working hypotheses on a positive relationship of satisfaction level with age and male gender were not evidenced, in contrast with a previous study conducted in kosovo (12), and also a fairly recent report from the neighbouring albania (unpublished – personal communication), which both reported a higher satisfaction level among younger and male primary healthcare users. on the other hand, the association with socioeconomic level evidenced in our study is compatible with the previous reports from kosovo (12) and albania. a few studies conducted in turkey employing the same europep instrument have reported a higher level of satisfaction with primary healthcare services among the low-educated participants (13,14), a finding which is in line with our study. a factor that may be related to users’ satisfaction concerns the individuals’ expectations from health care: the lower the expectations, the higher the level of satisfaction, and vice versa (15). this may also explain the higher satisfaction level evidenced in our study among the loweducated individuals. in our study we found a lower satisfaction level with primary healthcare services among ethnic minorities. this finding is compatible with international reports which have similarly evidenced a lower satisfaction level among ethnic minorities (16-20). regarding the inverse association between satisfaction level and income status, our findings are not in line with a previous study (21), whereas several other studies have reported similar results with our study (i.e., a higher level of satisfaction among the lowincome individuals) (22,23). however, there are several limitations of this study conducted in three regions of kosovo which consist of the sample size of primary healthcare users, the sample representativeness, the odds of information bias and the issue of study design. seemingly, the sample size included in our study was sufficient to assess the extent (magnitude) of satisfaction level among primary healthcare users and the association with sociodemographic characteristics. yet, subtle differences in the level of satisfaction among patients belonging to different sociodemographic categories might have been kamberi h, tanushi v, kadrija m, kamberi s, jerliu n. level of satisfaction and socio-demographic correlates among users of primary health care services in kosovo (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5922 p a g e 8 | 9 missed, given the sample size at hand. hence, a larger sample size would allow for exploration and comparison of smaller differences in the levels of satisfaction between different socioeconomic groups. more importantly, study participants were pertinent only to three regions of kosovo and, therefore, generalizability of our findings should be interpreted with caution. the europep instrument employed in our study has been previously successfully validate in the adult population of primary healthcare users in kosovo (12), which is comforting. nonetheless, the possibility of information bias cannot be discarded. finally, associations observed in crosssectional studies do not imply causality. despite of these potential limitations and drawbacks, this study 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improving nutrition and health among albanian school children (policy brief). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5709 p a g e 1 | 9 policy brief improving nutrition and health among albanian schoolchildren jolanda hyska1,2 1 department of public health, faculty of medicine, university of medicine, tirana, albania; 2 department of food and nutrition, institute of public health, tirana, albania. corresponding author: jolanda hyska; address: rr. aleksander moisiu, no. 88, tirana, albania; telephone: +355672052972; email: lhyska@yahoo.it hyska j. improving nutrition and health among albanian school children (policy brief). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5709 p a g e 2 | 9 abstract nutrition is a critical part of health and development. better nutrition is related to improved infant, child and maternal health, stronger immune systems, safer pregnancy and childbirth, lower risk of non-communicable diseases and longevity. prevention of malnutrition among adolescents and improvement of the nutritional status of children are considered important targets in albanian health system efforts to achieve benefits in the population’s health. key approaches for improving nutritional status and nutrition-related knowledge, attitude and practices among school-children in albania (based on the main findings from the in-depth analysis of three nationwide surveys conducted in albania between 2015 and 2018 on nutritional status and nutrition-related knowledge, attitudes and practices among schoolchildren in albania and other findings) consist ofprevention and promotion from an early age, focus on knowledge, attitudes and practices, limit exposure to less healthy foods and increase parental awareness and involvement. these studies findings and respective recommendations can support the development of a national school food and nutrition education programme in albania. while there is evidence for the need to intervene at the national level, the stratified analysis at regional and district levels points to the need for the design and implementation of specific interventions at the local level. it is also very crucial to strengthen and improve anthropometric nutrition and surveillance systems for nutritional risk factors for children and adolescents, and use the data obtained by these systems effectively and appropriately. keywords: albania, attitude, nutrition, nutritional status, school-age children. conflicts of interest: none declared. acknowledgment: this document is based on the in-depth analysis of three nationwide surveys conducted recently in albania regarding ‘nutritional status and nutrition-related knowledge, attitude and practices among school-children in albania”carried out by ass. prof jolanda hyska in the framework of the project "improving the nutritional status of children in schools in albania", a project developed by the albanian center for economic research (acer), funded by unicef albania. the views and opinions expressed in this publication are those of the author and do not necessarily represent the official opinion of acer nor of unicef. hyska j. improving nutrition and health among albanian school children (policy brief). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5709 p a g e 3 | 9 the impact of nutrition on health nutrition is a critical part of health and development. better nutrition is related to improved infant, child and maternal health, stronger immune systems, safer pregnancy and childbirth, lower risk of noncommunicable diseases (such as diabetes and cardiovascular disease), and longevity (1). two of the major challenges of our times are malnutrition in all its forms and the degradation of environmental and natural resources. both are happening at an accelerated pace (2). the state of food security and nutrition in the world report (sofi 2019) shows that the number of the undernourished has been slowly increasing for several years in a row, and at the same time the number of overweight and obese people all over the world is increasing at an alarming rate. poor diets are a major contributory factor to the rising prevalence of malnutrition in all its forms. moreover, unhealthy diets and malnutrition are among the top ten risk factors contributing to the global burden of disease. in addition, the way we produce and consume food is taking a toll on the environment and natural resource base. food production accounts for the use of 48 percent and 70 percent of land and fresh water resources respectively at the global level (2). the health effects of poor nutritional practices and habits are manifested from early childhood and have implications for health status in adulthood (who, 2018). it is well established that poor nutrition for children has negative effects for their health, growth and development, school performance and, consequently, for their productivity in adulthood (3). both undernutrition and overweight and obesity among children reflect poor nutritional practices. adequate and healthy nutrition is essential for children to reach their full potential at every stage of their development. what children eat today and their understanding of how food affects their health are crucial for tackling the problem of obesity (4) and other health problems resulting from poor dietary practices. prevention of malnutrition among adolescents and improvement of the nutritional status of children are considered important targets in albanian health system efforts to achieve benefits in the population’s health by increasing the proportion of people who have access to adequate, safe and nutrient-rich food, eat a balanced diet and maintain a healthy body weight (5). as the linkages between childhood nutrition and health, and development and productivity in adulthood have become increasingly evident, it is clear that addressing malnutrition is central to improving individual development and well-being, improving the overall economic and social development of families and communities and supporting societal development (6). given the high human and economic returns that investments in child and adolescent nutrition bring and the growing recognition of the right to adequate food, the global commitment to addressing malnutrition has intensified. it now features prominently on the international agenda, including the sustainable development goals (sdgs), the rome declaration and framework for action adopted by the second international conference on nutrition (icn2), and the un decade of action on nutrition 2016–2025, among others (7,8). the role of school-based food and nutrition education more and more, schools have become a focus for policies and programmes that aim to address malnutrition and other health problems related to poor nutrition and unhealthy diets. schools reach the majority of school-age children (9) in non-crisis contexts over a prolonged period of time, and can extend benefits to families, the hyska j. improving nutrition and health among albanian school children (policy brief). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5709 p a g e 4 | 9 whole school community and to the surrounding community. school-based food and nutrition education (sfne) consists of coherent and mutuallyreinforcing educational strategies and learning activities which, supported by a healthy food environment, help schoolchildren, adolescents and their communities improve their food choices and diets. when implemented successfully, sfne helps schoolchildren, along with school staff and parents, achieve lasting improvements in their diets, food practices, outlooks and knowledge, build their capacity to change and adapt to external change, and to pass on their learning to others. essential elements of sfne are: 1) a healthy food environment and safe and nutritious school food; 2) food and nutrition education; 3) inclusive food procurement (including local production) and nutritionsensitive value chains; and 4) enabling policy, legal and institutional environments. successful sfne involves a holistic approach with explicit linkages, interactions and coherence between each of these elements. school food and nutrition approach is a direct response to the international call for improved nutrition and food systems, and supports sdgs 2 (zero hunger), 3 (good health and well-being), 4 (quality education), 5 (gender equality) and 12 (responsible consumption and production) (10). sfne also plays an important role in complementing global efforts to improve food environments, and in empowering children and adolescents to become active participants and future leaders in shaping food systems that are better able to deliver healthy and sustainable diets. key approaches for improving nutritional status and nutritionrelated knowledge, attitude and practices among school-children in albania (based on the main findings from the indepth analysis of three nationwide surveys conducted in albania between 2015 and 2018 on nutritional status and nutritionrelated knowledge, attitudes and practices among school-children in albania and other findings) (11,12) 1. prevention and promotion from an early age prevention is the best cost–benefit method to control overweight and obesity in children and thus future adults. children are considered a priority population for prevention strategies because weight loss is difficult for adults and there are more interventions available for children than for adults. some of these potential strategies for intervention in children can be implemented by targeting schools as a natural development zone for nutrition education (13).  prevention can be achieved through various interventions that target the school environment, physical activity and diet, such as: high importance of physical activity; healthy foods in cafeteria, ban on sweetened beverages and energydense junk food; training of teachers regarding health education; incorporation of more knowledge about nutrition and physical activity and nutrition-related diseases in school curriculum, etc. (14).  as eating patterns and dietary habits are established early in life, and behaviour change later in life is more difficult, it is most effective to help children form good habits at an early age by improving their everyday skills in making good food choices, planning and preparing healthful meals, protecting the quality and safety of the foods they eat and in establishing healthful hyska j. improving nutrition and health among albanian school children (policy brief). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5709 p a g e 5 | 9 personal habits and lifestyles, based on activity-approaches with less emphasis on reading and more on learning by doing, with a variety of activities, exercises, investigations and analysis that can be done in groups or individually (12). data showed that: two-thirds of children say they know only an average amount or less about food, health and nutrition. two out of five children (40%) are more concerned about how much they eat than what kind of food they eat. only one-third (36.7%) of children believe it is important for their growth and health for them to have three main meals and in between snacks. only one in three children believes that without breakfast they “can’t learn as much”. only about half of children indicate meat and chicken as very good foods and one-third are uncertain about fat intake and health. about half of the children (47%), believe also that skipping breakfast can result in being less able to follow the lessons.  in albania a holistic and integrated approach is imperative to develop health promotion programs for children in the fight against childhood obesity, which aim to change behaviour rather than simply providing information alone (which often has little impact on what people do) as: the prevalence of overweight and obesity is still a public health problem in the country, with a rising trend among children 6-15 years old (from 21.7% in 2016 to 27.9% in 2018); overweight/obesity level is about 30% lower among children with good knowledge compared with children who exhibited poor knowledge about food, health and nutrition, the likelihood of consuming breakfast was 30% higher among normal weight children compared to their overweight/obese counterparts; this prevalence is higher in children from urban areas compared with rural areas, and among boys compared to the girls; moreover, obesity is a multifactorial disease where preventive interventions should address all causal factors. 2. focus on knowledge, attitudes and practices good nutrition education helps children to become “nutritionally literate”. children educated in this way will come to know how to make good foodand lifestylechoices and develop good eating habits for themselves and for others. nutritionally literate adults will know where to get answers to questions about food, diet and health. the value of nutrition education to the long-term development of a society is plain to see (15). nutrition education has the best chance of making a real impact if it involves action, direct experience and participation by the children; stimulates all their faculties; takes learning outside the classroom into real-life situations (15).  there is a need to promote healthy nutrition in school-aged children by focusing on behaviour, in addition to knowledge, especially regarding the consumption of those foods most important for children’s growth and development. while virtually all children recognize the importance of breakfast, on the measurement day only three out of five of hyska j. improving nutrition and health among albanian school children (policy brief). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5709 p a g e 6 | 9 children reported they had eaten breakfast. breakfast consumption in children (selfreported) is lower than the other main meals (71%, compared with 89% for lunch and 87% for dinner). there is a considerable proportion of children who do not consume milk on a daily basis, with a range 47%-65% (11). children’s positive attitudes toward healthy foods, healthy nutritional habits and health benefits do not often correlate with their nutritional practices (behaviours); they seem to know the benefits of eating fresh fruits and vegetables, with almost all of them saying that fruit is very good for their health (92%), actually less than three in five children consume fruits on a daily basis whereas vegetable consumption is far too lower (with a range: 20%30% in all three surveys). the tv is switched on during meals every day in 43% of the families. one third of children eats their dinner while watching tv, using a mobile phone, or tablet (37%) every day, or almost every day. 3. limit exposure to less healthy foods food marketing has a huge effect on children’s health. limiting the advertising of unhealthy foods to the maximum possible has been assessed as a very effective intervention to improve the food environment, promote good eating habits and reduce the problems caused by malnutrition.  it is important to assess the need for specific arrangements related to the advertising of unhealthy foods and to make recommendations that adequately address the prohibition of advertising of unhealthy food in the premises of basic education educational institutions, as: children in albania are a target group from unhealthy food advertisements (12). even some public schools (both urban and rural) allow some form of food and beverage advertisements in the school building or on the school grounds. although the legal framework in force has widely regulated the issue of food marketing, the standard regulation lacks regulations dedicated to food and nutrition of children (12).  it is crucial that schools provide food for children at school and control foods that are being bought by children to eat at school, limit exposure to less healthy food options, improve the nutritional quality of any foods sold in schools’ environments, and ensure that the healthy option is always available and the easier option, as: only one in three children (33%) takes food from home to eat at school every day or almost every day, much more frequent among children in the 4th grade and in those with a better family income. more than half of the children (58%) carry money to school for buying food, beverages, or lunch every day or almost every day, and one-fifth (22%) sometimes do; most schools have some kind of food shop, cafeteria or vending machine in the school vicinity or on the premises, from which adults and children can purchase foods. however, the quality of the foods offered is poor, consisting primarily of candies, hyska j. improving nutrition and health among albanian school children (policy brief). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5709 p a g e 7 | 9 chips, chocolates, or peanuts (81%), pies, pizza, or sandwiches (78%), and sweetened or fizzy beverages (73%). very few of these vendors offer fresh fruit, vegetables, milk or yoghurt. about half of schools do not provide children with access to drinking water, either free or for purchase. very few schools provide some form of meal or snack. only about 5% of parents confirm that their children eat food provided by the school. 4. increase parental awareness and involvement  it will be important to increase parental awareness and involvement that enables sustainable changes in support of healthy lifestyles, which could make poor nutrition prevention interventions more effective as: there were a significant association between breakfast consumption and the relationship with caregiver’s education: children of highly educated caregivers reported a higher prevalence of breakfast consumption compared with children with low-educated caregivers (16). the parental perception of the body image of their children was different from the actual nutritional status for all three conditions namely children who were thin, overweight, or obese in both studies. the parental perception gets marginalized for those who have overweight and especially obese children. consumption of fresh fruit and vegetables was significantly higher among children with highly educated parents. conclusions prevention policies focused on key factors such as healthy diet and regular physical activity are among the best investments in the personal well-being of a young european generation in good health (17).  these studies findings and respective recommendations can support the development of a national school food and nutrition education (sfne) programme in albania,  while there is evidence for the need to intervene at the national level, the stratified analysis at regional and district levels points to the need for the design and implementation of specific interventions at the local level.  it is also very crucial to strengthen and improve anthropometric nutrition and surveillance systems for nutritional risk factors for children and adolescents, and use the data obtained by these systems in effectively and appropriately. references 1. world health organization. nutrition. available from: https://www.who.int/healthtopics/nutrition (accessed: april 12, 2022). 2. food and agriculture organization of the united nations & world health organization. sustainable healthy diets guiding principles. fao and who; rome: 2019. available from: http://www.fao.org/3/ca6640en/ca 6640en.pdf (accessed: april 12, 2022). hyska j. improving nutrition and health among albanian school children (policy brief). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5709 p a g e 8 | 9 3. food and agriculture organization. incorporating nutrition considerations into development policies and programmes brief for policymakers and programme planners in developing countries. fao; 2004. available from: http://www.fao.org/docrep/007/y53 43e/y5343e00.htm#content (accessed: april 12, 2022). 4. clark jk, marquis c, raja s. the local food policy audit: spanning the civic-political agrifood divide. in: nourishing communities. springer international publishing; 2017:131-46. 5. unicef. national action plan for food and nutrition 2013-2020. available from: https://www.unicef.org/albania/rep orts/national-action-plan-food-andnutrition-2013-2020 (accessed: april 12, 2022). 6. global panel on agriculture and food systems for nutrition. healthy meals in schools: policy innovations linking agriculture, food systems and nutrition. policy brief no. 3. glopan; 2015. available from: https://glopan.org/sites/default/files /healthymealsbrief.pdf (accessed: april 12, 2022). 7. fao & who. conference outcome document: framework for action [online]. second international conference on nutrition, rome, 19–21 november 2014. available from: http://www.fao.org/3/amm215e.pdf (accessed: april 12, 2022). 8. un general assembly. transforming our world: the 2030 agenda for sustainable development. resolution adopted by the general assembly; 2015. available from: http://www.un.org/ga/search/view_ doc.asp?symbol=a/res/70/1&lan g=e (accessed: april 12, 2022). 9. world bank. school enrolment, primary, world. wb: washington, dc; 2018. available from: https://data.worldbank.org/indicato r/se.prm.nenr (accessed: april 12, 2022). 10. food and agriculture organization. school-based food and nutrition education – a white paper on the current state, principles, challenges and recommendations for lowand middle-income countries. fao; rome: 2020. available from: https://doi.org/10.4060/cb2064en (accessed: april 12, 2022). 11. albanian center for economic research (acer). nutritional status and nutrition-related knowledge, attitude and practices among school-children in albania. -in-depth analysis of three nationwide surveys conducted recently in albania. 12. albanian center for economic research (acer). background analysis on marketing of unhealthy foods: regulatory framework for the marketing of unhealthy food. 13. menza v, probart c. eating well for good health: lessons on nutrition and healthy diets. fao; 2013. available from: http://www.fao.org/3/i3261e/i3261 e00.htm (accessed: april 12, 2022). 14. dehghan m, akhtar-danesh n, merchant at. childhood obesity, prevalence and prevention. nutr j 2005;4:1-8. 15. food and agriculture organization. nutrition education in primary schools. vol. 1: the reader. fao; 2005. 16. institute of public health of albania. iniciativa e survejancës së obezitetit në moshën fëminore hyska j. improving nutrition and health among albanian school children (policy brief). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5709 p a g e 9 | 9 (cosi) në republikën e shqipërisë: rezultatet e vitit; 2016. [in albanian]. available from: http://ishp.gov.al/wpcontent/uploads/2015/04/raport i-obeziteti-tek-femijet.pdf (accessed: april 12, 2022). 17. council of the european union. healthy nutrition for children: the healthy future of europe 2018/c 232/01. available from: https://eur-lex.europa.eu/legalcontent/en/txt/pdf/?uri=cele x:52018xg0703(01)&from=en) (accessed: april 12, 2022). __________________________________________________________________________________________ © 2022 hyska; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. south eastern european journal of public health special volume no. 6, 2022 addiction & dependency contributions to a major health problem jacobs publishing house executive editor prof. dr. genc burazeri phd faculty of medicine, st. dibres, no. 371, tirana, albania, and caphri, faculty of health, medicine and life sciences, maastricht university, 6200 md, maastricht, the netherlands email: genc.burazeri@maastrichtuniversity.nl and: gburazeri@gmail.com skype: genc.burazeri volume editors dr. frank houghton email: frank.houghton@tus.ie section co-editor dr. lisa o’rourke scott email: lisa.orourkescott@tus.ie section co-editor assistant executive editor kreshnik petrela ba tirana, albania email: kreshnikp@gmail.com technical editor meri roshi ba tirana, albania email: meriroshi90@gmail.com publisher dr. hans jacobs jacobs publishing house am prinzengarten 1, d 32756 detmold, germany email: info@jacobs-verlag.de the publication of the south eastern european journal of public health (seejph) is organised in cooperation with the bielefeld university library. https://www.seejph.com/index.php/seejph/management/settings/context/mailto:genc.burazeri@maastrichtuniversity.nl https://www.seejph.com/index.php/seejph/management/settings/context/mailto:genc.burazeri@maastrichtuniversity.nl mailto:frank.houghton@tus.ie mailto:lisa.orourkescott@tus.ie https://www.seejph.com/index.php/seejph/libraryfiles/downloadpublic/126 https://www.seejph.com/index.php/seejph/management/settings/context/mailto:kreshnikp@gmail.com https://www.seejph.com/index.php/seejph/libraryfiles/downloadpublic/127 https://www.seejph.com/index.php/seejph/management/settings/context/mailto:urankurtishi@gmail.com mailto:info@jacobs-verlag.de https://www.ub.uni-bielefeld.de/ seejph south eastern european journal of public health www.seejph.com/ special volume 6, 2022 publisher: jacobs/germany issn 2197-5248 issn2197-5248 doi 10.11576/seejph-5770 bibliographic information published by die deutsche bibliothek. die deutsche bibliothek lists this publication in the deutsche nationalbibliografie; detailed bibliographic data is available on the internet at http://dnb.ddb.de south eastern european journal of public health (open access journal). copyright 2022 by jacobs publishing house: am prinzengarten 1, d 32756 detmold, germany copyright cover picture: wordpress foundation: http://wordpressfoundation.org/gnu general public license table of contents editorials utilising ‘new’ power strategies for public health education in addiction and dependency: learning from social media influencers lisa o’rourke scott case study the potential of men’s sheds as a resource for men coping with mental health challenges and addiction melinda heinz review article tribal communities and opioids margo hill position papers connecting the person by removing the stigma: why ireland should follow the portuguese model of drug decriminalization aisling finucane, jennifer moran stritch commentary researching gambling: have we learned nothing from big tobacco’s overt manipulation of science? frank houghton hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 1 | 9 review article tribal communities and opioids margo hill1 1) eastern washington university corresponding author: margo hill, associate professor, department of urban and region planning eastern washington university email: mhill86@ewu.edu hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 2 | 9 abstract american indians/ alaskan natives (ai/an) experience overdose rates higher than any other ethnic/ racial group in the us. in recent decades the opioid epidemic has had a particularly negative impact on ai/an populations. to respond effectively to this issue, it is vital to understand its root cause. a range of factors are responsible, with some dating back hundreds of years. the main factors are the impact of colonization and exclusion; forced migration to peripheral areas; forced removal of children and attempts at cultural genocide; poor social environments; poverty and unemployment; adverse childhood experiences; and inadequate and under-funded federal health services. particular blame can be attributed to the pharmaceutical industry and its active over-promotion of opioid use. a number of strategies for tackling this scourge are outlined. keywords: tribal communities, opioids, north america, pharmaceutical industry hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 3 | 9 in 2015, american indian and alaskan natives (ai/an) had the highest drug overdose rates of any population in the united states (1). the opioid mortality rates from ai/an populations have risen almost continuously for nearly two decades and are comparable to the mortality rates of nonhispanic whites that are often cited as the highest ethnic or racial group (2). as we look at the data, experts believe that the ai/an drug overdose rates may be underestimated by as much as 35% due to race, ethnicity, and misclassification on death certificates (1). according to the northwest portland area indian health board, the death rate from drug overdose among american indian & alaska natives (ai/an) in washington state was 43.1 per 100,000 people in 2016 (3). this rate was almost 3 times the national ai/an rate and the washington state average. while the overall overdose death rate in washington state has remained relatively stable since 2007, the rates for ai/an in washington has increased 36% since 2012, and almost 300% since 2000. in terms of polysubstance deaths of ai/an in washington state in 2014-16, almost half of the drug overdose deaths involved more than one drug, and a third involved more than one opioid. common combinations included deaths involving cocaine and an opioid. in 74% of deaths from overdose the deceased had used a deadly combination of cocaine and opioids (3). moreover, 59% of deaths involving methamphetamine (‘meth’) involved an opioid, and 17% of deaths involving heroin also involved a prescription opioid (3). what are the underlying causes of this disproportionate impact of opioid abuse and substance abuse on ai/an? in our tribal communities we know the reasons why tribal people struggle with substance abuse and particularly opioids. the united states government inflicted colonization and federal indian policies that were devastating to tribal communities. brave heart and debruyn discuss how the u.s. government enacted a range of punitive policies such as: removing native children from native homes to boarding schools; forced assimilation through relocation to urban centers; and termination of tribal governments (4). all such policies have had long lasting negative impacts on american indians and disrupted tribal family systems. for american indians the united states was the ‘perpetrator’ of their holocaust (4). ai/an continue to deal with historical trauma and loss of culture which lends itself to substance abuse disorders. unresolved historical grief and trauma that ‘...contributes to the current social pathology of high rates of suicide, homocide, domestic violence, child abuse, alcoholism, and other social problems among american indians’ (4). these government inflicted policies have placed tribal communities in disadvantaged circumstances such as the geographic location of american indian reservations. the european white settlers moved onto and claimed the most fertile lands, and reservations were created in remote, geographically less viable locations. leonard, parker and anderson found that land designations were not randomly selected and instead were chosen to avoid conveying highvalue agricultural land to native americans (5). this contributes to high rates of poverty, unemployment and lack of opportunity (6). ai/an still struggle to gain a foothold in mainstream america. although some members of tribal communities successfully navigate society and gain education and employment, many members still struggle. according to a recent survey by adamsen et al. one-in-four ai/ans live in poverty, and tribal communities report the lowest hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 4 | 9 employment rate nationally (7). the policies of the united states government such as boarding schools and welfare systems that continued to remove children from ai/an homes until the late 1970s were particularly hard on tribal families and disrupted family systems of child rearing. native american children were forced to go to boarding schools, ai/an culture was seen as a problem and the purpose of these schools was forced assimilation (4) as a result of forced assimilation and relocation, we have broken families that often lead to relationship difficulties. the federal governments’s indian policies disrupted tribal cultural systems, took children away from their families, and often resulted in historical trauma, leading to an increased prevalence of substance abuse. why are there higher rates of substance use disorders (sud) amongst ai populations? brave heart & debruyn unequivocally outline the causes as ‘...an outcome of internalized aggression, internalized oppression, and unresolved grief and trauma’ (4). there are many root causes of substance abuse disorders and all tribal communities are different, depending on their history, location and resources. however, one leading cause is our social environment: social influences; peer influence; social policies; availability of illicit substances; and family systems. in much of the country, the counties with the lowest levels of social capital have the highest overdose rates (8). these are all mechanisms that are responsible for the adoption maintenance and maintenance of addictions in our communities. we also see in our tribal communities that our young people start alcohol and substance abuse at a relatively young age. swaim and stanley note that early initiation for american indian youths include increasing rates of use in early and later adulthood, higher risk of developing a substance use disorder (9). for our tribal communities, social influence, our families, our cousins and friends, are very powerful influences. another indicator of substance abuse are adverse childhood experience (aces), such as exposure to alcoholism, drug abuse, domestic violence, emotional neglect, incarceration of a parent, physical or sexual abuse (10). toxic stress from aces can change brain development and affect how body responds to stress and are linked to substance misuse in adulthood (11). these adverse childhood experiences lead to higher risk of addiction. again, many of these issues can be traced back to lack of control, and lower levels of certainty, as a result of government policies that dominated the lives of american indians and alaskan natives. as a result of loss of ancestral lands and loss of cultural identity, we often see that life on reservations can result in dire poverty and hopelessness (12). decker discusses the chaos of many american indian families that can lead to addiction, mental health issues, domestic violence and suicide (12). these issues are passed from generation to generation, leading to an intense need to escape the pain and loss. often substances provide an escape by numbing the pain (12). opioids have been described as providing an escape and a euphoria that washes over you, taking away both physical and emotional pain (13). opioids disrupt the natural reward system by flooding the brain with large amounts of dopamine. when people are addicted to opioids and do not have the opiates, they experience uncontrollable cravings which persists even after they stop taking the opioid (13,14) opioid drugs target the brain’s pleasure center, where we have a natural source of dopamine. this is usually triggered by things that we enjoy such as hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 5 | 9 food, sex or music; ‘dopamine triggers a surge of happiness. when the dopamine rolls into amygdala, the brain’s fear center, it relieves anxiety and stress. both of these events reinforce the idea that opioids are rewarding’ (15). it has been described to this author as being like ‘fireworks going off’. how does opioid abuse start? prescription painkillers like hydrocodone, oxycodone, percocet, vicodin, morphine, codeine, and fentanyl are all substances that have been overprescribed by doctors and led to dependency and abuse (16) for tribal elders, perhaps they were prescribed oxycodone after a heart attack, such as in my dad’s case. for younger people, like my nephew in his 20s, the first time they were prescribed opiates may have been after a simple dental procedure. we know that pharmaceutical companies were marketing the right to be pain free. purdue pharma’s sales reps ‘fanned out to evangelized doctors and dentists with a message: prescribing oxycontin for pain was the moral, responsible and compassionate thing to do’ (17). drug companies targeted primary care doctors and ads promoted long-term pain relief. they falsely stated that the risk of addiction was rare. purdue pharma’s david haddox claimed that oxycontin was safe with addiction rates less that 1 percent (17). prescribing doctors were encouraged to use pain as the fifth vital sign and seek to improve pain management (17,18). this led to a dramatic overprescribing of pain pills (17). often expensive surgeries that are needed by tribal members are not funded by the indian health service (his), and hence people have little alternative but to mask their pain with opioids. american indian tribes ceded their lands to the united states government with two primary promises: healthcare and education (4). by ceding their land they essentially prepaid for their healthcare. the united states government has a legal obligation to provide health services for native people. this obligation is the result of treaties between the federal government and native nations, as well as federal statute (19). however, the indian health service (ihs) is never adequately funded. many the specialized healthcare needs and surgeries needed are not funded and people have little option therefore but to mask their pain and discomfort with medications, such as opioids. opioids are also more likely to be prescribed in counties with more uninsured people (20), and those that have insurance may find that prescription narcotics are more reliably covered than other medical interventions (21). in the us surgery is often considered too costly for economically depressed and low density populations (22). insurance companies often disapprove medical procedures and approved prescribed pain medications. compounding these factors, indian health clinics are severely underfunded (19). tribal clinics are placed on priority one status which means you can only get coverage for a procedure only when life and limb are at immediate risk. this means when local ihs facilities cannot provide needed services for patients, they may contract out to private health care centers through the contract health services (chs) program. it should be noted that only american indians who live on the reservation are eligible for contract health services. sick or injured patients with contract health who are not covered for treatment of the cause of pain instead receive options to manage it, and are often prescribed opioids. indian health service physicians, like many american physicians, were also sold the right to be ‘pain free’ concept, and thus readily dispensed opioid prescriptions to patients. in hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 6 | 9 indian country it is cheaper to prescribe pain pills than to get the necessary surgery for a back injury or a knee injury. we see opioid significant levels of misuse in rural areas. health care challenges are compounded due to a shortage of primary care providers and thus opioids are again prescribed more commonly in rural areas (18,19,22,23). as well as the impact of social environments, the impacts of genetics and physiology on addiction cannot be ignored. the role of genetics is clear in alcoholism is clear. there is a higher risk ratio for individuals when a high number of their relatives have alcohol abuse issues. (24). other traditional markers that we consider in looking at substance abuse are severity and tolerance. the need for more of the substance is an indicator that there is a problem. you need more of the substance to get the same affect. a commonly used term for opioid withdrawal is ‘dopesick’ (17). one us law firm filing a class action stated ‘long-term opioid use changes the way nerve cells work in the brain. opioids create artificial endorphins in the brain, which bind the brain’s opioid receptors producing euphoric effects and providing pain relief. opioids trick the brain into stopping production of endorphins. when this happens, users experience excruciating withdrawal symptoms’ (25) . an addict will tell us that the physiological pain of not having the pills is unbearable and leads to intense drug seeking behavior. in opiate withdrawal, when a dose is not taken, the body experiences painful symptoms such as vomiting, sweating, nausea, runny nose, dilated pupils, watery eyes, anxiety, insomnia, physical pain and constipation (26). what does the opioid do to your body? it has many effects and is similar to heroin or the morphine molecule, especially when taken in ways other than prescribed by the doctor. opioid pills can be melted down, smoked, or injected intravenously. many addicts started by snorting the pills, before moving on to ‘routinely injecting the liquified crushed-up powder with livestock syringes they bought (or stole) from local feed stores’ (17). there have been three waves of drug use in recent years; first, prescriptions like oxycontin became widespread and abused. tribal leaders and health care providers became aware of the opioid abuse and began restrictive policies controlling prescriptions. they monitored opioid prescriptions via databases on nearby reservations and offreservation (27). second, once access and prescriptions were restricted addicts turned to illicit street drugs like heroin. around 2013, there was an increase in synthetic opioids like fentanyl. a particular danger with such drugs is that people can overdose when they start ‘using’ again after having experienced a period of abstinence, due to factors such as treatment or jail time (23). how do we stop opioid abuse in tribal communities? (28) in my experience as a tribal attorney for 10 years, it often comes in the form of providing consequences to those abusing drugs. consequences include going to jail, the removal of children, job loss, and being ordered to attend treatment. the hope is that once the addict is not using they will be able to detox and get out of the cycle of addiction and drug seeking behaviors. if abusers are not able to get out of the cycle of addiction they will likely end up in jail, or overdose, or end up dead. however, even when people want to get clean and sober the continuing challenges of finding employment, housing and accessing outpatient treatment programs can be significant barriers (28). however, we are now seeing illicit opioids like heroin becoming more accessible. in tribal communities, there are numerous stressors, including distress, sadness and hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 7 | 9 poverty. our tribal governments struggle to provide treatment that combines holistic tribal cultural healing practices, alongside western biomedical science and treatment grounded in evidence-based practices. the social determinants of addiction are significant and include: economic opportunity; poverty level; substance availability; genetic predisposition; mental health condition;self-image; substance use among family and friends; family conflict/abuse; and level of supervision. it is an unfortunate reality that all of these factors are significant issues in tribal communities (29,30). the environmental factors of stress, trauma and pain often lead to experimentation with opioids, and later to cycles of dependence. tribal governments, like states, counties and cities have expended millions of dollars of precious resources towards addressing the opioid epidemic. as judge polster, of n.d. ohio federal district court stated ‘everyone shares some of the responsibility, and no one has done enough to abate it. this includes the manufacturers, the distributors, the pharmacies, the doctors, the federal government and the state government, local governments and hospitals’ (31). references 1. mack ka, jones cm, ballesteros mf. illicit drug use, illicit drug use disorders, and drug overdose deaths in metropolitan and nonmetropolitan areas—united states. am j transplant. 2017;17:3241–3252. 2. tipps rt, buzzard gt, mcdougall ja. the opioid epidemic in indian country. j law med ethics. 2018;46:422–436. 3. northwest portland area indian health board. american indian & alaska native opioid & drug overdose data brief. accessed on 22nd june 2022 at: https://www.nihb.org/docs/04092020 /washington%20opioid%20&%20d rug%20overdose%20data%20brief. pdf 4. brave heart my, debruyn lm. the american indian holocaust: healing historical unresolved grief. american indian and alaska native mental health research. 1998;8(2):56–78. 5. leonard, b., parker, d. and anderson, t., land quality, land rights, and indigenous poverty november 2018. accessed june 21, 2022 at: https://aae.wisc.edu/dparker/wpcontent/uploads/sites/12/2018/11/le onard-parker-anderson-11-1318.pdf 6. 2005 bureau of indian affairs american indian population & labor force report. accessed june 21st at: https://www.bia.gov/sites/default/file s/dup/assets/public/pdf/idc001719.pdf. 7. adamsen c, schroeder s, lemire s, carter p. education, income, and employment and prevalence of chronic disease among american indian/alaska native elders. preventing chronic disease. 2018;15:e37. https://doi.org/10.5888/pcd15.17038 7 8. zoorob mj, salemi jl. bowling alone, dying together: the role of social capital in mitigating the drug overdose epidemic in the united states. drug alcohol depend. 2017;173:1–9. 9. swaim rc, stanley lr. substance use among american indian youths on reservations compared with a https://www.nihb.org/docs/04092020/washington%20opioid%20&%20drug%20overdose%20data%20brief.pdf https://www.nihb.org/docs/04092020/washington%20opioid%20&%20drug%20overdose%20data%20brief.pdf https://www.nihb.org/docs/04092020/washington%20opioid%20&%20drug%20overdose%20data%20brief.pdf https://www.nihb.org/docs/04092020/washington%20opioid%20&%20drug%20overdose%20data%20brief.pdf https://aae.wisc.edu/dparker/wp-content/uploads/sites/12/2018/11/leonard-parker-anderson-11-13-18.pdf https://aae.wisc.edu/dparker/wp-content/uploads/sites/12/2018/11/leonard-parker-anderson-11-13-18.pdf https://aae.wisc.edu/dparker/wp-content/uploads/sites/12/2018/11/leonard-parker-anderson-11-13-18.pdf https://aae.wisc.edu/dparker/wp-content/uploads/sites/12/2018/11/leonard-parker-anderson-11-13-18.pdf https://www.bia.gov/sites/default/files/dup/assets/public/pdf/idc-001719.pdf https://www.bia.gov/sites/default/files/dup/assets/public/pdf/idc-001719.pdf https://www.bia.gov/sites/default/files/dup/assets/public/pdf/idc-001719.pdf https://doi.org/10.5888/pcd15.170387 https://doi.org/10.5888/pcd15.170387 hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 8 | 9 national sample of us adolescents. jama network open. 2018; 1(1), e180382. https://doi.org/10.1001/jamanetwork open.2018.0382 10. aces public-private initiative (appi). appi the washington state aces public-private initiative. accessed 22nd june 2022 at: https://www.appi-wa.org/ 11. centers for disease control and prevention. adverse childhood experiences (aces). accessed on 22nd june 2022 at: https://www.cdc.gov/vitalsigns/aces/i ndex.html 12. care + advocacy. fighting opioid abuse in indian country. accessed on 22nd june 2022 at: https://cqrcengage.com/ahca/app/doc ument/17521408;jsessionid=1cs3uol zxj8ptapahmdde2daw 13. bechara a, berridge kc, bickel wk, morón ja, williams sb, stein js. a neurobehavioral approach to addiction: implications for the opioid epidemic and the psychology of addiction. psychological science in the public interest. 2019;20(2): 96–127. 14. shah m, huecker mr. opioid withdrawal. [updated 2022 mar 7]. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2022 jan-. available from: https://www.ncbi.nlm.nih.gov/books/ nbk526012/ 15. akpan, n., griffin j., how a brain gets hooked on opioids. accessed june 21, 2022 at: https://www.pbs.org/newshour/scien ce/brain-gets-hooked-opioids.. 16. shepherd j. combating the prescription painkiller epidemic: a national prescription drug reporting program. american journal of law & medicine. 2014;40(1):85-112. 17. macy b. dopesick: dealers, doctors, and the drug company that addicted america. boston, ma: little, brown and company; 2018. 18. scher c, meador l, van cleave jh, reid mc. moving beyond pain as the fifth vital sign and patient satisfaction scores to improve pain care in the 21st century. pain manag nurs. 2018 apr;19(2):125129. 19. soeng n, chinitz j. native health underfunded & promises unfullfilled. accessed june 21 2022 at: https://www.allianceforajustsociety.o rg/wpcontent/uploads/2021/07/nativehealth-underfunded.pdf. 20. cdc. 2018. prescription opioid data. accessed on 22nd june 2022 at: https://www.cdc.gov/drugoverdose/d eaths/prescription/index.html 21. gounder c. “who is responsible for the pain-pill epidemic." the new yorker, 8th novemnber, 2013. accessed on 22nd june 2022 at: https://www.newyorker.com/busines s/currency/who-is-responsible-forthe-pain-pill-epidemic. 22. meldrum ml. the ongoing opioid prescription epidemic: historical context. am j public health. 2016;106:1365. 23. dasgupta n, beletsky l, ciccarone d. opioid crisis: no easy fix to its social and economic determinants. american journal of public health. 2018;108(2):182-186. 24. diclemente c. addiction and change: how addictions develop and addicted people recover. new york: guilford press; 2006. https://www.allianceforajustsociety.org/wp-content/uploads/2021/07/native-health-underfunded.pdf https://www.allianceforajustsociety.org/wp-content/uploads/2021/07/native-health-underfunded.pdf https://www.allianceforajustsociety.org/wp-content/uploads/2021/07/native-health-underfunded.pdf https://www.allianceforajustsociety.org/wp-content/uploads/2021/07/native-health-underfunded.pdf hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 9 | 9 25. skikos. the opioid crisis. accessed on 22nd july 2022 at: https://skikos.com/the-opioid-crisis/ 26. pergolizzi jv jr, raffa rb, rosenblatt mh. opioid withdrawal symptoms, a consequence of chronic opioid use and opioid use disorder: current understanding and approaches to management. j clin pharm ther. 2020;45(5):892-903. 27. martinez, marcus. personal interview; 2017. 28. whelshula m, hill m, galaitsi se, et al. native populations and the opioid crisis: forging a path to recovery. environ syst decis. 2021;41(3):334340. 29. mckenzie ha, dell ca. fornssler b. understanding addictions among indigenous people through social determinants of health frameworks and strength-based approaches: a review of the research literature from 2013 to 2016. curr addict rep. 2016;3:378–386. 30. park-lee e, lipari rn, bose j, et al. substance use and mental health issues among u.s.-born american indians or alaska natives residing on and off tribal lands. cbhsq data review. 2018; july:1-40. 31. dayton daily news, the federal judge handling the mdl, judge dan aaron polster in the northern district court of ohio, https://www.daytondailynews.com/n ews/butler-county-opioid-lawsuitpart-global-effort-endepidemic/pht0r5tkyfw5iohpcgllxo ____________________________________________________________________________________ © 2022 hill; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://skikos.com/the-opioid-crisis/ jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 1 original research the dutch long-term care reform: moral conflicts in executing the social support act 2015 wesley jongen1, peter schröder-bäck1, jos mga schols2 1 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, the netherlands; 2 department of health services research and department of family medicine, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, the netherlands. corresponding author: wesley jongen, phd, department of international health, maastricht university; address: po box 616, 6200 md, maastricht, the netherlands; telephone: +31433882204; email: w.jongen@maastrichtuniversity.nl jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 2 abstract on 1 january 2015, a new long-term care reform entered into force in the netherlands, entailing amongst others a decentralization of long-term care responsibilities from the national government to the municipalities by means of a new law: the social support act 2015. given the often disputed nature of the reform, being characterized on the one hand by severe budget cuts and on the other hand by a normative reorientation towards a participation society, this article examines to what extent municipalities in the netherlands take (potential) moral conflicts into account in their execution of the social support act 2015. in doing so, the article applies a ‘coherentist’ approach (consisting of both rights-based and consequentialist strands of ethical reasoning), thereby putting six ethical principles at the core (non-maleficence & beneficence, social beneficence, respect for autonomy, social justice, efficiency and proportionality). it is argued that while municipalities are indeed aware of (potential) moral conflicts, the nature of the new law itself leaves insufficient room for municipalities to act in a sufficiently proactive and supportive/empowering manner on these challenges. keywords: ethical reasoning, long-term care reform, moral conflicts, the netherlands. conflicts of interest: none. jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 3 introduction background in 2006, the council of the european union made reference to “a set of values that are shared across europe” in its ‘council conclusions on common values and principles in european health systems’ (1). the council conclusions stipulate that “[t]he health systems of the european union are a central part of europe's high levels of social protection, and contribute to social cohesion and social justice as well as to sustainable development. the overarching values of universality, access to good quality care, equity, and solidarity have been widely accepted in the work of the different eu institutions” (1). this set of values was subsequently reinforced a year later in the european commission’s ‘white paper together for health: a strategic approach for the eu 2008-2013’ (2), comprising the eu’s health strategy supporting the overall ‘europe 2020’ strategy (3). the healthcare sector, and more specifically the long-term care sector, has always been a source for ethical debate. typical ethical issues (or moral conflicts) in long-term care decision-making include the debate on whether we should only look at people’s deficits or also to their rest capacities (4),“the nature and significance of the elder's diminished capacity for self-care and independent living”, the question “whether an older adult should continue to live at home”, “the obligation of the elder to recognize and respect the limits that family members may justifiably set on their care giving responsibilities”, a loss of autonomy “when the decision is made to change either the elder’s place of living or support services” and “the balance to be struck between independence and safety” (5). however, as argued by ranci and pavolini (6), “[o]ver the past two decades, many changes have happened to the social welfare policies of various industrial countries. citizens have seen their pensions, unemployment benefits, and general healthcare policies shrink as ‘belt tightening’ measures are enforced”. at the same time, ranci and pavolini (6) argue, “longterm care has seen a general growth in public financing, an expansion of beneficiaries, and, more generally, an attempt to define larger social responsibilities and related social rights”. consequently, pavolini and ranci (7) conclude that “[f]aced with the problems associated with an ageing society, many european countries have adopted innovative policies to achieve a better balance between the need to expand social care and the imperative to curb public spending”. the adoption of such innovative policies is referred to here as reforms in longterm care policies. the unfold of long-term care reforms even seems to be exacerbated in the aftermath of the 2008 economic crisis, when many european countries introduced austerity measures that in many cases appeared to have adverse effects on health systems and/or social determinants of health (8-12). moreover, schröder-bäck et al. argue that “[t]he current protracted economic crisis is giving rise to the scarcity of public health resources in europe. in response to budgetary pressures and the eurozone public debt crisis, decision makers resort to a shortterm solution: the introduction of austerity measures in diverse policy fields. health and social policy tend to be easy targets in this regard, and budget cuts often include a reduction of healthcare expenditure or social welfare benefits” (13). jongen et al. (14) add to this that “this crisis has had a much more direct and short-term influence on the quality of countries’ long-term care system than more gradual developments such as population aging and declining workforces, mainly due to austerity measures being the result of, or being accelerated by, this crisis”. also the council conclusions make reference to this changing context of many european countries’ long-term care system, by stating that “[i]t is an essential feature of all our systems that we aim to make them financially sustainable in a way which safeguards these values into the future” (1). moreover, the document stresses patient empowerment, by stating that “[a]ll jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 4 eu health systems aim to be patient-centred. this means they aim to involve patients in their treatment, to be transparent with them, and to offer them choices where this is possible, e.g. a choice between different health care service providers” (1). at the same time, the council conclusions acknowledge that “[d]emographic challenges and new medical technologies can give rise to difficult questions (of ethics and affordability), which all eu member states must answer. […] all systems have to deal with the challenge of prioritising health care in a way that balances the needs of individual patients with the financial resources available to treat the whole population” (1). although sharing some characteristics, every long-term care reform is embedded within peculiar national traditions and is therefore unique. this is true all the more for the latest dutch long-term care reform, that entered into force on 1 january 2015, and which can be considered as the latest major step in a more all-encompassing ‘market-oriented reform’ of the dutch healthcare system in general. the 2015 reform can be characterized as having a “hybrid structure” (15), characterized, on the one hand, by a “reign in expenditure growth to safeguard the fiscal sustainability of ltc” (16), and on the other hand by a “multiplicity of regulations to safeguard public values” (15). more concretely, as argued by maarse and jeurissen (16), the 2015 long-term care reform consists of four interrelated pillars: expenditure cuts, a shift from residential to non-residential care, decentralization of nonresidential care (implying a transfer of responsibilities in that policy domain from the national government to the municipalities), and a normative reorientation. the latter refers to the notion that “[u]niversal access and solidarity in ltc-financing can only be upheld as its normative cornerstone, if people, where possible, take on more individual and social responsibility. the underlying policy assumption is that various social care services may be provided by family members and local community networks” (16). indeed, a general shift in focus from formal care provision to informal care provision is added by jongen et al. (17) as a key element of the 2015 dutch long-term care reform. it is, however, exactly this normative reorientation, and its underlying assumption of an increased informal care provision, that is often disputed. as argued by maarse and jeurissen (16): “an important line of criticism is not only that informal care is already provided at a large scale, but also that the potential of ‘unexplored’ informal care is overestimated. furthermore, the negative externalities for caregivers who deliver informal care are underestimated”. moreover, while residential care remains under the responsibility of the national government after the entry into force of the 2015 long-term care reform, and a large part of non-residential care came under the responsibility of the health insurers, it is the municipalities that became under the social support act 2015 (ssc 2015) [in dutch: wet maatschappelijkeondersteuning (wmo) 2015] responsible for particularly those parts of non-residential care dealing with support directed towards the social participation of people with severe limitations (in the wordings of the official legal text of the social support act 2015 (authors’ own translation): “people with disabilities, chronic mental or psychosocial problems”), as well as with support for informal caregivers (17). indeed, the official legal text of the social support act 2015 stipulates that “citizens who themselves or together with people in their immediate environment are not sufficiently self-sufficient or insufficiently able to participate [in society], must be able to rely on organized support by the government” (authors’ own translation). however, municipalities have a large discretion in making this obligation to provide support concrete (the so-called ‘postcode [zip code] rationing’), which may lead to unequal access to long-term care in different municipalities (16). literature research so far, the academic literature has not extensively scrutinized the potential moral conflicts resulting from the implementation of the social support act 2015, and is more about jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 5 organization and logistics than about ethics. the available literature either touches upon mere elements of an all-encompassing ethical debate, or upon the perspective of specific groups. as an example of the former, van der aa et al. (18) consider the presumed impact of the 2015 long-term care reform on such elements as good quality of care and solidarity. van der aa et al. argue that the above-mentioned ‘zip code rationing’ might well lead to differences between municipalities in the degree of solidarity as perceived by citizens (‘zip code solidarity’). furthermore, van der aa et al. argue that it should not be taken for granted that municipalities, by simply making an efficiency move, can guarantee an equal level of care quality with the decreased budget they are faced with for executing their new long-term care tasks. next, grootegoed and tonkens (19) consider the impact of the dutch shift in focus from formal to informal care provision on such elements as respect for autonomy or human dignity and argue that “the turn to voluntarism does not always prompt recognition of the needs and autonomy of vulnerable citizens” and furthermore that “the virtues of voluntarism may be overstated by policy makers and that the bases of recognition should be reconsidered as welfare states implement reform”. examples of literature focusing on the perspective of specific groups include the articles by dwarswaard et al. (20) and dwarswaard and van de bovenkamp (21) on, respectively, self-management support considered from the perspective of patients and the ethical dilemmas faced by nurses in providing self-management support (whereby self-management is defined as “the involvement of patients in their own care process” (21), and in that way relates to the above-mentioned notion of individual responsibility). study objectives and research questions no comprehensive ethical approach towards the impact of the social support act 2015, however, appears yet to exist. the current study intends to fill in this gap, by answering the following research question: to what extent did/do municipalities in the netherlands take potential moral conflicts into account when implementing and executing the social support act 2015? as the core of the 2015 dutch long-term care reform is characterized by, on the one hand, severe budget cuts, and, on the other hand, by a normative reorientation towards a participation society wherein people are expected to take on more individual and social responsibility (16,17), we additionally formulated the following sub-research questions: 1. how do municipalities divide scarce resources in the social domain in a fair way?; 2. how do municipalities empower citizens towards a participation society? in answering both research questions we consider the potential moral conflicts experienced by municipalities, as executers of the social support act 2015, with regard to those entitled (or proclaim to be entitled) to receive support on the basis of the social support act 2015, as well as with regard to relatives providing informal care to the previous group. despite the fact that the nature, as well as corresponding reforms, of individual countries’ long-term care systems differ, the systematic approach of assessing moral conflicts resulting from the introduction of new longterm policies as applied in this study could also be transferred to other countries were longterm care reforms are being implemented. at the same time, several policy lessons could be derived from the experiences of dutch municipalities with the 2015 long-term care reform. methods research method and study design to answer our research question, a mixed-method research approach was chosen. first, a document analysis was conducted, in order to explore if, and to what extent, ethical values and principles are literally incorporated in the legal text of the social support act 2015. for jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 6 this analysis we only considered the primary source (the legal text itself) and no other, secondary documents (such as municipal policy documents). second, policy advisors (responsible for the long-term care policy domain) of all 390 dutch municipalities were invited to complete anonline survey. henceforth, no sampling technique had to be applied, although of course we had to compile a mail distribution listconsisting of either the general email addresses of municipalities, or the e-mail addresses of the specific departments the intended policy advisors are working. in some smaller municipalities these policy advisors were not only responsible for the long-term care policy domain, but for the whole social domain (next to the long-term care decentralization, municipalities were simultaneously also faced withdecentralizations in the field of youth care and in the field of labor participation of people with an occupationaldisability); in large municipalities more than one person might be responsible for the long-term care policy domain. however, in our explanatory notes we specifically asked to forward our demand to one of the intended policy advisors, in order to avoid multiple respondents from the same municipality. the reason for choosing policy advisors, instead of politicians, had to do with the potential political bias that politicians might have with regard to the topic of this study. indeed, the potential ethical implications surrounding the long-term care decentralization constitutes a politically sensitive issue in many municipalities, as clearly came to the forefront in one of the two test-interviews, which was conducted with the major of a municipality (the other test-interview was conducted with a professor of old age medicine). moreover, while each municipality also has several socalled ‘social support act consultants’ [in dutch: wmoconsulenten], who do the actual fieldwork, implying the one-to-one contact with individual (potential) clients, these employees are believed to lack an overarching helicopter view. in principle, participation in the online survey was anonymous, except when a respondent declared to be willing to participate in an in-depth telephonic interview. these in-depth interviews constituted the third step in our mixed-method research approach, and were intended to expand on the survey, instead of asking new questions. anonymity of these respondents has been guaranteed by omitting persons’ and municipalities’ names here. theoretical framework and conceptual model for the analysis of the potential moral conflicts surrounding the implementation and execution of the social support act 2015, we applied a ‘coherentist’ approach(consisting of both rights-based and consequentialist strands of ethical reasoning) as offered by schröderbäck et al. (22), thereby putting six ethical principles at the core that are considered to capture the specificities of the current study (non-maleficence & beneficence, health maximisation / social beneficence, respect for autonomy, social justice, efficiency and proportionality). taking into account the variety of seemingly similar concepts such as ‘ethical dilemmas’, ‘moral conflicts’, ‘moral dilemmas’, et cetera, it should however first be clarified which definition is applied in this study and what is meant with it. given the heavily-loaded connotation of the term ‘ethical dilemma’, we prefer the term ‘moral conflict’ here. subsequently, based on the stanford encyclopaedia of philosophy (23), we define a ‘moral conflict’ as follows: a moral conflict appears if one thinks one has good moral reasons to do one thing, but also good moral reasons to not do it, or do something that is in conflict with it. so either decision is not perfect. or, in other words: a moral conflict arises if the moral norms and values we would like to follow guide us to conflicting/opposing actions. a coherentist ethical approach, then, implies that an ethical analysis “should be based on a variety of plausible norms and values” and that none of the traditional ethical approaches is therefore superior to the other (22). instead, they all contribute important moral insights. schröder-bäck et al. (22) add to this that “their norms do weigh prima facie the same and need to be plausibly unfolded and specified in a given setting. when they are contextualised jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 7 and specified they develop their normative weight and power”. this prima facie status of the ethical principles thus “supports the process of careful ethical deliberation and reflection”. moreover, specifying the more ‘overarching’ ethical approaches into a concise set of ethical principles is considered as a useful, practical, tool for medical and public health ethics (24). each of these six principles will be discussed in detail in the following. non-maleficence and beneficence: non-maleficence implies that “a healthcare professional should act in such a way that he or she does no harm, even if her patient or client requests this” (25). beneficence is connected to non-maleficence, the only difference being that nonmaleficence involves the omission of harmful action and beneficence actively contributes to the well-being of others (25). because of their intimate connection, both principles are considered under one heading here. considering the overarching approaches to ethical reasoning as mentioned above, the principles of non-maleficenceand beneficencecorrespond to the ‘do no harm’ principle under the consequentialist approach to ethical reasoning. health maximisation / social beneficence: although in the literature one can find either of these terms, we refer to social beneficence as the norm that says that it is a moral goal to improve the wellbeing of people on an aggregated population level. social beneficence resembles in a significant way the consequentialist principle of utilitarianism. utilitarianism is the ethical theory that requests from an action or omission to be in such a way that the maximization of best consequences would follow. respect for autonomy: the ‘respect for autonomy’ principle implies a tempering of the “paternalistic benevolence contained in the principles of non-maleficence and beneficence” (25). in that way, the ‘respect for autonomy’ principle is closely related to the ‘human dignity’ principle under the rights-based approach to ethical reasoning. moreover, without taking into account the ‘respect for autonomy’ principle, it would under the principle of health maximisation / social beneficence alone be allowed “to use individuals (or whole groups) for other than their own ends and even sacrifice them if only this provided a greater net benefit, i.e. maximised health” (24). social justice: the principle of (social) justice as referred to under the rights-based approach to ethical reasoningcan be considered another side constraint to the principle of health maximisation / social beneficence. as schröder-bäck et al. (24) put it: “it does not only matter to enhance the net-benefit; it also matters how the benefits and burdens are distributed”. moreover, this also includes “a fair distribution of health outcomes in societies, which is often discussed in terms of public health as ‘health equity’” (25), which is considered by daniels as a matter of fairness and justice (26). in fact, the principle of ‘equity’ constitutes the core of the values of the ‘council conclusions on common values and principles in european health systems’. as schröder-bäck et al. (22) put it: “the other three overarching values can be conceptualised as specifications of equity (and of social justice). access to good quality of care and universality can be seen as a reiteration of the core demands of equity and justice”, while “solidarity is seen as a characteristic that describes the willingness of members of communities to be committed to the principle of justice or to each other”. in short, one could argue thus that “[j]ustice approaches in health care often demand nothing more than universal access to good quality care” (22). or, as the world health organization (who) puts it: “universal health coverage (uhc) is defined as ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship” (27). efficiency: efficiency requires the efficient use and distribution of scarce health resources (24). jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 8 proportionality:the principle of proportionality, finally, emphasizes that it is “essential to show that the probable public health benefits outweigh the infringed general moral considerations. all of the positive features and benefits must be balanced against the negative features and effects“ (24). in their ‘ethical criteria for immunization programmes’, verweij and dawson (28) combine the principles of efficiency and proportionality under one heading, by stating that a “programme’s burden/benefit ratio should be favourable in comparison with alternative […] options”. data collection for the document analysis, we specifically considered the presence of the values as stipulated by the ‘council conclusions on common values and principles in european union health systems’, as well as the six ethical principles elaborated on above. next, for the survey and in-depth interviews, these principles have been broken down into representative survey/interview questions, allowing for a structured and comparative analysis of potential moral conflicts. schröder-bäck et al. (25) applied a similar approach within the context of developing a curriculum for a short course on ethics in public health programmes, by suggesting a checklist consisting of several questions around each of the ethical principles they applied in their study (largely comparable to the six principles as applied in the current study). with the respective author of that study, one question for each of the above six principles was chosen, adapting them to the specificities of the current study, and translated into dutch (see table 1 for the final survey/interview questions). the reason for choosing merely one question per category had to do with the practical limitations of using open-ended questions in an online survey: based on andrews (29) as well as on two test-interviews we conducted, the response rate to open-ended survey questions is considered to be substantially lower than in the case of closed-ended survey questions, especially when the number of questions would be too high. the questions covering each of the six ethical principles were preceded by a general question on the identification of potential moral conflicts (intended to trigger respondents, before directing them into the six predefined categories), and followed by two general questions on the way (if applicable) municipalities deal with the identified moral conflicts. data analysis the document analysis implied a scrutinization of the presence (or non-presence) of the values and principles elaborated on abovein the legal text of the social support act 2015, either in terms of a literal incorporationin the legal text, or in terms of indirect referrals to the respective values and principles. the data of the surveys and interviews were analysed through the application of a directed approach to qualitative content analysis (30). we chose for this approach, as it allows for an analysis that “starts with a theory or relevant research findings as guidance for initial codes” (30). in that way, we were enabled to directly apply our theoretical framework of ethical reasoning in the interpretation and categorisation of the research data, with the six predefined ethical principles as initial coding categories. within each of these categories, we clustered the respondents’ answers in ‘dominant responseclusters’ as a way of quantifying to some extent our qualitative survey results. this approach allowed for an organized inclusion of the main results in this article. obviously, qualitative results can never completely be quantified, as each specific answer remains unique. therefore, in order to add some extra weight to our results, we included direct respondents’ quotes to several of the dominant response clusters. jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 9 table 1. survey/interview questions part 1: identifying potential moral conflicts q1: according to you,what are the most important moral conflicts (if any) your municipality has been faced with in the context of implementing and executing the social support act 2015? ethical principles original selected ‘check marks’(25) adapted questions ethical principle 1: non-maleficence & beneficence overall, for both non-maleficence and beneficence, is it possible to assess whether more benefit than harm is produced by intervening (or not intervening) and, if so, on what side (benefit or harm) does the equation finally fall? q2: according to you, will more people (both care recipients as informal caregivers) have advantage or disadvantage as a result of the introduction of the social support act 2015? how do these advantages and disadvantages look like? ethical principle 2: health maximization / social beneficence does it [the proposed intervention] have a sustainable, long-term effect on the public’s health? q3: according to you, will the social support act 2015 have a sustainable, long-term, effect on the quality of life of the entire (older) population? ethical principle 3: efficiency awareness of scarcity of public money; saved money can be used for other goods and services. q4: according to you, how does your municipality deal with the availability of the scarce resources that are available for the social support act 2015? ethical principle 4: respect for autonomy does the intervention promote the exercise of autonomy? q5: according to you, does the social support act 2015 provide sufficient opportunity for people’s freedom of choice with regard to the care and support they wish to receive (and the way how they receive it)? ethical principle 5: (social) justice does the intervention promote rather than endanger fair (and real) equality of opportunity and participation in social action? q6: according to you, do people under the social support act 2015 have an equal opportunity to live their lives the way they want (or, in other words: is the freedom of choice as mentioned in the previous question also practically possible for every person)? ethical principle 6: proportionality are costs and utility proportional? q7: according to you, will costs and utility under the social support act 2015 be proportional? part 2: dealing with moral conflicts q8: according to you, how does your municipality deal with the moral conflicts as identified under part 1? or, in other words: what are your municipality’s solutions to these moral conflicts? q9: according to you, are there, for your municipality, alternative ways of executing the social support act 2015, that will lead to less moral conflicts? jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 10 results document analysis in terms of the values as stipulated by the ‘council conclusions on common values and principles in european union health systems’, the legal text of the social support act 2015 only literally makes reference to the value of ‘access to good quality care’, although quality of care should be understood here as ‘good quality of (social) support’. indeed, as was explained in the previous chapter, the dutch long-term care system is, as of 1 january 2015, divided into three laws, of which the social support act 2015 constitutes the one mainly dealing with social types of care (directed at increasing or maintaining the self-sufficiency and social participation of vulnerable citizens) instead of traditional healthcare. the municipalities’ responsibility under this law can therefore best be understood as providing adequate social support services instead of providing actual healthcare services. nevertheless, this focus on social types of care instead of traditional types of healthcare, or on ‘well-being’ instead of ‘health’ as a desired outcome of support, does not imply that the social support act 2015 should not be based on certain key ethical values or principles. also the council conclusions (1) go further than traditional healthcare, by implying that “[t]he health systems of the european union are a central part of europe's high levels of social protection, and contribute to social cohesion and social justice as well as to sustainable development”. with regard to good quality of social support, then, article 2.1.1 of the social support act 2015 stipulates that “[t]he municipal council is responsible for the quality and continuity of services” (authors’ own translation), while article 3.1 continues by stating that “[t]he provider shall ensure the provision of good quality services” (authors’ own translation). services either refer here to ‘general services’ (in dutch: algemenevoorzieningen), or to ‘customized services’ (in dutch: maatwerkvoorzieningen). the latter, subsequently, is defined in the legal text as a “range of services, tools, home adaptations and other measures, tailored to the needs, personal characteristics and capabilities of a person” (authors’ own translation). solidarity is by definition an important component of this law, and is referred to in the first sentence of the legal text, which points out that “citizens bear a personal responsibility for the way they organize their lives and participate in society, and that may be expected of citizens to support each other in doing so to the best of their ability” (authors’ own translation). the values of universality and the, more overarching, value of equity (being part of the principle of social justice in our theoretical framework) are indirectly referred to in the introduction of the legal text by stating that “citizens who themselves or together with people in their immediate environment are not sufficiently self-sufficient or insufficiently able to participate [in society], must be able to rely on organized support by the government” (authors’ own translation). as a result of the limited literal inclusion of these ethical values, it is not surprising that the more specified ethical principles derived from these values are hardly included in literal terms in the legal text neither. the only exception here is the ‘respect for autonomy’ principle, that could be derived from the wording of article 2.1.2 (4.c), which stipulates that municipalities in their social support policy should specifically take the freedom of choice into account of those citizens that are entitled to customized support services. survey and interviews having considered the literal inclusion of the ethical values and principles in the legal text of the social support act 2015, a next step in our research process was to examine to what extent municipal policy advisors consider the execution of the social support act 2015 to be in compliance with the six ethical principles as applied in this study. in totality 70 policy advisors completed the survey, constituting 18 per cent of dutch municipalities. in total, ten jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 11 of these respondents also appeared to be willing to participate in an in-depth interview. the results of the surveys and in-depth interviews are described question by question in the followingsection and discussed simultaneously (as the in-depth interviews were intended to expand on the survey results instead of asking new questions).given the number of respondents, only those answers that most frequently resulted from our analysis (the ‘dominant response clusters’ mentioned above) are discussed here. the direct respondents’ quotes that are included are believed to represent the respective cluster best and are the authors’ own translations from dutch to english. question 1 (general identification of moral conflicts). although not all respondents confirmed the existence of moral conflicts with regard to the implementation and execution of the social support act 2015, most respondents did identify one or more moral conflicts. in general, our respondents identified threetypes ofmoral conflicts. first, the conflict of adhering to the social support act’s underlying theory of moving towards a participation society vs. the limited budget and time-frame that is offered to municipalities for supporting this change process. indeed, the theoretical idea of moving towards a society wherein citizens take up more individual and social responsibility and where care and support is provided on a customized basis and closer to home, is considered by many as a positive normative development. however, the severe budget cuts that accompany the long-term care decentralization (expected to lead to budgetary shortfalls), as well as the rapidity of the reform process, hamper municipalities’ opportunities for supporting this development. or, as one respondent put it: “pragmatism prevails over quality demands”. second, respondents identified the conflict of how to efficiently coordinate responsibilities between the three different long-term care acts. the fact that municipalities under the long-term care reform only got responsibility for parts of the long-term care sector might lead to unclarity and confusion, not the least among (potential) recipients of care/support, regarding under which act one is entitled to care/support. moreover, some respondents indicated that an insufficient coordination between the three laws sometimes results in a lack of incentives among municipalities to invest in prevention and informal care support, as the financial benefits of these investments might not be evident for the ‘own law’, but only for the ‘other laws’. the third moral conflict identified relates to the correct assessment of citizens’ self-sufficiency and their ability to social participation vs. their care/support needs and the urge to empowerment. the fact that municipalities have a large policy discretion in executing their responsibilities under the social support act 2015 even complicates this point, as similar situations might well lead to different assessments in different municipalities. particularly difficult, then, is how to justify these differences to citizens. question 2 (ethical principle 1: non-maleficence and beneficence). most respondents appeared to have a rather neutral stance when it comes to assessing the non-maleficence and beneficence of the social support act 2015, arguing that the act leads to advantages for some and disadvantages for others, especially on the short-term. or, as one respondent put it: “it depends on the individual perception of people whether they experience the introduction of the new social support act as an advantage or a disadvantage”. moreover, getting used to a new situation always takes time, especially for those citizens that were already entitled to care or support under the pre-2015 situation. advantages primarily include the provision of customized care closer to home, in line with people’s specific living conditions, instead of standard care provisions like in the pre-2015 situation. disadvantages primarily include the, already above-mentioned, high degree of policy discretion of municipalities regarding their allocation of support measures—which tends to lead to perceptions of ‘unfairness’ or ‘subjectivity’ among citizens—, a lower level of formal care provision as experienced by individual citizens and consequently the increasing burden on informal caregivers. jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 12 question 3 (ethical principle 2: health maximization / social beneficence). the decreasing level of formal care provision can also be considered as a disadvantage on a societal level, when considering the more long-term expected consequences of the implementation of the social support act 2015. at the same time, a decreasing level of formal care provision is not considered by all respondents as a disadvantageous development. as one respondent put it: “if we execute it [the social support act 2015] well, this will increase quality of life. however, this also entails that we should carefully deal with informal caregivers”. one of the more long-term advantages is indeed believed to be the creation of a better awareness and appreciation among citizens about care in general, as a result of the diminishing resources for formal care provision, leading to a more inclusive society—characterized by the emergence of a new quality of life—wherein people have a better esteem of their own possibilities as well as a better appreciation of each other. at the same time, many respondents pointed out that this ‘emergence of a new quality of life’ is not so much due to the social support act 2015 (or the long-term care reform in general), but more to overarching trends such as demographical developments (people get older and older), technological developments in healthcare (which facilitate people in achieving a decent quality of life) and changing ways of thinking about care in general (such as other perspectives on civic engagement and patient empowerment). as one respondent put it: “the quality of life has always had a different standard than the generation before”. or, as another respondent put it: “laws don’t have an influence on quality of life”. question 4 (ethical principle 3: respect for autonomy). respect for autonomy was considered by most respondents as being sufficiently covered by the social support act 2015, specifically through the inclusion of the freedom of choice as mentioned under article 2.1.2 of the social support act 2015. concretely, the freedom of choice as referred to in article 2.1.2 implies either the choice between several by the municipality selected providers (when one is entitled to customized care services) or a fully open choice (when one is entitled to a personal budget). yet, respondents did put several remarks to this freedom of choice. first, due to the large discretion municipalities have in executing the social support act 2015, the interpretation of freedom of choice differs between municipalities (indeed, some municipalities offer a larger selection of providers than others). as one respondent put it: “the new social support act isn’t designed as to ‘support wishes’, nor as a ‘right to support’. therefore, there is a strong dependence on supplemental local rules”. second, in practice, freedom of choice is not always considered as an added value by people, especially by vulnerable people that are often just looking for good quality support. as one respondent put it: “for that [freedom of choice] there is little attention among people. moreover, it is questionable whether that is actually needed; people merely want good quality care instead of freedom of choice” (author’s own translation). question 5 (ethical principle 4: social justice). in line with the previous question, the question about social justice was basically about people’s capabilities of making use of their right to freedom of choice. answers to this question were divided. on the one hand, many respondents considered the majority of people that are entitled to support under the social support act 2015 to be indeed capable of making use of their right to freedom of choice. moreover, when necessary, support is offered to clients by the municipality. as one respondent put it: “the municipality is actively cooperating with ‘client supporters’ to facilitate people as good as possible in their freedom of choice” (these ‘client supporters’ are people that work independently from the municipality). on the other hand, other respondents emphasized that not everyone, especially vulnerable groups in society, are capable of applying their freedom of choice, neither has everyone a social network at her/his disposal to support them in doing so. moreover, freedom of choice depends to some extent on people’s jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 13 own resources. indeed, under the social support act 2015, the own financial contributions people are expected to pay for the care/support they receive have grown as compared to the pre-2015 situation, which might lead to the avoidance of care/support (31). as a result, respondents argue, differences in society grow when it comes to the possibility of people to make use of their freedom of choice under the social support act 2015. as one respondent put it: “a barrier to care is created, that leads to a split in society: if you have money you can buy care yourself; if you little money you’ll have to do it with a stripped care system”. question 6 (ethical principle 5: efficiency). with regard to the allocation of scarce resources, respondents’ views could be divided into three main groups. one part considered the budget available for the execution of their long-term care responsibilities, which was substantially lowered as compared to the pre-2015 situation, to be leading in the allocation of resources, implying that care/support demands are (according to these respondents) considered more critically—on the basis of stricter indications—as compared to the pre-2015 situation. as one respondent put it: “the resources are distributed as indicated by the national government”. moreover, some municipalities try to focus on general (collective) support services instead of on customized (individual) support services in order to remain within their budgetary margins. a second groups considered demand to be key in decision-making, implying that as much as possible is done to do what is necessary, at least for the most vulnerable groups. in case of shortages, solutions are (according to these respondents) considered to be the appeal to general municipal resources or the transfer of resources from other policy domains within the municipality. indeed, many municipalities are currently searching for more integral ways of working between the different parts of the social domain within their municipality (17). one respondent formulated it as follows: “it starts with the client and we do what is necessary; many roads lead to rome”. a third, though smaller, group took a more neutral stance and considered the underlying idea of the long-term care reform (truly progressing towards a participation society) to be key in decision-making, implying that ‘new’, ‘creative’, or ‘innovative’ solutions have to be sought in balancing between a limited budget and the existing (or even growing) care/support demand. one respondent covered this point by stating that we should “learn people how to fish instead of supplying the fish”. apart from an increased focus on prevention (e.g. by supporting, or cooperating with, citizens’ initiatives and/or informal care organizations), it remains however unclear what is exactly meant by ‘innovative solutions’. question 7 (ethical principle 6: proportionality). next, respondents were asked whether they think the social support act 2015 can be considered as a proportionate measure for the goals it intends to pursue. in general, respondents considered this proportionality indeed to be present, thereby primarily making the comparison to the pre-2015 situation, which was considered by many as ‘unfair’ and ‘untenable’ due to the often exaggerated care demands of people (the so-called ‘claim-mentality’). or, in the words of one respondent: “a greater reliance on an own network / own resources will eventually replace the claim-mentality (‘i am entitled to’) and thus be cheaper”.another group of respondents considered the underlying idea of the decentralization (providing care and support on a customized basis and closer to home) as a positive normative development, while being worried about the budget cuts that accompanied the decentralization. as one respondent put it: “there will only be a balance in case of sufficient budget and autonomy for municipalities”. for this group of respondents, the social support act 2015 is considered to be putting a disproportionate burden on society. for part of this latter group, this disproportionality is likely to reduce in the longer-term, due to a gradually reducing ‘claim-mentality’ within society. for another part, however, the reduction of long-term care costs in the longer-term will not be the result of a more efficient provision of long-term care, but will simply be the result of the mere fact jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 14 of less available financial resources (and thus less possibilities), leading logically to less expenses in the long-term care sector. question 8 (dealing with moral conflicts). the last two questions of the survey referred to the way municipalities deal with the identified moral conflicts. in general, most respondents pointed to the importance of communication and transparency here. on the basis of regular deliberations, meetings and conversations with both care/support providers, surrounding municipalities, care/support recipients and their informal caregivers, and other stakeholders, the execution of the social support act 2015 is evaluated regularly and adapted where necessary. moreover, although the large discretion that municipalities have in assessing citizens’ care/support needs is considered by many citizens as unfair or subjective (as we mentioned before), the best way of dealing with this discretion according to our respondents is to critically assess each individual situation in-depth, offer customized support where possible, be open and transparent towards care/support recipients and their informal caregivers, and thoroughly explain the choices made where necessary. as one respondent captured it: “continue discussions, while in the meantime also ensuring that the necessary care delivery continues”. question 9 (dealing with moral conflicts: alternatives). subsequently, respondents were asked whether they foresaw alternatives with regard to the execution of municipalities’ longterm care responsibilities. many pointed to the unlikelihood of such an option, as the social support act 2015 is an established fact by law. others argued that neither option would be perfect and that turning to an alternative law now would be going back to square one. most respondents, however, interpreted this question not so much in terms of alternatives to the social support act 2015 in itself, but in terms of possible alternatives in the execution of this law. most of these respondents pointed to the potential release of more financial resources by the national government. at the same time, respondents acknowledged that although the availability of more financial resources would make life easier, it would not dissolve moral conflicts. a second alternative would be a clearer delineation between (or integration of) the different long-term care acts. respondents argued for example that it would have made more sense if the complete package of non-residential care services was put under responsibility of either the municipalities, or the health insurers. currently, the majority of non-residential care services is under responsibility of the health insurers, and only a small part under responsibility of the municipalities. finally, respondents pointed to the need for more innovative and unorthodox solutions, arguing that the social support act 2015 is not an aim in itself, but a means to deliver good care/support. or, as one respondent put it: “every law has an article 5”, implying that governments should sometimes turn a blind eye in the execution of policies. discussion principal findings and conclusions the aim of this study has been to examine to what extent municipalities in the netherlands take/took potential moral conflicts into account when implementing and executing the social support act 2015. we intend to answer our research question by relating the results corresponding to each of the six principles of our theoretical framework back to the coherentist approach of ethical reasoning this framework was based on. as was mentioned before, the coherentist approach is based on two main strands of ethical reasoning, being the ‘rights-based approach’ and the ‘consequentialist approach’. within a consequentialist approach, “actions are judged for their outcome and overall produced value” (22). this approach is basically founded on such principles as ‘health maximisation’ and ‘do no harm’ (22), corresponding to the principles of non-maleficence & beneficence and social jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 15 beneficence in our theoretical framework. in a public health context a consequentialist approach to ethical reasoning implies that health should be maximised, “as long as health maximisation is not endangering the maximisation of the overall utility of people” (22). as was described in the previous chapter, most of our respondents appeared to have a rather neutral stance with regard to assessing the non-maleficence and beneficence of the social support act 2015, emphasizing that it depends to a large extent on the individual perception of people whether they experience the introduction of the new social support act as an advantage or a disadvantage. with regard to social beneficence we found that, despite worries about the decreasing level of formal care provision, most respondents considered the creation of a better awareness and appreciation among citizens about care in general to be one of the more long-term advantages of the social support act 2015. at the same time there are also doubts about the impact that a law can have on such developments as new ways of thinking about long-term care (referred to above as a ‘normative reorientation’ towards long-term care). indeed, concepts such as the concept of ‘positive health’ as developed by huber et al. (4) are gaining importance within the healthcare sector.the conceptof ‘positive health’ considers health as “the ability to adapt and to self manage” (4) instead of considering it under the traditional who definition as “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” (32). a rights-based approach is basically founded on such principles as ‘human dignity’ and ‘justice’, corresponding to the principles of respect for autonomy and social justice of our theoretical framework, and claims that “persons have rights to fair equality of opportunity” (22). in a public health context this implies that people have a right to (equal opportunity) “to receive appropriate healthcare and live in environments in which social determinants of health are distributed in a fair way” (22). as we saw in the previous chapter, most respondents considered respect for autonomy to be sufficiently covered by the social support act 2015, mainly by its emphasis on freedom of choice. at the same time, however, our respondents pointed out that exactly freedom of choice is something that is not always of added value in a context wherein people are often just looking for good quality support. moreover, while social justice (people’s capabilities of making use of their right to freedom of choice) was considered to be sufficiently present for the majority of people, it is also exactly this point that respondents appeared to be most worried about in light of the social support act 2015, especially when applying it to vulnerable groups in society. indeed, the legal text of the social support act 2015 hardly stresses the importance of such notions as ‘equity’, one of the core underlying values of the principle of social justice. although the legal text stipulates that “citizens who themselves or together with people in their immediate environment are not sufficiently self-sufficient or insufficiently able to participate [in society], must be able to rely on organized support by the government”, it remains unclear when exactly someone is ‘insufficiently self-sufficient’, ‘insufficiently able to participate in society’, and (in case someone is entitled to support) when one is entitled to ‘general services’ and when to ‘customized services’. indeed, as was argued by maarse and jeurissen (16), municipalities actually have a large policy discretion with regard to the allocation of support measures (the so-called ‘zip code rationing’), which may lead to unequal access to long-term care. in fact, this point was one of the three main moral conflicts as identified by our respondents under question 1 of the survey. moreover, as argued by van der aa et al. (18), with the advent of the social support act 2015 a shift can be witnessed from a ‘right to care’ to a ‘right to customized support’. next, although solidarity is by definition an important component of the social support act 2015, the act foresees a shift from formal to informal solidarity (18). it remains, however, doubtful how much can be expected of this informal solidarity. as maarse and jeurissen (16) already pointed out, “the potential of jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 16 ‘unexplored’ informal care is overestimated. furthermore, the negative externalities for caregivers who deliver intense informal care are underestimated”. finally, the legal text of the social support act 2015 stipulates that “it is desirable to set new rules, in order to bring citizens’ rights and duties more in line with each other” (authors’ own translation), which tends to imply a decreasing government responsibility for citizens’ rights to equality of opportunities regarding access to good quality care/support. our first sub-research question was specifically directed towards the way municipalities divide scarce resources in the social domain in a fair way. as we saw in the previous chapter, our respondents’ views towards principles of efficiency and proportionality were quite divergent. on the one hand, the availability of less public resources for long-term care and the higher own financial contributions people are expected to pay for the care/support they receive might eventually lead to a more conscious use of care (and in that way contribute to the normative reorientation of creating a true participation society). on the other hand, however, these developmentsmight unconsciously lead to the creation of an access barrier to care (especially for the less affluent in society) or to the avoidance of necessary care. in fact, the conflict of adhering to the social support act’s underlying theory of moving towards a participation society while at the same time having to deal with the limited budget and timeframe that is offered to municipalities for supporting this change process was one of the three main moral conflicts as identified by our respondents under question 1 of the survey. moreover, within the context of the social support act 2015 ‘efficiency’ might primarily be understood as a way of justifying the budget cuts that accompanied the long-term care decentralization, instead of as a moral obligation to efficiently use scarce health resources. at least part of the solution to the dilemma of how municipalities then can divide scarce resources in the social domain in a fair way might be provided by the ‘accountability for reasonableness’ approach of procedural justice by daniels and sabin (33), which offers a “minimum ethical standard in times of economic downturn characterized by scarcity of resources and when not all needs are being satisfied” (13). the accountability for reasonableness approach requires certain conditions to be met in order for a process of allocating scarce healthcare resources to be ‘fair’: the process (including the reasoning behind it) has to be transparent to the public, the reasons by which decisions were made have to be relevant, and it should be possible to revise any decision in case of new evidence or arguments (13). these conditions are quite in line with our results under question 8 (dealing with moral conflicts), emphasizing the importance of communication and transparency in the process of dealing with moral conflicts (such as the division of scarce resources). finally, in order to answer our second sub-research question (regarding the way municipalities empower citizens towards a participation society), it has to be determined how the kind of efficiency goals as discussed under the previous sub-question can be reconciled with moving towards a participation society; or, in other words, does the latter lead to the former, or does the former require the latter? is thus “participation” a good value or a fig leaf or metaphor for a liberalist mindset? we argue that although participation is an intended goal of the social support act 2015, citizens are insufficiently supported to achieve that participation. as we argued before, ‘support’ under the social support act 2015 is intended to be limited to those citizens who themselves or together with people in their immediate environment are not sufficiently self-sufficient or insufficiently able to participate. or, as maarse and jeurissen (16) put it: “the wmo 2015 gives applicants a right to publicly funded support if they cannot run a household on their ownand/or participate in social life”. however, proactively supporting citizens towards the initial goal of creating a participation society (e.g. by focusing on preventive measures), is much less pronounced in the legal text of the social support act 2015. article 2.1.2 (c, d and e)points in general terms at, jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 17 respectively, the early determination of citizens’ support needs, the prevention of citizens’ reliance on support, and the provision of general support services (provided without the prior examination of the recipient’s need, characteristics and capabilities). however, how to achieve these points is left to the municipalities’ discretion. in the same vein, article 2.1.2b points out that “the different categories of informal caregivers should be enabled as much as possible to perform their duties as informal caregiver” (authors’ own translation), but this point is not specified in the remainder of the legal text. this point is therefore, we argue, much less concrete as compared to the old 2007 social support act (under which municipalities where merely responsible for domestic help), where support for informal caregivers was concretized in such sub-themes as information, advice, emotional support, education, practical support, respite care, financial support and material support. at the same time, this high degree of policy discretionfor municipalities under the 2015 social support act gives room for ‘innovative and unorthodox solutions’, as was indicated by several of our respondents, although this may require the availability of more financial resources and/or a clearer delineation between (or integration of) the different long-term care acts (the latter being one of the three main moral conflicts as identified by our respondents under question 1 of the survey). coming back to our main research question (“to what extent did/do municipalities in the netherlands take potential moral conflicts into account when implementing and executing the social support act 2015?”), we conclude by arguing that while municipalities are indeed aware of (potential) moral conflicts, the nature of the new law itself leaves insufficient room for municipalities to act in a sufficiently proactive and supportive/empowering manner on these challenges, as well as on the long-term aim of the social support act 2015 of achieving a true participation society. the reasoning behind this argumentation is that although the new law appears to emphasise such ethical principles as social beneficence and respect for autonomy, the lack of emphasis on notions of social justice threatens to impede the effectuation of the intended goals in practice. moreover, the social support act 2015 seems to be mainly directed towards achieving a certain outcome (the maximisation of social beneficence through the creation of a participation society), instead of stipulating how that outcome should exactly be achieved in a fair manner. as such, the social support act 2015 insufficiently seems to provide equality of opportunity with regard to long-term care access, both between citizens within the same municipality, as (and perhaps especially) between different municipalities. at the more short-term, taking into account a minimum set of ethical principles allows for the allocation of (seemingly scarce) resources that is, at the least, as fair as possible. study strengths and limitations and suggestions for further research the principle strength of this study has been the application of a broad ethical approach towards scrutinizing a new, and still sensitive, policy responsibility of dutch municipalities. we have shown that taking into account a minimum set of ethical principles, raises awareness of (potential) moral conflicts within the context of the new social support act. being aware of such conflicts, at its turn, helps in executing the new responsibilities under the social support act in an appropriate manner (or in justifying decisions towards citizens) and gives room for municipalities to act in a as proactively as possible manner on the challengesresulting from these new responsibilities. next, the fact that all dutch municipalities were invited to participate in our study led to a reasonable response rate, in terms of reaching a saturation point in our data analysis. at the same time, the limited response rate to the invitation for a telephonic interview might have led to a certain selection bias, as not all respondents have given the same level of in-depth explanation to their survey answers. moreover, it might have been valuable if additional questions were added to the injongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 18 depth interviews, although also the semi-structured character of these interviews already allowed for a certain (though limited) degree of further exploration within and beyond the initial interview items. finally, also our argument with regard to the allegedly insufficient support with regard to achieving a participation society leaves room for further research, as this is exactly a topic that holds a more long-term perspective. as such, it may be worth considering within a number of years to what extent the social support act 2015 actually contributed (or not) to the creation of a true participation society. references 1. council of the european union. council conclusions on common values and principles in european union health systems (2006/c 146/01). official journal of the european union 2006;49:c 146/1-3. 2. commission of the european communities. white paper. together for health: a strategic approach for the eu 2008-2013. brussels: commission of the european communities, 2007. 3. commission of the european communities. europe 2020: a strategy for smart, sustainable and inclusive growth. brussels: 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(1) it shall be an offence for a person to— (a) manufacture, for sale in the state, (b) import, for sale in the state, or (c) sell to a person who is in the state, an article of clothing intended to be worn by a child, where the article promotes alcohol consumption or bears the name of an alcohol product or the trade mark, emblem, marketing image or logo, by reference to which an alcohol product is marketed or sold. an important parallel is the ban on sweets/candy that resemble tobacco products (section 9 of public health [tobacco] [amendment] act, 2004; section 38 of public health [tobacco] act, 2002), which was introduced almost 20 years ago. ireland’s laws on such tobacco marketing to children through candy and sweets align with article 13 of the world health organization’s (who) influential framework convention on tobacco control (fctc). it is evident that a similar prohibition on alcohol marketing is urgently required. such marketing is particularly problematic given ireland’s troubled relationship with alcohol (4,5), and in light of the proven impact of marketing, advertising, and sponsorship by the alcohol industry on adults, youths and children (6-8). a plethora of studies have also clearly demonstrated that children and youths in ireland are in danger themselves of developing similarly problematic habits of alcohol misuse to those of adults here and so continuing the cycle (9). youth and child alcohol misuse is of added concern because of research indicating the accentuated impact of alcohol on developing adolescent physiology and personality (10). it must be acknowledged that easter eggs featuring alcohol branding and logos are neither innocent, nor inconsequential. such coded marketing reinforces the ubiquitous nature of our intoxigenic environments. an amendment to the public health (alcohol) act, 2018, is urgently required to address this, and the many other deficits in the legislation that have been identified to date. now is not the time for avoidant and timid political leadership on this issue. in the meantime, retailers should refrain from selling such alcohol branded chocolate eggs, or failing that, restrict such sales to within the newly developed alcohol section of their premises. it is also clear that continual vigilance by public health and alcohol control advocates is required to combat the machinations of the alcohol industry. houghton f. easter eggs & ‘easter eggs’: alcohol branded chocolate eggs & intoxigenic environments in ireland (short report). seejph 2021, posted: 05 may 2021. doi: 10.11576/seejph-4395 p a g e 5 | 5 © 2021 houghton; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. references 1. chuvaieva a. how to make a video game easter egg: legaltips and tricks. j intell prop l pract 2019;14:864-75. 2. houghton f, mcinerney d. the public health (alcohol) act: spatial issues and glaring gaps. ir geogr 2021;53:179-84. doi: 10.2014/igj.v53i2.1423. 3. houghton f, mcinerney d. sponsorship, advertising & alcohol control in ireland: the importance of both premises and products in regulating intoxigenic environments. ir j med sci 2020;189:1035-7. doi: 10.1007/s11845-019-02154-w. 4. mongan d, long j. overview of alcohol consumption, alcohol-related harm and alcohol policy in ireland. hrb overview series 10. dublin: health research board; 2016. 5. alcohol action ireland. an overview of alcohol related harm; 2021. available from: https://alcoholireland.ie/facts/alcohol-relatedharm-facts-and-statistics/#:~:text=alcohol%20is%20responsible%20for%2088,of%20all%20suicides%20in%20ireland (accessed: march 8, 2021). 6. engels rc, hermans r, van baaren rb, hollenstein t, bot sm. alcohol portrayal on television affects actual drinking behaviour. alcohol alcohol 2009;44:244-9. 7. smith la, foxcroft dr. the effect of alcohol advertising, marketing and portrayal on drinking behaviour in young people: systematic review of prospective cohort studies. bmc public health 2009;9:1-11. available from: https://doi.org/10.1186/14712458-9-51 (accessed: march 8, 2021). 8. houghton f, scott l, houghton s, lewis ca. children’s awareness of alcohol sponsorship of sport in ireland: munster rugby and the 2008 european rugby cup. int j public health 2014;59:829-32. 9. espad group. espad report 2019: results from the european school survey project on alcohol and other drugs, luxembourg: emcdda joint publications, publications office of the european union; 2020. 10. ruan h, zhou y, luo q, robert gh, desrivières s, quinlan eb, et al. adolescent binge drinking disrupts normal trajectories of brain functional organization and personality maturation. neuroimage clin 2019;22:101804. __________________________________________________________________________ https://alcoholireland.ie/facts/alcohol-related-harm-facts-and-statistics/#:~:text=alcohol%20is%20responsible%20for%2088,of%20all%20suicides%20in%20ireland https://alcoholireland.ie/facts/alcohol-related-harm-facts-and-statistics/#:~:text=alcohol%20is%20responsible%20for%2088,of%20all%20suicides%20in%20ireland https://alcoholireland.ie/facts/alcohol-related-harm-facts-and-statistics/#:~:text=alcohol%20is%20responsible%20for%2088,of%20all%20suicides%20in%20ireland https://alcoholireland.ie/facts/alcohol-related-harm-facts-and-statistics/#:~:text=alcohol%20is%20responsible%20for%2088,of%20all%20suicides%20in%20ireland https://alcoholireland.ie/facts/alcohol-related-harm-facts-and-statistics/#:~:text=alcohol%20is%20responsible%20for%2088,of%20all%20suicides%20in%20ireland https://alcoholireland.ie/facts/alcohol-related-harm-facts-and-statistics/#:~:text=alcohol%20is%20responsible%20for%2088,of%20all%20suicides%20in%20ireland https://alcoholireland.ie/facts/alcohol-related-harm-facts-and-statistics/#:~:text=alcohol%20is%20responsible%20for%2088,of%20all%20suicides%20in%20ireland genc burazeri, sampath emani, ulrich laaser, transfer of the south eastern european journal of public health to the netherlands press. seejph 2022. posted: 21 march 2022 page 1 transfer of the south eastern european journal of public health to the netherlands press genc burazeri1,2, sampath emani3, ulrich laaser4 1department of public health, faculty of medicine, university of medicine, tirana, albania; 2department of international health, school caphri (care and public health research institute), maastricht university, maastricht, the netherlands; 3the netherlands press b.v. 4section of international health, faculty of health sciences, university of bielefeld, bielefeld, germany. corresponding author: genc burazeri rr. “dibres”, no. 371, tirana, albania; email: genc.burazeri@maastrichtuniversity.nl policy brief mailto:genc.burazeri@maastrichtuniversity.nl genc burazeri, sampath emani, ulrich laaser, transfer of the south eastern european journal of public health to the netherlands press. seejph 2022. posted: 21 march 2022 page 2 in 2014, the first volume of a new open access journal was published by jacobs publishing house, that is the south eastern european journal of public health (seejph) [1]. the wide range of countries of the corresponding authors appearing in most volumes published in the seejph represents the successful global orientation of seejph [2]. in addition, more than half of all related articles are classified as original papers, and the average of four authors per represented paper is comforting [2]. with the new year 2023, however, the seejph has been transferred from jacobs publishing house to the netherlands press, as the university of bielefeld cannot host the journal after the 31st of december 2022. the journal’s design has been modernized but the mission remains as follows: “the south eastern european journal of public health (seejph) is an open-access international peer-reviewed journal involving all areas of health sciences and public health. devoted to global health seejph welcomes submissions of scientists, researchers, and practitioners from all over the world, but particularly pertinent to southern and eastern countries in transition.” [3]. professors genc burazeri and ulrich laaser will stay respectively as executive and founding editors, and so will the board of editors, the board of regional editors, the advisory editorial board, and the board of emeritae and emeriti. we have to thank our board members, authors, and readers for almost a decade of fullhearted and competent support and advice as well as the library of the university of bielefeld for the highly competent technical environment provided throughout these years. of note, the transfer to a new publisher, which will eventually boost the impact of the journal, faces unavoidably some challenges related to transition of the online system, hosting issues, and other related technological problems. this is the “price” of any transfer which will ultimately materialize in a better profiling of the journal. we would, therefore, kindly ask for the patience and understanding of our network of collaborators and submitting authors. we look forward to a fruitful cooperation with the new publishing company and our global network! genc burazeri, sampath emani, ulrich laaser, transfer of the south eastern european journal of public health to the netherlands press. seejph 2022. posted: 21 march 2022 page 3 © 2023 genc burazeri et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. references 1. the south eastern european journal of public health (seejph), published by jacobs verlag, hellweg 72, d-32791 lage, germany. 2. petrela, k., et al., survey exploring the opinion of corresponding authors of articles published in the south eastern european journal of public health during 2014-2021. south eastern european journal of public health, 2023. 3. holst, j., et al., five years of the south eastern european journal of public health (seejph): focusing on health systems in transition and global health. south eastern european journal of public health, 2023. http://creativecommons.org/licenses/by/3.0) martin-moreno jm. facing the covid-19 challenge: when the world depends on effective public health interventions [editorial]. seejph 2020, posted: 04 may 2020. doi : 10.4119/seejph-3442 p a g e 1 | 4 editorial facing the covid-19 challenge: when the world depends on effective public health interventions jose m. martin-moreno1,2 1editorial board, south eastern european journal of public health (seejph); 2department of preventive medicine & incliva, university of valencia, spain. corresponding author: jose m. martin-moreno professor of preventive medicine and public health, medical school and incliva – clinical hospital, university of valencia, spain; address: avenida blasco ibañez 10, e-46010 valencia, spain; email: jose.martin-moreno@uv.es martin-moreno jm. facing the covid-19 challenge: when the world depends on effective public health interventions [editorial]. seejph 2020, posted: 04 may 2020. doi : 10.4119/seejph-3442 p a g e 2 | 4 on december 31, 2019, the wuhan municipal health commission in hubei province, people's republic of china, reported a cluster of 27 cases of pneumonia of unknown aetiology with onset of symptoms on december 8. there was a common exposure to a wholesale market for seafood, fish, and live animals in wuhan city (1). it was a report that many of us in the field of epidemiology and public health read from the news and alerts notified by the who, but... at that time (almost) nobody could even imagine the tsunami that was coming for most of the world. after the initial outbreak in china, it was quickly determined (on january 7) that the disease was caused by a new coronavirus, which had many similarities to the one which caused the 2003 sars pandemic. these similarities explained why it was named as severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (2). this virus has characteristic club-shaped spikes that project from their surface, which in microscopic image resembles the solar corona, from which their name derives. as a curiosity to additionally explain the term, the original latin word corona meant 'garland worn on the head as a mark of honour or emblem of majesty,' and, by extension, 'halo around a celestial body.' in fact, the word has come down through time more or less unchanged in spanish and italian (and other latin-based romance languages), in which the word for 'crown' is today written exactly as 'corona'. in parallel to the identification of the causative viral microorganism, public health measures were initiated. according to the information disclosed by the chinese authorities, an epidemiological investigation led by a national team of specialists began on december 31, 2019, and the following public health procedures were implemented: case isolation, identification and follow-up of contacts, environmental sanitation and laboratory research (3). since then, the situation has changed dramatically. the who first declared a global public health emergency on january 31, then announced on february 11 that the new coronavirus disease should be renamed "covid19", and on march 11, declared the outbreak a pandemic (4). after the already described onset of the outbreak in china, coronavirus cases started to spike in south korea and other asian countries at the beginning of february, and later in the month, covid-19 cases began to increase in italy and spain sharply. many other european countries were also affected, and on march 11, president trump banned all travel from 26 european countries. on march 13,he declared the us national emergency. the situation has escalated to a scenario of severe consequences and, at the time of writing this editorial, there have already been identified 3.3 million cases in the world, with about 1.2 million being active and ongoing cases, roughly 1 million recoveries, and more than 234,000 deaths (5). the virus has spread to at least 185 countries and regions around the world in four months, with half of humanity being locked down, something unprecedented in the memory of those of us who are living in this moment. in terms of health alone, the challenge is unprecedented. coordinated national responses, along with intelligent use of field data tools for surveillance of cases and contact-tracing, are needed to prevent the unrestrained spread of the virus and reduce the impact on the normal functioning of hospital systems. it is also crucial to search for a vaccine and proper treatments. given the global dimension of this challenge, which requires worldwide and regional coordination and coherence, and despite criticism martin-moreno jm. facing the covid-19 challenge: when the world depends on effective public health interventions [editorial]. seejph 2020, posted: 04 may 2020. doi : 10.4119/seejph-3442 p a g e 3 | 4 from individual governments and specific circles, we should strengthen with total determination the role and resources available to the who and, in our european dimension, to the ecdc. when it comes to finding guidance to guide our actions, in addition to all the inspiration provided by the above-mentioned international institutions, our set of ten "essential public health operations" (ephos) framework has proven to be vital in tackling this challenge (6,7). in this case, it is obvious the importance of the surveillance of population health (epho 1), and the monitoring and response to health hazards and emergencies (epho 2). however, we cannot forget the relevance of all other essential operations, such as: the communication and social mobilization for health (epho 9); the one which allows us to articulate solutions for an effective vaccine (epho 10 and 5); the health protection interventions including environmental, occupational, and food safety (epho 3); the promotion of population health and wellbeing tackling inequalities and the broader social and environmental determinants (epho 4); the proper health governance for health, together with reliable infrastructures and financing to ensure the resources and viability of public health interventions (epho 6 and 8); and, the responsibility to ensure a competent workforce (epho 7). and speaking of the latter, which many of us are passionately committed to, aspher, as europe's representative organization for schools of public health, has made a courageous statement in response to the situation raised by the novel coronavirus disease (covid-19) outbreak emergency (8), including the demand for recognition of public health professionals, and the provision of resources required to carry out their mission properly. the full aspher statement can be read through the link https://www.aspher.org/articles,4,68.html, and the complete list of signatories is available at https://www.aspher.org/aspher-covid19statement-signatories.html. beyond the strict public health and healthcare dimension, our societies will also need to tackle the significant economic and social challenges posed by this appalling event. the new coronavirus will cause direct damage due to the sharp fall in demand and supplyside disruption. its consequences will depend on the duration of the crisis and how it is managed at every level (international, supranational and national). in many of our countries, we are already seeing or foreseeing an impact on employment, along with all the associated consequences for social cohesion and politics, and for people's health. effective leadership capability at these three levels is critical. moreover, if we do well, we have the potential to emerge even better and stronger than we are now. we can try to avoid old mistakes and build a fairer society. on the other hand, the effects of the crisis may be a motivation or incentive to improve in various economic areas, such as technology, mobility, and energy dependence. furthermore, the pandemic comes at a critical juncture for multilateralism and integration. let me conclude with a sentence from the spanish nobel laureate jacinto benavente: "life is like a journey on the sea: there are days of calm and days of stormy weather; the important thing is to be a good captain of our ship." this is sound advice for public health practice and, but it is not always easy to take, especially in the permanent situation of uncertainty, feelings of vulnerability, or over information, most of the time confusing and distressing, that brings the crisis of the covid-19 under its arm. nevertheless, we live in a world where we are interconnected, we share more than ever what https://www.aspher.org/articles,4,68.html https://www.aspher.org/articles,4,68.html https://www.aspher.org/aspher-covid19-statement-signatories.html https://www.aspher.org/aspher-covid19-statement-signatories.html martin-moreno jm. facing the covid-19 challenge: when the world depends on effective public health interventions [editorial]. seejph 2020, posted: 04 may 2020. doi : 10.4119/seejph-3442 p a g e 4 | 4 © 2020 martin-moreno jm. this is an open-access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. we know, and i am sure that solutions will come much sooner than we could ever conceive. for all these reasons, there is reason for optimism, and for thinking that public health will come out more recognized and strengthened not because of our selfish interest, but for the good of our people. references 1. li q, guan x, wu p, et al. early transmission dynamics in wuhan, china, of novel coronavirus–infected pneumonia. n engl j med 2020; 382:1199-1207. doi 10.1056/nejmoa2001316. 2. xu j, zhao s, teng t, et al. systematic comparison of two animal-tohuman transmitted human coronaviruses: sars-cov-2 and sarscov. viruses. 2020; 12(2): 244. doi 10.3390/v12020244. 3. adhikari sp, meng s, wu yj. epidemiology, causes, clinical manifestation and diagnosis, prevention, and control of coronavirus disease (covid-19) during the early outbreak period: a scoping review. infect dis poverty 2020; 9(1):29. doi 10.1186/s40249-020-00646-x. 4. world health organization. who director-general's opening remarks at the media briefing on covid-19 march 11 2020. geneva: who; 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-openingremarks-at-the-media-briefing-oncovid-19---11-march-2020. 5. johns hopkins university (jhu). covid-19 dashboard by the center for systems science and engineering (csse). baltimore: jhu; 2020. https://gisanddata.maps.arcgis.com/a pps/opsdashboard/index.html#/bda7594740fd402994234 67b48e9ecf6. 6. foldspang a. towards a public health profession: the roles of essential public health operations and lists of competences. european journal of public health 2015; 25(3): 361– 362.doi 10.1093/eurpub/ckv007. 7. martin-moreno jm. self-assessment tool for the evaluation of essential public health operations in the who european region. copenhagen: world health organization, regional office for europe; 2015. isbn 978 92 890 50999 8. middleton j, martin-moreno jm, barros h, chambaud l, signorelli c. aspher statement on the novel coronavirus disease (covid-19) outbreak emergency. int j public health 2020;65(3):237238. doi 10.1007/s00038-02001362-x. ___________________________________________________________ alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 1 | 14 original research factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates maryam alawadhi1, khadija alhumaid2, sameeha almarzooqi1, shaima aljasmi1, ahmad aburayya1, said a. salloum3, waleid almesmari4 1dubai health authority, dubai, uae; 2 rabdan academy, abu dhabi, uae; 3school of science, engineering, and environment, university of salford, uk; 4 ministry of defence, uae airforce and airdefence office, abu dhabi, uae; corresponding author: dr. ahmad aburayya; assistant professor, business administration college, jefferson international university, california, usa; address: dubai health authority, dubai, uae; email: amaburayya@dha.gov.ae; q5110947@tees.ac.uk. mailto:amaburayya@dha.gov.ae mailto:q5110947@tees.ac.uk alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 2 | 14 abstract aim: medical training activities have been disrupted in many regions following the outbreak and rapid spread of the coronavirus disease 2019 (covid-19) across the globe. the most affected areas include organizations’ process of leveraging high-tech medical equipment from abroad to facilitate a practical approach to learning. also, as countries implemented covid-19 safety regulations, it became difficult for organizations to conduct face-to-face training. consequently, non-face-to-face learning methods have been introduced in the medical field to enable instructors to remotely engage with learners. the current research investigated the students' perceptions of the use of metaverse systems in medical training within the medical community of the united arab emirates (uae). methods: a conceptual model comprising the adoption properties of personal innovativeness, perceived enjoyment, and technology acceptance model concepts was utilised. the current research targeted students in uae medical universities. data was obtained by conducting online surveys that were implemented in the winter semester of 2021/2022 between 15th february and 15th may 2022. 500 questionnaires were issued to students following their voluntary participation and 435 questionnaire responses were obtained i.e. an 87% response rate. the research team tested the measurement model employing structural equation modeling using smart partial least squares version (3.2.7). results: statistically significant associations were confirmed to exist between personal innovativeness (pi) influenced by both the perceived ease of use (peou), and perceived usefulness (pu) (β= 0.456) and (β= 0.563) at p<0.001. the statistically significant associations involving perceived enjoyment (ej) and peou and pu (β= 0.554, p<0.05), (β= 0.571, p<0.05) were further confirmed. additionally, peou had a relationship with pu (β= 0.863, p<0.001). eventually, peou and pu significantly influenced the participants’ inclination to use the metaverse technology with (β= 0.745, p<0.001) and (β= 0.416, p<0.001), respectively. alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 3 | 14 conclusion: conclusions made during the research add to the existing literature regarding technology adoption by demonstrating how adoption properties, perceived enjoyment, and personal innovativeness influence students’ perceptions concerning innovational technologies used in education. keywords: metaverse; covid-19 pandemic; medical training; medical students; technology acceptance model; sem based analysis. conflicts of interest: none declared. alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 4 | 14 introduction with the rapidly increasing demand for digital products and services in the contemporary world, computer scientists and researchers develop ideas to improve the experiences of computer users. among the most recent innovations in the digital world is the use of three-dimensional virtual environments (1,2). metaverse is a term commonly used to refer to virtual and augmented reality. the term was invented in 1992 (3) where a science fiction novel was composed to describe the future of immersive 3-dimensional virtual reality technologies. virtual reality allows users to experience diverse digital mirrors of their world and aspects that do not exist in the real world (1,4–6). multiple research studies have been conducted in universities and other learning institutions to investigate the effectiveness of metaverse as a learning tool. such studies focus on the implementation of metaverse through a problem-based approach where different stakeholders in the learning environment can submit queries and obtain feasible solutions to diverse problems using the three-dimensional classes and the avatar (7–10). similarly, a study (11) confirmed that a metaverse platform constitutes a useful tool for increasing motivation and immersion among learners. through such a learning platform, students develop real feelings toward the innovative learning strategy and benefit from self-guided learning experiences. therefore, the metaverse has been praised to contribute to a positive learning experience. metaverse has also been observed to contribute to research in diverse fields. multiple studies (7,8,12) investigate key benefits of using metaverse systems in diverse fields of research. the studies predominantly focused on real-life experiments where virtual or augmented reality is used to develop solutions to various problems. with respect to inferences from the various studies, it is important to develop a conceptual framework that takes into consideration the influential role of metaverse systems in education. adopting such a conceptual framework could help to determine the effectiveness of the metaverse system by studying how students perceive it. through this study, a model will be developed to describe the crucial factors for an effective learning strategy, which include perceived enjoyment (ej) and personal innovativeness (pi). pi is influenced by two factors that include perceived usefulness (pu) and its perceived ease of use (peou) (13,14). therefore, this study will investigate how innovativeness of medical students who use the metaverse system is influenced by peou and pu of the technology. the general objective is to study key factors that determine the implementation of the metaverse in the united arab emirates (uae) medical education system and establish whether the peou and pu are depicted in the current metaverse system. the study will also describe how the technology impacts an individual’s enjoyment and pi following the implementation of the metaverse system. consequently, findings from the current study will summarise the key factors surrounding students’ perceptions regarding the implementation of metaverse systems. unlike similar past studies that have utilised the structural equation modeling (sem) strategy to develop theoretical models, the current study will integrate technology acceptance model (tam) to examine learners’ inclination to adopt metaverse as a learning tool (15). eventually, the study will validate the developed theoretical model by utilizing the partial least squares -sem (pls-sem) approach. alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 5 | 14 the innovation theory will be used to guide the research methodology. the theory classifies consumers of technological innovations as innovative members of society who actively seek information and innovational ideas (16,17). users of technology are often forced to overcome their uncertainty and develop a positive inclination to use technology. their innovativeness helps them to shape their beliefs and attitudes towards achieving greater innovation through the use of technology. pi has been observed to cause a substantial impact on a person’s ability to cognitively interpret information technology which symbolises the risk-taking inclination to use technology (18,19). tam describes how individuals’ innovativeness in the use of technology is influenced their perceptions regarding its usefulness and userfriendliness (15). therefore, the basic aspects of the proposed model comprise the perceived user-friendliness and the pu of the system. pu refers to the extent to which a user of technology believes that it will positively influence their ability to compete certain tasks. on the other hand, peou refers to how much a person is convinced that a technology would improve their experiences by reducing the effort required to complete certain tasks. significant associations have been confirmed to exist involving an individual’s behavioral intentions and the level of satisfaction with their use of the technology. therefore, the conceptual model suggests that the pu and perceived userfriendliness of technology are dependent on pi, which indicates the need to leverage the metaverse system in medical education (20,21). considering the identified assumptions, the current study theorises that: h1: pu is positively affected by pi. h2: peou is positively affected by pi. the study defines ej as the degree to which an individual feels enjoyment and is satisfied by their performance in certain tasks. it is often perceived as the extent to which consumers of technology gain satisfaction with the virtual reality technology. past studies have evaluated ej as a qualitative factor that influences the users’ sense of pleasure, disgust, or hate resulting from the use of technology, which further influences their behavior (22–24). as convenience and enjoyment enable users to develop positive perceptions, the ej of technology influences a user’s inclination to use technology, which determines their level of comfort in the long run (24,25). as such, the current study hypothesises that; h3: pu is positively affected by ej. h4: peou is positively affected by ej. the tam theory describes how the perceived user-friendliness and usefulness of technology influences the users’ inclination to accept and adopt it. the perceived userfriendliness is considered to be level of effectiveness and comfort that individuals experience after using an innovative technology. in contrast, pu refers to the effort-free experience that positively impacts the user’s performance (26). the current study theorises that; h5: pu is positively affected by the peou. h6: an individual’s intention to use metaverse system in medical training (in) is positively affected by the pu of the technology. h7: an individual’s intention to use metaverse system in medical training (in) is positively affected by the peou of the technology. based on the above, the study seeks to measure the acceptance and implementation of the metaverse system by analyzing the ej and pi relative to other independent variables. the proposed research model relies on the earlier identified hypotheses as depicted in figure 1 below. alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 6 | 14 figure 1. research model. methodology the current research targeted learners in uae universities. data was obtained by conducting online surveys that were conducted in the winter semester of 2021/2022 between 15th february and 15th may 2022. a link to the survey as well as details regarding the research objectives were emailed to members of the target population. the information was also shared across the students’ social media groups to maximise the response rate and gather a sufficient number of individuals to participate in the study. 500 questionnaires were issued to students following their voluntary participation and 435 questionnaire responses were obtained, which constituted an 87% response rate. the exclusive inclusion of students was since students are the most affected group of stakeholders who use the metaverse systems in the university setting. whenever technology presents challenges to students, universities consider leveraging more efficient tools to stimulate students' performance. as instructors possess vast experience and diverse competencies, they can contribute to the university’s process of leveraging new technologies that could provide better user experiences to students. the selected sample size was sufficient enough to provide the desired information during the study. as (27) suggests, a population of 1500 members ought to have an estimated number of at least 306 respondents taking part in a study. on that account, a sample size of 435 is considered large enough to meet the current research objectives. to validate its hypotheses, the study utilised a survey to collect the desired information. the survey comprised 14 items that helped to evaluate the five major constructs that the research sought to analyse. questions used in preceding studies were restructured to concur with the needs of the current study and facilitate the applicability of conclusions. the collected data was assessed using a fivepoint likert scale based on 5 statistics that ranged between strongly agreed (5) and strongly disagree (1). an evaluation using a alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 7 | 14 sem is efficient for the current study’s sample size, which would help to test the study hypotheses (28). although preestablished theories were used to develop the hypotheses, they focused on the implementation of the metaverse systems in the medical education setting. the research team tested the measurement model using smartpls version (3.2.7) while further assessments were conducted using the path model. the construct of reliability and validity was considered when assessing the measurement model. the strategy was recommended by (29) where construct reliability was confirmed by assessing composite reliability (cr), dijkstrahenseler's alpha (pa), and cronbach’s alpha (ca). additionally, validity was determined by establishing both the discriminant and convergent cogency. results participants’ description as demonstrated in table 1, the proportion of male and female participants was 53% and 47% respectively. the age distribution of the participants was generally even with 72% of the respondents ranging between 18 years and 29 years while 28% had surpassed the age of 29. a larger proportion of the respondents were seeking university degrees with 11% having doctoral degrees, 33% having master's degrees, and 56% of them having bachelor's degrees. a purposive sampling strategy was utilised in the study due to its effectiveness in studies where respondents are willing to volunteer (30). table 1 . demographic data of the respondents. criterion factor frequency percentage gender male 232 53% female 203 47% age between 18 to 29 314 72% between 30 to 39 78 18% between 40 to 49 35 8% between 50 to 59 8 2% education qualification bachelor 244 56% master 145 33% doctorate 46 11% convergent and discriminant validity as demonstrated in table 2, construct reliability was confirmed as ca ranged between 0.801 and 0.857, which were higher than the standard value of 0.7 (31). the assessment also revealed that the cr ranged between 0.812 and 0.859, which is greater than the standard threshold of 0.7 (32). therefore, it was necessary to consider evaluating and reporting cr using pa to check for the reliability of the research data (33). dijkstra-henseler's alpha ought to present values greater than 0.07 in investigative studies and values that exceed 0.8 for other types of research (31,34). as depicted in table 2 below, the reliability coefficients for all measurements exceed 0.70, which confirms the construct reliability. consequently, the constructs considered in the study were reported to be unbiased by the end of the study. the average extracted value (ave) and factor loading were also alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 8 | 14 tested during the study. such analyses facilitate the confirmation of convergent validity, which determines the overall reliability of research conclusions (29). as depicted in table 2, the factor loadings exceeded the standard value of 0.7 while ave values ranged between 0.625 and 0.755, which exceeds the standard value of 0.5. therefore, convergent validity was confirmed for all constructs. the heterotrait-monotrait ratio (htmt) is measured as the primary strategy to determine discriminant validity (29). the htmt values for all constructs were less than the standard value of 0.85 (35), which indicates the conformity of the htmt ratio as presented in table 3. as such, the discriminant validity was confirmed. as such, no significant inconsistencies related to validity and reliability were observed when conducting the assessment. findings from the analysis confirmed feasibility of the structural model in analyzing the research data. table 2. convergent validity results (factor loading & cronbach’s alpha,). constructs items factor loading cronbach's alpha cr pa ave perceived enjoyment ej1 0.815 0.851 0.85 3 0.85 0 0.62 5 ej2 0.829 ej3 0.836 personal innovativeness pi1 0.854 0.857 0.85 9 0.85 3 0.70 5 pi2 0.798 pi3 0.792 perceived ease of use peou1 0.841 0.826 0.83 2 0.82 1 0.65 9 peou2 0.836 peou3 0.856 perceived usefulness pu1 0.790 0.825 0.81 9 0.82 3 0.75 5 pu2 0.799 pu3 0.810 users’ intention to use the ms in1 0.822 0.801 0.81 2 0.80 2 0.70 2 in2 0.840 table 3. heterotrait-monotrait ratio (htmt). ej pi peou pu in ej pi 0.765 peou 0.369 0.632 pu 0.756 0.619 0.531 in 0.335 0.577 0.605 0.768 alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 9 | 14 hypotheses testing results key variables of the study had percentages of variance of 72%, 76%, and 70% respectively as presented in figure 2 and table 4. beta (β) values, t-values, and p-values presented in table 5. the empirical data used in the study confirmed the hypotheses h1, h2, h3, h4, h5, h6, and h7. statistically significant associations were confirmed to exist between pi was observed to be influenced by both the peou and pu (β= 0.456) and (β= 0.563) at p<0.001, which confirms hypotheses h1 and h2. the statistically significant associations involving ej, peou and pu (β= 0.554, p<0.05), (β= 0.571, p<0.05) confirmed the hypotheses h3 and h4. additionally, peou had a considerable relationship with pu (β= 0.863, p<0.001), which confirmed the validity of hypothesis h5. eventually, peou and pu significantly influenced the participants’ inclination to use the technology with (β= 0.745, p<0.001) and (β= 0.416, p<0.001), respectively, which confirmed the hypotheses h6 and h7. table 4. r2 of the endogenous latent variables. construct s r2 results in 0.698 high peou 0.724 high pu 0.762 high table 5. hypotheses-testing of the research model (significant at p** < = 0.01, p* < 0.05). h relationship path tvalue pvalue direction decision h1 pi -> pu 0.563 10.217 0.002 positive supported** h2 pi -> peou 0.456 8.302 0.005 positive supported** h3 ej -> pu 0.571 6.557 0.015 positive supported* h4 ej -> peou 0.554 5.689 0.018 positive supported* h5 peou -> pu 0.863 15.083 0.000 positive supported** h6 pu -> in 0.416 18.226 0.000 positive supported** h7 peou -> in 0.745 17.119 0.000 positive supported** alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 10 | 14 figure 2. path coefficient of the model (significant at p** < = 0.01, p* < 0.05). discussion and conclusion this study investigated the students' perceptions of the use of metaverse systems in medical training within the medical community in the uae. in essence, the metaverse system constitutes one of the technologies that will cause a meaningful impact on medical education. the innovative technology facilitates various educational practices in the contemporary world. the technology is likely to replace the internet and introduce greater innovation to transform teaching and learning. having investigated the perceptions among university students regarding the implementation of the metaverse technology in education within the uae, the current study found that pi, ej, pu, and peou factors are significantly affecting the learners’ perceptions concerning the use of metaverse in medical education at p<0.001. the current study found that there exists a close association between the learners’ perceptions concerning the use metaverse and their levels of innovativeness. indeed, this finding from the study concurred with past research works (15,18-21). users of technology are often forced to overcome their uncertainty and develop a positive inclination to use technology. their innovativeness helps them to shape their beliefs and attitudes towards achieving greater innovation through the use of technology. pi has been observed to cause a substantial impact on a person’s ability to cognitively interpret information technology which symbolises the risk-taking inclination to use technology (18,19). furthermore, the basic aspects of the tam model comprise the perceived userfriendliness and the pu of the system. in addition, the study findings revealed the ej factor has positive effects on pu and peou (p<0.001). past studies have evaluated ej as a qualitative factor that influences the users’ sense of pleasure, disgust, or hate resulting from the use of technology, which further influences their behavior (22–24). as convenience and enjoyment enable users to develop positive perceptions, the ej of technology influences a user’s inclination to use technology, which determines their level of comfort in the long run (24,25). the students’ perceptions regarding the technology were further influenced by alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 11 | 14 perceptions regarding the peou and eventual pu of the metaverse system in the education setting. findings from the study concurred with past research works as it describes students’ experiences with innovational technology used in the contemporary education sector. certainly, several technology theories describe how the perceived user-friendliness and usefulness of technology influences the users’ inclination to accept and adopt it. the perceived userfriendliness is considered to be level of effectiveness and comfort that individuals experience after using an innovative technology. in contrast, pu refers to the effort-free experience that positively impacts the user’s performance (26). however, the study had several limitations that included its exclusive reliance on two variables that include pi and ej. additionally, the tam constructs only used two constructs of peou and pu to make the 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population of the ziguinchor region in senegal martial coly bop 1, kossivi akoetey 2, boubacar gueye 1, cheikh tacko diop 1, papa gallo sow1, ouseynou ka 1, abdoulaye diop 4, fatou sarr sow 3 1 alioune diop university of bambey; 2 school of economics, clermont auvergne university; 3 cheikh anta diop university of dakar; 4 assane seck university of ziguinchor; corresponding author: dr martial coly bop; address: alioune diop university of bambey /region of diourbel, departement of bambey, box 54, bambey, senegal; email: martialcoly.bop@uadb.edu.sn mailto:martialcoly.bop@uadb.edu.sn bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 2 | 12 abstract access to health services is a concern around the world. different strategies were developed, but africa’s rate remains the lowest. this article aims to contribute to the population's access to healthcare, and to assess the determinants of the use of mutual health insurance by the population of the ziguinchor region in senegal. methods: the study is transversal and descriptive, carried out from july to august 2018. through the quota method we defined the number of patients to be interviewed. thus, by a geographic stratification according to the departments and a second-degree stratification taking into account the staff of the different hospital departments, 392 patients were selected. results: 73% at the regional hospital center and 27% at the regional peace hospital. response rate: 97%, women 60% and men 40%. the enrollment for women (24%) is slightly higher than that for men (21%). socio-economic factors. the rate of adherence is the highest of for patients with university level, followed by high school; income: the highest rate for patients with a monthly income between 200,000 and 500,000 fcfa, followed by patients with an income monthly between 100,000 and 200,000 fcfa. factors linked to the provision of care: the rate of mutual health insurance adherence follows distances from patients' homes. concerning the relation to satisfaction, education, distance and information are more determining than adherence rate. recommendations: 1) state: actions on education and distance; 2) sensitizing the population on mutual health insurance; 3) urging healthcare providers to reduce waiting times and respect schedules as well as appointments. keywords: mutual health insurance, membership factors, insurance, universal coverage, care services access, healthcare providers, senegal. bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 3 | 12 introduction during the colonial period, health care was free for the urban populations (6). faced with the difficulties of the health system, reorganization was adopted for the partial recovery of costs through the participation of the populations in care costs. despite these actions, several constraints remained, including the reduction in access to health care and the weakness of the social security system which only covers a tiny part of the african populations (1). access to health care and services is a concern around the world. this situation is explained by the multitude of barriers, financial, geographic and socio-cultural. in africa, with the end of the welfare state, countries subjected to the rigors of structural adjustment in the 1980s could no longer bear all the costs relating to the provision of care and services to the population. the low participation of the state in health expenditure generates about 85% of the expenditure borne by patients, resulting in increased expenditure and impoverishment of households. to help people get out of this self-sustaining poverty, situation, initiatives have been taken to improve the health sector and contribute to poverty reduction. however, the finding is less encouraging, and africa remains the continent with the lowest rate of access to health care (8,2%) (1). thus, the world health organization and the united nations international children's relief fund have agreed to help low-income countries to set up a system of pooling health risks to increase health coverage for populations and significantly reduce payment for health services at the fund. in this new impetus, many low-income countries, including senegal, have opted for the establishment of a risk pooling system based on mutual health insurance. developed in several african countries, it shows low population coverage (2, 7). several studies have been carried out, particularly in the region of ziguinchor and kaffrine in senegal (3, 4) to identify weaknesses and strengths in the system, to enable leaders to make corrections. we note that in senegal, more than 80% of the informal sector haven’t joined (5). it’s therefore to contribute to a better knowledge of the subject and provide useful information to public decision-makers that we situate our study, in order to understand the factors likely to strengthen the coverage of mutual health insurance (mhi) in africa, in particular, in senegal. thus, our objective is to assess the determinants of the use of mhi by the population of the region. methods the study was carried out in the ziguinchor region (three departments, 641,253 inhabitants (8) and two level 2 hospitals, regional hospital center (rhc) and peace hospital (ph) in ziguinchor. the information collected from the nursing services of the two structures enabled us to estimate the annual number of patients for the rhc at 63,756 and 43,206 for the ph. the study was cross-sectional and descriptive. the study population consisted of patients from hospitals, who are concerned with community-based health care services and coming from the region. any patient at the hospital who agreed to be interviewed was included in the study. however, any patient with limitations in responding or with a disability during the survey period or under the age of 18 or over 60 or receiving a health insurance institution or budget charge was excluded from the study. sampling and sample size the units in the sample were only patients from members and non-members of the mhi coming from all departments in the region for treatment. the quota method was used to define the number of patients to be interviewed, bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 4 | 12 according to the administrative departments and to the different hospital services. first, we did a geographic stratification according to the three departments of the region: the quotas of patients to be interviewed depended on the size of the populations in each department (table 1). table 1: distribution of the population according to the departments table 2: distribution of patients in hospital departments 2016-2017 départements population ajusted population (11%) ziguinchor 330 112 293800 bignona 318 478 283445 oussouye 64 850 57717 total 713440 634962 regional hospital hospital of peace services 2016 2017 average 2016 2017 average medecine 2961 3525 3243 2961 3525 3243 surgery viceral 886 574 730 886 767 827 surgery ortho 1927 1669 1798 1927 1667 1797 sau 10918 12143 11531 10918 12137 11528 maternity 7671 6981 7326 7671 6981 7326 orl 2187 2148 2168 2187 2148 2168 cardiology 560 465 513 560 495 528 stomatology 1265 1327 1296 1265 1327 1296 ophtalmology 5724 7239 6482 5724 7239 6482 physiotherapy 465 439 452 465 439 452 crao 530 368 449 530 347 439 radiology 7524 7454 7489 1322 2361 1842 laboratory 18856 17325 18091 2975 3207 3091 dermatology 2126 2254 2190 2126 2255 2191 total 63600 63911 63756 41517 44895 43206 bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 5 | 12 second, we did a second-degree stratification taking into account the staffing levels of the different departments of the two hospitals. the number of patients to be interviewed in the different departments was defined according to the number of patients in each department (table 2). to avoid duplication, we have only presented data on the number of consultants. to determine the sample size, we set a margin of error of 5% and a confidence level of 95%. in the framework of our study, the parent population is known and according to the theorem of the centered and reduced normal distribution, when a random sample of size is not greater than 30, the distribution of the sample follows a normal distribution n of mean p and standard deviation σ (p) with σ (p) = √𝑝 ∗ [(1 − 𝑝)]/𝑛 . assuming the assumption of the sample with replacement, we have: t * l with t the confidence rate that we establish at 95% and l the margin of error set at 5%. the formula for the size of the sample was thus obtained: 𝑛 = 𝑡2 × 𝑝(1 − 𝑝) 𝐿2⁄ , p being the rate of adhesion of the population to mhi in the region. according to the regional agency for universal disease coverage (acmu) of ziguinchor, it would be 39.9%. according to calculations, the minimum sample size is 369. at this figure, we weighted by adding a 10% margin to account for non-responses or recording errors. the sample size was estimated to be 405. variables studied the literature review helped to choose the variables cited below. the socio-economic determinants were composed of sex, marital status, level of education, socio-professional status, association membership and income of the patients. demographic determinants consisted of household size and patient age. the determinants linked to the use of mutual health insurance were represented by membership in a mutual health insurance, the reasons for membership, for non-membership in mhi, the means of information on mhi, the perception of members for mhi, preference for membership in mhi and respect for the medical pyramid. regarding services, the determinants related to the distance from the nearest health center, the competence of care providers, satisfaction with care, inequalities in relation to care and the waiting period. data collection data collection was carried out during the period from july to august 2018. we used the sphinx software for the design, layout and adjustments of the questionnaire. after designing the questionnaire, we had to train a total of eight people to collect the data. during the training, we translated the questionnaire into the local language, followed by a field test on patients not concerned by the survey, including patients from the entry office. this test step of the questionnaire allowed us to interview around 20 patients and correct shortcomings on the questionnaire, including the order of the questions and the way in which the answers were recorded. it also allowed us to determine together with the trained agents, a clear and concise message on the definition of mhi, the interest and the acceptance to participate in the study that was transmitted to patients who were not members or who have never heard of mhi, and also determine the interview time. data processing and analysis we used the sphinx software to enter and codify the data. after the entry, we did a detailed proofreading, and we corrected the anomalies observed in the database. then, the stata software helped in the statistical analysis of data on socio-economic bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 6 | 12 and demographic characteristics, the use of mhi and the provision of care. to deepen the analyzes in order to identify the factors related to the adhesion and use of mhi, we carried out an econometric modeling. the variable to be explained is adherence to mhi. it is made up of the yes modality if the patient is a member of an mhi and the no if not. the dependent variable being a binary qualitative variable with two modalities and the explanatory variables are either qualitative or quantitative. the logistic model was chosen for the data analysis. as the study is cross-sectional, this method allowed us to compare individuals with each other. to do this, we used the following logistic regression equation: logit𝑦𝑖 = 𝛼 + 𝛽j𝑥𝑖j + 𝜀𝑖: 𝑦𝑖 is the dependent variable for individual i in the sample. here it represents mhi membership and is a binary qualitative variable with 1 if the patient is a member of a mhi and 0 if not; 𝜶 is the constant that explains the random part of mhi membership; 𝛽j represents the effect of an explanatory variable j in the model, i.e. the effect of determinants on mhi adherence; 𝑥𝑖j represents the explanatory variable j for an individual i of the model; 𝜺𝒊 represents the error term. in order to capture all the possible effects of the explanatory variables, we adjusted the model. therefore, we performed the chi-square goodness-of-fit test. results in total, we surveyed 392 patients from the various hospital departments and departments in the region, including 73% surveyed at the rhc and 27% surveyed at the ph. compared to pre-established estimates, we recorded a response rate of 97%. socio-economic characteristics of patients the results of the survey showed that women made up 60% of the sample compared to 40% of men. the enrollment rate for women was slightly higher than for men. in the sample, married patients were predominantly represented, followed by single people. in contrast, the membership rate was higher among divorced people who represented only 7% of the total sample (table 3). patient demographics in our sample, the average household size was 10 people and a maximum of 30 people for larger families. the patients interviewed had in their families on average two children under 5 years old and on average two people over 60 years old. the average age of the patients was 34 years. factors related to the use of mhi the results of our survey of patients in hospitals in the region showed a 23% adherence rate. regarding patients who had no health coverage, 53% said they had never heard of universal or community health coverage. of those patients who had heard of it at least once, 67% said they did not have clear information about the enrollment processes, prices, location, and content of the program. the remainder said they did not trust mhi because some pharmacies and health centers would refuse members' diaries; or that they found the procedures too long or that «the program is no longer moving forward because the state is no longer providing funding» (table 4). the mhi encountered difficulties related to late payments of state subsidies, which limited their functioning and activities. they have a major problem related to the lack of staff. the voluntary staff in charge of the management of the mhi incurred exorbitant expenses related to travel and catering which were not reimbursed by the mhi. bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 7 | 12 table 3 : the socio-economic characteristics of the patients surveyed characteristics member non member total sample sexe female 24,15 75,85 60,46 male 20,92 79,08 39,54 marital status single 15,38 84,62 33,16 partner 0 100 0,26 divorced 30,77 69,23 6,63 married 27,03 72,97 57,4 vidower (vidow) 10 90 2,55 level of study no 13,64 86,36 16,84 koranic school 25 75 10,2 primary 15,56 84,44 11,73 secondary 24,39 75,61 42,35 university 31,08 68,92 18,88 socioprofessionnal status farmer/breeder 26,47 73,53 8,67 artisan 7,69 92,31 3,32 other 22,22 77,78 11,48 trader 20 80 27,3 employee(private) 36,11 63,89 18,62 student 18,92 81,08 18,88 household 17,39 82,61 11,73 associative membership in the past 27,5 72,5 11,8 no 20,16 79,84 38,35 yes 28,14 71,86 49,85 patients income under 30 15,52 84,48 29,59 30-60 24,46 75,54 14,54 60-100 26,56 73,44 3,06 100-200 28,07 71,93 35,97 200-500 33,33 66,67 16,58 over 500 0 100 0,26 bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 8 | 12 table 4: factors related to the use of mhi characteristics freq. percent member of a mhi no 300 77.12 yes 89 22.88 reasons for no belonging to mhi other 137 46.60 don’t know the mhi 157 53.40 reasons for non-mhi membership proceédures too long 2 1.52 to desist 1 0.76 pharmacies refuse notebooks 2 1.52 lack of information 88 66.67 lack of confidence 30 22.73 lack of means 3 2.27 program stopped 5 3.79 in progress 1 0.76 means of information on mhi other 17 12.98 mass awareness 13 9.92 member of mhi 28 21.37 the medias 27 20.61 a relative 46 35.11 perception des membres aux mhi good 99 84.62 bad 4 3.42 very good 14 11.97 preferred membership modes of members of mhi individual 10 8.70 family 99 86.09 (associative) group 6 5.22 respect for the medical pyramid no 21 36.21 yes 37 63.79 bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 9 | 12 factors related to the provision of care patients with a health center less than two kilometers from their homes have the highest adherence rate, followed by patients who have a health center between 2 and 5 kilometers from their homes and patients whose homes are more than 10 kilometers from a health center are not members of the mhi. most of the patients surveyed admit that healthcare providers are in control of their job and therefore competent. patients who think healthcare providers are very competent show a higher rate of 44% membership while those who think providers have no skills are not members of mhi. likewise, the majority of respondents are satisfied with the treatments received. the results of econometric modeling have shown that the presence of people over the age of 60 in the household has a significantly negative impact on mhi membership. with regard to overall satisfaction, the majority of patients surveyed declared that they were not satisfied; 55% of them say that the waiting times are too long and that they are not well received (table 5). table 5: factors related to the provision of care characteristics member non member total sample distance to the nearest health center under 2 26,58 73,42 56,89 ]2-5] 19,33 80,67 38,78 ]5-10] 7,69 92,31 3,32 ]10-20] 0 100 0,51 over 20 0 100 0,51 health care provider skills no skills 0 100 1,81 moderately competent 17,86 82,14 14,51 competent 16,07 83,93 58,55 very competent 44,33 55,67 25,13 satisfaction with care yes 23,33 76,67 84,87 no 20,69 79,31 15,13 inequalities in relation to care yes 29,25 70,75 28,57 no 21,51 78,49 71,43 timeout short 38,46 61,54 3,34 normal 28,57 71,43 41,39 too long 17,84 82,16 55,27 bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 10 | 12 the results of the estimations showed that neither the income, nor the association membership, nor the presence of children in the household, nor the age of the patients, nor the satisfaction linked to the treatments received nor the aforementioned waiting times have significant impact on mhi membership. regarding the level of study, the estimations carried out have shown a significant effect of the secondary level of education on the adherence to the mhi. patients who have a level of secondary education have a 195% chance of adhering to the mhi, in contrary to patients who don’t have any level of study. likewise, the estimates of the results from the logistic regression and the robustness model have shown that variables such as household size, the presence of elderly people in the household, the perception that individuals have on mhi and their self-confidence, and the respect of the long procedures to receive care have a significant impact on the adhesion to the mhi. the significantly positive impact of the size of the household on the membership in the mhi companies shows that the larger a household, the more it adheres to mhi. finally, the result of our data analyzes showed a significantly negative effect of adherence to the medical pyramid on mhi adherence. this means that the more restrictions there are in the procedures to be followed in order to receive care, the less the members have free choice of treating physicians and the less they adhere to the mhi. in addition, some patients felt that the posts and health centers are full of poor skills and can worsen their health in the event of illnesses that would require strong skills or emergencies. these results, little known in the literature, constitute a particular contribution of this study (table 6). table 6 : logistic regression logistic regression number of obs = 332 lr chi2(6) = 230.76 log likelihood = -71.316718 prob > chi2 = 0.0000 pseudo r2 = 0.6180 appartenencems2 odds ratio std. err. z p>|z| [95% conf. interval] pyramidmedical .1125208 .0543078 -4.53 0.000 .0436922 0.2897759 taillemenage 1.143535 .0461296 3.32 0.001 1.056604 1.237618 confiancems 8.769468 4.12697 4.61 0.000 3.48652 22.0574 personneagee .3468341 .1663387 -2.21 0.027 .1354855 .8878728 niveausecond 2.957122 1.42276 2.25 0.024 1.151677 7.592902 perceptionms 56.59515 29.61976 7.71 0.000 20.29049 157.8578 cons .000432 .0005158 -6.49 0.000 .0000416 .0044867 bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 11 | 12 discussion the shortcomings identified in the context of our work are of three types: representativeness bias, information bias and judgment bias. according to the literature, depending on the nature of the questions asked, the answers of those in favor can tend to be those of biased actors (9), which can generate judgment biases. to this end, it would imply caution in interpreting the results across the region. studies on the determinants of mhi adhesion and use are few and lack of available data (10). the few rare studies that have addressed the subject are unanimous on a number of factors such as: education, lack of communication and low household income. in our study, the results showed that adherence is progressive depending on the level of study. these results are similar to the one carried out in ziguinchor (3) which claims to have found a significant link between the level of education of the head of household and membership in the mhi. also, as patients' income increases, so does their willingness to pay mhi premiums. education has a significant impact on health. it enables highly educated people to have a high socio-economic status, improves entrepreneurial capacities (11). thus, people with a high level of education would be likely to have health coverage and by extension, to join more in the mhi. like education, according to the literature (10, 4), income is a key variable in the factors of mhi adherence. in contrast, in other work (2, 12), the authors have shown that they found no significant association between income and mhi membership. demographics also play an important role in mhi membership. household size and the presence of elderly people in the household have a significant impact on mhi membership. the significantly positive impact of household size on membership in mhi shows that the larger a household, the more it adheres to mhi. conversely, the presence of people over the age of 60 in the household has a significantly negative impact on mhi membership. this result is confirmed by the study carried out in the ziguinchor region (3). it could no doubt be explained by the establishment of free programs of the state for the latter. the almost free care for people over 60 years old would prevent them and those around them from joining the mhi. in order for there to be consistency between the free programs put in place and the health coverage program by the mhi, a partial subsidy for the care of the latter would make the two programs more equitable and would prevent individuals, especially older, to anticipate not to join the mhi. then, the state could put in place a policy of gradual subsidies in favor of large families. one of the main factors which would constitute a brake on adhesion identified through this study is the lack of information, which has also been identified in certain works (3, 2). thus, mhi, through their unions departments, should organize more mass awareness sessions in public places, in the media and more in private than public training centers. the study did not identify a significant impact between factors related to the provision of care services and adherence to mhi, as some studies suggest (1, 3, 13). this would undoubtedly be linked to the embryonic state of the start of the mhi system in senegal. in contrast, the patients surveyed raised huge issues that need to be addressed to support the process towards mhi maturity. the results of the study showed that the mhi adherence rate also tracks distances from patients' homes. these results are supported by various studies (12, 3) of households which indicate that low adherence is linked to the distance between the household and the health center and the residence in rural areas. this study examining factors related to mhi adherence and use, admittedly had its limitations such as representativeness bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 12 | 12 © 2021 coly et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. bias, information bias and judgment bias, but also had advantages. it could provide a broader knowledge of the functioning of the mhi in senegal and help to identify the factors which would constitute a hindrance to the membership of the mhi in the region. it also provided useful information to help local policy makers and mutual managers to improve the operating system of mhi for greater membership. indeed, our study has shown that the factors which would constitute a brake on the adhesion and the use of the mhi are essentially the lack of information, the income, the education, the large size of households and the presence in household of persons over 60 years of age. conclusions mutual health insurance is a topical issue in the health systems of african countries today. this initiative is taking on an unprecedented scale in the journey of building a resilient health system in africa. although the health risk coverage system through the mhi in senegal is still in a state of initiation and requires more monitoring, it has solid foundations and considerable advantages that could serve as a reference model for other countries on the continent. recommendations: 1) state actions on education and distance; 2) sensitizing the population on mutual health insurance; and 3) urging healthcare providers to reduce waiting times and respect schedules as well as appointments. ____________________________________________________________________________ simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 review article the role of health service delivery networks in achieving universal health coverage in africa knovicks simfukwe1, yusuff adebayo adebisi2, amos abimbola oladunni3, salma elmukashfi eltahir mohammed4, don eliseo lucero-prisno iii5 1the university of zambia, school of veterinary medicine, lusaka, zambia 2 university of ibadan, faculty of pharmacy, ibadan, nigeria 3 ahmadu bello university, faculty of pharmacy, nigeria 4uppsala university, department of public health and caring science, uppsala, sweden 5global health focus-africa corresponding author: knovicks simfukwe; address: the university of zambia, school of veterinary medicine, great east road, lusaka, zambia; email: knovicks26simfukwe@gmail.com abstract mailto:knovicks26simfukwe@gmail.com simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 most countries in africa are faced with health system problems that vary from one to the next. countries with a low human development index (hdi) seem to be more prone to challenges in health service delivery. to mark its 70th anniversary on world health day, the world health organization (who) selected the theme “universal health coverage (uhc): everyone, everywhere” and the slogan “health for all. ”uhc refers to ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation, and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial hardship. uhc is a who’s priority objective. most governments have made it their major goal. this paper provides a perspective on the challenges of achieving uhc in sub-saharan africa (ssa). it also endeavors to spotlight the successful models of health service delivery networks (hsdns) that make significant strides in making progress towards achieving uhc. hsdns propose models that facilitate the attainment of affordability and accessibility while maintaining quality in delivering health services. additionally, it brings up to speed the challenges associated with setting up hsdns in health systems in ssa. it then makes propositions of what measures and strategic approaches should be implemented to strengthen hsdns in ssa. this paper further argues that uhc is not only technically feasible but it is also attainable if countries embrace hsdns in ssa. keywords: health systems, human development index, universal health coverage, sub-saharan africa, health service delivery networks, world health organization. simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 introduction achieving universal health coverage (uhc) is a core target of the sustainable development goals (sdgs) (1). the world health organization (who) defined uhc as ensuring that all people have access to needed health services of “sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial hardship.” (2). in low and middle-income countries (lmics), uhc has become an integral aspect of health reforms (3). unfortunately, many people in developing countries do not have access to quality health services, especially those living in poor and marginalized communities (4). in most countries, challenges towards achieving this target range from reaching all population groups (coverage and accessibility) to the accommodation of all needed services (readiness) and achievement of a reasonable proportion of health service delivery covered (health financial security) (2). health outcomes in african countries remain poor despite commitments and efforts towards achieving uhc. there are expansive shortcomings across all building blocks of health, and progress has been slow in lmics. this is complicated by inadequate resources, inequitable access to health services, and weak health system governance. other challenges such as poverty, unemployment, climate change, conflict, insecurity, among others, have created distractions that make prioritizing health difficult (5). thus, health outcomes tend to correlate with donor support. strengthened preventable maternal and child deaths, strong resilience to public health emergencies, reduced financial insecurity and strengthened the foundation of long-term economic growth will be discerning attributes of countries that achieve uhc by 2030 (11). unfortunately, the increasing population growth rates of countries in africa pose a significant threat to long-term inclusive growth (6). this is further complicated by the double burden of communicable and non-communicable diseases (7). population distribution and geography constitutes substantial challenges to delivering quality health services in africa (8), and accessibility, as well as coverage of essential health services, are very low in africa. there is a lack of a sufficient health workforce to meet the demand of the growing population (13), with a health workforce density of 2.3 healthcare workers per 1000 population (9). other studies from africa have also confirmed that wealth is also closely related to the place of delivery, i.e., the poorest women are least likely to use facility delivery services. out of pocket expenditure on health has been attributed to limited access to health care in the under-served population (11). concerning the shortage of skilled health workers, insufficient resource expenditure on training, poor working environment, difficult living expenses, and poor career path (12) are implicating factors. therefore, there is need to secure greater access to skilled health workers that meet population demands, especially in underserved communities. momentum for uhc in africa is building, and many african countries have already integrated uhc into their national health strategies. but with about 11 million africans pushed into extreme poverty each year because of out-ofpocket health expenses, how can africa achieve uhc, which delivers a quality package of care for people living in africa? to answer this question of significant importance, global health think-tanks and relevant stakeholders such as world bank, who, etc., are not looking any further from health service delivery networks (hsdns) as the prime solution. uhc requires well-functioning health systems that provide high-quality, affordable, accessible, and efficient health services. as such, hsdns provide these strategies aimed at achieving uhc. simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 what are health service delivery networks? it has become obvious to note that networks of collaborating organizations have become critical mechanisms for the effective delivery of healthcare (13). “the rise in network popularity has come largely from the recognition that money alone cannot sufficiently improve the quality of health systems, and that the major health problems facing societies are unlikely to be successfully addressed by individual organizations acting in isolation.” (14, 15). population health may improve only if resources, talents, and strategies are pooled from across a range of actors and organizations (16). networks are defined ‘as a set of nodes and the set of ties representing some relationship, or lack of relationship, between the nodes’ (16). relationships between nodes are typically non-hierarchical and may be founded on many and varied factors, including formal or informal flows of resources, information, people, or ideas (17). the pan american health organization (paho) defines health service delivery networks (hsdns) or organized health services systems, or clinically integrated systems, or integrated health organizations, “as a network of organizations that provides, or makes arrangements to provide, equitable, comprehensive, integrated, and continuous health services to a defined population and is willing to be held accountable for its clinical and economic outcomes and the health status of the population served” (14). this would include referrals between services and is based on the need to provide comprehensive services (18). the final aim is to improve health outcomes, and health services are the most proximate to that end. additionally, health services include infrastructure, human resources, and supplies and technologies necessary to provide care to patients (19). hsdns can be characterized as vertical, i.e., between different levels of service delivery from the community level to the clinic and hospital level, or horizontal, i.e., with providers or organizations working at the same level of service delivery (20). considering the wide range of health system contexts, it’s extremely difficult to prescribe a single organizational model for hsdns in africa. each country’s policymakers must design a model that meets each system’s specific organizational needs. below is an illustration outlining the four domains of the attributes of hsdns. figure 1: pan american health organization. integrated health services delivery networks concepts, policy options and a road map for implementation in the americas. (series: renewing primary health care in the americas no.4) washington, dc, 2010, pp. 32-33) simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 methods a tt r ib u te s o f h e a lt h s e r v ic e d e li v e r y n e tw o r k s financial allocation and incetives adquate funding and financial incetives aligned with network goals. organizati on and manageme nt result based management an integrated network system that links all network members with data dissagregated by sex,place of residence ethnic origin and other partinent variables. sufficient, committed and competent human resources for health that are valuable by the network integrated management of clinic, administrative and logistical support system governance and strategy a unified system of governace for the entire network broad social participation intersectorial action that addresses wider determinant of health and equity in healthy mode of care clear definition of the population territory covered and extensive knowledge of the health needs and preferences of this population, which determines the supply of health services extensive network of health facilities that offers health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation and palliative care and that engages program targeting specific diseases, risk and populations as well as personal and public health needs a multi-disciplinary first level of care that covers the population, serves as a get way to the system and integrate and coordinates first level of care in additon to meeting most of the population health needs existence of mechanism to co-ordinate health care throughout the health service continuum delivery of specialized services of the most appropriate location, preferably in nonhospital settings care that is person, family and community centered and that takes into account cultural and gender related characteristics and delivery simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 eligibility criteria for studies included in the review we considered studies on uhc with or without ssa. in this paper, we considered hsdns as the exposure variable and uhc as the outcome variable. only published articles in peered reviewed journals were considered. articles in languages other than english weren’t considered. in duplicate publications, the article with more complete data was included. pubmed, medline, google scholar, and google search served as sources for these articles. other articles we identified from reference lists of related studies from the included study. dates of coverage were specified. search terms that were used employed the use of boolean operators “and,” “or,” and “not” to refine searches by limiting or combining terms. the key terms to search for articles were “universal health coverage,” “health service delivery networks,” “health systems,” and “sub-saharan africa”. abstract information served was the screening basis and the cochrane risk of bias tool was used to assess the risk of bias. results challenges of setting up health service delivery networks in africa hsdns are distinct from a conventional organizational structure that is devoid of shared commitments to meet the health care needs of the population (21). therefore, organizations establishing hsdns must be aware of potential challenges (22). these challenges form foundations of disadvantages that potentially undermine the establishment of health system models that are compatible with hsdns in africa: the model of hospital care and management, personnel training, governance, financing strategies, and use of technologies. health care processes in africa are fragmented and are not integrated with other levels of care which generates a lack of quality and consistency in health (23). although there is a wide distribution of public health sectors in africa, patients prefer to seek health care in the private sector predominantly due to the perception of confidentiality and quality service delivery in private health establishments compared to the public health sector. private healthcare provision at the primary health care (phc) level has been an independent set of service providers varying significantly in quality of health services with few linkages with a structured health system (24). the implication of this is that it establishes a negative perception of incompetency and mistrust in public health hospitals among users of health care, thereby promoting health-seeking behavior in private establishments and contributing to high out-of-pocket spending. figure 2: health systems in africa simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 perceptions and perspectives (who, 2012. who regional office for africa, 2012). the imbalance between health service needs and health service utilization also constitutes a potential challenge to health hsdns in africa. this creates a deficit and inadequate response capacity at the first level of care in terms of resources (health workforce, medication, and lab supplies) and a weak public hospital network (referral, counter-referral, and feedback system). the exclusive tendency of an international organization to determine health priorities limits the participation of member states in the decision-making process (25,26). this focuses on health intervention projects on the specific disease (vertical programming) rather than communityoriented primary health care intervention (horizontal programming) (24). this situation poses a challenge to the implementation of hsdns due to a lack of shared responsibility among multilateral organizations, ngos, governments, communities, the private sector, medical professionals, and other stakeholders (23). for this reason, there is a need to develop a mechanism that promotes the development of primary health care and improve collaborative network across healthcare levels in an integrated system context that improves accessibility, affordability, availability, and quality of care for the underresourced population. africa has the highest population growth rate (27) and lacks a sufficient health workforce to meet the demand of the growing population (28). this creates shortcomings in the distribution of skilled 0.10% 0% 1.50% 69% 54.90% 67% 30.90% 45.10% 31.50% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% central africa0.1% east & southern africa west africa don't know dissatfisfied satisfied simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 health workforce across the different levels of health care and constitutes a serious challenge to establishing hsdns. a review of the health workforce in five african countries (mali, sudan, uganda, botswana, and south africa) revealed that a minority of doctors, nurses, and midwives are working in primary health centers (phc) and shortage of skilled health personnel are the greatest in rural areas (29). a greater number of doctors trained in mali, uganda, and sudan do not stay to work in government health establishments in their countries, let alone in primary health care, due to inadequate resource expenditure on recruiting or training, poor working environment, difficult living expenses, and poor career path (30). these imbalances in the health workforce model can create a huge gap in health service readiness towards establishing sustainable hsdns in africa. population distribution and topography in ssa present many challenges for health care delivery (31) and hsdns. a geocoded inventory of hospital services across 48 countries in africa reveals that only 16 countries met the international recommendation of more than 80% of the population within a 2-h time of travel to a hospital (32). this situation creates a considerable gap between the demand and supply of health care services among a geographically marginalized population which potentially limits the implementation of hsdns in affected african countries. innovative approaches for integrated hsdns in healthcare delivery in africa are required in specific geographical locations, including improvement of ambulatory services, transportation modes, communication systems, and the number of quality health service centers. information and communication technology (ict) is integral in operationalizing hsdns. although technology in health has a potential beneficial impact on hsdns, high implementation cost and lack of technical skills (33), security and confidentiality concerns (33,34) are barriers to implementation of both in africa. the major barrier to e-health adoption and one that can potentially affect the implementation of hsdns in africa is the lack of cooperativeness between health information systems (hiss) (35). the presence of varying standards in hiss often creates a conflict of interest which makes it quite difficult to establish cooperative governance that offers quality health services in a coordinated and timely fashion. figure 3: access to emergency hospital care simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 ouma et al. access to emergency hospital care provided by the public sector in sub-saharan africa in 2015: a geocoded inventory and spatial analysis. lanc glob health. 2018. vol 6, issue 3, e342-e350. https://www.thelancet.com/journals/langlo/article/piis2214-109x(17)30488-6/fulltext discussion examples of successful models of health service delivery networks the referral pathway model referral systems in healthcare are processes in which a health worker at one level of the health system with insufficient resources (drugs, equipment, skills) to manage a clinical condition seeks the assistance of a betterresourced facility at a higher level to assist him/her, or take over the management of, the client’s case (36). clients/patients in ghana, just like in other african countries such as mozambique, south africa, and zambia, among others, are expected to access services from primary services incrementally (e.g., the community-based health planning services, chps, and health centers), through to secondary facilities (e.g., district hospitals) and if required to the highest services (regional and tertiary hospitals) (37). 36.90% 23.30% 23.30% 46.90% 4.30% 17.40% 6.60% 51.50% 53.10% 3.40% 27.70% 34.40% 46.30% 16.70% 24.20% 57.40% 49.30% 16.40% 13.80% 38.50% 7.10% 43.30% 38.50% 53.40% 7.20% 36.20% 61.40% 49.90% 23.20% 57.20% 7.70% 11.20% 2.70% 39.70% 39.60% 39.60% 5.20% 77.20% 53.80% 6.10% 24.90% 14.70% 17.50% 40.10% 2.70% 20.70% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% % p o p u l a t io n countries https://www.thelancet.com/journals/langlo/article/piis2214-109x(17)30488-6/fulltext#figure simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 figure 4: the referral pathway model amoah p.a, philips d.r. 2017. strengthening the referral system through social capital: a qualitative inquiry in ghana. healthcare 2017, 5, 80. social marketing model the marketing strategies used by the majority of these organizations include both promotion of these services to the poor and the design of these services to meet the needs of this group. social marketing refers to the application of marketing techniques to achieve behavioral changes (38). the population services international (psi) in africa has been making use of this concept for many years. psi runs programs that offer educational programs on reproductive health for urban youth in africa. magazines, television spots, call-in radio shows, and radio drama serve as avenues to address the taboo subject of safe sexual behavior (39). studies have shown that youths have been responsive to these programs, and this resulted in increased contraceptive use and hiv testing (40). in a nutshell, this concept has largely contributed to making health services accessible. simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 contracting out model this involves the delegation of a health-related responsibility by the state to a private partner, and this can be a philanthropic or commercial basis (4,42). the private partner usually includes mining companies in zambia and south africa and faith-based based hospitals in tanzania. these private partners tend to provide subsidized health services to the community, sometimes even those not covered in the contract. type specificity, quantity, quality, and duration of services delegated are outlined in a contract (42). antenatal care, delivery and postnatal services, and the prevention of mother to child transmission of hiv (pmtct) are among the services that are contracted out by the state to private partners. because of the very nature of this model, there has been overwhelming evidence that it improves access to health services and some evidence on improved equity in access (43). foreign-aided model global public-private partnership (gppp) is a collaborative, three-way partnership, including international donors and recipient governments, usually funded by multinational health initiative through a substantial disbursement of funds, in which both government and non-governmental entities participate in decision-making through a mutually agreed upon and well-defined division of labor (44). most of the gppp in african countries such as botswana, malawi, zambia, etc. is aimed at hiv prevention and care-such as the african comprehensive hiv/aids partnership (achap), and detection and treatment of women’s cancers -pink ribbon, red ribbon (with pepfar and the gates foundation). with regards to botswana, gppp has provided the urgently needed infrastructure, equipment, human resources, and training of healthcare providers (45). consequently, gppp cuts the cost of health services on national budgets while improving the access, coverage and, quality of health services being delivered to the people. lower operating costs through simplified medical services “operating costs were lowered by simplifying the medical services provided and using less than fully qualified providers.” (46). for example, east africa and some parts of southern africa have introduced a diploma in clinical medicine. these clinical officers have contributed heavily to hiv/aids prevention and treatment initiatives in africa (47). the use of community health workers (chws) is an excellent catalyst in providing “basic health promotion and healthcare within the communities in which they live” (48). chws are laypeople of varied background, coming from, or based in the communities they serve, who have received brief training on a health problem they have volunteered to engage with have been “cited as part of the solution to the shortage of health workers and lack of universal access to healthcare in low-income” (49, 50) and feature prominently in the who’s workforce 2030 strategy for human resources for health (50). ultimately, this model of hsdns improves the accessibility of health services to poor people. high volume and low unit costs this model is very effective at improving the affordability of healthcare services through maximizing the use of infrastructure, and health personnel, and alternate use of cheaper medical procedures and equipment (51). hospitals that implement this model tend to be located in high-density areas and target low-income groups requiring basic medical care. since the available services are limited, there’s high patient throughput (100 patients per day per doctor). the high productivity of simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 health personnel helps to make the services affordable. r-jolad hospital in nigeria, nsambya hospital in uganda, and selian lutheran hospital in tanzania are examples of successful case studies (52). human resource optimization healthcare organizations have expanded the use of laypeople who are then equipped with skills and help in the distribution of oral contraceptive pills or eye exams. aravind eye system trains high school graduates into paramedical staff like patient flow managers, providers of simple diagnostic procedures, etc. (53). another example is the kisumu medical, and educational training (kemt) model in kenya embarks on improving the quality of care by leveraging human resources. kemt trains existing health workers in a safe procedure (54). these models trek miles in improving access, coverage, and quality of health services. increasing practice in rural areas model ssa experiences a disproportionate burden of access to health services. in its quest to reach the poor, narayarana hrudayala (nh) heart hospital provides health camps in rural areas of india. healthcare workers in these camps provide a cardiac diagnosis with transportation to the hospital for patients who require it (55). this model enhances accessibility to health services. recommended measures that can be implemented to strengthen health service delivery networks in sub-saharan africa.  empowering and engaging people and communities: this strategy allows for skill acquisition and places resources to people as a means of making them become empowered users of health services and advocates for a reformed health system. this is achieved through health education, engaging laypeople as community health workers. empowering and engaging people is also about reaching the underserved and marginalized groups of the population to guarantee universal access to and benefit from quality services that are co-produced according to their specific needs.  strengthening governance and accountability: the requirements for strengthening governance include a participatory approach to formulating policies, decision-making, and performance evaluation at all levels of the health system, from policy-making to the clinical intervention level. the need for good governance in ensuring the best possible results cannot be over-emphasized. this demands that transparency, inclusiveness, reduced vulnerability to corruption which facilitates the best use of available resources and information, become the norm in hsdns.  reorienting the model of care: this strategic approach prioritizes primary and community care services and the co-production of health. this brings about a shift in inpatient to outpatient and ambulatory care and from curative to preventive care. it requires investment in holistic and comprehensive care, including health promotion and illhealth prevention strategies that support people’s health and well-being. reorienting the model of care ensures efficient healthcare services.  coordinating services within and across sectors: the needs and demands of people serve as the basis for coordinating services within and across sectors. for this to be achieved, health care providers within and across health care settings, development of referral systems and networks among levels of care, and the creation of linkages between health and other sec simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 tors should be integrated. this approach improves the delivery of care through the alignment and harmonizing of the processes and information among the different services.  creating an enabling environment: this complex strategy aims at effecting transformational change in leadership 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(original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 1 | 12 original research contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. nathalie ambounda ledaga 1, robertine mamche 1, sylvain honore woromogo 1, jesse saint saba antaon 1, fatou sow saar 2 1interstate centre for higher public health education in central africa (ciespac), brazzaville, congo. 2 director of the gender and family institute dakar, senegal. corresponding author: nathalie ambounda ledaga; address: interstate centre for higher public health education in central africa (ciespac), brazzaville, congo; e-mail: ledagan@yahoo.com mailto:ledagan@yahoo.com ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 2 | 12 abstract aims: this study aims to assess the knowledge of people from central africa about universal health coverage and show the contribution of information-education-communication for its adoption. methods: a cross-sectional analytical study across 4 of 6 central african countries was conducted. independent variables are sociodemographic characteristics. dependent variables are knowledge about information-education-communication and universal health coverage. the questionnaire was disseminated by whatsapp images or word file or copy/paste of the text and send to the contacted and trained focal points. from the smartphone, the filmed or transferred data were entered into a cspro 5.0 input form. mean score calculations and odd ratio with 95 % confidence interval for p < 0.005 were used to make associations. results: the universal health coverage had never been heard of by 56.3% of the participants. the universal health coverage was defined as health insurance by (43.9%), free care (30.3%). respondents with secondary and higher education are more likely to have heard of the uhc than respondents with no education or those with elementary education [or = 2.95 (1.01-8.64), p = 0.021] and [or = 4.27 (1.50 – 12.16), p = 0.002] respectively. conclusion: 9.3% of the economic and monetary community of central africa (cemac) population is aware of the universal health coverage; 89.4% of these accept universal health coverage in their country, and 87.4% of them think that the information education communication could enable better adherence to the universal health communication. implemention of universal health coverage for the general population and adoption of information-education-communication to promote universal health coverage and pool efforts and affiliation procedures in the cemac zone is very important. keywords : universal health, coverage, central africa ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 3 | 12 introduction according to who's definition, universal health coverage (uhc) is achieved when ‘all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship’ (1, 2). universal health coverage « is driving the global health agenda; it is embedded in the sustainable development goals (sdgs) and is now designated by an official united nations uhc day on december 12. ‘although many sub-saharan african countries have made efforts to provide universal health coverage for their citizens, several of these initiatives have achieved little success’ (3,4). local health authorities need guidance on how they can set fair and sustainable priorities (5,6). ‘progressive realisation is invoked as the guiding principle for countries on their own path to uhc and achievement of the sdg health targets. it refers to the governmental obligations to immediately and progressively move towards the full realisation of uhc, recognising the constraints imposed by limited available resources’ (7). information-education-communication (iec) is a process for individuals, communities and societies to develop communication strategies to promote health-promoting behaviour (8). africa's population is young and the burden of non-communicable and communicable diseases is a double burden, the lack of health knowledge could become a triple burden if nothing is done for iec to move towards disease-related communication for development and universal health coverage to prevent, detect and treat diseases early and cheaply (9, 10). within the economic and monetary community of central africa (cemac) countries, university health coverage seems to be unknown to the population despite the commitments made by the states to move towards it (11-14). the objective of this work was to study the contribution of iec in the adoption of universal health coverage by the populations in the cemac zone in 2020. methods study design: this was a cross-sectional, analytical, interventional study conducted from july 15 to july 30 2020 in the major cities of the cemac countries as cameroon, central african republic (car), congo, gabon, equatorial guinea (eg) and chad. study population: residents of the cemac countries, whose general population is estimated at 55 781 513, constituted the target population studied (15). residents under 15 years of age and those who refused to answer the questionnaire were not included. sampling: probabilistic and exhaustive type of sampling was chosen. the sample size, to ensure representativeness, was calculated using daniel schwartz's formula (16): n= p(1-p)(z(α/2) ) 2/ i², where n is the minimum sample size, p is the prevalence of uhc in africa (50%), z(α/2) = is the confidence level of the study at risk α = 95%, i.e. 1.96, i is the accepted printing error on either side of the result, i.e. 5%. we obtained n = 403. sample size by country : the general population by country was 23 779 022 (cameroon), 5 745 135 (car), 5 279 517 (congo), 2 074 656 (gabon), 2 015 334 (eg) and 15 162 044 (chad). to obtain the sample per country, we used the following formula n = (country population x 403) / general population for the 6 countries. thus, we obtained 182 for cameroon, 42 for car, 40 for ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 4 | 12 congo, 16 for gabon, 15 for eg and 110 for chad. data collection tool and collection procedure: we used a questionnaire with two sections, a definition and concepts. the questionnaire was disseminated by whatsapp images or word file or copy/paste of the text and send to the contacted and trained focal points. through relationships with ngos adolescence et santé, exit gate from gabon, whatapps contacts were made in the capitals of the countries; volunteer interviewers were trained and deployed in the city respecting the barrier gestures also those who could fill in numerically did so. in the end, there was one principal interviewer in each country except cameroon where there were two. the questionnaires were filled in and collected in the community face to face in focus groups of less than 5 people and through the whatsapp network on the questionnaire sent online. for the digital responses, questionnaires were sent by whatsapp to the country correspondents who collected the responses via whatsapp before transmitting them via the same channel or internet. variables independent variables : sociodemographic characteristics (age, gender, level of education, marital status, occupation. dependent variables : knowledge of iec and uhc, attitudes towards iec and uhc, adoption of iec and uhc. data entry and analysis: from the smarthphone, the filmed or transferred data were entered into a cspro 5.0 input form, imported and analysed using spss. mean score calculations and or with 95 % ci for p < 0.05 were used to make associations. ethical considerations: requests for authorisation were sent to the ministries of health of the 6 countries with acknowledgement of receipt. informed consent file submitted to participants who read and agreed before participating in the interview. results a total of 403 questionnaires, of which 100 were on hard paper and 303 on digital, were submitted and transferred to the population. only 302 responded, i.e. a participation rate of 74.94% (302/403). out of 6 countries, 4 returned the questionnaires. cameroonian participation represented 37.7%, congolese 34.2%, gabonese 18.5% and central african 9.6% (table 1). sociodemographic characteristics : the mean age was 31.29 ± 10.74 years. the 2534 age group accounted for 39.1%; the 15-24 and 35-44 age groups for 29.1 and 18.9% respectively. the female and male sex represented 46% and 54% respectively, sex ratio: 1.17 (163/139). higher education was found in 52% of the participants. the marital status revealed 65.9% of single people. unemployed participants represented 47.7% (table 1). ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 5 | 12 table 1. sociodemographic characteristics of participants variables number percentage (%) country participation rates cameroon 114 37.7 central african republic (rca) 56 18.5 congo 103 34.2 gabon 29 9.6 age (years) : mean/sd 31.29 (10.74); min/max 15/74 15-24 88 29.1 25-34 175 58.0 45-54 39 12.9 sex sex ratio : 1.17 female 139 46.0 male 163 54.0 education no education 22 7.3 primary 21 7.0 secondary 101 33.4 university 158 52.3 marital status single 199 65.9 married 86 28.5 divorced 14 4.6 widowed 3 1.0 sector of activities public 51 16.9 private 64 21.1 liberal 38 12.6 without 149 49.4 knowledge of uhc and iec: the uhc had never been heard of by 56.3% of the participants. the information sources mentioned by the participants were television (25.8%) and social networks (28%). the uhc was defined as health insurance by (43.9%), free care (30.3%) participants. the concept of iec was not known by 63.6% of participants. social networks, health structures and television represented 24.1%, 24.1% and 15.7% respectively. the participants who acknowledged not having received iec on uhc represented 59.3% (table 2). ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 6 | 12 table 2. knowledge of participants about uhc and iec knowledge number percentage n = 302 % have you heard about uhc ? yes 132 43.7 no 170 56.3 what is the uhc ? health insurance 58 43.9 mutual insurance 4 3.0 free care 40 30.3 dont’t know 24 18.2 other 3 2.3 not specified 3 2.3 you heard through which channel? tv 34 25.8 radio 18 13.6 social networks 37 28.0 health structure 20 15.2 other 18 13.6 not specified 5 3.8 have you heard about iec ? yes 108 35.7 no 192 63.6 not specified 2 0.7 you heard through which channel? tv 17 15.7 radio 16 14.8 social networks 26 24.1 health structure 26 24.1 other 22 20.4 not specified 1 0.9 was there an iec on uhc? yes 39 36.1 no 64 59.3 not specified 5 4.6 ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 7 | 12 attitudes towards the iec and uhc: the uhc was accepted in their country by 89.4% of participants; 81.8% were willing to enrol and 88.4% accepted the iec on uhc. participants without uhc represented 89.4%; of the 9.3% with insurance 42.9% had full coverage (table 3). the origin of the uhc fund was not known for 28.8%. 80.5% of the participants were willing to practice iec. iec on uhc does not exist in their country according to 55.6% of the participants. 87.4% of the participants felt that uhc is necessary for the population; 74.8% had not been trained on iec and 87.4% thought that iec can improve adherence to uhc. table 3. attitudes of participants towards uhc and iec attitudes number percentage n =302 % do you agree with the uhc in your country ? yes 270 89.4 no 30 9.9 not specified 2 0.7 are you ready to subscribe to the uhc ? yes 247 81.8 no 55 18.2 would you accept the iec on uhc ? yes 267 88.4 no 29 9.6 not specified 6 2.0 have you subscribed to an uhc ? yes 28 9.3 no 270 89.4 not specified 4 1.3 if yes total or partial ? total 2 7.1 partial 12 42.9 not specified 14 50.0 are you willing to practice iec ? yes 243 80.5 no 56 18.5 not specified 3 1.0 in your country has there been iec on uhc ? yes 30 9.9 enough 23 7.6 not enough 78 25.8 no 168 55.6 not specified 3 1.1 ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 8 | 12 have you ever been trained on iec ? yes 75 24.8 no 226 74.8 not specified 1 0.4 does iec lead to better adherence to uhc ? yes 264 87.4 no 36 11.9 not specified 2 0.7 influences of socio-demographic factors on the level of knowledge: respondents with secondary and higher education are more likely to have heard of the uhc than respondents with no education or those with elementary education [or = 2.95 (1.01-8.64), p = 0.021] and [or = 4.27 (1.50 – 12.16), p = 0.002] respectively. public, private and liberal sector workers are more likely to have heard of the uhc than non-employees [or = 8.67 (4.26-17.66), p < 0.001], [or = 2.39 (1.29 – 4.44), p = 0.00] and [or = 2.34 (1.11 4.91), p = 0.013] respectively. workers are more likely to have heard of the iec than non-workers (table 4). table 4. influences of sociodemographic factors on the level of knowledge sociodemographic factors yes no or (95% ci) p knowledge: heard about uhc education without education 05 17 primary 9 12 2.55 (0.68 – 9.54) 0.090 secondary 47 54 2.95 (1.01 – 8.64) 0.021 university 88 70 4.27 (1.50 12.16) 0.002 sector of activities public 42 14 8.67 (4.26 – 17.66) < 0.001 private 29 35 2.39 (1.29 – 4.44) 0.003 liberal 17 21 2.34 (1.11 – 4.91) 0.013 without 37 107 144 (100) knowledge: heard about iec sector of activities public 30 26 2.89 (1.53 – 5.48) < 0.001 private 28 36 1.95 (1.06 – 3.60) 0.017 liberal 21 17 3.10 (1.49 – 6.47) 0.001 without 41 103 143 (100) ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 9 | 12 discussion the most represented age group was 25-34. the young african population may explain the predominant age ranges. more than half of our respondents were men and university education was more represented as well as the private sector of activity. the period of containment may explain the higher participation rate of men as they are more out of the home and also as workers in the private sectors have many more work constraints than those in the public sector. knowledge: we assessed participants' knowledge of universal health coverage and iec and the ways in which they acquired this knowledge. more than half of the participants had never heard of universal health coverage and the concept of iec, although we found that more than half of the respondents were employees or had attended university. our findings clearly show the low level of knowledge and perception of universal health coverage among the urban population of the cemac zone countries. taking into account the expectations of the populations of the districts of certain countries, which notably show that ‘respondents seek improvements in the quality of care, community engagement activities, expansion of the range of services to include emergency referral services, and enhancement of clinical health insurance coverage to include preventive health services’ (17), it is important for the countries of the cemac zone to initiate perspectives aimed at strengthening the implementation of the uhc by taking into account the actions recommended by the who and certain studies (7,18). the case of nepal and ghana which illustrates the role and contribution of community health worker counseling family is prominent (8, 19, 20, 21). almost half of the respondents defined the uhc as health insurance. one of the paths for strengthening the practice of uhc is therefore health insurance. in the cemac zone, only gabon has adopted this policy; countries are encouraged to have their population subscribe to health insurance, considering that the role of insurance in the achievement of universal coverage within a developing country context has been demonstrated (22) as well as that of the iec (18, 23). health services are expected to play an important role in the implementation of the uhc as more than half of the respondents mentioned these health services. finally, we noted that knowledge of the uhc and iec is related to the respondents' level of education as well as their business sector. cemac member states are encouraged to use different methods to sensitise the population on the uhc as we have noted that correspondents have mentioned social networks and television as the main sources of information on the uhc. it can be seen today that there is an increase in the number of people using social networks and television as sources of information. attitudes : the uhc was accepted in their country by 89.4% of participants; 81.8% were willing to enrol and 88.4% accepted the iec on uhc. we noticed that people are willing to embrace the uhc and the concept of iec, which many have found to be innovative. governments can build on this to boost the uhc. but before that it would be useful to go through a situational analysis at different levels of the community and business sector as proposed by some studies (7,18). study limitations : for this study, covid-19 imposed digital communication and this ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 10 | 12 seemed to be little used by the populations for the surveys; the high penetration rates and costs of the internet seemed to reduce the enthusiasm of the investigators and the surveyed population. the spanish language in malabo obstructed the data collection process. in ndjamena, the investigator did not adopt the digital tool. the rainy season in bangui and the expensive and poorly penetrating internet were reported by the investigator to explain the low participation rate. conclusions less than 10%of the cemac population is aware of the uhc; 89.4% of them accept universal health coverage in their country and 87.4% of them think that the iec could enable better adherence to the uhc. only 30% have an uhc. in view of these results, the following suggestions are proposed to the cemac states: implemention of uhc for the general population, adoption of iec as a means of promoting uhc and to pool efforts and affiliation procedures in the cemac zone is very important. references 1. verrecchia r, thompson r, yates r. universal health coverage and public health : a truly sustainable approach. lancet 2019 ; 4(1) : e10-e11 2. who. what is health financing for universal health coverage ? geneva : world health organization. http://www.who.int/health_financial/universal_coverage_definition (accessed april 04 2021) 3. mclntyre d, garshong b, mtei g, meheus f, thiede m, akazili j, ally m, aikins m, mulligan ja, goudge j. beyong fragmentation and towards universal coverage : insights from ghana, south africa and the united republic of tanzania. bull world health organ 2008 ; 86(11) :871-6 4. chukwuemeka au. challenges toward achieving universal health coverage in ghana, kenya, nigeria, and tanzania. int j health plann manage 2018 ; 33(4) : 794-805 5. jansen mpm, bijlmakers l, baltussen r, rouwette ea, broekhuizen h. a sustainable apporach to universal health coverage. lancet glob health 2019 ; 7(8) : e1013 6. sakolsatayadorn p, chan m. breaking down the barriers to universal health coverage. bull world health organ 2017 ; 95(2) :86 7. who consultative group on equity and universal health coverage. making fair choices on the path to uhc. geneva 2016 8. schwarz r, thapa a, sharma s, kalaunee sp. at a crossroads : how can nepal enhance its community health care system to achieve sustainable development goal 3 and universal health coverage ? j glob health 2020 ; 10(1) :010309 9. sanofi [internet]. the rise and rise of chronic diseases in africa. 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(original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 12 | 12 © 2021 ledaga et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 22. van der heever am. the role of insurance in the achievement of universal coverage within a developing country context : south africa as a case study. bmc public health 2012 ; 12(1) : s5 23. kushitor mk, biney aa, wright kj, phillips jf, awoonor-williams jk, bawah aa. a qualitative appraisal of stakeholders' perspectives of a community-based primary health care program in rural ghana. bmc health serv res 2019 ; 19(1) : 675 __________________________________________________________________________ comment bjegovic-mikanovic, marinkovic-eric. misunderstanding should be avoided by precise formulation: comment on jerliu et al. “public health in kosovo after five difficult years of independence” (letter to editors). seejph 2014, posted: 19 april 2014. doi 10.12908/seejph-2014-21. letter to editors misunderstanding should be avoided by precise formulation: comment on jerliu et al. “public health in kosovo after five difficult years of independence” vesna bjegovic-mikanovic1, jelena marinkovic-eric2 1 university of belgrade, faculty of medicine, centre-school of public health and management, institute of social medicine, belgrade, serbia; 2 university of belgrade, faculty of medicine, institute of medical statistics and informatics, belgrade, serbia. corresponding author: prof. dr. vesna bjegovic-mikanovic, faculty of medicine, belgrade university; address: dr subotica 15, 11000 belgrade, serbia; telephone: +381112643 830; email: bjegov@med.bg.ac.rs 1 bjegovic-mikanovic, marinkovic-eric. misunderstanding should be avoided by precise formulation: comment on jerliu et al. “public health in kosovo after five difficult years of independence” (letter to editors). seejph 2014, posted: 19 april 2014. doi 10.12908/seejph-2014-21. in this review paper, jerliu and co-authors describe the recent steps to reorganize the system of health care in kosovo1 (1-3). only at the end of the abstract and the conclusions the authors speak of five years since the (unilateral) kosovar declaration of independence (not cited among the references) or elsewhere in the text of “transformation to an independent state”, whereas in the title, unfortunately, they speak only of independence. also, the authors state that kosovo currently has been recognized by 105 countries, however, the un family consists of 193 countries, and – as they indicate correctly – kosovo is not yet a member of the world health organization. the precisely formulated expression in international documents is as follows: “the designation of kosovo is without prejudice to positions of status, and in line with the united nations security council resolution 1244/99 and the international court of justice opinion on the kosovo declaration of independence”. the imprecise wording in this paper can lead to misunderstanding which should be avoided (4). beyond the difficult definition of the status of kosovo in the current transition phase, a more important deficit of this paper is the lack of historical reference with regard to the development after world war ii. in 1950, infant mortality in that part of serbia was 141/1000 live births (5), down to 24 in 1995 (6). likewise, maternal mortality has been reduced due to improved health status in general, based on mother and child programmes, healthy community interventions, increased standards of living, and other interventions. health services in kosovo were the same as in the entire yugoslavia including the network of health institutions [796 inhabitants per physician (5)], particularly primary health care centres [a network of 22 “dom zdravlja’s” and 379 general practitioner units (5)], staffed with committed health professionals as is cited by the authors from the health sector strategy (hss) of kosovo. also, the state health insurance system of serbia, based on solidarity, included the population of kosovo as any other people in the former republics of yugoslavia. therefore, today, kosovo can build on the historical achievements during that period which should have been acknowledged in a more pronounced way. however, as the authors write, “…the nineties left kosovo with a very inefficient health system characterized by a lack of trained personnel, disparities in health force distribution, leading to variations in access to primary care, corruption and informal payments as well as deteriorated child and adult health indicators”. this statement seems to be somewhat contradictory to the hss, cited above from this paper. hopefully, one day, an unprejudiced analysis of the development of the health system in kosovo before and after world war ii will become possible. references 1. ec. enlargement. “kosovo* this designation is without prejudice to positions on status, and is in line with unscr 1244 and the icj opinion on the kosovo declaration of independence”. http://ec.europa.eu/enlargement/countries/detailedcountry-information/kosovo/ (accessed: april 19, 2014). 2. unscr resolution 1244, 1999. http://www.un.org/docs/scres/1999/sc99.htm (accessed: april 19, 2014). 3. international court of justice. accordance with international law of the unilateral declaration of independence in respect of kosovo, advisory opinion. i.c.j. reports 2010, p.403. http://www.icj-cij.org/docket/files/141/15987.pdf (accessed: april 19, 2014). 1 kosovo*: this designation is without prejudice to positions on status, and is in line with unscr 1244 and the icj opinion on the kosovo declaration of independence”. http://ec.europa.eu/enlargement/countries/detailedcountry-information/kosovo/ (accessed april 19, 2014). 2 bjegovic-mikanovic, marinkovic-eric. misunderstanding should be avoided by precise formulation: comment on jerliu et al. “public health in kosovo after five difficult years of independence” (letter to editors). seejph 2014, posted: 19 april 2014. doi 10.12908/seejph-2014-21. 4. the brussels agreement of 2013. http://eeas.europa.eu/top_stories/2013/190413__eufacilitated_dialogue_en.htm (accessed: april 19, 2014). 5. statistical office of the republic of serbia. statistical yearbook 1990. belgrade: sors 1990. http://webrzs.stat.gov.rs/website/default.aspx (accessed: april 19, 2014). 6. unmik. kosovo state of the environment report. http://enrin.grida.no/htmls/kosovo/kosovo_soe_part1.pdf (accessed: april 19, 2014). ___________________________________________________________ © 2014 bjegovic-mikanovic et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 3 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 1 original research enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania herion muja1,2, genc burazeri1,2, peter schröder-bäck1, helmut brand1 1department of international health, school caphri, care and public health research institute, maastricht university, maastricht, the netherlands; 2 institute of public health, tirana, albania. corresponding author: herion muja, md; address: rr. “aleksander moisiu”, no. 88, tirana, albania; telephone: +355672315056; email: herionmuja@gmail.com http://doi.org/10.4119/unibi/seejph-2017-143 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 2 abstract to inform policymakers well, there is a need to promote different types of health examination surveys as additional sources of valuable information which, otherwise, would not be available through routine/administrative statistics. this is especially important for former communist countries of south eastern europe including albania, where the existing health information system (his) is weak. among many efforts to strengthen the his in albania, there is currently a commitment to undertake a second round of a nationwide demographic and health survey (dhs). this survey will involve a nationwide representative sample of about 17,000 private households, where all women aged 15-59 years and their respective partners will be interviewed and examined. externally, the upcoming albanian dhs will contribute to the european union accession requirements regarding provision of standardized and valid health information. furthermore, the dhs will considerably enhance the core functions of the albanian health system in line with the who recommendations. internally, the dhs will promote societal participation and responsibility in transitional albania. importantly, the forthcoming survey will promote good governance including transparency, accountability and health system responsiveness. also, the dhs will allow for collection of internationally valid and standardized baseline sociodemographic and health information for: assessment of future national trends; monitoring and evaluation of health programs and interventions; evidencing health disparities and inequities; and cross-national comparisons between albania and different countries of the european region. ultimately, findings of the dhs will enable rational decision-making and evidencebased policy formulation in albania including appropriate planning, prioritization and sound resource allocation. however, transfer of the information collected and implementation in public health policies and interventional programs is rather challenging for most of the countries, particularly for transitional post-communist countries of south eastern europe including albania. keywords: albania, demographic and health survey (dhs), health examination survey, health information system, health interview survey, health system governance. conflicts of interest: none. http://doi.org/10.4119/unibi/seejph-2017-143 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 3 the need to strengthen health information systems a “health information system” (his) is conventionally defined as a system which collects, stores, processes, conducts analysis, disseminates and communicates all the information related to the health status of the population and the activities and performance of health institutions and other health-related organizations (1). from this point of view, a suitable and well-designed his incorporates data generated from routine information systems, disease surveillance systems, but also laboratory information systems, hospital and primary care administration systems, as well as human resource management information systems (1,2). the ultimate goal of a well-functioning his is a continuous and synchronized endeavor to gather, process, report and use health information and the knowledge generated for the good governance of health systems; in other words: influence policy and decision-making, design activities and programs which eventually improve the health outcomes of the population, but also contribute to more efficient use of (often limited) resources (1,3,4). at the same time, the evidence generated from his may suggest the need for further research in certain areas (1,5). nevertheless, a major prerequisite for a good health system governance consists of a wide array of valid and reliable data, which are not often available from a traditional (routine) or administrative his (2,6).therefore, there is a clear need to promote different types of health examination surveys and health interview surveys as valuable sources for generation of additional health information which, otherwise, would not be available based on routine/administrative statistics. this is important in any health care system, where reforms are underway constantly (7). health examination surveys and health interview surveys issues related to the quality of life of individuals, patient satisfaction of health care delivery, knowledge, attitudes, perceptions, or beliefs of individuals, as well as health literacy levels in general are all important components which should be measured at a population level in order to design and tailor health strategies and policies accordingly (1,3). from this perspective, health examination surveys are a powerful tool which enrich a certain his and provide useful clues about the health status of populations, quality of life, as well as access, utilization and satisfaction with health care services. in this framework, the european health examination surveys (ehes: http://www.ehes.info/) and the european health interview surveys (ehis: http://ec.europa.eu/eurostat/web/microdata/european-health-interview-survey) constitute two major exercises which are carried out in most countries of the european union (eu). indeed, health examination surveys and health interview surveys are conducted periodically in most of the eu countries generating important evidence about the magnitude and distribution of selected ill-health conditions and health determinants at a population level. based on the unique value of health examination surveys and health interview surveys, there is a clear call for undertaking a similar exercise also in transitional former communist countries of south eastern europe including albania. country profile: albania after the collapse of the communist regime in early 1990s, albania has undergone significant political, social and economic changes striving towards a market-oriented economy (8). nevertheless, the particularly rapid transition from state-enforced collectivism towards a capitalistic system was associated with poverty, high unemployment rates, financial loss and social mobility, and massive emigration (9). at the same time, however, the transition period in albania was associated with increased personal and religious freedom in a predominantly muslim secular society (8,10). all these features continue to spot albania as a distinctive http://doi.org/10.4119/unibi/seejph-2017-143 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 4 country in europe, notwithstanding the similarities in many characteristics with other transitional countries in the western balkans and beyond. the health care sector has suffered substantially during the transition period and there has been a significant change in the epidemiological profile of the population in the past few decades with a remarkable transition towards non-communicable diseases (ncds) (11,12). indeed, there is a tremendous increase in the total burden of ncds in albania including heart disease, cancer, lung and liver diseases, and diabetes (11,12). against this background, there is an urgent need for an integrated approach for both prevention and improvement of health care in order to face the high burden of ncds in transitional albania (12). in any case, the existing his in albania has insufficient routine health data for a valid and reliable analysis of disease trends and the associated risk factors. the first round of a nationwide demographic and health survey (dhs) in albania was conducted in 2008-2009 (13). almost ten years later, there is currently an urgent need to carry out a second dhs round which would generate valuable information regarding selected key socio-demographic characteristics and health data of the albanian population, which are otherwise not available based on routine/administrative statistics. not only that with new data new needs for priorities in the health system governance can be identified, but the changes and potential effects of health policy decision-making of the last years can be measured too. the albanian demographic and health survey (dhs) 2017-2018 among many efforts to strengthen the his in albania, there is currently a commitment to undertake a second round of a nationwide dhs. the upcoming round of dhs in albania will be implemented by the national institute of public health and the institute of statistics with technical support from the us-based company icf international (https://www.icf.com/). funding has been already provided by the swiss cooperation and the united nation agencies operating in albania. the dhs will involve a nationwide representative sample of about 17,000 private households. all women aged 15-59 years and their respective husbands/partners living permanently in the selected households or present in the household on the night before the survey visit will be eligible to be interviewed in the dhs. the specific objectives of the dhs will be to: i) collect data at a national, regional and local level which will allow the calculation of key demographic rates; ii) analyze the direct and indirect factors which determine the level and trends of fertility and abortion in albania; iii) measure the level of contraceptive knowledge and practice of albanian men and women; iv) collect data on family health including immunization coverage among children, prevalence of most common diseases among children under five and maternity care indicators; v) collect data on infant and child mortality and maternal mortality; vi) obtain data on child feeding practices including breastfeeding, collect anthropometric measures to use in assessing the nutritional status of children including anemia testing; vii) measure the knowledge and attitudes of women and men about sexually transmitted diseases and hiv/aids; viii) assess key conventional risk factors for ncds in albanian men and women aged 15-59 years including dietary patterns and nutritional habits, smoking status, alcohol consumption, physical activity, systolic and diastolic blood pressure, and measurement of anthropometric indices (height and weight, as well as waist and hip circumferences). the data collected will be scientifically analyzed and scientific reports and policy briefs will be subsequently written and disseminated for a wide audience including health professionals, social workers, policymakers and decision-makers, as well as the general public. in addition, http://doi.org/10.4119/unibi/seejph-2017-143 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 5 the open data source approach will enable secondary (in-depth) analysis to all interested researchers and scientists all over the world. contribution of the demographic and health survey (dhs) to health system governance in albania table 1 presents the potential contribution of the upcoming albanian dhs at different levels (international, national, regional, and local level), recognizing that different actors of health system governance which are located at different levels, yet, interact with each-other (14,15). selected potential contributing characteristics (features) include different dimensions pertinent to both, the international environment and cooperation, as well as the internal (national) situation/circumstances. table 1. international relevance and contribution of the “albanian demographic and health survey 2017-18” to governance processes at national, regional and local levels international relevance characteristic description european union fulfillment of accession requirements, and contribution to the “europeanization” process of albania world health organization (who) strengthening of the core functions of the health system (in line with the who recommendations) national (central) government characteristic description democracy a good exercise for strengthening societal participation and responsibility governance enhancing good governance: transparency, accountability and responsiveness informing policy prioritization, evidence-based planning and allocation of resources research strengthening research capacities at a national level national data collection of (good quality) nationwide representative health data national disparities evidencing overall (national) disparities in terms of place of residence (urban vs. rural areas), ethnicity, minorities, vulnerable subgroups, socioeconomic categories, as well as sexand-age group differences baseline national data useful baseline data for assessing national trends over time, as well as monitoring and evaluation of nationwide health programs and interventions cross-country comparisons use of internationally valid/standardized instruments will eventually enable cross-national comparisons with the neighboring countries and beyond regional level: interface between the central and the local government characteristic description research strengthening research capacities at a regional level regional data collection of sub-national data regional disparities evidencing sub-national (regional) health disparities and inequities baseline regional data baseline data for assessing regional trends, as well as monitoring and evaluation of regional health initiatives, programs and interventions local government characteristic description research strengthening research capacities at a local level local data collection of health data at a local level local disparities evidencing local health disparities and inequities individual-based data potential for intervention (treatment and counseling of people in need) baseline local data baseline data for assessing local trends, as well as monitoring and evaluation of interventions implemented at a local level http://doi.org/10.4119/unibi/seejph-2017-143 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 6 regarding the international environment, the upcoming albanian dhs will significantly contribute in terms of fulfillment of accession requirements to the eu related to provision of standardized and valid health information/data. on the other hand, the dhs will also contribute considerably to the enhancement of the core functions of the albanian health system in line with the who recommendations (16). according to who, four vital functions of health systems include provision of health care services, resource generation, financing, and stewardship (16).the upcoming survey will support most of these core functions in the context of a particularly rapid process of transformation and reform of the albanian health system. as for the internal environment, at a central (national) level, the dhs will be an important exercise for strengthening societal participation and responsibility, which is fundamental given the low participation rates and societal contribution in post-communist countries such as albania. from a governmental point of view (4), the forthcoming survey is expected to promote good governance in terms of transparency, accountability and health system responsiveness. conversely, the dhs exercise will considerably strengthen national research capacities in albania. the survey will be conducted in close collaboration with the university of medicine, tirana, and other scientific and research institutions in albania which will help to further strengthen the epidemiological and the overall capacities of the albanian research community. furthermore, the dhs will allow for collection of nationwide high-quality information including a wide array of demographic and socioeconomic characteristics and valuable health data. such data will provide useful baseline information for assessment of national trends in the future, as well as monitoring and evaluation of nationwide health programs and health interventions. in addition, this baseline information will evidence national disparities and inequities regarding the place of residence (urban vs. rural areas), ethnicity groups and minorities, vulnerable/marginalized segments, socioeconomic disadvantaged categories, as well as sexand-age group health differences. at the same time, employment of standardized and internationally valid instruments for data collection will allow for cross-national comparisons between albania and different countries of the european region. ultimately, at a central (national) level, findings of the dhs will enable rational decision-making and evidence-based policy formulation in albania including appropriate planning, prioritization and sound resource allocation. at a lower level, the dhs exercise will help to strengthen research capacities and collaboration at a regional level. this will be an important added value given the new administrative/territorial reform which was fairly recently implemented in albania. in addition, availability of health data at a regional level will help to tailor regional policies in accordance with the epidemiological profile and health problems of the respective population groups, as well as monitoring and evaluation of different interventions and programs implemented at a regional level. at the lowest (i.e., local) level, the dhs will similarly but even more specifically contribute to evidence-based policy formulation and rational decision-making at a local/community level. likewise, the survey will contribute to the enhancement of research capacities at a local level, which will be particularly valuable for many under-resourced communities in albania characterized by limited and not properly trained research personnel. it should be noted that, for the first time ever, the upcoming dhs round will be a unique opportunity to collect representative data at the lowest administrative level in albania. also, importantly, the survey will offer a unique opportunity for intervention regarding potential treatment and especially counseling of individuals in need, particularly those who, for different reasons, have limited access to health care services, such as the case of roma community (17). http://doi.org/10.4119/unibi/seejph-2017-143 https://en.wikipedia.org/wiki/health_care_provider muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 7 conclusion the upcoming dhs round will be a unique opportunity for albania for strengthening research capacities at a national and local level. in addition, the dhs will provide valuable baseline evidence highlighting regional disparities and subgroup inequities which are assumed to have been rapidly increasing given the rapid political and socioeconomic transition of albania in the past three decades. furthermore, this survey will offer an opportunity for evidence-based policy formulation in albania. overall, the dhs exercise will be an important tool for strengthening the core functions of the albanian health system contributing also to the europeanization process and accession to the eu. however, transfer of the information collected and implementation in public health policies and interventional programs is rather challenging for most of the countries, particularly for transitional postcommunist countries of south eastern europe including albania. references 1. world health organization. framework and standards for country health information systems. geneva, switzerland, 2008. http://apps.who.int/iris/bitstream/10665/43872/1/9789241595940_eng.pdf (accessed: 14 march, 2017). 2. kilpeläinen k, tuomi-nikula a, thelen j, gissler m, sihvonen ap, kramers p, aromaa a. health indicators in europe: availability and data needs. eur j public health 2012;22:716-21. 3. holland w. overview of policies and strategies. in: detels r, beaglehole r, langsan m, et al. (eds.). oxford textbook of public health, 5th edn. oxford university press, 2009:257-61. 4. greer sl, wismar m, figueras j (eds.). strengthening health system governance: better policies, stronger performance. open university press, 2016. 5. beaglehole r, bonita r. public health at the crossroads: which way forward? lancet 1998;351:590-2. 6. detels r. the scope and concerns of public health. in: detels r, beaglehole r, langsan m, et al, editors. oxford textbook of public health, 5thedn. oxford: oxford university press, 2009:3-19. 7. marušič d, prevolnik rupel v. health care reforms. zdr varst 2016;55:225-7. 8. nuri b, tragakes e. health care systems in transition: albania. copenhagen: european observatory on health care systems, 2002. 9. burazeri g, goda a, tavanxhi n, sulo g, stefa j, kark jd. the health effects of emigration on those who remain at home. int j epidemiol 2007;36:1265-72. 10. burazeri g, goda a, kark jd. religious observance and acute coronary syndrome in predominantly muslim albania: a population-based case-control study in tirana. ann epidemiol 2008;18:937-45. 11. institute for health metrics and evaluation (ihme). global burden of disease database. seattle, wa: ihme, university of washington, 2014. http://www.healthdata.org (accessed: 14 march, 2017). 12. albanian institute of public health. national health report: health status of the albanian population. tirana, albania, 2014. 13. institute of statistics, institute of public health (albania) and icf macro. albania demographic and health survey 2008-09. tirana, albania: institute of statistics, http://doi.org/10.4119/unibi/seejph-2017-143 https://www.ncbi.nlm.nih.gov/pubmed/?term=kilpel%c3%a4inen%20k%5bauthor%5d&cauthor=true&cauthor_uid=22294775 https://www.ncbi.nlm.nih.gov/pubmed/?term=tuomi-nikula%20a%5bauthor%5d&cauthor=true&cauthor_uid=22294775 https://www.ncbi.nlm.nih.gov/pubmed/?term=thelen%20j%5bauthor%5d&cauthor=true&cauthor_uid=22294775 https://www.ncbi.nlm.nih.gov/pubmed/?term=gissler%20m%5bauthor%5d&cauthor=true&cauthor_uid=22294775 https://www.ncbi.nlm.nih.gov/pubmed/?term=sihvonen%20ap%5bauthor%5d&cauthor=true&cauthor_uid=22294775 https://www.ncbi.nlm.nih.gov/pubmed/?term=kramers%20p%5bauthor%5d&cauthor=true&cauthor_uid=22294775 https://www.ncbi.nlm.nih.gov/pubmed/?term=kramers%20p%5bauthor%5d&cauthor=true&cauthor_uid=22294775 https://www.ncbi.nlm.nih.gov/pubmed/?term=aromaa%20a%5bauthor%5d&cauthor=true&cauthor_uid=22294775 https://www.ncbi.nlm.nih.gov/pubmed/22294775 https://www.ncbi.nlm.nih.gov/pubmed/22294775 https://www.ncbi.nlm.nih.gov/pubmed/?term=beaglehole%20r%5bauthor%5d&cauthor=true&cauthor_uid=9492800 https://www.ncbi.nlm.nih.gov/pubmed/?term=bonita%20r%5bauthor%5d&cauthor=true&cauthor_uid=9492800 https://www.ncbi.nlm.nih.gov/pubmed/?term=public+health+at+the+crossroads%2c+beaglehole+r%2c https://www.ncbi.nlm.nih.gov/pubmed/?term=maru%c5%a1i%c4%8d%20d%5bauthor%5d&cauthor=true&cauthor_uid=27703543 https://www.ncbi.nlm.nih.gov/pubmed/?term=prevolnik%20rupel%20v%5bauthor%5d&cauthor=true&cauthor_uid=27703543 https://www.ncbi.nlm.nih.gov/pubmed/?term=zdrav+var+2016%3b+55(3)%3a+225-227 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=retrieve&dopt=abstractplus&list_uids=17436387&query_hl=1&itool=pubmed_docsum muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 8 institute of public health and icf macro, 2010. https://dhsprogram.com/pubs/pdf/fr230/fr230.pdf (accessed: 14 march, 2017). 14. barbazza e, tello je. a review of health governance: definitions, dimensions and tools to govern. health policy 2014;116:1-11. 15. kuhlmann e, larsen c. why we need multi-level health workforce governance: case studies from nursing and medicine in germany. health policy 2015;119:1636-44. 16. world health organization. world health report 2000 – health systems: improving performance. geneva, switzerland, 2000. http://www.who.int/whr/2000/en/index.html (accessed: 14 march, 2017). 17. de graaf p, rotar pavlič d, zelko e, vintges m, willems s, hanssens l. primary care for the roma in europe: position paper of the european forum for primary care. zdr varst 2016;55:218-24. ______________________________________________________________________________________ © 2017 muja et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://doi.org/10.4119/unibi/seejph-2017-143 http://www.ncbi.nlm.nih.gov/pubmed/?term=kuhlmann%20e%5bauthor%5d&cauthor=true&cauthor_uid=26321192 http://www.ncbi.nlm.nih.gov/pubmed/?term=larsen%20c%5bauthor%5d&cauthor=true&cauthor_uid=26321192 http://www.ncbi.nlm.nih.gov/pubmed/26321192 http://www.who.int/whr/2000/en/index.html https://www.ncbi.nlm.nih.gov/pubmed/?term=de%20graaf%20p%5bauthor%5d&cauthor=true&cauthor_uid=27703542 https://www.ncbi.nlm.nih.gov/pubmed/?term=rotar%20pavli%c4%8d%20d%5bauthor%5d&cauthor=true&cauthor_uid=27703542 https://www.ncbi.nlm.nih.gov/pubmed/?term=zelko%20e%5bauthor%5d&cauthor=true&cauthor_uid=27703542 https://www.ncbi.nlm.nih.gov/pubmed/?term=vintges%20m%5bauthor%5d&cauthor=true&cauthor_uid=27703542 https://www.ncbi.nlm.nih.gov/pubmed/?term=willems%20s%5bauthor%5d&cauthor=true&cauthor_uid=27703542 https://www.ncbi.nlm.nih.gov/pubmed/?term=hanssens%20l%5bauthor%5d&cauthor=true&cauthor_uid=27703542 https://www.ncbi.nlm.nih.gov/pubmed/?term=zdrav+var+2016%3b+55(3)%3a+218-224 kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 1 | 27 original research epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. laurant kollçaku1 1 pediatrics department, unit of endocrinology and diabetes, university hospital center 'mother teresa', tirana, albania. corresponding author: laurant kollçaku address: university hospital center “mother teresa”, rr. dibres, no. 371, tirana, albania; email: laurantkollcaku@gmail.com kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 2 | 27 abstract aim: diabetes mellitus is a major public health problem worldwide. type 1 diabetes mellitus (t1dm) is the most common metabolic chronic disease in genetically susceptible children and adolescents, due to an autoimmune process characterized by a selective destruction of insulin producing β-cells. the aim is to assess the epidemiological features of new-onset t1dm in children and adolescent at the national level during the period 2010-2014 in department of pediatrics, endocrine unit, university hospital center 'mother teresa', tirana, as the unique center for pediatric endocrinology and diabetology in albania. methods: the clinical and laboratory characteristics of 152 patients aged <15 years newly diagnosed with t1d from 1 january 2010 to 31 december 2014 were studied. t1d was diagnosed according to who 2006 criteria and dka was diagnosed based on ispad 2014 criteria. patients were classified into 3 sub-groups (i: 0-4 years, ii: 5-9 years, and iii; 10-14 years). statistical analysis was performed using spss 26. results: the incidence of new-onset of t1dm was 5.012/100.000/year. the mean age of children at diagnosis was 8.3 ± 3.6 years. the patients were mostly diagnosed at ages 5-9 years (40.1%), and 10-14 years (39.5%), followed by the 0-4 years age group (20.4%). mean duration of symptoms was 23.35 ± 17.16 days; longer in the subgroup 5-9 years (p= 0. 0.013). three quarters (75%) of children with t1dm live in urban areas. viral infections or other circumstance triggers were in 41.9% of children aged 0-4 years compared to other subgroups (p=0.002). most of the children were born in the spring−summer months (53.23%) compared to the autumn−winter months (46.77%). approximately 1/4 of the children were born and diagnosed with type 1 diabetes in each of the seasons of the year and 52.63% of the patients studied were first born. family history for dmt1 and dmt2 is observed in 15.8% and 17.8% of the children, respectively. polyuria (99.3%), polydipsia (99.6%) and weight loss (98.1%) were the most common symptoms and 67.8% of patients presented with diabetic ketoacidosis (dka). misdiagnosis was in 21 (13.8%) patients. mean glycosylated hemoglobin a1c (hba1c) was 11.63%; 11.9 ± 2.0 in dka positive children and 11.1 ± 2.4 in dka negative children (p= 0.195). at diagnosis and during follow up of t1dm 25% (38/152) developed associated autoimmune diseases; 68.42% at diagnosis of t1dm and 65.79% (25/38) of patients were female. during follow up children with t1dm developed associated cd and sat, 2.54, and 2.19 years, respectively. conclusion: diabetes mellitus is one of the major public health problems worldwide. albania is a country with middle incidence of t1dm and the age at onset is decreasing. the symptoms lasted significantly longer and mean hba1c levels were significantly higher in older children. the incidence of dka in children with newly diagnosed t1dm is high. keywords: autoantibodies, children, diabetic ketoacidosis, incidence, seasons, type 1 diabetes. conflicts of interest: none declared. kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 3 | 27 s introduction type 1 diabetes mellitus (t1dm) is the most common endocrine and metabolic disease in children and adolescents aged 0–14 years (1). t1dm represents 5-15% of the diabetic population; 85-95% have t2dm and less than 2% have other forms of diabetes (2). the incidence of childhood type 1 diabetes is increased worldwide more than two to three folds during the last decades, particularly in finland and sardinia (“hot spots” of the world) (3). the incidence of t1d in children < 15 years of age is increasing significantly, approximately 3% (range 2-5%) (1,4,5). from 1965 to 2012 the incidence of type 1 diabetes in pediatric population has increased significantly from 9.44% (8.22–10.66) to 19.58% (14.55–24.60) (6), with the exception of central america and the west india (4). the overall incidence of dmt1 is 11.43/100,000/year, and according to gender; 11.42 (10.23–12.61) in boys and 11.11 (9.94– 12.27) in girls (4). in many european countries the overall incidence has increased to 3.9% (ranges from 0.6% 9.3%); the increase is higher in children aged 0-4 years with 5.4%, compared to 4.3% and 2.9% for age groups 5-9 and 10-14, respectively (4). the main epidemiological characteristics of type 1 diabetes in children < 15 years old are: the large variation of incidence from 0.1 in venezuela to 62.3 per 100,000 per year in finland (7); the increasing incidence in countries with lower incidence and the trend of occurrence towards the younger age group (0-4 years) (3). variation of type 1 diabetes incidence cannot be explained by genetic factors alone (frequency of protective hladq alleles between populations) suggests the importance of environmental factors in the complex pathogenesis of dmt1. exposure to one or more environmental factors of genetically predisposed individuals, triggers an immune response that causes the selective destruction of pancreatic beta cells. among environment factors include: latitude and geographic position (811); frequent and high exposure to cow's milk and its products (12), consumption of foods high in carbohydrates (13); short-time exposure to ultraviolet radiation and insufficiency and deficiency of vitamin d; oceanic climate (cold winter and summer) (6); prenatal and postnatal viral infections (14-16); pregnancy-related factors (parental age at birth, order of birth, maternal illness, viral infections) and perinatal period (birth weight, gestational age) (17); use of pharmaceutical products (antibiotics); obesity (increased bmi) (18-20); migration; socio-economic status with high income (7); gender and age (21) as well as the month and season of birth (22) are all associated with increased risk of type 1 diabetes. this study aims to investigate the epidemiological features of t1dm in children and adolescents aged <15 years, during the period 2010-2014 in albania. patients and methods study type this study represents a series of patients (cases) newly diagnosed with type 1 diabetes mellitus presented at the specialty service, endocrinology clinic, "mother teresa" university hospital center, tirana (qsut), during the period 2010-2014. study population this prospective study from january 1, 2010 to december 31, 2014, included 152 patients who met the criteria: children diagnosed with t1d for the first time < 15 years old in albania. the number of children and adolescents aged 0-14 years old from 20102014 according to instat is 3,032,819 children (1,451,992 females and 1,580,827 males). patients are classified into 3 age kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 4 | 27 groups (i: 0-4 years, ii: 5-9 years, and iii: 1014 years). inclusion criteria: the study included 1) new cases aged < 15 years diagnosed for the first time with diabetes mellitus type 1 during the period january 2010 december 2014 resident in albania, which from a geographical point of view corresponds to the administrative borders and census; 2) individuals who received their first insulin injection before their 15th birthday and resident in albania at the time of the first insulin administration. exclusion criteria: new cases ≥ 15 years of age during the period 2010-2014, cases of diabetes mellitus from secondary causes as a result of a primary pathology (cystic fibrosis, corticotherapy, mody, etc.) were excluded from the study. data collection data for this study were collected prospectively using a standardized clinical record. information was collected on a range of demographic and laboratory data. the epidemiological data regarding the date of birth, the date of initial presentation of t1dm and age at diagnosis, the order of birth, the birth weight, the mode of delivery, and pubertal status were obtained from the patients’ clinical records. the diagnosis of t1d was determined according to who, 2006 criteria; the ispad, 2014 criteria were used to determine dka; hyperglycemia (glycemia> 200 mg/dl or > 11 mmol/l), metabolic acidosis (ph < 7.30, and /or plasma bicarbonate level < 15 mmol/l or ketones in urine (ketonuria > 2+), accompanied by history of polyuria, polydipsia, nocturia, weight loss, dehydration, nausea, vomiting, abdominal pain, respiratory signs (acetone odor, respiratory distress, dyspnea), level of consciousness (classified into 3 categories: normal, altered consciousness and coma according to the pediatric glasgow coma scoring system), and different triggers conditions. anthropometric measurements (weight, height, body mass index, bmi (kg/m2) also expressed in standard deviation (bmi-ds), stage of pubertal development according to tanner. the severity of dka was determined by the ph and concentration of plasma bicarbonates and was categorized into 3 groups: (a) mild: ph <7.30 and/or serial bicarbonate <15 mmol /l; (b) moderate: ph <7.2 and /or bicarbonate <10 mmol /l and (c) severe: ph <7.1 and /or bicarbonate <5 mmol/l (table 1). according to ispad, new-onset t1dm with ph > 7.3 and hco3 > 15 meq/l was classified as t1dm without ketoacidosis. ethics approval and consent of participate: informed written consensus was obtained from all patients' parents. it is approved by the albanian national ethics committee. statistical analysis absolute numbers and corresponding percentages were used to describe the categorical data. to describe numerical data, the reporting of the central tendency measures, in this case the mean value, and the dispersion measures, in this case the standard deviation, was used. the square hi test was used to compare categorical variables; in case the resulting table was in the size of 2x2, then the value of p was reported according to fisher's exact test, which gives a more accurate calculation of the p-value. to compare the mean values of the numerical dependent variable according to the categories of the independent variable, the non-parametric mann-whitney u test was used for two independent samples in the case where the independent variable had only two categories; otherwise, when the independent variable had >2 categories the nonparametric kruskal wallis test was used for k kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 5 | 27 independent samples. non-parametric tests were used in case the dependent variable was found to be abnormally distributed in the study population. otherwise, for normally distribute numerical variables, the student's ttest for two independent samples was used. binary logistic regression test was used to identify the associations between the presence of diabetic ketoacidosis and the independent variables. various tables depending on the information were used to present the data. graphs of different types were used to present and illustrate the study findings. in all cases, the associations between the variables were considered significant if the value of the statistical significance was ≤ 0.05 (or ≤ 5%). all statistical analyzes were performed through the statistical package for social sciences, version 26 (ibm spss statistics for windows, version 26) software program. results a total of 152 (52% male and 48% female) children age < 15 years were diagnosed with type 1 diabetes mellitus (t1dm) during the study period. the mean age at diagnosis, age, sex and residence distribution of the study population are shown in table 1. the mean age of the subjects at the time of diagnosis is 8.3 years ± 3.6 years. at the time of diagnosis, 40.1% were between ages 5-9 years, followed by 39.5% between ages 1014 years and 20.4% younger than 5 years. three quarters (75%) of children with t1dm live in urban areas and 25% in rural areas. table 1. mean age at diagnosis, age, sex and residence distribution of the study population variable frequency (%) mean age at diagnosis (mean value ± standard deviation) 8.3 ± 3.6 agegroup 0-4 years 5-9 years 10-14 years 31 (20.4%) 61 (40.1%) 60 (39.5%) gender male female 79 (52%) 73(48%) residence urban rural 114 (75%) 38 (25%) total 152 (100.0) mean duration of symptoms to the diagnosis of t1d was 23.35 ± 17.16 days. no statistically significant gender differences were observed regarding mean duration of symptoms, while the age differences were statistically significant: 17.48 days among children 0-4 years old, 28.61 days among children 5-9 years old and 21.03 days among children 10 -14 years (table 2). kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 6 | 27 table 2. duration of symptoms to the diagnosis of t1dm statistical parameter time of onset of symptoms to diagnosis of dmt1 (in days) p-value according to gender p-value according to subgroups mean average value 23.35 0.362* 0.013** the standard deviation 17.16 median 21.00 mode 30 minimum value 0 maximum value 90 the spectrum 90 * p value according to the non-parametric mann-whitney u test for two independent samples. ** p value according to the non-parametric kruskal wallis test for k independent samples. at diagnosis of t1d1, 13.8% were misdiagnosed as viral infection, gastrointestinal and respiratory airways infection and less often as surgery emergency. table 3. misdiagnosis at new onset of t1dm variable frequency (%) suspicion of diabetes at the time of admission no yes 21 (13.8%) 131 (86.2%) family history for dmt1 were in 15.8%, dmt2 in 17.8% and both types in 2.6% of the children. among children with a positive family history of dmt1, the grandfather/grandmother was most often affected (54.2%), followed in 29.2% of cases by the brother/sister. table 4. family history and t1dm and/or t2dm variable frequency (%) family history with t1dm 24 (15.8%) family history with dmt2 27 (17.8%) kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 7 | 27 figure 1a. positive family history of t1dm figure 1b. positive family history of t2dm regarding the season of birth and the season of diagnosis of type 1 diabetes of the children in the study, it is noted that approximately 1/4 of the children were born in each of the seasons of the year. however, more than half of dmt1 were diagnosed in autumn and winter (60.5%). table 5. distribution of children at diagnosis of t1dm according to the seasons of birth and seasons of diagnosis 0 2 4 6 8 10 12 mother grandfather father mother and grandfather others (aunts, uncles,causins) siblings siblings and grandfather 0 2 4 6 8 10 12 mother father & others (aunts, uncles,causins) grandfather grandfather & others (aunts, uncles,causins) father others (aunts, uncles,causins) kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 8 | 27 birth season 0-4 years 5-9 years 10-14 years spring 8 14 17 summer 6 15 15 autumn 7 21 13 winter 10 12 14 total 31 62 59 season's diagnosis spring 3 18 18 summer 5 8 8 autumn 13 20 16 winter 10 16 17 total 31 62 59 figure 2. distribution of diagnosis and frequency of birth in different seasons of year the data analysis showed that most of the children were born in the spring−summer months (53.23%) compared to the autumn−winter months (46.77%) (figure 3a). most of the children were born in december, followed by those born in november, april, august and september (figure 3a). significantly more children were diagnosed with t1dm during the colder months of the year, october−march (53.3%) compared to 46.7% during the warmer months, april−september (figure 3b). 25.7 13.8 32.2 28.3 25.7 23.7 27 23.7 spring summer autumn winter birth season season of diagnosis kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 9 | 27 figure 3. a) distribution of children according to month of birth. b) frequency of diagnosis of t1dm during the cold and warm months kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 10 | 27 table 6. birth order birth order 1 2 3 4 total 80 43 27 2 0-4 years 15 10 4 2 5-9 years 35 15 12 0 14-10 years 30 18 11 0 52.63% of the patients studied were first born, 28.3% were the second child of the family, 17.8% were the third child, 4.6% the fourth child and 1.3% were the fifth child (fig. ). the differences observed with respect to the order of birth are statistically significant (chi-squared test, p < 0.001). figure 4. a) birth order b) birth order according to the age the mean birth weight of our study group was 3325 ± 463.8 g (min: 1500 g, max: 5100 g). 1.3% of the patients had a birth weight below 2500 g, 70.4% between 2500 0 10 20 30 40 50 60 70 80 90 1 2 3 4 0 5 10 15 20 25 30 35 1 2 3 4 0-4 years 59 years 10-14 years kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 11 | 27 and 3500 g and 28.3% >3500 g. most of the patients (82%) were born by normal vaginal delivery and 18% by cesarean section. among the children diagnosed with dmt1, in 23.7% of cases the presence of viral infections (enteroviruses, hepatitis, frequent upper respiratory tract infections, gastroenteritis) and one case chest trauma were identified. psychosocial stress (divorce, death of a parent and family member) was observed in 2.6% of children. there were no statistically significant gender differences related to these indicators. the percentage of viral infections history or other trigger conditions were higher in children aged 0-4 years (41.9%) compared to children aged 5-9 years (27.9) and aged 1014 years (10%) [p=0.002] and no statistically significant age differences were observed regarding the psychosocial stress. polyuria (100%), polydipsia (100%), and weight loss (98.1%) were the most common complaints. the frequency of malaise, vomiting, enuresis nocturnal, acetone odor, dyspnea, drowsiness and confusion was higher among children with dka (p < 0.001). figure 5. the presenting clinical manifestations of children and adolescents at the time of diagnosis, the overall incidence of ketoacidosis was 67.8%. the mean age of children with dka was 7.75 ± 3.64 years, and 9.29 ± 3.39 years in children without dka (p = 0.012). there were no statistically significant differences by age subgroup and living residence; the percentage of females was higher in t1dm children with dka (54.4%) than among those without dka (34.7%) (p = 0.025). 102 49 26 96 5 5 12 25 4 15 3 56 45 35 45 36 22 4 46 18 1 36 2 0 3 3 0 3 1 3 0 0 0 1 0 0 0 20 40 60 80 100 120 p o ly u ri a a n d … a p p e ti te v a ri a ti o n n o c tu rn a l e n u re si s w e a k n e ss ,… h e a d a c h e c o n st ip a ti o n a b d o m in a l p a in v o m it in g d ia rr h e a o ra l c a n d id ia si s m o n il ia l… a c e to n e s m e ll k u ss m a u l… t a c h y p n e a /p o ly … d y sp n o e a s o m n o le n c e c o n fu si o n c e re b ra l e d e m a t1dm with dka t1md without dka kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 12 | 27 figure 6. frequency of dka at diagnosis of t1dm positive family history of type 1 diabetes increases the odds ratio (or) of the presence of dka by 1.52 times, and positive family history of type 2 diabetes decrease 1.56 (1/0.64) times the presence of dka (protective role), compared to children without family history for dmt2 but this difference is not statistically significant (p>0.05). a positive family history for both dmt1 and dmt2 increases the likelihood of the presence of kad by 8.73 times, but even these differences did not reach statistical significance (p>0.05). viral infections and other trigger conditions increase the likelihood of the presence of kad by about 1.58 times; however, there were not statistical significance difference (p> 0.05). regarding the association of psycho-social stress and presence of kad in type 1 diabetes, seems that psycho-social stress may be a risk factor for the presence of dka in diabetic children (being that 3.9% of diabetic children). table 7. association between the presence of dka in diabetic children and selected variables – odds ratio (or) by binary logistic regression test variable or § 95% ci * p-value † lower interval upper interval positive family history of t1dm 1.52 0.56 4.10 0.411 positive family history of t2dm 0.64 0.27 1.50 0.300 positive family history of t1dm or t2dm 6.00 0.60 59.80 0.127 positive family history of t1dm and t2dm 8.73 0.82 92.85 0.073 viral infections and other trigger conditions 1.58 0.68 3.68 0.290 67.8 32.2 t 1 d m w i t h d k a t 1 d m w i t h o u t d k a kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 13 | 27 female with dka 2.24 1.11 4.54 0.025 subgroup 0-4 years with kad 2.97 1.06 8.32 0.038 age (year) -0.126 †† 0.016 urban residence and dka 1.32 0.61 2.84 0.484 duration of signs and symptoms (day) 0.015 †† 0.179 § odds ratio (or) of the presence of kad in diabetic children versus its absence, according to the binary logistic regression procedure; * 95% confidence interval (95% ci) for or; † statistical significance value (p value) according to the binary logistic regression test. table 8 presents the association of the kad with symptoms and signs of children in the study. it appears that presence of nocturnal enuresis, malaise, vomiting, acetone smell and drowsiness increase the odds of the presence of dka in diabetic children by 16.21, 4.95, 4.98, 18.27 and 25.79 times, respectively, and these differences are statistically significant (p<0.05). it must be said that kussmaul respiratory distress, polypnea/tachypnea, dyspnea, confusion and cerebral edema/coma appear to be significant predictive factors of the presence of dka in diabetic children, but the absence of these signs in children without kad made binary logistic regression analysis impossible. table 8. association between the presence of dka in diabetic children and selected variables – odds ratio (or) by binary logistic regression test variable or § 95% ci * p-value † lower interval upper interval nocturnal enuresis 16.21 2.13 123.35 0.007 malaise 4.95 1.83 13.40 0.002 headache 1.20 0.22 6.41 0.832 abdominal pain 2.02 0.54 7.52 0.294 vomiting 4.98 1.42 17.41 0.012 oral candidiasis 2.61 0.72 9.49 0.144 monilial vaginitis 1.44 0.15 14.21 0.755 acetone smell 18.27 5.34 62.54 <0.001 somnolence 25.79 3.42 194.67 0.002 glycaemia 0.006 †† 0.001 ph -78.275 0.022 hco3 -0.312 0.001 triglycerides 0.009 0.009 table 9 presents the relationship between the presence of dka and some laboratory parameters of the diabetic children in the study. data analysis showed that blood glucose and triglycerides are positively related to the presence of dka, being that each additional unit of glycemia and triglycerides increases the odds of dka by 0.006 and 0.099 times, respectively, and these changes are statistically significant (p<0.05). in the meantime, ph and hco3 are negatively related to the presence of kad: kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 14 | 27 thus, one additional unit of ph and hco3 decreases the likelihood of dka by 78.275 and 0.312 times, respectively and these differences are statistically significant (p<0.05). table 9. association between dka and laboratory parameters t1dm with dka t1dm without dka p-value frequency of dka at diagnosis (%) 67.8 32.2 mean age 7.75 ± 3.64 9.29 ± 3.39 0.012 † gender (male/female) (%) 45.6/54.4 65.3/34.7 0.025** residence (urban/rural) (%) 76.7/23.3 71.4/28.6 0.549** age-groups 0-4 years 25 (24.3) * 6 (12.2) 5-9 years 43 (41.7) 18 (36.7) 0.082** 10-14 years 35 (34.0) 25 (51.0) duration of symptoms (days) 24.65 ± 17.39 20.61 ± 16.51 0.169* family history of t1dm/t2dm (%) 17.5/15.5 12.2/22.4 0.482/ 0.364** viral infections trigger 26.2 18.4 0.316** serum glucose level (mg/dl) 513.2 ± 193.2 386.5 ± 138.3 <0.001 glycated hemoglobin (hba1c) at baseline 11.9 ± 2.0* 11.1 ± 2.4 0.195 ** blood ph 7.2 ±0.1 7.4 ± 0.1 <0.001 hco3 8.7 ± 5.4 19.9 ± 4.5 <0.001 triglycerides 217.5 ± 189.9 118.2 ± 55.7 0.001 presentation with severe dka based on venous ph (<7.1) 17 (32.1) * <0.001** presentation with severe dka based on hco3 (<5) 15 (28.8) <0.001** the mean hba1c level of the total study population was 11.65±2.2%. hba1c levels did not differ by age subgroups or gender. age (years) 0-4 5-9 10 -14 mean value hba1c 11.63 ± 2.05 11.76 ± 162 11.70 ± 1.76 there were no significant differences of mean hba1c values between diabetic children with and without kad (11.9 ± 2.0% vs. 11.1 ± 2.4%, p=0.195) at diagnosis and during follow up. the average values of hba1c at diagnosis and over time in diabetic children with and without kad are presented in the following figure 7. it can be seen from the figure 7 that the progress of hba1c over time is more favorable for diabetic children without kad compared to diabetic children with kad, since in diabetic children without kad the average level of hba1c is constantly lower than in children with kad, while in children with kad the average level of this parameter remains more or less constant but at quite high levels (between 89%). kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 15 | 27 figure 7. mean hba1c level (in %) among diabetic children with and without dka, during study * mean value ± standard deviation. ** statistical significance value according to the non-parametric mann-whitney test for two independent samples. at diagnosis of t1dm, 17.10% (26/152) of the children had concomitant autoimmune diseases (ad): 14.47% (22/152) autoimmune thyroid disease (atd) and 2.63% (4/152) cd; 65.38% (17/26) were female and 34.62% (9/26) male. half of children (13/26) with autoimmune diseases were presented with dka. according to the specific age group 7.7% were in the age group 0-4 years; 57.7% in the age group 5-9 years and 34.6% belong the group age 10-15 years old. at the time of diagnosis, among children with atd, 68.2% were female, ages 8-10 were the most affected (59.09%), 23% children had tsh >5 mu/l and 77% of children were positive tpo and 80% e children with positive tpo had normal thyroid function. among children that developed concomitant cd at diagnosis of t1dm, 2 patients were female and 2 males; 2 age group 0-4 years and 1 age group 5-10 years and 1 age group 10-14 years. of these, 1 girl, age 1.4 years preceded the diagnosis of dmt1 by 4 months (table). during follow-up, 8.55% of children developed sat and cd; 8 children cd and 4 children sat. the mean age of developed of cd and sat after the diagnosis of t1d were 2.19 and 2.54 years, respectively. of these, 1 child developed sat and cd; hashimoto 1.023 years and cd 4.11 years after the diagnosis of dmt1. kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 16 | 27 table 10. concomitant autoimmune diseases (ad) in children with t1dm discussion the study included 152 children and adolescents aged 0-14 years, diagnosed with dmt1, presented to the pediatric department, "mother teresa" university hospital, tirana during the period january 1, 2010 to on december 31, 2014. to our knowledge, there are no similar studies conducted earlier in albania that illuminate the epidemiological characteristics of children with dmt1. in this context, the present study takes a greater importance. dmt1 is one of the most common autoimmune chronic metabolic diseases in children and adolescents. the incidence of childhood onset type 1 diabetes is increasing by ∼50% every 10 years (1,4). according to the data of the international diabetes federation (idf) 2017 (23), the number of children and adolescents living with diabetes during the last decades is growing rapidly, especially among younger children. in european population the incidence of type 1 diabetes varied tenfold (24); from the lowest in georgia (4.6/100,000/year) to very high in finland (62.3/100,000/year) (25). however, most european countries have intermittent incidence (5.0-9.99 per 100,000 population) (1). during the 2010-2014 study period, the incidence of t1dm among albanian children ages < 15 years was 5.012/100,000/year, places albania among countries with middle risk (1). countries that have an incidence of t1dm close to albania are belarus (5.6), romania (5.4) and macedonia (5.8) (25). besides north macedonia, bosnia-herzegovina (8.2) and croatia (9.1) (25), other countries of the southern european region, have a high incidence (10-19.99/100,000/year) (1). frequency (%) ad at diagnosis of t1dm ad post diagnosis of t1dm age (years) 0-4 5-9 10-14 12 /152 (7.89%) atd+cd 26/152 (15.79%) 1 (0.66%) female 17/26 (65.38%) 1 (5.9%) 10 (58.82%) 6 (35.3%) male 9 /26 (34.62%) 1 (11.11%) 5 (55.56%) 3 (33.3%) atd female male 22/152 (14.47%) 15/22 (68.2%) 7/22 (31.8%) 5 (3.96%) 4 1 cd female male 4/152 (2.63%) 2 2 2 1 1 8 (35%) 4 4 tsh > 5 mu/l 6 (23%) ac. anti tpo > 25 iu/ml 20 (77%) dka 13 (50%) positive tpo & normal thyroid function 16/20 (80%) mean age after diagnosis of t1dm sat cd 2.19 years 2.54 years kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 17 | 27 in general, the incidence increases with age until middle puberty, with a peak at age 10– 14 years compared to other ages is attributed the rapid hormonal changes (26,27) and decreases after puberty, particularly in females compared to young male adults (28,29). approximately 45% of children are first presented before age 10 (30). the mean age of children with t1dm included in this study was 8.3 ± 3.6 years. in our study, at the time of diagnosis of dmt1 about 40% were 10-14 years old; 40% were 5-9 years old and 20% were 0-4 years old of children with diabetes. these findings are consistent with international literature data. interestingly, in search study the distribution of children with diabetes by age group was about 21% of children 0-4 years, in the philadelphia registry, 37% were 5-9 years and 41% were 10-14 years (26), quite similar to that of our study. according to the eurodiab registry, 24% of children with type 1 diabetes were 0–4 years old, 35% were 5–9 years old, and 41% were 10–14 years old (26), these results are quite similar to the findings of our study. a study in france of 1299 children 0–14 years old at the time of t1d diagnosis reported that 26% were 0–4 years old, 34% were 5–9 years old, and 40% were 10–14 years old (31), these findings are completely similar to the age distribution of t1dm evidenced in our study. although most autoimmune diseases more commonly affect females, in the overall incidence of childhood t1dm there no gender difference. in our study, it was observed an almost equal gender distribution among children with type 1 diabetes; 52% male and 48% female. these data are also supported by international studies. the search study on diabetes in youth reported both genders are equally affected by type 1 diabetes (26). type 1 diabetes mellitus is characterized by global, modest seasonal variation, with the highest incidence in the cold months (autumn-winter) and the lowest in the warm months (spring-summer). (32) the diamond project demonstrated that the seasonality of the incidence of type 1 diabetes mellitus in children ages < 15 years is a real phenomenon. statistical differences in the seasonality of the development of type 1 diabetes have been found in populations with intermediate and high incidence compared to the general population (3,33). there is a significant tendency of younger patients to be diagnosed in the cold months. the reason for this seasonal difference is not completely understood, it may be related to the pathogenic role of various environmental triggers including infections encountered more frequently in the younger age groups, especially due to kindergarten enrollment, although there are no definitive conclusions regarding the role of specific infections in the occurrence of dmt1 (34). a study among children ages 0-14 years in bulgaria reported that a greater proportion of children with dmt1 were diagnosed during the autumnwinter period (about 62.5%) (35), a figure completely similar to the finding in our study where 60.5% of children with dmt1 were diagnosed in autumn-winter. in our study we did not observe any clear trend regarding the seasonality of the birth and diagnosis of children with dmt1, as about a quarter of children with dmt1 were born and about a quarter of them were diagnosed in each season of the year. however, 60.5% of dmt1 cases in our study were diagnosed in autumn-winter and 39.5% in spring-summer. there is a connection between the month of birth and the development of dmt1 during the later stages of life (34). children born during the spring and summer months, especially in countries with intermediate incidence such as eastern european countries, have a higher risk of developing type 1 diabetes compared to children born during the fall and winter months (36,37). it kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 18 | 27 is thought to be related to seasonal environmental factors during fetal-perinatal life and thereafter (38) which influence fetuses and children to develop islet autoimmunity (6,23,39) and the disease at different ages (34). our finding was similar to a study in greece (40), while several other studies reported the opposite (26,34). seasonal character of birth month and t1dm development in some sub-populations is related to gender, ethnicity and race, and viral infections. in some countries males born in the spring and summer months are prone to develop t1dm while in others predominate females (41). in our study, 56% (42/75) of children born in the spring summer months were boys. in homogenous populations despite incidence of type 1 diabetes children born in the spring summer months have a higher risk of developing type 1 diabetes, while this association is not in ethnically heterogeneous populations (42). the increased risk of t1dm manifestation in children born in spring-summer is also related to viral infections including enteroviruses, rotavirus, mumps virus, cytomegalovirus, rubella virus, etc. based on serological, immunological findings (43). a variety of infections play a role in the conversion of endogenous beta-cell antigens into immunogenic structures, where infiltration of the islets of langerhans, by activated autoreactive t cells is considered to be the major driver of the onset and progression of type 1 diabetes mellitus. if the pregnancy occurs during the months with the highest presence of viral infections (43) they are more likely to be infected and to transmit the virus to the fetus. consequently, given a normal gestation period of 40 weeks, children born in spring and summer are more likely to develop type 1 diabetes. the order of birth has been associated with t1dm presentation. the study by eirini kostopoulou., et al 2021 (44); chris r cardwell., et al. 2011 (45) showed increase the risk of childhood type 1 diabetes in first born children and reduction risk in secondor later born children particularly among children aged <5 years. the cause of any increase in the risk of childhood type 1 diabetes in first born children is unknown. it is possible related with younger maternal age, maternal prenatal immune response to environment exposures (46), congenital infections and use of antibiotics by mothers during pregnancy (43), reduced or delayed exposure to infections such as enteroviruses (47), household with older siblings who are exposed to infectious agents at school or day care or parents pay attention differently for their first child compared with subsequent children. our findings are consistent with international literature data. this finding may provide indirect support for the hygiene hypothesis, which suggests that the immune system requires stimulation by infections and other immune contests in early life to achieve a mature and balanced repertoire of responses (48). the higher incidence of dmt1 in western countries can be dedicated to the phenomenon of "hygiene hypothesis"; according to this hypothesis, decrease of the frequency of infections of diabetogenic viruses may lead to an increase in the incidence of dmt1 (43). however, exposure to viruses does not necessarily appear to be the cause of dmt1 but rather may be beneficial in some cases (43). regarding viral infections in our country, data is not available. a relatively low level of hygiene, especially in rural areas point toward that viruses are one of the main etiological factors of t1dm. based on the fact that in our study only 25% of diabetic patients lived in rural areas, it appears that this study supports that part of the literature that emphasizes a protective role of viral infections in the development of dmt1 in children. kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 19 | 27 in our study, three quarters of children with t1dm lived in urban areas. such finding has been evidenced into similar studies conducted in the balkan countries (35). however, other studies have evidenced a higher incidence of dmt1 among children living in rural areas (49-53) suggested that the higher incidence of dmt1 in rural areas may be related to a lower exposure of these children to protective environmental factors (53). the international literature suggests the role of psycho-social stress in the development of t1dm in children. a study among 338 children with dmt1 aged 0–14 years in sweden and 528 controls suggested that stressful life events (threats or fear of losing family members, such as divorce or death of parents) adverse psychosocial stressful events (including events with difficult adjustment, child behavioural deviations, and disordered and chaotic family functioning) 12-24 months before the diagnosis of t1dm, during the two years before t1d diagnosis in children statistically significantly increased the risk of t1d (54) and may have different impacts at with a relative risk (rr) of 1.82 in different ages (55). the stressful life events, are associated with the development of t1d in children aged 5-9, acting as a risk factor for this disease (56). in our study, we did not have a comparison group to analyse whether stressful psychosocial life events are a risk factor for t1dm in children, but psychosocial stress related to parental divorce or death was evidenced in 2.6% of children with t1dm at aged 5–9 years compared to the children aged 0–4 and 10-14 years, confirming the findings of the study in sweden. further studies can be undertaken to verify whether psychosocial stress is a risk factor for t1dm in our country. in our study, it was found that 23.7% of children with dmt1, had a history of precipitating viral infections, significantly higher among children aged 0-4 years (41.9%) compared to children aged 5-9 years (27.9) or those aged 10-14 years (10 %) [p=0.002]. more than 85% of individuals who develop type 1 diabetes have no family history, so the general population screening to identify risk in is an important goal (56). in our study we found that 15.8% of children with dmt1 had a family history of dmt1, 17.8% had a family history of dmt2, 28.3% had a family history of dmt1 or dmt2, and 2.6% had a family history of both dmt1 and dmt. the genetic component of the development of dmt1 is known. the risk of developing dm1 in first degree relatives is 8 to 15 times higher (57-59) and about twice as high in second-degree relatives compared to children with no relatives with diabetes (5760). about 10-12% of children with t1dm have a family history of diabetes at the time of diagnosis, which may increase more than 20% during their lifetime (60-63) data which are very similar to the findings of our study. a study among 1488 children aged 0–14 years in finland reported that 21.8% of them had a firstor second-degree relative with type 1 diabetes at the time of diagnosis (64). the fathers transmit dmt1 to their offspring more often than mothers (58,65). similar findings were observed to our study: 12.5% of children with dmt1 had a father and only 8.4% of them had a mother with dmt1 at the time of diagnosis. different studies have reported different data regarding the time between the appearance of symptoms and the moment of diagnosis. the duration of symptoms to the diagnosis can vary greatly, ranging from a few days to several weeks or months depending on the level of education of the parents, the fact of the presence of diabetes in other family members, level of health care, the age of the patient, etc. (66). the average duration of symptoms to the diagnosis of dmt1 in our study we was 23.35 ± 17.16 days, ranging from 0 days (immediate diagnosis) to a kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 20 | 27 maximum of 90 days (ie, 3 month). our results regarding the duration of symptoms were similar to those reported by demir f, et al (67) and usher-smith et al (68). the age of the patient is important because younger patients usually present with mild, vague symptoms, while older children usually present with the classic symptoms of the disease such as polyuria, polydipsia and weight loss (66). younger children are more likely to present in severe stages of the disease, reflecting this in a higher frequency of ketoacidosis (kad) compared to older children due to higher levels of respiratory and gastrointestinal infections in this group, which may delay diagnosis (66). it has been proven that the diagnosis of dmt1 can be established later in girls than in boys, for unknown reasons (66). there are no statistically significant gender differences regarding this parameter, but there are significant age differences where this time was longer in children 5-9 years old (28.61 days) (p = 0.013). polyuria, polydipsia and weight loss were the most common symptoms, 99.3%, 99.3% and 98.1%, receptively. the second and most serious, life-threatening presentation of t1dm is dka. although the incidence of dka in many developed countries has been reduced (69-71), various studies around the world reported a 6-fold variation of dka in presentation from 12.8% to 80% of children diagnosed with t1d for the first time (72). in our study the overall incidence of ketoacidosis was 67.8%. the mean age of children with dka was 7.75 ± 3.64 years, while that of children without dka was 9.29 ± 3.39 years (p = 0.012). the mean age at diagnosis of children with dmt1 with kad is significantly higher than that of children with dmt1 without kad (24.65 ± 17.39 vs 20.61 ± 16.51, p=0.169). in general, children with dmt1 with kad are diagnosed earlier than children with dmt1 without kad, possibly because of their more gravity of clinic. in our study we found that the frequency of dka was higher among girls (76.7%) than among boys (59.5%) and this difference was statistically significant (p = 0.025). the higher frequency of dka among girls with t1d than among boys with t1d is also reported in the international literature. the girls were stated to experience dka more frequently, possibly due to some sexrelated social or biological differences (72). our results were similar to the data of demir f., et al (67). females and ages 0-4 years were identified as factors related to the presence of kad in children with t1dm; 2.24 and 2.97 times, respectively more likely to be affected by kad compared to males and children ages 10-14 years, respectively (p<0.05). nevertheless, was evidenced a negative and statistically significant relationship between age and the presence of kad: for every year increase of the age of children, the possibility of the presence of kad decreases by 0.126 times. positive family history for dmt1 is considered a protective factor and is associated with a reduced risk of dka at t1dm diagnosis because cases are diagnosed in an earlier stage (73). our results did not reach agreement with these findings. pawlowicz et al (74) and also reported that a positive family history had no such impact. positive family history for dmt1 and dmt2 was not statistically significantly associated with the presence of kad in children with dmt1. however, children who have a positive family history of dmt1 or dmt2 were 6 times more likely to be affected by kad (p=0.127); children with a history of dmt1 and dmt2 were 8.73 times more likely to be affected by kad compared to children with dmt1 without a positive family history of dmt1 or dmt2 (p=0.073, borderline). the presence of viral infections or other precipitating conditions increased the odds of kad by 1.58 times compared to kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 21 | 27 children without these conditions, this difference did not reach statistical significance. regarding residence, children living in urban areas are 1.32 times more likely to be affected by kad compared to children in rural areas. the misdiagnosed were in 13.8% of cases, of which respiratory and gastrointestinal and infectious illnesses were the most common. almost all were presented with kad; and almost half (45.3%) were in the age group 04 years similar results were found in the study małgorzata pawłowicz et al (14.13%) (74). autoimmune diseases are more common in females. in children and adolescents with t1dm of both genders carry similar risk and have no significant differences in overall incidence (75). the gender predominance of dmt1 is thought to be influenced by race, age of diabetes diagnosis, and incidence. in certain populations the incidence of dmt1 is more frequent in males (76) and in some more frequent in females (77). in caucasians, in high-incidence countries (23/100,000/year) (78), children ages < 6 and ≥13 years of european origin (age group which is more likely to develop diabetes for the same age and geographical localization (male: female ratio 3:2) (79) men have a slightly higher incidence than females. on the other hand, the female predominance is seen in of non-caucasian origin (80), african and asian, low incidence countries (81), peripubertal age (82). age, urban residence and year of diagnosis (35) and factors are related to viruses’ infections, dietary factors such as gluten, obesity in childhood, improvement of hygienic-sanitary conditions, etc. (83) are statistically significant risk factors for the occurrence of dmt1 in children. t1dm is associated with an increased risk of developing other autoimmune diseases as a result of genetic susceptibility to autoimmune diseases (ad). the most common comorbidities include: autoimmune thyroid disease (atd) and celiac disease (cd) (84), possibly because of some common pathogenetic mechanisms including certain gene expressions (34). these ad are observed more frequently in females with t1dm (85). at diagnosis and during follow up of t1dm 19.74% (30/152) developed associated autoimmune diseases; 11.85% atd and 7.89% cd. of them, 60% at diagnosis of t1dm and 68% of patients were female. during follow up children with t1dm developed associated cd and sat, 2.54, and 2.19 years, respectively. these findings are consistent with international literature data. references 1. diamond project group. incidence and trends of childhood type 1 diabetes worldwide 19901999. diabet med 2006;23:857-66. doi: 10.1111/j.14645491.2006.01925.x. 2. international diabetes federation. diabetes atlas (4th edition). brussels, belgium: idf; 2009. 3. gale ea. the rise of childhood type 1 diabetes in the 20th century. diabetes 2002;51:3353-61. doi: 10.2337/diabetes.51.12.3353. 4. patterson cc, dahlquist gg, gyurus e, green a, soltesz g. incidence trends for childhood type 1 diabetes in europe during 1989-2003 and predicted new cases 2005-20: a multicentre prospective registration study. lancet 2009;373:2027-33. 5. search for diabetes in youth study group. the burden of diabetes mellitus among us youth: prevalence estimates from the search for diabetes in youth study. pediatrics 2006;118:1510-8. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4439892/#ref12 kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. 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(original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 27 | 27 85. fröhlich-reiterer ee, hofer s, kaspers s, herbst a, kordonouri o, schëarz hp, et al. screening frequency for celiac disease and autoimmune thyroiditis in children and adolescents with type 1 diabetes mellitus—data from a german/austrian multicentre survey. pediatr diabetes 2008;9:546-53. ________________________________________________________________________________________ © 2022 kollçaku; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. kureta e, basho m, murati e, roshi e, burazeri g, bino s. screening for viral hepatitis b in the roma community in tirana, albania (original research). seejph 2019, posted: 03 october 2019. doi 10.4119/seejph-2355 1 original research screening for viral hepatitis b in the roma community in tirana, albania elona kureta1, mimoza basho1, ermelinda murati2, eugena tomini1, enver roshi3, silvia bino1,3 1 institute of public health, tirana, albania; 2 directorate of public health, tirana, albania; 3 faculty of medicine, university of medicine, tirana, albania. corresponding author: elona kureta, md address: rr. “aleksander moisiu”, no. 80, tirana, albania; telephone: +355693600966; e-mail: ekureta@gmail.com kureta e, basho m, murati e, roshi e, burazeri g, bino s. screening for viral hepatitis b in the roma community in tirana, albania (original research). seejph 2019, posted: 03 october 2019. doi 10.4119/seejph-2355 2 abstract aim: according to the previous studies conducted in albania involving roma communities and in general populations, the prevalence of hbv was 13% and 7%-9%, respectively. due to this high prevalence of hbv and difficulties accessing adequate healthcare, a screening was performed in some areas where roma populations live. the aim of this study was to assess the prevalence of hbv in the roma population in albania in order to make evidencebased recommendations for increasing the awareness of the population about this disease and increase the access to the vaccination. methods: a cross-sectional study was conducted in three rural areas and in four urban areas in tirana district with known limited population movement. openepi was used to calculate the sample size. the laboratory methods used consisted of the immune chromatographic method, rapid test and elisa. results: 27 out of 174 specimens tested positive for hbv. the prevalence of hbsag was 15.5% (95%ci=10.8%-21.6%). the age-related positivity of hbsag was 10.6% for the agegroup 19-24 years, 19.4% for the age 25-44 years and 11.8% for the age 45-59 years. of the positive cases, 15 were females and 12 were males. the areas with the highest positivity rate for hbsag were tufina (24%), health care center no.8 (23.1%) and sauk (15.4%). conclusion: a higher prevalence of hbv was found among roma population in tirana district compared to the general population. the age-group 25-44 years, males, and people residing in tufina area showed a higher hbsag positivity rate. improvement of the sentinel surveillance, increase of the awareness about the disease, promotion of vaccination and healthy behaviour, are the recommended actions that should target the roma population. keywords: hbv, prevalence, roma, screening. conflicts of interest: none. kureta e, basho m, murati e, roshi e, burazeri g, bino s. screening for viral hepatitis b in the roma community in tirana, albania (original research). seejph 2019, posted: 03 october 2019. doi 10.4119/seejph-2355 3 introduction hepatitis b represents inflammation of the liver caused by hepatitis b virus (1). the disease spreads through contact with infected blood, infected semen or other infected body fluids or from infected mother to baby at birth. hiv, multiple sex partners, homosexual relations and unprotected sex increase the risk of hbv. hbv can cause acute or chronic infection; the acute infection could be very mild (mostly undetected) to severe forms requiring hospitalization (2). most persons infected with hbv are able to “clear” the virus. chronic hbv could lead to serious liver and overall health problems, including liver cancer and death. the best way to prevent hbv is through vaccination (3). pregnant women and blood donors are usually considered as representatives of general population regarding prevalence of hbv whereas high risk groups comprise injecting drug users, males who have sex with males, migrants, etc (4). roma in albania are recognized as an important ethnic minority. official sources state that there are about 35,000 roma individuals in albania. roma communities are found all over the country, but the largest are settled in central and southeast regions of albania. roma population is a vulnerable group in albania (5). according to previous studies conducted in roma communities, the prevalence of hbv was 13% (6), and the prevalence of hbv in the general population is 7%-9%. vaccination is mandatory in albania since 1994 for all newborns within 24 hours of birth. the national immunization program (under iph department of control of infectious diseases) has conducted several vaccination campaigns in order to reduce the gap and increase the immunization into the roma population. vaccination coverage of roma children is high on the first doses due to vaccination at birth done in maternities. for example, during 2014, in tirana, in 114 roma children born, 113 (99%) were vaccinated at 24 hours of birth. after that, there is a gradual decrease of coverage for further doses of basal vaccination (from 90% at 2 months 67% at 4 months 57% at 6 months) (7). vaccination is free-of-charge for the roma population and other vulnerable groups near gp practitioners. roma families have difficulties accessing adequate healthcare because they do not pay health insurance within the insurance scheme, which in turn, denies them benefiting from the services in due way (8). the aim of this study is to estimate the prevalence of viral hepatitis in this population at risk in order to make evidence-based recommendations for increasing the awareness of population about these diseases and promote the vaccination. methods this cross-sectional study was conducted among roma population in tirana district during the year 2016. the total roma population in tirana is around 16,000 persons. rural areas of tufine, babrru, sauk and urban areas that correspond to health care center no.11, no.8, no.7 and no.10 were selected for the study. the total study population consists of 2,022 individuals including all roma population resident in these areas. for each positive person was recommended to visit the specialist for further follow-up. screening tests the methods used included the immune chromatographic method, the rapid test and elisa. hbsag rapid test: infection with the hepatitis b virus is characterized by the appearance of certain viral markers including hepatitis b surface antigen (hbsag) in the blood. hbsag rapid test is a visually read, qualitative immunoassay kureta e, basho m, murati e, roshi e, burazeri g, bino s. screening for viral hepatitis b in the roma community in tirana, albania (original research). seejph 2019, posted: 03 october 2019. doi 10.4119/seejph-2355 4 for in vitro detection of hepatitis b surface antigen in serum or plasma. the test is intended as an aid to diagnosis of hepatitis b infection. the antigen found in the envelope of hbv is designated hepatitis b surface antigen (hbsag) and its presence in serum or plasma indicates active hbv infection. hbsag rapid test is a simple, one-step test that detects the presence of hbsag. this is only a screening test. the test does not rule out hepatitis b infection because hbsag may not be present in sufficient quantity to be detected at a very early stage of infection. positive results must be confirmed by other diagnostic procedures and clinical data. the systematic use of rapid tests performed at points-of-care may facilitate hepatitis b virus (hbv) screening and substantially increase hbv infection awareness. case definition: a positive case is considered any person that tested positive for hbsag with rapid test and then confirmed with elisa method. sample size: openepi (9) was used to calculate the sample size. areas where the process was conducted were selected according to the number of population and their internal migration. there were taken into consideration the areas where the movement of the population is stable and the number of them is higher than the other areas where roma lives. the selected areas were rural ones of tufine, babrru, sauk and urban areas corresponding to health care center no.11, no.8, no.7 and no.10. a total of 174 individuals were included in the study according to the method of probability proportional to size. recruitment process / selection of individuals the working group was composed by state and territorial epidemiologists and microbiologists. the chart below shows the steps that the working group did in the field. step 1. step 2. step 3. step 1 in each area we contacted the director of the health care center, general practitioners, and representatives of the relevant roma associations who were informed in advance with the procedure of screening. they all agreed for this screening. step 2 meeting with each roma resident in the hcc. they were selected randomly at site. to all of them it was explained about the disease and the reason of this screening test. before performing the procedure each person signed a consent form. step 3 the process of the blood samples collection. data and specimens collection inclusion criteria: eligible for the study were only individuals aged 19 years and older. exclusion criteria: individuals aged 0-18 years because they were already vaccinated against hbv. also from the agreement for the screening sign the consent form from each person meeting the director, gp of each hcc, roma representatives meeting with roma in hcc sample collection kureta e, basho m, murati e, roshi e, burazeri g, bino s. screening for viral hepatitis b in the roma community in tirana, albania (original research). seejph 2019, posted: 03 october 2019. doi 10.4119/seejph-2355 5 study were excluded all persons that suffered from other liver diseases. the reason for both these exclusion criteria was to control for the confounding factors that could affect the results of the study. an individual questionnaire with demographic and vaccination data was matched to each serum sample. all sera samples collected were analyzed in national virology laboratory in institute of public health. statistical analysis data was analyzed using the statistical package for the social sciences (spss) (version 20.0). categorical variables are presented as absolute frequencies and percentages. chi-square test was used to compare the proportions between categorical variables. a p-value ≤0.05 was considered significant. results in total, 174 individuals were tested for viral hepatitis b. 29.9% of them were males and 70.1% females with a mean age 33.7 (10.7) years and range 19 to 59 years. the majority of individuals (53.4%) belonged to age group of 25-44 years old (p<0.01). overall, 27 individual tested positive for hbv. the prevalence of hbsag was 15.5% (95% ci 10.8% to 21.6%). the positivity rate for hbv among males was (23.1%) as compared to females (12.3%), without significant difference p=0.1 (table 1). table 1. testing results by gender gender tested cases for hbv positive cases percent positive female 122 15 12.3 male 52 12 23.1 the most affected was the age group 25-44 years (19.4%), followed by age group 45-59 years (11.8%) p=0.3 (table 2). table 2. testing results by age group age-group total cases positive for hbsag percent positive 19-24 years 47 5 10.6 25-44 years 93 18 19.4 45-59 years 34 4 11.8 no significant difference in positivity rate for hbv was found by areas of the study, as shown in table 3. kureta e, basho m, murati e, roshi e, burazeri g, bino s. screening for viral hepatitis b in the roma community in tirana, albania (original research). seejph 2019, posted: 03 october 2019. doi 10.4119/seejph-2355 6 table 3. distribution of hbv cases by areas study area no. of samples no. of samples positive for hbsag percent positive tufine 49 12 24.5 babrru 9 1 11.1 health center no.8 26 6 23.1 health center no.7 12 1 8.3 sauk 13 2 15.4 health center no.11 14 1 7.1 health center no.10 51 4 7.8 total 174 27 15.5 figure 1. distribution of hbv cases by area in tirana district discussion albania is among countries with a relatively high prevalence of hbsag. a previous study conducted in general population in 2009 reported a prevalence of 9.5% (10). the presence of one or more serological markers of hbv infection and the high rate of infection in children aged 1 to 10 years confirms the endemic nature of this virus in albania. the abovementioned data of hbv infection in albania were undoubtedly related to low kureta e, basho m, murati e, roshi e, burazeri g, bino s. screening for viral hepatitis b in the roma community in tirana, albania (original research). seejph 2019, posted: 03 october 2019. doi 10.4119/seejph-2355 7 hygiene and poor economic situation, overcrowded conditions, lack of disposable needles and syringes, lack of safe blood and its products for transfusion, inadequate sterilization of reusable equipment, difficulties in obtaining appropriate personal equipment to prevent exposure to blood, and lack of an immunization program against hbv before the year 1994. taking into consideration the reinforcement of the general preventive measures, such as the implementation of the safe injection procedures, proper sterilization of the medical and dental equipment, proper screening of the blood and its products, and progress in health education and vaccination of some high-risk groups (health care workers, hemodialysis and thalassemic patients), the significant reduction of hbv markers among the nonvaccinated general population (9.5%) compared to the previous rate of 19931995 (18%-19%), may be attributed to the 12 consecutive years of vaccination of newborn children against hbv. in a study conducted in 2011 the prevalence of hbsag in adolescents of area peze-ndroq in tirana was 22.4% versus 15.1% in adults (11). in our study conducted in 2018 a higher prevalence of hbv was found among roma population in tirana district compared to the general population. considering the high prevalence of hbv in roma population and the problems that this vulnerable group has towards the vaccination process and difficulties accessing adequate healthcare, the institute of public health (iph) in collaboration with the directorate of public health of tirana have performed screening in some areas where roma populations live. limitations: the study was conducted only in the areas with known limited population and using a convenience sampling approach which potentially introduces a selection bias. the laboratory testing included only the rapid test and elisa and not pcr which is a confirmatory method in diagnosing hbv. conclusion improvement of the sentinel surveillance for detecting new hbv cases, increasing of the awareness about the disease, promoting healthy behaviour, health education and vaccination in order to increase vaccination coverage are the recommended actions that should target the roma population. references 1. world health organization. hepatitis b in the who european region; 2017. available from: http://www.euro.who.int/__data/assets/ pdf_file/0009/283356/fact-sheet-enhep-b-edited-2.pdf?ua=1 (accessed: july 10, 2019). 2. european centre for disease prevention and control. surveillance of hepatitis b and c in the eu/eea – 2017 data. available from: https://ecdc.europa.eu/en/hepatitis-b (accessed: july 10, 2019). 3. hahné sj, veldhuijzen ik, wiessing l, lim ta, salminen m, van de laar m. infection with hepatitis b and c virus in europe: a systematic review of prevalence and cost-effectiveness of screening. bmc infect dis 2013;13:181. doi:10.1186/14712334-13-181. 4. ulqinaku d, basho m, hajdini m, qyra s, bino s, kakarriqi e. prevalenca e hepatiteve virale te gratë shtatëzëna në shqiperi. [surveillance systems for acute viral hepatitis in albania]. revista mjekësore (albanian medical journal) 2006;3:55-63. 5. kondili la, ulqinaku d, hajdini m, basho m, chionne p, madonna e, et al. hepatitis b virus infection in health http://www.euro.who.int/__data/assets/pdf_file/0009/283356/fact-sheet-en-hep-b-edited-2.pdf?ua=1 http://www.euro.who.int/__data/assets/pdf_file/0009/283356/fact-sheet-en-hep-b-edited-2.pdf?ua=1 http://www.euro.who.int/__data/assets/pdf_file/0009/283356/fact-sheet-en-hep-b-edited-2.pdf?ua=1 https://ecdc.europa.eu/en/hepatitis-b kureta e, basho m, murati e, roshi e, burazeri g, bino s. screening for viral hepatitis b in the roma community in tirana, albania (original research). seejph 2019, posted: 03 october 2019. doi 10.4119/seejph-2355 8 care workers in albania: a country still highly endemic for hbv infection. infection 2007;35:94-7. 6. albania behavioral and biological surveillance study report-biobss 2005. usaids & family health international; 2006. 7. simon p, galanxhi e, dhono o. roma and egyptians in albania: a socio demographic and economic profile based on the 2011 census. united nations support to social inclusion in albania programme; 2015. 8. institute of public health. vaccination in albania. available from: http://www.ishp.gov.al/category/vaksin imi/ (accessed: july 10, 2019). 9. open source epidemiologic statistics for public health. www.openepi.com. 10. resuli b, prifti s, kraja b, nurka t, basho m, sadiku e. epidemiology of hepatitis b virus infection in albania. world j gastroenterol 2009;15:849-52. doi: 10.3748/wjg. 15.849. 11. kone e, ceka x, ostreni v, shehu b, arapi i. prevalence of hepatitis b virus infection in adolescents in tirana area (albania). j environ prot ecol 2011;12:271-8. ________________________________________________________________________ © 2019 kureta et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ishp.gov.al/category/vaksinimi/ http://www.ishp.gov.al/category/vaksinimi/ http://www.openepi.com/ annapaola rizzoli, climate and health action award to the one health commission speech at the award ceremony. seejph 2023. posted: vol. xx. page 4 short report climate and health action award to the one health commission, speech at the award ceremony annapaola rizzoli research and innovation centre, edmund mach foundation, italy corresponding author: annapaola rizzoli dvm, phd address: research and innovation centre, edmund mach foundation via e. mach, 1 38010 s. michele all'adige (tn) – italy email: annapaola.rizzoli@fmach.it annapaola rizzoli, climate and health action award to the one health commission speech at the award ceremony. seejph 2023. posted: vol. xx. page 5 dear awards committee and governing council of the world federation of public health associations (wfpha), and wfpha delegates, on behalf of the one health commission executive director dr. cheryl stroud, who unfortunately could not be here today, we are incredibly honored to receive the climate and health action award assigned to the one health commission (ohc). we thank dr. ulrich laaser for nominating the ohc for this award. dr. laaser is a scientist who has embraced the one health concept and worked hard alongside the ohc on a number of initiatives highlighting our urgent global need to implement one health thinking, acting, and living at all levels of academia, government, policy, and research. as highlighted in one of his recent papers, the definition of "one health" has been recently reviewed by four global institutions joined together as the one health quadripartite (fao, who, woah, and unep): "one health is an integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals, and ecosystems. it recognizes the health of humans, domestic and wild animals, plants, and the wider environment (including ecosystems) are closely linked and interdependent. the approach mobilizes multiple sectors, disciplines, and communities at varying levels of society to work together to foster well-being and tackle threats to health and ecosystems while addressing the collective need for clean water, energy, and air, safe and nutritious food, taking action on climate change, and contributing to sustainable development". climate change, in particular, is one of the significant global challenges that provides an opportunity to share ideas and knowledge across disciplines to promote sustainable development under the one health framework. a one health approach to climate change mitigation and adaptation may, in fact, significantly contribute to animal, human and ecosystem health by improving healthy eating habits such as those included in the mediterranean diet, with consequences on the entire global food production system, especially on the animal food production chain that is thought to contribute to climate change, as well as to animal welfare. implementation of one health communitybased surveillance of zoonoses (diseases that pass between animals and humans) such as vector-borne diseases (vbds), provides annapaola rizzoli, climate and health action award to the one health commission speech at the award ceremony. seejph 2023. posted: vol. xx. page 6 another practical example of how to mitigate the health effects of climate change. vbds reveal the ‘interconnections’ of the interconnections as climate change expands vector ranges, exposing animals and humans alike to greater disease risks. a dynamic one health leadership and management framework requires both bottom-up and top-down structural elements, interacting based on scientific reasoning and guiding long-term one health advancement. innovative ideas and subsequent initiatives are often initiated bottom-up, as is the societal dimension of one health and its social dynamism[1]. yet, to be sustainable, one health interventions also require support ‘top down’ from policy makers and governments. the one health commission is one of the best examples of a bottom-up initiative to implement this paradigm shift that will bridge the many disciplines which characterize our current systems. incorporated in 2009 in washington, dc, as a non-profit organization, the one health commission was formed as an outcome of a one health initiative task force led by the american veterinary medical association (avma) and the american medical association (ama), as well as other partner organizations. the ohc is a globally focused organization working to further implementation of one health and one health actions worldwide. it highlights and connects 498 entities working for one health around the world, including academic, governmental, regional, private, and nonprofit organizations. the ohc seeks to raise awareness and to educate all audiences about the importance of transcending institutional and disciplinary boundaries to transform how animal, human, plant, and ecosystem health professionals work together for the health of all living creatures and the planet. its mission is to: 'connect' one health advocates and stakeholders, to 'create' networks and teams that work together across disciplines to 'educate' about one health and one health issues. connect those working for one health around the world to facilitate needed synergistic relationships and collaborations at all levels of academia, government, policy, and research; create opportunities for human, animal, plant, and ecosystem health-related disciplines and institutions to work together in transformative collaborations; annapaola rizzoli, climate and health action award to the one health commission speech at the award ceremony. seejph 2023. posted: vol. xx. page 7 © 2023 annapaola rizzoli; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. educate the public about the importance and urgent need for the one health approach. this includes established professionals and students from all disciplines (from anthropology to architectural design to biology/chemistry to food scientists to medicine to psychology to sociology to zoology, etc.), agricultural and food production sectors, health care providers from human and animal domains, policy and lawmakers, 'everyone'. prepare the next generation of one health leaders and professionals by supporting students for one health and facilitating their efforts to further the one health paradigm shift. among its initiatives, in 2016 the ohc helped launch and leads today the annual global one health day, a timely initiative that gives scientists and one health advocates a powerful platform and voice for moving beyond current provincial approaches to emerging infectious diseases, antimicrobial resistance, climate change, environmental pollution, and many other issues. the ohc also oversees since 2015 the monthly one health happenings newsletter that provides an overview of articles and other news from the global one health movement and about one health topics gathered from media worldwide. for more information, please visit the ohc website[2]. we also wish to thank all the organizational sponsors of the one health commission. their contributions are fundamental to supporting the activities led by the ohc. to conclude, via this award, the one health commission is honored to share the one health concept with the wfpha and the broader international public health community. this award motivates the ohc to continue and to expand its efforts to make one health thinking and acting the default way of living at all levels of academia, industry, research, government and policy. thanks again for this highly appreciated award. references 1. laaser, u., et al., exchange and coordiantion: challenges of the global one health movement. south eastern european journal of public health (seejph), 2022. 2. the one health commission at: www.onehealthcommission.org __________________________________________________________________________ satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 1 | 15 original research how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic adhitya satyamoorthy1, helmut brand1,2, robin van kessel1,3 1 department of international health, care and public health research institute (caphri), maastricht university, maastricht, the netherlands; 2 prasanna school of public health, manipal academy of higher education, manipal, karnataka, india; 3 maastricht working on europe, studio europa, maastricht university, maastricht, the netherlands. corresponding author: prof. dr. helmut brand; address: department of international health, maastricht university, duboisdomein 30, 6229 gt maastricht, the netherlands; email: helmut.brand@maastrichtuniversity.nl satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 2 | 15 abstract aims: the article aims to analyze what can be learned from the last financial crisis from 2008 on to minimize the negative health effects in the european union due to the economic recession caused by the covid-19 pandemic. methods: systematic literature reviews were conducted to analyze the interventions taken to combat the last financial crisis and their consequences on health. parallel to this, a qualitative document analysis of the ongoing discussion about the measures taken or to be taken in the covid-19 pandemic to fight the current economic recession was conducted using institutional websites and international media. results: the main methods taken to combat the financial crisis from 2008 were, bailing out banks, austerity measures, and the european stability mechanism. there is evidence that the financial crisis had negative effects on the european health systems in general. austerity measures in some countries, led to an increase in psychological disorders. overall mortality was not affected but the decrease of avoidable mortality slowed down. various economic interventions such as bailing out essential industries e.g., the aviation sector, cash injections, tax relief, short-work salary compensation, modified esm, and the pandemic emergency purchase program (pepp) were taken during the covid-19 pandemic to help stabilize the economy. conclusion: the current recession is not caused by internal failures of the financial system as it was in the financial crisis of 2008, but by an outside event the covid-19 pandemic. measures were taken by the governments and the european union to avoid an economic crisis, and by these, the negative health effects were created during the financial crisis in 2008, but the lockdown phase seems to lead to similar negative health effects regarding psychological disorders and delay of planned screening and treatment. keywords: austerity, covid-19, economic measures, financial crisis, health, pandemic. conflict of interest: none declared. satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 3 | 15 introduction in december 2019 an outbreak of the virus, severe acute respiratory syndrome coronavirus 2 (sars-cov-2), occurred in wuhan, china, which developed into the covid-19 pandemic (1). the virus that caused covid19 spreads mainly when an infected person is in close contact with another person or small droplets and aerosols is in the air (1). at the beginning of 2020, 23 million people were infected worldwide, out of which, 800,961 people died (2). to combat the pandemic in the absence of a vaccine several non-pharmaceutical measures such as lockdowns were adapted by infected countries. this was to prevent the spread of the disease and not overload the health system with patients. a side-effect of these measures is that they had and still have a serious influence on the economies of infected countries that finally led to a worldwide recession (3). the gross domestic product (gdp) shrank by 12.1 % in the european union at end of july 2020 (4). by this, the covid-19 pandemic has the highest negative effect on the economy of all infectious disease outbreaks in the last decades (5). next to the direct burden of ill-health due to infected people, there is the risk of an indirect burden of ill-health caused by the measures taken to combat the economic recession as we learned from studies that looked into the effect of economic decline on health (6). the european union and its member states had to choose interventions to minimize these negative health effects. figure 1, originally presented by douglas and colleagues (7), visualizes the interdependencies between the different measures taken to fight the pandemic and illustrates the pathway of economic consequences leading to indirectly attributable morbidity and mortality. the last financial crisis started in august 2007 in the united states. the excessive risk taken by banks along with the bursting of the united states housing bubble caused the financial downturn in the united states (8). real estate was hit the most damaging various financial institutions globally. this was then followed by a global financial crisis in september 2008 that later developed into the great recession in 2009-2010. the financial crisis of 2008 in europe initially affected portugal, ireland, italy, greece, and spain. this led to a loss of confidence in european businesses and economies. unsustainable fiscal policies and overleveraged banks led to a sovereign debt crisis in the euro area in 2010 (8). the research objective of this article is to analyze if the measures taken to combat the last financial crisis should be applied this time too. by comparing the current economic recession with the financial crisis of 2008 and the economic measures taken then, we can theorize if the measures would work during the economic crisis caused by the covid-19 pandemic. methods ethical consideration this literature review was based on published reports and was therefore exempted from ethical approval. a systematic literature review was conducted on the measures taken to combat the financial crisis of 2008 and, on the health effects the crisis had, using databases pubmed, web of science, and econpapers from the years 2009 to 2020 using a combination of boolean operators (and/or), medical subject headings (mesh) and predefined keywords. peer-reviewed papers in english on measures taken to combat the financial crisis of 2008 and the health effects of the crisis were retrieved and independently evaluated for eligibility based on the title and abstract. thereafter, full texts of eligible papers were accessed according to the pre-defined inclusion and exclusion criteria. the preferred reporting items for systematic reviews and meta-analyses (prisma) 2009 guidelines were followed (9). satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 4 | 15 figure 1. effects of social distancing measures (7) search strategy and data collection for the review on the measure taken to combat the financial crisis in 2008 and health effects caused by the crisis, keywords were “financial crisis 2008”, “economic impact”, “eurozone crisis”, “measures”, “austerity”, “health effects”, “behavioral effects”, and “europe”. the time span of publications was from 2009 to june 2020. the great american recession 2007-2009, the measures taken during the financial crisis of 2008 in the united states of america, countries outside the european union, and published articles in other languages apart from english were excluded. parallel to this, a qualitative document analysis regarding the content of the ongoing discussion about the measures taken or to be taken in the coronavirus pandemic to fight the economic recession was conducted to watch out for evidence about indirectly attributable morbidity and mortality. sources monitored were the institutional websites, e.g., of the european commission (ec), the european centre for disease prevention and control (ecdc), the european central bank (ecb), the world bank, the european investment bank (eib), the international monetary fund (imf), the organisation for economic co-operation and development (oecd), and major international consultant companies and newspapers. for the review on how to combat the 2008 financial crisis and the health effects of the financial crisis of 2008, 668 articles could be identified via the databases searched, and 35 articles via additional sources. satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 5 | 15 after checking for relevance 36 articles were included. the qualitative document analysis of the institutional websites was included till the end of june 2020 and 13 results were used. figure 2. systematic literature review on economic measures taken during the financial crisis 2008 (9) records identified through database searching (n =407) sc re e n in g in cl u d e d e lig ib ili ty id e n ti fi ca ti o n additional records identified through other sources (n = 21) records after duplicates removed (n =378) records screened (n = 378) records excluded (n =280) full-text articles assessed for eligibility (n =98) full-text articles excluded, with reasons (n =84) studies included in synthesis (n = 14) satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 6 | 15 results measures taken to combat the financial crisis of 2008 the primary cause of the 2008 financial crisis in europe was the bursting of a property bubble in the united states of america in 2007 (10). the crisis resulted from a structural problem of the eurozone, and a combination of factors, which included the globalization of finance, easy credit system that encourage high-risk borrowing, lending practices, international trade imbalances, a real estate bubble, unsustainable fiscal policy approaches related to government revenues, and expenses and approaches used by certain nations to bail out troubled banks and private bondholders (11). the first interventions were to prevent the collapse of the banking figure 3. systematic literature review on health effects of financial crisis of 2008 (9) records identified through database searching (n =261) s cr e e n in g in cl u d e d e li g ib il it y id e n ti fi ca ti o n additional records identified through other sources (n =14) records after duplicates removed (n =246 ) records screened (n = 246 ) records excluded (n =203) full-text articles assessed for eligibility (n =43) full-text articles excluded, with reasons (n =21) studies included in synthesis (n =22) satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 7 | 15 sector and the second interventions tried to avoid a massive drop in demand (12). member states made efforts to prevent mass unemployment and made sure workers would retain their relationship with the labor market, e.g., by implementing short-time work schemes. this was one of the main reason’s governments had to raise taxes and cut back social expenditure (13). investments in jobs and government infrastructure, tax measures, and tax reliefs were implemented (12). other measures such as lowering interest rates and buying government bonds were part of the monetary policies of the eu that would help to cope with the financial crisis (14). between october 2008 and may 2009, the european central bank (ecb) lowered its interest rate to maintain price stability in the euro area. the enhanced credit system focused on commercial banks, as they were the main source of funding for businesses and households in the euro area interbank market (15). public debt increased, national credit ratings fell and the cost of borrowing increased. this led governments in europe to impose harsh austerity measures which would reduce public spending (13). during the crisis, unemployment increased rapidly in europe. the european central bank (ecb), the european investment bank (eib), and the international monetary fund (imf) along with leaders of european member states placed a priority to reduce the deficit (16). the majority of the deficit reduction policies by european governments involved further budget cuts rather than tax increases (16). health effects of the financial crisis of 2008 in europe the 2008 financial crisis in europe not only had an economic impact but has also a short, medium, and long-term impact on the health systems and the health of individuals (16,17). economic growth, democratization, and improved living conditions have contributed to better population health in most european countries, but health inequalities are still prevalent (18). these inequalities are mainly caused by daily living conditions, inequalities in available money, and resources which affect individuals during a financial crisis due to loss of employment. this leads to a change in lifestyle which may include smoking, alcohol consumption, and nutrition intake (19,20). in times of an economic crisis, households will also limit their spending on health (21). the financial crisis of 2008 caused, in some countries, severe psychological disorders which included depression, anxiety, and suicidal behavior (22). over time suicides and psychological disorders increased by 7% because of unemployment, loss of income, and housing instability e.g. (in some southern european countries) (23). countries such as greece started to reduce their health care budget during the financial crisis in 2008. the tight restrictions of budgets on the health care system worsened the health system performance and also led to a slowdown in the reduction of avoidable mortality (24). impact of the covid-19 pandemic on the economy in europe the impact of covid-19 pandemic on the economy is severe (25). the manufacturing sector was affected due to lockdown measures as e.g., it depends on the physical presence of the workers. the travel and tourism sector experienced great difficulties as the movement of people was restricted. the closing of public places led to a supply chain disruption. educational institutions had to shift to online education. the entertainment industry experienced a total standstill as gatherings were forbidden. all of this resulted in the loss of jobs and income and also reduced demand and supply (25-27). this influenced the consumers’ confidence as they hesitate to buy products in the face of possible job loss satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 8 | 15 or reduced income. in summary both, supply and demand were reduced in the pandemic (3,28). some of the currently discussed economic measures to solve the crises are already implemented (25,29,30). they focus either on individuals by offering temporary cash for vulnerable households, expand short-time work schemes, and increasing resources for health care (27,31). for the industry, the reduction or delay of paying taxes for affected sectors is discussed (32). at the state level, fiscal consolidation is needed to expand liquidity and availability of credit to firms (32,33). regulations on reporting bankruptcy have been delayed. regarding macroeconomic policies, the expansion of liquidity to banks is discussed (30). further, it should be ensured that monetary policy can respond to extreme market conditions (32). the european union (eu) agreed upon a recovery fund and a long-term budget that supports its citizens and business from the economic crisis caused by covid -19. the european union’s long-term budget called the multiannual financial framework (mff), of 1,100 billion euros for the year 2021 to 2027 can be considered vital in the recovery of the economy (27). the eu has also sanctioned temporary funding of 750 billion euros called the pandemic emergency purchase program (pepp) (30,33). the pepp program would help the member states in supporting their citizens and businesses. this included compensation on employees’ wages, supporting small and medium-sized enterprises (sme), and supporting businesses with tax reliefs or delayed taxes (25,27,31). the effect of the measures is still unknown due to the recent implementation. some european member state governments have started to bail out national airlines (34) as the aviation and the travel sector were one of the most affected sectors during the lockdown. but not all sectors were affected equally. the it sector for example is expected to double its revenue in the second quarter compared to the first quarter in march 2020. companies such as apple and google even saw an increase in their share price from the beginning of february to the first week of august by 8.26% and e-commerce companies such as amazon and ebay saw an increase in their share price by 29.64% from the first week of march to the first week of august (35). the increase in growth of online sales has helped the e-commerce industry because consumer confidence has increased in online sales. this in return helped increase business and industry confidence. the supply chain for certain products from china had come to a standstill. as china today is seen as the workbench for europe this had major implications for the availability of most goods. this was very eminent in the discussion about missing ppe due to the import from china. therefore, many countries are encouraging companies to relocate production in their own country and have committed to support this with dedicated investments into manufacturing through programs such as the escalar (35). health effects of economic recession 2020 in europe the mortality impact of covid-19 has been of major concern in europe and the rest of the world. as of the beginning of august 2020, there were a total of 216,478 deaths (32). the impact of lockdowns adopted by the member states can have unintended health effects (36). lack of social contact can result in mental health issues, limiting physical activity can result in obesity and a rise in domestic violence. the current financial situation can cause uncertainty and stress that would result in a negative health effect in the short term (37). due to lockdown, people are not traveling and by this, the number of traffic accidents is supposed to go down (38,39). there have been concerns that the measures taken to mitigate the covid-19 pandemic satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 9 | 15 could increase the number of deaths from other diseases. one of the major issues is that people hesitate to go for treatment as they fear they would be infected by the covid19 virus. or, that they do not like to burden the healthcare system when it is already under pressure due to the pandemic (37,40). hospitals are delaying the treatment of noncovid-19 patients as they are trying to prioritize the cases related to the pandemic (40). therefore, apart from the official covid-19 deaths, there are additional deaths that may be directly or indirectly related to it. due to the lockdown and social distancing measures about 2.1 million people missed out on cancer screening. there have also been up to 290,000 people with suspected symptoms that have not been referred to any hospital or any treatments (37). this is because during the lockdown health systems focused on patients with covid-19 and other services like cancer screening were postponed. due to this, there might be around 230,000 cases of cancer gone undetected. cancer requires prompt diagnosis and treatment; hospitals can’t do so because they are over capacitated by covid-19 patients. this would increase the number of cancer cases over the long term (41). discussion the rapid spread of covid-19 prompted many governments to impose serious and strict lockdown measures. these measures have made many businesses shut down temporarily, led to restrictions on free movement and travel, financial market going turmoil, and decreased consumer confidence (42). the measures taken in europe to help and boost the economy are relatively large compared to those measures taken during the financial crisis in 2008. the magnitude of the impact of these measures on the growth of gdp is still unknown due to their recent implantation. data on the economic effect of the pandemic are not yet available or accessible since some statistics are produced on a quarterly or yearly basis. as there are different reasons for the origin of the crisis, some macro-economic effects might be different so the actions to be taken might not be the same. table 1 compares the reasons for the two crises, the effects on the economy, the measures taken, and their effects. table 1. comparison of the financial crisis of 2008 with the economic recession 2020 financial crisis 2008 economic recession 2020 reason for crises from inside the financial system (bursting of a property bubble) from outside of the financial system (sars-cov-2) effects on the economy global recession, credit crunch. global recession, no demand and no supply. measures taken bailing out banks, austerity measures, european stability mechanism (esm) introduced. bailing out essential industries e.g. the aviation sector, cash injections, tax relief, short-work salary compensation, modified esm, pandemic emergency purchase program (pepp). effect of measures taken the economy recovered over time. short-term economic recovery, long-term economic recovery is unclear. satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 10 | 15 the reasons for the shock and impact on the world economy are different in 2020 when compared to the financial crisis in 2008. in 2008, the problem was a banking crisis which was the result of too much “bad debt”. now it is the supply chain shock having a knockout effect on the market (43). various leading economists have urged governments to bring out measures to fight the economic downfall. they suggest reducing personal and corporate bankruptcies, ensure people keep spending even though they are not working, increase public investment, increase healthcare spending, and using an unconventional policy called the helicopter money where the governments print new money and distribute it among the public during a recession (44). stock markets fell about 33% from march compared with 55% during the 2008 financial crisis. but this comparison is for the short period of the economic crisis in 2020 with a much longer period of the financial crisis of 2008. the shock on the economy in 2020 is different since the lockdown has severely hampered every sector from the beginning when compared to the financial crisis of 2008 where mostly the banks were affected first. this shows that the economic outcome of the covid-19 pandemic seems worse when compared to the financial crisis in 2008 in a short term. one can compare the fall of the stock markets to the post-collapse of lehman brothers which stands at 33% and 19% respectively. if income is held up for even four months, it will drive firms into insolvency which will result in unemployment, loss of income, reduced consumer confidence. consumer confidence slumped to a level that has not been seen since the financial crisis in 2008. this shows that the pandemic has a serious toll financially and economically (45). the consumer confidence indicator fell to minus -15.6 points during the covid-19 economic crisis compared to 11.2 points during the financial crisis in 2008 (46,47). unemployment, loss of income, lack of supply or production which lead to increased prices have all severely decreased consumer confidence. this also shows that most of the people are unsure and pessimistic that the covid-19 pandemic will have a lasting impact on the economy, and this would be a lengthy recession (43). financial markets and the economy already bounced back, but the question is if this will be in the form of a sharp “v”, a prolonged “u” or even an up and down in the form of a “w” (48). in general, it is hard to attribute adverse health effects to a single cause in a situation of economic downturn. the available literature on the health consequences of the financial crisis 2008 is (surprisingly) still scarce and prone to bias from an epidemiological viewpoint. the results for the health effects of the financial crisis in 2008 and assumed health effects of the economic recession in 2020 are summarized in table 2. the hypothetic health effects of the current pandemic are marked by “(?)” satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 11 | 15 table 2. health effects of the financial crisis in 2008 compared to observed and hypothetic health effects of the economic recession in 2020. hypothetic effects marked by “(?)” financial crisis 2008 economic recession 2020 short health systems experienced financial stress, increase of hiv infections (due to the decrease of preventive measures), less road traffic accidents. covid related mortality increased, increase of alcohol consumption and violence in families, increase in depression and anxiety disorders, reduced physical activity during the lockdown, less traffic and work-related (?) accidents, less cardio-vascular diseases due to better air quality (?). medium access to and coverage of care decreased in some countries, unmet need in health increased in countries with high co-payment, increase of depression, suicide, and other psychological disorders, increase in homicide and alcohol-related death. increase of non-covid related mortality, increase of cardio-vascular mortality (stroke, myocardial infarction) due to delay in treatment because of corona fear and unemployment (?), psychological stress for younger people because of delay in schooling, graduation, and first-time employment (?). long increase of health inequalities, lower self-rated health in unemployed, no effect on overall mortality, decrease of household spending on health, decrease of avoidable mortality slowed down, no change in birth weight, fetal death, or infant mortality, small but significant increase in overall morbidity. more cancer cases due to low uptake of screening and delayed treatment (?), no increase in overall mortality (?). this take-away summary shows, in general, no surprises in the expected events. mental disorders occur when societies are under stress. the consequences of this are higher rates of alcoholism and violence in families. these “predictable” consequences give the possibility to prepare for them before they run out of control. this is especially important if further lockdowns would be necessary. indirect consequences of a lockdown as fewer road and work accidents are positive side effects but not in the focus of discussion. delayed treatment of acute diseases might lead to a higher disease burden later. at the moment there are no clear answers to this question. new is the situation of missed education for children. here indirect health consequences might occur in form of psychosocial stress with long-term effects (49). as we do not know if these health-related problems are temporary or permanent, there is the need to monitor them to be aware of their prevalence. only by this, one can shift necessary resources to the area of need. there are already clear signs that the austerity measures which followed the financial crisis of 2008 will not be applied by governments and the eu this time. in opposition, it is the first time that the eu is willing to go into debt itself. by this, further concerted actions regarding health issues become more, probably which will help to avoid the negative health effects of the recession. satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the 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https://ec.europa.eu/info/sites/info/files/flash_con sumers_2020_06_en.pdf (accessed: march 3, 2021). 47. organisation for economic co-operation and development. consumer confidence index (cci). oecd; 2020. available from: https://data.oecd.org/leadind/consumer-confidence-index-cci.htm (accessed: march 3, 2021). 48. european stability mechanism. euronomics: the building blocks of recovery. esm; 2020. available from: https://www.esm.europa.eu/blog/euronomics-building-blocks-recovery (accessed: march 3, 2021). 49. chung h, bekker s, houwing h. young people and the post-recession labour market in the context of europe 2020. transfer 2012;8:301-17. so l. utilising ‘new’ power strategies for public health education in addiction and dependency: learning from social media influencers. (editorial). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5721 editorial utilising ‘new’ power strategies for public health education in addiction and dependency: learning from social media influencers lisa o’rourke scott 1 technological university of the shannon region: midwest corresponding author: dr. lisa o’rourke scott, technological university of the shannon region: midwest e-mail: lisa.orourkescott@tus.ie https://orcid.org/0000-0003-2242-653 so l. utilising ‘new’ power strategies for public health education in addiction and dependency: learning from social media influencers. (editorial). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5721 the traditional goal of work in public health is the promotion of population health (1). within this very broad definition arise debates about the best way to target health behaviours, what is considered important, and who should be the focus of public health interventions. this paper will examine some of the current issues that arise when considering how to combat addiction and dependency though public health interventions in the context of a world dominated by information communication technologies (ict). in particular, it will argue that lessons for public health communication on addiction and dependency can be learned from the growth of anti-vaccination sentiment during the global pandemic and that public health needs to embrace the ‘new’ power of communication to effectively promote healthy behaviours. definitions of what constitutes addiction and dependency vary in different social, cultural, and historical contexts, as well as being contested in varying academic debates about the topic. for example, the diagnostic and statistical manual in the current version dsm-5-tr (march 2022), lists nine types of substance addictions in the category of ‘substance-related and addictive disorders’: alcohol; caffeine; cannabis; hallucinogens; inhalants; opioids; sedatives; hypnotics and anxiolytics; stimulants; and tobacco. the current version has also included gambling under this category. other behaviours such as excessive sexual behaviour, compulsive buying, internet use, or stealing, were not included as addictions because the research was thought to be insufficient (2). there are also debates about models of understanding and how they relate to intervention. for example, the use of the disease model and its impact on personal responsibility; combatting stigma; the biological predisposition model; the possibility of selfmedication for other issues (3-6); the relative influence of peers and family; culture and social expectations; the meaning that various substances and behaviours have in different contexts; and of course sociological explanations relating to social capital, poverty, access to healthcare, and social exclusion (7). all these debates add further complexity to those who wish to reduce addiction and dependency and the associated behaviours. once the definition debate has been negotiated, if a public health initiative is to be designed, it is then necessary to think about what kind of public health intervention is likely to be effective. although public health interventions work best when grounded in theories of behavioural change, there is no real consensus about what motivates behaviour. for example, one scoping review found 82 separate theories of behaviour referenced in public health literature (8). the majority of these focused on individual rather than social determinants. even when we narrow behavioural motivation to the determinants of addiction, the picture remains contested and unclear (9). despite the complexity of variable definitions, understandings of motivations and theories of behavioural change, public health interventions have managed to have some success in reducing unhealthy behaviours (8). work on preventing drinking and driving, for example, has operated at various levels with legal changes, enforcement, and monitoring, alongside campaigns to change how people think about the action of drinking and driving, and this has substantially reduced road deaths across the european union (10). the number of people in ireland who believe that there is no acceptable amount of alcohol that a driver can consume and be safe to drive has so l. utilising ‘new’ power strategies for public health education in addiction and dependency: learning from social media influencers. (editorial). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5721 increased from 61% in 2015 to 73% in 2017 (11). however, in addition to the absence of a clear uncontested understanding of what motivates behaviour and how to change it, there is another issue. as even the most casual observer of advertising campaigns will attest, the mechanisms for behavioural influence vary according to historical context, which is why the methods of communication used by advertisers change over time. at present, a hugely important source of influence is ict. one of the lessons that was learned during the pandemic is health advice and methods of intervention are subject to challenge and distrust. resistance to and refusal of vaccination, for example, has been a growing problem, which escalated substantially during the period of lockdown. perera et al. (12) claim that the greatest influence on this escalation of rejection of public health advice is attributable to social media. they also note that blocking content on one platform will inevitably cause it to move to another, as people who mistrust advice will share contrary information among their own networks. such is the scale of this issue that the world health organisation (who) now lists ‘vaccine hesitation’ as one of the top threats to world health (13). perera et al. argue that ict influence has changed the narratives that are used to position health advice (12). medical power is represented as an ‘old’ power, which is believed by some people to be open to various inaccuracies, dishonesty, corruption, or malice. ‘old’ power is regarded as suspect because it is believed to be part of a system of influence and power from which many feel disenfranchised. social media driven understandings, on the other hand, are perceived as a ‘new’ power. ‘new’ power acknowledges that the powerful use their power and disseminate knowledge to their advantage. it uses different ways to transmit information, most notably peer to peer sharing. this means that certain populations are more likely to trust information from this source. pintado and sánchez (14), suggest that ict social networks engage in two main areas of activity that maintain their influence: the creation of new content and development of social relationships. content is then shared among a social network. one example of the influence of this kind of ‘new’ power is in relation to the circulation of positive marijuana messages, which has been to increase the likelihood of marijuana use among young people exposed to the information (15). leaving aside debates about the veracity or otherwise of information on marijuana, or about abuse of power for the gain of a small elite, what is clear is that internet memes and information are influencing what potentially addictive substances mean to people and how they feel about them. for this reason, garcia del castillo et al. argue that ict should be used for prevention and promotion of health (16). calling for a public health agenda for social media, they argue that preventative promotional material should be disseminated for a range of public healthy lifestyle initiatives, in particular in relation to legal activities such as smoking and alcohol but also for illegal drug use. perera et al. make three suggestions about how we can learn from the so called ‘new’ and use it for health promotion (12). firstly, they argue, we need to create a context rather than specific content. using the example of the growth of anti-vaccination sentiment during the pandemic, they note that despite the disavowal of andrew wakefield’s so l. utilising ‘new’ power strategies for public health education in addiction and dependency: learning from social media influencers. (editorial). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5721 retracted research on mmr vaccinations (17), numerous groups abound on social media that discuss vaccines together (12). wakefield did not organise these groups, but he created the context for their formation. secondly, they suggest we should not attempt to use facts over narratives, as it is counterproductive to pit ‘old’ power against ‘new’ and make people choose between them. their third suggestion is that we spread narratives that resonate with a target audience and will be passed from peer to peer. the idea of counter narratives which challenge power relations are by no means new. for example, shen argues that irving welsh’s 1993 novel and 1996 film trainspotting offered representations of heroin addiction which provided a counter narrative to the individual choice discourses in post thatcherite britain, by representing heroin use as an existential choice (18). it offered a counter explanation for why people become addicted to heroin. furthermore, in the academy there have been sustained critiques of the notion of moral panic (19); the notion that the behaviours of certain people, like for example the young, indulge in substance use and misuse, and are inherently dangerous and are thus the subject of, often unjustifiable, public outrage and concern. moral panic, in this context can be regarded as a tool to justify the eradication of rights of the oppressed by the powerful. a more sustained critique of the ways in which the medical model has obtained and sustained power by the special knowledge it holds and the ability to problematize certain groups has come from foucault (20). this critique which has been extended to what rose (21) describes as the ‘psy’ disciplines. he argues that psychology, psychiatry, psychotherapy and other ‘psy’ disciplines have played a key role in ‘inventing our selves’, changing the ways in which human beings understand and act upon themselves, and how they are acted upon by politicians, managers, doctors, therapists, and a multitude of other authorities. these mutations are intrinsically linked, he claims, to recent changes in ways of understanding and exercising political power. in this tradition using foucault’s genealogical approach, johansen et al. (22), for example, trace the construction of the ‘addict’ in 19th century policy and its relationship to drug reforms and social regulation attempts and argue that the ‘addict’ was brought into being as a result of various forms of social and political power. as sedgwick (23) has observed the addict seems to be a perfect candidate for a list of identities that emerged at the end of the eighteenth century and intensified throughout the nineteenth: the hysterical woman; the malthusian couple; the masturbating child; and the perverse adult. all of these are thus argued to be identities that have been bought into being to regulate and control the populace. furthermore, the medical model itself has been subject to criticism in relation to the validity of the claims it makes when diagnosing illness (24-26). on a more prosaic level, attention has also been drawn to the relationship between academia and the alcohol industry and to who funds research and the implications of this (27), as well as the development of an addictions industry (28). so, while discussion and challenge in relation to the influence of medical power is not a new phenomenon, it has certainly been taken up enthusiastically by users of ict to the extent that ict represents a ‘new’ power that must not be ignored or dismissed when designing public health interventions. those who wish to work so l. utilising ‘new’ power strategies for public health education in addiction and dependency: learning from social media influencers. (editorial). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5721 with reducing dependency and addiction by means of public health education, would be wise to take cognizance of the advice of perera et al and create context rather than content, avoid challenging ‘new’ power with ‘old’ power, and use online peer to peer networks for dissemination (12). references 1. verweij m, dawson a. the meaning of 'public' in 'public health'. in angus dawson & marcel verweij (eds.), ethics, prevention, and public health. oxford: clarendon press; 2007. 2. grant ej, chamberlain rs. (2017). expanding the definition of addiction: dsm-5 vs. icd-11. cns spectrums. 2016;21(4): 300303. doi:10.1017/s1092852916000183 3. berkman lf, glass t. social integration, social networks, social support, and health. in l.f. berkman & i. kawachi (eds.), social epidemiology (pp. 174– 190). new york, ny: oxford university press; 2000. 4. berkman lf, glass t, brissette i, seeman te. from social integration to health: durkheim in the new millennium. social science medicine. 2000;51:843– 857. 5. krieger n. theories for social epidemiology in the 21st century: an ecosocial perspective, international journal of epidemiology. 2001;30(4):668– 677. 6. link bg, phelan j. social conditions as fundamental causes of disease. j health soc behav. 1995;spec no:80-94. 7. kawachi i, berkman l. social cohesion, social capital, and health. in: berkman, l.f. and kawachi, i. eds., pages 174-190. social epidemiology. new york: oxford university press; 2000. 8. davis r, campbell r, hildon z, hobbs l, michie s. theories of behaviour and behaviour change across the social and behavioural sciences: a scoping review. health psychology review. 2015;9(3):323-344. 9. hellmen m, majamaki m, rolando s, bujalski m, lemmens p. what causes addiction problems. substance use and misuse. 2015;50:419-438. 10. etsc. progress in reducing drink driving in europe. brussels: european transport safety council; 2018. 11. drugnet. public attitudes to drugs in ireland. dublin: health research board; 2019. 12. perera k, timms h, heimans j. new power versus old: to beat antivaccination campaigners we need to learn from them. bmj. 2019;367:l6447. 13. nejm. who releases list of 10 threats to global health. journal watch, 2019. retrieved 06 01, 2022, from https://www.jwatch.org/fw114986/ 2019/01/18/who-releases-list-10threats-global-health 14. pintado e, sanchez j. nuevas tendencias en comunicación estratégica. esic; 2017. 15. moreno ma, gower ad, jenkins mc, kerr b, grisson j. marijuana promotions on social media: adolescents’ views on prevention strategies. substance abuse, treatment, prevention and policy. 2018;13:23. so l. utilising ‘new’ power strategies for public health education in addiction and dependency: learning from social media influencers. (editorial). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5721 © 2022 , o’rourke scott; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 16. garcia del castillo ja, garcia del castillo lopez a, dias pc, garcia castillo f. social networks as tools for the prevention and promotion of health among youth. psicol. refl. crít. 2020; 33:13. 17. wakefield a. retracted: ileallymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. the lancet. 1998; 351(9103): 637641. 18. shen l. post-leftism: contesting neoliberal consensus in irving welsh's trainspotting. scottish literary review. 2017;11(2):165183. 19. cohen s. folk devils and moral panics: the creation of the mods and rockers. london: mcgibbon and kee; 1972. 20. foucault m. history of madness. (j. murphy, ed., and j. murphy, trans.) new york: routledge; 1976. 21. rose n. identity, genealogy, history. in p. du gay, j. evans, and p. redman, identity: a reader (pp. 313-326). london: sage; 2008. 22. johansen ka, vandenbroeck m, vandevelde s. on the biopolitics of humane drug policies: what can we learn from 19 century sobriety boards? nordic studies on alcohol and drugs. 2021; 38(5):498-516. 23. sedgewick e. tendencies. durham, north carolina: duke university press; 1983. 24. laing rd. the divided self: an existential study in sanity and madness. harmondsworth: penguin; 1960. 25. szastz t. the myth of mental illness: foundations of a theory of personal conduct. harper & row; 1974. 26. illich i. limits to medicine, medical nemesis: the exploration of health. harmondsworth: penguin; 1977. 27. babor tf. alcohol research and the alcoholic beverage industry: issues concerns and conflicts of interest. addiction. 2009;104(supp 1): 3447. 28. munro d. inside the $35 billion addiction treatment industry. forbes april 27th 2015. accessed on 22oth june 2016 at: https://www.forbes.com/sites/danm unro/2015/04/27/inside-the-35billion-addiction-treatmentindustry/?sh=326dd55d17dc _________________________________________________________________________________ eliakimu es, mans l. taking up from cop26 going forward: contribution of the book “survival: one health, one planet, one future by george r. lueddeke” (commentary) seejph 2022, posted: 16 december 2022. doi: 10.11576/seejph-6119 p a g e 1 | 11 commentary taking up from cop26 going forward: contribution of the book “survival: one health, one planet, one future by george r. lueddeke” eliudi saria eliakimu1 and linda mans2,3 1health quality assurance unit, ministry of health; dodoma, tanzania 2an independent consultant and researcher in support of healthy people and a healthy planet, manskracht; nijmegen, netherlands 3policy officer science and knowledge development healthcare at the netherlands institute for health services research (nivel); utrecht, netherlands corresponding author: eliudi saria eliakimu, (md, mph) ministry of health, health quality assurance unit, nhif building 05th floor, 2 ukaguzi road, p. o. box 743, dodoma, tanzania. +255 754361400 email: eliakimueliudi@yahoo.co.uk and eliudi.saria@afya.go.tz mailto:eliakimueliudi@yahoo.co.uk mailto:eliudi.saria@afya.go.tz eliakimu es, mans l. taking up from cop26 going forward: contribution of the book “survival: one health, one planet, one future by george r. lueddeke” (commentary) seejph 2022, posted: 16 december 2022. doi: 10.11576/seejph-6119 p a g e 2 | 11 abstract since its publication in 2019, the book "survival: one health, one planet, one future", written by george r. lueddeke, has proven to be timely and useful in these uncertain and tense ("rattling" – lueddeke’s word) times we are experiencing. indeed, we have had (and still are experiencing) the covid-19 pandemic and the war between russia and ukraine that was started early 2022. in this article, we recall the urgency of climate action, the goals of cop26 (that took place from 31st october to 12th november 2021) and provide suggestions for topics that might deserve a place in a possible update of the book. these topics include (i) a critical analysis of the effects of russia and ukraine war and lessons from the perspective of one health and wellbeing; (ii) progress in various countries in using the one health approach to address issues that affect the health and wellbeing of population (equity), the environment and ecosystems in general (including global trends in non-communicable diseases and antimicrobial resistance); and (iii) look at the current global governance systems in relation to how they can better function proactively to prevent future wars (interconnected challenges). keywords: climate change, conference of parties 26, one health approach, covid-19, and russia and ukraine war. acknowledgements: we acknowledge the work of the president of cop26 and the secretariat for the draft decision document that has been one of our foundational references. we also thank all the authors of the references cited in our paper for their wonderful work. source of funding: no funding was received for this work. conflicts of interest: the authors declare that there is no any conflict of interest. disclaimer: the authors alone are responsible for the views expressed in this publication, and they do not represent views of their organisations. eliakimu es, mans l. taking up from cop26 going forward: contribution of the book “survival: one health, one planet, one future by george r. lueddeke” (commentary) seejph 2022, posted: 16 december 2022. doi: 10.11576/seejph-6119 p a g e 3 | 11 introduction the coronavirus disease 2019 (covid-19) pandemic has affected the life of populations globally both socially and economically causing deaths of millions of people globally in a way that has even challenged our capacity for deaths registration (1). the pandemic has also led to a consecutive two-years (2020-2022) retardation in the progress of implementation of the sustainable development goals (sdgs) (2); hence, affecting well-being of people in terms of mental health (3). covid-19 has also exposed vulnerabilities in health systems in high income countries (hics) (4), as well as in lowand middle-income countries (lmics) including countries in sub-saharan africa (5). as much as countries around the world have been struggling with covid-19, another challenge of climate change effects has also been reported in various countries in both hics and lmics settings such as: floods in south africa in which 400 people died, destroyed more than 12,000 houses and forced about 40,000 people from their homes (6); wild fires in united sates (7); and heat waves in india during the period of march – may, 2022 (8). all these challenges have demonstrated the need for the world to come together to put strategies that can ensure we minimize the effects of climate change (9); and also, to have health systems that are more resilient, sustainable and well prepared against future pandemics (10). sadanandan (2022) has documented lessons from the covid19 pandemic for policy makers on management of pandemics which can help decision makers to perform better in future pandemics (11). one of the key instruments for tackling climate change is “the united nations framework convention on climate change (unfccc)” which entered into force on 21st march 1994 and as of 25 june 2022, its status showed that it has 165 signatories and 197 parties. all the countries that have ratified the convention are called “parties to the convention” (12, 13). each year since 1997 the “parties to the convention” meet annually for meetings that are commonly named as “conference of parties (cop)”. on 31st october–12th november 2021 the 26th conference of parties (cop26) was held in glasgow, scotland (12). the cop26 had four goals namely “mitigation, adaptation, finance and collaboration”. from a public health perspective, a broad approach to health was discussed, which considered socio-economic and environmental determinants, health and equity (14). the cop26 draft decision proposed by the president (15), focused on the following eight key areas (as quoted from the draft decision): “(i) science and urgency importance of science for effective climate change action and policy; (ii) adaptation urged parties to further integrate adaptation into local, national and regional planning; (iii) adaptation finance – “urged developed country parties to increase their provision of climate finance, technology transfer and capacity-building, financial institutions and private sector to mobilize funds; (iv) mitigation parties to consider further actions to reduce by 2030 non-carbon dioxide greenhouse gas emissions, including methane; accelerate the development, deployment and dissemination of technologies, and the adoption of policies, to transition towards low-emission energy systems; and protecting, conserving and restoring nature and ecosystems, including forests and other terrestrial and marine ecosystems; (v) finance, technology transfer and capacity-building for mitigation and adaptation emphasizing on the importance of strengthening cooperative action on technology development and transfer for the implementation of mitigation and adaptation action; (vi) loss and damage the importance of strengthening partnerships between developing and developed countries, eliakimu es, mans l. taking up from cop26 going forward: contribution of the book “survival: one health, one planet, one future by george r. lueddeke” (commentary) seejph 2022, posted: 16 december 2022. doi: 10.11576/seejph-6119 p a g e 4 | 11 funds, technical agencies, civil society and communities to enhance understanding of how approaches to averting, minimizing and addressing loss and damage can be improved; (vii) implementation importance of protecting, conserving and restoring ecosystems in which parties need to take an integrated approach for protecting, conserving and restoring ecosystems in national and local policy and planning decisions; and to ensure just transitions that promote sustainable development and eradication of poverty; (viii) collaboration – taking up key issues that will ensure: meaningful youth participation and representation in multilateral, national and local decisionmaking processes, including under the convention and the paris agreement; important role of indigenous peoples’ and local communities’ culture and knowledge in effective action on climate change, and urges parties to actively involve indigenous peoples and local communities in designing and implementing climate action; and to increase the full, meaningful and equal participation of women in climate action and to ensure genderresponsive implementation and means of implementation, which are vital for raising ambition and achieving climate goals” (15). against that background, in addressing the climate change and other emerging challenges, we aimed to explore the contribution of the book “survival: one health, one planet, one future” by george r. lueddeke. routledge taylor and francis group abingdon – oxon, london and new york, first published 2019; ebook isbn 9780429444081. 254 pages. doi: https://doi.org/10.4324/978042944 4081. methods a narrative analysis of the content of the book was done taking into account the goals of the cop26; and reviewed literature on climate change and other issues related to content of the book. based on the analysis, highlights of some actions that need to be taken are presented in the discussion section under sub-section “going forward”. the conclusion section includes suggestions for topics that might deserve a place in a possible update of the book. results the book brings to our attention the need for “changing the way we relate to the planet and to one another and confronting how we use technology (dataism) for the benefit of both humankind and the planet”. the author george r. lueddeke (who is an educational advisor in higher and medical education and chairs the global one health education task force for the one health commission and the one health initiative) has been able to touch broadly around key topics related to protection of our environment, humanity, and the ecosystem in general, while focusing on the future with a special eye on young generations (which he refers to as generation z) in terms of their education and their relation with the fast growing technology. the author introduced the book well and organized it into three parts. part one highlighted on challenges we face as we strive to protect well-being of people and the planet including: urbanization; climate change and sdgs focusing as well on non-communicable diseases (ncds) and antimicrobial resistance (amr); technology and our lives; increasing population and the problem of overconsumption; and capitalism including issues that require attention in twenty-first century. part two delt with war and peace; projections into 2050 in terms of shifting global economic powers, automation effects to society, corruption, democracy and decision making in twentyfirst century; shaping the society for a https://doi.org/10.4324/9780429444081 https://doi.org/10.4324/9780429444081 eliakimu es, mans l. taking up from cop26 going forward: contribution of the book “survival: one health, one planet, one future by george r. lueddeke” (commentary) seejph 2022, posted: 16 december 2022. doi: 10.11576/seejph-6119 p a g e 5 | 11 sustainable future with a note on dangers such as endless new weapon systems; growing antagonism among nations; the poison in our politics; and climate change; and one health approach. part three of the book mainly focused on how to create a more just, sustainable and peaceful world touching on global education as a way of building foundations for future; detailed description of key leading global and national organizations in the area of one health and well-being initiatives; challenges faced in leadership in an era of “uncertainty, upheaval and anxiety” probably pointing to a “new world order”; and defined generation z and the challenges they are likely to face including the technological as well as socioeconomic challenges that leaders in the twenty-first century need to be aware of, and engage the generation in finding appropriate solutions that are tailored to their context and aspirations. discussion the book has pointed out broadly on many of the issues that were also focused in the cop26 meeting including: protection of nature and ecosystems with a look on effects of overpopulation and overconsumption; ensuring just transition that will enable sustainable development and eradication of poverty; meaningful participation and involvement of young generations in protection of our planet to ensure a better and safer future; and the use of technology for betterment but also potential effects of technological use if not well managed depending on how the young generation (referred to in the book as generation z) is prepared to cope with the technological era (fourth industrial revolution). the book has further looked at the topics that affect the health of population which require a multi-sectoral approach in addressing them such as ncds and amr. these are among the major challenges that are likely to overwhelm global and national health systems and ultimately affecting the life of populations. the challenge of overpopulation has also been noted by mackenbach (2022) regarding the need for using persuasive interventions on top of the usual public health interventions and family planning measures in order to address people reproductive preferences (16). the recent global report on global burden of bacterial amr in 2019 has shown that “amr is a leading cause of death around the world, with the highest burden in lowresource settings” (17). therefore, as noted by weldon, et al, (2022) it is important to strengthen governance of amr globally drawing on lessons from the paris climate agreement (18). the challenge of ncds require multisectoral actions at national and global level (19); and also, it requires incorporation of behavioural medicine strategies in policies and intervention frameworks (20). the book also touched on social, political, and economic determinants of health such as poverty, inequality, war and peace, corruption, democracy, and decision making in the twenty-first century. the ongoing war between russia and ukraine is a testimony on why we need to focus on peace and avoid wars given the fact that the war has already affected the whole world causing: exacerbation of the worsening economies that had already been weak due to the covid-19 pandemic; shortages of food supply globally pushing populations into famine; increase in oil and gas prices as well as other commodities prices; and pushing millions of ukrainian people into refugee situation (21). democracy has been shown to have impact on health outcomes. for instance: countries with democratic governance had better responses to the covid-19 leading to a decrease in “excess mortality” (22); and improvement in democracy has contributed to increase in life expectancy and decrease in infant eliakimu es, mans l. taking up from cop26 going forward: contribution of the book “survival: one health, one planet, one future by george r. lueddeke” (commentary) seejph 2022, posted: 16 december 2022. doi: 10.11576/seejph-6119 p a g e 6 | 11 mortality in the “post-communist states” (23). the one health approach is the cornerstone for addressing global health challenges that transcend the boundaries of health sector. as noted by ghebreyesus, et al, (2022), “issues beyond the health sector such as changing demographic patterns, climate change, changing land use, de-forestation and increased animalhuman proximity, coupled with increasing population density and globalization are increasing the likelihood of further pandemics or other crises. now is the time for all sectors to work together on health” (24). one health is also a critical element in surveillance of infectious diseases (25, 26), and for tackling zoonotic diseases (27). for one health to achieve this all stakeholders and various sectors need to come together and work in partnerships “accommodating competing political perspectives and include flexibility to allow multisector partnerships to respond to changing external dynamics” (28). there is a need for a more strengthened one health to expand its ethical considerations for animals and the environment for it to be more useful in addressing the current global health challenges and threats (29). one health also needs to harness and promote its growing component – “planetary health” (30); and also consider possibility of integration of principles of ecological economics and pluralist economic thinking (31). going forward the author (george r. lueddeke) has rightly put it that there is a need to put efforts in “shaping the society for a sustainable future and address the ongoing dangers such as endless new weapon systems; growing antagonism among nations; the poison in our politics; and climate change”; this is the time to stop and take concrete actions. the war between russia and ukraine is more than an alarm that our future is in great danger. ongoing wars and armed conflicts will exacerbate inequalities and affect the chances for the world (and affected countries) to achieve the sdgs. we need to keep focus on children, youths, and women by involving them in all actions for addressing climate change and achieving a green, healthy and just transition, while avoiding war and upholding peace. in this, there is a room for bringing in psychologists to assist us with “the language of the psychology of survival” in what is referred to as “planetary psychology to try to address the planetary context of the individual psyche” (32). also, community involvement, e.g., by recognising and establishing a variety of trusted community members as change agents and involving populations in marginalized positions in climate action will help to ensure we have a just transition towards sustainable development. to this end, we need to work on strengthening efforts to track effects of climate change on human health and the environment so that we can design effective strategic interventions (33). global food systems must be strengthened, and further studies need to be done drawing on lessons from various disruptions (including covid-19; and the russia and ukraine war) taking into account roles of social scientists including economists (34). there is also a need for equipping next generation of public health professionals with knowledge and skills necessary for addressing the climate challenge (as an important competency for them) (35). ministries responsible for health in various countries need to take concrete actions that will improve health and equity, following example from actions put forward by the united states’ department of health and human services after participating in the cop26 (36). growing hate behaviour in various countries leading to violence such as gun eliakimu es, mans l. taking up from cop26 going forward: contribution of the book “survival: one health, one planet, one future by george r. lueddeke” (commentary) seejph 2022, posted: 16 december 2022. doi: 10.11576/seejph-6119 p a g e 7 | 11 violence in united states of america (37), point to a gloomy future if we are not able to address the situation. also, racism is becoming a threat to wellbeing of clients of health facilities as it may affect the quality of services provided (38). as put forward by bailey, et al, (2021), there is a need for tackling racism by focusing on structural issues (such as laws, rules, and practices) in government structures at all levels, economic systems, and in social and cultural norms (39). in order to address this from the public health perspective, it requires capacitating public health professionals with knowledge and skills on the “critical race theory” to help them in preventing racism in health systems and uphold public health (40). conclusion apart from the challenge of climate change; 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112:850-2. doi: 10.2105/ajph.2022.306846. _____________________________________________________________________ © 2022 eliakimu et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://doi.org/10.1056/nejmp2118259 https://www.medpagetoday.com/surgery/generalsurgery/99022?xid=nl_mpt_dhe_2022-06-02&eun=g1334223d0r&utm_source=sailthru&utm_medium=email&utm_campaign=daily%20headlines%20evening%202022-06-02&utm_term=nl_daily_dhe_dual-gmail-definition https://www.medpagetoday.com/surgery/generalsurgery/99022?xid=nl_mpt_dhe_2022-06-02&eun=g1334223d0r&utm_source=sailthru&utm_medium=email&utm_campaign=daily%20headlines%20evening%202022-06-02&utm_term=nl_daily_dhe_dual-gmail-definition https://www.medpagetoday.com/surgery/generalsurgery/99022?xid=nl_mpt_dhe_2022-06-02&eun=g1334223d0r&utm_source=sailthru&utm_medium=email&utm_campaign=daily%20headlines%20evening%202022-06-02&utm_term=nl_daily_dhe_dual-gmail-definition https://www.medpagetoday.com/surgery/generalsurgery/99022?xid=nl_mpt_dhe_2022-06-02&eun=g1334223d0r&utm_source=sailthru&utm_medium=email&utm_campaign=daily%20headlines%20evening%202022-06-02&utm_term=nl_daily_dhe_dual-gmail-definition https://www.medpagetoday.com/surgery/generalsurgery/99022?xid=nl_mpt_dhe_2022-06-02&eun=g1334223d0r&utm_source=sailthru&utm_medium=email&utm_campaign=daily%20headlines%20evening%202022-06-02&utm_term=nl_daily_dhe_dual-gmail-definition https://www.medpagetoday.com/surgery/generalsurgery/99022?xid=nl_mpt_dhe_2022-06-02&eun=g1334223d0r&utm_source=sailthru&utm_medium=email&utm_campaign=daily%20headlines%20evening%202022-06-02&utm_term=nl_daily_dhe_dual-gmail-definition https://www.medpagetoday.com/surgery/generalsurgery/99022?xid=nl_mpt_dhe_2022-06-02&eun=g1334223d0r&utm_source=sailthru&utm_medium=email&utm_campaign=daily%20headlines%20evening%202022-06-02&utm_term=nl_daily_dhe_dual-gmail-definition https://www.medpagetoday.com/surgery/generalsurgery/99022?xid=nl_mpt_dhe_2022-06-02&eun=g1334223d0r&utm_source=sailthru&utm_medium=email&utm_campaign=daily%20headlines%20evening%202022-06-02&utm_term=nl_daily_dhe_dual-gmail-definition https://www.medpagetoday.com/surgery/generalsurgery/99022?xid=nl_mpt_dhe_2022-06-02&eun=g1334223d0r&utm_source=sailthru&utm_medium=email&utm_campaign=daily%20headlines%20evening%202022-06-02&utm_term=nl_daily_dhe_dual-gmail-definition https://doi.org/10.1016/j.hjdsi.2022.100630 https://doi.org/10.1056/nejmms2025396 https://doi.org/10.2105/ajph.2022.306846 south eastern european journal of public health special volume no. 5, 2022 modern health systems developments in the united arab emirates collection from the frontline jacobs publishing house executive editor prof. dr. genc burazeri phd faculty of medicine, st. dibres, no. 371, tirana, albania, and caphri, faculty of health, medicine and life sciences, maastricht university, 6200 md, maastricht, the netherlands email: genc.burazeri@maastrichtuniversity.nl and: gburazeri@gmail.com skype: genc.burazeri volume editor prof. dr. ulrich laaser dtm&h, mph faculty of health sciences, bielefeld university pob 10 01 31, d-bielefeld, germany email: ulrich.laaser@uni-bielefeld.de guest editor ass. prof. dr. ahmad aburayya assistant professor, faculty of health business administration, jefferson international university 441 alaska avenue, torrance ca 90501, california, usa email: amaburayya@dha.gov.ae; 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detailed bibliographic data is available on the internet at http://dnb.ddb.de south eastern european journal of public health (open access journal). copyright 2022 by jacobs publishing house: am prinzengarten 1, d 32756 detmold, germany copyright cover picture: wordpress foundation: http://wordpressfoundation.org/gnu general public license table of contents original research factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates maryam alawadhz, khadija alhumaid, sameeha almarzooqi, shaima aljasmi, ahmad aburayya, said a. salloum, waleid almesmari the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals shaima aljasmi, ihssan aburayya, sameeha almarzooqi, maryam alawadhi, ahmad aburayya, said a. salloum, khalid adel predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach khaled mohammad alomari an empirical study into factors that influence e-learning adoption by medical students in uae afrah alsharafi review article the impact of covid-19 lockdowns on air quality: a systematic review study butros m. dahu, ahmad aburayya, beenish shameem, fanar shwedeh, maryam alawadhi, shaima aljasmi, said a. salloum, hamza aburayya, ihssan aburayya wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 1 original research piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia helmut wenzel 1 , vesna bjegovic-mikanovic 2 , ulrich laaser 3 1 health economic consultant; 2 institute of social medicine, faculty of medicine, university of belgrade, serbia; 3 section of international health, faculty of health sciences, university of bielefeld, germany. corresponding author: helmut wenzel, m.a.s. address: d78464 konstanz, germany; e-mail: hkwen@aol.com wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 2 abstract aim: political decisions usually emerge from the competing interests of politicians, voters, and special interest groups. we investigated the applicability of an advanced methodological concept to determine whether certain institutional positions in a cooperating network have influence on the decision-making procedures. to that end, we made use of the institutional network of relevant health care and health governance institutions, concentrated in belgrade, serbia. methods: we used a principal component analysis (pca) based on a combination of measures for centrality in order to evaluate the positions of 25 players in belgrade‟s institutional network. their directed links were determined by a simulated position approach employing the authors‟ long-term involvement. software packages used consisted of visone 2.9, ucinet 6, and keyplayer 1.44. results: in our analysis, the network density score in belgrade was 71%. the pca revealed two dimensions: control and attractiveness. the ministry of health exerted the highest level of control but displayed a low attractiveness in terms of receiving links from important players. the national health insurance fund had less control capacity but a high attractiveness. the national institute of public health‟s position was characterized by a low control capacity and high attractiveness, whereas the national drug agency, the national health council, and non-governmental organisations were no prominent players. conclusions: the advanced methodologies used here to analyse the health care policy network in belgrade provided consistent results indicating that the intended decentralization of the health care network in belgrade may be incomplete, still with low participation of civil society representatives. with the present study we set the stage for a broad-range surveybased data collection applying the methodology piloted in belgrade. keywords: belgrade‟s health care policy network, policy analysis, serbia, social network analysis, sources of power. conflicts of interest: none. acknowledgments: this work was supported by the ministry of science and technological development, republic of serbia, contract no. 175042. wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 3 introduction political decisions are not primarily the result of scientific (rational) problem solving like e.g. the illustration of the policy cycle suggests (1,2). the decisions usually will emerge from the competing interests of politicians, voters, and special interest groups. the policy literature considers this issue and suggests a variety of frameworks and analytic models for policy analysis (3). the spectrum ranges from the rather normative scientific problem solving approach to a more „incrementalistic‟ way (4). lindblom even calls it „muddling through‟ (5) and finally to the paradigm of „bounded rationality‟ (6,7). analyzing decision outcomes (policies) has to consider the specific organisational structure (policy) and the initiated processes (politics), comparable to donabedian‟s concept of structure and process as a prerequisite of outcome quality (8). related questions are: how will political decision processes possibly influence policy-making (6)? do certain individual or institutional positions in a cooperating network have more or less influence on the decision-making procedures? to explore the complex governmental portfolio of resources, hood et al. (9,10) propose a classification scheme, which gets to the point with only four important sources of power: nodality, authority, treasure and organisation. they state that nodality denotes the property of being in the middle of an information or social network (10). a high degree of nodality gives a player a strategic position from which he allocates information, and which enables him to draw in information. authority is the formal and legitimate official power (11). that is the formal power to demand, forbid, guarantee, and arbitrate. treasure gives the government the ability to exchange goods, using the coin of money or something that has a money-like property. finally, organisation gives to a government the physical ability to act directly, using its own forces (10). with the serbian health insurance act of 2005 (12) the serbian government aimed at reorienting the health care system and transform it into a more decentralised organisation. these changes would hopefully offer to the insured population an opportunity for a greater selfmanagement. as most of the relevant institutions are concentrated in the serbian capital belgrade, we used this example to investigate the applicability of the aforementioned methodological concept. with the disclosure of the players‟ nodalities that make up belgrade‟s health care policy network, we envisaged to analyse to which degree the decentralisation of decision making has progressed since the legislation of 2005, extending our preliminary analysis (13). with the present step we focus on institutional players and their nodality only, without consideration of potentially influential individual players. the analysis of belgrade‟s health policy network is a pilot project appropriate for testing the feasibility of a countrywide survey. this analysis was based on a questionnaire survey. methods to break down the abstract notion of power and influence, different paradigms were used in sociology and political science: reputation approach, decision approach, or position approach (14). for a critical review of the approaches see domhoff (14). in our understanding, influential actors can be best described by the position approach, i.e. a policy network. a policy network is described by its various players public as well as non-governmental their formal and informal connections and the specific boundary of the network under consideration. the links between the players are likely to be understood as communication channels for the exchange of information, expertise, trust and other policy resources (15). depending on the scientific disciplines, e.g. coming from community power research (14), or systems thinking (16,17), various technical approaches and measures have been used to identify, describe and wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 4 analyse formal or informal networks within organisations. necessary data can be collected by means of survey (questionnaires, interviews), observations, or by analysing secondary data. for economic reasons, a heuristic procedure as outlined e.g. by vester (16) or bryson (18) was applied and possible actors [so-called boundary specification (19, p. 77)] were enumerated in a brainstorming session listed in a “cross-impact matrix” of influences (16, p. 188). finally, the strength and direction of their connections was estimated (16, p. 188) by the authors for the purpose of this methodological study. these are “soft data” (16, p. 22), but nevertheless they are based on experience, knowledge of the health care system and observations. as newman points out, collecting data by directly questioning participants (or, players) does not necessarily provide a higher accuracy and is also a laborious endeavour (20). for visualisation of the network and a more in-depth analysis, we recurred to the analytic tools of social network analysis (sna). the concept of nodality corresponds well with the measures used in sna and, basically, two viewpoints are possible: primarily focusing on a specific player (ego-centred) only, and analysing and evaluating the network as a whole, taking all connections and all players into account (socio-centred) (13). on a socio-centred level, the network structure can be described by measuring density and centralization. centralization is defined as the variation in the centrality scores of the nodes or players in the network. this variation shows the extent to which there is a centre i.e., very central players and a periphery i.e., players with very low centrality scores (21). density is a basic network property that reflects the overall intensity of the connected players: the more connected the network, the greater its density. a dense network is one where a lot of activity or a large number of strong ties exist among its members (22). on an ego-centred (individual) level, we focused on the players‟ importance. importance reflects the visibility to other network members (23) and is broken down into indices like influence and prestige. measures of centrality the concept of centrality is a crucial aspect when representing policy networks (24). centrality measures will identify the most prominent players. these are the players who are extensively involved in relationships with other network members (25) without necessarily discriminating between formal or informal links (depending on the data collection approach). the most frequently centrality measures used include degree centrality, betweenness centrality, and closeness centrality. they reflect the view that information is transferred along the shortest pathways (26). degree centrality is an indicator of expertise and is measured by the sum of all other players who are directly connected to a specific player (25). asymmetric networks are particular in that the distinction between indegree-centrality and outdegree-centrality has to be taken into account (13). players receiving many ties (indegree) have a high prestige (23). players with a high flow of outgoing connections (outdegree) are able to exchange with many others, or at least make others aware of their views (13). this means that players with a high outdegree centrality are said to be influential players (27). betweenness centrality counts how many times a player connects other players, who otherwise would not be able to reach one-another (25). it measures the potential for control, because a player who shows a high betweenness degree will be able to operate as a gatekeeper by controlling the flow of resources between the other nodes that are connected through him (25) on shortest paths (28). wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 5 closeness centrality is based on the concept of distance. a player who is close to all others in the network, e.g. having a distance of no more than one, is not dependent on any other to reach everyone in the network (25). closeness centrality measures independence or efficiency (25). in the context of sna, efficiency means that the higher the closeness centrality of a node, the shorter is its average distance to any other node, thus indicating a better position for spreading information (29). further centrality measures are hub function and authority. in directed networks, players that have important resources should get a high centrality score too. newman defines it as follows: “authorities are nodes that contain useful information on a topic of interest; hubs are nodes that tell us where the best authorities are to be found” (30, p. 179). in the framework of sna, formal authority has to be differentiated from informal authority (11). hubs are enablers of effective knowledge transfer (31, p. 225). a high hub player points to many important authorities (high outdegree) whereas a high authority player receives ties from many important hubs (high outdegree). they can effectively connect different sub-groups of the network and facilitate knowledge flows; removing them from the network can lead to its fragmentation (31, p. 225). study setting for investigating the applicability of the methodological concept we chose a position approach as it best describes the potential of power and influence, combined with a heuristic data collection. to that end, the authors all well informed about the serbian health care system and the situation in belgrade listed 25 players, identified the links between the players and the perceived strength of their relationship together in an open process. as pointed out earlier (13), the links can point in one direction only (unidirectional), or include both directions (bidirectional). the strength of the relationship was rated on a scale ranging from 0 to 4. very weak links with a value of 1 were put on a level with 0 for “no link” (13). the rating of the links reflects the averaged assessment of the authors. the resulting “cross-impact matrix” was exported to visone 2.9 (15) for further analysis. in some cases where the analytic toolset of visone 2.9 did not provide the calculation of specific indices, we used ucinet 6 (32), and keyplayer1.44 (33) instead. to visualise the analytical findings in an easily understandable format, we chose the design of a target diagram, which is also a built-in feature of visone 2.9. in this diagram, the 25 players (nodes) are placed according to their scores. this means that the player with the highest score is positioned in the centre of the diagram; the others, according to their decreasing scores, are moved toward the periphery of the structure, correspondingly. to ensure a largely undisturbed view, the authors of visone 2.9 applied a specialized layout algorithm that aims at minimizing entanglement by reducing the number of crossing lines and occlusions determine the angular location. the different score levels are displayed as thin concentric circles. this allows comparing the scores of the players easily, without looking at the output table (15, p. 17). brandes et al. (15) successfully used these diagrams to analyse local health policies and the underlying structure of the various players, e.g. to disclose the differences in the local drug policy of two german municipalities and the networks of players that form the basis of the policy making. furthermore, to facilitate an overall perspective (holistic view) of the indices applied, we merged the results with the help of a principle component analysis (pca) diagram. pca is a multivariate data analysis method which is used to reduce complexity by transforming a set of possibly correlated variables into a set of uncorrelated variables, wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 6 i.e., principal components (34,35). this approach explains best the variance of data and helps to reveal the internal structure of the data. results the network matrix was composed by 25 players and 158 directed and valued links or connections as determined for the purpose of this methodological study by the authors. the network density was calculated as 71% realized links out of all possible ones. a density greater than 50% is considered high (36). therefore, we assumed here that the players in belgrade were well connected. for valued networks (see figure 1), the centralization score has to be calculated separately for outdegree and indegree centrality. the outdegree score here was 46.3% of all possible connections, whereas the indegree score was 19.1% (calculated with ucinet 6). this would disclose a distinct centralisation. however, the range of outdegree scores was larger than that of indegree scores, and the players showed a higher variability. the coefficient of variation was 93% for outdegree and 54% for indegree centrality, indicating that the network was less homogeneous with regard to outdegree centrality, or influence (27). the possible influence of the players in the network varied largely, i.e., the positional advantages were rather unequally distributed. the most important players – identified in terms of degree centrality (figure 1a and table 1) were the national health insurance fund [1], the ministry of health [15], the national government [14], and the medical faculty, belgrade [22]. the health insurance fund [1] received most of the strongest [blue] links. the players with the highest indegree centrality or wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 7 prestige were the clinical hospital centres, belgrade [8], the institute of public health, belgrade [4], the national health insurance fund [1], and the clinical hospital centre of the republic [7]. players with the highest outdegree centrality or influence were the national government [14], the ministry of health [15], the medical faculty, belgrade [22], the state revisor [18], and the national health insurance fund [1]. table 1. ranking of players by centrality indices (based on percentages – for the numeric codes, see table 3 in the annex) indices of centrality degree centrality indegree centrality outdegree centrality betweenness closeness hub function authority 1 8 14 8 14 14 3 15 4 15 15 15 15 8 14 1 22 22 18 18 4 22 7 18 7 22 1 7 7 3 1 19 19 22 23 8 5 17 1 7 17 1 18 6 7 20 1 20 25 5 23 20 11 20 7 9 4 25 19 23 23 11 2 17 9 11 5 17 19 10 19 15 23 6 11 5 15 20 23 8 9 16 23 6 23 2 5 23 8 8 23 6 10 16 18 10 10 5 11 22 9 12 3 9 13 3 12 6 17 9 16 17 23 19 10 3 23 6 16 9 13 4 4 21 2 19 25 17 2 10 12 4 12 2 11 12 2 5 23 22 10 20 21 14 6 21 20 12 16 23 16 2 12 11 16 21 3 21 4 3 21 13 18 25 25 25 25 18 21 14 13 13 13 13 14 with respect to the betweenness centrality, the clinical hospital centres, belgrade [8] were the most central players. the ministry of health [15], the medical faculty, belgrade [22], the clinical hospital centre of serbia [7], and the serbian physicians society [19] seemed to be very close to each-other, but located more to the margin. players with a high degree of closeness were the national government [14], the ministry of health [15], the state revisor [18], the medical faculty, belgrade [22], and the serbian physicians society [19]. the picture changed when we looked at hub functions. as pointed out, hubs are enablers of effective knowledge transfer, they can effectively connect different sub-groups of the network and facilitate knowledge flows; removing them from the network can lead to its fragmentation (31, p. 225). considering the hub function, the national government [14] was in the most wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 8 favourable position (see figure 1b), followed by the ministry of health [15]. the national health insurance fund [1] moved more to the periphery indicating a loss of importance for knowledge transfer. the state revisor [18] and the mof budget inspection [17] also moved more to the centre of the diagram. as hannemann and riddle note, the question of how structural positioning implicates power is still a matter of research and debate (34). to reduce the complexity, eventually sort out redundant information and get an integral view, we applied pca which is displayed in table 2 and figure 2. table 2. contribution of centrality measures to the dimensions of the pca (percentages) centrality measures d1 (control) d2 (attractiveness) degree 22.645 3.186 indegree 0.159 40.837 outdegree 22.820 3.876 betweenness 12.246 7.907 closeness 19.822 3.205 hub function 21.654 3.607 authority 0.654 37.381 the pca provides evidence of two dimensions (figure 2); they explain 88.81% of the data. the first dimension consists of degree, outdegree, closeness, and hub function. the second dimension consists of indegree and authority. the first dimension d1 represents the capacity for “control”; the second dimension d2 depicts what we called “attractiveness”. the main players: the ministry of health [15] apart from the formal aspect i.e. legal authority and organisation was highly ranked on the first dimension of control. on the second dimension of attractiveness, it was ranked just above the average. this picture was confirmed in the classification by hub function and authority. the ministry of health was a hub as well as an authority in this analysis, whereas the hub feature was more pronounced. this would mean that it was connected to many popular players and received links from important players. the national government [14] was likewise highly ranked on the first dimension, but showed the lowest score on the second dimension. this means that control was high but the attractiveness was low. on the other hand, the national government [14] was also a hub, which means that it was connected to many very important players, and its influence might be based on this feature, primarily. the national health insurance fund [1] showed less potential of control [first dimension] than the ministry of health [15], but had a higher score on the attractiveness axis [second dimension]. the national health insurance fund [1] was a hub and an authority too. the hub score was lower than that of the ministry of health or the national government, but its authority score was very pronounced. this means, its authority feature receiving links from important players – in our pilot study was more important. according to this analysis, effective decentralisation would require more autonomy for institutions like the national institute of public health [3], the national drug agency [10], the national health council [13], and non-governmental organisations [21], all ranking with the exception of the national institute of public health [3] towards the end in table 1 and low on both dimensions in figure 2. but, also the chambers of health professionals [11, 12] could play a more important role as well as the trade unions [20] and the branches of the national health insurance fund [2]. wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 9 figure 2. the position of players by two dimensions legend: the yellow triangles mark the national government and the ministry of health; the green diamonds signify the players focussed in the analysis; the blue circles represent the remaining players. for the numeric codes, see table 3 in the annex. the national institute of public health [3] ranked below average on the first dimension (control) and was positioned above average on the second dimension (attractiveness) that is players were seeking contact. its high authority score confirmed this, but as a hub it ranked very low (table 1). according to borgatti, such players are primarily mediators (37). discussion it is a widespread view in the literature that no single or generally accepted method for measuring decentralization exists (38); there are many different definitions, understandings of the concepts and diverse measurement instruments (39). thus, measuring centralization or decentralization is mostly based on analyzing the financial autonomy or regulatory mechanisms (39,40). independent of the underlying “intellectual tradition” (41), disciplinary and language differences, and the way the various indices were constructed, these approaches focus on formal aspects. informal ways of influence and power are not taken into account. however, these informal relationships may superimpose the formal balance of power, supporting or even hindering structural changes or specific policy-making, and possibly will underestimate the real balance of power. the concept of nodalities, used here, is based on relationships (links). these links cannot only indicate subordination but can also stand for information 14 15 18 1 22 17 20 7 11 19 5 23 8 10 9 16 6 2 4 24 21 12 3 25 13 -2 -1.5 -1 -0.5 0 0.5 1 1.5 2 2.5 -2.5 -2 -1.5 -1 -0.5 0 0.5 1 1.5 2 2.5 d 2 a tt r a c ti v it y ( 3 3 .4 % ) d1 control (55.4 %) observations (axes d1 and d2: 88.81 %) after varimax rotation wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 10 channels. insofar, mapping the nodalities, is complementary to the approaches mentioned above and will round off the picture. compared to other european countries, serbia is among the most centralized systems (42). it ranks second on a list of thirteen countries (38). the analysis of the degree and appropriateness of decentralization, however, is not an end in itself. it is a means to achieve a broader spectrum of goals (43) or, more generally speaking, it is an important component of good governance (38). very often it is emphasized that decentralization is a very significant step in promoting democracy (44,45). with decentralization essential goals should be achieved, such as effectiveness and efficiency, fairness, quality, financial responsibility, and respect for local preferences (43,45). decentralization is one of the most important issues on the agenda of health care reform in many countries. however, there is little information from research that can show the likely correlation between the degree of centralization and health outcomes, i.e. the health of the population (40). furthermore, observations and case studies indicate that, if inadequately planned, and implemented, i.e. too rapidly or inconsistently, decentralization can have serious consequences on the provision of health services to the population (43). for that reason, appropriate planning, and considering corresponding experiences in other countries, may prevent disappointment and slow-down of processes. decentralization also will shift the role of the ministry of health, from direct management and decision making toward formulating health care policies, technical counselling and assistance, as well as monitoring and evaluation of programmes and activities. decentralization represents the transfer of authority and responsibility for public functions from the central to subordinate levels and/or to the private sector (43,45). the essential task, then, is to define the adequate level of decentralization (45) by entities, i.e., regions, districts, and municipalities, and by appropriate forms of bureaucratic autonomy, i.e. deconcentration, delegation, and devolution. any consideration on whether decentralization is necessary and how much will be feasible has to undergo a detailed examination in the context of a (rational) organisational structure (46); this is very often perceived a common place, and ignored with associated consequences. certain aspects of decentralization deserve closer attention. for example, the possibility of local authorities to adapt to local conditions should be carefully balanced against a common vision and the goals of the health care system (4). for this reason, the policy of decentralization should include mechanisms of coordination, since the local political interests grow as more responsibilities are transferred to that level (47). furthermore, decentralization bears the risk of fragmenting responsibility for different types of health care (specialist hospitals, general hospitals, primary care etc.) between the levels of regional and municipal government (43). in this context, it is indicative that the coordinative and integrative potential of the national health council of serbia [13] seemingly is not used. this body could include non-governmental organisations [21] in the field of health, as well as trade union representatives from the most important health institutions. the limitations of our approach relate to its validity and reliability. a valid model has to be isomorphic, thus representing a true picture of the system to be modelled. the level of isomorphism can be disclosed in analogy to the revision of „validity of structure and processes‟ (48), or „expert concurrence‟ (49). however, in this study the boundaries and the links remain to be crosschecked as a next research step, especially as the present dataset relies only on the author‟s evaluation of the situation. missing data, i.e., the absence of players and/or links can also have an important impact (50,51) on the „application validity‟. another criticism that raised concerns relates to the shortest paths-based measures as they do not take into account wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 11 diffusion along non-shortest paths (52). however, the modelling algorithms used here are consistent with validated standard computer software. in order to challenge the appropriate level and structure of a health care system and to control any process of reorganisation, it is essential to be fully familiar with the positive interaction of the various players. in this context, it is an important cornerstone to know the nodality of the health care network, in our example that of belgrade hosting most of the national health institutions. the network depicted would also provide a basis for what-if-scenarios to anticipate the likely effects of intended changes. furthermore, the methodology used for the network and its description, which examines the system from a relatively high level (bird‟s eye view), can be adapted to specific decision-making situations, and tailored to support specific planning processes. conclusion the advanced methodologies used here to analyse the health care policy network in belgrade deliver consistent results indicating that the intended decentralization of the health care network in belgrade may be incomplete, still with low participation of civil society representatives. with the present study we hope to prepare for a broad-range survey-based data collection and to apply the methodology piloted in belgrade. references 1. bridgman p, davis g. what use is a policy cycle? plenty, if the aim is clear. aust j pub admin 2003;62:98-102. 2. may jv, wildavsky ab. the policy cycle. beverly hills, sage publications; 1978. 3. parag y. a system perspective for policy analysis and understanding: the policy process networks. systemist 2006;28:212-24. 4. hayes mt. incrementalism and public policy. new york ny u.a, longman; 1992. 5. lindblom ce. the science of "muddling through". in: 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national health insurance fund 2 nhif, belgrade branch 3 national institute of public health 4 institute of public health, belgrade 5 secretary for health, belgrade 6 primary health care centres (17), belgrade 7 clinical hospital centre of serbia 8 clinical hospital centres (4), belgrade 9 national accreditation agency 10 national drug agency 11 national chambers of health professionals 12 chambers of health professionals, belgrade branches 13 national health council 14 national government 15 ministry of health 16 ministry of finance 17 mof budget inspection 18 state revisor 19 serbian physicians society 20 trade unions 21 non-governmental organisations 22 medical faculty, belgrade 23 council of the medical faculty, belgrade 24 special hospitals, belgrade 25 tertiary medical institutes, belgrade ___________________________________________________________ © 2015 wenzel et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ulrich laaser, richard seifman, oneness in one health. south eastern european journal of public health 2023. posted: 09-04-2023, vol. xx, doi: https://doi.org/10.56801/seejph.vi.365 page 1 editorial oneness in one health ulrich laaser1, richard seifman2 1faculty of health sciences, university of bielefeld, germany 2board member, united nations association, capital area washington dc, usa corresponding author: professor dr, med. ulrich laaser, dtm&h, mph, address: university of bielefeld, school of public health, pob 10 01 31, d 33501 bielefeld, germany email: ulrich.laaser@uni-bielefeld.de ulrich laaser, richard seifman, oneness in one health. south eastern european journal of public health 2023. posted: 09-04-2023, vol. xx, doi: https://doi.org/10.56801/seejph.vi.365 page 2 background the health of populations everywhere is determined by the interplay between society and the environment, regulated by a moral value system. the role of scientific exploration, research, and the results, is to shape the scope for potentially effective action, providing a context for political leaders to find ways to implement it. the scope is far broader than the human medical domain, embracing health sciences, veterinary science, social sciences, environmental science, and indeed virtually all sectors. the critical value proposition for such endeavours must be the extent to which it is in touch with and contributes to the ultimate beneficiaries, the community of people. this requires a heightened awareness of the constraints in doing so, broadly reflected in four areas [1]: validated public information, a deficit aggravated by the surge of fake news and its use of social media; social deficits in terms of societal, intergenerational, and cultural disintegration, the disparities summarized by the term inequity; preventive strategies, reflected in recent experiences with the covid -19 pandemic, and newly emerging avian flu outbreaks; and regulatory deficits in terms of pursuing topdown bottom-up approaches, ones depending governmental mechanisms to listen to and integrate voices from the community, a forum for exchange and coordination. this latter point is critical if we are going to successfully build our future anchored on the one health approach. the “one health” concept has been known for more than a century; namely that human, animal, and plant health are interdependent and bound to the health of the ecosystems in which they exist. the vision is to engage a collaborative, whole-of-society, whole-of-government approach to understand, anticipate, and address risks to global health. there are some promising signs that this concept is gaining traction. four international organizations [2] -who, fao, woah, and unep, now known as “the quadripartite”, established the one health high-level expert panel (ohhlep), and agreed on an operational definition of one health, a heretofore major impediment. very recently their leaders jointly announced a “call for action” with seven key elements, briefly: international prioritization of one health; strengthening of national, regional, and intersectoral engagement; strengthening of one health monitoring and intersectoral workforces; strengthening prevention of ulrich laaser, richard seifman, oneness in one health. south eastern european journal of public health 2023. posted: 09-04-2023, vol. xx, doi: https://doi.org/10.56801/seejph.vi.365 page 3 pandemics at source; encouragement of one health scientific knowledge; and increasing investment in one health strategies. also, there are now operational frameworks for guiding countries and communities to apply one health concepts and a newly created “pandemic fund” by who and the world bank to address prevention, preparedness, and response, which encompasses one health. further, the world one health congress in november 2022 in singapore was a major event that embraced a wide range of matters, including the need to emphasize down-top approaches and the need for better communication between scientists, policymakers, and communities. these certainly are promising developments, especially if “prevention” is given its proper attention [3]. but the acid test will be if the full range of one health concerns are embraced as concrete measures by national legislatures, and communities, whether the private sector can create partnerships with the public, academia, research institutes, and non-governmental entities to translate words into action. actions to be taken wording coined in the early 2010s on the state of global health [4] applies well to the paradigm of one health, namely that “soft global health governance” is based on meetings and declarations, dominated by veterinarians, and characterized by a high degree of reductionism and fragmentation. in november 2022a collaborative effort produced a pilot study on the challenges of the global one health movement [5]. it examined a relatively small, stratified sample of fifty organizations selected from the websites of the one health commission and the one health initiative. the study showed serious deficits in terms of fragmentation and lack of coordination, therefore limitations of the desired impact, relevant especially to civil society organizations (csos) – one of the three groupings investigated, along with academic organizations, and administrative/governmental organizations. an indicator of the marginal role healthrelated civil society organizations (csos) or non-governmental organizations (ngos) play concerning global public sector organizations is in the official websites of the united nations and the council of europe. modern and integrative terms such as “global health, public health, one health, planetary health, and environmental health” appear in the names of accredited csos/ngos only in 1.3% respectively 0.7%. ulrich laaser, richard seifman, oneness in one health. south eastern european journal of public health 2023. posted: 09-04-2023, vol. xx, doi: https://doi.org/10.56801/seejph.vi.365 page 4 even in a very broad definition of relevant terms health, medicine, and environment, only 4.4% populate the united nations list, however, 24.6% at the council of europe list (almost three quarters contributed by the term “environment”). on the website of the one health commission (ohc) of the total of listed organizations, 180 contain in their title the term one health, whilst there are only two on un and coe servers. conclusion the current economic, social, and environmental trajectories at the global scale and within most regions of the world, follow an unsustainable development path. without being more effectively integrated by bottomup initiatives, better coordinated, and accompanied by well-crafted and relevant science, governments will not move. if we fail to see the broader vision encompassed by the one health concept, we will be destined to miss an opportunity to better human, animal, plant, and ecosystem well-being. our future is in our collective hands: let’s hope that we grasp and grab the chance: oneness in one health! civil society / non-governmental organizations containing a selection of related health terms in their name (i) in consultative status with the united nations and (ii) in participatory status with the council of europe. i. the united nations list 6343 organizations with consultative status at: https://esango.un.org/civilsociety/displaycon sultativestatussearch.do?method=search ii. the council of europe list 301 international non-governmental organizations ( ingos)with participatory status (conference of ingos) at: https://coengo.org/#/ingos search a united nations n=6343 council of europe n=301 global health 9 0 public health 7 2 one health 2 0 planetary * 4 0 environmental * 61 0 total 83 (1.3%) 2 (0.7%) search b health 133 19 medicine 17 1 environment 128 54 total 278 (4.4%) 74 (24.6%) * the addition “health” is omitted to generate >1 mention. https://esango.un.org/civilsociety/displayconsultativestatussearch.do?method=search https://esango.un.org/civilsociety/displayconsultativestatussearch.do?method=search https://coe-ngo.org/#/ingos https://coe-ngo.org/#/ingos ulrich laaser, richard seifman, oneness in one health. south eastern european journal of public health 2023. posted: 09-04-2023, vol. xx, doi: https://doi.org/10.56801/seejph.vi.365 page 5 references 1. laaser u. the interdependence of society, environment, and health, and its relevance for societal development. euras journal of health (ejoh) vol. 1, december 2020; doi: 10.17932/ejoh.2020.022/ejoh_v01i100 1 2. food and agriculture organization of the united nations (fao), united nations environment programme (unep), world health organization (who), and world organisation for animal health (woah), the quadripartite: call to action for one health for a safer world. https://www.woah.org/en/quadripartite -call-to-action-for-one-health-for-asaferworld/?fbclid=iwar0xyjr_jagx2vtsj the trajectories have met by ulrich laaser blackish purple a ribbon of clouds drenched in blood between the horizons the edges darken ashes of our existence lost we’ve learned in hellish courts where from we are an extraneous god his face unmoved presides as chair his angels far did ever he sent them to us my tears are blown in the wind under the sand astral rocks half-hidden die trends haben sich getroffen by ulrich laaser tiefrot ein wolkenband getränkt mit blut quer zwischen den horizonten die ränder verdunkelt asche unserer existenz verloren haben wir erfahren in hoellen des gerichts woher wir sind ein fremder gott unbewegten gesichts uebernahm den vorsitz seine engel fern hat er sie je zu uns geschickt meine tränen verweht im wind halbverborgen im sand sternengestein ulrich laaser, richard seifman, oneness in one health. south eastern european journal of public health 2023. posted: 09-04-2023, vol. xx, doi: https://doi.org/10.56801/seejph.vi.365 page 6 d0iyogbiecio7jnrishbs43ccaochc-em-dzittkm 3. seifman r. we need one health prevention approaches to infectious disease. the impacter 2023 at: https://impakter.com/need-one-healthprevention-infectious-disease/ 4. leboeuf a. making sense of one health, cooperating at the humananimal-ecosystem health interface. health and environment reports no. 7 /2011. paris: institut francais de relations internationals (ifri). 5. laaser u, stroud c, bjegovicmikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, & roopnarine r. (2022). exchange and coordination: challenges of the global one health movement. south eastern european journal of public health, 11– 40. retrieved from https://www.seejph.com/index.php/see jph/article/view/337 __________________________________________________________________________ © 2023 ulrich laaser et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 1 review article neglect, abuse and violence against older women: definitions and research frameworks patricia brownell1 1 fordham university, new york city, new york, usa. corresponding author: patricia brownell, phd, lmsw – associate professor emerita of social service, fordham university, new york city, new york, usa; email: brownell@fordham.edu. brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 2 abstract the aging of the global population with women living longer than men, resulting in the feminization of aging, focuses attention on the intersection of gender and age. women across the lifespan can be victims of violence but there has been little attention to date to the neglect, abuse and violence against older women. because of this gap in knowledge and remedies, little is known about neglect, abuse and violence against older women, particularly its prevalence as well as evidence-based prevention and intervention strategies. several definitions of neglect, abuse and violence are reviewed here, along with conceptual frameworks that operationalize these definitions differently, resulting in differences in findings on prevalence as well as fragmentation in the way that older women victims of abuse are viewed. three definitions of older adult abuse are discussed, including those formulated by the toronto declaration, the national research council, and the united states center for disease control. each focuses on a different aspect of abuse of older women: active ageing, old age dependency, and domestic violence in later life. a fourth conceptual framework, the human rights perspective, shows promise for addressing abuse of older women in a more holistic manner than the other definitions, but is not fully developed as a way of understanding neglect, abuse and violence against older women. this is the first of a four-part series on older women and abuse. keywords: ageing, elder abuse, neglect, older women, violence. brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 3 older women, socio-demographics, and human rights population aging is a global trend that is changing economies and societies around the world (1). in 2012, people aged 60 years and older represented almost 11.5% of the global population and by 2050 this is expected to double to 22%. older women outnumber older men: in 2012 for every 100 women aged 60, there were 84 men, and for every 100 older women aged 80 and above, there were only 61 men. the feminization of aging, representing the intersection of age and gender, has important implications for policy as the world continues to age. gender discrimination across the lifespan has a cumulative effect, and neglect, abuse and violence across the lifespan results in a high lifetime rate for older women. neglect, abuse and violence against older women have been largely overlooked as a focus of research; this is in spite of the fact that unique and compounded disadvantages are experienced by older women (2). older women aged 60 years and older have been identified as subject to discrimination by the convention to eliminate all forms of discrimination against women (cedaw) experts in 2010 and by the united nations (un) department of economic and social affairs (desa) in their 10-year review of the implementation of the madrid international plan of action on ageing (3). one area of discrimination in the form of human rights violations that has been largely overlooked by policy makers, researchers and advocates for girls’ and women’s rights is neglect, abuse and violence of older women. because of this gap in knowledge and remedies, little is known about neglect, abuse and violence against older women, particularly its prevalence as well as evidence-based prevention and intervention strategies. in november 2013, to begin to address this gap, the un desa held an expert group meeting (egm) inviting researchers and other experts from around the world to new york city to review the state of knowledge, gaps and next steps to address this area of human rights violations against women and older people. one of the recommendations in the final report, “neglect, abuse and violence against older women”, prepared by the un desa department of social policy and development, is that “while both quantitative and qualitative research have begun to develop salient factors in cultural differences, age-related differences and service needs and gaps for older women victims” (2), more data are needed both on prevalence as well as practices to prevent neglect, abuse and violence against older women. in addition, unifying themes that connect older women in developing and developed countries, and in both modern and traditional societies, should be identified along with unifying themes that connect women of all ages. discrimination against older women women across the lifespan can be victims of violence, but neither the women’s domestic violence movement nor the aging empowerment movement has mobilized to end violence against older women. while elder abuse has been the object of many studies, abuse of older women has had only modest attention in the gender based literature (4). older women have lacked status as battered women in domestic violence research and activism. older women are often excluded in studies of violence against women and often completely absent as though older women do not belong in the category of women. older women are often absent from discussions about shelters and hotlines, and there is the lack of a debate on circumstances and special needs of older women victims of abuse that may affect help seeking behavior. however, a gender analysis of violence against women and girls focuses on male dominance and subordination of women, and subordination seems especially relevant for older women (4). is the women’s domestic violence movement ageist? why haven’t older people taken ownership of mistreatment of their peers (5)? why hasn’t the professional leadership in this field joined with older people to form a grass roots movement like the women’s movement to speak out against elder abuse? could social ambivalence brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 4 about old age be one reason, and the double jeopardy of sexism and ageism another? abuse of older women is neglected by advocates of gender equity, women’s rights activists and aging advocates. is it because the link to frailty and dependency makes older abused women appear to lack agency? gender inequality and the life course the united nations special rapporteur on violence against women observes that the inequality and discrimination experienced by women intensifies with old age (6). discrimination against older women on the basis of age and gender can result in situations where they experience neglect, abuse and violence (7). ageism ageism is defined as “the systematic stereotyping and discrimination against older people because they are old, just as racism and sexism accomplished this with skin color and gender” (8). ageism reinforces systems of oppression in two ways. it focuses on individual perspectives and actions and leaves hidden insidious forms of discrimination. age blindness implicitly uses the privileged as the norm and judges others by that standard (9). ageism and sexism create a socially constructed dependency in old age of which feminization of poverty is a key factor. these factors make discrimination and disadvantage seem inevitable. for older women, invisibility is symbolic of this process (10). whittaker (10) suggests that the failure of gender experts to do this analysis is a measure of the entrenched ageism within the women’s movement. cultural norms and social expectations social expectations and changing social norms can also create a perception of abuse toward older family members (11). in studies of older adult abuse in asia and south asia, the daughter-in-law is often identified as an abuser for not serving a traditional role of caregiving in the home while engaging in paid work or a career (12). public policy and availability of social and health programs political decisions about social protections for older women, and availability of health, mental health, criminal justice and other resources can limit options within families and communities for addressing issues of neglect, abuse and violence, according to shankardass (13). multi-dimensional nature of neglect, abuse, and violence against older women manjoo (6) argues for a holistic approach to understanding abuse of older women and how to address it. recognizing intersectionality and the continuum of violence against older women requires analysis of violence in four spheres: violence in the family; violence in the community; violence that is perpetrated or condoned by the state, including custodial settings like care homes and hospitals; and violence in the transnational sphere as it affects migrant, refugee and asylum seeking older women (6). gender inclusion while abuse can affect all older adults, older women are arguably more likely to experience many of these forms and levels of abuse than older men. first, women live longer and with chronic impairments for which they may need support in the home and community. second, older women are less likely to have adequate pensions and other benefits than older men, giving them fewer resources to ensure their independence. finally, women across the lifespan brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 5 experience cumulative disadvantages and lower status than men, leaving them more vulnerable to abuse and neglect in old age. purpose the purpose of this series of articles is to discuss the current state of knowledge about abuse of older women. it explores various definitions of neglect, abuse and violence against older adults and discusses whether there are agreed upon definitions of neglect, abuse and violence against older women. it addresses main forms or categories, prevalence and risk factors of neglect, abuse and violence against older women, as well as health consequences of violence and abuse, and data sources along with problems in collecting such information. it also provides an overview of needs of older women survivors of neglect, abuse and violence. it discusses preventive measures to address the issue, presenting evaluations of their effectiveness where available. it provides an overview of main approaches to addressing abuse of older women, and key interventions including policies and programs for the protection of older women victims of abuse along with outcomes where evaluations have been completed. finally, recommendations are offered for further improvement of policies in these areas. this paper focuses on definitions of neglect, abuse and violence against older adults based on current conceptualizations of abuse. it proposes that there are three dominant conceptual frameworks for understanding neglect, abuse and violence against older women. these are: older adult mistreatment, informed by social gerontology and using a definition proposed in the toronto declaration on elder mistreatment (14); older adult protection, informed by geriatrics using a definition that was formalized by the national research council (15); and intimate partner violence or domestic violence against older women, informed by feminist gerontology and adapting a definition originally formulated by the usa centers for disease control (cdc) (16). a fourth, a human rights perspective, is an emergent framework for examining abuse of older women, and is currently under development (17) (bridget sleap, senior policy advisor, helpage international, personal communication, august 8, 2013). differing definitions have led to research findings, policy responses, and programs and practices that may appear contradictory and confusing to those not familiar with the field of elder abuse and neglect (18). each is linked to different assumptions and theoretical explanations for abuse of older women, and interventions including policies, and programs and practices to prevent and end neglect, abuse and violence against older women. forms of abuse main forms of abuse used to categorize mistreatment of older women include: physical, sexual, psychological (also called emotional, verbal and non-physical) abuse, financial (also called material) exploitation, neglect, and violation of personal rights (19). different conceptual frameworks use a combination of different forms to operationalize abuse. the elder mistreatment and older adult protection frames use most of the forms cited above, with the possible exception of violation of personal rights, sometimes termed social abuse (20). the intimate partner violence (ipv) frame uses physical, sexual, and psychological forms of abuse, and sometimes violation of personal rights, but not neglect and usually not financial exploitation (unless included in a measure of psychological abuse) (16). physical/sexual: some studies of older women and abuse categorize sexual abuse as a sub-set of physical abuse. physical abuse includes actions intended to cause physical pain or injury to an older adult, such as pushing, grabbing, slapping, hitting, or assaulting with a weapon or thrown object. sexual abuse can include offensive sexual behaviors as well as physical contact of a sexual nature (14). brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 6 psychological: this form of abuse is also called verbal or emotional abuse, which may be further defined as active or passive. this describes actions intended to inflict mental pain, anguish or distress on an older person (19). qualitative research studies have examined forms of psychological abuse against women in greater depth. montminy (21) found 14 types of psychological abuse, which can be active or passive, perpetrated by intimate partners against older women. these include: control, denigrate, deprive, intimidate, threaten, abdicate responsibility, manipulate, blame, harass, negate victim’s reality, sulk, infantilize, show indifference, and provoke guilt. in ipv studies, financial exploitation or material abuse (use of property or possessions without victims’ permission) can be a subset of psychological abuse. also in ipv research, psychological abuse may be limited to threats of physical or sexual violence. neglect: the national research council (nrc) definition of elder abuse, with its inclusion of vulnerability as a core concept associated with victims, provides the most explicit link with neglect of older care dependent adults. this definition is further operationalized to include neglect as an “omission by responsible caregivers that constitutes ‘neglect’ under applicable federal or state law” and caregiver as “a person who bears or has assumed responsibility for providing care or living assistance to an adult in need of such care or assistance” (15). it is further operationalized as refusal or failure of these responsible for providing a caredependent older adult with assistance in daily living tasks or essential supports such as food, clothing, shelter, health and medical care. this can also include desertion of a care dependent older adult, also called abandonment (14). there is no overarching theoretical framework for elder abuse (22). this makes it difficult to operationalize neglect of older women as part of a larger discussion of neglect, abuse and violence. in addition, in spite of a general observation that older adult caregiving dyads are most likely female (23), there is a paucity of studies that focus on neglect as a form of elder abuse perpetrated against elderly care dependent women by female formal or informal caregivers. research and discussions that link caregiving of care dependent older adults and neglect by caregivers in general are either gender neutral or treat gender as a study variable. financial exploitation and material abuse: this form of abuse describes actions of illegal or improper use of an older person’s money, property or assets. women have been found to be especially vulnerable to this form of abuse and were twice as likely to be victims of financial abuse as men in a recent study conducted in the usa (24). most victims in this study were between the ages of 80 and 89 years old, lived alone, and had some care needs that required help in their homes. violation of personal rights: linked to the concept of individual human rights, this form of abuse includes the infringement of personal rights as a form of elder abuse (19). it includes behaviors that violate an older person’s right to privacy, right to autonomy and freedom, and right to have access to family and friends. this form of abuse is also known as social abuse (20). definitions, differences and agreements most professionals in the field of elder abuse agree that lack of a generally accepted definition of abuse, mistreatment or maltreatment of older adults is a barrier to understanding this social problem. the lack of a commonly accepted definition of elder or older adult abuse is also a challenge for understanding the abuse of older women from a global perspective. because definitions tend to use similar language in different frameworks, it can be confusing to differentiate among them. the discussion below attempts to clarify some of this definitional confusion. brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 7 purposes of definitions definitions of elder abuse and neglect are used for research, particularly prevalence and population studies, policy and program development, and practice. three influential definitions reflecting divergent underlying assumptions about elder abuse and abuse of older women have guided research and policy decision making. they are presented here. mistreatment of older adults (elder mistreatment) in the toronto declaration on the global prevention of elder abuse, elder abuse is defined as “a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person. it can be of various forms: physical, psychological, emotional, sexual, and financial or simply reflect intentional or unintentional neglect” (14). this is linked to the active ageing concept of older adulthood, in which older women and men are considered to have the capacity to be productive contributors to society (25). this definition originated with a united kingdom ngo, action on elder abuse in 1995 (26), and was adopted by an expert group on elder abuse from the international network for the prevention of elder abuse (inpea) and the world health organization (who) that met in toronto, canada in 2002. age of the victim is not defined as part of this definition but is usually 60 years of age and older in studies that use this definition, because they tend to focus on older adults living in the community. this definition used in elder abuse research, policy and practice formulation is influenced by social gerontology. critics of the who definition state that while it has become popular for policy purposes, it is difficult for researchers to operationalize and includes data elements, such as ‘appropriate action’, ‘expectation of trust’, and ‘distress’, which are largely subjective. the use of ‘a single or repeated acts’ as a baseline measure has been identified as ambiguous (26). ‘trusting relationship’ is a key concept in both elder mistreatment and older adult protection frameworks. this speaks to the nature of the relationship between older adult victims and perpetrators of abuse: crimes committed against older women by strangers are not defined as elder abuse in these research frames. this is not the case in ipv research, where rape and other forms of violence can be perpetrated against girls and women of all ages through casual dating experiences and by strangers. abuse of vulnerable adults (older adult protection) abuse of vulnerable older adults refers to “intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder, or failure by a caregiver to satisfy the elder’s basic needs or protect the elder from harm” (15). this definition of elder abuse was developed by an expert panel (panel to review risk and prevalence of elder abuse and neglect) convened by the national research council of the united states national academy of science for the purpose of creating a suggested uniform definition and operationalized data elements on elder abuse for research, policy, and program development and practice purposes. in this definition, self-neglect, victimization by strangers, and intimate partner abuse of older adults, unless vulnerability exists above and beyond old age, is not considered elder mistreatment (27). the conceptualization of elder abuse victims as frail and vulnerable older adults in need of protection falls under this definition. care dependent older adults in home or institutional care settings with physical, mental or cognitive impairments, including alzheimer’s disease, may be viewed as potential victims of physical or emotional abuse, neglect, or financial brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 8 exploitation by family or professional caregivers with whom they have the expectation of a relationship of trust. the vulnerable older adult conceptualization of elder abuse has been criticized as reflecting too closely the measures used in child abuse (18). while the toronto definition is broad, the definition promoted by the us national research council on elder mistreatment has been criticized as overly narrow in defining victims as vulnerable, rendering it unusable for studies on late life domestic violence life, which can be experienced by able-bodied older people (26), and in precluding self-neglect. it has also been criticized as too broad in other definitional elements, such as “any harm ... and can include but is not limited to”, which allows too much discretion and latitude (26). the concept of vulnerable adult, which is a key dimension of the nrc definition, has been criticized for being ambiguous and meaning different things in different frames. goergen & beaulier (28) have engaged in a critical analysis to better understand the concept of vulnerability within the context of elder mistreatment. in the elder mistreatment frame, older adults may range from unimpaired and independent to impaired and dependent, with only the latter group identified as vulnerable. in the contemporary feminist frame, often older women are assumed to be vulnerable based on age alone, and grouped with other categories of marginalized women as reflected in the panel for international women’s day sponsored by un women at the united nations, new york, on march 8, 2013. intimate partner violence against girls and women of all ages intimate partner abuse is defined as violence against women that “incorporates intimate partner violence (ipv), sexual violence by any perpetrator, and other forms of violence against women, such as physical violence committed by acquaintances or strangers (28). this definition was developed by an expert panel convened by the united states centers for disease control and prevention in 1996 to formulate a uniform definition and recommended data elements for gathering surveillance data on intimate partner violence. it was intended to promote consistency in data collection for public health surveillance and as a technical reference for automation of the surveillance data (29). operationalized data elements broaden the scope of this definition somewhat. the victim is anyone who is the target of violence or abuse. the perpetrator is the person who inflicts the violence or abuse or causes the violence or abuse to be inflicted on the identified victim. in this definitional set, the perpetrator is assumed to be an intimate partner, defined as current or former spouse or common-law spouse, and current or former non-marital partner including dating partner (heterosexual or same sex), boyfriend or girlfriend. violence can include physical, sexual, threat of physical or sexual violence, and psychological or emotional abuse. psychological abuse is defined apart from threat of physical or sexual abuse to include humiliating the victim, controlling the victim’s behavior, withholding information from the victim, getting annoyed if the victim disagrees with perpetrator, deliberately doing something that makes the victim feel diminished, using the victims’ money, taking advantage of the victim, disregarding what the victim wants, isolating the victim from family or friends, prohibiting the victim’s access to transportation or telephone, getting the victim to engage in illegal activities, using the victims’ children to control victims’ behavior, threatening loss of custody of children, smashing objects or destroying property, denying the victim access to money or other basic necessities, and disclosing information that would tarnish the victims’ reputation. it also includes consequences such as impairment, injury, disability and use of health, mental health and substance abuse services (29). this conceptualization of abuse is not necessarily gender or age specific although it typically is applied to analyses of abuse and violence toward women of reproductive age. it does not brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 9 define the victim as incapacitated or care dependent. financial or material exploitation if included at all is defined as a form of psychological abuse. it assumes a power and control relationship between the victim and perpetrator. according to this definition, sexual abuse could be perpetrated by an acquaintance or stranger; physical abuse could be perpetrated by a one-time date. violence the world health organization (who) has used another definition of violence for a multicountry study of intimate partner violence against women. in this definition, violence is defined as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that results in or has a high likelihood of resulting in injury, death, psychological harm, or deprivation (30). it links intentionality with the commitment of the violent act, and] links the acts to a power relationship. this includes threats and intimidation as well as physical violence. it also includes neglect and all types of physical, sexual and psychological abuse, as well as selfabusive acts such as suicide (31). this definition of violence against women was used in the who multi-country study on women’s health and domestic violence against women focused on intimate partner abuse of women that includes physical and sexual violence, emotional abuse, controlling behaviors and physical violence in pregnancy. it also includes a life course perspective on violence by non-partners since 15 years of age, and childhood sexual abuse before 15 years of age. victim subjects were defined as ever partnered (currently or in the past) and even though the definition of victim did not specify age, in this study subjects were between the ages of 15-49 (22). lifetime abuse prevalence is sometimes calculated across the lifespan for girls and women of all ages: this provides a relatively standardized prevalence measure that can be used to compare abuse rates across cohorts of women into old age (32). human rights and abuse of older people human rights is a recent conceptual framework that was the subject of discussion in fora like the expert group meeting on neglect, abuse and violence of older women and the elder abuse symposium sponsored by the elder abuse interest group at the 2013 gerontological society of america meeting. the human rights framework is believed by some elder abuse experts to hold promise for understanding neglect, abuse and violence against older women in a holistic way without the potential for fragmentation of other frameworks (33). while it is still too early to propose a human rights theory of neglect, abuse and violence against older women, some of the elements of such a theory can be tested using existing data. this includes applying a life course perspective using longitudinal data, and focusing on the experiences of older women specifically, not older people in general or women in general. it also includes awareness of intersectionality, specifically related to gender and age, but also including race/ethnicity, class, access to health and mental health, and relationships. including the concept of intersectionality begins to draw on a human rights framework. this states that human rights are interdependent and the level of enjoyment of any one right is dependent on the level of realization of the other rights. the convention for the elimination of all forms of discrimination against women (cedaw) and the cedaw general recommendation no. 27 (human rights of older women) lay out the rights of older women to live lives of dignity free of discrimination and abuse (34). the human rights framework defines older adults as rights bearers, because they have a right to live lives of dignity, free of abuse, and family members and caregivers as duty bearers, to explain their obligation to ensure that older adults to whom they are related or to whom they brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 10 have a commitment to provide care. the state (government) is a duty enforcer, with the obligation to ensure that the rights of older people are upheld, and sometimes are duty bearers, when the state is directly responsible for older people’s care. the most recent research on older adults and abuse using this framework has been undertaken by helpage international in collaboration with the london school of economics. each of the frameworks used to study and understand neglect, abuse and violence against older women leads to different and conflicting findings, including prevalence and risk factors associated with the neglect, abuse and violence. in the next issue of the journal, findings from prevalence and qualitative studies as well as risk factors will be presented and discussed. acknowledgment dr. patricia brownell served as consultant to the united nations department of economic and social affairs (desa) in drafting a paper on neglect, abuse and violence against older women. in november 2013, the un desa held an expert group meeting (egm) inviting researchers and other experts from around the world to new york city to review the state of knowledge, gaps and next steps to address this area of human rights violations against women and older people. conflicts of interest: none declared. references 1. united nations population fund. ageing in the twenty-first century: a celebration and a challenge, united nations: new york, 2012. 2. 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(eds.) world report on violence and health. geneva, switzerland: world health organization, 2002. 30. garcia-moreno c, jansen ha, ellsberg m, heise l, watts c. who multi-country study on women’s health and domestic violence against women: initial results on prevalence, health outcomes and women’s responses. geneva, switzerland: world health organization, 2005. brownell p. neglect, abuse and violence against older women: definitions and research frameworks (review article). seejph 2014, posted: 13 january 2014. doi 10.12908/seejph-2014-03. 12 31. garcia-moreno c, pallitto c, devries h, stöckl h, watts c, abrahams n. global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. geneva, switzerland: world health organization, 2013. 32. united nations. convention on the elimination of all forms of discrimination against women: general recommendation no. 27 on older women and protection of their human rights,2010:http://daccessddsny.un.org/doc/undoc/gen/g10/472/53/pdf/g1047253.p df?openelement. 33. united nations human rights. human rights indicators: a guide to measurement and implementation. united nations human rights office of the high commissioner, geneva, switzerland, 2012. 34. centre for analysis of social exclusion (case) and helpage international. developing an indicator-based framework for monitoring older people’s human rights: panel, survey and key findings for peru, mozambique and kyrgyzstan. london, uk: case report 78, 2013. ___________________________________________________________ © 2014 brownell; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. skeraj f, czabanowska k, bojaj g, burazeri g. self-perceived level of competencies of family physicians in post-war kosovo (original research). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-22 1 original research self-perceived level of competencies of family physicians in transitional kosovo fitim skeraj1,2, katarzyna czabanowska3,4, gazmend bojaj2, genc burazeri2,3 1 principal family medicine center, prizren, kosovo; 2 university of medicine, tirana, albania; 3 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 4 institute of public health, faculty of health sciences, jagiellonian university, medical college, krakow, poland. corresponding author: dr fitim skeraj, principal family medicine center, prizren; address: rr. “xhemil fluku”, pn 20000, prizren, kosovo; telephone: +37744191073; e-mail: fitim_opoja@hotmail.com skeraj f, czabanowska k, bojaj g, burazeri g. self-perceived level of competencies of family physicians in post-war kosovo (original research). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-22 2 abstract aim: family physicians and general practitioners are currently facing increasing demands to meet patients’ expectations and rapid technological and scientific developments. the aim of this study was to determine the self-perceived level of competencies of primary health care physicians in kosovo, a post-war country in the western balkans. methods: a cross-sectional study was conducted in kosovo in 2013 including a representative sample of 597 primary health care physicians (295 men and 302 women; mean age: 46.0±9.4 years; response rate: 90%). a structured self-administered questionnaire was used in order to determine physicians’ competencies regarding different domains of the quality of health care. the questionnaire included 37 items organized into six subscales/domains. answers for each item of the tool ranged from 1 (“novice” physicians) to 5 (“expert” physicians). an overall summary score (range: 37-185) and a subscale summary score for each domain were calculated for each participant. general linear model was used to assess the association of physicians’ self-perceived level of competencies with covariates. results: the internal consistency of the whole scale (37 items) was cronbach’s alpha=0.98. mean summary score of the 37-item instrument and subscale summary scores were all higher in men than in women. in multivariable-adjusted models, mean level of self-perceived competencies was higher among older physicians, in men, those with >10 years of working experience, physicians serving >2500 people, specialized physicians and those involved in training activities. conclusion: our study provides useful evidence on the self-assessed level of competencies of primary health care physicians in post-war kosovo. future studies in kosovo and other transitional settings should identify the main determinants of possible gaps in self-perceived levels of physicians’ competencies vis-à-vis the level of physicians’ competencies from patients’ perspective. keywords: competencies, family physicians, general practitioners, primary health care. skeraj f, czabanowska k, bojaj g, burazeri g. self-perceived level of competencies of family physicians in post-war kosovo (original research). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-22 3 introduction in the past few years, there is evidence of a growing interest in competency-based medical education as – among other things – it focuses on outcomes such as development of abilities, skills and competencies (1). therefore, competency-based education has also been introduced in public health training and education in order to close the gap between public health educational content and the competencies required in public health practice (2). as a matter of fact, there is overwhelming evidence indicating that primary health care professionals are presently facing growing demands in order due to meet patients’ expectations for higher quality health care services, as well as the rapid technological developments and scientific progress (3,4). therefore, at a global scale, health care professionals are increasingly expected to provide better-quality health care services, especially in line with the aging population trend observed in most of the countries. consequently, quality improvement in different domains and components of health care services are currently recognized as essential issues in health care practice (3,4). for this very reason, quality improvement needs to be included at all levels of medical education and in all aspects of health care services with the ultimate goal of improving the health of the populations (4). the required competencies for quality improvement are especially relevant for primary health care professionals who face a continuous and huge demand for high-quality health care services from the serving populations. in order to cope with this situation, there have been recently suggested models of required or desirable abilities, skills and competences for medical doctors and health professionals at all levels of care including also continuous professional development (5). such frameworks or models of abilities, skills and competencies are also deemed as a valuable tool for self-assessment of primary health care professionals aiming at improving their health care practices, analyze their clinical experience, plan improvement strategies, and determine a supposed improvement integrating knowledge, skills and abilities into the routine daily practice (4,6,7). however, to date, the information about the content, structure and outcomes of teaching quality improvement topics within the medical curricula in european countries and beyond is scant. this is especially true for the former communist countries of southeast europe including albania and kosovo1. in 2008, kosovo emerged as the newest state of europe after ten years under united nations’ administration following a devastating war (8). currently, kosovo is trying to rebuild its health system (9,10) and, among the reforming efforts, an important aspect is the reorientation of health services to ensure basic medical care for all individuals but especially so for the vulnerable segments of the population (9-11). one of the main challenges of the reform concerns the human resources pertinent to the health sector. nevertheless, there are no well-documented reports informing on the level of competencies of physicians and other health care professionals in kosovo. in this framework, the aim of our study was to determine the self-perceived level of competencies of primary health care physicians in kosovo, a post-war country in the western balkans which is currently facing a difficult period of political and socioeconomic transition. methods a cross-sectional study was conducted in kosovo in 2013 including a representative sample of primary health care physicians. 1 kosovo: this designation is without prejudice to positions on status, and is in line with unscr 1244 and the icj opinion on the kosovo declaration of independence”. http://ec.europa.eu/enlargement/countries/detailedcountry-information/kosovo/ (accessed: april 19, 2014). skeraj f, czabanowska k, bojaj g, burazeri g. self-perceived level of competencies of family physicians in post-war kosovo (original research). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-22 4 study population our study targeted a representative sample of primary health care physicians in five regions of kosovo, namely pristine, gjilan, gjakove, prizren and peje. according to the calculations of the sample size, a minimum of 612 physicians was required for inclusion in this survey. we decided to recruit 660 physicians (220 in pristine and 110 in each of the other regions) in order to increase the power of the study. of the 660 targeted physicians, 597 participated in the survey (overall response rate: 597/660=90%). the response rate was somehow lower in peje (87%) and gjakove (88%), but higher in prizren (95%). in pristine, the capital of kosovo, the response rate was 91%. of the 597 physicians included in our study, 295 (49.4%) were men and 302 (50.6%) were women. mean age in the overall study population was 46.0±9.4 years. the study was approved by the ethical board of the ministry of health of kosovo. all physicians were sent an official invitation letter where the aims and procedures of the survey where explained in detail. data collection an international instrument was developed with the support of the european community lifelong learning program aiming to self-assess the level of skills, abilities and competencies of primary health care physicians (4). this instrument has been already validated (crossculturally adapted) in albanian settings (12,13). all physicians included in this survey were asked to self-assess their level of skills, abilities and competencies regarding the following six essential domains of quality of primary health care (4): (i) patient care and safety (8 items); (ii) effectiveness and efficiency (7 items); (iii) equity and ethical practice (8 items); (iv) methods and tools (5 items); (v) leadership and management (4 items), and; (vi) continuing professional development (5 items). responses for each item of each subscale ranged from 1 (“novice”= physicians have little or no knowledge/ability, or no previous experience of the competency described and need close supervision or instruction) to 5 (“expert”=physicians are the primary sources of knowledge and information in the medical field). an overall summary score (including 37 items; range: 37-185) and a subscale summary score for each of the six domains were calculated for all primary health care physicians included in this study. demographic data (age and sex of participants), information on working experience, number of population served, working place, type of specialization and involvement in teaching/training activities were also collected. statistical analysis median values (and their respective interquartile ranges) were used to describe the distribution of age, duration of work experience and the number of population served among male and female physicians included in this study. on the other hand, frequency distributions (absolute numbers and their respective percentages) were used to describe the distribution of sex, working place, specialization, involvement in teaching and training activities of study participants. cronbach’s alpha was employed to assess the internal consistency of the overall scale (37 items) and each of the six subscales/domains of the measuring instrument. mean values (and their respective standard deviations) were used to describe the distribution of the summary score of the overall tool (37 items) and the summary scores of each of the six subscales/domains. mann-whitney’s u-test was used to assess sex-differences in the mean values of the overall level of competencies (37 items) and the competency levels of each subscale of the instrument. skeraj f, czabanowska k, bojaj g, burazeri g. self-perceived level of competencies of family physicians in post-war kosovo (original research). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-22 5 general linear model was used to assess the association of self-assessed overall level of competencies with demographic characteristics, work experience, type of specialization and involvement in teaching/training of physicians included in this study. initially, crude (unadjusted) mean values of the overall level of physicians’ self-perceived competencies and their respective 95% confidence intervals (95%cis) were calculated for each category of the covariates (age, dichotomized into: ≤40 years vs. >40 years; sex: men vs. women; working experience, dichotomized into: ≤10 years vs. >10 years; number of population served, dichotomized into: ≤2500 people vs. >2500 people; working place, dichotomized into: pristina vs. other regions; specialization: general practice, family medicine, other specializations; and involvement in teaching/training activities: no vs. yes). subsequently, multivariable-adjusted mean values and their respective 95%cis were calculated. spss (statistical package for social sciences, version 15.0), was used for all the statistical analyses. results overall, median age among study participants was 47 years (interquartile range: 40-53 years) (table 1). conversely, median duration of working experience in the overall sample of physicians was 13 years (interquartile range: 6-21 years). about 34% of primary health care physicians worked in pristina, whereas 66% of them worked in the other regions of kosovo. about 31% of participants were general practitioners, 49% were family medicine, whereas 20% had received different medical specializations (such as cardiology, paediatrics, internal medicine, gastroenterology, rheumatology, or obstetrics-gynaecology). about 29% of the physicians were involved in teaching and training activities in family medicine (table 1). table 1. distribution of demographic characteristics, work experience and specialization in a representative sample of primary health care physicians in kosovo, in 2013 (n=597) variable distribution age (years) 47.0 (40.0-53.0)* sex: men women 295 (49.4)† 302 (50.6) working experience (years) 13.0 (6.5-21.0)* number of population served 3000 (2500-4000)* working place: prishtina gjilan gjakova prizren peje 201 (33.7)† 98 (16.4) 97 (16.2) 105 (17.6) 96 (16.1) specialization: general practice family medicine other specializations‡ 187 (31.3)† 292 (48.9) 118 (19.8) involved in teaching: no yes 427 (71.5)† 170 (28.5) * median values and interquartile ranges (in parentheses). † numbers and column percentages (in parentheses). ‡ cardiology, paediatrics, internal medicine, gastroenterology, or rheumatology. skeraj f, czabanowska k, bojaj g, burazeri g. self-perceived level of competencies of family physicians in post-war kosovo (original research). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-22 6 the internal consistency of the overall scale (37 items) was cronbach’s alpha=0.98 (table 2). in general, cronbach’s alpha was high for all the subscales [ranging from 0.86 (for the “leadership and management” domain) to 0.94 (for the “patient care and safety” and “methods and tools” subscales)]. table 2. internal consistency of each domain (subscale) of the instrument domain (subscale) cronbach’s alpha overall scale (37 items) 0.98 patient care and safety (8 items) 0.94 effectiveness and efficiency (7 items) 0.93 equity and ethical practice (8 items) 0.90 methods and tools (5 items) 0.94 leadership and management (4 items) 0.86 continuing professional development (5 items) 0.90 in the overall sample of male and female physicians (n=597), the summary score for the 37 items of the tool was 147.7±24.3 (table 3). the summary score of self-perceived competency level was significantly higher in men compared to women (151.2±24.3 vs. 144.1±23.8, respectively, p<0.001). as a matter of fact, the subscale scores were all significantly higher in men than in women, except the “methods and tools” domain which was not significantly different between men and women (19.6±4.0 vs. 19.0±4.0, respectively, p=0.09). table 3. summary score of each domain (subscale) of the instrument by sex domain (subscale) overall (n=597) sex-specific men (n=295) women (n=302) p† overall scale (score range: 37-185) 147.7±24.3* 151.2±24.3 144.1±23.8 <0.001 patient care and safety (score range: 8-40) 31.5±5.6 32.4±5.6 30.6±5.5 <0.001 effectiveness and efficiency (score range: 7-35) 27.1±4.9 27.8±4.9 26.3±4.9 <0.001 equity and ethical practice (score range: 8-40) 33.7±5.3 34.5±5.2 33.0±5.4 0.001 methods and tools (score range: 5-25) 19.3±4.0 19.6±4.0 19.0±4.0 0.090 leadership and management (score range: 4-20) 15.8±3.2 16.2±3.3 15.4±3.2 <0.001 continuing professional development (score range: 5-25) 20.2±3.4 20.8±3.4 19.7±3.4 <0.001 * mean values ± standard deviations. † p-values from mann-whitney u test. table 4 presents the association of self-perceived competencies with covariates. in crude/unadjusted general linear models, mean level of self-assessed competencies was significantly higher among older physicians, in men, those with >10 years of working experience, physicians serving >2500 people, specialized physicians and those involved in teaching and training activities (all p<0.001). physicians working in the capital city had a borderline significantly higher mean level of self-perceived competencies compared with their counterparts operating in the other regions of kosovo (p=0.052). upon multivariableskeraj f, czabanowska k, bojaj g, burazeri g. self-perceived level of competencies of family physicians in post-war kosovo (original research). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-22 7 adjustment, findings were somehow attenuated, but remained essentially the same and highly statistically significant. hence, mean level of self-perceived competencies was higher among older physicians (p=0.022), in men (p<0.001), those with >10 years of working experience (p<0.001), physicians serving >2500 people (p=0.007), specialized physicians (p<0.001) and those involved in teaching and training activities (p<0.001). on the other hand, in multivariable-adjusted models, physicians working in pristina had a significantly higher mean level of self-perceived competencies than those operating in the other regions of kosovo (150.1 vs. 145.6, respectively, p=0.008). table 4. association of self-assessed competencies with demographic characteristics, work experience and specialization of primary health care physicians in kosovo variable crude (unadjusted) models * multivariable-adjusted models† mean (95%ci) p mean (95%ci) p age: ≤40 years >40 years 129.3 (125.9-132.6) 154.5 (152.4-156.5) <0.001 145.2 (141.4-149.0) 150.5 (148.2-152.7) 0.022 sex: men women 151.2 (148.5-153.9) 144.1 (141.4-146.9) <0.001 150.9 (148.1-153.8) 144.7 (142.2-147.2) <0.001 working experience (years): ≤10 years >10 years 132.5 (129.9-135.0) 158.8 (156.6-160.9) <0.001 143.7 (140.7-146.8) 151.9 (148.8-155.1) <0.001 number of population served: ≤2500 >2500 137.3 (134.2-140.4) 153.4 (151.1-155.7) <0.001 145.5 (142.4-148.6) 150.2 (147.8-152.6) 0.007 working place: prishtina other regions 150.4 (147.0-153.7) 146.3 (143.9-148.7) 0.052 150.1 (147.0-153.2) 145.6 (143.3-147.9) 0.008 specialization: general practice family medicine other 126.9 (124.1-129.7) 154.9 (152.7-157.2) 162.8 (159.2-166.3) reference <0.001 <0.001 135.3 (131.9-138.7) 151.7 (148.8-154.6) 156.5 (152.3-160.7) reference <0.001 <0.001 involved in teaching: no yes 142.9 (140.7-145.1) 159.5 (156.0-163.0) <0.001 144.1 (141.9-146.4) 151.5 (148.3-154.8) <0.001 * mean values, 95% confidence intervals (95%ci) and p-values from the general linear model. † general linear models simultaneously adjusted for all the variables presented in the table. discussion our study obtained evidence on the self-perceived level of competencies of physicians working at primary health care services in post-war kosovo. the sample size included in this survey was big and representative of all the physicians working at primary health care services in kosovo. main findings of our study include a higher level of self-perceived competencies among male physicians, older participants, those with a long working experience, physicians serving a larger population size, specialized physicians and those involved in training activities. overall, the international instrument employed in this survey exhibited a high internal consistency in this representative sample of physicians operating at primary health care skeraj f, czabanowska k, bojaj g, burazeri g. self-perceived level of competencies of family physicians in post-war kosovo (original research). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-22 8 centres in different regions of kosovo. in general, the internal consistency was high for each domain/subscale of the instrument. it should be noted that each subscale/domain of the instrument employed in our survey taps a crucial component of the quality of primary health care. as reported elsewhere (4), the domains of the instrument imply reflection and self-assessment in order to improve the quality of health care provision (6). furthermore, each domain of the instrument measures a number of specific competencies which represent individual standards (7). many studies reported in the international literature have linked the quality of health care services with health outcomes of the population (14,15). this is especially relevant for primary health care services which are considered as the most important level of health care in many developed countries (16), but also developing and transitional countries. therefore, physicians and other health care professionals working at primary health care centers should be extremely concerned of users’ demands, a process which is related to the need for continuous improvement of the quality of primary health care services. furthermore, the “gate-keeping” function of primary health care services requires a substantial degree of patients’ satisfaction. future studies should be conducted in the western balkans and beyond employing a similar methodology and the same standardized instrument as reported in our study conducted in kosovo. if so, it would be interesting to compare our findings on the self-perceived level of primary health care physicians’ competencies with their counterparts from the neighbouring countries in southeast europe and beyond. also, determinants of self-perceived level of physicians’ competencies should be explored in future research studies. a study was conducted in kosovo in 2013 including a representative sample of 1340 primary health care users aged ≥18 years (49% males aged 50.7±18.4 years and 51% females aged 50.4±17.4 years) in order to assess their perceptions on the level of competencies of their primary health care physicians (17). according to this report, the level of competencies of family physicians from patients’ perspective was significantly lower than physicians’ selfassessed level of competencies evidenced in our study. hence, the mean value of the overall summary score for the 37-item instrument was 118.0±19.7 according to patients’ perspective (17), which is considerably lower compared with our findings related to the mean value of physicians’ self-assessed level of competencies (147.7±24.3) (table 3). in the primary health care users’ survey, the perceived level of physicians’ competencies was higher among the younger and the low-income participants, and in patients who reported frequent health visits and those not satisfied with the quality of the medical encounter (17). on the other hand, no sex, or educational differences were evident in the survey including primary health users (17). it is appealing to determine in future studies the underlying factors of this differential competency level between health care providers (physicians) and users of services (patients). our study may have several limitations. our survey included a large representative sample of primary health care physicians and the response rate was high. nevertheless, we cannot exclude the possibility of information bias. in any case, we used a standardized instrument which was cross-culturally adapted in the albanian settings (12,13). furthermore, there is no reason to assume differential reporting on the level of competencies by different demographic categories of physicians, or other background variables included in our study. in conclusion, our study provides useful evidence on the self-assessed level of competencies of primary health care physicians in post-war kosovo. findings from this study may help policymakers and decision-makers in kosovo to perform necessary adjustments to the job description and terms of references pertinent to the work contracts of primary health care physicians in this transitional country. nonetheless, future studies in kosovo and other transitional settings should identify the main determinants of the apparent gaps in selfskeraj f, czabanowska k, bojaj g, burazeri g. self-perceived level of competencies of family physicians in post-war kosovo (original research). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-22 9 perceived levels of physicians’ competencies vis-à-vis the level of physicians’ competencies from patients’ perspective. source of support: the instrument for this survey was developed with the support of the european commission lifelong learning program in the framework of the leonardo da vinci project “innovative lifelong learning of european general physicians in quality 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http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=mcelduff%20p%5bauthor%5d&cauthor=true&cauthor_uid=15175489 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=lyratzopoulos%20g%5bauthor%5d&cauthor=true&cauthor_uid=15175489 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=edwards%20r%5bauthor%5d&cauthor=true&cauthor_uid=15175489 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=heller%20rf%5bauthor%5d&cauthor=true&cauthor_uid=15175489 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=shekelle%20p%5bauthor%5d&cauthor=true&cauthor_uid=15175489 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=roland%20m%5bauthor%5d&cauthor=true&cauthor_uid=15175489 skeraj f, czabanowska k, bojaj g, burazeri g. self-perceived level of competencies of family physicians in post-war kosovo (original research). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-22 10 incentives introduced to improve quality of care in the uk. qual saf health care 2004;13:191-7. 15. starfield b, shi l, macinko j. contribution of primary care to health systems and health. milbank q 2005;83:457-502. 16. atun r. what are the advantages and disadvantages of restructuring a health care system to be more focused on primary care services? health evidence network report. copenhagen: who regional office for europe, 2004. available from: http://www.euro.who.int/__data/assets/pdf_file/0004/74704/e82997.pdf (accessed: may 20, 2014). 17. bojaj g, czabanowska k, skeraj f, burazeri g. level of competencies of family physicians from patients’ viewpoint in post-war kosovo. seejph 2014;1. doi: 10.12908/seejph-2014-05. ___________________________________________________________ © 2014 skeraj et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=will%20changes%20in%20primary%20care%20improve%20health%20outcomes%3f%20modelling%20the%20impact%20of%20financial%20incentives%20introduced%20to%20improve%20quality%20of%20care%20in%20the%20uk http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=starfield%20b%5bauthor%5d&cauthor=true&cauthor_uid=16202000 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=shi%20l%5bauthor%5d&cauthor=true&cauthor_uid=16202000 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed?term=macinko%20j%5bauthor%5d&cauthor=true&cauthor_uid=16202000 http://www-ncbi-nlm-nih-gov.ezproxy.ub.unimaas.nl/pubmed/16202000 hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 1 | 9 review article tribal communities and opioids margo hill1 1) eastern washington university corresponding author: margo hill, associate professor, department of urban and region planning eastern washington university email: mhill86@ewu.edu hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 2 | 9 abstract american indians/ alaskan natives (ai/an) experience overdose rates higher than any other ethnic/ racial group in the us. in recent decades the opioid epidemic has had a particularly negative impact on ai/an populations. to respond effectively to this issue, it is vital to understand its root cause. a range of factors are responsible, with some dating back hundreds of years. the main factors are the impact of colonization and exclusion; forced migration to peripheral areas; forced removal of children and attempts at cultural genocide; poor social environments; poverty and unemployment; adverse childhood experiences; and inadequate and under-funded federal health services. particular blame can be attributed to the pharmaceutical industry and its active over-promotion of opioid use. a number of strategies for tackling this scourge are outlined. keywords: tribal communities, opioids, north america, pharmaceutical industry hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 3 | 9 in 2015, american indian and alaskan natives (ai/an) had the highest drug overdose rates of any population in the united states (1). the opioid mortality rates from ai/an populations have risen almost continuously for nearly two decades and are comparable to the mortality rates of nonhispanic whites that are often cited as the highest ethnic or racial group (2). as we look at the data, experts believe that the ai/an drug overdose rates may be underestimated by as much as 35% due to race, ethnicity, and misclassification on death certificates (1). according to the northwest portland area indian health board, the death rate from drug overdose among american indian & alaska natives (ai/an) in washington state was 43.1 per 100,000 people in 2016 (3). this rate was almost 3 times the national ai/an rate and the washington state average. while the overall overdose death rate in washington state has remained relatively stable since 2007, the rates for ai/an in washington has increased 36% since 2012, and almost 300% since 2000. in terms of polysubstance deaths of ai/an in washington state in 2014-16, almost half of the drug overdose deaths involved more than one drug, and a third involved more than one opioid. common combinations included deaths involving cocaine and an opioid. in 74% of deaths from overdose the deceased had used a deadly combination of cocaine and opioids (3). moreover, 59% of deaths involving methamphetamine (‘meth’) involved an opioid, and 17% of deaths involving heroin also involved a prescription opioid (3). what are the underlying causes of this disproportionate impact of opioid abuse and substance abuse on ai/an? in our tribal communities we know the reasons why tribal people struggle with substance abuse and particularly opioids. the united states government inflicted colonization and federal indian policies that were devastating to tribal communities. brave heart and debruyn discuss how the u.s. government enacted a range of punitive policies such as: removing native children from native homes to boarding schools; forced assimilation through relocation to urban centers; and termination of tribal governments (4). all such policies have had long lasting negative impacts on american indians and disrupted tribal family systems. for american indians the united states was the ‘perpetrator’ of their holocaust (4). ai/an continue to deal with historical trauma and loss of culture which lends itself to substance abuse disorders. unresolved historical grief and trauma that ‘...contributes to the current social pathology of high rates of suicide, homocide, domestic violence, child abuse, alcoholism, and other social problems among american indians’ (4). these government inflicted policies have placed tribal communities in disadvantaged circumstances such as the geographic location of american indian reservations. the european white settlers moved onto and claimed the most fertile lands, and reservations were created in remote, geographically less viable locations. leonard, parker and anderson found that land designations were not randomly selected and instead were chosen to avoid conveying highvalue agricultural land to native americans (5). this contributes to high rates of poverty, unemployment and lack of opportunity (6). ai/an still struggle to gain a foothold in mainstream america. although some members of tribal communities successfully navigate society and gain education and employment, many members still struggle. according to a recent survey by adamsen et al. one-in-four ai/ans live in poverty, and tribal communities report the lowest hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 4 | 9 employment rate nationally (7). the policies of the united states government such as boarding schools and welfare systems that continued to remove children from ai/an homes until the late 1970s were particularly hard on tribal families and disrupted family systems of child rearing. native american children were forced to go to boarding schools, ai/an culture was seen as a problem and the purpose of these schools was forced assimilation (4) as a result of forced assimilation and relocation, we have broken families that often lead to relationship difficulties. the federal governments’s indian policies disrupted tribal cultural systems, took children away from their families, and often resulted in historical trauma, leading to an increased prevalence of substance abuse. why are there higher rates of substance use disorders (sud) amongst ai populations? brave heart & debruyn unequivocally outline the causes as ‘...an outcome of internalized aggression, internalized oppression, and unresolved grief and trauma’ (4). there are many root causes of substance abuse disorders and all tribal communities are different, depending on their history, location and resources. however, one leading cause is our social environment: social influences; peer influence; social policies; availability of illicit substances; and family systems. in much of the country, the counties with the lowest levels of social capital have the highest overdose rates (8). these are all mechanisms that are responsible for the adoption maintenance and maintenance of addictions in our communities. we also see in our tribal communities that our young people start alcohol and substance abuse at a relatively young age. swaim and stanley note that early initiation for american indian youths include increasing rates of use in early and later adulthood, higher risk of developing a substance use disorder (9). for our tribal communities, social influence, our families, our cousins and friends, are very powerful influences. another indicator of substance abuse are adverse childhood experience (aces), such as exposure to alcoholism, drug abuse, domestic violence, emotional neglect, incarceration of a parent, physical or sexual abuse (10). toxic stress from aces can change brain development and affect how body responds to stress and are linked to substance misuse in adulthood (11). these adverse childhood experiences lead to higher risk of addiction. again, many of these issues can be traced back to lack of control, and lower levels of certainty, as a result of government policies that dominated the lives of american indians and alaskan natives. as a result of loss of ancestral lands and loss of cultural identity, we often see that life on reservations can result in dire poverty and hopelessness (12). decker discusses the chaos of many american indian families that can lead to addiction, mental health issues, domestic violence and suicide (12). these issues are passed from generation to generation, leading to an intense need to escape the pain and loss. often substances provide an escape by numbing the pain (12). opioids have been described as providing an escape and a euphoria that washes over you, taking away both physical and emotional pain (13). opioids disrupt the natural reward system by flooding the brain with large amounts of dopamine. when people are addicted to opioids and do not have the opiates, they experience uncontrollable cravings which persists even after they stop taking the opioid (13,14) opioid drugs target the brain’s pleasure center, where we have a natural source of dopamine. this is usually triggered by things that we enjoy such as hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 5 | 9 food, sex or music; ‘dopamine triggers a surge of happiness. when the dopamine rolls into amygdala, the brain’s fear center, it relieves anxiety and stress. both of these events reinforce the idea that opioids are rewarding’ (15). it has been described to this author as being like ‘fireworks going off’. how does opioid abuse start? prescription painkillers like hydrocodone, oxycodone, percocet, vicodin, morphine, codeine, and fentanyl are all substances that have been overprescribed by doctors and led to dependency and abuse (16) for tribal elders, perhaps they were prescribed oxycodone after a heart attack, such as in my dad’s case. for younger people, like my nephew in his 20s, the first time they were prescribed opiates may have been after a simple dental procedure. we know that pharmaceutical companies were marketing the right to be pain free. purdue pharma’s sales reps ‘fanned out to evangelized doctors and dentists with a message: prescribing oxycontin for pain was the moral, responsible and compassionate thing to do’ (17). drug companies targeted primary care doctors and ads promoted long-term pain relief. they falsely stated that the risk of addiction was rare. purdue pharma’s david haddox claimed that oxycontin was safe with addiction rates less that 1 percent (17). prescribing doctors were encouraged to use pain as the fifth vital sign and seek to improve pain management (17,18). this led to a dramatic overprescribing of pain pills (17). often expensive surgeries that are needed by tribal members are not funded by the indian health service (his), and hence people have little alternative but to mask their pain with opioids. american indian tribes ceded their lands to the united states government with two primary promises: healthcare and education (4). by ceding their land they essentially prepaid for their healthcare. the united states government has a legal obligation to provide health services for native people. this obligation is the result of treaties between the federal government and native nations, as well as federal statute (19). however, the indian health service (ihs) is never adequately funded. many the specialized healthcare needs and surgeries needed are not funded and people have little option therefore but to mask their pain and discomfort with medications, such as opioids. opioids are also more likely to be prescribed in counties with more uninsured people (20), and those that have insurance may find that prescription narcotics are more reliably covered than other medical interventions (21). in the us surgery is often considered too costly for economically depressed and low density populations (22). insurance companies often disapprove medical procedures and approved prescribed pain medications. compounding these factors, indian health clinics are severely underfunded (19). tribal clinics are placed on priority one status which means you can only get coverage for a procedure only when life and limb are at immediate risk. this means when local ihs facilities cannot provide needed services for patients, they may contract out to private health care centers through the contract health services (chs) program. it should be noted that only american indians who live on the reservation are eligible for contract health services. sick or injured patients with contract health who are not covered for treatment of the cause of pain instead receive options to manage it, and are often prescribed opioids. indian health service physicians, like many american physicians, were also sold the right to be ‘pain free’ concept, and thus readily dispensed opioid prescriptions to patients. in hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 6 | 9 indian country it is cheaper to prescribe pain pills than to get the necessary surgery for a back injury or a knee injury. we see opioid significant levels of misuse in rural areas. health care challenges are compounded due to a shortage of primary care providers and thus opioids are again prescribed more commonly in rural areas (18,19,22,23). as well as the impact of social environments, the impacts of genetics and physiology on addiction cannot be ignored. the role of genetics is clear in alcoholism is clear. there is a higher risk ratio for individuals when a high number of their relatives have alcohol abuse issues. (24). other traditional markers that we consider in looking at substance abuse are severity and tolerance. the need for more of the substance is an indicator that there is a problem. you need more of the substance to get the same affect. a commonly used term for opioid withdrawal is ‘dopesick’ (17). one us law firm filing a class action stated ‘long-term opioid use changes the way nerve cells work in the brain. opioids create artificial endorphins in the brain, which bind the brain’s opioid receptors producing euphoric effects and providing pain relief. opioids trick the brain into stopping production of endorphins. when this happens, users experience excruciating withdrawal symptoms’ (25) . an addict will tell us that the physiological pain of not having the pills is unbearable and leads to intense drug seeking behavior. in opiate withdrawal, when a dose is not taken, the body experiences painful symptoms such as vomiting, sweating, nausea, runny nose, dilated pupils, watery eyes, anxiety, insomnia, physical pain and constipation (26). what does the opioid do to your body? it has many effects and is similar to heroin or the morphine molecule, especially when taken in ways other than prescribed by the doctor. opioid pills can be melted down, smoked, or injected intravenously. many addicts started by snorting the pills, before moving on to ‘routinely injecting the liquified crushed-up powder with livestock syringes they bought (or stole) from local feed stores’ (17). there have been three waves of drug use in recent years; first, prescriptions like oxycontin became widespread and abused. tribal leaders and health care providers became aware of the opioid abuse and began restrictive policies controlling prescriptions. they monitored opioid prescriptions via databases on nearby reservations and offreservation (27). second, once access and prescriptions were restricted addicts turned to illicit street drugs like heroin. around 2013, there was an increase in synthetic opioids like fentanyl. a particular danger with such drugs is that people can overdose when they start ‘using’ again after having experienced a period of abstinence, due to factors such as treatment or jail time (23). how do we stop opioid abuse in tribal communities? (28) in my experience as a tribal attorney for 10 years, it often comes in the form of providing consequences to those abusing drugs. consequences include going to jail, the removal of children, job loss, and being ordered to attend treatment. the hope is that once the addict is not using they will be able to detox and get out of the cycle of addiction and drug seeking behaviors. if abusers are not able to get out of the cycle of addiction they will likely end up in jail, or overdose, or end up dead. however, even when people want to get clean and sober the continuing challenges of finding employment, housing and accessing outpatient treatment programs can be significant barriers (28). however, we are now seeing illicit opioids like heroin becoming more accessible. in tribal communities, there are numerous stressors, including distress, sadness and hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 7 | 9 poverty. our tribal governments struggle to provide treatment that combines holistic tribal cultural healing practices, alongside western biomedical science and treatment grounded in evidence-based practices. the social determinants of addiction are significant and include: economic opportunity; poverty level; substance availability; genetic predisposition; mental health condition;self-image; substance use among family and friends; family conflict/abuse; and level of supervision. it is an unfortunate reality that all of these factors are significant issues in tribal communities (29,30). the environmental factors of stress, trauma and pain often lead to experimentation with opioids, and later to cycles of dependence. tribal governments, like states, counties and cities have expended millions of dollars of precious resources towards addressing the opioid epidemic. as judge polster, of n.d. ohio federal district court stated ‘everyone shares some of the responsibility, and no one has done enough to abate it. this includes the manufacturers, the distributors, the pharmacies, the doctors, the federal government and the state government, local governments and hospitals’ (31). references 1. mack ka, jones cm, ballesteros mf. illicit drug use, illicit drug use disorders, and drug overdose deaths in metropolitan and nonmetropolitan areas—united states. am j transplant. 2017;17:3241–3252. 2. tipps rt, buzzard gt, mcdougall ja. the opioid epidemic in indian country. j law med ethics. 2018;46:422–436. 3. northwest portland area indian health board. american indian & alaska native opioid & drug overdose data brief. accessed on 22nd june 2022 at: https://www.nihb.org/docs/04092020 /washington%20opioid%20&%20d rug%20overdose%20data%20brief. pdf 4. brave heart my, debruyn lm. the american indian holocaust: healing historical unresolved grief. american indian and alaska native mental health research. 1998;8(2):56–78. 5. leonard, b., parker, d. and anderson, t., land quality, land rights, and indigenous poverty november 2018. accessed june 21, 2022 at: https://aae.wisc.edu/dparker/wpcontent/uploads/sites/12/2018/11/le onard-parker-anderson-11-1318.pdf 6. 2005 bureau of indian affairs american indian population & labor force report. accessed june 21st at: https://www.bia.gov/sites/default/file s/dup/assets/public/pdf/idc001719.pdf. 7. adamsen c, schroeder s, lemire s, carter p. education, income, and employment and prevalence of chronic disease among american indian/alaska native elders. preventing chronic disease. 2018;15:e37. https://doi.org/10.5888/pcd15.17038 7 8. zoorob mj, salemi jl. bowling alone, dying together: the role of social capital in mitigating the drug overdose epidemic in the united states. drug alcohol depend. 2017;173:1–9. 9. swaim rc, stanley lr. substance use among american indian youths on reservations compared with a https://www.nihb.org/docs/04092020/washington%20opioid%20&%20drug%20overdose%20data%20brief.pdf https://www.nihb.org/docs/04092020/washington%20opioid%20&%20drug%20overdose%20data%20brief.pdf https://www.nihb.org/docs/04092020/washington%20opioid%20&%20drug%20overdose%20data%20brief.pdf https://www.nihb.org/docs/04092020/washington%20opioid%20&%20drug%20overdose%20data%20brief.pdf https://aae.wisc.edu/dparker/wp-content/uploads/sites/12/2018/11/leonard-parker-anderson-11-13-18.pdf https://aae.wisc.edu/dparker/wp-content/uploads/sites/12/2018/11/leonard-parker-anderson-11-13-18.pdf https://aae.wisc.edu/dparker/wp-content/uploads/sites/12/2018/11/leonard-parker-anderson-11-13-18.pdf https://aae.wisc.edu/dparker/wp-content/uploads/sites/12/2018/11/leonard-parker-anderson-11-13-18.pdf https://www.bia.gov/sites/default/files/dup/assets/public/pdf/idc-001719.pdf https://www.bia.gov/sites/default/files/dup/assets/public/pdf/idc-001719.pdf https://www.bia.gov/sites/default/files/dup/assets/public/pdf/idc-001719.pdf https://doi.org/10.5888/pcd15.170387 https://doi.org/10.5888/pcd15.170387 hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 8 | 9 national sample of us adolescents. jama network open. 2018; 1(1), e180382. https://doi.org/10.1001/jamanetwork open.2018.0382 10. aces public-private initiative (appi). appi the washington state aces public-private initiative. accessed 22nd june 2022 at: https://www.appi-wa.org/ 11. centers for disease control and prevention. adverse childhood experiences (aces). accessed on 22nd june 2022 at: https://www.cdc.gov/vitalsigns/aces/i ndex.html 12. care + advocacy. fighting opioid abuse in indian country. accessed on 22nd june 2022 at: https://cqrcengage.com/ahca/app/doc ument/17521408;jsessionid=1cs3uol zxj8ptapahmdde2daw 13. bechara a, berridge kc, bickel wk, morón ja, williams sb, stein js. a neurobehavioral approach to addiction: implications for the opioid epidemic and the psychology of addiction. psychological science in the public interest. 2019;20(2): 96–127. 14. shah m, huecker mr. opioid withdrawal. [updated 2022 mar 7]. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2022 jan-. available from: https://www.ncbi.nlm.nih.gov/books/ nbk526012/ 15. akpan, n., griffin j., how a brain gets hooked on opioids. accessed june 21, 2022 at: https://www.pbs.org/newshour/scien ce/brain-gets-hooked-opioids.. 16. shepherd j. combating the prescription painkiller epidemic: a national prescription drug reporting program. american journal of law & medicine. 2014;40(1):85-112. 17. macy b. dopesick: dealers, doctors, and the drug company that addicted america. boston, ma: little, brown and company; 2018. 18. scher c, meador l, van cleave jh, reid mc. moving beyond pain as the fifth vital sign and patient satisfaction scores to improve pain care in the 21st century. pain manag nurs. 2018 apr;19(2):125129. 19. soeng n, chinitz j. native health underfunded & promises unfullfilled. accessed june 21 2022 at: https://www.allianceforajustsociety.o rg/wpcontent/uploads/2021/07/nativehealth-underfunded.pdf. 20. cdc. 2018. prescription opioid data. accessed on 22nd june 2022 at: https://www.cdc.gov/drugoverdose/d eaths/prescription/index.html 21. gounder c. “who is responsible for the pain-pill epidemic." the new yorker, 8th novemnber, 2013. accessed on 22nd june 2022 at: https://www.newyorker.com/busines s/currency/who-is-responsible-forthe-pain-pill-epidemic. 22. meldrum ml. the ongoing opioid prescription epidemic: historical context. am j public health. 2016;106:1365. 23. dasgupta n, beletsky l, ciccarone d. opioid crisis: no easy fix to its social and economic determinants. american journal of public health. 2018;108(2):182-186. 24. diclemente c. addiction and change: how addictions develop and addicted people recover. new york: guilford press; 2006. https://www.allianceforajustsociety.org/wp-content/uploads/2021/07/native-health-underfunded.pdf https://www.allianceforajustsociety.org/wp-content/uploads/2021/07/native-health-underfunded.pdf https://www.allianceforajustsociety.org/wp-content/uploads/2021/07/native-health-underfunded.pdf https://www.allianceforajustsociety.org/wp-content/uploads/2021/07/native-health-underfunded.pdf hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 9 | 9 25. skikos. the opioid crisis. accessed on 22nd july 2022 at: https://skikos.com/the-opioid-crisis/ 26. pergolizzi jv jr, raffa rb, rosenblatt mh. opioid withdrawal symptoms, a consequence of chronic opioid use and opioid use disorder: current understanding and approaches to management. j clin pharm ther. 2020;45(5):892-903. 27. martinez, marcus. personal interview; 2017. 28. whelshula m, hill m, galaitsi se, et al. native populations and the opioid crisis: forging a path to recovery. environ syst decis. 2021;41(3):334340. 29. mckenzie ha, dell ca. fornssler b. understanding addictions among indigenous people through social determinants of health frameworks and strength-based approaches: a review of the research literature from 2013 to 2016. curr addict rep. 2016;3:378–386. 30. park-lee e, lipari rn, bose j, et al. substance use and mental health issues among u.s.-born american indians or alaska natives residing on and off tribal lands. cbhsq data review. 2018; july:1-40. 31. dayton daily news, the federal judge handling the mdl, judge dan aaron polster in the northern district court of ohio, https://www.daytondailynews.com/n ews/butler-county-opioid-lawsuitpart-global-effort-endepidemic/pht0r5tkyfw5iohpcgllxo ____________________________________________________________________________________ © 2022 hill; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://skikos.com/the-opioid-crisis/ abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 1 | 12 short report covid-19 in the gaza strip and the west bank under the political conflict in palestine yehia abed1 1 al quds university, school of public health, gaza city. corresponding author: prof. yehia abed md, mph, dr.ph; address: al quds university, school of public health, gaza city; e-mail: yabed333@yahoo.com mailto:yabed333@yahoo.com abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 2 | 12 abstract covid-19 is a serious pandemic with variation of spread, morbidity, and fatalities between countries. palestinians are facing the epidemic, with around 2 million inhabitants under siege in the highly populated gaza strip for the last 14 years. the siege may be the main threat for the spread of disease among the palestinian population. the palestinians faced the corona epidemic with limited facilities in their hand. however, the risk factors remain multiple, the most important are overcrowding in the gaza strip, poor health care facilities, and the risk of workers moving between the west bank and israel. palestinian health authorities responded directly to the pandemic and took strict closure measures to prevent rapid spread. the palestinian strategy has focused on social spacing, personal hygiene, control of border crossings and health preparedness to deal with medical cases while continuing to provide health services to the population. the difficult economic situation is the major obstacle facing palestinians to overcome the disease spread where workers continue their jobs inside israel and gaza cannot enforce low-income workers to stay at home. more is needed to ensure community engagement, support coordination among all health care providers in palestine, and take effective steps to promote social spacing. friendly countries and international organizations can assist and support the palestinian population in providing laboratory diagnostic materials, providing personal protective devices, strengthening intensive care units, and supporting outreach activities and training programmes. keywords: control measures, covid-19, gaza strip, palestine. conflicts of interest: none declared. abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 3 | 12 introduction palestine is located on the eastern coast of the mediterranean sea. its remaining area is divided into two geographically distinct regional units, the west bank and the gaza strip. according to the palestinian central bureau of statistics the total population in 2017 was about five million, thereof two million throughout the last 14 years locked in the gaza strip (gs) with its 365 square kilometers one of the most densely populated areas in the world (5,324 people per square kilometer) (1). in one of the unrwa refugee camps population density reaches even 80,000 per square kilometer (2). the unemployment rate in the gaza strip is around 52% (3) whereas 53% of the population are suffering from poverty (1), and 69% are exposed to food insecurity (4). historically the first known epidemic reported in palestine was “amwas plague, 639 a.d.” so-called by the name of a small palestinian village between jerusalem and ramallah. this plague spread throughout great syria leading to the death of estimated 25,000 people (5). in 1799 the plague of acre city erupted between the french soldiers led by napoleon bonaparte after a two-month siege of the city. this plague led to the death of about 2000 french soldiers (6). in the last 50 years, gaza was exposed to more than 20 epidemics including poliomyelitis 1974 and 1976, cholera 1981 and 1995, measles between 1971 and 1991, meningitis 1997, avian flu 2006, and swine flu 2009. this paper aims to study the extent and determinants of the covid-19 epidemic in the palestinian territories, to identify the readiness of the palestinian health sector to face the covid-19 epidemic, and to develop recommendations that may help decision-makers to reduce the spread of the epidemic. the palestinian health system and its challenges the palestinian national authority assumed responsibility for health services in the west bank and gaza strip which israel occupied in 1967 following the oslo peace agreement between the palestine liberation organisation (plo) and the government of israel in september 1994. the palestinian national authority (pna) was established in may 1994, and the ministry of health shortly thereafter. the health care system consists of four service providers: the ministry of health, the united nations relief and works agency (unrwa), non-governmental organisations (ngos), and the private sector. questions have been raised about the pna's limited ability to prioritize health services and interventions. political insecurity and socio-economic instability have affected the health of the population and the ability of palestinians to develop a modern health system, particularly intensive care rooms, respirators, and lack of access to serve residents in the neighbourhoods of jerusalem and the occupied areas "c" in the west bank (wb). despite increased health spending, the impact of the political split has been severe and harms the population of the gaza strip. there is a chronic shortage of basic medicines and health supplies for more than one-third of what is needed, especially with regard to emergency rooms, operations, intensive care, orthopaedic services, nephrology, and neonatal care. the palestinian people have faced many restrictions that have affected their ambition to create a functional palestinian health system that responds to the needs of the population, most important the containment for the last fourteen years. first, the blockade imposed on two million palestinians in the gaza strip deprives them abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 4 | 12 of the development of their scientific capabilities, prevents the entry of equipment, medicines and diagnostic materials and prevents patients from receiving their health services even within the palestinian territories, which have been torn apart by the division. second, the detention of palestinian tax funds, which have severely disrupted the life of palestinian society, thereby preventing palestinians from using their resources to operate the health system. seizing tax revenues by the israeli government lead to major obstacles in the daily work of the palestinian health care centres, including reduction of the salaries of health workers who in spite of that continued to work with minimum salaries. third, the usa assistance to the palestinian authority, including jerusalem hospitals and health projects in the gaza strip, has stopped by a political decision to put pressure on the palestinians. for example the author and his team spent more than one year preparing plans and responding to usaid requirements but finally the project was cancelled without implementing the planned field activities and abandoning multiple health activities that were prepared over a long period and after a lot of effort to respond to multiple requirements developed by usaid. fourth, the cut of financial aid to unrwa and pressure on other countries to cut off their support either. it is worth stating that the establishment of unrwa was based on the international resolution on action and relief for the palestinian population. this decision affects the most the population of the gaza strip, where 70% of the population are refugees receiving their primary health care services through unrwa. fifth, three devastating israeli military attacks on gaza in 2008, 2012 and 2014 destroyed buildings, schools, and health centres, requiring permanent efforts to restore buildings and functionality. the health and humanitarian needs and challenges facing the people of gaza remain tied to the continuing siege, lack of supplies and equipment, drugs, and human resources, as well as limited availability of electrical power. the increasing impact of ncds on the healthcare system; and the growing number of denials and delays related to requests for medical services abroad have resulted in increased morbidity and mortality. on average, the ministry of health (moh) in gaza is facing shortages accumulating e.g. to onethird of essential drugs and medical disposables. these restrictions have damaged the palestinian health system and deprived it of development and even the provision of basic health services to the population. the current covid-19 epidemic is increasing the burden on the system. the covid-19 pandemic during the past two decades, the world has been stricken by two pathogenic respiratory coronavirus pandemics; the severe acute respiratory syndrome (sars) (7) and the middle east respiratory syndrome (mers) (8). in december 2019, a third respiratory coronavirus has emerged starting from a large metropolitan area in china’s hubei province, wuhan. most of the cases present with fever, dry cough, and tiredness, although clinical presentation ranges from asymptomatic to atypical severe pneumonia (9). by 11 march 2020, the who declared covid19 a pandemic (10). neither medication nor a vaccine has been approved for example by the american food and drug administration (fda). preventive measures are the only solution to save lives and to provide the countries with more time to prepare for the arrival of the virus (11). within a short time, the disease spread to include most of the world countries. all countries in the arab region have reported covid-19 cases, yemen abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 5 | 12 was the last. most arab countries also have available a national rapid response for timely investigation and response to public health threats (12). similar to other countries, palestinians started preparations to face the coming virus with their scarce resources by forming scientific committees to review the available emergency plans and protocols supported by the world health organization and train the local staff for relevant subjects including infection prevention, proper use of personal protective devices, and case management including intensive care for seriously ill patients. the preparedness activities were followed by the response when the first case was reported in bethlehem city in the west bank (wb). the effort focused on the complete isolation of the city and closure of markets, schools, universities, mosques, and churches, as well as a ban of major social gatherings. in gaza, the first two cases appeared three weeks later than in the west bank which allowed time to prepare the same regulations. by may 20 (last modified date), 602 cases had been registered, of which 547 were in the west bank, including east jerusalem, and 55 in the gaza strip. it became clear that the limited prevalence of cases in the west bank was concentrated in the middle of the country, i.e. in the governorates of jerusalem and bethlehem with a northern expansion to include parts of ramallah and a south expansion to include parts of the hebron governorate. the integrity of the northern west bank was preserved, as no cases are reported in some governorates there. seventy-five percent of all cases can be attributed to a single source, the workers moving across the green line and their contacts, while in the gaza strip, the registration of cases is still limited to the quarantine centres and no positive endogenous cases have been reported so far. eighty percent of cases occurred among young people under 50 years of age and two-thirds of cases were identified among males, with a higher prevalence among workers. like for other countries, the risk groups are aged people with chronic disease and workers moving to and from inside israel where the latter constitute a major risk of disease transmission to wb. thousands of palestinian prisoners in israeli jails are also exposed to high risk. outbreak scenarios in palestine the palestinian public health institute, in collaboration with the world health organization and the advisory committees of the ministry of health, is working on preparing scenarios for the future of the epidemic in the palestinian territories and has developed scenarios in the west bank that will be studied and announced. in the gaza strip, it was difficult to implement the same scenarios as no endogenous cases are reported up to now. the extremely high population density in the gaza strip of 5,200 persons/km2 together with the long incubation period of 14 days according to who standard results in a worstcase scenario of 20,000 cases based on the record of wuhan, i.e. 8 cases per 1,000 citizens. to counter this scenario, we are prepared to take strict closures to flatten the epidemic curve to extend for a longer period of up to 10 months, with an estimated forecast of 2,000 cases per month. it is expected that 20% or 400 of the cases calculated per month will need hospital services. the gaza european hospital and surrounding areas have been prepared to accommodate these numbers (advisory committee-gaza). if endogenous cases in gaza are reported, the ministry of health will start case-investigation and draw on the basis of these data the real pandemic curve to be compared daily with the forecasted curve of 2,000 cases per month abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 6 | 12 and 400 hospitalisations. if the real curve remains below the forecasted curve, this indicates that the system can absorb the patients requiring hospital services. if, however, the real curve is out of the forecasted curve the health system is facing a pandemic beyond its absorption capacity. decision-makers will have to take then the necessary measures, either to increase the capacity of the health system or to establish stronger measures of isolation and social spacing, details outlined as follows. palestinian strategies to control the covid-19 pandemic 1. prevention of infection through social distance, personal hygiene, and use of protective devices. 2. virus containment through controlling entrance at border crossings by quarantine of travellers. 3. health care facilities preparedness and handling of the discovered cases. 4. early discovery of cases by pcr testing and contact tracing. 5. continuation of essential health services for the population. 6. surveillance and response based on the situation in palestine and neighbouring countries. 1. prevention of infection through social distance, personal hygiene, and use of protective devices facing a virus without specific treatment and without vaccines to prevent, we have to work in two directions, the first one is personal hygiene and environmental protection and the second is the social distance. prevention of infection will be applied at three levels:  support health education programmes propagating the importance of wearing face masks and the need to wash hands and disinfect surfaces of furniture and work offices.  closing overcrowded places such as schools, universities, mosques, sport clubs, wedding halls, funeral homes, and major markets.  isolation of communities with confirmed cases either by curfew or movement restriction between communities. in the west bank, the three levels were implemented while in the gaza strip activities were limited to the first 2 levels as zero cases were reported outside the quarantine departments. in gaza overcrowding continues in the markets and streets and the population has been encouraged by the false feeling of security, i.e. that the virus will not enter the gaza strip. as there are high rates of unemployment, which exceeds 70% among the youth, and daily individual work became the only means of achieving a limited income for thousands of palestinian families, the deteriorated economic status prevents the public to respond to social distance and reduced overcrowding in the markets. local voices call for curfew application for the entire gaza strip, but ethical considerations are to be considered too as people should be provided with basic needs as food, drink, safety measures, and medications for chronically ill people but the funds are not available to cover these expenses. 2. virus containment through controlling border crossings by quarantine of travellers crossings with jordan and egypt have been closed, but the crossings with israel are facing problems due to the multiplicity of crossing points in the west bank and the loss of abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 7 | 12 security control by palestinian guards in areas "c". a large number of workers – estimated to be around 180,000 pass through these crossings. they constitute the largest risk of virus transmission from israel to the palestinian territories. according to reports from the palestinian ministry of health, 75% of the positive cases reported in palestine are workers returning from inside israel and their contacts. as regards the gaza strip there is only scarce movement across borders due to the israeli restrictions. besides, there are only two crossings, the beit hanon (eretz) crossing for those coming through israeli and the rafah crossing for those coming through egypt. returnees from these crossings were required to be quarantined for two weeks, the quarantine policy to be compulsory within school buildings. the process was initially severely disturbed and the facilities not equipped for quarantine, lacking provision of basic needs. based on this experience a policy was developed for the quarantine process:  provision of daily basic needs such as food, drinks, medicine, and communications to all inhabitants.  ensuring that infections do not reach and spread within quarantine centres.  procedures to prevent spread of infections outside the centres. quarantine measures in the early phase have been extended to some hotels and health institutions. within a short period, 1,000 single quarantine rooms have been replaced in school buildings. the quarantine period in gaza exceeded the 14 days recommended by who by an extra week to take into consideration possible incubation periods longer than 2 weeks. 3. health care facilities preparedness and handling of discovered cases there is a small isolation hospital in the gaza strip with a capacity of 35 beds and 6 intensive care beds for positive cases located close to the egyptian border. the european hospital and surrounding areas have been set up to accommodate 400 cases to face the expansion of the epidemic. in the west bank, 13 hospitals were selected to isolate positive cases. in jerusalem, isolation departments have been set up at augusta victoria hospital, st. joseph's and makassed hospitals (13). respirator rate in palestine is 10 devices per 100,000 citizens and 4 in the gaza strip. compared to other countries, these rates are 30 in germany and 50 in israel while israelis are seeking to raise them to 150 devices per 100,000 inhabitants. many countries are investing a lot on more devices, germany for example has increased the health system's capacity to add 10,000 units. the united states of america has spent $2.9 billion to acquire 19,000 devices more. in contrast, the possibilities of the palestinian authority do not allow the purchase of any new equipment. obtaining an effective drug or obtaining a protective vaccine requires a longer time, because it takes meticulous scientific, legal and ethical procedures, starting with the identification of the genetic map of the virus and followed by success to form the required substance and its approval from international and scientific institutions such as the fda. then the drug or vaccine has to pass successfully in experimental animals, followed by guarantees of safety and effectiveness in humans and the authorization of testing the product on humans in small groups followed by large groups. if successful the compound is displayed for manufacturing and marketing and then who and experts will determine which categories should receive this drug or vaccine with adherence to the prohibitions of use if necessary. therefore, a long time is needed to produce a suitable drug or vaccine. also abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 8 | 12 some compounds are considered as promising that have been used previously in the treatment e.g. of malaria with chloroquine or hydroxychloroquine (14). another example is the oxford vaccine based on previous trials of mers and remdesivir which has been successful in treating ebola, sars and mers in laboratories but has not achieved clinically relevant results at that time. clinical trials are underway to determine the appropriate dose and treatment periods for use in coronatherapy. at the same time, who is conducting a large-scale solidarity trial that aims to rapidly discover whether any of the drugs slow disease progression or improve survival in different parts of the world including such as remdesivir and lopinavir/ritonavir with interferon beta-1a. accordingly, the advisory committee recommended not to rush to use drugs or vaccines that have not been proven globally and to wait for stronger evidence. people acquire long-term immunity to any microbe in one of two ways, either by vaccination or getting sick and recovering from a disease. from the advocates of the herd immunity scenario it is understood that 70% of a population should be infected which implies a high rate of case fatalities which is ethically unacceptable. therefore, social spacing remains for the time being the best and safest option to deal with the covid-19 pandemic. social spacing is expected to reduce the transmission, leading to a significant reduction in the epidemic dynamics. the pna has excellent health teams but a severe shortage of diagnostic facilities and equipment. therefore the main focus should be on personal hygiene social spacing. 4. early discovery of cases by pcr testing in the gaza strip, all arrivals to quarantine centres are examined physically and by pcr testing. this strategy has succeeded in detecting 66 cases up to date in gaza, preventing epidemic expansion among the population. in the west bank, all arrivals across the jordan bridge were screened by pcr testing. the success of this strategy depends on the availability of a sufficient number of pcr swaps and kits. 5. continuation of essential health services for the population who recommends that health services to the population continue to be provided in the face of the epidemic, particularly immunization programmes and care of chronic patients. some health centres were closed because of curfew in the wb and subsequent reallocation of health staff to work in isolation units. in the gaza strip 37 out of a total of 54 government centres are open. non-governmental health institutions provide also basic services to the population as the government sector is busy confronting the epidemic. unrwa provides excellent primary health-care activities by establishing a public hotline to provide people with home treatment and health consultations and is ready to reach all those registered for non-communicable disease services at home, as well as to provide social assistance at home to avoid overcrowding in the centres. the agency also continued vaccination programmes. during disease outbreaks and emergencies, the advisory committee stresses the importance of maintaining basic health services such as immunization, and effectively involving ngos and communities in health planning and service provision (1517). 6. surveillance and response based on the situation in palestine and neighbouring countries who advises in principle not to rush back to normal life before the final elimination of the abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 9 | 12 epidemic, but there is public pressure to return to open markets and mosques accompanied by a government eagerness to boost the economy and increase government incomes. who therefore recommends a return gradually to normal life, at least in communities with low risk. however, decision-makers should link the mitigation plan to pandemic indicators over time, i.e. to follow up on the rate of positive laboratory tests, the rate of growth and change over time of multiplication (number of new cases due to one source contact), to determine the effectiveness of these measures, to tighten them and mitigate them as the epidemic changes. the economic burden the current pandemic overburdens the system and aborts the response to population health needs. the economic factor is a major component responsible for variations between countries. israel allocated $2.8 billion to control the current pandemic i.e. to cover treatment and drugs as well as social insurance to their inhabitants. pna has no resources either to ensure the cost of the pandemic nor to ensure social insurance for the population. it is worthy to mention that gdp per capita in israel is 15 folds higher than in palestine. these economic variations are reflected the daily activities to control the pandemic. by the end of march, all examined blood samples for early detection amounted to 830 in palestine while in israel health authorities examined daily around 4000 blood samples. by early june 2020 the number of tests in israel is almost more than tenfold as compared to palestine, 593,499 vs. 44,876 or 11,637/100,000 vs. 1,360. it is noteworthy that the economic factor played a major role in the public's failure to accept preventive measures, even though people are aware of the seriousness of the matter. in the northern governorates, thousands of workers and their families still work within israel as a primary source of livelihood and the interruption of work will lose their entire income, which leads them to continue their work and move between the workplace and their places of residence. planning and funding based on the who guidelines health authorities in the gaza strip and the west bank have developed strategic plans to address the epidemic. prevention, and treatment protocols have been developed in quarantine departments, contact tracing and follow-up of cases, and estimates of expected costs. who has been involved in the work of the various committees. among the global strategic goals, who has recommended that government sectors mobilize all community sectors to ensure that they are responsible for reporting and reducing the number of cases through citizen hygiene practices and physical spacing between individuals. financial estimates, prepared by the ministry of health, estimated $137 for palestine in total. who has issued an appeal for $6.5 million for funding activities of the ministry of health, unrwa, and some health ngos. financial estimates have also been developed at the ministry of health in gaza. the health cluster april 2020 report states: "to respond to the growing health needs of covid, the health group requires a total of $19 million". having received $10.8 million a funding gap of $8.2 million remains. health group partners require $37.5 million to meet the health needs of the most vulnerable communities in the occupied palestinian territory for 2020. to date, a total of $10 million has been secured so far, leaving a gap of $27.5 million (13). no reports have been issued of the donor response, and everyone is looking for abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 10 | 12 ward to prepare a single strategic plan to address the epidemic, cover the requirements of the palestinian people, develop treatment protocols, and organise uniform and broader community participation to control the epidemic. main coordination deficit: absence of a palestinian central national committee facing the current pandemic different technical and administrative committees were formed in the gaza strip and the west bank with minimum coordination. committee members were mostly official governmental employees, universities were invited to participate in epidemiological and consultative committees, and ngos to participate in administrative committees. the absence of a central national coordination committee for both west bank and gaza resulted in a poor estimation of the needs, miscommunication with the donor community, an unclear role of the health care providers, and unfair distribution of resources. many delegates asked to expand the role of ngos, where their role is not clear and limited to clinical activities. furthermore technical and administrative protocols have been prepared separately for the west bank and the gaza strip without full communication between palestinian experts and as well resource allocation and requests for funding were poorly coordinated. recommendations  until the development of a covid19 vaccine, the constant urge to support the policy of social distance and personal hygiene among the population is the best, safest and most acceptable option to deal with the pandemic.  establishment of central national committee presenting governmental and non-governmental sectors to revise and set policies to control the spread of the epidemic, seek funding, define roles of players and ensure the equitable distribution of resources among the partners.  review the diagnostic and treatment protocols and update them according to international evidence-based recommendations and continue as well the training of health care providers and volunteer teams.  train community groups regarding personal protective devices and environmental and personal hygiene.  community involvement and participation to support the official authority in the field implementation of their plans and activities. clearly defined tasks are needed.  support economic development to establish solutions to solve problems related to working conditions within the green-line and advocate for productive jobs within the palestinian land.  urge donors to provide health authorities with laboratory diagnostic materials, personal protective devices, strengthening intensive care units, supporting outreach activities and training programmes. acknowledgment i would like to extend my appreciation to the palestinian center for policy research and strategic studies (masarat) for giving me the chance to prepare this paper, to present to a group of palestinian health experts, and to take their feedback. thanks for the epidemiology committee in the ministry of health and the covid19 consultation community in gaza for their support and provision of the required information. abed y. covid-19 in the gaza strip and the west bank under the political conflict in palestine [short report]. seejph 2020, posted: 27 june 2020. doi: 10.4119/seejph-3543 p a g e 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creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. derstroff, m.; hartling, v.e.; hölttä, e.a.w.; traub, m. h.; van der linden, l.a.p.j.; thomas, j.c. stemming the tide of disinformation in public health. (policy brief). seejph 2023. posted: 09 april 2023 p a g e 132 policy brief stemming the tide of disinformation in public health marie derstroff1, victoria e. härtling1, wilhelmiina hölttä1, mike h. traub1, linda a.p.j. van der linden1, james c. thomas2 1faculty of health, medicine, and life sciences, maastricht university, the netherlands. these authors contributed equally to this work; 2gillings school of global public health, university of north carolina, chapel hill, north carolina, united states of america. corresponding author:marie derstroff address: demertstraat 77, 6227 an maastricht, the netherlands; email: marie.derstroff@t-online.de mailto:marie.derstroff@t-online.de derstroff, m.; hartling, v.e.; hölttä, e.a.w.; traub, m. h.; van der linden, l.a.p.j.; thomas, j.c. stemming the tide of disinformation in public health. (policy brief). seejph 2023. posted: 09 april 2023 p a g e 133 abstract context: disinformation, or incorrect information that is intended to mislead, was pronounced during the covid pandemic. disinformation that steers away from life-saving practices or toward life-threatening practices can be fatal. the european union has in place policies and offices to combat disinformation. however, they lack the full mandate and clarity of systems to meet the needs for quick and effective responses. policy options:means to enhance the effectiveness of existing policies include [1] clarifying a rapid response framework, [2] enhancing media literacy in the public, [3] inoculating the public against anticipated disinformation, and [4] engendering public trust through coordinated and consistent communication. recommendations:among these four, options 2 and 3 were deemed the best opportunities for quick action, early successes, and the fewest institutional or political hurdles. we recommend [a] that the eu commission establishes an eu media agency with a solid governance structure to support innovative media literacy undertakings and successful implementation; [b] that the existing media literacy expert group create a media literacy program implementation framework; and [c] that existing eu initiatives on disinformation debunking, media literacy, and inoculation strategies be merged into a single misinformation community within the european institute of innovation and technology [eit]. keywords:communication policy, covid pandemic, disinformation, public health emergencies derstroff, m.; hartling, v.e.; hölttä, e.a.w.; traub, m. h.; van der linden, l.a.p.j.; thomas, j.c. stemming the tide of disinformation in public health. (policy brief). seejph 2023. posted: 09 april 2023 p a g e 134 introduction large-scale protests, and public health professionals receiving threats and refusal of adequate therapies: the infodemic, which was rampant during the covid-19 pandemic, emphasized the urgency to tackle the negative effects of disinformation (1). a recent umbrella review by the world health organization [who] summarizes the undermining effects of infodemics and health disinformation on public health policies. disinformation has led to misinterpretation of scientific evidence, opinion polarization, increased spread of fear and panic as well as decreased credibility of existing evidence and information (2). it undermines trust in governmental institutions (3), lowering vaccine acceptance and adherence to public health regulations such as mask-wearing (4).disinformation is not just incorrect information, known as misinformation, but is communicated with the intent to mislead (2). via social media, disinformation is fast and ubiquitous. in contrast to media through television, radio or print which are filtered through editors and have a delayed release, internet-based social media are often unfiltered and instantaneous. moreover, disinformation can be more titillating than scientific facts. a study on twitter found that fake news tweets reached between 1 000 and 100,000 users through subscriptions and sharing, while factual news usually reached no more than 1,000 people(5, 6). the wide dissemination of fake news makes it profitable. advertisers are more likely to invest in a source with a larger readership. more ads on a site generate more ad clicks, which in turn can lead to more ads and income for the site owner (7). possible explanations include the reluctance of governments to communicate decisively in crises of missing and uncertain information, leaving room for misinformation to spread while the population demands reliable answers (8). especially unclear and sometimes contrary communication by governments increases uncertainty (9) and the information overload resulting from the infodemic made it difficult to filter meaningful and evidencebased information out of the mass of information (10). disinformation affects nearly every portfolio of the eu commission groups, since it is not only a threat to public health, but also derstroff, m.; hartling, v.e.; hölttä, e.a.w.; traub, m. h.; van der linden, l.a.p.j.; thomas, j.c. stemming the tide of disinformation in public health. (policy brief). seejph 2023. posted: 09 april 2023 p a g e 135 the environment and democracy (11). therefore, the eu commission needs to take a more prominent role in leading eu efforts in encountering this ongoing threat. context current eu policy to counteract the harmful effects of disinformation, the european union [eu] launched the “action plan against disinformation” in 2018 (12). the plan was accompanied by the “code of practice on disinformation” non-binding tool that was signed by online platforms such as meta, google, twitter and mozilla. in response to the covid pandemic, the code was updated in 2022 to the “strengthened code of practice on disinformation.” the effect of the code is blunted by the fact that signatories can decide which commitments they agree to, and there are no means to verify self-reports of progress (13).bound by law, eu efforts need to balance the fight against disinformation with the fundamental right to freedom of expression and open internet. furthermore, when it comes to eu ambitions to control the spread of disinformation, challenges remain in legal leeway, establishing governance structures, accountability networks and overcoming procedural shortcomings (14). in march 2019, as covid was emerging, the europeanexternal action service [eeas] launched an online rapid alert system [ras], to coordinate and share responses to disinformation inside and outside the eu (12). however, only a few eu member states actively engaged on the website and there was no means of triggering an alert to eu countries about a particular disinformation claim (13, 15). these eu strategies are not sufficient to mitigate the effects of media that are instantaneous, ubiquitous, and profitable. especially, the lack of binding regulations, clear terminology and active engagement of all eu member states elucidate important shortcomings of the eu strategy (13). based on the umbrella review by borges do nascimento, et al. the spread of misinformation should be addressed by “[…] developing legal policies, creating and promoting awareness campaigns, improving health-related content in mass media and increasing people’s digital and health literacy” (2). the audiovisual media services directive [avmsd], revised in 2018, strengthens the role of enhancing media literacy. article 33a of this directive requires member states to promote measures that develop media literacy skills (16). in 2016, the european commission installed the derstroff, m.; hartling, v.e.; hölttä, e.a.w.; traub, m. h.; van der linden, l.a.p.j.; thomas, j.c. stemming the tide of disinformation in public health. (policy brief). seejph 2023. posted: 09 april 2023 p a g e 136 european expert group on media literacy [mleg]. the mandate of the mleg is focused on exploring good practices in the field of media literacy; facilitating networking between different stakeholders and exploring ways of coordinating eu policies, support programs and media literacy initiatives (17). however, the effectiveness of these programs highly depends on their implementation potential (18, 19). the european audiovisual observatory provides snapshots of media literacy efforts throughout the eu, but the most recent study was conducted in 2016 (20).furthermore, the broad-scale implementation of the media literacy week innovations awards winners in 2019 (media mashup, html heroes, media mistakes) is not at hand. the eu council acknowledges that more has to be done, and better implementation has to be supported. however, it does not state how to go about it(21). inoculation theory the continuous influx of disinformation is difficult to retract and correct once they havetaken root in human memory (22). the inoculation theory can be compared with vaccination: exposing people to weakened doses of challenging information leads to immunity to adopting misinformation (23). within the context of health disinformation, issue-based inoculations have shown to be more effective than post-hoc corrections at increasing people’s intentions to, for example, vaccinate children (24). inoculation theory relies on two main mechanisms. the first are forewarnings or threats (“be aware of...”) to promote alertness and resistance. the second is pre-emptive refutation (“these are arguments against…”) to help model the counter‐arguing process and provide people with specific content that they can use to refute future persuasive challenges (23, 25). there are different types of interventions, for example, simple texts, infographs, videos and games (e.g. goviralgame.com) that have been proven to be significantly effective (26). policy options primary and secondary sources of information were consulted to identify promising strategies to counter disinformation. the strategies were subsequently translated into potential policy options. how they relate to eu policy is visualized in figure 1. preventing the actual spread of disinformation would be very effective, but, as stated earlier, has vast limitations by its legal, credibility and procedural challenges. it involves private entities whose cooperation is mostly voluntary. the proposed policy options below are therefore based on existing eu actions (ras, mleg) and novel strategies (inoculation theory) countering the negative effects, rather than tackling the spread of disinformation. derstroff, m.; hartling, v.e.; hölttä, e.a.w.; traub, m. h.; van der linden, l.a.p.j.; thomas, j.c. stemming the tide of disinformation in public health. (policy brief). seejph 2023. posted: 09 april 2023 p a g e 137 figure 1 (authors’ figure): strategies that can affect disinformation exposure to eu citizens. media companies control posts and producer access and therefore the spread of disinformation. eu efforts aim at cooperation with media companies, limiting the effect of disinformation by actively factcheck and debunking on platforms and facilitating programs to protect eu citizens against its harmful effects. option 1: clarifying a rapid response framework problem addressed: the eeas launched a ras to enable common situational awareness of misinformation in all eu member states and to foster the development of common responses (27). however, the ras currently lacks the specificity of processes and authority, resulting in onlya few eu member states sharing information through the system. action proposed: give the ras a mandate to clarify its data policies and lines of authority, along with stakeholder responsibilities. the ras should define its criteria for assessing evidence and rating derstroff, m.; hartling, v.e.; hölttä, e.a.w.; traub, m. h.; van der linden, l.a.p.j.; thomas, j.c. stemming the tide of disinformation in public health. (policy brief). seejph 2023. posted: 09 april 2023 p a g e 138 news content credibility. it should also clarify the system’s political mandate and legal foundation. problem solved: starting in december 2018, the eu commission launched its action plan against disinformation, which remains the key pillar of the eu policy. the enhanced specificity of the ras mandate and process will facilitate the realization of three of the four action plan goals: [1] “improving the capabilities of eu institutions to detect, analyze, and expose disinformation; [2] strengthening coordinated and joint responses to disinformation; [and][3] mobilizing the private sector to tackle disinformation”(12). remaining challenges: identification of disinformation is a task, in which a huge range of actors is involved: mainstream media and journalists, dedicated institutions, civil society and governmental agencies (28). as the number of stakeholders indicates, there may be issues in coordination of all players involved commonly comes at the cost of effectiveness, and the fact-checking organizations, such as international factchecking network, the ebu, invid, crosscheck and fatisk, currently lack the resources for funding and professional workforce(28). currently, the eu relies solely on the self-regulation of social media platforms. the digital service act is a new eu law designed to regulate online platforms such as facebook, twitter and tiktok. even so, the eu commission agreed that platforms should be free to choose how they handle disinformation and mitigate its impact(29). this leaves an uncertain legal foundation for all stakeholders. option 2: enhancing media literacy problem addressed: the impact of disinformation can be lessened by enhancing the ability of the public to understand how it works and learn how to identify it(19). however, political, financial, and technological barriers are forestalling the broad-scale implementation of media literacy programs. action proposed: introduction of a media literacy program implementation framework to add an implementationoriented perspective to the current development-oriented perspective of the eu. the current mandate of the mleg is more for research than for implementation. they explore effective practices in the field of media literacy, facilitate networking between different stakeholders, and explore derstroff, m.; hartling, v.e.; hölttä, e.a.w.; traub, m. h.; van der linden, l.a.p.j.; thomas, j.c. stemming the tide of disinformation in public health. (policy brief). seejph 2023. posted: 09 april 2023 p a g e 139 ways of coordinating eu policies(30). identifying and overcoming barriers in implementing media literacy strategies (e.g. political, financial, technological) should lead to more effective dissemination of these strategies and successful program implementation. problem solved: with an implementation framework for eu countries to work from, there will be more and more effective media literacy programs implemented. remaining challenges: to move towards an implementation-oriented perspective, the mandate of the mleg should be evaluated: does it provide the necessary legal and governmental flexibility to incorporate the formulation and monitoring of implementation strategies? if not, we recommend the eu commission propose an amendment to this mandate to facilitate implementation actions by the mleg. additionally, executing the elements of the framework will require an increase in administrative resources. moreover, the diversity of educational structures across the eu poses another challenge to implementing media literacy programs effectively, which needs to be considered when evaluating the programs(31). adaptations specific to member states may be required, highlighting the need for continuous (local) stakeholderinvolvement. a limitation to the effectiveness of the framework is the pace of new social media and technological innovations. what’s new today will be outdated tomorrow. option 3: inoculating against disinformation problem addressed: disinformation has an outsized impact on scientific information. the difference can be mitigated by inoculating the public against foreseeable counterstories to scientific evidence. inoculation is the exposure of people to weakened doses of disinformation, which has been shown to increase “immunity” to disinformation(23, 32). action proposed: create an eu inoculation expert group [ieg] to explore inoculation strategies and facilitate and evaluate interventions. inoculation interventions are of two main types: [1]forewarnings or threats (“be aware of...”) to promote alertness and resistance, and [2]pre-emptive refutation (“these are arguments against…”) “to help model the counter‐arguing process and provide people with specific content that they can use to refute future persuasive challenges”(23, 25). intervention means include simple texts, infographics, videos derstroff, m.; hartling, v.e.; hölttä, e.a.w.; traub, m. h.; van der linden, l.a.p.j.; thomas, j.c. stemming the tide of disinformation in public health. (policy brief). seejph 2023. posted: 09 april 2023 p a g e 140 and games (e.g. goviralgame.com) (26). evaluation should include the advantages and setbacks of various interventions and their scale, effect sizes, and costs. problem solved:if done early, inoculation can get ahead of disinformation campaigns through social media, thereby blunting the effects of social media speed. remaining challenges: eu governance structures have to be evaluated on their leeway regarding the implementation of inoculation theory-based strategies. furthermore, introducing a new task force would place yet another burden on the eu administrative resources. moreover, the effectiveness of inoculation strategies may differ among the various cultures composing the eu. interventions like games are also subject to trends, which come and go very quickly. therefore, the inoculation strategies have to be societal context-aware and thus flexibility and a dynamic approach to the ilp are required to be effective(32). option 4: engendering public trust through coordinated and consistent communication problem addressed: time delays in communication, lack of clarity and consistency and overloads of information by various institutions duringcrises contribute to a lack of trust in national governments in recent decades(3, 33). rebuilding public trust in light of crises demands inclusive, targeted approaches to communication and responsiveness to public questions(3, 8). action proposed: establish an eu infodemic communication task force within the eu public affairs committee to develop templates for structured information on strategic communication during times of crisis for member states. the templates will include recommendations for communication with different target groups, considering their abilities and preferences, i.e. in communication media and their personal biases. an example of this is social media communication, which can significantly contribute to the mutual reinforcement of the dynamic between citizens and institutions and the relationship of trust (8). in addition to the templates, the task force may be involved in monitoring and analysis of social media to identify public concerns and trends of disinformation, as a basis for further communication strategies (i.e. debunking). problem solved: these recommendations will allow for overarching, uniform communication that speaks with one voice derstroff, m.; hartling, v.e.; hölttä, e.a.w.; traub, m. h.; van der linden, l.a.p.j.; thomas, j.c. stemming the tide of disinformation in public health. (policy brief). seejph 2023. posted: 09 april 2023 p a g e 141 and thus reduces information overload. moreover, this should speed up decisionmaking on communication, as information is collected in a targeted manner and presented in condensed form in the recommendations. this enables timely access to public information and transparency and accountability of the member states. further, it allows for a timely response and is a core building block for building trust, as citizens, alongside evidence, are put at the center of communication (8). remaining challenges: the provision of communication does not limit the emergence and spread of disinformation, as it does not include countermeasures on online platforms. in addition, people with low media literacy and people who read with a strong bias may not be reached. thus, the influence of disinformation, while potentially inhibited, persists and poses a threat to public health. recommendations to select among these four options, we considered the urgency of the matter, existing political momentum, the likelihood of a quick success even if partial, and the relative absence of remaining challenges to frustrate the implementation of the policy.based on these criteria, we identified enhancing media literacy and inoculating against disinformation as the two most promising policy options. inoculation provides a means of anticipating and getting ahead of disinformation. there is political momentum in the european expert group on media literacy. initial small-scale programs could demonstrate their effectiveness. and there are no major political impediments to the implementation of these policies. the added value of the recommendations below can be real-time, measured by an increase in the number of programs implemented and the number of (institutions in) member states involved. the actual exposure of pre-bunking interventions to eu citizens and their effectiveness requires research and an extensive evaluation of the applied strategies. the first recommendations based on the selected policy options are addressed to the european commission. they can take action by putting in place an eu media agency with a solid governance structure to support innovative undertakings and successful implementation. this media agency will bring together the currently highly derstroff, m.; hartling, v.e.; hölttä, e.a.w.; traub, m. h.; van der linden, l.a.p.j.; thomas, j.c. stemming the tide of disinformation in public health. (policy brief). seejph 2023. posted: 09 april 2023 p a g e 142 fragmented eu organizations and programs, promote more unification of interventions, prevent overlap of efforts and thus lead to more efficient use of eu resources. furthermore, the eu commission should appoint an ieg to incorporate inoculation (“pre-bunking”) strategies to prevent the negative effects of disinformation on eu citizens’ public health. finally, the mandate for the mleg should be assessed on its potential to be actively involved with the implementation of media literacy programs. the second recommendation applies to this mleg of the european commission. we advise introducing a media literacyprogram implementation framework that promotes the effective implementation of media literacy programs (see figure 1) elements formulated in the program proposal are partially taken from the information items collected by the european audiovisual observatory in 2016 (30), complemented by elements that we also consider relevant. the third and last recommendation is addressed to the eit.eu-supported initiatives on the development of factchecking, debunking, media literacy programs and inoculation strategies (e.g. ebu, invid, crosscheck, emdo, heros, soma) could be brought together into a specific disinformation community within the eit. limitations introducing new policy options for a supranational entity like the eu has limitations. evaluating and, if necessary, adjusting the mandate of the mleg takes time, but should be done promptly. the financial and administrative resources that will be needed to execute the elements of the framework and run a new task force for inoculation can be a barrier to executing the recommendations. other issues involve the diversity within the eu which may limit transferability. this diversity has to be considered when developing and evaluating media literacy programs. specific adaptations in member states may be necessary, so a continuous involvement of (local) stakeholders is important. this also accounts for the potential difference in cross-cultural effectiveness of inoculation strategies. the inoculation strategies have to be societal context-aware for every member state and thus flexibility and a dynamic approach of the ieg are required to be effective. derstroff, m.; hartling, v.e.; hölttä, e.a.w.; traub, m. h.; van der linden, l.a.p.j.; thomas, j.c. stemming the tide of disinformation in public health. (policy brief). seejph 2023. posted: 09 april 2023 p a g e 143 figure 2 (author’s figure): a depiction of the media literacy-programme implementation framework, showing the means of engagement of the mleg and media literacy programs in development, implementation, evaluation and the eventual outcome of the program; information obtained from (30). finally, a limitation of the effectiveness of media literacy programs and inoculation is the high pace of technological innovations and the emergence of new online media platforms. it can be assumed that the success of an intervention (e.g. a game) is highly affected by its compatibility with popular platforms and trends. what’s new today, will be outdated tomorrow. conclusion the instantaneous, ubiquitous, and profitable spread of disinformation on online media, poses a challenge to public health. current eu policy strategies lack effectiveness in limiting the harmful effects of disinformation. preventing the spread of disinformation takes place in an online environment over which the eu has very limited control. therefore, enhancing media literacy and exploring inoculation efforts in derstroff, m.; hartling, v.e.; hölttä, e.a.w.; traub, m. h.; van der linden, l.a.p.j.; thomas, j.c. stemming the tide of disinformation in public health. 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roozenbeek j, compton j. inoculating against fake news about covid-19. front psychol 2020; 11:566790. 33. simon f, howard pn, kleis nielsen r. types, sources, and claims of covid-19 misinformation; 2020 apr 7 [cited 2022 dec 3]. available from: url: https://reutersinstitute.politics.ox.ac.uk /types-sources-and-claims-covid-19misinformation. ____________________________________________________________________________________________ © 2023 derstroff et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. alomari km. predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach (original research). seejph 2021, posted:20 august 2022. doi: 10.11576/seejph5827 p a g e 1 | 12 original research predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach khaled mohammad alomari1 1) academic programs for military colleges, abu dhabi university, uae corresponding author: khaled mohammad alomari; academic programs for military colleges, abu dhabi university, uae e-mail: khaled.alomari@adu.ac.ae, orcid (0000-0001-6677-6301) alomari km. predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach (original research). seejph 2021, posted:20 august 2022. doi: 10.11576/seejph5827 p a g e 2 | 12 abstract aim: the volume of research being conducted on the acceptance of social media platforms is rising. but the factors influencing the acceptance for academic reasons are still not properly identified. this study's goal is two-fold. initially, by including technology acceptance model (tam) and external variables, analyze the students' intention to use social media networks. secondly, to employ machine learning (ml) algorithms and partial least squares-structural equation modeling (pls-sem) to verify the proposed theoretical model. methods: the focus of this research is to create a conceptual model by supplementing tam with a subjective norm to assess students' adoption of social media in the classroom. students currently at one private university in the united arab emirates (uae) provided a sum of 627 acceptable questionnaire surveys out of 700 distributed corresponding to 89.6%. the collected data were evaluated using ml and pls-sem. results: according to the research findings, students' intention to utilize social media networks for learning is significantly predicted by “subjective norms, perceived usefulness, and perceived ease of use”. these findings illustrated how crucial it is for students to feel capable and secure using social networks in their academic work. for validation using machine learning classifiers, the results showed that j48 (a decision tree) typically outperformed other classifiers. conclusion: according to the empirical findings, "subjective norm," "perceived usefulness and ease of use" all significantly increase students' intention to use social networks for learning. these results were in line with earlier research on social network acceptability. lawmakers and managers of social media platforms in education must therefore concentrate on those factors that are crucial to promoting education and enhancing students' capacity for developing and implementing successful social media applications. keywords: social media networks; acceptance; technology acceptance model; pls-sem. conflicts of interest: none declared. alomari km. predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach (original research). seejph 2021, posted:20 august 2022. doi: 10.11576/seejph5827 p a g e 3 | 12 introduction facebook and twitter are social media networking platforms that was originally invented keeping college students in mind. a social network is an online community where members post their images, news, videos, and happenings to bring people their shared opinions, likes, experiences, and pursuits (1–3). users can communicate with one another on the internet via email and instant messaging via these online communities (4–6). on facebook, users build profiles for themselves and add images, videos, and personal information. facebook is a one-way communication tool that is effective for information sharing (7,8). additionally, it enables students to work remotely with their classmates. individuals can also join facebook groups, where individuals do not need to be friends (2,9,10). these groups' users have free access to instantaneous upload and share of a file, article, link, information, and video (11,12). the widespread usage of social media is largely due to technological developments, such as the expansion of broadband service accessibility, improved software applications, and the creation of more robust computers and mobile phones (13,14). in truth, this type of media has spread widely and has become a crucial component of the daily lives of many individuals all over the globe (15). since instructors and learners make up most internet users, social media appears to have had a significant role in how we instruct and study (16,17). the acceptance of social media in academia could be affected by many factors. finding these factors continues to be difficult and varies from one region to the next. the majority of technology acceptance research typically evaluates the theoretical models using the structural equation modeling (sem) methodology. in keeping with the body of current literature, there is limited empirical research on the usage of social media in schools in the united arab emirates (uae) and knowledge of the factors influencing students' actual use. consequently, this study's goal is two-fold. initially, by including the technology acceptance model (tam) (18) and external variables, analyze the students' intention to use social media networks. secondly, to employ plssem and ml algorithms to verify the proposed theoretical model. research hypotheses the research model is shown in figure 1. the main goal of the present research is to develop a conceptual model centered on the tam. the correlations between the constructs in the model are described in the ensuing subtopics. 1. subjective norm (sj) sj, defined as "the degree of belief associated with the improvement in his or her job performance likely to be brought about by the use of a specific system by any person," was shown to have a positive influence on social media usage (18). a significant determinant of user intent to use social media networks, according to the study, is the aspect of the subjective norm. thus, it is evident that: h1: subjective norm (sj) would predict the perceived usefulness (pu). h3: subjective norm (sj) would predict the intention to use social media sites (ism). 2. tam constructs pe indicates "the degree to which the person believes that adopting a given system will be effortless" (19). the term "degree to which the individual believes that employing a particular system would improve his/her job performance" is pu (19) and alludes to this belief. it is thought that pu and the perceived ease of use (peou) make it easier for people to accept new technology. the behavioral intention to use social networks is significantly positively influenced by these two factors, according to a study (20,21). pe was also alomari km. predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach (original research). seejph 2021, posted:20 august 2022. doi: 10.11576/seejph5827 p a g e 4 | 12 thought to have a significant positive effect on pu. as a result, we propose the following: h2: perceived usefulness (pu) would predict the perceived ease of use (peou). h4: perceived usefulness (pu) would predict the intention to use social media sites (ism). h5: perceived ease of use (peou) would predict the intention to use social media sites (ism).these hypotheses form the foundation of the proposed research model, as shown in figure 1. a structural equation model is initially used to represent the theoretical model, and it is then evaluated employing machine learning methods. figure 1. the research model. alomari km. predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach (original research). seejph 2021, posted:20 august 2022. doi: 10.11576/seejph5827 p a g e 5 | 12 methodology context and subjects the data was collected between january and april of 2022 using self-administered surveys. students studying at one private university in the united arab emirates (n = 1.500) make up the original study population. the survey participants volunteered to participate, and they received no remuneration for doing so. the data for this study were collected using a convenience sampling method. students who are interested in participating in the research have received an e-mail with the research's goal and a link to the survey. the survey link was also shared on the university's respective facebook and whatsapp groups to increase response rates. the students' participation was entirely voluntary. out of the 700 surveys that were sent, 627 students satisfactorily completed the whole survey, yielding an 89.6 percent response rate (22). the total quantity of proper responses of 627 was an appropriate sample size for the research, as stated by krejcie & morgan (1970) because the required sample size for a population of 1500 would be n=306 respondents. there were 297 men and 330 women in the sample, 73% of the participants were between the ages of 18 and 29. in addition, 64% of participants were pursuing a bachelor's degree, while 24% a master's, 9% a ph.d., and 3% were pursuing a diploma. study instrument the first section will focus on gathering participant demographic data, while the second is intended to get feedback on the factors of the conceptual model. this study's research instrument is divided into two parts as mentioned. the second section's elements were measured employing a "5-point likert scale." the peou and pu measurement items were adapted from choi & chung, davis, and venkatesh (18,23,24). the items employed to measure social media usage intentions and the items for the subjective norm were modified accordingly (18,23) . table 1 contains a listing of the constructs and the underlying items for each. the 11 items) will be assessed using a five-point likert scale, which includes the following weights: strongly disagree (1), disagree (2), neutral (3), agree (4), and strongly agreed (5). table 1. constructs, indicators, and their sources. construct items instrument source “intention to use social media sites “ ism1 facebook and twitter both encouraged networking and the growth of social bonds. (18,23) ism2 twitter and facebook help individuals build stronger social bonds. “perceived ease of use” peou1 i have been able to communicate clearly and easily using twitter and facebook. (18,23,24) peou2 twitter and facebook's userfriendly interfaces make communication quick and easy without taxing the brain. peou3 i find it simple to learn how to navigate facebook or twitter. “perceived usefulness” pu1 information can be found more readily on twitter or facebook. (18,23,24) pu2 i will keep using twitter and facebook. alomari km. predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach (original research). seejph 2021, posted:20 august 2022. doi: 10.11576/seejph5827 p a g e 6 | 12 pu3 i will utilize twitter and facebook for purposes other than information research. “subjective norm” sn1 individuals think twitter or facebook is necessary and inescapable. (23,25) sn2 almost all my friends and colleagues assume that i frequently use facebook or twitter. sn3 if i stop using twitter or facebook, i might face opposition from others. results data analysis this research takes advantage of the smartpls software with partial least squares-structural equation modeling (pls-sem) (26,27). the primary justification for using pls-sem in this work is that it offers contemporaneous evaluation for both the measurement and structural model, which yields more precise results (28). the second technique is used in this research to predict the dependent variables in the conceptual model by employing machine learning algorithms via weka (29). the developed theoretical model is evaluated in this research using these two mentioned separate techniques. measurement model assessment the “cronbach's alpha and composite reliability (cr)” measures were employed for reliability analysis. each of these measurements should have a value of ≥ 0.70 (30). the reliability is corroborated by the findings in table 2, which show that both measures' numbers are satisfactory. the validity and reliability of the measurement model are evaluated (30). the “average variance extracted (ave)” and factor loadings were evaluated for convergent validity. while the numbers of factor loadings ought to be ≥ 0.70 (31), the values of ave must be ≥ 0.50 (32). the convergent validity is established based on the findings in table 2 and the acceptable numbers for both measures. table 2. convergent validity. constructs items factor loading cronbach's alpha cr ave “intention to use social media sites” ism1 0.887 0.896 0.824 0.609 ism2 0.721 “perceived ease of use” peou1 0.767 0.882 0.786 0.621 peou2 0.780 peou3 0.889 “perceived usefulness” pu1 0.756 0.774 0.860 0.732 pu2 0.751 pu3 0.706 ‘subjective norm’ sn1 0.747 0.898 0.774 0.674 sn2 0.779 sn3 0.868 alomari km. predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach (original research). seejph 2021, posted:20 august 2022. doi: 10.11576/seejph5827 p a g e 7 | 12 1.1 hypotheses testing and coefficient of determination each path's variance description (r2 value) and each connection's path relevance in the research model were evaluated. figure 2 and table 3 show the formalized path coefficients and path significance. the combination assessment of the nine stated hypotheses was conducted using the structural equation modeling (sem) method. all hypotheses were validated by the data. according to figure 2, “the perceived usefulness, perceived ease of use, and intention to use social media networks” all had r2 values that varied from 0.756 to 0.863. as a result, these constructs seem to have high predictive power (33). all the constructs from earlier studies were confirmed in the model (sn, pu, peou, and ism). the empirical data supported hypotheses h1, h2, h3, h4, and h5, according to the data analysis. the findings supported hypothesis h1 by demonstrating that pu greatly impacted sn (β= 0.648, p<0.001). the finding that perceived ease of use (peou) significantly influences pu (β= 0.651, p<0.001) validates hypothesis h2. consequently, h3, h4, and h5 are validated since “the intention to use social media networks (ism)” greatly impacts sn (β= 0.418, p<0.01), pu (β= 0.758, p<0.001), and peou (β= 0.575, p<0.01). table 3. test results. h relationship path t-value p-value direction decision h1 sn -> pu 0.648 18.528 0.000 + s** h2 pu -> peou 0.651 15.546 0.000 + s** h3 sn -> ism 0.418 12.651 0.002 + s** h4 pu -> ism 0.758 15.743 0.000 + s** h5 peou -> ism 0.575 10.715 0.001 + s* note:+, positive; s, supported. “p**=<0.01, p* <0.05significant at p**=<0.01 , p* <0.05”. figure 2. the structural model of the study. alomari km. predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach (original research). seejph 2021, posted:20 august 2022. doi: 10.11576/seejph5827 p a g e 8 | 12 1.2 hypotheses testing using machine learning algorithms the “bayesnet, adaboostm1, lwl, logistic, j48, and oner” classifier-based predictive model was employed using weka (version 3.8.3) (34). to predict the correlations in the proposed theoretical model, this study utilizes machine-learning classification algorithms by employing a variety of methodologies, such as “bayesian networks, decision trees, if-then-else rules, and neural networks”. the 10-fold cross-validation showed that the decision tree algorithm j48 successfully predicted the pu with an accuracy of 92.2 percent. as can be seen from the findings in table 4, j48 outperforms the other classifiers in estimating the pu of social media networks. h1 is therefore supported. in comparison to the other classifiers, this one performed higher in regard to tp rate (.921), precision (.919), and recall (.920). table 4. predicting the pu by sn. classifier cci1 (%) tp2 rate fp3 rate precision recall f-measure bayesnet 85.31 .853 .320 .854 .851 .854 logistic 85.44 .854 .381 .855 .853 .859 lwl 86.36 .863 .334 .865 .866 .867 adaboostm1 86.38 .864 .431 .868 .862 .866 oner 87.30 .873 .476 .875 .874 .874 j48 92.19 .921 .895 .919 .920 .921 1cci: “correctly classified instances, 2tp: true positive, 3fp: false positive”. j48 predicted the peou with a 79.90% accuracy rate utilizing the criteria of perceived usefulness (pu). the results also showed better classifier performance by j48 when predicting the peou when opposed to other classifiers, as seen in table 5 as a result, h2 received support. table 5. predicting the peou by pu. classifier cci1 (%) tp2 rate fp3 rate precision recall f-measure bayesnet 79.25 .793 .536 .794 .794 .798 logistic 80.31 .803 .565 .810 .805 .807 lwl 81.19 .811 .595 .819 .812 .812 adaboostm1 82.35 .824 .598 .835 .829 .828 oner 84.64 .846 .624 .849 .847 .848 j48 89.83 .898 .679 .899 .897 .895 the classifier j48 in table 5 predicted the intention to use the social media networks (ism) system with a 90.4 percent accuracy rate. according to the results presented in table 6, j48 performed better than other classifiers in estimating the intention to use social media networks (ism) utilizing attributes of sn, pu, and peou. therefore, h3, h4, and h5 had support. alomari km. predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach (original research). seejph 2021, posted:20 august 2022. doi: 10.11576/seejph5827 p a g e 9 | 12 table 6. predicting the ism by sn, pu, and peou. classifier cci1 (%) tp2 rate fp3 rate precision recall f-measure bayesnet 84.30 .843 .624 .844 .845 .844 logistic 85.37 .853 .644 .856 .852 .852 lwl 85.69 .857 .647 .858 .855 .856 adaboostm1 86.17 .862 .732 .864 .861 .863 oner 88.31 .883 .719 .887 .884 .885 j48 90.35 .903 .772 .909 .903 .912 2. discussion because this research is one of the rare efforts (give references here again) to implement machine learning algorithms in predicting the actual use of social media, it is hoped that the adoption of a parallel multi-analytical approach would bring a new addition to the literature on information systems (is). this research employed “pls-sem and machine learning classification algorithms” in a parallel manner to assess the proposed model. it is significant to remember that pls-sem can be utilized for both dependent variable prediction and conceptual model validation depending on the extension of an existing theory (35-38). similar to this, supervised machine learning algorithms can be implemented to predict a dependent variable by relying on independent variables (29). these methods have a pre-defined dependent variable. it is also intriguing to see how many varied classification algorithms with distinct methodologies, including “decision trees, bayesian networks, association rules, neural networks, and if-then-else rules”, were used in the research. more particular, the results showed that j48 (a decision tree) typically outperformed other classifiers. it is important to note that the sample was divided into homogeneous sub-samples depending on the most important independent variable, and the decision tree (nonparametric) was adopted to classify both continuous (numerical) and categorical variables (29). on the other side, pls-sem (a nonparametric procedure) was applied to generate a large number of subsamples at random and verify the significant coefficients with substitutes from the sample. there has been a thorough investigation in the current research to assess the external variables associated with user’s behavioral intention to use social media sites among uae students namely the “subjective norm, perceived usefulness, and perceived ease of use”. however, it is also imperative to investigate and validate the technology acceptance by user with respect to the individual and organizational factors affecting technology. this calls for conducting a similar study with greater number of external variables which will help generalize the study outcomes. after this, we can use a longitudinal study to test the proposed argument. it is also possible to use a longitudinal study to comprehend the potential adoption of social media sites by education workplaces in developing countries. this will require comparative analysis of the current research model at different time periods. conclusion and future works the tam was used and extended by "perceived playfulness" to accomplish this goal. from the students studying at reputable universities in the united arab emirates, a alomari km. predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach (original research). seejph 2021, posted:20 august 2022. doi: 10.11576/seejph5827 p a g e 10 | 12 record of 627 acceptable questionnaire surveys were gathered. by use of the “plssem and machine learning approaches”, the suggested model was verified. according to the empirical findings, "subjective norm," "perceived usefulness," and "perceived ease of use" all significantly increase students' intention to use social networks for learning. these results were in line with earlier research on social network acceptability (15,16,23,39,40). these findings illustrated how crucial it is for students to feel capable and secure using social networks in their academic work. the primary goal of this research was to explore the variables influencing students' acceptance of social networks in the classroom. lawmakers and managers of social media platforms in education must therefore concentrate on those factors that are crucial to promoting education and enhancing students' capacity for developing and implementing successful social media applications. the statistics were only gathered from one private university in the uae as a restriction. the findings might not generalize to other higher education schools in the uae. to evaluate the commonalities and differences 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social medicine with informatics, primary health center valjevo, valjevo, serbia; 2 institute of social medicine, faculty of medicine, university of belgrade, belgrade, serbia; 3 zemun gymnasium, zemun, serbia. corresponding author: prof. janko jankovic, md, phd; address: institute of social medicine, faculty of medicine, university of belgrade, dr subotica 15, 11000 belgrade, serbia; telephone: +381 11 2643 830; fax: +381 11 2659 533; e-mail: drjankojankovic@yahoo.com jovanovic d, jankovic j, mirilovic n. socio-demographic inequalities in satisfaction with primary health care and utilization of chosen doctors’ services: a cross-sectional study (original research). seejph 2020, posted: 11 february 2020. doi: 10.4119/seejph-3311 p a g e 2 | 12 abstract aim: the aim of the study was to examine socio-demographic inequalities in user satisfaction with phc and utilization of chosen doctors’ services. methods: this cross-sectional study was conducted in 2016 among 232 respondents who participated in phc user satisfaction survey in phc center valjevo, serbia. inclusion criteria were an age of at least 20 years, sufficient skills of serbian language to fill in questionnaires and consent to participation. two hundreds and six patients completed an anonymous questionnaire about the user satisfaction with phc. results: the chosen doctor was seven times more often visited by the elderly (or=7.03) and almost three times more often by the middle-aged (or=2.66) compared to the youngest category of respondents. those with low education and poor financial status of the household visited a doctor four (or=4.14) and almost nine times (or=8.66) more often, respectively, compared to those with high education and good socioeconomic status. a statistically significant higher level of phc satisfaction was recorded in the rural population (p<0.001) and among respondents with poor socioeconomic status of the household (p=0.014). conclusion: the chosen doctor was more frequently visited by respondents with low education and those with poor socioeconomic status of the household, while a higher degree of satisfaction with phc was recorded in the rural population as well as in those with poor socioeconomic status of the household. keywords: cross-sectional study, inequalities, primary health care, serbia, service utilization, user satisfaction. conflicts of interest: none declared. jovanovic d, jankovic j, mirilovic n. socio-demographic inequalities in satisfaction with primary health care and utilization of chosen doctors’ services: a cross-sectional study (original research). seejph 2020, posted: 11 february 2020. doi: 10.4119/seejph-3311 p a g e 3 | 12 introduction health inequalities are "systematic differences in health or distribution of health resources between different population groups" and mainly produced by different socio-demographic determinants such as education, material status, employment, gender, type of settlement, age and ethnicity (1). sociodemographic inequalities in health pose a major challenge for health policy makers in a country because they are unfair, unjust and avoidable. they are also a persistent and widespread public health problem, both in the countries of the european region and worldwide (2,3). serbia is no exception in this respect, as the presence of health inequalities between different population groups (4), as well as in the domicile population has been documented (5-7). primary health care (phc) represents the first contact and entry into a country's health system and most health problems that occur in the population have been addressed at the phc level (8). a good phc system in a country ensures a more equitable distribution of health services and better health outcomes for the entire population (9) and this can be to some extent done by continuous testing and analysis of user satisfaction as a valid and comprehensive indicator of quality in health care (10,11). satisfaction with phc is the users’ response to provided primary care services and also implies users’ attitude towards the doctor, other healthcare personnel, and health care system in general (12-14). it is natural for different persons to have different perceptions and experiences regarding provided health services, relationship with physicians and other healthcare personnel, availability of health care and other quality indicators (14). data from 2013 serbian health survey (15) showed that 53.8% of citizens were satisfied with public health services. the less educated, the poorest, as well as the residents of rural settlements were the most satisfied with the provided health care services. speaking about utilization of health care it refers to obtain the necessary services from the health service in the form of contact. more illustratively, it is the point where patients' needs meet the health care system and are satisfied (16). one measure of phc use is the average number of visits to chosen physician per capita per year. according to the latest health survey of the serbian population (15), approximately two thirds of the population aged 14 years and older (65.5%) visited the chosen doctor or pediatrician in 2013. each adult visited its chosen physician 4.8 times in average (17). despite the fact that serbia has a comprehensive universal health care system with free access to primary care services, inequalities in the utilization of health care services are present (6,15). men and women belonging to the poor and men with lower education were less likely to visit general practitioners (gps), regardless of their health status (6). the aim of the study is to examine the influence of demographic (gender, age, type of settlement) and socioeconomic determinants of health (education, socioeconomic status of the household) on the users’ satisfaction with phc and the utilization of chosen doctors’ services. methods study population and setting the cross-sectional study was conducted in the primary health care center valjevo, serbia. a total of 232 patients were enrolled during a 6-week period in june and july 2016. the sample size was calculated based on the number of total and first visits in the previous year. assuming a standard error of 2%, the minimum sample size was 180 patients. to allow for no respondents at least 200 patients were enrolled. to diminish selection bias, patients were selected consecutively from the medical charts of patients waiting to be seen. inclusion criteria were an age of at least 20 years, sufficient skills of serbian language to fill in questionnaires and consent to participation. we excluded patients coming to the practice only for picking up a prescription, who did not aim to see the physician, or who needed immediate emergency care. all eligible consecutive patients visiting the primary health care center valjevo and its branches in brankovina and gola glava were informed about the purpose of the study and invited to participate. written informed consent was obtained from all participants prior to beginning the testing. the study was approved by the ethical board of primary health care center valjevo, serbia (number of approval: dz-01-1656/1, date of approval 8 june 2016). research instrument the user satisfaction with the primary health care (phc) was examined according to the professionalmethodological manual from the institute of public health of serbia (iphs) “dr. milan jovanovic batut” (18). a modified anonymous questionnaire about the user satisfaction of the work of the general medicine department was used. the validity and reliability of the questionnaire was tested during the prior study conducted in valjevo (19). the original questionnaire was slightly shortened in order to achieve higher consistency, to avoid asking similar questions, and with the goal of an easier, faster and more effective jovanovic d, jankovic j, mirilovic n. socio-demographic inequalities in satisfaction with primary health care and utilization of chosen doctors’ services: a cross-sectional study (original research). seejph 2020, posted: 11 february 2020. doi: 10.4119/seejph-3311 p a g e 4 | 12 filling out of the questionnaire by the respondents. the original questionnaire about user satisfaction was constructed based on the questionnaire recommended by who for the evaluation of the use, availability, coordination and comprehensiveness of the health care. at the consensus workshop in 2009, the iphs questionnaire was adapted for chosen doctors in serbia (13). the users of valjevo primary health care center services, as well as the ambulance services in brankovina and gola glava, were given anonymous questionnaires upon completing their visit to the chosen doctor. the respondents were filling them out on their own, consulting with the interviewers only about the questions they were not sure about. upon completion of the questionnaires, they were put in the sealed boxes, so the total anonymity was guaranteed. variables the demographic determinants used in this study were: age, sex (male and female), and type of settlement (urban and rural). the age was categorized into three age groups: 20 to 39, 40 to 64, and 65+ years. the socio-economic characteristics were the level of education and self-assessed socioeconomic status of the household. education was defined as low, middle and high, while self-assessed socioeconomic status as poor, average and good. the outcome variables selected in the present study were the number of visits to a chosen doctor per year and the customer satisfaction with the primary health care. the number of visits was dichotomized into two categories: up to 5 visits to the doctor per year and 5 or more visits in the same period. for items "skipped check-ups due to financial constraints" and "wait too long for check-up" two answers were offered: yes or no. to examine patient satisfaction with the nurses and doctors in phc we were interested to know how they felt about the following statements: "nurses at the counter are kind", "nurses at the interventions are kind", "nurses offer all information", "doctor is familiar with the previous diseases", "doctor takes enough time for conversation", and "doctor gives clear explanations about the diseases and the medicines" (the offered answers were: yes, partly and no). the general assessment of customer satisfaction with the primary health care was grouped into three categories: satisfied, partly satisfied and unsatisfied. statistical analysis the data was analyzed using the methods of descriptive statistics, as well as bivariate and multivariate linear and logistical regression analysis. to find statistically significant differences between socio-demographic (sex, age, type of settlement, level of education and self-assessed socioeconomic status of the household) and outcome variables, the chi-squared test was used. bivariate and multivariate logistic regression analyses were performed to estimate the association between the use of chosen doctors’ services and socio-demographic variables. to assess the association between user satisfaction with the primary health care and socio-demographic variables, methods of bivariate and multivariate linear regression analyses were used. the results of logistic regression analyses were reported with odds ratios (ors) and 95% cis, and with unstandardized regression coefficients (b) and probability in linear models. statistical significance was set at 2-sided p<0.05. all statistical analyses were performed using the statistical ibm package spss v.20.0 (spss inc., chicago, illinois, usa). results of the 232 enrolled primary care patients, 206 completed the questionnaire, yielding a response rate of 88.8%. out of 206 patients, 135 (65.5%) patients were from the urban area and 71 (34.5%) from the rural area. most of the patients were woman (54.9%). the mean age of the patients was 54.5 years (sd = 17.0; age range 20 to 86 years). 26 patients (most of them from the youngest age group and from the urban area) refused to participate, typically because of lack of time or unwillingness to fill in the questionnaire. distribution of socio-demographic characteristics and user satisfaction indicators with the primary health care by type of settlement is shown in table 1. the largest percentage of respondents belonged to the middle age group (45.8%), finished middle education (51.0%) and rated their socioeconomic status as average (52.9%). slightly over a half of patients (54.7%) visited their chosen doctor five and more times per year, and most of them did not skip their check-ups due to financial constraints (80.1%). more than one-third of patients (37.4%) were not satisfied with the kindness of the nurses at the counter, 14.1% considered that the doctor was not familiar with their previous diseases, and 17.0% stated that the doctor did not take enough time for conversation with the patient. more than half of the respondents (55.1%) were satisfied with the primary health care, while approximately every eighth respondent was unsatisfied (12.7%). concerning type of settlement, people residing in rural area were older (45%), with low education (52.2%), and with an average socioeconomic status (53.5%), whilst urban jovanovic d, jankovic j, mirilovic n. socio-demographic inequalities in satisfaction with primary health care and utilization of chosen doctors’ services: a cross-sectional study (original research). seejph 2020, posted: 11 february 2020. doi: 10.4119/seejph-3311 p a g e 5 | 12 respondents were mainly with middle educational attainment (56.3%). around two-thirds (66.2%) of the respondents from the rural area visited their chosen doctor five or more times per year, compared to 48.5% of those in the urban area. rural patients compared with their urban counterparts had lower level of “waiting too long for check-up”, and higher levels of “nurses at the counter and at the interventions are kind”, “information provided by nurses”, “doctors being familiar with the previous diseases”, “doctor taking enough time for conversation” and “doctor providing clear explanations about the diseases and the medicines”. a general satisfaction with the primary health care was expressed by 78.8% patients from the rural area, and 42.2% from the urban area. table 1. distribution of socio-demographic characteristics and user satisfaction indicators with primary health care by type of settlement variables total (206) urban (135) rural (71) p* n % n % n % age categories 20 – 39 40 – 64 65+ 46 94 66 22.0 45.8 32.2 37 64 34 27.4 47.4 25.2 9 30 32 12.7 42.3 45.0 0.005 sex male female 93 113 45.1 54.9 62 73 45.9 54.1 31 40 43.7 56.3 0.756 education high middle low 33 105 68 16.0 51.0 33.0 28 76 31 20.7 56.3 23.0 5 29 37 7.0 40.8 52.2 <0.001 socioeconomic status of the household good average poor 70 109 27 34.0 52.9 13.1 46 71 18 34.1 52.6 13.3 24 38 9 33.8 53.5 12.7 0.988 number of visits to a chosen doctor per year < 5 ≥ 5 92 111 45.3 54.7 68 64 51.5 48.5 24 47 33.8 66.2 0.016 skipped check-ups due to financial constraints yes no 41 165 19.9 80.1 31 104 23.0 77.0 10 61 14.1 85.9 0.313 wait too long for check-up yes no 110 96 53.4 46.6 85 50 63.0 37.0 25 46 35.2 64.8 <0.001 nurses at the counter are kind yes partly no 83 46 77 40.3 22.3 37.4 50 30 55 37.0 22.2 40.8 51 16 4 71.9 22.5 5.6 <0.001 nurses at the interventions are kind yes partly 92 58 44.9 28.3 55 44 41.0 32.9 54 14 76.1 19.7 <0.001 jovanovic d, jankovic j, mirilovic n. socio-demographic inequalities in satisfaction with primary health care and utilization of chosen doctors’ services: a cross-sectional study (original research). seejph 2020, posted: 11 february 2020. doi: 10.4119/seejph-3311 p a g e 6 | 12 no 55 26.8 35 26.1 3 4.2 nurses offer all information yes partly no 84 55 66 41.0 26.8 32.2 49 40 45 36.6 29.9 33.6 49 15 7 69.0 21.1 9.9 <0.001 doctor is familiar with the previous diseases yes partly no 125 52 29 60.7 25.2 14.1 73 40 22 54.1 29.6 16.3 52 12 7 73.2 16.9 9.9 0.028 doctor takes enough time for conversation yes partly no 102 69 35 49.5 33.5 17.0 52 53 30 38.5 39.3 22.2 50 16 5 70.4 22.6 7.0 <0.001 doctor gives clear explanations about the diseases and the medicines yes partly no 109 60 37 52.9 29.1 18.0 58 47 30 43.0 34.8 22.2 51 13 7 71.8 18.3 9.9 <0.001 customer satisfaction with the primary health care satisfied partly satisfied unsatisfied 113 66 26 55.1 32.2 12.7 57 55 23 42.2 40.8 17.0 56 12 3 78.8 16.9 4.2 <0.001 * χ2 test. the distribution of user satisfaction with the primary health care and visits to the chosen doctor per year by socio-demographic variables is shown in table 2. the oldest users were the most satisfied ones (65.2%), compared to the middle-aged (57.5%) and the youngest (34.1%). in the rural type of settlement, patients were more satisfied (78.8%) compared to those from the urban area (42.2%). there were no statistically significant differences in user satisfaction according to education and socioeconomic status of respondents. regarding visits to the chosen doctor, respondents with low education (83.2%), the poorest (88.5%), the elderly (78.5%) and those from the rural area (66.2%) visited their doctor more frequently, that is five and more times in the year preceding the survey. jovanovic d, jankovic j, mirilovic n. socio-demographic inequalities in satisfaction with primary health care and utilization of chosen doctors’ services: a cross-sectional study (original research). seejph 2020, posted: 11 february 2020. doi: 10.4119/seejph-3311 p a g e 7 | 12 table 2. distribution of user satisfaction with primary health care and visits to the chosen doctor per year by socio-demographic variables variables level of satisfaction number of visits to the chosen doctor (per year) unsatisfied partly satisfied satisfied p* < 5 ≥ 5 p* n (%) n (%) n (%) n (%) n (%) age categories 20 – 39 40 – 64 65+ 7 (14.9) 10 (10.7) 9 (13.6) 24 (51.1) 30 (31.9) 14 (21.2) 16 (34.1) 54 (57.5) 43 (65.2) 0.015 36 (78.3) 43 (46.2) 14 (21.5) 10 (21.7) 50 (53.8) 51 (78.5) <0.001 sex male female 15 (16.2) 11 ( 9.6) 31 (33.3) 36 (32.5) 47 (50.6) 66 (57.9) 0.323 45 (48.9) 48 (42.9) 47 (51.1) 64 (57.1) 0.349 type of settlement urban rural 23 (17.0) 3 (4.2) 55 (40.8) 12 (16.9) 57 (42.2) 56 (78.8) <0.001 69 (51.9) 24 (33.8) 64 (48.1) 47 (66.2) 0.016 education high middle low 5 (15.2) 11 (10.4) 10 (14.7) 11 (33.3) 42 (39.6) 15 (22.1) 17 (51.6) 53 (50.0) 43 (63.3) 0.218 22 (66.7) 60 (58.3) 11 (16.2) 11 (33.3) 43 (41.7) 57 (83.2) <0.001 socioeconomic status of the household good average poor 6 (8.4) 16 (14.7) 4 (14.80) 19 (26.8) 37 (33.9) 12 (44.4) 46 (64.8) 56 (51.4) 11 (40.70) 0.175 46 (64.8) 44 (41.1) 3 (11.5) 25 (35.2) 63 (58.9) 23 (88.5) <0.001 * χ2 test. the results of the bivariate and multivariate logistical regression analyses related to the correlation between socio-demographic variables and visits to the chosen doctor per year are shown in table 3. the oldest respondents visited their doctor seven times more (or = 7.03), while those in the age group between 40 and 64 years did it about three times more (or = 2.66) than the youngest ones. the respondents with a low education had four times more visits to the doctor per year (or = 4.14) compared to those with high education, while patients with poor self-assessed socioeconomic status of the household used their doctors' services almost nine times more (or = 8.66) than those with a good socioeconomic status. the results of the bivariate and multivariate linear regression analyses related to the correlation between user satisfaction with primary health care and sociodemographic characteristics are presented in table 4. the respondents from the rural area were more satisfied with primary health care (p<0.001), as well as those with the poor socioeconomic status of the household (p=0.014). jovanovic d, jankovic j, mirilovic n. socio-demographic inequalities in satisfaction with primary health care and utilization of chosen doctors’ services: a cross-sectional study (original research). seejph 2020, posted: 11 february 2020. doi: 10.4119/seejph-3311 p a g e 8 | 12 table 3. odds-ratios (ors) and 95% confidence intervals (cis) for the number of visits to the chosen doctor per year by socio-demographic characteristics variables n % or (95% ci) blr mlr age categories 20 – 39 40 – 64 65+ 45 93 65 22.2 45.8 32.0 1.00 4.07 (1.81-9.17) 12.75 (5.09-31.95) 1.00 2.66 (1.11-6.36) 7.03 (2.56-19.34) sex male female 92 111 45.3 54.7 1.00 1.30 (0.75-2.27) 1.00 1.33 (0.68-2.59) type of settlement urban rural 132 71 65.0 35.0 1.00 2.08 (1.14-3.79) 1.00 1.27 (0.61-2.66) education high middle low 33 102 68 16.3 50.2 33.5 1.00 1.46 (0.64-3.32) 10.36 (3.93-27.33) 1.00 1.22 (0.48-3.07) 4.14 (1.36-12.61) socioeconomic status of the household good average poor 70 107 26 34.5 52.7 12.8 1.00 2.58 (1.38-4.80) 13.80 (3.77-50.57) 1.00 2.27 (1.10-4.67) 8.66 (2.06-36.37) blr – bivariate logistic regression; mlr – multivariate logistic regression; referent category – number of visits to the chosen doctor (up to 5 per year). table 4. the relationship between the level of user satisfaction with primary health care and sociodemographic characteristics – results of linear regression analyses variables bivariate multivariate b*(p) b*(p) age 0.150 (0.025) 0.107 (0.111) sex 0.143 (0.150) 0.146 (0.114) type of settlement 0.495 (<0.001) 0.458 (<0.001) education 0.065 (0.368) -0.011 (0.889) socioeconomic status of the household -0.169 (0.025) -0.185 (0.014) *unstandardized regression coefficient referent category – unsatisfied with primary health care. jovanovic d, jankovic j, mirilovic n. socio-demographic inequalities in satisfaction with primary health care and utilization of chosen doctors’ services: a cross-sectional study (original research). seejph 2020, posted: 11 february 2020. doi: 10.4119/seejph-3311 p a g e 9 | 12 discussion socio-demographic inequalities in the utilization of chosen doctors’ services our results showed significant inequalities in the utilization of chosen doctors’ services. respondents aged 65 and over visited their doctor seven times, while middle-aged patients (40-64 years) did it three times more frequently than the youngest (20-39 years), which may be explained by the increased needs of the elderly for health services within the natural process of aging and its biological manifestations. more frequent visits to gps by older patients have been linked to their rather poor health, as shown by a systematic review of european studies from uk, sweden, germany, denmark, italy, and slovenia (20). the authors concluded that the main reason that older people are more likely to use phc services is their real need for medical treatment. respondents with a low level of education in this study were four times more likely to visit their physician than those with university degree, which is in line with the results of the 2013 serbian health survey (15) showing that 71.9% people (aged 14 years and more) with the lowest educational attainment visited a gp general practitioner or pediatrician in the year preceding the survey. our finding is also in accordance with the studies conducted in sweden (21) and denmark (22) which showed a significant negative correlation between the level of education and the number of visits to the gp, indicating that a higher level of education was associated with fewer visits to phc. research by chinese authors (23) showed that lower level of education as well as poorer socioeconomic status also implied lower health literacy rate, which might explain the more frequent visits of this population to the chosen doctor. namely, due to low health literacy, the population does not distinguish serious from ordinary health problems, and minor health problems are often the reason why they go to the doctor. conversely, more educated respondents have more capacity (cognitive, communicative), they are better informed and make more effective decisions for their health, reflecting their high health literacy rate (24). accordingly, they visit a doctor less frequently. the poor, and thus the low-educated, in serbia had a significantly higher prevalence of chronic diseases than the rich (7). this implies their greater health care needs, and might explain the more frequent utilization of the chosen doctors’ services in our study. the results of this study also showed that people with poor financial status of the household visited their doctor almost nine times more per year (or = 8.66) compared to better-off. this result is in contrast to the 2006 serbian health survey and study by janković et al. (7), according to which gps were less frequently visited by poor people and those with lower educational attainment (7,25), but in agreement with the last national health survey conducted in 2013, in which the least educated and the poorest population had the highest percentage of visits to the gp (15). the use of gps services in bosnia and herzegovina was much lower for the uninsured, who are most often unemployed and most likely to be poorer, than for the insured (26). also, in montenegro, access to phc health services is lower for people with lower household incomes and mainly for roma population (27). the prevalence of chronic diseases is higher among the poor population in serbia and they also have a high risk of infectious diseases, lower life expectancy at birth, high prevalence of smoking, alcohol and drugs, as well as a higher incidence of mental health problems (5,28). more health problems imply greater need for health care, which is the reason why the poor in our study used more frequently the services of their chosen doctor. this practice is in line with the health insurance law that made phc more accessible to certain groups in the republic of serbia (29), that is, socially disadvantaged groups are exempted from paying official out-of-pocket payments (30). in this way, phc has become more economically accessible to them, which is confirmed by the greater number of their visits to the chosen physician. socio-demographic inequalities in user satisfaction with phc the results of our study regarding the association of socio-demographic variables with user satisfaction showed a significantly higher degree of satisfaction with phc in rural areas (p<0.001) and among respondents who self-assessed their socioeconomic status as poor (p=0.014). regarding type of settlement our findings are in accordance with 2013 serbian health survey (15) where the most satisfied people with state health services were those from rural areas. higher satisfaction with the phc as a whole among respondents who live in rural area could be explained by their better scoring in the items (indicators) of partial satisfaction (such as waiting time and doctorpatient interaction), but also by their lower health expectations related to the fact that the population with a low level of education and, consequently, poorer health literacy lives in the rural area. often, these individuals do not recognize or minimize their health jovanovic d, jankovic j, mirilovic n. socio-demographic inequalities in satisfaction with primary health care and utilization of chosen doctors’ services: a cross-sectional study (original research). seejph 2020, posted: 11 february 2020. doi: 10.4119/seejph-3311 p a g e 10 | 12 problems because they are not sufficiently aware of their own health needs. also, there is a lack of knowledge about patients’ rights, as well as obligations in the health care system (31). for this reason, they are satisfied with basic health services such as medical check-up and/or prescribing medicines while preventive services such as influenza vaccination or screening for early detection of colon cancer made them more than satisfied. if we take into account that there are exempt from official payments on the basis of legal regulations (29), their satisfaction becomes easy to explain, even rational. a study of user satisfaction conducted in croatia (10) showed results opposite to ours, that is, respondents in rural settlements were less satisfied with phc compared to those in urban and suburban settlements. the reasons for this were non-respect of working hours by healthcare professionals and dissatisfaction with the manner in which patients' confidential information was stored. a cross-sectional study from germany (32) also showed that respondents from rural areas were less satisfied with phc and the reason was lower accessibility of phc to them. the higher level of satisfaction with the phc among people with poor socioeconomic status of the household, recorded in our paper, was also found in a study conducted in spain (33). a possible explanation might be high expectations of wealthier users, whose unmet health needs lead to dissatisfaction. on contrary, the results of the study by vojvodić et al. (34) showed that people with estimated good socioeconomic status were significantly more satisfied with phc (84.9%), and this is probably due to their general satisfaction with socio-economic status and life. study limitations this research has some limitations. a methodological weakness of this study is a relatively small sample size which made the study results difficult to generalize for all outpatient service consumers. also, some study participants were not willing to respond. age, gender and socioeconomic differences of eligible patients refusing participation were not documented consistently and we have not all data for few nonrespondents. yet, given the low non-response-rate of about 11%, it is very unlikely that study participants are a strongly biased sample. also, the cross-sectional study design does not allow us to establish causal relationships among variables. we measured users’ utilization of chosen doctors’ services and satisfaction with phc during a single visit, and so were unable to examine outcomes longitudinally. one of the limitations is patient subjectivity in response ,which is not avoidable and is present in all similar studies. conclusion taking into consideration all limitations, this study showed the presence of inequalities in the utilization of chosen doctors’ services as well as in the satisfaction with phc. the chosen doctor was more frequently visited by respondents with low education and those with poor socioeconomic status of the household, while a higher degree of satisfaction with phc was recorded in the rural population as well as in those with poor socioeconomic status of the household. more research on larger samples is needed. references 1. marmot m. social determinants of health inequalities. lancet 2005;365:1099-104. 2. acheson d. independent inquiry into inequalities in health: report. hm stationery office; 1998. 3. sigriest j. social variations in health expectancy in europe. in: an esf scientific programme 1999–2003. 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___________________________________________________________ © 2020 jovanovic et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://doiserbia.nb.rs/phd/fulltext/bg20121226jankovic.pdf http://doiserbia.nb.rs/phd/fulltext/bg20121226jankovic.pdf http://doiserbia.nb.rs/phd/fulltext/bg20121226jankovic.pdf https://www.ncbi.nlm.nih.gov/pubmed/29262798 https://www.ncbi.nlm.nih.gov/pubmed/25748498 relative income and acute coronary syndrome: a population-based case-control study in tirana, albania kurti v, hafizi h, kurti b, marku f, mema d, burazeri g. sex-differences in socioeconomic status and healthseeking behaviour among tuberculosis patients in transitional albania in 2012-2013 (original research). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-30 1 original research sex-differences in socioeconomic status and health-seeking behaviour among tuberculosis patients in transitional albania in 2012-2013 vera kurti 1 , hasan hafizi 2 , bardhyl kurti 3 , fitim marku 3 , donika mema 2 , genc burazeri 2,4 1 primary health care centre “dispensary for chest diseases”, tirana, albania; 2 university of medicine, tirana, albania; 3 university hospital of trauma, tirana, albania; 4 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, the netherlands. corresponding author: dr. vera kurti address: rr. “reshit petrela”, lgj. no. 4, tirana, albania; telephone: +355672088785; e-mail: verakurti68@yahoo.com kurti v, hafizi h, kurti b, marku f, mema d, burazeri g. sex-differences in socioeconomic status and healthseeking behaviour among tuberculosis patients in transitional albania in 2012-2013 (original research). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-30 2 abstract aim: there is little scientific evidence about the main determinants of sex discrepancies in tuberculosis rates in albania. the aim of this study was to assess the sex-differences in socioeconomic characteristics, knowledge and attitudes about tuberculosis and access to health care among tuberculosis patients in albania, a transitional country in the western balkans. methods: our analysis involved all the new cases of pulmonary tuberculosis diagnosed in albania during the period june 2012 – june 2013 (n=197; 69% males; overall mean age: 44±19 years). the recording and reporting system of tuberculosis cases was performed according to the who and eurotb surveillance guidelines. information on socioeconomic characteristics of the patients, knowledge and attitudes about tuberculosis and access to health care was also collected. logistic regression was used to assess the correlates of sexdifferences among tuberculosis patients. results: in multivariable-adjusted models, female sex was positively related to unemployment (or=3.7, 95%ci=1.8-7.7), bad living conditions (or=3.0, 95%ci=1.4-6.5), a longer distance to health care facility (or=3.0, 95%ci=1.4-6.3), a lower level of knowledge about tuberculosis (or=3.1, 95%ci=1.3-7.1) and a higher level of stigma against tuberculosis (or=3.6, 95%ci=1.6-7.9). conclusion: our study informs about selected correlates of sex-differences in tuberculosis rates in post-communist albania. future studies should more vigorously explore determinants of sex-differences in tuberculosis rates in countries of the western balkans. keywords: access to health care, albania, case detection rate, health seeking behaviour, pulmonary tuberculosis, sex-differences, socioeconomic characteristics. conflicts of interest: none. kurti v, hafizi h, kurti b, marku f, mema d, burazeri g. sex-differences in socioeconomic status and healthseeking behaviour among tuberculosis patients in transitional albania in 2012-2013 (original research). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-30 3 introduction to date, the information about determinants of sex-differences in tuberculosis occurrence is scant (1,2), notwithstanding the available evidence suggesting that, at a global level, tuberculosis affects men more frequently than women (3). in any case, tuberculosis remains a crucial public health issue at a global scale which, regardless of sex, affects mostly the disadvantaged young population subgroups (4,5). hence, only for the year 2012, there were reported 8.6 million new tuberculosis cases and 1.3 million tuberculosis deaths (6). for the european region, the tuberculosis case notification rate in 2012 was substantially higher than the global average notification rates (7). however, the relatively higher casenotification rate in the european region on the whole does not necessarily apply for the former communist countries of the western balkans including albania and kosovo. among all countries of the western balkans, kosovo exhibits the highest incidence rate of tuberculosis (8,9). it should be noted that in both albania and kosovo, the tuberculosis notification rates resemble the respective incidence rates (8,9). furthermore, both albania and kosovo have a low prevalence of hiv infection (8,9). however, the information about the sex-differences of tuberculosis rates in albania is scarce. after the breakdown of the communist regime in 1990, albania undertook a difficult journey from a rigid communist regime towards an open society (10,11). nevertheless, the transition towards a democratic regime was associated with considerable socio-economic changes coupled with huge internal and external migration (12), which are believed to affect also the case-notification rates of tuberculosis. yet, there are no recent scientific reports informing about the magnitude and determinants of tuberculosis in albania. in this context, the aim of our study was to assess the sex-differences in socioeconomic characteristics, knowledge and attitudes about tuberculosis and access to health care among male and female tuberculosis patients in albania, a transitional country in the western balkans with a low prevalence of hiv/aids. methods design and study population a cross-sectional study was conducted including all new pulmonary tuberculosis patients diagnosed in albania from june 2012 to june 2013. during this time period, overall, there were recorded 197 new tuberculosis patients in albania (69% males and 31% females; overall mean age: 43.84±19.2 years). data collection all the recorded tuberculosis data from registers of the tuberculosis program in albania were used for this analysis. the recording and reporting system was performed according to the who and eurotb surveillance guidelines (13). all tuberculosis patients underwent a structured interview inquiring about factors related to access to health care, health seeking behavior and demographic and socioeconomic characteristics. information about access to health care and health seeking behaviour included data on the distance to health care facility (dichotomized into: ≤10 km vs. >10 km), knowledge about tuberculosis (dichotomized into: yes vs. no) and stigma against tuberculosis (yes vs. no). demographic and socioeconomic characteristics included age (dichotomized into: ≤45 vs. >45 years), gender (males vs. females), place of residence (urban areas vs. rural areas), employment status (dichotomized into: unemployed vs. employed/students/retired), educational attainment (dichotomized into: 0-8 years of formal schooling, vs. ≥9 years of formal schooling) and living conditions (dichotomized into: good/average vs. bad). kurti v, hafizi h, kurti b, marku f, mema d, burazeri g. sex-differences in socioeconomic status and healthseeking behaviour among tuberculosis patients in transitional albania in 2012-2013 (original research). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-30 4 statistical analysis chi-square test was used to compare the distribution of socioeconomic characteristics, knowledge and attitudes about tuberculosis and access to health care among male and female tuberculosis patients. binary logistic regression was used to assess sex-differences in socioeconomic characteristics, knowledge and attitudes about tuberculosis and access to health care among tuberculosis patients. initially, crude (unadjusted) odds ratios (ors), their respective 95% confidence intervals (95%cis) and p-values were calculated. subsequently, multivariable-adjusted ors, their respective 95%cis and p-values were calculated. hosmer-lemeshow test was used to assess the goodness of fit of the logistic regression models. in all cases, a p-value of ≤0.05 was considered statistically significant. statistical package for social sciences (spss, version 15.0) was used for all the statistical analysis. results table 1 presents the distribution of socioeconomic characteristics, knowledge and attitudes about tuberculosis and access to health care among tuberculosis patients in albania by sex. males were somehow younger than females, a finding which was not statistically significant (p=0.09). there was no sex-difference in the proportions of urban/rural residents. conversely, the unemployment rate was considerably higher among females (59% vs. 29% in males, p<0.001). similarly, the proportion of low-educated (0-8 years of formal schooling) and individuals with bad living conditions was higher among females than in males (77% vs. 60%, p=0.02 and 46% vs. 24%, p=0.02, respectively). a significantly higher proportion of females reported a longer distance to health care facility (>10 km) compared with their male counterparts (64% vs. 40%, respectively, p=0.002). the knowledge about tuberculosis was lower among females (66% vs. 81% in males, p=0.03), whereas the level of stigma against tuberculosis was considerably higher (71% vs. 49%, respectively, p=0.008) [table 1]. table 1. distribution of socioeconomic characteristics, knowledge and attitudes about tuberculosis, and access to health care among tuberculosis patients in albania by sex variable females (n=61) males (n=136) p † age: ≤45 years >45 years 27 (44.3) * 34 (55.7) 79 (58.1) 57 (41.9) 0.089 place of residence: urban areas rural areas 24 (39.3) 37 (60.7) 64 (47.1) 72 (52.9) 0.354 employment status: unemployed employed/students/retired 36 (59.0) 25 (41.0) 40 (29.4) 96 (70.6) <0.001 educational level: 0-8 years ≥9 years 47 (77.0) 14 (23.0) 81 (59.6) 55 (40.4) 0.023 living conditions: good/average bad 33 (54.1) 28 (45.9) 104 (76.5) 32 (23.5) 0.002 distance to health facility: ≤10 km >10 km 22 (36.1) 39 (63.9) 82 (60.3) 54 (39.7) 0.002 tuberculosis knowledge: kurti v, hafizi h, kurti b, marku f, mema d, burazeri g. sex-differences in socioeconomic status and healthseeking behaviour among tuberculosis patients in transitional albania in 2012-2013 (original research). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-30 5 yes no 40 (65.6) 21 (34.4) 110 (80.9) 26 (19.1) 0.029 stigma: no yes 18 (29.5) 43 (70.5) 69 (50.7) 67 (49.3) 0.008 * absolute numbers and their respective column percentages (in parentheses). † p-values from the chi-square test. in crude (unadjusted) logistic regression models, there was no significant sex-difference in the age or place of residence of tuberculosis patients (table 2). on the other hand, female gender was positively and significantly associated with unemployment (or=3.5, 95%ci=1.8-6.5), a lower educational attainment (or=2.3, 95%ci=1.2-4.5), bad living conditions (or=2.8, 95%ci=1.5-5.2), a longer distance to health care facility (or=2.7, 95%ci=1.4-5.0), a lower level of knowledge about tuberculosis (or=2.2, 95%ci=1.1-4.4) and a higher level of stigma against tuberculosis (or=2.5, 95%ci=1.3-4.7) [table 2]. table 2. sex-differences in socioeconomic characteristics, knowledge and attitudes about tuberculosis, and access to health care among tuberculosis patients in albania; crude/unadjusted odds ratios from binary logistic regression variable or * 95%ci * p * age: ≤45 years >45 years 1.00 1.75 reference 0.95-3.21 0.073 place of residence: urban areas rural areas 1.00 1.37 reference 0.74-2.53 0.315 employment status: employed/students/retired unemployed 1.00 3.46 reference 1.84-6.45 <0.001 educational level: ≥9 years 0-8 years 1.00 2.28 reference 1.15-4.54 0.019 living conditions: good/average bad 1.00 2.76 reference 1.45-5.23 0.002 distance to health facility: ≤10 km >10 km 1.00 2.69 reference 1.44-5.03 0.002 tuberculosis knowledge: yes no 1.00 2.22 reference 1.13-4.38 0.021 stigma: no yes 1.00 2.46 reference 1.29-4.69 0.006 * crude/unadjusted odds ratios (or: female vs. male), 95% confidence intervals (95%ci) and p-values from binary logistic regression. upon simultaneous adjustment for all covariates (table 3), female sex was positively related to unemployment (or=3.7, 95%ci=1.8-7.7), bad living conditions (or=3.0, 95%ci=1.46.5), a longer distance to health care facility (or=3.0, 95%ci=1.4-6.3), a lower level of kurti v, hafizi h, kurti b, marku f, mema d, burazeri g. sex-differences in socioeconomic status and healthseeking behaviour among tuberculosis patients in transitional albania in 2012-2013 (original research). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-30 6 knowledge about tuberculosis (or=3.1, 95%ci=1.3-7.1) and a higher level of stigma against tuberculosis (or=3.6, 95%ci=1.6-7.9). table 3. sex-differences in socioeconomic characteristics, knowledge and attitudes about tuberculosis, and access to health care among tuberculosis patients in albania; multivariableadjusted odds ratios from binary logistic regression variable or * 95%ci * p * age: ≤45 years >45 years 1.00 1.87 reference 0.88-3.98 0.102 place of residence: urban areas rural areas 1.00 1.19 reference 0.57-2.50 0.645 employment status: employed/students/retired unemployed 1.00 3.68 reference 1.78-7.65 0.001 educational level: ≥9 years 0-8 years 1.00 1.64 reference 0.73-3.65 0.230 living conditions: good/average bad 1.00 2.97 reference 1.36-6.48 0.006 distance to health facility: ≤10 km >10 km 1.00 3.00 reference 1.42-6.34 0.004 tuberculosis knowledge: yes no 1.00 3.06 reference 1.33-7.08 0.009 stigma: no yes 1.00 3.57 reference 1.62-7.88 0.002 * multivariable-adjusted odds ratios (or: female vs. male), 95% confidence intervals (95%ci) and pvalues from binary logistic regression. discussion main findings of our study include a strong positive association of female gender with a lower socioeconomic status among tuberculosis patients diagnosed in albania during mid-2012 to mid-2013. in particular, unemployment and poor living conditions were considerably more prevalent among female patients with tuberculosis compared with their male counterparts. furthermore, a lower access to health care and scarce personal resources for a proper and effective health seeking behaviour were substantially more prevalent among female tuberculosis patients. the finding of a positive association of female sex with a lower socioeconomic status, a lower access to health care and a poor health seeking behaviour may point to a lower degree of case notification rate among females compared to males in albania. indeed, our finding pointing to a higher case notification rate of tuberculosis among males compared with the females is generally in line with the abundant global evidence on this matter (3-7). nonetheless, despite the current evidence obtained in various countries and regions, it is not clear whether these sex-differences reflect a distinctive tuberculosis epidemiology (14), or an under-notification kurti v, hafizi h, kurti b, marku f, mema d, burazeri g. sex-differences in socioeconomic status and healthseeking behaviour among tuberculosis patients in transitional albania in 2012-2013 (original research). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-30 7 driven by socio-cultural characteristics and/or access to health care services or health seeking behavior (15,16). regardless of sex, it has been shown that there is a high possibility of under-notification of tuberculosis cases in low-and-middle income countries due to their limited resources coupled with a weak tuberculosis surveillance system (17,18). in this context, the under-notification may affect mostly females, which are assumed to be more vulnerable in terms of their socioeconomic conditions and health seeking behaviour. thus, biological explanations aside, it has been argued that there is a link between female under-notification rates in the context of specific cultural factors which play an important role in developing and transitional societies (19), such as the case of albania and perhaps other former communist countries in the western balkans. in any case, given the lack of sufficient information, the world health organization stimulates further vigorous research related to determinants of sex-differences in case notification rates of tuberculosis (2). on the other hand, in our study, there was no evidence of sex-differences with regard to the place of residence (urban areas vs. rural areas) of tuberculosis patients. our analysis may have several limitations. notwithstanding the fact that we included all new patients with tuberculosis diagnosed during the period june 2012 – june 2013, the possibility of under-recording of tuberculosis cases may affect differentially males and females in albania. furthermore, it is reasonable to assume a differential recording of new cases based on the demographic and socioeconomic profiles of the patients with tuberculosis. also, measurement of socioeconomic characteristics and health seeking behaviour – which was based on interview – may have affected, to some degree, our findings. therefore, future studies in albania should more vigorously assess determinants of sex-differences in tuberculosis rates in the overall population. in conclusion, our study provides useful evidence about selected correlates of sex-differences among tuberculosis patients in albania. health care providers, policymakers and decisionmakers in albania should be aware of the current sex-differences in socioeconomic characteristics, access to health care and health seeking behaviour among tuberculosis patients in this post-communist society. future studies in albania and other transitional countries of the western balkans should further explore the main determinants of sex-differences in tuberculosis rates. references 1. weiss mg, sommerfeld j, uplekar mw. social and cultural dimensions of gender and tuberculosis. int j tuberc lung dis 2008;12:829-30. 2. uplekar m, rangan s, ogden j. gender and tuberculosis control: towards a strategy for research and action, who/tb/2000.280. geneva: world health organization, 1999. 3. world health organization (regional office for europe) and the european centre for disease prevention and control. tuberculosis surveillance and monitoring in europe 2014. http://www.ecdc.europa.eu/en/publications/publications/tuberculosissurveillance-monitoring-europe-2014.pdf (accessed: august: 25, 2014). 4. world health organization. global tuberculosis report 2012. geneva: world health organization, 2012. 5. glaziou p, falzon d, floyd k, raviglione m. global epidemiology of tuberculosis. semin respir crit care med 2013;34:3-16. 6. world health organization (who). global tuberculosis report 2012. who press, world health organization. geneva: switzerland, 2013. kurti v, hafizi h, kurti b, marku f, mema d, burazeri g. sex-differences in socioeconomic status and healthseeking behaviour among tuberculosis patients in transitional albania in 2012-2013 (original research). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-30 8 7. european centre for disease prevention and control and the world health organization, regional office for europe. tuberculosis surveillance and monitoring in europe, 2012. 8. kosovar aids committee. kosovar strategy for hiv/aids prevention 2004-2008. pristina: kosovo, 2009. 9. kurhasani x, hafizi h, toci e, burazeri g. tuberculosis incidence and case notification rates in kosovo and the balkans in 2012: cross-country comparison. mater sociomed 2014;26:55-8. 10. rechel b, mckee m. healing the crisis: a prescription for public health action in south eastern europe. new york, usa: open society institute press, 2003. 11. nuri b, tragakes e. health care systems in transition: albania. copenhagen: european observatory on health care systems, 2002. 12. burazeri g, goda a, tavanxhi n, sulo g, stefa j, kark jd.the health effects of emigration on those who remain at home. int j epidemiol. 2007;36:1265-72. 13. veen j, raviglione m, rieder hl, et al. standardized tuberculosis treatment outcome monitoring in europe. recommendations of a working group of the world health organization (who) and the european region of the international union against tuberculosis and lung disease (iuatld) for uniform reporting by cohort analysis of treatment outcome in tuberculosis patients. eur respir j 1998;12:505-10. 14. borgdorff mw, nagaldkerke nj, dye c, et al. gender and tuberculosis: a comparison of prevalence surveys with notification data to explore gender differences in case detection. int j tuberc lung dis 2000;4:123-32. 15. hudelson p. gender differentials in tuberculosis: the role of socio-economic and cultural factors. tubercle lung dis 1996;77:391-400. 16. weiss m, auer c, somma d, abouihia a. gender and tuberculosis: cross-site analysis and implications of a multi-country study in bangladesh, india, malawi and columbia. tdr/sdr/seb/rp/06.1. geneva, switzerland: who, 2006. 17. thorson a, hoa np, long nh, allebeck p, diwan vk. do women with tuberculosis have a lower likelihood of getting diagnosed? prevalence and case detection of sputum smear positive pulmonary tb, a population-based study from vietnam. j clin epidemiol 2004;57:398-402. 18. long nh, johansson e, lönnroth k, eriksson b, winkvist a, diwan vk. longer delays in tuberculosis diagnosis among women in vietnam. int j tuberc lung dis 1999;3:388-93. 19. johansson e, long nh, diwan vk, winkvist a. gender and tuberculosis control: perspectives on health seeking behaviour among men and women in vietnam. health policy 2000;52:33-51. ___________________________________________________________ © 2014 kurti et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed?term=kurhasani%20x%5bauthor%5d&cauthor=true&cauthor_uid=24757405 http://www.ncbi.nlm.nih.gov/pubmed?term=hafizi%20h%5bauthor%5d&cauthor=true&cauthor_uid=24757405 http://www.ncbi.nlm.nih.gov/pubmed?term=toci%20e%5bauthor%5d&cauthor=true&cauthor_uid=24757405 http://www.ncbi.nlm.nih.gov/pubmed?term=burazeri%20g%5bauthor%5d&cauthor=true&cauthor_uid=24757405 http://www.ncbi.nlm.nih.gov/pubmed/24757405 http://www.ncbi.nlm.nih.gov/pubmed?term=burazeri%20g%5bauthor%5d&cauthor=true&cauthor_uid=17768161 http://www.ncbi.nlm.nih.gov/pubmed?term=goda%20a%5bauthor%5d&cauthor=true&cauthor_uid=17768161 http://www.ncbi.nlm.nih.gov/pubmed?term=tavanxhi%20n%5bauthor%5d&cauthor=true&cauthor_uid=17768161 http://www.ncbi.nlm.nih.gov/pubmed?term=sulo%20g%5bauthor%5d&cauthor=true&cauthor_uid=17768161 http://www.ncbi.nlm.nih.gov/pubmed?term=stefa%20j%5bauthor%5d&cauthor=true&cauthor_uid=17768161 http://www.ncbi.nlm.nih.gov/pubmed?term=kark%20jd%5bauthor%5d&cauthor=true&cauthor_uid=17768161 http://www.ncbi.nlm.nih.gov/pubmed/?term=burazeri+g%2c+international+journal+of+epidmiology centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 1 | 11 short report serbian citizens’ opinion on the covid-19 epidemic centre for international public policy, department for public opinion research ivanović marta, đorđević mirjana, klarić aleksandar ma, mikanović filip, nikolić kristina, perić tamara, savić tamara, steljić katarina, subotić lazar, todorović marko, todorovski irena, totić bojan corresponding author: aleksandar klarić ma centre for international public policy, department for public opinion research belgrade, serbia email: aklaric@cmjp.rs centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 2 | 11 summary aim: the centre for international public policy has undertaken a public opinion research in which we tested the opinions of the citizens of serbia on the coronavirus epidemic. the respondents had the opportunity to express their opinion on measures undertaken by the serbian government to combat the virus, to state their trust in the media, as well as the health system in general. in addition, we tested the prevalence of different conspiracy theories among citizens, whether the pandemic gave china a new image in the minds of the people and, most importantly, the level of solidarity among serbian citizens as well as within the european / international community as a whole. methods: in seven days, from 8-15 th april 2020, we gathered a convenient sample of n=5989 respondents, which makes this the largest public opinion research project in serbia on the topic of covid-19 since the start of the epidemic. the electronic questionnaire consisted of 24 questions of mixed and closed type. results: the findings of this research suggest that citizens of serbia are not afraid of covid-19, but are nevertheless cautious (86%). the percentage of those willing to consult a doctor when they notice any symptoms lies at 70%. half of the respondents do not believe in alternative theories regarding the origin of the covid-19 virus. the majority of the respondents (55%) hold government officials accountable for spreading panic through public speeches and daily public addresses. moreover, 60% of the respondents do not trust the serbian media outlets that are currently reporting on the covid-19 pandemic. furthermore, over half of the respondents are prepared to report their neighbour when he or she is coming from abroad and violates the obligation to self-isolate. however, mostly due to the significant fines, 65% of the respondents would not report the elderly when they are breaking the limited-movement restriction measures. conclusion: as before the epidemic, opinions of the serbian population on current topics are somewhat polarized. although the majority of the respondents are cautious, a significant number also believes in conspiracy theories and does not fully trust the information provided by the media or the government. keywords: covid-19, opinion survey, epidemic. references: 1. johns hopkins university. covid-19 dashboard by the centre for systems science and engineering (csse). baltimore: johns hopkins university; 2020. https://coronavirus.jhu.edu/map.html. 2. martin-moreno, j. m. (2020) “facing the covid-19 challenge: when the world depends on effective public health interventions”, south eastern european journal of public health (seejph). doi: 10.4119/seejph-3442. https://coronavirus.jhu.edu/map.html centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 3 | 11 1) is there a presence of fear and which prevention measures have the citizens of serbia undertaken? we were astounded by the fact that 86% of the respondents said that they are not afraid that they or their family members are susceptible to being infected by the virus. still, in times when we are witnessing the heavy toll of the consequences due to the pandemic on mental health globally, this in an encouraging sign. the question of the level of responsibility among the citizens can be answered with the following data: of the above-mentioned 86%, 79% stated that, although they are not afraid, they are taking preventive measures. further data states that: 85% of respondents wash their hands more frequently, 85% implement social distancing measures and 75% use masks and gloves. also noticeably, 2,5% of respondents said they are not taking any preventive measures. there is noticeable optimism among respondents in the following topics: 60% of the respondents do not believe that we are likely to reach the “italian scenario” of exponential growth of new cases and overloading the health system, while as many as 90% believe that the virus will be contained by the 1st of june and that life will return to normal. 2) would the citizens of serbia report on their co-citizens who do not abide by the selfisolation measures? having in mind the special movement restrictions for citizens of the age 65 or above, we were interested in how many respondents would report on their senior co-citizens who leave their home, thus potentially endangering their lives. the largest number of respondents (65%) stated that they would not report on their co-citizens but would advise them not to go out, likely because of the expensive penalties that would be incurred by the senior citizens; 20% would not 14% 86% are you concerned that you or one of your family members may get infected? concerned not concerned 44% 90% 17% 5% until may 1st until june 1st until july 1st longer how long do you believe the state of emergency will last? centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 4 | 11 report them, as it does not concern them, while 15% would. the results showcase a lack of motivation for including government institutions in solving this problem, as many respondents would rely on self-initiative. this could point to the demotivating factor of high penalties for reporting third parties’ wrongdoings. the situation greatly differs regarding the question of the neighbour returning from abroad. half of the respondents would report a returning neighbour who does not abide by the self-isolation measures. about a quarter of the respondents would not report on their neighbour, but would be more careful, while 17% would alert other neighbours. there was a considerably lower number of indifferent respondents, since only 8% stated that this matter is none of their concern. this leads to the question of why this is so and what role did government authorities play in the formation of these opinions, given their open criticism of citizens returning from working abroad (the so called “gastarbeiter”). 3) how much trust do the citizens of serbia have in the health system and the crisis staff? even with the citizens’ outpouring of solidarity towards health workers “on the front lines” of the epidemic with the symbolic applause each evening at 20h on their balconies, we still wanted to test the level of trust citizens have in the health system. on the question “if you were to feel virus symptoms, would you call the doctor or stay at home”, 70% of the respondents would call the doctor, while a significant portion (25%) would only call if the situation drastically worsens. with the constantly changing recommendations of the crisis staff on the right measures to 15% 65% 20% i would i would advise them it doesn't concern me would you report on citizens above the age of 65 who are leaving their homes, thus potentially endangering their lives? 50% 25% 17% 8% i would i would be more careful i would alert other neighbors it doesn't concern me would you report on a neighbor who arrived from abroad and doesn’t abide by the self-isolation measures? centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 5 | 11 undertake, we chose to classify these 25% among those who do not have complete faith in the health system. additionally, 5% of the respondents stated that they would stay at home. the greatest experts among the doctors have been invited to form the crisis staff and their recommendations affect the measures further adopted by the government in handling the pandemic. for 6 weeks, every day at 3 pm we sit docked in front of the tv screen, waiting to hear the latest information on the number of infected and about future measures. therefore, we were interested in which member of the crisis staff citizens of serbia trust the most. in the first place, leading with 27%, there is prof. dr. predrag kon, then dr. darija kisić tepavčević with 20%, dr. goran stevanovic with 15%, while the least trusted member is prof. dr. branimir nestorovic with 8%. however, the most common answer given, (by as many as 30% of respondents!), is that the citizens did not trust any member of the crisis staff! these results are an indicator of citizens putting members’ expertise in the background, while their appearances in the media are mostly perceived in the context of the current political climate in the country, i.e. citizens often understand them as politicized. 4) how much do the citizens of serbia trust the media and high state officials? it has been repeatedly said that “the media is adherent to the doctors,” as one side fights the infectious virus and the other unverified information and fake news. in this regard, we were interested in the degree of trust that the citizens have in the information they receive from the media. the results of the research tell us that as many as 60% of respondents do not 25% 70% 5% if you were to feel virus symptoms, would you call the doctor or stay at home? would call the doctor if the situation worsens would call the doctor would stay at home 70% 30% do you trust the members of the crisis staff? i do i do not centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 6 | 11 trust the information they receive from the media about the corona virus! among them, 25% of the respondents think the virus is more dangerous, and that the number of infected and deceased is higher than the official information states. also, there are 35% of those who believe that the virus is not so dangerous and that the whole crisis is exaggerated to divert the publics’ attention from other problems. at the top of the crisis management chain is the state management. although politicians' ratings are often measured in opinion polls, we were interested in the kind of impression that high state officials give the citizens when addressing them about the virus. exactly 55% of respondents stated that government officials and their public appearances cause them distress and panic. on the other hand, 30% of the respondents rated their behaviour as responsible and serious and 15% of them rated it as positive “they calm us down and they bring hope that everything will be all right." when comparing these results to the previous questions’, one could ask: if 55% of respondents think politicians are bringing discomfort and panic, while at the same time, 86% say they are not concerned about the virus, are the politicians losing the trust of the people? 5) how much traction have conspiracy theories gained among serbian citizens? along with the first coronavirus cases came the emergence of the first conspiracy theories. by focusing all their resources on suppressing the exponential growth of the virus, countries failed to prevent the exponential growth of conspiracy theories. there are countless conspiracy theories today, but we have singled out a few. the answers to the popular question of whether the virus was transmitted from bats to humans or 40% 35% 25% how much do you trust the information received from the media? i believe it the virus isn't so dangerous the virus is more dangerous 17% 39% 44% how was the coronavirus created? transmitted from a bat made in a laboratory i don't know centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 7 | 11 if it was made in someone's lab showed that the highest percentage of people believe that the virus was made by scientists, as much as 44% of respondents! when combined with the undecided (39%), we conclude that a large percentage (83%!) of people either completely reject or distrust the theory that the transmission of the virus occurred from an animal to a human. only 17% of respondents believe that the pandemic came from one of the wet markets containing exotic animals in wuhan. while on the topic of wuhan, in addition to being considered the world's epicentre of the covid19 virus, it was also among the first cities in china where 5g technology was deployed. it didn't take long for new conspiracy theories to emerge, as we are already hearing about how the british are destroying their lampposts. what is the situation in serbia? as much as 15% of respondents think 5g technology is harmful and that there is a correlation between it and the pandemic, while twice as many people (30%) believe that this is a mere coincidence and do not believe this theory. most of the respondents were undetermined 55%. these respondents also differ from one another, as we have 40% who are suspiciously waiting for scientific evidence to be presented, and 15% of those who have no opinion on this matter. also, among the most popular in serbia are the following alternative interpretations: everything is a plot of the pharmaceutical mafia that only wants to profit, ”they created a virus in order to sell us the vaccine” (believed by 28%), a pandemic is a front for settling migrants in europe (27%) and the us made the virus to destroy china economically (24%). the reverse theory, also present in the world, but with a lower acceptance in the serbian public 10% of the respondents considered it to be a virus made by china in order to overtake the united states in a battle for the world's largest force. overall, it is encouraging that half of the respondents said that they hold no beliefs in conspiracy theories. 6) which country do citizens of serbia believe will be the first in developing a vaccine? the fact that the “made in china” label is no longer undesirable demonstrates to what extent crises can change the world, as well as peoples’ awareness about it. this is shown by the fact that more than half of the respondents (60%) 50% 50% do you believe in conspiracy theories? i do i don't centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 8 | 11 believe that chinese scientists will be the first to develop a vaccine for covid-19. former technological giants, countries who led the world in innovations and high standards of living are now ranked below china regarding the development of a vaccine. this is demonstrated by the fact that the united states enjoys only 24% of respondents’ trust, whereas a mere 11% of respondents believe germany will develop a vaccine first. 7) how do the citizens of serbia evaluate their government’s measures and its’ management of the crisis? when it comes to the capability of the domestic industry to develop respirators, surprisingly, almost half of the respondents (49%) believe that serbia has the capacity to develop them; 29% of the respondents disagree with this statement, whereas 22% of the respondents claim that yugoslavia would have been the country capable of doing so. when asked about the 24 hour (total) lockdown as ordered by the government, serbian public opinion as measured between the 8th and 15th of march has been significantly divided: 43% of the respondents stated that they support the lockdown, considering it ''the only measure that can put us in line and create order.'' an identical percentage (43%) believes that the 24 hour lockdown is too harsh of a measure and therefore do not condone it. the rest (14%) of the respondents do not have an opinion on the matter. a financial aid package of 5,1 billion euros has ignited tremendous public attention, especially regarding an initiative to give 100 euros to every adult serbian citizen. during the presentation of the economic measures, serbian president aleksandar vučić made a remarkable statement: ''people simply cannot believe that serbia has money''. with this remark in mind, we decided to pose the question to the public in this way: "do you believe that serbia has the money to overcome the crisis?’’ opinions were divided: 48% of the respondents agree that the money will be provided, but also believe that pursuing this policy will have negative long-term consequences; 35% of the respondents believe that serbia does not have enough money for such an endeavour, whereas 17% of them claim that, because of its responsible fiscal and monetary policy, serbia does have enough resources to overcome this crisis. centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 9 | 11 “only unity saves the serbs”, which is a famous and widely-used proverb in serbia, has had to share its’ symbolic and moral importance with another phrase that has gained almost the same weight over the course of the past 20 years – namely the saying that “there has never been a greater solidarity than during the (nato) bombing”. this made us wonder whether this pandemic and its’ ever-growing economic impact have had enough of an effect on the population as to re-awaken that reputable serbian unity. it appears that enthusiasm has been somewhat lost: 60% of the respondents are of the opinion that solidarity is somewhat higher than usual. however, the ends of the spectrum provide a more compelling analysis with only 10% of the respondents claiming that solidarity is at an all-time-high (like during the 1999 bombing), whereas 30% of them claim that people are more selfish than ever, as demonstrated by increased panic buying and the stockpiling of groceries. 8) how do the citizens of serbia evaluate other crisis management models (usa, eu, sweden)? although the evaluation of domestic solidarity was not very positive, it's surprising to see that 85% of the respondents believe that global issues such as a pandemic are most efficiently resolved through international cooperation. meanwhile, only 15% of the respondents believe that it is in every country's best interest to rely on its’ own capacities. the results show a growing awareness among the public of the necessity of a global approach when dealing with global issues. solidarity and cooperation between countries up until recently served as synonyms for the european union. how does this stand today? the results show that only 10% of the respondents believe that the eu is aiding the countries struck by the virus in every way it can. however, a large percentage of respondents (45%) believe that the response of the eu to this crisis was inadequate, stating that it left italy and spain stranded to their own devices. there is a 17% 35% 48% do you believe serbia has enough money to implement the economic stimulus package? yes no yes, but there will be negative consequences centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 10 | 11 surprisingly high percentage of respondents (45%) who do not have an opinion on the matter. such results imply a possible tendency of declining trust in eu institutions in serbia after the crisis. the research results have shown that there is little interest in the different models of crisis management, since 35% of the respondents have no opinion on president trump's plan regarding the pandemic and 60% do not have a clear opinion regarding the so-called swedish model, even though sweden is unique among european countries in its’ approach to the crisis. only 10% of the respondents support the swedish model, stating that it is adequate. when it comes to the us, almost half of the respondents consider saving human lives more important than president trump’s quest of salvaging the economy; 15% of the respondents condone the latter, considering his worry about the economy justified. in the end, the respondents were asked to pick the two, in their opinion, most important consequences of isolation and social distancing. more than half of (60%) believe a temporary economic halt and the arrival of a new economic crisis to be the main negative consequence. the positive consequences of the crisis, according to the respondents, would be the recovery of nature, as well as a decrease in climate change and air pollution. 10% 45% 45% do you believe the eu reaction was adequate? yes, the eu is sending help no, the eu left italy and spain on their own i don't have an opinion centre for international public policy, serbian citizens’ opinion on the covid-19 epidemic. seejph 2020, posted: 16 may 2020. doi : 10.4119/seejph-3459 p a g e 11 | 11 discussion the goal of the centre for international public policy when conducting this online research was to enable citizens to indirectly state their opinion on current issues, which have proven themselves to be existentially important to them in these uncommon circumstances. we also wanted to provide a better insight for the public and for the media into the citizens’ personal positions regarding the current state of affairs, as well as their expectations for the time that lies ahead of them. the positive findings of this research suggest that citizens of serbia are not afraid of covid-19, but are nevertheless cautious (86%). the percentage of those willing to consult a doctor when they notice any symptoms lies at 70%. half of the respondents do not believe in alternative theories regarding the origin of the covid-19 virus, as they seem to approach the matter objectively. of particularly high concern is the fact that 55% of the respondents hold government officials accountable for spreading panic through public speeches and daily public addresses. moreover, 60% of the respondents do not trust the serbian media outlets that are currently reporting on the covid-19 pandemic. furthermore, over half of the respondents are prepared to report their neighbour when he or she is coming from abroad and violates the obligation to self-isolate. however, mostly due to the outrageously high fines, 65% of the respondents would not report the elderly when they are breaking the limited-movement restriction measures. south eastern european journal of public health volume vii, 2017 genc burazeri, ulrich laaser, jürgen breckenkamp, jose m. martin-moreno, peter schröder-bäck(eds.) jacobs verlag south eastern european journal of public health genc burazeri, ulrich laaser, jürgen breckenkamp jose m. martin-moreno, peter schröder-bäck. executive editor genc burazeri (tirana, albania and maastricht, the netherlands) faculty of medicine rr. “dibres”, no. 371 tirana, albania phone: 0035/5672071652 skype: genc.burazeri assistant executive editors florida beluli, ervin toci, kreshnik petrela, all at: faculty of medicine rr. “dibres”, no. 371 tirana, albania editors jürgen breckenkamp, faculty of health sciences, university of bielefeld, germany (2016). genc burazeri, faculty of medicine, tirana, albania and department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands (2013). ulrich laaser, faculty of health sciences, university of bielefeld, germany (2013). jose m. martin-moreno, school of public health, valencia, spain (2013). peter schröder-bäck, department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands (2014). regional editors suzanne m. babich, associate dean of global health and professor, health policy and management, at the indiana university richard m. fairbanks school of public health in indianapolis, indiana, usa, for north america. samir n. banoob, president, intenational health mangement, tampa, florida, usa, for the middle east. evelyne de leeuw, free lance health consultant, sydney, australia, for the western pacific region. damen haile mariam, university of addis ababa, ethiopia, for the african region. charles surjadi, faculty of medicine, atmajaya university, jakarta, indonesia, for the south east asian region. laura magana valladares, secretaria académica, instituto nacional de salud pública, mexico, mexico, for latin america. advisory editorial board tewabech bishaw, african federation of public health associations (afpha), addis ababa, ethiopia jadranka bozikov, department for medical statistics, epidemiology and medical informatics, andrija stampar school of public health, school of medicine, university of zagreb, zagreb, croatia. helmut brand, department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands. patricia brownell, fordham university, new york city, new york, usa. franco cavallo, department of public health and paediatrics, school of medicine, university of torino, torino, italy. doncho donev, institute of social medicine, faculty of medicine, university “ss cyril and methodius”, skopje, macedonia. mariana dyakova, university of warwick, faculty of public health, united kingdom. florentina furtunescu, department of public health and management, university of medicine and pharmacy "carol davila", bucharest, romania. andrej grjibovski, norwegian institute of public health, oslo, norway and school of public health, arkhangelsk, russia motasem hamdan, school of public health, al-quds university, east jerusalem, palestine. mihajlo jakovljevic, faculty of medical sciences, university of kragujevac, kragujevac, serbia. aleksandra jovic-vranes, institute of social medicine, medical faculty, belgrade university, serbia. ilona kickbusch, graduate institute of international and development studies, geneva, switzerland. mihali kokeny, free lance consultant, budapest, hungary. dominique kondji, cameroon public health association, douala, cameroon. giuseppe la torre, department of public health and infectious diseases, university sapienza, rome, italy. oleg lozan, school of public health management, chisinau, moldova. george lueddeke, consultant in higher and medical education, southampton, united kingdom. izet masic, university of sarajevo, sarajevo, bosnia and herzegovina. martin mckee, london school of hygiene and tropical medicine, london, united kingdom. bernhard merkel, visiting research fellow, london school of hygiene and tropical medicine, london, uk. naser ramadani, institute of public health, prishtina, kosovo. enver roshi, school of public health, university of medicine, tirana, albania. maria ruseva, south east european health network (seehn), sofia, bulgaria. fimka tozija, institute of social medicine, faculty of medicine, university “ss cyril and methodius”, skopje, macedonia. theodore tulchinsky, hadassah–braun school of public health and community medicine, jerusalem, israel. lijana zaletel-kragelj, faculty of medicine, university of ljubljana, ljubljana, slovenia. publisher dr. hans jacobs (lage, germany) editorial office jacobs verlag hellweg 72 d 32791 lage germany email phone: 0049/5232/979043 fax: 0049/05232/979045 mailto:info@jacobs-verlag.de� seejph south eastern european journal of public health www.seejph.com/ volume vii, 2017 genc burazeri, ulrich laaser, jürgen breckenkamp, jose m. martin-moreno, peter schröder-bäck (eds.) publisher: jacobs/germany issn 2197-5248 jacobs verlag http://www.seejph.com/� issn2197-5248 doi 10.4119/unibi/seejph-2016-174 bibliographic information published by die deutschebibliothek. die deutsche bibliothek lists this publication in the deutsche nationalbibliografie; detailed bibliographic data is available on the internet at http://dnb.ddb.de south eastern european journal of public health (open access journal) copyright 2016 by jacobs publishing company hellweg 72, 32791 lage, germany copyright cover picture: wordpress foundation: http://wordpressfoundation.org/gnu general public license http://dnb.ddb.de/� http://wordpressfoundation.org/gnu� table of contents page editorial the mark of women’s leadership on solutions to global health problems 1-3 valia kalaitzi original research ethnic differences in smoking behaviour: the situation of roma in eastern europe 4-16 laetitia duval, françois-charles wolff, martin mckee, bayard roberts the relevance of ethics in the european union’s second public health programme 17-35 nelly k. otenyo trajectories of life satisfaction during one-year period among university students: 36-47 relations with measures of achievement strategies and perception of criteria for adulthood giovanni piumatti review articles nurses’ roles, knowledge and experience in national disaster pre-paredness and emergency 48-66 response: a literature review thomas grochtdreis, nynke de jong, niels harenberg, stefan görres, peter schröder-bäck the emerging public health legislation in ukraine 67-75 iryna senyuta short reports protecting the planet and sustainable development 76-82 laura h. kahn socio-demographic factors and selected clinical characteristics of patients with retinal 83-90 occlusions in transitional albania manushaqe rustani-batku, ali tonuzi kalaitzi v. the mark of women’s leadership on solutions to global health problems (editorial). seejph 2016, posted: 07october2016. doi: 10.4119/unibi/seejph-2016-131 1 editorial the mark of women’s leadership on solutions to global health problems valia kalaitzi1 1department of international health, school for public health and primary care (caphri), faculty of health, medicine and life science, maastricht university, maastricht, the netherlands. corresponding author: valia kalaitzi, msc, phdc; address: 25 vas sofias, 10674 athens greece; telephone: +30 6932285055; e-mail: valiakalaitzi@maastrichtuniversity.nl mailto:valiakalaitzi@maastrichtuniversity.nl� kalaitzi v. the mark of women’s leadership on solutions to global health problems (editorial). seejph 2016, posted: 07october2016. doi: 10.4119/unibi/seejph-2016-131 2 “man is the measure of all things”, stated protagoras in 485 bc (1). maybe it’s time to add women to that equation and adapt protagoras’ saying into:“women who are leaders are the measure of global health challenges”. what protagoras meant, of course, was that man is the point of reference, the centre of universe; he adjusts his world to fit his needs. in other words, man has the ability to shape his living conditions, the environment and solutions to the challenges in life. in that sense, the challenges are managed according to the terms and conditions of man. indeed, global health challenges of the 21st century are widespread. they are many, and they are of great magnitude. world health leaders are challenged by crises such as polio, zika virus, and h1ni, to mention a few. many health systems around the world have been challenged to respond effectively to these crises, spotlighting major gaps in worldwide surveillance, disease control, resources, and infrastructure required to protect and support the public’s health. the economic crisis that affected europe has been linked to several infectious disease outbreaks including tb and hiv, compounded by recent waves of migration, although the links between these events remain unclear (2). debates ensue about the value and feasibility of universal health coverage, the increasing role of the private sector in the global health landscape and the subsequent changing roles of global health actors that shape the new health economy. these are complex times, and they require skilful players if we hope to translate public and private sector investments in health into both economic growth and equitable improvements in health. such goals require inspired, inclusive, and effective leadership. these very traits are the hallmark of women’s leadership. women have been observed to possess certain traits and characteristics that may accelerate effective and sustainable solutions to challenging global health problems. it is widely accepted that women who are leaders act as a normative agent of change and developmental processes (3-8). they practice people-centred, inclusive leadership and balance strategic priorities with collective dynamics. in this regard, they may exhibit greater mastery as compared to men in relation to key competencies required to make progress. one may argue that we experience a collision of worlds in respect of the old and the new tradition of gender-based roles in global health governance, and the implications for our freshly made, globalized world. however, the balance of global gender roles in our contemporary world is the outcome of politics and power. that balance can be changed to benefit global health. if the collective political community “aims at some good and the community which has the most authority of all and includes all the others aims highest”(9), then, our current, turbulent suffering societies expect global leaders to practice the quality of leadership as described by plato (10). that form of leadership combines the following components: • wisdom, as the knowledge of the whole including both knowledge of the self and political prudence; • civic courage, in the sense of preserving rights and standing in defence of such values as friendship and freedom on which a good society is founded, and; • moderation, a sense of the limits that bring peace and happiness to all. global health leadership falls behind in providing the opportunities and motivation to female leaders to unfold their talents and give their touch to new health challenges. the huge reservoir of talented women remains mostly untapped. the transformative attributes of female leaders to create opportunities out of a web of complexity, to promote systematic preparedness and to create a starting point for change out of chaos have been underestimated and sacrificed to stereotypes and social constraints. kalaitzi v. the mark of women’s leadership on solutions to global health problems (editorial). seejph 2016, posted: 07october2016. doi: 10.4119/unibi/seejph-2016-131 3 of course, numerous notable initiatives have been introduced; important foundations have been established and contribute considerably towards this end. nonetheless, the relative lack of women who are leaders in top decision-making positions in global health should be looked upon like a well-diagnosed, but mistreated disease. what kind of politicians and leaders do we need to provide the proper room for experiencing the mark of women on global health challenges? maybe politicians and decision-makers should be wise enough to adapt the saying of protagoras (1). from now on, let’s call loudly for women who are leaders to be “the measure of global health challenges”! conflicts of interest: none. references 1. sholarin ma, wogu iap, omole f, agoha be."man is the measure of all things": a critical analysis of the sophist conception of man. res human socsci2015;5:178-84. 2. kentikelenis a, karanikolos m, williams g, mladovsky p, king l, pharris a, et al. how do economic crises affect migrants’ risk of infectious disease? a systematic narrative review.eur j public health 2015;25:937-44. doi:10.1093/eurpub/ckv151. 3. eaglyah, chin jl. diversity and leadership in a changing world. am psychol2010;65:216-24. doi: 10.1037/a0018957. 4. northouse pg.leadership: theory and practice (5thed.). sage publications; 2010. 5. silverstein m, sayre k. the female economy. harvard business review2009;87:46 53. https://hbr.org/2009/09/the-female-economy (accessed: october 5, 2016). 6. mckinsey global institute. the power of parity: how advancing women’s equality can add $12 trillion to global growth;2015. http://www.mckinsey.com/global themes/employment-and-growth/how-advancing-womens-equality-can-add-12 trillion-to-global-growth (accessed: october 5, 2016). 7. world economic forum. the global gender gap report; 2014. http://reports.weforum.org/global-gender-gap-report-2014/(accessed: october 5, 2016). 8. world health organization. health in 2015 from sdgs to mdgs; 2015. http://apps.who.int/iris/bitstream/10665/200009/1/9789241565110_eng.pdf(accessed: october 5, 2016). 9. aristotle. political theory. stanford encyclopedia of philosophy (online). http://plato.stanford.edu/entries/aristotle-politics/#polview (accessed: october 5, 2016). 10. plato. political philosophy. internet encyclopedia of philosophy (online). http://www.iep.utm.edu/platopol/ (accessed: october 5, 2016). © 2016 kalaitzi; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.ncbi.nlm.nih.gov/pubmed/?term=kentikelenis%20a%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26318852� https://www.ncbi.nlm.nih.gov/pubmed/?term=kentikelenis%20a%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26318852� https://www.ncbi.nlm.nih.gov/pubmed/?term=williams%20g%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26318852� https://www.ncbi.nlm.nih.gov/pubmed/?term=mladovsky%20p%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26318852� https://www.ncbi.nlm.nih.gov/pubmed/?term=king%20l%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26318852� https://www.ncbi.nlm.nih.gov/pubmed/?term=pharris%20a%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26318852� https://www.ncbi.nlm.nih.gov/pubmed/?term=how%2bdo%2beconomic%2bcrises%2baffect%2bmigrants%e2%80%99%2brisk%2bof%2binfectious%2bdisease%3f%2ba%2bsystematic-narrative%2breview� http://www.mckinsey.com/global-� http://reports.weforum.org/global-gender-gap-report-2014/(accessed� http://apps.who.int/iris/bitstream/10665/200009/1/9789241565110_eng.pdf(accessed� http://plato.stanford.edu/entries/aristotle-politics/#polview� http://www.iep.utm.edu/platopol/� http://creativecommons.org/licenses/by/3.0)� 4 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 original research ethnic differences in smoking behaviour: the situation of roma in eastern europe laetitia duval1, françois-charles wolff2, martin mckee3, bayard roberts3 1 school of public health, imperial college london, norfolk place, london w2 1pg, united kingdom; 2 lemna, université de nantes, bp 52231 chemin de la censive du tertre, 44322 nantes cedex, france and ined, paris, france; 3 ecohost – the centre for health and social change, faculty of public health and policy, london school of hygiene and tropical medicine, london, united kingdom. corresponding author: laetitia duval, school of public health, imperial college london; address: norfolk place, london w2 1pg, united kingdom; e-mail: l.duval@imperial.ac.uk mailto:l.duval@imperial.ac.uk� 5 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 abstract aim: to investigate ethnic differences in smoking between roma and non-roma and their determinants, including how discrimination faced by roma may influence smoking decisions. methods: we analysed data from the roma regional survey 2011 implemented in twelve countries of central and south-east europe with random samples of approximately 750 households in roma settlements and 350 households in nearby non-roma communities in each country. the overall sample comprises 11,373 individuals (8,234 roma) with a proportion of women of 57% and an average age of 36 years. statistical methods include marginal effects from probit and zero-truncated negative binomial estimates to explain cigarette consumption. results: we found that roma have a higher probability of smoking and are heavier smokers compared to otherwise comparable non-roma. these differences in smoking behaviour cannot purely be explained by the lower socio-economic situation of roma since the ethnic gap remains substantial once individual characteristics are controlled for. the probability of smoking is positively correlated with the degree of ethnic discrimination experienced by roma, especially when it is related to private or public health services. conclusions: by providing evidence on smoking behaviour between roma and non-roma in a large number of countries, our findings support the need to understand smoking behaviour of roma from a comparative perspective, and may ultimately contribute to more effective anti-smoking messages for roma. however, if the health disadvantage faced by roma is to be addressed adequately, this group must be involved more effectively in the policy and public health process. keywords: central and south-east europe, cigarette smoking, discrimination, ethnicity, roma. conflicts of interest: none. acknowledgements: we are indebted to one anonymous reviewer for very helpful comments and suggestions on a previous draft. funding statement: this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. 6 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 introduction while much is now known about the determinants of smoking, relating both to individuals (such as gender, age, marital status, and socio-economic characteristics), and product characteristics (such as price, availability, and marketing) (1-9), there has been less attention to ethnic differences in smoking behaviour, even though tobacco control measures may need to take account of factors, such as health beliefs, that might influence the effectiveness of certain policies and messages (10-12). roma are the largest ethnic minority group in europe (estimated to number 10-12 million), most living in central and south-east europe (13). they suffer multiple disadvantages, with lower education, worse living conditions, and lower socio-economic status (14-17) and face discrimination in many areas of life, including barriers in accessing health services and health information (18-22). consequently, roma have worse health on many measures (15,17,19) than the majority populations in the same countries. research on the roma population has largely focused on communicable diseases and child health (18), but more recent contributions have also investigated non-communicable diseases and health care (17,23). however, there have been fewer studies on health behaviours, although those that have been conducted show increased prevalence of risk factors, including smoking (24,25). paulik and colleagues (23) report attitudes to tobacco control from a small cross-sectional survey, with only 83 roma and 126 non-roma, finding roma respondents reluctant to accept restrictions on tobacco use. petek and colleagues (26) conducted a small qualitative study of the meaning of smoking in roma communities in slovenia, but with only three women and nine men of roma origin. they reported how smoking is seen as part of the cultural identity of roma and is accepted by men, women and children, while invoking fatalism and inevitability to explain why smoking is not identified by roma interviewed as a threat to health (26). given growing recognition of the role of smoking-related disease in perpetuating or accentuating health inequalities and lack of evidence on tobacco use among roma, the aim of the present study is to investigate ethnic differences in smoking between roma and non roma as well as their determinants, which includes how discrimination faced by roma may influence smoking. methods data and samples we use data from the roma regional survey, a cross-sectional household survey commissioned by the united nations development programme, the world bank and the european commission. further details on the survey methodology can be found at: http://www.eurasia.undp.org/content/rbec/en/home/ourwork/sustainable development/development-planning-and-inclusive-sustainable-growth/roma-in-central-and southeast-europe/roma-data.html the sample comprises both roma (n=9,207) and non-roma (n=4,274) households living in countries with high proportion of roma, namely albania, bosnia and herzegovina, bulgaria, croatia, the czech republic, hungary, macedonia, moldova, montenegro, romania, serbia and slovakia. the survey was conducted from may to july 2011. the intention was to include roma living in distinct settlements and compare them with non-roma living nearby. given this intention, http://www.eurasia.undp.org/content/rbec/en/home/ourwork/sustainable-� 7 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 it would have been inappropriate to compare what are known to be very deprived roma settlements (27) with the general population, which would include many affluent groups who have little in common with those living in the settlements. consequently, 350 non-roma households living in the same neighbourhood – defined as households living in close proximity, within 300 meters, of a roma settlement – were selected. a stratified cluster random sampling design was used. thus, the first stage sampling frame comprised known roma settlements, from which those to be included were sampled at random. then non roma settlements nearby were selected, again at random. in the second sampling stage, households were randomly chosen with equal probability within each cluster for both populations. the method of data collection was face-to-face interviews at the respondent’s household. the overall sample comprised 13,481 households corresponding to 54,660 family members. among them, 9,207 households were roma (68.3%) and 4,274 were non-roma (31.7%). we focus on the current smoking behaviour of respondents aged between 16 and 60 at the time of the survey. there is no information in the survey on past smoking decisions. this leaves us with a sample comprising 11,373 individuals, 8,234 of whom were roma (72.4%). the survey covers demographic characteristics, education, employment status, living standards, social values and norms, migration, discrimination, and health. socio-economic status is proxied using a household asset index. this aggregate index is derived from a principal component analysis of a list of household possessions following the methodology described by filmer et al. (28). the list of items included comprises radio receiver, colour tv, bicycle or motorbike, car/van for private use, horse, computer, internet connection, mobile phone or landline, washing machine, bed for each household member including infants, thirty and more books except school books, and power generator. the principal component technique was implemented on the entire sample, pooling roma and non-roma individuals. higher values of the asset index correspond to higher long-run socioeconomic status. the characteristics of respondents are summarised in table 1. table 1. descriptive statistics of the sample (n=11,373) variables (1) all (2) roma (3) non-roma (4)p-value respondents respondents respondents of (2)-(3) female 57,7% 57,8% 57,6% 0.848 age in years 36,0 35,0 38,8 0.000 in a couple 69,5% 71,4% 64,5% 0.000 divorced – separated 8,0% 7,9% 8,3% 0.473 widowed 5,0% 5,2% 4,7% 0.330 single 17,5% 15,6% 22,5% 0.000 household size (number of persons) 4,3 4,7 3,5 0.000 no formal education 18,4% 24,8% 1,6% 0.000 primary education 20,7% 26,4% 5,7% 0.000 lower secondary education 34,2% 36,9% 27,1% 0.000 upper/post-secondary education 26,7% 11,8% 65,7% 0.000 paid activity – self-employed 31,7% 25,8% 47,2% 0.000 homemaker – parental leave 19,7% 21,7% 14,2% 0.000 retired 5,2% 4,1% 8,2% 0.000 not working – other 43,4% 48,4% 30,4% 0.000 asset index (value) 0,0 -0,6 1,5 0.000 8 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 capital/district center 33,5% 33,0% 34,7% 0.103 town 26,1% 26,2% 25,8% 0.665 village/unregulated area 40,4% 40,8% 39,6% 0.238 number of respondents 11,373 8,234 3,139 source: authors’ calculations, undp/wb/ec regional roma survey 2011. about 58% are women and the average age is 36 years. on average, roma are younger than non-roma (35.0 versus 38.8). roma have lower educational attainment and are more likely to be outside the formal labour market. overall, scores on the asset index are worse for roma ( 0.563 compared to 1.477 for the non-roma), although the scale of relative disadvantage varies, with the largest gaps in croatia, romania and bulgaria. for smoking behaviour, we used the two following questions. first, respondents indicated whether they smoked or not at the time of the survey: “with regard to smoking cigarettes, cigars, or a pipe, which of the following applies to you?”. possible answers were “i currently smoke daily”, “i currently smoke occasionally”, “i used to smoke but have stopped” and “i have never smoked”. second, those reporting one of the first two answers (either daily or occasionally) were asked: “on average, how many cigarettes, manufactured or hand-rolled do you smoke each day?”. note that it may be more difficult for occasional smokers to assess their daily consumption. to examine the role of discrimination, we used the three following questions: i) “does your household have a doctor to approach when needed?”; ii) “do you feel safe in regards health protection – do you have the confidence that you will receive service in case you need it?”; and iii) “were there any instances in the past 12 months when your household could not afford purchasing medicines prescribed to, needed for a member of your household?”. we also included in our regressions variables from a specific section about general discrimination and rights awareness. discrimination is defined as being treated less favourably than others because of a specific personal feature such as age, gender or minority background. self assessed discrimination was assessed with the following question: “in the past 12 months (or since you have been in the country), have you personally felt discriminated against on the basis of one or more of the following grounds: a) because of ethnicity for non-roma, because you are a roma for roma, b) because you are a woman/man, c) because of your age, d) because of your disability, e) for another reason”. finally, we investigated the role played by access to health care system using answers to the following question: “during the last five years; have you ever been discriminated against by people working in public or private health services? that could be anyone, such as receptionist, nurse or doctor.” the reason attributed to the discrimination was specified: it could be either a discrimination on the basis of ethnic background or a discrimination because of other reasons. statistical analysis we analysed the determinants of smoking behaviour both in terms of smokers versus non smokers and number of cigarettes among smokers. to isolate as far as possible the role of ethnicity, we adjusted for the following individual characteristics, available for each household member: gender, age, marital status, household size, education level, asset index, occupation and location (capital or district centre, town, village or rural area). we compared the pattern of smoking not only by ethnicity, but also by country to account for the potential role of country-specific factors such as tobacco price. as an initial comparison 9 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 showed that roma were, as expected, materially worse off, we turned to an econometric analysis to explain both the decision to smoke and the consumption of cigarettes among smokers. we began with an investigation of the determinants of the probability of smoking using probit regressions, with marginal effects for various specifications (table 3). we also examined correlates of smoking intensity among smokers. since the dependent variable had non-negative integer values, we used count data models and estimated a zero-truncated negative binomial regression to account for over-dispersion as in (29,30). finally, we investigated the role of discrimination as a potential factor explaining the widespread smoking behaviour among the roma population (table 4). results determinants of cigarette consumption a comparison of cigarette consumption by ethnicity and country in table 2 shows that, while overall the proportion of smokers is 50.0%, there are substantial differences between countries. when pooling all countries, we found a much higher proportion of smokers among roma than non-roma (columns 2-4). the gap between these groups amounted to 15.5 percentage points. the prevalence differential was greatest in the czech republic (+31.4 points for roma), followed by hungary (+23.7 points), slovakia (+22.7 points) and bosnia and herzegovina (+22.6 points). conversely, there was no significant difference between roma and non-roma in bulgaria, macedonia and montenegro. the situation was a little different in terms of intensity of smoking. there were significant differences in daily number of cigarettes (among smokers) between roma and non-roma in only four countries: czech republic (+3.8 cigarettes for roma), bosnia and herzegovina (+3.1 cigarettes), slovakia (+1.6 cigarettes) and moldova (-5.1 cigarettes). table 2. cigarette consumption, by ethnicity and country albania 33.5 36.6 26.5 0.002 17.7 17.7 17.5 0.832 bosnia and herzegovina 54.6 61.1 38.5 0.000 21.2 21.8 18.7 0.009 bulgaria 51.7 53.3 46.8 0.108 12.0 11.8 12.9 0.233 croatia 57.3 64.1 38.4 0.000 16.1 16.2 15.5 0.766 czech republic 68.7 78.0 46.6 0.000 15.1 15.9 12.1 0.000 hungary 55.2 61.3 37.6 0.000 15.5 15.4 16.1 0.469 macedonia 42.1 43.2 39.3 0.279 17.2 17.4 16.6 0.443 moldova 29.8 33.5 19.4 0.000 16.7 15.9 21.0 0.004 montenegro 42.5 42.4 42.7 0.946 22.3 22.8 21.0 0.057 romania 46.7 50.5 34.8 0.000 12.8 12.8 12.8 0.728 serbia 58.9 61.7 51.5 0.004 18.4 18.3 18.7 0.627 slovakia 57.4 64.2 41.5 0.000 14.2 14.5 12.9 0.005 all countries 50.0 54.2 38.7 0.000 16.5 16.7 16.2 0.139 source: authors’ calculations, undp/wb/ec regional roma survey 2011. we examined the role of individual characteristics in explaining differences in cigarette consumption between roma and non-roma. as shown in column 1a of table 3, we found a positive correlation between the ethnic dummy and the smoking decision. at the sample means, the probability of smoking was 16.1 percentage points higher among roma compared country proportion of current smokers (in %) cigarette consumption among smokers (1) all (2) roma (3) non(4)p-value (5) all (6) roma (7) non(8)=p-value roma of (2)-(3) roma of (6)-(7) 10 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 to non-roma. this marginal effect accounted for the role of country heterogeneity. the country dummies in the regression captured the influence of differences in tobacco prices as well as other unobserved differences in anti-smoking policies or tobacco advertising. next, we accounted for by individual characteristics, given the demographic and socio economic differences in roma and non-roma respondents (column 2a). our main result was that the roma dummy was still positively correlated with the propensity to smoke at the one per cent level of significance. however, controlling for differences in respondents’ characteristics strongly reduced the marginal effect of ethnic origin. being roma was now associated with an increase of 8.5 percentage points in the probability of smoking. we also estimated separate regressions for each ethnic group (columns 3a and 4a). many covariates such as gender, age, household size or education had a similar influence on the likelihood of smoking among roma and non-roma, but we noted some differences. for instance, the marginal effect associated with the asset index was three times higher for non roma compared to roma. similarly, having a paid activity and being homemaker were significantly correlated with probability of smoking (respectively positively and negatively) only for non-roma. in column 1b, we found a positive correlation between roma origin and cigarette consumption. in column 2b, the positive effect of roma origin was still significant (at the five percent level) once individual characteristics were controlled for. table 3. probit and zero-truncated negative binomial estimates of cigarette consumption – marginal effects variables probability of smoking cigarette consumption among smokers (1a) all (2a) all (3a) roma (4a) non-roma (1b) all (2b) all (3b) roma (4b) non-roma roma 0.161** 0.085** 0.734* 0.927* (15.15) (5.91) (2.39) (2.49) female -0.138** -0.125** -0.166** -2.784** -2.892** -2.034** (-12.69) (-9.60) (-8.64) (-9.82) (-8.76) (-3.65) age 21-30 0.090** 0.067** 0.143** 2.374** 2.123** 3.587* (ref: ≤20) (4.85) (3.26) (3.35) (4.33) (3.59) (2.37) 31-40 0.123** 0.105** 0.128** 3.214** 2.800** 4.896** (6.28) (4.86) (2.81) (5.53) (4.48) (3.01) 41-50 0.157** 0.158** 0.129** 4.168** 3.993** 5.090** (7.61) (6.87) (2.75) (6.44) (5.65) (2.98) 51-60 0.119** 0.117** 0.090 4.103** 3.485** 6.028** (5.32) (4.63) (1.85) (5.83) (4.54) (3.29) marital status divorced – separated 0.035 0.042 0.031 0.508 0.577 0.392 (ref: in a couple) (1.87) (1.93) (0.92) (1.07) (1.06) (0.41) widowed 0.032 0.035 0.004 -0.050 -0.204 1.153 (1.32) (1.26) (0.09) (-0.08) (-0.30) (0.77) single -0.031* -0.041* -0.057* -0.185 -0.724 1.205 (-2.00) (-2.19) (-2.08) (-0.47) (-1.59) (1.48) household size 0.007** 0.006* 0.015* 0.085 0.107 -0.017 (2.81) (2.09) (2.30) (1.36) (1.60) (-0.09) education primary 0.002 -0.001 -0.110 -0.958* -1.040** -0.273 (ref: no formal) (0.15) (-0.08) (-1.48) (-2.48) (-2.60) (-0.13) lower secondary -0.008 -0.028 -0.102 -1.071** -1.337** -0.688 (-0.55) (-1.68) (-1.44) (-2.77) (-3.25) (-0.38) upper/post-secondary -0.061** -0.090** -0.138 -1.459** -1.595** -0.593 (-3.17) (-3.95) (-1.89) (-3.08) (-3.04) (-0.31) activity paid activity – self-employed 0.023 0.021 0.039 0.188 0.262 0.397 (ref: not working – other) (1.81) (1.43) (1.66) (0.60) (0.72) (0.62) homemaker – parental leave -0.019 -0.013 -0.065* -0.511 -0.615 0.256 (-1.35) (-0.83) (-2.11) (-1.37) (-1.52) (0.26) retired -0.089** -0.071* -0.098* -1.098 -0.925 -1.331 (-3.58) (-2.22) (-2.56) (-1.73) (-1.21) (-1.16) asset index -0.026** -0.016** -0.048** 0.189* 0.266** -0.101 11 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 (-7.62) (-4.00) (-7.58) (2.15) (2.63) (-0.56) location town -0.040** -0.050** 0.001 -1.445** -1.570** -1.112 (ref: capital/district center) (-2.96) (-3.14) (0.03) (-4.38) (-4.19) (-1.61) village/unregulated area -0.049** -0.039** -0.059* -2.186** -2.360** -1.437* (-3.81) (-2.63) (-2.50) (-6.87) (-6.53) (-2.15) country dummies yes yes yes yes yes yes yes yes number of respondents 11,373 11,373 8,234 3,139 5,682 5,682 4,466 1,216 source: authors’ calculations, undp/wb/ec regional roma survey 2011. note: the probability of smoking is explained using a probit model, the cigarette consumption among smokers is explained using a zero-truncated negative binomial model. significance levels are p<0.01 (**) and p<0.05 (*). when comparing the estimates obtained separately on the roma and non-roma samples (columns 3b and 4b), the correlation between consumption of cigarettes and gender, age as well as location had the same sign for both ethnic groups. conversely, we observed some differences in the role of education and asset index among smokers. first, the negative correlation between education and cigarettes was only significant for roma. second, we found a positive correlation between consumption of cigarettes and the asset index only for roma. as roma are economically disadvantaged, only those with adequate resources will be able to purchase and smoke cigarettes. finally, we estimated country-specific regressions. for ease of interpretation, we presented the marginal effect associated with the roma dummy (figure 1). figure 1. the gap in smoking between roma and non-roma, by country a. probability of smoking b. cigarette consumption among smokers 25 20 15 10 5 0 -5 bosnia and czech hungary croatia romania moldova slovakia albania serbia montenegro bulgaria macedonia herzegovina republic 12 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 source: authors’ calculations, undp/wb/ec regional roma survey 2011. the probability of smoking was 24.1 percentage points higher among roma than non-roma in bosnia and herzegovina. the gap was significant in seven other countries: by decreasing order of magnitude, the czech republic (19.7 percentage points), hungary (15.6), croatia (13.7), romania (13.7), moldova (12.5), slovakia (7.1) and albania (2.8). roma consumed additional cigarettes per day in the czech republic compared to non-roma smokers. the situation was very similar in bosnia and herzegovina (+3.7 cigarettes), slovakia (2.7), romania (1.3) and montenegro (1.1). smoking and discrimination the proportion of respondents who felt discriminated against because of ethnicity was much higher among roma (34.6%) than non-roma (4.9%) (+29.7 percentage points). the ethnic differential was lower but still significant when considering other forms of discrimination: +6.9 points because of gender (8.3% for roma compared to 3.1% for non-roma), +1.9 points because of age (6.2% against 4.3%) and +1.8 points because of disability (3.6% against 1.8%). when pooling the various reasons, the ethnic gap amounted to 26 percentage points (36.7% against 16.7%). we added indicators of health inequalities to our previous regressions explaining smoking decisions (panel a of table 4). table 4. discrimination and cigarette consumption – marginal effects from probit and zero truncated negative binomial models variables probability of smoking cigarette consumption among smokers (1a) all (2a) all (3a) roma (4a) non roma (1b) all (2b) all (3b) roma (4b) non roma panel a: roma 0.085** 0.081** 0.927* 0.920* (5.91) (5.63) (2.49) (2.47) 4 2 0 -2 -4 czech bosnia and slovakia romania montenegro macedonia serbia croatia hungary bulgaria moldova albania republic herzegovina 13 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 doctor to approach when needed 0.037* 0.033 0.050 0.211 0.336 -0.826 (2.23) (1.82) (1.31) (0.50) (0.74) (-0.69) feel safe in regards health protection -0.015 -0.015 -0.012 -0.219 -0.155 -0.401 (-1.11) (-0.95) (-0.44) (-0.63) (-0.41) (-0.49) cannot afford purchasing medicine prescribed 0.032** 0.028* 0.033 0.027 0.012 0.258 (2.92) (2.34) (1.46) (0.10) (0.04) (0.40) control variables yes yes yes yes yes yes yes yes number of respondents 11,373 11,373 8,234 3,139 5,682 5,682 4,466 1,216 panel b: roma 0.085** 0.077** 0.927* 0.828* (5.91) (5.27) (2.49) (2.19) discriminated against in the past 12 months 0.041** 0.034** 0.045 0.482 0.450 0.269 (3.62) (2.80) (1.55) (1.67) (1.46) (0.32) control variables yes yes yes yes yes yes yes yes number of respondents panel c: roma 11,373 0.085** 11,373 0.072** 8,234 3,139 5,682 0.927* 5,682 0.825* 4,466 1,216 (5.91) (4.93) (2.49) (2.17) discriminated against in the past 12 months 0.059** 0.060** -0.001 0.399 0.187 1.582 because of ethnicity (4.62) (4.40) (-0.02) (1.26) (0.56) (1.23) discriminated against in the past 12 months -0.038* -0.058** 0.043 0.172 0.482 -1.376 because of other reasons (-2.30) (-3.10) (1.21) (0.41) (1.03) (-1.50) control variables yes yes yes yes yes yes yes yes number of respondents panel d: roma 11,373 0.085** 11,373 0.079** 8,234 3,139 5,682 0.927* 5,682 0.891* 4,466 1,216 (5.91) (5.46) (2.49) (2.38) discriminated against by people working in health 0.078** 0.072** 0.057 0.467 0.238 3.901 servicesbecause of ethnicity (4.29) (3.84) (0.79) (1.06) (0.53) (1.54) discriminated against by people working in health -0.053 -0.060 -0.035 -0.409 0.146 -4.160* servicesbecause of other reasons (-1.79) (-1.84) (-0.49) (-0.55) (0.18) (-2.41) control variables yes yes yes yes yes yes yes yes number of respondents 11,373 11,373 8,234 3,139 5,682 5,682 4,466 1,216 source: authors’ calculations, undp/wb/ec regional roma survey 2011. note: the probability of smoking is explained using a probit model, the cigarette consumption among smokers is explained using a zero-truncated negative binomial model. significance levels are p<0.01 (**) and p<0.05 (*). we found that people who could approach a doctor when needed has a higher probability of smoking (column 2a). this result is seemingly counterintuitive but it may be that those living in areas with access to a doctor have higher (unobserved) levels of income or can more easily buy cigarettes. however, there may also be reverse causation as smokers are likely to have more health problems and thus more frequent interactions with doctors. while feeling safe had no influence on smoking, the correlation between probability of smoking and inability to purchase medicines prescribed was positive for roma respondents only (column 3a). none of our indicators of health inequalities had an influence on intensity of cigarette consumption among smokers. in panel b of table 4, we found a positive correlation between smoking behaviour and feeling of discrimination (whatever its reason). the probability of smoking increased by 4.1 percentage points for those who felt discriminated against (column 2a). the role played by discrimination was mainly observed in terms of probability rather than intensity of smoking. the correlation between discrimination and cigarette consumption among smokers was not significant when separating roma and non-roma (columns 2c and 2d).as shown in panel c, most of the effect came from discrimination on the basis of ethnic background. indeed, the coefficient associated with ethnic discrimination was positive and significant, but it was negative for other forms of discrimination. as a final step, we explored the correlation between smoking and discrimination in access to the health care system (panel d). the probability of smoking is higher among respondents 14 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 who felt discriminated against by people working in health services on ethnic grounds (+7.8 points). conversely, the correlation is negative for the other forms of discrimination (-5.3 points) while there was no significant relationship with smoking intensity. discussion in this paper we compared the smoking behaviour of roma and those in the majority population living nearby in twelve countries of central and south-east europe. the strengths of this study lie in the use of a large study sample across multiple countries. previous research on roma health tends to be restricted to a small number of countries, mainly hungary, the czech republic and slovakia (15,16,23,26), and which often use small sample sizes which make comparisons between roma and non-roma groups of population difficult. this study is, however, subject to a number of limitations. first, by design, it does not provide a representative sample of the roma population in the countries concerned. this is an inevitable and well-known problem facing all research on roma health, reflecting problems of defining the roma population (31). there are varying degrees of assimilation in each country and estimates of the roma population vary, reflecting in part the reason why a particular survey was undertaken and thus the incentive to self-identify as roma. furthermore, in some situations there may be strong disincentives to do so, given the previous experience of this population in their dealings with authority. for this reason, much of the existing research has adopted the approach used here, focussing on the most marginalised roma groups, and the most easily and consistently identifiable. second, the sample size in each country is relatively small, limiting the power to compare sub-groups. third, there is a need for qualitative research to understand better the place that smoking occupies within roma communities and the barriers that exist to reducing smoking rates. qualitative research has found that smoking is important in cultural and ethnic identity of roma, with smoking being introduced by older family members to younger ones. even where there is awareness of health risks associated with smoking, there is little willingness to consider quitting, to reduce exposure to second-hand smoke, or to prohibit children from smoking because it is considered part of growing up (23). policies that attempt to limit tobacco access to children or eliminate smoking in public places are rejected (26). fourth, some factors that might influence smoking behaviour are missing from the roma regional survey. for instance, we could not include household income in our regressions, although we were able to use an asset index, which captures household wealth. fifth, interpretation of findings on discrimination is complex. from an individual perspective, the perception of discrimination is a sensitive topic. feeling discriminated against is subjective and may be subject to justification bias. this would occur if roma respondents report being discriminated in order to justify their smoking decision. at the same time, according to the eu-midis report on discrimination argues, discrimination against roma seems to be largely unreported (32). finally, a limitation, inherent in the cross-sectional design, is that we are unable to show a causal association between discrimination and smoking. it may be that roma decide to smoke because they feel less accepted by the rest of the population, but their higher smoking prevalence may also be perceived as a potential signal of their ethnicity, as noted above. our findings show that roma respondents are more likely to smoke and are heavier smokers on average compared to non-roma (with substantial heterogeneity in the gap between the 15 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 two groups between countries).a recent study found no genetic basis for differences in smoking among roma and non-roma in hungary (33). now, this study shows that differences in smoking behaviour cannot simply be explained by the worse socio-economic situation of roma. first, the non-roma comparison population comprises those living in close proximity to roma settlements and not the general population. thus, our data will presumably underestimate the overall gap between the roma and non-roma population in each country. second, the ethnic gap remains substantial once individual characteristics are controlled for, although of course it is possible that our indicators do not fully capture relative disadvantage. importantly, this conclusion is consistent with another study using a different data set but similar methodology in hungary (34). we also find some positive correlation between the probability of smoking and discrimination reported by roma, especially with respect to private or public health services, but not in terms of smoking intensity. our findings support other literature on the disadvantage and discrimination faced by roma in central and south-east europe (13,15,21,22,35,36) with roma considered by some as the most discriminated against group in europe (32). this reinforces the importance of developing messages through a shared process, involving roma participation, and in ways that avoid stigmatisation, as part of comprehensive policies to tackle disadvantage and discrimination (37). conclusions to the best of our knowledge, this study is the first to provide comparative evidence on smoking behaviour between roma and non-roma in a large number of countries. our findings support the need to understand smoking behaviour of roma from a comparative perspective, and may ultimately contribute to improved anti-smoking policies towards roma. if roma health vulnerability is to be addressed adequately, efforts need to be concentrated on involving roma in the policy and public health process, including measures that specifically address the factors that lead to high rates of smoking in this multiply disadvantaged population. references 1. perez-stable ej, ramirez a, villareal r, talavera ga, trapido e, 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smoking in the roma population seems to have no genetic background. nicotine tob res 2016;18:2260-7. 34. voko z, csepe p, nemeth r, kosa k, kosa z, szeles g, et al. does socioeconomic status fully mediate the effect of ethnicity on the health of roma people in hungary? j epidemiol community health 2009;63:455-60. 35. hajioff s, mckee m. the health of the roma people: a review of the published literature. j epidemiol community health 2000;54:864-9. 36. duval l, wolff fc, mckee m, roberts b. the roma vaccination gap: evidence from twelve countries in central and south-east europe. vaccine 2016;34:5524-30. 37. fesus g, ostlin p, mckee m, adany r. policies to improve the health and well-being of roma people: the european experience. health policy 2012;105:25-32. © 2016 duval et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0)� 18 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 original research the relevance of ethics in the european union’s second public health programme nelly k. otenyo1 1department of international health, school of public health and primary care (caphri), faculty of health, medicine, and life sciences, maastricht university, maastricht, the netherlands. corresponding author: nelly k. otenyo, msc address: department of international health, maastricht university, postbus 616, 6200md, maastricht, the netherlands; email: nellyotenyo@gmail.com mailto:nellyotenyo@gmail.com� 19 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 abstract aim: the objective of this paper was to investigate whether ethical values were explicitly identified in the second public health programme (2008-2013) of the european commission. methods: a qualitative case study methodology of exploratory nature was followed. the data used were the summaries of the project proposals and public health programme objectives and was retrieved from the publicly available consumers, health and food executive agency database. since the php was finalized during the study, the study only focused on the summaries of the fifty-five finalized project proposals while excluding the ongoing projects and those projects at the reporting stage. the full proposals for the projects are confidential and thus could not be retrieved. however, the project summaries were inarguably sufficient to conduct the study. using a table, a content analysis method in addition to the ethical framework, was applied in order to analyze and categorise the project findings. results: the results unfold that, out of the seven ethical principles, only ‘equity’ and ‘efficiency’ were explicitly considered in eighteen projects and four projects respectively. moreover, from the shared health values, eight projects identified aspects pertaining to ‘accessibility to quality health care’ while ‘solidarity’ was only discussed in one project. lastly, the ethical aspects ‘ethics’ and ‘values’ were identified in three projects and in one project respectively. conclusions: from the results, there is a limited consideration of ethical principles within the projects. therefore, future public health programmes could use this as an opportunity to emphasis on the inclusion and application of ethical principles in public health projects. keywords: accessibility for quality health care, efficiency, equity, respect for human dignity, universality. conflicts of interest: none. 20 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 introduction in the recent years, there has been an increased focus on implementing policies that promote better health, that are cost effective and use targeted strategies against targeted ill-health worldwide. this interest has sparked an even greater concern for public health practices, as well as how ethics is observed with regards to health, especially since populations continue to suffer from emerging health challenges (1). it is also commonly known that human health is greatly influenced or affected by public health practices as well as socio-economic circumstances of individuals. in a response to solve this, researchers are constantly evaluating and checking their research work against ethical aspects of public health; assessing whether the recommendations that are or can be derived from their work can be ethically justified. even though there has been a growing interest on how ethics applies to public health, it has not yet gained a prominent position in all public health research. with the increasing burden of disease and emergent public health programmes, it is important to emphasize the need for public health ethics and develop this interest into maturity in order for it to have benefits (2). ethics is an academic discipline that questions what is required to be done, what is right, fair, just and good. therefore, ethics clearly defined is the study of human values and reasoning, but also refers to the systematizing of these values or rules or moral conduct that guides human lives. through the application of ethics, policy makers are able to frame policies and make critical decisions (3). the rise in the study of how public health and ethics are connected has been gradually developing in the past last years, due to human mal-practices, actions and problems in healthcare practice. public health focuses on ways to detect and quantify factors that put the population’s health at risk, once these factors are quantified policies are formulated to tackle or reduce adverse health outcomes for the population (4). public health ethics is concerned with the dissemination of health resources in a more equitable, efficient way and protecting the society (5). numerous studies have been carried out on ethics and public health actions and these have led to normative frameworks of public health ethics. hence, one could assume that ethical aspects are considered by researchers and public health professionals to be significant in enabling a functioning plan, execution and development of various public health programs. within the european commission, the 2007 health strategy ‘together for health’ is a better example of a health policy that considers values, as it is based on shared values. moreover, founded on these values, the second php 2008-2013 was implemented (6). it therefore goes without saying that when ethics are considered, public health is safeguarded, particularly when the ethical aspects are predicted or recognized in advance through critical investigations and discussions (7). an example of how ethical values can be considered in different public health disciplines is through gostin’s work. gostin looks at public health ethics from three viewpoints. the first is ethics of public health, by which professionals need to work for the common good with regards to their public duty and trust from the society. the second, ethics in public health, involves examining the position of ethics in public health. it involves communal and individual interests in relation to the allocation of returns and harms in an equitable way, e.g. in decision making and implementation of public health policies. ethics for public health, gostin’s third point, mainly entails a healthy population where the needs of the vulnerable and marginalized populations are considered in a more practical manner (8). as outlined in gostin’s perspectives, the ethical framework applied in this paper acts as an umbrella to ascertain whether the professionals carrying out the projects are working for the good of the 21 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 public, whether the allocation and distribution of resources is fair, and whether the needs of the minorities are taken into consideration to ensure a healthy population. ethical principles and standards are not only important for public health, they are also considered important for other disciplines, institutions and they have been used in recent years to guide professional conduct and behaviour (9). the european union (eu) is an example of such organizations, it does not only fund research through its framework programmes, but also monitors how health research is done or how projects are implemented (european union, n.d). through the health programme funding, the directorate general for health and consumer affairs (dg sante) oversees the health programme which is managed by the consumers, health and food executive agency (chafea) (chafea, n.d). every year, the european commission through chafea sends a call for proposal for operating grants, conferences as well as joint actions and sets the criteria for funding options available (chafea, n.d). the european commission has so far adopted three public health programmes (hereafter referred to as php). in this work, we will focus on the second php 2008-2013 because of its significance in forming part of the commission’s execution of the eu health strategy “together for health” (10). the objectives of php 2008-2013 were directed towards improving the health information and knowledge of eu citizens. this is done so as to increase the competences of how individuals respond to health threats or how they consider various determinants to stimulate better health or obviate disease (chafea, n.d). against this background, the php 2008-2013 was also aligned with the health strategy ‘together for health’. the first principle of shared health values emphasizes overarching values of solidarity, universality, access to good quality care and equity (6). for this paper, it is interesting to see how the funded projects of the php explicitly dealt with these ethical values and whether they used them as a foundation for setting their public health priorities. it is important to note that exploring the scope and the role of values in public health actions and strategies relates to the discipline of ethics. thus, this paper explores whether ethical values, principles and aspects have been explicitly considered in the second php objectives, proposals and its finalized projects. theoretical framework in order to investigate whether ethical aspects or concerns were considered in the php objectives, projects funded by dg sante, a selection and combination of ethical appropriate principles, safeguarding and incorporating relevant values and aspects of human rights retrieved from studies addressing various aspects of public health ethics are proposed. there are five principles for public health ethics which are also known as ethical principles, these are: health maximization, respect for human dignity, social justice, efficiency and proportionality (11), the principle of respect for autonomy (1), and finally equity as a principle proposed by tannahill are also combined (12). to formulate the framework for this study, these ethical principles will be combined with the shared health values of the eu health strategy namely: ‘universality’, ‘solidarity’, ‘accessibility for quality health care’. respect for autonomy is targeted at various aspects, such as the decision-making power of individuals in relation to their health or the general public health. additionally, it focuses on individual autonomy relating to self-domination, privacy, personal choice and free will (1). respect for human dignity compliments respect for autonomy, it guards the various interests of an individual and his or her absolute value so that an individual is referred to with respect 22 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 solidarity especially for his or her liberties, such as self-control (11). it further emphasizes that an individual’s liberties should not be defiled unless it harmfully affects others (13). health maximization is applied in practices where the monetary values of various projects are considered so as to give priority to the most cost effective project but also making sure that the public takes full advantage of all health benefits. the principle social justice guards against segregation and marginalization of vulnerable individuals. it ensures that individuals are treated fairly, particularly in matters of equity and maximization of health benefits, so as to minimize and avoid inequalities related to health care services. due to the growing public health needs and the inadequate public health resources, the principle of efficiency is significant in public health ethics. it is viewed as a moral act that ensures benefits are maximized especially in the execution of public health strategies, done by promoting the dissemination of basic necessities in a resourceful way. the proportionality principle advocates for benefits to be considered and assessed alongside the harmful properties, especially when debates on individual liberty versus public good arise (11). equity seeks to ensure that, the less privileged are not secluded in key public health actions that are important to them. in response to this, interventions and strategies that analyze the unfair allocation of services across different populations are implemented to target those at risk in a way to find the influencing factors and decrease inequalities (12). from the health strategy, shared values, universality value ensures that every eu citizen has equal access to use the available healthcare and services and that no one is denied care. the value access to good quality care guarantees that the available health care and services are of high quality and no eu patient is denied any high-quality care. equity as a value ensures that every eu patient is entitled to receive health care and services irrespective of their ethnic, gender or social economic backgrounds and status. solidarity ensures that all the financial arrangements made by the respective member states will promote the accessibility of health care and services to all citizens (6). using this framework, this paper will explore whether ethical principles, values and the 2007 strategy’s shared values were sufficiently addressed in objectives, proposals and finalized projects of the second php. table 1. overview of ethical principles and health strategy values (source: references 11-13) health maximization complete utilization of health benefits respect for human dignity no violation of individual liberties social justice promotes fairness and guards against discrimination promotes cost effectiveness, maximizing of benefits and limits wastefulness proportionality considers the benefits alongside harm respect of autonomy promotes individual’s free will and privacy supporting the fair access with reference to the need but regardless of origin, sex, age, social or economic rank universality no patient is denied access to health services and care accessibility to quality health care ensure accessibility of high quality health care for all the financial organization of a member states’ health system so as to ensure health is accessible for all. ethical aspect description equity efficiency 23 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 methods a qualitative study design was carried out to gain insights into the ethical concepts and determine whether they have a role in the funding allocation of phps and in the reported project results. the search items used, relate to the seven principles and basic terms of ethics: ‘equity’, ‘autonomy’, ‘health maximization’, ‘respect’, ‘dignity’, ‘social justice’, ‘justice’, ‘efficiency’, ‘proportionality’, ‘ethics’, ‘moral’, ‘value’, ‘ethic’, ‘ethical framework’. including the shared health values ‘universality’, ‘solidarity’, ‘accessibility’ and ‘quality health care’. it is important to note that despite the fact that, a number of projects used ‘equity’ to imply the reduction of inequalities, the term ‘inequalities’ was still excluded used as a keyword. all data was retrieved from the consumers, health and food executive agency (chafea). the proposals were available as summaries which included the following sections: general objectives, strategic relevance and contribution to the public health program, methods, means and expected outcomes (chafea, n.d). the research focused on the summaries of the fifty-five finalized project proposals at the data collection time and excluded projects that were still ongoing as well as projects at the reporting stage. the study included all the projects from all the three strands of the chafea project database: health information, determinants/health promotion, and health threats/health security. for the analysis, the individual project aims, goals and principles were compared against the ethical framework principles and the shared health values so as to show the overlapping concepts and which ethical gaps still need to be addressed. moreover, the identified ethical aspects are further scrutinized to ascertain whether they were only mentioned as keywords or whether they were expected outcomes of the analyzed project. methodological and theoretical limitations including other potential challenges the results from this study will indicate whether ethical concepts and public health ethics are already a constituent part of public health projects particularly with regard to the second eu public health programme. however, since this is a qualitative research, the study may encounter some limitations. to ensure validity as proposed by bowling the researcher intends to organize, clustering the retrieved data into relevant and respective ethical themes (14). this study has looked into the php’s, assessing whether ethical aspects were explicitly considered in its objectives and the summaries of the project proposals. the study recognizes that, by focusing on the only the explicit role of ethics in php through the eyes of only the seven principles and the shared health values, other ethical relations and aspects which are still vital in phps may have been excluded. in addition, not all projects that implicitly discussed aspects related to the principles and shared values were reported due to the act that, out 55 finalized projects, ethical principles and related concepts were identified both explicitly and implicitly in 27 projects. since the researcher used the given description of the principles to decide which ethical aspects and values were related to each other, there may be some form of interpretation bias. however, as discussed in the paper, it is inarguable that there are various definitions of ethics and ethical frameworks depending on different disciplines. this has led different ethical frameworks to be defined and applied to suit certain situations. the seven ethical principles proposed for the framework may therefore be exclusive in terms of excluding other significant values and concepts. additionally, given different definitions, application and 24 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 descriptions of the principles, it is clear that some aspects may refer to various principles such as universality and accessibility to health care. the study recognizes that, by focusing on the explicit role of ethics in the php through the eyes of only the seven principles and the shared health values, other ethical relations and aspects which are still vital in phps may have been excluded. the results focusing on the project proposals show minimal external validity as they only apply to the 55 finalized projects and may perhaps not be adequately generalized to a broader setting. however, regarding the results focusing on the objectives of the php, the representativeness of the findings cannot be questioned since the objectives apply to all the projects funded during the 2008-2013 php. thus, it can be generalized to improve the projects that are yet to be finalized and even aid in the drafting of the objectives of future php’s in the case of learning from best practices. since most of the projects and proposals from the second php 2008-2013 were still in the final phase during the data collection, only the projects that were finalized by june 2014 were included and the projects submitted at any later date were excluded. the full proposals for the projects were also confidential and thus could not be retrieved. therefore, it may be likely that some ethical principles and values might have been considered elsewhere in the full proposals hence resulting in limitations on the findings of this study. however, the project summaries were inarguably sufficient to conduct this study as they included a detailed executive summary of the project objectives in relation to the php objectives. results after examining the summaries of the 55 project proposals and the eu public health programme objectives, the findings were as follows. out of the seven ethical principles from the theoretical framework, only two principles were identified. other terminologies used in the analysis included ‘ethics’ and ‘values’ which were identified in three projects and in one project respectively. since the second php was founded on values prioritized in the eu health strategy: together for health, the keywords ‘universality’, ‘access’, ‘quality health care’ and ‘solidarity’ retrieved from the first principle of the health strategy were identified differently in nine projects. eight projects identified aspects pertaining to accessibility to quality health care and solidarity was only discussed in one project. additionally, out of the four shared health values, only ‘equity’, ‘solidarity’ and ‘access to quality health care’ was identified explicitly in the objectives of the php. the projects were analysed basing on the seven ethical principles, the four shared health values and the ethical concepts ethics, morals and values. the results will be analysed and presented in the following categories. the different research questions will be answered and discussed in their respective sub-sections below. table 2. presentation of the findings ethical concepts in php objectives & project morals, values, ethics, ethics, values, proposals those identified in project proposals and/or in php objectives categories used in analysis and the terminologies used how results are presented 25 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 shared health values identified in php objectives and project proposals ethical principles identified in php project proposals equity, accessibility to quality health care, universality and solidarity health maximization, equity, proportionality, respect for human dignity, autonomy, solidarity, universality and accessibility to quality health care efficiency and equity efficiency, social justice. ethical concepts and shared health values in the php-2008-2013 objectives ethical concepts such as, ‘ethics’, ‘morals’ and ‘values’ were not identified in the php objectives. however, the shared health values equity, solidarity and access to quality health care were explicitly identified in the php objectives. from the general objectives of the php, the common goal evident is improving ways that will ensure and promote the health security of the eu citizens. this goal is in line with the shared health value of ensuring ‘accessibility to quality health care’. even though ‘accessibility’ is not explicitly mentioned in the php objectives, it is one of the main objectives of the php because through the php, the eu commission seeks to improve the member state’s capacities of responding to all kinds of health threats and ensure that the health care services, treatment and medications, for example transplant organs, are of the highest quality. the php 2008-2013 also aims to promote the health of the eu citizens while reducing health inequalities. solidarity ensures that all member states commit to working in unity while supporting each other for the growth and development of the entire eu. moreover, with regards to the solidarity value, the php was envisioned to complement, offer assistance and add value to the member state’s policies by developing, distributing and sharing all information, evidence, best practices and expertise relating to health to all member states. since solidarity ensures that less capable countries are not left out in the development or growth, the php fully supports this value as it aims to see to it that prosperity in the european union is increased, and as a counter effect public health is improved. table 3. shared health values in the php-2008-2013 objectives (source: adapted from reference no. 15) reduces inequalities among the minorities mutual support and commitment among the ms “promote health and reduce health inequalities” “it is intended to complement, support and add value to the policies of the member states and contribute to increasing solidarity and prosperity in the european union” “generate and disseminate health information and how the concept is used in the php objectives shared health values of the eu description as given in health strategy chapter 4 of this paper equity solidarity 26 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 knowledge, exchanging knowledge and best practice on health issues’’ access to quality health care safe and quality health care is made available to everybody “promoting actions related to patient safety through high quality and safe healthcare, scientific advice and risk assessment, safety and quality of organs, substances of human origin and blood” 27 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 ethical principles in the php 2008-2013 project proposals from the 55 projects, only 6 projects explicitly discussed findings that related to equity, while efficiency was only identified in four projects. • equity: the project ‘daysafeimproving patient safety of hospital care through day surgery’, recognized existing challenges health systems face while trying to ensure fair access to high quality and safe health care. the project therefore proposes to offer applicable solutions and as a result increase patient satisfaction, safety, equity and quality of health care. according to the ‘chain of trust’ project, increasing the awareness and understanding of the available recommendations regarding the perceptions, challenges and advantages resulting from the use of tele-health, will equip all the key stakeholders with knowledge and information that will add value and further promote the provision of health care equitable to all patients in the eu. the ‘healthvent’ project discusses equity under the strategic relevance and contribution to the public health programme section of their proposal. it emphasizes that, its objectives will be aligned with those of the php as it aims to tackle environmental health determinants specifically those related to the use of energy in homes, schools and various public buildings so as to prevent chronic diseases and further decrease inequalities in health. ‘crossing bridges’ builds on the execution of article no. 168 of the ec treaty to ensure that the hiap vision is accomplished for equity across the eu. moreover, ‘crossing bridges’ expects that through the project results, the respective stakeholders will be encouraged to implement policies that will result in health equity. by developing a suitable surveillance and information system for health the ‘eumusc.net’ project expects to increase and harmonise the quality of care to allow for equity in care for rheumatic illnesses and musculoskeletal disorders across the member states. through the consideration of structural aspects of gender inequality and gender stereotypes that openly affect men and women’s health, ‘engender’ project aims to ensure equity by creating an online inventory of good practice of policies and programmes that focus on promoting health. • efficiency: ‘daysafe’ expects to improve the technical efficiency of health services by ensuring that the policy-makers are well-informed and recognize the factors limiting the performance of ds, such as operational issues and incompetently designed structures. ‘healthvent’ project: through establishing a health-related ventilation guideline focussing on buildings such as schools, homes, offices and nursery buildings among others, ‘healthvent’ expects that inhabitants will utilize energy in a more reasonable manner so as to have more energy efficient buildings. bordernet project aims to improve the prevention, testing and treatment of hiv/aids/stis by reducing obstacles related to practice, policies and cooperation between border countries and among member states though a more transparent and sustainable network. this will further improve the effectiveness and efficiency capacity of organizations of various sectors responding to aids/stis. ‘engender’ expects that increasing the awareness and creating a platform for all stakeholders to be well informed through the online inventory of best practices, will result in effective, efficient policies and programs that focus on achieving gender equity in health. 28 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 table 4. efficiency aspects identified in project proposals improving patient safety of hospital care through day surgery (daysafe). "the project will enhance ds which represents a crucial strategic approach toward the improvement of health services safety and quality, including patient’s satisfaction, together with technical efficiency and, possibly, equity" the (guidelines) "will reconcile health and energy impacts by protecting people staying in these health-based ventilation guidelines for europe (healthvent) buildings against risk factors, and at the same time taking into account the need for using energy rationally and the need for more energy efficient buildings" "the improved effectiveness and efficiency on highly active prevention: scale up hiv/aids/sti prevention, diagnostic and therapy across sectors and borders in cee and see (bordernetwork) regional and cross-border level in interdisciplinary response to aids/stis and scale up of hiv/sti testing will put forward the practical implementation of hiv combination prevention" "increased awareness and knowledge for all inventory of good practices in europe for promoting gender equity in health (engender) stakeholders including: policy makers, politicians, researchers, ngos and citizens, within and outside the health sector about effective, efficient policies and programmes to achieve gender equity in health" shared values of the 2007 eu health strategy in the php 2008-2013 project proposals? out of the four shared health values, only accessibility to quality health care and equity were addressed in the summaries of the project proposals. basing on the description given for universality, the value was in a way linked to the context used to describe accessibility. from this assessment, more principles are seen to be used in association such as, ‘accessibility and universality’, ‘universality and equity’. • accessibility to quality health care: accessibility was analyzed in the projects in two parts: first, those projects that promote high quality health care services and secondly, those that ensure high quality of health care are accessible to all. ‘coorenor’, ‘daysafe’ and ‘implement’ projects discuss ‘high quality of health care’ by stating that quality assurance models are present in their projects and will ensure safe and high quality of services across the eu. ‘imp.ac. t’ and ‘promovox’ projects promote actions that particularly focus on marginalized groups and migrants. ‘imp.ac. t’ aims to ensure that access to hiv/tb testing for marginalized groups is improved, and ‘promovox’ emphasizes the facilitation of better access of immunizations among the migrant population. ‘care-nmd’ relates accessibility of healthcare to reduced inequalities. the project believes that, by improving the access aspects of efficiency/ efficient identified in the php project proposals project title 29 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 to expert care, there will be a reduction of inequalities among member states and within a member state. 30 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 table 5. accessibility to quality health care as identified in the summaries of the project-proposals coordinating a european initiative among national organizations for organ transplantation (coorenor) "all requirements for ensure recipient safety and high quality of the treatment as well as running models for quality assurance will be considered and transferred to the eu institutions "the general objective of the improving patient safety of hospital care through day surgery (daysafe) project is to improve patient safety & quality of hospital care through the promotion of ds best practice and standards. implementing strategic bundles for infection prevention and management (implement) "aims to improve patient safety through high quality and safe healthcare". “bordernetwork' focuses both highly active prevention: scale up hiv/aids/sti prevention, diagnostic and therapy across sectors and borders in cee and see. (bordernetwork) disease causes and underlying social determinants of health, aiming to improve responses to prevention offers and accessibility of care services”. a) “improving access to hiv/tb improving access to hiv/tb testing for marginalized groups (imp.ac.t) testing for marginalized groups b) “to increase the percentage of idus and migrants having access to hiv and tb testing” “improve migrants understanding promote vaccinations among migrant populations in europe (promovax) & acceptance of immunizations and facilitate their access to immunizations by identifying a network of relevant sites”. "improved access to specialist care dissemination and implementation of the standards of care for duchenne muscular dystrophy in europe (including eastern countries) (care-nmd) for dmd and reduction of inequalities between countries & within countries due to better trained health professionals" accessibility to quality health care value as used in the php project proposals project title 31 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 ethical concepts or aspects in the php 2008-2013 • ethics: under the strategic relevance and contribution to the php section, ‘chain of trust’ acknowledges that the consideration of ethical associated issues while developing recommendations related to the approval of telemedicine by patients and health professionals is important especially during the implementation of telemedicine. ‘apyn’ will assist in realizing the work plan priority 3.3.4 for preventing addiction and further contribute to the alcohol strategy. the project proposes to consider “ethically sound actions” which, according to the priority areas for 2008 as stated in the 2008 work plan, refers to the ethical aspects outlined in the charter of fundamental rights of the european union. “ethical considerations: any proposal, which contravenes fundamental ethical principles particularly those set out in the charter of fundamental rights of the european union may be excluded from the evaluation and selection process” (16). apyn’ and ‘healthy eco life’ will support the work plan actions through the “involvement of new (non-traditional) actors for health in sustained, co-operative and ethically sound actions, both at regional or local level and across participating countries” (chafea, n.d). • values: ‘active’ intends to introduce a new method that will engage children between 5-8 years of age in europe. it is evident from their title that the project aims to teach and inspire the children with values and views concerning healthy eating and physical activity‘animation for children to teach and influence values and views on healthy eating and physical activity (active)’. however, the project only mentions the term ‘values’ in its title. discussion these ethical principles ensure that the individuals or professionals governed by them align their actions and conduct with the principles in order to uphold the society’s trust. most of the ethical principles used in public health actions and research assist in making sure that researchers and public health professionals are held responsible by society. moreover, ethical principles enable researchers to develop trust with the society, which often may cause them to receive funding or financial support for their research from the public because of their reliable and excellent work. furthermore, upholding ethical principles in research will stimulate the consideration of significant moral and social values (9). therefore, it is important for public health professionals and all stakeholders to abide by ethical principles in their duties. additionally, ethical consideration is not limited to public health professionals only at a european level, it is also relevant for public health research and projects of the eu’s public health programmes. with the php 2008-2013 being aligned with the health strategy ‘together for health’, which was explicitly value based in setting priorities, ethics still plays a significant role in the explicit project proposals; yet, this role is not evident in all the phps. however, it is surprising to see that less than half of the projects considered the principle equity which is regarded as a public health and an eu strategy priority. it is clear from the projects, that the mention of equity in their objectives and expected outcomes is not a sufficient indication of ethical consideration, for example, by mentioning that project actions will promote the coordination of abilities from both eastern and western 32 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 europe, coorenor project justifies its role in reducing health inequalities. this is an example to show that the mere mention of ethical principle is not an indication for its consideration in the entire project implementation and therefore the project falls short of explicitly considering equity. in spite of this, various projects still gave relevance to ethical principles and values as they exhaustively discussed in their project summaries matters that related to ethics. ‘daysafe’ recognizes that challenges exist which cause inaccessibility to quality and safe health care, hence they progress to propose methods that will promote equity in health. in discussing ‘efficiency’, the four projects, ‘bordernetwork’, ‘healthvent’, ‘daysafe’ and ‘engender’,only discussed how their activities and methods will result in efficient services and materials. they however fail to show in their methods how this will be attained and only limit it to mention that providing of policy guidelines will promote efficiency. regarding ‘accessibility to quality health care’, the projects questioned the quality and safety of health care services offered in europe and offered to foster a high level of surveillance and monitoring to further ensure that the quality health care is accessible to all patients. they linked quality assurance strategies to high quality services. even though some projects did not explicitly mention ‘accessibility’, their objectives and method description matched the value ‘universality’ while also linking it to reduced inequalities, as they emphasized that no one particularly minorities such as, migrants, hiv/aids and tb patients, should be denied access to health care. most of the projects had implicit discussions of how best practices should be shared across the eu and coordination among all different stakeholders should be supported in order to reduce inequalities in health instead of the explicit mention of solidarity. ex-post evaluation of the health programme the aim of this evaluation was to assess the main results that were reached as well as recognize the key challenges and solutions especially after consideration of recommendations from preceding assessments. the post evaluation study was guided by four key themes that is programme management, dissemination methods, the effect of the health programme collaboration with other programmes and services. according to the assessment, the programme lacked proper management as monitoring data was not used, thus making follow up a challenge. in order to increase the number of accepted and executed health programme funded actions, the main results of the health actions have to be made available to the relevant target groups. the 2nd health programme objectives were very broad, covering various significant needs of the member states as well as those of the stakeholders. it was therefore recommended that the health programme ought to introduce more specific progress analysis as they have been defined in the 3rd health programme. with regard to the 2nd health programme’s objectives, the funded actions led to significant advancements such as, promoting cross-border partnerships. it is important to note that, the administrative duties of the programme were increasingly efficient. moreover, the 2nd programme has shown major eu added value in recognizing best practices as well as networking (17). even though, the objectives of the health programme are commendable as they seek good practices and also focus on national priorities while contributing to a healthy status for the european population, they are still very broad and only focus on the relevance of the action. therefore, they may fail to explicitly address most of the ethical principles used in this study. 33 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 since the study has examined only the explicit use of ethical principles and concepts in the project summaries and the php objectives, the ethical framework may therefore exclude implicit discussions of ethical principles and other significant ethical values especially those based on ethical definitions not considered in the descriptions provided for this study. despite the fact that the ethical framework used for this assessment was based on seven principles, the study therefore doesn’t provide a full picture of this ethical role in php but provides a new mentality and platform that will enable the explicit rethinking and reconsidering of ethics and ethical aspects in public health. this new mentality and concern according to callahan and jennings will lead us to considering vital questions such as: “what are the basic ethical issues of public health? what ethical orientations are most helpful in the clarification and resolution of these issues? how are ethical principles and concepts incorporated into decision making in public health agencies and programs? how adequately are ethical dimensions of public health policy identified and debated?” this is because as public health gains more prominence, the ethical aspects regarding health issues increase too (2). conclusions this paper has presented and outlined ethical aspects that were explicitly identified in the 2008-2013 programme objectives and available project reports of the php. the projects were assessed, based on the theoretical framework consisting seven ethical principles. furthermore, the four shared health values of the eu health strategy were considered as they were more general ethical concepts. from the analysis, the principle ‘equity’ was extensively discussed and considered by some of the projects, followed by the ‘efficiency’ principle and then the value ‘accessibility to quality health care’. the study recognizes that by focusing on the role of ethics in php through the eyes of only the seven principles and the shared health values, other ethical relations and aspects which are still vital in phps may have been excluded. most commonly addressed values of the eu health strategy: ‘together for health’ by the projects were, ‘equity’, ‘accessibility’ and ‘universality’ as it seemed expected from them since the php was based on values. it is encouraging to see that most of the shared health values were discussed in most of the projects. even though vital principles such as‘respect for human dignity’, ‘autonomy’, and ‘health maximization’ were not addressed by any of the projects. it is clear from the projects, that the mere mention of a principle briefly such as ‘project will ensure equity’ in the project objectives and expected outcomes is not enough to justify that the principle will be adequately considered or that the project understands or acknowledges the significance of ethics in public health today. the project needs to consistently consider ethical aspects in its entire proposal, in this case a project summary, and not just mention it, since it is required and expected to be included under the ‘strategic relevance and contribution to public health programme’ section. this study has tried to paint a picture of the role of ethics in public health programmes. even with its prominence, ethics in public health programmes and activities still needs to be encouraged. moreover, more awareness in understanding ethics and ethical aspects in public health activities will further steer more ethical considerations not only amongst public health professionals and researchers, but also a more explicit and consistent consideration in phps and public health actions. in addition, basing on gostin’s work, ethical values ought to be 34 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 considered firstly by professionals in order to guide them in working for the common good of the society. secondly, in public health in terms of how decision making influences the balance between individual and communal interests especially in the implementation of public policies. thirdly, ethics for public health where the needs of the population are met in practical ways, such as more emphasis on training and research to improve ethical knowledge, as well as applications. this study has therefore provided a new mentality and platform that will enable the explicit rethinking and reconsidering of ethics and ethical aspects in public health. references 1. beauchamp tl, childress jf. principles of biomedical ethics: oxford university press; 2001. 2. callahan d, jennings b. ethics and public health: forging a strong 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11. schröder-bäck p, brand h, escamilla i, davies jk, hall c, hickey k, et al. ethical evaluation of compulsory measles immunisation as a benchmark for good health management in the european union. centr eur j public health 2009;17:183. 12. tannahill a. beyond evidence—to ethics: a decision-making framework for health promotion, public health and health improvement. health promot int2008;23:380-90. 13. sørensen k, schuh b, stapleton g, schröder-bäck p. exploring the ethical scope of health literacy: a critical literature review. alban med j 2013;2:71-83. 14. bowling a. research methods in health: investigating health and health services: mcgraw-hill international; 2009. 15. council directive. decision 1350/2007ec of the european parliament and of the council of europe; 23 october 2007. 16. commission. e. guide for the evaluation for proposals for action grants and operating grants, joint actions; 2008. 17. directorate-general for health and consumers: the second health programme 2008 2013. http://ec.europa.eu/health/programme/policy/2008-2013_en. accessed 13 july 2015. http://ec.europa.eu/health/programme/policy/2008-2013_en� 35 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 © 2017 otenyo; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0)� 36 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 original research trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood giovanni piumatti1 1 department of psychiatry, university of oxford, oxford, uk. corresponding author: giovanni piumatti, phd; address: warneford hospital, ox3 7jx, oxford, uk; telephone: +393335251387; email: giovanni.piumatti@psych.ox.ac.uk mailto:giovanni.piumatti@psych.ox.ac.uk� 37 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 abstract aim: the aim of this study was to examine how university students’ achievement strategies in an academic context and perceptions of criteria for adulthood relate to life satisfaction trajectories across one year. methods: a convenience sample of 143 young adults 18-28 years (mean age: 20.9±2.7 years; 109 females and 34 males) attending the university of turin in northwest italy completed questionnaires at three points with a six-month interval between each measurement. latent growth curve modelling and latent class growth analysis were used to assess longitudinal changes in life satisfaction and the related heterogeneity within the current sample. results: three trajectories of life satisfaction emerged: high stable (37%), moderate decreasing (57%), and low stable (6%). at every time point high success expectations were related to a high stable life satisfaction trajectory. in turn, those adopting achievement avoidance strategies were more likely to have low-stable or moderately decreasing life satisfaction trajectories. the perception of the criteria deemed important to be defined as adults did not change across time points or across life satisfaction trajectories’ groups. conclusion: these findings suggest that self-reported measures of achievement strategies among university students relate longitudinally to life satisfaction levels. positive and optimistic dimensions of personal striving may be protective factors against the risk of decrease of life satisfaction among university students. keywords: achievement strategies, criteria for adulthood, developmental trajectories, life satisfaction, person-oriented approach. conflicts of interest: none. note of the author: some results of the present paper have been previously presented at the 7th conference of the society for the study of emerging adulthood in miami, florida, october 14-16, 2015. 38 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 introduction according to diener, emmons, larsen, and griffin (1) life satisfaction (ls) is defined as an individual’s overall appraisals of the quality of his or her life. in the social and psychological sciences this construct has become a key variable for analyzing individuals overall subjective well-being (2). longitudinal studies have shown that after adolescence the majority of people experience stability in ls over long periods of times (3). however, depending on the length of time, one may observe short-, intermediateand long-term influences on ls (4). indeed, in the field of life-span research, the development of ls over time has become a very important baseline through which more variegated trajectories of individual development are observed (5). especially among older cohorts (i.e., aged 18 and above), given the relative stable differences in ls between observed latent growth groups in comparison with the more turbulent adolescence years, many have adopted a person-oriented approach (6,7) to describe which other characteristics unite individuals of a certain developmental trajectory of ls. for example, ranta, chow, and salmela-aro (8) have associated trajectories of ls among young adults to their self-perceived financial situation, concluding that positive ls trajectories relate to being in a positive self-perceived financial situation. röcke and lachman (3) observed how to maintain stable trajectories of positive ls individuals need intact social relations as well as a high sense of control. in addition, salmela-aro and tuominen-soini (9) and salmela-aro and tynkkynen (7) found that education achievement during and after secondary education positively correlated with high stable ls. emerging adulthood research proposes that the growing acquisition of maturity regarding adulthood-related duties and roles such as the commitment to life-long relationships or the importance attributed to forming a family are parallel to a stable ls path (10). in general, in the age range 18-30 years, perceiving oneself as an adult correlates to higher levels of ls and positive affect (11). such findings contributed to give credit to the theoretical assumption stating that among young adults the increasing acquisition of an adult identity and the endorsement of adulthood-related criteria are concurrent factors in determining positive outcomes at the individual level, as for example higher ls. at the same time, if we adopt a person-oriented approach to look at this issue, we might expect that others characteristics may define those young adults proceeding through transitions while exhibiting a mature adult identity and high ls. in an academic context, for example, the kinds of cognitive and attributional strategies individuals deploy provide a basis for their success in various situations (12), as well as for the positive development of their well-being (13). accordingly, in the present study we aimed at integrating the research literature on the relationship between the attainment of adult maturity and well-being with indicators of individual achievement strategies typical of life-span studies. more specifically, through a longitudinal approach, we questioned whether university students’ ls changes during a one year period and what kind of trajectories can be found. secondly, we examined young adults’ perception of the criteria deemed important for adulthood and achievement strategies in the academic context in relation to ls trajectories. the italian context university students account for a good proportion of the population aged 18-30 years in italy, although italian national statistics show a steady decrease in the overall university enrolment rates (14). moreover, italy reports one of the highest rates of university withdrawals among oecd members (15), with some regional differences between north and south (with dropout rates being higher in the latter), but overall widespread across the country (16). despite the considerable high social cost related to dropout rates during tertiary education and the interrelation between motivation, education attainment and well-being among young adults 39 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 (17), very few studies have examined from a longitudinal and psychological perspective how self-reported measures of well-being such as ls interact with motivational strategies in an academic context in italy (18). accordingly, the present study aimed to test the specific research hypothesis that positive motivational attitudes in an academic context relate to higher ls levels among young adults attending university and, possibly, to a higher acquisition of adulthood maturity. methods sample the empirical data of the present study were collected through the submission at three time points of an online questionnaire to a convenience sample of university students in the north western italian city of turin. participants were reached in various university settings of the faculty of psychology, including libraries, canteens, cafeterias and public leisure spaces. the criteria to take part in the study were being enrolled as a full-time university student, being italian and aged between 18 to 30 years. students provided their email contacts if they were interested in taking part in the study. then, they received a link to the online questionnaire through email. at time 1, 645 individuals (76% females; mean age: 22.1 years) completed the questionnaire. at time 2, six months afterwards, 252 individuals (79% females; mean age: 22.3 years) completed again the same questionnaire. finally, at time 3, twelve months after time 1, 150 individuals (77% females; mean age: 22.1 years) filled in the questionnaire. the very high dropping rate from time 1 to time 2 and time 3 can be explained by the total absence of an incentive for the participants to take part in the study (e.g., money, or school credits). therefore, it is reasonable to imagine that only those personally interested in the topic or in the research itself were willing to fill in the questionnaire. in fact, while the dropping rate from time 1 to time 2 was equal to 61%, from time 2 to time 3 it was equal to 41% (of the total number of participants at time 2), indicating a significant decline in the number of people dropping out. this may be explained by the fact that at time 2 the proportion of participants interested in the research was higher than at time 1. moreover, only the participants who filled in the questionnaire at time 2 were contacted again at time 3. measures life satisfaction ls was measured using the satisfaction with life scale (1). participants rated five items (for example, “i am satisfied with my life”, and “the conditions of my life are excellent”) on a 7 point likert-type scale ranging from 1 (totally disagree) to 7 (totally agree). a mean score was calculated for all items. cronbach’s alphas ranged from 0.69 to 0.79 across the three measurement points, indicating a good level of internal consistency with respect to the ls variable. achievement strategies four different types of achievement strategies in an academic context were assessed: success expectation, (cronbach’s alphas ranged from 0.68 to 0.73), measuring the extent to which people expect success and are not anxious about the possibility of failure (4 items, e.g., “when i get ready to start a task, i am usually certain that i will succeed in it”); task irrelevant behaviour (α from 0.76 to 0.82), measuring the extent to which people tend to behave in a social situation in ways which prevent rather than promote involvement (7 items, e.g., “what often occurs is that i find something else to do when i have a difficult task in front of me”); seeking social support (α from 0.73 to 0.77) measuring the extent to which 40 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 people tend to seek social support from other people (6 items, e.g., “it is not worth complaining to others about your worries”); and avoidance (α from 0.77 to 0.76), measuring the extent to which people have a tendency to avoid social situations and feel anxious and uncomfortable in them (6 items, e.g., “i often feel uncomfortable in a large group of people”). the scales belong to the strategy and attribution questionnaire (19). criteria for adulthood participants rated the importance of 36 criteria for adulthood (20) on their degree of importance on a scale of 1 (not at all important) through 4 (very important). based on previous research (10,20), these criteria were grouped into six categories: interdependence (α from 0.60 to 0.65; 5 items; e.g., “committed to long-term love relationship”), role transitions (α from 0.84 to 0.86; 6 items; e.g., “have at least one child”), norm compliance (α from 0.77 to 0.82; 8 items; e.g., “avoid becoming drunk”), age/biological transitions (α from 0.70 to 0.74; 4 items; e.g., “grow to full height”), legal transitions(α from 0.81 to 0.86; 5 items; e.g., “have obtained license and can drive an automobile”) and family capacities (α from 0.75 to 0.77; 8 items; e.g., “become capable of caring for children”). analysis the analyses followed three steps. first, to examine how ls changes during a one-year period, latent growth curve modelling (lgcm) (21) estimated the average initial level and slope of ls among the participants. the following indicators assessed the goodness-of-fit of the estimated lgcm: χ²-test, the comparative fit index (cfi) with a cut-off value of ≥0 .95, and the standardized root mean square residual (srmr) with a cut-off value of≤0 .09. subsequently, to evidence whether different types of ls trajectories emerge from the total sample, the analyses of this longitudinal data set extended into latent class growth analysis (lcga) (22). lcga examines unobserved heterogeneity in the development of an outcome over time, by identifying homogeneous subpopulations that differ with respect to their developmental trajectories within the larger heterogeneous population. lcga is exploratory by nature, which means that there are no specific a priori assumptions regarding the exact number of latent classes. when testing lcga models, different class solutions are specified. the best-fitting model is then selected based on the goodness-of-fit indices and theoretical considerations. here, the following goodness-of-fit indices evaluated the models: akaise’s information criteria (aic), bayesian information criteria (bic) and adjusted bayesian information criteria (abic) of the alternative models. entropy values were also examined, with values close to 1 indicating a clear classification. following marsh, lüdtke, trautwein, and morin (18), groups of ≥ 5% of the sample were considered the smallest to give an acceptable solution. practical usefulness, theoretical justification and interpretability of the latent group solutions were also taken into consideration (23). the analyses were controlled for age, gender and self-perceived socio-economic status (participants were asked how they would rate their actual socio-economical position on a scale from 1 – not good at all to 5 – very good). both lgcm and lcga analyses were conducted with the mplus 5.0 statistical software program. at last, one-way analysis of variance (anova) examined if the ls trajectory groups differed in terms of their achievement strategies and importance attributed to criteria for adulthood. post-hoc comparisons using the games-howell test examined differences between groups. 41 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 results development of life satisfaction the specified lgcm with a linear slope for ls change across the three time points fits the data well, χ²=3.99(1), p<0.05; cfi=0.98; srmr=0.04. in particular, while the intercept indicating the initial level of ls was statistically significant, the linear slope was not (intercept m= 3.02, se=0.05, p<0.001; slope m = -0.11, se=0.02, p>0.05). in addition, while the variance of the intercept was significant the variance of the slope was not (intercept variance =0.15, p<0.001; slope variance 0.01, p>0.05). together these results indicate that first, on average, there was no significant longitudinal change in ls across the three measurement points, and second, that there was a significant individual variance in the initial levels but not in the rate of change. thus, the significant heterogeneity among individuals was analyzed further adopting the person-oriented approach of latent class growth models. more specifically, these results suggest that, rather than investigating different rates of longitudinal change in ls within the overall sample, it would be more plausible to observe latent groups exhibiting stable trajectories of ls across time while being concurrently significantly different between each-other from baseline to the last follow-up. identifying life satisfaction trajectories lcga identified three sub-groups of individuals according to their levels of ls across measurement points. table 1 shows the fit indices and class frequencies for different latent class growth solutions. the four-class solution was unacceptable given the presence of a group with zero individuals. the three-class solution was thus the most optimal given the numerical balance of the observed groups and its higher entropy value with respect to the two-class solution (i.e., values closed to zero are indicative of better fit). figure 1 displays the estimated growth curves for the different latent trajectories of ls, whereas table 1 reports lcgm results. figure 1. life satisfaction trajectories (mean values in a scale 1-7) 7 6 5 high stable (n = 52; 37%) 4 moderate decreasing (n = 82; 57%) 3 low stable (n = 9; 6%) 2 1 0 t1 life satisfaction t2 life satisfaction t3 life satisfaction 42 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 table 1. fit indices and class frequencies based on estimated posterior probabilities for latent class growth models of life satisfaction with different numbers of latent trajectory groups number of groups bic abic aic entropy 1 766.94 751.12 752.13 2 (n1 = 69%, n2 = 31%) 684.93 659.62 661.23 .747 3 (n1 = 37%, n2 = 6%, n3 = 57%) 652.44 617.64 619.85 .827 4 (n1 = 6%, n2 = 58%, n3 = 0%, n4 = 36%) 667.33 623.03 625.85 .863 note. bic = bayesian information criteria; abic = adjusted bayesian information criteria; aic = akaike information criteria. the chosen option is marked in bold. the latent trajectories of ls were labelled high stable (37%), moderate decreasing (57%), and low stable (6%). ls mean levels of the high and the low stable trajectory groups remained stable over time. on the other hand, the moderate decreasing group exhibited a significant decrease in ls mean levels over time (see table 2). anova and chi-square tests evidenced how the three sub-groups did not differ according to age, f(2, 150)=0.01, p>0.05, gender, x2 (2, 150)=1.56, p>0.05, and self-perceived socio-economic position, x2 (2, 150)=8.13, p>0.05. table 2. estimation results of the final growth mixture model with five latent classes (unstandardized estimates; standard errors in parentheses) mean structure high stable (n=52; 37%) moderate decreasing (n=82; 57%) low stable (n=9; 6%) level 3.42 (0.05)** 2.83 (0.05)** 1.91 (0.11)** change -.09 (0.06) -.25 (0.05)** -.14 (0.20) note. variance is kept equal across the different latent groups. ** p< .001 differences in achievement strategies and criteria for adulthood the second analytical step consisted of testing whether the three observed ls trajectory groups were significantly different at each time point concerning self-reported achievement strategies outcomes in the academic context and the importance attributed to criteria for adulthood. table 2 reports all effects and pairwise mean comparisons between ls groups. since we did not observe any significant effect of ls trajectory group membership on the mean levels of the importance attributed to the criteria for adulthood, we decided not to report in a table such results for parsimony reasons. on the other hand, it appears clear how the three developmental trajectories groups consistently differed across time points regarding the types of achievement strategies they adopted in their academic activities. more specifically, from time 1 to time 3, the high stable group showed the highest levels of success expectation and the lowest levels of task irrelevant behaviour and avoidance. diametrically opposite was the performance of individuals in the low stable group who consistently showed the lowest levels of success expectation and the highest levels of task irrelevant behaviour and avoidance. finally, the moderate decreasing group reported a stable success expectation over time, but a slight increasing in avoidance. in fact, while at time 1, the avoidance did not differ between the moderate and the high stable group, from time 2 to time 3, individuals in the moderate decreasing group showed the same level of avoidance as the individuals in the low stable group. 43 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 44 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 overall, these results indicate that the types of achievement strategies in the current sample are linked to different ls development trajectories. furthermore, such measures of personal agency did not relate to different perceptions of the criteria deemed important for adulthood, nor the latter seem to correlate with ls developmental trajectories. discussion the current research focused on a longitudinal convenience sample of young adults attending university in the north-western italian city of turin. the person-oriented model tested here provided theoretical evidence of the overtime interconnection between motivational strategies in an academic context and well-being among university students. the main contribution of the present study was the adoption of a person-oriented approach (6) to focus on the issue of the perception of adulthood among young adults. indeed, to date, very few studies (24) have opted not to focus entirely on the relations between singular variables but instead to look at more elaborated systems of individual characteristics to draw a ‘picture’ of different ‘types’ of emerging adults in western societies. moreover, the longitudinal nature of the trajectory analysis contributed to test whether for emerging adults the perception of what it means to be considered adults nowadays is a stable construct over time, even if just across only one-year period. in particular, the latent curve growth analysis implemented here has represented a more fruitful way for examining young adults’ individual development (22). indeed, a single growth trajectory would have oversimplified the heterogeneity of the changes in emerging adults’ life satisfaction over time, as some experience an increase and some a decrease in life satisfaction, although the majority seem to experience a significant stability (7). in this study, it was possible to identify meaningful latent classes of individuals according to the initial levels and the longitudinal changes in their life satisfaction across the three measurement points. adopting this multiple trajectories approach resulted in a model of three developmental trajectories. overall, two major conclusions can be drawn from the present study. first, starting from the non-significant findings, it appeared that the perception of the most important criteria for adulthood (i.e., family capacities, interdependence, norm compliance) are not correlated to life satisfaction trajectories, either low or high. second, achievement strategies reflecting notions of agency were closely linked to life satisfaction, both about initial level and development. the first findings can reasonably be the result of the limited time span across which we aimed at observing developmental changes. indeed, we already know that emerging adults are more prone to change their perception of adulthood especially in correspondence with crucial life events, such as getting married, experience of parenthood, finishing the studies and start working (10,11). therefore, the impossibility to control for such events in the present study or simply the fact that the very small sample did not include a sufficient number of people going through specific transitions’ thresholds, can explain why we did not observe significant differences across developmental groups who instead remained stable in their opinions over the curse of one year. however, we were not just interested in looking at changes, but we argued for stable differences across developmental trajectory groups. again, despite the fact that we observed trajectory groups that showed significant differences in motivational strategies across time, these did not relate to adulthood self-perception. these results might confirm how the major sources of adulthood identity variation over time are significant experiences related to it. the significant differences between groups in terms of achievement strategies suggest that these measures of motivation and life satisfaction are strictly related. specifically, individuals with a high level of positive achievement approach strategies demonstrated high levels of life satisfaction. on the contrary, high levels of avoidance and irrelevant behaviours mostly 45 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 related to low levels of life satisfaction. a closer look revealed that individuals in the moderate decreasing life satisfaction trajectory maintained a more stable level of avoidance over time than the other two groups that both showed instead a decreasing in avoidance. thus, personal strivings and strategies may be protective factors against a decrease in life satisfaction. in summary, the findings from the current study are aligned with previous research work focusing on samples of young adults attending university and evidencing how individuals’ achievement strategies measured during university studies affect subjective well-being outcomes (25,26), including life satisfaction (27,28). in particular, in accordance with our results, success expectations are positively associated with higher satisfaction (29) and poor engagement relate to low well-being (27). these evidences should guide future research with the aim of further investigating the role of different types of agentic personality traits among university students in relation to positive life outcomes and health behaviours as factors strongly related to subjective well-being outcomes. study limitations and conclusions it is important to point out the main limitations of the current study. firstly, owning to the person-oriented statistical approach and despite the study longitudinal design, the analyses did not explicitly report on any causal relationship between measures of achievement strategies and overall satisfaction with life. future studies should look more specifically into cause-effect models using these types of self-reported measures of achievement strategies and various well-being outcomes. secondly, the convenience sample of university students included in this study cannot be considered representative of the entire population of university students in the context of reference (i.e., the university of turin in italy). accordingly, the generalizability of the current findings should be considered with caution while they may well represent a base 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grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 review article nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review thomas grochtdreis1,2, nynke de jong3, niels harenberg2, stefan görres2, peter schröder-bäck4,5 1 department of health economics and health services research, hamburg centre for health economics, university medical centre hamburg-eppendorf, hamburg, germany; 2 institute for public health and nursing science, university of bremen, bremen, germany; 3 department of educational development and research, school of health professions edu cation, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 4 department of international health, caphri school for public health and primary care, faculty of health, medicine and life sciences, maastricht university, maastricht, the neth erlands; 5 faculty for human and health sciences, university of bremen, bremen, germany. corresponding author: thomas grochtdreis, department of health economics and health services research, hamburg centre for health economics, university medical centre ham burg-eppendorf; address: martinistr. 52, 20246 hamburg, germany; telephone: +49407410-52405; email: t.grochtdreis@uke.de mailto:t.grochtdreis@uke.de� mailto:t.grochtdreis@uke.de� mailto:t.grochtdreis@uke.de� 49 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 abstract aim: nurses play a central role in disaster preparedness and management, as well as in emergency response, in many countries over the world. care in a disaster environment is dif ferent from day-to-day nursing care and nurses have special needs during a disaster. how ever, disaster nursing education is seldom provided and a lack of curricula exists in many countries around the world. the aim of this literature review is to provide an overview of nurses‟ roles, knowledge and experience in national disaster preparedness and emergency response. methods: an electronic search was conducted using multiple literature databases. all items were included, regardless of the publication year. all abstracts were screened for relevance and a synthesis of evidence of relevant articles was undertaken. relevant information was extracted, summarized and categorized. out of 432 reviewed references, information of 68 articles was included in this review. results: the sub-themes of the first main theme (a) roles of nurses during emergency re sponse include the expectations of the hospital and the public, general and special roles of nurses, assignments of medical tasks, special role during a pandemic influenza, role conflicts during a disaster, willingness to respond to a disaster. for (b) disaster preparedness knowl edge of nurses, the corresponding sub-themes include the definition of a disaster, core com petencies and curriculum, undergraduate nursing education and continuing education pro grams, disaster drills, training and exercises, preparedness. the sub-themes for the last theme (c) disaster experiences of nurses include the work environment, nursing care, feelings, stressors, willingness to respond as well as lessons learned and impacts. conclusion: there is consensus in the literature that nurses are key players in emergency response. however, no clear mandate for nurses exists concerning their tasks during a disas ter. for a nurse, to be able to respond to a disaster, personal and professional preparedness, in terms of education and training, are central. the framework of disaster nursing competen cies of the who and icn, broken down into national core competencies, will serve as a suf ficient complement to the knowledge and skills of nurses already acquired through basic nursing curricula. during and after a disaster, attention should be applied to the work envi ronment, feelings and stressors of nurses, not only to raise the willingness to respond to a disaster. where non-existent, national directives and concepts for disaster nursing should be developed and nurses should be aware of their duties. nursing educators should prepare nurses for disasters, by adjusting the curricula and by meeting the increased need for educa tion and training in disaster nursing for all groups of nurses. the appropriateness of theoreti cal and practical preparation of disaster nursing competencies in undergraduate nursing courses and continuing education programmes should be evaluated. keywords: disasters, disaster planning, emergencies, emergency preparedness, nurses. conflicts of interest: thomas grochtdreis is a member of the german red cross and vice president of the german red cross youth. the other authors do not declare any conflicts of interest. 50 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 introduction disasters are defined by the centre for research on the epidemiology of disasters (cred) as “a situation or event, which overwhelms local capacity, necessitating a request to a na tional or international level for external assistance; an unforeseen and often sudden event that causes great damage, destruction and human suffering” (1). disasters are classified as natural, biological, geophysical, climatological, hydrological, meteorological, and techno logical (2). recent examples of major disasters are the earthquake in haiti in 2010 as an example of a natural disaster and the earthquake followed by a tsunami and the nuclear catastrophe in ja pan in 2011 as an example of a mixed natural and manmade disaster. within the countries of western europe, more than five million people have been affected by a variety of disaster types (e.g., 4,295,600 people affected by storms, 684,492 by floods, and 816 by epidemics) in the last 20 years. within this timeframe, 8,835 people were injured and 38,643 people were killed (3). in order to master a huge number of affected people due to a disaster within a short period, it is important to have well trained first-response personnel or volunteers. here, an essential role is allotted to nurses for integrating communicating efforts across these protagonists and for having role competencies in disaster preparation. it is quite probable that at some time in the future, nurses may be called upon to respond to a mass casualty event or disaster outside of the hospitals. therefore, a need for nurses, who are well trained and prepared, arises on a national as well as on an international level (4). referring to the conditions in the usa, four strengths of nurses, which are key to a central role in disaster preparedness and management, as well as in emergency response, can be stated (5): (i) nurses are team players and work effectively in interdisciplinary teams needed in disaster situa tions; (ii) nurses have been advocates for primary, secondary, and tertiary prevention, which means that nurses can play key roles at the forefront in disaster prevention, preparedness, response, recovery, and evaluation; (iii) nurses historically integrate the psychological, social support, and family-oriented aspects of care with psychological needs of patients/clients; and (iv) nurses are available and practic ing across the spectrum of health care delivery system settings and can be mobilized rapidly if neces sary. however, approximately two out of five health care professionals would not respond during health emergencies. the nurses‟ intention to respond to disasters, the needs of nurses who respond to disasters and other health emergencies, and as well as the influence of the nursing shortage and the lack of education preparing nurses for disaster response are important issues which need to be approached (6). concerning the anticipated needs of nurses during a disaster, giarratano, orlando and savage (7) report that during a disaster nurses have to live through the uncertainty of the situation and have to be prepared to adapt to the needs that arise in both patient care and self preservation situations. in order to prepare for emergency response, education within the field of disaster nursing is essential. disaster nursing curricula and preparation of nursing faculty members are distinctly needed to teach disaster nursing in order to prepare nursing students for possible disaster situations adequately in future (6). extensive work towards a comprehensive list of core competencies has been done by the who and icn in their framework of disaster nursing competencies (8). pang, chan and cheng (9) suggest that this framework should equip nurses with similar competencies from around the world while giving attention to local appli cations. 51 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 there is no comprehensive review covering all relevant fields of professional socialization: role, knowledge and experience. recent reviews do concentrate on either the nurses‟ disaster preparedness, or the response of nurses working during a bioterrorism event (10). the aim of this literature review is to provide an overview of the nurses‟ role, knowledge and experience in national disaster preparedness and emergency response within the international scientific literature. methods search strategy a database search was conducted during september-november 2012 using cinahl (eb sco), pubmed, cochrane library, and carelit. a search strategy was used utilizing the terms „disaster‟ and „nursing‟ as keyword searches or subject headings, where applicable. all study designs as well as expert opinions were included in the review. inclusion criteria were the existence of a relevant abstract on the role, knowledge and experience in the field of dis aster nursing. all results, independent of their publication year and country of publication, written in english or german language, were included. selection criteria in total, 503 articles were identified within the databases; out of these, 71 appeared in more than one database. the abstracts of all included literature (432 references) were scanned for their relevance on the topic. articles were excluded if they definitely lacked relevance, mean ing that the topic of disaster nursing did not appear at all (242 references). as a second step, the articles, which were deemed relevant (190 references), were evaluated in-depth by the first author by initial reading and appraising the relevance in relation to the aim of the litera ture review. articles were excluded if they failed to address nurses‟ role, knowledge or ex perience in national disaster preparedness and emergency response in their full text (103 ref erences) or if they were not available for evaluation (19 references) resulting in 68 included references. a flow chart of the selection process is presented in figure 1. figure 1. flow chart of the selection process 52 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 n=68 no full text avail able: n=19 n=190 double: n=71 data analysis as articles differed in their (study) design, no meta-analysis was possible. therefore, synthe sis of the written evidence was undertaken. categories for analysis, which were predefined through the aim of this literature review, included: (a) roles of nurses during emergency re sponse, (b) disaster preparedness knowledge of nurses and (c) disaster experiences of nurses. for each category, sub-themes were determined out of the different focuses of the articles on disaster nursing (11). for each article, the narratives about a particular sub-theme were ex tracted. the narratives were paraphrased and generalized, where possible. results in total, 68 relevant sources were identified from the literature search. the majority of the studies were descriptive (40%), or expert opinions/case reports (40%). furthermore, 15% of the studies were qualitative and correlational studies, whereas 3% were systematic reviews. the three categories, according to which the articles where analysed, represented also the most important themes: (a) roles of nurses during emergency response, (b) disaster prepared ness knowledge of nurses and (c) disaster experiences of nurses. most of the articles on disas ter nursing were drafted in north america. in europe, no articles concerning disaster experi ences of nurses had been published. below, each theme is divided into paragraphs, which are equivalent to the determined sub-themes. roles of nurses during emergency response the six identified sub-themes include expectations of the public and the hospital, general and special roles of nurses, assignments of medical tasks, special role during a pandemic influ enza and biological terrorism, role conflicts during a disaster and willingness to respond to a disaster. expectations of the public and the hospital: the public expects that nurses are prepared at a personal and professional level and that they have procedures in place, which enable them to pubmed: n=170 abstract not rele vant: n=242 cochrane: n=2 carelit: n=34 cinahl: n=297 article not rele vant: n=103 53 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 serve in an emergency (12). reinforcing, the public has a right to expect effective response from healthcare professional, including nurses (13). moreover, it is anticipated from the hos pitals that nurses know before a disaster what will be expected from them in such a situation, what tasks will have to be fulfilled and who is authorized to issue directives towards them and many employees in hospitals do not know what their role during a disaster will be (14). in order to develop or to optimize the field of disaster nursing nationwide, it is proposed to develop a national committee to help define the discipline, build disaster curricula, and to set disaster competencies. furthermore, nurses need to participate in disaster preparedness plan ning to become familiar with their responsibilities in disaster situations (15). general and special roles of nurses: in general, nurses will have to provide care in a very different context than in their usual practice during disasters (16,17). further, it is imperative that nurses are able to continue working to provide care to additional patients (18). different authors acknowledge that nurses are key players in emergency response (15,17-22). in other words, it can be determined that nurses are in a natural position to assist in a disaster (23), they are the most vital resources in dealing with disasters (24), they have been part of disaster response as long as nurses have existed, nurses will continue to be key players (20) and when nurses are not involved yet in the aspects of disaster care, the involvement should become mandatory (25). particularly, nurses working in disaster-prone areas need to know their pro fessional role in a disaster (26). not every nurse is expected to fulfil any assigned role, and special roles before, during and after a disaster are assigned to nurses with different qualifications (table 1). table 1. general and special roles of nurses nurses meeting surge capacity needs (20) nurses within hospitals (20,27) nurses in general (28-30) nursing executives (31) public health nurses (20) conducting surveillance in the field dispensing mass medication or vaccination in shelters staffing information hotlines in departments of health admitting patients in hospitals identify signs and symptoms of injuries and exposures work in a disciplined team follow clear lines of communication perform according their assigned role directions and responsibilities establish disaster plans train responders coordinate the disaster response provision of care for disaster victims support and protect others from health hazards make life-and-death decisions and decisions about prioritization preserve open lines of communication ensure the quality of patient care, provide current education influence policy and political decisions provide security for staff, patients and families. screening administer first aid and psychosocial support implement infection control procedures and monitoring assignments of medical tasks: during a disaster, nurses are expected to be able to fulfil the role of a medical practitioner in some ways. this role can be described as outside of the nor mal scope of nursing practice, their knowledge or their abilities (32). nevertheless, it is im groups of persons role description 54 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 perative that nurses are trained in disaster medicine in order to be assigned to medical tasks in emergency response (30). the task of triaging patients as an assigned medical task is figured prominently in the literature (19,29,32). special role during a pandemic influenza and biological terrorism: the tasks during epi demic situations are contact tracing, conducting case investigations, engaging in surveillance and reporting, collecting specimens, administering immunizations and educating the commu nity (20). furthermore, in hospital settings, it is expected from nurses to be able to identify, manage and treat infectious outbreaks (32). role conflicts during a disaster and willingness to respond to a disaster: nurses might have conflicts between their professional, their private and their community role, respectively (33). nurses might be therefore less willing to respond to work during a disaster. other reasons influencing the willingness to respond are low baseline knowledge, low perception of per sonal safety, and low perception of clinical competence (34). it is also stated that these fac tors will lead to a shortage of nurses to provide care during a disaster. nurses not responding to a disaster describe having feelings of guilt towards their jobs and co-workers, recognizing the impact of their decision. on the other hand, it is also possible that nurses maintain being able to respond to disasters beyond normal working hours (33). disaster preparedness and knowledge of nurses the six identified sub-themes include definition of a disaster, core competencies and curricu lum, undergraduate nursing education and continuing education programs, disaster drills, training and exercises, as well as preparedness. definition of a disaster: it is acknowledged that nurses might perceive a disaster differently than described from official definitions and classifications such as the one of the cred (1,2). in a study by fung et al. (29), nurses described their perception of a disaster in a fourfold manner. most of the nurses attributed specific characteristics to disasters. exemplarily, these characteristics are being unpredictable, sudden, unexpected or unpreventable, being out of control and not manageable, urgent response, horrible crisis or unknown disease with no treatment available. another way of describing a disaster is by impact, as for example: large numbers of victims, damage to the environment, adverse psychological effects, loss of fam ily, and serious consequences. moreover, disasters were described as demanding emergency services and care. examples are being in need for immediate medical attention, a challenge to professional services or requiring extensive work force to cope. only few nurses described disasters in a way a definition would do: epidemics, accidents, terrorist attacks, natural disas ters, extreme weather and war. core competencies and curriculum: for preparedness purposes, it is very important to have core competencies for education and training as well as for the effectiveness and efficiency of response during a disaster (35). the identification of core competencies and knowledge needed to help and protect self and others during a disaster is an important first step to qualify nurses for disaster response (20,35). weiner (36) refers to the core competencies defined by the nursing education preparedness education coalition (nepec) (table 2). when compar ing knowledge and experiences underpinning these competencies with nursing practice, it can be concluded that many of them are basic to a nursing curriculum (35). furthermore, others claim that nurses already possess the skills enabling them to respond to a disaster. these are purported to be the values of human caring, creativity, the ability to improvise, communica tion and management skills (20,23). on the other hand, usher and mayner (22) state that working in an emergency department or a similar area is (still) not good enough to meet the 55 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 required competencies to respond to a disaster. others claim that nurses working in acute care already have specific disaster nursing core competencies (28). some authors annotate that the area of disaster nursing is underrepresented or lacking in un dergraduate nursing curricula, nurses and nurse practitioners are not able to meet required disaster nursing competencies and that it is urgent to include content in order to enable nurses to respond in times of disasters (6,12,15,17). nursing educators are hold accountable to pre paring nurses for disasters, for example by adjusting the curricula and by meeting the in creased need for education and training in disaster nursing for all groups of nurses (6,17,37). concerning a disaster curriculum, lund et al. (30) propose seven modules for a comprehen sive nursing curriculum to address chemical and biological warfare (table 2). elsewhere, such a training of specialized skills and knowledge is criticized because they are unlikely to be retained until an opportunity to use them is afforded (38). others propose educational components that are more medically oriented (table 2) (14,24). undergraduate nursing education and continuing education programs: the fields of under graduate education and continuing education programmes for nurses are widely discussed in the literature. because nurses have to be aware of disasters and be prepared for them, it is imperative that disaster management and nursing contents and experience are integrated into undergraduate nursing and continuing education programme curricula (15,17,22,24,35,39 41). it has to be acknowledged that all nurses, irrespective of being educated and trained or not, may be called during a disaster and therefore, all nurses must have a minimal knowledge and skills for appropriateness of their response (17,26,29,35). education is critical to the feel ing of safety and competence as well as the willingness to participate in an emergency (32,34), but it needs to be tailored according to the specific needs of the location such as ca pacity and expected role of nurses (16). for australia, usher and mayner (22) state that the theoretical and practical preparation of disaster nursing competencies in undergraduate nurs ing courses are inadequate or only little is known about the inclusion and that professional development opportunities are needed. one possibility for an adequate provision of knowledge and skills required in a disaster could be the collaboration and sharing of knowledge between nursing schools and the military medical communities as well as other trained medical professionals, for example volunteers from the red cross or red crescent and other medical response teams (17). another effec tive strategy might be the dissemination of information and educational materials related to disasters (18). it is central that nurses receive education which is specific to their actual knowledge and skills in order to not duplicate efforts or miss important content because the more advanced nurses are, concerning both experience and knowledge, the more likely they are to implement advanced disaster nursing (15,32,35). disaster drills, training and exercises: drills and training play also an important role for dis aster preparedness. it is concluded, that intensive training and periodical drill programs simu lating hospitals‟ emergency plans will improve capabilities of nurses for emergency response (15,20,21,31,42,43). all nurses are recommended to participate in periodic emergency re sponse drills and disaster training, and nursing schools should collaborate with the local ems to give their students a disaster field experience and to expedite teamwork between first re sponders and first receivers, because during a disaster an enormous pool of nurses will be needed (20,21,23,25,35). further reasons for participating in and specific issues for disaster training are described in table 3. others contrarily describe specific medical tasks and conclude that these tasks should be tailored to the nurses‟ background knowledge and clinical experience (13,16). 56 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 with any disaster training, a broad range of topics should be covered in order to prepare nurses to function in disasters due to any hazard and settings other than their work settings (41). goodhue et al. (21) conclude that having disaster training, besides having a specified role in the workplace disaster plan, is the most easily modifiable variable with the most im pact on increasing the likelihood of response in the event of a disaster. preparedness: disaster preparedness of nurses is pivotal to the ability and capacity to re spond as well as the delivery of effective disaster response (6,18,24,33). there are two ways of viewing preparedness, personal preparedness and professional preparedness. special atten tion is given to bioterrorism preparedness, because being especially prepared for bioterrorism and thus infectious disease emergencies, has a positive impact on patients, families and the nurses themselves, for example by preventing a secondary spread (18,45). furthermore, bioterrorism preparedness readies nurses for other disasters, because the skills and response actions are the same and misconceptions can be prevented (46). due to this importance, bioterrorism preparedness should be part of continuing education and nursing school curric ula (18,43). other special fields where preparedness is necessary are described in table 4. 57 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 table 2. core competencies and disaster curriculum core competencies de fined by the nursing emergency preparedness education coalition (nepec) (36) already existing specific disaster nursing core competencies of nurses working in acute care (28,41) disaster curriculum modules of lund et al. (30) nursing curriculum to address chemical and biological warfare (40) medically oriented edu cational components (14,24) protect self and others from harm participate in a multidisciplinary, coordinated response communicate in a professional manner recognize disaster situations and potential for mass casualty events seek additional information and resources needed to manage the event recognize your roles and limitations in disaster response efforts cope with challenges that occur in disaster situations define terms relative to disaster management response discuss ethical issues related to mass casualty events describe community health issues related to mass casualty events triage securing of personnel, supplies and equipment recordkeeping patient transport decontamination patient management of specific illnesses and injuries patient management of special needs population evacuation development of disaster plans ethics response to stress reactions anatomy of a disaster epidemiology of disaster disaster planning communications in disaster introduction to disaster medicine introduction to pathophysiology of disaster the disaster response introduction to biological and chemical terrorism surveillance systems for bioterrorism identification of agencies communication response systems biological and chemical agents of concern mass immunization decontamination and mass triage therapy and pharmacology psychosocial effects of terrorism nursing leadership during emergencies first aid basic life support advanced cardiovascular life support infection control field triage pre-hospital trauma life support advanced trauma care nursing post-traumatic psychological care peri-trauma counselling description contents 58 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 table 3. reasons for participating and specific issues for disaster training reasons for participating in disaster training (10,13,15,18,21,24,26,27) specific issues for disaster training (38,43,44) specific medical tasks (13,16) test and maintain disaster preparedness create awareness for disasters in general create awareness for physical and mental limits increase personal safety increase confidence in disaster management minimize emotional and psychological trauma triage mass casualty management (bio-) terrorism preparedness communications command and control interagency cooperation waste management decontamination personal protection cardiopulmonary resuscitation central venous catheter insertion trauma care table 4. personal and professional disaster preparedness personal preparedness (15,18-20,27,47) professional preparedness (15,19,26,27,29,47) special fields of disaster preparedness (33,34,40) go-pack containing essential personal supplies preparing and protecting the family personal plan for times of disaster knowing employment contract statement about obligation to report to duty during a disaster pre-registering in a disaster registry developing and knowing disaster plans assembling emergency supplies studying evacuation or shelter options ongoing training and drills experience in disaster nursing bioterrorism disasters involving special need populations chemical or radiation disasters according to al khalaileh et al. (15), jordanian nurses consider themselves being weakly to moderately prepared for a disaster and think that additional training would be beneficial. the same issues are made out for hong kong nurses and the existence of a lack of understanding their preparedness needs with regard to disaster is concluded (24,29). being prepared for a disaster as a nurse might maximise safe conditions, decrease vulnerability and minimise risk to individuals during a disaster (12). disaster experiences of nurses the six identified sub-themes are work environment, nursing care, feelings, stressors, and willingness to respond to disasters and to treat patients as well as lessons learned and impacts. description contents description contents 59 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 work environment: nurses will experience challenging working conditions, an environment of fear and difficult infection control requirement conditions during a bioterrorist event (10). nurses believe that during a disaster will be a chaotic clinical environment without a clear chain of command, with insufficient protective equipment and little freedom to leave (47). manley et al. (38) assume, even if hospitals are well prepared, that during a disaster will be chaos, inadequate resources, deaths and injuries, confusion and contention over who is in command, lapses in security and breakdowns in communication. during a disaster, problems concerning organizational and social supports caused by challenges with care for children, elderly or pets during prolonged shifts and quarantine might also prevail (48). nursing care: nursing care during a disaster is a special type of care because of the excep tional situation and the change of routine. during a disaster, care is provided by an interde pendent team of nurses, clinicians and ems professionals, each playing unique roles (41). thus, nurses especially feel as advocates for their patients, especially those who are fright ened or most vulnerable, and their merits of caring and unity are the most appreciated aspects of their rescue experience, reinforced through communal sprit with their colleagues and the feeling of being rewarded by the victims (7,27). nurses are confronted with conflicts and ethical issues when working during a disaster. because of increased staff requirement and the allocation of resources nurses come into conflict with the delivery of dependent care (27,48). other challenges for nurses are the identification of unfamiliar infectious agents, long work ing hours, limited supplies, unfamiliar environments, provision of care to infected patients, or fear of infection (10). chaffee (49) concludes that tasks like triage, quarantine and mandatory administration of medication might be ethically challenging during a disaster. if uncertainty of the conditions worsens, nurses might experience discouragement and fear (7). feelings: on the one hand, nurses feel guilty when taking leave, are concerned about causing pain and distress to their patients, are overwhelmed by the scale of the tragedy, feel disgusted or distressed at the nature of the injuries and the scale of the suffering or felt apprehensive about being able to cope. on the other hand, nurses also feel excited and challenged by what they have to do, or feel to be valued as much-needed colleague (50). anger towards people in authority, because of the expectation to fulfil the duty to care, is another feeling described by nurses (7). fear, anxiety, stress and confusion are perceived to be felt in the event of bioter rorism. fears might arouse in consequence of the possibility of acquiring a lethal disease from exposure to an infectious agent, transmitting an infectious agent to other patients or the family, lack of knowledge about disease agents, isolation procedures, and access to content resources (47). other feelings might be uncertainty, hopelessness, or abandonment related to the issue of chaos in general and evacuation in special (7). stressors: there is a widespread assumption that nurses “by virtue of their training and per sonality traits are relatively impervious to the effects of distressing experiences”, such as dis asters (50). newer studies disqualify this assumption, because for example, the work of nurses can be compromised when a lack of adequate rest, poor nutrition, erratic eating pat terns and insufficient fluid intake prevails (26). other stressors might be information and work overload, crisis, confusion, uncertainty, chaos, disruption of services, casualties, or dis tractions with crowds and media, decline of infrastructure, limited medical supplies and loss of electricity and potable water (7,25,31,47,48). moreover, poor knowledge and working skills, combined with a heavy workload and lack of equipment, leads to emotional distress during a disaster (25). a disaster can also lead to personal trauma because of the experienced loss of homes, workplaces, and close relationships as well as suffering or dying patients (7). willingness to respond to a disaster and to treat patients: main issues related to a reduced willingness to treat patients during an epidemic include having a high level of concern about 60 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 an infection and lack of medical knowledge (46). during a disaster, nurses will have the same vulnerability to property damage, injury or displacement, will have fear and concern about own and family‟s safety and will, therefore, have to make a decision whether to report to work or to care for oneself, one‟s family, or personal property (49). other reasons for unwill ingness to respond to a disaster are responsibilities to children or elderly, a second job, trans portation issues or obligations to care for a pet (49). goodhue et al. (21) found out in their study that less than one third of paediatric nurse practitioners would definitely respond during a disaster. one result of the study of o‟boyle et al. (47) is that many nurses would leave hos pitals or would not report for work when a bio-terroristic event occurred. not all nurses will be willing to respond to chemical, biological or radiological disasters, because of personal risk and not all nurses will be able to respond because of the unavailability of personal pro tective equipment (33). in order to raise the willingness to respond to a disaster, nurses need to be educated on what the hospital expects from them and what the implications of certain choices of not responding to work will be (49). other factors might be: knowing that family members are safe and pro vided for, having a home disaster plan, having disaster training, having an assigned role in the workplace disaster plan and prior disaster experience (21). lessons learned and consequences: based on experience, often lessons learned and conse quences for the future are stated. ammartyothin et al. (42) conclude that medical personnel, such as volunteers, should be incorporated into the organic medical staff during a disaster as well as that communication systems are important for disaster management and have to with stand the actual event and the unavoidable. as a health institution, it is important to find out about the nurses‟ determinants of reporting for work when a disaster strikes in order to be better prepared (46). during a disaster, it is imperative, that food, water and a place to sleep or a quiet area are available for continued functioning of nurses. in order to ensure an effec tive response, nurses need to build functional partnerships with physicians, to support one another and to express a sense of responsibility and empathy for colleagues and patients (7,25,39). for future disaster responses, the performance of nurses during a disaster needs to be evaluated and the most frequently used skills need to be identified for further training (13). discussion concerning the general role of nurses in disasters, different attributions are observed. on the one hand, there is international consensus that nurses are key players in emergency response is somehow contemporary. on the other hand, it does not seem finally clear which expecta tions are cherished towards nurses. is it only the continuation of the provision of care in dif ferent circumstances or is the assumption of medical tasks, in fact? of course, not every nurse needs to be able to fulfil every role, but medical tasks during a disaster might be mandatory to undertake. it does not become finally clear from the literature review which medical tasks most certainly are needed in general and particularly for specific disasters. moreover, hetero geneity about the field of application of nurses exists in the literature. in some it is described, that nurses will work on-site of the disaster area in others nurses will be deployed in their own hospital or in a hospital in the proximity of the disaster area and yet in others nurses will work in the community. these heterogeneities surely are due to the different healthcare sys tems and professional qualifications in the different countries, a diversity that is remains un answered in this review. however, it seems convincing that preparedness for a disaster as well as an effective response are expectations of the public towards nurses in all countries. special attention is given to the roles of nurses before and during a pandemic influenza and biological terrorism. nurses have a share in the identification, management and treatment of 61 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 infectious outbreaks. again, the specific tasks during such an event are dependent on the pro fessional education of the nurses. the professional roles during a disaster might be in conflict with the personal duties in the family and in the community. such conflicts can undermine supply of work force during a disaster immensely. the definition of disaster is perceived differently by nurses than from the officially used defi nitions. officially used definitions mainly focus on the cause of a disaster. thereby, the pas sage between a mass casualty event and a disaster is fluent. for nurses, a disaster is mainly considered through the impact it has for their daily work, the persons who they care for and their own life. thus, the unpredictability and suddenness as well as the number of victims, their injuries and clinical picture play a greater role in the perceptions of nurses. furthermore, terrorism does not explicitly appear in the disaster classification of the cred; yet, nurses do think that terrorism might be a threat for their country (2). in order to be prepared for a disaster, it is important to define core competencies applicable to the different professional qualifications of nurses. a comprehensive list might be the who and icn in their framework of disaster nursing competencies (8). this supranational framework has to be broken down into national core competencies for nurses and a list of competencies for undergraduate and continuous nursing education, at the end, because it may very well be the case that some knowledge and skills acquired through basic nursing curricula already equip nurses for disaster response. on the other hand, some disaster nursing compe tencies might be highly specialized, and thus uncommon in practise as well as unlikely to be retained. thereby, a careful choice between specialization and generalization of skills and knowledge for undergraduate and continuous nursing education should be made. both, undergraduate education and continuing education programmes have to raise awareness and preparedness for a disaster adequately. by tailoring education to the local needs, such as the likelihood of specific disasters or existing disaster plans, and the needs of the nurses, such as the requirements for general disaster management knowledge or specialized medical skills, all nurses should be able to respond to a disaster appropriately. it remains unclear which strategy for the education of nurses in disaster management is the most effective. the col laboration with medical communities and other medical response teams, as well as the dis semination of information materials on the topic seem to be promising, not only for education but also for drills and training. emergency response drills and disaster training are important elements of individually and professionally preparing nurses for disaster and evaluating exist ing disaster plans. again, emergency response drills and disaster training need to be tailored according to the local needs and the needs of the nurses, leading to an improvement of the nurses‟ willingness to respond to a disaster and the response as such. being prepared for a disaster as a nurse means being personally and professionally prepared. nurses are considered to be personally prepared, when they are able to protect their family as well as when they know their obligation to report to duty during a disaster and have all their essential personal supplies standing by. professional preparedness of nurses means the regis tration in a relevant disaster registry, knowing the disaster plans and being trained. further more, special preparedness is needed for nurses‟ working areas with special needs popula tions and specific disaster types. the work environment of a nurse during a disaster will likely be challenging and chaotic. nurses need to know beforehand what they might expect; therefore, preparing them through education and training is essential. furthermore, a need for a good disaster plan, where chains of command and effective alternatives in communication are described, arises considering the high possibility of an adverse work environment. for nurses, it has to be clear, that care dur 62 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 ing a disaster differs from the routine work. interdependence in a team will become even more important as well as advocacy for patients, the allocation of resources and ethically challenging decisions (for example, during triage). during a disaster, negative feelings, such as guiltiness, disgust, anger or fear, are dominant in descriptions of nurses‟ experiences, besides positive feelings of excitement or being chal lenged. no information is given on the impacts of those feelings on working capacity and mental health. nurses also experience specific stressors during a disaster, likely leading to emotional distress and possibly to personal trauma. these stressors can either have a personal character, such as uncertainty about the safety of the family or themselves, an organizational character, such as being cut-off from support sources, and an occupational character, such as hazards, lack of equipment or high workload. the willingness to respond to a disaster is dependent on the level of concern, responsibilities and the medical knowledge of nurses. concern may exist for example due to property dam age or own and family‟s safety, responsibilities may be towards children, elderly or another employer. it is important that nurses are educated and trained on the expectations of the hos pitals and that they have their own disaster plan. disaster experiences importantly should lead to impacts for the future, the so-called lessons learned. often, these lessons learned refer to optimizing communication systems, nurses‟ determinants of reporting for work, controlling the hospital environment during a disaster and the knowledge and skills of nurses. nurses themselves will acquire experience, and might rethink their commitment to nursing. in summary, it can be stated that, after a disaster is, with all probability, before a disaster and it is therefore inevitable to prepare anew. conclusions and implications it seems self-evident that nurses are key players in emergency response. in order to prepare nurses for disasters, clear roles should be defined according to the professional education of the nurses, which should be communicated beforehand. these roles of nurses during a disas ter should be realistic in relation to their skills and practical experiences. in order to raise the availability of nurses during a disaster, roles should be adjusted to each nurses‟ personal du ties in the family and in the community, in the best case. roles should also be tailored ac cording to the characteristics of the different disaster types, with special attention to pan demic influenza and biological terrorism. in order to satisfy public expectations towards nurses, national directives and concepts for disaster nursing should be developed, where non existent, and nurses have to be called attention to their duties. moreover, distinctions towards roles of physicians and nurses during a disaster are needed in order to define the medical tasks of nurses clearly, which have to be trained and performed during a disaster. existent definitions of disasters seem not to be appropriate for the working environment of nurses. defining disasters out of the experience of nurses could help to give a better under standing for such a sweeping event. a definition from the perspective of a nurse could be an unpredictable, sudden event that is hardly but urgently manageable with serious conse quences to the population and environment demanding an extensive need for professional health services personnel. in order to develop national disaster nursing core competencies, the framework of disaster nursing competencies from the who and icn (8) should be interpreted for the needs of each professional group of nurses. national disaster nursing core competencies then should be adjusted to the demands formulated in the undergraduate nursing curricula in order to meet the national criteria. nurses should receive education and training tailored to the local needs and their actual competencies. collaboration with relevant national institutions and organiza 63 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 tions is indicated for making education and training in disaster nursing more efficient, pre cisely if nursing educators are not knowledgeable in the field of disaster nursing. for personal and professional preparedness and in order to raise willingness to respond, nurses need to pack their essential personal supplies standing by for emergencies, need to know that their families are protected and need to be registered in a disaster registry as well as know their relevant disaster plan. a personal disaster plan will help to arrange personal matters when responding to a disaster. in order to counteract the high possibility of challenging and chaotic working conditions dur ing a disaster, nurses need to be prepared for many situations and hospitals need to develop or improve their disaster plans. it has to become a given for every nurse, that nursing care dur ing a disaster will change from its routine way, including all consequences, such as the allo cation of resources. not much is known about the feelings of nurses responding to a disaster and their resistance to stressors. in order to be able raise the willingness to work in a disaster, it is imperative that possible distressing situations during a disaster are identified and reduced, and nurses become prepared for coping. it is central to learn from a disaster experience and to prepare anew. not only will the optimizing of processes during a disaster written down in a disaster plan have to be evaluated, but the performance of the nurses who were on duty and the reasons of the non performance of the nurses who were not able or not willing to respond to the disaster, as well. an overview of the implications and the relevance to nursing practice, nursing education and research is presented in table 5. table 5. relevance to nursing practice, nursing education and research all nurses, regardless of their professionalization, need to receive disaster preparedness education in their undergraduate and continuous nursing education, in order to have a great pool of nurses during a disaster. all nurses should periodically take part in emergency response drills and disaster training in order to be prepared for disasters. for being prepared for a disaster and willing to respond, nurses need to be personally and profession ally prepared. a personal disaster plan will help to arrange personal matters. hospitals need to have a disaster plan, wherein chains of commands, alternative communications and task descriptions for groups of nurses during disasters are described. during a disaster, the routine way of nursing care changes and nurses need to be prepared to make ethically challenging decisions. nursing educators should prepare nurses for disasters, by adjusting the curricula and by meeting the increased need for education and training in disaster nursing for all groups of nurses. nursing research should find definitions of disasters appropriate for the working environment of nurses. research should be done in order to review the appropriateness of theoretical and practical preparation of disaster nursing competencies in undergraduate nursing courses and continuing educa tion programmes. disaster preparedness of nurses needs to be evaluated regularly in order to maximise safe conditions, decrease vulnerability and minimise risk to individuals during a disaster. distressing situations for nurses during a disaster should be identified and reduced, nurses should be prepared by equipping them with possible coping strategies through education and post-disaster psy chosocial care should be ensured. relevance to nursing practice: relevance to nursing education and research: 64 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 references 1. guha-sapir d, vos f, below r, ponserre s. annual disaster statistical review 2011: the numbers and trends. université catholique de louvain, brussels, belgium, 2012. http://cred.be/sites/default/files/2012.07.05.adsr_2011.pdf (accessed: december 13, 2016). 2. international federation of red 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conflict among nurses during large-scale outbreaks. prehosp disaster med 2009;24:321-5. 49. chaffee mw. disaster care. making the decision to report to work in a disaster: nurses may have conflicting obligations. am j nurs 2006;106:54-7. 50. alexander da. burn victims after a major disaster: reactions of patients and their care-givers. burns 1993;19:105-9. © 2016 grochtdreis et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0)� 67 senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 review article the emerging public health legislation in ukraine iryna senyuta1 1 danylo halytskyi lviv national medical university, lviv, ukraine. corresponding author: assoc. prof. iryna senyuta, ph.d. in law, head of the department of medical law of the danylo halytskyi lviv national medical university; address: solodova street 10, 79010, lviv, ukraine; email: prlawlab@uk.net mailto:prlawlab@uk.net� 68 senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 abstract as ukraine has started the legal process for a public health legislation, this narrative review attempts to: i) characterize recent legal acts (which are current as well as drafts) and international standards in the sphere of public health; ii) analyze the definitions of public health legally relevant to ukraine, in particular: public health and public health protection; iii) discuss related definitions relevant to the health sector; iv) characterize the main subjects tasked to protect public health; v) and clarify the necessary educational innovations, which are the basis in the preparation of human resources for an efficient implementation of the public health concept. after referring to the current legislative process and a discussion of some of the concepts and terminologies available in the literature, the following understanding of the terminology is proposed here: i) ‘public health’ should be understood as mental and physical health of the population in a certain territory, determined by the best achievable demographic indicators, characterized by decreasing morbidity and mortality and increasing the potential to lead an active and long life; ii) the term ‘public health protection’ (or, ‘protection of public health’) should address a system of measures which are aimed at prevention and control of morbidity, optimization of demographic indicators, promoting a value-oriented state policy, securing biological and genetic safety and relying on joint societal efforts. it is essential that the implementation of a public health law is underpinned by adapting the postgraduate educational system to the new challenges in ukraine. keywords: health care, multiprofessionality, public health, public health protection, ukraine. conflicts of interest: none. acknowledgements: the author expresses her cordial gratitude to prof. ulrich laaser, faculty of health sciences, bielefeld, germany, for his valuable comments and input. 69 senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 introduction ukraine entered an active process to integrate public health into the national health system as part of the wide spectrum of transformations of all ukrainian systems. the “embryo” of public health has a long national history. in the historical context, it is worth paying attention to the state sanitary-epidemiological service, which was responsible for protection of public health and had two main functions, i.e. control of communicable diseases and environmental protection (monitoring the quality of water, air, soil and food) (1). scholars, who worked on various aspects of public health development in ukraine include y. bazylevych, i. gryga, n. chala, v. moskalenko, v. lekhan, v. rudiy and others. in particular i. gryga researched the issue of public health funding in ukraine and proved the idea of introducing official patient payments in ukraine in order to avoid informal or quasi official payments (2). the system of state bodies responsible for public health protection was the focus of interest of v. lekhan and v. rudiy (1). this process started to actively develop when ukraine signed the association agreement with the european union in 2014 (3). the article 426 of chapter 22 of the association agreement foresees that the parties shall develop their cooperation in the field of public health, to raise the level of public health safety and protection of human health as a precondition for sustainable development and economic growth. a conceptual provision of the association agreement within its chapter 22 is the “health in all policies” approach. hence, public health and health care should be a starting point for the state authorities to develop policies benefitting their population, since human wellbeing constitutes the core of any health system. correspondingly, the article 3 of the constitution of ukraine states that an individual, his or her life and health, honour and dignity, inviolability and security shall be recognized in ukraine as the highest social value. value-oriented law-making foresees the satisfaction of universal human needs and interests and it creates a relevant social toolset to meet these objectives. in the philosophical-legal interpretation, a value means objects, phenomena, social processes and their features, which are treated by a human being as those, which satisfy his or her social needs, interests, desires and which he or she involves to one’s sphere of life activity (4). public health is a collective good, which has an individual value effect – human health. in this paper i try to elucidate some aspects of the formation and development of the public health concept as a national ukrainian paradigm; to clarify the terminological framework as a basis for the creation of the forthcoming public health legislation; to define public health in the ukrainian environment and characterize the main educational innovations to support the preparation of well-trained human resources. in order to achieve these objectives the following is required: i) to characterize recent legal acts (which are current as well as drafts) and international standards in the sphere of public health; ii) to analyze the definitions of public health legally relevant to ukraine, in particular: public health and public health protection; iii) to discuss related definitions relevant to the health sector; iv) to characterize the main subjects tasked to protect public health; v) and to clarify the necessary educational innovations, which are the basis in the preparation of human resources for an efficient implementation of the public health concept. recent legal initiatives in ukraine currently, the establishment of an effective public health system is one of the priorities of the ukrainian ministry of health (3). in a strategic document of the world health organization (who) regional office for europe, issued in 2012: “health 2020: a european policy framework supporting action across government and society for health and well-being” (5), it 70 senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 is noted that “...all 53 member states in the who european region have agreed on a new common policy framework – health 2020. their shared goals are to “significantly improve the health and well-being of populations, reduce health inequalities, strengthen public health and ensure people-centred health systems that are universal, equitable, sustainable and of high quality”. recommendations of the parliamentary hearings on the topic: “on health care reform in ukraine” of 21 april 2016 (6), which is currently the sole strategic document for the envisaged transformations of the health system, also encompasses the public health sector. the ‘recommendations’ define the list of tasks of the state bodies with regard to public health, including: • development and approval of the concept of the public health system reform; • preparation of a draft-law on the public health system in ukraine; hence, the government started coordinating a process aiming at the legal foundation of a national system of public health, which should include the following elements: • a modern system of epidemiologic surveillance of communicable diseases; • a modern system of epidemiologic surveillance of non-communicable diseases; • creating a system of public health, which is based on the principle “ukraine 80+”. for the first time the principle “ukraine 80+” was mentioned in the agenda of the head of the committee on health of the verkhovna rada of ukraine, namely professor o. bogomolets (“health care reform: 25 steps to happiness”). in order to implement this principle it was foreseen that there should be developed such a system of public health which would secure an increase in life expectancy of the ukrainian people. however, this principle was not further legally established in order to be implemented, except for some initial measures of organizational character, in particular official meetings with the european union representatives. subsequently, the “concept of public health system development in ukraine” (7) (hereinafter – the “concept”) and the draft “law on principles of state policy of health care” (8) (hereinafter the “draft law”) have been issued. for the first time, the draft concept foresees the definition of the term ‘system of public health’, which is a set of instruments, procedures and measures, which are implemented by state and non-state institutions in order to strengthen the health of the population, prevent disease, support an active aging, and promote a healthy lifestyle, as a joint effort of the whole society. the draft law attempts to provide a legal definition of the public health notion as a set of activities aiming at the maintenance and strengthening of the health of the population and increasing life expectancy. the state agencies and the bodies of local self-government are responsible for the organization of these societal efforts. definitions of public health legally relevant to ukraine since the legal framework for a system of public health is under consideration, the terminology and meaning of the central term ‘public health’ has to be thoroughly examined. there are many scientific and legal definitions of this term. therefore, a comparative discussion has to be conducted with regard to terms and concepts relevant to the health system. one of the oldest definitions has been formulated by charles-edward winslow in 1920: “public health refers to the science and art of preventing disease, prolonging life and promoting health through organized efforts and informed choices of society, organizations, public and private, communities and individuals” (9). according to the who definition in 1978 (10): “public health is the science and art of preventing disease, prolonging life and https://en.wikipedia.org/wiki/health� 71 senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 promoting mental and physical health and efficiency through organized community efforts for the sanitation of the environment, the control of communicable infections, the education of the individual in personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of social machinery to ensure to every individual a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity”. the dimension of health according to who refers to “...a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. also, this understanding of public health incorporates the interdisciplinary approaches of epidemiology, biostatistics, community health, behavioural health, health economics, health management, health policy, health insurance, mental health, and occupational health as important subfields. however, probably, the most common definition has been coined by donald acheson in 1988 (11): “public health is the science and art of preventing disease, prolonging life and promoting health through organised efforts of society”. in contrast, in john last’s famous dictionary of public health in 2006 (12), it reads as follows: “the mission of public health is to protect, preserve and promote the health of the public. public health is the art and science of promoting and protecting good health, preventing disease, disability, and premature death, restoring health when it is impaired, and maximizing the quality of life when health cannot be restored. public health requires collective action by society; collaborative teamwork involving physicians, nurses, engineers, environmental scientists, health educators, social workers, nutritionists, administrators, and other specialized professional and technical workers; and an effective partnership with all levels of government”. ukrainian laws in force do not foresee a legal definition of the term public health; the above mentioned draft legal acts do that for the first time. it is worth paying attention to the legislation of other countries, which have special laws with a relevant legal glossary. for instance, the article 3 of the ‘law of georgia on public health’ of 27 june 2007 (13) provides a definition of the term ‘protection of public health’ as a set of measures aimed at improving the health of the population, prevention and monitoring of diseases. the article 1 of the ‘law on public health’ of the kyrgyz republic of 25 june 2009 (14) defines ‘public health’ as the health of the population or certain groups and communities defined by a geographic, social or another characteristic, which is evaluated by demographic indicators, characteristics of physical development, morbidity and disability, whereas ‘public health protection’ is defined as a system of measures, directed at the protection of public health, prevention of diseases, prolongation of life and strengthening of human health owing to organizational efforts of all parties, the population, public and private organizations, communities and individuals. these two examples demonstrate that the respective legislators have adapted elements from the aforementioned definitions which are deemed relevant in their national contexts. related definitions relevant to the health sector however, terminological problems can easily occur importing and translating terms during the process of their adaptation to national legal systems. for example, in chapter 22 of the association agreement (3), the term ‘public health’ is used solely to define the name of the chapter but in the text of the agreement the term ‘health care’ is used, which has a different meaning underlining individual health rather than population health. https://en.wikipedia.org/wiki/interdisciplinary� https://en.wikipedia.org/wiki/epidemiology� https://en.wikipedia.org/wiki/epidemiology� https://en.wikipedia.org/wiki/epidemiology� https://en.wikipedia.org/wiki/community_health� https://en.wikipedia.org/wiki/community_health� https://en.wikipedia.org/wiki/community_health� https://en.wikipedia.org/wiki/health_economics� https://en.wikipedia.org/wiki/public_policy� https://en.wikipedia.org/wiki/insurance_medicine� https://en.wikipedia.org/wiki/occupational_safety_and_health� 72 senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 taking into consideration the definitions of public health discussed so far, it is worthwhile to relate the term ‘public health’ to other terms in the field of health care and identify its place in the relevant system. especially relevant for the ukrainian legislatory process is the understanding of public health as the health of the population impacted by activities which are not restricted to the public sector – a common misunderstanding of the terminology. therefore, we propose to consider in addition the term “public health protection” which denotes the set of activities to be performed not only by the public services in order to achieve the best possible public health (health of the population) as a vision and objective. also, verweij and dawson (15) for example argue that the term ‘public health’ combines two words, each of which can be ambiguous and that among the many definitions of public health, the word “public” has two general interpretations. in a straightforward interpretation, “public” is an aggregate concept and is equated with the “population”. in this meaning, “public health” refers to the state of population’s health in general or a certain population group. the second interpretation of “public” is in terms of “collective action”, which has the goal to protect and promote a population’s health alongside efforts to prevent diseases. although historically, the same term “public health” was used in both meanings to characterize the state of the population in general and to define joint measures, which have to be taken in order to protect and improve such health (16). in the ukrainian context, it seems preferable to apply two different terms: “public health” – to define a state of health of the population and “public health protection (or: “protection of public health” – to describe collective measures. however, most scholars agree that the essence of public health is the prevention of diseases, in order to maintain and strengthen both individual and collective (population’s) health (17). with reference to the above considerations, in the ukrainian legislatory process, the following understanding of the terminology should be adopted: • public health is understood as mental and physical health of the population in a certain territory, determined by the best achievable demographic indicators, characterized by decreasing morbidity and mortality and increasing the potential to lead an active and long life. • under the term ‘public health protection’ (or, ‘protection of ‘public health’) we understand a system of measures, which are aimed at prevention and control of morbidity, optimization of demographic indicators, promoting a value-oriented state policy, securing biological and genetic safety and relying on joint societal efforts. according to article 3 of the law of ukraine on: “principles of ukrainian health care legislation” (18), medical care is the activity of the professionally trained medical workers, aimed at prophylaxis, diagnosis, treatment and rehabilitation pertinent to diseases, injuries, intoxications and pathological conditions, as well as pregnancy and childbirth. consequently, the complexity of public health’s legal nature is caused by its multidisciplinary character, which generates the following formula: “medical care” and “public health protection” are partially overlapping in the area of prophylaxis. at the same time, both terms are part of the umbrella term ‘health care’. hence, both terms are within the realm of ‘health care’. the term ‘medical care’ by its content is narrower than ‘public health protection’, since providing equal access to effective and high quality medical care is only one of the functions of the protection of public health. on this basis, the main functions of the protection of public health include: • monitoring: evaluation, analysis, and comparison of the state of health of the population in order to identify the existing problems and develop priorities. 73 senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 • control: provision of biological and genetic security, decreasing the morbidity level. • prevention: prophylaxis of diseases and formation of a healthy lifestyle of the population. • strategy and coordination: formation of the state and local policy on the basis of “health in all policies”. • communication: interaction of different subjects in terms of implementing the values of public health protection into social and state life. • medical: securing equal access of the population in general and each person in particular to high-quality and effective medical services. • integration: consolidation of the national and international efforts aimed at the protection of public health. public health service according to paragraph 1.2 of the concept (7), the key central body of executive power, which is responsible for the management of public health system, is the ministry of health of ukraine. the department of public health as a structural subdivision is targeted at securing proper management of the public health system. in order to implement policy and provide services in the sphere of public health at the national level, on 31 may 2016, the government established a state institution “centre of public health of the ministry of public health of ukraine” (hereinafter – the centre). according to its charter, the centre is a scientific and practical institution of medical profile, which fulfils the following functions: ensure the permanent strengthening of the population’s health; carrying out social and hygienic monitoring of diseases; epidemiological supervision and biological security; conducting the group and population oriented prophylaxis of morbidity; combating epidemics; and execute the strategic management of all public health issues. at the regional level, it is foreseen to create regional centres of public health. at the level of districts and cities, the provision of public health services will be coordinated by a public health specialist (epidemiologist) of the regional centre who will be appointed to a certain territory. the concept also envisages that family doctors, mid-level medical personnel and representatives of the civil society should be involved in public health services. preparing human resources for the implementation of the upcoming public health legislation when creating a new structure no less important are the human resources, which will be the element of the system that takes responsibility to implement a state policy in the sphere of public health. an important step in area of education was made after the resolution of the cabinet of ministers of ukraine passed on 23 november 2016. according to this resolution, a new specialty labelled “public health” was added to the list of fields of knowledge and specialties, according to which, persons who receive higher education, are trained. this step became a foundation for the implementation of bachelor and master programs on public health. consequently, this new sector will promote the professionalization of the public health workforce. currently, in ukraine, schools of public health are being actively established and these schools will be the major centres responsible for educating the new generation of public health professionals. on the one hand, according to the multidisciplinary character of public health, specialists can be trained after different undergraduate studies (bachelor programs) and, on the other hand, training of professionals is conducted with a focus on different competencies, which are necessary for the public health sphere (for instance, with a legal specialization). 74 senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 one of the examples of innovations in the sphere of education includes the departments of medical law, which were established within medical schools. these departments are to provide advanced training for health care managers and physicians. therefore, they should be involved in the training of public health professionals, especially for those who are going to specialise on legal issues of public health. in this respect, the example of the department of medical law of the danylo halytskyi lviv national medical university is of interest, which became already an associated member of aspher (19). at this department, a postgraduate course on medical law has been established targeting physicians, health care managers, and lawyers. in addition, this department has implemented other innovative educational programs, among them for example “leadership in the sphere of health care, human rights and public health law”, focusing on an advanced training of health care managers and comprising 78 hours, including lectures, practical classes and individual work. conclusions the legislative initiative to formulate a public health law for ukraine requires a careful analysis of the concepts and the term ‘public health’ and the pre-existing services and service providers in ukraine. after referring to the current legislative process and a discussion of some of the concepts and terminologies available in the literature, the following understanding of the terminology is proposed here: • ‘public health’ should be understood as mental and physical health of the population in a certain territory, determined by the best achievable demographic indicators, characterized by decreasing morbidity and mortality and increasing the potential to lead an active and long life. • the term ‘public health protection’ (or, ‘protection of public health’) should address a system of measures which are aimed at prevention and control of morbidity, optimization of demographic indicators, promoting a value-oriented state policy, securing biological and genetic safety and relying on joint societal efforts. it is essential that the implementation of a public health law is underpinned by adapting the postgraduate educational system to the new challenges in ukraine. references 1. lekhan v, rudiy v, richardson e. ukraine: health system review. health syst transit 2010;12:1-183. 2. gryga i, stepurko t, danyliv a, gryga m, lynnyk o, pavlova m et al. attitudes towards patient payments in ukraine: is there a place for official patient charges? zdrowie publiczne i zarządzanie-zeszyty naukowe ochrony zdrowia. 2010;8:74-5. 3. association agreement between the european union and its member states, of the one part, and ukraine, of the other part; 2016. http://eeas.europa.eu/ukraine/docs/association_agreement_ukraine_2014_en.pdf (accessed: 2 october, 2016). 4. peterylo i. pravo yak tsinnisna katehoriya (law as a value category) [kand. yuryd. nauk]. instytut derzhavy i prava im. v.m. korets’ koho; 2006. 5. health 2020. a european policy framework and strategy for the 21st century; 2016. http://www.euro.who.int/en/health-topics/health-policy/health-2020-the-european policy-for-health-and-well-being/publications/2013/health-2020.-a-european-policy framework-and-strategy-for-the-21st-century-2013 (accessed: 2 october 2016). 6. rekomendatsiyi parlament·s'kykh slukhan' na temu “pro reformu okhorony zdorov’ya v ukrayini”: postanova verkhovnoyi rady ukrayiny vid 21.04.2016 r. http://eeas.europa.eu/ukraine/docs/association_agreement_ukraine_2014_en.pdf� http://www.euro.who.int/en/health-topics/health-policy/health-2020-the-european-� 75 senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 (recommendations of the parliamentary hearings on the topic “on health care reform in ukraine” of 21 april 2016. http://zakon2.rada.gov.ua/laws/show/1338-19 (accessed: 2 october 2016). 7. kontseptsiya rozvytku systemy hromads'koho zdorov"ya v ukrayini (concept of public health system development in ukraine). moz.gov.ua. 2016. http://moz.gov.ua/ua/portal/pro_20160309_0.html (accessed: 2 october 2016). 8. pro zasady derzhavnoyi polityky okhorony zdorov’ya: zakon ukrayiny (law on principles of state policy of health care). w1.c1.rada.gov.ua. 2016 http://w1.c1.rada.gov.ua/pls/zweb2/webproc4_1?pf3511=56118 (accessed: 2 october 2016). 9. winslow ce. the untilled field of public health. science 1920;51:23-33. 10. definitions of public health. med.uottawa.ca. 2016. http://www.med.uottawa.ca/sim/data/public_health_definitions_e.htm (accessed: 2 october 2016). 11. acheson d. public health in england: the report of the commitee of inquiry into the future development of the public health function. london: the stationary office; 1988. 12. last j. a dictionary of epidemiology. new york: oxford university press; 2001. 13. zakon hruzyy ob obshchestvennom zdorov'e (law of georgia on public health). http://faolex.fao.org/docs/pdf/geo137723.pdf (accessed: 2 october 2016). 14. zakon kyrhyzskoy respublyky "ob obshchestvennom zdravookhranenyy" (law of kyrgyz republic on public health care”) [internet]. base.spinform.ru. 2016 http://base.spinform.ru/show_doc.fwx?rgn=28650 (accessed: 2 october 2016). 15. dawson a, verweij m. ethics, prevention, and public health. oxford: clarendon press; 2007. 16. thurston, m. key themes in public health/ m. thurston. london: routledge; 2014. 17. gzhegots'kyy m, fedorenko v, shtabs'kyy b. narysy profilaktychnoyi medytsyny (essays on prophylaxis medicine). l'viv: medytsyna i pravo; 2008. 18. osnovy zakonodavstva ukrayiny pro okhoronu zdorov"ya: zakon ukrayiny vid 19.11.1992 r. principles of ukrainian health care legislation: law of ukraine” zakon5.rada.gov.ua. 2016 (accessed: 2 october 2016). http://zakon5.rada.gov.ua/laws/show/2801-12 (accessed: 2 october 2016). 19. association of schools of public health in the european region (aspher). www.aspher.org. © 2017 senyuta; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://zakon2.rada.gov.ua/laws/show/1338-19� http://moz.gov.ua/ua/portal/pro_20160309_0.html� http://w1.c1.rada.gov.ua/pls/zweb2/webproc4_1?pf3511=56118� http://www.med.uottawa.ca/sim/data/public_health_definitions_e.htm� http://faolex.fao.org/docs/pdf/geo137723.pdf� http://base.spinform.ru/show_doc.fwx?rgn=28650� http://zakon5.rada.gov.ua/laws/show/2801-12� http://www.aspher.org/� http://creativecommons.org/licenses/by/3.0)� 76 kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-135 short report protecting the planet and sustainable development laura h. kahn1 1program on science and global security, woodrow wilson school of public and international affairs, princeton university, new jersey, usa. corresponding author: laura h. kahn, md, mph, mpp, woodrow wilson school of public and international affairs, princeton university; address: 221 nassau street, 2nd floor, princeton, new jersey 08542, usa; telephone: 609 258 6763; email: lkahn@princeton.edu mailto:lkahn@princeton.edu� 77 kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-135 abstract the united nations has made a commitment for sustainable development. an important component of this is a healthy environment. but what exactly is a healthy environment? environmental health specialists typically focus on occupational exposures in workers; the field mainly addresses the abiotic (i.e. non-living) aspects of environments. ecosystem health addresses biotic (i.e. living) aspects of environments. merging these two realms is essential for sustainable development but will be challenging because the fields are so different. the united nations, individual countries, and schools of public health could do much to help merge these realms by implementing environmental/ecosystem health into their missions and curriculums. keywords: ecosystem, healthy environment, planet, sustainable development. conflicts of interest: none. 78 kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-135 expanding the definition of environmental health the definition of environmental health must be expanded. the twenty-first century presents many challenges to global health. a growing human population, estimated to reach approximately 9 billion by 2050 if estimated growth rates continue, will require food, water, and other natural resources to survive. meeting humanity’s demands for natural resources threatens the environment including worsening deforestation, land degradation and contamination, water contamination, diminishing biodiversity, and spreading vector-borne and other zoonotic diseases. a warming climate with extreme weather conditions including drought and floods threatens agriculture and food security, the foundation of civilization. in the midst of all of these developments, a healthy environment seems almost impossible. but, the need for a healthy environment is imperative for life to continue, and the need to educate the next generation on the importance of sustainable development in a habitable world is essential (1,2). the question is:“what exactly is a healthy environment and how should it be defined?” the national environmental health association (neha) defines environmental health as “the science and practice of preventing human injury and illness and promoting well-being by identifying and evaluating environmental sources and hazardous agents and limiting exposures to hazardous physical, chemical, and biological agents in air, water, soil, food and other environmental media or settings that may adversely affect human health”(3). this definition focuses primarily on the hazards that affect humans. from a one health perspective, however, it leaves out animals and the environment, itself. one health is the concept that human, animal, and environmental health are linked, and because they are linked, complex subjects such as emerging diseases, food safety and security, antimicrobial resistance, and waterborne illnesses must be examined and addressed in an interdisciplinary, holistic way. the term is relatively new, but the concept is ancient. nevertheless, environmental health has been difficult to integrate into one health for a variety of reasons. first, those who work on environmental health, such as occupational and environmental physicians, nurses, and environmental health specialists, focus their work primarily on abiotic (i.e. non-living) contaminants, pesticides, and toxic waste exposures in occupational settings that affect workers. while this is extremely important, it is not the only aspect of what constitutes a healthy environment. ecosystem health focuses on the biotic (i.e. living) components of an environment and their interactions. many scientists and other professionals from a variety of academic disciplines work on ecosystem health such as wildlife veterinarians, biologists, geologists, ecologists, plant pathologists and others. they study the web of life, complex interactions between many interconnecting systems. man-made alterations to entire ecosystems have many consequences, both intentional and unintentional, potentially harming the health of current and future generations (4). environmental/ecosystem health would address the inter-action between the biotic (i.e. living) and abiotic components of environments and ecosystems. unchecked development, including the destruction of ecosystems for agricultural or other purposes, potentially jeopardizes the health of regions, including the health of animals and humans. the challenge is integrating both the environmental and ecosystem health realms into a unified field that incorporates the one health paradigm. a new inclusive term should be developed to reflect the expanded mandate. efforts are underway to establish new integrated environmental/ecosystem health fields. one is called “planetary health” (5). advocates for planetary health seek to educate a new cadre of individuals (6). the challenge with this strategy is that it focuses primarily on humans and the 79 kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-134 environment, minimizing the importance of animal health and zoonotic diseases. also, planetary health is a broad, general term; it’s not entirely clear what exactly its practitioners would do, or who would hire them. one health recognizes the vast breadth of knowledge and skills needed for human, animal, and environmental/ecosystem health and seeks to increase communication and collaboration between medical, veterinary medical, and public health professionals and scientists to achieve these goals. a global international body and environmental protection a global, coordinating international body must be in charge of environmental monitoring and protection. currently, there is no united nations environmental protection organization, but there is an environment programme that was established in 1972 with the mission to promote wise use of the environment and assess global trends (7). for the fiscal year 2014-2015, its total planned budget, from voluntary contributions from member states, was approximately $619 million, which was a 134 percent increase from the previous fiscal year(8). to put this budget into perspective, the world health organization’s budget for 2014-2015 was almost $4 billion (9) (who has an environmental health section that addresses sanitation and water and air pollution but not necessarily ecosystems). the 2014-2015 budget for the food and agriculture organization (fao) was approximately $2 billion (10). fao focuses primarily on food safety and security. in contrast, the 2014-2015 budget for the world organization for animal health (oie) was €22 million (approximately $17.2 million in 2014 usd) (11,12). the oie’s mission is to ensure healthy food animals for food safety. vast disparities in international funding between human, animal, and environmental health makes implementing a global one health strategy extremely difficult, if not impossible. if world leaders were serious about protecting the environment/ecosystems of the planet, they should consider establishing a world environment/ecosystem protection organization with a mandate to examine and address environmental/ecosystem alterations and their resulting outcomes; the organization should have a budget at least comparable to the fao, and it should have enough power to influence nations to act in the best interest of humanity to ensure planetary habitability and survival. countries’ commitments countries must make commitments to study and protect their environments/ecosystems. analogous to the international level, many nations such as the u.s., allocate little for analyzing, managing, and protecting their environments/ecosystems. in the u.s., responsibilities for environmental/ecosystem health are split between government agencies, which can dilute the overall effectiveness of efforts. the u.s. department of the interior oversees the u.s. fish and wildlife service, which has the responsibility to manage biological resources and enforce laws like the marine mammal protection act and the endangered species act (13). in the fiscal year 2012, its budget was $1.48 billion, a two percent decrease from the previous year (14). the environmental protection agency (epa), established in 1970 because of public concern about environmental pollution, conducts monitoring, standard-setting, research, and enforcement activities to protect the public from environmental contaminants, toxic wastes, and other health hazards (15). in the fiscal year 2015, its budget was $7.89 billion, a 4 percent decrease from the fiscal year 2014 (16). president donald trump has vowed to eviscerate, and possibly eliminate, the epa (17). the us geological survey, under the aegis of the department of the interior, was created in 1879 to provide scientific information to understand the earth and to manage the nation’s water, biological, energy, and mineral resources in order to protect life (18). the usgs 80 kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-134 monitors, collects, and analyzes data concerning natural resources. they provide scientific information to policy makers, planners, and others (18). in the fiscal year 2012, the u.s. fish and wildlife service’s budget was approximately $ 1.48 billion, an approximate 2 percent decrease from the previous year (19). these entities do work together, but funding is tight, and efforts might not necessarily be coordinated. the trump administration and the republican-controlled congress threaten to undo many of the conservation and environmental/ecosystem protection efforts over the past sixty years (20). the role of schools of public health schools of public health should offer interdisciplinary courses in conjunction with geological sciences and agriculture and forestry on environmental and ecosystem health, sustainable agriculture and biodiversity, food safety and security, water management and others. schools of public health traditionally teach subjects such as biostatistics, epidemiology, health policy and management, socio-medical sciences, population and family health, and environmental health. environmental health concentrates primarily on reducing carcinogens, toxic waste exposures, and other harmful chemicals. however, the health threats we face in the 21st century extend well beyond traditional public health subject areas. massive waste production from megacities and large animal production facilities threatens water and land quality as run-off from sludge seeps into soils and groundwater. sanitation and hygiene will become one of the most important fields of public health, particularly in an era of worsening antimicrobial resistance. preventing disease by lowering microbial burdens must be a global priority. contaminated land and water contributes to food and water-borne illnesses. severe droughts, floods, and unpredictable weather threaten food security as well as food safety. arthropod-borne diseases are spreading, and will continue to do so with on-going deforestation, upending delicate ecosystems. the curricula of schools of public health need to change to meet the challenges of the 21st century. much more emphasis should be given to emerging zoonotic diseases, entomology, parasitology, virology, and bacteriology. food safety and security should to be taught along with sanitation and hygiene, environmental and ecosystem health, climate and health. one health policy should be taught to examine the intersection between public health, agriculture, and environmental/ecosystem health. the importance of agriculture is rarely discussed outside of agriculture and animal husbandry courses. this must change. with worsening climate change, agriculture will be threatened in unprecedented ways. food security and its impact on civil society will be an increasingly important subject in the decades ahead. one health education should be team-based (analogous to business schools) and should be focused on researching and analyzing national and international government infrastructures relevant to human, animal, and environmental health. most health policy courses focus on healthcare delivery such as in hospitals and clinics. health insurance coverage is another common area of study. but, policy education must be expanded to examine the larger issues such as biodefense, food safety and security, and disaster preparedness. the world needs creative thinkers and problem solves who can conduct fieldwork projects at local, regional, national, and international levels to improve global one health. conclusion in conclusion, environmental/ecosystem health must be better defined to meet the challenges of the 21st century. expanding human populations, deforestation, land degradation, water contamination, massive human and animal manure production, crumbling sanitation 81 kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-134 infrastructures, the growth of megacities, diminishing biodiversity, food safety and security, agriculture and animal husbandry, emerging zoonotic diseases are all tied together and adversely impact the world’s environments/ecosystems, and ultimately, global health. these subjects must be examined and taught using an integrated one health framework to adequately understand and address them. united nations member states have already made a commitment for sustainable development. at a united nations sustainable development summit meeting in september 2015, world leaders adopted 17 sustainable development goals for the 2030 agenda for sustainable development. world leaders recognize the importance of setting goals for leaving future generations a habitable planet. expanding the definition of environmental health to include ecosystems and integrating it into a holistic, interdisciplinary one health framework would be an important first step forward. 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http://www.nytimes.com/2016/11/12/science/myron-� http://www.usgs.gov/about/about-us/who-we-� http://www.fws.gov/budget/2013/pdf%20files%20fy%202013%20greenbook/3� http://www.washingtonpost.com/news/energy-environment/wp/2017/01/17/these-� http://creativecommons.org/licenses/by/3.0)� 83 rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 short report socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania manushaqe rustani-batku1, ali tonuzi2 1 primary health care center no. 2, tirana, albania; 2 university hospital center “mother teresa”, tirana, albania. corresponding author: dr. manushaqe rustani-batku, primary health care center no. 2, tirana; address: rr. “arkitekt kasemi”, 51, tirana, albania; telephone: +355682359312; email: manushaqebatku@yahoo.com http://wikimapia.org/street/16408710/sq/rruga-arkitekt-kasemi� mailto:manushaqebatku@yahoo.com� 84 rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 abstract aim: the aim of our study was to assess the distribution of socio-demographic factors and the clinical profile of individuals diagnosed with retinal vein occlusion (rvo) in albania, a former communist country in south-eastern europe which has been undergoing a rapid transition in the past decades. methods: this study was carried out in 2013-2016 at the primary health care centre no. 2 in tirana municipality, which is the capital of albania. during this timeframe, on the whole, 44 patients were diagnosed with rvo at this primary health care centre (17 women and 27 men; overall mean age: 69.5±11.5 years). the diagnosis of rvo was based on signs and symptoms indicating a quick reduction of the sight (vision), fundoscopy, fluorescein angiography and the optical coherence tomography. data on socio-demographic factors and clinical characteristics were also gathered for each study participant. results: the prevalence of glaucoma was considerably higher in men than in women (67% vs. 24%, respectively, p=0.01). diabetic retinopathy was somehow more prevalent in women than in men (18% vs. 11%, respectively), whereas an opposite finding was noted for the presence of hypertensive retinopathy (6% vs. 11%, respectively). the prevalence of cataract was higher in female patients compared with their male counterparts (18% vs. 7%, respectively, p=0.36). both macular oedema and papillary oedema were almost equally distributed in men and in women (22% vs. 18% and 4% vs. 6%, respectively). all female patients had comorbid conditions compared to 85% of their male counterparts (p=0.15). the prevalence of hypertension was almost identical in both sexes (52% in men vs. 53% in women), whereas the prevalence of diabetes was somehow higher in men than in women (26% vs. 18%, respectively). conclusion: this is one of the very few studies informing about the distribution of socio demographic factors and selected clinical characteristics of individuals diagnosed with rvo in transitional albania. keywords: albania, clinical profile, ophthalmology, retinal vein occlusion, socio demographic factors. conflicts of interest: none. 85 rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 introduction retinal vein occlusion (rvo) is a major reason for severe ocular impairment and blindness (1,2). the available evidence, based on many studies carried out in different countries of the world, indicates that rvo is linked to an increased risk of cardiovascular disease, especially hypertension, diabetes mellitus, and coronary artery disease (3-5). the incidence and prevalence of rvo is substantially higher among older people, notwithstanding the fact that this condition is a frequent cause of painless visual loss also in middle-aged individuals (6-8). data from the global burden of disease (gbd) 2010 study indicate that albania is the only country in the south-eastern european region that has experienced an increase in the mortality rate from ischemic heart disease and cerebrovascular diseases in the past two decades (9), exhibiting an early evolutionary stage of the coronary epidemic, which was evident many decades ago in the western countries (10). indeed, ischemic heart disease and cerebrovascular disease were among the highest ranking causes regarding the number of years of life lost due to premature mortality in albania in 2010 (9). furthermore, the burden of diabetes mellitus has almost doubled in albania in both sexes in the past two decades (10). in males, there was an increase of 96% in disability-adjusted life years (dalys) from diabetes, whereas in females this increase was 85%. overall, the sex-pooled proportional dalys for diabetes in albania in 2010 increased 50% compared with 1990 (9). currently, there is evidence of a gradual increase in the diabetes burden which is also due to improvements in the accessibility of health care (that is adequate registration and management of all cases with diabetes) coupled with a steady increase in the ageing population (which, in turn, is associated with an increase in the prevalence of diabetes) (10). yet, data on the prevalence and determinants of rvo in albania are scarce. indeed, to date, there are no scientific papers available providing evidence about the magnitude and occurrence of rvo in the population of albania. in this context, the aim of our study was to assess the distribution of socio-demographic factors and the clinical profile of individuals diagnosed with rvo in albania, a former communist country in south-eastern europe which has been undergoing a rapid transition in the past decades. methods a case-series study was carried out at the primary health care centre no. 2 in tirana municipality during the time period 2013-2016. overall, the number of patients diagnosed with rvo in this health centre during the study period was 44. of these, 27 (61%) patients were males and 17 (39%) were females. on the whole, mean age of the patients was 69.5±11.5 years (with a range from 42 years to 93 years). median age was 70.5 years (interquartile range: 60.3-77.8 years). the diagnosis of rvo was based on the following criteria: i) signs and symptoms indicating a quick decrease and reduction of the unilateral sight; ii) fundoscopy, a conventional examination technique of the fundus employed at the primary health care services in albania (a procedure which indicates the retinal veins that are dilated or tortuous, as well as the retinal haemorrhages); iii) fluorescein angiography, which was the main examination procedure in this study, and; iv) the optical coherence tomography (oct). furthermore, information about selected clinical characteristics of each patient diagnosed with rvo was gathered. more specifically, the clinical information for all the patients diagnosed with rvo included the presence of glaucoma (yes vs. no), the type of glaucoma (open angle, closed angle, secondary, or absolute glaucoma), presence of diabetic 86 rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 total (n=44) p* women (n=17) men (n=27) variable retinopathy, hypertensive retinopathy, cataract, macular oedema, papillary oedema, or comorbidity (all dichotomized into: yes vs. no), as well as the type of comorbidity (hypertension, diabetes, or both conditions). information on socio-demographic characteristics was also collected based on a structured interview. more specifically, for each patient it was gathered information on demographic factors (age and sex) and selected socio-economic characteristics [place of residence (dichotomized into: urban vs. rural areas) and employment status (trichotomized into: employed, unemployed, retired)]. the study was approved by the faculty of medicine in tirana and all patients who agreed to participate in this study gave their informed consent. mean values and the respective standard deviations were calculated for the age of the overall sample of study participants, as well as separately in men and in women. conversely, absolute numbers and their respective percentages were calculated for the other socio demographic factors (place of residence and employment status) and all the clinical characteristics of the patients. mann-whitney u-test was used to compare the age between male and female patients diagnosed with rvo. on the other hand, fisher’s exact test was used to assess sex-differences in the distribution of the other socio-demographic factors (see table 1) and all the clinical characteristics in the sample of patients included in this study (table 2). a p-value of≤0.05 was considered as statistically significant in all ca ses. statistical package for social sciences (spss, version 17.0) was used for all the statistical analyses. results the distribution of socio-demographic characteristics of the patients included in this study is presented in table 1. mean age in men was 71.1±10.9 years, whereas in women it was 67.0±12.4 years. yet, there was no evidence of a significant sex-difference in the mean age of the patients included in this study (mann-whitney u-test: p=0.27). about 19% of male patients and 29% of females were residing in rural areas, without evidence of a sex-difference though (p=0.47). similarly, there was no evidence of a statistically significant difference in the distribution of employment status between genders, regardless of a higher rate of unemployment in women compared to men (29% vs. 15%, respectively, p=0.51) [table 1]. table 1. socio-demographic characteristics of a sample of patients diagnosed with rvo during 2013-2016 in tirana, albania age (in years) [mean±sd] 71.1±10.9 67.0±12.4 0.272 69.5±11.5 place of residence [n (column %)] urban areas 22 (81.5) 12 (70.6) 0 473 34 (77.3) rural areas 5 (18.5) 5 (29.4) 10 (22.7) employment status [n (column %)] employed 2 (7.4) 1 (5.9) 3 (6.8) unemployed 4 (14.8) 5 (29.4) 0.505 9 (20.5) retired 21 (77.8) 11 (64.7) 32 (72.7) * mann-whitney u-test was used for the comparison of age between men and women, whereas fisher’s exact test was used to test sex-differences regarding the distribution of place of residence and employment status. 87 rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 the distribution of selected clinical characteristics of the patients included in this study is presented in table 2. the prevalence of glaucoma was considerably and significantly higher in men than in women (67% vs. 24%, respectively, p=0.01). absolute glaucoma was found in 26% of men, but only in 6% of women, notwithstanding the lack of a statistically significant sex-difference in the distribution of glaucoma types (p=0.26), possibly due to the modest sample sizes. diabetic retinopathy was somehow more prevalent in women than in men (18% vs. 11%, respectively), whereas an opposite finding was noted for the presence of hypertensive retinopathy (6% vs. 11%, respectively). yet, none of these differences was statistically significant. the prevalence of cataract was higher in female patients compared with their male counterparts (18% vs. 7%, respectively), regardless of the lack of statistical significance (p=0.36). both macular oedema and papillary oedema were almost equally distributed in men and in women (22% vs. 18% and 4% vs. 6%, respectively). table 2. distribution of clinical characteristics in a sample of patients diagnosed with rvo during 2013-2016 in tirana, albania clinical characteristic men (n=27) women p† (n=17) total (n=44) no 9 (33.3)* 13 (76.5) 0.012 22 (50.0) yes 18 (66.7) 4 (23.5) 22 (50.0) glaucoma type: open angle 5 (18.5) 5 (29.4) 10 (22.7) closed angle 4 (14.8) 5 (29.4) 0.261 9 (20.5) secondary 11 (40.7) 6 (35.3) 17 (38.6) absolute 7 (25.9) 1 (5.9) 8 (18.2) diabetic retinopathy: no 24 (88.9) 14 (82.4) 0.662 38 (86.4) yes 3 (11.1) 3 (17.6) 6 (13.6) hypertensive retinopathy: no 24 (88.9) 16 (94.1) 0.999 40 (90.9) yes 3 (11.1) 1 (5.9) 4 (9.1) cataract: no 25 (92.6) 14 (82.4) 0.359 39 (88.6) yes 2 (7.4) 3 (17.6) 5 (11.4) macular oedema: no 21 (77.8) 14 (82.4) 0.999 35 (79.5) yes 6 (22.2) 3 (17.6) 9 (20.5) papillary oedema: no 26 (96.3) 16 (94.1) 0.999 42 (95.5) yes 1 (3.7) 1 (5.9) 2 (4.5) comorbidity: no 4 (14.8) 0 (-) 0.147 4 (9.1) yes 23 (85.2) 17 (100.0) 40 (90.9) type of comorbidity: hypertension 14 (51.9) 9 (52.9) 23 (52.3) diabetes 7 (25.9) 3 (17.6) 10 (22.7) both 6 (22.2) 5 (29.4) 11 (25.0) 88 rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 * absolute numbers and the respective column percentages (in parentheses). † fisher’s exact test was employed to test sex-differences regarding the distribution of all clinical characteristics presented in the table. all female patients had comorbid conditions compared to 85% of their male counterparts (p=0.15). the prevalence of hypertension was almost identical in both sexes (52% in men vs. 53% in women), whereas the prevalence of diabetes was somehow higher in men than in women (26% vs. 18%, respectively) [table 2]. discussion this study provides evidence about the distribution of socio-demographic factors and the clinical profile of individuals diagnosed with rvo at primary health care services in tirana, the capital and the largest city in post-communist albania. essentially, the main findings of this study consist of a higher prevalence of glaucoma, hypertensive retinopathy and diabetes in men than in women. on the other hand, women exhibited a higher prevalence of diabetic retinopathy, cataract and comorbid conditions. it should be noted that there are no previous studies describing the socio-demographic factors and clinical characteristics of albanian patients with rvo. the incidence and prevalence of rvo will increase steadily in albania in line with the population aging. thus, according to the last census conducted by the albanian institute of statistics in 2011, the proportion of individuals aged 65 years and over increased to 11% (11). this gradual increase of the older population bears important implications for the heath care sector including also provision of more specialized care against visual impairment. several systemic risk factors for rvo are also associated with arterial thromboembolic events including myocardial infarction and cerebrovascular disease (12,13). from this perspective, it has been shown that the retinal blood vessels exhibit similar anatomic features and physiologic characteristics with cerebral vessels (1,14). based on this evidence, it has been convincingly argued that there might be an association between rvo and myocardial infarction and cerebrovascular disease occurrence (1,14). our study may have several potential limitations due to the sample size and, particularly, sample representativeness. from this point of view, the number of individuals involved in this study was small and was confined only to one of the eleven primary health care centres of the municipality of tirana. in addition, some individuals suffering from rvo might have not preferred to seek care in primary health services. instead, some patients might have preferred more specialized care which is available at the university clinic of ophthalmology as a part of the university hospital centre “mother teresa”, the only public hospital in tirana. also, some patients might have used private ophthalmology clinics which may currently provide better care in albania. based on these considerations, the representativeness of our study sample may be questionable and, therefore, our findings should not be generalized to the general population of tirana and the overall population of albania. instead, findings of this study should be interpreted with extreme caution. on the other hand, the diagnosis of patients with rvo in our study was based on standardized and valid instruments, similar to studies conducted elsewhere. nonetheless, we cannot entirely exclude the possibility of information bias related to socio-demographic data, in particular regarding the employment status of study participants. 89 rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 in conclusion, notwithstanding some possible limitations, this study offers useful information about the distribution of socio-demographic factors and the clinical profile of primary health care users diagnosed with rvo in transitional albania, an under-researched setting. population-based studies should be carried out in the future in albania in order to determine the magnitude and occurrence of rvo in the general population. 90 rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 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https://www.ncbi.nlm.nih.gov/pubmed/?term=impact%2bof%2bretinal%2bvein%2bocclusion%2bon%2bstroke%2bincidence%3a%2ba%2bmeta-analysis� https://www.ncbi.nlm.nih.gov/pubmed/?term=impact%2bof%2bretinal%2bvein%2bocclusion%2bon%2bstroke%2bincidence%3a%2ba%2bmeta-analysis� http://www.healthdata.org/� http://www.instat.gov.al/media/178070/rezultatet_kryesore_t� https://www.ncbi.nlm.nih.gov/pubmed/?term=elkind%20ms%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=9932614� https://www.ncbi.nlm.nih.gov/pubmed/?term=sacco%20rl%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=9932614� http://creativecommons.org/licenses/by/3.0)� jacobs verlag executive editor assistant executive editors editors regional editors advisory editorial board publisher table of contents editorial the mark of women’s leadership on solutions to global health problems conflicts of interest: none. original research ethnic differences in smoking behaviour: the situation of roma in eastern europe abstract conflicts of interest: none. introduction methods data and samples statistical analysis results determinants of cigarette consumption smoking and discrimination discussion conclusions references original research the relevance of ethics in the european union’s second public health programme nelly k. otenyo1 abstract conflicts of interest: none. theoretical framework table 1. overview of ethical principles and health strategy values (source: references 11-13) methods methodological and theoretical limitations including other potential challenges results table 2. presentation of the findings ethical concepts and shared health values in the php-2008-2013 objectives table 3. shared health values in the php-2008-2013 objectives (source: adapted from reference no. 15) ethical principles in the php 2008-2013 project proposals table 4. efficiency aspects identified in project proposals table 5. accessibility to quality health care as identified in the summaries of the project-proposals ethical concepts or aspects in the php 2008-2013 discussion ex-post evaluation of the health programme conclusions references original research giovanni piumatti1 abstract conflicts of interest: none. introduction the italian context methods sample measures analysis results development of life satisfaction identifying life satisfaction trajectories differences in achievement strategies and criteria for adulthood discussion study limitations and conclusions references review article abstract introduction methods search strategy selection criteria figure 1. flow chart of the selection process data analysis results roles of nurses during emergency response table 1. general and special roles of nurses disaster preparedness and knowledge of nurses table 2. core competencies and disaster curriculum table 3. reasons for participating and specific issues for disaster training table 4. personal and professional disaster preparedness disaster experiences of nurses discussion conclusions and implications table 5. relevance to nursing practice, nursing education and research references review article the emerging public health legislation in ukraine abstract conflicts of interest: none. introduction recent legal initiatives in ukraine definitions of public health legally relevant to ukraine related definitions relevant to the health sector public health service preparing human resources for the implementation of the upcoming public health legislation conclusions references short report protecting the planet and sustainable development abstract conflicts of interest: none. a global international body and environmental protection countries’ commitments the role of schools of public health conclusion references short report manushaqe rustani-batku1, ali tonuzi2 abstract conflicts of interest: none. methods results discussion references hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. (policy brief). seejph 2023.posted: 09 april 2023 page 56 policy brief on urgently tackling the mosquito-borne diseases in the european union zuwaira paula hashim1,2, jeny aguilera-cruz1,2, addiena luke-currier1,2, karolina airapetian1, loredana andreea silaghi1, issam alsamara1,2* 1department of international health, governance and leadership in european public health master, faculty of health medicine and life sciences, maastricht university, maastricht, the netherlands. 2europubhealth+ joint diploma master in european public health, rennes, france. all the authors contributed equally to this work. corresponding author: zuwaira paula hashim address: meerssenerweg 247 6224ag, maastricht, netherlands email: zuwairahashim1@gmail.com mailto:zuwairahashim1@gmail.com hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. (policy brief). seejph 2023.posted: 09 april 2023 page 57 abstract context: according to a recent lancet report the world is dangerously close to reaching climatedriven points of no return. climate change, together with other drivers, contributed to a large diffusion of mosquito-borne diseases (mbds) in the last decades. the intensity of such a phenomenon led various mosquito species to migrate to new areas, outside their historical habitats. europe is among the affected territories. moreover, the problem is projected to rise and expand within the continent, including populations who have never been exposed to mbds and impacting the whole society, especially the most vulnerable groups. as europe is a relatively new area for the diffusion of mbds, no strong and unified measures have been put into practice yet. meanwhile, mbds surveillance experiences implemented across europe report gaps, such as the absence of entomological research and legal support, the capacity limitation for surveillance, and variability in entomological and epidemiological surveillance systems. hence, it could be necessary to use the experiences from latin america, asia and africa. given the aforementioned overview, this policy brief aims to provide policy options in order for the european union to address mbds, with a particular emphasis on strengthening surveillance across the member. states given recent attention drawn to this issue by the ecdc’s 2021 report on vector control and surveillance. policy options and recommendations: this advisory group conducted a non-systematic literature review to determine three policy options, with a specific focus on surveillance, to address the issue of mbds. 1. surveillance systems for mosquitoes and mbds should be implemented in all member states, and case definitions for these mbds should be harmonised to enable coordination and consistency of mbds surveillance across the european union (eu). 2. create an eu-level networks umbrella for financial and organisational coordination of member states (ms)’ multi-sectoral collaboration on mbds surveillance. 3. developing the competencies for surveillance and research professionals for mosquitoes and mbds surveillance. keywords: mosquito-borne diseases, europe, climate change, one health, preparedness, surveillance. hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. (policy brief). seejph 2023.posted: 09 april 2023 page 58 introduction diseases that are spread between humans and animals through the bite of infected mosquitoes are known as “mosquito-borne diseases” (hereafter mbds) (1). the most commonly transmitted pathogens worldwide are malaria, dengue, west nile virus (wnv), chikungunya, and zika (1). more specifically, viruses such as wnv, chikungunya, and dengue have started to expand in the mediterranean basin, especially in the places where aedes albopictus or aedes aegypti mosquitoes are present (2). this is evidenced by recent world health organization (who) europe reports which indicate that mbds represent 17% of communicable diseases with 700,000 deaths annually attributed to them worldwide (3). moreover, no effective treatments or vaccines have been developed for all mbds, a condition that highlights the importance of prevention (4). it is as well relevant to note that mbds are likely to impact the most vulnerable members of society, i.e., the elderly, those with poor socio-economic status (for poorer populations display higher morbidity and mortality rates (5), and those with comorbidities. despite being more prevalent in tropical countries, mbds have been spreading in europe in the last decades (6). the diffusion of mbds is facilitated by nonclimate drivers such as globalisation, urbanisation, environment, sociodemographics (for instance, living lower social conditions is associated with increased vulnerability to health risks and lower healthy lives), public health systems (i.e., poor financial investment and lack of effective vector control strategies, and weak political commitment) and vector and pathogen characteristics (7,8). climate change, which has been acknowledged by the who as the most serious public health threat of the 21st century, is a notable climate driver facilitating the expansion of mbds and, specifically, aedes mosquitoes (9). indeed, the increase in temperature not only contributes to mosquitoes' migration to new areas but also allows for greater incidence of mbds and longer transmission periods (7). the combination of the aforementioned factors contributes to altering the environmental and ecological conditions of several areas of the world, thus hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. (policy brief). seejph 2023.posted: 09 april 2023 page 59 allowing new places to become suitable for mosquitoes (7). the complexity and urgency of the phenomenon warrant prevention and control strategies. thus, a one health approach is crucial for addressing the multifaceted nature of mbds. this type of approach contributes to integrated human and animal surveillance and response systems and facilitates multi-sectoral collaboration across several fields (10). furthermore, the one health has benefits as evidence shows that the approach can save costs of hospitalizations and compensation for transfusion-associated diseases (11). in recent years, there has been an increasing engagement between health and climate experts, the scientific sector, the corporate sector, and politics. this has led to the implementation of mitigation and adaptation measures to alleviate the effects of climate change, albeit the intersection between health and climate change is relatively low compared to the overall engagement (6). in the specific context of climate change and mbds, enhanced intersectoral cooperation among experts in mbds drivers, climate and health sector as well as between these professionals and policymakers, represents a pivotal first step in investigating the complexity of the phenomenon and allowing for the mutual exchange of ideas and building on the body of evidence on mbds. context narrowing the perspective to the sole european context, it is evident that climate change consequences are becoming intensified. in 2022, lancet reported that europe suffered the hottest summer ever recorded and an alarming increase in healthrelated hazards. indeed, given the rise in ambient temperatures, the vector capacity of culex species and the establishment of aedes mosquitoes are expanding, leading mbds to be notably on the rise in europe (6). regarding mbds diffusion within the european continent, several outbreaks have been witnessed in the last decade. sporadic autochthonous dengue outbreaks have been reported in spain and france. in 2018, was reported the largest outbreak of wnv with 1584 locally acquired infections, mainly in south and east european countries (6). hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. (policy brief). seejph 2023.posted: 09 april 2023 page 60 chikungunya and zika have been reported also in france and italy since 2019 (12). projections from the modelling of mbds highlight that this issue will continue to rise. the length of the transmission season (lts) is predicted to increase over the balkans and in northern italy by 2100. specifically, the malaria-epidemic and dengue-epidemic belts are predicted to increase northward to include central northern europe. if mbds expand into populations unexposed to these diseases or in ill-prepared health systems with limited public health workforce training in mbds and epidemiological and entomological mbds surveillancethis situation may lead to outbreaks (13). the prevention measures across europe are still suboptimal (14). for instance, the limited entomological research, legal support, the capacity limitation for surveillance, and variability in entomological and epidemiological surveillance systems represent some of the gaps in the european response. to address these and other gaps, the member states (ms) must incorporate prevention, surveillance, and control of re-emerging mbds into the political agenda and develop effective national plans (15,16). coordinated actions between the mss and other european institutions such as the european commission, the european centre for disease prevention and control (ecdc), the health emergency preparedness and response authority (hera), and who europe are also crucial. therefore, given the aforementioned overview on the significant rising threat of mbds three key areas were identified that require improvement to address the challenges around preparation and coordination of control and prevention within the eu. the areas were identified after a broad literature review of the following databases: pubmed and google scholar. in doing so, the literature review consulted peer-reviewed articles, grey literature and reports and aimed to identify existing gaps and evaluate europe's preparedness to tackle rising mbss to develop the following policy options. 1. surveillance for mosquitoes and mbds is not present across the eu. harmonised surveillance is also hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. (policy brief). seejph 2023.posted: 09 april 2023 page 61 hindered by the lack of implementation of common case definitions. 2. intersectoral collaboration is insufficient in some ms due to a lack of organisational and human resources, and the existing eu-level networks which aim to support ms are not sustainable and often have overlapping objectives. 3. treatment and detection of mbds are hindered by a lack of entomologists and entomological research, as well as a low-risk perception of mbds by healthcare professionals. the policy options suggested are underscored by the current who strategy: ‘global vector control response 2017-2030 (gvcr)’. this strategy is grounded in four pillars. first, strengthening interand intrasectoral within and outside the health sector. second, engaging and mobilising existing mbd-related networks. third, scaling up and integrating vector control tools and approaches. lastly, enhancing entomological surveillance and monitoring and evaluation. furthermore, gvcr is supported by a foundation of vector control capacity strengthening and increased basic and applied research and innovation. there are enabling factors, including country leadership, advocacy, resource mobilisation, partner coordination, and regulatory, policy, and normative support (5). against this background, the following recommendations are proffered. policy recommendation 1: surveillance systems for mosquitoes and mbds should be implemented in all member states, and case definitions for mbds should be harmonised to enable coordination and consistency of mbds surveillance across the eu surveillance: surveillance is critical for the prevention of mbds (17). although as is demonstrated below in figure 1, vector surveillance for mosquitoes is not fully present across the eu. the countries without this surveillance include slovakia, romania, and estonia. while in estonia and slovakia, there is not yet local transmission, romania does have local transmission of wnv, and the vector hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. (policy brief). seejph 2023.posted: 09 april 2023 page 62 is currently present for dengue, chikungunya, and zika. however, the threat of these diseases is growing and could reach these areas in the future, requiring action now (14). in addition, according to the ecdc, six countries lack surveillance specifically for dengue/chikungunya/zika, and three countries lack wnv surveillance. countries, where surveillance should be particularly supported, include romania, slovakia, and hungary, where it is reported that surveillance for all the above-mentioned diseases is lacking (14). figure 1: mosquito control and surveillance in europe (14). case definitions: to ensure that the severity of mbds can be compared across europe and support policy decisions in relation to this, case definitions must be harmonised across the eu. common case definitions have been established to be critical for the sensitivity of a surveillance system (16). particularly within the context of the eu, it has been long recognised that the free movement of people and goods increases the need for common case definitions and clear communication between ms (18,19). while dengue, chikungunya, malaria, zika, and wnv european union case definitions (most recently from 2018) are available, not all european countries use these definitions, which can lead to possible issues in comparison. as demonstrated by figure 2, wnv and malaria are key diseases for which no case definition harmony exists. figure 2: mosquito-borne disease use of official eu case definitions across the eu (20) hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. (policy brief). seejph 2023.posted: 09 april 2023 page 63 additionally, figure 3 shows that germany, the czech republic, the netherlands, and france are the specific countries which do not use an eu case definition for surveillance. please see appendix 1 for further information. figure 3: eu countries least utilizing official eu mbd case definitions (20) how to achieve policy option 1: the fundamental aspects of such a harmonised system are already available through the common eu case definitions. however, leadership is needed to adopt these case definitions, and clearly identify and address barriers to their implementation to utilise these existing frameworks. the eu can look to the americas, where vector-borne diseases have been a significant issue and where agreements and resolutions across countries have resulted in action. for example, resolution cd55 r.6 of the who/paho arboviral disease prevention and control and resulting meetings. this resolution urged signing members to improve their surveillance systems for mbds (21). a number of meetings were held for this resolution. of note is the meeting organised by the who/paho where health ministers shared experiences of surveillance and control of mbds (22). sharing experiences at this level would be helpful for european countries specifically as many of the states without mosquito surveillance systems state that it is because of a lack of a legal framework, which other states have, giving them the opportunity to learn from each other. resolution cd55 r.6 resulted in many other actions, such as countries developing their own one health oriented ministries, standardising the evaluation of vector surveillance across countries and mobilising financial resources to assist states in technical aspects such as training hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. (policy brief). seejph 2023.posted: 09 april 2023 page 64 personnel and obtaining necessary laboratory supplies (19). the eu must investigate these efforts by the americas and start by working together at the health ministry level, through the council of europe, to dedicate themselves to sharing experiences and improving surveillance and in turn prevention. health ministers have the opportunity to lead this change through recommendations. council recommendations in the area of health have been successful in the past in directing future action, for example through the conclusions on alcohol-related harm reduction (17). surveillance systems and common case definitions are critically intertwined with the following policy options and improvements in these areas will also contribute to improvements in surveillance through further sharing of experiences and improving technical capacities for surveillance across the eu. policy recommendation 2: create an eulevel networks umbrella for financial and organisational coordination of ms multisectoral collaboration on mbd surveillance the covid-19 outbreak shone a light on the importance of eu collaboration to not leave any country with a lack of resources behind and became a reason for establishment of the eu subsidy health programme (eu4health), for strengthening healthcare and promoting innovation (23). moreover,per who gvcr framework, interand intra-sectoral action and collaboration is the first pillar to achieve locally adapted and sustainable vector control (5). at the moment, the level and areas of collaboration in terms of the one health approach dramatically vary from one ms to another. for instance, spain has no mbd control collaboration between public and veterinary health sectors, and france faces the same issue in addition to a lack of collaboration with the environmental sector. while italy has multiple areas of collaboration (vector surveillance design, vector control design, data collection, data sharing, data management or/and storage, data analysis and interpretation, and communication), greece asserts only data hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. (policy brief). seejph 2023.posted: 09 april 2023 page 65 sharing (14). please see appendix 2 for further information. furthermore, the ecdc recent report has shown that the most significant challenges for tackling mbds are related to funding and human resources (14) in european countries (14). hence, the above-mentioned challenges could be avoided with the coordination and funding of networks of the cross-sectoral workforce at a pan-european level, according to the ecdc technical report (14). though, despite the range of existing voluntary, created, or supported by eu mbd-related networks, their objectives are overlapped (please see appendix 3). for instance, prepare4vbd (grant by horizon europe) and earlywarning system for mosquito-borne diseases (part of eurogeo action group) both intend to become a gold standard tool for vectorborne diseases in terms of model-based surveillance for early detection, forecasting and monitoring mbds. furthermore, mbds networks are based on a different pool of experts, fields, and institutions for the same aim (24, 25). this case exemplifies the problematic separation of experts and duplications in network objectives, scopes, and processes. finally, collaboration would also be beneficial for existing networks involved. an eu-umbrella coordination of the existing networks will bring added value in terms of: ● avoiding duplications and redundancy among the networks; ● sustainable collaboration; ● an advisory role for ms harmonised surveillance actions; ● facilitating the cross-border knowledge, data and workforce exchange. how to achieve policy option 2: an example of a good practice from which the eu can learn from is the establishment of the african network on vector resistance to insecticides (anvr) in 2000 and coordinated by the regional office for africa. malaria prevalence in the african region declined by 68% of the clinical cases between 2000 and 2015 (5). anvr has played an important role in mbd prevention hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. (policy brief). seejph 2023.posted: 09 april 2023 page 66 in the african region for 22 years as a platform for successful partnerships between research institutions, national vector control programs, ngos and the private sector. anvr initiative has driven the development of a medical entomology network, standardising protocol for testing malaria vector susceptibility to insecticides, training activities, collection of preliminary data on the status of malaria vector susceptibility to insecticides. as well, anvr created guidelines for planning implementation and monitoring of vector resistance for countries in the african region (26). with regards to anvr-specific terms of reference and the who europe framework, the umbrella network should be based on the following objectives: 1. collaboration with all relevant institutions in order to standardise and harmonise methodologies, protocols, and guidelines for analysis of data and interpretation of results to enhance evidence-based policy and strategy development 2. assistance for ms in capacity building for vector surveillance and epidemic preparedness and response 3. building consensus on approaches to the surveillance and control of mbd and preparing practical guidelines at the national level 4. coordination of network activities, facilitating and promoting the dissemination and exchange of information on mbd surveillance and control 5. the development and assessment of new monitoring tools and the continuous production of updated vector distribution and resistance maps for each country and for the whole region. policy recommendation 3: to develop capacity for surveillance and research professionals for mosquitoes and mosquito-borne disease surveillance. the who gvcr 2017-2030 has recognised the need for capacity building as a pillar of the gvcr framework (5). the capacity to address emerging mbd threats is reliant upon the readiness of the healthcare system hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. (policy brief). seejph 2023.posted: 09 april 2023 page 67 (27). this is made evident with adequate infrastructure, standard guidelines, equipment, diagnostic capacity, and trained personnel (27). due to the intersectionality of current issues, a range of professionals entomologists, virologists, and public health workersare required to ensure detection and treatment of mbds. however, there is a low to medium-risk perception of mbds among healthcare professionals in europe, a shortage of medical entomologists worldwide, and an absence of entomological research (28). therefore, capacity building on mbd surveillance through training healthcare and public health workforce is paramount to ensure preparedness. trained personnel: the role of healthcare professionals in the mbd a study undertaken in france assessing the perceived risk of three mbds (dengue, chikungunya, and zika) identified a low to medium risk perception among infectious disease physicians (29). factors such as professional training, tropical experience, and knowledge of the national plan against the spread (nps) of dengue, chikungunya, and zika influenced physicians’ disease risk perception. this study and many others have pointed to a need to “assure a competent workforce,” (30). training on mbds diagnosis, treatment, and surveillance is particularly important. healthcare professionals have a key role in promoting and adopting disease-prevention behaviours (20). additionally, capacity can be built in emergency preparedness training across all sectors (28). this highlights a need for modification and, in turn, the application of a training manual of this kind across the eu. trained personnel: the role of entomologists in mbd among the seventeen activities established by who to mitigate mbds, two are related to entomologist capacity. the first is training of relevant staff from health ministries or supporting institutions in public health entomology. the second activity is developing national and regional institutional networks to support training hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. (policy brief). seejph 2023.posted: 09 april 2023 page 68 and education in public health entomology and technical support (5). however, across the eu there is a need for more information on how many entomologist workforces are available, and how entomologist training is developing through the public health workforce in the member states (ms). furthermore, creating entomologist capacity across the eu has been limited by a short-term surveillance vision and the lack of financial and human resources. during the covid-19 pandemic, some european countries stopped or did not implement their entomological surveillance strategies (16, 31). how to achieve policy option 3: creating capacity building in healthcare professionals in mbd capacity building can be achieved through training with the aid of a manual. research suggests that training relevant personnel plays a key role in mitigating mbds (27). however, presently, in the eu, there is no harmonised guideline or training manual for which surveillance, research and healthcare professionals can be trained on mbds. whilst the who established a training manual in 2016, aimed at providing knowledge to european professionals and supporting their skills in dealing with mosquito-borne diseases (32). creating capacity building in public health entomology: to create preparedness and entomological capacity, it is fundamental that european countries inform the entomologist workforce available to the ecdc and include this information in the technical report of vector surveillance and control in europe. secondly, a long-term entomological surveillance strategy, with financial and legislative support, must be encouraged to ensure success even through crises such as covid-19 pandemic. furthermore, specific actions to create capacity building must be suggested to ms, and at different levels and sectors. for instance, the vector control program against dengue in singapore has included capacity development as one of its strategic pillars and implemented it among the public health workforce, intersectoral, and community (33). hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. (policy brief). seejph 2023.posted: 09 april 2023 page 69 overall, the program has included ongoing professional development through courses organised by the national environment agency (nea). it provided staff rotations between departments other than health, courses to the community, financial support, and leave to attend higher education, establish contacts with academic and research institutions to offer degrees, and develop research in entomology (33). recommendations: 1. surveillance systems for mosquitoes and mbds should be implemented in all member states, and case definitions for mbds should be harmonised to enable coordination and consistency of mbds surveillance across the eu 2. create an eu-level networks umbrella for financial and organisational coordination of ms’ multi-sectoral collaboration on mbd surveillance 3. to develop capacity for surveillance and research professionals for mosquitoes and mosquito-borne disease surveillance there are methodological limitations of this paper. given that this is a non-systematic literature review, all policy options for the given problem were not analysed. the search strategy for this paper was limited to searches conducted primarily in english. given the one health nature of this paper, it is also a limitation that all authors come from the public health field, thus there is potential for a lack of consideration of the problem from the point of view of other sectors. conclusion mbds are a growing threat that europe must be prepared to address. the nature of mbds requires prevention and control to be the primary strategy. a one health approach, bringing together stakeholders such as entomologists and public health professionals, across sectors can optimise these preventative measures. european countries need to commit to this action specifically in the areas of surveillance, hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. (policy brief). seejph 2023.posted: 09 april 2023 page 70 coordination of efforts and capacity building of professionals. the eu can look on other countries experiences for successful examples and utilise guidance from the who to build on their existing networks and take additional measures to address this issue and prepare for the approaching danger of mbds conflicts of interest: none declared acknowledgements: the authors wish to thank and acknowledge dr. katarzyna czabanowska for their support and guidance throughout the development of this policy brief, in the context of the public health leadership module at maastricht university. references 1. centers for disease control and prevention, atlanta, the usa: https://www.cdc.gov/niosh/topics/outd oor/mosquito-borne/default.html (accessed: 2022 dec 7). 2. emmanouil m, evangelidou m, papa a, mentis a. importation of dengue, zika and chikungunya infections in europe: the current situation in greece. new microbes and new infections 2020;35:100663. 3. world health organization regional office for europe, copenhagen, denmark: http://www.euro.who.int/en/publicatio ns/abstracts/regional-framework-forsurveillance-and-control-of-invasivemosquito-vectors-and-re-emergingvector-borne-diseases,-20142020-2013 (accessed: 2022 dec 1). 4. aggarwal a, garg n. newer vaccines against mosquito-borne diseases. the indian journal of pediatrics 2018 feb;85(2):117-23. 5. world health organization central office, geneva, switzerland: https://apps.who.int/iris/bitstream/han dle/10665/259205/9789241512978eng.pdf(accessed: 2022 dec 1). 6. van daalen kr, romanello m, rocklöv j, semenza jc, tonne c, markandya a, et al. the 2022 europe report of the lancet countdown on health and climate change: towards a climate resilient future. the lancet public health 2022. 7(11), e942–e965. 7. rocklöv j, dubrow r. climate change: an enduring challenge for vector-borne disease prevention and control. nature immunology 2020;21(5):479–83. 8. why even healthy low-income people have greater health risks than higher-income people commonwealth fund, new york, usa: https://doi.org/10.26099/y2gbwa98 (accessed: 2023 jan 04) 9. watts n, amann m, arnell n, ayebkarlsson s, beagley j, belesova k, et al. the 2020 report of the lancet countdown on health and climate change: responding to converging crises. the lancet 2021;397(10269):129–70. https://www.cdc.gov/niosh/topics/outdoor/mosquito-borne/default.html https://www.cdc.gov/niosh/topics/outdoor/mosquito-borne/default.html http://www.euro.who.int/en/publications/abstracts/regional-framework-for-surveillance-and-control-of-invasive-mosquito-vectors-and-re-emerging-vector-borne-diseases,-20142020-2013 http://www.euro.who.int/en/publications/abstracts/regional-framework-for-surveillance-and-control-of-invasive-mosquito-vectors-and-re-emerging-vector-borne-diseases,-20142020-2013 http://www.euro.who.int/en/publications/abstracts/regional-framework-for-surveillance-and-control-of-invasive-mosquito-vectors-and-re-emerging-vector-borne-diseases,-20142020-2013 http://www.euro.who.int/en/publications/abstracts/regional-framework-for-surveillance-and-control-of-invasive-mosquito-vectors-and-re-emerging-vector-borne-diseases,-20142020-2013 http://www.euro.who.int/en/publications/abstracts/regional-framework-for-surveillance-and-control-of-invasive-mosquito-vectors-and-re-emerging-vector-borne-diseases,-20142020-2013 https://apps.who.int/iris/bitstream/handle/10665/259205/9789241512978-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/259205/9789241512978-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/259205/9789241512978-eng.pdf https://doi.org/10.26099/y2gb-wa98 https://doi.org/10.26099/y2gb-wa98 hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. 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(policy brief). seejph 2023.posted: 09 april 2023 page 73 https://atlas.ecdc.europa.eu/public/inde x.aspx(accessed: 2022 dec 7). 36. braks m, schaffner f, medlock jm, berriatua e, balenghien t, mihalca ad, et al. vectornet: putting vectors on the map. front. public health 2022, 10:809763. 37. jelinek t, myrvang b. surveillance of imported infectious diseases in europe: report from the 4th tropneteurop workshop. acta trop. 2004 jun;91(1):47-51. ___________________________________________________________________________ © 2023 hashim z.p et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://atlas.ecdc.europa.eu/public/index.aspx https://atlas.ecdc.europa.eu/public/index.aspx hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. (policy brief). seejph 2023.posted: 09 april 2023 page 74 appendix 1. table no.1: case definitions of mosquito borne-diseases across the eu (34,35) mosquitoborne diseases (mbds) official case definition: confirmed case clinical criteria laboratory criteria epidemiological criteria countries included in analysis case definition used sum other: which countries unknown: which countries eu 2008 eu 2012 eu 2018 other unknown west nile virus infection (wnv) must meet the laboratory criteria one of the below 1. encephalitis 2. meningitis 3. fever at least one of the below: 1. isolation of wnv from blood or csf 2. detection of wnv nucleic acid in blood or csf 3. wnv specific antibody response (igm) in csf 4. wnv igm high titre and detection of wnv igg, and confirmation by neutralisation at least one of the below: 1.animal to human transmission 2. human to human transmission through vertical transmission, transplants, or blood transfusion eu except for denmark 7 6 11 1 1 26 france germany dengue must meet the laboratory criteria fever at least one of the below: 1. dengue virus from clinical spectrum 2. detection of dengue viral nucleic acid 3. detection of dengue viral antigen 4. detection of dengue specific igm antibodies in a single serum sample and confirmed by neutralisation seroconversion or four-fold antibody titre increase of dengue specific antibodies in paired serum samples travel to/residence in area with ongoing transmission of dengue documented in the past two weeks from the start of the symptoms eu except for denmark, cyprus, bulgaria 3 5 11 4 1 24 czechia, germany, and netherlands, and portugal france hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. (policy brief). seejph 2023.posted: 09 april 2023 page 75 chikungunya must meet the laboratory criteria fever at least one of the below: 1. isolation of chikungunya virus 2. detection of chikungunya viral nucleic acid 3. detection of chikungunya specific igm antibodies in a serum sample and confirmation by neutralisation 4. seroconversion or four-fold antibody titre increase of chikungunya specific antibodies in paired serum samples travel to/residence in area with ongoing transmission of chikungunya documented in the past two weeks from the start of the symptoms eu except for denmark, cyprus, bulgaria 4 4 12 3 1 24 czechia, germany, sweden france zika must meet the laboratory criteria rash one of the below: 1. detection of zika virus nucleic acid 2. detection of zika virus antigen 3. isolation of zika virus 4. detection of zika virus specific igm antibodies in serum sample(s) and confirmation by neutralisation test 5. seroconversion or four-fold increase in the titre of zika specific antibodies in paired serum samples travel to/residence in area with ongoing transmission of dengue documented in the past two weeks fromthe start of the symptoms or sexual contact with a person exposed/confirm ed to zika eu except for bulgaria, denmark, poland, sweden 1 3 8 8 3 23 czechia, germany, hungary, ireland, netherlands, slovakia, slovenia (portugal: eu case definition which is legacy/depre cated) croatia, france, malta malaria any person meeting the clinical and the laboratory criteria fever or a history of fever one of the below: 1. demonstration of malaria parasites by light microscopy in blood film 2. detection of plasmodium nucleic acid 3. detection of plasmodium antigen 4. detection of plasmodium antigen na eu except for denmark 8 5 11 2 0 26 france and germany hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. (policy brief). seejph 2023.posted: 09 april 2023 page 76 appendix 2. table no.2: organisation of surveillance on mbds in southern european countries in terms of the one health approach (17) one health italy france spain grece is there a formalised collaboration between public and veterinary health sector related to vector surveillance or vector control? vector surveillance, vector control vector surveillance, vector control vector surveillance surveillance, control if yes, please specify the area(s) of collaboration vector surveillance design, vector control design, data collection, data sharing, data management or/and storage, data analysis and interpretation, communication data sharing, data management or/and storage, data analysis and interpretation, communication vector surveillance design, data collection, data sharing, communication data sharing is there a formalised collaboration between public/veterinary health sector and the environmental sector related to vector surveillance or vector control? vector surveillance and control no formalised collaboration exists vector surveillance, control vector control if a formalised collaboration exists, please specify the area(s) of collaboration other none biocides regulation biocides regulation hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. (policy brief). seejph 2023.posted: 09 april 2023 page 77 appendix 3. table no.3 the intersection of existing mbds networks across the european union (24,25, 36,37) network purpose eu network providing expert advice on the optimal diagnosis and management of imported tropical and infectious diseases tropenet/ vectornet providing a platform for collaborative research on travel-related infectious and non-infectious diseases tropenet/ eywa providing evidence-based recommendations on key issues related to tropical and travel medicine in europe. tropnet to set the basis for pan-european administrative unit distribution maps of the major arthropod vectors of diseases vbornet /vectornet to define priority strategic topics concerning the public health perspective of vector-borne diseases and vector surveillance vbornet to improve preparedness and response for vector-borne diseases following one health approach vectornet/ prepare4vbd collection of data on vectors and pathogens in vectors related to human and animal health vectornet hashim zp, aguilera-cruz j, luke-currier a, airapetian k, silaghi la, alsamara i. on urgently tackling the mosquito-borne disease in the european union. (policy brief). seejph 2023.posted: 09 april 2023 page 78 database (medical, veterinary experts and organizations) on the presence and distribution of vectors and pathogens in vectors vbornet/ vectornet ad-hoc scientific advice to support ecdc and efsa with technical questions on vector surveillance and vector-borne diseases in humans and animals tropnet/ vectornet combines interdisciplinary scientific fields (entomology, epidemiology, ecology, eo, big data analytics, ai/ml, ensemble dynamic/hybrid vs data-driven models, data fusion, and citizen sciences) towards building new directions in applied research and innovative services for public health, such as outbreak forecasting and decision support modeling for vector control applications and other mitigation actions eywa/ tropnet offer a scalable, reliable, sustainable, and cost-effective early warning system (ews) relying on big earth observation (eo) data in conjunction with environmental, climatic, and meteorological essential parameters, socioeconomic and population data, ecosystem and morphological related parameters, as well as epidemiological and entomological data to forecast and monitor mbds. eywa/ prepare4vbd developing of new knowledge, detection tools, and surveillance systems to improve preparedness for vbds prepare4vbd/ vectornet developing of improved tools for rapid detection and state-of-art model-based surveillance for early detection and forecasting to form a blueprint for best practices for optimized vbd surveillance strategies for the targeted diseases prepare4vbd/ eywa kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 1 | 15 review article risk management and prevention of antibiotics resistance: the prevent it project kiranjeet kaur1, stefano greco2, sunil d. saroj3, shaikh shah hossain4, himanshu sekhar pradhan5, sanjeev k. singh6, francesca clerici7, meenakshi sood1, helmut brand4,8, preethi john1, peter schröder-bäck8 1 chitkara school of health sciences, chitkara university, punjab, india; 2 chitkara spaak centre for multidisciplinary european studies, chitkara university, punjab, india; 3 symbiosis school of biological sciences, symbiosis international (deemed university), pune, maharashtra, india; 4 prasanna school of public health, manipal academy of higher education, manipal, karnataka, india; 5 school of public health, kiit deemed to be university, bhubaneswar, odisha, india; 6 department of medical administration, amrita institute of medical sciences, kochi, india; 7 department of pharmaceutical sciences, university of milan, milan, italy; 8 department of international health, care and public health research institute (caphri), maastricht university, the netherlands. corresponding author: dr. kiranjeet kaur; address: chitkara school of health sciences, chitkara university, punjab campus, chandigarhpatiala national highway (nh-64), tehsil: rajpura, distt. patiala-140401, india; telephone: +91-9815193584; email: kiranjeet.kaur@chitkara.edu.in kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 2 | 15 abstract background: globally, a significant increase in the emergence of antibiotic resistant (abr) pathogens has rendered several groups of antibiotics ineffective for the treatment of life-threatening infections. it is an endemic in hospital settings and a major concern while handling pathogens involved in an epidemic or pandemic. abr is a matter of great concern due to its recusant impact on public health and cost to the healthcare system, especially in developing country like india. an indiscriminate and inappropriate usage of antimicrobials, poor infrastructure and sanitation are the major factors driving the evolution of abr in such countries. therefore, in addition to the development of novel therapeutics and safeguarding the efficacy of existing antibiotics, there is an urgent need for a programme focussed on the education in risk management and prevention of abr. aim: to promote qualitative teaching activities in academia and society to visualize a future where every individual is aware of abr and empowered with right education to address the issue. methods: the project ‘risk management and prevention of antibiotics resistance prevent it’, funded by the erasmus+ programme of the european union, converges academicians and non-government organizations (ngos) to inculcate a sense of awareness towards the increase in the frequency of abr pathogens, judicial usage of antimicrobials and the economic/health burden of abr, in students, academicians, clinicians and population at large. expected outcome: the project commissioned envisages a behavioural change in individuals and attempts to support policymakers by executing stable changes in the curricula of institutes of higher education, developing advanced workshop modules for the training of academicians and disseminating abr-related information through conferences/seminars, social media campaigns and an online platform dedicated to abr. in addition, the project aims to develop a europeanindian network for the management of risk and prevention of abr. keywords: antibiotic resistance, education, erasmus plus, europe, global action plan, india. conflicts of interest: none declared. kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 3 | 15 introduction of the various health issues faced by the world today including covid 19, antimicrobial resistance (amr) is a growing problem that poses a grave threat to global public health (1). the term amr pertains to the inability of the antibiotic to treat or cure the infection caused by microorganisms. reports from the world health organization (who), have also declared amr being the sole factor to be responsible for approximately 10 million deaths by 2050 (2). given the fact that amr is not constricted by demography or geography, it needs to be addressed globally (3). the global amr response is listed in the who’s core mandate, stressing the importance and priority to seek its remedy. the global action plan on antimicrobial resistance by who (4) and the national action plan on antimicrobial resistance napamr (5) by the govt. of india are some of the global and local initiatives to combat the predicted adverse conditions. these action plans hinge on a multi-pronged approach that include: 1. creating awareness through education and training 2. amr surveillance 3. prevention and control measures, including 3a. rational use of antibiotics 3b. research and innovative practices like improved diagnostics for reducing use of antibiotics 3c. therapeutics; that minimizes use of antibiotics 4. collaboration facilitation though, all the approaches mentioned above are equally significant, creating awareness through education, targets the problem at the base level. as per a review conducted in 2016 by o’neill (6), the emphasis was laid on the urgency of creating global awareness campaign to educate the public, particularly youngsters about the ramifications of drug resistance. these initiatives have the potential to bring about behavioral change in the mindset of the youth. it is said that developing countries, such as india, with their enormous youth population could see their economies rise, only if they invest profoundly in young people's education and health (7). an innovative project initiated to address these challenges, named risk management and prevention of antibiotics resistance prevent it, is being undertaken in india, in alignment with the national action plan (nap) and funded by the european commission under the erasmus+ scheme. the project comprises of seven indian partners and four european partners. the vision of the project is a future where every individual is aware of antibiotic resistance (abr) and empowered with the right education to address and seek remedial course of action to prevent the further development of drug resistance. it is imperative for all the key stakeholders academicians, researchers and non-governmental organizations to coordinate and collaborate to ensure that health systems are better prepared to prevent and tackle the amr threat. background the year 1928 ushered in the modern era of medicine with the discovery of the first antibiotic, penicillin (8) that transformed the consequence of infections. however, unfortunately the bacteria evolved to become resilient to antibiotic/s leading to ‘resistance’ viz. antibiotic resistance (abr). the likely causes of the increasing resistance are multifactorial including the involvement of three parties: humans, animals and the environment. it spans inappropriate antibiotic prescription, over-the-counter sale of antibiotics, disproportionate use of antibiotics in food of animals (livestock, aquatic, pets), and poor sanitation and hygiene (9). further, hospital kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 4 | 15 effluents, water from wastewater treatment plants (wwtp), industrial effluents appear to act as reservoir for abr in soil and aquatic environment (10,11). one cannot also ignore the contribution of other factors such as release of unused antibiotics or their non-metabolized residues into the environment via manure/feces and increased international travel. thus, it is vital to apprehend that amr is a multi-faceted problem which can only be tackled by employing the “one health approach” so that collaborative efforts can be made by the health authorities dealing with these spheres (12). a report by world health organization states that there will be approximately 10 million deaths worldwide due to antimicrobial resistance (amr), mostly due to resistant bacterial infections by 2050 (13). the problem is, if the present condition is not tackled rightly, the global economic burden may reach about $120 trillion (2). recent data suggests that at least 700,000 people die each year due to drug-resistant diseases (6). out of this, at least 230,000 people die only from multidrug-resistant tuberculosis (13). of all the developing countries, india bears the highest burden of resistant bacterial infections with a crude mortality rate from infectious diseases of 417 per 100,000 persons (14). at the same time, india ranks first in worldwide consumption of antibiotics for human use, with 10.7 units of antibiotics consumed per person in 2010. a rise of about 67% has been projected in antibiotic consumption by the year 2030 (15). also, the incidence will double in brics countries (brazil, russia, india, china, and south africa), which are developing at fast pace and are amongst the vastly populated countries of the world. in the absence of real data reflecting the current effect of abr indian scenario, few reports (16) have identified it as an emerging threat to public health. one of the major sources for environmental pollution in india are the hospital effluents and pharmaceutical waste waters which are passed into the nearby water bodies. moreover, there is no ample treatment and improper disposal of unused antibiotics which is thrown in water or landfill. a study conducted by akiba et al. (17) in south india found resistant escherichia coli strains to third generation cephalosporin in both domestic water and hospital effluents. not only this, 100% resistance to cephalosporin (third generation drug) was seen in case of 283 e. coli isolates obtained from indian river cauvery located in karnataka (18). furthermore, a variable percentage of oxytetracycline resistant gram-negative bacilli and staphylococcus aureus were detected in cow and buffalo milk in west bengal and gujarat. another study by sudha et al. (19) in shellfish and crabs in kerala found strains of vibrio cholera and v. parahaemolyticus 100% resistant to ampicillin. further, it has been reported that india will be contributing to the major relative rise in antibiotics consumption between 2010 and 2030, especially for use in livestock (20). various initiatives have been introduced both at global level and national level to fight against this adverse and alarming situation of amr. emphasizing the threat amr poses to human health in may 2015, the world health assembly (wha) recommended a global action plan (gap) on amr comprising abr (4). these initiatives include vigilant use of antibiotics and surveillance of antibiotics by engaging the “one health approach”. the wha resolution also emphasized on practical measures and requested the member states to align their national action plans with gap-amr by may 2017. in this framework, india has approved the national action plan on antimicrobial resistance in alignment with global action plan (20172021) (5). the initiative was coordinated by kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 5 | 15 ministry of health & family welfare, government of india. also, india has given due cognizance to the problem of amr and launched “national programme on the containment of antimicrobial resistance” prior under the aegis of the national centre for disease control (ncdc) in twelfth five-year plan (2012 2017) (21). further, recently in the year 2019, indian council of medical research published “treatment guidelines for antimicrobial use in common syndromes” (22). however, in spite of taking measures at the basal level, the final output could not stop the development of amr (23). both global and national action plan call for an increased awareness, hence it is very important the education sector must also be included strategically to make a difference. today this is a glaring gap. as at grassroot level – the communities, students both in school and higher education sector are not currently recipients/beneficiaries of this awareness programme. academic institutions across the globe including india need to introduce and modify the content of its courses to enable their students to grow intellectually, politically, socially and culturally. education of this type needs a new pedagogy where beings can develop skills to find out critically and contemplate systematically about difficulties/problems (24). a further study conducted by fien (25) has suggested that making change in curriculum will directly influence the overall political, economical, and social development. another approach is ‘capacity building’ which is one of the key prerequisites for its successful implementation, involving strategies, resources aiming to increase collective power of people. thus, there is an urgent need to influence curriculums by incorporating information related to risk management and prevention of amr/abr. the project entitled; “risk management and prevention of antibiotics resistance prevent it” aims to address these challenges via educational initiatives. context looking at the current scenario, it would not be wrong to say that india is becoming a hub of resistant infections not only for humans but animals as well. the poor sanitation, lack of infrastructure and huge population density are the contributing factors towards this situation. though historically, amr did not receive much attention in india, today tremendous efforts are being made in this direction. for instance, the initiation of a national action plan aligned to a global action plan and active participant in glass. however, even after such initiatives, the dearth of financial help in developing countries acts as barrier in the implementation of these plans. thus, use of primordial measure of prevention working at the grass root level with an aim to prevent any infection with low cost involvement is the need of the hour. one such initiative is creating awareness amongst society, especially youth of a country through education. in this regard, the innovative character of the prevent it project is to create the first indo-european collaboration aimed at developing abr specific curricula and disseminating expertise in abr prevention. the experts from academia will reach students from different background while non-governmental organizations (ngos) will be spreading awareness among citizens. the project will bring sustainable change by creating awareness both at organizational and societal level. functioning of the prevent it project: goal the goal of the project is to create a future where every individual will be aware of antibiotic resistance (abr) and empowered with the right education to address the issue of kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 6 | 15 abr. therefore, the project aims to promote qualitative learning activities in academia as well as in the society. objectives 1. to establish the first european-indian network for risk management and prevention of abr by developing interdisciplinary curricula on risk management and prevention of abr at indian partner universities. 2. to spread awareness in academicians, students, policy makers and general public through public events and awareness campaigns on social media. 3. to create super-expertise in delivering abr advanced vocational training to young indian academicians. 4. to create an interdisciplinary free online course for spreading awareness, enlarging the target groups empowered in the framework of the project. 5. to promote informative events at community level in cooperation with projects' ngos. funding agency and cohort of the project the erasmus+ programme of the european commission has opportunities for individuals as well as organizations aiming for research, teaching mobility, and policy reform acts. out of these key actions, prevent it was granted under the category of capacitybuilding in the field of higher education (cbhe) to support modernization, accessibility, and internationalization of higher education in developing and transition countries. the project is a consortium of partners from five countries, namely india, portugal, latvia, italy and netherlands. there are nine higher education institutions and two nongovernmental organizations involved, making a total of eleven partners. of these, seven partner organizations are situated in different states of india, thus justifying the diversity of the group (figure 1). the health sciences team of the project comprises of the experts from each higher education institutes (heis)/organizations responsible to undertake the academic and scientific tasks of the project. the detailed description of other stakeholders is given in figure 1. figure 1. geographical distribution of the partners kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 7 | 15 strategic priorities the prevent it project outlines interventions and priorities planned to be executed over 2019-2021 to combat the public health challenge of abr not only in india but globally too. the key strategic priorities include “education & training” and “dissemination & awareness” – which are in line with the global and national action plan. as it is said, “one always has time enough, if one applies it well”, the key activities (figure 2a & 2b) involved in achieving the strategic priorities are planned on yearly basis. figure 2a and 2b. strategic priorities of prevent it project kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 8 | 15  education and training education this project seeks to influence education by modifying the existing curriculum, or creating new course/s at the graduate, post graduate and doctoral level at indian universities, as well as ngos. this will serve to ensure the sustainable application of the knowledge on abr. an expert review committee was also established called the indo-european network whose functioning was to ensure a robust curriculum. create an indo-european expert network on abr in order to create an indo-european network on abr, the first milestone of the project was to organize three intra-consortium empowerment camps of four days each comprising a total of eighty four hours. these empowerment camps are very crucial in terms of skills and team building. the mission is to create the health sciences team of interdependent experts from heis and ngos with a great ingenuity in antibiotics prevention and risk management – with specific knowledge on indian milieu. the key role of the first two empowerment camps is to create the new/modernized curricula for the indian universities as well as ngos. creation and implementation of new/modernized curriculum on abr first of all, the existing curricula of healthcare programs will be reviewed by the respective partner organizations for the existence or non-existence of relevant topics that must be taught on abr. the gaps observed in curriculum will be enlisted and proposed revised or new curricula will be shared and presented in front of indo-european network during the empowerment camps. the feedback/s (online) on the curricula will be provided by indo-european expert group depending on the field of expertise (allied health sciences, optometry, physiotherapy, microbiology, pharmacy, biotechnology, bachelor of medicine and bachelor of surgery (mbbs), nursing, public health, bachelor of dental surgery (bds), doctorate level). the discussion/s will aim at evolving the teaching methodology and assessment pattern followed at different heis. for the sustainable implementation of the curricula, attempt will be made to ensure the incorporation of the proposed curricula as part of the existing syllabus. the curricula to be implemented at universities will be subjected to the approval from board of studies and academic councils while ngos need approval from their respective personnel/entities. the expected key outcomes of the first two camps is to finalize the list of teaching modules with details of updated course plan – including course nomenclature; target audience; teaching methodologies; assessment pattern; bibliography pattern at academic and community level. key output: the implementation of the finalized curricula is planned to begin at respective organizations by june, 2020, aiming to modernize the multidisciplinary courses in health sciences, thus influencing approximately nine hundred students. training the term “training” corresponds to strengthen the knowledge of young researchers in india so that they can emerge as the future experts in the field of abr. these experts will have capacity to conduct teaching activities and develop sustainable tools for creating awareness on abr besides developing online course, social media campaign, and carry out focused abr publications. also, the selection of young scientists on projects for their post-graduation and doctoral work based on amr is significant. kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 9 | 15 strengthening the knowledge of young researchers of india for this, five full time (associate researchers) will be engaged at the indian universities from the second year onwards. they will be trained through various capacity building trainings to emerge as subject experts engaged in teaching and creating online courses and publications dedicated to abr. the training to be imparted in two phases: the first phasetraining at chitkara university and the second phasetraining at the partner european universities, while training at host institutions will be there throughout. the training at indian university will be to understand the goal, objectives and key activities of the project along with team building. the exhaustive training will be provided at european universities for about four weeks. the content of the training will include expert talks on abr by european faculties, learning of new teaching methodology such as problem based learning, exposure to organization of the hospital/pharmacy prescribing antibiotics etc. the key idea is to use these subject specialists to further train the trainers at their respective host and intra-consortium organizations. it has also been observed that younger people wish to have health information via the internet or electronic means, thus attempts to update and stimulate a sub-group of a population by means of organized communication actions through explicit channels will be done (25). an interdisciplinary open access course will be developed by the young researchers under the guidance of health science expert group. the technical portion of the on-line course will be supervised by the european experts from maastricht university. the effort will be made to write and publish minimum six research/review articles in peer reviewed journal/s on abr in order to create awareness on the risk management and prevention of abr. key output: to prepare and equip abr experts to further share the knowledge on abr through teaching activities. further, there will be development of a free on-line certificate course for healthcare professionals. also, to publish minimum six research/review articles in peer reviewed journal/s on abr in order to spread awareness on the risk management and prevention of abr.  dissemination & awareness recent literature on social marketing campaigns, including online campaigns, advocate that the campaigns can impact people to bring out change in their behavior and can also inspire policy-makers (26). also, awareness campaigns are being documented as one of the most proficient means of communicating information especially to the general public. according to the state of change model, if the awareness campaign is propagated effectively for a specific issue, it will bring change in the attitudes of the society, finally reflecting the change in person’s perception about his/her own capacity to perform an act. however, it has been observed that often campaigns on health have been funded on short time-scales but in order to achieve behavior change, long term strategies are needed (27). thus, a series of comprehensive events are being planned to make students, academicians, policy makers and general public aware about the alarming situation on abr. the events will be planned in a way so that the intra-consortium mobility of europeans as well as indians is promoted. the key aim is to strengthen the network and understanding of team work for the noble cause. improve awareness on abr at university and societal level in total, nine dissemination events and fourteen network workshops will be conducted kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 10 | 15 during the tenure of the project. the key activities involved will be the more or less common for both the categories. the steps involved will be to: identify and consolidate existing communication/information resources/products on amr in various sectors/stakeholder groups; map the expertise of individual, stakeholders plus organizations (public/ private) to develop communication strategy. the content and teaching methodology for the event will vary according to the targeted stakeholders. the target audience varies from students of intra-consortium, students from other universities policy makers, academicians, accredited social health activist (asha) workers, self-help groups, farmers, pharmacists etc. maximizing the awareness on abr through social media a multifaceted approach will be undertaken to ensure the awareness and visibility via social media campaigns. one of the key activities will be website hosting which will be updated periodically, in order to share abr news, articles, information – which will boost visitor’s figures. social media will be used intensely for the visibility and outreach of the prevent it project. the communication will be done on three social sites viz. facebook, twitter and linkedin. the social media of the project handle will be shared by the young researchers and will do the needful for its further promotion. key output: outreach maximum population and spread the awareness to lower the incidence of abr expected outcome/s of the project:  help create a consensus amongst scientists working across the globe on the problem of amr and its remedies in an atmosphere of urgency and mutual cooperation.  develop and implement international, interdisciplinary teaching curricula at indian universities on risk management and prevention of abr.  invest in young talents, empowering indian super-experts having an international outlook.  spread awareness among academicians, students, policy makers and general public through events and social media campaigns.  create an interdisciplinary online course to educate a multidisciplinary audience.  establish the first european-indian network to develop further initiative for risk management and prevention of abr. perspective the proposal is the direct output of the collective preliminary-assessment study conducted since september 2016. in accordance with recent statement of the indian ministry of health & family care, historically antimicrobial/antibiotics resistance (amr/abr) did not receive adequate focus and attention in india (21). the topic was selected due to numerous scientific publications warnings – and reiterated world health assembly resolutions on global risks of antibiotics resistance. it is worthy to note that india, a developing country, is one of the nations with highest burden of bacterial infections (14). further, the emergence of resistant bacterial infections event to the newer class of antibiotics is making situation more worrisome (28). moreover, the preliminary research conducted by prevent it team has identified the following problems: i) lack of awareness in heis, civil society organizations and citizens; ii) lack of compulsory curricula for kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 11 | 15 heis’ students which requires antibiotics resistance prevention skills; iii) lack of projects in asia tackling antibiotics resistance at grassroots level; iv) legislative gap in indian context: absence in the legislation of restrictions on pharmacological pollution in water sources; v) few indian heis’ scientific publication on abr – correlation to brain drain; vi) lack of asian-centered mooc on abr – and skills’ glitches in mooc creation at indian heis. thus, in order to bridge the gap, this project will act as a stepping stone. key strengths: geographical spread and inter-disciplinary experts: the primary strength of the project is the diversity of the partners and collaboration amongst european and indian experts. creating a pool of super-expertise from different health sciences backgrounds with a great heterogeneity of geographical distribution is the key weapon of the project. there is involvement of the partners from europe (latvia, netherlands and portugal), who are known worldwide for being the countries with lowest and controlled incidence of abr (29). further, university of maastricht is well known for creating online courses (mooc) as well as the famous learning methodology i.e. problem based learning. another partner, university of milan is one of the largest universities in europe and is ranked among top five universities of italy. the pharmaceutical sciences departments have great experience both in the development of new antibiotics and studying antibiotic resistance mechanisms and in regulatory aspects and quality control. this inter-exchange of knowledge would definitely ensure in creating breakthrough knowledge bank, resources and expertise that would prove consequential in targeting the abr threat. all the indian universities have been associated with the erasmus plus funded projects at some point of time. the associated indian universities have well established departments and prowess in various domains to be influenced by the project. the range varies from public health – microbiology –nursing – medical doctors – dentists allied health sciences – biotechnology – pharmacy etc. the three universities, amrita vishwa vidyapeetham university, manipal academy of higher education and kalinga institute of industrial technology are already contributing to the clinical care and academic training seamlessly. the focus is on infection prevention and control (ipc) activities and antimicrobial stewardship (amsp) initiatives to combat hospital associated infections in association with who and quality council of india (qci). both the ngos are well equipped to provide capacity building through training and programs to be delivered to general public. looking at the dissimilitude of competence and geographical distribution of indian partners (including higher educational institutions and non-governmental organizations) within consortium needs no further explanation. empowering young talent: capacity building: one of the major outcomes of the project is training the young associate researchers to become subject expert on abr. these experts will be responsible for training the trainers, students and conducting different dissemination events for general public. sustainable goals and outcomes: the endeavor is to bring about sustainable changes in the form of curriculum, publication and mooc course. the curriculum is so created that it can be incorporated in the academic program guide to make sure the pervasive implementation of the same. this will definitely sensitize the students, ensuring the kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 12 | 15 fact that when they enter the health care sector, they are honed enough to contribute in decreasing the incidence of abr. another approach is to encourage reflection amongst academicians working in different fields of health care though publications. an effort will be made to bring on plate the sad reality of the current situation of abr and highlighting the steps involved in risk management and prevention of abr. last but not the least, in order to outreach student population at large, a free online certification course will be created using inter-disciplinary approach. this initiative will enable the project to reach out to the students across india as well as other parts of the world. creating awareness: one of the major outcomes of the project is to sensitize healthcare, non-healthcare students and general public. the mode of delivery will be through expert talks, skits, dramas, posters, etc. during dissemination events. however, the content of the delivery will change according to the target audience. this is setting in motion a very sustainable process as the students who are being trained are the ones entering healthcare workforce tomorrow as well as will become the future academicians and researchers. limitations a major limitation of this project, similarly to every other project promoting capacity building activities in a vast country as india, is the financial shortcoming vis-à-vis the magnitude of the challenges addressed. the project although targets a wide audience of students and general public but measures to involve farmers and animal husbandry, covering all hemispheres of ‘one health’ is lacking and the execution of the curriculum programme is restricted to regions within india. despite the direct involvement of five indian higher education institutions – and two non-governmental organizations, risk management and prevention of antibiotics resistance in india require an integrated approach, involving an enlarged and differentiated platform of stakeholders, combining the bottom-up approach utilized in the project, with coordinated topdown initiatives. also, at present, government agencies involved in policy making are not directly involved in the execution of the project. moreover, specific intervention studies such as counselling programs to bring a behavioural change in pharmacists, clinicians, farmers and animal husbandry are beyond the current objectives of the project. prevent it is expected to generate a major improvement in the capabilities of indian universities and ngos to educate different target groups with foundational and advanced skills in abr. due to the erasmus+ funding scope, the activities financed are only marginally focusing on research, partially hampering the scientific credibility – and visibility – of the project in the international academic community. conclusion projects like prevent it unify the researchers, students, academicians, non-governmental organizations from different parts of the world and provide them a common platform to work in unison for the noble cause assuring good health. these types of projects will accelerate the pace of curriculum change globally, keeping in line with changes in healthcare trends. preventing abr through a behavioural change is the first step of this collaborative process and the success of the project would open up further novel alternatives to combat abr. as it is rightly said, ‘he who has health, has hope; and he who has hope, has everything’; it is high time we should collaborate across disciplines to bring sustainable changes in the kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 13 | 15 healthcare sector for better, happier and healthier future. acknowledgment: the authors would like to acknowledge the contribution of partners from ngos, riga stradins university and catholic university of portugal for their continuous help and support. this project has been funded with support from the european commission. this manuscript reflects the views only of the author, and the commission cannot be held responsible for any use which may be made of the information contained therein. join this initiative: please follow us on facebook (www.facebook.com/preventit), twitter (https://twitter.com/itprevent) and linkedin (https://www.linkedin.com/in/prevent-it-1995a7192). references 1. ayukekbong ja, ntemgwa m, atabe an. the threat of antimicrobial resistance in developing countries: causes and control strategies. antimicrob resist infect control 2017;6:47. 2. o’neill j. tackling drug-resistant infections globally: final report and recommendations–the review on antimicrobial resistance [internet]. wellcome trust and hm government; 2016. available from: https://amr-review.org/sites/default/files/160518_final%20paper_with %20 cover.pdf (accessed: may 28, 2020). 3. prestinaci f, pezzotti p, pantosti a. antimicrobial resistance: a global multifaceted phenomenon. pathog glob health 2015;109:309-18. 4. world health organization. global action plan on antimicrobial resistance. geneva: who; 2015. 5. government of india. national action plan on antimicrobial resistance (nap-amr) 2017 2021 [internet]; 2017. available from: https://ncdc.gov.in/writereaddata/linkimages/amr/file645.pdf (accessed: may 28, 2020). 6. o’neill j. tackling drug-resistant infections globally: final report and recommendations–the review on antimicrobial resistance [internet]. wellcome trust and hm government; 2016. available from: https://amr-review.org/sites/default/files/160518_final%20paper_with %20 cover.pdf (accessed: may 28, 2020). 7. united nations. youth population trends and sustainable development. pop facts 2015:1. 8. fleming a. on the antibacterial action of cultures of a penicillium, with special reference to their use in the isolation of b. influenzae. br j exp pathol 1929;10:226-36. 9. michael ca, dominey-howes d, labbate m. the antimicrobial resistance crisis: causes, consequences, and management. front public health 2014;2:145. 10. baquero f, martínez jl, cantón r. antibiotics and antibiotic resistance in water environments. curr opin biotechnol 2008;19:260-5. 11. ram s, vajpayee p, shanker r. prevalence of multi-antimicrobialagent resistant, shiga toxin and enterotoxin producing escherichia coli in surface waters of river ganga. environ sci technol 2007;41:7383-8. 12. dahal r, upadhyay a, ewald b. one health in south asia and its kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 14 | 15 challenges in implementation from stakeholder perspective. vet rec 2017:249-53. 13. world health organization. global tuberculosis report 2017 [internet]; 2017. available from: https://www.who.int/tb/publications/global_report/gtbr2017_main_text.pdf (accessed: may 28, 2020). 14. klein ey, tseng kk, pant s, laxminarayan r. tracking global trends in the effectiveness of antibiotic therapy using the drug resistance index. bmj glob health 2019;4:e001315. 15. van boeckel tp, gandra s, ashok a, caudron q, grenfell bt, levin sa, et al. global antibiotic consumption 2000 to 2010: an analysis of national pharmaceutical sales data. lancet infect dis 2014;14:742-50. 16. sivalingam p, poté j, prabakar k. environmental prevalence of carbapenem resistance enterobacteriaceae (cre) in a tropical ecosystem in india: human health perspectives and future directives. pathogens 2019;8:174. 17. akiba m, senba h, otagiri h, prabhasankar vp, taniyasu s, yamashita n, et al. impact of wastewater from different sources on the prevalence of antimicrobial-resistant escherichia coli in sewage treatment plants in south india. ecotoxicol environ saf 2015;115:203-8. 18. skariyachan s, mahajanakatti ab, grandhi nj, prasanna a, sen b, sharma n, et al. environmental monitoring of bacterial contamination and antibiotic resistance patterns of the fecal coliforms isolated from cauvery river, a major drinking water source in karnataka, india. environ monit assess 2015;187:279. 19. sudha s, mridula c, silvester r, hatha aam. prevalence and antibiotic resistance of pathogenic vibrios in shellfishes from cochin market. indian j mar sci 2014;43:815-24. 20. van boeckel tp, brower c, gilbert m, grenfell bt, levin sa, robinson tp, et al. global trends in antimicrobial use in food animals. proc natl acad sci u s a 2015;112:5649-54 . 21. government of india. national programme on containment of anti-microbial resistance (amr) [internet]. available from: https://ncdc.gov.in/index1.php?lang=1&level=2&sublinkid =384&lid=344 (accessed: may 28, 2020). 22. indian council of medical research. treatment guidelines for antimicrobial use in common syndromes. 2nd edition. new delhi: icmr-hq; 2019. 23. gaur rk. antibiotic resistance: alternative approaches. indian j pharmacol 2017;49:208-10. 24. hayles cs, holdsworth se. curriculum change for sustainability. j educ built environ 2008;3:25-48. 25. fien j. education for sustainable consumption: towards a framework for curriculum and pedagogy. in: jensen bb, schnack k, simovka v. editors. critical environmental and health education: research issues and challenges. copenhagen: danish university of education; 2000:45-66. 26. maher ca, lewis lk, ferrar k, marshall s, de bourdeaudhuij i, vandelanotte c. are health behavior change interventions that use online kaur k, greco s, saroj sd, hossain ss, pradhan hs, singh sk, et al. risk management and prevention of antibiotics resistance: the prevent it project (review article). seejph 2020, posted: 30 august 2020. doi: 10.4119/seejph-3684 p a g e 15 | 15 © 2020 kaur et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. social networks effective? a systematic review. j med internet res 2014;16:e40. 27. wakefield ma, loken b, hornik rc. use of mass media campaigns to change health behaviour. lancet 2010;376:1261-71. 28. lübbert c, baars c, dayakar a, lippmann n, rodloff ac, kinzig m, et al. environmental pollution with antimicrobial agents from bulk drug manufacturing industries in hyderabad, south india, is associated with dissemination of extended-spectrum beta-lactamase and carbapenemaseproducing pathogens. infection 2017;45:479-91. 29. altorf-van der kuil w, schoffelen af, de greeff sc, thijsen sf, alblas hj, notermans dw, et al. national laboratory-based surveillance system for antimicrobial resistance: a successful tool to support the control of antimicrobial resistance in the netherlands. euro surveill 2017;22. ______________________________________________________ tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 1 | 8 review article syndromic surveillance in early detection of outbreaks of infectious diseases eugena tomini1, artan simaku1, elona kureta1, adela vasili1, silva bino1 1 institute of public health, tirana, albania. corresponding author: eugena tomini, md, phd; address: rr. “aleksander moisiu”, no. 88, tirana, albania; telephone: 00355672052938; email: genatomini@yahoo.com tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 2 | 8 abstract aim: motivated by the threat of infectious diseases and bioterrorism, syndromic surveillance systems are being developed and implemented around the world. the aim of the study was to describe the early warning surveillance system in albania. methods: syndromic surveillance is a primary health care-facilityand emergency room (er)based syndromic surveillance system aiming at detecting outbreaks and undertaking public health actions. it is based on weekly notifications of nine syndromes by over 1,600 general practitioners (gps) in the 36 districts of albania. data is aggregated by district epidemiologists (de) and centralized by the national institute of public health. results: a syndrome is “a set of symptoms or conditions that occur together and suggest the presence of a certain disease or an increased chance of developing the disease.” in the context of syndromic surveillance, a syndrome is a set of non-specific pre-diagnosis medical and other information that may indicate the release of a bioterrorism agent or natural disease outbreak. since its inception, syndromic surveillance has mainly focused on early event detection: gathering and analysing data in advance of diagnostic case confirmation to give early warning of a possible outbreak. conclusion: the system is useful for detecting and responding to natural disease outbreaks such as seasonal and pandemic flu, and thus they have the potential to significantly advance and modernize the practice of public health surveillance. keywords: albania, early event detection, public health, situational awareness. tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 3 | 8 introduction the epidemiology of infectious diseases is one of the major crises facing human society. following the course of epidemic outbreaks of diseases such as sars (severe acute respiratory syndrome), a health emergency that shocked the world at the end of 20022003 or of the influenza pandemic caused by the ah1n1 virus in 2009 to arrive at covid19 pandemic, the appropriate management of crises health issues that exceed borders, takes an important role (1-3). human cases of ah5n1 influenza are still being reported in asia, and the emergence of new infectious disease epidemics is still a major concern. early detection of outbreaks of infectious diseases is essential for taking measures against the disease. in recent years, "syndromic surveillance" has attracted attention as a new technology that meets these needs. the term "surveillance" is used when observing the trends of an infectious disease (4-6). it refers to the systematic collection, analysis and interpretation of data necessary for the planning, implementation and evaluation of measures against diseases, due to the continuous monitoring of the situation and the trend of disease occurrences, thus making it possible to take effective measures based on timely results and continuous feedback evaluations of decision-making bodies (7,8). syndromic surveillance focuses on the patient's symptoms such as fever, diarrhoea, etc. syndromic surveillance takes less time than diagnosis-based surveillance, so it enables an early investigation of infectious disease epidemics and taking measures to prevent their spread. in the situation where "improvement and reinforcement of surveillance" is at the top of the list for measures to be taken for the prevention of infectious diseases, including new subtypes of influenza viruses and sars-cov-2 variants, expectations for syndromic surveillance are high, as was discussed at the international conference maintained by the world health organization (who) (9,10). in syndromic surveillance, the technologies of epidemic intelligence, epidemiological analysis of information about the patient's symptoms thanks to statistical methods, as well as the technologies of efficient collection, processing and distribution of information, play a very important role. this article focuses on the role of syndromic surveillance in taking measures against infectious diseases in humans. what is syndromic surveillance? description and objectives of surveillance the research, development and practical application of syndromic surveillance has been promoted since the anthrax cases that occurred after the september 2001 attacks in the united states of america, as well as after the sars epidemic in 2002-2003, with the aim of developing measures against bioterrorism, early detection of the emergence and re-emergence of epidemics from infectious diseases, especially unknown or rare ones (11). the us centres for disease control and prevention proposed the following definition of syndromic surveillance as the most appropriate and acceptable: syndromic surveillance is an investigative approach by which health department staff, assisted by data from automated and the construction of comparative statistics, monitors disease indicators in real or near-real time, in order to detect disease epidemics earlier than was possible with traditional public health methods (12-16). in other words, syndromic surveillance is an action that captures disease outbreaks in real or near-real time, focusing on symptoms that serve as disease indicators, collecting information automatically, and analysing tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 4 | 8 information from an epidemiological point of view thanks to the use of statistical methods. syndromic surveillance is an early investigation of the epidemic of an infectious disease, thanks to the rapid and early identification of the growing number of patients with specific symptoms, before the diagnosis is confirmed by the doctor. it is a "surveillance of syndromes", with the aim of quickly engaging in the "early dictation" of new epidemics, especially those of reappearing diseases, of unknown or rare infectious diseases, a description that also explains the objective of syndromic surveillance. if all the above points are summed up, it can be said that syndromic surveillance "collects information about the patient's symptoms, analyses the information from an epidemiological point of view using statistical methods, notifies family physicians and government organizations about the results, and quickly takes measures for public health" as and "an effective action that prevents the epidemic spread of infectious diseases caused by humans (bio-terrorism) or by nature" (17-20). system organization and action views the operative process of syndromic surveillance consists of three steps:  selection of information source and data collection;  analysing the information collected and based on the results of judgment about the chances of an epidemic;  notifying health professionals and government organizations responsible for taking measures against infectious diseases. these steps are the same for all types of syndromic surveillance. but since epidemics of infectious diseases vary in form based on the microbiological characteristics of the pathogen and the area of the outbreak, and since syndromic surveillance uses different sources of information, the collection and analysis algorithms are different. the main goal of syndromic surveillance is to establish these algorithms and the various research results. the inability of different countries to detect and contain epidemic outbreaks, identify an infectious agent and understand the dynamics of its transmission in time, has contributed to the spread of infectious diseases in the past (21-24). the international health regulations (ihr) were revised to meet the risks and challenges of the emergence or re-emergence of diseases in the 21st century (25). according to this regulation, all states must report as soon as possible all public health events that have a potential international impact, so that control and prevention measures can be implemented as soon as possible (26). this is achieved by strengthening syndromic surveillance of infectious diseases as a function of the early warning and response of the public health surveillance system, which also helps to collect important data on the epidemiology of endemic diseases. this early warning system was implemented in albania during the influx of kosovar refugees in april 1999 (27,28). this was carried out in collaboration with the institut de veille sanitaire (invs) and the world health organization (who). after the departure of kosovar refugees in july 1999, the system was redesigned to meet the needs of the national health system. the system of early warning and response to infectious diseases alert, was established in september 1999, as part of the national surveillance system coordinated by the institute of public health (iph). the goal of the alert system is the early detection of epidemic outbreaks. it is a syndromic surveillance system based on health centers and emergency departments tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 5 | 8 that produces information for action. the participation of general practitioners in surveillance and preventive activities is mandatory and is included in their employment contract with the institute of health insurance. the system also includes the emergency departments in the hospitals of 36 districts of the country. at the end of each week, gps report the syndrome cases they have examined during the week, including reporting zero cases. the system includes nine infectious syndromes. data are reported to infectious disease information system which is a web-based integrated platform. after visual verification of the data for any outbreak signal, the data are analysed and a weekly bulletin is prepared on the epidemiological situation all over the country. the information produced by the pih is distributed to the epidemiological service of the districts in the form of weekly and quarterly bulletins. the verification of the alert signal and the epidemiological investigation is also carried out at the district level with the help of the pih if necessary. the district epidemiology service is responsible for distributing the weekly newsletter to general practitioners. in some cases, general practitioners are informed in the form of alert data summaries during their monthly meetings with the administration of the institute of health insurance and the directorate of the primary health service (29,30). the "alert" system is integrated and complementary with the mandatory routine reporting system of diagnosed diseases the major disease-based surveillance system, along with other case-based surveillance systems. table 1. type of syndromes and target diseases syndromes clinical definition disease(s) target diarrhoea without blood more than 3 loose stools in 24h salmonellosis… diarrhoea with blood more than 3 loose stools with blood in 24h shigellosis… upper respiratory infections fever, and at least one of the following: rhinitis, cough, sore throat influenza … lower respiratory infections fever and fast breathing (= 50 breathing/min) and at least one of the following: cough, dyspnoea bacterial or viral pulmonary infections sars… avian influenza rash (exanthema) with fever rash with fever measles, rubella, varicella, … jaundice yellow eyes and skin hepatitis virus infection … tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 6 | 8 congenital anomalies structural or functional anomalies that occur during intrauterine life congenital rubella syndrome (crs), congenital syphilis, congenital cytomegalovirus (ccmv) infection and congenital zika syndrome (czs) acute conjunctivitis in neonates conjunctival inflammation occurring within the first 30 days of life chlamydia, bacteria, viral diseases syndromes are broken down by age-group and different automated reports and graphs are produced by epidemiological triad timeplace-person. integration of different surveillance system aiming at maximizing case detection and fast control actions within infectious disease information system is shown in figure 1. figure 1. scheme of integration of different surveillance systems conclusion the alert component of the surveillance of infectious diseases in albania is one of the few systems in the world spread over the entire territory of the country. it can be improved by re-examining the case definition and the disorders under surveillance, and its integration with routine surveillance at the district level. re-structuring, training, feedback to family doctors can be more frequent, increasing the acceptability of the system. the alert system remains very useful, and complements other surveillance systems in a timely and effective manner. tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 7 | 8 choices made in building the system—such as frequency of reporting, software used, and syndromes under surveillance—are appropriate. references 1. heymann dl, rodier gr. hot spots in a wired world: who surveillance of emerging and re-emerging infectious diseases. lancet infect dis 2001;1:345-53. 2. world health organization. background paper for health metrics network: disease surveillance (draft); 2003. 3. factors in emergence. in: mark s.smolinski, margaret a.hamburg, joshua lederberg (eds), committee on emerging 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surveillance of communicable diseases among the kosovar refugees in albania, april-june 1999. euro surveill 1999;4:92-5. 16. valenciano m, coulombier d, lopes cb, colombo a, alla mj, samson s, et al. challenges for communicable disease surveillance http://www.bseinquiry.gov.uk/report/index.htm http://www.bseinquiry.gov.uk/report/index.htm tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 8 | 8 and control in southern iraq, apriljune 2003. jama 2003;290:654-8. 17. gesteland ph, wagner mm, chapman ww, espino ju, tsui fc, gardner rm, et al. rapid deployment of an electronic disease surveillance system in the state of utah for the 2002 olympic winter games. proc amia symp 2002;2859. 18. weber sg, pitrak d. accuracy of a local surveillance system for early detection of emerging infectious disease. jama 2003;290:596-8. 19. malison md. surveillance in developing countries. in: halperin w, baker eljr, monson rr, editors. public health surveillance.new york: van nostrand reinhold; 1992. p. 56-61. 20. world health organization, dept.of communicable disease surveillance and response. global outbreak alert and response. report of a who meeting geneva, switzerland 26-28 april, 2000 (who/cds/csr/2000.3). 21. centers for disease control. framework for evaluating public health surveillance systems for early detection of outbreaks. mmwr morb mortal wkly rep 2004;53:1-14. 22. centers for disease control. framework for evaluating syndromic surveillance systems for bioterrorism preparedness. mmwr morb mortal wkly rep 2004;53(rr-5):1-14. 23. grein tw, kamara kb, rodier g, plant aj, bovier p, ryan mj, et al. rumors of disease in the global village: outbreak verification. emerg infect dis 2000;6:97-102. 24. world health organization. regional office for europe. the dubrovnik pledge on surveillance and prioritization of infectious diseases: report on a who meeting, bucharest, romania 21-23 november, 2002. 25. the albanian center for economic research (acer). un common country assessment: albania; 2002. 26. nuri b. health care systems in transition – albania; 2002. 27. valenciano m, bergeri i, jankovic d, milic n, parlic m, coulombier d. strengthening early warning function of surveillance in the republic of serbia: lessons learned after a year of implementation. euro surveill 2004;9:24-6. 28. valenciano m, pinto a, coulombier d, hashorva e, murthi m. surveillance of communicable diseases among the kosovar refugees in albania, april-june 1999. euro surveill 1999;4:92-5. 29. kakarriqi e. survejanca e shendetit publik. leksion per specializantet pasuniversitare te fakultetit te mjekesise (universiteti i tiranes); 2003 (in albanian). 30. kakarriqi e. epidemiologjia e semundjeve infektive ne shqiperi (1960-2001) dhe kontrolli e parandalimi i tyre ne kontekstin: fatkeqesite natyrore dhe semundjet infektive. tiranë; 2003 (in albanian). _____________________________________________________________________________________________ © 2022 tomini et al; this is an open access article distributed under the terms of the creative commons attribution license (http:// creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 1 | 19 original research knowledge and perception about climate change among healthcare professionals and students: a cross-sectional study giuseppe la torre1, alice de paula baer2, cristina sestili1, rosario andrea cocchiara1, domenico barbato1, alice mannocci1, angela del cimmuto1 1 department of public health and infectious diseases, sapienza university of rome, italy; 2 faculty of medicine, university of sao paulo, brazil. corresponding author: giuseppe la torre; address: piazzale aldo moro 5 – 00161, rome, italy; telephone: +39(0)649694308; e-mail: giuseppe.latorre@uniroma1.it la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 2 | 19 abstract aim: the aim of this study was to assess knowledge on climate change (cc) and related consequences among students and professionals of healthcare setting. methods: a cross-sectional study involving 364 people was conducted. the survey was performed at sapienza university (rome) using questionnaire previously developed and validated by the same research group. results: findings indicate awareness about cc and its effects and correct identification of practices that could help to mitigate its repercussions. the majority of the participants believed that cc had an impact on the health of humans (96.7%), animals (99.5%) and on the environment (99.7%). results from the multivariate analysis regarding overall knowledge, show an increased odd in professionals (or=2.08; 95%ci=1.02-4.26), individuals from the north (or=3.34; 95%ci=1.37-8.15) and from the center (or=2.07; 95%ci=1.17-3.66). regarding factors able to modify earth's climate, correct answer had higher odds of being chosen by professionals (or=2.83; 95%ci=1.41–5.70), and from individuals from south/islands than by the ones from the center (or=0.65; 95%ci=0.40-1.06). the main sources of information resulted to be tv and school/university. conclusions: these new evidences could guide policymakers on increasing the awareness of the population about this fundamental subject. keywords: climate change, cross sectional, health professionals, italy, students, survey. funding: this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. author contributions: conceptualization, g.l.t. and a.d.c..; methodology, g.l.t. and a.m..; formal analysis, a.d.p.b., c.s., r.a.c., d.b.; investigation, a.d.p.b., c.s., r.a.c., d.b.; data curation, a.d.p.b., c.s.; writing – original draft preparation, r.a.c., d.b.; writing – review & editing, r.a.c., d.b., a.m..; supervision, g.l.t..; project administration, g.l.t. conflicts of interest: none declared. la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 3 | 19 introduction in 2009, the first lancet commission for global health identified climate change (cc) as “the biggest global health threat of the 21st century” (1). ten years later, the world meteorological organization registered that the global mean surface temperature in 2018 was about 1.0 °c higher than pre-industrial levels (1850-1900) (2). seventeen out of the 18 warmest years in the 136-year record conducted by nasa have all occurred since 2001, except for 1998 (3). this observed pattern of warming is known to be related to anthropogenic activity, and particularly to the use of fossil fuels. that is correlated to the increase of greenhouse gases, mainly carbon dioxide (co2). as consequence, sea levels are rising, glaciers are melting, weather-related natural disasters are becoming more frequent and precipitation patterns are changing. cc is strongly impacting on humans’ health: reduction in air quality; threatened food production and safety; increased water-related illnesses; increased morbidity and mortality from extreme temperatures; increased and new infectious disease exposures; negative consequences for mental health (e.g. anxiety, depression and substance abuse) (4,5). the best forecast for a low gas emission scenario, a world that takes sustainable energy use as a priority, is an air warming of 1.8°c. however, in a world that mainly uses fossil fuels and has rapid economic and global population growth, the best estimation is that temperatures will rise by 4.0°c (2.4°c to 6.4°c) (6). in order to mitigate the rising of earth temperature, it is essential that the population is aware of cc, its consequences and the actions that could be taken into account to avoid it. for this reason, an effective communication is fundamental. they need information in order to have an attitude of constructive engagement (7). in particular, health professionals could deeply contribute in making recommendations and supporting favorable policies as they have the expertise to recognize the health consequences related to cc and they have a strong impact on the public opinion (8). the scientific literature was investigated in order to assess the presence of studies addressing knowledge on cc of health professionals and students. a review was performed in june 2019 searching pubmed database. the following search string was used: “(climate change) and education and university students and (nurses or medicine)”. out of 59 studies, that were firstly retrieved, 14 were recognized as relevant for our purposes (9-22). the topic appears widespread all over the continents: four studies were performed in europe; four were conducted in asia; three were from oceania; two from america; one was performed in africa. these researches were published from 2009 on, with a peak that was recorded in 2018. the aim of the studies was to measure the knowledge and perceptions of health professionals and students about cc and its consequences. in this regard, surveying the population's knowledge on this topic becomes necessary, because these data could show what is already known, what are people's sources of information on cc and what are the knowledge gaps that need to be filled for allowing a proper adaptation of the society. the studies included in the review applied validate questionnaire: children’s environmental health knowledge questionnaire (9); children’s environmental health skills questionnaire (9); sustainability attitudes in nursing survey (sans-2) (11,18,20). according to the scientific evidences from the literature, the potential of communication and social marketing as means to influence population health and environmental outcomes is clear, but it has to be put into practice (23). it has been found, for example, that mass media could be an important source of information (13,24), but the issue has not gained much attention from it. a literature review concluded that most residents of developed countries have little knowledge about the health relevance of cc (7) and, according to other researches, this awareness could be related to level of education, country of residence and living environment (13,25). although surveys have been conducted in that matter, to our knowledge none has included the italian population. thus, the aim of this study was to collect data from italy to verify knowledge on cc within a population of students and professionals from the healthcare settings. methods study design a cross-sectional study, according to the strobe statement (26) was performed during the period february 2018-march 2019. participants and setting a total of 569 individuals were invited to take part to the survey. respondents were contacted through a mailing list of students of medical area (medicine, la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 4 | 19 nursing, prevention technicians) of sapienza university of rome and health professionals (nurses, doctors, technicians of the prevention). the link to access the anonymous online questionnaire, which also contained the informed consent form, was shared via mail with the audience. questionnaire an italian questionnaire previously developed and validated by the same research group on a sample of 64 individuals was used (27). the questionnaire contained a sociodemographic section on age, sex, marital status and educational level. the subsequent section contained 19 questions about cc. to complete the survey respondents were required to choose specific answers or enter free text in specific box. questions could include more than one correct answer. the survey covered different categories of questions: definition of cc and greenhouse gases; knowledge about the effects of global warming; respondents’ awareness about the argument and options to fight cc and pollution. annex 1 reports the administered questionnaire. approval by ethical committee was not required for this study, since this was an observational study. statistical analysis the statistical analysis was performed using statistical package for social sciences (spss) version 25. descriptive analysis was performed using frequencies, mean and sd. bivariate analysis was computed using chi-square test in order to assess the possible associations between the answers to the questionnaire and above listed socio-demographic variables. a scoring system was created by assigning one point for each correct answer to questions that evaluated cc knowledge. the highest achievable punctuation was 13. in the question about the possible implications of cc, in which more than one answer was possible, the assigned score went from 0 to 1, according to the number of chosen alternatives; the score 1 was given to those who pointed out all the correct options. furthermore, multivariate analysis including logistic regression and linear regression were performed. for logistic regression model, in order to verify the relationship between participants’ answers and gender, age, occupation and civil status, all the variables were dichotomized including the sum of the correct answer. zero was attributed to the ones who achieved less than mean score (9.2) and 1 to the ones who achieved 9.2 or more. a multiple linear regression analysis with stepwise using the backward wald selection was used to confirm the relationship between score and socio-demographic variables. the goodness of fit of linear regression model was assessed using the r2. a statistically significant difference was accepted at a p-value of less than 5%. results sample demographic characteristics a total of 364 people completed the questionnaire (chronbach alpha = 0.74), with a global response rate of 64.2%%. among students, the highest response rate was observed for medical students (77%) and the lowest for nursing students (23.5%). conversely, among professionals, no substantial differences between these two groups were observed (nurses 68.7% vs. doctors 68.9%). the mean age was 23.7 (sd: 6.6). all respondents lived in italy, mostly in the centre (56.3%). most of the respondents were female (65.1%). regarding civil status, 77.1% were single. as to professional situation, most of participants were medical students (63.7%), followed by nurse professionals (15.7%) (table 1). table 1. sample’s socio-demographic information variables n(%) or mean (sd) gender females 237 (65.1) males 127 (34.9) total 364 age 23.7 (6.587) civil status married 31 (8.5) cohabitant 47 (12.9) la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 5 | 19 separated 3 (0.8) single 281 (77.1) widow(er) 2 (0.5) professional status other 2 (0.5) phd student 1 (0.3) nurse 57 (15.7) doctor 20 (5.5) nursing student 24 (6.6) medical student 232 (63.7) prevention and environmental technician student 23 (6.3) prevention and environmental technician 5 (1.4) region of residence (macroarea) north 35 (9.6) center 205 (56.3) south and islands 66 (18.1) missing 58 (15.9) participants' source of information about climate change most respondents (98.1%) had already heard about cc, 72.3% of them in tv, the most common source, followed by school/university (33%) and internet (22.2%). statistically significant associations were found between having heard about cc and being under 24 years old (p=0.002) and from center (p=0.002). having school as a source of information was related with being under 24 (p< 0.001), single (p< 0.001), student (p< 0.001) and from the center of italy (p= 0.011). being female (p= 0.01) was also related with having newspaper as a source. being single was statistically associated with having the scientific literature as source of information (p=0.037). students and subjects younger than 24 showed statistically significant association with having heard about cc at home (p=0.007; p=0.012). lastly, hearing it from congresses was statistically associated with being male (p= 0.004). only 25.8% affirmed that university courses addressed global warming, mainly females (p= 0.010), people younger than 24 (p<0.001), single (p=0.003) and students (p< 0.001) (table 2). table 2. participants’ knowledge and source of information question yes/true gender n(%) age n(%) civil status n(%) professional status n(%) macro area n(%) n(%) female male <=24 >24 single cohabitant /married student profession al north center south/ islands have you heard of climate change before? 357 (98.1) 292(64.7) 141(35.3) 261 (73.1) 96 (26.9) 280(78.4) 77(21.6) 278(77.9) 79(22.1) 35(11.5) 203(67) 65(21.5) 0.429a 0.002 a 0.642 a 0.192 a 0.002 a where did you hear about it? tv 263(72.3) 166(63.1) 97(36.9) 189(71.9) 74(28.1) 203(77.2) 60(22.8) 200(76.9) 63(23.1) 27(12.3) 146(66.1) 48(21.6) 0.129 a 0.144 a 0.994 a 0.582 a 0.838 a where did you hear about it? school/unive 120 (33) 73(60.8) 47(39.2) 104 (86.7) 16 (13.3) 105 (87.5) 15 (12.5) 107 (89.2) 13 (10.8) 11 (9.9) 84 (75.7) 16 (14.4) 0.090 a <0.001 <0.001 a <0.001 a 0.011 a la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 6 | 19 rsity where did you hear about it? internet 81 (22.2) 54(66.7) 27(33.3) 54(66.7) 27(33.3) 58(71.6) 23(28.4) 59 (72.8) 22 (27.2) 8(11.4) 47(67.1) 15(21.4) 0.896 a 0.716 a 0.484 a 0.722 a 0.781 a where did you hear about it? newspaper 83(22.8) 46 (55.4) 37 (44.6) 52 (62.7) 31 (37.3) 59 (71.1) 24 (28.9) 61 (73.5) 22 (26.5) 13 (18.3) 40 (56.3) 18 (25.4) 0.015 a 0.773 a 0.540 a 0.507 a 0.249 a where did you hear about it? scientific literature 23 (6.3) 16(69.6) 7(30.4) 18(78.3) 5(21.7) 21(91.3) 2(8.7) 19(82.6) 4(17.4) 3(16.7) 9(50) 6(33.3) 0.819a 0.087 a 0.037 a 0.129 a 0.448 a where did you hear about it? home 15 (4.1) 8(53.3) 7(46.7) 14(93.3) 1(6.7) 14(93.3) 1(6.7) 15(100) 0(0) 2(14.3) 12(85.7) 0 (0) 0.260 a 0.012 a 0.071 a 0.007 a 0.114 a where did you hear about it? conventions 5 (1.4) 0 (0) 5 (100) 3 (60) 2 (40) 3 (60) 2 (40) 2 (28.6) 5 (71.4) 0 (0) 4(100) 0 (0) 0.004 a 0.516 a 0.516 a 0.676 a 0.296 a where did you hear about it? associations/ ongs 6 (1.6) 2 (33.3) 4 (66.7) 4 (66.7) 2 (33.3) 5(83.3) 1 (16.7) 6(100) 0(0) 1(16.7) 3(50) 2(33.3) 0.075a 0.800 a 0.557 a 0.093 a 0.796 a where did you hear about it? radio 4 (1.1) 2(50) 2 (50) 4(100) 0(0) 3(75) 1 (25) 4(100) 0 (0) 0(0) 4(100) 0(0) 0.469 a 0.301 a 0.914 a 0.175 a 0.302 a during the course of your university studies was the subject of global warming addressed? 94 (25.8) 51 (54.3) 43 (45.7) 82 (87.2) 12 (12.8) 84 (89.4) 10 (10.6) 87 (92.6) 7 (7.4) 5(5.5) 65(71.4) 19(20.9) 0.010 a <0.001 a 0.003 a <0.001 a 0.094 a a p-value of chi-square test bold: p<0.05 participants' knowledge on cc and its consequences the majority of the participants believed that cc had an impact on human (96.7%), animal (99.5%) and on the environment (99.7%) health. concerning greenhouse gases, 92.6% of respondents were aware of human responsibility in emissions; 62.6% of participants answered correctly that co2, methane (ch4) and nitrous oxide (n2o) were all responsible for rising earth's temperature. still, concerning causes of cc, 54.4% of participants recognized changes that occur in solar radiation, variations of the albedo and the introduction of gases as factors that could modify the chemical composition of the atmosphere. answering this correctly was related to be over 24 (p= 0.001). respondents (93.4%) mostly agreed that a healthcare professional could contribute in reducing the impact of cc, and this was associated with being younger. when asked in what way, most of them marked all alternatives as correct in the questions regarding transportation (67.3%), energy use (86.5%) and waste disposal (81.6%). correct answers regarding transports were associated with being over 24 years old (p=0.020) and student (p=0.018); regarding waste disposal, with being single (p=0.005) and from the center (p=0.012) (table 3 and table 4). la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 7 | 19 table 3. knowledge on the consequences of cc question yes/true gender n(%) age n(%) civil status n(%) professional status n(%) macro area n(%) female male <=24 >24 single cohabitant / married student professi onal north center south and islands most scientists agree that the warming is due to the increasing concentrations of greenhouse gases, which imprison the heat in the atmosphere, a process determined by human activities and not just by natural causes? 337 (92.6) 215(63.8) 122(36.2) 245(72.7) 92(27.3) 265(78.6) 72(21.4) 262(77.7) 75(22.3) 33(11.7) 193(68.4) 56(19.9) 0.123 a 0.541 a 0.927 a 0.751 a 0.238 a do you think global warming can have an impact in the environment’s health? 363 (99.7) 236(65) 127(35) 262(72.2) 101 (27.8) 286(78.8) 77(21.2) 282(77.7) 81(22.3) 35(11.4) 205(67) 66(21.6) 0.464 a 0.109 a 0.214 a 0.063 a 0.917 a do you think global warming can have an impact in animals’ health? 362 (99.5) 237(66.5) 125(34.5) 262(72.4) 100(27.6) 285(78.7) 77(21.3) 281(77.6) 81 (22.4) 35(11.5) 204(66.9) 66(21.6) 0.053 a 0.023 a 0.323 a 0.351 a 0.802 a do you think global warming can have an impact in humans’ health? 352 (96.7) 229(65.1) 123(34.9) 255(72.4) 97(27.6) 276(78.4) 76(21.6) 272(77.3) 80(22.7) 35(11.7) 200(67.1) 63(21.2) 0.908 a 0.285 a 0.683 a 0.621 a 0.009 a do you think a health professional can contribute to reduce the impact of climate change? 340 (93.4) 222(65.3) 118(34.7) 250(73.5) 90(26.5) 268(78.8) 72(21.2) 267(78.5) 73(21.5) 34(11.8) 193(67) 61(21.2) 0.781 a 0.013 a 0.659 a 0.069 a 0.190a a p-value of chi-square test bold: p<0.05 table 4. results of the bivariate analysis concerning causes, consequences and actions towards cc n (%) gender n(%) age n(%) civil status n(%) professional status n(%) macro area n(%) female male <=24 >24 single cohabitan t/ married student professional north center south/ islands in what way can a health professional contribute to diminish the impacts of climate change by transport? all are correct 245(67.3) 163(66.5) 82 (33.5) 167 (68.2) 78(31.8) 189 (77.1) 56 (22.9) 181 (73.9) 64 (26.1) 25 (12.3) 142 (70) 36 (17.7) error 119(32.7) 74 (62.2) 45(37.8) 95 (79.8) 24(20.2) 97 (81.5) 22(18.5) 101 (84.9) 18 (15.1) 10 (9.7) 64 (61.5) 30 (28.8) p-valuea 0.414 0.020 0.341 0.018 0.081 in what way can a health professional contribute to diminish the impacts of climate change by energy use? all are correct 315 (86.5) 203 (64.4) 112 (35.6) 223(70.8) 92(29.2) 245 (77.8) 70 (22.2) 240 (76.2) 75 (23.8) 33 (12.4) 180 (67.7) 53 (19.9) error 49 (13.5) 34 (69.4) 15 (30.6) 39(79.6) 10(20.4) 41 (83.7) 8 (16.3) 42 (85.7) 7 (14.3) 2 (5) 25(62.5) 13 (32.5) p-valuea 0.525 0.202 0.454 0.197 0.147 la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 8 | 19 in what way can a health professional contribute to diminish the impacts of climate change regarding waste disposal? all of the above are correct 297 (81.6) 198 (66.7) 99 (33.3) 209(70.4) 88(29.6) 225 (75.8) 72(24.2) 224(75.4) 73(24.6) 31(12.3) 174(68.8) 48(18.9) error 67 (18.4) 39(58.2) 28(41.8) 53(79.1) 14(20.9) 61 (91) 6 (9) 58(86.6) 9(13.4) 4(7.5) 31(58.5) 18(34) p-valuea 0.203 0.150 0.005 0.052 0.012 what are the main factors able to modify the climate on the earth? all are correct 198(54.4) 136 (68.7) 62(31.3) 111(63.1) 65(36.9) 156(78.8) 42(21.2) 150 (75.8) 48 (24.2) 22(13.1) 109(64.9) 37(22) error 166(45.6) 101(60.8) 65(39.2) 151(80.3) 37(19.7) 130(78.3) 36(21.7) 132(79.5) 34(20.5) 13(9.4) 96(69.6) 29(21) p-valuea 0.118 <0.001 0.912 0.392 0.718 which gases that are rising in the atmosphere as a consequence of human activities cause an increase in earth's temperature? all of the above 228(62.6) 150 (65.8) 78 (34.2) 142(71.7) 56(28.3) 168(73.7) 60(26.3) 160(70.2) 68(29.8) 29 (15.8) 117(63.5) 38(20.7) error 32(37.4) 25(78.1) 7(21.9) 120(72.3) 46(27.7) 21(65.6) 11(34.4) 18(56.3) 14(43.8) 2(9.5) 11(52.4) 8(38.1) p-valuea 0.164 0.904 0.338 0.112 0.181 which are the main repercussions of climate change? (more than one answer was possible to this question) rising of earth’s temperature 328 (90.1) 209 (63.7) 119 (36.3) 244 (7.4) 84 (25.6) 261(79.6) 67(20.4) 260 (79.3) 68 (20.7) 33 (11.7) 193 (68.7) 55 (19.6) p-valuea 0.993 0.002 0.160 0.013 0.017 melting of ice caps 313 (86) 203(64.9) 110(35.1) 231(73.8) 82(26.2) 249(79.6) 64(20.4) 243(77.6) 70(22.4) 31 (11.6) 186 (69.7) 50 (18.7) p-valuea 0.801 0.055 0.258 0.853 0.006 ice retraction 262 (72) 160(61.1) 102(38.9) 191(72.9) 71(27.1) 210(80.2) 52(19.8) 210(80.2) 52(19.8) 28 (12.4) 161 (71.2) 37(16.4) p-valuea 0.010 0.530 0.239 0.050 0.001 rising of sea level 254 (69.8) 149 (58.7) 105 (41.3) 188(74) 66(26) 201(79.1) 53(20.9) 205(80.7) 49(19.3) 25 (11.5) 153 (70.5) 39 (18) p-valuea <0.001 0.188 0.691 0.025 0.054 biodiversity will be reduced 236 (64.8) 150(63.6) 86(36.4) 172(72.9) 64(27.1) 188(79.7) 48(20.3) 185(78.4) 51(21.6) 20(9.8) 141(68.4) 45(21.8) p-valuea 0.399 0.602 0.492 0.569 0.393 the food production will be at risk 176 (48.4) 105 (59.7) 71 (40.3) 129(73.3) 47(26.7) 135(76.7) 41(23.3) 141(80.1) 35(19.9) 14(9.3) 106(70.2) 31(20.5) p-valuea 0.035 0.588 0.401 0.243 0.401 increased water shortage 163 (44.8) 93 (57.1) 70 (42.9) 117(71.8) 46(28.2) 126(77.3) 37(22.7) 130(79.8) 33(20.2) 17(12) 98(69) 27(19) p-valuea 0.004 0.939 0.595 0.348 0.598 weatherrelated natural disasters will occur more frequently: storms, droughts. floods and heat waves 307(84.3) 200(65.1) 107(34.9) 221(72) 86(28) 245(79.8) 62(20.2) 238(77.5) 69(22.5) 29(11) 176(66.9) 58(22.1) p-valuea 0.973 0.993 0.183 0.956 0.786 the economy will suffer 126 (34.6) 74(58.7) 52(41.3) 89(70.6) 37(29.4) 99(78.6) 27(21.4) 98(77.8) 28(22.2) 9(8.6) 75(71.4) 21(20) p-valuea 0.063 0.678 1.000 0.919 0.407 population will face 200 (54.9) 123(61.5) 77(38.5) 153(76.5) 47(23.5) 160(80) 40(20) 163(81.5) 37(18.5) 19(11.1) 120(70.2) 32(18.7) la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 9 | 19 food and water shortages. leading to conflicts and migration p-valuea 0.111 0.034 0.463 0.042 0.352 catastrophic transformati ons can occur 210 (57.7) 132(62.9) 78(37.1) 162(77.1) 48(22.9) 167(79.5) 43(20.5) 168 (80) 42 (20) 16(9.1) 126(71.6) 34(19.3) p-valuea 0.292 0.010 0.605 0.178 0.118 diseases will spread 153 (42) 91(59.5) 62(40.5) 114(74.5) 39(25.5) 119(77.8) 34(22.2) 122(79.7) 31(20.3) 14(10.7) 91(69.5) 26(19.8) p-valuea 0.055 0.360 0.753 0.378 0.727 a p-value of chi-square test bold: p<0.05 regarding the consequences of cc, the rising of earth temperature was selected by 90.1% of participants. being female was associated with marking ice retraction (p=0.010), rising of the sea level (p<0.001), risks for food production (p=0.035) and increased water shortage (p=0.004) as consequences. being younger resulted associated with considering that higher earth temperature (p=0.002), conflicts/migrations (p=0.034) and catastrophic transformations (p=0.010) could occur. other important associations are shown in table 4. a sum of all correct answers per participant was calculated, being 13 the highest achieved value, with all answers correct, and 4.42 the lowest; only 0.8% of participants reached the highest score. however, the mean sum was 9.2 (sd 1.76), which shows a high level of knowledge (figure 1). multivariate analysis results from the multivariate analysis regarding the dichotomous score show an increased odd for good knowledge in professionals (or=2.08; 95%ci=1.02-4.26), individuals from north (or= 3.34; 95%ci= 1.37-8.15) and center (or=2.07; 95%ci=1.17-3.66). regarding factors able to modify earth's climate, correct answers had higher odds of being chosen by professionals (or=2.83; 95%ci=1.41–5.70), and individuals from south/islands than from center (or=0.65; 95%ci= 0.40-1.06). the correct predicted increase in temperature for 2100 was associated with males (or=0.47; 95%ci=0.27–0.81) and cohabitant/ married participants (or=2.38; 95%ci=1.22–4.64). rising of earth’s temperature was recognized as possible repercussion for cc with higher odd by cohabitant/married individuals (or=2.38; 95%ci=1.22-4.64), and with lower odd from females (or=0.47; 95%ci= 0.27-0.81). females were associated with reductions in odds of having knowledge about cc repercussions, such as ice-retraction (or=0.48; 95%ci=0.27-0.86), rising of sea level (or= 0.35; 95%ci=0.19–0.64), risks to food production (or=0.66; 95%ci=0.41–1.06), increased water shortage (or= 0.52; 95%ci=0.32– 0.83) and conflicts and migration due to lack of resources (or=0.63; 95%ci=0.39–1.02). twentyfour year-old participants or older had a reduction on odds of choosing conflicts/migration (or=0.50; 95%ci=0.29–0.88) and catastrophic transfor mations (or= 0.44; 95%ci= 0.25–0.77) as consequence of cc. participants from center italy were associated with choosing ice retraction, rising of sea level, melting of ice caps and catastrophic transformations (respectively or= 2.97; 95%ci=1.63–5.41; or=2.06; 95%ci= 1.12–3.78; or=2.42; 95%ci=1.22–4.77; or=1.55; 95%ci=0.95-2.52). conversely, participants from the north of italy showed a higher odd of choosing ice retraction (or=3.50; 95%ci=1.32-9.27) and rising of sea level (or=2.34; 95%ci=0.92-5.97). students had higher odds of choosing rising of sea level as repercussion of cc (or= 0.47; 95%ci=0.24–0.95). on the questions about possible contributions that they could give to diminish these effects, choosing the correct answer regarding means of transportation had an increase in the odds for participants belonging to the professional category (or= 2.07; 95%ci=0.97–4.44) and from the center (or=1.6; 95%ci=0.96-2.66). on the subject of waste disposal, higher odds of giving the correct answer were found for participants from the north (or=2.77; 95%ci=0.84–9.15) and center (or= 2.41; 95%ci= 1.22–4.76), and also married/cohabitants people (or=6.47; 95%ci=1.50–27.9) (table 5). la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 10 | 19 figure 1. knowledge score's distribution table 5. multivariate analysis: logistic regression with “backward wald” elimination procedure question gender age civil status professional status macro area or (95% ci) or (95% ci) or (95% ci) or (95% ci) or (95% ci) female male* <=24* >24 single* cohabitant/ married student * professional north center south/ islands * binary codification of knowledge score 1 2.08 (1.02-4.26) 3.34 (1.378.15) 2.07 (1.17-3.66) 1 in what way can a health professional contribute to diminish the impacts of climate change by transport? all are correct 1 2.07 (0.97-4.44) 1.6 (0.96-2.66) 1 in what way can a health professional contribute to diminish the impacts of climate change regarding waste disposal? 1 6.47 (1.50-27.9) 2.77 (0.849.15) 2.41 (1.22-4.76) 1 la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 11 | 19 all are correct what are the main factors able to modify the climate on the earth? all are correct 1 2.83 (1.41-5.70) 0.65 (0.40-1.06) 1 which are the main repercussions of climate change? rising of earth’s temperature 0.47 (0.27-0.81) 1 1 2.38 (1.22-4.64) which are the main repercussions of climate change? ice retraction 0.48 (0.27-0.86) 1 3.50 (1.329.27) 2.97 (1.63-5.41) 1 which are the main repercussions of climate change? rising of sea level 0.35 (0.19-0.64) 1 1 0.47 (0.24-0.95) 2.34 (0.925.97) 2.06 (1.12-3.78) 1 which are the main repercussions of climate change? melting of ice caps 2.42 (1.22-4.77) 1 which are the main repercussions of climate change? the food production will be at risk 0.66 (0.41-1.06) 1 which are the main repercussions of climate change? increased water shortage 0.52 (0.32-0.83) 1 which are the main repercussions of climate change? population will face food and water shortages. leading to conflicts and migration 0.63 (0.39-1.02) 1 1 0.50 (0.29-0.88) which are the main repercussions of climate change? catastrophic transformations can occur 1 0.44 (0.25-0.77) 1.55 (0.95-2.52) 1 la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 12 | 19 do you think a health professional can contribute to reduce the impact of climate change? yes 1 0.31 (0.12-0.83) what temperature increase do un climate experts predict by 2100? 1.4°–5.8°c 0.47 (0.27-0.81) 1 1 2.38 (1.22-4.64) *reference group white cells indicate p-value>0.05 linear regression showed that being older is predictor for having higher knowledge scores (β=0.124; p=0.030). discussion results show that participants were sufficiently aware of cc and its effects, and mostly could identify individual practices that could help to mitigate its repercussions. significant differences on the amount of information regarding the consequences of global warming were found mainly related to the region of residence and to gender, with females having lower odds of giving the correct answers. most of participants had already heard about cc, with the main sources of information being tv and school/university. the results from this study show to be similar to the ones from a previous study conducted in china with health professionals (28), in which tv also appeared as main source. the importance of mass media is also highlighted in a survey conducted in bangladesh (29), while the key role of school as a source of information appears in a study made with iranian students, in which school was the main source, with 38, 5% of answers (30). however we cannot deny the role of social media in this field. lewandowsky et al. (31) underline the role of internet blogs that became a very useful tool for discussing scientific issues, and cc is now one of the most chosen in the discussions. these authors believe that the use of blogs, and particularly the comment sections of blogs, can play a very important role in disseminating different positions around this issue. it is possible to conclude that mass media have a fundamental role on the dialogue with the italian population about cc, and therefore should be used to disseminate information to the public. however, television coverage of public health issues has problems, such as individual selection of information of viewers, journalists’ unfamiliarity with the topics and spread of misinformation (32). taking this into account, television should be used carefully, and it should be as well important to valorize the key role that educational institutions play, being a more reliable information disseminator. also, it is worth paying attention that, although the question “where have you heard about climate change?” was open answered, no participant cited doctors or other health professionals. a research conducted at yale university showed that, for information about cc-related health problems, americans mostly trust their primary-care doctor (33). another study done in the usa concluded that the public health community has an important perspective about cc that, if shared, could help the public to better understand cc issues. their findings also suggest that the communication should not be focused on the problem of cc, but on solutions and co-benefits: a healthier future offers environmental benefits (34). the potential of health professionals as disseminators of information on global warming, according to these results, seems to be underused. concerning the causes of global warming, more than 50% of participants understood that greenhouse gases were co2, n2o and ch4, although a significantly amount choose only co2. still, on the matter of greenhouse gases, most of respondents (92.5%) were aware of human’s responsibility on their emissions and on scientists’ agreement on the subject, showing a positive consonance between italian population's knowledge and scientific consensus. also, in the usa research (35), more than one third of participants from 2009 mentioned mainly anthropogenic causes as "things that could cause global warming", such as cars and industries, and 26% specifically mentioned fossil fuel use. similar reasons were mentioned by the china participants (28). however, in the usa 18% affirmed that natural causes were also primary drivers of global warming and also in the study made with nursing students in arab countries respondents la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 13 | 19 believed cc was due to a balance between nature and human causes (13). in the arab region, most of respondents said that all presented health‐related effects had already increased due to cc; similar findings were presented by a study conducted in montana with nursing students (36). although this research did not specifically focus on the consequences of cc for health, options such as the spread of diseases, water shortage and risks to food production were chosen by less than 50% of participants, with the exception of the one related to conflicts and migration (54.2%). being this a cohort of mostly health professionals and students, the found results disagree with the existing literature. this should be seen as an aspect worthy of improvement: past experiences with smoking cessation, hiv prevention, physical activity promotion and other health issues have proved that health professionals can have an important and effective role on educating and empowering people about health. however, little of this understanding on effective health communication has been applied to cc (37). the proportion of male students that recognized possible consequences of cc was significantly higher compared to women. this gender difference was also found in the studies conducted in the arab region. it is known that some population groups are more vulnerable to the health effects of cc, and among these there are women, children and elderly, people with previous health problems or disabilities, and poor and marginalized communities (38). a study from 2016 in the usa showed that approaching cc as a health issue is an effective way of communicating with vulnerable audiences, specially addressing individual, immediate-term health effects and practical advices for protective behaviors (39). regarding the level of education, significant differences were found between students and professionals, related to source of information – students, younger and single had higher odds of having heard of it in school and during university studies. this evidence suggests the importance that education should have in informing new generations. the implementation of courses and conferences will help to increase the awareness among both students and professionals of the healthcare setting and this could also contribute to widespread correct information about cc within the society. in the multivariate analysis, professionals had higher odds of having a sum of correct answers above the mean. in other studies, dose-response associations were found between cc knowledge and the educational level (29). in this survey, associations were also related to age, with younger participants having bigger odds of having heard of cc and higher accuracy odds on the question about the related causes. regarding region of residence, south and islands were associated with lower odds of having a higher score. this might be related to socio-economic and cultural differences among different areas within the country, although no scientific evidence about this data was found. the limitations of this study include a small sample size and the recruitment of participants. the population was made of individuals specifically belonging to the university setting, which makes it difficult to generalize the results for the entire italian population. more important, the participants were professionally related to the health area and this even more limits the potential of this study to make generalizations. also, it must be underlined that the study design does not allow to derive inference from the results, since cross-sectional studies refer to punctual evidences in time and space. strengths of this study concern the geographic distribution of the sample size that offers a wide description of the italian scenery and gives robustness to the evidences. secondly, this study fills the gap in the scientific literature furnishing an innovative focus on this emerging issue. furthermore, it will be possible to replicate this investigation in order to assess changes in knowledge over time. conclusions it is possible to conclude that, although the italian students and professionals included in the study have a good knowledge on cc, it is essential to invest in informing the most vulnerable population groups and also to potentialize the role that health professionals can have on disseminating information on the subject. the results presented on this study will allow improvements in communication and in creating policies related to cc in this country and elsewhere, with the final objective of avoiding the rapid progression of cc and its consequences. finally, we must recognize the concept of “one world, one health”. we cannot forget the deep link between animal diseases, public health, and the environment (40). the use of the one health approach can be very important to increase the awareness of the usefulness of cooperation activities in this field. on the basis of these 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developing effective communication materials on the health effects of climate change for vulnerable groups: a mixed methods study. bmc public health 2016;16:946. 40. de giusti m, barbato d, lia l, colamesta v, lombardi am, cacchio d, et al. collaboration between human and veterinary medicine as a tool to solve public health problems. lancet planet health 2019;3:e64-5. ______________________________________________________________ © 2020 la torre et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 17 | 19 annex 1: climate change and health dear participant, sapienza university of rome, a member of the planetary health alliance, is conducting a survey on the perception of the climate change issue. please answer with the most sincerity, thank you. socio-demographic 1. age: … 2. gender: o male o female 3. marital status: o single o married o divorced o widower o cohabitant 4. where do you live? specify the italian region… 5. occupation: o medical doctor o nurse o preventative health experts o scientist (biological, natural, environmental, chemical, physical and mathematical) o medical student o nursing student o student of preventative health o science student (biological, natural, environmental, chemical, physical and i. mathematical) o high school student o middle school student o other: ____ climate change 1. have you heard of climate change before? o yes o no 2. where did you hear about it? …. 3. during the course of your university studies was the subject of global warming addressed? o yes o no 4. most scientists agree that the warming is due to the increasing concentrations of greenhouse gases, which imprison the heat in the atmosphere, a process determined by human activities and not just by natural causes? o yes o no 5. what is the average temperature of the earth today? o 22°c o 18°c la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 18 | 19 o 15°c o 12°c o i don't know 6. what temperature increase do un climate experts predict by 2100? o 1°–3,8°c o 1,4°–5,8°c o 1,9°–6,8°c o i don't know 7. do you think global warming can have an impact in the environment’s health? o yes o no 8. do you think global warming can have an impact in animals’ health? o yes o no 9. do you think global warming can have an impact in humans’ health? o yes o no 10. do you think a health professional can contribute to reduce the impact of climate change? o yes o no 11. in what way can a health professional contribute to diminish the impacts of climate change by transport? o going on foot o taking public transports o taking the bus o moving by driving their own cars o taking the bike o using car pooling o taking flights o all previous answers are correct o none of the answers are correct o i don’t know 12. in what way can a health professional contribute to diminish the impacts of climate change by energy use? o reducing the consumption of home appliances o lowering the temperature of the heating systems o keeping chargers always plugged in o using devices with reduced consumption o keeping lights always on o turning off the lights that are not needed o all previous answers are correct o none of the answers are correct o i don’t know 13. in what way can a health professional contribute to diminish the impacts of climate change regarding waste disposal? o differentiating waste o using single-use devices o reusing the packaging o using plastic objects o reducing waste la torre g, de paula baer a, sestili c, cocchiara ra, barbato d, mannocci a, et al. knowledge and perception about climate change among healthcare professionals and students: a crosssectional study (original research). seejph 2020, posted: 02 march 2020. doi: 10.4119/seejph-3347 p a g e 19 | 19 o all previous answers are correct o none of the answers are correct o i don’t know 14. what are the main factors able to modify the climate on the earth? o changes that occur in solar radiation o variations of the albedo: the fraction of solar radiation that is reflected in various parts of the earth o the introduction of gases that modify the chemical composition of the atmosphere o all of these answers are correct o none of the answers are correct o i don't know o all of these answers are correct 15. which gases that are rising in the atmosphere as a consequence of human activities cause an increase in earth's temperature? o carbon dioxide o methane o nitrogen oxides o all previous answers are correct o none of the answers are correct o i don’t know 16. which are the main repercussions of climate change? (more than one answer was possible) o rising of earth’s temperature o melting of ice caps o ice retraction o rising of sea level o biodiversity will be reduced o the food production will be at risk o increased water shortage o weather-related natural disasters will occur more frequently: storms. droughts. floods and heat waves o the economy will suffer o population will face food and water shortages. leading to conflicts and migration o catastrophic transformations can occur o diseases will spread heinz m. the potential of men’s sheds as a resource for men coping with mental health challenges and addiction (case study). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5766 p a g e 1 | 5 case study the potential of men’s sheds as a resource for men coping with mental health challenges and addiction melinda heinz1 1) upper iowa university, fayette, iowa, usa corresponding author: melinda heinz, phd associate professor of psychology 605 washington st. p.o. box 1857 215 liberal arts building upper iowa university fayette, ia 52142, usa email: heinzm@uiu.edu mailto:heinzm@uiu.edu heinz m. the potential of men’s sheds as a resource for men coping with mental health challenges and addiction (case study). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5766 p a g e 2 | 5 abstract men’s sheds are defined as grassroots community-based organizations comprised of men coping with mental health challenges and addiction. men in need experience the benefits of receiving support from other men and feel that their levels of loneliness and depression declined after they joined the men’s shed. men’s sheds could serve as a mental health refuge for a variety of men with diverse needs. it may be worthwhile to pilot a program investigating the efficacy of using men’s sheds to support individuals recovering from addictions. conflicts of interest: none declared source of funding: none declared heinz m. the potential of men’s sheds as a resource for men coping with mental health challenges and addiction (case study). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5766 p a g e 3 | 5 for the last four months i have been fortunate to be immersed in several men’s sheds throughout ireland including both rural and more urban settings. i received approval to do the research from the technological university of the shannon: midlands midwest (tus). men’s sheds are defined as grassroots community-based organizations comprised of men who come together to engage in discussion “shoulder to shoulder” while working on a craft (e.g., woodwork, art, gardening, etc.; (1). men’s sheds are informal networks and create welcoming and inclusive spaces for men. men’s sheds originated in australia (2) and have expanded to other parts of europe including the u.k. and ireland. although men’s sheds exist in america, they are not as widespread. currently, the u.s. has 17 men’s sheds dispersed throughout country (3). their inclusive and accepting ethos offer a wide array of benefits to their members. during my research with the men’s sheds i set out to learn more about how irish men’s sheds contributed to purpose and meaning in the lives of older men. men i interviewed spoke about the importance of having a place to gather with other men and the benefit of having a purpose when they got up each day. the men discussed the benefits of receiving support from other men and felt that their levels of loneliness and depression declined after they joined the men’s shed. after completing and reflecting on the interviews it was apparent to me that the men’s sheds could serve as a mental health refuge for a variety of men with diverse needs. for example, kelly et al.4 suggested that men’s sheds may be especially helpful for populations of men with unique needs, including addiction. as mental health concerns and addictions increase around the world (5), it is important to consider a wide array of interventions and solutions to address these challenges. men’s sheds may offer a worthwhile support framework for these men. research indicates that men are more likely to suffer from substance abuse and antisocial disorders as compared to women (6) and the world health organization (who)7 reported that men’s risk for premature mortality is higher than women’s. men are less likely to go to the doctor, more likely to engage in riskier behaviors, and imbibe higher quantities of alcohol (7). they also face greater risk of death from opioid overdose compared to women (8). given these gendered health differences, men’s sheds may provide spaces to address some of the health inequities between men and women. wilson and cordier9 explained that men’s sheds were ideal environments for promoting men’s health and wilson et al.10 reported that men’s sheds served as safe spaces where members felt comfortable talking about their health concerns. of the limited research available, it seems men who engage with men’s sheds felt that the environment positively contributed to their wellbeing. for example, findings indicate that men who participated in men’s sheds reported improved wellbeing, including better selfworth and increased ability to cope with depression (11). however, additional research is required to understand the effectiveness of men’s sheds and its usefulness in helping members cope with mental health and other challenges. likewise, it may be worthwhile to pilot a program investigating the efficacy of using men’s sheds to support individuals recovering from addictions. gendered approaches for coping with addiction are not new, but men’s sheds already possess the structure to serve as ideal support infrastructures. milligan et al.12 explained that men are reluctant to join groups if they perceive the group to be dominated by women and can struggle to make friendships, heinz m. the potential of men’s sheds as a resource for men coping with mental health challenges and addiction (case study). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5766 p a g e 4 | 5 particularly in older adulthood. the ethos and constitution of men’s sheds also appear to foster healthy environments for all men. for example, the men’s sheds constitution states that the men’s sheds spaces are designed to be substance free (1), creating safe environments for men in the early stages of recovery. robertson & nesvåg13 noted that it is best when recovery environments include social networks of individuals who do not use substances. the structure and routine of visiting a place like the men’s shed could also be beneficial for individuals focused on addiction recovery. for example, men could attend the men’s sheds throughout the week and find benefit from the comradery, support, and guidance of other men (4) and gain opportunities to learn new skills. building routine and structure into one’s life is beneficial when coping with recovery (14) and engaging in regular visits to the men’s sheds would likely be a positive outlet for these men. including rural men’s sheds for pilot interventions investigating the efficacy of men’s sheds as support resources could also be useful as mental health services and resources for addiction are less widespread in these areas (15, 16). in addition, monnat and rigg17 explained that opioid related deaths in rural areas have increased significantly in the last 20 years and that initiatives designed to combat the expanding issues in rural areas have been relatively ineffective. likewise, patel et al.18 advocated for additional treatment options for individuals with opioid addictions, particularly in rural areas. conducting interventions in australia, the u.k., or ireland would be ideal given the wide array of men’s sheds available in both rural and urban areas. if successful, interventions could be rolled out in parts of the u.s. where men’s sheds are less widely known. perhaps the number of men’s sheds would increase in america if research findings demonstrated the effectiveness of these spaces as support resources for men coping with mental health challenges and addictions. references 1. irish men’s sheds association what is a men’s shed?, dublin, ireland: https://menssheds.ie/aboutmens-sheds/ (accessed: may 3, 2022). 2. carragher l, golding b. (2015). older men as learners: irish men’s sheds as an intervention. adult education quarterly, 2015;65:152168. 3. u.s. men’s sheds find a men’s shed. https://usmenssheds.org/finda-shed/ (accessed: may 3, 2022) 4. kelly d, steiner a, mason h, teasdale s. men’s sheds: a conceptual exploration of the causal pathways for health and well-being. health and social care in the community 2019;27:1147-1157. 5. world health organization depression and other common mental disorders: global health estimates, geneva, switzerland: https://apps.who.int/iris/bitstream/ha ndle/10665/254610/who-msdmer-2017.2-eng.pdf (accessed may 11, 2022). 6. rosenfield s, smith d. (2010). gender and mental health: do men and women have different amounts or types of problems? in scheid tl, brown, tn, editors. a handbook for the study of mental health: social contexts, theories, and systems. cambridge: cambridge university press, 2010: 256-267. 7. world health organization men’s health and well-being in the who european region, geneva, switzerland: https://journals.sagepub.com/action/dosearch?target=default&contribauthorstored=nesv%c3%a5g%2c+sverre+martin https://menssheds.ie/about-mens-sheds/ https://menssheds.ie/about-mens-sheds/ https://usmenssheds.org/find-a-shed/ https://usmenssheds.org/find-a-shed/ https://apps.who.int/iris/bitstream/handle/10665/254610/who-msd-mer-2017.2-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/254610/who-msd-mer-2017.2-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/254610/who-msd-mer-2017.2-eng.pdf heinz m. the potential of men’s sheds as a resource for men coping with mental health challenges and addiction (case study). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5766 p a g e 5 | 5 https://www.euro.who.int/en/healthtopics/healthdeterminants/gender/mens-health (accessed: may 11, 2022). 8. silver er, hur c. (2020). gender differences in prescription opioid use and misuse: implications for men’s health and the opioid epidemic. preventive medicine 2020,131; 105946. 9. wilson nj, cordier r. (2013). a narrative review of men’s sheds literature: reducing social isolation and promoting men’s health and well-being. health & social care in the community 2013;21:451-463. 10. wilson nj, cordier r, doma k., misan g, vaz, s. men’s sheds function and philosophy: towards a framework for future research and men’s health promotion. health promotion journal of australia 2015;26:133-142. 11. crabtree l, tinker a, glaser, k. men’s sheds: the perceived health and wellbeing benefits. working with older people 2018;22:101-110. 12. milligan c, neary d, payne s, hanrattys b, irwin, p, dowrick c. (2016). older men and social activity: a scoping review of men’s sheds and other gendered interventions. ageing & society, 2016;36:895-923. 13. robertson ie, nesvåg sm. into the unknown: treatment as a social arena for drug users’ transition into a non-using life. nordic studies on alcohol and drugs 2019;36:248-266. 14. davies s, filippopoulos p. (2015). changes in psychological time perspective during residential addiction treatment: a mixedmethods study. journal of groups in addiction & recovery 2015;10:249270. 15. lister j l, weaver a, ellis jd, himle ja, ledgerwood dm. a systematic review of rural-specific barriers to medication treatment for opioid use disorder in the united states. the american journal of drug and alcohol abuse 2020;46:273-288. 16. ziller ec, anderson nj, coburn a f. access to rural mental health services: service use and out-ofpocket costs. the journal of rural health 2010;26:214-224. 17. monnat sm, rigg kk. university of new hampshire carsey school of public health, durham, nh). the opioid crisis in rural and small town america. carsey research national issue brief; summer 2018. report no. 135. https://scholars.unh.edu/cgi/viewcont ent.cgi?article=1342&context=carse y (accessed: may 13, 2022). 18. patel k, bunachita s, agarwal aa, lyon a, patel u k (2021). opioid use disorder: treatments and barriers. cureus 2021;13:e13173. __________________________________________________________________________________________ © 2022 heinz; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.euro.who.int/en/health-topics/health-determinants/gender/mens-health https://www.euro.who.int/en/health-topics/health-determinants/gender/mens-health https://www.euro.who.int/en/health-topics/health-determinants/gender/mens-health https://journals.sagepub.com/action/dosearch?target=default&contribauthorstored=nesv%c3%a5g%2c+sverre+martin https://scholars.unh.edu/cgi/viewcontent.cgi?article=1342&context=carsey https://scholars.unh.edu/cgi/viewcontent.cgi?article=1342&context=carsey https://scholars.unh.edu/cgi/viewcontent.cgi?article=1342&context=carsey edite sadiku, irgen tafaj, aldo shpuza, stela taci, bledar kraja, predictors, severity and associate factors of acute pancreatitis: a tertiary hospital’s experience. seejph 2023. posted: 30-05-2023, vol. xx. page 57 original research predictors, severity and associate factors of acute pancreatitis: a tertiary hospital’s experience edite sadiku1, irgen tafaj1, aldo shpuza2, stela taci1, bledar kraja1 1gastro-hepatology service, university hospital center mother teresa, tirana, albania 2department of public health, university of medicine, tirana, albania corresponding author: edite sadiku, md, phd address: faculty of medicine, rr. dibres, no. 371, tirana, albania email: editesadiku@gmail.com edite sadiku, irgen tafaj, aldo shpuza, stela taci, bledar kraja, predictors, severity and associate factors of acute pancreatitis: a tertiary hospital’s experience. seejph 2023. posted: 30-05-2023, vol. xx. page 58 abstract aim: acute pancreatitis is a common disorder that occurs following an acute response to a pancreatic injury. the aim of this study was to assess predictors of severity and associated factors, as well as the association of different classification systems of severity among patients with acute pancreatitis (ap). methods: a retrospective case series study was conducted in albania including 150 patients with ap between march 2021 and march 2022. variables such as baseline characteristics, laboratory findings, and calculated scores of known severity classifications were analyzed. patients were graded as having mild, moderate, or severe acute pancreatitis based on the revision of the atlanta classification (rac). ordinal logistic regression was used to model the relationship between the ordinal variable (rac categories) and the explanatory variables mentioned above. results: women with ap had a higher average age than men with ap (62.5 vs. 57.5 years old, respectively, p<0.05). additionally, the alcoholic etiology in males prevailed in 100% of cases, while the biliary etiology was more common in females (64.2% compared to 35.8% in males, p<0.001). ordinal logistic regression showed that a one unit increase in the ct severity index (ctsi) and bedside index for severity in acute pancreatitis resulted in a 0.968 and 0.430 times increase, respectively, in the ordered log-odds of being in a higher rac classification category. the presence of systemic inflammatory response syndrome (sirs) (vs. non-present) resulted in a 2.98 higher ordered logit. conversely, a one unit increase in saturation level decreased the ordered log-odds by approximately 0.4 times. conclusion: the severity of acute pancreatitis is a medical event that requires accurate prediction, for which many classification systems have been compiled, with the rac being the most recent consensus. ctsi, the presence of sirs, and saturation levels are significantly associated with rac, without excluding the discussion on the predictive value of laboratory findings, such as glycemia, azotemia, and creatinine. keywords: acute pancreatitis, etiology, predictors, severity. edite sadiku, irgen tafaj, aldo shpuza, stela taci, bledar kraja, predictors, severity and associate factors of acute pancreatitis: a tertiary hospital’s experience. seejph 2023. posted: 30-05-2023, vol. xx. page 59 introduction acute pancreatitis is a common disorder that occurs following an acute response to a pancreatic injury [1]. despite the controversial pathogenic theories investigated over the years, in most cases of acute pancreatitis, obstruction of the ducts by migrating gallstones and alcohol abuse are identified as major causes [2]. other known causes of acute pancreatitis include infectious causes (viral, bacterial, parasitic), congenital pancreatic divisum, intraduct papillary mucinous tumor, endoscopic retrograde cholangiopancreatography, hypercalcemia and other combined or idiopathic causes [2, 3]. in the meantime, there are assumptions about a causal relationship between covid-19 and acute pancreatitis, but the cause has yet to be proven, whether it is covid-19 or idiopathic disease [4]. the activation of trypsinogen to trypsin, the formation of reactive oxygen species (ros), and the release of proinflammatory cytokines are key factors that contribute to pancreatic inflammation [2]. among the three diagnostic elements of this disease, are the typical clinical symptoms, increased laboratory values of pancreatic enzymes, and imagery (useful for differential diagnostics, but not always required) [5]. however, recent studies have suggested the use of point-of-care ultrasound (pocus) as a reliable and cost-effective tool for the diagnosis and monitoring of acute pancreatitis [6]. the follow-up of this disease is important in terms of prognosis and severity. the diagnosis of acute presentation might be simple, but the main challenge is strictly forecasting the progression of the disease and its outcome [7]. multiple ap severity classifications have placed clinicians and researchers in positions and having consistently evolved to better characterize clinical scores and other diagnostic elements, gave rise to two valid classifications, such as the revision of the atlanta classification (rac) and determinant based classification [8]. according to rac, the severity of ap of is classified as mild, moderately severe, and severe acute pancreatitis [9]. as mentioned above, there are several multi-factorial rating systems such as ranson, the bedside index for severity in acute pancreatitis (bisap), the acute physiology and chronic health evaluation (apache ii) and modified ct severity index (ctsi), which edite sadiku, irgen tafaj, aldo shpuza, stela taci, bledar kraja, predictors, severity and associate factors of acute pancreatitis: a tertiary hospital’s experience. seejph 2023. posted: 30-05-2023, vol. xx. page 60 attempt to predict the severity of ap [10]. in terms of laboratory results, by aetiology, amylase and lipase pancreatic enzymes remain the diagnosis’s cornerstone, although their sensitivity and specificity vary and there may be room for further lab findings that diagnose acute pancreatitis [11]. the treatment of acute pancreatitis typically involves supportive care and management of complications such as fluid and electrolyte imbalances, pancreatic necrosis, and infected pancreatic necrosis. in severe cases, surgical intervention may be required to remove necrotic tissue and prevent the development of pancreatic abscesses or systemic infection [12]. according to a systematic review that included 10 cohort studies on ap, global estimates of incidence's ap was 33·74 cases (95% ci 23·33–48·81) per 100 000 per-son-years [13]. while acute pancreatic mortality rates vary widely, in the united states the mortality rate is approximately 5% [14]. intuitively and evidently, case fatality for patients of high severity is reported to be higher than total mortality due to ap [15]. we aim to study predictors, severity and associate factors of ap, as well as the association between different classification systems of severity among patients with ap. methods a retrospective case series study was conducted during march 2021-march 2022. the sample size of this study was one hundred and fifty patients. the sampling technique included consecutive patients who presented at the university hospital: "mother teresa", tirane with suspected ap have been diagnosed and treated in gastrohepatology service during the period of the study. the criteria for the inclusion of participants in the study were: 1. patients admitted in emergency or recommended by regional hospitals 2. patients diagnosed with ap 3. patients who have provided consent for the use of their data for the study. we obtained the data by reviewing all the medical records of the patients who met the inclusion criteria in the study. to ensure the accuracy and completeness of our data, two independent reviewers extracted the relevant information from the medical records of each patient. this methodology ensures that the study sample is representative of patients with acute pancreatitis who seek medical edite sadiku, irgen tafaj, aldo shpuza, stela taci, bledar kraja, predictors, severity and associate factors of acute pancreatitis: a tertiary hospital’s experience. seejph 2023. posted: 30-05-2023, vol. xx. page 61 care at the hospital, and that the data collected is accurate and reliable. the information collected from the medical records was processed by statistical programs such as microsoft-excel and statistical package for social sciences (spss) version 25.0. the statistical tests and techniques applied in the data analysis of this study are described in detail below: at first, scores were calculated for all ap severity classification systems. the apache score is calculated based on the patient's physiological parameters at admission, including temperature, blood pressure, heart rate, respiratory rate, oxygenation, ph, serum potassium level, serum creatinine level, hematocrit level, and glasgow coma scale (gcs) score, ranging from 0 to 71 [16]. the ranson’s criteria have been modified over time and includes the following parameters [17]: clinical parameters: •age greater than 55 years •white blood cell count greater than 16,000/mm3 •blood glucose greater than 200 mg/dl •serum ldh greater than the upper limit of normal •ast greater than the upper limit of normal laboratory parameters: •serum calcium less than 8 mg/dl •hematocrit decrease of more than 10% from admission to 48 hours •arterial oxygen tension (pao2) less than 60 mm hg •bun increase greater than 5 mg/dl within 48 hours •serum albumin less than 3.2 g/dl a score of 0-2 indicates a mild pancreatitis, whereas a score of 3 or higher indicates severe pancreatitis. while the parameters included in the bisap score are [18]: •blood urea nitrogen (bun) level greater than 25 mg/dl •impaired mental status (glasgow coma scale score < 15) •systolic blood pressure (sbp) less than 90 mm hg •age greater than 60 years •pleural effusion present on imaging the total score ranges from 0 to 5. edite sadiku, irgen tafaj, aldo shpuza, stela taci, bledar kraja, predictors, severity and associate factors of acute pancreatitis: a tertiary hospital’s experience. seejph 2023. posted: 30-05-2023, vol. xx. page 62 the ctsi is based on two major categories of findings seen on a ct scan: pancreatic and extrapancreatic complications [19]. the pancreatic complications include gland necrosis, peri-pancreatic fluid collections, and pseudocysts. the extrapancreatic complications include peripancreatic fat necrosis, bowel wall thickening, and pleural effusion. the ctsi score ranges from 0 to 10, with higher scores indicating more severe pancreatitis. the atlanta 2012 revision is the most commonly used and includes three categories of acute pancreatitis [20]: • mild acute pancreatitis no organ failure, and local or systemic complications are absent or transient. • moderate acute pancreatitis transient organ failure (<48 hours) or local or systemic complications without persistent organ failure. •severe acute pancreatitis persistent organ failure (>48 hours). organ failure is defined as the presence of any of the following: hypotension requiring vasopressors, acute lung injury or acute respiratory distress syndrome, renal failure requiring dialysis, or circulatory failure requiring mechanical ventilation. all these scores were treated in data analysis as numerical variables. in addition to the severity assessments, demographic data, comorbidities, clinical symptoms, laboratory results, and imaging findings were also collected and analyzed. all examinations and laboratory findings were obtained on the first day of patient admission and were also treated as numerical variables. the measurement of variables were as below: age: continuous variable measured in years, reported as mean (+ standard deviation), gender: categorical variable with two levels (male and female), reported as counts and percentages, accompanying conditions: categorical variable with three levels (nonpresent, another condition, 2 or more conditions), reported as counts and percentages, etiology: categorical variable with six levels (migrating gallstones, alcohol abuse, hypertriglyceridemia, idiopathic, infectious, combined), reported as counts and percentages, sirs's presence: categorical variable with two levels (yes and no), reported as counts and percentages. heart rate, saturation, azotemia, glucose level and creatinine were measured as numerical. edite sadiku, irgen tafaj, aldo shpuza, stela taci, bledar kraja, predictors, severity and associate factors of acute pancreatitis: a tertiary hospital’s experience. seejph 2023. posted: 30-05-2023, vol. xx. page 63 all participants in the study were informed about the purpose and objectives of the study. frequencies (absolute numbers) and corresponding percentages were calculated for all categorical variables. for all numerical variables, the relevant central trend and dispersion values were calculated. the chi square test and fisher's exact test were used to evaluate the differences between the obtained categorical variables, while the mann whitney u test was used to compare differences between two independent groups when the dependent variable is either ordinal or continuous, but not normally distributed. crude (unadjusted) ordinal logistic regression was used to assess the association (association) between independent variables (heart rate, saturation, glycemia, azotemia, creatinine and sirs) and the dependent variable (rac severity categories), and then multivariable adjusted ordinal logistic regression was applied for these variables. multivariable adjusted ordinal logistic regression was used also to assess the association between independent variables (ranson, bisap, apache ii, ctsi) and the dependent variable (rac severity categories). generalized linear model with gamma log link was used to evaluate association of different severity’ s classification categories (ranson, bisap, apache ii, ctsi, rac) with hospital stay. this model was chosen in addition of assumptions’ compliance: “the dependent variable (hospital stay) always takes positive values (2-34, in our study) and its distribution was positively skewed”. in all cases, p≤0.05 values were considered statistically significant. results the baseline characteristics are given in table 1. the mean age (± standard deviation) of 150 participants was 60.1±15.7. 51.3% of patients with ap were women and 48.7% were men. women with ap have a higher average age than men with ap 62.5 vs 57.5 years old, respectively, p<0.05. in addition, the alcoholic etiology in males prevails in 100% of cases, while the biliary etiology is more common in females, 64.2% compared to 35.8% in males, and to a lesser extent, other etiologies, p<0.001. in the majority of cases (46%), the patients did not refer to having accompanying conditions, 36% of edite sadiku, irgen tafaj, aldo shpuza, stela taci, bledar kraja, predictors, severity and associate factors of acute pancreatitis: a tertiary hospital’s experience. seejph 2023. posted: 30-05-2023, vol. xx. page 64 them referred to having another condition and 18% of them referred to having at least two other conditions. 18.7% of patients were diagnosed with sirs. table 1. baseline characteristics of patients with ap baseline characteristics n (%)* gender p males females age 60.1 (+15.7) 57.5 (+15.2) 62.5 (+15.8) 0.035 gender males females 73 (48.7) 77 (51.3) n/a† n/a n/a accompanying conditions non-present another condition 2 or more conditions 69 (46.0) 54 (36.0) 27 (18.0) 36 (52.2) 26 (48.1) 11 (40.7) 33 (47.8) 38 (51.9) 16 (59.3) 0.585 etiology migrating gallstones alcohol abuse hypertriglyceridemia idiopathic infectious combined 95 (63.3) 25 (16.7) 5 (3.3) 18 (12.0) 3 (2.0) 4 (2.7) 34 (35.8) 25 (100.0) 2 (40.0) 8 (44.4) 1 (33.3) 3 (75.0) 61 (64.2) 0 (0.0) 3 (60.0) 10 (55.6) 2 (66.7) 1 (25.0) <0.001 sirs’s presence yes no 28 (18.7) 122 (81.3) 59 (48.4) 14 (50.0) 63 (51.6) 14 (50.0) 1.0 * absolute numbers and their respective percentages. † non applied. the results of crude (unadjusted) ordinal logistic regression are given in table 2. a one unit increase in heart rate, azotemia, glycemia, creatinine would result in a 0.043, 0.020 and 0.05, 1.18 times increase in the ordered log-odds of being in a higher rac classification category. also the ordered logit for the presence of systemic inflammatory response syndrome (sirs) (vs. non present) was 3.32 higher. conversely, one unit increase in saturation level, decrease the ordered log-odds by 0.486 times. edite sadiku, irgen tafaj, aldo shpuza, stela taci, bledar kraja, predictors, severity and associate factors of acute pancreatitis: a tertiary hospital’s experience. seejph 2023. posted: 30-05-2023, vol. xx. page 65 table 2. association between rac classification categories and clinical examinations and laboratory findings; results from unadjusted ordinal logistic regression models parameter estimate std. error wald df sig. 95% confidence interval lower bound upper bound heart rate .043 .012 13.711 1 .000 .020 .066 saturation -.486 .113 18.465 1 .000 -.708 -.264 azotemia .020 .008 6.960 1 .008 .005 .035 glycemia .005 .002 6.800 1 .009 .001 .009 creatinine 1.184 .396 8.955 1 .003 .409 1.960 [sirs=yes] 3.220 .594 29.362 1 .000 2.1 4.4 [reference] 0a . . 0 . . . the results of multivariate adjusted ordinal logistic regression are given in table 3. a one unit increase in saturation level would result in 3.96 times decrease in the ordered log-odds of being in a higher rac classification category. the ordered logit for the presence of systemic inflammatory response syndrome (sirs) (vs. non present) was 2.98 higher. table 3. association between rac classification categories and clinical examinations and laboratory findings; results from multivariable-adjusted ordinal logistic regression estimate std. error wald df p 95% ci lower upper threshold [atlanta classification = 1] -37.702 11.312 11.108 1 .001 -59.873 -15.531 [atlanta classification = 2] -33.626 11.177 9.051 1 .003 -55.532 -11.719 location heart rate .002 .015 .012 1 .914 -.027 .030 saturation -.396 .113 12.270 1 .000* -.618 -.175 azotemia -.013 .013 .989 1 .320 -.039 .013 glycemia .000 .002 .008 1 .930 -.004 .005 creatinine .524 .489 1.151 1 .283 -.434 1.482 [sirs=yes] 2.983 .697 18.343 1 .000* 1.618 4.348 [reference] 0a . . 0 . . . *significance at p<0.05. edite sadiku, irgen tafaj, aldo shpuza, stela taci, bledar kraja, predictors, severity and associate factors of acute pancreatitis: a tertiary hospital’s experience. seejph 2023. posted: 30-05-2023, vol. xx. page 66 the results of ordinal logistic regression are given in table 4. a one unit increase in ctsi and bisap would result in 0.968 and 0.430 times increase in the ordered log-odds of being in a higher rac classification category. table 4. ordinal logistic regression, with the dependent variable (rac classification categories) and independent variable (other severity classification categories of ap) estimate std. error wald df p 95% ci lower upper threshold [atlanta classification = 1] 3.729 .547 46.555 1 .000 2.658 4.801 [atlanta classification = 2] 8.784 1.203 53.335 1 .000 6.426 11.141 location apacheii .081 .059 1.885 1 .170 -.035 .197 ranson .213 .162 1.719 1 .190 -.105 .530 bisap .430 .237 3.288 1 .070 -.035 .894 ctsi .968 .184 27.533 1 .000 .606 1.329 *significance at p<0.05 the results of generalized linear model with gamma log link are given in table 5. a one unit increase in ranson and atlanta would result in 0.069 and 0.227 unit increase in hospital stay. table 5. generalized linear model with gamma log link, with the dependent variable (hospital stay) and independent variable (severity classification categories of ap) parameter b std. error 95% wald ci hypothesis test lower upper wald chi-square df p (intercept) 1.836 .0853 1.669 2.003 463.308 1 .000 apacheii -.015 .0097 -.034 .004 2.411 1 .120 ranson .069 .0280 .014 .124 6.039 1 .014* bisap .003 .0387 -.073 .078 .004 1 .947 atlanta classification .227 .0717 .087 .368 10.070 1 .002* ctsi .023 .0264 -.029 .074 .732 1 .392 (scale) .150a .0169 .121 .187 dependent variable: hospital stay model: (intercept), apacheii, ranson, bisap, atlanta classification, ctsi a. maximum likelihood estimate. edite sadiku, irgen tafaj, aldo shpuza, stela taci, bledar kraja, predictors, severity and associate factors of acute pancreatitis: a tertiary hospital’s experience. seejph 2023. posted: 30-05-2023, vol. xx. page 67 discussion the total incidence of acute pancreatitis has increased by 3.07% per year, constituting an important issue for the health care system [21]. comparing the overall mortality rate of acute pancreatitis (4-5%) with the mortality rate of severity acute pancreatitis (16%), the evidence shows that the timely prediction of severity with all the necessary diagnostic tools can significantly reduce the attributable risk of this pathology [14, 15]. consistent to the literature, our study shows a mortality rate of 4.7% for ap, but with a high mortality rate of 63.6% for the high risk severity category. in this framework, in accordance with the purpose of our study, we researched the associated predictive factors of severity, believing that the calculation of the values of diagnostic indicators can prevent high severity cases and thus reduce the mortality rate. the baseline characteristics of the individuals in the study showed that women with ap have a higher average age than men with ap. these differences can be explained in terms of etiological justification, since it is known that cholelithiasis has been determined as the main cause of ap among the older patients, with a higher frequency in women [22]. in the same vein, alcoholic etiology is most common in middle-aged males [23]. the results of our study showed that, the alcoholic etiology in males prevails in 100% of cases, while the biliary etiology is more common in females, 64.2% compared to 35.8%, p<0.001. there were no significant differences regarding the presence of concomitant diseases or sirs, between men and women with ap. the severity of acute pancreatitis is already known to be higher in patients with sirs than in patients without sirs [24]. our analysis of the data showed that the presence of sirs increases the likelihood of the patient falling into the most severe severity categories by about three times. the role of sirs in predicting the severity of ap has also been evaluated using scoring systems, such as the bisap and the systemic inflammatory response syndrome criteria (sirs-c). a study by wu et al. (2019) found that the sirs-c score had a higher accuracy in predicting the severity of ap compared to the bisap score [25]. acute pancreatitis may cause chemical changes that affect pulmonary function, causing the oxygen level in your blood to drop to dangerously low levels [26]. after applying edite sadiku, irgen tafaj, aldo shpuza, stela taci, bledar kraja, predictors, severity and associate factors of acute pancreatitis: a tertiary hospital’s experience. seejph 2023. posted: 30-05-2023, vol. xx. page 68 the multivariate adjusted ordinal logistic regression model, high levels of oxygen (saturation) were associated with a lower coefficient (-.486) of moving to the most severe severity categories. hypoxemia has been shown to be associated with increased severity of ap, as measured by apache ii score and the revised atlanta classification (rac) criteria [27]. regarding other indicators and laboratory findings such as heat rate, azotemia, creatinine serume levels and glycemia, though they were not significant after the adjusted multivariable model, their crude (unadjusted) value's increase was associated with a higher likelihood of the patient exceeding the more serious severity categories. in fact, elevated serum creatinin (on or 48 hours after admission) is a known unfavorable prognostic parameter in acute pancreatitis [28]. even glycemia, azotemia and heart rate can be used as indicators for evaluating the severity of ap [29-31]. our results showed that a unit increase in the levels of glucose and nitrogen in serum, as well as heart rate, would result in 0.05, 0.20 and 0.43 times increase in the ordered log-odds of being in a higher rac classification category. in fact, several studies have shown that patients with hyperglycemia on admission had a higher risk of developing systemic complications, including acute respiratory distress syndrome, renal failure, and sepsis and had a higher incidence of pancreatic necrosis, infected pancreatic necrosis, and multi-organ failure [32]. azotemia, defined as an elevation in serum creatinine and blood urea nitrogen (bun) levels, is a common complication of acute pancreatitis and it has been shown to be associated with worse outcomes, correlated with the severity of acute pancreatitis, as determined by (apache ii) score, including higher mortality rates and longer hospital stays [33]. the atlanta classification remains the most widely used severity classification system. however, it has several limitations, including the inability to accurately predict disease severity at admission and the inability to identify patients who are at risk of developing complications. to overcome these limitations, several other classification systems have been proposed [20]. ranson's criteria, which were introduced in 1974, have been used to predict ap severity, although they have several limitations, including poor sensitivity and specificity, edite sadiku, irgen tafaj, aldo shpuza, stela taci, bledar kraja, predictors, severity and associate factors of acute pancreatitis: a tertiary hospital’s experience. seejph 2023. posted: 30-05-2023, vol. xx. page 69 the bisap score, which includes five easily obtainable variables, has been found to be useful in predicting ap severity and the apache-ii score, which is a more comprehensive scoring system, has been found to be useful in predicting ap severity and mortality [34]. regarding the results of our study of ap severity classification systems, we found the increase in the ctsi score and to a lesser extent bisap was accompanied by an increase in the probability of moving into the highly severe category in the rac. the results were not significant for other classification systems such as: apacheii and ranson. in fact, another study estimates that bisap is the best predictor of severity (in terms of organ failure) [34]. the available evidence suggests that the ctsi is a useful tool for predicting the severity of ap and complements the rac [35]. while the rac is widely used and has a long history of research, the ctsi provides an objective and reproducible way to assess the severity of ap based on ct imaging findings. all classification systems have shown in various studies a satisfactory area under curve, in terms of predictive accuracy [34]. however, in addition to accuracy results, combination of different regression models can help more with updating current classification systems, even taking into account new diagnostic elements. another study found a moderate correlation between the ranson criteria and the apache ii score (r = 0.58) in predicting mortality in patients with acute pancreatitis [36]. in general, different scoring systems may have different strengths and limitations, and their correlations may vary depending on the patient population and the specific outcomes being assessed. therefore, it is important to use a combination of different severity scores and clinical judgment to accurately assess and manage patients with acute pancreatitis. most patients with ap can leave the hospital after 5-10 days (usually 1 week required to recover), however, recovery takes longer in serious cases, as complications that require extra treatment may occur [37]. in this line of thought, our study predicted that the increase in rac and ranson is significantly associated with hospital stay’s extension. studies show that ranson is also comparable to the rac in predicting mortality from ap [38]. edite sadiku, irgen tafaj, aldo shpuza, stela taci, bledar kraja, predictors, severity and associate factors of acute pancreatitis: a tertiary hospital’s experience. seejph 2023. posted: 30-05-2023, vol. xx. page 70 we believe that rac atalanta is a good classification for the severity of ap. we also believe that computed tomography and glycemia can play an important role in predicting and classifying severity of ap. however, it is worth discussing the fact that although ranson did not produce a significant positive association with rac, on the contrary, it produced significant positive association with hospital stay. based on an exclusionary logic, on predictors of severity, glucose can actually be the predictor (determinant found only in ranson) that influences the severity of rac and possibly hospital stay. the length of hospital stay is significantly higher in patients classified as severely acute pancreatitis, compared to patients in the category of mild and moderate acute pancreatitis likely due to increased tissue damage from inflammatory mediators [39]. in fact, another study supports the idea that serum glucose at (190 mg/dl) or higher was the single best predictor of severe pancreatitis in non-diabetic patients [40]. with regard to the pathophysiological mechanisms, the importance of acid cell death in the form of apoptosis and necrosis as a determinant of the severity of pancreatitis is underlined [41]. this can be a valid biological justification for the glucose increase, considering that the acinar-derived cells secreted insulin and it was precisely their apoptosis that affects the severity of ap [42]. the findings of this study could contribute to a better understanding of the epidemiology, pathogenesis, and management of acute pancreatitis, and guide clinicians in making more accurate and timely diagnoses and treatment decisions for patients with this condition. although this study provides valuable insights, there are a few limitations that should be acknowledged. one such limitation is the relatively low number of patients for some categories of variables, which may have impacted the statistical power of the analysis. additionally, the retrospective design of the study may have introduced biases and limited the scope of the findings. finally, the potential selection bias of the case series should also be considered when interpreting the results, as this may have affected the representativeness of the sample. edite sadiku, irgen tafaj, aldo shpuza, stela taci, bledar kraja, predictors, severity and associate factors of acute pancreatitis: a tertiary hospital’s experience. seejph 2023. posted: 30-05-2023, vol. xx. page 71 conclusion the severity of acute pancreatitis is a medical event that requires accurate prediction, for which numerous classification systems have been developed, with the rac being a recent consensus. ctsi, the presence of sirs, and saturation levels are all significantly associated with rac, but the predictive value of laboratory findings, such as glycemia, azotemia, and creatinine, should also be considered. of these severity classifications, rac and ranson are considered the most reliable predictors of hospital stay. however, it is worth noting that the discussion surrounding the predictive value of laboratory findings, such as glycemia, should not be overlooked. by accurately predicting the severity of acute pancreatitis and length of hospital stay, clinicians can make informed decisions and provide timely interventions for their patients. statement of ethics this study was approved by the ethics committee of the university hospital “mother theresa”. confidentiality and privacy of participation were assured. all the participants gave their consent for anonymous use of their data for research purposes. finally, the study was conducted in accordance with the helsinki declaration protocol, which outlines the ethical principles for medical research involving human subjects, further ensuring the ethical integrity of the study. conflict of interest statement the authors have no conflict of interest to declare. references 1. mohy-ud-din, n. and s. morrissey, pancreatitis. 2019. 2. wang, g.-j., et al., acute pancreatitis: etiology and common pathogenesis. world journal of gastroenterology: wjg, 2009. 15(12): p. 1427. 3. rawla, p., s.s. bandaru, and a.r. vellipuram, review of infectious etiology of acute pancreatitis. gastroenterology research, 2017. 10(3): p. 153-158. 4. babajide, o.i., et al., covid‐19 and acute pancreatitis: a systematic review. jgh open, 2022. 6(4): p. 231-235. 5. munsell ma, b.j., acute pancreatitis. j hosp med, 2010. 5(4): p. 241–250. 6. burrowes, d.p., et al., utility of ultrasound in acute pancreatitis. edite sadiku, irgen tafaj, aldo shpuza, stela taci, bledar kraja, predictors, severity and associate factors of acute pancreatitis: a tertiary hospital’s experience. seejph 2023. posted: 30-05-2023, vol. xx. page 72 abdominal radiology, 2020. 45: p. 1253-1264. 7. gapp j, t.a., chandra s., acute pancreatitis. in: statpearls. statpearls publishing, 2022. 8. yadav, d., acute pancreatitis: too many classifications—what is a clinician or researcher to do? clinical gastroenterology and hepatology, 2014. 12(2): p. 317-319. 9. seppänen, h. and p. puolakkainen, classification, severity assessment, and prevention of recurrences in acute pancreatitis. scandinavian journal of surgery, 2020. 109(1): p. 53-58. 10. harshit kumar, a. and m. singh griwan, a comparison of apache ii, bisap, ranson’s score and modified ctsi in predicting the severity of acute pancreatitis based on the 2012 revised atlanta classification. gastroenterology report, 2018. 6(2): p. 127-131. 11. smotkin, j. and s. tenner, laboratory diagnostic tests in acute pancreatitis. journal of clinical gastroenterology, 2002. 34(4): p. 459-462. 12. tenner, s., et al., american college of gastroenterology guideline: management of acute pancreatitis. official journal of the american college of gastroenterology| acg, 2013. 108(9): p. 1400-1415. 13. xiao, a.y., et al., global incidence and mortality of pancreatic diseases: a systematic review, meta-analysis, and meta-regression of populationbased cohort studies. the lancet gastroenterology & hepatology, 2016. 1(1): p. 45-55. 14. natov, n., t. keo, and s. hegde, acute pancreatitis mortality trend in the united states: 2006-2013: 38. official journal of the american college of gastroenterology| acg, 2015. 110: p. s16. 15. fu, c.-y., et al., timing of mortality in severe acute pancreatitis: experience from 643 patients. world journal of gastroenterology: wjg, 2007. 13(13): p. 1966. 16. knaus, w.a., et al., apache ii: a severity of disease classification system. critical care medicine, 1985. 13(10): p. 818-829. 17. ranson jh, r.k., roses df, fink sd, eng k, spencer fc, prognostic signs and the role of operative management in acute pancreatitis. surg gynecol obstet, 1974. 139(1): p. 69–81. 18. wu, b.u., et al., the early prediction of mortality in acute pancreatitis: a large population-based study. gut, 2008. 57(12): p. 1698-1703. 19. balthazar, e.j., acute pancreatitis: assessment of severity with clinical and ct evaluation. radiology, 2002. 223(3): p. 603-613. 20. banks, p.a., et al., classification of acute pancreatitis—2012: revision of the atlanta classification and definitions by international consensus. gut, 2013. 62(1): p. 102111. 21. iannuzzi, j.p., et al., global incidence of acute pancreatitis is increasing over time: a systematic review and meta-analysis. gastroenterology, 2022. 162(1): p. 122-134. 22. koziel, d., et al., elderly persons with acute pancreatitis–specifics of the clinical course of the disease. clinical interventions in aging, 2019: p. 33-41. edite sadiku, irgen tafaj, aldo shpuza, stela taci, bledar kraja, predictors, severity and associate factors of acute pancreatitis: a tertiary hospital’s experience. seejph 2023. posted: 30-05-2023, vol. xx. page 73 23. klochkov, a., et al., alcoholic pancreatitis, in statpearls [internet]. 2021, statpearls publishing. 24. singh, v.k., et al., early systemic inflammatory response syndrome is associated with severe acute pancreatitis. clinical gastroenterology and hepatology, 2009. 7(11): p. 1247-1251. 25. wu, b.u., et al., dynamic measurement of disease activity in acute pancreatitis: the pancreatitis activity scoring system. the american journal of gastroenterology, 2017. 112(7): p. 1144. 26. pancreatitis symptoms and causes. mayo clinic.; available from: https://www.mayoclinic.org/diseases -conditions/pancreatitis/symptomscauses/syc-20360227. 27. baig, s.j., a. rahed, and s. sen, a prospective study of the aetiology, severity and outcome of acute pancreatitis in eastern india. tropical gastroenterology, 2008. 29(1): p. 20. 28. lankisch, p.g., et al., high serum creatinine in acute pancreatitis: a marker for pancreatic necrosis? official journal of the american college of gastroenterology| acg, 2010. 105(5): p. 1196-1200. 29. sun, y.-f., et al., correlation between the glucose level and the development of acute pancreatitis. saudi journal of biological sciences, 2019. 26(2): p. 427-430. 30. zhang, l., et al., role of heart rate variability in predicting the severity of severe acute pancreatitis. digestive diseases and sciences, 2014. 59: p. 2557-2564. 31. lin, s., et al., blood urea nitrogen as a predictor of severe acute pancreatitis based on the revised atlanta criteria: timing of measurement and cutoff points. canadian journal of gastroenterology and hepatology, 2017. 2017. 32. zechner, d., et al., impact of hyperglycemia and acute pancreatitis on the receptor for advanced glycation endproducts. international journal of clinical and experimental pathology, 2013. 6(10): p. 2021. 33. chiuţu, l., et al., severity factors of acute renal failure in severe acute pancreatitis. chirurgia (bucharest, romania: 1990), 2006. 101(6): p. 609-613. 34. papachristou, g.i., et al., comparison of bisap, ranson's, apache-ii, and ctsi scores in predicting organ failure, complications, and mortality in acute pancreatitis. official journal of the american college of gastroenterology| acg, 2010. 105(2): p. 435-441. 35. vriens, p.w., et al., computed tomography severity index is an early prognostic tool for acute pancreatitis. journal of the american college of surgeons, 2005. 201(4): p. 497-502. 36. chatgpt. available from: https://chat.openai.com. 37. acute pancreatitis illnesses & conditions. nhs inform [internet]. 38. nambi, d. and b. giridharan, comparison of ranson’s and glasgow criteria with revised atlanta in prediction of mortality in acute pancreatitis patients. https://www.mayoclinic.org/diseases-conditions/pancreatitis/symptoms-causes/syc-20360227 https://www.mayoclinic.org/diseases-conditions/pancreatitis/symptoms-causes/syc-20360227 https://www.mayoclinic.org/diseases-conditions/pancreatitis/symptoms-causes/syc-20360227 https://chat.openai.com/ edite sadiku, irgen tafaj, aldo shpuza, stela taci, bledar kraja, predictors, severity and associate factors of acute pancreatitis: a tertiary hospital’s experience. seejph 2023. posted: 30-05-2023, vol. xx. page 74 international surgery journal, 2019. 6(5): p. 1629-1636. 39. karim, t., et al., clinical and severity profile of acute pancreatitis in a hospital for low socioeconomic strata. indian journal of endocrinology and metabolism, 2020. 24(5): p. 416. 40. maher, m.m. and b.a.m. dessouky, simplified early predictors of severe acute pancreatitis: a prospective study. gastroenterology research, 2010. 3(1): p. 25. 41. bhatia, m., et al., pathophysiology of acute pancreatitis. pancreatology, 2005. 5(2-3): p. 132-144. 42. minami, k., et al., lineage tracing and characterization of insulinsecreting cells generated from adult pancreatic acinar cells. proceedings of the national academy of sciences, 2005. 102(42): p. 1511615121. __________________________________________________________________________________________ © 2023 edite sadiku et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. review of biographical lexicon of public health by izet masic, 410 pages ,2015 avicena, sarajevo (isbn 978-9958-720-60-4) at the occasion of the 70th anniversary of the publication of “medical archives”, its readers should be informed of the availability of a new book by its prolific editor professor izet masic. he just published the first biographical lexicon in the field of public health. it includes about 750 names in alphabetical order. this work is an original contribution to the history and to the state of the art in public health. it describes the life and work of prominent contributors to the wide field of population based health improvement, disease prevention and community care. these biographies cover all five continents with personal stories about the development of public health in 50 nations and through international cooperation. the main usefulness of this work is to provide a large set of references to professionals all over the world. in addition, professor masic wrote in his book a comprehensive preface that clarifies the meaning of the terms lexicon and biography. he also described historical milestones in the concepts of social medicine, statistical analysis, epidemiologic studies, communicable diseases prevention, chronic diseases epidemiology, health services organization, health economics, medical record linkage, health informatics, quality of care indicators, health policies, social coverage, risks factors intervention trials, as well as key-role players in the former years for the advances in these various areas. the specific contribution of south east european countries is particularly well described. it adds knowledge for the public health scientists from other european countries and from other continents. as underlined by the author, this lexicon might require a constant updating. even if this first edition contains worldwide biographies of a very large number of developers for many aspects of public health, some names might be missing and could be added in a second edition. another point that might be taken into account is a more standardized presentation of some biographies. it is not always possible to obtain enough information on date of birth, nationality and the original character of the contribution of each person listed. finally, after closing the book, i wondered if we could not have a dream for a longer term future edition: to obtain an index of the specific areas of public health in which each name listed in the lexicon has mainly contributed. this might remain a dream, because requiring an enormous work. such a suggestion only indicates that this publication is an important input to the not always well understood and regularly renewing field of public health. izet masic gives to his readers not only information that was missing. he stimulates his readers to help him to go further in his way. francis roger france, md, ms, phd professor emeritus of the university of louvain, belgium aljasmi sh, aburayya i, almarzooqi s, alawadhi m, aburayya a, salloum as, adel k. the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals (case studies). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph-5758 p a g e 1 | 13 original research the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals shaima aljasmi1, ihssan aburayya2, sameeha almarzooqi1, maryam alawadhi1, ahmad aburayya1, said a. salloum3, khalid adel4 1dubai health authority, dubai, uae; 2faculty of medicine, university of constantine 3, constantine, algeria; 3school of science, engineering, and environment, university of salford, uk; 4 rak medical & health sciences university, ras al khaimah, uae; corresponding author: dr. ahmad aburayya; assistant professor, business administration college, jefferson international university, california, usa; address: dubai health authority, dubai, uae; email: amaburayya@dha.gov.ae; q5110947@tees.ac.uk. mailto:amaburayya@dha.gov.ae mailto:q5110947@tees.ac.uk aljasmi sh, aburayya i, almarzooqi s, alawadhi m, aburayya a, salloum as, adel k. the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals (case studies). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph-5758 p a g e 2 | 13 abstract aim: maintaining service quality and value using quality and management tools is crucial in any organization. in essence, improving service quality boosts both efficiency of organizations and consumer pleasure. the deployment of quality development programs such as total quality management (tqm) is one technique that businesses may employ to deliver exceptional customer service. the health sector, in particular, is one of the industries that require tqm adoption due to its complexity and the need for constant service improvement. tqm helps to improve service quality in health facilities through advanced clinical and administrative procedures. this research comprehensively assesses tqm levels and the impact of hospital demographics on its implementation process in hospitals in the united arab emirates (uae). methods: the study used a quantitative research strategy based on a survey study design. questionnaires were used to gather primary data from respondents deployed a self-administered technique. 1850 questionnaires were delivered to the hospital's senior staff based on their number in each hospital. of the 1850 questionnaires distributed, 1238 usable questionnaires were analyzed, yielding a response rate of 66.9%. the study used a binary logistic regression model to determine if hospital demographics affected tqm implementation. the study data were examined and analysed using version 25.0 of the spss software. results: the results show that most of the health facilities with an overall tqm between 4.12 and 4.82 were utilized, governmental, accredited and utilized and large hospitals, while the hospitals with a mean between 2.91 and 3.45 were small, unaccredited private, and non-specialised. thus, large hospitals have a higher tqm utilization rate than small hospitals. in addition, the findings of the t-test revealed that a high tqm is represented by means of 4.68, 4.67, 4.43, and 4.12 for accredited, utilized, governmental and large hospitals. the binary regression analysis also reveals similar results: large, governmental, utilized and accredited hospitals have greater chances of tqm adoption than other categories of hospitals (exp (b): 1.2; 95%ci: 1.001 – 1.421, p< .05); (exp (b): 1.3; 95%ci: 1.012 – 1.721, p< .05); (exp (b): 1.5; 95%ci: 1.127 – 2.051, p< .01); and (exp aljasmi sh, aburayya i, almarzooqi s, alawadhi m, aburayya a, salloum as, adel k. the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals (case studies). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph-5758 p a g e 3 | 13 (b): 1.5; 95%ci: 1.102 – 2.012, p< .05); correspondingly. another observation from the results is that hospitals that implemented technological tools had a greater chance of successfully executing the tqm program than hospitals that did not utilize advanced technologies due to the limited availability of resources (exp (b): 1.7; 95%ci: 1.332 – 2.187, p< .01). conclusion: even though health facilities need to adopt tqm, its implementation depends on the hospital size and demographics that significantly influence the adoption of tqm programs. however, this study will help bridge the current gap on the usage of tqm in the health context by examine the influence of demographic factors on adopting tqm in hospitals. hence, provide adequate information to help the uae hospital administrators appropriately execute the tqm program in the hospitals and enhance the efficacy of their operations. keywords: total quality management, quality improvement strategy, hospital service quality, hospital size, hospital demographic factors, binary logical regression model. conflict of interest: none declared. aljasmi sh, aburayya i, almarzooqi s, alawadhi m, aburayya a, salloum as, adel k. the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals (case studies). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph-5758 p a g e 4 | 13 introduction healthcare system quality has become a major societal concern, as pointed out in several reports such as ‘the state of health care quality’, and ‘to err is human: building a safer health system’ (1,2). on the contrary, studies (1-4) based on the institute of medicine (iom) report indicate that the absence of quality care leads to human error, which causes around 98,000 deaths yearly. another factor that raises the mortality rate is unnecessary hospital admissions, responsible for as many as 81,000 deaths and 3.6 billion usd in yearly expenditures. also, johns hopkins university school of medicine conducted research on a similar issue in 2016 and discovered that over 250,000 americans die annually due to avoidable medical mistakes (5). however, aburayya et al. (1,2) also reported that if the entire healthcare system provided quality services, especially total quality management (tqm), many of these deaths and expenses could be avoided. tqm helps minimise the number of future medical error-related fatalities by streamlining the hospital processes and operations. the application of tqm in the healthcare context has followed the effective trial studies which showed that the model could work in the healthcare. the national demonstration project on quality improvement in healthcare (ndpqih) which has approximately 20 specialists on healthcare from diverse establishments detailed that the tqm strategy could be practically applied in the healthcare setting (6,7). likewise, tqm was also found to have the power to improve patient satisfaction, reduce medical mistakes, and increase the safety of patients (8). furthermore, lashgari et al. (9) agreed that the tqm model improved customer experience, staff morale, and productivity in various industries. the implementation of comprehensive management programs such as tqm is dependent on several factors such as the size of the organisation, organization’s type (government or private), organization’s accreditation profile, organization’s functionality (specialised and non specialised), and technology adoption (1,2,8,10-15). however, several studies (8,13,14,16) indicate that smaller businesses find it more difficult to develop due to the lack of adequate resources, inability to reach suppliers, ineffective leadership, insufficient analytical tools and the inability to track and adjust to their processes. this is proven by other results from the above studies, which reveal that tqm approaches were first utilised in major and large companies in japan and the united states. as a result, research indicates the importance of attaining specific standards and necessities to gain the ability to integrate tqm into their operations among small organisations (13). moreover, study (17) notes that the deployment of tqm in small and large companies is different as the former is less formal and more absorbed by people, while the latter is based on certain procedures. on the converse, sila (18) offers a contradicting opinion that tqm execution in both small and large firms shows no significant difference. thus, more research is required on how factors such as size determine tqm implementation in several organisations. attitude towards quality has also been a huge determinant in tqm. for example, considerable researchers (1, 2, 7) have reported that private companies value tqm implementation compared to government organisations. in contrast, large organisations tend to invest significantly more in training and education to encourage the adoption of tqm processes. studies (1, 8, 10,14) support the above research by showing that tqm approaches have greater importance and can be more easily implemented in firms that have earned quality accreditation. the companies also ought to have embraced aljasmi sh, aburayya i, almarzooqi s, alawadhi m, aburayya a, salloum as, adel k. the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals (case studies). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph-5758 p a g e 5 | 13 technology as the process requires adequate resources, which many small companies with no specialisation lack. the impact of size or scale on quality has dominated the research for a long time, following the desire to improve patient outcomes through tqm. numerous studies (1, 10, 19) report a significant relationship between a hospital's size and its capacity to deliver high-quality medical treatment. the quality of services a hospital supply depends on its size, kind, and operation. this is due to the high level of collaboration in large hospitals. studies (20-23) explains that closeness and teamwork facilitate collaboration, eventually increasing the quality of services delivered. also, the health facilities can integrate various digital solutions into their processes to improve health outcomes. for instance, accredited hospitals have adequate resources to afford an electronic medical record system (emr), which helps the health providers to pursue advanced quality improvement programs and interventions (21-23). there exists insufficient research on the tqm adoption in the uae. specifically, a literature search has revealed that the demographic parameters associated with the successful implementation of tqm in uae hospitals were under-discussed (2). thus, following insufficient research on the topic, this study will help bridge the gap and provide adequate information to help the uae hospital administrators and healthcare providers appropriately execute the tqm program in the hospitals. the research is also committed to determining the effect of such traits and variables on the level of medical care delivered by uae hospitals in terms of patient outcomes. in addition, the healthcare industry needs to investigate the connection between the demographic features of hospitals and the implementation of tqm. this will help locate suitable strategies for utilising the approach because previous attempts (1-2, 6-8,24-26) have examined the application of tqm in the medical business and have presented no adequate answers to the many implementation issues. another aim is to fill the gap that most studies have discovered on the lack of understanding of the implementation of tqm in the gulfstream area, notably in the uae (1,2,10,26-28). as a result, the research explores tqm using scientific and practical ways to compensate for this deficit. this is the first research of its type to look into the tqm adoption rate and level in uae health facilities (uae). according to this study, tqm deployment in hospitals is linked to the demographic features of hospitals, which is achieved through research aims and current literature in assembling the findings. tqm implementation level was also evaluated for its efficacy in addition to this. after providing sufficient information on the topic, the health experts can use the findings and suggestions of this study to implement better hospital quality management standards in uae hospitals. as a result, the study is committed to investigating the tqm level in the uae hospitals, considering the opinions of executive hospital staff. another method of how the study plans to fill the research gap is by examining whether the hospital size and demographic differences affect tqm being used in those facilities. methods and materials the research looked at how hospital size and demographic characteristics affected the adoption of tqm in uae health facilities using quantitative research and survey techniques. the primary data were derived from respondents who self-reported and responded to surveys they supplied to themselves. all administrative and clinical hospital directors in dubai make up the sample unit or the staff, which is a great source of knowledge about quality procedures (29). the study was carried out in aljasmi sh, aburayya i, almarzooqi s, alawadhi m, aburayya a, salloum as, adel k. the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals (case studies). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph-5758 p a g e 6 | 13 dubai between october 15, 2019, and february 12, 2020, covering hospitals in the uae. convenience sampling was used in this study since it was challenging to get a sample frame list from these organisations. according to (30), convenience sampling is the most suitable for this study because it can cut costs and time involved in the research process and gives quick access to the right sample size. additionally, the sampling method is frequently used for research since it is convenient, cheap and can access large data (30). for instance, this study utilised a larger sample size to lower the chances of committing errors associated with the type of sampling. employing a huge sample in the research also helped boost the accurateness and predictive validity of the sampling findings. likewise, with a 95% confidence level and a margin of error of 5%, the raosoft sample size calculator used in the research managed to generate 975 samples. for this investigation, hospital administrators received 1,850 questionnaires. out of the 1,850 questionnaires distributed, 1,238 valid surveys were returned, yielding a response rate of 66.9%. furthermore, the research led to the creation of exceptional items of tqm building measurement instruments. thirty-two different items were used to computing tqm elements published in various studies (1,2,6,8,17). this study utilised a five-point likert scale to record people's views, with one point meaning "strongly disagree" and five points denoting "strongly agree". the contents of the questionnaire included (1) socio-demographic characteristics (7 items), such as age, gender, hospital size, hospital type, hospital accreditation profile, hospital functionality, technology adoption; (2) perceived factors affecting the implementation of tqm (32 items). checkboxes serve as symbols for different answers to the closed-ended questions for the study. questions related to sociodemographic characteristics were treated as categorical variables. questions related to main factors affecting the implementation of tqm treated as continuous variables. the researcher asked the participants to express their views and opinions on whether they agreed or disagreed with the statements they were provided with. a study conducted by diamond and jefferies (31) shows that a fivepoint likert scale's extension is divided by the sum of scale points to determine the length of the scale. as a result, the extension of each scale is calculated in this investigation by subtracting five from one to get four, then dividing the total length of each scale by four to get 0.80. consequently, 0.8 was added to each scale code which resulted in adopting 3.41 as threshold for identifying factors affecting the success implementation of tqm. in order to compare the means of two groups for a similar variable, the study employed an independent t-test for the groups. this enabled the researchers to determine whether there were significant differences between the tqm components in various hospital types. furthermore, the study used a binary logistic regression model to determine if hospital demographics affected the chance that tqm deployment would have an impact. the study data were examined and analysed using version 25.0 of the spss software. results participants and hospitals profile table 1 displays the features of the participants in the study. in this research, 1,238 participants participated, where 58% were men and 42% were women. additionally, two-thirds of the sample belonged to the designated age ranges; 3039 and 40-49, who reported 65%, equivalent to two-thirds of the sample. three of the six hospitals that comprise this study's sample are large, operated by the government, specialised, accredited by joint commission aljasmi sh, aburayya i, almarzooqi s, alawadhi m, aburayya a, salloum as, adel k. the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals (case studies). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph-5758 p a g e 7 | 13 international (jci), and equipped with cutting-edge technology. of the 1238 respondents, 76% (945) worked for large hospitals, whereas 293 (24%) worked for smaller ones. additionally, more than twothirds of the respondents worked for government or institutions in different specialisations. regarding hospital accreditation and technology adoption, 80% of respondents who worked in accredited hospitals stated their facilities regularly employ various technological tools effectively. table 1. the characteristics of respondents demographic factors frequency percent (%) gender male 724 58 female 514 42 age 20-29 138 11 30-39 412 34 40-49 388 31 over 50 300 24 hospital size large 945 76 small 293 24 hospital type government 854 69 private 384 31 hospital functionality specialised 799 65 non-specialised 439 35 accreditation certification yes 1002 81 no 236 19 technology adoption yes 998 80 no 240 20 hospitals’ demographic factors and overall tqm implementation in this study, eight tqm elements were identified. the researcher deals with each of these elements together to determine the level of overall tqm implementation in the targeted hospitals. findings from table 2 show that a mean tqm implementation score of 4.82 was recorded in most hospitals that effectively employ diverse technical solutions, which positions them at the top of the list. in addition, the overall averages of 4.68, 4.67, 4.43, and 4.12 imply that accredited, specialist, government and large hospitals implemented tqm at a greater rate than small, private, non-accredited, and nonspecialised hospitals. at the .05 levels of significance, the t-test demonstrates a aljasmi sh, aburayya i, almarzooqi s, alawadhi m, aburayya a, salloum as, adel k. the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals (case studies). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph-5758 p a g e 8 | 13 significant difference between the small hospital's mean tqm implementation and the large hospital's mean tqm implementation, suggesting large discrepancies between accredited, specialist, government, and technology-adopted hospitals and the means of other types of hospitals. consequently, it is realistic to anticipate that tqm adoption in large, accredited, government-specialised, and technology-adopted hospitals is substantially greater than in hospitals of other categories. the link between sample demographics and hospital tqm implementation was evaluated utilising multivariate research applying binary logistic regression analysis. there is a link between hospital size and successful tqm adoption, as evidenced by the multivariate data given in table 2 results. the findings imply that large hospitals were more likely than small hospitals to have a substantial degree of tqm application (exp (b): 1.2; 95 percent ci: 1.001 1.421, p 0.05). the type of hospital has also been proven to be a significant factor in adopting tqm in health facilities. government hospitals have greater chances of utilising tqm extensively (exp (b): 1.3; 95 percent ci: 1.012 1.721, p 0.05). it is also considered that hospital functionality affects tqm adoption. furthermore, tqm use is stronger in specialised hospitals than in nonspecialist hospitals (exp (b): 1.5; 95 percent ci: 1.127 2.051, p.01), while the hospital's accreditation profile greatly influences tqm adoption, as illustrated in table 2. the results reveal that hospitals with quality accreditation certificates have a higher ability to adopt tqm than non-accredited hospitals (exp (b): 1.5; 95 percent ci: 1.102 2.012, p 0.05). moreover, hospitals that possessed the ability to utilise the digital tools successfully had a greater chance twice in adopting the tqm models (exp (b): 1.7; 95 percent ci: 1.332 2.187; p.01). thus, the results confirm the proposition that the demographic aspects and size of the hospital considerably affect the tqm implementation's efficacy. table 2. t-independent test &logistic regression analysis of factors predicting the overall tqm implementation among hospitals demographic factors overall tqm t-test p-value exp (b) 95.0% c.i. for exp(b) p hospital size large 4.12 1.654 .021* ref (1.00) 1.194* 1.001 1.421 p< .05 small 3.45 hospital type government 4.43 1.801 .013* ref (1.00) 1.326* 1.012 1.721 p< .05 private 3.34 functionality specialised 4.67 1.127 aljasmi sh, aburayya i, almarzooqi s, alawadhi m, aburayya a, salloum as, adel k. the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals (case studies). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph-5758 p a g e 9 | 13 non-specialised 3.07 1.986 .002** ref (1.00) 1.521** 2.051 p< .01 accreditation yes 4.68 1.889 .007** ref (1.00) 1.505* 1.102 2.012 p< .05 no 3.11 technology adoption yes 4.82 2.954 .000*** ref (1.00) 1.657** 1.332 2.187 p< .01 no 2.91 note: *p<0.05; **p<0.01; ***p<0.001. discussion and conclusion this study investigates senior hospital personnel’s perspectives on adopting and implementing tqm in the healthcare industry. according to the results of multiple regression analysis, tqm has a large and beneficial effect on the quality of hospital service. the research also evaluated the link between hospital demographic characteristics and tqm implementation in different hospitals in dubai and the influence of hospital size, hospital type, hospital functioning, accreditation profile, and technology adoption on tqm implementation in healthcare. according to the study findings, large, government, specialist, accredited, and technologyadopting hospitals in the uae had a comparatively high degree of tqm adoption compared to the smaller heath facilities. consequently, hospitals in the uae became aware of the advantages and aims of implementing tqm to boost the value of services. also, the results, which have also been consistent with previous research (1, 2, 7, 10), confirm that the administration of these hospitals also supports the value of tqm in boosting patient satisfaction and institutional performance. however, the results of this research are in agreement with a considerable body of past studies. the study contained a significant variance in the mean of tqm components between small and large hospitals at the .05 significance level, with large hospitals implementing tqm more successfully. correspondingly, elfaituri’s study (13) further confirms that when successful management methods become mainstream, large organisations are often the first to embrace them. on the other hand, studies (8, 16, 17) indicate that small enterprises deal with a lack of information infrastructure, insufficient leadership, and supplier concerns, among other barriers. in addition, the absence of statistical tools and process control is still a huge barrier to tqm implementation among small enterprises, and numerous studies continue to prove that the adoption of tqm in government and accredited hospitals is much larger than in private and non-certified facilities. accreditation of a government hospital confirms that its performance fulfils nationally established criteria based on government rules. moreover, many hospitals have their assessment and self-improvement process, which, ideally, leads to adherence to the standard of care and improved results. aljasmi sh, aburayya i, almarzooqi s, alawadhi m, aburayya a, salloum as, adel k. the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals (case studies). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph-5758 p a g e 10 | 13 seelbach et al. (32) conducted a study on quality management to examine whether joint commission hospital accreditation had an impact on patient outcomes compared to health facilities with other accreditation. the researchers discovered that large facilities inspire better trust among the general public, indicating higher client satisfaction. the findings further showed that specialized and technologically equipped hospitals are among those that apply tqm management efficiently. the study confirms studies’ (1,8,10,17) that hospitals with high levels of specialization and technology usage invest much more in management leadership, training, and education to support tqm implementation than hospitals with low specialization and technology adoption. studies (1,6-9,17,21) added that these hospitals majorly focus on comparing their tqm processes and have greater operationquality relationships than hospitals with lesser specialism and technology usage. thus, hospital functioning corresponds with the quality of care services (8,11,17,24). the teamwork ability, closeness and employing various tools or technology, such as an emr system, according to almarzouqi et al. (20) and hamadneh et al. 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[cited 2022 jun 29]; available from: https://doi.org/10.4209/aaqr.220053 35. cao y, dahu bm, scott gj. a geographic computational visual feature database for natural and anthropogenic phenomena analysis from multi-resolution remote sensing imagery. proceedings of the 9th acm sigspatial international workshop on analytics for big geospatial data, bigspatial 2020 [internet]. 2020 nov 3 [cited 2022 jun 29];10. available from: https://doi.org/10.1145/3423336.342 9349 ___________________________________________________________________ http://dx.doi.org/10.1108/02635570910982300 http://dx.doi.org/10.1108/02635570910982300 http://dx.doi.org/10.2307/3151953 https://smex-ctp.trendmicro.com/wis/clicktime/v1/query?url=https%3a%2f%2fdoi.org%2f10.4209%2faaqr.220053&umid=2e3f612b-8e7f-4a5f-a65c-ff7ae973d780&auth=2e67fbfa2fb6c049f414ed817d22962c1dec540f-71e1435759af6e587ad0665d97009f94a93afe9f https://smex-ctp.trendmicro.com/wis/clicktime/v1/query?url=https%3a%2f%2fdoi.org%2f10.1145%2f3423336.3429349&umid=2e3f612b-8e7f-4a5f-a65c-ff7ae973d780&auth=2e67fbfa2fb6c049f414ed817d22962c1dec540f-d1d9e7139bd2cad112236731f36f6e4ddb9fe337 https://smex-ctp.trendmicro.com/wis/clicktime/v1/query?url=https%3a%2f%2fdoi.org%2f10.1145%2f3423336.3429349&umid=2e3f612b-8e7f-4a5f-a65c-ff7ae973d780&auth=2e67fbfa2fb6c049f414ed817d22962c1dec540f-d1d9e7139bd2cad112236731f36f6e4ddb9fe337 the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals schröder-bäck p, maeckelberghe e, royo-bordonada má. the ethics effect (editorial). seejph 2014, posted: 23 september 2014. doi 10.12908/seejph-2014-31 1 editorial the ethics effect peter schröder-bäck 1-4 , els maeckelberghe 3-5 , miguel ángel royo bordonada 4,6 1 department of international health, school for public health and primary care (caphri), maastricht university, the netherlands; 2 faculty for human and health sciences, bremen university, germany; 3 eupha section “ethics in public health”; 4 aspher working group on ethics and values; 5 institute for medical education, university medical center groningen, the netherlands; 6 national school of public health, institute of health carlos the third, madrid, spain. corresponding author: priv.-doz. dr. peter schröder-bäck, maastricht university, faculty of health, medicine and life science, school for public health and primary care (caphri), department of international health, postbus 616, 6200 md maastricht, the netherlands; telephone: +31(0)433882343; e-mail: peter.schroder@maastrichtuniversity.nl mailto:peter.schroder@maastrichtuniversity.nl schröder-bäck p, maeckelberghe e, royo-bordonada má. the ethics effect (editorial). seejph 2014, posted: 23 september 2014. doi 10.12908/seejph-2014-31 2 moral issues – also in public health sometimes researchers and practitioners of public health are confronted with situations where it is not self-evident which option for action is the better choice. a decision about implementing a particular public health intervention can be difficult because there is a lack of scientific evidence that would speak clearly for or against its effectiveness. moreover, a decision can be difficult because of moral values that are at stake. indeed, taking a decision might sometimes feel like replacing one evil with another; or at least accepting some restrictions of liberty of individuals in the trade-off for another good, e.g. the health of others. examples of difficult choices can be to implementing quarantines and isolations (like those being currently in place in relation to the ebola outbreak in west-africa), obligatory immunizations, prohibitions of risky behaviour or (re-)distributing resources. ethics is the discipline in which one asks systematically what the right and good choices are – in life in general, but also in academic and professional fields such as public health. ethics asks “why should i do this or that?” and the reply consists of giving reasons and developing an argument. ethics hereby draws on principles, values and virtues and has developed substantive theories in the last two-and-a-half-thousand years. in medicine, the value of ethics for taking the right choices in the context of professional conduct, deeply rooted in the hippocratic oath, has a successful tradition of some decades by now. in the last century the combination of ethical argumentation with medical problems lead to intensive discourses under the name “bioethics” (1). bioethics, however, focuses on the individual patient and does not (usually) have a public health perspective. yet, in public health there are, as just mentioned, many ethical challenges that request reasoning about choices. in 2003, gaare bernheim carried out a study with public health professionals. she found that public health practitioners “often feel ill-prepared to make the ethical trade-offs and perceive a need for more education and support to make these decisions” (2). thus, it is no surprise that more and more actors in public health research and practice requested to introduce the discipline of ethics into public health science, practice and education. schools of public health in the european region asked for more support from their association (aspher) to introduce ethics in their schools and curricula, because only some schools do offer ethics training in their bachelor or master programmes (3). integrating ethics into public health the implementations of difficult public health interventions have usually lacked explicit preceding ethical analyses or had to contend with conflictive and ambiguous ethical principles. yet, when we started several years ago to advocate introducing ethics into academic european public health discourses (4), we did not only preach to the converted. in fact, the term „ethics‟ also had a negative effect on some public health researchers. even though many researchers and practitioners applauded the introduction of ethical discourses into public health, we have also quite often heard that ethics is not the most urgently awaited for input for public health research. colleagues were sceptical because, in their opinion, ethics commissions are the institutions that may hinder proper public health research. sometimes public health practitioners were doubtful: can ethics really be helpful? the answer becomes obvious when we realize that no health intervention, including a preventive or health promotion program, is risk-free. even when the harm caused to a particular person by a public health intervention might be minimal, the impact can be extremely relevant if the intervention is targeted at the population level, most of whose recipients are healthy. among the opportunities ethics offers when being introduced into public health discourses are reflections about leading values and decision-making criteria, identification of normative loopholes or inconsistencies in argumentation, shifting burdens of proof among actors, and schröder-bäck p, maeckelberghe e, royo-bordonada má. the ethics effect (editorial). seejph 2014, posted: 23 september 2014. doi 10.12908/seejph-2014-31 3 the like. among the limits are that ethics does not offer a ready to use algorithm for making decisions and often the feeling prevails that after an ethical discussion one has not a definitive answer or is still confused – but on a higher level (as the physicist enrico fermi once formulated it in a different context). the way forward in our perspective, recent developments to establish public health ethics discourses are highly welcome, because of the ethics effect on human practice in general and public health research and practice in particular: having an understanding of what are the reasons for choosing a over b. ethics can help to identify good reasons and unmask bad reasons. it is through the exchange of arguments, within discourses, through which public health can get (even) better: doing the right thing for the right reason. because only if it is for the right reason – and not by chance, based on a prejudices or because of following a dogma – one can convince others; as sen says “bad reasoning can be confronted by better reasoning” (5). and to identify good and convincing arguments is a task of ethics. thus, ethics can and should be further integrated in public health education, research and practice – but it is still a long way to go until ethics is as well integrated into public health as it is into medicine. let‟s continue to bring ethical discourses onto the table of public health researchers and practitioners. to contribute to this endeavour, we welcome in this journal articles that have ethics integrated into the public health perspective; or articles that deal with public health ethics explicitly. references 1. beauchamp tl, childress jf. principles of biomedical ethics. 6th edition. oxford university press: new york, 2009. 2. bernheim rg. public health ethics: the voices of practitioners. j law med ethics 2003;31:104-9. 3. aceijas c, brall c, schröder-bäck p, otok r, maeckelberghe e, stjernberg l, strech d, tulchinsky t. teaching ethics in schools of public health in the european region – results of a screening survey. public health rev 2012;34:146-55. 4. maeckelberghe el, schröder-bäck p. public health ethics in europe – let ethicists enter the public health debate. eur j public health 2007;17:542. 5. sen a. the idea of justice. cambridge ma: belknap press, 2009. ___________________________________________________________ © 2014 schröder-bäck et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ministry of health consolidated work plan 2016/17 ministry of health republic of liberia consolidated operational plan fy 2016/17 september 2016 ministry of health consolidated work plan 2016/17 2 foreword liberia emerged out of 14 years (1989-2003) of brutal conflict that ravaged gains made in every sector of the society. with one decade of relative peace and stability, liberia restored health services and started making enormous strives in childhood mortality reduction, decline in aids related deaths and expansion of health services. unfortunately, in 2014, the country was hit with an incomparable ebola outbreak that shattered gains in health status, social values and the economy. the impact of the evd outbreak was very grave, affecting households’ income, health status and food security. the crisis depleted the health workforce, led to low utilization of health services and desertion of health facilities by service providers. the economic forecast shows that the outbreak is draining the finances of governments—increasing national deficits due to additional expenditures incurred during the evd crisis amidst drastic shortfalls in domestic revenue. the ministry of health in 2007 developed a post conflict policy and strategic plan that guided the health sector into restoration and recovery for five years (2007-2011). the five years plan were revised to ten years with new strategies to maintain gains and further improve health outcomes. the 2011-2021 national health plan was launched in 2011 and implemented until 2014 when ebola exposed the health systems vulnerabilities. in order to address the health systems fragilities, the health sector investment plan was formulated to drive responsiveness and resiliency in the sector. the investment plan has nine vital areas for improving the sector effectiveness, efficiency, and resilience. it is my conviction that despite the colossal challenges we have to surmount in the health sector to attain the health related sustainable development goals (sdgs) and resiliency, i am confident that the fy 2016/17 operational will be instrumental in translating the strategic priorities of the health sector recovery and development as stipulated in the investment plan (2015-2021) into concrete actions. i trust that partnership will take us to alignment and harmonization, and make the operational plan a reality. i am pleased to express my deep appreciation and sincere gratitude to all stakeholders, partners, and moh staff that contributed technical and financial support in the development of the operational plan 2016/17. dr. bernice dahn md, mph, flcp minister of health ministry of health consolidated work plan 2016/17 3 acknowledgement the annual operational plan is the road map for the implementation of the post evd recovery plan and the health sector investment plan for building a resilient health system. the overall objective of the plan is to ensure a functional and resilient health system that guarantees its population an effective and equitable health. the plan is a consolidation of both central and county levels work plans. the ministry of health is pleased to recognize the effort of all of those who contributed to the development of the fy 2016/17 annual operational plan. special thanks are extended to members of the county health teams, moh departments, programs and divisions for their contributions towards the formulation of the annual operational plan. without their involvement, the consolidated operational plan would not have been finalized. the moh is grateful to the world health organization for providing financial and technical support for the orientation and training workshops for county health teams and partner and the elaboration of the annual consolidated operational plan together with epos eu ta. special gratitude is extended to usaid (fara project) for providing funds for the county level planning process. we want to express our appreciation to all ngos, un agencies for technical support and county officials that participated in the planning exercise. your participation and contributions have made this document useful and inclusive. it is our hope and aspiration that the annual operational plan will be used as the health sector development agenda for fy 2016/17 at all levels to build a system that is responsive, effective and resilient. let us solicit the financial and technical resources to implement this operational plan together. ministry of health consolidated work plan 2016/17 4 table of contents 1.0 introduction ......................................................................................................................6 1.1 background ................................................................................................................................... 6 1.2 health sector governance and management ................................................................................ 6 2.0 planning cycle and processes ..........................................................................................8 2.1 planning objectives ....................................................................................................................... 8 2.2 planning process ........................................................................................................................... 8 3.0 situational analysis and performance fy 2015/16 ...................................................... 10 3.1 situational analysis ........................................................................................................... 10 3.2 performance fy 2015/16 ................................................................................................... 11 4.0 operational plan 2016/17 ................................................................................................ 12 4.1 health infrastructure ................................................................................................................. 12 4.2 human resources for health ...................................................................................................... 13 4.3 health care financing ................................................................................................................. 14 4.4 emergency preparedness and response (epr) .............................................................................. 14 4.5 health service delivery and quality of care ................................................................................ 17 4.6 drugs and supply chain management ......................................................................................... 31 4.7 health information systems, m&e and research ........................................................................ 32 4.8 community engagement .............................................................................................................. 34 4.9 leadership and governance ......................................................................................................... 34 5.0 costing and budgeting .................................................................................................... 35 5.1 national budget................................................................................................................... 36 6.0 monitoring and review of investment plan ................................................................ 36 annexes ............................................................................................................................................ annex a: health infrastructure needs fy 2016/17 ......................................................... 37 annex b: supply chain fy 2016/17 activities ............................................................................................ 38 annex c: health sector performance framework ................................................................................... 38 annex d: county level performance framework ..................................................................................... 40 ministry of health consolidated work plan 2016/17 5 abbreviations cha community health assistant chw community health worker csa civil service agency evd ebola virus disease epr emergency preparedness response epi expanded program on immunization fara fixed amount reimbursement arrangement fhd family health division fy fiscal year hr human resources hf health facility his health information system hmer health information system, monitoring and evaluation and research hmis health management information system m&e monitoring and evaluation mfdp ministry of finance and development planning moh ministry of health nacp national aids & stds control program nds national drug osc one stop center op operational plan sop standard operating procedure ttms trained traditional midwives ministry of health consolidated work plan 2016/17 6 1.0 introduction 1.1 background the 10-year strategic plan (2011–2021) and the post ebola crisis national investment plan (2015–2021), provide an overall guide and orientation, while the instrument that is required to ensure that the strategy is implemented is the operational plan (op). the health sector recognizes its inherent health system challenges and weaknesses that were further amplified by the impact of the ebola crisis. the operational plan is the annual roadmap to implement the national investment plan (2015-2021). the op provides priorities activities and establishes targets that are linked to budget, which is funded through a combination of known domestic and external resources. it was formulated based on county and central levels consultations with various stakeholders. in view of the national investment plan, the current operational plan, while focusing on safe and quality health services, recognizes the need to invest on key support components of the health system that enable service provision and fosters donor coordination and alignment at decentralized and central levels of the health system. the process of planning has also taken account of existing capacity and resources through integrating the contributions of most development partners into a consistent framework, both in terms of financial and of technical assistance. the plan intends to address issues related to recovery through phased or incremental changes but in an equitable and sustainable manner. furthermore, the recovery phase of the operational plan goes beyond the hardware required to include the regulatory and implementation capacity building components. moreover, products of the annual plan consist of aligning available funding with planned activities, resources, and service delivery targets. 1.2 health sector governance and management the liberian government comprises three separate branches, the executive, judiciary, and house of representatives and the senate. administratively, the country is divided into 15 counties and 73 political districts. the country is however demarcated into 89 health districts for operational purposes. the superintendents are the heads of the counties. the superintendents and other county functionaries (district commissioners, paramount chiefs, clan chiefs, city majors and town chiefs) are appointed by the president. with the wave of reforms in governance, the superintendents and other government functionaries in the future are likely to be elected by the people if the local government act now before the ministry of health consolidated work plan 2016/17 7 house is passed into law. in the draft act, the county structure consists of 9 departments. the county health team becomes a department of health. 1.2.1 structure of ministry of health the minister of health is appointed by the president and is not a member of the house of representatives or of the senate. the minister is assisted by four deputies manning the following departments: health services; planning, policy and development; administration, and public health recently included out of the aches of the ebola crisis. there are several assistant ministers heading bureaus and managers heading divisions and vertical programs such as the national tb & leprosy control program (ntlcp), the national aids & stds control program (nacp), etc. there are four levels of supervision: (i) central level, which includes departments, programs, divisions and units, (ii) county level, hospitals and lower level health units, (iii) district level, and (iv) community based health services. the county health services and community health services units of the ministry of health have been established to provide direct support to the counties and community based services, respectively. while systems for supervision and monitoring exist, there are enormous challenges. the fiscal year plan is to redress issues of the essential services and other components of the investment plan. strong involvement and engagement of communities and their representatives are expected to play a critical role in the management and monitoring of the operational plan at all levels of the health system. minister department of health services bureau of curative services 15 county health and social welfare teams bureau of preventive services national programs (e.g., tb, epi, malaria, etc department of planning and statistics bureau of planning and policy bureau of vital statistics department of administration bureau of fiscal affairs bureau of administration department of public health minister department of health services bureau of curative services 15 county health and social welfare teams bureau of preventive services national programs (e.g., tb, epi, malaria, etc department of planning, policy and development bureau of planning and policy bureau of vital statistics department of administration bureau of fiscal affairs bureau of administration department of public health ministry of health consolidated work plan 2016/17 8 2.0 planning cycle and processes 2.1 planning objectives the overall objectives of the operational plan are to ensure a functional and resilient health system that guarantees its population an effective and equitable health. the operational plan however, is to enhance implementation of the investment plan for recovery and resilience through coherent planning and budgeting at different levels of the health care delivery and management systems. the specific objectives are as follows: 1. identify and measure needs, 2. map available resources (hr, infrastructure and financial); 3. establish baselines and set targets for the priority activities of the recovery of the investment plan; 4. prioritize activities for implementation of programs and delivery of services during the fiscal year; and 5. develop a harmonized and integrated annual plan in line with the investment plan (2015-2021). 6. the expected results of the annual operational plan, 2016/2017 1. annual health sector plans for 15 counties, 2. a consolidated national integrated annual plan fy 2016/217 2.2 planning process in 2014, the ministry of health with support from its development partners reviewed the implementation of its 10-year national health plan and strategy (2011-2021) and developed a post evd response national health investment plan and strategy (2015-2021) aimed at restoring health care services and to incrementally enhance resilience and health security in the health services delivery system. one fiscal year of implementing this resilience strategy elapsed at the close of the fy 2015/16. to operationalize the national health investment plan (2015-2021) the department of planning, research & human development is mandated to specify the investment plan into core and comprehensive operational plans at community, health facility, county, and national levels. the process involves the provision of technical support for the development of each county’s operational plan from the levels of the community to health facility including the districts that culminated into the counties’ operational plans for the ensuing fiscal year. the central level support by extension is also aimed at building the capacities of counties in planning, budgeting, data analyses and service delivery target setting. ministry of health consolidated work plan 2016/17 9 additionally, the county planning process is comprehensive and entails the review of counties performance over the preceding fiscal year with an assessment of the previous plan to inform the development of the ensuing fiscal year. coupled with this, the process also includes the customization of the planning tools, templates and developing national targets while at the same time aligning activities and resources at the county level with all implementing partners providing services at all levels within the counties (community, facility district, and county). the process of producing the ministry of health’s consolidated operational plan follows its planning cycle aligned with that of the government of liberia. it begins with the situational analysis, followed by the priority settings, options appraisal, programming and monitoring and evaluation. moreover, it focuses on possible health system diagnosis, including bottleneck analysis, the enabling environment at operational levels that follows the select of appropriate target setting and integration of resources and activities mappings to ensure the harmonization and alignment at county and national levels. the process follows a consultative and participatory process to ensure that all key stakeholders are involved. the activities and steps that follow are conducted both at county and national levels to facilitate the development of the consolidated national health operational plan. step 1: compile and share operational planning tools, guides, and reference documents: a. all key documents to be used in the process are collected, compiled and distributed to all relevant stakeholders at county and national levels; b. existing moh operational planning guides and revised tools are adapted to respond to the needs of the planning exercises. step 2: prepare and orientate technical working groups consisting of moh health managers and partners for the operational planning exercise: a. set national targets that aligned with the national health investment plan; b. conduct activity and resource mapping (local, government, donors and partners); c. adapt planning tools and guides to inform planning at all levels; d. identify national and county teams and technical assistance to support the operational planning process and plan orientation sessions e. hold central and county levels operational planning orientation sessions step 3: assess and mobilize resources, both on and off budget at all levels of the health system step 4: develop operational plans at various levels (facility, district, county and central levels) ministry of health consolidated work plan 2016/17 10 a. update county situational analyses with improved data/information; b. establish targets for main service delivery components aligned with the national indicative targets; c. identify priority strategies/actions to achieve targets; d. analyze health service delivery systemic components (human resources for health, financing, infrastructure, supply chain) and set objectives; e. estimate resource requirements to implement planned priority interventions f. establish objectives, activities and funding step 5: finalize, consolidate, and implement national health operational plan (the consolidated plan guides the sector for the ensuing fiscal year) a. policy and planning unit collaborates with central moh departments, divisions, units and programs to develop central level plans; a. operational plans get reviewed and feed backs provided until plans meet the standards and deliverables; b. the policy and planning unit coordinates with technical team to consolidate national health operational plan for dissemination and consequent implementation 3.0 situational analysis and performance fy 2015/16 3.1 situational analysis in 2015, the health sector led by the moh developed a post evd recovery plan and an investment plan to restore basic health service and build a health care delivery system that is resilient. the investment plan identified nine (9) critical health system areas for investment that will drive the system to be more responsive, efficient and resilient. there are currently, 727 health facilities in liberia of which 64% are public. these facilities provide 71% of liberians geographical access within 1 hour of walking distance or within 5km of walking distance. though nationally, 29% of the population lacks physical access to health care, 20% (3 out 15) of the counties have over 50% of their population living beyond 5km or 1hour walking distance within reach of a health facility. the 2013 liberia demographic and health survey results revealed that 65% of households do not drive by cars but walk to health facilities in case of need. the 2016 health workforce census results show that 35% of health facilities lack electricity while 32% do not have water supplies. the health workforce census documented 16,064 health workers of which 10,672 are within the employed of the moh. one-third of the public health workers are clinical and their distribution is skewed towards urban areas. there acute shortage of critical health workers such as physicians, midwives, lab technicians and specialist doctors (ie: surgeons, pediatricians, psychiatrics, etc). ministry of health consolidated work plan 2016/17 11 drugs and medical supplies is an essential component of the health system. however, this area is characterized by irregular supply of drugs and medical supplies, limited number of personnel, (pharmacists), to prescribe, quantify and dispense medicines to patients. due to inadequate budgetary allocation to procure and distribute drugs and medical supplies, patients are often given prescription to buy unavailable essential medicines. monitoring, supervision and mentoring has been weak and irregular. furthermore, the capacity of the hmis is still inadequate for example data collection and timely reporting from the service delivery sites have remained incomplete and less integrated. information use culture at the collection and intermediate aggregation levels has remained weak. the utilization of health services in liberia is poor due to limited access and/or poor quality of health services and patients and providers’ relationship. in 2015/16, utilization rate was 1.06, which is only 21% of the optimal utilization rate (5.0). antenatal care (4 visits) was 57.5% and only one-third of postnatal mothers received care. half (51%) of the pregnant women delivered in health facilities and 60% of children under age one were fully immunized with all basic vaccines. 3.2 performance fy 2015/16 the health sector performance was appalling in 2014 due to the devastation caused by evd in the country. however, during the restoration and recovery stages of the investment plan (2015), basic health services were restored and utilization increased. the sector has made progress since the cessation of the evd crisis, although few of the health service delivery targets were not achieved. table 3.1 presents service delivery summary accomplishments. on the other hand, hmis report submission increased from 70% in 2014 to 78% in 2015/16 and timeliness improved from 41% to 57% over the same period. the proportion of health facilities with basic utilities (ie: water and electricity) increased from 55% in 2014 to 66% (hr census 2016). table 3.1: health service delivery indicators, targets and achievement in fy 2015/16 # health service delivery indicators baseline targets fy 2015/16 achievement 1 % of children under 1yr fully immunized 46% 64% 60% 2 penta -3 63% 75% 65% 3 measles 58% 64% 64% 4 anc 1st visits 61% 75% 75% ministry of health consolidated work plan 2016/17 12 5 anc 4th visits and more 46% 51% 58% 6 institutional delivery 40% 45% 52% 7 % of deliveries by skilled birth attendants 39% 42% 51% 8 % of pregnant women receiving second dose iptp 39% 44% 41% 9 % of postnatal mothers that received pnc 29% 34% 33% the number of health facilities providing health services increased by 71 from 2014 – 2015 (656 in 2014 to 727 in 2015). additionally, the public health workforce increased from 10,052 in 2014 to 10,673 in 2016. the number of health workers placed on government of liberia payroll increased from 5,920 in 2014 to 7,214 in 2016. 4.0 operational plan 2016/17 4.1 health infrastructure health infrastructure is the second priority pillar of the health sector investment plan that allows access to health care. expanding access to quality health care through the construction, renovation and improvement of health facilities is critical for reaching the 1.2 million liberians that are derived of basic health services. investment in this pillar is enormous and requires both domestic and external resources. objective: to increase physical access to the ephs services. to accomplish this objective, ten major activities have been earmarked for the fiscal year 2016/17 excluding the national drug service warehouse and the health workers housing unit projects. below is the list of the 2016/17 planned activities: central level activities 1. construct national drug depot (nds warehouse) 2. assess and complete 16 abandoned clinics 3. build 168 staff housing units county level activities 1. construct 29 primary clinics 2. construct 47 maternal waiting homes 3. construct 41 incinerators 4. construct 34 triages ministry of health consolidated work plan 2016/17 13 5. fence 52 health facilities including phebe hospital 6. construct 26 clinics laboratory 7. build 17 district health teams’ offices 8. renovate 20 health facilities annex a provides a table depicting major infrastructure activities by county as recorded in their operational plan. the table precludes national level activities. 4.2 human resources for health objective: build a fit for purpose productive and motivated health workforce that equitably and optimally delivers quality services target 1: to ensure the recruitment of needs-based health workforce central level activities 1. conduct health workforce hiring plan to address priority gaps in the health workforce model required for the restoration of essential health services. 2. create 5,000 payroll slots (2015-2016/phase 3. expand payroll slots in relation to needs-based workforce (2016 and beyond) target 2: eliminate fragmentation and inefficiencies in the remuneration payment process and establish platforms for timely, efficient and transparent bank and mobile money transfer systems. central level activities 1. hold consultative meeting with civil service agency and ministry of finance and development planning to establish a singular payroll system. 2. moh and mofdp establish and validate mobile money accounts for salary disbursement of salaries and manage queries and complaints. 3. moh, csa and technical assistance costs to develop remuneration packages options analysis and proposal. 4. explore remuneration package chws county level activities target: ensure the availability of adequate health workforce with inclusive capacity building, supervision and performance appraisal systems at county level. 1. recruit clinical and non-clinical staffers at facility, district and county levels 2. conduct in-service infection prevention and control at county levels 3. ensure county, district and facility levels staffers supervision, appraisal monitoring and performance ministry of health consolidated work plan 2016/17 14 4. conduct evidence-based capacity building sessions for staffers at county, district and facility levels 4.3 health care financing objective: establish sustainable health financing systems that will ensure sufficient and predictable resource generation, risk pooling mechanisms and strategic purchasing of services. implementation of the below noted activities will require collaboration between all health financing functions within the ministry of health and partners, specifically the health financing unit (planning department), office of financial management (administration department), the performance-based financing unit (health services department), fara management office and pool fund management office. central level activities 1. evaluate effectiveness of pbf in liberia to date-full impact evaluation study depending on available resources and feasibility-swot analysis 2. finalize fiscal space analysis and disseminate by end of fy 2016/ 2017 3. finalize resource allocation formula in consultation with stakeholders and apply to fy 2017/18 budget 4. train selected staffers of 15 chts in planning, costing and budgeting (activity based costing) 5. finalize legal proceedings and legislate liberia health equity fund (lhef) act 6. conduct publicity and advocacy in 4 counties on revolving drug fund (rdf) and lhef county level activities 1. support county level capacity building in financial management and auditing 2. develop strategy to mobilize domestic resources and ensure financial sustainability to support county level operational plan 3. establish fixed assets management systems at county level 4. provide short term financial management training for financial officers at county level 4.4 disease prevention and control objective: strengthen national core capacities in compliance with international health regulation (2005) requirements capable to timely detect, investigate and response to epidemic prone diseases and other health related events. central level activities ministry of health consolidated work plan 2016/17 15 1. train and deploy 2000 community health assistants to implement cebs 2. finalize idsr technical guidelines and other relevant operational tool (reporting forms, cebs manual, health facility sop on idsr, maternal death sop, etc) 3. reproduce and distribute training modules and simulation tools for poe 4. develop and disseminate monthly idsr dash board 5. produce and disseminate weekly and quarterly epidemiological bulletin 6. establish functional idsr situational awareness rooms in 16 eocs (national and 15 counties) 7. conduct annual idsr/ihr program implementation review meetings 8. develop national risk communication plan for public health events 9. conduct external assessment of ihr core capacities 10. conduct health risk and vulnerability assessment /mapping 11. develop risk communication operational plan 12. produce and air prevention messages using local radio (idsr jingles, drama, etc) 13. print and disseminate surveillance reporting forms to all levels 14. print and disseminate patient care report form for 100 ambulances 15. print and disseminate idsr technical guidelines to 1,000 health facilities 16. print and disseminate cebs manual to all 1,000 facilities and poes 17. print and disseminate idsr strategic plan to all counties and district offices 18. print and disseminate 100 ambulance guidelines 19. print and disseminate national and county epr plans 20. print and disseminate relevant sops, ems protocol and guidelines 21. print and disseminate job aides: cebs, clinical 22. develop, reproduce, and disseminate idsr priority disease media kits to media houses. specific objective 1: improve idsr data and specimen management, biosafety regulations, ensure interoperability with dsis activities 1. provide logistical support to 3 laboratories 2. validate, reproduce and disseminate national public health lab strategic plan (2017 2022) 3. procure idsr lab. sample collection kits for peripheral health facilities 4. train and mentor idsr focal persons at national, county, district and health facilities 5. scale up idsr surveillance (edews) implementation in 11 counties 6. improve rapid sharing of public health and scientific information and data 7. purchase and distribute reagents, lab supplies, and equipment cholera, lassa fever, yellow fever, evd, measles, shigella, rabies, afp (support transportation and sample referral) ministry of health consolidated work plan 2016/17 16 specific objective 2: strengthen emergency preparedness and response and enhance crosssector coordination and collaboration 1. establish, train and deploy rapid response teams (rrt) at national, county and district levels. 2. support rrt simulation activities across target levels 3. support internal functionality of ph emergency operation centers to coordinate the epidemic preparedness and response at national and county levels (stationeries, fuel, internet connectivity) 4. develop national and county specific epr and disease specific contingency plans 5. work with partners to provide counties emergency contingency fund 6. procure and deploy preparedness stocks in all counties for all priority public health events: cholera, evd, rabies, bloody diarrhea, lassa fever, yellow fever, meningitis 7. conduct midterm review and update of national and county specific epidemic preparedness and response plans specific objective 3: institutional support, capacity building, advocacy, and communication. project coordination, fiduciary management, monitoring and evaluation, data generation, and knowledge management central level activities 1. provide credentialing and capacity building in surveillance staff, including field epidemiology laboratory training programs (feltp-frontline: 3 months; intermediate9 moths; and advance-masters)), and phd programs targeting hospital, chos, national staff, cso, moa, 2. work with the pre-service institutions (medical and para-medical) to build hr instructional capacity and strengthen curriculum 3. train dsos in dead body swabbing and safe specimen collection, packaging and transport 4. support short course (international) in emergency management/ims for all incident command managers at national and county levels 5. train 3 national, 15 counties and 92 district rrts 6. train 15 county health promotion focal persons in risk/outbreak communication 7. cross border coordination meeting at all levels 8. provide incentives for dso county level activities 1. train traditional healers in community case definition of priority diseases 2. provide refresher training on idsr for health facility staff 3. conduct weekly surveillance coordination meeting 4. conduct rrt refresher training for surveillance team 5. refresher training to all hcw on ipc standard precautions ministry of health consolidated work plan 2016/17 17 6. conduct quarterly mentorship on ipc standard precautions 7. supply facilities with iec/bcc materials 8. to conduct health talk using available iec/bcc materials 9. conduct epidemiological investigation of rumors/suspected disease of epidemic potential 10. conduct edews supervision 11. establish data storage for surveillance 12. continue community events based surveillance 13. ensure the supply of ppe for epr purpose 14. establish facilities epr team and conduct in-service training 15. liaise with county health team to provide the updated epr plan to the district and health facilities. 16. work with county pharmacist to supply and maintain the minimum stock of epr supply at all levels 17. work with partner to provide logistic supports (fuel & stationaries) for district epr activities. 18. provide communication equipment (phones, vhf radio etc) for surveillance activities 19. review idsr plan every 6 months to evaluate and improve the performance of surveillance and response systems and provide feedback within and across levels of the health system 4.5 health service delivery and quality of care 4.5.1 improve health of mothers, and newborns services objective: to improve availability and readiness of quality of and demand for maternal, newborn, adolescent and reproductive health services to improve access and coverage. target 1: improve coverage of family planning with couple year of protection in all the 15 counties. central level activities 1. conduct mapping of community based family planning distributors 2. train/refresh cbd to scale up distribution points 3. provide rh commodity storage boxes (wooden) for community based distributors 4. conduct post partum family planning training 5. conduct training/refresher to strengthen and scale up epi/fp integration in all fifteen counties 6. support provision of iucd insertion kits to health care facilities 7. provide financial support for nds for quarterly supply of rh commodities ministry of health consolidated work plan 2016/17 18 8. provide support for printing of revised family planning strategy 9. review, print and disseminate to operationalize the family planning road map 10. support development of messages, radio talk show, jingles/dramas to educate on the side-effects of family planning commodity to reduce myths 11. provide vehicle to support rmncah supportive 12. provide maintenance for vehicles 13. support 1 ta for rh commodities quantification 14. procure 1 laptop for data management (ppmr) at fhd level 15. print and disseminate mother and child health cards to the 15 counties 16. conduct quarterly mentoring in all counties county level activities 1. provide motivational package for gchvs providing cbd services 2. provide logistical support for mentors to implement fp activities at health facility and community levels 3. establish/reactivate condom distribution points in 300 communities 4. implement providers initiated counseling on family planning in all routine health services at all levels 5. identify and train cbd to pilot community depo/injectable administration in three counties 6. integrated family planning, epi, and mch outreach target 2: coverage to basic and comprehensive emergency obstetric and neonatal care (emonc) and essential maternal and newborn care increased in nine counties (health centers and hospitals) central level activities 1. conduct refresher training and tot in blss/emonc quarterly 2. review and consolidate 15 county rh supervisors and partners work plans and consolidate fy 2016/17 3. ensure a sufficient and reliable supply of safe blood for cemonc 4. build new clinics and upgrade select clinics to health centers to improve access to care. 5. deploy community base certified midwives to underserved areas to care for women without access to facilities. county level activities 1. the fhd will review, revise and print the midwifery constitution and disseminate copies to all facilities and stakeholders. 2. validation, printing and dissemination of standards for midwifery practice will be done including monitoring of its use. ministry of health consolidated work plan 2016/17 19 3. fhd will provide support for strengthening implementation of safe delivery services under the national health policy & plan related to maternal, newborn and child health through promotion of delivery kits to facilities. 4. conduct emergency obstetrics and neonatal care (emonc) training basic and comprehensive to nurses and midwives in 6 counties. target 6: strengthen national capacity to address gender-based violence using a multi-sectoral approach and the provision of high quality services to survivors. central level activities 1. support to the 12 existing one stop centers (osc) 2. procure and distribute rape treatment (pep/kit3) 3. provide transportation incentive for osc personnel 4. refurbish two additional oscs in two counties (lofa and nimba) 5. train clinical staff in the management of gbv/sgbv 6. produce medical reporting form-10000 copies 7. supervise and mentor staff at all oscs county level activity 1. implement, supervise and monitor performance target 7: prevention, management and control of pmtct strengthened at national and county level central level activities 1. provide program management, strengthened coordination and collaboration 2. provide on-site training in adherence counseling skills and ensure acceptance attitude for knowing your hiv status for pregnant women. 3. train service providers on option b+, ttms/tba, mother peers, and exposed infants for pcr county level activities 1. provide hiv care, treatment and support services (antiretroviral therapy art) for hiv positive pregnant women and children 2. strengthen and provide mother to mother peer support services (preventing lost to follow-up) father and adolescent 3. provide supportive supervision, on-site mentoring and ensure data accuracy 4. strengthen community based organizations and structures to provide community awareness, sensitization and mobilization on emtct/pediatric and adolescent hiv target 8: improving health and education with emphasis on reduced maternal and child mortality and education achievement services and as well enhanced ministry of health consolidated work plan 2016/17 20 national capacity for treatment and social reintegration of obstetric fistula. central level activities 1. produce 25 copies magazines of fistula survivors success stories 2. provide support for surgical outreach in hard-to-reach counties 3. maintain fistula facilities and services (including patients feeding, laundry services, cleaning) 4. provide salary payment for project staff 5. provide support to operational activities county level activity 1. implement robust mobilization campaigns in 3 hard-to-reach counties 4.5.2 improve child health objective: to improve availability and readiness of child health services to improve access and coverage target 1: reviewed and revised the national child survival strategy (20082011) central level activities 1. undertake comprehensive assessment of process actors and context 2. define goals and priorities 3. validate a national policy target 2: minimum 75% of the monthly target of children under 1 year in all counties vaccinated by august 2015 (for all antigens to achieve 85%), central level activities 1. provide quarterly financial support to 534 hf for outreach vaccination teams for 12 months @ us50.00 2. conduct refresher training on immunization in practice 3. tot for 45 counties participants, 15 national, 6 facilitators 4. conduct quarterly periodic intensification of routine immunization (piri) in all counties 5. conduct national micro-planning exercise 6. implement urban immunization strategy 7. support social mobilization and communication for urban immunization with montserrado county 8. support the development/production of messages 9. procure 100 motorbikes for integrated outreach services ministry of health consolidated work plan 2016/17 21 10. conduct quarterly cold chain and vaccine management monitoring & supervision visits 11. produce, printing and distribution of epi monitoring tools (i.e. child health cards, ledgers, tally booklets, monitoring charts, summary forms and job-aids) 12. train cco and csfp on equipment maintenance and vaccine management 13. procure bundle vaccines and other supplies. 14. distribute bundle vaccines to county depots. county level activities 1. periodic intensification of routine immunization (piri), round 3 2. continue regular immunization with outreach services 3. training for hf personnel on immunization in practice (iip) 4. conduct quarterly monitoring and supportive supervision to district and hfs (provide us$150/month for 12 months), target 3: at least 85% of all 15 counties will attain all epi surveillance indicators by december 2016 central level activities 1. provide regular logistics support and equipment for the conduct of active surveillance activities at counties and districts, 2. support outbreak investigation and response 3. procure data management and ict equipment (e.g. lap top, back-up, antivirus, etc) for county and national levels 4. provide financial support for ncc, nec, and npec activities 5. conduct quarterly surveillance visits to rotavirus sentinel site at redemption hospital 6. develop immunization supply chain (iscm) sops 7. procure and install continuous temperature monitoring device at epi regional cold stores 8. conduct temperature mapping study of cold/freezer rooms at national and regional stores; and temperature monitoring study in vaccine supply chain in accordance with who protocol. 9. conduct cold chain inventory assessment and develop equipment replacement plan 10. procure fuel for county generators 11. procure fuel for county vehicles for vaccine distribution 12. provide financial support to procure immunization supplies and spare parts for motorcycles maintenance for district & hf 150 @ $20/month 13. support running and maintenance of central and 2 regional cold room 14. procure one 4 x 4 utility truck for delivery of assorted immunization supplies and one refrigerated truck for vaccine transportation; three toyota 4x4 pick-up and one 4x4 nissan jeep ministry of health consolidated work plan 2016/17 22 county level activities 1. intensify and strengthen afp surveillance nationwide 2. conduct epi biannual surveillance supervisory visits to priority sites 3. conduct regular quarterly cross border meeting on immunization activities objective: to ensure that at least 90% of all epi data (i.e. absolute numbers & coverage rates) from health facilities are verified by the end of the year. target 4: immunization data quality improved from 85% to 95% completion, by the end 2015. central level activities 1. train health workers (chdd, csfp, data manager & cco) on district vaccination data monitoring tool (dvd-mt) from all counties, 2. conduct quarterly data harmonization and validation. 3. reinforce and recognize good practices publically county level activities 1. conduct independent integrated supportive supervision to districts, and health facilities 2. monthly meetings with chdcc 3. improve documentation and timely reporting to the central level 4. enhance stakeholder coordination at county and below, on monthly and quarterly bases target 5: at least 95% of all 554 hfs have bundle vaccines and supplies available with functional cold chain equipment at all times central level activities 1. forecast and procure bundle vaccines 2. expand cold chain thru the procurement and installation of additional solar direct drive (sdd), wicr, refrigerators, cold boxes, etc. target 6: central and 15 county program management improved central level activities 1. build capacity of county and health facility epi management team 2. conduct mid-term and end of period programme evaluation and planning county level activities 1. train community and health facility managers on basics of health services planning and monitoring ministry of health consolidated work plan 2016/17 23 2. undertake regular supportive supervision 3. facilitate and support stakeholder coordination at health facility and community levels 4. provide timely feedback 4.5.3 community health services objective: strengthen community based health services to improve access and coverage of essential services for communities and families that reside beyond 5 km. target 1: establish support systems to strengthen implementation of quality services (hr, m&e, supply chain and operations, supervision, performance and quality improvement) central level activities 1. develop, define, standardize and validate minimum set of indicators (including community births and deaths) in collaboration with programs 2. develop, field test and finalize data collection and reporting tools for chas and chsss 3. develop cbis database and modules in affiliated systems (ihris, lmis, dhis2, etc) 4. develop sops for cbis data management (data reporting, analysis, use and feedback) and integration with other systems including cebs, lmis, ihris, etc) 5. hold validation workshop for cbis tools and sops 6. print and supply monitoring & evaluation materials (including cbis sops, indicator guidelines/definitions, data collection and reporting forms to counties and health facilities) 7. conduct training and roll-out of cbis at in all 15 counties 8. carry out bi-annual joint coaching & mentoring visits to cha implementation sites target 2: recruitment & training of 2000 chas, 300 chsss and 100 master trainers central level activities 1. develop and validate training modules and guideline 2. facilitate and hire master trainers 3. train hss from the 15 counties 4. train chas 5. deploy and manage work of chas 6. develop supervision checklist and train chss 7. print curriculum, training sops, job aids, tools, and training materials ministry of health consolidated work plan 2016/17 24 target 3: strengthen national advocacy, coordination, partnerships, and leadership at all levels central level activities 1. launch community health assistant program at national level 2. develop a dissemination guide and fact sheet for dissemination at county and local level 3. print policy, strategic plan, implementation guide for dissemination, 4. conduct dissemination workshops & tool kit orientation (implementation guide, tors, recruitment guidelines, etc.) for revised community health services policy & strategic plan and launch cha program in all counties 5. establish and hold monthly coordination meeting for community health partners, chaired by director of chsd 6. organize & host annual review of the community health program county level activities 1. establish county and health facility coordination mechanisms among implementing entities, 2. strengthen health facility boards 3. support chas and health facility health workers integrate advocacy and social mobilization, 4. supervise implementation at community and health facility 5. undertake bimonthly monitoring and review at health facility and community level 6. organize biannual review at county level 4.5.4 improve coverage of health related nutrition services objective: strengthen integration and analysis of nutrition program information and surveillance system. central level activities 1. collect and collate monthly nutrition information not included in the current hmis using moh endorsed nutrition reporting tools 2. organize monthly forums to discuss and address bottlenecks identified in the nutrition program 3. support development and dissemination of quarterly nutrition dashboard county level activity 1. organize monthly forums to discuss and address bottlenecks identified in the nutrition program ministry of health consolidated work plan 2016/17 25 4.5.5 improve mental health services objective 1: enhance the capacity of the national health coordination unit, thereby improving mechanisms for coordination, collaboration and monitoring all mental health related activities by june 2017. target 1: capacity of the national health coordination unit built thereby improving mechanisms for coordination, collaboration and monitoring all mental health related activities. county level activities 1. print the updated national mental health policy & strategic plan to include implementation framework and county specific plan. 2. ensure the provision of additional one 4x4 vehicle to capacitate mental health unit to conduct supervision and other mental health activities 3. conduct quarterly national mental health & psychosocial coordination meeting 4. support to evd survivors to be able to communicate the challenges and tell their stories through individual advocacy, and participatory research through photo voice programs 5. to conduct rapid situation analysis & strengthen mental health data reporting/recording systems integrated with existing hmis and other information management systems as well as, designing software/ database for mental health information system objective 2: increase the clinical capacity of mental health professional target 2: additional 1500 phc workers trained central level activities 1. revise the national mental health policy and update the strategic plan with cost, specification of county level structure and an overall timeframe 2. ensure that all county referral hospitals are well prepared with trained phc workers with mhgap-ig materials to host mentally ill patients 3. print and distribute 500 copies of the validated mhgap materials and launch 4. institute supervision mechanisms to follow up on mhgap trainees 5. increase in the # of mental health clinicians county level activities 1. conduct in service training at the primary care level for additional 1500 phc workers using mhgap materials by dec. 15, 2016 2. conduct training for new cadre of the mental health clinicians (child & adolescent) ministry of health consolidated work plan 2016/17 26 objective 3: advocacy and awareness of mental health issues through celebration of mental health illness reduced misconceptions, common fears to reduce stigma and discrimination for people living with mental illnesses, substance use disorders and epilepsy. target 3: five key mental health days celebrated and advocacy meetings held (both among health workers and populous) county level activities 1. celebrate key mental health days such as world mental health day, world epilepsy day, world drug day, world children mental health day and work with resources in the community (e.g. chws, religious leaders & traditional healers) to raise awareness on mental, neurological and substance abuse disorders and to identify and refer clients 2. mental health unit (mhu) to undertake mental health promotion activities 3. mhu to celebrate international children mh day 4. mhu and dea to celebrate world drug day 5. celebrate international mental health day and work with structures in community (eg chws, religious leaders & traditional healers) to raise awareness on mental, neurological and substance abuse disorders and to identify and refer clients 6. conduct additional community healing dialogue for 1,500 evd affected survivors, family and community members 7. raise awareness on mental illnesses, substance use disorders and epilepsy (radio advent, unmil & elbs) objective 4: to improve the accessibility and availability of quality mental health treatment and services including epilepsy and substance abuse disorders management of all persons at all levels of the health care provision. ensure the improvement, accessibility, availability, distribution and utilization of cost effective psychotropic medications. target 4: accessibility and availability of quality mental health treatment and services improved this should include improvement of epilepsy and substance abuse disorders management of all persons at all levels of the health care provision. county level activities 1. advocate for uninterrupted drug supply chain of essential medicines for mental and neurological disorders to be captured on the national essential medicines list 2. conduct regular supportive supervision and monitor available stocks of psychotropic medication and mental health services at each level of service provision ministry of health consolidated work plan 2016/17 27 3. mhu to work with supply chain management unit (scmu) with forecasting and quantification tools for mental and neurological health care products at national and county levels. 4. mhu to work with scmu in strengthening procurement and the distribution based on needs and request 5. provide mhpss to children affected by evd in 15 counties 6. mental health unit to work with lmhra to regulate, evaluate and register of essential medicines for mental and neurological disorders 7. establish mechanisms to support to evd survivors to be able to communicate the challenges and tell their stories through individual advocacy, and participatory research through photo voice programs remain available 8. conduct psychotropic drugs monthly inventory from 15 counties county level activities 1. conduct independent integrated supportive supervision to districts, and health facilities 2. monthly meetings with chdcc 3. improve documentation and timely reporting to the central level 4. enhance stakeholder coordination at county and below, on monthly and quarterly bases 4.5.6 improve hygiene & environmental services objective: to improve accessibility to, quality of hygiene and environmental determinants of health and related services. target 1: increase hygiene awareness and ensure access to acceptable sanitation with 200 households trigger clts, 50% access to sanitation and 35% practice improved hygiene central level activities 1. develop/produce and disseminate national hygiene promotion guidelines 2. revise clts guidelines strengthen national capacity to manage clts 3. increase access to clts triggering and odf monitoring, capacity building of ntcu staff, re-activation of csc, 12 routines monitoring of clts 4.5.7 county health services objective: to strengthen structures for partnership & coordination at cht and central levels. ministry of health consolidated work plan 2016/17 28 target: structures for coordination and partnership revitalized and monitored central level activities 1. attend monthly prison health coordination meetings to strengthen collaboration 2. develop county heath team partners data base and update to ensure proper coordination and partnership county level activities 1. review and harmonize program work plans for implementation at county levels 2. coordinate with qmu, chts and secondary pbf hospitals to establish qi committees 3. attend monthly prison health coordination meetings to strengthen collaboration 4. develop county heath team partners data base and update to ensure proper coordination and partnership specific objective 2: to ensure implementation of the ephs target 1: routine use of the ephs for health service implemented central level activities 1. support the implementation of ephs package 2. receive all requests including liquidation from chts, pass requests to appropriate unit and ensure prompt action is taken county level activities 1. monitor and evaluate primary health care activities in the county specific objective 3: to strengthen systems through capacity building activities at central mohsw and county levels target 1: systems for capacity building activities are strengthened at central moshw and county levels central level activities 1. work closely with contracting-in coordinator to finalize capacity building 2. provide supportive guidance on the design and implementation of cb activities within the counties county level activities 1. provide supportive guidance on the design and implementation of cb activities within the counties 2. monitor the implementation of cb plan ministry of health consolidated work plan 2016/17 29 specific objective 4: to improve prison health activities and ensure that prisons are provided with quality health care within the 15 counties target 1: prison health activities are improved central level activities 1. conduct quarterly monitoring visits for protection officers & health workers in 15 counties 2. provide essential hygienic materials for inmates county level activity 1. provide essential hygienic materials for inmates specific objective 5: to strengthen contracting mechanisms for the delivery of the ephs target 1: harmonization of contracting mechanisms central level activities 1. organize meeting with all donors’/fund holders for the implementation of various contract schemes 2. standardize all contracting mechanisms approach 3. develop zero draft of the contracting guidelines and tool 4. pretesting of the zero draft of the contracting guidelines and tool 5. validation of revised contracting-in guidelines and tool 6. conduct end of contracts performance appraisal for all contracts county level activities 1. conduct readiness assessment for county to be contracted in 2. conduct training for chts on the guidelines and tool 3. capacity building mentoring and coaching for contracting-in 4. quarterly monitoring of county readiness for contracting 5. conduct end of contracts performance appraisal for all contracts 4.5.8 national health promotion specific objective 1: improved coordination among major stakeholders in promoting healthy practices by the end of 2016 target 1: health promotion policy, strategic plan and communication strategy finalized, validated, printed and disseminated central level activities ministry of health consolidated work plan 2016/17 30 1. complete and validate health promotion policy, strategic plan and communication strategy, 2. develop and disseminate health promotion policy briefs and conduct policy dissemination events at the county level. 3. develop national emergency risk communication strategy 4. initiate partner mapping in all counties 5. establish health promotion technical working groups at county and district levels 6. conduct joint assessment on risk communication capacity 7. training of ecap2 ngo network on health messaging using lla training methodology 8. initiate bio-safety and traffic health hazard awareness and sensitization 9. assessment on knowledge on cervical cancer and rota vaccine (diarrhea vaccine) 10. development of messages and materials to create awareness and sensitize the general public for all vaccine preventable diseases 11. under the leadership of the hptwg/messages and materials development (mmd) working group, draft and disseminate rmnch message guide. 12. development of messages and materials to create awareness and sensitize the general public to prevent stigmatization of ebola survivors 13. review and revise pretest questionnaire for message and materials development 14. identify, recruit and train volunteers for pretesting of messages and materials 15. introduction of hpv vaccine and rota vaccine launching nation wide campaign on healthy life brand and airing of radio spots to increase demand of and utilization of health services county level activities 1. initiate partner mapping in all counties 2. awareness campaign on non communication disease in all 15 counties 3. development of messages and materials to create awareness and sensitize the general public to prevent stigmatization of ebola survivors 4. introduction of hpv vaccine and rota vaccine specific objective 2: strengthen and sustain community engagement, to identify health needs and take actions target 1: community stakeholders will be aware and sensitized to disseminate information to community members central level activities 1. dialogue with community stakeholders (chiefs, religious, traditional, youths leaders and women groups 2. radio distance learning program to enable chvs to implement more effective health promotion and social mobilization activities leading to improved health practices and return to rmnch services ministry of health consolidated work plan 2016/17 31 3. continue the orientation of select chvs and their supervisors on the community engagement tool, bridges of hope 4. training of 1,500 chcs on health messaging and community health risk reduction plan county level activity 1. dialogue with community stakeholders (chiefs, religious, traditional, youths leaders and women groups specific objective 3: empower media to inform and educate the public to promote healthy life style by the end of 2016 central level activities 1. strengthen partnership with media in health promotion activities 2. conduct radio/tv shows, print news letter and provide information to the public 3. continue and maintain the dey say rumor tracker system, expand network of users, conduct roundtables with local media, orient chws and chvs to dey say use, mentor journalists on the use of dey say 4. establish resource center/ documentation 4.6 drugs and supply chain management drugs and medical supplies is an essential component of the investment plan for building a resilient health care in liberia. this pillar is under-funded, with insufficient capacity to effectively deliver and maintain commodities and supplies at the service delivery levels. these factors result in frequent stock out, distribution of prescriptions to patients and low utilization of health services. objective: to put in place a cost-effective and efficient supply chain management systems for essential medicines and supplies, including ppes. to achieve this objective, 18 major activities have been earmarked for the fiscal year 2016/17. below is the list of the 2016/17 planned activities: central level activities 1. develop and decentralize lmis 2. evaluate interim approach 3. distribute drug and medical supplies from nds 4. assess drug national and counties drug depots 5. conduct six counties drug depots (lofa, grand kru, sinoe, bomi, grand bassa and grand cape mt) 6. build drug shelves in 350 health facilities and at supply chain offices ministry of health consolidated work plan 2016/17 32 7. de-junk and incinerate health facilities and depots expire drugs 8. automate the lmis into the general hmis of the moh 9. procure ict equipment (laps, desktops, scanners, printers, etc) 10. train supply chain officers and program managers on reporting, supervision, monitoring, quantification and supply chain management 11. dispose of expired pharmaceuticals and medical equipment without harming the environment and the community 12. procure drugs and medical supplies 13. procure motorcycles a for supply chain officers 14. procure vehicles for county pharmacists 15. train dispenser on rational use of drugs and supply chain management 16. conduct quarterly monitoring and audit county level activities 1. conduct last mile drug and medical supplies distribution 2. procure lab reagent 3. conduct quarterly monitoring and supervision 4. procure essential drugs and medical supplies 4.7 health information systems, m&e and research health information system, research and m&e are the fulcrum for the evidence-based management that the ministry of health subscribes to. the his, m&e and research units have set objectives and earmarked key activities that are geared towards strengthening data collection, information generation and inquiry to support management decision making, implementation tracking and performance monitoring. the objectives and key activities include: objective: strengthen m&e, research and his capacity and coordination to ensure a functional m&e system with harmonized data sources that meets all stakeholders’ needs. central level activities 1. hold monthly hmer technical working groups with all national programs and technical partners 2. hold quarterly hmer coordination committee meeting with senior moh manager and representative of donor institutions. 3. map key partners for research, local and international to identify opportunities for collaboration and support for research 4. train county m&e staff in monitoring and evaluation concept and practices for effective m&e at the lower levels ministry of health consolidated work plan 2016/17 33 5. train county and district health teams on data use in ongoing management decision making 6. mentor county health m&e team to master core m&e skills and execute their functions with efficiency and effectiveness, and transfer skills down to the district levels 7. train district health team on data validation, analysis and interpretation 8. decentralize dhis-2 to district levels on an incremental basis as district health teams developed. 9. produce and disseminate revised national m&e policy and strategy 10. validate, produce and disseminate moh indicator reference book to all stakeholders including the chts and districts offices. 11. mobilize resources for logistics to facilitate core m&e activities to the decentralized levels 12. develop unique code for id for every health facility in collaboration with key stakeholders including lisgis and liberia medical and dental council. 13. produce master facility registry capturing all health facilities in the country indicating their facility types and gps coordinates. 14. work towards the development of the seven sub-information systems on an incremental basic with standards and capabilities to interoperate and exchange data 15. train 20 health managers on research methodologies, analysis and report writing. 16. train 15 health managers on the use of statistical packages and technical writing skills 17. establish health research repository 18. produce quarterly dashboard and scorecards using selected core indicators to measure moh’s overall and key programs performance 19. produce quality of performance report to inform management on some of the factors influencing and or impeding progress on service delivery, quality of care, and health system strengthening; and to document those enablers, challenges, lessons, and good practices to inform remedial management actions. 20. conduct quarterly verification of implementation and monitoring visits to counties monitor counties’ implementation of the nhpp as expressed in their annual operational plan, looking at chts, facilities and communities as well a ngo partners’ activities. 21. county m&e teams to conduct routine data verification, monitoring and m&e supervision to the districts and facilities levels 22. county m&e to produce quarterly reports to inform chts of their performances as well as central moh on where each county stand on progress towards their annual targets and activities plan. 23. conduct annual nation review of the health system to take stock of performance for the year in review and fine-tune operation plan for the following year. 24. conduct quarterly review at central to look at output and assess progress towards national annual target and key investment activities ministry of health consolidated work plan 2016/17 34 25. county conduct quarterly data and performance review meetings involving facilities, districts and local authorities to discuss success and failures and look at assess strategies against challenges 4.8 community engagement objective: strengthen community awareness on health risks and their engagement and linkages with the health system. central level activities 1. develop community engagement policy and strategy 2. conduct stakeholders’ orientation on community engagement policy and strategy county level activities 1. engage ttms to refer pregnant women from communities to health facilities 2. conduct awareness and public education on ena by ttms and gchvs 3. support gchvs/cha to deliver integrated community health services 4. conduct monthly meeting with chdc to take ownership of health facilities 5. conduct idsr refresher training for gchvs, ttms and community leaders in community event based surveillance 4.9 leadership and governance objective: strengthen governance, leadership and management capacities at all levels to implement the national and county plans. central level activities 1. finalize and validate the ministry of health organizational structure 2. finalize the organizational structure of the chts 3. develop, review and validate county health boards mandate, membership and tors (operational manual) 4. establish, finalize and validate organizational structures of dhts 5. reactivate /establish district health boards 6. review and align the ministry of health decentralization policy and strategy to the national health investment plan (2016-2021) 7. print and disseminate the revised national health sector decentralization policy & plan (2016-2021) target 1: 15 county annual plans and the consolidated national plan 2016/17 with an effective feedback mechanism from the central to counties, districts, and communities are developed. ministry of health consolidated work plan 2016/17 35 1. develop standardized guides and tools for formulating the annual operational plan. 2. apply a bottom up approach to develop annual operation plans for the district and counties with the participation of all stakeholders 3. facilitate and conduct horizontal plan for the central moh and a consolidated annual plan for the whole health sector for the fiscal year county level activities 1. conduct quarterly county health board meetings 2. orientate county health board members on their roles and responsibilities (csh) 3. conduct quarterly district health coordination meetings 4. conduct bi-annual county review meeting with (csh) in collaboration with partners 5. conduct quarterly health board meeting 6. organize chc meetings and disseminate revised community health policy 7. training of communities leaders and oics on the ephs components 8. conduct monthly meeting with gchvs and ttms in the communities 9. train dht on supervision and reporting 10. refresher training for oic, cm, registrar, and dispenser on data management 11. work through the district superintendent/commissioner to establish district health committees 12. conduct bi-annual operational plan review meeting to review the county work plan, identify progress, gaps and address the gaps 13. work with dhts to engage community leadership on taking ownership of health facilities 5.0 costing and budgeting the amount of us$ 149.89 million is required to fully implement the fy 2016/17 operational plan of the national investment plan for building a resilient health system. the moh financing unit conducted a resource mapping within the sector and has identified us$ 251,513,495 as commitment from the government of liberia (us$ 72, million) and partners (us$ 179.45 million) for the fiscal year. table 5.1: estimated budget and committed resources by investment areas # investment pillars estimated cost committed partners & donors resources 1 fit for purpose motivated workforce 21.3 million 2 re-engineer health infrastructure 10.9 million emergency preparedness and ministry of health consolidated work plan 2016/17 36 3 response 29.7 million 4 health care financing 3.8 million 5 quality of health services 57.2 million 6 drugs and medical supplies 13.9 million 7 comprehensive information system and research 0.387 million 8 leadership and governance 11.3 million 9 community engagement 1.4 million total us$ us$ 149.89 million 5.1 national budget the approved fy 2016/17 national health sector budget is us$ 72 million of which the ministry of health has us$ 57 million. the budget will be used to fund activities in the operational plan at the national, county, district and health facility levels. below is a description of the draft health sector fy 2016/17 budget. table 5.2 : health sector government draft budget fy 2016/17 health sector expending entities fy 2016/17 budget ministry of health 57,126,248 john f. kennedy medical center 6,295,156 phebe hospital and school of nursing 2,130,956 liberia institute of bio-medical research 487,778 liberia board for nursing and midwifery 188,628 liberia pharmacy board 189,938 liberia medical and dental council 387,358 liberia college of physician and surgeons 1,117,500 liberia medical and health products regulation 458,079 national aids commission 844,367 jackson f. doe hospital 2,835,468 total budget 72,061,476 6.0 monitoring and review of investment plan this operational health plan will be monitored using the performance framework available in annex c. the list of core output and short term outcome indicators contained in the framework will be used to track performance at every level of the health system. the performance framework will guide all stakeholders including partners to monitor and review the health system for the fiscal year. district and facility teams will focus on service delivery and community engagement indicators, while county and central levels will focus on indicators in their monitoring and reviews. ministry of health consolidated work plan 2016/17 37 reviews will take place quarterly and annually. at the decentralized level, review will be done quarterly involving service providers, health managers and local authorities. this quarterly review will look back at performance over the previous three months at the end of the quarters. it will focus on successes and failures, weakness and strengths, good practices and learn lessons to improve results in the subsequent quarters. at the central level, quarterly review will be done looking at performance on the core list of indicators and the implementation of central level planned activities and achievement of key deliverables in the investment plan. at the end on the fiscal year, a comprehensive review will be done using a mixed of methodologies and gauge the sector’s performance for the fiscal year ended. outcomes of the review will form the agenda for the annual health review conference of all stakeholders in the sector. this annual meeting will take place preferably in october will document progress towards 2021 and re-align the moh priorities towards achievements of the milestones set forth in the national health plan and the investment plan for building a resilient health plan. annex c presents national and county levels performance framework. annex a: health infrastructure needs fy 2016/17 # county clinic maternal home staff quarter dht /cht office lab incinerators fence hf triag e cost 1 bomi 2 22 22 2 bong 5 127,200 3 gbarpolu 2 3 7 3 4 6 5 8 4 grand bassa 4 21 20 8 22 10 775,150 5 grand cape mt 2 1 2 192,950 6 grand gedeh 4 4 3 149,400 7 grand kru 10 1 2 8 lofa 10 9 margibi 10 maryland 11 montserrado 5 7 1 8 2 12 nimba 2 10 7 8 18 13 rivercess 3 6 14 river gee 6 1 12 15 sinoe 7 2 5 2 775,600 total 39 47 69 17 26 41 52 34 2,020,300 ministry of health consolidated work plan 2016/17 38 annex b: supply chain fy 2016/17 activities # activity cost 1 develop and decentralize lmis 100,000 2 evaluate interim approach 27,700 3 distribute drug and medical supplies from nds 200,000 4 assess drug national and counties drug depots 20,000 5 conduct six counties drug depots (lofa, grand kru, sinoe, bomi, grand bassa and grand cape mt) 900,000 6 build drug shelves in 350 health facilities and at supply chain offices 245,000 7 de-junk and incinerate health facilities and depots expire drugs 200,000 8 automate the lmis into the general hmis of the moh 350,000 9 procure ict equipment (laps, desktops, scanners, printers, etc) 100,000 10 train supply chain officers and program managers on reporting, supervision, monitoring, quantification and supply chain management 100,000 11 dispose expired pharmaceuticals and medical equipment without harming the environment and the community 150,000 12 conduct last mile drug distribution 250,000 13 procure drugs and medical supplies 3,000,000 14 procure lab reagent 100,000 15 conduct quarterly monitoring and audit 200,000 16 procure motorcycles a for supply chain officers 70,000 17 procure vehicles for county pharmacists 525,000 18 train dispenser on rational use of drugs and supply chain management 100,000 total 6,637,700 annex c: health sector performance framework no. indicators baseline 2015/2016 baseline year data sources target fy 2016/17 1 percentage of pregnant mothers attending 4 anc visits 50% 2015/16 hmis 76% 2 percentage of pregnant mothers receiving ipt-2 37% 2015/16 hmis 60% 3 percentage of hiv positive pregnant women initiated on arv prophylaxis or art to reduce the risk of mtct tbd hmis 60% ministry of health consolidated work plan 2016/17 39 4 percentage of deliveries attended by skilled personnel 50% 2015/16 hmis 72% 5 percentage of infants fully immunized 52% 2015/16 hmis 75% 6 percentage of children zero to five months of age exclusively breast fed tbd tbd 7 tb case detection rate (all forms) 56% 2015/16 hmis 75% 8 proportion of children one year old immunized against measles 63% 2015/16 hmis 70 9 treatment success rate among smear positive tb cases (under directly observed treatment short course) 72% 2015/16 hmis 85 10 % of health facilities meeting minimum ipc standards tbd qu 100% 11 percentage of population living within 5 km from the nearest health facility 71% 2013 dhs 80% 12 functional health facilities per 10,000 population 1.8 2016 hr census 2 13 percentage of health facilities with all utilities, ready to provide services (water, electricity) 64% 2016 sara 80% 14 number of counties with funded outbreak preparedness and response plans non funded 90% 15 number of counties reporting event based surveillance data 100% 2016 dcp weekly epi report 100% 16 percentage of health facilities with no stock-outs of tracer drugs at any given time (amoxicillin, cotrimoxazole, paracetamol, ors, iron folate, act, fp commodity) tbd sata 85% 17 opd consultations per inhabitant per year 1.08 2016 hmis 2.0 18 skilled health workforce (physicians, nurses, midwives, physician assistants) per 1,000 persons 4,756 2016 hr census 11.0 19 proportion of health facilities with at least two skilled health workers na n/a 20 proportion of health workers on government payroll 6,272 2015/16 gol payroll n/a 21 timeliness of hmis reports quarterly 2016 hmis 75% 22 proportion of facilities that submitted hmis reports 2016 hmis 75% 23 per capita public health expenditure in usd us$ 11.23 2015 moh ar us$70 24 public expenditure in health as % of total public expenditure us$ 12.4 2015 moh ar 15% ministry of health consolidated work plan 2016/17 40 annex d: county level performance framework # county anc 4 visits iptp2 institutional delivery baselines targets baselines targets baselines targets 1 bomi 77% 85% 47% 55% 57% 62% 2 bong 77% 79% 73% 79% 78% 80% 3 gbarpolu 33% 48% 23% 53% 29% 41% 4 grand bassa 67% 70% 41% 55% 52% 60% 5 grand cape mt 47% 52% 35% 46% 46% 50% 6 grand gedeh 67% 70% 41% 55% 52% 60% 7 grand kru 8 lofa 9 margibi 49% 0% 37% 0% 42% 0% 10 maryland 11 montserrado 44% 45% 22% 25% 24% 30% 12 nimba 44% 85% 40% 70% 46% 80% 13 rivercess 14 river gee 15 sinoe 73% 78% 53% 62% 61% 66% national 50% 76% 37% 60% 50% 72% # county delivery by sba fully immunized penta-3 baselines targets baselines targets baselines targets 1 bomi 57 62 71 91 76 82 2 bong 57 62 71 91 76 82 3 gbarpolu 29 41 0 0 82 94 4 grand bassa 44 50 43 50 57 60 5 grand cape mt 46 50 55 60 74 78 6 grand gedeh 44% 50% 43% 50% 57% 60% 7 grand kru 8 lofa 9 margibi 42% 0% 71% 0% 82% 0% 10 maryland 11 montserrado 24% 30% 53% 60% 62% 68% 12 nimba 46% 80% 40% 13 rivercess 14 river gee 15 sinoe 61% 66% 68% 76% 92% 94% national 50% 72% 52% 75% ministry of health consolidated work plan 2016/17 41 # county measles hmis reporting rate hmis reporting timeliness baselines targets baselines targets baselines targets 1 bomi 66% 70% 100% 100% 100% 100% 2 bong 95% 96% 100% 100% 100% 100% 3 gbarpolu 63% 79% 100% 100% 100% 100% 4 grand bassa 69% 75% 93% 100% 97% 100% 5 grand cape mt 60% 60% 94% 100% 97% 100% 6 grand gedeh 48% 54% 93% 100% 93% 100% 7 grand kru 8 lofa 9 margibi 73% 10 maryland 11 montserrado 60% 68% 12 nimba 68% 70% 80% 90% 80% 90% 13 rivercess 63% 65% 100% 100% 100% 100% 14 river gee 15 sinoe 85% 90% 100% 100% 100% 100% national 63% 70% 75% 75% # county pnc within 2 wks utilization rate anc 1st visits baselines targets baselines targets baselines targets 1 bomi 56% 60% 86% 90% 2 bong 46% 50% 86% 90% 3 gbarpolu 20% 40% 41% 59% 4 grand bassa 33% 40% 80% 89% 5 grand cape mt 56% 60% 71% 75% 6 grand gedeh 37% 40% 70% 75% 7 grand kru 8 lofa 9 margibi 10 maryland 11 montserrado 28% 30% 90% 90% 12 nimba 78% 80% 94% 96% 13 rivercess 34% 40% 73% 75% 14 river gee 15 sinoe 45% 49% 79% 85% national john m, katarzyna c. advancing policies for public health benefit: a collection of policy briefs developed by the maastricht university students. (policy brief). seejph 2023. posted: 09 april 2023 p a g e 1 editorial advancing policies for public health benefit: a collection of policy briefs developed by the maastricht university students john middleton1,2, katarzyna czabanowska3,4 1past president, association of schools of public health in the european region (aspher), brussels, belgium. 2honorary professor of public health, faculty of education, health and wellbeing, wolverhampton, university, wv11ad, united kingdom. 3department of international health, care and public health research institute (caphri), fhml, maastricht university, maastricht, the netherlands. 4department of health policy and management, institute of public health, jagiellonian university, krakow, poland. corresponding author: john middleton address: ave de tervueren 153, brussels 1050 belgium. email: johnmiddleton@phonecoop.coop mailto:johnmiddleton@phonecoop.coop john m, katarzyna c. advancing policies for public health benefit: a collection of policy briefs developed by the maastricht university students. (policy brief). seejph 2023. posted: 09 april 2023 p a g e 2 abstract where there is no vision, the people perish’ has never been truer than today. we need new models of how to train the future public health leaders in the 21st century to improve and protect people and planet”. the maastricht university public health leadership course has been described previously (1). the course aims to create leaders with vision, who can see a future different to the status quo, who can influence and drive change, who are able to communicate their vision and win others to embrace and implement it. john m, katarzyna c. advancing policies for public health benefit: a collection of policy briefs developed by the maastricht university students. (policy brief). seejph 2023. posted: 09 april 2023 p a g e 3 introduction ‘where there is no vision, the people perish’ has never been truer than today. we need new models of how to train the future public health leaders in the 21st century to improve and protect people and planet”. the maastricht university public health leadership course has been described previously (1). the course aims to create leaders with vision, who can see a future different to the status quo, who can influence and drive change, who are able to communicate their vision and win others to embrace and implement it. modern day efforts seek to deliver health, which is more than the absence of disease and public health, which is the prevention of disease, the prolongation of life, and the promotion of health, through the organized efforts of society (2). vision is a key word there is no leadership without a vision. vision can be for better, or for worse; for societal good, or for individual greed. in public health we are striving for a leadership vision which improves and protects health, which prevents suffering and disability and can convey such benefits as a satisfying role in society, friendship, companionship, and meaningful relationships with friends, neighbours, and community. even at the end of life, being ‘healthy’ can mean having settled our worldly affairs, having been resolved our differences and been able to die with dignity’. society is the other key in the work of public health leaders. we need, not just, the organised efforts of doctors and nurses, not just, the organised efforts of health services: we need the organised efforts of society (2). we have begun to recognise that our public health venture also requires the efforts of environmental scientists, information scientists, health promotion and health policy specialists, pharmacists, physiotherapists, dietitians and other allied health care professions and social care professionals. we have also learned in more recent years, that our efforts require new disciplines to come into the public health community; amongst these are the climate scientists, ecologists, political scientists, theologians, economists, and international lawyers (3). the international lawyer who could deliver the wording of an international trade-related intellectual property (trips) waiver on vaccines, might be the most powerful public health professional of all john m, katarzyna c. advancing policies for public health benefit: a collection of policy briefs developed by the maastricht university students. (policy brief). seejph 2023. posted: 09 april 2023 p a g e 4 timecapable of saving lives and relieving disability on an unimaginable scale. and such a waiver might not just apply to covid vaccines, but to all the childhood vaccine preventable infections and much more (4). the 21st century requires public health leaders not just to be in command of their own body of expertise, but also to have sufficient knowledge of other disciplines, to earn respect, find common areas of interest and develop shared actions. we need to develop leaders in public health at every level (5). public health leadership attributes and development have been neglected until relatively recently. public health leadership has been provided largely by charismatic individuals and thought leaders. this has not created the critical mass required to secure public health leadership in every country, every regional and local administration and through every academic institution where public health should be nurtured and supported. the mindset to lead on public health issues is vital; the belief and recognition and the vision that better health and quality of life is possible, is central to how we develop new public health leaders. public health professionals work at the intersection of practice, research and policy and work widely with other disciplines, business, and community interests. they need to identify and understand public health problems, use research and scientific evidence to prepare policy options and make recommendations for policy change to improve health and wellbeing or effectively advocate for it (1). in the 21st century they also need to understand the expanding range of anti-health forces that are deployed against them. the public health role is the noblest vocation and the most rewarding role, but also, in the new geopolitical world, it is the most challenging and dangerous. the public health leaders of the 21st century will operate in complex and interconnected systems which require alliance-building skills, horizontal and distributed leadership, as well as interdisciplinary approach. whichever discipline is required to take the lead for a particular issue, should do so. we should break down silos and avoid narrow channels of control for problems that confront all agencies and all communities and can only be addressed by multidisciplinary action where we pool sovereignty. this applies whether it is, for example, drug dependency, prevention of john m, katarzyna c. advancing policies for public health benefit: a collection of policy briefs developed by the maastricht university students. (policy brief). seejph 2023. posted: 09 april 2023 p a g e 5 accidents, reducing soil erosion and crop failure, mitigating climate breakdown, or stopping the cause of mass migration. we need to develop a vision of public health leadership which can lead across disciplines, deferring to the expertise of others and following where and when necessary, leading from the front, always bring along partners, allies, acknowledging and involving communities of interest, effectively neutralizing, or converting negative forces against health along the way. the maastricht university public health leadership course seeks to address these issues and create new public health leaders able to operate in this complex multi-system world. the main objective of this leadership course was twofold: 1) to facilitate the development of change leadership competencies by the students based on the eight-step kotter model of leading change (5) including: establishing a sense of urgency, creating a guiding coalition, developing a change vision, communicating the vision for buy-in, empowering broad-based action, generating short-term wins, never letting up, and incorporating changes into the culture, and 2) to help the students develop the skills of writing a policy brief as both an advocacy communication and policy change tool that can support public health leaders who want to introduce change . in this edition of the seejph supplement we present eight policy briefs prepared by small group seminar sessions held over six meetings in the autumn of 2022. the project areas are listed in the table 1 and in the contents page. the policy briefs aim at national regional and local administrations, proposing strongly researched, evidencebased interventions in each case. the briefs are aimed at a range of policy and decisionmakers, including the polish prisons administration, the granada city government, and the eu on their fishery policy. there is no area of decision making where public health should not be contributing. the briefs demonstrate how our students are considering all the angles, all their potential supporters, all their detractors, all the risks, and all the benefits. these policy briefs show our new generation of public health professionals are more than ready to demonstrate their expertise and push it out there in the public policy making arena. john m, katarzyna c. advancing policies for public health benefit: a collection of policy briefs developed by the maastricht university students. (policy brief). seejph 2023. posted: 09 april 2023 p a g e 6 table 1. eight policy briefs developed by the students of the maastricht university public health leadership programme 2022 1. policy recommendations to improve mental health in polish prisons 2. human papillomavirus vaccines: call for a european change to tackle current and future shortages 3. beyond silos: a call to include hospital support staff in cultural competency training 4. on urgently tackling the mosquito-borne diseases in the european union 5. out of cars, onto the cycle paths: aligning granada's traffic infrastructure with the european green deal 6. sustainable reform of european union (eu): common fisheries policy 7. reducing the burden of hiv and hcv among sex workers who use drugs in france 8. stemming the tide of disinformation in public health we have a pleasure of inviting colleagues and the seejph readership to find out how the students at maastricht university propose policy change by reading the following collection of policy briefs. references 1. czabanowska k, kalaitzi v. babich s. teaching public health change leadership. south eastern european journal of public health special volume no. 3, 2021. editorial. 2. acheson, d. public health in england. the report of the committee of inquiry into the future development of the public health function. london: hmso, 1988. 3. middleton j, isis? crop failure? and no antibiotics? what training will we need for the future of public health, european journal of public health, 2016: volume 26, issue 5: 735–736. https://doi.org/10.1093/eurpub/ckw12 8 4. a vaccine waiver now: summary statement from the association of schools of public health in the european region (aspher) , global network of academic public health ( gnaph) and the world federation of public health associations (wfpha. https://s3.amazonaws.com/aspph_m edia_files/docs/211026+gnaph+sh ort_trips-waiver-statement_final.pdf 5. kotter j. leading change. why transformation efforts fail. best of harvard business review. january 2007. _____________________________________________________________________________________________ © 2023 middleton j et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 1 | 12 original research prevalence of chronic obstructive pulmonary disease (copd) in albania holta tafa1, donika mema2, arian mezini1, jolanda nikolla3, alma teferici1, dafina todri1, genc burazeri4, hasan hafizi1 1 university hospital “shefqet ndroqi”, tirana, albania; 2 institute of public health, tirana, albania; 3 american hospital, tirana, albania; 4 faculty of medicine, university of medicine, tirana, albania. corresponding author: hasan hafizi, md, phd; address: rr. “shefqet ndroqi”, tirana, albania telephone: +355697491518; email: hasanhafizi@hotmail.com tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 2 | 12 abstract aim: the objective of this study was to determine the prevalence of copd and its associated factors among adults in albania. methods: this was a cross-sectional study conducted in albania in 2013-14. a nation-wide representative sample of 1200 adults aged ≥40 years was selected using multistage cluster sampling technique. all participants were interviewed about socio-demographic characteristics, respiratory symptoms, smoking status and clinical characteristics. spirometry was performed according to standard methods. copd was defined as post-bronchodilator fev1/fvc ratio <70% predicted. results: of the 1200 adults invited to participate, 939 adults or 78% (467 men and 472 women) were eligible for the study. the overall copd prevalence (gold stage 1 or higher) was 12.4%; it was higher in men (17.4%) than in women (7.7%). using lower limit of normal (lln), the prevalence of copd was 9.9%, again higher in men (13.2%) than women (6.6%). the prevalence of doctor-diagnosed copd was 1.3% (1.9% in men, 0.6 % in women). male sex, smoking and increasing age were significantly associated with copd diagnosis. conclusion: the overall prevalence of copd in albania was 9.9% using bold standards. smoking and increasing age were the main risk factors for copd. the study highlights the importance of raising awareness of copd among health professionals. keywords: albania, bold study, copd prevalence, risk factors. conflicts of interest: none declared. tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 3 | 12 introduction chronic obstructive pulmonary disease (copd) is currently the fourth leading cause of death in the world but is projected to be the 3rd leading cause of death by 2020 (1). globally, the copd burden is projected to increase in coming decades because of continued exposure to copd risk factors and aging of the population (2). copd prevalence, morbidity and mortality vary across countries and across different groups within countries. copd is the result of a complex interplay of long-term cumulative exposure to noxious gases and particles, combined with a variety of host factors including genetics, airway hyper-responsiveness and poor lung growth during childhood (3,4). often, the prevalence of copd is directly related to the prevalence of tobacco smoking, although in many countries outdoor, occupational and indoor air pollution (resulting from the burning of wood and other biomass fuels) are major copd risk factors (5,6). despite a growing burden, copd is often a neglected disease and its epidemiology is largely unknown in particular in low and middle income countries (7). existing copd prevalence data vary widely due to differences in survey methods, diagnostic criteria and analytical approaches (2). many patients with copd are still underdiagnosed, inadequately evaluated and under-recognized leading to significant underreporting of the disease (8,9). community based studies using appropriate methods are needed to determine the epidemiology of copd and to enable the development of prevention and management strategies for the future. the burden of obstructive lung disease (bold) initiative aimed at developing and using a standardized method to measure the prevalence of copd and its risk factors in various areas around the world (10,11). in our study, we used bold protocol to estimate the prevalence and burden of copd in albania. methods bold developed standardized methods including standardized spirometry equipment, meticulous quality control measures, standard protocols, validated and translated questionnaires and standard data entry and analysis. bold operations centre (oc) emphasized data quality control at every stage of the process. the study was conducted in close collaboration with the bold operations centre (oc) in london which provided oversight, training, materials, quality control, and data analysis. national bioethics committee’s approval was a prerequisite for study implementation. study design this was a cross-sectional study conducted in albania in 2013-14, which consisted of a copd prevalence survey among adults aged ≥40 years. a representative sample of adult individuals in this age range was asked to fill in the questionnaires and perform spirometry tests designed by bold. target population and sampling procedure: a nation-wide representative sample was drawn. a multi-stage cluster sample of 1200 individuals (600 men and 600 women) aged ≥40 years was drawn based on the sampling frame (alias the target population) available from the national institute of statistics (instat). boldoc in london, uk, reviewed and approved the sampling approach calculated by a local expert. recruitment of participants: participants were contacted through home visits and were tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 4 | 12 asked to provide an informed consent to schedule a clinic visit and where necessary. study measures spirometry was performed by eight trained and certified technicians (easyone spirometer; ndd medizintechnik; zurich, switzerland). copd was defined as a post-bronchodilator fev1/fvc <70% predicted. spirometry data were sent electronically to the oc where each spirogram was reviewed and graded using ats guidelines (12). post bronchodilator spirometry tests were performed at least 15 min after achievement of at least 3 acceptable and 2 reproducible pre bronchodilator spirometry tests. the number of pack-years of cigarette smoking was defined as the average number of cigarettes smoked per day divided by 20 (i.e., packs per day) times the duration of smoking in years. data recording and analysis data for bold study consisted of electronically generated spirometry records, responses to questionnaires administered to study participants, individual tracking data, and aggregate data about the target population. our data were reported to oc for validation and analysis. estimated population prevalence of copd for the overall city population was computed using survey data methods in stata v. 12 (stata corporation, college station, tx, usa), and stratified by sex, age and smoking status. the study was conducted from october 2012 to december 2013. results of the 1200 adults invited to participate, 997 (83%) of them were eligible for the study. among them 11 participants were excluded because of lost spirometry data due to the faulty spirometer and 47 other participants due to unacceptable post bd spirometry. table 2 shows that there were no differences between responders and non-responders who were eligible for the study, except for smoking status and other co-morbid conditions (p<0.001 and p<0.007, respectively). participants that were current smokers and those with co-morbid conditions were less likely to be responders. table 3 shows the prevalence of smoking in albania by sex and age. overall, 21.6% of individuals ≥40 years old were smokers at the time of the study. smoking was much more prevalent in males than in females. the percentage of smoker was higher in age group 50-59. the overall prevalence of gold stage i or higher copd was 12.4%, and was higher in male (17.4%) than female sex (7.7%) and in those >70-year old. using lower limit of normal (lln) the prevalence of copd was 9.9%, again higher in males (13.2%) than females (6.6%) and like using gold criteria was higher in individuals > 70 years old (table 4). the prevalence of copd was strongly related to smoking history expressed as pack years as shown in table 5. table 6 shows the prevalence of smoking in albania by sex and age. overall, 21.6% of individuals ≥ 40 years old were smokers at the time of the study. smoking was much more prevalent in males than in females. the percentage of smokers was higher in age group 50-59. the prevalence of doctordiagnosed copd was much lower than spirometry-confirmed copd, with an overall estimate of 1.3% (1.9% in males, 0.6 % in females) (table 28). it was higher in group >70 years. tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 5 | 12 table 1. disposition of study participants for bold site: tirana, albania outcome men women unknown total responders: full data collected (core ques plus qc acceptable post bd spirometry) 467 472 0 939 full data collected (core ques plus qc unacceptable post bd spirometry) 27 20 0 47 full data collected (spirometry data lost due to faulty spirometer)* 2 9 0 11 total responders 496 501 0 997 non-responders: partial data collected 51 49 0 100 refused (minimal data collected) 2 2 0 4 refused (no minimal data collected) 43 32 0 75 known to have temporarily left area 3 10 0 13 unreachable (couldn’t reach)† 4 5 0 9 total non-responders 103 98 0 201 ineligible: deceased 1 1 0 2 permanently left catchment area 0 0 0 0 age ineligible 0 0 0 0 institutionalized 0 0 0 0 untraceable (bad address & phone)‡ 0 0 0 0 total ineligible 1 1 0 2 total selected for recruitment¶ 600 600 0 1200 * some spirometry data was lost before it could be transferred, due to a faulty spirometer; † contact information apparently correct, but no response to contact attempts; ‡ contact information incorrect, no updated information available; ¶ number of responders + non-responders + ineligibles. table 2. comparison of responders* and non-responders† for albania responders non-responders p-value‡ age 40-49 351 (36%) 81 (40%) 0.382 50-59 330 (33%) 55 (27%) 60-69 191 (19%) 40 (20%) 70+ 114 (12%) 25 (12%) gender male 494 (50%) 103 (51%) 0.768 female 492 (50%) 98 (49%) smoking status current 213 (22%) 46 (23%) <0.001 ex 148 (15%) 9 (4%) never 625 (63%) 146 (73%) doctor diagnosed asthma, emphysema, cb or copd yes 64 (6%) 6 (3%) 0.056 no 922 (94%) 194 (97%) other co-morbid conditions yes 260 (26%) 72 (36%) 0.007 no 726 (74%) 129 (64%) * responders are those who completed post-bd spirometry (regardless of qc scores) and the core questionnaire. † non-responders are eligible individuals who are missing the core questionnaire and/or post-bd spirometry, but for whom the tabulated variable is known. ‡ two-sided p-value based on pearson’s chi-square test tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 6 | 12 table 3. estimated population prevalence (se) of gold stage 1 or higher copd* by age and sex for albania age-group sex 40-49 50-59 60-69 70+ total male 3.8 (0.5) 10.0 (2.3) 28.4 (6.7) 52.5 (7.5) 17.4 (2.5) female 2.3 (0.5) 4.1 (1.9) 17.0 (6.1) 14.7 (5.2) 7.7 (2.3) total 3.0 (0.4) 7.0 (1.5) 22.4 (4.7) 32.3 (4.9) 12.4 (1.7) * post-bd fev1/fvc <70%. table 4. estimated population prevalence (se) of copd in tirana, albania, using lower limit of normal (lln): modified stage 1 or higher copd* by age and sex (local equations) age-group sex 40-49 50-59 60-69 70+ total male 4.2 (0.9) 5.3 (2.3) 21.2 (2.2) 41.2 (11.0) 13.2 (2.6) female 3.8 (1.4) 4.1 (1.9) 12.3 (5.5) 10.7 (2.4) 6.6 (1.4) total 4.0 (0.8) 4.7 (1.5) 16.5 (3.2) 24.9 (5.4) 9.9 (1.4) * post-bd fev1/fvc < lln table 5. estimated population prevalence (se) of gold stage 1 or higher copd* by pack years and sex in tirana, albania pack-years sex never smokers 0-10 10-20 20+ total male 6.2 (2.2) 10.2 (4.8) 7.6 (2.3) 27.6 (4.6) 17.4 (2.5) female 6.1 (2.9) 19.8 (18.9) 24.2 (11.5) 9.0 (8.4) 7.7 (2.3) total 6.1 (2.1) 14.8 (9.5) 14.3 (5.5) 27.0 (4.5) 12.4 (1.7) * post-bd fev1/fvc < 70% and post-bd fev1 < 80% predicted table 6. prevalence of current smoking by age and sex in tirana, albania age-group sex 40-49 50-59 60-69 70+ total responders with usable data* male 40.5% 44.6% 29.3% 21.0% 35.8% female 7.8% 8.4% 5.3% 3.0% 7.3% total 22.5% 23.6% 19.9% 15.8% 21.6% population† male 44.5% (5.2) 46.7% (1.7) 29.4% (5.6) 21.1% (7.8) 38.7% (3.2) female 6.5% (3.2) 8.3% (1.8) 4.8% (4.2) 5.2% (4.5) 6.5% (0.9) total 25.3% (3.2) 27.9% (1.0) 17.1% (4.4) 12.4% (4.0) 22.4% (1.8) * non-weighted data for the sample of responders. † weighted population estimate, with se shown in parenthesis. tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 7 | 12 table 7. estimated population prevalence (se) of doctor-diagnosed copd* by age and sex in tirana, albania agegroup sex 40-49 50-59 60-69 70+ total male 0 1.7 (1.4) 3.8 (1.8) 4.4 (2.6) 1.9 (0.8) female 0 2.3 (0.7) 0 0 0.6 (0.1) total 0 2.0 (0.8) 1.9 (0.9) 2.0 (1.2) 1.3 (0.4) * includes chronic bronchitis, emphysema or copd discussion this is the first copd prevalence study ever conducted in albania. response rate for albania was high, both for males and females, 82.3%. response rates among females were slightly higher, 84% as compared to 83% for males, although not statistically significant. we did not observe any difference among the responders according to age groups, doctor diagnosed asthma, emphysema, chronic bronchitis (cb) or copd, but we found statistically significant difference in relation to smoking status and other co-morbid conditions. the percentage of responders and nonresponders among current smokers was similar, showing that completing questionnaires and performing spirometry was not easy for a current smoker. the percentage of never smokers for non-responders and responders was respectively 73% and 63%, (p<0.001), showing that never smokers are less concerned about respiratory health status. among participants with co-morbid conditions, the percentage of non-responders and responders was respectively 64% and 74%, (p<0.007), showing that presence of co-morbid conditions is likely to increase awareness about respiratory health status. our study showed that the overall copd prevalence (gold stage 1 or higher) in albania was 12.4%, and was higher in males (17.4%) than females (7.7%) and in those aged > 70 years old. using lower limit of normal (lln) the prevalence of copd was 9.9%, again higher in males (13.2%) than females (6.6%) and like when using gold criteria, was higher in those aged > 70 years old. thus, the prevalence of copd using lln was lower than the prevalence estimated using gold criteria. the global initiative for chronic obstructive lung disease (gold) uses a fixed ratio of fev1/fvc of 0.7 for the diagnosis of obstruction by spirometry, regardless of age, sex or height (13). this may result in falsepositive diagnose of copd in elderly subjects, as the ratio has a small but significant age related regression (14). the ats/ers task force has recommended the use of lower limit of normal (lln) rather than a fixed ratio to avoid overdiagnosis of copd (15). in our study we used lln for that purpose. a literature review of the epidemiology of chronic obstructive pulmonary disease showed that the prevalence estimates varied widely, depending on the methods used for diagnosis and classification of copd (1618). the reported prevalence of copd ranged from 0.2% in japan to 37% in usa (19). another systematic review for europe countries showed that prevalence estimates varied from 2.1% to 26.1%, depending on country, age group and methods used (20). comparing our data to the international bold studies we conclude that copd prevalence in albania is lower than that reported from many other countries like: austria tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 8 | 12 26.1% (21); iceland 18% (22); germany 13.2% (23), and higher than that of other countries like: china 8.2% (24) and australia 7.9% (25). these geographical differences, despite the use of the bold protocol, could be attributed to different levels of smoking in the local population, or possibly other risk factors, such as genetic predisposition, occupation, biomass and air pollution. our study showed a significant correlation between age and smoking history expressed as pack years (r = 0.500; p < 0.001). the association of copd with old age may be attributed to a greater exposure to risk factors (26,27). the prevalence of copd in women in our study was lower than in men like in most of the countries worldwide due to the fact that women traditionally smoke much less than men (28). this situation has changed in some developed countries, where the prevalence of smoking in women is now often as high as that in men (29). the prevalence of copd in never smokers was surprisingly similar for both men and women, which differs from that of most of the studies. the high prevalence of copd among women in most of the developing countries is attributed to biomass and cooking conditions (30-32). in albania it does not appear to be a major contributory factor. the prevalence of smoking in our study was 21.6%. it was higher in males than females, 35.8% and 7.3% respectively. the highest prevalence was in age groups 50-59 and 4049 years; there was a trend for smoking cessation with increasing age. we think that this fact is related to the co-morbidities that associate the age group above 60 years old. an important fact is noted in relation to female smoking status. in females over 40 years smoking was not as prevalent as in males in population. this is related to the fact that our society is a conservative one. but this trend has changed for younger generations: in females under 40 years old an increase in smoking prevalence was observed. our study showed that the prevalence of smoking was 17% in group age 20-39, as compared to 7.3% in other group ages above 40 years old. this high percentage was found mainly in the urban areas, whereas in rural areas smoking prevalence in this group age did not differ compared to other group ages. the prevalence of copd in the smoker group (both former and current smoker) was found to be much higher than that in the non smoker group. similar findings were reported in most studies and cigarette smoking is the most common risk factor for copd worldwide (26,33). consistent with the present understanding of the role of smoking, we found a strong doseresponse relationship with pack-years of smoking (27,34). as found in other studies there was also a positive trend with the increasing of packyears, confirming smoking as an important risk factor for disease development (35,36). our data showed a low prevalence of doctor diagnosed copd reported by participants, only 1.3% and this finding was similar to most of the countries where under-diagnosis of copd is common (37). but there are countries where prevalence of doctor-diagnosed copd was higher like in south arabia 9.8% (38) and in salzburg, austria 5.6% (39). skipping spirometric confirmation of copd, thus leading to over-diagnosis, might be the reason behind reported data in south arabia (38). our data are consistent with those of other countries where there is still a high level of under-diagnosis. the need for spirometry tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 9 | 12 testing should be brought to the attention of primary care physicians. our study has several strengths. this is the first study conducted in balkan areas using bold protocol. moreover, we applied the bold protocol with standardized methodology and high-quality post-bd spirometry. such standardized methodology included standardized spirometry equipment, meticulous quality control measures, standard protocols, validated questionnaires and standard data recording, reporting and analysis. moreover, the use of a large sample size represents the whole country. conclusion we found that the prevalence of copd among adults in albania was high, with an estimated prevalence of 12.4% in adults ≥40 years old; 17.4% and 7.7% in men and women respectively. using lln, the prevalence of copd was lower, 9.9% (13.2% and 6.6% in men and women respectively). copd prevalence was strongly related to smoking and national smoking cessation policies are needed. doctor diagnosed copd reported by the participants was very low. these numbers clearly show a high degree of copd underdiagnosis and highlight the need to improve physicians’ knowledge about copd diagnosis and greater use of spirometry references 1. lozano r, naghavi m, foreman k, lim s, shibuya k, aboyans v, et al. global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the global burden of disease study 2010. lancet 2012;380: 2095-128. 2. mathers cd, loncar d. projections of global mortality and burden of disease from 2002 to 2030. plos med 2006;3:e442. 3. lange p, celli b, agustí a, boje jensen g, divo m, faner r, et al. lung-function trajectories leading to chronic obstructive 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barnes pj. is exposure to biomass smoke the biggest risk factor for copd globally? chest 2010;138:3-6. 34. buist as, mcburnie ma, vollmer wm, gillespie s, burney p, mannino dm, et al. international variation in the prevalence of copd (the bold study): a population-based prevalence study. lancet 2007;370:741-50. 35. vanfleteren le, franssen fm, wesseling g, wouters ef. the prevalence of chronic obstructive pulmonary disease in maastricht, the netherlands. respir med 2012;106:871-4. 36. hill k, goldstein rs, guyatt gh, blouin m, tan wc, davis ll, et al. prevalence and underdiagnosis of chronic obstructive pulmonary disease among patients at risk in primary care. cmaj 2010;182:673-8. 37. al ghobain m, alhamad eh, alorainy hs, al kassimi f, lababidi h, al-hajjaj ms. the prevalence of chronic obstructive pulmonary disease in riyadh, saudi arabia: a bold study. int j tuberc lung dis 2015;19:1252-7. 38. schirnhofer l, lamprecht b, vollmer wm, allison mj, studnicka tafa h, mema d, mezini a, nikolla j, teferici a, todri d, et al. prevalence of chronic obstructive pulmonary disease (copd) in albania (original research). seejph 2021, posted: 09 february 2021. doi: 10.11576/seejph-4164 p a g e 12 | 12 m, jensen rl, et al. copd prevalence in salzburg, austria: results from the burden of obstructive lung disease (bold) study. chest 2007;131:29-36. 39. penña vs, miravitlles m, gabriel r, jiménez-ruiz ca, villasante c, masa jf, et al. geographical variations in prevalence and underdiagnosis of copd: results of the iberpoc multicentre epidemiological study. chest 2000;118:981-9. ________________________________________________________________________________________ © 2021 tafa et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. msokwa r. improving access to health services in malawi (original research). seejph 2021, posted: 26 april 2021. doi : 10.11576/seejph-4383 p a g e 1 | 9 original research improving access to health services in malawi robert msokwa1 1 dedza district hospital, ministry of health, malawi; corresponding author: robert msokwa (bsc, mbbs college of medicine); address: dedza district hospital, ministry of health, malawi; email: m201650043380@stud.medcol.mw mailto:m201650043380@stud.medcol.mw msokwa r. improving access to health services in malawi (original research). seejph 2021, posted: 26 april 2021. doi : 10.11576/seejph-4383 p a g e 2 | 9 . abstract background: timely access to health care can substantially reduce mortality. the united nations sustainable development goal 3, target eight recommends provision of quality care to all must include usually underserved groups by 2030. universal access to healthcare remains unavailable particularly in rural areas, due to a shortage of labor, a lack of basic health-facility infrastructure, poor management practices, and insufficient financing in malawi, universal access to healthcare remains unavailable particularly in rural areas, however, no data is available from villagers themselves on improving access to health services. the aim of the study was to find ways of improving access to health services in malawi with focus on people staying in rural areas. methods: quantitative cross-sectional study. simple random sampling. face to face interview was conducted. results: the survey included 126 people, 97(77%) were women and 29 (23%) were men. 52 % participants were farmers, 7% of participants were employed, and 5% attainted tertiary education. common barriers to access health services which participants (35%) mentioned were lack of drugs and medical equipment, shortage of health personnel (25%), another 25% complained of long distance to nearest health facility. 10 % of participants fail to access health services due to poor design of hospitals and 5% failed to access health services due to rudeness of health workers. accessibility of health services in malawi can be improved by increasing number of clinics which was suggested by 28% of participants, 25% of study participants suggested training more health workers, 23% suggested of setting up of community fund to transport patients in cases of emergency, 20% of participants suggested of introducing mobile clinics and 4% suggested of designing of tricycle to be used for transport in rural areas. conclusion: access to health services in malawi can be achieved by training more health workers, introducing community funds, empowering local people to own the health facilities, increasing number of health facilities, designing tricycle which could travel in rural areas and improve drug supply and quality of medical equipment through increased funding from central government keywords: world health organization, health care workers, united nations, tuberculosis, acquired immune deficiency syndrome, human immune virus, christian health association of malawi, barriers, health services, health care access, sub-saharan africa msokwa r. improving access to health services in malawi (original research). seejph 2021, posted: 26 april 2021. doi : 10.11576/seejph-4383 p a g e 3 | 9 introduction ‘universal health coverage is defined as ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation, and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user the financial hardship’ (1). the united nation through sustainable development goal 3 recommends universal access to health services. this translates equal access to health services no matter you are rich or poor. every human being has a right to life by having access to universal health services [2]. nobody must die due to failure to access health services. death may only occur after doctors have tried all means to save life, but all available interventions have failed. according to the united nations (un) sustainable development goal 3, target eight, recommends ‘the provision of quality care to all must include underserved groups’, however studies had unveiled that most countries do not meet the world body recommendations. at least half of the world’s population does not get essential health services (3). according to a new report from the world bank and who, each year 100 million of people are being pushed into poverty extreme because they must pay for health care out of their own pockets, forcing them to survive on just $1.90 or less a day. ‘currently, 800 million people spend at least 10 percent of their household budgets on health expenses for themselves, a sick child or other family member’ (3). other continents are better in terms of access to health services as compared to africa. in africa, accessibility and coverage of essential health services are very low (4). ‘physical access to emergency hospital care provided by the public sector in africa remains poor and varies substantially within and between countries’ (5). africa accounts for almost half of the world’s deaths of children under five and has the highest maternal mortality rate, hiv /aids, tb, and malaria (7). people in sub-saharan africa have the worst health on the average in the world. it has only 3% of the world health workers [6].three countries (malawi, the philippines, and tanzania) saw deteriorations in both service coverage and financial protection (7). malawi as one of sub-saharan countries, health care provision is difficult because the population is largely rural, and 15 percent of malawians were unable to attend to their medical-health needs (8). malawi health care is also dispersed across the country. according to usaid report 2019, malawi has a high unmet need for family planning services (26%), with acute needs among young people [9]. in malawi almost one million people live with hiv, and about 34,000 new cases every year, 37 percent of malawian children suffer from chronic malnutrition and a large of malaria cases with an ‘incidence rate of 332 cases annually per every 1,000 people and approximately 4.8 million episodes of malaria per year. over a third of established positions in the health sector are vacant and there is a perpetual shortage of qualified health workers in facilities across the country’ (8). universal access to healthcare remains unavailable particularly in rural areas, due to a shortage of labor, a lack of basic health-facility infrastructure, poor management practices, and insufficient financing (7). methods the study design was a quantitative crosssectional study, and the study setting was chitipa, dedza and mangochi districts in malawi. the study was conducted between march and july 2020.the sampling strategy was simple random sampling. people who met the preferred age group were interviewed. the sample size was determined by msokwa r. improving access to health services in malawi (original research). seejph 2021, posted: 26 april 2021. doi : 10.11576/seejph-4383 p a g e 4 | 9 assessing the number table of numbers was used in coming up with sample size. from population of three hundred twenty five people in three selected areas, a sample had 126 participants for ±7% precision level and confidence level was 95% and p<0.5. about thirty-one patients were selected from chitipa, forty-eight were selected from dedza and ninety-five patients were selected from mangochi. local people aged between 18 years and above who use health services participated in the study. data was collected using a structured questionnaire with close – ended questions was formulated in english. questions which were in cooperated in the questionnaire answer objectives of the study that was mainly focused on accessing universal health services in malawi.there after each participant was interviewed using a questionnaire. three clerks were trained to collect the data. data management included questionnaires being collected from study participants were checked for mistakes. thereafter it was transported in a locked brief case to the house of the researcher. upon arrival at home, it was kept safely and locked in drawer to prevent access by other people. to ease entry in the computer, coding was done to all questions on a questionnaire. after finishing coding, the data was entered in the computer using excel database. data analysis data analysis was done using computer aided programs such as microsoft excel and epi info tables, pie charts and bar graphs were constructed using excel. ethical consideration consent was obtained from the district commissioner, institutional research team, traditional authority and village leader before conducting the study. consent was also be obtained from participants. participants names were not indicated on the questionnaire. results the study was conducted in chitipa, dedza and mangochi districts in malawi. a total of 126 participants were interviewed in rural health centers. the target population are people aged 18 years and above (table: 1). the majority of the participants (43%) were within the age group of 23-33 years, 1% of participants were in 83-93 age range. most women (77%) participated in the study. 80% of the participants were married and 12% were single. 56% of the participants had attained primary education and 2% were illiterate. 52% of participants were farmers and 3% earn their living by doing business. 27% of study participants were c.c.a.p. members and 2% were muslims. malawians have several barriers to access health services (figure 1) according to the study findings; 35% of study participants said that lack of drugs and medical equipment was a barrier to access health services while 25% of participants said that shortage of health care workers was a barrier to access health services. participants proposed several methods of improving accessing to health services in their respective areas (figure 2); 28% participants suggested that increasing number of clinics can improve access to health services which is seconded by 25% participants who suggested that by training more health care workers could improve access to health services. table 1: social demographic characteristics of the study population msokwa r. improving access to health services in malawi (original research). seejph 2021, posted: 26 april 2021. doi : 10.11576/seejph-4383 p a g e 5 | 9 characteristics variable number (n=126) percent age sex female 97 77% male 29 23% age group 18-23 34 27% 23-33 54 43% 33-43 20 16% 43-53 4 3% 53-63 5 4% 63-73 6 5% 73-83 1 1% 83-93 2 1% marital status married 101 80% single 15 12% divorced 5 4% windowed 5 4% education level primary 71 56% secondary 47 37% tertiary 6 5% illiterate 2 2% occupation employed 2 7% business 1 3% farmer 16 52% others 12 39% religion c.c.a.p. 34 27% catholic 26 21% pentecostal 14 11% muslim 3 2% others 49 39% figure 1: common barriers to seek universal health services msokwa r. improving access to health services in malawi (original research). seejph 2021, posted: 26 april 2021. doi : 10.11576/seejph-4383 p a g e 6 | 9 figure 2: methods of improving health services to people discussion the universal declaration of human rights of the united nations states in article 3 that everyone has the right to life, liberty, and security of person (12). every human being at some point in his/her journey become sick., to restore normal human health some health 25% 35% 5% 25% 10% 0% 5% 10% 15% 20% 25% 30% 35% 40% barriers to seek health services 4% 25% 23% 20% 28% methods of improving health services tricycle train more health workers community fund mobile clinics introduction increasing numberr of clinics msokwa r. improving access to health services in malawi (original research). seejph 2021, posted: 26 april 2021. doi : 10.11576/seejph-4383 p a g e 7 | 9 conditions requires to seek health services failing to do so result into loss of life. therefore, access to health services is a human right. contrary to united nations recommendation, the study carried out in some parts of malawi had revealed that people do not have access to right to health services. the study (figure 1) has found several factors hindering people to access health services. in the study, 35% of participants fail to access health services due to lack of drugs and medical equipment. malawi as developing country does not have sophisticated equipment to diagnose some diseases. currently there is only one magnetic resonance imaging (mri) for imaging brain tumors). there is no radiotherapy facility for cancer patients. as result some patients become disappointed with this and never return to the hospital for the second time when they are sick. the study findings correlate with usaid report for 2019 which stated that malawi has poor health services due to poor health financing although percentages were not mentioned [9]. however, a study conducted by institute of public opinion and governance (7) found that 29% of malawians cited the absence of necessary treatment as a reason for being unable to attend to their medical services which a bit lower than in our study. the difference may be due to the target population interviewed. the study had revealed the second barrier to access health services in malawi as lack of health workers which was at 25%. usaid global health for 2019 reported similar results. ‘over a third of established positions in the health sector are vacant and there is a perpetual shortage of qualified health workers in facilities’ across malawi (8). long distance of travel to visit the nearest is another barrier to seek health services which also at 25%. most health facilities are dispersed especially in rural. a study conducted in malawi by institute of public opinion and governance in 2016 reported similar findings. another study conducted by lancet global health across africa revealed that hospitals in the continent are dispersed and people take long time to access health services to the nearest hospital. the investigator was interested in approaches of improving universal access to health services. formulation of solutions for access to health services depends on the problems identified. different countries have different barriers for access to health services. in the study conducted in malawi by the researcher (figure 2), participants came with several solutions of improving access to health services. the majority (28%) of participants suggested that access to health services can be improved by increasing number health facilities such as clinics in locations where people stay. most participants said that health services must be brought closer to end users. the government must allocate more money to build health facilities according to the abuja declaration (10) and world bank report of 2018 [11]. the study agrees with world bank, global health report for 2018 (13) which recommends at least 15% budget allocation to the health sector. another group of participants (25%) suggested training of more health workers to work in hospitals could solve the problem. by training more health workers, will result improving quality of health services. the world bank report for 2018 also recommends improving quality health services as one way of improving access to health services. some participants (20%) reported introduction of mobile clinics can improve access to health services. mobile clinics can help to screen some diseases, provision of primary health care, and manage conditions associated with the elderly. halina et al. (14) also recommends improving primary health care as one way to improve access to health services. furthermore, universal health services can be improved by protecting all people from pandemics (12). msokwa r. improving access to health services in malawi (original research). seejph 2021, posted: 26 april 2021. doi : 10.11576/seejph-4383 p a g e 8 | 9 conclusion the study found that common barriers to access universal health services are lack of drugs and medical equipment, long distance of health facilities from residential areas of patients, and shortage of health workers. access to health services can be improved by improving drugs supplies, building more hospitals, empowering communities to own health facilities and training more health workers. references 1. who, "universal health coverage," 4 may 2020. (online). available: https://www.who.int/healthsystems/universal_health_coverage/en/. (accessed 31 july 2020). 2. un, "the universal declaration of human rights," united nations, new york, 1948. 3. w. &. w. bank, "tracking universal health coverage," world health organization, geneva, 2015. 4. m. yoshizu, "half the world lacks access to essential health services, 100 million still pushed into extreme poverty because of health expenses," who news letter, tokyo, 2017. 5. s. yaya, "universal health coverage and facilitation of equitable access to care in africa," front global health, vol. 7, no. 02, p. 3, 2019. 6. l. g. health, "access to emergency hospital care provided by the public sector in sub-saharan africa in 2015: a geocoded inventory and spatial analysis," lancet global health, vol. 6, no. 3, p. 4, 2018. 7. w. b. -ifc, "health and education," 16 june 2020. (online). available: https://www.ifc.org/wps/wcm/connect/region__ext_content/ifc_external_corporate_site/sub-saharan+africa/priorities/health+and+education/. (accessed 31 july 2020). 8. i. o. p. o. a. governance, "the local governance permonce index(lgpi) in malawi: selected findings on health," univesity of gothenburg, 2017. 9. usaid, "improving the health status of malawians in targeted districts," 19 november 2019. (online). available: https://www.usaid.gov/malawi/global-health. (accessed 25 july 2020). 10. a. &who, "abuja declaration: ten years on," 2011. (online). available: https://www.who.int/healthsystems/publications/abuja_declaration/en/e abuja declaration: ten years on. (accessed 29 july 2020). 11. w. bank, "lack of health a waste human capital.:5 ways to achieve universal access to health services by 2030," world bank, new york, 2018. 12. a. f. d. s. n. rozita halina tun hussein, "opinion: 5 ways to make progress towards universal health coverage," devex, 12 december 2017. (online). available: https://www.devex.com/news/opinion-5-ways-to-make-progress-towards-universal-health-coverage91726. (accessed 25 july 2020). 13. s. n. adam wagstaff &, "a comprehensive assessment of universal health coverage in 111 countries: a retrospective observational study," lancet global health, vol. 8, no. 1, p. 13, 2019. 14. p. k. trani jean-francois, "assessment of progress towards universal msokwa r. improving access to health services in malawi (original research). seejph 2021, posted: 26 april 2021. doi : 10.11576/seejph-4383 p a g e 9 | 9 © 2021 msokwa et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. health coverage for people with disabilities in afghanistan: a multilevel analysis of repeated cross-sectional surveys," lancet global health, vol. 14, no. 6, 2017. ____________________________________________________________________________ kalaitzi v. the mark of women’s leadership on solutions to global health problems (editorial). seejph 2016, posted: 07october2016. doi: 10.4119/unibi/seejph-2016-131 1 editorial the mark of women’s leadership on solutions to global health problems valia kalaitzi 1 1 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life science, maastricht university, maastricht, the netherlands. corresponding author: valia kalaitzi, msc, phdc; address: 25 vas sofias, 10674 athens greece; telephone: +30 6932285055; e-mail: valiakalaitzi@maastrichtuniversity.nl kalaitzi v. the mark of women’s leadership on solutions to global health problems (editorial). seejph 2016, posted: 07october2016. doi: 10.4119/unibi/seejph-2016-131 2 “man is the measure of all things”, stated protagoras in 485 bc (1). maybe it’s time to add women to that equation and adapt protagoras’ saying into:“women who are leaders are the measure of global health challenges”. what protagoras meant, of course, was that man is the point of reference, the centre of universe; he adjusts his world to fit his needs. in other words, man has the ability to shape his living conditions, the environment and solutions to the challenges in life. in that sense, the challenges are managed according to the terms and conditions of man. indeed, global health challenges of the 21 st century are widespread. they are many, and they are of great magnitude. world health leaders are challenged by crises such as polio, zika virus, and h1ni, to mention a few. many health systems around the world have been challenged to respond effectively to these crises, spotlighting major gaps in worldwide surveillance, disease control, resources, and infrastructure required to protect and support the public’s health. the economic crisis that affected europe has been linked to several infectious disease outbreaks including tb and hiv, compounded by recent waves of migration, although the links between these events remain unclear (2). debates ensue about the value and feasibility of universal health coverage, the increasing role of the private sector in the global health landscape and the subsequent changing roles of global health actors that shape the new health economy. these are complex times, and they require skilful players if we hope to translate public and private sector investments in health into both economic growth and equitable improvements in health. such goals require inspired, inclusive, and effective leadership. these very traits are the hallmark of women’s leadership. women have been observed to possess certain traits and characteristics that may accelerate effective and sustainable solutions to challenging global health problems. it is widely accepted that women who are leaders act as a normative agent of change and developmental processes (3-8). they practice people-centred, inclusive leadership and balance strategic priorities with collective dynamics. in this regard, they may exhibit greater mastery as compared to men in relation to key competencies required to make progress. one may argue that we experience a collision of worlds in respect of the old and the new tradition of gender-based roles in global health governance, and the implications for our freshly made, globalized world. however, the balance of global gender roles in our contemporary world is the outcome of politics and power. that balance can be changed to benefit global health. if the collective political community “aims at some good and the community which has the most authority of all and includes all the others aims highest”(9), then, our current, turbulent suffering societies expect global leaders to practice the quality of leadership as described by plato (10). that form of leadership combines the following components:  wisdom, as the knowledge of the whole including both knowledge of the self and political prudence;  civic courage, in the sense of preserving rights and standing in defence of such values as friendship and freedom on which a good society is founded, and;  moderation, a sense of the limits that bring peace and happiness to all. global health leadership falls behind in providing the opportunities and motivation to female leaders to unfold their talents and give their touch to new health challenges. the huge reservoir of talented women remains mostly untapped. the transformative attributes of female leaders to create opportunities out of a web of complexity, to promote systematic preparedness and to create a starting point for change out of chaos have been underestimated and sacrificed to stereotypes and social constraints. kalaitzi v. the mark of women’s leadership on solutions to global health problems (editorial). seejph 2016, posted: 07october2016. doi: 10.4119/unibi/seejph-2016-131 3 of course, numerous notable initiatives have been introduced; important foundations have been established and contribute considerably towards this end. nonetheless, the relative lack of women who are leaders in top decision-making positions in global health should be looked upon like a well-diagnosed, but mistreated disease. what kind of politicians and leaders do we need to provide the proper room for experiencing the mark of women on global health challenges? maybe politicians and decision-makers should be wise enough to adapt the saying of protagoras (1). from now on, let’s call loudly for women who are leaders to be “the measure of global health challenges”! conflicts of interest: none. references 1. sholarin ma, wogu iap, omole f, agoha be."man is the measure of all things": a critical analysis of the sophist conception of man. res human socsci2015;5:178-84. 2. kentikelenis a, karanikolos m, williams g, mladovsky p, king l, pharris a, et al. how do economic crises affect migrants’ risk of infectious disease? a systematicnarrative review.eur j public health 2015;25:937-44. doi:10.1093/eurpub/ckv151. 3. eaglyah, chin jl. diversity and leadership in a changing world. am psychol2010;65:216-24. doi: 10.1037/a0018957. 4. northouse pg.leadership: theory and practice (5 th ed.). sage publications; 2010. 5. silverstein m, sayre k. the female economy. harvard business review2009;87:4653. https://hbr.org/2009/09/the-female-economy (accessed: october 5, 2016). 6. mckinsey global institute. the power of parity: how advancing women’s equality can add $12 trillion to global growth;2015. http://www.mckinsey.com/globalthemes/employment-and-growth/how-advancing-womens-equality-can-add-12trillion-to-global-growth (accessed: october 5, 2016). 7. world economic forum. the global gender gap report; 2014. http://reports.weforum.org/global-gender-gap-report-2014/(accessed: october 5, 2016). 8. world health organization. health in 2015 from sdgs to mdgs; 2015. http://apps.who.int/iris/bitstream/10665/200009/1/9789241565110_eng.pdf(accessed: october 5, 2016). 9. aristotle. political theory. stanford encyclopedia of philosophy (online). http://plato.stanford.edu/entries/aristotle-politics/#polview (accessed: october 5, 2016). 10. plato. political philosophy. internet encyclopedia of philosophy (online). http://www.iep.utm.edu/platopol/ (accessed: october 5, 2016). __________________________________________________________ © 2016 kalaitzi; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.ncbi.nlm.nih.gov/pubmed/?term=kentikelenis%20a%5bauthor%5d&cauthor=true&cauthor_uid=26318852 https://www.ncbi.nlm.nih.gov/pubmed/?term=karanikolos%20m%5bauthor%5d&cauthor=true&cauthor_uid=26318852 https://www.ncbi.nlm.nih.gov/pubmed/?term=williams%20g%5bauthor%5d&cauthor=true&cauthor_uid=26318852 https://www.ncbi.nlm.nih.gov/pubmed/?term=mladovsky%20p%5bauthor%5d&cauthor=true&cauthor_uid=26318852 https://www.ncbi.nlm.nih.gov/pubmed/?term=king%20l%5bauthor%5d&cauthor=true&cauthor_uid=26318852 https://www.ncbi.nlm.nih.gov/pubmed/?term=pharris%20a%5bauthor%5d&cauthor=true&cauthor_uid=26318852 https://www.ncbi.nlm.nih.gov/pubmed/?term=how+do+economic+crises+affect+migrants%e2%80%99+risk+of+infectious+disease%3f+a+systematic-narrative+review adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 1 | p a g e c original research pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3-year post implementation evaluation david ayobami adewole1, temitope ilori2, wuraola ladepo1, olusola augustus akande3, ganiyu owolabi3 1 department of health policy and management, college of medicine, university of ibadan, nigeria; 2 family medicine unit, department of community medicine, college of medicine, university of ibadan, nigeria; 3 oyo state health insurance agency, ministry of health, secretariat, ibadan, nigeria. corresponding author: david ayobami adewole; address: department of health policy and management, college of medicine, university of ibadan, nigeria; telephone: +234 8034052838; email: ayodadewole@yahoo.com mailto:ayodadewole@yahoo.com adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 2 | p a g e abstract aims: social health insurance scheme is capable of minimizing inequity of access to health services, and thereby enhance an improvement in population health outcomes. recently the national health insurance scheme (nhis) of nigeria decentralized its management to the subnational levels, thus the emergence of state health insurance schemes (shis). the shis of oyo state nigeria started operations about three years ago (june 2017). there is limited/sparse evidence on the performance of the scheme since its inception. therefore, the aim of this study was to assess the scheme’s level of population coverage in the first three years of implementation. the findings will also provide an evidence base to inform the repositioning of the scheme for improved performance and enable it achieve the purpose of its establishment. methods: service data from the server of oyo shis were downloaded, collated and analyzed with excel software. data extraction, cleaning and analysis covered a period of three months (september – october, 2020). descriptive statistics were used to summarise the data. population coverage distributions were expressed as frequency and percentages. frequency tables and graphs were generated to disaggregate the findings. results: since inception, the population coverage of the scheme has remained low at less than 1% of the total population of the state over the past three years. this trend is depicted across the various sociodemographic sections of the population. conclusion: stakeholders in the oyo state shis need to re-strategize to reposition the scheme for an accelerated population coverage as a proxy for performance assessment. keywords: beneficiaries, coverage, national health insurance scheme, oyo state, population coverage, state supported social health insurance programme. acknowledgements: authors wish to acknowledge oyo state health insurance agency for the permission to make use of the data and to submit the manuscript for publication. we authors would like to sincerely acknowledge the contributions of prof. charles wiysonge and that of dr. chukwudi nnaji for the comprehensive review and suggestions made on this manuscript. many thanks. authors' contributions: david adewole conceived and designed the study. wuraola ladepo and temitope ilori did data collection and analysis. adewole, owolabi and akande contributed equally to the manuscript write up. all authors read through the manuscript draft the second time. all authors agreed to the final manuscript. conflict of interests: none declared. adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 3 | p a g e introduction different countries the world over had attained universal health coverage (uhc) within different time duration (1). while it has taken countries like germany and some other western european countries about a century to achieve uhc, some other countries in recent times especially in the asian blocks have done tremendously achieving same within a period of a few decades (1,2). encouraging reports about the speed of achieving uhc were also documented in many latin american countries especially brazil, costa rica, cuba, and argentina among others (3). similar achievements have been reported in some african countries like rwanda (4-6) and ghana (4,7). for reasons of equity of access to available health care services and to accelerate the achievement of uhc, some countries in africa, asia and latin america have made significant strides towards achieving uhc. these countries have engaged all levels of health care delivery especially the primary health care level facilities as service providers in their health system reforms especially the social health insurance schemes (3). challenges with social health insurance schemes in many of the ssa countries include poverty, low level of awareness, superstitious belief, poor technical skills of the personnel in the industry (8), and inability to differentiate it from other pre-existing microfinance schemes among others (9). uptake of health insurance have been found to be more likely among those who are more likely to need health care services more such as married individuals, the elderly and those with chronic illnesses (10). the poor population health indices common in developing countries is majorly as a result of inequity of access to available health care (11-13). however, when it is efficiently managed, social health insurance scheme is capable of minimizing inequity of access to health services, and thereby enhance an improvement in population health outcomes (3,4,8,14). following almost two decades of efforts to achieve universal health coverage (uhc) through the national health insurance scheme (nhis) of nigeria (15), and not satisfied with the achievement made by the nhis in terms of population coverage so far, the national council on health (nch) and other stakeholders in the health system of nigeria approved the establishment of the state supported social health insurance programme (sship) in the year 2015. this is a form of decentralization of the nhis to the sub-national governments, that is, the states. it was the belief that this reform will bring about the necessary sense of ownership and commitment to the prepayment system for health among stakeholders in these states and thus enhance a steady progress of the scheme to achieving uhc (16). stakeholders were optimistic that decentralization of prepayment scheme will provide the necessary impetus for the state stakeholders to design a sustainable prepayment scheme. with this, the sub-national levels of government, that is, the 36 states (including the federal capital territory, fct) were empowered to design, implement and manage a form of social health insurance scheme for people in the respective states of the country. statutorily, the nhis provides technical and some level of financial support to the states operating their own sship. findings from a commissioned report on the scheme shows that oyo (state) sship commenced operations in the year 2017, following the recommendation of a planning and design committee whose membership consisted of stakeholders from the state ministry of health, the nhis, private and public health care providers (including pharmacists and laboratory scientists), academics, and the health maintenance organizations. the report further shows that just before the commencement of its operations, a public hearing on it held whereby members of the public and committee on health of the house adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 4 | p a g e of representatives of oyo state held a town hall meeting with the purpose of having contributions from all stakeholders. the meeting aimed to social market and enhance the acceptance of the scheme among potential beneficiaries (17). the sship aimed to achieve uhc through a state-wide implementation strategy partnering with both the public and private health care facilities in all the lgas of the state. the bill that established oyshia was signed into law 2016, however, implementation of the scheme commenced in 2017 (18). generally, with a lower level of awareness (19) and poor financial capacity to pay premiums (8), social health insurance schemes have been reported to favour the rich majorly (20), while the informal sector population tends to be poorly represented (21). there was no comprehensive assessment of the performance of the scheme since inception. the only information about the scheme was a one year post-implementation report. the report only assessed the level of awareness of the populace about the scheme and as well as available service providers (17). prior this study, there was no report on the performance and coverage of the scheme among socio-demographic and geographical divides. this study was conducted as a means of assessing the level of and implementation mechanisms of the scheme. findings will assist in identifying gaps and areas of success. this information will assist in taking appropriate steps where and when necessary to ensure the scheme is kept on track to achieving its objectives. it will also be useful to similar settings making efforts to achieve universal health coverage for their populations. methods study design/area this is a descriptive cross-sectional study. it was carried out in oyo state, one of the 6 states in the southwest geo-political zone of nigeria. the capital of the state is ibadan, a city of about 150km northeast of lagos, the former capital of nigeria. currently, the estimated population of the state is 7.6 million people, with male to female ratio almost of equal proportion. the state has 33 local government areas (lgas), with varying population sizes. typical of developing country, the state has a much larger informal population compared with those in the formal or organized private sector. more of the people lives in the rural areas (22). data collection and analysis with the permission of oyshia, data on monthly enrolment in the state’s health insurance scheme were downloaded from the scheme’s website. the agency’s data bank on enrolees is built as information on new enrolees is collected at registration. this is a continuous process across all designated registration points in the state. data collected are uploaded into the agency’s website as and when due. collected data were analysed to suite the purpose of the study. downloading of data from the website and subsequent analyses were accomplished over a period of three months (may-july, 2020). data were used to plot a graph-displaying pattern of enrolment in the scheme by month over a period 36 months (july 2017 – june 2020) (fig. 1). other relevant charts were produced from the data. a map of oyo state showing all the lgas and the proportion of enrolees in the scheme by lga was also produced. the data were publicly available online. there was no need for ethical approval for this study because secondary data of all enrolees in the health insurance scheme of the state were used. there were no exclusion criteria. results figure 1 below shows the pattern of enrolment in the health insurance scheme over a period of three years since inception (june 2017 – july 2020) with a common pattern of periods of increased enrolment followed by decline in enrolment in the scheme. this pattern is uniform for the three-year period. adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 5 | p a g e figure 1. secular trend of enrolment in oyshi scheme in first 3 years of operation figure 2 (and appendix 1) shows the spatial distribution of the lgas in the state and the proportion of uptake of health insurance against the total population is as displayed in the map. the highest proportion of those who enrolled in the scheme in any of the lgas was found in two lgas (ibadan northwest and lagelu) and were not higher than 2% of the total population in each of these two lgas. in total, less than 1% of the current total population of oyo state was covered, only two lgas, ibarapa north 8 (0.04%) and olorunsogo 71 (0.14%) recorded an increase in the total number of enrolees over the three-year period, while 29,726 (35.0%) of the total population ever registered in the state had dropped out of the scheme. figure 2. geographical pattern of enrolment in oyshi scheme by lga adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 6 | p a g e figure 3 below shows the pattern of enrolment by age group. enrolees in the age group between 20 and 59 years had the highest proportion of those currently registered 55,119 (100%). of this age group, those in the 40-59 years were more, 40,010 (72.6%) compared with those between 20 and 39 years 12,774 (23.2%). individuals who were 80 years and above 25(0.05%) were the least group represented. figure 3. pattern of enrolment in oysh scheme by age group figure 4 below shows that almost twothirds 33,644 (61.0%) of the total currently enrolled individuals were females compared to males 21,475 (38.9%). figure 4. pattern of enrolment in oysh scheme by sex adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 7 | p a g e almost all enrolees reported been married individuals, 51,098 (92.7%) compared with singles who were much less in number 3,960 (7.2%) (appendix ii). in the three-year period of the scheme, 84,845 individuals have ever registered. however, as at the end of the first three years (june 2020), the number of enrolees on the scheme was 55,119. thus, individuals who have dropped out of the scheme was 29,726 (35.0%) (appendix iii). of the total enrolees, individuals from the civil service of oyo state had the highest number 51,585 (93.5%). the least was among the organized private sector, 809 (1.5%) (appendix iv). discussion the state social health insurance scheme having enrolment service points in all the lgas in the state is an encouraging development. however, the population coverage in the last three years has remained extremely low at less than one percent of the total population. the scenario is worsened by a drop out at over one-third of the original enrolment figure. an encouraging development in the scheme is having enrolment centres in all the lgas which have provided equal opportunity for the citizens in the state to enjoy the benefit associated with membership of the scheme. this pattern of start-up is also capable of an accelerated population coverage with the foci of enrolment eventually coalescing with time. it would also avoid the political insinuation that some lgas were better favoured than others which could arise if some lgas were selected as pilot sites. it has also avoided unnecessary schism in existing cooperation needed for growth and development in the state. however, it should be noted that generally, the rate of enrolment in the scheme across the lgas and the state as a whole was quite slow. studies have shown different periods of achieving universal health coverage (uhc) in different countries (1,2). in western european countries such as germany and other developed economies where prepayment schemes for health are well established, it has been reported that attainment of uhc took an average of a century in countries like belgium and germany, (1). however, some other countries especially in latin america such as costa rica and brazil (3) and as well as japan and republic of korea in asia (1) were able to achieve uhc in less than half of a century. it has been reported that the average period to attain between 60-80% population coverage is 9 years post implementation of a social health insurance scheme (2). in this study, and using available data, the rate of population coverage is estimated at 18,373 per year. assuming a static population, it would take more than four centuries to cover the present population of oyo state [7,690,472]. nevertheless, the population will not remain static. this analysis should be a startling reality and for the stakeholders in the state’s health insurance industry as well as actors in relevant other sectors, to re-strategize for the achievement of uhc in reasonably good period. awareness creation, education about the mechanisms of operation of a social health insurance scheme has been found to improve uptake in some other settings (19). other efforts to overcome the common challenges in the uptake of a social health insurance scheme in developing countries of the saa has been suggested (23). however, it is certain that the solution should be a multi-pronged approach. this study shows that the working age population group had the highest representation in the scheme. this may not be farfetched as the scheme is mandatory for civil servants. again, the lower proportion of other age groups who were obviously not likely to be employees of the government would be more of the difficulty to enrol those who are in the informal sector as there was no register for those outside of the formal government employment for reason of retirement or for any other reason. capturing population group in the informal adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 8 | p a g e sector for mandatory health insurance is one of the common challenges faced by prepayment schemes in developing countries (8). it should also be noted that the lower proportion of those in the twenties and late thirties may have to do with the current present prevailing age structure in the civil service of oyo state. however, further studies are necessary to clarify this observation. the same explanation goes for the higher proportion of females than males in the study. individuals who are more likely to need health care services such as married, the elderly, women and those who are chronically ill have been identified to have better disposition to register in a health insurance scheme (10). this may suffice to explain the higher proportion of married people and women in this study. however, the lower proportion of elderly people as against the observed norm could be due to other reasons such as inability to pay premium, lack of an efficient platform to pay premium, poor understanding of the mechanisms of operation of the scheme or lack of awareness of the existence of the scheme. this study could not establish any of the suggested reasons. it would require further research efforts, particularly qualitative studies to clarify. this study also observed that more than one-third of the total number of enrolees have dropped out of the scheme. this should be a cause for concern. factors of disincentive in a health insurance scheme have been linked to what could breach the trust of people such as poor attitude of health care personnel in the facilities, lack of drugs, equipment and personnel and other factors that could cause dissatisfaction in health care (24). none of these factors could be proven in this study because secondary data were used. it is desirable to know for certainty what could have been the reasons for this observation. studies to unravel the cause(s) will go a long way in the efforts to achieving uhc for the scheme. this study attempts to assess the performance of a state health insurance scheme using the extent of population coverage as a proxy. it has chosen to make use of the enrolment pattern across the sectors of the civil service, organized private sector and the informal population group. based on available data on these three sectors, it could, with caution, conclude that the performance of the scheme is generally very low for the following reasons. first, the scheme is compulsory for civil servants, thus the high proportion of this group could not be said to be because of civil servants’ satisfaction with the scheme but rather is more like a compulsion. secondly, informal sector population is known to be the larger sector than any other sector in developing countries (8). therefore, a smaller proportion of the informal sector in the enrolment status under this scheme is a point to the fact of the scheme’s low performance than otherwise. stakeholders in the health insurance industry in oyo state definitely have a big task to make the scheme achieve a uhc in the state. concerted efforts and re-strategizing are needed. limitation/recommendation this study made use of secondary data. therefore, individuals could not be interviewed to enable an in-depth knowledge of the factors that may have contributed to or caused the study findings. this is a call for further studies that will need primary data and involve individual as study participants to enable a more robust assessment of the scheme. in conclusion, this study has shown that the population coverage of the present social health insurance scheme in oyo state is poor and as it is presently, it is not likely to reduce inequity of access to health care. strategies for achieving sustainable uhc in oyo state and in similar other settings in the african region must target specific population groups such as the elderly and those in the informal sector. associated adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 9 | p a g e challenges that serve as barriers with enrolment in prepayment schemes and access to available health services under it should be appropriately and specifically addressed. references 1. carrin g, james c. social health insurance: key factors affecting the transition towards universal coverage. int soc secur rev 2005;58:45-64. 2. carrin g, james c, adelhardt m, doetinchem o, eriki p, hassan m, et al. health financing reform in kenya assessing the social health insurance proposal. s afr med j 2007;97:130-5. 3. atun r, de andrade lo, almeida g, cotlear d, dmytraczenko t, frenz p, et al. health-system reform and universal health coverage in latin america. lancet 2015;385:1230-47. 4. lagomarsino g, garabrant a, adyas a, muga r, otoo n. moving towards universal health coverage: health insurance reforms in nine developing countries in africa and asia. lancet 2012;380:933-43. 5. nyandekwe m, nzayirambaho m, kakoma jb. universal health coverage in rwanda: dream or reality. pan afr med j 2014;17:232. 6. saksena p, antunes af, xu k, musango l, carrin g. mutual health insurance in rwanda: evidence on access to care and financial risk protection. health policy 2011;99:203-9. 7. odeyemi i, nixon j. assessing equity in health care through the national health insurance schemes of nigeria and ghana: a reviewbased comparative analysis. int j equity health 2013;12:1-18. 8. chuma j, mulupi s, mcintyre d. providing financial protection and funding health service benefits for the informal sector: evidence from sub-saharan africa. resyst working paper 2. available from: https://resyst.lshtm.ac.uk/resources/ resyst-working-paper-2-providingfinancial-protection-and-fundinghealth-service-benefits (accessed: september 4, 2020). 9. adewole da, akanbi sa, osungbade ko, bello s. expanding health insurance scheme in the informal sector in nigeria: awareness as a potential demand-side tool. pan afr med j 2017;27. 10. kirigia jm, sambo lg, nganda b, mwabu gm, chatora r, mwase t. determinants of health insurance ownership among south african women. bmc health serv res 2005;5:17. 11. murray cj, lopez ad. mortality by cause for eight regions of the world: global burden of disease study. lancet 1997;349:1269-76. 12. murray cj, lopez ad. measuring the global burden of disease. n engl j med 2013;369:448-57. 13. world bank. health indicators: the world bank; 2020. available from: http://data.worldbank.org/indicator. 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2015. 17. minstry of health oyo state. strategic review report on oyo state health insurance scheme in: (oyshia) oshia, editor. ibadan; 2018. 18. oyo state. the pacesetter state; 2017. available from: https://oyostate.gov.ng/about-oyostate/ (accessed: june 22, 2017). 19. nyagero j, gakure r, keraka m. health insurance education strategies for increasing the insured among older population–a quasi experimental study in rural kenya. pan afr med j 2012;12. 20. kimani jk, ettarh r, kyobutungi c, mberu b, muindi k. determinants for participation in a public health insurance program among residents of urban slums in nairobi, kenya: results from a cross-sectional survey. bmc health serv res 2012;12:1-11. 21. carapinha jl, ross-degnan d, desta at, wagner ak. health insurance systems in five subsaharan african countries: medicine benefits and data for decision making. health policy 2011;99:193-202. 22. national population commission nigeria. national demographic and health survey 2013. abuja, nigeria; 2013. available from: https://dhsprogram.com/publication s/publication-fr293-dhs-finalreports.cfm (accessed: july 21, 2017). 23. adewole da. understanding the concept of health insurance: an innovative social marketing tool. j public health afr 2018;9:739. 24. carrin g. social health insurance in developing countries: a continuing challenge. int soc secur rev 2002;55:57-69. __________________________________________________________________________________________ https://oyostate.gov.ng/about-oyo-state/ https://oyostate.gov.ng/about-oyo-state/ https://dhsprogram.com/publications/publication-fr293-dhs-final-reports.cfm https://dhsprogram.com/publications/publication-fr293-dhs-final-reports.cfm https://dhsprogram.com/publications/publication-fr293-dhs-final-reports.cfm adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 11 | p a g e appendix 1. pattern of enrolment and drop out in the scheme by lga lga number ever registered in scheme current population coverage projected pop @ 2.7% annual increase % current pop. covered % dropped out of ever registered afijio 856 847 182,150 0.465001 9 (0.011) akinyele 5,855 2,529 291,876 0.866464 3326 (0.56) atiba 1,963 968 231,843 0.417524 995 (0.50) atisbo 737 727 151,532 0.479767 10 (0.014) egbeda 4,470 3,064 390,860 0.783912 1406 (0.31) ibadan north east 3,083 1,105 456,730 0.241937 1978 (0.64) ibadan north 7,839 6,088 424,588 1.433861 1751 (0.22) ibadan north west 10,878 4,663 212,252 2.196917 6215 (0.57) ibadan south east 2,505 369 367,178 0.100496 2136 (0.85) ibadan south west 8,282 5,354 390,109 1.372437 2928 (0.35) ibarapa central 1,889 1,820 142,269 1.279267 69 (0.04) ibarapa east 566 549 161,477 0.339986 17(0.03) ibarapa north 184 192 138,204 0.138925 8(0.04) ido 3,674 1,805 143,432 1.258436 1869 (0.50) irepo 542 467 167,069 0.279525 75 (0.14) iseyin 1,753 1,615 352,243 0.45849 138 (0.08) itesiwaju 478 470 175,545 0.267738 8 (0.02) iwajowa 692 691 141,723 0.487571 1 (0.001) kajola 1,166 1,152 276,328 0.416896 14 (0.01) lagelu 7,313 4,576 204,127 2.241742 2737 (0.37) ogbomoso north 2,876 2,580 274,028 0.94151 296 (0.10) ogbomoso south 3,032 2,571 138,322 1.858706 461 (0.15) ogooluwa 96 69 89,843 0.076801 27 (0.28) olorunsogo 499 570 112,085 0.508543 71(0.14) oluyole 3,503 1,736 280,369 0.619184 1767 (0.5)) onaara 3,606 2,381 365,957 0.650623 1225 (0.33) orelope 902 875 143,318 0.61053 27 (0.02) oriire 51 38 205,884 0.018457 13 (0.25) oyo east 1,148 1,030 171,003 0.602329 118 (0.10) oyo west 2,310 2,251 188,038 1.197098 59 (0.02) saki east 1,549 1,510 150,143 1.005708 39 (0.02) saki west 439 394 376,563 0.104631 45 (0.10) surulere 109 63 193,387 0.032577 46(0.42) total 84845 55119 7,690,472 0.716718 29,726(35.0) total ever registered total currently registered total population oyo state proportion currently of registered in oyo state adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 12 | p a g e appendix ii. pattern of enrolment in oysh scheme by marital status appendix iii. discontinuity with membership of oyshi scheme among enrolees adewole da, ilori t, ladepo w, akande oa, owolabi g. pattern of population coverage of a social health insurance scheme in a southwest nigeria state: a 3 year post implementation evaluation (original research). seejph 2021, posted: 30 march 2021. doi: 10.11576/seejph-4287 13 | p a g e appendix iv. enrolment pattern in the oyshi scheme by sector salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 1 | p a g e c review article innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review mobolaji modinat salawu1, obinna emmanuel onwujekwe2, olufunmilayo ibitola fawole1 1 department of epidemiology and medical statistics, faculty of public health, college of medicine, university of ibadan, nigeria; 2health policy research group, department of pharmacology and therapeutics, college of medicine, university of nigeria enugu campus, enugu, nigeria; corresponding author: mobolaji modinat salawu address: department of epidemiology and medical statistics, faculty of public health, college of medicine, university of ibadan, nigeria; e-mail address: sannibolaji@yahoo.com mailto:sannibolaji@yahoo.com salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 2 | p a g e abstract african nations have failed to achieve the mandate of health for all forty years after alma ata declaration. to achieve universal health coverage (uhc), government alone are unable to solve the problems of health service delivery such as lack of good infrastructure, poor management, inter-cadre conflicts, lack of skilled birth attendants amongst others. this review assessed the involvement of non-state actors (private sector/philanthropists) in achieving uhc in africa. we explored eight databases and search engines using specific search terms. we retrieved and conducted a detailed review of 47 publications comprising published literature and reports focused on private sector/philanthropy involvement in achieving uhc in africa, and explored the challenges and opportunities. we included both qualitative and quantitative studies published in english. inequity and a wide gap exist in countries’ health care service delivery due to numerous challenges such as chronic economic instability, bureaucracy, poor healthcare financing, corruption among others. review of existing literature suggests that as africa embarks on reforms toward uhc there is a great need for involvement of private sector/philanthropists to support government in addressing challenges facing health care system. the type of involvement revealed were; provision of infrastructure (hospital buildings/facility, good roads), technical support, technological innovations, provision of diagnostic and therapeutic equipment, financial support and other support services. this scoping review showed that private and philanthropist actors’ involvement in healthcare system have huge potentials to improve, restore and maintain health service delivery in african nations. this will accelerate progress towards the achieving uhc by 2030. keywords: private, philanthropy, health service delivery, universal health coverage, africa salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 3 | p a g e introduction the alma ata declaration of 1978 identified primary health care (phc) as the key to attainment of the world health organisation (who) goal of ‘health for all’ (1). however, forty years after, this declaration is yet to be fulfilled by most countries of the world especially, the african nations. in 2018, the who endorsed the astana declaration to renew the commitment to strengthen phc and achieve a universal health coverage (uhc) which is one of the targets of health related sustainable development goals (sdgs) (2). uhc is the bedrock for health-related sdgs to ensure equitable and sustainable health outcomes as well as contributing to other sdgs to ensure an effective health system (3). uhc is defined as all people having access to quality health services without suffering financial hardship associated with paying for care (4). this means all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality, while ensuring that the use of these services does not expose the user to financial distress (5). to achieve uhc, six essential health systems attributes are embraced which are reflected in the health policy objectives across regions. these are; quality, efficiency, equity, accountability, sustainability and resilience (6), summarized into three related objectives: (i) equity in access to health services everyone who needs services should get them, not only those who can pay for them; (ii) the quality of health services should be good enough to improve the health of those receiving services; and (iii) people should be protected against financial-risk, ensuring that the cost of using services does not put people at risk of financial harm (7). the health systems for uhc consists of three pillars which are necessary to improve well-being of the people in african nations; these are service delivery, health financing and governance (8). in africa, health service delivery is faced with problems of poor management; inter-cadre conflicts; lack of good infrastructure, lack of skilled birth attendants; essential medical commodities and high cost of treatments among others (9). this results in poor utilization of health services with poor health outcomes such as low immunisation coverage, high morbidity and mortality from communicable and non-communicable diseases (ncds) (9, 10). the government is unable to guarantee availability, accessibility, acceptability, and quality of all health-related services for everyone residing on her territory (11). pregnant women and children are mostly affected by these challenges as evident by the poor health indicators reported in the who african region. this includes, maternal mortality rate of roughly two-thirds (196 000) of global burden, infant mortality rate six times higher than who european region (51/1,000 live births), and rising cases of ncds (12, 13). research has documented that some african countries, such as ghana, kenya, morocco, rwanda, south africa and senegal are on the path to achieving some aspects of uhc. these countries have provided insurance coverage for the low-income group and improved on access to health care (8, 14, 15). rwanda and ghana have progressed the furthest toward achievement of uhc evidenced by improvement in the country’s health indices (14). however, the progress of most african nations towards achieving uhc is rather slow (8). in addition, most african countries are yet to adopt the african union’s abuja declaration of 2001 which was to increase spending on public to at least 15 % of the government’s budget (16). instability in governance, lack of political will, financial constraints are some of the other causes of poor health service delivery, which is one of the who health systems building blocks. health service delivery is confronted with challenges which have de salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 4 | p a g e prived individuals, families and communities, of the people centered care that phc offers (2). undoubtedly, government of many african nations are unable to handle health service delivery, hence the need to shift focus from government as major providers and financiers of healthcare to nonstate actors (private/philanthropists) for provision of affordable, accessible and quality healthcare. also, it is important to strengthen the health service delivery with private/philanthropy participation to bring quick progress towards attainment of uhc by 2030. philanthropy is a strategic private initiative, established on rebuilding the system and meant for public good. it is an approach for promoting the welfare of others to better humanity especially by generous donation of money to good course (17). the donations aim primarily to promote the economic development, welfare and health of developing countries. in addition, they refer to transactions which could be in cash or kind that originate from foundations’ own sources, notably endowment, donations from companies and individuals including high net worth individuals (hnwis), crowdfunding and legacies, as well as income from royalties, investments (including government securities), dividends and lotteries (18). the private sector plays a vital role in most of the world’s health systems. they can be for-profit, not-for-profit, informal, formal, domestic or foreign. their involvement in health care delivery is usually for a specific goal. the private sector provides a mix of goods and services including: medicines and medical products, infrastructure and support services, direct provision of health services, financial supports, training for the health workforce and information technology (19). challenges to appropriate health service delivery minimum standards are set on health service delivery in terms of the human resources, infrastructure, medicines and health technologies, as well as the way people are treated when seeking health services (6). however, health service delivery in most african nations have experienced user by-pass basically because of many confronting chronic challenges. hence, africans are unable to access affordable and quality healthcare. these are discussed in the following paragraphs according to the six who health systems building blocks to strengthen health systems. 1) service delivery availability of a well-maintained health infrastructure with conducive consulting rooms, equipped emergency rooms, patient wards, ambulance, on-site laboratory, pharmacy services, and information and communication technology are essential to a proper health service delivery (20). poor infrastructure and access to health care facilities is a fundamental weakness of health service delivery (21). majority of health facilities in africa lack good road access; consist of poor and dilapidated infrastructure which has facilitated medical tourism (9). for instance, in nigeria, over 5000 people leave the country every month for various forms of treatment abroad and about 1.2 billion usd of nigerian economy is lost to medical tourism yearly (22) . 2) health workforce overtime, health facilities have been grossly understaffed with staff mix that does not meet the population demand. africa nations continuously experience shortage of health care workers due to brain drain as a result of poor wages and staff welfare (23). this has resulted in increased workload on the available staff with associated reduced efficiency and effectiveness, long clinic waiting time and poor staff attitude (22). inter-cadre conflict is another barrier which has rendered the health system unworkable (13). in addition, many salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 5 | p a g e african nations still lack skilled birth attendants who address complications during pregnancy and childbirth, hence the high maternal and neonatal morbidity and mortality rates (24). 3) access to essential medicines another challenge of health service delivery is the recurrent shortages and weak supply chain of quality essential medical commodities, such as drugs and equipment in most health facilities in africa (23). this results in high cost of treatment which the patients could barely afford. hence, patients are unable to obtain required medication or treatment as and when due. this unavailability and perceived high cost of care with apparent low quality has contributed to low utilization of health facilities in some african nations like nigeria (10, 25). 4) health information systems health management information system (hmis) contributes to the production, analysis, dissemination, use of reliable and timely health information by decision-makers and practitioners at different levels of the health system (26). unfortunately, the national health information system in african is weak. implementing hmis has been difficult because of factors such as poor funding, governance, poor socio-economic conditions, corruption, etc. (27). most african nations still operate paper-based system of record keeping which is cumbersome, ineffective and often lead to loss of health information. 5) leadership/governance leadership in healthcare system is one of the biggest challenges that hindered expected progress of healthcare interventions in africa (26). there is poor integration of healthcare programmes due to limited community participation in planning, management and monitoring of health services. the government of most african nations lack the political will in implementing government policy and guidelines; there is poor resource management and corruption (28). 6) financing financial barriers to healthcare system remain a prevalent problem in most africa nations with high rates of out-of-pocket expenditure (oop), owing to ineffective national health insurance system. a study found that about 40% of total healthcare expenditure (the) is made up of oop payments in most african nations. the average the in african countries was us$ 135 per capita in 2010 compared to us$ 3 150 spent on healthcare in an average high-income country (29). poor healthcare financing is a recurring problem and seem to be beyond the capability of governments of african nations, hence the need to maximise the involvement of non-state actors in mobilizing resources and providing innovations to support health service delivery towards achieving uhc. this approach has worked in developed countries and some regions in africa with huge potentials in improving, restoring and maintaining health service delivery and overall improvements in health outcomes of the people (19, 30). this can be further studied and adapted by other african countries. various studies have explored the benefit of private sector in achieving uhc but few studies have looked into private sector/philanthropist participation in optimizing government activities in the progress towards uhc. in this paper, we reported the findings of a scoping review which synthesized evidence on healthcare challenges in africa nations, inefficiency of african governments and the possibilities and areas of private sector/philanthropists’ involvement in health service delivery on the way to ‘‘achieving uhc in africa leaving no one behind’’. salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 6 | p a g e methods this scoping review focused on countries where private actors/philanthropy are involved in health care delivery towards achieving uhc in africa. we retrieved and conducted a scoping review on 47 publications comprising grey, primary literature and reports. we focused on studies from developed and developing countries, especially african nations. we included both qualitative and quantitative studies published in english. the inclusion criteria were that literature must focus on private sector/philanthropy for uhc in who regions. search strategy and screening various databases and search engines were explored such as pubmed, google, google scholar, directory of open access jounals, science direct, hinari and researchgate. boolean operators were used to make search more specific using strings with combination of terms (table 1). titles and abstracts of peer reviewed articles, reports and other grey literatures were retrieved and reviewed. we also searched reference lists of included studies in order to look for additional relevant literature. results and discussion from primary searches, 358 published, unpublished and grey literature and reports were retrieved. other sources included technical reports from governmental and non-governmental organisations (ngo) news article, online magazine, civil society organizations, and book chapters. after initial screening, 47 matched the inclusion criteria and were reviewed. the flow chart describing this process is shown in figure 1. table1: literature search terms 1. “private actors” or “private provider” or “private sector” 2. philanthropy or philanthropist or “philanthropic actors” 3. “universal health coverage” 4. “developing country” or “low-middle income countries” or lmic or “sub-sahara africa” 5. “western pacific region” or “south east asia” or “region of americas” or “european region” or “eastern mediterranean region” or “africa region” 6. challenge* or threats and 7. opportunit* or benefit* 8. #1 and #2 and #3 and #4 and #5 and #6 and #7 salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 7 | p a g e figure 1: flow chart showing detailed article extraction and evaluation method we included articles published from year 2000. these studies employed diverse methodological approaches, using a range of quantitative and qualitative methods. to enable an understanding of this concept of private/philanthropy involvement in health care, we first established the outcome and impacts of poor health service delivery in africa using the health indices. we also stated the causes of these poor health indicators which result in high morbidity and mortality. thereafter, we highlighted the challenges service delivery such as inefficiency, bureaucratic bottle necks, economic instability, lack of political will, and other gaps in health service delivery. subsequently, the definitions of private actors/sector and the types; philanthropy and their activities in health service delivery were discussed. we also highlighted some of the agencies that reinforce this sector, dimensions they take and their mechanism of services alongside corresponding interventions. studies on involvement of private actors and benefits on health care delivery are well represented in literature for both developed and developing countries. however, the few studies conducted on philanthropy actors revealed that the aids and grants awarded to nations contributed immensely to the health system growth of such nations. we also found studies that discussed the risks associated with involvement of private actors in health care delivery especially the for-profit private sector. however, the advantages far outweigh the risks which could 180 identified unique articles were scrutinized a total of 358 full text articles published between 2000 and 2020 were assessed for relevance eligibility 178 articles were excluded for irrelevance and duplication a total of 133 articles were excluded after screening titles and abstracts for relevance 47 full text articles were reviewed for focus and coverage of developing countries salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 8 | p a g e actually be controlled by instituting policy and guidelines for the operationalization of private actors. some of the reviewed literatures are listed in table 2. evidence of best practices with private/philanthropist participation in health care delivery the involvement of non-state actors in health service delivery is not a new phenomenon globally, especially in developed countries where it contributes to the growth and success achieved in their health sector (30). this participation as a comparative advantage, such as infrastructural development, technological innovation, training of healthcare workers, provision of health related services, manufacture of materials and technologies used in health care provision; and financial support which the government can leverage upon (7). private sector involvement private actors in health care delivery can either be for-profit or not-for-profit organisations. they are important stakeholders in any country’s healthcare delivery as they cushion, complement and assist the government in strengthening the healthcare system (31). they are found in situations and communities where governments presence and activities are weak in terms of infrastructure, personnel, finance, commodities and when public facilities are closed or on industrial strike (30). the for-profit private actors such as big corporate hospitals are able to mobilise substantial private financing for expensive medical equipment and technology such as those used in advanced treatments of cancers and cardiovascular diseases (32). the non-for-profit private actors such as medicines san frontiers (msf) known to have more experience and better resources, are quick to mount emergency epidemic and disaster responses compared to the government. in addition, marie stopes international, with highly experienced staff who are experts in family planning services work in different countries to ensure regular access to family planning products and commodities (32). both forprofit and non-profit private actors provide a mix of goods and services including: direct provision of health services, medicines and medical products, financial products, training for the health workforce, information technology, infrastructure and support services (e.g. health facility management) (7). consequently, most countries operate “mixed health systems”, where a mix of public and private providers deliver health-related goods and services (7, 33). research showed that among 27 high-income countries, 21 have their primary health care delivered by the private sector (33). grepin in a household survey in 70 lowand middle-income countries, reported that private services provide about 65% of care for childhood illness, but the proportions varied widely by country (34). between 2007 and 2008, the international finance corporation found that in africa, the private sector already delivered about half of africa’s health products and services (35). this was as a result of the perceived lack of efficiency, quality in the provision of public health care and largely from increased costs with reduced budgets for health care due to the financial crisis experienced during the period. a report by the african development bank highlights that africa’s private sector accounts for over 80% of the total production, 65% of total investment, and 70% of total credit to the economy, and employs 90% of the working age population (36). in 2005, of the total health expenditure of $16.7 billion in subsaharan africa, about 50% were captured by private providers (36). it is thus becoming important to engage the non-state actors in enhancing the services of the public sector. in uganda, the united state agency for international development (usaid) secured the private sector’s role towards the costs of hiv service delivery through a counter-part funding scheme that enabled for-profit clinics to commence provision of salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 9 | p a g e hiv services in 2009 (37). usaid provided medical equipment and health workforce trainings thereby expanding the national network of hiv treatment sites across uganda especially in parts of the country where government presence was particularly weak (38). the assessment of private sector activities in uganda was said to be too important to be ignored in attaining uhc (39). table 2: summary of papers reviewed sector challenges of health care delivery authors that elaborated on interventions private service delivery (infrastructure, medical, laboratory services and equipment, technological innovations) a. hallo de wolf and b. toebes (2016), who 2018, d. montagu and c. goodman (2016), d. clarke et al (2019), k. grepin (2016), international finance corporation (2007), m. baig (2014), r. brugha and a. zwi (2002), r. kumar (2019) health workforce (technical expertise) usaid (2013) the health initiatives for the private sector (hips) project final evaluation report, d. montagu and c. goodman (2016), h. zakumumpa (2016), africa healthcare federation, 2020 finance (financial support) international finance corporation (2007), s. basu (2012), world bank (2016) uganda private sector assessment in health, m. baig (2014), s. pour doulati et al (2011), o. olu et al (2019), p. bakibinga et al., (2014) access to essential medicine (medicines, medical products) s. pour doulati (2011), b. uzochukwu (2015) health information systems d. clarke et al (2019), who (2018), r. kumar (2019) philanthropy service delivery (infrastructure, medical, laboratory services and equipment) oecd netfwd. (2019), africa healthcare federation, 2020, s. basu (2012), b. uzochukwu (2015), africa portal. (2018), university of ibadan. (2020). otunba tunwase national paediatric centre, p. bakibinga et al (2014) finance (financial provision/donations) united nations. (2019). inter-agency task force on financing for developmentofficial development assistanc, oecd netfwd. (2019), africa portal. (2018), m. sulek (2009) access to essential medicine (provision of essential medicine) alliance magazine. (2018), university of ibadan. (2020), f. b. dennis. (1993) salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 10 | p a g e research from southeast asia, middle east and some african countries have reported rewarding experiences from government and private engagement. improvement was seen in the areas of infrastructure, laboratory services, equipment and supplies which resulted in affordability and patient satisfaction (40, 41). better performances in the maternal and child healthcare utilization was observed as a result of improved infrastructure and supplies (15). evidence from islands of cabo verde showed that private/philanthropist involvement produced positive health outcomes through technological innovations like telemedicine to bridge the gap in human resource and service shortfall (23). governments of african countries can leverage upon some of these existing services for continuity while the non-state actors continue to execute impactful activities in strategic areas of health service delivery. private sector participation in health service delivery is not without risks and concerns such as quality of services they provide, pricing among others (42). however, the benefits outweigh the risks which can be managed by all the parties involved with well-established regulations and guidelines. the who as a governing body can help to support countries to develop policy guidelines and monitoring tool for managing private/philanthropy and government activities. philanthropic involvement philanthropy donations aim primarily to promote the economic development, welfare and health of developing countries (18). these donor funding from government could be in form of loans or aids grants from donor countries who contribute a target of 0.7% of their gross national product as official development assistance (oda) to developing countries (43, 44). philanthropic actors have contributed enormously to healthcare on various programs to combat diseases as well as deliver health interventions in developing countries. between 2013 and 2015, international philanthropists contributed usd 12.6 billion to reproductive health as well as to combat aids, tuberculosis and malaria. the top five foundations that provide 87% of funding in health and reproductive health globally include; bill & melinda gates foundation bmgf (72%), the susan thompson foundation (5%), the children’s investment fund foundation (4%), wellcome trust (3%), and bloomberg philanthropies (2%) (18). evidence showed that philanthropic donation is concentrated in africa and asia. according to geographical allocation of giving, the top 25 foundations target india (usd 679 million), nigeria (usd 511 million), ethiopia (usd 268 million), pakistan (usd 208 million) and mexico (usd 144 million). between 2013 and 2015, africa received 24% of philanthropic funds for health and reproductive health, and asia received 13%. the funding went into reproductive health/family planning for ethiopia (usd 89 million) and infectious disease for nigeria (usd 310 million) (18, 45). most of these foundations channel their funds for health through intermediary organisations such as ngos, civil society, multilateral organisations, universities and research institutes. indigenous foundations also contribute to healthcare development in africa through local foundations, community groups, and wealthy individuals. a formal structure of philanthropy which include foundations and trusts was set up by hnwis and charitable organisations with distinct objectives relating to african development (46). well-known foundations by hnwis include, the aliko dangote foundation in nigeria, nicky oppenheimer brenthurst foundation in south africa, and the chandaria foundation in kenya, while charitable trusts and vehicles that promote philanthropy include the southern african trust, and the ghana-based african women’s development fund (46). the performance of private and philanthropy https://www.alliancemagazine.org/feature/big-philanthropy-and-policy-change-in-africa/ https://www.alliancemagazine.org/feature/big-philanthropy-and-policy-change-in-africa/ salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 11 | p a g e actors in health care delivery is resourceful in ensuring improvement in the area of quality health care, equity of access and efficiency of services which catalyses government activities and achievement. this can be in the aspect of financial support to increase funds for health to meet up with international standards. in addition, prioritisation of phc, increasing funding to rural poor especially by redistributing resource allocation between levels of care for preventive and promotive care (30). discussion this scoping review has identified various challenges hindering provision of quality healthcare in african nations, most of which are recurrent and implicated in the slow progress towards attainment of uhc. government of african nations have failed in their responsibility to provide quality, affordable and accessible healthcare for their citizens. the health system therefore requires support from private sector/philanthropy which have become important sources of health care provision for developing nations. the benefits of private/philanthropy participation in health system delivery are enormous and have helped in delivery of quality healthcare with improvement in health status of the people. successes reported in the health system of high income countries are as a result of the major contributions of private sector/philanthropy in their health care delivery (18). this invariably contributed to the excellent health system, best quality of life and good health indicators experienced in developed countries. in essence, health care delivery in african nations may not survive without assistance from non-state actors (7, 47). some african nations have been supported by private sector/philanthropy both from external and within the african nations with health care interventions to combat health problems such as infectious diseases e.g. malaria, hiv/aids, tuberculosis; non communicable diseases and reproductive health issues (18, 36, 46). this has contributed immensely to the improvement in healthcare system in the supported nations. it is therefore important for governments of african nations to strategically optimise the involvement of private/ philanthropist actors in mitigating the challenges of health service delivery. this will go a long way to restore, improve and maintain health service delivery of african nations; thereby accelerating the progress towards attainment of uhc by 2030. acknowledgements we acknowledge the contribution of drs j.o akinyemi, s.a adebowale, s. bello and m.d dairo of the department of epidemiology and medical statistics, university of ibadan, nigeria; for their intellectual and technical assistance. we also thank the world health organisation for the technical support and publishing this manuscript. references 1. who. human rights and health 2017 [available from: https://www.who.int/newsroom/fact-sheets/detail/humanrights-and-health. 2. who. declaration on primary health care astana 2018 [available from: https://www.who.int/primary-health/conference-phc/declaration. 3. kieny mp, bekedam h, dovlo d, fitzgerald j, habicht j, harrison g, et al. 4. strengthening health systems for universal health coverage and sustainable development. perspective bulletin of the world health organization. 2017. 5. who. what is universal health coverage? 2013 [available from: https://www.who.int/news-room/fact-sheets/detail/human-rights-and-health https://www.who.int/news-room/fact-sheets/detail/human-rights-and-health https://www.who.int/news-room/fact-sheets/detail/human-rights-and-health https://www.who.int/primary-health/conference-phc/declaration https://www.who.int/primary-health/conference-phc/declaration https://www.who.int/primary-health/conference-phc/declaration salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. 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(review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 15 | p a g e kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 1 | 27 original research epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. laurant kollçaku1 1 pediatrics department, unit of endocrinology and diabetes, university hospital center 'mother teresa', tirana, albania. corresponding author: laurant kollçaku address: university hospital center “mother teresa”, rr. dibres, no. 371, tirana, albania; email: laurantkollcaku@gmail.com kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 2 | 27 abstract aim: diabetes mellitus is a major public health problem worldwide. type 1 diabetes mellitus (t1dm) is the most common metabolic chronic disease in genetically susceptible children and adolescents, due to an autoimmune process characterized by a selective destruction of insulin producing β-cells. the aim is to assess the epidemiological features of new-onset t1dm in children and adolescent at the national level during the period 2010-2014 in department of pediatrics, endocrine unit, university hospital center 'mother teresa', tirana, as the unique center for pediatric endocrinology and diabetology in albania. methods: the clinical and laboratory characteristics of 152 patients aged <15 years newly diagnosed with t1d from 1 january 2010 to 31 december 2014 were studied. t1d was diagnosed according to who 2006 criteria and dka was diagnosed based on ispad 2014 criteria. patients were classified into 3 sub-groups (i: 0-4 years, ii: 5-9 years, and iii; 10-14 years). statistical analysis was performed using spss 26. results: the incidence of new-onset of t1dm was 5.012/100.000/year. the mean age of children at diagnosis was 8.3 ± 3.6 years. the patients were mostly diagnosed at ages 5-9 years (40.1%), and 10-14 years (39.5%), followed by the 0-4 years age group (20.4%). mean duration of symptoms was 23.35 ± 17.16 days; longer in the subgroup 5-9 years (p= 0. 0.013). three quarters (75%) of children with t1dm live in urban areas. viral infections or other circumstance triggers were in 41.9% of children aged 0-4 years compared to other subgroups (p=0.002). most of the children were born in the spring−summer months (53.23%) compared to the autumn−winter months (46.77%). approximately 1/4 of the children were born and diagnosed with type 1 diabetes in each of the seasons of the year and 52.63% of the patients studied were first born. family history for dmt1 and dmt2 is observed in 15.8% and 17.8% of the children, respectively. polyuria (99.3%), polydipsia (99.6%) and weight loss (98.1%) were the most common symptoms and 67.8% of patients presented with diabetic ketoacidosis (dka). misdiagnosis was in 21 (13.8%) patients. mean glycosylated hemoglobin a1c (hba1c) was 11.63%; 11.9 ± 2.0 in dka positive children and 11.1 ± 2.4 in dka negative children (p= 0.195). at diagnosis and during follow up of t1dm 25% (38/152) developed associated autoimmune diseases; 68.42% at diagnosis of t1dm and 65.79% (25/38) of patients were female. during follow up children with t1dm developed associated cd and sat, 2.54, and 2.19 years, respectively. conclusion: diabetes mellitus is one of the major public health problems worldwide. albania is a country with middle incidence of t1dm and the age at onset is decreasing. the symptoms lasted significantly longer and mean hba1c levels were significantly higher in older children. the incidence of dka in children with newly diagnosed t1dm is high. keywords: autoantibodies, children, diabetic ketoacidosis, incidence, seasons, type 1 diabetes. conflicts of interest: none declared. kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 3 | 27 s introduction type 1 diabetes mellitus (t1dm) is the most common endocrine and metabolic disease in children and adolescents aged 0–14 years (1). t1dm represents 5-15% of the diabetic population; 85-95% have t2dm and less than 2% have other forms of diabetes (2). the incidence of childhood type 1 diabetes is increased worldwide more than two to three folds during the last decades, particularly in finland and sardinia (“hot spots” of the world) (3). the incidence of t1d in children < 15 years of age is increasing significantly, approximately 3% (range 2-5%) (1,4,5). from 1965 to 2012 the incidence of type 1 diabetes in pediatric population has increased significantly from 9.44% (8.22–10.66) to 19.58% (14.55–24.60) (6), with the exception of central america and the west india (4). the overall incidence of dmt1 is 11.43/100,000/year, and according to gender; 11.42 (10.23–12.61) in boys and 11.11 (9.94– 12.27) in girls (4). in many european countries the overall incidence has increased to 3.9% (ranges from 0.6% 9.3%); the increase is higher in children aged 0-4 years with 5.4%, compared to 4.3% and 2.9% for age groups 5-9 and 10-14, respectively (4). the main epidemiological characteristics of type 1 diabetes in children < 15 years old are: the large variation of incidence from 0.1 in venezuela to 62.3 per 100,000 per year in finland (7); the increasing incidence in countries with lower incidence and the trend of occurrence towards the younger age group (0-4 years) (3). variation of type 1 diabetes incidence cannot be explained by genetic factors alone (frequency of protective hladq alleles between populations) suggests the importance of environmental factors in the complex pathogenesis of dmt1. exposure to one or more environmental factors of genetically predisposed individuals, triggers an immune response that causes the selective destruction of pancreatic beta cells. among environment factors include: latitude and geographic position (811); frequent and high exposure to cow's milk and its products (12), consumption of foods high in carbohydrates (13); short-time exposure to ultraviolet radiation and insufficiency and deficiency of vitamin d; oceanic climate (cold winter and summer) (6); prenatal and postnatal viral infections (14-16); pregnancy-related factors (parental age at birth, order of birth, maternal illness, viral infections) and perinatal period (birth weight, gestational age) (17); use of pharmaceutical products (antibiotics); obesity (increased bmi) (18-20); migration; socio-economic status with high income (7); gender and age (21) as well as the month and season of birth (22) are all associated with increased risk of type 1 diabetes. this study aims to investigate the epidemiological features of t1dm in children and adolescents aged <15 years, during the period 2010-2014 in albania. patients and methods study type this study represents a series of patients (cases) newly diagnosed with type 1 diabetes mellitus presented at the specialty service, endocrinology clinic, "mother teresa" university hospital center, tirana (qsut), during the period 2010-2014. study population this prospective study from january 1, 2010 to december 31, 2014, included 152 patients who met the criteria: children diagnosed with t1d for the first time < 15 years old in albania. the number of children and adolescents aged 0-14 years old from 20102014 according to instat is 3,032,819 children (1,451,992 females and 1,580,827 males). patients are classified into 3 age kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 4 | 27 groups (i: 0-4 years, ii: 5-9 years, and iii: 1014 years). inclusion criteria: the study included 1) new cases aged < 15 years diagnosed for the first time with diabetes mellitus type 1 during the period january 2010 december 2014 resident in albania, which from a geographical point of view corresponds to the administrative borders and census; 2) individuals who received their first insulin injection before their 15th birthday and resident in albania at the time of the first insulin administration. exclusion criteria: new cases ≥ 15 years of age during the period 2010-2014, cases of diabetes mellitus from secondary causes as a result of a primary pathology (cystic fibrosis, corticotherapy, mody, etc.) were excluded from the study. data collection data for this study were collected prospectively using a standardized clinical record. information was collected on a range of demographic and laboratory data. the epidemiological data regarding the date of birth, the date of initial presentation of t1dm and age at diagnosis, the order of birth, the birth weight, the mode of delivery, and pubertal status were obtained from the patients’ clinical records. the diagnosis of t1d was determined according to who, 2006 criteria; the ispad, 2014 criteria were used to determine dka; hyperglycemia (glycemia> 200 mg/dl or > 11 mmol/l), metabolic acidosis (ph < 7.30, and /or plasma bicarbonate level < 15 mmol/l or ketones in urine (ketonuria > 2+), accompanied by history of polyuria, polydipsia, nocturia, weight loss, dehydration, nausea, vomiting, abdominal pain, respiratory signs (acetone odor, respiratory distress, dyspnea), level of consciousness (classified into 3 categories: normal, altered consciousness and coma according to the pediatric glasgow coma scoring system), and different triggers conditions. anthropometric measurements (weight, height, body mass index, bmi (kg/m2) also expressed in standard deviation (bmi-ds), stage of pubertal development according to tanner. the severity of dka was determined by the ph and concentration of plasma bicarbonates and was categorized into 3 groups: (a) mild: ph <7.30 and/or serial bicarbonate <15 mmol /l; (b) moderate: ph <7.2 and /or bicarbonate <10 mmol /l and (c) severe: ph <7.1 and /or bicarbonate <5 mmol/l (table 1). according to ispad, new-onset t1dm with ph > 7.3 and hco3 > 15 meq/l was classified as t1dm without ketoacidosis. ethics approval and consent of participate: informed written consensus was obtained from all patients' parents. it is approved by the albanian national ethics committee. statistical analysis absolute numbers and corresponding percentages were used to describe the categorical data. to describe numerical data, the reporting of the central tendency measures, in this case the mean value, and the dispersion measures, in this case the standard deviation, was used. the square hi test was used to compare categorical variables; in case the resulting table was in the size of 2x2, then the value of p was reported according to fisher's exact test, which gives a more accurate calculation of the p-value. to compare the mean values of the numerical dependent variable according to the categories of the independent variable, the non-parametric mann-whitney u test was used for two independent samples in the case where the independent variable had only two categories; otherwise, when the independent variable had >2 categories the nonparametric kruskal wallis test was used for k kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 5 | 27 independent samples. non-parametric tests were used in case the dependent variable was found to be abnormally distributed in the study population. otherwise, for normally distribute numerical variables, the student's ttest for two independent samples was used. binary logistic regression test was used to identify the associations between the presence of diabetic ketoacidosis and the independent variables. various tables depending on the information were used to present the data. graphs of different types were used to present and illustrate the study findings. in all cases, the associations between the variables were considered significant if the value of the statistical significance was ≤ 0.05 (or ≤ 5%). all statistical analyzes were performed through the statistical package for social sciences, version 26 (ibm spss statistics for windows, version 26) software program. results a total of 152 (52% male and 48% female) children age < 15 years were diagnosed with type 1 diabetes mellitus (t1dm) during the study period. the mean age at diagnosis, age, sex and residence distribution of the study population are shown in table 1. the mean age of the subjects at the time of diagnosis is 8.3 years ± 3.6 years. at the time of diagnosis, 40.1% were between ages 5-9 years, followed by 39.5% between ages 1014 years and 20.4% younger than 5 years. three quarters (75%) of children with t1dm live in urban areas and 25% in rural areas. table 1. mean age at diagnosis, age, sex and residence distribution of the study population variable frequency (%) mean age at diagnosis (mean value ± standard deviation) 8.3 ± 3.6 agegroup 0-4 years 5-9 years 10-14 years 31 (20.4%) 61 (40.1%) 60 (39.5%) gender male female 79 (52%) 73(48%) residence urban rural 114 (75%) 38 (25%) total 152 (100.0) mean duration of symptoms to the diagnosis of t1d was 23.35 ± 17.16 days. no statistically significant gender differences were observed regarding mean duration of symptoms, while the age differences were statistically significant: 17.48 days among children 0-4 years old, 28.61 days among children 5-9 years old and 21.03 days among children 10 -14 years (table 2). kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 6 | 27 table 2. duration of symptoms to the diagnosis of t1dm statistical parameter time of onset of symptoms to diagnosis of dmt1 (in days) p-value according to gender p-value according to subgroups mean average value 23.35 0.362* 0.013** the standard deviation 17.16 median 21.00 mode 30 minimum value 0 maximum value 90 the spectrum 90 * p value according to the non-parametric mann-whitney u test for two independent samples. ** p value according to the non-parametric kruskal wallis test for k independent samples. at diagnosis of t1d1, 13.8% were misdiagnosed as viral infection, gastrointestinal and respiratory airways infection and less often as surgery emergency. table 3. misdiagnosis at new onset of t1dm variable frequency (%) suspicion of diabetes at the time of admission no yes 21 (13.8%) 131 (86.2%) family history for dmt1 were in 15.8%, dmt2 in 17.8% and both types in 2.6% of the children. among children with a positive family history of dmt1, the grandfather/grandmother was most often affected (54.2%), followed in 29.2% of cases by the brother/sister. table 4. family history and t1dm and/or t2dm variable frequency (%) family history with t1dm 24 (15.8%) family history with dmt2 27 (17.8%) kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 7 | 27 figure 1a. positive family history of t1dm figure 1b. positive family history of t2dm regarding the season of birth and the season of diagnosis of type 1 diabetes of the children in the study, it is noted that approximately 1/4 of the children were born in each of the seasons of the year. however, more than half of dmt1 were diagnosed in autumn and winter (60.5%). table 5. distribution of children at diagnosis of t1dm according to the seasons of birth and seasons of diagnosis 0 2 4 6 8 10 12 mother grandfather father mother and grandfather others (aunts, uncles,causins) siblings siblings and grandfather 0 2 4 6 8 10 12 mother father & others (aunts, uncles,causins) grandfather grandfather & others (aunts, uncles,causins) father others (aunts, uncles,causins) kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 8 | 27 birth season 0-4 years 5-9 years 10-14 years spring 8 14 17 summer 6 15 15 autumn 7 21 13 winter 10 12 14 total 31 62 59 season's diagnosis spring 3 18 18 summer 5 8 8 autumn 13 20 16 winter 10 16 17 total 31 62 59 figure 2. distribution of diagnosis and frequency of birth in different seasons of year the data analysis showed that most of the children were born in the spring−summer months (53.23%) compared to the autumn−winter months (46.77%) (figure 3a). most of the children were born in december, followed by those born in november, april, august and september (figure 3a). significantly more children were diagnosed with t1dm during the colder months of the year, october−march (53.3%) compared to 46.7% during the warmer months, april−september (figure 3b). 25.7 13.8 32.2 28.3 25.7 23.7 27 23.7 spring summer autumn winter birth season season of diagnosis kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 9 | 27 figure 3. a) distribution of children according to month of birth. b) frequency of diagnosis of t1dm during the cold and warm months kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 10 | 27 table 6. birth order birth order 1 2 3 4 total 80 43 27 2 0-4 years 15 10 4 2 5-9 years 35 15 12 0 14-10 years 30 18 11 0 52.63% of the patients studied were first born, 28.3% were the second child of the family, 17.8% were the third child, 4.6% the fourth child and 1.3% were the fifth child (fig. ). the differences observed with respect to the order of birth are statistically significant (chi-squared test, p < 0.001). figure 4. a) birth order b) birth order according to the age the mean birth weight of our study group was 3325 ± 463.8 g (min: 1500 g, max: 5100 g). 1.3% of the patients had a birth weight below 2500 g, 70.4% between 2500 0 10 20 30 40 50 60 70 80 90 1 2 3 4 0 5 10 15 20 25 30 35 1 2 3 4 0-4 years 59 years 10-14 years kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 11 | 27 and 3500 g and 28.3% >3500 g. most of the patients (82%) were born by normal vaginal delivery and 18% by cesarean section. among the children diagnosed with dmt1, in 23.7% of cases the presence of viral infections (enteroviruses, hepatitis, frequent upper respiratory tract infections, gastroenteritis) and one case chest trauma were identified. psychosocial stress (divorce, death of a parent and family member) was observed in 2.6% of children. there were no statistically significant gender differences related to these indicators. the percentage of viral infections history or other trigger conditions were higher in children aged 0-4 years (41.9%) compared to children aged 5-9 years (27.9) and aged 1014 years (10%) [p=0.002] and no statistically significant age differences were observed regarding the psychosocial stress. polyuria (100%), polydipsia (100%), and weight loss (98.1%) were the most common complaints. the frequency of malaise, vomiting, enuresis nocturnal, acetone odor, dyspnea, drowsiness and confusion was higher among children with dka (p < 0.001). figure 5. the presenting clinical manifestations of children and adolescents at the time of diagnosis, the overall incidence of ketoacidosis was 67.8%. the mean age of children with dka was 7.75 ± 3.64 years, and 9.29 ± 3.39 years in children without dka (p = 0.012). there were no statistically significant differences by age subgroup and living residence; the percentage of females was higher in t1dm children with dka (54.4%) than among those without dka (34.7%) (p = 0.025). 102 49 26 96 5 5 12 25 4 15 3 56 45 35 45 36 22 4 46 18 1 36 2 0 3 3 0 3 1 3 0 0 0 1 0 0 0 20 40 60 80 100 120 p o ly u ri a a n d … a p p e ti te v a ri a ti o n n o c tu rn a l e n u re si s w e a k n e ss ,… h e a d a c h e c o n st ip a ti o n a b d o m in a l p a in v o m it in g d ia rr h e a o ra l c a n d id ia si s m o n il ia l… a c e to n e s m e ll k u ss m a u l… t a c h y p n e a /p o ly … d y sp n o e a s o m n o le n c e c o n fu si o n c e re b ra l e d e m a t1dm with dka t1md without dka kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 12 | 27 figure 6. frequency of dka at diagnosis of t1dm positive family history of type 1 diabetes increases the odds ratio (or) of the presence of dka by 1.52 times, and positive family history of type 2 diabetes decrease 1.56 (1/0.64) times the presence of dka (protective role), compared to children without family history for dmt2 but this difference is not statistically significant (p>0.05). a positive family history for both dmt1 and dmt2 increases the likelihood of the presence of kad by 8.73 times, but even these differences did not reach statistical significance (p>0.05). viral infections and other trigger conditions increase the likelihood of the presence of kad by about 1.58 times; however, there were not statistical significance difference (p> 0.05). regarding the association of psycho-social stress and presence of kad in type 1 diabetes, seems that psycho-social stress may be a risk factor for the presence of dka in diabetic children (being that 3.9% of diabetic children). table 7. association between the presence of dka in diabetic children and selected variables – odds ratio (or) by binary logistic regression test variable or § 95% ci * p-value † lower interval upper interval positive family history of t1dm 1.52 0.56 4.10 0.411 positive family history of t2dm 0.64 0.27 1.50 0.300 positive family history of t1dm or t2dm 6.00 0.60 59.80 0.127 positive family history of t1dm and t2dm 8.73 0.82 92.85 0.073 viral infections and other trigger conditions 1.58 0.68 3.68 0.290 67.8 32.2 t 1 d m w i t h d k a t 1 d m w i t h o u t d k a kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 13 | 27 female with dka 2.24 1.11 4.54 0.025 subgroup 0-4 years with kad 2.97 1.06 8.32 0.038 age (year) -0.126 †† 0.016 urban residence and dka 1.32 0.61 2.84 0.484 duration of signs and symptoms (day) 0.015 †† 0.179 § odds ratio (or) of the presence of kad in diabetic children versus its absence, according to the binary logistic regression procedure; * 95% confidence interval (95% ci) for or; † statistical significance value (p value) according to the binary logistic regression test. table 8 presents the association of the kad with symptoms and signs of children in the study. it appears that presence of nocturnal enuresis, malaise, vomiting, acetone smell and drowsiness increase the odds of the presence of dka in diabetic children by 16.21, 4.95, 4.98, 18.27 and 25.79 times, respectively, and these differences are statistically significant (p<0.05). it must be said that kussmaul respiratory distress, polypnea/tachypnea, dyspnea, confusion and cerebral edema/coma appear to be significant predictive factors of the presence of dka in diabetic children, but the absence of these signs in children without kad made binary logistic regression analysis impossible. table 8. association between the presence of dka in diabetic children and selected variables – odds ratio (or) by binary logistic regression test variable or § 95% ci * p-value † lower interval upper interval nocturnal enuresis 16.21 2.13 123.35 0.007 malaise 4.95 1.83 13.40 0.002 headache 1.20 0.22 6.41 0.832 abdominal pain 2.02 0.54 7.52 0.294 vomiting 4.98 1.42 17.41 0.012 oral candidiasis 2.61 0.72 9.49 0.144 monilial vaginitis 1.44 0.15 14.21 0.755 acetone smell 18.27 5.34 62.54 <0.001 somnolence 25.79 3.42 194.67 0.002 glycaemia 0.006 †† 0.001 ph -78.275 0.022 hco3 -0.312 0.001 triglycerides 0.009 0.009 table 9 presents the relationship between the presence of dka and some laboratory parameters of the diabetic children in the study. data analysis showed that blood glucose and triglycerides are positively related to the presence of dka, being that each additional unit of glycemia and triglycerides increases the odds of dka by 0.006 and 0.099 times, respectively, and these changes are statistically significant (p<0.05). in the meantime, ph and hco3 are negatively related to the presence of kad: kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 14 | 27 thus, one additional unit of ph and hco3 decreases the likelihood of dka by 78.275 and 0.312 times, respectively and these differences are statistically significant (p<0.05). table 9. association between dka and laboratory parameters t1dm with dka t1dm without dka p-value frequency of dka at diagnosis (%) 67.8 32.2 mean age 7.75 ± 3.64 9.29 ± 3.39 0.012 † gender (male/female) (%) 45.6/54.4 65.3/34.7 0.025** residence (urban/rural) (%) 76.7/23.3 71.4/28.6 0.549** age-groups 0-4 years 25 (24.3) * 6 (12.2) 5-9 years 43 (41.7) 18 (36.7) 0.082** 10-14 years 35 (34.0) 25 (51.0) duration of symptoms (days) 24.65 ± 17.39 20.61 ± 16.51 0.169* family history of t1dm/t2dm (%) 17.5/15.5 12.2/22.4 0.482/ 0.364** viral infections trigger 26.2 18.4 0.316** serum glucose level (mg/dl) 513.2 ± 193.2 386.5 ± 138.3 <0.001 glycated hemoglobin (hba1c) at baseline 11.9 ± 2.0* 11.1 ± 2.4 0.195 ** blood ph 7.2 ±0.1 7.4 ± 0.1 <0.001 hco3 8.7 ± 5.4 19.9 ± 4.5 <0.001 triglycerides 217.5 ± 189.9 118.2 ± 55.7 0.001 presentation with severe dka based on venous ph (<7.1) 17 (32.1) * <0.001** presentation with severe dka based on hco3 (<5) 15 (28.8) <0.001** the mean hba1c level of the total study population was 11.65±2.2%. hba1c levels did not differ by age subgroups or gender. age (years) 0-4 5-9 10 -14 mean value hba1c 11.63 ± 2.05 11.76 ± 162 11.70 ± 1.76 there were no significant differences of mean hba1c values between diabetic children with and without kad (11.9 ± 2.0% vs. 11.1 ± 2.4%, p=0.195) at diagnosis and during follow up. the average values of hba1c at diagnosis and over time in diabetic children with and without kad are presented in the following figure 7. it can be seen from the figure 7 that the progress of hba1c over time is more favorable for diabetic children without kad compared to diabetic children with kad, since in diabetic children without kad the average level of hba1c is constantly lower than in children with kad, while in children with kad the average level of this parameter remains more or less constant but at quite high levels (between 89%). kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 15 | 27 figure 7. mean hba1c level (in %) among diabetic children with and without dka, during study * mean value ± standard deviation. ** statistical significance value according to the non-parametric mann-whitney test for two independent samples. at diagnosis of t1dm, 17.10% (26/152) of the children had concomitant autoimmune diseases (ad): 14.47% (22/152) autoimmune thyroid disease (atd) and 2.63% (4/152) cd; 65.38% (17/26) were female and 34.62% (9/26) male. half of children (13/26) with autoimmune diseases were presented with dka. according to the specific age group 7.7% were in the age group 0-4 years; 57.7% in the age group 5-9 years and 34.6% belong the group age 10-15 years old. at the time of diagnosis, among children with atd, 68.2% were female, ages 8-10 were the most affected (59.09%), 23% children had tsh >5 mu/l and 77% of children were positive tpo and 80% e children with positive tpo had normal thyroid function. among children that developed concomitant cd at diagnosis of t1dm, 2 patients were female and 2 males; 2 age group 0-4 years and 1 age group 5-10 years and 1 age group 10-14 years. of these, 1 girl, age 1.4 years preceded the diagnosis of dmt1 by 4 months (table). during follow-up, 8.55% of children developed sat and cd; 8 children cd and 4 children sat. the mean age of developed of cd and sat after the diagnosis of t1d were 2.19 and 2.54 years, respectively. of these, 1 child developed sat and cd; hashimoto 1.023 years and cd 4.11 years after the diagnosis of dmt1. kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 16 | 27 table 10. concomitant autoimmune diseases (ad) in children with t1dm discussion the study included 152 children and adolescents aged 0-14 years, diagnosed with dmt1, presented to the pediatric department, "mother teresa" university hospital, tirana during the period january 1, 2010 to on december 31, 2014. to our knowledge, there are no similar studies conducted earlier in albania that illuminate the epidemiological characteristics of children with dmt1. in this context, the present study takes a greater importance. dmt1 is one of the most common autoimmune chronic metabolic diseases in children and adolescents. the incidence of childhood onset type 1 diabetes is increasing by ∼50% every 10 years (1,4). according to the data of the international diabetes federation (idf) 2017 (23), the number of children and adolescents living with diabetes during the last decades is growing rapidly, especially among younger children. in european population the incidence of type 1 diabetes varied tenfold (24); from the lowest in georgia (4.6/100,000/year) to very high in finland (62.3/100,000/year) (25). however, most european countries have intermittent incidence (5.0-9.99 per 100,000 population) (1). during the 2010-2014 study period, the incidence of t1dm among albanian children ages < 15 years was 5.012/100,000/year, places albania among countries with middle risk (1). countries that have an incidence of t1dm close to albania are belarus (5.6), romania (5.4) and macedonia (5.8) (25). besides north macedonia, bosnia-herzegovina (8.2) and croatia (9.1) (25), other countries of the southern european region, have a high incidence (10-19.99/100,000/year) (1). frequency (%) ad at diagnosis of t1dm ad post diagnosis of t1dm age (years) 0-4 5-9 10-14 12 /152 (7.89%) atd+cd 26/152 (15.79%) 1 (0.66%) female 17/26 (65.38%) 1 (5.9%) 10 (58.82%) 6 (35.3%) male 9 /26 (34.62%) 1 (11.11%) 5 (55.56%) 3 (33.3%) atd female male 22/152 (14.47%) 15/22 (68.2%) 7/22 (31.8%) 5 (3.96%) 4 1 cd female male 4/152 (2.63%) 2 2 2 1 1 8 (35%) 4 4 tsh > 5 mu/l 6 (23%) ac. anti tpo > 25 iu/ml 20 (77%) dka 13 (50%) positive tpo & normal thyroid function 16/20 (80%) mean age after diagnosis of t1dm sat cd 2.19 years 2.54 years kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 17 | 27 in general, the incidence increases with age until middle puberty, with a peak at age 10– 14 years compared to other ages is attributed the rapid hormonal changes (26,27) and decreases after puberty, particularly in females compared to young male adults (28,29). approximately 45% of children are first presented before age 10 (30). the mean age of children with t1dm included in this study was 8.3 ± 3.6 years. in our study, at the time of diagnosis of dmt1 about 40% were 10-14 years old; 40% were 5-9 years old and 20% were 0-4 years old of children with diabetes. these findings are consistent with international literature data. interestingly, in search study the distribution of children with diabetes by age group was about 21% of children 0-4 years, in the philadelphia registry, 37% were 5-9 years and 41% were 10-14 years (26), quite similar to that of our study. according to the eurodiab registry, 24% of children with type 1 diabetes were 0–4 years old, 35% were 5–9 years old, and 41% were 10–14 years old (26), these results are quite similar to the findings of our study. a study in france of 1299 children 0–14 years old at the time of t1d diagnosis reported that 26% were 0–4 years old, 34% were 5–9 years old, and 40% were 10–14 years old (31), these findings are completely similar to the age distribution of t1dm evidenced in our study. although most autoimmune diseases more commonly affect females, in the overall incidence of childhood t1dm there no gender difference. in our study, it was observed an almost equal gender distribution among children with type 1 diabetes; 52% male and 48% female. these data are also supported by international studies. the search study on diabetes in youth reported both genders are equally affected by type 1 diabetes (26). type 1 diabetes mellitus is characterized by global, modest seasonal variation, with the highest incidence in the cold months (autumn-winter) and the lowest in the warm months (spring-summer). (32) the diamond project demonstrated that the seasonality of the incidence of type 1 diabetes mellitus in children ages < 15 years is a real phenomenon. statistical differences in the seasonality of the development of type 1 diabetes have been found in populations with intermediate and high incidence compared to the general population (3,33). there is a significant tendency of younger patients to be diagnosed in the cold months. the reason for this seasonal difference is not completely understood, it may be related to the pathogenic role of various environmental triggers including infections encountered more frequently in the younger age groups, especially due to kindergarten enrollment, although there are no definitive conclusions regarding the role of specific infections in the occurrence of dmt1 (34). a study among children ages 0-14 years in bulgaria reported that a greater proportion of children with dmt1 were diagnosed during the autumnwinter period (about 62.5%) (35), a figure completely similar to the finding in our study where 60.5% of children with dmt1 were diagnosed in autumn-winter. in our study we did not observe any clear trend regarding the seasonality of the birth and diagnosis of children with dmt1, as about a quarter of children with dmt1 were born and about a quarter of them were diagnosed in each season of the year. however, 60.5% of dmt1 cases in our study were diagnosed in autumn-winter and 39.5% in spring-summer. there is a connection between the month of birth and the development of dmt1 during the later stages of life (34). children born during the spring and summer months, especially in countries with intermediate incidence such as eastern european countries, have a higher risk of developing type 1 diabetes compared to children born during the fall and winter months (36,37). it kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 18 | 27 is thought to be related to seasonal environmental factors during fetal-perinatal life and thereafter (38) which influence fetuses and children to develop islet autoimmunity (6,23,39) and the disease at different ages (34). our finding was similar to a study in greece (40), while several other studies reported the opposite (26,34). seasonal character of birth month and t1dm development in some sub-populations is related to gender, ethnicity and race, and viral infections. in some countries males born in the spring and summer months are prone to develop t1dm while in others predominate females (41). in our study, 56% (42/75) of children born in the spring summer months were boys. in homogenous populations despite incidence of type 1 diabetes children born in the spring summer months have a higher risk of developing type 1 diabetes, while this association is not in ethnically heterogeneous populations (42). the increased risk of t1dm manifestation in children born in spring-summer is also related to viral infections including enteroviruses, rotavirus, mumps virus, cytomegalovirus, rubella virus, etc. based on serological, immunological findings (43). a variety of infections play a role in the conversion of endogenous beta-cell antigens into immunogenic structures, where infiltration of the islets of langerhans, by activated autoreactive t cells is considered to be the major driver of the onset and progression of type 1 diabetes mellitus. if the pregnancy occurs during the months with the highest presence of viral infections (43) they are more likely to be infected and to transmit the virus to the fetus. consequently, given a normal gestation period of 40 weeks, children born in spring and summer are more likely to develop type 1 diabetes. the order of birth has been associated with t1dm presentation. the study by eirini kostopoulou., et al 2021 (44); chris r cardwell., et al. 2011 (45) showed increase the risk of childhood type 1 diabetes in first born children and reduction risk in secondor later born children particularly among children aged <5 years. the cause of any increase in the risk of childhood type 1 diabetes in first born children is unknown. it is possible related with younger maternal age, maternal prenatal immune response to environment exposures (46), congenital infections and use of antibiotics by mothers during pregnancy (43), reduced or delayed exposure to infections such as enteroviruses (47), household with older siblings who are exposed to infectious agents at school or day care or parents pay attention differently for their first child compared with subsequent children. our findings are consistent with international literature data. this finding may provide indirect support for the hygiene hypothesis, which suggests that the immune system requires stimulation by infections and other immune contests in early life to achieve a mature and balanced repertoire of responses (48). the higher incidence of dmt1 in western countries can be dedicated to the phenomenon of "hygiene hypothesis"; according to this hypothesis, decrease of the frequency of infections of diabetogenic viruses may lead to an increase in the incidence of dmt1 (43). however, exposure to viruses does not necessarily appear to be the cause of dmt1 but rather may be beneficial in some cases (43). regarding viral infections in our country, data is not available. a relatively low level of hygiene, especially in rural areas point toward that viruses are one of the main etiological factors of t1dm. based on the fact that in our study only 25% of diabetic patients lived in rural areas, it appears that this study supports that part of the literature that emphasizes a protective role of viral infections in the development of dmt1 in children. kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 19 | 27 in our study, three quarters of children with t1dm lived in urban areas. such finding has been evidenced into similar studies conducted in the balkan countries (35). however, other studies have evidenced a higher incidence of dmt1 among children living in rural areas (49-53) suggested that the higher incidence of dmt1 in rural areas may be related to a lower exposure of these children to protective environmental factors (53). the international literature suggests the role of psycho-social stress in the development of t1dm in children. a study among 338 children with dmt1 aged 0–14 years in sweden and 528 controls suggested that stressful life events (threats or fear of losing family members, such as divorce or death of parents) adverse psychosocial stressful events (including events with difficult adjustment, child behavioural deviations, and disordered and chaotic family functioning) 12-24 months before the diagnosis of t1dm, during the two years before t1d diagnosis in children statistically significantly increased the risk of t1d (54) and may have different impacts at with a relative risk (rr) of 1.82 in different ages (55). the stressful life events, are associated with the development of t1d in children aged 5-9, acting as a risk factor for this disease (56). in our study, we did not have a comparison group to analyse whether stressful psychosocial life events are a risk factor for t1dm in children, but psychosocial stress related to parental divorce or death was evidenced in 2.6% of children with t1dm at aged 5–9 years compared to the children aged 0–4 and 10-14 years, confirming the findings of the study in sweden. further studies can be undertaken to verify whether psychosocial stress is a risk factor for t1dm in our country. in our study, it was found that 23.7% of children with dmt1, had a history of precipitating viral infections, significantly higher among children aged 0-4 years (41.9%) compared to children aged 5-9 years (27.9) or those aged 10-14 years (10 %) [p=0.002]. more than 85% of individuals who develop type 1 diabetes have no family history, so the general population screening to identify risk in is an important goal (56). in our study we found that 15.8% of children with dmt1 had a family history of dmt1, 17.8% had a family history of dmt2, 28.3% had a family history of dmt1 or dmt2, and 2.6% had a family history of both dmt1 and dmt. the genetic component of the development of dmt1 is known. the risk of developing dm1 in first degree relatives is 8 to 15 times higher (57-59) and about twice as high in second-degree relatives compared to children with no relatives with diabetes (5760). about 10-12% of children with t1dm have a family history of diabetes at the time of diagnosis, which may increase more than 20% during their lifetime (60-63) data which are very similar to the findings of our study. a study among 1488 children aged 0–14 years in finland reported that 21.8% of them had a firstor second-degree relative with type 1 diabetes at the time of diagnosis (64). the fathers transmit dmt1 to their offspring more often than mothers (58,65). similar findings were observed to our study: 12.5% of children with dmt1 had a father and only 8.4% of them had a mother with dmt1 at the time of diagnosis. different studies have reported different data regarding the time between the appearance of symptoms and the moment of diagnosis. the duration of symptoms to the diagnosis can vary greatly, ranging from a few days to several weeks or months depending on the level of education of the parents, the fact of the presence of diabetes in other family members, level of health care, the age of the patient, etc. (66). the average duration of symptoms to the diagnosis of dmt1 in our study we was 23.35 ± 17.16 days, ranging from 0 days (immediate diagnosis) to a kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 20 | 27 maximum of 90 days (ie, 3 month). our results regarding the duration of symptoms were similar to those reported by demir f, et al (67) and usher-smith et al (68). the age of the patient is important because younger patients usually present with mild, vague symptoms, while older children usually present with the classic symptoms of the disease such as polyuria, polydipsia and weight loss (66). younger children are more likely to present in severe stages of the disease, reflecting this in a higher frequency of ketoacidosis (kad) compared to older children due to higher levels of respiratory and gastrointestinal infections in this group, which may delay diagnosis (66). it has been proven that the diagnosis of dmt1 can be established later in girls than in boys, for unknown reasons (66). there are no statistically significant gender differences regarding this parameter, but there are significant age differences where this time was longer in children 5-9 years old (28.61 days) (p = 0.013). polyuria, polydipsia and weight loss were the most common symptoms, 99.3%, 99.3% and 98.1%, receptively. the second and most serious, life-threatening presentation of t1dm is dka. although the incidence of dka in many developed countries has been reduced (69-71), various studies around the world reported a 6-fold variation of dka in presentation from 12.8% to 80% of children diagnosed with t1d for the first time (72). in our study the overall incidence of ketoacidosis was 67.8%. the mean age of children with dka was 7.75 ± 3.64 years, while that of children without dka was 9.29 ± 3.39 years (p = 0.012). the mean age at diagnosis of children with dmt1 with kad is significantly higher than that of children with dmt1 without kad (24.65 ± 17.39 vs 20.61 ± 16.51, p=0.169). in general, children with dmt1 with kad are diagnosed earlier than children with dmt1 without kad, possibly because of their more gravity of clinic. in our study we found that the frequency of dka was higher among girls (76.7%) than among boys (59.5%) and this difference was statistically significant (p = 0.025). the higher frequency of dka among girls with t1d than among boys with t1d is also reported in the international literature. the girls were stated to experience dka more frequently, possibly due to some sexrelated social or biological differences (72). our results were similar to the data of demir f., et al (67). females and ages 0-4 years were identified as factors related to the presence of kad in children with t1dm; 2.24 and 2.97 times, respectively more likely to be affected by kad compared to males and children ages 10-14 years, respectively (p<0.05). nevertheless, was evidenced a negative and statistically significant relationship between age and the presence of kad: for every year increase of the age of children, the possibility of the presence of kad decreases by 0.126 times. positive family history for dmt1 is considered a protective factor and is associated with a reduced risk of dka at t1dm diagnosis because cases are diagnosed in an earlier stage (73). our results did not reach agreement with these findings. pawlowicz et al (74) and also reported that a positive family history had no such impact. positive family history for dmt1 and dmt2 was not statistically significantly associated with the presence of kad in children with dmt1. however, children who have a positive family history of dmt1 or dmt2 were 6 times more likely to be affected by kad (p=0.127); children with a history of dmt1 and dmt2 were 8.73 times more likely to be affected by kad compared to children with dmt1 without a positive family history of dmt1 or dmt2 (p=0.073, borderline). the presence of viral infections or other precipitating conditions increased the odds of kad by 1.58 times compared to kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 21 | 27 children without these conditions, this difference did not reach statistical significance. regarding residence, children living in urban areas are 1.32 times more likely to be affected by kad compared to children in rural areas. the misdiagnosed were in 13.8% of cases, of which respiratory and gastrointestinal and infectious illnesses were the most common. almost all were presented with kad; and almost half (45.3%) were in the age group 04 years similar results were found in the study małgorzata pawłowicz et al (14.13%) (74). autoimmune diseases are more common in females. in children and adolescents with t1dm of both genders carry similar risk and have no significant differences in overall incidence (75). the gender predominance of dmt1 is thought to be influenced by race, age of diabetes diagnosis, and incidence. in certain populations the incidence of dmt1 is more frequent in males (76) and in some more frequent in females (77). in caucasians, in high-incidence countries (23/100,000/year) (78), children ages < 6 and ≥13 years of european origin (age group which is more likely to develop diabetes for the same age and geographical localization (male: female ratio 3:2) (79) men have a slightly higher incidence than females. on the other hand, the female predominance is seen in of non-caucasian origin (80), african and asian, low incidence countries (81), peripubertal age (82). age, urban residence and year of diagnosis (35) and factors are related to viruses’ infections, dietary factors such as gluten, obesity in childhood, improvement of hygienic-sanitary conditions, etc. (83) are statistically significant risk factors for the occurrence of dmt1 in children. t1dm is associated with an increased risk of developing other autoimmune diseases as a result of genetic susceptibility to autoimmune diseases (ad). the most common comorbidities include: autoimmune thyroid disease (atd) and celiac disease (cd) (84), possibly because of some common pathogenetic mechanisms including certain gene expressions (34). these ad are observed more frequently in females with t1dm (85). at diagnosis and during follow up of t1dm 19.74% (30/152) developed associated autoimmune diseases; 11.85% atd and 7.89% cd. of them, 60% at diagnosis of t1dm and 68% of patients were female. during follow up children with t1dm developed associated cd and sat, 2.54, and 2.19 years, respectively. these findings are consistent with international literature data. references 1. diamond project group. incidence and trends of childhood type 1 diabetes worldwide 19901999. diabet med 2006;23:857-66. doi: 10.1111/j.14645491.2006.01925.x. 2. international diabetes federation. diabetes atlas (4th edition). brussels, belgium: idf; 2009. 3. gale ea. the rise of childhood type 1 diabetes in the 20th century. diabetes 2002;51:3353-61. doi: 10.2337/diabetes.51.12.3353. 4. patterson cc, dahlquist gg, gyurus e, green a, soltesz g. incidence trends for childhood type 1 diabetes in europe during 1989-2003 and predicted new cases 2005-20: a multicentre prospective registration study. lancet 2009;373:2027-33. 5. search for diabetes in youth study group. the burden of diabetes mellitus among us youth: prevalence estimates from the search for diabetes in youth study. pediatrics 2006;118:1510-8. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4439892/#ref12 kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. 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(original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 27 | 27 85. fröhlich-reiterer ee, hofer s, kaspers s, herbst a, kordonouri o, schëarz hp, et al. screening frequency for celiac disease and autoimmune thyroiditis in children and adolescents with type 1 diabetes mellitus—data from a german/austrian multicentre survey. pediatr diabetes 2008;9:546-53. ________________________________________________________________________________________ © 2022 kollçaku; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 1 | 11 original research level of satisfaction among primary health care workers in kosovo haxhi kamberi1,2, vanesa tanushi2, muhamet kadrija2,3 1 regional hospital “isa grezda”, gjakova, kosovo; 2 faculty of medicine, university of gjakova “fehmi agani”, gjakova, kosovo; 3 family medicine center, gjakova, kosovo. corresponding author: vanesa tanushi, faculty of medicine, university of gjakova “fehmi agani”, gjakova, kosovo; address: str. "sabrije vokshibija", n.n., 50 000 gjakova, kosovo; telephone: +383 45686337; email: vanesa.tanushi@uni-gjk.org kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 2 | 11 abstract aim: the objective of this study was to assess the extent and selected corelates of work satisfaction among primary healthcare professionals in kosovo. methods: a cross-sectional study was conducted in selected regions of kosovo during the period may-june 2022 including a representative sample of 500 primary healthcare workers (209 men and 291 women; overall mean age: 42.0±12.3 years). a structured 9-item questionnaire was administered to all participants aiming at assessing the level of satisfaction among primary healthcare workers (each item ranging from 1 [high] to 5 [low]). a summary score was calculated for all 9 items related to satisfaction level ranging from 9 (the highest satisfaction level) to 45 (the lowest satisfaction level). binary logistic regression was used to assess the association of satisfaction level (dichotomized into “satisfied” vs. “unsatisfied”, based on median value of the summary score) with selected demographic factors and work characteristics of primary healthcare workers. results: mean summary score of the 9 items related to the satisfaction level of primary healthcare workers was about 23±5; median score was 23 (interquartile range: 20-26). in multivariableadjusted logistic regression models, the level of satisfaction was not significantly related to any demographic factor, but positively associated with the years of working experience of primary healthcare workers [or(for 1 year increment in the work experience)=1.03, 95%ci=1.00-1.05] . conclusion: the evidence from this study conducted in kosovo indicates no significant relationships of the level of satisfaction with demographic factors of primary healthcare workers, but a strong association with their working experience. policymakers in kosovo and in other countries should be aware of the importance of working conditions and working environment in order to gradually increase the level of satisfaction of the staff, which is a basic prerequisite for quality improvement of service delivery at primary healthcare level. keywords: epidemiology, family physicians, kosovo, nurses, primary health care, satisfaction, staff, work characteristics. kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 3 | 11 introduction the health indicators in kosovo are worse than most of the european union countries including, in particular, life expectancy (1). furthermore, almost 15 years after declaring its independence, kosovo is still struggling to shifting its formerly semashko healthcare system toward social health insurance, in line with the trends observed in many former communist countries in central and eastern europe (2). however, primary health care services in kosovo are currently well-regulated and standardized in all regions of the country. according to the most recent information, there were registered about 3.2 million visits at primary health care services in 2021 (3). according to an assessment of the world health organization, in alignment with the regulatory framework, primary health care in kosovo provides quality and safe health services, based on the principles of family medicine and led by the needs and requirements of individuals, families and communities with the final aim at promoting, preserving and improving health for all (4). however, primary health care payment schemes need to be revised to encourage higher performance (4). the available evidence about the level and determinants of satisfaction of primary healthcare workers in kosovo is scant. of note, assessment of satisfaction level of primary healthcare workers constitutes an important component of the overall assessment of health care services regarding quality and health care system responsiveness (5,6). the international literature suggests that the satisfaction of healthcare professionals is related to both patients’ satisfaction and the quality of care provided and also to more favourable health outcomes (7-10). moreover, the way medical staff communicates with patients seems to have a significant effect on the level of patients’ satisfaction, as evidenced by international literature: not applying a dominant position, being caring and committed to patients, and positive attitudes have a favorable influence on the functioning of the relationship between health personnel and patients (11,12). conversely, the degree to which primary healthcare staff is satisfied is influenced by several factors, including salary, individual characteristics, infrastructure of health care institutions, time pressure, autonomy in making decisions, professional relationships with colleagues, and the like (13-15). stress at work also affects the reduction of satisfaction of health personnel, while the possibility of having control over the schedule of visits and working hours seems to be related to a greater satisfaction at work (16). likewise, job satisfaction or dissatisfaction seems to be related to physicians’ plans to leave work (with younger physicians being more likely to plan to leave medical practice in the future), and dissatisfaction with remuneration and with the work environment (17). in this framework, the objective of this study was to assess the level of satisfaction and selected demographic and work characteristics correlates among primary healthcare workers in kosovo, a country in the western balkans which is currently undergoing profound reforms in all sectors including health sector. methods a cross-sectional study was conducted during the period may-june 2022 including a representative sample of primary healthcare workers in selected regions of kosovo. kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 4 | 11 the study was carried out in three regions of kosovo: gjakova, peje, and prizren, which are among the main regions of the republic of kosovo. more specifically, this study included a random sample of 500 primary healthcare workers aged 18 years and above in the regions of gjakova, peje and prizren (209 men and 291 women; overall response rate: 97%). the level of satisfaction of primary healthcare workers was based on an adapted version of the dartmouth-hitchcock medical center instrument (17). this instrument covers nine different aspects (work characteristics) relevant to primary healthcare staff including: respect at the workplace; availability of equipment and instruments; work recognition by colleagues and authorities; stress at workplace; access to information about different aspects of the work; moral and attitudes of the colleagues; continuous improvement of the environment at the workplace; overall perceived quality of healthcare facility; and staff remuneration (18). potential answers for each question are arranged in a 5-point likert scale from 1 (“highest satisfaction” level) to 5 (“lowest satisfaction” level). this questionnaire has been already validated in the context of primary healthcare workers in kosovo (19). a summary score was calculated for all 9 items related to the level of satisfaction among primary healthcare workers ranging from 9 (highest level of satisfaction) to 45 (lowest level of satisfaction). in the analysis, the summary score was dichotomized into “satisfied” vs. “unsatisfied’ based on its median value. furthermore, information about demographic factors (age, gender, place of residence) and work characteristics (profession, work experience, years in the current job position, and engagement in continuous professional education) were collected for all study participants. of note, the study was approved by the ethics commission and council of the faculty of medicine, university of gjakova. fisher’s exact test was used to compare differences in selected demographic factors and work characteristics (age-group, place of residence, region, profession and continuous professional education) between male and female participants. similarly, fisher’s exact test was employed to compare differences in demographic factors and work characteristics between satisfied and unsatisfied primary healthcare workers. conversely, student’s ttest was used to compare gender differences in mean values of work experience and years in current job position. binary logistic regression was used to assess the association of the summary score of the satisfaction (9item instrument, dichotomized in the analysis into “satisfied” vs. “unsatisfied” based on median value of the summary score) with demographic factors and work characteristics of study participants. initially, crude (unadjusted) odds ratios (ors), their respective 95% confidence intervals (95%cis) and p-values were calculated. subsequently, multivariable-adjusted binary logistic regression models were run controlling simultaneously for all demographic factors and work characteristics of study participants (age-group, sex, place of residence, region, profession, continuous professional education and work experience). multivariable-adjusted ors, their respective 95%cis and p-values were calculated. in all cases, a p-value ≤0.05 was considered as statistically significant. statistical package for social sciences (spss, version 19.0) was used for all the statistical analyses. results mean age (±sd) of primary health care workers included in this study was 42.0±12.3 years; median age was 42 years (interquartile range: 32-53 years); the age range was: 19-64 kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 5 | 11 years (data not shown in the tables). table 1 presents the distribution of demographic factors and work characteristics of study participants (n=500), separately in men and in women. overall, about 23% of individuals were aged ≤30 years, whereas 28% of participants (24% in men vs. 30% in women; p=0.04) were 51 years and above. about 32% of primary healthcare professionals worked in rural areas (38% in men vs. 28% in women; p=0.02). about 33% of individuals were resident in prizren region (40% in men vs. 28% in women; p=0.01). around 17% (25% in men vs. 12% in women) were family physicians, 13% (14% in men vs. 11% in women) were general practitioners, and 67% (57% in men vs. 74% in women) were nurses (overall p<0.01). more than 2/3rd of participants (68%) was actively engaged in continuous professional education (73% in men vs. 65% in women; p=0.07). on average, the staff included in this survey had about 16 years of work experience and about 12 years in the current job position, without evidence of any gender differences (table 1). table 1. distribution of demographic factors and work characteristics in a sample of primary health care workers in kosovo in 2022 (n=500) demographic factors and work characteristics total (n=500) men (n=209) women (n=291) p† age-group: ≤30 years 31-50 years ≥51 years 114 (22.8)* 247 (49.4) 139 (27.8) 41 (19.6) 117 (56.0) 51 (24.4) 73 (25.1) 130 (44.7) 88 (30.2) 0.044 place of residence: urban areas rural areas 339 (67.8) 161 (32.2) 129 (61.7) 80 (38.3) 210 (72.2) 81 (27.8) 0.015 region: gjakove peje prizren 171 (34.2) 165 (33.0) 164 (32.8) 58 (27.8) 67 (32.1) 84 (40.2) 113 (38.8) 98 (33.7) 80 (27.5) 0.005 profession: family physician general practitioner nurse other 87 (17.4) 63 (12.6) 335 (67.0) 15 (3.0) 53 25.4) 30 (14.4) 120 (57.4) 6 (2.9) 34 (11.7) 33 (11.3) 215 (73.9) 9 (3.1) <0.001 continuous professional education: no yes 160 (32.0) 340 (68.0) 57 (27.3) 152 (72.7) 103 (35.4) 188 (64.6) 0.065 work experience (years): mean (sd) median (iqr) 15.6±11.7 14 (4-24) 15.6±10.7 15 (5-24) 15.6±12.3 14 (3-24) 0.985 years in current position: mean (sd) 12.3±10.4 12.2 ±9.5 12.4±11.0 0.798 kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 6 | 11 median (iqr) 10 (3-20) 10 (4-17) 10 (2-20) * absolute numbers and column percentages (in parenthesis). † p-values from fisher’s exact test (for comparison of age-group, place of residence, region, profession and continuous professional education) and student’s t-test (for comparison of work experience and years in current job position). a summary score was calculated for all 9 items of the satisfaction level of primary healthcare workers ranging from 9 (indicating the highest level of satisfaction of primary healthcare workers) to 45 (indicating the lowest level of satisfaction of primary healthcare workers). mean summary score of the 9 item-instrument of the level of satisfaction of primary healthcare workers was 22.9±4.6; median score was 23 (interquartile range: 20-26) [data not shown in the tables]. the summary score was subsequently dichotomized into “satisfied” vs. “unsatisfied” staff based on its median value. table 2 presents the distribution of the level of satisfaction (dichotomized into “satisfied” vs. “unsatisfied”) by selected demographic factors and work characteristics of primary healthcare workers. the proportion of men was slightly higher among the satisfied staff as compared with the unsatisfied individuals (about 43% vs. 40%, respectively), but this small gender difference was not statistically significant. furthermore, the percentage of staff aged 51 years and above was higher among the satisfied workers compared with their unsatisfied counterparts (about 32% vs. 23%, respectively), a difference which was statistically significant (p=0.04). there was a borderline statistically significant association with place of residence (p=0.1), with a higher proportion of urban residents among the satisfied workers than among the unsatisfied ones (about 70% vs. 65%, respectively). in addition, the proportion of family physicians was higher among the satisfied workers compared with the unsatisfied staff (20% vs. 15%, respectively; p=0.05). conversely, there was no association of the level of satisfaction with region, or engagement in continuous professional education (table 2). table 2. distribution of the level of satisfaction by selected demographic factors and work characteristics of primary healthcare workers demographic factors and work characteristics unsatisfied (n=226) satisfied (n=274) p† gender: men women 90 (39.8)* 136 (60.2) 119 (43.4) 155 (56.6) 0.466 age-group: ≤30 years 31-50 years ≥51 years 61 (27.0) 113 (50.0) 52 (23.0) 53 (19.3) 134 (48.9) 87 (31.8) 0.037 place of residence: urban areas rural areas 146 (64.6) 80 (35.4) 193 (70.4) 81 (29.6) 0.098 region: gjakove peje prizren 69 (30.5) 79 (35.0) 78 (34.5) 102 (37.2) 86 (31.4) 86 (31.4) 0.291 kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 7 | 11 profession: family physician general practitioner nurse other 33 (14.6) 37 (16.4) 147 (65.0) 9 (4.0) 54 (19.7) 26 (9.5) 188 (68.6) 6 (2.2) 0.045 continuous professional education: no yes 72 (31.9) 154 (68.1) 88 (32.1) 186 (67.9) 0.998 * absolute numbers and column percentages (in parenthesis). † p-values from fisher’s exact test. table 3 presents crude (unadjusted) and multivariable-adjusted association of the level of satisfaction (dichotomized into “satisfied” vs. “unsatisfied”) with demographic factors and work characteristics of primary healthcare workers, according to results obtained from binary logistic regression. in crude models, there was evidence of a positive association of the level of satisfaction with age of primary healthcare workers (overall p=0.04). there was no signification association with gender, or place of residence, albeit higher odds of males and especially urban residents among the satisfied staff compared with their unsatisfied counterparts. on the other hand, there was a graded positive relationship with age-group: the odds of satisfaction were significantly lower among younger participants compared with their older counterparts (or=0.5, 95%ci=0.3-0.9). in addition, the odds of family physicians were considerably higher (about 2.5 times) among satisfied vs. unsatisfied workers, a finding which was, overall, statistically significant (p=0.05). notably, the odds of satisfaction increased by 3% for an increment of one year in the work experience of study participants (p<0.01). in multivariable-adjusted logistic regression models controlling simultaneously for all demographic factors and work characteristics presented in table 3, the association with profession was no longer statistically significant, whereas the positive relationship with work experience persisted [or(for 1 year increment in the work experience)=1.03, 95%ci=1.00-1.05], albeit borderline significant (p=0.08). table 3. association of the level of satisfaction with demographic factors and work characteristics of primary healthcare workers – results from binary logistic regression socio-demographic factors unadjusted models multivariable-adjusted models or* 95%ci* p* or 95%ci p gender: men women 1.16 1.00 0.81-1.66 reference 0.416 1.24 1.00 0.84-1.81 reference 0.281 age-group: ≤30 years 31-50 years ≥51 years 0.52 0.71 1.00 0.31-0.86 0.46-1.08 reference 0.038 (2)† 0.011 0.112 1.30 1.17 1.00 0.52-3.24 0.62-2.18 reference 0.855 (2) 0.578 0.628 place of residence: kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 8 | 11 urban areas rural areas 1.31 1.00 0.90-1.90 reference 0.165 1.26 1.00 0.85-1.87 reference 0.245 region: gjakove peje prizren 1.34 0.99 1.00 0.87-2.07 0.64-1.52 reference 0.292 (2) 0.184 0.954 1.40 0.99 1.00 0.89-2.21 0.63-1.54 reference 0.241 (2) 0.150 0.955 profession: family physician general practitioner nurse other 2.46 1.06 1.92 1.00 0.80-7.52 0.33-3.32 0.67-5.51 reference 0.048 (3) 0.116 0.928 0.226 1.76 0.90 1.55 1.00 0.55-5.68 0.28-2.89 0.53-4.55 reference 0.222 (3) 0.341 0.856 0.427 cpe: no yes 1.01 1.00 0.69-1.48 reference 0.951 1.03 1.00 0.70-1.53 reference 0.874 work experience (years) 1.03 1.01-1.04 0.001 1.03 1.00-1.05 0.078 * odds ratios (or: “satisfied” vs. “unsatisfied”), 95%ci and p-values from binary logistic regression. range of the summary score (dichotomized into satisfied vs. unsatisfied based on its median value) was from 9 (the highest level of satisfaction) to 45 (the lowest level of satisfaction among primary healthcare workers). † overall p-values and degrees of freedom (in parentheses). discussion this study provides valuable evidence about the level of satisfaction of primary healthcare workers in kosovo, a country which is presently emerged into deep political and socioeconomic reforms including also the health sector. in our study, upon multivariable-adjustment for a range of characteristics, there was no evidence of independent associations of satisfaction level with demographic factors of primary healthcare workers. on the other hand, there was evidence of a strong and significant relationship with working experience of the primary healthcare staff. our finding on a positive association of satisfaction level with working experience of primary healthcare staff is compatible with a previous report from kosovo (19). a study among health personnel in rural areas of iran reported that only 17% were satisfied with their work (20), whereas a study among public primary healthcare physicians in delhi, india, reported that all personnel were dissatisfied with training policies and practices, with the level of wages and opportunities to make a career in the system (21), findings which are not in line with the results of our study, where the personnel was generally satisfied with the working environment and working “spirit” in primary healthcare services and the dimensions where dissatisfaction was relatively high included wages (remuneration) and stress at work. a recent study conducted in saudi arabia reported that none of the sociodemographic variables had significant association with job satisfaction (22). according to this report, about two thirds of the primary health care workers were not satisfied with their job (22). on the other hand, a job satisfaction survey with nhs employees reported that, despite the evident limitations placed by the environment, a significant degree of job satisfaction was evidenced among primary health care workers, with 58% of respondents kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 9 | 11 expressing they looked forward to going to work and 65% saying they enjoyed being at work (23). also, a majority of 62% had no plans to change employers (23). a fairly recent study conducted in turkey reported that primary health care workers were generally dissatisfied with their working conditions and they declared that they were not sufficiently qualified to work in primary care. their overall satisfaction was found to be moderate and the most important predictor for job satisfaction was found to be “liking the workplace” (24). conversely, a study on the satisfaction of public healthcare (hospital) staff in 2011 in serbia used some questions similar to those used in our questionnaire (for example, satisfaction with available medical equipment, personal relationships with colleagues, satisfaction with salary, availability of available protocols) (25). the most important factors related to health staff satisfaction in this study (ranked from the most important factor) included: receiving clear instructions regarding the objectives to be achieved in the workplace, the opportunity for professional development in the workplace, good relations with colleagues, satisfactory salary, adequate clinical tools, adequate time to carry out tasks, opportunity for continuing education in the workplace, and the like (25). of note, some of these factors were also affirmed by the health personnel in our study conducted in kosovo. nonetheless, there may be several limitations of the current study conducted in kosovo. our study included only three regions of kosovo and, notwithstanding the fact that the regions included are fairly representative of the whole country, findings may not be generalizable to all the primary healthcare workforce in kosovo. in addition, although the sample size included in this study was sufficient to assess the satisfaction level among primary healthcare workers, it may have not allowed to detect small differences in the satisfaction level between different demographic groupings. the instrument used in our study for assessment of satisfaction level has been previously validated in primary healthcare workers in kosovo (18) but, nevertheless, the possibility of information bias cannot be entirely excluded. also, associations observed in this type of study (cross-sectional survey) are not assumed to be causal. regardless of these potential limitations, this study provides useful evidence about the level of satisfaction among primary healthcare workers operating in three regions of kosovo. this study indicates no significant relationships of the level of satisfaction with demographic factors of primary healthcare workers, but a strong association with their working experience. in all cases, policymakers in kosovo and in other countries should be aware of the importance of working conditions and working environment in order to gradually increase the level of satisfaction of the staff, which is a basic prerequisite for quality improvement of service delivery at primary healthcare level. references 1. the world bank. life expectancy at birth in kosovo. https://data.worldbank.org/indicator/ sp.dyn.le00.in?locations=xk (accessed: 29 october, 2022). 2. pavlova m, tambor m, stepurko t, merode g, groot w. assessment of patient payment policy in cee countries: from a conceptual framework to policy indicators. soc econ. 2012;34:193-220. 3. the world bank. total fertility rate in kosovo. https://data.worldbank.org/indicator/ kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 10 | 11 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kumar p, khan am, inder d, sharma n. job satisfaction of primary health-care providers (public sector) in urban setting. j family med prim care 2013;2:227-33. 22. aljumail e, rabbani u. job satisfaction among primary health care workers in buraidah, qassim, saudi arabia. world family medicine 2021;19:27-33. doi: 10.5742/mewfm.2021.94173. 23. campden health. job satisfaction survey; 2013. https://www.cogora.com/wpcontent/uploads/2016/11/jobsatisfaction.pdf (accessed: 29 october, 2022). 24. bucaktepe pge, celik sb, celik f. job satisfaction in primary care after the health reform in a province of turkey. eur rev med pharmacol sci 2022;26:2363-72. 25. janicijevic i, seke k, djokovic a, filipovic t. healthcare workers satisfaction and patient satisfaction where is the linkage? hippokratia 2013;17:157-62. © 2022 kamberi et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3. 0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. s khadragy, m elshaeer, t mouzaek, d shammass, f shwedeh, a aburayya, a jasri, s aljasmi, predicting diabetes in united arab emirates healthcare: artificial intelligence and data mining case study. seejph 2022. posted: 26-07-2022. page 1 original research predicting diabetes in united arab emirates healthcare: artificial intelligence and data mining case study saada khadragy1, mohamed elshaeer2, talal mouzaek3, demme shammass4, fanar shwedeh5, ahmad aburayya5, ammar jasri6, shaima aljasmi6 1assistant professor, mis department, business college, city university ajman, ajman, united arab emirates 2pharma program, college of pharmacy, gulf medical university, ajman, uae 3senior specialist physician, sheikh khalifa general hospital umm al quwain, umm al quwain, uae 4specialist internal medicine, intensive care unit, midclinic city hospital, dubai, uae 5assistant professor, mba department, business college, city university ajman, ajman, uae 6senior specialist registrar, dubai academic health corporation, dubai, uae corresponding author: dr. fanar shwedeh mba department, business college, city university ajman, ajman, uae. s khadragy, m elshaeer, t mouzaek, d shammass, f shwedeh, a aburayya, a jasri, s aljasmi, predicting diabetes in united arab emirates healthcare: artificial intelligence and data mining case study. seejph 2022. posted: 26-07-2022. page 2 abstract aim: the primary aim of this article is to address the scarcity of tools available to examine the relationships between different attributes in medical datasets within the healthcare industry. specifically, the focus is on developing a predictive model for diabetes using artificial intelligence and data mining techniques in the united arab emirates healthcare sector. methods: the paper follows a comprehensive approach, employing the four data mining steps: data preprocessing, data exploration, model building, and model evaluation. to build the predictive model, the decision tree algorithm is utilized. data from 2856 patients, collected from prime hospitals in dubai, united arab emirates, are analyzed and used as the basis for model development. results: the research findings indicate that several factors significantly influence the likelihood of developing diabetes. specifically, age, gender, and genetics emerge as critical determinants in predicting the onset of diabetes. the developed predictive model demonstrates the potential to provide accurate and easy-to-understand results regarding the likelihood of diabetes in the future. conclusion: this study highlights the importance of artificial intelligence and data mining techniques in predicting diabetes within the united arab emirates healthcare sector. the findings emphasize the significance of age, gender, and genetics in diabetes prediction. this research addresses the current data scarcity and offers valuable insights for healthcare professionals. furthermore, the study recommends further research to enhance diabetes prediction models and their application in clinical settings. keywords: artificial intelligence, data mining, decision tree algorithm, diabetes, healthcare industry, medical center data, patient attributes, predictive modeling, risk factors. s khadragy, m elshaeer, t mouzaek, d shammass, f shwedeh, a aburayya, a jasri, s aljasmi, predicting diabetes in united arab emirates healthcare: artificial intelligence and data mining case study. seejph 2022. posted: 26-07-2022. page 3 introduction the healthcare industry has accumulated vast data through record keeping and patient care (1,2). efforts have been made to bridge the gap between generated and stored data, and automated medical records have facilitated the archiving of doctor-patient interactions. this emergence of "big healthcare data" presents opportunities for data analysis, healthcare management, and treatment outcome prediction. big data analytics has the potential to transform the healthcare sector by improving effectiveness, disease outbreak response, medical experimentation, and healthcare expenditure optimization (3,4). with the increasing aging population, the prevalence of chronic diseases, and expensive medical technology, there is a need to enhance the sustainability of healthcare models. by improving healthcare system efficiency, substantial savings in community spending can be achieved, reaching up to 20% of the gross domestic product on average within the oecd, potentially amounting to €330 billion in the united states of america (usa) and europe based on 2021 figure 1. figure 1: efficiency of the health care system the healthcare industry has generated a significant amount of data that has impacted various fields. however, adopting big data approaches has been slow in the industry (3,4,8). this paper aims to explore the reasons behind this reluctance and highlight the potential of big data in extracting valuable insights from existing datasets. the report will examine the four perspectives of care data analytics (descriptive, diagnostic, prognostic, and prescriptive) to demonstrate the opportunities for innovation and the development of business models (9,10,11). additionally, it will discuss how implementing big data technologies can enhance healthcare productivity and accessibility and outline the steps required to achieve this goal. s khadragy, m elshaeer, t mouzaek, d shammass, f shwedeh, a aburayya, a jasri, s aljasmi, predicting diabetes in united arab emirates healthcare: artificial intelligence and data mining case study. seejph 2022. posted: 26-07-2022. page 4 literature review big data in the healthcare field the healthcare industry generates significant data, encompassing patient records, diagnostic tests, treatment plans, and more. however, harnessing the potential of big data in healthcare requires advanced management and storage solutions. while data analytics is commonly used in the healthcare sector, implementing big data approaches is still in its early stages (6,7,11). healthcare data is often fragmented and stored in separate systems, making it challenging to access and analyze comprehensively. integrating various data sources, including electronic medical records, vital signs, laboratory results, medication records, and patient-generated data from internet of things (iot) devices, holds great potential for valuable insights (7,12). linking these datasets can provide a holistic understanding of patient conditions, treatment outcomes, and population health. this integrated approach to healthcare data analytics has implications for personalized treatment plans, disease progression prediction, resource allocation optimization, and lifestyle improvement programs. by identifying patterns and correlations, healthcare professionals can make informed decisions and improve patient outcomes (7). moreover, comprehensive analysis of healthcare data can drive innovation and inform business models in the healthcare industry. it enables the identification of trends, inefficiencies, and opportunities for improvement (13). although challenges exist in accessing and analyzing fragmented healthcare data, integrating and linking disparate datasets can unlock valuable insights for improved healthcare outcomes, resource allocation, and the development of innovative approaches in the field. the full potential of big data in healthcare is yet to be realized, but its impact holds promise for transformative advancements in patient care and healthcare management (14). medical database the elderly population is growing rapidly, leading to an increase in demand for healthcare services due to the prevalence of chronic diseases among the elderly. according to projections, the number of individuals aged 85 years and older will increase from 14 million to 19 million by 2020 and to 40 million by 2050. the impact s khadragy, m elshaeer, t mouzaek, d shammass, f shwedeh, a aburayya, a jasri, s aljasmi, predicting diabetes in united arab emirates healthcare: artificial intelligence and data mining case study. seejph 2022. posted: 26-07-2022. page 5 of this growing demand is evident from a study by accenture conducted in 2021, which found that one-third of european hospitals reported operating losses (1,3). to analyze this challenge, the concept of the triangle of healthcare is often used, which comprises three elements: quality, access, and cost (4,5). the effectiveness, value, and resulting outcomes of care reflect the quality of a healthcare system. access refers to who can receive care and when they need it. cost represents the price tag of care and its affordability for patients and payers. the problem is that these elements often compete with each other in the healthcare sector. healthcare optimization approaches can improve the triangle of health. still, a groundbreaking breakthrough is needed to fully disrupt the iron triangle where quality, access, and cost are optimized simultaneously. the healthcare industry holds vast amounts of valuable data, which has the potential to revolutionize the triangle. traditionally stored as text, there is a trend towards converting this data into more accessible formats (5). classification models based on rule sets identifying complex decision trees is challenging, especially when data is consistently presented within the tree. c4.5 is often referred to as a statistical classifier (12,13). c4.5 introduced a structure that clusters the directions of statements together, simplifying the identification process. each statement's directions are grouped, and a case is classified based on the first direction that meets its criteria. if no direction is satisfied, it is directed to a specified class (12). decision tree algorithm decision tree algorithms include cart, id3, and c4.5, (12,13) which differ in their splitting methods, stopping criteria, and class assignment. cart utilizes the gini index to measure split impurity, making it suitable for high-dimensional numerical data. decision trees can handle continuous data but require modifications for categorical data (15-17). methods this study collected data from uae medical centers to create a predictive model in spss (11,14) for assisting in the diagnosis of diabetic patients. the model aims to support healthcare professionals in making informed decisions using reliable electronic sources. the study utilized the "if conditions then conclusion" rule and the k-means algorithm s khadragy, m elshaeer, t mouzaek, d shammass, f shwedeh, a aburayya, a jasri, s aljasmi, predicting diabetes in united arab emirates healthcare: artificial intelligence and data mining case study. seejph 2022. posted: 26-07-2022. page 6 for clustering. data from 2856 patients in leading dubai hospitals were collected. if and then regulations encompass two fundamental elements: the regulation initiator (if section) that outlines certain conditions associated with predictor attributes' significance, and the regulation result (then section) that articulates an anticipated value for a target attribute (12). possessing a precise expectation regarding the target attribute's value can enhance the decision-making process. if-then expectation regulations find widespread application in data analytics, as they embody explicit knowledge at a profound level of comprehension (12). in healthcare, this concept can be employed as follows: by considering specific indicators and past medical history, one can deduce the underlying cause of a particular disease. k-mean algorithm for data clustering algorithms aid in knowledge discovery by identifying attribute relationships and describing the nature of connections between them. categorization and clustering are commonly utilized methods for gaining insights into this process. the categorized analysis involves supervised learning algorithms that examine pre-categorized datasets to generate classification rules. conversely, clustering employs unsupervised learning algorithms to partition a dataset into cohesive groups or clusters. clustering is a fundamental data mining technique across diverse domains like education and healthcare (18-20). gathering patient data and information from medical centers in person posed a significant challenge during the initial stages of this study. to overcome this obstacle, the following steps were taken: • an official letter was issued to collect medical data. regional hospitals didn't provide data, except for prime hospitals in dubai. the researcher contacted a prime hospital, which requested data collection. the researcher then started the four-step data mining process, beginning with data cleaning (figure 2). figure 2: the steps of data mining s khadragy, m elshaeer, t mouzaek, d shammass, f shwedeh, a aburayya, a jasri, s aljasmi, predicting diabetes in united arab emirates healthcare: artificial intelligence and data mining case study. seejph 2022. posted: 26-07-2022. page 7 • the initial form of the provided data was unsuitable for this research study as it contained negative values for age and weight and missing information on gender and genetics. • the data was subsequently cleaned and organized to fit the requirements of this type of research. table 1 represents the final form of the data after the cleaning process. results after implementing the previous steps on the collected data, the results indicate a significant influence of all the independent variables (genetics, gender, and age) on the dependent variable (diabetes). figure 3 depicts the resultant predictive model generated by a decision tree, which can aid in diagnosing whether an individual is likely to develop diabetes based on their genetic history, age, and gender. the conclusive outcomes establish the following regulations: • if both parents have diabetes, then there are no significant statistical differences among the other variables. • if a male is under 40 years old and has one parent with diabetes, then he has a 100% chance of having the same disease. • if a female is under 40 years old and has one parent with diabetes, then she has a 51.8% chance of having the same disease. • if a male is between 52 and 63 years old and has one parent with diabetes, then he has an 88.12% chance of having the same disease. • if a female is between 52 and 63 years old and has one parent with diabetes, then she has a 100% chance of having the same disease. • if a female is between 63 and 71 years old and has one parent with diabetes, then she has a 52.5% chance of having the same disease. • if a male is between 63 and 71 years old and has one parent with diabetes, then he has a 98.7% chance of having the same disease. prior to developing the final model, which is illustrated in figure 3, we utilized the entropy manual method to determine which independent variable to initiate the classification model. consequently, the information gained from the independent variable "genetics" was found to be greater than that of the other independent variables. therefore it was prioritized as the starting point for the predictive model, as shown in the decision tree (fig. 3). s khadragy, m elshaeer, t mouzaek, d shammass, f shwedeh, a aburayya, a jasri, s aljasmi, predicting diabetes in united arab emirates healthcare: artificial intelligence and data mining case study. seejph 2022. posted: 26-07-2022. page 8 figure 3: predictive model with decision tree algorithm we identified relevant attributes for the healthcare predictive model and used spss no ??? for the interpretation. after data cleaning, we obtained the final database with 2857individuals from the prime hospital in dubai (table 1). table 1. dependent and independent variables. gender age genetics diabetic patient n valid 2857 2857 2857 2857 missing 0 0 0 0 table 1 displays the independent variables, including age, gender, and genetics, alongside the dependent variable, which is the diabetic patient. table 2. data classification s khadragy, m elshaeer, t mouzaek, d shammass, f shwedeh, a aburayya, a jasri, s aljasmi, predicting diabetes in united arab emirates healthcare: artificial intelligence and data mining case study. seejph 2022. posted: 26-07-2022. page 9 frequency percent valid percent cumulative percent valid no 1131 39.7 39.7 39.7 yes 1727 60.5 60.5 100.1 total 2857 100.1 100.1 table 2 displays the dataset comprising2856 individuals, of which 1130 (39.6%) are nondiabetic, and 1726 (60.4%) are diabetic. the following tables illustrate the statistical associations between the dependent variable, diabetes, and the independent variables, genetics, age, and gender. table 3. the effect of genetics on diabetes. genetics frequency percent valid percent cumulative percent valid none 899 32.5 32.5 32.3 1 1225 41.8 41.8 75.4 2 735 24.8 24.8 101.1 total 2857 101.1 101.1 table three displays the association between the initial independent variable (genetics) and the dependent variable (diabetes). with the if-then rule applied, the following outcomes can be obtained: -if both parents have diabetes, then 90.7% of the total number of individuals will have diabetes. as can be observed from the table, the number of diabetic patients who have both parents diagnosed with diabetes is 734, representing 25.7% of the total sample size. out of these, 699 individuals could be diabetic patients due to genetic reasons since both of their parents have diabetes. -if both parents have diabetes, then 9.3% of the total number will not be diabetic patients. furthermore, it can be observed that there are 45 individuals in the sample who do not have diabetes despite having both of their parents with the disease. s khadragy, m elshaeer, t mouzaek, d shammass, f shwedeh, a aburayya, a jasri, s aljasmi, predicting diabetes in united arab emirates healthcare: artificial intelligence and data mining case study. seejph 2022. posted: 26-07-2022. page 10 upon analyzing the data, it was discovered that 1224 individuals (42.9% of the total sample size) have one parent with diabetes. of these individuals, 402 do not have diabetes while 822 have the disease. this implies that: -if one parent has diabetes, then the probability of having the same disease would be decreased for the next generations. the final rule pertains to individuals whose parents are not diabetic patients. out of the total sample size, 899 (32.4%) individuals were found to have non-diabetic parents. among them, 682 (76.9%) do not have diabetes, whereas 217 (24.2%) are diabetic patients, indicating that: -if both parents do not have diabetes, then the disease for the next generations would be rare. we have deduced the following findings from our analysis using the if conditions then conclusion rule: -if both parents have diabetes, then there will not be any significant statistical differences between age and diabetes. -to obtain accurate results for the first case where both parents are not diabetic patients, we applied the frequency method to clean and verify the age data provided. we then divided the data into six age intervals as follows: for the first age interval (≥ 39), a frequency analysis was conducted to clean and organize the data. the interval had a total of 56 cases, which accounted for 2% of the entire dataset. of those 56 cases, 52 (92.9%) did not have diabetes, while only 4 (7.1%) had the disease. this suggests that age may not be a significant factor in the development of diabetes for individuals in this age range. •if the person's age is below 40 and both of their parents are not diabetic patients, then the likelihood of developing diabetes in the future is low with a percentage of 7.1%. •if the person's age is below 40 and both of their parents are not diabetic patients, then the probability of not having diabetes in the future is high with a percentage of 92.9%. the second age interval is [39, 46], and it includes 74 individuals, which is 2.6% of the total sample. among them, 52 individuals do not have diabetes, which accounts for 70.3%, while 22 individuals have diabetes, which accounts for 29.7%. this implies: •if the person is between 39 and 46 years old and has non-diabetic parents, the likelihood s khadragy, m elshaeer, t mouzaek, d shammass, f shwedeh, a aburayya, a jasri, s aljasmi, predicting diabetes in united arab emirates healthcare: artificial intelligence and data mining case study. seejph 2022. posted: 26-07-2022. page 11 of having diabetes in the future is lower, with a percentage of 29.7%. •if the person is between 39 and 46 years old and has non-diabetic parents, the likelihood of not having diabetes in the future is higher, with a percentage of 70.3%. the third interval, which is [46, 52], includes 87 individuals, representing 3% of the total sample. of these individuals, 18 do not have diabetes, accounting for 20.7% of the group, while 69 are diabetic, representing 79.3% of the group. this indicates that: if the person is between 46 and 52 years old and has non-diabetic parents, then the likelihood of developing diabetes in the future would increase with a percentage of 79.3%. -on the other hand, if the person is in this age group and has non-diabetic parents, then the probability of not having diabetes in the future would decrease with a percentage of 20.7%. the fourth interval, which is [52, 55], consists of 199 individuals, accounting for 7% of the total sample. out of these, 19 individuals do not have diabetes while 190 individuals have the disease. •if the individual is between 52 and 55 years old and neither of their parents have diabetes, then there is a high probability of having diabetes in the future with a percentage of 90.5%. •if the individual is between 52 and 55 years old and neither of their parents have diabetes, then the probability of not having diabetes in the future is low with a percentage of 9.5%. the fifth age interval is [55, 61]. there are 100 individuals in this group, which represents 3.5% of the total population. out of these individuals, 63 do not have diabetes, while 37 have been diagnosed with the disease. •if the individual is between 55 and 61 years old and neither of their parents are diabetic patients, then the likelihood of developing diabetes in the future would increase by 63%. •if the individual is between 55 and 61 years old and neither of their parents are diabetic patients, then the likelihood of not developing diabetes in the future would decrease by 37%. the sixth interval is for individuals older than 61 years. out of the total population, 382 individuals with a percentage of 13.4% fall into this category. among them, 317 s khadragy, m elshaeer, t mouzaek, d shammass, f shwedeh, a aburayya, a jasri, s aljasmi, predicting diabetes in united arab emirates healthcare: artificial intelligence and data mining case study. seejph 2022. posted: 26-07-2022. page 12 individuals do not have diabetes, while 65 individuals have the disease. •for individuals up to 61 years old and with non-diabetic parents, the likelihood of developing diabetes in the future would increase to 17%. •for individuals up to 61 years old and with non-diabetic parents, the likelihood of not developing diabetes in the future would decrease to 83%. •age ≥ 39: among 56 cases (2% of the dataset), 92.9% did not have diabetes and 7.1% had the disease. age may not be a significant factor for diabetes in this age range. •age [39, 46] out of 74 individuals (2.6% of the sample), 70.3% did not have diabetes and 29.7% had the disease. the likelihood of diabetes is lower in this age group. •age [46, 52]: among 87 individuals (3% of the sample), 79.3% had diabetes and 20.7% did not. the likelihood of diabetes increases in this age range. •age [52, 55]: out of 199 individuals (7% of the sample), 90.5% had diabetes and 9.5% did not. there is a high probability of having diabetes in this age group. •age [55, 61]: among 100 individuals (3.5% of the population), 63% had diabetes and 37% did not. the likelihood of developing diabetes increases in this age range. •age > 61: out of 382 individuals (13.4% of the population), 83% did not have diabetes and 17% had the disease. the likelihood of developing diabetes increases for individuals up to 61 years old. in the second scenario, where only one parent has diabetes, we also classified age into five intervals as follows: interval 1: age ≥ 39 out of 195 cases, 6.8% were aged 39 or younger. among them, 66 cases (33.8%) didn't have diabetes, while 129 cases (66.2%) had diabetes. interval 2: ages 39-42 166 individuals (5.8% of the total) fall within this range. among them, 40 individuals (24.1%) don't have diabetes, while 126 (75.9%) have it. interval 3: ages 42-46 there are 118 cases (4.1% of the total). among them, 18 individuals (15.3%) don't have diabetes, while 100 (84.7%) have it. s khadragy, m elshaeer, t mouzaek, d shammass, f shwedeh, a aburayya, a jasri, s aljasmi, predicting diabetes in united arab emirates healthcare: artificial intelligence and data mining case study. seejph 2022. posted: 26-07-2022. page 13 interval 4: ages 46-52 there are 89 cases (3.1% of the total). among them, 57 individuals don't have diabetes (64%), while 32 (36%) have it. interval 5: ages 52-63 there are 305 cases in this range. among them, 19 individuals (6.2%) don't have diabetes, while 296 (96.7%) have it. •if an individual is between 52 and 63 years old and has one parent with diabetes, then there is a 97.04% probability of developing diabetes in the future. •if an individual is between 52 and 63 years old and has one parent with diabetes, then the probability of not developing diabetes in the future is only 6.2%. table 4: the effect of the gender variable on diabetes. gender frequency percent valid percent cumulative percent valid female 68 2.6 2.5 2.3 female 1361 47.7 47.7 50.1 male 1427 50.1 50.1 100.1 total 2857 100.1 100.1 table 5 illustrates the correlation between the predictor variable (gender) and the response variable (diabetes). based on our data set, we obtained the following findings: •if both parents are diabetic patients, there is no significant association between the gender of the patient and the occurrence of the diabetic disease. •if one parent is a diabetic patient, there are significant associations between the gender and age group of the patient and the occurrence of the diabetic disease. the first interval, which includes individuals aged ≤ 39, yielded 58 male patients with diabetic disease in our sample. among the 137 female individuals in this age group, 66 were not diabetic patients, while 71 had the disease. this result confirms the following pattern: s khadragy, m elshaeer, t mouzaek, d shammass, f shwedeh, a aburayya, a jasri, s aljasmi, predicting diabetes in united arab emirates healthcare: artificial intelligence and data mining case study. seejph 2022. posted: 26-07-2022. page 14 •if a male is under 40 years old and has one parent who is a diabetic patient, then he is certain to have the disease. •if a female is under 40 years old and has one parent who is a diabetic patient, then there is a 51.8% chance that she will have the disease. table 5 demonstrates the correlation between gender and diabetes. our findings are as follows: both parents’ diabetic: no significant association between gender and diabetes. one parent diabetic: significant associations between gender, age group, and diabetes. interval 1: age ≤ 39 58 male patients with diabetes. among 137 females, 66 were not diabetic, while 71 had the disease. patterns: male under 40 with one diabetic parent always has the disease. female under 40 with one diabetic parent has a 51.8% chance of having the disease. the second interval of the age, [age 52-63], includes 160 males in our sample. among them, 19 do not have diabetes while 141 have the disease. additionally, 145 females are in the same age range and all of them have diabetes. this implies that: •if a male is between 52 and 63 years old and has one diabetic parent, the probability of having diabetes in the future is 88.1%. •if a female is between 52 and 63 years old and has one diabetic parent, the probability of having diabetes in the future is 100%. the third age interval is [63, 71]. among the participants in our sample, there were 82 males between the ages of 63 and 71, with only one not having the diabetic disease and the remaining 81 being diabetic patients. among the 156 females in the same age interval, 74 do not have the disease while 82 are diabetic patients. this suggests that: •for males aged between 63 and 71 years with one diabetic parent, 81 out of 82 have the disease, which means the probability of having diabetes is 98.7%. •for females aged between 63 and 71 years with one diabetic parent, 82 out of 156 have the disease, which means the probability of having diabetes is 52.5%. application of k-means algorithm for clustering s khadragy, m elshaeer, t mouzaek, d shammass, f shwedeh, a aburayya, a jasri, s aljasmi, predicting diabetes in united arab emirates healthcare: artificial intelligence and data mining case study. seejph 2022. posted: 26-07-2022. page 15 the study utilizes the k-means clustering analysis algorithm to perform vector quantization and cluster the large groups of variables, as stated by jain (2020). the ageindependent variable is categorized into four clusters with mean ages of 31, 68, 49, and 88. the results indicate that individuals in the first cluster are less vulnerable to diabetes, while those in the fourth cluster are more susceptible to the disease. please refer to table 5 for details. table 5: the initial cluster centers. initial cluster centers cluster 1 2 3 4 age 32 67 48 89 a.convergence achieved due to no or small change in cluster centers. the maximum absolute coordinate change for any center is .000. the current iteration is 6. the minimum distance between initial centers is 18.000 (see table6) table 6: iteration history iteration history iteration change in cluster centers 1 2 3 4 1 4.411 2.094 .445 8.608 2 .828 1.592 .628 3.363 3 .752 .525 .663 1.231 4 .597 .593 .581 1.071 5 .596 .203 .614 .347 6 .000 .000 .000 .000 -the subsequent procedure involved taking a subset of our data and calculating the distance between each age and the cluster center, as shown in (see appendix 11)table 8, using the k-means algorithm. table 8 shows that the first case has a distance of 7.183 points from the cluster center. similarly, case number 10 has a distance of 7.138 points from the cluster center. tables 10, 11, and 12 provide two additional sets of samples where the distances between each case and its respective cluster center are directly recorded. the last step involves creating new clusters, which are presented in table13. the table indicates changes in the mean values, where the initial cluster had a mean of 31, while it increased to 38 in the final clustering. table 12: the final cluster centers. final cluster centers cluster 1 2 3 4 age 39 64 52 74 the distances between the final cluster centers are presented in table 13. it can be observed that the first and second clusters are 24.811 units apart, the distance between the first and third clusters is 12.857 units, the third and fourth clusters are separated by s khadragy, m elshaeer, t mouzaek, d shammass, f shwedeh, a aburayya, a jasri, s aljasmi, predicting diabetes in united arab emirates healthcare: artificial intelligence and data mining case study. seejph 2022. posted: 26-07-2022. page 16 22.342 units, and the first and fourth clusters are 35.199 units apart, indicating the variation between the initial and final clusters. table 13: final cluster centers distances. final cluster centers distances cluster 1 2 3 4 1 24.812 12.858 35.198 2 24.811 11.955 10.388 3 12.857 11.955 22.342 4 35.199 10.388 22.342 table 14: cases in each cluster number of cases in each cluster cluster 1 742.001 2 942.001 3 722.001 4 450.001 valid 2856.001 missing .001 the analysis of the provided data reveals several important insights regarding the relationship between the study variables: genetics, age, and diabetes. genetics: the findings indicate a strong association between genetics and diabetes. specifically, if both parents have diabetes, there is a high probability that the individual will also have diabetes. this suggests a hereditary component to the disease. however, it's worth noting that there are cases where individuals do not develop diabetes despite having both parents with the disease. this implies that other factors, such as environmental or lifestyle factors, may also play a role in the development of diabetes. further research is needed to explore these additional factors and their interactions with genetic predisposition. age: the analysis highlights the influence of age on the likelihood of developing diabetes. s khadragy, m elshaeer, t mouzaek, d shammass, f shwedeh, a aburayya, a jasri, s aljasmi, predicting diabetes in united arab emirates healthcare: artificial intelligence and data mining case study. seejph 2022. posted: 26-07-2022. page 17 for individuals with non-diabetic parents, the probability of having diabetes generally increases with age. this aligns with the common understanding that age is a risk factor for diabetes. however, the data also reveals variations in the likelihood of diabetes depending on specific age intervals. for instance, individuals aged 39 or younger, regardless of parental diabetes status, have a relatively low likelihood of having diabetes. this suggests that younger age groups are less prone to the disease. on the other hand, individuals between the ages of 52 and 63 with one parent having diabetes have a significantly higher probability of developing diabetes. this finding underscores the importance of considering both age and parental diabetes status when assessing an individual's risk for the disease. gender: the provided data does not include a separate analysis of gender and its relationship with diabetes. as a result, no specific conclusions or insights can be drawn regarding the influence of gender on diabetes based on the given information. it is possible that gender was not a variable of interest in this particular study or that data regarding gender was not collected or included in the dataset. further investigation or additional data would be required to assess the potential impact of gender on diabetes risk in this context. overall, the results emphasize the significant role of genetics and age in determining the likelihood of developing diabetes. the findings also suggest that there may be complex interactions between these factors and other potential risk factors for diabetes, highlighting the need for further research to gain a comprehensive understanding of the disease's etiology. study limitations • sample size: the paper's findings are based on data collected from a specific set of medical centers in the uae. the limited sample size may not fully represent the diverse population and healthcare settings in the country. • generalizability: due to the focus on uae healthcare sector and specific patient attributes, the generalizability of the predictive model to other regions or populations may be limited. • data quality: the accuracy and completeness of the medical center data used in the analysis may have inherent limitations. s khadragy, m elshaeer, t mouzaek, d shammass, f shwedeh, a aburayya, a jasri, s aljasmi, predicting diabetes in united arab emirates healthcare: artificial intelligence and data mining case study. seejph 2022. posted: 26-07-2022. page 18 inaccurate or missing data points can affect the reliability of the predictive model. • causality vs. correlation: while the paper identifies risk factors associated with diabetes, it is important to note that the analysis establishes correlations rather than causation. other unmeasured factors may also contribute to the development of diabetes. conclusion to summarize, there have been numerous attempts to create predictive models in the healthcare sector, specifically targeting the diagnostic phase of various diseases, including diabetes, which has been a focus due to the large volume of data it generates. despite the considerable effort invested, a significant number of these models have not been implemented in practice. this has resulted in an increase in the amount of data produced, which can be challenging to manage without effective tools for analysis and decision-making. however, despite the current lack of implementation of predictive models in healthcare, many experts (ref???) believe that such models represent a promising way to revolutionize the use of technology in the field. these models can be utilized as a reliable source of electronic information to assist hospitals in making informed decisions about their patients and guided planning of resources. by analyzing and processing large amounts of data, predictive models can provide valuable insights into patients' health and well-being, allowing healthcare providers to deliver more personalized and effective care. in conclusion, although there is a long way to go in terms of fully realizing the potential of predictive models in healthcare, they represent an exciting avenue for exploration and innovation. with further research and development, these models have the potential to transform the way healthcare is delivered, enabling more efficient and effective decision-making that can ultimately lead to improved patient outcomes. references 1. thangarasu g, subramanian k. big data analytics for improved care delivery in the healthcare industry. international journal of online and biomedical engineering. 2019; 2. dirienzo g. informatics and the clinical lab: present and future. biochim clin. 2020; s khadragy, m elshaeer, t mouzaek, d shammass, f shwedeh, a aburayya, a jasri, s aljasmi, predicting diabetes in united arab emirates healthcare: artificial intelligence and data mining case study. seejph 2022. posted: 26-07-2022. page 19 3. ravikumar r, kitana a, taamneh a, aburayya a, shwedeh f, salloum s, et al. the impact of big data quality analytics on knowledge management in healthcare institutions: lessons learned from big ' 'data's application within the healthcare sector. south eastern european journal of public health (seejph) [internet]. 2022 dec 22 [cited 2023 apr 27]; available from: https://www.biejournals.de/index.php/se ejph/article/view/6194 4. rejitha ravikumar akataafsssks. impact of knowledge sharing on knowledge acquisition among higher education employees. computer integrated manufacturing systems [internet]. 2022 dec 9 [cited 2023 apr 27];28(12):827–45. available from: http://cimsjournal.com/index.php/cn/article/view/ 462 5. wang yc, mcpherson k, marsh t, gortmaker sl, brown m. health and economic burden of the projected obesity trends in the usa and the uk. the lancet [internet]. 2011 aug 27 [cited 2023 apr 27];378(9793):815–25. available from: http://www.thelancet.com/article/s0140 673611608143/fulltext 6. shwedeh f, hami n, zakiah s, baker a. effect of leadership style on policy timeliness and performance of smart city in dubai: a review. 7. shwedeh f, hami n, bakar sza, yamin fm, anuar a. the relationship between technology readiness and smart city performance in dubai. journal of advanced research in applied sciences and engineering technology [internet]. 2022 dec 23 [cited 2023 apr 27];29(1):1–12. available from: https://semarakilmu.com.my/journals/in dex.php/applied_sciences_eng_tech/arti cle/view/996 8. dragneva r, wolczuk k. russia, the eurasian customs union and the eu: cooperation, stagnation or rivalry? ssrn electronic journal [internet]. 2012 aug 6 [cited 2023 apr 27]; available from: https://papers.ssrn.com/abstract=212591 3 9. shwedeh f, adelaja aa, ogbolu g, kitana a, taamneh a, aburayya a, et al. entrepreneurial innovation among international students in the uae: differential role of entrepreneurial education using sem analysis. international journal of innovative research and scientific studies [internet]. 2023 [cited 2023 apr 27];6(2):266–80. available from: https://ideas.repec.org/a/aac/ijirss/v6y20 23i2p266-280id1328.html 10. aburayya a, salloum sa, alderbashi ky, shwedeh f, shaalan y, alfaisal r, et al. sem-machine learning-based model for perusing the adoption of metaverse in higher education in uae. international journal of data and network science. 2023 mar 1;7(2):667– 76. 11. shwedeh f, aburayya a, alfaisal r, adelaja aa, ogbolu g, aldhuhoori a, et al. smes&rsquo; innovativeness and technology adoption as downsizing strategies during covid-19: the moderating role of financial sustainability in the tourism industry using structural equation modelling. sustainability 2022, vol 14, page 16044 [internet]. 2022 dec 1 [cited 2023 apr 27];14(23):16044. available from: 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ksssaafs& bs. is blockchain the answer? a qualitative study on how blockchain technology could be used in the education sector to improve the quality of education services and the overall student experience. computer integrated manufacturing systems [internet]. 2022 nov 14 [cited 2023 apr 27];28(11):543– 56. available from: http://cimsjournal.com/index.php/cn/article/view/ 237 16. wong ty, rosamond w, chang pp, couper dj, sharrett ar, hubbard ld, et al. retinopathy and risk of congestive heart failure. jama [internet]. 2005 jan 5 [cited 2023 apr 27];293(1):63–9. available from: https://pubmed.ncbi.nlm.nih.gov/15632 337/ 17. ``sherief abdallah baaaensssaaa& fs. a covid19 quality prediction model based on ibm watson machine learning and artificial intelligence experiment. computer integrated manufacturing systems [internet]. 2022 nov 14 [cited 2023 apr 26];28(11):499–518. available from: http://cimsjournal.com/index.php/cn/article/view/ 235 18. ahmad a, dey l. a k-mean clustering algorithm for mixed numeric and categorical data. data knowl eng. 2007 nov 1;63(2):503–27. 19. mohammad salameh atakaafsssksdv. the impact of project management ' 'office's role on knowledge management: a systematic review study. computer integrated manufacturing systems [internet]. 2022 dec 9 [cited 2023 apr 27];28(12):846– 63. available from: http://cimsjournal.com/index.php/cn/article/view/ 463 20. salloum s, al marzouqi a, alderbashi ky, shwedeh f, aburayya a, rasol m, et al. sustainability model for the continuous intention to use metaverse technology in higher education: a case study from oman. sustainability 2023, vol 15, page 5257 [internet]. 2023 mar 16 [cited 2023 apr 27];15(6):5257. available from: https://www.mdpi.com/20711050/15/6/5257/htm __________________________________________________________________________________________ © 2023 s khadragy et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. holst j. when the world depends on effective public health intervention – and public health does not deliver (editorial). seejph 2020, posted: 23 may 2020. doi: 10.4119/seejph-3469 p a g e 1 | 7 editorial when the world depends on effective public health intervention – and public health does not deliver jens holst1 1 department of nursing and health sciences, fulda university of applied sciences, fulda, germany. corresponding author: jens holst; address: leipziger strasse 123, d-36037 fulda, germany; telephone +4966196406403; email: jens.holst@pg.hs-fulda.de holst j. when the world depends on effective public health intervention – and public health does not deliver (editorial). seejph 2020, posted: 18 may 2020. doi: p a g e 2 | 7 abstract the covid-19 crisis offers both special opportunities and challenges for public health. the initial management of the pandemic was dominated by virologists, supported by epidemiologists who did not always meet indispensable scientific requirements. interdisciplinary and complex public health concerns and expertise, however, did not have tangible impact in the covid-19 debate. since social and other upstream determinants of health play a central role, public health is universal and goes beyond health security. as an explicitly political concept public health must safeguard its broad socio-political approach and obviate all tendency towards biomedical reductionism. keywords: biomedical reductionism, covid-19, health security, power, public health, public policy, social determinants of health. conflicts of interest: none declared. holst j. when the world depends on effective public health intervention – and public health does not deliver (editorial). seejph 2020, posted: 18 may 2020. doi: p a g e 3 | 7 the covid-19 challenge in view of the covid-19 challenge, analysists cannot agree more with the world’s dependence on “effective public-health interventions” as stated by josé martín moreno in the editorial to this edition of the south eastern european journal of public health (1). however, the long-term outcome for and the effect of the covid-19 crisis on public health as well as on global health remain uncertain. instead of strengthening public health, which can be seen the national breakdown of global health, the current handling of the pandemic worldwide rather threatens to become a challenge for public health. in any case, the covid-19 crisis has highlighted more clearly than ever the complex nature of public health and likewise of global health. but at the same time, it has revealed the extent to which biomedicine and biotechnology still dominate the debate. for weeks, politicians and the media provided the populations in many countries around the world with a mix of partly meaningless epidemiological figures, sorrowful scenarios and disturbing images of intensive care units. apart from “old” public health in the form of mainly national public health services and epidemiologists, the voice of public health as theory and practice of protecting and improving people’s health was hardly to be perceived during the first weeks of the covid19 pandemic. the infodemics associated with the global spread of covid-19 shows that the complexity and transdisciplinarity inherent to public health failed to achieve sufficient impact in the media and general public (2). even more so, good science in the sense of “old” public health was challenged even by a hitherto respected public-health institution, johns hopkins university in baltimore, by unleashing continuously updated absolute numbers of confirmed covid-19 cases, deaths and recoveries to the global public (3), and the world health organization did not shy away from confronting and comparing absolute numbers among different countries and populations (4). presenting and publishing absolute figures without the slightest idea of what the reference values are, counteracts the most basic concepts and conventions of old public health. meaningful epidemiological data require both a numerator and a denominator; however, the latter is absolutely missing as there is an unknown number of unreported cases (5), and data about the number of tests realised were initially unavailable and are still likely to be incomplete. moreover, even the numerator is doubtful due to a mix of under-reporting (people with or without symptoms who are not tested) and over-reporting (as not all patients who die with positive tests die from covid-19). the attempts to address this problem by using the term “deaths in connection with covid-19” reduces the meaningfulness of figures while creating another level of incompleteness, namely the under-reporting of collateral fatalities indirectly caused by covid-19 (6). pandemic challenging public health in spite of all declarations about the relevance of public health in a pandemic outbreak, it was not public and global health experts other than virologists and epidemiologists to become the second group to enter the global and national scenes. instead, economists and business experts were next on the scene creating awareness of economic consequences of lock-down decisions, and law experts warning about cuts of civil and human rights. only at a later stage did public health experts make a noticeable appearance. recent experience during the early phases of the covid-19 crisis has shown that the rapid succession of epidemic and even pandemic holst j. when the world depends on effective public health intervention – and public health does not deliver (editorial). seejph 2020, posted: 18 may 2020. doi: p a g e 4 | 7 outbreaks does not automatically contribute to shape the awareness of public health or global health. in contrast, the initial dominance of virologists and epidemiologists in media and political crisis management will end up weakening public health as a whole rather than strengthening it. it has to be stressed that public health comprises much more than health security. the concept of public health is per se universal, whereas security-oriented policies tend to focus on safeguarding the status quo, however inequitable and unfair it may be. this will also apply to innovative vaccines and medicines, which are extremely unlikely to be equally available for all people living on earth. the great importance decision makers attach to biomedical and biotechnical solutions compared to the determination with which they address social determinants of health will corroborate the hegemony of the global north and contribute to release the pressure to address the upstream determinants of pandemic outbreaks. the huge amounts of money invested in developing covid-19 vaccines (7) and the megatrial launched by who for accelerating the research on medicines to fight the current coronavirus pandemic (8) will primarily benefit the better-off part of the world’s population. strikingly, there is and will certainly not be any comparable research fund in sight for investigating the social, political, economic and ecological determinants of the pandemic. the prevailing biomedical reductionism tends to supplant calls for more community health efforts and marginalise the perspective of social medicine and social determinants of health (9,10). the prevalent concentration of public health policy on the spread of dangerous infectious diseases often lacks an indepth understanding of political, social and economic conditions and requirements. policies and health strategies in the context of the coronavirus pandemic do not fully grasp the complexity, interdiscipinarity and universality of (new) public health since they are increasingly determined by cross-border relations, international policy priorities and particularly by often hegemonic security concerns, and the securitisation of health is meanwhile considered a key feature of health governance (11). politicising instead of securitising global health the desire for security is well understandable in an increasingly inequitable, unstable and frightening world. however, it often remains unclear what is meant by security, who defines security and how it is to be created. it is not the criticism of the actual causes of global health crises such as the social, economic and political determinants of health that is at the centre of the debate, but the question of how efficiently a crisis can be managed without having to tackle the underlying causes. the prevailing concept of public health does not pursue the question of how to combat risks at their origin, but how to deal with future risks in such a way that they do not threaten the status quo or put at risk vested interests. the focus is mostly on how the health problems resulting from the living and environmental conditions can be identified and contained as early and far as possible, instead of changing them. neither are upstream determinants of health usually high on the health agenda, nor political priorities, power relations or the influence of stakeholders (12). public health is by no means immune to being instrumentalised for economic and political interests, it is rather interspersed with power relations (13), which health-related policies need to explicitly acknowledge (14). indeed, the existing power relations determine the predominant understanding of public health and global health to a much holst j. when the world depends on effective public health intervention – and public health does not deliver (editorial). seejph 2020, posted: 18 may 2020. doi: p a g e 5 | 7 greater extent than usually assumed or often discussed. the whole debate about global health governance, governance for global health and global governance for health (15) falls short in regard of analysing underlying power and power relations (16). the recent covid-19 reaction has exhibited an interesting policy shift: the short-term return of the strong state. after many years of spreading the neoliberal ideology and increasingly evicting the state from its responsibilities, the state reasserted its claim to political control with surprising clarity and decision. governments decided to intervene in individual and social life and to restrict economic and entrepreneurial freedom. for protecting people’s health, the lock-down and the interventions of the reinvigorated state appeared comprehensible, as they were scientifically justified. the state's regained strength vis-à-vis the private sector and even transnational corporations must be maintained beyond the covid-19 crisis. the state is the only entity capable of guaranteeing and enforcing the right to health as it is ultimately the only one accountable for human rights violations (17). for improving and safeguarding people’s health, public policies must be geared to the rights and legal entitlements of people, as laid down in the charta of human rights and in the who constitution. public health requires protecting those who are most in need the poor and the marginalised – from health risks and bad health by overcoming poverty, inequities and social injustice. as important as good medical care is, it has less influence on people’s health than their living, labour, income and environmental conditions, education, equal opportunities and social cohesion. even in times of pandemic outbreaks, public health must consistently follow its broad socio-political approach instead of being deviated towards biomedical reductionism (12). conclusion in a world gone upside down due to a pandemic outbreak, public health must not be reduced to the search for medicines and vaccines. it must make a case for health-in-all policies require addressing the social, economic, political and environmental causes of dangerous virus infections and all upstream determinants of health. this will inevitably clash with powerful players and vested interests, as it touches the core of today’s global economy, the prevailing growth model and ultimately the distribution of power. for coming out “more recognized and strengthened” (1), as concluded by josé martín moreno, public health has to become more explicit, more straightforward and ultimately more politicised. references 1. martín-moreno j. facing the covid-19 challenge: when the world depends on effective public health interventions. seejph 2020, xiv. doi: 10.4119/seejph-3442. 2. nielsen n. coronavirus: tech giants must stop covid-19 'infodemic', say doctors. euobserver 7. may 2020. available from: https://euobserver.com/coronavirus/148281 (accessed: may 10, 2020). 3. jhu. covid-19 dashboard by the center for systems science and engineering (csse). baltimore: johns hopkins university; 2020. available from: https://coronavirus.jhu.edu/map.html (accessed: may 10, 2020). 4. world health organization. who coronavirus disease (covid-19) dashboard. data last updated: 2020/5/11. geneva: who; 2020. available from: https://euobserver.com/coronavirus/148281 https://euobserver.com/coronavirus/148281 https://coronavirus.jhu.edu/map.html https://coronavirus.jhu.edu/map.html holst j. when the world depends on effective public health intervention – and public health does not deliver (editorial). seejph 2020, posted: 18 may 2020. doi: p a g e 6 | 7 https://covid19.who.int (accessed: may 10, 2020). 5. ebmnetzwerk. covid-19 – where is the evidence? berlin: german network for evidence-based medicine; 2020. available from: https://www.ebmnetzwerk.de/en/publications/covid19 (accessed: may 10, 2020). 6. kansagra a, goyal m, hamilton s, albers g. collateral effect of covid19 on stroke evaluation in the united states. n engl j med 2020. doi: 10.1056/nejmc2014816. available from: https://www.nejm.org/doi/pdf/10.105 6/nejmc2014816 (accessed: may 10, 2020). 7. schäferhoff m, yamey g, mcdade kk. funding the development and manufacturing of covid-19 vaccines: the need for global collective action. brooking, april 24, 2020. available from: https://www.brookings.edu/blog/future-development/2020/04/24/funding-the-development-and-manufacturing-of-covid19-vaccines-the-need-for-global-collective-action/ (accessed: may 10, 2020). 8. kupferschmidt k, cohen j. who launches global megatrial of the four most promising coronavirus treatments. science mag, march 22, 2020. available from: https://www.sciencemag.org/news/2020/03/wholaunches-global-megatrial-fourmost-promising-coronavirus-treatments (accessed: may 10, 2020). 9. aggleton p, parker r. moving beyond biomedicalization in the hiv response: implications for community involvement and community leadership among men who have sex with men and transgender people. am j public health 2015;105:15528. 10. adams v, behague d, caduff c, löwy i, ortega f. re-imagining global health through social medicine. glob public health 2019;14:1383-400. doi: 10.1080/17441692.2019.15876 39. 11. labonté r, gagnon m. framing health and foreign policy: lessons for global health diplomacy. glob health 2010;6:14. doi: 10.1186/1744-8603-6-14. 12. holst j. global health – emergence, hegemonic trends and biomedical reductionism. glob health 2020;16:42. doi: 10.1186/s12992-020-00573-4. 13. moon s. power in global governance: an expanded typology from global health. glob health 2019;15:74. doi: 10.1186/s12992019-0515-5 14. shiffman j. global health as a field of power relations: a response to recent commentaries. int j health policy manag 2015;4:497-9. doi: 10.15171/ijhpm.2015.104. 15. kickbusch i, szabo mm. a new governance space for health. glob health action 2014;7:23507. doi: 10.3402/gha.v7.23507. 16. lee k, kamradt-scott a. the multiple meanings of global health governance: a call for conceptual clarity. glob health 2014;10:28. doi: 10.1186/1744-8603-10-28. 17. ohchr /who. the right to health. fact sheet no. 31. new york / geneva: office of the united https://covid19.who.int/ https://www.ebm-netzwerk.de/en/publications/covid-19 https://www.ebm-netzwerk.de/en/publications/covid-19 https://www.ebm-netzwerk.de/en/publications/covid-19 https://www.nejm.org/doi/pdf/10.1056/nejmc2014816 https://www.nejm.org/doi/pdf/10.1056/nejmc2014816 https://www.brookings.edu/blog/future-development/2020/04/24/funding-the-development-and-manufacturing-of-covid-19-vaccines-the-need-for-global-collective-action/ https://www.brookings.edu/blog/future-development/2020/04/24/funding-the-development-and-manufacturing-of-covid-19-vaccines-the-need-for-global-collective-action/ https://www.brookings.edu/blog/future-development/2020/04/24/funding-the-development-and-manufacturing-of-covid-19-vaccines-the-need-for-global-collective-action/ https://www.brookings.edu/blog/future-development/2020/04/24/funding-the-development-and-manufacturing-of-covid-19-vaccines-the-need-for-global-collective-action/ https://www.brookings.edu/blog/future-development/2020/04/24/funding-the-development-and-manufacturing-of-covid-19-vaccines-the-need-for-global-collective-action/ https://www.brookings.edu/blog/future-development/2020/04/24/funding-the-development-and-manufacturing-of-covid-19-vaccines-the-need-for-global-collective-action/ https://www.sciencemag.org/news/2020/03/who-launches-global-megatrial-four-most-promising-coronavirus-treatments https://www.sciencemag.org/news/2020/03/who-launches-global-megatrial-four-most-promising-coronavirus-treatments https://www.sciencemag.org/news/2020/03/who-launches-global-megatrial-four-most-promising-coronavirus-treatments https://www.sciencemag.org/news/2020/03/who-launches-global-megatrial-four-most-promising-coronavirus-treatments https://www.sciencemag.org/news/2020/03/who-launches-global-megatrial-four-most-promising-coronavirus-treatments holst j. when the world depends on effective public health intervention – and public health does not deliver (editorial). seejph 2020, posted: 18 may 2020. doi: p a g e 7 | 7 © 2020 holst; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. . nations high commissioner for human rights. world health organization; 2007. available from: https://www.ohchr.org/documents/publications/factsheet31.pdf (accessed: may 10, 2020). ____________________________________________________________ https://www.ohchr.org/documents/publications/factsheet31.pdf https://www.ohchr.org/documents/publications/factsheet31.pdf finucane a, stritch jm. connecting the person by removing the stigma: why ireland should follow the portuguese model of drug decriminalisation (position paper). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5768 p a g e 1 | 7 position paper connecting the person by removing the stigma: why ireland should follow the portuguese model of drug decriminalisation aisling finucane1, jennifer moran stritch1 1) technological university of the shannon, limerick, ireland corresponding author:aisling finucane, technological university of the shannon, limerick, ireland. e-mail: jennifer.stritch@lit.ie mailto:jennifer.stritch@lit.ie finucane a, stritch jm. connecting the person by removing the stigma: why ireland should follow the portuguese model of drug decriminalisation (position paper). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5768 p a g e 2 | 7 abstract the decriminalisation of drugs and how it can impact addiction, crime and mental health is a subject that inspires global interest and debate. much has been written about the positive outcomes of decriminalisation from a public health perspective, including the elimination of aggressive policing and community oversight and the shift to offering treatment and social supports for those affected by addiction. ireland has yet to move to a model of decriminalisation, although a system similar to the one employed in portugal has been suggested. this article briefly outlines reasons why a paradigm shift is vital if progress is to be made in reducing addiction in contemporary ireland. the potential benefits could include a reduction in the pervasive social stigma connected with substance abuse, leading to less social exclusion within the irish population. keywords: drug decriminalisation, stigma, ireland finucane a, stritch jm. connecting the person by removing the stigma: why ireland should follow the portuguese model of drug decriminalisation (position paper). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5768 p a g e 3 | 7 it is widely accepted that struggles with addiction can keep individuals trapped in an ongoing maelstrom of social exclusion, poverty and poor health. this cycle may be made intractable by exposure to the criminal justice system and incarceration, which is a predominant response across the globe to the possession, use and distribution of most illegal drugs. these punitive policies, centred on policing and prison, may in fact exacerbate social and personal issues for those mired in addiction (1,2). however, the decriminalisation of drugs has been mooted as a public health solution to the web of addiction, arrest, incarceration and reincarceration. decriminalisation, or the legalisation of certain illegal activities that were formerly punishable by law (3,4) raises many complex issues. as of this writing, the possession of illegal substances for the purpose of sale or supply remains a crime in ireland. decriminalisation would create a policy framework that would allow a public health response to drug addiction rather than a punitive justice system approach. this piece discusses the impact of stigma linked to criminalisation for the individual struggling with substance abuse and addiction, and sets out our brief argument for decriminalisation in ireland. a move to this approach would require a definitive change in the way we think about substances, criminality, drug treatment and mental health, but we believe it is the best way forward for irish society. according to the 2021 world drug report, persons convicted of drug offenses account for 18% of the global jail population (5). over 80% of reported drug offences in european countries included possession for personal use, with the remainder involving trafficking (6). apart from the social and economic implications, worldwide drug policy has been chastised for decades for being shaped by political and moralistic approaches, positioned as "tough on crime" or fighting the "war on drugs." negative public perceptions of drugs and drug users have encouraged political leaders to maintain stringent control measures, as it is generally a comfortably conservative and politically safe alternative to meet the public desire for strict enforcement (7). prohibition and criminal sanctions against the possession and use of substances is a public health quandary. an increased risk of overdose death, spurred on by secret and hurried episodes of use and lack of inspection or regulation, has been linked to aggressive policing and enforcement techniques (8). it is commonly acknowledged that heavier sanctions have a limited deterrent effect on drug use, while inadvertently harming users more than the substances themselves (9). in many countries, racial, ethnic, and socially marginalised minorities are disproportionately affected by tough drug policies. research suggests that law enforcement officers in the field tend to implement rules in a discriminatory manner, causing disadvantaged groups in the community to be subject to more frequent arrests and incarceration due to drug possession (10). in ireland, drug-related hazards are a major worry, with concerns ranging from increased overdose rates to the negative influences of violent and organised crime which are part and parcel of the illegal drug trade. research indicates a rate of nearly two drug-related deaths every day in ireland in 2015 (11). drug-induced mortality rates in ireland are at finucane a, stritch jm. connecting the person by removing the stigma: why ireland should follow the portuguese model of drug decriminalisation (position paper). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5768 p a g e 4 | 7 the higher end of the range in the european union (12). drug policy approaches in ireland over the last four decades have shifted to targeting individual drug-using behavior. a greater emphasis on individual responsibility, power centralisation, and a public management system focused on measuring outputs, effectiveness, and value for money – all of which are completely disconnected from the needs of people and communities affected by addiction – are just a few examples of this focus (13). furthermore, studies undertaken in irish jails have revealed a prevalent drug culture that potentially encourages drug use (14,15,16) suggesting that most inmates have serious drug addiction concerns. clearly, the interplay of addiction, policing and incarceration does not solve, and in fact may exacerbate, the problem of illegal drugs in irish society. the label of addiction, with the negative connotations of secrecy and criminality, creates almost insurmountable difficulties for those affected by it. the term "stigma" can be traced back to the ancient greeks, indicating "a blemished person, ritually defiled, to be avoided, particularly in public places"(17). goffman (17) provides a detailed explanation in his seminal work of how stigmatised people interact with others, and how their encounters are negatively affected by their mutual awareness of stigma. many drug users experience stigma, compounded by the exclusion created by incarceration and ongoing involvement in the criminal justice system (18,19). removing the punitive aspects of policing, legal sanctions and imprisonment may lessen the stigma and create more pathways for treatment and positive social connection for the chronically addicted. from a public health perspective, the portuguese model of decriminalization could provide some answers for ireland, reorienting the approach from punishment and isolation to treatment and support. this reorientation could also result in a reduced level of stigma around drugs and drug use. the success of decriminalization in portugal is evidenced by population drug use rates well below the european norm and far below those in the united states (20). following the enactment of decriminalisation, the number of people arrested and referred to the portuguese courts for drug offenses decreased by more than 60% each year (20). the number of individuals incarcerated in portugal for violating drug laws has also dropped considerably, from 44% in 1999 to 24% in 2014 (21). there is some evidence that portugal's 2001 decriminalisation of all illicit substances resulted in lessened stigma around substance use, with positive public health consequences (22, 23). in 2015, the oireachtas (irish parliament) joint committee backed the decriminalisation of drugs for personal use, emphasising the utility of the portuguese model of decriminalisation (24). this is a positive development which, we argue, should be fully resourced and implemented as soon as possible. decriminalisation, aimed at harm reduction and supporting therapeutic responses to addiction rather than a punitive criminal justice approach, could have huge public health benefits for ireland and many other countries. references 1. buchman. j.& young. l. (2000). the war on drugs: a war on drugs users? drugs: education, prevention and policy(7), p.409-423. finucane a, stritch jm. connecting the person by removing the stigma: why ireland should follow the portuguese model of drug decriminalisation (position paper). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5768 p a g e 5 | 7 2. bartram, m. (2021) ‘“it’s really about wellbeing”: a canadian investigation of harm reduction as a bridge between mental health and addiction recovery’, international journal of mental health & addiction, 19(5), pp. 1497–1510. doi: 10.1007/s11469-020-00239-7. [accessed 1st march 2022]. 3. levesque, r., 2020. encyclopaedia of adolescence "decriminalization". cham: springer international publishing. 4. luzon, g. 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(1990). abstinence in treated and untreated opiate abusers: a study of a prison sample. irish journal of psychological medicine, 7 (2), 121-123. 16. kennedy, h.g., monks, s., curtin, k., wright, b., linehan, s., duffy, d., teljeur, c. & kelly, a. (2005). mental illness in irish prisoners: psychiatric morbidity in sentenced, remanded and newly committed prisoners. dublin: national forensic mental health service. 17. goffman, e. (1963), stigma: notes on the management of spoiled identity. englewood cliffs, nj: prentice-hall. 18. matheson, c. (1998). views of illicit drug users on their treatment and behaviour in scottish community pharmacies: implications for the harm reduction strategy. health education journal, 57, 31 41. 19. radcliffe, p., & stevens, a. (2008). are drug treatment services only for 'thieving junkie scumbags'? drug users and the management of stigmatised identities. social science & medicine (1982), 67(7), p.10701075. 20. rego, x., oliviera, m.j., lameiria, c. (2021) 20 years of portuguese drug policy developments, challenges and the quest for human rights. substance abuse treatment prevention & policy 16, 59 (2021). https://doi.org/10.1186/s13011-02100394-7 21. félix, s. and portugal, p. (2017) ‘drug decriminalisation and the price of illicit drugs’, international journal of drug policy, 39, pp. 121– 129. doi: 10.1016/j.drugpo.2016.10.014 22. hughes c. e., stevens a. “what can we learn from the portuguese decriminalisation of illicit drugs?” british journal of criminology. 2010, p 157-198. 23. eastwood, n., fox edward, & rosmarin ari. (2016). a quiet revolution: drug decriminalisation across the globe (second ed.). london: release publication. 24. department of health (2019). working group to consider alternative approaches to the possession of drugs for personal use. 2021: https://health.gov.ie/wpcontent/uploads/2019/08/report-ofworking-group-alternativespossession-of-drugs.pdf. [accessed 1 february 2022] ________________________________________________________________________________ https://www.citywide.ie/assets/files/pdf/cdatf_outcome_report_drug_harms.pdf https://health.gov.ie/wp-content/uploads/2019/08/report-of-working-group-alternatives-possession-of-drugs.pdf https://health.gov.ie/wp-content/uploads/2019/08/report-of-working-group-alternatives-possession-of-drugs.pdf https://health.gov.ie/wp-content/uploads/2019/08/report-of-working-group-alternatives-possession-of-drugs.pdf https://health.gov.ie/wp-content/uploads/2019/08/report-of-working-group-alternatives-possession-of-drugs.pdf finucane a, stritch jm. connecting the person by removing the stigma: why ireland should follow the portuguese model of drug decriminalisation (position paper). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5768 p a g e 7 | 7 © 2022 finucane et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. oduor k, ogweno s, ajwang’ d, okinyi n. incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach (review). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4317 1 | p a g e c review article incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach kevin oduor1, stephen ogweno1, danor ajwang’2, nyawade okinyi2 1 stowelink, nairobi, kenya; 2 plan international corresponding author: mr. kevin oduor address: nairobi, p.o. box 43844-00100, kenya email: oduorkevin@stowelink.com oduor k, ogweno s, ajwang’ d, okinyi n. incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach (review). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4317 2 | p a g e abstract mhealth is the use of mobile and wireless devices to improve health outcomes, healthcare services, and health research. an estimated 68% of the world’s population own mobile phones, with kenya having approximately 80% of mobile phone penetration. this makes it feasible to accelerate the uptake of mhealth interventions to improve health services delivery. while some evidence has shown how various forms of mhealth interventions have been used to transform health services, health outcomes, and health research in kenya and globally, many remain largely anecdotal or undocumented. this paper examines the various forms of mhealth interventions that have been incorporated into kenya’s health infrastructure, and their effectiveness in improving health services delivery in kenya. a systematic review of peer-reviewed articles, policy briefs, and credible materials published on mhealth have shown that mhealth has succeeded in the health infrastructure such as in collecting and transferring health and patient data, remote diagnosis, treatment, and patient follow-up. the paper also examines the barriers around the uptake of mhealth interventions and recommends how these interventions can be integrated into kenya’s health infrastructure. even though there is every reason to believe that mhealth can allow limited resource settings to “leapfrog” over more advanced settings in using mobile technologies to improve health services delivery, mhealth is not a panacea. there are limited will and resources to scale up and integrate mhealth into the health infrastructure with attempted integration met with a negative attitude from the strained health workforce who still view mhealth as additional work, among other challenges. despite the challenges, there may be an opportunity for kenya’s government to leverage mobile and wireless devices to improve the delivery of health services to areas that were previously unreachable, thereby fast-tracking its commitment to achieving universal health coverage. keywords: ehealth, health systems, mhealth, mobile phones, telemedicine, universal health coverage. conflict of interest: none declared. oduor k, ogweno s, ajwang’ d, okinyi n. incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach (review). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4317 3 | p a g e introduction background of the study the world health organization states that universal health coverage (uhc) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship (1). uhc has continued to gain momentum even as nations around the world move towards protecting their citizens against financial hardships in accessing health care. kenya has shown great commitment towards achieving uhc with president uhuru kenyatta including it in his big four agenda (2). uhc has been piloted in kisumu, isiolo, nyeri and makueni counties of kenya to inform the uptake and the metrics for upscaling (3). but even as uhc is being implemented, one of the questions that linger is how kenya can leverage the huge mobile phones penetration which stands at an estimated 80 % (4) to accelerate the achievement of uhc. reliable studies on mhealth around the world strongly suggest that mobile phones can be used for instantaneous access, for direct communication and for prompt transfer of health information (5). mobile technologies are currently being used to monitor patient’s adherence to treatments such as tb using apps (6), for patient’s communication, to improved access to health services and diagnosis and for management of chronic diseases (7). with evidence of mhealth success around the world, kenya too is at a vantage position to reap the benefits that come with its huge mobile phone subscriptions. but even as research in this field is growing day by day, information is still limited as to the impact of mhealth interventions at scale (8). as such, a thorough systematic review of the available evidence was greatly warranted to inform the parameters of integrating mhealth, especially during this period when the call to achieve universal health coverage is beckoning. to this end, the objective of this study was to conduct a systematic review that established how mhealth intervention could be incorporated into kenya’s health infrastructure to augment universal health coverage. statement of the problem experts are in agreement that mobile health technologies hold great opportunity to revamp the health care industry (9) while addressing the inequalities that have remained so prevalent in kenya. however, even with the huge mobile penetration for kenya to leverage on in accelerating uhc, implementing the mobile health technologies requires more than purchasing a gadget and using them for health. available studies are only providing evidence of the potential benefits that mhealth offers and not necessarily the implementation matrix (8). though the field of mhealth is rapidly emerging, there is little evidence as to the impact of mhealth when rolled on a large scale and especially in achieving the muchdesired universal health coverage. furthermore, uhc in kenya continues to grapple with inadequate service delivery 2 years after the kenyan government ambitious plan to improve access to health care (10). as such, this systematic review is greatly warranted to inform on how mhealth can be integrated into kenya’s health infrastructure to augment universal health coverage and subsequently improve service delivery. justification of the study this review is particularly important at this time when the call to hasten the achievement of universal health coverage is emphasized. the aim of this review is to provide evidenced based recommendations on how mhealth technologies can improve service delivery and fast-track the achieve oduor k, ogweno s, ajwang’ d, okinyi n. incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach (review). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4317 4 | p a g e ment of uhc. moreover, findings from this study will help in augmenting universal health coverage to reduce the burden of delivering health in the long term. and since the field of mhealth is rapidly evolving (11), research in this area is needed to inform the impact it has at scale and the strategies for integration. it will also inform the policy around mhealth by bringing together lessons learned while incorporating mhealth in kenya. objectives of the study the purpose of this study is to systematically review the mhealth interventions in kenya and establish how they can be incorporated into kenya’s health infrastructure to augment universal health coverage. specific objectives 1. examine the various forms of mhealth interventions incorporated into kenya’s health infrastructure. 2. assess the effectiveness of mhealth interventions in improving health services delivery in kenya. 3. establish the challenges facing the uptake of mhealth interventions in kenya. 4. determine ways in which mhealth interventions can be integrated into kenya’s health infrastructure. research questions 1. in what forms have mhealth interventions been incorporated into kenya’s health infrastructure? 2. have mhealth interventions been effective in improving health services delivery in kenya? 3. what have been the challenges facing the uptake of mhealth interventions in kenya? 4. in what ways can mhealth interventions be integrated into kenya’s health infrastructure? methodology this review followed the preferred reporting items for systematic reviews checklist. the search criterion was derived from the review’s objectives and the search done on cinahl and pubmed. to ensure the search was contextual, exhaustive terms including mhealth, text messaging, kenya, and low-middle income countries were used. similarly, the search was limited to studies conducted around health between 2010-2020 that meet the expected threshold of validity and reliability. these studies were in english language. four authors thoroughly reviewed the articles and their abstracts to establish if they were aligned to the objectives. the articles were cross verified for rigor, authority, and relevance before being subjected to review. inclusion & exclusion criteria the review was conducted using a common search methodology. the reviewed studies and citations were assigned to reviewers before they could be confirmed for review. the review articles and citation conformed with the inclusion and exclusion criteria below:  recent i.e., 2010-2020.  relevant i.e., ehealth and mhealth.  quality of evidence (from reputable journals i.e., pubmed eanso frontiers and hindawi)  geographical context i.e., low-middle income settings. data extraction and quality assessment two authors conducted data extraction following an agreed format and criteria. the findings of were then reviewed by two other senior authors. in the data extraction process, journal, study design, country of implementation, main findings, forms of mhealth intervention, challenges facing mhealth interventions, impact and effectiveness of mhealth interventions and oduor k, ogweno s, ajwang’ d, okinyi n. incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach (review). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4317 5 | p a g e mhealth interventions scale up. to assess the methodological correctness, the reviews were evaluated using the measurement tool to assess systematic review (amstar). results the search strategy identified 41,047 citations which were both peer-reviewed and non-peer-reviewed (see figure 1). an additional 25 publications were retrieved through hand searches of blogs from web searches, institutions websites, and from appropriate documents. when we applied the filter to focus on kenya, we got 142 citations on mhealth and 12 publications from the hand search. the researchers then applied the filter of time to look at research from 10 years ago and 139 citations from research and 8 the hand searchers emerged. the final filtering criteria involved reviewing original randomized controlled research and previous systematic reviews which led to a total of 27 papers of interest for review in addition to the 8 other citations from searches. finally, researchers met to review the remaining documents and settled on reviewing 24 total research citations and 5 hand searched citations bringing the total of reviewed articles to 29. figure 1: review strategy, authors synthesis oduor k, ogweno s, ajwang’ d, okinyi n. incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach (review). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4317 6 | p a g e forms of mhealth interventions in the health care system mhealth interventions have taken many forms addressing various needs in the health care delivery system. according to world health organization (12), mhealth interventions have taken the following forms i.e., health call centers, emergency toll-free telephone services, mobile telemedicine, health surveys, surveillance, awareness-raising, and decision support systems. call centers, sms and mobile apps are the most common forms of implementing mhealth interventions in the country with sms being used most predominantly (13-16). most mhealth interventions are implemented in nairobi county with about 37 counties in kenya having at least one mhealth intervention working in the health system (13). mhealth interventions in the form of mobile apps are also mostly found in cities where there is access to good internet connectivity and higher phone penetration while sms and call centers generally are found in both cities and rural areas (13). of the 29 mhealth citations reviewed, findings indicate that only 3 projects have been scaled nationally and with one project relying on the use of mobile money systems to achieve its objectives (17,18). most mhealth interventions in kenya focus majorly on hiv aids, maternal and child health and malaria (7). these interventions are provided from both private and government service providers including non-governmental organizations like pham access, safaricom and ampath bringing mhealth solution ranging from sms daily reminders, hiv drugs compliance programmes and even medical insurance and telemedicine (9). a review of the study conducted by vedanthan et al. reveals that community health workers used smartphones to improve linkages to hypertension care (14). however, this study concluded that the strategy has to combine a tailored behavioral communication and mhealth (14). effectiveness of mhealth interventions in service delivery mhealth interventions have shown success in achieving their intended outcomes. from the reviewed citations, mhealth showed success in achieving retention in care (16), behavior change (19) cultural change and adaptation of new health-friendly behavior (15), maternal and child health improvements (20). indeed, mhealth interventions have managed to achieve effectiveness at a small scale. most mhealth interventions have not been able to successfully scale up nationally to augment health delivery at a national level (13). in terms of cost effectiveness, of all the citations that were reviewed in this study, only two research did a cost-benefit analysis indicating that sms use for mhealth was a cheap and cost-effective way of achieving certain health outcomes. text messaging was found to be 35% less expensive compare to the control group through reduction in the workforce involved such as research assistants, wages, salaries required, and communication costs (5,21). in assessing the effectiveness of text messaging in clinical outcomes, the citations reviewed revealed that there is positive outcome demonstrated with moderatequality evidence of greater improvement in the symptoms score compared to the control group (mean difference 0.36, 95% ci 0.56 to -0.17) (5). similarly, a review of this citation further revealed that there are increased hospital visits for those in the sms group compared to the control group. there is also reduction in number of days in hospitalization and reported better symptom control using spirometry transmission to health caregiver via sms and cell/telephone counseling (5). further, out of all the citations reviewed, two reviews yielded that oduor k, ogweno s, ajwang’ d, okinyi n. incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach (review). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4317 7 | p a g e mobile technology led to fewer symptoms being reported for congestive heart failure (5,22). a randomized control study on cellphone counseling in kisumu, kenya, showed that there was higher retention in the intervention arm than the control arm during delivery (16). the retention rate in the intervention arm was reported to be at 95.2% while that of the control arm was recorded as 77.7%. the 6 weeks postpartum was at 93.9% for the interventional arm and 72.9% for the control arm (16). overall, despite the many mhealth interventions currently happening in the country, very few interventions have been evaluated and very few have been research based making it difficult to track overall effectiveness of mhealth interventions (13). challenges facing mhealth interventions together with the potential impact that comes with mhealth intervention, there are myriad of challenges hovering around their implementation. gurupur & wan in their systematic review indicates that usability is a challenge to mhealth implementation (23). in considering the use of mobile health technologies in providing feedback for researchers, the review submits that issues of efficacy, effectiveness and satisfaction with which users can achieve specific goals are concerns of usability. in reviewing the study by gurupur & wan, we found out that usability has several components which includes learnability, efficiency, memorability, and satisfaction (23). a study by kariuki & okanda (24) on the adoption of mhealth and usability challenges in kenya also seem to have the same argument as that of gurupur & wan. the issue of usability is highlighted in the kimmnchip m-health application. the application was in english language hence the users who did not understand the language found it difficult to use it. further, the study submits that the interoperability was also a challenge as the web interface did not suit every device. the display was rather disfigured and difficult to use (24). the weltel intervention in kenya and canada also revealed some of the challenges facing mhealth interventions. in reviewing their study, bardosh et al reveals that juggling different interest, establishing the most appropriate financing pathways, maintaining network growth and “packaging” the intervention for impact and relevance is a challenge both in canada and kenya where the intervention is implemented (15). implementing mhealth technologies require more than just procuring the gadgets and using them. there are legal formalities that must be followed to approve their application (25). in reviewing the article by ryan (25), it is quite evident that incorporating mobile health solutions into the larger health infrastructure calls for its implementation to be harmonized in order to remove potential inequalities that may come with it. in the view of the aforementioned, the long and bureaucratic process that involves the approval of its application is poised to cause considerable timeline challenges (25). apart from the regulation challenges, security concerns also present another challenge that policymakers are grappling with. from the report submitted by elliot (26), itis evident that over 400 million people are using different forms of mobile health technologies. with this huge number, a single flaw in the system can render the data available to hackers or malware. the flaw also leads to the breach of the healthcare data (27). furthermore, mhealth has received a major blow even as critics suggest that without proper guidelines, mhealth intervention can infringe on patient’s data safety. this is a widespread concern especially in the context of electronic health records (27). still on the issue of data safety, review of the systematic review by gurupur & wan reveals that there is inherent problem with cloud computingstorage of data in unknown locations (23). this poses a significant threat to data and can be accessed by unauthorized persons. oduor k, ogweno s, ajwang’ d, okinyi n. incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach (review). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4317 8 | p a g e atun et al., indicate that apart from problems with cloud computing, data can also suffer risk of storage in non-secure locations (28). mhealth integration into kenya’s health infrastructure our focus in this systematic review was to determine how mhealth can be integrated into kenya’s health infrastructure to augment universal health coverage. we were concerned about how such integration can improve service delivery and in turn, fast track the achievement of universal health coverage. in our reviewed citations, we found out that mhealth integration is possible due to the increased smartphone penetration in kenya (24). in this study, the authors accessed the cost of accessing uzazi poa web application in terms of internet bundles. the accumulative percentage of 100% of the respondents submitted that access to mhealth application was not expensive and they would adopt it at will (24). the authors are in agreement that this was attributed to the prototype being developed using light graphics which ensure prompt transmission of data from the server to the mobile phone of the user (24). in light of the above, one thing that becomes clear is the issue of usability. for mhealth intervention to be fully optimized in kenya, the different forms of mhealth interventions must ensure efficiency which is a component of usability (23). universal health coverage as defined by who seeks to alleviate financial hardships in accessing health care services (1) meaning that mhealth intervention must be as efficient as possible. with the huge mobile penetration in kenya, addressing the usability concerns opens a pathway for mhealth integration into the larger health care infrastructure. four of the studies reviewed pointed out to the issue of an effective regulatory framework to be developed to inform the implementation of mhealth solutions (13-16,29). the ministry of health in kenya has the obligation of implementing mhealth committee or governing body because the field of technology and mhealth is ever-changing (29). it is paramount that the ministry of health set specific groups to keep up to date with new development in regard to how mobile technologies can be used to fasttrack achievement of universal health coverage. a proper regulatory framework will help in data security and the protection of individual information. similarly, integrating mhealth intervention into kenya’s health infrastructure will require more than just having a governing body. a study on the integration of mhealth in low-middle income settings suggests that governments should produce mhealth strategy and forge partnerships with ngos implementing mhealth solutions. this partnership enhances reporting and effectiveness more so because the government is involved and has systems to accept mhealth technologies (29,30). the issue of small mhealth project reaching to scale in kenya can also be made possible if the ministry of health consider endorsement of mhealth technologies as providing an acceptable standard of care (30). changamka’s linda jamii health insurance programme financed through a partnership between the kenyan government and safaricom is an example of how endorsement is critical for adoption and integration (29). again, for mhealth to be fully integrated into kenya’s health infrastructure to augment uhc, there is a growing body of need for investment in technology and infrastructure (13). the increased mobile penetration in kenya is not a coverup for internet connectivity. it is important that the government focus on increasing cellular and data coverage and increase data speed and transmission even in most remote parts of the country (13). while at it, app developers also have the responsibility of developing applications that are efficient and can fit oduor k, ogweno s, ajwang’ d, okinyi n. incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach (review). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4317 9 | p a g e well into kenya’s technological infrastructure (28). if mhealth solutions are going to fast-track the achievement of uhc, then it is only making sense if they are feasible and can be integrated into health infrastructure without major bottlenecks. coming back on the issue of usability, mhealth interventions must be continually evaluated and reassessed to sidestep the potential problems when the intervention reaches scale (28,29). discussion this systematic review was set out to identify mhealth interventions in kenya and how mhealth could be integrated into the health system to facilitate and enhance health service delivery with the aim of augmenting universal health coverage in the country. the authors used various approaches to ensure they extensively review existing projects which fit the research criterion. the analysis of the various works in the mhealth sector revealed strong points to which mhealth interventions have indeed improved health service delivery. mhealth interventions have proven effective in achieving various health objectives necessary for the achievement of universal health coverage including improving health literacy (13), improving compliance to medication (7), enhancing positive behavior change (14,15,19), improving access to health (14,20) and improving health financing and mobile health insurance (29). in the analysis, it was also noted that mhealth interventions are a feasible way of improving service delivery (24) due to the supportive environment that the country has, which includes being one of the highest internet connection subscription rates (31), and the demographic advantage as the country mostly consists of mostly the younger population with median age being 20 years (32). finally, one of the biggest factors in the mhealth interventions that have the potential to support and highly improve service delivery and universal health coverage is the availability of the various forms of mhealth interventions that have been adopted and implemented in various parts of the country with success (13-16). the various forms of mhealth interventions make it very possible to fast track the achievement of universal health coverage. some of the identified challenges and limitations in the mhealth interventions included the scalability factor (13). most mhealth interventions are implemented regionally and have not been able to scale up to various parts of the country. another challenge identified was lack of a national governing body for mhealth interventions (29). most mhealth interventions have been developed by private entities and until very recently, there was nobody in the government charged with streamlining mhealth interventions in the country. finally, the biggest limitation of this research was the fact that there is a huge gap in mhealth research. despite the numerous interventions, very few have actually been documented and even fewer have been evaluated through research (13). conclusion in conclusion, this review confirms that there has been indeed a lot of mhealth interventions in kenya, and mhealth is rapidly catching up and improving with the improved mobile internet penetration. there has been a lot of successful mhealth interventions in the country both locally and nationally. the adaptation of mhealth has been shown through research to greatly improve health service delivery and achieve various health objectives. despite the increased developments in the mhealth space, there has been significant challenges including around perceptions, usability, interoperability, funding, and scalability. but since we are just in the beginning stages of mhealth interventions in the country and the region, these challenges are definitely expected. owing to the findings of in this oduor k, ogweno s, ajwang’ d, okinyi n. incorporating mhealth interventions into kenya’s health infrastructure to augment universal health coverage, service delivery improvement approach (review). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4317 10 | p a g e review, and the existing evidence and future trends, it is the researcher’s opinion that mhealth indeed has the potential to improve health service delivery and as a result, augment universal health coverage not only in kenya but also around the world. recommendations this review recommends the following: 1. in kenya and even globally, more research needs to be undertaken to meas ure effectiveness and impact of already existing mhealth interventions. 2. mhealth interventions need to be monitored and amplified through government support and through creating a governing body for mhealth at a national level. 3. nationwide education and sensitization should be undertaken by the governments and its partners to debunk the myths, misconceptions and ideologies surrounding mhealth to improve its acceptability by the potential users. references 1. world health organization. what is universal coverage? who; 2019 available from: www.who.int/health_financing/universal_coverage_definition/en/ (accessed: january 15, 2021). 2. kenya school of government., (2019). the launch of the big four. knowledge hub. available at: http://ksg.ac.ke/knowledgehub/86/launch-big-four/ [accessed 4 apr. 2021]. 3. world health organization. building health: kenya's move to universal health coverage. who; 2018. available from: 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population (live). (n.d.). retrieved august 01, 2020. available from https://www.worldometers.info/world-population/kenyapopulation/ (accessed: january 15, 2021). mone i, kraja b, roshi e, burazeri g. overview on health status of the albanian population (review article). seejph 2022, posted: 02 october 2022. doi: 10.11576/seejph-5913 p a g e 1 | 6 review article overview on health status of the albanian population iris mone1, bledar kraja1, enver roshi1, genc burazeri1,2 1 faculty of medicine, university of medicine, tirana, albania; 2 department of international health, school caphri (care and public health research institute), maastricht university, maastricht, the netherlands. corresponding author: iris mone, university of medicine, tirana; address: rr. “dibres”, no. 371, tirana, albania; telephone: 00355692149301; email: iris_mone@yahoo.com mone i, kraja b, roshi e, burazeri g. overview on health status of the albanian population (review article). seejph 2022, posted: 02 october 2022. doi: 10.11576/seejph-5913 p a g e 2 | 6 abstract the albanian population is rapidly aging (in 2020, almost 15% of the population was ≥65 years) as a result of a steady increase in life expectancy (74.4 years in men and 78.7 years in women in in 2021), a gradual decrease in fertility rate (1.6 children per woman of childbearing age in 2020), and emigration of particularly young adults. this demographic transition experienced in the past three decades has inevitably led to a significant change in the epidemiological profile of the albanian population, characterized by a remarkable shift towards non-communicable diseases (ncds), particularly cardiovascular diseases (cvd), cancer, chronic respiratory diseases, and diabetes. the main risk factors in the albanian population consist of high blood pressure (top risk factor, accounting for about 34% of the overall mortality), nutritional-related risks (second, constituting about 25% of the overall mortality), and smoking (third risk factor, accounting for about 20% of the overall mortality). the national “health strategy, albania 2021-2030” is a political document of the albanian government that aims to define and achieve the objectives of the program for the protection and improvement of the health of the albanian population. following the national “health strategy, albania 2021-2030”, two new action plans were recently developed: the “action plan on ncds, albania 2021-2030” and the “action plan on health promotion, albania 2022-2030”. keywords: albania, demographic transition, epidemiological transition, health profile, western balkans. mone i, kraja b, roshi e, burazeri g. overview on health status of the albanian population (review article). seejph 2022, posted: 02 october 2022. doi: 10.11576/seejph-5913 p a g e 3 | 6 demographic characteristics of the albanian population as of january 2022, the population of albania consists of about 2.8 million inhabitants (1), displaying a gradual decrease in the past decade due to a decrease in fertility rate and emigration. as a matter of fact, fertility rate in albania has decreased steadily in the past few decades, exhibiting a level of 1.6 children per woman of childbearing age in 2020 (2), which is only slightly higher than the average in the european union countries (1.5 live births per woman in 2020) (3). according to the official figures provided by the national institute of statistics, in 2021, life expectancy in albania was 74.4 years in men and 78.7 years in women (4), representing a significant decrease compared with the pre-covid-19 pandemic (in 2019, life expectancy in men was 77.6 years, whereas in women it was 80.6 years). seemingly, there is evidence of a considerable excess death due to covid-19, especially among adult men in albania during the period 2020-2021. nevertheless, covid-19 aside, there is evidence of a steady increase in life expectancy in albania in the past three decades (4). in the past three decades following the breakdown of the communist regime, albania has experienced an unprecedented level of emigration, which continuous unabated. the net migration rate in albania is estimated to be between -5% to -10%, which involves a loss of more than 300,000 people only due to emigration in the past two decades (5). only during 2019-2020, the net migration rate in albania was about -40 thousand individuals (5). as a consequence of a gradual increase in life expectancy in the past few decades, the decrease in fertility rate, and the massive emigration of especially young adults, there is evidence of a significant demographic transition of the albanian population, with a substantial increase in the proportion of older individuals (≥65 years): from about 4% in 1990 to almost 15% in 2020 (4). mortality indicators of the albanian population in the past two decades, the age-standardized mortality rates in albania have declined more rapidly than in most of the other countries of the european region including especially the neighbouring countries of the western balkans (6). the overall mortality rate (number of deaths per 100,000 population) in albania in 2021 was 1,085, with cardiovascular diseases comprising about 53% of proportional mortality (7). according to the global burden of disease (gbd) estimates, the age-standardized overall mortality in albania in 2019 was about 575 (95%ci=460-714) deaths per 100,000 population, whereas in 1990 it was 830 (95%ci=813-849) deaths per 100,000 population (6). consistent with the overall increase in life expectancy in albania, infant mortality and child mortality, on the whole, have both decreased in the past three decades, a trend which was nevertheless interrupted in the past few years (2019-2021). in 2021, infant mortality rate was 8.4 deaths per 1,000 live births, whereas under-5 mortality rate was 9.2 deaths per 1,000 live births (4). the plateau or even worsening of child indicators in the past few years should be a cause of concern to policymakers and decisionmakers in albania, pointing to lack of sufficient attention in strategies and interventions targeting traditional mother and child health care programs and probably budget shifts toward other healthcare services. conversely, maternal mortality ratio in albania in 2020 was 3.6 deaths per 100,000 livebirths, indicating a decrease in the past decade (in 2012, it was 5.6 deaths per 100,000 livebirths) (4). of note, there has been a significant change in the mone i, kraja b, roshi e, burazeri g. overview on health status of the albanian population (review article). seejph 2022, posted: 02 october 2022. doi: 10.11576/seejph-5913 p a g e 4 | 6 epidemiological profile of the population in the past few decades with a remarkable transition towards non-communicable diseases (ncds), characterized by an increase of cardiovascular diseases (cvd), cancer, chronic respiratory diseases, and diabetes (8). the age-standardized mortality rate from all ncds in 2019 was estimated at 520 (95%ci=413-649) deaths per 100,000 population, whereas in 1990 it was estimated at 673 (95%ci=657-705) deaths per 100,000 population (6). in 2019, about 93% (95%ci=92%-94%) of all deaths in albania (all ages) were caused by ncds, as opposed to only about 71% (95%ci=69%-76%) in 1990 (6). cvd mortality in 2019 was estimated at 474 (95%ci=374-596) deaths per 100,000 population, constituting 57% (95%ci=52%60%) of the overall mortality in the albanian population (6). furthermore, mortality from neoplasms in 2019 was estimated at 173 (95%ci=131-223) deaths per 100,000 population, accounting for 21% (95%ci=19%-23%) of the overall mortality (6). in addition, mortality rate from chronic respiratory diseases in 2019 was 30 (95%ci=22-39) deaths per 100,000 population, comprising 3.6% (95%ci=3.1%4.2%) of the overall mortality (6). mortality rate from diabetes mellitus in 2019 was 6.4 (95%ci=4.8-8.5) deaths per 100,000 population, comprising 0.8% (95%ci=0.7%0.9%) of all-cause mortality (6). on the other hand, in 2019, mortality rate from communicable diseases, maternal, neonatal and nutritional disorders altogether was estimated at 27 (95%ci=22-33) deaths per 100,000 population, comprising 3.2% (95%ci=2.8%-3.8%) of all-cause mortality (6). in turn, mortality rate from injuries in 2019 was 31 (95%ci=24-39) deaths per 100,000 population, comprising 3.7% (95%ci=3.5%3.9%) of all-cause mortality (6). based on this rapid epidemiologic transition (from infectious diseases toward ncds), there is a pressing need for an effective strategy for control and prevention of ncds, which has been a core component of the health sector reform in albania, culminating with the fairly recent development of the “national plan on ncds, albania 20212030” (document pending official endorsement by the albanian ministry of health and social protection). disease burden and the main risk factors in the albanian population regarding the burden of disease (mortality and disability combined), in 2019, ncds accounted for 82% (95%ci=81%-84%) of all disability-adjusted life years (dalys) (6). cvds only constituted 29% (95%ci=25%33%) of the overall disease burden in the albanian population (6). conversely, neoplasms, chronic respiratory diseases, and diabetes accounted respectively for 15%, 2.6% and 2.1% of the overall burden of disease in the albanian population (6). the ncd burden in albania is caused by a wide range of health determinants, but, particularly, due to a high prevalence of high blood pressure (top risk factor for the albanian population according to the most recent gbd estimates, accounting for about 34% of the overall mortality); nutritional related risks (second, constituting slightly more than 25% of the overall mortality); smoking (third risk factor, accounting for about 20% of the overall mortality), as well as overweight and obesity, high plasma sugar level and physical inactivity (6). regarding the trends in the main conventional risk factors, the prevalence of smoking has slightly decreased in albanian men in the past few years, whereas in women it remains low (as a matter of fact, the lowest mone i, kraja b, roshi e, burazeri g. overview on health status of the albanian population (review article). seejph 2022, posted: 02 october 2022. doi: 10.11576/seejph-5913 p a g e 5 | 6 in the region) (9). in 2019, mortality attributed to smoking comprised about 50% of chronic respiratory diseases deaths, 31% of deaths from neoplasms, and 17% of cvd deaths (6). on the other hand, the average alcohol consumption has increased by half a litter (per capita) in the past few years. in 2019, mortality attributed to alcohol consumption comprised about 5% of deaths from neoplasms, and 1.7% of cvd deaths (6). as for the high blood pressure, which is the main risk factor in the albanian population, its attributable mortality in 2019 accounted for more than 57% of cvd deaths (6). of note, there is evidence of a considerable increase in the prevalence of obesity in both men and women in albania in the past decade (overall, 28% increase) (9). in 2019, mortality attributed to high body mass index constituted about 43% of deaths from diabetes mellitus, more than 19% of cvd deaths, and about 5% of deaths from neoplasms (6). current strategies and policies to address disease burden in the albanian population the national “health strategy, albania 20212030” is a political document of the albanian government that aims to define and achieve the objectives of the program for the protection and improvement of the health of the albanian population (10). this policy document defines the main objectives for improving health and healthcare for the period 2021-2030, although the vision presented in the strategy will also be suitable for the period after the official implementation of this strategy (10). the drafting of the national “health strategy, albania 2021-2030” was led by the ministry of health and social protection through an inter-institutional technical working group, which was established by a special order of the minister of health and social protection and was supported with technical assistance of local and international experts (10). following the national “health strategy, albania 2021-2030”, two new action plans were recently developed: the “action plan on ncds, albania 2021-2030” and the “action plan on health promotion, albania 20222030”. both documents are still pending official approval by the albanian ministry of health and social protection. nonetheless, the new action plans are based on positive developments and progress of albania in general and reforms in the health sector in particular. the documents take into consideration the updated legislation and the regulatory framework adopted in albania during the last decade, in close cooperation and with the technical assistance of various partner organizations and international agencies. also, both action plans address the actual public health challenges and the priorities 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http://www.instat.gov.al/al/temat/treguesit-demografik%c3%ab-dhe-social%c3%ab/migracioni-dhe-integrimi-i-migrant%c3%abve/#tab2 http://www.instat.gov.al/al/temat/kushtet-sociale/sh%c3%abndet%c3%absia/publikim http://www.instat.gov.al/al/temat/kushtet-sociale/sh%c3%abndet%c3%absia/publikim http://www.instat.gov.al/al/temat/kushtet-sociale/sh%c3%abndet%c3%absia/publikim http://www.instat.gov.al/al/temat/kushtet-sociale/sh%c3%abndet%c3%absia/publikim http://seehn.org/web/wp-content/uploads/2015/02/albanian-health-report_download.pdf http://seehn.org/web/wp-content/uploads/2015/02/albanian-health-report_download.pdf http://seehn.org/web/wp-content/uploads/2015/02/albanian-health-report_download.pdf https://www.ishp.gov.al/wp-content/uploads/2015/04/adhs-2017-18-complete-pdf-final-ilovepdf-compressed-1.pdf https://www.ishp.gov.al/wp-content/uploads/2015/04/adhs-2017-18-complete-pdf-final-ilovepdf-compressed-1.pdf https://www.ishp.gov.al/wp-content/uploads/2015/04/adhs-2017-18-complete-pdf-final-ilovepdf-compressed-1.pdf https://www.ishp.gov.al/wp-content/uploads/2015/04/adhs-2017-18-complete-pdf-final-ilovepdf-compressed-1.pdf https://konsultimipublik.gov.al/konsultime/detaje/434 https://konsultimipublik.gov.al/konsultime/detaje/434 hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 1 | 14 original research childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study phoebe w. hwang1, cristiano dos santos gomes2, mohammad auais3, kathryn l. braun1, catherine m. pirkle1 1 office of public health studies, university of hawaii at mānoa, hawaii, usa; 2 federal university of rio grande do norte, natal, brazil; 3 school of rehabilitation therapy, queen’s university, ontario, canada. corresponding author: phoebe w. hwang address: 1960 east west road, biomedical sciences bldg #d104t, honolulu, hawaii 96822; telephone: (808) 232-3223; e-mail: pwnhwang@hawaii.edu hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 2 | 14 abstract aim: the purpose is to examine the relationship between childhood adversity and leisure time physical activity (ltpa) among community-dwelling older adults from high and middle-income sites. methods: cross-sectional analysis of 2012 data from older adult ages 64-75 years old from kingston, canada; st. hyacinthe, canada; tirana, albania; manizales, colombia; and natal, brazil. principal exposure variables were childhood social and economic adversity. covariates included participant age, sex, income, and educational attainment. outcome variables were ltpa and leisure time sports activity (ltsa). results: high-income sites had higher ltpa prevalence than middle-income sites. females were less likely to engage in ltpa compared to males in tirana (or:0.53, 95%ci:0.30-0.94), but were more likely to engage in ltpa in manizales (or:2.54, 95%ci:1.54-4.18). low education was less likely than high education to engage in ltpa in kingston (or:0.38, 95%ci:0.19-0.73) and natal (or: 0.52, 95%ci:0.28-0.97). low income was less likely than high income to engage in ltpa in st. hyacinthe (or: 0.42, 95%ci:0.20-0.89) and manizales (or:0.33, 95%ci:0.16-0.55). in tirana, low income was more likely than high income to engage in ltpa (or:5.27, 95%ci:2.06-13.51). conclusions: childhood economic and social adversity were not significantly associated with ltpa. sex, income, and education were associated with older adult pa engagement, however the direction of the association varied by site location. this suggests that the paradigms surrounding pa behavior may vary from city to city. understanding the site-specific risk factors to pa engagement may better inform clinical recommendations and public health approaches to increase pa engagement among older adults across the globe. keywords: childhood adversity, gerontology, global health, physical activity. conflicts of interest: none declared. hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 3 | 14 introduction physical activity (pa) is protective against chronic diseases and delays the onset of agerelated health complications (1). leisure time physical activity (ltpa) in particular is more effective in improving overall health than transportation, occupational, and sport-related pa among older adults. unfortunately, the amount of ltpa decreases as age increases (2). a large portion of pa literature explores individual level theories of pa behavior change, such as self-efficacy theory and the transtheoretical model, or individual-microenvironment level theories, such as the social cognitive model (3). consequently, there is no shortage of behavior-based interventions directed to increase older adult pa. whether home, group, or educational-based, evaluations of these interventions have come to the same conclusion: individual behavior reinforcement strategies alone are not effective in maintaining older adult pa behavior (4). etiological studies applying a life course perspective may be informative for interventions aimed in improving pa (2). among the many exposures life course researchers have examined, early-life exposures appear the most cogently popular. studies have shown that early life exposures and socio-demographic characteristics affect an individual’s health behaviors and outcomes. gender, social and material adversity, and living in a disadvantaged neighborhood are all documented to influence overall health during adulthood (5,6). these findings suggest that early childhood events may have long-term consequences on health behaviors and that pa behaviors may have roots situated in early life circumstances. this study focused on community dwelling older adults of diverse socioeconomic status and global settings, recruited as part of the international mobility in aging study (imias). the objective is to examine the relationship between childhood adversity, and self-reported pa behaviors. since early-life adversity negatively impacts many later life health behaviors, the authors hypothesize that childhood adversity is associated with lower levels of older adult pa behavior. previous early life adversity studies that utilize a life course model were unable to examine crosssocietal influences on behaviors due to sample homogeneity. cross-societal investigations may provide insights on the contribution of broad social structures to pa behaviors, which in turn, may improve interventions geared at individual behavior change. methods site location descriptions imias is a longitudinal study focused on older adult health. baseline data were obtained in 2012, with follow-up collections in 2014 and 2016 (7). data were community samples collected from five distinct study sites: kingston and st. hyacinthe, canada; tirana, albania; natal, brazil; and manizales, colombia. the entire sample size is 2002 (roughly 200 men and 200 women from each site), which is large enough to examine how childhood adversity influences later life physical activity behavior. population socioeconomic, cultural, and religious demographics within each study site are relatively homogenous, whereas between sites there is substantial heterogeneity in socio-demographic characteristics. this give us a broad spectrum of different life exposures and health outcomes, thus providing a comprehensive picture of life course exposures and later life health outcomes across the globe. for a detailed description on hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 4 | 14 site locations and study, please refer to gomez et al (7). population and data collection participants of this study are male and female community-dwelling older adults age 65-74 years. at canadian sites, university ethics committees did not allow researchers to recruit potential participants directly. family physicians sent letters of invitation to potential participants that invited them to contact a field coordinator for further information regarding the study. participants were recruited from health center registries in tirana, natal, and manizales. a random sample of potential participants was drawn from health center registries, and these individuals were recruited directly by interviewers. interviewers were trained with a standardized protocol. comparisons of recruited participants to census data suggest samples are representative of the towns/cities from which they were recruited (7). individuals who had four or more errors on leganes cognitive test orientation scale (8) were excluded from the study. low scores indicated inability to complete study procedures. recruitment continued until about 400 responses were obtained in each locale. exposure childhood adversity was measured using a series of retrospective questions on events that occurred within the first 15 years of the participants’ life. imias survey questions regarding childhood adversity were from the survey on health and well-being elders (sabe study) (9,10), and the canadian community health survey (cchs) (11). the events were: death of parent, parental substance abuse, parental divorce, witnessing physical violence in the family, low economic status, having been hungry, having been physically abused, and parental unemployment. members of the imias team previously performed an exploratory factor analysis on these indicators to yield two categories: economic adversity (low economic status, hunger, and parental unemployment), and social adversity (parental substance abuse, witnessing family physical violence, having been physically abused) (12). adversity summary scores of economic and social adversity were recoded into two variables with binary responses—having experienced adversity (having experienced >0 of the indicators listed above) in childhood and no adversity experiences in childhood (having experienced none of the indicators listed above). covariates education, income, age, and sex were chosen as covariates based on research into the social determinants of health (13). education was previously trichotomized into three categories: illiterate/primary school only, secondary schooling, and post-secondary schooling. analyses indicated insufficient variability within sites for comparison across sites. to allow for comparisons across sites, total years of education was split categorically into tertiles of high, medium, and low education by site to obtain a variable called “relative education”. thus, it is possible for a participant to have high educational attainment relative to his/her community, but medium or low attainment compared to another site in imias. sex is an interviewer reported categorical variable (male/female). age is a self-reported continuous variable re-coded into a binary categorical variable (64-69/70-75 years). income is a self-reported continuous variable of annual income recoded into an ordinal variable (poor/middle/high) based on site-specific hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 5 | 14 poverty thresholds (7). site location is based on the location of data collection. outcomes the outcomes for this study were ltpa and ltsa. ltpa was defined as leisure time activity that involved bodily movement produced by large skeletal muscles that require energy expenditure (14). ltsa was defined as any reported leisure time activity that is considered an official event in the olympics (15). ltsa is a subset of ltpa. participants were asked to report any leisure time activities and to specify those activities. responses were categorized into yes or no ltpa or ltsa based on the definitions above. statistical analysis bivariate analyses were performed using pearson’s chi-squared test for categorical data in order to assess potential differences in proportions between different groups. assumptions were met for all comparisons. the exposures and covariates listed above were tested as correlates to ltpa and ltsa behavior using logistic regression. preliminary analysis demonstrated a strong site-specific interaction with the outcome variables childhood social and economic adversities. this was expected given the substantial economic and societal differences between the sites. therefore, this study focuses on the effect modification per site and analyses were stratified by site to highlight the different relationships. please refer to the imias cohort profile for additional information regarding study sites (7). all regression models statistically adjusted for age, educational attainment, current income, sex, and site location. stata/se 14.0 was used to conduct the analyses. results the prevalence of ltpa and ltsa engagement by site is displayed in table 1. kingston (68.1%) and st. hyacinthe (51.4%) had higher prevalence of ltpa compared to tirana (17.5%), manizales (27.3%), and natal (22.6%). similar patterns were also observed in ltsa. of all the participants, 36.7% in kingston, 31.7% in st. hyacinthe, 4.1% in tirana, 5.7% in manizales, and 5.5% in natal engaged in ltsa. table 1. proportion of participants reporting leisure time physical and sports activity engagement by site kingston (n=398) st. hyacinthe (n=401) tirana (n=394) manizales (n=407) natal (n=402) ltpa engagement, n (%)* 68.1% 51.4% 17.5% 27.3% 22.6% ltsa engagement, n (%)† 36.7% 31.7% 4.1% 5.7% 5.5% missing data: kingston=24; st. hyacinthe= 46; tirana= 7; manizales= 10. *ltpa = activity done for leisure that results in energy expenditure by major skeletal muscles. †ltsa = activity done for leisure that requires physical exertion and skill for competition. table 2 summarizes socio-demographic characteristics and adversity. in manizales, compared to men, women were significantly more likely to report ltpa engagement (33.8% versus 21.9%). at both canadian sites, those with higher levels of education were significantly more likely to report ltpa compared to those with medium and low site-specific education levels. in kingston for example, 81.8% of highly educated participants report ltpa compared to 63.5% of those with low education. it should be hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 6 | 14 noted, however, that even low educated participants from kingston and st. hyacinthe reported more ltpa than any educational category at the middle-income sites. income was significantly associated with ltpa engagement in st. hyacinthe, tirana, and manizales. however, the nature of these associations varied by site. in both st. hyacinthe and manizales, high income participants were more likely to report ltpa engagement (67.4% and 41.7%, respectively), compared to poor income participants (47.2% and 23.2%, respectively). the opposite was true in tirana. poor income participants were more likely to report ltpa engagement (32.6%) compared to high income (10.6%). in tirana, 21.3% of participants who experienced childhood economic adversity engaged in ltpa compared to 13.3% of those who didn’t experience childhood economic adversity. table 2. summary of leisure time physical activity engagement (ltpa)‡ by participant socio-demographic characteristics and childhood adversity, according to site ltpa engagement kingston (n=398) st. hyacinthe (n=401) tirana (n=394) manizales (n=407) natal (n=402) sex (%) male 76.6% 59.9% 21.7% 21.9%† 24.0% female 68.7% 56.4% 14.3% 33.8% 21.4% age in years (%) 64 to 69 72.4% 59.5% 17.1% 26.9% 24.2% 70 to 74 72.6% 55.5% 18.7% 29.2% 20.9% education (%)¶ low 63.5%† 50.0%† 17.9% 26.1% 16.7%† medium 76.5% 61.3% 18.3% 23.2% 24.5% high 81.8% 66.1% 17.0% 35.9% 19.0% income (%) poor 64.4% 47.2%* 32.6%* 23.2%† 12.1% middle 72.9% 66.4% 19.0% 28.07% 21.0% high 74.5% 67.4% 10.6% 41.7% 27.6% childhood economic adversity (%)§ yes 71.7% 55.0% 21.3%† 28.9% 22.0% no 72.7% 59.7% 13.3% 27.4% 22.0% childhood social adversity (%)ii yes 74.7% 55.0% 21.7% 27.7% 26.2% no 71.6% 59.1% 17.0% 28.2% 21.4% pearson’s chi-square analysis was used to test for association of categories within sites *p<0.001 †p<0.05 ‡leisure time physical activity is defined as activity done for leisure that results in energy expenditure by major skeletal muscles. §childhood economic adversity is defined as having experienced poor economic status, hunger, or parental unemployment. iichildhood social adversity is defined as having experienced parental substance abuse, family physical violence, or physical abuse. ¶education calculated from total years of education categorized by site-specific tertiles hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 7 | 14 table 3 summarizes socio-demographic characteristics and adversity by ltsa engagement. men were significantly more likely to report ltsa engagement in kingston (49.3%), st. hyacinthe (43.1%), and tirana (7.1%) compared to women (29.8%, 29.3%, and 1.5%, respectively). the younger age group (43.8%) was significantly more likely to engage in ltsa compared to the older age group (32.9%) only in kingston. in manizales, high education and high income were significantly associated with ltsa engagement. in tirana, presence of childhood economic adversity was significantly associated with ltsa engagement. in natal, presence of childhood social adversity was significantly associated with ltsa. table 3. summary of leisure time sport activity engagement (ltsa)‡ by participant sociodemographic characteristics and childhood adversity, according to site ltsa engagement kingston (n=398) st. hyacinthe (n=401) tirana (n=394) manizales (n=407) natal (n=402) sex (%) male 49.3%* 43.1%† 7.1%† 6.1% 6.8% female 29.8% 29.3% 1.5% 5.5% 4.3% age in years (%) 64 to 69 43.8%† 35.3% 3.6% 7.1% 6.5% 70 to 74 32.93% 36.7% 4.7% 4.3% 4.3% education (%)¶ low 33.9% 34.5% 5.2% 4.9%† 5.1% medium 43.1% 33.1% 3.9% 2.9% 5.8% high 39.4% 39.1% 3.0% 10.3% 5.8% income (%) poor 34.0% 32.0% 5.2% 4.9%† 5.1% middle 45.9% 36.6% 3.9% 2.9% 5.8% high 39.4% 40.2% 3.0% 10.3% 5.6% childhood economic adversity (%)§ yes 44.2% 34.9% 6.3%† 5.4% 4.6% no 36.8% 36.3% 1.2% 6.09% 7.1% childhood social adversity (%)ii yes 35.8% 34.1% 5.8% 2.1% 9.4%† no 40.3% 36.4% 3.8% 7.0% 4.1% pearson’s chi-square analysis was used to test for association of categories within sites. * p<0.001 † p<0.05 ‡ leisure time sport activity is defined as activity done for leisure that requires physical exertion and skill for competition. § childhood economic adversity is defined as having experienced poor economic status, hunger, or parental unemployment. ii childhood social adversity is defined as having experienced parental substance abuse, family physical violence, or physical abused ¶ education calculated from total years of education categorized by site-specific tertiles tables 4 and 5 summarize the results of the multivariate models. childhood social and economic adversities were not significantly associated with ltpa engagement in all sites. in kingston, participants with lower education were less likely to engage in ltpa (or:0.38, 95%ci:0.19-0.73) compared to high education. in st. hyacinthe, poor income participants were less likely to engage hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 8 | 14 in ltpa (or:0.42, 95%ci:0.20-0.89) compared to high income. the opposite relationship was observed in tirana. poor (or:5.27, 95%ci:2.06-13.51) and middle income (or:2.44, 95%ci:1.20-4.99) participants were more likely to engage in ltpa compared to high income. in manizales, women were more likely to engage in ltpa compared to men (or:2.54, 95%ci:1.54-4.18). also, poor (or:0.33, 95%ci:0.16-0.65) and medium income participants (or:0.46, 95%ci:0.23-0.92) were less likely to engage in ltpa compared to high income participants from this site. in natal, participants with low education were also less likely to engage in ltpa compared to high education (or:0.52, 95%ci0.28-0.97). for ltsa in natal, participants who experienced childhood social adversity were more likely to engage in ltsa compared to those who did not (or:3.31, 95%ci:1.31-8.41). females were less likely to engage in ltsa compared to males in kingston (or:0.40, 95%ci:0.250.65) and tirana (or:0.17, 95%ci:0.040.64). in manizales, participants with medium level education were less likely to engage in ltsa compared to high level (or:0.25, 95%ci:0.10-0.82). in natal, middle income participants were less likely to engage in ltsa compared to high income (or:0.29, 95% ci:0.10-0.82). table 4. association of participant socio-demographic characteristics and childhood adversity measures with self-reported ltpa†,‡ kingston (n=398) st. hyacinthe (n=401) tirana (n=394) manizales (n=407) natal (n=402) or 95% ci or 95% ci or 95% ci or 95% ci or 95% ci sex male 1.00 1.00 1.00 1.00 1.00 female 0.74 0.44-1.23 1.24 0.74-2.05 0.53* 0.30-0.94 2.54* 1.54-4.18 0.99 0.60-1.65 age (years) 64 to 69 1.00 1.00 1.00 1.00 1.00 70 to 74 1.18 0.72-1.95 0.89 0.56-1.43 0.91 0.53-1.58 1.08 0.68-1.70 0.81 0.50-1.31 education¶ low 0.38* 0.19-0.73 0.78 0.80 0.38-1.71 0.83 0.44-1.54 0.52* 0.28-0.97 medium 0.88 0.43-1.78 1.05 0.55-2.00 0.83 0.41-1.69 0.65 0.36-1.19 0.85 0.47-1.52 high 1.00 1.00 1.00 1.00 1.00 income poor 0.82 0.40-1.67 0.42* 0.20-0.89 5.27* 2.06-13.51 0.33* 0.16-0.65 0.35 0.11-1.10 middle 1.31 0.72-2.39 0.95 0.49-1.83 2.44* 1.20-4.99 0.46* 0.23-0.92 0.76 0.44-1.31 high 1.00 1.00 1.00 1.00 1.00 childhood econo mic adversity§ yes 0.96 0.56-1.64 0.86 0.53-1.39 1.65 0.92-2.93 1.29 0.79-2.09 1.19 0.71-1.99 no 1.00 1.00 1.00 1.00 1.00 childhood social adversityii yes 1.42 0.78-2.56 1.08 0.63-1.85 0.93 0.47-1.87 0.90 0.52-1.56 1.43 0.84-2.45 no 1.00 1.00 1.00 1.00 1.00 *p<0.05 †leisure time physical activity is defined as activity done for leisure that results in energy expenditure by major skeletal muscles. ‡logistic regression models have been adjusted for age, sex, education, and income. §childhood economic adversity is defined as having experienced poor economic status, hunger, or parental unemployment. iichildhood social adversity is defined as having experienced parental substance abuse, family physical violence, or physical abuse ¶education calculated from total years of education categorized by site-specific tertiles hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 9 | 14 table 5. association of participant socio-demographic characteristics and childhood adversity measures with self-reported ltsa†,‡ kingston (n=398) st. hyacinthe (n=401) tirana (n=394) manizales (n=407) natal (n=402) or 95% ci or 95% ci or 95% ci or 95% ci or 95% ci sex male 1.00 1.00 1.00 1.00 1.00 female 0.40* 0.25-0.65 0.65 0.39-1.08 0.17* 0.04-0.64 1.09 0.44-2.67 0.70 0.27-1.85 age (years) 64 to 69 1.00 1.00 1.00 1.00 1.00 70 to 74 0.64 0.40-1.02 1.14 0.71-1.83 1.04 0.36-2.97 0.59 0.24-1.46 0.64 0.25-1.60 education¶ low 0.89 0.49-1.61 0.95 0.51-1.75 2.05 0.46-9.10 0.54 0.17-1.69 1.56 0.48-5.10 medium 1.62 0.90-2.93 1.17 0.62-2.19 1.28 0.29-5.65 0.25* 0.07-0.87 1.44 0.46-4.54 high 1.00 1.00 1.00 1.00 1.00 income poor 1.01 0.50-2.05 0.59 0.28-1.24 3.88 0.79-10.07 0.65 0.18-2.36 0.53 0.10-2.69 middle 1.21 0.69-2.10 0.84 0.44-1.59 1.37 0.37-5.03 1.42 0.44-4.58 0.29* 0.10-0.82 high 1.00 1.00 1.00 1.00 1.00 childhood econo mic adversity§ yes 1.62 0.98-2.66 0.88 0.54-1.43 4.35 0.94-20.13 1.31 0.50-3.39 0.60 0.24-1.51 no 1.00 1.00 1.00 1.00 1.00 childhood social adversityii yes 0.78 0.46-1.34 1.10 0.64-1.92 0.76 0.22-2.69 0.24 0.5-1.10 3.31* 1.31-8.41 no 1.00 1.00 1.00 1.00 1.00 *p<0.05 †leisure time physical activity is defined as activity done for leisure that results in energy expenditure by major skeletal muscles. ‡logistic regression models have been adjusted for age, sex, education, and income. §childhood economic adversity is defined as having experienced poor economic status, hunger, or parental unemployment. iichildhood social adversity is defined as having experienced parental substance abuse, family physical violence, or physical abuse. ¶education calculated from total years of education categorized by site-specific tertiles. discussion this study examined the relationship between childhood adversity, occurring before 15 years of age, and self-reported later life pa behaviors among community-dwelling older adults from diverse global settings. this study hypothesized that since previous imias studies demonstrated a strong association between childhood adversity and older adult physical performance, there must also be a relationship between childhood adversity and physical activity behavior. however, findings from these studies demonstrated that childhood social adversity was associated with self-reported ltpa only in tirana and natal, and childhood economic adversity was not associated with pa engagement at all. as expected, sex, income and education were associated with older adult pa engagement, however the direction of the association varied by site location. this suggests that the paradigms surrounding pa behavior may vary, possibly depending on geographical, cultural, social, and/or historical influences. thus, the risk factors associated with low pa engagement differ from city to city. understanding the site-specific risk factors to pa hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 10 | 14 engagement may better inform clinical recommendations and public health approaches to increase pa engagement among older adults across the globe. childhood adversity and physical activity behavior in a previous imias study, the presence of social and economic childhood adversity was associated with poor physical performance. however, the mechanisms of this relationship were unexplored. since physical activity is commonly associated with good physical performance (16), we hypothesized that low physical activity engagement may partially explain the association observed by sousa et al. contrary to our hypotheses, self-reported childhood adversity experiences did not correlate strongly with ltpa/ltsa engagement among older adults. moreover, the nature of the association differed from what we hypothesized. in tirana, self-reported childhood economic adversity was marginally associated with both ltpa/ltsa engagement. while not statistically significant, participants in tirana who reported childhood economic adversity had 4.35 times the odds of reporting ltsa engagement. in natal, reporting childhood social adversity was also associated with ltsa. there is no doubt that early life adversity is associated to poor health behaviors and health outcomes in later life. therefore, it was puzzling to find that early life adversity did not correlate strongly with ltpa/ltsa. unfortunately, there is currently no literature that examines the relationship between childhood adversity and later life physical activity behaviors to which we can compare this study. our current results suggest that physical activity behavior may not explain the relationship between early life adversity and physical performance. one possible explanation for our contrary findings may be selective survival, since data were collected only among older adults aged 65-74 (17), and the average life expectancies at birth between the sampled sites varied greatly. for example, in 1960, the life expectancy at birth in brazil was 54.7 years, whereas canada’s average life expectancy was 71.13 years old (18). therefore, those in brazil who survived until study recruitment reflect the survivors of their birth cohort. selective survival has been observed in previous studies where the differences in health and mortality between groups of high and low socioeconomic statuses decline as age increases (19). in fact, a study conducted in israel found that older adults who survived past 61 years old have higher community resilience scores compared to the younger population, indicating that healthy older adults have a better ability to alleviate the detrimental effects of adverse events (20). this may explain why childhood adversity was associated with physical activity engagement in the middle income sites. those who managed to overcome childhood adversity and live past the average life expectancy of their cohort may have distinctively different behaviors from those who did not survive. site-specific influences on physical activity behavior overall, childhood adversity did not correlate as strongly to ltpa/ltsa as compared to the other socio-demographic factors that were observed in this study. ltpa/ltsa engagement was notably greater in high income (kingston, st. hyacinthe) compared to middle-income sites (tirana, manizales, natal). these results were consistent with a study that analyzed physical activity trends using data from the world health organization. among adults aged 15 years and over, brazil, hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 11 | 14 colombia, and albania’s physical inactivity rates were higher than canada’s (21). additionally, the authors found that ltpa increased as occupational pa decreased over time in high-income countries. the same analysis could not be done with low and middle-income countries because these data were not available (21). our study is one of the first to estimate ltpa prevalence in community dwelling older adults from middle-income settings. the observed associations between socio-demographic factors and reported pa behavior varied notably by study site as well. the relationships between ltpa/ltsa engagement and socio-demographic variables may be dependent on site-specific norms. for example, income was significantly associated with ltpa engagement in st. hyacinthe, tirana, and manizales, but not in a consistent direction. in tirana, poor income participants were five times more likely to engage in ltpa compared to high income participants, whereas in st. hyacinthe, poor income participants were less likely to engage in ltpa compared to high income. our study further justifies that social norms may influence pa behaviors. similar results can be found within the united states (22), and high-income east asian countries (23). however, to the authors’ knowledge, no studies have identified cross-societal differences of factors associated to ltpa engagement across study sites of varying income categorization. ltpa versus ltsa this paper examined pa behavior by type— ltpa and ltsa. ltsa is a subcategory of ltpa. it can be said that all ltsa is considered ltpa, but not all ltpa is considered ltsa. ltsa have a set of rules and goals to train and excel in specific athletic skills. moreover, ltsa in general, has a more competitive edge (24). in this study, sex was a significant correlate to ltsa engagement for all sites except natal. males were more likely to engage in ltsa compared to females. yet, sex was not significantly associated to ltpa. results from this study were congruent to other studies that examined sex differences in pa behaviors. in the united states, females are less likely to engage in vigorous pa from adolescence to adulthood (2). among college attending young adults, females were less likely to engage in sports compared to males (25). historical and anthropological studies suggest that males experience an evolutionary history of physical competition for courtship and warfare more often than females (26). further, men are more likely to engage in extreme physical competitive aggression compared to women (27). understanding how sex is correlated with physical activity type preference may give us insight on the social norms of pa, and guide sex-specific pa intervention design. limitations although the large gap between middle and high-income sites clearly shows a difference in pa engagement prevalence, bivariate sitespecific analyses that examine the correlates to pa engagement may have been underpowered as very few participants from middle income sites reported ltsa engagement, and relatively few reported ltpa engagement. a second limitation to this study is that the ltpa/ltsa measure used has not been previously validated. however, widely used ltpa measurement tools such as godin leisure time questionnaire, international physical activity questionnaire, and sedentary behavior questionnaire have been only validated with populations aged 18 to 69 years old, just missing the older adult population. hwang pw, gomes cds, auais m, braun kl, pirkle cm. childhood adversity and leisure time physical and sports activity in older adults: a cross-sectional analysis from the international mobility in aging study (original research). seejph 2020, posted: 26 october 2020. doi 10.4119/seejph-389 p a g e 12 | 14 further, pilot studies were previously conducted to validate the ipaq in santa cruz, brazil, using accelerometers. results showed that ipaq had poor validity (28); therefore, it was not considered for this study. lastly, since this is a secondary data analysis, sample size could not be determined a priori. thus, the sample size may not be powered for this particular analysis. however, given the richness of the data, it allows us to deeply examine the multiple factors involved in the life course. conclusions since the 1990’s, there has been a progress in research that examines environment-level factors correlates and causes of pa. unfortunately, many studies focused only on high-income countries (29). as the world ages, and the global burden of non-communicable diseases increase, health behaviors such as pa are becoming more relevant in lower-income settings. several studies have shown a link between childhood adversity at adult pa behavior, but have not followed the participants into older adulthood (30). this study is one of the few that makes cross-societal inferences on the effects of childhood adversity on older adult pa behavior and it highlights the powerful influences of social norms on ltpa/ltsa engagement. references 1. hackney me, hall cd, echt kv, wolf sl. dancing for balance: feasibility and efficacy in oldest-old adults with visual impairment. nurs res 2013;62:138-43. 2. caspersen cj, pereira ma, curran km. changes in physical activity patterns in the united states, by sex and cross-sectional age. med sci sports exerc 2000;32:1601-9. 3. king ac, stokols d, talen e, brassington gs, killingsworth r. theoretical approaches to the promotion of physical activity: forging a transdisciplinary paradigm. am j prev med 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__________________________________________________________________ © 2020 hwang et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://papyrus.bib.umontreal.ca/xmlui/handle/1866/7133 https://papyrus.bib.umontreal.ca/xmlui/handle/1866/7133 stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 1 | 14 original research two sides of a broken medal: disease prevention and health promotion in schools of public health zeljka stamenkovic1, helmut wenzel2, janko jankovic1, vesna bjegovic-mikanovic3 1 university of belgrade, faculty of medicine, institute of social medicine, belgrade, serbia; 2 independent consultant, konstanz, germany; 3 university of belgrade, faculty of medicine, centre school of public health and management, belgrade, serbia. corresponding author: željka stamenković address: dr subotica 15, 11000 belgrade, serbia telephone: +381 11 2643 830; fax: +381 11 2659 533; e-mail: zeljka.stamenkovic@med.bg.ac.rs stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 2 | 14 abstract aim: disease prevention and health promotion are closely related through the lifestyle concept and teaching modules on them should be a part of the postgraduate curriculum of every school of public health (sph) in the european region and beyond. we aimed to determine to which degree the european sph offer modules on disease prevention and health promotion in their postgraduate programs, but also the delay in full implementation for the target year 2030 that has been set at 100% for all sphs. methods: the association of schools of public health in the european region (aspher) conducted two surveys on the activities of its members in 2011 and 2015/16. a group of 48 sph responded in both surveys. questions were related to the content offered by sphs, the types of teaching methods that are in use and presentations of the modules at social networks. results: for both modules, the 2nd survey in 2015/16 shows slightly less positive results as compared to the 1st survey in 2011 (72.9% vs. 77.1% and 81.3% v. 87.5%). the only exception is the use of social media which increased for disease prevention from 20.8% to 37.5% of all sph and for health promotion from 22.9% to 39.6%. referring to the set target of 100%, delays between 4 and 13.5 years accumulate for the target year 2030. conclusion: with the exception of the use of social media, progress towards 2030 is slow or even negative. serious efforts have to be made by aspher to revert this process. keywords: disease prevention, european region, health promotion, schools of public health. acknowledgments: the authors would like to thank all members of aspher for their commitment in responding to the survey questionnaire and providing examples of good practices in education, training and research for public health. conflict of interest: none declared. stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 3 | 14 introduction health promotion and disease prevention are closely related through the lifestyle concept and can be considered as two sides of the same medal. whereas research in the field of prevention tries to analyze, detect and modify risk factors which may with a certain probability lead to disease, in the field of health promotion efforts are made to find out how to change risky lifestyles, at the individual as well as at the community level by identifying upstream system determinants as codified in the ottawa charter (1) and their impact on health defined in health in all policies (2). the ottawa charter recognized the need to reorient the health system towards health promotion and disease prevention with a focus on environments and policies that can make the healthy choice the easy choice (1). recent global policy priorities of the united nations have given further impetus to health promotion and to an increased focus on equity in prevention. the most prominent global policy includes sustainable development goals 2030 with its focus on equity – ensuring that ‘no one is left behind’ (3). except for ottawa charter where the concept of health promotion is elaborated, who defined 10 main categories of essential public health operations (ephos), out of which "health promotion including action to address social determinants and health inequity and disease prevention, including early detection of illness" represent two core services delivery of ephos (4,5). additionally, health promotion, health protection and disease prevention is one of the 6 main chapters of aspher’s european list of public health generic core competences for the public health professional (6). in this regard, health promotion and disease prevention are an essential composite of any bachelor or master program in public health. all european schools of public health (sph) should offer these two modules in their programs with a focus on modifiable risk factors. there are two interrelated modern risk behaviors, the sedentary lifestyle and, usually associated, the intake of high caloric food and alcoholic beverages which both lead to overweight and elevated levels of blood pressure and cholesterol as well to diabetes mellitus, often accompanied by smoking as a key risk factor for lung cancer and cardiovascular diseases (7). on the other hand, physical inactivity and eating habits are the leading modifiable risk factors (8,9). the individual consequences in terms of reduced quality of life can be considerable (10) but also the socioeconomic costs constitute a heavy economic burden for the population (11). thus, health is more than an individual concern. a public health educational capacity in european countries significantly increased during the last decades and manifests itself in a growing membership (schools and university departments of public health) of the association of schools of public health in the european region (aspher): during 2006–2016, from 69 to 112 institutional members situated all over europe (12). there are numerous public health programs offered across europe. the most frequent include bachelor and master’s programs in comprehensive public health. also, together with programs for specialization in public health for physicians and nurses, continuing education supporting the process of lifelong learning, they form a relevant background for shaping a generalist professional, accredited and authorized in comprehensive public health (12-14). however, if we focus on the two priority fields of health promotion and disease prevention, the broader corresponding modular concepts on teaching and training can be described as a framework for two standard training modules (15): stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 4 | 14 health promotion. scholars will be prepared to design, implement and evaluate health promotion programs at all levels from local to international. health promotion is fundamental to public health and forms an integral part of all public health activities. scholars will review the development of health promotion, studying key documents such as the ottawa charter, jakarta declaration and related international statements. both the theoretical and practical aspects of health promotion will be examined, exploring different models of health and methods of achieving behaviour change on a population and individual basis. detailed competency profiles have been published for disease prevention and health promotion by the aspher (6) and for health promotion by the international union for health promotion and education (iuhpe) (16). disease prevention. scholars will be introduced to the basic principles, methods and application of screening in early detection and prevention of disease. they will be taught to calculate basic parameters of screening tests: sensitivity, specificity, positive and negative predictive values. also, they will be introduced to take into account the ethical and economic aspects of screening, as well as the planning and organization of screening programs. special attention will be paid to the assessment of the effectiveness of screening, such as randomized controlled trials, prospective cohort and case-control studies. economic evaluation methods, such as cost-effectiveness-analysis, cost-utilityanalysis, cost-benefit-analysis, and technology assessment tools are available (6). study objectives in this paper, we attempt to analyze: 1. to which degree the european sphs offer modules on disease prevention and health promotion in their postgraduate master-programs; 2. the distribution of different types of teaching methods that are in use for modules on disease prevention and health promotion; and 3. the delays in the implementation of disease prevention and health promotion teaching modules. methods research design and study population aspher conducted two methodologically equal studies on the activities of sphs in the european region between january 2015 and march 2016 (survey ii (17)) and in 2011 (survey i (13)). between two surveys, the membership of aspher increased from 80 to 96 members with approximately the same percentage participating, 66 (82.5%) in 2011 and 78 (81.3%) in 2015/16. however, this analysis focused on the 48 sphs which responded in both surveys. data collection the online questionnaire for survey ii was made available by aspher with a few modifications vs. the one used in survey i. questions were related to the content areas offered by sphs, the types of teaching methods that are in use (% of hours approximately spent per method) and presentations of the offered modules at social networks. data analysis the statistical analyses were done using the methods of descriptive and analytical statistics. in descriptive data analysis, absolute numbers and percentages were used. graphs and tables were used to display data. to determine delays in the implementation of the respective teaching modules we used a gap stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 5 | 14 analysis according to the united nations development program (18). the data analysis was done with tibco software (19). results the comparison of the frequency of teaching modules on disease prevention and health promotion in the aspher surveys of 2011 and 2015/16 is shown in table 1. the second survey (2015/16) showed slightly less positive results as compared to the first survey (2011) regarding both programs (table 1). while in 2015/16 there were 35 sphs that tough disease prevention, in 2011, 37 sphs offered this module (table 1 a). the same pattern has been observed regarding health promotion module that was offered by 39 sphs in 2015/16 vs. 42 sphs in 2011 (table 1 b). table 1. comparison of the frequency of modules on disease prevention and health promotion in the aspher surveys of 2011 and 2015/16 a. comparison i: frequency in dp module in both surveys second survey 2015/16; disease prevention ii yes no sum first survey 2011 disease prevention i yes 27 (56.3) 10 (20.8) 37 (77.1) no 8 (16.7) 3 (06.3) 11 (22.9) sum 35 (72.9) 13 (27.1) 48 (100.0) b. comparison ii: frequency in hp module in both surveys second survey 2015/16; health promotion ii yes no sum first survey 2011 health promotion i yes 35 (72.9) 7 (14.6) 42 (87.5) no 4 (08.3) 2 (04.2) 6 (12.5) sum 39 (81.3) 9 (18.8) 48 (100.0) c. comparison iii: frequency of both modules in 2011 survey first survey 2011; health promotion i yes no sum first survey 2011 disease prevention i yes 37 (77.1) 0 (00.0) 37 (77.1) no 5 (10.4) 6 (12.5) 11 (22.9) sum 42 (87.5) 6 (12.5) 48 (100.0) d. comparison iv: frequency of both modules in 2015/16 second survey 2015/16; health promotion ii yes no sum second survey 2015/16 disease prevention ii yes 32 (66.7) 3 (06.3) 35 (72.9) no 7 (14.6) 6 (12.5) 13 (27.1) sum 39 (81.3) 9 (18.8) 48 (100.0) stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 6 | 14 frequency of modules for disease prevention and health promotion in surveys i and ii (n=48) is presented in figure 1. out of the 48 sphs in this analysis, 11 sphs in the first and 16 sphs in the second survey did not indicate to teach both subjects (“either/or” plus “none”). while disease prevention was taught by 27 sphs in 2011 and 2015/16, health promotion was offered as a teaching program in 35 sphs in both survey years (figure 1). figure 1. frequency of modules for disease prevention (dp) and health promotion (hp) in surveys i and ii (n=48) dp i & dp ii = disease prevention in survey i & ii hp i & hp ii = health promotion in survey i & ii dp i & hp i = disease prevention & health promotion in survey i dp ii & hp ii = disease prevention & health promotion in survey ii the proportion of methods in teaching and training for disease prevention and health promotion programs are shown in table 2 and figure 2. all methods of teaching and training were more prevalent for health promotion program than disease prevention programs. however, when comparing survey i (2011) and survey ii (2015/16) for both programs, significantly lower participation of all forms of teaching methods was observed in the latter year. the exception is the presentations of programs at social networks which increased almost double for both programs (disease prevention: from 20.8% to 37.5%; health promotion: from 22.9% to 39.6%). 27 35 37 32 18 11 5 10 3 2 6 6 dp i & dp ii hp i & hp ii dp i & hp i dp ii & hp ii both either/or none stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 7 | 14 table 2. methods in teaching and training for disease prevention and health promotion disease prevention health promotion teaching methods survey i survey ii survey i survey ii lectures 37 (77.1) 29 (60.4) 42 (87.5) 31 (64.6) small group work 37 (77.1) 30 (62.5) 41 (85.4) 33 (68.8) practice training 33 (68.8) 25 (52.1) 38 (79.2) 26 (54.2) fieldwork 25 (52.1) 21 (43.8) 28 (58.3) 23 (47.9) social networks 10 (20.8) 18 (37.5) 11 (22.9) 19 (39.6) figure 2. methods in teaching and training for disease prevention and health promotion (n=48) the results of the gap analysis for disease prevention and health promotion programs towards the target years 2020 and 2030 are shown in table 3. the target set at 100% in 2030 requests all 48 sph to offer both modules in 2030 the latest. this allows to determine the time gap, i.e. the time remaining to achieve the agreed target of 100% earlier or with delay, based on the progress made between 2011 and 2015/16. 37 29 42 31 37 30 41 33 33 25 38 2625 21 28 23 10 18 11 19 disease prevention survey i disease prevention survey ii health promotion survey i health promotion survey ii lectures small group work practice training field work social networking stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 8 | 14 table 3. gap analysis for disease prevention and health promotion of 48 sph in the european region towards the 100% target for the years 2020 and 2030 target: 48 sph offer programs on disease prevention and health promotion latest in 2020 resp. 2030 2011 2015/16 time gap to the year 2020 target time gap to the year 2030 target disease prevention 37 35 -5.6/-1.13 -7.5/-0.50 health promotion 42 39 -8.5/-1.70 -13.5/-0.90 both programs together 37 32 -8.1/-1.62 -12.6/-0.84 both programs either/or 42 42 -4.0/-0.80 4.0/-0.27 social networks in prevention 10 18 -2.1/-0.42 0/0 social networks in promotion 11 19 -2.1/-0.41 +0.1/+0.01 however, we found a considerable delay between 2.1 and 8.5 years for 2020 because of the negative trend between 2011 and 2015/16 between 4 and 13.5 years accumulating for 2030. the same tendency we find for the training/teaching methods with regard to lecturers, small group work, practice training and fieldwork (data not shown in the table). the only exception of these trends is the use of social networks with a much smaller delay of only 2.1 years for 2020 and achievement in time for 2030. discussion this study provided valuable information on to which degree the european sphs offer modules on disease prevention and health promotion in their postgraduate programs including continuing education and to comparable analysis of the results from two surveys conducted in 2011 and 2015/16. however, the results are disappointing. there is a significant decline in the number of sphs that offer these modules. also, the proportion of all teaching methods such as lectures, small group works and practical works for these two modules has been decreased. since noncommunicable diseases are substantially preventable and investment in the prevention of risk factors and health promotion could benefit the whole population, the central question is why the decline happened in 5-years period and why it is important to put disease prevention and health promotion in the focus of curricula for future ph professionals. one of the possible explanations lies in the fact that there is not a clear distinction between disease prevention and health promotion. although the core competencies for health promotion and disease prevention have been elaborated during the last decade and published in who european action plan for strengthening public health capacities and services (4,5) and aspher’s european stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 9 | 14 list of public health generic core competences for the public health professional (6), these two programs interrelate so it might be possible that students learn about both within one program. a small number of sphs that offer programs on health promotion and disease prevention might be a reflection of the lack of investment in the necessary health promotion and primary prevention systems at a global level which has been recognized by the international union for health promotion and education (iuhpe) (20). big community trials on health promotion and primary prevention have shown to effect upon non-communicable diseases at the population level (21). these successes should have been reflected in postgraduate education. as werkhoven et al. stated, perceptions held or acquired during tertiary study can influence health promotion students’ interactions with their future clientele and their long-term sustainability as health promotion practitioners (22). since current trends in the field of health promotion and disease prevention emphasize community-based programs employing multiple interventions as the main strategy for achieving population-level change in risk behaviors and health, the focus should be on a communityand population-based approach representing a shift in emphasis from individually focused explanations of health behavior to ones that encompass social and environmental influences (23, 24). this paper focuses on postgraduate education including continuing education where the latter is especially important to close deficits in primary health care provision. only a minority of primary health care physicians understands health promotion as an integral part of practice (25). also, the european union sees both subjects interlinked (26,27), but to transfer the community dimension into primary health care may prove extremely difficult as leppin et al. concluded from their study in southeast minnesota: primary care and community-based programs exist in disconnected worlds (28). by transferring the community dimension to primary health care, most of the activity falls within the role of health professionals and health-care providers in primary care which could be an additional burden (29). a more optimistic analysis is presented by march et al. after review of 39 health-promoting community interventions concluding that nevertheless there is lack of evidence on many community interventions in primary health care (30). however, in western countries, there are many primary care-based chronic diseases intervention studies that confirm positive effects (31,32) which encourage us to achieve the best possible effects on population health. the systematic review of health promotion and disease prevention strategies in some curricula revealed that the inclusion of health promotion and disease prevention programs varied considerably, but was strongest in programs claiming social accountability and responding to medical education standards of the more influential regulators (33). this is a pattern that should be applied at the postgraduate level as well. although the contribution of medical education to improvements in health care and the health of populations is difficult to measure, examples are demonstrating that investment in these programs brings benefits to the population. as such, north karelia project is a classic example of a big community trail that has shown the feasibility of interventions at the community level and with a specific focus in preventing ncds especially cardiovascular diseases (34). similar programs were conducted the united states leading to a significant decrease in blood pressure levels and improvement in blood pressure management (32). stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 10 | 14 since physical inactivity, unhealthy diet, and harmful use of alcohol are the common risk factors for ncds such as hypertension, cardiovascular diseases, and cancers, with all these projects the focus has shifted from cardiovascular disease prevention to ncd prevention due to the similarity in risk factors. the overwhelmingly disappointing results of our study concerning the expected progress in teaching and training identified in the european region can be described as the two sides of a medal but unfortunately, the one with cracks. not only the number of schools that offer these programs decrease but the proportion of teaching methods of the respective modules is unsatisfactory. however, the increase of social networks for program presentation is visible as a bright side of the unexpectedly discouraging results but still could be better. after finishing the first survey, the authors identified lack of modernity regarding continuing education (13,35) as a potential space for improvement. since the use of social networks has been almost doubled for both modules, these results could be viewed as a shift from traditional to modern technological advances. further, it represents a ground for the future use of social networks not only for the presentations of programs but for the full process of learning and teaching. with technology advancements, it seems that traditional ways of learning are likely to be replaced with blended or online learning. it is important to highlight some limitations of the study. at the time of the second survey in 2015/6 aspher had 96 members out of which only 48 or 50.0% could be subjected to our analysis therefore results may be less representative. also, the study design is limited by potential bias because the quality of answers to the questionnaire could not be controlled. in addition, the two surveys have been conducted five and ten years ago, respectively and may not provide an accurate picture of aspher’s institutional membership as of today in 2021. however, there is no indication that the picture changed considerably in the last five years. to stimulate improvement, it may be preferable to assume an estimated straight trend of development. also, the two subjects may overlap to some degree in the practice of lecturing which could be the reason for a more favorable picture then analyzed here. the projected progress towards achievement of the sdgs in 2030 as calculated on the basis of the years 2011 and 2016 seems to be too slow in many areas: in the delay of up to 13.5 years. only for achieving targets for presentation at social networks for both programs, a significant delay is observed in all program areas. the long time passed since the collection of information in the field remains the main limitation for identification of the causal factors responsible for the slow progress during the period between the two surveys. a future study in 2021 focusing on the progress and innovations would be of a great interest. in survey ii several proposals for improvement have been made (17) out of which the following may relate especially to teaching health promotion and to some degree also disease prevention and may partly be implemented since: 1) to correspond adequately to the comprehensive character of the key topics in public health it is certainly advisable to move towards a mix of modular transversal courses and schedule an increased number of hours for learning in small groups and/or extend field practice, especially in remote rural or disadvantaged urban areas. this move is expected to be accelerated by the coronavirus pandemic in 2020. stamenkovic z, wenzel h, jankovic j, bjegovic-mikanovic v. two sides of a broken medal: disease prevention and health promotion in schools of public health (original research). seejph 2021, posted: 09 may 2021. doi: 10.11576/seejph-4420 p a g e 11 | 14 2) to provide knowledge and experience in the cultural dimension of health and train intensively communication skills and how to interact with the general public. 3) to interact with the policymaking process at the local and national level in order to overcome resistance on the side of governments to implement health policies in collaboration with the researchers. conclusion the study clearly indicates the significant decline in the number of sphs that offer disease prevention and health promotion modules. the share of all teaching methods such as lectures, small group works and practical works for these two modules has been decreased except the use of social networks for program presentation which is in accordance with technology advances nowadays. given the epidemic of non-communicable diseases, public health services are as relevant now as they have ever been. it implies that the need for a competent public health workforce has never been greater. based on that, aspher, as the leading 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jousilahti p. background, principles, implementation, and general experiences of the north karelia project. glob heart 2016;11:173-8. 35. aspher working group on innovation and good practice in public health education. what do schools of public health and employers of public health professionals think about performance? report on the survey of the european schools and departments of public health and the employers of public health professionals. brussels: aspher; 2012. __________________________________________________________________________ phoebe w. hwang, mohammad auais, afshin vafaei, nicole t.a. rosendaal, yan yan wu, catherine m. pirkle, disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the international mobility in aging study. seejph 2023. posted: 09-04-2023, vol. xx. page 1 original research disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the international mobility in aging study phoebe w. hwang1, mohammad auais2, afshin vafaei3, nicole t.a. rosendaal1, yan yan wu4, catherine m. pirkle4 1department of psychiatry, john a. burns school of medicine, university of hawaiʻi at mānoa, honolulu, hawaiʻi, usa 2school of rehabilitation therapy, queen’s university, kingston, ontario, canada 3department of health sciences, lakehead university, thunder bay, ontario, canada 4office of public health studies, university of hawaiʻi at mānoa, honolulu, hawaiʻi, usa corresponding author: dr. phoebe w. hwang address: 1356 lusitana street, uht #407, honolulu, hi 96813 email: hwangp@dop.hawaii.edu mailto:hwangp@dop.hawaii.edu phoebe w. hwang, mohammad auais, afshin vafaei, nicole t.a. rosendaal, yan yan wu, catherine m. pirkle, disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the international mobility in aging study. seejph 2023. posted: 09-04-2023, vol. xx. page 2 abstract introduction: the relationships between falls, fear of falling, poor mobility, and pa avoidance occur in a cyclic, multi-directional fashion. aim: this study investigates the concomitant associations of fall history, fear of falling, and physical performance (sppb) on physical activity using a crossnational sample of community-dwelling older adults from middle and high-income countries. methods: linear mixed-effects models looking at the influence of individual and environmental factors were used and participants were nested within each study site. results: estimated walking minutes was 52% lower for those with low sppb compared to high sppb, 20% lower for those with medium level fear of falling compared to low levels, and 50% lower for those with high level fear of falling compared to low levels. conclusion: an individual’s fear of falling and physical performance may be important to consider when making pa recommendations to older adults regardless of sex, age, and environment. keywords: fall, fear of falls, gerontology, global health, physical function, walking. phoebe w. hwang, mohammad auais, afshin vafaei, nicole t.a. rosendaal, yan yan wu, catherine m. pirkle, disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the international mobility in aging study. seejph 2023. posted: 09-04-2023, vol. xx. page 3 introduction falls are a major public health concern for older adults globally. it is estimated that 30% of community-dwelling older adults (>65 years) will fall at least once per year [1]. across the globe, 80% of fatal falls occur in lowor middle-income countries [2]. non-fatal falls often lead to serious medical injuries that result in loss of disability-adjusted life years, which can be costly for the individual and his/her community [3]. overall, it is estimated that significant injuries occur in 4-15% of falls and 23-40% of injury-related deaths in older adults are due to falls [4]. fear of falling (fof) is observed in 50%60% of community-dwelling individuals who have fallen [2] and is identified as a significant health concern because of its close association with falls and other mobility-related measures. correlates to fof, such as low mobility [5], frailty, and low physical activity (pa) behavior [6, 7] overlap with fall risk factors. thus, falls, fear of falling, poor mobility, and pa avoidance occur in a cyclic, multidirectional fashion [8] and should be considered together. there is limited research that considers falls, fof, physical function, and pa together and at the same time accounts for individuals and environmental influences. the socioecological model has been successfully used as a framework to understand mobility limitations in older adults in the past [9, 10] and may prove useful for conceptualizing the complex relationship between falls and pa. this framework provides a broader perspective on the determinants of pa behavior by considering the context of a health behavior within different social and physical environments, thus bridging the gap between individual and environmental constructs [11]. in this article, we propose to use the socioecological model as a framework to investigate the concomitant associations of fall history, fof, and physical performance on pa using a cross-national sample of community-dwelling older adults from middle and high-income countries. this study examined models that included individual risk factors commonly associated with falls, such as sex, age, fall history, and fof, and perceived environmental risk factors such as, uneven sidewalks, community safety, and community barriers. phoebe w. hwang, mohammad auais, afshin vafaei, nicole t.a. rosendaal, yan yan wu, catherine m. pirkle, disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the international mobility in aging study. seejph 2023. posted: 09-04-2023, vol. xx. page 4 results from this study help better identify how individual and environmental-level fall risks affect an older adult’s pa levels in diverse populations in order to improve falls related interventions. methods data source data were collected as part of the international mobility in aging study (imias) at the following study sites: kingston (n=398) and st. hyacinthe (n=401), canada; tirana, albania (n=394); natal, brazil (n=407); and manizales, colombia (n=402). each site sampled near equal proportions of men and women, with the total sample containing 955 men and 1047 women. these diverse sites were chosen because the varying demographic factors maximize the spectrum of exposures that participants face across the life-course, allowing for exploration of distributional tails that would have been impossible with a single site [12]. baseline data were obtained in 2012, with follow-up collections in 2014 and 2016. only baseline data for the five sites were used for this study. participants comprised of communitydwelling older adults aged 65 to 74 at baseline. university ethics committees did not allow researchers to recruit or contact potential participants directly in kingston and st. hyacinthe. thus, participants were recruited through their physicians in these sites. in tirana, natal, and manizales, participants were randomly sampled and recruited from health center registries. potential participants were then approached directly by interviewers to participate in the study [1]. all interviewers were trained according to a standardized protocol. response rates were 90% in tirana and nearly 100% in manizales and natal. while 30% of invited participants in kingston and st. hyacinthe contacted the field coordinator, 95% agreed to participate in this study. individuals who had four or more errors on the leganes cognitive test orientation scale [13] were excluded from the study, as low scores indicated an inability to complete study procedures. gomez et al compiled a cohort profile to describe recruitment and retention details [14]. phoebe w. hwang, mohammad auais, afshin vafaei, nicole t.a. rosendaal, yan yan wu, catherine m. pirkle, disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the international mobility in aging study. seejph 2023. posted: 09-04-2023, vol. xx. page 5 principal exposures principal exposures for this analysis were personal level factors: fall history in the last year, physical performance, and fof. fall history (yes/no) was assessed by asking participants whether or not they had fallen within the past 12 months. physical performance was evaluated with the extensively validated short performance physical battery test (sppb), which includes tests of balance, gait speed, and chair stand. each component has a maximum score of four. total possible sppb score 0-12 and the battery is described in detail elsewhere [15]. to simplify results’ interpretation, we recoded the total sppb score into a binary variable of high versus low physical function. sppb scores of less than eight indicate low or limited physical performance, and sppb scores of eight of more indicate higher physical performance [16]. fof was assessed with the falls efficacy scale international (fes-i) questionnaire (yardley et al. 2005). fes-i quantifies the fall concerns of older persons related to 16 activities that occur inside and outside of the home. the level of falling concern was measured on a four-point likert scale (1 = not at all concerned to 4 = very concerned). total fes-i scores range between 16 and 64, with higher scores indicating greater concern. for this study, fes-i scores were categorized into three groups: no/low [15-18], moderate [19-26], and high (>27) concern about a fall [17]. outcome for pa, average minutes walking daily over a week was a continuous measure collected with a validated computer animated assessment tool for older adults, the mobility assessment tool for walking (mat-w) [18]. perceived environmental-level covariates since the perceived environment has a stronger association with pa behavior than objective environment [19], two perceived physical environment factors, uneven sidewalks and a community barrier scale (cbs), and a perceived social environment measure, perception of safety scale (poss) were included in the analysis. missing values for both cbs and poss variables were imputed. the presence of uneven sidewalks in the participants’ neighborhood is a self-reported variable that was assessed by asking “does your neighborhood have uneven sidewalks?” responses were phoebe w. hwang, mohammad auais, afshin vafaei, nicole t.a. rosendaal, yan yan wu, catherine m. pirkle, disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the international mobility in aging study. seejph 2023. posted: 09-04-2023, vol. xx. page 6 measured using a likert scale: 1a lot, 2 some, 3-not at all. for this study, responses were categorized as yes or no. “yes” included the responses “a lot” or “some.” “no” reflected the response “not at all.” participants that indicated “i don’t know” (n=80, 4%) were excluded from this study and labelled as missing. cbs was developed using explanatory and confirmatory factor analyses on 8 items related to local community from the home and community environment (hace) scale [20]. three items--parks/walking areas that are easy to access and use; safe parks/walking areas, and places to sit and rest at bus stops; parks, or other places where people walk--loaded into a single factor. the absence of an item (e.g. park/walking area) was considered a community barrier [21]. the sum of barriers ranged from 3 to 9. the higher the score, the more perceived barriers. since preliminary analysis showed a non-linear relationship between cbs and walking, cbs scores were categorized into tertiles of high, middle, and low scores. poss was developed using explanatory and confirmatory factor analyses on 10 items on perceived safety developed by sampson and raudenbush [22, 23]. our measure of poss, after the factor analyses, included 8 items with possible range of 8 to 24. the higher the score, the safer the individual perceived his/her community. since preliminary analysis showed a non-linear relationship between poss and walking, poss scores were categorized into tertiles of high, middle, and low scores. individual-level covariates education, age, sex, and site location were chosen as covariates based on the socioecological models used to examine older adult mobility determinants [10]. sex, age, and education are personal-level attributes. total years of education were split categorically into tertiles of high, medium, and low education by site to obtain a variable called “relative education”. thus, a participant can have high educational attainment relative to his/her community, but medium or low attainment compared to another site in imias. sex is an interviewer reported categorical variable (male/female). age is a self-reported continuous variable re-coded into a binary categorical variable (64-69/70-75). phoebe w. hwang, mohammad auais, afshin vafaei, nicole t.a. rosendaal, yan yan wu, catherine m. pirkle, disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the international mobility in aging study. seejph 2023. posted: 09-04-2023, vol. xx. page 7 analysis stata/se (version 14.0; statacorp lp, college station, tx usa) was used to conduct the analyses. one-way anova analyses were performed to test differences in average minutes walking per day for all variables. multivariate linear mixed-effects models were used to examine the strength and direction of the relationship between covariates and outcome measures aggregated by study site (kingston and st. hyacinthe, canada; tirana, albania; manizales, colombia; and natal, brazil). figure 1 depicts the conceptual model underpinning our analyses. the linear mixed-effects models were used because of the hierarchical structure of the data with imias participants nested within study sites. four models were generated to test whether individual-level and perceived environmental-level exposures affect the relationship between walking and falls, fear of falling, and sppb. for these models, we allowed the intercepts to vary randomly and estimated the site-level intra-class correlations (icc). the estimated icc provided the proportion of variation explained by between-site variations, i.e., within-site similarity adjusting for covariates. initial analysis showed that the residuals of the outcome variable, minutes of walking, were positively skewed, therefore it was log transformed to meet the model assumptions. regression coefficients were exponentiated (e.g. back-transformed) to provide meaningful interpretation in the tables. the exponentiated values are the changes in the ratio of the expected geometric means of the original outcome variable. variance inflation factors were calculated for the multivariate models to inspect for collinearity and showed that there was little collinearity between variables due to the low variance inflation factor (vif). phoebe w. hwang, mohammad auais, afshin vafaei, nicole t.a. rosendaal, yan yan wu, catherine m. pirkle, disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the international mobility in aging study. seejph 2023. posted: 09-04-2023, vol. xx. page 8 figure 1: conceptual framework depicting the inter-relatedness of physical activity with fear of falling, physical performance, and fall history ethics all methods were carried out in accordance to the guidelines and regulations set by the ethical committees per prospective site. ethical approval for this project was obtained from the ethics review committees of the research centers of the university of montreal hospitals (cr-chum), queen’s university (kingston), the albanian institute of public health, the federal university of rio grande do norte (brazil) and the university of caldas (colombia). informed consent was obtained from participants prior to the start of the study. no participants under 18 years of age were included in this study. results table 1 displays individual-level and environmental-level covariate frequencies by fall history, physical performance, and fear of falling. notably, among those reporting at least a fall in the 12 months preceding data collection, a higher proportion of participants were female and from kingston or manizales. while participants from kingston reported falls more frequently than any other site, relatively few had low sppb scores and the frequency of those reporting low fear of falling was higher than all sites except st. hyacinthe. manizales, in contrast, had relatively few participants reporting low fear of falling compared to the other sites. both low sppb and fear of falling were more phoebe w. hwang, mohammad auais, afshin vafaei, nicole t.a. rosendaal, yan yan wu, catherine m. pirkle, disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the international mobility in aging study. seejph 2023. posted: 09-04-2023, vol. xx. page 9 frequent among women than men and among those with low educations. while there was a greater proportion of the older age group with low sppb scores, their proportions were lower in the no fall history and low fear of falling categories. the participants frequently reported uneven sidewalks, but the proportion was smallest among those with a low fear of falling. the low fear of falling group also reported the fewest community barriers and highest perceived safety. table 1. individual and environmental level covariates fall history, physical performance, and fear of falling fall history, n=1985 sppb, n(%), n=1998 fear of falling, n(%), n=1992 no (n=1430) yes (n=555) >=8 (n=1735) <8 (n=263) low (n=892) medium (n=645) high (n=455) sex, n(%) male 720(50.4) 225(40.5) 863(49.7) 90(34.2) 538(60.3) 279(43.3) 133(29.2) female 710(49.7) 330(59.5) 872(50.3) 173(65.8) 354(39.7) 366(56.7) 322(70.8) age, n(%) 64-69 782(54.7) 312(56.2) 989(57.0) 114(43.4) 533(59.8) 343(53.2) 224(49.2) 70-74 648(45.3) 243(43.8) 746(43.0) 149(56.7) 359(40.3) 302(46.8) 231(50.8) education, n(%) high 378(26.4) 179(32.3) 512(29.5) 48(18.3) 281(31.5) 190(29.5) 89(19.6) medium 487(34.1) 173(31.2) 576(33.2) 88(33.5) 280(39.4) 214(33.2) 167(36.7) low 565(39.5) 203(36.6) 647(37.3) 127(48.3) 331(37.1) 241(37.4) 199(43.7) uneven sidewalk, n(%) yes 986(71.9) 386(72.5) 1180(70.8) 199(80.6) 554(65.3) 452(73.0) 369(83.9) no 386(28.1) 145(27.5) 486(29.2) 48(19.4) 294(34.7) 167(27.0) 71(16.1) community barrier scale, x ± sda 7.0(2.0) 6.6(2.0) 6.7(2.0) 7.7(1.4) 6.5(2.1) 6.9(1.9) 7.5(1.6) perception of safety, mean(sd)b 20.8(3.8) 20.5(3.7) 20.9(3.7) 19.4(4.2) 21.8(3.0) 20.4(3.9) 19.1(4.3) site location, n(%) kingston 240(16.8) 154(27.8) 369(21.3) 27(10.3) 218(24.4) 130(20.2) 46(10.1) st. hyacinthe 309(21.6) 91(16.4) 376(21.7) 25(9.5) 283(31.7) 89(13.8) 28(6.2) tirana 318(22.2) 69(12.4) 314(18.1) 78(29.7) 200(22.4) 106(16.4) 84(18.5) manizales 267(18.7) 136(24.5) 364(21.0) 43(16.4) 57(6.4) 184(28.5) 165(36.3) phoebe w. hwang, mohammad auais, afshin vafaei, nicole t.a. rosendaal, yan yan wu, catherine m. pirkle, disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the international mobility in aging study. seejph 2023. posted: 09-04-2023, vol. xx. page 10 natal 296(20.7) 105(18.9) 312(18.0) 90(34.2) 134(15.0) 136(21.1) 132(29.0) missing values-fall history: n=17, sppb: n=3, fear of fall: n=10, uneven sidewalk: n=85, community barrier scale: n=47, perception of safety: n= 110, average minutes walking per day: n=80 acommunity barrier scale ranges from 3 to 9, higher score indicates more community barriers bperception of safety scale ranges from 8 to 24, higher score indicates higher perceived safety in table 2, the outcome measure, average minutes walking per day, is displayed by fall history, physical performance, fear of falling, and covariates. the results are stratified by site location to depict sitespecific differences. individuals with higher physical performance, lower fear of falling, who are males, with higher education, and who are younger walked significantly more. for site location, the highest average daily walking time was in kingston (m=38.3), followed by tirana (m=35.6), st. hyacinthe (m=29.5), manizales (m=28.3), and natal (m=16.8). although not statistically significant with all sites combined, there was a significant difference in walking time by fall history in tirana and uneven sidewalks in kingston. in tirana, individuals who had not fallen within the past 12 months had higher mean daily walking minutes (m=37.8) compared to those who reported a recent fall (m=24.6). in kingston, individuals who reported having uneven sidewalks in their neighborhoods walked more (m=43.1) compared to individuals who reported no uneven sidewalks (m=30.5). those who perceived low community barriers had the highest daily mean walking minutes (m=33.6), followed by high barriers (m=29.1) and middle barriers (m=25.3). those with middle levels of perceived safety had the highest daily mean walking minutes (m=33.8), followed by high perceived safety (m=31.2) and low perceived safety (m=24.5). table 2. average minutes walking per day by fall history, physical performance, fear of falls, and covariates, stratified by site location average minutes walking per day, x(sd) all sites, n=1922 kingston, n=374 st. hyacinthe, n=355 tirana, n=387 manizales, n=404 natal, n=402 fall history no 30.6(30.7) 41.9(3.2) 29.5(2.6) 37.8(2.1)* 27.9(1.8) 17.8(1.2) yes 26.6(32.6) 32.7(2.9) 29.3(3.8) 24.6(3.5) 29.2(3.1) 13.9(1.8) phoebe w. hwang, mohammad auais, afshin vafaei, nicole t.a. rosendaal, yan yan wu, catherine m. pirkle, disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the international mobility in aging study. seejph 2023. posted: 09-04-2023, vol. xx. page 11 sppb >=8 31.9(37.0)* 39.4(2.3) 30.6(2.3)* 40.3(2.1)* 30(1.7)* 18.7(1.2)* <8 13.4(24.0) 24.9(9.3) 13.5(3.0) 16.9(3.1) 12.8(2.5) 10.3(1.6) fear of falling low 36.0(41.0)* 44.2(3.2)* 32.2(2.9) 43.8(2.9)* 29.5(3.5)* 21.5(2.0)* medium 29.2(33.1) 34.6(3.7) 25.2(3.1) 34.8(3.1) 32.1(2.7) 18.5(1.7) high 17.7(24.3) 22.7(5.7) 16.2(3.5) 16.1(2.2) 23.3(2.1) 10.4(1.2) uneven sidewalk no 32.5(33.7) 30.5(2.9)* 30.7(3.1) 39.9(3.2) 33.6(3.1) 10.3(2.6) yes 28.5(36.3) 43.1(3.2) 28.8(3.2) 34.0(2.3) 26.4(1.8) 17.5(1.0) sex male 33.7(1.2)* 39.4(3.4) 32.9(2.8)* 44.5(3.1)* 31.1(2.2) 21.8(1.7)* female 25.7(1.1) 37.4(3.0) 26.5(3.2) 27.7(2.1) 25.6(2.2 12.4(0.9) age 64-69 31.9(1.2)* 40.0(3.2) 32.4(3.0) 40.1(2.8)* 30.4(2.3) 17.0(1.4) 70-74 26.6(1.1) 36.2(3.1) 24.4(2.8) 31.2(2.4) 25.9(2.2) 15.6(1.3) education high 34.8(1.6)* 36.6(3.7) 35.3(3.3) 43.8(4.2)* 40.6(3.8)* 20.8(2.2)* medium 27.8(1.5) 37.5(4.2) 28.3(5.7) 33.8(3.1) 25.3(2.1) 15.0(1.5) low 27.3(1.2) 40.1(3.7) 28(2.7) 31.6(2.5) 21.2(2.1) 15.8(1.5) community barrier scalea low 33.6(1.4)* 39.9(2.5) 29.1(1.8) 31.2(8.2) 31.2(3.0) 19.3(2.6) middle 25.3(1.6) 26.6(5.7) 34.9(8.8) 33.5(4.7) 29.4(2.4) 17.0(1.4) high 29.1(1.4) 35.6(11.0) 25.5(8.5) 36.5(2.1) 24.6(3.0) 16.4(1.6) perception of safetyb high 31.2(1.6)* 40.1(3.9) 30.2(2.8) 33.2(2.6) 20.2(2.2)* 11.9(4.8) middle 33.8(1.5) 34.8(3.2) 34.1(5.0) 37.0(2.6) 34.5(3.2) 18.8(2.9) low 24.5(1.2) 37.6(4.3) 24.7(4.3) 41.3(6.3) 28.2(2.4) 16.5(1.1) site location kingston 38.3(43.6)* ---------- st. hyacinthe 29.5(40.7) ---------- tirana 35.6(36.8) ---------- manizales 28.3(31.8) ---------- natal 16.8(19.8) ---------- *one-way anova test of difference in average walking time for the whole sample and by each study site, p <0.05. missing values-fall history: n=17, sppb: n=3, fear of fall: n=10, uneven phoebe w. hwang, mohammad auais, afshin vafaei, nicole t.a. rosendaal, yan yan wu, catherine m. pirkle, disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the international mobility in aging study. seejph 2023. posted: 09-04-2023, vol. xx. page 12 sidewalk: n=31 acbs reported by tertiles with all site combined, low indicates low levels of perceived community barriers bposs reported by tertiles with all sites combined, high indicates high levels of perceived safety table 3 displays the results of four mixedeffects models clustered by site location, along with the icc for each model. model coefficients and 95% confidence intervals are exponentiated for easier interpretation. in model 1, only sppb and fear of falls are significant correlates to average minutes walking per day. estimated walking minutes are 52% lower for those with low sppb compared to high sppb, 20% lower for those with medium level fear of falling compared to low levels, and 50% lower for those with high level fear of falling compared to low levels. there was little change observed in coefficients and confidence intervals for principal exposures across the four models. in model 3, which included only perceived environmental-level factors, high cbs was associated with less walking compared to low barriers, and middle poss was associated with more walking compared to high-perceived safety. the icc is presented at the bottom of each model and is a measure of the total variance in walking time that is attributable to clustering by study site. the iccs for all models were low (less than 0.06) thus, less than 6% of the variation in walking time can be attributed to how individuals within site resemble each other. table 3. mixed linear regression models for geometric mean minutes walking for reference group, ratio of geometric mean minutes by principal exposures, individual-level exposures, and perceived environmental level exposures clustered by site location model 1 model 2 model 3 model 4 β 95% ci β 95% ci β 95% ci β 95% ci principal exposures fall history no 1.00 1.00 1.00 1.00 yes 0.99 0.87-1.13 0.97 0.86-1.11 0.94 0.83-1.08 0.93 0.82-1.06 sppb >=8 1.00 1.00 1.00 1.00 phoebe w. hwang, mohammad auais, afshin vafaei, nicole t.a. rosendaal, yan yan wu, catherine m. pirkle, disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the international mobility in aging study. seejph 2023. posted: 09-04-2023, vol. xx. page 13 <8 0.48* 0.39-0.57 0.49* 0.41-0.59 0.50* 0.41-0.61 0.51* 0.42-0.61 fear of falling low 1.00 1.00 1.00 1.00 medium 0.80* 0.70-0.92 0.85* 0.74-0.97 0.82* 0.71-0.86 0.86* 0.74-0.99 high 0.50* 0.42-0.59 0.55* 0.46-0.65 0.51* 0.42-0.61 0.56* 0.47-0.67 individual-level sex male - 1.00 - 1.00 female - 0.83* 0.74-0.93 - 0.84* 0.75-0.95 age 64-69 - 1.00 - 1.00 70-74 - 0.89* 0.79-0.99 - 0.88* 0.79-0.99 education high - 1.00 - 1.00 medium - 0.78* 0.67-0.90 - 0.76 0.66-1.13 low - 0.81* 0.70-0.93 - 0.84* 0.72-0.96 environmentallevel uneven sidewalk no - - 1.00 1.00 yes - - 1.01 0.88-1.16 1.01 0.88-1.16 community barrier scalea low - - 1.00 1.00 middle - - 0.88 0.74-1.04 0.88 0.74-1.05 high - - 0.79* 0.65-0.96 0.81* 0.67-0.97 perception of safetyb high - - 1.00 1.00 middle - - 1.21* 1.02-1.44 1.22* 1.03-1.45 low - - 1.12 0.97-1.31 1.10 0.95-1.28 icc 0.04 0.04 0.06 0.06 icc= intraclass correlation coefficient, low icc is <0.4 *p<0.05 acbs reported by tertiles with all site combined, low indicates low levels of perceived community barriers bposs reported by tertiles with all sites combined, high indicates high levels of perceived safety phoebe w. hwang, mohammad auais, afshin vafaei, nicole t.a. rosendaal, yan yan wu, catherine m. pirkle, disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the international mobility in aging study. seejph 2023. posted: 09-04-2023, vol. xx. page 14 discussion using the socioecological model, we examined the role of individual-level and perceived environmental-level exposures on the relationship between falls, fear of falling, and physical performance (sppb) on walking. this study is one of the first to examine multilevel factors using crossnational data. fall history was not associated with walking times, but sppb and fear of falling were associated with them. although individual and environmental level factors such as sex, age, education, cbs, and poss had a significant relationship with minutes walking in all 4 models, these individual and environmental factors had little influence on the relationship between the principal exposures and outcome. in other words, the relationship between fall history, fear of falling, and sppb on walking did not change despite adding individual and environment level factors into the models. these findings reflected davis et al.’s findings that, within middle income countries, individual and interpersonal level factors were associated with older adults meeting physical activity guidelines, and not community or organizational level factors [24]. as expected, lower physical performance and higher fear of falling were associated with less walking time. the relationship between these variables remained relatively constant even with the addition of individual and environmental level covariates. although this study did not identify the causal pathway of these variables, it supports the results of previous studies that observed similar variables separately. cooper et al is of the many authors who demonstrated that increased physical activity levels improve physical performance and other health outcomes [25]. delbere et al demonstrated that fear-related avoidance of physical activity in belgium could have negative effects on physical ability due to the lack of physical activity and training [8]. surprisingly, fall history (whether the individual has experienced falls), was not associated with minutes walking in all four models. based on previous studies, fall history was expected to influence minutes walking. one explanation may be that the difference in culture, government structure, and health policies among the different high and middle income sites affect and cancel out the relationships observed between the variables. although the low icc in the phoebe w. hwang, mohammad auais, afshin vafaei, nicole t.a. rosendaal, yan yan wu, catherine m. pirkle, disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the international mobility in aging study. seejph 2023. posted: 09-04-2023, vol. xx. page 15 mixed models clustered by site suggests low influence from the site, bivariate analysis shows that the high income site, kingston, has the highest proportion of those who reported falls history, yet the lowest proportion of those who have high fear of falling. the opposite was observed in tirana. one explanation could be that illness is often overreported in higher income households. for example, an individual with higher income and education, who is generally healthy most of the time, may be able to identify if she or he is ill more than an individual with lower income and education [26]. furthermore, foster argues that higher income individuals have the means to dampen the impacts of poor health, whereas lower income individuals do not, thus the impacts of poor health should be observed more closely among lower income individuals. in model 3 with only individual level covariates, female sex, older age group, and lower education were associated with less walking time. a study of older adults conducted in australia by booth et al. yielded similar results. although falls were not incorporated into booth’s study, booth et al. concluded that pa was sex and age dependent. that is, males and younger age groups were more active [27]. it is well established that socioeconomic status plays a role in health behaviors and outcomes. therefore, it is not surprising that lower education was associated with less walking time. in the model with only environmental level factors (i.e. model 3), the indicator, uneven sidewalks, was surprisingly not significantly associated with walking. pa literature has repeatedly demonstrated the importance of the built environment, such as having uneven sidewalks, on pa outcomes [28]. perhaps since uneven sidewalks is a self-reported measure, only those who are regularly physically outdoors notice uneven sidewalks. bivariate analysis results in table 2 show that the relationship between cbs and walking is not linear. this was confirmed in the multivariate model when only high cbs was associated with less walking compared to low cbs. these results broadly corroborate with other studies that show community barriers, such as lack of access to public areas decreases older adult pa behavior [29]. the non-linear relationship seen in this study may suggest that there is a threshold of community barriers that need to be met before having a phoebe w. hwang, mohammad auais, afshin vafaei, nicole t.a. rosendaal, yan yan wu, catherine m. pirkle, disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the international mobility in aging study. seejph 2023. posted: 09-04-2023, vol. xx. page 16 negative impact on walking. future studies should examine whether or not the amount and type of community barriers might determine walking. similar to cbs, poss did not have a linear relationship with walking. unexpectedly, middle levels of poss were associated with higher levels of walking. although not statistically significant, it should be noted that low levels of poss were also associated with higher levels of walking compared to high levels of poss. this was not the result we expected. poss aims to measure environmental safety and possible social distress from the neighborhood. previous studies have demonstrated that people living neighborhoods with high levels of social disorganization are not willing to recognize the negative aspects of their neighborhood due to feelings of community belonging. while another possible explanation for why middle levels of poss had higher minutes of walking compared to high levels is that we might be capturing walking for occupational or transportational purposes instead of leisure. in which case, these needs may outweigh the safety concerns [30, 31]. this study focused on walking since it was a common pa recommendation for older adults. since pa done for leisure is associated with better health outcomes compared to occupational pa [32], it may be worthwhile to expand further the definition of walking. when comparing the effects of the environment versus individuals, different studies have contrasting results from each other. a study conducted in australia showed that the effects of physical environment was not as strong as the effects of individual characteristics [33]. the physical environment supports and enhances pa in complement with individual characteristics and social environment. conversely, a study conducted in the united states showed that physical environment played a stronger role in determining pa compared to individual traits [34]. results from this study support the notion that environmental and indivdiual factors influence minutes walking. although both environmental and individuals level factors seem to play a role in determining minutes walking, adding them to the models did not affect the relationship of falls, fear of falling, and sppb on walking, or, as observed in model 4 (table 3) with each other. this may suggest that cross-national phoebe w. hwang, mohammad auais, afshin vafaei, nicole t.a. rosendaal, yan yan wu, catherine m. pirkle, disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the international mobility in aging study. seejph 2023. posted: 09-04-2023, vol. xx. page 17 health promotion efforts can increase walking among older adults by addressing their fear of falling and improving physical performance. strengths & limitations this study takes into account environmental and individual level factors to pa in a crossnational sample of participants from middle and high income countries. the analysis strategy applied to this study was grounded in a well-established theoretical foundation, the socioecological model. four mixedeffects models were used to test the interactions between individual and environmental level factors. a nested model was used based on the theory that was applied. despite sampling from four very different study sites, the variance of walking was not due primarily to study site, or geographical location. instead, sppb and fear of falling, along with other individual characteristics such as sex, were strong predictors. while their study has many strengths, there are limitations too. first, we are unable to determine etiology with a cross-sectional data set. however, since the benefits of walking for older adults are wellestablished, the purpose of this paper was to identify any correlates to walking that can potentially be of public health value. second, the accuracy of the self-reported environmental exposures may affect the results. participants would have to be outdoors in order to accurately report environmental factors, cbs and poss. if participants are already outdoors, then they may already be engaging in pa. furthermore, there might be a possibility of misclassification error as mentioned in the discussion above. nonetheless, studies have shown that the perceived environment is a stronger predictor of pa compared to objective environment (20). lastly, although the effects of site location have been statistically accounted for, examining the relationship between safety and walking may be a bit more complicated and depend on unmeasured factors unaccounted for in this study. for instance, theoretically speaking, sex and gender play a role in how an individual perceives their environmental safety [35]. phoebe w. hwang, mohammad auais, afshin vafaei, nicole t.a. rosendaal, yan yan wu, catherine m. pirkle, disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the international mobility in aging study. seejph 2023. posted: 09-04-2023, vol. xx. page 18 conclusion many older adults remain or become increasingly physically inactive over time. an individual’s fall concern and physical performance may be important to consider when making recommendations to increase pa; however, fall history doesn’t seem to affect minutes walking. individual and environmental level factors do not seem to affect the relationship. identifying and addressing barriers to pa in older adults may be useful for health care practitioners and health policy advocates to generate a multifaceted, multilevel targeting interventions. declarations ethics approval and consent to participate all methods were carried out in accordance to the guidelines and regulations set by the ethical committees per prospective site. ethical approval for this project was obtained from the ethics review committees of the research centers of the university of montreal hospitals (cr-chum), queen’s university (kingston), the albanian institute of public health, the federal university of rio grande do norte (brazil) and the university of caldas (colombia). informed consent was obtained from participants prior to the start of the study. no participants under 18 years of age were included in this study. consent for publication consent to publish unidentifiable data was obtained from participants. availability of data and materials the results/data/figures in this manuscript have not been published elsewhere, nor are they under consideration (from you or one of your contributing authors) by another publisher. all of the material is owned by the authors and/or no permissions are required. i am the author responsible for the submission of this article and i accept the conditions of submission and the bmc copyright and license agreement as detailed above. the study materials are available in table form in this paper. competing interests no, i declare that the authors have no competing interests as defined by bmc, or other interests that might be perceived to influence the results and/or discussion reported in this paper. phoebe w. hwang, mohammad auais, afshin vafaei, nicole t.a. rosendaal, yan yan wu, catherine m. pirkle, disentangling the relationship between falls, fear of falling, physical function and walking by applying a socioecological framework to the international mobility in aging study. seejph 2023. posted: 09-04-2023, vol. xx. page 19 funding n/a. authors' contributions p.w.h. was lead on the paper. she conceptualized the paper, wrote the manuscript text, analyzed data, and finalized the tables. m.a. conceptualized the paper and assisted with writing and data analysis. a.v. assisted with data analysis and tables. n.t.a.r assisted with data analysis and summary. y.y.w. provided biostatistics support and assisted with data summary. c.m.p. oversaw the project. acknowledgements n/a. references 1. pirkle, c.m., et al., early maternal age at first birth is associated with chronic diseases and poor physical performance in older age: crosssectional analysis from the international mobility in aging study. 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(http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. tozija f, lizana t. migrant health policy in european union (eu) and non eu country: current situation and future challenges for improvement (original research). seejph 2020, posted: 16 march 2020. doi: 10.4119/seejph-3369 p a g e 1 | 11 original research migrant health policy in european union (eu) and a non eu country: current situation and future challenges for improvement fimka tozija1, tona lizana2 1 institute of public health of republic of north macedonia, medical faculty, sts cyril and methodius university, skopje, republic of north macedonia; 2 public health agency of catalonia, barcelona, spain. corresponding author: fimka tozija, md, phd; address: 50 divizija no 6, 1000 skopje, republic of macedonia; telephone: +38970248619; e-mail: ftozija@t-home.mk tozija f, lizana t. migrant health policy in european union (eu) and non eu country: current situation and future challenges for improvement (original research). seejph 2020, posted: 16 march 2020. doi: 10.4119/seejph-3369 p a g e 2 | 11 abstract aim: the influx of refugees, asylum seekers and migrants in europe is an ongoing reality and migrant health has become very important public health problem. the aim of this paper is to analyze and compare the health profile, migrant situation and migration integration health policy in spain as a european union (eu) country and republic of north macedonia as a country in process of european union accession. methods: migration integration policy index (mipex) health strand questionnaire (2015) was applied to compare health policies for migrant integration in both countries. results: there are differences between spain and macedonia in health care coverage and access to health services for migrants. spain has health strand total score of 52 and is in the same group with austria, ireland, belgium, netherlands, denmark and sweden. macedonia has lower health strand total score 38 and is in the same group with turkey, cyprus, slovakia. targeted migrant health policies are stronger and services more responsive in spain compared to macedonia which offers migrants legal entitlements to healthcare, but health services should be more culturally responsive to migrant health needs. conclusion: health migration policy in both countries is closely tied to the general immigration policy. keywords: health, integration policy, migrant, mipex. conflicts of interest: none declared. tozija f, lizana t. migrant health policy in european union (eu) and non eu country: current situation and future challenges for improvement (original research). seejph 2020, posted: 16 march 2020. doi: 10.4119/seejph-3369 p a g e 3 | 11 introduction the influx of refugees, asylum seekers and migrants into the european region is an ongoing reality that will affect european countries, with security, economic and health implication. the number of refugees and migrants entering european states is increasing, driven by the wars in syria, iraq, afghanistan, eritrea and elsewhere. it is estimated that 75 million international migrants live in the european region, which is 8.4% of the total european population and one third of all international migrants worldwide. over 1 million refugees and migrants entered the european region in 2015. since 2013, the numbers of refugees and migrants crossing the mediterranean has increased significantly. more than 3,700 refugees drowned in the mediterranean sea (1). increases in arrivals have also been recorded in greece and spain. unhcr data shows that 63,311 migrants have risked their lives reaching europe by sea in 2019 (1,028 drowned in the sea). there are 5,690 sea arrivals registered so far in 2020, including refugees and migrants arriving by sea to italy, greece, spain, cyprus and malta and 1,152 land arrivals including refugees and migrants arriving by land to greece and spain (2). eu states without external borders need to accept far larger numbers of refugees who landed in the southern european member states (3). figure 1. immigration and european migrant crisis 2015 (source: http://geoawesomeness.com/wp-content/uploads/2017/03/map_of_the_ european_migrant_crisis_2015.png) http://geoawesomeness.com/wp-content/uploads/2017/03/map_of_the_%20european_migrant_crisis_2015.png http://geoawesomeness.com/wp-content/uploads/2017/03/map_of_the_%20european_migrant_crisis_2015.png tozija f, lizana t. migrant health policy in european union (eu) and non eu country: current situation and future challenges for improvement (original research). seejph 2020, posted: 16 march 2020. doi: 10.4119/seejph-3369 p a g e 4 | 11 the integration of the schengen area and the recent conflicts in the middle east increased the concentration of immigrants and refugees seeking better life chances in the european union (eu), due to the ease movement between the countries. the european union is home to around 1 million recognized refugees. the most attractive eu countries for asylum seekers that are hosting the most refugees are france, germany, united kingdom, sweden and italy. in 2008 eu member states signed the european pact on immigration and asylum (4), which was intended to be the basis for european union immigration and asylum policies in a spirit of mutual responsibility and solidarity between member states and a renewed partnership with non-eu countries. many asylum-seekers and refugees move and face difficulties in applying for asylum at borders, inadequate or insufficient reception conditions, or a lack of local integration prospects (1). underlying causes of refugee movements need to be tackled and eu states need to implement their global health strategies (5). spain, due to its geographical position, between the atlantic ocean, the mediterranean sea and its proximity to africa, is a destination point for immigrants and refugees from africa, to reach other countries in the northern part of europe, mainly germany. since 2000 spain has had one of the highest rates of immigration in the world, coinciding with a period of remarkable economic expansion. this influx began to decline rapidly after 2007 as the economy began to slow down. in 2015, 291,387 people immigrated to spain, thus increasing foreign population to 4,454,353, coming mainly from romania, morocco, italy, the united kingdom and venezuela (6). according to unhcr, in 2016, 59.5% of immigrants and refugees arrived by sea (2). in spain, the concentration of the immigrant population is in the autonomous communities of madrid, catalonia and valencia. in catalonia, 15.3% of the total population in 2016 was foreigners, mostly immigrants from morocco, romania and ecuador, with a mean age of 32.2 years and 111 men per 100 women. in catalonia there are 21% of the total number of foreigners in spain and 27% of the total non-eu population in spain (7). the immigration process in the republic of north macedonia (macedonia further in the text) is quite different than in spain. macedonia, largely a country of emigration, has become a country of transit and permanent immigration, experiencing several refugee crises. migrant health became serious public health problem in macedonia, as in other european countries with the migrant influx in 2015. there has been a notable growth of transit and illegal migration in macedonia from greece in 2015 mainly from syria, afghanistan, pakistan and iraq, and given the geographic position of the country, there is a high likelihood of further growth of such migratory developments. according to unhcr 747,240 refugees left the country from july 1st 2015 (up to 10,000 refugees daily). since september 2015, the proportion of women and children transiting the western balkans route has progressively increased to more than 50% (2). the aim of this paper is to analyze and compare the health profile, migrant situation and migration integration health policy in spain as a european union (eu) country and republic of north macedonia as a country in process of european union accession. tozija f, lizana t. migrant health policy in european union (eu) and non eu country: current situation and future challenges for improvement (original research). seejph 2020, posted: 16 march 2020. doi: 10.4119/seejph-3369 p a g e 5 | 11 methods migration integration health policy was compared in eu and non eu country, applying migration integration policy index (mipex) health strand as the most comprehensive and reliable tool. mipex was first published in 2004 as the european civic citizenship and inclusion index. there are 167 policy indicators on migrant integration in the mipex designed to benchmark current laws and policies against the highest standards in 8 policy areas, with 4 dimension scores for each area per country (8). health strand is a questionnaire designed to supplement the existing seven strands of mipex, which in its edition (2015) (9) monitors policies affecting migrant integration in 38 different countries. the health strand questionnaire is based on the recommendations on mobility, migration and access to health care adopted by the council of europe in 2011, which were based on a consultation process that lasted two years and involved researchers, intergovernmental organizations, nongovernmental organizations and a wide range of specialists in health care for migrants. the questionnaire measures the equitability of policies relating to four issues: migrants’ entitlements to health services; accessibility of health services for migrants; responsiveness to migrants’ needs; and measures to achieve change. mipex health strand survey was part of the equihealth project carried out by the international organization for migration (iom) from 2013 to 2016, in collaboration with the migration policy group (mpg) and cost action is1103, adapting european health services to diversity (adapt). mipex health strand study was conducted in all 38 countries, as well as bosnia and herzegovina and macedonia. data collection was organized by the iom, while experts and peer reviewers responsible for completing the health strand questionnaire were members of adapt. results from mipex 2015 health strand were analyzed. desk review was done on strategic documents, legislation, reports and studies for both countries. results health profiles the political and economic processes have brought new lifestyles to the society influencing the health of the population as well; new disease patterns emerged, with the non-communicable and chronic diseases taking over the lead in morbidity and mortality trends. when compared the basic health indicators for both countries it is obvious that the health of population in spain is much better than in macedonia, with 6 years longer life expectancy, lower rate of infant mortality, lower sdr of diseases of circulatory system, lower rate of tb incidence etc (10). this is directly correlated with the economic situation in the countries, spain is high income country with more than twice higher gross national income per capita (11) than macedonia an upper middle income country and higher total health expenditure 9% of gdp in spain compared to 6.5% in macedonia, despite the impact of the 2008 economic crisis. in macedonia noncommunicable diseases and injuries are generally on the rise, while communicable, maternal, neonatal, and nutritional causes of dalys are generally on the decline. cerebrovascular disease, ischemic heart disease and lung cancer were the three leading causes of premature death in 2015, followed by cardiomyopathy and diabetes (12). migration integration health policy migration in spain is regulated by the organic law 4/2000 on the rights and freedoms of foreigners in spain and its tozija f, lizana t. migrant health policy in european union (eu) and non eu country: current situation and future challenges for improvement (original research). seejph 2020, posted: 16 march 2020. doi: 10.4119/seejph-3369 p a g e 6 | 11 social integration (13). royal decree 240/2007 (14) makes the schengen treaty effective by containing freedom of movement for community citizens. in order to respond to the common european asylum system, law 12/2009 on the right of asylum and subsidiarity is created (15). spain is a member of the european union, so the right to health is protected with the charter of fundamental rights of the eu (16) and the universal declaration of human rights (1948) (17). at the national level, the right to health is regulated by act 14/1986 (18), with which all spanish and foreign citizens in the spanish territory have the right to health with the following characteristics: universal coverage, free services, public financing, high quality and comprehensive care. the reforms of the spanish constitution gave the autonomous communities some competences such as health planning, public health and health care. autonomous communities have the ability to manage public services and special programs for asylum seekers and foreigners (reform of the organic law of 2/2009) (19). since 2000, catalonia has been supporting and formalizing its migration competencies with the creation of the secretariat for immigration. the national pact for immigration integrated the efforts of the different catalan sectors that work on public policies of social integration (20). law 10/2010 (21) stipulates an annual report on the state of integration of immigration while the citizenship and migration plan 2016, considers the implementation of programs (22). from its establishment in 1981, the pillars of the catalan health system have been universal coverage, comprehensive health service basket and gate keeping model. it is funded by taxes and offers almost universal access to health services, free at the point of delivery, based on act 15/1990 or health ordinance of catalonia (23). macedonia has ratified the main united nations conventions, contributed to establishing integration policies with respect for cultural and social differences, human rights and dignity. with the overall mipex score of 44/100 (8) the country’s policies for societal integration is just below the european average and slightly better than other countries in the region, such as serbia, bosnia and herzegovina, croatia and bulgaria (24). the macedonian government adopted the first national strategy on integration of refugees and foreigners 20082015 (25) and the national plan of action (26), providing a national policy framework across sectors relevant to support the refugee integration. health care is a guaranteed universal right for citizens in macedonia (27, 28), and is financed by the compulsory health insurance and from the central budget through the ministry of health vertical programs. compulsory health insurance is based on solidarity, equity and equality providing universal coverage with basic benefit package to all insured persons and is defined by the health insurance law (29). foreigners (or legal migrants) in macedonia are covered by the same risk-sharing system for health care, but are subject to additional requirements such as permission to stay and paid employment. entitlement to health services including right to health insurance is regulated with law on foreigners (30) and with the health insurance law (29). migrants with access to compulsory health insurance are obliged to pay co-payments at the same level as nationals. asylum seekers are covered by the same system as nationals, with no additional requirements and no forms of care excluded. health care of asylum seekers is regulated tozija f, lizana t. migrant health policy in european union (eu) and non eu country: current situation and future challenges for improvement (original research). seejph 2020, posted: 16 march 2020. doi: 10.4119/seejph-3369 p a g e 7 | 11 with law on asylum and temporary protection (31), law on international and temporary protection (32) and health insurance law, and costs for the health insurance are covered by the ministry of labour and social policy. undocumented migrants have no access to the same system as nationals: private insurance or payment of full costs of the services is required. emergency care in life threatening situations should be delivered (documentation should be provided later). migrants that entered the country illegally are transferred to the transition centre of the ministry of interior and the costs for health services are paid by the government. if they seek asylum they become asylum seekers and are being transferred to asylum reception centre and have the same entitlements to health care as asylum seekers. although the law may grant migrants certain entitlements to healthcare coverage, administrative procedures often prevent them from exercising this right in macedonia. there are differences in migration integration policy between countries in europe in health as in other strands (9). the lowest total mipex health strand score in europe is in latvia 17, while the highest is in switzerland 70. spain has health strand total score of 52 and is in the same group with austria, ireland, belgium, netherlands, denmark and sweden. macedonia has lower health strand total score 38 and is in the same group with turkey, cyprus, slovakia (figure 2) (33). figure 2. mipex 2015 health strand total scores in europe (source: summary report on the mipex health strand and country reports) (33) tozija f, lizana t. migrant health policy in european union (eu) and non eu country: current situation and future challenges for improvement (original research). seejph 2020, posted: 16 march 2020. doi: 10.4119/seejph-3369 p a g e 8 | 11 in spain there are immigrant shelter centres responsible for providing social services and temporary shelter to immigrants and asylum seekers. the beneficiaries have access to health services, psychological support, legal services, training and recreation activities. however, they are only found in the two most important entry points, ceuta and melilla. in spain, act 16/2012 (34) denies the right to health of irregular migrants. irregular immigrants are only entitled to receive emergency health care, assistance in pregnancy and childbirth, health care for children under 18 years. the government of macedonia as a response to the migrant crisis in 2015 changed the legislation on june 19th 2015 providing free health services for all registered migrants, national coordination body was formed, technical expert group established, migrant action plan adopted and two transit centers opened at the borders with greece and serbia. the following problems were faced in macedonia during migrant crisis: huge number of undocumented migrants particularly upon arrival at entry points, no resources such as interpreters, intercultural mediators, communication problems between migrants and health care personnel and administrative staff (24). discussion migration exposes people to vulnerable situations and their health is related to different determinants: individual (behaviour, genetic factors, age, and gender), environmental factors (physical, economical, social and cultural) and health services (availability, accessibility and quality). migrant children and mothers are the most vulnerable and they require access to special protection and care (24). migrant health is very important and longoverdue issue in eu member states and of special concern is potential widening of the health gap between migrant and host populations. variation of national migration integration policies for entitlements to health services in european countries is a barrier to health care for refugees, asylum seekers and especially for un-documented migrants (35). health systems need to be responsive to the migrant health needs and cultural differences such as concept of health and disease, felt and expressed health needs, language barriers, etc. migrants arriving on european union territory should be treated in a responsible and dignified manner and the need for accessible health services is more than obvious (36). there are differences between spain and macedonia in health care coverage and access to health services for migrants. spain has relevant regulations for immigrants, refugees and international protection, but also regulations that guarantee basic human rights, such as the right to health. targeted migrant health policies are stronger and services more responsive in spain as a country with greater wealth (gdp), compared to macedonia which offers migrants legal entitlements to healthcare, but still more efforts should be undertaken to adapt services to their needs. effective health care delivery to migrant and minority groups is compromised by the absence of culturally sensitive health services in macedonia. no resources such as interpreters, cultural mediators (there are only roma mediators), health and social care professionals trained on multicultural approaches are available in macedonia. strategies and policies are relatively new in macedonia, along with the fact that such strategies are also subject to constant upgrade to the level of eu requirements (1) due to their wide socioeconomic impact and replaced migration developments. although government has taken commendable action to establish the necessary services, the tozija f, lizana t. migrant health policy in european union (eu) and non eu country: current situation and future challenges for improvement (original research). seejph 2020, posted: 16 march 2020. doi: 10.4119/seejph-3369 p a g e 9 | 11 country has limited resources and requires support. there is a need to invest more, and sooner, in the health care to address migrants' specific health needs. the integration of migrants into their host societies promotes equal opportunities for migrants and nationals (37), thereby fostering economic development in countries of origin and destination (38). limitations migrant integration health policy has been analyzed only in two countries, spain member of the european union and accession country republic of north macedonia, both facing with the migrant influx and responding to the needs of the migrants. conclusions the government of macedonia adopted national legal framework and strategic documents on integration and established institutional framework and measures regarding immigrants’ healthcare and broader welfare issues remain closely tied to the general framework of immigration policy. there is a need to create appropriate structures in health system accessible to refugees, responsive to different cultures, based on universal human rights. meanwhile, the government of spain has responded to international and european union conventions regarding the elaboration of regulatory mechanisms on international protection, immigration and health. references 1. world health organization. strategy and action plan for refugee 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official gazette of rm. no. 35/06, 66/2007, 117/2008, 92/2009, 156/2010, 158/2011, 84/2012, 13/2013, 147/2013, 148/2015, 217/2015, 97/2018. 31. law on asylum and temporary protection. official gazette of rm. no. 49/2003, 66/2007, 142/2008, 146/2009, 166/2012. 32. law on international and temporary protection. official gazette of rm. no 64/2018. 33. summary report on the mipex health strand and country reports. international organization for migration, geneva; 2016. 34. act 16/2012 of april 20. spain congress; 2012. available from: https://www.boe.es/diario_boe/txt.ph p?id=boe-a-2012-5403 (accessed: november 25, 2019). 35. international migration, health and human rights. international organization for migration. geneva; 2013. available from: https://publications.iom.int/books/int ernational-migration-health-andhuman-rights (accessed: january 11, 2020). 36. razum o, bozorgmehr k. disgrace at eu’s external borders. int j public health 2015;60:515-6. doi: 10.1007/s00038-015-0689-4. 37. united nations development programme. human development report 2009. overcoming barriers: human mobility and development. new york, usa; 2009. 38. ooms g, hammonds r. global constitutionalism, responsibility to protect, and extra-territorial obligations to realize the right to health: time to overcome the double standard (once again). int j equity health 2014;13:68. doi:10.1186/s12939-014-0068-4. ______________________________________________________________________________________ © 2020 tozija et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.boe.es/diario_boe/txt.php?id=boe-a-2012-5403 https://www.boe.es/diario_boe/txt.php?id=boe-a-2012-5403 https://publications.iom.int/books/international-migration-health-and-human-rights https://publications.iom.int/books/international-migration-health-and-human-rights https://publications.iom.int/books/international-migration-health-and-human-rights https://www.researchgate.net/deref/http%3a%2f%2fdx.doi.org%2f10.1007%2fs00038-015-0689-4?_sg%5b0%5d=hy6nod3dy8-oyv3iqoag9u6v7lkej9acaff1nub1ndgukculoi06k82lz9d9wragps_qwb3chcbbngg_9vlbgyl7gq.cqva9suvbm8dvuswqqjldj2cdbx3qshb1ucpiwts61qdasowx8ql4hw4tyfai3tupsw4thvihknpgs6v0dvupg https://doi.org/10.1186/s12939-014-0068-4 dobe m, sahu m. how the kurnool district in andhra pradesh, india, fought corona (case study). seejph 2020, posted: 18 november 2020. doi: 10.4119/seejph-3963 p a g e 1 | 9 case study how the kurnool district in andhra pradesh, india, fought corona madhumita dobe1, monalisha sahu1 1 department of health promotion and education, all india institute of hygiene and public health, west bengal, india. corresponding author: madhumita dobe; address: 110, chittaranjan avenue, kolkata 700073, west bengal, india; telephone: +9830123754; email:madhumitadobe@gmail.com dobe m, sahu m. how the kurnool district in andhra pradesh, india, fought corona (case study). seejph 2020, posted: 18 november 2020. doi: 10.4119/seejph-3963 p a g e 2 | 9 abstract background: kurnool, one of the four districts in the rayalaseema region of the indian state of andhra pradesh, emerged as a covid-19 hotspot by mid-april 2020. method: the authors compiled the publicly available information on different public health measures in kurnool district and related them to the progression of covid-19 from march to may 2020. results: two surges in pandemic progression of covid-19 were recorded in kurnool. the initial upsurge in cases was attributed to return of people from other indian states, along with return of participants of a religious congregation in delhi, followed by in-migration of workers and truckers from other states and other districts of andhra pradesh, particularly from the state of maharashtra (one of the worst affected states in india) and chennai (the koyambedu wholesale market epicenter of the largest cluster of covid-19 in tamil nadu). in a quick response to surging infections the state government launched operation ‘kurnool fights corona’ to contain the outbreak. kurnool had taken a targeted approach to testing, scaled up testing in areas with high case load, and conducted contact tracing for each positive case, along with requisitioning oxygenated beds in the district hospitals to meet the anticipated spurt in the number of positive cases. this combined approach paid rich dividends and from 26th april to may 9th, the growth curve flattened. conclusion: although the in migration of laborers and return of residents from other indian states and abroad during the covid-19 pandemic was a complex challenge, the timely actions of testing, tracing and isolation conducted by the district authorities in kurnool greatly reduced transmission. although this response assessment is based on a single district, the perspectives have revealed some important lessons regarding risk communication, preparedness and response for pandemics which will facilitate consolidation of the policy and program response to pandemics in future. keywords: contact tracing, covid-19, isolation, kurnool, preparedness, testing. acknowledgement: dr sanjoy sadhukhan (professor, aiih&ph) and district authorities of kurnool for their support. conflicts of interest: none. dobe m, sahu m. how the kurnool district in andhra pradesh, india, fought corona (case study). seejph 2020, posted: 18 november 2020. doi: 10.4119/seejph-3963 p a g e 3 | 9 background kurnool district is one of the four districts in the rayalaseema region of the indian state of andhra pradesh (1). the district is located in the west-central part of the state and is bounded by mahbubnagar district of telangana in the north, raichur district of karnataka in the northwest, bellary district of karnataka in the west, ananthapur district in the south, ysr kadapa district in the south east and prakasham district in the east. the district is the second largest by area and seventh largest by population in the state with a total population of 4.53 million as per 2011 census, 72% of which reside in rural areas. the main occupation and source of livelihood for this district is agriculture. more than 70% of the population in the kurnool district engages in farming. however, as kurnool is a drought prone area, many of the villagers are forced to migrate not only to other states but also to other districts within the state in search of livelihood. the district has three revenue divisions viz., kurnool, nandyal, adoni divisions with 54 mandalas and 53 panchayat samitis (blocks) under these revenue divisions (1,2). methods the authors compiled and reviewed all publicly available information (government database, newspaper articles, reports) and interviewed government officials during field visits on different public health measures taken in kurnool district to contain the ongoing covid-19 pandemic in progression from the month of march to may 2020. results everything seemed in line with the overall progress of the pandemic in india when the nation-wide lockdown was first announced on march 24 to contain covid-19 outbreak. over 300 foreign returnees from italy, uk/scotland, saudi arabia (mecca) were under surveillance and the district administration collected samples for tests. on march 28 the first case in the district was reported, as a 23-year-old male with a travel history to rajasthan tested positive for the virus (3). the number of positive cases remained low for the next two weeks. spikes of cases were reported on april 5 and april 6 with 49 and 18 cases emerging respectively in those two weeks till april 13 (4). but things changed from april 14 when the numbers kept shooting up. the first surge of cases: during midmarch, tablighi jamaat (religious congregation) was held at nizamuddin markaz in new delhi. many people from kurnool had attended the congregation. the first alarm went off when three persons from kurnool district, who attended the tablighi jamaat at nizamuddin, tested positive for covid-19 (5). the number of positive cases in the district went up from one to four with these three persons hailing from kurnool city, owk and banaganapalli. district officials felt that the influx of 357 tablighi jamaat (tj) congregation returnees from new delhi triggered the sudden spurt. the returnees and their primary and secondary contacts accounted for majority of the cases in the district which had the highest number of delhi returnees in the state. the challenge was formidable since on one hand, authorities were unable to precisely locate all tj meeting returnees and on the other, those traced by them did not come forward voluntarily for diagnostic tests and were unwilling to be taken https://en.wikipedia.org/wiki/rayalaseema https://en.wikipedia.org/wiki/states_and_union_territories_of_india https://en.wikipedia.org/wiki/states_and_union_territories_of_india https://en.wikipedia.org/wiki/andhra_pradesh https://en.wikipedia.org/wiki/mahabubnagar_district https://en.wikipedia.org/wiki/mahabubnagar_district https://en.wikipedia.org/wiki/telangana https://en.wikipedia.org/wiki/raichur_district https://en.wikipedia.org/wiki/raichur_district https://en.wikipedia.org/wiki/karnataka https://en.wikipedia.org/wiki/bellary_district https://en.wikipedia.org/wiki/bellary_district https://en.wikipedia.org/wiki/karnataka https://en.wikipedia.org/wiki/ananthapur_district https://en.wikipedia.org/wiki/ananthapur_district https://en.wikipedia.org/wiki/ysr_kadapa_district https://en.wikipedia.org/wiki/ysr_kadapa_district https://en.wikipedia.org/wiki/prakasham_district https://en.wikipedia.org/wiki/prakasham_district https://en.wikipedia.org/wiki/revenue_division https://en.wikipedia.org/wiki/revenue_division https://en.wikipedia.org/wiki/kurnool https://en.wikipedia.org/wiki/nandyal https://en.wikipedia.org/wiki/adoni https://en.wikipedia.org/wiki/mandal https://en.wikipedia.org/wiki/panchayat_samiti_(block) https://en.wikipedia.org/wiki/panchayat_samiti_(block) dobe m, sahu m. how the kurnool district in andhra pradesh, india, fought corona (case study). seejph 2020, posted: 18 november 2020. doi: 10.4119/seejph-3963 p a g e 4 | 9 to isolation or quarantine wards. since there was no single source which had details of all participants and their addresses, there was difficulty in identifying those who attended the meet in delhi. due to these issues, there was a delay of 10 days initially in identifying the tablighi jamaat returnees and their contacts which led to a spike in the number of cases in the district. also, problem lay in lack of vrdl (virus research and diagnostic laboratory) in kurnool and dependence on laboratories far away from the district headquarters. sample results were delayed thereby hindering initial contact tracing. one hundred and ninety-five cases emerged in 13 days, making kurnool one among the few districts in south india to see a dramatic surge (6). by april 25, the district administration had declared 40 red zones in 20 of a total 54 mandalas and urban areas including kurnool city with 239 active cases, 9 deaths, and 31 recoveries (4,6). the worstaffected areas were kurnool city and nandyal town (figure 1). figure 1. administrative map of kurnool district and the covid-19 affected mandalas. data as on 25th april 2020 (2,6) the district, now accounted for over a quarter of the cases in andhra pradesh and figured high on the list of districts with the highest number of covid cases in south india after chennai in tamil nadu, hyderabad in telangana and kasaragod in kerala (4). to battle against this, operation “kurnool fights corona (kfc)’ was launched (7). the second surge: with the lockdown imposed, the migrant workers from the district started to return without effective controls. in consequence a fresh upsurge of cases was noted with average daily increase to seven new cases (from 6th to 21st may 2020). most cases were seen among migrant workers and lorry drivers returning from maharashtra (one of the worst affected states in dobe m, sahu m. how the kurnool district in andhra pradesh, india, fought corona (case study). seejph 2020, posted: 18 november 2020. doi: 10.4119/seejph-3963 p a g e 5 | 9 india) and from koyambedu (chennai’s popular wholesale market, and the epicenter of the largest cluster of covid-19 in the neighbouring state of tamil nadu), along with their primary and secondary contacts. out of 8,069 workers who returned from other states, 236 were tested positive to covid-19. similarly, of another 3,337 workers who returned from mumbai, 314 tested positive to the virus (3). however, probably only those who had reported or were intercepted during their journey back were tested. in-migration from other districts: by 4th may another 40,000 migrant workers returned to kurnool district from other districts in the same state of andhra pradesh. almost all of them were working in chili fields at guntur and prakasam districts. most of these migrant laborers had left for work in january and february. containment measures: the district put well streamlined contact tracing and quarantine measures in place. the state formulated an action plan to bring back about 200,000 of its migrants held up in 13 states with well-planned quarantine measures. a. quarantine facilities for in migrants and returnees: responding to the upsurge, the existing number of 244 quarantine centers were increased to 1 in each village secretariat (one village secretariat has been set up for every population of 2,000 ), readying over 100,000 beds at village secretariats, with nutritious food, hygienic toilets for the returnees (10). each village secretariat was made suitable to accommodate 1015 people during quarantine. arrangements for quarantine were as follows:  home quarantine for asymptomatic migrants from within state;  community quarantine for symptomatic migrants from within state at village secretariat level / school buildings;  institutional quarantine at block level-school buildings for migrants from other low risk states;  institutional quarantine at district level (housing flats) for migrants from other high risk states e.g. maharashtra and chennai (koyembadu);  hotels & lodges for paid quarantine facilities for affordable rich persons/ foreign returnees. the health, medical and family welfare department of andhra pradesh directed all district collectors to establish quarantine centers at district level with 200 beds and constituency level with 100 beds each. by march 25, all district hospitals in the state were instructed by the health department of andhra pradesh, to setup isolation wards. the state, on 31 march, identified dedicated covid-19 hospitals4 at state and 13 at district level. on 31 march 2020, all district administration in andhra pradesh was directed by the state government to prepare shelter with lodging and boarding services for migrant labourers. these shelters were managed by individual 'nodal officer', appointed by the district collector or municipal commissioner. immediately after their entry into kurnool, the returnees coming from various high-risk states like maharashtra-the worst-hit state, were taken in specially-arranged buses to the institutional quarantine centers set up by the administration in kurnool and adoni before returning to their respective homes. covidhttps://www.thehindu.com/news/cities/chennai/did-authorities-fail-to-read-the-signs/article31513339.ece?homepage=true https://www.thehindu.com/news/cities/chennai/did-authorities-fail-to-read-the-signs/article31513339.ece?homepage=true https://en.wikipedia.org/wiki/andhra_pradesh dobe m, sahu m. how the kurnool district in andhra pradesh, india, fought corona (case study). seejph 2020, posted: 18 november 2020. doi: 10.4119/seejph-3963 p a g e 6 | 9 19 tests were done for all the migrants and they were allowed to go home only after 14 days of quarantine as per the protocol. counselling and other support systems were also being arranged by district authorities in the quarantine centers to help people cope up the stress and anxiety. limitations: on the flip side, mandatory quarantine was accompanied by fear, alarm, and panic. this, augmented by media, spread farther and aggravated the risk of being stigmatized. field workers reported that those returning from quarantine were discriminated in the form of:  other people avoiding or rejecting them;  verbal abuse; or  physical violence. this led to isolation, depression, anxiety, or public embarrassment for these individuals sometimes leading to challenges in contact tracing as reported by community health workers participating in active surveillance in the communities. even healthcare workers, sanitary workers and police, who were in the frontline for management of the outbreak, were facing discrimination on account of heightened fear and misinformation about infection. district authorities addressed these issues through busting the myths and sharing accurate information about how the virus spreads and does not spread. they used news media and social media, to speak out against stereotyping groups of people who experience stigma because of covid-19 and spoke out against negative behaviours and statements. b. contact tracing activities: contact tracing teams were put in action, manned by medical doctors and health workers. the data base and line listing was maintained rigorously by the contact tracing team (11). the line listing of the cases is presented in table 1. table 1. line listing of the cases among returnees in kurnool by 19 th may 2020 category total no. of persons total positives primary contacts traced primary contacts positive secondary contacts traced secondary contacts positive foreign returnees 840 1 2 0 12 0 delhi returnees 361 114 1048 35 2786 44 delhi returnees-contacts 3834 79 718 0 1756 1 koyembedu returnees 473 12 69 0 324 0 total 5508 206 1837 35 4878 45 after receiving line list of positive cases, the positive cases were contacted through phone calls. they were extended support and were inquired about their contacts. the contacts were listed, identified and classified into primary, secondary and tertiary contacts. the information of the contacts was shared with the sample testing team, home isolation department, integrated disease surveillance program and municipal health office to eensure they have access to medical care and social services. they are dobe m, sahu m. how the kurnool district in andhra pradesh, india, fought corona (case study). seejph 2020, posted: 18 november 2020. doi: 10.4119/seejph-3963 p a g e 7 | 9 notified about their exposure, offered treatment if required and instructed to limit their contact with other people. medical officers and auxiliary nurse midwives (anms) were informed to acquire further information on the contacts including associated comorbidities. follow up of the contacts for testing, quarantine and isolation was done by the local teams. monitoring of actions in collaboration and coordination with municipal health officers, medical officers, auxiliary nurse midwives and ward volunteers was done on regular basis. special challenge of contact tracing of koyembadu market returnees: koyambadu market complex is one of asia’s largest hubs for perishable goods. retail vendors come from a minimum radius of 100 km. kurnool is one of the main sources of onion for tamil nadu, and many sellers had travelled to the market even during lockdown period for business purposes and as vendors and market laborers including load men returning from koyembadu began to test positive, tracing and testing all index cases was aggressively undertaken, what marked the beginning of a challenging process was contact tracing. the cluster was different owing to the massive crowds involved (8,9). in a normal situation, a person who tests positive for covid-19 will have 20 to 30 contacts but this was not the case with the koyambedu cluster where some who tested positive had roughly 200 to 250 contacts. this combined approach paid rich dividends and from 26th april to may 9th, the number of new cases gradually declined with a doubling rate of 25 (figure 2). figure 2. graph representing temporal variation of new cases, cumulative cases and active cases from kurnool district till may 5th 2020 (source: district data provided by nodal officer) dobe m, sahu m. how the kurnool district in andhra pradesh, india, fought corona (case study). seejph 2020, posted: 18 november 2020. doi: 10.4119/seejph-3963 p a g e 8 | 9 conclusion although the in-migration of laborers during the covid-19 pandemic was a complex challenge, the timely actions conducted by the district authorities in kurnool greatly reduced transmission. hundreds of migrants and those who had close contact with the positives among them, were placed in quarantine centers run by the government. hot spots with high case load were locked down immediately, and the government communicated frequently with citizens to keep them informed and involved in the public health response. also, in a quick response to surging infections the state government launched operation ‘kurnool fights corona’ to contain the outbreak. in summary kurnool had taken a targeted approach to testing, scaled up testing in areas with high case load, and conducted contact tracing for each positive case, along with requisitioning oxygenated beds in the district hospitals to meet the anticipated spurt in the number of positive cases. this combined approach paid rich dividends and from 26th april to may 9th, the growth curve flattened. although this response assessment is based on a single district, the problems faced by kurnool have revealed some important lessons regarding risk communication, preparedness and response for pandemics which will facilitate consolidation of the policy and program response to pandemics in future. references 1. government of andhra pradesh. kurnool district. available from: https://kurnool.ap.gov.in/ (accessed: july 17, 2020). 2. government of andhra pradesh. andhra pradesh space applications centre. available from: https://apsac.ap.gov.in/ (accessed: july 17, 2020). 3. the times of india. kurnool reports first corona positive case. available from: https://timesofindia.indiatimes.com/city/vijayawada/kurnoolreports-first-corona-positive-case/articleshow/74867409.cms (accessed: july 17, 2020). 4. the new indian express. battle of kurnool: with over 279 coronavirus cases in one month govt steps up fight to stop spread. available from: https://www.newindianexpress.com/states/andhra-pradesh/2020/apr/27/battle-kurnoolwith-over-279-coronavirus-cases-inone-month-govt-steps-up-fight-tostop-spread-2135834.html (accessed: july 17, 2020). 5. the hindu.70 nizamuddin’s tablighi jamaat returnees identified in kurnool district. available from: https://www.thehindu.com/news/national/andhra-pradesh/70-nizamuddin-returnees-sent-to-quarantine/article31215260.ece (accessed: july 17, 2020). 6. arogya andhra on twitter: “kurnool district has the highest number of #covid19 positive cases in the state.” available from: https://twitter.com/arogyaandhra/status/1254039414956625920 (accessed: july 17, 2020). 7. the times of india. operation ‘kurnool fights corona’ launched; 14 new cases in district, 24 patients 24 patients discharged. available from: http://timesofindia.indihttps://kurnool.ap.gov.in/ https://apsac.ap.gov.in/ https://apsac.ap.gov.in/ https://timesofindia.indiatimes.com/city/vijayawada/kurnool-reports-first-corona-positive-case/articleshow/74867409.cms https://timesofindia.indiatimes.com/city/vijayawada/kurnool-reports-first-corona-positive-case/articleshow/74867409.cms 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pradesh, india, fought corona (case study). seejph 2020, posted: 18 november 2020. doi: 10.4119/seejph-3963 p a g e 9 | 9 atimes.com/articleshow/75383053.cms?utm_source =contentofinterest&utm_medium=text&utm_campaign=cppst (accessed: july 17, 2020). 8. the hindu. what turned koyambedu, chennai’s popular wholesale complex market, into a covid-19 hotspot? available from: https://www.thehindu.com/news/national/tamil-nadu/coronavirus-whatturned-koyambedu-chennais-popular-wholesale-complex-market-intoa-covid-19-hotspot/article31546292.ece (accessed: july 17, 2020). 9. the hindu. koyambedu market impacts four districts in andhra pradesh. available from: https://www.thehindu.com/news/national/andhra-pradesh/koyambedumarket-impacts-four-districts-in-andhra-pradesh/article31569117.ece (accessed: july 17, 2020). 10. deccan hearald. andhra uses village secretariat buildings to ready 1 lakh quarantine beds for people returning to state. available from: https://www.deccanherald.com/national/andhra-uses-village-secretariat-buildings-to-ready-1-lakh-quarantine-beds-for-people-returning-tostate-833076.html (accessed: july 17, 2020). 11. government of andhra pradesh. department of health & family welfare. available from: arogyaandhra (@arogyaandhra) | twitter; twitter.com › arogyaandhra. _______________________________________________________________ © 2020 dobe et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://timesofindia.indiatimes.com/articleshow/75383053.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst http://timesofindia.indiatimes.com/articleshow/75383053.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst http://timesofindia.indiatimes.com/articleshow/75383053.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst http://timesofindia.indiatimes.com/articleshow/75383053.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst https://www.thehindu.com/news/national/tamil-nadu/coronavirus-what-turned-koyambedu-chennais-popular-wholesale-complex-market-into-a-covid-19-hotspot/article31546292.ece https://www.thehindu.com/news/national/tamil-nadu/coronavirus-what-turned-koyambedu-chennais-popular-wholesale-complex-market-into-a-covid-19-hotspot/article31546292.ece https://www.thehindu.com/news/national/tamil-nadu/coronavirus-what-turned-koyambedu-chennais-popular-wholesale-complex-market-into-a-covid-19-hotspot/article31546292.ece https://www.thehindu.com/news/national/tamil-nadu/coronavirus-what-turned-koyambedu-chennais-popular-wholesale-complex-market-into-a-covid-19-hotspot/article31546292.ece 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https://www.deccanherald.com/national/andhra-uses-village-secretariat-buildings-to-ready-1-lakh-quarantine-beds-for-people-returning-to-state-833076.html https://www.deccanherald.com/national/andhra-uses-village-secretariat-buildings-to-ready-1-lakh-quarantine-beds-for-people-returning-to-state-833076.html https://www.deccanherald.com/national/andhra-uses-village-secretariat-buildings-to-ready-1-lakh-quarantine-beds-for-people-returning-to-state-833076.html https://www.deccanherald.com/national/andhra-uses-village-secretariat-buildings-to-ready-1-lakh-quarantine-beds-for-people-returning-to-state-833076.html https://www.deccanherald.com/national/andhra-uses-village-secretariat-buildings-to-ready-1-lakh-quarantine-beds-for-people-returning-to-state-833076.html https://twitter.com/arogyaandhra?lang=en https://twitter.com/arogyaandhra?lang=en https://twitter.com/arogyaandhra?lang=en https://twitter.com/arogyaandhra?lang=en kinsagala e, mbivnjo el, okeah bo, khan ma. community and informal care providers at the heart of universal health coverage in sub-saharan africa: a position paper (position paper). seejph 2021, posted: 17 april 2021. doi : 10.11576/seejph-4353 p a g e 1 | 15 position paper community and informal care providers at the heart of universal health coverage in sub-saharan africa: a position paper ephraim kisangala1,2, etheldreda leinyuy mbivnjo3, bernard ojiambo okeah4, mohammed azhar khan5 1 african centre for systematic reviews and knowledge translation, college of health sciences, makerere university (african centre makchs) p.o. box 7072 kampala, uganda; ephraimkis@gmail.com; 2 kairos hospital, p.o. box 7573 kampala, uganda; 3 biaka university institute of buea, p.o. box 77 buea, cameroon; metheldreda@gmail.com; 4 school of healthcare sciences, bangor university, ll57 2ef gwynedd, united kingdom; bernardokeah@gmail.com; 5 dr. m a khan dental practice, unit b, 10 barnard road, sherwood, durban 4091, south africa; mazhar015@gmail.com; corresponding author: ephraim kisangala; address: african centre for systematic reviews and knowledge translation, college of health sciences, makerere university (african centre makchs) p.o. box 7072 kampala, uganda; email: ephraimkis@gmail.com; mailto:metheldreda@gmail.com mailto:bernardokeah@gmail.com mailto:bernardokeah@gmail.com kinsagala e, mbivnjo el, okeah bo, khan ma. community and informal care providers at the heart of universal health coverage in sub-saharan africa: a position paper (position paper). seejph 2021, posted: 17 april 2021. doi : p a g e 2 | 15 . abstract globally, increased demand on often scarce healthcare resources and those challenges incumbent in responding to the coexistence of infectious and non-communicable diseases warrant the need to address persistent health inequities. understanding the complex intersectionality of vulnerability and reaching those in most critical need of healthcare lies at the heart of fostering and sustaining resilient healthcare systems. harnessing the long-recognised value of community and informal care providers (cicps) is instrumental to universal health coverage (uhc). the present covid-19 context serves as a poignant example of where access to formal healthcare services by many has become increasingly difficult. here, the value of informal or volunteer-led health services has been a lifeline for many. for several decades, formal reportage has evidenced the established role of cicps, particularly across sub-saharan africa with quantifiable efficacy across a number of domains, such as, maternal and child health, neglected tropical disease prevention, tuberculosis care and malaria control. cicps have been sustainable and effective as a conduit between the formal and informal health sectors, and between health facilities and the remotest of communities. maximising the function of cicps relies on socio-culturally, geographically sensitive, and bespoke support; psychosocial, practical, and logistical capacitation coupled with situationally and culturally appropriate monitoring and evaluation. the astana declaration highlights the centrality of building on existing knowledge, insight and resource. we therefore argue that cicps are indispensable in africa’s move towards uhc, and hold promise for acceptable, accessible, affordable, and quality healthcare to everyone who needs to get, be and stay healthy. keywords: community health workers, informal caregivers, universal health coverage, subsaharan africa source of funding: the who african regional office and hidayo noguchi african prize (hnap) for medical services sponsored the processing fee for this article. conflict of interest statement: the authors declare no financial or non-financial conflicts of interest. acknowledgments: the authors acknowledge the mentorship of professor margaret gyapong, director of the institute of health research, university of health and allied sciences, ghana. authors’ contributions: ek contributed to the body of the essay and managed correspondences with the mentor and who african regional office; elm wrote the outline, abstract and introduction of the essay; boo made contributions to the body of the essay, wrote the conclusion and compiled the first complete draft; and mak contributed to the body of the essay. kinsagala e, mbivnjo el, okeah bo, khan ma. community and informal care providers at the heart of universal health coverage in sub-saharan africa: a position paper (position paper). seejph 2021, posted: 17 april 2021. doi : p a g e 3 | 15 background africa’s life expectancy is 11 years below global mean levels (1), and hosts three countries (central african republic, lesotho, and swaziland) with the least life expectancy at birth (<50 years) between 2010 and 2015. in west africa, the life expectancy at 60 years is 14.1 years for men and 14.7 years for women (2). sub-saharan africa is now facing a dual burden of non-communicable and communicable diseases with an age-standardised disability-adjusted life-years (dalys) of 21 757·7 per 100,000 population for non-communicable diseases which is comparable to that of communicable, maternal, neonatal and nutritional disorders combined (26 491·6 dalys) in 2017, highlighting the need for health systems to address these changing tides (3). managing non-communicable diseases is costly, and poses additional threats for african healthcare systems that have relied heavily on donors and the private sector for healthcare financing while the share of health in public funds is comparatively small (4,5). in addition, out-of-pocket expenditure has put 1.14 billion people below the poverty line, africa has the poorest access to essential quality health services in the world (1) with inefficient information systems and health inequalities (6) amidst poor governance and inadequate human resources for health (7). good health and wellbeing is a pre-requisite, measure and consequence of sustainable development, making its universal and equitable access an absolute necessity (6). consequently, the world health organisation (who) has established the triple billion agenda with universal health coverage (uhc) for one billion additional individuals by 2023 as one of its targets (8). this comes as a reinforcement to the tokyo declaration on uhc (9) and the astana declaration on primary health care as the gateway to uhc(10). also, the harmonisation for health in africa initiative has been revisited and a package for essential healthcare services established to drive the move towards uhc in the african region (1). the astana declaration is committed to training, recruiting and retaining health personnel including those providing primary care in the most rural/remote areas with special attention to developing countries (10) which reiterates community health workers’ (chws) pivotal role in uhc (11). more so, the who has developed guidelines to enhance chw programme design, implementation, performance and evaluation by member states and partners to support the strive towards uhc as a fundamental pillar for achieving the sustainable development goals (sdgs) (12). chws are generalist or specialist (13,14) paid or unpaid lay and paraprofessionals who provide culturally acceptable care to communities in which they live and have undergone short standardised training (15). closely related to them are informal helping or social support networks (family, friends, neighbours, natural helpers, role-related helpers, people with same problems and volunteers) who willingly offer unpaid services and people naturally turn to them for help (16), creating a near balance in care demand and supply. in this position paper, chws and informal helping networks will be collectively referred to as community and informal care providers (cicps) and excludes medicine sellers identified as informal providers by some studies (17). these cicps have been in use since the mid twentieth century (13,16) and have proven their worth in the ongoing coronavirus pandemic (18,19). in addition, the kampala statement notes the contribution of chws to sustainable development goals (sdgs) 1, 2, 3, 5, 6, 10 and 17 (20). furthermore, sdg 4 is promoted by training/educat kinsagala e, mbivnjo el, okeah bo, khan ma. community and informal care providers at the heart of universal health coverage in sub-saharan africa: a position paper (position paper). seejph 2021, posted: 17 april 2021. doi : p a g e 4 | 15 ing chws (13,15), and the relationship between the third sdg (good health and wellbeing) and all other sixteen sdgs (6), demonstrates chws crucial role in both uhc and sustainable development (see figure 1 and figure 2 below). thus, uhc provides a critical linchpin without which attaining the united nation's health-related agenda may remain elusive. we therefore argue that with appropriate support, monitoring and evaluation, cicps are indispensable in africa's move towards uhc and hold promise for acceptable, accessible, affordable, and quality healthcare to everyone who needs to get, be and stay healthy. figure 1: cicps drive sustainable development by ensuring uhc figure 2: community and informal care providers (cicps) at the heart of good health and well-being (adapted from the who health in the sdg era infographic) sustainable development uhc cicps kinsagala e, mbivnjo el, okeah bo, khan ma. community and informal care providers at the heart of universal health coverage in sub-saharan africa: a position paper (position paper). seejph 2021, posted: 17 april 2021. doi : p a g e 5 | 15 cicps in accelerating uhc health systems in sub-saharan africa are grossly underfunded and this has a huge limitation on the extent to which health services are made available to citizens (20). besides, the available health services may not be easily accessible due to barriers partly occasioned by socio-political contexts. cicps can potentially expand the reach of healthcare services in hard to reach areas thereby immensely improving uhc. one area that has greatly benefited from the invaluable work of cicps is hiv management services. evidence from a multi-country study published by the community action network (can) conducted in ethiopia, malawi, zambia, and south africa revealed how cicps continue to improve access to universal counselling and testing as well as scaling up anti-retroviral therapy (21). the research further showed that cicps were actively involved in mobilizing communities for hiv prevention services and providing hiv testing in some instances. moreover, the cicps are instrumental in promoting the health-seeking behaviour of communities thus contributing to the uptake of hiv related services such as prevention of mother to child transmission (pmtct) (21). other potential areas for the application of cicps include providing support to hiv patients and directly observed treatment (dot) for hiv and tuberculosis. in uganda, cicps have been utilized in the provision of home-based care for children living with hiv (22). although some have argued that cicps lack the knowledge and skills to deliver quality healthcare services, pre-deployment training and continuous supportive supervision with remote digital support may help bridge this gap. cicps play a role in the long-term management of chronicillnesses including non-communicable diseases (ncds). a south african based study recorded the roles undertaken by cicps (informal caregivers) and the challenges they face while looking after advanced cancer patients in end of life care (23). in such instances, the work undertaken by cicps complements palliative care services provided by hospices. undoubtedly, end of life care can be very challenging and distressful even to the best qualified professionals, hence, the need to provide relevant support including stress management services for cicps undertaking such roles. some countries lack organized palliative care services, hence, the vital role of cicps who are the main service providers as evidenced by a ghanaian study that explored the motivations and experiences for family caregivers for advanced breast cancer patients (24). delivering essential healthcare services is often complicated in emergency situations including disasters and other catastrophic events. more often, there is limited access to life-saving interventions by extremely vulnerable populations considering the delays as emergency responders undertake risk assessments before accessing the affected persons. a recent publication on the covid-19 emergency response actions highlighted on the utilization of cicps through informal networks to bolster local response to a serious health problem in informal settlements namely the kibera slums in kenya (25). specifically, the cicps have played an immense role in promoting sanitation, contact tracing, and initiating isolation measures for suspected cases. additional examples of the application of cicps in emergency response includes the ebola virus epidemics in west africa and the drc where they mobilized community adherence to kinsagala e, mbivnjo el, okeah bo, khan ma. community and informal care providers at the heart of universal health coverage in sub-saharan africa: a position paper (position paper). seejph 2021, posted: 17 april 2021. doi : p a g e 6 | 15 basic infection prevention measures including sanitation precautions (26). a distinct advantage is the use of cicps in populations suffering from the ravages of war or natural disasters such as the democratic republic of congo and somalia. notably, cicps have been used successfully to undertake screening for cardiovascular disease in war tone countries like syria and yemen (27); this has potential application in warring african states. this versatility proves that cicps have a great utility in supporting health systems that are under pressure. in such circumstances, cicps have the potential to make an enormous difference as first-line responders and coordinating with external responders through rapid exchange of actionable data (28). this reduces the cost of emergency response since the cicps are already within the emergency situation and may take prompt actions when provided with relevant support. another successful example of the enormous potential of the cicps in emergency response applicable to african settings is the vietnamese village health collaborators who extend the reach of services beyond the formal health system (29). established in 1999 through a ministerial directive, this informal workforce has sustainably contributed to the betterment of key health indicators in addition to accelerating uhc. during the prevailing covid-19 crisis, vietnam remains one of the countries with the lowest number of cases (268 cumulative cases, 216 recoveries, and no deaths as at jun 2020). although vietnam has a limited capacity for massive testing, the cicps (village health workers) have been instrumental in surveillance, detection of cases at the grassroots, and effecting quarantine measures. the mountainous nature of vietnam renders most of the country inaccessible, hence, the vital role of the informal health workforce that resides within the community and has a better contextual understanding. in addition to providing a readily available workforce deployable in emergency situations, cicps also provide health education, hygiene and sanitation, food safety, disease prevention, maternal and child health, first aid, family planning, and implementing health programs. as such, the work undertaken by the cicps has an immense impact on uhc and could be potentially augmented through additional capacity building and support. cicps within the informal networks also have the potential to support the health of the elderly population that continues to grow rapidly in sub-saharan africa from approximately 46 million to 165 million by 2050 according to who estimates (30). family members and friends constitute part of the informal social networks with the potential for improving health outcomes for the elderly particularly when empowered and accorded the relevant support from the formal health sector. cicps have also shown much promise in the provision of rehabilitative services including traumatic brain injury (31). this potentially takes the caring burden off the formal healthcare workers as family and informal networks step in to support the rehabilitation of their loved ones. a nigerian based study also shows how cicps have been relied upon to provide rehabilitative services to children with cerebral palsy (32). though not widely acknowledged, the formal healthcare system equally utilizes cicps in meeting the care needs of hospitalised patients. more than often, family and friends provide additional care including nutrition, promoting patient hygiene, and providing ongoing psychosocial support to the hospitalized patients. for instance, a recent publication shows how cicps provided informal care to stroke patients admitted in an acute nigerian hospital (33). despite the availability of organised health services, utilisation kinsagala e, mbivnjo el, okeah bo, khan ma. community and informal care providers at the heart of universal health coverage in sub-saharan africa: a position paper (position paper). seejph 2021, posted: 17 april 2021. doi : p a g e 7 | 15 may be influenced by the complexities of socio-cultural context. the intersectionality of gender dynamics, belief systems and perceptions of health care and of health professionals are notable factors (34). uptake of existing healthcare services is fundamental in achieving the uhc agenda, hence, the need for considerations to overcome any potential barriers. however, the formal healthcare system is already overburdened and has limited capacity to navigate all the socio-cultural barriers limiting service utilization. cicps provide a unique workforce residing within the same social environment. in the context of marginalized communities, cicps are capable of providing socio-culturally acceptable and accessible healthcare services thus promoting good health and well-being. cicps have been successfully utilized in bridging health disparities as observed in a study where cicps provided parent-child interaction therapy (pcit) to treat development conduct disorders amongst latino families (35). with relevant support and training, the cicps were able to overcome social-cultural barriers by virtue of their unique positioning and effectively delivered the pcit to families that required it (36). there is a marked difference between the type of care provided by the formal healthcare workers and cicp’s. cicps provide a more personal level of care due to their closeness to the individuals under their care. care is directed appropriately since cicp’s have an intimate knowledge of the patient’s circumstances (37). the utility of cicps is equally evident in improving access to health promotion interventions that rely on informal networks in promoting health behaviour change. this is exemplified in the "health works for women" intervention where work-based natural helpers influenced women to adopt positive health behaviours namely smoking cessation, healthy eating, physical activity, and cervical screening (38). notable is the relevant training and information materials given to the natural helpers involved in this intervention. informal networks provide a suitable environment for individuals to continuously discuss their health concerns with cicps freely and obtain relevant advice. unlike in the formal healthcare system, people tend to trust their friends and peers more than a healthcare worker they have met for the first time. studies of sexual and reproductive health amongst adolescents in uganda, found that young people approached cicps about contraception and sexually transmitted diseases (stds) since they had a longer relationship with them that was built on trust and confidentiality (39). evidence has shown that gender differences may pose a challenge to accessing healthcare services thus undermining the ultimate goal of uhc. a recent study on social support and informal health networks reported a tendency for inclination towards one’s gender when seeking social support (40). mental health services also utilize cicps for continuity of services outside the formal healthcare systems. despite facing many challenges, cicps have provided care to persons with severe mental disease in ghana (41), a country with limited capacity for mental health services. another study on alternative mental health services described the vital role played by churches in promoting the mental well-being of their members (42). persons in need of mental health support tend to easily trust service providers from their socio-ethnic context. as such, it is much easier to establish a therapeutic relationship and this could significantly impact on the treatment outcomes as chronicled in "the role of the black church in the south" study (42). this is also supported by another study which demonstrated how natural helpers bridged health disparities amongst minority african american men kinsagala e, mbivnjo el, okeah bo, khan ma. community and informal care providers at the heart of universal health coverage in sub-saharan africa: a position paper (position paper). seejph 2021, posted: 17 april 2021. doi : p a g e 8 | 15 (43). informal care providers could also provide psychological support following traumatic events. this was the case following the september 11 terrorist attack where a significant number of people shared their traumatic experiences with hairdressers, librarians, and bartenders (44). cicps are also critical in the management and prevention of ntds through a series of activities including mass drug administration, health education and providing feedback on the side effects experienced by the community members (45). even in civil unrest, cicps continue to deliver care and worthy of note is the malaria testing and treatment programme during 6 years of war in the central african republic (46). in integrated community case management of childhood illnesses, cicps have provided essential treatment for diarrhoea, pneumonia and malaria in remote areas of uganda (47)and the cost evaluation of such interventions by chws in south africa showed that they can be funded from domestic health budgets (48) thereby reducing the risk of economic hardship resulting from large out-ofpocket expenditures. cicps are also very instrumental in the early diagnosis of cervical cancer (49) a growing health challenge in africa (2). criticisms and counterarguments discussions on whether or not to integrate cicps as part of the formal healthcare delivery system remain inconclusive with protagonists highlighting some perceived challenges. several cases have been highlighted in mainstream media whereby cicps masquerade as trained healthcare professionals providing substandard services and often soliciting payments for poor quality services. this may also be compounded by the weak law enforcement mechanisms in sub-saharan africa and endemic corruption that endangers the health of the unsuspecting public. it’s also been argued that cicps lack the capacity to self-regulate as professionals and often align themselves with multiple programmes provided, they earn a stipend, and this potentially compromises their effetivness as well as the set standards in care delivery. in addition, the dynamics in urban populations may make it impossible for cicps to fulfil their primary objectives. however, these challenges can be overcome through the establishment of the necessary regulatory structures to govern the capacity building of cicps, integration into the formal healthcare services, their practice, and other professional bottlenecks. cicps may occasionally feel overburdened and distressed to meet the high demands on their constantly changing roles. in addition, their lack of training prior to assuming their roles further complicates their functioning and may undermine the quality of care they provide. however, it is possible to provide the cicps with additional support and training either remotely or through organised formal learning activities. the cicps also gain knowledge and experiences through caring which are transferrable as they continue to support other members of their social networks with similar health needs undoubtedly relieving pressure from the formal health systems. involving cicps in providing mental health support services has also been criticised due to the risk of suffering compassion fatigue specifically following prolonged exposure to traumatic accounts (50) in addition to the stresses that come with this role (51). however, this can be overcome by creating the relevant psychosocial support systems for cicps to cater for their mental health needs. additionally, providing appropriate links to the formal healthcare system could make the cicps more effective especially when required to kinsagala e, mbivnjo el, okeah bo, khan ma. community and informal care providers at the heart of universal health coverage in sub-saharan africa: a position paper (position paper). seejph 2021, posted: 17 april 2021. doi : p a g e 9 | 15 escalate the care of patients requiring specialized treatments. it is important to note that informal care givers quickly transition into their roles often requiring huge adjustments that may include discontinuing school, and changing or giving up formal employment. the mental pressure associated with these sudden adjustments may overwhelm some caregivers and render them helpless (23,30,52–54). consequently, providing vital support including training of the cicps helps minimize any potential distress and make them more effective in their inevitable roles (55). although family caregiving has some therapeutic effects on the caregiver (56), looking after deteriorating patients may increase their stress levels (52) which in turn disrupts the harmonious functioning of the cicp’s family (57). informal caregivers also bear huge economic burdens due to the lack of compensation, additional expenses they incur to look after loved ones, and the opportunity costs for getting formal employment or running a business (53,58–60). another criticism for utilizing cicps is linked to the challenges associated with the recruitment and retention of this critical workforce into the formal healthcare services. a high attrition rate of the cicps has always characterized programs utilizing this approach. in some instances, resentment and lack of trust have led to the alienation of cicps. however, it is possible to overcome these challenges by carefully tailoring the cicps recruitment and deployment. as suggested by evidence from a ugandan based study (61), applying the natural helper model can potentially bolster the community's trust and cooperation with informal care providers. the burdens faced by cicps may also be overcome by adapting gender identities and enhancing generational social exchange as highlighted by a review on the care working dynamics within the complexities of widespread hiv infections and fragmented families in the east and south african regions (62). conclusion healthcare systems in sub-saharan africa face enormous challenges that could potentially slow the attainment of uhc. the constantly changing needs for sub-saharan africa’s population specifically the ballooning elderly population, acute healthcare worker shortages, widespread epidemics, and poorly equipped healthcare systems increases the need to further strengthen and expand her health workforce. notably, the acute shortage of healthcare workers significantly limits access to essential healthcare services. this calls for an urgent need to innovatively diversify and extend the reach of healthcare workers. cicps offer potential promise and can improve access to existing healthcare services by complementing the formal healthcare system. this is based on evidence of their application across different services, for example, hiv management, mental health, emergency response, rehabilitative services, chronic diseases, malaria and end of life care. undoubtedly, the demands on cicps have continued to rise with increasing life expectancy making their utility ineffective (63). despite the highlighted shortcomings, remote assistance including psychological support for cicps can potentially improve the community’s health competence, which proves invaluable in varied circumstances beyond the reach of formal health services and accelerate uhc. having considered the different points of view regarding this subject, our position on integrating and capacitating cicps as part of the formal healthcare to accelerate uhc remains the best option! kinsagala e, mbivnjo el, okeah bo, khan ma. community and informal care providers at the heart of universal health coverage in sub-saharan africa: a position paper (position 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salloum s, shaalan k. the impact of big data quality analytics on knowledge management in healthcare institutions: lessons learned from big data's application within the healthcare sector (original research) seejph 2022, posted: 22 december 2022. doi: 10.11576/seejph-6194 p a g e 1 | 17 original research the impact of big data quality analytics on knowledge management in healthcare institutions: lessons learned from big data's application within the healthcare sector rejitha ravikumar1, abdelkarim kitana2, abdallah taamneh3, ahmad aburayya4, fanar shwedeh4, said salloum5, khaled shaalan1 1faculty of engineering &it, the british university in dubai, 345015, dubai, uae; 2associate professor, human resource management department, city university ajman, uae; 3assistant professor, human resource management department, city university ajman, uae; 4assistant professor, business administration college, city university ajman, uae; 5school of science, engineering, and environment, university of salford, salford m5 4wt, uk corresponding author: dr. ahmad aburayya; assistant professor, business administration college, mba department, city university ajman, ajman, uae; email: a.aburrayya@cuca.ae mailto:a.aburrayya@cuca.ae ravikumar r, kitana a, taamneh a, aburayya a, shwedeh f, salloum s, shaalan k. the impact of big data quality analytics on knowledge management in healthcare institutions: lessons learned from big data's application within the healthcare sector (original research) seejph 2022, posted: 22 december 2022. doi: 10.11576/seejph-6194 p a g e 2 | 17 abstract it is widely acknowledged that knowledge management is critical to an organization's survival and growth. every day, higher education institutions that are considered knowledge centers generate massive volumes of data. when this data is analyzed using appropriate computational methods and technology, it can provide knowledge to improve organizational performance and students' academic experience. healthcare organizations create massive volumes of data as a result of the usage of digital technologies to manage patient information and the organization's operations. when used successfully, this data aids in the creation of information that improves patient health and everyday organizational functioning, as well as the prevention of unfavorable public health scenarios such as the spread of infectious illnesses. this is where big data analytics comes in, providing rational methods for navigating enormous quantities of data to disclose knowledge that assists businesses and analysts in making faster and better decisions. higher education, like healthcare, creates large amounts of heterogeneous data that hides useful knowledge. as a result, the strategies used by healthcare companies to improve their performance using big data are replicable in the education domain as well. this article examines the use of big data for knowledge management in healthcare using case studies incorporating various analytics and draws parallels to be applied in higher education. as a result, it highlights the possibility of adapting analytics technology and tools from healthcare to higher education with appropriate revisions and adaptations. keywords: big data, higher educational institutions, healthcare, knowledge management, big data analytics, learning analytics, education ravikumar r, kitana a, taamneh a, aburayya a, shwedeh f, salloum s, shaalan k. the impact of big data quality analytics on knowledge management in healthcare institutions: lessons learned from big data's application within the healthcare sector (original research) seejph 2022, posted: 22 december 2022. doi: 10.11576/seejph-6194 p a g e 3 | 17 introduction knowledge management is most important for the growth and sustenance of organizations (1-3). researches state that the benefits of knowledge management can only be obtained if organizations invest in the technology and also emphasize and support the other elements at the organizational level such as the cultural, and managerial elements of the organization (4–10). a proliferation of information technology has led to knowledge being generated from millions and millions of sources. some of this knowledge is not visible and available for use immediately unless techniques and technology are used to reveal the knowledge. data generated in each industry is therefore valuable for the industry as it conceals knowledge that can be harnessed to enhance organizational value. one such tool that can harness such organizational knowledge is big data analytics. figure 1 depicts the use of big data analytics in knowledge creation (11–15). figure 1: a representation of knowledge creation using big data analytics. this lays the basis for a model for the relationship of big data to knowledge creation. figure 2: from big data to knowledge creation. big data • generated from disparate sources analytical tools and technology • varying tools and technology for varied industries knowledge creation in the form of actionable insights • lessons learned from actions adds to the organizational learning and knowledge repository ravikumar r, kitana a, taamneh a, aburayya a, shwedeh f, salloum s, shaalan k. the impact of big data quality analytics on knowledge management in healthcare institutions: lessons learned from big data's application within the healthcare sector (original research) seejph 2022, posted: 22 december 2022. doi: 10.11576/seejph-6194 p a g e 4 | 17 the domain of healthcare and its institutions are multi-dimensional systems, comprising different constituents namely the healthcare professionals such as the nurses and physicians, the treatment facilities, the management offices, and other staff in these offices (16). these institutions are a knowledge-based community for sharing knowledge between its different constituents to manage better the administrative costs and the quality of care provided. it is therefore clear that these organizations can only succeed when there is a seamless creation and transfer of knowledge within the different entities of these institutions (17). the trend of digitizing healthcare workflows resulted in the creation of bulk quantities of electronic data every day from patient records, clinical processes, treatment plans, laboratory records, insurance details, and many other data sources (18) the huge amounts of data generated in these healthcare institutions can be categorized as big data due to the volume that is produced, its velocity of generation and its variety (19). this data if analyzed using appropriate methods, can result in cost savings and most importantly in astute decision-making. big data analytics can be used effectively as a technique for knowledge management in the healthcare sector. higher education institutions similarly have huge amounts of data generated from all its stakeholders including students, faculty, and staff. these institutions are constantly engaged in knowledge management processes including the creation, dissemination, and application of knowledge (20). further, these institutions are faced with changing environmental factors such as the student population, industry needs, and available funding. these organizations generate huge amounts of academic data such as details of courses offered and programs of study in addition to the data required for the daily running of the institutions. analyzing this large volume of data can benefit these institutions as well, by providing valuable insights to improve teaching and learning processes. big data analytics is similarly not restricted to healthcare or education sectors alone. most other organizations that generate huge amounts of data can also benefit from big data analytics. healthcare organizations have been known to use big data analytics not just to improve their organizational performance, but also to provide better treatment options for patients. research into the use of data analytics in healthcare organizations has further identified the areas of use in risk and disease management, precision medicine, preventing emergencies for patients, and predicting pandemics, to name a few. the healthcare sector even though producing bulk amounts of structured and unstructured data, has been one of the leaders in using big data analytics. 1. literature review 1.1 knowledge management it is well understood that globally there is an information overload. so much data and information become available in the smallest unit of time. from all this information, the actionable part is what we call knowledge. this knowledge is exemplified in the work practices, theories, skills, processes, and heuristics of the employees, students, patients, and other people involved in these sources of knowledge (21). the systematic coordination of an organization’s people, organizational structure, processes, and ravikumar r, kitana a, taamneh a, aburayya a, shwedeh f, salloum s, shaalan k. the impact of big data quality analytics on knowledge management in healthcare institutions: lessons learned from big data's application within the healthcare sector (original research) seejph 2022, posted: 22 december 2022. doi: 10.11576/seejph-6194 p a g e 5 | 17 technology for adding value to the organization through reuse and innovation can be attributed to the definition of knowledge management (21). to achieve this coordination there is a need to thoroughly create, share, and apply knowledge and also feed the lessons learned and the best practices back into the organization to continue with the organizational learning (21). knowledge management requires the use of special techniques, methodologies, and tools and techniques depending on the area of application. in any industry, robust bodies of knowledge need to be created or discovered using suitable methods and practices that work with and for knowledge (22). so, industries that generate data need to use techniques that enable knowledge to be discovered from this data. 1.2 big data analytics the origin of the term big data is disputed (23). there is a mention of the term as early as the 1990s by (24) who defined it as data that was so large and complex that it needed special computing mechanisms. gartner glossary defines big data as “high-volume, high-velocity and/or high-variety information assets that demand costeffective, innovative forms of information processing that enable enhanced insight, decision making, and process automation.” (25). this definition stresses the 3 vs that characterize big data and points to the need for special computational methods to process such data to derive useful insights from it. oxford english dictionary defines big data as “computing data of a very large size, typically to the extent that its manipulation and management present significant logistical challenges.” manyica et al., 2019 refer to data sets whose size is beyond the ability of the typical database software tools to capture, store, manage and analyze.” both these definitions emphasize the need for special methods and technology to process big data. many other definitions exist where the authors depict big data as subjective and capable of growing further with the passing years. many other researchers also convey the need to employ special computational methods in big data analysis for delivering value to organizations and other stakeholders involved in generating this data. it is because of this that big data analytics has been widely researched and applied in various industries for the past decade and later. some areas where it has been implemented in our business intelligence, crime prevention, improving travel facilities, urban informatics, meteorology, genomics, healthcare, and environmental research among other areas (26). in the healthcare sector specifically, insights gained from analyzing big data can be used to not only improve the health of individuals but also to boost the performance of the system itself (27,28). groves et al., (2016) point out that health sector data grows exponentially, due to the use of computer-based systems and also mainly due to population increase. it is therefore all the more pertinent that healthcare professionals begin using big data to its fullest capacity. the growing needs of the healthcare sector is well supported by ict and big data analytics to provide quick data analysis and decision support in its various functions. it is known that the data in healthcare is very complex as it is generated from various sources such as research, clinicians' case ravikumar r, kitana a, taamneh a, aburayya a, shwedeh f, salloum s, shaalan k. the impact of big data quality analytics on knowledge management in healthcare institutions: lessons learned from big data's application within the healthcare sector (original research) seejph 2022, posted: 22 december 2022. doi: 10.11576/seejph-6194 p a g e 6 | 17 notes, patient data in hospitals including admission and discharge notes, records from pharmacies, insurance companies, laboratories, wearable, and other devices, genomics, social media as well as research articles (29). data in the higher education setting is also complex to some extent, as it is similarly obtained from various sources such as student data, examinations, or assessment data. the successful use of big data analytics in healthcare sets a precedent for similar use in higher educational organizations. 1.3 healthcare sector and big data big data analytics opened up a wide range of opportunities for the healthcare sector to deliver better healthcare for all (30). this includes harnessing the technology of hadoop clusters to store bulk amounts of data economically or employing improved techniques and better technologists to make sense of data that meets the condition of the five vsvolume, veracity, velocity, variety, and value (31). in clinical practices, effective decision-making is a critical factor for the successful treatment of patients. the advent of big data analytics and its effective use helps to provide patient-specific health assessments and recommendations using evidence-based decisions rather than ad-hoc decisions by clinicians (31). big data analytics thus makes the clinical decisionmaking process easier and cost-effective for both the healthcare facility and the patients as it allows relatively effortless use of data recorded from various sources such as patients themselves, wearable devices, and genomics (32). big data analytics allows clinicians to identify those who are at high risk of developing chronic illnesses and helps to treat a disease even before it surfaces. this helps in unnecessary, extensive hospitalization, thus cutting down on expenses for all stakeholders including the patient and the insurance company. to enable big data analytics in the health sector, suitable predictive models are used for improving the outcomes in all areas at once. the areas in the health sector where big data analytics brings potential benefits were identified by mckinsey and company as clinical care, population health, and research and development (33). various predictive models are used to provide insights into these three areas. in clinical care, the data generated from lab testing, biometrics, insurance claims, and patient health, can be used to create risk scores. these risk scores can be used to predict the services to be rendered or to plan wellness activities for individuals (34). another case in alabama huntsville hospital combined predictive analytics and clinical decision support tools to reduce sepsis mortality in patients by more than half. duke university studied that electronic health records (ehrs) and patient registration data can be used in predictive analytics to predict patient no-shows thus enabling a better organization of the clinician’s schedule. using the ehr data and a standard questionnaire for predictive analytics, kaiser permanente, a prominent health research institute in the us, identified with accuracy, individuals at high risk for suicide attempt. at the level of the hospital executives, predictive tools help to determine and reduce variations in the ordering of supplies and their utilization. this however is at a low utilization level at the healthcare institutions (34). kaiser permanente medical network is ravikumar r, kitana a, taamneh a, aburayya a, shwedeh f, salloum s, shaalan k. the impact of big data quality analytics on knowledge management in healthcare institutions: lessons learned from big data's application within the healthcare sector (original research) seejph 2022, posted: 22 december 2022. doi: 10.11576/seejph-6194 p a g e 7 | 17 also a case in point of how the healthcare sector manages big data as it manages the data of more than 9 million members (18). sophia genetics a global leader in datadriven medicine uses analytics and artificial intelligence for several clinical needs such as identifying disease-causing mutations in genomic profiles of patients and suggesting suitable and effective care. sophia has been adopted across many countries and regions globally (18). 1.4 big data analytics in other domains business organizations of all sizes use analytics to support core business functions, such as sales and marketing, merchandising, and risk management (35). there is a dramatic data explosion in various industries as a result of the use of devices including embedded sensors, smartphones, and tablet computers that are used in conducting the daily activities of these industries. this data should be able to provide the required knowledge to improve the activities in different industries such as oil and gas, surveillance, finance, and others (36). in any domain, the data possessed are considered big data when the characteristics of volume, variety, and velocity are large for that specific domain, irrespective of whether it may be considered small in other domains (37). therefore big data may vary from domain to domain and its size would range from megabytes to petabytes. irrespective of the domain, the challenge is to be able to analyze the data for decision-making and process improvement (37). the use of big data in healthcare may contribute at different levels such as in “increasing early diagnosis and giving effective and quality treatments with early discovery of likely symptoms or signals, early intervention and reduced probability of adverse reactions or increasing the prevention of diseases by identification of risk factors or making more informed decisions for patient health and safety or the early prediction of undesirable outcomes” as reported by the study on big data in public health, telemedicine, and healthcare of the european commission (27). 1.5 big data analytics in higher educational institutions higher educational institutions have a humongous amount of data being generated regularly due to the ever-increasing digitalization of educational methods, processes, and policies. a variety of data in different formats such as audio, video, pictures, and text get stored in multiple platforms like student information systems, online data repositories including learning management systems, and other systems for administrative purposes (38). data, therefore, is vast and is produced from disparate, multiple sources. this data when consolidated and analyzed can provide useful information for various processes and individual performance improvement (39). big data analytics has been employed in certain higher educational institutions in the field of administrative decision-making, resource allocation, early identification of atrisk students, improving teaching and learning techniques, and using the data gathered regularly from the lmss, social networks, and the learning activities to transform the curriculum (40). a prominent area in which big data analytics can be usefully employed is in curriculum improvement in higher educational ravikumar r, kitana a, taamneh a, aburayya a, shwedeh f, salloum s, shaalan k. the impact of big data quality analytics on knowledge management in healthcare institutions: lessons learned from big data's application within the healthcare sector (original research) seejph 2022, posted: 22 december 2022. doi: 10.11576/seejph-6194 p a g e 8 | 17 institutions (41,42). besides, universities can improve student retention and thus minimize the loss of revenue from tuition and fees (35). data analytics in higher educational institutions fall under different categories. institutional analytics is performed on institutional data to improve performance in various organizational areas. it analytics helps to analyze other critical data which may include data about student access to it systems. academic analytics analyses data at a programmer level giving useful information about the resource utilization and other administrative functions of the programmers. learning analytics provide insights into the student learning process and is useful for improving student retention and student academic performance (38). attaran, stark and stotler, (2018), explored several successful analytics platforms in several universities in the united states with different objectives including identification and support of at-risk students, intrusive advising, identification of students missing assignments or classes, student retention and graduation, identification of possible donors to the university funds etc. these cases clearly show limited use of data analytics in these higher educational institutions where the focus is on solving either one or at most two problems. there is a gap in the integrated use of data analytics in the different areas or departments in the organization. a university needs a well-designed analytics platform that integrates data from all the different departments in the organization. this will help to easily discover and dispense insightful information for the benefit of the whole organization (43). higher educational institutions are also varied in the percentage use of data analytics. a survey conducted by kpmg revealed limited use of big data analytics in various decision-making processes (44). 1.6 knowledge gap a bibliometric mapping analysis of the current literature on big data in the two sectors of healthcare and higher education was conducted to identify the research gap through the use of the vos viewer tool. a total of 78 articles were located in the titles using the keywords “big data in higher education” or “big data in healthcare” through a search on the scopus database. the bibliometric analysis results as in figure 1 indicate that big data analytics in healthcare was more prominent than big data in higher education. the link strength and the number of keywords in healthcare analytics was a lot more than those of higher education analytics as shown in figure 2. this indicates that healthcare big data analytics is much more researched than big data analytics in higher educational institutions. it is clear that due to the need to offer the best solutions for their patients, the healthcare sector has more readily embraced cutting edge technology such as the big data analytics in different spaces within these entities. ravikumar r, kitana a, taamneh a, aburayya a, shwedeh f, salloum s, shaalan k. the impact of big data quality analytics on knowledge management in healthcare institutions: lessons learned from big data's application within the healthcare sector (original research) seejph 2022, posted: 22 december 2022. doi: 10.11576/seejph-6194 p a g e 9 | 17 figure 3: keywords in existing literature for big data in healthcare and higher educational institutions. further, it was observed that prominent keywords in the researched areas connecting big data and higher education were “digital storage”, “advanced analytics”, “data analytics”, “teaching”, “information use”, “information management”, “data analytics”, “conceptual frameworks” and “computing”. most of these keywords indicate the research direction involving learning analytics that involves performance improvement of students and at-risk prediction of student performance. figure 4: keywords in existing literature for big data and higher educatio a google scholar search showed some more research areas involving big data implementation platforms or architecture such as hadoop, mapreduce, nosql, spark, etc., learning analytics tools for collaborative and interactive learning, personalized learning, social learning, etc., predictive analytics for course selection, student performance prediction, dropout prediction, etc. and data sources for big data such as lms, moocs etc. however, a gap was noticed in an integrated approach to big data analytics as well as in suggestions for the best tools and techniques used for an integrated approach. research in to the international standards and governance that is needed for the adoption and implementation of big data analytics across the board in all higher educational institutions is necessary for such institutions to accept this tool and technology. ravikumar r, kitana a, taamneh a, aburayya a, shwedeh f, salloum s, shaalan k. the impact of big data quality analytics on knowledge management in healthcare institutions: lessons learned from big data's application within the healthcare sector (original research) seejph 2022, posted: 22 december 2022. doi: 10.11576/seejph-6194 p a g e 10 | 17 2. problem statement and solution 2.1 identification and analysis though big data analytics is employed in higher educational institutions to a varying extent, it has still not been extensively adopted across all higher educational institutions. the cost and the time required to establish the infrastructure to implement big data analytics, the necessity to employ specialist analysts to execute big data analytics and the lack of analytical knowledge among some or higher educational institutions employees are some of the reasons for the hesitancy in adopting big data analytics in higher educational institutions (45). the practical reason for the lack of implementation of the applications of big data analytics in higher education is the many different challenges that they face. these challenges need to be addressed in order for the adoption of big data analytics on a larger scale in higher education. one of the challenges is that many higher education institutions lack the appropriate technology and skills for implementing analytics and even if implemented, there is a lack of internal resources to interpret and take the data-driven insights (35). due to this they either use outsourced analytics support or, do not leverage the insights that the data or information possessed within their systems (35). however, it is seen that the healthcare sector uses big data analytics more rigorously to make informed decisions than higher educational institutions. in europe, many different solutions are available that have the potential to improve the health of individuals and also improve the outcomes of healthcare institutions. one of these, the big data analytics for precision medicine can only succeed with appropriate data acquisition and timely data analysis for detecting and preventing diseases. in most parts of the world, the healthcare sector similarly employs big data analytics to a great extent. it is also stated that big data analytics when employed requires effective and proportionate governance of health-related data and appropriate collaboration from stakeholders to modify the design and presentation of their systems to achieve the maximum potential (27). it is therefore essential to have international standards and also develop newer methods for making use of the ever-growing big data besides making the information easily available and accessible to healthcare professionals (27). healthcare sector data and higher education data are comparable due to their similarities in the disparate nature of data, the unstructured type of data, and also the bulk or volume of data generated daily. therefore, similarities can also be observed in the problems that exist in healthcare and in higher education. solutions to the problems seen in healthcare can then be adapted to the higher education sector. there is a need to enhance the use of big data analytics in higher educational institutions. the commonalities in healthcare data and higher education institutions' data make it a possibility for comparing the methods used in healthcare big data analytics to be adapted to big data analytics in higher educational institutions. the areas of use of big data analytics in healthcare can therefore guide big data analytics in higher educational institutions. for this to succeed, there is a strict need to ravikumar r, kitana a, taamneh a, aburayya a, shwedeh f, salloum s, shaalan k. the impact of big data quality analytics on knowledge management in healthcare institutions: lessons learned from big data's application within the healthcare sector (original research) seejph 2022, posted: 22 december 2022. doi: 10.11576/seejph-6194 p a g e 11 | 17 formulate international standards and appropriate governance for the adoption of big data in higher education. there is also the need to identify the best tools and platforms for each area of big data analytics in higher education institutions. 2.2 possible solutions a comparison of areas of use of big data analytics in healthcare and higher education institutions provides a direction for adopting big data analytics more in higher educational institutions. the healthcare sector even though is considerably larger in dimension compared to the higher education sector, has been more successfully adopted and thrives on big data analytics. several big companies have developed solutions for health data analytics and provide this on a commercial basis. ibm’s watson health, flatiron health’s technology-based cancer research, medeanalytics’ performance management solutions, and apixio’s cognitive health computing platforms for analyzing clinical data are some popular commercial data analytics platforms(16). besides these some specific applications exist for clinical decision support such as the help system namely the health evaluation through the logical processing system, or the qmr system for supporting physicians (46). all these research and existing applications can therefore serve as a guide for higher educational institutions in deciding their organizational policies for the adoption of big data analytics. a comparative study of the use of big data analytics in different areas of healthcare and higher education indicates that this is possible. table 1 shows the results of this comparative study. table 1: comparative study of the use of big data analytics in different areas of healthcare and higher education. level of action criteria healthcare sector higher educational institution at the customer level risk aversion through early prediction early patient-centered disease prediction prediction of academic failure through identification of at-risk students. personalized services for customer personalized patient care and health management plans personalized management plans for student academic success re-admission management monitor and follow up on patient health and use precision medicine to minimize re-admission predict student drop-out accurately and intervene early to avoid students retaking courses or entire programs. recommendation system precision medicine recommendation or healthcare provider recommendation personalized recommendation for the type of academic materials, course selection etc. at the organization level transparency and compliance with regulations. transparency in hospital management, and health records handling through well-defined analytical tools. transparency in institutional management, academic, financial, and other organizational records handling. accreditation standards maintenance of global healthcare standards. benchmarking and meeting accreditation requirements. resource optimization resource management – healthcare professionals, equipment, space, etc. resource management – faculty, space, tools, technology, etc. ravikumar r, kitana a, taamneh a, aburayya a, shwedeh f, salloum s, shaalan k. the impact of big data quality analytics on knowledge management in healthcare institutions: lessons learned from big data's application within the healthcare sector (original research) seejph 2022, posted: 22 december 2022. doi: 10.11576/seejph-6194 p a g e 12 | 17 security and risk management secure organizational networks and patient health records from unauthorized access. release of medical records only by following strict organizational and international standards. prevent unauthorized handling of student and institutional data. secure the release of student data. 3. discussion and conclusion the healthcare sector is a more willing adopter of big data technological tools for harnessing insightful information. this is essential for the sector to stay ahead in the field and to provide an enhanced service to its stakeholders. the domain of healthcare can be used to pave the way for other businesses that generate similar types of fragmented data to use big data analytics. higher education is somewhat comparable to healthcare due to the huge amounts of structured and unstructured data that is produced. this is why the methods used in healthcare for data analytics can be used in higher education as well. a comparative study of the processes in healthcare and higher education data shows many areas requiring similar attention with appropriate revisions and adaptations, knowledge, or insightful actions; therefore, the analytical methods are adaptable from the former to the latter. better management of big data analytics applications to higher education will help to improve transparency in all areas, improve educational quality and experience of all stakeholders and therefore improve the organizational stature and business value. table 2 shows some applications of big data in higher educational settings (47). these applications are all comparable to the analytics implemented in the healthcare sector (48-49). it is therefore plausible to adapt the analytics technology and tools from healthcare to higher education. table 2: application of big data in higher education institutions. criteria predictive analytics reporting and compliance analysis and visualization security and risk mitigation • predicting at-risk students and intervening early. • predicting and preventing student dropout from courses and programs of study. • predicting more accurately the applicant levels for enrolment or recruitment to programs of study. • predicting employability of students on graduation • understanding student behavior for recruitment, retention and engagement, strategic planning, etc. • meeting accreditation requirements • benchmarking for competitiveness • transparency enhancement through publishing information and making information accessible • compliance to regulations • various kinds of report generation periodically • resource optimization • improving campus services • securing institutional network and data cost-effective security ravikumar r, kitana a, taamneh a, aburayya a, shwedeh f, salloum s, shaalan k. the impact of big data quality analytics on knowledge management in healthcare institutions: lessons learned from big data's application within the healthcare sector (original research) seejph 2022, posted: 22 december 2022. doi: 10.11576/seejph-6194 p a g e 13 | 17 4. limitations and future studies this article has discussed a comparative study of implementing big data analytics in higher education institutions from the successful implementations that happen in the healthcare sector. in a future study, it is recommended to identify 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providers in the primary healthcare sector in dubai. linguist antverp 2021; 21:2995-301. 49. alsuwaidi sr, alshurideh m, al kurdi b, aburayya a. the main catalysts for collaborative r&d projects in dubai industrial sector. in: proceedings of the international conference on artificial intelligence and computer vision (aicv2021). cham: springer international publishing; 2021. p. 795–806. ____________________________________________________________ cuschieri s. the diabetes epidemic in malta (original research). seejph 2020, posted: 19 february 2020. doi 10.4119/seejph-3322 p a g e 1 | 10 original research the diabetes epidemic in malta sarah cuschieri1 1 centre for molecular medicine and biobanking, university of malta, msida, malta. corresponding author: dr. sarah cuschieri, md ph.d; address: msida, msd 2080, malta; telephone: +356 79415298; e-mail: sarah.cuschieri@um.edu.mt mailto:sarah.cuschieri@um.edu.mt cuschieri s. the diabetes epidemic in malta (original research). seejph 2020, posted: 19 february 2020. doi 10.4119/seejph-3322 p a g e 2 | 10 abstract aim: the small european mediterranean island state of malta is a highly prevalent type 2 diabetes (t2dm) country. over recent decades drastic environmental, cultural and ethnic changes occurred and it was considered timely to undergo a cross-sectional survey to establish up-to-date prevalence of t2dm, its socio-geographical distribution and ultimately estimating the economic burden of t2dm. methods: a health examination survey was conducted (2014-16) including a representative sample of the adult population stratified by 18-70 years, gender and locality (n=3,947; males n=1,997 male). the survey consisted of a socio-demographic questionnaire, various health examination measurements and blood samples for fasting blood glucose (fbg). prevalence for t2dm (depending on medical history, medication and fbg >7mmol/l) were calculated for the general population as well as for each of the districts making up the maltese islands. the economic burden of t2dm for 2017 and projected burden for 2045 were calculated using secondary sources and by incorporating 2% compound interest per annum respectively. results: a total response rate of 47.15% was obtained, with a mean age of 48 years for males and 46 years for females. out of the total adjusted population (n=3,947, male n=1,998), the prevalence of t2dm was of 10.31%, with 6.31% already known to have t2dm while 4% were newly diagnosed. females were diagnosed with t2dm at an earlier age than the males. no significant geographical t2dm prevalence differences were established. the total annual diabetes health care expenditure was approximately €107,316,517.82 for 2017, while the projected expenditure for 2045 was estimated at €244,136,040. conclusion: malta is a country with a high prevalence of diabetes. the females were observed to be at an earlier risk of developing undiagnosed diabetes compared to males. although geographical location did not appear to have significant effect on t2dm distribution, this disease contributes to a high economic burden. the expected exponential increase in diabetes prevalence is subsequently expected to affect negatively the healthcare expenditure. this puts forward the recommendation for development of early screening programmes as part of preventive action strategies. keywords: diabetes, epidemic, health care, health expenditures, mass screening, type 2 diabetes. source of funding: the author is extremely grateful for the strong support forthcoming from the university of malta (through the medical school and research innovative development trust department) and from the alfred mizzi foundation as major sponsors, as well as that of a host of others, including atlas health insurance (malta). the in-kind support and encouragement of the parliamentary secretariat for health of the government of malta is also gratefully acknowledged. acknowledgment: a note of appreciation and acknowledgement is forwarded to professor julian mamo, professor josanne vassallo and professor neville calleja for their continuous support and advice during the academic progression. conflicts of interest: none declared. cuschieri s. the diabetes epidemic in malta (original research). seejph 2020, posted: 19 february 2020. doi 10.4119/seejph-3322 p a g e 3 | 10 introduction type 2 diabetes mellitus (t2dm) is a global epidemic with an estimated 463 million adults (20-79 years) suffering from this condition in 2019 (1). the mediterranean island of malta is no exception. in malta, diabetes has been reported to be a health problem since the eighteenth century (2). the first epidemiological study aiming at assessing the prevalence of t2dm in malta was conducted in 1964 (3). in 1981, the world health organization (who) conducted the first national representative diabetes prevalence study in malta (4). more recently, a pilot study was conducted in 2010 the european health examination survey (ehes) (5). this gave an estimate of the diabetes burden in malta (5). different studies reported increasingly higher diabetes prevalence within the maltese population, often higher than neighbouring countries (1). consequently, malta was considered a mediterranean hub for diabetes (6). over recent years, malta has sustained a cultural change, with more ethnical and socio-economic diversity, and new variety in the genetic imprints, as well as a shift to a more westernised lifestyle (7). all these factors are contributors for population metabolic transition, which could possibly increase the diabetes prevalence within the maltese population (7). a national representative survey was undertaken between 2014 and 2016 to update the dysglycaemic status of malta (8). it was hypothesised that with the drastic environmental, cultural and ethnic changes that have occurred in malta over the past few decades, the prevalence of t2dm and its distribution among the population have altered from the previous studies. the aim of this study was to update the prevalence of t2dm in malta as well as to determine the sociogeographical distribution of the disease and ultimately estimate the economic burden methods the university of malta conducted a nationally representative health examination survey (2014 – 2016) entitled sahhtek (your health). the detailed study methodology can be found elsewhere (8). briefly, a population-based sample stratified by age (18-70 years), gender and locality (approximately 1% from each of the 68 towns) was obtained from a national register. the selected individuals (n=3,947; males n=1,998) with a mean age of 48 years for males and 46 years for females, were invited to participate in the survey that consisted of a previously validated questionnaire, blood pressure measurements, weight, height, waist circumference and hip circumference measurements. blood samples for fasting blood glucose and a lipid profile were also gathered. informed written consent was obtained from every participant. ethical and data protection approvals were granted from the university of malta research ethical committee (urec) and the information and the data protection national commissioner, respectively. participants obtaining a fasting blood glucose (fbg) level between 5.60 to 6.99 mmol/l were referred to as impaired fasting glucose (ifg), while those with a fbg >=7 mmol/l were considered as newly diagnosed diabetes mellitus, provided they were not previously diagnosed as diabetics or were on oral hypoglycaemic agents (9). participants with a previous history of diabetes mellitus or on oral hypoglycemic agents, irrespective of their measured fasting plasma glucose, were considered as cases of previously diagnosed diabetes mellitus. the global t2dm prevalence level was calculated by dividing the sum of newly diagnosed and previously diagnosed diabetics over the total number of participating individuals. the prevalence levels for previously diagnosed diabetes and newly diagnosed diabetes were established separately and in total. the prevalence levels were stratified by age and gender and compared to the previously reported prevalence levels by the who 1981 study (4). following the eurostat system of local administrative units (laus), the diabetes prevalence was stratified into the six districts of southern harbour, northern harbour, south eastern, western, northern and gozo districts (10). for each district, the t2dm prevalence level (global, previously and newly diagnosed t2dm) were calculated. the economic burden of t2dm was calculated by multiplying the total diabetic maltese population by the estimated mean diabetes-related expenditure per person for malta as reported by the international diabetes federation (idf) atlas in 2017 (11). this expenditure incorporated the provision of health services (preventive and curative), family planning activities, nutritional activities, emergency aid for both public and private healthcare expenditures (11). the original idf estimation for healthcare expenditure was based on the idf diabetes prevalence (an overestimation for malta), the united nations population estimates, the who annual health care expenditure and mortality rates, as well as ratios of healthcare expenditure for diabetics compared to non-diabetics (11-14). the progressive diabetes prevalence between the twohealth examination surveys (1981 and 2016) was cuschieri s. the diabetes epidemic in malta (original research). seejph 2020, posted: 19 february 2020. doi 10.4119/seejph-3322 p a g e 4 | 10 calculated, while assuming that the progressive prevalence level remained constant across the 35 years duration. this progressive prevalence level was utilized to project the diabetes prevalence for the year 2045. the previously calculated diabetes expenditure per person was also projected for the year 2045 by incorporating a 2% compound interest increase per annum (15). using the eurostat projected total maltese population for the year 2045, the projected diabetes prevalence level for 2045 was then estimated (16). this 2045 diabetes population estimate was used to estimate the diabetes economic burden. results a total of 3,947 adults (1,998 male and 1,949 female) were invited to participate in the health examination survey held between november 2014 and november 2015. of these, 1,861 adults (836 male and 1,025 female) participated, giving a response rate of 47.15% (p=<0.01). since the responders were found to be significantly different from the non-responders, a weighting factor was applied to each of the responder. the weighting factor enabled the data to maintain its representative nature by ensuring that each town was represented by 1% by each age and sex. a detailed description of the weighting protocol can be found elsewhere (8). the final weighted (adjusted) population was of 3,947 (males n=1998), of whom 10.31% (ci 95%: 9.40%-11.30%) suffered from diabetes mellitus. this included those previously diagnosed (6.31%, ci 95%: 5.59%-7.11%), as well as newly diagnosed (4.00% ci 95%: 3.43%-4.66%) diabetics. comparing this study’s results to the last nationally representative study (1981), an increase in diabetes prevalence rate was observed (figure 1). a steeper increase was observed between 1981 and 2016 amongst the newly diagnosed diabetics. a slight increase was also observed when the current study was compared to the european health examination pilot study (n=212) conducted in 2010 (total diabetes prevalence of 9.8%). on age and gender stratification of the diabetes prevalence, the female population exhibited an earlier onset of diabetes mellitus (30-39 years) when compared to the male population (40-49 years) amongst the current study population. figure 2 compares the global diabetes prevalence levels between the 1981 and 2016 studies, by age group and gender. a more evident difference in the diabetes prevalence levels could be observed between the two studies amongst the elderly population (70 years). figure 1. comparison between the diabetes prevalence rate amongst the who 1981 and sahhtek 2014 – 2016 studies 7.70% 10.31% 5.90% 6.31% 1.80% 4.00% 0% 2% 4% 6% 8% 10% 12% who (1981) sahhtek (2016) d ia b e te s p re v a le n ce total dm previously dm newly dm cuschieri s. the diabetes epidemic in malta (original research). seejph 2020, posted: 19 february 2020. doi 10.4119/seejph-3322 p a g e 5 | 10 figure 2. diabetes prevalence rates amongst the who 1981 and sahhtek 2014 – 2016 studies, by age groups and gender the diabetes prevalence differed across the six districts (p=0.10), with the northern harbour and the western districts exhibiting the highest global diabetes prevalence rates (figure 3). the southern harbour, northern harbour and gozo districts had the same newly diagnosed diabetes prevalence level of 5%. while the western, south eastern and northern districts had lower 3% of newly diagnosed diabetes prevalence level each (p=0.47) (figure 4). the western district exhibited the highest previously diagnosed diabetes prevalence level as compared to the other districts (p=0.15) (figure 4). 1% 4% 14% 32% 44% 4%4% 18% 25% 52% 0% 10% 20% 30% 40% 50% 60% 20 29 30 39 40 49 50 59 60 69 70 d ia b e te s p re v a le n ce r a te age groups (years) male population 1981 (n=79) 2016 (n=271) 2% 9% 41% 45% 3%4% 3% 7% 32% 54% 30 39 40 49 50 59 60 69 70 d ia b e e ts p re v a le n ce r a te age groups (years) female population 1981 (n=128) 2016 (n=136) cuschieri s. the diabetes epidemic in malta (original research). seejph 2020, posted: 19 february 2020. doi 10.4119/seejph-3322 p a g e 6 | 10 figure 3. global diabetes prevalence levels by district in malta 2014 – 2016 the maltese diabetes economic burden for 2017 was estimated to be €2,416 per diabetic individual per year (11). considering the global diabetes prevalence of 10.31% and the total maltese adult population for 2017 to be 430,835 people, the total annual diabetes health care expenditure was estimated to be approximately €107,316,517.82 (€97,844,351.84 – €117,621,401.68). the projected mean diabetes expenditure per individual for the year 2045 is expected to be €4,206. while, the projected global diabetes prevalence for the year 2045 is expected to be 12.47% and the total projected maltese population (2045) to be 465,440 adults. hence, the total diabetes healthcare expenditure for that year would be approximately €244,136,040. cuschieri s. the diabetes epidemic in malta (original research). seejph 2020, posted: 19 february 2020. doi 10.4119/seejph-3322 p a g e 7 | 10 figure 4. previously diagnosed and newly diagnosed prevalence rates by district a. previously diagnosed diabetes b. newly diagnosed diabetes cuschieri s. the diabetes epidemic in malta (original research). seejph 2020, posted: 19 february 2020. doi 10.4119/seejph-3322 p a g e 8 | 10 discussion diabetes mellitus type 2 is a major health and economic burden at individual, population and global levels (1,15). over 35 years (1981 to 2016), an exponential rise was observed in the diabetes prevalence rate of malta, which is consistent with the ongoing global epidemic (1). the majority of this rise is attributed to population growth and ageing (17). consequently, the economic burden of diabetes will continue to increase in the years to come, particularly among the ever-aging population. concomitantly, the global economic burden for this disease is expected to increase by 104 billion from 2017 to 2045 (11). a parallel transition is envisaged for the maltese islands, with a projected estimated increase of €136,819,523 in the economic annual burden of the disease from 2017 to 2045. even though the current and projected official idf health expenditure figures are inflated, the growing economic burden of diabetes on the health system is significant and calls for action. the geographical residing location of the maltese population may have an effect on the diabetes burden. the highest undiagnosed diabetes levels were observed within the northern harbour, southern harbour and gozo districts, even though not statistically different from the other districts, may underlie some important trends. further research is recommended with possibility of targeted preventive actions. it is well documented that undiagnosed diabetes is subject to higher healthcare usage and therefore incur a larger healthcare expenditure (1). the presence of diabetes mellitus was observed to become frequent from a relatively young age, especially for the female population in malta. considering that 1 in 10 adults in malta eventually suffer from diabetes, it is worth considering the established criteria for early screening of this condition in the population, given its frequency and impact. in spite of the fact that international guidelines suggest that routine diabetes check-ups should initiate from the age of 45 years, it is evident that for malta this should be even earlier and possibly from the age of 30 years (9). over 35 years, there has also been a shift in the gender predominance of type 2 diabetes mellitus. the current study demonstrates a male diabetes predominance contrasting with findings of the 1981 and 2010 surveys, which showed a female diabetic predominance. similarly, a female predominance was also reported by a norwegian health examination survey conducted between 1984 and 1986 with a gender shift on repeating the survey between 1995 and 1997 (18). this gender shift is in keeping with the rest of the world, where diabetes seemingly now affects more males than females (11). the male diabetes predominance has been reported to be due to an increasing obesity level, from a young age, when compared to the female population. this increase in obesity susceptibility could have been the result of a change in social factors (18). nowadays, the majority of the jobs are sedentary in contrast to the early part of the past century where jobs were more labour intensive, and travelling was done by foot or bicycle (18). furthermore, males have greater hepatic and visceral fat stores and are physiologically less insulin sensitive than females (19). therefore, one can hypothesize that males require less weight gain than females to develop t2dm, which would explain the male diabetes predominance. in fact, it was reported that biological differences between males and females are the fundamental components for the development of t2dm (20,21). however, environmental, socioeconomic and cultural factors also play a role in t2dm susceptibility and gender differences (20-22). these may be the underlying factors contributing to the high diabetes prevalence rate. it is a very intriguing fact that malta “excels” in diabetes and obesity rates when compared to neighbouring countries. malta is highly dependent on imports of foods and goods especially from sicily, which is another island in the mediterranean sea, but yet, not as diabetic prevalent as malta. this raises the question whether it is the small size of the island along with the islandness state that are contributing to such a health burden or is it the multi-cultural and environmental changes that took place in malta. this calls for further research and interventions. study limitations the response rate obtained was 47.15%. this was considered as an adequate response rate considering the invasive measurements performed. in fact, when compared to other european health examination surveys such as the czech edition of the european health examination survey (ehes) obtained a response of 31.69% (23). while the better-established shes in scotland managed a response rate of 64% from all across scotland (24). however, potential selection bias might still have occurred. responders may have been different to non-responders and it remains difficult to remove this bias altogether. the decision to conduct weighting of the data by age, gender and towns was an effort to try to maintain the representation characteristics. even though the population data was weighted, some subgroups still cuschieri s. the diabetes epidemic in malta (original research). seejph 2020, posted: 19 february 2020. doi 10.4119/seejph-3322 p a g e 9 | 10 remained with small numbers. this may have affected the power of specific subgroups statistical testing, resulting in possible type ii errors. considering that the data collection took place over a period of oneyear, seasonal variations may have had an effect on the response rate as well as on the biological measures, such as blood pressure, fbg, blood lipid levels, bmi and waist circumference. the study was a health examination survey and hence clinical diagnosis could not be established. however, being a health examination survey high-risk population for particular conditions could be identified. the study does not cover the whole population but only a subset of the adult population. general demographic data was based on the published reports from 2013. the mean diabetes expenditure per individual was based on the idf’s maltese specific cost, which was generated from multiple sources. however, this expenditure did not differentiate between newly diagnosed and previously diagnosed diabetes, as well as it was based on overestimation of diabetes prevalence rate. the cost did not take in consideration intangible costs, which is difficult to quantify. the projections for 2045 were based on current conditions with the assumption that all demographic and risk factors would continue at their current rates. conclusion type 2 diabetes is an epidemic in malta same as globally. the onset of newly diagnosed diabetes appears to affect females from the very young as the fourth decade of life irrespective of their geographical habitat. furthermore, as the years progress, so do the estimated health expenditure contributed to this disease. this puts forward the recommendation that urgent preventive action is merited to tackle diabetes at a population level targeting the young generation. such action would consequently reduce the health burden on the health care system and economy. references 1. international diabetes federation. idf diabetes atlas 9th ed. brussels, belgium; 2019. 2. savona-ventura c. mortality trends from diabetes mellitus in a high prevalence island population. int j risk saf med 2001;14:8793. 3. zammit maemple j. diabetes in malta. lancet 1965;2:1197-200. 4. katona g, aganovic i, vuskan v, skrabalo z. national diabetes programme in malta: phase i and ii final report. geneva: world health organization; 1983. 5. directorate for health information and research. the european health examination survey pilot study 2010; 2012. 6. cuschieri s, mamo j. malta: mediterranean diabetes hub – a journey through the years. malta med j 2014;26. 7. formosa c, savona-ventura c, mandy a. cultural contributors to the development of diabetes mellitus in malta. int j diabetes metab 2012;20:25-9. 8. cuschieri s, vassallo j, calleja n, pace n, mamo j. diabetes, pre-diabetes and their risk factors in malta: a study profile of national cross-sectional prevalence study. glob health epidemiol genom 2016;1. available from: https://doi.org/10.1017/gheg.2016.18 (accessed: december 10, 2019). 9. american diabetes association. classification and diagnosis of diabetes: standards of medical care in diabetes 2018. diabetes care 2018;41:13-27. 10. national statistics office. regional statistics malta. valletta; 2017. 11. international diabetes federation. idf diabetes atlas, 8th ed. brussels, belgium; 2017. 12. world health organization. global health expenditure database. 2017. 13. world health organization. projections of mortality and burden of disease 2002 to 2030. 2006. 14. zhang p, zhang x, brown j, vistisen d, sicree r, shaw j, et al. global healthcare expenditure on diabetes for 2010 and 2030. diabetes res clin pract 2010;87:293-301. available from: https://doi.org/10.1016/j.diabres.2010.01.02 6 (accessed: december 10, 2019). 15. cuschieri s, vassallo j, calleja n, pace n, abela j, ali ba, et al. the diabesity health economic crisis-the size of the crisis in a european island state following a crosssectional study. arch public health 2016;74:52. available from: https://doi.org/10.1186/s13690-016-0164-6 (accessed: december 10, 2019). 16. eurostat european commission. eurostat country projections 2016. avilable from: http://ec.europa.eu/eurostat (accessed: may 23, 2019). https://doi.org/10.1017/gheg.2016.18 https://doi.org/10.1016/j.diabres.2010.01.026 https://doi.org/10.1016/j.diabres.2010.01.026 https://doi.org/10.1186/s13690-016-0164-6 cuschieri s. the diabetes epidemic in malta (original research). seejph 2020, posted: 19 february 2020. doi 10.4119/seejph-3322 p a g e 10 | 10 17. ncd risk factor collaboration (ncdrisc). worldwide trends in diabetes since 1980: a pooled analysis of 751 populationbased studies with 4.4 million participants. lancet 2016;387:1513-30. available from: 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reventlow s, malterud k, et al. the impact of gender on the long-term morbidity and mortality of patients with type 2 diabetes receiving structured personal care: a 13 year follow-up study. diabetologia 2016;59:275-85. available from: https://doi.org/10.1007/s00125-0153804-4 (accessed: december 10, 2019). 23. čapková n, lustigová m, kratěnová j, žejglicová k, kubínová r. selected population health indicators in the czech republic – ehes 2014. hygiena 2017;62:35-7. available from: https://doi.org/10.21101/hygiena.a1511 (accessed: december 10, 2019). 24. scottish government. the scottish health survey. edinburgh; 2016. ______________________________________________________ © 2020 cuschieri; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://doi.org/10.1016/s0140-6736(16)00618-8 https://doi.org/10.1016/s0140-6736(16)00618-8 https://doi.org/10.1007/s001250051573 https://doi.org/10.1016/j.genm.2009.02.002 https://doi.org/10.1210/er.2015-1137 https://doi.org/10.1186/2042-6410-3-13 https://doi.org/10.1007/s00125-015-3804-4 https://doi.org/10.1007/s00125-015-3804-4 https://doi.org/10.21101/hygiena.a1511 federman l, wilhelm m, strohmaier l, rodriguez af, middleton j. out of cars, onto the cycle paths: aligning granada’s traffic infrastructure with the european green deal (policy brief). seejph 2023. posted: 09 april 2023 p a g e 79 policy brief out of cars, onto the cycle paths: aligning granada's traffic infrastructure with the european green deal larissa federmann1, merle wilhelm1, lena strohmaier1, andrea fiallos rodriguez1, john middleton2 1department of international health, governance and leadership in european public health master, faculty of health medicine and life sciences, maastricht university, maastricht, the netherlands.these authors contributed equally to this work; 2association of schools of public health in the european region. corresponding author: larissa federmann address: universiteitssingel 60, 6229er maastricht, the netherlands; email: l.federmann@student.maastrichtuniversity.nl federman l, wilhelm m, strohmaier l, rodriguez af, middleton j. out of cars, onto the cycle paths: aligning granada’s traffic infrastructure with the european green deal (policy brief). seejph 2023. posted: 09 april 2023 p a g e 80 abstract if greenhouse gas emissions are not sharply reduced, air pollution, extreme weather events, and desertification in southern spain will occur, along with many deaths, and collapses of the health system and the country’s main economic sectors, agriculture, and tourism. the european union adopted a strategy in 2019 with a series of environmental policy initiatives to protect the population from climate change hazards as ‘the green deal’.this strategy provides funding opportunities for granada, one of spain's most polluted and climate change-vulnerable cities, to reduce its high emissions of harmful greenhouse gases from transport. a spacious, well-connected, and safe cycling infrastructure is needed. new on-road cycle lanes and cycle paths with planted barriers to the car lane should be constructed. an e-bike sharing system can also enable people with special needs to cycle in the hilly city and drive tourism. extensive participation opportunities and assessments of disparate impacts on access and health outcomes of different population groups need to be used to ensure that existing inequalities are not exacerbated. keywords: climate change;cycling;european green deal; granada;sustainabletransport. federman l, wilhelm m, strohmaier l, rodriguez af, middleton j. out of cars, onto the cycle paths: aligning granada’s traffic infrastructure with the european green deal (policy brief). seejph 2023. posted: 09 april 2023 p a g e 81 introduction over the last 30 years, europe has recorded the highest temperature increase in the world. according to the world meteorological organization (wmo)’s 2021 report, this increase is more than twice the global average(1). if this trend continues, the consequences of warming, such as forest fires, floods, or exceptional weather, will have negative impacts on ecosystems, the economy, and on society’s health(1, 2). the intergovernmental panel on climate change in 2022 has shown that spain is one of the most vulnerable european countries to climate change, especially regarding water stress, wildfires, and more severe heat waves. consequently, there is a greater risk of heat waves worse than the one in 2003, which caused around 6,500 to 8,600 deaths in spain, and cost about 810 million euros in the agriculture sector alone (3, 4). at the same time spain is one of the five eu countries with the highest greenhouse gas emissions(5). most greenhouse gases in spain are emitted in the transport sector(6). if greenhouse gas emissions are not reduced, spain's health system will collapse in the coming decades and by the end of the century, southern spain will become a desert(7, 8). furthermore, climate change can also lead to a decline in tourism, which will impact the spanish economy enormously, considering it is the second most visited country in the world. tourism constituted 11.7% of the country’s gdp(9). according to the eurobarometer survey on mobility and transport(2020), the share of cycling in daily mobility as the main mode of transport is 8% on average in europe(10). however, spain has not yet reached this level, its share is 2%. in this study, electric scooters are also counted under bicycles. thereby spain is one of the three countries in the eu where, with over 70%, most car drivers can imagine switching to environmentally friendly modes of transport for their daily mobility(10). nevertheless, inter-modality, which describes movement by more than one mode of transport during a single journey, is a topical issue in most spanish cities(10, 11). about 66% of the population support an alternative mobility policy to the one that gives priority to the car, although they are not culturally attached to cycling(10). the federman l, wilhelm m, strohmaier l, rodriguez af, middleton j. out of cars, onto the cycle paths: aligning granada’s traffic infrastructure with the european green deal (policy brief). seejph 2023. posted: 09 april 2023 p a g e 82 latter became evident in the barometer report 2022 in spain(12). accordingly, a third of spanish people consider the car the fastest way to move in their location. however, in comparison to other regions, more people cycle in andalusia than the spanish average. furthermore, among regular cyclists, cycling is now the second most mentioned mode of transport after the car which shows its positive and potential impact(12). under the condition that the sustainable form of transport is less expensive than car use, students in particular can imagine driving less with their cars in the cities(10). as a university city, granada has numerous student population and thus potentially a great willingness to change their mobility habits(13). through more sustainable mobility, the effects of the temperature rise due to climate change and air pollution, which affect granada more than other cities in spain, could be minimized. granada is one of the three most polluted cities in spain(1416).the european environment agency estimates that 338 premature deaths in granada in 2019, could have been prevented if the who air quality guidelines had been met(17, 18).granada is located in a valley. it receives 350mm of precipitation per year, making it one of the cities with the least rainfall in spain. this means there are few ways to remove pollutants from the atmosphere naturally(19). as a response to climate change at a european level, in 2019, the european commission approved a series of environmental policy initiatives: the european green deal. it aims to protect all living beings from climate change-related hazards. at the same time, this strategy seeks to strengthen the economy through rebalancing and creating new jobs(20). in granada, most of the greenhouse gases are emitted by the transport sector(19), which exacerbates the nitrogen dioxide (no2) levels in the atmosphere, a greenhouse gas that is highly harmful to health(17). no2 causes various lung and cardiovascular diseases(17, 21, 22). therefore, granada’s city council, ayuntamiento de granada, should make more efforts for a stronger reduction of greenhouse gas emissions from transport, aligning with the goal of the green deal’s sustainable and smart mobility federman l, wilhelm m, strohmaier l, rodriguez af, middleton j. out of cars, onto the cycle paths: aligning granada’s traffic infrastructure with the european green deal (policy brief). seejph 2023. posted: 09 april 2023 p a g e 83 strategyofreducing mobility-related greenhouse gas emissions by 90% by 2050(23). context transportin granada it is estimated that in granada 79% of the population uses cars, while only 13% reach their destination by bicycle or by foot(24, 25). this is because the metropolitan street system in granada is designed to favour motor vehicle access over other types of sustainable mobility (25). the city has only 15 km of bike lanes that are not connected and are not very functional(26). in granada, the urban sustainable mobility plan was adopted in 2012, but the interventions introduced under the plan have only been partially successful(27). the walkability of the city is high and the public transport network in the city of granada is now excellent (25, 28). with around 97% of the population living within 240 meters of a bus stop. besides the buses, which are partly replaced by low-emission electric buses (29), a high capacity line (lac) and since 2017 a tram (metropolitano) can also be used in granada. the tram is considered successful due to 11 million users in the first year and an estimated annual saving of 3,234 tonnes of co2 through 8,000 less-used vehicles in granada every day(28, 29). in contrast, interventions to promote cycling were just rarely implemented and showed little success(24, 30). the number of motorized private vehicles remains high, and the share of bicycles of all vehicles in transport has only increased from 4.6% to 4.9% between 2017 and 2021 (24, 26). one reason for this is insufficient funding, which has led to a limitation on low-cost interventions such as traffic signalling, safety-focused bicycle training, and traffic restriction in key areas (24, 31, 32). the funding opportunities of the eu green deal should be used to close this funding gap and make cycling a more attractive option to the car.because compared to private motor vehicles, bicycles emit virtually no co2 or no2 emissions during their operation(33). furthermore, there are health and economic benefits if more people use bicycles instead of private cars for urban journeys. on the federman l, wilhelm m, strohmaier l, rodriguez af, middleton j. out of cars, onto the cycle paths: aligning granada’s traffic infrastructure with the european green deal (policy brief). seejph 2023. posted: 09 april 2023 p a g e 84 one hand, the expansion of the cycling sector will create more local jobs for lowerskilled workers than in the motorized transport sector(34). in 2021, almost 7,800 unemployed were registered with job applications in the areas of transport and communications or commerce and repairs(35). on the other hand, studies have shown that in cycling-friendly areas the economy of local shops, cafés, or other businesses can increase due to the higher frequency of visits by cyclists than by people using other means of transport.for example, the installation of protected bicycle lanes at 8th and 9th avenues in manhattan correlated with a 49% increase in retail sales(34). the health benefits of switching from motorized transport to cycling are also extensive(36). air pollution can be reduced by 2-4% for every 1% travelled by bicycle instead of motorizedvehicles(37). in addition, a meta-analysis showed that weekly cycling of 2.5h reduces mortality risk by around 10%(38). a large share of existing public health crises such as diabetes, obesity, and increasing rates of respiratory disease is exacerbated by carcentric urban design and planning (39). inequalities the described adverse health effects of the climate crisis and transport infrastructure do not affect all population groups equally.concerningthe impacts of climate change, inequalities cause disadvantaged groups to suffer disproportionately from the negative, which, in turn, leads to greater inequality(40). because of their pre-existing multimodal inequalities, disadvantaged people are more vulnerable to damage caused by climate conditions. for example, their housing situation or reduced access to resources may leave them unable to protect themselves from environmental disasters. ultimately, they have fewer opportunities to recover from or to cope with environmental consequences(40).other important social determinants of healthare affecting the health of vulnerable people as a consequence of extreme metrological events according to their age, health status, and living conditions (see figure 1). federman l, wilhelm m, strohmaier l, rodriguez af, middleton j. out of cars, onto the cycle paths: aligning granada’s traffic infrastructure with the european green deal (policy brief). seejph 2023. posted: 09 april 2023 p a g e 85 figure 1. climate-sensitive health risks and their vulnerability factors(41) in the city of granada, 26% of the 230,000 residents are unemployed. thereby, granada has the third highest unemployment ratein spain, and the province granada is the third province with the lowest gdp in spain(42). according to bienvenido-huertas et al., (43)granada has a large combination of energy needs because of its variable climatic conditions and a relatively high proportion of people living in financial poverty. this is especially true given the current increase in gas and oil prices due to the ukraine war(44).with rising gas prices, providing people with a safe and attractive alternative to driving allows more spending for recreational activities, which has a positive impact on both the health of the people and the local economy as well(39). thus, people from low-income neighbourhoods, which are situated mainly in the north of the capital, have a disproportionately higher mortality rate by chronic obstructive pulmonary disease (copd) or ischemic heart disease than wealthier regions(45). overall, in 2019, the main cause of mortality in the province was heart disease, accounting for 29% of the deaths, followed by cancer (25%) and respiratory diseases (11%) which are the diseases most related to air pollution(46). federman l, wilhelm m, strohmaier l, rodriguez af, middleton j. out of cars, onto the cycle paths: aligning granada’s traffic infrastructure with the european green deal (policy brief). seejph 2023. posted: 09 april 2023 p a g e 86 funding there have been many attempts to promote bicycle use to address the presented issues, the latest one being a cycling strategy approved in 2021 with a budget of 5 million euros. however, 2 million euros will be used for road networks. compared to other countries in europe, spain’s budget for implementing bicycle lanes is limited(47). therefore, granada’s city council should use the funding opportunities of the green deal. a total of €1 trillion euros will be made available under the green deal. this funding will come from the eu's nextgenerationeu (ngeu) program and cohesion policy. as established, at least 30% to 37% (ngeu) of the money received by member states must be invested in climate action. in addition, the investeuprogram stipulates that at least 30% of all public and private investments must be made under the green deal(48). for achieving the goal of reducing greenhouse gas emissions from transport in granada that are harmful to health and the environment, it is crucial to create a joint policy with the european regional development fund (erdf), which provides funds to poorer regions for connected and environmentally friendly transport infrastructure(49). this funding provides an opportunity for spain, one of the poorest countries in the eu, especially in granada, a city in spain's poorest region, andalusia, to implement changes that will contribute to the mitigation of the climate change effects(50, 51). policy options the overall objective of the city council,ayuntamiento de granada, should be to transform the car-centred transport infrastructure into a cycling-centred one, align with the eu sustainable and smart mobility strategy, to address the problems described above. as can be seen in figure 2, there are only a few cycle lanes and paths in granada, which are often disconnected and do not form a sufficient cycle network(28). federman l, wilhelm m, strohmaier l, rodriguez af, middleton j. out of cars, onto the cycle paths: aligning granada’s traffic infrastructure with the european green deal (policy brief). seejph 2023. posted: 09 april 2023 p a g e 87 figure 2.granada’s cycling infrastructure(52) red = cycle lane; blue = pacified lane; bright red = other municipalities;purple = cycle street yellow = cycle-rail-bus-vmp (personal mobility vehicles); green = cycle path however, the construction of cycle paths can significantly increase the proportion of cyclists(53). in lisbon, for example, an extensive expansion of the cycling network in 2016 and 2017 increased the cyclists' volume by 3.5 times(54). considering the space constraints that are present in the historic areas of granada, it would be suitable to use the existing car lanes for on-road bicycle lanes. the number of traffic accidents could also be reduced with this intervention. a study in north carolina, for example, calculated a three to four times lower risk of bicycle accidents on on-road bicycle lanescompared to car lanes without bicycle lanes on the road (55). in granada, almost 90% of the 60-70 bicycle accidents per year between 2015 and 2017 happened on roads without bicycle lanes(28). in a survey in dublin with 1941 participants from the business sector, 56.4% stated that the implementation of connected on-road cycle lanes would encourage them to cycle to work in the future(56). the use of cycle lanes is particularly high when there is a barrier to the car lane(57). federman l, wilhelm m, strohmaier l, rodriguez af, middleton j. out of cars, onto the cycle paths: aligning granada’s traffic infrastructure with the european green deal (policy brief). seejph 2023. posted: 09 april 2023 p a g e 88 on roads with more space, plants could ideally be used as barriers. indeed, vegetation along the cycle lane reduces the exposure of cyclists to air pollutants(58). in addition, plants along roadsides make cycling more attractive(59, 60). an attractive cycling infrastructure promotes not only cycling but also e-biking. especially people who cannot or do not want to ride a bike due to age or a hilly orography, like in granada, use e-bikes as a climate-friendly alternative in transport(61). due to the high initial costs of bicycles and e-bikes, it was beneficial that in 2017 the two global bike-sharing companies ofo and obike stationed bicycles in granada and obike planned to expand their fleet to include e-bikes. however, both companies had major problems with vandalism and withdrew their bikes from granada (28, 62).nevertheless, the introduction of a new e-bike sharing system in granada could also lead to an increase in tourist frequency at tourist locations (63, 64). there is sporadic evidence that interventions such as membership cards to accurately identify bike users can reduce the risk of vandalism (65). however, the evidence base on this is currently still insufficient, and further research is needed. for the described infrastructural interventions to be accepted by the citizens of granada and to address their needs, community participation is necessary.the perception of the transport infrastructure and social norms in the population, as well as the special needs of different population groups, must be identified (66). this is crucial becauseinterventions can quickly exacerbate existing inequalities. several different methods for community participation can be used and should go beyond informing(67). in participatory processes, questions such as whether the 318 bike lots in granada are sufficient for an expansion of the bicycle infrastructure or whether enough userfriendly charging stations for e-bikes are available, should be clarified (68). in addition, the question whether the transition from cycling to public transport is perceived as easy and comfortable in terms of multimodal transport could be also interesting to look at. furthermore, the participants of the cycling training of the city council of granada should be asked why the training could not increase their federman l, wilhelm m, strohmaier l, rodriguez af, middleton j. out of cars, onto the cycle paths: aligning granada’s traffic infrastructure with the european green deal (policy brief). seejph 2023. posted: 09 april 2023 p a g e 89 cycling behaviour and how it can be improved(69). besides participation, it is also important to assess the impact of the interventions on different population groups in granada. to assess how equitably distributed the expansion of the bicycle network is, the tool by cunha and silva(70)can be used, while a health impact assessment is suitable for assessing the health impacts of the interventions(71). limitations one of the limitations of the presented policy brief, is that the authors based their knowledge on published data and scientific surveys and therefore could not form a picture of the reality in granada. furthermore, the culture on cyclingisdifferent, which complicates possible reflections. the culture could also make it difficult to change people's attitudes towards cycling and encourage more people to use bicycles as a mode of transportation(10). in addition, cycling culture and infrastructure are constantly evolving and changing, thus it is important to check the most recent information available. it depends on various factors and is difficult to gather in a snapshot. at last, the proposed intervention must consider that the changes are not appropriate for all people. for example, blind people or people with no mobility capacity are more likely to still not be able to make their own mobility choices. conclusion harmful greenhouse gas emissions from motorizedtraffic are particularly damaging to the economy, environment, and health of the population in spain and especially granada. granada's city council should improve the cycling infrastructure. in narrow areas, there should be on-road cycle lanes, and in more spacious areas cycle paths with planted barriers to the car lane. it should be clarified how an e-bike sharing system can be set up that is safe from vandalism. furthermore, the needs of the population should be included in the intervention planning and the impact of the interventions on different population groups should be analysed. conflicts of interest federman l, wilhelm m, strohmaier l, rodriguez af, middleton j. out of cars, onto the cycle paths: aligning granada’s traffic infrastructure with the european green deal (policy brief). seejph 2023. posted: 09 april 2023 p a g e 90 none declared acknowledgments the authors would like to thank katarzyna czabanowska and dimitri eerensfrom maastricht university for their expertise and continuous support throughout the leadership course. they would also like to thank alberto fernández and ariane bauernfeind from the andalusian school of public health for their helpful and constructive feedback. without the contribution of all these people, the work would not 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(policy brief). seejph 2021, posted: vol. xx. p a g e 94 71. mueller n, rojas-rueda d, cole-hunter t, de nazelle a, dons e, gerike r, et al. health impact assessment of active transportation: a systematic review. preventive medicine2015 2015/07/01/;76:103-14. _____________________________________________________________________________________ © 2023 federmann et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. maviglia a, bitar e, schmidt j, winters p, de souza s, clemens t. hpv vaccines: call for a european change to tackle current and future shortages (policy brief). seejph 2023.posted: 09 april 2023 page 19 policy brief human papillomavirus vaccines: call for a european change to tackle current and future shortages arianna maviglia1, elvis bitar1, jelena schmidt1, philippe winters1, sander de souza1,2, timo clemens1 1department of international health, governance and leadership in european public health master, faculty of health medicine and life sciences, maastricht university, maastricht, the netherlands; 2europubhealth+ joint diploma master in european public health, rennes, france. all authors contributed equally to this work. corresponding author: sander de souza address: sorbonnelaan 184, 6229 hd maastricht, the netherlands; email: sby.desouza@student.maastrichtuniversity.nl mailto:sby.desouza@student.maastrichtuniversity.nl maviglia a, bitar e, schmidt j, winters p, de souza s, clemens t. hpv vaccines: call for a european change to tackle current and future shortages (policy brief). seejph 2023.posted: 09 april 2023 page 20 abstract context there is a global human papillomavirus (hpv) vaccine shortage until 2024. the world health organization recommended a temporary suspension of hpv vaccination for boys until all girls who need the vaccine can get it. in the european union (eu), practices to define and monitor hpv vaccine shortages differ between the member states. prior policy initiatives were insufficient to address current vaccine shortages. policy options different policy options are recommended, divided into three self-developed clusters: prevention, response, and supply side. the policy options for the prevention part include decentralised surveillance and centralised surveillance. the policy options for the response part include dose sparing, eu joint procurement, postponing injection for young children, postponing vaccination for boys, and prioritisation in favour of lowand middle-income countries. the policy option for the supply side part is novel procurement agreements. recommendations a traffic light system to assist policymakers has been developed. the traffic light system recommends when policymakers should implement the suggested policy options. the traffic light system describes four stages: green light (shortage prevention); amber light (imminent shortage prevention); red light (shortage management); shortage lessons. these recommendations will improve eu crisis management. keywords: healthcare disparities; hpv; papillomavirus infections; papillomavirus vaccines. maviglia a, bitar e, schmidt j, winters p, de souza s, clemens t. hpv vaccines: call for a european change to tackle current and future shortages (policy brief). seejph 2023.posted: 09 april 2023 page 21 introduction the human papillomavirus (hpv) is a deoxyribonucleic acid (dna) virus species that include more than 200 identified genotypes. its transmission is skin-to-skin, mostly during sexual intercourse. most hpv infections are asymptomatic. some types of hpv cause benign skin and genital warts. others are responsible for 99% of all cervical cancers but are also part of other anogenital (vulva, vagina, penis) and oropharyngeal cancers (1). in 2020, in the 27 countries of the european union (eu), more than 30,000 cervical cancer cases have been diagnosed, and more than 13,000 women died of this disease (2). the incidence rate (age-standardised to the european population) was 12.8 new cases per 100,000 women annually, with important disparities between countries; the two extreme rates were malta (5.7) and romania (32.3) (2). the mortality rate was 5.3 deaths per 100,000 women annually, with the same critical disparities between countries, from finland (2.1) to romania again (16.9) (2). with the introduction of hpv vaccination, a significant decrease has been shown in terms of hpv infections and cervical neoplasia for women, along with anogenital warts for women and men (3). in australia, the first country in the world to implement hpv vaccination in 2007, an elimination of cervical cancer (defined by four new cases per 100,000 women annually) is expected in 2028 (4). in the european region, the world health organization (who) published a 2022-2030 roadmap towards the elimination of cervical cancer (5). the who has focused on hpv vaccination (6–8) and has called for the elimination of cervical cancer (7). the triple target to meet by 2030 is the following: 90% of girls fully vaccinated by 15 years of age; 70% of women screened by 35 and 45 years of age; 90% of diagnosed women receiving treatment (5). likewise, the goal of the europe beating cancer plans is to vaccinate at least 90% of the eu target population (8). context hpv vaccination shortage there is a global shortage of hpv vaccines (9). the shortage will have a serious impact on girls at risk of contracting maviglia a, bitar e, schmidt j, winters p, de souza s, clemens t. hpv vaccines: call for a european change to tackle current and future shortages (policy brief). seejph 2023.posted: 09 april 2023 page 22 cervical cancer living in lowand middleincome countries (lmics)(10), and is therefore risking the achievement of the elimination goal by the who (11). to a lesser extent, even the eu experiences the effects of this shortage, above all in its countries with the lowest income such as romania (12,13). according to sibiliaquilici, executive director of vaccines europe, the main reason for this shortage is the increase in demand. “there has been a five-year period of stable demand with regard to hpv, and suddenly, in 2018, the demand doubled”, she said (14). challenges in addressing the doses shortage to circumvent major step backs in the achievement of the 2030 elimination plan, the who’s strategic advisory group of experts (sage) recommended a temporary suspension of hpv vaccination for boys, to prioritise girls living in countries where the burden of cervical cancer is high. however, most european countries are not following this advice and are implementing a genderneutral vaccination program (11). another challenge which became apparent is the lack of comparable data on hpv vaccination in the eu. currently, the definition of coverage of hpv vaccines varies between the member states, as does the information systems of shortages and the requirements for shortage notification (table 1). this makes it difficult to quantify the demand for hpv vaccines and the number of vaccine shortages (15,16). lastly, no country offers any data on stocks of hpv vaccines (table 1). the differences in definitions, indicators, and monitoring systems result in a barrier in comparison and preclude the eu from preventing and adequately responding to vaccine shortages. these challenges pose a problem today and set challenges for tomorrow: planning an eu strategy, setting targets and indicators when there is a lack of data and definitions change between eu countries; foreseeing shortage without comparable national or supranational surveillance; reacting to an existent shortage while aiming for the vaccination targets set out in the strategies/initiatives. maviglia a, bitar e, schmidt j, winters p, de souza s, clemens t. hpv vaccines: call for a european change to tackle current and future shortages (policy brief). seejph 2023.posted: 09 april 2023 page 23 table 1: examples of information about hpv vaccination in five eu countries country definition of hpv vaccine coverage indicators or data on vaccine hesitancy hpv vaccine stocks measures information on the current shortage finland proportion of boys or girls who received one dose of an hpv vaccine. it assesses how many boys or girls have received the vaccine in the specific year they were born (e.g. 2008, 2009, 2010…). individuals older than 15 need three doses. however, coverage is only shown for one dose (17,18) charts on vaccine hesitation and underlying reasons. it also collects data on changes in vaccination coverage per region (19) no data searchable database (20) france two categories: “at least one dose at 15 years old” and “complete vaccination at 16 years old” (taking into consideration two doses before 15 years old and three doses after)(21) national and local studies. some quantitative and qualitative data about vaccination hesitancy among specific groups, such as general practitioners (gps) and families (22–24) information available on the website of the french medicines agency (25) no information about an hpv vaccine doses shortage on the french medicines agency website germany percentage of girls/boys aged 15/18 fully vaccinated (depending on their age, whether two or three times)(26) no data from the government; different studies assess vaccination hesitancy (27,28) no data the paul-ehrlich institute (pei) provides information on current vaccine supply shortages (29) maviglia a, bitar e, schmidt j, winters p, de souza s, clemens t. hpv vaccines: call for a european change to tackle current and future shortages (policy brief). seejph 2023.posted: 09 april 2023 page 24 italy italy measures vaccine coverage by assessing how many people born in a specific year received the vaccine, starting from the year they were eligible until today (30) independent researchers conduct surveys, interviews, and questionnaires to measure vaccine hesitancy among parents. data on vaccine hesitancy are not published by the government (31) no data the italian medicines agency publishes a “list of medicines currently in short supply”, which is periodically updated (32) netherland s vaccination coverage is determined at 14 years of age and without age limit, by birth cohort with two doses over five months apart in percentage (33) the national institute for public health and the environment (rivm) performs studies about both acceptance of the national immunisation programme and specific vaccines as well as the intention to receive vaccination (33) no data no data this policy brief addresses the european commission and the member states and advocates for a change at the eu level to be more resilient and to tackle the current and future hpv vaccine shortages. policy options the policy options can be separated into three self-developed clusters: i. “prevention”: what to do to prevent future vaccine shortages. ii. “response”: what to do when there is a vaccine shortage. iii. “supply side”: what changes are needed for the side of the suppliers. cluster i – prevention: surveillance and monitoring a common framework with standard definitions of indicators, the same for each country, is needed to, first, better monitor demand and supply and flag up mismatches leading to shortages, and, second, assess where, in times of shortages, vaccines could be temporarily suspended and redistributed. the following table (table 2) shows possible indicators. the surveillance could be performed decentralised or centralised. maviglia a, bitar e, schmidt j, winters p, de souza s, clemens t. hpv vaccines: call for a european change to tackle current and future shortages (policy brief). seejph 2023.posted: 09 april 2023 page 25 table 2. list of potential indicators for decentralised surveillance category indicator demography ● composition of the population for each birth year and gender vaccination reserves and use ● number of doses delivered ● number of doses administered by birth year and gender ● number of doses expired (so discarded) ● number of doses that left the territory vaccination coverage by birth year and gender (from n-11 to n-25) ● at least one dose (all ages) ● two doses out of three (more than 15 years only) ● complete vaccination (two or three doses, depending on the age) option ia – decentralised surveillance with a decentralised framework, the eu is setting the indicators (exemplarily, table 2), but each member state is responsible for surveying and monitoring themselves. the decentralised framework is mostly aimed at shortage prevention to see when the available national stocks are not sufficient to fill the demand. option ib – centralised surveillance in a centralised surveillance framework, an eu body would collect the hpv vaccine data to develop an overview of the current hpv uptake and shortages in the member states. there are some observable developments, upon which a centralised framework for an emergency situation can be built. in 2021, the european cancer organisation’s hpv action network addressed the urgency of developing an hpv vaccine tracker by the european centre for disease prevention and control (ecdc). this system would provide an overview of the continuous information on the hpv vaccine coverage of the eu member states (8). following the covid-19 pandemic, developments to harmonise shortage notifications can be observed. the establishment of a harmonised system of monitoring shortages of medicinal products and medical devices (“european shortages monitoring platform”) at the european medicines agency (ema) is being requested until 2025 (34,35). a limitation is, that the monitoring only encompasses the maviglia a, bitar e, schmidt j, winters p, de souza s, clemens t. hpv vaccines: call for a european change to tackle current and future shortages (policy brief). seejph 2023.posted: 09 april 2023 page 26 medicinal products on the critical medicines list or the ones whose shortage can lead to a public health emergency (decision 1082/2013/eu – article 12). the executive steering group on shortages of medical devices (mdssg) is responsible for the development of the list of critical medicines (regulation (eu) 2022/123 – article 6). we advocate for the inclusion of hpv vaccines on this list. to fully grasp the supply situation in europe, it would be further useful to have an extension of the monitoring system to report stocks. however, a challenge concerning exchanging information relating to production capacities, sales, or market shares is the eu competition rules, which prohibit the exchange of confidential, strategic information between competitors. this means that information on planned production, and capacity for vaccines needs to be aggregated and anonymised to prevent the identification of specific companies (36). the centralised approach is a more urgent way of shortage management, where active redirection of vaccines is needed according to the scenario. cluster ii – response: the demand side the goal for a fast response lies in the prioritisation of vaccines to the risk groups for which the burden of disease is higher. for this reason, the moral question of where should the available doses be allocated has to be raised and answered. four possible policy interventions can be undertaken in case of an hpv vaccine shortage, to be adopted according to the severity of the situation, from green to red. 1. hpv dose sparing and joint procurement (green) 2. postponing vaccination for young children (yellow) 3. postponing vaccination for boys (orange) 4. prioritisation in favour of lowand middle-income countries (red) figure 1. severity level of shortage and corresponding intervention maviglia a, bitar e, schmidt j, winters p, de souza s, clemens t. hpv vaccines: call for a european change to tackle current and future shortages (policy brief). seejph 2023.posted: 09 april 2023 page 27 option iia – dose sparing currently, the use of a single dose does not appear in recommendations. however, evidence is culminating in considering this implementation. in costa rica and india, immunogenicity after a single dose could be observed, even if inferior compared to levels after two or three doses of vaccine. in australia, denmark, and the united states, one dose of the 4-valent recombinant hpv vaccine seems as effective as two or three doses in protecting the subject against highgrade cervical lesions. five more randomised controlled trials and two observational studies are currently taking place in costa rica, kenya, tanzania, gambia, south africa and thailand, and their preliminary results seem positive (11). hence, dose sparing might be the solution to future hpv vaccine shortage in the future. option iib – eu joint procurement the newly established eu health emergency preparedness and response (hera) structure can be key to managing and funding a joint procurement of hpv vaccines in the eu (37,38). the effectiveness of eu joint procurement initiatives is scarcely researched (39). however, during the covid-19 pandemic, the procurement initiative of the eu successfully gathered vaccines and distributed them, which prevented vaccine nationalism and gave smaller countries more substantial purchasing power associated with pooled order volumes (40). additionally, there is criticism of small joint procurement initiatives which consist of two to three countries and not on a supranational level (40–43). however, in specific circumstances, especially in the context of high global demand, there is no alternative to procurement organised by a coalition of governments and supranational organisations (40). some research on joint procurement of hpv vaccines shows a significant price decrease (9,44). however, good procurement practices are essential for public procurement to be successful (40,45,46). this policy option provides an eu-wide change in the procurement of hpv vaccines. the european commission should enable the mechanisms of hera to procure hpv vaccines jointly and distribute them viaresceu in times of high global demand. maviglia a, bitar e, schmidt j, winters p, de souza s, clemens t. hpv vaccines: call for a european change to tackle current and future shortages (policy brief). seejph 2023.posted: 09 april 2023 page 28 option iic – postponing injections for young children in the case in which postponement of vaccination for certain groups has to be considered, our recommendation is to start by considering young children, both girls and boys. in many european countries, children receive their first dose when they are very young, years before their first sexual experience could occur. for instance, in the netherlands, from 2022 boys and girls that turn 10 will receive two doses in the same year (47). in austria, they receive the first dose when they are nine years old, and in portugal when they turn 10. in the vast majority of european countries, children receive the first two doses in their twelfth year of life (11). it could be argued that by delaying the vaccination of one or two years, the children would still not be a part of a risk group since, given their age, they would have not yet engaged in sexual intercourse. another possible option would be to extend the interval between the first and the second dose, offering the second dose two or three years after the first one. this measure would be cost-effective and gain time while addressing the shortage (11). option iid – postponing vaccination for boys in the case in which postponing vaccination for the younger groups would not be enough, postponement of vaccination for boys should be considered. although males are also affected by the burden of disease and can contract hpv-related cancers such as penile cancer or anal cancer, the main threat to the health of the individual affected by hpv is cervical cancer (48). boys represent a risk group and deserve equal protection. nevertheless, in terms of health benefits, a delay in vaccinations for boys would have fewer consequences than for girls (11). option iie – prioritisation in favour of low and middle-income countries the current shortage has sparked a debate on whether vaccination for boys should be suspended to have enough doses for girls living in lmics. the extension of hpv vaccination to boys implied a substantial increase in demand, which, combined with the covid-19 pandemic, led to the current shortage. hence, until 2024, the who maviglia a, bitar e, schmidt j, winters p, de souza s, clemens t. hpv vaccines: call for a european change to tackle current and future shortages (policy brief). seejph 2023.posted: 09 april 2023 page 29 declared that the girls living in countries with a high burden of cervical cancer would not have a sufficient amount of doses. the who calls for action did not lead to a european response. we call for change and want to highlight the moral obligation that the eu has to protect these girls and prioritise public health over national interests. in many lmics, prevention and screening strategies are still insufficient, and 84% to 90% of all cervical cancers are registered in these countries. moreover, the average individual health benefit gained from giving a dose of vaccine administered to a boy in europe is substantially lower than the average individual health benefit gained by giving that dose to a girl living in a lmic (11). therefore, our policy recommendation is to prioritise lmic girls and allocate vaccines in those countries in case we find ourselves in times of extreme global shortages. cluster iii – supply side: novel procurement agreements current procurement practices have a shortterm horizon and disregard production and planning periods for manufacturers. further, public procurement poses the threat of creating a significant shortage of vaccines, as smaller manufacturers, who have lost a public bid, will exit the vaccine market. this leads to the existence of a single manufacturer and no “backup” manufacturer in times of crisis (15). if manufacturers know the future vaccine demand, they can decide which capacity investments they can perform (15). longterm and accurate forecasting of vaccine demand is, therefore, crucial to sustaining the supply of vaccines, contributing to a stronger vaccine industry and enabling sustainable supply (36). furthermore, even though the eu public procurement directive 2014/24/eu emphasises the focus on quality and innovation aspects of procured goods, many member states are still using the lowest price as a rationale. this leads manufacturers to avoid future tenders and focus on countries with more sustainable business conditions (15). we are recommending the following points for future procurement agreements: maviglia a, bitar e, schmidt j, winters p, de souza s, clemens t. hpv vaccines: call for a european change to tackle current and future shortages (policy brief). seejph 2023.posted: 09 april 2023 page 30 ● long-term tender ● splitting of tender awards between manufacturers ● focus on quality and innovation aspects instead of price only box 1. recommendations for procurement agreements recommendations appropriate preparation and reaction to a vaccination shortage would be a composite solution from the options proposed above. resilience is defined as “the ability to prepare for, manage (absorb, adapt and transform) and learn from shocks” by who. these policy recommendations are an adaptation from the four-stage shock cycle in their 2020 policy brief about strengthening health systems resilience (49). a traffic light colour system could help the eu and the member states to adapt their response. this barometer could be available on the website of the ema for transparency, following the example of the french and italian medicines agencies (25,32). stages stage 1: green light – shortage prevention at this baseline stage, there is no shortage. the decentralised surveillance system builds upon the information the member states and the pharmaceutical industry provides and collects it at a regular pace set in advance. based on the surveillance system, member states can perform long-term and accurate demand planning. jointly with the establishment of new procurement agreements, this would enable an adaptation of the production to suit the needs and forecast a potential shortage. no joint procurement is planned at this stage. stage 2: amber light – imminent shortage preparation at this stage, a potential shortage is looming, as flagged by the system of sensors described above (stage 1). the information from the member states and the pharmaceutical industry is being used to prepare for different scenarios, with a calculation of the doses concerned for each one of them, using the data available: demography composition, stocks, vaccination coverage, etc. the aim is to prepare a checklist of decisions to make in case a plan has to be activated on short notice, i.e. the “trigger”. for instance, is dose-sparing or postponing doses relevant in the coming shortage? if so, at what intensity, maviglia a, bitar e, schmidt j, winters p, de souza s, clemens t. hpv vaccines: call for a european change to tackle current and future shortages (policy brief). seejph 2023.posted: 09 april 2023 page 31 and for which groups? how many doses could be derived for the countries that need it the most? stage 3: red light – shortage management at this crisis stage, the shortage is a reality. the list of countermeasures has already been set at the previous stage and can be “triggered” at any time. centralised surveillance or stock management (joint procurement) could be a solution handled by health authorities. a combination of the scenarios discussed in stage 2 could participate in redirecting the correct number of doses needed. stage 4: shortage lessons at this recovery stage, the shortage is behind. each stakeholder would estimate the impact of the measures taken: the relevance of using centralised surveillance or a joint procurement, an estimation of doses derived with the measures taken and the feedback from the pharmaceutical industry about the redirection of the vaccine production. the assessment produced at this stage could serve as a road map for the return to stage 1. table 3. stages of vaccination shortage management summary of stages stage 1 green light shortage prevention ● prevention: decentralised surveillance ● response: none ● supply side: better procurement agreements stage 2 amber light imminent shortage preparation ● prevention: intensification of data surveillance (more frequent) ● response: assess different scenarios and assessing the number of doses for each one, ready for a quick activation (preparing the “trigger”) stage 3 red light shortage management ● prevention: centralised surveillance, joint procurement (depending on scenarios) ● response: “trigger”. active redirection of doses where they are needed according to the different scenarios assessed stage 4 shortage lessons ● prevention: evaluate the efficacy of the surveillance system ● response: estimate the number of doses redirected (given, spared, etc.) maviglia a, bitar e, schmidt j, winters p, de souza s, clemens t. hpv vaccines: call for a european change to tackle current and future shortages (policy brief). seejph 2023.posted: 09 april 2023 page 32 ● supply side: feedback on the actions taken during the shortage limitations the scope of this policy brief obstructs a detailed look at the issue and consequently allows a partially superficial view of the problem. other relevant elements, especially related to the sociopolitical and cultural fields, could have been included in the research to explain the in-depth issue and its determinants. the policy brief represents the input and an overview of a broader issue that could be addressed in more detail with further research. especially the introduction of a surveillance system on hpv, while innovative, lacks evidence in the literature. furthermore, the implementation process could have been further elaborated by addressing barriers to the engagement of the stakeholders and limitations in their scope of action. moreover, being hera a new institution, it is hard to foresee the role that it could play in tackling future shortages. conclusion hpv shortages have resulted in unequal access to the vaccine globally and in europe. moreover, definitions of hpv coverage and data collection differ between eu member states. this makes it hard for scientists and politicians to quantify the demand for hpv vaccines and the number of vaccine shortages. additionally, stocks of hpv vaccines are also not documented. the current policy landscape was not sufficiently designed to address the hpv shortages. that highlights the importance of a shortand long-term strategy and more decisive european leadership towards change for hpv vaccination, as theorised by john kotter (50). this paper provides recommendations for the eu to become more resilient in times of crisis. it gives policy options according to three clusters: prevention, response, and supply. this paper then identified policy options that suit the assigned cluster's demand. moreover, this paper concluded when policymakers should implement these policy options with a simple traffic light colour system. altogether, these recommendations will give the eu more resilience towards hpv vaccine shortages. maviglia a, bitar e, schmidt j, winters p, de souza s, clemens t. hpv vaccines: call for a european change to tackle current and future shortages (policy brief). seejph 2023.posted: 09 april 2023 page 33 conflicts of interest the authors declare no conflict of interest. acknowledgments the authors would like to thank prof.dr. kasia czabanowska from maastricht university for the leadership training in the master “governance and leadership in european public health” and for 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rijksinstituutvoorvolksgezondheiden milieu (rivm). rivm expands hpv vaccination programme: girls and boys protected from six types of cancer with one vaccine. 2022: https://www.rivm.nl/en/news/rivmexpands-hpv-vaccination-programmegirls-and-boys-protected-from-sixtypes-of-cancer-with (accessed: 2022 dec 3) 48. lei j, ploner a, elfström km, wang j, roth a, fang f, et al. hpv vaccination and the risk of invasive cervical cancer. new england journal of medicine. 2020 oct 1;383(14):1340–8. 49. european observatory on health systems and policies, thomas s, sagan a, larkin j, cylus j, figueras j, et al. strengthening health systems resilience: key concepts and strategies. world health organization. regional office for europe; 2020: https://apps.who.int/iris/handle/10665/ 332441 (accessed: 2022 nov 29) 50. kotter jk. leading change. why transformation efforts fail. harvard business review. 1995 mar;10. __________________________________________________________________________________________ © 2023 maviglia et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://apps.who.int/iris/handle/10665/207152 https://apps.who.int/iris/handle/10665/207152 https://ec.europa.eu/info/live-work-travel-eu/coronavirus-response/public-health_en https://ec.europa.eu/info/live-work-travel-eu/coronavirus-response/public-health_en https://ec.europa.eu/info/live-work-travel-eu/coronavirus-response/public-health_en https://www.rivm.nl/en/news/rivm-expands-hpv-vaccination-programme-girls-and-boys-protected-from-six-types-of-cancer-with https://www.rivm.nl/en/news/rivm-expands-hpv-vaccination-programme-girls-and-boys-protected-from-six-types-of-cancer-with https://www.rivm.nl/en/news/rivm-expands-hpv-vaccination-programme-girls-and-boys-protected-from-six-types-of-cancer-with https://www.rivm.nl/en/news/rivm-expands-hpv-vaccination-programme-girls-and-boys-protected-from-six-types-of-cancer-with https://apps.who.int/iris/handle/10665/332441 https://apps.who.int/iris/handle/10665/332441 sanije h-g, musli g, naser r, sefedin m, myvedete t, smoking prevalence among the adult population of kosovo: results of steps survey 2019. seejph 2023. posted: 09-04-2023, vol. xx. page 22 original research smoking prevalence among the adult population of kosovo: results of steps survey 2019 sanije hoxha-gashi1.2, musli gashi2,3, naser ramadani1.2, sefedin muçaj1,2*, myvedete tërshnjaku2 1faculty of medicine, university of prishtina “hasan prishtina”, prishtina, kosovo. 2national institute of public health of kosovo, prishtina, kosovo. 3university clinical center of kosovo, prishtina, kosovo. corresponding author: sefedin muçaj address: faculty of medicine, university of prishtina “hasan prishtina”, street lagjja e spitalit p.n. 10000, prishtina, kosovo email: sefedin.mucaj@uni-pr.edu sanije h-g, musli g, naser r, sefedin m, myvedete t, smoking prevalence among the adult population of kosovo: results of steps survey 2019. seejph 2023. posted: 09-04-2023, vol. xx. page 23 abstract aim: tobacco use remains the leading preventable cause of death worldwide. the vast majority of these deaths occur in low – and middle-income countries, and the gap is expected to widen further in the coming decades. this study aimed to evaluate the prevalence of smoking among kosovo adults by gender, age group and type of smoking. methods: a population-based survey was conducted among people aged 18-69 years from april 2018 to june 2019 using the who steps instrument. 2800 randomly selected households were approached using multistage cluster sampling, and 2695 agreed to participate in the survey (response rate 96.2%). results: according to the findings of our study, 25.7% of the population aged 18-69 years was a current smoker (men 35.3% vs. women 15.9%) and 90.1% of them smoked tobacco products on a daily basis (men 91.5% current smokers on daily basis vs. women 87.1% on daily basis). smokers started smoking at an average age of 19.3 years. women started smoking significantly later than men, at the age of 20.9 years, compared to 18.6 years for men, and the younger age group started smoking earlier. the average smoking duration is 19.3 years, with no gender differences (men 19.5 years vs. women 19.0 years average smoking duration). on average, 97.4% of daily smokers smoke manufactured cigarettes. conclusion: smoking prevalence was high among kosovo adults, especially men and the majority of them smoke on daily basis. keywords: kosovo, smoking prevalence, steps survey. sanije h-g, musli g, naser r, sefedin m, myvedete t, smoking prevalence among the adult population of kosovo: results of steps survey 2019. seejph 2023. posted: 09-04-2023, vol. xx. page 24 introduction tobacco use remains the leading preventable cause of death worldwide. every year, it claims the lives of nearly 8 million people worldwide, of which more than 1.2 million deaths are due to secondhand smoke and 65 000 are children. over 80% of the world’s 1.3 billion tobacco users live in low-and middle-income countries. in 2020, 22.3% of the global population used tobacco, 36.7% of all men and 7.8% of the world’s women [1]. in 2015, tobacco use caused 6.9% of the global disease burden as estimated by dalys [2]. current smokers who quit smoking lower their risk of noncommunicable diseases like heart and respiratory disease, stroke and cancer [3]. according to the 2011 census, the total population of kosovo is 1,739,825 inhabitants, of which 24% are 0-14 years old, 67% are 15-64 years old, and 9% are 65 and older [4]. in 2021, the crude birth rate was 12.8 ‰ and the crude death rate was 7.3‰ [5, 6]. the life expectancy at birth is 76.7 years (females 79.4 years vs. males 74.1 years). there are currently 38 municipalities and 1,469 settlements [7]. in 2018, circulatory system diseases were the leading cause of death in kosovo, with neoplasms coming in second [8]. because an electronic health information system has not yet been fully implemented, health statistics data are incomplete and fragmented. this steps survey provided internationally comparable weighted data on risk factors for non-communicable diseases (ncds) in kosovo. a previous study in 2011 has reported unweighted data and therefore its findings are difficult to interpret [9]. this study aimed to evaluate the prevalence of smoking among kosovo adults by gender, age group and type of smoking using weighted data which are internationally comparable. methods the survey was conducted using the who stepwise approach to surveillance (steps), [10]. study design and sample a population-based survey was conducted among people aged 18-69 years in kosovo from april 2018 to june 2019 using the who steps instrument [10]. a two-stage cluster random sampling scheme was devised. to begin, 307 enumeration areas were chosen as primary sanije h-g, musli g, naser r, sefedin m, myvedete t, smoking prevalence among the adult population of kosovo: results of steps survey 2019. seejph 2023. posted: 09-04-2023, vol. xx. page 25 sampling units using probability proportional to size. households were then randomly selected as the secondary sampling units. 2800 randomly selected households were approached. within each of the households one resident aged 18-69 years was randomly selected for participation in the survey and 2695 (96.2%) agreed to participate. the protocol was approved by the committee on ethical issues, kosovo doctors chamber nr. 06/2018. written informed consent was obtained before participants were enrolled in the study, following ethical norms [11]. measurements to collect data for risk factors on ncds s we have used the english 3.2 version of the who steps questionnaire [12, 13], which was translated and adapted from the kosovo survey team. a steps questionnaire with core and expanded tobacco questions was used in face-to-face interviews to collect sociodemographic data and information on tobacco use (current and previous; frequency of smoking, duration of smoking, etc.). showcards were customized for the local context and used to clarify terminology. all data were directly entered into a tablet by the survey team. statistical analysis weights were assigned to account for the following factors; selection probability, nonresponse, gender, and age differences between the sample and the target population. data analysis was conducted in epi info [14], version 3.5.1 (centre for disease control and prevention, atlanta, ga) and prevalence rates with corresponding 95% confidence intervals (cis) were estimated. the results were considered statistically significant if there was no overlap between two cis of comparing groups (e.g. males vs. females) or if there is p<0.05 if they are tested with the chi test or fisher exact test. results there were 1115 men (41.4%) and 1580 women (58.6%) among the 2695 respondents to the survey. almost 60% of all respondents were between the ages of 45 and 69, with similar proportions by gender. the average time spent in school was 10.6 years. nearly an equal number of respondents had completed secondary sanije h-g, musli g, naser r, sefedin m, myvedete t, smoking prevalence among the adult population of kosovo: results of steps survey 2019. seejph 2023. posted: 09-04-2023, vol. xx. page 26 education (34.2%) as had less than primary school education (34.1%), 12.9% had completed college/university, 7.8% had a primary school education, 4.2% had a postgraduate degree and 3.0% had high school degree. the vast majority (92.0%) of the population was identified as albanian, with the remainder belonging to other ethnic groups. table 1. respondents by age group and sex age group (years) men women both sexes n % n % n % 18-44 458 41.1 682 43.2 1140 42.3 45-69 657 58.9 898 56.8 1555 57.7 18-69 1115 100.0 1580 100.0 2695 100.0 more than a quarter of the population (25.7%) currently smoked tobacco. men smoked more than twice as much as women (15.7%), and the difference was statistically significant. there were no significant differences in current smoking prevalence by age group and gender (table 2). table 2. percentage of current smokers by age group and gender – kosovo steps survey 2019 age group men women both sexes p-value (years) n % current smoker 95% ci n % current smoker 95% ci n % current smoker 95% ci 18-44 458 34.3 28.7-40.0 682 14.7 11.518.0 1140 24.6 21.4-27.9 p<0.0001 chi test=59.3 45-69 657 37.8 33.2–42.5 892 19.0 15.922.2 1555 28.5 25.7-31.3 p<0.0001 chi test=68.3 18-69 1115 35.3 31.1-39.5 1580 15.9 13.318.6 2695 25.7 23.4-28.1 p<0.0001 chi test=134.8 the majority of current smokers (90.1%) smoked tobacco products daily, with no significant difference among men (91.5% ) and women (87.1%), while the population in older age groups smoked more on a daily basis (table 3). sanije h-g, musli g, naser r, sefedin m, myvedete t, smoking prevalence among the adult population of kosovo: results of steps survey 2019. seejph 2023. posted: 09-04-2023, vol. xx. page 27 table 3. current daily smokers among smokers by age and sex age group men women both sexes p-value (years) n % daily smoke rs 95% ci n % daily smoker s 95% ci n % daily smoke rs 95% ci 18-44 163 89.8 83.096.7 115 83.4 74.492.3 278 87.9 82.393.6 p=0.214 chi test = 1.54 45-69 253 95.2 91.599.0 161 94.6 90.898.5 414 95 92.098.1 p=1.000 fisher test 18-69 416 91.5 86.196.9 276 87.1 81.093.3 692 90.1 85.894.5 p=0.356 chi test = 0.85 the average age at which smokers began smoking was 19.3 years. women started smoking significantly later than men, at 20.9 years compared to 18.6 years for men. the average smoking duration is 19.3 years, with no significant difference by gender (men mean duration of 19.5 years vs. women's mean duration of 19.0 years) (table 4). table 4. mean age when started smoking and mean duration of smoking, by sex (years) mean age started smoking age group men women both sexes (years) n mean age 95% ci n mean age 95% ci n mean age 95% ci 18-44 149 18.1 17.418.7 101 19.9 19.120.7 250 18.6 18.019.1 45-69 235 19.7 18.720.7 152 22.6 21.423.8 387 20.7 19.921.5 18-69 384 18.6 18.019.1 253 20.9 20.221.6 637 19.3 18.819.7 mean duration of smoking age group men women both sexes (years) n mean duration 95% ci n mean duration 95% ci n mean duration 95% ci sanije h-g, musli g, naser r, sefedin m, myvedete t, smoking prevalence among the adult population of kosovo: results of steps survey 2019. seejph 2023. posted: 09-04-2023, vol. xx. page 28 18-44 149 12.5 11.014.0 101 12.4 10.314.6 250 12.5 11.213.8 45-69 235 35.1 33.736.6 152 30.8 29.532.2 387 33.7 32.634.8 18-69 384 19.5 17.521.4 253 19 16.821.2 637 19.3 17.820.9 on average, 97.4% of daily smokers smoke manufactured cigarettes, with no significant gender difference (men 97.1% vs. women 98.0%) (table 5). on average, each smoker smoked 18.8 cigarettes per day. women smoke 13.7 cigarettes per day, while men smoke 22.0 cigarettes per day. more than half of male smokers (54.7%) and over onethird of female smokers (38.8%) smoked 1524 cigarettes per day; while 12.1% (men) and 38.3% (women) respectively, smoked 10-14 cigarettes per day (table 6). table 5. manufactured cigarette smokers among daily smokers by gender (%) manufactured cigarette smokers among daily smokers age group men women both sexes (years) n % manufactured cigarette smoker 95% ci n % manufactured cigarette smoker 95% ci n % manufactured cigarette smoker 95% ci 18-44 151 97.8 95.0100.5 101 98.1 96.0100.2 252 97.9 95.8-99.9 45-69 242 95.7 92.5-99.0 151 97.7 94.2101.2 393 96.4 93.9-98.9 18-69 393 97.1 95.0-99.3 252 98 96.1-99.8 645 97.4 95.8-99.0 manufactured cigarette smokers among current smokers age group men women both sexes (years) n % manufactured cigarette smoker 95% ci n % manufactured cigarette smoker 95% ci n % manufactured cigarette smoker 95% ci 18-44 162 97.3 94.4100.1 114 95.1 90.5-99.8 276 96.6 94.3-99.0 45-69 250 95.1 91.6-98.5 159 96.6 92.8100.4 409 95.6 93.0-98.2 18-69 412 96.6 94.4-98.8 273 95.6 92.2-99.1 685 96.3 94.5-98.1 sanije h-g, musli g, naser r, sefedin m, myvedete t, smoking prevalence among the adult population of kosovo: results of steps survey 2019. seejph 2023. posted: 09-04-2023, vol. xx. page 29 table 6. number of manufactured or hand-rolled cigarettes smoked daily per smoker, by sex (%) percentage of daily smokers smoking given quantities of manufactured or hand-rolled cigarettes per day age group men (years) n % <5 cigs. 95% ci % 59 cigs. 95% ci % 1014 cigs. 95% ci % 1524 cigs. 95% ci % 95% ci ≥ 25 cigs. 18-44 148 0.6 -2.4 2.8 -8.5 15.3 8.222.4 57.7 48.566.9 23.6 15.9-31.2 45-69 237 0.6 -1.8 2.6 0.25.1 4.8 1.08.6 48 40.555.5 43.9 36.4-51.4 18-69 385 0.6 -1.7 2.7 -6.1 12.1 7.017.2 54.7 47.861.6 29.9 23.7-36.1 percentage of daily smokers smoking given quantities of manufactured or hand-rolled cigarettes per day age group women (years) n % <5 cigs. 95% ci % 59 cigs. 95% ci % 1014 cigs. 95% ci % 1524 cigs. 95% ci % 95% ci ≥ 25 cigs. 18-44 99 2.9 -6.5 17.4 8.626.3 47.3 30.763.9 31.2 18.643.8 1.2 -3.5 45-69 150 3.7 0.46.9 9 3.714.3 22.5 14.830.1 52.3 41.662.9 12.6 5.7-19.6 18-69 249 3.2 0.85.6 14.4 8.320.5 38.3 27.449.2 38.8 31.046.6 5.3 2.3-8.3 percentage of daily smokers smoking given quantities of manufactured or hand-rolled cigarettes per day age group both sexes (years) n % <5 cigs. 95% ci % 59 cigs. 95% ci % 1014 cigs. 95% ci % 1524 cigs. 95% ci % 95% ci ≥ 25 cigs. 18-44 247 1.3 0.12.5 6.9 3.110.8 24.4 16.632.1 50.2 42.258.2 17.2 11.6-22.8 45-69 387 1.6 0.42.9 4.7 2.27.2 10.6 6.914.3 49.4 43.355.5 33.5 27.7-39.4 18-69 634 1.4 0.52.3 6.2 3.49.0 19.9 14.525.2 50 44.455.5 22.6 18.0-27.1 sanije h-g, musli g, naser r, sefedin m, myvedete t, smoking prevalence among the adult population of kosovo: results of steps survey 2019. seejph 2023. posted: 09-04-2023, vol. xx. page 30 discussion the who steps methodology for measuring risk factors for chronic diseases was used in this cross-sectional study. it is the second time kosovo has conducted such research, but unlike the first time, when the data were presented unweighted, the data this time are weighted, allowing us to make a more accurate international comparison. it should be noted, however, that the target populations were not all the same age (18-69 years steps 2019 vs. 15-64 years steps 2011), [15]. any comparison of these two data sets should be used only as e reference and not as evidence of changes in risk factor prevalence. the estimated smoking prevalence in steps (25.7%) is similar to the 2011 survey (28.4%), [16]. the study revealed a very high prevalence of smoking tobacco in kosovo. one-fourth (25.7%) of the population aged 18-69 years was a current smoker, including one-third of all men (35.3%) and one-sixth (15.9%) of women. compared to the data for tobacco users in the european region these data are higher for men and lower for women. according to who in 2020, approximately one-third of men (33%) in the region used tobacco. male current tobacco users numbered 117 million in the european region in 2020, down from around 153 million (47%) in 2000; the figure is expected to fall to around 108 million (30%) by 2025. according to who, approximately one-fifth (18%) of women in the european region used tobacco in 2020, which is higher than the smoking prevalence of kosovo women (15.9%). female current tobacco users in the european region numbered 63 million in 2020, down from around 77 million (23%) in 2000; the figure is expected to fall further to around 60 million (17%) by 2025, [17-19]. compared to data from steps 2011 prevalence of current tobacco smoking has trends to falling down [20]. smoking prevalence varies greatly across european countries, with eastern europe (28%) having the highest prevalence and northern europe (20%) having the lowest [21]. the prevalence of smoking among adults in kosovo is comparable to the prevalence of smoking in the majority of balkan countries [22-29]. the majority of current smokers are daily smokers (90.1%) similar to the study from the ear 2011 (16). kosovo’s tobacco control law went into effect in may 2013, but the effect of this law sanije h-g, musli g, naser r, sefedin m, myvedete t, smoking prevalence among the adult population of kosovo: results of steps survey 2019. seejph 2023. posted: 09-04-2023, vol. xx. page 31 on smoking prevalence from 2011 to 2019 is small, indicating that the implementation of those measures is inadequate. the mean age when smokers started smoking was 19.3 years (women 20.9 years vs. men 18.6 years). compared to 2011, the results of the 2019 steps survey show that the mean age is younger (in 2011 mean age was 20.9 years) as well as according to gender (in 2011 mean age for women was 23.4 years and for men 19.7 years). the results show that during the previous 30 days, more people noticed information encouraging people to quit smoking than cigarette advertisements, and nearly half of the current smokers (45.5%) considered quitting after seeing health warnings on cigarette packages, while every fifth current smoker (20.2%) had tried but failed to quit smoking. conclusions the study found that smoking prevalence continues to be high in kosovo. one-fourth (25.7%) of the population aged 18-69 years was a current smoker, including one-third of all men (35.3%) and one-sixth (15.9%) of women. every fifth current smoker (20.2%) had attempted but failed to quit smoking. there has been no significant change in the current smoking prevalence estimates in this study compared to the 2011 steps study on the same population. kosovo has a young population, with a high percentage of young males smoking. to reduce active and secondhand tobacco use in kosovo, aggressive and long-term public health interventions are required. funding the steps survey was organized by the ministry of health, the national institute of public health of kosovo and who, with the technical assistance of who and aqh (accessible quality healthcare project). conflicts of interest: none declared. author contributions all the authors have contributed equally to the conception and design of the study, drafting the article or revising it, and approving the version to be submitted. references 1. organization, w.h., who report on the global tobacco epidemic, 2017: monitoring tobacco use and prevention policies. 2017: world health organization. 2. collaborators, g.r.f., global, regional, and national comparative risk assessment of 79 behavioural, sanije h-g, musli g, naser r, sefedin m, myvedete t, smoking prevalence among the adult population of kosovo: results of steps survey 2019. seejph 2023. posted: 09-04-2023, vol. xx. page 32 environmental and occupational, and metabolic risks or 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control of noncommunicable diseases 20132020. 2013: world health organization. 20. gallus, s., et al., who smokes in europe? data from 12 european countries in the tackshs survey (2017–2018). journal of https://ask.rks-gov.net/media/6975/kosovo-in-figures-2021.pdf https://ask.rks-gov.net/media/6975/kosovo-in-figures-2021.pdf https://ask.rks-gov.net/media/6975/kosovo-in-figures-2021.pdf https://ask.rks-gov.net/media/5818/shkaqet-e-vdekjeve-2019.pdf https://ask.rks-gov.net/media/5818/shkaqet-e-vdekjeve-2019.pdf https://ask.rks-gov.net/media/5818/shkaqet-e-vdekjeve-2019.pdf https://www.who.int/ncds/surveillance/steps/en https://www.who.int/ncds/surveillance/steps/en https://www.who.int/ncds/surveillance/steps/esteps_user_manual.pdf https://www.who.int/ncds/surveillance/steps/esteps_user_manual.pdf https://www.cdc.gov/epiinfo/index.html https://www.cdc.gov/epiinfo/index.html sanije h-g, musli g, naser r, sefedin m, myvedete t, smoking prevalence among the adult population of kosovo: results of steps survey 2019. seejph 2023. posted: 09-04-2023, vol. xx. page 33 epidemiology, 2021. 31(2): p. 145151. 21. seniori costantini, a., et al., population health and status of epidemiology in western european, balkan and baltic countries. international journal of epidemiology, 2015. 44(1): p. 300323. 22. vasilj, i., et al., cardiovascular risk factors research in bosnia and herzegovina. collegium antropologicum, 2009. 33(2): p. 185188. 23. pilav, a., et al., cardiovascular risk factors in the federation of bosnia and herzegovina. the european journal of public health, 2007. 17(1): p. 75-79. 24. ross, h., et al., results from the albanian adult tobacco survey. central european journal of public health, 2008. 16(4). 25. shapo, l., et al., prevalence and determinants of smoking in tirana city, albania: a population-based survey. public health, 2003. 117(4): p. 228-236. 26. samardžić, s., g. vuletić, and d. tadijan, five-year cumulative incidence of smoking in adult croatian population: the crohort study. collegium antropologicum, 2012. 36(1): p. 99-103. 27. poljičanin, t., et al., the changing pattern of cardiovascular risk factors: the crohort study. collegium antropologicum, 2012. 36(1): p. 9-13. 28. koprivnikar, h. and a. korošec, age at smoking initiation in slovenia. slovenian journal of public health, 2015. 54(4): p. 274-281. 29. martínez-sánchez, j.m., et al., smoking behaviour, involuntary smoking, attitudes towards smokefree legislations, and tobacco control activities in the european union. plos one, 2010. 5(11): p. e13881. __________________________________________________________________________________________ © 2023 sanije hoxha-gashi et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 1 | 8 review article syndromic surveillance in early detection of outbreaks of infectious diseases eugena tomini1, artan simaku1, elona kureta1, adela vasili1, silva bino1 1 institute of public health, tirana, albania. corresponding author: eugena tomini, md, phd; address: rr. “aleksander moisiu”, no. 88, tirana, albania; telephone: 00355672052938; email: genatomini@yahoo.com tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 2 | 8 abstract aim: motivated by the threat of infectious diseases and bioterrorism, syndromic surveillance systems are being developed and implemented around the world. the aim of the study was to describe the early warning surveillance system in albania. methods: syndromic surveillance is a primary health care-facilityand emergency room (er)based syndromic surveillance system aiming at detecting outbreaks and undertaking public health actions. it is based on weekly notifications of nine syndromes by over 1,600 general practitioners (gps) in the 36 districts of albania. data is aggregated by district epidemiologists (de) and centralized by the national institute of public health. results: a syndrome is “a set of symptoms or conditions that occur together and suggest the presence of a certain disease or an increased chance of developing the disease.” in the context of syndromic surveillance, a syndrome is a set of non-specific pre-diagnosis medical and other information that may indicate the release of a bioterrorism agent or natural disease outbreak. since its inception, syndromic surveillance has mainly focused on early event detection: gathering and analysing data in advance of diagnostic case confirmation to give early warning of a possible outbreak. conclusion: the system is useful for detecting and responding to natural disease outbreaks such as seasonal and pandemic flu, and thus they have the potential to significantly advance and modernize the practice of public health surveillance. keywords: albania, early event detection, public health, situational awareness. tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 3 | 8 introduction the epidemiology of infectious diseases is one of the major crises facing human society. following the course of epidemic outbreaks of diseases such as sars (severe acute respiratory syndrome), a health emergency that shocked the world at the end of 20022003 or of the influenza pandemic caused by the ah1n1 virus in 2009 to arrive at covid19 pandemic, the appropriate management of crises health issues that exceed borders, takes an important role (1-3). human cases of ah5n1 influenza are still being reported in asia, and the emergence of new infectious disease epidemics is still a major concern. early detection of outbreaks of infectious diseases is essential for taking measures against the disease. in recent years, "syndromic surveillance" has attracted attention as a new technology that meets these needs. the term "surveillance" is used when observing the trends of an infectious disease (4-6). it refers to the systematic collection, analysis and interpretation of data necessary for the planning, implementation and evaluation of measures against diseases, due to the continuous monitoring of the situation and the trend of disease occurrences, thus making it possible to take effective measures based on timely results and continuous feedback evaluations of decision-making bodies (7,8). syndromic surveillance focuses on the patient's symptoms such as fever, diarrhoea, etc. syndromic surveillance takes less time than diagnosis-based surveillance, so it enables an early investigation of infectious disease epidemics and taking measures to prevent their spread. in the situation where "improvement and reinforcement of surveillance" is at the top of the list for measures to be taken for the prevention of infectious diseases, including new subtypes of influenza viruses and sars-cov-2 variants, expectations for syndromic surveillance are high, as was discussed at the international conference maintained by the world health organization (who) (9,10). in syndromic surveillance, the technologies of epidemic intelligence, epidemiological analysis of information about the patient's symptoms thanks to statistical methods, as well as the technologies of efficient collection, processing and distribution of information, play a very important role. this article focuses on the role of syndromic surveillance in taking measures against infectious diseases in humans. what is syndromic surveillance? description and objectives of surveillance the research, development and practical application of syndromic surveillance has been promoted since the anthrax cases that occurred after the september 2001 attacks in the united states of america, as well as after the sars epidemic in 2002-2003, with the aim of developing measures against bioterrorism, early detection of the emergence and re-emergence of epidemics from infectious diseases, especially unknown or rare ones (11). the us centres for disease control and prevention proposed the following definition of syndromic surveillance as the most appropriate and acceptable: syndromic surveillance is an investigative approach by which health department staff, assisted by data from automated and the construction of comparative statistics, monitors disease indicators in real or near-real time, in order to detect disease epidemics earlier than was possible with traditional public health methods (12-16). in other words, syndromic surveillance is an action that captures disease outbreaks in real or near-real time, focusing on symptoms that serve as disease indicators, collecting information automatically, and analysing tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 4 | 8 information from an epidemiological point of view thanks to the use of statistical methods. syndromic surveillance is an early investigation of the epidemic of an infectious disease, thanks to the rapid and early identification of the growing number of patients with specific symptoms, before the diagnosis is confirmed by the doctor. it is a "surveillance of syndromes", with the aim of quickly engaging in the "early dictation" of new epidemics, especially those of reappearing diseases, of unknown or rare infectious diseases, a description that also explains the objective of syndromic surveillance. if all the above points are summed up, it can be said that syndromic surveillance "collects information about the patient's symptoms, analyses the information from an epidemiological point of view using statistical methods, notifies family physicians and government organizations about the results, and quickly takes measures for public health" as and "an effective action that prevents the epidemic spread of infectious diseases caused by humans (bio-terrorism) or by nature" (17-20). system organization and action views the operative process of syndromic surveillance consists of three steps:  selection of information source and data collection;  analysing the information collected and based on the results of judgment about the chances of an epidemic;  notifying health professionals and government organizations responsible for taking measures against infectious diseases. these steps are the same for all types of syndromic surveillance. but since epidemics of infectious diseases vary in form based on the microbiological characteristics of the pathogen and the area of the outbreak, and since syndromic surveillance uses different sources of information, the collection and analysis algorithms are different. the main goal of syndromic surveillance is to establish these algorithms and the various research results. the inability of different countries to detect and contain epidemic outbreaks, identify an infectious agent and understand the dynamics of its transmission in time, has contributed to the spread of infectious diseases in the past (21-24). the international health regulations (ihr) were revised to meet the risks and challenges of the emergence or re-emergence of diseases in the 21st century (25). according to this regulation, all states must report as soon as possible all public health events that have a potential international impact, so that control and prevention measures can be implemented as soon as possible (26). this is achieved by strengthening syndromic surveillance of infectious diseases as a function of the early warning and response of the public health surveillance system, which also helps to collect important data on the epidemiology of endemic diseases. this early warning system was implemented in albania during the influx of kosovar refugees in april 1999 (27,28). this was carried out in collaboration with the institut de veille sanitaire (invs) and the world health organization (who). after the departure of kosovar refugees in july 1999, the system was redesigned to meet the needs of the national health system. the system of early warning and response to infectious diseases alert, was established in september 1999, as part of the national surveillance system coordinated by the institute of public health (iph). the goal of the alert system is the early detection of epidemic outbreaks. it is a syndromic surveillance system based on health centers and emergency departments tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 5 | 8 that produces information for action. the participation of general practitioners in surveillance and preventive activities is mandatory and is included in their employment contract with the institute of health insurance. the system also includes the emergency departments in the hospitals of 36 districts of the country. at the end of each week, gps report the syndrome cases they have examined during the week, including reporting zero cases. the system includes nine infectious syndromes. data are reported to infectious disease information system which is a web-based integrated platform. after visual verification of the data for any outbreak signal, the data are analysed and a weekly bulletin is prepared on the epidemiological situation all over the country. the information produced by the pih is distributed to the epidemiological service of the districts in the form of weekly and quarterly bulletins. the verification of the alert signal and the epidemiological investigation is also carried out at the district level with the help of the pih if necessary. the district epidemiology service is responsible for distributing the weekly newsletter to general practitioners. in some cases, general practitioners are informed in the form of alert data summaries during their monthly meetings with the administration of the institute of health insurance and the directorate of the primary health service (29,30). the "alert" system is integrated and complementary with the mandatory routine reporting system of diagnosed diseases the major disease-based surveillance system, along with other case-based surveillance systems. table 1. type of syndromes and target diseases syndromes clinical definition disease(s) target diarrhoea without blood more than 3 loose stools in 24h salmonellosis… diarrhoea with blood more than 3 loose stools with blood in 24h shigellosis… upper respiratory infections fever, and at least one of the following: rhinitis, cough, sore throat influenza … lower respiratory infections fever and fast breathing (= 50 breathing/min) and at least one of the following: cough, dyspnoea bacterial or viral pulmonary infections sars… avian influenza rash (exanthema) with fever rash with fever measles, rubella, varicella, … jaundice yellow eyes and skin hepatitis virus infection … tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 6 | 8 congenital anomalies structural or functional anomalies that occur during intrauterine life congenital rubella syndrome (crs), congenital syphilis, congenital cytomegalovirus (ccmv) infection and congenital zika syndrome (czs) acute conjunctivitis in neonates conjunctival inflammation occurring within the first 30 days of life chlamydia, bacteria, viral diseases syndromes are broken down by age-group and different automated reports and graphs are produced by epidemiological triad timeplace-person. integration of different surveillance system aiming at maximizing case detection and fast control actions within infectious disease information system is shown in figure 1. figure 1. scheme of integration of different surveillance systems conclusion the alert component of the surveillance of infectious diseases in albania is one of the few systems in the world spread over the entire territory of the country. it can be improved by re-examining the case definition and the disorders under surveillance, and its integration with routine surveillance at the district level. re-structuring, training, feedback to family doctors can be more frequent, increasing the acceptability of the system. the alert system remains very useful, and complements other surveillance systems in a timely and effective manner. tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 7 | 8 choices made in building the system—such as frequency of reporting, software used, and syndromes under surveillance—are appropriate. references 1. heymann dl, rodier gr. hot spots in a wired world: who surveillance of emerging and re-emerging infectious diseases. lancet infect dis 2001;1:345-53. 2. world health organization. background paper for health metrics network: disease surveillance (draft); 2003. 3. factors in emergence. in: mark s.smolinski, margaret a.hamburg, joshua lederberg (eds), committee on emerging microbial threats to health in the 21st century, editors. microbial threats to health: emergence, detection and response. washington, dc: the national academies press; 2003. p. 53-148. 4. jernigan db, raghunathan pl, bell bp, brechner r, bresnitz ea, butler jc, et al. investigation of bioterrorism-related anthrax, united states, 2001: epidemiologic findings. emerg infect dis 2002;8:1019-28. 5. martens p, hall l. malaria on the move: human population movement and malaria transmission. emerg infect dis 2000;6:103-9. 6. the bse inquiry. the bse inquiry report. volume 1: findings and conclusions. http://www.bseinquiry.gov.uk/report/ index.htm. 7. enserink m. infectious diseases. who wants 21st-century reporting regs. science 2003;300:717-8. 8. cash r, narasimhan v. impediments to global surveillance of infectious diseases: consequences of open reporting in a globa leconomy. bull world health organ 2000;78:135867. 9. bean nh, martin sm. implementing a network for electronic surveillance reporting from public health reference laboratories: an international perspective. emerg infect dis 2001;7:773-9. 10. heffernan r, mostashari f, das d, karpati a, kuldorff m, weiss d. syndromic surveillance in public health practice, new york city. emerg infect dis 2004;10:858-64. 11. moran gj, kyriacou dn, newdow ma, talan da. emergency department sentinel surveillance for emerging infectious diseases. ann emerg med 1995;26:351-4. 12. vogt rl. laboratory reporting and disease surveillance. j public health manag pract 1996;2:28-30. 13. goldenberg a, shmueli g, caruana ra, fienberg se. early statistical detection of anthrax outbreaks by tracking over-the-counter medication sales. proc natl acad sci usa 2002;99:5237-40. 14. lewis md, pavlin ja, mansfield jl, o'brien s, boomsma lg, elbert y, et al. disease outbreak detection system using syndromic data in the greater washington dc area. am j prev med 2002;23:180-6. 15. valenciano m, pinto a, coulombier d, hashorva e, murthi m. surveillance of communicable diseases among the kosovar refugees in albania, april-june 1999. euro surveill 1999;4:92-5. 16. valenciano m, coulombier d, lopes cb, colombo a, alla mj, samson s, et al. challenges for communicable disease surveillance http://www.bseinquiry.gov.uk/report/index.htm http://www.bseinquiry.gov.uk/report/index.htm tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 8 | 8 and control in southern iraq, apriljune 2003. jama 2003;290:654-8. 17. gesteland ph, wagner mm, chapman ww, espino ju, tsui fc, gardner rm, et al. rapid deployment of an electronic disease surveillance system in the state of utah for the 2002 olympic winter games. proc amia symp 2002;2859. 18. weber sg, pitrak d. accuracy of a local surveillance system for early detection of emerging infectious disease. jama 2003;290:596-8. 19. malison md. surveillance in developing countries. in: halperin w, baker eljr, monson rr, editors. public health surveillance.new york: van nostrand reinhold; 1992. p. 56-61. 20. world health organization, dept.of communicable disease surveillance and response. global outbreak alert and response. report of a who meeting geneva, switzerland 26-28 april, 2000 (who/cds/csr/2000.3). 21. centers for disease control. framework for evaluating public health surveillance systems for early detection of outbreaks. mmwr morb mortal wkly rep 2004;53:1-14. 22. centers for disease control. framework for evaluating syndromic surveillance systems for bioterrorism preparedness. mmwr morb mortal wkly rep 2004;53(rr-5):1-14. 23. grein tw, kamara kb, rodier g, plant aj, bovier p, ryan mj, et al. rumors of disease in the global village: outbreak verification. emerg infect dis 2000;6:97-102. 24. world health organization. regional office for europe. the dubrovnik pledge on surveillance and prioritization of infectious diseases: report on a who meeting, bucharest, romania 21-23 november, 2002. 25. the albanian center for economic research (acer). un common country assessment: albania; 2002. 26. nuri b. health care systems in transition – albania; 2002. 27. valenciano m, bergeri i, jankovic d, milic n, parlic m, coulombier d. strengthening early warning function of surveillance in the republic of serbia: lessons learned after a year of implementation. euro surveill 2004;9:24-6. 28. valenciano m, pinto a, coulombier d, hashorva e, murthi m. surveillance of communicable diseases among the kosovar refugees in albania, april-june 1999. euro surveill 1999;4:92-5. 29. kakarriqi e. survejanca e shendetit publik. leksion per specializantet pasuniversitare te fakultetit te mjekesise (universiteti i tiranes); 2003 (in albanian). 30. kakarriqi e. epidemiologjia e semundjeve infektive ne shqiperi (1960-2001) dhe kontrolli e parandalimi i tyre ne kontekstin: fatkeqesite natyrore dhe semundjet infektive. tiranë; 2003 (in albanian). _____________________________________________________________________________________________ © 2022 tomini et al; this is an open access article distributed under the terms of the creative commons attribution license (http:// creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. mone, i, kraja b, hyska g, burazeri g. chocolate intake is associated with a lower body mass index in adult men and women in transitional albania (original research). seejph 2021, posted: 02 april 2021. doi : 10.11576/seejph-4297 p a g e 1 | 9 original research chocolate intake is associated with a lower body mass index in adult men and women in transitional albania iris mone1,2, bledar kraja1,2, jolanda hyska1, genc burazeri1,3 1 university of medicine, tirana, albania; 2 university hospital center mother theresa, tirana, albania; 3 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands. corresponding author: iris mone, md, phd address: rr. “dibrës”, no. 371, tirana, albania telephone: +355692149301; e-mail: iris_mone@yahoo.com acknowledgments: genc burazeri was a recipient of an irma milstein international fellowship at the hebrew university–hadassah school of public health and community medicine, jerusalem, israel, which provided support for the study. mone, i, kraja b, hyska g, burazeri g. chocolate intake is associated with a lower body mass index in adult men and women in transitional albania (original research). seejph 2021, posted: 02 april 2021. doi : 10.11576/seejph-4297 p a g e 2 | 9 abstract aim: in light of the controversial evidence regarding health effects of chocolate intake, we aimed to assess its association with body mass index (bmi) among adult individuals in albania, a transitional post-communist country in south eastern europe which has traditionally employed a mediterranean dietary pattern. methods: a cross-sectional study was conducted in 2003-2006 involving a population-based sample of 737 tirana residents aged 35-74 years (469 men, 268 women; overall response: 70%). of these, 565 individuals (373 men and 192 women) provided data on chocolate intake and anthropometrics (77% of the sample). a 105-item food frequency questionnaire, including chocolate consumption, was administered to all individuals. nine categories were used to assess the average frequency of intake of each food item in the past 12 months. in the analysis, chocolate intake was dichotomized into: consumption of <1/month vs. ≥1/month. a physical examination included measurement of weight and height. furthermore, information on socio-demographic characteristics and classical risk factors was collected. multivariable-adjusted general linear model was used to calculate the mean bmi values by chocolate intake groupings. results: upon simultaneous adjustment for socio-demographic characteristics, classical risk factors and nutritional factors, there was an inverse association between bmi and chocolate intake in both sexes (sex-pooled mean bmi: 26.1 among participants who consumed chocolate <1/month vs. 27.0 in those with an intake of ≥1/month; p<0.001). conclusions: this study points to a beneficial effect of moderate chocolate intake on lowering bmi, which deserves further vigorous investigation and replication in prospective studies in albania and other populations. keywords: albania, body mass index, chocolate, cross-sectional study, epidemiology. mone, i, kraja b, hyska g, burazeri g. chocolate intake is associated with a lower body mass index in adult men and women in transitional albania (original research). seejph 2021, posted: 02 april 2021. doi : 10.11576/seejph-4297 p a g e 3 | 9 introduction chocolate is a typical sweet food that evokes ambivalent feelings: pleasure as the result of its taste, flavor and appearance, and concerns as the results of its content with high sugar and calorie (1). therefore, previous epidemiological studies have observed healthy and unhealthy effects of chocolate intake. several studies have reported a positive link between frequent chocolate intake and a lower body mass index (bmi) (2,3), or a reduction in the risk of cardio-metabolic disorders (4) and diabetes (5). furthermore, chocolate consumption has been linked to beneficial effects on human health and diseases (6) including cardiovascular health (7,8) blood pressure and vascular function (9). however, a cross-sectional study reported a positive association between chocolate intake and bmi in a dose-response pattern (10). hence, according to this report, the positive relationship between chocolate intake and a lower body mass was evident only among participants with preexisting serious obesityrelated illness (10). also, a meta-analysis of 10 observational studies concluded that the evidences on the association between chocolate intake and cvd risk need to be confirm in further studies (11). in light of the controversial evidence regarding health effects of chocolate intake, we aimed to assess its association with bmi among adult individuals of both sexes in albania, a transitional post-communist country in south eastern europe which has traditionally employed a mediterranean dietary pattern. methods a cross-sectional study involving a representative sample of 35-74-year-old residents of tirana, the albanian capital, was conducted in 2003-2006 (12). study population and sampling the sample consisted of an age-and-sexstratified random sample from the adult population of the tirana municipality, as registered in the albanian census of april 2001. we sampled a total of 1200 individuals, 720 men and 480 women (12). of the estimated 1046 subjects (644 men and 402 women) who met the eligibility criteria (12), 737 individuals participated in the study (469 men, 268 women; overall response: 70%). data collection a semi-quantitative food frequency questionnaire (ffq), consisting of 105 food items including chocolate consumption, was administered to all individuals (13). participants were asked to indicate how often, on average, they had eaten specified amounts of each food item in the past 12 months. nine categories were used to assess the average frequency of intake of each food item: <1/month, 1-3/month, 1/week, 2-4/week, 56/week, 1/day, 2-3/day, 4-5/day, and >6/day. in the analysis, chocolate intake was dichotomized into: consumption of <1/month vs. ≥1/month. microdiet, version 2 (downlee systems limited, uk, 2005) was employed to calculate for each food item the daily calorie intake. the respective values for all 105 food items were added up in order to get a summary score for each participant (13) for the total daily calorie intake expressed in kcal, protein, fat and carbohydrate (in the analysis, all expressed as percentage of total calorie intake) and sfa, mufa, pufa and trans fatty acid intake (in the analysis, all expressed as g/daily calories*100). in addition, information on socio-demographic characteristics (age and educational level) and classical risk factors (physical exercise and alcohol intake) was collected for each participant. furthermore, a physical examination included measurement of weight and height (based on which we calculated the mone, i, kraja b, hyska g, burazeri g. chocolate intake is associated with a lower body mass index in adult men and women in transitional albania (original research). seejph 2021, posted: 02 april 2021. doi : 10.11576/seejph-4297 p a g e 4 | 9 body mass index [bmi]: kg/m2) and waist and hip circumferences (based on which we calculated the waist-to-hip ratio [w/h]) (12). the study was approved by the albanian committee of medical ethics. participants gave written consent after being informed about the aims and procedures of the study. statistical analysis the statistical analysis included 565 individuals (373 men and 192 women) for whom data on chocolate intake and anthropometric measurements were available (565/737=77% of the overall sample of study participants). general linear model was used to assess the association between chocolate consumption and socio-demographic characteristics (age and education) and behavioral factors (exercise, alcohol intake, bmi, w/h and nutrients), separately in men and women. age-adjusted mean values and their respective 95% confidence intervals (95%cis) were calculated for each covariate by the two categories of chocolate intake (<1/month vs. ≥1/month). subsequently, multivariable-adjusted (footnote to table 2) mean bmi values and their respective 95%cis were calculated by the two categories of chocolate intake (<1/month vs. ≥1/month), separately in men and women. spss (statistical package for social sciences, version 19.0), was used for all the statistical analyses. results mean age was significantly higher among women who reported chocolate intake at least once per month compared with their counterparts who consumed chocolate <1/month (56 years vs. 50 years, respectively; p<0.001) – a finding which was not evident in men (table 1, upper panel). mean educational level was not significantly different between the two groups distinguished by frequency of chocolate intake in either sex. a similar finding was evident for alcohol intake, notwithstanding the particularly low consumption of alcohol among women. conversely, in both sexes, participants who reported chocolate consumption of ≥1/month were more physically active than individuals who reported a chocolate intake of <1/month (in men: 201 kcal vs. 87 kcal, respectively, p<0.001; in women: 164 kcal vs. 95 kcal, respectively, p<0.001). furthermore, mean bmi was considerably lower among participants who consumed chocolate ≥1/month than those who consumed chocolate <1/month (in men: 26 vs. 28, respectively, p<0.001; in women: 25 vs. 27, respectively; p<0.001). in men only, mean w/h was significantly lower among participants who reported a chocolate intake ≥1/month compared with individuals who consumed chocolate <1/month (0.93 vs. 0.95, respectively; p<0.001). in both sexes, the total calorie intake was significantly higher among individuals who consumed chocolate ≥1/month than those who consumed chocolate <1/month (table 1, lower panel). in men only, a higher chocolate intake was related to a lower protein (as percentage of total calories), whereas in women only a higher chocolate consumption was associated with higher total fats. in men, a higher chocolate intake was related to higher total carbohydrates, whereas in women there was evidence of the opposite. in both sexes, pufa level (g/daily calories) was significantly higher among participants who consumed chocolate ≥1/month than those who consumed chocolate <1/month. in women only, mufa level was higher in participants with a higher chocolate consumption. on the other hand, in men only, there was evidence of a higher level of trans fatty acids in those who consumed chocolate ≥1/month compared to those who consumed chocolate <1/month. mone, i, kraja b, hyska g, burazeri g. chocolate intake is associated with a lower body mass index in adult men and women in transitional albania (original research). seejph 2021, posted: 02 april 2021. doi : 10.11576/seejph-4297 p a g e 5 | 9 table 1. association of chocolate intake with socio-demographic characteristics, conventional risk factors and nutrient intake in a population-based sample of albanian adults; age-adjusted mean values from general linear models upper panel: socio-demographic and classical risk factors men (n=373) women (n=192) n* mean 95%ci p n* mean 95%ci p age (years): <1/month ≥1/month 146 227 52.1 51.8 50.5-53.7 50.5-53.1 0.742 74 118 55.7 50.0 53.3-58.0 48.2-51.9 <0.001 education (years): <1/month ≥1/month 146 226 11.8 11.2 11.3-12.4 10.7-11.6 0.060 72 118 10.9 10.6 10.1-11.8 9.9-11.2 0.514 alcohol intake (drinks/week): <1/month ≥1/month 146 226 3.6 4.4 2.4-4.8 3.4-5.4 0.320 73 118 0.8 0.6 0.2-1.3 0.2-1.1 0.657 physical exercise (kcal): <1/month ≥1/month 146 225 86.8 201.5 69.5-104.1 187.5-215.4 <0.001 71 117 94.7 164.4 76.1-113.4 150.0-178.7 <0.001 bmi: <1/month ≥1/month 146 226 28.0 25.8 27.5-28.5 25.4-26.2 <0.001 74 118 27.1 24.7 26.3-27.9 24.0-25.3 <0.001 w/h: <1/month ≥1/month 146 226 0.95 0.93 0.94-0.95 0.92-0.94 <0.001 74 118 0.87 0.86 0.86-0.88 0.85-0.87 0.139 lower panel: nutrients men women n* mean 95%ci p n mean 95%ci p total calorie intake (kcal): <1/month ≥1/month 146 227 2909 3186 2824-2996 3117-3255 <0.001 74 118 2431 2711 2333-2529 2634-2788 <0.001 total proteins (% of calories): <1/month ≥1/month 146 227 17.9 16.8 17.6-18.2 16.6-17.1 <0.001 74 118 17.7 17.6 17.4-18.0 17.4-17.9 0.670 total fats (% of calories): <1/month ≥1/month 147 227 35.1 35.5 34.5-35.6 35.0-35.9 0.281 74 118 38.3 39.8 37.6-39.0 39.3-40.4 0.001 total carbohydrates (% of calories): <1/month ≥1/month 146 227 47.4 48.2 46.8-48.1 47.7-48.7 0.053 74 118 46.1 44.7 45.3-46.9 44.1-45.4 0.013 sfa (g/daily calories*100): <1/month ≥1/month 146 227 1.34 1.32 1.32-1.36 1.30-1.34 0.231 74 118 1.43 1.47 1.40-1.46 1.45-1.49 0.038 mufa (g/daily calories*100): <1/month ≥1/month 146 227 1.48 1.50 1.45-1.51 1.48-1.52 0.395 74 118 1.65 1.71 1.60-1.69 1.68-1.75 0.018 pufa (g/daily calories*100): <1/month ≥1/month 146 227 0.76 0.83 0.74-0.78 0.81-0.85 <0.001 74 118 0.86 0.94 0.83-0.90 0.91-0.96 0.002 trans (g/daily calories*100): <1/month ≥1/month 146 227 0.022 0.024 0.021-0.023 0.023-0.025 0.003 74 118 0.025 0.025 0.024-0.027 0.023-0.026 0.378 * discrepancies in the totals are due to missing covariate values. mone, i, kraja b, hyska g, burazeri g. chocolate intake is associated with a lower body mass index in adult men and women in transitional albania (original research). seejph 2021, posted: 02 april 2021. doi : 10.11576/seejph-4297 p a g e 6 | 9 in crude/unadjusted models (table 2, model 1), mean bmi was substantially lower among participants who consumed chocolate ≥1/month compared to those who consumed chocolate <1/month (sex-pooled mean bmi: 25.3 vs. 27.5, respectively; p<0.001). adjustment for age (model 2) did not affect the findings (sex-pooled mean bmi: 25.2 vs. 27.5, respectively; p<0.001). table 2. association of chocolate intake with bmi; unadjusted and multivariable-adjusted mean bmi values by sex model men (n=373) women (n=192) overall (n=565)* mean 95%ci p mean 95%ci p mean 95%ci p model 1†: <1/month ≥1/month 27.98 25.79 27.4728.49 25.3826.21 <0.001 26.94 24.77 26.1227.76 24.1225.42 <0.001 27.46 25.28 27.0227.91 24.9225.64 <0.001 model 2‡: <1/month ≥1/month 27.99 25.79 27.4828.50 25.3826.20 <0.001 27.10 24.67 26.2727.94 24.0225.33 <0.001 27.52 25.23 27.0827.97 24.8925.61 <0.001 model 3¶: <1/month ≥1/month 27.00 26.41 26.5827.42 26.0826.74 0.046 26.47 24.86 25.8327.11 24.3925.34 <0.001 27.04 26.13 26.6627.41 25.8426.43 <0.001 * adjusted for sex. † model 1: crude/unadjusted models. ‡ model 2: adjusted for age. ¶ model 3: adjusted for age, education, exercise, alcohol intake and w/h, total calorie intake, protein, fat and carbohydrate (all expressed as percentage of total calorie intake) and sfa, mufa, pufa and trans fatty acid intake (all expressed as g/daily calories*100). upon simultaneous adjustment for all covariates (model 3), the inverse association between bmi and chocolate intake was attenuated but nevertheless remained statistically significant in both sexes (sex-pooled mean bmi: 26.1 vs. 27.0, respectively; p<0.001). discussion we found a strong inverse relationship between frequency of chocolate intake and bmi, which was consistent in both sexes and persisted upon adjustment for a wide array of socio-demographic characteristics and behavioral factors including nutrient intake as assessed by a detailed ffq. the results of the present study are comparable with a previous study conducted by golomb et al. (2), which examined the crosssectional relationship of chocolate intake and bmi among american adults. they reported that chocolate consumption frequency is linked to lower bmi in unadjusted model (p=0.008) and in adjusted models adding age, sex, activity, saturated fats, fruit and vegeta mone, i, kraja b, hyska g, burazeri g. chocolate intake is associated with a lower body mass index in adult men and women in transitional albania (original research). seejph 2021, posted: 02 april 2021. doi : 10.11576/seejph-4297 p a g e 7 | 9 bles, mood and calories (p=0.001). also, another study found that high chocolate consumption was associated with lower bmi, body fat and waist circumference in young people regardless of different confounders (age, sex, total energy, saturated fats, fruit and vegetable, and physical activity) (3). one possible explanation for these findings is due to the fact that the caloric components as well as the other biologically active components of the food could influence bmi. hence, the observed inverse association between chocolate consumption and bmi may relate to the effects of other biologically active components of chocolate such as flavanols including catechin, epicatechin, and procyanidins which have a variety of beneficial physiologic actions (6). flovanols promote the release of nitric oxide which has been shown to increase oxidation of fatty acids and glucose in skeletal muscle, inhibits fat synthesis in adipose tissue, and stimulates lipolysis in adipocytes (6). the netherlands cohort study after 14 years of follow-up reported that women with the highest dietary intake of total flavonols had significantly lower increases in bmi than women with the lowest intake, over time (0.41 and 0.91, respectively; p<0.05), suggesting a favorable effect of dietary flavanols intake on maintaining of body weight (14). additionally, animal studies have shown that dietary flovanols intake may possibly reduce weight gain through effects of epicatechin and catechin on target tissues (15,16). epicatechin improves the mitochondrial content, structure and function as well as capillarity of skeletal muscle (15), whereas catechin increases energy expenditure, decreases fatty acid synthase levels in adipose tissue and inhibits adipocyte differentiation (16). another explanation for the observed findings may relate to the effect of chocolate consumption on appetite and satiety. massolt et al. have shown that chocolate eating and smelling both could reduce appetite (17) whereas in a randomized, controlled study, tey et al. demonstrated that chocolate consumption could decrease satiety (18). these findings suggest that chocolate consumption may aid for weight maintenance as a result of early termination of food intake. the main advantages of this study are its community-based design which included men and women from general population of albania and use of a validated questionnaire for assessment of nutrient intake and physical activity. the ffq we used for measurement of dietary patterns was customized to the albanian context and previously validated in a small sample of albanian adults of both sexes. seemingly, there is no plausible reason to assume differential reporting among participants distinguished by socioeconomic characteristics or bmi groupings. nevertheless, we cannot entirely exclude the possibility of information bias. our study has other limitations. the response rate raises the possibility of selection bias. male non-respondents, in addition to being older than participants, were more likely to be retired; however, exclusion of retirees from the analysis did not affect the magnitude of the association. in women, respondents and non-respondents were more similar. if non-response among thinner individuals was associated with higher chocolate intake, this could attenuate the findings. conversely, if obese individuals who did not respond tended to employ a higher chocolate consumption, this could spuriously strengthen the findings, but would be unlikely to rule out the entire association. also, importantly, the data included in this analysis are old. in conclusion, our findings point to a beneficial effect of moderate chocolate intake on lowering the body mass, which deserves further vigorous investigation and replication in mone, i, kraja b, hyska g, burazeri g. chocolate intake is associated with a lower body mass index in adult men and women in transitional albania (original research). seejph 2021, posted: 02 april 2021. doi : 10.11576/seejph-4297 p a g e 8 | 9 prospective studies in albania and other populations. conflicts of interest: none declared. references 1. roeline g. kuijer, jessica a. boyce. chocolate cake. guilt or celebration? associations with healthy eating attitudes, perceived behavioural control, intentions and weight-loss. appetite 2014;74:48–54. 2. golomb ba, koperski s, white hl. association between more frequent chocolate consumption and lower body mass index. arch intern med 2012;172:519-21. 3. magdalena cuenca-garc, jonatan r. ruiz, francisco b. ortega, manuel j. castillo. association between chocolate consumption and fatness in european adolescents. nutrition 2014;30:236–9. 4. buitrago-lopez a, sanderson j, johnson l, warnakula s, wood a, di angelantonio e, franco oh. chocolate consumption and cardiometabolic disorders: systematic review and meta-analysis. bmj 2011;343:d4488. 5. greenberg ja. chocolate intake and diabetes risk. clin nutr 2015;34:129133. doi: 10.1016/ j.clnu.2014.02.005. 6. katz dl, doughty k, ali a. cocoa and chocolate in human health and disease. antioxid redox signal 2011;15:2779e811. 7. corti r, flammer aj, hollenberg nk, lüscher tf. cocoa and cardiovascular health. circulation 2009;119:1433-41. 8. fernández-murgaa, j.j. tarínb, m.a. garcía-perezc, a. canoa. the impact of chocolate on cardiovascular health. maturitas 2011;69:312–21. 9. sudano i, flammer aj, roas s, enseleit f, ruschitzka f, corti r, noll g. cocoa, blood pressure, and vascular function. curr hypertens rep 2012;14:279-84. 10. greenberg ja, brian buijsse b. habitual chocolate consumption may increase body weight in a dose-response manner. plos one 2013;8:e70271. 11. zhizhong zhang, gelin xu, xinfeng liu. chocolate intake reduces risk of cardiovascular disease: evidence from 10 observational studies. int j cardiol 2013;168:5448–77. 12. burazeri g, kark jd. hostility and acute coronary syndrome in a transitional post-communist muslim country: a population-based study in tirana, albania. eur j public health 2011;21:469-76. 13. mone i, bulo a. total fats, saturated fatty acids, processed foods and acute coronary syndrome in transitional albania. mat soc med. 2012;24:91-3. 14. hughes la, arts ic, ambergen t, brants ha, dagnelie pc, goldbohm ra, et al. higher dietary flavone, flavonol, and catechin intakes are associated with less of an increase in bmi over time in women: a longitudinal analysis from the netherlands cohort study. am j clin nutr 2008;88:1341–52. 15. nogueira l, ramirez-sanchez i, perkins ga, et al. (-)-epicatechin enhances fatigue resistance and oxidative capacity in mouse muscle. j physiol 2011;589(pt 18):4615-31. 16. wolfram s, raederstorff d, wang y, et al. teavigo (epigallocatechin mone, i, kraja b, hyska g, burazeri g. chocolate intake is associated with a lower body mass index in adult men and women in transitional albania (original research). seejph 2021, posted: 02 april 2021. doi : 10.11576/seejph-4297 p a g e 9 | 9 © 2021 mone et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. gallate) supplementation prevents obesity in rodents by reducing adipose tissue mass. ann nutr metab 2005;49:54–63. 17. massolt et, van haard pm, rehfeld jf, posthuma ef, van der veer e, and schweitzer dh. appetite suppression through smelling of dark chocolate correlates with changes in ghrelin in young women. regul pept 2010;161:81–6. 18. siew ling tey, rachel c brown, andrew r gray, alexandra w chisholm, conor m delahunty. long-term consumption of high energy-dense snack foods on sensoryspecific satiety and intake. am j clin nutr 2012;95:1038–47. ____________________________________________________________________________ sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 09 august 2020. doi : 10.4119/seejph-3614 p a g e 1 | 15 case study how the largest slum in india flattened the covid curve? a case study monalisha sahu1, madhumita dobe1 1 department of health promotion and education, all india institute of hygiene and public health, west bengal, india. corresponding author: monalisha sahu; address: 110, chittaranjan avenue, kolkata 700073, west bengal, india. telephone: +91 9873927966 e-mail: drmonalisha@outlook.com sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 2 | 15 abstract mumbai-the economic capital of india, shrivelled with panic as its infamous slum ‘dharavi’ recorded its first positive case of covid-19 on 1st april 2020. dharavi is the largest slum in india and one of the most densely populated areas in the world. its narrow lanes, teeming with people and chock-a-block with settlements, make physical distancing practically impossibleposing as an excellent breeding ground for the deadly virus. however, with a policy of ‘chasing the virus’ based on strategy of ‘tracing tracking testing and treating’ dharavi flattened its epidemic curve within a hundred days. this was achieved through the immediate public health response with strict containment measures, aggressive active and passive surveillance and integration of resources from government and private sectors to provide essential services. in this paper, we have summarized the ongoing measures for successful prevention and control of covid-19 in dharavi, which could provide useful learning for other similar settings worldwide. keywords: containment measures, covid-19, india, megacity-slum, mumbai. conflicts of interest: none declared. acknowledgments: to the health staff and officers of brihan mumbai corporation. author contributions: ms conceptualized the idea and wrote the first draft; md & ms reviewed and edited the final version. all authors have read and agreed to the published version of the manuscript. sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 3 | 15 background on the first day of april 2020 when the first case of covid-19 got diagnosed with subsequent death in baliga nagar dharavi, mumbai authorities sensed their worst nightmare was about to begin. people feared that the deadly virus may have already possibly taken a firm grip on the overcrowded shanties. what followed next was several deaths one after another as the sars cov-2 virus started spreading swiftly even amidst nationwide lockdown with a growth rate of 12% and doubling period of 18 days (1, 2). it took a little over a fortnight for dharavi to add 100 cases to its tally and by may 3, it crossed the 500 mark. till may 6, the doubling rate of covid-19 cases in dharavi was shortened to six days. subsequently, dharavi emerged as one of the most challenging hotspots in india (3). multiples strict measures to contain the spread have been implemented since the beginning of the outbreak in dharavi in april 2020. these measures resulted in the low spread of cases and reduced mortality by june 2020. this paper aims to focus on documenting the control measures taken to stop the spread of covid-19 in one of the world’s densest slums. the information presented in the paper was obtained through the analysis of recent policies, official press, articles, reports, presentations, and credible data sources. a thematic approach to analysis was used to identify the emerging lessons, which then informed the structure of the reported results. ms excel and google maps were used for processing the data and preparing spot maps of the containment zone. i. what makes dharavi such a ticking time bomb? located in the g north municipal ward of mumbai, dharavi is home to around 1 million people living in a 2.16 square kilometres maze of narrow, haphazard, dirty lanes, in shanties and ramshackle buildings next to open sewers. its narrow passages, overcrowded houses, miserable, unsafe and unhygienic living conditions offer the perfect breeding ground for pathogens like sars cov-2 (4). figure 1. administrative map of mumbai with ward divisions (4) * dharavi is located in g north ward of mumbai with mahim & dadar. sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 4 | 15 ii. the socio-demographic milieu dharavi is home to an estimated one million people with a population density of 270,000 per square kilometre, living mostly in g+1 low rise building, where upper floor act as factories (2). they mostly eke out a living as factory workers in some 5,000 small factories and 15,000 single-room workshops of leather, pottery and textile stitching businesses. many of its residents’ work as helpers and chauffeurs to the financial capital mumbai's well-heeled residents. dharavi also serves as the plastic recycling hub of mumbai. the original inhabitants of dharavi were kolis the fishermen but today their number is less than 2%. majority of dharavi population is made of migrants both formal and informal mostly from other districts of maharashtra, tamil nadu, gujrat, up and bihar (5). there has been slight increase of migrants from up and bihar over the last few years, and they mostly form the informal floating population of dharavi. most of them are informal dailywage workers who don't cook at home and go out to get their food on daily basis. figure 2. segmentation of residents living in dharavi* * formal migrants are mostly from states of other parts of maharashtra, gujrat and tamilnadu, whereas floating population is mostly from states of uttar pradesh & bihar. the situation became worse for the migrant workers when in view of the ongoing covid-19 pandemic, india went into nationwide lockdown on march 25, 2020, for maintaining adequate social distance to stop spread of the disease (1). many of the migrant workers living in dharavi left for their villages before the lockdown could be strictly implemented, possibly taking the virus far and wide. however, an even bigger number of migrant workers were struck in the slum with no money to buy food or other essential items. sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 5 | 15 iii. unsafe physical environment urban slums of dharavi constitute one of the most disadvantaged sections of society. health is a major challenge in the slums of dharavi, were the struggles to maintain it are faced with multi-layered challenges like: a. overcrowding: in dharavi eight to 10 people live typically in a cramped 150 sq. ft shanty with no natural light or ventilation and without provision for safe drinking water, sanitation or other basic services. b. poor sanitation: most of the (80%) slum households did not have a private toilet facility inside their homes (2). the limited public lavatories they share are filthy, unhygienic and unsafe. mahim creek is a local river that is widely used by local residents for open urination and defecation. also, the open sewers in the city drain to this creek facilitating the spread of contagious diseases. c. unsafe drinking water: in dharavi 30% of the residents don’t have kitchen in their houses and depend on outside food (6,7). almost 35% of the residents need to step out of their homes to collect drinking water from public taps, tube wells, and wells stationed throughout the slum (6,7). insanitary conditions coupled with people crowding around public taps and toilets makes social distancing impossible. also, hourly restrictions on water availability adds to the challenge of washing hands to keep away from infection. there is low acceptance for preventive measures amidst other pressing challenges like food, water and shelter. even simple precautionary measure like regular hand washing and physical distancing are privileges they are unable to afford. they only realize the need for health when it is lost and then most of them are not in position to afford existing medical services. in addition, within a densely packed slum like dharavi many people lack even a postal address, which itself poses unique challenges for health care services. iv. the first few covid-19 cases and contacts transmission investigation (ffx) the index case reportedly was a 56-year-old garment unit owner living in a 320 sqm flat in slum rehabilitation authority (sra) colony, baliga nagar. he initially developed mild cough and fever on 23rd april [8]. when his symptoms worsened even after consulting a local doctor, he was referred and admitted to the civic-run sion hospital where his throat swab was sent for testing. by the time the reports came positive for covid-19 he succumbed to the disease. a five-member team consisting of two medical officers, a sanitary inspector (si) and two community health volunteers (chvs) started contact tracing to identify source of infection and plan how to contain it. the team fanned out in the area to inspect the building and the common spaces between closely constructed squad of five buildings. the area had eight buildings comprising of 300 flats and 91 shops (8,9). during contact tracing it was found that the index case had possibly hosted some people who had attended a religious congregation in nizamuddin delhi in march, which was india’s first big cluster of covid-19 cases (10). based on contact tracing, a list of 15 immediate high-risk contacts including the deceased’s wife, his four sons, two daughters, immediate neighbours, the local doctor the man had visited and two of the staff at the doctor’s clinic were identified and tested. the family’s acquaintances were categorized as low risk and alerted. with the help of pest control officers (pco) the entire building sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 6 | 15 was disinfected and sealed. the sion hospital opd, was shifted outdoors while the building was sanitized. the entire baliga nagar housing society was sealed and declared containment zone with about 2,500 residents stamped for quarantine. parallelly, a nearby sports complex was converted into a 300-bed facility for isolation. a team of police was stationed outside the colony to ensure the quarantine is not violated. a containment officer (co) was deployed at the site to coordinate with the police, the bmc and the residents to ensure the residents get essential supplies like food, milk, water and medicines every day. in addition, six volunteers were identified who could step out for essentials on rotation basis. elderly people with co-morbidities like hypertension, asthma and diabetes were screened and nine particularly vulnerable people with respiratory illness were tested. apart from it, 75 people who came in contact of the visitors from delhi were isolated, in an attempt to break the chain of infection. second case was reported within 24 hrs as a 52-year-old conservancy worker from worli who was on duty in dharavi. third case was of a surgeon resident of vaibhav apartment in dharavi, who was working with one private hospital, which had earlier reported many infections among its healthcare workers. the doctor’s wife also tested positive later. so, all these cases had different source of exposure and were in building setup. the real alarm was set off on 4th april when a positive case was reported from a slum shanty of mukund nagar, where a 48-year-old-man living with his 11 family members in a tworoom house (100 sq. ft) came positive. due to emerging of multiple cases from multiple parts of dharavi, medical camps were started to screen people in areas with multiple cases. gauging the increasing spread maharashtra medical council officials in collaboration with bmc started active surveillance of cases by door-to-door screening. by 25th april total 214 active cases and 13 deaths were recorded mostly from the areas of mukund nagar, azad nagar, dharavi cross road, matunga labour camp and indira nagar. individual slum pockets were grouped together to form high risk zones based on the case load. five such slum pockets in dharavi were identified as hot spots and marked as high risk/red zones (11). within a span of one month, around four lakh residents in dharavi were screened for the symptoms of covid-19 by teams of 24 health practitioners. around 47,500 people were screened in high-risk zones by door-to-door visits by doctors and private clinics, about 14,970 people were screened with the help of mobile vans, and rest were surveyed by bmc health workers. out of these, 2,000 were suspect cases and 600 were subjected to tests. following the screening, about 5,857 were put in institutional quarantine and 31,725 residents were directed to remain under home quarantine. also, around 8246 senior citizens were surveyed and as part of its policy of ‘timely separation’ from the other community to effectively limit the transmission (2). even with all ongoing activities, a whopping 1,400 covid-19 patients were added to the tally by mid-may, a figure almost 380 percent higher than the april figures. with a rise in containment zones to 202 from a mere 49 such zones at the end of april, the hotspots or high-risk zones increased to 10 from five with matunga labour camp, 90 ft road, dharavi cross road, kunchi korve nagar being the particular focus areas due to rising cases (12 sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 7 | 15 figure 3. spatial distribution of five high-risk zones for covid-19 outbreak in dharavi as on 25th april 2020 legend: dharavi borders of dharavi 5 hot spots of covid-19 (dharavi kumbharwada, dharavi cross road, matunga labour camp, kunchikorve nagar, 90 feet road). figure 4. spatial distribution of high-risk zones of dharavi as on 23rd may 2020 legend: dharavi borders of dharavi 10 hot spots of covid-19 (mahim sion link road, rajiv gandhi nagar, mukund nagar, marlyamma temple, muslim nagar, transit camp, kumbharwada, matunga labour camp, chota sion hospital and dharavi cross road). sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 8 | 15 the maximum number of cases in dharavi were reported from the matunga labour camp (55 cases), followed by mukund nagar (49 cases), kumbharwada (45 cases) and dharavi cross road (38 cases). majority of cases in dharavi (75%) were reported in people aged 21 to 60 years. almost 35% of the cases had contracted infection within their families. dharavi also reported increased mortality due to covid10 in may (70 deaths) in comparison with april (18 deaths). v. specific processes and activities in implementation of ‘mission dharavi’ under the clear leadership of brihan mumbai corporation (bmc) the local civic body which is asia’s richest municipality, mission dharavi was launched with a slew of proactive steps to contain the virus (13). at the heart of mission dharavi, the motto was to chase the virus by tracing tracking testing & treating. ‘corona war room’ was launched in the disaster control unit for various activities like planning, prevention and management of the pandemic 24/7 functional. early diagnosis and early treatment were key measures to reduce the new infection and mortality rates. the major activities conducted under ‘mission dharavi’ are as follows: 1. focussed high risk areas with watertight containment zones: bmc’s covid containment strategy included identification of maximum possible containment zones, these are places where positives have been detected and those surrounding areas have been sealed to protect everyone inside and outside from further spread (13). the containment zones were further classified into the following for the purpose of triaging and focussed efforts (14): a. red which are congested areas; b. orange which are congested, but still more manageable than red; c. blue which are the buildings. the state government chalked out a threefold strategy of an effective containment, conducting comprehensive testing and ensuring uninterrupted supply of goods and essential supplies to the community. to make sure the harsh containment worked, officials partnered with non-profits to provide free meals rations and medicine to the residents and migrant workers left jobless by a weeks-long nationwide lockdown. community kitchen were opened to provide food packets (2). the g-north ward also launched a 12-hour helpline number to help people contact bmc for food, grocery, transportation and stay. social media platforms were used to inform residents about relief efforts. 2. perimeter control: to maintain the perimeter control, police were deputed. considering the overcrowding, bmc started monitoring movements within the red zones by drones which alerted police if residents attempted to leave their homes and a fine was imposed. local leaders and youth of the area were identified as volunteers named “corona yodhdhas” (corona warriors) to help the community with procurement of essential commodities. free meals and food rations were provided to residents trapped at home without work and income. 3. early diagnosis: early detection and treatment are of utmost importance for favourable outcomes and reducing the mortality rates (figure 4). dharavi was not only dealing with an increased number of cases but also increased mortality. it was seen that those who were brought late to the facility had higher mortality rates. to ensure early detection of disease targeted testing approach was tried. a. aggressive active surveillance: screening effort involving door to door active surveillance, taking help of private clin sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 9 | 15 ics/doctors, were conducted. teams comprising of community health volunteers (chvs) and local covid volunteers under the leadership of the medical officer conducted door to door active surveillance for cases. each team in personal protective gear on an average visited 100-150 households of high risk and low risk contacts and screened them for fever and oxygen concentration with the help of thermal guns and pulse oximetry. altogether 47,500 people from the high-risk zones and 1.25 lakh residents of containment zones of dharavi were screened (2). this became a game changer. b. passive surveillance at fever camps: fever camps were conducted at regular intervals in strategic locations of the slum. at each camp about 80100 residents were screened every day by medical officer with the help of health workers for fever and blood oxygen levels using infrared thermometers and pulse oximeters. the local private practitioners were also instructed to report and refer all the patients with fever or /and respiratory symptoms like cough, sore throat and shortness of breath to the fever clinics for further testing. those who tested positive were moved to local institutional quarantine facilities with the guidance of health workers. 4. early treatment with triaging of facilities: to ensure proper utilization of limited resources medical care centres for covid 19 were divided in four categories (13): a. corona care centre type 1 (ccc1): these facilities were meant for high-risk contacts and those awaiting reports and were arranged in hotels, lodges, halls or newly constructed buildings, and they don’t have round-the clock medical staff; b. corona care centre type 2 (ccc2) facilities for asymptomatic to mild positive patients. they have round-the clock medical staff and oxygen facilities. food, multi-vitamins and medicines are supplied free of cost to the people admitted; c. dedicated covid health centre (dchc) for moderate to critical patients; d. dedicated covid hospital (dch) for critical patients. there are five covid-19 dedicated hospitals, sai hospital, ayush hospital, life case hospital, family care hospital and prabhat nursing home, for residents of dharavi. the triaging helped in judicial utilization of resources and only critical patients were shifted for admission to hospitals and icus. centralized toll-free number for live availability of icu beds was generated for the community. ambulances and mobile vans with oxygen facility to transfer patients from ccc1/ccc2 to dch as and when required were made available. sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 10 | 15 figure 5. strategy for reducing the new infection rates and mortality due to covid-19 because of these proactive steps, even with limited resources the virus was detected early and promptly treated, increasing the recovery rates and lowering the mortality rates. dharavi reported recovery rate of about 51% as compared to 41% in the rest of mumbai, where most patients reached hospitals late. also, almost 90% of the patients were treated inside dharavi itself (2). 5. institutional quarantine facilities: instead of putting people in home quarantine, the government decided to put high-risk people from dharavi in institutional quarantine because at home they were still sharing the public toilet. in order to increase the capacity of quarantine centres, makeshift shelters and transit camps were erected. schools, colleges, hotels, lodges, marriage halls, sports complexes were transformed into quarantine centres, equipped with facilities like lights, fans, charging points & daily usable. the g north ward prepared a capacity of about 3,000 quarantine beds in facilities like rajiv gandhi sports complex, dharavi municipal school, manohar joshi vidyalaya, d’silva high school, ruparel college hostel, scout & guide hall, mahim nature park, and various other hotels and lodges in the ward. the ratio of positive to institutional quarantined ratio increased to 1:5.45 in may from 1:3.381 in april (15). every person in the isolation centres received three meals and round-theclock medical supervision free of cost. taking care of the religious sentiments during ramadan -the muslim holy month, authorities ensured they got fruits and dates and distributed proper meals at appropriate times for breaking their religious fasts at sunset. such activities increased the acceptance of institutional quarantine in the community. also, mental health aspect of quarantine inmates sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 11 | 15 was taken care of with the help of dedicated counsellors, yoga and meditation sessions. 6. improved sanitation: poor sanitation in community toilets in dharavi have been the key source of spread of infectious diseases like covid. in order to improve sanitation, the 225 public toilets were disinfected and fumigated twice daily. the g north ward also installed foot operated devices for using washbasins, toilet flush, and so on. public awareness campaigns about sanitising hands and washrooms were regularly conducted (16). 7. social mobilization processes were undertaken, exploring opportunities and innovative means to bring together all societal influences to raise awareness, like local leaders and bollywood stars to assist in the delivery of services and resources. it included: a. community engagement: community engagement is central to any public health intervention even more so during public health emergencies. it involves those affected in understanding the vulnerabilities they face, and involves them in response actions. the dharavi model adopted the process of working collaboratively with and through groups of people in the affected community to address issues to bring about environmental and behavioural changes that will improve the health of the community members. this involved recruitment of local volunteers to influence and serve as catalysts for changing practices, reaching out to and informing the community of policy directions of the government and build community awareness and understanding. frontline health workers played critical roles in the prevention by providing health education on preventive measures for all people in the containment zones. the transparency of updated information and clear communication messages on covid-19 through official and social media were important contributors to changing community behaviours towards wearing masks, hand washing, and social distancing, from february 2020. b. public private partnership (ppp): even when covid care facilities were ready, arrangement of manpower to run them was a real challenge. to tackle the issue of trained health workforce strategic public private partnerships were forged and all available ‘private’ practitioners from the nine dispensaries and 350 private clinics located in dharavi were roped in. all practitioners were encouraged and supported with resources to open their clinics to attend to the patients and communicate to bmc in case any covid-19 suspects were found. the added advantage of including the private practitioners was that they had the trust and confidence of the residents who will approach them even for slight fever, or any other symptoms making it easy for screen and test. 8. exodus of migrants: apart from the above initiatives, reverse migration of thousands of migrant workers residing in dharavi, towards their homes in other states also contributed directly and indirectly towards decreasing the case load in dharavi. vi. temporal variation of cases and the epidemic curve with the strategy of actively ‘chasing the virus’, the epidemic curve of dharavi displayed signs of flattening by late may (figure 3). a steady decline in the number of covid-19 cases was observed in late may which continued in june when daily reported new infections dropped to 5 cases in third week of june sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 12 | 15 from a high of 94 cases a day in early may (13). figure. 6. temporal variation in number of new covid-19 cases in dharavi legends: no. of cases the drop in the new cases in dharavi was also associated with a steep rise in the doubling time of 18 days in the last week of april to 78 days as of june 19. the growth rate declined to 1.02% and the case fatality rate dipped to 3.7% by the month of june (2,13). figure 7. comparative analysis of covid 19 growth rate and doubling time for dharavi 0 20 40 60 80 100 120 3/10/2020 3/30/2020 4/19/2020 5/9/2020 5/29/2020 6/18/2020 7/8/2020 n o . o f n e w c a se s days 12% 4.30% 1.02% 5% 4% 3.70% 0% 2% 4% 6% 8% 10% 12% 14% apr-20 may-20 jun-20 growth rate case fatality rate dp=18 dp =43 days dp=78 days sahu m, dobe m. how the largest slum in india flattened the covid curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 13 | 15 the ministry of health and family welfare (mohfw) also mobilized provision of medical equipment and organized several site visits for central inter-ministerial and public health teams to support local health facilities to prepare for combating covid-19. vii. challenges dharavi’s war against the virus is still far from over. the severe lockdown measures can’t continue forever. though relief efforts for providing food and ration are continued in the area, many are still not able to procure them and are forced to step out of their home to arrange meals. upcoming monsoon with waterlogging can pose a serious threat on the makeshift quarantine facilities. also, monsoon will increase the burden of other communicable diseases like dengue and malaria, which will further overburden the health system. with the unlock and start of local trains, buses and other modes of transportation the virus can easily make its way back to the slum. the community still lack awareness, and many are ignorant to preventive measures like wearing masks properly and maintaining physical distance. hence, the chances of a second wave in near future cannot be denied. arranging trained health workforce and icu beds can be difficult with the already overburdened health workers and health system. therefore, there should be continued administrative measures and screening at all points of entry till the virus is chased out from the state and the country which is again a challenge. conclusion almost a hundred days after dharavi began its fight against covid-19, asia’s largest slum seems to have flattened the curve. the dharavi model is based on the dogged approach to “chase the virus” by screening, contact-tracing and isolating infected patients along with multi-sectoral approach, social mobilization and community engagement. however, for sustaining the ‘mission dharavi win’, it is important to resolve the environment and sanitation issues on a longterm basis. this chase the virus approach could also be used as an example in similar settings like slums in pakistan, bangladesh, favelas of brazil or shanty towns in south africa. however, the wider applicability of these experiences is subject to differences in socio-political environments and further remodelling of this strategy can be done to fit the contextspecific needs of the affected communities. references 1. government of india. press information bureau, delhi. government of india issues orders prescribing lockdown for containment of covid19 epidemic in the country. new delhi, march 24, 2020. available from: https://www.mha.gov.in/sites/default/files/pr_nationallockdown_26032020_0.pdf (accessed: july 2, 2020). 2. press information bureau, delhi. covid-19 updates. “chasing the virus” in dharavi, and ensuring a steep decline of daily cases from an average 43 in may to 19 in third week of june. june 21, 2020. available from: https://pib.gov.in/pressreleasepage.aspx?prid=1633177 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curve? a case study (case study). seejph 2020, posted: 07 august 2020. doi:10.4119/seejph-3614 p a g e 15 | 15 © 2020 sahu et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 13. brihan mumbai municipal corporation. department of health. stop corona in mumbai. available from: https://stopcoronavirus.mcgm.gov.in/iom-treatmentfacilities (accessed: july 2, 2020). 14. mumbai live. mumbai’s containment areas to be classified into red, orange, and blue zones based on the severity of cases. may 2, 2020. available from: https://www.mumbailive.com/en/infrastructure/mumbai's-containment-areas-to-be-classified-into-red-orange-and-blue-zonesbased-on-the-severity-of-cases48568 (accessed: july 2, 2020). 15. daily hunt. bmc has quarantined over 6,500 at its facility in dharavi so far. may 18, 2020. available from: https://m.dailyhunt.in/news/india/english/mumbai+live+englishepaper-mliveng/bmc+has+quarantined+over+6+500+at+its+facility+in+dharavi+so+far-newsidn185467382 (accessed: july 2, 2020). 16. bmc. embracing innovation to take on the virus! june 23, 2020. available from: https://twitter.com/mybmc/status/1275386375945154562 (accessed: july 2, 2020). ______________________________________________________ https://stopcoronavirus.mcgm.gov.in/iom-treatment-facilities https://stopcoronavirus.mcgm.gov.in/iom-treatment-facilities https://stopcoronavirus.mcgm.gov.in/iom-treatment-facilities https://www.mumbailive.com/en/infrastructure/mumbai's-containment-areas-to-be-classified-into-red-orange-and-blue-zones-based-on-the-severity-of-cases-48568 https://www.mumbailive.com/en/infrastructure/mumbai's-containment-areas-to-be-classified-into-red-orange-and-blue-zones-based-on-the-severity-of-cases-48568 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social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 1 | 20 original research successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being valery chernyavskiy1, helmut wenzel2, julia mikhailova1, alla ivanova1,3, elena zemlyanova1,3, vesna bjegovic-mikanovic4, alexander mikhailov1, ulrich laaser5 1 federal research institute for health organization and informatics of the russian ministry of health, moscow, russian federation; 2 independent consultant, konstanz, germany; 3 institute of socio-political research of the russian academy of sciences, moscow, russian federation 4 university of belgrade, faculty of medicine, institute of social medicine, belgrade, serbia; 5 university of bielefeld, bielefeld school of public health, bielefeld, germany. corresponding author: prof. dr. med. ulrich laaser; address: bielefeld school of public health, university of bielefeld, germany; e-mail: ulrich.laaser@uni-bielefeld.de chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 2 | 20 abstract context: the ‘northern dimension on public health and social well-being’ is a platform for dialogue and cooperation of countries around the baltic sea, established in 2003, guided by the sustainable development goal 3 on health and social well-being and the strategy for the baltic sea region of the european union adopted in 2009. in this paper we determine the overall progress of the russian federation and its north west federal okrugin in particular, with regard to the reduction of mortality. methods: for the purpose of inter-country comparison and progress over time we make use of age-standardised potential years of life lost (pyll) applied to quantifiable strategic targets, the sustainable development goal 3 on health and social well-being and the european union strategy of the baltic sea region. a gap analysis is performed to determine whether the target achievement is in delay or on track. results: with reference to the baseline of 2009 – corresponding to the most relevant recent period 2009-2020 respectively 2009-2030 – the russian federation as a whole is on track achieving the two strategic targets in advance by 2.7 years. for the north west federal okrug around st. petersburg and kaliningrad bordering the baltic sea the target achievement is estimated to be 4.8 and 10.8 years in advance of the deadlines 2020 and 2030. in comparison to the baltic sea states the russian federation takes a middle position after estonia, latvia and finland. the early target achievement is confirmed if the period 2003-2020 respectively 20032030 is considered. conclusion: although the region is progressing there may be a slowdown towards 2030. a careful analysis is required to determine to which degree the activities of the partnership for health and social well-being have contributed to the success and what should be proposed to increase the impact on premature mortality. keywords: gap analysis, northern dimension, north west federal okrug, premature mortality, public health, russian federation. chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 3 | 20 introduction since 1999 the countries around the baltic sea (figure 1) initiated in several steps a platform for cooperation the ‘northern dimension’(nd) (1,2) with meanwhile four partnerships on culture, environment, health and social well-being, and transport. the ‘northern dimension partnership on public health and social well-being’ (ndphs) (2) was formally established at a ministerial-level meeting on 27 october 2003, in oslo, norway. today the membership comprises ten countries characterised by very diverse population size, history, health status and culture: estonia, finland, germany, iceland, latvia, lithuania, norway, poland, the russian federation, and sweden (denmark is not included) as well as related international organisations, the european union (eu), the baltic sea states sub-regional cooperation (bsssr), the northern dimension institute (ndi), the world health organisation (who-euro) and several more. coordinated by a secretariat in stockholm the ndphs promotes dialogue, practical cooperation and development (3) in two priority fields: i. to reduce the spread of major communicable diseases, and ii. to prevent life-style related noncommunicable diseases. emphasis is placed on encouraging proper nutrition, physical exercise, safe sexual behaviour, ensuring good social and work environments, as well as supporting alcohol, drug and smoke-free leisure activities. during the decade 2010-2020 two strategies for development of the baltic sea region have been most relevant: i. the sustainable development goals (sdg), especially sdg 3 on health and social well-being (4): sdg target 3.4, by 2030: reduce by one third premature mortality from non-communicable diseases (ncds) through prevention and treatment and promote mental health and well-being. ii. the eu strategy for the baltic sea region (eu-sbsr) adopted by the european council october 2009 (5): eu-sbsr action target, by 2020 1) reduce by at least 10% premature preventable mortality determined as potential years of life lost (pyll) in the countries of the baltic sea region. 2) reduce by at least 10% the difference between the lowest (best) and the highest (worst) pyll rates for women and men in the countries of the baltic sea region. in this framework, the russian federation (ruf) is fully engaged as an entire member state and especially regarding its northwest federal okrug (nwo) including st. petersburg and kaliningrad and stretching from the baltic to the barents sea with a territory of 1,686,970 km2. chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 4 | 20 figure 1. the geographical area of the northern dimension partnership on health and social well-being figure 2. the geographical area of the north west federal okrug of the russian federation chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 5 | 20 with our analysis, we attempt to determine to which extent it is possible for the ruf and the nwo to achieve the targets of the eu-sbsr and sdg. in addition, we try to identify the russian federation’s rank of target achievement in comparison with the other baltic sea states. for the nwo a specific strategy and action plan of social and economic development has been developed. it lists 109 activities together with the responsible institutions and timelines ending at the 4th quarter 2020: 12 activities relate to the health of the population, of which 3 are linked to maternal and child health (activities 63, 68, and 74). activity 71 refers to primary health care, and activity 77 to hiv. health related activities can also be found in other sections, e.g. activities 79 and 80 aiming at elderly services and 81 to rehabilitation. of interest is also activity 40 on the implementation of cross-border cooperation programmes. methods losses of years of life up to the age of 69 years inclusive are predominantly preventable. it is in this sense that we will use the terms “premature” and “preventable” losses as synonyms. the preventable years of life lost (pyll) were calculated by vienonen et al. (6) for all countries except the russian federation up to the age of 69, based on the method of haenszel (7) i.e. calculating the “...number of deaths in a theoretical standard population obtained by multiplying the specific death rates by the standard population”. to standardize the rates the oecd 1980 standard population (8) was applied. for age standardisation the direct method was used as recommended e.g. by armitage (9). the likelihood of achieving the sdg targets (4) and eu-sbsr (5) is determined by the indicators’ time gap (g), i.e. the time needed to achieve an agreed target deadline related to the time remaining between the year of observation and the target year. to this end we use the mathematical model of the united nations development program (undp) originally employed to assess advancement towards the target year of the millennium development goals (mdg) (10), based on linear progress between the value of an earlier ‘baseline year’ and the year of observation; for details of the calculation see bjegovic-mikanovic et al. (11,12). we applied the eu-sbsr targets for 2020 with an intended reduction of 10% (4) and for 2030 of 33% (5). as noncommunicable conditions make up for more than 2/3 of premature mortality, it seems to be justified for the purpose of intercountry comparison to apply the sdg-3 target to the calculated pyll rates. a positive time gap g indicates that the respective country is “on track” to achieve the target on time or even earlier; a negative value indicates that it may still be “likely” or even “unlikely” to achieve the target within the targeted timeframe i.e. here in 2020 respectively 2030. a country is still considered likely to achieve the target as long as a negative value does not make up for more than 25% of the remaining time (gap ratio). the gap ratio multiplied by the remaining time since the year of observation i.e. 2020-2013 = 7 or 2030-2013 = 17 indicates the number of years in advance or delay given the target year. table 1 provides details of the calculation using the year of observation 2013 and the russian federation as an example. the demographic data have been provided by the federal research institute for health organization and informatics of the russian ministry of health (annex 1). chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 6 | 20 table 1. calculation of premature years of life lost before age 70 (pyll) in 2013 for the russian federation (ruf) standardized death rates 2013 direct standardization study population (russian federation) standard population deaths population (oecd 1980) crude rate expected deaths (study pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di * (remaining years to upper age limit) 0-4 18,549 8,793,034 80,269,483 0.00211 169,329 11,429,730 5-9 1,878 7,551,502 84,285,393 0.00025 20,961 1,310,070 10-14 1,930 6,755,920 85,828,597 0.00029 24,519 1,409,849 15-19 5,479 7,053,780 87,597,591 0.00078 68,041 3,572,160 20-24 15,314 10,409,826 82,619,776 0.00147 121,543 5,773,282 25-29 29,730 12,539,043 77,252,661 0.00237 183,166 7,784,539 30-34 44,424 11,503,329 73,604,119 0.00386 284,247 10,659,271 35-39 51,039 10,536,321 61,676,142 0.00484 298,765 9,709,877 40-44 53,882 9,656,787 57,394,499 0.00558 320,244 8,806,717 45-49 68,120 9,365,912 54,245,506 0.00727 394,538 8,877,095 50-54 111,658 11,310,281 52,537,987 0.00987 518,669 9,076,699 55-59 146,852 10,508,048 48,323,994 0.01398 675,337 8,441,714 60-64 177,781 8,819,230 36,727,063 0.02016 740,356 5,552,674 65-69 126,245 4,861,125 36,887,734 0.02597 957,986 2,394,966 sum 852,881 129,664,138 919,250,545 0.00706 4,777,702 94,798,643 standardized rate (per 100 000) 520 10,313 results table 2 presents the premature years of life lost (pyll) for the russian federation (ruf). the data are used below for the calculation of the gap status for the target years 2020 and 2030 (for further details see annex 2). chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 7 | 20 table 2. overview of age standardized pyll rates of the russian federation, based on the oecd 1980 standard population age groups pyll 2003 pyll 2009 pyll 2013 0-4 18,229,269 12,183,235 11,429,730 5-9 2,215,671 1,612,951 1,310,070 10-14 2,146,975 1,681,090 1,409,849 15-19 5,589,625 4,317,138 3,572,160 20-24 9,726,159 6,893,909 5,773,282 25-29 12,106,799 9,949,936 7,784,539 30-34 13,094,532 11,961,014 10,659,271 35-39 12,824,630 9,977,662 9,709,877 40-44 14,212,643 10,036,011 8,806,717 45-49 15,208,226 10,587,880 8,877,095 50-54 16,014,381 11,134,913 9,076,699 55-59 13,353,138 10,139,068 8,441,714 60-64 8,350,403 6,339,159 5,552,674 65-69 3,546,838 2,902,400 2,394,966 sum of pyll 146,619,290 109,716,365 94,798,643 age standardised rate/100,000 15,950 11,935 10,313 we see in table 2 an impressive reduction of premature years of life lost from 15,950 in 2003 to 10,313 in 2013, which translates if continued at the same speed into a positive gap ratio for 2020 and 2030 standing for an early target achievement ranking 4th among the member states of ndphs (table 3). the gap ratios for the ruf based on 2009 of 0.39 for the target year 2020 and 0.16 for 2030 correspond to 2.7 years in advance of either target (calculated from 0.39 * 7 years and 0.16 * 17 years up to the corresponding target year). if 2003 is used as the baseline year the gap analysis shows the following results: pyll 2003 / 100,000 15,950 pyll 2013 / 100,000 10,313 target 2020 (-10%) = 9,282 target 2030 (-33%) = 6,875 gap value 2020 = 0.62 (4.4 years in advance) gap value 2030 = 0.40 (6.8 years in advance) table 4 presents the corresponding data for the now (for details see annex 3). progress between 2003 and 2009 is very slow but accelerates considerably between 2009 and 2013. chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 8 | 20 table 3. gap analysis of the mortality in the russian federation and ndphs member states (estonia, latvia, finland, poland, germany, russian federation, sweden, lithuania, ru) countries ranked according to achievement 2009-2013 -2020 change of country ranks 2009-2030 baseline value 2009 all death: pyll/ 100,000 observed value 2013 all death: pyll/ 100,000 target value 2020 (-10% as of 2013) all death: pyll/ 100,000 target value 2030 (-33% as of 2013) all death: pyll/ 100,000 gap ratio 2020 according to baseline 2009 gap ratio 2030 according to baseline 2009 1) est est1 6247 4979 4481 3319 0.557 0.299 2) lat lat2 8247 6837 6153 4558 0.487 0.237 3) fin fin3 3741 3115 2803 2077 0.477 0.229 4) ruf ruf4 11935 10313 9282 6875 0.390 0.160 5) pol pol5 5649 4901 4411 3267 0.379 0.152 6) ger ger7 3219 3008 2707 2005 0.076 -0.021 7) swe swe8 2670 2511 2260 1674 0.039 -0.038 8) lit lit6 8351 7369 6632 4913 0.033 0.118 lit swe 5681 4858 4372 3239 0.420 0.181 table 4. overview of age standardized pyll rates of the north west federal okrug, based on the oecd 1980 standard population age groups pyll 2003 pyll 2009 pyll 2013 0-4 15,994,997 9,627,834 8,660,105 5-9 2,279,635 2,512,981 1,189,746 10-14 2,066,224 2,939,012 1,180,353 15-19 5,248,957 5,051,446 2,998,759 20-24 9,630,348 7,584,853 4,984,555 25-29 13,542,067 12,095,659 6,912,712 30-34 15,222,446 16,309,283 10,162,831 35-39 15,455,366 16,274,079 9,581,213 40-44 17,978,711 17,318,045 8,800,723 45-49 18,879,238 16,853,065 9,053,049 50-54 19,914,378 18,018,859 9,311,518 55-59 15,444,599 17,242,066 8,640,291 60-64 9,238,993 12,450,710 5,528,433 65-69 3,712,069 6,661,087 2,323,054 sum of pyll 164,608,028 160,938,978 89,399,156 age standardised rate/100,000 17,907 17,508 9,725 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 9 | 20 the demographic and mortality data in table 4 provided for the nwo allow for the following calculation of the pyll target achievement for 2020 and 2030 (reduction of pyll, 0-69 years of age, direct agestandardisation, population base 2003, 2009 and 2013): baseline value 2009 (pyll nwo) 17,508 observed value 2013 (pyll nwo) 9,725 target value 2020 (-10% of 2013) 8,753 target value 2030 (-33% of 2013) 6,483 gap 2020 0.69 (4.8 years in advance) gap 2030 0.64 (10.8 years in advance) if 2003 is used as the baseline year the gap analysis shows the following results: pyll 2003 / 100,000 17,907 pyll 2013 / 100,000 9,725 target 2020 (-10%) = 8,753 target 2030 (-33%) = 6,483 gap 2020 = 0.31 (2.2 years in advance) gap 2030 = 0.55 (9.3 years in advance) discussion with reference to the baseline of 2009 corresponding to the most relevant recent period 2009-2020 respectively 2009-2030 the northern dimension and all its member states including the ruf and the now are on track or are likely to achieve the targets in time (sweden and germany with slight delays regarding the sdg targets [the borderline for “not likely” is a gap status <0.25. the status “likely” is indicated by a gap status <0 and >= -0.25]). this can be considered a success to which the ndphs contributed. however for all countries the positive gap (indicating achievement before the targeted time) is smaller for the sdg targets of 2030 than for 2020. this may indicate a slowing down of the dynamics in reducing mortality. the analysis is confirmed if the period 2003-2020 respectively 2003-2030 is considered. the russian federation keeps throughout the years a middle position among the ndphs member states included in table 3 whereas the nwo would even take a top position for its more than 12 million inhabitants in front of the neighbouring estonia. this relative good positioning is unlikely to be due to data inconsistencies as figure 3 shows an impressive homogeneity of mortality development throughout age groups in 2003, 2009 and 2013. nevertheless the nwo shows accelerated progress. chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 10 | 20 figure 3. percentage of deaths by age-groups in the russian federation 2003, 2009 and 2013 limitations the straight projection of past progress into the future may be modified by the realities of historical development with its unpredictable interference in positive as well as negative direction. however, advanced achievement of targets may encourage to continue along the path of success whereas delays should stimulate to add up efforts. for the target year 2020 most nd member states have already achieved the target one or two years ago, so did the russian federation. also in this paper we applied the targeted sdg-3 reduction by one third for non-communicable diseases to the pyll rates which include to a minor degree communicable diseases too. the russian government’s activities during the last decade were marked by big investments in healthcare (around 10bln us dollars per year) with main focus to reconstruction of old health facilities including purchasing of modern medical equipment for diagnostics and treatment. a model of avoidable mortality was used to analyze causes of death related to insufficient diagnostics and treatment (healthcare factor), and causes associated with behavioural risks (lifestyle factor) (13). a comparison of regions of north-western russia and neighbouring european countries confirmed that the higher the mortality levels the stronger the contribution of avoidable causes i.e. up to 50% in average in 0.00 5.00 10.00 15.00 20.00 25.00 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 age groups % of age groups 2003 % of age groups 2009 % of age groups 2013 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 11 | 20 north-western russia, varying between 45% in st. petersburg and 67% in pskov and novgorod. healthcare does substantially contribute to mortality reduction, however its role is not the leading one. for this moment our analysis could include only one federal okrug but it would be a fascinating task to analyse target achievement for all okrugs of the huge territory of the russian federation. as the russian federation borders the near and far east this may induce dynamic exchange and a more global than national perspective (14), especially if combined with a more precise sub-grouping according to gender and to specific disease groups. the very good ranking of the russian federation and its nwo are encouraging although it will be difficult to keep the pace of improvement as it started from very high levels of premature mortality in 2009 and even worse in 2003. a national strategy may be considered in this regard. also for the european union (15) a technical cooperation in this area may be of mutual interest. conflicts of interest: none declared. references 1. the european external action service (eeas). the northern dimension. available at: https://eeas.europa.eu/diplomaticnetwork/northerndimension/347/northern-dimension_en (accessed: 10 august, 2019). 2. chernyavskiy v, mikhailova j. russia: a key partner in the northern dimension partnership. seejph 2019;12. doi 10.4119/unibi/seejph-2019-218. 3. the northern dimension partnership on health and social well-being (ndphs). available at: http://www.ndphs.org/?about_ndphs#b ackground_about_ndphs (accessed: 10 august, 2019). 4. united nations: united nations: the sustainable development goals report 2016. available at: https://unstats.un.org/sdgs/report/2016/ (accessed: 10 august, 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office; 2006:107-11. https://eeas.europa.eu/diplomatic-network/northern-dimension/347/northern-dimension_en https://eeas.europa.eu/diplomatic-network/northern-dimension/347/northern-dimension_en https://eeas.europa.eu/diplomatic-network/northern-dimension/347/northern-dimension_en http://doi.org/10.4119/unibi/seejph-2019-218 http://www.ndphs.org/?about_ndphs#background_about_ndphs http://www.ndphs.org/?about_ndphs#background_about_ndphs https://unstats.un.org/sdgs/report/2016/ http://edz.bib.uni-mannheim.de/edz/pdf/swd/2017/swd-2017-0118-en.pdf http://edz.bib.uni-mannheim.de/edz/pdf/swd/2017/swd-2017-0118-en.pdf http://edz.bib.uni-mannheim.de/edz/pdf/swd/2017/swd-2017-0118-en.pdf https://stats.oecd.org/index.aspx?datasetcode=pop_five_hist https://stats.oecd.org/index.aspx?datasetcode=pop_five_hist chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the 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iceland; 2019. 14. laaser u, dorey s, nurse j. a plea for global health action bottom-up. front public health 2016;4:241. doi: 10.3389/fpubh.2016.00241. available at: http://journal.frontiersin.org/article/10.3 389/fpubh.2016.00241/full?&utm_sour ce=email_to_authors_&utm_medium= email&utm_content=t1_11.5e1_author &utm_campaign=email_publication&fi eld=&journalname=frontiers_in_publi c_health&id=209500 (accessed: 10 august, 2019). 15. european external activity service (eeas). european union and russian federation. available at: https://eeas.europa.eu/headquarters/hea dquarters-homepage/35939/europeanunion-and-russian-federation_en (accessed: 10 august, 2019). https://doi.org/10.1080/19932820.2019.1607698 https://doi.org/10.1080/19932820.2019.1607698 http://journal.frontiersin.org/article/10.3389/fpubh.2016.00241/full?&utm_source=email_to_authors_&utm_medium=email&utm_content=t1_11.5e1_author&utm_campaign=email_publication&field=&journalname=frontiers_in_public_health&id=209500 http://journal.frontiersin.org/article/10.3389/fpubh.2016.00241/full?&utm_source=email_to_authors_&utm_medium=email&utm_content=t1_11.5e1_author&utm_campaign=email_publication&field=&journalname=frontiers_in_public_health&id=209500 http://journal.frontiersin.org/article/10.3389/fpubh.2016.00241/full?&utm_source=email_to_authors_&utm_medium=email&utm_content=t1_11.5e1_author&utm_campaign=email_publication&field=&journalname=frontiers_in_public_health&id=209500 http://journal.frontiersin.org/article/10.3389/fpubh.2016.00241/full?&utm_source=email_to_authors_&utm_medium=email&utm_content=t1_11.5e1_author&utm_campaign=email_publication&field=&journalname=frontiers_in_public_health&id=209500 http://journal.frontiersin.org/article/10.3389/fpubh.2016.00241/full?&utm_source=email_to_authors_&utm_medium=email&utm_content=t1_11.5e1_author&utm_campaign=email_publication&field=&journalname=frontiers_in_public_health&id=209500 http://journal.frontiersin.org/article/10.3389/fpubh.2016.00241/full?&utm_source=email_to_authors_&utm_medium=email&utm_content=t1_11.5e1_author&utm_campaign=email_publication&field=&journalname=frontiers_in_public_health&id=209500 http://journal.frontiersin.org/article/10.3389/fpubh.2016.00241/full?&utm_source=email_to_authors_&utm_medium=email&utm_content=t1_11.5e1_author&utm_campaign=email_publication&field=&journalname=frontiers_in_public_health&id=209500 https://eeas.europa.eu/headquarters/headquarters-homepage/35939/european-union-and-russian-federation_en https://eeas.europa.eu/headquarters/headquarters-homepage/35939/european-union-and-russian-federation_en https://eeas.europa.eu/headquarters/headquarters-homepage/35939/european-union-and-russian-federation_en chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 13 | 20 annex 1: population and mortality data of the russian federation for 2003, 2009, and 2013 annex 1a: population and mortality in the russian federation 2003 age-group total population males females total mortality males females 00-04 6,565,695 3,364,592 3,201,103 22,090 12,754 9,336 05-09 6,818,772 3,486,662 3,332,110 2,868 1,791 1,077 10-14 9,760,069 4,985,362 4,774,707 4,246 2,778 1,468 15-19 12,669,554 6,432,752 6,236,802 15,399 11,128 4,271 20-24 11,713,409 5,913,034 5,800,375 29,030 23,001 6,029 25-29 10,717,142 5,360,243 5,356,899 39,519 31,466 8,053 30-34 9,963,892 4,973,305 4,990,587 47,270 37,095 10,175 35-39 9,888,714 4,863,197 5,025,517 63,268 49,281 13,987 40-44 12,324,267 5,972,742 6,351,525 110,977 85,938 25,039 45-49 11,777,383 5,564,681 6,212,702 146,751 111,219 35,532 50-54 10,316,215 4,737,479 5,578,736 179,688 131,720 47,968 55-59 5,976,065 2,638,995 3,337,070 132,107 91,857 40,250 60-64 7,045,054 2,854,945 4,190,109 213,572 141,469 72,103 65-69 6,718,590 2,573,559 4,145,031 258,403 155,124 103,279 00-69 132,254,821 63,721,548 68,533,273 1,265,188 886,621 378,567 annex 1b: population and mortality in the russian federation 2009 age-group total population males females total mortality males females 00-04 7,793,807 3,994,295 3,799,512 17,525 10,064 7,461 05-09 6,887,915 3,530,220 3,357,695 2,109 1,273 836 10-14 6,784,360 3,470,481 3,313,879 2,311 1,416 895 15-19 9,274,152 4,699,081 4,575,071 8,706 6,073 2,633 20-24 12,354,120 6,242,785 6,111,335 21,702 16,795 4,907 25-29 11,788,055 5,916,062 5,871,993 35,724 27,844 7,880 30-34 10,751,459 5,306,042 5,445,417 46,591 36,183 10,408 35-39 9,997,601 4,903,848 5,093,753 49,765 37,620 12,145 40-44 9,307,938 4,493,889 4,814,049 59,185 44,056 15,129 45-49 11,415,509 5,393,625 6,021,884 99,028 73,183 25,845 50-54 11,292,748 5,136,151 6,156,597 136,765 98,957 37,808 55-59 9,821,361 4,274,188 5,547,173 164,853 113,724 51,129 60-64 6,497,033 2,694,911 3,802,122 149,520 100,238 49,282 65-69 5,059,895 1,869,565 3,190,330 159,249 94,717 64,532 00-69 129,025,953 61,925,143 67,100,810 953,033 662,143 290,890 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 14 | 20 annex 1c: population and mortality in the russian federation 2013 age-group total population males females total mortality males females 00-04 8,793,034 4,513,291 4,279,743 18,549 10,567 7,982 05-09 7,551,502 3,865,465 3,686,037 1,878 1,120 758 10-14 6,755,920 3,462,420 3,293,500 1,930 1,234 696 15-19 7,053,780 3,608,295 3,445,485 5,479 3,930 1,549 20-24 10,409,826 5,300,627 5,109,199 15,314 12,034 3,280 25-29 12,539,043 6,323,822 6,215,221 29,730 22,980 6,750 30-34 11,503,329 5,734,090 5,769,239 44,424 33,885 10,539 35-39 10,536,321 5,145,842 5,390,479 51,039 38,699 12,340 40-44 9,656,787 4,689,062 4,967,725 53,882 39,702 14,180 45-49 9,365,912 4,444,475 4,921,437 68,120 49,808 18,312 50-54 11,310,281 5,204,736 6,105,545 111,658 80,673 30,985 55-59 10,508,048 4,587,151 5,920,897 146,852 101,408 45,444 60-64 8,819,230 3,635,352 5,183,878 177,781 118,451 59,330 65-69 4,861,125 1,877,877 2,983,248 126,245 76,787 49,458 00-69 129,664,138 62,392,505 67,271,633 852,881 591,278 261,603 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 15 | 20 annex 2: complete gap analysis based on the demographic data of the russian federation for 2003, 2009, and 2013 annex 2a: standardized death rates 2003, direct standardization study population (russian federation) standard population deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di * (remaining years to upper age limit) 0-4 22,090 6,565,695 80,269,483 0.00336 270,063 18,229,269 5-9 2,868 6,818,772 84,285,393 0.00042 35,451 2,215,671 10-14 4,246 9,760,069 85,828,597 0.00044 37,339 2,146,975 15-19 15,399 12,669,554 87,597,591 0.00122 106,469 5,589,625 20-24 29,030 11,713,409 82,619,776 0.00248 204,761 9,726,159 25-29 39,519 10,717,142 77,252,661 0.00369 284,866 12,106,799 30-34 47,270 9,963,892 73,604,119 0.00474 349,188 13,094,532 35-39 63,268 9,888,714 61,676,142 0.00640 394,604 12,824,630 40-44 110,977 12,324,267 57,394,499 0.00900 516,823 14,212,643 45-49 146,751 11,777,383 54,245,506 0.01246 675,921 15,208,226 50-54 179,688 10,316,215 52,537,987 0.01742 915,108 16,014,381 55-59 132,107 5,976,065 48,323,994 0.02211 1,068,251 13,353,138 60-64 213,572 7,045,054 36,727,063 0.03032 1,113,387 8,350,403 65-69 258,403 6,718,590 36,887,734 0.03846 1,418,735 3,546,838 sum 1,265,188 132,254,821 919,250,545 0.01089 7,390,966 146,619,290 standardized rate (per 100,000) 804 15,950 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 16 | 20 annex 2b: standardized death rates 2003, direct standardization study population (russian federation) standard population deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di * (remaining years to upper age limit) 0-4 17,525 7,793,807 80,269,483 0.00225 180,492 12,183,235 5-9 2,109 6,887,915 84,285,393 0.00031 25,807 1,612,951 10-14 2,311 6,784,360 85,828,597 0.00034 29,236 1,681,090 15-19 8,706 9,274,152 87,597,591 0.00094 82,231 4,317,138 20-24 21,702 12,354,120 82,619,776 0.00176 145,135 6,893,909 25-29 35,724 11,788,055 77,252,661 0.00303 234,116 9,949,936 30-34 46,591 10,751,459 73,604,119 0.00433 318,960 11,961,014 35-39 49,765 9,997,601 61,676,142 0.00498 307,005 9,977,662 40-44 59,185 9,307,938 57,394,499 0.00636 364,946 10,036,011 45-49 99,028 11,415,509 54,245,506 0.00867 470,572 10,587,880 50-54 136,765 11,292,748 52,537,987 0.01211 636,281 11,134,913 55-59 164,853 9,821,361 48,323,994 0.01679 811,125 10,139,068 60-64 149,520 6,497,033 36,727,063 0.02301 845,221 6,339,159 65-69 159,249 5,059,895 36,887,734 0.03147 1,160,960 2,902,400 sum 953,033 129,025,953 919,250,545 0.00831 5,612,089 109,716,365 standardized rate (per 100,000) 611 11,935 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 17 | 20 annex 2c: standardized death rates 2013, direct standardization study population (russian federation) standard population deaths population (oecd 1980) crude rate expected deaths (study pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di * (remaining years to upper age limit) 0-4 18,549 8,793,034 80,269,483 0.00211 169,329 11,429,730 5-9 1,878 7,551,502 84,285,393 0.00025 20,961 1,310,070 10-14 1,930 6,755,920 85,828,597 0.00029 24,519 1,409,849 15-19 5,479 7,053,780 87,597,591 0.00078 68,041 3,572,160 20-24 15,314 10,409,826 82,619,776 0.00147 121,543 5,773,282 25-29 29,730 12,539,043 77,252,661 0.00237 183,166 7,784,539 30-34 44,424 11,503,329 73,604,119 0.00386 284,247 10,659,271 35-39 51,039 10,536,321 61,676,142 0.00484 298,765 9,709,877 40-44 53,882 9,656,787 57,394,499 0.00558 320,244 8,806,717 45-49 68,120 9,365,912 54,245,506 0.00727 394,538 8,877,095 50-54 111,658 11,310,281 52,537,987 0.00987 518,669 9,076,699 55-59 146,852 10,508,048 48,323,994 0.01398 675,337 8,441,714 60-64 177,781 8,819,230 36,727,063 0.02016 740,356 5,552,674 65-69 126,245 4,861,125 36,887,734 0.02597 957,986 2,394,966 sum 852,881 129,664,138 919,250,545 0.00706 4,777,702 94,798,643 standardized rate (per 100,000) 520 10,313 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 18 | 20 annex 3. demographic and mortality data and the resulting pyll rates of the north west federal okrug (nwo) of the russian federation for 2003, 2009 and 2013 study population (nwo district) standard population annex 3a deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 0-4 1,666 564,500 80,269,483 0.00295 236,963 15,994,997 5-9 244 564,321 84,285,393 0.00043 36,474 2,279,635 10-14 357 852,259 85,828,597 0.00042 35,934 2,066,224 15-19 1,362 1,193,690 87,597,591 0.00114 99,980 5,248,957 20-24 2,787 1,135,751 82,619,776 0.00245 202,744 9,630,348 25-29 4,238 1,027,373 77,252,661 0.00412 318,637 13,542,067 30-34 5,264 954,497 73,604,119 0.00552 405,932 15,222,446 35-39 7,347 952,804 61,676,142 0.00771 475,550 15,455,366 40-44 13,686 1,201,468 57,394,499 0.01139 653,771 17,978,711 45-49 18,436 1,191,875 54,245,506 0.01547 839,077 18,879,238 50-54 23,048 1,064,075 52,537,987 0.02166 1,137,964 19,914,378 55-59 16,456 643,591 48,323,994 0.02557 1,235,568 15,444,599 60-64 21,782 649,414 36,727,063 0.03354 1,231,866 9,238,993 65-69 26,624 661,425 36,887,734 0.04025 1,484,828 3,712,069 sum 143,296 12,657,040 919,250,545 0.01233 8,395,289 164,608,028.34 standardized rate (per 100,000) 913.28 17,906.76 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 19 | 20 2009 study population (nwo district) standard population annex 3b deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 0-4 1,178 662,703 80,269,483 0.00178 142,635 9,627,834 5-9 281 590,035 84,285,393 0.00048 40,208 2,512,981 10-14 335 561,830 85,828,597 0.00060 51,113 2,939,012 15-19 880 801,242 87,597,591 0.00110 96,218 5,051,446 20-24 2,238 1,157,868 82,619,776 0.00193 159,681 7,584,853 25-29 4,207 1,141,931 77,252,661 0.00368 284,604 12,095,659 30-34 6,185 1,046,782 73,604,119 0.00591 434,914 16,309,283 35-39 7,872 969,565 61,676,142 0.00812 500,741 16,274,079 40-44 9,872 899,724 57,394,499 0.01097 629,747 17,318,045 45-49 15,352 1,111,823 54,245,506 0.01381 749,025 16,853,065 50-54 22,146 1,129,981 52,537,987 0.01960 1,029,649 18,018,859 55-59 28,516 999,024 48,323,994 0.02854 1,379,365 17,242,066 60-64 31,156 689,278 36,727,063 0.04520 1,660,095 12,450,710 65-69 33,458 463,209 36,887,734 0.07223 2,664,435 6,661,087 sum 163,675 12,224,992 919,250,545 0.01528 9,822,430 160,938,978.09 standardized rate (per 100,000) 1,068.53 17,507.63 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, mikhailov a, laaser u. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being (original research). seejph 2019, posted: 25 october 2019. doi 10.4119/seejph-3129 p a g e 20 | 20 2013 study population (nwo district) standard population annex 3c deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 0-4 1,220 757,156 80,269,483 0.00161 129,362 8,731,919 5-9 145 642,852 84,285,393 0.00023 19,036 1,189,746 10-14 137 573,546 85,828,597 0.00024 20,528 1,180,353 15-19 394 603,558 87,597,591 0.00065 57,119 2,998,759 20-24 1,252 985,677 82,619,776 0.00127 104,938 4,984,555 25-29 2,587 1,228,690 77,252,661 0.00211 162,652 6,912,712 30-34 4,193 1,138,908 73,604,119 0.00368 271,009 10,162,831 35-39 4,956 1,036,737 61,676,142 0.00478 294,807 9,581,213 40-44 5,259 943,130 57,394,499 0.00558 320,026 8,800,723 45-49 6,779 913,922 54,245,506 0.00742 402,358 9,053,049 50-54 11,182 1,104,138 52,537,987 0.01013 532,087 9,311,518 55-59 15,070 1,053,570 48,323,994 0.01430 691,223 8,640,291 60-64 17,942 893,981 36,727,063 0.02007 737,124 5,528,433 65-69 13,078 519,162 36,887,734 0.02519 929,222 2,323,054 sum 84,195 12,395,023 919,250,545 0.00695 4,671,490 89,399,155.82 standardized rate (per 100,000) 508.18 9,725.22 ___________________________________________________________________________ © 2019 chernyavskiy et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. editorial comment on the editorial policy of seejph with reference to the comments by bjegovic-mikanovic & marinkovic, and by jankovic ulrich laaser, co-editor, seejph as one of the editors of seejph, i welcome the discussion on the paper by jerliu et al. it demonstrates the vitality of the new journal. nevertheless, i believe that a scientific journal does not need to be politically correct, but rather scientifically accurate! both criteria have been questioned with regard to the paper by jerliu et al. in the comments of bjegovicmikanovic & marinkovic and of jankovic. whereas i admit that we as editors were not sufficiently aware of the political context when the paper was published on october 31 st , 2013 1 , we rather left it to the authors to take responsibility for political correctness regarding the status of kosovo according to the unscr 2 . one of us, prof. slavenka jankovic together with her colleagues from serbia clearly marked this deficit in their recent comments and even more the reference to independence of kosovo in the title, which was declared unilaterally on february 17 th , 2008, however judged not to violate international law by the international court of justice (1). the journal of course obeys to the political framework set by unscr, icj and the brussels agreement (2) and in the future we will take care of the proper designation of kosovo. much more relevant i consider the scientific critique on the paper. this is in my view most welcome and, as far as i understand the issues raised, widely justified. the kosovo was one of the least developed regions in the former yugoslavia and it underwent a positive development in most health indicators between the fifties and the eighties of the last century. although our criteria for reviews laid out in the section on instructions for authors are not fulfilled completely in all categories, nevertheless the reviewers accepted the paper in the early development phase of the journal. we always strive to improve the rigidity of our reviewers’ work and, therefore, i welcome the critique by prof. slavenka jankovic from a scientific point of view. it is essential to raise our standards and to enhance the quality of seejph. references 1. international court of justice. accordance with international law of the unilateral declaration of independence in respect of kosovo, advisory opinion. i.c.j. reports 2010, p.403. available at: http://www.icj-cij.org/docket/files/141/15987.pdf (accessed: may 01, 2014). 2. the brussels agreement of 2013. available at: http://eeas.europa.eu/top_stories/2013/190413__eu-facilitated_dialogue_en.htm (accessed: may 01, 2014). 1 the decision to publish the paper by jerliu at al. was reconfirmed by all editors in writing including prof. slavenka jankovic (by email of 26 february 2014) 2 this designation is without prejudice to positions on status, and is in line with unscr 1244 and the icj opinion on the kosovo declaration of independence”. http://ec.europa.eu/enlargement/countries/detailedcountry-information/kosovo/. kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 1 original research efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit ermira kola1, ermela çelaj1, iliriana bakalli1, robert lluka1, gjeorgjina kuli-lito2, sashenka sallabanda1 1 pediatric intensive care unit, university hospital center “mother teresa”, tirana, albania; 2 department of pediatric infectious diseases, university hospital center “mother teresa”, tirana, albania. corresponding author: dr. ermira kola, university hospital center “mother teresa”; address: rr. “dibrës”, no. 371, tirana, albania; telephone: +355672059975; email: ermirakola@gmail.com. kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 2 abstract aim: additional treatments for sepsis to be administered alongside the standard therapy recommended by the surviving sepsis campaign have recently undergone evaluation. due to its anti-bacterial, anti-inflammatory and immunomodulatory properties, intravenous polyvalent immunoglobulin m (igm)–enriched immunoglobulins (igm preparation) has been investigated as one of these potentially valid adjunctive therapies. the aim of this trial was to assess the efficacy of an igm preparation as adjuvant therapy in the treatment of pediatric patients with sepsis. methods: in our study, 78 septic patients admitted to a pediatric intensive care unit (picu) at the university hospital center “mother teresa” in tirana, albania, were randomized into two groups (intervention and control). all patients were treated according to standard picu sepsis guidelines. additionally, patients in the intervention group received the igm preparation pentaglobin® while patients in the control group received standard sepsis therapy, but no immunoglobulin administration. results: the survival rate was higher in the intervention group (87%, n=34) than in the control group (64%, n=25), and this difference was statistically significant (p=0.03). length of stay (los) was also significantly shorter in the intervention group. conclusion: in this study conducted in albania, use of an igm preparation, in addition to standard sepsis therapy, led to a significant increase in the survival rate as well as a significant reduction in los compared with placebo, when administered in picu patients with sepsis. keywords: bacterial infections, igm preparation, immunoglobulin, immunotherapy, pentaglobin®, sepsis. kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 3 introduction sepsis is a major cause of morbidity and mortality in critically ill pediatric patients (1,2). about 25% of all picu admissions are due to life–threatening infections in pediatric patients (2). although numerous advances in the management of critically ill children with severe infections have occurred in recent years, the mortality associated with severe sepsis and septic shock remains unacceptably high, with a rate between 20% to 56% (1,3-10). because of its broad and potent activity against bacteria and their exotoxins as well as against the excessively activated pro-inflammatory host response, an igm preparation was investigated as an adjunctive treatment for patients with severe bacterial infections (11-13). this igm preparation is the only approved intravenous immunoglobulin for treating severe bacterial infections and contains antibacterial, anti-inflammatory and immunomodulatory antibodies from the immunoglobulin classes igm, igg, and iga. in this respect, the preparation differs from all other standard intravenous immunoglobulin preparations, which contain almost only igg (3,14,15). to date, there are no studies conducted in albania assessing the efficacy of igm preparations in pediatric wards. in this framework, the objective of this trial was to assess the efficacy of an igm preparation as adjuvant therapy in the treatment of pediatric patients with sepsis in albania. we hypothesized that administration of the igm preparation in combination with standard-of-care antibiotics would increase the overall survival rate in septic patients admitted to picu. methods this was a prospective, double-blinded, randomized, placebo-controlled trial conducted in the picu of the university hospital center “mother teresa” in tirana, albania, between january 2009 and december 2010. the ethics committee of the university of tirana approved the study protocol and a written informed consent was obtained from the parents or guardians of all of the patients. the study was conducted in accordance with the declaration of helsinki and followed good clinical practice guidelines and national regulations. the study was registered in a clinical trial registry. to increase patient homogeneity and to strengthen internal validity, strict diagnostic criteria were applied. proven sepsis was defined according to 2001 accp/sccm sepsis criteria (16). patients with sepsis (sirs, sepsis, severe sepsis, septic shock) documented infection and dysfunction of an organ or hypotension were enrolled in the study. patients fulfilling one or more of the following criteria were not included in the study: severe immunosuppression, irreversible endstage damage of vital organs, a glasgow coma score of 3/15, comorbidities and/or contraindications to any of the study treatments. one hundred and three patients were assessed for eligibility in the study. eighteen children did not meet the inclusion criteria, whereas seven parents declined study participation of their children. intervention the study utilized a parallel-group design whereby patients were stratified by baseline characteristics such as age and gender and also according to diagnosis and severity of disease. patients were randomly assigned in a 1:1 ratio to the intervention or control group. treatment assignment was randomly generated by computer in stratified permuted blocks of two. the intervention group received the igm preparation while the control group did not receive any immunoglobulin administration (figure 1). fluid administration was protocolized. all patients received isotonic intravenous fluid bolus kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 4 20-40ml/kg in 1 hr. repeated boluses were administered depending on clinical parameters, including heart rate, capillary refill, blood pressure, urine output and level of consciousness. a researcher sealed envelopes labeled only with the patient number and containing the respective study medication. corresponding envelopes were opened by the researcher only after the enrolled participants had completed baseline assessments and were about to be allocated to a treatment group. other investigators, staff, parents of the children, the nurse who administered the treatment and endpoint assessors were all blinded to treatment assignment. study protocol all patients received standard sepsis therapy which comprised intravenous antibiotics. patients in the intervention group received the igm preparation pentaglobin® intravenously. administration of the igm preparation was started on the day of sepsis diagnosis at a volume of 5 ml/kg body weight per day and was infused over six hours for three consecutive days. patients in the control group received standard sepsis therapy, but no immunoglobulin administration. a detailed clinical history was taken from all cases who were also subjected to physical examination. demographic data (age and gender), body weight, height, [based on which the body mass index (bmi) was calculated] diagnosis at picu admission, duration of stay in the picu and outcome at discharge were recorded for each patient (table 1). study treatment was administered within eight hours after randomization. patients were observed throughout their stay in picu. compliance, laboratory parameters, vital signs, hemodynamic data laboratory parameters and organ dysfunction were monitored on a daily basis. protocol violations were defined before the start of the study. the study endpoint was death in pciu. statistical analysis based on literature review and in our previous experience, the expected mortality rate in the control group was anticipated as 60%, whereas the magnitude of the expected treatment effect was set at 40%. type i error was set as α=0.05 in a two-tailed test and type ii error as β=0.05. the 95% confidence interval (ci) for the difference between proportions was calculated as follows: (d) = d 0.236 to d + 0.236. after adjusting for a 5% drop-out rate, the sample size was estimated at 39 individuals in each group. the primary efficacy analysis was performed according to intention-to treat (itt) principles, rather than as an explanatory analysis. all randomized patients were included in the itt population and the per-protocol population included only patients who completed the treatment originally allocated in both groups. normal distribution of continuous variables was tested with the kolmogorov-smirnov test. mann-whitney test was used to compare age, height and body weight of patients between the two groups. chi-square test was used to compare gender differences and laboratory values in each treatment group and the independent sample t-test was used to compare the length of stay (los) in the picu as well as the bmi. mortality rates in the intervention and control group were compared with the chi-square test. the difference in survival rates between groups was assessed using the kaplan-meier method and the log-rank test. the censoring time for the survival analysis was the picu stay duration. all statistical analyses were performed with spss, version 16.0. kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 5 enrollment assessed for eligibility (n=103) excluded (n= 25) did not meet inclusion criteria (n=18) declined to participate (n=7) randomized (n=78) allocated to intervention (n= 39) received igm preparation (n= 38) did not receive igm preparation (died) (n= 1) allocation allocated to control (n=39) received placebo (n=38) did not receive placebo (died) (n=1) follow-up lost to follow-up (n= 0) discontinued treatment (n=0) lost to follow-up (n= 0) discontinued treatment (n=0) analysis included in itt analysis (n=39) excluded from analysis (n=0) included in itt analysis (n=39) excluded from analysis (n=0) figure 1. patients included in the study kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 6 results a total of 78 consecutive patients (aged from one month to thirteen years) with proven sepsis were included in the study after adjusting for drop-outs and non-evaluable patients. there were no statistical differences between treatment groups in baseline characteristics at picu admission (table 1). one patient in each group died before receiving the full course of therapy. a four-month old patient died on the first day of treatment in the intervention group and a sixmonth old patient died on the second day of treatment in the control group. there were no major or minor violations of the protocol. no withdrawals, patient exclusions and or losses to follow-up occurred in either treatment group. mean treatment duration in both groups was three days. no other concomitant treatments were given in addition to the study treatment in both groups. table 1. baseline characteristics in the itt population variable intervention group (n=39) control group (n=39) p age (years) 2.1 (3.1) (1.07 – 3.08)* 1.8 (2.7) (0.87 – 2.66) 0.6 picu stay (days) 5.1 (3.1) (4.08 – 6.06)* 7.1 (2.4) (6.35-7.90) <0.01 males (n, %) 25 (64.1) (48.4 – 77.2)† 29 (74.4) (58.9 – 85.4) 0.4 body weight (kg) 12.9 (8.1) (10.4 – 15.6)* 12.3 (6.9) (10.0 – 14.5) 0.7 height (cm) 84.7 (24.8) (76.7 – 92.8)* 83.0 (22.6) (69.9 – 87.8) 0.8 bmi 16.7 (0.92) (16.4 – 17.0)* 16.8 (24.8) (16.5 – 17.1) 0.8 * data reported as mean (sd) (95%ci). † number (%) (95%ci). ----------------------------------------- intention to treat analysis (itt) overall, of the 78 patients included in this study, 59 (75.6%) individuals survived. however, the survival rate was higher in the intervention group (87.2%, n=34) than in the control group (64.1%, n=25), with the difference of 23.1% being statistically significant (p=0.03). the odds ratio (or) for survival was 3.8 (95%ci=1.2-11.9). a kaplan-meier survival analysis also showed a statistically significant difference in the survival rate in the intervention group (log-rank=4.0, p=0.04) [figure 2]. furthermore, los in the picu was significantly shorter for patients in the intervention group, compared to the control group (5.1±3.1 days vs 7.1±2.4 days; p<0.01). twelve (30.8%) children in the intervention group and nine (23.1%) in the control group were mechanically ventilated without a significant difference between them (p=0.6). cardiac, pulmonary, renal, cns (central nervous system) and adrenal dysfunctions were involved, as well as glycemic control disturbances. mods (multiple organ dysfunction) in our study occurred in 8 (10.3 %) patients. we used hydrocortisone in 18 (23.1%) cases with catecholamine resistance and suspected or proven adrenal insufficiency (total cortisol concentration <18mg/dl). kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 7 100 90 80 70 60 group control 50 pentaglobin 40 30 20 10 0 2 4 6 8 10 12 14 icu days figure 2. kaplan-meier survival analysis inotropes and vasopressors were administered in 26 (33.3%) patients. there was no surgical procedure involved during the study period. the causes of death were renal failure, brain damage, hepatic failure, metabolic derangements, diffuse intravascular coagulation (dic), ventilator-associated pneumonia (vap). no adverse events occurred during the study period. additionally, no fatalities occurred after discharge from the hospital. in our study we focused on anaphylactic reaction or anaphylactic shock to define an adverse event. adverse reactions described in the enclosed leaflet of pentaglobine did not occur. blood samples were collected daily from each treatment group for the evaluation of hematological and laboratory parameters (table 2). there were no statistically significant differences in the total wbc count, platelets, base excess in blood, and c-reactive protein levels between the two groups at baseline. after treatment, the intervention group had statistically significant improvements in two inflammatory markers. proportions of patients with c-reactive protein levels and total leucocyte and neutrophil counts <10000 were significantly higher in the intervention group, compared with controls (p=0.04 and p<0.01, respectively). there were no significant differences in changes in platelet counts and base excess in blood between treatment groups. per-protocol analysis in total, 59 (77.6%) of the 76 patients who completed treatment survived. the survival rate was higher in the intervention group (89.5%) than in the control group (65.8%), with the difference being statistically significant (p=0.03). a kaplan-meier survival analysis also demonstrated a statistically significant difference in the survival rate for the intervention group, with a hazard ratio of 3.1 (95%ci=1.1-8.6). kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 8 table 2. patients with abnormal laboratory values before and after treatment laboratory parameter intervention group (n=39) n (%) of patients control group (n=39) n (%) of patients p baseline wbc <10000 24/39 (61.5%) 25/39 (64.1%) ns* platelets <40000 10/39 (25.7%) 9/39 (23.1%) ns base excess>8 19/39 (48.7%) 20/39 (51.2%) ns c-reactive protein >n 29/39 (74.3%) 29/39 (74.3%) ns after treatment wbc <10000 10/39 (25.6%) 18/39 (46.2%) <0.01 platelets <40000 6/39 (15.4%) 8/39 (20.5%) ns base excess>8 11/39 (28.2%) 20/39 (51.2%) ns c-reactive protein >n 12/39 (30.8%) 22/39 (56.4%) 0.04 *non-significant. -------------------------------- discussion treatment of sepsis is complicated and typically requires a multidisciplinary approach. in recent years, the immunotherapeutic approach has been extensively studied but the results of both experimental and clinical investigations have been puzzling. the administration of monoclonal antibodies directed against specific sepsis mediators has produced disappointing results, whereas the administration of polyvalent immunoglobulins has been associated with better outcomes across various subgroups of patients (1,4,13). recently, a number of studies have indicated that an igm preparation is associated with reduced morbidity and an increased survival rate in patients with sepsis, severe sepsis or septic shock (2,14,17). in children, however, all the trials have been relatively small and the evidence is insufficient to support a robust conclusion of the benefit. in the present study, administration of an adjunctive igm preparation in septic pediatric patients resulted in a statistically significant increase in survival rate of 23.1% in the intervention group, compared to control group. another interesting result was the significantly shorter mean los in the picu for patients receiving the igm preparation, compared with controls. a similar outcome in los was shown in a study by el nawawy et al. in which the mean los in the intervention group who received the adjuvant igm preparation was significantly shorter than in the control group, with durations of six and nine days, respectively (2). furthermore, a study published fairly recently showed that early administration of the igm preparation is crucial. delay in administration significantly increased the absolute risk of death by 2.8% every 24 hours. therefore, in this study, the igm preparation was administered additionally to antibiotics on the day of sepsis diagnosis and study inclusion (18,19). in a meta-analysis comparing two types of polyvalent immunoglobulin preparations, an igm preparation was found to be superior over a standard immunoglobulin preparation which contains mostly igg (20). statistically significant increases were shown in the survival rates of kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 9 adult and neonatal patients with sepsis and septic shock when treated with the igm preparation in addition to standard sepsis therapy (11). the pooled results showed a relative reduction in mortality of 34% in adult sepsis patients who received the adjunctive igm preparation (relative risk: 0.66; p=0.0009). the standard adjunctive immunoglobulin preparation showed a relative reduction in mortality of only 15% (relative risk: 0.85; p=0.04). in neonates with sepsis, a relative reduction in mortality of 50% was reported for the adjunctive igm preparation (relative risk: 0.50; p=0.0003). the standard adjunctive immunoglobulin preparation resulted in a relative reduction in mortality of only 37% (relative risk: 0.63; p=0.03) (11,14,21,22). a head-to-head clinical trial in neonates with sepsis showed similar results. haque et al. (20) conducted a clinical trial with these two different polyvalent immunoglobulin preparations (igm or standard immunoglobulin preparations). a statistically significant increase in the survival rate in the group treated with the igm preparation was shown when compared with the control group treated with the standard immunoglobulin preparation where no increase in survival rate was observed (8,9). moreover, other clinical studies in neonates and children have shown increases in survival rates due to administration of an adjunctive igm preparation of between 28%-56% (11,17,22,23) – further demonstrating a survival benefit from this treatment. efficacy of the igm preparation in patients of all ages is thought to be due to higher antibody titers against a broader variety of bacterial pathogens and their toxic products compared with standard immunoglobulin preparations (7,10,24). additionally, the immune system initially responds with the production of igm as the first line of defense against bacterial pathogens and hence igm antibody titers increase before igg antibody production starts (23,25). moreover, igm is more efficient in activating the complement cascade and leads to a more rapid and specific antibody response, compared with igg (15,25). with respect to neonatal sepsis, the efficacy of an igm preparation is possibly due to the relatively low igm levels in neonates after birth. during pregnancy, only a low level of igm is transferred via the placenta to the fetus and endogenous igm production in neonates starts only gradually. conclusion the use of an adjuvant igm preparation pentaglobin® in the treatment of pediatric sepsis patients resulted in an increase in the survival rate, a reduction in the los and an improvement in infection severity, all of which were found to be statistically significant in this study conducted in albania. conflicts of interest: none declared. references 1. goldstein b, giroir b, randolph a. international pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. pediatr crit care med 2005;6:2-8. 2. el-nawawy a, el-kinany h, el-sayed mh, boshra n. intravenous polyclonal immunoglobulin administration to sepsis syndrome patients: a prospective study in a pediatric intensive care unit. j trop pediatr 2005;51:271-8. 3. bayry j, misra n, latry v, et al. mechanisms of action of intravenous immunoglobulin in autoimmune and inflammatory diseases. transfus clin biol 2003;10:165-9. 4. martin gs, mannino dm, eaton s, moss m. the epidemiology of sepsis in the united states from 1979 through 2000. n engl j med 2003;348:1546-54. http://www.ncbi.nlm.nih.gov/pubmed/12798851 http://www.ncbi.nlm.nih.gov/pubmed/12798851 kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 10 5. cavazzuti i, girardis m. early use of immunoglobulin in septic shock. infection. (supplement ii). 5th international congress “sepsis and multiorgan dysfunction” vol 39; 2011. 6. khalid n. haque use of intravenous immunoglobulin in the treatment of neonatal sepsis: a pragmatic review and analysis. j med sciences 2010;3:160-7. 7. wilkinson jd, pollack mm, glass nl, kanter rk, katz rw, steinhart cm. mortality associated with multiple organ system failure and sepsis in pediatric intensive care unit. j pediatr 1987;111:324-8. 8. gašparović v, gornik i, ivanović d. sepsis syndrome in croatian intensive care units. croat med j 2006;47:404-9. 9. becker ju, theodosis c, jacob st, wira cr, groce ne. surviving sepsis in lowincome and middle-income countries: new directions for care and research. lancet infect dis 2009;9:577-82. 10. kissoon n, carcillo ja, espinosa v, argen a, devictor d, madden m, singhi s, van der voort e, jos latour j. world federation of pediatric intensive care and critical care societies: global sepsis initiative. pediatr crit care med 2011;12:494-503. 11. kreymann kg, de heer g, nierhaus a, kluge s. use of polyclonal immunoglobulins as adjunctive therapy for sepsis or septic shock. crit care med 2007;35:2677-85. 12. pildal j, gotzsche pc. polyclonal immunoglobulin for treatment of bacterial sepsis: a systematic review. clin infect dis 2004;39:38-46. 13. haque kn, remo c, bahakim h. comparison of two types of intravenous immunoglobulins in the treatment of neonatal sepsis. clin exp immunol 1995;101:32833. 14. rodríguez a, rello j, neira j, maskin b, ceraso d, vasta l, palizas f. effects of highdose of intravenous immunoglobulin and antibiotics on survival for severe sepsis undergoing surgery. shock 2005;23:298-304. 15. wang je, dahle mk, mcdonald m, foster sj, aasen ao, thiemermann c. peptidoglycan and lipoteichoic acid in gram-positive bacterial sepsis: receptors, signal transduction, biological effects, and synergism. shock 2003;20:402-14. 16. levy mm, fink mp, marshall jc, abraham e, angus d, cook d, cohen j, opal sm, vincent jl, ramsay g. 2001 sccm/esicm/accp/ats/sis international sepsis definitions conference. intensive care med 2003:29;530-8. 17. karatzas s, boutzouka e, venetsanou k, myrianthefs p, fildisis g, baltopoulos g. the effects of igm-enriched immunoglobulin preparations in patients with severe sepsis: another point of view. crit care 2002;6:543-4. 18. ehrenstein mr, notley ca. the importance of natural igm: scavenger, protector and regulator. nature reviews 2010;10:778-86. 19. trautmann m, held tk, susa m, karajan ma, wulf a, cross as, marre r. bacterial lipopolysaccaride (lps)-specific antibodes in commercial human immunoglobulin preparations: superior antibody content of an igm-enriched product. clin exp immunol 1998;111:81-90. 20. haque kn, zaidi mh, bahakim h. igm-enriched intravenous immunoglobulin therapy in neonatal sepsis. am j dis child 1988;142:1293-6. 21. alejandria mm, lansang ma, dans lf, mantaring jbv. intravenous immunoglobulin for treating sepsis and septic shock. cochrane database syst rev 2002:1. 22. nierhous a. immuno pathophysiology in sepsis the care for immunoglobulins. sepsis symposium, budapest 20-21 may, 2011. kola e, çelaj e, bakalli i, lluka r, kuli-lito g, sallabanda s. efficacy of an igm preparation in the treatment of patients with sepsis: a double-blind randomized clinical trial in a pediatric intensive care unit (original research). seejph 2014, posted: 09 february 2014. doi 10.12908/seejph-2014-04. 11 23. norrby-teglund a, haque kn, hammarstrom l.a. intravenous polyclonal igmenriched immunoglobulin therapy in sepsis: a review of clinical efficacy in relation to microbiological aetiology and severity of sepsis. j intern med 2006;260:509-16. 24. berlot g, vassallo mc, busetto n, bianchi m, zornada f, rosato i, tomasini a. relationship between the timing of administration of igm and iga enriched immunoglobulins in patients with severe sepsis and septic shock and the outcome: a retrospective analysis. j crit care 2012;27:167-71. 25. olas k, butterweck h, teschner w, schwarz h, reipert b. immunomodulatory properties of human serum immunoglobulin a: anti-inflammatory and proinflammatory activities in human monocytes and peripheral blood mononuclear cells. clin exp immunol 2005;140:478–90. ___________________________________________________________ © 2014 kola et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. siepmann i, chen t, andelic p. how can we champion young women working in public health? (viewpoint). seejph 2021, posted: 10 may 2021. doi: 10.11576/seejph-4424 viewpoint how can we champion young women working in public health? ines siepmann1,2, tara chen2,3, petra andelic1,2 1 faculty of health, medicine, and life sciences, maastricht university, the netherlands; 2 young professionals programme, association of schools of public health in the european region (aspher), brussels, belgium; 3 department of social work, tzu-chi university, hualien, taiwan. corresponding author: ines siepmann address: faculty of health, medicine, and life sciences, maastricht university, the netherlands; email: i.siepmann@student.maastrichtuniversity.nl siepmann i, chen t, andelic p. how can we champion young women working in public health? (viewpoint). seejph 2021, posted: 10 may 2021. doi: 10.11576/seejph-4424 women, especially early in their careers, have been systematically excluded from public health leadership positions, only holding 25% of the leading roles despite compromising 70% of the workforce (1). they face difficulties in entering the field, ensuring a work life balance, and receiving adequate support. this disparity has been highlighted during the covid-19 pandemic, in which the public health workforce (phwf) has been placed at the forefront of the crisis response. this spotlight on public health has demonstrated the gaps within the system, namely the inability to respond to current and future public health demands and to adapt to constantly changing environments. the failures of public health systems have been in part attributed to the fact that the phwf, particularly its leaders, have not been adequately supported and strengthened, resulting in a homogeneous, nonrepresentative workforce (2). a revitalized phwf is urgently needed. the new workforce must address the nonrepresentative nature of current leaders and support individuals and organizations ready to champion a new era of public health. “champions” themselves are described as engaging, innovative individuals who are passionate, persistent, persuasive, and influential (3). the combination of these values is critical for effective public health leadership, and is associated with improved population health and well-being. these characteristics in a woman, however, can be seen as disruptive, loud, assertive and emotional. this viewpoint discusses how this and additional barriers impact young women from entering the field, achieving a work life balance, and receiving adequate support. it provides key takeaways based off of these observations, and demands institutional change for the betterment of individual and population health. entering the public health field the demographics of the public health workforce are largely unexplored. in a field intended to be diverse and representative of the public, this is a large oversight. diversity and inclusion in public health is tied to better health outcomes, which is simultaneously the goal of public health (4). data often showcases gender distribution for healthcare practitioners such as physicians and nurses, but data collection does not extend to public health practitioners and students. the majority of educational institutions do not collect demographic data regarding students or faculty, and organisations are even less likely to collect and share data (5). for those that do, the gender gap remains, with women being underrepresented in higher positions (6). this knowledge gap demonstrates an early stage ignorance of the disparities present within public health. by not knowing who chooses to enter the public health field and why, barriers that individuals might face when considering entering the field are ignored. generally, public health leaders are not visible to the public. this is exacerbated for young women, as they see few female leaders in the field. it is essential to be exposed to people they can identify with in a leadership position to consequently see a potential future for themselves. as a result, the field would be richer through a more diverse representation, knowledge and leadership traits (1). achieving a work-life balance the challenge of championing young women does not end just by breaking the barrier of entering into the workforce. it transitions to the next question of “what now?”. with the pressures of today’s society and health needs, the public health workforce is faced with the conundrum of balancing a high, active engagement in their work with family and personal life. https://www.zotero.org/google-docs/?7r5ol2 https://www.zotero.org/google-docs/?utee1q https://www.zotero.org/google-docs/?qzwliv https://www.zotero.org/google-docs/?zxxmkr https://www.zotero.org/google-docs/?gefnue https://www.zotero.org/google-docs/?y19gkk https://www.zotero.org/google-docs/?uapt63 siepmann i, chen t, andelic p. how can we champion young women working in public health? (viewpoint). seejph 2021, posted: 10 may 2021. doi: 10.11576/seejph-4424 women are expected to take on multiple roles in life, such as a homemaker and a working woman, as well as maintaining strong social networks. research findings continuously emphasize that women are paid less for doing the same work, that being a ‘working mother’ has made it harder for women to advance in their job or career, that work conditions are designed for men, and that woman face additional pressures to being a good parent and friend compared to men (7). these imbalances warrant stress, and are linked to unwanted health issues. the high expectations can be intimidating and alienating for young women trying to advocate for themselves in the public health workforce (8). receiving adequate support once a young woman has entered the phwf, she is faced not only with high professional and personal expectations, but also with the limitations of our current mentorship system. very few programmes and organizations, both academic and in industry, have established cohesive mentoring frameworks. public health organizations are underfunded and under resourced, with limited time to develop robust mentorship systems. genuine, bidirectional inclusion of young people is necessary for better health programmes and subsequent outcomes (9). however, mentorship is hard to come by, due to the high pressures of academia and silos between private and public sectors. above all, opportunities are not casually offered to young mentees. academia and research follow a publish-orperish system, which has resulted in a culture of selfishness and gender disparity. women are significantly underrepresented in scholarly journals (10); this is particularly damaging in a field such as public health, which thrives off of multidisciplinary, relational work. by building a workforce in which the members are competing to be seen, it limits its own ability to effectively teach and collaborate in the workforce. the culture also disproportionately impacts women, who due to other responsibilities, may not be as able to compete for recognition. the essence of female empowerment lies in increasing female representation in the organization’s social order to bring forth the idea that this is possible. female leaders in health systems have a common element in their careers: a strong social network early on that helped them develop confidence and credibility (11). to advance in the career, a robust professional social network is necessary. today’s next generation is suffering from a high impact, fast-paced global environment. these high demands as a young woman in public health challenges the notions of being a visible part of the workforce in demanding situations. key takeaways the public health infrastructure needs strengthening to be gender responsive. to do so, women, particularly young women, must be more intentionally welcomed into the field and given the opportunity to reach their full potential in leadership roles. the demographics of the public health workforce are not established and female leaders are not clearly visible to the public. to address this gap, public health educators, practitioners, and leaders need to consider how public health organisations function and recruit at all levels, from initial visibility of the field, to opportunities and support once women have entered. gender transformative policies need to be created and adopted to push the health sector to empower women and girls. public health must: ● have representative leadership, including women and young people ● recognize the barriers to entry for young women, including workplace https://www.zotero.org/google-docs/?gyxzra https://www.zotero.org/google-docs/?wp3g4l https://www.zotero.org/google-docs/?zykj8k https://www.zotero.org/google-docs/?rvmihx https://www.zotero.org/google-docs/?flsocf siepmann i, chen t, andelic p. how can we champion young women working in public health? (viewpoint). seejph 2021, posted: 10 may 2021. doi: 10.11576/seejph-4424 demands and availability of role models ● bolster mentorship and support networks, particularly for young women to highlight women empowerment ● support career advancement and gender parity in leadership positions providing equal and equitable opportunities for young women working in public health is essential to achieve the necessary strengthening of the public health infrastructure. making overdue changes to systemically gender biased and discriminatory infrastructures is crucial for the future of public health, and will strengthen public health’s post-pandemic response. conflict of interest: none declared. acknowledgements: we would like to thank kasia czabanowska and lisa wandschneider for their thoughtful feedback. references 1. who. delivered by women, led by men: a gender and equity analysis of the global health and social workforce [internet]. world health organization; 2019 [cited 2021 may 6]. (human resources for health observer issue 24). available from: http://www.who.int/hrh/resources/he alth-observer24/en/. 2. treviño‐reyna g, czabanowska k, haque s, plepys cm, magaña l, middleton j. employment outcomes and job satisfaction of international public health professionals: what lessons for public health and covid19 pandemic preparedness? employment outcomes of public health graduates. int j health plann manage. 2021 april 4. doi: https://doi.org/10.1002/hpm.3140. 3. fhi360. engaging innovative advocates as public health champions [internet]. 2010. available from: https://www.fhi360.org/sites/default/f iles/media/documents/engaginginnovative-advocates-as-publichealth-champions.pdf. 4. kalina p. challenges to diversity and inclusion in health care. hum resour manag res. 2018;8(3):45–8. doi: https://doi.org/10.5923/j.hrmr.201808 03.01. 5. claeys-kulik a-l, jørgensen te, stöber h. diversity, equity and inclusion in european higher education institutions [internet]. 2019. available from: https://eua.eu/downloads/publications /web_diversity%20equity%20and%2 0inclusion%20in%20european%20hi gher%20education%20institutions.pd f. 6. statistikportal. geschlechterbezogene hochschuldaten nrw [internet]. 2021. available from: https://www.gender-statistikportalhochschulen.nrw.de/start. 7. poduval j, poduval m. working mothers: how much working, how much mothers, and where is the womanhood? 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(viewpoint). seejph 2021, posted: 10 may 2021. doi: 10.11576/seejph-4424 © 2021 siepmann et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 2019 oct 1;3(10):673–5. doi: https://doi.org/10.1016/s23524642(19)30247-0. 10. west jd, jacquet j, king mm, correll sj, bergstrom ct. the role of gender in scholarly authorship. hadany l, editor. plos one. 2013 jul 22;8(7):e66212. doi: 10.1371/journal.pone.0066212. 11. javadi d, vega j, etienne c, wandira s, doyle y, nishtar s. women who lead: successes and challenges of five health leaders. health syst reform. 2016 jul 2;2(3):229–40. doi: https://doi.org/10.1080/23288604.201 6.1225471. _________________________________________________________________________________________ https://www.zotero.org/google-docs/?8kbwo1 https://doi.org/10.1016/s2352-4642(19)30247-0 https://doi.org/10.1016/s2352-4642(19)30247-0 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://dx.doi.org/10.1371%2fjournal.pone.0066212 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://www.zotero.org/google-docs/?8kbwo1 https://doi.org/10.1080/23288604.2016.1225471 https://doi.org/10.1080/23288604.2016.1225471 elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 1 | 16 review article national health systems strengthening as the primary strategy to achieve universal health coverage in african countries yasir ahmed mohammed elhadi 1,2, yusuff adebayo adebisi 3, uchechukwu victor abel 3, ekpoh mfonobong daniel 4, ashraf zaghloul 1, don eliseo lucero-prisno iii 5 1department of health administration and behavioral sciences, high institute of public health, alexandria university, alexandria, egypt 2department of public health, medical research office, sudanese medical research association. khartoum, sudan 3faculty of pharmacy, university of ibadan, ibadan, nigeria 4faculty of pharmaceutical sciences, university of port harcourt, nigeria 5founder and managing director, global health focus africa corresponding author: yasir ahmed mohammed elhadi; address: high institute of public health 165 el horreya avenue 21561 alexandria, egypt; email: hiph.yelhadi@alexu.edu.eg author's contribution: yasir elhadi developed the concept for this paper and wrote the first draft. yasir elhadi, yusuff adebisi, uchechukwu abel and ekpoh mfonobong assisted in data search and draft of the manuscript with important contribution from ashraf zaghloul and don lucero-prisno iii in writing reviewing and editing. mailto:hiph.yelhadi@alexu.edu.eg elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 2 | 16 abstract africa is the second largest continent and has its socioeconomic and health peculiarities. countries are faced with varying challenges towards its universal health coverage (uhc) achievement and hence the region requires health system reforms to drive equitable and balanced medical services to its populace. the main objectives of the paper were to explore the complexities of the african health systems, subsequently highlighting major challenges to uhc and to provide a framework for strategic approaches to health system strengthening to ensure realization of uhc. information presented in this paper was collected from published literature and reports on rwanda, kenya, nigeria, tanzania, ghana, tunisia, democratic republic of congo, zambia, egypt and south africa, amidst other african countries. the published literature points to the presence of a somewhat slow progress towards uhc or at least an existent knowledge of it. however, common challenges faced can be grouped into 1) financial constraints which include low levels of government expenditure on health and increased out-of-pocket percentages, (2) lack of coverage of key services which includes majorly immunization rates and existence of health insurance for citizens, (3) input constraints ranging from drug availability to skilled healthcare workforce, information and research and (4) lack of political support and commitment towards universal health coverage. to overcome the above-stated constraints, two broad groups of interventions were identified; general interventions largely focusing on reprioritization of health budget, quality and improved services, equipped facilities and efficient social protection systems; and specific interventions which emphasizes the importance of eliminating shortage of health workers, ensuring availability of essential medicines/ products, embracing decentralization at supply chain management, validating data/ information system and advocacy for impactful health education/promotion. although there will be strength and weakness for whatever reforms adopted, implementation is totally contextual and contingent upon countries' specific health system bottlenecks. keywords: universal health coverage, health system strengthening, africa, framework, health sector reform. sources of funding none conflicts of interest the authors declare no conflict of interest acknowledgement we would like to thank dr. augustinoting mayai for assistance and mentorship elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 3 | 16 introduction the world health organization's (who) definition of universal health coverage is "all people have access to services and do not suffer financial hardship paying for them" (page ix) (1). the need to build consensus on the definition of uhc is crucial for setting priorities, polices and budgeting changes needed to realize uhc (2). the principle of universal health coverage aims at ensuring equitable and efficient access to health services. therefore, it has become priority objective and major goal of health reform in many countries (3). health system reform interventions are complex in nature depending on a country's individual context and system bottlenecks, these interventions take place at different levels in the health system. achievement of uhc through continued health systems reform in african countries is, therefore, the most promising strategy. the experience of different countries in implementing uhc strategies has revealed successful lessons and pitfalls to avoid in ensuring the progress towards universal health coverage (4). the health system strengthening (hss) initiatives are usually composed of multiple strategies designed to work at different levels and components of the health system (1). recognizing complex interconnections and interactions of combined strategies, health planners and policy makers should account for proper coordination between the intervening links and pay more attention in designing specific interventions (4). many health system frameworks have been developed to focus on strengthening health systems to improve health outcomes. the available frameworks differ in conceptualising health systems' functions, which directly influence strategies and policies (5). this review aims to evaluate progress towards uhc and introduce holistic approaches to strengthening health systems in 10 african countries (rwanda, kenya, nigeria, tanzania, ghana, tunisia, democratic republic of congo, zambia, egypt and south africa) by using who health system framework. methods this is a review study on health systems strengthening strategies and progress towards universal health coverage in 10 african countries (rwanda, kenya, nigeria, tanzania, ghana, tunisia, democratic republic of congo, zambia, egypt, and south africa). reviews of published articles and official reports were used to gather information on progress toward universal health coverage in studied african countries and key challenges in african health system components. the search was done on 13th to 19th july 2020 using pubmed, medline, and scopus electronic databases and public search engines such as google scholar and google. the relevant keywords used in the search consisted of phrases considered by the authors to describe targeted information about service delivery, health workforce density and distribution in african countries, health financing, leadership and governance, health information systems and research, and health systems strengthening strategies and interventions. search query was adapted to the specific needs of each database. search phrases used were "healthcare services delivery in africa", "health workforce density in africa", "health financing in african countries", and "health information systems in africa", "health system strengthening strategies", "universal health coverage in africa". additionally, latest published reports of the who, world bank and fmoh on rwanda, kenya, nigeria, tanzania, ghana, tunisia, elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 4 | 16 democratic republic of congo, zambia, egypt and south africa were also reviewed to provide in depth analysis of health systems problems and impediments to uhc in each country. finally, the authors provide a framework for health systems strengthening in the african region, general and specific interventions to overcome the reported health systems bottlenecks and constraints to uhc in the african countries based on evidence-based guidelines and lesson learned from previous countries' experience. results progress toward uhc in african countries the uhc monitoring framework developed by the world bank and the who focuses on the coverage of critical services, population coverage, and financial protection (6). our analysis of the extent of service coverage included maternal health-related indicators, access to essential hiv/aids services, and childcare interventions, amongst others. most of the interventions related to maternal health have improved in the last couple of decades in these selected countries; antenatal care visit (at least 4) has increased by about 40% between 2004 and 2014, and the proportion of birth attended by skilled health personnel has improved by about 10% in the last decade coming up to 2014. the most rapid improvement has been the change in the coverage of insecticide-treated bed nets for children increasing on average by about 15% per year between 2006 and 2014. prior studies show notable variation in antiretroviral therapy (art) coverage among people with hiv eligible for art ranging from 17% in north africa to 54% in esa in the year 2016 (7). the coverage of diphtheria-tetanus toxoid (dtp3) vaccination has seen an increase over the period except for five countries (benin botswana, equatorial guinea, kenya, and south africa), among which equatorial guinea is the only one with a 35% coverage rate (7). health financing total health expenditure in the region has grown over the last two decades. (8) shows the trend of total health expenditure for the african region over a period of 9 years. we see that more countries have been increasing expenditures on health over this period although the rates vary among the countries. for example, information from the 2010 world health report (9) indicates that rwanda more than doubled its per capita expenditure on health over a period of 10 years, with a large part of this increase attributed to external funds (9). however, three countries have remained below the expenditure level of us$ 20 per capita, with thirty countries persistently spending over us$ 44 per capita over the same period. in 14 of the 47 countries included in the above analysis, the level of funding for health was below the minimum level of us$ 44 per capita recommended for 2009 by the high level task force on innovative international financing for health systems (8). information and research low investment in data management infrastructure shows that priority is not given to health research and data, which are crucial for sustainable development. consequently, several functions. hence, several functions of the health research systems are either non-existent or weak. furthermore, the research elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 5 | 16 arena in the african region is characterized by a multiplicity of externally driven agendas, dispersed efforts, and unclear results in relation to impact on priority health problems. in addition, although publications have increased by 10.3% each year in recent years, this has not translated into the conversion of evidence to policy and calls for more to be done (10). health workforce statistics as at 2016 show that twenty-five percent of doctors, and five percent of nurses trained in africa are currently working in developed countries. this brain drain has resulted in a shortfall of over 1.5 million health workers in the region (11). table 1 shows the health workforce density of ten countries in the region. “the health sector in rwanda has pioneered task-shifting by transferring agency for many clinical decisions and activities to nurses and community health workers” (12). however, a persistent shortage of adequately trained health professionals poses a major barrier to scaling up the availability and quality of specialized care. in 2016, nearly 70% of the health workforce was composed of nurses and midwives. the density of doctors, nurses and midwives per 1,000 population is estimated to be 1.01, 108% increase since 2005, rwanda still falls far below the minimum level recommended by the who of 2.3 providers per 1000 population (13). in nigeria, the health workforce density is estimated at 1.95 per 1000 population (14) as at 2016. table 1: density of doctors, nurses and midwives per 1,000 population in the 10 african countries source: world bank data. country density of doctors per 1,000 population nurses & midwives per 1,000 population ghana (2017) 0.18 4.2 rwanda (2017) 0.13 1.2 nigeria (2018) 0.38 1.2 kenya (2018) 0.16 1.2 drc (2016) 0.07 1.1 tanzania (2016) 0.01 0.6 zambia (2018) 1.2 1.3 south africa (2017) 0.9 1.3 egypt (2018) 0.5 1.9 tunisia (2017) 1.3 2.5 elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 6 | 16 lessons learned from previous countries' experience and major barriers to uhc despite the great diversity of african countries, many of them are facing common challenges; these can be grouped into financial constraints, coverage of key services and input's constraints. the key financial constraints are low levels of government expenditure on health and overall expenditure on health. among ten countries studied in the region, it was shown that seven of which allocated less than 5% of the gross domestic product (gdp) as expenditure on health in 2017. the average government expenditure on health as a percentage of the gross domestic profit (gdp) was 4.75% ranging from 3.2% in ghana to 8.11% in south africa. government spending on health as a percentage of total government spending varied, from a low of 3.3% in drc to a high of 13.63% in tunisia. government spending on health as a percentage of total health spending appears to be decreasing moderately over the past decade for countries, rwanda and tanzania, whereas south africa maintained a relatively stable share while egypt and kenya experienced an increase in 2017 (15). rwanda appears to be the most advanced country in africa regarding universal coverage. the country has achieved 96.15% coverage in health insurance as of 2011, with a 95% utilization rate (16). out of pocket expenditure as a percentage of total health expenditure was as low as 6.25% in 2017 (18). the world health organization states that it is very difficult to achieve uhc if out-ofpocket (oop) as a percentage of total health spending is equal or greater than 30%. the who defines households with catastrophic health expenditure (che) as a household with a total oop health payment equal to or exceeding 40% of a household's capacity to pay. a non-poor household is impoverished by health payments when it gets poor below the poverty line after paying for health services (17, 19) the share of oop as a percentage of total health spending ranged from a low of 6.25% in rwanda to a high of 77.22% in nigeria in 2017. in 2013, south africa had a rate of 39%, in zambia it was 11% in 2014, 18% for tanzania in 2009, drc was 45% in 2015, kenya was 22% in 2013, ghana was 12% in 2006, no data was available for egypt, tunisia for recent years (18). households covered under health insurance, engaged in mutual health organizations, or an informal social safety network have a reduced risk of catastrophic spending (20, 21) as informal financing mechanisms through mutual organizations, “informal groups and merry go rounds unlike formal health insurance is observed to reduce the risk of che” (22). in certain cases, health insurance, however, is not a significant determinant, as for instance, in kenya, where it only covers a small proportion of households and only inpatient services (23). for coverage of key services for uhc, a key indicator is immunization rates. as (8) shows, dtp3 immunization coverage among children ages 12-23 months has decreased roughly in ghana, rwanda, tanzania, south africa, egypt, tunisia, increased sharply in kenya and steeply in drc in the most recent years. in general, rates have fluctuated in all these countries in the last decades with a relatively constant rate in nigeria from (2017-2018). tanzania consistently has the highest vaccination rates of 98% and above during this period, followed by ghana, rwanda and tunisia at 97%, the countries with working national or community-based insurance schemes in africa. governments have used different methods to expand coverage for health services for some vulnerable groups; countries such as ghana, rwanda have exemption guidelines within the health financing framework that target poor and vul elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 7 | 16 nerable groups. however, many of these targeted services are not within the reach of the poor and, as a result, many are not covered by health insurance schemes. of the selected countries, rwanda is the only one with wide coverage of the poor (24). the "ubudeheprogramme" in rwanda has been proven effective in identifying those most in need of exemptions under the cbhi. tanzania and kenya have no specific exemption guidelines for the poor, but some waivers are given to patients in tanzania who are assessed to be too poor to pay their bills. in ghana, after almost twelve years of introducing national health insurance less than 40% of the population is covered by the scheme and less than 2% of them make up the poor. input's constraint comprises of the availability of drugs, human resources, data collection, and skilled workforce. insufficient healthcare providers and unequal distribution of health professionals continue to remain significant problems in the african countries (table 1). the ratio of doctors ranged from one doctor per100, 000 populations in tanzania, to 130 doctors per 100,000 populations in tunisia. in all the african countries, there were more nurses and midwives than doctors in the population. the shortage of health workers in sub-saharan africa (ssa) is due majorly to high attrition rates and the inability to produce and recruit the appropriate cadres of health workers (25–28). in 2015 fifteen countries in ssa had developed the human resource for health (hrh) policy and strategic areas that all the hrh plans included were the scaling up of the education and training process of health worker. earlier in 2012, rwanda announced collaboration between the u.s., rwandan governments and 1https://hms.harvard.edu/news/how-rwanda-dramatically-expanding-its-health-workforce 25 leading u.s. academic institutions in fulfillment of their hrh plans. $150 million program launched in kigali. under the program, each year more than 100 american health care professionals from medicine, nursing and midwifery, dentistry and health management work in rwanda alongside rwandan faculty to build residency programs, strengthen instruction quality and substantially increase the output of new health workers. rwanda's example and the human resources for health program in particular, have the potential to transform global health by serving as a model for any country that wants to increase the efficiency of foreign aid and improve the health of its people.1 the major challenges and barriers toward uhc can also be contextualized in each of the african countries included in this study. ghana was the first country in africa to finance its national health insurance scheme with revenue from a value-added tax (vat), this means that revenue can benefit from its economic growth (29). however, ghana stills struggles with how to attain universal population coverage under this scheme as it currently has active coverage around 40 % of the population (30). from 2010 to 2012, public and external assistance declined, while the share of private expenditure (mostly out-ofpocket payments) tripled, indicating an increased financial strain on its citizens (6). in rwanda, inadequacy in the health workforce and insufficient funds has hindered access to health services for some 80 per cent of the population thereby hindering progress toward uhc for the population. the ratio of doctors to population in rwanda is amongst the lowest in africa (13 doctors for every 100,000 population, 2017). although this deficit in health workers i.e. doctors, nurses https://hms.harvard.edu/news/how-rwanda-dramatically-expanding-its-health-workforce https://hms.harvard.edu/news/how-rwanda-dramatically-expanding-its-health-workforce elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 8 | 16 and midwives “was partly compensated by the large number of chws who visit people's houses to monitor health events and suggest early intervention”, improvements are needed for effective and timely access to health care in rwanda. furthermore “in addition to the insufficient number of skilled health workers, capacity building is needed for health workers and managers. distribution of health workers across regions has to be made more equitable, especially between urban and rural areas. cbhi's low contribution rates have resulted in hospitals bearing large debts and patients having to buy drugs themselves from pharmacies without reimbursement”. (31). in nigeria, one of the main challenges that have affected its attainment of uhc is inadequate government health financing and budgetary allocations to the health sector. the government is yet to commit to adequate health financing and budgetary provisions for the health of nigerians. out‐of‐pocket payments estimated at 77% as at 2017 (6) is said to be the most common source of health‐care financing in nigeria. similarly, since the nhis (national health insurance scheme) was launched in 2005, only the contributions from government (employer) are still largely available to fund the contributory social health insurance scheme. in kenya, the main problem is simply a shortage of government budgetary resources for health care in relation to increasing demand and need for care. the effect of the budgetary shortfall is seen in the deterioration in the quality and effectiveness of publicly provided health services (32). “in addition to an absolute shortage of resources going into the health sector, patterns of spending in most countries cause or reflect an inequitable and inefficient allocation of inputs and services. the clearest example of this is the concentration of government resources in large, urban hospitals. on average, people who live in urban areas have higher incomes than those in rural areas, yet the urban bias in government health spending means that the costs of gaining access to good quality care are highest for the most remote, and usually poorest, groups of the population” (33). in the drc, with less than 10% of the urban population covered by formal health insurance programs and even less for the rural population ensures that the national health system heavily relies on households' direct contributions. thereby, the financial risk incurred by the households in the region increases, which serves as the biggest barrier to achieving uhc (34).i n zambia, although zambian governments have increased and continue to increase domestic funding for the country's health services, the health system as a whole is subsidized by foreign donor funds and that funding is decreasing since 2010 following the global financial crisis. also, changes in the composition and concentrations of the national population have also led to an increase in chronic non-communicable diseases (35). health system strengthening framework for african countries it is not acceptable that some members of society should face death, disability, ill health, or impoverishment for reasons that could be addressed at limited cost” (36). the need for a clear health system strengthening guide has recently grown, especially among stakeholders working at the country level. with many available competing frameworks health planners and policy makers often encounter conceptual confusion, which hinders them from properly defining and describing their health system functions; and accordingly designing and implementing the suitable interventions. efforts have been continuously directed to address this confusion through conversion of elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 9 | 16 multiple frameworks to revitalize available strengthening approaches (37). the access, bottlenecks, costs, and equity (abce) project, led by institute for health metrics and evaluation (ihme) and country collaborators in ghana, kenya, uganda, and zambia, is an example of the kind of comprehensive and detailed assessment that is a top priority to health policymaking and resource allocation – and which rarely occurs because health system functions worldwide are complex and multidimensional (38). developing of strong health financing system is a main goal for all african countries. according to the world bank classifications most of african countries ranked in area of lowand middle-income countries, so shortage of funds for health in these countries and insufficient investments in the health sector is critical challenges to enhancing health outcomes in africa. world health organization highlights three main policies that aim to strengthen the financial health system in africa; aligning budget resources and health priorities; closing the gap between health budget allocation and expenditure; maximizing uhc performance with the money available (39). community-based health planning and service approach one of the best approaches in increasing community commitments towards health system strengthening, enhancing equitable access, delivery of primary health care, and resource mobilizations (40). table 2 below summarizes main bottlenecks (problems) of health system components in the african region with related strengthening strategies. table 2: health system strengthening framework for african countries health system component current problems strengthening strategies health financing reliance on out-of-pocket payments. lack of investment in health sector and overdependence on funds from foreign donors. increase social insurance schemes, encourage progressive taxation, reprioritize government budgets to reduce impoverishment and give money to health. internal assessment of country's revenue modalities/ matched funding. strengthen domestic mechanisms for prepaid funding. workforce workforce shortage and unequal distribution at sub-national level. increase support and facilitate medical education. engage informal community health workers. redistribution of human resources throughout rural areas. leadership/governance graft and corruption. politicians appointed as health ministers and not health experts. populist decision making and not based on science. poor/lack of evidence-based enacted policies appoint professional managers. train them in good governance, transparency and accountability. implement properly laws on graft and corruption. utilization of technical expert in evidence-based policy making. elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 10 | 16 discussion selection, implementing and monitoring of health system strengthening strategies relative prioritization debate in selecting specific strategies for a particular context has always been evolving among global health stakeholder, heath planners and policy makers. complexity of interconnection in intervening links directly influence relative importance of one strategy over the other (5). however, assessment and proper identification of key bottlenecks in health system ensure selection of the most appropriate strategies. achieving universal health coverage despite the diversity of needs and contextual factors in african region requires adopting holistic and combined approaches to guide health system strengthening initiatives. these approaches fall into two recommended strategic domains; general and specific interventions of health system strengthening. general interventions as shown in table 3, these include evidencebased strengthening strategies (41 43) to expand dimensions of universal health coverage in terms of cost coverage, service coverage, and population coverage. table 3: general strategies for health systems strengthening with major strengths and weaknesses. uhc dimension strategies of hss strength weakness cost coverage increasing funds through efficient revenue collection and reprioritization of government budgets to give more money to the health sector. support public, private and social insurance schemes. eliminate corruption with healthcare system. decrease out of pocket payments and reduce financial hardship. may impact the overall government budget. service delivery unequal distribution of health facilities between urban and rural areas unnecessary medical tourism. build new facilities, partner with civil society organizations (cso), properly maximize international collaborations and improve quality of services for underserved populations through effective primary health care. build infrastructure, equipped to competing standards, expand and ensure sufficient services provision. medical products, vaccines and technologies medicine, medical supplies and supply chain shortages. decrease organizational barriers and introduce more decentralization at supply chain management. information system lack of surveillance systems, knowledge and expertise of it. absence of proper data management and transfer systems. no technical knowledge. build data accountability systems and provide scientific and technical support. deliberately work with research institutes to encourage researchers. elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 11 | 16 service coverage increase provision of health services in term of number and type of services. introduce new health technology based on the need of specific population. monitor quality of services through implementing of quality assurance and quality assessment programs. increase the overall patient satisfaction. may decrease the cost coverage unless additional resources were generated. population coverage redistribution of health care facilities and health workers. construction of localized health care facilities. reduce geographic barriers to access to health services. if disadvantaged and underserved population were not identified properly lead to inefficient use of resources. specific interventions shown in table 4 these strategies are designed mainly to target specific problems that directly impact health system performance, with proper identification and removal of key bottlenecks in the health system and focus mainly on the quality of service provision to underserved and disadvantaged populations. table 4: specific strategies for health systems strengthening with major strengths and weaknesses. health system problem/system bottleneck specific strategies strength weakness health workers shortage increase support and facilitate medical education. engage informal community health workers. redistribution of human resources throughout rural areas. increased competency and skills of staff. build engagement with localized communities. ensure equitable access to good quality health services. some system constrains may limit the implementation of these strategies. elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 12 | 16 supply chain bottlenecks decrease organizational barriers and introduce more decentralization at supply chain management. design alternative supply chains for specific areas based on the specific need of disadvantaged population. increase system responsiveness to supply shortages. ensure delivery of products. unless designed, implemented and monitored properly may lead to inefficient use of resources medicines and medical products shortage reassessment of national priority to select most appropriate products. efficient use of resources and avoid catastrophic impact of life saving health products. unless designed, implemented and monitored properly may lead to inefficient use of resources data unavailability design and implement data accountability system and information-based health centers ensure proper identification of disadvantaged population and their needs. may be limited by environmental constrains. insufficient health education design national health campaigns about country specific disease burden. increase awareness of community and compliance with health advisor. may deplete available human resources for health. implementation of strengthening strategy requires framework that accounts for potential interaction and contextual constrains within the health system. based on previous experience of african countries, strengthening should be considered a continuous learning process; also, adjustment of contextual factors is crucial to ensure effectiveness of interventions (44). engagement of the private sector and public-private partnerships when implementing strengthening initiatives through african countries is strongly recommended (45). however, there is need for effective approaches for monitoring quality of health services provided by the private sector (46-48). conclusion and recommendations uhc is a good economic investment, and we believe the african region has great potential in achieving quality, affordable and equitable healthcare for its populace if the right interventions are made. to stay committed to uhc, it is important that african countries implement country-led strategies/ interventions to better reform their health systems. to overcome the above-stated constraints, two broad groups of interventions are recommended; general interventions largely focused on reprioritization of budget, quality and improved services, equipped facilities and efficient social protection systems; and elhadi yam, adebisi ya, abel uv, daniel em, zaghloul a, lucero-prisno iii de. national health systems strengthening as the primary strategy to achieve uni-versal health coverage in african countries (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4445 p a g e 13 | 16 specific interventions which emphasizes the importance of eliminating shortage of health workers, ensuring availability of essential medicines/ products, embracing decentralization at supply chain management, validating data/ information system and advocacy for impactful health education/promotion. although there will be strengths and weaknesses of whatever reforms adopted, implementation is totally contextual. in times of emergence/ re-emergence of pandemics, increased communicable and non-communicable diseases, and various epidemiological changes, health services provision has become more vital and valuable. political commitment to health spending, improved education/ remuneration of workforce, and improved health markets are essential for decreasing rates of impoverishment, alleviating health inequities, increasing economic growth and development. these intertwined commitments are essential for an effective african health system. references 1. 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v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 1 | 17 original research facilitators and barriers to the use of economic evaluations in nutrition and public health alessandra lafranconi1-3, vera meusel3,4, sandra caldeira3, suzanne babich5, katarzyna czabanowska1,6 1department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 2centro di studio e ricerca sulla salute pubblica, università degli studi milano bicocca, italy; 3european commission, joint research centre, ispra, italy; 4friedrich-alexander-universität erlangen-nürnberg, germany; 5indiana university purdue university indianapolis, richard m. fairbanks school of public health, united states; 6national institute of public health, warsaw, poland. corresponding author: sandra caldeira; address: via enrico fermi 2749, i 21027 ispra (va), italia; telephone: +39 0332 78 38 87; e-mail:sandra.caldeira@ec.europa.eu mailto:sandra.caldeira@ec.europa.eu lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 2 | 17 abstract aims: interventions targeting diets have the potential to reduce a consistent fraction of the chronic disease burden. economic evaluations of such interventions can be an important tool in guiding public health practitioners and decision makers at various levels, yet there are still not many economic evaluations in this area. this qualitative study explored facilitators and barriers in conducting and using economic analyses to inform decision makers in the field of public health nutrition. methods: data were collected through written, open-ended questionnaires administered to twentythree participants (13 from academia and 10 from government) using purposive sampling and analysed through a conventional content analysis. results: the analysis revealed two broad categories of barriers, which included: i) “methodological challenges”, and; ii) “barriers related to application of economic evaluations.” two main categories of facilitators were also identified: i) “facilitators to improving the methodology of economic evaluations”, with subcategories further detailing frameworks and methods to be applied, and; ii) “facilitators to broaden the use of economic evaluations”, with most subcategories addressing science-into-policy translations. these barriers and facilitators to the use of economic evaluations in public health are perceived differently by researchers and policymakers, the former more focused on implementation aspects, the latter more concerned by methodological gaps. conclusion: public health nutrition policies seldom take into account data from formal economic evaluations. economic evaluation methodologies can be improved to ensure their broader application to decision making. keywords: economic evaluations, interviews, nutrition, public health, public policy. conflicts of interest: none declared. acknowledgements: the work of al is partially supported by a jean monnet erasmus+ grant (574376epp-1-2016-1-it-eppjmo-module). lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 3 | 17 introduction the social and economic burden of chronic diseases is a major source of concern for public health researchers and decision makers worldwide. according to the global burden of disease (gbd) study, over 91% of deaths and almost 87% of disability adjusted life years (dalys) in the european union are the result of non-communicable diseases (ncds), mainly cardiovascular disease and cancers (1). with regards to dietary risk factors, the gbd study group estimates that in the european union over 950,000 deaths and over 16 million dalys are attributable to dietary risks due to unhealthy diets, such as low whole grains, fruit and vegetables intake, low omega-3 intake and high sodium intake (2). along with an ageing population, obesity is a leading risk factor contributing to the burden of chronic diseases, and will play a key role in shaping the future use of healthcare services (3). mean body mass index (bmi) has increased worldwide over the last four decades (4). already in 2008, the prevalence of adult obesity in european countries reached “epidemic proportions”, with some countries recording obesity rates higher than 25% (5). the prevalence of overweight or obesity is about22% among 11-years-oldsin europe, and in southern and eastern europe such prevalence is as high as 38-39% (6,7). inequalities have been documented not only between, but also within countries. for example, there is a gradient throughout the educational attainment spectrum, where those with lower levels are more likely to be overweight or have obesity; the inequality gap is particularly marked in women (8,9). the future does not look brighter; according to projections modelled through 2030, on the basis of past and current bmi trends, obesity and obesity-related chronic diseases will continue increasing in almost all countries from the who european region(10) and worldwide (11,12). chronic disease risk factors associated with poor dietary habits are often modifiable and preventable. actions to reduce the exposure to such risk factors have the potential to reduce the social and economic burden of overweight, obesity (13), and chronic diseases (14). economic evaluations can be used to estimate costs and benefits related to different interventions or policy options and help to guide the decision making processes (15).in the field of nutrition, economic evaluations have shown that most of nutrition-related interventions and policies are cost-effective, especially those applied at the population level, such as reformulation initiatives to lower salt intake (16) or a legal limit on industrial trans-fat use in the european union (17). yet, as stated by some authors who performed economic evaluations of interventions aimed at improving dietary factors: “given the potential health gains related to such interventions, the paucity of such studies is alarming and indicates that additional evidence in this area is needed. it is difficult to design evidence-based policies with so little empirical evidence.” (18). although methodological challenges of economic evaluations in public health, and specifically in the field of nutrition, have been identified by various authors (19-22), to our knowledge there is little research on challenges and facilitators in transferring economic evidence of public health and nutrition interventions into policy (23). lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 4 | 17 the aim of this pilot study is to identify key barriers and facilitators to performing and applying data from economic evaluations in the decision making processes in nutrition and public health. we report on the perceptions of policymakers and academic experts in the field of nutrition, public health and economics, to better understand and encourage the use of economic evaluations in planning, implementing and evaluating future interventions and policies. methods study design open-ended written interview questions (two broad questions, each with three subquestions, box 1) were given to participants on a dedicated web platform. a link to the questionnaire was sent to each participant via e-mail. conventional content analysis was applied to analyse the qualitative data (24), with the overall purpose of describing participants’ experiences, field knowledge and views on a topic that has received little previous investigation (25). participants participants were recruited from a pool of 30experts who participated in the 2015 workshop “public health and nutrition economics: the numbers behind prevention?”, organized by the joint research centre of the european commission. participants of the workshop were purposively chosen to ensure a range in expertise (public health, nutrition, and economics), representation (policymaking, academia, private sector, advocacy groups), and reach of action (local, national or international). moreover, geographical criteria (eu and neighbouring countries) were taken into account. inclusion criteria consisted of being a policymaker or an academic expert in any of the abovementioned fields, and of having at least intermediate theoretical knowledge and/or work experience across all expertise domains (i.e. at least three years of study/experience in all domains: public health, nutrition and economics). twenty-seven people met the inclusion criteria, and 23 (13 from academia, 10 from government) participated in the study. procedure the participants were selected between july and october 2015, the workshop took place on november 12-13, 2015, and the written interview was administered two weeks before the workshop, with a reminder sent after one week. the interview was sent via email, with the indication that the answers would be made available to all workshop participants, to foster discussion. oral or written consent of all participants was obtained. the study adhered to principles of ethical research practice (26). data analysis data were analysed through conventional content analysis, according to which coding categories are derived directly from the text data, through an inductive process, in order to move from specific instances to general statements. the advantage of such technique is that information is obtained directly from study participants, without imposing preconceived categories or theoretical perspectives. an example of the process is illustrated in box 1. lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 5 | 17 box 1. themes of the written interview and example of meaning unit, condensed meaning unit and codes from content. bau = business as usual. tfa = trans-fatty acids. phee = public health economic evaluations. themes 1: how have economic evaluations of policies/interventions informed decision making in public health?  general observations on facilitators and barriers to the use of economic evaluations in public health, nutrition and prevention of chronic diseases  examples of success stories in public health o from direct experience o from literature  examples of success stories in nutrition and physical activity o from direct experience o from literature 2: what are examples of possible or existing policies/interventions where economic evaluations are needed to help decision makers?  general observations on facilitators and barriers to the use of economic evaluations in public health, nutrition and prevention of chronic diseases  examples of gaps in public health o from direct experience o from literature  examples of gaps in nutrition and physical activity o from direct experience o from literature meaning unit (mu) condensed mus codes categories “i think it was easy to argue in this case because there is hardly any controversy in this case in what regards the heart effects of tfa consumption and so there was/is no opposition to the ban but the calculation of the health effects and the costs saved are strong arguments to those that are perhaps less health-minded to prioritise and implement it.” when there are no controversies on health effects, it is possible to implement policies. scepticism barriers related to the use of phee in policy settings the calculation of health effects and costs in case of inaction is a strong argument to less health-minded policymakers. inclusion of bau scenarios to reveal costs of inaction facilitators to widen the use of phee in policy settings lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 6 | 17 data were already in written format, and firstly two researchers (al and vm) read all the texts consequently, to immerse themselves in the data, have a common understanding, and detect both manifest and latent content. secondly, al and vm selected four interviews (two for each participant category, i.e. academia and government), and, for each interview, independently identified and condensed simple meaning units (words, sentences or paragraphs containing aspects related to each other through their content and context).discussion and resolution of discrepancies by consensus followed this second stage. third, al extracted the condensed meaning units of the remaining interviews; vm reviewed the extraction process, and discrepancies were again discussed and resolved by consensus. at a fourth stage, al created and assigned codes to all condensed meaning units; subsequently, vm independently assigned the codes created by al and added new codes as necessary. subsequently, discussion between al and vm took place to reach consensus on the coding procedure. finally, similar codes were grouped into comprehensive subcategories and categories, through an inductive process carried out by al, which consisted of comparison, reflection and interpretation. the software qda data miner was used to facilitate the above processes. results twenty-three participants (10 from policymaking bodies, and 13 from academia) were engaged in this study, for a total of 5,436 words (median: 161 words; interquartile range iqr 25-75: 79-237 words).their main characteristics (gender, expertise, reach of action and geographic coverage) are presented in table 1. table 1. participants characterisation policymakers gender expertise area of action geographic area m 7 public health 4 eu 4 eu 9 f 3 economics 4 national or sub-national 6 non-eu 1 nutrition 2 researchers gender expertise area of action geographic area m 6 public health 3 non applicable eu 8 f 7 economics 7 non-eu 5 nutrition 3 lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 7 | 17 the participants identified two sets of barriers to performing phee, and two categories of facilitators: methodological challenges in performing phee, barriers related to the use of phee in policy settings, facilitators to improve the methodology of phee, facilitators to widen the use of phee in policy settings. these categories and their subcategories are summarized in table 2. table 2. facilitators and barriers classified in categories and subcategories, with examples obtained from data analysis sub-categories examples m e th o d o lo g ic a l c h a ll e n g e s definition and measurement of outcomes “public health interventions […] are supposed to have a substantial impact on health and health care systems, but the assessment and the consequences on health are not sufficiently analysed, for multiple reasons [such as] difficulties to measure the impact (indirect and/or direct consequences)”. (policymaker) “some questions arise: should we focus on health-related behaviours or on anthropometrics (weight, waist circumference,…)? how long should the intervention last in order to have an impact?” (researcher) “calculations for [long-term] cost-effectiveness should be [performed in] every project in the area of primary prevention. this would enable reviewers/decision makers to decide which of the proposed actions would give the highest long-lasting (i.e. longitudinal) impact for the money spent”. (researcher) lack of adequate frameworks “methods to evaluate public health interventions are less well established than those for medical interventions” (policymaker) “lack of standardised methodologies and evidence based approaches, and no special focus of hta units and bodies [are challenges encountered] in public health evaluations”. (policymaker) “[in public health nutrition,] the magnitude of the association [between exposure and outcome] is relatively small. so, the case for carefully designed cost-effectiveness analysis appears to be strong” (researcher) im p le m e n ta ti o n c h a ll e n g e s scepticism “my feeling is that there is still some controversy around the real effect [of ssb taxation] on [ssb] consumption and eventually health”. (policymaker) “requests for evaluations are happening in (and are a symptom of) a context in which policymakers are increasingly confronted with intractable problems to which science may not always be fully equipped to reply. policymakers are flooded with scientific literature (some of which of weak basis), institutional reports, lobbyists’ papers and social media posts”. (policymaker) lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 8 | 17 “i would highlight the decision of withdrawing the gras (generally recognized as safe) status to tfas (trans-fatty acids) in the us and the ongoing eu considerations of setting a limit to its content in foods as a success story. in both cases there were economical evaluations made that clearly demonstrated the added value of a "ban" on the industrially produced tfa both in health and economic terms. i think it was easy to argue in this case because there is hardly any controversy in this case in what regards the heart effects of tfa consumption and so there was/is no opposition to the ban”. (policymaker) lack of strategy for effective budget allocation “the conclusion [from an economic evaluation] was that there was no need [for a new highly specialized hospital yard], but the final decision was to open one any way”. (researcher) “actions and interventions [to promote healthy lifestyles and to reduce obesity] proposed in the national preventive program for public health […] fall within budget planning, without any solid proofs for (cost) effectiveness of actions and interventions undertaken”. (researcher) m e th o d o lo g ic a l fa c il it a to rs growing interest in frameworks and methods “[there is a growing] interest in the development of appropriate methodological frameworks and methods to assess interventions aimed at improving nutrition behaviour”. (researcher) “evidence based on result from nutrition studies following harmonized methodology, indicators and cut offs for different indicators [is available]”. (researcher) multidimensional evaluations (whole-of-society approach) “due to [its] complex nature and multiple causes, improving nutrition requires the collaboration of multiple sectors, including agriculture, health, education, trade, environment, and social protection. [practically, we should start suggesting] to include an expert in the field of health economics when planning a primary prevention programme or a scientific project”. (researcher) “it would be good to (…) have a solid and as much as possible global assessment of the effects of [fiscal] policies (by global i mean 360 degrees, what effects did it have on consumption, health, market, industry, reformulation, innovation, country finances, etc)”. (policymaker) data stratification at different levels “there is lacking economic evaluation of [breast, cervical and colon cancer] screenings and it is necessary to introduce national based evidence to support such interventions”. (researcher) “a lot of evaluations of obesity prevention programs have been performed, but there is more research needed on obesity prevention in lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 9 | 17 the socially deprived families. […] these people are the hardest to reach”. (researcher) “such programs [targeted to socially deprived families] will probably need more financial resources than prevention programs for the general population, but the cost-savings in the long-term could be potentially higher in this subgroup.” (researcher) sustainable research infrastructure “primary prevention actions and their evaluations must be continuous and must have continuous financial support because once the project stops almost all effort is lost”. (researcher) im p le m e n ta ti o n f a c il it a to rs production of comparative analysis “cost-effectiveness evaluations (…) may be crucial when deciding which actions from the same division are to be considered at the top priority”. (researcher) “economic evaluation contributes to evidence-based decision making by helping the public health community identify, measure, and compare activities”. (policymaker) targeted evaluations that respond to concrete needs “evaluations on the efficacy and efficiency of tools are useful to guide policymakers (…). the evaluation [of implementation processes], although not a full-fledged evaluation, [could be] important for political guidance.” (policymaker) “phe evaluations in general would support impact assessments for eu/national policies/initiatives (including repeals of existing legislation) in the area of food and health. examples are: measures addressing nutritional composition of foods; marketing (and not only advertising to children) of products; school/public workplace policies aiming to improve diet/physical activity”. (policymaker) transposal of good practices “many countries are considering ssb taxes in different forms and (…) a solid [economic evaluation] could inform other countries and other potential taxes, too”. (policymaker) inclusion of bau scenarios to reveal costs of inaction “given the potentially sizeable benefits of healthier lifestyles for improved population health, understanding the costs and impacts of lifestyle-focused health promotion interventions is an important policy priority” (policymaker) “the calculation of the health effects and the costs saved are strong arguments to those that are perhaps less health-minded to prioritise and implement [a nutrition policy]”. (policymaker) transparency “national governments should enhance the transparency and publicity of operation by disclosing all decisions and contracts” (researcher) “it is crucial to have transparent decision making based on evidence, including […] economic evidence”. (researcher) *bau = business as usual. lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 10 | 17 methodological challenges in performing phee participants considered issues related to definition and measurement of outcomes as fundamental barriers in performing phee. the choice and definition of the outcome to report on (from behaviours to biomarkers and the number of related diseases and deaths) are not trivial issues, as such choices can yield very different results in terms of costeffectiveness and may challenge the validity of the analysis. measurement difficulties identified pertained primarily to the assessment of exposures to dietary risk factors, outcomes related to such exposures, social and economic costs of diseases, and economic costs of policy interventions. moreover, the long time lag (between implementing an intervention and seeing health benefits at the population level) requires use of modelling techniques to project possible benefits into the future, and to relate them to changes in disease patterns. a second challenge, perceived by both researchers and policymakers, is the absence of adequate frameworks to guide a phee. the participants pointed out that, adequate frameworks exist and are commonly used in clinical settings, and mentioned health technology assessment (hta); on the contrary, there are no such frameworks and standardised methodologies for the evaluation of nutrition interventions. the need for carefully designed frameworks and methodologies suitable to public health nutrition is therefore high. barriers related to the use of phee in policy settings many participants noted that the background evidence, on which phee should be based, is at times controversial or scientifically weak, and other voices and stakeholders may easily discredit these efforts. there is therefore scepticism in using phee in policymaking settings, especially because of low quality evidence. when the level of scepticism towards a particular nutrition-related issue is low, as in the case of the effects of trans-fatty acids consumption on cardiovascular disease, the economic evaluation is more likely to succeed in influencing such policy. on the other hand, most of the interviewed researchers pointed out that the allocation of public budgets does not always reflect what is recommended by the evidence (economic evidence or, in more extreme cases, evidence of effect), and gave some examples of stakeholder influence in funding public health interventions. they considered this a barrier to the use of phee. facilitators for improvement of the methodology of phee this category consists of four subcategories, identified mainly by the researcher participants: 1) growing interest in frameworks and methods, 2) multidimensional evaluations, following a wholeof-society approach, 3) data stratification at different levels, according to ses and geographic regions, and 4) sustainable research infrastructure. lack of a suitable framework has been previously identified as a major methodological barrier in phee. researchers are optimistic that this issue will be addressed, as there is a growing interest in developing better frameworks and methods to perform economic evaluations in public health; for instance, the following areas have been mentioned: harmonized methodology, measurement of exposure and outcome, lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 11 | 17 identification of indicators and sensitive cutoffs for such indicators. a thorough identification of the stakeholders’ perspectives, such as the healthcare perspective or the whole of society perspective, appeared to be crucial for wellsuited economic evaluations, according to researchers and decision makers. interventions and policies in the field of nutrition and obesity prevention have an impact not only on the targeted population groups, but also on various sectors of our societies. economic analysis should therefore be multidimensional and address costs and benefits for all relevant stakeholders. health economists should attempt to provide costs and benefits for each group of stakeholders. in addition to assessing and reporting specific costs and benefits of interest to different stakeholders, there is also interest in disaggregating results according to geographic specificities, or to ses of populations. according to the researchers consulted, such stratifications, if available, would increase the credibility of phee. for example, estimates obtained using countrylevel data would be perceived as more reliable and more relevant than estimates obtained with regional or global data. last, a sustainable research infrastructure should be in place to ensure the production of methodologically sound phee. according to some researchers, such infrastructure should have a dedicated team or unit, and consistent financial support. facilitators to widen the use of phee in policy settings this category includes facilitators of the demand for phee and consists of five subcategories: 1) production of comparative analyses; 2) targeted evaluations that respond to concrete needs; 3) transposal of good practices; 4) inclusion of bau (business as usual) scenarios to reveal costs of inaction; 5) transparency in decision making. acknowledging the limitations on both financial and human resources, researchers and policymakers agreed on the importance of economic evaluations in comparing different policy options targeting nutrition and, more broadly, public health. comparative analysis enables the choice of the most cost-effective option and could increase the demand for phee. some of the policymakers interviewed have used economic evaluations “to guide” or influence colleagues in a decision-making process. there is the potential for demand for phee to rise if economic evaluations respond to concrete needs, thus having a direct impact on decision makers, and providing guidance in daily practices. moreover, some of the policymakers interviewed, indicated that having more examples of legislation informed by economic evidence may in itself stimulate the greater demand for phee. economic evaluations can be useful also in evaluating transposal of good practices from their inception into different practice contexts; for instance, economic evaluations of taxation interventions can be carried out in those countries where sound public health taxation has been already implemented, to best inform countries in the process to design similar schemes. according to some of the policymakers interviewed, such cases can increase the demand for phee. the costs of inaction need also to be known. this could be done, for example, by including bau scenarios when performing comparative economic analyses. a case in point is to clarify the high costs of inaction in lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 12 | 17 obesity and related chronic diseases, both in social and monetary terms, as noted by some policymakers. this could be a key driver for action but also for increasing the demand for phee. lastly, most researchers identify a desire for transparency in policy decision making as a very important rationale for economic evaluations. discussion main findings and comparison to the literature this qualitative analysis aimed to identify key barriers and facilitators of performing public health economic evaluations and in including them in the development of policies in the area of nutrition and prevention of chronic diseases. we found that barriers (methodological challenges and barriers related to the use of phee) were symmetrical to facilitators (facilitators to improve the methodology and increase the use of phee), meaning that facilitators were those factors that reduced barriers in either performing or using phee. policymakers and researchers diverged in their opinions and perspectives. for instance, in the category “barriers related to the use of phee”, researchers identified “lack of strategy for effective budget allocation.” in evaluations (whole-of-society approach), and data stratification at different levels (geographical and social determinants enable the inclusion of equity considerations in economic analyses). a wide variation in approaches and methodologies in economic studies on dietary factors, and the consequent call for an adequate framework, has also been documented (20,22). an expert meeting on nutrition economics has also previously identified and commented on key features of economic evaluations in nutrition, such as: societal perspective and multi-stakeholder approach in identification of costs and benefits, comparison of alternatives, and generalisability of results (28). our findings on methodological barriers and facilitators resonate with previous literature, indicating that researchers performing economic evaluations need to improve their communication of the structure and results of their analyses to decision makers (27). for instance, weatherly and colleagues (19) identified four main methodological challenges in assessing the cost-effectiveness of public health interventions: attribution of effect, measuring and valuing outcomes, identifying inter-sectoral costs and consequences, and incorporating equity considerations. they are similar to those identified in our study: definition and measurement of outcomes (where “definition” includes effect attribution and “measurement” includes measuring and valuing outcomes), multidimensional contrast, policymakers mentioned “scepticism” attributed largely to doubts about the quality of the data, conclusiveness of the findings, controversies and limitations of current phee practices. nonetheless, both groups provided numerous insights about methodological challenges and data paucity. with regards to facilitators, only researcher participants identified the availability of stratified data for geographical and social lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 13 | 17 conditions as a facilitator towards the production of methodologically sounder phee, and only policymaker participants highlighted the need for providing targeted evaluations responding to concrete needs as a facilitator of greater use of phee. generally speaking, researchers focused on methodological facilitators, while policymakers stressed a need for more widespread use of phee (figure 1). figure 1. main categories and subcategories of facilitators and barriers to phee identified by researchers only (light grey boxes), policymakers only (dark grey boxes) or both (white boxes) our findings on methodological barriers and facilitators resonate with previous literature, indicating that researchers performing economic evaluations need to improve their communication of the structure and results of their analyses to decision makers (27). for instance, weatherly and colleagues (19) identified four main methodological challenges in assessing the cost-effectiveness of public health interventions: attribution of effect, measuring and valuing outcomes, identifying inter-sectoral costs and consequences, and incorporating equity considerations. they are similar to those identified in our study: definition and measurement of outcomes (where “definition” includes effect attribution and “measurement” includes measuring and valuing outcomes), multidimensional evaluations (whole-of-society approach), and data stratification at different levels (geographical and social determinants enable the inclusion of equity considerations in economic analyses). a wide variation in approaches and methodologies in economic studies on dietary factors, and the consequent call for an adequate framework, has also been documented (20,22). an expert meeting on nutrition economics has also previously identified and commented on key features of economic evaluations in nutrition, such as: societal lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to the use of economic evaluations in nutrition and public health (original research). seejph 2020, posted: 13 january 2020. doi: 10.4119/seejph-3271 p a g e 14 | 17 perspective and multi-stakeholder approach in identification of costs and benefits, comparison of alternatives, and generalisability of results (28). strengths and limitations despite existing discussions on generalisability of qualitative studies, nonetheless we consider our analysis as the first attempt to systematically collect perceptions on barriers and facilitators in translating economic evidence into policy from a broad, though small, sample of both researchers and policymakers from the european region. while the general nature of the questions posed allowed for great freedom in responses and could accommodate the differences in the participants’ expertise, more specific questions would have returned more concrete thoughts and examples. the fact that answers were made available to all workshop participants without anonymity could also have influenced the respondents and resulted in their more cautious expressions and examples. because of the limited number of questions asked and the relatively small number of participants, findings should be taken with caution; subsequent work might be done, including a larger number of participants with a more in-depth interview questionnaire. implications for policy and research to our knowledge, there are no other studies addressing facilitators and barriers to the use of economic evidence in public health nutrition: so far studies have addressed only methodological gaps in economic evaluations of public health interventions (19,21,22) and nutrition interventions (20). the paucity of successful cases in which economic evaluations played a role in shaping policies should also be considered, as pointed out by most participants during in the questionnaire and during the workshop. some expressions, such as “my feeling” or “science may not always be fully equipped”, may reflect this fact. such observations may also reflect the difficulties in accounting for complex societal phenomena: changes in eating habits (29) or environmental sustainability (30) are two among numerous examples. the results from our analysis show an increasing interest and unmet demand for public health policies informed by economic evaluations. enablers of the use of economic evaluation should be further facilitated. expanding the application of sound phee to policymaking will ensure a better informed process and, presumably, better outcomes in terms of the intended effects of the policies. acknowledgements we wish to thank all the interviewed experts. we are indebted to jan wollgast for critical reading of the manuscript and constructive suggestions. conflicts of interest: none declared. references 1. james sl, abate d, abate kh, abay sm, abbafati c, abbasi n, et al. global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the global burden of disease study 2017. lancet 2018;392:1789-858. lafranconi a, meusel v, caldeira s, babich s, czabanowska k. facilitators and barriers to 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'du bist was du isst': challenges in european nutrition policy. eur j public health 2017;27(suppl. 4):26-31. ___________________________________________________________ a jasri, s aljasmi, a aburayya, employing pls-sem analysis to examine the mediation role of artificial intelligence in physician experience. an empirical study of the effect of the medical smartwatch on physician satisfaction. seejph 2022. posted: 30-07-2022. page 1 original research employing pls-sem analysis to examine the mediation role of artificial intelligence in physician experience. an empirical study of the effect of the medical smartwatch on physician satisfaction ammar jasri1, shaima aljasmi1, ahmad aburayya2 1senior specialist registrar, dubai academic health corporation, dubai, uae 2assistant professor, mba department, business college, city university ajman, ajman, uae corresponding author: dr. shaima aljasmi senior specialist registrar, dubai academic health corporation, dubai, uae email: shaima_aljasmi@yahoo.com a jasri, s aljasmi, a aburayya, employing pls-sem analysis to examine the mediation role of artificial intelligence in physician experience. an empirical study of the effect of the medical smartwatch on physician satisfaction. seejph 2022. posted: 30-07-2022. page 2 abstract objective: the rapid advancements in the internet of things (iot) have allowed end users to enjoy restriction-free access to information. one of the notable developments in iot is the introduction of wearable technologies, such as smartwatches. the growing popularity of wearable technology has made it possible for users to receive health and fitness data regardless of time or place. this study aims to examine the mediation role of artificial intelligence in physician experience toward using the medical smartwatch, particularly examining the effect of the medical smartwatch on physician satisfaction. methods: this study utilized a deductive research approach employing a cross-sectional design. data was collected through online questionnaires from healthcare providers, particularly physicians in the united arab emirates (uae). the structural equation modelling analysis (sem) was employed to evaluate the theoretical and final path models. this study further assessed the theoretical model using the partial least squares (pls) as it offers concurrent analysis for evaluating the structural model and enhancing result accuracy. results: artificial intelligence (ai) experience significantly influenced physicians’ satisfaction. additionally, the study provided supporting, satisfying evidence for the mediating effects of ai experience. conclusion: the study provided supporting evidence for the mediating effects of ai experience on physicians’ satisfaction. this study bridges the gap in the literature regarding the absence of studies examining physicians’ perceptions of medical smartwatch usage in the medical domain by providing a profound understanding of physicians’ satisfaction and perceptions regarding smartwatch usage in the uae. this study bridges the gap in the literature regarding the absence of studies examining physicians’ perceptions of medical smartwatch usage by providing a profound understanding of physicians’ satisfaction and perceptions regarding smartwatch usage in the uae. keywords: artificial intelligence; medical smartwatch; health wearable technology; healthcare; physician satisfaction; structural equation modelling; partial least squares. a jasri, s aljasmi, a aburayya, employing pls-sem analysis to examine the mediation role of artificial intelligence in physician experience. an empirical study of the effect of the medical smartwatch on physician satisfaction. seejph 2022. posted: 30-07-2022. page 3 1. introduction recently, technology has proven to have vast effects on human lives, individually and collectively, influencing nearly every facet (1-4). the most recent edition of technology is artificial intelligence (ai) (5). over time, ai has witnessed massive and rapid developments that saw it being integrated into numerous sectors, including healthcare services within government sectors. ai is “the natural predispositions, genetic inheritance or learned skillsets forming the core of individual personalities” (5,6). ai implicates the use of machine-learning techniques and algorithms integrated within computer systems intended to mimic the functions of a human brain to make decisions (4,6). ai bridges the gap between patients and medical professionals (4,7). whereas physicians try to address patients’ demands, and patients seek to satisfy their own. the rapid advancements in the internet of things (iot) have allowed end users to enjoy restriction-free access to information. one of the notable developments in iot is the introduction of wearable technologies, such as smartwatches (7). the growing popularity of wearable technology has made it possible for users to receive health and fitness data regardless of time or place (4,8). due to the advantages they offer regarding the health and fitness data of users, smartwatches’ development and sales have seen rapid growth. the ease of connectivity to mobile phones via bluetooth technology has led to people’s mass adoption of smartwatches, where they can access several mobile features from their wrists, such as reading notifications, making phone calls, and tracking their physical activities (5, 7). there has been significant growth in demand for wearable technologies in the medical field. these devices allow users to monitor vital physical well-being indicators such as physical activity and step count, blood pressure, blood oxygen, and glucose levels. the increased need for a technology that can help people in observing health-cantered features and the rise in health awareness have ignited a notable and rapid shift of the innovation in smartwatch research and development (9). research performed by counterpoint’s global smartwatch tracker indicated that there had been a 37% growth worldwide in smartwatch shipments in the second quarter of 2018, 41% of which was dominated by apple (10). additionally, since 90% of a jasri, s aljasmi, a aburayya, employing pls-sem analysis to examine the mediation role of artificial intelligence in physician experience. an empirical study of the effect of the medical smartwatch on physician satisfaction. seejph 2022. posted: 30-07-2022. page 4 smartwatches sold currently lack cellular capabilities, smartwatch manufacturers are attempting to integrate cellular connectivity capabilities for standalone use cases (10). although numerous researchers have conducted studies on the usage and adaptation factors of smartwatches (9, 1113), none of them have studied how physicians’ perceptions of medical smartwatches—including their quality, adequacy, appropriateness, relevance, usability, brand, and ai experience—are influenced by these factors. this study intends to bridge this gap and provide a profound understanding of physicians’ perceptions regarding smartwatch usage in the medical field in the united arab emirates (uae). essentially, this research study utilizes the integrated and innovative research approach to examine the factors that influence physicians’ satisfaction with the use of medical smartwatches (msw) through the role al experience played as a mediator in this context. more specifically, the integrated and innovative research model integrates the diffusion of innovation (doi) model, technology acceptance model (tam), and the flow model to assess the predictors of physicians’ satisfaction with msw and the impact of amplified embracing of this technology. moreover, the model explores how al’s experience influences physicians’ satisfaction as a mediating factor. the primary objective of this study is to evaluate the success of msw in the medical domain since a successful implementation of this technology is equally important to doctors and patients. msw’s success relies on endusers’ decisions and a feedback loop of relevant information within a network of patients and doctors, which can influence attitudes and behaviors. this research builds upon previous studies investigating exogenous variables as determining factors of msw use. prior studies like (8-13) have explored the effect of external factors like availability and mobility on using msw. however, this study focuses on external factors such as richness of content and innovations as the primary determinants of physicians’ satisfaction with msw. while several studies have explored the degree of acceptance of msw, this study is the first to evaluate physicians’ satisfaction with msw use, specifically within the uae medical field, employing an integrated research model. a jasri, s aljasmi, a aburayya, employing pls-sem analysis to examine the mediation role of artificial intelligence in physician experience. an empirical study of the effect of the medical smartwatch on physician satisfaction. seejph 2022. posted: 30-07-2022. page 5 2. methods and materials this study utilized a deductive research approach employing a cross-sectional design. data was collected through online questionnaires from healthcare providers in the uae, i.e., from seven hospitals and ten primary healthcare clinics from december 14, 2021, to january 14, 2022. the researchers contacted the targeted physicians through official emails and social media platforms, including whatsapp, to administer the questionnaires. the collected data were judged reliable as it was obtained from participants working in a healthcare setting, which is the most suitable environment for gathering information on healthcare practices (14). moreover, the study followed recommendations from healthcare service management studies in selecting the targeted population as the component of analysis [1416]. the chosen sample units had sufficient familiarity with their organization’s procedures and health quality [14-15]. in this study, non-probability sampling, specifically convenience sampling, was employed due to difficulties accessing comprehensive physician lists in the selected units of analysis. moreover, convenience sampling was cost-effective and time-efficient and enabled a larger sample size to be utilized [14,16]. the authors randomly distributed two thousand questionnaires. respondents replied to 1418 out of the initial 2000 questionnaires distributed. ten questionnaires were rejected due to missing values resulting in 1408 completed questionnaires ready for analysis, leading to a 70.4% response rate. the sample size of 1408 in this study exceeded the suggested sample size of 323 for a population of 2000 [17]; thus, the use of structural equation modelling (sem) to test the hypotheses was justified [19]. although the hypotheses were built upon existing models, they were structured within the framework of msw. sem was employed to evaluate the theoretical model and the final path model. this study assessed the theoretical model using the pls-sem as it offers concurrent analysis for evaluating the structural model and enhancing result accuracy [15,19]. furthermore, pls-sem also helps examine the predictors of the conceptual model, contributing to information systems research as a complementary multi-analytical method. this research study will be one of the few in a jasri, s aljasmi, a aburayya, employing pls-sem analysis to examine the mediation role of artificial intelligence in physician experience. an empirical study of the effect of the medical smartwatch on physician satisfaction. seejph 2022. posted: 30-07-2022. page 6 the medical field using pls-sem to examine physicians’ satisfaction with using msw. the survey instruments used to test for the hypotheses consisted of 47 items intended to measure ten constructs included in the questionnaire. the questions within the survey were revised and restructured, building upon previous studies (14-16, 20) to improve the generalizability of the study. to measure the 47 items, a 5-point likert scale (1= strongly disagree; 5 = strongly agree) was used. a pilot study was conducted with 75 randomly selected participants (5.3% of the total sample) to assess the reliability of the questionnaire items. to test for the internal reliability of measurement instruments, ibm spss statistics version 23 was used to perform cronbach’s alpha test. according to social science studies (9,19,21), a cronbach’s alpha coefficient of 0.7 is sufficient for questionnaire items. the performed cronbach’s alpha analysis indicated that the measurement items were adequate. furthermore, a single-factor harman’s test was conducted with seven factors to confirm that the data were not affected by common method bias (cmb) (19,21). the seven factors were then loaded into a single factor, which explained 26.54% of the variation, but fell below the 50% threshold recommended [9], indicating the absence of cmb in the collected data. 3. data analysis and results 3.1 demographic information table 1 presents the demographic characteristics of the study participants. the table indicates that the sample consisted of individuals from diverse genders, age groups, educational backgrounds, and work experience in various sectors. regarding gender, 29.9% of the respondents were female, while 70.1% were male. the table also reveals that most participants (43.6%) were aged 41 to 50. furthermore, most of the participants had achieved a high level of education. according to table 1, 60.4% held bachelor’s degrees, 22.2% had master’s degrees, and 17.4% completed doctoral education. additionally, the table indicates that 77.9% of the sample had work experience ranging from 1 to 10 years. a jasri, s aljasmi, a aburayya, employing pls-sem analysis to examine the mediation role of artificial intelligence in physician experience. an empirical study of the effect of the medical smartwatch on physician satisfaction. seejph 2022. posted: 30-07-2022. page 7 table 1. the profile of respondents. frequency percent (%) gender male 987 70.1 female 421 29.9 age 20-30 101 7.2 31-40 456 32.4 41-50 614 43.6 over 51 237 16.8 education level bachelor degree 851 60.4 master degree 312 22.2 phd degree 245 17.4 years of experience less than 1 year 41 2.9 1-5 years 798 56.7 6-10 years 298 21.2 more than 10 years 271 19.2 total 1408 100.0 3.2 convergent validity to assess the reliability of the measurement model, cronbach’s alpha test and composite reliability were conducted. additionally, the discriminant and convergent validity of the model were examined (21). table 2 presents cronbach’s alpha coefficients, which range from 0.701 to 0.878, surpassing the threshold of 0.7 (22). additionally, the composite reliability (cr) values in table 2 range from 0.677 to 0.776, exceeding the threshold of 0.7 (23). these results confirmed the reliability of the constructs while being measurementerror-free. the average variance extracted (ave) and factor loading were performed to evaluate convergent validity (21). the factor loading values shown in table 2 surpass the threshold of 0.5. however, the ave values ranging from 0.529 to 0.845 fall short of the required 0.5 thresholds. nevertheless, the results suggest that all constructs in the study demonstrate satisfactory convergent validity. table 2. factor loading & cronbach’s alpha coefficient construct & item no. cronbach’s alpha cr & ave factor loadings f1 f2 f3 f4 f5 f6 f7 f8 f9 relevance (rel) 5 .831 0.748 & 0.854 .725 .827 .619 .728 a jasri, s aljasmi, a aburayya, employing pls-sem analysis to examine the mediation role of artificial intelligence in physician experience. an empirical study of the effect of the medical smartwatch on physician satisfaction. seejph 2022. posted: 30-07-2022. page 8 .884 timeliness (tl) 4 .712 0.736 & 0.529 .712 .754 .854 .762 sufficiency (suf) 6 .843 0.765 & 0.801 .664 .803 .876 .799 .837 .789 perceived convenience (pc) 5 .878 0.758 & 0.554 .765 .899 .654 .786 .578 product quality (pq) 5 .782 0.677 & 0.689 .723 .738 .879 .808 .823 service quality (sq) 5 .772 0.776 & 0.673 .754 .852 .654 .879 .811 usability (us) 6 .838 0.748 & 0.776 .607. .741 .723 .760 .782 .796 perceived ease of use (peu) 5 .759 0.761 & 0.663 .778 .761 .886 .951 .977 ai experiencee (ai e) 5 .701 0.756 & 0.548 .665 .762 .774 .639 .773 3.3 causal model analysis & hypotheses testing the present study utilized a hybrid partial least squares structural equation modeling (pls-sem) methodology using smart pls to assess the hypothesized relationships among variables in the proposed research model. pls-sem was selected due to the exploratory nature of the theoretical model a jasri, s aljasmi, a aburayya, employing pls-sem analysis to examine the mediation role of artificial intelligence in physician experience. an empirical study of the effect of the medical smartwatch on physician satisfaction. seejph 2022. posted: 30-07-2022. page 9 and the lack of prior related research. the study followed the general guidelines for using pls-sem in information systems (is) research. it used a two-step technique that involves measurement and structural models as put forward by previous literature (24). ipma was also used to evaluate the model’s constructs in terms of relevance and practicality. the coefficient of determination (r²) and path coefficients were used to assess the structural model’s predictive accuracy. the literature indicates that r² is an indicator for determining a model’s predictive accuracy (25). table 3 shows p-values, tvalues, and path analysis coefficients for all the hypotheses, revealing that all the hypotheses (h1 to h9) were empirically supported through the data analysis (refer to fig. 1). the coefficient of determination r² was used to evaluate the obtained structural models where the correlation between the predicted dependent variable and the actual values were squared (25). subsequently, r² indicates the degree of variation in the dependent construct. the obtained r² value of 0.743 indicated that the model had a high level of prediction for physicians’ satisfaction towards the use of msw, explaining 74% of the variation in satisfaction. the results illustrate that rel, tl, and suf had a significant effect on pc (β = 0.578, p < .05), (β = 0.478, p = .018), and (β =. 299, p < .05) respectively (see table 3). accordingly, h1, h2, and h3 are supported. the results also reveal that pc, peu, pq, sq, and us significantly influenced ai experience (β = 0.502, p < .01), (β =. 637, p = ,000), (β = 0.311, p < .01), (β = 0.539, p < .01), and (β = 0.662, p = .000) respectively. thus, the results support h4, h5, h6, h7, and h8. furthermore, the results also reveal that ai experience significantly affects physicians’ satisfaction with using msw. consequently, h9 was confirmed (see figure 1). table 3. hypotheses-testing of the research model. association hypothesis path coefficient tvalue pvalue decision rel pc h1 0.378 3.887 0.041 supported* tl pc h2 0.487 4.682 0.018 supported* suf pc h3 0.299 3.211 0.035 supported* pc aie h4 0.502 7.549 0.001 supported** peu aie h5 0.637 12.479 0.000 supported*** pq aie h6 0.311 3.305 0.032 supported* sq aie h7 0.539 7.367 0.002 supported** us aie h8 0.662 13.802 0.000 supported*** a jasri, s aljasmi, a aburayya, employing pls-sem analysis to examine the mediation role of artificial intelligence in physician experience. an empirical study of the effect of the medical smartwatch on physician satisfaction. seejph 2022. posted: 30-07-2022. page 10 aie pst h9 0.789 18.778 0.000 supported*** note: relevance (rel); timeliness (tl); sufficiency (suf); perceived convenience (pc); product quality (pq); service quality (sq); usability (us); perceived ease of use (peu); ai experiencee (ai e); physician satisfaction (pst). *if a p-value is less than 0.05, it is flagged with one star (*). if a p-value is less than 0.01, it is flagged with 2 stars (**). if a p-value is less than 0.001, it is flagged with three stars (***). figure 1. path test of the research theoretical model. 4. discussion the primary objective of this research was to examine the utilization of ai-powered smartwatches for self-health monitoring and assess how physician experience affects satisfaction by employing a novel model built upon the integrated and innovative theory to explore the factors that determine physicians’ satisfaction with ai-driven msw, with a particular focus on the mediating role played by ai experience. data analysis revealed significant impacts of rel, tl, suf, pc, pq, sq, us, and peu on physicians’ satisfaction. furthermore, ai experience was found to influence physicians’ satisfaction significantly. additionally, the study provided supporting evidence for the mediating effects of ai experience on physicians’ satisfaction. this study bridges the gap in the literature regarding the absence of studies examining physicians’ perceptions of msw usage in the medical domain by providing a profound understanding of physicians’ satisfaction and perceptions regarding smartwatch usage in the uae. the study contributes to the literature on smartwatch studies that previously examined external variables as contributing factors for msw adoption. several studies [9,26,27] have investigated the influence of external factors such as availability and mobility on msw. in contrast, this study focuses on external factors like content richness and a jasri, s aljasmi, a aburayya, employing pls-sem analysis to examine the mediation role of artificial intelligence in physician experience. an empirical study of the effect of the medical smartwatch on physician satisfaction. seejph 2022. posted: 30-07-2022. page 11 innovations as the primary determinants affecting physician satisfaction with msw. this research study has established empirical evidence of a positive correlation between content richness and msw, demonstrating that content richness plays a crucial role in achieving high satisfaction with smartwatches. furthermore, the research findings indicate that content richness influences the increased usage of smartwatches. specifically, content richness shows a significant positive impact on pc, which in turn affects msw positively. these findings also align with prior studies that have emphasized the influence of quality content on pc (28,29). additionally, this study revealed a significant impact of pq and sq on the levels of users’ satisfaction and experience. these findings are consistent with prior research that underscores the importance of product and service quality in ensuring positive user experiences, trust, and satisfaction when utilizing such devices (30,31,32). essentially, a product’s quality reduces the disparity between the received and expected products. in the case of smartwatches, product quality encompasses various aspects, including the device’s functionalities and performance. these qualities are reflected in the smartwatches’ personalized content abilities, instantaneous support, up-to-date information, and seamless user interaction (9, 33). on the other hand, service quality pertains to the reliability with which smartwatches are designed to handle users’ personal and health information and their capability to accurately detect and monitor conditions like hypertension, diabetes, irregular heart rates, and other diseases safely and securely (34). in terms of the reduced time and effort required for usage, this study revealed that pc significantly influences physicians’ trust, experience, and satisfaction. these findings are consistent with the research conducted by pham et al. (35). additionally, several studies have emphasized that physicians’ satisfaction is positively correlated with the convenience of having readily available medical information and services (36), real-time information accessibility and assistance, as well as advanced guidance (9,14,15). such information’s time and place restriction-free features become crucial in emergencies like the covid-19 pandemic. enhancing the overall user experience is achieved through the positive contributions offered by selfservice, real-time, and time-saving a jasri, s aljasmi, a aburayya, employing pls-sem analysis to examine the mediation role of artificial intelligence in physician experience. an empirical study of the effect of the medical smartwatch on physician satisfaction. seejph 2022. posted: 30-07-2022. page 12 convenience (14-16). moreover, service convenience is crucial in inspiring users to actively utilize products such as smartwatches to attain a good and memorable experience (37,38). in addition to facilitating a favorable experience, the convenience offered by ai-powered smartwatches fosters a sense of trust among smartwatch users. by eliminating barriers, promoting a sense of satisfaction for users, and evaluating service efficacy, user trust is cultivated, which as in turn, encourages users to utilize ai-powered devices such as smartwatches (33-38). regarding perceived ease of use (eeu), the study’s results affirmed its significance concerning user satisfaction, trust, and user experience. these findings align with previous studies conducted by jarrahi (39). having older users who may have lower proficiency with technology highlights the importance of the perceived ease of use construct. users, especially older ones, feel more at ease using devices like smartwatches if they are designed to be user-friendly, simple to handle, and require minimal effort for maintenance. thoughtfully crafted layouts, intuitive navigation, and visually pleasing designs that prioritize simplicity and user-friendliness help minimize physical effort and reduce mental strain, ultimately resulting in positive user experiences (9-16). with repeated use, users become more familiar with the technology, enhancing their confidence and fostering trust. moreover, the synchronization function with physicians’ smartphones proves to be more practical than a fitness tracker, especially when they need to navigate traffic congestion while riding a motorcycle. this feature allows them to determine whether an incoming call is significant enough to warrant pulling over safely. our data analysis confirmed the mediating role of ai experience in influencing physicians’ satisfaction. the study revealed significant pq, sq, pc, us, and peu effects on both experience and user satisfaction. furthermore, the study demonstrated that these predictors also had substantial indirect effects on satisfaction when mediated by ai experience. in other words, experience acted as a partial mediator in these relationships. positive experiences with ai-powered smartwatches in the user ai experience context directly enhance the relationships between predictors (pq, sq, pc, us, and peu) and physician satisfaction. these results are consistent with previous empirical a jasri, s aljasmi, a aburayya, employing pls-sem analysis to examine the mediation role of artificial intelligence in physician experience. an empirical study of the effect of the medical smartwatch on physician satisfaction. seejph 2022. posted: 30-07-2022. page 13 research studies that have recognized the significance of ai experience construct as a mediator (40). in healthcare, empirical evidence indicates that prior experience significantly reinforces the relationships between several factors, including satisfaction with using ai-powered devices [31-40). from a practical standpoint, individuals who have had positive past experiences using ai-powered smartwatches to monitor their health conditions and receiving endorsements from medical professionals regarding such devices will likely experience improved satisfaction. finally, it is essential to acknowledge the limitations of this study. first, the use of a purposive sampling technique restricts the findings’ generalizability to 40 years old or above users, where the sample was dominated by male respondents (41-49). additionally, respondents were selected from just three emirates within uae. future studies should utilize random sampling techniques and include a more comprehensive range of locations, including developing countries. expanding the sampling coverage to encompass a broader range of individuals would ensure a more accurate population representation. it is also crucial to provide a more balanced picture of both male and female respondents in the sample. additionally, future research should consider incorporating alternative theories, such as the unified theory of acceptance and use of technology (utaut). lastly, future models can explore the impact of alenabled smartwatches on various types of diseases and the potential for device personalization. 5. conclusion this study holds significant importance in shedding light on using the e-doctor concept through ai-powered smart devices, including smartwatches. the findings further contribute to the body of literature aiming to understand physicians’ satisfaction and optimal utilization of ai-enabled devices in healthcare and related domains. while ai technology continues to evolve and essential services like healthcare become more accessible to a broader population, selfmanaging one’s health becomes increasingly crucial. brands should therefore strive to make their products and services more adaptable by comprehending user behaviors and their use patterns, ultimately ensuring effective utilization and user satisfaction. a jasri, s aljasmi, a aburayya, employing pls-sem analysis to examine the mediation role of artificial intelligence in physician experience. an empirical study 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creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 1 | 12 original research can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? valery chernyavskiy1, helmut wenzel2, julia mikhailova1, alla ivanova3, elena zemlyanova3, vesna bjegovic-mikanovic4, alexander mikhailov1, ulrich laaser5 1 federal research institute for health organisation and informatics of the russian ministry of health, moscow, russian federation; 2 independent consultant, konstanz, germany; 3 institute for demographic research branch of the federal center of theoretical and applied sociology of the russian academy of sciences, moscow, russian federation 4 university of belgrade, faculty of medicine, institute of social medicine, belgrade, serbia; 5 university of bielefeld, bielefeld school of public health, bielefeld, germany. corresponding author: prof. dr. med. ulrich laaser address: bielefeld school of public health, university of bielefeld, germany; e-mail: ulrich.laaser@uni-bielefeld.de chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 2 | 12 abstract aim: this study reviews the ability of the russian federation to reduce the high mortality until 2030 evenly across the country and in accordance with the sustainable development goals (sdg). methods: we adopted the method suggested by haenszel for estimating premature years of life lost for the age group <70 years and applied a projected reduction of 33% by 2030 as proposed for sdg 3.4. to calculate the potential time gap we used the model of the united nations development programme and standardized the rates by the oecd 1980 standard population employing the direct method. results: if russia keeps the present level of effort the reduction by one third of the level of premature mortality as in 2013 will be in reach already in 2024 i.e. 5.9 years in advance of the sdg 3 target for 2030. this target is achieved quite evenly also throughout the 8 districts of the russian federation between 10.6 and 5.0 years in advance and in selected special districts/republics with the highest and lowest mortality rates. conclusion: after the steep decrease of life expectancy during the 1990ies the russian federation returned to the original trajectory. keywords: gap analysis, premature mortality, public health, russian federation, sdg. conflicts of interest: none declared. statement of funding: none declared. note: valery chernyavskiy, helmut wenzel, julia mikhailova, alla ivanova, elena zemlianova, vesna bjegovic-mikanovic, alexander mikhailov, ulrich laaser. can russia’s high mortality return until 2030 to trajectory of the 1980ies and reach the sdgs evenly across the country? published 13 november 2020 in parallel by: social'nye aspekty zdorov'a naselenia / social aspects of population health [serial online] 2020; 66(5):14; doi: 10.21045/2071-50212020-66-5-12. available from: http://vestnik.mednet.ru/content/view/1205/30/lang,ru http://vestnik.mednet.ru/content/view/1205/30/lang,ru/ chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 3 | 12 introduction the russian federation (rf) is with 17.1 million sqkm the largest country in the world with a population of 146 million, distributed over the territory quite unevenly. life-expectancy is increasing like in most regions of the world after a steep downturn in the 1990ies (1): for russia from 69.5 in 1988 to 64.5 years in 1994, to 65.5 in 2000 and to 72.4 in 2017, however with the highest gap worldwide between males and females (2), e.g. in 2017 67.1 vs. 77.4, a difference of 10.3 years, as compared to the european union (3) with a life-expectancy of 80.9 and a much smaller gender gap (e.g. in 201778.3 vs. 83.5). according to vlassov (4), vladimir putin when re-elected as president in 2018 declared a life expectancy at birth for both sexes of 76 years to be achieved in 2024 and of 80 in 2030. for the calculation of premature mortality, in russia mainly determined by non-communicable diseases (ncds), usually a borderline age of <70 years is considered as upper limit. the sustainable development goals (5) ask for a reduction by one third of ncds mortality up to 2030. for russia as a whole this seems to be in reach as published earlier (6). in this paper we analyse the eight federal districts of the russian federation with regard to their premature mortality as there are: north caucasus, south, privolzhskiy (volga), far east, uralskiy, siberian, central, and north west federal districts. in addition, we determine whether each of the eight districts is on track to reach the sdg target by 2030. furthermore we also try to analyse selected subunits e.g. oblasts as the russian federation consists in total of 85 subjects, including 22 republics (for example karelia, altai, tatarstan, chechnia etc.), 9 territories (e.g. perm territory), 46 regions (e.g. kaliningrad region), cities of federal significance (e.g. moscow and sankt petersburg), 1 autonomous oblast (jewish autonomous region) and 4 autonomous districts (chukotka, yamalo-nenets, khantymansijsk (yugra), and nenets). however, in this paper we do not consider a possible impact of the corona pandemic in 2020 but plan to do that on the basis of reliable figures later. methods we adopted the method suggested by haenszel (7) for estimating premature years of life lost (pyll) <70 years of age and applied a projected reduction of 33% by 2030 as proposed by the united nations for sdg 3.4 targeting non-communicable diseases (ncd) (5) which make up for 87% of the total mortality in russia (8). we gave preference to the determination of pyll instead of life expectancy (le) to avoid the instability of the highest age-groups. as for other components of total mortality: in russia the levels of the maternal mortality ratio (mmr, sdg 3.1) and neonatal mortality rate (nmr, sdg 3.2), are already well below the un targets (70 for mmr and 12 for nmr): mmr 17/100.000 live births; nmr 5.4/1.000 live births. sdg 3.3 refers to communicable diseases (5% of total mortality incl. mmr and nmr) and sdg 3.6 to road traffic accidents (8% of total mortality) for which reductions between appr. 30% and 90% are defined. in conclusion we consider it justified to apply an overall reduction by 1/3 to the total mortality until 2030, with reference to the years 2013, 2015 (estimated), and 2018. chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 4 | 12 to calculate the time gap (g), i.e. the time needed to achieve an agreed target deadline related to the time remaining between the year of observation and the target year, we use the mathematical model of the united nations development programme (9). the likelihood of achieving the sdg target 2030 will be determined by the indicators’ time gap, i.e. the time remaining to achieve an agreed target, according to the following equations: [1]tr = tt − tc and: [2]tn = tt − [tb + (tt − tb) ( xc – xb) / (xt – xb)] then the resulting time-gap g is calculated as: [3]g = tr − tn tr remaining time tn time needed to achieve the target (in linear progress) xb baseline value of the indicator xt target value of the indicator xc observed value of the indicator g time gap (gain or delay) tt target year tcyear of observation tb baseline year a positive time-gap g indicates that the respective country is “on track” to achieve the target on time or even earlier; a negative value indicates that it may still be “likely” or even “unlikely” to achieve the target within the target timeframe i.e. in 2030. a country is still considered likely to achieve the target as long as a negative value for g does not make up for less than -25% of the remaining time tr i.e. the relative gap gr is: gr = g / tr>= 0.25. we standardized the rates by the oecd 1980 standard population (10) (annex 1) employing the direct method (e.g. armitage (11). for details of the calculation see also chernyavskiy et al. (6). the federal research institute for health organization and informatics of the russian ministry of health provided the demographic data (annex 1 and 2) which are used to calculate the time gap for sdg 3 of the entire russian federation and separately for the 8 districts. on the basis of these data we analyze the age groups 0-<70, 0-<30, and 30-<70 as well as both sexes together and separate. for the determination of the gap in 2024 and 2030 and the analysis of the trajectory 19602030, based on life expectancy data, we made use of the database of the world bank (1) and identified the peak data before and after the crisis during the 1990ies. chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 5 | 12 results if russia keeps the present level of effort to improve the life of the russian citizens a reduction of one third of the level of premature mortality as in 2013 will be in reach already in 2024 (table 1) i.e. 6.1 years in advance of the sdg 3 target for 2030, here applied not only to ncd mortality in general but to the overall premature mortality before age 70. table 1. projected reduction of premature years of life lost (pyll) targeted 2013-2030 russian federation and federal districts pyll/ 100,000 2013* pyll/ 100,000 2018 pyll/ 100,000 target 2030 based on 2013 years up to 2030 in 2018 years needed as of 2018 years in advance/delay of 2030 gr to be >= -0.25 eu-27 (for comparison) 3,243 3,066 2,162 12 14.2 -2.2 -0.18 russian federation 0-<70 years of age 10,313 8,060 6,875 12 5.9 6.1 0.51 0-<30 years of age 6,283 4,043 4,189 12 -1.2 13.2 1.10 30-<70 years of age 15,073 12,881 10,049 12 9.6 2.4 0.20 males 0-<70 15,137 11,480 10,091 12 4.7 7.3 0.61 females 0-<70 5,809 4,689 3,873 12 7.2 4.8 0.40 federal districts: north caucasus 7,153 4,970 4,769 12 1.4 10.6 0.88 south 8,351 6,032 5,567 12 2.8 9.2 0.76 privolzhskiy (volga) 10,010 7,295 6,667 12 3.2 8.8 0.73 far east 12,529 9,203 8,352 12 3.5 8.5 0.71 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 6 | 12 * for sevastopol 2015-2020 all districts reach the target in advance of 2030, the district of north caucasus 10.6 years earlier and the north west district still 5 years in advance of 2030. for comparison, the progress of the eu-27 has been calculated which at a considerably lower level shows smaller rates of reduction and therefore a delay of -2.2 years in 2030. already in 2016 russia achieved the corresponding target for the younger age group 0<29 years of age and needs only 9.6 years to reach the target in the elder group 30-<70. for males the target will be achieved 7.3 years in advance i.e. in 2022 and for females 4.8 years in advance. the example of males and females 0-<70 is used in table 2 to demonstrate the level of uncertainty. the averaged trend we use is a conservative estimate between the straight continuation of the trend 2013-2018 and the target line for 2030. uralskiy 11,910 9,032 7,940 12 4.7 7.3 0.61 siberian 11,829 9,133 7,885 12 5.4 6.6 0.55 central 9,322 7,272 6,208 12 5.8 6.2 0.52 north west 9,726 7,824 6,483 12 7.0 5.0 0.41 special territories: crimea 0-<70 9,730 8,388 6,480 12 11.6 0.4 0.03 sevastopol 0-<70 10,085 7,252 6,723 12 9.6 2.4 0.80 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 7 | 12 table 2. projected reduction of premature years of life lost (pyll) targeted 2013-2030 for both sexes separately with levels of uncertainty trend projections males 0-<70 pyll/100,000 females 0-<70 pyll/100,000 targets based on 2013 reduced by 1/3 10,091 3,873 averaged estimate of trends 8,957 3,721 corresponding to 7.3 years in advance of 2030 for males and 4.8 years for females (see table 1) straight projection of the trend 20132018 to 2030 7,823 3,569 as the sdgs have been accepted in 2015/16 (2) we applied the 1/3 reduction in addition to the baseline in 2013 also to the data estimated for 2015 as an average of 2013 and 2018, and to the data of 2018 which constitutes a more demanding i.e. lower target for 2030 (annex 4a and b). however, the general impression is the same in that still all federal districts would achieve the target before 2030 whether the 1/3 reduction is based on 2015 or 2018. furthermore we applied different baselines for the entire russian federation, namely also 2003 and 2009 (annex 4c), which predict likewise an achievement of the targets before 2030. a look at the presidential targets, formulated as improvements in life expectancy (le), demonstrates that targeted achievements in 2024 and 2030 are possible with only small delays of 0.9 and 1.3 years respectively (annex 4d). finally we show data for smaller subunits i.e. the 4 oblasts with the highest mortality and 4 republics/autonomous districts with the lowest mortality (annex 5). the uralskiy district contains the highest as well as one of the lowest ranking oblasts. although the rates are already considerably lower in the caucasian republics, they show similar reductions of mortality as indicated for the north caucasus in table 1, in other words the positive developments seem to be similar across the entire russian federation. discussion the gap-analysis shows clearly that all districts of the russian federation are in line and will reach the targeted reduction of premature mortality several years before 2030. it is astonishing how the russian federation managed to continue the upward trend of the late 1980ies after the catastrophic down-turn in the mid-nineties (1), an observation which has been noted already very early in 2003 (12). an explanation may be a short-termed ‘glasgow-effect’ (13), the observation that life expectancy is persistently much lower in chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 8 | 12 one district of glasgow than in the rest of the united kingdom, likely due to persisting social deprivation. the deprivation of the midnineties has obviously been overcome in the early 2000s contrary to the united kingdom, taking the example of glasgow. nevertheless, russia had and has higher levels of mortality than the eu average, a situation that persists until today (3). the decrease in pyll began to slow down in the second half of the last decade. whereas the trajectory 2003-2018-2030 results in a gap ratio of 0.71 allowing to reach the target already in 2021, for the trajectory 2013-2018-2030 (used in the main body of this paper) we get a gap ratio of 0.51 corresponding to 2023 or 6.1 years in advance of 2030. accordingly gr is further reduced if we base the target calculation on the observation year 2018, however, still the 2030 target will be reached at least 2.8 years in advance. in the formula (9), as described above, the factor (xc − xb) / (xt – xb) determines the proportion of the remaining time to achieve the targets. the higher the baseline value (compared to the observed value) the faster the targeted reduction is achieved, and the lower the baseline, the flatter is the projected line of reduction. this phenomenon follows the rule of “diminishing marginal returns” as varian (14) states: “…the marginal product of a factor will diminish as we get more and more of that factor”. depending where a combination of input/output is located on a production curve, i.e. in a steep or more flatten part of the curve, the effectivity of the input will be higher or lower. to maintain nevertheless the same size of the product it would require more and more resources or time. the latter applies to the situation wherein we find the eu27: the projection of its trajectory 20132018 to 3030 is flatter than required and leads to a delay of at least -2.2 years or more whereas the corresponding trajectory of the rf is much steeper and indicates an earlier achievement by at least +6.1 years. there are other reasons to be skeptical about the future of the recent steep increase in russian life expectancy. in adulthood e.g. at age 30 to <70 years –the pyll rate did not decrease to a degree comparable to the younger age group under 30 years of age according to the data presented in table 1. this means that although russia went through the epidemiological transition already in the mid-20th century, progress in the prevention and management of chronic conditions remained weak. the initial question, posed in the headline of this paper, is whether the russian federation returned to the trajectory of 1988. based on the le data of the world bank (1) the calculations presented in table 3 demonstrate that this question can be answered positively: after the nineties russia returned to the earlier trajectory. chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 9 | 12 table 3. life expectancy at birth according to the trajectory 1960-1988 for the russian federation targeting 2017 and 2030 along the same trajectory year 1960 1988 improvement of le 1988-1960 per 10 years 2017 le target based on 1960-1988 2017 le observed 2030 le target based on 1960-1988 gapanalysis 19601988-2030 life expectancy (le) 66.1 69.5 +1.2 72.9 72.4 74.5 0.3 years in advance; gr = +0.01 the objective of increasing the longevity of russian people has been an important element of state policy for the past 18 years. the current health and demography national projects are aimed at improving the performance of health services and to raise the living standards of the russian citizens in such a way that they not only live longer but lead active lives in decent conditions. russia plans to spend 1.7 trillion rubles ($26.68 billion) on dramatically improving health care to accomplish the goal of raising life expectancy. these plans may be even accelerated given the devastating effects of the covid19 pandemic (15). conclusion the russian federation is on track with regard to sdg 3 and very likely will have reduced its mortality rates calculated as pyll by one third as of 2013. this is mainly due to a steep improvement in the age group 0-<30, a success which occurred after the deep decrease of life expectancy in the mid-nineties. the impressive improvement occurred quite evenly throughout the 8 administrative districts of the russian federation, between north caucasus best and the north west district still in advance. also the smaller subunits (oblasts or republics) obviously follow the same trajectories whether ranking highest or lowest regarding their mortality rates. in summary after the steep decrease of life expectancy during the 1990ies the russian federation returned to the original trajectory. key-points:  during the 1990ies russia experienced a steep decrease of life expectancy from 69.5 in 1988 to 64.5 years in 1994.  since the 2000nds premature years of life lost as well as life expectancy improved again so that russia is likely to reach the sdg target of mortality reduction by 1/3 in 2030.  the reduction of premature mortality is with some variation evenly distributed across all eight federal districts chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 10 | 12 of the russian federation and subunits with highest or lowest mortality rates.  the positive trajectory of the 1980ies has been regained during the 2010s. references 1. world bank. life expectancy at birth, total (years) russian federation; 2017. available from: https://data.worldbank.org/indicator/sp.dyn.le00.in?end=2017&lo cations=ru&name_desc=true&start=19 60&view=chart (accessed: june 16, 2020). 2. starodubov vi, marczak lb, varavikova e, bikbov b, ermakov sp, gall j, et al. the burden of disease in russia from 1980 to 2016: a systematic analysis for the global burden of disease study 2016. lancet 2018;392:1138-46. doi.org/10.1016/s01406736(18)31485-5. 3. eurostat. database. available from: https://appsso.eurostat.ec.europa.eu/nui/show.do?dataset=demo_mlexpec&lang=en (accessed august 12, 2020) 4. vlassov v. russia needs to look beyond longevity. lancet public health 2019;4:e169-70. doi.org/10.1016/s24682667(19)30043-x. 5. united nations. the sustainable development goals report 2016. available from: https://unstats.un.org/sdgs/report/2016/ (accessed: june 16, 2020). 6. chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, bjegovic-mikanovic v, et al. successful reduction of premature mortality in the russian federation and the countries around the baltic sea working together on health and social well-being. seejph 2020;viii. doi: 10.4119/seejph-3129. 7. haenszel w. a standardized rate for mortality defined in units of lost years of life. am j public health 1950;40:17-26. 8. world health organisation. ncd, russian federation; 2016. available from: file:///c:/users/ulrich~1/appdata/local/temp/rus_en.pdf (accessed: august 12, 2020). 9. united nations development programme (undp), regional bureau for europe and the commonwealth of independent states. national millennium development goals: a framework for action. appendix 2 and appendix 3. new york: undp office 2006;107-11. 10. organisation for economic co-operation and development (oecd). total population; 2016. last updated 26-jan-2016 3:42:32 pm. available from: https://stats.oecd.org/index.aspx?datasetcode=pop_five_hist (accessed: june 16, 2020) 11. armitage p. statistical methods in medical research. oxford et al.: blackwell 1971;xv:504. 12. men t, brennan p, boffetta p, zaridze d. russian mortality trends for https://data.worldbank.org/indicator/sp.dyn.le00.in?end=2017&locations=ru&name_desc=true&start=1960&view=chart https://data.worldbank.org/indicator/sp.dyn.le00.in?end=2017&locations=ru&name_desc=true&start=1960&view=chart https://data.worldbank.org/indicator/sp.dyn.le00.in?end=2017&locations=ru&name_desc=true&start=1960&view=chart https://data.worldbank.org/indicator/sp.dyn.le00.in?end=2017&locations=ru&name_desc=true&start=1960&view=chart https://data.worldbank.org/indicator/sp.dyn.le00.in?end=2017&locations=ru&name_desc=true&start=1960&view=chart file:///c:/users/ulrich%20laaser/documents/200305-%20d-200316/vch/ruf%20all%20districts%20191211/:vol.%20392/issue%2010153 https://doi.org/10.1016/s0140-6736(18)31485-5 https://doi.org/10.1016/s0140-6736(18)31485-5 https://appsso.eurostat.ec.europa.eu/nui/show.do?dataset=demo_mlexpec&lang=en https://appsso.eurostat.ec.europa.eu/nui/show.do?dataset=demo_mlexpec&lang=en https://appsso.eurostat.ec.europa.eu/nui/show.do?dataset=demo_mlexpec&lang=en https://doi.org/10.1016/s2468-2667(19)30043-x https://doi.org/10.1016/s2468-2667(19)30043-x https://unstats.un.org/sdgs/report/2016/ https://unstats.un.org/sdgs/report/2016/ https://stats.oecd.org/index.aspx?datasetcode=pop_five_hist https://stats.oecd.org/index.aspx?datasetcode=pop_five_hist https://stats.oecd.org/index.aspx?datasetcode=pop_five_hist chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 11 | 12 1991-2001: analysis by cause and region. br med j 2003;327:964. 13. cowley j, kiely j, collins d. unravelling the glasgow effect: the relationship between accumulative biopsychosocial stress, stress reactivity and scotland's health problems. prev med rep 2016;4:370-5. doi: 10.1016/j.pmedr.2016.08.004. 14. varian hr. intermediate microeconomics a modern approach. 8th. new york, london: w. w. norton & company; 2010:339. 15. mckee m, stuckler d. if the world fails to protect the economy, covid-19 will damage health not just now but also in the future. nat med 2020;26:640-2. doi.org/10.1038/s41591-020-0863-y. _________________________________________________________________________________________ © 2020 chernyavskiy et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://dx.doi.org/10.1016%2fj.pmedr.2016.08.004 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlyanova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 p a g e 12 | 12 annexed data the annexed data are attached to this pdf (left upper corner of the screen). chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 1 | p a g e annex 1a): reference population and demographic data for the russian federation age group total total (%) age groups (%) (0-69 years) males females 0-4 80,269,483 8.12 0.09 41,086,449 39,183,034 5-9 84,285,393 8.52 0.09 43,136,842 41,148,551 10-14 85,828,597 8.68 0.09 43,940,121 41,888,476 15-19 87,597,591 8.86 0.10 44,669,180 42,928,411 20-24 82,619,776 8.36 0.09 41,732,681 40,887,095 25-29 77,252,661 7.81 0.08 38,886,927 38,365,734 30-34 73,604,119 7.44 0.08 37,039,695 36,564,424 35-39 61,676,142 6.24 0.07 30,868,724 30,807,418 40-44 57,394,499 5.80 0.06 28,587,578 28,806,921 45-49 54,245,506 5.49 0.06 26,895,533 27,349,973 50-54 52,537,987 5.31 0.06 25,502,142 27,035,845 55-59 48,323,994 4.89 0.05 22,432,778 25,891,216 60-64 36,727,063 3.71 0.04 16,649,007 20,078,056 65-69 36,887,734 3.73 0.04 16,137,708 20,750,026 subtotal 919,250,545 92.97 1.00 457,565,365 461,685,180 >= 70 years 69,516,189 7.031 total 988,766,734 100 oecd population as of 1980 used as reference population chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 2 | p a g e age group total total (%) age groups (%) (0-69 years) males females 0-4 8,793,034 6.13 0.07 4,513,291 4,279,743 5-9 7,551,503 5.26 0.06 3,865,465 3,686,038 10-14 6,755,921 4.71 0.05 3,462,421 3,293,500 15-19 7,053,773 4.92 0.05 3,608,288 3,445,485 20-24 10,409,834 7.25 0.08 5,300,635 5,109,200 25-29 12,539,045 8.74 0.10 6,323,823 6,215,222 30-34 11,503,330 8.02 0.09 5,734,091 5,769,239 35-39 10,536,322 7.34 0.08 5,145,843 5,390,480 40-44 9,656,787 6.73 0.07 4,689,062 4,967,725 45-49 9,365,913 6.53 0.07 4,444,476 4,921,438 50-54 11,310,282 7.88 0.09 5,204,737 6,105,546 55-59 10,508,049 7.32 0.08 4,587,152 5,920,897 60-64 8,819,230 6.15 0.07 3,635,352 5,183,878 65-69 4,861,126 3.39 0.04 1,877,878 2,983,249 subtotal 129,664,146 90.35 1 62,392,510 67,271,637 >= 70 years 13,842,849 9.65 total 143,506,995 100 russian federation population as of 2013 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 3 | p a g e age group total total (%) age groups (%) (0-69 years) males females 0-4 9,050,624 0.06 6.90 4,652,417 4,398,207 5-9 8,836,526 0.06 6.74 4,535,274 4,301,252 10-14 7,591,733 0.05 5.79 3,885,862 3,705,871 15-19 6,784,546 0.05 5.18 3,468,156 3,316,390 20-24 7,112,528 0.05 5.43 3,625,761 3,486,767 25-29 10,511,622 0.07 8.02 5,354,210 5,157,412 30-34 12,537,872 0.09 9.57 6,290,436 6,247,436 35-39 11,397,288 0.08 8.70 5,629,199 5,768,089 40-44 10,359,339 0.07 7.90 4,995,282 5,364,057 45-49 9,437,707 0.07 7.20 4,515,230 4,922,477 50-54 9,050,420 0.06 6.90 4,200,786 4,849,634 55-59 10,756,648 0.07 8.21 4,792,508 5,964,140 60-64 9,737,757 0.07 7.43 4,045,900 5,691,857 65-69 7,912,023 0.05 6.04 3,043,166 4,868,857 subtotal 131,076,633 0.91 100 63,034,187 68,042,446 >= 70 years 13,401,216 9.276 total 144,477,849 100 russian federation population as of 2018 (without crimea & sevastopol) chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 4 | p a g e age group total total (%) age groups (%) (0-69 years) males females 0-4 18,550 0.99 2.17 10,567 7,982 5-9 1,878 0.10 0.22 1,120 758 10-14 1,930 0.10 0.23 1,234 696 15-19 5,478 0.29 0.64 3,930 1,549 20-24 15,314 0.82 1.80 12,034 3,280 25-29 29,729 1.59 3.49 22,980 6,750 30-34 44,424 2.37 5.21 33,885 10,539 35-39 51,038 2.73 5.98 38,699 12,340 40-44 53,882 2.88 6.32 39,702 14,180 45-49 68,119 3.64 7.99 49,808 18,312 50-54 111,658 5.97 13.09 80,673 30,985 55-59 146,852 7.85 17.22 101,408 45,444 60-64 177,781 9.50 20.84 118,451 59,330 65-69 126,244 6.74 14.80 76,787 49,458 subtotal 852,878 45.56 100 591,277 261,601 >= 70 years 1,018,931 54.436 total 1,871,809 100 number of deaths, russian federation as of 2013 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 5 | p a g e study population (russian federation) deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 0-4 10,565 9,050,624 80,269,483 0.00117 93,698 6,316,727 5-9 1,624 8,836,526 84,285,393 0.00018 15,494 966,888 10-14 1,912 7,591,733 85,828,597 0.00025 21,617 1,240,846 15-19 4,073 6,784,546 87,597,591 0.00060 52,592 2,755,719 20-24 7,026 7,112,528 82,619,776 0.00099 81,614 3,874,045 25-29 15,858 10,511,622 77,252,661 0.00151 116,545 4,952,301 sum 41,058 49,887,579 497,853,501 0.00078 381,559 20,126,858.00 standardized rate (per 100 000) 76.64 4,042.73 russian federation age groups 0-29 standardized death rates 2018 direct standardization study population (russian federation) deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 0-4 18,550 8,793,034 80,269,483 0.00211 169,338 11,430,295 5-9 1,878 7,551,503 84,285,393 0.00025 20,957 1,309,802 10-14 1,930 6,755,921 85,828,597 0.00029 24,520 1,409,873 15-19 5,478 7,053,773 87,597,591 0.00078 68,034 3,571,808 20-24 15,314 10,409,834 82,619,776 0.00147 121,542 5,773,229 25-29 29,729 12,539,045 77,252,661 0.00237 183,161 7,784,361 sum 72,879 53,103,108 497,853,501 0.00121 587,552 31,279,367.54 standardized rate (per 100 000) 118.02 6,282.85 russian federation age groups 0-29 standardized death rates 2013 direct standardization chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 6 | p a g e study population (russian federation) deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 30-34 44,424 11,503,330 73,604,119 0.00386 284,247 10,659,263 35-39 51,038 10,536,322 61,676,142 0.00484 298,762 9,709,774 40-44 53,882 9,656,787 57,394,499 0.00558 320,243 8,806,685 45-49 68,119 9,365,913 54,245,506 0.00727 394,534 8,877,020 50-54 111,658 11,310,282 52,537,987 0.00987 518,668 9,076,695 55-59 146,852 10,508,049 48,323,994 0.01398 675,339 8,441,739 60-64 177,781 8,819,230 36,727,063 0.02016 740,355 5,552,659 65-69 126,244 4,861,126 36,887,734 0.02597 957,981 2,394,951 sum 779,999 76,561,038 421,397,044 0.01144 4,190,129 63,518,786.64 standardized rate (per 100 000) 994.34 15,073.38 russian federation age groups 30-69 standardized death rates 2013 direct standardization study population (russian federation) deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 30-34 31,700 12,537,872 73,604,119 0.00253 186,094 6,978,526 35-39 46,057 11,397,288 61,676,142 0.00404 249,236 8,100,156 40-44 54,854 10,359,339 57,394,499 0.00530 303,911 8,357,561 45-49 60,855 9,437,707 54,245,506 0.00645 349,779 7,870,031 50-54 79,395 9,050,420 52,537,987 0.00877 460,892 8,065,619 55-59 133,886 10,756,648 48,323,994 0.01245 601,481 7,518,515 60-64 177,631 9,737,757 36,727,063 0.01824 669,957 5,024,674 65-69 203,002 7,912,023 36,887,734 0.02566 946,444 2,366,111 sum 787,381 81,189,054 421,397,044 0.01043 3,767,795 54,281,192.39 standardized rate (per 100 000) 894.12 12,881.25 russian federation age groups 30-69 standardized death rates 2018 direct standardization without crimea and sevastopol chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 7 | p a g e study population (russian federation) deaths males population males (oecd 1980) males crude rate males expected deaths (standard pop.) males pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) males 0-4 10,567 4,513,291 41,086,449 0.00234 96,199.80 6,493,487 5-9 1,120 3,865,465 43,136,842 0.00029 12,496.00 781,002 10-14 1,234 3,462,421 43,940,121 0.00036 15,663.30 900,641 15-19 3,930 3,608,288 44,669,180 0.00109 48,648.30 2,554,034 20-24 12,034 5,300,635 41,732,681 0.00227 94,746.80 4,500,475 25-29 22,980 6,323,823 38,886,927 0.00363 141,308.60 6,005,616 30-34 33,885 5,734,091 37,039,695 0.00591 218,882.80 8,208,104 35-39 38,699 5,145,843 30,868,724 0.00752 232,143.80 7,544,673 40-44 39,702 4,689,062 28,587,578 0.00847 242,048.20 6,656,327 45-49 49,808 4,444,476 26,895,533 0.01121 301,409.60 6,781,716 50-54 80,673 5,204,737 25,502,142 0.0155 395,281.50 6,917,426 55-59 101,408 4,587,152 22,432,778 0.02211 495,921.80 6,199,023 60-64 118,451 3,635,352 16,649,007 0.03258 542,474.80 4,068,561 65-69 76,787 1,877,878 16,137,708 0.04089 659,871.90 1,649,680 sum 591,277 62,392,510 457,565,365 0.01101 3,497,097 69,260,763.68 standardized rate (per 100 000) 764.28 15,136.80 russian federation standardized death rates 2013 males direct standardization chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 8 | p a g e study population (russian federation) deaths females population females (oecd 1980) females crude rate females expected deaths (standard pop.) females pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) females 0-4 7,982 4,279,743 39,183,034 0.00187 73,083 4,933,134 5-9 758 3,686,038 41,148,551 0.00021 8,460 528,762 10-14 696 3,293,500 3,293,500 41,888,476 0.00021 8,849 508,837 15-19 1,549 3,445,485 42,928,411 0.00045 19,296 1,013,056 20-24 3,280 5,109,200 40,887,095 0.00064 26,246 1,246,696 25-29 6,750 6,215,222 38,365,734 0.00109 41,664 1,770,737 30-34 10,539 5,769,239 36,564,424 0.00183 66,794 2,504,757 35-39 12,340 5,390,480 30,807,418 0.00229 70,524 2,292,044 40-44 14,180 4,967,725 28,806,921 0.00285 82,227 2,261,244 45-49 18,312 4,921,438 27,349,973 0.00372 101,763 2,289,678 50-54 30,985 6,105,546 27,035,845 0.00507 137,204 2,401,064 55-59 45,444 5,920,897 25,891,216 0.00768 198,721 2,484,010 60-64 59,330 5,183,878 20,078,056 0.01145 229,795 1,723,460 65-69 49,458 2,983,249 20,750,026 0.01658 344,004 860,010 sum 261,601 67,271,637 461,685,180 1,408,631 26,817,489.06 standardized rate (per 100 000) 305.11 5,808.61 russian federation standardized death rates 2013 females direct standardization chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 9 | p a g e study population (russian federation) deaths males population males (oecd 1980) males crude rate males expected deaths (standard pop.) males pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) males 0-4 6,004 4,652,417 41,086,449 0.00129 0.00021 0.00031 0.00082 0.00146 0.00222 0.00374 0.00597 0.00793 0.00959 0.01345 0.01929 0.02945 0.04069 0.00974 53,021.0 3,578,915 5-9 963 4,535,274 43,136,842 0.00021 9,157.5 572,345 10-14 1,198 3,885,862 43,940,121 0.00031 13,552.0 779,238 15-19 2,829 3,468,156 44,669,180 0.00082 36,439.3 1,913,063 20-24 5,295 3,625,761 41,732,681 0.00146 60,949.8 2,895,115 25-29 11,860 5,354,210 38,886,927 0.00222 86,140.9 3,660,988 30-34 23,498 6,290,436 37,039,695 0.00374 138,364.4 5,188,665 35-39 33,579 5,629,199 30,868,724 0.00597 184,135.6 5,984,408 40-44 39,606 4,995,282 4,995,282 4,995,282 28,587,578 0.00793 226,659.8 6,233,143 45-49 43,288 4,515,230 26,895,533 0.00959 257,848.3 5,801,588 50-54 56,512 4,200,786 25,502,142 0.01345 343,074.5 6,003,803 55-59 92,468 4,792,508 22,432,778 0.01929 432,822.4 5,410,279 60-64 119,151 4,045,900 16,649,007 0.02945 490,310.9 3,677,332 65-69 123,829 3,043,166 16,137,708 0.04069 656,659.4 830,510 sum 560,081 63,034,187 457,565,365 0.00974 2,989,136 52,529,392.22 standardized rate (per 100 000) 653.27 11,480.19 russian federation standardized death rates 2018 males direct standardization without crimea and sevastopol chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 10 | p a g e study population (russian federation) deaths females population females (oecd 1980) females crude rate females expected deaths (standard pop.) females pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) females 0-4 4,559 4,398,207 39,183,034 0.00104 40,615 2,741,509 5-9 656 4,301,252 41,148,551 0.00015 6,272 391,992 10-14 707 3,705,871 41,888,476 0.00019 7,987 459,276 15-19 1,238 3,316,390 42,928,411 0.00037 16,027 841,402 20-24 1,724 3,486,767 40,887,095 0.00049 20,211 960,035 25-29 3,973 5,157,412 38,365,734 0.00077 29,552 1,255,968 30-34 8,133 6,247,436 36,564,424 0.00130 47,603 1,785,098 35-39 12,309 5,768,089 30,807,418 0.00213 65,744 2,136,675 40-44 14,938 5,364,057 28,806,921 0.00278 80,221 2,206,069 45-49 17,108 4,922,477 27,349,973 0.00348 95,053 2,138,688 50-54 22,275 4,849,634 27,035,845 0.00459 124,182 2,173,180 55-59 40,680 5,964,140 25,891,216 0.00682 176,599 2,207,488 60-64 57,538 5,691,857 20,078,056 0.01011 202,965 1,522,234 65-69 77,949 4,868,857 20,750,026 0.01601 332,204 830,510 sum 263,786 68,042,446 461,685,180 0.00359 1,245,234 21,650,123.93 standardized rate (per 100 000) 269.71 4,689.37 russian federation standardized death rates 2018 females direct standardization without crimea and sevastopol chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 11 | p a g e annex 1b): demographic data for eu-27 (2013 – 2018) population 2013 age group total males females 0-4 26,367,688 13,522,230 12,845,458 5-9 26,055,719 13,361,936 12,693,783 10-14 26,002,566 13,336,156 12,666,410 15-19 27,170,288 13,932,044 13,238,244 20-24 30,484,999 15,517,232 14,967,767 25-29 31,881,413 16,078,060 15,803,353 30-34 33,931,920 17,054,549 16,877,371 35-39 34,909,609 17,560,009 17,349,600 40-44 36,790,201 18,454,921 18,335,280 45-49 37,384,521 18,679,726 18,704,795 50-54 35,350,828 17,498,896 17,851,932 55-59 32,830,780 16,022,787 16,807,993 60-64 30,566,866 14,692,794 15,874,072 65-69 25,481,804 12,022,423 13,459,381 subtotal 435,209,202 217,733,763 217,475,439 >= 70 years 65,691,666 total 500,900,868 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 12 | p a g e population 2018 age group total males females 0-4 25,936,779 13,091,321 12,845,458 5-9 26,581,279 13,887,496 12,693,783 10-14 26,308,664 13,642,254 12,666,410 15-19 27,011,063 13,772,819 13,238,244 20-24 30,484,999 15,517,232 14,967,767 25-29 31,881,413 16,078,060 15,803,353 30-34 33,931,920 17,054,549 16,877,371 35-39 34,909,609 17,560,009 17,349,600 40-44 36,790,201 18,454,921 18,335,280 45-49 37,384,521 18,679,726 18,704,795 50-54 35,350,828 17,498,896 17,851,932 55-59 32,830,780 16,022,787 16,807,993 60-64 30,566,866 14,692,794 15,874,072 65-69 25,481,804 12,022,423 13,459,381 subtotal 435,450,726 217,975,287 217,475,439 >= 70 years 72,815,781 total 508,266,507 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 13 | p a g e direct standardization study population (europe-27) deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 0-4 22,551 26,367,688 80,269,483 0.00086 68,651 4,633,914 5-9 2,404 26,055,719 84,285,393 0.00009 7,776 486,031 10-14 2,649 26,002,566 85,828,597 0.00010 8,744 502,766 15-19 7,280 27,170,288 87,597,591 0.00027 23,471 1,232,221 20-24 12,239 30,484,999 82,619,776 0.00040 33,170 1,575,569 25-29 15,212 31,881,413 77,252,661 0.00048 36,861 1,566,575 30-34 20,527 33,931,920 73,604,119 0.00060 44,527 1,669,746 35-39 30,890 34,909,609 61,676,142 0.00088 54,575 1,773,673 40-44 51,336 36,790,201 57,394,499 0.00140 80,087 2,202,383 45-49 87,021 37,384,521 54,245,506 0.00233 126,269 2,841,048 50-54 139,002 35,350,828 52,537,987 0.00393 206,583 3,615,205 55-59 208,505 32,830,780 48,323,994 0.00635 306,901 3,836,261 60-64 288,697 30,566,866 36,727,063 0.00944 346,879 2,601,590 65-69 351,949 25,481,804 36,887,734 0.01381 509,485 1,273,713 sum 1,240,262 435,209,202 919,250,545 0.00292 1,853,977 29,810,693.11 standardized rate (per 100 000) 201.68 3,242.93 europe 27 standardized death rates 2013 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 14 | p a g e study population (europe-27) deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 0-4 20,568 25,936,779 80,269,483 0.00079 63,654 4,296,653 5-9 2,131 26,581,279 84,285,393 0.00008 6,757 422,318 10-14 2,620 26,308,664 85,828,597 0.00010 8,547 491,476 15-19 6,753 27,011,063 87,597,591 0.00025 21,900 1,149,758 20-24 10,496 30,484,999 82,619,776 0.00034 28,446 1,351,186 25-29 14,067 31,881,413 77,252,661 0.00044 34,086 1,448,659 30-34 19,823 33,931,920 73,604,119 0.00058 42,999 1,612,480 35-39 29,729 34,909,609 61,676,142 0.00085 52,523 1,707,009 40-44 47,033 36,790,201 57,394,499 0.00128 73,374 2,017,778 45-49 79,064 37,384,521 54,245,506 0.00211 114,723 2,581,269 50-54 129,631 35,350,828 52,537,987 0.00367 192,656 3,371,481 55-59 200,067 32,830,780 48,323,994 0.00609 294,481 3,681,011 60-64 292,481 30,566,866 36,727,063 0.00957 351,425 2,635,689 65-69 392,665 25,481,804 36,887,734 0.01541 568,426 1,421,065 sum 1,247,128 435,450,726 919,250,545 0.00297 1,853,999 28,187,834.47 standardized rate (per 100 000) 201.69 3,066.39 europe 27 standardized death rates 2018 direct standardization chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 15 | p a g e annex 2): demographic data for crimea and sevastopol 2015 – 2018 age group total total (%) males females 0-4 117,804 6.13 60,691 57,113 5-9 108,083 5.62 55,308 52,775 10-14 84,242 4.38 43,248 40,994 15-19 81,483 4.24 41,866 39,617 20-24 106,545 5.54 54,411 52,134 25-29 152,380 7.93 76,975 75,405 30-34 152,465 7.93 76,831 75,634 35-39 136,698 7.11 68,023 68,675 40-44 125,490 6.53 60,553 64,937 45-49 117,916 6.13 55,540 62,376 50-54 138,461 7.20 63,119 75,342 55-59 146,255 7.61 63,420 82,835 60-64 133,454 5.12 54,820 78,634 65-69 98,440 5.12 37,530 60,910 subtotal 1,699,716 86.60 812,335 887,381 >= 70 years 222,524 11.576 total 1,922,240 98 population of crimea as of 2015 source: копия pop-deaths-crimea 15-18.xlsx chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 16 | p a g e age group total total (%) males females 0-4 113,197 0.06 58,121 55,076 5-9 118,013 0.06 60,779 57,234 10-14 98,431 0.05 50,333 48,098 15-19 78,903 0.04 40,501 38,402 20-24 89,382 0.05 46,032 43,350 25-29 127,652 0.07 64,635 63,017 30-34 162,655 0.08 81,839 80,816 35-39 145,774 0.08 73,020 72,754 40-44 132,382 0.07 64,605 67,777 45-49 121,248 0.06 57,587 63,661 50-54 120,690 0.06 55,323 65,367 55-59 143,834 0.07 63,187 80,647 60-64 137,752 0.07 56,726 81,026 65-69 119,098 0.06 45,890 73,208 subtotal 1,709,011 0.88 818,578 890,433 >= 70 years 222,440 11.517 total 1,931,451 100 population of crimea as of 2018 source: копия pop-deaths-crimea 15-18.xlsx age group total total (%) males females 0-4 182 0.63 104 78 5-9 24 0.08 12 12 10-14 25 0.09 16 9 15-19 48 0.17 33 15 20-24 130 0.45 93 37 25-29 283 0.97 222 61 30-34 454 1.56 325 129 35-39 647 2.22 482 165 40-44 824 2.83 597 227 45-49 981 3.37 719 262 50-54 1,465 5.04 1,038 427 55-59 2,090 7.19 1,413 677 60-64 2,807 9.65 1,835 972 65-69 2,629 9.04 1,526 1,103 subtotal 12,589 43.28 8,415 4,174 >= 70 years 16,499 56.721 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 17 | p a g e total 29,088 100 258,475 270,288 number of deaths crimea as of 2015 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 18 | p a g e age group total total (%) males females 0-4 105 0.39 50 55 5-9 24 0.09 12 12 10-14 18 0.07 8 10 15-19 49 0.18 38 11 20-24 88 0.33 61 27 25-29 193 0.71 150 43 30-34 426 1.58 318 108 35-39 608 2.25 439 169 40-44 817 3.03 590 227 45-49 966 3.58 681 285 50-54 1,112 4.12 798 314 55-59 1,812 6.71 1,249 563 60-64 2,502 9.27 1,642 860 65-69 2,948 10.92 1,758 1,190 subtotal 11,668 43.22 7,794 3,874 >= 70 years 15,331 56.784 total 26,999 100 244,013 264,423 number of deaths crimea as of 2018 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 19 | p a g e study population crimea deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 0-4 182 117,804 80,269,483 0.00154 124,011 8,370,773 5-9 24 108,083 84,285,393 0.00022 18,716 1,169,731 10-14 25 84,242 85,828,597 0.00030 25,471 1,464,574 15-19 48 81,483 87,597,591 0.00059 51,602 2,709,104 20-24 130 106,545 82,619,776 0.00122 100,808 4,788,372 25-29 283 152,380 77,252,661 0.00186 143,474 6,097,627 30-34 454 152,465 73,604,119 0.00298 219,173 8,219,002 35-39 647 136,698 61,676,142 0.00473 291,917 9,487,301 40-44 824 125,490 57,394,499 0.00657 376,867 10,363,848 45-49 981 117,916 54,245,506 0.00832 451,294 10,154,126 50-54 1,465 138,461 52,537,987 0.01058 555,883 9,727,957 55-59 2,090 146,255 48,323,994 0.01429 690,555 8,631,940 60-64 2,807 133,454 36,727,063 0.02103 772,497 5,793,730 65-69 2,629 98,440 36,887,734 0.02671 985,147 2,462,867 sum 12,589 1,699,716 919,250,545 0.00721 4,807,416 89,440,953.28 standardized rate (per 100 000) 522.97 9,729.77 crimea standardized death rates 2015 direct standardization chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 20 | p a g e study population crimea deaths population (oecd 1980) crude rate expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di* (remaining years to upper age limit) 0-4 105 113,197 80,269,483 0.00093 74,457 5,025,840 5-9 24 118,013 84,285,393 0.00020 17,141 1,071,306 10-14 18 98,431 85,828,597 0.00018 15,695 902,486 15-19 49 78,903 87,597,591 0.00062 54,399 2,855,973 20-24 88 89,382 82,619,776 0.00098 81,342 3,863,761 25-29 193 127,652 77,252,661 0.00151 116,800 4,964,003 30-34 426 162,655 73,604,119 0.00262 192,772 7,228,956 35-39 608 145,774 61,676,142 0.00417 257,241 8,360,342 40-44 817 132,382 57,394,499 0.00617 354,212 9,740,833 45-49 966 121,248 54,245,506 0.00797 432,182 9,724,087 50-54 1,112 120,690 52,537,987 0.00921 484,069 8,471,201 55-59 1,812 143,834 48,323,994 0.01260 608,779 7,609,734 60-64 2,502 137,752 36,727,063 0.01816 667,076 5,003,073 65-69 2,948 119,098 36,887,734 0.02475 913,072 2,282,680 sum 11,668 1,709,011 919,250,545 0.00643 4,269,238 77,104,274.01 standardized rate (per 100 000) 464.43 8,387.73 crimea standardized death rates 2018 direct standardization chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 21 | p a g e age group total total (%) males females 0-4 23,079 5.60 11,926 11,153 5-9 20,924 5.07 10,630 10,294 10-14 16,881 4.09 8,638 8,243 15-19 17,514 4.25 9,729 7,785 20-24 24,960 6.05 14,442 10,518 25-29 34,683 8.41 17,600 17,083 30-34 35,612 8.64 17,951 17,661 35-39 31,119 7.55 15,453 15,666 40-44 28,121 6.82 14,043 14,078 45-49 24,114 5.85 11,548 12,566 50-54 26,996 6.55 12,170 14,826 55-59 29,216 7.08 12,258 16,958 60-64 28,561 5.49 11,436 17,125 65-69 22,647 5.49 8,456 14,191 subtotal 364,427 86.93 176,280 188,147 >= 70 years 47,987 11.636 total 412,414 99 sevastopol population as of 2015 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 22 | p a g e age group total total (%) males females 0-4 25,907 0.06 13,385 12,522 5-9 24,440 0.06 12,622 11,818 10-14 21,176 0.05 10,747 10,429 15-19 18,187 0.04 9,617 8,570 20-24 23,031 0.05 13,814 9,217 25-29 31,677 0.07 16,935 14,742 30-34 41,106 0.09 20,599 20,507 35-39 36,998 0.08 18,544 18,454 40-44 32,102 0.07 15,810 16,292 45-49 27,831 0.06 13,667 14,164 50-54 25,327 0.06 11,859 13,468 55-59 29,555 0.07 12,747 16,808 60-64 29,432 0.07 11,955 17,477 65-69 26,716 0.06 10,125 16,591 subtotal 393,485 0.89 192,426 201,059 >= 70 years 50,858 11.446 total 444,343 100 sevastopol population as of 2018 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 23 | p a g e age group total total (%) age groups (%) (0-69 years) males females 0-4 33 0.54 1.21 23 10 5-9 2 0.03 0.07 2 0 10-14 3 0.05 0.11 1 2 15-19 12 0.20 0.44 9 3 20-24 31 0.51 1.14 24 7 25-29 61 1.00 2.24 48 13 30-34 135 2.22 4.96 109 26 35-39 159 2.61 5.85 124 35 40-44 215 3.53 7.90 164 51 45-49 206 3.38 7.57 156 50 50-54 275 4.52 10.11 202 73 55-59 462 7.59 16.99 325 137 60-64 553 9.08 20.33 356 197 65-69 573 9.41 21.07 315 258 subtotal 2,720 44.67 100 1,858 862 >= 70 years 3,369 55.329 total 6,089 100 258,475 270,288 number of deaths sevastopol as of 2015 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 24 | p a g e age group total total (%) age groups (%) (0-69 years) males females 0-4 19 0.34 0.82 13 6 5-9 2 0.04 0.09 1 1 10-14 2 0.04 0.09 1 1 15-19 3 0.05 0.13 2 1 20-24 18 0.32 0.78 13 5 25-29 45 0.80 1.94 35 10 30-34 103 1.82 4.45 81 22 35-39 145 2.57 6.26 112 33 40-44 167 2.96 7.21 130 37 45-49 193 3.42 8.33 140 53 50-54 234 4.15 10.10 161 73 55-59 349 6.18 15.06 241 108 60-64 448 7.94 19.34 293 155 65-69 589 10.43 25.42 346 243 subtotal 2,317 41.05 100 1,569 748 >= 70 years 3,328 58.955 total 5,645 100 244,013 264,423 number of deaths of sevastopol as of 2018 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 25 | p a g e study population sevastopol deaths population (oecd 1980) crude rate expected deaths (oecd pop.) expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di = ri * std pi di* (remaining years to upper age limit) 0-4 33 23,079 80,269,483 0.00143 114,775.0 114,775 7,747,315 5-9 2 20,924 84,285,393 0.00010 8,056.3 8,056 503,521 10-14 3 16,881 85,828,597 0.00018 15,253.0 15,253 877,047 15-19 12 17,514 87,597,591 0.00069 60,018.9 60,019 3,150,992 20-24 31 24,960 82,619,776 0.00124 102,612.7 102,613 4,874,103 25-29 61 34,683 77,252,661 0.00176 135,871.0 135,871 5,774,516 30-34 135 35,612 73,604,119 0.00379 279,022.7 279,023 10,463,351 35-39 159 31,119 61,676,142 0.00511 315,129.2 315,129 10,241,700 40-44 215 28,121 57,394,499 0.00765 438,811.5 438,811 12,067,315 45-49 206 24,114 54,245,506 0.00854 463,406.1 463,406 10,426,637 50-54 275 26,996 52,537,987 0.01019 535,188.4 535,188 9,365,797 55-59 462 29,216 48,323,994 0.01581 764,159.5 764,160 9,551,994 60-64 553 28,561 36,727,063 0.01936 711,111.9 711,112 5,333,339 65-69 573 22,647 36,887,734 0.02530 933,310.0 933,310 2,333,275 sum 2,720 364,427 919,250,545 0.00722 4,876,726 4,876,726 92,710,902.83 standardized rate (per 100 000) 530.51 10,085.49 sevastopol standardized death rates 2015 direct standardization chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 26 | p a g e study population sevastopol deaths population (oecd 1980) crude rate expected deaths (oecd pop.) expected deaths (standard pop.) pyll age groups di pi std pi ri = di/pi di = ri * std pi di = ri * std pi di* (remaining years to upper age limit) 0-4 19 25,907 80,269,483 0.00073 58,869.0 58,869 3,973,660 5-9 2 24,440 84,285,393 0.00008 6,897.3 6,897 431,083 10-14 2 21,176 85,828,597 0.00009 8,106.2 8,106 466,107 15-19 3 18,187 87,597,591 0.00016 14,449.5 14,449 758,598 20-24 18 23,031 82,619,776 0.00078 64,571.9 64,572 3,067,166 25-29 45 31,677 77,252,661 0.00142 109,744.3 109,744 4,664,132 30-34 103 41,106 73,604,119 0.00251 184,431.1 184,431 6,916,166 35-39 145 36,998 61,676,142 0.00392 241,716.9 241,717 7,855,798 40-44 167 32,102 57,394,499 0.00520 298,575.8 298,576 8,210,835 45-49 193 27,831 54,245,506 0.00693 376,177.0 376,177 8,463,983 50-54 234 25,327 52,537,987 0.00924 485,406.4 485,406 8,494,613 55-59 349 29,555 48,323,994 0.01181 570,633.5 570,634 7,132,919 60-64 448 29,432 36,727,063 0.01522 559,042.0 559,042 4,192,815 65-69 589 26,716 36,887,734 0.02205 813,253.3 813,253 2,033,133 sum 2,317 393,485 919,250,545 0.00573 3,791,874 3,791,874 66,661,009.41 standardized rate (per 100 000) 412.50 7,251.67 sevastopol standardized death rates 2018 direct standardization chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 27 | p a g e annex 3): demographic data of the 8 federal districts federal districts population 2013 2018 north caucasus 9,565,422 9,844,851 south* 13,937,027 14,095,516 privolzhkiy (volga) 29,755,536 29,469,957 far east 8,304,660 8,205,643 uralskiy 12,215,884 12,353,188 siberian 17,219,879 17,201,749 central 38,749,394 39,344,729 north-west 13,759,196 13,962,038 sum 143,506,998 144,477,671 russian federation 143,506,998 144,477,879 difference (districts rf) 0 -178 * without crimea and sevastopol chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 28 | p a g e annex 4a): projected reduction of premature years of life lost (pyll) for 8 federal districts, targeted as of 2015 (estimated) -2030 federal district pyll/ 100,000 2013 pyll/ 100,000 2018 pyll/ 100,000 2015 (estimated as average 2013/2018) pyll/ 100,000 target 2030 based on 2015 years needed years in advance gr to be >= -0.25 north caucasus 7,153 4,970 6,062 4,041 5.1 6.9 0.58 privolzhkiy (volga) 10,010 7,295 8,653 5,768 6.1 5.9 0.49 far est 12,529 9,203 10,866 7,243 6.3 5.7 0.47 uralskiy 11,910 9,032 10,471 6,980 7.1 4.9 0.41 siberian 11,829 9,133 10,481 6,987 7.5 4.5 0.37 south 8,351 6,032 7,359 4,906 7.8 4.2 0.35 central 9,322 7,272 8,297 5,531 7.8 4.2 0.35 north-west 9,726 7,824 8,775 5,849 8.7 3.3 0.28 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 29 | p a g e annex 4b): projected reduction of premature years of life lost (pyll) for 8 federal districts, targeted as of 2018-2030 federal district pyll/ 100,000 2013 pyll/ 100,000 2018 pyll/ 100,000 target 2030 based on 2018 years needed years in advance gr to be >= -0.25 south 8,351 6,032 4,245 7.1 4.9 0.41 north caucasus 7,153 4,970 3,313 7.3 4.7 0.39 privolzhkiy (volga) 10,010 7,295 4,863 8.0 4.0 0.33 far est 12,529 9,203 6,135 8.2 3.8 0.32 uralskiy 11,910 9,032 6,021 8.7 3.3 0.28 siberian 11,829 9,133 6,089 9.0 3.0 0.25 central 9,322 7,272 4,848 9.2 4.8 0.23 north-west 9,726 7,824 5,216 9.8 2.2 0.18 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 30 | p a g e annex 4c): calculation of target achievement of the russian federation using different baseline years 2003 2009 2013 2018 2030 based on 2013 2030 based on 2018 different baselines pyll/ 100,000 pyll/ 100,000 based on 2013 years in adv. gr based on 2018 years in adv. gr 2003 15950 8060 6875 8.5 0.71 5373 5.1 0.43 2009 11935 8060 6875 7.1 0.58 5373 3.4 0.28 2013 10313 8060 6875 6.1 0.51 5373 2.8 0.23 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 31 | p a g e annex 4d): achievability of the presidential targets for 2024 and 2030 target le 2024 target le 2030 le 2013 le 2017 target 2024 target 2030 76 80 70.6 72.4 -0.9 -1.3 chernyavskiy v, wenzel h, mikhailova j, ivanova a, zemlianova e, vesna bjegovic-mikanovic v, et al. can russia’s high mortality return until 2030 to trajectory of the 1980-ies and reach the sdgs evenly across the country? [original research]. seejph 2020, posted: 21 september 2020. doi: 10.4119/seejph-3813 32 | p a g e annex 5): selected oblasts respectively districts, republics and autonomous regions with the highest and the lowest mortality rate per 100.000 population * autonomous district 2013 2018 2030 oblasts, republics or districts with the highest /lowest mortality in the russian federation death rate per 100,000 population part of larger administra tive district or region deaths per 100,000 populati on pyll per 100,000 populat ion deaths per 100,000 populati on pyll per 100,000 population target value pyll/ 100,000 target achieved, years in advance highest tyumen oblast 2,066 uralskiy federal district 1,155 25,054 976 18,479 16,703 8.4 pskov oblast 1,859 northwestern district 661 12,650 567 10,024 8,433 5.6 tver oblast 1,801 central federal district 637 12,765 549 9,932 8,510 6.3 novgorod oblast 1,783 northwestern district 662 13,322 562 10,369 8,881 6.3 lowest republic dagestan 550 north caucasus 252 7,033 211 5,014 4,689 9.6 yamalo-nenets district * 513 uralskiy federal district 354 9,831 301 7,023 6,554 9.6 republic chechenskaya 493 north caucasus 369 7,050 306 4,603 4,700 12.7 republic ingushetia 350 north caucasus 243 5,325 189 3,756 3,550 10 nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 1 | 16 original research school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation maha nubani husseini1,2, milka donchin2,3 1 faculty of public health, al-quds university, palestine; 2 linda joy pollin cardiovascular wellness center for women, division of cardiology, hadassah university hospital, jerusalem, israel; 3 braun school of public health, hadassah & the hebrew university-hadassah medical school, israel corresponding author: maha nubani husseini, rn, mph, phd; address: po box 51915, abu dies campus, palestine; telephone: +972 (0) 522520104; email: dhus802@hadassah.org.il / m_nubani@hotmail.com nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 2 | 16 abstract aim: school-based interventions have the potential to intervene with the students and teachers, and to reach their families. a controlled program trial was designed to promote healthy eating and physical activity among palestinian females, while the process evaluation aimed to monitor the program’s implementation and identify factors that led to its success. methods: a randomized controlled program trial was conducted in 14-palestinian schools under 4-different jurisdictions, divided into 7-control and 7-intervention schools chosen randomly after applying a sample size calculation. a monitoring system, elucidated factors which contributed to improved outcomes, was applied in the intervention schools only, while the control schools continued with their regular curriculum. the process evaluation tracked the timing and implementation of interventions including changes in the school strategy, policy and structure, teachers’ capacity building, mothers’ education and involvement, the school’s supportive health environment, and integration food consumption records and physical activity into the daily class routine. results: the intervention included 3,805 schoolchildren and their mothers’ as-well-as 147 teachers. at the completion of the 18-month intervention the schools had successfully participated in the various intervention activities. only the private school did not sustain some of the interventions, which put it at 55% completion of the school supportive environment activities compared to the other schools which all reached the 100% completion of planned activities. conclusion: this process evaluation approach enabled a more comprehensive understanding of the intervention implementation and outcomes and identified factors that contribute to the sustainability of the intervention. each school required a different amount of time for understanding, applying and implementing the program depending on its needs. keywords: intervention, nutrition, physical activity, process evaluation, school, schoolchildren. acknowledgments: the authors thank the participating schools, the palestinian ministry of education, the unrwa office of education and jerusalem municipality for facilitating fieldwork. i would like to acknowledge my gratitude to my doctoral thesis supervisors, prof. elliot berry and prof. ziad abdeen. source of funding: this study is a part of ph.d. degree. the researcher received scholarship from joint distribution committee (jdc). the author thanks nutrition and health research institute al-quds university for funding part of the research. the linda joy pollin cardiovascular wellness center for women at the division of cardiology of hadassah university medical center, directed by dr. donna zfat funded the mothers’ activities and lectures towards the end of the intervention, as well as the implementation of the program at the control schools one year after the study ended, as they were promised when they got selected. conflicts of interest: none declared. nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 3 | 16 introduction obesity is a significant risk factor for chronic diseases, including type ii diabetes mellitus, coronary heart disease, hypertension, stroke and certain types of cancer (1-3). the prevalence of obesity in children and adolescents is increasing throughout the world (1). in palestine, there is a lack of a nationally representative survey that reveals the prevalence rates of overweight/obesity and physical activity among all age groups. a cross sectional study conducted in 2017 in palestine showed that the prevalence of overweight and obesity was 14.5 and 15.7% respectively among palestinian children between the ages of 6-12 years (2). while 15.1% of the female were overweight and 13.8% were obese. another systematic review showed that the prevalence of overweight and obesity in adults was 30% and 18% respectively (1). in east jerusalem, rapid urbanization, modernization, and sedentary lifestyles have contributed to the growing frequency of overweight and obesity in all age groups (3). the need for effective preventive and protective measures to control the obesity epidemic has become a major focus of attention. evidence suggests that increased childhood body mass index (bmi) can predict adulthood overweight and obesity (4) indicating that these interventions should be introduced as early as possible so that people employ a healthy lifestyle from childhood. healthy nutrition and physical activity are the key factors in preventing and reducing obesity in children (5). programs aimed at promoting healthy nutrition and physical activity may be best addressed in a school setting, as schools offer a safe and supportive environment where children can learn and implement these healthy practices (6,7). several published studies on weight management interventions in the school setting show promising results (8), but there is a lack of process evaluation data to assist investigators in designing optimal studies. process evaluation can illuminate how the intervention was implemented, participants’ level of engagement, and the level of maintenance during the intervention (9). process evaluation is crucial in providing a better understanding of the different factors influencing the implementation process (10). analysis of process data may clarify the causal mechanisms that lead to outcomes. process evaluation informs subsequent interventions, enabling replication in other settings (9). this paper describes a process evaluation of a school-based randomized controlled program trial that took place over two academic years in each school. the intervention was implemented in seven girls’ elementary schools in east jerusalem, with seven additional schools serving as a control group. the aim of this intervention was to promote healthy eating and physical activity among the schoolchildren, their mothers and teachers. the process evaluation aimed to monitor the program’s implementation and to elucidate which factors improved the outcomes. methods the study design and objectives have been described elsewhere in detail (11). briefly, the intervention aimed to improve knowledge, attitudes and health behaviors of schoolchildren, their teachers and their mothers with regard to healthy nutrition (12) and physical activity. the sample size calculation, described in detail elsewhere (11), was based on the estimated prevalence of healthy behaviors relating to physical activity (>5 days per week), which was estimated at 25% among girls in grade 6 in the heath behavior school children study nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 4 | 16 (13). fourteen girls' schools operating in east jerusalem under differing jurisdictions: (jerusalem municipality (jm), palestinian authority (pa), united nations relief and works agency (unrwa), and private schools) were stratified by jurisdiction and then randomized into 7 intervention and 7 control schools. the preand postintervention data for the outcome evaluation was collected from one 4th grade class and one 5th grade class in each of the schools; however, the intervention activities and monitoring were implemented within all the intervention schools’ body including all schoolchildren in all different grades, while control schools continued with regular curriculum. the study procedures were approved by the hebrew university of jerusalem/authority for research students committee, as well as the israeli ministry of education, palestinian ministry of education, unrwa office of education department and the private schools’ principals. intervention development and delivery the intervention was designed and implemented through the utilization of the socio-ecological model (figure 1) to promote healthy eating and physical activity in the intervention schools, whereas the control schools continued with their regular curriculum. the program was designed and implemented as a multi-level intervention, targeting schoolchildren, their mothers, and their teachers, as well as addressing school policies and the physical and social environments. the intervention included numerous components related to healthy eating and physical activity, and encompassed the entire school setting. the program had the support and commitment of the school principals. figure 1. ecological model nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 5 | 16 intervention strategy and structure: in each school, a teacher was appointed as the program coordinator and headed the health steering committee. the health steering committee consisted of representatives of teachers, mothers, schoolchildren, and the owner of the canteen (8-10 individuals). teachers’ capacity building: teachers were trained through five training sessions of 120150 minutes long given in the setting of inservice training for professional credit. mothers’ education and involvement: mothers were represented on the health steering committee and were invited to seven workshops held in each of the schools (120150 minutes long each), focusing on the importance of healthy eating (mediterranean diet pattern) and physical activity. supportive health environment and policy: the components of the program were developed by the school team in cooperation with the researcher. intervention activities are presented in table 2. successful and creative components that were suggested by school health steering committees were then disseminated to other schools as possible interventions. schools ended up implementing activities that included: a. changing the school canteen offerings to exclusively healthier food choices (no sugared drinks, candy, or chips, and more fresh juices, fruit, and vegetables); b. integrating health messages into the morning announcements (the importance of healthy food and regular exercise); c. a healthy wall magazine displayed in each class twice a year, created by the students under the supervision of their teacher; d. a healthy corner in each classroom; e. decorating the hallways with paintings encouraging healthy nutrition; f. decorating the play yards with games such as “snakes and ladders,” “tic tac toe,” and “hopscotch” to promote physical activity during breaks; g. morning aerobics supervised by the physical education teacher; h. health promotion checklist in each class to track schoolchildren’s daily healthy habits of eating breakfast, drinking milk, and bringing healthy lunches (i.e. sandwiches, fruit, and vegetables). after a few months, a number of other activities were added, such as an active break (with directed physical activity during the break.); i. alternative rewards. integrating food consumption records in the daily class routine: in addition to the health promotion checklists, a reward system was designed to encourage the children to opt for healthy food choices: students were incentivized with prizes such as healthy snacks or school stationery, instead of with candies or other unhealthy products, to emphasize the importance of staying healthy. process evaluation the process evaluation included using a checklist to monitor and document the implementation of the planned activities in the intervention schools, and an assessment of whether the intervention was proceeding as designed. the researcher visited the intervention schools on a bi-weekly basis to directly observe classrooms (decoration, healthy corner, class wall magazine, checklists and active break), hallways (decorations), canteens (products sold) and school yards (decorations and games). the health steering committee met every 4-6 weeks to discuss the current activities and the need for any changes or additions. these meetings were followed by semi-structured interviews (teachers, schoolchildren and their mothers) to monitor the intervention activities, progress and the schools’ performance. nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 6 | 16 in addition to the researcher’s regular observation visits to the schools throughout the 18 months of the program, specific program evaluation visits were conducted during february–april of the second year of the program, which included the postintervention questionnaire for the schoolchildren, mothers, and teachers, and interviews with the principals. these visits ensured that the activities were going according to plan and included periodic interviews with mothers and teachers regarding the program as a whole as well as their satisfaction with specific activities. in order to further explore the components leading to success in the intervention, at the end of the program, the researcher did faceto-face interviews with principals, health steering committee members, and mothers from the more successful intervention schools. results the total number of intervention participants was 3,805 schoolchildren and their mothers as well as 147 teachers in 7 different schools of the intervention. the timeline summarizing the implementation of the intervention is presented in table 1. the school principal designated one teacher as program coordinator, who was responsible for implementing and running the program at her school with the help of a health steering committee. the principal also nominated a health steering committee whose members represented teachers, mothers, schoolchildren, and the owner of the canteen (8-10 persons). the researcher met with the committee once every four-six weeks. during the first meeting, the results of each school’s baseline study were presented and compared with the data from all fourteen schools, serving as a basis for discussing the program elements. based on this data, the committee outlined objectives to meet their needs, then designed and implemented the intervention using their own resource. the program activities were then assigned to members of the teaching staff who were trained as part of the teachers’ capacity building (see below). for example, the art teacher was responsible for health promotion hallway decoration, the physical education teacher was assigned to leading morning aerobics, and the homeroom teacher oversaw the school’s health magazine and the health promotion checklist (details in table 2). these activities were monitored by the health steering committee. nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 7 | 16 table 1. program process evaluation timetable-school monthly performance *numbers in the table refer to schools that implemented the activity table 2. intervention activities components of the socioecological model steps of the intervention procedures providers schoolchildren (n=3,805) morning announcements the teacher in charge prepared a monthly list of topics related to health issues to be discussed during the morning announcements. a group of schoolchildren were assigned to a certain topic and directed to prepare to present it in a fun and informative way. schoolchildren nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 8 | 16 the teacher went through the information to certify what would be presented. morning aerobics every morning schoolchildren would participate in a physical activity such as aerobics, zumba, dancing, etc. before entering the classroom. physical education teacher health behavior checklist/ health promotion card a checklist to show schoolchildren healthy habits such as eating breakfast, drinking milk, and bringing a sandwich, water, and fruits and vegetables to school. different formats of a health promoting checklist were designed in each class to track schoolchildren’s daily healthy habits. schoolchildren were rewarded with healthy snacks or stationery. homeroom teacher mothers (n=3,805) mothers’ workshops 4 training sessions (120-150 minutes long each)  healthy eating  physical activity dietitian physical educator schools activities school health day school staff teachers (n=147) teachers’ training 5 training sessions (120-150 minutes long each)  healthy eating  physical activity  strategies for building school health programs and methods to integrate health into subjects being taught dietitian physical educator health promoter school’s policy & environment (n=7) active break schoolchildren started to eat their sandwiches in class before the 10 o’clock break so they could subsequently go outside for active playtime. teachers decorations the hallways and the walls of the schools play yards were decorated with paintings of water, fruit and vegetables. teachers and schoolchildren school yard games school play yards were decorated with games such as snakes and ladders, tic tac toe, and hopscotch to promote physical activity during breaks. teachers nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 9 | 16 wall magazine a wall magazine was created in each classroom twice every year. it included information on healthy habits, physical activity and specific foods with information about health benefits or harm. schoolchildren with the homeroom teacher health education and healthy corner in class teachers integrated health topics into the subjects they taught after receiving training in this field, and established a healthy corner with the help of the schoolchildren. material included three dimensional shapes for healthy food products, the food pyramid, etc. teachers healthy food choices in the canteen the owner of the canteen was part of the health steering committee and was included in all steps of the intervention. school canteens were given a transition period to change their food products to include healthier food choices and limit unhealthy food choices. the canteens stopped selling unhealthy snacks (sugared drinks, candy, chips, etc.) and started selling healthy fresh juices, lupin beans, fruit and vegetables, etc. owner of the canteen and the health steering committee the teachers’ capacity building training sessions were held separately in each of the schools. the training targeted 1st–6th grade teachers, 80% of whom received training on the principles and importance of healthy nutrition and physical activity, as well as methods for incorporating this content into class curricula. teachers were also trained in the principles and strategies of building a school health program. the majority of the training sessions for teachers were attended by the school principal and/or the viceprincipal. during the same period mothers’ workshops on importance of healthy nutrition and physical activity were conducted in each of the schools, followed by the opening day kick-off with a clown who presented the main messages of the program to the schoolchildren in a fun and interactive way. together with their children, mothers also participated in a field day physical activity program as well as several other activities devoted to healthy eating campaigns. mothers were also involved in preparing healthy lunches. toward the end of the first school term, all seven schools implemented the morning announcements and the healthy wall magazines. they also began changing the products sold at the canteen, except for the private school which did not apply this intervention (since their canteen was a private business and not owned by the school). health promotion checklists were initiated in each of the classes, monitoring the nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 10 | 16 schoolchildren’s healthy behaviors such as eating breakfast daily, drinking milk before arriving to school, bringing fruit and vegetables to school as snacks, etc. the morning aerobics were introduced in all seven schools at the beginning of the second term; however, the private school did not continue this component. the seven schools also decorated their hallways and created the healthy corner in every class. they began discussing health during the weekly homeroom period. the private school did not implement this activity as well. soon after, teachers in all seven schools were trained on how to introduce an active break and began implementation. this intervention distinguished between a recess designed for eating, supervised by teachers in the classroom, and an outdoor recess in the play yard. this encouraged the students to eat a healthy mid-morning snack and to use their time in the play yard for exercise. prior to this intervention, students were given one long break in the play yard, during which they were expected to both eat and play at their discretion. teachers received their final training session on integrating physical activity and healthy eating into the subjects they taught, toward the end of the academic year. mothers’ activities continued during this period. they received additional workshops on nutrition, followed by physical activity, reaching a total of four mothers’ workshops during the academic year in each of the schools. finally, the mothers participated in the school’s health activities, such as the open health day. school environment was addressed by the beginning of the second academic year of the program; all the schools except for the private school had decorated their schoolyards. at the completion of the 18 months’ intervention, the pa, jm, unrwa and private schools had successfully participated in the various intervention activities, including the school strategies and structure, the teachers’ trainings, and mothers’ workshops. however, when it came to implementing the school supportive environment, the private school did not sustain the morning announcements or decorate the hallways. they also did not decorate the school yard with games, or take part in changing the food products at the canteen. this put the private school at 55% completion of the school supportive environment activities while the other schools all reached the 100% completion. learning from success as mentioned earlier, interviews were conducted at the end of the intervention as part of the process evaluation in order to learn from the most successful school’s practices. the following insights were obtained: interviews with the school principals: a. school principals reported that their full support and commitment as well as the teachers’ support were of great impact to the success of the program. b. they also reported that parents played a crucial role in supporting the programs’ activities. parents helped decorate the hallways, covered the costs of printing the healthy messages, and participated in the workshops and open health days at the schools. c. school principals reported that the schoolchildren were eager to play a main role in the program. as such, they were motivated to compete to get more points on the checklist, or to be chosen to give the morning announcements. nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 11 | 16 d. according to the school principals, the program had a considerable overall impact on the school environment, the schoolchildren, and their lives inside and outside of school. interviews with the health steering committee: a. according to the health steering committee, the school principals’ full support, commitment and provision of the needed equipment was paramount. b. the health steering committee also reported that team spirit among teachers was a crucial factor to the program’s success. c. finally, the health steering committee noted that the physical education and science teachers were particularly active on the school health steering committee and played a main role in implementing the program. interviews with the mothers: a. the mothers were convinced of the health benefits and the program's positive impact on them, their daughters and whole family; as such, they were fully supportive of the program and showed increased interest in ensuring that their children consumed healthy food. b. the mothers felt involved in the program’s activities and were committed to implementing their new knowledge with their families and in their homes. c. the mothers ate breakfast daily with their children, especially once their daughters began requesting this. d. educating the mothers on the topic of nutrition, and on the impact of healthy nutrition on decreasing overweight and obesity, further improved their implementation. discussion during this 18-month randomized controlled trial of a school-based health promotion intervention, the process evaluation which monitored implementation was essential for understanding how the program worked, whether it had worked as planned, and identifying the challenges and achievements associated with implementation. building school capacity for implementing a sustainable health promotion program is known to be a long-term process (13,14). the process evaluation during the program helped the staff appreciate that each school needed a different time frame for understanding, applying, and implementing the program. environmental interventions presented one of the challenges, as decorating the hallways and yards—one of the program activities— could not take place at the pa schools before the second year as the schools were undergoing renovations at the end of the first school year. the private schools chose not to implement many of the environmental aspects of the program. as these schools are private businesses, there may have been economic factors that entered into the decision. it is important to note that several of the schools had already been made aware of the aspects of the health promotion program through municipality programs designed to encourage “health promoting schools.” there were training sessions available for individual teachers through standard inservice training; however, these training activities did not provide the specific tools necessary for designing, creating and building a program. nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 12 | 16 as the program progressed, the school health steering committee implemented its roles and duties more effectively by creating and instituting additional health activities after each meeting, which took place every 4–6 weeks. according to the literature, the sustainability of an intervention program depends greatly on the school health committee's role in planning and implementing the program (15,16). the incorporation of physical education and science teachers as part of the health steering committee was identified as a positive influence, as they both understood the material and were able to incorporate the program’s activities in their classes. differences have been reported in teachers’ ability to apply health education programs successfully (18), and science and physical education teachers in particular have been found to be most effective in teaching health related topics (19). through our study, we were able to observe that when the schoolchildren began eating in class as part of the “active break” intervention, they were directly encouraged by their teachers to consume healthier food products and to decrease their intake of less healthy foods such as salty snacks, chocolates, and sweetened juices (20). teachers also began eating foods both in school and at home that were healthier, consuming breakfast and more fruits and vegetables in order to be positive role models for their schoolchildren. as part of our program, schoolchildren detailed their health habits according to the health promotion checklist, which included eating breakfast at home, drinking milk, and bringing a sandwich, water, and fruits and vegetables to school. in the process of rewarding their students, teachers themselves became more directed toward healthy practices. teacher training played a crucial role in the intervention program’s success, as seen in other studies (16,21). the provision of training to guide teachers in incorporating health information into their teaching, as well as offering specific guidance in planning interventions was perceived as an important factor. in this study, 80% of the teachers received training. this represents a better coverage than the 50% of the teachers who received training in a program instituted in hong kong (22). also, our intervention study aimed to train the largest possible number of targeted teachers, whereas the hong kong study aimed to train at least one teacher in each school (23). in the second semester, additional training was encouraged by the administration and the principals at all of the schools, and was attended by all the teachers. here too, the private school was the exception, with very low participation in training by the teachers at this school. a systematic review showed that in 30 interventions which included training for teachers, 25 of the interventions showed statistically significant results in improving fundamental movement skills and physical activity among the schoolchildren (24). an additional study showed that when teachers enjoyed the trainings they received in physical education and learned its impact on health, they decided to share the experience with their students in order to further promote physical activity (25). the qualitative assessment revealed that different components of the intervention program, involving the various dimensions of the ecological model, each contributed to meeting the program objectives and led to behavioral change (14). an important factor in the program’s success was the schoolchildren’s participation in planning, application, and implementation of the program. children were trained on how to nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 13 | 16 perform an active break, while selected students rotated responsibility for leadership of this period’s activities, with new students chosen every 3–4 weeks. since these changes had been planned by their classmates, students found it easier to accept them. the mothers’ involvement positively influenced the intervention’s success, as the mothers helped plan and implement the program. the mothers’ role began with participation in the school health steering committee. although the committee included only 3–4 mothers, each of them spread the information that was discussed at the meetings and being applied at the schools. mothers also attended the workshops held at each school and the mother-daughter activities (25,26). their role was most effective at the private school since the school did not implement all the required changes, particularly those at the canteen. since the mothers were interested in the program and its offerings, they attended all of the workshops and prepared the healthy meals/sandwiches for their daughters. schmied and his colleagues (28) suggested that participation of family members in the intervention increases the program's impact. all of the school staff (the principal, coordinator, teachers, and the owner of the canteen) as well as the parents demonstrated their full support for the program throughout its implementation period and expressed their commitment to continuing the program. during the regular visits to the schools, the researcher followed the activities and gave her feedback on the progress of the program and informed the team whether the intervention was going as planned or not. in general, through tracking participants’ experiences before, during, and after the intervention, process evaluation enhances sustainability as well as providing an accurate description for designing future projects (29). in summary, the factors that emerge from the process evaluation that promoted successful implementation of this program included the commitment and involvement of the principal and administration, training of a large percentage of the teachers rather than a single representative, involvement of mothers and children as well as teachers and administration, and follow up and encouragement on the part of the researcher. the private schools opted to implement a smaller percentage of interventions, possibly due to economic factors. limitations of this study this study is limited by the absence of process data from control schools. since these schools had been randomized to the no intervention condition, we were concerned that any data collection other than the pre post-questionnaire would be perceived as an intervention and adversely affect the control condition, and promote them to do better on their own. the comprehensive multi-sector design of the intervention did not permit an isolated assessment of the different factors of the intervention. the study is also limited by the fact that the researcher conducted the process evaluation, but this enabled direct insight to witness the implementation of the program. conclusion up-front design of the quantitative and qualitative process evaluation enabled a structured evaluation throughout the entire intervention and added insight as to variability and factors that enabled or obstructed timely execution of planned activities. the process evaluation indicated the intervention with its several components was implemented with successful results leading to the desired changes in the school nubani-husseini m, donchin m. school-based intervention to promote healthy nutrition and physical activity in palestinian girls process evaluation (original research). seejph 2020, posted: 15 april 2020. doi: 10.4119/seejph-3407 p a g e 14 | 16 environment and healthy habits of the participants. process evaluation further identified factors that will contribute to the sustainability of the intervention even when the researchers withdraw, and will facilitate the design of more effective interventions in the future. 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process evaluation to forecast use and sustainability of an intervention: theory and data from the efficacy trial for lunch is in the bag. heal educ behav 2017;44:559-69. ___________________________________________________________ https://doi.org/10.1007/s00038-012-0335-3 https://doi.org/10.1007/s00038-012-0335-3 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 1 original research ethnic differences in smoking behaviour: the situation of roma in eastern europe laetitia duval 1 , françois-charles wolff 2 , martin mckee 3 , bayard roberts 3 1 school of public health, imperial college london, norfolk place, london w2 1pg, united kingdom; 2 lemna, université de nantes, bp 52231 chemin de la censive du tertre, 44322 nantes cedex, france and ined, paris, france; 3 ecohost – the centre for health and social change, faculty of public health and policy, london school of hygiene and tropical medicine, london, united kingdom. corresponding author: laetitia duval, school of public health, imperial college london; address: norfolk place, london w2 1pg, united kingdom; e-mail: l.duval@imperial.ac.uk duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 2 abstract aim: to investigate ethnic differences in smoking between roma and non-roma and their determinants, including how discrimination faced by roma may influence smoking decisions. methods: we analysed data from the roma regional survey 2011 implemented in twelve countries of central and south-east europe with random samples of approximately 750 households in roma settlements and 350 households in nearby non-roma communities in each country. the overall sample comprises 11,373 individuals (8,234 roma) with a proportion of women of 57% and an average age of 36 years. statistical methods include marginal effects from probit and zero-truncated negative binomial estimates to explain cigarette consumption. results: we found that roma have a higher probability of smoking and are heavier smokers compared to otherwise comparable non-roma. these differences in smoking behaviour cannot purely be explained by the lower socio-economic situation of roma since the ethnic gap remains substantial once individual characteristics are controlled for. the probability of smoking is positively correlated with the degree of ethnic discrimination experienced by roma, especially when it is related to private or public health services. conclusions: by providing evidence on smoking behaviour between roma and non-roma in a large number of countries, our findings support the need to understand smoking behaviour of roma from a comparative perspective, and may ultimately contribute to more effective anti-smoking messages for roma. however, if the health disadvantage faced by roma is to be addressed adequately, this group must be involved more effectively in the policy and public health process. keywords: central and south-east europe, cigarette smoking, discrimination, ethnicity, roma. conflicts of interest: none. acknowledgements: we are indebted to one anonymous reviewer for very helpful comments and suggestions on a previous draft. funding statement: this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 3 introduction while much is now known about the determinants of smoking, relating both to individuals (such as gender, age, marital status, and socio-economic characteristics), and product characteristics (such as price, availability, and marketing) (1-9), there has been less attention to ethnic differences in smoking behaviour, even though tobacco control measures may need to take account of factors, such as health beliefs, that might influence the effectiveness of certain policies and messages (10-12). roma are the largest ethnic minority group in europe (estimated to number 10-12 million), most living in central and south-east europe (13). they suffer multiple disadvantages, with lower education, worse living conditions, and lower socio-economic status (14-17) and face discrimination in many areas of life, including barriers in accessing health services and health information (18-22). consequently, roma have worse health on many measures (15,17,19) than the majority populations in the same countries. research on the roma population has largely focused on communicable diseases and child health (18), but more recent contributions have also investigated non-communicable diseases and health care (17,23). however, there have been fewer studies on health behaviours, although those that have been conducted show increased prevalence of risk factors, including smoking (24,25). paulik and colleagues (23) report attitudes to tobacco control from a small cross-sectional survey, with only 83 roma and 126 non-roma, finding roma respondents reluctant to accept restrictions on tobacco use. petek and colleagues (26) conducted a small qualitative study of the meaning of smoking in roma communities in slovenia, but with only three women and nine men of roma origin. they reported how smoking is seen as part of the cultural identity of roma and is accepted by men, women and children, while invoking fatalism and inevitability to explain why smoking is not identified by roma interviewed as a threat to health (26). given growing recognition of the role of smoking-related disease in perpetuating or accentuating health inequalities and lack of evidence on tobacco use among roma, the aim of the present study is to investigate ethnic differences in smoking between roma and nonroma as well as their determinants, which includes how discrimination faced by roma may influence smoking. methods data and samples we use data from the roma regional survey, a cross-sectional household survey commissioned by the united nations development programme, the world bank and the european commission. further details on the survey methodology can be found at: http://www.eurasia.undp.org/content/rbec/en/home/ourwork/sustainabledevelopment/development-planning-and-inclusive-sustainable-growth/roma-in-central-andsoutheast-europe/roma-data.html the sample comprises both roma (n=9,207) and non-roma (n=4,274) households living in countries with high proportion of roma, namely albania, bosnia and herzegovina, bulgaria, croatia, the czech republic, hungary, macedonia, moldova, montenegro, romania, serbia and slovakia. the survey was conducted from may to july 2011. the intention was to include roma living in distinct settlements and compare them with non-roma living nearby. given this intention, duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 4 it would have been inappropriate to compare what are known to be very deprived roma settlements (27) with the general population, which would include many affluent groups who have little in common with those living in the settlements. consequently, 350 non-roma households living in the same neighbourhood – defined as households living in close proximity, within 300 meters, of a roma settlement – were selected. a stratified cluster random sampling design was used. thus, the first stage sampling frame comprised known roma settlements, from which those to be included were sampled at random. then nonroma settlements nearby were selected, again at random. in the second sampling stage, households were randomly chosen with equal probability within each cluster for both populations. the method of data collection was face-to-face interviews at the respondent’s household. the overall sample comprised 13,481 households corresponding to 54,660 family members. among them, 9,207 households were roma (68.3%) and 4,274 were non-roma (31.7%). we focus on the current smoking behaviour of respondents aged between 16 and 60 at the time of the survey. there is no information in the survey on past smoking decisions. this leaves us with a sample comprising 11,373 individuals, 8,234 of whom were roma (72.4%). the survey covers demographic characteristics, education, employment status, living standards, social values and norms, migration, discrimination, and health. socio-economic status is proxied using a household asset index. this aggregate index is derived from a principal component analysis of a list of household possessions following the methodology described by filmer et al. (28). the list of items included comprises radio receiver, colour tv, bicycle or motorbike, car/van for private use, horse, computer, internet connection, mobile phone or landline, washing machine, bed for each household member including infants, thirty and more books except school books, and power generator. the principal component technique was implemented on the entire sample, pooling roma and non-roma individuals. higher values of the asset index correspond to higher long-run socioeconomic status. the characteristics of respondents are summarised in table 1. table 1. descriptive statistics of the sample (n=11,373) variables (1) all respondents (2) roma respondents (3) non-roma respondents (4)p-value of (2)-(3) female 57,7% 57,8% 57,6% 0.848 age in years 36,0 35,0 38,8 0.000 in a couple 69,5% 71,4% 64,5% 0.000 divorced – separated 8,0% 7,9% 8,3% 0.473 widowed 5,0% 5,2% 4,7% 0.330 single 17,5% 15,6% 22,5% 0.000 household size (number of persons) 4,3 4,7 3,5 0.000 no formal education 18,4% 24,8% 1,6% 0.000 primary education 20,7% 26,4% 5,7% 0.000 lower secondary education 34,2% 36,9% 27,1% 0.000 upper/post-secondary education 26,7% 11,8% 65,7% 0.000 paid activity – self-employed 31,7% 25,8% 47,2% 0.000 homemaker – parental leave 19,7% 21,7% 14,2% 0.000 retired 5,2% 4,1% 8,2% 0.000 not working – other 43,4% 48,4% 30,4% 0.000 asset index (value) 0,0 -0,6 1,5 0.000 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 5 capital/district center 33,5% 33,0% 34,7% 0.103 town 26,1% 26,2% 25,8% 0.665 village/unregulated area 40,4% 40,8% 39,6% 0.238 number of respondents 11,373 8,234 3,139 source: authors’ calculations, undp/wb/ec regional roma survey 2011. about 58% are women and the average age is 36 years. on average, roma are younger than non-roma (35.0 versus 38.8). roma have lower educational attainment and are more likely to be outside the formal labour market. overall, scores on the asset index are worse for roma (-0.563 compared to 1.477 for the non-roma), although the scale of relative disadvantage varies, with the largest gaps in croatia, romania and bulgaria. for smoking behaviour, we used the two following questions. first, respondents indicated whether they smoked or not at the time of the survey: “with regard to smoking cigarettes, cigars, or a pipe, which of the following applies to you?”. possible answers were “i currently smoke daily”, “i currently smoke occasionally”, “i used to smoke but have stopped” and “i have never smoked”. second, those reporting one of the first two answers (either daily or occasionally) were asked: “on average, how many cigarettes, manufactured or hand-rolled do you smoke each day?”. note that it may be more difficult for occasional smokers to assess their daily consumption. to examine the role of discrimination, we used the three following questions: i) “does your household have a doctor to approach when needed?”; ii) “do you feel safe in regards health protection – do you have the confidence that you will receive service in case you need it?”; and iii) “were there any instances in the past 12 months when your household could not afford purchasing medicines prescribed to, needed for a member of your household?”. we also included in our regressions variables from a specific section about general discrimination and rights awareness. discrimination is defined as being treated less favourably than others because of a specific personal feature such as age, gender or minority background. selfassessed discrimination was assessed with the following question: “in the past 12 months (or since you have been in the country), have you personally felt discriminated against on the basis of one or more of the following grounds: a) because of ethnicity for non-roma, because you are a roma for roma, b) because you are a woman/man, c) because of your age, d) because of your disability, e) for another reason”. finally, we investigated the role played by access to health care system using answers to the following question: “during the last five years; have you ever been discriminated against by people working in public or private health services? that could be anyone, such as receptionist, nurse or doctor.” the reason attributed to the discrimination was specified: it could be either a discrimination on the basis of ethnic background or a discrimination because of other reasons. statistical analysis we analysed the determinants of smoking behaviour both in terms of smokers versus nonsmokers and number of cigarettes among smokers. to isolate as far as possible the role of ethnicity, we adjusted for the following individual characteristics, available for each household member: gender, age, marital status, household size, education level, asset index, occupation and location (capital or district centre, town, village or rural area). we compared the pattern of smoking not only by ethnicity, but also by country to account for the potential role of country-specific factors such as tobacco price. as an initial comparison duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 6 showed that roma were, as expected, materially worse off, we turned to an econometric analysis to explain both the decision to smoke and the consumption of cigarettes among smokers. we began with an investigation of the determinants of the probability of smoking using probit regressions, with marginal effects for various specifications (table 3). we also examined correlates of smoking intensity among smokers. since the dependent variable had non-negative integer values, we used count data models and estimated a zero-truncated negative binomial regression to account for over-dispersion as in (29,30). finally, we investigated the role of discrimination as a potential factor explaining the widespread smoking behaviour among the roma population (table 4). results determinants of cigarette consumption a comparison of cigarette consumption by ethnicity and country in table 2 shows that, while overall the proportion of smokers is 50.0%, there are substantial differences between countries. when pooling all countries, we found a much higher proportion of smokers among roma than non-roma (columns 2-4). the gap between these groups amounted to 15.5 percentage points. the prevalence differential was greatest in the czech republic (+31.4 points for roma), followed by hungary (+23.7 points), slovakia (+22.7 points) and bosnia and herzegovina (+22.6 points). conversely, there was no significant difference between roma and non-roma in bulgaria, macedonia and montenegro. the situation was a little different in terms of intensity of smoking. there were significant differences in daily number of cigarettes (among smokers) between roma and non-roma in only four countries: czech republic (+3.8 cigarettes for roma), bosnia and herzegovina (+3.1 cigarettes), slovakia (+1.6 cigarettes) and moldova (-5.1 cigarettes). table 2. cigarette consumption, by ethnicity and country country proportion of current smokers (in %) cigarette consumption among smokers (1) all (2) roma (3) nonroma (4)p-value of (2)-(3) (5) all (6) roma (7) nonroma (8)=p-value of (6)-(7) albania 33.5 36.6 26.5 0.002 17.7 17.7 17.5 0.832 bosnia and herzegovina 54.6 61.1 38.5 0.000 21.2 21.8 18.7 0.009 bulgaria 51.7 53.3 46.8 0.108 12.0 11.8 12.9 0.233 croatia 57.3 64.1 38.4 0.000 16.1 16.2 15.5 0.766 czech republic 68.7 78.0 46.6 0.000 15.1 15.9 12.1 0.000 hungary 55.2 61.3 37.6 0.000 15.5 15.4 16.1 0.469 macedonia 42.1 43.2 39.3 0.279 17.2 17.4 16.6 0.443 moldova 29.8 33.5 19.4 0.000 16.7 15.9 21.0 0.004 montenegro 42.5 42.4 42.7 0.946 22.3 22.8 21.0 0.057 romania 46.7 50.5 34.8 0.000 12.8 12.8 12.8 0.728 serbia 58.9 61.7 51.5 0.004 18.4 18.3 18.7 0.627 slovakia 57.4 64.2 41.5 0.000 14.2 14.5 12.9 0.005 all countries 50.0 54.2 38.7 0.000 16.5 16.7 16.2 0.139 source: authors’ calculations, undp/wb/ec regional roma survey 2011. we examined the role of individual characteristics in explaining differences in cigarette consumption between roma and non-roma. as shown in column 1a of table 3, we found a positive correlation between the ethnic dummy and the smoking decision. at the sample means, the probability of smoking was 16.1 percentage points higher among roma compared duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 7 to non-roma. this marginal effect accounted for the role of country heterogeneity. the country dummies in the regression captured the influence of differences in tobacco prices as well as other unobserved differences in anti-smoking policies or tobacco advertising. next, we accounted for by individual characteristics, given the demographic and socioeconomic differences in roma and non-roma respondents (column 2a). our main result was that the roma dummy was still positively correlated with the propensity to smoke at the one per cent level of significance. however, controlling for differences in respondents’ characteristics strongly reduced the marginal effect of ethnic origin. being roma was now associated with an increase of 8.5 percentage points in the probability of smoking. we also estimated separate regressions for each ethnic group (columns 3a and 4a). many covariates such as gender, age, household size or education had a similar influence on the likelihood of smoking among roma and non-roma, but we noted some differences. for instance, the marginal effect associated with the asset index was three times higher for nonroma compared to roma. similarly, having a paid activity and being homemaker were significantly correlated with probability of smoking (respectively positively and negatively) only for non-roma. in column 1b, we found a positive correlation between roma origin and cigarette consumption. in column 2b, the positive effect of roma origin was still significant (at the five percent level) once individual characteristics were controlled for. table 3. probit and zero-truncated negative binomial estimates of cigarette consumption – marginal effects variables probability of smoking cigarette consumption among smokers (1a) all (2a) all (3a) roma (4a) non-roma (1b) all (2b) all (3b) roma (4b) non-roma roma 0.161** 0.085** 0.734* 0.927* (15.15) (5.91) (2.39) (2.49) female -0.138** -0.125** -0.166** -2.784** -2.892** -2.034** (-12.69) (-9.60) (-8.64) (-9.82) (-8.76) (-3.65) age 21-30 0.090** 0.067** 0.143** 2.374** 2.123** 3.587* (ref: ≤20) (4.85) (3.26) (3.35) (4.33) (3.59) (2.37) 31-40 0.123** 0.105** 0.128** 3.214** 2.800** 4.896** (6.28) (4.86) (2.81) (5.53) (4.48) (3.01) 41-50 0.157** 0.158** 0.129** 4.168** 3.993** 5.090** (7.61) (6.87) (2.75) (6.44) (5.65) (2.98) 51-60 0.119** 0.117** 0.090 4.103** 3.485** 6.028** (5.32) (4.63) (1.85) (5.83) (4.54) (3.29) marital status divorced – separated 0.035 0.042 0.031 0.508 0.577 0.392 (ref: in a couple) (1.87) (1.93) (0.92) (1.07) (1.06) (0.41) widowed 0.032 0.035 0.004 -0.050 -0.204 1.153 (1.32) (1.26) (0.09) (-0.08) (-0.30) (0.77) single -0.031* -0.041* -0.057* -0.185 -0.724 1.205 (-2.00) (-2.19) (-2.08) (-0.47) (-1.59) (1.48) household size 0.007** 0.006* 0.015* 0.085 0.107 -0.017 (2.81) (2.09) (2.30) (1.36) (1.60) (-0.09) education primary 0.002 -0.001 -0.110 -0.958* -1.040** -0.273 (ref: no formal) (0.15) (-0.08) (-1.48) (-2.48) (-2.60) (-0.13) lower secondary -0.008 -0.028 -0.102 -1.071** -1.337** -0.688 (-0.55) (-1.68) (-1.44) (-2.77) (-3.25) (-0.38) upper/post-secondary -0.061** -0.090** -0.138 -1.459** -1.595** -0.593 (-3.17) (-3.95) (-1.89) (-3.08) (-3.04) (-0.31) activity paid activity – self-employed 0.023 0.021 0.039 0.188 0.262 0.397 (ref: not working – other) (1.81) (1.43) (1.66) (0.60) (0.72) (0.62) homemaker – parental leave -0.019 -0.013 -0.065* -0.511 -0.615 0.256 (-1.35) (-0.83) (-2.11) (-1.37) (-1.52) (0.26) retired -0.089** -0.071* -0.098* -1.098 -0.925 -1.331 (-3.58) (-2.22) (-2.56) (-1.73) (-1.21) (-1.16) asset index -0.026** -0.016** -0.048** 0.189* 0.266** -0.101 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 8 (-7.62) (-4.00) (-7.58) (2.15) (2.63) (-0.56) location town -0.040** -0.050** 0.001 -1.445** -1.570** -1.112 (ref: capital/district center) (-2.96) (-3.14) (0.03) (-4.38) (-4.19) (-1.61) village/unregulated area -0.049** -0.039** -0.059* -2.186** -2.360** -1.437* (-3.81) (-2.63) (-2.50) (-6.87) (-6.53) (-2.15) country dummies yes yes yes yes yes yes yes yes number of respondents 11,373 11,373 8,234 3,139 5,682 5,682 4,466 1,216 source: authors’ calculations, undp/wb/ec regional roma survey 2011. note: the probability of smoking is explained using a probit model, the cigarette consumption among smokers is explained using a zero-truncated negative binomial model. significance levels are p<0.01 (**) and p<0.05 (*). when comparing the estimates obtained separately on the roma and non-roma samples (columns 3b and 4b), the correlation between consumption of cigarettes and gender, age as well as location had the same sign for both ethnic groups. conversely, we observed some differences in the role of education and asset index among smokers. first, the negative correlation between education and cigarettes was only significant for roma. second, we found a positive correlation between consumption of cigarettes and the asset index only for roma. as roma are economically disadvantaged, only those with adequate resources will be able to purchase and smoke cigarettes. finally, we estimated country-specific regressions. for ease of interpretation, we presented the marginal effect associated with the roma dummy (figure 1). figure 1. the gap in smoking between roma and non-roma, by country a. probability of smoking b. cigarette consumption among smokers -5 0 5 10 15 20 25 r o m a g a p m a rg in a l e ff e c t (p ro b . in % ) bosnia and herzegovina czech republic hungary croatia romania moldova slovakia albania serbia montenegro bulgaria macedonia duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 9 source: authors’ calculations, undp/wb/ec regional roma survey 2011. the probability of smoking was 24.1 percentage points higher among roma than non-roma in bosnia and herzegovina. the gap was significant in seven other countries: by decreasing order of magnitude, the czech republic (19.7 percentage points), hungary (15.6), croatia (13.7), romania (13.7), moldova (12.5), slovakia (7.1) and albania (2.8). roma consumed 3.8 additional cigarettes per day in the czech republic compared to non-roma smokers. the situation was very similar in bosnia and herzegovina (+3.7 cigarettes), slovakia (2.7), romania (1.3) and montenegro (1.1). smoking and discrimination the proportion of respondents who felt discriminated against because of ethnicity was much higher among roma (34.6%) than non-roma (4.9%) (+29.7 percentage points). the ethnic differential was lower but still significant when considering other forms of discrimination: +6.9 points because of gender (8.3% for roma compared to 3.1% for non-roma), +1.9 points because of age (6.2% against 4.3%) and +1.8 points because of disability (3.6% against 1.8%). when pooling the various reasons, the ethnic gap amounted to 26 percentage points (36.7% against 16.7%). we added indicators of health inequalities to our previous regressions explaining smoking decisions (panel a of table 4). table 4. discrimination and cigarette consumption – marginal effects from probit and zerotruncated negative binomial models variables probability of smoking cigarette consumption among smokers (1a) all (2a) all (3a) roma (4a) nonroma (1b) all (2b) all (3b) roma (4b) nonroma panel a: roma 0.085** 0.081** 0.927* 0.920* (5.91) (5.63) (2.49) (2.47) -4 -2 0 2 4 r o m a g a p m a rg in a l e ff e c t (c ig a re tt e s ) czech republic bosnia and herzegovina slovakia romania montenegro macedonia serbia croatia hungary bulgaria moldova albania duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 10 doctor to approach when needed 0.037* 0.033 0.050 0.211 0.336 -0.826 (2.23) (1.82) (1.31) (0.50) (0.74) (-0.69) feel safe in regards health protection -0.015 -0.015 -0.012 -0.219 -0.155 -0.401 (-1.11) (-0.95) (-0.44) (-0.63) (-0.41) (-0.49) cannot afford purchasing medicine prescribed 0.032** 0.028* 0.033 0.027 0.012 0.258 (2.92) (2.34) (1.46) (0.10) (0.04) (0.40) control variables yes yes yes yes yes yes yes yes number of respondents 11,373 11,373 8,234 3,139 5,682 5,682 4,466 1,216 panel b: roma 0.085** 0.077** 0.927* 0.828* (5.91) (5.27) (2.49) (2.19) discriminated against in the past 12 months 0.041** 0.034** 0.045 0.482 0.450 0.269 (3.62) (2.80) (1.55) (1.67) (1.46) (0.32) control variables yes yes yes yes yes yes yes yes number of respondents 11,373 11,373 8,234 3,139 5,682 5,682 4,466 1,216 panel c: roma 0.085** 0.072** 0.927* 0.825* (5.91) (4.93) (2.49) (2.17) discriminated against in the past 12 months 0.059** 0.060** -0.001 0.399 0.187 1.582 because of ethnicity (4.62) (4.40) (-0.02) (1.26) (0.56) (1.23) discriminated against in the past 12 months -0.038* -0.058** 0.043 0.172 0.482 -1.376 because of other reasons (-2.30) (-3.10) (1.21) (0.41) (1.03) (-1.50) control variables yes yes yes yes yes yes yes yes number of respondents 11,373 11,373 8,234 3,139 5,682 5,682 4,466 1,216 panel d: roma 0.085** 0.079** 0.927* 0.891* (5.91) (5.46) (2.49) (2.38) discriminated against by people working in health 0.078** 0.072** 0.057 0.467 0.238 3.901 servicesbecause of ethnicity (4.29) (3.84) (0.79) (1.06) (0.53) (1.54) discriminated against by people working in health -0.053 -0.060 -0.035 -0.409 0.146 -4.160* servicesbecause of other reasons (-1.79) (-1.84) (-0.49) (-0.55) (0.18) (-2.41) control variables yes yes yes yes yes yes yes yes number of respondents 11,373 11,373 8,234 3,139 5,682 5,682 4,466 1,216 source: authors’ calculations, undp/wb/ec regional roma survey 2011. note: the probability of smoking is explained using a probit model, the cigarette consumption among smokers is explained using a zero-truncated negative binomial model. significance levels are p<0.01 (**) and p<0.05 (*). we found that people who could approach a doctor when needed has a higher probability of smoking (column 2a). this result is seemingly counterintuitive but it may be that those living in areas with access to a doctor have higher (unobserved) levels of income or can more easily buy cigarettes. however, there may also be reverse causation as smokers are likely to have more health problems and thus more frequent interactions with doctors. while feeling safe had no influence on smoking, the correlation between probability of smoking and inability to purchase medicines prescribed was positive for roma respondents only (column 3a). none of our indicators of health inequalities had an influence on intensity of cigarette consumption among smokers. in panel b of table 4, we found a positive correlation between smoking behaviour and feeling of discrimination (whatever its reason). the probability of smoking increased by 4.1 percentage points for those who felt discriminated against (column 2a). the role played by discrimination was mainly observed in terms of probability rather than intensity of smoking. the correlation between discrimination and cigarette consumption among smokers was not significant when separating roma and non-roma (columns 2c and 2d).as shown in panel c, most of the effect came from discrimination on the basis of ethnic background. indeed, the coefficient associated with ethnic discrimination was positive and significant, but it was negative for other forms of discrimination. as a final step, we explored the correlation between smoking and discrimination in access to the health care system (panel d). the probability of smoking is higher among respondents duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 11 who felt discriminated against by people working in health services on ethnic grounds (+7.8 points). conversely, the correlation is negative for the other forms of discrimination (-5.3 points) while there was no significant relationship with smoking intensity. discussion in this paper we compared the smoking behaviour of roma and those in the majority population living nearby in twelve countries of central and south-east europe. the strengths of this study lie in the use of a large study sample across multiple countries. previous research on roma health tends to be restricted to a small number of countries, mainly hungary, the czech republic and slovakia (15,16,23,26), and which often use small sample sizes which make comparisons between roma and non-roma groups of population difficult. this study is, however, subject to a number of limitations. first, by design, it does not provide a representative sample of the roma population in the countries concerned. this is an inevitable and well-known problem facing all research on roma health, reflecting problems of defining the roma population (31). there are varying degrees of assimilation in each country and estimates of the roma population vary, reflecting in part the reason why a particular survey was undertaken and thus the incentive to self-identify as roma. furthermore, in some situations there may be strong disincentives to do so, given the previous experience of this population in their dealings with authority. for this reason, much of the existing research has adopted the approach used here, focussing on the most marginalised roma groups, and the most easily and consistently identifiable. second, the sample size in each country is relatively small, limiting the power to compare sub-groups. third, there is a need for qualitative research to understand better the place that smoking occupies within roma communities and the barriers that exist to reducing smoking rates. qualitative research has found that smoking is important in cultural and ethnic identity of roma, with smoking being introduced by older family members to younger ones. even where there is awareness of health risks associated with smoking, there is little willingness to consider quitting, to reduce exposure to second-hand smoke, or to prohibit children from smoking because it is considered part of growing up (23). policies that attempt to limit tobacco access to children or eliminate smoking in public places are rejected (26). fourth, some factors that might influence smoking behaviour are missing from the roma regional survey. for instance, we could not include household income in our regressions, although we were able to use an asset index, which captures household wealth. fifth, interpretation of findings on discrimination is complex. from an individual perspective, the perception of discrimination is a sensitive topic. feeling discriminated against is subjective and may be subject to justification bias. this would occur if roma respondents report being discriminated in order to justify their smoking decision. at the same time, according to the eu-midis report on discrimination argues, discrimination against roma seems to be largely unreported (32). finally, a limitation, inherent in the cross-sectional design, is that we are unable to show a causal association between discrimination and smoking. it may be that roma decide to smoke because they feel less accepted by the rest of the population, but their higher smoking prevalence may also be perceived as a potential signal of their ethnicity, as noted above. our findings show that roma respondents are more likely to smoke and are heavier smokers on average compared to non-roma (with substantial heterogeneity in the gap between the duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 12 two groups between countries).a recent study found no genetic basis for differences in smoking among roma and non-roma in hungary (33). now, this study shows that differences in smoking behaviour cannot simply be explained by the worse socio-economic situation of roma. first, the non-roma comparison population comprises those living in close proximity to roma settlements and not the general population. thus, our data will presumably underestimate the overall gap between the roma and non-roma population in each country. second, the ethnic gap remains substantial once individual characteristics are controlled for, although of course it is possible that our indicators do not fully capture relative disadvantage. importantly, this conclusion is consistent with another study using a different data set but similar methodology in hungary (34). we also find some positive correlation between the probability of smoking and discrimination reported by roma, especially with respect to private or public health services, but not in terms of smoking intensity. our findings support other literature on the disadvantage and discrimination faced by roma in central and south-east europe (13,15,21,22,35,36) with roma considered by some as the most discriminated against group in europe (32). this reinforces the importance of developing messages through a shared process, involving roma participation, and in ways that avoid stigmatisation, as part of comprehensive policies to tackle disadvantage and discrimination (37). conclusions to the best of our knowledge, this study is the first to provide comparative evidence on smoking behaviour between roma and non-roma in a large number of countries. our findings support the need to understand smoking behaviour of roma from a comparative perspective, and may ultimately contribute to improved anti-smoking policies towards roma. if roma health vulnerability is to be addressed adequately, efforts need to be concentrated on involving roma in the policy and public health process, including measures that specifically address the factors that lead to high rates of smoking in this multiply disadvantaged 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commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 1 original research health-related behaviour among managers of slovenian hospitals and institutes of public health jerneja farkas1,2, mitja lainscak2, andreja kukec1, mitja kosnik2 1 faculty of medicine, university of ljubljana, ljubljana, slovenia; 2 university clinic of respiratory and allergic diseases golnik, golnik, slovenia. corresponding author: jerneja farkas, md, phd, faculty of medicine, university of ljubljana; address: zaloska cesta 4, 1000 ljubljana, slovenia; telephone: +38615437566; e-mail: jerneja.farkas@mf.uni-lj.si mailto:jerneja.farkas@mf.uni-lj.si farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 2 abstract aim: behavioural risk factors have a significant impact on health. we aimed to assess healthrelated behaviour, health status, and use of healthcare services among managers of slovenian hospitals and institutes of public health. methods: this was a cross-sectional study which included management (directors, scientific directors, directors’ deputies) of slovenian hospitals and institutes of public health (63 respondents; 57% women; overall mean age: 51±7 years; response rate: 74%). data were obtained using an anonymous self-administered questionnaire. results: about 35% of respondents were directors. more than half of the respondents were overweight or obese (52%), the majority were not sufficiently physically active (59%) and overloaded with stress (87%). hypercholesterolemia (36%), spinal disease (17%), and arterial hypertension (16%) were most common chronic diseases. whilst only few participants visited their general practitioner due their health complaints, blood pressure (76%), cholesterol (51%), and glucose (54%) were measured within last year in most of the respondents. conclusion: our findings point to a high prevalence of overweight and obesity as well as workplace-related stress among slovenian public health managers. therefore, effective preventive strategies should be focused on stress management along with promotion of healthy behavioural patterns. keywords: behavioural risk factors, healthy lifestyle, health promotion, healthcare institutions, managers. farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 3 introduction behavioural risk factors such as smoking, excessive alcohol consumption, unhealthy diet, lack of physical activity, and stress have a significant impact on health. previous studies have shown that cardiovascular disease, cancer, diabetes mellitus and some other chronic diseases are main causes of morbidity and mortality in developed countries, which can be largely attributed to unhealthy lifestyle (1). in a large prospective randomized study (n=2,339), knoops and colleagues clearly indicated that individuals who followed the principles of the mediterranean diet, consumed alcohol moderately, were regularly physically active, and refrained from smoking, had significantly lower cardiovascular and cancer mortality when compared to those with at least one behavioural risk factor (2). significant changes in employment policies that have emerged recently have exposed employees to new risks in terms of workplace safety and health. these are not limited to physical, biological and chemical risks, but expand to work-related psychosocial risk in particular (1,3). funding restrictions, constant need for cost reduction, implementation of modern technology and clinical guidelines, as well as increased patient awareness and expectations increase the burden and responsibilities hospital managers need to cope with (3). sounan and colleagues reported about negative associations between performance and health of hospital managers with workload, stress, psychical burden, and burnout they are exposed to (4). furthermore, studies have shown that individual lifestyle pattern of managers also influences attitudes towards preventive activities and health promotion in the organisations they are employed in (5-8). in slovenia, there is scarce information about health-related behaviour and health status of healthcare institution managers. in 2005, stergar and urdih-lazar conducted a survey among slovenian managers about their attitudes towards own and employees’ health and their willingness to implement health promotion programs (9). they mailed 5,500 questionnaires to large, medium and small enterprises and public institutions (including healthcare institutions) and received reply from about one third. respondents were willing to take measures in different lifestyle areas, primarily in the fields of diet, physical activity, and weight management. more than two thirds, mostly those who already had health promotion in place and those who considered there is room for improvement of employees’ health, would take health promotion actions and would be involved personally (9). individual health-related behaviour and healthy lifestyle pattern can translate to wider community, in particular if the individual is in position and has capacity to involve appropriate mechanisms. healthcare institutions should serve as an example for preventive strategies and healthy lifestyle, which should be promoted and organized from a top-down perspective. with little available information, we aimed to assess health-related behaviour, health status and use of healthcare services among managers in slovenian hospitals and institutes of public health. our objectives were to have a snapshot of their daily habits, risk factor and disease burden, as well as their incentives to prevent diseases of modern age. methods study design and subjects in this cross-sectional study, we invited management (directors, scientific directors, directors’ deputies) of slovenian general hospitals, university clinics, regional institutes of public health and national institute of public health – figure 1. information on the composition of each healthcare institution management is publicly available and accessible through healthcare institutions’ websites; thus, we were able to invite all eligible subjects. farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 4 the study was conducted under auspices of slovenian network of health promoting hospitals and health services in collaboration with chair of public health, faculty of medicine, university of ljubljana. the study protocol was revised and approved by the national medical ethics committee. figure 1. healthcare institutions included in the study □ 1-regional institute of public health (riph) koper; 2-riph nova gorica; 3-riph kranj; 4-riph ljubljana; 5-national institute of public health of the republic of slovenia; 6-riph novo mesto; 7-riph celje; 8-riph ravne na koroskem; 9;riph maribor; 10;riph murska sobota. ○ 1-general hospital (gh) izola; 2-gh dr. franca derganca nova gorica; 3-gh jesenice; 4-university clinic of respiratory and allergic diseases golnik; 5-university medical centre ljubljana; 6-university rehabilitation institute of the republic of slovenia; 7-institute of oncology ljubljana; 8-gh novo mesto; 9-gh brezice; 10-gh trbovlje; 11-topolsica hospital; 12-gh slovenj gradec; 13-gh celje; 14-university medical centre maribor; 15-gh dr. jozeta potrca ptuj; 16-gh murska sobota. data collection the “countrywide integrated non-communicable disease intervention (cindi) health monitor core questionnaire”, a standardized, validated and publicly available questionnaire, previously used for national health-related behaviour studies in slovenia (10,11) was used to compile the study questionnaire. anonymity was provided for all participants. overall, 30 questions were organized into three sections: demographic and other basic characteristics, health-related behaviour (smoking status, dietary habits, alcohol intake, physical activity, body weight and height), and health status including use of healthcare services (self-rated health, care for health, healthcare services utilization, diseases, and medication use). questions regarding stress were also included. additionally, we inquired farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 5 about participants’ beliefs regarding the risk factor that predominantly contributes to poor health and high morbidity and mortality burden of the slovenian adult population. to reduce the risk for confounding responses the data collection was designed using a multiple-choice format with obligatory (required) items to be answered. in only five opened questions we inquired about year of birth, number of daily meals, body weight and height, and number of days per week and duration of physical exercise (all numerical values). questionnaires were mailed during april 2012 with study description, an invitation for study participation, and preaddressed return envelope. to enhance the study response, a gentle reminder notice was sent to all participants twice after first invitation and served as acknowledgement of participation (if individuals already responded), or as reminder to complete the questionnaire (if they did not respond to the initial invitation). one unit of fruit or vegetables corresponded to 100g of fruit or vegetables (e.g. two tomatoes, or one bowl of salad, or one pot of turnip for vegetables; one middle sized apple, or one small banana, or one pot of cherries for fruits), as already used previously (10). body mass index (bmi) was calculated as body weight in kilograms divided by square of body height in meters. malnutrition was defined as bmi<18.49 kg/m2, normal nutritional status as 18.50-24.99 kg/m2, overweight as 25.0-29.99 kg/m2, and obesity as >30.0 kg/m2 (12). we inquired about leisure-time physical activity, including type and intensity of exercise (vigorous intensity: aerobics, running; moderate intensity: brisk walking, slow swimming; low intensity: walking), usual number of days with activity per week, and usual duration of exercise (less than, or more than 30 minutes). as per world health organisation (who) recommendations, at least 150 minutes of moderate or more intensive exercise was considered as beneficial for health (13), and subjects were divided into two groups by this cut-off. when asked about contacts with their general practitioner or specialist, only visits related to personal issues were relevant for this study. statistical analysis descriptive statistics were used to present mean values and their respective standard deviations for the numerical variables, and absolute numbers and their respective proportions for the categorical variables. spss, version 19.0 (statistical package for social sciences, spss inc., chicago, illinois, usa) was used for all the statistical analyses. results response rate and study participants’ characteristics we mailed 85 questionnaires to all eligible management members, and received 66 responses (77.6%). of those, three questionnaires were incomplete; thus, our final sample consisted of 63 (74.1%) subjects with an average age of 51.3±7.5 years. most of them were women (57.1%), with at least a university degree (92.1%), and were acting as a director (34.9%). other basic characteristics of study participants are presented in table 1. health-related behaviour most of respondents never smoked (68.3%), whereas 12.7% were current smokers. three daily meals was the most common type of dietary pattern (50.8%), whilst 20.6% and 7.9% of respondents consumed two or five meals, respectively. when consuming dairy products, 74.6% would usually select low-fat products. whole-grain (27.0%), various sorts (25.4%) and white (15.9%) would usually be the first choice of bread. almost two thirds of respondents (63.5%) consumed daily 1-3 units of vegetables and 1-3 units of fruit. most of respondents farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 6 never used salt for served food (57.1%), and the rest would taste food prior to any additional salt. during last year, 19 (30.2%) respondents consumed alcohol few times yearly, 15 (23.8%) consumed alcohol twice a week, and 6 (9.5%) of respondents abstained completely. mean bmi was 25.2±4.2 kg/m2, with 28 (44.4%) subjects being overweight and 5 (7.9%) obese; 50.8% were satisfied with their weight, whereas 30 (47.6%) would have liked to lose weight. car was a usual means of transport for most of respondents (84.1%), and only 7.9% walked or ride a bike to workplace. very intense exercise was not practiced by 28 (44.4%), and the rest were usually active for >30 minutes per session, but mostly only once per week. most individuals (49.2%) practiced moderate exercise up to three times/week, for >30 minutes (63.6%). walking at least five times/week (65.0% of them for >30 minutes) was practiced by 17.5% of participants. who’s criteria for healthy physical activity were not met by 58.7% of respondents. table 1. basic characteristics of study participants basic characteristics number (column percentage) sex: women men 36 (57.1) 27 (42.9) age: 30-39 years 40-49 years 50-59 years 60-69 years 5 (8.0) 18 (28.7) 33 (52.4) 7 (11.2) marital status: married consensual union single divorced widowed 46 (73.0) 7 (11.1) 6 (9.5) 4 (6.3) 0 (0) education: secondary college university master or doctoral degree 1 (1.6) 4 (6.3) 31 (49.2) 27 (42.9) position: director scientific director deputy, nursing deputy, other 22 (34.9) 11 (17.5) 13 (20.6) 17 (27.0) residence community: urban suburban rural 33 (52.4) 16 (25.4) 14 (22.2) tension or stress was reported as daily, frequent and occasional experience by 6.3%, 31.7% and 49.2% of respondents, respectively. workplace was the main cause of stress (73.0%), followed by poor relations with co-workers (20.6%) and family issues (6.3%). figure 2 presents how respondents cope with stress. holiday leave pattern was balanced as 52.4% take few days several times per year and the rest prefers a longer leave. farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 7 we also inquired about participants’ beliefs regarding importance of risk factors for poor health, morbidity and mortality burden in slovenia (figure 3). figure 2. management of tensions, stress and pressures figure 3. the risk factor that predominantly contributes to poor health and high mortality of the adult population in slovenia farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 8 health status and use of healthcare services most of respondents rated their health as good (68.3%), or very good (19.0%). more than half (58.7%) considered they took sufficient care for their health, whereas about a third (28.6%) deemed their care as inadequate. during past year, 50.8% did not see their general practitioner or specialist, 44.4% cumulated three visits, and 4.8% had four or more visits. table 2 summarizes the prevalence of diseases or conditions diagnosed by a doctor and figure 4 provides information about various diagnostic tests. in the week prior to study, 63.5% of respondents regularly took one medication, 25.4% had two, and 9.5% had three drugs. vitamins and minerals (44.4%), medications against headache (27.0%), herbal medications (19.0%), antihypertensives (15.9%) and hypolipemics (12.7%) were the most commonly used medications. table 2. prevalence of diseases or conditions in study participants diagnosed by a doctor discussion among slovenian healthcare institution management, insufficient physical activity, overweight, and stress associated with workplace were most common behavioural risk factors. most of respondents assessed chronic disease risk factors within last three years, perceived their health as good or better and considered they take sufficient care of their health. the most common disease was hypercholesterolemia, with a prevalence higher than the prescription of hypolipemic medications. in comparison to results of “cindi health monitor survey 2008” (n=7,352, aged 25-74 years) managers in our study were somewhat more likely to report healthy dietary habits (e.g. low-fat dairy products, whole-grain bread, several units of fruit and vegetable daily) than the slovenian general population, with no difference in number of daily meals (14). additionally, managers in our study performed less often leisure-time physical activity, whilst frequent or daily exposure to stress was more common and usually associated with workplace burden and poor relations with co-workers. disease or condition number (percentage) arterial hypertension 10 (15.9) hypercholesterolemia 23 (36.5) diabetes mellitus 2 (3.2) myocardial infarction 1 (1.6) angina pectoris 0 (0) heart failure 0 (0) stroke 1 (1.6) diseases and injuries of spine 11 (17.5) arthritis or arthrosis 7 (11.1) chronic obstructive pulmonary disease 0 (0) asthma 3 (4.8) gastric or duodenal ulcer 1 (1.6) liver cirrhosis 0 (0) depression 0 (0) thyroid disease 1 (1.6) farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 9 many healthcare institution managers have medical background thus comparison with previous reports of healthcare workers are possible. fortic reported about regular smoking prevalence in the period 1972-1986, which was 30% among male healthcare workers and 20% among female healthcare workers (15). a recent slovenian national institute of public health study showed that 20.9% of healthcare workers are regular smokers, which is lower than a decade ago, and also lower than among general population. about half (52.9%) started smoking during the secondary school, but 15.6% started during the first years of work in a healthcare institution. moreover, about a quarter reported that employees in their institution are not following the smoking ban (16). similar information about smoking prevalence among healthcare workers is evident from greece, spain, portugal, france, and poland, with figures being the same or higher than among the general population (17). our findings (12.7%), however, are more comparable to a lifestyle survey among 1,770 italian cardiologists (12.4%), which in both cases is relevant and somehow balances inadequate physical activity and exposure to stress (18). figure 4. time periods in which study participants completed various diagnostic tests *women only; **men only. although most slovenian managers would like to stay physically active, this is mostly sporadic or limited to sport and recreational events. the latter is also driven with competitiveness; yet, the results usually are below expectations. importantly, balanced lifestyle with daily physical activity, healthy diet, and relaxation is the key to success and farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 10 satisfaction with daily work (19). our findings are in line with previous reports, as high intensity exercise was sporadic, and moderate intensity exercise was not meeting the quantity goal for health benefits. moreover, overweight or obesity was present in more than half of our respondents, as was dissatisfaction with body weight. european survey of enterprises on new and emerging risks (esener) showed that workplace related stress often induces issues for managers in healthcare and social sector (3). jericek et al. reported an association between stress and healthcare institution workplace specifics, including conflicts among co-workers, potential lack of skills and knowledge needed for patient care, and ever increasing expectations of patients and public (20). similar is mirrored by our finding that as many as 93.6% of respondents reported workplace-related stress that is difficult to manage. it is therefore not surprising that stress (followed by smoking and lack of physical activity) was identified as the most important risk factor contributing to poor health and high mortality among slovenian adult population. to tackle this burden, martincic emphasizes risk management strategies as well as communication, management and coordination skills, along with teamwork and regular assessment of organisational aspects (21). top managers need to recognize safety and health aspects over economical issues, which follows a general strategy in an institution or enterprise (22). healthcare workers need to be aware of their role model in promotion of healthy lifestyles, which also provides additional credibility in daily professional routine (23,24). it is wellknown that healthcare workers, who personally follow healthy lifestyle measures, are more in favour of health promotion and disease prevention activities in their clinical practice (18,2527). in a survey that included 496 swiss doctors, cornuz and colleagues reported that personal lifestyle (more than three units of alcohol daily, sedentary lifestyle, and poor awareness about arterial hypertension) predicted a lower chance of alcohol and smoking advice delivered to the patients (23). howe and colleagues studied personal health behaviours of 183 american hospital doctors in association with patient-related lifestyle counselling and reported an association between regular physical activity (>150min/week) and patient advice to exercise regularly and follow healthy diet (24). similar to this, healthcare institution managers have a similar role model and should give personal examples to foster recognition of preventive activities and health promotion among co-workers and patients. therefore, healthcare institutions have a certain degree of societal responsibility against patients and caregivers, employees, and local community. thus, they should act accordingly (5,6). according to reports of international network of health promoting hospitals and health services, hospital management attitudes are crucial for clinical health promotion among patients, implementation of health promotion activities for employees and quality control (58). we corroborated a previous report by stergar and urdih-lazar (9) for self-rated health, which predominantly was good or better; this is in contrast with results among the general population, where the proportion with good or better self-rated health is halved (14,28), whereas there is little difference in attitudes towards health (14). exact reasons are unknown but could be associated with better socioeconomic status and possibilities to implement healthy lifestyles. chronic diseases like hypercholesterolemia, spinal disease, and arterial hypertension were the most prevalent among our respondents. most of these conditions would require management; yet, the extent of pharmacological therapy was not meeting the epidemiological situation. it may well be that non-pharmacological measures were in place or patients did not meet the risk profile for treatment initiation. it could also be due to personal preferences or discontinuation of therapy. whilst most have had their risk factors assessed within last year, more than half of individuals had no appointment at their general practitioner or specialist. farkas j, lainscak m, kukec a, kosnik m. health-related behaviour among managers of slovenian hospitals and institutes of public health (original research). seejph 2014, posted: 02 june 2014. doi 10.12908/seejph-2014-24 11 managers usually attend their regular health check-ups (every 3-4 years) and in-between these visits, they prefer to have specialist assessment (e.g. cardiologist, sonography, etc.) but rarely make an appointment with their general practitioner (19). average age likely influenced screening for breast cancer, as almost two-thirds had no mammography (available for women between 50-69 years), and cervical carcinoma, with less than half having an exam within last year (29,30). screening for occult gastrointestinal bleeding, colonoscopy and measurement of prostate specific antigen was less common; whilst, this could be a procedure related for colonoscopy, no evident reason for the others was present. our results need to be interpreted in the context of available information and some limitations. cross-sectional studies in the field are lacking thus our findings contribute to present knowledge and action strategies. it also identifies issues that need more investigation to gain additional insight into health-related behaviours, health status, and use of healthcare services among this population. although sample size can be regarded as modest, the response rate in relative terms was considerable. due to study design, selection and recall bias as well as socially desirable answers are possible, particularly for behavioural risk factors. finally, it would be more appropriate to compare our findings to subjects of similar educational level and socioeconomic status rather than to general population, but there are no available studies in the slovenian population. conclusion managers of slovenian hospitals and institutes of public health tend to keep a healthy diet, drink alcohol with moderation and rarely smoke. nonetheless, more than half were either overweight or obese, most did not meet physical activity levels for a good health and reported significant exposure to stress, primarily due to workplace and poor relations with co-workers. hypercholesterolemia, spinal disease and arterial hypertension were the most commonly reported diseases, but not all were treated. risk factor assessment but not actual visits within 12 months were reported for most of respondents. our results suggest there are some burning issues among slovenian healthcare institution managers that would need to be addressed. generally, healthy lifestyle should be promoted, with particular emphasis on stress management, the most prevalent and important workplacerelated risk factor. with individual awareness and positive attitudes towards personal health, community activities and interventions get more feasible, with potential implications for community risk and health profile. acknowledgement the authors would like to thank all managers who responded to this survey. we acknowledge the contribution of milena osojnik from university clinic of respiratory and allergic diseases golnik and the assistant professor irena grmek kosnik, md, phd from the institute of public health kranj for their help with the study. references 1. world health organization. preventing chronic diseases: a vital 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http://www.ncbi.nlm.nih.gov/pubmed/20860642 http://www.ncbi.nlm.nih.gov/pubmed/20860642 http://www.ncbi.nlm.nih.gov/pubmed/1983932 http://www.ncbi.nlm.nih.gov/pubmed/1983932 http://www.ncbi.nlm.nih.gov/pubmed/16563924 http://www.ncbi.nlm.nih.gov/pubmed/16563924 http://www.ncbi.nlm.nih.gov/pubmed/20033254 http://www.ncbi.nlm.nih.gov/pubmed/20033254 http://dora.onko-i.si/ http://zora.onko-i.si/ дългосрочна системна оценка на резултатите от лекарствени политики на ценови отстъпки и споразумения за контролиран достъп на пациентите в българия vekov ty. control of public expenditure on drug products in bulgaria – policies and outcomes (short report). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-28 1 short report control of public expenditure on drug products in bulgaria – policies and outcomes toni yonkov vekov1 1 faculty of public health, medical university, pleven, bulgaria. corresponding author: prof. toni yonkov vekov, medical university, pleven; address: 1 sv kliment ohridski st., 5800 pleven, bulgaria; telephone: +359 29625454; e-mail: t.vekov.mu.pleven@abv.bg vekov ty. control of public expenditure on drug products in bulgaria – policies and outcomes (short report). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-28 2 abstract aim: the aim of this study was to assess the economic performance of the application of the policy for negotiating discounts on drug products and agreements on the controlled access of patients in bulgaria. methods: the methodology involves comparison of the amounts of public spending on medicines in two periods – during the course of the analyzed drug policies (january 2007 – june 2009), and the period in which negotiations on the price of medicines and programs for the controlled access of the patients was discontinued (july 2009 – december 2012). results: in bulgaria, the government did not apply methods for controlling public expenditure on medicines bargaining price concessions from manufacturers and implementing agreements on controlled access of patients after june 2009. this led to an annual increase in the expenditures on drug products for home treatment (on average, 17% for the period 2009-2012). conclusion: this trend in bulgaria will continue in the future since expenditure control only through price control by means of a reference system and the positive list of medicines is ineffective. there is a need for implementation of combined drug policies in bulgaria in the form of negotiations on rebates with manufacturers and agreements on controlled access of patients and reference pricing. keywords: bulgaria, drugs, negotiation, national health insurance fund, prices. conflict of interest: none. vekov ty. control of public expenditure on drug products in bulgaria – policies and outcomes (short report). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-28 3 introduction the contemporary approaches to drug policy in a number of european union (eu) countries include negotiating discounts and rebates between the health insurance funds and the pharmaceutical manufacturers, as well as agreements for risk sharing in order to reduce the impact of the new patented medicines on the public budget. negotiating some form of discount between the manufacturers and the funds has different forms and ways of administration in different countries and, in some cases, pharmacies give up part of their statutory surcharges (e.g. the netherlands) (1). in other cases, they impose administrative requirements for discounts on the pharmaceutical manufacturers (germany, spain, portugal) (2), whereas in further cases manufacturers recover part of the cost of the reimbursed medicines when the previously agreed annual limits are exceeded (france) (3). such policies of paying back are becoming more and more popular and are currently being applied in at least ten eu countries. until june 2009, the national health insurance fund (nhif) in bulgaria negotiated discounts with manufacturers on the prices of patented medicines and administratively determined the conditions of pharmacies for their dispensing. for these products, pharmacists were not allowed to charge the statutory determined retail surcharge and received a minimum fixed fee for the dispensing of medicines. subsequently, in june 2009, with the adoption of a positive drug list (pdl), the possibility of nhif to negotiate prices and discounts on medicines were legally discontinued. the agreements for sharing the financial risk and the controlled access of patients to treatment with proprietary medicinal products are also a tool for the management and control of public spending. the need for such agreements highlights the rapidly growing share of drug costs for the treatment of certain diseases such as cancer, viral infections, neurological diseases, or diabetes and the increasing concern of the governments about the relatively high level of health consumption of new drugs compared to the standard therapeutic alternatives. in the eu countries, there exist several different schemes for financial risk sharing: • agreements of the type “price-quantity”. these are purely financial schemes that lead to recovery when there is an excess in the previously agreed schemes by the producers’ sales. • agreements of the type “controlled access for the patients”. they are based on an approach that the medicines are provided free-of-charge or at a lower price by the manufacturer for a limited period in order to facilitate financing (4). • agreements based on the results. they are based on the recovery of the costs, if a previously agreed upon level of therapeutic results is not reached, e.g. the desired improvement of health. ultimately, no matter what the specific approach will be, the agreements for risk sharing reduce the risk of overspending the budget of the public health insurance fund. they are particularly useful for restricting the use of drugs by those segments of the population which generate the least benefits (5). in the bulgarian health system, agreements for the controlled access of patients were applied until june 2009 in the form of health programs for expensive treatment of socially significant diseases such as diabetes, chronic renal failure, hepatitis, multiple sclerosis, schizophrenia, bipolar disorder, or parkinson’s disease. access to these health programs was granted for patients who met specific criteria for the disease and diagnostic indicators, confirmed by special medical commissions. these health programs for the controlled access of patients have been discontinued since june 2009 and the access was extended to all patients with these diagnoses. as a modern political tool that limits the impact on public spending, especially for innovative vekov ty. control of public expenditure on drug products in bulgaria – policies and outcomes (short report). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-28 4 drugs of uncertain benefit, the agreements for sharing the financial risk are an interesting and promising approach. at present, however, there is no systematic evaluation of their application and results achieved in bulgaria. in this context, the aim of the current study was to assess the economic results of the implementation of the policies for negotiating discounts and medical products and the agreements on the controlled access of patients in bulgaria. the study questions included a comparative analysis of the cost of the expenses for drug products throughout two periods, in which different practices for their regulation were employed – in the first period there were employed policies of negotiating the prices, internal reference pricing and programs for regulated access to patients, while in the next period only policies for external and internal reference pricing were used. the tested hypothesis was that the complex policy of reference pricing, negotiating prices and programs for a controlled access contribute to the success of a more effective regulation of the drug products costs, in comparison to the separate employment of policies for external and internal reference pricing. methods the methodology consisted of comparing the value of public spending on medicines in two periods – during the course of the analyzed drug policies (january 2007 – june 2009) (6) and the period when negotiating the price of medicines and the programs for the controlled access of patients was discontinued (july 2009 – december 2012) (7). the official data for the expenses of nhif for reimbursing the medicinal products were used for the current analysis. we compared the quantities and the value of the medicinal products, which have been completely reimbursed and were used for the treatment of multiple sclerosis, hepatitis, schizophrenia and diabetes. these expenses constitute 25% of the costs for the completely reimbursed medicinal products. at the beginning of the period under consideration (2007), medicines had patent protection and there were no registered generic products in the market. up to 2009, public expenses of these medicinal products were controlled through a complex of measures which included agreements for sharing the financial risk and policies of price discounts. results the public expenditure on nhif medicines for the period of 2007-2012 are presented in figure 1. the costs up to june 2009 are presented in two parts – partially reimbursed medicines and completely free medicines, which are controlled by negotiating discounts, an administrative reduction of the surplus charge of pharmacies and programs to control patient access to the expensive treatment of certain socially significant diseases. after june 2009, all the nhif approaches employed to control costs were terminated, and the cost of public funds for medicines were operated only by the pdl, based on external and internal reference pricing. the data analysis shows that during the period 2007-2009 (when discount policies and agreements on the controlled access were applied), the cost of medicines for three years increased from 282 million bgn to 325 million bgn, i.e. an increase of 15%. for a similar period (2010-2012), when the public spending was controlled only by external and internal reference pricing, the cost of medicines increased from 366 million bgn to 524 million bgn (up to 43%). therefore, it is reasonable to conclude that the long-term results of drug policies on discounts and programs for the controlled access of patients are more effective in terms of public spending, than the independent application of a reference price system within the pdl. vekov ty. control of public expenditure on drug products in bulgaria – policies and outcomes (short report). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-28 5 figure 1. public expenditure on nhif medicines for the period 2007-2012 (source: statement of the cash execution of the nhif budget) table 1 displays the quantitative analysis of the most commonly used medicines for the treatment of multiple sclerosis, hepatitis, schizophrenia and diabetes, which in 2008 were dispensed under the programs for controlled access that were discontinued after june 2009. after the termination of the agreements for controlled access, the reimbursed amounts of the nhif drug products increased between 14% (insulin human) and 157% (peginterferon) by 2012 compared to 2008. table 1. the amount of annual sales during the period 2008-2012 (source: ims health, 2008-2012) medicine 2008 (number) 2009 (number) 2010 (number) 2011 (number) 2012 (number) interferon β 12,277 15,863 19,364 21,175 25,741 peginterferon 14,087 18,285 35,435 34,731 36,244 olanzapinе 62,650 70,145 64,002 71,958 105,744 aripiprazole 24,224 26,799 35,265 39,147 41,429 insulin human 4,527,237 4,783,584 4, 854, 414 5,082,538 5,166,258 table 2 displays an analysis of the values that were reimbursed by the nhif for the same products. public spending on the examined medicinal products increased between 16% (insulin human) and 118% (peginterferon) by 2012. an exception is the reimbursed expense for olanzapine. the main reason is the expiry of the patent protection and the registration of generic medicines. table 2. the value of annual sales during the period of 2008-2012 (source: ims health, 2008-2012) medicine 2008, bgn 2009, bgn 2010, bgn 2011, bgn 2012, bgn interferon β 9,717,166 12,585,278 16,392,076 16,207,345 18,495,318 peginterferon 5,571,752 6,563,072 12,485,396 12,293,382 12,166,795 olanzapinе 11,871,082 11,319,137 9,592,246 8,795,552 7,686,233 aripiprazole 5,178,861 4,883,137 5,713,810 6,376,297 6,711,932 insulin human 44,209,976 45,246,122 44,617,054 49,667,806 51,433,736 175 161 105 107 134 63 157 366 473 524 0 100 200 300 400 500 600 2007 2008 2009 2009 2010 2011 2012 costs, controlled by external and internal reference policy costs, controlled by discounts, agreements and programs for controlled access 282 295 168 ja nu ar yju ne 2 00 9 ju ly -d ec em be r 2 00 9 million bgn vekov ty. control of public expenditure on drug products in bulgaria – policies and outcomes (short report). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-28 6 discussion the increased public spending after 2009 once again demonstrates that the combination of various drug policies like negotiating discounts with manufacturers, agreements for the controlled access of patients and reference pricing are much more effective for the management and control of costs, than the administration of external and internal reference pricing by a pdl. the complex approach is the only possibility for price control of the innovative medicinal products (interferon, peginterferon, insulin, aripiprazole), where there are no generic alternatives and the internal reference pricing approach cannot be applied. moreover, the pharmaceutical companies have control over the external reference pricing to a large degree and prefer to register their innovative products first at the high price markets in the eu (8). in these situations, the small pharmaceutical markets, such as the bulgarian market, are threatened by a delayed access to the contemporary drug therapies. there is a high probability that analogical cases would occur in all countries in southeast europe and it is recommended that complex drug policies are applied for the management of the public costs on medicinal products. the general rationale of the integrated approach to the drug policy is to accelerate the patient access towards innovative medicines, while ensuring that the financial risks are shared on the basis of estimated or actual cost-effectiveness and the impact of the consumption of medicines on the public budget. the decrease in the cost of the product olanzapine by 35% in 2012 compared to 2008, confirms the effectiveness of the approach for generic substitution, which regulates public spending without compromising the therapeutic goals. by 2015, according to the data from ims health, over 60% of the patent-protected drugs as of 2012 will be available as generics (9,10). the expiration of patent protection will make a large segment of the market available for generic medicines, and this will create a huge potential for saving financial resources. in addition, generics are just as good for health as original drugs are (11). conclusion after june 2009, the government of bulgaria did not apply methods to control the public expenditure of drug products, such as negotiating price discounts from manufacturers and the implementation of agreements for the controlled access to patients. this led to an annual increase in the expenditure of nhif for medicines for home treatment by an average of 17% for the period 2009-2012. this trend will continue in the future because the cost control only through price controls by the reference system and the pdl is ineffective. it is necessary to implement a combination of policies on medicines, like negotiating discounts with the manufacturers, agreements for the controlled access of patients and reference pricing (12,13). the contemporary drug policies presume that there is an increase in the role of pharmacoeconomic evaluation when making decisions for the reimbursement of the medicinal products and the management of public expenses (14). the countries of southeast europe are still beginners in this process, but the fast creation of academic structures for economic evaluation of the medicinal therapies, which help the decision making committees on reimbursement, will improve the future efficacy of the complex drug policies for control of public expenses on medicinal products (15). references 1. cameron a, ewen m, ross-degnan d, ball d, laing r. medicine prices, availability and affordability in 36 developing and middle-income countries. lancet 2009;373:240-9. http://www.ncbi.nlm.nih.gov/pubmed?term=cameron%20a%5bauthor%5d&cauthor=true&cauthor_uid=19042012 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http://www.ncbi.nlm.nih.gov/pubmed?term=wendykowska%20k%5bauthor%5d&cauthor=true&cauthor_uid=20529296 http://www.ncbi.nlm.nih.gov/pubmed?term=aaserud%20m%5bauthor%5d&cauthor=true&cauthor_uid=16625648 http://www.ncbi.nlm.nih.gov/pubmed?term=dahlgren%20at%5bauthor%5d&cauthor=true&cauthor_uid=16625648 http://www.ncbi.nlm.nih.gov/pubmed?term=k%c3%b6sters%20jp%5bauthor%5d&cauthor=true&cauthor_uid=16625648 http://www.ncbi.nlm.nih.gov/pubmed?term=oxman%20ad%5bauthor%5d&cauthor=true&cauthor_uid=16625648 http://www.ncbi.nlm.nih.gov/pubmed?term=ramsay%20c%5bauthor%5d&cauthor=true&cauthor_uid=16625648 http://www.ncbi.nlm.nih.gov/pubmed?term=sturm%20h%5bauthor%5d&cauthor=true&cauthor_uid=16625648 salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 1 | p a g e c review article innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review mobolaji modinat salawu1, obinna emmanuel onwujekwe2, olufunmilayo ibitola fawole1 1 department of epidemiology and medical statistics, faculty of public health, college of medicine, university of ibadan, nigeria; 2health policy research group, department of pharmacology and therapeutics, college of medicine, university of nigeria enugu campus, enugu, nigeria; corresponding author: mobolaji modinat salawu address: department of epidemiology and medical statistics, faculty of public health, college of medicine, university of ibadan, nigeria; e-mail address: sannibolaji@yahoo.com mailto:sannibolaji@yahoo.com salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 2 | p a g e abstract african nations have failed to achieve the mandate of health for all forty years after alma ata declaration. to achieve universal health coverage (uhc), government alone are unable to solve the problems of health service delivery such as lack of good infrastructure, poor management, inter-cadre conflicts, lack of skilled birth attendants amongst others. this review assessed the involvement of non-state actors (private sector/philanthropists) in achieving uhc in africa. we explored eight databases and search engines using specific search terms. we retrieved and conducted a detailed review of 47 publications comprising published literature and reports focused on private sector/philanthropy involvement in achieving uhc in africa, and explored the challenges and opportunities. we included both qualitative and quantitative studies published in english. inequity and a wide gap exist in countries’ health care service delivery due to numerous challenges such as chronic economic instability, bureaucracy, poor healthcare financing, corruption among others. review of existing literature suggests that as africa embarks on reforms toward uhc there is a great need for involvement of private sector/philanthropists to support government in addressing challenges facing health care system. the type of involvement revealed were; provision of infrastructure (hospital buildings/facility, good roads), technical support, technological innovations, provision of diagnostic and therapeutic equipment, financial support and other support services. this scoping review showed that private and philanthropist actors’ involvement in healthcare system have huge potentials to improve, restore and maintain health service delivery in african nations. this will accelerate progress towards the achieving uhc by 2030. keywords: private, philanthropy, health service delivery, universal health coverage, africa salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 3 | p a g e introduction the alma ata declaration of 1978 identified primary health care (phc) as the key to attainment of the world health organisation (who) goal of ‘health for all’ (1). however, forty years after, this declaration is yet to be fulfilled by most countries of the world especially, the african nations. in 2018, the who endorsed the astana declaration to renew the commitment to strengthen phc and achieve a universal health coverage (uhc) which is one of the targets of health related sustainable development goals (sdgs) (2). uhc is the bedrock for health-related sdgs to ensure equitable and sustainable health outcomes as well as contributing to other sdgs to ensure an effective health system (3). uhc is defined as all people having access to quality health services without suffering financial hardship associated with paying for care (4). this means all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality, while ensuring that the use of these services does not expose the user to financial distress (5). to achieve uhc, six essential health systems attributes are embraced which are reflected in the health policy objectives across regions. these are; quality, efficiency, equity, accountability, sustainability and resilience (6), summarized into three related objectives: (i) equity in access to health services everyone who needs services should get them, not only those who can pay for them; (ii) the quality of health services should be good enough to improve the health of those receiving services; and (iii) people should be protected against financial-risk, ensuring that the cost of using services does not put people at risk of financial harm (7). the health systems for uhc consists of three pillars which are necessary to improve well-being of the people in african nations; these are service delivery, health financing and governance (8). in africa, health service delivery is faced with problems of poor management; inter-cadre conflicts; lack of good infrastructure, lack of skilled birth attendants; essential medical commodities and high cost of treatments among others (9). this results in poor utilization of health services with poor health outcomes such as low immunisation coverage, high morbidity and mortality from communicable and non-communicable diseases (ncds) (9, 10). the government is unable to guarantee availability, accessibility, acceptability, and quality of all health-related services for everyone residing on her territory (11). pregnant women and children are mostly affected by these challenges as evident by the poor health indicators reported in the who african region. this includes, maternal mortality rate of roughly two-thirds (196 000) of global burden, infant mortality rate six times higher than who european region (51/1,000 live births), and rising cases of ncds (12, 13). research has documented that some african countries, such as ghana, kenya, morocco, rwanda, south africa and senegal are on the path to achieving some aspects of uhc. these countries have provided insurance coverage for the low-income group and improved on access to health care (8, 14, 15). rwanda and ghana have progressed the furthest toward achievement of uhc evidenced by improvement in the country’s health indices (14). however, the progress of most african nations towards achieving uhc is rather slow (8). in addition, most african countries are yet to adopt the african union’s abuja declaration of 2001 which was to increase spending on public to at least 15 % of the government’s budget (16). instability in governance, lack of political will, financial constraints are some of the other causes of poor health service delivery, which is one of the who health systems building blocks. health service delivery is confronted with challenges which have de salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 4 | p a g e prived individuals, families and communities, of the people centered care that phc offers (2). undoubtedly, government of many african nations are unable to handle health service delivery, hence the need to shift focus from government as major providers and financiers of healthcare to nonstate actors (private/philanthropists) for provision of affordable, accessible and quality healthcare. also, it is important to strengthen the health service delivery with private/philanthropy participation to bring quick progress towards attainment of uhc by 2030. philanthropy is a strategic private initiative, established on rebuilding the system and meant for public good. it is an approach for promoting the welfare of others to better humanity especially by generous donation of money to good course (17). the donations aim primarily to promote the economic development, welfare and health of developing countries. in addition, they refer to transactions which could be in cash or kind that originate from foundations’ own sources, notably endowment, donations from companies and individuals including high net worth individuals (hnwis), crowdfunding and legacies, as well as income from royalties, investments (including government securities), dividends and lotteries (18). the private sector plays a vital role in most of the world’s health systems. they can be for-profit, not-for-profit, informal, formal, domestic or foreign. their involvement in health care delivery is usually for a specific goal. the private sector provides a mix of goods and services including: medicines and medical products, infrastructure and support services, direct provision of health services, financial supports, training for the health workforce and information technology (19). challenges to appropriate health service delivery minimum standards are set on health service delivery in terms of the human resources, infrastructure, medicines and health technologies, as well as the way people are treated when seeking health services (6). however, health service delivery in most african nations have experienced user by-pass basically because of many confronting chronic challenges. hence, africans are unable to access affordable and quality healthcare. these are discussed in the following paragraphs according to the six who health systems building blocks to strengthen health systems. 1) service delivery availability of a well-maintained health infrastructure with conducive consulting rooms, equipped emergency rooms, patient wards, ambulance, on-site laboratory, pharmacy services, and information and communication technology are essential to a proper health service delivery (20). poor infrastructure and access to health care facilities is a fundamental weakness of health service delivery (21). majority of health facilities in africa lack good road access; consist of poor and dilapidated infrastructure which has facilitated medical tourism (9). for instance, in nigeria, over 5000 people leave the country every month for various forms of treatment abroad and about 1.2 billion usd of nigerian economy is lost to medical tourism yearly (22) . 2) health workforce overtime, health facilities have been grossly understaffed with staff mix that does not meet the population demand. africa nations continuously experience shortage of health care workers due to brain drain as a result of poor wages and staff welfare (23). this has resulted in increased workload on the available staff with associated reduced efficiency and effectiveness, long clinic waiting time and poor staff attitude (22). inter-cadre conflict is another barrier which has rendered the health system unworkable (13). in addition, many salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 5 | p a g e african nations still lack skilled birth attendants who address complications during pregnancy and childbirth, hence the high maternal and neonatal morbidity and mortality rates (24). 3) access to essential medicines another challenge of health service delivery is the recurrent shortages and weak supply chain of quality essential medical commodities, such as drugs and equipment in most health facilities in africa (23). this results in high cost of treatment which the patients could barely afford. hence, patients are unable to obtain required medication or treatment as and when due. this unavailability and perceived high cost of care with apparent low quality has contributed to low utilization of health facilities in some african nations like nigeria (10, 25). 4) health information systems health management information system (hmis) contributes to the production, analysis, dissemination, use of reliable and timely health information by decision-makers and practitioners at different levels of the health system (26). unfortunately, the national health information system in african is weak. implementing hmis has been difficult because of factors such as poor funding, governance, poor socio-economic conditions, corruption, etc. (27). most african nations still operate paper-based system of record keeping which is cumbersome, ineffective and often lead to loss of health information. 5) leadership/governance leadership in healthcare system is one of the biggest challenges that hindered expected progress of healthcare interventions in africa (26). there is poor integration of healthcare programmes due to limited community participation in planning, management and monitoring of health services. the government of most african nations lack the political will in implementing government policy and guidelines; there is poor resource management and corruption (28). 6) financing financial barriers to healthcare system remain a prevalent problem in most africa nations with high rates of out-of-pocket expenditure (oop), owing to ineffective national health insurance system. a study found that about 40% of total healthcare expenditure (the) is made up of oop payments in most african nations. the average the in african countries was us$ 135 per capita in 2010 compared to us$ 3 150 spent on healthcare in an average high-income country (29). poor healthcare financing is a recurring problem and seem to be beyond the capability of governments of african nations, hence the need to maximise the involvement of non-state actors in mobilizing resources and providing innovations to support health service delivery towards achieving uhc. this approach has worked in developed countries and some regions in africa with huge potentials in improving, restoring and maintaining health service delivery and overall improvements in health outcomes of the people (19, 30). this can be further studied and adapted by other african countries. various studies have explored the benefit of private sector in achieving uhc but few studies have looked into private sector/philanthropist participation in optimizing government activities in the progress towards uhc. in this paper, we reported the findings of a scoping review which synthesized evidence on healthcare challenges in africa nations, inefficiency of african governments and the possibilities and areas of private sector/philanthropists’ involvement in health service delivery on the way to ‘‘achieving uhc in africa leaving no one behind’’. salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 6 | p a g e methods this scoping review focused on countries where private actors/philanthropy are involved in health care delivery towards achieving uhc in africa. we retrieved and conducted a scoping review on 47 publications comprising grey, primary literature and reports. we focused on studies from developed and developing countries, especially african nations. we included both qualitative and quantitative studies published in english. the inclusion criteria were that literature must focus on private sector/philanthropy for uhc in who regions. search strategy and screening various databases and search engines were explored such as pubmed, google, google scholar, directory of open access jounals, science direct, hinari and researchgate. boolean operators were used to make search more specific using strings with combination of terms (table 1). titles and abstracts of peer reviewed articles, reports and other grey literatures were retrieved and reviewed. we also searched reference lists of included studies in order to look for additional relevant literature. results and discussion from primary searches, 358 published, unpublished and grey literature and reports were retrieved. other sources included technical reports from governmental and non-governmental organisations (ngo) news article, online magazine, civil society organizations, and book chapters. after initial screening, 47 matched the inclusion criteria and were reviewed. the flow chart describing this process is shown in figure 1. table1: literature search terms 1. “private actors” or “private provider” or “private sector” 2. philanthropy or philanthropist or “philanthropic actors” 3. “universal health coverage” 4. “developing country” or “low-middle income countries” or lmic or “sub-sahara africa” 5. “western pacific region” or “south east asia” or “region of americas” or “european region” or “eastern mediterranean region” or “africa region” 6. challenge* or threats and 7. opportunit* or benefit* 8. #1 and #2 and #3 and #4 and #5 and #6 and #7 salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 7 | p a g e figure 1: flow chart showing detailed article extraction and evaluation method we included articles published from year 2000. these studies employed diverse methodological approaches, using a range of quantitative and qualitative methods. to enable an understanding of this concept of private/philanthropy involvement in health care, we first established the outcome and impacts of poor health service delivery in africa using the health indices. we also stated the causes of these poor health indicators which result in high morbidity and mortality. thereafter, we highlighted the challenges service delivery such as inefficiency, bureaucratic bottle necks, economic instability, lack of political will, and other gaps in health service delivery. subsequently, the definitions of private actors/sector and the types; philanthropy and their activities in health service delivery were discussed. we also highlighted some of the agencies that reinforce this sector, dimensions they take and their mechanism of services alongside corresponding interventions. studies on involvement of private actors and benefits on health care delivery are well represented in literature for both developed and developing countries. however, the few studies conducted on philanthropy actors revealed that the aids and grants awarded to nations contributed immensely to the health system growth of such nations. we also found studies that discussed the risks associated with involvement of private actors in health care delivery especially the for-profit private sector. however, the advantages far outweigh the risks which could 180 identified unique articles were scrutinized a total of 358 full text articles published between 2000 and 2020 were assessed for relevance eligibility 178 articles were excluded for irrelevance and duplication a total of 133 articles were excluded after screening titles and abstracts for relevance 47 full text articles were reviewed for focus and coverage of developing countries salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 8 | p a g e actually be controlled by instituting policy and guidelines for the operationalization of private actors. some of the reviewed literatures are listed in table 2. evidence of best practices with private/philanthropist participation in health care delivery the involvement of non-state actors in health service delivery is not a new phenomenon globally, especially in developed countries where it contributes to the growth and success achieved in their health sector (30). this participation as a comparative advantage, such as infrastructural development, technological innovation, training of healthcare workers, provision of health related services, manufacture of materials and technologies used in health care provision; and financial support which the government can leverage upon (7). private sector involvement private actors in health care delivery can either be for-profit or not-for-profit organisations. they are important stakeholders in any country’s healthcare delivery as they cushion, complement and assist the government in strengthening the healthcare system (31). they are found in situations and communities where governments presence and activities are weak in terms of infrastructure, personnel, finance, commodities and when public facilities are closed or on industrial strike (30). the for-profit private actors such as big corporate hospitals are able to mobilise substantial private financing for expensive medical equipment and technology such as those used in advanced treatments of cancers and cardiovascular diseases (32). the non-for-profit private actors such as medicines san frontiers (msf) known to have more experience and better resources, are quick to mount emergency epidemic and disaster responses compared to the government. in addition, marie stopes international, with highly experienced staff who are experts in family planning services work in different countries to ensure regular access to family planning products and commodities (32). both forprofit and non-profit private actors provide a mix of goods and services including: direct provision of health services, medicines and medical products, financial products, training for the health workforce, information technology, infrastructure and support services (e.g. health facility management) (7). consequently, most countries operate “mixed health systems”, where a mix of public and private providers deliver health-related goods and services (7, 33). research showed that among 27 high-income countries, 21 have their primary health care delivered by the private sector (33). grepin in a household survey in 70 lowand middle-income countries, reported that private services provide about 65% of care for childhood illness, but the proportions varied widely by country (34). between 2007 and 2008, the international finance corporation found that in africa, the private sector already delivered about half of africa’s health products and services (35). this was as a result of the perceived lack of efficiency, quality in the provision of public health care and largely from increased costs with reduced budgets for health care due to the financial crisis experienced during the period. a report by the african development bank highlights that africa’s private sector accounts for over 80% of the total production, 65% of total investment, and 70% of total credit to the economy, and employs 90% of the working age population (36). in 2005, of the total health expenditure of $16.7 billion in subsaharan africa, about 50% were captured by private providers (36). it is thus becoming important to engage the non-state actors in enhancing the services of the public sector. in uganda, the united state agency for international development (usaid) secured the private sector’s role towards the costs of hiv service delivery through a counter-part funding scheme that enabled for-profit clinics to commence provision of salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 9 | p a g e hiv services in 2009 (37). usaid provided medical equipment and health workforce trainings thereby expanding the national network of hiv treatment sites across uganda especially in parts of the country where government presence was particularly weak (38). the assessment of private sector activities in uganda was said to be too important to be ignored in attaining uhc (39). table 2: summary of papers reviewed sector challenges of health care delivery authors that elaborated on interventions private service delivery (infrastructure, medical, laboratory services and equipment, technological innovations) a. hallo de wolf and b. toebes (2016), who 2018, d. montagu and c. goodman (2016), d. clarke et al (2019), k. grepin (2016), international finance corporation (2007), m. baig (2014), r. brugha and a. zwi (2002), r. kumar (2019) health workforce (technical expertise) usaid (2013) the health initiatives for the private sector (hips) project final evaluation report, d. montagu and c. goodman (2016), h. zakumumpa (2016), africa healthcare federation, 2020 finance (financial support) international finance corporation (2007), s. basu (2012), world bank (2016) uganda private sector assessment in health, m. baig (2014), s. pour doulati et al (2011), o. olu et al (2019), p. bakibinga et al., (2014) access to essential medicine (medicines, medical products) s. pour doulati (2011), b. uzochukwu (2015) health information systems d. clarke et al (2019), who (2018), r. kumar (2019) philanthropy service delivery (infrastructure, medical, laboratory services and equipment) oecd netfwd. (2019), africa healthcare federation, 2020, s. basu (2012), b. uzochukwu (2015), africa portal. (2018), university of ibadan. (2020). otunba tunwase national paediatric centre, p. bakibinga et al (2014) finance (financial provision/donations) united nations. (2019). inter-agency task force on financing for developmentofficial development assistanc, oecd netfwd. (2019), africa portal. (2018), m. sulek (2009) access to essential medicine (provision of essential medicine) alliance magazine. (2018), university of ibadan. (2020), f. b. dennis. (1993) salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 10 | p a g e research from southeast asia, middle east and some african countries have reported rewarding experiences from government and private engagement. improvement was seen in the areas of infrastructure, laboratory services, equipment and supplies which resulted in affordability and patient satisfaction (40, 41). better performances in the maternal and child healthcare utilization was observed as a result of improved infrastructure and supplies (15). evidence from islands of cabo verde showed that private/philanthropist involvement produced positive health outcomes through technological innovations like telemedicine to bridge the gap in human resource and service shortfall (23). governments of african countries can leverage upon some of these existing services for continuity while the non-state actors continue to execute impactful activities in strategic areas of health service delivery. private sector participation in health service delivery is not without risks and concerns such as quality of services they provide, pricing among others (42). however, the benefits outweigh the risks which can be managed by all the parties involved with well-established regulations and guidelines. the who as a governing body can help to support countries to develop policy guidelines and monitoring tool for managing private/philanthropy and government activities. philanthropic involvement philanthropy donations aim primarily to promote the economic development, welfare and health of developing countries (18). these donor funding from government could be in form of loans or aids grants from donor countries who contribute a target of 0.7% of their gross national product as official development assistance (oda) to developing countries (43, 44). philanthropic actors have contributed enormously to healthcare on various programs to combat diseases as well as deliver health interventions in developing countries. between 2013 and 2015, international philanthropists contributed usd 12.6 billion to reproductive health as well as to combat aids, tuberculosis and malaria. the top five foundations that provide 87% of funding in health and reproductive health globally include; bill & melinda gates foundation bmgf (72%), the susan thompson foundation (5%), the children’s investment fund foundation (4%), wellcome trust (3%), and bloomberg philanthropies (2%) (18). evidence showed that philanthropic donation is concentrated in africa and asia. according to geographical allocation of giving, the top 25 foundations target india (usd 679 million), nigeria (usd 511 million), ethiopia (usd 268 million), pakistan (usd 208 million) and mexico (usd 144 million). between 2013 and 2015, africa received 24% of philanthropic funds for health and reproductive health, and asia received 13%. the funding went into reproductive health/family planning for ethiopia (usd 89 million) and infectious disease for nigeria (usd 310 million) (18, 45). most of these foundations channel their funds for health through intermediary organisations such as ngos, civil society, multilateral organisations, universities and research institutes. indigenous foundations also contribute to healthcare development in africa through local foundations, community groups, and wealthy individuals. a formal structure of philanthropy which include foundations and trusts was set up by hnwis and charitable organisations with distinct objectives relating to african development (46). well-known foundations by hnwis include, the aliko dangote foundation in nigeria, nicky oppenheimer brenthurst foundation in south africa, and the chandaria foundation in kenya, while charitable trusts and vehicles that promote philanthropy include the southern african trust, and the ghana-based african women’s development fund (46). the performance of private and philanthropy https://www.alliancemagazine.org/feature/big-philanthropy-and-policy-change-in-africa/ https://www.alliancemagazine.org/feature/big-philanthropy-and-policy-change-in-africa/ salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. (review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 11 | p a g e actors in health care delivery is resourceful in ensuring improvement in the area of quality health care, equity of access and efficiency of services which catalyses government activities and achievement. this can be in the aspect of financial support to increase funds for health to meet up with international standards. in addition, prioritisation of phc, increasing funding to rural poor especially by redistributing resource allocation between levels of care for preventive and promotive care (30). discussion this scoping review has identified various challenges hindering provision of quality healthcare in african nations, most of which are recurrent and implicated in the slow progress towards attainment of uhc. government of african nations have failed in their responsibility to provide quality, affordable and accessible healthcare for their citizens. the health system therefore requires support from private sector/philanthropy which have become important sources of health care provision for developing nations. the benefits of private/philanthropy participation in health system delivery are enormous and have helped in delivery of quality healthcare with improvement in health status of the people. successes reported in the health system of high income countries are as a result of the major contributions of private sector/philanthropy in their health care delivery (18). this invariably contributed to the excellent health system, best quality of life and good health indicators experienced in developed countries. in essence, health care delivery in african nations may not survive without assistance from non-state actors (7, 47). some african nations have been supported by private sector/philanthropy both from external and within the african nations with health care interventions to combat health problems such as infectious diseases e.g. malaria, hiv/aids, tuberculosis; non communicable diseases and reproductive health issues (18, 36, 46). this has contributed immensely to the improvement in healthcare system in the supported nations. it is therefore important for governments of african nations to strategically optimise the involvement of private/ philanthropist actors in mitigating the challenges of health service delivery. this will go a long way to restore, improve and maintain health service delivery of african nations; thereby accelerating the progress towards attainment of uhc by 2030. acknowledgements we acknowledge the contribution of drs j.o akinyemi, s.a adebowale, s. bello and m.d dairo of the department of epidemiology and medical statistics, university of ibadan, nigeria; for their intellectual and technical assistance. we also thank the world health organisation for the technical support and publishing this manuscript. references 1. who. human rights and health 2017 [available from: https://www.who.int/newsroom/fact-sheets/detail/humanrights-and-health. 2. who. declaration on primary health care astana 2018 [available from: https://www.who.int/primary-health/conference-phc/declaration. 3. kieny mp, bekedam h, dovlo d, fitzgerald j, habicht j, harrison g, et al. 4. strengthening health systems for universal health coverage and sustainable development. perspective bulletin of the world health organization. 2017. 5. who. what is universal health coverage? 2013 [available from: https://www.who.int/news-room/fact-sheets/detail/human-rights-and-health https://www.who.int/news-room/fact-sheets/detail/human-rights-and-health https://www.who.int/news-room/fact-sheets/detail/human-rights-and-health https://www.who.int/primary-health/conference-phc/declaration https://www.who.int/primary-health/conference-phc/declaration https://www.who.int/primary-health/conference-phc/declaration salawu mm, onwujekwe oe, fawole oi. innovative strategies to strengthen health service delivery for universal health coverage in africa – a scoping literature review. 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(review article). seejph 2021, posted: 27 april 2021. doi: 10.11576/seejph-4384 15 | p a g e hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 1 review article effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. salisu hassan1, jamila aliyu mohammed2 1centre of excellence for development communication department of theatre and performing arts ahmadu bello university zaria kaduna state nigeria 2 centre of excellence for development communication department of theatre and performing arts ahmadu bello university zaria kaduna state nigeria corresponding author: salisu hassan; address: media and public relations division, national health insurance scheme damaturu, yobe state nigeria; email: salisu2015.sh@gmail.com mailto:salisu2015.sh@gmail.com hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 2 abstract national health insurance scheme (nhis) designed various social health insurance programmes to achieve universal coverage in healthcare delivery in the country. the scheme is adjudged to have failed to achieve its primary objective, especially in the informal sector, due to communication lapses. this study has employed an integrative literature review method to appraise the principles underlying effective health communication, the communication approaches of the nhis, and recommended plausible alternatives. media integration, advocacy campaign, social media, domestications of icts, communication in multiple languages, and active involvement of communities in the programme were found to imbibe some practical communication principles that can help improve communications to a target audience. keywords: nhis, social health insurance, effective communication approaches, universal health coverage hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 3 introduction increasing access to healthcare remains pivotal to the improvement of healthcare and the attainment of sustainable development goals (sdgs) in nigeria. more importantly, the need to provide health services to vulnerable groups such as pregnant women and children under five and those in hard-to-reach communities remains a herculean task for health stakeholders to address. universal health coverage (uhc) can be achieved through the effective implementation of social health insurance. health care coverage is adjudged to be an essential block of sustainable development, and it is a vital index for measuring the growth of a nation. one of the important duties of government is to provide the masses access to basic healthcare and protection from catastrophic health expenditures (1). however, financial constraints often limit the ability of the government to provide healthcare for all using government funding. many responsible governments consequently embrace social health insurance as a governance responsibility to provide quality and affordable healthcare. apart from quality and affordability, healthcare also needs to have universal coverage to boost accessibility (2). universal health coverage refers to a healthcare system in which all people who need health services can receive them without undue financial hardship (3). many authors have described social health insurance as ideal for quality, affordable and accessible healthcare for the masses (4,5). because of these qualities, social health insurance (shi) is becoming a more popular option in providing healthcare, particularly in developing countries where it is challenging to sustain the taxbased or out-of-pocket pay-based health financing options. nigeria is one of the developing countries that have embraced the social health insurance scheme. nigeria christened her shi designed to ensure universal health coverage. this study problematizes the extant communication approaches the national health insurance system (nhis) of nigeria deploys in communicating health. it appraises the methods used by the nhis vis-à-vis its reach to vulnerable groups in hard-to-reach communities in nigeria. before delving into the communication approaches deployed by the nhis, it is imperative to provide some core conceptual principles of nhis in nigeria to its citizenry, particularly the less privileged. social health insurance provides the opportunity for those who cannot afford out-of-pocket payment to access quality healthcare through various health insurance programmes. this also saves the government from having to go borrowing above her means to finance humongous healthcare needs. national health insurance scheme in perspective to achieve universal health coverage, the national health insurance scheme (nhis)was established in nigeria by act 35 of the nigerian1999 constitution (now cited as nhis act cap 42 lnf,2004) with a mandate to promote, regulate and administer the effective implementation of social health insurance programme to ensure easy access to quality and affordable health services to all nigerians. the nhis has a presidential mandate for achieving universal health coverage. this is to be achieved through various programmes designed to target different social-economic groupings in the country. it is believed that for the presidential mandate of universal health coverage to be achieved, the nhis must extend the deliverables of social health insurance to the informal sector (comprising over 75% of the total nigerian population). to give mobility to its term of hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 4 reference, the nhis, over the years, has developed various programmes to cater to the diverse health demands of vulnerable groups, community-based organizations, permanently disabled, tertiary institutions, and the formal sector (6). the spirit of these programmes was to reach people in rural and urban centres and get them to enroll in the scheme. nevertheless, these programmatic efforts met low enrolments in many parts of the country, especially in the informal sector (7). as many studies have shown, the root of this challenge is traceable to the communication strategy employed by the scheme. nhis focuses more on conventional media in its communication (8). the level of active community involvement in the various programmes of the scheme was also low (7). other factors that limited high enrolment in social health insurance programmes have been found to include misconceptions and the lack of consumers' understanding about the concept, underlying principles, and the benefits of the schemes (9). specifically, authors have identified that ineffective communication is one of the impediments to the success of health insurance more significantly, the informal sector. (9,10). reasons for non-patronage of social health insurance programmes have also been tied to ignorance of their processes, operations, and benefits attached to participation (11). hence, there is the need to adopt effective communication approaches that would help increase enrollment rate into the nhis programmes and engender active community involvement to enable the scheme to attain its mandate for achieving universal health coverage. methods the study has employed an integrative literature review method to appraise the various issues in the study. both online and offline literature were reviewed, critiqued, and synthesized. both qualitative and quantitative data were used to establish a position in this study. for this study, about 108 publications were consulted. the information obtained was also used to support the evidence found in the review by using descriptive statistics. results principles of effective health communication towards ensuring that health communications are effective, the who(2017)developed six principles to guide health communicators. the principles demand that health communications are accessible, actionable, credible (trusted), relevant, timely, and understandable (12). in nigeria, these principles have mostly found relevance in the formal sector. at the rural and, in some cases, periurban centres, none of these principles can be said to apply. this may be because nhis messages are arguably communicated in english language even though most rural or peri-urban centres are speech communities of diverse indigenous languages. furthermore, the messages shared, where they managed to be communicated in indigenous languages, does not engage people and set them to take action. the messages are passive with no channel ensuring instantaneous feedback. accessibility, being the first point of call, constitutes its own problem. studies have shown that, despite the numerous campaigns to create awareness about health insurance scheme in the country, many people are still not aware that such scheme exists. other studies revealed that many people who are aware do not have an appreciable level of information on the scheme's modus operandi, thereby stifling possible interest in the hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 5 scheme. therefore, there is a gap in communication about the scheme. authors have blamed the communication gap on the accessibility of media through which information about the health insurance schemes is disseminated. social health insurance is often communicated through the mainstream media like radio and television. radio is very well accessible to many people, particularly in northern nigeria. still, the energy crisis facing the country limits the potential of radio as an effective medium of disseminating useful information about the programme. television as the only medium of information dissemination about health insurance cannot provide a much-desired result. to pass the accessibility test, communications about health insurance need to go beyond the mass media. one of the delimitations with conventional media is that its feedback mechanism is neither non-existent nor not pulsating enough to propel the critical population to action. the goal of the nhis messages on radio or television is basically to inform, not to share. this is problematic because the awareness does not translate to action. the who (2017) recommended that communicators identify all available channels and map their capacities to reach priority audiences. the organization advises that communicators use the right mix of media to help empower audiences with the information they need to make informed decisions. using the right mix of media tends to improve accessibility to information about social health insurance (12). who's recommendation is instructive in that communication should involve both conventional and unconventional communication tools to facilitate participatory change. empowerment comes through active participation. from active participation, the target audience learns and makes an informed decision to impact or change their lives. so far, the nhis has not used or exhausted indigenous media in communicating its key messages. the use of indigenous media tools is arguably, almost non-existent on the fringes of nigerian communities. next to accessible is 'actionable' on the who's effective communication principles list. actionable communication is communication designed to increase audience engagement and motivation to take action (13). to be successful, communicators must understand the target audience's knowledge, attitudes, and behaviours to create messages that address barriers and encourage the audience to take action (12). in nigeria, the vulnerable groups who are the prime target of the programme are often very attached to their culture and religion. in other words, the audience's knowledge, attitudes, and behaviours are assumed to have been shaped by their culture. communications that will elicit the emotion and action of these people may, therefore, need to take cognizance of their culture (14). this aspect of the core principle is crucial. where there are cultural or religious myths against some aspects of nhis practices, as it is evident in some parts of nigeria, only actionable messages can transform attitudes. this is where peoplecentric and direct engagement with communities is beneficial. drama, as well as other theatrical performances, has proven to be helpful in this regard. however, the nhis has not explored this option enough in rural communities and for the target population to bring about sustainable health practice. another principle of effective communication is credibility. for instance, contributory health insurance programme, as the name indicates, requires participatory funding from the audience. for them to be committed to contributing their meager financial resource to the scheme, the scheme has to be perceived or known to be credible. transparency is key to credibility; thus, communicators must be hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 6 transparent in their dealings with the audience. therefore, communications aimed at encouraging participation in social health insurance need to emphasize the scheme's credibility by citing authoritative sources, showing verifiable case studies and perhaps, having a timeline for the measure of progress. 'relevance' is another principle of effective communication. according to who (2017), to be relevant, contacts must help audiences see the health information, advice, or guidance as applicable to them, their families, or others they care about. relevant communications are essential towards the personalization of benefits derivable from participating in shi. when the audience can identify with the problem that shi is trying to solve and see the benefits as applicable to them, they would more likely embrace the scheme. to make relevant communication, who recommends knowing the background of the audience and their concerns, attitudes, and behavior. apart from the need for communication to be accessible, actionable, credible, and relevant, it also needs to be timely. it is essential to make information, advice, and guidance available conveniently, so audiences have the information they need when they need it to make appropriate health decisions (12). wrong timing can cause communication to become irrelevant to the audience's needs. once the relevance quality is lost, the communication becomes useless, leading to resource wastage. communications have to be delivered timely so that the audience can have enough time to evaluate and or assimilate inherent information and decide to act on it. finally, health communication also needs to be understandable. making communications understandable is particularly important given that target audiences are people who may not individually afford to finance their healthcare needs. most of these people belong to the vulnerable group who are educationally disadvantaged. hassan and adie(2018) stated that the imperativeness of health insurance, primarily for vulnerable groups, may not be appreciated without considering the state of human capital development in the country. table 1: nhis application of the principle of effective health communication principle of health communication literature consulted frequency percentage accessible 10 yes no 6 5 54.54 45.45 actionable 11 yes no 6 5 54.54 45.45 credible 11 yes no 7 4 63.63 36.36 relevant 11 yes no 8 3 72.72 27.27 timely 11 yes no 6 5 54.54 45.45 understandable 11 yes no 7 4 63.63 36.36 hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 7 given that human capital development (education) is low, particularly in northern nigeria, technical jargon that impedes understanding needs to be avoided, or better, translated into memorable indigenous jargon that the people can relate to. technical terms in communication need to be simplified and presented clearly. anything that can serve as noise should be preconceived, identified, and avoided (11). when the audience fails to understand communication, counterproductive misinformation can occur (15). having appraised the principles/qualities that can make health insurance communication effective, it is plausible to evaluate the approaches used in the shi communication in nigeria to recommend a better option. communication approaches of the national health insurance scheme many studies have established that the communication approaches of nhis and by extension, the informal sector have not been very effective (11, 10, 16). hassan and adie (2018) warned that the communication lapses could have dire consequences on the programme's overall success. hassan (2010) reported that the nhis communication approaches had been mainly either proactive or reactive since inception. nhis communications have been less interactive (17). according to joseph & chukwuemeka (2016), proactive communication allows an organisation to seize control of the public relations messages presented to the public (14). it enables communicators to preempt response through careful evaluation (18). reactive public relations or communication is usually impromptu and can be less thoughtful and compelling. according to hassan (2010), reactive communication stems from anger, fear, resentment, and uncertainty(17). this type of communication can be counterproductive, causing new problems while trying to solve existing ones(19). of the three communication approaches, the interactive is considered more appropriate in disseminating information about health insurance schemes (19,20). interactive communication involves engaging the stakeholders through various interactive methods such as participatory learning and action (pla) tools, workshops, and storytelling. the predominant use of either proactive or reactive communication approaches by nhis has not yielded noticeable positive results in the informal sector (17), hence the need to try interactive communication to disseminate information about the programme. table 2: shows the nature of the use of the three communication approaches by nhis. communication approaches consulted literature frequency percentage proactive 13 yes no 8 5 61.53 38.46 reactive 13 yes no 7 6 53.84 interactive 13 yes no 6 7 46.15 53.84 hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 8 considerations of alternative communication model for nhis to make nhis messages interactive, there is a need to consider applied interactional methodologies. baezconde-garbanati et al.(2014) recommended using various media combinations and testing what works and what does not(21). besides, hamel (2010) has shown that combining interpersonal, folk, and mass media would enhance the communication of nhis in nigeria (22). dauda mani (in hassan 2019) commented that: fusion between local indigenous media and the mainstream media would be in no small measure contributed toward adequate awareness creation and provision of health insurance knowledge to the local communities. integration of media and what steve abah calls "methodological conversation" approaches tend to create more awareness about the nhis and instigate the critical population to action. conversational tools like pla, fgds, drama-in-education (die), theatre for development (tfd), and other applied methodologies can stimulate serious advocacy campaigns targeting critical stakeholders. methodological conversation advocates for a synergy between the sciences, social sciences and humanities, to address community-centered interventions. the term is used to describe a synergizing process and interface between (tfd and pla) to engage local communities in a constructive process of social change. it is premised on the agglutination or convergence of ideas, principles, and approaches to produce a common goal. hence, interactive tools such as live or playback theatre can be viable instruments across disciplines. medical or scientific interventions can be re-enacted or performed for easy comprehension. for example, as seen in ahmadu bello university, the department of community medicine can partner with the theatre and performing arts department to organize medical community outreaches where all the intended health messages are communicated using the performing arts. those mentioned above can provide avenues to sensitize people and subsequent follow-up of policymakers and other stakeholders to arouse their interest to get them committed. when nhis engages in constant advocacy, the scheme would have an opportunity to carry information, education, and communication (iec) materials which can be essential for creating awareness, motivating people, and promoting desired changes in behavior while educating and informing people. abosede (2003) stated that advocacy materials carry messages easily understood, remembered, and retained for future use. this aligns with the 'understandable' and 'actionable' principles of effective communication highlighted by the who (2017). continuous social mobilization extensive social mobilizations contribute to awareness and knowledge creation but also helps in motivating and encouraging the community members to act positively. traditional religious leaders, ngos, and health workers could be turned to mobilizers of the community on the programme (7). one tool that has proven to be effective in social mobilization is the theatre. many empirical case studies and workshops, such as the samaru project and the community theatre engagements of the department of theatre and perfuming arts of ahmadu bello university zaria, have achieved many results (hassan, 2019). one way theatre has succeeded as a tool for social mobilization and communication is a mass appeal and the use of local or indigenous idiolects to communicate health messages. rather than run a commentary or health talk, the health messages are dramatized and acted before the local audience. the hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 9 community people are asked to dialogue on the outcome of the drama or what they have watched. this tool is engaging. it draws the target people into the performance as events in their lives, health behaviour, and practices are acted before them. this way, they can see themselves being played out for what or who they are. as deployed by the university department, the tool is even more stimulating as members of the community often take roles in the performance or story told by them and acted by them. effective utilization of social media a report from hassan (2019) indicates that the nhis utilization of social media channels was below average compared to the other channels of communication, such as radio, television, newspapers, etc. though social media falls within the scope of the new media and targets elites, it can improve 'accessibility' to information about the shi, particularly among the educated youths who are internet-inclined. hence there is a need for more utilization of social media such as youtube, facebook, instagram, etc., to reach more people, particularly those that are information technology compliant. again, using social media goes beyond uploading videos or writing health messages. it also involves identifying catch-nets to draw or attract young people. in this regard, high or pop music can be potent. more, urban legends or celebrities with mass online followership can also be branded as nhis ambassadors and made for sharing useful health messages to their online followers. domestication of information and communication technologies (icts) icts can be utilised to reach people in the community efficiently. icts can also help enrollers to become more involved in their own decisions. small handsets can be tailored to provide various services to rural areas by using the available icts. for this to work, locally-made applications should be developed to make enrolment less difficult so much so that anyone can register at every where or point in time. using a multi-lingual approach in communicating the various nhis programmes using appropriate language plays a vital role in reaching the enrollees. inegbedion (2015) indicates that english was the dominant language being used by nhis in communication with the general public (10). hence, there is the need to use various significant languages spoken in the country to reach people, especially those in rural areas. jegede (2010) advocated for using local languages to enable the development partners to implement their programmes (23) fully. according to adewole and osungbade (2016), using a multilingual approach can rapidly facilitate the nhis program's implementation. emphasis on behavior change communication bcc is a research-based consultative process of addressing knowledge, attitude, and practice by identifying, analyzing, and segmenting audience and participants in programmes (24). nhis should emphasize communication that would change the negative perception and misunderstanding of people about health insurance. hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 10 table 3: further confirmation of the level of effectiveness of the highlighted communication approaches above that can be used towards achieving universal health coverage through social health insurance. communication approaches literature consulted frequency percentage media integration 15 yes no 14 1 93.33 6.66 continues social mobilization 13 yes no 11 2 84.61 18.16 utilization of social media 11 yes no 9 3 81.81 27.27 demonstration of icts 10 yes no 8 2 80 20 multi-lingual approach 8 yes no 7 1 87.50 12.50 emphasis on behavior change communication 14 yes no 12 2 85.71 14.28 active community involvement 13 yes no 12 1 92.30 7.69 active community involvement studies (odeyemi, 2014; carrin et al., 2005) suggest that when communities are actively involved during the implementation of any development programme, the sustainability of that programme would be high. this follows the findings of ihidero and hassan (2019), which observes that true empowerment comes when community people actively participate in their own development affairs. nhis as a development-oriented scheme should, therefore, be able to adequately involve the communities in its various activities to enable it communicated its various programmes to target enrollees (25, 16, 2). discussion in its effort to communicate its various programmes to achieve universal health coverage, we found that national health insurance scheme has applied the six principles of effective health communication given by who (2017) to some degree. table 1 further confirmed how the health communication principles were applied to communicate social health insurance. in table 1, 54.54% of the literature consulted ensures that nhis has followed the principle of "accessibility" in communicating its programme. also, another hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 11 54.54% of the literatures consulted confirms that the nhis has followed the principle of "actionably" while 63.63% of the literature affirm the application of "credibility" and also 72.72% affirms the principle of "relevance". however, 54.54% of the nhis communication to the audience has confirmed" timely" and 63.63% confirmed the principle of "understandable". evidence from this study established that the national health insurance scheme's existing communication approaches are proactive and reactive than interactive. the literature further indicated that an interactive communication approach would be needed for nhis to ensure the achievements of universal health coverage in the country. table 2 in this study confirms 61.53% of the literature and documents consulted approved that nhis has been applying a proactive approach in communicating its various programmes and activities. also, 53.84% of the consulted literature and records show that the nhis communication approach is reactive. and lastly, 46.15% of the consulted evidence provided that the nhis communication approach is interactive. the study recommends that various media for communicating health insurance effectively was found in the study. hence, a fusion between mass media, inter-personal and folk media would be a viable option for sharing health insurance to achieve universal health coverage. table 3 also shows that 93.33% of the literature and documents have confirmed that media integration would enhance health insurance communication in nigeria. however, it was also observed that continuous social mobilization as a communication approach would create awareness and enhance the knowledge of the health insurance enrollees. about 84.61% of the literature consulted showed that continuous social mobilization would facilitate the awareness and knowledge creation of health insurance customers in such a way that they would be able to take positive action toward the programme. this study also found that effective utilization of social media would provide access to information to the social health insurance enrollees in nigeria. about 81.61% of the sources confirm that if social media is effectively utilized for communicating health insurance, there is a more favorable result. moreover, it was observed that the domestication of information and communication technologies can enhance the promotion of health insurance in such a way that it would facilitate the attainment of universal health coverage in the country. in about 80% of the literature verified, it was found that if icts are carefully domesticated, this will facilitate the promotion of various health insurance programmes. in this study, however, it was found that most of the contents of communication materials and programmes of the national health insurance scheme are in the english language, neglecting the other indigenous languages. hence, about 87.59% of the consulted literature recomme nded that using indigenous language in communicating health insurance would motivate people to act positively towards the programme. reports in this study have shown that people have different cultural and religious perceptions of social health insurance. because of these different perceptions and attitudes, there is the need of more emphasis on behaviour change communication by the nhis. about 85.71% of the literature consulted has provide the need for a national health insurance scheme to focus more on behavioral change communication to change the negative perception of people towards the scheme's programmes and activities. lastly, it was observed that active involvement of the hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. (review articles). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4449 12 indigenous communities during the planning and the implementation of the nhis programmes and activities would encourage ownership and sustainability. about 92.3% of the literature consulted have shown the need for active community involvement to ensure adequate coverage of social health insurance in rural areas. without active community involvement achieving universal health coverage through health insurance would be very difficult. conclusion nhis has designed various social health insurance programmes to ensure the universal coverage of healthcare in nigeria. despite the multiple approaches put in place by nhis to reach the nigerians and create awareness about the scheme, many nigerians are not aware of the programme or do not fully understand the operational guidelines due to the excessive conventionalization of its communication tools and channels. to find an effective communication approach that can help improve awareness and participation, this study reviewed relevant literature and suggested alternative communication tools that can help the nhis achieve its mandate. a review of principles underlying effective communication was done, and communication approaches with qualities that can help improve social health insurance were identified. media integration, advocacy campaign, the use of social media, domestication of icts, communication in multiple languages, emphasis on behaviour change communication and active community involvement were found to imbibe some of the effective communication principles and are therefore recommended towards effective communication that would facilitate the universal health coverage in nigeria. importantly, there is a need for more empirical studies on nhis that draws from or uses multi-disciplinary analytic approaches. current accessible literature on nhis is mainly within the disciplines of medical sciences and social sciences. worse, the methodological approaches to such literature are mostly stand-alone and mostly depend on numbers instead of a well-triangulated outcome that shows actionable results achieved through collective community action. empirical studies should quantify data and emphasize the process of engaging the community because therein lies development and the global call for convergence in terms of methodology. acknowledgments first and foremost, my gratitude goes to the who regional office for africa the organizer of hideyo noguchi african prize for sponsoring this work. i am also using this medium to appreciate dr. dorcas kamuya of kemri welcome trust, kenya for her wonderful mentorship throughout this work . i am very grateful to dr. jamila aliyu mohammed of centre of excellence for development communication, abu zaria nigeria, for assisting me with some of the literatures as well as helping me in editing this work to ensure it's better shape. last but not the least i am very grateful to mr. victor osae ihiedero of the department of theatre and performing arts, abu zaria for his advice to ensure the success of this work. hassan s, mohanned ja. effective communication approaches as tool for achieving universal health coverage through social health insurance in nigeria. 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"community-driven development at the heart of 26. sustainable agriculture: an assessment of fadama ii intervention in kajuru lga, kaduna state otukpa: a journal of the faculty of humanities and social sciences, federal university otuoke. vol.1. nos. 1 &2. ___________________________________________________________________________________ kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 1 | 17 phd disseratation navigating barriers to gender equality in the european union context: the case of healthcare sector stavroula kalaitzi1 1 department of international health, care and public health research institute (caphri), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands. corresponding author: stavroula kalaitzi, phd; care and public health research institute (caphri), department of international health, maastricht university; address: duboisdomein 30, 6229 gt maastricht, the netherlands; telephone: +306932285055; email: valia.kalaitzi@maastrichtuniversity.nl. kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 2 | 17 abstract context: progress towards achieving gender equality in the european union context is reported slow and fragmented, although some achievements have been made. scholarship has been discussing extensively the gendered barriers, yet their manifestation on a comprehensive and prevalence basis has received scant attention so far. highlighting the big picture of all (in)visible gendered barriers and their manifestation in relation to countries’ specificity may contribute in understanding better the missing link between policy and practice. this study aims firstly, to identify comprehensively the gendered barriers and their prevalence, and secondly, to gain deeper insights on how a persisting policy problem at the eu and member states level remained poorly addressed for over two decades. methods: a mixed methods approach was adopted to ensure the qualitative research quality criteria. the systematic literature review, questionnaire and semi-structured interviews methods to obtain and analyze data were included. qualitative analysis was supplemented by the fundamental tenet of feminist research on the centrality of women. results: twenty-six gendered barriers with quantitative logic and varying degree of prevalence were identified and depicted in the barriers thematic map (btm) across healthcare, academia and business sectors. twenty and twenty-one gendered barriers in greek and maltese healthcare settings were found respectively unveiling the country’s specificity in barriers’ manifestation. the sustainable development thinking in gender equality objectives in eu and ms was found suffering from inconsistencies and misplaced priorities. conclusion: the gendered barriers are multiple, manifest themselves in chorus and with a varying degree of prevalence across sectors and are greatly influenced by country’s specificity. evidence informed gendered policies respecting national priorities may need to be revisited by policy actors to deliver the promised egalitarian social orderand sustainable future for the eu citizens. keywords: gendered barriers, gender equality, women’s leadership, barriers thematic map, european union gender policy. kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 3 | 17 introduction progress towards achieving gender equality in the european union context is reported slow, fragmented and uneven. arguably, the centrality of gender equality in eu’s legal and policy commitments has not yet been translated in adequate gender equality outcomes across member states, although some achievements have been made (1). for example, employment rates have reached historically the highest levels in the eu and more women are in leading positions than ever, whereas the gender gap in education is being closed and even reversed in some disciplines. yet, women participate in labor market at about 11,5% less than men, are paid at an average 16% lower than men and they hardly reach an equal share on the highest decisionmaking echelons assuming only 6,3% of ceo positions in major companies across eu (2). hence, many indicators on gender equality are stagnating, while others are worsened in several member states (3). scholarship on gender equality and women’s leadership is productive in dispelling myths and facts about several forms of gender inequalities, yet shedding light in a scattered and fragmented way on gendered barriers. the manifestation of barriers within an organization or a sector on a comprehensive and prevalence basis has received scant attention so far. for example, stereotypes, gender pay gap, bias, sexual harassment have been explored on a one to one basis, but rarely through the big picture perspective and how each barrier contributes to shape this picture (4-6). this study aspires to highlight the big picture of all (in) visible gendered barriers, the context within which they are developed, the underlying mechanisms that feed the durability and transferability of each barrier within socio-cultural and economic reality and which may be the missing link between policy and practice. thereby, understanding the barriers that make up the labyrinth of women’s leadership (7) may provide deeper insights on how to address effectively the complexities of gender equality challenges at both social and economy level. furthermore, it may make it easier to understand how to dismantle and de-power deeply rooted gendered perceptions, and to develop effective and gender responsive policies. thereby, this study aims firstly, to identify the gendered barriers and their prevalence across sectors, such as healthcare, academia and business on the grounds that these sectors cover a big part of society and economy, and, secondly, to gain deeper insights on how a persisting and central policy problem at the eu and member states level remained poorly addressed for over two decades (8,9). to have a clearer focus and gain deeper insights on gendered barriers, current research concentrated on healthcare sector for three reasons: firstly, women are significantly underrepresented in leading positions across healthcare although the sector being women populated and their added value is widely acknowledged; secondly, healthcare sector is currently considered one of the major employers, encompassing several domains, such as academic, clinical and medical, and job categories; and, thirdly, healthcare is of critical importance to health systems’ sustainability; health workforce is a key component to health systems, whereas the gender balanced health workforce is linked to health systems’ improved performance (10,11). these features are considered to offer ample ground to gain deeper insights on the research question. thereby, the research is developed at the intersection of gendered barriers in the healthcare sector within country’s socio-cultural and economic contexts. kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 4 | 17 methods this study applied a qualitative research methodology built on a profound concern to understand the explored phenomenon and offer an interpretation of informed and sophisticated knowledge reconstructions (12). adopting the social constructionism paradigm and on the grounds that some methods are more suited than others for conducting research on human construction of social realities (13), this study applied a mixed methods qualitative approach to ensure the quality criteria of trustworthiness, authenticity and triangulation incongruence of experiential and practical knowing (12). in alignment with the qualitative research commitments, the research included obtaining and analyzing textual data, such as comments on a questionnaire and interviews’ transcripts and data generated from the interaction between researchers and participants. reflexivity relied on critical subjectivity; transparency as the study progresses, contextual understanding of particular social processes and application of qualitative research findings to other situations were also included in methodology considerations (14). qualitative research was supplemented by the fundamental tenet of feminist research on the centrality of women aiming to “put the social construction of gender at the center of one’s enquiries” (15) and interpret the experiences through immersion in the data (16). study design and methods a mixed methods qualitative approach was applied to collect a variety of enriched data on the barriers to women’s leadership and gender equality, validate the findings and triangulate the results (17). following progressive analysis and comparison of collected data, an explanatory theory was formulated on addressing effectively the explored phenomenon and be plausibly applied and tested in other contexts (18). the study was supplemented by qualitative findings on eu gender equality policy and implementation to deduce conclusions on potential policy inconsistencies and ways of improvement. the study was grouped into three parts (figure 1). figure 1. study design and methods kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 5 | 17 i)problem statement and hypothesis: a systematic literature review was undertaken aiming a) to uncover gendered barriers across healthcare, academy and business sectors, b) to contrast the differences in gendered barriers across sectors and c) to develop the gendered barriers thematic map (btm)with quantitative logic and a prevalence chart. the geographical target of the study was europe with the time range for publications from 2000 to 2015 (19). ii) hypothesis testing: the hypothesis testing on btm and barriers’ prevalence was focused on healthcare sector within two eu countries’ socio-cultural and economic contexts: greece and malta. it was deployed in two sub-studies: one exploratory study conducted within one country’s healthcare sector and one comparative study realized in two countries’ healthcare sector (academic, clinical and medical facets): the exploratory study was set out aiming to forage for the most and the least important barriers to women’s leadership based on btm. the study was drawn upon perceptions of women healthcare leaders in greece in relation to gendered barriers; interest stemmed from country’s poor performance on gender equality index and current economic turbulence (20). the semi-structured interviews, comparative study was conducted aiming to assess empirically gendered barriers to women’s leadership in healthcare through the lens of national socio-cultural and economic contexts. study focused on greece and malta; interest was drawn from countries’ poor performance in the gender employment gap and the rapid socio-cultural and economic changes occurring in the european mediterranean region (21), and iii)eu policy and implementation level: an interpretive discourse analysis was followed to gain deeper insights of the sustainable development thinking in gender equality policy agenda adopted by eu and in relation to its relevance to interests and challenges faced by member states’ citizens. in particular, the relevance of eu sdg5 themes and indicators and the prioritization of policy objectives to actual social reality across member states was considered. a qualitative analysis of organizational change was used to explore the transformative capacity of the developed eu gender mainstreaming toolkits aiming to unpack the complexity among toolkits, organizational culture, climate and outcomes and to gain nuances on potential room for improvement. data collection to ensure the trustworthiness of the findings, qualitative and quantitative data was harvested from primary and secondary sources (12). primary data:  primary data on barriers to women’s leadership and their prevalence was harvested applying a systematic literature review method (19).  primary data of an online questionnaire harvested by 30 purposively invited women healthcare greek leaders (20).  primary data was collected from 36 semi-structured interviews with healthcare leaders, including women and men in greece and malta (21). secondary data:  a content analysis of ten websites of key organizations, such as european parliament, european institute for kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 6 | 17 gender equality, standing committee of european doctors, the world bank, mckinsley global institute.  eu evaluation reports and policy documents, communications, minutes of high level  a narrative literature search in google scholar, pubmed, web of science and on dedicated websites discussing the implications of economic crisis on gender equality and on healthcare sector.  a narrative literature search on interpretive discourse analysis of eu gender equality policy and the adoption of eu sustainable development goals (sdgs).  a narrative literature review on theory of organizational and social change and on implementation sciences. ethical approval ethical approval was received from ethics committees from maastricht university (no metc 16–4-266, january 19, 2017), national and kapodistrian university of athens (medical school) (february3, 2017) and from the university of malta (march 10, 2017). theoretical and conceptual considerations the explored topic involves several aspects and thus requires an all-encompassing approach which may not fall easily into a single theoretical framework. the study applies theories of gender equality, women’s leadership, gender equality policy and implementation at eu and member states level. gender equality in this study the concept of gender is approached as a cross-cutting socio-cultural and economic variable (22, 23). gender is understood as “the socially constructed roles, behaviors, activities and attributes that a given society considers appropriate for women and men” (24) in contrast to “sex” referring to “the different biological and physiological characteristics of males and females such as reproductive organs, chromosomes, hormones, etc.” (25). these characteristics tend to differentiate humans as men and women, whereas gender refers to a socially acquired identity connected to “being male or female in a given society at a given time and as a member of a specific community within that society” (26, 27). hence, gender identity prescribes what is expected, allowed or valued in a woman or a man within a given context (22, 23). gender equality refers to “equal visibility, empowerment, responsibility and participation of women and men in all spheres of public and private life. it also means an equal access to and distribution of resources between women and men and valuing them equally” (28). also known as “equality of opportunity” (29), it implies that women’s and men’s interest, needs and priorities are taken into consideration irrelevant to their gender. thus, it is recognized that gender equality is not a women’s issue but should interest and fully engage men and women in the sense of supporting women’s capacity to make life choices in a context where this capacity was previously denied to them (27,28). gender equality policy in the eu context european union anchored firmly the concept of gender equality in the european treaties and expressed its commitment with policies on economic development, social cohesion and democratic societies (30). the milestones of the trajectory of gender equality policy agendas arrayed from the treaty of rome (1957, art 141) focusing on “equal pay kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 7 | 17 for equal work” to the treaty of amsterdam (1997, art 3.2) “to eliminate inequalities and to promote equality between men and women” in all eu activities (31-33). later, in the treaty of lisbon (2009) (34) eu broadened its binding commitment to observe gender equality principle and pursuit gender equality objectives. in 2015 eu committed to fully integrate the un sustainable development goal towards achieving gender equality and women’s empowerment (sdg5) in eu policy framework under the concept of social and economic development. gender equality and women’s leadership women’s leadership has been perceived as central component towards achieving gender equality and women’s empowerment objectives within eu sustainable development policy framework (33). in particular, the target of women’s leadership advancement was embedded directly to the theme of “leadership positions”, but was also related indirectly to themes of “education” and “employment” (35). hence, women’s leadership advancement was approached to a certain extent by eu policy agenda as a driver to equal opportunities for full and effective participation to leading positions at all levels of decision making, in all employment areas and in all societal spheres (2). women’s leadership in the healthcare sector healthcare is populated mainly by women; 74% of health workforce are women but only 14% assume high level positions in decision making (10). the healthcare sector is regarded as an investment driver across european union (36,37) and, thereby, is considered a key component for health systems’ sustainability. it also enjoys a prominent position among the biggest employers in eu (35). however, health systems miss female talent and perspectives, especially in higher echelons and turn weaker, underperformed since the women who deliver them do not have an equal say in the management and leadership of the systems, they know best (38). hence, a substantial share of talents pool remains untapped, whereas the deficit for transformative leaders in healthcare grows bigger. findings the undertaken qualitative study produced the following findings: part i explored the barriers to women’s leadership and gender equality across three vital sectors, healthcare, academia and business in eu context. a comprehensive map of barriers to women’s leadership was devised. the barriers thematic map (btm)included twenty-six barriers with quantitative logic and varying degree of prevalence. the btm uncovered gendered inequalities across sectors and drew attention to under-studied barriers’ prevalence across sectors (figure 2, figure 3, figure 4) (19). kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 8 | 17 figure 2. gendered barriers across healthcare, academy and business sectors – systematic literature review findings figure 3. gendered barriers in business (%), academia (%) and in healthcare (%) kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 9 | 17 figure 4. barriers thematic map (btm) to gender equality part ii focused on hypothesis testing by investigating the btm within social reality, contextualizing and interpreting the findings and gaining in depth insights in relation to research hypothesis on healthcare sector within the context of two, comparable countries, greece and malta. firstly, empirical findings (online survey) on perceptions of greek women healthcare leaders on barriers to career advancement identified the twenty-six barriers included in btm (figure 5) (20). six barriers (stereotypes, work/life balance, lack of equal career advancement, lack of confidence, gender gap, and gender bias) prevailed in women leaders’ perceptions in constraining opportunities for pursuing leading positions in greek healthcare setting, whereas all twenty-six barriers presented varying degree of prevalence. secondly, qualitative research findings (semi-structured interviews) identified twenty and twenty-one barriers to women’s leadership within the greek and maltese healthcare settings, respectively (figure 6) (21). in both research settings prevailing barriers included work/life balance, lack of family (spousal) support, culture, stereotypes, gender bias and lack of social support, yet countries’ similarities and differences in prevalence of the identified barriers were observed. notably, cultural tightness was found to be experienced against socio-cultural transformation in maltese context; the recent economic crisis was found to be responsible for a backlash in previously achieved gender equality objectives in greece. thus, research findings unveiled underlying interactions kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 10 | 17 among gender, leadership and countries’ socio-cultural and economic contexts elucidating the varying degree of strength of norms and barriers embedded in a society’s egalitarian practice. figure 5. a btm-based best-worst scaling (bws) assessment on gendered barriers across greek women healthcare leaders part iii turned to gender equality policy agenda at the eu level. the chapter considered the sustainable development thinking in gender equality policy objectives in eu pertaining to its relevance to challenges faced by member states’ citizens. in particular, the chapter explored the relevance of eu sdg5 themes and indicators and the prioritization of policy objectives to actual social reality across member states. findings identified inconsistencies in application of gender equality related articles binding for both eu and ms (treaty of lisbon, art 2, art 3.3, art 6.1, and art 9), posing thus questions about the prioritization of gendered challenges from eu and national policy actors and stakeholders. the translation of sdg5 into national achievable targets was discussed under the perspective of persistent and uneven gender inequalities across ms. the study argued for eu’s proactive leadership, underpinned by academia and civil society contributions to optimize support to the ms to revisit their national policies and develop evidence-informed policies; thus, the sustainable development efforts may be strengthened to align with the gendered priorities and challenges at ms level. moving to the policy implementation realms, the study identified that the inherent duality of toolkits (gender and governance) may be held responsible for their suboptimal transformative capacity within organizational context; furthermore, the under-developed qualitative elements of the toolkits, such as the sesame features (simple, easy, specific, affordable, measurable and efficient) and the lack of gender expertise at policy and decision makers level may also need to be further developed to facilitate effectively the organizational change processes kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 11 | 17 figure 6. a btm-based semi-structured interviews study on gendered barriers across women and men healthcare leaders in greece and malta discussion european union’s high level legal and political commitment towards achieving gender equality objectives has produced suboptimal outcomes. the gendered priorities misplaced by policy makers and the inconsistent commitment across eu bodies and agencies fostered the persistence of gendered barriers and equal representation in economy and society, undermining thus the undertaken efforts. the policy intentions and policy implementation have not been sufficiently bridged; the suboptimal transferring of the academic knowledge to policy practice servants and the lack of gender disaggregated data feeding bottom up, customized policies at both country and eu level may be hold responsible, amongst others, for shortcomings in policy prioritization and effective implementation (3,9,39,40). inconsistent commitment and lack of collective action gender scholars argue that eu gender policies are the battleground for eu institutions underpinned by shifts in power relations (41). the way gender (in)equality is framed, engages differently the different actors across the eu policy making arena which results in fading away the centrality of the policy problem; hence, the gender equality policy objective is placed as the “side dish” of the actual eu policy making goals (42). for example, the european commission framed gender equality policies through gender mainstreaming in all policies undertaken by actors normally involved in policy making (40,41,43); yet it ended up to bureaucrats with a rather technical than political conceptualization of kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 12 | 17 gender equality principle shaping accordingly the policy agenda (44,45). on that note, inconsistencies in funding and budgeting may conflict directly with the eu’s full legal and political commitment (art 2, art 3.3, art 6.1, art 9; treaty of lisbon, 2007) (34) and, then, result to limited positive impact on gender equality issues, such as gendered unemployment (41,46). lack of gender disaggregated data putting evidence into practice is complicated and context dependent; yet, it remains a dynamic process with a continuous interaction between academic research and policy makers which may identify priorities and evaluate the level of responsiveness to key audiences. almost none of the eu gender related policies incorporate a systematic and consistent mechanism, such as disaggregated data collection, to evaluate whether the policy has successfully responded to its objectives and the potential room for improvement (3,47). the critical gap of a gender disaggregated data pool enhanced the fuzzy evaluation of the gender equality policies, in particular at member states implementation level (47). robust evidence generated by academic knowledge may fill in the gaps in the policy cycle and contribute in developing evidence informed gendered policies, responsive to gendered barriers faced within country’s specific socio-cultural and economic contexts. gendered barriers: the case of healthcare sector the interest of scholars, civil society, european and international agencies on the persisting underrepresentation of women in leading positions and the implications to health systems, economy and society has been growing rapidly during the latest years. for example, a growing interest on gender inequalities in health and healthcare from civil society actors has been observed in recent years. non-governmental organizations (ngos) (e.g., women in global health research initiative) and associations (e.g. european health management association) advocate gender equality in health workforce from several perspectives, such as equal opportunities to career advancement and equal pay. in the same line, european and international agencies keep a close eye to eu region and discussed intensively in recent years the women’s underrepresentation in healthcare. in particular, dr tedros, director general of who, re-stated the necessity for gender transformative action in health (38) and launched the who global health workforce equity hub in 2017 (48). arguably, the considerable, multi-disciplinary effort to unpack the complexity of barriers to gender equality demonstrates scholarship’s unanimous voice on achieving gender equality objectives and, thereby, on addressing the gendered barriers in a feasible and effective way. however, although all involved actors argue for the importance and urgency of gendered challenges in healthcare and established the relevance of gender equality in health workforce to sustainable transformation and governance of health systems, the results remain poor. health workforce is the beating heart of healthcare and health systems which are mainly populated by women. thereby, maybe the extra mile towards achieving a gender balance workforce may need to be undertaken by academia with the main aim to detail the health workforce’s capacity as a change agent towards achieving gender equality objectives within work and social contexts and project the gender balanced health workforce as a paradigm to society and economy. kalaitzi s. navigating barriers to gender equality in the european union context: the case of healthcare sector [dissertation: university of maastricht, 2019]. seejph 2020, posted: 01 june 2020. doi: 10.4119/seejph-3492 p a g e 13 | 17 implications the study introduces the feature of comprehensiveness and prevalence of gendered barriers; nonetheless, there is ample room for further research, which would be extremely informative and would maximize the impact of the findings at hand. additional study on the twenty-six identified barriers through a multi-disciplinary lens would be of added value to the field; in particular, the barriers’ contextuality in terms of their durability and transferability might have also been recognized and assessed differently through the lens of several academic disciplines, such as sociology, psychology, political science, management and organizational behavior science, gender science, feminism; similarly, gendered barriers manifestation across various sectors (e.g. ngos, agriculture) would offer interesting insights to the explored phenomenon’ prism. on the grounds of the provided evidence-informed insights on the context sensitive and country specific gendered barriers, policy actors and decision makers are invited to follow the “think globally – act locally” strategy in gender equality policies and practices in their efforts to close the gap between policy and reality. furthermore, the findings of this research may serve to raise awareness to policy and social actors on the gender asymmetries’ influence in terms of power and authority within a country’s social and cultural context. policy and social stakeholders are invited to revisit the level of responsiveness of adopted policies to social audiences and to re-evaluate the dynamic dialogue among societal culture, leadership and gender in enabling social and cultural change. at the author’s best knowledge, this study is one of the first to develop a barriers thematic map (btm) with a prevalence feature. the btm may be developed to a digital tool for self-awareness and a reality check on gendered challenges at organizational level. applying the btm, a snapshot of the gendered barriers’ manifestation and prevalence within organizations may be generated. providing data anonymization, the tool may offer the room to unveil both apparent and implicit barriers experienced by all genders bypassing, thus, potential power relations within organizations. this evidence-based overview may disclose policy gaps and be linked to organizational practices for improvement. the yielded evidence-based information will also contribute to effective use of resources, which may be channeled to fulfil customized needs and, therefore, improve organization’s change capabilities and performance. conclusions the study demonstrated that the gendered barriers are numerous, manifest themselves in chorus and with a varying degree of prevalence across and within sectors and are greatly influenced by country’s socio-cultural and economic contexts. hence, in contrast to published literature, the findings support that barriers to gender equality need to be addressed comprehensively, not on a one to one basis, aiming to capture the wholeness of the problem and, thus, design and 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(original research). seejph 2022, posted: 29 october 2022. doi: 10.11576/seejph-5976 p a g e 1 | 10 original research a study on risk perception, cognitive awareness and emotional responses to identify unmet training needs of frontline health care workers for covid-19 containment in india madhumita dobe1, monalisha sahu1, chandrashekhar taklikar1, shibani dutta1 1 all india institute of hygiene and public health, kolkata, india. corresponding author: dr. monalisha sahu address: 110, chittaranjan avenue, kolkata – 700073, india; telephone: +919873927966; e-mail: drmonalisha@outlook.com mailto:drvikaspsm@gmail.com dobe m, sahu m, taklikar c, dutta s. a study on risk perception, cognitive awareness and emotional responses to identify unmet training needs of frontline health care workers (flhcws) for covid-19 containment in india (original research). seejph 2022, posted: 29 october 2022. doi: 10.11576/seejph-5976 p a g e 2 | 10 abstract aim: frontline health care workers (flhcws) are the key workforce in the fight against ongoing covid-19 pandemic. they hail from the community and are responsible for supporting the health system in generating awareness, implementing preventive strategies, contact tracing and isolating potential cases. in their job responsibilities, flhcws thus may perceive heightened risk of exposure to the virus, leading to overwhelming emotional response and psychological distress. the objective of this study was to investigate risk perception, cognitive awareness and emotional responses among flhcws trained to deal with covid 19, to identify unmet needs of this training in india. methods: a cross-sectional study was conducted in a total of 131 frontline workers selected by a multistage sampling process from two states (odisha and himachal pradesh) of india. the flhcws were interviewed personally (when feasible) with the help of a predesigned pretested semi-structured questionnaire. results: the findings suggested that majority (90%) of the flhcws perceived that they are susceptible to ncov-19 infection and 77.1% of flhcws felt high probability of them getting infected with the ncov-19. almost 90% of them responded that it is something they think about all the time and 41% of flhcws admitted that they feel helpless in the situation. about 63% of flhcws perceived that the ncov-19 infection was a severe illness and 35% perceived it to be very severe and life threatening. although most of them had received some unstructured and non-uniform training on preventive measures against covid-19, yet only 38% felt that the knowledge was adequate to protect themselves from the ncov-19 infection. the training sessions lacked psychological component for capacitating them with coping skills to address their emotional and psychological responses. conclusion: the flhcws experienced heightened risk perception and symptoms of emotional distress in significant numbers even after trainings. a more inclusive public health policy dialogue to address the emotional and psychological coping skills is needed for capacitation of these frontline workers to address the challenges of pandemic response now and in future. keywords: capacity building, covid-19, emotional response, flhcws, pandemic, social support. conflicts of interests: none declared. acknowledgments: we would like to thank all participants to our study, whose time is even more precious in this difficult situation for all the country, who participated. dobe m, sahu m, taklikar c, dutta s. a study on risk perception, cognitive awareness and emotional responses to identify unmet training needs of frontline health care workers (flhcws) for covid-19 containment in india (original research). seejph 2022, posted: 29 october 2022. doi: 10.11576/seejph-5976 p a g e 3 | 10 introduction the novel coronavirus 2019 (ncov-19) pandemic has caught the health systems off-guard and countries are struggling to control the galloping rates of transmission (1). the role of frontline health care workers (flhcw) in generating awareness and promoting preventive methods to limit further transmission of ncov-19 in the communities is critical. with 13,36,861 confirmed cases and 31,358 total deaths, india presently has the third highest number of confirmed ncov19 cases and the eighth highest number of deaths due to ncov-19 worldwide (2). the government of india has launched a massive operation to engage lakhs of flhcws in form of accredited social health activists (ashas) to contain the spread of ncov-19 in the rural areas of different states of the country (3). they serve as an important link between community and the health facilities and are particularly indispensable to reach out to populations in remote and rural parts of india for dealing the ncov-19 pandemic. the job responsibilities of flhcws fighting ncov-19 in india involves (4):  generating awareness in the community through inter-personal communication about (a) uptake of preventive and control measures including regular handwashing, practicing respiratory hygiene, maintaining social distance (b) addressing myths and misconceptions;  supporting auxiliary nurse midwives (anms)/supervisor in house-to-house active surveillance and contact tracing including (a) identification of hrg, probable cases and their contacts;  mobilizing community to ensure uptake of medical services in urban and rural areas; and  reporting and providing feedback across different phases of ncov-19 pandemic (number of cases, imported/sporadic cases, clusters and community wide transmission). in their line of duties, many flhcws had to work for longer hours with personal protective equipment (ppe) on and survey around 30 to 50 houses in a day depending on the risk levels of the area. due to ‘corona phobia’, they were often encountering stigma and physical violence during their home-to-home surveys (5). there is great fear regarding personal wellbeing secondary to community transmission of the disease. this may result in overreaction, and plethora of other psychological manifestations like excessive worry, fear of infection and death and feeling of helplessness etc. psychological preparedness of flhcws, their cognitive awareness and coping for emotional responses in these situations, have compelling relevance during this pandemic (6). perspectives on emotional and psychological preparedness especially the needs of specific populations like flhcws while working for ncov-19 are sparse. this study was conducted with the following objectives:  to assess the gaps in risk perceptions, cognitive awareness and capacity for coping with emotional responses in their job responsibilities during covid 19 pandemic;  to identify unmet needs for training and various challenges flhcws face while working in the community for covid-19 containment. methods a cross-sectional study was carried out from april 2020–june 2020 at selected 15 districts from the eastern state of odisha and northern city of himachal pradesh in india. a multistage sampling scheme was followed. the required sample size was calculated as 122 considering prevalence of dobe m, sahu m, taklikar c, dutta s. a study on risk perception, cognitive awareness and emotional responses to identify unmet training needs of frontline health care workers (flhcws) for covid-19 containment in india (original research). seejph 2022, posted: 29 october 2022. doi: 10.11576/seejph-5976 p a g e 4 | 10 fear as 80% (as quoted from another study conducted in india by parikh et al) at 10% error level and considering design effect as 2. adjusting for non-response additional 10% sample size was added to 122 making the total sample size as 134. however, three of the responses were incomplete and were omitted and finally 131 responses were included in the study. in the first stage purposive selection of districts were done to select 13 districts from odisha (puri, gajapati, keonjhar, kendrapara, jagatsinghpur, cuttack, angul, bhadrak, balasore, mayurbhanj, sambalpur, sundargarh, sonepur) and 2 districts from himachal pradesh (mandi, kangda). in the second stage fifteen health centers (14 phc and 1 chc) from each district were selected by using simple random selection technique. list of flhcw was prepared working under these centers. in the third stage the sample of 131 flhcws were randomly selected from the list and interviewed in person (when feasible) or over telephone, using a predesigned pretested semi-structured interview schedule consisting of 34 items. written informed consent was taken prior to the interviews. confidentiality and anonymity of the respondents was maintained throughout the study. data was analysed using microsoft excel and spss ver. 20. appropriate statistical tests of significance were applied as necessary. the data were analysed using descriptive and inferential statistics. results sociodemographic profile of flhcws nearly half (52%) of the flhcws were between the age group of 21-40 years old. majority of them (70%) were educated up to matric or higher level. most of them were trained for covid-19 (table 1). table 1. distribution of the flhcws according to the sociodemographic profile and training status (n=131) socio-demographic characteristics number percent age (in yrs.) 21 – 30 07 5.34 31 – 40 61 46.56 41 – 50 58 44.28 51 – 60 05 3.82 educational qualification primary 1 0.77 upper primary 39 29.78 matric 56 42.74 higher secondary 22 16.79 graduation 13 9.92 training trained 125 95.5 untrained 6 4.5 perception of risk: majority (90%) of the flhcws felt that they are susceptible to ncov-19 infection. 58% of them expressed that despite having knowledge about preventive measures it is difficult for them to avoid acquiring the infection. most of the dobe m, sahu m, taklikar c, dutta s. a study on risk perception, cognitive awareness and emotional responses to identify unmet training needs of frontline health care workers (flhcws) for covid-19 containment in india (original research). seejph 2022, posted: 29 october 2022. doi: 10.11576/seejph-5976 p a g e 5 | 10 flhcws (77.1%) felt that probability of them getting infected with the ncov-19 is likely or extremely likely. perception of severity: 63% of them feared that ncov-19 infection causes severe illness and 35% perceived it to be very severe and life threatening. table 2. distribution of flhcws according to their knowledge and risk perception (n=131) knowledge and risk perception no. flhcws % knowledge of protective measures against ncov-19 not at all 0 0.0 inadequate/some 80 61.1 adequate 51 38.9 perception regarding possibility of avoiding ncov infection extremely difficult 3 2.3 difficult 74 56.5 easy 43 32.8 extremely easy 11 8.4 total 131 100 perception of susceptibility to ncov-19 infection not at all susceptible 14 10.7 susceptible 67 51.1 very susceptible 50 38.2 perception regarding possibility of getting themselves infected with the ncov-19 extremely unlikely 1 0.8 unlikely 29 22.1 likely 83 63.4 extremely likely 18 13.7 perception about severity of ncov-19 infection not severe 2 1.5 severe 84 63.1 6 very severe and life threatening 47 35.3 4 cognitive awareness regarding effectiveness of various preventive measures and the ease of practicing them [figure 1]: cognitive awareness is the most important part of decision making and practicing a particular behaviour. when asked about their perceptions regarding the protective measures against ncov-19 infection, most of the flhcws (61.1%) reported that they have some knowledge about how to protect themselves from ncov-19 but only 38% dobe m, sahu m, taklikar c, dutta s. a study on risk perception, cognitive awareness and emotional responses to identify unmet training needs of frontline health care workers (flhcws) for covid-19 containment in india (original research). seejph 2022, posted: 29 october 2022. doi: 10.11576/seejph-5976 p a g e 6 | 10 believed that the knowledge was adequate to protect themselves from the ncov-19 infection. when asked to rank the preventive measures based on their effectivity, majority (74.8%) of the flhcws responded that washing hands frequently with soap and water was the most effective way to avoid infection followed by social distancing. very few of them mentioned measures like staying at home, registering names in govt. portals like ‘arogya setu’, using gloves and not spitting in public place as preventive measures that are important in preventing spread of ncov-19. (table 3). on applying chi-square test those who were educated up to higher secondary and above had significantly better knowledge of protective measures against ncov-19 (chi=79.56 p<0.01). their perception regarding possibility of getting themselves infected with the ncov-19 was that chances of getting infected was low if preventive measures were practised properly (chi=6.64 p<0.05). figure 1. distribution of ashas according to their cognitive awareness of preventive measures to limit spread of covid-19 infection on questioning about their ease to practice preventive measures like washing hands and wearing masks, few (1.5%) of the flhcws said that wearing mask always was very inconvenient. 46% of them reported feeling uneasy and suffocated while wearing mask all the time. some flhcws (22.1%) felt inconvenient to maintain social distancing while others (10%) found washing hands frequently with soap and water very inconvenient. capacity for coping with emotional responses in covid 19 pandemic work when asked about their emotional response to ncov-19 infection, almost all of them (99%) answered that they feel worried about the possibility of acquiring ncov-19 dobe m, sahu m, taklikar c, dutta s. a study on risk perception, cognitive awareness and emotional responses to identify unmet training needs of frontline health care workers (flhcws) for covid-19 containment in india (original research). seejph 2022, posted: 29 october 2022. doi: 10.11576/seejph-5976 p a g e 7 | 10 infection. 94% of them said that ncov-19 is causing a lot of fear amongst them. 90% of them also responded that it is something they think about all the time and 41% of flhcws admitted that they feel helpless because of ncov-19. 22% of flhcws admitted that they search for information about ncov-19 more than 10 times a day. most of them (64% reported checking covid related information more than 10 times a day due to worry. 42% of the respondents said that getting infected due to their job responsibilities, was a major concern to them; some others (5.3%) reported non availability of sufficient ppe kits as a major concern. however, 59% of flhcws felt that ncov19 infection could be combatted through their own practices. figure 2. perceptions of flhcws about ncov-19 infection and emotional response towards it (n=131) on probing about other challenges faced while doing active surveillance in the community, more than half of the flhcws reported that the stigma against the virus has also set off a chain of harassment against them, further demolishing their morale. anxieties of their family members over their possibility of getting infected and transmitting it to others in the household also affected their attitude towards work. some of them also reported feeling lonely and depressed when they stayed isolated at home due to the compulsion of maintaining physical distancing from their friends, relatives and family members. identified unmet needs for training of flhcws for effectively addressing these gaps: for performing covid-19 related work, almost 96.2% of the flhcws had received some training regarding covid-19. however, most of them said that the training sessions were unstructured and not uniform. also, the training session lacked psychological component for capacitating them with coping skills to address the psychological responses. discussion in a similar study for risk perception assessment of covid-19 among portuguese healthcare professionals (hcps) it was found that 54.9% of hcps believed there was a high probability of becoming infected. regarding the likelihood of family and friends becoming infected, about 60% of them felt there was dobe m, sahu m, taklikar c, dutta s. a study on risk perception, cognitive awareness and emotional responses to identify unmet training needs of frontline health care workers (flhcws) for covid-19 containment in india (original research). seejph 2022, posted: 29 october 2022. doi: 10.11576/seejph-5976 p a g e 8 | 10 a “moderate” probability. regarding the perceived effectiveness of the quarantine measures, more than 70% believing it to be “very effective”. most participants (60.0%) had the opinion that communication from the health authorities was “moderately adequate”. when asked about health services' preparations to manage this pandemic, 63.5% of the hcps responded to be “poorly prepared” (7). in another study conducted in italy it was found that health workers reported higher risk perception, level of worry, and knowledge as related to covid-19 infection compared to general population. psychological state, gender, and living area were found to be important predictors of these factors. instead, judgments about behaviours and containment rules were more linked to demographics, such as gender and alcohol consumption (8). in a questionnaire-based on-line survey taken by a total of 744 healthcare personnel (mostly indian) about 80% of the healthcare professionals were worried about being infected. almost 98% of healthcare professional, identified ‘difficulty in breathing” as the main symptom and more than 90% of the respondents knew and practiced different precautionary measures. a minority of the respondents (28.9%) knew that there was no known cure yet. almost all respondents from both the groups agreed on seeking medical help if breathing difficulty is involved and selfquarantine if required (9). in another cross-sectional, web-based study conducted among 529 hcws in iran, it was seen that a significant proportion of hcws had poor knowledge of its transmission (61%) and symptom onset (63.6%) but showed positive perceptions of covid-19 prevention and control. factors such as age and profession were associated with inadequate knowledge and poor perception of covid-19 (10). a cross-sectional study was performed between january 2020 and february 2020 at district hospital, ho chi minh city in 327 healthcare workers showed good knowledge with approximately two thirds of the participants well aware about the mode of transmission, isolation period and modalities of treatment and held positive attitude regarding the risk of personal and family members getting illness. there was a negative correlation between knowledge scores and attitude scores (r=-0.21, p<0.001) (11). an online cross-sectional study undertaken in a teaching hospitals (muths) in uganda through whatsapp messenger among hcws reported that hcws had sufficient knowledge, 21% (n = 29) had positive attitude, and 74% (n = 101) were following good practices toward covid19. factors associated with good practices were age 40 years or more (aor: 48.4; 95% ci: 3.1–742.9; p = 0.005) and holding a diploma (aor: 18.4; 95% ci: 1–322.9; p = 0.046) (12). findings from an online survey-based study conducted among healthcare professionals in pakistan showed hcps have good knowledge (93.2%, n=386), positive attitude and good practice regarding covid-19. hcps perceived that limited infection control material and poor knowledge regarding transmission of covid-19 are the major barriers in infection control practice. factors such as age, experience and job were significantly associated with good knowledge and practice. conclusion risk perception and fear of vulnerability to covid 19 was high among the flhcws leading to a greater chance of flhcws being unwilling to participate actively in the programs for response to pandemics in future. flhcws need to be better trained with substantial emphasis on emotional and mental wellbeing and should be provided with all the essential commodities particularly sufficient personal protective equipment, to conduct active surveillance safely. emphasis is needed during training dobe m, sahu m, taklikar c, dutta s. a study on risk perception, cognitive awareness and emotional responses to identify unmet training needs of frontline health care workers (flhcws) for covid-19 containment in india (original research). seejph 2022, posted: 29 october 2022. doi: 10.11576/seejph-5976 p a g e 9 | 10 to build capacity emotional and psychological coping skills for reducing emotional and psychological distress of flhcws deployed for work during pandemics. the community also need to be better informed and motivated to avoid stigmatization and harassment of the flhcws. references 1. world health organization. coronavirus disease 2019 (covid-19) situation report – 98. who; 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(accessed: april 28, 2020). __________________________________________________________________________________________ © 2022 dobe et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.medrxiv.org/content/10.1101/2020.04.13.20063198v1.full.pdf https://www.medrxiv.org/content/10.1101/2020.04.13.20063198v1.full.pdf https://www.medrxiv.org/content/10.1101/2020.04.13.20063198v1.full.pdf bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 1 | 12 original research evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal martial coly bop 1, kossivi akoetey 2, boubacar gueye 1, cheikh tacko diop 1, papa gallo sow1, ouseynou ka 1, abdoulaye diop 4, fatou sarr sow 3 1 alioune diop university of bambey; 2 school of economics, clermont auvergne university; 3 cheikh anta diop university of dakar; 4 assane seck university of ziguinchor; corresponding author: dr martial coly bop; address: alioune diop university of bambey /region of diourbel, departement of bambey, box 54, bambey, senegal; email: martialcoly.bop@uadb.edu.sn mailto:martialcoly.bop@uadb.edu.sn bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 2 | 12 abstract access to health services is a concern around the world. different strategies were developed, but africa’s rate remains the lowest. this article aims to contribute to the population's access to healthcare, and to assess the determinants of the use of mutual health insurance by the population of the ziguinchor region in senegal. methods: the study is transversal and descriptive, carried out from july to august 2018. through the quota method we defined the number of patients to be interviewed. thus, by a geographic stratification according to the departments and a second-degree stratification taking into account the staff of the different hospital departments, 392 patients were selected. results: 73% at the regional hospital center and 27% at the regional peace hospital. response rate: 97%, women 60% and men 40%. the enrollment for women (24%) is slightly higher than that for men (21%). socio-economic factors. the rate of adherence is the highest of for patients with university level, followed by high school; income: the highest rate for patients with a monthly income between 200,000 and 500,000 fcfa, followed by patients with an income monthly between 100,000 and 200,000 fcfa. factors linked to the provision of care: the rate of mutual health insurance adherence follows distances from patients' homes. concerning the relation to satisfaction, education, distance and information are more determining than adherence rate. recommendations: 1) state: actions on education and distance; 2) sensitizing the population on mutual health insurance; 3) urging healthcare providers to reduce waiting times and respect schedules as well as appointments. keywords: mutual health insurance, membership factors, insurance, universal coverage, care services access, healthcare providers, senegal. bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 3 | 12 introduction during the colonial period, health care was free for the urban populations (6). faced with the difficulties of the health system, reorganization was adopted for the partial recovery of costs through the participation of the populations in care costs. despite these actions, several constraints remained, including the reduction in access to health care and the weakness of the social security system which only covers a tiny part of the african populations (1). access to health care and services is a concern around the world. this situation is explained by the multitude of barriers, financial, geographic and socio-cultural. in africa, with the end of the welfare state, countries subjected to the rigors of structural adjustment in the 1980s could no longer bear all the costs relating to the provision of care and services to the population. the low participation of the state in health expenditure generates about 85% of the expenditure borne by patients, resulting in increased expenditure and impoverishment of households. to help people get out of this self-sustaining poverty, situation, initiatives have been taken to improve the health sector and contribute to poverty reduction. however, the finding is less encouraging, and africa remains the continent with the lowest rate of access to health care (8,2%) (1). thus, the world health organization and the united nations international children's relief fund have agreed to help low-income countries to set up a system of pooling health risks to increase health coverage for populations and significantly reduce payment for health services at the fund. in this new impetus, many low-income countries, including senegal, have opted for the establishment of a risk pooling system based on mutual health insurance. developed in several african countries, it shows low population coverage (2, 7). several studies have been carried out, particularly in the region of ziguinchor and kaffrine in senegal (3, 4) to identify weaknesses and strengths in the system, to enable leaders to make corrections. we note that in senegal, more than 80% of the informal sector haven’t joined (5). it’s therefore to contribute to a better knowledge of the subject and provide useful information to public decision-makers that we situate our study, in order to understand the factors likely to strengthen the coverage of mutual health insurance (mhi) in africa, in particular, in senegal. thus, our objective is to assess the determinants of the use of mhi by the population of the region. methods the study was carried out in the ziguinchor region (three departments, 641,253 inhabitants (8) and two level 2 hospitals, regional hospital center (rhc) and peace hospital (ph) in ziguinchor. the information collected from the nursing services of the two structures enabled us to estimate the annual number of patients for the rhc at 63,756 and 43,206 for the ph. the study was cross-sectional and descriptive. the study population consisted of patients from hospitals, who are concerned with community-based health care services and coming from the region. any patient at the hospital who agreed to be interviewed was included in the study. however, any patient with limitations in responding or with a disability during the survey period or under the age of 18 or over 60 or receiving a health insurance institution or budget charge was excluded from the study. sampling and sample size the units in the sample were only patients from members and non-members of the mhi coming from all departments in the region for treatment. the quota method was used to define the number of patients to be interviewed, bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 4 | 12 according to the administrative departments and to the different hospital services. first, we did a geographic stratification according to the three departments of the region: the quotas of patients to be interviewed depended on the size of the populations in each department (table 1). table 1: distribution of the population according to the departments table 2: distribution of patients in hospital departments 2016-2017 départements population ajusted population (11%) ziguinchor 330 112 293800 bignona 318 478 283445 oussouye 64 850 57717 total 713440 634962 regional hospital hospital of peace services 2016 2017 average 2016 2017 average medecine 2961 3525 3243 2961 3525 3243 surgery viceral 886 574 730 886 767 827 surgery ortho 1927 1669 1798 1927 1667 1797 sau 10918 12143 11531 10918 12137 11528 maternity 7671 6981 7326 7671 6981 7326 orl 2187 2148 2168 2187 2148 2168 cardiology 560 465 513 560 495 528 stomatology 1265 1327 1296 1265 1327 1296 ophtalmology 5724 7239 6482 5724 7239 6482 physiotherapy 465 439 452 465 439 452 crao 530 368 449 530 347 439 radiology 7524 7454 7489 1322 2361 1842 laboratory 18856 17325 18091 2975 3207 3091 dermatology 2126 2254 2190 2126 2255 2191 total 63600 63911 63756 41517 44895 43206 bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 5 | 12 second, we did a second-degree stratification taking into account the staffing levels of the different departments of the two hospitals. the number of patients to be interviewed in the different departments was defined according to the number of patients in each department (table 2). to avoid duplication, we have only presented data on the number of consultants. to determine the sample size, we set a margin of error of 5% and a confidence level of 95%. in the framework of our study, the parent population is known and according to the theorem of the centered and reduced normal distribution, when a random sample of size is not greater than 30, the distribution of the sample follows a normal distribution n of mean p and standard deviation σ (p) with σ (p) = √𝑝 ∗ [(1 − 𝑝)]/𝑛 . assuming the assumption of the sample with replacement, we have: t * l with t the confidence rate that we establish at 95% and l the margin of error set at 5%. the formula for the size of the sample was thus obtained: 𝑛 = 𝑡2 × 𝑝(1 − 𝑝) 𝐿2⁄ , p being the rate of adhesion of the population to mhi in the region. according to the regional agency for universal disease coverage (acmu) of ziguinchor, it would be 39.9%. according to calculations, the minimum sample size is 369. at this figure, we weighted by adding a 10% margin to account for non-responses or recording errors. the sample size was estimated to be 405. variables studied the literature review helped to choose the variables cited below. the socio-economic determinants were composed of sex, marital status, level of education, socio-professional status, association membership and income of the patients. demographic determinants consisted of household size and patient age. the determinants linked to the use of mutual health insurance were represented by membership in a mutual health insurance, the reasons for membership, for non-membership in mhi, the means of information on mhi, the perception of members for mhi, preference for membership in mhi and respect for the medical pyramid. regarding services, the determinants related to the distance from the nearest health center, the competence of care providers, satisfaction with care, inequalities in relation to care and the waiting period. data collection data collection was carried out during the period from july to august 2018. we used the sphinx software for the design, layout and adjustments of the questionnaire. after designing the questionnaire, we had to train a total of eight people to collect the data. during the training, we translated the questionnaire into the local language, followed by a field test on patients not concerned by the survey, including patients from the entry office. this test step of the questionnaire allowed us to interview around 20 patients and correct shortcomings on the questionnaire, including the order of the questions and the way in which the answers were recorded. it also allowed us to determine together with the trained agents, a clear and concise message on the definition of mhi, the interest and the acceptance to participate in the study that was transmitted to patients who were not members or who have never heard of mhi, and also determine the interview time. data processing and analysis we used the sphinx software to enter and codify the data. after the entry, we did a detailed proofreading, and we corrected the anomalies observed in the database. then, the stata software helped in the statistical analysis of data on socio-economic bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 6 | 12 and demographic characteristics, the use of mhi and the provision of care. to deepen the analyzes in order to identify the factors related to the adhesion and use of mhi, we carried out an econometric modeling. the variable to be explained is adherence to mhi. it is made up of the yes modality if the patient is a member of an mhi and the no if not. the dependent variable being a binary qualitative variable with two modalities and the explanatory variables are either qualitative or quantitative. the logistic model was chosen for the data analysis. as the study is cross-sectional, this method allowed us to compare individuals with each other. to do this, we used the following logistic regression equation: logit𝑦𝑖 = 𝛼 + 𝛽j𝑥𝑖j + 𝜀𝑖: 𝑦𝑖 is the dependent variable for individual i in the sample. here it represents mhi membership and is a binary qualitative variable with 1 if the patient is a member of a mhi and 0 if not; 𝜶 is the constant that explains the random part of mhi membership; 𝛽j represents the effect of an explanatory variable j in the model, i.e. the effect of determinants on mhi adherence; 𝑥𝑖j represents the explanatory variable j for an individual i of the model; 𝜺𝒊 represents the error term. in order to capture all the possible effects of the explanatory variables, we adjusted the model. therefore, we performed the chi-square goodness-of-fit test. results in total, we surveyed 392 patients from the various hospital departments and departments in the region, including 73% surveyed at the rhc and 27% surveyed at the ph. compared to pre-established estimates, we recorded a response rate of 97%. socio-economic characteristics of patients the results of the survey showed that women made up 60% of the sample compared to 40% of men. the enrollment rate for women was slightly higher than for men. in the sample, married patients were predominantly represented, followed by single people. in contrast, the membership rate was higher among divorced people who represented only 7% of the total sample (table 3). patient demographics in our sample, the average household size was 10 people and a maximum of 30 people for larger families. the patients interviewed had in their families on average two children under 5 years old and on average two people over 60 years old. the average age of the patients was 34 years. factors related to the use of mhi the results of our survey of patients in hospitals in the region showed a 23% adherence rate. regarding patients who had no health coverage, 53% said they had never heard of universal or community health coverage. of those patients who had heard of it at least once, 67% said they did not have clear information about the enrollment processes, prices, location, and content of the program. the remainder said they did not trust mhi because some pharmacies and health centers would refuse members' diaries; or that they found the procedures too long or that «the program is no longer moving forward because the state is no longer providing funding» (table 4). the mhi encountered difficulties related to late payments of state subsidies, which limited their functioning and activities. they have a major problem related to the lack of staff. the voluntary staff in charge of the management of the mhi incurred exorbitant expenses related to travel and catering which were not reimbursed by the mhi. bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 7 | 12 table 3 : the socio-economic characteristics of the patients surveyed characteristics member non member total sample sexe female 24,15 75,85 60,46 male 20,92 79,08 39,54 marital status single 15,38 84,62 33,16 partner 0 100 0,26 divorced 30,77 69,23 6,63 married 27,03 72,97 57,4 vidower (vidow) 10 90 2,55 level of study no 13,64 86,36 16,84 koranic school 25 75 10,2 primary 15,56 84,44 11,73 secondary 24,39 75,61 42,35 university 31,08 68,92 18,88 socioprofessionnal status farmer/breeder 26,47 73,53 8,67 artisan 7,69 92,31 3,32 other 22,22 77,78 11,48 trader 20 80 27,3 employee(private) 36,11 63,89 18,62 student 18,92 81,08 18,88 household 17,39 82,61 11,73 associative membership in the past 27,5 72,5 11,8 no 20,16 79,84 38,35 yes 28,14 71,86 49,85 patients income under 30 15,52 84,48 29,59 30-60 24,46 75,54 14,54 60-100 26,56 73,44 3,06 100-200 28,07 71,93 35,97 200-500 33,33 66,67 16,58 over 500 0 100 0,26 bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 8 | 12 table 4: factors related to the use of mhi characteristics freq. percent member of a mhi no 300 77.12 yes 89 22.88 reasons for no belonging to mhi other 137 46.60 don’t know the mhi 157 53.40 reasons for non-mhi membership proceédures too long 2 1.52 to desist 1 0.76 pharmacies refuse notebooks 2 1.52 lack of information 88 66.67 lack of confidence 30 22.73 lack of means 3 2.27 program stopped 5 3.79 in progress 1 0.76 means of information on mhi other 17 12.98 mass awareness 13 9.92 member of mhi 28 21.37 the medias 27 20.61 a relative 46 35.11 perception des membres aux mhi good 99 84.62 bad 4 3.42 very good 14 11.97 preferred membership modes of members of mhi individual 10 8.70 family 99 86.09 (associative) group 6 5.22 respect for the medical pyramid no 21 36.21 yes 37 63.79 bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 9 | 12 factors related to the provision of care patients with a health center less than two kilometers from their homes have the highest adherence rate, followed by patients who have a health center between 2 and 5 kilometers from their homes and patients whose homes are more than 10 kilometers from a health center are not members of the mhi. most of the patients surveyed admit that healthcare providers are in control of their job and therefore competent. patients who think healthcare providers are very competent show a higher rate of 44% membership while those who think providers have no skills are not members of mhi. likewise, the majority of respondents are satisfied with the treatments received. the results of econometric modeling have shown that the presence of people over the age of 60 in the household has a significantly negative impact on mhi membership. with regard to overall satisfaction, the majority of patients surveyed declared that they were not satisfied; 55% of them say that the waiting times are too long and that they are not well received (table 5). table 5: factors related to the provision of care characteristics member non member total sample distance to the nearest health center under 2 26,58 73,42 56,89 ]2-5] 19,33 80,67 38,78 ]5-10] 7,69 92,31 3,32 ]10-20] 0 100 0,51 over 20 0 100 0,51 health care provider skills no skills 0 100 1,81 moderately competent 17,86 82,14 14,51 competent 16,07 83,93 58,55 very competent 44,33 55,67 25,13 satisfaction with care yes 23,33 76,67 84,87 no 20,69 79,31 15,13 inequalities in relation to care yes 29,25 70,75 28,57 no 21,51 78,49 71,43 timeout short 38,46 61,54 3,34 normal 28,57 71,43 41,39 too long 17,84 82,16 55,27 bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 10 | 12 the results of the estimations showed that neither the income, nor the association membership, nor the presence of children in the household, nor the age of the patients, nor the satisfaction linked to the treatments received nor the aforementioned waiting times have significant impact on mhi membership. regarding the level of study, the estimations carried out have shown a significant effect of the secondary level of education on the adherence to the mhi. patients who have a level of secondary education have a 195% chance of adhering to the mhi, in contrary to patients who don’t have any level of study. likewise, the estimates of the results from the logistic regression and the robustness model have shown that variables such as household size, the presence of elderly people in the household, the perception that individuals have on mhi and their self-confidence, and the respect of the long procedures to receive care have a significant impact on the adhesion to the mhi. the significantly positive impact of the size of the household on the membership in the mhi companies shows that the larger a household, the more it adheres to mhi. finally, the result of our data analyzes showed a significantly negative effect of adherence to the medical pyramid on mhi adherence. this means that the more restrictions there are in the procedures to be followed in order to receive care, the less the members have free choice of treating physicians and the less they adhere to the mhi. in addition, some patients felt that the posts and health centers are full of poor skills and can worsen their health in the event of illnesses that would require strong skills or emergencies. these results, little known in the literature, constitute a particular contribution of this study (table 6). table 6 : logistic regression logistic regression number of obs = 332 lr chi2(6) = 230.76 log likelihood = -71.316718 prob > chi2 = 0.0000 pseudo r2 = 0.6180 appartenencems2 odds ratio std. err. z p>|z| [95% conf. interval] pyramidmedical .1125208 .0543078 -4.53 0.000 .0436922 0.2897759 taillemenage 1.143535 .0461296 3.32 0.001 1.056604 1.237618 confiancems 8.769468 4.12697 4.61 0.000 3.48652 22.0574 personneagee .3468341 .1663387 -2.21 0.027 .1354855 .8878728 niveausecond 2.957122 1.42276 2.25 0.024 1.151677 7.592902 perceptionms 56.59515 29.61976 7.71 0.000 20.29049 157.8578 cons .000432 .0005158 -6.49 0.000 .0000416 .0044867 bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 11 | 12 discussion the shortcomings identified in the context of our work are of three types: representativeness bias, information bias and judgment bias. according to the literature, depending on the nature of the questions asked, the answers of those in favor can tend to be those of biased actors (9), which can generate judgment biases. to this end, it would imply caution in interpreting the results across the region. studies on the determinants of mhi adhesion and use are few and lack of available data (10). the few rare studies that have addressed the subject are unanimous on a number of factors such as: education, lack of communication and low household income. in our study, the results showed that adherence is progressive depending on the level of study. these results are similar to the one carried out in ziguinchor (3) which claims to have found a significant link between the level of education of the head of household and membership in the mhi. also, as patients' income increases, so does their willingness to pay mhi premiums. education has a significant impact on health. it enables highly educated people to have a high socio-economic status, improves entrepreneurial capacities (11). thus, people with a high level of education would be likely to have health coverage and by extension, to join more in the mhi. like education, according to the literature (10, 4), income is a key variable in the factors of mhi adherence. in contrast, in other work (2, 12), the authors have shown that they found no significant association between income and mhi membership. demographics also play an important role in mhi membership. household size and the presence of elderly people in the household have a significant impact on mhi membership. the significantly positive impact of household size on membership in mhi shows that the larger a household, the more it adheres to mhi. conversely, the presence of people over the age of 60 in the household has a significantly negative impact on mhi membership. this result is confirmed by the study carried out in the ziguinchor region (3). it could no doubt be explained by the establishment of free programs of the state for the latter. the almost free care for people over 60 years old would prevent them and those around them from joining the mhi. in order for there to be consistency between the free programs put in place and the health coverage program by the mhi, a partial subsidy for the care of the latter would make the two programs more equitable and would prevent individuals, especially older, to anticipate not to join the mhi. then, the state could put in place a policy of gradual subsidies in favor of large families. one of the main factors which would constitute a brake on adhesion identified through this study is the lack of information, which has also been identified in certain works (3, 2). thus, mhi, through their unions departments, should organize more mass awareness sessions in public places, in the media and more in private than public training centers. the study did not identify a significant impact between factors related to the provision of care services and adherence to mhi, as some studies suggest (1, 3, 13). this would undoubtedly be linked to the embryonic state of the start of the mhi system in senegal. in contrast, the patients surveyed raised huge issues that need to be addressed to support the process towards mhi maturity. the results of the study showed that the mhi adherence rate also tracks distances from patients' homes. these results are supported by various studies (12, 3) of households which indicate that low adherence is linked to the distance between the household and the health center and the residence in rural areas. this study examining factors related to mhi adherence and use, admittedly had its limitations such as representativeness bop mc, akoetey k, gueye b, diop cht, sow pg, ka o, diop a, sow fs. evaluation of determinants of the use of health mutuals by the population of the ziguinchor region in senegal (original research). seejph 2021, posted: 25 april 2021. doi: 10.11576/seejph-4380 p a g e 12 | 12 © 2021 coly et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. bias, information bias and judgment bias, but also had advantages. it could provide a broader knowledge of the functioning of the mhi in senegal and help to identify the factors which would constitute a hindrance to the membership of the mhi in the region. it also provided useful information to help local policy makers and mutual managers to improve the operating system of mhi for greater membership. indeed, our study has shown that the factors which would constitute a brake on the adhesion and the use of the mhi are essentially the lack of information, the income, the education, the large size of households and the presence in household of persons over 60 years of age. conclusions mutual health insurance is a topical issue in the health systems of african countries today. this initiative is taking on an unprecedented scale in the journey of building a resilient health system in africa. although the health risk coverage system through the mhi in senegal is still in a state of initiation and requires more monitoring, it has solid foundations and considerable advantages that could serve as a reference model for other countries on the continent. recommendations: 1) state actions on education and distance; 2) sensitizing the population on mutual health insurance; and 3) urging healthcare providers to reduce waiting times and respect schedules as well as appointments. ____________________________________________________________________________ amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 1 | p a g e c review article post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa mcking i. amedari 1, ifunanya carista ejidike 2 1department of preventive and community dentistry, obafemi awolowo university teaching hospitals complex, ile-ife, osun state, nigeria; 2access to medicine foundation, amsterdam netherlands; corresponding author: dr. mcking i. amedari bds, mph; department of preventive and community dentistry, obafemi awolowo university teaching hospitals complex, ile-ife, osun state, nigeria; email: mckingamedari@yahoo.com mailto:mckingamedari@yahoo.com amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 2 | p a g e abstract aim: to analyse options for maximising the capacity of human resources for health to achieve universal health coverage (uhc) in africa. methods: articles were retrieved from a pubmed search and additional snowballing was conducted to provide other relevant sources. further utilizations were made of campbell's modified framework of the human resources for health (hrh) and universal health coverage with the who labour market dynamics framework for universal health coverage. four sub-themes viz improved hrh performance, labour market factors, rural health workers retention factors, and information technology factors were analysed. results: labour market factors such as the dynamics of demand and supply of health workers determine the availability of health workers. supportive supervision enables the health workers to improve in their performance and enhance optimised utilisation of available resources. this supervision can be more effective by complementing it with tools such as information technology that focus on improving the quality of health care, considering the growth in the number of internet and broadband users in the continent. conclusion: expanding the training opportunities for health workers and also increasing the funding to human resources for health are useful policy options to consider. cost-effective approaches such as a focus on community health committees which stimulate the demand for health services in rural communities to tackle the disproportionate distribution of health workers should be considered in the context of the uncertain economic aftermath of the covid-19 outbreak. keywords: covid-19, human resources for health, supportive supervision, market factors, information technology. sources of funding nil acknowledgement we express profound gratitude to prof flavia senkubuge for providing technical help and writing assistance during the preparation of this manuscript. we also appreciate dr. aborisade adetayo for assisting with editing of the manuscript. conflicts of interest the authors declare no conflict of interest. author contributions mia drafted the entire manuscript. ice provided a critical review and made substantial contributions to the design of the manuscript. amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 3 | p a g e introduction africa is inundated with a dual burden of diseases (1). communicable diseases are more prevalent on the african continent than elsewhere, and it is mainly linked with extreme poverty and the poor living conditions that many experience (1). non-communicable diseases (ncds) are also on the rise, especially among poorer communities: its under-reporting, however, makes the spectrum complicated to detect and treat. in countries like namibia, seychelles, and mauritius, 50% of deaths among adults are attributable to ncds (1,2). the covid-19 outbreak has exacerbated poor health outcomes in badly affected countries on the continent culminating in rising cases of ncd related morbidities and mortalities (3). this invariably overburdens health systems that are previously struggling to respond to health needs and further weakens the capacity of human resources to play a central role in mounting a robust response to the emerging health problems in the context of an epidemiologic and demographic transition (1,4). it has become imperative that "adequate, skilled, well trained and motivated" human resources for health is needed in the trajectory towards universal health coverage (4). many countries in africa face socio-economic challenges, with constraints on their fiscal space and limited government expenditure on health (5). some countries are only just emerging from conflict situations or security challenges, or natural disasters that impose specific limitations on the healthcare worker's availability. the number of healthcare workers present at the health centres and the actual number needed at these facilities is customarily imbalanced and although there have been attempts at planning workforce using epidemiological and demographic surveys, not much more attention has been given to the evolving market factors that also influence this situation (6,7). the shortage of health workers is a global challenge, but this is more prevalent in africa with its perilous shortages projected to be up to 6 million health workers by 2030 (7). this shortage becomes glaring in the context of the rural-urban disproportionate health worker distribution despite a larger population size in rural communities (8). beyond availability, possession of adequate competency, motivation to deliver quality health services provided in a culturally acceptable way as well as an equitable distribution of health workers are necessary considerations for effective coverage of the health system (7). community health workers remain an integral part of the workforce in rural communities and have to deal with multifarious tasks and poor remuneration in carrying out their duties. nevertheless, with attention to supportive supervision, it is suggested that this will enhance the motivation and the performance of these workers and also improve the quality of health care (9). additionally, investment in innovative technologies for health systems has also been suggested as a cost-effective solution to challenges such as lack of trainers or quality guidance for the workers in the frontline (10). while the focus is on human resources for health, implementation and contextual factors limit interventions to improve health outcomes in africa. this review seeks to analyse options for maximising human resources for health to achieve universal health coverage in africa. methods the review uses themes from the campbell's modified framework of the human resources for health (hrh) and universal health coverage (uhc) with the who labour market dynamics framework for universal health coverage presented in the who global strategy for workforce towards uhc in 2030. by focusing on the common difficulties that affect health amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 4 | p a g e worker training, retention, performance and quality of service provision according to the hrh strategy document (7), sub-themes were purposively determined to guide the analysis in this review. these include labour market and the availability of health workers, retention of health workers in the rural areas, training (supportive supervision) and information technology to improve performance. a detailed search was next conducted utilizing the pubmed database. this database was selected because it comprises the largest collection of peer-reviewed articles globally. there are over 30 million citations on the database and fulltext contents are linked with it. the search was guided by the four study sub-themes and conducted using several keywords including: "market forces", "market factors" "human resource for health", "hrh", "africa", "retention", "communities", "rural", "supportive supervision", "quality", "health care", "universal health coverage"," uhc", "information technology", appropriate boolean terms "and" "or" were utilized to facilitate the search. no date filter was used and relevant articles to the topic were selected from a large pool of 173 articles at the first search. (please refer to appendix). targeted snowballing from the list of references was also conducted to complement the list of scientific publications used, following the guidance of: figure 1. human resources for health and effective coverage (campbell et al, 2013 as cited by (7): p.11); figure 2. who labour market dynamics. (sousa a, scheffler m r, nyoni j, et al, 2013 as cited by (7): p. 13). results the results will be presented considering, the main factors influencing the availability, accessibility, acceptability, and overall quality of hrh divided into four umbrella factors or subthemes namely, labour market factors, rural health workers retention factors, health workers obligatory education and supportive supervision factors and information technology factors. furthermore, these four factors are underpinned by financial, professional, infrastructural, and procedural support, see figure 3 in the appendix. labour market factors attention should be focused on the health worker preferences and the dynamic labour market (6). health workers may be interested in alternative positions or may emigrate against the health care needs that require their availability. furthermore, there is an imbalance between the supply (health workers available) and the demand for health workers (health workers hired) resulting in either inefficiency of government spending or under-employment (6). the labour market in the health sector is determined by the interactions between the supply and the demand for health workers. the demand for health workers has hinged on the government, private or external donor readiness to pay (hire) health workers (6). this is a function of the flexibility of spending or the fiscal space from which health care expenses can be determined. notably, per capita income and health worker density are both lowest in africa compared to other continents (5,7,11). supply of health workers, on the other hand, depends on the emoluments and upon other socio-economic, political and demographic factors. an analysis of these market conditions is necessary to guide policymaking concerning human resources for health towards achieving universal health coverage. policies can be directed towards the increase of training opportunities for health workers when the challenge is supply related or towards increased government allocation of funds for the health workforce in when the challenge is demand related. additionally, a more comprehensive approach will be a bidirectional policy inclination (6). amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 5 | p a g e while the two options require major government spending to increase the availability of hrh, many african countries lack the capacity for flexible expenditure (5). a pragmatic way is to invest in more cost-effective spending such as funding community-based health workers. this category of health workers requires training of shorter duration and lower financial investment. they also play a prominent role in stimulating demand for health services in rural areas, expanding coverage of health services and improving health outcomes in neglected communities. this has been exemplified in countries like ethiopia and niger where constraining macroeconomic conditions informed this approach. similarly, this category of health workers are shown to be more readily retained in underserved areas and not as easily affected by the conditions of the labour market in the health sector (6, 11, 12). furthermore, wage bills can influence health workforce availability or the attractiveness of the health sector to unemployed health workers. government wage bill policies have been implemented in some african countries such as rwanda, kenya and zambia. vujicic et al. (13) studied the consequences of the bill on the health workforce of these countries with mixed outcomes. expansion of the health workforce occurred in rwanda while the wages were maintained. in zambia however, challenges with occupying budgeted posts were identified as the obstacle to expansion and in kenya reduction of the wage bill prevented the growth of the workforce. in ghana, government spending on the public sector wage bill increased from 3.6 in 2000 to 6.7% in 2008, while the health sector wage bill rose as a percentage of the total wage bill from 9% to 15% (14). although with minor changes, in monetary terms, the public spending on health increased. during the same period, while the wage bill increased by 5 times the health sector workforce increased substantially. with a largely decentralized health workforce to regions and districts, the resource allocation was channeled to districts, subdistricts and community-based committees and funding increased by 10%, while allo cation to tertiary hospitals dropped by 3% (14). rural health workers retention factors the disproportionate distribution of health care workers between rural and urban areas despite a majority of the population residing in rural communities, results in higher mortality rates from these remote and rural areas. this leaves many residents seeking primary care and overcrowding the health centres in urban areas (8). this inefficient delivery of health care causes skilled workers to be underutilized and consequently overburdened; this could also be complicated by emigration of these workers for a more rewarding income package. against this backdrop, the who provided evidence-based recommendations to improve retention of health workers in rural communities (8). these include a focus on training (enrolling students with a background in the rural communities), regulation (such as ensuring a required posting in rural and remote areas) and providing enabling incentives in the form of financial and/or professional support (8,15). in nigeria, recruitment at the primary health centre (phc) is at the call of the local government (for junior workers) and the state government (senior cadres). due to this form of governance, health worker attrition is highest at the phc and unlike the doctors and nurses, only the community health workers are readily available at the phcs (16). in zambia, hrh decentralization was also recommended for easy resource allocation to enable task shifting for essential service provision where trained professionals are unavailable (15). community health committees which are recognized in the national health policy, along with the phcs form an amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 6 | p a g e extra tier of governance that plays a key role in the retention of health workers at the phc in nigeria. these committees are made up of key persons in the community such as teachers, religious leaders and other respectable persons in the community. they support the retention of health workers by intervening when salaries to health workers are delayed or not paid and also provide social and financial support of these workers in rural communities. the resurgent awareness of the role of community health committees in retaining health workers in rural communities calls for policies that reinforces the establishment of these committees. the government and policy analysts should consider the role of community engagements such as educating the workers on their various roles to adequately uphold the provision for the scheme. notably, also, community engagements through the community health committee offer various incentives for retention of worker with or without financial investment (16). in zambia, the ministry of health introduced strategies to facilitate retention of health workers at rural communities (15). these incentives included adjunct allowances such as on-call allowances, hardship allowance, retention allowances etc. however, there was no relationship between these strategies and the worker’s desire to remain in the sector. thus, it was recommended that strategies that enable the health workers to perceive and understand the context and the characteristics of working in the facilities should be implemented. similarly, updating the financial incentives in line with the realities of inflation as it affects the cost of living should be considered for the different training duration, working hours or level of experience (15). implementation of the who recommendations on retention of health workers in rural communities requires contextualization according to individual country’s need. south africa contextualized it’s strategies to deal with a hrh crisis. in the aspect of education, it focused on training health workers in underserved communities, it also developed a social accountability framework to better respond to the communities need. other strategies included having students trained from communities where the need is greatest as well as using target community health and social needs to guide education (17). health workers obligatory education and supportive supervision factors at the heart of achieving universal health coverage is the certainty of quality of healthcare. clients are not willing to utilize healthcare in situations where the services are poor, hindering realistic achievement of uhc. and in some situations where the health service is still utilized, the health outcomes are also undermined. there are few, sufficiently trained and motivated health care staff with the requisite resources to offer essential health care in many african countries which: this culminates in poor quality of care (18,19). continuous professional development (cpd) has been identified as a means of maintaining knowledge capacity through ‘on the job’ training of nurses and midwives to function competently and attain universal health coverage (20). about 70% of the anglophone countries (n=21) including nigeria and ghana and only rwanda among francophone countries (n=20) have demonstrated evidence of mandatory cpd being operational. these programs are run by the nursing councils and the health professional councils. through this obligatory system of education, targeting global health indicators such as hiv is made possible vis the who afro region dictating licensure from specific cpd modules. also, some countries require cpd points to ensure license renewal on an annual basis. nevertheless, only 10 member states in the who-afroregion make cpd a mandatory program to complete, and there is still a shortage of nurses as well as a lack of interest among amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 7 | p a g e nurses which slows the movement towards uhc and sdg attainment in the region (20). supportive supervision is a process that promotes quality at all levels of the health system by strengthening relationships within the system, focusing on the identification and the resolution of problems. it also helps to optimize the allocation of resources'. (9: p.989) it involves enabling the health workers to always get better at the performance of their work in a nonforceful but respectful manner through supervisory visits (21). a reported increase in the proportion of health workers (community health workers), improved quality of care and sustained performance as a result of supportive supervision has been documented in the literature (22). in a systematic review of supportive supervision carried out on phc workers in low and in middleincome countries in africa, it was revealed that efficiency, quality of care, motivation and job satisfaction were positively influenced (22). critical to the improved motivation and performance was an open twoway communication and feedbacks, a fervent team spirit and the development of mutual trust between the supervisor(s) and the health worker(s) (22). the performance of community health workers is a function of the interaction with the complex health system, and it may also be influenced by intrinsic factors such as the personality of an individual. a supportive environment is thus needed to enable these health workers to play their roles as agents of social change. this implies a need to be skilled in building confidence, solving problems and communicating well with the immediate community (23). perceptibly, the higher-level health workers do not regard the inputs or efforts of these community health workers, hence organizing joint training sessions of the higher-level health workers and the community health workers aids in building better relationships between both categories. the supervisors also need to be trained about the significant roles community health workers play in strengthening the relationship with the community and its people. management and technical skills should be inculcated into the training. likewise, team building activities should be included in the training of supervisors to reduce the social distance between the supervisor and the community health workers; this will result in better relationships and an overall better performance. the community will more likely recognize the community health worker due to better supervision occurring within the health sector (23). to make supportive supervision more effective renggli et al. (19). in their tanzanian study described the effectiveness of an electronic tool to improve the quality of health care (etiqh). it was found that across different contexts in tanzania, the quality standard of primary health care was improved, and it was demonstrated to have shown a direct impact on the overall quality of care that was obtained. with strong supervision, a 'virtuous cycle' is built. there is an increase in community health worker's confidence, more cohesion between all cadres of health workers, a sense of inclusion with the health system and recognition by the community, as well as an effective referral system (22). supportive supervision, however, is not without its problems. these include the propensity for diverting attention to quantity rather than quality, also supervisory visits may be fragmented, infrequent, and inconsistent. a gap also often exists between what is known and what is done. there is often no ownership of quality development activities at the facility level without feedback on this development up to the council level as described in countries like tanzania. similarly, supervision could be de-motivating when carried out with fault-finding and can be irregularly executed. weak supervisions can also lead to a 'vicious' cycle of neglect among the health workers, absence of technical assistance, weak referral of patients and bad treatments (19, 24). amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 8 | p a g e information technology factors between 2007 and 2011, the number of subscribers for mobile broadband in developing countries rose astronomically to 458 million from 43 million, representing over 10-fold increase in the number of users (10). this implies more users of mobile devices, as well as increased access to the internet. the internet and mobile devices are also fast becoming essential tools for the health professionals in urban and rural communities. the use of mobile devices to practice medicine and public health has facilitated services in the difficult terrains and geographically inaccessible areas in developing countries. the adoption of this technology has been proposed to limit the rural health worker isolation that is usually experienced, and a study revealed that mobile dependent technologies are gradually being embraced by the health workers. it is transformative and can bridge the existing gap in human resources for health accessibility and acceptability (10). information technology can be utilized to support communication between the health providers and the clients as well as enable the capacity building of the health worker which engenders more demand for a high quality of care from the community. health workers are usually exposed to standard educators through webcasting, recording, and video conferencing. this mode of training is shown to be more cost-effective compared to educational programs held face to face. it is not considered an alternative to face-to-face education, rather it aids in reducing the challenges faced by this traditional method. it has been reported that presenting educational content and gaining competency is the goal of an educational strategy and when complemented by information technology, this goal can be essentially achieved (10). in a study on a post-conflict setting on the utilization of information technology for the retention of health workers, there was a positive perception about information technology among health worker(s) even in a setting where the applications of information technology were rare and remote. thus, there is a need to increase investments in information and technology, mobilise health workers and train the workers on the use of information technology for the delivery of health services (25). additionally, studies have proposed that information technology can serve as a major boost to health worker retention apart from other traditional strategies for retention (25,26). despite the general benefits of information technology, there are barriers to its implementation. these barriers include unreliable internet connection, unstable power supply, lack of knowledge on information technology, expensive access to computers and lack of effective policies on information technology (25). other barriers include cultural barriers and deficient interoperability between technologies and platforms (10). in addressing some of these challenges, interventions on information technology should be prioritized especially at post-conflict settings as well as for rural communities. computers are not indispensable, as smartphones can be provided for health workers in the rural communities which are useful in accessing health information and communication with professional colleagues. incentives might be required to enable health workers to accept information technology and overcome their reluctance with the approach. similarly, the collaboration between relevant ministries such as information, finance, education and health are important to develop a synergy and proper coordination of information technology use among health workers (10, 25). discussion and conclusions the post-covid-19 agenda must include human resources for health as a key critical component. human resources for health forms an essential component of any health system. yet this component of the health amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 9 | p a g e system is faced with immense crisis that borders on the shortage, maldistribution, and performance. market factors such as demand and supply issues, wage bill incre ments as well as socioeconomic factors play a role in influencing human resources availability. existing rural-urban inequalities create a disproportionate distribution of health workers in the african region which demands steps to ensure health workers are retained especially in rural communities and post-conflict communities. considering the limited fiscal space and constrained macro-economic environment in many african countries, cost-effective interventions should be adopted to ensure the sustenance in the delivery of quality health care in the remote and inaccessible areas. thus, approaches that utilize the services of community health workers who play a crucial role in stimulating demand for health care should be applied. the duration of training is shorter, they can be recruited from communities with highest health need, they form a pragmatic alternative to higher earning and higher cadres of health workers and are usually closer to the members of the community. supervision of these health workers is a vital part of the promotion of the delivery of quality health services. by focusing on the virtuous cycle created by strong supervision of community health workers, a cohesive and confident health workforce with a strong connection with the community is built and inherent in this approach is health system strengthening. embracing information technology also presents an effective means of maximizing human resources for universal health coverage. by multi-stakeholder collaboration, the challenges with the use of technology can be overcome and technology can be utilized to prevent the isolation of health workers in remote areas, encourage their retention at rural communities, facilitate their training and interaction with other health professionals. policy formulation should, therefore, focus on market factors that influence health worker retention, as well as developing sustainable supportive supervision of community health workers and the establishment of pathways for utilizing information technology as leverages in the trajectory towards universal health coverage in africa. recommendations 1. financial support: the need to improve financial investment in education and training of health workers cannot be overemphasized. more attention should be given to the provision of incentives for health workers in remote and largely inaccessible areas. 2. professional support: a broader view into health worker demand and the availability of health workers to deliver the needed services especially in the context of a post-covid19 era reveals the need for the delivery of essential health services through delegated roles in form of task shifting with a combination supportive supervision to maximize the performance. 3. infrastructural support: considering the growth in the number of users of mobile technology on the continent and the benefit it brings to the health system, efforts should be directed at removing the outlined barriers such as unstable internet and irregular power supply to aid its proper functioning in maximizing hrh capacity. 4. procedural support: an improved understanding of the contextual factors that influence retention of health workers especially at remote and rural communities is expedient for the decision-makers and government stakeholders in health. there is an urgent need to correct negative amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 10 | p a g e trends leading to health worker attrition especially at the lower tiers of governance in member states' health systems. references 1. narayan k, donnenfeld z. envisioning a healthy future: africa’s shifting burden of disease. african futures paper. iss. 2016. available from: https://media.africaportal.org/documents/african_futures18.pdf. (accessed: october 10, 2020). 2. world health organisation. available from: https://www.who.int/nmh/ncdtools/who-regionsafrican/en/(accessed: october 10, 2020). 3. mbunge e. effects of covid-19 in south african health system and society: an explanatory study. diabetes metab syndr clin res rev. 2020. available from: https://www.sciencedirect.com/scie nce/article/abs/pii/s1871402120303 696?via%3dihub (accessed: october 10, 2020). 4. mozart s, marie-paule k, ruediger k, et al. human resources for universal health coverage: from evidence to policy and action. bull world health organ 2013: available from: https://www.who.int/bulletin/volum es/91/11/13-131110.pdf (accessed : july 18, 2020). 5. world health organisation;2017.available from: https://www.who.int/healthtopics/health-accounts/#tab=tab_1 (accessed: july 18, 2020). 6. mcpake b, maeda a, correia araújo e, et al. why do health labour market forces matter? bull world heal organ; 2013. available from: https://www.who.int/bulletin/volum es/91/11/13-118794.pdf (accessed july 18, 2020). 7. world health organisation.; 2016. available from: http://www.who.int/hrh/resources/p (accessed july 18, 2020). 8. buchan j, couper id, tangcharoensathien v, et al. early implementation of who recommendations for the retention of health workers in remote and rural areas. bull world heal organ. ;2013 ;91:834–840. 9. kok mc, dé rique valliè res f, tulloch o, et al. does supportive supervision enhance community health worker motivation? a mixedmethods study in four african countries. health policy plan. 2018;33:988–998. 10. bollinger r, chang l, jafari r, et al. leveraging information technology to bridge the health workforce gap . bull world heal organ.2013;91:890–892. 11. wakabi w. extension workers drive ethiopia’s primary health care. lancet. 2008; 372: 880-880. 12. amouzou a, habi o, bensaïd k. reduction in child mortality in niger: a countdown to 2015 country case study. lancet. 2012;380(9848):1169–1178. 13. vujicic m, ohiri k, sparkes s. working in health : financing and managing the public sector health workforce. washinghton, dc: world bank publications;2009. 14. ebenezer a, christopher hh, agnes s, et al. toward interventions in human resources for health in ghana: evidence for health workforce planning and results. washinghton, dc: world bank; 2013. https://media.africaportal.org/documents/african_futures18.pdf https://media.africaportal.org/documents/african_futures18.pdf https://media.africaportal.org/documents/african_futures18.pdf https://ideas.repec.org/b/wbk/wbpubs/2621.html https://ideas.repec.org/b/wbk/wbpubs/2621.html https://ideas.repec.org/b/wbk/wbpubs/2621.html https://ideas.repec.org/s/wbk/wbpubs.html amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 11 | p a g e 15. goma fm, murphy gt, mackenzie a, et al. evaluation of recruitment and retention strategies for health workers in rural zambia. hum resour health. 2014. available from: https://human-resourceshealth.biomedcentral.com/articles/1 0.1186/1478-4491-12-s1-s1 ub_globstrathrh-2030/en/ (accessed :july 18, 2020). 16. abimbola s, olanipekun t, igbokwe u, et al. how decentralisation influences the retention of primary health care workers in rural nigeria. glob health action 03 may 2015. available from:https://www.tandfonline.com/ doi/full/10.3402/gha.v8.26616 (accessed july 18, 2020). 17. world health organisation; 2010 available from: https://apps.who.int/iris/bitstream/h andle/10665/44369/9789241564014 _eng.pdf?sequence=1 (accessed: july 18, 2020). 18. johnson mc, schellekens o, stewart j, et al. safecare: an innovative approach for improving quality through standards, benchmarking, and improvement in low-and middle-income countries. jt comm j qual patient saf; 2016 ;42(8):350-360. 19. renggli s, mayumana i, mboya d, charles c, mshana c, kessy f, et al. towards improved health service quality in tanzania: contribution of a supportive supervision approach to increased quality of primary healthcare. bmc health serv res. 2019; 19(1):848-864 20. baloyi ob, jarvis ma. continuing professional development status in the world health organisation, afro-region member states. int. j. africa nurs. sci.2020 jan 1;13:100258. 21. world health organisation;2008. available from: https://www.who.int/immunization/ documents/mlm/en/ (accessed :july 18, 2020). 22. snowdon da, leggat sg, taylor nf. does clinical supervision of healthcare professionals improve effectiveness of care and patient experience? a systematic review. bmc health serv res. 2017;17:786-797. 23. kok mc, broerse jew, theobald s, et al. performance of community health workers: situating their intermediary position within complex adaptive health systems [internet]. vol. 15, hum. resour. health.2017;15(1):59-66 24. ludwick t, turyakira e, kyomuhangi t, manalili k, robinson s, brenner jl. supportive supervision and constructive relationships with healthcare workers support chw performance: use of a qualitative framework to evaluate chw programming in uganda. hum resour health. 2018. available from: https: https://human-resourceshealth.biomedcentral.com/articles/1 0.1186/s12960-018-0272-1 (accessed:july 18, 2020). 25. yagos wo, tabo olok g, ovuga e. use of information and communication technology and retention of health workers in rural post-war conflict northern uganda: findings from a qualitative study. bmc med inform decis mak. 2017;17(1):1-7 26. mbemba g, gagnon mp, paré g, interventions for supporting nurse retention in rural and remote areas: an umbrella review. hum resour health.; 2013. available from: https://human-resourceshealth.biomedcentral.com/articles/1 amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 12 | p a g e © 2021 mcking et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 0.1186/1478-4491-11-44 (accessed :july 18, 2020). ____________________________________________________________ amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 13 | p a g e quality of hrh service utilization acceptability of hrh acceptability to hrh availability of hrh theoretical coverage by ‘availability’ of health workforce effective coverage gap population + health needs: who is provided effective coverage? appendix overview of article selection because no date filter was initially used at the first search, a total of 173 articles emerged. this was via the use of keywords and bolean terms on pubmed as stated in the main text. the titles and abstracts of these publications were next evaluated for suitability based on the two guiding frameworks: the human resource for health and effective coverage and the who labour market dynamics. the number of articles were thus reduced to 40 articles for consideration. selection criteria was then determined. these included publications not older than 20 years, who bulletins and publications and a targeted snow balling from key who articles on the themes. this was independently agreed upon by the two authors, mia and ice. consequently, this led to a final selection of 22 articles used for the review. figure 1. human resources for health and effective coverage amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 14 | p a g e figure 2. who: labour market dynamics economy, population, and broader societal drivers education sector labour market dynamics education in health education in other fields pool of qualified health workers* abroad employed unemployed out of labour force health care sector** other sectors h ig h s ch o o l health workforce equipped to deliver quality health service u n iv e rs a l h e a lt h c o v e ra g e w it h s a fe , e ff e ct iv e , p e rs o n ce n tr e d h e a lt h s e rv ic e s. policies on production  on infrastructure and material  on enrolment  on selecting students  on teaching staff policies to address inflows and outflows  to address migration and emigration  to attract unemployed health workers  to bring healthy workers back into the health care sector policies to address maldistribution and insuffciencies to improve productivity and performance to improve skill mix composition. to retain health workers in underserved areas policies to regulate the private sector  to manage dual practice  to improve quality of training  to enhance service delivery migration amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 15 | p a g e amedari mi, ejidike ic. post covid-19 agenda: maximizing human resources for health towards universal health coverage in africa. (review article). seejph 2021, posted: 08 april 2021. doi: 10.11576/seejph-4318 16 | p a g e figure 3. factors influencing the maximizing of human resources for health towards universal health coverage in africa.  labour market factors  rural health workers retention factors  health workers supportive supervision factors  information technology factors 4 main hrh factors in africa these 4 main factors affect hrh  hrh availability  hrh accessibility,  hrh acceptability,  overall hrh quality financial support | professional support | infrastructural support |procedural support these factors are underpinned by  information technology factors lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 1 review article towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights george r. lueddeke 1 1 consultant in higher and medical education, united kingdom. corresponding author: george r. lueddeke phd, consultant in higher and medical education; address: 9 lakeland gardens, southampton, hampshire, so40 4xg, united kingdom; e-mail: glueddeke@aol.com lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 2 abstract following the millennium summit of the united nations in 2000, the adoption of the united nations (un) millennium declaration by 189 nations, including the eight millennium development goals (mdgs), has been hailed as a unique achievement in international development. although the mdgs have raised the profile of global health, particularly in lowand middle-income countries, underpinned by the urgent need to address poverty worldwide, progress has been uneven both between and within countries. with over one billion people, africa is a case in point. aside from children completing a full course in primary school and achieving gender equality in primary school, none of the twelve main targets set for ss africa has been met. a key reason suggested for this lack of progress is that the mdgs fall far short in terms of addressing the broader concept of development encapsulated in the millennium declaration, which includes human rights, equity, democracy, and governance. to strengthen the likelihood of realizing the post-2015 sustainable development goals (sdgs), particularly with regard to “planet and population” health and well-being , un and other decision-makers are urged to consider the adoption of an integrated sdg framework that is based on (i) a vision of global justice underpinned by peace, security and basic human rights; (ii) the development of interdependent and interconnected strategies for each of the eleven thematic indicators identified in the un document the world we want; and (iii) the application of guiding principles to measure the impact of sdg strategies in terms of holism, equity, sustainability, ownership, and global obligation. while current discussions on the sdgs are making progress in a number of areas, the need for integration of these around a common global vision and purpose seems especially crucial to avoid mdg shortcomings. keywords: global justice, human rights, mdgs, peace, sdgs, security, sustainable development. conflict of interest: none. acknowledgement: appreciation is extended to springer publishing company for allowing the pre-publication of this section of the forthcoming book entitled global population health and well-being in the 21 st century: towards a new worldview with regard to potentially informing on-going and future discussions relating to the mdgs/sdgs. http://en.wikipedia.org/wiki/millennium_summit http://en.wikipedia.org/wiki/united_nations http://en.wikipedia.org/wiki/united_nations_millennium_declaration http://en.wikipedia.org/wiki/united_nations_millennium_declaration lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 3 “the adoption of the millennium declaration in 2000 by all united nations member states marked an historic moment, as world leaders committed to tackle extreme poverty in its many dimensions and create a better life for everyone” (1). the eight millennium development goals (mdgs) and indicators (2), “arguably, the most politically important pact ever made for international development”, (3) were adopted on a voluntary basis by 189 nations to “free a major portion of humanity from the shackles of extreme poverty, hunger, illiteracy and disease” (4), several recognizing fundamental human rights, such as health and education, to be achieved by 2015. in the foreword to the “millennium development goals report 2013” (5), ban ki-moon, secretary-general of the united nations (un), asserts that “[t]he millennium development goals (mdgs) have been the most successful global anti-poverty push in history”. he further adds: “[t]here have been visible improvements in all health areas as well as primary education.” progress on the millennium development goals according to who director-general, dr margaret chan, while “[a]ll eight of the mdgs have consequences for health”, three put health at front and centre – they concern child health (mdg 4), maternal health (mdg 5), and the control of hiv/aids, malaria, tuberculosis and other major communicable diseases (mdg 6) ” (6). mdg 1, “eradicating extreme poverty and hunger,” is on course to being achieved and has “fallen to under half of its 1990 value” (3), but remains a very serious problem in oceanian nations, according to world bank estimates. aside from “north korea and somalia,” where “the poor are getting poorer,” matt ridley in his article, „start spreading the good news on equality,‟ observes that global income inequality is “plunging downwards.”(7). from a mdg perspective, professors ulrich laaser and helmut brand point out these advances cannot be attributed to mdg commitments per se (8). their analysis shows that “the goal of 21% living below the poverty line defined as 1.25 usd/day was within reach in 2005. however, this was calculated from a baseline set at 1990, i.e., a decade before the mdgs were declared. if one compares the progress between 1990 and 1999 of 11 percentage points to the progress between 1999 and 2005 of 6 percentage points, then it becomes apparent that the pace of development has been quite similar before and after the mdg commitment in the year 2000” (8). in addition, the authors highlight “the largest chunk of progress is due to the over-achievement of china, not only halving but quartering its poorest population. the same argument can be made for malnutrition, according to the authors, standing at “19.8% in the developing countries in 1990 coming down to 16.8 in 1995 and remaining stagnant at 15.5% in 2006. however, the sheer numbers of malnourished remain stable at 848 million in 1990 vs. 850 in 2008. in sub-saharan africa, (ss africa) the numbers even increased in the last period (2003–2008) from 211 to 231 million” (9). reducing “by half the proportion of people without sustainable “access to drinking water has been achieved” (3), although the number of people without a “safe drinking water source” is still steadily increasing, and by mid-2014 there were close to 800,000 deaths from water-related diseases (10), more than 10 percent of those who do not have access to safe water. in terms of mdg 2, “[s]ignificant steps towards achieving universal primary education have also been made with “[m]ore than 9 million children … enrolled in primary education and more than 720, 000 primary school teachers have received training (2004-2009)” (11). progress has been slowest in the ss africa as well as the middle east and north africa lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 4 regions. however, according to the european union „gender equality‟ report, “the heavy focus on enrolment rates has come at the cost of educational quality and retention disproportionately affecting girls” (11). furthermore, the report underlines that “[s]econdary school completion is particularly important for gender equality and should command increasing attention.” the aim of mdg 3 is “[t]o promote gender equality and empower women”. and, while the targets and indicators within mdg 3 are important they were, according to the european union study (11), “narrowly defined,” and along with most other mdgs, “[p]rogress has been uneven both between and within countries, and indicators were inadequate to capture the lagging behind of the most marginalised groups and those facing multiple discrimination.” all ss african countries are lagging behind the mdgs, especially with regard to mdg 4 “to reduce child mortality” and mdg 5 on maternal mortality which calls for “a reduction in the number of child deaths from 12 million in 1990 to fewer than 4 million by 2015” (11). and, although “[a]ll regions have made progress, with the highest reductions in eastern asia (69%), northern africa (66%) and southern asia (64%)” (11) since the turn of the millennium progress toward mdg 4 and 5 is “well below the target to reduce the maternal mortality ratio by three-quarters by 2015” and “[o]n current trends, this is one of the targets least likely to be met by 2015” (11). as shown in figure 1, “significant disparities in infant mortality persist across regions. in sub-saharan africa, one in every 10 children born still dies before their fifth birthday, nearly 16 times the average rate in high-income countries” (12). faster progress in other regions has seen the burden of global under-five deaths shift increasingly to sub-saharan africa. figure 1: number in thousands and percent (of global total) of under-five deaths by region 2012 (12) the approach taken by the partnership for maternal, newborn and child health (pmnch) may hold important lessons for other mdgs (13). the pmnch‟s main aim is to enable lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 5 “partners to share strategies, align objectives and resources, and agree on interventions to achieve more together than they would be able to achieve individually”. partners who have joined from various organizations, including those from “the reproductive, maternal, newborn and child health (rmnch) communities” to form “an alliance of more than 500 members, across seven constituencies: academic, research and teaching institutions; donors and foundations; health-care professionals; multilateral agencies; non-governmental organizations; partner countries; and the private sector”. their evidence-based approach made clear the urgency of their work as studies revealed inter alia that “[n]early nine million children under the age of five die every year, with “[a]round 70% of these early child deaths...due to conditions that could be prevented or treated with access to simple, affordable interventions”. alarmingly, “[o]ver one third of all child deaths are linked to malnutrition” and “[c]hildren in developing countries are ten times more likely to die before the age of five than children in developed countries”. developed within the framework for the „every woman, every child initiative‟(14), their concerted action has been successful and led to the „every newborn action plan‟, which was endorsed by the 194 member-states at the 67 th world health assembly in 2014. the plan now paves “the way for national implementation and monitoring of key strategic actions to improve the health and well-being of newborns and their mothers around the world” (15). translating vision into reality includes establishing “effective quality improvement systems,” “competency-based curricula,” “regulatory frameworks for midwifery and other health care personnel” and “multidisciplinary teams” (15). mdg 6 focuses on combatting “hiv/aids, malaria and other diseases”. michel sidibé, unaids executive director, in his foreword to the “unaids report on the global aids epidemic 2013” (16), reflects that “[o]ver the years, the gloom and disappointments chronicled in the early editions of the unaids have given way to more promising tidings, including historic declines in aids-related deaths and new hiv infections and the mobilisation of unprecedented financing for hiv-related activities in lowand middle-income countries”. in his view much has been achieved since “the dawn of this century” when there was “a lack of critical hiv treatment and prevention tools” which “often hindered efforts to respond effectively to the epidemic”. today, he posits “we have the tools we need to lay the groundwork to end the aids epidemic”. achievements such as “the sharp reductions in the number of children newly infected with hiv” and “life-saving antiretroviral therapy” to the synergistic efforts of diverse can be traced to “stakeholders – the leadership and commitment of national governments, the solidarity of the international community, innovation by programme implementers, the historic advances achieved by the scientific research community and the passionate engagement of civil society, most notably people living with hiv themselves”. as with partnership (pmnch) for maternal, newborn and child health initiative (13), an important element of progressing the mdgs/sdgs lies with forming committed and workable alliances which have a common cause. while acknowledging the significant progress that has been made toward new hiv infections, zero discrimination and zero aids-related deaths, he is concerned that “[i]n several countries that have experienced significant declines in new hiv infections, disturbing signs have emerged of increases in sexual risk behaviours among people”. this ongoing uneasiness was highlighted at the prince mahidol award conference in 2014 in thailand with the overall theme, transformative learning for health equity (17). at this event dr. anthony fauci, director of the us institute of allergy and infectious diseases, outlined the challenges remaining in ending the hiv/aids pandemic, citing that in 2012 lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 6 there were over “70 million total hiv infections; 36 million total aids deaths; 35.5 million people living with aids” killing 1.6 million in 2012 alone; and 2.3 million new hiv infections. the intervention model adopted by the institute places reliance on treatment and prevention with basic and clinical research given highest priority, especially regarding antiretroviral drugs, with 12.7 million people receiving these in 2012 compared to about 200,00 in 2002. and, as mentioned, while treatment is having good results in some areas, preventive measures are faring less well as fewer “than 10 percent of people in the world who are at risk of hiv infection are reached with prevention services.” this low number is disappointing especially after “the global approach to hiv prevention” in the last three decades “has moved from a fragmented one, initiated by different communities affected by hiv, to a unified approach led by international and national organisations and governments” (18). two conclusions that may be drawn from these less-than-satisfactory statistics are, first, that “[e]xpansion of the combination prevention approach is essential to avoid future hiv infections and for the health and well-being of people living with hiv”. and, secondly, that prevention needs to be given much more priority especially in terms of resources for educational measures with a view to “empowering communities who are affected by hiv to deliver the prevention techniques that work for them”. progress with mdg 7, which seeks “to ensure environmental sustainability,” is „sluggish‟ in ss africa, southern and western asia, and oceanian countries. as one example, “[t]he proportion of people with sustainable access to safe drinking water increased from 76% to 89% between 1990 and 2011” but “accounts for just 63% in ss africa” (11). in addition, “while access to sanitation improved from 49 % to over 60%, it remains well below the target of 75%”, and has a major influence “on women and girls, for example, in their ability to go to school and in the prevention of violence. where water sources are still not available, women and girls do most of the collection”. moreover, alarmingly, high rates of deforestation hamper progress with regard to mdg 7. by mid-2014, losses in forest over a six month period were 2,187,086 hectares and land lost to soil erosion 2,944,409 hectares (10). mdg 8 “relates to the need to develop a global partnership for development” but “is conspicuous by the absence of any indicators to monitor progress” (11). this omission is highly significant as “[t]rade agreements, including intellectual property rights, discussed in 4.3, directly impact on the cost and availability of pharmaceutical products and therefore the right to health”. a millennium development goal „report card‟ table 1 shows average ratings of progress toward each of the eight mdg-2015 goals based on an informal survey involving twenty-four members of a universitas 21 health sciences mdg workshop group meeting in dublin, ireland (19). the main focus of the unmdg initiative, which comprises a network of 27 global research-intensive universities, is to facilitate incorporation of the unmdgs (future sdgs) into health care curricula through the use of interprofessional case-study pedagogy. to this end, in the past few years the unmdg team, drawn from members across the world, has conducted workshops in dublin, hong kong, nottingham, melbourne, lund, to name several locations. in addition, members have contributed to global mdg projects focusing on raising awareness about the unmdgs and networking with similar groups. mdgs 3, 6, and 8 received the highest scores but are still well below acceptable levels. mdgs 1, 3, 4 seem to fare slightly better than mdgs 5 and 7. lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 7 s c o r e -c a r d 1 (b e st ) – 5 ( w o r st ) 3 .1 3 .1 2 .8 3 .1 3 .4 2 .9 3 .4 2 .9 r e p o r te d a s o u ts ta n d in g a fr ic a p o v e rt y r is e ; 3 6 c o u n tr ie s (9 0 % o f w o rl d ‟s u n d e rn o u ri sh e d c h il d re n ); 1 o u t o f 8 p e o p le r e m a in h u n g ry ; 2 .5 b il li o n la c k i m p ro v e d s a n it a ti o n f a c il it ie s – 1 b il li o n p ra c ti c e o p e n d e fe c a ti o n , a m a jo r h e a lt h /e n v ir o n m e n ta l h a z a rd . c a . 7 2 m c h il d re n o f p ri m a ry s c h o o l a g e (5 7 % g ir ls ) n o t b e in g e d u c a te d a s o f 2 0 0 5 . f a r m o re w o m e n t h a n m e n w o rl d w id e m o re t h a n 6 0 % a re c o n tr ib u ti n g a s u n p a id f a m il y w o rk e rs ( w o rl d b a n k g ro u p g e n d e r a c ti o n p la n ) a c c e le ra te d i m p ro v e m e n ts n e e d e d u rg e n tl y i n s o u th a si a a n d s u b -s a h a ra n a fr ic a ; c a . 1 0 m c h il d re n < 5 d ie d i n 2 0 0 5 ; m o st d e a th s w e re f ro m p re v e n ta b le c a u se s (2 0 1 4 : 3 .1 m ). p ro b a b ly o n e o f th e l e a st l ik e ly m d g s to b e m e t. n u m e ro u s c a u se s o f m a te rn a l d e a th s re q u ir e a v a ri e ty o f h e a lt h c a re in te rv e n ti o n s to b e m a d e w id e ly a c c e ss ib le . f e w e r th a n 5 0 % o f b ir th s a tt e n d e d i n t h e a fr ic a n w h o r e g io n . a id s i s le a d in g c a u se o f d e a th i n s u b s a h a ra n a fr ic a ( 1 .6 m i n 2 0 0 7 ), c a se s o f h iv /a id s 3 6 m . 3 0 0 t o 5 0 0 m c a se s o f m a la ri a e a c h y e a r le a d in g t o m o re t h a n 1 m d e a th s. t re a tm e n t m e e ts o n ly 3 0 % o f n e e d . w o rl d i s a lr e a d y e x p e ri e n c in g e ff e c ts o f c li m a te c h a n g e . e m p h a si s o n p a rt n e rs h ip s e .g . t h e g lo b a l p a rt n e rs h ip f o r e d u c a ti o n a n d t h e w o rl d b a n k . c u r r e n t 1 9 9 0 -2 0 0 4 : p o v e rt y f e ll f ro m a lm o st a t h ir d to l e ss t h a n a f if th . c h il d re n i n s c h o o l in d e v e lo p in g c o u n tr ie s in c re a se d f ro m 8 0 % 1 9 9 1 t o 8 8 % i n 2 0 0 5 . t id e t u rn in g s lo w ly f o r w o m e n i n t h e la b o u r m a rk e t. s o m e i m p ro v e m e n t in s u rv iv a l ra te s g lo b a ll y . d e a th s o f c h il d re n l e ss t h a n 5 y e a rs o f a g e f e ll f ro m 1 2 m il li o n i n 1 9 9 1 t o 6 .9 m il li o n i n 2 0 0 5 . m o st o f a b o u t 5 0 0 ,0 0 0 w o m e n w h o d ie d u ri n g p re g n a n c y o r c h il d b ir th e v e ry y e a r li v e i n s o u th a si a a n d s u b -s a h a ra n a fr ic a . 2 0 1 2 : o v e r 7 0 m il li o n t o ta l h iv i n fe c ti o n s; 3 6 m il li o n t o ta l a id s d e a th s; 3 5 .5 m il li o n li v in g w it h a id s a n d k il li n g 1 .6 m il li o n ; a n d 2 .3 m il li o n n e w h iv i n fe c ti o n s. c o n ti n u in g l o ss e s o f fo re st s, s p e c ie s, a n d fi sh s to c k s a c ro ss t h e g lo b e . d o n o rs h a v e t o f u lf il t h e ir p le d g e s to m a tc h th e c u rr e n t ra te o f h e a lt h c a re p ro g ra m d e v e lo p m e n t. m d g 1 ) e r a d ic a te p o v e r ty a n d h u n g e r 2 )a c h ie v e u n iv e r sa l p r im a r y e d u c a ti o n 3 ) p r o m o te g e n d e r e q u a li ty 4 ) r e d u c e c h il d m o r ta li ty 5 ) im p r o v e m a te r n a l h e a lt h 6 ) c o m b a t h iv /a id s , m a la r ia , a n d o th e r d is e a se s 7 ) e n su r e e n v ir o n m e n ta l s u st a in a b il it y 8 ) in c r e a se g lo b a l p a r tn e r sh ip f o r d e v e lo p m e n t lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 8 lessons learned from the mdg initiative a key question the who director-general raises in her introduction to the world health report 2013, „research for universal health coverage‟(5), is how lessons learned in other nations can help to reduce deaths everywhere. one answer appears to be making better use of community-based interventions, which according to “randomized controlled trials provide the most persuasive evidence for action in public health”. by 2010, findings from “18 such trials in africa, asia and europe had shown that the participation of outreach workers, lay health workers, community midwives, community and village health workers, and trained birth attendants collectively reduced neonatal deaths by an average of 24%, stillbirths by 16% and perinatal mortality by 20%. maternal illness was also reduced by a quarter. these trials clearly do not give all the answers – for instance, the benefits of these interventions in reducing maternal mortality, as distinct from morbidity, are still unclear – but they are a powerful argument for involving community health workers in the care of mothers and newborn. contributors to a study conducted by the university of london international development centre (lidc) and published with the lancet, „the millennium development goals: a cross-sectoral analysis and principles for goal setting after 2015‟ (3), identify difficulties with the mdgs in four areas: “conceptualisation, execution, ownership, and equity.” in their view, the goals were “too narrow and fragmented, leaving gaps in which other important development objectives are missing”. rather than focusing on the wider vision of the millennium declaration, the mdgs concern only “development and poverty eradication,” not “peace, security and disarmament, and human rights”. moreover, investments have focused on vertical vs horizontal components (e.g. communicable diseases) with “variable effect on improving national health systems”. education targeted mostly primary education and mdg2 “under-develops secondary and tertiary education where substantial improvements income and in health are the greatest”, including the development of skilled workers. fragmentation between such areas as “education, poverty reduction, health and gender” at national and local levels with “responsibilities of different line ministries nationally, subnationally, and locally” [means] “that the potential for simultaneous actions in the same location, working with the same communities and households, is unlikely”. the same separation holds true for environmental sustainability “with potentials for synergies across sectors.” ownership has also been problematical as input from developing countries to the mdg framework “was small...mixed and often weak”, along with “t]erritorial issues with leadership”, with examples from communicable diseases (hiv/aids, tb, malaria), professional groups, the maternal and child health communities, and the pharmaceutical industry. another central issue for the mdgs is equity mainly because in their initial formulation the mdgs targeted poverty reduction and development goals aimed at poor countries rather than “global goals for all countries”, usually associated with economic aspects (e.g. income, education) but also distribution. the main shortcoming of the current mdg framework is that it is concerned “with just adequate provision for some, ignoring the needs of those who are too hard to reach and not addressing the difficulties of inequality in societies that have deleterious consequences for everyone, not only the poorest people”. it is clear that the mdgs have had considerable impact by “focusing resources and efforts on important development goals”, and more generally “in raising public and political interest in the development agenda, engaging for the first time a wide range of sectors and disciplines in a concerted effort”. lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 9 however, in the light of difficulties with „conceptualisation, execution, ownership, and equity‟, there appears to be a need for new mdg directions post-2015. the contributors to the lidc mdg report concluded that “future development goals should be framed by a vision of global justice at the present moment, when there are no appropriate institutions to deliver this vision”. an important feature of their thinking is that “it is important to focus on the choices that are actually on offer in a globally-inter-related world”, including plurality of principles and procedures and “permissibility of partial resolutions (i.e. that making some things a bit better than waiting for the best solutions”. the core of their thinking lies in the definition of „development,‟ which they define “as a dynamic process involving sustainable and equitable access to improving wellbeing”. drawing on amartya sen‟s work, the idea of justice,(20) in which he views wellbeing as a combination of the aspiration that “human lives can go much better”, they agree that “improvement can be brought about through a strengthening of human agency, a person‟s capability (vs capability deprivation) to pursue and realise things that he or she values and has reason to value”, thereby linking “wellbeing with the capability to make choices and act effectively with respect to, for example, health, education, nutrition, employment, security, participation, voice, consumption, and the claiming of rights”. finally, the authors suggest that future developments of millennium goals should follow – and ideally be measured through a lens consisting of five guiding principles:  holism-avoiding “gaps in a development agenda and realising synergies between components, acknowledging that „people‟s wellbeing and capabilities depend on human development, social development and environmental development”.  equity-achieving “the development of a more equitable world, built on more equitable societies in which there are adequate flows of information, understanding, resources, training, and respect to enable diverse individuals to attain a decent quality of life”.  sustainabilitydelivering “an outcome such as wellbeing, in terms of its capacity to persist, and to resist or recover from shocks that affects its productivity” [and] is “both viable in social and economic terms”.  ownership – beginning “from a comprehensive conceptualisation of development and the core development principles proposed to govern both the specifications of development goals and the processes by which they are specified”.  global obligation – arguing “for the importance of a position on global obligation that values human rights with respect to human, social, and environmental development”, ensuring that „concerns with wellbeing are not just limited to the obligations we have to citizens of our own country, but to individuals anywhere”. to a large extent, the lidc report findings are echoed by dr. tewabech bishaw, managing director of the alliance for brain-gain & innovative development and secretary general of the african federation of public health associations (afpha) in ethiopia. in her keynote address at the 7 th public health association of south africa (phasa) conference (2011), entitled „what public health actions are needed in african countries to confront health inequalities?‟ (21), she discusses the gaps that need to be addressed and shares her thoughts on public health actions “that could contribute to redressing existing gaps and inequalities”. with dismay she observes that by 2011 “out of the twelve mdg targets many of the countries in africa have scored positively on only two – children completing a full course in primary school and achieving gender equality in primary school”. calling for urgent action, she also notes that “many of the health problems that developing countries in africa are faced with are preventable. emerging new communicable diseases and expansion of the old due to lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 10 climate change has doubled the challenge. in addition, the increasing burden of non communicable diseases alongside the communicable diseases is further burdening the health system making the situation more challenging. many of the unnecessary and unjustified deaths especially death of newborns, children and mothers could be averted. many young talents are wasted due to poverty, environmental degradation, ill health, under nutrition, lack of access to health services, clean water, hygienic living conditions, education and other essential services. unemployment continues to weaken productive human resources with disabilities worsening the vicious circle of unproductively leading to perpetual poverty”. her recommendations reflect many of the guiding principles of the lidc mdg report for redressing inequalities and other challenges, highlighting especially the importance of health being fundamentally “a human rights issue”. in addition, she advocates the need for prioritizing policy, strategy and action based on accurate analysis of reliable health information and epidemiological data; engaging in collaborative partnerships and networks; promoting good governance and accountability; using national think tank groups; scaling up and sustaining critical intervention for sustainable health development; promoting and supporting problem solving research; and developing and using participatory monitoring and evaluation systems. a theme that weaves through her keynote address is the need to listen to and learn from many voices in trying to address the deep-seated and pressing issues facing africa. her determination is in keeping with professor david griggs, director of the monash sustainability institute (msi) in australia (22). he cites albert einstein, who reportedly „once said that if he had just one hour to find a solution on which his life depended, he would spend the first 55 minutes defining the problem‟, and „once he knew the right question to ask, he could solve the problem in less than five minutes‟. professor griggs emphasizes that “today, humanity faces such a life-threatening problem: how are we to provide adequate nutrition and a decent quality of life to a global population that is set to surpass nine billion by 2050, without irreparably damaging our planetary life-support system?”. it seems highly unlikely that even einstein‟s huge thinking capacity could easily resolve issues facing the planet and its people today. this question is, of course, one of many that confront the post-2015 sdg deliberations. in retrospect, while there is wide variability among global regions with regard to meeting the mdgs, according to some, by and large, they “did a good job in increasing aid spending and led to improved development policies, but left many of the bigger issues unresolved” (23). the main critique of the cross-sectorial analysis is that the mdg goals were “too narrow and fragmented,” and that they concern only “development and poverty eradication not peace, security and human rights.” other weaknesses are that investments focused on vertical vs horizontal components (e.g., communicable diseases) and that education targeted primary education and not secondary and tertiary education. the united nations conference on sustainable development the united nations conference on sustainable development (uncsd) – also known as rio 2012 and rio-20) from 13-22 june 2012, with 192 attending nations and about 45,000 participants made a commitment to the promotion of a sustainable future through sustainable development goals (sdgs) (24). redefining the sdgs as “development that meets the needs of the present while safeguarding earth‟s life‐support system, on which the welfare of current and future generations depends” (25), a group of international scientists go further than focusing just on improving people‟s lives. they posit that “[c]ountries must now link poverty eradication to protection of the lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 11 atmosphere, oceans and land” and propose six sustainable development goals (sdgs); including: goal 1: thriving lives and livelihoods goal 2: sustainable food security goal 3: sustainable water security goal 4: universal clean energy. goal 5: healthy and productive ecosystems goal 6: governance for sustainable societies taking into consideration the latter and other contributions, the mechanism to evolve new sdg goals has been through a two phase process by the un general assembly (unga) open working group (owg), co-chaired by csaba kőrösi, hungary ambassador to the united nations and macharia kamau, kenya ambassador to the united nations: the first phase focused on „stocktaking‟ from march 2013 to february 2014, followed by phase two from february-september 2014 which concentrated on the development of the report for the 68 th meeting of the un general assembly in september 2014 (26). while the deliberations are on-going, the mdg interim report in june 2013 concluded that „wide support‟ exists for a “single post-2015 un development framework containing a single set of goals”, which are universally applicable but adaptable to national priorities (27). in addition, the report proposes “the need for a narrative that frames and motivates the sdgs, in particular to focus on poverty eradication as the overarching objective and central proposal of the goals”. however, while this focus remains crucial, it is vital to emphasise that sustainable global poverty reduction can only be accomplished in a world that makes „peace, security and human rights‟ its core aspiration, as advocated by the contributors of the lidc mdg cross-sectoral analysis (3). these global ideals, so claim lant pritchett, and charles kenny, both senior fellows at harvard‟s center for global development, also recalling the lancet report, could “put into measurable form the high aspirations countries have for the well-being of their citizens” (28), thereby offering “a rationale for upper middle-income engagement with the post-2015 development agenda”, and providing “the rationale for a far broader engagement with development on the behalf of rich countries than attempting to kink progress through aid transfers”. „the world we want‟ however, their proposal may need to remain a future possibility as the un‟s top priorities through „the world we want‟ (29) and „beyond 2015‟ (30) lie with supporting 88 of the poorer countries “to convene national consultations on the post 2015 development agenda.” stakeholder inputs are requested “on current and emerging challenges in respect to eleven defined substantive issues”:  inequalities  health  population dynamics  education  energy  water  environmental sustainability  food security and nutrition  conflict and fragility  growth and employment lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 12  governance the overall aim is to build “a global, multi-stakeholder civil society movement for a legitimate post-2015 framework” (30,31). the national consultations – essentially a “global conversation” – are “organized by un country teams, under the leadership of the un resident coordinator”, and “are working with a wide range of stakeholders including governments, civil society, the private sector, media, universities and think tanks”. to date, over two million have contributed to the exercise, including considerable input through the myworld survey (32). it is pleasing to note the interest taken by the younger generation as 50 percent of the voters to date have been between 16to 30 years of age. their top priority is education (254,505), followed by healthcare (210,550), job opportunities (195,117), honest and responsive government (189,311), protection against crime and violence ( 156,687), and clean water and sanitation (152,434). conciliation resources, a peace-building ngo, reminds us that “war shatters lives. it creates poverty and wastes billions every year. the people living in the midst of the violence often have the greatest insight into its causes. yet they are often excluded from efforts to find a resolution” (33). in relation to the mdgs, dr. teresa dumasy, working on policy change and learning in the field of peace building at conciliation resources, draws attention to the 2011 „world development report‟ (34), which highlighted that “no conflict-affected or fragile state has achieved a single mdg, nor are they expected to do so by 2015. of the 42 countries at the bottom of undp‟s human development index, 29 are fragile states. countries where people are feeling the socially debilitating effects of fragility and conflict have simply been left behind”. she further notes that “[e]xperience shows that the targets set within the current mdgs have not proved sufficiently relevant to those countries grappling with the peace building and state building issues so central to their recovery”. moreover, she posits that the mdgs “speak to the symptoms, rather than the drivers of conflict” (33). referencing a statement by civil society organisations, „bringing peace into the post-2015 development framework: a joint statement by civil society organisations‟ (35), she mentions key elements “that address the fundamental notion of „fairness‟, the absence of which can drive conflict and that should be included in any successor framework”. these goals “are supported by more than 40 governments and multilateral organisations”:  legitimate politics foster inclusive political settlements and conflict resolution;  security establish and strengthen people‟s security;  justice address injustices and increase people‟s access to justice;  economic foundations generate employment and improve livelihoods;  revenues and services manage revenue and build capacity for accountable and fair service delivery. conciliation resources contend that “[t]he post-2015 targets must be much more broadly owned and also relevant to countries affected by fragility and conflict, as they persevere in their efforts to attain lasting peace and a significant reduction in poverty levels”. the importance that conciliation resources places on the causes and consequences of conflicts is echoed by war child international (36), a specialist agency, working in countries devastated by armed conflict such as iraq, afghanistan, dr congo, uganda, central african republic and syria. according to war child international, and as mentioned earlier, without focussing on the plight of children in conflict areas, there is no hope of achieving the mdgs, nor the sdgs, one may add. however, if we are to optimize the success of the post-2015-sdgs, we may lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 13 need to learn to work differently. this message is conveyed by co-founder of war child international, dr. samantha nutt, who, after close to 20 years visiting conflict zones, reflects on shortcomings of international aid, concluding that: “we‟re not spending enough time, effort and resources on the preventive aspects of it: programs that focus on education, people‟s employment and income opportunities for women and young people.... something happens in the news and we throw money at it and a year later we expect it to be better. until you start investing in the local community organizations and addressing these structural deficits, you‟ll always be chasing your tail” (37). her concern with „scaling up‟ community support and development is in keeping with who director-general dr. chan‟s reflections on how mdg/sdg interventions can be improved (5), and will assuredly contribute to “the process of setting the sdg agenda,” discussed at the 67 th world health assembly (wha) in geneva (38). at the latter wha, member states also agreed that health needs to be “at the core of the post-2015 development agenda” including “the unfinished work of the health millennium development goals, newborn health, as well as an increased focus on non-communicable diseases, mental health and neglected tropical diseases along with the importance of universal health coverage and the need to strengthen health systems”. completing the outstanding mdg work is of course of vital importance to ensuring global population health and well-being. however, taking into account lessons learned from the mdgs 2000-2015, achieving the „health‟ goals will depend largely on significant and expeditious progress being made alongside the other ten thematic indicators underpinned by „the world we want‟ initiative. dr. tewabech‟s keynote at the phasa conference is a case in point (21). too little progress has been made since 2000, and some areas have actually worsened despite timely and realistic strategic plans for improving health care. the gap between good intentions, meaningful application and outcomes remains vast, and, as argued compellingly by the london international development centre (3), conciliation resources (33), and war child international (36), the sdgs-2015 need to be conceptualized and enacted through a wider lens that subsumes, expands and interrelates the mdgs in a framework with a view to realizing „fairness‟ and „global justice – underpinned by peace, security and basic human rights‟. as one example, mdg 1 poverty and mdg 3, on gender equality, could become part of the inequalities indicator. it is of course too late from a planning perspective, but recognizing the threats imposed by „modernity‟, discussed in chapter 2.0, an additional thematic indicator could have drawn attention to „modern lifestyle and well-being‟, the probable cause in the rise of non-communicable diseases or conditions. to this end and, as an illustrative example, figure 2 juxtaposes goal guiding principles from the lancet report (3) and eleven indicators that underpin „the world we want‟ (29). emerging indicators, such as population dynamics and growth and employment, would require considerable global analyses of scope, priorities and enabling actions based to a large extent on the mdg experience. lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 14 figure 2. towards an integrated sustainable development goals framework inequalities health population dynamics education energy waterenvironmental sustainability food security and nutrition conflict and fragility growth and employment governance global justice (peace, security & basic human rights) global obligation ownership sustainability equity holism the african ‘health for all people’ campaign universal health coverage (uhc), discussed further in the next section, is about achieving health equity worldwide; it is also, to a large extent, an essential ingredient or „stepping stone‟ of a longer-term global aim for global justice „peace, security, and basic human rights‟. jonathan jay, coordinator of the health for all post-2015 campaign (39), launched in march 2014, commends policymakers for the progress achieved by the mdgs in areas such as „aids, childhood immunization, access to family planning and reproductive healthcare‟, along with helping to usher in a “golden age”. however, he also points out that “the rapid scale-up was leaving people behind”, and that “health inequalities continued to grow, both within and across countries”, (and) “[a]dvances in child survival and maternal care left a concentration of deaths in the poorest regions, with persistent gaps in access”. furthermore, while acknowledging considerable progress with regard to preventing and controlling aids/hivs, “hot spots of increased risk among groups that are marginalized and vulnerable” remain. these health concerns are now also being exacerbated by the increase in “non-communicable diseases”, which he labels a “growing hidden iceberg” in developing countries – so daunting a global health challenge that many key players have been virtually paralyzed. the global civil society campaign, health for all post-2015, that is now underway in ethiopia, nigeria and kenya calls “for an approach that would correct inequities and bring everyone along–ushering not just the next era, but truly a new era in global health”. achieving „a new era in global health‟ echoing the goals of the international scientists (25), according to a global alliance of research institutes, the independent research forum (irf), “sustainable development can only be achieved if four foundations exist” (40):  economic progress  equitable prosperity and opportunity http://www.healthmetricsandevaluation.org/publications/policy-report/financing-global-health-2012-end-golden-age http://www.undp.org/content/undp/en/home/librarypage/mdg/the-millennium-development-goals-report-2013/ http://www.thelancet.com/journals/lancet/article/piis0140-6736%2813%2961349-5/abstract http://healthforallcampaign.org/health-for-all-post-2015/about-the-post-2015-campaign/ http://www.iied.org/think-tank-alliance-identifies-eight-shifts-needed-for-sustainability lueddeke g. towards an integrative post-2015 sustainable development goal framework: focusing on global justice – peace, security and basic human rights (review article). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-26 15  healthy and productive ecosystems  stakeholder engagement and collaboration achieving the sdgs that are more inclusive and integrated in terms of „planet and population‟ sustainability, as indicated in figure 3, according to the irf, will be optimized if eight major shifts take place:  from donor/beneficiary country relationships to meaningful international partnerships  from top-down decision-making to processes that involve everyone;  from economic models that do little to reduce inequalities to those that do;  from business models based on enriching shareholders to models that also benefit society and the environment;  from meeting relatively easy development targets – such as improving access to financial services to actually reducing poverty;  from conducting emergency response in the aftermath of crises to making countries and people resilient before crises occur;  from conducting pilot programmes to scaling-up the programmes that work;  from a single-sectoral approach, such as tackling a water shortage through the water ministry, to involving various sectors, like the agriculture and energy sectors, which also depend on water. bringing “fairness” and “civil society goals” into the development framework unquestionably, in order to meet un and other sdg challenges “[m]uch depends on the fulfilment of mdg-8 – the global partnership for development” (5), rightly recognized as a key factor by un secretary general, ban ki-moon in 2012. these “global partnerships”, he asserts, should stretch beyond volunteerism – and could be greatly enhanced if „fairness‟ and the civil society goals, mentioned previously (35), were simultaneously advanced by global leaders (41-44) – especially by those who place „global justice 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https://www.seejph.com/index.php/seejph/management/settings/context/mailto:kreshnikp@gmail.com https://www.seejph.com/index.php/seejph/libraryfiles/downloadpublic/127 https://www.seejph.com/index.php/seejph/management/settings/context/mailto:urankurtishi@gmail.com mailto:info@jacobs-verlag.de https://www.ub.uni-bielefeld.de/ p a g e 2 | 6 seejph south eastern european journal of public health www.seejph.com/ special volume 3, 2021 publisher: jacobs/germany issn 2197-5248 p a g e 3 | 6 issn2197-5248 doi 10.11576/seejph-4677 bibliographic information published by die deutschebibliothek. die deutsche bibliothek lists this publication in the deutsche nationalbibliografie; detailed bibliographic data is available on the internet at http://dnb.ddb.de south eastern european journal of public health (open access journal). copyright 2021 by jacobs publishing company: am prinzengarten 1, d 32756 detmold, germany copyright cover picture: wordpress foundation: http://wordpressfoundation.org/gnu general public license http://dnb.ddb.de/ p a g e 4 | 6 editorial teaching public health change leadership katarzyna czabanowska1,2, valia kalaitzi1 and suzanne babich3 1 department of international health, care and public health research institute, maastricht university, maastricht, netherlands 2 department of health policy management, institute of public health, faculty of health care, jagiellonian university, krakow, poland 3 department of global health and health policy and management, richard m. fairbanks school of public health, indiana university, usa “the time for leaders is too great to leave their emergence to chance” (1). there is a documented need to develop leaders in public health educational programmes at every level (2). we need leaders with vision who can see a future different than the status quo, who can influence and drive change, who are able to communicate their vision and win others to embrace and implement it. current and future complex public health challenges require public health leaders to use scientific, evidencebased approaches and leadership skills, especially in the area of transformation and leading change. public health professionals work at the intersection of practice, research, and policy; therefore, they need to identify and understand public health problems, use research and scientific evidence to prepare policy options, and make recommendations for policy change to improve health and wellbeing or effectively advocate for it. we present the collection of nine policy briefs developed by the students of the governance and leadership in european public health master at maastricht university in the netherlands in the academic year 2020-2021. the development of policy briefs was a part of the course on leading change in public health, which is one of the topic areas in leadership education and training in this programme. the change leadership approach in this instance was adapted from a doctoral health leadership programme model first implemented in 2005 by babich and brooks and colleagues at the university of north carolina at chapel hill, (4) with further adaptation more recently at indiana university in the united states. the main objective of this course was twofold: 1) to facilitate the development of change leadership competencies by the students based on the eight-step kotter model of leading change (5) including establishing a sense of urgency, creating a guiding coalition, developing a change vision, communicating the vision for buyin, empowering broad-based action, generating short-term wins, never letting up, and incorporating changes into the culture, and 2) to help the students develop the skills of writing a policy brief as both an advocacy communication and policy change tool that can support public health leaders who want to introduce change. the students worked in nine five-person leadership tutorial groups. each group had a case study or problem devoted to a current public health problem, including achievement of sustainable development goals (sdgs), autism and inclusive education, diversity and inclusion in public health organizations, vaccination, public health workforce, artificial intelligence, green deal, nutrition and food policy in the eu and health inequalities and vulnerabilities. experienced academic facilitators were guiding the students in achieving the objectives of the course. not only had the p a g e 5 | 6 participants define and contextualise the problem, which requires policy change, research possible policy options, and develop recommendations for policymakers but also had to propose a plan for implementation of a selected policy option addressing the stakeholders, barriers, and facilitators of change using the kotter model. a result of this educational innovation was a policy brief, structured according to the common policy brief logic (6), including: • title • executive summary • context/rationale for action on the problem • aims • proposed policy option(s) • policy recommendations • sources consulted or recommended • information on original research/analysis we hope that this course helped the students see leadership in a different way, not as a top-down, manage and control process but instead envision a change or transformational leadership, where it is possible to empower teams, collectively solve problems and spark lasting change. we hope that the course helped the students acquire and reflect on some of the leading change competencies such as: serve as a driving force for change (including strategies of change), being able to identify and communicate the need to innovate when the opportunity arises, understand how change occurs and what stages it involves, lead a team and yourself, influence and communicate, work in interdisciplinary teams, solve problems and understand the impact of change on health. in order to educate a new generation of leaders in public health, the educational approaches need to change and provide opportunities for students to act as experts, co-designing real projects that can bring positive systemic changes. we have the pleasure of inviting colleagues and the seejph readership to find out how the students of the maastricht university public health leadership programme propose policy change by reading the following collection of policy briefs. references 1. institute of medicine, the future of public health. national academy press. 1988. 2. czabanowska k, rethmeier ka, lueddeke g, smith t, malho a, otok r, stankunas m. public health in the 21st century: working differently means leading and learning differently. eur j public health. 2014 dec;24(6):1047-52. 3. czabanowska k, kuhlmann e. public health competences through the lens of the covid19 pandemic: what matters for health workforce preparedness for global health emergencies. int jhealth plann mgmt. 2021;36(s1):14–19. 4. hobbs, suzanne havala, brooks, edward, wang, virginia, and skinner, ashley. “developing practitioner leaders in a distance education doctoral program: challenges and opportunities.” journal of health administration education, 24(3): 283300, summer 2007. 5. kotter j. leading change. why transformation efforts fail. best of harvard business review. january 2007. 6. eóin young and lisa quinn. an essential guide to writing policy briefs. centre for policy advocacy.2017 p a g e 6 | 6 table of contents van ravenswaaij hp, sharjeel m, slaats p, andelic p, rojas d, paric m. improving the health status of sex workers in europe: a policy brief with recommendations kusters j, millner m.a, omelyanovskaya k, tangerli mm, laszewska a, van kessel r. addressing ableism in inclusive education policies: a policy brief outlining italy, poland, the netherlands and the united kingdom böbel s, bormans m, siepmann i, tirekidis i, wall k, kalaitzi v. diverse and inclusive leadership teams in public health schools: the change agents for sustainable and inclusive public health education de bruin j, machado m, nabbe m, saccà r, verhoeven j, clemens t. increasing influenza vaccination rates among healthcare workers by focusing on workplace and patient safety haque s, terêncio i, stankutė i, bikniūtė i, staišiūnaitė a. towards harmonisation of public health master education based on who-aspher competency framework for public health workforce in the european region bimczok sp, godynyuk ea, pierey j, roppel ms, scholz ml, hrzic r. how is excellence and trust for using artificial intelligence ensured? evaluation of its current use in eu healthcare alaze af, coomans sk, persefoni dimitsaki p, mol ma, smith-cornwall m. time for action towards a sustainable future: a policy brief for “green supermarkets” van asselt e, elamin a, sánchez gc, kalesi a, majoor e. incorporating sustainability into food based dietary guidelines by traffic light ecolabelling argyrou f, hirschler j, karan f, kugel r, romancencoa e, neicun j. committed collaboration to address homelessness in the netherlands executive editor volume editor prof. dr. kasia czabanowska assistant executive editor technical editor meri roshi ba tirana, albania email: meriroshi90@gmail.com publisher nauka ima za cilj da promovira saznanja prikupljanjem i otkrivanjem objektivnih istina; činjenica koje su nezavisne od ljudskih interesa, njihovoh vrijednosti ideologija i biasa masic i. ethics in research and publication of research articles (review article). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-29 1 review article ethics in research and publication of research articles izet masic1 1 faculty of medicine, university of sarajevo, sarajevo, bosnia and herzegovina. corresponding author: prof. izet masic, president of academy of medical sciences in bosnia and herzegovina; address: faculty of medicine, university of sarajevo, bosnia and herzegovina, 71000, sarajevo, cekalusa 90; e-mail: imasic@lol.ba; izetmasic@gmail.com masic i. ethics in research and publication of research articles (review article). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-29 2 abstract science aims at promoting knowledge by gathering and discovering the objective truth, the facts that are independent of human interests, their values, ideology and biases. the way in which scientists come to this goal is through the universally accepted and thoroughly regulated processes – the scientific method. there is no clear definition which will answer the question what is unethical in biomedical research. all people recognize some common ethical norms but different individuals interpret, apply, and balance these norms in different ways in light of their own values and life experiences. generally, it can be said that unethical behaviour in science is any significant mistreatment of intellectual property or participation of other parties, deliberately hampering the research process or distortion of scientific evidence, as well as all the behaviours that affect the integrity of scientific practice. given the importance of the primary goal of scientific enterprise, that is search for truth and trustworthy results, ethics in science has increasingly come into focus. there are several reasons why it is important to adhere to ethical norms in research. norms promote the aims of research, such as knowledge and truth, variety of moral and social values and help to build public support for research. this paper analyzes the major principles of ethical conduct in science and closely related topics on ghost authorship, conflict of interest, co-authorship assignment, redundant/repetitive and duplicate publications. furthermore, the paper provides an insight into the fabrication and falsification of data, as the most common forms of scientific fraud. keywords: conflict of interest, ethics, fabrication and falsification of data, ghost authorship, publication, redundant and duplicate publication, research. conflict of interest: none. masic i. ethics in research and publication of research articles (review article). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-29 3 ethics in science and scientific research science aims at promoting knowledge by gathering and discovering the objective truth, the facts that are independent of human interests, their values, ideology and biases. the way in which scientists come to this goal is through the universally accepted and thoroughly regulated processes – the scientific method (1-8). every step of this method, if implemented correctly and truthfully, helps to reach objective goals, with significant contribution to the welfare of the society as a whole (1). there is no clear definition which will answer the question what is unethical in biomedical research. all people recognize some common ethical norms but different individuals interpret, apply, and balance these norms in different ways in light of their own values and life experiences. generally, it can be said that unethical behaviour in science is any significant mistreatment of intellectual property or participation of other parties, deliberately hampering the research process or distortion of scientific evidence, as well as all the behaviours that affect the integrity of scientific practice. in 2000, in the united states, fraud in scientific research was defined as fabrication, falsifying and plagiarism in the process of proposing, conducting and publishing the results (1). the nordic countries proposed a much broader definition of fraud in scientific research describing it as “any degree of dishonesty”. given the importance of the primary goal of scientific enterprise, search for truth and trustworthy results, ethics in science has increasingly come into focus. william lipscomb, 1976 nobel-prize-winner in chemistry, states that: “i no longer put my most original ideas in my research proposals, which are read by many referees and officials. i hold back anything that another investigator might hop on and carry out. when i was starting out, people respected each-other’s research more than they do today, and there was less stealing of ideas”. the following is a general summary of some ethical principles in scientific research and publication: honesty, objectivity, integrity, carefulness, openness, respect for intellectual property, confidentiality, responsible publication, responsible mentoring, respect for colleagues, social responsibility, non-discrimination, competence, legality, animal care, and human subjects’ protection. there are several reasons why it is important to adhere to ethical norms in research. norms promote the aims of research, such as knowledge and truth, variety of moral and social values and help to build public support for research. whatever the definition be, there are numerous examples of unethical behaviour in biomedical research which include (1): bringing patients at risk (inadequate study design, inadequate supervision of the research, ignoring side effects or inadequate implementation of the protocol of the study); participation in fraud; creation or falsification of scientific results; falsification of consent letters; plagiarism. there is no single solution that would allow full ethics in scientific research. studies show that the misconduct is directly related to the following factors (1): increased academic expectations and greater desire for publishing papers; personal ambition, vanity and desire for fame; predilection; greed, which is directly linked to the financial gain; lack of moral capacity to distinguish the right from the wrong. masic i. ethics in research and publication of research articles (review article). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-29 4 in regard to the above listed values of the characteristic of many of us is to be expected that the behaviour that we are talking about can only be more pronounced over time and, as such, it may leave many consequences to science in general. it is therefore very important to take preventive measures that will greatly limit the implementation of these unethical measures. as a rule of thumb, the following preventive measures should be undertaken: make ethical standards very clear to all researchers; provide education and training for all researchers; clearly identify methods of sanctioning such behaviour; introduce stricter control of sponsored research. forms of unethical behaviour in biomedical articles the various forms of unethical behaviour in publishing of the results of scientific research are described in the vast scientific literature (1). the most frequent types include: redundant publications (24%), animal welfare concerns (16%), duplicate publications (15%), authors’ disputes (14%), data fabrication (8%), human welfare concerns (8%), plagiarism (7%), conflict of interest (5%), other forms including reviewer bias, or submission irregularities (3%). ghost authorship ghost authorship occurs when an individual who has significantly contributed to and participated in the development of a specific scientific work is not mentioned as an author. a special form of ghost authorship is a publication from an “invisible” author by the request of industry, where the credibility of results is questionable on account of the conflict of interest. an example is a situation where influential pharmaceutical industry or any other party can offer the benefit, employs professional writers or agencies to produce an article that will later be attributed to a certain recognized scientific researcher. example from practice: • redux case: medications dexfenfluramine and phentermine (fen-phen) are drugs that have been prescribed for the simultaneous use in the treatment of excess weight until 1997 when it was found that the application of phentermine leads to primary pulmonary hypertension and heart valve damage. in may 1999, it was revealed that wyeth-ayerst laboratories, a company that produces dexfenfluramine (redux), hired ghost authors to write the results of research on this drug but the results were published under the names of prominent researchers. also, during this period the company had participated in the destruction of data concerning the negative effects of the drug, which were published in medical journals. ghost authorship raises many ethical questions: • conflict of interest: conflict of interest is a serious problem. evidence-based medicine requires that clinical decisions are based on clear empirical evidences published in medical journals which are regularly audited. if clinicians base their decisions on such inadequate research results, it can have serious negative consequences for patients. for example, a certain medication that may not be the best drug of choice for a particular disease or patient but, for example, is strongly promoted by an influential expert in a reputable medical journal. in this way, patients may receive suboptimal treatment. • academic integrity: authorship in certain research papers is often described as academic currency. employment, wages and reputation in academic circles is largely related to the number, quality and frequency of publication of research papers, and regularly is considered as a valid indicator of one’s work and abilities. in the case of masic i. ethics in research and publication of research articles (review article). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-29 5 ghost authorship, when often a particular author is hired for a specific publication, which was actually written by another person, this publication is no longer an adequate measure of his/her work. furthermore, ghost authorship separates the author from the responsibility. universally accepted, an individual or group of authors are considered responsible for the information presented to the public. knowing that they will be held responsible for their results presented in the paper, the researchers are trying to implement all the measures to better prepare the work before its publication. therefore, if a person is listed as an author, but did not contribute to any stage of work or research project, his/her responsibility is questioned. the international committee of medical journal editors has clearly published guides in which the author of a scientific paper must take an active participation in its preparation and publication, and accepts responsibility for its content. hence, assigning co-authorship must be based on a significant contribution to the work, either in the feasibility study, analysis, interpretation, editing facilities, revision, and approval of the final version, as well as publication of the study. redundant / repetitive publication it is considered as a special form of plagiarism. redundant/repetitive publication is defined as the publication of copyright material with the addition of new, unpublished data. thus, this is a form of un-ethics in science, where part or parts of already published article, but not the complete article, are published again. there are several reasons why this form of publishing is unethical. first, it undermines the international copyrights. second, duplication of data with new data consumes the (valuable) time of peer-reviewers. third, it leads to unnecessary expansion of already huge amount of published literature. fourth, it leads to inadequate highlighting of certain information. this may also lead to potential interferences with subsequent meta-analysis. committee on publication ethics (cope) proposes several recommendations concerning repetitive publications (1): already published studies should not be republished if they do not further support the actual study; repeated publication of an article that has been published in another language is allowed only when is clearly stated the original source; at the time of the article submission, the authors must submit the materials that are used in their article. therefore, the basis is that authors should not attempt to publish information that is already published in other articles. if authors consider that the already published data are of utmost importance for their study, then they should repeat the study or parts of the research, and use these data in the new publication. duplicate publication it is defined as a publication of an article which is identical or largely overlaps with the article already published, with or without acknowledgments. two articles share the same hypothesis, results and conclusions. why scientists try to republish the same article? one reason is their perception that if someone wants to survive in the highly competitive field of science, one must create voluminous curriculum vitae. this is true in certain situations, especially subsequently when the number of articles rather than their quality, are largely valued as a factor in promotion and academic progress. another, perhaps more justifiable reason for resorting to such unethical behaviour, lies in the fact that the authors sometimes try to reach the readers who are not so familiar with the journals in which the first article was already masic i. ethics in research and publication of research articles (review article). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-29 6 published, especially if the article was published in another language, such as for example the chinese language which is relatively inaccessible. however, authors must have the consent of both journals before they decide to republish a certain article. duplicate publication is considered unethical for several reasons (4,5). the first is that, in an inadequate manner, the authors attempt to increase the scope of their own published works. another important reason is that the article has the potential to change the image of documents. for example, if the results were taken into account twice or even more in a metaanalysis conducted to outline some best practices, the results would not be valid. this was the case of a study including all the published papers in which authors investigated the effect of the drug ondansetron on postoperative vomiting. it was observed that 17% of the published papers were duplicates, of which 28% of the patient data were duplicated. this led to a situation in which the efficacy of this drug was overestimated by 23%. this example points out the danger of duplication of publications by scientists who have conducted research, especially when making conclusions about the efficacy and safety of a certain drug. good practice in publishing scientific work requires that authors can submit drafts of their work only to one journal at a given moment. authors may choose to re-propose to the same or another journal a revised version of the scientific work only when the first application receives negative answer on its publication. regardless of these considerations, duplicate papers still occur and as such continue to be a significant problem across scientific journals. with the increasing availability of computerized medical databases such as pubmed, it becomes increasingly difficult for scientists to duplicate the previously published works. when the duplicated article is detected and reported by the reviewer, the journal rejects the proposed work or withdraws the article if it is already published. a statement on duplication is published in pubmed, which can have serious consequences for the author’s reputation. conflict of interest in the research and publication of scientific papers it is vital to ensure objectivity in order to preserve the integrity of the research, the reputation of the institution and the journals which published the study. from the author that conducted a study, it is expected to objectively present the results of the research, whereas from the reviewers it is expected to evaluate these results objectively. when experts at prominent positions get into a conflict of interest, it results in a biased or a poor decision-making; hence, the information that reaches the scientific circles and the readers in general can be modified and can be potentially devastating. conflict of interest may be individual or institutional. recognizing the potential conflict of interest is usually simple, but sometimes it can be a challenge to determine whether a conflict exists or not, if it is not communicated. this is serious, because everything which is not transparent can be interpreted as a bias or corruption. therefore, authors must clearly highlight potential conflicts, so as they can be treated appropriately. since 1995, the national institute of health (nih) has decided to terminate a number of restrictions that had previously existed in terms of external cooperation, all in order to get the renowned scientists from different fields. this means the abolition of limits on the amount of articles that scientists can publish, or the time that can be spent on work outside the institute, as long as it does not affect their current job. yet, it is very important for all scientists to clearly specify each source of income beside their regular employment. however, it turned out that the big problem is the cooperation with pharmaceutical and biotech companies, and many experts share the opinion that such cooperation should be terminated. this also led the new england journal of medicine to ban the authors to write review articles if they had a financial interest in the company concerning the research. masic i. ethics in research and publication of research articles (review article). seejph 2014, posted: 01 september 2014. doi 10.12908/seejph-2014-29 7 however, in recent years it is increasingly difficult to identify authors who are completely independent of the industry. financial interest means everything from salaries or other income, interest in shares and intellectual property (patents, copyrights, etc.). authorship being the author of a scientific paper is a privilege and a great academic satisfaction. not only that authorship contributes to science in general, but it also brings respect and reputation and also serves as a measure for the promotion and advancement. however, this seems only a part of the author’s equation. another aspect is that authorship entails a great responsibility. every scientist has its own vision of what it takes to become the author. but often, among the authors of a project, these visions are different. personal conflicts and turmoil can often lead to disagreements on the issue of whom belongs the authorship. there are some guides, issued by the nih, that define the authorship. in a broad sense, the author is any person who has significant intellectual contribution to a particular study. the international committee of medical journal editors (icmje) is a recognized organization dealing with ethical issues in biomedical research, and defines authorship as follows (1): a) significant contribution to the concept, design, collection, analysis and interpretation of the study; b) writing study template or revision in terms of intellectual content; c) final approval of the version which will be sent for publication. the author needs to meet “a”, “b” and “c” criteria. also, the first author should coordinate the study, and should respect all the rules of the study results submission. in addition, he/she should be responsible for communicating with the editors and the reviewers of the scientific journals. fabrication and falsification of data fabrication and falsification of data represents half of all cases reported as a form of unethical behaviour. falsification of data includes its creation, selective publication of results (e.g. those corresponding to the study goals) and the omission of conflicting data, as well as the conscious exclusion or modification of data. this can include everything from the rejection of unwanted pieces of information to their unfounded creation. this is unethical for several reasons (1,2): it affects the integrity of other studies, also the authors which are their creators and other authors in the same field of science; if such article is not discovered on time, the other authors lose their energy and time in vain trying to take advantage of the presented results in their studies; creates a negative image of science in general and affects the general trust. the problem of this kind of behaviour is particularly evident in clinical studies and may have negative consequences for the patients. for a scientist who carries out a study concerning a potential new treatment or management of a disease, the impact on the patient can be fatal or at the very least psychologically devastating, if the crucial information is false or deleted. the number of such papers containing falsified or fabricated data is increasing. therefore, each author must faithfully and accurately collect, present and publish the experimental data. masic i. ethics in research and publication of research articles (review article). seejph 2014, 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importance of proper citation of references in biomedical articles. acta inform med 2013;21:148-55. doi: 10.5455/aim.2013.21.148-155. ___________________________________________________________ © 2014 masic; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed?term=benos%20dj%5bauthor%5d&cauthor=true&cauthor_uid=15905149 http://www.ncbi.nlm.nih.gov/pubmed?term=fabres%20j%5bauthor%5d&cauthor=true&cauthor_uid=15905149 http://www.ncbi.nlm.nih.gov/pubmed?term=farmer%20j%5bauthor%5d&cauthor=true&cauthor_uid=15905149 http://www.ncbi.nlm.nih.gov/pubmed?term=gutierrez%20jp%5bauthor%5d&cauthor=true&cauthor_uid=15905149 http://www.ncbi.nlm.nih.gov/pubmed?term=hennessy%20k%5bauthor%5d&cauthor=true&cauthor_uid=15905149 http://www.ncbi.nlm.nih.gov/pubmed?term=kosek%20d%5bauthor%5d&cauthor=true&cauthor_uid=15905149 http://www.ncbi.nlm.nih.gov/pubmed?term=gold%20jl%5bauthor%5d&cauthor=true&cauthor_uid=16220624 http://www.ncbi.nlm.nih.gov/pubmed?term=gill%20ss%5bauthor%5d&cauthor=true&cauthor_uid=16220624 http://www.ncbi.nlm.nih.gov/pubmed?term=rochon%20pa%5bauthor%5d&cauthor=true&cauthor_uid=16220624 http://dx.doi.org/10.5455%2faim.2012.20.208-213 http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=22104051 http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=22104051 http://dx.doi.org/10.1097%2facm.0b013e31823aadc7 http://dx.doi.org/10.5455%2faim.2013.21.148-155 grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 1 | 14 original research national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study thomas grochtdreis1,2, peter schröder-bäck3,4, niels harenberg2, stefan görres2, nynke de jong5 1 department of health economics and health services research, hamburg center for health economics, university medical center hamburg-eppendorf, hamburg, germany; 2 institute for public health and nursing science, university of bremen, bremen, germany; 3 department of international health, care and public health research institute (caphri), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 4 faculty for human and health sciences, university of bremen, bremen, germany; 5 department of educational development and research, school of health professions education (she), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands. corresponding author: dr. thomas grochtdreis; address: department of health economics and health services research, hamburg center for health economics, university medical center hamburg-eppendorf, martinistr. 52, 20246 hamburg, germany; telephone: +49 (0)40 7410-52405; e-mail: t.grochtdreis@uke.de grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 2 | 14 abstract aim: this study aimed to explore the german nurses’ perceptions of their knowledge, roles and experience in the field of national preparedness and emergency response. methods: an exploratory qualitative design was used with open-ended questions during semistructured interviews with qualified nurses currently working in hospitals. the setting of the study consisted of wards of different hospitals in three northern federal states of germany. the data analysis was done by summarizing analysis of the contents. from a convenient sample of n=31 hospitals, n=13 nurses were included in the study. results: the median age of the participants was 45 years and 38% were female. within the three professional socialization fields, knowledge, roles and experience, 17 themes were clustered. conclusion: within the themes of knowledge, role and experience in national disaster preparedness and emergency response, similarities and differences were explored in comparison to international literature. keywords: disaster management, disaster planning, disasters, emergencies, emergency preparedness, experience, knowledge, nurses, qualitative research, roles. source of funding: this study did not receive any form of financial or other support. acknowledgements: we would like to thank the nurses who participated in this study. we would also like to thank the nursing managers of the hospitals, the head of the departments and the head nurses for approaching their employees and colleagues. conflict of interest: none declared grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 3 | 14 introduction disasters have always been a challenge and disasters are to happen all over the world, including europe and germany. in the future, disasters will be likely to happen again all over the world. the situation in germany may serve as an example for other european countries, when reviewing european disasters in past years and comparing the preceding situation to the current health and climatic situation. a concrete current example is the covid-19 pandemic that lead to disasters globally, including europe. nurses already play a central role in disaster preparedness and management, as well as in emergency response, in many countries all over the world (1). all nurses, regardless of their level of professionalization, need to receive disaster preparedness education in their undergraduate and continuous nursing education, in order to have a great pool of nurses during a disaster. in germany, the law on health care explicitly mentions that the training of nurses has to qualify to be actively involved in disaster preparedness and emergency response (2). however, involvement in disaster preparedness and emergency response is neither a particular part of the formal qualification nor the regular professional practice of nurses in germany (3). care providers are considered important protagonists of disaster preparedness and emergency response (4). in the literature, an essential role is allotted to nurses for integrating communicating efforts and for having role competencies in disaster preparation (5). nurses are able to reduce premature death, impaired quality of life, and altered health status, which can be caused by disasters (5). health care professionals, including nurses, are feeling responsible for responding to disasters. however, nurses’ intention to respond to disasters, the needs of nurses who respond to disasters and other health emergencies, as well as the influence of the nursing shortage and the lack of education preparing nurses for disaster response are scarcely known (6). in order to prepare for emergency response, education within the field of disaster nursing is essential. in the usa, before 2001, few nurses received any formal education in the areas of emergency preparedness or disaster response, unless they served in the military, worked as pre-hospital providers, were employed in a hospital emergency department, or participated in humanitarian disaster relief work (7). occasionally, disaster nursing education is seldom provided at the basic nursing education level (8). it has become apparent, that there is a distinct need for disaster nursing curricula and for preparation of nursing faculty members to teach disaster nursing in order to adequately prepare nursing students for possible disaster situations in future (9). according to the world health organization and the international council of nurses, nurses, as the largest group of health care practitioners, need to develop competencies in disaster response and recovery, but training is often fragmented or not available (10). in order to understand the essence of national disaster preparedness and emergency response for and of nurses as well as the meaning they give to this topic in germany, the following research questions were formulated for providing nursing practice and nursing research with valuable information: ‘how do german nurses perceive the educational system in the field of disaster nursing?’, ‘how do german nurses describe their role in the field of national preparedness and emer grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 4 | 14 gency response?’ as well as ‘what is the experience of german nurses in the field of national preparedness and emergency response?’. therefore, the aim of this study was to explore the knowledge, role and experience in national disaster preparedness and emergency response of german nurses. methods an exploratory qualitative design was used with open-ended questions during semistructured interviews with qualified nurses currently working in hospitals. research design the field of nursing care might be well described by lived experiences of nurses working in this field. in order to reach insight in these lived experiences, a careful description of ordinary conscious experience of everyday life is necessary. based on the pre-formulated research aim, it was essential to identify preconceived beliefs and opinions to bracket out any presuppositions to confront the data in pure form (11). for not violating the inductive assumption of qualitative research, theory was used to focus the inquiry and to give it boundaries for comparison in facilitating the development of the theoretical or conceptual outcomes. this means that the conceptual framework of this research was used as a template, with which results will be compared and contrasted (figure 1) (12). the conceptual framework consists of the three relevant fields of professional socialization: knowledge, roles and experience (13). according to the conceptual framework, knowledge in disaster nursing supports necessary roles during a disaster and having roles during a disaster leads to experience. based on a literature review, sub-topics for each field have been identified (14). basic interpretivist research was followed, in fact to gather qualitative data and to analyse their content in a way that experiences, as well as perceived general roles, tasks and responsibilities as well as knowledge of nurses in the topic under research can be best described and interpreted. figure 1. conceptual framework [based on: grochtdreis et al. (14)] grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 5 | 14 setting and sample the setting of the research was different wards of hospitals in three northern federal states of germany (bremen, hamburg, lower saxony). based on experience, for gathering enough data for a sufficient analysis, at least twelve qualified nurses were considered to participate in the study. in order to have a comparable gender distribution between the participants and qualified nurses in general, at least two male nurses were considered to take part in the research. in germany, approximately 14% of qualified nurses were male in the year 2010 (15) and it was anticipated that the interpretation of experience of men and women is somehow different. eligible participants were qualified nurses currently working in the field of nursing care. furthermore, it was anticipated to select participants with different lengths of work experiences. the participants were not selected randomly, since it was more important to select people who will make good informants. good informants were defined as knowledgeable, articulate, reflective, and willing to talk at length with the researcher (11). the basic approach of the sampling was a convenient approach, based on a volunteer sample out of all hospitals. the volunteer sample was put together from nursing managers of cooperating hospitals. in total, a convenient sample of n=31 hospitals was asked for participation. of those, n=4 hospitals provided access towards potential participants (n=5 hospitals were willing to participate, n=9 hospitals were unwilling to participate, n=13 hospitals did not respond). finally, n=13 nurses were included in the study. data collection in order to elicit data in the study, nurses working in hospitals were asked identical open-ended questions during an interview. the specific questions were developed out of a literature review on nurses’ roles, knowledge and experience in national disaster preparedness and emergency response (14). based on relevant topics extracted from the literature review, a semi-structured interview guideline with open-ended questions was developed and pretested (11,16,17). during the interviews (male interviewer, tg), it was given as much time as needed to narrate to the questions of the interview guideline. all interviews were audio taped with a digital recording device and transcribed using the computer software f4 (dr. dresing & pehl gmbh, germany) (18). ethical considerations the ethical review committee of university of bremen ascertained no reason for an objection of the study. all interviewees gave written informed consent. a description of the purpose of the study was made available during recruitment, reiterated in writing within the consent form and verbally before each interview. withdrawal of consent without personal consequence was possible at any time point and participants were aware of their freedom. confidentiality of participation was secured and participants were made aware of the anonymization of personal information. data analysis the data analysis was accomplished by using summarizing analysis of the contents of semi-structured interviews using mayring’s method (tg) (19). therefore, the interviews have been open coded as a first step, using the computer software maxqda 11 (verbigmbh, germany) (20,21). out of these coded text parts paraphrases have been created. in a next step, these paraphrases were abstracted. synonymous paraphrases were grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 6 | 14 deleted. these two last steps were repeated until a satisfactory level of abstraction was reached (19). based on these abstracted statements, themes were developed, which were validated by the original text passages. all analyses were based on texts in its original language, translation into english took place while the first abstraction of paraphrases. as all interviews were conducted in german, presentation of original quotations in the results was waived. results participant characteristics characteristics of the participants are presented in table 1. the median age was 45 years (interquartile range 5) and 38% were female. the specialty areas of nurses were emergency care (n=5), intensive care (n=4), internal medicine (n=3) and orthopaedics (n=1). the median practical nursing experience was 21 years (interquartile range 9). the majority of participants (n=11) reported one or two job specializations, including specialization as head nurse (n=8) as well as in anaesthesia care and intensive care (n=5). participation in disaster nursing-related continuing education programs was reported by five participants with a mean participation number of six education programs. volunteer involvement in an aid organization was reported by two participants. disaster preparedness and knowledge within the first professional socialization field, knowledge, seven themes were clustered (table 2). table 1. participant characteristics (n=13) characteristics median (iqr) n (%)** age: years 45 (5) work experience: years 21 (9) female sex 5 (38.5) specialty area emergency care 5 (38.5) intensive care 4 (30.8) internal medicine 3 (23.1) orthopaedics 1 (7.7) job specialisation* head nurse 8 (61.5) anaesthesia care and intensive care 5 (38.5) disaster-related continuing education 5 (38.5) volunteer involvement: n (%) 2 (15.4) iqr: interquartile range *multiple response allowed **absolute numbers and their respective percentages (in parentheses) grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 7 | 14 table 2. identified themes of relevant topics topic themes (i) disaster preparedness and knowledge of german nurses definition of a disaster knowledge and skills undergraduate nursing education continuing education programs disaster drills willingness to help disaster preparedness (ii) roles of german nurses during emergency response general roles of nurses expectations of society and the hospital role conflicts assignments of medical tasks special roles during a pandemic influenza (iii) disaster experiences of german nurses work environment nursing care feelings burdens and stressors call of duty impacts a dominant definition of a disaster was that disasters are man-made and technical. furthermore, terror attacks, meteorological and natural disasters as well as biological and chemical disasters were described as possible disaster sub-groups. a majority of participants defined a disaster as a mass casualty incident, which is hardly controllable without external assistance and accompanied by severe personal and material damage. alternatively, disasters were defined as a situation with a large number of affected and/or killed people as well as an unpredictable, sudden and challenging event, lasting for a longer time. knowledge and skills were perceived as highly necessary regarding disasters. knowledge about the hospital emergency action plan and the corresponding roles during a disaster was considered essential. additionally, knowing the hospital structures such as the hospital alarm system, the triage system and the supplies maintenance as well as knowing the federal state law for disaster control and about the duty to report to work were assumed important. emotional skills, communicative and organizational skills, and professional skills were considered important for disaster preparedness. according to the participants, undergraduate nursing education did not address disaster nursing, yet emergency care and trauma care nursing has been addressed. however, communicative and organizational skills as well as certain professional skills are well trained in undergraduate nursing education. a future need for an explicit disaster nursing education for undergraduate nurses was addressed. a need for nurses to be continuously educated and trained in disaster nursing has been made clear. a minority of participants affirmed that training and education in disaster nursing would be existent in their own hospital. the plurality of the participants stated that disaster drills had not been performed in their hospitals yet. however, nearly every partici grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 8 | 14 pant saw advantages in regular and mandatory disaster drills, such as experiencing disasters in hospitals, recognizing roles and emotions during a disaster and practising and optimizing alerting, assembly, the hospital emergency action plan, communications and triage. willingness to help during a disaster was taken for granted and as an ethical obligation by almost all participants. willingness and unwillingness to help were influenced by several factors, such as preparedness, prior disaster experience, the scope and type of the disaster or being personally affected by a disaster. professional disaster preparedness was perceived by barely half of participants, as they already had training in psychosocial emergency care, long-term caring experience or knowledge of the hospital emergency action plan and medical care. furthermore, aspects of disaster preparedness were receiving regular education in disaster management and knowing the own roles during a disaster. half of the participants felt personally prepared, due to volunteer activity in a disaster relief organisation, knowledge about behaviour during disasters or information of the own family. roles during emergency response within the second professional socialization field, roles, five themes were clustered (table 2). most of the participants defined the following general roles during disasters: patient care, assistance during triage, on-scene command, setting priorities, communication, public relations, clearing of space for additional patients, recruitment and deployment of personnel. according to the participants, patient care will be reduced to psychological care and emergency care. according to the majority of the participants, nurses are expected by society and the hospital to be willing to help and to stay able to cope during a disaster. furthermore, nurses are expected to be prepared, knowledgeable and skilled and to give quick and high quality aid. in particular, the hospital was believed to expect professional care, psychological care, organizational capabilities, teamwork, courage and versatility during a disaster. participants identified conflicts between their professional and private, either when they would be personally hit by a disaster or when they were single parents, have an infant or were responsible for the care of relatives. the assignment of medical tasks, such as triage or tracheal intubation, was perceived as “realistic” by the majority of participants. however, others stated that they could not imagine performing medical tasks, such as diagnosis or the administration of drugs, during a disaster. for the case of a pandemic influenza, participants identified that nurses were responsible for infection protection, hygiene, disinfection and of the correct use of personal protective equipment. furthermore, nurses needed information about the course of epidemics, conduct case investigations and educate colleagues, patients and relatives about epidemics in order to calm their fears. disaster experiences within the third professional socialization field, experience, five themes were clustered (table 2). almost all participants described a (potential) work environment in hospital during a disaster as being tense, chaotic, rushed, panicky as well as crowded with patients and relatives. moreover, a disaster was described an exceptional situation for a hospital, accompanied grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 9 | 14 by an overwhelmed capacity. the work environment was also described as being disturbed by the military or the press. nursing care was described as possible to a limited extend and controlled by priorities. according to the participants, different nursing tasks were attributed to different groups of nurses during a disaster (table 3). participants described six domains of feelings they may experience during a disaster: excessive demands, fear and panic, feeling of horror, feeling of terror, feeling of incapability, as well as positive feelings, such as feeling of security and a good feeling of being able to help. furthermore, the larger part of the participants agreed that disasters are or might be physically and psychically burdensome. nurses described four domains of disaster burdens: disgusting conditions, work environment-related burdens, care-related burdens and disaster impact-related burdens. the majority of the participants took it for granted to get to the hospital and to work beyond regular working hours when they would be called for duty during a disaster. in addition, there was almost no doubts that other nurses would get to the hospital, as well. table 3. nursing tasks during disasters for different groups of nurses groups of nurses nursing tasks and characteristics nurses in general be on call for duty during a disaster perform delegated medical tasks support each other and work together high flexibility ready to work for extended periods of time emergency nurses triage emergency care dependent on triage section clinical nurses expansion of capacity by discharging patients assurance of the availability of supplies assurance of the availability of medicines and medical equipment professional care for present and additional patients head nurses ensure readiness of nurses organisation and decision-making deploy nurses according to their qualifications a specific part of the participants considered debriefing and giving feedback to the team after a disaster important in order to identify needs of colleagues. in addition, the evaluation of the disaster response and the processing of problems were considered important. the following professional impacts of a disaster were described: disaster experience, improving skills and knowledge as well as identification with the team and as a nurse. the following personal impacts of a disaster were described: strengthening personality, achievement of success, gratitude for life, nevertheless, also not wanting to experience another disaster anymore. discussion participants of the study were able to find definitions of disasters corresponding to the definition of centre for research on the epidemiology of disasters (22). both definitions emphasized unpredictability, the sudden onset and the great personal and material damage. it is noteworthy that participants of the grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 10 | 14 current study mentioned that disasters are challenging local capacity, but not overwhelming it. another study about nurses’ perception of disaster identified similar attributes to disasters as the current study (e.g. being unpredictable, sudden, unexpected or unpreventable) (1). existing disaster nursing curricula set other priorities for education and training than the participants of the current study (23,24). those curricula did not address the topics duty to work and hospital structures. however, there is strong consent in the need for disaster nursing undergraduate nursing education and continuing education programs among the current study and international studies (1,25-28). in the literature, regular and mandatory disaster drills were demanded (29,30), as they were expected to improve emergency response capabilities (31-33). according to international studies, requirements for disaster preparedness were pre-registering in a disaster registry, having experience in disaster nursing and continuingly taking part in trainings and drills (1,31,33-37). indeed, those requirements were in line with requirements stated in the current study. the requirements for personal disaster preparedness, however, deviated largely. in the literature, for instance, the following requirements were described: having a go-pack containing essential personal supplies, preparing and protecting the family and having a personal plan for times of disaster (31,32,34,37-40). however, the majority of the nurses who participated in the current study did not feel personally prepared. and those who did, thought they were personally prepared, if they merely informed their families about their role in hospital during a disaster. for personal and professional preparedness and in order to raise willingness to respond, nurses need to pack their essential personal supplies standing by for emergencies, need to know that their families are protected and need to be registered in a disaster registry as well as know their relevant disaster plan. a personal disaster plan will help to arrange personal matters when responding to a disaster. in contrast to the responses of the participants of current study, it has been occasionally described in international studies that nurses will definitely be assigned medical tasks (34,41). furthermore, different roles special roles during a pandemic influenza, such as contact tracing, engaging in surveillance and reporting, collecting specimens or administering immunizations, were described elsewhere (32). the disaster experiences described, for instance the descriptions of the (potential) work environment during a disaster, were in line with descriptions from other studies (33,42,43). however, potentially hazardous work environments due to inferred security or potentially lethal situations were not described by any participant of the current study (33). no other study did describe feelings potentially experienced during a disaster, as the current study did. one study described guilt when taking leave, concern about causing pain to patients, being overwhelmed by the tragedy, disgust and distress as feelings of nurses experienced during a disaster. other studies described fear, stress and confusion (34), uncertainty, hopelessness, abandonment (44) and vulnerability (45) as feelings of nurses experienced during a disaster. the participants of the current study described disgusting conditions as a dominant domain of burdens and stressors during a disaster. in the literature, however, excessive demands (e.g., due to lack of satisfaction of basic needs, due to decline of infrastructure) were the dominantly represented domain of grochtdreis t, schröder-bäck p, harenberg n, görres s, de jong n. national disaster preparedness and emergency response of nurses in germany: an exploratory qualitative study (original research). seejph 2020, posted: 26 november 2020. doi: 10.4119/seejph-3972 p a g e 11 | 14 burdens and stressors during a disaster (33,44-49). in the aftermath of a disaster, both, positive and negative consequences of disaster experiences, such as improvement of professional competency and rethinking of the commitment to nursing, play an important role in the current study as well as in the international literature (50). limitations of the study first, the gathering of qualitative data and the analysis of their content were based on texts in its original language to best describe and interpret their content. translation of descriptions and interpretations of the content might have leaded to a distortion or transformation of their true meaning. second, this study is not representative of the german nursing population, but it explored the field of the role, experience and knowledge in national disaster preparedness and emergency response. the results of this study may not be representative for healthcare systems and educational systems in other countries. last, different from expectation, a majority of nurses who participated in the study were male. it is possible that experiences of women were not adequately reflected. furthermore, participant characteristics have to be distinguished for its overly large number of nursing specialists in emergency care and intensive care. conclusion the results of this exploratory qualitative study implied similarities but also differences in the knowledge, role and experience in national disaster preparedness and emergency response of german nurses, compared to other countries. there is a need of further research in order to further explore the knowledge, role and experience in a broader sample of nurses in germany. the results of this explorative qualitative study can be used to design a national survey with representative samples in order to expand and validate its findings. nurses need to get involved in all aspects of disaster management and need to receive proper education and training. it is imperative that nurses know about their duties and their roles, especially within the execution of medical tasks, before and during disasters and epidemics. hospitals and federal states of germany need to organize regular and mandatory disaster drills for nurses. nurses themselves need to get informed about their possibilities for personal and professional disaster preparedness. close attention is needed on ethical aspects and the assumption of responsibility by nurses during disasters. it is necessary that nurses know about feelings which can be created during disasters and have coping strategies for stressful and burdensome situations, which are applicable in exceptional circumstances and in the aftermath, as well. hospitals and the federal state offices for civil protection and disaster control need to be aware that not every nurse will anticipate getting to the hospital and having longer working hours during a disaster for self-evident. references 1. fung wmo, lai kyc, loke ay. nurses' perception of disaster: implications for disaster nursing curriculum. j clin nurs 2009;18:3165-71. 2. bundesministerium der 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matern child nurs 2008;33:249-57. 49. o'sullivan tl, amaratunga c, phillips kp, corneil w, o'connor e, lemyre l, et al. if schools are closed, who will watch our kids? family caregiving and other sources of role conflict among nurses during large-scale outbreaks. prehosp disaster med 2009;24:321-5. 50. shih fj, liao yc, chan sm, duh br, gau ml. the impact of the 9-21 earthquake experiences of taiwanese nurses as rescuers. soc sci med 2002;55:659-72. ________________________________________________________________________ © 2020 grochtdreis et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. lo cw, deniz s, hardt j, pérez lópez r,pleyer j,babich sm. sustainable reform of european union (eu) common fisheries policy (policy brief). seejph 2023. posted: 09 april 2023 p a g e 95 policy brief sustainable reform of european union (eu): common fisheries policy chungwan lo 1, selin deniz 1, jakob hardt 1, rosario pérez lópez 1, jule pleyer1, suzanne m. babich 2,1 1department of international health, governance and leadership in european public health master, faculty of health medicine and life sciences, maastricht university, maastricht, the netherlands. 2indiana university, richard m. fairbanks school of public health, the usa. corresponding author: suzanne m. babich, address: 1050 wishard blvd, indianapolis, in 46202, united states; email: smbabich@iu.edu mailto:smbabich@iu.edu lo cw, deniz s, hardt j, pérez lópez r,pleyer j,babich sm. sustainable reform of european union (eu) common fisheries policy (policy brief). seejph 2023. posted: 09 april 2023 p a g e 96 abstract context: oceans are encountering great loss of biodiversity. global overfishing and overconsumption of aquatic foods prompted the european union to create the common fishery policy (cfp) with the intention of supporting sustainability of the environment, economy, and society, and to protect the long-term supply of aquatic foods. the mediterranean sea is a vulnerable european region due to fishing at unsustainable levels. factors exacerbating the situation in this region include socioeconomic conditions, weakregulatory power of the eu, poor communication and low levels of consensus among stakeholders. policy options: three policy options are highlighted: 1) fish-restricted areas (fra) in eight mediterranean regions to maintain or reverse fish collapse, as a means to recover fish stocks in regions with higher exploitation rates: 2) supporting and improving small-scale fisheries (ssf) to reduce the impact on marine wildlife and increase selectivity, including standard gear and size restrictions,as well asstrict seasonal closures; 3) integration of participatory action research (par) to improve stakeholder compliance with the landing obligation. recommendations: policy options were assessed by four evaluation criteria (economic feasibility, effectiveness, political feasibility, and equity). integrating the par into the cfp was deemed to be the best option of those examined. a positive impact on the economy, political feasibility, and equity for stakeholders would be expected outcomes of implementation of this alternative. regular evaluation and continuous improvement would increase the likelihood of policy success. keywords: common fisheries policy (cfp), fish-restricted areas (fra), mediterranean sea, participatory action research (par), sustainability. lo cw, deniz s, hardt j, pérez lópez r,pleyer j,babich sm. sustainable reform of european union (eu) common fisheries policy (policy brief). seejph 2023. posted: 09 april 2023 p a g e 97 introduction background oceans are encountering a significant loss of biodiversity due to mismanagement, exploitation, and climate change(1). overfishing depletes stocks faster than they can be replenished. globally, overfishing has tripled in the last 50 years; one-third of the world’s fishing yieldis exceeding recommended fishing limits (2). in the last few years, consumption of sea foods has reached a peak – approximately20.2 kg per capita in 2020 – double the consumption level as compared to 50 years ago (3). the european union (eu) is a major contributor to the decline of fish species worldwide, as a result of member countries' fishing activities in international waters (4). it also represents the largest market in seafood imports (4). there is an urgent need to improve fisheries management to protect the long-term supply of aquatic foods and to re-establish ecosystems to a healthy state. the eu established in the treaty of rome, 2002, a common fisheries policy (cfp) with the primary aim of ensuring sustainable fisheries and securing incomes and stable jobs (5). over time, the policy has evolved. in the treaty of lisbon, 2013, a revised cfp focused on improvements in sustainability for the environment, economy, and society. scientific evidence and socio-economic data have informed decisions related to the biological state of stocks and fishing catch quotas. in addition, cfp regulates in an accountable, transparent, and fair way, all european fisheries, not only in waters of eu member states (ms) but also in international waters through agreements and rules, including sanctions for wrongdoers(1-3). the cfp 2013 had three main pillars: (i) the new cfp (6); (ii) the common organization of the markets in fishery and aquaculture products (7); (iii) the new european maritime and fisheries fund (emff) (8) (appendix 1). however, the full implementation of the cfp remained weak. in the long term, cfp improved lo cw, deniz s, hardt j, pérez lópez r,pleyer j,babich sm. sustainable reform of european union (eu) common fisheries policy (policy brief). seejph 2023. posted: 09 april 2023 p a g e 98 the situation of some fish populations, but its effects remain weak, especially in the mediterranean sea. this area comprised83% of assessed stocks that were overfished. this policy brief will focus on one area, the mediterranean sea, as it has historically been a primary european region for fishing at unsustainable levels (4). problem framing through the cfp, the eu engaged with many regional fisheries management organizations (rfmos), which were required to follow provisions of article xiv of the constitution of the food and agriculture organization of the united nations (fao). one rfmo, the general fisheries commission for the mediterranean (gfcm), regulates mediterranean fishing activities. to achieve the goal, the gfcm established three primary regulations for marine ecosystems: (i) gear regulation, (ii) minimum conservation reference size, and (iii) selective closure of areas and seasons. nevertheless, mediterranean fish stocks have declined (5). maximum sustainable yield (msy) is the maximum catch (in numbers or mass) that can be removed from a population over a definite period, which served as an indicator as well. the exploitation of that limit is believed to have remained above the recommended msy level (9). fishing catches have remained stable, however, during the last decade(1). additionally, socio-economic complexity creates another challenge, due to the large number of small-scale vessels operating in diverse cultural, social, and economic conditions of countries that share fishing resources. governance with low regulatory power has been a challenge, as well (6). in the mediterranean sea, regulatory mechanisms such as msy (for general estimation), and total allowable catches (tac) (for most commercial fish stocks) were not introduced, despite beingeffectivein marine system maintenance in the north east atlantic(2). https://www.fao.org/docrep/x5584e/x5584e0i.htm https://www.fao.org/docrep/x5584e/x5584e0i.htm https://www.fao.org/docrep/x5584e/x5584e0i.htm lo cw, deniz s, hardt j, pérez lópez r,pleyer j,babich sm. sustainable reform of european union (eu) common fisheries policy (policy brief). seejph 2023. posted: 09 april 2023 p a g e 99 in addition to the eu, other 19 mediterranean states and three black sea states were also participants in the gfcm. this limited the value of the cfp, reducing it to only a powerful reference rather than a direct and strong influence. namely, non-regulatory power and an unfilled scientific knowledge gap, for instance, msy and tac, diminished the intended outcome of the cfp. as a result, the eu has given attention to the mediterranean sea and, especially, to cooperation with non-eu states. stakeholder analysis cooperation and engagement of stakeholders in eu marine policy are key to the success of any management plan. thus, the participation of all stakeholders in the policy process is crucial. in this case, stakeholders are defined as groups interested in the science and management of fisheries (7). a clear understanding of the interests of these actors is critical to identifying viable policy options and implementation gaps. the fishery sector and numerous other interest groups have a stake in the cfp. these include players in such sectors as government authorities, scientists, business and industry and others (table 1). the fishery sector can be subdivided into the catching sector in the eu and the processing sector. regulators, investors, dependent businesses and communities comprise the authorities and industry groups (8). scientists, consumers, third countries, ngos, civil society eu-citizens and ingo and engos such as the un and who are additional interested parties. government authorities include those at the eu level (eu commission, parliament and council), member states and the gfcm (general fisheries commission for the mediterranean) and the medac (mediterranean advisory council). all of these stakeholders wield different levels of power, though the member states and eu governmental bodies bear the most power and a high degree of vested interest. the category of scientist encompasses marine and fishery lo cw, deniz s, hardt j, pérez lópez r,pleyer j,babich sm. sustainable reform of european union (eu) common fisheries policy (policy brief). seejph 2023. posted: 09 april 2023 p a g e 100 science and researchers from related areas. marine and fishery scientists and other researchers, as well as public health professionals, provide information and scientific data to inform policymaking. with relatively low power in decision-making but high interest, this group is nevertheless an important player. the processing and catching sectors, as well as production and packaging, have high levels of interest and high degrees of power in this case. lastly, others, including ngos or engos, as well as eu citizens and consumers, have low levels of power despite medium to high interest in the issue. table 1. stakeholders and their key interests stakeholders key interests and focus areas estimated power estimated priority (1) government authorities eu sector regulators european commission, council, european parliament compliance with the un sdgs regulatory compliance and effectiveness of the cfp high high member states managerial interest regulatory compliance sovereignty public image and reputation high medium/high gfcm (general fisheries commission of the mediterranean) medac (mediterranean advisory council) managerial and advisory interest in the mediterranean area and the aim to ensure the conservation and the sustainable use of living marine resources (eaa) harmonizing the collection of aquatic data sharing knowledge and best practices productive fisheries, healthy seas, compliance and enforcement and sustainable aquaculture development (fao) high high (2) scientists marine and fishery science sustainability of fishery approaches eco-system approach provide information and evidence for policy recommendations medium/low high researchers sustainability best practice good governance provide evidence to ensure proper agenda setting and inclusion of evidence in the policy process low medium (3) industry catching and processing sector availability of resources cost effectiveness financial & resource interest livelihood dependency, personal/direct interest and influence in stock health and aquatic high high lo cw, deniz s, hardt j, pérez lópez r,pleyer j,babich sm. sustainable reform of european union (eu) common fisheries policy (policy brief). seejph 2023. posted: 09 april 2023 p a g e 101 developments fishery companies financial interests resource availability influences in the internal and external market and market control high high (4) others who, un, ngos and engos sdg safe consumption of products planetary health and well being public health and well being medium high eucitizens, eu consumers safe consumption regarding public health and well being sustainability &transparency low medium policy options policy option i – fishery restricted area (fra) the hake is an important food source in western europe. the risk of fish collapse has been cited (10)and measures are needed to mitigate this risk(2). the species has some of the highest exploitation rates in the region, followed by blue and red shrimp and norway lobster, and it is under the highest fishing pressure with a five times higher mortality rate than the target fishery mortality(11). exploitation arises from a faster fishing rate than replenishment (12); exploitation of juvenile fish is a possible reason (5). up to 20% of juveniles are accidentally killed and/or discarded for adult fish, resulting in no economic benefit (13). for species conservation, essential fish habitats must be restored and vulnerable marine ecosystems preserved (1416). the fao recommends the establishment of fras to recover stocks in exploitation(2, 17). a temporal or permanent fishing closure is imposed in the areas. it protects important habitats for the recruitment process in which high bycatch and discard rates are recorded. areas with a high discarding rate of fish below the minimum conservation reference size (mcrs) are identified as critical areas (18). for the european hake, the following hot zones in the southern european seas were identified lo cw, deniz s, hardt j, pérez lópez r,pleyer j,babich sm. sustainable reform of european union (eu) common fisheries policy (policy brief). seejph 2023. posted: 09 april 2023 p a g e 102 and illustrated in figure 2, which can be assigned to the geographical subareas (gsa) in figure 3. hot zones include the south of tarragona area in the catalan sea (1a in gsa 6b), the eastern side of the adventure bank (1b in gsa16a/b) in the south of sicily, and the coastal area of lisbon and sines lisbon and sines (1c in gsa 9. a) in portuguese waters. four further zones lie in the ligurian and northern tyrrhenian seas, three in the north and one in the south of elba island (1d in gsa 9a/b). these areas may be designated as fras by politicians. implementation may be inspired by those already implemented fras of the gfcm., such as the best practice example jabuka pomo pit(3, 19). figure 2. hot spots for discarding with the highest densities of individuals below the minimum conservation reference size (mcrs)(18) lo cw, deniz s, hardt j, pérez lópez r,pleyer j,babich sm. sustainable reform of european union (eu) common fisheries policy (policy brief). seejph 2023. posted: 09 april 2023 p a g e 103 figure 3. geographical subareas (gsa) delimited by the gfcm (20) policy option ii – embracing and improving small-scale fisheries (ssf) the commission regulation (ec) no 26/2004 defines small-scale fishing (ssf) as fishing activities conducted by ships of less than 12 meters and not using trawling techniques. bottom trawling, an active fishing technique, is deleterious to marine life by destroying the seafloor, bringing debris into the water, and releasing captured co2 into the atmosphere(20). small-scale fisheries on the other hand require less fuel and rely on different techniques than trawling. compared to bottom/beam trawling or longline fishing of large vessels, ssf has lower discards (<15%) and therefore a lesser impact on vulnerable bycatch (21). small-scale fisheriesarealso,inmany countries, important aspects of cultural heritage and provide as many as 134,300 jobs (22). however, 27 species caught as bycatch by french, italian, and spanish ssf boats are considered vulnerable, which calls for adaptation of fishing techniques(23). to further reduce ssf impact on marine wildlife and increase selectivity, concrete gear and size restrictions for fishing gear and strict seasonal closures must be developed and implemented (22). many countries, primarily spain and italy, still employ trawlers and dredgers among the lo cw, deniz s, hardt j, pérez lópez r,pleyer j,babich sm. sustainable reform of european union (eu) common fisheries policy (policy brief). seejph 2023. posted: 09 april 2023 p a g e 104 registered ssf boats. to further alleviate pressure from their destructive practices, trawling must be stopped for good and a focus on passive fishing techniques must grow. no fishing practice is perfect, but gillnets, pots and traps are more selective and do not destroy crucial mediterranean marine habitats like seagrass meadows, rocky seabeds, or coral reef structures (22). lastly, close monitoring of ssf activities is crucial. this includes a comprehensive understanding of the mediterranean fleet and their practices, the integration of knowledge of local fishermen to develop best practices, and quantitative data on caught species, bycatch/discards, and landing value.(24). these aspects can be included in the already established medpan network, which until now has exclusively focused on marine protected areas. however, it is an important, science-based monitoring protocol guide which yields great potential in improving ssf in the mediterranean sea (25). the proposed policy option is further in line with article 29 (26)to promote human capital, job creation and social dialogue in small-scale fisheries. it includes professional training, joint projects, and the exchange of experiences of best practices between stakeholders. policy option iii – participatory action research (par) one factor contributing to the lack of environmental sustainability is noncompliance with the cfp(27). for example, the lack of acceptance by the fishing industry is the main barrier to compliance with the landing obligation (27a). fishermen tend to have negative perceptions of limitations on fishing activities and new restrictive management measures (28). control rules such as capacity, selectivity, and effort limitation are the main measurement in fisheries management that may lead to low compliance (29). to nurture a culture of compliance, transparent management plans with cross-sector and multi-stakeholder coordination lo cw, deniz s, hardt j, pérez lópez r,pleyer j,babich sm. sustainable reform of european union (eu) common fisheries policy (policy brief). seejph 2023. posted: 09 april 2023 p a g e 105 must be developed. involving stakeholders with different backgrounds in a cooperative approach can help to increase collective awareness about the issues (29) and the inclusion of fishermen's attitudes and knowledge is essential for successful implementation(30, 31). even if the cfp (32) promotes a bottom-up approach through a more interactive governance system, a more transparent procedure for decision-making was suggested to facilitate stakeholders’ compliance (33). fishermen, scientists and fisheries managers support proactive and adaptive fisheries management rather than biologically-based management, which is perceived only as a restriction on fishing activities and inefficient for decreasing catches and improving the efficacy of vessels (28). participatory action research is an opportunity to extend the cfp (28). it is “a realistic method for testing and informing eu and national management plans against local concerns, needs and alternatives that fishermen can develop to meet the challenges of fisheries” (28) and should be considered in policy development. article 18 (32)for regional cooperation on conservation measures is not sufficient to involve stakeholders appropriately in article 3(32). an extension of article 18 to include mandatory participatory action research is conceivable. recommendations the three policy options were evaluated by four assessment criteria. ‘economic feasibility’ is related to the profitability of the fishery sector after the establishment of the measures. for ‘effectiveness,’ the ecologically sustainable impact, such as the contribution to the recovery of fish stocks, was estimated. ‘political feasibility’ refers to stakeholder compliance and willingness to support the option. the last criterion, ‘equity,’ refers to social and ethical aspects. the assessment was based on literaturebased estimations. likely outcomes were rated from 1 (+) low to 5 (+++++) high, shown in lo cw, deniz s, hardt j, pérez lópez r,pleyer j,babich sm. sustainable reform of european union (eu) common fisheries policy (policy brief). seejph 2023. posted: 09 april 2023 p a g e 106 table 2. the explication of the results is further described in appendix 2. we recommend the integration of the participatory research approach into article 18 (32). in the evaluation, it achieved the highest score of 16 out of 20 points. compared to the other two options, par has the great advantage of being a more comprehensive approach that involves stakeholders and can be applied to any fisheries measure. the par alone does not bring about more sustainable fishing practice, but the integration of stakeholders in the entire research process is associated with positive effects on economic and political feasibility. a single intervention is not enough to tackle this complicated situation; however, it is possible to improve the condition only when multiple approaches are introduced. fish populations and the overall ecological state of marine habitats are undergoing constant changes due to a variety of influencing factors. therefore,related policies and potential alternatives should be re-evaluated regularly and modified when necessary to ensure they achieve their intended goals. table 2. the assessment policy options policy alternatives economic feasibility effectiveness political feasibility equity i. fishery restricted area (fra) +++ +++++ +++ +++ ii. embracing and improving small-scale fisheries (ssf) ++ +++++ +++ ++++ iii. participatory action research (par) ++++ +++ ++++ +++++ conclusion this policy brief explored reform of the common fisheries policy (cfp) in the eu. applyingfour evaluation criteria (economic feasibility, effectiveness, political feasibility, and equity). integration of the par into the cfp was deemed the best option of those examined. however, the policy options and recommendations may have limited impact, given the nature of the problem they are meant lo cw, deniz s, hardt j, pérez lópez r,pleyer j,babich sm. sustainable reform of european union (eu) common fisheries policy (policy brief). seejph 2023. posted: 09 april 2023 p a g e 107 to solve.a cycle of regular evaluation and continuous, evidence-based policy improvement will be necessary for long-term effectiveness. conflicts of interest the authors declare no conflict of interest. acknowledgements the team would like to thank the course coordinator katarzyna czabanowska for being granted the opportunity to assess a policy situation and develop policy options for a topic in the field of fisheries and sustainability. without her profound integral support, we wouldn’t have a chance to complete this achievement. references 1. food and agriculture organization of the united nations (fao). the state of world fisheries and aquaculture 2018 meeting the sustainable development goals rome; 2018. 2. food and agriculture organization of the united nations (fao). 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and repealing council regulations (ec) no 2328/2003, (ec) no 861/2006, (ec) no 1198/2006 and (ec) no 791/2007 and regulation (eu) no 1255/2011 of the european parliament and of the council, (2014). 27. ørebech p. getting it right’’: the birth of a new eu common fishery policy?*legislative and legal perspectives on the annulling of the ‘‘five structural failings. arctic review on law and politics. 2015;6(2):111-31. 27a. aranda m, ulrich c, gallic b, borges l, metz s, prellezo r, et al. research for pech committee — eu fisheries policy – latest developments and future challenges, european parliament. policy department for structural and cohesion policies, brussels; 2019. 28. gómez s, maynou f. balancing ecology, economy and culture in fisheries policy: participatory research in the western mediterranean demersal fisheries management plan. journal of environmental management. 2021;291:112728. 29. lembo g, bellido jm, bitetto i, facchini mt, garcía-jiménez t, stithou m, et al. preference modeling to support stakeholder outreach toward the common fishery policy objectives in the north mediterranean sea. front mar sci. 2017;4:328. 30. de vos bi, döring r, aranda m, buisman fc, frangoudes k, goti l, et al. new modes of fisheries governance: implementation of the landing obligation in four european countries. marine policy. 2016;64:1-8. 31. garza-gil md, amigo-dobaño l, surísregueiro jc. institutions and governance in the european common fisheries policy: an empirical study of spanish fishers' attitudes toward greater participation. marine policy. 2017;79:33-9. 32. verordening (eu) nr. 1380/2013 van het europees parlement en de raad van 11 december 2013 inzake het gemeenschappelijk visserijbeleid, tot wijziging van verordeningen (eg) nr. 1954/2003 en (eg) nr. 1224/2009 van de raad en tot intrekking van verordeningen (eg) nr. 2371/2002 en (eg) nr. 639/2004 van de raad en besluit 2004/585/eg van de raad, (2013). 33. the north sea advisory council (nsac). nsac advice on lessons learned from the dogger bank process. 2020 april 17. 34. european maritime and fisheries fund (emff) 2022 [cited 2022 dec 2]. available from: https://oceans-andfisheries.ec.europa.eu/funding/europeanmaritime-and-fisheries-fund-emff_en. lo cw, deniz s, hardt j, pérez lópez r,pleyer j,babich sm. sustainable reform of european union (eu) common fisheries policy (policy brief). seejph 2023. posted: 09 april 2023 p a g e 110 appendices appendix 1. the influence of past reforms of cfp (1) the new cfp the new cfp introduced practical approaches to maximize fishers’ catches without endangering the fish stocks. firstly, the maximum sustainable yield (msy) was introduced to tackle ambiguity, which was one of the reasons for ineffective fishing regulation. based on the msy, the committee of ministries of fish or related departments could evaluate total allowable catches (tac) for most commercial fish stocks. secondly, eu member states must collect, and manage biological, environmental, and socioeconomic data for scientific advice, which might help estimate msy and modify future regulations. thirdly, landing obligations were brought to address the wasteful practice of fish discarding, which means returning unwanted catches to the sea. to achieve the above goals, furthermore, financial support and technical measures were also mentioned and implemented in the new reform. (2) the common organization of the markets in fishery and aquaculture products the market plays an important role in fishing practices and policy compliance. for the fish industry, a fisheries control system was introduced to ensure members’ compliance. this included the aim to fight against illegal, unreported, and unregulated fishing (iuuf). for consumers, new marketing standards concerning labelling, quality, and traceability allow better and clearer information about the origin, mode of production, and processing of the fish. (3) the new european maritime and fisheries fund (emff) the emff was a fund for the eu's maritime and fisheries policies for 2014-2020 (34) over one quarter (26.26%) of the budget went to sustainable fisheries, which aims at reducing unintended catches. in 2021, a new european maritime, fisheries, and aquaculture fund (emfaf) were adopted to ensure the sustainable use of aquatic and maritime resources. this not only supported sustainable fisheries but also conserved marine biological resources. most importantly, this also helped achieve the un’s sustainable development goal (sdg) 14 (conserve and sustainably use the oceans, seas and marine resources) https://eur-lex.europa.eu/summary/glossary/member_states.html https://ec.europa.eu/oceans-and-fisheries/fisheries/rules/discarding-fisheries_en https://ec.europa.eu/oceans-and-fisheries/fisheries/markets-and-trade/seafood-markets_en#ecl-inpage-721 https://ec.europa.eu/oceans-and-fisheries/fisheries/markets-and-trade/seafood-markets_en#ecl-inpage-721 lo cw, deniz s, hardt j, pérez lópez r,pleyer j,babich sm. sustainable reform of european union (eu) common fisheries policy (policy brief). seejph 2023. posted: 09 april 2023 p a g e 111 appendix 2. the explication of the policy option assessment policy alternatives economic feasibility effectiveness political feasibility equity i. fishery restricted area (fra) approximately 10 % increase in revenue between 2016 and 2020 in the adriatic sea. the region is generally the “only subregion where the share of revenue is significantly greater than the share of employment” feld (2), which advertises economic efficiency. no data could be found for economic benefit from the specific fra but based on the general data it can be assumed that the fra don’t have a negative impact on economic benefit. since the implementation in 2017 of the jabuka/pomo pit, a higher abundance and densities of main commercial species such as the european hake and juvenile european hake, norway lobster, and deep-water rose shrimp were measured inside the fra. also, outside in the general northern adriatic sea the fra contributed to the recovery of stocks. in addition, a lower exploitation rate and a slight increase in biomass of the european hake is reveal)(2). the jabuka/pomo pit is a best-practice example of transnational cooperation and is accompanied by a comprehensive scientific monitoring plan (3, 19). if stakeholders are not involved in the process, the measurement can simply fail, because fishermen react often with noncompliance to restrictive management measurements (29). the views of fishers and stakeholders were integrated into the implementation process of the jabuka/pomo pit fra (2).in the adriatic sea “benefits from fisheries are not equally distributed between sff [smallscale fisheries] and industrial fisheries” (2, 17). industry fisheries generate 71% of revenue. the share of employment is significantly smaller than the share of revenue, justified by a lower percentage of smallscale vessels. no data are available for the specific fra. the european hake (and thus the recovery of this species) play a decisive role in supporting livelihood of the employees onboard fishing vessels (2). ii. embracing and improving ssf the depletion of fish stocks in the mediterranean has resulted in shrinking fleets and a loss of jobs (23). while more regulations might first result in lower landings, it is a crucial step in long-term thinking. we as societies must be all presented steps are based on scientifically proven effectiveness. however, the authors must acknowledge that even though the proposed actions will have a positive impact, they will not single-handedly solve the issue of overfishing. even though it is hard to predict how political leaders will perceive it, they must acknowledge that the cfp has not reached its intended goals. furthermore, the eu and european countries have committed to environmental ssf in the mediterranean make up 80 % of the fishing (1). as the name suggests, those boats belong to fishers and small companies, who are important to the local culture and economy. lo cw, deniz s, hardt j, pérez lópez r,pleyer j,babich sm. sustainable reform of european union (eu) common fisheries policy (policy brief). seejph 2023. posted: 09 april 2023 p a g e 112 willing to accept moderate catch rates to secure a long-term food source. if the mediterranean sea won’t protect more, fish stocks are likely to be fully depleted for the whole economic sector to collapse. protection and tackling climate change. moreover, the approach could positively impact the local businesses and guarantee job security. empowering ssf is certainly equitable, as some communities have long-standing histories as fishermen and certainly require more support than large-scale commercial vessels. iii. participatory action research (par) no data on the economics could be found. high expenditure can be expected for the process, as stakeholders are to be involved in the whole research process (29). however, compliance achieved in this way can avoid later costs. the small-scale fishery is based on cultural values transmitted through generations (29). the cultural hesitate is seen as a vehicle for sustainable fishing and as a guarantor of marine custody (29). however, the integration of the par into the cfp alone cannot contribute to sustainability. based on the approach, specific measures need to be implemented. the par follows a community-based approach and aims to survey local interests and concerns to improve stakeholders’ well-being and is understood as and process of knowledge exchange between stakeholders and scientists (29). the par is focused on the sociocultural integration in the implementation and decision-making processes of fisheries policies. stakeholder needs and concerns are included by inquiring their knowledge and perception (29). ___________________________________________________________________________ © 2023 chungwan lo, et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 1 | 19 review article hepatitis c in several risk groups: literature review albiona rashiti-bytyçi1, naser ramadani1,2, ariana kalaveshi1,2, sefedin muçaj1,2, luljeta gashi1, premtim rashiti2 1 national institute of public health in kosovo, prishtina, kosovo; 2 university of prishtina “hasan prishtina”, prishtina, kosovo. corresponding author: prof. dr. naser ramadani, md, phd, mphe, cmis, cieh; address: rr. nëna tereze p.n., rrethi i spitalit, 10.000, prishtina, kosovo; telephone: +38338551431; email: naser.ramadani@uni-pr.edu rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 2 | 19 abstract aim: the objective of this study was to assess the distribution of hepatitis c in selected risk groups such as haemodialysis patients, pregnant women, healthcare workers, hiv-hcv co-infected patients, patients with mental health diseases and piercing and tattoo procedures. furthermore, it aimed at evidencing common transmitting routes and highlighting the importance of preventive measures among these groups. methods: the literature review was conducted using online databases (medline) with search query involving the keyword “hepatitis c” in conjunction with keywords describing risk groups such as "dialysis", or "haemodialysis", or "pregnancy", or "pregnant", or "mental health", or "tattoo", or "piercing", or "hiv", or "health professionals”. results: after assessing all the retrieved publications, 39 of them were considered for inclusion: 17 on haemodialysis patients, 7 on pregnant women, 8 on hiv-hcv co-infection and 7 publications on health professionals, patients of mental health wards and piercing and tattoo procedures. the high rate of hepatitis c is still a high problem and in some cases it is considered as a new issue, as in the case of pregnancy. some of the transmission routes have been identified earlier, such as the hiv-hcv co-infection but some, such as piercing and tattoo, are becoming new transmission routes. health professionals are still identified as high risk group while mental health patients are a potentially high risk group. conclusion: even though some patients are routinely screened for hepatitis c, there are indications for performing such a routine test in other groups. in almost all of the risk groups, it is advocated to use stricter preventive measures and to disseminate knowledge on risks of hepatitis c. keywords: haemodialysis, healthcare workers, hepatitis c, human immunodeficiency virus, mental health diseases, piercing and tattoo, pregnancy. conflict of interest: none declared. rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 3 | 19 introduction hepatitis c, as a liver infection, is caused by the hepatitis c virus (hcv), blood borne virus. the virus can cause both acute and chronic hepatitis, ranging in severity from a mild illness lasting a few weeks to a serious, lifelong illness. approximately 60%-80% of infected people may progress to chronic liver disease and 20% of them will develop cirrhosis (1). according to who, globally, an estimated 71 million people have chronic hepatitis c infection (2). an estimated 3.5 million people in the united states have chronic hepatitis c (3). globally, morbidity and mortality from hepatitis c virus infection (hcv) is increasing. according to estimation from recent studies, more than 185 million people around the world are infected with hepatitis c virus (1). total global prevalence of hcv is 2.5%, varying from 2.9% in africa to 1.3% in america, with global viremic rate 67% (118.9 million hcvrna positive cases), varying from 64.4% in asia to 74.8% in australasia (4). in europe, the prevalence of hepatitis c (hcv) is estimated to be around 1.7% and includes 13 million cases, the lowest prevalence (0.9%) is reported in western europe (except some rural regions in south of italy and greece) and the highest prevalence in central europe (3.1%) specifically in romania and russia (5). according to estimation from global burden of disease study, deaths rate from hepatitis c was 333000 in 1990, 499000 in 2010 and 704000 in 2013 (6). these cases of deaths are result of complications from hcv, including liver cirrhosis, hepatocellular carcinoma and liver failure (7). the following groups are at increased risk for hcv infection:  current or former injection drug users;  chronic haemodialysis patients;  people with known exposures to hcv, such as (health care workers after needle sticks involving hcv-positive blood, recipients of blood or organs from a donor who tested hcvpositive);  people with hiv infection;  children born to hcv-positive mothers;  patients of mental health wards and also were at risk:  recipients of clotting factor concentrates made before 1987, when less advanced methods for manufacturing those products were used;  recipients of blood transfusions or solid organ transplants prior 1992, before better testing of blood donors became available (8); conversely, the transmission routes and epidemiology include:  intravenous drug use;  non-intravenous recreational drug exposure;  healthcare procedures;  accidental exposure;  mother to child vertical transmission;  sexual exposure etc. (8). methods search and study identification the aim of the study was to identify, through literature review, studies addressing the following: cases of hepatitis c, most common transmitting route, the importance of preventive measures, among several risk groups such as: haemodialysis patients, pregnant women, healthcare rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 4 | 19 workers, hiv-hcv co-infected patients, patients with mental health diseases and practitioners of piercing and tattoo. articles published were identified by literature survey in online database medline through pubmed interface, using keywords: "hepatitis c" and ("dialysis" or "haemodialysis" or "pregnancy" or "pregnant" or "mental health" or "psychiatry" or "tattoo" or "piercing" or "hiv" or "health professionals" or "health workers"). from the search query, 1788 publications were identified and from these only original publications were included. the following data were excluded from our analysis: data with unclear definition of hcv infection, duplicated data, all short communications or reviews. next, the remaining 688 publications were selected and after removing publications without abstract, there were left 617 of them. after reading abstracts of 617 publications we selected 150 publications that fulfilled our research interests. all 150 publications were studied and publications that dealt with detailed treatments, or included other groups of interests were excluded. finally, we selected 39 publications for analysing and presenting their results, as presented in figure 1. figure 1. search and study identification rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 5 | 19 overview of the results after a full text screening, as presented in figure 2, a total of 39 articles were considered for inclusion: 17 on haemodialysis patients, 7 on pregnant women, 8 on hiv-hcv coinfection and in total 7 publications on health professionals, patients of mental health wards and piercing and tattoo procedures. in following sections, each group will be discussed and in the end of each section, a short conclusion will be presented. figure 2. publications with hcv data by risk groups results on haemodialysis / hcv from 17 publications on hcv and haemodialysis, 10 of the publications included on their results prevalence of hcv on haemodialysis centres, while 7 other publications included on their result other findings or association of hcv with other factors. for hcv, prevalence estimates that were considered representative for haemodialysis centres were available for 10 countries as presented in table 1. a prospective study conducted in japan in 2016 (9) included 41 haemodialysis centres, with total of 2986 haemodialysis patients. the aim of the study was to screen for hcv antibody, and hcv rna, but as well to determine genotype of hepatitis c and the treatment of hcv patients. in its findings, authors have reported that 5.02% of patients were hcv ab positive and from this number 72.31% were hcv rna positive. another interesting conclusion of the study, was that 62.1% of tested patients were hcv genotype 1 and that the combined therapy of daclatasvir and asunaprevir was effective at hcv positive patients in haemodialysis. another study performed in japan, but this time a retrospective one (10), included 3064 patients on haemodialysis. the aim of the study was to find the association of hepatitis c virus infection with the prognosis of chronic haemodialysis patients. the results of the study suggested that of those patients, 14.0% were hcv rna positive, while 2.4% were hbsag positive and 0.3% were double positive. also in the study, it was reported that by 2010, 49% of haemodialysis patients were deceased. from that percentage, 60% of them were hcv rna positive, and 47% hcv rna negative. a prospective study was con17 7 8 3 2 2 0 2 4 6 8 10 12 14 16 18 rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 6 | 19 ducted in brazil (11) that included 798 haemodialysis patients, with the aim of determination of prevalence of hcv infection and genotypes in patients undergoing haemodialysis. the study found that performing elisa test, 8.4% of the patients resulted hcv positive, while 86.1% of them had determined viral genotype 1 and 11.6% determined genotype 2 and 2.3% determined genotype 3. one of the suggestions of the authors was to strengthen the control strategies for hepatitis c in haemodialysis centres. a cross-sectional study conducted in china in 2013 (12), included 2120 patients on haemodialysis and 409 patient partners. this study investigated the prevalence and risk factors of hcv and hbv infection and the distribution of hcv genotypes among haemodialysis patients and their spouses. authors findings were that 6.1% of the patients were anti-hcv positive, 4.6% of them were hcv rna and 7.0% of them resulted in hbsag positive. regarding the prevalence of their partners, it resulted that 0.5% of them were anti-hcv positive, while 0.2% rna hcv positive and 4.2% hbsag positive. some of the risk factors that authors have mentioned were: the duration of dialysis and blood transfusion. the predominant genotype was 1b with 89% while 2a had 7.7% and genotype 3a, 3b, 6a each by1.1%. authors’ suggestion, due to the persistence of nosocomial infection, were strict infection control measures to be strengthened with the aim of reducing the transmission of hcv. another prospective study, that involved 170 patients on haemodialysis, was performed in us (13), with the aim to overview the incidence and preventive measures for hcv in the haemodialysis centre. the study resulted in finding 5.4% new hcv cases, from which 4 cases were genotype 1a, 2 cases of genotype 1b. the other 37.6% of old cases, 29 cases were genotype 1a, 16 cases were genotype 1b, and 2 cases were genotype 3a. cross sectional survey in sudan included 353 patients of haemodialysis, aiming to determine the seroprevalence and risk factors for hepatitis c and hepatitis b in their dialysis centres (14). their finding resulted in 16 cases that were hbsag positive and 30 cases that were anti-hcv positive. the long duration of dialysis and surgical intervention, were most common risk factors, related to infection. in the middle east, authors (15) conducted a prospective investigation, to find the impact of an identical isolation policy on incidence of nosocomial hcv infection in haemodialysis centre. study was conducted in two phases, phase one involving 189 patients and phase two involving 198 patients affected of haemodialysis. their study resulted in finding 83 (43.9%) phase one patients with anti hcv positive, while the remaining 106 (56.1%) patients resulted as anti hcv negative. an interesting fact is the correlation between hcv positivity and the dialytic age (of 83 patients who had positive results for antihcv antibodies had a mean dialytic age of 48.5 ± 14.2 months, compared with 25.0 ± 8.6 months among the 106 anti-hcv-negative patients). in phase ii, they had similar results, 85 (42.9%) of 198 patients had antihcv positive results, and 113 (57.1%) continued to have a negative status for anti-hcv antibodies. interesting relation between phase one and two is the addition of two new anti-hcv positive cases (none of them belonging to the added 9 after phase one), that occurred over 12 months of study period, leading to an hcv seroconversion rate of 1.01% per year (15). netherlands conducted a nationwide prospective study on the prevalence and incidence of hepatitis c virus infections among dialysis patients in 1996 (16). in 34 haemodialysis centres, a total of 2281 patients were included, dividing the research into two phases: the first phase with 2281 patients – where the hcv rna positive rate was 2.9%, and the second phase after one rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 7 | 19 year with the sample of 2286 patients, where 3.4% of the cases were hcv rna positive. main risk factors were also identified by the study, and those being: haemodialysis before 1992, kidney transplantation before 1994, birth in other countries, and receiving dialysis abroad during vacations. another cross sectional study was conducted in canada, aiming to study hepatitis c prevalence and risk factors in dialysis population, with 336 patients included in the study (17). the study resulted in finding that prevalence of antihcv antibody was 6.5% (22/336), 77.2% (17/22) of cases that were anti-hcv positive resulted hcv rna positive. another prospective study was conducted with 128 patients in usa, with findings of 25% of them positive hcv eia (18), but tests were not specific because in 6 cases it was detected and resulted negative, which speaks about past infection. it is known that pcr remains the only reliable test to determine the presence of the virus. table 1. hepatitis c in haemodialysis centres paper year country study design study sample laboratory tests hcv ab positive hcv rna positive (9) 2016 japan prospective 2986 hcv antibody, hcv rna 5.02% from total of hcv ab positive cases, 72.31% were hcv rna positive (10) 2010 japan retrospective 3064 hcv rna / 14.00% (11) 2013 brazil prospective 798 hcv antibody 8.40% / (12) 2013 china cross-sectional 2120 hcv antibody, hcv rna 6.10% from total of hcv ab positive cases 4.6% were hcv rna positive; (13) 2009 usa prospective 170 hcv rna / 5.4% new hcv cases and 37.6% older hcv cases (14) 2010 sudan crosssectional 353 hcv antibody 8.50% / (15) 2003 arabia retrospective and prospective 189 hcv antibody phase i, 43.9% phase ii, 42.9% / (16) 1996 netherlands prospective 2281 (phase i) 2286 (phase ii) hcv rna / first phase 2.9%; second phase 3.4% (17) 1997 canada crosssectional 336 hcv antibody, hcv rna 6.5% hcv from total of hcv ab positive cases 77.2% were rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 8 | 19 hcv rna positive (18) 1998 usa prospective 128 hcv antibody 25% / in relation to haemodialysis patients, some other studies were conducted to find the connection between haemodialysis patients and hcv and other risk factors. since that connection is believed to be of importance, findings of those studies are briefly presented in the following paragraphs. one of the studies investigated bleeding epidemic that has erupted on september-october 2013, in haemodialysis unit in vietnam, involving 119 patients with 9 positive hcv cases and 9 positive hbv cases. authors found that hcv prevalence in the epidemic was 6%, which is 7.5 times higher than in the vast population of vietnam (19). another retrospective study conducted in usa found correlation between hcv and hepatocellular carcinoma (hcc), when checking 32860 hcv cases, that resulted in 262 cases with hcc (20). hcc was 12 times more common in cases of cirrhosis, 3 times more frequent in cases of alcohol consumption and 1.3 times higher in cases of diabetes, with the likelihood of hcc increasing with age. another correlation, this time linear, between incidence and prevalence, was found in a study in france, concluding that doubling the value of p(c) doubles the incidence of cases with hepatitis c (21). a prospective study conducted in spain, found initial prevalence (p <0.0001) and time (p <0.0001) emerging as independent variables associated with the decrease of hcv prevalence (22). authors of another study, conducted in france, found that hcv seroconversion was associated with the number of hemodialysis sessions undergone on a machine shared with or in the same room as a patient who was anti-hcv (genotype 2a/2c) positive (23). a cross sectional study in usa found by using multivariate logistic regression analysis, that the longer duration of receiving dialysis associated with a history of intravenous drug use, were the only risk factors that remained independently associated with hcv seropositivity (24). authors of a study in france found that overall, hcv rna became undetectable in 16 patients (69.6%) 1 month after starting ifn-a therapy and in 21 patients (91.3%) at the end of treatment (25). results on pregnancy /hcv conducting the literature review, 7 studies that presented a relation between hcv infection and pregnancy were included, as shown in table 2. a research conducted in pakistan (26), enrolled 119 cases of pregnant women with hcv positive, and 238 control cases, from the total of 5621 pregnant women, of whom 5339 were screened. their result showed that iatrogenic exposure (health care injections, hospitalizations and pregnancies) are the major risk factors for transmission of hcv among pregnant women. therefore, the authors call for strengthening the prevention aspect of the hepatitis control program to focus on behaviour change for reducing injection reuse and overuse. a study in the usa, which included 1013 obstetric patients identified that use of intravenous drugs resulted as the fastest risk factor (27) in hcv. authors emphasize that the epidemiologic data are consistent with sexual and parenteral modes of transmission, however, according to them routine screening for hepatitis c is not advocated. another study in the usa, with 599 pregnant hospitalised women, identified rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 9 | 19 4.3% were hcv positive, from which 3 positive hiv cases, and 2 of them had coinfection with hepatitis c. another correlation between hepatitis b and hepatitis c, resulted in 1 coinfection from 5 cases with hepatitis b (28). another study in italy, reported that hcv transmission was higher in mothers with fluctuating alt levels (31/154; 20.1%) when compared with mothers with normal alt levels (35/292; 12%). the hcv transmission was the highest in the group of mothers with constantly raised alt levels (8/31; 25.8%) (29). vertical transmission of hcv was investigated in three studies. the first study (30), had as a subject 2447 hcv pregnant women, from whom 78 women (3.2%) were anti-hcv positive, 60 women (2.5% or 77% of all cases of positive anti-hcv) were positive hcv-rnas. regarding the newborns, 60 of them (50%) remained hcvrna negative, throughout 22 of them (36.7%) were rna-hcv positive in one case and 8 of them (13.3%) were rna-hcv positive at least in the two following tests and only 2 children (3.3%) remained positive rna-hcv, testing after 8 to 24 months (30). the second vertical transmission study was conducted in ireland with 36 hcv pregnant women (31). from the study resulted that all 36 cases were positive when tested with elisa and 26 women (76%) were pcr positive for hcv genotype 1. in terms of vertical transmission only one child resulted positive when tested with pcr hcv (31). the third study conducted with 3712 pregnant women, resulted in 35 (0.94%) women that were antihcv positive and out of this number 20 women (57%) were hcv rna positive (32). the vertical transmission rate was 5%, where only one new-born of 29 of maternal rna hcvs positive resulted hcv rna even after 12 months of birth that speaks for hcv persistent infection (32). table 2. hepatitis c related to pregnancy paper year country study design study sample laboratory tests results (26) 2006 pakistan case control 5339 elisa hcv 119 (2%) were hcv positive (27) 1992 usa prospective 1005 hcv antibody 2.28% (n = 23) were hcv positive (28) 1994 usa prospective 599 elisa hcv 4.3% were hcv positive (29) 2006 italy case control 74 hcv rna transmitting mothers and 403 hcvrna not transmitting hcv rna, alt hcv transmission was higher in mothers with fluctuating alt levels (31/154; 20.1%) when compared with mothers with normal alt levels (35/292; 12%) (30) 1997 italy prospective 78 hcv positive anti-hcv, hcv rna 8 of 60 (13.3%) infants born to hcv-rna positive mothers acquired hcv infection, but only 2 (3.3%) were still infected by the end of follow-up. (31) 2001 ireland retrospective 36 women with hcv elisa hcv. hcv rna the 36 cases were positive elisa and 26 (76%) were pcr positive for hcv genotype 1b. in terms of rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 10 | 19 vertical transmission only one child resulted positive pcr hcv. (32) 1996 germany prospective 3712 pregnant women anti-hcv, hcv rna out of 3712 women, 35 (0.94%) were anti-hcv positive and out of this number 20 (57%) were hcv rna positive. the vertical transmission rate was 5%. results on hiv / hcv coinfection regarding the relation between the hcv and hiv, a number of research papers, presented in table 3, discussed the coinfection, while proving unfortunately that the problem is on the rise. the first study reviewed, was a prospective study performed in ghana, where from 1520 hiv infected cases, hcv rna test was performed in all hbsag positive subjects (n=236) and a random subset of hbsag negative subjects (n=172), which resulted in 4 positive cases (3 cases of genotype 2 and 1 case of genotype 1). from these four infected cases surgical procedures and blood transfusion procedure was reported as an important risk factor for hcv infection (33). in 2018, a study in spain was performed including 322 patients with hepatocellular carcinoma in patients with hiv/hcv coinfection (34). the study aimed finding the relationship between the use of antiviral agents and the risk of hcc in hiv/hepatitis c coinfected patients. as a result, 42 (13%) of patients occurred after sustained virological response. it is interesting to mention that after using direct antiviral agents in hiv/hcv coinfected patients, the frequency of hepatocellular carcinoma was not increased. a study conducted in canada between 2005 and 2015, examined the relationship between hiv-seropositivity and having access to a physician for regular hcv care (35). in total, 1627 hcv-positive cases were eligible for analysis; from whom 582 (35.8%) were hivpositive at baseline and 31 (1.9%) became hiv-positive during follow-up. their results demonstrated a positive relationship between hiv-seropositivity and having access to a physician for regular hcv care, which is partially explained through increased frequency of engagement in health care (35). in 11 european countries, data were used for performing retrospective and cross sectional study with 229 hcv / hiv cases of children and young adults (36). that resulted in 63% of cases that were infected with hepatitis c vertically, 7% of them were infected with hepatitis c as nosocomial infection, 17% with drug use and 13% of them has no data about the way of infection. study also reveals that among infected patients with hepatitis c, a high number of patients with progressive liver disease was present, so it suggests the importance of improving monitoring procedures and offering earlier hcv proper treatment (36). a study in 9 emergency units in england, in 2014, during “going viral” campaign, 7807 patients were tested (37). that resulted in 39 hcv infected persons (15 newly diagnosed), 17 hiv infected persons (six newly diagnosed), and 15 hbv infected persons (11 newly diagnosed). it also revealed that those aged 25–54 years had the highest prevalence: 2.46% for hcv, 1.36% for hiv and 1.09% for hbv. another study performed with 4950 participants in some regions in china resulted with hiv and hcv prevalence of yanyuan county were 0.06% and 0.15%, respectively. hcv prevalence of muli county was 0.06% hcv and none was found to be hiv positive (38). another important finding from this survey was that hiv epidemics has not spread from high risk groups to the general population. a systematic review and meta-analyses of 10 studies (39), 2382 infants, were included in rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 11 | 19 an analysis of hcv-infected mothers (defined by anti-hcv and antibody assays) with and without concomitant hiv infection. the risk estimate of hcv vertical transmission was 2.82 from anti-hcv positive/hiv positive co-infected mothers compared with antihcv positive/ hiv negative mothers. this finding revealed that the risk of hcv vertical transmission is higher in infants born to hiv co-infected mothers. rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 12 | 19 table 3. hiv – hcv coinfection paper year country study design study sample laboratory tests results (33) 2014 ghana prospective study from 1520 infected hiv, all hbsag-positive subjects (n = 236) and a random subset of hbsag-negative subject (n = 172) were screened for hcv rna hcv rna 4 positive cases (34) 2018 spain prospective study 322 hcc cases in hiv/hcv co-infected patients n/a after svr 42 cases (13%) (35) 20052015 canada prospective cohort 1627 hcv positive cases hcv rna, hiv test 582 (35.8%) were hiv-positive at baseline; and 31 (1.9%) became hivpositive during follow-up (36) 2016 11 european countries retrospective cross sectional 229 children and young adults with hiv/hcv hcv rna, hiv rna 63% of cases infected with hepatitis c vertically, 7% infected with hepatitis c as nosocomial infection, 17% drug use and 13% no data (37) 2014 england prospective 9 units of emergency departments (7807 patients) hivag/ab, hbsag, hcv ab 39 hcv infections (15 newly diagnosed), 17 hiv infections (six newly diagnosed), and 15 hbv infections (11 newly diagnosed). (38) 2011 china randomised prospective 4950 participant elisa hiv, elisa hcv hiv and hcv prevalence of yanyuan county were 0.06% and 0.15%, respectively. hcv prevalence of muli county was 0.06% hcv and none was found to be hiv positive (39) 2003 usa a systematic review 2382 infants from hcv infected mothers hiv rna, hcv rna risk estimate of hcv vertical transmission was 2.82 from anti-hcv+/ hiv+ co-infected mothers compared with antihcv+/hiv-mothers (40) 2014 usa review of recommendations / / / rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 13 | 19 results on health workers, tattoo and piercing procedures, patients of mental units / hcv three of seven studies involved in the survey and presented in table 4, revealed that health practitioners are the major risk group of getting hcv while giving care to their positive hcv patients. study on health care professionals approach to patients with hepatitis c revealed that during treatment they use stricter measures to protect themselves from infection (40). in the study, a questionnaire was sent to 3675 health professionals and in the end 1347 completed questionnaires were taken for analysis. as a final result, the study suggests that focusing education strategies on changing health practitioners’ attitudes toward people with hepatitis c, injecting drug users, and infection control guidelines rather than concentrating solely on medical information might ultimately improve patient care. another study conducted in usa, revealed that hiv and hcv infection was transmitted to health care workers from nursing home patients, when they dealt with these infections through non-intact skin exposure. in these cases, the infection may have been prevented by consistent, unfailing use of barrier preventive measures (41). in italy the research that was performed in 9 haemodialysis centres with 1002 patients for detecting infection with hepatitis b, hepatitis c and hiv, resulted with prevalence of hbsag in patients of 5.1%; hcv antibody 39.4%; antibodies to hiv 0.1%. another important result in this study emphasized that health professionals in haemodialytic centres has 4000 and 8000 times lower for hiv than for hepatitis b and hepatitis c, respectively (42). regarding the relation of hcv with mental illness, in the review are included two studies. the first study, with 293 veterans with hcv positive, resulted with 93% of the participants had at least one psychiatric problem and 73% had more than 2 mental disorders (43). the authors concluded that the routine screening for underlying psychiatric and substance use disorders and early treatment intervention before initiating antiviral therapy is essential. another study with 931 patients with mental illness, revealed that among this group there is a high number of infected persons with hiv, hepatitis b and hepatitis c 3.1% with hiv, 23.4% cases with hepatitis b and 19.6% cases with hcv (44). a big problem, authors found, is the large number of undetected cases with hepatitis c, and delay in detection is related to treatment delay and also might be a source of infection to others. regarding the relation of hcv and tattooing or piercing procedures, two studies are included. the first study, of 10 case-control studies, 6 reported no increased risk of hcv infection from tattooing when they controlled for injected drug use and other risk behaviours, and 2 studies reported a 2–3 times higher risk for hcv infection when the tattoo was received in nonprofessional settings (45). another study about knowledge of tattoo practitioners about hcv and transmission revealed that from 35 employees, 34 were aware of guidelines and body piercing (46). the average number of piercing procedures during the week was 5.5. study showed that body-piercing practitioners had inadequate training, and lacked knowledge and understanding of hcv transmission, infection control, and universal precautions. as a conclusion health care practitioners are in high risk for getting hcv infection from infected patients, so they should stricter measures. also it was identified high rate of hcv infection among patient with mental health diseases, and large number of undetected cases, that is a sign for occurring epidemics inside mental health wards. another conclusion related to piercing and tattoo procedures revealed that risk of hcv infection is significant among risk groups. also lack of knowledge about hcv transmission among rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 14 | 19 body piercing and tattoo practitioners could be a risk factor on rise. table 4. hepatitis c related to health care practitioners, mental disease patients, tattoo and piercing procedures paper study group year country study design results (41) health professionals 2006 australia analytic cross sectional study focusing education strategies on changing health practitioners’ attitudes toward people with hepatitis c, injecting drug users, and infection control guidelines (42) health professionals 2003 usa case report hiv and hcv transmission from the patient to the hcw appears to have occurred through non-intact skin exposure (43) health professionals 1993 italy prospective the risk of acquiring infection was calculated to be 8000 times lower for hiv than for hepatitis c. (44) mental health patients 2005 usa prospective 93% of the patients had a current or past history of at least 1 psychiatric disorder, and 73% had ⩾2 disorders (45) mental health patients 2001 usa prospective prevalence rates of hbv (23.4%) and hcv (19.6%) were approximately 5 and 11 times the overall estimated population rates for these infections, respectively (46) tattoo and piercing procedures 2015 usa meta –analyse risk of hcv infection is significant, especially among high-risk groups (adjusted odds ratio, 2.0–3.6), when tattoos are applied in prison settings or by friends (47) tattoo and piercing procedures 2003 australia cross sectional survey body piercing practitioners had inadequate training, and lacked knowledge and understanding of hcv transmission, infection control, and universal precautions discussion as for the first part of the research on haemodialysis, presented in table 1, most of the studies were of prospective nature, indicating the importance of following up the relations between the haemodialysis and hcv. less than half of the studies had a bigger sample than 1000 patients. the timing of haemodialysis and the risk of infection with hepatitis c virus appear to be in the right proportion, as the years of haemodialysis increase and the risk of acquiring hepatitis c infection increases. the laboratory tests in almost all of the studies, included hcv antibody and/or hcv rna but considering that hcv rna test is more expensive, in developing countries like sudan, only the hcv antibody test rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 15 | 19 was conducted, which can’t differentiate between an active infection versus a chronic or previously acquired infection. but, still the hcv antibody test, can provide an overview of the infected population with hepatitis c. this is also confirmed by the results of three studies (9,12,17) where over 70% of hcv ab positive cases were found to be hcv rna positive. generally, most of the studies suggest stronger preventive measures and stronger infection control strategies on haemodialysis centres. the second part of the research, dealing with relation between hepatitis c and pregnancy, presented in table 2, most of the studies were of prospective nature. injections (intravenous drugs) and hospitalization were identified as most common pathways of infection of pregnant women with hcv. other studies focused on vertical transmission, identified that new-borns were infected with hcv. these results emphasise the importance of routine screening for hcv during pregnancy. the part of the research dealing with hepatitis c and hiv co-infection, identified several publications, where most of them conducted prospective studies. the laboratory tests included hcv rna and hiv test. several studies call for routine screening in order to find out if they are infected but as well to offer earlier and proper treatment. the last part of the research included health care practitioners, mental health patients and tattoo and piercing procedures. according to the publications, health care practitioners are in high risk for getting hcv infection, from infected patients, so they should use stricter measures. also, a high rate of hcv infection among patient with mental health diseases was observed, and large number of undetected cases, that is a sign for occurring epidemics inside mental health wards. meanwhile, related to piercing and tattoo procedures, research revealed that risk of hcv infection is significant among risk groups. also lack of knowledge about hcv transmission among body piercing and tattoo practitioners could be a risk factor on the rise. conclusion after discussing the most important aspects presented in all 39 papers, the authors’ viewpoints are as follows: the most common test used to identify hepatitis c is hcv rna, even though as an expensive test, sometimes elisa / hcv antibody test can provide a valuable overview on infection. most of the studies were of prospective nature, indicating the importance of following up the disease. almost every study suggests stronger preventive measures and stronger control on haemodialysis centres. unfortunately, the hepatitis c incidence is on the rise. in line with these viewpoints, it is of paramount importance to emphasize that the routine screening can be life changing in finding out new cases and educating the population about the importance of preventive measures, as well as the early treatment. references 1. mohd hanafiah k, groeger j, flaxman ad, wiersma st. global epidemiology of hepatitis c virus infection: new estimates of age-specific antibody to hcv seroprevalence. hepatology 2013;57:1333-42. 2. world health organization. hepatitis c. available from: https://www.who.int/newsroom/fact-sheets/detail/hepatitis-c (accessed: november 18, 2020). 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care worker. am j infect control 2003;31:168-75. 42. petrosillo n, puro v, jagger j, ippolito g. the risks of occupational exposure and infection by human immunodeficiency virus, hepatitis b virus, and hepatitis c virus in the dialysis setting. am j infect control 1995;23:278-85. rashiti-bytyçi a, ramadani n, kalaveshi a, muçaj s, gashi l, rashiti p. hepatitis c in several risk groups: literature review (review article). seejph 2021, posted: 31 may 2021. doi: 10.11576/seejph-4487 p a g e 19 | 19 © 2021 rashiti-bytyçi et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 43. fireman m, indest dw, blackwell a, whitehead aj, hauser p. addressing tri-morbidity (hepatitis c, psychiatric disorders, and substance use): the importance of routine mental health screening as a component of a comanagement model of care. clin infect dis 2005;40:s286-91. 44. rosenberg sd, goodman la, osher fc, swartz ms, essock sm, butterfield mi, et al. prevalence of hiv, hepatitis b, and hepatitis c in people with severe mental illness. am j public health 2001;91:31. 45. tohme ra, holmberg sd. transmission of hepatitis c virus infection through tattooing and piercing: a critical review. clin infect dis 2012;54:1167-78. 46. hellard m, aitken c, mackintosh a, ridge a, bowden s. investigation of infection control practices and knowledge of hepatitis c among body-piercing practitioners. am j infect control 2003;31:215-20. sheehan, c. callejas de luca, e. leon, h. boch, s. a call to include hospital support staff in cultural competency training. seejph 2022, posted: 8th december 2023. posted: 09 april 2023 page 38 policy brief beyond silos: a call to include hospital support staff in cultural competency training ciara sheehan¹, estefanía callejas de luca¹, hélène marguerite leon¹, simon boch¹ ¹department of international health, governance and leadership in european public health master, faculty of health medicine and life sciences, maastricht university, maastricht, the netherlands. all authors contributed equally to this work. corresponding author: ciara sheehan address: duboisdomain 30, 6229 gt, maastricht, the netherlands email: c.sheehan@student.maastrichtuniversity.nl mailto:c.sheehan@student.maastrichtuniversity.nl sheehan, c. callejas de luca, e. leon, h. boch, s. a call to include hospital support staff in cultural competency training. seejph 2022, posted: 8th december 2023. posted: 09 april 2023 page 39 abstract context: patient populations are becoming more diverse. as a result, the “one-size fits all” approach to healthcare delivery is no longer sufficient. today, quality of care is highly influenced by the cultural competency (cc) of healthcare providers (hcps). hcps, however, are not the only members of hospital staff who influence quality of care. another group, hospital support staff (hss), also play a critical role in the healthcare delivery process. yet, hss remain under-recognized and have been left out of hospital-led cc training. aim: this policy brief offers a novel perspective, advocating for the inclusion of hss in hospital-led cc training, as it has been acknowledged by previous research that increasing the cc of healthcare staff is an appropriate strategy to improve the quality of care for patients. methods: to gain more insight, interviews and surveys were conducted (october 2022) among a group of hss at the ronald mcdonald house (rdmh). these hss include volunteers and managers who enable family centred care (fcc) for maastricht university medical centre (mumc+). a non-systematic literature review on the topic of cultural competency development was also conducted. results: to develop policy recommendations, options were first assessed using a pre-established framework for developing organisational cc by castillo & guo (10). in addition, a stakeholder analysis was completed. together with the survey responses and interviews, this confirmed hss, need and want to be culturally competent. these results feed into the development of policy recommendations. recommendations:thus, three policy recommendations are made: (1) formalise cc training at mumc+; (2) include hss in such a cc training; and (3) develop and monitor training with participatory action research (par). keywords: cultural competency, high-quality care, hospital support staff. sheehan, c. callejas de luca, e. leon, h. boch, s. a call to include hospital support staff in cultural competency training. seejph 2022, posted: 8th december 2023. posted: 09 april 2023 page 40 introduction and context the changing landscape of dutch hospitals in recent years, the netherlands has seen increasing ethnic diversity among its patient populations, due to migration patterns (1). for example, by 205030%-40% of the total population in the netherlands is expected to have at least one non-dutch parent (2). this demographic shift will have important implications for the dutch health sectorin terms of how it can serve highly diverse patient populations (1). language of people, belief system, and ethnic origins influence the experience of illness and level of adherence to healthcare advice (3). to keep pace with these transitions and ensure care remains of high-quality for all patient groups, dutch hospitals are beginning to evolve as foundat maastricht university medical centre (mumc+). feedback provided from mumc+outlined that a de&i group has recently been established to examine what de&i policies can be developed in mumc+. among other initiatives, this group introduced training for healthcare professionals (hcps) about patients’ cultural differences. cultural competency (cc) training as recognised by previous research, increasing the cultural competency of healthcare professionals (hcps) appears to be an appropriate strategy to improve the quality of care for today's multicultural populations(3) (figure 1). "cultural competence denotes the knowledge, skills, attitudes, and behaviours necessary for a professional to provide optimal healthcare services to people from a wide range of cultural and ethnic backgrounds" (3, p. 92). a lack of cultural competency amongst hcpscan result in negative impacts on quality of careand persisting health inequalities for patients of an ethnic minority (1). for example, a 2017 comparison of dutch and ethnic-minority patients revealed that the latter experienced poorer levels of empathy from hcp’s and had shorter consultations (1). a key stakeholder is missing healthcare professionals are, however, not the only members of hospital staff who interact with patients and influence quality of care. non-medical, or hospital support staff (hss), ensure hcps can deliver high quality care, both directly and indirectly sheehan, c. callejas de luca, e. leon, h. boch, s. a call to include hospital support staff in cultural competency training. seejph 2022, posted: 8th december 2023. posted: 09 april 2023 page 41 (e.g., by providing meals, transportation, and a hygienic environment) (4). typically, hss represent a third of the total hospital staff, including administrators, financial advisors, or cleaners (table1). in the united states, 45% of people working in hospitals are non-clinical staff (including administrative and other support staff), while this proportion is around 30% in switzerland, france and iceland (5). data on non-medical personnel in the dutch health system, for example cleaning and administrative staff, is not available. in addition to their standard tasks, hss may offer emotional support to patients and their families. cleaning staff provide “mental, emotional, and spiritual, person-centred care” in the 10-20 minutes (per day) they spend with a particular patient (6, p. 6). sheehan, c. callejas de luca, e. leon, h. boch, s. a call to include hospital support staff in cultural competency training. seejph 2022, posted: 8th december 2023. posted: 09 april 2023 page 42 policy brief aim vance et al. (6) are among few authors that have elucidated the role of hss in patient care. therefore, the potential of hss to maximise quality of care is overlooked. broadly, this policy brief advocates for the recognition of hss as key stakeholders in the hospital setting. further, it argues that an immediate action towards this goal is the inclusion of hss in hospital-led cc training. at the local level, this call is made to decision-makers in mumc+. the recent establishment of a de&i group at mumc+ points to a desire by the organisation to engage in de&i initiatives. cc competency training for all members of the healthcare workforce from hcp’s through to hss is an option for mumc+ to consider. methods to gather the data from rmdh maastricht,managers and volunteers of rmdh were interviewed and surveyed (october 2022). during the interview, key barriers and facilitators in providing fcc (under the umbrella of cultural competency) were discussed. an anonymous survey of the volunteers was conducted to assess four areas: (1) demographics; (2) perceived need for cultural competency and de&i initiatives; (3) current barriers related to cultural competency that impact “hospitality”; (4) desire to improve cultural competency and de&i practices. in total 22 responses were received (17 online and 5 on paper). to gain insight from mumc+, feedback was received from an ambassador of the mumc+ de&i group on current de&i policies inplace in the organisation and plans for future programs, including cc training. a non-systematic literature review was conducted on the topic of developing cc and it’s benefits for the delivery of healthcare services. evidence and study description 1. why should hss be included in de&i initiatives, such as cc training in terms of the evidence gathered, rmdh maastricht serves families from a large range of cultural and ethnic backgrounds, while the demographic of the volunteers is mainly white dutch women over the age of fifty. while the survey data indicated that ethnic diversity of rmdh service-users is sheehan, c. callejas de luca, e. leon, h. boch, s. a call to include hospital support staff in cultural competency training. seejph 2022, posted: 8th december 2023. posted: 09 april 2023 page 43 varied, this has not been met with increasing diversity among rmdh staff. in terms of perceived need,responses from volunteers noted that personal awareness and communication were critical to make parents and families of a non-dutch background feel more “at home”.to understand the motivation for participating in cc training, several de&i initiatives related to developing cultural competencies were listed for the respondents’ consideration. results suggest that the volunteers would be willing to participate in cc training programmes which develop understanding of cultural habits of oneself and others, how cultural practices and ideas affect health and understanding of quality of health services, andthe role of care providers in different cultures. on the basis oftheinterview data, there is a gap in demographics of the volunteers and service users. a potential benefit of cc training for the organisation would be an increase of inclusivity and hospitality which could improve services provided to the families. also, a collaboration between rmdh and mumc+onde&i initiatives could also be of benefit for service users, as both organisations share similar barriers such as language and cultural differences. at mumc+ there has been efforts made to date surrounding cc. for example, training has been provided to healthcare professionals in terms of cultural differences in patient populations. the de&i group intend to continue provision of such training to enable staff to be informed of and appreciate cultural diversity. finally, evidence suggests that improved cultural competency of healthcare staff can improve the quality of care provided to patients, as knowledge of cultural groups can be used appropriately to increase the quality of healthcare services provided (9). 2. how can hss be included in de&i initiatives such as cultural competency training? castillo & guo (10) have developed a framework for how healthcare organisations can develop cultural competence in an impactful way. the selected framework (figure 3) is made up of three elements (9): (1) the board of directors and chief executive officer (ceo) ensuring that sheehan, c. callejas de luca, e. leon, h. boch, s. a call to include hospital support staff in cultural competency training. seejph 2022, posted: 8th december 2023. posted: 09 april 2023 page 44 cultural competence is integrated into all organisational policies; (2) developing a strategic plan with anticipatory and long-term processes and objectives that emphasise the importance of cultural competence training; and (3) facilitating continuous monitoring and evaluating efforts in order to assess the level of cultural competence and whether objectives in developing cultural competence have been achieved. this framework will be employed to identify potential areas in mumc+ where policies to develop cultural competence can be executed. these policies should ensure longterm change and provide opportunities for hss to be recognised. as set out in the framework, the ultimate aim of adoption of such policies is to increase cultural competence, leading to improvements in quality of care. sheehan, c. callejas de luca, e. leon, h. boch, s. a call to include hospital support staff in cultural competency training. seejph 2022, posted: 8th december 2023. posted: 09 april 2023 page 45 box 1. a specific case: the ronald mcdonald house maastricht (rmdh) what is the ronald mcdonald house (rmdh)? ronald mcdonald kinderfonds nederland (rmkn) was established 35 years ago in the netherlands and encompasses the ronald mcdonald houses (n=12), living rooms (n=12), and holiday homes (n=3) (11). the rmdh maastricht provides a “home away from home” for parents (and siblings) with a child in the nicu, picu, or children's ward of the mumc+ (11). rmkn has ensured sick children and their families can be close to each other, contributing to global, upward trends in family centred care (fcc). hereby, rmkn plays an essential role in promoting the physical and mental well-being of sick and care-intensive children and their families. for instance, an impact analysis in 2015 revealed that 97% of families indicated they were able to care for their sick child better by staying at the ronald mcdonald house (11). moreover, rmkn has four core values, including: (1) make families feel at home; (2) provide a listening ear (3) remain quality driven; and (4) be reliable and transparent. to upload these values, rmkn must closely monitor developments in healthcare and society, such as patient diversification. thus, a key focus of rmkn’s 2020-2023 “multi-year strategy” is developing and implementing a “cultural program” with “cultural ambassadors'' (11). what is family centred care (fcc)? how does it influence quality of care? hss at rmdh play an integral role in the provision of family centred care (fcc). the family-centred care approach requires a change in the role of the patient and his/her family (11). the patient and family represent an active component of care and the patient's potential sheehan, c. callejas de luca, e. leon, h. boch, s. a call to include hospital support staff in cultural competency training. seejph 2022, posted: 8th december 2023. posted: 09 april 2023 page 46 well-being depends on teamwork involving the patient, family, and healthcare workers (12).thus, in this approach the patient is no longer a passive recipient of treatment and medicine. further, the institute for fcc established some core concepts that are at the heart of this model, they are: dignity and respect, information sharing, participation and collaboration (13). lastly, on an organisational level fcc offers means to improve quality of care and stimulates higher job satisfaction among hcps (12). policy options the evidence gathered from literature, and interview and survey dataoutlines firstly the importance of developing cultural competency amongst the healthcare workforce and secondly, that non-medical personnel such as hss are aware of the need and are motivated to participate in developing these skills. as de&i practices have not yet been extended to include hss, this research advocates for action to incorporate this group of the healthcare workforce in de&i policies. policy options to do so exist at four different levels corresponding to the castillo & guo (10) framework. these options are identified and described in table 1. table 1. policy options based on castillo & guo (10) framework. tier name description of options 1 governance (board of directors and ceo) at the governance level of both mumc+ and rmkn (rmdh), de&i should hold a prominent position in the “annual agenda”. commitment to de&i could be exemplified by the funding and allocation of human resources to cc training for all staff. sheehan, c. callejas de luca, e. leon, h. boch, s. a call to include hospital support staff in cultural competency training. seejph 2022, posted: 8th december 2023. posted: 09 april 2023 page 47 this commitment could be further demonstrated by the governance level requiring all hcps and hss, involved in fcc, to ascertain a cc training certificate. 2 the mission, vision, values statement in order for de&i to hold a prominent position in the delivery of fcc, de&i policies should be integrated into all organisational policies at the hospital and rmkn. this would demonstrate a long-term commitment by the governance level which will feed down into the culture of both organisations. 3 strategic plan the development of a strategic plan at the hospital and rmkn should be developed to offer cultural competency training for hcp’s and hss. such a plan should recognise the evidence that cultural competency training can improve quality of care. furthermore, including hss in future strategic plans will acknowledge their role as “important players” in the delivery of high-quality care. 4 monitor and evaluation implementation of any de&i policy, strategic plan, or initiative cannot be effective without progress monitoring (of pre-defined outcomes) and routine evaluation. a key measure will be “level of engagement and participation” of hcps and hss. sheehan, c. callejas de luca, e. leon, h. boch, s. a call to include hospital support staff in cultural competency training. seejph 2022, posted: 8th december 2023. posted: 09 april 2023 page 48 social media (e.g., facebook and linkedin) could be implemented as channels through which the rmkn can easily reach their audience to deliver a message about cc. given cc training is a “new” approach in the netherlands, resistance is anticipated. to proactively address any resistance from key stakeholders, strategies such as participatory action research (par) could be utilised. stakeholders as outlined in table 1, “stakeholder engagement” is necessary at every level (or tier) to develop organisational cc. hence, stakeholders are considered the most influential part of this policy brief. the stakeholders necessary to implement and progress policy recommendations are visualised in figure 4 and figure 5 (based on their involvement in cultural competency). an important stakeholder group is the rmkn; whose role is to create a sense of belonging and inclusion in all the dutch rmdhs. the rmkn organises activities during the year where employees and volunteers are invited to attend. events include charity runs, theatre performances, fundraisers, etc. interviews with rmdh maastricht management revealed, the current organisation of these events makes it difficult for volunteers and staff to engage. in fact, the events are organised only in the main cities (e.g., amsterdam, eindhoven), creating geographical barriers for volunteers. arguably, more attention to these details could result in achieving higher participation as well as a stronger sense of belonging. lastly, the stakeholder analysis confirmed hss are key stakeholders in the hospital setting. correspondingly, survey responses indicated hss have a strong willingness to sheehan, c. callejas de luca, e. leon, h. boch, s. a call to include hospital support staff in cultural competency training. seejph 2022, posted: 8th december 2023. posted: 09 april 2023 page 49 take action on de&i. however, resistance from hss (reflected in some interview/survey responses of rmdh volunteers) as well as other staff members is anticipated. thus, leaders (e.g., hospital management) need to be prepared to overcome this resistance and allow for participation and inclusion of all stakeholders. for example, one option is for rmdh to be included in the recently formed de&i initiative group at mumc+, thus allowing this under-represented group in the workforce to play a role in the development and implementation of de&i policies. figure 4. stakeholders involved in our case study (created by authors). figure 5.level of stakeholder interaction with patients (created by authors) sheehan, c. callejas de luca, e. leon, h. boch, s. a call to include hospital support staff in cultural competency training. seejph 2022, posted: 8th december 2023. posted: 09 april 2023 page 50 policy recommendations based on the research conducted and considering the policy options available throughout the tiers of the cc framework (10), the following recommendations are being made to facilitate the development of cc at rmdh maastricht and mumc+. recommendation 1: formalise cultural competency training at maastricht university medical centre (at tier 3). a desire for progress of de&i was reflected at the hospital level. a de&i initiative group has recently (2022) been started by and for mumc+ staff members. there have been substantive consultations with university maastricht (academic institution) to inform this initiative. a de&i initiative group organised a training for hcps on cultural differences in patient populations. this training has not been formalised as an annual, mandatory cultural competency training. a mission of mumc+ is to guide staff from unconsciously incompetent to consciously competent, both for cultural diversity and for other forms of diversity. thus, the de&i group should commit to formalising this cultural training, as a cc training. in addition, as reflected by the intentions of the de&i group, such training should become a point on the annual agenda of mumc+. recommendation 2: include hss in cultural competency (cc) training (at tier 3). a review of literature found (globally) de&i agendas and policies focus on frontfacing clinical staff: neglecting a traditionally under-recognized group of hss. however, surveys at rmdh revealed hss are important players in the delivery of high-quality care, especially family centred care (fcc). there exists a significant and visible gap between the demographics of volunteers/management staff of rmdh (e.g., white, dutch women over the age of 50) and its guests (e.g., young arabic, polish, or ukrainian parents). this gap extended to “spoken-language”; such that the languages spoken by volunteers (e.g., dutch, english, french) did not align with those of non-dutch rmdh families (e.g., arabic, polish, ukrainian). importantly, all survey responses indicated “language” was a significant barrier to creating a “welcome atmosphere” for sheehan, c. callejas de luca, e. leon, h. boch, s. a call to include hospital support staff in cultural competency training. seejph 2022, posted: 8th december 2023. posted: 09 april 2023 page 51 rmdh families. other barriers included: guests’ bias towards females, the “stand-off” nature of guests, and a lack of understanding about cultural norms. rmdh management staff indicated this was also true for the mumc+. however, the hcps at the hospital make use of a translator available by telephone. therefore, of possible de&i priorities, the survey results illustrate cc training (to address language barriers and the increasing ethnic diversity among patients and their families) would have the greatest impact on the quality of fcc at mumc+. parallel, both the rmdh and mumc+ are committed to developing de&i policies, including policies aimed at increasing cultural awareness. rmdh staff knowledge, accept, and are motivated to participate in those de&i initiatives. recommendation 3: develop and monitor cc training for hss through participatory action research (par) (at tier 4). given the central role hss play in maximising quality of care, it is essential their participation in de&i progress be facilitated and they be recognized as an important, valuable stakeholder (15). rmdh management staff believe that de&i policies are necessary. likewise, volunteers at rmdh demonstrated a keen desire to participate in de&i initiatives related to cultural competency development. namely, more than half of survey-respondents were interested in “a session on the advantages and disadvantages of one's own and other cultural habits”. interestingly, while language was seen as a significant barrier to creating a “welcome atmosphere” few respondents wanted to participate in a “polish or arabic language class”. to ensure cc training is targeted to hss appropriately, par may be employed. importantly, par will engage hss and enable them to share interactions/relationships of daily life in the workplace. furthermore, par challenges the interests of stakeholders, destabilising established habits, hierarchies, and power dynamics (16). lastly, par may be used to motivate hss to participate in future de&i programs, as those programs can be appropriately targeted to them. par is a valuable methodology to approach hss, understand sheehan, c. callejas de luca, e. leon, h. boch, s. a call to include hospital support staff in cultural competency training. seejph 2022, posted: 8th december 2023. posted: 09 april 2023 page 52 their perspectives, and encourage a “flexibility” within them. ultimately, this may lead to organisational internal development. in addition, it is a low-level, cost-effective and holistic approach to monitoring and evaluation (16). future considerations 1. at rmkn level: there is an awareness among rmdh management staff of the importance of de&i. this arose after the annual rmkn annual meeting, which focused on de&i at rmdhs. the management team indicated, however, while de&i efforts have been made, they may not have the desired impact at a local level. for example, the organisation of de&i events such as the theatre performance had very little interest expressed from maastricht rmdh staff. in organising such events, more attention to the preferences of staff and volunteers at the local levels could result in increased engagement and participation by hss. 2. recruitment practices: in terms of supporting the diversity that rmdh maastricht wants to embody, the management staff discussed how changes could be made to recruitment practices. management discussed placing recruitment posters in more diverse locations and adjusting the language of recruitment material. also, they expressed that the requirement to speak dutch to be a volunteer at the rmdh could be a point to reconsider. 2. data availability: lastly, at present, no (quantitative) analysis of the demographic characteristics of rmdh staff and serviceusers is possible. this is because data on these characteristics is not collected by the mumc+ or rmdh administration. management staff reported volunteers are diverse in terms of ethnicity, gender, sexuality, and disability. limitations in terms of limitations, data related to the demographics of hss in the dutch health care system and from rmdh of the demographics of both volunteers and service users was not readily available. while the survey data and interviews from rmdh did indicate a gap between cultural and ethnic background across both groups, there is no quantifiable data available as this is not collected by the organisation. the use of cc training as a tool was the only initiative examined to improve quality sheehan, c. callejas de luca, e. leon, h. boch, s. a call to include hospital support staff in cultural competency training. seejph 2022, posted: 8th december 2023. posted: 09 april 2023 page 53 of care for minority patient populations. there are many facets to delivering care that is of high quality and standards, especially for patients from ethnic and cultural minorities. further study of the factors that impact their care, outside of the cultural competence of staff, is an important consideration for future research. conclusion as demonstrated hss can be highly involved stakeholders in the delivery of care to patients and their families, as exemplified by the services provided at rmdh maastricht. given the frequent and lowbarrier nature of contact between hss and patients, they are considered important players for the delivery of high-quality care, particularly fcc. their under-recognition must be addressed urgently, as advocated for by this research. this can be achieved by incorporating hss in policies that seek to improve quality of care (i.e., organisational cc). this policy brief found, up to now, hospitalled de&i initiatives only include hospital staff. mumc+ and rmdh maastricht are aware of the need for de&i policies and are taking the initial steps to progress organisational change. therefore, synchronising the work of mumc+’s de&i initiative group with rmdh, would provide an opportunity for both organisations to maximise de&i efforts. at the centre of harnessing this potential are multi-level stakeholders. thus, particular attention should be paid to proactively addressing the stakeholders' resistance by encouraging greater participation activities promoting cultural competencies. through the interviews and surveys conducted, the need, motivation and will to incorporate de&i change efforts is present at both rmdh maastricht and mumc+. this research has provided three key recommendations which can be considered to further the development of cultural competency across both organisations; (1) formalise cc training at mumc+; (2) include hss in such a cc training; and (3) develop and monitor training with participatory action research (par). conflicts of interest there are no conflicts of interest to declare. acknowledgments the authors wish to extend gratitude to the mumc+ de&i initiative group and the management staff and volunteers at rmdh sheehan, c. callejas de luca, e. leon, h. boch, s. a call to include hospital support staff in cultural competency training. seejph 2022, posted: 8th december 2023. posted: 09 april 2023 page 54 maastricht for their feedback and willingness to engage on this topic. in addition, the authors would like to thank stefanie beinert and katarzyna czabanowska for their support and feedback. references 1. seeleman mc. cultural competence and 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(policy brief). seejph 2023. posted: 09 april 2023 page 1 policy brief policy recommendations to improve mental health in polish prisons juan roman mora barrios1,2*, anne van den broek1*, riccardo buttarelli1, han reuvers1, wiktoria sobotka1, martina paric1 1department of international health, governance and leadership in european public health master, faculty of health, medicine, and life sciences, maastricht university, maastricht, the netherlands; 2 europubhealth+ joint diploma master in european public health, rennes, france. * these authors contributed equally. corresponding author: juan román mora barrios address: duboisdomein 30, 6229 gt maastricht; postbus 616, 6200 md maastricht email: juanro.barrios@gmail.com mailto:juanro.barrios@gmail.com mora barrios, j; van den broek, a; buttarelli, r; reuvers, h; sobotka, w; paric, m. policy recommendations to improve mental health in polish prisons. (policy brief). seejph 2023. posted: 09 april 2023 page 2 abstract context: mental health is a central aspect of public health and social development, as such it corresponds to target 3.4 of the sustainable development goals. this target aims to promote mental health and well-being, making it especially necessary to address this matter in environments such as prisons where exposure to risk factors is high. incarceration itself is a cause of mental illness. central and eastern european countries hold some of the highest prison populations in the region and poland numbers in this regard are 50% higher than the average in the european union (eu) (about 179 inmates per 100,000 inhabitants). in polish prisons, the chance of receiving adequate psychiatric and psychological care is limited due to a shortage of trained personnel and scarce infrastructure. however, data on mental health in polish prisons is not routinely reported from official sources. article 150 of the polish penal code attempts to protect the mental health of inmates; yet, in reality, there is no legal enforcement to apply these measures, a feature shared with most of its neighbouring countries. the aim of this policy brief is to offer recommendations to lower recidivism rates, up-scale prison staff and create spill-over effects on (mental) healthcare and security in polish prisons. policy options: the world health organization (who) european framework for action on mental health 2021-2025 should be adapted to the polish prison system. best practices focus on a collaborative approach centred on healthcare services, labour policies, well-being and rehabilitation. ideally, incarceration provides inmates with the possibility to be included and active, to see their relatives, to vote, to be engaged and maintain contact with the outside society. these best practices statistically reduce mental illnesses, lower recidivism and promote inclusion and rehabilitation. recommendations: to tackle mental health challenges that prisoners in poland experience, it is recommended to adapt a new approach with the following components: improving methodological quality of data collection as well as routine reporting to enable good governance structures, promoting collaborative efforts among stakeholders, and strengthening existing resources through capacity building which has been convincingly demonstrated as the most cost-effective type of interventions. keywords: mental health, poland, policy brief, health in prisons, prison health systems, health services. mora barrios, j; van den broek, a; buttarelli, r; reuvers, h; sobotka, w; paric, m. policy recommendations to improve mental health in polish prisons. (policy brief). seejph 2023. posted: 09 april 2023 page 1 introduction more than 10.77 million people worldwide are imprisoned, but this number might exceed 11.5 million if we consider the unreported data (1). in the european union (eu), 104 in every 100,000 inhabitants were imprisoned in 2020, this equals a total of 463,700 individuals (2). when the focus is placed on the central and eastern european countries, prison population figures are located among the second highest in the region, ranging from 150 to 200 prisoners per 100,000 inhabitants (see appendix 1) (3). 10.2% of the male prisoners and 14.1% of the female prisoners suffer from a major depressive disorder, while in the general population the age-standardised prevalence is at 2.81 (4,5). prisoners are part of the population that is already at a higher risk for mental health problems and substance abuse (6). see box 1. the prevalence of self-harm in prisoners is estimated to be 5%-6% in men and 20%-24% in women, which is much higher compared to the general population, where this number does not exceed 1% (0.24% agestandardised) (7,8). prisoners that face selfharming behaviours are 6 to 8 times more likely to die by suicide, which is why selfharm is also considered a risk factor for suicide among inmates, including the afterrelease period (7). in 2016, the standardised suicide rate in prisoners in the eu was 4.4 times higher when compared to the general standardised suicide rate in the eu (1.41 per 10,000 inhabitants) (9). mental health is a central aspect of public health and it is therefore an eu wide task to safeguard it through incisive programmes. implementation of said programmes must be considered in prison settings, a context with underserved populations that are at increased risk for mental health illness. in 2021, during the 74th world health assembly, the comprehensive mental health action plan 2013-2030 was endorsed recognising mental health as a public health priority and an essential action point towards the achievement of sustainable development goal (sdg) 3, which explicitly mentions mental health in target 3.4 (10,11). box 1. risk factors for increased mental health disorders in prison settings (6): • limited contact with family/outside community • overcrowded facilities • higher of violence • partial or complete deficit in privacy • loss of autonomy mora barrios, j; van den broek, a; buttarelli, r; reuvers, h; sobotka, w; paric, m. policy recommendations to improve mental health in polish prisons. (policy brief). seejph 2023. posted: 09 april 2023 page 2 aligned with this, mental health in all policies (mhiap) comprises an approach that aims to promote population mental health and well-being by impacting actions and development of public policies other than health that posit an effect on mental health determinants (12). in the case of prison systems, they can be considered units of measurement used to assess the status of progress of social rights of citizens in the eu, as well as the level of inclusion and solidarity procured in their member state. to date, healthcare in prison settings is still an unsolved issue in most countries, and mental health in prisons is a topic that has its own recent and unstructured development (6,13,14). in previous research, it is highlighted that exprisoners face difficulties securing employment upon release (15). former prisoners with a mental illness are also more likely to be excluded from services targeting employment due to their difficulties and low expectations concerning their ability to work (15). this inability to fulfil a job in society is a high burden on the economy as less productivity is perceived. in addition, it is likely that there is a large reduction in personal earnings as a result of employment penalties after incarceration (16). furthermore, procuring a labour situation in which prisoners and prison staff possess the same labour rights, and contribute to the economic system in the same magnitude, makes it possible to overcome some of the confrontation and violence that occurs in prisons with obvious positive results for all (14). poland is currently facing challenges in ensuring a fair and effective political, social and economic system in which all individuals and social groups have equal access to resources and opportunities. these challenges include implementing judicial reforms, imposing restrictions on freedom of expression, and controlling the media (17). the mental health situation in polish prisons is especially alarming. in 2017, more than 72,000 psychiatric consultations were conducted and as many as 1,164 patients were treated in psychiatric wards in prison hospitals (18). poland lacks comprehensive statistical data showing the scale of the problem of mental health in prisons. reports by the european prison observatory reveals similar situations regarding healthcare in prisons in latvia (9). although the ministry mora barrios, j; van den broek, a; buttarelli, r; reuvers, h; sobotka, w; paric, m. policy recommendations to improve mental health in polish prisons. (policy brief). seejph 2023. posted: 09 april 2023 page 3 of justice is responsible for data collection, they do not have a clearly developed system for it (19). databases reveal lack of comprehensive data regarding prison population portraying consistent deficits of national data collection structures in this concern throughout other central and eastern europe countries (19). in general, it is estimated that mental health issues cost 3% of gdp in poland (13). the mental health of prisoners has been proven to be poorer in comparison with the general population (20). when looking at the incarceration of adults, mental illnesses have an extraordinarily high cost to the economy. there are direct costs such as the involvement in the criminal justice system, while indirect costs include lost productivity resulting from untreated and underrated mental illness (15,16). the european commission has already issued recommendations for the polish prison healthcare system (14). the involvement of ombudsman, the helsinki committee, amnesty international, the legal intervention association in poland and other local stakeholders is required for improving mental health in polish prisons following the recommendations provided in this policy brief. context it is acknowledged that country contexts, and prison and health structures vary significantly among member states, however the core concept of imprisonment lays upon the protection of society against crime and the reduction of recidivism. this principle is detailed in the united nations standard minimum rules for the treatment of prisoners, a document that also observes that applicability in full extent in all places and at all times is not possible (21,22). see box 2. health services are inherently destined to be framed in a person-centred approach and so are prison health systems. along with this, continuity of care should also be guaranteed for these settings (23–25). data from the 2021 space i report on prisons and prisoners in europe shows that the landscape is not portraying these principles. poland held prison population rates 3.2 times higher by january 2021 than the ones encountered in norway, and suicide rates per 10,000 inmates ranging from 4 to 6.6 in said nations (2020) (3). see figure 1. mora barrios, j; van den broek, a; buttarelli, r; reuvers, h; sobotka, w; paric, m. policy recommendations to improve mental health in polish prisons. (policy brief). seejph 2023. posted: 09 april 2023 page 4 this makes the economy suffer as a whole, making the cost of the effect of mental health problems during and after incarceration significant to a nation’s economy. when incarceration ends, ex-inmates have difficulty finding employment which carries a direct and indirect significant cost as a personal and socioeconomic burden (15,16). another indirect cost to the economy covers the involvement of family members and associates of former inmates with mental health issues. it is not only the former inmates who experience a loss of productivity, it is also a reality for family members who provide unpaid care for the person with mental illness (26). this represents an additional burden to the economy. what is happening in poland? as of november 4, 2022, the population in prisons and detention centres in poland covered 87.7% of capacity nationwide. there are currently 87 prisons, as well as 37 external wards subordinated to them. sixtyseven pre-trial detention centres are also used to carry out prison sentences (27). medical care in the polish prison system providing inmates with proper medical care is one of the basic duties of the state. the right of prisoners to medical and sanitary care is indicated primarily by article 102 paragraph 1 of the executive penal code (28). see box 3. box 2. the united nations standard minimum rules for the treatment of prisoners – the nelson mandela rules (21): 4.1. the purposes of a sentence of imprisonment or similar measures deprivative of a person’s liberty are primarily to protect society against crime and to reduce recidivism. those purposes can be achieved only if the period of imprisonment is used to ensure, so far as possible, the reintegration of such persons into society upon release so that they can lead a law-abiding and self-supporting life. 5.1. the prison regime should seek to minimize any differences between prison life and life at liberty that tend to lessen the responsibility of the prisoners or the respect due to their dignity as human beings. 5.2. prison administrations shall make all reasonable accommodation and adjustments to ensure that prisoners with physical, mental or other disabilities have full and effective access to prison life on an equitable basis. mora barrios, j; van den broek, a; buttarelli, r; reuvers, h; sobotka, w; paric, m. policy recommendations to improve mental health in polish prisons. (policy brief). seejph 2023. posted: 09 april 2023 page 5 respect for the human dignity of the convict is also mandated by article 4 par. 1, which prohibits torture and degrading treatment of prisoners. according to article 115, detainees are provided with free health services, medicines and sanitary supplies, provided primarily by medical providers (28). health services for persons deprived of liberty are provided by treatment entities established in detention centres and prisons (27,28). these entities are under the authority of the ministry of justice. they provide health services to prisoners in the following areas: medical examinations and advice, medical treatment, psychological examinations and therapy, rehabilitation, box 3. article 102executive penal code of the republic of poland (28) in particular, a convict has the right to: (1) food, clothing, living conditions, accommodation, as well as health services and adequate hygienic conditions appropriate for the preservation of health; figure 1. prison population in europe, 2021. source: aebi mf, cocco e, molnar l, tiago mm. prisons and prisoners in europe 2021: key findings of the space i report. 2022 apr. mora barrios, j; van den broek, a; buttarelli, r; reuvers, h; sobotka, w; paric, m. policy recommendations to improve mental health in polish prisons. (policy brief). seejph 2023. posted: 09 april 2023 page 6 diagnostic tests, care of the sick and disabled, prevention of injuries and diseases through preventive measures and mandatory vaccinations (28). if health services cannot be delivered to inmates, it is necessary to grant them a temporary pass to receive these services in a non-prison medical entity, such as public hospitals. under these circumstances, healthcare services are delivered by providers regulated by the ministry of health rather than the ministry of justice, as it is the norm (27,28). norwegian prison system contrasting the polish prison system with the norwegian prison system (kriminalomsorgen) serves as a best practice locator methodology more than a comparison between them. in norway the punishment for the crimes committed comprises only the restriction of freedom within the community. however, inmates preserve their right to vote, study, and interact with the external world to facilitate reintegration after release. norwegian prisons are characterised by structured active participation, a real possibility for redemption and rehabilitation into the society based on labour (29). the healthcare system in prisons is regulated by the ministry of health and allows the inmates to be personally followed during their incarceration, focusing on their mental rehabilitation (19,29). see box 4. this approach leads to lower criminality levels; for instance, the murder rate in norway is 0.6 per 100,000 people, as one of the top lowest murder rates worldwide, and the total number of crimes in norway is about 330,000 per year (30). even the number of inmates has decreased progressively, and to date, the population in norwegian prisons remains stable at around 3,000 individuals (31,32). for these reasons, the system is not systematically comparable to the polish, but these best practices could suggest a different efficient approach. box 4. norway: an import model (29). crucial services for reintegration are delivered to the prison by local and municipal service providers. these are imported from the community. advantages: • a better continuity in the deliverance of services – the offender will already have established contact during his time in prison; • involvement from the community with the prison system – more and better cross-connections. mora barrios, j; van den broek, a; buttarelli, r; reuvers, h; sobotka, w; paric, m. policy recommendations to improve mental health in polish prisons. (policy brief). seejph 2023. posted: 09 april 2023 page 7 is this difference determined by the type of facility or the governing structure? data collected in the health in prisons european database (hiped) last reviewed in 2019, shows a difference in the authority in charge of prison healthcare, its funding and the budget administration. whilst in norway, guidelines follow the helsinki recommendations aligned with the nelson mandela rules and the united nations bangkok rules entitling the ministry of health to the management and provision of healthcare services in prisons and secure settings, the polish prison healthcare system relies solely on the ministry of justice for this role (19). mental health in prison settings notions of psychiatric care in prisons and secure settings date from 1993, and according to this, mentally distressed prisoners should be “kept and cared for in a hospital facility which is adequately equipped” (33). mental health in prisons also attains and maintains the well-being of prisoners as much as it would in the outside community. the european mental health action plan 2013-2020 portrayed a diagram representing the cycle of mental well-being (see appendix 2) underlying the modifiable and nonmodifiable inputs to achieve well-being for all individuals regardless of their freedom status (34). another area that is overlooked by healthcare services is prisoners’ contact with the outside world as a means of mental health promotion and well-being; in norway, for example, most prisoners are engaged in purposeful activities which promote a sense of normality and allow for meaningful human contact to be established (35). mental health in polish prisons a study shows that a mentally ill person in a polish prison has a limited chance of receiving adequate psychiatric care (36). there is a shortage of prison hospital wards providing round-the-clock care. those that do exist tend to have inadequate conditions for the rehabilitation and treatment of mentally ill patients, as they are mainly for observation and assessment of sanitary conditions (37). patients there often have no access to any form of treatment other than medication. today, only one psychiatric hospital, at the detention centre in szczecin, provides mentally ill inmates not only with pharmacotherapy, but also with rehabilitation activities (psychological assistance sessions, particularly in the form of individual, group mora barrios, j; van den broek, a; buttarelli, r; reuvers, h; sobotka, w; paric, m. policy recommendations to improve mental health in polish prisons. (policy brief). seejph 2023. posted: 09 april 2023 page 8 or family psychotherapy; education and psycho-education; occupational therapy; social skills training; art therapy; physical therapy) (38). most inmates with mental illness who do not require hospital treatment are placed in one of the 23 therapeutic wards with a total of 1,780 available places, where convicts serve their sentences in the therapeutic system (27). those in the worst situation are those whose mental illness manifested itself after conviction and incarceration. according to article 150 of the penal code, it is then mandatory to postpone imprisonment until the "cessation of the obstacle", and thus allow the convict to receive treatment (28). the problem is that there is no legal basis for applying protective measures to such a person, such as placement in a psychiatric facility or control at large (27). the ombudsman, who is positioned to objectively resolve the dispute between the citizen and the state, has repeatedly argued in poland that such people in whom a psychiatric disorder has appeared while serving a sentence should not be placed in prisons or prison psychiatric hospitals, as this does not give them a chance for effective therapy (39). however, a legal loophole stands in the way of this, the ombudsman warns (39). due to loopholes in the law, there are no designated facilities to which convicts who develop mental illness in prison can be sent to (40). policy options the cycle of mental well-being (appendix 2) is a model proposed by who and can be used to identify all the intersecting inputs and action points for the prevention and treatment of mental illness (34). under the aforementioned contexts, the following policy options have been identified: the who european framework for action on mental health 2021-2025 can be adapted to the polish prison system. with this adaptation, a mental health in all policies (mhiap) approach could reduce the impact that mental health inequalities have on the polish health, social and economic structure (10,12,41). individuals in polish prisons and secure settings need to be integrated as part of the vulnerable and discriminated population that encounter impeded access to mental health services (12). evidence shows that setting a standardised mental health care pathway, along with active labour policies aimed at the reintegration of mora barrios, j; van den broek, a; buttarelli, r; reuvers, h; sobotka, w; paric, m. policy recommendations to improve mental health in polish prisons. (policy brief). seejph 2023. posted: 09 april 2023 page 9 inmates into society, have positive repercussions on the data concerning drug consumption, suicide, and self-harm rates, as well as psychological disorders (15,42,43). the following recommendations can help to foster preventative mental health services in prisons and secure settings. recommendations recommendations are intended to achieve a comprehensive response to the challenges that inmates in secure settings face daily in poland, especially those of mental health nature. the following strategies can lead to the desired outcomes: 1) data collection for good governance align with the who european framework for action on mental health 2021-2025 to develop a mental health data platform that enables routine data collection from prison systems in poland to foster adequate planning, budgeting, and coordination of service delivery and evaluation (10). this would improve data collection and reporting strategies, transparency and accountability as markers of a strong governance structure (44,45). facilitate the development of participatory-action research (par) within prisons and secure settings to guarantee knowledge production from first-person narratives while maintaining quality evidence for decision-making (46–49). the outcomes intended to achieve with par are: o strong sources of evidence from populations in prisons and secure settings for the promotion of high-quality health (and mental health) research and further policymaking. o engagement of all relevant stakeholders in the decisionmaking process: identification of mental health needs, design of strategies, data collection, internal and external communication, implementation, evaluation, and re-designing relevant to the given context. this is not only important to identify mora barrios, j; van den broek, a; buttarelli, r; reuvers, h; sobotka, w; paric, m. policy recommendations to improve mental health in polish prisons. (policy brief). seejph 2023. posted: 09 april 2023 page 10 trends and risk factors for mental health illness in these environments, but also to identify mitigating factors. 2) collaborative approach closer collaboration between the polish ministry of justice and the ministry of health would allow for the adequate resource allocation towards preventative mental health services. we recommend the creation of an interagency collaboration working group – mental health in polish prisons (icwg-mhpp). the icwg-mhpp should be composed of all intersecting public and private entities who can provide a comprehensive and collaborative structure to shape policy actions deemed appropriate (42,50,51). education, health, judiciary, labour, finance, housing and social welfare are some of the departments suggested to be part of the icwgmhpp in equal representation along with inmate and family members, representatives and stakeholders relevant to the context. assess the opportunity to design, implement and evaluate a strategy to migrate from the current approach of the polish prison system to a more human-centred approach. this is similar to the norway ‘import model’ (see box 4.) where prisoners are seen as an extension of the outside community. this ensures continuity of (mental) healthcare from the outside community to prison settings and vice versa. applying the import model re-structures the prison system from a place of punishment towards a space for rehabilitation (29,50–52). 3) capacity building promote quality of care by up-scaling prison staff, non-specialized healthcare providers, health planners, managers and policy makers to favour equal access to mental healthcare services within prison settings. additionally, by developing the appropriate skill-mix among the prison workforce better integration can be achieved. this would promote capacity building and enable the compliance of the helsinki mora barrios, j; van den broek, a; buttarelli, r; reuvers, h; sobotka, w; paric, m. policy recommendations to improve mental health in polish prisons. (policy brief). seejph 2023. posted: 09 april 2023 page 11 recommendations on ethical practice of care (24). adapting the mental health gap action program (mhgap) v2. in the design, assessment, implementation and evaluation of mental health services in polish prisons is highly recommended. the mhgap is a model guide developed by the who that is adaptable to local contexts aiming to scale up prison staff, nonspecialized healthcare providers, health planners, managers and policy makers with the overarching objective of developing a good skillmix among the entire prison workforce (53). the polish prison health system can adapt the mhgap to the current needs in their facilities in terms of mental, neurological and substance use disorders. the integration of this tool in the polish prison system can be the first step to achieve more sustainable goals in this matter and address current shortages in mental health and healthcare services. we acknowledge that its fulfilment depends on the level of commitment, social and financial barriers that polish context allows. however, a joint effort involving all the stakeholders identified can be a pathway in the right direction. limitations this policy brief does not intend to establish a comparison between prison systems in the eu. however, in order to identify the best practices that might be applicable to polish prison system, it was needed to contrast with better performing countries. a limitation that needs to be taken into account is the language of official documents from poland. even though translations might be accurate, no official translations were found and this could play a role in the power of the evidence adjudicated to the information found. this limitation was counteracted by proofreading and review by one of the authors who is a native a polish speaker. another limitation found during the development of this policy brief was the lack of up-to-date official information regarding the prison systems and secondary sources were used to attain it. conclusion focusing our efforts on target 3.4 and addressing mental health is central to fully mora barrios, j; van den broek, a; buttarelli, r; reuvers, h; sobotka, w; paric, m. policy recommendations to improve mental health in polish prisons. (policy brief). seejph 2023. posted: 09 april 2023 page 12 attain sdg3, to promote health and wellbeing for all. polish prison numbers in this matter are alarming because of limited chances to receive adequate care and therefore, action is required. an emphasis on mental health in polish prison settings will promote reintegration policies that lower recidivism rates fostering social inclusion and solidarity-oriented community collaboration towards those who today are mostly abandoned to their fate. the recommendations provided in this document are based on best practices and can be applied contextually in different member states within the comprehensive mental health action plan 2013-2030 and a mhiap approach. it takes time, resources and political will among relevant stakeholders for these recommendations to be applied and impact mental health in prisons. this is why recommendations are provided on the strengthening of existing structures and collaboration among ministries and organisations. implementing stronger data collection strategies is recommended to obtain a better insight into the extent of the problem, while better mental health care could be reached by up-scaling the prison workforce and policy-making structures. actions taken on these policy options are useful for the polish prison system, and also for other countries where mental health in prisons is at risk. conflicts of interest none declared. acknowledgments we would like to extend our sincere gratitude to katarzyna czabanowska and the university of maastricht for being facilitators of this opportunity. lastly, we would like to thank our families, who helped and sustained us personally and professionally. their efforts have led us to be the public health professionals we are today, and may this policy brief be a reason of pride for them and a call to action for decision makers references 1. fair h, walmsley r. world prison population list. 2021. 2. eurostat. prison statistics [internet]. 2022 [cited 2022 dec 3]. available from: https://ec.europa.eu/eurostat/statisticsexplained/index.php?title=prison_stati stics 3. aebi mf, cocco e, molnar l, tiago mm. prisons and prisoners in europe 2021: key findings of the space i mora barrios, j; van den broek, a; buttarelli, r; reuvers, h; sobotka, w; paric, m. policy recommendations to improve mental health in polish prisons. 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(policy brief). seejph 2023. posted: 09 april 2023 page 15 activities. strasbourg; 1993 jun. 34. who regional office for europe. the european mental health action plan 2013-2020. copenhagen: who regional office for europe; 2015. 35. european committee for the prevention of torture and inhuman or degrading treatment or punishment. 29th general report of the cpt. 2020 may. 36. nowak mk. więzienie to nie miejsce dla chorych psychicznie. ale nie ma co z nimi zrobić [internet]. oko press. 2019 [cited 2022 dec 6]. available from: https://oko.press/wiezienie-tonie-miejsce-dla-chorych-psychicznie 37. chaberek a. więzienne blaski i cienie … opieka zdrowotna [internet]. służba więzienna. 2016 [cited 2022 dec 4]. available from: https://sw.gov.pl/aktualnosc/zakladkarny-w-przytulach-starychwiezienne-blaski-i-cienie-sluzbazdrowia 38. jędrzejczyk a. pięć propozycji zmian w traktowaniu więźniów chorujących psychicznie. wystąpienie rpo do premiera [internet]. biuletyn informacji publicznej rpo. 2020 [cited 2022 dec 4]. available from: https://bip.brpo.gov.pl/pl/content/prop ozycje-zmian-w-traktowaniuwiezniow-chorujacych-psychicznie-rpo-do-premiera 39. starzewski l. jak powinna wyglądać opieka medyczna wobec osób pozbawionych wolności [internet]. biuletyn informacji publicznej rpo. 2019 [cited 2022 dec 4]. available from: https://bip.brpo.gov.pl/pl/content/jakpowinna-wyglądać-opieka-medycznawobec-osób-pozbawionych-wolności 40. rojek-socha p. osadzeni chorzy psychicznie – skazani na więzienie z powodu luki prawnej [internet]. prawo. 2018 [cited 2022 dec 4]. available from: https://www.prawo.pl/prawnicysady/osadzeni-chorzy-psychicznieskazani-na-wiezienie-z-powodu-lukiprawnej,74677.html 41. kienzler h. mental health in all policies in contexts of war and conflict. lancet public heal. 2019 nov 1;4(11):e547–8. 42. berger ra. kriminalomsorgen: a look at the world’s most humane prison system in norway. ssrn electron j. 2016 dec 10; 43. shammas vl. prisons of labor: social democracy and the triple transformation of the politics of punishment in norway, 1900–2014. scand penal hist cult prison pract. 2017;57–80. 44. greer sl, wismar m, figueras j. strengthening health system governance european observatory on health systems and policies series. 2016. 45. hawkins b, parkhurst j. the “good governance” of evidence in health policy. evid policy. 2016 nov 1;12(4):575–92. 46. freeman e. feminist theory and its use in qualitative research in education. in: oxford research encyclopedia of education. oxford university press; 2019. 47. testoni i, nencioni i, arbien m, iacona e, marrella f, gorzegno v, et al. mora barrios, j; van den broek, a; buttarelli, r; reuvers, h; sobotka, w; paric, m. policy recommendations to improve mental health in polish prisons. (policy brief). seejph 2023. posted: 09 april 2023 page 16 mental health in prison: integrating the perspectives of prison staff. int j environ res public health. 2021;18(21). 48. murphy t, aakjær m, pallesen e, rosenberg c. mirrors of prison life— from compartmentalised practice towards boundary crossing expertise. in: kloetzer l, kajamaa a, hean s, johnsen b, editors. improving interagency collaboration, innovation and learning in criminal justice systems supporting offender rehabilitation. palgrave macmillan uk; 2021. p. 59–85. 49. parker j, heaslip v, crabtree sa, johnsen b, hean s. people in contact with criminal justice systems participating in service redesign: vulnerable citizens or democratic partners? in: hean s, johnsen b, kajamaa a, kloetzer l, editors. improving interagency collaboration, innovation and learning in criminal justice systems supporting offender rehabilitation. palgrave macmillan uk; 2021. p. 297–321. 50. lahtinen p, kajamaa a, seppänen l, johnsen b, hean s, esko t. interorganisational collaboration in a norwegian prison challenges and opportunities arising from interagency meetings. in: hean s, johnsen b, kloetzer l, kajamaa a, editors. improving interagency collaboration, innovation and learning in criminal justice systems supporting offender rehabilitation. palgrave macmillan uk; 2021. p. 31– 57. 51. kriminalomsorgen. operational strategy for the norwegian correctional service 2021-2026. 2020. 52. kriminalomsorgen. 2020 annual report. 2020. 53. world health organization. mhgap intervention guide for mental, neurological and substance use disorders in non-specialized health settings: mental health gap action programme version 2.0. vol. 2. world health organization; 2016. mora barrios, j; van den broek, a; buttarelli, r; reuvers, h; sobotka, w; paric, m. policy recommendations to improve mental health in polish prisons. (policy brief). seejph 2023. posted: 09 april 2023 page 17 appendixes appendix 1. prison population rate per 100,000 inhabitants, 2021. source: prison population in europe, 2021. source: aebi mf, cocco e, molnar l, tiago mm. prisons and prisoners in europe 2021: key findings of the space i report. 2022 apr. mora barrios, j; van den broek, a; buttarelli, r; reuvers, h; sobotka, w; paric, m. policy recommendations to improve mental health in polish prisons. (policy brief). seejph 2023. posted: 09 april 2023 page 18 appendix 2. the cycle of well-being. source: who regional office for europe. the european mental health action plan 2013-2020; 2015. ___________________________________________________________________________ © 2023 mora barrios et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. jong aee, sarač m, verweij w, bastić jr, geerling gw. human health in the flood risk management planning under the european union floods directive: pilot study in the sava river basin (original research). seejph 2023, posted: 12 january 2023. doi: 10.11576/seejph-6212 p a g e 1 | 12 original research human health in the flood risk management planning under the european union floods directive: pilot study in the sava river basin anniek e. e. de jong1, mirza sarač2, wilko verweij1, jovana rašeta bastić2, and gertjan w. geerling1,3 1 department of freshwater ecology and water quality, deltares, boussinesqweg 1, 2629 hv delft, the netherlands 2 the secretariat of international sava river basin commission, kneza branimira 29/ii, 10000 zagreb, republic of croatia 3 department of environmental science, radboud institute for biological and environmental sciences, radboud university, heyendaalseweg 135, 6525 aj nijmegen, the netherlands corresponding author: gertjan w. geerling telephone +31883357114; e-mail gertjan.geerling@deltares.nl mailto:gertjan.geerling@deltares.nl jong aee, sarač m, verweij w, bastić jr, geerling gw. human health in the flood risk management planning under the european union floods directive: pilot study in the sava river basin (original research). seejph 2023, posted: 12 january 2023. doi: 10.11576/seejph-6212 p a g e 2 | 12 abstract the eu floods directive (2007/60/ec) has the purpose to establish a framework for the flood risks assessment and management. it requires the implementation of coordinated measures on a basin-wide level for the reduction of adverse consequences to human health and life. however, mainly direct fatalities are taken into consideration in these plans. to develop more integrated and adaptive risk management and governance it is important to include both direct and indirect consequences. to define effective measures clearer understanding of the relation between floods and impact on human health is needed. we present a first attempt to provide a roadmap for the inclusion of health issues of concern to flood risk management within the sava river basin as an example. an overview of the potential flood effects to health issues was made and a roadmap plan was set up to analyse and map these flood risks. we concluded that indirect health effects can contribute significantly to the overall adverse consequences to health, and although relations are complex, a preliminary assessment could be made. mapping of adverse consequences to health issues in the planning stages should lead to systemic insights and proposed measures in the prevention, protection, and preparedness while considering the characteristics of the river basin or sub-basins. by incorporating a health-risk-analysis in the planning process, health-oriented preparation is not only aimed at improving post-flood relief efforts, but to minimise the actual impacts and decrease post flood recovery time and costs. keywords: eu floods directive, flood risk management, health risk. jong aee, sarač m, verweij w, bastić jr, geerling gw. human health in the flood risk management planning under the european union floods directive: pilot study in the sava river basin (original research). seejph 2023, posted: 12 january 2023. doi: 10.11576/seejph-6212 p a g e 3 | 12 introduction floods have the potential to cause fatalities, displacement of people and damage to the environment, to severely compromise economic development and to undermine the economic activities. the adverse consequences of flooding for human health are diverse and have impacts long after floods have receded. a flood event can affect human health directly causing fatalities by drowning and can affect the exposed people by injuries or direct physical trauma. subsequently the flood event can have indirect effects associated with the damage done by the water to the natural and built environment. for example, human health can be impacted by pollution of food and drinking water sources, interruption of water supply services and threatened by limited accessibility to the medical treatment. furthermore, floods can have detrimental impacts on local governance and public administration, emergency response, health care facilities, and education. in 2007, the directive 2007/60/ec of the european parliament and of the council on the assessment and management of flood risks (eu floods directive) came into force (1). the eu floods directive aims “to establish a framework for the assessment and management of flood risks, aiming at the reduction of the adverse consequences for human health, the environment, cultural heritage and economic activity associated with floods in the community” (art. 1). it provides approaches for identifying areas where potential significant risks exist or might be considered likely to occur, and for managing the risks, all at the river basin scale. in the enumeration in art. 1, human health is one of the main protection targets. also, the preamble mentions health in two points: • (3): “it is feasible and desirable to reduce the risk of adverse consequences, especially for human health and life” • (14): “flood risk management plans should [..] consider where possible [..] measures to prevent and reduce damage to human health” preamble point 3 speaks about “human health and life”. implicitly it is stated here that direct as well as indirect consequences of floods to human health and lives should be considered. human health concern is therefore an integral part of the eu floods directive and should be taken into consideration as a part of the risk receptor. an initial milestone when implementing the eu floods directive was the preliminary flood risk assessment (pfra), which the eu members states undertook for each river basin district, or unit of management or the portion of an international river basin district. the pfra, among other assessments, includes a description of floods which have occurred in the past and which had significant adverse impacts on human health and life, as well as where significant adverse consequences of similar future floods might be envisaged. based on areas identified by the pfra, flood hazard and risk maps are prepared. flood hazard maps cover the geographical areas which could be flooded according to different scenarios, showing the flood extent, water depths or water level, and where appropriate, the flow velocity or the relevant water flow. flood risk maps show the potential adverse consequences associated with different flood scenarios in terms, among others, of the indicative number of inhabitants potentially affected, including their health and life. following the maps, the flood risk management plans (frmp) address all aspects of flood risk management and focus on prevention, protection, and preparedness measures. in 2019, the frmps were commissioned by the european commission (2,3). for 16 out of those 24 frmps that were published by jong aee, sarač m, verweij w, bastić jr, geerling gw. human health in the flood risk management planning under the european union floods directive: pilot study in the sava river basin (original research). seejph 2023, posted: 12 january 2023. doi: 10.11576/seejph-6212 p a g e 4 | 12 the member states, “strong evidence”1 was found that potential adverse consequences to human health were considered, for 7 there was “some evidence”2, for 1 there was “no evidence”3 found. however, from these documents it does not become very clear how and which health risks were considered by the member states. a detailed analysis of the direct and indirect health impacts caused by the flood events is required by the eu floods directive but has not been extensively accounted for in the frmp so far. human health should be taken into consideration as a part of one of the risk receptors to protect the population from negative aspects of flood risks where possible. to include the variety of flood risks to all potential health issues in the flood risk management planning a roadmap is needed. here, we provide a preliminary roadmap to incorporate health risk analysis into planning process by using the sava river basin as pilot study. improvements and extensions of the analysis at a later stage are possible, but most importantly it shows that the implementation is feasible and can provide positive prevention and protection effects of human health. this roadmap was used to update the frmp for the sava river basin for the second planning cycle (by 22 december 2021), and will be evaluated by the european commission in 2024. overview of flood risk management planning in the sava river basin four of six countries that share the sava river basin, namely bosnia and herzegovina, croatia, serbia and slovenia (parties) are currently members of the international sava river basin commission (isrbc) established in 2005 with the main purpose to implement the framework agreement on the sava river 1 defined as: clear information provided, describing an approach followed in the frmp to address the criterion. 2 defined as: reference to the criterion is brief and vague, without a clear indication of the approach basin (fasrb) (4), see figure 1 for a map of the sava river basin. the fasrb implementation goals are the establishment of an international regime of navigation on the sava river and navigable tributaries, establishment of sustainable water management and undertaking of measures to prevent or limit hazards, and reduce and eliminate adverse consequences, including those from floods, among others. croatia and slovenia are eu member states and therefore obliged to implement the eu floods directive. the four countries signed the protocol on flood protection to the fasrb (5), entered into force in 2015, in which all sava countries commit themselves to implement the eu floods directive provisions at the sava river basin level. the sava frmp, prepared by isrbc in close cooperation with the relevant national institutions, was officially approved by the parties at their 8th meeting held in sarajevo on october 24, 2019 (6). the sava frmp represents a milestone in the cooperation of the parties leading towards fulfilment of one of the main objectives of the fasrb – to prevent or limit hazards and reduce and eliminate adverse consequences from floods to all receptors defined by the eu floods directive. based on national areas with potential significant flood risk, the sava frmp identified 21 areas of mutual interest for flood protection at the sava river basin level (named amis), as basic units for analysing the flood risks, with a total surface of 5,659 km2, representing 5.8% of the sava river basin area and home to 1.4 million people. in the amis 38 infrastructural measures were identified with a total value of over € 250 million while at 42 non-infrastructural measures were also identified, that mostly relate to the entire amis or the sava river basin. used for the criterion. depending on the comment in the adjacent column, “some evidence” could also be construed as “weak evidence”. 3 defined as: no information found to indicate that the criterion was met. jong aee, sarač m, verweij w, bastić jr, geerling gw. human health in the flood risk management planning under the european union floods directive: pilot study in the sava river basin (original research). seejph 2023, posted: 12 january 2023. doi: 10.11576/seejph-6212 p a g e 5 | 12 the implementation of the measures will strongly contribute to meeting the commonly agreed objectives – avoidance of new flood risks, reduction of existing flood risks during and after the floods, strengthening resilience, raising awareness about flood risks, and implementing solidarity principle. in the sava frmp completed as part of the first planning cycle, flood risk to human health was analysed only as an indicative number of populations in the amis generally endangered by floods, while indirect effects to human health were not. figure 1. map of the sava river basin and its geographic setting (inset top right; source isrbc). the maps also indicate areas of mutual interest (ami) for flood protection being the planning scope of the international sava river basin commission (isrbc) the set-up of the preliminary roadmap for the assessment of the various health risks in the sava river basin isrbc recognized the importance to incorporate an analysis with indirect health risks of flooding into the planning process and an initial stage of the update of preliminary flood risk assessment. the first step was to make an overview of the data and information available related to the consequences of the past flood events to human health. furthermore, internationally recognized health risks of flooding are assessed in accordance with their relevance for the sava river basin based on (future possible) presence of pathogen and host/vector, environmental effects of climate change, and present infrastructure. comprising the available information, the preliminary list of potential health risks that can be caused or increased by floods in the sava river basin was prepared. secondly a roadmap plan was set up to analyse and map the health risks. overview of flood related health effects in the sava river basin the (post) flood related health issues can be manifold (table 1) and are distributed in space and time. we recognise four jong aee, sarač m, verweij w, bastić jr, geerling gw. human health in the flood risk management planning under the european union floods directive: pilot study in the sava river basin (original research). seejph 2023, posted: 12 january 2023. doi: 10.11576/seejph-6212 p a g e 6 | 12 overlapping time-frames: immediate health effects occur as the flood spreads (hours to few days), the short-term effects are the health risks that are present in the period that the flood is present (days after a disaster), intermediate is the immediate start of the recovery phase (days to weeks) after the onset flood event, and long-term effects is the reconstruction phase (weeks to months or years) after the onset of the flood event and may not always be recognized as caused by the flood event. the immediate health risks include fatalities from drowning and accidents, and injuries from physical trauma (7), while mental health issues, like fear and anxiety, also affect people from day one. short-term health risks include exposure to toxic substances that might be in the water, and higher risk of outbreaks of waterborne diseases, such as leptospirosis and diarrheal diseases (79). intermediate health risks include risks of vector-borne diseases through the expansion in number and range of vector habitats (10). west nile fever is of most concern in the sava river basin, since the conditions after residing of the floodwater are ideal for this mosquito (culex spp.) and the mosquito is present in the region (11,12). the mosquito aedes albopictus is present in the mid-section of the sava river basin and could raise the potential for disease transmission upon introduction of arboviruses (e.g. dengue, zika or chikungunya virus via travellers) (13). secondary outbreaks of infectious diseases may occur due to overcrowding following population displacement (10), for example increased cases of covid-19, which might have happened during the floods in summer 2021 in the netherlands (14). long-term health risks become apparent after months to years and may not always be recognized as result of the flood event, for example non-communicable diseases, mental health disorders, and the effects of chemical pollution (7,15,16). other long-term effects include food insecurity, as harvests may be destroyed by the water or chemically contaminated, machinery is damaged, and decrease in production of farm animals due to stress or illness (7,17). extra pressure on the health system arises due to incidents with displaced landmines and unexploded objects, since warning signs are washed away, or the object is displaced with the water or a landslide (17). in addition, on the wet walls in houses mould could grow (as well as in the flooded parts of the buildings as other locations due to rising damp). the fungi can cause respiratory infections and breathing problems (18,19). the anticipated mortality and morbidity of injuries and diseases may subsequently be exacerbated by infrastructural losses impacting treatment availability and/or access to alternative sources. for example, broken health care services or damaged hospitals lead directly to an increase in the health burden as the health care becomes limited or lost. damage or disruption of ict infrastructure, transport systems threaten the delivery of supply like water, food, medicine and manpower. damage to water supply and sanitation can (in)directly increase the burden of water-borne diseases. in the end, the health burden is expected to vary between affected populations (related to their vulnerability, exposure and capacity to reduce risks and cope with the event), type of flood (slow or fast onset) and the background health situation of the population and their access to health services. a comprehensive flood–health risk analysis for the sava basin for detailed elaboration of the health issues, health risks should be mapped and analysed to be able to include them in the flood risk management planning stages. for the mapping and analysis of health risks, we recognised three main dimensions, i.e., “hazards”, “exposure” and “vulnerability” (figure 2). the “hazards” dimension describes the components related to the floodwater itself. the “exposure” dimension contains the various health risk jong aee, sarač m, verweij w, bastić jr, geerling gw. human health in the flood risk management planning under the european union floods directive: pilot study in the sava river basin (original research). seejph 2023, posted: 12 january 2023. doi: 10.11576/seejph-6212 p a g e 7 | 12 categories that vary in the underlying mechanisms. the “vulnerability” dimension indicates parts of the population that are susceptible, and the healthcare infrastructure that, when affected, exacerbates local vulnerability during and after floods. all dimensions will probably have spatial ‘hotspots’ popping up in the mapping & analysis. ultimately, measures to prevent or limit health risks can be aimed at lowering risks inside these dimensions, lower vulnerability (increase resilience) and lower the (exposure to) hazards. the dimensions contain components that are quantifiable and mappable to estimate the potential health risks (figure 2), such as chemical factories as potential sources of chemical pollution, farms, sewers, septic tanks, wastewater treatment plants as sources of microbial pollution. some components are easier to quantify than others. long-term health effects, for example mental health effects and birth outcomes, are difficult to relate to a flood event and to quantify. the vulnerable population can be estimated and mapped based on for example age distribution, socio-economic spatial data, remoteness/isolation, transport capabilities, etc. the actual mapping is proposed to be further elaborated in the next planning stages. if desired, an aggregated health risk can be produced to identify areas of risk to hazards and exposure, and/or higher vulnerability. figure 2. overview of determinants of health risk during and after floods, result of quick scan. the figure was inspired by the inform risk index (20) made for disaster related epidemics the health risk mapping and analysis in the next planning stages should lead to systemic insights and proposed measures in every phase of the flood risk management planning cycle. the analysis feeds into prevention and preparedness phases to target known causes of hazards and exposure, to limit these in case a flood happens. also, the (spatially) identified vulnerable population groups can be better prepared, and supporting health infrastructure, linked to its serving area and its supporting infrastructure, be made more resilient to floods. responses in high-risk areas, now with known health effect causes, can be more informed about resources needed, and similarly the recovery efforts can be more targeted if the spatial distribution of potential health risks is known. jong aee, sarač m, verweij w, bastić jr, geerling gw. human health in the flood risk management planning under the european union floods directive: pilot study in the sava river basin (original research). seejph 2023, posted: 12 january 2023. doi: 10.11576/seejph-6212 p a g e 8 | 12 by incorporating a health risk analysis into flood risk management planning, healthoriented preparation is not only aimed at improving emergency relief efforts during a flood, but also to lower the actual impacts and efforts needed by more integrated flood management planning. conclusion for sava river basin from the quick scan of existing evidence for the pilot study in the sava river basin it became clear that the indirect health risks can contribute significantly to the overall health risks of floods. the potential health risks are dependent on many components, like disease presence in the region, infrastructure, and socio-economic conditions, cultural values, and behavior. nonetheless, a preliminary assessment could be made. the next step would be the health hazard, exposure & vulnerability mapping and analysis. future the previous paragraph shows that a preliminary assessment of direct and indirect health risks is feasible and leads to new insights for flood risk management. although a fully quantitative analysis is a challenge, a quick scan seems sufficient to put the indirect health risks on the agenda and is recommended for all (european) river basins. the preliminary health risk scan can be progressed to a mature qualitative assessment to ultimately derive health risk reducing actions and measures in the next cycle of the flood risk management planning. references 1. ec. directive 2007/60/ec of the european parliament and of the council of 23 october 2007 on the assessment and management of flood risks. official journal of the european union. 2007 (2007/60/ec). 2. european commission. report from the commission to the european parliament and the council on the implementation of the water framework directive. brussels; 2019. 3. european commission. commission staff 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10.11576/seejph-6212 p a g e 9 | 12 9. brown l, murray v. examining the relationship between infectious diseases and flooding in europe. disaster health. 2013 apr 21;1(2):117–27. 10. ivers lc, ryan et. infectious diseases of severe weather-related and flood-related natural disasters. current opinion in infectious diseases. 2006;19(5):408–14. 11. the government of the republic of serbia. serbia floods 2014. available from: https://www.ilo.org/wcmsp5/groups /public/--ed_emp/documents/publication/wc ms_397685.pdf (accessed: 2021 nov 10). 12. european centre for disease prevention and control. west nile fever maps 2014. available from: https://www.ecdc.europa.eu/en/west -nile-fever/surveillance-and-diseasedata/disease-data-ecdc (accessed: 2021 nov 10). 13. european centre for disease prevention and control. rapid risk assessment, floods in bosnia and herzegovina, croatia, and serbia: communicable disease risks. stockholm; 2014 jun. available from: https://www.ecdc.europa.eu/en/publ 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asian-oriented, risk-based watershed management. singapore: springer singapore; 2018;p. 45–55. 20. de groeve t, poljansek k, vernaccini l. index for risk management-inform. jrc sci policy reports—eur comm, 2015;96.10.2788: 636388. 21. world health organization regional office for europe. floods in the balkans: bosnia and herzegovina, croatia and serbia. 2014;situation report 3. 22. fernandez a, black j, jones m, wilson l, salvador-carulla l, astell-burt t, black d. flooding and mental health: a systematic mapping review. plos one. 2015;10(4): e0119929. doi 10.1371/journal.pone.0119929. ______________________________________________________________ © 2023, geerling et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 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https://www.ecdc.europa.eu/en/publications-data/floods-bosnia-and-herzegovina-croatia-and-serbia-communicable-disease-risks https://www.ecdc.europa.eu/en/publications-data/floods-bosnia-and-herzegovina-croatia-and-serbia-communicable-disease-risks https://www.ilo.org/wcmsp5/groups/public/---ed_emp/documents/publication/wcms_397687.pdf https://www.ilo.org/wcmsp5/groups/public/---ed_emp/documents/publication/wcms_397687.pdf https://www.ilo.org/wcmsp5/groups/public/---ed_emp/documents/publication/wcms_397687.pdf https://www.ilo.org/wcmsp5/groups/public/---ed_emp/documents/publication/wcms_397687.pdf jong aee, sarač m, verweij w, bastić jr, geerling gw. human health in the flood risk management planning under the european union floods directive: pilot study in the sava river basin (original research). seejph 2023, posted: 12 january 2023. doi: 10.11576/seejph-6212 p a g e 10 | 12 table 1. potential health impacts in the sava river basin. abbreviations used: ptsd, post-traumatic stress disorder; wwtp, wastewater treatment plant health impact pathway specific health impact transmission route health impact source response phase potential (gis)indicator ref. accidental death and injuries drowning, electrocution, physical trauma, wounded/death by falling/moving objects besides accidents, death and injuries could come from failing infrastructure, displaced landmines and unexploded objects water depth, infrastructure, collapsing danger of buildings, early warning of citizens immediately water depth, city plan, infrastructure, population density 7, 10, 17 mental health and well-being anxiety, depression, stress, ptsd, behavioral issues warning of citizens, personal losses, impact of flood on live, first aid response time important during each phase 3, 16, 17, 22 water related infections escherichia coli o157:h7 bacteria that spreads via the fecaloral route, contaminated food and water bacterial reservoir in cattle and other ruminants. contaminated water due to overflowing septic tanks, wwtp, sewage, or agricultural runoff. first weeks location of drinking water reservoirs, septic tanks, wwtps, sewage system, agricultural land, city plan, population density 7, 8, 10, 13 leptospirosis bacteria that spreads via urine of infected animals into water/soil/food agricultural and stormwater runoff hepatisis a virus spreads via fecal-oral route, mainly contamination of water/food overflow septic tank/wwtp/sewage, agricultural runoff, stormwater runoff, infected person cryptosporidiosis parasitic disease spreads via fecaloral route, mainly contaminated water sources overflow septic tank/wwtp/sewage, infected person giardiasis parasitic disease spreads via fecaloral route from humans or infected animals overflow septic tank/wwtp/sewage, agricultural runoff, stormwater runoff, infected person shigellosis bacteria spread via fecal-oral route, or contamination of water and food. overflow septic tank/wwtp/sewage, infected person norovirus virus spreads via fecal-oral route, vomit, contamination of water/food overflow septic tank/wwtp/sewage, infected person jong aee, sarač m, verweij w, bastić jr, geerling gw. human health in the flood risk management planning under the european union floods directive: pilot study in the sava river basin (original research). seejph 2023, posted: 12 january 2023. doi: 10.11576/seejph-6212 p a g e 11 | 12 health impact pathway specific health impact transmission route health impact source response phase potential (gis)indicator ref. rotavirus virus spreads through fecal-oral route, or contamination of water and food overflow septic tank/wwtp/sewage, infected person vector borne diseases west-nile virus bite by culex spp endemic in the region first weeks to months flooded area, population temperature, rain 7, 12, 21 dengue, chikungunya bite by aedes spp via viraemic visitors, but can become endemic in the future vaccine preventable diseases tuberculosis spreads through the air infected person, overcrowding months location and population density of temporary shelters 13, 17 poliomyelites polio virus spreads via person-toperson contact infected person. it is a human only disease and is mainly associated with poor hygiene and overcrowding. chemical pollution e.g. heavy and light metals, oil and grease, hydrocarbons, agrochemicals skin diseases, earache, nausea, cancer, liver and kidney diseases, gastrointestinal diseases, cardiovascular diseases, neurological diseases, carbon monoxide poisoning chemicals can come into the water in many ways e.g. broken equipment in hospitals (x-ray, thermometers, heating systems), runoff of chemical dump, chemical plant months to a year location of factories, hospitals, water depth, flooded area, water inlet point for drinking water 3, 11 secondary effects months to a year 7, 10, 11, 17 moulding asthma, allergy symptoms, respiratory disorders damp surfaces, poor living standards food insecurity undernutrition, micronutrient-related malnutrition, diseases from carcasses of (farm)animals, health issues of farm animals polluted agcricultural lands, broken/loss agricultural material, sick animal husbandry jong aee, sarač m, verweij w, bastić jr, geerling gw. human health in the flood risk management planning under the european union floods directive: pilot study in the sava river basin (original research). seejph 2023, posted: 12 january 2023. doi: 10.11576/seejph-6212 p a g e 12 | 12 health impact pathway specific health impact transmission route health impact source response phase potential (gis)indicator ref. birth outcomes unappropriate birth conditions (causing problems for mother and/or child), low birth weight, spontaneous abortion stress, well-being, food insecurity failing health infrastructure/ lower accessibility disruption/lowering of health services resilience inaccessible health care facilities, disruption of roads, broken health care material, lower accessibility of medicines crowding infectious diseases infected person/water/food, bad hygiene laaser u, bjegovic-mikanovic v. the united nations millennium development and post-2015 sustainable development goals: towards long-term social change and social stability (editorial). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-27 1 the united nations millennium development and post-2015 sustainable development goals: towards long-term social change and social stability an introduction ulrich laaser 1 , vesna bjegovic-mikanovic 2 1 faculty of health sciences, university of bielefeld, bielefeld, germany; 2 university of belgrade, faculty of medicine, centre school of public health and management, belgrade, serbia. corresponding author: prof. ulrich laaser, section of international public health, faculty of health sciences, university of bielefeld; address: faculty of health sciences, university of bielefeld, pob 100131, d-33501, bielefeld, germany; e-mail: ulrich.laaser@uni-bielefeld.de laaser u, bjegovic-mikanovic v. the united nations millennium development and post-2015 sustainable development goals: towards long-term social change and social stability (editorial). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-27 2 most millennium development goals (mdgs) show considerable progress on a global scale, but advance is inequitable if one, for example, compares the improvement in health between sub-saharan africa and eastern asia, or even other developing countries (1). whereas health and its social determinants play a major role in the debate on the post 2015 sustainable development goals (sdgs), another major issue is only marginally mentioned, the devastating impact of armed conflicts. conflict and war produce specific vulnerable groups: women, children, the elderly, and the special risk groups of technologically and drug dependent patients (intensive care, dialysis, incubator, radiotherapy, and chemotherapy). moreover, 90% of the victims in modern wars are civilians; always war causes mental health damage with long-term outcomes even in the next generation. although, for example, one of the latest documents (5-9 may 2014) of the united nations (un) sustainable development knowledge platform, the working document for the eleventh session of the open working group on sdgs (2), devotes its last 16 th focus area to peaceful and inclusive societies, typically that section deals only – important enough – with crime, violence, and exploitation especially of children and women. similarly, in the „health we want‟ report (1) security takes up a page (p. 35), but fig. 1 (p. 42) pictures the 16 commissions, conferences etc. before and after the turn of the century. the summarizing 10 principles and 6 new health goals (p. 54) do not refer to the social causes and the prevention of armed conflict at all. also, the un economic and social council (ecosoc) seem to concentrate on countries emerging from conflict (3,4) in contradiction to the mission statement on its homepage referring to prevention. armed conflicts cause more deaths and permanent invalidity than most diseases [in the 20 th century averaging to 460.000 deaths per year (5)] and analyses show that the fragile states at the lowest human development index (hdi) level contribute to most of the lack of achievement of the mdgs. the sdg debate has to be re-adjusted to the dominating problem of security in large parts of the world. in the joint statement of the un platform on social determinants of health (6), declared as an informal document, one of the chapters deals with conflict and fragility but the solutions offered do not seem to be very realistic e.g. expecting that developing health and information systems are possible to a relevant degree in a situation of conflict, and implicitly could prevent armed conflicts; rather, peace and security are a precondition for developing stable and sustainable health systems. hence, the third claim here, namely to strengthen the policy making functions, seems to be much more to the point. this request corresponds in a way to the results of the global survey of the world federation of public health associations on the experience of public health professionals from 71 countries with the mdgs (7-9), where the importance of “politics” was ranked highest in all continents, in particular by official spokespersons of public health associations. the modern concept of public health carries a great potential for healthy and therefore less aggressive societies. development of the health systems has to contribute to peace, since aggression, violence, and warfare are among the greatest risks for health and economic welfare (10). on the other hand, world military expenditure in 2013 totalled $1.75 trillion (11), more than enough to make a difference in people‟s health across the world. building on his book, transforming medical education for the 21 st century: megatrends, priorities and change (12), george lueddeke, a global consultant in higher and medical education, advances arguments along similar lines in a forthcoming publication, global population health and well-being in the 21 st century: towards a new worldview (published by march 2015). the south eastern european journal of public health (seejph) publishes in advance the chapter on the un-mdgs and the ongoing debate on the post-2015 sustainable development goals (sdgs). laaser u, bjegovic-mikanovic v. the united nations millennium development and post-2015 sustainable development goals: towards long-term social change and social stability (editorial). seejph 2014, posted: 25 june 2014. doi 10.12908/seejph-2014-27 3 in total, the book comprises nine chapters, which range from historical perspectives on public/population health to contemporary challenges, including those triggered by „modernity‟, which might benefit from „fifth wave‟ interventions and the need to consider a new worldview. the author reviews the collective impact that external drivers are having on public health education and offers specific suggestions for modernizing public health curricula and learning. the volume includes an epilogue on „global health, governance and education‟, developed over the past few years by a think tank of 35 senior practitioners from 27 nations. it emphasizes that the core focus of the post-2015 sdgs needs to go beyond „sustainable development‟ and take its lead, as many others have advocated, from achieving global justice peace, security and basic human rights. references 1. health in the post-2015 agenda report of the global thematic consultation on health, april 2013: p.45. http://www.worldwewant2015.org/health (accessed: june 13, 2014). 2. working document for the eleventh session of the open working group on sdgs. http://sustainabledevelopment.un.org/content/documents/3686workingdoc_0205_add itionalsupporters.pdf (accessed: june 13, 2014). 3. un economic and social council. http://www.un.org/en/ecosoc/about/peacebuilding.shtml (accessed: june 13, 2014). 4. jonnalagadda haar r, rubenstein l. health in post-conflict and fragile states. united states institute of peace, 2012. 5. garfield, rn, neugut ai. epidemiologic analysis of warfare, a historical review. jama 1991;266:688-92. doi:10.1001/jama.1991.03470050088028. 6. health in the post-2015 development agenda: need for a social determinants of health approach; joint statement of the un platform on social determinants of health (undated). http://www.who.int/social_determinants/advocacy/health-post2015_sdh/en/ (accessed: june 13, 2014). 7. lomazzi m, theisling m, tapia l, borisch b, laaser u. mdgs – a public health professional‟s perspective from 71 countries. j public health policy 2013;34:e1–e22. doi:10.1057/jphp.2012.69. 8. lomazzi m, borisch b, laaser u: the millennium development goals: experiences, achievements and what‟s next. global health action 7 (2014). http://www.globalhealthaction.net/index.php/gha/issue/current (accessed: june 13, 2014). 9. lomazzi m, laaser u, theisling m, tapia l, borisch b: millennium development goals: public health professionals claim their role in the political debate. gha 2014 (submitted). 10. laaser, u., d. donev, v. bjegovic, y. sarolli: public health and peace (editorial). croat med j 2002;43:107-13. 11. stockholm international peace research institute (sipri). http://www.sipri.org/media/pressreleases/2014/milex_april_2014 (accessed: june 13, 2014). 12. lueddeke g. transforming medical education for the 21st century: megatrends, priorities and change. london: radcliffe publishing, 2012. ___________________________________________________________ © 2014 laaser et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.worldwewant2015.org/health http://sustainabledevelopment.un.org/content/documents/3686workingdoc_0205_additionalsupporters.pdf http://sustainabledevelopment.un.org/content/documents/3686workingdoc_0205_additionalsupporters.pdf http://sustainabledevelopment.un.org/content/documents/3686workingdoc_0205_additionalsupporters.pdf http://www.un.org/en/ecosoc/about/peacebuilding.shtml http://www.globalhealthaction.net/index.php/gha/issue/current http://www.sipri.org/media/pressreleases/2014/milex_april_2014 houghton f. easter eggs & ‘easter eggs’: alcohol branded chocolate eggs & intoxigenic environments in ireland (short report). seejph 2021, posted: 05 may 2021. doi: 10.11576/seejph-4395 p a g e 1 | 5 short report easter eggs & ‘easter eggs’: alcohol branded chocolate eggs & intoxigenic environments in ireland frank houghton1 1 healr research group, limerick institute of technology, limerick, ireland. corresponding author: dr. frank houghton; address: healr research group, limerick institute of technology; telephone: + 353-(0)87-7101346; e-mail: frank.houghton@lit.ie houghton f. easter eggs & ‘easter eggs’: alcohol branded chocolate eggs & intoxigenic environments in ireland (short report). seejph 2021, posted: 05 may 2021. doi: 10.11576/seejph-4395 p a g e 2 | 5 abstract alcohol branded easter eggs were observed in a mainstream irish supermarket. the public health (alcohol) act, 2018 fails to deal with such child-friendly marketing. an amendment to the current legislation to counter this deficit is urgently required. the absence of such legislation is particularly notable given the longstanding inclusion of clauses to this effect in tobacco control legislation in ireland. keywords: alcohol branding, alcohol control, alcohol marketing, children, easter eggs, ireland. conflict of interests: none declared. houghton f. easter eggs & ‘easter eggs’: alcohol branded chocolate eggs & intoxigenic environments in ireland (short report). seejph 2021, posted: 05 may 2021. doi: 10.11576/seejph-4395 p a g e 3 | 5 the term ‘easter egg’ to define a hidden message, image, or feature in a computer game, film, or other, normally electronic, medium, was coined by steve wright of atari in the late 1970s (1). the irony therefore in spotting traditional chocolate easter eggs emblazoned with alcohol industry messaging on the shelves of a mainstream supermarket (tesco, nenagh, co. tipperary) in ireland was significant. two examples of such alcohol branded easter eggs were observed, positioned at a height of less than one metre, and surrounded by a selection of other well-known brands, including cadbury’s cream eggs, rolo, and lion (see figure one a-d). the alcohol brands noted were baileys (cream, cocoa, whiskey liqueur) and guinness (stout). figure 1 (a-d). guinness and bailey’s easter eggs on display a b c d houghton f. easter eggs & ‘easter eggs’: alcohol branded chocolate eggs & intoxigenic environments in ireland (short report). seejph 2021, posted: 05 may 2021. doi: 10.11576/seejph-4395 p a g e 4 | 5 of particular concern was the guinness easter egg, which featured not just its iconic dark livery and easily identifiable harp logo, but three ‘guinness chocolate pints’ sweets as well (see figure one d). the blatant deficit in the protection of children from alcohol advertising in the public health (alcohol) act 2018 that allows such marketing is yet another inadequacy in this legislation that has been identified (2,3). although section 17 of the act prohibits alcohol branding on children’s clothing, other goods are not subject to any such controls, even sweets and confectionary (see table 1). table 1. section 17 of ireland’s public health (alcohol) act 2018 17. (1) it shall be an offence for a person to— (a) manufacture, for sale in the state, (b) import, for sale in the state, or (c) sell to a person who is in the state, an article of clothing intended to be worn by a child, where the article promotes alcohol consumption or bears the name of an alcohol product or the trade mark, emblem, marketing image or logo, by reference to which an alcohol product is marketed or sold. an important parallel is the ban on sweets/candy that resemble tobacco products (section 9 of public health [tobacco] [amendment] act, 2004; section 38 of public health [tobacco] act, 2002), which was introduced almost 20 years ago. ireland’s laws on such tobacco marketing to children through candy and sweets align with article 13 of the world health organization’s (who) influential framework convention on tobacco control (fctc). it is evident that a similar prohibition on alcohol marketing is urgently required. such marketing is particularly problematic given ireland’s troubled relationship with alcohol (4,5), and in light of the proven impact of marketing, advertising, and sponsorship by the alcohol industry on adults, youths and children (6-8). a plethora of studies have also clearly demonstrated that children and youths in ireland are in danger themselves of developing similarly problematic habits of alcohol misuse to those of adults here and so continuing the cycle (9). youth and child alcohol misuse is of added concern because of research indicating the accentuated impact of alcohol on developing adolescent physiology and personality (10). it must be acknowledged that easter eggs featuring alcohol branding and logos are neither innocent, nor inconsequential. such coded marketing reinforces the ubiquitous nature of our intoxigenic environments. an amendment to the public health (alcohol) act, 2018, is urgently required to address this, and the many other deficits in the legislation that have been identified to date. now is not the time for avoidant and timid political leadership on this issue. in the meantime, retailers should refrain from selling such alcohol branded chocolate eggs, or failing that, restrict such sales to within the newly developed alcohol section of their premises. it is also clear that continual vigilance by public health and alcohol control advocates is required to combat the machinations of the alcohol industry. houghton f. easter eggs & ‘easter eggs’: alcohol branded chocolate eggs & intoxigenic environments in ireland (short report). seejph 2021, posted: 05 may 2021. doi: 10.11576/seejph-4395 p a g e 5 | 5 © 2021 houghton; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. references 1. chuvaieva a. how to make a video game easter egg: legaltips and tricks. j intell prop l pract 2019;14:864-75. 2. houghton f, mcinerney d. the public health (alcohol) act: spatial issues and glaring gaps. ir geogr 2021;53:179-84. doi: 10.2014/igj.v53i2.1423. 3. houghton f, mcinerney d. sponsorship, advertising & alcohol control in ireland: the importance of both premises and products in regulating intoxigenic environments. ir j med sci 2020;189:1035-7. doi: 10.1007/s11845-019-02154-w. 4. mongan d, long j. overview of alcohol consumption, alcohol-related harm and alcohol policy in ireland. hrb overview series 10. dublin: health research board; 2016. 5. alcohol action ireland. an overview of alcohol related harm; 2021. available from: https://alcoholireland.ie/facts/alcohol-relatedharm-facts-and-statistics/#:~:text=alcohol%20is%20responsible%20for%2088,of%20all%20suicides%20in%20ireland (accessed: march 8, 2021). 6. engels rc, hermans r, van baaren rb, hollenstein t, bot sm. alcohol portrayal on television affects actual drinking behaviour. alcohol alcohol 2009;44:244-9. 7. smith la, foxcroft dr. the effect of alcohol advertising, marketing and portrayal on drinking behaviour in young people: systematic review of prospective cohort studies. bmc public health 2009;9:1-11. available from: https://doi.org/10.1186/14712458-9-51 (accessed: march 8, 2021). 8. houghton f, scott l, houghton s, lewis ca. children’s awareness of alcohol sponsorship of sport in ireland: munster rugby and the 2008 european rugby cup. int j public health 2014;59:829-32. 9. espad group. espad report 2019: results from the european school survey project on alcohol and other drugs, luxembourg: emcdda joint publications, publications office of the european union; 2020. 10. ruan h, zhou y, luo q, robert gh, desrivières s, quinlan eb, et al. adolescent binge drinking disrupts normal trajectories of brain functional organization and personality maturation. neuroimage clin 2019;22:101804. __________________________________________________________________________ https://alcoholireland.ie/facts/alcohol-related-harm-facts-and-statistics/#:~:text=alcohol%20is%20responsible%20for%2088,of%20all%20suicides%20in%20ireland https://alcoholireland.ie/facts/alcohol-related-harm-facts-and-statistics/#:~:text=alcohol%20is%20responsible%20for%2088,of%20all%20suicides%20in%20ireland https://alcoholireland.ie/facts/alcohol-related-harm-facts-and-statistics/#:~:text=alcohol%20is%20responsible%20for%2088,of%20all%20suicides%20in%20ireland https://alcoholireland.ie/facts/alcohol-related-harm-facts-and-statistics/#:~:text=alcohol%20is%20responsible%20for%2088,of%20all%20suicides%20in%20ireland https://alcoholireland.ie/facts/alcohol-related-harm-facts-and-statistics/#:~:text=alcohol%20is%20responsible%20for%2088,of%20all%20suicides%20in%20ireland https://alcoholireland.ie/facts/alcohol-related-harm-facts-and-statistics/#:~:text=alcohol%20is%20responsible%20for%2088,of%20all%20suicides%20in%20ireland https://alcoholireland.ie/facts/alcohol-related-harm-facts-and-statistics/#:~:text=alcohol%20is%20responsible%20for%2088,of%20all%20suicides%20in%20ireland peposhi i, tafa h, bardhi d, hafizi h. clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 [original research]. seejph 2020, posted: 16 august 2020. doi: 10.4119/seejph-3631 p a g e 1 | 10 original research clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 ilir peposhi1, holta tafa1, donika bardhi1, hasan hafizi1 1university hospital of lung diseases “shefqet ndroqi”, tirana, albania. corresponding author: ilir peposhi, md; address: rr. “shefqet ndroqi”, tirana, albania telephone: +355682090755; email: ilirpeposhi@yahoo.com peposhi i, tafa h, bardhi d, hafizi h. clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 [original research]. seejph 2020, posted: 16 august 2020. doi: 10.4119/seejph-3631 p a g e 2 | 10 abstract aim: to estimate the clinical and epidemiological pattern of tuberculosis (tb) in albania over the period 2009-2018. methods: a retrospective analysis of clinical and epidemiological data based on tb individual notification forms during the period 2009-2018. results: during the 10-years period, tb incidence increased from 14 to 15.5, but without a significant increasing trend. the total number of tb cases increased from 440 to 447. the proportion of extra-pulmonary tb decreased from 32% to 25% in 2018 (p=0.015), with and average mean change of 29 cases. males prevail among tb cases and male-to-female ratio ranges from 2:1 to 3:1. drug susceptibility testing (dst) was carried out depending on the availability of the reagents and there were 54%, 18% and 96% culture cases confirmed positive in 2009, 2014 and 2019, respectively. the overall treatment completion rate was 85% and 88.2% in 2009 and 2018, respectively. however, there was a significant drop in cured cases from 26% in 9.3%, whereas the percentage of deaths has increased from 0.5% in 4.1%. all treatment outcomes exhibited a significant change (p<0.001). conclusion: tb continues to be a public health challenge in albania regardless of the seemingly generally stable epidemiological situation. keywords: drug resistance, epidemiology, incidence, treatment outcomes, tuberculosis. conflicts of interest: none declared. peposhi i, tafa h, bardhi d, hafizi h. clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 [original research]. seejph 2020, posted: 16 august 2020. doi: 10.4119/seejph-3631 p a g e 3 | 10 introduction tuberculosis (tb) is a communicable disease that is a major cause of ill health, one of the top 10 causes of death worldwide and the leading cause of death from a single infectious agent (ranking above hiv/aids). tb affects more than 10 million people, causing 1.6 million deaths worldwide and about a quarter of the world’s population is infected with m. tuberculosis (1). geographically, most tb cases in 2018 were in the who regions of south-east asia (44%), africa (24%) and the western pacific (18%), with smaller percentages in the eastern mediterranean (8%), the americas (3%) and europe (3%) (2). drug-resistant tb continues to be a public health threat. in 2018, there were about half a million new cases of rifampicin-resistant tb, of which 78% had multidrug-resistant tb (mdr) (3). despite the notable progress achieved in the fight against tb, countries still face a variety of challenges in reaching the goal to end the epidemic. proper and fast diagnosis of tb is essential. the sooner a patient is diagnosed, the faster their treatment can begin, easing suffering and preventing further disease transmission. since 1994, the world health organization (who) has developed three main strategies for tb prevention and control: directly observed treatment short course (dots), stop tb and end tb (4,5). those strategies focused on case notification and monitoring of treatment outcome as the essential measures to evaluate the effectiveness of interventions and identify potential gaps in tb control (6). the efficacy and successful management of any national tuberculosis control program requires reliable clinical and bacteriological diagnosis. in order to provide these data, a national tuberculosis surveillance system was implemented based on individual data since 2008. trend in case notification rate, age group affected by tb, bacteriological resistance, treatment outcomes and clinical form are the main indicators used to evaluate the national tb program. all these indicators were analysed in the current study (7-9). the aim of the present study was to estimate the clinical and epidemiological pattern of tb in albania over the period 2009-2018. methods the data were obtained from the register at the national tuberculosis control program (ntbp) at the university hospital of lung diseases "shefqet ndroqi" (susm), tirana, albania. data on tuberculosis patients are recorded and reported individually and in accordance with the guidelines of the world health organization and the european tb supervision centre (6). the data are collected and reported for each individual patient in accordance with the notification reporting form designed in 2001. the notification form includes detailed data on tb and other related factors. the study analyse the data reported, recorded and evaluated at ntbp and included general patient data, address, sex, occupation, age, diagnosis, direct sputum and culture results, as well as anti-tuberculosis drug sensitivity results and treatment outcomes. statistical analysis was performed in spss 25.0 (statistical package for social sciences). categorical variables were presented in absolute numbers and corresponding percentages. arithmetic averages were calculated for all numerical variables. differences between groups for discrete variables, nonparametric data, were performed using the hi-square test. the values of p≤0.05 were considered peposhi i, tafa h, bardhi d, hafizi h. clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 [original research]. seejph 2020, posted: 16 august 2020. doi: 10.4119/seejph-3631 p a g e 4 | 10 significant. population estimates were based on 2002 census data, with extrapolation. results trends analysis of tuberculosis incidence in the study period, the incidence rate of tb per 100,000 inhabitants/year went from 13.4 in 2009 to 14.2 in 2018 (figure 1); there is no evidence of any significant linear trend in the incidence rate of tuberculosis in albania in the past decade (p>0.05). the mean percentage of annual changes of tb notification rate from 2009 to 2018 was 6.6%. figure 1. tb incidence during the period 2009-2018 tuberculosis cases by site of disease the number of reported cases of pulmonary tb in albania varies by about 5.3% on average each year, from 2009 to 2018. as a result, the proportion of total cases with extra pulmonary decreased from 32% in 2009 to 25% in 2018 (p=0.015, difference between 2009 vs 2018).the average mean change is 29 cases, which shows a stable trend. figure 2 shows the total number of cases related to site of disease. 14 14 13.5 13.5 16.8 14 14.4 14.4 16.5 15.5 0 2 4 6 8 10 12 14 16 18 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 peposhi i, tafa h, bardhi d, hafizi h. clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 [original research]. seejph 2020, posted: 16 august 2020. doi: 10.4119/seejph-3631 p a g e 5 | 10 figure 2. total cases with tb, pulmonary and extra-pulmonary cases sex and age distribution males predominate among tb cases in all study period and male: female ratio ranges from 2:1 to 3:1. young adults (15-44) and the middle-aged (45-64) together represented 76.5% of all cases and respectively 47.4% and 29.1% in 2009. young adults and the middle-aged represented 73% in 2018, but there was a significant increase in the age group>65 from 19.7% in 2009 to 26.1% in 2018(p=0.014). table 1. tb by age groups *chi-square test. 447 445 430 420 474 408 414 413 503 440 305 275 301 312 333 261 296 299 346 330 142 170 129 108 141 147 118 114 157 110 0 100 200 300 400 500 600 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 n o . o f ca se s total tb cases pulmonary ex pulmonary age groups years p-value* 2009 n (%) 2018 n (%) 0-15 18 (4.03) 4 (0.91) 0.002 15-25 86 (19.24) 81 (18.41) 0.409 25-35 63 (14.09) 83 (18.86) 0.034 35-45 62 (13.87) 37 (8.41) 0.006 45-55 71 (15.88) 58 (13.18) 0.148 55-65 59 (13.20) 62 (14.09) 0.386 >65 88 (19.69) 115 (26.14) 0.014 peposhi i, tafa h, bardhi d, hafizi h. clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 [original research]. seejph 2020, posted: 16 august 2020. doi: 10.4119/seejph-3631 p a g e 6 | 10 figure 3. distribution (in %) according to age groups there was an increase in the age group 25-34 from 14.2% to 18.8% and in the age group over 65 from 19.4% to 26.1%, while there was a decrease in the age group 35-44 from13.9% to 8.5%. children accounted respectively for 4.1% and 0.9% in 2009 and 2018. young adults (15-44) and the middle-aged (45-64) together represented 76.5% of all cases and respectively 47.4% and 29.1% in 2009. young adults and the middle-aged represented 73% in 2018, but there was a significant increase in age group >65 in 2018(p=0.014). bacteriological confirmation and drug susceptibility testing the proportion of bacteriologically confirmed cases remained high during the study period and there was not great variation annually in smear confirmation cases. average mean change was 17 ± 13 cases per year, which shows a constant trend. drug susceptibility testing (dst) was carried out in a small proportion of pulmonary tb cases, only for 30% of cases in 2018 due to shortage of reagent. the number of cultures tested dropped from 201 in 2009 to 63 in 2018, but starting from 2013 the number of tests was reduced dramatically, and consequently the mdr data are not reliable for our country. 4.1 19.3 14.2 13.9 15.8 13.3 19.4 0.9 18.4 18.8 8.5 13.2 14.1 26.1 0-14 15-24 25-34 35-44 45-54 55-64 >65 year 2009 year 2018 peposhi i, tafa h, bardhi d, hafizi h. clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 [original research]. seejph 2020, posted: 16 august 2020. doi: 10.4119/seejph-3631 p a g e 7 | 10 table 2. proportion of smear positive cases, mdr and number of drug susceptibility testing year ptb smear positive % of smear positive mdr cases dst 2009 305 192 63% 0 201 2010 275 165 60% 2 182 2011 301 190 63% 5 203 2012 312 206 66% 0 163 2013 333 212 64% 1 27 2014 261 175 67% 2 29 2015 296 209 71% 3 13 2016 299 206 69% 1 40 2017 346 210 61% 0 79 2018 330 208 63% 2 63 treatment outcomes the overall treatment success rate was 85% and 88.2% in 2009 and 2018, respectively. there is a significant drop in cured cases in 2009 from 26% to 9.3% in 2018. also, the percentage of deaths increased from 0.5% to 4.1%. all treatment outcomes displayed a significant change (p<0.001). figure 4. treatment outcomes (in percent) 25.95 59.60 0.50 2.90 11.40 9.31 78.86 4.10 0.23 7.50 cured treatment completed dead failure lost to follow up 2018 2009 peposhi i, tafa h, bardhi d, hafizi h. clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 [original research]. seejph 2020, posted: 16 august 2020. doi: 10.4119/seejph-3631 p a g e 8 | 10 discussion the number of patients diagnosed with tuberculosis in the study period had a slight oscillation with an insignificant trend of increase in tb incidence. the incidence increased from 13.4% in 2008 to 15.3% in 2018. there was no evidence of a trend and a statistically significant change in the incidence rate over the study period. the incidence of tb appears to be more or less stable, but if we compare it with the neighbouring countries or other european countries, we notice that albania is the only country in the region with increased tb incidence and a positive mean annual change (table 3). there is a wide variation in tb incidence in the balkan region from 4 (greece) to 39 (kosova) cases per 100,000 population. table 3. tb incidence in the balkan region country tb incidence 2009 (cases per 100,000) tb incidence 2018 mach* 2014-2018 albania 13.4 15.3 2.0% kosova 60 39.2 -4.6% montenegro 19.2 13.4 -7.2% north macedonia 23.2 10.4 -6.6% serbia 17.2 9.4 -7.0% grecee 5.2 4 -4.1% this indicates that stability of tb incidence over the years in albania is not a good tb programme indicator and the national tb programme has to analyse the cause of this stagnation. furthermore, despite the stable incidence, the proportion of pulmonary tb cases increased to 75% in 2018, posing a serious risk of spreading cases with infectious tb and consequently increasing tb incidence in coming years. the proportion of extra pulmonary tb continues to be high despite the significant decrease during the last years. the lowest proportion 25% was in 2018 and the higher was 38% in 2010. there is a stable trend in decreasing the proportion of extra pulmonary cases, although the proportion remains high compared to the region. the proportion of extra-pulmonary tb was 14% in greece, 11% in serbia, 12% in monte negro, 24% in north macedonia and 29% in kosovo in 2019. the variances in the reporting of extra-pulmonary tb may result from different diagnostic practices across the country in the region or epidemiological factors and the prevailing m. tb strains (10). males predominate among tb cases in all study period and male: female ratio ranges from 2:1 to 3:1. there were twice as many males as females reported among all incident tb cases in european region, but large variation was observed for male predominance in the sex distribution of tb cases, ranging from almost an even distribution to over three times greater in armenia and albania. there are few publications on tb gender differences worldwide and it is not clear whether the differences in morbidity between the sexes are due to biological factors, socioeconomic context, or under diagnosis of tb in women who are peposhi i, tafa h, bardhi d, hafizi h. clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 [original research]. seejph 2020, posted: 16 august 2020. doi: 10.4119/seejph-3631 p a g e 9 | 10 likely to have the least access to health care (11,12). in albania, the disease of tuberculosis continues to be an important cause of morbidity in women. the differences between the sexes have been constantly ascertained, but there is no study to assess these changes (13). bacteriological confirmation of tb diagnosis was high during the study period, over 60%, and there was not great variation annually in smear confirmation cases. a high proportion of bacteriologically confirmed ptb cases might imply a delay in diagnosis and may reflect several gaps in diagnosis, such as lack of capacity by the program to accurately diagnose tb through bacteriological examination (14). the proportion of bacteriologically confirmed cases among pulmonary tb varied considerably among the countries in the region from 45% in kosovo to 95% in serbia. the increasing proportion in other countries in the region is due to the implementation of the new technology in these countries, specifically genexpert. thus, the proportion of bacteriologically confirmed cases before and after application of genexpert in monte negro was 59% and 86% respectively, in bosnia and herzegovina 42% and 74% and in north macedonia 65% and 90%, respectively. albania has installed last year two genexpert and we expect an increase in the bacteriological confirmation like in other neighbouring countries (15). mdr-tb is a major issue in the balkan region with the percentage of mdr-tb among all tb cases increasing over the last 10 years from 4.3% to 7.5% (16). drug susceptibility testing was carried out in a small proportion of pulmonary tb cases (only for 30% of the cases) and we cannot analyse this important indicator, but the proportion of mdr resistance remains low (less than 3% over the study period). albanian government must provide the necessary reagent for performing drug susceptibility test and evaluating the real situation of mdr in albania. over the study period, the treatment success rates continued to improve, but the cure rate decreased significantly due to the lack of bacteriological confirmation during the follow up treatment phase. the number of deaths increased, but there are only few numbers to draw a valid statistical conclusion. conclusion despite the stagnation of the total number of tb cases during the study period, the epidemiological situation should not be assessed as stable, but deteriorating. mdr situation is unknown due to the shortage of reagent and pose a threat to tb control. the other epidemiological indicators like treatment outcomes and age group improved during the study period. references 1. world health organization (who). global tuberculosis report 2018. geneva: who; 2018. available from: https://apps.who.int/iris/bitstream/handle/10665/274453/9789241565646eng.pdf?sequence=1&isallowed=y (accessed: august 1, 2019). 2. world health organization. moscow declaration to end tb; first who global ministerial conference on ending tb in the sustainable development era: a multisectoral response. geneva: world health organization and the ministry of health of the russian federation; 2017. available from: https://www.who.int/tb/features_archive/moscow_declaration_to_end_tb_final_english.pdf?ua=1(accessed: june 28, 2019). https://apps.who.int/iris/bitstream/handle/10665/274453/9789241565646-eng.pdf?sequence=1&isallowed=y https://apps.who.int/iris/bitstream/handle/10665/274453/9789241565646-eng.pdf?sequence=1&isallowed=y https://apps.who.int/iris/bitstream/handle/10665/274453/9789241565646-eng.pdf?sequence=1&isallowed=y https://www.who.int/tb/features_archive/moscow_declaration_to_end_tb_final_english.pdf?ua=1 https://www.who.int/tb/features_archive/moscow_declaration_to_end_tb_final_english.pdf?ua=1 https://www.who.int/tb/features_archive/moscow_declaration_to_end_tb_final_english.pdf?ua=1 https://www.who.int/tb/features_archive/moscow_declaration_to_end_tb_final_english.pdf?ua=1 peposhi i, tafa h, bardhi d, hafizi h. clinical and epidemiological evaluation of tuberculosis in albania during the period 2009-2018 [original research]. seejph 2020, posted: 16 august 2020. doi: 10.4119/seejph-3631 p a g e 10 | 10 3. world health organization.thirteenth general programme of work, 2019– 2023. geneva: who; 2018. available from: https://apps.who.int/iris/bitstream/handle/10665/324775/whoprp-18.1-eng.pdf(accessed: august 1, 2019). 4. world health organization (who) and stop tb partnership. the stop tb strategy. building on and enhancing dots to meet the tb-related millennium development goals. geneva: who;2006. 5. world health organization (who). implementing the end tb strategy: the essentials. geneva: who; 2015. 6. european centre for disease prevention and control (ecdc). tuberculosis surveillance and monitoring in europe, 2017. stockholm: ecdc; 2018. 7. schwoebel v, lambregts-van weezenbeek cs, moro ml, drobniewski f, hoffner se, raviglione mc, et al. standardization of anti-tuberculosis drug resistance surveillance in europe. recommendations of a world health organization (who) and international union against tuberculosis and lung disease (iuatld) working group. eur respir j 2000;16:364-71. 8. world health organization/international union against tuberculosis and lung disease. guidelines for surveillance of drug resistance in tuberculosis. int j tuberc lung dis 1998;2:72-89. 9. veen j, raviglione m, rieder hl, migliori gb, graf p, grzemska m, et al.standardized tuberculosis treatment outcome monitoring in europe.eur respir j 1998;12:505-10. 10. uplekar m, rangan s, ogden j. gender and tuberculosis control: towards a strategy for research and action. geneva: who; 1999:6-10 11. hudelson p. gender differentials in tuberculosis: the role of socio-economic and cultural factors. tuber lung dis1996;77:391-400. 12. caws m, thwaites g, dunstan s, hawn tr, lan nt, thuong nt, et al.the influence of host and bacterial genotype on the development of disseminated disease with mycobacterium tuberculosis. plos pathog 2008;4:e1000034. 13. hafizi h, dilika e, bardhi d, shehu e. the treatment outcomes for tb patients in albania from 2001-2006.gender differences in tb disease in albania. ajmhs 2008;2. 14. desikan p. sputum smear microscopy in tuberculosis: is it still relevant? indian j med res 2013;137:442-4. 15. agrawal m, bajaj a, bhatia v, dutt s. comparative study of genexpert with zn stain and culture in samples of suspected pulmonary tuberculosis. j clin diagn res 2016;10:9-12. 16. world health organization. tuberculosis surveillance and monitoring in europe 2020: 2018 data. who; 2020. _________________________________________________________________________ © 2020 peposhi et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. de bruin, j.; machado, m.; nabbe, m.; saccà, r.; verhoeven, j.; clemes, t. increasing influenza vaccination rates among healthcare workers by focusing on workplace and patient safety. (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4683 p a g e 1 | 10 policy brief increasing influenza vaccination rates among healthcare workers by focusing on workplace and patient safety jeanine de bruin1, matilde machado1, nabbe marie1, riccardo saccà1, jeske verhoeven1, timo clemens1 1faculty of health, medicine, and life sciences, maastricht university, the netherlands corresponding author: jeanine de bruin j.debruin@student.maastrichtuniversity.nl duboisdomein 30, 6229 gt, maastricht, the netherlands de bruin, j.; machado, m.; nabbe, m.; saccà, r.; verhoeven, j.; clemes, t. increasing influenza vaccination rates among healthcare workers by focusing on workplace and patient safety. (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4683 p a g e 2 | 10 abstract context: in 2014, the influenza vaccine uptake in europe was below 35% among healthcare workers (hcws). due to a lack of confidence in vaccination as a result of safety concerns, hcws increasingly do not take the influenza vaccine. consequently, there is a rising influenza burden which results in increasing mortality of vulnerable patients and absenteeism in hospitals. this policy brief aims to increase the awareness of hcws regarding the importance of influenza vaccination uptake, which may result in improved patient and workplace safety. policy options: to increase vaccination coverage and reduce vaccine hesitancy among hcws, a change in attitude towards and knowledge about the influenza vaccine is needed. two potential approaches are presented in this paper. firstly, a mandatory vaccination policy is discussed. practical and ethical challenges of implementing a mandatory vaccination policy are considered. secondly, information campaigns are described, consisting of three pillars: safety, information, and knowledge. recommendations: it is recommended to initiate information campaigns focussing on patient safety. furthermore, a structural approach to increase access to vaccination at the workplace must be taken. higher vaccination rates of hcws lead to an improved workplace safety. the recommended information campaign can also be used for other vaccine preventable diseases or in other situations, such as hcws vaccine hesitancy regarding covid-19 vaccines. lessons from the covid-19 pandemic regarding acceptance of vaccines should be considered for the improvement of future influenza vaccine uptake. keywords: healthcare workers, information campaign, influenza vaccination, mandatory vaccination, vaccine hesitancy acknowledgments: we would like to thank kasia czabanowska for the opportunity to develop this policy brief and timo clemens for his guidance and extensive feedback during the writing process authors’ contributions: all authors contributed equally to this work. conflict of interest: none declared source of funding: none declared de bruin, j.; machado, m.; nabbe, m.; saccà, r.; verhoeven, j.; clemes, t. increasing influenza vaccination rates among healthcare workers by focusing on workplace and patient safety. (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4683 p a g e 3 | 10 introduction influenza is an annual public health concern [1]. the world health organization (who) estimates that seasonal influenza annually infects 5% to 15% of the global population, with 3–5 million cases of severe illness and up to half a million deaths [2]. infected healthcare workers (hcws) are the major cause of hospital-acquired influenza cases [2], since asymptomatic infection cases may still transmit the influenza virus to vulnerable patients [3]. the hospital-acquired cases constitute particularly high mortality, with an estimated median of 60% in high-risk groups, such as patients aged over 65 years, patients with chronic diseases, and intensive care unit patients [1, 2]. accordingly, a significant proportion of the burden of this disease is vaccine-preventable [2]. the who, the centers for disease control and prevention (cdc and ecdc), and the public health institutes strongly recommend that all hcws take annual influenza vaccination [1, 4], taking up the principles of beneficence and non-maleficence [2]. studies found that immunizing hcws against influenza each year decreases mortality in influenza cases [5]. however, influenza vaccine uptake among hcws remains low in european countries. in 2014, for the 10 european union (eu) countries that could provide data on hcw vaccination rates, the vaccine uptake reported was less than 35% [1]. context hcws are considered the most trusted source of vaccine-related information. however, studies are showing that they are losing confidence in vaccination for their children, themselves, or their patients. in other words, despite the effectiveness and safety of vaccinations being well documented [6-8], the vaccine hesitancy among hcws is increasing and affecting others as well. the sage working group on vaccine hesitancy defined “vaccine hesitancy” as “a behavior, influenced by a number of factors including issues of confidence, complacency, and convenience” [8]. vaccine hesitant hcws can have a forceful influence on vaccination decisions. they might recommend vaccines less frequently to their patients, or otherwise undermine confidence and contribute to vaccine hesitancy among the general population. this is a particular concern given the benefits associated with influenza vaccination in high-risk groups [5]. hcws have their patients’ health at heart, and they must be reminded of the dangers of vaccine-preventable diseases and the low risks of vaccine side effects [9]. influenza infection in hcws is also a major reason for absenteeism in the hospital during winter, increasing the influenza burden [1]. this shows the importance of encouraging the vaccine hesitant hcws who do not actively care for their own health to take the influenza vaccine. research into vaccine hesitancy and its reasons among hcws showed generally high levels of trust and confidence in vaccination [9]. however, there were concerns about safety, questions about the need for vaccines, and/or mistrust in pharmaceutical companies. the most important concern was the fear of vaccine side effects. furthermore, there was strong mistrust in pharmaceutical companies due to perceived financial interests and a lack of communication about side effects. it was also shown that hcws present a lack of confidence in the need for and the effectiveness of some vaccines, particularly the seasonal influenza vaccine. a few doctors demonstrated being entirely against vaccination and decided not to recommend it to their patients, which constitutes a particular concern on hcws influence on vaccination intentions. de bruin, j.; machado, m.; nabbe, m.; saccà, r.; verhoeven, j.; clemes, t. increasing influenza vaccination rates among healthcare workers by focusing on workplace and patient safety. (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4683 p a g e 4 | 10 another important concern for hcws related to influenza vaccination was trust. in france, eight out of ten general practitioners (gp) trust the ministry of health, but 50% of them also believe that the ministry is influenced by pharmaceutical companies [9]. hence, this group of vaccine hesitant hcws require specific persuasion to increase their uptake of the influenza vaccine. recently, the covid-19 vaccines were approved, and the vaccination campaigns have started. throughout the european union member states, acceptance of the new covid-19 vaccines differs. it is claimed that high acceptance of covid-19 vaccines is linked to the availability and active share of information to hcws from national public health authorities [10]. nonetheless, concerns among hcws on the safety and effectiveness of the covid-19 vaccines show similarity to the debate on influenza vaccine hesitancy [11]. leadership coalition tactics can be applied to get the support of other parties to assist in influencing the target [12]. a stakeholder that is involved in the problem of vaccine hesitancy among hcws and tries to address this issue is the coalition for vaccination. in 2019, the coalition was convened by the european commission, bringing together european associations of hcws and relevant student associations in the field. the coalition aims to support delivering accurate information to the public, combating myths around vaccines, and exchanging best practices on vaccination. the purpose of this policy brief is to increase the awareness of the coalition for vaccination on hcws’ concerns that contribute to vaccine hesitancy and how to prevent and respond to vaccine hesitancy among hcw using a workplace and patient safety approach. policy options information campaigns since vaccination coverage among hcws is insufficient and vaccine hesitancy is on the rise, there is a need for change in the attitude of hcws towards the influenza vaccination. to achieve the latter, more collaboration between stakeholders in this field is needed. an efficient way to combat vaccine-hesitant hcws is through information campaigns. these vaccine awareness campaigns can be based on three different pillars, namely safety, knowledge and trust. safety higher vaccination coverage among hcws can lead to a higher level of safety and protection, both to the patients, who are vulnerable individuals visiting the healthcare facility, and the workplace, including the healthcare staff themselves. hcws have their best intentions when it comes to their patients’ safety, which is why it is necessary to remind them of the dangers of vaccine-preventable diseases and the low risks of vaccines. hcws are responsible for the health and safety of their patients, which can be safeguarded through vaccination. some hcws feel responsible for potential side effects, but the benefits of the influenza vaccine are higher than the potential risks, and hcws should be aware of that [9]. additionally, vaccination contributes to workplace safety. not only are hcws responsible for the health and safety of their patients, but they can also protect their patients by making sure that they are vaccinated against influenza themselves to prevent infecting patients or other hospital staff [13]. moreover, the vaccination of hcws poses a major benefit to the hospitals and healthcare staff. it reduces costs by decreasing absence due to illness and improves health and morale among the hcws themselves, creating a stronger and more united team [14]. communication about safety could be implemented as an initiative from de bruin, j.; machado, m.; nabbe, m.; saccà, r.; verhoeven, j.; clemes, t. increasing influenza vaccination rates among healthcare workers by focusing on workplace and patient safety. (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4683 p a g e 5 | 10 hospitals or other healthcare entities. they could provide training sessions or courses for their staff regarding the safety of vaccines. supplying them with free influenza vaccina tion on an accessible location would also be beneficial. knowledge compared to the safety approach, the knowledge approach frames the appeal to the hcws in a different way. as a result of these training sessions on workplace and patient safety, awareness and knowledge on influenza vaccines are increased. awareness and knowledge of hcws on this subject increases their willingness to recommend vaccination to their patients. moreover, hcws who are more knowledgeable about the subject are also more likely to get vaccinated themselves [13]. more knowledge of vaccines can be provided by the healthcare institutes through hcws training and information campaigns. subsequently, this knowledge can be passed on between colleagues. a study by duval et al. (2009) found social and collegial support to be important contributors to the confidence of hcws in advising patients about vaccination [15]. lack of knowledge is not homogeneous among hcws. for instance, the head of a department might be more educated in the field of vaccination than an intern or a nurse [16]. as heads of department are responsible for the health and safety of their employees, they need to take a more active leadership role in promoting influenza vaccination among hcws. furthermore, collegial support and targeted training might be beneficial for improving knowledge and awareness in all healthcare staff. trust another important factor for vaccine hesitancy is (lack of) trust. although hcws trust policymakers, their level of trust towards pharmaceutical companies is considerably lower [9]. some hcws even believe that authorities are influenced by pharmaceutical companies, or that pharmaceutical companies withhold information as a form of power control [17]. hcws are not only influenced by their direct environment, but by a wide scale of socio-economic, political, and cultural contexts on concerns about vaccines [9]. therefore, there is a need to bridge the gap between these different contexts. to achieve this and build trust and confidence, a high degree of transparency and information sharing between the various fields is necessary. to do so, news and media outlets should be used in a positive way to send a message to hcws and different stakeholders. the power of the media can be used to benefit healthcare entities on an organizational, clinical, and patient level and is crucial for the implementation of new policies [18]. in 2020, the coalition has been conducting an advocacy campaign to promote the uptake of vaccines among hcws and their patients, aiming to remind that immunization through vaccination is the best protection there is against serious, even deadly, preventable diseases [19]. mandatory vaccination an alternative policy to increase influenza vaccination uptake in hcws is mandatory vaccination. mandatory vaccination is defined as requiring individuals to receive at least one vaccination to access a service or be employable, with penalties in case of noncompliance (20). policies regarding the introduction of mandatory vaccinations for hcws are seen as controversial in europe and met with strong resistance by working unions [21]. vaccination hesitancy results from concerns on the effectiveness and safety of vaccines, combined with other contextual influences like religious beliefs [22]. however, when it comes to mandatory vaccinations for hcws, it de bruin, j.; machado, m.; nabbe, m.; saccà, r.; verhoeven, j.; clemes, t. increasing influenza vaccination rates among healthcare workers by focusing on workplace and patient safety. (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4683 p a g e 6 | 10 seems that the debate revolves around ethical issues more than practical ones [23]. given the difficulties related to the implementation of mandatory vaccinations among hcws and the main benefits of the procedure stemming from the protection of vulnerable patients [23], mandatory vaccination policy, in europe, is largely reserved to hcws which operate in elderly homes or high-risk hospital wards where they are constantly in close contact with vulnerable patients. this collective of vulnerable individuals includes people that are immunocompromised, immunosuppressed or have other medical conditions that result in seasonal influenza becoming a sizable threat to their health [24]. mandatory vaccination policies are not common in europe. however, in the united states, these policies have already been implemented in hospitals and other medical entities with success since 2004 [25]. indeed, the vaccination rates among hcws were low before the policy implementation [26]. the mandatory vaccination policy achieved coverage of 98% among 5000 employees [27]. however, this applied in private settings which are not that common in europe, which makes the transferability of the policy to the european territory difficult [28]. moreover, trying to implement mandatory vaccination in europe may be perceived as a coercive power that would undermine its effects. recommendations the purpose of this policy brief is to encourage the coalition for vaccination to prolong their work on vaccine hesitancy among hcws. to respond to the latter, it is advised to implement an information campaign on workplace and patient safety. to do so, several aspects need to be considered. creating a sense of urgency for the improvement of influenza vaccination uptake is essential. based on the considered policy options above, it is recommended to implement the campaign focusing on the safety pillar. mandatory vaccination was excluded from the implementation process as it can be seen as a coercive power, which creates a negative connotation. furthermore, targeting the campaign specifically on trust or knowledge needs to be tailored to specific environments, whereas the safety pillar will have a broader effect on all hcws. focusing on safety will strike the most result in the first stage of the information campaign because hcws have their patient’s health at heart. they take an oath when becoming a doctor and swear that they will care for the sick, promote good health and alleviate pain and suffering [29]. hence, appealing to the area of safety will gain the most result in improving vaccination rates. it is essential to address patient safety, as well as workplace safety, when implementing the information campaign. addressing patient safety underlines the hcws awareness of their obligation to promote good health. when hcws decide to take the influenza vaccine, their positive stance towards the vaccine might spill over to their patients. a patient usually trusts the doctor and, therefore, relies on the doctor’s opinion on the necessity to receive the influenza vaccine. additionally, it is important to focus on workplace safety and the protection of colleagues. hcws who have influenza with only minor symptoms might still infect colleagues which could lead to an increase in absenteeism. the best timing for initiation of the information campaign on influenza vaccination is in september and october, just before the start of the vaccination program. this timing appeals to a sense of urgency and concern for the professionals as the influenza season will be around the corner. it is essential to differentiate between big and small healthcare entities during the implementation of the infor de bruin, j.; machado, m.; nabbe, m.; saccà, r.; verhoeven, j.; clemes, t. increasing influenza vaccination rates among healthcare workers by focusing on workplace and patient safety. (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4683 p a g e 7 | 10 -mation campaign (figure 1). figure 1. approach for spreading the information campaign the campaigns in the big structures, such as hospitals, should be driven by employers. practically, it is recommended to perform small information campaigns inside the buildings and hence have a campaign closer to the professionals. videos or posters can be presented in departments, waiting rooms or coffee places to encourage the discussion between people on influenza vaccination and safety. universities also need to be targeted and medical students are encouraged to spread the campaign to their teachers during their practical internships. furthermore, flyers are provided with a more extensive explanation of the problem on low influenza vaccine uptake and reasons why hcws should become vaccinated. in the small structures, the information campaign targets hcws such as general practitioners, dentists or pharmacists. here, the campaign relies mostly on giving these hcws access to the information in different ways such as providing them with posters and flyers. furthermore, the information campaign will spread further when medical students are doing internships at smaller practices. in addition to the information campaigns in big and small structures, it is important to take a structural approach to increase influenza vaccine uptake amongst hcws. this means that, for example, time slots for vaccination should be organized in the workplace as often as possible to facilitate access to the vaccine. to increase the visibility of the information campaign, the national and local members of the institutions taking part in the coalition for vaccination are encouraged to develop partnerships with, for example, medical journals to further spread the. de bruin, j.; machado, m.; nabbe, m.; saccà, r.; verhoeven, j.; clemes, t. increasing influenza vaccination rates among healthcare workers by focusing on workplace and patient safety. (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4683 p a g e 8 | 10 indeed, the reading of medical papers is part of the daily practice of hcws. therefore, it creates awareness of the problem of low vaccination uptake and the reasons why hcw should become vaccinated. this might encourage non-vaccinated hcws to get the influenza vaccine. the members of the coalition for vaccination are encouraged to spread the information as much as possible throughout the countries of their members, by the newsletter for example, and to provide it in the national languages. it is important to plan the time to translate the information in different languages before the start of the campaign. a reference to the english version of the campaign should also be kept available for people who want to check out the official source and to prevent misunderstandings due to the translation. regarding the financing of the campaign, funds are to be requested from the european union. national health institutes or organizations are also encouraged to take part in the funding. furthermore, the coalition for vaccination is asked to help spread the campaign by all means amongst its members and contribute financially if possible. finally, the big and small structures such as hospitals and general practitioners might contribute according to their available capacities. conclusion it is advised to combine a structural and holistic approach in the implementation of information campaigns to address vaccine hesitant hcws. although the main focal point of the information campaign must be patient safety, workplace safety should not be disregarded. furthermore, a structural approach is to be taken to increase access to vaccination at the workplace. the recommended information campaign to address vaccine hesitancy among hcws not only applies to the influenza vaccine but can also be implemented for other vaccine preventable diseases or in other situations. decreasing, for example, the number of vaccine hesitant hcws in the current covid-19 pandemic can be achieved by creating more awareness of hcws’ patientand workplace safety. hence, they can be persuaded or encouraged to become vaccinated. lessons from the covid-19 pandemic regarding the acceptance and the uptake of the vaccine should also be taken into account for the influenza vaccine. addressing hcws by referring to their patients’ safety, as well as their own safety, influences their role as leaders in an emotionally intelligent process. by combining these approaches, it is aimed to create more debate on vaccine hesitancy, and it is expected to result in a positive change in hcws’ attitudes towards vaccination. references 1. pichon m, gaymard a, zamolo h, bazire c, valette m, sarkozy f, et al. web-based analysis of adherence to influenza vaccination among french healthcare workers. j clin virol. 2019;116:29-33. 2. grech v, borg m, gauci c, barbara c, attard-montalto s, agius s, et al. needed: less influenza vaccine hesitancy and less presenteeism among health care workers in the covid19 era. early hum dev. 2020:105215. 3. organisation wh. how to implement seasonal influenza vaccination of healtworkers 2019. available from:https://apps.who.int/iris/bitstream/handle/10665/325906/9789241515597eng.pdf. de bruin, j.; machado, m.; nabbe, m.; saccà, r.; verhoeven, j.; clemes, t. increasing influenza vaccination rates among healthcare workers by focusing on workplace and patient safety. 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(http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. jeffrey levett, steer clear of red herrings: grant v mahler hygiene’s philosophical advice to the world health assembly. south eastern european journal of public health 2023. posted: 25-05-2023, vol. xx page 1 commentary steer clear of red herrings: grant v mahler hygiene’s philosophical advice to the world health assembly jeffrey levett professor, public health & health diplomacy, honorary president, world philosophical forum, athens, greece corresponding author: professor jeffrey levett, address: international gusi peace prize laureate professor, public health & health diplomacy, honorary president, world philosophical forum athens, greece e-mail: jeffrey.levett@gmail.com jeffrey levett, steer clear of red herrings: grant v mahler hygiene’s philosophical advice to the world health assembly. south eastern european journal of public health 2023. posted: 25-05-2023, vol. xx page 2 background dear participant of the 76th world health assembly, may 2023 i greet you on behalf of the world philosophical forum, athens (cc to the 78th un general assembly october 2023) while taking the opportunity to call on the good offices of the international community to better direct thought and support to deal with existential problems and to restate our expressed views that applied philosophy can modulate behavior and influence actions to slow down the ongoing unraveling of complex biological systems that prop up human consciousness, bring pause to the precipitation of a nuclear big bang and provide insight into the problem space of a technologically manipulated future of limited freewill through artificial intelligence. vietnam's "golden bridge" in ba na hills as our world becomes more digital and more divided it becomes much more about if you are not with us, then you are against us with solidarity having less of a chance than obfuscation to win out. without philosophy we risk finding ourselves tomorrow of being no longer in the state of who we are or think we are, or who we are assumed to be or declared to be, but who-what we are translated to be by ai. until philosophy is consistently tried we cannot say that man and his institutions are incapable of finding a new way for humanity. in this the year of the 76th general assembly of the world health organization we are too dangerously close to hell to know it! the world health organization consistently points to a coming avalanche of mental health jeffrey levett, steer clear of red herrings: grant v mahler hygiene’s philosophical advice to the world health assembly. south eastern european journal of public health 2023. posted: 25-05-2023, vol. xx page 3 problems but fails to use health and philosophy in any executive capacity. philosophy is a vehicle that can take us to a more reasonable world; a passport to reason and to wisdom may be just a universal philosophical tweak away. without doubt, it is central to global governance for hand in hand world peace, and global health. the wit of dag hammarskjold is worth recalling when he said that the united nations was not created to take the man to heaven but to save humanity from hell on earth. that task now falls on your shoulders. 75 world health assemblies ago the president of the first world health assembly, 1948 andrija štampar saw the world health organization as an instrument to solve global health problems in a spirit of true international cooperation. although the drafting of the constitution took place in a mood of optimistic confidence he was aware of the darker shadows of our world. he understood that global health was in need of nurture and good governance. he fought quackery, condemned governments in the hands of gangsters and his metaphor for disease [malaria] was it transforms land into cemeteries, a form of balkan banditry. exiled in china, 1931, andrija štampar told the chinese authorities guns and cannons cannot solve social problems. those darker shadows prevail and have given rise to a dire description of the un secretary general of humanity on the brink (or at armageddon’s gate) in his recent briefing to the general assembly, 6 february 2023. he warned of a confluence of challenges unlike any other seen in our lifetimes with epic geopolitical divisions undermining global solidarity and trust and war as the deadest of ends and the antithesis of development, except for the arms industry. nowhere however, did the secretary-general turn to philosophy as did his predecessor but all too temporarily. philosophy can add transparency to a world health organization seen by many as an opaque system and more serious with critics who rate it as a failure or charge it with orchestrating an impending power grab that will remove basic rights and bring about a massive population reduction. philosophy can add wise critique to the salespersons of any and all new world orders; black rock, international monetary fund’s pandemic preparedness push, the great reset and world economic forum, geneva, moscow’s noosphere and the great freeset. to jeffrey levett, steer clear of red herrings: grant v mahler hygiene’s philosophical advice to the world health assembly. south eastern european journal of public health 2023. posted: 25-05-2023, vol. xx page 4 maintain focus and foster trust we suggest that urgency be reduced in order to take further stock and maintain focus. as science is slandered and inadequately supported it is painfully easy to feel the heat of an apocalypse on our doorstep or to imagine mankind returned to the stone age by a nuclear mishap or slowly convulsed by climate change during our children’s and children’s children life time. fortunately, we remain enchanted with the magical buds of may and i want to think that your hands will come up full from positive deliberations of the 76th world health assembly. dear participant, the 76th world health assembly comes at a time of so called reset, great and less great and at the time of war in the ukraine; far from resolution, distanced from global health and universal peace. during the assembly you will be voting on new regulations for international health (ihr) and on a pandemic treaty that begs many questions. to quote my colleague fidel gutierrez vivanco: peace is a desire of humanity; even war he says is the search for peace along the wrong path and is dependent on the resilient autonomy of extremely complex systems. prevention as in public health like peace is easily impeded-prevented. in western health sectors it is pushed aside by much needed clinical medicine and side stepped by philanthropists. with respect to war glen martin asks what do future generations matter when weapons corporations rake in billions in profits. however prevention may remain a pipe dream if our lead is taken from capitol hill when once upon a time two prestigious scientists testified on the issue of prevention of disease and the promotion of health. the entry of denton cooley into the chamber caused a stampede of senators to touch the great heart surgeon’s white coat while d.a. henderson, the man, who through smallpox eradication saved millions of lives sat ignored. henderson’s proposal to develop a network of health promoting and disease preventing institutions never made it to implementation. the secretary of health correctly and ironically said that prevention is being promoted by spending as little as possible. we endorse wholeheartedly the international community’s aim that everyone should have the right to life, liberty, happiness and personal security and believe that such a humanitarian cause can be well served by jeffrey levett, steer clear of red herrings: grant v mahler hygiene’s philosophical advice to the world health assembly. south eastern european journal of public health 2023. posted: 25-05-2023, vol. xx page 5 philosophy. on the ground and once again we suggest that the appointment of classical philosophers to controversial and complex peace and health activities can help pave a practical way out of our socially demented world. as you congregate in geneva (may) threatened with instantaneous and slow burn extinction we do say yes to: health for all and saving lives as well as yes to: peace and security and the re-admittance of abandoned philosophy to the halls of the international community. we do say keep going but do better! at this the time of christ’s ascension into heaven we must not draw comfort from his words on the cross forgive them for they know not what they do because the despoilers of our planet and the makers of war know very well what they are doing and should be stopped! we ask for a deliberate but necessary return to the agenda of the united nations and the ideas of ban ki-moon in his education first initiative and with added incentives for global citizenship and the revitalization of unesco’s programmer for the widespread study of philosophical knowledge and for you to reconsider and improve upon the coalescence of public health and disaster management as suggested by gro brutland. on the ground and once again world philosophical forum, athens, moscow, kuala lumpur, manila, lima we urge the appointment of classical philosophers to controversial and complex activities within the international community in our confident belief that philosophy will help pave a practical way out of our socially demented world and remind all participants in the world health assembly that the world health organization has miles to go and promises to keep. we hope that inspired by peitho you will apply such leadership that all current world orders will change their mindset to support a revitalization of empathic and creative humanity and health for all during the 76th world health assembly as well as make a major breakthrough to peace. __________________________________________________________________________ © 2023 jeffrey levett; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. burazeri g, laaser u. health status of the populations in the western balkans region (editorial). seejph 2021, posted: 11 march 2021. doi: 10.11576/seejph-4232 p a g e 1 | 3 editorial health status of the populations in the western balkans region genc burazeri1,2, ulrich laaser3 1 department of public health, faculty of medicine, university of medicine, tirana, albania; 2 department of international health, school caphri (care and public health research institute), maastricht university, maastricht, the netherlands; 3 section of international health, faulty of health sciences, university of bielefeld, bielefeld, germany. corresponding author: genc burazeri, university of medicine, tirana; address: rr. “dibres”, no. 371, tirana, albania; telephone: 00355674077260; email: genc.burazeri@maastrichtuniversity.nl burazeri g, laaser u. health status of the populations in the western balkans region (editorial). seejph 2021, posted: 11 march 2021. doi: 10.11576/seejph-4232 p a g e 2 | 3 for more than twenty years by now, the countries of the western balkans have enjoyed peace after a terrifying warfare in the nineties of the last century. it is time to look at the progress made since. all countries in the western balkans region are undergoing deep reforms aiming at accession to the european union (eu) which is a priority and a key policy driver for all sectors. albania, north macedonia, montenegro, and serbia are currently candidate countries (1). conversely, bosnia and herzegovina and kosovo are potential candidate countries with a prospect for eu accession in the future (1). regarding the health domain, countries report on acquis, which includes a chapter on consumer and health protection (2,3). the eu commission monitors these criteria in line with the administrative capacities of each country in their respective stages of the accession process (4). health status of the populations in the western balkans region is characterized by an excessive mortality compared with the eu average (5). life expectancy in the western balkan countries ranges from 76.3 years in serbia (the lowest) to 77.3 years in bosnia and herzegovina (the highest), whereas the average value in the eu countries in 2017 was 80.9 years (5). according to the global burden of disease (gbd) estimates (6), the age-standardized all-cause mortality rate in albania in 2019 was the lowest in the balkans region (about 575 deaths per 100,000 population), whereas in north macedonia it was the highest (around 929 deaths per 100,000 population). however, the overall mortality rates have declined steadily in all balkan countries in the past decade (figure 1). figure 1. age-standardized all-cause mortality rate (deaths per 100,000 population) in the western balkan countries in the past three decades [source: institute for health metrics and evaluation http://ghdx.healthdata.org/gbd-results-tool (6)] the vast majority of mortality is due to noncommunicable diseases (ncds), which explain from 93% of all deaths in albania (the lowest ncd share) to more than 95% in serbia (the highest) (6). age-standardized mortality rate due to cardiovascular diseases in albania bosnia-herzegovina montenegro serbia north macedonia http://ghdx.healthdata.org/gbd-results-tool burazeri g, laaser u. health status of the populations in the western balkans region (editorial). seejph 2021, posted: 11 march 2021. doi: 10.11576/seejph-4232 p a g e 3 | 3 © 2021 burazeri et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 2019 was the lowest in albania (estimated at 314 deaths per 100,000 population) and the highest in north macedonia (569 per 100,000 population) (6). for the same year, the age-standardized mortality rate due to neoplasms was the lowest in albania (113 deaths per 100,000 population) and the highest in serbia (184 per 100,000 population) (6). on the other hand, the age-standardized mortality rate from diabetes in 2019 was estimated at only 4 deaths per 100,000 in albania (the lowest in the region), but more than 38 deaths per 100,000 population in bosnia and herzegovina (the highest) (6). regarding the universal health coverage (uhc) index reported by the world health organization (who), the service coverage index in 2017 ranged from 59 in albania (the lowest in the region) to 72 in north macedonia (the highest) (5). however, the coronavirus disease (covid19) pandemic has undermined the health systems and uhc reforms in all countries of the western balkans region, similar to the rest of the world. the excessive mortality and morbidity associated with covid-19 in the past year has highlighted the lack of preparedness of most of health systems in the region, influencing rather negatively the achievement of the sustainable development goal for health (sdg 3) (5). there is an urgent need to increase investments in order to strengthen health systems and improve the service coverage in all countries of the western balkans to face the current health challenges imposed by the ongoing corona crisis. references 1. european commission. candidate countries and potential candidates. https://ec.europa.eu/environment/enlarg/candidates.htm#:~:text=albania%2c%20the%20republic%20of%20north,possible%20request%20for%20transition%20periods (accessed: february 26, 2021). 2. mckee m, maclehose l and nolte e. health policy and european union enlargement. open university press; 2004. 3. grabbe h. european union conditionality and the acquis communautaire. int polit sci rev 2002;23:24968. 4. copeland n. the european union accession procedure; 2013. https://www.europarl.europa.eu/regdata/bibliotheque/briefing/2013/130437/ldm_bri(2013)1 30437_rev3_en.pdf (accessed: february 26, 2021). 5. world health organization. world health statistics 2020: monitoring health for the sdgs, sustainable development goals. geneva: world health organization; 2020. https://apps.who.int/iris/bitstream/handle/10665/332070/9789240005105eng.pdf (accessed: february 26, 2021). 6. institute for health metrics and evaluation (ihme). global burden of disease estimates. http://ghdx.healthdata.org/gbd-results-tool (accessed: february 26, 2021). ____________________________________________________________________________ http://ghdx.healthdata.org/gbd-results-tool http://ghdx.healthdata.org/gbd-results-tool fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 1 | 15 original research voluntary blood donation promotion in haute matsiatra region of madagascar jocia fenomanana1, heritiana gisèle ramaminiaina1, fidiniaina mamy randriatsarafara2, zely arivelo randriamanantany3 1service laboratoire chu andrainjato fianarantsoa 301 madagascar; 2département de santé publique université d’antananarivo ; 3direction de la transfusion sanguine tananarive madagascar and direction générale de fourniture des soins ministère de la santé publique madagascar ; corresponding author: jocia fenomanana; address: service laboratoire chu andrainjato fianarantsoa 301 madagascar ; e-mail: jfenomanana@yahoo.fr mailto:jfenomanana@yahoo.fr fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 2 | 15 abstract aims: access to sufficient, secure supplies of blood and safe transfusion services is an essential part of any strong health system. the haute matsiatra region has a need for blood and blood products that exceeds current availability (only 7% of needs are met). the aim of this study ls to assess community knowledge, attitude, and practice regarding voluntary blood donation in order to identify the obstacles. methods: we have conducted a community-based cross-sectional study from 26th to 31th july 2019 within a sample of 300 subjects using a structured questionnaire and face-to-face interview. data were analyzed using r software version 4.0.2. results: all participants were unanimous about vital role of blood so that 62.3% were willing to donate blood but only 13% have ever donated blood. the majority of respondents (60.0%) had never heard sensitization about blood donation. the reason for non-donation were related to fears of needlestick injuries during the blood collect (38.3%), fear of blood borne diseases (17%), the lack of sensitization (6%). there was a positive significant relationship between level of education and willingness to donate blood (p-value <0, 05). the likelihood of blood donation was found to be higher among male participant 28 (71.8%) p<0.05, and among >45 years group (21.4 %) p= 0.03. among those who ever donated blood, only 37 (26.6%) of them have received sensitization about donation. conclusion: there is growing interest in blood donation among the population. activities to promote blood volunteer donation should take into account the demotivating reasons for blood donation. source of funding : none conflict of interest statement: the authors report no conflicts of interest in this work. authors’ contributions : all authors contributed toward data analysis, drafting and critically revising the paper and agree to be accountable for all aspects of the work. acknowledgments : we thank all those who, directly or indirectly, have contributed to this publication. fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 3 | 15 introduction access to sufficient, secure supplies of blood and safe transfusion services is an essential part of any strong health system (1). blood transfusions contribute for saving patients whose lives are at risk. they can help patients who have a life-threatening disease, complications during pregnancy and childbirth, severe trauma, surgical procedures. they are also regularly used for patients with hematologic disease such as sickle cell disease, thalassemia and hemophilia (2). despite advanced research, there is currently no substitute for human blood (3). according to the world health organization (who), about 118.5 million blood donations are collected around the world, in which 40% are collected in high-income countries, home to 16% of the world’s population (4). unpaid voluntary donors have the lowest rates of transfusion-associated infections and are the ideal population from which to recruit donors as bloods are given for genuine altruistic reasons. voluntary donors do not have any reason to give false information about lifestyle factors which might place them at risk of transmitting infectious agents. there is therefore a reduced risk of obtaining blood during the 'window' period of hiv infection (5). the who’s goal is to obtain for each country all their respective blood supplies through voluntary unpaid donors, in accordance with the art 28.72 of world health assembly adopted resolution in 1975 (6). in madagascar, the blood donation rate in 2013 was 1.0 unit per 1000 inhabitants. among all donors, only 18.6% are voluntary non remunerated (7). the region of haute matsiatra, in particular, has a need for blood and blood products that exceeds current availability (only 7 % of needs are met). the voluntary blood donor insufficiency is a major challenge in this area even if information about donation is offered regularly (16.41% in 2019: haute matsiatra region blood bank, unpublished data, 2019). replacement blood donors recruited by families are the major source of blood in this region. this situation contributes to the persistent high mortality rates associated with potentially reversible conditions such as haemorrhage and anaemia. factors affecting blood donation often vary in various populations (8) (9). therefore, better understanding on the level of community knowledge, attitude, and the practice of donors may help to strengthen the blood donation program in this area. in order to identify obstacles to blood donation among the population of haute matsiatra region, we have conducted a preliminary survey that aim to assess knowledge, attitude, and practice towards blood donation and its associated factors. methods we implemented a cross-sectional community-based study in the haute matsiatra region. haute matsiatra is located at 400km from the capital city of madagascar. based on malagasy population and housing census 2019 estimation, the total population of this region was estimated 1 447 296 inhabitants, 189 879 of which are urban populations (10). multi-stage sampling technique was used to in order to recruit the study participants. on the first stage, 6 fokontany (equivalent of village) were selected from the total of 50 of the region by lottery method. we used then a systematic random sampling technique to select 50 households per fokontany. to select one study participant per household we employed a lottery method. study population: all adults aged 18 65 years residing in haute matsiatra region were the source population. they were selected by multi-stage sampling technique and lived in the study area for at least six months fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 4 | 15 were included. sample size determination: we calculated the sample size with a single population proportion formula using 95 % ci and 5 % margin of error. the sample size was found to be n=300 after considering a 1.69 % non-response rate. data processing and analysis: malagasy structured questionnaire was used to collect the data at each selected household. the tools were developed after reviewing of relevant literatures and adapted to the context of the study area (11). information on the sociodemographic characteristics (15 questions), knowledge (9 questions), attitude (17 questions), and practice-related questions (12 questions) on blood donation were included. then, separated face to face interview from questionnaire data were entered into r software version 4.0.2 for univariate and multivariate analysis. ethical considerations: the study was approved by an ethics committee. written informed consent was obtained from all the study participants. they were adequately preinformed of the aim and the implication of the study and were told about their right to refuse or withdraw their verbal consent to participate in the research. confidentiality of information was kept including omitting personal identifiers such as the name of the respondent. results sociodemographic characteristics: from the calculated 305 sample size, 5 subjects recruited was not related to the sample size, 300 participants were involved in the study. a total of 122 (40.7%) participants were in the age group of 18-25 years, more than half 167 (55.7%) were females and 175 (58.3%) were married (table 1). table 1: sociodemographic characteristics of the study participants (n=300) variables frequency n=300 percentage (%) age group in years 18-25) 122 40,7 26-35) 82 27,3 36-45) 40 13,3 > 45 56 18,7 gender female 167 55.7 male 133 44.3 marital status married 175 58,3 single 104 34,7 separated 11 3,7 widowed 10 3,3 religion christian 298 99.3 other 2 0.7 fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 5 | 15 *tertiary sector: commerce, administration, transport, financial and real estate activities, business and personal services, education, health and social work knowledge about voluntary blood donation the majority of respondents 180 (60.0%) had never heard sensitization about blood donation. mass media was the main source of information of 186 (62.7%) participants. among the 300 study participants, 263 (87.7%) were affirmed that blood transfusion “can save life”. only 13 (4.4%) study participants had the right answers concerning minimum criteria for blood donation (age 18-65 years, weight above 45kg, basic good health). two hundred eighty-seven (95.7%) participants replied that hospital is the only site of blood collection. digestive hemorrhage, anemia, accident were the main cited indications of blood transfusion, 69 (23%) participants didn’t have any idea. two hundred and ten participants (70.0%) replied that donating blood advantages were “to save life”, “to benefit from free analysis”12 (4.0%), “to earn money”6 (2%). cited disadvantages were 55 (18.4%) “fear of degraded health after donation”, 6 (2.0%) “fear of acquired diseases”, 4 (1.3%) “fear of bloodborne disease”, 3 (1.0%) “fear of anemia”, 1 (0.3%) “fear of sudden death after donation” (table 2). table 2: knowledge about voluntary blood donation (n=300) variables frequency n=300 percentage (%) main cited indications of blood donation digestive hemorrage 96 32.0 anemia 53 17.7 bleeding 44 14.7 accident injuries 17 5.6 delivery 9 3.0 surgical intervention 12 4.0 do not have any idea 69 23.0 main cited advantages of blood donation educational status illiterate 15 5 elementary education 101 33.7 secondary education 111 37.0 graduated education 73 24.3 occupation sector primary 152 50.7 secundary 37 12.3 tertiary* 111 37.0 fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 6 | 15 satisfaction saving life 210 70.0 to ameliorate health 47 15.7 benefit from free analysis 12 4.0 to earn money 6 2.0 no advantages 25 8.3 main cited disadvantages of blood donation degraded health after donation 55 18.4 risk of acquired diseases 6 2.0 blood born infections 4 1.3 anemia 3 1.0 sudden death after donation 1 0.3 no disadvantages 214 71.3 do not have any idea 17 5.7 attitude toward voluntary blood donation among respondents, 153 (51%) of them approve of voluntary blood donation but only 49 (16.3%) showed their willingness to donate blood in the future if needed (table 3). the likelihood of favorable attitudes towards blood donation was higher among male gender (36.3% p<0.05), those who attended secondary school (28 % p<0.005). media user had higher chance of having favorable attitude compared to other source of information user (42% p<0.05). about 34.3% of those who had previous sensitization had favorable attitude towards blood donation (table 4). table 3: study participants’ attitude toward voluntary blood donation (n=300) variables frequency n=300 percentage (%) do you approuve of voluntary blood donation? approve 153 51.0 strongly approve 111 37.0 disapprove 18 6.0 i do not know 18 6.0 have you ever been sollicited for blood donation ? yes 49 16.3 no 251 83.7 are you motivated to donate blood for a relative if there is need? yes 243 81.0 no 57 19.0 what reasons could motivate you to blood donation ? fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 7 | 15 to benefif from free blood tests 121 40.3 fear of not receiving blood when need 88 29.3 to earn money 65 21.7 to save life 17 5.7 for the maintenance of good health 9 3.0 table 4: factors associated with the attitudes towards blood donation among participants (n=300) variables attitude to donate blood pvalue favorable % unfavorable % age 0.02 18-25) 88 29.33 34 11.34 26-35) 48 16.00 34 11.34 36-45) 20 6.66 20 6.66 > 45 ans 31 10.34 25 8.33 gender 0.29 male 109 36.33 58 19.33 female 78 26.00 55 18.34 occupation sector 0.00 primary 67 22.33 85 28.34 secundary 31 10.33 6 2.00 tertiary 89 29.66 22 7.34 marital status 0.00 married 90 30.00 85 28.34 single 83 27.67 21 7.00 widowed 8 2.67 2 0.66 separated 6 2.00 5 1.66 educational status 0.00 illiterate 2 0.66 13 4.34 elementary education 35 11.66 66 22.00 secondary education 84 28.00 27 9.00 undergraduate education 66 22.00 7 2.34 source of information 0.00 media 126 42.00 60 20.00 medecin 33 11.00 4 1.34 community worker 19 6.33 37 12.34 fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 8 | 15 friends 5 1.66 5 1.66 other 4 1.33 7 2.34 previous sensitization 0.00 yes 103 34.33 36 12.00 no 84 28.00 77 25.67 the mainly cited barriers for blood donation related to fears of needlestick injuries during the blood collect (38.3%), fear of blood-born diseases (17%), and lack of sensitization (6%) (figure 1). figure 1: main cited barriers for blood donation (n=300) practice of blood donation and its associated factors total number of participants who have already practiced blood donation was 39 (13 %) from which 22 (56.4 %), 11 (28.2 %), 3 (3%) and 3 (7.7%) have donated respectively once, two, three and more than 3 times. the reasons for donation were to save relative’s life 22 (56.4 %), moral duty 7(17.9 %), due to efficient sensitization 6 (15.4 %), to save other peoples’ lives 4 (10.3%). overall, the majority were satisfied with the blood collection session, 6 among 39 felt not reassured. significant factors associated to blood donation was age group >35 years (41.4 %): p= 0.02, male gender, marital status (married status has positive influence). participants having secondary school level education were more likely (22/39) to donate blood compared to those who have a high degree education: p=0.04. among those who ever donated blood, majority 37 (34.3%) of them have received general sensitization before donation: p0.02 (table 5). 0 5 10 15 20 25 30 35 40 percentage… fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 9 | 15 table 5: factors associated with practice of blood donation among participants. (n=300) variables have already donated blood pvalue yes % no % age 0.03 18-25) 9 7.4 113 92.6 26-35) 10 12.2 72 87.8 36-45) 8 20.0 32 80 > 45 ans 12 21.4 44 78.6 gender 0.0004 male 28 21.1 105 78.9 female 11 6.60 156 93.4 marital status 0.07 married 27 15.4 148 84.6 single 8 7.7 96 92.3 widowed 3 30 7 70 separated 1 9.1 10 90.9 educationalstatus 0.04 illiterate 0 0 15 100 elementary education 10 9.9 91 90.1 secondary education 22 19.8 89 80.2 undergraduate education 7 9.6 66 90.4 source of information 0.01 media 29 15.6 157 84.4 medecin 3 8.1 34 91.9 communityworker 5 8.9 51 91.11 friends 0 0 10 100 others 0 0 11 100 previous sensitization 0.02 yes 37 34.3 102 65.7 no 2 28.00 159 72 discussion in this study, the overall level of knowledge (about minimum criteria for blood donation) towards blood donation was found to be much lower than a community based study conducted in the debre markos town of ethiopia (56.5%) (12), in the city of mekelle (49 %) (13), and another study, conducted among fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 10 | 15 students of health science in addis ababa (83 %)(14). the difference in socio-economic status and in educational status of population might explain the discrepancy with the above findings. this is possible, ‘because more educated people might be in a better position to access the media and availability of awareness creation at primary and secondary school and higher educational institutions’ (12). moreover, the majority of respondents had never heard any sensitization about blood donation before the study. partly, this might be explained by the limitations of awareness campaigns on addressing the intended goals. in addition to individual factors, the characteristics of the collection site fixed or mobile are important in explaining variation in donor behavior. satisfaction with the blood bank opening hours, collection site type, the traveled distance to the medical examination site and blood collection, represent important clues for blood bank policies and interventions to improve donor motivation (15). television and the internet are the most effective tools for promotion and recruitment for blood donation in guangzhou china (16). social media have become the second most important motivation reason to recruit voluntary donor beside relatives and friends. in the study area, facebook is the preferred social media to transmit and receive information about the blood donation process, however, access to internet is still limited compared with mass media and is not used sufficiently for awareness campaigns. for repeat donors, experience of the last donation process plays a key role, the more it is positive, the more it is motivating for the future (17). some participants are scared of what they regard as side effects of blood donation. as per a nigerian study, 36·1% of university graduated donors believe that they can contract human immunodeficiency virus (hiv) and/or hepatitis infection from blood donation (18). it highlights the fact that knowledge of blood donation is an essential prerequisite before voluntary blood donation, and it is an important tool for avoiding fear and building positive attitude. creating awareness on the general public regarding hiv, hbsag and hcv transmission and prevention should be strengthened (19). the overall intention of respondents to donate blood voluntarily can be due to the malagasy culture (the “fihavanana”) of sustaining social relationships and being generous to help anytime anywhere. the findings of this study are consistent with studies across the world, which found overall positive attitudes towards blood donation among respondents(20), (21), (14), (22), (23). findings were lower in other studies conducted in karachi (42%) (23), mekelle (61 %) (13) and addis ababa (68 %) due to cultural differences (14). regarding factors affecting blood donation, a range of socio-demographic, organizational, physiological and psychological may influence people's willingness to donate blood (24). in the current study, factor significantly associated to favorable attitude for blood donation were age group, male gender, media and previous sensitization. young participants were indeed significantly associated with favorable attitude for voluntary blood donation. this could be due to a large proportion of young adult’s state that they are able and willing to donate blood compared with elder one (25). it was also noted that male gender was significantly favorable to blood donation compared with female which is consistent with overall studies across the world (26). this could be in congruent to cultural belief that male is better and stronger to take responsibility than female. also, women have to face many different temporary restrictions for blood donation because of the menstrual cycle or lactation period (27, 28). herein, most of donors were satisfied with previous blood collection expe fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 11 | 15 rience and felt reassured. personal blood-donation experience (quality of donor reception, pleasant medical staff, good atmosphere during donation, organization of blood collecting and processing facilities, perceived physical, psychological and social impact) was indeed cited as a significant predictor of behavioral intentions to donate blood. in fact, occurrence of positive experience may make blood donation less frightening and perhaps even attractive. one of the most important incentive for being a donor was also the direct approach by another donor (29). concerning the frequently cited motivation for blood donation, altruism was not highlighted for males compared with females, but was combined with 'warm glow' in novice males (30). in a sample of primary healthcare users in a brazilian municipality, fear of blood, vasovagal reactions, and lack of knowledge regarding the donation process were revealed as important barriers to the decision to donate blood (26). the study showed that some of the participants had a history of blood donation which are not permanent as of now. people donate when there is a need related to family member, not because there is need of safe blood in the community. that could be due to the lack of social marketing toward blood donation and periodic sensitization in the study area. according to the study results, the greatest barrier that prevents people from donating blood were fear of needles, degraded health, physical weakness, bloodborne disease, lack of sensitization. while lack of time and fear of blood donation were the main barriers in saudi arabia and some developing countries (30). the findings of this study were different to those barriers reported in gangzhou china which was self‐ perception of poor health (33·1%) (16). in a brazilian study, fear of blood, injections or vasovagal reactions, and a lack of knowledge of the donation process were revealed as important barriers to the decision to donate blood (28). in a qualitative investigation of indian non-donors living in england, lack of awareness and accessibility were prominent barriers; in contrast, there was a strong preference for donated blood to be distributed within the family, as opposed to unknown recipients (30). globally, ‘the greatest barrier that prevents people from donating is a lack of convenience and a lack of knowledge of the importance of donating’ (5, 8). it suggests that an intensive blood donation campaign should be promoted. this would allow people to be well informed, changing the positive attitude of saving life through blood donation to a regular practice. recommendations it is vital to consider, in the light of the predicted shortages in blood supply, methods to maximize donation rates. as per who criteria, availability of blood in a country for transfusion should be indicated by 10 blood donations at least per 1000 population (4). in madagascar, the number of whole blood donations per 1000 population was less than 5 which remains too low to cover the blood requirements. donations by repeat voluntary non-remunerated blood donor is 13% (4). promotion of blood voluntary donation should take into account the demotivating reasons for blood donation which calls governmental commitment and required the need to improve research evidence in this area of practice. particularly, the existence of a data collection and reporting system is an important element of a well-managed nationally coordinated blood transfusion programme. adequate national data on blood availability and safety allow the area to set priorities and to further strengthen the blood system. it would be suitable to readjust the strategies for implementing the national blood transfusion policy based on the results of the target population survey. it is then necessary to convince non-donors and retain regular volunteer fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 12 | 15 donors. consequently, we suggest the following changes: awareness campaigns should focus on strategies to unlock obstacles to donation and insisting on common misconceptions about blood (the belief to a high risk to get infected through the process of donation, blood banks sell donated blood to patients, blood donation believed to cause physical weakness). some information has to be clarified (the donation process does not spend more than one hours, menstruation is just a temporary contraindication of blood donation). number of mobile collections should be increased to be closer to volunteers (lack of time is sometimes cited as obstacle). use of radio spots, tv spots, telephone messages, leaflets, the press or banners on the internet, can serve as very good advertising media. guarantee an excellent reception and collection session to avoid negative perception about blood donation process promotion of research in the field of «knowledge, attitude and practice towards blood donation », « donor sources of motivation », « blood donation experience ». in fact, having an adequate data on blood availability, safety and a feed-back from donors allow the area to set priorities and to further strengthen the regional blood system. training of medical staff (quality of reception, humanization of care, confidence in donors) implementation of educational programs in terms of educational sessions, media presentations, brochures distribution, and raising awareness of students on blood donation in haute matsiatra region. conclusion the study shows positive attitudes and a great interest in blood donation in the haute matsiatra region. it has been identified that fear is the most significant barrier to blood donation among the area population. these findings can be a baseline for health care professionals and may contribute to develop an educational platform on blood donation at national levels. references 1. y. abdella, a. a. pourfathollah, h. slama, et m. raouf, « the role of access to affordable and quality assured blood and blood products for achieving universal health coverage (editorial) », east. mediterr. health j. rev. sante mediterr. orient. al-majallah al-sihhiyah lisharq al-mutawassit, vol. 24, no 3, p. 235‑236, juin 2018, doi: 10.26719/2018.24.3.235. 2. s. sharma, p. sharma, et l. n. tyler, « transfusion of blood and blood products: indications and complications », am. fam. physician, vol. 83, no 6, p. 719‑724, mars 2011. 3. r. haldar, d. gupta, s. 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seroprevalence and associated risk factors for hiv, hepatitis b and c among blood donors in south gondar district blood bank, northwest ethiopia », bmc infect. dis., vol. 19, no 1, p. 430, mai 2019, doi: 10.1186/s12879-019-4051-y. 20. h. j. shahshahani, m. t. yavari, m. attar, et m. h. ahmadiyėh, « knowledge, attitude and practice study about blood donation in the urban population of yazd, iran, 2004 », transfus. med., vol. 16, no 6, p. 403‑409, déc. 2006, doi: 10.1111/j.1365-3148.2006.00699.x. 21. h. mirza, f. khan, f. j. naeem, et b. ashraf, « blood safety and donation knowledge, attitude and practice (kap) among 1st year medical students at lmdc, lahore. », p. 3. 22. k. m. sabu, a. remya, v. s. binu, et r. vivek, « knowledge, attitude and practice on blood donation among health science students in a university campus, south india », online journal of health and allied sciences, juill. 30, 2011. http://cogprints.org/7962/ (consulté le juill. 30, 2020). 23. z. ahmed, m. zafar, a. a. khan, m. u. anjum, et m. a. siddiqui, « knowledge, attitude and practices about blood donation among undergraduate medical students in karachi », mars 2014, consulté le: juill. 30, 2020. en ligne). disponible sur: https://eresearch.qmu.ac.uk/handle/20.500.12289/3848. 24. b. m. masser, k. m. white, m. k. hyde, et d. j. terry, « the psychology of blood donation: current research and future directions », transfus. med. rev., vol. 22, no 3, p. 215‑233, juill. 2008, doi: 10.1016/j.tmrv.2008.02.005. 25. a. h. misje, v. bosnes, et h. e. heier, « recruiting and retaining young people as voluntary blood donors », vox sang., vol. 94, no 2, p. 119‑124, 2008, doi: 10.1111/j.14230410.2007.01004.x. 26. j. m. kabinda, s. a. miyanga, p. misingi, et s. y. ramazani, « les hépatites b et c chez les donneurs bénévoles de sang et non rémunérés de l’est de la république démocratique du congo », transfus. clin. biol., vol. 21, no 3, p. 111‑115, juin 2014, doi: 10.1016/j.tracli.2014.04.001. 27. z. a. randriamanantany et al., « séroprévalence du vih chez les donneurs de sang au centre national de transfusion sanguine d’antananarivo de 2003 à 2009 », rév méd madag, vol. 2, no 2, p. 138–44, 2012. 28. s. yang et al., « seroprevalence of human immunodeficiency virus, hepatitis b and c viruses, and treponema pallidum infections among blood donors at shiyan, central china », bmc infect. dis., vol. 16, no 1, p. 531, 01 2016, doi: 10.1186/s12879-016-1845-z. 29. l. a. staallekker, r. n. stammeijer, et c. dudok de wit, « a dutch blood bank and its donors », transfusion (paris), vol. 20, no 1, p. 66‑70, févr. 1980, doi: 10.1046/j.15372995.1980.20180125042.x. 30. a. carver, k. chell, t. e. davison, et b. m. masser, « what motivates men to donate blood? a systematic review of the evidence », vox sang., vol. 113, no 3, p. 205‑219, avr. 2018, doi: 10.1111/vox.12625. fenomanana j, ramaminiaina hg, randriatsarafara fm, randriamanantany za. voluntary blood donation promotion in haute matsiatra region of madagascar (original research). seejph 2021, posted: 11 may 2021. doi: 10.11576/seejph-4425 p a g e 15 | 15 © 2021 fenomanana et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. __________________________________________________________________________ bop mc, diop ct, diarra b, gueye b, ka o. determinants of low birth weight in the health district of bounkiling in senegal (original research). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5931 p a g e 1 | 9 original research determinants of low birth weight in the health district of bounkiling in senegal martial coly bop1, cheikh tacko diop1, bou diarra2, boubacar gueye1, ousseynou ka1 1 alioune diop university, bambey, senegal; 2 health district of bounkiling, sédhiou, senegal. corresponding author: dr. martial coly bop; address: unité de formation et de recherchee en santé et déveeloppement durable (ufr/sdd), université alioune diop de bambey, bp 30, sénégal telephone: 00221772550239; email: martialcoly.bop@uadb.edu.sn mailto:martialcoly.bop@uadb.edu.sn bop mc, diop ct, diarra b, gueye b, ka o. determinants of low birth weight in the health district of bounkiling in senegal (original research). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5931 p a g e 2 | 9 abstract aim: low birth weight (lbw), 9.1 million deaths per year, is a global health issue. the proportion of lbw in senegal is estimated at 12% (in 2017) and is at 11.7% (in 2017) in the region of sedhiou. in this regard, rigorous management is required to address this issue, especially in rural areas. the objective of the study was to identify the determinants of lbw. methodology: this is a case-control study which has been conducted in the district of bounkiling. socio-demographic characteristics of the mothers, their obstetrical and medical history, and information on the health status of the newborn in the case group were compared with that of the controls. bivariate and multivariate analyses are performed using epi info 7 software to identify the determinants. results: low-weights accounted for 97.05% of lbw. the sex ratio was 0.87 in favor of girls. the apgar score at birth was not good for 31.4% of newborns. teenage mothers accounted for 17.08%. the multivariate analysis showed that the determinants of lbw (p < 0.05) were the female sex of the newborn, the apgar score at birth, the maternal age <=19 years, the household income < 83.96 usd, maternal history of low birth weight and physical labor during pregnancy. conclusion: strengthening communication on early marriages and pregnancies, empowering women and improving pregnancy monitoring would be levers to counter the determinants of low birth weight. keywords: determinants, district of bounkiling, low birth weight, senegal. coflicts of interests: none declared. bop mc, diop ct, diarra b, gueye b, ka o. determinants of low birth weight in the health district of bounkiling in senegal (original research). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5931 p a g e 3 | 9 introduction infant mortality is a worldwide concern, particularly in developing countries where deaths occur more in the neonatal period (1). the efforts made by countries have led to a decrease in neonatal mortality. however, it still remains high: 36.6 per thousand in 1990 to 17.5 per thousand in 2019 (2). the high neonatal mortality rate is closely connected with the high number of deaths among low birth weight newborns. in 2015, 20.5 million children born globally weighed less than 2500 grams at birth. nearly 90% of these births took place in lowor middle-income countries, particularly in south asia and sub-saharan africa (3). according to the world health organization (who), newborns with low birth weight (lbw) account for 17% of all live births. this frequency of lbw varies from country to country, ranging from 7% in developed countries to 19% in developing countries (4). in sub-saharan africa, the prevalence of low birth weight varies between countries with 13% in cape verde, 15% in togo, 16% in benin, 19% in burkina faso and 23% in mali (3). in senegal, the proportion of low birth weights dropped from 18% (in 2000) to 12% (in 2017) and 11.7% (5) in the region of sedhiou. in the health district of bounkiling, administrative data showed that the number of children born with low birth weight in health facilities was below the data provided by demographic surveys. the proportions were 7.4% in 2019 and 10.3% in 2020 of all live births recorded in health facilities. lbw are a predictor of the quality of child survival. they also cause the deaths of 9.1 million children worldwide each year (6). various studies have shown that low birth weight newborns have higher mortality and morbidity rates than normal-weight infants (6-9). low birth weights are the cause of several very severe and sometimes irremediable disabilities (4). low birth-weight newborns and more particularly premature infants require rigorous care, especially in semi-rural and rural areas because of the under-equipment and lack of qualified personnel (10,11). based on this observation, we conducted this study in the health district of bounkiling located in the region of sedhiou, to identify risk factors and contribute to improving the health of the mothers and children. methods the study was carried out in the district of bounkiling which covers the department of the same name (bounkiling) located in the region of sedhiou. it has an area of 3,005 km2 and a population of 183,842 inhabitants, or 62 inhabitants per km². it also includes a health center and twentyfour health posts settled throughout three boroughs, namely diaroumé, bona and bogal. according to the national health developmment plan phase ii (nhdp ii) standards, the gaps in the number of health centers and health posts are four and eighteen, respectively and are characterized by the lack of personnel (doctors, nurses and midwives). we carried out a case-control study on the different factors associated with low birth weights, based on the birth records of women found in the district maternity wards in the course of the year 2020. (births taking place in maternities are under the responsibility of health professionals whereas those home birth are under the responsibility of non-professionals). the study population consisted of all the mothers who gave birth in the health facilities and the newborns resulting from these deliveries. the cases were all live newborns weighing less than 2500 grams and all women who gave birth to live newborns weighing less than 2500 grams in the district maternity bop mc, diop ct, diarra b, gueye b, ka o. determinants of low birth weight in the health district of bounkiling in senegal (original research). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5931 p a g e 4 | 9 wards during the study period (from 01 january to 31 december 2020). the controls were all live newborns weighing more than 2500 grams and all women who gave birth to live newborns weighing more than 2500 grams in the district maternity wards during the study period. all live newborns whose birth weight is not traced, women from twin pregnancies with low birth weight and low birth weight infants whose mothers were from outside the district were excluded from the study (excluded: low weight from twin pregnancies (13), low weight whose mothers lived outside the district (5) and those whose records were not complete (14). the number of discarded low birth weight newborns was 33. the sampling was exhaustive and the sample size was two hundred and thirtyseven (237) on each side: low birth weight records and records of birthweights over 2500 grams (selected low birth weights 237 were matched to 237 birth weights of 2500g or more). the data was collected using a form filled with the socio-demographic characteristics of the women, the maternal history, the pathologies related to pregnancy, and the clinical examination of the newborn. to complete the data collection, a field visit was conducted and selected women were those whose health records were used. they were recorded in the sphinx software iq then exported to epi info tm 7.2 in view of a descriptive and analytical analysis. as regards the description, the frequencies were calculated for the categorical variables. on the other hand, regarding the quantitative variables, calculation of the position and dispersion was made. in the analytical section, we performed a bivariate analysis using the statistical tests of fisher and a multivariate analysis by a logistic regression. results the average weight of newborns was 2581.1 (±561.1) grams. in the group of newborns weighing less than 2500 grams, low birth weight accounted for 97.05% and very low birth weights were 2.95%. the sex ratio was 0.87 in favor of girls. the apgar score at birth was not normal (below 7) for 31.43% of newborns. birth defects were found in 1.27% of births consisting mainly of polydactyly and microcephaly. the socio-demographic characteristics collected among the mothers surveyed showed that the average maternal age was around 25.6 (±6.2) years, teenage mothers (14 to 19 years) accounted for 17.08%, outof-school women were 71.34% and those who lived in households with a monthly income of less than 50,000 cfa francs per month were 63.71%. the history of abortions and stillbirths at birth was noted in 10.55% and 3.16% of the mothers surveyed, respectively. the delivery of a low birth weight child was found in the obstetrical history of 5.91% of the women surveyed. the maternal pathologies found during the study were essentially high blood pressure (3.38%), malnutrition (2.53%), anemia 0.84%. the behavioral factors which mothers presented during pregnancy were physical work (52.11%), tabacco via vaginal route (8.5%) and geophagia (3.80%). bivariate analysis showed that the link between the birth of a female newborn and the occurrence of low birth weight was statistically significant (p equal to 0.013). newborns with low birth weight were almost twice as likely (or=1.89) to have a low apgar score than those of normal weight. a teenage mother aged 19 and under was more likely to give birth to a low-birthweight child. the prevalence was 62.96% in this age group. teenage mothers are almost twice as likely to give birth to a low birth weight child (or=1.89 with 95% ci =1.15 3.09). women whose households was less than 77.73 usd were surveyed and they were 1.55 times more likely to give birth to a low birth weight child (or=1.55 with 0 95% ci bop mc, diop ct, diarra b, gueye b, ka o. determinants of low birth weight in the health district of bounkiling in senegal (original research). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5931 p a g e 5 | 9 =1.06 2, 26) than those with a regular income. the association was statistically significant, p = 0.01. those exposed to strenuous labor during pregnancy were almost twice more likely to deliver a low birth weight newborn compared to those who were spared from heavy labor (or = 1.69 with 95% ci = 1.17 – 2.43). the association was statistically significant with a p equal to 0.002. women with a history of low birth weight were almost 3 times more likely to give birth to an lbw child than those without a history of lbw (or=2.89 with ci=1.67 – 4.97). a statistically significant association was found between the history of lbw and the occurrence of a lbw birth (p = 0.00005). the absence of high blood pressure in mothers would be a protective factor with regard to the occurrence of a low-weight birth (p = 0.009). the birth of a low birth weight newborn is significantly related to the presence of malnutrition in the mothers (p = 0.007). this association was not found in mothers with pathologies such as anemia, diabetes, hiv infection and malaria in their pregnancy. the bivariate analysis showed the existence of risk factors for the occurrence of low birth weight among women in the health district of kolda (table 1). table 1. risk factors associated with low birth weight factors associated with lbw p value or 95% ic female 0.013 1.53 1.06 – 2.20 apgar score < 7 0.0007 1.92 1.29 – 2.85 age less than 19 years 0.007 1.89 1.15 – 3.09 monthly household income under 50000 0.01 1.55 1.06 – 2.26 mother's height less than or equal to 150 cm 0.01 4.16 1.15 – 14.93 hard work during pregnancy 0.002 1.69 1.17 – 2.43 number of anc ≤ 2 0.002 1.82 1.20 – 2.75 history of lbw deliveries 0.00005 2.89 1.67 – 4.97 maternal malnutrition 0.007 3.58 1.30 – 9.88 history of high blood pressure 0.009 4.52 1.27 – 16.09 the risk factors correlated with the occurrence of low birth weight were the female sex of the newborns, the apgar score < 7, the maternal age of less than 19 years, the monthly household income of less than 83.96 usd, the height of the mother less than or equal to 150 centimeters, heavy labor during pregnancy, the low number of prenatal visits (≤2) carried out, the existence of a history of delivery of an infant with lbw, the history of high blood pressure during pregnancy and malnutrition in the mother. these variables were under consideration in the multivariate analysis to control for possible confounding factors. thus, the multivariate analysis showed that the independently and significantly associated factors were maternal age less than 19 years (or=2.42 with ci = 1.43-4.12); p equal to 0.001, household income less than 83.96 usd, (or=1.97 with ci=1.27-3.04); p equal to 0.002, maternal history of low birth weight (or=3.62 with ic=2.02-6.50); p=0.000001, physical work during pregnancy (or=1.80 with ci=1.20 – 2.69); p = 0.004, the female sex of a newborn (or=1.59 with ic=1.07 – 2.35); p equal to 0.019 and the apgar score at birth (or=2.79 with ci=1.77 – 4.41); p equal to 0.000001 (table 2). bop mc, diop ct, diarra b, gueye b, ka o. determinants of low birth weight in the health district of bounkiling in senegal (original research). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5931 p a g e 6 | 9 table 2. results of the multivariate analysis factors associated with lbw multivariate analyze or adjusted p female 1.59 0.019* apgar score < 7 2.79 0.000001* age less than 19 years 2.42 0.001* monthly household income under 50000 1.97 0.002* mother's height less than or equal to 150 cm 3.12 0.12 physical labor during pregnancy 1.80 0.004* number of anc ≤ 2 1.42 0.08 history of lbw deliveries 3.62 0.000001* maternal malnutrition 2.83 0.06 history of high blood pressure 2.95 0.11 tabacco via vaginal route 0.67 0.28 history of abortions 1.26 0.48 birth defects 2.28 0.49 *statistically significant. discussion various limitations have been identified in this work. these were representativeness biases, information biases and biases relating to case-control studies. in view of he study carried out in 2019 (16), the representativeness biases are largely explained by the importance of home births recorded in health structures and estimated at 15% and 23% the lack of information in some birth records was a limitation in this work and justified the use of comprehensive records of mother-child pairs. control case studies which are by nature retrospective, may imply drawbacks such as selection bias (over or under-estimation of the risk factor) and information bias (missing data, memorization, interviewer subjectivity). the study focused on determinants related to newborns (sex, apgar score, birth defects) and mothers (individual, biological, socio-economic and behavioural). newborn characteristics the categorization of newborns with low birth weight shows that the majority (97.05%) weighed between 1500 and 2499 grams. based on distribution of newborns by birth weight, this same trend has been observed in other studies carried out in the health district of kolda in senegal (12) and in moroco (13). the link existing between the delivery of a female child and the low birth weight which was found in our study is similar to that found in work done in tunisia (14) and in the democratic republic of congo (15). however, this relation (13,16) was not found in other studies. the results showed that low birth weights are about five times more likely to have an apgar score under 7 which reflects a poor neurological condition of the newborn, than those of normal weight. this conclusion was observed in studies carried out in cameroon, tunisia and madagascar (1719). this relation was statistically significant in our study. however, this result was not found in kolda (12). but, it had been found that lbw are more likely to have an apgar score under 7. depending on the contexts of study and the determinants which were identified, we noted that the conclusions are not identical. however, the management of low birth bop mc, diop ct, diarra b, gueye b, ka o. determinants of low birth weight in the health district of bounkiling in senegal (original research). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5931 p a g e 7 | 9 weight must be rigorous with regard to the consequences of a low apgar score on newborns health. maternal characteristics and risk factors mothers under the age of 19 are 2.42 times more likely to give birth to a newborn with low birth weight. there is a statistically significant association (p<0.05) between young maternal age and the delivery of a lowweight newborn. this link can be observed given that teenage pregnancy remains a public health issue for the young mother and her newborn (21). in senegal, studies have shown that the probability for a woman to give birth to a child with low birth weight was present in adolescents (12,21) age group. these results were similar to those of studies carried out in mali (23) and cameroon (17). however, this link was not found in other studies (2325). this could be explained by the significant pace of growth and of change during this period, and especially by the context of the precocity of reproductive life. women living in families with a monthly income of less than 77.73 usd were 1.97 times more likely to give birth to a child with low birth weight (p<0.05). this significant difference was found in guédiawaye (26) and kolda (12). however, in morocco, the study did not show any statistically significant link (13). in bounkiling, the results can be explained by the fact that the region of sédhiou is one of the poorest localities in the country. this poverty has an impact on the household income and on meeting primery needs, particularly for pregnant women (27). women empowerment can help improve the management of the basic needs of this target. the prevalence of low birth weight was 3.62 times higher among women with past obstetric history of low birth weight than among those who gave birth to children with normal weight in their previous pregnancy. similar results have been found in studies conducted in senegal and burkina (12,26,29). on the other hand, the study conducted in tunisia (18) did not establish a statistically significant relation in this regard. the existence of this nonmodifiable risk factor could reflect a lack of management of pregnancy (12). women who did physical labor during pregnancy were 1.80 times more likely to give birth to a child with low birth weight than those who did not engage in physical labor. a statistically significant link was found (p equal to 0.004). similar results were found in studies conducted in senegal and in burkina (26,29). however, mangane (12) did not establish any statistically significant relation. this can be explained by the context of poverty causing women to carry out daily arduous tasks such as farming activities and trade over long distances. the lack of running water means that women also have to draw water from wells for domestic work, which is non-optional. these difficult living conditions could lead to an early onset of labor, thus, the birth of premature infants, and therefore lowweight newborns. conclusion identifying the risk factors associated with low birth weight is a prerequisite for developing prevention strategies. scaling up strategies focused on the reproductive health of adolescent girls, strengthening communication towards adolescent girls and towards community leaders on early marriages and pregnancies, empowering women and improving pregnancy monitoring would be levers to address the risk factors for low birth weight that have been identified in the district of bounkiling. references 1. who/fhe/msm/93.7 coverage of maternity cares, genève, suisse: http://www.santetropicale.com/res ume/104603.pdf (accessed: october 23, 2021). http://www.santetropicale.com/resume/104603.pdf http://www.santetropicale.com/resume/104603.pdf bop mc, diop ct, diarra b, gueye b, ka o. determinants of low birth weight in the health district of bounkiling in senegal (original research). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5931 p a g e 8 | 9 2. world bank. mortality rate, neonatal (per 1,000 live births). available from: https://data.worldbank.org/indicato r/sh.dyn.nmrt?end=2020&star t=1990&view=chart (accessed: october 23, 2021). 3. wardlaw t (ed). low birth 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[mémoire]. genève: haute école de santé; 2018. 21. ndiaye o, diallo d, ba mg, diagne i, moreau jc, diadhiou f, et al. maternal risk factors and low birth weight in senegalese teenagers: the example of a hospital centre in dakar. santé 2001;11:241-4. 22. traore b, diallo h, diarra as, fakir s, nejjari c. facteurs associés au faible poids de naissance au centre de santé communautaire de yirimadio (mali). annales des sciences de la santé 2016;7:8-15. 23. demmouche a, benali ai, ghani ae, mai h, beddek f, chalal h, et al. etiologie du faible poids de naissance au niveau de la maternité de sidi bel abbes (ouest algérie). antropo 2015;33:103-9. 24. pope sk, whiteside l, brooksgunn j, kelleher kj, rickert vi, bradley rh, et al. low-birthweight infants born to adolescent mothers: effects of coresidency with grandmother on child development. jama 1993;269:1346-400. 25. de onis m, habicht jp. anthropometric reference data for international use: recommendations from a world health organization expert committee. am j clin nutr 1996;64:650-8. 26. camara b, diack b, diouf s, signate/sy h, sall mg, ba m, et al. les faibles poids de naissance: fréquence et facteurs de risque dans le district de guediawaye. dakar med 1995;40:213-9. 27. agence nationale de la statistique et de la démographie (ansd). enquête démographique et de santé continue (eds-continue). dakar, sénégal; 2017. available from: http://www.ansd.sn/ressources/rapp orts/rapport%20final%20eds%2 02017.pdf (accessed: october 25, 2021). 28. amine m, aboulfalah a, isaf h, abassi h. facteurs de risque du faible poids de naissance: étude cas–témoins. rev epidemiol sante publique 2009;57:s8. 29. kabore p, donnen p, dramaixwilmet m. facteurs de risque obstétricaux du petit poids de naissance à terme en milieu sahélien. sante publique 2007;6:489-97. __________________________________________________________________________________________ © 2022 bop et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, andreproduction in anymedium, provided the original work is properly cited. http://www.ansd.sn/ressources/rapports/rapport%20final%20eds%202017.pdf http://www.ansd.sn/ressources/rapports/rapport%20final%20eds%202017.pdf http://www.ansd.sn/ressources/rapports/rapport%20final%20eds%202017.pdf p w adi, singgih h, s k purnama, r i doewes, sugiyanto, m doewes, methods of physical exercise as a way to optimize the physical condition of football players: a systematic review. seejph 2023. posted: 09-04-2023, vol. xx. page 34 original research methods of physical exercise as a way to optimize the physical condition of football players: a systematic review pomo warih adi1, singgih hendarto1, sapta kunta purnama1, rumi iqbal doewes1, sugiyanto1, muchsin doewes1 1universitas sebelas maret, jl. ir. sutami 36 a surakarta 57126, jawa tengah indonesia. corresponding author: pomo warih adi address: jl. ir. sutami 36 a surakarta 57126, jawa tengah indonesia. email: pomowarih@staff.uns.ac.id p w adi, singgih h, s k purnama, r i doewes, sugiyanto, m doewes, methods of physical exercise as a way to optimize the physical condition of football players: a systematic review. seejph 2023. posted: 09-04-2023, vol. xx. page 35 abstract objective: investigating the training methods used to optimize the physical condition of football players and describing the results of each study. methods: this is a systematic review of published research. articles published between 2015 and 2021 describing training methods to improve the physical condition of football players were reviewed. electronic searches were conducted via google scholar, web of science, scopus, and pubmed. all articles presenting methods of physical exercise to improve physical condition performance were included. results: there were 41 articles that used training methods to improve the physical condition of football players. from these articles, they are grouped according to the physical condition that is assessed and which is improved. some of the training methods that can be used include neuromuscular, unilateral and bilateral, ballistic, plyometric, combined weight & plyometric, mixed training with optimum load, complex cod & plyometric, strength, combined strength, eccentric, repeated-sprint, resisted/unresisted sprint, resistance, elastic band, core, combine core & small-sided games, aerobic interval training, blood flow restriction aerobic interval training, intermittent, anaerobic speed endurance, high-intensity interval training, high-intensity interval training & small-sided games, tabata sprint, very-heavy sled, pilates, and functional. conclusion: after a systematic review, several training programs were found to improve the physical condition of football players such as strength, aerobic and anaerobic endurance, muscle power, speed and acceleration, flexibility, agility, and balance. p w adi, singgih h, s k purnama, r i doewes, sugiyanto, m doewes, methods of physical exercise as a way to optimize the physical condition of football players: a systematic review. seejph 2023. posted: 09-04-2023, vol. xx. page 36 introduction in a football game, the level of activity and physiological responses during the game reflect the physical demands inherent in playing it. therefore, football players must have optimal physical conditions to respond the physical demands that are typical of playing at a competitive level. training sessions are part of an effort to achieve physical demands, containing a systematic program in preparation for achieving longterm career or formal preparation when involved in competition. physical conditioning training is the most important element in football training, aimed at increasing physiological potential and developing biomotor skills at the highest level. since football has a complex technical and tactical content, physical training can also be achieved in its own way which is oriented from a structural and developmental point of view towards the training goals. the physical condition component is identified exclusively with off-ball activities. the football player is a functional unit that behaves as a whole, so its performance cannot be divided into separate parts, which determines the formation of training in accordance with the requirements of the sport. therefore, this study aim of investigating the training methods used to optimize the physical condition of football players and describes the results of each study. so that it can be seen the method of physical condition training in accordance with the game of football. methods database and search profile this systematic review was conducted using google scholar, web of science, scopus, and pubmed electronic searches. the keyword combinations used for the electronic search were “training”, “soccer”, and “football”. the search strategy is divided into four stages. the first stage was an electronic search on the databases of google scholar, web of science, scopus, and pubmed which identified 557 articles. the second stage was filtering titles and abstracts (165 articles), eliminating 392 articles. furthermore, articles were excluded based on reasons (59 articles), leaving 106 articles. the third stage was reading and analysis of the entire article starting from the title, abstract, method, results and p w adi, singgih h, s k purnama, r i doewes, sugiyanto, m doewes, methods of physical exercise as a way to optimize the physical condition of football players: a systematic review. seejph 2023. posted: 09-04-2023, vol. xx. page 37 discussion, as well as conclusions. after reviewing the articles, 65 were eliminated because not meeting the inclusion criteria. fourth stage was review the relevant articles. at this stage, there is not new studies were included. thus, the total number of articles for the systematic review consisted of 41 articles (figure 1). inclusion and exclusion criteria inclusion and exclusion criteria described in table 1. table 1. inclusion and exclusion criteria inclusion criteria exclusion criteria 1. articles published in the last 7 years (january 2015 to december 2021) 2. written in english. 3. only experimental studies were included. 4. the samples used in the study were male and female football players aged between 15 and 30 years. 5. the training session is fully explained. 6. the research method is a comparative study, which produces a certain impact in physical exercise. 7. the exercise method used physical exercise. 8. the study results explain the changes in the assessed physical conditions. 1. articles using samples of age < 15 years and > 30 years. 2. articles using a sample of footbal players with cerebral palsy 3. articles that use samples are not only football players, but players of other sports. 4. the article does not describe the training sessions. figure 1. flowchart of article identification in systematic review methodological quality assessment 11 pedro (physiotherapy evidence database) criteria were used to assess the quality of the articles reviewed. assessment was done by giving an asterisk on each criterion. articles with a score of eight to p w adi, singgih h, s k purnama, r i doewes, sugiyanto, m doewes, methods of physical exercise as a way to optimize the physical condition of football players: a systematic review. seejph 2023. posted: 09-04-2023, vol. xx. page 38 eleven were considered to have high methodological quality, from four to seven moderate, and below four to low (moseley et al., 2002). results and discussion number of results reviewed on an electronic search via google scholar, web of science, scopus, and pubmed, 557 articles were identified and found no duplicate articles. then the 557 articles were filtered by title and abstract, leaving 165 articles to be re-read. the results left 106 articles reviewed in total. of the 106 articles, 65 were eliminated because they did not meet the inclusion criteria. thus, the total number of studies for systematic review consists of 41 articles. this article is grouped by physical condition (table 2). exercise significance results a total of 41 articles met the eligibility criteria based on the pedro scale. of the 41 articles selected and reviewed, regardless of gender, age, level of professionalism, beginner or elite players, or the type of training carried out, 39 articles revealed significant results on the physical condition of football players, namely [1-6]; [7-38] and only 2 articles, namely articles [39]&[40] which did not provide significant results on the physical condition of football. table 2. characteristics and results of physical condition training methods for football players author, year physical condition variable training type perform ance da silva, et al., 2015 1 aerobic endurance: vo2max aerobic interval training mendiguchia, et al., 2015 2 hamstring strength neuromuscular training ↑ iaia, et al., 2015 3 anaerobic endurance anaerobic speed endurance training: sep (speed endurance production) sem (speed endurance maintenance) ↑ chinnavan, et al., 2015 4 flexibility pilates training ↑ loturco, et al., 2015 5 acceleration, strength ballistic exercise, (jump squat (js) and half squat (hs)) ↑ los arcos, et al., 2015 6 aerobic fitness small-sided games (ssg) vs aerobic interval training (it) ↑ p w adi, singgih h, s k purnama, r i doewes, sugiyanto, m doewes, methods of physical exercise as a way to optimize the physical condition of football players: a systematic review. seejph 2023. posted: 09-04-2023, vol. xx. page 39 de hoyo, et al., 2016 7 sprint, muscle power, agility (change of direction) low/moderate load strength training: sq (full-back squat), rs (resisted sprint), plyo (plyometric training) ↑ yanci, et al., 2016 8 strength, sprint, agility plyometric training mohr & krustrup, 2016 9 anaerobic endurance anaerobic speed endurance training: sep (speed endurance production) sem (speed endurance maintenance) ↑ tous-fajardo, et al., 2016 10 agility eccentric-overload and vibration training (evt) ↑ styles, et al., 2016 11 strength strength training ↑ rađo, et al., 2016 12 muscle power functional strength training ↑ borges, et al., 2016 13 speed resisted print training (rs), plyometric training (pt) ↑ ruivo, et al., 2016 14 muscle endurance, strength strength training ↑ morin, et al., 2017 15 acceleration very-heavy sled training ↑ eniseler, et al., 2017 16 anaerobic endurance high-intensity small-sided games (ssgt), repeated-sprint training (rst) ↑ rodríguez-rosell, et al., 2017 17 strength, acceleration weight training (fsg), combined weight training and plyometrics (com) ↑ hammami, et al., 2017 18 speed, agility, strength strength training standard (st), contrast strength training (cst) ↑ loturco, et al., 2017 19 strength, speed, agility optimum power load (opl) + resisted sprint (rs) opl + vertical/horizontal plyometrics (pl) ↑ rey, et al., 2017 20 strength eccentric hamstring training: nordic hamstring exercise (nhe), russian belt (rb) ↑ selmi, et al., 2017 21 acceleration, strength small-sided games (ssg), repeated sprint (rs) ↑ otero-esquina, et al., 2017 22 strength, speed, agility combined strength training ↑ ajayaghosh, 2017 23 speed tabata sprint training ↑ hammami, et al., 2018 24 strength strength training ↑ gill, et al., 2018 25 speed, agility, strength resisted sprint training (rst), unresisted sprint training (ur) ↑ beato, et al., 2018 26 speed, muscle power complex cod and plyometric training (codj), cod training (cod) ↑ p w adi, singgih h, s k purnama, r i doewes, sugiyanto, m doewes, methods of physical exercise as a way to optimize the physical condition of football players: a systematic review. seejph 2023. posted: 09-04-2023, vol. xx. page 40 barbalho, et al., 2018 27 strength, muscle power resistance training: nonlinear periodization model ↑ amani, et al., 2018 28 aerobic endurance blood flow restriction (bfr) aerobic interval training ↑ ozcan, et al., 2018 29 anaerobic endurance small-sided games training (ssgt), conventional aerobic interval training (cait) ↑ zouhal, et al., 2019 30 agility neuromuscular training ↑ paul, et al., 2019 31 anaerobic endurance, muscle power agility small-sided games & high intensity training (ssg & hit) ↑ tasevski, et al., 2020 32 agility functional training ↑ pardos-mainer, et al., 2020 33 speed, agility combined strength and power training (cspt) ↑ stren, et al., 2020 34 strength strength and power training: unilateral (ug), bilateral (bg) ↑ januševičius, et al., 2020 35 strength elastic band training ↑ de oliveira, et al., 2020 36 strength pragmatic nordic hamstring training (nhe) ↑ calandro, et al., 2020 37 aerobic endurance intermittent training ↑ atli, 2021 38 muscle power, speed, agility flexibility core training ↑ gökkurt & kivrak, 2021 39 speed, agility, acceleration high intensity interval training ↑ fischerova, et al., 2021 40 strength strength training ↑ arslan, et al., 2021 41 speed, strength, balance combined core training + small-sided games (ssgcore), small-sided games training (ssg) ↑ discussion neuromuscular training most studies in adolescents examine neuromuscular training as a strategy that includes strength, balance, and agility [18]. as menezes et al [36], showed after 12 weeks a significant improvement in flexibility, balance, countermovement vertical jump height in prepubertal football players (age 8 years) in the experimental p w adi, singgih h, s k purnama, r i doewes, sugiyanto, m doewes, methods of physical exercise as a way to optimize the physical condition of football players: a systematic review. seejph 2023. posted: 09-04-2023, vol. xx. page 41 group. the same thing is also shown by chappell & limpisvasti [8], that the neuromuscular training program improves performance in vertical jumps, one right foot hop and one left foot hop. this means that undergoing a 6-week neuromuscular training program improves certain measures of athletic performance and changes movement patterns during the jump task in female football players. study of mendiguchia et al [35], the experimental group showed an increase in hamstring strength so that they were able to maintain the sprint performance of male amateur football players aged 21-22 years after undergoing 7 weeks neuromuscular training program. on the other hand, zouhal et al [41], with their agility variable, showed that neuromuscular training significantly increased agility after elite football players aged 16-17 years underwent a neuromuscular training program for 6 weeks. unilateral and bilateral training due to the adaptation of the explosive action of the neuromuscular system, unilateral and bilateral training strategies have emerged. both of these training are equally effective for inducing increased strength and leg power as well as strength development. in line with this, stern et al [42] have proven in their experiments 1 group underwent unilateral and 1 group underwent bilateral. after 6 weeks of training, both of them showed an increase in some of the measured strength variables. of the 13 strength variables measured, bilateral showed a significant increase in back squat, rfess, broad jump, 10m and 30m sprint (5 strength variables). unilateral showed a significant increase in rfess, left foot slcmj, left foot slbj, 10m sprint, and right foot 505change of direction (5 variables of strength). stern et al [42] showed that both unilateral and bilateral only increased in 5 strength variables. combined, the two exercises can provide significant results. ramírezcampillo et al [43], who both underwent unilateral and bilateral training and combining the two exercises gave different results in football players aged 11 years. after undergoing 6 weeks of training, the combination of unilateral and lateral showed a significantly higher change in 13 of the 21 performance measures, whereas if it was only unilateral it showed 6 and if it was only bilateral it showed 3. so that the combination of these two exercises would be more beneficial to boost performance. p w adi, singgih h, s k purnama, r i doewes, sugiyanto, m doewes, methods of physical exercise as a way to optimize the physical condition of football players: a systematic review. seejph 2023. posted: 09-04-2023, vol. xx. page 42 significant changes during high-intensity, short-term explosive exercise. ballistic training football players need strength and speed for any explosive action like jumping and kicking. ballistics training is one of the exercises to optimize muscle strength and power. ballistic training consist of dynamic motor activities such as throwing, jumping, and running using external or self-resistance [30]. in this case, loturco et al [34], used ballistic exercises in the form of jump squats (js) and half squats (hs) on male elite football players aged 23-24 years. after 4 weeks of different exercises, both groups (js and hs) increased their acceleration from 5 to 10m. js is more effective at reducing acceleration drop more than 0-5m. hs increases the height of the squat jump. meanwhile, to increase the potential for strength and speed at the same time using ballistic exercises, krawczyk & pociecha [30] in their experiments showed that by applying a combination of ballistic and plyometric training methods for 6 weeks helped increase the speed and strength of young soccer players, this was due to body adaptation. increased against effort based on explosive muscle work. plyometric training mengsh, et al [37], explained that plyometric training is an exercise program that increases strength and speed. this exercise is needed for football players, because football players must have the ability to respond quickly and strongly when attacking and defending. in line with this, de villarreal, et al [16] have proven plyometric training in increasing explosive action by finding improvements in cmj, abalakov vertical jump, 10m sprint, and 10m agility. however, several studies have shown the opposite result. in the yanci et al (2016) experiment, after 6 weeks of training in the form of horizontal plyometric training (countermovement jump) in two groups with different volumes (1:1 and 2:1), there was no significant increase in post-training (p> 0.05) in the sprint, change of direction ability (coda) and horizontal arm swing countermovement jump were reported in both groups. similar to borges et al [40], in their experiment comparing resisted-sprint training with plyometric training, the results showed better rsa ability and sprint time in the training-resistant group. this can be explained perhaps because of the different forms of exercise that are carried out so that p w adi, singgih h, s k purnama, r i doewes, sugiyanto, m doewes, methods of physical exercise as a way to optimize the physical condition of football players: a systematic review. seejph 2023. posted: 09-04-2023, vol. xx. page 43 it affects the results of the exercise. however, when combined with other exercises, it gives different results, such as rodríguez-rosell et al [44] who combined weight training and plyometric training in a 3-group experiment. 1 group only underwent weight training, 1 group underwent weight training and plyometric training, and 1 group acted as control. after 6 weeks of training, the results show that the combination of weight training and plyometric training provides more efficient benefits in improving sprint, acceleration and deceleration abilities, as well as jumps, when compared to weight training alone. similar is the case with beato et al [6], with their combined experiment between complex change of direction (cod) and plyometric training. after 6 weeks of training, combined training (complex change of direction (cod) and plyometric training) gave a greater effect in sprints and jumps, in contrast to if only undergoing cod training alone. on the other hand, if the addition of a load to plyometric training gives different results as in the loturco, et al [33] experiment. if yanci et al (2016) apply 2-4 times each form of exercise, it is different from loturco et al [33] which applies 3-8 times with 6 repetitions. the results showed an increase in cod velocity, sj and cmj heights. in line with this, a progressive increase in the volume of plyometric training shows more favorable results for encouraging the specific performance of football players aged 13.0 ± 2.3 years [45]. strength training the need for injury prevention to support health related to playing football, has led to various forms of training for injury prevention such as eccentric training, neuromuscular training and exercises that focus on strength, flexibility, balance and stability [46]. strength training is strength training to improve muscle strength performance and reduce the incidence of injuries in football players aged 15-23 years [20, 23, 24, 47-49]. in line with this, zouita et al [46] also proved strength training in improving performance and reducing injury rates in young football players aged 13-14 years. despite the age difference, strength training still gives significant results. after undergoing 12 weeks of training, the experimental group showed better performance in sprinting both speed and time, increased number of jumps, and lower p w adi, singgih h, s k purnama, r i doewes, sugiyanto, m doewes, methods of physical exercise as a way to optimize the physical condition of football players: a systematic review. seejph 2023. posted: 09-04-2023, vol. xx. page 44 incidence of injuries. on the other hand, otero-esquina et al [50], in a combined experiment of strength training consisting of full-back squats, yo-yo leg curls, plyometric exercises, and resisted-sprints, where the implementation used 2 week different sessions (1 session per session) and 2 sessions per week). after 7 weeks of training, the results provided an increase in the variables of cmj, cod, and linear velocity of u17 and u19 youth football players. however, it is necessary to do a minimum of two sessions per week to improve sprints and cod tasks, while one session per week is sufficient to improve jumping ability. in addition, the combination of strength training, combined with power training, also gave a higher increase in speed performance and cod of female football players aged 16 years [51]. eccentric training in football, muscle injuries often occur during eccentric contractions where muscle contractions are accompanied by lengthening or stretching of the muscles. this incident can occur due to a lack of muscle strength, so a muscle strengthening exercise program is proposed, one of which uses eccentric training. in this case, de hoyo et al [13], have proven the use of eccentric training. after the subjects underwent eccentric training in the form of leg-curls and half-squats for 10 weeks, it resulted in a reduction in the incidence and severity of muscle injuries, showing improvement in soccer tasks such as jumping and running. on the other hand, rey et al [52] in their experiments showed the same results although with different forms of exercise, namely nordic hamstring exercise (nhe) and russian belt (rb). after 10 weeks, both forms of exercise were effective in developing eccentric hamstring strength in right and left slhb. nhe is effective in reducing bilateral asymmetry in hamstring strength. de oliveira et al [15], also gave significant results using the nhe exercise program. after 4 weeks, it significantly increased the players’ eccentric knee flexor strength in both the right and left limbs. in addition to increasing the player’s muscle strength, eccentric training also affects agility. de hoyo et al [14], in their 10-week experiment using eccentric-overload training effectively increased kinetic variables during 2 cod maneuvers, namely crossover and explosive sidestep cutting. similarly, tousfajardo et al [53] with eccentric-overload p w adi, singgih h, s k purnama, r i doewes, sugiyanto, m doewes, methods of physical exercise as a way to optimize the physical condition of football players: a systematic review. seejph 2023. posted: 09-04-2023, vol. xx. page 45 training and combining other types of exercise, namely vibration training, gave more significant results on agility performance after 11 weeks of training, when compared to eccentric-overload training alone. through combined training (eccentric-overload + vibration training), it not only improves agility in changing directions but also linear speed. repeated-sprint training repeated-sprint training (rst) is defined as a series of short sprints of 3-7 seconds duration, each separated by a short recovery period of <60 seconds. rst is an exercise strategy targeting complex neuromuscular development such as single sprint performance or metabolic function or both simultaneously [25]. within 6 weeks consisting of 3 sets of 6 repetitions of a maximum 40 m sprint (straight sprints in the 1st set, alternating directions of 450 and 900 in the 2nd and 3rd sets) with passive recovery of 20 seconds between sets, the rst showed improvement in rsadecrement and increased in yo-yo ir1 professional junior football players aged 16 years [19]. within 7 weeks, rst can improve sprint time and leg strength in 18year-old professional football players [54]. resisted/unresisted sprint training to increase running capacity in the form of speed and acceleration, it can be done using resisted sprint training. this exercise involves the athlete running with added weights or uphill or dune training. in line with this, borges et al [40] in their experiment using resisted sprint training (sprints with a sled load of 10-13% body mass) on football players aged 16 years for 7 weeks, resulting in a greater increase in sprint time. on the other hand, gill et al (2018) in their experiments produced new findings that resisted sprint training not only increases speed and acceleration, but also as a means of increasing agility and strength. through gill et al’s experiment for 6 weeks on 22-year-old elite football players using 2 groups (resisted and unresisted). subjects underwent a squat jump exercise session and a resisted/unresisted running protocol. the resisted group underwent a running protocol with additional weights using elastic cords and sheaves, elastic cords were attached to the athlete’s waist during training. the results showed a significant increase in running ability across all distances (5m, 10m, 15m, 20m, 25m), direction change, sj, and cmj. p w adi, singgih h, s k purnama, r i doewes, sugiyanto, m doewes, methods of physical exercise as a way to optimize the physical condition of football players: a systematic review. seejph 2023. posted: 09-04-2023, vol. xx. page 46 resistance training it is important for football players to have strong muscles as they help in performing football playing actions such as running, kicking and jumping. resistance training stimulates protein in muscle cells, which in turn increases the muscle’s ability to generate strength [55]. the proof, barbalho et al [5] in their 15-week experiment on football players aged 18-20 years using resistance training with a nonlinear periodization model showed significant results in increasing muscle strength and power without destroying speed and agility. elastic band training to increase muscle capacity so that it has functional task ability, trainers can use elactic band exercises that are effective and safe if performed by athletes [56]. the proof can be seen in the study of januševičius et al [27], in his experiment on 23-year-old professional football players who underwent elastic band training for 5 weeks. subjects in this experiment underwent full rom hamstring curls and maximal movement rate when lying on their stomach, 4-6 sets, duration 4 seconds, passive rest 3 minutes between sets. participants in pairs, one holding a 1 m long elastic band tied with a special strap at the ankle while standing behind. the results show that maximum movement frequency of knee extensionflexion increase without significant effect on strength, jump, and sprint performance. core training a strong body reduces the risk of injury and provides power to football players. core training is one of the body parts that are responsible for developing power. yakup [57], in a 12-week experiment, showed that core training applied to 16-year-old junior level players gave a significant increase in the parameters of balance, vertical jump, standing long jump, speed, and shuttle. the same thing was also shown by atli [4], after 6 weeks of core training, the experimental group showed a significant difference in pre and post values in the 30m speed, vertical jump, flexibility and agility of soccer players aged 18-24 years, while the control group did not show the difference. also in the study of arslan et al [3], which combined core training with small-sided games on football players aged 16 years for 6 weeks, showed a significant increase in 20m sprint time, cmj, sj, three corner run test, and an increase in higher on the balance football of both feet. p w adi, singgih h, s k purnama, r i doewes, sugiyanto, m doewes, methods of physical exercise as a way to optimize the physical condition of football players: a systematic review. seejph 2023. posted: 09-04-2023, vol. xx. page 47 aerobic interval training aerobic interval training is known as exercise that induces a higher aerobic metabolic rate than anaerobic. aerobic interval training for 5 weeks for soccer players aged 17 years which was applied based on pvp-car with 100% pv intensity, 4 sets of 4 minute bouts with 3 minute intervals were used in both groups. in group 1 (t12:12), for 4 minutes, the athletes performed repeated bouts of 10 x 12 seconds shuttle runs (with a change of direction every 6 seconds) separated by a 12 second recovery period. in group 2 (t6:6) consisted of 20 x 6 seconds separated by a recovery period of 6 seconds, and the athlete did not change direction. both did not give significant results on the change in vo2max between the period before and after exercise. thus, aerobic interval training with and without direction changes applied based on pv the results in increasing vo2max are the same [11]. unlike the case with los arcos et al [32], in their experiment running aerobic interval training for 6 weeks (2-3 sessions per week), with an intervention of 3 bouts of 4 minutes each running at an exercise intensity of 90-95% hrmax for each player separated by 3 minutes of active jogging rest periods at 50-60% hrmax. the results show that it is effective in maintaining the aerobic fitness of 15-yearold football players. even though in experiment comparing with small-sided games, the results were that both aerobic interval training and small-sided games training were equally effective in maintaining aerobic fitness, however, ssg increased significantly and increased the level of player play. on the other hand, by running conventional aerobic interval training for 6 weeks (2 sessions per week), 5 sets of 6 minutes duration of work at an intensity according to the anaerobic threshold and 3 minutes of rest between sets, can increase the anaerobic endurance parameters of amateur football players aged 21 years. [58]. blood flow restriction aerobic interval training this exercise has been proposed as an exercise that brings many benefits to improve adaptation in skeletal muscles and peripheral blood vessels, especially in the conduit arteries and capillary beds [59]. this exercise is performed with a blood pressure cuff combined with low weight resistance training. amani et al [1], reported that p w adi, singgih h, s k purnama, r i doewes, sugiyanto, m doewes, methods of physical exercise as a way to optimize the physical condition of football players: a systematic review. seejph 2023. posted: 09-04-2023, vol. xx. page 48 exercise based on aerobic energy system intervals combined with blood flow restriction which was run for 2 weeks (4 sessions per week), exercise intensity was based on 60-70% maximum hr reserve where with a pressure of 140mmhg the first session and then increased to 180mmhg, can increase aerobic capacity and rpe simultaneously and prevent a decrease in vo2max due to exercise in young football players aged 23 years. intermittent training football matches are intermittent, so the ability to repeat high-intensity training is very important. intermittent exercise training can be used to increase physical demands according to the actual needs of the competition [17]. calandro et al [7] reported that a young football player aged 16 years, after undergoing intermittent training for 12 weeks (2-3 sessions per week) with sprints of 4-8 sets per session, work duration of 1030 seconds and recovery of 10-30 seconds, showing a significant difference in aerobic performance. therefore, intermittent training is an easy training method, even for young athletes, because it minimizes lactic acid production and the risk of injury. this study also shows the importance of paying attention to the recovery phase where the heart rate is feared to be low if recovery is >30 seconds. anaerobic speed endurance training all football players are required to produce maximum effort in a short time interspersed with a short recovery period, thus triggering fatigue during play. thus, high-intensity training is essential for competitive football players. anaerobic speed endurance training is one of the exercises that can be done to overcome the endurance conditions of football players by optimizing rsa. there are two subcategories of this exercise, namely sep and sem. iaia et al [26], in their experiment compared two subcategories of anaerobic speed endurance training for 3 weeks (3 sessions per week). the results show that sep with 6-8 repetitions of 20 seconds of all-out running bouts and 2 minutes of passive recovery can improve the performance of high-intensity repetitive and intermittent sprints, while sem with 6-8 repetitions of 20 seconds of all-out efforts and 40 repetitions of exercise. seconds of passive recovery can increase the muscle’s ability to maximize fatigue tolerance and maintain speed development during repetitive, short duration exercises. in p w adi, singgih h, s k purnama, r i doewes, sugiyanto, m doewes, methods of physical exercise as a way to optimize the physical condition of football players: a systematic review. seejph 2023. posted: 09-04-2023, vol. xx. page 49 line with previous research, mohr & krustrup [38] also gave similar results that after 19-year-old sub-elite football players underwent training for 4 weeks (2 sessions per week), sep ratio of 1:5 (30 seconds: 150 seconds) increased capacity for intense intermittent exercise and repeated sprint ability to a higher level than 1:1 ratio sem exercise (45 seconds: 45 seconds). this could be due to the higher exercise intensity during the sep exercise intervention than the sem. if the goal is to increase fatigue resistance, sem can be a recommended alternative exercise. high-intensity interval training laursen & jenkins [31] explained that endurance will be increased if using hit. this increase is partly due to the upregulation of aerobic and anaerobic metabolism for energy requirements. several studies explain that high-intensity interval training programs are implemented to increase cardiorespiratory capacity. but on the other hand, the high-intensity interval training program that is run can also give different results. as cvetković et al [10], in their experiment gave different results that a 12-week high-intensity interval training program could lead to positive changes in muscle fitness, flexibility, and biochemical parameters in overweight and obese children. in addition, gökkurt & kivrak [22], also gave different results. after undergoing a high-intensity interval training program for 8 weeks, the experimental group experienced significant improvements in speed, acceleration, and agility. when combined with other types of exercise also give different results. as in the experiment of paul et al [60], which combined highintensity training and small-sided games, for 4 weeks effectively increased anaerobic endurance, power, and agility in football players aged 16.2 ± 0.7 years. different case if separated, will give different results. ssg training is an effective exercise to improve technical ability and agility, while hiit is more suitable for speed and rsa-based conditioning in young football players [2]. tabata sprint training tabata training helps improve athletic performance. the tabata training protocol was carried out with constant exercise intensity (that is, 170% vo2max) from the first to the last exercise session [61]. the tabata protocol is one of the hiit models with a short time but high intensity followed by a relatively short recovery compared to p w adi, singgih h, s k purnama, r i doewes, sugiyanto, m doewes, methods of physical exercise as a way to optimize the physical condition of football players: a systematic review. seejph 2023. posted: 09-04-2023, vol. xx. page 50 execution time. nithin et al [62] explained that the tabata training method lasted for 4 minutes with 8 intervals. the exercise is carried out with a work duration of 20 seconds, 10 seconds of recovery and then repeat the pattern 8 times. in this case, ajayaghosh [39], with a protocol of more than 4 minutes reported findings that during 12 weeks of tabata sprint training carried out with 3 exercise protocols (4.05 minutes short term, 8 minutes medium term, and 11 minutes long term), showed a significant improvement on the speed of football players aged 20-25 years. the short-term protocol was performed in 1 set with a duration of 20 seconds of work and 15 seconds of recovery per set, 7 repetitions. the medium-term protocol was performed with 2 sets with a duration of 20 seconds of work and 10 seconds of recovery per set, 6 reps. the long-term protocol was performed in 3 sets with a duration of 20 seconds of work and 10 seconds of recovery per set, 6 repetitions. very-heavy sled training very-heavy sled training is a weight training based on body mass. kawamori et al [28] used an external load that reduced sprint velocity by about 30 and 10%, respectively, reporting that the heavy group significantly increased sprint time of 5 and 10m by 5.7 ± 5.7 and 5.0 ±, respectively. 3.5% (p<0.05). on the other hand, morin et al [63] also in their experiment for 8 weeks (2 sessions per week) on 26-year-old soccer players showed that using a much larger load of 80% of body mass, clearly increased the maximum horizontal-force production. compared to standard unloaded sprint training. in addition, the increase in sprint performance of 5 m and 20 m was moderate and small for the very-heavy sled group and small and trivial for the control group. pilates training segal et al [64] explained that pilates training is designed to improve flexibility and overall health by emphasizing core strength, posture, breathing, and movement coordination. pilates exercises are designed to place participants in positions that minimize unnecessary muscle recruitment and lead to decreased stability, premature fatigue, or impaired recovery. chinnavan et al [9] reported that pilates training for 4 weeks (5 sessions per week) performed with leg circles, leg ups and downs, scissocrs, sidekicks, the saw, spine stretch, soulder bridge, neck pulls, pilates push ups, showed p w adi, singgih h, s k purnama, r i doewes, sugiyanto, m doewes, methods of physical exercise as a way to optimize the physical condition of football players: a systematic review. seejph 2023. posted: 09-04-2023, vol. xx. page 51 an increase in hamstring flexibility in football players aged 17-20 years. increased flexibility involves biomechanical, neurological, and molecular mechanisms that determine long-term outcomes. after undergoing pilates training, the muscles become elastic gradually. functional training functional training is considered as an alternative to improve various measures of muscle fitness including strength, endurance, coordination and balance [65]. functional training consists of characteristic physical movements to develop strength aimed at the entire human body. during functional training, the correct execution of exercises will lead to the development of the athlete’s mobility and stability. this increased capability reduces the risk of accidents being suffered during the attempt. tasevski et al [66] reported that functional training for 6 weeks with 4 sessions per week in the form of circuits had a positive effect in improving agility test results. in the first 2 weeks, 3 rounds were carried out at each station, 20 seconds duration per station, 90 seconds pause between stations. week 3 and 4, 3 rounds at each station, duration 30 seconds per station, 90 seconds pause between stations. week 5 and 6, 3 rounds at each station, duration 40 seconds per station, 90 seconds pause between stations. conclusion after a systematic review, several training programs were found to improve the physical condition of football players such as strength, aerobic and anaerobic endurance, muscle power, speed and 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education, sport and health, skopje, 2020. __________________________________________________________________________________________ © 2023 pomo warih adi et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 1 | 16 original research switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study salvatore italia1, peter schröder-bäck1, helmut brand1 1 department of international health, school caphri: care and public health research institute, maastricht university, the netherlands. corresponding author: salvatore italia address: duboisdomein 30, 6229 gt maastricht, the netherlands telephone: +31 433882343; e-mail: salvatore.italia@maastrichtuniversity.nl italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 2 | 16 abstract aim: unwanted pregnancy is an important social issue, not least among teenagers. emergency contraceptives (emcs) can prevent from unintended pregnancy, if taken quickly after unprotected sex. this study’s objective was assessing abortion/birth rates among adult and teenage women in europe before/after an emc switch to non-prescription status. methods: national authorities were consulted for emc consumption data and abortion/live birth statistics. rates (n=26 countries) in the year before the switch (= year of reference) were compared with rates before/after the change (up to ±15 years). the focus was laid on the european union and further countries closely related to the european union. results: all countries with available data (n=12) experienced a substantial increase of emc consumption after the switch. on average, abortion rates among women aged 15–49 years were 83% higher 15 years before (compared with the year of reference) and 14% lower 15 years after the switch. correspondingly, teenage abortion rates were 35% higher 15 years before and 40% lower 15 years after the switch. in 2017, no country had higher teen abortion rates than at time of the switch. teen birth rates continued decreasing at almost the same rate after the switch as before. conclusion: an emc switch to non-prescription status increases emc use and may contribute reducing unwanted pregnancy among teenage girls. keywords: emergency contraceptives, europe, levonorgestrel, over-the-counter, prescription status, ulipristal acetate. conflicts of interest: none declared. italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 3 | 16 introduction for 2008, about 41% of pregnancies worldwide were estimated to be unplanned (1). four years later, this proportion was stable at 40%, highest in latin america (56%) (2). unwanted pregnancies are an important social issue in europe as well (rate estimated at 45%), and many are likely to end in induced abortion (50%) or unplanned birth (about 38%). especially among teenagers, the rate of unintended pregnancy is supposed to be very high (roughly 80% of all pregnancies among american teenagers are unwanted) (1). using long lasting oral reversible hormonal contraceptives regularly could be an ongoing protection from unwanted pregnancy, but this reliable method is not used by all fertile women (in 2012, by 82.5% in portugal, but only by 33.2% in lithuania) (3). one effective option avoiding unintended pregnancy after unprotected sex is quickly taking an emergency contraceptive (emc). in europe, mainly two active ingredients are used for emergency contraception, levonorgestrel (lng) and ulipristal acetate (upa), which have to be taken within 72 hours (lng) or 120 hours (upa) after unprotected sex. as time is a crucial factor and emcs are considered to have a good safety profile, the european medicines agency (ema) recommended switching upa (ellaone®) from prescription-only to non-prescription status in november 2014 to speed up access to emcs. the following legally binding decision of the european commission valid (in principle) throughout the european union (eu) made upa available as an over-thecounter (otc) drug across the eu (3,4). about 20 years ago, when lng or upa were not (freely) available for emergency contraception, pregnancy rates among teenagers were higher in many european countries compared to 2017, e.g. 55 per 1000 adolescents aged 15–19 years (england and wales), or 68 per 1000 adolescents aged 15– 19 years in hungary (5), and most teen pregnancies ended in abortions or presumably unplanned births. one hope linked with facilitated access to emcs was reducing abortion/teen births rates. however, also concerns were expressed regarding prescription-free availability of emcs, moral worries as well as medical fears, e.g. that changes in sexual behaviour especially among adolescents could also lead to misuse and hence increase abortion rates instead of decreasing them (6), or that sexually transmitted infections might rise again (7,8). this study’s objective was to analyse the potential impact of an emc switch to nonprescription status on unwanted pregnancy. this was done by assessing abortion rates among women aged 15–49 years and abortion and live birth rates among adolescents <20 years in europe since and also before the switch of emcs to nonprescription status. within europe, we mainly focused on the european union (eu) and the european free trade association (efta). a further aim was collecting emc consumption data since their market introduction. methods consumption of emcs emc consumption was investigated at the national medicines authorities (direct contact or yearly consumption reports). another source for data on emc use were drug consumption databases and emc-related publications (9,10). year of reference italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 4 | 16 following emcs with their anatomical therapeutic chemical classification codes (atc) were under research: 1. atc code g03ad01 (lng); approved first in eastern europe in 1979 and marketed in western europe since the 1990s. 2. atc code g03ad02 (upa); approved in europe in 2009 and recommended by the ema in november 2014 to have nonprescription status. 3. atc code g03aa07 (levonorgestrel + ethinylestradiol); dedicated preparations (brand names tetragynon®, schering pc4®) marketed as prescription-only products in several european countries (since the 1980s) and first emc with non-prescription status in iceland (in 1998). the year/month of an emc switch to nonprescription status (date one out of the three emcs mentioned above was made available without medical prescription for the first time) was checked at the national medicines authorities (homepage or contact by e-mail). additionally, emc-related publications were screened. the year preceding the switch was defined as ‘year of reference’ for comparing development of rates after/before the switch, if the switch became operative between january and october. for countries where the switch came into force in november or december, the year of switch was defined as ‘year of reference’, as a switch towards the end of the year may hardly have had an impact on the same year’s abortion statistics. the year of switch was defined being the first year ‘after’ a switch. hence, statistics after the switch were compared with figures in the ‘year of reference’ ended. correspondingly, to take into account long-term trends, also rates in the years before the switch were compared with rates of the ‘year of reference’ ended. analysis of rates to obtain statistics on abortions and teen births, the homepages of national statistical offices were consulted or respective authorities were contacted directly (data sources available as supplementary material). for analysis of induced abortion rates (spontaneous abortions were not considered, as not mentioned in many abortion statistics) among the whole fertile female population, the total number of legally induced abortions was sought and referred to 1000 women aged 15–49 years. if stratified data were available, induced abortions performed to the countries’ residents only were considered. population structures were obtained from national statistical offices. respectively, the number of induced abortions and live births (still births were excluded, since not available for all countries) among adolescents <20 years was referred to 1000 women aged 15–19 years. if absolute numbers for abortions/live births were not available, rates were adopted as reported by the countries’ authorities. generally, abortion and live birth rates for women aged 15–19 years presented in this study mostly include the figures for girls <15 years, as this is mainly the method how authorities report the rates for this age group. however, abortion/birth figures for girls <15 years are almost negligible for the calculation of teenage abortion/birth rates. abortion statistics for residents from ireland and northern ireland were extracted from the annual abortion reports of the united kingdom, since ireland and northern ireland italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 5 | 16 have very restrictive abortion laws and only few abortions were performed in ireland and northern ireland. rates for countries (e.g. england and wales, the netherlands, sweden) generally reporting rates among women aged 15–44 years (instead of 15–49 years) were recalculated for the 15 to 49-year-old female population. for some years, figures on abortions or live births were not available from the national authorities. therefore, rates were extracted from graphs provided by national health/statistical authorities or calculated based on figures from the historical johnston archive (11), the world health organization (12), eurostat (13), or the world bank (14). data were collected up to the year 2017. results history of emc accessibility exactly 26 countries were included in this comparative study (23 eu countries, 3 efta countries). iceland (1998) and france (1999) were the first countries making emcs available without medical prescription. according to the icelandic medicines agency, the first emc available (tetragynon®) was classified as otc medicine immediately after receiving marketing authorization in june 1998, as well as lng, which was freely available since january 2003. among the last european countries changing at least one emc (upa or lng) to otc status were germany, italy, and croatia (all in 2015). hungary decided keeping the prescriptiononly status for all emcs, poland switched upa to otc status in april 2015, but the new polish government abolished the decision and re-switched upa to prescription-only status again in july 2017 (lng never received otc status in poland). the most recent european countries making emcs accessible without medical prescription were malta (december 2016) and andorra (june 2018). in gibraltar, a self-governing british overseas territory, emcs were switched to otc status in august 2017 only, about 8 years after the switch in the neighbouring country spain, and more than 16 years later than in the united kingdom itself. rates after the switch in the year before the switch, total abortion rates ranged between 3.2 (croatia) and 31.5 (estonia) abortions per 1000 women aged 15–49 years. the mean for the 26 included countries was 11.8. exactly 19 countries experienced a reduction of abortion rates since the switch. the sharpest decline was observed in latvia (-63% within 15 years). in 7 countries, abortion rates among the total female population were slightly higher in 2017 (or in the year with most recent available figure) compared with the year of reference (table 1). the development of abortion rates among adolescents aged 15–19 years revealed a relatively uniform picture (table 1). in all countries except belgium and greece (for which most recent figures were available for 2011 and 2012 only) abortion rates fell. the biggest reductions since the switch were visible in latvia (-73%) and norway (-67%). on average, abortion rates dropped from 12.0 at time of the switch to 6.9 abortions/1000 adolescents aged 15–19 years in 2017. italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 6 | 16 table 1. induced abortion and live birth rates at time of the otc switch compared with rates in 2017 rates in the year of referencea rates in 2017a country switch reference abortions 15-49 abortions 15-19 births 15-19 abortions 15-49 abortions 15-19 births 15-19 belgium apr 01 2000 5.6 6.9 10.7 7.8* 8.4* 5.8 bulgaria jan 06 2005 22.4 15.6 40.4 16.0 14.3 39.7 croatia apr 15 2014 3.2 1.8 10.3 2.7 1.5 9.3 czech republic nov 11 2011 9.6 7.1 11.3 8.2 5.6 11.9 denmark jun 01 2000 12.5 14.2 7.9 12.1*** 11.3*** 2.8 estonia sep 03 2002 31.5 28.9 23.0 13.9 10.8 10.1 finland jan 02 2001 8.9 15.5 10.7 8.2 7.6 4.9 franceb may 99 1998 13.4 13.2 7.1 14.4 10.4 4.7 germany mar 15 2014 5.6 4.4 6.1 5.8 4.0 6.3 greece jun 05 2004 6.0 2.1 10.8 6.8** 2.4** 9.0 iceland jun 98 1997 13.6 20.6 24.3 13.3 12.6 6.0 ireland feb 11 2010 3.7 3.2 14.4 2.6 1.4 6.9 italy apr 15 2014 7.0 5.4 5.6 6.2 4.3 4.3 latvia may 03 2002 25.1 17.0 21.5 9.2 4.6 15.0 lithuania jul 08 2007 11.7 7.3 19.5 6.9 3.2 12.2 netherlands jan 05 2004 7.4 8.2 4.6 7.2 5.3 2.0 norway jul 00 1999 13.4 19.0 11.7 10.6 6.3 3.0 romania nov 06 2006 28.3 23.1 40.1 12.4 10.2 38.5 slovak republic apr 04 2003 9.8 6.6 20.8 5.8 4.3 27.3 slovenia mar 11 2010 9.0 6.7 4.9 8.1 4.0 4.0 spain sep 09 2008 9.7 12.7 13.2 8.7 8.8 7.2 sweden apr 01 2000 15.6 21.1 5.0 16.8 13.0 3.1 switzerland (cantone berne)c oct 02 2001 5.2 4.9 3.4 5.0 3.2 2.1 uk (england & wales) jan 01 2000 14.1 23.7 29.3 14.4 14.7 12.7 uk (scotland) jan 01 2000 9.6 18.4 29.3 9.9 12.9 13.0 uk (northern ireland) jan 01 2000 3.7 4.8 25.6 2.2 2.1 12.4 mean 11.8 12.0 15.8 8.9 6.9 10.5 arates are displayed per 1000 women of the respective age group (figures for girls <15 years are normally included) bfrance métropolitaine (=france without guadeloupe, martinique, guyane, la réunion, mayotte) cno long-term abortion data available for switzerland as a whole rates in bold letters are higher compared with rates in the year of reference * 2011 figures ** 2012 figures ***2015 figures italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 7 | 16 live birth rates among women aged 15–19 years fell in most countries. only the czech republic and germany had slightly higher rates in 2017 compared with the year of reference. however, the slovak republic had clearly higher birth rates after the switch and was the only country in this study were the sum of teenage abortion and live birth rates was higher in 2017 compared to the year of reference. further abortion and live birth rates for some european countries with incomplete statistics are displayed in table 2. table 2. induced abortion and live birth rates for further european countries rates in the year of referencea rates in 2017a country switch reference abortions 15-49 abortions 15-19 births 15-19 abortions 15-49 abortions 15-19 births 15-19 andorra jun 18 2017 na na 3.4 na na 3.4 austria dec 09 2009 no stat no stat 10.4 no stat no stat 6.8 cyprus ? --no stat no stat --no stat no stat 6.6 hungary still rx --na na na 12.6 16.1 23.2 luxembourg may 05 2004 no stat no stat 10.9 no stat no stat 5.2 malta dec 16 2016 na na 13.6 na na 12.5 polandb apr 15 2014 na na 13.4 na na 11.1 portugal oct 00 1999 na na 21.1 6.7 5.5 8.0 rx=prescription-only na=not applicable (abortion illegal or emcs available with prescription only) no stat=no official data available ?=emcs have otc status, but date of switch not determinable arates are displayed per 1000 women of the respective age group (figures for girls <15 years are normally included) bemcs were re-switched to prescription-only status in july 2017 long-term analysis of rates fifteen years before the switch, the average abortion rates were 26.9 per 1000 women aged 15–49 years (data available for n=25 countries) and 15.2 per 1000 girls aged 15– 19 years (data available for n=20 countries), ranging from 4.4 (northern ireland) to 153.8 (romania) for all age groups and from 1.6 (greece) to 55.0 (romania) for teenagers. live birth rates (mean=24.4; data available for n=26 countries) were lowest in switzerland (3.0) and highest in bulgaria (69.9). in the mean, abortion rates among women aged 15–49 years were 83% higher 15 years before the switch in comparison with the year of reference, whereas 15 years after the switch, rates were 14% lower compared with the year of reference (figure 1). the corresponding percentages for abortions among teenagers were +35% (15 years before switch) and -40% (15 years after the switch). hence, the falling trend for abortions among teenagers was visible already before the emc switch, but the mean decline was stronger after the switch. in contrast, for all age groups the trend towards lower abortion italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 8 | 16 rates was almost stopped after the switch (also when considering that the slight decline after the switch is mostly attributable to the decline among adolescents, which are included in the figures for the total age groups). on average, live birth rates declined at almost the same rate after the switch as they did already before the emc change to otc status. figure 1. long-term analysis of abortion/live birth rates for n=26 european countries 15 years before and after the year of reference.* *for the calculation of the mean relative change (rate in the year concerned/rate in year of reference), each country contributes the relative change according to availability of data (e.g. denmark for all years from -15 to +15, ireland from -15 years to +7 years, etc.). in most countries from eastern europe, abortion rates declined extremely after the fall of the berlin wall in 1989, which might be explained by the fact that regular contraceptives were used less compared with western europe. hence, abortion might have been regarded being a common option for family planning. for eight countries from western europe only (finland, denmark, iceland, norway, sweden, switzerland, united kingdom (england & wales), united kingdom (scotland)), a full history of 15 years before and after the emc switch is available. these countries (figure 2) may therefore provide a picture which is biased less by social turmoil as it might have been if including also data from eastern europe (figure 1). moreover, almost all dispensing pharmacists from these eight countries may have respected nonprescription rules before the switch, which may possibly not be the case if viewing at all 26 included countries. italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 9 | 16 figure 2. long-term analysis of abortion/live birth rates 15 years before and after the year of reference for eight countries with a complete ±15 year-history before/after the emc switch.* *the eight included countries are finland, denmark, iceland, norway, sweden, switzerland, united kingdom (england & wales), united kingdom (scotland). emc sales figures for 12 countries, precise consumption numbers or sufficiently reliable estimations were available (figure 3). almost all countries showed a quick and strong increase of sales after the switch and reached an almost stable consumption peak after 8–10 years, seven countries evening out at about 80–100 used emcs per 1000 women aged 15–49 years per year. norway, showing the biggest increase, is observing a reduction of emc use since reaching the peak ten years after the switch, now also approaching a level of 100 emcs per 1000 women aged 15–49 years. across the included countries, a direct linear correlation of emc consumption and abortion rates is, however, not visible, as e.g. france and finland have now similar per capita emc consumptions, but different abortion rates. the results (figure 3) are approximately in line with corresponding results from a study providing estimations of emc consumption in 2013 for almost all eu countries (15). nevertheless, several countries with the lowest per capita consumption of emcs in 2013 are currently among the eu countries with the highest teenage abortion and/or live birth rates (romania, bulgaria, hungary, slovakia, england & wales, czech republic, poland). italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 10 | 16 figure 3. emc consumption over time (figures include atc codes g03ad01, g03ad02 and g03aa07).* *for scotland, the consumption may be underestimated between 2001 (year of switch) and 2008 (introduction of free-of-costs program) as figures for emcs sold without prescription are not available and hence are not included in data provided by the national health service in figure 3. for further countries with no long-term data on emc consumption, there have been reports of markedly higher emc use after the switch, e.g. switzerland, portugal, spain (1618). discussion emergency contraception is a highly controversially discussed topic, to which various societal institutions such as medical/pharmaceutical societies, the churches, or feminist organizations contribute their opinion, which may sometimes be based more on personal beliefs or interests rather than on crude facts. the issue of barrier-free access to emcs deserves, however, a sober analysis, evaluating its potential risks and benefits, as discussed for lng in a 2003 publication (19). the efficacy of emcs containing lng or upa has been proven sufficiently by several studies (20,21). similarly, the ema estimated that for women taking upa within five days after unprotected sex, it would be able to prevent about three-fifths of pregnancies. based on the positive riskbenefits ratio, the ema recommended upa to be changed to non-prescription status throughout europe (22). in contrast to some concerns expressed before, facilitated access to emcs did not increase teen abortion rates in general, e.g., due to a change of sexual behavior, incorrect or excessive use of emcs instead of ongoing hormonal contraception (23). no country (except belgium and greece, where latest italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 11 | 16 available figures are from 2011/2012 and may have fallen since then) showed longterm trends towards higher abortion rates among teenagers after the switch, and in only seven countries total abortion rates were slightly higher in 2017 than at time of the switch. interestingly, in andorra, having very restrictive abortion laws, live birth rates were almost stable from 2000 to 2008 for younger and older women as well. since 2009, rates began falling strongly until 2017 for the two youngest age groups (-60% for teenagers; 63% for women aged 20–24 years), while live birth rate for women aged 25–49 years fell by only 20%. two emc-related events may explain the drop especially among young girls: firstly, emcs were available in andorra at least with a medical prescription since 2008 (switch to otc in 2018 only), and secondly, emcs received otc-status in the bordering state of spain in 2009, easily accessible in case of need for women residing in andorra. a 2016 study found a direct correlation within germany of higher emc use with lower abortion rates. german regions with highest use (bavaria, baden-württemberg) showed the lowest abortion rates, those with lowest use had the highest abortion rates (saxony-anhalt, mecklenburgvorpommern) (24). on the other hand, the question arises whether in countries with a substantial growth of emcs sales after the switch abortion/teen birth rates should not have declined stronger and faster after the switch than observed in reality (e.g. france). possibly, country-specific social factors have also great weight, and perceptible reductions of abortion rates should not be expected quickly, anyway, as it takes roughly 8–10 years on average until emc consumption reaches an almost stable maximum. additionally, it may also take several years until most girls have learned using emcs correctly (quick administration; taking a second dose in case of emesis within 3 hours after the first dose; respecting interactions with other medicines; etc.). with concern to emcs’ action of mechanism, the who asserted clearly that lng and upa have no abortifacient effects (25). however, this debate has not been fully settled yet, and some authors state that emcs’ actions of mechanism (especially with regard to upa) might potentially be interpreted as being abortifacient (26-28). nevertheless, even if emcs should have abortifacient effects, the question rises, how many of the women not taking an emc (because of restricted access) after unprotected sex would finally anyway seek abortion service if getting pregnant unintentionally. hence, it could be discussed if a hypothetical early-stage abortion would not be preferable to having a real abortion at a later stage of pregnancy, which of course is a serious and stressing decision. unwanted pregnancy represents an economic burden for society as well, as shown for norway (for teenagers, direct and indirect costs estimated at €1573 per unwanted pregnancy) and the uk (direct health care costs estimated at £1663 per unwanted pregnancy) (29,30). thus, it may be worth it also from an economic point of view assessing whether emcs should be covered by social security (at least for teenagers), although an increase of emc consumption after a switch, of course a welcome business for the producing pharmaceutical companies, may be a challenge for those social security systems fully covering emcs (31). however, some studies/figures showed that barrier-free access to emcs seems sometimes to be more important rather than full coverage (32,33). italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 12 | 16 it is, finally, an ironic twist of fate, that the very country (hungary), where modern lng-containing emcs had been developed and approved first in 1979 is now one of the very few european countries keeping the prescription-only status for lng and upa (34,35). remarkably, in contrast to most of the other countries, abortion rates among hungarian teenagers fell only slightly since 2001 (16.1 in 2017 vs. 19.7 in 2001), and teen live births rates are almost on the same high level (23.2 in 2017 vs. 22.0 in 2001) as one and a half decades ago. today, both teen abortion and live birth rates in hungary are among the highest in europe. limitations for this study, recent/historical abortion statistics for most eu and efta countries were collected from national statistical offices or health authorities, which are supposed to provide the best possible national data on abortion and birth statistics. to our knowledge, this is the first study comparing on european level the development of abortion rates with respect to the year emcs were made available without medical prescription. however, no data were available for the efta country liechtenstein and for two micro-states closely related to the eu (san marino, monaco). the quality and methods of data collection may vary across the european countries as well as legal definitions of ‘abortion’ or differences between officially reported numbers of legally induced abortions and estimated numbers of induced abortions actually performed (e.g. greece) (36). several aspects may have interfered with the use of emcs and development of abortion rates over time. however, according to agestratified consumption data from denmark and sweden (precise data from other countries are scarce), use of conventional hormonal contraceptives (which may also have changed over time) was not directly linked to the development of abortion/birth rates during the respective observation periods. no reliable information is available about how the legal status of pharmaceuticals is respected by pharmacies in the included countries. in some countries, prescriptiononly status may exist pro forma only (37), thus self-medicated emcs may have influenced abortion/live birth rates already before the formal switch to over-the-counter status. finally, the exact levels of awareness about and correct use of emcs were not available, and it is likely that time to reach high levels of awareness about otc availability of emcs and their correct use differ between countries. conclusions this study cannot provide evidence of a causal link between an emc switch and subsequent changes in abortion/live birth rates. however, pooled data, timely correlation of drops in abortion/live birth rates with emc switch and the increase of emc use after the switch suggest that overthe-counter availability of emcs contributes reducing unwanted pregnancy especially among teenagers. further studies are necessary to explain why in many countries the reduction of abortion rates was limited mainly to younger age groups (according to danish data, per capita use of emcs is highest among teenagers, thus possibly older women use generally emcs less in other countries, too). also, the question should be addressed why in some countries the decline of abortion rate was visible several years after the emc switch only, despite of an italia s, schröder-bäck p, brand h. switching emergency contraceptives to non-prescription status and unwanted pregnancy among adult and teenage women: a long-term european comparative study (original research). seejph 2020, posted: 17 january 2020. doi: 10.4119/seejph-3277 p a g e 13 | 16 immediate and substantial rise in emc consumption after the change. weighing the pros and cons, it seems that in sum, the benefits of otc access to emcs may prevail. additional measures such as free-of-cost dispensing of emcs to minors or intensive information campaigns may support achieving lower abortion rates, if the switch to non-prescription status proves being not sufficient. reasonable self-medication, however, requires safe and affordable drugs, access to high-quality advice about emcs (e.g. in pharmacies) and/or well informed people. acknowledgements we would like to thank all authorities who contributed detailed information and also gedeon richter for providing data with regard to the date of switch of emcs in bulgaria and romania. references 1. the european society of contraception and reproductive health (esc) and the international federation of gynecology and obstetrics (figo) [internet]. the global epidemic of unintended pregnancies. available from: https://www.figo.org/sites/default/fil es/uploads/generalresources/figo_esc_unwanted%2 0pregnancy%20slides.pdf (accessed: may 11, 2019). 2. guttmacher institute [internet]. new study finds that 40% of pregnancies worldwide are unintended. 2014. available from: https://www.guttmacher.org/newsrelease/2014/new-study-finds-40pregnancies-worldwide-areunintended (accessed: may 11, 2019). 3. european consortium for emergency contraception [internet]. available from: www.ec-ec.org (accessed: may 11, 2019). 4. italia s, brand h. status of emergency contraceptives in europe one year after the european medicines agency’s recommendation to switch ulipristal acetate to 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health matters 2004;12:174-83. 37. roshi d, italia s, burazeri g, brand h. prevalence and correlates of emergency contraceptive use in transitional albania. gesundheitswesen 2019;81:e127e132. doi: 10.1055/s-0043-119085. ___________________________________________________________ © 2020 italia s et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.abda.de/fileadmin/assets/zdf/zdf_2018/abda_zdf_2018_brosch.pdf https://www.abda.de/fileadmin/assets/zdf/zdf_2018/abda_zdf_2018_brosch.pdf https://www.abda.de/fileadmin/assets/zdf/zdf_2018/abda_zdf_2018_brosch.pdf https://postinorpill.com/about-richter-gedeon/ https://postinorpill.com/about-richter-gedeon/ joshua ia, bauche j, abdulla s. managing antimicrobial resistance from medical and veterinary health systems perspectives to achieving universal health coverage in the african region (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4446 1 | p a g e review article managing antimicrobial resistance from medical and veterinary health systems perspectives to achieving universal health coverage in the african region istifanus anekoson joshua1, joel bauche2, salim abdulla3 1department of community medicine, college of medicine, kaduna state university, kaduna, kaduna state, nigeria 2department of veterinary public health and preventive medicine, faculty of veterinary medicine, ahmadu bello university, zaria, kaduna state, nigeria 3ifakara health institute, box 78373, dar-es-salaam, tanzania corresponding author: dr. istifanus anekoson joshua, address: department of community medicine, kaduna state university, pmb 2339 tafawa balewa way, kaduna state, nigeria; e-mail: dristifanus@yahoo.com mailto:dristifanus@yahoo.com joshua ia, bauche j, abdulla s. managing antimicrobial resistance from medical and veterinary health systems perspectives to achieving universal health coverage in the african region (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4446 2 | p a g e abstract antimicrobial resistance (amr) is a threat to global health security and may reverse the gains in preventive medicine. this is worsened by the fact that development of resistance out-paces that of new antimicrobials. the factors driving the development of amr range from health systems to socio-economic and environmental factors. these include poor antimicrobial stewardship, poor access to quality drugs, prescribing antimicrobials without susceptibility laboratory tests, use of antimicrobials in crop, animal production and aquaculture farming. others are lack of coordinated medical and veterinary health systems strengthening, poor universal health coverage and practice of one health. the burden of the problem is of public health importance especially in africa where there is high incidence of poverty, high incidence of out-of-pocket health expenditure, lack of basic social amenities and weak health systems with poor collaboration. the impact of amr includes increased burden on the healthcare system, hospital admission, cost of patient treatment, poor clinical outcomes and impact on food security, among others. in view of the interplay of various systems and factors in the development and emergence of amr, there is need for multi-sectoral and interdisciplinary approach at global, regional, national and local levels for its prevention and mitigation. strengthening of health systems from the medical and veterinary perspectives and universal health coverage are critical in the fight against amr. the relevant stakeholders include political leaders, community leaders, health professionals, academics, and research institutions, federal and state ministries of health, agriculture, education and nongovernmental organisations among others. keywords: africa, antimicrobial resistance, health systems, universal health coverage conflict of interest: none declared joshua ia, bauche j, abdulla s. managing antimicrobial resistance from medical and veterinary health systems perspectives to achieving universal health coverage in the african region (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4446 3 | p a g e introduction the increasing health threat from emerging infectious diseases and antimicrobial resistance (amr) require an urgent global response, especially in africa for reasons such as weak medical and veterinary health systems (hs) and high poverty level, among others. these could reduce access to appropriate, quality antimicrobials and subsequent emergence of amr. antimicrobial resistance has been described as a global crisis by the united nations (un) general assembly, world health organisation (who), world leaders of g7 and g20, world bank (wb), african union (au) , european union (eu); and it is one of the greatest threats to public health requiring urgent global response (1,2,3). it is a trans-boundary problem in which the organisms require no international passport (4). amr threatens all countries in different ways and to varying extents; and despite scanty information, the data available showed evidence of increasing trends of amr in the african region and the rest of the world (5, 6). this paper discussed antimicrobial resistance, hs and universal health coverage (uhc), their interactions and the potential of applying the principle of universal health coverage to prevent/ mitigate the problem of amr (figure 1). methods this paper is a narrative review using searches of peer-reviewed articles published between 1999 and 2020 in databases such as pubmed, medline, african journal online (ajol), bioline international, popline and google scholar; and grey literatures such as reports and research briefs. the words used for search were africa, antimicrobial resistance, health systems and universal health coverage. results and discussion antimicrobials and antimicrobial resistance antimicrobials are drugs used for the treatment of infectious agents such as bacteria, viruses, fungi, parasites and have played prominent role in human and veterinary medicine, agriculture and environment (7). they are global public good which have improved health care, saved lives and enhanced economic gains (8, 9). antimicrobials are cornerstone on which the hs is standing on, not only for the basic treatment of infections, but also for medical and surgical procedures (10, 11). however, the emergence of resistant microorganisms has compromised their effectiveness (12). amr is defined as the development of resistance in a microorganism to an antimicrobial agent to which it was previously sensitive (13). access to quality antibiotics which is a subset of antimicrobials used to treat bacteria is very essential in the treatment and prevention of resistance. in africa, amr has been documented to be a problem for hiv and the pathogens that cause tuberculosis (tb), typhoid, meningitis, gonorrhea; bovine tb, pseudomonas oryzae and pseudononas syringae infections (1,14 ,15). sixty percent of pathogens harmful to humans are of animal origin; humans and animals share the same bacteria (9). drivers of antimicrobial resistance many factors are contributing to the emergence and spread` of amr globally and in africa. these include the overuse and misuse joshua ia, bauche j, abdulla s. managing antimicrobial resistance from medical and veterinary health systems perspectives to achieving universal health coverage in the african region (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4446 4 | p a g e figure 1: chart showing the links between universal health coverage, health systems and antimicrobial resistance. universal health coverage decrease antimicrobial resistance medical and veterinary health systems joshua ia, bauche j, abdulla s. managing antimicrobial resistance from medical and veterinary health systems perspectives to achieving universal health coverage in the african region (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4446 5 | p a g e of antimicrobials, sub-optimal infection control, use of antibiotics as massive depot preparation in animal production with no observe of withdrawal periods, antimicrobial agents use for growth promotion in animal husbandry, use of substandard and/ or counterfeit drugs in both medical and veterinary practices, poor capacity to conduct antimicrobial susceptibility testing, among others (1, 16, 17, 18, 19). the transmission of amr is accelerated by impaired access to potable water, limitations in public health prevention programs such as immunization and sanitation (1). vaccination of humans and animals is a very effective way to prevent them from becoming infected, thereby reducing the need for antibiotics for the infections that do not have existing vaccines (20). the development of amr and its spread to other organisms via mobile genetic elements (plasmids and transposons) has been amplified by industrial discharges (pharmaceutical, agricultural) and human wastes contaminating the environment (21). in addition, antimicrobials are used to treat human, animal and plant diseases, depending on the species treated and particular drug used, 1080% of the drug used is absorbed or metabolized, while the remainder are excreted as active compounds through urine and faeces into the environment (21). manure and waste water are used as fertilizers in farms and sub-therapeutic antimicrobials used for treatment can serve as selective forces in amr emergence (21). antimicrobial resistant genes and bacteria with resistance to one or more drugs have been detected in surface waters, in soils, in animal feeds and on edible plants globally (21). food is likely to be quantitatively the most important potential transmission pathway from livestock to humans, although direct evidence linking amr in humans to food consumption is lacking (22). the use of antibiotics in chicken could cause resistance in humans; and mrsa in animals have been linked with that in humans (23, 24, 25, 26, 27). the globalizations of trade in food products, conventional and medical tourisms facilitate the spread of resistant bacteria (9). socioeconomic status has also been shown to have an influence on what antibiotic agents are prescribed and association with resistance and the linkages between poverty and amr (28, 29, 30). poor people are less likely to seek for medical prescription when indicated and may not afford complete treatment with adequate dose of antimicrobials (30). the burden of antimicrobial resistance the economic burden of amr is difficult to calculate due to insufficient data and the need to account for externalities especially in africa (31). however, estimates of the impact of amr on the us economy are exceedingly high, including $20 billion in direct health care costs with additional indirect costs as high as $25 billion, 2 million illnesses and 23000 deaths per year(32). the wb projects that 24 million people could fall into extreme poverty by 2030 because of amr and most would come from low and middle income countries. globally, amr is estimated to account for more than 700,000 deaths per year and if current trends continue, it will cost approximately 10 million lives per year and over us$100 trillion in lost output globally by 2050 (4). it has been estimated that about 4,150,000 deaths will be attributed to amr in africa by 2050 (4, 13, 33).the increase in amr could lead to a reduction in options available to treat infectious diseases, support joshua ia, bauche j, abdulla s. managing antimicrobial resistance from medical and veterinary health systems perspectives to achieving universal health coverage in the african region (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4446 6 | p a g e chemotherapy, surgery, and this will have a significant impact on the hs and economies (13). infections with resistant organisms have been associated with increased hospital stay, increased morbidity and mortality, use of additional drugs, laboratory tests and increased treatment cost (34, 35). this has financial implications for the individuals, families, communities and the hs (13). this has increased poverty as it has been documented that millions of africans fall into poverty due to high out of pocket health payments (36). amr could lead to loss of productivity from the spread of diseases to other animals and death of the animals, thereby threatening the sustainability and security of food production and the livelihood of farmers. drug related causes of amr and health systems poverty has been cited by who as a major force driving development of amr (37). in developing countries factors such as inadequate access to effective drugs, unregulated dispensing and manufacture of antimicrobials related to cost are contributory (37). while in america, poverty-driven practices such as medication-sharing, use of “leftover” antibiotics, the purchase and use of foreignmade drugs of questionable quality are likely contributing to amr; this has also been reported in africa (38). in many hs, widespread inappropriate use of antibiotics combined with inadequate access especially for the poor contributes to the problem of amr (5). poor collaboration between the human and veterinary/animal health sectors is also a problem. little data exist about the individual practices of veterinarians in africa and most antibiotic prescriptions are used during animal production. veterinary antibiotics can be purchased on the open market just as human antibiotics and the lack of separation of antibiotics used for animals and that for humans, which have negative public health consequences. lack of stringent penalties on manufacturing and distribution of substandard and counterfeit drugs in africa is also a challenge (39). what has been done in response to amr? the who 2015 global action plan on amr underscores the need for collaboration between human, animal, food and environmental sectors (7). also, the who 2018 competency framework for health workers’ education and training on amr has four main amr domains, namely building awareness of amr, appropriate use of antimicrobials, infection prevention and control and diagnostic stewardship (40). in africa, the africa centre for disease control and prevention (africa cdc) has established the amr surveillance network (amrsnet) which is a network of public health institutions and leaders from human and animal health sectors who will collaborate to measure, prevent, and mitigate harms from resistant organisms. amrsnet’s four goals are: improve surveillance of amr organisms among humans and animals; delay emergence of amr; limit transmission of amr and mitigate harm among patients infected with amr organisms (1). the tripartite collaboration between who, food and agricultural organisation (fao) and the world organisation for animal health (oie) has provided critical leadership to foster concerted efforts aimed at combating the threat of amr at a global level in recent years but remains seriously underresourced (41, 42). nigeria, being the most populated country in west africa has to take joshua ia, bauche j, abdulla s. managing antimicrobial resistance from medical and veterinary health systems perspectives to achieving universal health coverage in the african region (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4446 7 | p a g e the lead in tackling amr using the ‘one health’ approach, which acknowledges the links among humans, animals and the environment as the corner stone of its plan (39). the government has focused on good leadership, multidisciplinary approach, enforcement of regulations, public education and community participation on tackling the growing amr problem (39). the medical and veterinary health systems health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health (43). a good hs should be “steeep”, namely safe, timely, effective, efficient, equitable and patient-centred. the who health system framework describes hs in terms of six core components or “building blocks”, which are leadership/governance, health workforce, financing, service delivery, health information system and access to essential medicine, antibiotics inclusive. therefore, to preserve antibiotic effectiveness, interventions need to be implemented throughout the whole hs and the whole of society (11). universal health coverage universal health coverage which is the access by all who need all basic health care services at a cost that will not expose them to financial hardship. it has the advantage of equity, quality, efficiency, accountability, sustainability and resilience. uhc include financial risk protection, access to essential healthcare services, access to safe, effective, quality and affordable essential medicines and vaccines for all. the role of uhc is vital in order to have access to these essential medicines in africa in particular, where majority of people pay for healthcare with out-ofpocket expenditure (35, 36). it ensures access by all people, to all quality services at cost not exposing them into financial difficulties, and it is central to improved access to quality drugs e.g. antimicrobials. financial access is crucial in view of the high poverty level and burden of infectious diseases in africa (35). an estimated 11 million people become poor each year and one-third of africans in need of healthcare do not have access because of financial barrier (36, 44). the uhc ensures that every citizen gets at least the minimum health package by the system. health system could have structured financing mechanism in which the government pays for the people and the one in which the people contribute. however, a pooling financing mechanism (from government or insurance) could help in risk sharing and resources allocation for majority of the citizens. the national health insurance scheme (nhis) is the best way to finance the hs whereby both government and individual have responsibilities for health and the mechanism gives people better access to healthcare. however, the nhis in nigeria mainly captures the formal sector (about 10% of the population) (45). many countries in the region have 3 key financing sources namely, donor funding, oop payment and tax-based government financing. oop payments have increased in nearly all countries, and the regional average has increased from us$15 per capita in 1995 to us$38 in 2014 (36), and oop spending for health care services in nigeria is among the highest in the world with 72% [39]. this could lead to poor access to quality healthcare and quality antimicrobial which will result in amr. out-of-pocket payment is the simplest financing mechanism, and because it does not ensure equity and financial risk protection, it is universally joshua ia, bauche j, abdulla s. managing antimicrobial resistance from medical and veterinary health systems perspectives to achieving universal health coverage in the african region (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4446 8 | p a g e agreed to be the worst way to finance hs (46). here the health services are according to ability to pay not need. the uhc as an approach that is linked to financing mechanism, it has health, political and economic benefits (46), and can provide an ideal platform to manage amr through adequate provision and rational use of antimicrobials (table 1). the health system attributes and the uhc actions for addressing amr include equity, quality, efficiency, accountability, sustainability and resilience. universal health coverage can build system governance and coordination capacities that are highly relevant to tackling amr (47). government can take informed decisions and wisely allocate health investment in areas such as training of health workers, strengthening of medical and veterinary systems, improved health information, effective infection prevention and control program, vaccines and evidence-based antibiotic stewardship program, research and development (26, 33, 48). for the any uhc to be successful, the relevant stakeholders such as political leaders, community leaders, health professionals, academics, and research institutions, federal and state ministries of health, agriculture, and education and nongovernmental organisations need to work together. health financing in the abuja declaration of april 2001, the heads of states of the au countries pledged to set the target of at least 15% of the annual budgets to improve the health sector. however, only four countries met the abuja target of 15 percent of general government spending in 2014. limited commitment of domestic resources is often reflected in shortages of critical inputs namelymanpower, materials, money and minute (4ms). financial protection is generally low in africa, requiring most patients to pay for health services from their own household income (oop payments). out-of-pocket payment for health services predisposes person or families to catastrophic health expenditure and poverty. in addition, it does not allow pooling of resources and risk sharing that is beneficial to the sick persons and government. access to essential medicines sub-standard and counterfeit antibiotics are widely available in africa and have a substantial negative impact on the medical and veterinary health systems. they facilitate amr and worsen case-fatality. patients with infectious diseases that are not properly treated could develop complications requiring second-line medications that are very expensive; and sometimes may result in poor health outcomes. this can also happen in the veterinary hospitals/clinics. nigeria is among the 10 countries projected to have increased antibiotics use in veterinary medicine by 2030 (25). leadership/governance accelerating progress toward uhc in africa is within reach but will require political leadership and a clear strategic vision (36). the quality of leadership and stewardship varies at all levels of the health sector, from the top positions in the health down to officers’ incharge of hospitals or health centres. laws and policies play critical roles in framing, enabling, and protecting public health. the au and africa cdc have been playing important role. issues such as regulations for antimicrobials in food and feed, strengthening of anti joshua ia, bauche j, abdulla s. managing antimicrobial resistance from medical and veterinary health systems perspectives to achieving universal health coverage in the african region (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4446 9 | p a g e table 1: entry-points for integrating amr into universal health covering using the health systems elements (adapted from reference 43) element of health systems measures to tackle antimicrobial resistance service delivery -provision of clean water, sanitation, immunization, infection prevention and control -facilitate rational drug use through diagnostics and primary health care increase investment in veterinary services and animal health health workforce -invest in professional education, training, certification and development as well as regulation of professionals. joint scientific meetings and conferences by medical and veterinary professionals and other stakeholders health information systems -strengthen monitoring and surveillance across networks focusing on laboratories and set standards for diagnostics. access to essential medicines -ensure antimicrobials are accessible, but not used irrationally. this requires linking access with ensuring responsible use -use alternatives to antibiotics such as probiotics, prebiotics, organic acids, exogenous enzymes and essential oils among others as growth promoters in animal production health financing -consider antimicrobial resistance a risk to both the sustainable financing of universal health coverage and the individual’s ability to pay for higher cost of treatment -approach financing of universal health coverage through an antimicrobial resistance-lens -delink health worker income and profit of companies and institutions from the volume of antimicrobials sold. leadership/governance -strong political leadership, advocacy and accountability -the impact of antimicrobial resistance goes beyond health care, and systems changes should therefore be applied to the agricultural and environmental sectors regulations on antimicrobial use and prevention of infections. joshua ia, bauche j, abdulla s. managing antimicrobial resistance from medical and veterinary health systems perspectives to achieving universal health coverage in the african region (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4446 10 | p a g e microbial policies, engaging civil society organisations and standard treatment guidelines for human, terrestrial and aquatic animals, plants and environment are very crucial (1,41). health workforce health professionals are the most critical input in the delivery of health services and functioning of any hs. sufficient human resources with adequate education and skills are needed for amr surveillance and control in both human and animal health sectors (1). africa cdc has identified the need to promote stewardship programs to increase the proportions of physicians and veterinarians adhering to prudent antibiotic use guidelines, which will help delay emergence of amr and improve outcomes among patients already infected with amr organisms (1). service delivery health care services should be people-centred, qualitative, target the poor and marginalized, including those in hard-to-reach areas (35) which will improve access to basic services to the majority. however, infrastructure in most government facilities in some african countries is poor; hospital wards, outpatient clinics, health centres and health posts, along with their water and electricity supplies and sanitation are usually in need of repair, renovation or expansion. enhancing capacity of the health care workers will improve the quality of the health services, better health status of the people and animal and reduced incidence of sickness. health information systems the critical need for timely, relevant and reliable medical and veterinary data to support evidence-based decision making is very important. evidence based information is required to facilitate behavioural changes on appropriate use of antimicrobials and safeguard human and animal health (41). health data is very essential for planning, delivery of evidence based health care services, research and tracking of hs (42). real time and reliable data will help in the planning of the medical and veterinary services, identification of gaps and optimization of services. updated antibiogram results will help in rational use of antibiotics and reduced misuse, which will decrease the emergence of amr in medical and veterinary health sectors. the one health concept one health is a collaborative effort of multiple disciplines working locally, nationally, and globally to obtain optional health for people, animals and our environment (47). one health is a public good that has the potential to mitigate the negative externality of amr (47). the canadian science center for human and animal health is the first organization worldwide to house in one facility the laboratory for human and animal diseases research (47). studies have shown that implementing one health especially in low income countries will save lots of money for the veterinary and medical health systems (49). this money can be used to enhance surveillance and improve capacities in medical and veterinary hs. 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distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 48. iskandar k, molinier l, hallit s, sartelli m, catena f, coccolini f, hardcastle tc, roques c, salameh p. drivers of antibiotic resistance transmission in low and middle-income countries from a “one health” perspective—a review. antibiotics 2020, 9, 372; doi:10.3390/antibiotics9070372. www.mdpi.com/journal/antibiotics (accessed 1 november, 2020). 49. centers for disease control and prevention. core elements of hospital antibiotic stewardship programs; us department of health and human services, cdc: atlanta, ga, usa, 2014. 50. world bank group. operational framework for strengthening human, animal, and environmental public health systems at their interface; international bank for reconstruction and development/the world bank: washington, dc, usa, 2018. mendelsonm.; matsoso m.p. the world health organization: the global action plan for antimicrobial resistance. south afr. med. j 2015, 105, 325. __________________________________________________________________________ http://www.mdpi.com/journal/antibiotics http://www.mdpi.com/journal/antibiotics "сhallenges(approaches to)forinternational standards application inhealth south eastern european journal of public health volume viii, 2017 genc burazeri, ulrich laaser, jürgen breckenkamp, jose m. martin-moreno, peter schröder-bäck(eds.) jacobs verlag south eastern european journal of public health genc burazeri, ulrich laaser, jürgen breckenkamp jose m. martin-moreno, peter schröder-bäck. executive editor genc burazeri (tirana, albania and maastricht, the netherlands) faculty of medicine rr. “dibres”, no. 371 tirana, albania phone: 0035/5672071652 skype: genc.burazeri assistant executive editor kreshnik petrela, institute of public health, rr. “a.moisiu” nr. 80, tirane, albania technical editor florida beluli institute of public health, rr. “a.moisiu” nr. 80, tirane, albania editors jürgen breckenkamp, faculty of health sciences, university of bielefeld, germany (2016). genc burazeri, faculty of medicine, tirana, albania and department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands (2013). ulrich laaser, faculty of health sciences, university of bielefeld, germany (2013). jose m. martin-moreno, school of public health, valencia, spain (2013). peter schröder-bäck, department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands (2014). regional editors suzanne m. babich, associate dean of global health and professor, health policy and management, at the indiana university richard m. fairbanks school of public health in indianapolis, indiana, usa, for north america. samir n. banoob, president, intenational health mangement, tampa, florida, usa, for the middle east. jadranka bozikov, department for medical statistics, epidemiology and medical informatics, andrija stampar school of public health, school of medicine, university of zagreb, zagreb, croatia evelyne de leeuw, free lance health consultant, sydney, australia, for the western pacific region. damen haile mariam, university of addis ababa, ethiopia, for the african region. charles surjadi, faculty of medicine, atmajaya university, jakarta, indonesia, for the south east asian region. fimka tozija institute of social medicine, faculty of medicine, university “ss cyril and methodius”, skopje, macedonia, for south eastern europe. laura magana valladares, secretaria académica, instituto nacional de salud pública, mexico, mexico, for latin america. advisory editorial board tewabech bishaw, african federation of public health associations (afpha), addis ababa, ethiopia. helmut brand, department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands. patricia brownell, fordham university, new york city, new york, usa. franco cavallo, department of public health and paediatrics, school of medicine, university of torino, torino, italy. doncho donev, institute of social medicine, faculty of medicine, university “ss cyril and methodius”, skopje, macedonia. mariana dyakova, university of warwick, faculty of public health, united kingdom. florentina furtunescu, department of public health and management, university of medicine and pharmacy "carol davila", bucharest, romania. andrej grjibovski, norwegian institute of public health, oslo, norway and school of public health, arkhangelsk, russia motasem hamdan, school of public health, al-quds university, east jerusalem, palestine. mihajlo jakovljevic, faculty of medical sciences, university of kragujevac, kragujevac, serbia. aleksandra jovic-vranes, institute of social medicine, medical faculty, belgrade university, serbia. ilona kickbusch, graduate institute of international and development studies, geneva, switzerland. mihali kokeny, free lance consultant, budapest, hungary. dominique kondji, cameroon public health association, douala, cameroon. giuseppe la torre, department of public health and infectious diseases, university sapienza, rome, italy. oleg lozan, school of public health management, chisinau, moldova. george lueddeke, consultant in higher and medical education, southampton, united kingdom. izet masic, university of sarajevo, sarajevo, bosnia and herzegovina. martin mckee, london school of hygiene and tropical medicine, london, united kingdom. bernhard merkel, visiting research fellow, london school of hygiene and tropical medicine, london, uk. naser ramadani, institute of public health, prishtina, kosovo. enver roshi, school of public health, university of medicine, tirana, albania. maria ruseva, south east european health network (seehn), sofia, bulgaria. theodore tulchinsky, hadassah–braun school of public health and community medicine, jerusalem, israel. lijana zaletel-kragelj, faculty of medicine, university of ljubljana, ljubljana, slovenia. publisher dr. hans jacobs (lage, germany) editorial office jacobs verlag hellweg 72 d 32791 lage germany email phone: 0049/5232/979043 fax: 0049/05232/979045 mailto:info@jacobs-verlag.de� seejph south eastern european journal of public health www.seejph.com/ volume viii, 2017 genc burazeri, ulrich laaser, jürgen breckenkamp, jose m. martin-moreno, peter schröder-bäck (eds.) publisher: jacobs/germany issn 2197-5248 jacobs verlag http://www.seejph.com/� issn2197-5248 doi 10.4119/unibi/seejph-2017-175 bibliographic information published by die deutschebibliothek. die deutsche bibliothek lists this publication in the deutsche nationalbibliografie; detailed bibliographic data is available on the internet at http://dnb.ddb.de south eastern european journal of public health (open access journal) copyright 2016 by jacobs publishing company hellweg 72, 32791 lage, germany copyright cover picture: wordpress foundation: http://wordpressfoundation.org/gnu general public license http://dnb.ddb.de/� http://wordpressfoundation.org/gnu� table of contents page editorial reflections on the liberian civil war, 1989-2003 1-3 ulrich laaser original research introduction of the european union case definitions to primary care physicians has improved the quality 4-12 of communicable diseases notification in tuzla, bosnia and herzegovina martin rusnak, predrag duric, denisa jakubcova, viera rusnakova, amina obradovic-balihodzic enhancing health system’s governance through demographic and health surveys in transitional 13-20 european countries: the example of albania herion muja, genc burazeri, peter schröder-bäck, helmut brand evaluation of an implementation strategy for a world health organization (who) public health report: 21-37 the implementation of the international perspectives on spinal cord injury (ipsci) in romania per m. von groote, dimitrios skempes, jerome e. bickenbach the dutch long-term care reform: moral conflicts in executing the social support act 2015 38-56 wesley jongen, peter schröder-bäck, jos mga schols from their own words: an explorative qualitative study on the experience of combatants 57-69 disabled in the liberian civil war,1989-2003 aloysius p. taylor review articles preparing society to create the world we need through“one health”education 70-91 george r. lueddeke, gretchen e. kaufman, joann m. lindenmayer, cheryl m. stroud approaches to the international standards application in healthcare and public health in 92-103 different countries vitaliy sarancha, vadym sulyma, nenad pros, ksenija vitale letters to editor high level communiqué from the interaction council 104-106 george lueddeke laaseru. reflections on the liberian civil war, 1989-2003 (editorial). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-154 1 editorial reflections on the liberian civil war, 1989-2003 ulrich laaser1 1 faculty of health sciences, university of bielefeld,bielefeld, germany. corresponding author: ulrich laaser address: faculty of health sciences, university of bielefeld, pob 10 01 31, d-33501, bielefeld, germany; e-mail: ulrich.laaser@uni-bielefeld.de conflicts of interest: none. mailto:ulrich.laaser@uni-bielefeld.de� laaseru. reflections on the liberian civil war, 1989-2003 (editorial). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-154 2 the generation which experienced war in europe – world war ii – is passing away and with it those who can tell ‘in their own words’ from war experience and trauma. on the other hand accelerating globalization confronts us with a series of armed conflicts all over the world. the civil war in liberia was one of these. all of the possible fuelling factors were brought to bear on it: ethnic differences, economic domination by a ruling class the progeny of the freed slaves in 1822, and the long litany of misrule by various administrations crowned by the execution of predominantly people of american descent in the 1980 coup d’état, all set the stage for a final showdown. the conflict involved eight armed factions fighting for dominance and lasted with a short interruption from 1989 to 2003. whereas, for example in germany, there is an abundance of literature describing and analyzing personal and social experience during the war[for example translated into english (1)]; it is not so in liberia. the veterans of the various rebel groups and even former members of the regular army usually live in very poor conditions and those invalidated populate begging the streets. furthermore there are thousands of civil victims and especially an estimated 10-15% of the female population raped, more than half a million (out of a population of about four million at the time) were killed (2) and close to one million dislocated. although people have generally enjoyed peace in liberia for over a decade by now that peace can still be described as fragile. every year one can observe signs of simmering instability when ex-combatants make threats on radio and in newspapers that they will disturb the peace in the country for claims of perceived benefits they have against the government in concert with left behind widows and children and their disabled comrades. the condition of those who are physically or mentally disabled is appalling, the standard of living at the edge as usually there is no income; the acquisition of a daily meal becomes a problem. they are considered by the national community to be responsible for the atrocities and the suffering of the civilian people although they were often in the child and adolescent age when entering the armed factions, hardly mature enough to discern between what was right and what was wrong to do even in a war situation (3). different from the reaction on the ebola epidemic (4) which posed a threat to themselves, the international community has rarely taken notice of the victims of the civil war in liberia and few people seem to be concerned about the abundance of psychiatric disease including posttraumatic stress disorder. even less realized is the threat of further social disruption as any organized reconciliation process involving ex-combatants is missing. documented experience in europe and notably germany shows war traumata handed over through several generations, from the parents experiencing war to their children and even grand-children, a threat for social stability and cohesion: ‘because of the war my parents simply did not experience that the world is a safe place where one can feel well and protected. and exactly the same feeling i ascertained in myself although there was no external inducement’ [own translation (1)]. to listen to the ostracized invalids from the civil war and take note of what they have to say is the aim of the explorative study by aloysius taylor hoping to initiate public discussion aimed at healing the liberian society. references 1. bodes. the forgotten generation – the war children break their silence. klett cotta, stuttgart; 2004. https://www.sabine-bode-koeln.de/war-children/the-forgotten generation/. 2. edgertonrb. africa’s armies: from honor to infamy. amazon; 2004. https://www.amazon.co.uk/africas-armies-infamy-robert-edgerton/dp/0813342775. https://www.sabine-bode-koeln.de/war-children/the-forgotten-generation/� https://www.amazon.co.uk/africas-armies-infamy-robert-edgerton/dp/0813342775� laaseru. reflections on the liberian civil war, 1989-2003 (editorial). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-154 3 3. kokulofasuekoi j. a journalist’s photo diary. auto-publication, date unknown, monrovia, liberia. https://www.barnesandnoble.com/w/rape-loot-murder-james kokulo-fasuekoi/1105497189?ean=9781468591620. 4. gostin lo, lucey d, phelan a. the ebola epidemic: a global health emergency. jama 2014;312:1095-6. © 2017 laaser; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.barnesandnoble.com/w/rape-loot-murder-james-kokulo-fasuekoi/1105497189?ean=9781468591620� http://jamanetwork.com/searchresults?author=alexandra%2bphelan&amp;amp%3bq=alexandra%2bphelan� http://creativecommons.org/licenses/by/3.0)� 4 rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 original research introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina martin rusnak1, predrag duric2, denisa jakubcova1, viera rusnakova1, amina obradovic-balihodzic3 1 department of public health, faculty of health sciences and social work, trnava university in trnava, slovakia; 2 institute for global health and development, queen margaret university, edinburgh, uk; 3 institute for public health of canton sarajevo, sarajevo, bosnia and herzegovina. corresponding author: prof. martin rusnak; address: trnava university in trnava, faculty of health sciences and social work, department of public health, univerzitnenamestie 1, 918 43 trnava, slovakia; telephone: +421335939495; e-mail: rusnakm@truni.sk mailto:rusnakm@truni.sk� 5 rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 abstract aim: the public health reform ii project was implemented in bosnia and herzegovina from december 2011 to december 2013 and was funded by the european union aid schema. the principal aim of the project was to strengthen public health services in the country through improved control of public health threats. workshops for primary care physicians were provided to improve the situation and increase communicable diseases notification rates in eight selected primary care centres. they were followed with visits from the project’s implementing team to verify the effects of trainings. methods: the quality of notifications from physicians in tuzla region was compared before and after the workshop. the timeliness was used as an indicator of quality. medians of timeliness before and after the training were compared by use of wilcoxon test, whereas the averages of timeliness were compared by use of the t-test. results: there were 980 reported cases, 80% before the training and 20% after the training. a lower median of timeliness for all the reported cases after the training was statistically significant compared to the median value before the training. a similar picture was revealed for specific diseases i.e. tuberculosis and enteritis, not so for scarlet fever and scabies. conclusion: the significant reduction in time response between the first symptoms and disease diagnosis indicates the positive impact of the training program in tuzla. hence, primary care physicians provided better quality of reported data after the training course. keywords: bosnia and herzegovina, communicable diseases notification, surveillance, timeliness, tuzla. conflicts of interest: none. acknowledgements: the authors are grateful to all primary care physicians and epidemiologists for their interest in training topics and to the management teams of health care centres for their close cooperation. funding: the data used for this study were collected within the public health reform ii project in bosnia and herzegovina. the project was funded by the european union (eu) as a part of the instrument for pre-accession assistance (ipa). the project was implemented by the consortium comprising the ceu consulting gmbh, wien, austria and diadikasia, athens, greece. 6 rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 introduction surveillance on communicable diseases is defined as an ongoing, systematic collection, analysis, interpretation and dissemination of infectious disease data for public health action (1,2). effective surveillance provides information on infections that are the most important causes of illness, disability and death, populations at risk, outbreaks, demands on health care services and effectiveness of control programs so priorities for prevention activities can be determined (3,4). the primary aim of infectious diseases surveillance is to eliminate and eradicate disease incidence with two core functions: early warning system for outbreaks and early response to disease occurrence, known also as epidemiological intelligence. an early warning and response system for the prevention and control of communicable diseases is essential for ensuring public health at the regional, national and global levels. recent cases of severe acute respiratory syndrome, avian influenza, haemorrhagic fevers and especially the threats arising from the possibility of misuse of biological and chemical agents demonstrate the need for an effective system of surveillance and early warning at national level providing a higher data structure (5 7). the structure of surveillance system is based on the existing legislation, goals and priorities, implementation strategies, identification of stakeholders and their mutual connections, networks and partnerships and also capacity for disease diagnosis. primary care physicians or general practitioners who provide the first contact with a patient play a crucial role in the system. the surveillance system relies on the detection of communicable disease in the patients and disease notification (8-10). the project public health reform ii (europe aid/128400/c/ser/ba)was implemented in bosnia and herzegovina from december 2011 till december 2013 and was funded by the european union aid schema. its principal aim was to strengthen public health services in the country through improved control of public health threats. one of the three components of the project dealt with enhancing and improving assessment of global public health and the system of communicable diseases notification. based on an interest from regional public health authorities, eight of them were selected to participate in some workshops. interviews with general practitioners in each region were taken during the initial phase of the activities. professionals who were interviewed indicated the following challenges for the surveillance system they contribute to: the list of mandatory notified diseases too long, clear case definitions and rationale for surveillance missing, mixture of case-based (11) and syndromic surveillance (12), lack of capacity for cases confirmation and a low level of communication among all surveillance stakeholders. the interview findings led to organization of workshops for primary care physicians in eight primary health care centres during march 2013. the aim was to improve the situation and increase notification rates. it was expected that acquiring deeper insights into the role of disease notification would lead to an increased effectiveness of the surveillance system. outcomes from the effort to improve the quality of notifications in the region of tuzla are reported in this paper. physicians from the county were invited in cooperation with the local public health office and notifications were stored in electronic format. this set-up of the endeavour was uniformly repeated across all the eight regions of bosnia and herzegovina. 7 rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 methods study design the study was designed with the aim of revealing potential effects of updating primary care physicians with details of surveillance. thus, a cohort of primary care physicians was used to follow the effects. selection of participants was on the basis of interest. no attempts to randomize were undertaken. the project collected baseline data on notification from the database maintained by the tuzla epidemiologists for year 2012 up to february 2013. the workshop was carried in march 2013. the project attempted to keep contact with participants by email and by personal visits. data from the same source were collected until october 2013. there were 20 participants at the first workshop. estimating the proportion from the total of those who serve the region was not possible because of the lack of data. however, the total number of general practitioners listed in 2014 was 378 physicians (13) as our participants were mostly from offices within the city of tuzla. our estimate is based on the average number of citizens per general practitioners (gps) in the region which is 1263 inhabitants per gp. tuzla has 120441 inhabitants according to the census from 2013, which results in about 95 general practitioners in the city. hence, participation in the workshop represents approximately 21% of all primary care physicians in tuzla. workshop the workshop started with an introduction of aims and expected outcomes. assessment of knowledge on surveillance, disease reporting and attitudes to disease notification followed. principles of communicable disease surveillance and use of case definitions with emphasis on importance of surveillance, techniques, categories and use of the eu case definitions were presented by the project. following discussion dealt with everyday problems and opinions on the system of surveillance as well as the use of the eu case definitions. at the end of the workshop each participant received a copy of the eu case definitions, translated into the local language. local management of primary health care centres and people from epidemiology department were also invited to participate as observers. all data were anonymised and no ethical considerations were identified. data processing the timeliness for notifications obtained from primary care physicians in the town of tuzla was compared before and after the workshop. the timeliness was used as an indicator of quality, as it reflects the speed between steps in a public health surveillance system (14). we chose the following definition of timeliness out of several options: “average time interval between date of onset and date of notification by general practitioners/hospital (by disease, region and surveillance unit). it means time interval between the first symptoms of diseases and reporting”, as defined by the ecdc (15). timeliness was computed from dates stated in individual notifications separately for those noted before and after the workshop. the file was sorted based on the icd-10 diagnosis stated by the physician notifying the case and laboratory confirmation. timeliness was computed for all the diagnoses as well as selected icds for tuberculosis (a15), scarlet fever (a38), enteritis (a09) and scabies (b86). differences in medians before and after the workshop were compared by use of the two-sample wilcoxon rank sum test and signed rank tests and the average values were compared by the two-sample independent t-test from the r project (16), with a level of statistical significance set at p≤0.05. 8 rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 results as table 1 illustrates, the sample comprised 980 reported cases, 784 (80%) were before the training and 196 (20%) were reported after the workshop. in total, 147 primary care physicians reported syndromic diagnosis of a communicable disease case (140 before the workshop and 69 after the workshop). table 1. timeliness for notified cases before and after the workshop total sample sample total before after p-value total cases 980 784 196 median 1 6 1 0.030* average 12 20.2 9.2 0.039† maximum 152 152 133 minimum 0 0 0 tuberculosis sample total before after p-value total cases 159 99 60 median 58 60 13 0.014* average 57.1 57.6 27 0.019† maximum 152 152 133 minimum 0 0 0 enteritis (a09) sample total before after p-value total cases 132 86 46 median 2 3 2 0.035* average 3.7 3.2 2.7 0.065† maximum 41 41 23 minimum 0 0 0 scarlet fever (a38) sample total before after p-value total cases 33 17 16 median 0 1 0 0.487* average 1.8 1.6 1.5 0.611† maximum 13 13 13 minimum 0 0 0 scabies (b86) sample total before after p-value total cases 98 71 27 median 0 1 0 0.512* average 1.7 3.9 2.7 0.481† maximum 37 37 13 minimum 0 0 0 *p-values from wilcoxon test. †p-values from t-test. the difference in medians of timeliness for the total sample (table 1) indicates a reduction from 6 days to 1 day following the workshop; the average of the indicator was reduced to one half. the difference was statistically significant for both the median value (p=0.03) and the mean value (p=0.04). the reduction for notified cases of tuberculosis was more pronounced. it 9 rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 went down from a median of 60 days to 13 days (p=0.01), whereas the mean from 57.6 days to 27.0 days and this difference was statistically significant too (p=0.02). the median of timeliness notification for enteritis cases was significantly lowered after the workshop from 3 days to 2 days and this difference was statistically significant (p=0.03). furthermore, this difference was also evident in the comparison of mean values. there were no significant differences in both median and mean values in the timeliness for scarlet fever and scabies before and after the workshop (table 1). discussion the surveillance system in bosnia and herzegovina suffered after the war. it is not stabilized yet, experiencing lack of funds, and it is both organizationally as well as politically divided. it is run on a regional basis, where all primary care physicians are legally required to notify cases based on syndromic diagnosis. such a system is characterized by underreporting due to lack of responsibility and weak supervision from authorities. nevertheless, some authors have demonstrated positive effects of an information campaign on improved notifications in a province of vojvodina, serbia (17) where public health services operate in a similar environment to bosnia and herzegovina. this project in bosnia and herzegovina aimed to increase syndromic notification rates through focused workshops as an example for regional epidemiologists how to continue with improving quality of the surveillance. however, we are aware that the quality consists of a multidimensional character and the timeliness is only one of them. thus, using it for a proxy of quality has its limitations. timeliness of a surveillance system depends on a number of factors and its assessment should include a consideration of how the data will be used and is specific for individual diseases under surveillance (3,18). other indicators of timeliness are also available, such as the average time interval between the date of outbreak notification and the date of the first investigation or proportion of outbreaks notified within 48 hours of detection and the like. obtaining a comprehensive assessment of surveillance quality requires considering more attributes, such as sensitivity, representativeness, usefulness, simplicity, acceptability and flexibility (15,19). therefore, even so, this report demonstrates a significant reduction in notification time between syndromic diagnosis and notifications, and the quality improvement was achieved incompletely. another opened question is whether or not achievements are to be sustained. nevertheless, the changes in notifications were observed after the workshops, based on a follow-up evaluation. our findings are congruent with similar studies where timeliness of disease notification was also followed and reported, before and after some type of intervention with a main aim to reduce time response between two steps in the process of reporting. implementation of electronic laboratory reporting resulted in reducing the median of timeliness to 20 days versus 25 days for non-electronic laboratory reporting (20). another study has demonstrated reduced median of timeliness for notifications by 17 days from the year 2000 to 2006 with a higher rate of notification completeness (21). the importance of increased interaction between primary care physicians and surveillance professionals in notifying communicable diseases was demonstrated in our study, as well. providing case definitions from the eu and along with the local ones was appreciated and probably contributed to improved notification rates. the fact that standard case definition is a premise for data quality and validity (22) was reconfirmed with similar studies reported (23,24), where increased dedication to reporting with data qualitytimeliness and completeness was observed. there are factors which are beyond the influence of physicians, such as patient’s awareness of symptoms, patient’s search for medical care, capacity for case confirmation, 10 rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 reporting of laboratory test results back to the physician and to other surveillance stakeholders and public health agencies, which limit the validity of interpretation of the findings, too. another limitation stems from the limited time of the study, where 80% of cases were reported before the workshop and 20% of cases were notified after the workshop. another serious limitation of this study stems from the design used. given the specific audience we worked with, namely general practitioners from various parts of the administrative area, the selection of the study participants was "on the basis of interest". as an europeaid project we had no other choice. therefore, the results based on such constrained participation should not be utilized with valid statistical inference on the level of population. the sample representativeness may seriously affect the generalizability (external validity) of the findings. nevertheless, the study was intended to be more of a pilot nature, demonstrating the feasibility of monitoring the quality of the surveillance system. communicable disease surveillance is the first step towards prevention and it is one of the most important tools used in public health. the surveillance system should be regularly evaluated in terms of usefulness and quality by defined standards and recommendations. in this report, we shared results of the surveillance system evaluation in tuzla, bosnia and herzegovina by using one of quality standardstimeliness of disease notification before the training and after the training. this study underlined the importance and effectiveness of increased communication and feedback procedures between primary care physicians and surveillance professionals, use of standard case definition and surveillance evaluation. the identified outcomes of evaluation should be the basis for setting priorities and activities to improve the quality and effectiveness of the surveillance system. references 1. world health organization. communicable disease surveillance and response systems. geneva, switzerland; 2006. http://www.who.int/csr/resources/publications/surveillance/who_cds_epr_lyo_2006 _2.pdf (accessed: 29 march, 2017). 2. world health organization. recommended surveillance standards (second edn.). geneva, switzerland; 1999. http://www.who.int/csr/resources/publications/surveillance/whocdscsrisr992.pdf (accessed: 29 march, 2017). 3. centres for disease control and prevention. progress in improving state and local disease surveillance – united states, 2000–2005. atlanta, usa; 2005. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5013a1.htm (accessed: 21 july, 2015). 4. lemon sm, hamburg ma, sparling fp, choffnes er, mack a. global infectious disease surveillance and detection: assessing the challengesfinding solutions. washington, dc: the national academies press; 2007. 5. european centre for disease control and prevention. surveillance objectives. stockholm, sweden. http://ecdc.europa.eu/en/activities/surveillance/pages/surveillance_objectives.aspx (accessed: 29 march, 2017). 6. weinberg j. surveillance and control of infectious diseases at local, national and international levels. clin microbiol infect 2005;11:11-4. 7. rolfhamre p, grabowska k, ekdahl k. implementing a public web based gis service for feedback of surveillance data on communicable diseases in sweden. bmc infect dis 2004;4:17. http://www.who.int/csr/resources/publications/surveillance/who_cds_epr_lyo_2006_2.pdf� http://www.who.int/csr/resources/publications/surveillance/who_cds_epr_lyo_2006_2.pdf� http://www.who.int/csr/resources/publications/surveillance/who_cds_epr_lyo_2006_2.pdf� http://www.who.int/csr/resources/publications/surveillance/who_cds_epr_lyo_2006_2.pdf� http://www.who.int/csr/resources/publications/surveillance/whocdscsrisr992.pdf� http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5013a1.htm� http://ecdc.europa.eu/en/activities/surveillance/pages/surveillance_objectives.aspx� http://ecdc.europa.eu/en/activities/surveillance/pages/surveillance_objectives.aspx� http://ecdc.europa.eu/en/activities/surveillance/pages/surveillance_objectives.aspx� 11 rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 8. jamison dt, breman jg, measham ar, alleyne g, claeson m, evans db, et al. disease control priorities in developing countries, 2nd edition. washington dc: world bank; 2006. 9. baker mg, fidler dp. global public health surveillance under new international health regulations. emerg infect dis2011;7:1058-63. 10. souty c. improving disease incidence estimates in primary care surveillance systems. popul health metr 2014;19:12. 11. who. who technical consultation on event-based surveillancemeeting report. lyon: france; 2013. http://www.episouthnetwork.org/sites/default/files/meeting_report_ebs_march_2013_fina l.pdf (accessed: 29 march, 2017). 12. henning, kj. what is syndromic surveillance. mmwr morb mortal wkly rep 2004;53:7-11. 13. institute for public health fb& h. health statistics annual federation of bosnia and herzegovina. sarajevo; 2013. http://www.zzjzfbih.ba/wp content/uploads/2009/02/zdravstveno-statisticki-godisnjak-fbih-20121.pdf (accessed: 29 march, 2017). 14. thackers sb, stroup df. future directions for comprehensive public health surveillance and health information systems in the united states. am j epidemiol 1994;140:383-97. 15. european centre for disease control and prevention. data quality monitoring and surveillance system evaluation – a handbook of methods and applications. stockholm, sweden; 2014. http://ecdc.europa.eu/en/publications/publications/data-quality monitoring-surveillance-system-evaluation-sept-2014.pdf (accessed: 29 march, 2017). 16. the r project for statistical computing. vienna, austria.http://www.r-project.org/ (accessed: 29 march, 2017). 17. duric p, ilic s. quality of infectious diseases surveillance in primary health care. sri lank j infect dis 2012;2:37-46. 18. yoo hs, park o, park hk, leeeg, jeong ek, lee jk, et al. timeliness of national notifiable diseases surveillance system in korea: a cross-sectional study. bmc public health 2009;9:93. 19. buehler jw, hopkins sr, overhage jm, sosin dmt. framework for evaluating public health surveillance systems for early detection of outbreaks: recommendations from the cdc working group. mmwr recomm rep 2004;53:1-11. 20. samoff e, fangman mt, fleischauer at, waller ae, macdonald pd. improvements in timeliness resulting from implementation of electronic laboratory reporting and an electronic disease surveillance system. public health rep 2013;128:393-8. 21. jansonn a. timeliness of case reporting in the swedish statutory surveillance of communicable diseases 1998-2002. scand j infect dis 2004;36:865-72. 22. jajosky ra, groseclose s. evaluation of reporting timeliness of public health surveillance systems for infectious diseases. bmc public health 2004;4:29. 23. turnberg w, daniell w, duchin j. notifiable infectious disease reporting awareness among physicians and registered nurses in primary care and emergency department settings. am j infect control 2010;38:410-13. 24. keramarou m, evans mr. completeness of infectious disease notification in the united kingdom: a systematic review. j infect 2012;64:555-64. http://www.episouthnetwork.org/sites/default/files/meeting_report_ebs_march_2013_final.pdf� http://www.zzjzfbih.ba/wp-content/uploads/2009/02/zdravstveno-statisticki-godisnjak-fbih-20121.pdf� http://ecdc.europa.eu/en/publications/publications/data-quality-monitoring-surveillance-system-evaluation-sept-2014.pdf� http://www.r-project.org/� 12 rusnak, duric, jakubcova, rusnakova, obradovic-balihodzic. introduction of the european union case definitions to primary care physicians has improved the quality of communicable diseases notification in tuzla, bosnia and herzegovina (original research). seejph 2017, posted: 22 may 2017. doi: 10.4119/unibi/seejph 2017-143 © 2017 rusnak; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0)� 13 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 original research enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania herion muja1,2, genc burazeri1,2, peter schröder-bäck1, helmut brand1 1department of international health, school caphri, care and public health research institute, maastricht university, maastricht, the netherlands; 2 institute of public health, tirana, albania. corresponding author: herion muja, md; address: rr. “aleksander moisiu”, no. 88, tirana, albania; telephone: +355672315056; email: herionmuja@gmail.com http://doi.org/10.4119/unibi/seejph-2017-143� mailto:herionmuja@gmail.com� 14 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 abstract to inform policymakers well, there is a need to promote different types of health examination surveys as additional sources of valuable information which, otherwise, would not be available through routine/administrative statistics. this is especially important for former communist countries of south eastern europe including albania, where the existing health information system (his) is weak. among many efforts to strengthen the his in albania, there is currently a commitment to undertake a second round of a nationwide demographic and health survey (dhs). this survey will involve a nationwide representative sample of about 17,000 private households, where all women aged 15-59 years and their respective partners will be interviewed and examined. externally, the upcoming albanian dhs will contribute to the european union accession requirements regarding provision of standardized and valid health information. furthermore, the dhs will considerably enhance the core functions of the albanian health system in line with the who recommendations. internally, the dhs will promote societal participation and responsibility in transitional albania. importantly, the forthcoming survey will promote good governance including transparency, accountability and health system responsiveness. also, the dhs will allow for collection of internationally valid and standardized baseline socio demographic and health information for: assessment of future national trends; monitoring and evaluation of health programs and interventions; evidencing health disparities and inequities; and cross-national comparisons between albania and different countries of the european region. ultimately, findings of the dhs will enable rational decision-making and evidence based policy formulation in albania including appropriate planning, prioritization and sound resource allocation. however, transfer of the information collected and implementation in public health policies and interventional programs is rather challenging for most of the countries, particularly for transitional post-communist countries of south eastern europe including albania. keywords: albania, demographic and health survey (dhs), health examination survey, health information system, health interview survey, health system governance. conflicts of interest: none. http://doi.org/10.4119/unibi/seejph-2017-143� 15 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 the need to strengthen health information systems a “health information system” (his) is conventionally defined as a system which collects, stores, processes, conducts analysis, disseminates and communicates all the information related to the health status of the population and the activities and performance of health institutions and other health-related organizations (1). from this point of view, a suitable and well-designed his incorporates data generated from routine information systems, disease surveillance systems, but also laboratory information systems, hospital and primary care administration systems, as well as human resource management information systems (1,2). the ultimate goal of a well-functioning his is a continuous and synchronized endeavor to gather, process, report and use health information and the knowledge generated for the good governance of health systems; in other words: influence policy and decision-making, design activities and programs which eventually improve the health outcomes of the population, but also contribute to more efficient use of (often limited) resources (1,3,4). at the same time, the evidence generated from his may suggest the need for further research in certain areas (1,5). nevertheless, a major prerequisite for a good health system governance consists of a wide array of valid and reliable data, which are not often available from a traditional (routine) or administrative his (2,6).therefore, there is a clear need to promote different types of health examination surveys and health interview surveys as valuable sources for generation of additional health information which, otherwise, would not be available based on routine/administrative statistics. this is important in any health care system, where reforms are underway constantly (7). health examination surveys and health interview surveys issues related to the quality of life of individuals, patient satisfaction of health care delivery, knowledge, attitudes, perceptions, or beliefs of individuals, as well as health literacy levels in general are all important components which should be measured at a population level in order to design and tailor health strategies and policies accordingly (1,3). from this perspective, health examination surveys are a powerful tool which enrich a certain his and provide useful clues about the health status of populations, quality of life, as well as access, utilization and satisfaction with health care services. in this framework, the european health examination surveys (ehes: http://www.ehes.info/) and the european health interview surveys (ehis: http://ec.europa.eu/eurostat/web/microdata/european-health-interview-survey) constitute two major exercises which are carried out in most countries of the european union (eu). indeed, health examination surveys and health interview surveys are conducted periodically in most of the eu countries generating important evidence about the magnitude and distribution of selected ill-health conditions and health determinants at a population level. based on the unique value of health examination surveys and health interview surveys, there is a clear call for undertaking a similar exercise also in transitional former communist countries of south eastern europe including albania. country profile: albania after the collapse of the communist regime in early 1990s, albania has undergone significant political, social and economic changes striving towards a market-oriented economy (8). nevertheless, the particularly rapid transition from state-enforced collectivism towards a capitalistic system was associated with poverty, high unemployment rates, financial loss and social mobility, and massive emigration (9). at the same time, however, the transition period in albania was associated with increased personal and religious freedom in a predominantly muslim secular society (8,10). all these features continue to spot albania as a distinctive http://doi.org/10.4119/unibi/seejph-2017-143� http://www.ehes.info/)� http://ec.europa.eu/eurostat/web/microdata/european-health-interview-survey)� 16 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 country in europe, notwithstanding the similarities in many characteristics with other transitional countries in the western balkans and beyond. the health care sector has suffered substantially during the transition period and there has been a significant change in the epidemiological profile of the population in the past few decades with a remarkable transition towards non-communicable diseases (ncds) (11,12). indeed, there is a tremendous increase in the total burden of ncds in albania including heart disease, cancer, lung and liver diseases, and diabetes (11,12). against this background, there is an urgent need for an integrated approach for both prevention and improvement of health care in order to face the high burden of ncds in transitional albania (12). in any case, the existing his in albania has insufficient routine health data for a valid and reliable analysis of disease trends and the associated risk factors. the first round of a nationwide demographic and health survey (dhs) in albania was conducted in 2008-2009 (13). almost ten years later, there is currently an urgent need to carry out a second dhs round which would generate valuable information regarding selected key socio-demographic characteristics and health data of the albanian population, which are otherwise not available based on routine/administrative statistics. not only that with new data new needs for priorities in the health system governance can be identified, but the changes and potential effects of health policy decision-making of the last years can be measured too. the albanian demographic and health survey (dhs) 2017-2018 among many efforts to strengthen the his in albania, there is currently a commitment to undertake a second round of a nationwide dhs. the upcoming round of dhs in albania will be implemented by the national institute of public health and the institute of statistics with technical support from the us-based company icf international (https://www.icf.com/). funding has been already provided by the swiss cooperation and the united nation agencies operating in albania. the dhs will involve a nationwide representative sample of about 17,000 private households. all women aged 15-59 years and their respective husbands/partners living permanently in the selected households or present in the household on the night before the survey visit will be eligible to be interviewed in the dhs. the specific objectives of the dhs will be to: i) collect data at a national, regional and local level which will allow the calculation of key demographic rates; ii) analyze the direct and indirect factors which determine the level and trends of fertility and abortion in albania; iii) measure the level of contraceptive knowledge and practice of albanian men and women; iv) collect data on family health including immunization coverage among children, prevalence of most common diseases among children under five and maternity care indicators; v) collect data on infant and child mortality and maternal mortality; vi) obtain data on child feeding practices including breastfeeding, collect anthropometric measures to use in assessing the nutritional status of children including anemia testing; vii) measure the knowledge and attitudes of women and men about sexually transmitted diseases and hiv/aids; viii) assess key conventional risk factors for ncds in albanian men and women aged 15-59 years including dietary patterns and nutritional habits, smoking status, alcohol consumption, physical activity, systolic and diastolic blood pressure, and measurement of anthropometric indices (height and weight, as well as waist and hip circumferences). the data collected will be scientifically analyzed and scientific reports and policy briefs will be subsequently written and disseminated for a wide audience including health professionals, social workers, policymakers and decision-makers, as well as the general public. in addition, http://doi.org/10.4119/unibi/seejph-2017-143� http://www.icf.com/)� 17 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 the open data source approach will enable secondary (in-depth) analysis to all interested researchers and scientists all over the world. contribution of the demographic and health survey (dhs) to health system governance in albania table 1 presents the potential contribution of the upcoming albanian dhs at different levels (international, national, regional, and local level), recognizing that different actors of health system governance which are located at different levels, yet, interact with each-other (14,15). selected potential contributing characteristics (features) include different dimensions pertinent to both, the international environment and cooperation, as well as the internal (national) situation/circumstances. table 1. international relevance and contribution of the “albanian demographic and health survey 2017-18” to governance processes at national, regional and local levels international relevance characteristic description european union fulfillment of accession requirements, and contribution to the “europeanization” process of albania world health organization (who) strengthening of the core functions of the health system (in line with the who recommendations) national (central) government characteristic description democracy a good exercise for strengthening societal participation and responsibility governance enhancing good governance: transparency, accountability and responsiveness informing policy prioritization, evidence-based planning and allocation of resources research strengthening research capacities at a national level national data collection of (good quality) nationwide representative health data evidencing overall (national) disparities in terms of place of residence national disparities (urban vs. rural areas), ethnicity, minorities, vulnerable subgroups, socioeconomic categories, as well as sexand-age group differences useful baseline data for assessing national trends over time, as well as baseline national data cross-country comparisons monitoring and evaluation of nationwide health programs and interventions use of internationally valid/standardized instruments will eventually enable cross-national comparisons with the neighboring countries and beyond regional level: interface between the central and the local government characteristic description research strengthening research capacities at a regional level regional data collection of sub-national data regional disparities evidencing sub-national (regional) health disparities and inequities baseline regional data baseline data for assessing regional trends, as well as monitoring and evaluation of regional health initiatives, programs andinterventions local government characteristic description research strengthening research capacities at a local level local data collection of health data at a local level local disparities evidencing local health disparities and inequities individual-based data potential for intervention (treatment and counseling of people in need) baseline local data baseline data for assessing local trends, as well as monitoring and evaluation of interventions implemented at a local level http://doi.org/10.4119/unibi/seejph-2017-143� 18 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 regarding the international environment, the upcoming albanian dhs will significantly contribute in terms of fulfillment of accession requirements to the eu related to provision of standardized and valid health information/data. on the other hand, the dhs will also contribute considerably to the enhancement of the core functions of the albanian health system in line with the who recommendations (16). according to who, four vital functions of health systems include provision of health care services, resource generation, financing, and stewardship (16).the upcoming survey will support most of these core functions in the context of a particularly rapid process of transformation and reform of the albanian health system. as for the internal environment, at a central (national) level, the dhs will be an important exercise for strengthening societal participation and responsibility, which is fundamental given the low participation rates and societal contribution in post-communist countries such as albania. from a governmental point of view (4), the forthcoming survey is expected to promote good governance in terms of transparency, accountability and health system responsiveness. conversely, the dhs exercise will considerably strengthen national research capacities in albania. the survey will be conducted in close collaboration with the university of medicine, tirana, and other scientific and research institutions in albania which will help to further strengthen the epidemiological and the overall capacities of the albanian research community. furthermore, the dhs will allow for collection of nationwide high-quality information including a wide array of demographic and socioeconomic characteristics and valuable health data. such data will provide useful baseline information for assessment of national trends in the future, as well as monitoring and evaluation of nationwide health programs and health interventions. in addition, this baseline information will evidence national disparities and inequities regarding the place of residence (urban vs. rural areas), ethnicity groups and minorities, vulnerable/marginalized segments, socioeconomic disadvantaged categories, as well as sexand-age group health differences. at the same time, employment of standardized and internationally valid instruments for data collection will allow for cross-national comparisons between albania and different countries of the european region. ultimately, at a central (national) level, findings of the dhs will enable rational decision-making and evidence-based policy formulation in albania including appropriate planning, prioritization and sound resource allocation. at a lower level, the dhs exercise will help to strengthen research capacities and collaboration at a regional level. this will be an important added value given the new administrative/territorial reform which was fairly recently implemented in albania. in addition, availability of health data at a regional level will help to tailor regional policies in accordance with the epidemiological profile and health problems of the respective population groups, as well as monitoring and evaluation of different interventions and programs implemented at a regional level. at the lowest (i.e., local) level, the dhs will similarly but even more specifically contribute to evidence-based policy formulation and rational decision-making at a local/community level. likewise, the survey will contribute to the enhancement of research capacities at a local level, which will be particularly valuable for many under-resourced communities in albania characterized by limited and not properly trained research personnel. it should be noted that, for the first time ever, the upcoming dhs round will be a unique opportunity to collect representative data at the lowest administrative level in albania. also, importantly, the survey will offer a unique opportunity for intervention regarding potential treatment and especially counseling of individuals in need, particularly those who, for different reasons, have limited access to health care services, such as the case of roma community (17). http://doi.org/10.4119/unibi/seejph-2017-143� https://en.wikipedia.org/wiki/health_care_provider� 19 muja h, burazeri g, schröder-bäck p, brand h. enhancing health system’s governance through demographic and health surveys in transitional european countries: the example of albania (original research). seejph 2017, posted: 15 august 2017. doi 10.4119/unibi/seejph-2017-148 conclusion the upcoming dhs round will be a unique opportunity for albania for strengthening research capacities at a national and local level. in addition, the dhs will provide valuable baseline evidence highlighting regional disparities and subgroup inequities which are assumed to have been rapidly increasing given the rapid political and socioeconomic transition of albania in the past three decades. furthermore, this survey will offer an opportunity for evidence-based policy formulation in albania. overall, the dhs exercise will be an important tool for strengthening the core functions of the albanian health system contributing also to the europeanization process and accession to the eu. however, transfer of the information collected and implementation in public health policies and interventional programs is rather challenging for most of the countries, particularly for transitional post communist countries of south eastern europe including albania. references 1. world health organization. framework and standards for country health information systems. geneva, switzerland, 2008. http://apps.who.int/iris/bitstream/10665/43872/1/9789241595940_eng.pdf (accessed: 14 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http://creativecommons.org/licenses/by/3.0)� 21 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 original research evaluation of an implementation strategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania per m. von groote1-3, dimitrios skempes1,2, jerome e. bickenbach1,2 1department of health sciences and health policy, university of lucerne, lucerne, switzerland; 2swiss paraplegic research, nottwil, switzerland; 3institute of social and preventive medicine (ispm), university of bern, bern, switzerland corresponding author: per m. von groote, institute of social and preventive medicine (ispm), university of bern; address: finkenhubelweg 11, ch-3012, bern, switzerland; e-mail: per.vongroote@gmail.com mailto:per.vongroote@gmail.com� 22 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 abstract aim: this paper aims to evaluate a strategy for the implementation of public health policy recommendations from the world health organization’s (who) report “international perspectives on spinal cord injury” in romania. more specifically, it seeks to: a) evaluate implementation actions with a focus on a number of people reached and status of completion at 12 months follow-up; b) describe implementation activities undertaken in the course of one year, and; c) evaluate perceived barriers and facilitators of implementation at 12 months follow-up. methods: a cross-sectional design was adopted with two surveys administered in 2014/15 among key implementers in romania. the questionnaires contained open-ended, multiple choice and 5-point likert scale questions. results on the implementation status, implementation activities performed and self-reported barriers and facilitators were analysed and reported using descriptive statistics. results: implementation completion rate was 75%, with 4390 persons directly or indirectly benefiting from the implementation-related activities listed in the final implementation plan reporting. a broad range of implementation experiences was reported. most common activity types were delivery of services, technical trainings, implementation coordination and development meetings. most useful tools and processes were the romanian language version summary of the report, educational meetings, and local consensuses processes. reported outcomes included the direct output produced, evidence of services provided, and individual or organizational level impact. most barriers were named for the policymakers and academia as stakeholder groups and most facilitating influences for the private sector, with dependence of policymakers on constituency interest scoring highest barrier and the general availability of european commission and european structural funds highest facilitator. conclusion: the surveys proved to be both feasible and useful tools to expand our understanding of implementation and to supplement the more standard used implementation strategies at country level. keywords: implementation, implementation strategy, public health report, spinal cord injury, world health organization. conflicts of interest: none. funding statement: the project received funds from the swiss-romanian cooperation programme as part of swiss contribution to the enlarged eu. acknowledgments: the authors would specifically like to thank dr. cristina ehrmann bostan for her continuous support in analysing the data and preparing display items, and dr. jan d. reinhardt for his conceptual feedback in drafting the manuscript. 23 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 introduction although spinal cord injury (sci) is a low-incident condition, it can be devastating and costly in both human and social terms (1). sci can occur as a consequence of trauma, infection, inflammation, degeneration, tumour, or another disease and often results in a significant decline of physical capacity (2). sci a principal cause of permanent disability has become a significant concern for public health mainly because it places substantial socioeconomic burden on affected individuals and their families, communities and the healthcare system (3). it is considered a particularly pervasive stressor as people who sustain these injuries experience profound alterations in almost all aspects of their life (4). however, many of the difficulties experienced by people with sci do not result from the condition itself, but from inadequate medical care and rehabilitation services, and from barriers in the physical, social and policy environments (5). implementation of measures aiming at removing barriers to access to healthcare and enhancing the effectiveness of rehabilitation and community reintegration is therefore imperative (1). to help propel the implementation of evidence-informed health care and policy for people with sci forward, the world health organization (who) in collaboration with the international spinal cord society in 2013 published a global report titled “international perspectives on spinal cord injury” (ipsci) (6). the report assembles and summarizes the best available scientific evidence and information on spinal cord injury together with the lived experience of people with spinal cord injury and makes recommendations for actions that are consistent with the aspirations for inclusion and participation as expressed in the united nations convention on the rights of persons with disabilities (crpd) (1). the crpd (7) reaffirms the universal human rights and fundamental freedoms of all people with disabilities and calls upon states to secure and promote their inclusion and participation in all aspects of civil, social, economic and community life. notably, the treaty marks a paradigm shift in understanding disability as the result of physical and social barriers interacting with impairments and health states in a way that deprives people of equal opportunities for societal participation. this view implies that multiple systems and stakeholders from health to social and employment sectors must undertake coordinated actions to translate the normative recommendations of international law into concrete benefits for those living with disability (8). for this reason, the who has recognized the necessity to strengthen governments’ capacities in implementing their legal obligations through evidence based programmatic guidance, including guidance on policy implementation. indeed, while the convention is among the “most significant policy catalysts” for disability policy at the global level, nonetheless, “the most significant implementation constraints are at the national level” (7,9). to investigate all aspects of implementation, including activities used to put interventions or innovations into practice and contextual factors that influence these activities, one can look toward implementation research (10). this discipline offers insights for selecting evidence informed policies and interventions, identifying how to implement these in the disability context across populations and resources, and evaluating outcomes. in implementation research, widespread development of programmatic instruments and innovative tools promises to expedite policy implementation in various contexts. these tools are to a large extent tailored to specific purposes and contexts and have limited prospects for large-scale or long-term prospective testing (11). it is now well-established, however, that the transfer of knowledge to support implementation is more complex than it usually appears and is more difficult in the trans-disciplinary domain of public health policy (12,13). pragmatically, there is no “one-size-fits all” health policy and it would be naive to expect 24 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 implementation tools to work across different domains of public health policy, from clinical care guidelines to policy recommendations of international public health organizations. generally, the who’s effort to strengthen health policy implementation research and practice has been led by the alliance for health policy and systems research with its international academic and civil society partners network (14).the alliance highlights the value in documenting and analysing implementation experiences and sharing lessons for unravelling the otherwise invisible facets of the complex process of policy implementation and allowing implementing agents, facilitators and ‘champions’ to better understand their practice and realize their roles by reframing their perspective and refocusing their expectations. this will lead to better judgments about whether a particular strategy works or is relevant to other circumstances and situations, leading to measurable improvements in efficient health systems (15). in light of this, the objective of this paper is to evaluate an implementation strategy for the who ipsci report in romania. the context the research project was led by a partnership between a romanian non-governmental organization dedicated to delivering health and social services to people with disabilities and a swiss health research institute specialized in sci. the partnership organized the development of a strategy to implement the ipsci report in romania in august 2012. the strategy consisted of a set of implementation actions or interventions described in a central implementation plan, to work in combination, and administered by a coordinated group of implementers. the resulting implementation activities that are evaluated in the present paper started in march 2014 and lasted for 12 months. implementation research is by definition a participatory, stakeholder-driven and evidence informed process (10). adopting this approach is particularly important in disability research as persons with disabilities have long been denied equal voice in research and policy processes due to power asymmetries and misallocation of technical and financial resources. in this project, the participatory process of developing the implementation strategy and its evaluation involved three main phases: the preparatory phase, the implementation strategy development phase, and the monitoring and evaluation phase. the preparatory phase consisted of a group discussion by the research project team to identify and select mechanisms to develop the strategy. the implementation strategy development phase encompassed focus group interviews (fg) of people with sci, policy makers, system and service developers and managers, and representatives of ngos to elicit insights into key implementation considerations, a stakeholder dialogue (sd) with participants from the same pool of fg participants from romania and international experts to develop an implementation strategy, including the use of tools and processes. the development process was informed by a conceptual framework and guiding principles which have been previously developed by the authors (16). the monitoring and evaluation phase included surveys administered over the course of one year to monitor implementation activities by a core implementation group and evaluate the strategy. the question was now, what actually happened on the ground during 12 months of implementation and in how far the development process infused implementation activities that were successful. more specifically, this paper seeks to: a) evaluate implementation actions with a focus on the number of people reached and the status of completion at 12 months follow-up; b) describe implementation activities undertaken in the course of one year; and c) evaluate perceived barriers and facilitators of implementation at 12 months follow-up. 25 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 methods due to the lack of validated instruments to measure activities using the conceptual implementation framework, and given the research aim of focusing on the tools developed during the sd and documenting their use in implementation activities undertaken, new and fit-for-purpose survey questions were developed by the research project team. as a result, two surveys were developed in the preparatory phase and finalized after the implementation strategy development phase: first, the online report card survey to document implementation activities throughout the course of one year, and second a one year sd follow-up survey to capture implementation experiences such as perceived barriers and facilitators, among others. in addition, the implementation plan was used as a basis for the summative evaluation of activities at 12 months after the start of implementation. surveys development: the online report card survey questions were first developed by the lead author along the central elements of the comprehensive implementation framework and based on insights from the fgs and sd (16). the survey was independently reviewed by an implementation science expert and an expert on rehabilitation systems and services from the research project team. the survey was tested by a third health scientist who was not involved in the project. the questions were revised based on feedback. the one year sd follow-up survey questions were developed based on the online survey and on first screening of response data to its questions. this survey was reviewed by two team members and reviewer comments were incorporated in the revision. setup and design: the surveys were self-administered, with both quantitative and qualitative data elements. they contained both open-ended questions and questions with predefined response options ranging from yes/no (‘did the activity take place in relation to another event or initiative?’) to five-level psychometric scales (‘what tools were used during the implementation activity and how useful where they?’ – ‘very useful’ to ‘not at all useful’). both surveys were administered in english. the online survey was administered beginning after the sd in four waves from march 2014 until february 2015 capturing implementation activities during 3-month reporting periods each. it took approximately 20 minutes to complete each time. the sd followup survey was a one time, one year follow up survey to the sd. components: the online survey was composed of nine personal and demographic questions followed by 26 questions categorized by the essential implementation components asking, among others, about the kind of implementation activity, relation to the three central themes identified during the sd (medical rehabilitation and follow up in the community, independent living, employment and inclusive education), tools used including those introduced during the sd, processes followed, relation of activity to ipsci recommendation, and perceived receptiveness of audience. in the one year sd follow-up survey participants were asked to judge the extent (0 -5 likert scale) of hindering and facilitating influence attributes or factors of stakeholder groups had on implementation. these attributes had been jointly identified during the sd and were now being evaluated based on 12 months of implementation experience. participant recruitment: participants included a convenience sample of ten residents of romania, seven who had participated in the sd and three from the focus groups. as described elsewhere, participants of the sd and focus groups had been recruited on a participant roster developed by the researchers to maximize heterogeneity and representativeness. all participants were given an information sheet about the survey and asked to sign a consent form. 26 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 data analysis: qualitative survey data from open-ended questions were content-analysed by two researchers. the specificity and intensity of responses were determined by means of a thematic, open and selective description of meaningful concepts and themes using sentences as units of analysis (17,18). categories were then produced using inductive reasoning. conversely, descriptive statistics of quantitative data, such as frequency distributions, were carried out. implementation plan during the sd, five documents were developed that separately described problems related to the three central themes identified during the sd (i.e., sci medical rehabilitation and follow up in the community, independent living, employment and inclusive education), options to target these problems, facilitators and barriers by stakeholder groups, and next steps. these documents then served as a baseline analysis for the development of the implementation plan. the final evaluation of the plan was based on the categories ‘number of people reached’ and ‘status’ defined as either ‘completed’ or ‘incomplete’ at 12 months implementation by the core implementation group. results implementation plan the implementation plan listed 40potential actions in the categories presentations, publications, report development activities, trainings, services, consultations, conferences, and social events. actions planned included, among others: the development of a group statement based on ipsci recommendations, which was disseminated among key stakeholders; a 2-day scientific conference held in bucharest; a disability gala that was broadcasted on national television; an emergency call centre for persons with sci; an sci rehabilitation guide; and a meeting with high ranking government officials. of those listed, 29 actions were rated as “completed” and 11 as “incomplete” (75% completion rate). those listed as incomplete included also activities already planned or still in progress at 12 months. in total, 4390 persons had directly or indirectly benefited from the implementation related activities listed in the final implementation plan reporting. they were either active participants in activities, such as trainings, or the audience of oral presentations. implementation activities captured although the response rate dropped in the online report card survey, all ten participants responded at least, and often more than, once over the course of the year (10, 8, 3, 4 at time points 14). the one year sd follow up survey to the same pool of core implementers had a response rate of 9/10, one survey was returned incomplete. overall, respondents seemed to have understood the questions well, as the large majority of open responses were clear and to the point intended. no respondent reported technical problems accessing the online survey platform or the paper based questionnaires. one respondent reported language difficulties and was assisted by a colleague. the online report card survey captured 36 (14, 12, 5, 5 in time points one to four) implementation activities overall. table 1 provides an overview of these implementation activities. 27 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 table 1. implementation activities reported implementation activities (number of repor ts: 36) type of activity percent (number) delivery of social support services 30.5% (11) icf training 19.4% (7) implementation coordination and development meeting 19.4% (7) icf implementation in support services 5.6% (2) oral presentation 5.6% (2) dissemination through personal communication 2.8% (1) expert workshop 2.8% (1) guideline development 2.8% (1) organizing a scientific conference 2.8% (1) review of current state and report development 2.8% (1) stakeholder meeting 2.8% (1) workshop at scientific conference 2.8% (1) venue or setting percent (number) within an organization 36.1% (13) workshop by invitation only 33.3% (12) meeting by invitation 27.8% (10) during a scientific conference 8.3% (3) other 8.3% (3) within government ministry 2.8% (1) link to other activity percent (number) yes 61.1% (22) no 38.9% (14) implementation goal percent (number) delivery of workshop 22.2% (8) development implementation content and/or group 19.4% (7) promotion or dissemination of implementation content 13.9% (5) professionalization of services 11.1% (4) social reintegration of wheelchair users 8.3% (3) implement specialized knowledge 8.3% (3) improve independence of people with sci 5.6% (2) increase awareness 5.6% (2) improve services and procedures 2.8% (1) raising level of acceptance and self-competence in pwsci 2.8% (1) influencing the revision of disability assessment 2.8% (1) publish report 2.8% (1) organizing a conference 2.8% (1) influence administration of existing services 2.8% (1) delivery of products and services 2.8% (1) main implementation theme percent (number) independent living 55.6% (20) medical rehabilitation and follow up in the community 27.8% (10) employment & inclusive education 16.7% (6) target audience percent (number) people with disabilities 50% (18) disability professionals 33.3% (12) representatives of government and public authorities 33.3% (12) civil society 22.2% (8) health professionals 19.4% (7) students 11.1% (4) family members of people with disabilities 8.3% (3) implementers, implementation and human rights experts 8.3% (3) 28 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 pupils and teachers 8.3% (3) support service professional 8.3% (3) representatives of international organizations 2.8% (1) link with ipsci recommendation percent (number) 2. empower people with spinal cord injury and their families 30.6% (11) 3. challenge negative attitudes to people with spinal cord injury 19.4% (7) 7. implement recommendations 19.4% (7) 1. improve health sector response to spinal cord injury 11.1% (4) 5. support employment and self-employment 11.1% (4) 6. promote appropriate research and data collection 5.6% (2) use of materials and content 4. ensure that buildings, transport and information are accessible 2.8% (1) percent (number) icf case studies (distributed) 69.4% (25) facilitators 66.7% (24) barriers 63.9% (23) the problem 50% (18) the options 50% (18) next steps 50% (18) scientific paper on implementation (distributed) 27.8% (10) other 16.7% (6) adaption of content to local context percent (number) no, the documents were used as they are 36.1% (13) yes, they were translated further 36.1% (13) yes, they were shortened 13.9% (5) other 13.9% (5) yes, they were rearranged 11.1% (4) yes, they were rewritten 11.1% (4) not applicable 5.6% (2) monitoring tools percent (number) longitudinal patient or recipient documentation 30.6% (11) outcome questionnaire 22.2% (8) activity documentation 8.3% (3) group discussion 2.8% (1) mapping of documents 2.8% (1) testimonials 2.8% (1) no monitoring of activities 30.6% (11) receptiveness of audience percent (number) in favour 66.7% (24) slightly in favour 30.6% (11) neither in favour nor against 2.7% (1) implementation activities respondents participated in most were by a large margin social support services (31%), followed by icf trainings and implementation coordination and development meetings (both 20%). the majority of implementation activities took place within an organization (34%) and participation was by invitation in 63% of activities. about two thirds of activities were related to other events or projects (63%). asked to state the explicit goal of the implementation activity they were part of, respondents named the delivery of a workshop or training (n=8) most often, followed by the development of implementation content and / or forming an implementation group (n=5), the promotion or dissemination of implementation content (n=4), and professionalization of services (n=4). in terms of goals targeting the person level, improving independence of people with sci (n=2), social reintegration of wheelchair users (n=2), their participation in services (n=3), and raising the level of acceptance and self-competence in people with sci (n=1) were named. 29 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 respondents were also asked to what main implementation theme, identified during the sd as main focus of implementation efforts, the activities related to. in 56% of cases and by a large margin these were related to the theme independent living. in addition, implementation activities mainly related to the ipsci recommendation empower people with spinal cord injury and their families (31%). the recommendation challenge negative attitudes to people with spinal cord injury (20%) and implement recommendations scored both second highest. key messages of activities were directed at raising awareness toward problems people with sci face in terms of accessibility barriers, poor health, denial of rights, and social exclusion. these messages highlighted an inclusive and rights based approach (obstacles can be overcome and people live independently with the right supports; people with disabilities should be socially and financially independent; people with disabilities have rights they should access). further key messages targeted the system and service level, calling for an improvement of medical sci rehabilitation, provision of services based on the icf approach, and stating that better access to at and mobility training improves the lives of people with disabilities and the elderly. in addition, employment services should consider all abilities of people with sci also in relation to their functioning capacity in a specific environment and not only assessed from a medical point of view. finally, key messages toward implementation stated that successful implementation of ipsci recommendations would first require a rethinking of legislation and policies on disability in line with crpd, and that it necessitates joint action by key experts, sustained by policy. the main target audience of activities were people with disabilities followed by disability professionals and representatives from government and public authorities. out of the seven total documents created or introduced during the sd, the icf case studies and the facilitators’ document were used most often. in 73% of cases respondents had adapted these documents to the local context, mostly by translation (36%). in terms of processes or techniques used and their usefulness (figure 1), respondents found in61% of their activities elements of educational meetings or teachings (of health professionals, government employees, people with sci and families) either fairly useful or very useful as well as local consensus processes (meeting to discuss and agree on implementation goals, steps, etc.) in 47% of cases. tools rated most useful during implementation activities (figure2) were the ipsci summary in romanian (83% of cases), the ipsci full report in english (61%), the icf and own documents or media (53%). other, very specific who media was in the majority of cases not used. twenty-five out of 36 activities were monitored. about 97% of the target audience reported to have been in favour or slightly in favour (0-5 likert scale) of the implementation activities. asked to describe the main outcomes of their activities, respondents named direct output produced, evidence of services provided, and individual or organizational level impact. activity related output included the development of and promotion of implementation content (n=11), such as an implementation plan, technical information, or a journal article. also, the organization of an expert group to develop an implementation plan was highlighted as one such direct output. evidence of service provision (n=13) included the recruitment of clients and services delivered (registration, assessment, program development, training). in addition, some activities were evaluated by participants (n=3) leading to sum scores of how far training participant’s expectations were met. individual level impact (n=23) was reported as knowledge gain or change of perspective and awareness in the target audiences, including a better understanding of rehabilitation 30 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 objectives, outcomes and problems by health professionals. furthermore, specific skills were acquired by the target audience, their independence improved, and their activity and social participation increased. finally, one respondent named improved working procedures and working tools used within the target organization as a direct organizational level impact (n=1). during the sd participants had listed most anticipated barriers for the stakeholder group policy makers and ngo. figure 1. implementation techniques and their perceived usefulness by number of cases 31 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 figure 2. implementation tools and their perceived usefulness by number of cases respondents also rated the extent of hindering and facilitating factors by stakeholders had on implementation during the last 12 months (figure 3). these factors had been jointly formulated during the sd and listed most barriers for the policy maker and academia stakeholder group (6 & 4) and most facilitating influences for the private sector (4). only nine out 26 factors had been rated of no influence and all as either of large or very large influence. the dependence of policy makers on constituency interest scored as highest barrier and the general availability of european commission and european structural funds highest facilitator, possibly counterbalancing the general lack of funds and resources as general barrier. 32 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 figure 3. perceived barriers and facilitators by stakeholder group and in general terms legend: ac academia; dpo – disabled people’s organization; ggeneral; ngo – non governmental organizations; pm – policy makers; ps – private sector; sci – people with sci; spp service and product providers. 33 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 discussion summary of main results when summarizing the main results of the surveys it is important to note that multiple and different kinds of implementation activities were undertaken over the course of the monitoring period. these were to a very large extent completed (75%) and had involved over 4000 people. the activities produced direct output, evidence of services provided, and indications of individual or organizational level impact. on closer examination patterns become apparent in the data. a majority of activities were concerned with the delivery of social support services, icf trainings, and implementation coordination and development meetings. these activities mostly took place within an organization, by invitation and related to other events or projects. consequently, goals were largely related to improving independence of people with sci, the delivery of workshops or trainings, and development of implementation content or formation of an implementation group. subsequently, activities largely related to the overall theme of independent living with key messages of the need for awareness raising, improvement of service provision, and the necessity to coordinate implementation efforts. evenly matched are the target audiences - people with disabilities, disability professionals and representatives from government and public authorities. the most useful processes were educational meetings or teachings and local consensus processes. most notably in terms of tool usefulness is that the ipsci summary in romanian, the ipsci full report in english, the icf and their own documents and media scored most useful, while who media products were least used or useful. although these tools had been introduced during the sd, implementers resorted to using tools that were more linguistically accessible or their own tools. an additional indication that language accessibility is an important issue is the fact that in one third of cases sd documents were translated for further use in implementation. finally, the implementers rated substantial hindering and facilitating influences stakeholder groups had on their implementation efforts. lessons learned beyond offering insights into actual implementation experiences, we can draw three lessons from the experience that can help in the development and application of an implementation strategy for a who public health report. first, we can see that the overall implementation strategy worked in terms of pre-defining activities in a plan and coordinating the implementation groups’ efforts. this was apparent in activity achievement as documented in the implementation plan and established through implementation content and group development meetings as documented in the monitoring survey. secondly, results indicate that the process of developing the implementation strategy had a positive impact of building the team for the core implementation group, ownership and participation, as well as on focus and the continuation of efforts, and, lastly, on implementation outcomes. finally, the monitoring mechanism drafted during the implementation strategy development process is feasible, faithful and useful as the surveys were able to display the broad range of implementation experiences with their many facets. this fact underscores the usefulness of the underlying conceptual implementation framework used to map out the survey questions across core implementation components toward planning, administering and monitoring implementation (16). 34 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 however, the surveys could also benefit from a closer alignment with recently developed surveys in similar contexts (19,20). in particular, this would mean adding survey questions within the online report card survey assessing the specific impacts the process to develop the strategy had, similar to those survey cycles used in stakeholder dialogue researched by boyko and colleagues (21). overall, survey design, analysis and interpretation can be standardized by further application in similar case studies to improve data quality. results in light of research in the field waltz and colleagues as part of the expert recommendations for implementing change (eric) study recruited a panel of experts in implementation science to sort 73 implementation strategies and to rate their relative importance and feasibility. the ratings reflect similar processes identified in the present case as the most important and feasible, for instance, identifying barriers and facilitators to implementation, developing stakeholder interrelationships, training and educating stakeholders, and engaging consumers (22). furthermore, participatory implementation strategy development mechanisms create strong coherence in the implementation group and a shared sense of commitment greatly benefiting outcomes. findings from the international consortium project ‘equitable’ of two european and four african countries highlight very similar lessons learned when developing and implementing a joint project (23). likewise, identifying implementers during strategy implementation in terms of professional knowledge, involvement in issue, networks, ability to influence, and interpersonal competencies will benefit implementation processes (24,25). finally, drawing on standard outcome variables proposed for implementation outcome research (26) this study shows that the following are the most relevant: reach in terms of the number of people directly or indirectly involved throughout romania; adoption and fidelity in terms of level of activity completion; perceived usefulness of implementation tools and processes; and signs of sustainability in terms of technical expertise introduced to services on the ground. limitations and implications for future research in the present case, much of the implementation success must be attributed to the core implementation group and the influence the individual implementers had in their respective organizations (27). this is particularly evident in the role of main project partners and their effective interplay. although the core implementation group members were selected from the pool of focus group and sd participants who in turn were invited based on a detailed participants’ recruitment scheme to reach heterogeneity in group composition, the group constitutes a small convenience sample lacking representativeness. this limits the generalisability of results. expanding on the number of implementers involved will increase reach and generalisability of results. however, inclusion of participants from one particular country only will always introduce a cultural bias. respondents could have over or underrated specific elements or tools of implementation that are either lacking in their country or are in general under prioritized. in effect, what was accomplished here is a pilot of two surveys that are innovative in their own right and fill an important gap in the toolset of implementation research. subsequent research using these, or modified versions of these surveys also in other contexts and countries will help to refine the methodology and strengthen the survey approach. another limitation might be the reporting bias of the implementers. the implementers might have felt obliged to report favourably on implementation interventions within the realm of their own organizations, although specific precautions were made in term of anonymity of responses and disclosure of implementation group composition. it must be kept in mind, however, that the concern here is not so much the accuracy of the reporting, as the self 35 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 awareness of the implementers of what they have committed themselves to do. it is extremely difficult to avoid self-serving responses in this context, and independent verification of these results would go far beyond this study. when it comes to evaluation, defining appropriate impact indicators at the start of the project will help measure implementation outcomes and impact in wider contexts in addition to the project-related process and output indicators (28,29). context data and information on stakeholder influences on implementation could be set in reference to network analysis as it has been applied in health systems research (11,30). conclusion as who’s alliance for health policy and systems research has made clear, any effort to strengthen health policy implementation research and practice depends on clear documentation and analysis of the experience of implementers ‘on the ground’. agents, facilitators and other implementation ‘champions’ have always been the engine of implementation, and it is crucial to understand their motivations, experiences, and self perception of their implementation roles. in this paper we have presented one important method for achieving this, in the form of surveys used to evaluate an implementation strategy for the who ipsci report in romania. despite limitations in this study – described above – it is clear from this initial, piloting of the surveys that they are both feasible and extremely useful tools to supplement the more standard used implementation strategies at country level. references 1. world health organization, international spinal cord society. international perspectives on spinal cord injury. geneva: who; 2013. 2. kirshblum sc, burns sp, biering-sorensen f, donovan w, graves de, jha a, et al. international standards for neurological classification of spinal cord injury (revised 2011). j spinal cord med 2011;34:535-46. 3. weerts e, wyndaele jj. accessibility to spinal cord injury care worldwide, the need for poverty reduction. spinal cord 2011;49:767. 4. post mw, van leeuwen cm. psychosocial issues in spinal cord injury, a review. spinal cord 2012;50:382-9. 5. von groote pm, shakespeare t, officer a. prevention of spinal cord injury. inj prev 2014;20:72. 6. biering-sorensen f, brown dj, officer a, shakespeare t, von groote p, wyndaele jj. ipsci, a who and iscos collaboration report. spinal cord 2014;52:87. 7. united nations. convention 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gibson m, block ma, haines a, et al. a framework for mandatory impact evaluation to ensure well informed public policy decisions. lancet 2010;375:427-31. 30. blanchet k, james p. how to do (or not to do), a social network analysis in health systems research. health policy plan 2012;27:438-46. http://www.who.int/alliance-hpsr/en/(accessed� 37 von groote pm, skempes d, bickenbach je. evaluation of an implementationstrategy for a world health organization (who) public health report: the implementation of the international perspectives on spinal cord injury (ipsci) in romania (original research). seejph 2017, posted: 11october 2017. doi 10.4119/unibi/seejph-2017-151 © 2017 von groote et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0)� 38 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 original research the dutch long-term care reform: moral conflicts in executing the social support act 2015 wesley jongen1, peter schröder-bäck1, jos mga schols2 1 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, the netherlands; 2 department of health services research and department of family medicine, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, the netherlands. corresponding author: wesley jongen, phd, department of international health, maastricht university; address: po box 616, 6200 md, maastricht, the netherlands; telephone: +31433882204; email: w.jongen@maastrichtuniversity.nl mailto:w.jongen@maastrichtuniversity.nl� 39 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 abstract on 1 january 2015, a new long-term care reform entered into force in the netherlands, entailing amongst others a decentralization of long-term care responsibilities from the national government to the municipalities by means of a new law: the social support act 2015. given the often disputed nature of the reform, being characterized on the one hand by severe budget cuts and on the other hand by a normative reorientation towards a participation society, this article examines to what extent municipalities in the netherlands take (potential) moral conflicts into account in their execution of the social support act 2015. in doing so, the article applies a ‘coherentist’ approach (consisting of both rights-based and consequentialist strands of ethical reasoning), thereby putting six ethical principles at the core (non-maleficence & beneficence, social beneficence, respect for autonomy, social justice, efficiency and proportionality). it is argued that while municipalities are indeed aware of (potential) moral conflicts, the nature of the new law itself leaves insufficient room for municipalities to act in a sufficiently proactive and supportive/empowering manner on these challenges. keywords: ethical reasoning, long-term care reform, moral conflicts, the netherlands. conflicts of interest: none. 40 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 introduction background in 2006, the council of the european union made reference to “a set of values that are shared across europe” in its ‘council conclusions on common values and principles in european health systems’ (1). the council conclusions stipulate that “[t]he health systems of the european union are a central part of europe's high levels of social protection, and contribute to social cohesion and social justice as well as to sustainable development. the overarching values of universality, access to good quality care, equity, and solidarity have been widely accepted in the work of the different eu institutions” (1). this set of values was subsequently reinforced a year later in the european commission’s ‘white paper together for health: a strategic approach for the eu 2008-2013’ (2), comprising the eu’s health strategy supporting the overall ‘europe 2020’ strategy (3). the healthcare sector, and more specifically the long-term care sector, has always been a source for ethical debate. typical ethical issues (or moral conflicts) in long-term care decision-making include the debate on whether we should only look at people’s deficits or also to their rest capacities (4),“the nature and significance of the elder's diminished capacity for self-care and independent living”, the question “whether an older adult should continue to live at home”, “the obligation of the elder to recognize and respect the limits that family members may justifiably set on their care giving responsibilities”, a loss of autonomy “when the decision is made to change either the elder’s place of living or support services” and “the balance to be struck between independence and safety” (5). however, as argued by ranci and pavolini (6), “[o]ver the past two decades, many changes have happened to the social welfare policies of various industrial countries. citizens have seen their pensions, unemployment benefits, and general healthcare policies shrink as ‘belt tightening’ measures are enforced”. at the same time, ranci and pavolini (6) argue, “long term care has seen a general growth in public financing, an expansion of beneficiaries, and, more generally, an attempt to define larger social responsibilities and related social rights”. consequently, pavolini and ranci (7) conclude that “[f]aced with the problems associated with an ageing society, many european countries have adopted innovative policies to achieve a better balance between the need to expand social care and the imperative to curb public spending”. the adoption of such innovative policies is referred to here as reforms in long term care policies. the unfold of long-term care reforms even seems to be exacerbated in the aftermath of the 2008 economic crisis, when many european countries introduced austerity measures that in many cases appeared to have adverse effects on health systems and/or social determinants of health (8-12). moreover, schröder-bäck et al. argue that “[t]he current protracted economic crisis is giving rise to the scarcity of public health resources in europe. in response to budgetary pressures and the eurozone public debt crisis, decision makers resort to a short term solution: the introduction of austerity measures in diverse policy fields. health and social policy tend to be easy targets in this regard, and budget cuts often include a reduction of healthcare expenditure or social welfare benefits” (13). jongen et al. (14) add to this that “this crisis has had a much more direct and short-term influence on the quality of countries’ long-term care system than more gradual developments such as population aging and declining workforces, mainly due to austerity measures being the result of, or being accelerated by, this crisis”. also the council conclusions make reference to this changing context of many european countries’ long-term care system, by stating that “[i]t is an essential feature of all our systems that we aim to make them financially sustainable in a way which safeguards these values into the future” (1). moreover, the document stresses patient empowerment, by stating that “[a]ll 41 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 eu health systems aim to be patient-centred. this means they aim to involve patients in their treatment, to be transparent with them, and to offer them choices where this is possible, e.g. a choice between different health care service providers” (1). at the same time, the council conclusions acknowledge that “[d]emographic challenges and new medical technologies can give rise to difficult questions (of ethics and affordability), which all eu member states must answer. […] all systems have to deal with the challenge of prioritising health care in a way that balances the needs of individual patients with the financial resources available to treat the whole population” (1). although sharing some characteristics, every long-term care reform is embedded within peculiar national traditions and is therefore unique. this is true all the more for the latest dutch long-term care reform, that entered into force on 1 january 2015, and which can be considered as the latest major step in a more all-encompassing ‘market-oriented reform’ of the dutch healthcare system in general. the 2015 reform can be characterized as having a “hybrid structure” (15), characterized, on the one hand, by a “reign in expenditure growth to safeguard the fiscal sustainability of ltc” (16), and on the other hand by a “multiplicity of regulations to safeguard public values” (15). more concretely, as argued by maarse and jeurissen (16), the 2015 long-term care reform consists of four interrelated pillars: expenditure cuts, a shift from residential to non-residential care, decentralization of non residential care (implying a transfer of responsibilities in that policy domain from the national government to the municipalities), and a normative reorientation. the latter refers to the notion that “[u]niversal access and solidarity in ltc-financing can only be upheld as its normative cornerstone, if people, where possible, take on more individual and social responsibility. the underlying policy assumption is that various social care services may be provided by family members and local community networks” (16). indeed, a general shift in focus from formal care provision to informal care provision is added by jongen et al. (17) as a key element of the 2015 dutch long-term care reform. it is, however, exactly this normative reorientation, and its underlying assumption of an increased informal care provision, that is often disputed. as argued by maarse and jeurissen (16): “an important line of criticism is not only that informal care is already provided at a large scale, but also that the potential of ‘unexplored’ informal care is overestimated. furthermore, the negative externalities for caregivers who deliver informal care are underestimated”. moreover, while residential care remains under the responsibility of the national government after the entry into force of the 2015 long-term care reform, and a large part of non-residential care came under the responsibility of the health insurers, it is the municipalities that became under the social support act 2015 (ssc 2015) [in dutch: wet maatschappelijkeondersteuning (wmo) 2015] responsible for particularly those parts of non-residential care dealing with support directed towards the social participation of people with severe limitations (in the wordings of the official legal text of the social support act 2015 (authors’ own translation): “people with disabilities, chronic mental or psychosocial problems”), as well as with support for informal caregivers (17). indeed, the official legal text of the social support act 2015 stipulates that “citizens who themselves or together with people in their immediate environment are not sufficiently self-sufficient or insufficiently able to participate [in society], must be able to rely on organized support by the government” (authors’ own translation). however, municipalities have a large discretion in making this obligation to provide support concrete (the so-called ‘postcode [zip code] rationing’), which may lead to unequal access to long-term care in different municipalities (16). literature research so far, the academic literature has not extensively scrutinized the potential moral conflicts resulting from the implementation of the social support act 2015, and is more about 42 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 organization and logistics than about ethics. the available literature either touches upon mere elements of an all-encompassing ethical debate, or upon the perspective of specific groups. as an example of the former, van der aa et al. (18) consider the presumed impact of the 2015 long-term care reform on such elements as good quality of care and solidarity. van der aa et al. argue that the above-mentioned ‘zip code rationing’ might well lead to differences between municipalities in the degree of solidarity as perceived by citizens (‘zip code solidarity’). furthermore, van der aa et al. argue that it should not be taken for granted that municipalities, by simply making an efficiency move, can guarantee an equal level of care quality with the decreased budget they are faced with for executing their new long-term care tasks. next, grootegoed and tonkens (19) consider the impact of the dutch shift in focus from formal to informal care provision on such elements as respect for autonomy or human dignity and argue that “the turn to voluntarism does not always prompt recognition of the needs and autonomy of vulnerable citizens” and furthermore that “the virtues of voluntarism may be overstated by policy makers and that the bases of recognition should be reconsidered as welfare states implement reform”. examples of literature focusing on the perspective of specific groups include the articles by dwarswaard et al. (20) and dwarswaard and van de bovenkamp (21) on, respectively, self-management support considered from the perspective of patients and the ethical dilemmas faced by nurses in providing self-management support (whereby self-management is defined as “the involvement of patients in their own care process” (21), and in that way relates to the above-mentioned notion of individual responsibility). study objectives and research questions no comprehensive ethical approach towards the impact of the social support act 2015, however, appears yet to exist. the current study intends to fill in this gap, by answering the following research question: to what extent did/do municipalities in the netherlands take potential moral conflicts into account when implementing and executing the social support act 2015? as the core of the 2015 dutch long-term care reform is characterized by, on the one hand, severe budget cuts, and, on the other hand, by a normative reorientation towards a participation society wherein people are expected to take on more individual and social responsibility (16,17), we additionally formulated the following sub-research questions: 1. how do municipalities divide scarce resources in the social domain in a fair way?; 2. how do municipalities empower citizens towards a participation society? in answering both research questions we consider the potential moral conflicts experienced by municipalities, as executers of the social support act 2015, with regard to those entitled (or proclaim to be entitled) to receive support on the basis of the social support act 2015, as well as with regard to relatives providing informal care to the previous group. despite the fact that the nature, as well as corresponding reforms, of individual countries’ long-term care systems differ, the systematic approach of assessing moral conflicts resulting from the introduction of new long term policies as applied in this study could also be transferred to other countries were long term care reforms are being implemented. at the same time, several policy lessons could be derived from the experiences of dutch municipalities with the 2015 long-term care reform. methods research method and study design to answer our research question, a mixed-method research approach was chosen. first, a document analysis was conducted, in order to explore if, and to what extent, ethical values and principles are literally incorporated in the legal text of the social support act 2015. for 43 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 this analysis we only considered the primary source (the legal text itself) and no other, secondary documents (such as municipal policy documents). second, policy advisors (responsible for the long-term care policy domain) of all 390 dutch municipalities were invited to complete anonline survey. henceforth, no sampling technique had to be applied, although of course we had to compile a mail distribution listconsisting of either the general e mail addresses of municipalities, or the e-mail addresses of the specific departments the intended policy advisors are working. in some smaller municipalities these policy advisors were not only responsible for the long-term care policy domain, but for the whole social domain (next to the long-term care decentralization, municipalities were simultaneously also faced withdecentralizations in the field of youth care and in the field of labor participation of people with an occupationaldisability); in large municipalities more than one person might be responsible for the long-term care policy domain. however, in our explanatory notes we specifically asked to forward our demand to one of the intended policy advisors, in order to avoid multiple respondents from the same municipality. the reason for choosing policy advisors, instead of politicians, had to do with the potential political bias that politicians might have with regard to the topic of this study. indeed, the potential ethical implications surrounding the long-term care decentralization constitutes a politically sensitive issue in many municipalities, as clearly came to the forefront in one of the two test-interviews, which was conducted with the major of a municipality (the other test-interview was conducted with a professor of old age medicine). moreover, while each municipality also has several so called ‘social support act consultants’ [in dutch: wmoconsulenten], who do the actual fieldwork, implying the one-to-one contact with individual (potential) clients, these employees are believed to lack an overarching helicopter view. in principle, participation in the online survey was anonymous, except when a respondent declared to be willing to participate in an in-depth telephonic interview. these in-depth interviews constituted the third step in our mixed-method research approach, and were intended to expand on the survey, instead of asking new questions. anonymity of these respondents has been guaranteed by omitting persons’ and municipalities’ names here. theoretical framework and conceptual model for the analysis of the potential moral conflicts surrounding the implementation and execution of the social support act 2015, we applied a ‘coherentist’ approach(consisting of both rights-based and consequentialist strands of ethical reasoning) as offered by schröder bäck et al. (22), thereby putting six ethical principles at the core that are considered to capture the specificities of the current study (non-maleficence & beneficence, health maximisation / social beneficence, respect for autonomy, social justice, efficiency and proportionality). taking into account the variety of seemingly similar concepts such as ‘ethical dilemmas’, ‘moral conflicts’, ‘moral dilemmas’, et cetera, it should however first be clarified which definition is applied in this study and what is meant with it. given the heavily-loaded connotation of the term ‘ethical dilemma’, we prefer the term ‘moral conflict’ here. subsequently, based on the stanford encyclopaedia of philosophy (23), we define a ‘moral conflict’ as follows: a moral conflict appears if one thinks one has good moral reasons to do one thing, but also good moral reasons to not do it, or do something that is in conflict with it. so either decision is not perfect. or, in other words: a moral conflict arises if the moral norms and values we would like to follow guide us to conflicting/opposing actions. a coherentist ethical approach, then, implies that an ethical analysis “should be based on a variety of plausible norms and values” and that none of the traditional ethical approaches is therefore superior to the other (22). instead, they all contribute important moral insights. schröder-bäck et al. (22) add to this that “their norms do weigh prima facie the same and need to be plausibly unfolded and specified in a given setting. when they are contextualised 44 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 and specified they develop their normative weight and power”. this prima facie status of the ethical principles thus “supports the process of careful ethical deliberation and reflection”. moreover, specifying the more ‘overarching’ ethical approaches into a concise set of ethical principles is considered as a useful, practical, tool for medical and public health ethics (24). each of these six principles will be discussed in detail in the following. non-maleficence and beneficence: non-maleficence implies that “a healthcare professional should act in such a way that he or she does no harm, even if her patient or client requests this” (25). beneficence is connected to non-maleficence, the only difference being that non maleficence involves the omission of harmful action and beneficence actively contributes to the well-being of others (25). because of their intimate connection, both principles are considered under one heading here. considering the overarching approaches to ethical reasoning as mentioned above, the principles of non-maleficenceand beneficencecorrespond to the ‘do no harm’ principle under the consequentialist approach to ethical reasoning. health maximisation / social beneficence: although in the literature one can find either of these terms, we refer to social beneficence as the norm that says that it is a moral goal to improve the wellbeing of people on an aggregated population level. social beneficence resembles in a significant way the consequentialist principle of utilitarianism. utilitarianism is the ethical theory that requests from an action or omission to be in such a way that the maximization of best consequences would follow. respect for autonomy: the ‘respect for autonomy’ principle implies a tempering of the “paternalistic benevolence contained in the principles of non-maleficence and beneficence” (25). in that way, the ‘respect for autonomy’ principle is closely related to the ‘human dignity’ principle under the rights-based approach to ethical reasoning. moreover, without taking into account the ‘respect for autonomy’ principle, it would under the principle of health maximisation / social beneficence alone be allowed “to use individuals (or whole groups) for other than their own ends and even sacrifice them if only this provided a greater net benefit, i.e. maximised health” (24). social justice: the principle of (social) justice as referred to under the rights-based approach to ethical reasoningcan be considered another side constraint to the principle of health maximisation / social beneficence. as schröder-bäck et al. (24) put it: “it does not only matter to enhance the net-benefit; it also matters how the benefits and burdens are distributed”. moreover, this also includes “a fair distribution of health outcomes in societies, which is often discussed in terms of public health as ‘health equity’” (25), which is considered by daniels as a matter of fairness and justice (26). in fact, the principle of ‘equity’ constitutes the core of the values of the ‘council conclusions on common values and principles in european health systems’. as schröder-bäck et al. (22) put it: “the other three overarching values can be conceptualised as specifications of equity (and of social justice). access to good quality of care and universality can be seen as a reiteration of the core demands of equity and justice”, while “solidarity is seen as a characteristic that describes the willingness of members of communities to be committed to the principle of justice or to each other”. in short, one could argue thus that “[j]ustice approaches in health care often demand nothing more than universal access to good quality care” (22). or, as the world health organization (who) puts it: “universal health coverage (uhc) is defined as ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship” (27). efficiency: efficiency requires the efficient use and distribution of scarce health resources (24). 45 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 proportionality:the principle of proportionality, finally, emphasizes that it is “essential to show that the probable public health benefits outweigh the infringed general moral considerations. all of the positive features and benefits must be balanced against the negative features and effects“ (24). in their ‘ethical criteria for immunization programmes’, verweij and dawson (28) combine the principles of efficiency and proportionality under one heading, by stating that a “programme’s burden/benefit ratio should be favourable in comparison with alternative […] options”. data collection for the document analysis, we specifically considered the presence of the values as stipulated by the ‘council conclusions on common values and principles in european union health systems’, as well as the six ethical principles elaborated on above. next, for the survey and in-depth interviews, these principles have been broken down into representative survey/interview questions, allowing for a structured and comparative analysis of potential moral conflicts. schröder-bäck et al. (25) applied a similar approach within the context of developing a curriculum for a short course on ethics in public health programmes, by suggesting a checklist consisting of several questions around each of the ethical principles they applied in their study (largely comparable to the six principles as applied in the current study). with the respective author of that study, one question for each of the above six principles was chosen, adapting them to the specificities of the current study, and translated into dutch (see table 1 for the final survey/interview questions). the reason for choosing merely one question per category had to do with the practical limitations of using open-ended questions in an online survey: based on andrews (29) as well as on two test-interviews we conducted, the response rate to open-ended survey questions is considered to be substantially lower than in the case of closed-ended survey questions, especially when the number of questions would be too high. the questions covering each of the six ethical principles were preceded by a general question on the identification of potential moral conflicts (intended to trigger respondents, before directing them into the six predefined categories), and followed by two general questions on the way (if applicable) municipalities deal with the identified moral conflicts. data analysis the document analysis implied a scrutinization of the presence (or non-presence) of the values and principles elaborated on abovein the legal text of the social support act 2015, either in terms of a literal incorporationin the legal text, or in terms of indirect referrals to the respective values and principles. the data of the surveys and interviews were analysed through the application of a directed approach to qualitative content analysis (30). we chose for this approach, as it allows for an analysis that “starts with a theory or relevant research findings as guidance for initial codes” (30). in that way, we were enabled to directly apply our theoretical framework of ethical reasoning in the interpretation and categorisation of the research data, with the six predefined ethical principles as initial coding categories. within each of these categories, we clustered the respondents’ answers in ‘dominant responseclusters’ as a way of quantifying to some extent our qualitative survey results. this approach allowed for an organized inclusion of the main results in this article. obviously, qualitative results can never completely be quantified, as each specific answer remains unique. therefore, in order to add some extra weight to our results, we included direct respondents’ quotes to several of the dominant response clusters. 46 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 table 1. survey/interview questions q1: according to you,what are the most important moral conflicts (if any) your municipality has been faced with in the context of implementing and executing the social support act 2015? ethical principles original selected ‘check marks’(25) adapted questions ethical principle 1: non-maleficence & beneficence ethical principle 2: health maximization / social beneficence ethical principle 3: efficiency ethical principle 4: respect for autonomy ethical principle 5: (social) justice ethical principle 6: overall, for both non-maleficence and beneficence, is it possible to assess whether more benefit than harm is produced by intervening (or not intervening) and, if so, on what side (benefit or harm) does the equation finally fall? does it [the proposed intervention] have a sustainable, long-term effect on the public’s health? awareness of scarcity of public money; saved money can be used for other goods and services. does the intervention promote the exercise of autonomy? does the intervention promote rather than endanger fair (and real) equality of opportunity and participation in social action? q2: according to you, will more people (both care recipients as informal caregivers) have advantage or disadvantage as a result of the introduction of the social support act 2015? how do these advantages and disadvantages look like? q3: according to you, will the social support act 2015 have a sustainable, long-term, effect on the quality of life of the entire (older) population? q4: according to you, how does your municipality deal with the availability of the scarce resources that are available for the social support act 2015? q5: according to you, does the social support act 2015 provide sufficient opportunity for people’s freedom of choice with regard to the care and support they wish to receive (and the way how they receive it)? q6: according to you, do people under the social support act 2015 have an equal opportunity to live their lives the way they want (or, in other words: is the freedom of choice as mentioned in the previous question also practically possible for every person)? q7: according to you, will costs proportionality are costs and utility proportional? and utility under the social support act 2015 be proportional? q8: according to you, how does your municipality deal with the moral conflicts as identified under part 1? or, in other words: what are your municipality’s solutions to these moral conflicts? q9: according to you, are there, for your municipality, alternative ways of executing the social support act 2015, that will lead to less moral conflicts? part 1: identifying potential moral conflicts part 2: dealing with moral conflicts 47 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 results document analysis in terms of the values as stipulated by the ‘council conclusions on common values and principles in european union health systems’, the legal text of the social support act 2015 only literally makes reference to the value of ‘access to good quality care’, although quality of care should be understood here as ‘good quality of (social) support’. indeed, as was explained in the previous chapter, the dutch long-term care system is, as of 1 january 2015, divided into three laws, of which the social support act 2015 constitutes the one mainly dealing with social types of care (directed at increasing or maintaining the self-sufficiency and social participation of vulnerable citizens) instead of traditional healthcare. the municipalities’ responsibility under this law can therefore best be understood as providing adequate social support services instead of providing actual healthcare services. nevertheless, this focus on social types of care instead of traditional types of healthcare, or on ‘well-being’ instead of ‘health’ as a desired outcome of support, does not imply that the social support act 2015 should not be based on certain key ethical values or principles. also the council conclusions (1) go further than traditional healthcare, by implying that “[t]he health systems of the european union are a central part of europe's high levels of social protection, and contribute to social cohesion and social justice as well as to sustainable development”. with regard to good quality of social support, then, article 2.1.1 of the social support act 2015 stipulates that “[t]he municipal council is responsible for the quality and continuity of services” (authors’ own translation), while article 3.1 continues by stating that “[t]he provider shall ensure the provision of good quality services” (authors’ own translation). services either refer here to ‘general services’ (in dutch: algemenevoorzieningen), or to ‘customized services’ (in dutch: maatwerkvoorzieningen). the latter, subsequently, is defined in the legal text as a “range of services, tools, home adaptations and other measures, tailored to the needs, personal characteristics and capabilities of a person” (authors’ own translation). solidarity is by definition an important component of this law, and is referred to in the first sentence of the legal text, which points out that “citizens bear a personal responsibility for the way they organize their lives and participate in society, and that may be expected of citizens to support each other in doing so to the best of their ability” (authors’ own translation). the values of universality and the, more overarching, value of equity (being part of the principle of social justice in our theoretical framework) are indirectly referred to in the introduction of the legal text by stating that “citizens who themselves or together with people in their immediate environment are not sufficiently self-sufficient or insufficiently able to participate [in society], must be able to rely on organized support by the government” (authors’ own translation). as a result of the limited literal inclusion of these ethical values, it is not surprising that the more specified ethical principles derived from these values are hardly included in literal terms in the legal text neither. the only exception here is the ‘respect for autonomy’ principle, that could be derived from the wording of article 2.1.2 (4.c), which stipulates that municipalities in their social support policy should specifically take the freedom of choice into account of those citizens that are entitled to customized support services. survey and interviews having considered the literal inclusion of the ethical values and principles in the legal text of the social support act 2015, a next step in our research process was to examine to what extent municipal policy advisors consider the execution of the social support act 2015 to be in compliance with the six ethical principles as applied in this study. in totality 70 policy advisors completed the survey, constituting 18 per cent of dutch municipalities. in total, ten 48 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 of these respondents also appeared to be willing to participate in an in-depth interview. the results of the surveys and in-depth interviews are described question by question in the followingsection and discussed simultaneously (as the in-depth interviews were intended to expand on the survey results instead of asking new questions).given the number of respondents, only those answers that most frequently resulted from our analysis (the ‘dominant response clusters’ mentioned above) are discussed here. the direct respondents’ quotes that are included are believed to represent the respective cluster best and are the authors’ own translations from dutch to english. question 1 (general identification of moral conflicts). although not all respondents confirmed the existence of moral conflicts with regard to the implementation and execution of the social support act 2015, most respondents did identify one or more moral conflicts. in general, our respondents identified threetypes ofmoral conflicts. first, the conflict of adhering to the social support act’s underlying theory of moving towards a participation society vs. the limited budget and time-frame that is offered to municipalities for supporting this change process. indeed, the theoretical idea of moving towards a society wherein citizens take up more individual and social responsibility and where care and support is provided on a customized basis and closer to home, is considered by many as a positive normative development. however, the severe budget cuts that accompany the long-term care decentralization (expected to lead to budgetary shortfalls), as well as the rapidity of the reform process, hamper municipalities’ opportunities for supporting this development. or, as one respondent put it: “pragmatism prevails over quality demands”. second, respondents identified the conflict of how to efficiently coordinate responsibilities between the three different long-term care acts. the fact that municipalities under the long-term care reform only got responsibility for parts of the long-term care sector might lead to unclarity and confusion, not the least among (potential) recipients of care/support, regarding under which act one is entitled to care/support. moreover, some respondents indicated that an insufficient coordination between the three laws sometimes results in a lack of incentives among municipalities to invest in prevention and informal care support, as the financial benefits of these investments might not be evident for the ‘own law’, but only for the ‘other laws’. the third moral conflict identified relates to the correct assessment of citizens’ self-sufficiency and their ability to social participation vs. their care/support needs and the urge to empowerment. the fact that municipalities have a large policy discretion in executing their responsibilities under the social support act 2015 even complicates this point, as similar situations might well lead to different assessments in different municipalities. particularly difficult, then, is how to justify these differences to citizens. question 2 (ethical principle 1: non-maleficence and beneficence). most respondents appeared to have a rather neutral stance when it comes to assessing the non-maleficence and beneficence of the social support act 2015, arguing that the act leads to advantages for some and disadvantages for others, especially on the short-term. or, as one respondent put it: “it depends on the individual perception of people whether they experience the introduction of the new social support act as an advantage or a disadvantage”. moreover, getting used to a new situation always takes time, especially for those citizens that were already entitled to care or support under the pre-2015 situation. advantages primarily include the provision of customized care closer to home, in line with people’s specific living conditions, instead of standard care provisions like in the pre-2015 situation. disadvantages primarily include the, already above-mentioned, high degree of policy discretion of municipalities regarding their allocation of support measures—which tends to lead to perceptions of ‘unfairness’ or ‘subjectivity’ among citizens—, a lower level of formal care provision as experienced by individual citizens and consequently the increasing burden on informal caregivers. 49 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 question 3 (ethical principle 2: health maximization / social beneficence). the decreasing level of formal care provision can also be considered as a disadvantage on a societal level, when considering the more long-term expected consequences of the implementation of the social support act 2015. at the same time, a decreasing level of formal care provision is not considered by all respondents as a disadvantageous development. as one respondent put it: “if we execute it [the social support act 2015] well, this will increase quality of life. however, this also entails that we should carefully deal with informal caregivers”. one of the more long-term advantages is indeed believed to be the creation of a better awareness and appreciation among citizens about care in general, as a result of the diminishing resources for formal care provision, leading to a more inclusive society—characterized by the emergence of a new quality of life—wherein people have a better esteem of their own possibilities as well as a better appreciation of each other. at the same time, many respondents pointed out that this ‘emergence of a new quality of life’ is not so much due to the social support act 2015 (or the long-term care reform in general), but more to overarching trends such as demographical developments (people get older and older), technological developments in healthcare (which facilitate people in achieving a decent quality of life) and changing ways of thinking about care in general (such as other perspectives on civic engagement and patient empowerment). as one respondent put it: “the quality of life has always had a different standard than the generation before”. or, as another respondent put it: “laws don’t have an influence on quality of life”. question 4 (ethical principle 3: respect for autonomy). respect for autonomy was considered by most respondents as being sufficiently covered by the social support act 2015, specifically through the inclusion of the freedom of choice as mentioned under article 2.1.2 of the social support act 2015. concretely, the freedom of choice as referred to in article 2.1.2 implies either the choice between several by the municipality selected providers (when one is entitled to customized care services) or a fully open choice (when one is entitled to a personal budget). yet, respondents did put several remarks to this freedom of choice. first, due to the large discretion municipalities have in executing the social support act 2015, the interpretation of freedom of choice differs between municipalities (indeed, some municipalities offer a larger selection of providers than others). as one respondent put it: “the new social support act isn’t designed as to ‘support wishes’, nor as a ‘right to support’. therefore, there is a strong dependence on supplemental local rules”. second, in practice, freedom of choice is not always considered as an added value by people, especially by vulnerable people that are often just looking for good quality support. as one respondent put it: “for that [freedom of choice] there is little attention among people. moreover, it is questionable whether that is actually needed; people merely want good quality care instead of freedom of choice” (author’s own translation). question 5 (ethical principle 4: social justice). in line with the previous question, the question about social justice was basically about people’s capabilities of making use of their right to freedom of choice. answers to this question were divided. on the one hand, many respondents considered the majority of people that are entitled to support under the social support act 2015 to be indeed capable of making use of their right to freedom of choice. moreover, when necessary, support is offered to clients by the municipality. as one respondent put it: “the municipality is actively cooperating with ‘client supporters’ to facilitate people as good as possible in their freedom of choice” (these ‘client supporters’ are people that work independently from the municipality). on the other hand, other respondents emphasized that not everyone, especially vulnerable groups in society, are capable of applying their freedom of choice, neither has everyone a social network at her/his disposal to support them in doing so. moreover, freedom of choice depends to some extent on people’s 50 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 own resources. indeed, under the social support act 2015, the own financial contributions people are expected to pay for the care/support they receive have grown as compared to the pre-2015 situation, which might lead to the avoidance of care/support (31). as a result, respondents argue, differences in society grow when it comes to the possibility of people to make use of their freedom of choice under the social support act 2015. as one respondent put it: “a barrier to care is created, that leads to a split in society: if you have money you can buy care yourself; if you little money you’ll have to do it with a stripped care system”. question 6 (ethical principle 5: efficiency). with regard to the allocation of scarce resources, respondents’ views could be divided into three main groups. one part considered the budget available for the execution of their long-term care responsibilities, which was substantially lowered as compared to the pre-2015 situation, to be leading in the allocation of resources, implying that care/support demands are (according to these respondents) considered more critically—on the basis of stricter indications—as compared to the pre-2015 situation. as one respondent put it: “the resources are distributed as indicated by the national government”. moreover, some municipalities try to focus on general (collective) support services instead of on customized (individual) support services in order to remain within their budgetary margins. a second groups considered demand to be key in decision-making, implying that as much as possible is done to do what is necessary, at least for the most vulnerable groups. in case of shortages, solutions are (according to these respondents) considered to be the appeal to general municipal resources or the transfer of resources from other policy domains within the municipality. indeed, many municipalities are currently searching for more integral ways of working between the different parts of the social domain within their municipality (17). one respondent formulated it as follows: “it starts with the client and we do what is necessary; many roads lead to rome”. a third, though smaller, group took a more neutral stance and considered the underlying idea of the long-term care reform (truly progressing towards a participation society) to be key in decision-making, implying that ‘new’, ‘creative’, or ‘innovative’ solutions have to be sought in balancing between a limited budget and the existing (or even growing) care/support demand. one respondent covered this point by stating that we should “learn people how to fish instead of supplying the fish”. apart from an increased focus on prevention (e.g. by supporting, or cooperating with, citizens’ initiatives and/or informal care organizations), it remains however unclear what is exactly meant by ‘innovative solutions’. question 7 (ethical principle 6: proportionality). next, respondents were asked whether they think the social support act 2015 can be considered as a proportionate measure for the goals it intends to pursue. in general, respondents considered this proportionality indeed to be present, thereby primarily making the comparison to the pre-2015 situation, which was considered by many as ‘unfair’ and ‘untenable’ due to the often exaggerated care demands of people (the so-called ‘claim-mentality’). or, in the words of one respondent: “a greater reliance on an own network / own resources will eventually replace the claim-mentality (‘i am entitled to’) and thus be cheaper”.another group of respondents considered the underlying idea of the decentralization (providing care and support on a customized basis and closer to home) as a positive normative development, while being worried about the budget cuts that accompanied the decentralization. as one respondent put it: “there will only be a balance in case of sufficient budget and autonomy for municipalities”. for this group of respondents, the social support act 2015 is considered to be putting a disproportionate burden on society. for part of this latter group, this disproportionality is likely to reduce in the longer-term, due to a gradually reducing ‘claim-mentality’ within society. for another part, however, the reduction of long-term care costs in the longer-term will not be the result of a more efficient provision of long-term care, but will simply be the result of the mere fact 51 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 of less available financial resources (and thus less possibilities), leading logically to less expenses in the long-term care sector. question 8 (dealing with moral conflicts). the last two questions of the survey referred to the way municipalities deal with the identified moral conflicts. in general, most respondents pointed to the importance of communication and transparency here. on the basis of regular deliberations, meetings and conversations with both care/support providers, surrounding municipalities, care/support recipients and their informal caregivers, and other stakeholders, the execution of the social support act 2015 is evaluated regularly and adapted where necessary. moreover, although the large discretion that municipalities have in assessing citizens’ care/support needs is considered by many citizens as unfair or subjective (as we mentioned before), the best way of dealing with this discretion according to our respondents is to critically assess each individual situation in-depth, offer customized support where possible, be open and transparent towards care/support recipients and their informal caregivers, and thoroughly explain the choices made where necessary. as one respondent captured it: “continue discussions, while in the meantime also ensuring that the necessary care delivery continues”. question 9 (dealing with moral conflicts: alternatives). subsequently, respondents were asked whether they foresaw alternatives with regard to the execution of municipalities’ long term care responsibilities. many pointed to the unlikelihood of such an option, as the social support act 2015 is an established fact by law. others argued that neither option would be perfect and that turning to an alternative law now would be going back to square one. most respondents, however, interpreted this question not so much in terms of alternatives to the social support act 2015 in itself, but in terms of possible alternatives in the execution of this law. most of these respondents pointed to the potential release of more financial resources by the national government. at the same time, respondents acknowledged that although the availability of more financial resources would make life easier, it would not dissolve moral conflicts. a second alternative would be a clearer delineation between (or integration of) the different long-term care acts. respondents argued for example that it would have made more sense if the complete package of non-residential care services was put under responsibility of either the municipalities, or the health insurers. currently, the majority of non-residential care services is under responsibility of the health insurers, and only a small part under responsibility of the municipalities. finally, respondents pointed to the need for more innovative and unorthodox solutions, arguing that the social support act 2015 is not an aim in itself, but a means to deliver good care/support. or, as one respondent put it: “every law has an article 5”, implying that governments should sometimes turn a blind eye in the execution of policies. discussion principal findings and conclusions the aim of this study has been to examine to what extent municipalities in the netherlands take/took potential moral conflicts into account when implementing and executing the social support act 2015. we intend to answer our research question by relating the results corresponding to each of the six principles of our theoretical framework back to the coherentist approach of ethical reasoning this framework was based on. as was mentioned before, the coherentist approach is based on two main strands of ethical reasoning, being the ‘rights-based approach’ and the ‘consequentialist approach’. within a consequentialist approach, “actions are judged for their outcome and overall produced value” (22). this approach is basically founded on such principles as ‘health maximisation’ and ‘do no harm’ (22), corresponding to the principles of non-maleficence & beneficence and social 52 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 beneficence in our theoretical framework. in a public health context a consequentialist approach to ethical reasoning implies that health should be maximised, “as long as health maximisation is not endangering the maximisation of the overall utility of people” (22). as was described in the previous chapter, most of our respondents appeared to have a rather neutral stance with regard to assessing the non-maleficence and beneficence of the social support act 2015, emphasizing that it depends to a large extent on the individual perception of people whether they experience the introduction of the new social support act as an advantage or a disadvantage. with regard to social beneficence we found that, despite worries about the decreasing level of formal care provision, most respondents considered the creation of a better awareness and appreciation among citizens about care in general to be one of the more long-term advantages of the social support act 2015. at the same time there are also doubts about the impact that a law can have on such developments as new ways of thinking about long-term care (referred to above as a ‘normative reorientation’ towards long-term care). indeed, concepts such as the concept of ‘positive health’ as developed by huber et al. (4) are gaining importance within the healthcare sector.the conceptof ‘positive health’ considers health as “the ability to adapt and to self manage” (4) instead of considering it under the traditional who definition as “a state of complete physical, mental and social well being and not merely the absence of disease or infirmity” (32). a rights-based approach is basically founded on such principles as ‘human dignity’ and ‘justice’, corresponding to the principles of respect for autonomy and social justice of our theoretical framework, and claims that “persons have rights to fair equality of opportunity” (22). in a public health context this implies that people have a right to (equal opportunity) “to receive appropriate healthcare and live in environments in which social determinants of health are distributed in a fair way” (22). as we saw in the previous chapter, most respondents considered respect for autonomy to be sufficiently covered by the social support act 2015, mainly by its emphasis on freedom of choice. at the same time, however, our respondents pointed out that exactly freedom of choice is something that is not always of added value in a context wherein people are often just looking for good quality support. moreover, while social justice (people’s capabilities of making use of their right to freedom of choice) was considered to be sufficiently present for the majority of people, it is also exactly this point that respondents appeared to be most worried about in light of the social support act 2015, especially when applying it to vulnerable groups in society. indeed, the legal text of the social support act 2015 hardly stresses the importance of such notions as ‘equity’, one of the core underlying values of the principle of social justice. although the legal text stipulates that “citizens who themselves or together with people in their immediate environment are not sufficiently self-sufficient or insufficiently able to participate [in society], must be able to rely on organized support by the government”, it remains unclear when exactly someone is ‘insufficiently self-sufficient’, ‘insufficiently able to participate in society’, and (in case someone is entitled to support) when one is entitled to ‘general services’ and when to ‘customized services’. indeed, as was argued by maarse and jeurissen (16), municipalities actually have a large policy discretion with regard to the allocation of support measures (the so-called ‘zip code rationing’), which may lead to unequal access to long-term care. in fact, this point was one of the three main moral conflicts as identified by our respondents under question 1 of the survey. moreover, as argued by van der aa et al. (18), with the advent of the social support act 2015 a shift can be witnessed from a ‘right to care’ to a ‘right to customized support’. next, although solidarity is by definition an important component of the social support act 2015, the act foresees a shift from formal to informal solidarity (18). it remains, however, doubtful how much can be expected of this informal solidarity. as maarse and jeurissen (16) already pointed out, “the potential of 53 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 ‘unexplored’ informal care is overestimated. furthermore, the negative externalities for caregivers who deliver intense informal care are underestimated”. finally, the legal text of the social support act 2015 stipulates that “it is desirable to set new rules, in order to bring citizens’ rights and duties more in line with each other” (authors’ own translation), which tends to imply a decreasing government responsibility for citizens’ rights to equality of opportunities regarding access to good quality care/support. our first sub-research question was specifically directed towards the way municipalities divide scarce resources in the social domain in a fair way. as we saw in the previous chapter, our respondents’ views towards principles of efficiency and proportionality were quite divergent. on the one hand, the availability of less public resources for long-term care and the higher own financial contributions people are expected to pay for the care/support they receive might eventually lead to a more conscious use of care (and in that way contribute to the normative reorientation of creating a true participation society). on the other hand, however, these developmentsmight unconsciously lead to the creation of an access barrier to care (especially for the less affluent in society) or to the avoidance of necessary care. in fact, the conflict of adhering to the social support act’s underlying theory of moving towards a participation society while at the same time having to deal with the limited budget and time frame that is offered to municipalities for supporting this change process was one of the three main moral conflicts as identified by our respondents under question 1 of the survey. moreover, within the context of the social support act 2015 ‘efficiency’ might primarily be understood as a way of justifying the budget cuts that accompanied the long-term care decentralization, instead of as a moral obligation to efficiently use scarce health resources. at least part of the solution to the dilemma of how municipalities then can divide scarce resources in the social domain in a fair way might be provided by the ‘accountability for reasonableness’ approach of procedural justice by daniels and sabin (33), which offers a “minimum ethical standard in times of economic downturn characterized by scarcity of resources and when not all needs are being satisfied” (13). the accountability for reasonableness approach requires certain conditions to be met in order for a process of allocating scarce healthcare resources to be ‘fair’: the process (including the reasoning behind it) has to be transparent to the public, the reasons by which decisions were made have to be relevant, and it should be possible to revise any decision in case of new evidence or arguments (13). these conditions are quite in line with our results under question 8 (dealing with moral conflicts), emphasizing the importance of communication and transparency in the process of dealing with moral conflicts (such as the division of scarce resources). finally, in order to answer our second sub-research question (regarding the way municipalities empower citizens towards a participation society), it has to be determined how the kind of efficiency goals as discussed under the previous sub-question can be reconciled with moving towards a participation society; or, in other words, does the latter lead to the former, or does the former require the latter? is thus “participation” a good value or a fig leaf or metaphor for a liberalist mindset? we argue that although participation is an intended goal of the social support act 2015, citizens are insufficiently supported to achieve that participation. as we argued before, ‘support’ under the social support act 2015 is intended to be limited to those citizens who themselves or together with people in their immediate environment are not sufficiently self-sufficient or insufficiently able to participate. or, as maarse and jeurissen (16) put it: “the wmo 2015 gives applicants a right to publicly funded support if they cannot run a household on their ownand/or participate in social life”. however, proactively supporting citizens towards the initial goal of creating a participation society (e.g. by focusing on preventive measures), is much less pronounced in the legal text of the social support act 2015. article 2.1.2 (c, d and e)points in general terms at, 54 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 respectively, the early determination of citizens’ support needs, the prevention of citizens’ reliance on support, and the provision of general support services (provided without the prior examination of the recipient’s need, characteristics and capabilities). however, how to achieve these points is left to the municipalities’ discretion. in the same vein, article 2.1.2b points out that “the different categories of informal caregivers should be enabled as much as possible to perform their duties as informal caregiver” (authors’ own translation), but this point is not specified in the remainder of the legal text. this point is therefore, we argue, much less concrete as compared to the old 2007 social support act (under which municipalities where merely responsible for domestic help), where support for informal caregivers was concretized in such sub-themes as information, advice, emotional support, education, practical support, respite care, financial support and material support. at the same time, this high degree of policy discretionfor municipalities under the 2015 social support act gives room for ‘innovative and unorthodox solutions’, as was indicated by several of our respondents, although this may require the availability of more financial resources and/or a clearer delineation between (or integration of) the different long-term care acts (the latter being one of the three main moral conflicts as identified by our respondents under question 1 of the survey). coming back to our main research question (“to what extent did/do municipalities in the netherlands take potential moral conflicts into account when implementing and executing the social support act 2015?”), we conclude by arguing that while municipalities are indeed aware of (potential) moral conflicts, the nature of the new law itself leaves insufficient room for municipalities to act in a sufficiently proactive and supportive/empowering manner on these challenges, as well as on the long-term aim of the social support act 2015 of achieving a true participation society. the reasoning behind this argumentation is that although the new law appears to emphasise such ethical principles as social beneficence and respect for autonomy, the lack of emphasis on notions of social justice threatens to impede the effectuation of the intended goals in practice. moreover, the social support act 2015 seems to be mainly directed towards achieving a certain outcome (the maximisation of social beneficence through the creation of a participation society), instead of stipulating how that outcome should exactly be achieved in a fair manner. as such, the social support act 2015 insufficiently seems to provide equality of opportunity with regard to long-term care access, both between citizens within the same municipality, as (and perhaps especially) between different municipalities. at the more short-term, taking into account a minimum set of ethical principles allows for the allocation of (seemingly scarce) resources that is, at the least, as fair as possible. study strengths and limitations and suggestions for further research the principle strength of this study has been the application of a broad ethical approach towards scrutinizing a new, and still sensitive, policy responsibility of dutch municipalities. we have shown that taking into account a minimum set of ethical principles, raises awareness of (potential) moral conflicts within the context of the new social support act. being aware of such conflicts, at its turn, helps in executing the new responsibilities under the social support act in an appropriate manner (or in justifying decisions towards citizens) and gives room for municipalities to act in a as proactively as possible manner on the challengesresulting from these new responsibilities. next, the fact that all dutch municipalities were invited to participate in our study led to a reasonable response rate, in terms of reaching a saturation point in our data analysis. at the same time, the limited response rate to the invitation for a telephonic interview might have led to a certain selection bias, as not all respondents have given the same level of in-depth explanation to their survey answers. moreover, it might have been valuable if additional questions were added to the in 55 jongen w, schröder-bäck p, schols jmga. the dutch long-term care reform: moral conflicts in executing the social support act 2015(original research). seejph 2017, posted: 11 october 2017. doi 10.4119/unibi/seejph-2017-152 depth interviews, although also the semi-structured character of these interviews already 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permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://plato.stanford.edu/archives/fall2014/entries/moral-dilemmas/� http://www.who.int/health_financing/universal_coverage_definition/en/� http://www.binnenlandsbestuur.nl/sociaal/nieuws/kwart-zorggebruikers-mijdt-dure-� http://www.who.int/governance/eb/who_constitution_en.pdf� http://creativecommons.org/licenses/by/3.0)� 57 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 original research from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003 aloysius p. taylor1 1 affiliation: independent consultant corresponding author:aloysius p. taylor address: monrovia, liberia e-mail: aloysiustaylor@hotmail.com mailto:aloysiustaylor@hotmail.com� 58 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 abstract aim:to explore the experience of fighters disabled during the liberian civil war; what they did and what was done to them; and what happened after their demobilization. methods:six focus group discussions were organized in monrovia, the capital of liberia, with 50 invalid veterans aged 10 to 25 at their entrance into the war and eightwomen wounded, although civilians, sampled as in convenience. in addition,sevenkey-informant interviews took place. all encounters were agreeably taped, transcribed and summarized under the items of the discussion guide. results:most ex-combatants joined the fighting to protect themselves and their families who were targeted by rebel fighters or joined to revenge the killing of close family members by fighters from all sides including government soldiers. nearly all the former fighters interviewed expressed their desire to be trained in various areas of life skills. a vast majority of the ex-combatants are living from begging in the streets.those from factions feel that government cares for former regular soldiers and discriminates those from other warring factions. the lack of housing for ex-combatants with war related infirmities is of paramount concern to them. they feel that the post-war reintegration program did not achieve its objectives. in the communities, they are stigmatized, blamed as the ones who brought suffering to their own people. the key informants are calling for establishment of trust fund for survivors of the civil war who are disabled. recommendations: establishment of a trust fund for survivors of the civil war who are disabled; reform of the national bureau of veteran affairs to include the disabled ex combatants of all former warring factions; erection as planned of the proposed veterans hospital; a national census of disabled ex-combatants and war victims. keywords:civil war, demobilization, disabled combatants, liberia, reconciliation. conflicts of interest:none. acknowledgements: this study has been conducted with service providers in mind, based on the social, economic and health status of the former fighters who were wounded and made disabled by the liberian civil war. first and foremost, many thanks go to professor dr. ulrich laaser who took special interest in the disabled former combatants to the extent that he contributed the financial resources to enable the conduct of this study. he also encouraged colleagues of his to assist the research team implement. prominent among this is dr. moses galakpai who provided technical support to the research team and roosevelt mccaco who in his free time took care of the financial management. we appreciate the work of the research team members who made valuable contributions to the development of the documents leading to the completion of the study. special recognition goes to mr. richard duo of the amputees football club for his coordinating role in facilitating the key informant and focus group interviews. funding: private. 59 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 foreword the civil conflict has been over for nearly as many years as it lasted. the scars however are as visible today as were the horrible episodes of atrocities that characterized life during the war years. the wrecked economy of liberia following the onset of the civil war, gross human rights violations, involvement of child soldiers and use of harmful substances by both armed fighters and civilians are all hallmarks of the liberian civil war. thousands of young people who were active members in the numerous fighting forces got maimed and are today disabled for various causes. what is true for nearly all of them is the fact that they are living under difficult circumstances no jobs, no housing, and no sustainable care. with no preparation to face the harsh post conflict and post ebola environment in liberia, the disabled ex combatants deserve attention that will give them hope, attention that will harness their potentials not only for sustaining themselves but for promoting peace in the nation. this publication, though conducted in only one of the 15 counties of liberia, contributes to the knowledge needed for the attainment of a better living condition for disabled ex-combatants as well as promoting sustainable peace in liberia. dr. moses kortyassahgalakpai former deputy minister of health republic of liberia 60 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 introduction liberia, to mean „land of the free ‟, was founded by freed american slaves who were sponsored to settle in africa as early as 1822. annexation of land from the indigenous tribes enabled the country to be formed until statehood was declared 1847. the lack of full integration of the indigenes was the main trigger for the civil war beginning on christmas eve in1989 (1). the large number of young people exposed to arms and use of harmful substances constitutes a significant risk for the sustainability of peace in the country.the idea to undertaking this explorative study into their feelings and experience comes from the general observation of the appalling conditions of disabled veterans. unable to earn a living due to the lack of skills compounded by the fact that they have lost parts of their bodies, the former combatants are in serious need of assistance which is not forthcoming. not only are the disabled ex-combatants unable to provide daily food for themselves, but they are under incessant barrage of accusations of bringing suffering to their people. such stance inhibits a free flow of material assistance to them as well as social acceptance (2). therefore this investigation attempts to documentfrom their own wordsthe past and present experience of former fighters who were disabled and traumatized during the civil war in liberia including a selected number of civilian women wounded. in addition key informants have been interviewedand asked for their analysis and recommendations. methods study population the qualitative studytook place inmontserrado county which includes the capital monrovia with more than a million inhabitants, about a quarter of libe‟risa entire population. the respondents were recruited by non-probability sampling as in convenience between march 29 and may 3, 2017 through the amputees football club in monrovia (4) and consisted of two categories of respondents: the first comprised of five focus groups of ten former combatants each, together 50participants who were disabled as a result of their participation in the fighting. these persons were from various fighting forces including those from the national army. additionally, there were eight women who received their disabilities from bullets and bombs even though they were civilians; some were targeted while others were accidental.the selection process did not allow anyone to attend more than one focus group. focus group discussions the study relied on a participatory approach and semi-structured narrative format.the discussion guide for the focus groups,taking about three hours,comprised a set of nine questions, assembled by four experts three liberian and one european familiar with the setting. the questions were introduced to the focus groups by amoderator: 1) why and for which faction (out of eight) did you join the fight? 2) what was your rank and war-name and what weapons did you use? 3) what made you brave and how did you get wounded? 4) did you commit atrocities yourself? 5) did you meet later your comrades or your victims? 6) what is your experience with the demobilization program after the war ended? 7) where and how do you live now and how are you received by thecommunity? 8) are you satisfied with your living conditions and what are your expectations? 9) how did you as a women experience the civil war?voices of female survivors. 61 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 key-informant interviews the seven key informants contacted had witnessed events during the civil war and were knowledgeable about former fighters and the programs initiated for their return to civilian life. they saw what happened or took part in what happened such as rendering social, relief or medical services to the population affected by the war. these included stakeholders and others such as project officers, focal point persons in security sector institutions, community leaders, and relevant government personnel. although they were professionals in their own right, some of them were seen as rebel supporters because they operated in particular geographic locations controlled by warring factions. seven such persons were interviewed on issues surrounding the following topics: 1) the disarmament, demobilization, rehabilitation and reintegration program (ddrr) 2) key challenges facing ex-combatants 3) strategic recommendations information processing all encounters were agreeably taped, transcribed and summarized under the items of the discussion guide by a team of liberians under the guidance of the author. results i. the focus group interviews (fdg) characterization of the participants most of the discussants were young school-going children, when the war started. however, as the war progressed educational institutions in the war-affected areas were shut down, leaving thousands of idle youths susceptible to align themselves as child soldiers, boys and also girls (5),with the warring faction that was present in their areas of domicile. 1) why and for which fraction did you join the fight? for most, as seen from their age profile, serving in the military was never then thought of. the discussants disclosed that the war was brought home when they witnessed the gruesome murder and mutilation of their relatives, the personal pain inflicted on them by those bearing arms whether government troops or members of opposing warring factions, the looting of their family‟s properties or just the excitement of being with members of their age group, all thatserved according to them as motivating factors to become fighters themselves. a couple of others were forcefully recruited and others joined because they were used as porters of ammunition and goods for the men at arms.defections from the national army became commonplace joining one of the rebel factions (see box), some related to ethnical or religious background. their allegiance to the armed group to which they belonged became stronger than the bond with their families and socio-cultural institutions that nurtured them and that they once respected. 2) what was your rank and war name and what weapons did you use? in order to persuade their men to obey their authority, those in command assigned meaningless ranks to fighters under their command. such arbitrary ranks gave them an air of greatness. additionally, there was no previous training to back the ranks. the discussants informed that rebel training sometimes lasted for only two months. examples of these fake ranks given by the discussants are: field commander, full colonel, general, captain, brigadier general, lt. colonel, major, chief of staff. 62 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 war-names or nicknames played an important role in the behavior of the individual combatant and how he/she was perceived by comrades and commanders. besides being used as a means to motivate combatants into action, nicknames served to conceal the real identity of the fighter. nicknames were also used to promote certain behavior of the fighter. for example, “dog killer” could mean killer of the enemy (the dog). someone bearing such nick name would live to prove that he is a killer of the enemy. similar other nicknames of discussants were: major danger, super killer, no ma no pa. the discussants indicated that they used various weapons during the course of the war. the predominant one was the kalashnikov (ak47 and others in the series). the combatants used the guns to exploit the civilians in their controlled areas, a major factor for the mass exodus of people out of the country. the proliferation of small arms in all areas controlled by warring factions made the entire country unsafe at the time especially that the combatants according to them served as the “justice systems” in their controlled areas. many of these weapons were traded among warring factions as some combatants switched sides or needed money. however, heavier weapons fielded were more supervised by those in command. 3) what made you brave and how did you get wounded? myths and rumors surrounding the composition of rebel fighting forces and their use of mystic powers coupled with the governmen ‟ts mismanagement of the war, greatly aided the demoralization of the better trained government troops to the point of stimulating mass defections.the rapid advance of rebel forces mainly rested on the highly motivated youths most of whom were given drugs and other substances to influence their behavior, giving them a false sense of invincibility. some others mentioned the use of drugs and strong alcoholic drinks given them by their commanders as sources of their bravery. some wore amulets on their necks and “hands for protection” against bullets. a discussant explained that he was given a talisman belt to wear around his waist which could hold him tight and become very hot when enemies were around. these good luck charms turned up to be fake; many fighters died or got wounded due to their belief in these charms. other reasons cited as sources of their bravery are as follows: • colleagues made me brave • afl distributed the new testament bible • god and the arm given to me • the gun gave me power • the urge to revenge for the killing of relatives military groups named by participants as their own ones: armed forces of liberia (afl) • lofa defense force (ldf) • liberians united for reconciliation and democracy (lurd) • national patriotic front of liberia (npfl) o independent national patriotic front of liberia (inpfl) o national patriotic front of liberia-central revolutionary council (npfl-crc) • united liberation movement of liberia for democracy(ulimo) o united liberation movement of liberia for democracy-johnson faction (ulimo-j) united liberation movement of liberia for democracy-kromah faction (ulimo-k) https://en.wikipedia.org/wiki/armed_forces_of_liberia� https://en.wikipedia.org/wiki/lofa_defense_force� https://en.wikipedia.org/wiki/liberians_united_for_reconciliation_and_democracy� https://en.wikipedia.org/wiki/national_patriotic_front_of_liberia� https://en.wikipedia.org/wiki/independent_national_patriotic_front_of_liberia� https://en.wikipedia.org/wiki/national_patriotic_front_of_liberia-central_revolutionary_council� https://en.wikipedia.org/wiki/united_liberation_movement_of_liberia_for_democracy� https://en.wikipedia.org/wiki/united_liberation_movement_of_liberia_for_democracy-johnson_faction� https://en.wikipedia.org/wiki/united_liberation_movement_of_liberia_for_democracy-kromah_faction� https://en.wikipedia.org/wiki/united_liberation_movement_of_liberia_for_democracy-kromah_faction� https://en.wikipedia.org/wiki/united_liberation_movement_of_liberia_for_democracy-kromah_faction� 63 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 • american war movies • family members were not around, so fear left me when i joined. the discussants narrated various ways in which they received wounds which led to their disability today. to wit: • mistake from friendly forces • enemy fire, on the frontline • aerial bombardment by alpha jet • personal mistake handling grenade • fell in enemy ambush. some of the other causes of wounds which resulted into amputation of limbs are directly reflective of the low level of training of the fighters as regards safe handling of weapons. 4) did you commit atrocities yourself? discussants admitted that they also committed atrocities in response to what others did to them and their people. they said that they killed and raped in revenge for what was done to their family members or relatives. they informed that they saw wickedness in the extremes such disembowelling of pregnant women and using their intestines to intimidate other people at checkpoints. the discussants said that they burned houses and other peop‟lepsroperties because of anger. the discussants also admitted to beating people, looting goods and killing domesticated animals. asked if they have any regrets for also committing crimes against others, a few said they do regret but most of them said no, as they were under the influence of drugs or were forced by their commanders. one discussant said that he did not do anything to anyone but only killed enemies on the battlefield. 5) did you meet later your comrades or your victims? the participants said that they sometimes see their colleagues and those who commanded them during the war, most of them in same impoverished conditions as they are and sometimes even worse. these past commanders, they said, sometimes even asked for help from the disabled ex-combatants in this study: “our former commanders feel more frustrated than us, because they have no more power to do anything or command other people to do something for them”. some met also their victims and begged them to forgive, others saw them on the street but were not given a chance to talk to them or even beaten in revenge. 6) what is your experience with the demobilization program after the war ended? the most contentious issue reference the transition from active combatants to civilian life was the liberia disarmament, demobilization, rehabilitation and reintegration program (ddrr) up to 2009. nearly all of the discussants were not pleased with how it was handled. the vocational training to which some went was rather too short. they informed that they were promised packages at the end of the training which many of them did not receive. they said that their names were written down to be contacted when the packages were reading and up till now nothing has been done. a discussant informed that he entered the ddrr program and spent five days and afterwards used his id (identification) card to enter a vocational institution where he spent nine months, graduating with a certificate but the tools given him and his colleagues did not match the certificate. a few others admitted that they sold their id cards for money.according to discussants who fought for the warring factions, they are dissatisfied over how the government did not arrange a better package as that made for the regular soldiers when in their opinion all of them had served their country. • usd 150 was given to rebel fighters as a one-shot resettlement package 64 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 • government of liberia soldiers were given usd540 and also benefited from appropriate pension arrangement. 7) where and how do you live now and how are you received by the community? most of the disabled ex-combatants congregated in monrovia and its immediate environs for fear of reprisal as stigma against them in their original communities is described as high. most of them are blamed for the atrocities and the sufferings that the civilian population had to endure during the civil war. as a result the furthest distance from the city centre where most disabled are living turned out to becareysburg and gardnersville whereas the heaviest concentration is in paynesville, all less than 50 km away. the discussants were frankto also admitthat they wereashamed toreturn to their original places of residence. furthermore the high cost of rent, distance from their usual places of street begging and the fact that there are some people in their original locals who want them to die, were cited as compelling reason for finding new places to live.many of the fighters refused to go home even up to today. some participants were received well by their families but were rejected by their communities. one discussant said that his parents and other family members cried upon seeing him and later encouraged him not to harm himself. another discussant said that reception was good at first after ddrr but when the money they received from the ddrr was exhausted he was thrown out. yet another informed that he had a girl pregnant for him at time of disarmament but right after his money was finished too, she left him and said that the pregnancy was not his. the psychological anguish and social marginalization ex-combatants have been subjected to have led some of them to attempt suicide. the suicidal inclinations among freshly-wounded ex-combatants were motivated by feelings of being useless after losing limbs, ashamed of their conditions, thinking that they would be rejected by women, being mocked by children or just share embarrassment at the disability. asked why they did not carry out their desire to commit suicide after all, they gave the following reasons: • another disabled friend encouraged me not to kill myself • i made my own decision not to kill myself • nurses at the hospital talked to me and promised me “false legs” after one year. as a result of all these inconveniences, they move in groups and sleep in makeshift huts and market places where the night will find them after a hectic day of begging for alms from humanitarians in the street corners and in front of supermarkets and other public places. 65 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 figure 1. disabled war combatants 1017 8) are you satisfied with your living conditions and what are your expectations? the overwhelming majority of discussants indicated they are not satisfied with their present conditions, both physical and economic. however, they do accept the fact that their physical conditions in the given situation cannot be reversed, so they must live with it. they stated that “no one can be satisfied with this kind of condition, there is nothing we can do” (picture). all the respondents felt that the ddrr was hastily planed and haphazardly implemented and that the implementation period of less than 3 years was grossly inadequate. those who were enlisted in skills training programs were given 6 months to complete the training. they expected the program to last much longer to allow them acquire the knowledge and skills that are marketable. they expected the ddrr to provide free medical care and “we need housing and education for our children as well as jobs to move us from begging in the streets. we also need training to become peace ambassadors to reconcile our country and prevent war”. 9) how did you as a women experience the civil war?voices of female survivors “my son and his friend were hit when they went in our yard to get water from the well. i took them both to jfk hospital and when i went to front street, i was hit too and my hand got broken. i was assisted by government security and icrc; the ministry of finance gave me money to attend to my injury.” “i was a student in grade seven in 1996 when i got shot entering into my own father‟s house. the boy who shot me did it intentionally; five persons were also fired, 2 survived. i used tube for one year eight months.” “i got hit also in 1996. they took me to redemption hospital. one ecowas man helped me and carried me to ghana. i waited 9 month to remove the bullets. i lost one hand and foot.” “i made many attempts to kill myself, each time i tried to do so someone would interrupt.” “i did not go to school. i went to do business, when i got shot at the age of 23, only my mother stood by me, my boyfriend ran away.” “i have had two children since my injury. one is going to school.” “i am making and selling hand bags, neck ties, etc. don bosco taught me.” 66 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 “particles are still in my body; they can be removed but someone has to foot the bill.” “we need help. the government is not focused on the disabled.” “we need micro-loan, wheel chairs and all disabled materials” ii. perspectives of key informants during the study a number of key informants knowledgeable about the former fighters and the programs initiated for their return to civilian life were identified and interviewed. their perspectives have been summarized below. among the views expressed by all key informants is the fact that there was not a dependable exit strategy for the thousands of ex-fighters especially those who be invalids from the war. it is not surprising therefore that disabled ex-combatants are finding it difficult to survive today. having gained nothing from the war, physically impaired and not receiving any subsistence from government or other humanitarian organizations, the disabled ex-combatants civilians are the true victims of the liberian civil war. the key informants feel that for all practical purposes the ex-combatants are marginalized by the government of liberia and rejected by the larger society. 1) the disarmament, demobilization, rehabilitation and reintegration program (ddrr): all the key informants dubbed the ddrr program as a long-term failure exercise, not only because of its failure to retrieve all the weapons from the ex-combatants but its inability to implement a program for providing sustainable basis for marketable life skills. they were unanimous on their fact that the ddrr program also lacked credible trauma healing offering as well as the availability of psychosocial counselling. it is the view of some key informants that the major reason standing in the way of true reintegration of ex-combatants is that the ddrr only put a quick-fix program that did little to prepare the ex-fighters for the life they were destined to face after disarmament. 2) challenges facing ex-combatants: the current state of the disabled ex-combatants is appalling, their dependency on handouts to feed themselves and their dependents not guaranteed from day to day; hopelessness is written in their faces, said one key informant. their presence in the streets begging for livelihood reminds those who carry hurt in their hearts from the civil war. the informants generally believe that the provision of housing for disabled ex-combatants will not only dignify them and restore their self-esteem, but it will be easier to control or maintain them in any skilled training program that they may hereafter be given. they recommend skills training need assessment among disabled ex-combatants before any such training is initiated for them unlike the approach employed during the ddrr. a key informant who happens to be a medical doctor confided that some of those who sustained bullets wounds in their bodies need follow-up treatment but they lack the means. if their exit strategy had been thoroughly planned, a referral program could have been in place to address such persons‟ conditions.the need for access to free health care was discussed and emphasized. summary of some major findings • most ex-combatants joined the fighting to protect themselves and their families who were targeted by rebel fighters • others joined to revenge the killing of close family members by fighters from all sides including government soldiers • some ex-combatants joined the fighting because they were tired of carrying looted materials or 67 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 3) strategic recommendations the ex-combatants, especially those who are disabled and had come from the warring factions, are no longer in the mathematics associated with post-war assistance to fighters. the national bureau of veterans affairs caters exclusively to former armed forces of liberia (afl) fighters. there is no provision for free medical service. the afl still maintains a medical unit but does not have the mandate to give free treatment to disabled ex-fighters. an elaborate plan for the construction of a veterans hospital never got off the blueprint. aside from their inability to provide basic needs for themselves, disabled ex-combatants as well as their civilian victims need support to upkeep and educate their children. the need for conducting a census of those who became disabled by the war, ex-combatants as well as their victims, was underscored. women in this category were in significant number and are grappling with life‟s challenges. their leadership is calling for reparation for these innocent people and they have been advocating for this since the days of the trc, the truth and reconciliation commission, enacted by the parliament in 2005 but nothing has materialized. some disabled could be trained to perform a variety of tasks for their sustenance and for the promotion of national peace and security. they could be prepared to serve as receptionists, ticket sellers for the lma, the liberia marketing association, at city parking services, car washers and the like. discussion and recommendations certainly an explorative investigation as presented here does not allow generalizingthe results. however even the limited information collected indicates a major deficit in dealing with the sequelae of the liberian civil war. the hardship imposed on the disabled by the very nature of their disabilities is exacerbated by the lack of opportunities for gainful employment to match their various forms of disabilities and skills, the uncertain source of daily meal and sometimes hostile attitude from some of the community members. this investigation,however underlines the need to execute a more representativestudy including ammunition for fighters through long distances • nearly all the former fighters interviewed expressed their desire to be trained in several areas of life skills • a vast majority of the ex-combatants are living from begging in thestreets. • several ex-combatants are concerned about the education of their children and are asking for educational support for them • ex-combatants want to serve as peace ambassadors and are requesting to be trained to serve as counsellors for other youths to deter them from engaging in violent activities and prevent war in this nation • those from factions feel that government cares for former afl soldiers and discriminates those from other warring factions • the lack of housing for ex-combatants with war related infirmities is of paramount concern to them • the ex-combatants feel that the ddrr program did not achieve its objectives because it was poorly planned and implemented in the rush • in the communities, they are stigmatized. they are blamed as people who brought suffering to their own people. • they are denied job opportunities even when the job requires only elementary school knowledge • they are discriminated against even by taxicabs especially if they carrycrutches. • the key informants are calling for establishment of trust fund for survivors of the civil war who are disabled. 68 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 the disabled war veterans as well as their victims, a study which would allow representative data and their advanced qualitative and quantitative analysis. the present publication can only serve as a trigger. nevertheless the findings of the study demonstrate that the ex-combatants of the civil war and even more the disabled civilian victims are forgotten not only by the government of liberia, but also by aid agencies. the post-war status of the ex-combatants was not factored into the transitional arrangements such as the ddrr program for the combatan‟tsreturn to civilian lifeconfirming an earlier analysis of 2007 (6). if government and the nation at large continue to ignore the plight of these sizable population groups, the security of the nation will remain fragile(7) and national reconciliation will be elusive and unachievable. it is therefore recommended with priority that: • the government of liberia revisits or reforms the national bureau of veteran affairs to include the disabled ex-combatants of all former warring factions. • the proposed veterans hospital be erected as planned to cater to the health needs of active service personnel, veterans of the civil war and disabled ex-combatants of former warring factions for whom no health service is available. while this is being done, it is recommended that the mandate of the afl medical unit be expanded to provide free medical service to the disabled ex-fighters and war victims. • a national census of disabled ex-combatants is executed, an imperative about peace building in the aftermath of the civil crisis. this exercise would provide a thorough needs assessment that will put into place client-responsive actions that promote peace building, reconciliation and inclusiveness of those who are disabled by the war either during active combat or civilians as a result of inadvertent explosions and wanton acts of cruelty (8). • arrangements be made for a minimal (financial) survival package for each disabled ex combatant which can enable them to afford at least a meal a day so that they will be able to contribute to national peace and reconciliation efforts. furthermore it is highly recommended that: • some low cost housing arrangement be put into place for all disabled victims of the war. • carefully designedlife skills training programs that are effective and efficient to make ex combatants marketable or capable of sustaining themselves instead of begging in thestreets. • continued education programs for ex-combatants who have dropped out of school due to lack of support and are desirous of learning be established. • scholarship programs and tuition support for children of war victimsare put in place. references 1. gerdes f. civil war and state formation, the political economy of war and peace in liberia. campus frankfurt/new york; 2013. 2. lord je, stein ma: peacebuilding and reintegrating ex-combatants withdisabilities. the international journal of human rightsvol. 19/3,2015. http://www.tandfonline.com/doi/full/10.1080/13642987.2015.1031515?src=recsys. 3. harrell mc, bradley ma. data collection methods semi-structured interviews and focus groups. rand corporation: santa monica, ca: 2009. http://www.rand.org/content/dam/rand/pubs/technical_reports/2009/rand_tr718.p df. 4. bloomfield s. liberia's amputee footballers: from civil war to african champions their injuries are a painful reminder of a bitter conflict, but this football team is http://www.tandfonline.com/doi/full/10.1080/13642987.2015.1031515?src=recsys� http://www.rand.org/content/dam/rand/pubs/technical_reports/2009/rand_tr718.p� http://www.rand.org/content/dam/rand/pubs/technical_reports/2009/rand_tr718.p� http://www.rand.org/content/dam/rand/pubs/technical_reports/2009/rand_tr718.p� 69 taylor ap. from their own words: an explorative qualitative study on the experience of combatants disabled in the liberian civil war,1989-2003(original research). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-155 bringing pride to the country. the observer, 10 january 2010. https://www.theguardian.com/sport/2010/jan/10/liberia-amputee-football. 5. international labour office, programme on crisis response and reconstruction:red shoes experiences of girl-combatants in liberia. report coordinated by irma specht, geneva; 2017. http://www.ilo.org/wcmsp5/groups/public/@ed_emp/@emp_ent/@ifp_crisis/docume nts/publication/wcms_116435.pdf. 6. jennings km.the struggle to satisfy: ddr through the eyes of ex-combatants in liberia. international peacekeepingvol. 14/2,2007. http://www.tandfonline.com/doi/full/10.1080/13533310601150800?scroll=top&need access=true. 7. wiegink n.former military networks a threat to peace? the demobilisation and remobilization of renamo in central mozambique. stability: international journal of security and development. 4/1, 2015; p.art. 56. doi: http://doi.org/10.5334/sta.gk. 8. johnson k, asher j, rosborough s, raja a, panjabi r, beadling c, lawry l. association of combatant status and sexual violence with health and mentalhealth outcomes in post-conflictliberia. jama 2008;300:676-90. doi: 10.1001/jama.300.6.676. © 2017 taylor; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.theguardian.com/sport/2010/jan/10/liberia-amputee-football� http://www.theguardian.com/sport/2010/jan/10/liberia-amputee-football� http://www.theguardian.com/sport/2010/jan/10/liberia-amputee-football� http://www.ilo.org/wcmsp5/groups/public/%40ed_emp/%40emp_ent/%40ifp_crisis/docume� http://www.tandfonline.com/doi/full/10.1080/13533310601150800?scroll=top&amp;amp%3bamp%3bneed� http://doi.org/10.5334/sta.gk� https://www.ncbi.nlm.nih.gov/pubmed/?term=johnson%20k%5bauthor%5d&amp;amp%3bamp%3bcauthor=true&amp;amp%3bamp%3bcauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=johnson%20k%5bauthor%5d&amp;amp%3bamp%3bcauthor=true&amp;amp%3bamp%3bcauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=rosborough%20s%5bauthor%5d&amp;amp%3bamp%3bcauthor=true&amp;amp%3bamp%3bcauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=raja%20a%5bauthor%5d&amp;amp%3bamp%3bcauthor=true&amp;amp%3bamp%3bcauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=raja%20a%5bauthor%5d&amp;amp%3bamp%3bcauthor=true&amp;amp%3bamp%3bcauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/?term=beadling%20c%5bauthor%5d&amp;amp%3bamp%3bcauthor=true&amp;amp%3bamp%3bcauthor_uid=18698066� https://www.ncbi.nlm.nih.gov/pubmed/18698066� http://creativecommons.org/licenses/by/3.0)� 70 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 review article preparing society to create the world we need through “one health” education report of a global survey and web conference on “one health” k-12 education, 18 november 2016 george r. lueddeke1, gretchen e. kaufman1, joann m. lindenmayer2, cheryl m. stroud2 1 one health education task force; 2 one health commission. corresponding author: george r. lueddeke, co-chair, one health education task force; address: 9 lakeland gardens, southampton, hampshire, so40 4xg, united kingdom; email: glueddeke@aol.com http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� mailto:glueddeke@aol.com� 71 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 abstract aims: a previous concept paper published in this journal (1), and a press release in june 2016 (2), focused on the importance of raising awareness about the un-2030 sustainable development goals (sdgs) (3) and, in particular, developing a better understanding about the critical need to ensure the sustainability of people and the planet in this decade and beyond through education. the one health education task force (ohetf), led by one health commission (4) in association with the one health initiative (5) agreed to conduct an online survey and conference in the fall of 2016 to engage interested colleagues in a discussion about the possible application of one health in k-12 (or equivalent) educational settings. method: the survey instrument, reviewed by a panel of experts (below), was conducted in september and october 2016 and focused on basic concepts, values and principles associated with one health and well-being. input was sought on the various ways that one health intersects with the un sustainable development goals and how they might work together toward common objectives. questions also explored ‘why, how, and where’ one health could be incorporated into k-12 curricula, and who should be involved in creating this new curriculum. results and conclusions: overall, there was general consensus that this initiative could make a significant contribution to implementing the sdgs3 through the one health spectrum as well as the priorities and major challenges that would be encountered in moving this initiative forward. five strategies were presented for embedding the sdgs and one health through curriculum innovation from early years to tertiary education and beyond. importantly, a “community of practice” model was put forward as a means to support and promote the sdg goals through one health teaching and learning in a meaningful and supportive way for the benefit of all involved. a subsequent conference in november 2016 provided an opportunity to present the results of the survey and conduct a more in depth discussion about potential curriculum development designs, possible project funding sources, and implementation challenges. keywords: education, one health, global health. conflicts of interest: none. acknowledgements: the organizers would like to thank the members of the one health educationtask force for their contributions to the conference and survey development including, lee willingham and tammi kracek from the one health commission and representatives from the one health initiative autonomous pro bono team: bruce kaplan, laura kahn, lisa conti and tom monath. we are also grateful for the invaluable assistance from peter costa, associate executive director for the one health commission, in organizing and moderating the on-line conference. in addition we would like to thank the following reviewers who assisted in the development of the online survey: muhammad wasif alam, dubai health authority-head quarter, uae; stephen dorey, commonwealth secretariat, uk; jim herrington, university of north carolina at chapel hill, usa; getnet mitike, senior public health consultant, ethiopia; heather k. moberly; dorothy g. whitley texas a&m university, usa; joanna nurse, commonwealth secretariat, uk; christopher w. olsen, university of wisconsin-madison, usa; richard seifman, capacity plusintrahealth international, usa; neil squires, public health england, uk; erica wheeler, paho/who, barbados. http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� http://www.seejph.com/index.php/seejph/article/view/122� https://www.onehealthcommission.org/documents/filelibrary/commission_news/press_releases/61016__oh_education_press_releasefi_f7644a48f9910.pdf� https://sustainabledevelopment.un.org/post2015/transformingourworld� https://sustainabledevelopment.un.org/post2015/transformingourworld� https://www.onehealthcommission.org/� https://www.onehealthcommission.org/� http://www.onehealthinitiative.com/� http://www.onehealthinitiative.com/� http://www.onehealthinitiative.com/� http://www.onehealthcommission.org/� 72 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 introduction the one health concept is rightly gaining timely support and momentum worldwide as we are all becoming increasingly aware that humans, animals, plants and the environment must be in much better balance or harmony to ensure the present and future of our planet. it is gradually becoming clear that to realise or indeed re-capture this state of equilibrium, one health and well-being must be at the heart of socioeconomic, environmental and geopolitical decision making at global, regional, national and local levels, thereby informing, as the commonwealth secretariat health and education unit (comsec heu) posits governance, knowledge development, capacity building and advocacy (6). over the past 18 months or so, and in line with the un-2030 global goals (3) (or sustainable development goals-sdgs) agreed late 2015, that embraced a broad notion of sustainable development – how all things are interconnected – climate, energy, water, food, education -we have been researching and developing ideas on how the one health task force might support sustainability of the planet and people. our deliberations led us to the fundamental question of how we might address perhaps the most important social problem of our time, that is, ‘how to change the way humans relate to the planet and each other to ensure a more sustainable future for all life.’ (2) our unanimous conclusion is that learning about ‘one health and well-being’ needs to play a much greater role in the education of our children and younger generation as well as society in general. to these ends, we developed position papers, issued a press release (2) in june 2016, to which many webinar attendees responded, followed by an on-line survey in september october to solicit wider input on one health education. the survey thus informed an online one health education conference on november 18, 2016 (7). the main purpose of the webinar was to share and build on the survey findings with a view to informing a ‘robust’ one health education project funding proposal. a vital consideration governing the proposal was the potential of raising awareness about the social determinants of human-animal-environment interactions as well as the limitations presented by an unbridled human population expansion in the face of finite natural resources. many of the task force discussions reminded us that while we are advancing scientifically and technologically, we are also faced with a huge ingenuity gap – that is finding answers to unprecedented social problems that on many days seem to overwhelm us – climate change, health and food security, armed conflicts, ideological extremism, economic uncertainty, global inequalities, inequities and imbalances, to name a few. the ebola crisis especially caught the world’s attention in this regard. there are no easy answers. but encouraging young people to gain a better understanding of the planet we all share and need to sustain, along with our individual responsibilities to each other, and learning not only ‘to do things better’ but also, perhaps most importantly , ‘to do better things’ through collaboration and education, must surely be part of the way forward. underpinning our resolve to engage children and young adults in the pursuit of achieving the un-2030 global goals through education and the one health education initiative (ohei) is captured in the recently published book, global population health and well-being in the 21st century (8). a recurring theme in the publication is that achieving the 17 sdgs and targets requires a fundamental paradigm or mind-shift in the coming decades: moving us from a view that sees the world as ‘a place primarily for humans and without limits’ to one that views the world holistically, ensuring it is fit for purpose in the long run for humans, animals, plants and the environment or our ecosystem. one health provides us with the ‘unity around a common cause’ (9) toward which all of us need to aspire and which we believe is fundamental to building the world we need. http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html� http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html� 73 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 summary of online one health education survey results the purpose of the one health education online survey was to elucidate concepts, values and principles that respondents associated with one health, and to begin to define how the one health concept might be operationalized in k-12 schools. invitations to participate in the survey were sent to individuals that had previously expressed interest in the one health k-12 education initiative expressed through presentations, in response to the published concept note and a press release, and through individual conversations. seventy-six people responded to one or more questions on the survey. of the 52 (68.4%) respondents who answered the question about highest level of education attained, 31 held one or more doctoral-level (18 phd, 9 dvm, 4 md, 1 jd), 14 held master’s-level, and 7 held bachelor’s-level degrees. of the 53 (69.7%) respondents who answered the question about country where they worked, 21 answered usa, 15 europe (including 6 in the uk), 10 africa, 5 asia or southeast asia, 1 south america, and 1 answered middle east. one health concepts, values and principles words that respondents most commonly cited were “health” and the health domains (human, animal, environment/ecosystem/ecology). respondents also cited words that represented common ground among one health disciplines, e.g., inter-, coop-, collab-, coor-, integ-, uni and holi-. “sustain” and “educ-“ were mentioned frequently, as were “diseand “zoo-.” respondents preferred the venn diagram and triad representations of one health by far over other representations. values most commonly cited as most essential to one health are sustainability, cooperation, diversity/biodiversity and responsibility, leadership and understanding. innovation was also noted. the type of sustainability judged to be the most important type by far was ecologic sustainability, economic and cultural/social only moderately so. a high degree of agreement (>90%) was given to the following statements: “the health of humans, other animal species and plants cannot be separated,” and “environment includes both natural and built environments.” more than 80% of respondents agreed that “humans have a moral imperative to address one health challenges,” and “one health should be practiced so that there is no net (ecosystem) loss of biological diversity.” more than two-thirds of respondents agreed with all other statements except “when you optimize health for one species, health for others is marginalized or eliminated.” this implies that the health of species is inter-related and should not be viewed as mutually exclusive. the factors contributing most to current one health problems are compartmentalization of health services and policies, lack of knowledge/understanding, lack of funding streams that encourage collaboration and provide support for one health initiatives, poverty-distribution of wealth-inequity, overemphasis of treatment of individuals (human and animal) at the expense of preventive medicine and population health, political systems that support individual/corporate interests above all else, and overemphasis of human health at the expense of animal/environmental health. other factors mentioned were that one health was too veterinary-centric and that there was a need to acknowledge differences between the developed and developing world. one health education and the sdgs respondents related k-12 education most closely to sdg 3 (ensure healthy lives and promote well-being for all ages). also related, although slightly less so, were sdg 14 (conserve and sustainably use the oceans, seas and marine resources for sustainable development), sdg 15 http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 74 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 (protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification and halt and reverse land degradation and halt biodiversity loss), sdg 6 (ensure availability and sustainable management of water and sanitation for all), and sdg 2 (end hunger, achieve food security and improved nutrition and promote sustainable agriculture). other sustainability goals not included in the 17 sdgs included improving animal welfare, developing sustainable strategies for control of feral animals, invasive species and pests (to humans), moving to clean energy sources, developing new tools for impact assessment, and promoting greater intake of locally raised foods. operationalizing one health education in k-12 why? long-term outcomes of a one health-themed curriculum included products (trained educators, better policies and decisions, multidisciplinary approaches to risk, sustainable environment/ecosystems/communities, successful adaptation to climate change, new disciplines, better communication, reduction of the gender gap, more recycling, project design competitions), changes in attitudes and behaviors, more and better engagement as citizens with policy and as consumers, and better health and greater awareness of human populations relationship with the planet and its inhabitants. a number of people anticipated that systems/interdisciplinary thinking would be an outcome. what? students should be exposed to all concepts listed, although personal responsibility (how individual actions impact one health) and respect for natural systems and human responsibility for planetary health were the most important, followed by environmental contexts of one health issues and corporate, political and societal responsibility (how their actions impact one health). one person noted that equity and social justice was important, as was the moral imperative of viewing nature as equally important as humanity. students in one health-themed educational programs should learn collaboration, interdisciplinary thinking, systems-thinking, problem-solving and team-building skills. entrepreneurship, environmental ethics were also noted. one person remarked that “in my opinion, students in one health must, before anything else, gain the ability to immediately look for solutions from all media when facing a problem that requires a more complex approach. basically questioning themselves -what would an engineer/medic/chemist/vet/etc. do when faced with the current problem?” how? challenges most commonly cited that could be used to illustrate one health in k-12 education were diseases (vector-borne, zoonotic, food-born), food security, antimicrobial resistance, environmental pollution (of air, water, soil), climate change and loss of biodiversity/disruption of ecosystem services. where? college and university students are the groups most exposed at present to one health concepts (although fewer than 20% of respondents believed they were exposed at all). fewer than five percent of respondents believed that students at all other levels of education are exposed to these concepts. respondents believed that at levels below college/university, it’s most important to introduce one health concepts to students at all educational levels, although it’s most important in high/secondary schools and slightly less so in middle schools. http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 75 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 one health-themed curricula should be piloted in publicly-funded schools and in colleges or universities. one person suggested piloting one health education in religious classrooms because a lot of teaching goes on there from k-12 (nb: makes sense as long as pope francis is in charge!). virtual classrooms were also noted. barriers and challenges to piloting and scaling up the main barrier to incorporating a oh-themed program into k-12 education is constraints posed by the current educational system, including lack of knowledge and understanding on the part of teachers and the public, the need for adequate teacher training, rigid limits posed by established curricula, government objectives, and the requirement for standardized testing. also noted were overloaded curricula, lack of adequate resources (validated k-12 curricula, infrastructure, access to the internet and it, materials such as case studies, activities, textbooks, pedagogical methods and tools), and inertia of current educational systems and their representatives. many respondents stated that one health is complex, requires simplification, and concrete and practical examples to make it more easily understood. major logistical challenges to scaling-up a k-12 one health curriculum to a global stage that respondents anticipated were lack of funding and resources (it, infrastructure, human resources, content, simulation exercises, alternate delivery platforms), constraints posed by current educational systems (different education systems/formats/settings, teacher training, limitations imposed by pre-existing curriculum requirements, need for tailored education to different contexts, underserved areas sustainable funding), and cultural and language differences. one person noted the need to first measure the added value of pilot projects before scaling up. who? the most common educational stakeholder sector that should be represented in developing the concept of a one health-themed education initiative into a successfully-funded proposal included various members of educational systems (teachers and educators at all levels (including university) of public and private sector, educational/instructional/ curriculum designers, school administrators, teacher associations, teacher training institutions, teachers unions, and educational researchers). government was also mentioned frequently. interesting suggestions included church schools, where a great deal of education takes place, parents and students, and publishers of textbooks. funding organizations that might support implementation of a one health-themed education initiative included government sectors (education, development, health), various private foundations (wellcome trust, melinda & bill gates foundation, soros foundation, the josiah macy jr. foundation, rockefeller foundation, skoll foundation, the global fund, the foundation for international medical education and research), international nongovernmental organizations such as those originating in the eu and the un, and banks such as the world bank. also mentioned were the european social fund, the network: towards unity for health, the european horizon 2020 program, and the global partnership for education. other comments and suggestions worthy of mention were: • a one health curriculum has to be content rich and ‘not just another vague thing' about relationships and collaboration, and that it needs to address critical problems like climate change, agricultural intensification, comparative medicine, environmental health threats. • consider strengthening and using innovative on-line teaching, flipped class room, take advantage of existing educative one health tools (mooc on one health, environment challenges, etc.), and create new ones. http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� http://macyfoundation.org/� http://macyfoundation.org/� 76 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 • the biggest challenge we face in implementing a one health curriculum at a global stage is the lack of a major driving force in one health. although we are trying our best as one health clusters, we need to have a major support from a so called "poster boy", something that will catalyze our efforts. • one-health should be a process that start at pre-primary level to change mind-sets, although there should be entry-levels at all phases for those who were not exposed from the start. it will be beneficial if the one-health principles thinking can be incorporated as it relates to different subject streams (e.g. economics, social science, and others). • we need to understand that we, as individuals, are not quite the center of the universe and that our actions, even though they may not bring us much benefit/losses, surely can influence everyone around us. • this is an extremely important project at a very volatile time in our world. education is the key to supporting and delivering the un 2030 sdgs. strategies for k-12 one health curriculum innovation this segment of the conference presented some of the ways that the one health education task force has considered to utilize one health concepts in curriculum development for k-12 classroom applications. feedback from the participants was requested and additional ideas that might be considered for the program and funding proposal were encouraged. we have explored the following five potential options to consider for our proposal: curriculum innovation grants for educators, curriculum development workshops for teachers, teacher training programs, a one health education network, and an on-line knowledgebase of one health curriculum materials. we understand that there are different needs among various educational systems and across countries around the world, so the options presented below are not mutually exclusive and we could consider one or any combination of these within the larger project. i) curriculum innovation grants for educators the initial idea that we explored was a program that would offer grants to teachers to develop and implement a one health focused curriculum at their school that meets specific criteria and objectives set by the one health education task force. we are attracted to this idea because we understand that teachers themselves know best how to reach their students, what curricular designs work within their institutions and grade levels, and what tools are most effective at reaching outcomes. in addition, by engaging teachers directly and offering opportunities for innovation, we feel that other teachers would be more likely to adopt and share successful methods among themselves, either thru example and their existing networks, or with formal mentoring. this program would offer competitive innovation curriculum development grants to teachers or teams of educators on an annual basis. the focus of this program could be open ended or could involve a changing one health theme each year to ensure diversity of topics. applicants would be asked to meet very specific guidelines that target values, skills and knowledge criteria using one health approaches. these guidelines would be developed by the one health education task force and would be informed by wider conversations with the one health global community, including the survey recently conducted. proposals would need to emphasize interdisciplinary engagement as a fundamental tenet of one health principles. as time goes by, successful methods and curricula would be shared through the proposed oh education network and knowledgebase described below and would not be limited only to participants in the program. http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 77 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 ii) curriculum development workshops for teachers we have received feedback that some teachers would never have the time to devote to curriculum development themselves. some have also expressed concern that they do not know the subject area well enough to be able to write a curriculum or innovate very effectively along one health lines. in response, we decided we needed to create an opportunity for motivated teachers to learn more about one health and receive some direct assistance in creating one health themed curricula. we are proposing to do this through a series of summer workshops, which would include summer salary for participants. this would be an annual opportunity and could again be open ended or focused on changing themes or topics. workshops would involve participation by “experts” in one health, depending on the topics selected, and would also include curriculum development professionals to assist teachers in classroom applications. the workshops would emphasize innovative learning methods that target one health values, skills and knowledge criteria as described above and would provide an important networking opportunity for sharing and mentoring between teachers and experts. iii) teacher training programs a third concept that we are proposing is to work with teaching training programs already in existence that are interested in building one health approaches into their training programs. this approach would involve new teachers in the process of curriculum development and could be implemented through specific courses or teaching modules. by working with teaching training programs we would be creating opportunities for innovation from the ground up which may provide greater opportunity for broad integration of one health values across subjects. in this environment, we would also be in a good position to inculcate one health skills and knowledge in teachers during a critical period in their own development as educators. this approach would also ensure that appropriate regional programming is being developed that best meet the needs of local education systems and would maximize benefits and outcomes which may not be otherwise adaptable from a more universal, less regional approach. it was suggested that we think about promoting this opportunity to make sure teachers that need it to take advantage of it. this could be done by developing introductory one health presentations and using social media to reach a broad audience. the example of an ivsa program was given where they are “developing a one health presentation to school children on veterinary public health, one health and explaining the diversity and active contribution of vets and medics to the human-animal-environment interface. we plan to distribute it to our member organisations in over 60 countries and translate it to at least 2/3 languages for teachers to use. we hope to use social media to spread the word, to students will promote or present this workshop to communities, to families and then to schoolsto encompass student centred learning (bhavisha patel).” iv) one health education network the creation of a one health education network will be critical to global adoption of any curriculum innovation that results from this initiative. we feel that it would be very valuable to foster mentorship and sharing among project participants and provide opportunities for others outside the project to benefit from the teaching expertise that develops as a result of this initiative. over several years this could develop into a robust and supportive cohort of one health educators around the globe and provide the best mechanism for achieving sustainable development goals globally through one health. http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 78 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 the ohe network would provide a directory of one health educators, facilitate communication between educators with social networking tools, and facilitate mentorship connections between educators and one health experts. the network could act as a platform for organizing meetings and presentations, and would facilitate collaboration on future projects. importantly, the network could become self-sustaining simply through the interest and enthusiasm of the participants and provide longevity to the investment of this project for years to come. v) on-line knowledge base of one health curriculum materials finally, we want to openly share the products of any of these curriculum development programs as we start a movement and inspire teachers around the world to adopt one health principles in their teaching. we propose to build an open access technology platform for sharing curriculum that will serve as a repository for products of any grants or workshop programs developed through this initiative. sharing outwardly to the world would provide an opportunity for feedback and dialogue to improve these products and encourage, in an organic way, the transition of more curriculum to include one health principles. over time, this knowledgebase could also link to or include contributions from outside this project and broaden the impact and engagement for one health themed educational initiatives that furthers our global objective for achieving sustainable development goals through one health themed education. above are the five main programs we have focused on to date and we encourage feedback and input from a broader audience. there are many details to work out, and the scale of these programs is still undetermined. what follows is a summary of the participant suggestions and calls for clarification concerning the strategies presented. first and foremost we would like to clarify that the scope of this project is intended to be global. while initial implementation of pilot projects may precede full globe reach, the pilot projects would likely include a diversity of sites. the exact structure or timeline has not yet been determined. the different nature of various education systems around the world and even within a country like the us was brought up as a challenge. within the us, there is a great deal of variation and level of influence between state agencies and the federal government through the department of education. some states may be more receptive than others to the type of curriculum initiative we are proposing. we hoped that the first option which asks for teachers themselves to come forward, would take care of some of this diversity. teachers would presumably be proposing curriculum development that would work within their own context. the great differences between developed educational systems and developing educational systems will also be a challenge and may require two different efforts or pathways. some clarification about who will make up the group of “one health” experts to participate will be needed, especially since there are no specific well defined criteria for a one health expert, or any standardized system for accreditation or academic degree existing today. we are specifically look for content experts to provide necessary knowledge and resources, as well as curriculum development experts, and the specific qualifying criteria that defines a participating “expert” still needs to be worked out. an excellent suggestion was made to consider including parents in grants or workshops to help bridge the resource gap in some low-income schools where parent leaders play an important volunteer role. engaging with parents may also promote greater acceptance with the community outside the school. the concept of a “community of practice” approach was mentioned as a model for the knowledgebase as well as the network. one way to do this might be to target a specific group of people involved in middle and high school education and connect them with existing experts http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 79 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 or groups that might have resource materials to provide, such as the oie. we would very much like these two programs, the knowledgebase and the network, to operate as a community of practice in one health education. one significant outcome will a one health education foundational body of work that currently does not exist. another mentorship model to consider would be the twinning model, used in the usaid emerging pandemic threats program and others to share between developed and developing educational systems or institutions. there were a couple of cautionary remarks to conclude this section. first of all, considering the large scope of programs and challenges for implementation, there was some concern about staff time and capacity necessary to follow through with this initiative and a need to establish realistic priorities. we are very aware of this and will be considering these questions as we approach funders and develop a timeline. lastly, beware of the top down approach being proposed by our group of one health champions. this will not work without active engagement with k-12 education partners. we have discussed this at length and have been struggling to find the appropriate enthusiastic partners. we welcome any good ideas or introductions to institutions or people that we can draw in to this initiative that will provide the appropriate input. dr. lueddeke will provide more detail on our potential partners defined to date. funding considerations for a one health education initiative this segment of the conference focused on three main funding considerations: i) linking un 2030 sustainable development goals to one health education initiatives (10); ii) supporting projects through existing development mechanisms; iii) possible funding sources. a key argument for project funding decisions was that the one health concept and approach need to be considered as a lens or filter for shaping global policy and strategy regardless of the sdg goals and targets being evolved and implemented, including k-12+ education (fig.1). and, while the habitat iii the new urban agenda (11) agreed in october 2016 is a highly commendable achievement, according to a word search, the 19 documents failed to mention terms or explanatory paragraphs/recommendations related as planet, one health, conservation, animals, epidemic, root causes, overcrowding, inequities, automation, eco footprint, infectious disease, non-communicable disease and only singularly cited the words prevention, healthy lifestyles, ageing population, mental health. more than 70 % of the world’s 9 billion population will be living in cities by 2050 or before. one health crosses all discipline boundaries, and it is important that the project planners identify and collaborate across existing networks, as shown in fig. 2. consideration to seeking funding from multiple funding sources might also be appropriate (e.g., bill and melinda gates foundation, un agencies (e.g., undp, unesco), rockefeller foundation, macarthur foundation, the uk department for international development, and welcome trust). several avenues will be pursued in the next few months, including making personal contact with potential partners or collaborators. http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� https://www2.habitat3.org/bitcache/99d99fbd0824de50214e99f864459d8081a9be00?vid=591155&amp;amp%3bdisposition=inline&amp;amp%3bop=view� 80 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 figure 1. linking un 2030-global goals to k-12 one health and well-being education figure 2. global networks (selected) global networks: united nations 193 members states -2 observer states who collaborating centers (>700) world bank global learning development network (>120 institutions – 80 countries) the commonwealth (52 nations) the european union (27 nations) http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 81 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 further to a question about identifying good partners, it is recognised that a traditional top down approach is not likely to work in this situation. an example of behaviour change that worked well in the u.s. in 70s and 80s is recycling, a local, bottom up endeavour. interestingly, it was young people (children) being inspired by teachers that made the recycling movement happen in the u.s. we should be concerned about strictly advocating a top down approach for k-12 one health education. a successful approach has to start more locally, but be guided by national aspirations or goals. local and national interests should be working in tandem. in the and the u.k. there has been very little discussion so far about the sustainability development goals. we must draw on expertise locally and find support nationally to enable action groups. we like to think of the dual concepts of one health and ‘well-being’. one health is beyond any political or health system. it’s really saying here is our planet, a very small planet, and we have got to keep it healthy regardless of how we are living our lives. it is probably the only non-divisive concept that we have right now. the un development program folks have done a fairly good job with disseminating information. but, if the un had incorporated one health a year or so ago, we would be further along. meeting the needs of the diverse global community although we believe there exists one health core values, principles and concepts, we recognize that operationalizing one health in primary and secondary schools must recognize and appreciate educational, cultural and social differences among countries and educational systems. therefore, no one model or curriculum will fit all situations. how then, can we begin to frame a proposal that honours one health core values, principles and concepts, but is flexible enough to be adapted for diverse circumstances? a point well-taken from the survey is that a validated one health curriculum does not exist. for that reason, any attempt to propose one must include a pilot phase from which one could learn valuable lessons related to adoption, implementation, and evaluation of a curriculum before it could be modified and scaled up in one or more systems. therefore, a successful proposal will focus on pilot studies in one or more education systems (to be defined), but at the same time, it must include metrics that could be used to judge whether or not here is evidence that scaling up and/or out is feasible and of value. various models have been used to pilot educational interventions, even those that encompass one health, in colleges and universities and in the health workforce. historically these have been piloted in one or more systems that are not linked, but in the last decade a twinning model has gained interest and acceptance. this model links two or more educational systems that, at its best, involves equal partners that each learn from the other; it can, however, evolve to a mentor-mentee situation whereby one partner assumes most of the responsibility and the other partner(s) assume lesser, more receptive roles. there may be other models of which we are not yet aware, and we look to others to suggest them. twinning and other models have been implemented at various scales from local to national systems. participants seconded the idea of a proposal that takes a twinning approach and starts at the local level, with curricula that are meaningful to local communities and that involve parents, community members and students alike as teachers and learners. it would be instructive to apply twinning between a higher income and a lower income country, as is being done at a university level, and to look for points of alignment and difference. the proposal may want to http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 82 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 consider adopting a term other than ‘twinning,” which is so closely associated with university level activities and is, as was pointed out, often interpreted by higher income countries as “the world is here for us to remodel.” building on responses to the survey, participants suggested that there is a need for concrete yet simple to grasp examples illustrative of one health. if one health is ultimately about changing behaviours, previous successful examples of changing public behaviours such as recycling (which was started by teachers and taken home to parents and communities by students) and smoking cessation (for which youtube videos, cartoons and other popular media presentations have been developed and widely disseminated) might offer valuable lessons for how to accomplish behaviour change, but they must be grounded in one health principles and guided by local customs and beliefs. a proposal would have to involve social scientists, particularly those with expertise in behaviour change and public health. if messages were meaningful and easy to grasp they could be taken to households with the support of government and international organizations. the first nine months of a child’s life is critical to her/his perception of the environment as friendly or hostile, and having a ‘village’ teach one health to young children could well establish a ‘the environment is friendly’ mindset (see the foundation vie’s 1001 critical days of development, also the first five initiative in california). work on empowering girls is being conducted by the university of wisconsin in ghana and could illustrate successful implementation of this approach. a recent teacher training workshop using student-centred active approaches was very well received by teachers who are used to the ‘sage on the stage’ approach so common in many countries. and, rather than importing more new material into already packed curricula, a proposal could instead strengthen existing curricula, for example, by supporting teachers to adapt current material using more ‘hands-on’ learning with the natural world that incorporate ethics of how we view and treat each other, animals and the environment. a third option would be to develop ‘scaffolding’ lessons that integrate existing curricula across disciplines and grade levels. scaling up and out presumes some early measures of success, but the goal of a one health curriculum is to change behaviours. because this is a long-term outcome, it cannot be used to judge the success of a one health project in the short term. one suggestion was the level of involvement of a community could be used as an early indicator of success for a pilot project. another metric being used in ghana is the degree to which students who experience the curriculum in schools take that learning home to educate their parents, although the cultural appropriateness of children teaching adults has to be considered. successful pilot projects would be shared widely, thereby developing a “community of practice” that would reflect the common goals of one health teaching and learning and the richness of its adaptations. open panel discussion in this section we discussed additional questions and received numerous suggestions that are not included in the sections above. the topic of curriculum design was raised. we purposely do not want to prescribe what any given curriculum would look like, whether that be modules, week-long units, individual lectures or a scaffold of modules across grade levels and across subjects. we want to encourage innovation in curriculum design and pedagogy as much as possible and are hoping that educators would develop curricula together to produce integrated learning designs preferably to create modules that fit into an existing science class for example. programs that cut across courses and grades would be optimal. incentivizing collaborations and trans-disciplinary team based curricula was suggested, over didactic ‘preaching’. curricula should incorporate issues http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 83 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 based, inquiry based, problem based, small group based methods that focus on real issues, because our challenges today do cross disciplines. another suggestion was made to organize content around broad categories made up of a series of small modules or easy to digest, bite-sized pieces. this can be particularly important where language might be a challenge. the reference was made to experience in ghana in the one health and girls empowerment program with junior and senior high school girls. in those workshops they found that in addition to ‘content’ that the teachers loved learning about student-centred active teaching approaches that they had never been exposed to. they need to see other ways to teach. there are likely some other good programs already on the ground that we could learn from. several examples of these were mentioned including: • an 8-12 grade curriculum for veterinary science and one health science in the state of texas (try contacting dr. heather simmons); • a new mooc addressing one health that will be available through coursera (https://www.coursera.org/) in spring 2017; • a university of washington "conservation biology & global health" 3 day curriculum for high school students; • the california state first five initiative; • examples of twinning as a collaborative development and support mechanism (e.g. usaid emerging pandemic threats program). however we proceed, the idea of piloting programs in different regions was felt to be important along with the willingness to be flexible and respond to community and cultural diversity in different parts of the world. some discussion centred on the topic of behaviour change. it will be important to include social scientists on the development team that have expertise in this area. one of our challenges is the goal of changing the mindset. 97% of world health funds are going toward treatment of disease and only 3% goes to prevention. this is from a global budget of $7.7 trillion us dollars. because one health is all about prevention strategies, initiatives like the ghsa should be interested. it was suggested that there may be lessons learned from experiences in developing countries with hiv behaviour change programs, particularly how to reach communities. several participants stressed that one of the best ways to gain support for a new program and improve the possibility of success is to make sure there is a link with communities beyond the classroom, with the caveat that we need to be sensitive about the cultural appropriateness of kids teaching adults. another potential ally could be the network of school nurses, a group that is greatly under-utilized and under-appreciated. if appropriately empowered, they could be a valuable asset. in any event we will need good partners in the k-12 system before moving forward since a top down approach will likely not work here. some discussion came up on the topic of finding funding for educational initiatives. it was suggested that it might be helpful to look at the portfolios of the various donors (e.g. usaid, dfid, multilateral and regional banks, etc.) to look for compatible interests in education. it can be very challenging to get an innovative, technical assistance grant. reference was made to experience in a new regional project in west africa called the regional disease surveillance systems enhancement project, a huge world bank project that handles 15 countries in w africa with ohahu and who that involved several hundred million dollars. another suggestion was to explore existing zoonotic disease initiatives, such as predict or the global health security agenda (ghsa). http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� http://www.coursera.org/)� http://www.coursera.org/)� http://www.coursera.org/)� 84 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 some other potential funding sources mentioned include: skoll, ford, rockefeller, gates, the instituyo alana in sao paulo brazil, african union/ecowas. in some cases, appealing directly to ministries of education or health might find support for being the first one to institute something truly innovative (e.g. island nations like fiji and seychelles). conclusion we assumed that most people attending this conference (10) do support the idea of k-12 one health education. perhaps attendees, like us, are driven by the need to examine what is currently being done (in education) and to postulate what we need to be doing differently to prepare future generations. there are some attempts being made globally for one health education at the graduate and professional education levels. but that is too late to significantly affect behaviours and in still attitudes of open collaboration and interactions. by then young people are already in their academic silos. we are very concerned about current attitudes toward our human place on the planet. in this conference we have outlined some tangible, programmatic models that could be used in young children and expanded to a global community of practice to improve things for future generations. the un sustainable development goals are a wonderful target to aim for globally. but there is currently no mechanism to unite and implement them. one health thinking and acting can do that. indeed, one health is a pathway not only to the un sdgs and planetary health, but also to global security. health and well-being are profoundly embedded in and dependent on global government stabilities. as the last 10-15 years have shown, it can be very difficult to introduce one health concepts to already established systems. but k-12 children will be our future global leaders. how do we help them understand the severity of what is going on right now in the world? what is restraining us from doing new things like taking one health education and concepts to young children? we need to change today’s mindset/paradigm of using up our global resources without regard for the health and well-being of our planet because future generations will depend on mother earth. how do we get individuals, governments and corporate bodies to think more holistically and sustainably about the health and well-being of people, animals and the planet? there is much work to do to make one health the default way of doing business around the world. children and one health can be our ‘ray of hope’ for the future. references 1. lueddeke g, kaufman g, kahn l, krecek r, willingham a, stroud c, et al. preparing society to create the world we need through ‘one health’ education. seejph 2016;6. doi 10.4119/unibi/seejph-2016-122. 2. lueddeke g, stroud c. preparing society to create the world we need through ‘one health’ education! (press release). one health commission. available at: https://www.onehealthcommission.org/documents/filelibrary/commission_news/press _releases/61016 oh_education_press_releasefi_f7644a48f9910.pdf (accessed: march 20, 2017). 3. united nations. united nations. transforming our world: the 2030 agenda for sustainable development. available at: https://sustainabledevelopment.un.org/post2015/transformingourworld (accessed: march 20, 2017). http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2016-122� https://www.onehealthcommission.org/documents/filelibrary/commission_news/press_releases/61016__oh_education_press_releasefi_f7644a48f9910.pdf� https://www.onehealthcommission.org/documents/filelibrary/commission_news/press_releases/61016__oh_education_press_releasefi_f7644a48f9910.pdf� https://sustainabledevelopment.un.org/post2015/transformingourworld� 85 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 4. one health commission (ohc). (2017). mission. available at: https://www.onehealthcommission.org/en/why_one_health/ohc_mission/ (accessed: march 20, 2017). 5. one health initiative (ohi). mission statement. available at: http://www.onehealthinitiative.com/mission.php (accessed: march 20, 2017). 6. the commonwealth secretariat (health and education unit). advancingsustainable social development through lifelong learning and well-being for all. available at: https://drive.google.com/file/d/0b8wr6920su0arhlyd0pdoerlajq/view (accessed: march 20, 2017). 7. one health commission. one health education conference. available at: https://www.onehealthcommission.org/en/eventscalendar/one_health_education_onlin e_conference/ (accessed: march 20, 2017). 8. lueddeke g. global population health and well-being in the 21st century: toward new paradigms, policy and practice. new york: springer publication; 2016. available at: http://www.springerpub.com/global-population-health-and-well-being in-the-21st-century-toward-new-paradigms-policy-and-practice.html (accessed: march 20, 2017). 9. wwf international. living planet report 2014. available at: https://www.wwf.or.jp/activities/lib/lpr/wwf_lpr_2014.pdf (accessed: march 20, 2017). 10. lueddeke g. the un-2030 sustainable development goals and the one health concept: a case for synergistic collaboration towards a common cause. world medicine journal, vol. 62, 2016: 162-167. available at: http://lab.arstubiedriba.lv/wmj/vol62/december-2016/#page=44 (accessed: march 20, 2017). 11. un news centre. habitat iii: un conference agrees new urban development agenda creating sustainable, equitable cities for all. available at: http://www.un.org/apps/news/story.asp?newsid=55360#.wo3xddqrjkg (accessed: march 20, 2017). http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� https://www.onehealthcommission.org/en/why_one_health/ohc_mission/� http://www.onehealthinitiative.com/mission.php� https://drive.google.com/file/d/0b8wr6920su0arhlyd0pdoerlajq/view� https://www.onehealthcommission.org/en/eventscalendar/one_health_education_online_conference/� http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html� https://www.wwf.or.jp/activities/lib/lpr/wwf_lpr_2014.pdf� https://www.wwf.or.jp/activities/lib/lpr/wwf_lpr_2014.pdf� https://www.wwf.or.jp/activities/lib/lpr/wwf_lpr_2014.pdf� http://lab.arstubiedriba.lv/wmj/vol62/december-2016/#page%3d44� http://www.un.org/apps/news/story.asp?newsid=55360&amp;amp%3b.wo3xddqrjkg� 86 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 appendix i – participants in the one health education conference and survey (respondents to the survey who identified themselves included) james akpablie claire b. andreasen, iowa state university, college of veterinary medicine olutayo babalobi, one health nigeria christopher birt isabelle bolon bonnie buntain, university of arizona, school of veterinary medicine bill burdick peter cowen, north carolina state university stephen dorey, commonwealth secretariat, health and education unit eliudi eliakimu nirmal kumar ganguly, national institute of immunology, department of biotechnology, india julie gerland, noble institution for environmental peace, chief un representative aja godwin ralf graves michael huang lai jiang, institute of tropical medicine, belgium bruce kaplan, one health initiative getnet mitike kassie gretchen kaufman, one health education task force ulrich laaser sultana ladhani, commonwealth secretariat zohar lederman, national university singapore joann lindenmayer, one health commission jill lueddeke george lueddeke, one health education task force pamela luna donald noah, one health center, director martha nowak, kansas state university, olathe chris olsen, university of wisconsin olajide olutayo amina osman, commonwealth secretariat, health and education unit steven a. osofsky, cornell university bhavisha patel nikola piesinger, mission rabies, uk, education officer kristen pogreba-brown peter rabinowitz, university of washington vickie ramirez, university of washington ralph richardson, kansas state university, olathe, dean/ceo raphael ruiz de castaneda, institute of global health, oh unit, geneva laura schoenle richard seifman sara stone alexandru supeanu, one health romania http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 87 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 appendix ii – survey instrument the following survey was conducted by the one health education task force between october 16, 2016 and december 10, 2016 utilizing the survey monkey ® web based platform. introduction: the goal of this survey is to collect views on the importance of one health in preparation for an online pre-proposal conference scheduled for mid-november. survey feedback will help us define the parameters and design of a global one health-themed educational funding initiative, spearheaded by the one health commission in association with the one health initiative. the proposed project focuses on the development and support of one health (and well-being) curriculum materials, involving primarily k-12* teaching staff and education providers. the survey will help to identify ways of addressing challenges to successfully implement a number of pilot projects on a global scale. subsequent educational initiatives will address post-secondary and professional education. the survey will take approximately 20 minutes to complete. the survey employs the one health commission definition of one health: “one health is the collaborative effort of multiple health science professions, together with their related disciplines and institutions – working locally, nationally, and globally – to attain optimal health for people, domestic animals, wildlife, plants, and our environment.” *“k-12” is defined as organized pre-primary through secondary school education. we acknowledge that this is not uniform terminology around the world, but will use this term for convenience. survey questions objective 1: identifying complex issues/examples that can be used to address the drivers of one health challenges and can lead to sustainable solutions. 1) list 5 words that immediately come to mind when you think of one health (open question): 2) please rank the following types of sustainability from 1-5 in terms of their importance to one health (1=most important and 5=least important) a. ecological b. economic c. cultural/social d. ethical e. justicial (of or relating to justice, as opposed to judicial) 3) list 3-5 one health challenges that could be used to illustrate the need for a one health approach. include no more than one zoonotic disease. 4) please choose what you believe are the 5 most important contributing factors to the development of one health challenges (not limited to disease transmission) that should be considered in developing preventive policies or sustainable solutions or those challenges: a) lack of knowledge/understanding b) lack of methods and tools to investigate complex problems c) lack of uniform standards for information management and sharing d) compartmentalization of health services and policies e) lack of funding streams that encourage collaboration and provide support for one health initiatives f) overemphasis of treatment of individuals (human and animal) at the expense of preventive medicine and population health http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 88 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 g) overemphasis of human health at the expense of animal and environmental health h) human population growth and development i) poverty, distribution of wealth, inequity j) political systems that support individual/corporate interests above all else k) globalization in the absence of global standards of practice l) short-term decision/policy horizons m) over-exploitation of natural resources n) tribalism o) climate change p) otheropen ended objective 2: meeting the un sustainable development goals thru one health-themed education (http://www.un.org/sustainable-deevelopment-goals/). 5) how well do you think a one health-themed k-12 education program relates to each of the following sdgs (1=not at all related and 5=highly related)? a) end poverty in all its forms everywhere b) end hunger, achieve food security and improved nutrition and promote sustainable agriculture c) ensure health lives and promote well-being for all at all ages d) insure equitable and inclusive quality education and promote lifelong learning opportunities for all e) achieve gender equality and empower all women and girls f) ensure availability and sustainable management of water and sanitation for all g) ensure access to affordable, reliable, sustainable and modern energy for all h) promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all i) build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation j) reduce inequality within and among countries k) make cities and human settlements inclusive, safe, resilient and sustainable l) ensure sustainable consumption and production patterns m) take urgent action to combat climate change and its impacts n) conserve and sustainably use the oceans, seas and marine resources for sustainable development o) protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification and halt and reverse land degradation and halt biodiversity loss p) promote peaceful and inclusive societies for sustainable development, provide access to justice for all, and build effective and accountable, inclusive institutions at all levels q) strengthen the means of implementation and revitalize the global partnership for sustainable development 6) are there other sustainability goals that you think should be included (open-ended): objective 3: identifying values and principles that underlie a global one health approach towards health and well-being for the planet. http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� http://www.un.org/sustainable-deevelopment-goals/)� 89 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 7) which one of the following graphical representations best captures the valuesand principles of one health? f) none of the representations are satisfactory 8) which of the following values do you think are essential to the application of one health? (please select all that apply) • balance • community • compassion • competence • compromise • cooperation • diversity/biodiversity • empathy • experience • freedom • growth • humility • integrity • justice/fairness • leadership • mindfulness • reason • resilience • respect • responsibility • rigor • self-awareness • sustainability • synergy • tolerance • transparency • understanding • vision • other (open ended) 9) to what degree do you agree with each of the following statements as it relates to one health, where 1=strongly disagree and 5=strongly agree? a) when you optimize health for one species, health for others is marginalized or eliminated. b) one health should be practiced so that there is no net (ecosystem) loss of biological diversity. c) the health of humans, other animal species and plants cannot be separated. http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 90 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 d) one health recognizes the intrinsic value of life on earth (plants, animals, microbes) regardless of a direct benefit to humans. e) “environment” includes natural and built environments. f) one health embraces the value of social interaction as a critical component of health and well-being. g) humans have a moral imperative to address one health challenges. h) ecological, economic, social/cultural, ethical and justicial sustainability are equally important for one health. i) the world health organization defines “health” as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” this definition also applies to other animals and ecosystems. j) other (open ended). objective 4: designing a global one health-themed k-12 educational program that supports innovation by educators and learners. 10) in your experience, to what extent are students currently exposed to concepts related to one health (including well-being) where 1=not at all exposed and 5=highly exposed? a) pre-primary education b) primary education secondary education c) college and university education d) adult education e) other (open ended) 11) how important is it that students are introduced to one health concepts in the educational curriculum at the following educational levels, where 1=not at all important and 5=highly important? a) pre-primary school b) primary school c) middle school d) high school 12) in what types of schools would you pilot a one health-themed curriculum, understanding that not all school types are found in every country (please select all that apply)? a) publicly-funded schools b) privately-funded schools c) magnet schools d) charter schools e) independent schools f) home school networks g) extra-curricular education (after school) h) summer school or camps i) colleges or universities j) other (open ended) 13) what broad-based skills should students learn through a one healththemed educational program (please select any that apply)? a) collaboration b) communication to diverse audiences c) concept mapping d) conservation http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� 91 lueddeke gr, kaufman ge, lindenmayer jm, stroud cm. preparing society to create the world we need through “one health” education (review article). seejph 2017, posted: 20 april 2017. doi: 10.4119/unibi/seejph 2017-142 e) experimental design/methods/inquiry f) goal-setting g) interdisciplinary thinking h) leadership i) problem-solving j) systems thinking k) team-building l) other (open ended) 14) to what extent should students be exposed to the following concepts in a one health themed educational program, where 1=not at all exposed and 5=highly exposed? a) role of natural and built environments in human and animal health and well-being b) respect for natural systems and human responsibility for planetary health c) the connection between well-being and mental/physical health d) personal responsibility – how individual actions impact one health e) corporate, political and societal responsibility – how their actions impact one health f) climate change and health of the planet g) environmental contexts of one health issues h) staying healthy and making good choices for the environment i) “cradle-to-grave” thinking j) other (open ended) 15) in your opinion, what are 3 main barriers to incorporating a one health-themed program in k-12 education in your country (open ended)? 16) what do you believe should be some long term outcomes (how might it change the knowledge, understanding, attitudes or behaviors of students) of a one health-themed curriculum (open ended)? objective 5: identifying challenges that must be addressed for a proposal to be funded 17) what educational stakeholder sectors (e.g. state, private, other) should be represented in developing the concept of a one health-themed education initiative into a successfully funded proposal (open ended)? 18) please suggest up to 3 funding organizations that might support implementation of a one health -themed education initiative (open ended). 19) please list up to 3 major logistical challenges to scaling up a k-12 one health curriculum to a global stage (open ended)? 20) please provide any other comments or suggestions (open ended). © 2017 lueddeke et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://doi.org/10.4119/unibi/seejph-2017-142� http://doi.org/10.4119/unibi/seejph-2017-142� http://creativecommons.org/licenses/by/3.0)� 92 sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 review article approaches to the international standards application in healthcare and public health in different countries vitaliy sarancha1, vadym sulyma2, nenad pros3, ksenija vitale1 1 school of public health “a. stampar”, medical school, university of zagreb, zagreb, croatia; 2 department of traumatology, ivano frankivsk national medical university, ivano – frankivsk, ukraine; 3 quality management department, pastor tva jsc, croatia. corresponding author: vitaliy sarancha, md; address: 4 rockefeller st., zagreb 10000, croatia; email: saranchavi@gmail.com mailto:saranchavi@gmail.com� 93 sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 abstract as a result of consequent development, and guided by an increasing demand of different types of the organizations regarding structured management, the system of standardization has been established. the idea behind standardization is adjusting the characteristics of a product, process or a production cycle to make them consistent and in line with the rules regarding what is proper and acceptable. the “standard” is a document that specifies such established set of criteria covering a broad range of topics and applicable to commissioners of health, specialists in primary care, public health staff, and social care providers, as well as the local authorities and service users. health products, ranging from medical devices and health informatics to traditional medicines and unconventional healing tools are all in the focus of standards’ application. different countries have their own quality management traditions based on their history, mentality, socio-economic environment and the local regulations. taking into consideration that community social system organization and the quality of social infrastructure are the main foundations of social relations and future prosperity, here we review the existing standardization environment in the health sector in different countries, both developed and those on a convergence path. we focused on standardization environment in the united states of america, great britain, germany, ukraine, russian federation, croatia and albania. in order to simplify comprehension, we also demonstrate the algorithm of standardization, as well as the opportunities for application of the international standards in healthcare and public health. keywords: healthcare, international standards, public health. conflicts of interest: none. 94 sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 introduction first traces of quality development appeared more than four thousand years bc, at the time when commodity barter had been replaced by the development of trade among greek, roman, egyptian, arab and phoenician traders (1). artisans described to their suppliers, by experience, using simple words, what kinds of materials they preferred. this was common practice, since the craftsmen had no tools to measure the composition, strength, chemical or physical characteristics of a given material. industrial revolution contributed to the development of product specification (2). manufacturers began issuing precise descriptions of materials and processing methods in order to ensure that supplies met certain quality criteria (3). thus, producers were obliged to take samples from each batch, which was then subjected to tests determining its elasticity, tensile strength, etc. when the first factories were established, requirements for a higher degree of order, greater focus on precision and monitoring quality control of a product were introduced. evolving through different stages, beginning with the 'division of labour' in the late 1700s until the beginning of the 20th century, the scope of activities from the beginning of a production cycle to the final phase led to the occurrence of the first model-based managerial approach (4). when the demands of tasks became too complex basic managerial principles, such as planning, execution, monitoring, controlling, completion and improvement were implemented (5). therefore, to form a structurally oriented organization, systematic quality control became a necessity. later on, such quality patterns and models became generally accepted and are today known as the standards. in the modern society, social infrastructure quality is the main foundation of social relations and future prosperity, thus the purpose of this article is to review the existing standardization environment in the health sector in different countries, both developed and those on a convergence path; as well as to demonstrate a common algorithm for standardization and the opportunities for the application of international standards in healthcare and public health. definition and different types of standards the idea behind standardization is adjusting the characteristics of a product, process or a production cycle as to make them consistent and in line with the rules regarding what is proper and acceptable. standard is a document that specifies such established set of criteria. more than 21000 international standards covering almost all aspects of human activity, including healthcare, have been published since february 1947, when the delegates from 25 countries met at the institution of civil engineers in london and founded the international organization for standardization (iso). today, it encompasses 162 member countries and more than 238 technical committees taking care of the development of standards (6). after the foundation of the european union a network of new institutions, such as the european standardization organizations (esos) consisting of 33 european countries, and cen the european committee for standardization, has been established. cen together with the european committee for electro-technical standardization (cenelec) and the european telecommunications standards institute (etsi) are officially recognized by the european union and by the european free trade association to be responsible for developing voluntary standards on the european level (7). regarding various products, materials, services and processes, cen provides a platform for the european norms (ens) development (8). en is to be implemented on a national level by being given the status of a national standard, and by withdrawing any conflicting national standards used previously. therefore, the european standard becomes a national standard in each of the 33 cen-cenelec member countries once adopted by the national body (9). for example, croatia after entering eu had to harmonize the local hrns (croatian norms) to conform to the ens. 95 sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 standardization process the functional diagram (figure 1) introduces an 11-step assessment construct having been passed by any organization in attempt to obtain a particular certificate. figure 1. the 11-step assessment construct that an organization needs to go through in order to obtain a certificate (source: sarancha v, nenad pros 2016) formalization of workflow, introduction, implementation and staff training policies, guidlines, summaries, process diagrams, etc., ... manuals, procedures, instructions, check lists, etc., ... no document is valid yes ready for use document training confirmation record internal audit record, report nonconformities revealed notes, records yes no yes system is adjusted no audit by the certification body client report nonconformities revaled notes, records yes no yes system is adjusted no 2. introduction of norm general requirements 4. documentation set design 6. implementation and staff training 5. acceptance and authorization of the documentation system 3. establishment of company policy, responsibilities assingment, processes definition 11. document of conformity 10. corrective actions 9. external audit 8. corrective actions 7. internal audit documents in use 1. analisys of actual working conditions and workflow 96 sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 certification body is a third party auditing firm that assesses organization against a specific international standard. taking into account a huge amount of relevant documents and the complexity of the procedures, it is important to correctly identify the procedure required for the certification process at the beginning. approaches in different countries different countries have their own quality management traditions based on their history, mentality, socio-economic environment and the local regulations (10,11). this otherness is fundamental when considering well-developed countries such as the usa, germany and great britain in comparison with the converging countries of eastern and south-east europe (12,13). thereby, the usa has developed a quality infrastructure and there are many organizations that provide accreditation services covering various aspects of healthcare and public health. some of them include the accreditation association for ambulatory health care (14), the community health accreditation partner, the joint commission and the accreditation commission for health care, the american accreditation council, and the healthcare quality association on accreditation (15). one of the main acknowledged bodies in healthcare is the national association for healthcare quality (nahq). it certifies professionals in healthcare awarding the certified professional in healthcare quality (cphq). cphq plays an important role in clinical outcomes, reliability and financial stability of the healthcare organizations. the key elements of their knowledge refer to information management, measurement and analytics, quality measurement and improvements as well as planning, implementation, evaluation, training, strategic and operational tasks concerning patient safety. in great britain, the national standards body is bsi group (16). one of the outstanding resulting documents created by a group of representatives from bsi to help organizations put in place occupational health and safety performance is the occupational health and safety assessment series 18000 (ohsas) with its next revision ohsas 18002 which was accepted as a standard. in the updated edition “health” component was given greater emphasis and current version became more closely aligned with the structures of iso 9000 and iso 14000. thereby organizations could more easily adopt ohsas alongside the existing management systems (17). another institution is the united kingdom accreditation forum or ukaf. founded in 1998 by a group of leading healthcare accreditation organizations, nowadays ukaf is an umbrella structure for organizations providing healthcare accreditation. it operates with an interest in developing assessment and accreditation programmes in healthcare and public health (18). the national institute for health and care excellence (nice) provides guidance and contains governance information, publications, and policies concerning healthcare. it collaborates with the public health institutions, social care professionals and service users, and it also designs concise sets of statements and guidelines to drive measurable quality improvements within a particular area of healthcare (19). furthermore, there is a supervisory structure in the uk called the professional standards authority. this body is responsible for overseeing the uk’s nine health and care professional regulatory bodies (20). referring to the topics that focus on the subject it is important to mention the united kingdom accreditation service (ukas), the national health service (nhs), the department of health, etc. in germany, as a result of agreement with the german federal government, the national standards body is the german institute for standardization (din). its experts administer about 29,500 standards and it was one of the first well-structured certification institutions in europe. din remains the competent authority in respect to the technical issues and widely known specifications for products and materials. the accreditation body for the federal republic of germany is dakks. it has a special health/forensics division, which among other tasks attests third-party certification bodies taking care of healthcare, forensic medicine, medical laboratory 97 sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 diagnostics and medical devices. the german worker’s welfare association (awo) also plays an important role. together with iso they have formed an effective tandem that ensures quality in awo rehabilitation facilities and health organizations. the model combines requirements of iso 9001 with those of awo quality and risk assessment guidelines. consequently, quality of a particular facility is measured by the care provided, the organization structure and the satisfaction of patients and residents. in addition, important requirements for patient safety are formulated by a german initiative called the german coalition for patient safety. it provides a basis in processing the audits that are conducted in the client’s premises, with the aim of providing the client with a feedback regarding the degree of implementation of the quality dimension of “patient safety”, e.g. regarding a particular healthcare system unit. speaking of developed economies, it can be concluded that as of today standardization has taken a strong position. in our opinion this is due to understanding by the managers of its effectiveness, as well as the level of comfort regarding integration of standards, clear description of the processes and therefore adherence to the relevant rules and procedures. in spite of positive sides of standardization, we have to understand that human factor in healthcare should also be taken into account, which means inapplicability of one approach only, the engineering approach to the human being as a mechanism. in comparison with the quality management systems present in the developed countries, ukraine has relatively unbalanced quality infrastructure. it bears elements of the former ussr standardizing paradigm that has to be re-evaluated, updated and adapted to suit the existing economic and social environment. there are state and industry branch systems of standardization in ukraine (21). the state branch includes the ukrainian scientific research institute of standardization certification and informatics, and the ukrainian state research and production centre of standardization, metrology and certification (22,23). the most flexible are the service standards departments and the industrial standards departments. state social standards in the health sector are regulated by the ukrainian law “fundamentals of ukraine on healthcare” (24). since ukraine has become a participant of the euro integration process, the reform on the adaptation of local standards to the european and international norms has been significantly accelerated (25). the main principles are shown in the “national strategy on reforming the healthcare system in ukraine” which has been accepted for implementation in the period from 2015 – 2020 (26). more often, private clinics and research centres all over the country engage certification bodies to perform an external audit with the aim of meeting international quality requirements. standardization in russian federation is based on gosts. the word gost (russian: гост) is an acronym for “государственный стандарт” which means the national standard. there is a set of technical norms maintained by the euro-asian council for standardization, metrology and certification (easc) (27). one of the steps towards the standardization is by issuing the ordinance of the ministry of health “on the introduction of standardization into healthcare” (28). there are also many national programmes and ordinances in russia dealing with the implementation of particular standards in public health (29). the problem in russia is actually in hyper-regulation as regards the standardization. numerous ordinances, guidelines and procedures on one hand, and a lack of specific implementation mechanisms on the other hand causes confusion and regress with regard to the harmonization of national standards with their international counterparts. thus, the organization for economic co-operation and development (oecd) series on principles of good laboratory practice (glp) currently operates with gost r53434-2009 “principles of good laboratory practice” together with the support of other 14 interstate standards which have already been successfully implemented. in croatia, accreditation is provided only by the croatian accreditation agency (haa) which is a national accreditation body that complies with the requirements of the international and european standard for accreditation bodies adopted in the republic of 98 sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 croatia as the croatian standard hrn en iso/iec 17011: 2005. the haa is a member of the international laboratory accreditation cooperation (ilac) and the european co operation for accreditation (ea). the ilac is an international organization for accreditation bodies operating in accordance with iso/iec 17011 and involved in the accreditation of conformity assessment bodies including calibration laboratories (using iso/iec 17025), testing laboratories (using iso/iec 17025), medical testing laboratories (using iso 15189) and inspection bodies (using iso/iec 17020). the ea is an association of national accreditation bodies in europe which are officially recognised by their national governments to assess and verify (in line with the international standards) the organizations that carry out evaluation services such as certification, verification, inspection, testing and calibration (also known as conformity assessment services). on the other hand there are agencies in croatia dealing with quality control issues on the national level. thus, the agency for quality and accreditation in health care is an authority whose competence refers to quality improvement in healthcare services and social care, as well as medical technology assessment according to the corresponding law (official gazette of the republic of croatia 124/11) (30). targeted assistance in further development of quality infrastructure in croatia has been successfully implemented by the joint research centre of the european commission with amended action programmes such as cards croatia project on the “development of national metrology, standardization, conformity assessment and accreditation system” (31). other institutions that cope with quality paradigm introduction into the croatian healthcare and public health system are andrija stampar school of public health and the european society of quality in healthcare (32). according to the 2009 ministry of health national background report “health in albania”, the country has performed very well in sustaining high rates of economic recovery after the financial collapse of 1997 (33). quality assurance of health systems has been outlined as a priority in primary healthcare reform: a pilot project to provide evidence for health policy (34). the national agencies are empowered by the government to be responsible for accreditation of hospitals and licensing medical personnel. albania maintains the initiatives and continuous a dialog with the public institutions such as the institute of public health, private laboratories and clinics as well as with the international ngos, who, unicef, wb and usaid regarding a more active participation of the country in the international activities of the quality system implementation (35). international quality bodies are successfully co-operating with the aim to internationalize standardizing efforts in healthcare. one of such example is the international society for quality in health care (isqua). it is a parent institution for bodies providing international healthcare accreditation. isqua provides services in guidance to health professionals, providers, researchers, agencies, policy makers and consumers as to achieve excellence in healthcare delivery to the public and to continuously improve the quality of care (36). among others, quality bodies working on the international level are astm international (37), the international accreditation forum (iaf) (38), and the council for health service accreditation of southern africa (39), the quality management institute, etc. quality paradigm implementation in healthcare and public health standards cover a broad range of topics and are applicable to commissioners of health, specialists in primary care, public health staff, and social care providers as well as the local authorities and service users. health products, ranging from medical devices and health informatics to traditional medicines and unconventional healing tools are all in the focus of standards application (40). standards are designed to establish patterns of quality and performance including the measures to protect and improve the safety of patients, to promote a culture of continual improvement, support efficient exchange of information and data protection while benefiting the environment. depending on the scope of responsibilities and http://www.european-accreditation.org/brochure/ea-slides-rev24-02-17� http://www.european-accreditation.org/brochure/ea-slides-rev24-02-17� 99 sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 areas of activity every organization is able to voluntarily choose among the standards it wishes to implement. iso has created about 1200 health standards that are grouped in families. some of them, such as environmental management iso 14000, occupational health and safety ohsas 18000, guidance on social responsibility iso 26000, environmental management 14000 are featured as widely applicable to public health and healthcare. a family contains a number of standards, each focusing on different aspects of a corresponding topic. according to 2012 iso press release the most commonly used standard is quality management standard iso 9001 (belongs to iso 9000 quality management systems). due to its generic basis, it is applicable to all types of organizations. it enables a company to develop a quality management system (qms) which implies the introduction of quality planning, quality assurance, quality control and quality improvement, and it is a perfect tool to measure the fundamental way of developing health services. iso 9001 has been updated and together with the cooperation for transparency and quality (ktq) for hospitals became the most acknowledged “brand” for quality recognition in healthcare. ktq certification is aimed at hospitals, medical practitioners and institutions, rehabilitation centres, nursing homes, hospices, and emergency medical services. it shows that the focus is primarily on patient satisfaction, from the preparation of the patient’s stay until his discharge. a good example of such practical application of quality management in a combined clinic is perfectly demonstrated in the article by eckert h. and schulze u., (2004) (41). iso 13485:2016 – medical devices, is also a useful standard. it is designed to define the requirements of quality management system with the aim of demonstrating a company’s ability to provide medical devices and related services that meet the clients’ and regulatory requirements. together with en 15224:2012 certification of quality management systems in healthcare, with its emphasis on the hospital process and risk management, both standards become strong indicators of quality level of care provided at an institution. the best way to find a relative iso standard is to search through the work of a particular iso technical committee (tc) on the iso web page, as follows: tc 76, transfusion, infusion and injection, and blood processing equipment for medical and pharmaceutical use; tc 84, devices for administration of medicinal products and intravascular catheters; tc 94, personal safety protective clothing and equipment; tc 106, dentistry; tc 121, anaesthetic and respiratory equipment; tc 150, implants for surgery; tc 157, contraceptives/sti; tc 168, prosthetics and orthotics; tc 170, surgical instruments; tc 172, optics and photonics; tc 173, assistive products for persons with disability; tc 181, safety of toys; tc 194, biological evaluation of medical devices; tc 198, sterilization of healthcare products; tc 210, quality management and corresponding general aspects for medical devices; tc 212, clinical laboratory testing and in vitro diagnostic test systems; tc 215, health informatics; tc 249, traditional chinese medicine; iso/pc 283, occupational health and safety management systems. challenges, opportunities and benefits twenty-first century and the globalization bring new challenges to the organizations exposed to the global market. with a drastic number of competitors, growing demands of consumers and legislators, quality requirements of goods and services together with a lack of resources are constantly increasing (42). be it in environmental protection, in the food industry or public health objective testing and calibration play a notable role. assessments ensure that tested products, methods, services or systems are reliable with regard to their quality and safety, that they correspond to the technical criteria and conform with the characteristics, guidelines, and laws. observational findings indicate that nowadays oecd countries have a relatively developed infrastructure of standards implementation in almost all segments of human activity, including social care and public health. according to iso health report, http://www.iso.org/iso/home/standards_development/list_of_iso_technical_committees/iso_technical_committee.htm?commid=50044� http://www.iso.org/iso/home/standards_development/list_of_iso_technical_committees/iso_technical_committee.htm?commid=50044� http://www.iso.org/iso/home/standards_development/list_of_iso_technical_committees/iso_technical_committee.htm?commid=50252� http://www.iso.org/iso/home/standards_development/list_of_iso_technical_committees/iso_technical_committee.htm?commid=50252� http://www.iso.org/iso/home/standards_development/list_of_iso_technical_committees/iso_technical_committee.htm?commid=50580� http://www.iso.org/iso/home/standards_development/list_of_iso_technical_committees/iso_technical_committee.htm?commid=50580� http://www.iso.org/iso/home/standards_development/list_of_iso_technical_committees/iso_technical_committee.htm?commid=51218� 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public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 healthcare is one of the world’s largest and fastest-growing sectors of the society. in 2009 about 12.4% of gross domestic product of oecd was spent on healthcare. these countries are the basis for research and development, as well as the improvement of international standardization environment. on the other hand, studies have shown that south european countries together with ukraine and russia are, in the long run, heading towards the social paradigm shift and understanding of standardization principles. most frequently cited problems refer to failure of recognizing positive effects of a systematic approach, financial means, long waiting lists, systematic delays in first aid providers, lack of competent staff due to “brain-drain” and insufficient organizations’ preparedness for the implementation of structural changes at all levels. some health centres, clinics and hospitals are funded by the state or county budget revenues (beveridge’s model) or partly from social insurance contributions deducted from the citizens’ wages (bismarck model), and consequently do not recognize the need to increase the level of quality, responsibility and international standards compliance (43). in addition, high payroll taxes in eastern and south european countries are discouraging formal employment, dampening labour demand and increasing employment in the informal sector (44). a study published in british medical journal estimates that medical errors are the third leading cause of death in the united states, that caused a quarter-million fatalities in 2013 alone (45). it obviously means that the reduction of risks of all kinds is also an important problem that needs to be resolved (46). despite relatively well-structured lex artis in standardizing processes, its efficiency in many cases remains controversial. sometimes, due to enormous amount of paperwork and bureaucracy, standardization can become a nuisance causing waste of time and human resources. combination of all these factors, together with the unfair competition, weak governance and corruption may cause unwillingness towards continuous improvement which is the ultimate precondition for an efficient functioning of standardization in healthcare and public health (47). public health and healthcare are vital and sensitive issues, and their importance pervades all aspects of social life due to their medical, social, political, ethical, business, and financial ramifications. looking into the future, it is impossible to predict exactly how our world is going evolve, but current trends suggest that together with climate change, migration, urbanization, a growing and ageing population, poverty, emerging diseases, food and water shortages and a lack of access to health services, the future of health sector appears to be complicated. new fields of expertise such as medical tourism are on the rise (48). they create a pool of migrating specialists whose services and reliability need to be properly examined and permanently reviewed. in our opinion standardization is a step-by-step process that requires commitment and cooperation of all parties. it may flow both in the bottom-up and in the top-down directions. the key element of this evolutionary process is the end-user of services the patient, in whose best interest the described changes should be made. the patient, service provider, health insurance officer, public health institution, legislative body all of them form an integral network of relationships and responsibility. therefore, awareness regarding the benefits of the standardization process and full understanding of its stages, by those included, are key factors in the overall success of its implementation. quality management systems based on the international standards should be a strategic decision of the national public health institutions in an attempt to meet long-term strategic goals. if an organization wishes to use one of the worldwide-recognized norms it has to ensure its adherence to best practices in everything it is involved in (49). it also includes the mapping processes, setting performance targets and making sure that it continually improves and meets the goals of shareholders, clients, and patients. regular audit processes and subsequent annual assessments meet the needs of health service providers, patients, in this way guaranteeing the quality of services and achieving maximum results. in this way, the standardization creates powerful tools in order to fine-tune the performance and manage the risks while operating in 10 sarancha v, sulyma v, pros n, vitale k. approaches to the international standards application in healthcare and public health in different countries (review article). seejph 2017, posted: 07 june 2017. doi: 10.4119/unibi/seejph 2017-145 more efficient ways that allow time and capacity for innovation and 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best care. proc (bayl univ med cent) 2006;19:103-18. 48. medical tourism magazine. faq concerning the medical tourism, sept-oct 2009. 49. lee dh. implementation of quality programs in healthcare organizations. service business 2012;6:387-404. © 2017 sarancha et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://dx.doi.org/10.1136/bmj.i2139� http://ec.europa.eu/progress� http://www.ncbi.nlm.nih.gov/pubmed/?term=mayberry%20rm%255bauth%255d� http://www.ncbi.nlm.nih.gov/pubmed/?term=nicewander%20da%255bauth%255d� http://www.ncbi.nlm.nih.gov/pubmed/?term=qin%20h%255bauth%255d� http://www.ncbi.nlm.nih.gov/pubmed/?term=ballard%20dj%255bauth%255d� http://link.springer.com/journal/11628� http://creativecommons.org/licenses/by/3.0)� 10 lueddeke g. high level communiqué from the interaction council(letter to editors). seejph 2017, posted: 07 july 2017. doi: 10.4119/unibi/seejph-2017-146 letter to editors high level communiqué from the interaction council george lueddeke1 1 consultant in higher and medical education, united kingdom. corresponding author: george r. lueddeke, co-chair, one health education task force; address: 9 lakeland gardens, southampton, hampshire, so40 4xg, united kingdom; email: glueddeke@aol.com mailto:glueddeke@aol.com� 10 lueddeke g. high level communiqué from the interaction council(letter to editors). seejph 2017, posted: 07 july 2017. doi: 10.4119/unibi/seejph-2017-146 dear colleagues, here is a link to a copy of a high level communiqué from the interactioncouncil that may also be of interest to seejph readers. as you may be aware, the council brings together former world leaders (heads of government and senior officials) and focuses on issues related, among others, to global security and has been examining the role of health security over the last few years. at this year’s meeting (30-31 may), co-chaired by he obasanjo from nigeria and he bertie ahern from ireland, the session on planetary health, coordinated by professor john wyn owen, resulted in the endorsement of the “dublin charter for one health”. dr joanna nurse presented on the policy implications of planetary and one health in this session and is tasked by the interaction council with advancing the one health charter in collaboration with key partners. below is a summary of the main actions in the charter for one health that may in due course help to inform trans-disciplinary research, education and practice at national, regional and global levels with a view to sustaining people and planet health and well-being. your comments on how best to advance these key areas are requested-i.e. please let us know what is already happening, gaps and suggestions for how to advance the following: 1. strengthening multi-sector solutions for the sdgs the one health approach has the potential to act as a unifying theme; 2. resilience to emerging threats -including amr, disease outbreaks, climate change and environmental impacts; 3. mainstreaming one health within public health systems for uhc -including environmental health; 4. strengthen one health governance mechanisms for systems reform; 5. building leadership for one health for future generations; 6. establish an independent accountability mechanism for advancing action on one health. please send your comment to glueddeke@aol.com by 10 july. many thanks and best wishes! george lueddeke phd chair, one health education task force the one health commission in association with the one health initiative convenor/chair, one health global think tank for sustainable health & well-being 2030 consultant in higher and medical education southampton, united kingdom linked-in connection: http://www.linkedin.com/pub/dr-george-lueddeke/42/4b0/401 * link to the one health initiative news item: http://www.onehealthinitiative.com/news.php?query=interaction+council+issues+%91the +dublin+charter+for+one+health%92+communiqu%e9 http://interactioncouncil.org/final-communiqu-53� http://interactioncouncil.org/final-communiqu-53� mailto:glueddeke@aol.com� https://www.onehealthcommission.org/� http://www.onehealthinitiative.com/� http://www.seejph.com/index.php/seejph/article/view/114� http://www.linkedin.com/pub/dr-george-lueddeke/42/4b0/401� http://www.onehealthinitiative.com/news.php?query=interaction%2bcouncil%2bissues%2b%91the� 10 lueddeke g. high level communiqué from the interaction council(letter to editors). seejph 2017, posted: 07 july 2017. doi: 10.4119/unibi/seejph-2017-146 link to a one health primary to tertiary education article and proposal supporting the sdgs and one health: http://africahealthnews.com/development-project-proposal-supporting sustainable-future-people-planet/. conflicts of interest: none. © 2017 lueddeke et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://africahealthnews.com/development-project-proposal-supporting-sustainable-future-people-planet/� http://africahealthnews.com/development-project-proposal-supporting-sustainable-future-people-planet/� http://creativecommons.org/licenses/by/3.0)� jacobs verlag executive editor assistant executive editor editors regional editors advisory editorial board publisher table of contents editorial reflections on the liberian civil war, 1989-2003 conflicts of interest: none. references original research abstract conflicts of interest: none. introduction methods study design workshop data processing results table 1. timeliness for notified cases before and after the workshop discussion references original research abstract conflicts of interest: none. health examination surveys and health interview surveys country profile: albania the albanian demographic and health survey (dhs) 2017-2018 contribution of the demographic and health survey (dhs) to health system governance in albania conclusion references original research abstract conflicts of interest: none. introduction the context methods surveys implementation plan results implementation plan implementation activities captured discussion summary of main results lessons learned results in light of research in the field limitations and implications for future research conclusion references original research the dutch long-term care reform: moral conflicts in executing the social support act 2015 abstract conflicts of interest: none. background literature research study objectives and research questions methods research method and study design theoretical framework and conceptual model data collection data analysis results document analysis survey and interviews discussion principal findings and conclusions study strengths and limitations and suggestions for further research references original research abstract conflicts of interest:none. foreword introduction methods study population focus group discussions key-informant interviews information processing results the focus group interviews (fdg) figure 1. disabled war combatants 1017 perspectives of key informants discussion and recommendations references review article preparing society to create the world we need through “one health” education report of a global survey and web conference on “one health” k-12 education, 18 november 2016 abstract conflicts of interest: none. introduction summary of online one health education survey results one health concepts, values and principles one health education and the sdgs operationalizing one health education in k-12 strategies for k-12 one health curriculum innovation curriculum innovation grants for educators curriculum development workshops for teachers teacher training programs one health education network on-line knowledge base of one health curriculum materials funding considerations for a one health education initiative figure 1. linking un 2030-global goals to k-12 one health and well-being education meeting the needs of the diverse global community open panel discussion conclusion references appendix ii – survey instrument survey questions objective 1: identifying complex issues/examples that can be used to address the drivers of one health challenges and can lead to sustainable solutions. objective 3: identifying values and principles that underlie a global one health approach towards health and well-being for the planet. objective 4: designing a global one health-themed k-12 educational program that supports innovation by educators and learners. objective 5: identifying challenges that must be addressed for a proposal to be funded review article vitaliy sarancha1, vadym sulyma2, nenad pros3, ksenija vitale1 abstract conflicts of interest: none. definition and different types of standards standardization process approaches in different countries quality paradigm implementation in healthcare and public health challenges, opportunities and benefits references letter to editors conflicts of interest: none. van ravenswaaij, h., rojas, d., sharjeel, m., slaats, p., andelic, p., paric, m. improving the health status of sex workers in europe (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4680 p a g e 1 | 9 policy brief improving the health status of sex workers in europe: a policy brief with recommendations hilde van ravenswaaij1, daniela rojas1, muhammed sharjeel1, puck slaats1, petra andelic1, martina paric1 1 department of international health, faculty of health, medicine, and life sciences, maastricht university, the netherlands corresponding author: hilde van ravenswaaij, hildevr@outlook.com, couwenhoven 4215, 3703ed zeist, the netherlands. mailto:hildevr@outlook.com van ravenswaaij, h., rojas, d., sharjeel, m., slaats, p., andelic, p., paric, m. improving the health status of sex workers in europe (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4680 p a g e 2 | 9 abstract context: although the united nations and the european union are set to improve life on earth through the sustainable development goals (sdg) framework, sex workers have not been included in this framework, thereby further increasing various issues, which affect this group, such as discrimination, stigma, and poor mentaland physical health. the covid-19 pandemic has exacerbated the already existing disadvantages of sex workers, highlighting the need for a systematic change to sustainably improve the empowerment and health status of sex workers throughout the european union. policy options: the aim of this policy brief is to propose recommendations, which can contribute to the sustainable improvement of the health status and empowerment of sex workers throughout the eu. policy options include a bottom-up approach with use of community-based organizations and public-private partnerships, targeting inclusion of sex workers, the organization of workshops, and the distribution of toolkits. recommendations: inclusion of sex workers in the sdg framework; organization of community-based workshops by and for sex workers; distribution of culture-personalized toolkits by and to sex workers. keywords: sex workers; health; empowerment; policy brief; european union (eu) acknowledgments: we thank martina paric, our senior advisor, and kasia czabanowska for heart-warming support. authors’ contributions: all authors contributed equally to this work. conflict of interest: none declared source of funding: none declared van ravenswaaij, h., rojas, d., sharjeel, m., slaats, p., andelic, p., paric, m. improving the health status of sex workers in europe (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4680 p a g e 3 | 9 introduction to improve all life on earth, the united nations (un) has developed seventeen sustainable development goals (sdgs) (united nations, n.d.). each one of them is targeted towards a specific area or focus, which are meant to transform the world and make it a better place (united nations, n.d.). even though all member states of the european union (eu) have signed up to commit to the achievement of the goals and priority setting of sdgs on the eu agenda, the sdgs itself seem to lack addressing the complexity of issues at hand. for example, it has been found that while there has been mentioning of women’s empowerment and employment, the sdg framework fails to explicitly include sex workers in the agenda 2030 and in all sdgs associated (ingulfsen & koob, 2018). the exclusion of sex workers in the sdg framework seems to reaffirm the existing stigma and disempowerment of sex workers (ingulfsen & koob, 2018). one might wonder how to improve the health status of a group that is never mentioned. one of the barriers which hinders improvement in the health status of sex workers is the lack of access to (high-quality) healthcare for sex workers in a number of member states of the eu (international committee on the rights of sex workers in europe and sex workers’ rights advocacy network, 2020). another barrier regards migration and the legal rights of sex workers, as brussa (2009) found that up to an average of 70% of sex workers in the eu are migrants. due to the limitation of rights for migrants in some member states of the eu, sex workers face difficulty in accessing certain services such as hivand stis screening or treatment. the access to healthcare services can even be increasingly complicated for migrant sex workers with an illegal status (benoit et al., 2017). context the improvement of health status of sex workers increased in importance and relevance due to the recent covid-19 pandemic, as research has shown that the covid-19 pandemic has had an unproportionally large impact on sex workers. beyer et al. (2020) have termed covid-19 and hiv as syndemics given that both have similar structural and social drivers such as poverty, racism, lack of access to healthcare, and increased occupational exposure. the covid-19 pandemic and its related country-specific measures, have further exacerbated the barriers and issues that sex workers had to face. for example, sex workers were frequently ineligible to receive specialized covid-19 financial schemes provided by governments due to their unconventional labour agreements, illegality or lack of registration (platt et al., 2020). another barrier to health status improvement of sex workers, which became increasingly apparent during the covid-19 pandemic, is the limited amount of funding allocated by different independent and nongovernmental organizations (ngos) to improve the human rights situation of sex workers (the red umbrella fund, mama cash, & the open society foundations, 2014). this lead to the necessary development of selfhelp initiatives by sex workers, for instance sharing of accommodation, bills, food and other resources (international committee on the rights of sex workers in europe and sex workers’ rights advocacy network, 2020). the covid-19 pandemic highlighted the need for systematic change to sustainably improve the empowerment and health status of sex workers throughout the eu. the aim of this policy brief is to propose recommendations, which can contribute to the sustainable improvement of the health status and empow erment of sex workers throughout the eu. http://www.sexworkeurope.org/ http://www.sexworkeurope.org/ http://www.swannet.org/ http://www.swannet.org/ http://www.sexworkeurope.org/ http://www.sexworkeurope.org/ http://www.swannet.org/ http://www.swannet.org/ van ravenswaaij, h., rojas, d., sharjeel, m., slaats, p., andelic, p., paric, m. improving the health status of sex workers in europe (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4680 p a g e 4 | 9 this policy brief’s vision for change is to empower sex workers in the eu through community-based integrative approaches that improve their mental, physical and socio-economic health status. policy options schram (2017) found the bottom-up approach to be effective in solution development. in fact, community-based organizations could play an essential role in developing an inclusive and contextual policy response by collaborating with local, municipal, and national authorities (world health organization, 2013). community participation ensures recommended policy options to be effective, feasible and effectively engage migrant sex workers (beyrer et al., 2015). therefore, the focus of policy recommendations calls for a sustainable role of community-based organizations and initiatives through sufficient funding and technical support to overcome policy gaps. to provide the resources needed for recommended policies, public-private partnerships (ppps) are encouraged. within ppps, both parties invest in the project to contribute to a societal purpose. it is a promising strategy to provide accessible services for sex workers, who are more attracted by partnership approaches (kokku, mahapatra, tucker, saggurti, & prabhakar, 2014). inclusion of sex workers in the sdg framework first of all, the existing stigma and disempowerment of sex workers could be reduced by directly including the group in the sdg framework and support inclusion in the development of policies and agendas being set (ingulfsen & koob, 2018). not only does inclusion result in a more complete and broad policy or framework, it also increases the importance of the group or topic being included (kickbusch, 2009). community-based workshops to address empowerment and improve the health status of sex workers through a bottom-up approach, workshops by and for sex workers should be developed in collaboration with local sex worker’s organizations in available community spaces. the integrative approach can address physical health issues such as hiv and stds, but also mental health issues, including psychosocial well-being, discrimination, and stigma (mantsios et al., 2018). external experts, such as health professionals, could be encouraged to participate in workshops and to provide information on health and safety. conscientization, solidarity, understanding and hope are essential in achieving empowerment (freire, 1972). thereby, an individual is influenced by social structure, while in turn the social structure is maintained by the individuals. as a result, community empowerment can influence sex workers to take action, which can positively affect the community and workshops to be sustainable (mantsios et al., 2018; world health organization, 2005). furthermore, evidence shows that community empowermentbased approaches are associated with reductions in hiv and other stis, as well as increased condom use (kerrigan et al., 2015). for sex workers, a community is often referred to as individuals who share similar social ties and a physical space, as well as having an awareness of identity as a group (shannon et al., 2007). hence, a safe space should be developed, where the sex workers can share their experiences, educate each other, support one another, develop a sense of belonging, and reflect on their status in society. in addition, involving sex workers and other potential project partners in planning and executing the workshops, will attract them to participate (world health organization, 2005; world health organization, 2009). due to the lack of funding by governments van ravenswaaij, h., rojas, d., sharjeel, m., slaats, p., andelic, p., paric, m. improving the health status of sex workers in europe (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4680 p a g e 5 | 9 and organizations for sex workers this policy option could appeal to the sense of community service from these experts and ask them to volunteer their time and expertise (moore et al., 2014). these peer-led workshops have been shown to be effective in canada, south africa and india (benoit et al., 2017; huschke, 2019). finally, partnership will be sought with existing sex worker organizations and facility centres to implement the workshops. planning and evaluating needs can be collaborated with the sex workers, sex worker organizations and facility centres to achieve effective workshops regarding the needs in local regions. stakeholders can be attracted due to participation being voluntary, sustainable peer-to-peer workshops, and evidence-based approaches (kokku et al., 2014). culture-personalized toolkit the third strategy this policy brief recommends is to implement a toolkit for the sex worker community. firstly, the toolkit should consist of basic health-related needs, such as condoms, as well as self-testing kits for hiv and other stis. testing of hiv and stis should be executed confidentially, with informed consent and with counselling if needed (center for advocacy on stigma and marginalization, 2008). the self-testing kits will solely present the results to the sex workers themselves, which prevents stigmatization by healthcare providers and accommodates privacy (stevens, vrana, dlin, & korte, 2018). moreover, the burden on the health system is reduced, which is beneficial particularly during health crises such as covid-19. nonetheless, if test results appear to be positive for related diseases, for example hiv, hpv or chlamydia, sex workers should be provided the option of voluntary counselling and treatment (center for advocacy on stigma and marginalization, 2008). the toolkit can potentially also be used to provide other relevant equipment and information to the sex worker community, for example hygienic supplies and guides (nswp, 2020). the toolkit should entail information and guidelines provided in paper and a link to the digital form, applicable in the member state. the information-sheet will be broad, involving information on healthcare access, health education, insurance, counselling and potentially information with regards to the community-based workshops. since a large number of migrant sex workers from several nationalities exists, all available information and guidelines should be translated into several languages, to provide accessible information for all sex workers. in this case, sex workers themselves could be empowered to translate information for the informationsheet with their language skills, thereby contributing to affordable and sustainable change (world health organization, 2009). before the toolkit is implemented, local circumstances together with relevant stakeholders should be analysed, such as sex workers, local sex worker organizations and potential project partners. then, the creation of the toolkit can be supported by experts involved in the workshops to fill the information gaps identified by the sex workers. the stakeholders could be united with help from larger sex worker organizations which are experienced in developing projects, such as swan and icrse. the toolkit can obtain resources through donations of supplies, such as condoms, rather than funding. finally, the toolkit can also include tools for evaluating implemented interventions, such as evaluation forms, feedback systems, and guidelines on standardization of outcomes (world health organization, 2005). recommendations the following recommendations are proposed to improve the health status and em powerment of sex workers in the eu: van ravenswaaij, h., rojas, d., sharjeel, m., slaats, p., andelic, p., paric, m. improving the health status of sex workers in europe (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4680 p a g e 6 | 9 ➢ inclusion of sex workers in the sdg framework and actively supporting inclusion of sex workers in related policies being developed and agendas being set. this inclusion could reduce the current existing stigma and disempowerment of sex workers. ➢ community-based workshops by and for sex workers where, in an affordable manner they educate and support each other to tackle health-related issues, mental health challenges, and legal issues. these workshops should be developed by collaborating with local sex worker’s organizations and facility centres that provide available community spaces. these workshops can empower the workers in a safe environment. such an integrative approach is voluntary, low-cost and sustainable while effective in addressing a broad range of issues that affect sex workers. ➢ toolkits consisting of multiple components, to be provided during the workshops. the first component is a package of supplies to provide resources to tackle health related issues, for instance, condoms and hiv selftests. the second component is the distribution of multilingual (non-) health related information in paper form and a link to the same information stated digitally. conclusions the covid-19 pandemic exposed the lack of mental, physical, and socio-economic health status of sex workers throughout the eu. already existing barriers to the improvement of health status of sex workers include the lack of inclusion in the sdg framework and the limited funding available. the three recommendations are an attempt to show how a sustainable improvement in health status and empowerment of sex workers in the eu can be achieved during and after the covid-19 pandemic. if implemented simultaneously, the recommendations are expected to impact the overall health status of sex workers in the eu. references 1. benoit, c., belle-isle, l., smith, m., phillips, r., shumka, l., atchison, c., … & flagg, j. 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https://www.who.int/hiv/pub/sti/sex_ worker_implementation/en/ © 2021 van ravenswaaij et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.who.int/hiv/pub/sti/sex_worker_implementation/en/ https://www.who.int/hiv/pub/sti/sex_worker_implementation/en/ https://www.who.int/hiv/pub/sti/sex_worker_implementation/en/ https://www.who.int/hiv/pub/sti/sex_worker_implementation/en/ otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 1 original research the relevance of ethics in the european union’s second public health programme nelly k. otenyo1 1department of international health, school of public health and primary care (caphri), faculty of health, medicine, and life sciences, maastricht university, maastricht, the netherlands. corresponding author: nelly k. otenyo, msc address: department of international health, maastricht university, postbus 616, 6200md, maastricht, the netherlands; email: nellyotenyo@gmail.com otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 2 abstract aim: the objective of this paper was to investigate whether ethical values were explicitly identified in the second public health programme (2008-2013) of the european commission. methods: a qualitative case study methodology of exploratory nature was followed. the data used were the summaries of the project proposals and public health programme objectives and was retrieved from the publicly available consumers, health and food executive agency database. since the php was finalized during the study, the study only focused on the summaries of the fifty-five finalized project proposals while excluding the ongoing projects and those projects at the reporting stage. the full proposals for the projects are confidential and thus could not be retrieved. however, the project summaries were inarguably sufficient to conduct the study. using a table, a content analysis method in addition to the ethical framework, was applied in order to analyze and categorise the project findings. results: the results unfold that, out of the seven ethical principles, only ‘equity’ and ‘efficiency’ were explicitly considered in eighteen projects and four projects respectively. moreover, from the shared health values, eight projects identified aspects pertaining to ‘accessibility to quality health care’ while ‘solidarity’ was only discussed in one project. lastly, the ethical aspects ‘ethics’ and ‘values’ were identified in three projects and in one project respectively. conclusions: from the results, there is a limited consideration of ethical principles within the projects. therefore, future public health programmes could use this as an opportunity to emphasis on the inclusion and application of ethical principles in public health projects. keywords: accessibility for quality health care, efficiency, equity, respect for human dignity, universality. conflicts of interest: none. otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 3 introduction in the recent years, there has been an increased focus on implementing policies that promote better health, that are cost effective and use targeted strategies against targeted ill-health worldwide. this interest has sparked an even greater concern for public health practices, as well as how ethics is observed with regards to health, especially since populations continue to suffer from emerging health challenges (1). it is also commonly known that human health is greatly influenced or affected by public health practices as well as socio-economic circumstances of individuals. in a response to solve this, researchers are constantly evaluating and checking their research work against ethical aspects of public health; assessing whether the recommendations that are or can be derived from their work can be ethically justified. even though there has been a growing interest on how ethics applies to public health, it has not yet gained a prominent position in all public health research. with the increasing burden of disease and emergent public health programmes, it is important to emphasize the need for public health ethics and develop this interest into maturity in order for it to have benefits (2). ethics is an academic discipline that questions what is required to be done, what is right, fair, just and good. therefore, ethics clearly defined is the study of human values and reasoning, but also refers to the systematizing of these values or rules or moral conduct that guides human lives. through the application of ethics, policy makers are able to frame policies and make critical decisions (3). the rise in the study of how public health and ethics are connected has been gradually developing in the past last years, due to human mal-practices, actions and problems in healthcare practice. public health focuses on ways to detect and quantify factors that put the population’s health at risk, once these factors are quantified policies are formulated to tackle or reduce adverse health outcomes for the population (4). public health ethics is concerned with the dissemination of health resources in a more equitable, efficient way and protecting the society (5). numerous studies have been carried out on ethics and public health actions and these have led to normative frameworks of public health ethics. hence, one could assume that ethical aspects are considered by researchers and public health professionals to be significant in enabling a functioning plan, execution and development of various public health programs. within the european commission, the 2007 health strategy ‘together for health’ is a better example of a health policy that considers values, as it is based on shared values. moreover, founded on these values, the second php 2008-2013 was implemented (6). it therefore goes without saying that when ethics are considered, public health is safeguarded, particularly when the ethical aspects are predicted or recognized in advance through critical investigations and discussions (7). an example of how ethical values can be considered in different public health disciplines is through gostin’s work. gostin looks at public health ethics from three viewpoints. the first is ethics of public health, by which professionals need to work for the common good with regards to their public duty and trust from the society. the second, ethics in public health, involves examining the position of ethics in public health. it involves communal and individual interests in relation to the allocation of returns and harms in an equitable way, e.g. in decision making and implementation of public health policies. ethics for public health, gostin’s third point, mainly entails a healthy population where the needs of the vulnerable and marginalized populations are considered in a more practical manner (8). as outlined in gostin’s perspectives, the ethical framework applied in this paper acts as an umbrella to ascertain whether the professionals carrying out the projects are working for the good of the otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 4 public, whether the allocation and distribution of resources is fair, and whether the needs of the minorities are taken into consideration to ensure a healthy population. ethical principles and standards are not only important for public health, they are also considered important for other disciplines, institutions and they have been used in recent years to guide professional conduct and behaviour (9). the european union (eu) is an example of such organizations, it does not only fund research through its framework programmes, but also monitors how health research is done or how projects are implemented (european union, n.d). through the health programme funding, the directorate general for health and consumer affairs (dg sante) oversees the health programme which is managed by the consumers, health and food executive agency (chafea) (chafea, n.d). every year, the european commission through chafea sends a call for proposal for operating grants, conferences as well as joint actions and sets the criteria for funding options available (chafea, n.d). the european commission has so far adopted three public health programmes (hereafter referred to as php). in this work, we will focus on the second php 2008-2013 because of its significance in forming part of the commission’s execution of the eu health strategy “together for health” (10). the objectives of php 2008-2013 were directed towards improving the health information and knowledge of eu citizens. this is done so as to increase the competences of how individuals respond to health threats or how they consider various determinants to stimulate better health or obviate disease (chafea, n.d). against this background, the php 2008-2013 was also aligned with the health strategy ‘together for health’. the first principle of shared health values emphasizes overarching values of solidarity, universality, access to good quality care and equity (6). for this paper, it is interesting to see how the funded projects of the php explicitly dealt with these ethical values and whether they used them as a foundation for setting their public health priorities. it is important to note that exploring the scope and the role of values in public health actions and strategies relates to the discipline of ethics. thus, this paper explores whether ethical values, principles and aspects have been explicitly considered in the second php objectives, proposals and its finalized projects. theoretical framework in order to investigate whether ethical aspects or concerns were considered in the php objectives, projects funded by dg sante, a selection and combination of ethical appropriate principles, safeguarding and incorporating relevant values and aspects of human rights retrieved from studies addressing various aspects of public health ethics are proposed. there are five principles for public health ethics which are also known as ethical principles, these are: health maximization, respect for human dignity, social justice, efficiency and proportionality (11), the principle of respect for autonomy (1), and finally equity as a principle proposed by tannahill are also combined (12). to formulate the framework for this study, these ethical principles will be combined with the shared health values of the eu health strategy namely: ‘universality’, ‘solidarity’, ‘accessibility for quality health care’. respect for autonomy is targeted at various aspects, such as the decision-making power of individuals in relation to their health or the general public health. additionally, it focuses on individual autonomy relating to self-domination, privacy, personal choice and free will (1). respect for human dignity compliments respect for autonomy, it guards the various interests of an individual and his or her absolute value so that an individual is referred to with respect otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 5 especially for his or her liberties, such as self-control (11). it further emphasizes that an individual’s liberties should not be defiled unless it harmfully affects others (13). health maximization is applied in practices where the monetary values of various projects are considered so as to give priority to the most cost effective project but also making sure that the public takes full advantage of all health benefits. the principle social justice guards against segregation and marginalization of vulnerable individuals. it ensures that individuals are treated fairly, particularly in matters of equity and maximization of health benefits, so as to minimize and avoid inequalities related to health care services. due to the growing public health needs and the inadequate public health resources, the principle of efficiency is significant in public health ethics. it is viewed as a moral act that ensures benefits are maximized especially in the execution of public health strategies, done by promoting the dissemination of basic necessities in a resourceful way. the proportionality principle advocates for benefits to be considered and assessed alongside the harmful properties, especially when debates on individual liberty versus public good arise (11). equity seeks to ensure that, the less privileged are not secluded in key public health actions that are important to them. in response to this, interventions and strategies that analyze the unfair allocation of services across different populations are implemented to target those at risk in a way to find the influencing factors and decrease inequalities (12). from the health strategy, shared values, universality value ensures that every eu citizen has equal access to use the available healthcare and services and that no one is denied care. the value access to good quality care guarantees that the available health care and services are of high quality and no eu patient is denied any high-quality care. equity as a value ensures that every eu patient is entitled to receive health care and services irrespective of their ethnic, gender or social economic backgrounds and status. solidarity ensures that all the financial arrangements made by the respective member states will promote the accessibility of health care and services to all citizens (6). using this framework, this paper will explore whether ethical principles, values and the 2007 strategy’s shared values were sufficiently addressed in objectives, proposals and finalized projects of the second php. table 1. overview of ethical principles and health strategy values (source: references 11-13) ethical aspect description health maximization complete utilization of health benefits respect for human dignity no violation of individual liberties social justice promotes fairness and guards against discrimination efficiency promotes cost effectiveness, maximizing of benefits and limits wastefulness proportionality considers the benefits alongside harm respect of autonomy promotes individual’s free will and privacy equity supporting the fair access with reference to the need but regardless of origin, sex, age, social or economic rank universality no patient is denied access to health services and care accessibility to quality health care ensure accessibility of high quality health care for all solidarity the financial organization of a member states’ health system so as to ensure health is accessible for all. otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 6 methods a qualitative study design was carried out to gain insights into the ethical concepts and determine whether they have a role in the funding allocation of phps and in the reported project results. the search items used, relate to the seven principles and basic terms of ethics: ‘equity’, ‘autonomy’, ‘health maximization’, ‘respect’, ‘dignity’, ‘social justice’, ‘justice’, ‘efficiency’, ‘proportionality’, ‘ethics’, ‘moral’, ‘value’, ‘ethic’, ‘ethical framework’. including the shared health values ‘universality’, ‘solidarity’, ‘accessibility’ and ‘quality health care’. it is important to note that despite the fact that, a number of projects used ‘equity’ to imply the reduction of inequalities, the term ‘inequalities’ was still excluded used as a keyword. all data was retrieved from the consumers, health and food executive agency (chafea). the proposals were available as summaries which included the following sections: general objectives, strategic relevance and contribution to the public health program, methods, means and expected outcomes (chafea, n.d). the research focused on the summaries of the fifty-five finalized project proposals at the data collection time and excluded projects that were still ongoing as well as projects at the reporting stage. the study included all the projects from all the three strands of the chafea project database: health information, determinants/health promotion, and health threats/health security. for the analysis, the individual project aims, goals and principles were compared against the ethical framework principles and the shared health values so as to show the overlapping concepts and which ethical gaps still need to be addressed. moreover, the identified ethical aspects are further scrutinized to ascertain whether they were only mentioned as keywords or whether they were expected outcomes of the analyzed project. methodological and theoretical limitations including other potential challenges the results from this study will indicate whether ethical concepts and public health ethics are already a constituent part of public health projects particularly with regard to the second eu public health programme. however, since this is a qualitative research, the study may encounter some limitations. to ensure validity as proposed by bowling the researcher intends to organize, clustering the retrieved data into relevant and respective ethical themes (14). this study has looked into the php’s, assessing whether ethical aspects were explicitly considered in its objectives and the summaries of the project proposals. the study recognizes that, by focusing on the only the explicit role of ethics in php through the eyes of only the seven principles and the shared health values, other ethical relations and aspects which are still vital in phps may have been excluded. in addition, not all projects that implicitly discussed aspects related to the principles and shared values were reported due to the act that, out 55 finalized projects, ethical principles and related concepts were identified both explicitly and implicitly in 27 projects. since the researcher used the given description of the principles to decide which ethical aspects and values were related to each other, there may be some form of interpretation bias. however, as discussed in the paper, it is inarguable that there are various definitions of ethics and ethical frameworks depending on different disciplines. this has led different ethical frameworks to be defined and applied to suit certain situations. the seven ethical principles proposed for the framework may therefore be exclusive in terms of excluding other significant values and concepts. additionally, given different definitions, application and otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 7 descriptions of the principles, it is clear that some aspects may refer to various principles such as universality and accessibility to health care. the study recognizes that, by focusing on the explicit role of ethics in the php through the eyes of only the seven principles and the shared health values, other ethical relations and aspects which are still vital in phps may have been excluded. the results focusing on the project proposals show minimal external validity as they only apply to the 55 finalized projects and may perhaps not be adequately generalized to a broader setting. however, regarding the results focusing on the objectives of the php, the representativeness of the findings cannot be questioned since the objectives apply to all the projects funded during the 2008-2013 php. thus, it can be generalized to improve the projects that are yet to be finalized and even aid in the drafting of the objectives of future php’s in the case of learning from best practices. since most of the projects and proposals from the second php 2008-2013 were still in the final phase during the data collection, only the projects that were finalized by june 2014 were included and the projects submitted at any later date were excluded. the full proposals for the projects were also confidential and thus could not be retrieved. therefore, it may be likely that some ethical principles and values might have been considered elsewhere in the full proposals hence resulting in limitations on the findings of this study. however, the project summaries were inarguably sufficient to conduct this study as they included a detailed executive summary of the project objectives in relation to the php objectives. results after examining the summaries of the 55 project proposals and the eu public health programme objectives, the findings were as follows. out of the seven ethical principles from the theoretical framework, only two principles were identified. other terminologies used in the analysis included ‘ethics’ and ‘values’ which were identified in three projects and in one project respectively. since the second php was founded on values prioritized in the eu health strategy: together for health, the keywords ‘universality’, ‘access’, ‘quality health care’ and ‘solidarity’ retrieved from the first principle of the health strategy were identified differently in nine projects. eight projects identified aspects pertaining to accessibility to quality health care and solidarity was only discussed in one project. additionally, out of the four shared health values, only ‘equity’, ‘solidarity’ and ‘access to quality health care’ was identified explicitly in the objectives of the php. the projects were analysed basing on the seven ethical principles, the four shared health values and the ethical concepts ethics, morals and values. the results will be analysed and presented in the following categories. the different research questions will be answered and discussed in their respective sub-sections below. table 2. presentation of the findings categories used in analysis and how results are presented the terminologies used those identified in project proposals and/or in php objectives ethical concepts in php objectives & project proposals morals, values, ethics, ethics, values, otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 8 shared health values identified in php objectives and project proposals equity, accessibility to quality health care, universality and solidarity solidarity, universality and accessibility to quality health care ethical principles identified in php project proposals health maximization, equity, proportionality, respect for human dignity, autonomy, efficiency, social justice. efficiency and equity ethical concepts and shared health values in the php-2008-2013 objectives ethical concepts such as, ‘ethics’, ‘morals’ and ‘values’ were not identified in the php objectives. however, the shared health values equity, solidarity and access to quality health care were explicitly identified in the php objectives. from the general objectives of the php, the common goal evident is improving ways that will ensure and promote the health security of the eu citizens. this goal is in line with the shared health value of ensuring ‘accessibility to quality health care’. even though ‘accessibility’ is not explicitly mentioned in the php objectives, it is one of the main objectives of the php because through the php, the eu commission seeks to improve the member state’s capacities of responding to all kinds of health threats and ensure that the health care services, treatment and medications, for example transplant organs, are of the highest quality. the php 2008-2013 also aims to promote the health of the eu citizens while reducing health inequalities. solidarity ensures that all member states commit to working in unity while supporting each other for the growth and development of the entire eu. moreover, with regards to the solidarity value, the php was envisioned to complement, offer assistance and add value to the member state’s policies by developing, distributing and sharing all information, evidence, best practices and expertise relating to health to all member states. since solidarity ensures that less capable countries are not left out in the development or growth, the php fully supports this value as it aims to see to it that prosperity in the european union is increased, and as a counter effect public health is improved. table 3. shared health values in the php-2008-2013 objectives (source: adapted from reference no. 15) shared health values of the eu health strategy description as given in chapter 4 of this paper how the concept is used in the php objectives equity reduces inequalities among the minorities “promote health and reduce health inequalities” solidarity mutual support and commitment among the ms “it is intended to complement, support and add value to the policies of the member states and contribute to increasing solidarity and prosperity in the european union” “generate and disseminate health information and otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 9 knowledge, exchanging knowledge and best practice on health issues’’ access to quality health care safe and quality health care is made available to everybody “promoting actions related to patient safety through high quality and safe healthcare, scientific advice and risk assessment, safety and quality of organs, substances of human origin and blood” otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 10 ethical principles in the php 2008-2013 project proposals from the 55 projects, only 6 projects explicitly discussed findings that related to equity, while efficiency was only identified in four projects. • equity: the project ‘daysafeimproving patient safety of hospital care through day surgery’, recognized existing challenges health systems face while trying to ensure fair access to high quality and safe health care. the project therefore proposes to offer applicable solutions and as a result increase patient satisfaction, safety, equity and quality of health care. according to the ‘chain of trust’ project, increasing the awareness and understanding of the available recommendations regarding the perceptions, challenges and advantages resulting from the use of tele-health, will equip all the key stakeholders with knowledge and information that will add value and further promote the provision of health care equitable to all patients in the eu. the ‘healthvent’ project discusses equity under the strategic relevance and contribution to the public health programme section of their proposal. it emphasizes that, its objectives will be aligned with those of the php as it aims to tackle environmental health determinants specifically those related to the use of energy in homes, schools and various public buildings so as to prevent chronic diseases and further decrease inequalities in health. ‘crossing bridges’ builds on the execution of article no. 168 of the ec treaty to ensure that the hiap vision is accomplished for equity across the eu. moreover, ‘crossing bridges’ expects that through the project results, the respective stakeholders will be encouraged to implement policies that will result in health equity. by developing a suitable surveillance and information system for health the ‘eumusc.net’ project expects to increase and harmonise the quality of care to allow for equity in care for rheumatic illnesses and musculoskeletal disorders across the member states. through the consideration of structural aspects of gender inequality and gender stereotypes that openly affect men and women’s health, ‘engender’ project aims to ensure equity by creating an online inventory of good practice of policies and programmes that focus on promoting health. • efficiency: ‘daysafe’ expects to improve the technical efficiency of health services by ensuring that the policy-makers are well-informed and recognize the factors limiting the performance of ds, such as operational issues and incompetently designed structures. ‘healthvent’ project: through establishing a health-related ventilation guideline focussing on buildings such as schools, homes, offices and nursery buildings among others, ‘healthvent’ expects that inhabitants will utilize energy in a more reasonable manner so as to have more energy efficient buildings. bordernet project aims to improve the prevention, testing and treatment of hiv/aids/stis by reducing obstacles related to practice, policies and cooperation between border countries and among member states though a more transparent and sustainable network. this will further improve the effectiveness and efficiency capacity of organizations of various sectors responding to aids/stis. ‘engender’ expects that increasing the awareness and creating a platform for all stakeholders to be well informed through the online inventory of best practices, will result in effective, efficient policies and programs that focus on achieving gender equity in health. otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 11 table 4. efficiency aspects identified in project proposals project title aspects of efficiency/ efficient identified in the php project proposals improving patient safety of hospital care through day surgery (daysafe). "the project will enhance ds which represents a crucial strategic approach toward the improvement of health services safety and quality, including patient’s satisfaction, together with technical efficiency and, possibly, equity" health-based ventilation guidelines for europe (healthvent) the (guidelines) "will reconcile health and energy impacts by protecting people staying in these buildings against risk factors, and at the same time taking into account the need for using energy rationally and the need for more energy efficient buildings" highly active prevention: scale up hiv/aids/sti prevention, diagnostic and therapy across sectors and borders in cee and see (bordernetwork) "the improved effectiveness and efficiency on regional and cross-border level in interdisciplinary response to aids/stis and scale up of hiv/stitesting will put forward the practical implementation of hiv combination prevention" inventory of good practices in europe for promoting gender equity in health (engender) "increased awareness and knowledge for all stakeholders including: policy makers, politicians, researchers, ngos and citizens, within and outside the health sector about effective, efficient policies and programmes to achieve gender equity in health" shared values of the 2007 eu health strategy in the php 2008-2013 project proposals? out of the four shared health values, only accessibility to quality health care and equity were addressed in the summaries of the project proposals. basing on the description given for universality, the value was in a way linked to the context used to describe accessibility. from this assessment, more principles are seen to be used in association such as, ‘accessibility and universality’, ‘universality and equity’. • accessibility to quality health care: accessibility was analyzed in the projects in two parts: first, those projects that promote high quality health care services and secondly, those that ensure high quality of health care are accessible to all. ‘coorenor’, ‘daysafe’ and ‘implement’ projects discuss ‘high quality of health care’ by stating that quality assurance models are present in their projects and will ensure safe and high quality of services across the eu. ‘imp.ac. t’ and ‘promovox’ projects promote actions that particularly focus on marginalized groups and migrants. ‘imp.ac. t’ aims to ensure that access to hiv/tb testing for marginalized groups is improved, and ‘promovox’ emphasizes the facilitation of better access of immunizations among the migrant population. ‘care-nmd’ relates accessibility of healthcare to reduced inequalities. the project believes that, by improving the access otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 12 to expert care, there will be a reduction of inequalities among member states and within a member state. otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 13 table 5. accessibility to quality health care as identified in the summaries of the project-proposals project title accessibility to quality health care value as used in the php project proposals coordinating a european initiative among national organizations for organ transplantation (coorenor) "all requirements for ensure recipient safety and high quality of the treatment as well as running models for quality assurance will be considered and transferred to the eu institutions improving patient safety of hospital care through day surgery (daysafe) "the general objective of the project is to improve patient safety & quality of hospital care through the promotion of ds best practice and standards. implementing strategic bundles for infection prevention and management (implement) "aims to improve patient safety through high quality and safe healthcare". highly active prevention: scale up hiv/aids/sti prevention, diagnostic and therapy across sectors and borders in cee and see. (bordernetwork) “bordernetwork' focuses both disease causes and underlying social determinants of health, aiming to improve responses to prevention offers and accessibility of care services”. improving access to hiv/tb testing for marginalized groups (imp.ac.t) a) “improving access to hiv/tb testing for marginalized groups b) “to increase the percentage of idus and migrants having access to hiv and tb testing” promote vaccinations among migrant populations in europe (promovax) “improve migrants understanding & acceptance of immunizations and facilitate their access to immunizations by identifying a network of relevant sites”. dissemination and implementation of the standards of care for duchenne muscular dystrophy in europe (including eastern countries) (care-nmd) "improved access to specialist care for dmd and reduction of inequalities between countries & within countries due to better trained health professionals" otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 14 ethical concepts or aspects in the php 2008-2013 • ethics: under the strategic relevance and contribution to the php section, ‘chain of trust’ acknowledges that the consideration of ethical associated issues while developing recommendations related to the approval of telemedicine by patients and health professionals is important especially during the implementation of telemedicine. ‘apyn’ will assist in realizing the work plan priority 3.3.4 for preventing addiction and further contribute to the alcohol strategy. the project proposes to consider “ethically sound actions” which, according to the priority areas for 2008 as stated in the 2008 work plan, refers to the ethical aspects outlined in the charter of fundamental rights of the european union. “ethical considerations: any proposal, which contravenes fundamental ethical principles particularly those set out in the charter of fundamental rights of the european union may be excluded from the evaluation and selection process” (16). apyn’ and ‘healthy eco life’ will support the work plan actions through the “involvement of new (non-traditional) actors for health in sustained, co-operative and ethically sound actions, both at regional or local level and across participating countries” (chafea, n.d). • values: ‘active’ intends to introduce a new method that will engage children between 5-8 years of age in europe. it is evident from their title that the project aims to teach and inspire the children with values and views concerning healthy eating and physical activity‘animation for children to teach and influence values and views on healthy eating and physical activity (active)’. however, the project only mentions the term ‘values’ in its title. discussion these ethical principles ensure that the individuals or professionals governed by them align their actions and conduct with the principles in order to uphold the society’s trust. most of the ethical principles used in public health actions and research assist in making sure that researchers and public health professionals are held responsible by society. moreover, ethical principles enable researchers to develop trust with the society, which often may cause them to receive funding or financial support for their research from the public because of their reliable and excellent work. furthermore, upholding ethical principles in research will stimulate the consideration of significant moral and social values (9). therefore, it is important for public health professionals and all stakeholders to abide by ethical principles in their duties. additionally, ethical consideration is not limited to public health professionals only at a european level, it is also relevant for public health research and projects of the eu’s public health programmes. with the php 2008-2013 being aligned with the health strategy ‘together for health’, which was explicitly value based in setting priorities, ethics still plays a significant role in the explicit project proposals; yet, this role is not evident in all the phps. however, it is surprising to see that less than half of the projects considered the principle equity which is regarded as a public health and an eu strategy priority. it is clear from the projects, that the mention of equity in their objectives and expected outcomes is not a sufficient indication of ethical consideration, for example, by mentioning that project actions will promote the coordination of abilities from both eastern and western otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 15 europe, coorenor project justifies its role in reducing health inequalities. this is an example to show that the mere mention of ethical principle is not an indication for its consideration in the entire project implementation and therefore the project falls short of explicitly considering equity. in spite of this, various projects still gave relevance to ethical principles and values as they exhaustively discussed in their project summaries matters that related to ethics. ‘daysafe’ recognizes that challenges exist which cause inaccessibility to quality and safe health care, hence they progress to propose methods that will promote equity in health. in discussing ‘efficiency’, the four projects, ‘bordernetwork’, ‘healthvent’, ‘daysafe’ and ‘engender’,only discussed how their activities and methods will result in efficient services and materials. they however fail to show in their methods how this will be attained and only limit it to mention that providing of policy guidelines will promote efficiency. regarding ‘accessibility to quality health care’, the projects questioned the quality and safety of health care services offered in europe and offered to foster a high level of surveillance and monitoring to further ensure that the quality health care is accessible to all patients. they linked quality assurance strategies to high quality services. even though some projects did not explicitly mention ‘accessibility’, their objectives and method description matched the value ‘universality’ while also linking it to reduced inequalities, as they emphasized that no one particularly minorities such as, migrants, hiv/aids and tb patients, should be denied access to health care. most of the projects had implicit discussions of how best practices should be shared across the eu and coordination among all different stakeholders should be supported in order to reduce inequalities in health instead of the explicit mention of solidarity. ex-post evaluation of the health programme the aim of this evaluation was to assess the main results that were reached as well as recognize the key challenges and solutions especially after consideration of recommendations from preceding assessments. the post evaluation study was guided by four key themes that is programme management, dissemination methods, the effect of the health programme collaboration with other programmes and services. according to the assessment, the programme lacked proper management as monitoring data was not used, thus making followup a challenge. in order to increase the number of accepted and executed health programme funded actions, the main results of the health actions have to be made available to the relevant target groups. the 2nd health programme objectives were very broad, covering various significant needs of the member states as well as those of the stakeholders. it was therefore recommended that the health programme ought to introduce more specific progress analysis as they have been defined in the 3rd health programme. with regard to the 2nd health programme’s objectives, the funded actions led to significant advancements such as, promoting cross-border partnerships. it is important to note that, the administrative duties of the programme were increasingly efficient. moreover, the 2nd programme has shown major eu added value in recognizing best practices as well as networking (17). even though, the objectives of the health programme are commendable as they seek good practices and also focus on national priorities while contributing to a healthy status for the european population, they are still very broad and only focus on the relevance of the action. therefore, they may fail to explicitly address most of the ethical principles used in this study. otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 16 since the study has examined only the explicit use of ethical principles and concepts in the project summaries and the php objectives, the ethical framework may therefore exclude implicit discussions of ethical principles and other significant ethical values especially those based on ethical definitions not considered in the descriptions provided for this study. despite the fact that the ethical framework used for this assessment was based on seven principles, the study therefore doesn’t provide a full picture of this ethical role in php but provides a new mentality and platform that will enable the explicit rethinking and reconsidering of ethics and ethical aspects in public health. this new mentality and concern according to callahan and jennings will lead us to considering vital questions such as: “what are the basic ethical issues of public health? what ethical orientations are most helpful in the clarification and resolution of these issues? how are ethical principles and concepts incorporated into decision making in public health agencies and programs? how adequately are ethical dimensions of public health policy identified and debated?” this is because as public health gains more prominence, the ethical aspects regarding health issues increase too (2). conclusions this paper has presented and outlined ethical aspects that were explicitly identified in the 2008-2013 programme objectives and available project reports of the php. the projects were assessed, based on the theoretical framework consisting seven ethical principles. furthermore, the four shared health values of the eu health strategy were considered as they were more general ethical concepts. from the analysis, the principle ‘equity’ was extensively discussed and considered by some of the projects, followed by the ‘efficiency’ principle and then the value ‘accessibility to quality health care’. the study recognizes that by focusing on the role of ethics in php through the eyes of only the seven principles and the shared health values, other ethical relations and aspects which are still vital in phps may have been excluded. most commonly addressed values of the eu health strategy: ‘together for health’ by the projects were, ‘equity’, ‘accessibility’ and ‘universality’ as it seemed expected from them since the php was based on values. it is encouraging to see that most of the shared health values were discussed in most of the projects. even though vital principles such as‘respect for human dignity’, ‘autonomy’, and ‘health maximization’ were not addressed by any of the projects. it is clear from the projects, that the mere mention of a principle briefly such as ‘project will ensure equity’ in the project objectives and expected outcomes is not enough to justify that the principle will be adequately considered or that the project understands or acknowledges the significance of ethics in public health today. the project needs to consistently consider ethical aspects in its entire proposal, in this case a project summary, and not just mention it, since it is required and expected to be included under the ‘strategic relevance and contribution to public health programme’ section. this study has tried to paint a picture of the role of ethics in public health programmes. even with its prominence, ethics in public health programmes and activities still needs to be encouraged. moreover, more awareness in understanding ethics and ethical aspects in public health activities will further steer more ethical considerations not only amongst public health professionals and researchers, but also a more explicit and consistent consideration in phps and public health actions. in addition, basing on gostin’s work, ethical values ought to be otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 17 considered firstly by professionals in order to guide them in working for the common good of the society. secondly, in public health in terms of how decision making influences the balance between individual and communal interests especially in the implementation of public policies. thirdly, ethics for public health where the needs of the population are met in practical ways, such as more emphasis on training and research to improve ethical knowledge, as well as applications. this study has therefore provided a new mentality and platform that will enable the explicit rethinking and reconsidering of ethics and ethical aspects in public health. references 1. beauchamp tl, childress jf. principles of biomedical ethics: oxford university press; 2001. 2. callahan d, jennings b. ethics and public health: forging a strong relationship. am j public health 2002;92:169-76. 3. preston n. understanding ethics. the federation press; 2007. 4. mann jm. medicine and public health, ethics and human rights. hastings center report 1997;27:6-13. 5. kass ne. public health ethics from foundations and frameworks to justice and global public health. j law med ethics 2004;32:232-42. 6. commission e. white paper–together for health: a strategic approach for the eu 2008–2013; 2007. 7. coughlin ss. ethical issues in epidemiologic research and public health practice. emerg themes epidemiol2006;3:16. 8. gostin lo. public health, ethics, and human rights: a tribute to the late jonathan mann. j law med ethics 2001;29:121-30. 9. resnik db. what is ethics in research & why is it important. research triangle park, north carolina: national institute of environmental health sciences/national institute of health; 2010. 10. commission e. together for health: a strategic approach for the eu 2008–2013. white paper, ip/07/1571; 2007;23. 11. schröder-bäck p, brand h, escamilla i, davies jk, hall c, hickey k, et al. ethical evaluation of compulsory measles immunisation as a benchmark for good health management in the european union. centr eur j public health 2009;17:183. 12. tannahill a. beyond evidence—to ethics: a decision-making framework for health promotion, public health and health improvement. health promot int2008;23:380-90. 13. sørensen k, schuh b, stapleton g, schröder-bäck p. exploring the ethical scope of health literacy: a critical literature review. alban med j 2013;2:71-83. 14. bowling a. research methods in health: investigating health and health services: mcgraw-hill international; 2009. 15. council directive. decision 1350/2007ec of the european parliament and of the council of europe; 23 october 2007. 16. commission. e. guide for the evaluation for proposals for action grants and operating grants, joint actions; 2008. 17. directorate-general for health and consumers: the second health programme 20082013. http://ec.europa.eu/health/programme/policy/2008-2013_en. accessed 13 july 2015. otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 18 ___________________________________________________________ © 2017 otenyo; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. introduction in the recent years, there has been an increased focus on implementing policies that promote better health, that are cost effective and use targeted strategies against targeted ill-health worldwide. this interest has sparked an even greater concern fo... theoretical framework methods methodological and theoretical limitations including other potential challenges results ethical concepts and shared health values in the php-2008-2013 objectives ethical principles in the php 2008-2013 project proposals equity: the project ‘daysafeimproving patient safety of hospital care through day surgery’, recognized existing challenges health systems face while trying to ensure fair access to high quality and safe health care. the project therefore proposes to... efficiency: ‘daysafe’ expects to improve the technical efficiency of health services by ensuring that the policy-makers are well-informed and recognize the factors limiting the performance of ds, such as operational issues and incompetently designed s... shared values of the 2007 eu health strategy in the php 2008-2013 project proposals? ethical concepts or aspects in the php 2008-2013 ethics: under the strategic relevance and contribution to the php section, ‘chain of trust’ acknowledges that the consideration of ethical associated issues while developing recommendations related to the approval of telemedicine by patients and healt... ‘apyn’ will assist in realizing the work plan priority 3.3.4 for preventing addiction and further contribute to the alcohol strategy. the project proposes to consider “ethically sound actions” which, according to the priority areas for 2008 as stated ... apyn’ and ‘healthy eco life’ will support the work plan actions through the “involvement of new (non-traditional) actors for health in sustained, co-operative and ethically sound actions, both at regional or local level and across participating countr... values: ‘active’ intends to introduce a new method that will engage children between 5-8 years of age in europe. it is evident from their title that the project aims to teach and inspire the children with values and views concerning healthy eating and... discussion conclusions references dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 1 | 22 review article the impact of covid-19 lockdowns on air quality: a systematic review study butros m. dahu1, ahmad aburayya2 , beenish shameem 2 , fanar shwedeh2 , maryam alawadhi3 , shaima aljasmi 3, said a. salloum4 , hamza aburayya5 , ihssan aburayya6 1 institute of data science and informatics, university of missouri, columbia, usa; 2 assistant professor, business administration college, city university college of ajman, ajman, uae; 3 senior specialist registrar, primary health care sector, dubai health authority, dubai, uae; 4 school of science, engineering, and environment, university of salford, uk; 5faculty of medicine, jordan university of science & technology, irbid, jordan; 6faculty of medicine, university of constantine 3, constantine, algeria; corresponding author: dr. ahmad aburayya. assistant professor, business administration college, city university college of ajman, ajman, uae. address: city university college of ajman, ajman, uae. email: a.aburrayya@cuca.ae mailto:a.aburrayya@cuca.ae dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 2 | 22 abstract background: the purpose of this article was to review the published literature and evaluate the association between air quality/air pollution and the lockdown/stay-at-home orders during covid-19 pandemic. our goal is to identify the various environmental factors, such as urban and rural air quality, which were affected by the lockdown during the coronavirus disease (covid-19) pandemic. methods: we searched pubmed (2000–2021) for eligible articles using the following: (1) aerosol[title/abstract], and (2) air quality[title/abstract] or air pollution[title/abstract] and (3) covid-19[title/abstract]. a total of 39 articles were identified through the search conducted in pubmed. we first screened the title and the abstract of those 39 articles for eligibility. a total of 24 articles did not meet the eligibility criteria and were excluded based on the title and the abstract review. the 15 remaining articles were assessed in full text for eligibility and data extraction. after a full-text review, 3 articles were excluded. finally, a total of 12 selected articles were confirmed for data extraction. results: among the 12 studies, 5 articles focused on the effect of the air pollution, fine particulate matter, and air pollutants of covid-19 pandemic’s lockdown, while 1 article targeted the relationship between the weather/air quality and covid-19 death rate during lockdown. in addition, 5 papers focused on the association between the environmental factors, air pollution and air quality and covid-19 mortality rate. finally, 1 research study paper aimed to study the covid-19 positivity rate and the effect of air quality during the stay-at-home order or the lockdown which was occurred in march 2020. it is important to note that it has been found that an increase in the average pm2.5 concentration was correlated with a relative increase in the covid-19 test positivity rate. this explains the increase in the number of covid cases during the period of the wildfire smoke from august to october 2020 (1). conclusion: the findings indicate that the covid-19 lockdown has significant impact on the air quality across the world. the lockdown significantly reduces the air pollutants such as no2, co, o3 and particulate matter pm2.5 and pm10. this reduction led to a much healthier and safer outdoor air and hence improved the air quality during the lockdown/stay-at-home orders. more research is needed to validate that the air pollutants (no2, co, o3, pm2.5 and pm10) have a significant impact on the covid-19 mortality and fatality rates. keywords: covid-19; lockdowns; air quality; air pollution; environmental factors dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 3 | 22 introduction the coronavirus disease (covid-19) is an infectious disease caused by the sars-cov2 virus. the covid-19 pandemic has infected more than 262 million people and killed more than 5.2 million lives worldwide. the coronavirus pandemic has also caused an enormous economic, public health, and social damages. it is important to note that the risk factors of covid-19 are still under investigations, but some environmental factors, such as urban and rural air pollution and air quality play a vital role in increasing the population sensitivity to covid-19 pathogenesis (2). the united states national oceanic and atmospheric administration stated almost 30% decrease in nitrogen oxides (no2) emissions in the urban northeast during april 2020. in addition, there was a huge reduction in the volatile organic compound concentrations (3). research studies have proven that exposure to the fine particulate matter pm2.5 may cause a major harmful health effect. those effects include cardiovascular, respiratory, diabetes, kidney disease mortality and morbidity (4). additionally, ecological studies indicate that living in areas with higher levels of ambient fine particulate matter air pollution (pm2.5) increase the chance of having a higher risk of adverse covid-19 outcomes (5). the covid-19 restrictions have reduced the emission of the primary air pollutants worldwide in general and in the united states particularly due to the decrease in industrial activities and transportation (6). the coronavirus disease (covid-19) pandemic has created so many challenges to the united states government to balance economy and public safety. president donald trump declared a national emergency on march 13, 2020, where all municipalities and states issued different degrees of stay-athome and/or lockdowns policies matching the local specific conditions.(7). these local policies have impacted the air quality through decreasing the non-necessary energy consumption and transportation. according to the u.s. environmental protection agency (epa), the air pollutants and the national emissions contains 59% of carbon monoxide (co), and 74% of nitrogen oxides (nox, sum of nitrogen dioxide [no2] and nitric oxide [no]) as well as emissions from electric generation and the on-and-off road traffic (7). in addition, the ambient levels of the two pollutants pm2.5 and pm10 (particulate matter with aerodynamic diameters below 2.5 and 10 μm, respectively) might be the most affected by the lockdown (l. w. a. chen et al., 2020). it is important to mention that the ozone (o3) is developed in the atmosphere through the photochemical reaction of the volatile organic compounds (vocs) and nox. also, reducing the vocs and nox emissions could either lower or lift the ozone (o3) concentrations depending on the local photochemical regime (7). our aim is to estimate the association between air quality/air pollution and the lockdown/ stay-at-home orders during covid-19 pandemic. we sought to identify changes that were made to the air gases, air pollutants and particular matters during the covid-19 pandemic lockdown. in addition, our goal is to identify the various environmental factors, such as urban and rural air quality, which were affected by the lockdown during the coronavirus disease (covid-19) pandemic. finally, we will evaluate whether there was a uniform improvement in air quality during the covid-19 lockdown. we will also estimate the association between the covid-19 fatality rate and air quality by dragging our dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 4 | 22 attention on the direct relationship between the air quality and the covid-19 mortality across the world. furthermore, the changes in mobility were correlated with the relevant air quality parameters, such as no2, which in turn was highly correlated to o3. the study provides data and analysis to support future planning and response efforts in sharjah (united arab emirates) (8,9). also, previous studies show the large impact of human activities on the quality of air and present an opportunity for policymakers and decision-makers to design stimulus packages to overcome the economic slow-down, with strategies to accelerate the transition to resilient, low-emission economies and societies more connected to the nature that protect human health and the environment (9,10). methods data sources we searched pubmed (2000–2021) for eligible articles using combinations of the following search terms: (1) (aerosol[title/abstract])), (2) and (air quality[title/abstract])) or (3) (air pollution[title/abstract])) and (4) (covid19[title/abstract])). we also systematically searched the reference lists of the included studies and relevant reviews. we found 39 eligible articles on pubmed. inclusion and exclusion criteria the researchers reviewed the titles and abstracts of the identified citations and identified eligible articles based on the following criteria. the inclusion criteria included any randomized controlled trial, quasi-experimental study, or pre–post study evaluating the effect of the lockdown on the air quality. the included studies measured health outcomes, processes of care and the effect of the lockdown on the pollution rates in the united states major cities. in addition, we excluded studies published in a language other than english was excluded. furthermore, data that is not related to covid-19 were excluded (no other disease). study selection and data extraction the process of selection was performed in two steps. in the first step, we read the titles and abstracts of the citations by the search query to screen the articles based on the inclusion/exclusion criteria mentioned above. in the second step, we read the full text of the citations selected by the first step and based on that we decide if the paper is eligible for inclusion. the search criteria did not limit by publication date; due to recency of the field, the earliest eligible article was published in 2020. in addition, the researchers collected the following information from each article that was eligible: author and year, study objective, methods/tools, geographic location, particulate, and gases measured, source of data, samples collected for analysis and major findings and results. figure 1. shows, a total of 39 articles were identified through the search conducted in pubmed. we first screened the title and the abstract of those 39 articles for eligibility. a total of 24 articles did not meet the eligibility criteria and were excluded based on the title and the abstract review. the 15 remaining articles were assessed in full text for eligibility and data extraction. after a fulltext review, 3 articles were excluded. finally, a total of 12 selected articles were confirmed for data extraction. dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 5 | 22 figure 1. prisma flow diagram we summarize the basic information of the selected papers. for each paper, we evaluated the main aspects which include but are not limited to the following: 1) descriptions of the study design, 2) sample size, 3) air particles, 4) duration of study, 5) covid-19 mortality rate, 6) control groups, 7) process and outcome measures, 8) statistical significance, 9) effect of the ambient ozone, 10) ambient air pollutants, 11) urban air pollution, 12) ambient pm2.5 and pm10, 13) disparities in nitrogen dioxide pollution and 14) covid-19 fatality rate. results among the 12 studies, 5 articles focused on the effect of the air pollution, fine particulate matter, and air pollutants on covid-19 pandemic’s lockdown, while 1 article targeted the relationship between the weather/air quality and covid-19 death rate during lockdown. in addition, 5 papers focused on the association between the environmental factors, air pollution and air quality and covid-19 mortality rate. finally, 1 research study paper aimed to study the covid-19 positivity rate and the dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 6 | 22 effect of air quality during the stay-at-home order or the lockdown which was occurred in march 2020. one of the study results shows that the covid-19 lockdown reduced the disparity in air quality between the census tracts with low and high segments of nonwhite population in some of the rural areas of the united states (for example new york city). on the other hand, the racial gap in air quality remained the same with no notable change in urban areas (3). additionally, some research findings which have massive environmental policy relevance, indicating that mobility reductions by itself may be insufficient to reduce and decrease the particulate matter pm2.5 uniformly and substantially (4). it is important to note that it has been found that an increase in the average pm2.5 concentration was correlated with a relative increase in the covid-19 test positivity rate. this explains the increase in the number of covid cases during the period of the wildfire smoke from august to october 2020 (1). our results show that counties with higher air pollutants (no2, o3, co, pm2.5 and pm10) rates were found to be significantly associated with higher rates of covid-19 mortality rates. additionally, counties with higher average daily particulate matter (pm2.5) tend to have a significantly higher covid-19 mortality rate (11). on the other hand, counties with higher average temperatures are significantly associated with much lower mortality rates for covid19 (12). during the covid-19 lockdown the ozone (o3) concentration decreases which caused a decrease in the air pollution and improve the air quality. this makes the outdoor air much healthier and safer for the human lungs. it has been noticed that the ozone levels are negatively correlated with the covid-19 death rates (13). the lockdown reduced the concentration of the particulate matter pm2.5 which improves the air quality. our findings showed that an increase in pm2.5 would cause an increase in the risk of hospitalization caused by covid19 (12). it is important to mention that the association of pm2.5 and risk of hospitalization among covid-19 patients was present in each wave of the pandemic. also, our study analysis suggested that there was higher risk of hospitalization associated with pm2.5 in black people compared to white people and in those who living in socioeconomically disadvantaged neighborhoods (5). the covid-19 lockdown reduced the two air toxicants (i.e., nitrogen dioxide or no2, and benzidine), which caused an improvement in the air quality. our results proved that there is a relationship between the covid-19 lockdown and the air quality. it also confirmed the previously reported environmental factors associated with covid-19 mortality rate (14). our systematic review results show that the no2 (one of the air pollutants) concentrations were positively associated with covid-19 mortality and fatality rates (15). additionally, after adjusting for co-pollutants, per interquartile-range (iqr) increase in no2, the covid-19 case mortality rate and fatality rate were associated with an increase as well. we should note that we did not notice or observe any significant association between the long term exposure to o3 or pm2.5 and covid-19 mortality and fatality rates per iqr increase (2,11,16). the reductions of co and no2 are statistically significant with the covid-19 pandemic lockdown. it is also significant at two thirds of the sites and tend to increase with local population density. additionally, the lockdown has a significant reduction on particulate matter (pm2.5 and pm10), which also has a significant impact on the air quality (l. w. a. chen et al., 2020). the air pollution levels did not significantly change, compared with historical trends (5). in summary, our dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 7 | 22 results showed that the covid-19 locked down which occurred in march 2020 has affective the air quality positively. it has improved the air quality by decreasing the pollution rate. it also helps in decreasing the polluted gases such as no2, co, o3, pm2.5 and pm10. additionally, the air quality affected the covid-19 testing and positivity rates. this systematic review study has shown that the covid-19 testing, and positivity rates are higher in the areas with high pollution rates. the lockdown has improved the air quality, decreased the pollution rates, and decreased the covid-19 mortality and fatality rates. table 1. summary of the results analysis study objective methods/tools geographic location particulate & gases measured samples collected for analysis air pollution and the risk of hospitalization adjusted poisson regression united states pm2.5 with risk of hospitalization national cohort of 169,102 covid19 to evaluate the air quality to estimate the confidence interval & bootstrapping northeast and california/nevada metropolises, united states (no2), (co), (o3) & (pm2.5, pm10) six weeks or 42 days between march 15 and april 25, 2020 impacts of covid-19 lockdowns on pm2.5 regression model & synthetic control method” (scm) 455 pm2.5 monitoring sites across the united states the level of pm2.5 in air 455 monitors association of covid19 mortality multivariable regression model county-level united states no2 and benzidine 337 variables to estimate the association between weather and covid19 fatality rates models included state-level social distancing measures county-level longitudinal design across the united states min & max daily temperature, precipitation, o3, pm2.5 concentrations & u.v. light index time-constant factors at the county level, and linear and nonlinear timevarying factors examine whether wildfire smoke associated with an increased rate of covid time-series analysis western united states, in reno, nevada ambient pm2.5 hourly beta attenuation monitors with a very sharp cut cyclone estimate the association between no2, pm2.5 and o3 & covid-19 mortality conducted a cross-sectional nationwide study county level – united states no2, pm2.5 and o3 3141 us counties estimate the association between no2, pm2.5, and o3 and county-level covid-19 casefatality and mortality rates a cross-sectional nationwide study united states counties average no2 concentrations, and long-term exposure to pm2.5 or o3 monitors were hourly beta attenuation monitors with a very sharp cut cyclone (vscc) and temperature and humidity data. evaluate the association between opioid-related mortality & covid-19 mortality a multivariable negative-binomial regression model counties across the u.s. pm exposure estimate within each county data from 3142 counties across the u.s. identify changes in pediatric asthmarelated health care utilization viral transmissions were enacted in philadelphia philadelphia, united states pollution data for 4 criteria air pollutants changes in encounter characteristics, viral testing patterns, and air pollution before and after mar 17, 2020 investigated whether long-term average exposure to (pm 2.5) is associated with an increased risk of covid-19 death in the united states included a random intercept by state to account for potential correlation 3,000 counties in the united states particulate matter pm 2.5 negative binomial mixed models using county-level covid-19 deaths to investigate causality between the economic lockdown and changes in air quality triple difference-indifferences model high and low shares of non-white population in rural new york the change in pm2.5 pollution three samples: aod, pm2.5-atmonitor, and aod-at-monitor dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 8 | 22 discussion our findings suggested that the urban combustion sources such as traffic, may increase susceptibility to severe covid-19 outcomes due to the long-term exposure to no2. this is independent from the long term exposure of o3 and pm2.5. our results also support directed public health actions to protect the highly polluted regions with prominent levels of no2. the lockdown lowers the traffic emissions and ambient air pollution which will improve the air quality and reduce the risk of covid-19 case mortality and fatality (11). it is worth noting that exposure to higher levels of the particulate matter pm2.5 plays a very vital and direct role in increasing the risk of hospitalization among covid-19 infected patients. our results show that black race and people who are living in disadvantaged neighborhoods have a higher risk of hospitalization in the setting of covid-19 due to the untoward effect of pm2.5 (11). we have also found that wildfires cause an increase in air pollution due to the elevated pm2.5 (13). this will increase the covid19 test positivity rate. our research findings have indicated that pm2.5 from other sources, such as industry and vehicle traffic increase the susceptibility of covid-19 (1). lockdown reduces the emissions of pm2.5 coming from industries and vehicle traffic and hence reduce the air pollution and improve the air quality (1). there is also a direct relationship between weather changes and the us covid-19 fatality rates. it only appeared with the ozone levels and the minimum temperature. our study analysis showed an increase in the minimum daily temperature during the lockdown period which also associated with higher covid-19 fatality rates. in addition, fewer covid-19 deaths were associated with higher ozone levels (13). the methodology used in previous studies can be applied to evaluate the impacts of covid-19 or similar events on people’s mobility, air quality and utility consumption at other geographical locations (17)(10). particulate matter concentrations show a quite different pattern from the rest of pollutants examined and with substantial week-to-week variations (10)(17)(8). the current study concludes that due to declining automobile and industrial emissions in the northern emirates of the united arab emirates (neuae), the lockdown initiatives lowered no2, aod, and surface urban heat island intensity (suhii). in addition, the aerosols did not alter significantly since they are often linked to the natural occurrence of dust (10). our study has various limitations that are worth noting. in some of the eligible articles used in this literature review, the health care, demographic, utilization, and viral testing data were taken from a single institution and collected as part of routine care (18-25). additionally, the electronic health record (ehr) data is subject to bias and error. these errors are hard to be controlled and do not allow us to observe significant changes. lastly, future studies are necessary to refine our findings and improve our understanding of the effects of the covid-19 pandemic lockdown on the air quality (6). conclusion the findings indicate that the covid-19 lockdown has significant impact on the air quality across the world. the lockdown significantly reduces the air pollutants such as no2, co, o3, and particulate matter pm2.5 and pm10. this reduction led to a much healthier and safer outdoor air and dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 9 | 22 hence improved the air quality during the lockdown/stay-at-home orders. more research is needed to validate that the air pollutants (no2, co, o3, pm2.5 and pm10) have a significant impact on the covid-19 mortality and fatality rates. the lockdown during the covid-19 pandemic improved the air quality as well as decreasing the exposure and the emissions of the particulate matter pm2.5. this will help decrease the risk of hospitalization among covid-19 infected individuals. lastly, this study indicates the need for public health efforts during the hard hit of covid-19. it also improves the advantage of the lockdown on the air pollution and air quality. references 1. kiser d, elhanan g, 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pandemic on https://www.google.com/covid19/mobility/ https://www.google.com/covid19/mobility/ dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 11 | 22 © 2022 aburayya et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. the mental health status of healthcare providers in the primary health care sector in dubai. linguist antverp 2021; 21:29953015 19. almarzouqi a, aburayya a, salloum sa. prediction of user’s intention to use metaverse system in medical education: a hybrid semml learning approach. ieee access [internet]. 2022; 10:43421– 34 20. alaali n, al marzouqi a, albaqaeen a, dahabreh f, alshurideh m, mouzaek e, et al. the impact of adopting corporate governance strategic performance in the tourism sector: a case study in the kingdom of bahrain. j leg ethical regul issues. 2021;24(1):1– 18 21. al-maroof r, akour i, aljanada r, alfaisal a, alfaisal r, aburayya a, et al. acceptance determinants of 5g services. international journal of data and network science. 2021;5:613–628 22. hamadneh s, hassan j, alshurideh m, al kurdi b, aburayya a. the effect of brand personality on consumer self-identity: the moderation effect of cultural orientations among british and chinese consumers. journal of legal, ethical and regulatory issues. 2021;24:1-14 23. mouzaek e, al marzouqi a, alaali n, salloum s, aburayya a, suson, r. an empirical investigation of the impact of service quality dimensions on guests satisfaction: a case study of dubai hotels. journal of contemporary issues in business and government. 2021;27(3): 1186-1199 24. taryam m, alawadhi d, aburayya a, albaqa'een a, alfarsi a, makki i, et al. effectiveness of not quarantining passengers after having a negative covid-19 pcr test at arrival to dubai airports. systematic reviews in pharm acy. 2020; 11(11): 1384-1395 25. alsuwaidi sr, alshurideh m, al kurdi b, aburayya a. the main catalysts for collaborative r&d projects in dubai industrial sector. in: proceedings of the international conference on artificial intelligence and computer vision (aicv2021). cham: springer international publishing; 2021: 795–806. _________________________________________________________________________________ dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 12 | 22 appendix 1 table 2. data analysis of the impact of the covid-19 lockdown on air quality author & year study objective methods/ tools geographic location particulate & gases measured source of data samples collected for analysis major findings & results bowe et al., 2021 air pollution and the risk of hospitaliz ation among covid-19 positive individual s adjusted poisson regression united states pm2.5 with risk of hospitalizati on the us department of veterans affairs national healthcare databases and va corporate data warehouse (cdw) outpatient and inpatient encounters national cohort of 169,102 covid-19 positive united states veterans there were 25,422 (15.0%) hospitalizatio ns; 5,448 (11.9%), 5,056 (13.0%), 7,159 (16.1%), and 7,759 (19.4%) were in the lowest to highest pm2.5 quartile, respectively. in models adjusted for state, demographic and behavioral factors, contextual characteristic s, and characteristic s of the pandemic a one interquartile range increase in pm2.5 (1.9 µg/m3) was associated with a 10% (95% ci: 8%12%) increase in risk of hospitalizatio n. the association of pm2.5 and dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 13 | 22 risk of hospitalizatio n among covid-19 individuals was present in each wave of the pandemic. models of non-linear exposureresponse suggested increased risk at pm2.5 concentratio ns below the national standard 12 µg/m3. formal effect modification analyses suggested higher risk of hospitalizatio n associated with pm2.5 in black people compared to white people (p = 0.045), and in those living in socioeconom ically disadvantage d neighborhoo ds (p < 0.001). chen et al., 2020 to evaluate the air quality response to reduced economic activities. to estimate the confidence interval of δi%, a bootstrappi ng procedure northeast and california/ne vada metropolises , united states nitrogen dioxide (no2) and carbon monoxide (co), ozone (o3), particulate matter (pm2.5 and pm10) epa national core (ncore) network, and airnowtech & epa airdata website six weeks or 42 days between march 15 and april 25, 2020, was designated as the firstphase lockdown period (p1). a reference period deemed business as the reductions, up to 49% for no2 and 37% for co, are statistically significant at two thirds of the sites and tend to increase with local population density. significant dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 14 | 22 usual between january 25 and march 7, 2020 (p0) was selected reductions of particulate matter (pm2.5 and pm10) only occurred in the northeast and california/ne vada metropolises where no2 declined the most, while the changes in ozone (o3) were mixed and minor. chen et al., 2021 impacts of covid-19 lockdown s on pm2.5 regression model & synthetic control method” (scm) 455 pm2.5 monitoring sites across the united states the level of pm2.5 in air epa air quality system (aqs), epa air now system, & google earth engine 455 monitors remain to be used in our analyses the findings have immense environment al policy relevance, suggesting that mobility reductions alone may be insufficient to reduce pm2.5 substantially and uniformly. hu et al., 2021 associatio n of covid-19 mortality multivariab le regression model county-level united states nitrogen dioxide or no2, and benzidine nationwide county-level covid-19 mortality data in the contiguous us 337 variables characterizi ng the external exposome from 8 data sources were integrated, harmonized , and spatiotemp orally linked to each county all the 4 variables that were significant in both sets in phase 1 remained statistically significant in phase 2, including two air toxicants (i.e., nitrogen dioxide or no2, and benzidine), one vacant land measure, and one food environment dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 15 | 22 measure. this is the first external exposome study of covid-19 mortality. it confirmed some of the previously reported environment al factors associated with covid19 mortality, but also generated unexpected predictors that may warrant more focused evaluation. karimi et al., 2021 to estimate the associatio n between weather and covid-19 fatality rates models included state-level social distancing measures county-level longitudinal design across the united states primary measures included minimum and maximum daily temperature , precipitation , ozone concentratio n, pm2.5 concentratio ns, and u.v. light index. analyzed covid-19 deaths from public health departments’ daily reports models included state-level social distancing measures, census bureau demographic s, daily weather information, and daily air pollution. timeconstant factors using fixed effects at the county level, and linear and nonlinear timevarying factors, and serial correlation, social distancing measures 3141 us counties a 1 °f increase in the minimum temperature was associated with 1.9% (95% ci, 0.2% to 3.6%) increase in deaths 20 days later. an ozone concentratio n increases of 1 ppb (part per billion) decreased daily deaths by 2.0% (95% ci, 0.1% to 3.6%); ozone levels below 38 ppb negatively correlated with deaths. kiser et al., 2021 examine whether wildfire smoke from the time-series analysis using generalize western united states, in ambient pm2.5 environment al protection agency’s (epa’s) internet monitors were hourly beta attenuation monitors they found that a 10 µg/m3 increase in the 7-day dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 16 | 22 2020 wildfires associate d with an increased rate of sarscov-2 infections d additive models reno, nevada database, from four air quality monitors located in reno and sparks. temperature and humidity data were obtained from the krno weather station (via mesowest.ut ah.edu) (met one bam 1020s) with a very sharp cut cyclone (vscc) and temperatur e and humidity data. average pm2.5 concentratio n was associated with a 6.3% relative increase in the sarscov-2 test positivity rate, with a 95% confidence interval (ci) of 2.5 to 10.3%. this corresponde d to an estimated 17.7% (ci: 14.4-20.1%) increase in the number of cases during the period most affected by wildfire smoke, from 16 aug to 10 oct. dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 17 | 22 liang et al., 20 to estimate the associatio n between long-term (20102016) countylevel exposures to no2, pm2.5 and o3 and countylevel covid-19 casefatality and mortality rates in the us conducted a crosssectional nationwide study using zeroinflated negative binomial models county level – united states no2, pm2.5 and o3 from three databases: the new york times, usafacts, and 1point3acres .com between long-term (20102016) county-level exposures to no2, pm2.5 and o3 and county-level covid-19 case-fatality and mortality rates 1,027,799 covid cases and 58,489 deaths were reported in 3,122 us counties from january 22, 2020, to april 29, 2020, with an overall observed case-fatality rate of 5.8%. spatial variations were observed for both covid death outcomes and longterm ambient air pollutant levels. county-level average no2 concentratio ns were positively associated with both covid-19 case-fatality rate and mortality rate in single-, bi & tri-pollutant models (pvalues<0.05) . per interquartile range (iqr) increase in no2 (4.6 ppb), covid-19 case fatality rate and mortality rate were associated with an increase of 7.1% (95% ci 1.2% to 13.4%) and dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 18 | 22 11.2% (95% ci 3.4% to 19.5%), respectively. no observe significant associations between long-term exposures to pm2.5 or o3 and covid19 death outcomes (pvalues>0.05) , although per iqr inc in pm2.5 (3.4 ug/m3) was marginally associated with 10.8% (95% ci: 1.1% to 24.1%) increase in covid-19 mortality rate liang et al., 2020 to estimate the associatio n between long-term (20102016) countylevel exposures to no2, pm2.5, and o3 and countylevel covid-19 casefatality and mortality rates in a crosssectional nationwide study using zeroinflated negative binomial models used both singleand multipollutant models and controlled for spatial trends and a comprehe nsive set of potential united states counties average no2 concentratio ns, and long-term exposure to pm2.5 or o3 obtained the number of daily countylevel covid19 confirmed cases and deaths that occurred from january 22, 2020, the day of the first confirmed case in the united states, through july 17, 2020, in the united states from three databases: the new york times,2 usafacts,3 3,076 us counties from january 22, 2020, to july 17, 2020, 3,659,828 covid-19 cases and 138,552 deaths were reported in 3,076 us counties, with an overall observed case-fatality rate of 3.8%. county-level average no2 concentratio ns were positively associated with both covid-19 dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 19 | 22 the united states confounde rs and 1point3acres .com case-fatality rate and mortality rate in single-, bi-, and tripollutant models. when adjusted for co-pollutants, per interquartilerange (iqr) increase in no2 (4.6 ppb), covid-19 case-fatality rate and mortality rate were associated with an increase of 11.3% (95% ci 4.9%18.2%) and 16.2% (95% ci 8.7%24.0%), respectively. we did not observe significant associations between covid-19 case-fatality rate and long-term exposure to pm2.5 or o3, although per iqr increase in pm2.5 (2.6 μg/m3) was marginally associated, with a 14.9% (95% ci 0.0%-31.9%) increase in covid-19 mortality rate when adjusted for co-pollutants. dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 20 | 22 qeada n et al., 2021 to evaluate the associatio n between opioidrelated mortality and covid-19 mortality a multivariab le negativebinomial regression model counties across the u.s. pm exposure estimate within each county johns hopkins university center for systems science and engineering coronavirus site cdc wonder data from 3142 counties across the u.s. were used after controlling for covariates, counties with higher rates of opioidrelated mortality per 100,000 persons were found to be significantly associated with higher rates of covid-19 mortality (amrr: 1.0134; 95% ci [1.0054, 1.0214]; p = 0.001). counties with higher average daily particulate matter (pm2.5) exposure also saw significantly higher rates of covid-19 mortality. analyses revealed rural counties, counties with higher percentages of nonhispanic whites, and counties with increased average maximum temperatures are significantly associated with lower mortality rates from covid-19. dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 21 | 22 taquec hel et al., 2020 sought to identify changes in pediatric asthmarelated health care utilization, respirator y viral testing, and air pollution during the covid-19 pandemic viral transmissi ons were enacted in philadelphi a, were assessed, and compared with data from 2015 to 2019 as a historical reference philadelphia, united states pollution data for 4 criteria air pollutants data were extracted from children's hospital of philadelphia electronic health records, and pollution data for 4 criteria air pollutants were extracted from airnow changes in encounter characterist ics, viral testing patterns, and air pollution before and after mar 17, 2020 after march 17, 2020, inperson asthma encounters decreased by 87% (outpatient) and 84% (emergency + inpatient). video telemedicine, which was not previously available, became the most universally used asthma encounter modality (61% of all visits), and telephone encounters increased by 19%. concurrently, asthmarelated systemic steroid prescriptions and frequency of rhinovirus test positivity decreased, although air pollution levels did not change, compared with historical trends. wu et al., 2020 investigat ed whether long-term average exposure to fine particulate matter (pm 2.5) is included a random intercept by state to account for potential correlation in counties within the same state & 3,000 counties in the united states particulate matter pm 2.5 collected for more than 3,000 counties in the united states (representing 98% of the population) up to april 22, 2020, it negative binomial mixed models using county-level covid-19 deaths as the outcome and countythey found that an increase of only 1 μg/m 3 in pm 2.5 is associated with an 8% increase in the covid19 death rate (95% dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 22 | 22 associate d with an increased risk of covid-19 death in the united states conducted more than 68 additional sensitivity analyses from johns hopkins university level longterm average of pm 2.5 as the exposure confidence interval [ci]: 2%, 15%). the results were statistically significant and robust to secondary and sensitivity analyses. zhang et al, 2021 to investigat e causality between the economic lockdown and changes in air quality triple differenceindifferences model high and low shares of non-white population in rural new york the change in pm2.5 pollution nasa’s satellite imagery data, aerosol optical depth (aod), environment al protection agency’s (epa) & moderate resolution imaging spectroradio meter three samples: aod, pm2.5-atmonitor, and aodat-monitor the lockdown narrowed the disparity in air quality between census tracts with high and low shares of non-white population in rural new york, whereas the racial gap in air quality remained unchanged in urban new york. roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 1 | 13 review article pharmaceutical policies in post-communist albania: progress and challenges toward european union membership dajana roshi1,2*, eni tresa1,3*, alessandra lafranconi1, genc burazeri1,3, katarzyna czabanowska1,4, helmut brand1 1 department of international health, school caphri (care and public health research institute), maastricht university, maastricht, the netherlands; 2 national agency for drugs and medical devices, tirana, albania; 3 department of public health, faculty of medicine, university of medicine, tirana, albania; 4 institute of public health, faculty of health sciences, jagiellonian university, krakow, poland. * these authors contributed equally. corresponding author: dajana roshi, msc; address: national agency for drugs and medical devices, dibra street no. 359/1, tirana, albania; telephone: 0035569565614; e-mail: dajana.roshi@maastrichtuniversity.nl roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 2 | 13 abstract aim: shifting from a communist regime to a democratic system has affected health system fundamentally in most of the western balkan countries including albania. albania became a european union (eu) candidate country in 2014. since then, one of the main concerns has been to approximate the legislation with the eu framework. the aim of this paper is to review the evolvement of pharmaceutical legislation in albania and challenges toward achieving full approximation to the eu’s respective legislation. methods: we used qualitative techniques, especially means of conventional content analysis and two sources to collection data. first, we consulted the albania’s national publications office webpage and analysed all available legislation regarding “pharmacy”, “medicine” and “pharmaceutical products” from 1994 to 2021. then, we analysed the national integration plans that have been published by the government of albania from 2014 to 2021. results: the decrease of the price margin system goes in parallel with the increase of the pharmaceutical expenditure, including out-of-pocket expenditure on medicines and lack of adequate and sensitive reimbursement policies. the main pillars of the pharmaceutical sector in albania are well-covered legally but not fully in concordance with the eu framework. conclusion: there is a need to foster laws implementation that regulate the opening of pharmacies; a detailed regulation on pharmacovigilance; and a regulation on medicinal products for paediatric use. also, the existing legal framework should be aligned with the european one. medicine pricing methods should go in the same line with the decrease of out-of-pocket expenditure. keywords: albania, european union membership, legislation, pharmaceutical policies. roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 3 | 13 introduction the western balkan countries (wb) – albania, bosnia and herzegovina, republic of north macedonia, kosovo, montenegro and serbia – are facing a formidable array of challenges such as demographic, socio-economic and legislative (1). beside the complex past, wb aspirate to join the european union (eu) (2). albania is a eu candidate country since june 2014 and, from march 2020, the eu opened the accession negotiations with albania (3). the process of european integration is followed by “construction, diffusion and implementation of formal and informal rules, procedures, policy paradigms, styles, ’ways of doing things,’ and shared beliefs and norms which are first defined and consolidated in the eu policy process and then incorporated in the logic of domestic discourse, identities, political structures and public policy”, known as europeanization process (4). the albanian health system is mainly public, and the state provides the majority of services regarding promotion, prevention, diagnosis, and treatment of diseases (1). the private sector covers mostly the pharmaceutical and dental services, and some specialized diagnostic services (5). never the less, the europeanization process in expected to influence health sector and contribute to protection of health, safety and economic interests of consumers (6). in this regard, the government has started to align the pharmaceutical legislation and practices with the eu respective directives including measures to simplify the medicine registration, licensing of professionals and pharmacies, price controls and reimbursement of drugs and implication of ethical standards (7). the process of europeanization of medicines regulations “involves harmonization and mutual recognition of regulatory decision making as well as the transfer of some authority from member states to supranational eu regulatory agencies” (8). however, there are differences in the way the countries approach new pharmaceutical legislation including how various stakeholders are involved in policy making and how easy it is for the country to implement the new legislative changes (9). the national european integration plans (nip) have been regularly published and updated since 2014 aiming at description of achievements and setting new objectives (10). in this regard, the pharmaceutical policies have been changing, as it is shown in the nip and the official publications centre (from 1994 to 2014) (10,11). these changes are reflected in the law on medicines and pharmaceutical services, clinical trials, medicine pricing, reimbursement policies, the list of over the counter medicines/ medicines given without prescription (otc), and the pharmaceutical education, laws that regulate the most important parts of the pharmaceutical field in albania (11). in the same time, the number of the pharmacies in albania has been increasing from year 1993 to year 2014 (from 1,097 pharmacies in 1994 to 1,600 pharmacies in 2014) (7,12). however, there is not a clear picture of the pharmaceutical legislative development in albania fostered by the europeanization process. the aim of this review is to explore how the pharmaceutical legislation of albania has evolved from 1994 to 2021 and where does it stand toward achieving the full approximation to the eu respective legislation. methods this study is based on qualitative research techniques, especially means of content analysis. we used two sources to collect data. first, we consulted the albania’s national publications office webpage and analysed all roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 4 | 13 available legislation regarding “pharmacy”, “medicine” and “pharmaceutical products” from 1994 to 2021 (11). the second source of data were national integration plans (nip) that have been published by the government of albania from 2014 to 2021 (10). in both cases we included in the analysis the laws and chapters that contained the words “pharmacy”, “pharmaceuticals”, “price”, “medicine”, “out of pocket”. all consulted documents are available at appendix 1. then, we used conventional content analysis to group the data and identify the “coding categories directly from the text data” (13). each nip has 33 chapters that cover different areas. the chapter which covers pharmaceutical issues and medicines is chapter 28 on “consumer and health protection”. all data are presented in the results section based on four categories we identified through content analysis: sale at distance and pharmaceutical indicators; pricing policy and pharmaceutical expenditure; clinical trials; marketing authorization, distribution and storage practices. results and discussion the law on medicines and pharmaceutical service has changed many times from 1994 to 2014. the latest published version (the 2014 one) is the most compatible to the respective eu directive (directive 2001/83) (8,9). however, when comparing the eu pharmaceutical legal framework to the albanian one, it results that the albanian legal framework lacks many regulations such as the one on pharmacovigilance and the regulation on medicinal products for paediatric use. sale at distance and pharmaceutical indicators after the fall of the communist regime (in 1991), various reforms took place in albania such as the permission of private service providers to operate, decentralization of primary care management, the privatization of the pharmaceutical and dentistry sectors, and the founding of the health insurance institute (16). data shows that the number of pharmacies has been increasing from 1994 to 2014 (table 1) (7,12). this might be related to the opening of pharmaceutical private universities since 2003 which resulted to a higher number of pharmacists graduated annually in albania (17–19). even though, the government started to apply the professional state exam (to control the number and professional quality of pharmacist who graduated), the number pharmacists licenced annually continued to increase (11). the increased number of pharmacies is not proportional with the total population (table 1). table 1. pharmaceutical indicators (7,12,20–22) indicator 1990 2003 2005 last year available number of pharmacies (total) 1097 1000 1600 (2014) pharmacists per 100000 inhabitants 36.37 35.28 38.3 108.4 (2018) pharmacists graduated per 100000 inhabitants 0.7 1.2 2.8 3.5 (2013) roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 5 | 13 only the pharmacies that plan to have a contract with the compulsory health care insurance fund (chif) must fulfil some conditions before opening the pharmacy (23). as per the albanian legislation, a pharmacy that signs a contract with the with the chif for the first time should, be at least 50 meter square, at least 150 meter linear away from an existing pharmacy and in a distance at least 30 meter from the health care centre (23). the law on medicines and pharmaceutical service of 2004 specified that: the pharmacies could be opened in urban areas in a distance lower than 150 meters from each other, depending from population density (one pharmacy for 3000 inhabitants), but the legislations on distance is not in force anymore (compared to the actual law of 2014) (11). pharmacies are periodically controlled/inspected by the national agency for drugs and medical devices and chif (the regional branch and national office in case the pharmacy has a contract with this institution), by the order of pharmacist and the tax administration office (tao). all these institutions inspect the pharmacies regarding the conditions on storing the medicines; the order/timeline in which they keep the prescriptions; if they give any non-over the counter (otc) without prescription; if they sell medicines that do not have a marketing authorization (contraband medicine); if they store the expired medicines in a non-separate area inside the pharmacy; if the number of the reimbursed medicines is the same with the one shown in the electronic prescription system (only for the pharmacies with a contract with chif); if they give a coupon after each sale; or/and if the employed pharmacists are licensed (11,14). a yearly report from the state central inspectorate mentions that in 2017 were inspected and controlled 424 subjects out of which 352 were pharmacies and pharmaceutical agencies and 48 were pharmaceutical distributors or importing warehouses. in this regard, 25 administrative measures were taken (24). in 2018, the same report showed that out of 603 controlled subjects, 592 were pharmacies and pharmaceutical agencies, 11 were pharmaceutical distributors or importing warehouses, 14 inspections for expired medicines upon request of the subjects themselves and one inspection in collaboration with the state policy (sector against economic and financial crime). overall, 182 administrative measures were taken (25). the european directive (2001/83) specifies the sale at distance to the public (15). in this regard, taking in consideration the existing albanian law on medicines and pharmaceutical service 105/2014, the selling of medicines at distance to the public is difficult to be monitored (14). pricing policy and pharmaceutical expenditure medicine pricing in albania is done by an official committee assigned by the minister of health (19). this committee aims at achieving a lower price of the medicines regardless the quality. the committee uses a specific formula and the reference price to calculated the medicine price (20). the pricing policy since 2014 is as follows: i) the medicine reference price for albania should be the lowest among: the wholesale prices in the reference countries. the retail price the medicine has in its origin place. roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 6 | 13 the price that the medicine has had in the last 12 months of import (11). ii) the generic medicine price should be 80% of the patent medicine price registered in the national agency for drugs and medical devices. in case the patent medicine does not have a marketing authorization in albania, then its price in the origin place should be taken into consideration (19). iii) the retail selling price of the medicine should be the same with the price of the medicine in the origin place (19). in the meantime, the price margin has changed – table 2 shows the price margins during the period 2005-2006. table 2. regressive margin system for medicines in albania [source: imasheva & seiter, 2008 (7)] type of medicines importer and wholesale margin retail margin most expensive 8% 15% moderately expensive 10% 20% non-expensive 15% 30% least expensive 18% 33% the purpose of such regressive price margin is to reduce the incentive for pharmacists to recommend expensive, branded medicines over cheaper generics (7). until 2015, the price margin system has changed by decreasing the wholesale and retail margin (11). the decision no.143 date 18.02.2015 stated that the margin of the wholesale margin should be 11% (divided 8% for the importer and 3% for the distributor) and 25% for the retail seller (25% of the price that the medicine has once distributed to the pharmacy) (11). since 2015, in wb a lot of attention has been devoted to pharmaceuticals, which have become one of the largest and fastest growing components of health expenditure (26). the national health strategy nhs aims at increasing of the medicine quality, safety and affordability in accordance with the european standards (27). this is planned to be achieved by: reducing the prices and improving access through a progressive expansion of the reimbursable medicine list. registration of medical devices. establishing a tracking system to maintain, strengthen and ensure quality during all phases: production, import, distribution and sale at the final point. achieving quality on pharmaceutical service available throughout the country. strengthening the national agency for drugs and medical devices (27). table 3 indicates that the pharmaceutical expenditure as part of the total health expenditure has been increasing. it indicates a considerable out of pocket expense on medicines and also lack of reimbursement policies. roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 7 | 13 table 3. pharmaceutical expenditure in albania (28) pharmaceutical expenditure as a proportion of total health expenditure 1993 (earliest year available) 2007 (last year available) 23% 28% in albania, annual expenditures on reimbursed medicines increased from all 3.5 billion in 2007 to all 8.4 billion in 2013, due to a variety of reasons such as: expansion of the health insurance scheme, reimbursement of innovative medicines, the tendency of the physicians to prescribe expensive therapies, lack of rules and regulations controlling this sector, and lack of significant policy for using generic medicines as substitutes for expensive products with the same active substances (26). a study conducted on the affordability of healthcare payments in albania showed that the average nominal annual amount spent out of pocket per person increased with 37%, from 2009 to 2015 with an annual average growth rate over 5% (29). some of the main issues that come out of the nip, are: the health sector remains a major challenge; new initiatives aim significant changes in health care financing systems and achieving universal coverage of ongoing initiatives. new programs for periodic population examinations will improve disease prevention. introduction of universal coverage system is expected to improve the health care system and the provision of health services. (appendix1) the national medicine control strategy 2018–2022 is envisaged for approval in the last quarter of 2018. (the nips of 2018-2020). the national health strategy 20162020 was approved in may 2017 and aims to achieve universal healthcare coverage. (the nips of 2019-2021). in terms of public health, significant progress needs to be made to implement the policy framework and ensure health care coverage for all in albania. regarding medical devices, law 89/2014 "on medical devices" has been revised pursuant to the european regulation on medical devices. the revision of the law was made following the process of approximation of albanian legislation with the european one and aims to increase safety during the use of medical devices after their placement on the market and increase access for patients. (the nips of 2021-2023) (11). the national health strategy (nhs) cites that the medicine market in albania is wellregulated, while medicines and pharmaceutical services are offered by the private sector (27). the legislation, is progressively improved in line with the eu directives (27). the national agency for drugs and medical devices has been established in 2014, before it was known as the national centre of drug control (27). in order to increase the access to safe medicines and reduce their financial burden, in 2015 a series of medicines were traded at prices around 30% cheaper compared to 2013. also, the list of essential medicines has been updated with 200 new medicines compared to 2013, while the list of reimbursable medicines was updated with about 80 new medicines (27). in the last two years, cytostatic medicines are doubled, while medical materials for cardiology have increased by 50% (27). roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 8 | 13 clinical trials clinical trials have been a specific chapter of the albanian law on medicines since 1994 and later 2004 (11). in march 2018 for the first time the order on approving the guidelines for clinical trials was published (30). this regulation is nearly harmonized with the eu directive 2001/20 on the approximation of the laws, regulations and administrative provisions of the member states in relation to the implementation of good clinical practice during the conduct of clinical trials on medicinal products for human use (30). the european commission directive 2005/28/ec of 8 april 2005 on laying down principles and detailed guidelines for good clinical practice (including investigational medicinal products for human use, the requirements for authorization of the manufacturing or importation of such products) is far more detailed than the before mentioned albanian ordinance on guidelines on conducting clinical trials (31). therefore, this part of the pharmaceutical legislation lacks detailed regulation on conducting clinical trials. marketing authorization, distribution and storage practices regarding the granting of marketing authorization for medicines for human use, the procedure is nearly the same as in the eu (11). there is also a specific regulation on granting the marketing authorization for medicines for human use in albania, decision no.299 dated 08.04.2015 on the approval of the regulation on granting the medicines marketing authorization (11). until 2018, no specific regulation existed in albania on distribution and storage practice, although this chapter was part of the law on medicines on pharmaceutical service 105/2014 (14,32). this law states that a regulation regarding the good distribution and storage practices should be approved by the minister of health and should be obligatory for the importers, exporters, pharmaceutical distributors, pharmacies and pharmaceutical agencies (14). in the law 105/2014, existed an administrative offense for each pharmacy that did not comply with the foreseen practices, even though such regulation was not in place yet (14). such issues were solved out in 2018, when the regulation on distribution and storage practice was implemented for the first time (32). this ordinance was based on the european medicines agency’s scientific guidelines on the quality of human medicines; regulation (ec) no 726/2004 of the european parliament; world health organization technical report series, no. 908, 2003, guide to good storage practices for pharmaceuticals; us pharmacopoeia 1079, good storage and distribution practices; guidelines of 5 nov ec ember 2013 on good distribution practice of medicinal products for human use (2013/c 343/01); guidelines for the storage of essential medicines and other health commodities 2003; and pharmaceutical inspection co-operation scheme (pic/s) guide to good distribution practice for medicinal products (32). conclusion in conclusion, the main pillars of the pharmaceutical sector in albania are well-covered legally but not fully in concordance with the eu framework. there is a need to reinforce the laws that regulate the opening of pharmacies; a detailed regulation on supervising and controlling the online sale of medicines and taking administrative measures where appropriate; a regulation on implementing the track and trace system of medicines. there is no regulation regarding pharmacovigilance in albania. also, unlike the eu, in albania, there is no regulation on medicinal products for paediatric use. roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 9 | 13 conflicts of interest: none. references 1. sanfey p, milatovic j, kresic a. how the western balkans can catch up. european bank for reconstruction and development, 2016: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3119685 (accessed: 17.05.2021). 2. stanek p, wach k, ambroziak a, et al. conceptualizing europeanization: theoretical approaches and research designs. in: stanek p, wach k, editors. europeanization processes from the mesoeconomic perspective: industries and policies. krakow: krakow university of economics, 2015: 11-20. 3. delegation of the european union to albania: https://eeas.europa.eu/delegations/albania_en/6953/albania and the eu (accessed: 17.05.2021). 4. featherstone k, radaelli c. the politics of europeanization. new york: oxford university press, 2003. 5. institute of statistics. albania demographic health survey 2017-18: https://dhsprogram.com/pubs/pdf/fr348/fr348.pd f (accessed: 17.05.2021). 6. altenstetter c, permanand g. eu regulation of medical devices and pharmaceuticals in comparative perspective. rev policy res 2007;24:385405. 7. imasheva a, seiter a. health nutrition and population paper, the pharmaceutical sector of the western balkan countries. washington d.c: the world bank, 2008: https://openknowledge.worldbank.org /bitstream/handle/10986/13736/428270wp01no0p 1lsinwesternbalkansdp.pdf?sequence=1&isallowed=y (accessed: 17.05.2021). 8. abraham j, lewis g. europeanization of medicines regulation. in: abraham j, smith hl, editors. regulation of the pharmaceutical industry. london: palgrave macmillan, 2003: 4281. 9. borup r, traulsen jm, kaae s. regulatory capture in pharmaceutical policy making: the case of national medicine agencies related to the eu falsified medicines directive. pharmaceut med 2019;33:199-207. 10. ministria e puneve te jashtme integrimi i republikës së shqipërisë në bashkimin europian: http://integrimine-be.punetejashtme.gov.al/anetaresimi-ne-be/plani-kombetar-i-integrimit-pkie/ (accessed: 15.05.2021) (albanian). 11. qëndra e botimeve zyrtare: https://qbz.gov.al/ (accessed: 15.05.2021) (albanian). 12. voncina l, sallaku j. republic of albania, technical assistance review of albanian pharmaceutical policy. tirana: ministry of health, 2014. 13. hsieh hf, shannon s. three approaches to qualitative content analysis. qual health res 2005;15:127788. 14. kuvendi i shqipërisë: https://www.parlament.al/files/integrimi/ligj_nr_105_dt_31_7_2014_1 8582_12.pdf (accessed: 15.05.2021) (albanian). 15. official journal of the european communities directive 2001/83: roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 10 | 13 https://eur-lex.europa.eu/legal-content/en/txt/pdf/?uri=celex:320 01l0083&from=fr (accessed: 16.05.2021). 16. gabrani j, schindler c, wyss k. perspectives of public and private primary healthcare users in two regions of albania on non-clinical quality of care. j prim care community health 2020;11:1-3. 17. aldent university, history. https://ual.edu.al/ual.edu.al/rrethnesh/historiku/. 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https://eur-lex.europa.eu/eli/dir/2005/28/oj (accessed: 15.05.2021). 32. urdhri i farmacistëve të shqipërisë prakikat e ruajtjes dhe shpërndarjes së mirë të barnave: https://www.ufsh.org.al/content/uploads/2018/nov/9/rregullore-mbipraktikat-e-ruajtjes-dhe-shprndarjess-mir-t-barnave.pdf (accessed: 30.03.2021) (albanian). ______________________________________________________________________________ © 2021 roshi et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 12 | 13 appendix 1. list of consulted legislation, directives and orders no. the consulted legislation link last accessed 1 law nr.10 171, date 22.10.2009 on regulated professions in republic of albania https://www.arsimi.gov.al/wp-content/uploads/2017/10/ligj_nr_10_171_p rr.pdf 16.05.2021 2 law of medicine and pharmaceutical services 2004 https://qbz.gov.al/eli/ligj/2004/11/2 5/9323/25d3c84f-e0ad-4a23-980cd948f6c7a430;q=299 17.05.2021 3 decision no. 781, date 14.11.2007 on “technical functional characteristics of fiscal equipment; integrated computerized system for periodic and automatic transferring of financial declarations; communication system on procedure and documentation for its approval; and the criteria for the equipment authorized from the authorized companies for offering fiscal equipment. https://qbz.gov.al/preview/302da00f-7476-47a5-a2d7c583698f8c4e/cons/20181031 15.05.2021 4 law no. 10 383, date 24.2.2011 on compulsory health insurance in republic of albania https://qbz.gov.al/preview/1af1180f-c82e-4ec7-b37b9904e9aab976/cons/20170211 17.05.2021 5 order no.645 date 01.10.2014 on establishment and operation of the commission on medicine pricing https://qbz.gov.al/eli/vendim/2014/ 10/01/645/c05dd224-5c03-40ba99d9-0dc03882fa1c 17.05.2021 6 order no.143 date 18.02.2015 on designation of trade and fabrication margins of medicines https://qbz.gov.al/eli/vendim/2015/ 02/18/143/6d99b717-9493-41aeb77a-8ff1edc5ff63 17.05.2021 7 law on medicine and pharmaceutical services 1994 https://qbz.gov.al/eli/ligj/1994/04/2 0/7815/6103b566-80d1-4ccc-a6a99a67dcbc8559;q=299 15.05.2021 8 order no 299 on “on approving the regulation on granting the medicines marketing authorization and their classification on the republic of albania” https://qbz.gov.al/eli/vendim/2015/ 04/08/299/60e02154-8b2b-49eaaa45-6e3e1e849892;q=299 16.05.2021 9 national health strategy 2016-2020 https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/albania/draft_strategt_albania_2016-2020.pdf 16.05.2021 https://www.arsimi.gov.al/wp-content/uploads/2017/10/ligj_nr_10_171_prr.pdf https://www.arsimi.gov.al/wp-content/uploads/2017/10/ligj_nr_10_171_prr.pdf https://www.arsimi.gov.al/wp-content/uploads/2017/10/ligj_nr_10_171_prr.pdf https://www.arsimi.gov.al/wp-content/uploads/2017/10/ligj_nr_10_171_prr.pdf https://qbz.gov.al/eli/ligj/2004/11/25/9323/25d3c84f-e0ad-4a23-980c-d948f6c7a430;q=299 https://qbz.gov.al/eli/ligj/2004/11/25/9323/25d3c84f-e0ad-4a23-980c-d948f6c7a430;q=299 https://qbz.gov.al/eli/ligj/2004/11/25/9323/25d3c84f-e0ad-4a23-980c-d948f6c7a430;q=299 https://qbz.gov.al/preview/302da00f-7476-47a5-a2d7-c583698f8c4e/cons/20181031 https://qbz.gov.al/preview/302da00f-7476-47a5-a2d7-c583698f8c4e/cons/20181031 https://qbz.gov.al/preview/302da00f-7476-47a5-a2d7-c583698f8c4e/cons/20181031 https://qbz.gov.al/preview/1af1180f-c82e-4ec7-b37b-9904e9aab976/cons/20170211 https://qbz.gov.al/preview/1af1180f-c82e-4ec7-b37b-9904e9aab976/cons/20170211 https://qbz.gov.al/preview/1af1180f-c82e-4ec7-b37b-9904e9aab976/cons/20170211 https://qbz.gov.al/eli/vendim/2014/10/01/645/c05dd224-5c03-40ba-99d9-0dc03882fa1c https://qbz.gov.al/eli/vendim/2014/10/01/645/c05dd224-5c03-40ba-99d9-0dc03882fa1c https://qbz.gov.al/eli/vendim/2014/10/01/645/c05dd224-5c03-40ba-99d9-0dc03882fa1c https://qbz.gov.al/eli/vendim/2015/02/18/143/6d99b717-9493-41ae-b77a-8ff1edc5ff63 https://qbz.gov.al/eli/vendim/2015/02/18/143/6d99b717-9493-41ae-b77a-8ff1edc5ff63 https://qbz.gov.al/eli/vendim/2015/02/18/143/6d99b717-9493-41ae-b77a-8ff1edc5ff63 https://qbz.gov.al/eli/ligj/1994/04/20/7815/6103b566-80d1-4ccc-a6a9-9a67dcbc8559;q=299 https://qbz.gov.al/eli/ligj/1994/04/20/7815/6103b566-80d1-4ccc-a6a9-9a67dcbc8559;q=299 https://qbz.gov.al/eli/ligj/1994/04/20/7815/6103b566-80d1-4ccc-a6a9-9a67dcbc8559;q=299 https://qbz.gov.al/eli/vendim/2015/04/08/299/60e02154-8b2b-49ea-aa45-6e3e1e849892;q=299 https://qbz.gov.al/eli/vendim/2015/04/08/299/60e02154-8b2b-49ea-aa45-6e3e1e849892;q=299 https://qbz.gov.al/eli/vendim/2015/04/08/299/60e02154-8b2b-49ea-aa45-6e3e1e849892;q=299 https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/albania/draft_strategt_albania_2016-2020.pdf https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/albania/draft_strategt_albania_2016-2020.pdf https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/albania/draft_strategt_albania_2016-2020.pdf https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/albania/draft_strategt_albania_2016-2020.pdf https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/albania/draft_strategt_albania_2016-2020.pdf roshi d, tresa e, lafranconi a, burazeri g, czabanowska k, brand h. pharmaceutical policies in post-communist albania: progress and challenges toward european union membership (review article). seejph 2021, posted: 19 july 2021. doi: 10.11576/seejph-4604 p a g e 13 | 13 10 national european integration plan 20142020 http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2014-2020.pdf 14.15.2021 11 national european integration plan 20152020 http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2015-2020.pdf 16.05.2021 12 national european integration plan 20162020 http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2016-2020.pdf 16.05.2021 13 national european integration plan 20172020 http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2017-2020.pdf 17.05.2021 14 national european integration plan 20182020 http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2018-2020.pdf 15.05.2021 15 national european integration plan 20192021 http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2019-2021.pdf 15.05.2021 16 national european integration plan 20212023 https://qbz.gov.al/eli/vendim/2021/ 02/17/90/b8a74244-4688-4227bfb6-f75c873a5708;q=plani kombëtar 16.052021 17 directive 2001/83 of the european parliament and of the council of 6 november 2001 on the community code relating to medicinal products for human use https://eur-lex.europa.eu/legal-content/en/all/?uri=celex%3a320 01l0083 17.05.2021 18 commission directive 2005/28/ec of 8 april 2005 laying down principles and detailed guidelines for good clinical practice as regards investigational medicinal products for human use, as well as the requirements for authorisation of the manufacturing or importation of such products https://eur-lex.europa.eu/legal-content/en/txt/?uri=celex%3a32 005l0028 16.05.2021 19 directive 2001/20/ec of the european parliament and of the council of 4 april 2001 on the approximation of the laws, regulations and administrative provisions of the member states relating to the implementation of good clinical practice in the conduct of clinical trials on medicinal products for human use https://ec.europa.eu/health/sites/health/files/files /eudralex/vol1/dir_2001_20/dir_2001_20_en.pdf 17.05.2021 http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2014-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2014-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2014-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2015-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2015-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2015-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2016-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2016-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2016-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2017-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2017-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2017-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2018-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2018-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2018-2020.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2019-2021.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2019-2021.pdf http://integrimi-ne-be.punetejashtme.gov.al/wp-content/uploads/2020/04/pkie-2019-2021.pdf https://qbz.gov.al/eli/vendim/2021/02/17/90/b8a74244-4688-4227-bfb6-f75c873a5708;q=plani%20kombëtar https://qbz.gov.al/eli/vendim/2021/02/17/90/b8a74244-4688-4227-bfb6-f75c873a5708;q=plani%20kombëtar https://qbz.gov.al/eli/vendim/2021/02/17/90/b8a74244-4688-4227-bfb6-f75c873a5708;q=plani%20kombëtar https://qbz.gov.al/eli/vendim/2021/02/17/90/b8a74244-4688-4227-bfb6-f75c873a5708;q=plani%20kombëtar https://eur-lex.europa.eu/legal-content/en/all/?uri=celex%3a32001l0083 https://eur-lex.europa.eu/legal-content/en/all/?uri=celex%3a32001l0083 https://eur-lex.europa.eu/legal-content/en/all/?uri=celex%3a32001l0083 https://eur-lex.europa.eu/legal-content/en/txt/?uri=celex%3a32005l0028 https://eur-lex.europa.eu/legal-content/en/txt/?uri=celex%3a32005l0028 https://eur-lex.europa.eu/legal-content/en/txt/?uri=celex%3a32005l0028 https://ec.europa.eu/health/sites/health/files/files/eudralex/vol-1/dir_2001_20/dir_2001_20_en.pdf https://ec.europa.eu/health/sites/health/files/files/eudralex/vol-1/dir_2001_20/dir_2001_20_en.pdf https://ec.europa.eu/health/sites/health/files/files/eudralex/vol-1/dir_2001_20/dir_2001_20_en.pdf https://ec.europa.eu/health/sites/health/files/files/eudralex/vol-1/dir_2001_20/dir_2001_20_en.pdf ohia c, ongolo-zogo p, fawole oi. digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare pro viders (review article). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4381 p a g e 1 | 11 digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare providers chinenyenwa ohia1, pierre ongolo-zogo2, olufunmilayo ibitola fawole3 1 department of environmental health sciences, university of ibadan, faculty of public health, college of medicine, university of ibadan, nigeria; 2 agrégé des facultés de médecine fmsb, université de yaoundé 1, cameroon; 3 department of epidemiology and medical statistics, faculty of public health, college of med icine, university of ibadan, nigeria; corresponding author: ohia chinenyenwa m.d.; address: department of environmental health sciences, faculty of public health, college of medicine, university of ibadan; email: ohiacmd@gmail.com; phone: +234 703 831 8289 review article mailto:ohiacmd@gmail.com ohia ch, ongolo-zogo p, fawole oi. digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare pro viders (review article). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4381 p a g e 2 | 11 abstract in tandem with the current drive to achieve the sdg 2030 goals, the universal health coverage (uhc) is been projected as a strong propelling strategy with key indicators, all aimed at achiev ing universal access to health services without having to endure financial difficulties in individ ual countries. currently, africa is lagging in meeting the targets of the uhc with between 5% 25% coverage across countries. adoption of new innovations are critical for the actualization of universal health coverage in africa. digital health technology offers one of such novel approaches to providing quality healthcare services and can help countries achieve the universal health coverage targets. it has been suggested that digital health provides an opportunity to overcome the longstanding prob lems of inefficiency of health information gathering, sharing, and access. in addition, literature is already replete with various factors that can aid countries to achieve uhc and one of such fac tors is the urgency of generating valid and quality evidence to inform decision-making. although the primary health care remains at the core of the achievement of universal health coverage, the utilization of digital health technologies remains very poor at the grassroots in af rica and this poses a huge barrier to effectiveness and quality of healthcare delivery. given the foregoing, it is obvious that there is an urgent need to understand the landscapes, issues and bar riers to utilization of digital health at the primary health care levels. however, there remains a paucity of data to support evidence-based decision making about full implementation of digital health services across the continent while also taking into cognisance the peculiarities of individ ual countries. hence, there is a critical need to determine the current levels of knowledge, skills, attitude, prac tice and readiness to adopt digital health in service delivery by healthcare workers at the primary health care levels across the continent. the generation of such data from major stakeholders such as health workers and health managers, providers among others will provide important evi dence needed for attaining optimal utilization of digital health in the context of health for all. summarily, a clear understanding of the contextual and implementation bottlenecks highlighted from such assessment(s), especially as it relates to individual african countries, will go a long way to guide decisions to address the low utilization of digital health technologies in health ser vices delivery in africa. keywords: digital health technologies, willingness to adopt, primary healthcare providers, universal health coverage, africa. source of funding this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. acknowledgement the authors acknowledge the support of the department of environmental health sciences, uni versity of ibadan and contributions of prof. g.r.e. e ana, prof. m.k.c. sridhar, dr. e.c. uwalaka, dr. o.t. okareh and dr. o.m. morakinyo, in the writing of this paper. we also thank the world health organisation (who) for the technical support and the publishing of this manuscript. ohia ch, ongolo-zogo p, fawole oi. digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare pro viders (review article). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4381 p a g e 3 | 11 co is supported by consortium for advanced research training in africa (carta) which is funded by the carnegie corporation of new york (grant no--b 8606.r02), sida (grant no:54100029), the deltas africa initiative (grant no: 107768/z/15/z). conflict of interest statement the authors declare that they have no known competing financial interests or personal relation ships that could have influenced the writing of this paper. author contributions co: conceptualization; co, po and of: writingoriginal draft preparation, co, po and of: writingreviewing and editing. ohia ch, ongolo-zogo p, fawole oi. digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare pro viders (review article). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4381 p a g e 4 | 11 introduction the universal health coverage (uhc) target is a strategic ambition with an overarching goal that all individuals and communities re ceive universal access to good quality health services without having to endure pain and fi nancial difficulties [1-3]. in tandem with the sdg-2030 goals these ‘coverage’ refers to an array of services encompassing promotion, prevention, treatment, rehabilitation and pal liation, particularly the health-related goals of the sdgs [3]. uhc is widely recognised as a priority track to aid and accelerate the achievement of the sdg-2030 goals and consequently three key indicators for the achievement of uhc have been defined: (1) equity in access to health ser vices (those who need health services irrespective of whether they can or cannot af ford them should receive them); (2) quality of healthcare services (health services should be good enough to improve the health status of those receiv ing them); and (3) financial risk protection (the guarantee that health service costs do not expose people to financial problems) [4,5]. several factors can help countries to move to wards the achievement of the uhc goal and literature is already replete with suggestions of possible factors that can propel countries towards achieving uhc. one of such factors is the urgency of generating valid and quality evidence to inform decision-making. all these factors are important for all stages of the uhc process including the exploration, development and sustenance of interven tionsincluding novel strategies such as utili zation of digital health information technol ogyat the primary healthcare level. the aim of this paper is to enumerate and de scribe barriers identified from available liter ature as limiting the adoption of digital health information technology among pri mary healthcare providers and proffer the way forward to enhance adoption in order to ultimately propel the african continent to wards the actualization of the uhc targets. method a preliminary search of literature was con ducted to determine the need for the study. this was important and helped to refine the initial broad concept of digital health and gave clarity and objectivity to the choice of topic. then literature searches of electronic databases (pubmed, medline and google scholar) were carried out from may through november, 2020. in addition, the snowball ing technique of literature search was em ployed and this involved searches through the references of relevant published articles that were retrieved from the electronic databases. keywords used in the search included ‘digi tal health technologies’ or ‘mobile health’ and ‘willingness to adopt’ and ‘barriers to adoption’, ‘primary healthcare’ and ‘univer sal health coverage’. the inclusion criterion was that published articles should be pub lished in english. furthermore, articles not related to the aim of the study topic were ex cluded. figure 1further describes the stages of the literature search process that was un dertaken during this review. ohia ch, ongolo-zogo p, fawole oi. digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare pro viders (review article). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4381 p a g e 5 | 11 figure 1: stages of the literature search process discussion factors limiting the actualization of uni versal health coverage (uhc) targets in africa currently, africa is lagging in meeting the targets of the uhc with between 5% -25% coverage across countries. several barriers limit the actualization of the targets of the uhc in africa. these barriers are far reach ing and include high operational and finan cial costs required for the expansion of health service access to areas or communities cur rently lacking access [6]; paucity of data due to lack of appropriate researches [5]; exten sively weak health systems; poor infrastruc ture; inefficient transport; inadequate physi cal access to several communities due to in accessible, difficult topography, insecurity; and sociocultural barriers [7]. these barriers limit the potential of current approaches to health service delivery and may in the long run hinder the achievement of the uhc tar gets given the realities on ground. this is worrisome especially in the face of dwindling economic capabilities of these african na tions and the prevailing political and social environments. it is imperative to begin to consider new paradigm shifts and innova tions in the achievement of the uhc targets in africa for the ultimate actualization of the ohia ch, ongolo-zogo p, fawole oi. digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare pro viders (review article). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4381 p a g e 6 | 11 sdgs goals. hence, adoption of new innova tions is key for the actualization of universal health coverage in africa. digital health technology: a novel ap proach to delivering quality healthcare services and achieving the uhc targets in africa digital health technology offers one of such novel approaches to providing quality healthcare services and can help countries achieve the universal health coverage tar gets [7]. it has been suggested that digital health provides an opportunity to overcome the longstanding problems of inefficiency of health information gathering, sharing, and ac cess [5]. digital health information technol ogy is a term synonymous to mobile health (mhealth) or ehealth. this refers to a broad range of information and communication technologies that are used to gather, collate, transmit, display and store patient data [8 10]. the world health organisation (who) defines digital health as the use of mobile tel ecommunications and multimedia technolo gies to address health-associated issues within health service delivery and public health systems [11]. this concept encom passes a range of technologies, products and services comprising but not limited to medi cal devices, tele-monitoring instruments and devices, remote mobile health technologies, cloud-based services in addition to assistant and sensor technologies [12]. digital health information technology has the potential to enhance the quality, efficiency of health ser vice delivery for improved results, client safety and may possibly reduce healthcare delivery costs in resource poor settings as prevalent in africa. [13,14]. digital health approach finds application in several spheres of health service delivery including patient data management (e-health records), health information and services provision via mo bile technology (mhealth), remote services (telemedicine/telehealth), health knowledge learning and management [7]. application of digital health information technology ensures the prompt deployment of health information and thereby enhances accessibility of health services by all stake holders including patients, health service pro viders and relevant agencies of government. also, it can reduce medical mistakes, costs, and paperwork associated with medical ser vice delivery. this subsequently increases ef ficiency, quality of health service delivery while enhancing the empowerment of pa tients and healthcare providers including cli nicians [15]. the various applications of dig ital health have shown its potential for use in promoting individual health and public health at large. furthermore, these technologies can improve efficiency of health care services; reduce cost of health services delivery [16]; enhance the dynamism and timeliness of de cision making by expediting speedy trans mission of real time public health infor mation; and enhance the monitoring and evaluation capacity of the health system in general. this provides ample opportunity for enhanced planning, organization, and man agement of health services at all levels in cluding the primary health care level. how ever, in spite of the potential benefits of the digital health information technology, adop tion is a huge challenge especially in low and middle income countries including africa. this has greatly limited the utilization of the technology in health care service delivery. it is therefore imperative to identify the obsta cles to the adoption of digital health infor mation technology among relevant stake holders across levels in the health care ser vice delivery network especially at the pri mary healthcare level. ohia ch, ongolo-zogo p, fawole oi. digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare pro viders (review article). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4381 p a g e 7 | 11 barriers to adoption of digital health in formation technology among primary healthcare providers. a key impediment to adoption of digital health information technology in resource low communities is low level of technology knowledge and limited accessibility to tech nological devices. a study conducted in iran found that the level of technology literacy was poor; utilization of these technologies among health care personnel was limited [17]. in addition, computer possession and use among health care professionals and stu dents were low [17]. this may be due lack of structured trainings and limited access to technological devices such as computer in these settings [17]. despite the fact that ma jority of the respondents owned a computer, only a few number of them had acceptable skills and practice habits. another study in nigeria reported that just 18.9% of health personnel and medical students had good knowledge of computer while 58.8% had av erage knowledge and 22.3% revealed poor knowledge [18]. similarly, mohammed et al. [19] reported that only 33.7% of health work ers had sufficient knowledge of computer or other digital devices. in more developed countries the case is different, as 57.91% of health personnel were well-informed about digital information technologies including use of computers in india [20]. and majority (82%) of health workers in countries like po land were knowledgeable about the concept of telemedicine [21]. studies have shown that digital knowledge and experience of healthcare personnel have considerable im pact on their readiness, perception, attitude, and probability of adopting and utilizing these health technology applications in prac tice [22,23]. healthcare professionals with sufficient and requisite information technol ogy knowledge and experience are likely to have better and positive disposition towards the utilization of new innovations like digital health technology applications. thus the need to focus on developing context-specific training on digital health in order to fill the knowledge gap. another barrier to adoption is the low level of acceptance of the innova tion in most of low and middle income coun tries [14]. these maybe due to the fact that very few healthcare workers know and un derstand the enormous benefits of digital health information technology [24] in provid ing prompt and efficient services at any level of the healthcare system. resistance to the use of digital health technologies from healthcare professionals may be due to low level of digital literacy and limited skill in the use of digital health technology applications [25]. in addition, absence of motivation, poor organizational and management level poli cies also pose very formidable barriers to the adoption and utilization of these technologies [26]. poor technology infrastructure in rela tion to hardware, software, and networking facilities is also a main obstacle to healthcare personnel’s decision to embrace e-health technology applications [2529]. this is due to the fact that most digital infrastructure pro jects in countries have previously been run as pilot projects resulting in duplication of ef forts and technologies with little or no focus on sustainability [7, 26]. another salient lim itation to adoption in low and middle income countries (lmics) is monetary barriers espe cially with respect to budgeting and funding [26,30-32]. although the level of funding varies across countries, however most devel oping countries allocate very little funding for the health sector which are mostly lower than the world health organization (who) benchmark, that requires countries to appor tion at least 13 percent of their annual budg etary spending to the health sector. this makes funding of such investments such as digital health grossly inadequate in develop ing countries when compared to more devel oped countries. ohia ch, ongolo-zogo p, fawole oi. digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare pro viders (review article). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4381 p a g e 8 | 11 administrative issues including political will and bureaucracy related to organizational and management policies go a long way to deter mine the level of adoption of these technolo gies [33]. these could pose very formidable barriers to the efficiency of the implementa tion of these technologies at all levels of health service delivery. security barriers re lated to privacy and trust arise both among healthcare workers and patients [26]. this could be due to prevalent myths and socio cultural beliefs especially in african coun tries with the potential to negatively impact decisions when contemplating the adoption and utilization of digital health technology. although evident in most of the barriers dis cussed, it is important to consider human re source barriers distinctly in addressing the is sue of technology adoption. this is important especially in relation to individual attitude, readiness and belief of the overarching goal and benefits of digital health technologies. this has significant influence on the individ ual’s intention to adopt and use available dig ital health technology applications. table 1 provides a summary of barriers identified from available literature in the field. table 1: identified barriers to adoption and utilization of digital health information tech nology applications in most of low and middle income countries. s/n identified barriers to adoption references 1. low level of technology knowledge and limited accessibility to technological devices. 17-21 2. low level of acceptance of the innovation in most of low and middle income countries 14, 24.25 3. low level of digital literacy and limited skills in the utilization of digital health infor mation technology applications in most of low and middle income countries 21-23, 25 4. poor technology infrastructure in relation to hardware, software, and networking faci lities 7, 25-29 5. absence of motivation, poor organisational and management level policies to drive adoption of novel interventions at the primary healthcare level 26 6. monetary barriers especially with respect to budgeting and funding 26, 30-32 7. administrative issues including political will and bureaucracy related to organizatio nal and management policies 33 8. security barriers related to privacy and trust arise both among healthcare workers and patients 26 9. human resource barriers distinctly in addressing the issue of technology adoption 17-21, 25,26 way forward to enhance adoption of digi tal health information technology among primary healthcare providers. there is an urgent and critical need to deter mine the current levels of knowledge, atti tude, practice and readiness to adopt digital health in service delivery by healthcare work ers especially at the primary health care lev els across the continent. a mixed study approach including a longitu dinal study is recommended to enable the col lection of quality information. the genera tion of such data from major stakeholders such as health workers and health managers, providers among others will provide im portant evidence needed for attaining optimal utilization of digital health in the context of health for all. in addition, the deployment of ohia ch, ongolo-zogo p, fawole oi. digital health information technology utilization for enhanced health services delivery in africa: unravelling barriers to adoption among primary healthcare pro viders (review article). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4381 p a g e 9 | 11 context-specific digital health information technologies is essential in african countries, if the full potentials of the strategy are to be realized. it is also important to evaluate the outcomes, effect and cost effectiveness of proposed models of digital health alongside the development of clear sustainable funding models with contextual relevance to target countries. the need for community and stakeholder engagement, mobilization and education cannot be over-emphasised as ena blers and drivers of dynamic participation in digital health initiatives and activities at the primary care level in african countries. hence, policy and public health interventions such as creation of awareness and promotion of use of digital health will go a long way to enhance its integration into the mainstream healthcare system in countries. conclusion the primary health care remains at the cen tre of the actualization of universal health coverage and digital health technologies have huge potential to enhance service deliv ery and access to health with minimal finan cial burden to both individuals, communities and nations. however, the utilization of digi tal health technologies remains very meagre at the grassroots in africa and this poses im mense impediments to the efficiency and quality of healthcare delivery. in addition, there remains a paucity of data to support ev idence-based decision making about full im plementation of digital health services across the continent; aside from the reality of the in herent peculiarities of individual countries. this paper has identified some of the barriers to adoption of digital health approach in lmics especially in africa and posits that there is an urgent need to understand the con textual and political landscapes, issues and barriers to the utilization of digital health at the primary health care levels. in addition, some recommendations have been proffered as the way forward is sought to improve adoption level of digital health in africa. summarily, a clear understanding of the con textual and implementation bottlenecks high lighted from such assessment(s), especially as it relates to individual african countries, will go a long way to guide decisions to ad dress the low utilization of digital health tech nologies in health services delivery in africa. 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ma laysian public hospitals. international journal of social science and hu manity 2013; 3(2), 115. 30. obansa saj, orimisan a. health care financing in nigeria: prospects and challenges. mediterranean journal of social sciences 2013; 4(1):221_236 doi 10.5901/mjss.2013.v4n1p221. 31. eneji ma, juliana dv, onabe bj. health care expenditure, health status and national productivity in nigeria (1999_2012). journal of economics and international finance 2013; 5(7):258_272 doi 10.5897/jeif2013.0523. 32. sulaiman, h. healthcare information systems assimilation: the malay sian experience. 2011. rmit univer sity. 33. hossein ahmadi, leila shahmoradi, farahnaz sadoughi, azadeh bashiri, mehrbakhsh nilashi, abbas sheikhtaheri, sarminah samad, oth man ibrahim. a narrative literature review on the impact of organiza tional context perspective on innova tive health technology adoption. journal of soft computing and deci sion support systems 2018; 5:(4): 1 12. © 2021 ohia et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0) chinenyenwa ohia1, pierre ongolo-zogo2, olufunmilayo ibitola fawole3 source of funding acknowledgement introduction method figure 1: stages of the literature search process factors limiting the actualization of universal health coverage (uhc) targets in africa digital health technology: a novel approach to delivering quality healthcare services and achieving the uhc targets in africa barriers to adoption of digital health information technology among primary healthcare providers. table 1: identified barriers to adoption and utilization of digital health information technology applications in most of low and middle income countries. conclusion references department of health sciences how are the health needs of internally displaced persons adressed by international actors? bachelor thesis submitted by: myriam staub matriculation number: 1180493 study program: b. sc. international health sciences winter semester 2022/2023 first supervisor: prof. dr. dr. jens holst second supervisor: dr. franziska satzinger fulda, 01.02. 2023 i abstract the number of internal displacements has doubled over the last decade, as conflicts and climate related disasters have increasingly triggered movement within countries borders. due to the lack of a legally binding framework and international agency dedicated for the protection of internally displaced persons (idps), the needs of idps are underprioritized by international actors. evidence suggests that idps face worse health outcomes than any other crisis-affected population group. this leads to a policy analysis on the involvement of international actors on addressing the health needs of idps. the concept of humanitarianism will be utilized as the theoretical foundation and is the underlying motive of humanitarian action worldwide. as an altruistic desire to reduce suffering, humanitarianism aims to provide relief to victims of conflicts or disasters while adhering to the humanitarian principles. assessing the humanitarian concept helps to conceptualize the role of international actors in the humanitarian assistance of idps. for the methodology, a description of the literature search and the selection of certain material has been provided. it also examined why documents by international organizations like the unhcr, the ocha, the who and the iasc were used for this policy analysis. the first part of the findings identified the legal protection frameworks for idps. international law and the guiding principles on internal displacement represent the most suitable legal tools for idps. guiding concepts regarding the realization of health rights have also been developed by international organizations and national authorities. the second part of the results concentrated on the humanitarian coordination mechanisms for idps. although the unhcr does not hold an exclusive mandate for idps, the protection and assistance of idps relies mainly on the unhcr. the humanitarian coordination mechanism applicable in internal displacement settings is the iasc cluster approach. the cluster approach spreads accountability of un agencies across various sectors, including shelter, food security or health. despite individual interventions of ngos on the health of idps, the health cluster remains the most suitable tool for coordinating an emergency health response. health cluster country operations have targeted the health needs of idps through provision of essential health care. the country cluster operations have contributed to an effective humanitarian relief coordination for idps. due to the lack of an international legally binding framework, the lack of health funding for idps and limited accountabilities for idps, the issue of internal displacement will remain. strengthening humanitarian engagement in all sectors concerning the well-being of idps can be achieved through a holistic approach. ii contents 1 introduction ...................................................................................................................... 1 1.1 background ............................................................................................................ 1 1.2 research relevance and current research state ..................................................... 5 1.3 research objective ................................................................................................. 6 1.4 research question ................................................................................................. 7 2 theoretical foundation ..................................................................................................... 8 2.1 concept of humanitarianism ................................................................................... 8 2.1.1 the taxonomy of humanitarian action ......................................................... 9 2.1.2 history of humanitarianism ........................................................................11 2.1.3 international humanitarian system in change .............................................13 3 methodology ....................................................................................................................17 4 results .............................................................................................................................19 4.1 legal protection frameworks for idps ....................................................................19 4.1.1 international law ........................................................................................19 4.1.2 the guiding principles on internal displacement ......................................21 4.1.3 national legal frameworks .........................................................................22 4.1.4 the right to health for idps ........................................................................23 4.2 humanitarian coordination systems for idps ........................................................26 4.2.1 unhcr mandate for idps .........................................................................26 4.2.2 cluster approach .......................................................................................27 4.2.3 the joint unhcr-ocha note on mixed situations ..................................30 4.2.4 health clusters ..........................................................................................31 4.2.5 health cluster operations in idp settings ..................................................33 4.3 health funding for idps .........................................................................................35 5 discussion .......................................................................................................................38 5.1 challenges of the humanitarian coordination system ...........................................38 iii 5.2 barriers to health for idps .....................................................................................40 5.3 policy implications .................................................................................................41 5.4 strengths and limitations ......................................................................................42 6 conclusion .......................................................................................................................44 list of figures......................................................................................................................46 list of abbreviations ..........................................................................................................47 bibliography .......................................................................................................................49 appendix ............................................................................................................................... i introduction 1 1 introduction 1.1 background humanitarian emergencies have triggered internal displacements worldwide. due to conflicts and climate related disasters, people have lost their home and are forced to flee within their countries (idmc a, 2022). former un secretary-general kofi annan has already highlighted the global crisis of internal displacement and lack of recognition by international and national actors. he described in his un report from 2005 that idps “are among the most vulnerable of the human family [..]” and “often fall into the cracks between different humanitarian bodies [..]” (cohen, 2009, p. 101). the united nations guiding principles on internal displacement define idps as “persons or groups of persons who have been forced or obliged to flee or to leave their homes or places of habitual residence, in particular as a result of or in order to avoid the effects of armed conflict, situations of generalized violence, violations of human rights or natural or humanmade disasters [...]” (ohchr, 2022). compared to refugees, they do not cross an internationally recognized border (cantor et al., 2021). idps also do not receive the same access to international aid as they are not under an agreed international legal status unlike refugees (roberts et al., 2022). the term “internally displaced person” is simply descriptive and describe the factual circumstance of the individual (ohchr, 2022). there is also not a single agency or organization specifically targeted on the protection and assistance of idps, compared to the united nations high commissioner for refugees (unhcr). idps are citizens and residents of their country under the responsibility of the national authorities (thomas &thomas, 2004, p. 118). another crucial element of idps is the involuntary character of their movement. internal displacements can be attributed to two categories, either conflicts or natural disasters (etikan & babatope, 2019, p. 23). drawing attention to the rising scale of internal displacements, the global number of idps has more than doubled over the last decade (un a, 2022). on a global scale, the internal displacement monitoring centre (idmc) estimated 59.1 million internally displaced persons by the end of 2021. the year 2021 alone triggered 38 million displacements worldwide (idmc a, 2022). as a result of armed conflict and violence, 53.2 million people were classified as internally displaced in 59 countries by the end of 2021. the idmc categorized forms of conflict and violence into armed conflict, communal violence, criminal violence, political violence, and other forms of violence. conflict related displacements occurred mostly in sub-saharan africa and other conflict affected countries such as syria, afghanistan, columbia, or yemen (idmc a, 2022). the total number also includes those idps who have been displaced several years or even decades ago. in nigeria for example, the boko haram introduction 2 and other non-state armed groups have led to over 3 million displacements since 2009 (unhcr b, 2022). the idmc recorded 5.9 million internal displacements due to natural disasters across 84 countries by the end of 2021. afghanistan, china and the philippines had the highest numbers of displacements with more than three million idps total. internal displacement through disasters were mostly weather related, including storms, floods and droughts. geophysical disasters such as earthquakes, volcanic eruptions or landslides account only for the smaller percentage of displacements. although geophysical disasters seem smaller in numbers, they can have a significant impact on the infrastructure and repairment afterwards as seen in haiti in august 2021 (idmc a, 2022). the increase of 60 percent more internal displacements due to natural disasters can be linked to the global climate crisis (cazabat & o'connor, 2021). human settlements appear to be more unstable due to rising sea levels and extreme weather situations (un, 2021). the figure below illustrates the overall rise of internal displacements worldwide while drawing attention to the increase of internal displacements due to disasters since 2019. figure 1: total numbers of idps worldwide at year end (2012-2021) (source: idmc a, 2022) idps are in the most vulnerable position as they face exposure to violence, poverty and poor living conditions. they experience higher rates of mortality, communicable diseases, noncommunicable diseases, and mental disorders compared to other populations from conflict affected areas (cantor et al., 2022). aspects of their vulnerability can be categorized into different stages of displacements namely pre-flight, during flight and post-flight. the pre-flight phase of displacement already introduction 3 encompasses the presence of vulnerable groups which are more susceptible to the effects of a humanitarian emergency. they are more likely to be displaced and are an important predictor of the upcoming health burden (thomas &thomas, 2004, p. 119). during the actual flight, health-related problems are very likely to occur due to lack of capacities for basic needs such as food, shelter and sanitation or lack of access to emergency health care (thomas &thomas, 2004, p. 120). referring to the high vulnerability, women and girls make up more than half of the idps (un, 2021). the lack of reproductive health care and the exposure to sexual and gender-based violence puts them at a high-risk position (gpc, 2010). the post-flight phase of displacement focuses on the general needs by the entire displaced population at the arrival (thomas &thomas, 2004, p. 120). people affected most during the displacement process or those with preexisting health conditions require immediate action upon arrival to prevent further health difficulties. the degree of answering initial needs depends largely on the capacity of the receiving state or province (thomas &thomas, 2004, p. 120). even in places where basic services are provided, the influx of idps in already populated areas may lead to discrimination and tension between the host community and idps due to the competition over resources (ganhri, 2021). additionally, most internal displacements occur in lowand middle-income countries with already limited resources to health (ekezie et al., 2022). in 2020, the idmc has reported that 99,5 percent of conflict driven displacements occurred in lowand middleincome countries (lmic), with syria having the highest population of 6.7 million idps followed by the democratic republic of congo with 5.3 million idps (idmc a, 2022; roberts et al, 2022). the health concerns of idps are heterogeneous and multifaceted as they vary by emergency complexity, migration flow and country of origin (mitra, 2022). looking at existing data on idps health, several studies reported that idps face worse health outcomes than the baseline population in their country (owoaje et al., 2016, p. 169). this can be seen in higher crude mortality rates of idps in camp settings in sudan, democratic republic congo and chad compared with the international emergency threshold (grandesso et al., 2005, p. 1492; depoortere et al., 2004, p. 1318; ahoua et al., 2006). the crude mortality rate gives the average numbers of deaths per 1,000 population within specific period, while the excess mortality rate provides the number of deaths from all causes (ec, 2023; who, 2023). a meta-analysis of combined mortality studies even revealed a significantly higher excess mortality rate of idps than for refugees due to better access to humanitarian assistance (heudtlass et al., 2016). exposure to hazards from their new environment put idps at an increased risk of infectious diseases such as diarrhea, malaria or acute respiratory diseases (cantor et al., 2021). drivers of infectious diseases can be inadequate access to water, food insecurity, lack of sanitation facilities combined with overcrowding in idp camps (ajakaye & introduction 4 ibukunoluwa, 2019, p. 7). the sudden mass movement of people also disrupts the routine immunization services. this leaves idps at increased risk of vaccine-preventable diseases (vpd), particularly measles and respiratory infections (cantor et al., 2021). outbreaks of vpds including measles, meningococcal meningitis, cholera and polio have both been reported in idp and refugee camps across africa (owoaje et al., 2016, p. 169). therefore, vaccination interventions even in insecure settings for refugees and idps are essential to prevent shortand long-term health-related consequences (cantor et al. 2021). the epidemics of infectious diseases also put another strain on the healthcare system of the host country. through social mobilization, well trained health staff and adequate vaccine delivery systems into remote areas could increase the vaccine uptake of idps and refugees (lam et al., 2015, p. 2634). the research on the prevalence of non-communicable diseases (ncd) among idps has been relatively scarce (cantor et al., 2021). the provision of ncd care by humanitarian programmes have mainly focused on the big four, namely cardiovascular diseases, diabetes, chronic respiratory diseases, and cancer. studies in uganda, ukraine and georgia have noted that substance abuse due to psychological distress has been a trigger factor for cardiovascular disease, diabetes and liver diseases (ramachandran et al., 2019, p. 1144; roberts et al., 2011, p. 872; roberts et al., 2014). the body of research on mental health disorders among idps is broader compared with data on physical health outcomes. the lack of health workers and laboratory facilities to diagnose a physical health condition is associated with limited numbers of confirmed cases (owoaje et al. 2016, p. 169). commonly reported mental health disorders identified among idps were depression, anxiety and post-traumatic stress disorder (cantor et al., 2021). the exposure to violence in a conflict setting, the separation of families, impoverishment, the loss of livelihoods and multiple displacements can be all predictors for mental disorders (ganhri, 2021; makhashvili et al., 2014, p. 514). these experiences can occur in all three phases of displacement (thomas& thomas, 2004, p. 125). as for instance post-migration stress adds to the experience of previous traumatic events (silove et al. 2000, p. 604). there is a gap of mental healthcare interventions for idps. the education about mental disorder like anxiety and the provision of group therapy sessions is essential to help idps adjust into a new environment and prevent long term mental health conditions (thomas& thomas, 2004, p. 122) overall, the health concerns among idps not only bring an individual or community burden but also threaten public health systems in the new settlements and host areas. ill-health among idps can lead to adverse socio-economic effects on individuals, as untreated physical and mental health conditions hinder idps to obtain a new job and integrate into a introduction 5 new society (mitra, 2022). humanitarian crises have become more frequent and protracted. they have acute and long-term health impacts, while affecting predominantly populations in lmic. as mentioned before, humanitarian crises affect nearly every aspect of health, such as maternal and child health, infectious diseases, or mental health. neglecting the importance of health in fragile context can be compared with building a hospital without an emergency room (kohrt et al., 2019). recognizing humanitarian health as an integral part of global health is essential to prepare effective multi-agency health interventions (thomas& thomas, 2004, p. 125). 1.2 research relevance and current research state armed conflicts and natural disasters will further threaten the livelihood of vulnerable populations and movements within borders will continue. poor living conditions and limited access to healthcare will have prolonged consequences on idps physical wellbeing and mental health. in terms of international recognition, idps were never accounted as part of the general unhcr mandate (unhcr, 2022). the united nations guiding principles on internal displacement have been introduced into the un commission on human rights in 1998. they have raised awareness on the global crisis of displacements and are an important tool for dealing with situations of internal displacement, but they are not legally binding for any states (cohen, 2009, p. 102). with the lack of coordinated national and international assistance, the humanitarian situation of idps will worsen. not only are internal displacements examples for humanitarian emergencies, but they are also directly associated with challenges of governance, humanitarian assistance and global public health. largescale prolonged displacement can impact the stability and development of host communities and hamper the progress of achieving the sustainable development goals (sdgs) (un, 2021). although the research on internal displacements has been conducted by international entities like the idmc, idps remain underrepresented in academic literature due to missing epidemiolocal and demographic data (heudtlass et al., 2016). the total reported number of idps remains an overall estimate due to high unofficial numbers of idps (fearon, 2012, p. 66). idps remain hard to reach by international agencies due to the dynamics of displacements and restricted access to remote areas (hakamies et al., 2008, p. 34). other challenges of data collection on idps can be security issues due to ongoing conflicts or disease outbreaks (baal & ronkainen, 2017). only a limited numbers of studies have examined the health impacts and health investments of internal displacements. the lack of research investments undermines the low recognition of this global problem (cantor et al., 2022). research on the health of idps in humanitarian settings and developing health introduction 6 priorities is crucial for implementing effective strategies and approaches tailored to the needs of idps (kohrt et al., 2019). 1.3 research objective this research aims to conduct a policy analysis of the involvement of international actors in the humanitarian response of idps with a special focus on addressing the health needs of idps. a theoretical background will be established through the concept of humanitarianism. humanitarianism provides an underlying rationale for action and agendas set up by united nations agencies and non-governmental organizations (pacitto & fiddian-qasmiyeh, 2013). the four principles of humanitarianism namely humanity, neutrality, impartiality and independence built the foundation to humanitarian action and are functional guidelines for humanitarian agencies to provide relief and protection (barnett & weiss, 2012, p. 11 f.). with the aim to deliver live-saving aid to vulnerable groups, humanitarian activities differentiate from activities with political, religious, ideological, or military intentions (ec, 2022). then, the theoretical background will be utilized as a foundation to explain the role of international agencies in the humanitarian assistance of idps. at first, examining the existing international legal framework is needed to show how the rights of idps are manifested in the international law, guiding international standards and national legal frameworks. the right to health for idps will also be part of the assessment on legal protection frameworks of idps. the humanitarian coordination systems for idps will be outlined in the findings. one of the main concepts includes the cluster approach. it is applied by humanitarian organizations, both un and non-un, to coordinate an effective inter-agency response in various key sectors. the cluster approach spreads accountability across different cluster agencies responsible for health, food security, emergency shelter and other areas (unhcr a, 2022). it remains the most suitable humanitarian response mechanism for idps, while the refugee coordination model by the unhcr is applicable for refugee situations. in case refugees and idps are in the same setting, the coordination during mixed situations developed by the unhcr and ocha will be outlined as well (unhcr b, 2019). as the research focuses on the health of idps, the coordination and structure within the health cluster will be further analyzed. for a more practical insight, examples of country operations by the health cluster will be given to show the scope of work with idps. the lack of funding experienced within the idp assistance and the difference to other health development aid will be further discussed in the findings. introduction 7 1.4 research question the central research question for the thesis will be as followed: how are the health needs of internally displaced persons addressed by international actors? the main goal of this research is to analyze how idps are governed on the international agenda and how the health needs are addressed among international stakeholders. the paper will examine the role of international actors in providing protection and assistance to idps, when the national authorities lack the capacity or are unwilling to ensure an effective response to a humanitarian crisis. the mandate of the unhcr and their involvement within the iasc cluster system will be elaborated, as they play a central role in the protection and assistance of idps. subtopics of this paper will focus on the health barriers and vulnerabilities faced by idps as well as the legal frameworks applicable to the protection of idps. theoretical foundation 8 2 theoretical foundation 2.1 concept of humanitarianism humanitarianism is motivated by an altruistic desire with the overall aim to provide relief to victims of human-made or natural disasters (barnett & weiss, 2012, p. 11). the concept of humanitarianism has been an underlying rationale for humanitarian action and has shaped the agendas of humanitarian organizations. the debate over the principles, purposes and politics of humanitarianism reflects the complexity of the humanitarian identity. for many, humanitarianism is not limited to the termination of an emergency and alleviate suffering but is related to broader objectives such as peacebuilding, democracy promotion and development (barnett & weiss, 2012, p. 6). humanitarianism also shares many attributes with the moral-political concept of human rights as humanitarian interventions were rooted in protecting the human rights of innocent civilians (wilson &brown, 2009, p. 4 f.). human rights and humanitarianism both promote the human dignity and human welfare. but they need to be distinguished as humanitarian assistance follows moral principles whereas human rights are grounded in pre-existing international law for the protection of individuals. for instance, victims of human rights violation can seek actively an international criminal tribunal, whereas people in need for humanitarian aid cannot easily make their claim in front of an international setting (wilson &brown, 2009, p. 8). in terms of principles, the seven fundamental principles of the international red cross and red crescent movement unify the concept of humanitarianism. these principles have been adopted in 1965 by the twentieth international conference of the red cross. they consist of humanity, impartiality, neutrality, independence, voluntary service, unity and universality (icrc a, 2022). the first four principles define the core part of humanitarianism, while the last three are additional principles proposed by the icrc. humanity involves the prevention and alleviation of human suffering wherever it may be found. impartiality presumes that that humanitarian aid must be provided solely on the basis of need, regardless of their identity. the third principle, neutrality, means that humanitarian agencies should not take sides in hostilities or being allied to one side. theoretically, this neutrality should give them access to all vulnerable groups and prevents them from becoming targets. independence seeks for the autonomy of humanitarian principles from any political, religious, economic or military objectives (ec, 2022). the voluntary character of humanitarian aid puts forward the nonprofit effort only out of motivation to help without a desire for gain (icrc a, 2022). the principle of unity supports the idea of a humanitarian agency acting as a unifying force, for example there can only be one red cross in a specific territory. ending universal suffering theoretical foundation 9 with a collective response of aid agencies is promoted by the last principle of universality (icrc a, 2022). the seven fundamental principles go beyond an idealistic doctrine as they have operational relevance. maintaining independence and neutrality in situations of armed conflict and hostility reflects one of them (unhcr d, 2022). humanitarianism is a practical endeavor manifested in concrete humanitarian crisis, rather than an abstract idea. it involves the provision of medical care, delivering food, building shelters and protecting the rights of vulnerable groups (barnett & weiss, 2012, p. 7). humanitarian actors involve intergovernmental organizations, including the world food programme (wfp) or the united nations high commissioner for refugees as well as non-governmental organizations like world vision international (barnett & weiss, 2012, p. 13 f.). consistent adherence to humanitarian principles differentiates humanitarian organizations from for-profit relief enterprises. for-profit firms are more bound to contracts and not to the perceived need of a population group. although states and commercial firms provide humanitarian assistance as well, they often have underlying foreign political intentions such as building cooperation or alliances (barnett & weiss, 2012, p.14). the humanitarian sector has persistent gray areas because many humanitarian organizations cannot accomplish the idealized status of incorporating all seven principles. as humanitarian agencies are resourcestarved, they collaborate with other organizations to have the most effective humanitarian response (barnett & weiss, 2012, p. 5). humanitarian agencies like the medicine san frontières (msf) advocate for improving universal access to drugs and thus even hold an influence in political and economic plans (barnett &weiss, 2012, p.15). 2.1.1 the taxonomy of humanitarian action the humanitarian sector has seen an increase in terms of number of aid agencies and diversity of humanitarian action (barnett &weiss, 2012, p. 29). to gain more specific view on different humanitarian action, it is important to conceptualize the kinds of humanitarianism. they present different strategies by humanitarian actors that can be applied in internal displacement situations. the distinction between apolitical and political humanitarian operations is the first dimension. apolitical actions do not aim to change the governance and political agendas that can be an underlying cause of the humanitarian crisis. accepting the constraints and changing the constraints constitute as the second dimension of humanitarian actions. thus, a fourfold classification of the kinds of humanitarianism is established. (barnett & snyder, 2012, p. 145 f.). “a bed for a night” is the first part of the fourfold taxonomy that categorizes different strategies of humanitarian operations. inspired by the book “a bed for a night” from david theoretical foundation 10 reiff, this strategy aims to limit humanitarian intervention only to relief. the author describes the idea of a classical approach to humanitarian action with strict compliance to the principles of neutrality, impartiality and independence. this apolitical strategy allows humanitarian aid workers to help people on all sides of a conflict. accepting constraints is another nature of this approach as it provides short-term emergency relief and accepts the existing circumstances. outcomes of this short-term aid can be dependency and reinforcement of economic and political inequalities. while humanitarian emergencies have become more complex, the bed-for-the-night-humanitarianism has negative side effects and limitations that need to be recognized by aid workers (barnett& snyder, 2012, p. 147 f.) the do-no-harm policy in humanitarian interventions is used by many aid agencies around the world. like the bed-for-the-night-humanitarianism, it aims to remain apolitical while providing relief to the suffering population group. examining the outcomes of the humanitarian assistance and minimizing adverse effects of the intervention also characterizes the do-no-harm policy. this policy goes beyond the classical approach as it looks on long-term consequences of aid. humanitarian assistance should not limit the capacity of self-protection as well as the protection should not expose people to further threats. analyzing the outcomes of aid remains a challenge (barnett& snyder, 2012, p. 149; sandvik et al., 2017, p. 323). the third part of the taxonomy of humanitarian action involves the “comprehensive peace building”. the peace-building strategy is on many agendas of international aid organizations and states. in this approach, the humanitarian aid is part of a broader objective of removing the root causes of conflict (barnett & snyder, 2012, p.150). approaching the causes of the emergency and supporting structures that promote a more stable and peaceful system avoids the relapse into conflict. the peace-building strategy accounts to the development of a new humanitarianism as it partly neglects the principle of neutrality (weiss, 2006, p. 3-4). cooperating with multilateral organizations for more resources of relief-oriented activities and political advocacy for a stable post-conflict setting constitute the peacebuilding agenda. this idealistic goal is hampered by several circumstances. peace building in a setting with the lack of resources, destruction of an infrastructure and continuing interests of the local parties of conflict can be an impossible operation (doyle& sambanis, 2006). transforming a crisisprone state into a liberal democratic state cannot be accomplished within a few months as those countries lack the necessary institutional framework. the un has been involved in over sixty-two peacekeeping operations (un b, 2022). they are described as “multidimensional peacekeeping operations” as they range from the implementation of a peace agreement, performance of mediation to peace enforcement measures. the success of peacekeeping operations is often achieved when local authorities are exhausted by the traces of war and theoretical foundation 11 international incentives for transformation are seen as essential to restore stability in the country after humanitarian emergencies (barnett & snyder, 2012, p.153; un b, 2022). “back a decent winner” is the last component of the taxonomy of humanitarian action. it shares the same goal of the peace building strategy as it tackles the underlying cause of the suffering but remains more modest in its approach. as the name implies, the strategy aims to negotiate with a party that holds the power and is capable of rebuilding stability with the necessary resources. this approach rather accepts the constraints and follows political actions. back-a-decent-winner strategies involve an international recognition of the leading party by the international actors. this strategy can evoke problems as “decent winners” have included controversial cooperation in the past like with warlords in the mozambican civil war or a communist dictator in cambodia. another example has been the pakistan earthquake in 2005. international emergency aid was required and the government under the undemocratic regime of pervez musharraf was selected to provide relief to the victims of the natural disaster while fighting the jihadi terrorism. transforming political, economic, and social structures in pakistan has not been part of their humanitarian agenda (barnett & snyder, p. 154 f.). there is no ideal strategy for humanitarian action, as it varies by complexity of emergency and setting. since the end of the cold war, aid agencies have shifted from providing merely relief with the “bed-for-a-night” strategy to a do no harm and peacebuilding approach. aid agencies have become more aware of the negative outcomes of humanitarian assistance and have started to monitor the impact of aid. nowadays, investing in post conflict transformation and supporting comprehensive peace building plays a significant role for many aid agencies to have sustainable effect for their humanitarian activities (barnett & snyder, 2012, p. 157). 2.1.2 history of humanitarianism to understand the recent developments of the humanitarian sector, it is necessary to show how humanitarianism has evolved its importance in the past. humanitarianism has already been encouraged by a number of world religions as a moral paradigm as well as through enlightment ideas. the establishment of human rights manifestations, including the united states´ declaration of independence in 1776 or the french declaration of the rights of man and of citizen in 1789 contributed to the defense of violated rights (wilson& brown, 2009, p. 9). the contemporary humanitarianism has mainly emerged in the early nineteenth century (forsythe, 2009, p. 59). as a consequence of slave trade and forces of production during the industrial revolution, the alleviation of suffering has become more important to politicians, jurists and members of the church. thus, theoretical foundation 12 humanitarian ideas have been incorporated in social and political reforms, most prominently with abolishment of the british transatlantic slave trade in 1831 (barnett& weiss, 2012, p. 21). the classic humanitarian paradigm has its roots in the dunantist humanitarianism, named after the swiss humanitarian and entrepreneur henry dunant. influenced by the shocking experience of the battlefield of solferino, henry dunant published his book “a memory of solferino” in 1862 to document the lack of coordinated provision of relief to wounded soldiers. he was also responsible for organizing a relief effort while recruiting parts of the local population near solferino. recognizing the human dignity of the wounded and enhancing relief to the suffering lays the foundation of the dunantist paradigm (slaughter, 2009, p. 94). as an official response, the international committee of the red cross (icrc) was founded in 1863 by five members, including henry dunant. the icrc had a primarily coordinating role of military medical services with it headquarter in switzerland (icrc, 2016). another hallmark for the humanitarian movement has been the first geneva convention in 1864. the icrc initiated the first geneva convention to establish a legal framework for international humanitarian actions (forsythe, 2009, p. 72). the treaty was adopted by governments to recognize wounded soldiers and medical personal as neutral. the geneva convention also agreed on the obligation of armies to provide medical care for any wounded soldiers. it also established the unified emblem of the red cross on a white background (icrc, 2016). over the time, more core treaties from the geneva convention on international humanitarian law were introduced and adapted. after the world war ii, the humanitarian system under the icrc was shattered. in 1949, the treaties of the previous three geneva conventions were revised and extended to relief effort for victims of war at sea and prisoners of war. the geneva convention of 1949 also introduced the protection of civilians under enemy control which gives the icrc an essential mandate in today’s increasing armed conflicts (icrc, 2016). the icrc led to the development of today´s 192 national red cross and red crescent societies. according to its principles adopted in 1965, the icrc aims to embody independent, neutral and impartial humanitarian work (forsythe, 2009, p. 76). referring to the classic humanitarian paradigm by henry dunant, humanitarianism is entirely needs-based and is not rooted in any political motives. the classic paradigm is closely related to exceptionalism as a humanitarian crisis is of exceptional nature and differs from normality. this assumption also leads to immediate short-term relief for the victims and shortcycle funding but does not recognize long-term impact of a humanitarian crisis (hillhorst, 2016). an additional part of the dunanist humanitarianism has been the promotion of cosmopolitanism (forsythe, 2009, p. 73). the term international humanitarianism stems from theoretical foundation 13 the idea to relieve suffering that transcends national borders. part of this transnational humanitarian network along the red cross network and nongovernmental organizations (ngo) has been the united nations system (forsythe, 2009, p. 59). the foundation of the unhcr as part of the un system in 1950 was a first attempt for organized disaster response. the unhcr was first designed to act as a protection agency for the legal representation of refugees (forsythe, 2009, p. 62). it was primarily created in light of the aftermath of world war ii to assist around one million european civilians that had to resettle (unhcr c, 2022). the israeli-palestinian war over the territory of british palestine in 1948 led to the establishment of the united nations relief and works agency for palestine refugees in the near east (unrwa). the unrwa has been the first relief agency created by the un and is the only un agency dedicated to one specific group (forsythe, 2009, p. 62). the work of the unhcr increased over the next decades due to decolonization in african countries that led to hundreds of thousands of refugees or the flight of 10 million bengalis to india in 1971 (unhcr c, 2022). until 1970, other un specialized agencies including the world health organization (who) had not yet incorporated humanitarian disasters response in their agendas. the lack of coordination by the un during the well-publicized nigerianbiafra war from 1967 until 1970 led to a higher recognition of complex humanitarian emergencies (goetz, 2001). it triggered the creation of a united nations relief office in 1971, which was changed in 1991 into the united nations office for the coordinator of humanitarian affairs (ocha) (forsythe, 2009, p. 63). the nigerian-biafra war has also risen the debate over humanitarian assistance for idps as well as among the international humanitarian community and the repatriation of unaccompanied children (goetz, 2001). since the 1980s there has been a growth of international and regional organizations for coordinating humanitarian assistance for instance the european community humanitarian aid office (barnett& weiss, 2012, p. 32). un specialized agencies like unicef or the un world food program started to include refugees and idps in their mandate for humanitarian affairs. the unhcr and the unrwa transformed over time from a merely legal protection agency to a relief agency (forsythe, 2009, p. 63). overall, the humanitarian sector has been largely shaped by actions and agendas of northern agents and institutions, specifically the international committee of the red cross (pacitto & fiddian-qasmiyeh, 2013). its humanitarian principles are centered on united nations agencies and ngos. 2.1.3 international humanitarian system in change over time, the concept of humanitarianism has been reshaped and changed due to global developments (munslow, 2019, p. 358). theoretical foundation 14 recent developments have shown that the classic approach of the dunantist humanitarianism has been paralleled or replaced by a resilience paradigm (hillhorst, 2018). as natural disasters have rapidly grown due to climate change and national actors have started to adapt their resources, a new discourse of resilience has evolved. the classic paradigm differentiates between a crisis and normality, whereas the resilience humanitarianism adapts to the protraction and reoccurrence of a crisis. the new way of resilience thinking promotes the engagement of national and local authorities in the humanitarian response. it takes into account the larger control of national players in the service provision and capacity building. recognizing the role of other aid providers, specifically the private sector and local responders, is part of the resilience humanitarianism. it allows to decentralize the state’s power and allows a cooperation with other actors for an efficient response. the resilience paradigm also shifts away from aid recipients seen as victims to survivors or active respondents in a humanitarian crisis (hillhorst, 2018). this different perception of crisis-affected populations can be seen in the annual world disaster report of the international federation of the red cross in 2013. they defined aid recipients as “a significant force of first responders” (ifra, 2013). crisis-affected people become visible as they are primarily responsible for their survival while mobilizing resources provided by aid agencies. they adapt to new realities in a crisis and are engaged in the resilience building on the long-term. a suitable illustration of the continuity of a crisis is the refugee camp setting as refugees stay in camps for a longer period while adapting to the available resources. one major concern of the resilience humanitarianism are the thin boundaries of support of the local institutions and the real risk of abandonment often seen in refugee camps (hillhorst, 2018). the resilience paradigm views the humanitarian system as an ecosystem with different actors involved and not just primarily international humanitarian agencies (hillhorst, 2018). the new realities in a crisis evoked a change of the current models of delivery (munslow, 2019, p. 358). another main critique has been the change from humanitarian aid to development aid. development aid implies the cooperation with governments, which often have their own political agenda and might be one party in a conflict. due to resource constraints, humanitarian agencies partner with the private sector or governments (barnett & weiss, 2012, p. 5). this tendency interferes with the classic humanitarian assumption of impartial and neutral aid. it also makes humanitarianism more of a development issue with the consequence of weaking the immediate humanitarian health care response. the instrumentalization of humanitarianism by governments and non-state actors has been discussed increasingly by the international community over the years (munslow, 2019, p. 359). promoting an early engagement of development and humanitarian actors for a shared theoretical foundation 15 strategic vision has been a proposed solutions developed by the red cross eu office and the icrc in 2018 (red cross eu office& icrc, 2018). other significant developments have transformed the picture of humanitarianism. after the end of the cold war, there has been a global expansion of the humanitarian sector. since the 1990s governments have developed humanitarian units in their foreign offices. the number of ngos also increased and the professionalization within their system. these developments also led to a higher mobilization of humanitarian actors, which can be seen in the global response to the tsunami in 2004 as ngos were providing medical support within hours and states followed with giving their military humanitarian assignments (barnett, 2005, p. 723). but not all developments have had a positive impact on the humanitarian sector. nowadays, several factors pose a threat to the humanitarian sector. attacks on humanitarian personnel or on health facilities have seen a rise over the past decade (munslow, 2019, p. 358). the office for the coordination of humanitarian assistance (ocha) reported that from 2014 until 2017 660 attacks on more than 1,200 aid workers were recorded. there has also been a tendency to more violent attacks as in 2017 44 percent of attacked aid workers were killed (ocha, 2019). the geneva convention of 2019 recognized this as an attack on the humanitarian principles (munslow, 2019, p. 358). the rising climate emergency is another threat to the humanitarian sector, as it also affects social and environmental determinants of health. having a combination of a conflict-driven and climate emergencies create high numbers of displacements and the need coordinated humanitarian action (red cross eu office& icrc, 2018). the politicized purpose of humanitarian aid has been another concern along with the instrumentalization of the humanitarian sector. since the 1990s more humanitarian agencies have become concerned with tackling the root causes of the conflict. humanitarian agencies began to acknowledge the contribution of the state to transform local structures and have started to work alongside governments (barnett& snyder, 2012, p. 152). politicization has been the outcome of this development while undermining the humanitarian principles of independence and neutrality. the complete neglect of humanitarian principles was seen in countries of conflict like kosovo or afghanistan. humanitarian agencies were funded by governments responsible for the crisis. the concern of politized humanitarianism and corruption through the influence of private and state actors remains present (barnett, 2005, p. 724). another significant change has been the decline of direct field work by large aid agencies. most un agencies are confronted with non-operational activities like coordination of local staff and reporting to partners which implies also longer chains of intermediaries. the wfp is one of the only remaining un agencies with real operational capacities on the field along with other international agencies like the msf and the icrc (kent et al., 2016). theoretical foundation 16 taken together, these developments challenge the humanitarian sector. according to the recommendation of the red cross eu office and the icrc, humanitarian aid and development activities should coexist with independent and separated budget. cooperation between these two sectors is needed as humanitarian emergencies have become multifaceted and protracted, but this should compromise the humanitarian principles. investing in the resilience of crisis-affected people and communities while strengthening the local resources will have a long-lasting positive impact (red cross eu office& icrc, 2018). now more than ever, humanitarianism is on the global agenda and has expanded features like human rights, democracy building and economic development (barnett & weiss, 2012, p. 6). these developments within the humanitarian architecture help to conceptualize the role of international actors in the humanitarian assistance of idps. methodology 17 3 methodology this chapter describes the literature search and why certain material is used for the policy analysis on the health of idps. the problem of poor health outcomes among idps has been identified in the introductory part of the paper through scientific research on the health of idps from databases like pubmed. a policy analysis on the legal frameworks applicable for the protection of idps, involved stakeholders and humanitarian coordination mechanism follows through reviewing existing literature. to start with, a major source of information has been credential websites of international organizations like the unhcr, the ocha, the who and the iasc. through these websites, key terminologies, such as “cluster approach” were specified and important stakeholders for idps like the unhcr were identified. databases like refworld managed by the unhcr serve as a leading source of information to gather documents about refugees and idps. the database reliefweb, managed by the ocha, is a humanitarian information source where reports such as the yearly humanitarian response plan are published. both databases have been used with the key terminologies to find idp related documents. in addition, important documents and reports have been utilized from the website of the unhcr, ocha or the health cluster itself. these documents involved the policy on unhcr's engagement in situations of internal displacement, the unhcr global appeal, or the joint unhcr-ocha note on mixed situations. the unhcr emergency handbook gives clarification on the humanitarian coordination mechanisms, namely the cluster approach for idps and the refugee coordination model for a refugee situation. the who has also released a health cluster guide in form of a handbook which has been examined in the result chapter. referring to the legal frameworks, the handbook for the protection of internally displaced persons published by the global protection cluster clarifies the rights of idps manifested in international and national law. the guiding principles of internal displacement published by the ocha were also assessed as the main legal guidance for idps. a literature review on the health financing of idps has been conducted through scientific research on pubmed. key terminologies for the advanced search on pubmed comprised “health financing”, “idps”, “internally displaced persons” and “health overseas development aid”. to extend the systematic research, boolean operators such as “and” have been used. the search history on the health financing for idps has been added to the appendix. the study by robert et al. on the health overseas development aid for idps has been identified as the only one on its field. methodology 18 information on health cluster operations were given on pubmed through a study by bile et al. analyzing the health cluster operation in pakistan 2007 and through the humanitarian response plan of iraq. the health cluster bulletin published under the who gives country specific emergency situational updates, while including information about idp numbers and involved stakeholder in the health response. results 19 4 results 4.1 legal protection frameworks for idps internally displaced persons are entitled to enjoy the same rights and freedoms on an equal basis like any other person in the same country without discrimination under international and domestic law. the protection of idps is primarily manifested in national law as states are responsible to grant individual rights for their citizens or habitual residents without differentiating in the status of their displacement. although national law forms the primary legal framework for idps, international law should be incorporated in the state’s legal obligation to ensure the rights of idps (ganhri 2021; gpc, 2010). examining the existing international and national legal frameworks is essential to understand how humanitarian assistance for idps is grounded in protection of their basic rights. this chapter also covers the right to health for idps. 4.1.1 international law despite the lack of a legally binding global treaty targeted for the protection of idps such as the 1951 refugee convention, they are still protected through various bodies which includes national law and international law (icrc, 2002). international law derives from international treaties as agreements between states and from customary international law as “a general practice accepted as law” (icrc, 2010). the protection of idps by international law can be divided into three sub-branches of law which are applicable for all situations of internal displacement, including situations of armed conflict (ghráinne, 2021, p. 367). the three bodies of law consist of international human rights law, international humanitarian law and international criminal law (gpc, 2010). international human rights law applies to both times of war and peace and obliges states to guarantee human rights to all residents (ganhri, 2021). human rights are part of the international customary law which includes norms like the right to life, prohibition of torture, freedom from discrimination based on gender and race, or the right to peaceful enjoyment of property (gpc, 2010). many of these rights are particularly relevant for idps during all stages of their displacement. the rights to food, shelter, education and access to healthcare as well as the right to personal safety are part of the rights ensured by international human rights law (icrc, 2002). a number of international human rights instruments have been implemented and accepted by states in the past decades. the universal declaration of human rights in 1948 or convention against torture and other cruel, inhuman or degrading treatment or punishment in 1984 are part of these human rights instruments (gpc, 2010). results 20 regarding the legal protection of idps, a global advocate position has been established in 2010 with the “special rapporteur on the human rights of internally displaced persons by the human rights council” (gpc, 2010). the mandate was created to engage in the advocacy and dialogue with governments and international actors for protecting the human rights of idps. reporting to the united nations human rights council and the united nations general assembly is also among the task of the mandate. the special rapporteur also works towards strengthening the international response to the crisis of internal displacement. the position demands also undertaking country visits as well as funding research related to internal displacement (gpc, 2010; ohchr b, 2022). international humanitarian law also provides a legal body involved in the protection of idps rights as it applies in situations of armed conflicts (ganhri, 2021). idps are protected as citizens of their country under international humanitarian law as long they do not take part in hostilities (icrc, 2018). international humanitarian law (ihl) is legally binding to all parties of an armed conflict. ihl applies human right principles in a situation of armed conflicts, which involves also the right to freedom of movement. prohibiting forced displacement as well as attacks on the civilian population is among the core values of international humanitarian law. the use of civilians for military objectives or the starvation of civilians as a method of warfare is also always prohibited. displacement can only be allowed in special circumstances on a temporary basis when the security of civilians or military imperatives absolutely requires it. this also implies safe and humane conditions during the displacement and the right to voluntary return in safety to their homes or habitual residence (icrc b, 2022). families are also protected under ihl as parties of the armed conflict have to ensure that families are not separated and measures to facilitate a reunification should be taken (gpc, 2010). access to essential medical services for the wounded and sick should be established by the parties to the conflict (icrc b, 2022). key instruments of ihl have been implemented which include the four geneva conventions from 1949, particular the fourth geneva convention on the protection of civilians and two additional protocols. the rules of customary international humanitarian law are also law binding to all parties of a conflict and to the work of international humanitarian organizations (henckaerts & doswald-beck, 2009). the resolution of the united nations security council from 2000 puts a special focus on the peacekeeping missions for the protection of civilians as victims of conflict, most prominently affecting idps (gpc, 2010). international criminal law provides another body of law protecting idps from violations of international human rights and humanitarian law (gpc, 2010). national authorities are obliged to criminalize international crimes such as war crimes, crimes against humanity or genocide in their national legalization as well as the prosecutions in national courts results 21 (ganhri, 2021). the international criminal court is a judicial body that only exercise jurisdiction when national courts have failed to prosecute and punish those crimes (encyclopedia britannica, 2022) 4.1.2 the guiding principles on internal displacement although there is no legally binding instrument, such as a treaty dedicated to idps, the guiding principles of internal displacement represent a practical guideline for governments, intergovernmental organizations and ngos involved in the work with idps (ocha, 2004). initiated in 1998 by the first representative of the secretary-general on the human rights of internally displaced persons, they consist of thirty principles (ganhri, 2022). the guiding principles of internal displacement are based on legally binding standards of international law applied to the situation of idps (gpc, 2010). they circle around protecting and addressing the needs of idps at all stages of displacement (idmc b, 2022). after defining idps and explaining the purpose of the principles, the first four principles address the responsibility of national authorities to protect and assist idps as well as the entitlement to the same rights and freedoms without discrimination. the fourth principle takes into account the special needs of the most vulnerable people, primarily unaccompanied minors, expectant mothers or disabled people (ocha, 2004). principles five to nine deal with the protection from arbitrary displacement (idmc b, 2022). in this section, the unlawfully displacement of idps is even further elaborated compared to international law as it prohibits displacement due to ethnic or racial reasons, a collective punishment or as result of armed conflict unless evacuation is needed. the protection during displacement is covered from principle ten to twenty-three as they restate the civil, social, economic, and political rights of idps (ocha, 2004). this section targets different rights including the right to safe access to essential food, potable water, basic shelter, medical services and sanitation, the right to education and training without discriminating based on gender and the right to freedom of movement, in and out of idp camps (ganhri, 2022). the fourth section encompasses principles relating to humanitarian assistance (ocha, 2004). it allows international organization to provide services to idps when national authorities are unable to do so, as long these services do not interfere with states internal affairs (ocha, 2004). this again relates to the principles of impartiality and humanity as humanitarian assistance should focus on rapid relief of suffering without taking political sides (ganhri, 2022). the last section is concerned with the return, resettlement, and reintegration of idps. safely returning to their homes or voluntarily resettling in another region of the country as well as reintegrating into society through the right of participation in public affairs are all part of the durable solutions to displacement (gpc, 2010). results 22 the guiding principles may seem rather informative, but they allow to monitor to which extent the rights of idps are guaranteed in the country as well as advocating for the needs and rights of idps in national legal frameworks (gpc, 2010). on a global scale, the guiding principles on internal displacement have been recognized by national authorities as a significant tool for the response to idps. they have achieved considerable authority as the principles are reflected in national law of several countries. in the legal framework of angola, the rights of resettlements of idps have been strengthened or in peru the material compensation for idps has been covered in new laws (cohen, 2004, p. 470). un agencies and ngos have translated the guiding principles into over forty languages (gpc, 2010). but there remains a lack of legal protection obligation of idps which echoes the need for improving the institutional framework for idps (cohen, 2009, p. 104). the un principles on housing and property restitution for refugees and displaced persons, also called pinheiro principles, built another international legal framework for both idps and refugees (ganhri, 2022). adopted in 2005 by the sub-commission on the promotion and protection of human rights, they address the housing, land and property rights issues of displaced populations. as properties and homes of refugees and idps are unprotected during their flight, the pinheiro principles provide practical guidance on the postconflict restitution of property for refugees and idps (anderson, 2011, p. 305). 4.1.3 national legal frameworks the responsibility of protecting idps relies primarily on national authorities. some countries and regions have established national legal frameworks concerning idps in line with the guiding principles of internal displacement (gpc, 2010). the african union convention has been the first to develop a legally binding regional framework on internal displacement (ganhri, 2022). it is based on the pact on security, stability and development in the great lakes region that has been implemented by the members of the great lakes region member states (beyani, 2007, p. 173). two out of the ten protocols are specifically important to internal displacement: “the protocol on the protection and assistance to internally displaced persons” and “the protocol on the property rights of returning persons” (ganhri, 2022). the first mentioned protocol obligated governments to integrate the guiding principles into their national legislation. the africa union convention for the protection and assistance to internally displaced persons, also called kampala convention, has been developed in 2009. the kampala convention has become effective in 2012 and since then thirty members of the african union have become part of it. as it enhances compliance to the idp protection, the kampala convention targets results 23 different responses practices during all stages of displacement and to the displacement setting in africa (ganhri, 2022). despite the emphasis of other regional organizations like the council of europe to apply the guiding principles to their national policies, the kampala convention remains the only legally binding regional framework on internal displacement (icrc, 2020; ganhri, 2022). 4.1.4 the right to health for idps in order to examine the health rights of idps, it is necessary to define what are health rights. according to the who, health is not merely the absence of a diseases, but a state of complete physical, mental and social well-being. as a fundamental human right, health is an inclusive right. the right to health is linked to other determinants for enjoying the highest standard of health including access to safe water, food, shelter and sanitation (bermudez, 2022). other determinants such as the right to education, especially health literacy, and housing also impact the level of well-being. to the un committee on economic, social and cultural rights (cescr) has formulated in the general comment no. 14 various aspects of the right to health. it also encompasses the right to health facilities, goods and services based on an equal treatment without discrimination (cescr, 2000). the figure below illustrates different sectors that are connected with the protection of the health rights of idps (bile et al., 2011, p. 983). figure 2: protection of specific human rights during disasters (source: bile et al., 2011, p. 983) regarding the health rights of displaced population, the refugee convention from 1951 already emphasizes the right to the same access to medical services for displaced populations compared with the host population (bermudez, 2022). the guiding principle 19 results 24 specifically addresses the right to healthcare for idps, which is continuous through all phases of internal displacement. the health needs of women such as access to reproductive healthcare and mental support for victims of sexual abuse are also mentioned in principle 19. special attention is given to the prevention of infectious diseases like hiv among idps (ocha, 2004). the guiding principle reflect the right to healthcare and the right to healthy environment for idps as they support the combination of clinical and preventive perspectives (kaelin et al., 2010). referring to psychological services, the inter agency standing committee (iasc) has passed the guidelines on mental health and psychosocial support in emergency settings. they put forward the idea of psychological care as an integrated crosssectoral approach between host and displaced communities. the iasc guidelines also highlight the psychological impacts of emergency settings and the need for long-term mental healthcare of the affected population (iasc, 2007). in 2021, the un secretary’s high-level panel on internal displacement highlighted in its final report the urgency of psychological support for the recovery of traumatic experiences of idps (bermudez, 2022). the inter agency field manual for reproductive health in emergencies has been revised in 2018 and presents another global standard used response to reproductive health service during humanitarian emergencies (foster et al. 2017, p. 18 f.). the sphere humanitarian charter and minimum standards in disaster response gives an insight on how people affected by disasters should have access at least to a minimum standard of healthcare (sphere association, 2018). prioritizing health interventions that reduce main causes of excess mortality and morbidity is among the minimum standards. a disease surveillance system is essential to prepare for displacement-related health emergencies and to document and monitor the emergence of infectious and noncommunicable diseases (sphere association, 2018). the support of a standardized health information system in humanitarian emergencies is also needed for health agencies to collect relevant data on demographics, morbidity and mortality. other minimum standards formulated in the sphere handbook include the establishment of a health infrastructure and the eligibility of displaced populations to primary health care and clinical services. the handbook is a leading guideline for humanitarian agencies to supply displaced populations with basic services such as water, sanitation and shelter (kaelin et al., 2010). referring to health in humanitarian settings, a resolution by the 58th world health assembly in 2005 on health interventions during times of crisis has been passed to ensure that member states provide access to essential health care for all affected populations, including idps. similar to the sphere handbook, it prioritizes on the health needs of those most endangered and pays attention to maternal and newborn health (kaelin et al, 2010). three years later, the 61st world health assembly passed another resolution on the health of migrants, asylum seekers and refugees (bermudez, 2022). idps are implied in this resolution results 25 as migrants who do not cross borders. the resolution urges member states to implement migrant-sensitive health policies (who, 2010). an example country having implemented a national law for the right to equitable access to health services for idps has been colombia. the government passed a law in 1997 that guaranteed registered idps access to public primary health services. however, the law was limited in 2003 by a government decree that proposes unlimited access to health services only to idps with health insurance but lacking the financial means. the decree decentralized the accountability for idp health services on local authorities. this illustrates barriers to healthcare due to lack of documentation or health insurance and thus leaves idps only eligible for emergency medical services (kaelin et al., 2010; bermudez, 2022) overall, guiding concepts for health in humanitarian settings have been developed and revised over time by international organizations ensuring equal access to essential health care for idps. through international humanitarian law, idps and their well-being remain also protected in times of armed conflict (bermudez, 2022). results 26 4.2 humanitarian coordination systems for idps 4.2.1 unhcr mandate for idps refugees, returnees and non-refugee stateless person fall under the core mandate of the unhcr (unhcr e, 2022). the unhcr does not hold an exclusive or general mandate for coordinating the assistance of idps but remains the lead agency in the protection for people affected by forced displacement, including idps (unhcr, 2009; unhcr e. 2022). according to the global focus, unhcrs operational reporting webpage, the unhcr is engaged in 33 operations concerning the response to internal displacement (unhcr d, 2022). in the global appeal, the unhcr has also estimated among the 117.2 million forcibly displaced or stateless people that 61.2 million people will be considered as idps under their mandate in 2023 (unhcr f, 2022). a legal basis for unhcrs engagement with idps offers the un general assembly resolution 48/116 from 1994 it reaffirms the support through humanitarian assistance and protection for idps by the unhcr. the resolution recognizes the need for engaging with other un agencies like the department of humanitarian affairs, later renamed ocha, and international organizations like the icrc (unhcr b, 2019). the unhcr has released a number of documents on their guidance and policies with idps. those involve the policy on unhcr's engagement in situations of internal displacement and the guidance package for unhcr's engagement in situations of internal displacement, both revised in 2019 (unhcr a, 2019; unhcr b, 2019). the unhcrs initiative on internal displacement 2020–2021 provides information on the nine target country operations namely: afghanistan, burkina faso, colombia, the democratic republic of the congo, ethiopia, iraq, south sudan, sudan and ukraine (unhcr g, 2022). the report also demonstrates the main cornerstones of unhcrs work with idps as they involve delivering technical capacities, emergency preparedness and coordinated leadership (unhcr, 2021). in the next part of the paper, humanitarian coordination systems applied in situations of internal displacement will be outlined. the involvement of the unhcr in the humanitarian response for idps and the health cluster approach targeting the health needs for idps will be analyzed as well. https://www.refworld.org/docid/5d83364a4.html https://www.refworld.org/docid/5d83364a4.html https://www.refworld.org/docid/5d8335814.html https://www.refworld.org/docid/5d8335814.html https://reporting.unhcr.org/afghanistan https://reporting.unhcr.org/burkinafaso https://reporting.unhcr.org/burkinafaso https://reporting.unhcr.org/colombia https://reporting.unhcr.org/drc https://reporting.unhcr.org/ethiopia https://reporting.unhcr.org/iraq https://reporting.unhcr.org/southsudan https://reporting.unhcr.org/sudan https://reporting.unhcr.org/ukraine results 27 4.2.2 cluster approach one of the main concepts of humanitarian coordination systems includes the cluster approach. it is applied by humanitarian organizations to coordinate an effective inter-agency response in various key sectors (unhcr a, 2022). initiated within the un humanitarian reform agenda in 2005, the inter agency standing committee formed a “cluster leadership approach” (ocha, 2020). the un humanitarian reform was designed to create higher levels of predictability and strengthened leadership in the humanitarian response for idps. after the lessons learnt from two natural disasters in haiti and pakistan during 2010, the transformative agenda by the iasc was developed to create quicker response to a suddenonset humanitarian crisis, also called level 3 emergency. the cluster approach spreads accountability across different cluster agencies responsible for health, food security, emergency shelter and other areas. at the global level, each cluster is headed by an international organization with a specific expertise in a sector, called the “cluster lead agency” (unhcr a, 2022). the cluster approach can be applied at country level when cluster lead agencies, such as the who for health, work together with governments and ngos. in this case, the responsibility for coordinating and delivering the international humanitarian response within the country relies on the humanitarian coordinator (hc). enhancing the activation of the cluster-based response in alliance with the host government is among the tasks of the hc. the hc leads the humanitarian country team which consists of representatives of responsible un agencies, ngos and local authorities. the humanitarian country team (hct) is involved in the strategic decision-making in the crisis country, which is based on needs assessment and gap analysis. the cluster strategy is not only applicable in phases of disaster response but can also be applied through an early recovery cluster. additional members or observers of the hct can include the icrc or msf. both cluster lead agency and the hc are accountable to the emergency relief coordinator (erc). as undersecretary-general for humanitarian affairs and head of the iasc, the erc holds responsibility for all un humanitarian actions in complex emergencies. the erc is also entitled to elect a hc for a country affected conflict and disaster (ocha, 2020; unhcr a, 2022). the main objective of this collaborative approach is to fill responsibility gaps and to achieve a coordinated humanitarian response. it also aims to improve cross-sector partnerships as governments can co-lead clusters on a national level and ngos are able to co-chair the cluster along the lead agency (unhcr a, 2022). the cluster approach enhances technical capacities for an overall system wide preparedness (ocha, 2020). this cooperation should be in accordance with the humanitarian principles. results 28 the figure below presents the cluster approach with all currently existing eleven areas of humanitarian interventions lead by the responsible cluster lead agency through all phases of humanitarian coordination (unhcr a, 2022). figure 3: the cluster approach with the cluster lead agencies (source: unhcr a, 2022) as illustrated above, the unhcr leads the global protection cluster. several areas of responsibility are included in this cluster as it protects the affected populations, in particular idps, from human rights violations (unhcr a, 2022). those areas are sub coordinated by agencies like unicef for child protection, the united nations population fund for the protection against gender-based violence or the norwegian refugee council or housing, land and property. together with the international federation of red cross and red crescent societies (ifrc), the unhcr co-leads the global shelter cluster. the global camp coordination and camp management (cccm) cluster has the unhcr and the internal organization for migration (iom) as co-leads (unhcr a, 2019). as stated in the guidance package for unhcr's engagement in situations of internal displacement, the unhcr is required to have a minimum cluster capacity in order to lead a cluster at country level. skilled experts for leading the luster coordination or technical tools for information management are needed for an effective cluster response (morris, 2006, p. 54). in case a level 3 emergency occurs, the unhcr representatives can request the unhcr lead clusters to deploy technical capacities on a temporary basis (unhcr b, 2019). https://www.refworld.org/docid/5d8335814.html results 29 according to the policy on unhcr’s engagement in situations of internal displacement, the unhcr leads the shelter and cccm cluster at national level during a conflict induced crisis. as for the protection cluster, the unhcr can lead both scenarios when a disaster-induced displacement requires the in-country presence of the unhcr with the government request (unhcr b, 2019). the unhcr aim during all idp interventions is to strengthen the internal tri-cluster synergies, including by mainstreaming protection across all sectors (unhcr a, 2022). the unhcr has also been involved in other global clusters operating in internal displacement settings due to their expertise about idps. they have been part of activating early recovery clusters, as the unhcr is interested in providing durable solutions for idps through reintegration and return interventions while working with involved ngos. in the wash, sanitation and hygiene (wash) cluster, the unhcr has played an important role in developing guidance tools, providing technical capacities in field operations or in leading subproject to enhance technical advice. as a member of the steering committee within the global health cluster, the unhcr has been responsible for creating a health-nutrition tracking system (unhcr, 2009). many deaths during humanitarian crisis are attributed rather to communicable diseases and malnutrition than to violence. therefore, assessing the nutrition and health status of crisis affected people through an inter-agency evaluation framework is essential (iasc, 2007). additionally, the health information system toolkit is mostly used by the unhcr to monitor the health data from crisis affected people, including refugees and idps. information on vaccination status, hiv/aids status or number of maternal deaths are collected and stored among different sectors, such as the wash cluster (unhcr, 2010). concerning hiv and aids among refugees and idps, the unhcr plays a pivotal role in the international hiv response during humanitarian emergencies. as a cosponsor of the united nations program on hiv/aids (unaids), the unhcr brings together an inter-agency task team for the hiv response under the lead of unaids. having set up several hiv programs in african countries, the unhcr negotiates between governments dealing with an hiv epidemic and other international organizations. key areas of their hiv response operations include facilitating the availability of antiretroviral therapy for risk groups or the access to quality-assured hiv testing in refugee camps. advocacy for including displaced population in national hiv plans as well as for programs against sexual and gender-based violence are among the responsibilities of the unhrcr in the hiv response (unaids, 2022). results 30 4.2.3 the joint unhcr-ocha note on mixed situations in a non-refugee crisis, the cluster approach is used as governments are limited in their capacities responding to a larger crisis and a multi-sectoral humanitarian response is required. the refugee coordination model is applied by the unhcr in response to a refugee crisis. in case the crisis-affected population contains both refugee and idps, the joint unhcr-ocha note on mixed situations: coordination in practice gives practical guidance (unhcr a, 2022). the note clarifies the role of the unhcr representative and the humanitarian coordinator in a mixed setting. the practical interaction between the iasc cluster coordination, primarily dedicated for idps, and the unhcr coordination of refugees is proposed in the joint note (unhcr b, 2019). when idps and refugees are in a geographically separated setting, operational coordination and delivery is performed separately. the iasc cluster coordinate and deliver service for idps and the unhcr sector applies their humanitarian response to refugees, while both parts share information on national level. if refugees and idps are in the same geographic area, the emergency relief coordinator and high commissioner decide if iasc cluster or the unhcr sector is utilized for assistance delivery for both affected populations based on the available capacities. during an iasc cluster for a geographically mixed situation, the unhcr can enhance a protection working group and a refugee expert interacting within each cluster member for the needs of refugees. the humanitarian coordinator is accountable for idps and deployment of capacities during the delivery through the unhcr sector. sharing information between the inter-cluster coordinator and the unhcr refugee coordinated is substantial for mutual coordination. the note further outlines the role of the unhcr representative and humanitarian coordinator in different areas of responsibilities. an underlying rationale of the note is that the agency-specific response complies to the overall iasc coordination through sharing situational analysis of the humanitarian crisis and engaging in the humanitarian country team. the arrangement seeks to avoid duplicated delivery and enable a coordinated response even in a mixed situation (unhcr, 2014). an additional iasc arrangement has been made through the united nations secretary general’s (unsg) decision no. 2011/20 on durable solutions for idps and refugees returning to their country of origin (unsg, 2011). the decision authorizes the resident/humanitarian coordinator to guide the development of durable solution strategies together with national authorities (unhcr b, 2019). at the country level, the decision designates inter-cluster working groups to develop early recovery clusters with the coordination of the protection cluster. on the global level, the undp and unhcr are selected as the lead agencies for early recovery and protection through resources and expertise (unsg, 2011). results 31 4.2.4 health clusters the global health cluster, led by the who, focuses on alleviating suffering and restoring the well-being of affected population in humanitarian emergencies through coordination and provision of technical support (health cluster, 2022). as the global lead agency, the who is accountable to the emergency relief coordinator to fulfill its responsibilities. those responsibilities involve incorporating the cluster approach and following the protocols of the transformative agenda to build stronger partnerships with other global clusters. during a health cluster activation, the who commits to sharing leadership and coordination responsibilities with national authorities and ngos working in the health sector (who, 2020). the global health cluster also shows the interlinkages between health and human rights, as the global health cluster works towards ensuring the right to health during emergencies which is integrated in the human rights protection of the cluster approach (gpc, 2010) during a level 3 emergency, the iasc humanitarian scale-up activation will be applied as a system-wide humanitarian response for a short-term period of six months. the urgency, complexity, and scale of the emergency are considered before the scale-up activation is initiated. the urgency criterion for the system-wide mobilization also looks at the number of people displaced and the crude mortality rates. within 72 hours, a humanitarian country team will be established, and a central emergency response fund will be by deployed be the erc. as stated in the health cluster guide, the who is accountable for assessing the risk of an infectious disease event through information flows with their country offices, governments, the global outbreak alert and response network and other un agencies like the food and agriculture organization of the united nations (who, 2020). the assessment of an infectious disease outbreak by the who is in alliance with the international health regulations from 2005. this process is also manifested in the protocol for the control of infectious disease events, as the need for a scale-up response to a public health emergency, will be expressed by the director-general of who towards the erc and the united nations secretary-general within 24 hours. the final decision will be made by the erc influenced by the director-general of who and the iasc emergency directors group (who, 2020). the figure on the following page presents the five key criteria for a scale-up activation. when a country health cluster is activated, all health agencies on a national level are encouraged to participate in the joint health emergency response for the affected area (who, 2020). those partnerships with national health authorities or ngos built upon the five principles of partnership. developed by the global humanitarian platform (ghp) in 2007, the principle consists of: equality, transparency, results-oriented approach, responsibility and results 32 complementarity (ghp, 2007). at the current state, there are around 900 partners at country level of which 60 partners engage strategically at global level (health cluster, 2022). the structure of the country health cluster is usually formulated in the terms of reference, which is a management tool released in the first five month of cluster activation. depending on country and context, a health cluster at the national level involves a strategic advisory group and technical working groups. the strategic advisory group serves as a decisionsmaking forum of multiple health cluster partners through elected representatives. providing technical support and guidance on a specific aspect of the health response, such as hiv and tuberculosis, relies on the technical working group. the decision to form a technical working group will be made by the strategic advisory group or the health cluster coordination team. part of the iasc cluster system is also the minimum initial service package for sexual and reproductive health. at the onset of a humanitarian emergency, the who has to identify an agency, often the united nations populations fund, which provides emergency and comprehensive sexual and reproductive health interventions. this approach goes beyond clinical care for the response of gender-based violence as the sexual and reproductive health coordinator and the health cluster coordinator cooperate with other sub-clusters, especially the protection cluster, for preventive measures. at the subnational level, the health cluster vary by region and local circumstances. as a more decentralized coordination mechanism, the subnational clusters are directly responsible for the implementation of the humanitarian response plan and work directly with local partners. articulated in the terms of reference, the links are established between the national and subnational clusters through information sharing, regular meetings between both cluster levels and promoting compatibility of national health programs (who, 2020). other coordinating bodies participating in health emergency operations can be the emergency medical teams (emt). emts have been first initiated as a response to the earthquake in haiti from 2010 and since then have proven to be effective, for instance in the west african ebola (2014–2016) outbreak response. they comprise all clinical teams that are involved in the delivery of healthcare during an emergency response. as groups of health professionals, emts vary from doctors to paramedics and can stem from governments, ngos, the military or international humanitarian networks, such as médecins sans frontières (who, 2021). the emt network can be coordinated by the ministry of health within the national health emergency operations center or by the who (who, 2020). for more clarification, the figure on the following page visualizes the country health cluster structure. results 33 figure 4: typical country health cluster structure (source: who, 2020) 4.2.5 health cluster operations in idp settings to have a more practical view about the emergency health response to idps, this chapter provides an insight on the places and scope of health clusters activated in idp settings. health clusters have been implemented during internal displacement situations in countries around the world. currently, there are 31 health clusters/sectors, of which two are regional coordination mechanisms (health cluster, 2023). an example for an effective emergency health response through the cluster approach has been seen in pakistan. as a result of armed conflict in districts of the khyber pakhtunkhwa province and the federally administered tribal areas in 2008, 2,7 million people had to leave their homes. this led to a mobilization of 46 humanitarian partners within the health cluster led by the who and the local health authorities (bile et al., 2011, p. 981). delivering essential life-saving primary health care (phc) services to the affected population, including returnees and idps, has been the main goal of the established health cluster. as 60 percent of idps were displaced mothers and children, relief interventions within the phc delivery focused on maternal, neonatal and child health care. in advance, a rapid health needs assessment was conducted by the who field teams in the hosting communities. disparities in access to healthcare were found between ipds living in camps having better access to results 34 healthcare than idps hosted by families. strengthen phc capacities in hospitals and local facilities has been a response of the health cluster partners to this emerging disparity. official registration of all idps was initiated by the national disaster management authority through the technical support of the national database and registration authority and the unhcr (bile et al., 2011, p. 982 f.). within the registration process of idps, the protection cluster was responsible for registering 1100 unaccompanied children as well as about 3500 families headed by children or women. the detection of communicable diseases in the humanitarian crisis was enabled through disease early warning system surveillance networks. noticeably, higher diarrheal outbreaks rates among idps as result of cholera were detected compared to outbreaks during the earthquake in 2005. to prevent further infectious diseases, safe water access through water chlorination and equipment of sanitation facilities with hand washing sinks was established (bile et al. 2011, p. 986 f.). more recent examples of activated health clusters give countries like iraq. the humanitarian response plan of 2022 reports that 2.5 million people are in need, out of which 961,000 people require acute humanitarian assistance (ocha, 2022). as the infrastructure and livelihoods of millions has been damaged due to military operations against the islamic state of iraq and the levant since 2014, 6.1 million people have been displaced. although 80 percent of the displaced people were able to return home after four years, 1 million people remain classified as idps. despite having built up a more stable environment during their protracted displacement, informal settlements, lack of healthcare access and sanitation facilities put idps in the most vulnerable position. in total, 180.000 idps living in camp, 234,000 idps out of 549,000 idps living out of camp, and 577,000 out of 1.7 million returnees are critical humanitarian need. they constitute as a heterogenous groups as they face different needs. for instance, idps living in camps often lack a member of their household and have lack of civil documentation. as result of high dependence on governed assistance and humanitarian aid, access to healthcare, water and sanitation varies on the contingent of the provider. out-ofcamp idps have developed different coping strategies due to critical shelter and limited access to basic services such as phc (ocha, 2022). according to the health custer bulletin of august 2021, the health cluster in iraq has provided basic emergency healthcare in idp camps and return areas. vaccination efforts against covid-19 were also implied in the c, as the unhcr has reported high number of covid-19 cases in idp camps. the health cluster in iraq comprises 29 partners, such as 5 international ngos, 10 national ngos, 4 un agencies and 2 national authorities (health cluster, 2021). a decrease in partners and funding took place in 2021, which leaves the government and development actors responsible for establishing longer-term recovery services. the humanitarian response plan estimated the financial requirements for the iraq health cluster in 2022 of 46.8 million usd. contribution to achieving durable solutions has been made results 35 through public health system strengthening efforts. more specifically, cash and voucher assistance to reduce financial barriers for health services has been developed by the cash working group, the health cluster and the protection cluster and will be continued by the ministry of health (health cluster, 2021). 4.3 health funding for idps the last section of the results comprises an insight of the health overseas development funding for idps. a detailed insight on the health spending for idps gives the study by roberts et al. published in 2022, which also remains to this extent the only one on this field. the study examines the health-related official development assistance for lmic by international donors that target the health needs of idps. official development assistance (oda) can be provided by bilateral government donors, global health initiatives, such as the global fund, or philanthropic institutions, like the bill and melinda gates foundation. recipients of oda often are country governments, ngos or un agencies. the study gathered data on health oda disbursement from 2010 to 2019 through the creditor reporting system database, which has been established by the organization of economic cooperation and development (oecd). the findings showed that there has been a decrease of health oda for idps by 38 percent, as the health oda per idp capita changed form 5.4 us dollar (usd) in 2010 to usd 3.72 in 2019. main providers of oda for idps are the global fund, the governments of countries like germany, the united states, canada as well as the european union. other donor agencies such as the central emergency response fund with 1.2719 million usd and the world bank with 17.4977 million usd, whereas global alliance for vaccines and immunization (gavi) reported none. the objectives of health oda focused on funding basic services, such as malaria and tuberculosis control, followed by funding reproductive health programs targeting hiv/aids control. ncd control, including mental health services, received lower levels of oda, despite the increasing burden of cardiovascular diseases and mental disorders in conflict affected people (roberts et al., 2022). additionally, the study investigated on the health oda for refugees. in contrast to the decrease of health oda per idp capita, the findings revealed the health oda increased by 14 percent with usd 18.55 in 2010 and usd 23.31 in 2019. in general, the average health oda spent for refugees is six times higher than that of idps. possible explanations of this disparity can be the inclusion of idps as entitled citizens into domestic health services. the database may have also excluded data on health oda for idps as they were already implied in pooled funding mechanism for countries dealing with internal displacement (roberts et al., 2022). the authors conclude from the findings that idps are given lower priority by results 36 international and national stakeholders due to a lack of international legally binding framework (hakamies et al., 2008, p. 40; cantor et al., 2021). this indicates that there is a general need to even up the health oda for idps towards that of the refugees (roberts et al., 2022). the figure below illustrates the oda disbursement, and the number of idps and refugees. figure 5: health oda (usd per capita) explicitly for idps and refugees (2010–2019) (source: roberts et al., 2022) the lack of funding is not only an issue concerning idps, but also the cluster system. as for the global health cluster which targets 97.8 million people in need, only 34 percent of the requested 3.2 billion usd have been funded (health cluster, 2023). besides the results of this study, the un secretary-general’s high-level panel on internal displacement has already encouraged to strengthen the health financing for idps through its action agenda on internal displacement. in regard to finding solutions for internal displacement, the agenda puts forward the idea of integrating internal displacement solutions into systematic development financing. the un secretary-general’s high-level panel on internal displacement also recommends establishing catalytic financing in cooperation with affected country governments and development actors to initiate the process (un a, 2022). the un joint sdg fund could also be enabled for scaling up the financing for idps through a thematic section within the sdg fund. a development emergency modality has already been installed by the un joint sdg fund for financial response to countries affected by acute crisis (joint sdg fund, 2022). the capability of the private sector in idp setting is also noted within the agenda as the private sector could be engaged in three to four test results 37 operations while working with un resident coordinators. this possible engagement in internal displacement contexts should build upon the five principle of partnership and the un global compact (un a, 2022). discussion 38 5 discussion this chapter will be used for the reflection of the results and draws upon policy implications on internal displacement solutions. strengths and limitations of this policy analysis will also be identified in the discussion. 5.1 challenges of the humanitarian coordination system the main findings focused on the humanitarian coordination system, specifically the iasc clusters, the global health cluster and the work of the unhcr with idps. the cluster approach has been widely recognized by the international community as an effective and valuable tool for a multi-sectoral humanitarian response. at the start of the cluster initiative in 2005, important humanitarian sectors were missing, for instance the education cluster was established two years later. despite achievements in cluster country operations, the cluster approach has been criticized for being only applicable to un structures and not to the involved of ngos (morris, 2006, p. 55). although ngos are part of the humanitarian country teams, take part in regular meetings and even can co-chair the country cluster, they are underrepresented at the global picture of the iasc cluster. the cluster approach remains mainly un centric, while ngos often work on individual projects to remain visible and accountable for donors (morris, 2006, p. 55). the ifrc has a large impact on the emergency health response for idps. they may have developed their own agency structure, but they oblige to the legal frameworks of the iasc as well as the humanitarian principles (stumpenhorst et al., 2011, p. 590). communication and cooperation between both parties is key for an effective response and to prevent overlapping interventions, especially at the initial relief work (hakamies et al., 2008, p. 36). through regular feedback meetings between all agencies and timely information sharing, communication problems can be minimized (stumpenhorst et al., 2011, p. 591). in reference to the global health cluster, the who assists idps through their work as the lead agency for the global health cluster. as the only identified humanitarian coordination mechanism for also targeting the health needs of idps, the work of the country health cluster has increased worldwide. the success of the health cluster relies in the partnerships formed with national health authorities, un agencies and ngos. other humanitarian aid agencies such as msf, ifcr, medical teams international or emts have effectively coordinated lifesaving care within the activated health cluster (who, 2020). despite these achievements, the lack of funding within the humanitarian system also affects the global health cluster. the focus of the who during an emergency health response is not only on the health of idps rather on the health of all affected populations. this can comprise people returnees, host communities affected by a crisis and refugees. the who leaves the unhcr with their discussion 39 primary responsibility to provide protection and to find long-term solution for displaced populations. as stated in the results, the unhcr is the lead agency for protecting displaced people in humanitarian crises (unhcr b, 2019). the consistent operational engagement with idps has not always been the case. in the early 1990s the unhcr has noted their work with idps is only required in specific circumstances. interventions by the unhcr were conducted if they were requested by the un secretary general or other un agencies. if governments were lacking the capacities for operational delivery towards idps, the unhcr was able to operate with the consent of the affected government. through their expertise with refugees and returnees, the unhcr has the adequate resources and experience to prepare and deliver protection for idps with the involved state, if their staff safety is secured (unhcr e, 2022). over time, their engagement in internal displacement settings has expanded, especially through the involvement in the iasc cluster approach (morris, 2006, p. 55). nowadays, the unhcr works through a collective response with other agencies towards achieving durable solutions for idps (unhcr b, 2019). the international responsibility to assist idps and the recognition of the growing numbers of idps has increased over the last decade. the unhcr has also released a number of documents clarifying their role with idps. this also comprises a proposal of innovative financing mechanism for supporting idps (unhcr, 2020). one of the innovative findings mechanisms has been applied by kiva’s world refugee fund. working together with unhcr and ngos, the international non-profit organization kiva has launched the fund for refugees and idps to provide loans for refugees and idps (unhcr, 2020). despite not yet implemented, a land sharing value capture in somalia has been developed to give access to affordable housing, land, and property for idps. another innovative financing mechanism has been the humanitarian impact bond developed by the icrc. the program for humanitarian impact investment raised 26 million swiss franc for three new physical rehabilitation centers in nigeria, mali, and the democratic republic of congo providing health care for victims of armed conflict (icrc, 2017). this investment has accelerated social investments by the private sector (unhcr, 2020). it illustrates that unhcr is not the only international agency with the experience and skills provide emergency relief for idps, as the icrc has been involved in numerous idp operations. similar to the unhcr limitation on the core refugee mandate, the icrc is also limited in their scope of work as they often leave after the crisis has cleared up (cohen, 2009, p. 107). however, the mandate of the unhcr for idps remains variable, as the unhcr mandate is not exclusive for idps (unhcr e, 2022). the protection obligations for idps rely also on the discussion 40 capacities of other un agencies and the responsible national authorities. without expanded accountabilities for idps within the un system, a designated agency for the needs of idps and stronger legal frameworks, the situation of idps may worsen (cohen, 2009, p. 108). 5.2 barriers to health for idps despite existing health interventions through the cluster approach and health-related ngo operations, idps face several barriers for obtaining high standards of health. as stated in the general comment no. 14 by the cescr, public health facilities and services should be equally available for idps and the host communities (cescr, 2000). this availability is often not given, as internal displacements occur in resource starved lmics. an example of already existing shortage of medication and laboratories in an internal displacement context has been reported in iraq (kaelin et al., 2010). the iraq displacement review from 2006 by the international organization for migration (iom) revealed that one-third of the interviewed idps do not have access to needed medication and many specialist care providers, such as gynecologists, have left the country (iom, 2007). in terms of accessibility to health care, many idps experience financial hardships, long distances to health facilities, lack of transport, discrimination, and unsafe environments as barriers to health care (kaelin et al., 2010). victims of sexual violence might also fear stigmatization before even deciding to seek medical care (gpc, 2010). humanitarian agencies assisting idps can also face barriers. identified barriers for humanitarian agencies consists of resource constraints and collaboration barriers, as sometimes agencies can compete for the same resources (hakamies et al., 2008, p. 36-37). as mentioned in the theoretical part, attacks of humanitarian personnel have increased and can limit humanitarian agencies to operate in crisis affected areas due to security issues (ocha, 2019). the reproductive health needs of idps are often multifaceted and require an inter-agency collaboration (hakamies et al., 2008, p. 40). regarding reproductive health care, the general comment no. 14 already emphasizes the need for humanitarian interventions to respect medical ethics, cultural norms and ethnicity of individuals (cescr, 2000). reproductive healthcare behavior such as preferring a female traditional birth attendant can vary by gender specific needs (kaelin et al., 2010). another aspect of health service barriers can involve the quality of health services which is often limited in emergency settings (gpc, 2010). a shortage of qualified health personnel and missing awareness about the displacement-related health needs. lack of quality medical services can reduce the effectiveness, waste the already limited resources and can cause actual harm (kaelin et al., 2010). discussion 41 this leads to the assumption that the implementation of legal frameworks such as the guiding principles or the general comment on access to health services for idps by the cescr, can have obstacles in practice. a sensitivity towards cultural and religious norms by humanitarian agencies can increase the acceptability of healthcare among idps (kaelin et al., 2010). 5.3 policy implications in 2016, the un secretary general has already announced the goal to reduce 50 percent of new or protracted internal displacement by 2030 (un, 2016). this has not yet been achieved so far, as the numbers of idps have accelerated over time with new conflicts and disasters creating high numbers of idps (un a, 2022). working towards durable solutions for idps is a major step to limit the hardships of internal displacement. durable solutions for idps refer to the reintegration of idps into places of their origin or other local communities (un, 2021). this also involves not being in the status of need any more as idps have adequate access to secure livelihoods, education, and social protection systems. finding durable solutions can be a long-term and complex process (un, 2021). durable solutions for idps can be achieved through mainstreaming a holistic approach. this encompasses a whole-of-displacement approach as the needs of the host communities and those of the idps are included in the humanitarian assistance. extending innovative financing mechanism for idps while integrating them into national systems will provide long term solutions for idps (unhcr, 2020). the holistic way also takes into account a whole-of government approach as all parts of the government should integrate internal displacement into national development plans (un a, 2022). international humanitarian coordination systems should be integrated into national plans with clear accountabilities for idps instead of replacing them (stumpenhorst et al., 2011, p. 588). achieving durable solutions also shows the synergies between humanitarian assistance, peace building efforts to end conflict and development efforts for securing a stable life for idps (un a, 2022). the engagement of development actors and the private sector should be in line with the humanitarian principles, as a foundation of all humanitarian interventions. providing humanitarian protection and assistance, while working towards durable solutions and preventing further internal displacements is a comprehensive approach (un, 2021). prevention also implies the establishment of an early warning system for the population at risk (cohen, 2009, p. 107). the figure on the following page shows the three interlinked goals, which cannot simply standalone but reach maximum outcome when they are combined (un a, 2022). discussion 42 figure 6: three interlinked goals (source: un a, 2022) drawing upon the health needs of idps, a policy brief on internal displacement and health has been released as a result of a workshop by the internal displacement research programme and the academy of medical science. these policy implications are in alliance with the findings of this paper. they give four policy implications for strengthening the health of idps. as idps often face worse health outcomes than other crisis affected populations, they should be more included in essential health services such as routine immunizations. idps have specific health needs and vulnerabilities such as reproductive health care. assessing the health needs of idps in advance and streamlining specific health interventions into local plans is an important step for raising the health outcome. another policy implication has been the community engagement of idps through participation in health programs, for instance through mental health support services. assessing the health of idps can only be possible through available idp health data. data on internal displacement and should be consistently gathered by governments or agencies and shared between those entities (researching internal displacement, 2021). 5.4 strengths and limitations the results fit into the current research on idps. the theoretical background is essential for understanding the intentions and involvement of humanitarian actors in the idp assistance. as the humanitarianism discourse has developed over time, these changes impact also the coordination and response to idps by humanitarian actors. data on numbers, characteristics and causes of displacement for idps has been sufficiently covered by the idmc, unhcr and other un agencies. as the unhcr has increased their engagement with idps over time, they have released a number of idp related documents relevant to this research. discussion 43 while reviewing literature on the humanitarian coordination systems applicable for strengthening the health of idps, a lack of reference to idps was noted. this can be seen in the health cluster guide, as idps have not been mentioned by the authors. other scarcities of literature were found in the health financing for idps, as there has been only one study focusing on the health development aid for idps. the disparity on literature coverage between refugees and idps has been noted as well. this leads to the necessity of scaling up research investments on idps. another limitation besides the scarcity of literature on health interventions for idps, is the complexity of the research topic. the scope of research was not narrowed down to one country affected by a idp crisis but rather focused on idp engagement of international actors worldwide. not only leads this to a higher availability of data but reveals the broad research possibilities and the complexity of the idp coordination. conclusion 44 6 conclusion referring back to the theoretical foundation, the humanitarian principles lay the foundation for humanitarian action worldwide. the compliance to humanitarian principles has been extended with the humanitarian reform agenda in 2005 and the transformative agenda in 2010 by the iasc. humanitarianism seeks to alleviate suffering in an emergency setting while providing relief to its victims (barnett & weiss, 2012, p. 11). both humanitarian strategies, the do-no-harm and comprehensive peacebuilding strategy, can be found in the un humanitarian system depending on the context of the crises. the findings reflect the challenges of humanitarianism as humanitarian activities intersect with development actions for achieving durable solutions and increasing financial capacities. as development actions result often in private sector engagement, a compliance to the principles of partnership developed by the global humanitarian platform is needed. humanitarianism, peace building, and development work interact with each other more than ever. having shared vision and transparent communication between these sectors leads to more effective interventions while creating durable solutions (un a, 2022). the guiding principles on internal displacement have increased the international recognition of idps and have supported the accountabilities of international actors and states for idps. the rights of idps are not only manifested in the guiding principles, but also in other or national legal frameworks, such as the kampala convention. international standards for health response in emergency settings such as the sphere handbook or the iasc guidelines on mental health and psychosocial support in emergency settings have been developed as well. despite these accomplishments, there is no international binding legal framework specifically for idps. the lack of a global fund for idps or the lack of an international agency dedicated to idps add up to the problem of underrepresentation and underprioritizing of idps on the international agenda (cohen, 2009, p. 103; un, 2021). armed conflict and climate-related disaster will continue to trigger movements within country borders. the complexity and scale of conflicts has increased and left millions of people in new and protracted displacements. as several previous studies have confirmed, the mortality and morbidity of idps remains one of the highest among crisis affected populations (cantor et al., 2022). a variety of health areas show worse health outcomes among idps, including communicable diseases, vpds or mental health. idps are a heterogenous group with specific vulnerabilities and needs (mitra, 2022). recognizing different health needs of idps, such as or reproductive health care or mental health, will lead to a more effective and successful implementation of health interventions (kaelin et al., 2010). attaining high standards of health is strongly linked to other determinants of health including safe environment, education, or community engagement sanitation (bermudez, 2022). conclusion 45 strengthening humanitarian engagement is not only needed in the emergency health response but in all sectors concerning the well-being of idps. as identified in the findings of this paper, the cluster approach serves has suitable tool for a coordinated emergency response, while giving clear responsibilities to each cluster (unhcr a, 2022). but despite its achievements in their country operations, the iasc clusters face financial constraints, lack of involvement of ngos due to un-centric structures and challenges within the agency’s structures (morris, 2006, p. 55). the highest impact on the health of idps and long-term health interventions can only be achieved through a holistic approach. a whole-of-displacement approach with the inclusion of other affected populations such as refugees and the host communities will create more sustainable solutions (un, 2021). 46 list of figures figure 1: total numbers of idps worldwide at year end (2012-2021) .................................... 2 figure 2: protection of specific human rights during disasters ..............................................23 figure 3: the cluster approach with the cluster lead agencies .............................................28 figure 4: typical country health cluster structure ..................................................................33 figure 5: health oda (usd per capita) explicitly for idps and refugees (2010–2019) .........36 figure 6: three interlinked goals ..........................................................................................42 47 list of abbreviations cescr un committee on economic, social and cultural rights ec european commission emt emergency medical teams erc emergency relief coordinator ganhri global alliance of national human rights institutions gavi global alliance for vaccines and immunization ghp global humanitarian platform gpc global protection cluster hc humanitarian coordinator hct humanitarian country team iasc interagency standing committee icrc international committee of the red cross idmc internal displacement monitoring centre idp internally displaced person ifrc international federation of red cross and red crescent societies ihl international humanitarian law iom international organization for migration lmic lowand middle-income countries msf medicine san frontières ncd non communicable diseases ngo nongovernmental organization ocha united nations office for the coordinator of humanitarian affairs oda official development assistance 48 oecd organization for economic co-operation and development ohchr office of the high commissioner for human rights phc primary health care sdg sustainable development goals unaids united nations program on hiv/aids unhcr united nations high commissioner for refugees unicef united nations children’s fund unrwa united nations relief and works agency for palestine refugees in the near east unsg united nations secretary general usd us dollar vpd vaccine preventable diseases wash water, sanitation and hygiene wfp world food programme who world health organization 49 bibliography ahoua, l., tamrat, a., duroch, f., grais, r. f., & brown, v. 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(ed.) humanitarianism and suffering: the mobilization of empathy, cambridge university press https://apps.who.int/iris/handle/10665/334129 appendix appendix 1: literature search on pubmed on the health financing for idps id search terms/combinations for literature review on pubmed hits #1 search internally displaced persons [mesh terms] 16,516 #2 search idps [mesh terms] 1,847 #3 search internally displaced persons [mesh terms] and health financing [mesh terms] 74 #4 search health overseas development aid [mesh terms] 106 #5 search health overseas development aid [mesh terms] and internally displaced persons [mesh terms] 2 #6 search health overseas development aid [mesh terms] and idps [mesh terms] 1 van asselt, e., elamin, a., gonzález sánchez, c., kalesi, a. & majoor, e. incorporating sustainability into food based dietary guidelines by traffic light ecolabelling (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4687 p a g e 1 | 12 policy brief incorporating sustainability into food-based dietary guidelines by “traffic light ecolabelling” evelien van asselt1, abdullah elamin1, clara gonzález sánchez1, anastasia kalesi1, elodie majoor1 1 department of international health, school caphri, faculty of health medicine and life sciences, maastricht university corresponding author: evelien van asselt e-mail: e.vanasselt@student.maastrichtuniversity.nl address: inhealth department: duboisdomain, 30, 6229 gt, maastricht, the netherlands mailto:e.vanasselt@student.maastrichtuniversity.nl van asselt, e., elamin, a., gonzález sánchez, c., kalesi, a. & majoor, e. incorporating sustainability into food based dietary guidelines by traffic light ecolabelling (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4687 p a g e 2 | 12 abstract context: food-based dietary guidelines (fbdgs) are science-based recommendations in the form of guidelines for healthy eating. they provide information and advice on foods and dietary patterns to consumers to promote the overall health and prevent chronic disease. as of now, these fbdgs lack information about the sustainability of food products. consumer food choices have a large impact on human and planetary health and wellbeing, as the production and processing of diets make up between 20% and 30% of the total greenhouse gas emission of consumable goods in the european union (eu). a plethora of different ecolabels exist to aid consumers in making sustainable choices when purchasing items, both food and non-food products. these ecolabels make it easier for consumers to choose eco-friendly product alternatives, with the aim of lowering the environmental impact of the products a consumer buys. while the growth of ecolabels may be interpreted as a sign of success, label overload and gaps in the understanding might result in confusion for consumers, resulting in the limit of use of these already existing ecolabels. therefore, this policy brief proposes the development of a universal, understandable ecolabel for food products, to enable consumers to make better informed decisions. policy options: three policy options are examined. firstly, a hypothetical ‘do nothing’ scenario is considered, in which food ecolabels are not used. as a second alternative, the use of carbon footprint labelling is examined. lastly, the implementation of a “traffic light” colour pattern label that uses the colours green, orange and red to demonstrate low, medium and high environmental impact, respectively, is examined. recommendations: in order to determine the best policy option, the three proposed policy options are compared using five evaluation criteria (time of implementation, cost of implementation, ease of implementation, consumer friendliness and positive environmental impact). the traffic light ecolabel had the highest overall score, and it is thus recommended that this food ecolabel should be used. lastly, it is recommended that the ecolabel is incorporated into the already existing eu ecolabel, in an effort to increase consumer knowledge and understanding of this novel ecolabel. keywords: dietary guidelines, food labeling, policy recommendation, sustainability, traffic light ecolabel. acknowledgments: this research was supported by professor suzanne m. babich. associate dean of global health and professor, health policy and management, at the indiana university richard m. fairbanks school of public health in indianapolis, indiana, usa, for north america. authors’ contributions: all authors contributed equally to this work. conflict of interest: none declared. source of funding: none declared. van asselt, e., elamin, a., gonzález sánchez, c., kalesi, a. & majoor, e. incorporating sustainability into food based dietary guidelines by traffic light ecolabelling (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4687 p a g e 3 | 12 introduction food-based dietary guidelines (fbdgs) are science-based recommendations in the form of guidelines for healthy eating. they provide information and advice on foods and dietary patterns to consumers to promote the overall health and prevent chronic disease (1). as of now, fbdgs lack recommendations about the sustainability of food and food choices. the sustainability of food goes beyond nutrition and environment, and includes economic and socio-cultural dimensions as well. suffice to say, the failing incorporation of sustainability in fbdgs impacts human and planetary health and wellbeing gravely, as the production and processing of diets make up between 20% and 30% of the total greenhouse gas emission of consumable goods in the european union (eu) (2). this increase in greenhouse gas emissions has led to climate change, which has already had observable effects on the environment. glaciers have shrunk, ice on rivers and lakes is breaking up earlier, plant and animal ranges have shifted, and trees are flowering sooner (3). moreover, encouraging consumers to purchase and consume sustainable foods could reduce food waste by changing consumer behaviour. food waste is a significant problem because the burning of food waste requires considerable energy, and releases greenhouse gasses in the atmosphere, which also leads to global warming. although global warming may bring some localized benefits, such as increased food production in certain areas, the overall health effects of a changing climate for the population are overwhelmingly negative. climate change affects many of the environmental and social determinants of health, such as clean air, safe drinking water, sufficient food and secure shelter. also, high temperatures will raise the levels of ozone and other pollutants in the air which will exacerbate cardiovascular and respiratory disease in individuals. additionally, aeroallergen levels are higher in extreme heat, which can trigger asthma, affecting about 300 million individuals globally (4). not only does the food that consumers eat have an impact on the environment, choosing sustainable food options is also important to maintain a good health status among the population, as sustainable food options are often also healthier food choices for the consumer. a recent report by the dutch voedingscentrum recommended that consumers that were opting for a more sustainable diet should eat less meat, more plant-based foods, and avoid sugary drinks (5). this recommendation is fairly similar to healthy diet recommendations of more plant-based foods, whole grains, legumes, seeds and nuts, and less animal-based foods (6). thus, it can be argued that sustainable food choices benefit a person's health as it is less damaging to the environment, as well as through the improvement of the overall dietary intake of an individual. fortunately, in a study done by the european consumer organisation on consumer attitudes towards sustainable food, over half of consumers indicated that sustainability concerns have an influence on their eating habits, however, most consumers underestimated the impact of their food choices on the environment. two thirds of consumers are open to changing their eating habits for the environment, but price, lack of knowledge, unclear information, and limited choice of sustainable options prevents them from eating more sustainably (7). a plethora of different ecolabels exist to aid consumers in making sustainable food choices. these ecolabels are provided by certifiers that assess whether farmers and/or food processors comply with specific and transparent environmental or social standards. common certification categories include: “environment/organic”, “animal welfare”, “labour/worker welfare” and “fair van asselt, e., elamin, a., gonzález sánchez, c., kalesi, a. & majoor, e. incorporating sustainability into food based dietary guidelines by traffic light ecolabelling (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4687 p a g e 4 | 12 trade”. while the growth of ecolabels may be interpreted as a sign of success, label overload and gaps in the understanding of both the general concept of sustainability and of the specific sustainability labels might result in confusion for consumers, resulting in the limit of the use of such labels. unfortunately, there is no standardized certification process in place, and many different types of ecolabels are being used. certification processes can take place in three different ways: firstly, products can get a certification from the producers themselves. secondly, the company buying the product can confirm that a producer has met a certain set of standards. lastly, an independent party can undertake an audit to determine whether the producer has met the standards (8). it is thus up to the consumer to assess the trustworthiness of the certification process and the certifications. context overall, ecolabels have done a great deal to raise awareness, to create trust, to change what we expect from certain product categories, and to build capacity and create a common framework around sustainability (9). a great example of the effectiveness of ecolabels is the fairtrade movement in the uk, of which the sales topped £1bn in 2010. however, the large number of different ecolabels and the confusion surrounding the certification procedures of sustainable products leaves consumers feeling that the information provided is unclear, and that they have a lack of knowledge regarding the labelling of these products. it can thus be argued that a standardised certification and labelling process for foods that are sustainable would aid consumers in making more sustainable food choices. one place where a standardised ecolabel has already been effectively used for almost three decades is in non-food products and services. in 1992, the eu established this ecolabel that is now recognised worldwide: the eu ecolabel. it aims to promote the resource efficiency of industrial production, decrease the environmental impacts of products throughout their lifecycle and to enable consumers to make informed decisions on a product’s environmental performance. difficulties concerning policies on ecolabels in europe are due to the complex supply chains of the food sector, the vast array of stakeholders and a big variability of consumer preferences. also, while sustainability is an issue of general interest, in the context of food choice it competes with other issues like sensory quality and healthfulness, and a general interest in sustainability may therefore not necessarily translate into use of sustainability information when choosing food products (10). ecolabels are likely to form a part of a wider web of practices reinforced and supported by other factors and behaviour patterns (figure 1). the implementation of ecolabels could be of great benefit to the environment and ease the decision-making process for consumers. therefore, the development of a universal, understandable ecolabel for food products is recommended, to enable consumers to make better informed decisions. three policy options will be evaluated. policy options according to the regulation (eu) no 1169/2011 of the european parliament and the council on the 25th of october 2011, a number of specific information about food is mandatory and should be included on the food packaging as indispensable for the consumer. this information includes the name of the food, the list and quantity of ingredients, any ingredients causing allergies, the date of minimum durability as van asselt, e., elamin, a., gonzález sánchez, c., kalesi, a. & majoor, e. incorporating sustainability into food based dietary guidelines by traffic light ecolabelling (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4687 p a g e 5 | 12 well as use and storage conditions. the country of origin of the food product, the name of the food business operator and a nutrition declaration should also be indicated on the packaging. the scope of the regulation is to protect individual and public health and thus it focuses on consumer safety. it also provides the necessary information for the smooth and unhindered function of the internal market. however, in no place throughout the regulation is the notion of sustainability or the use of environmentally friendly practises mentioned and therefore the need for addressing environmental welfare in food labelling remains unmet. the farm to fork (f2f) strategy that was presented by the european commission in may 2020 and is situated in the heart of the european green deal is introducing a number of new food labelling schemes to better inform consumers and promote sustainability and individual as well as planetary health. through the european green deal the european union aspires to become the first major climate neutral economy by 2050, by offsetting greenhouse gases emissions using methods of removing warming gases from the atmosphere. the new labelling initiatives proposed by the f2f strategy focus on mandatory front-of-pack nutrition labelling, extending country of origin indication, nutrient profiles and amelioration of expiration date labelling to reduce food waste. the european commission also announced the creation of a sustainable food labelling framework that would take under consideration, apart from food safety and nutritional value, the environmental impact and animal welfare in regard to food production but no further information is provided and the proposal is expected in 2024 (11). as mentioned in the introduction, this policy brief aims to address the lack of adequate food labelling policies regarding sustainability and subsequently the many public health problems both in individual as well as in population level that this can lead to. ghgs and global warming resulting from the food industry, millions of tons of food waste and meat-based diets endanger planetary welfare and foster noncommunicable diseases. therefore, three different strategies are considered and evaluated for supporting sustainability in food labelling and subsequently promoting individual as well as public health. doing nothing” 1) implementing a food labelling strategy without first educating consumers in regard to climate change and contributing factors could result in bombarding consumers with an overwhelming number of choices and eventually too much responsibility in their hands. furthermore, combining information about a product’s nutritional value and profile with information about its impact on the environment could turn out to be a challenging task and lead to misunderstanding or misinterpretations and confusion on the consumers’ part. therefore, one way to go about promoting environmental welfare in regard to food products and their impact would be not using ecolabelling at all. ecolabels on food products allow for products of both high and low quality and environmental impact to be sold by the retailers and transfer the responsibility to the consumer to make the right choice for the environment based on the ecolabel. if labelling was absent, consumers would have to traditionally rely on environmental laws created by the government to decide for them whether a product is allowed to be sold according to national legislation or not. this solution would on one hand bring politicians and legislative authorities face to face with food companies’ financial interests and interfere with the notion of free market economy and on the other hand strip the consumers of their right to make informed choices on their own. van asselt, e., elamin, a., gonzález sánchez, c., kalesi, a. & majoor, e. incorporating sustainability into food based dietary guidelines by traffic light ecolabelling (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4687 p a g e 6 | 12 “carbon footprint labelling” 2) as a second alternative to address the lack of ecolabelling in food products, the use of carbon footprint labelling is considered. carbon footprint refers to the total amount of greenhouse gases-ghg (including carbon dioxide and methane) produced by a particular product throughout its life cycle (12). as mentioned before, a great percentage of the world’s carbon footprint is coming from the food and agricultural industry so it makes sense to focus on empowering consumers to opt for low-carbon food products. carbon trust, a private uk company set up by the british government, provides voluntary carbon certification services and in 2007 introduced the first carbon labelling scheme for individual products (9). examples from analogous initiatives around the world vary. in 2012 world renowned food retailer ‘tesco’ decided to drop its ambitious plan from 2007 to put carbon labels on 70,000 products due to the great amount of work needed and the lack of backing from other retailers (13). however, some years later, carbon-labelling seems to be making its way back with big food companies like ‘quorn’ and ‘oatly’ using carbon labelling on many of their products and ‘unilever’ and ‘nestlé’ planning to implement carbon labelling in the foreseeable future. standing at the threshold of a new era of carbon taxes and facing the urgent need to decarbonise, companies are calculating their ghg emissions along the supply chain and disclosing information about it, with french company ‘danone’ scoring best and ‘coca-cola’ scoring worst (14). with regard to individual countries, the danish government proposed carbon labelling for food as part of the government’s 38-point plan for a “greener future” in 2018. the swedish climate labelling initiative is another example of country wide policy showing that carbon labelling can be implemented with support from the government and the industry. however, there is no doubt that what makes such initiatives ambitious and time-consuming, especially when they come from individual countries and are not the result of group effort, is the difficulty and challenges in measuring carbon emissions for food products (due to the spread out and varied supply system) as well as the need to engage multiple actors like the government, retailers and other stakeholders (15). to avoid consumer confusion due to lack of knowledge regarding carbon footprint, we consider the use of a two metric scheme that would evaluate products according to the neutral reference point of carbon emission for that particular product and would qualify them only if emission levels were below that point. “a traffic-light food labelling scheme incorporated in the eu ecolabel” 3) last but not least we consider the incorporation of food labelling into the existing eu ecolabel through the use of a ‘traffic-light’ colour scheme, in an effort to support consumers in making sustainable food choices. regulation (ec) no 66/2010 of the european parliament and of the council of 25 november 2009 already sets out the environmental requirements that a product should fulfil in order to be awarded the eu ecolabel. a tough set of criteria, determined on a scientific basis and taking into account the whole product life cycle, assess the impact a product has on climate change, nature and biodiversity, energy and resource consumption, generation of waste, emissions to all environmental media, pollution through physical effects and use and release of hazardous substances (16). the eu ecolabel has already been awarded to thousands of different products across europe and this easily recognisable logo has made it easy for consumers to make quick and informed decisions in a world of too van asselt, e., elamin, a., gonzález sánchez, c., kalesi, a. & majoor, e. incorporating sustainability into food based dietary guidelines by traffic light ecolabelling (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4687 p a g e 7 | 12 many green labels and claims. the label has strong foundation and is being daily managed by various cooperating actors including the eu ecolabeling board composed of representatives of various institutions like the european consumer organisation (beuc) and the european chemical agency (echa), the european commission, competent bodies, stakeholders (industry, trade unions, retailers) and the eu ecolabel helpdesk. we consider the extension of this worldwide recognised environmental excellence label, limited until now only to shampoos, detergents, baby clothes, paints, electrical goods, hotels etc, to food products in order to ensure that a food product is of good quality, safe and environmentally friendly. as in the already existing eu ecolabel the whole life cycle of food products (primary production, processing, transport, packaging and retail) will be taken under consideration and products will be assessed according to their impact in climate change, greenhouse gas emissions and pollution, fresh water and land use, eutrophication, biodiversity, generation of waste and animal welfare. following the examples of the eu energy label as well as the front-of-pack traffic light health labelling on food products in the uk, we suggest the implementation of a “traffic light” colour pattern that will use the colours green, orange and red to demonstrate low environmental impact, medium environmental impact and high environmental impact respectively. each product shall be attributed one of the three colours according to a standardised procedure assessing the effect the product has on the environment in regard to the aforementioned criteria. the eu ecolabel is a well-recognised label of environmental excellence that has been around for almost 30 years and is based on a solid foundation. the functioning of the label is based on european regulation and it is operating under the supervision of accredited institutions like the european commission together with bodies from the member states and other stakeholders. all these credits make for an excellent foundation for an extension of the label to food products. our suggestion to use the ‘traffic light’ colour pattern as the labelling scheme is based on the efficiency of the pattern in similar efforts like for example the eu energy label which, according to the special barometer 492, is recognised by 93% of consumers and taken under consideration by 79% when they are buying energy efficient products (17). a detailed evaluation of the three options according to specific criteria follows. recommendations in order to decide on the best policy option, a comparison of the three options previously considered has been done (figure 2) according to the following evaluation criteria: time of implementation, cost of implementation, ease of implementation, consumer friendliness and positive environmental impact. these evaluation criteria are measured as low, medium or high (scoring for example that the policy proposed will require low time of implementation or that it will create a high positive environmental impact). time of implementation firstly, the amount of time that would be needed to implement each of the policy options was considered. the first strategy of keeping the current food labelling without any modifications would not require any time of implementation. however, the other two alternatives would represent the necessity of a longer period of time to implement them. according to an article published by the guardian, to calculate the carbon footprint of food van asselt, e., elamin, a., gonzález sánchez, c., kalesi, a. & majoor, e. incorporating sustainability into food based dietary guidelines by traffic light ecolabelling (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4687 p a g e 8 | 12 products would require a minimum of several months’ work for each product. it is foreseeable that even more time would be needed to implement the third alternative (i.e., the traffic light label), as it evaluates many sustainability aspects, including the carbon footprint. cost of implementation one of the challenges of introducing the eu ecolabel in the food, feed and drink sector are the costs and resources needed for the products to meet a set of sustainability criteria, especially for producers, chain actors and public bodies. the “do nothing” policy option would not represent any cost incurred; however, the other two options would require a higher budget to implement them. the current fee of certification of the eu ecolabel from the eu competent bodies is around €350 to €3,000 per operator per year. this would be applicable for both traffic light and carbon footprint labels. however, according to a study on the feasibility of eu ecolabel for food and feed products done by oakdene hollins consultants, if the carbon footprint label alternative was utilised, the costs of assessment and implementation would increase significantly, around €10,000 to €20,000 per product (18). ease of implementation considering the ease of implementation and the space that each policy option would require in the food package, the first alternative is the easiest policy option to implement as nothing in the food labelling must be changed. the carbon footprint approach would require a big surface of the food labels in order to add and explain the symbol, as it should include a footprint symbol, a number representing the total set of greenhouse gas emissions caused throughout the whole life cycle of the food product (expressed for example in grams of co2 emissions per grams or ml of food product), and a concise explanation of what the aforementioned number would mean in regard to the level of sustainability. in the contrary, the traffic light alternative would require a smaller surface, as only a selfexplanatory small colour pattern symbol (i.e., red, orange, or green) would need to be added, hence, making this third alternative easier than the other two policy options to implement in food and drink products. consumer friendliness in regard to the approachability or consumer friendliness, the traffic light label option was evaluated as the most consumer friendly policy. according to the research at chalmers technological university in sweden, a traffic-light coloured label implemented in a student catering facility increased the sales of green labelled meals by 11.5% compared with the control phase, without these labels (19). the green-orange-red colour pattern is already a familiar construct for consumers, where green is always associated with a positive rating, orange with an intermedium grade and red being linked to a negative score. this standardised and clear label would not require any further explanation besides the colour symbol itself and would make it very easy for consumers to understand its meaning in relation to sustainability. in essence, consumers will easily and effortless relate the green label to an environmentally friendly product and the red label to a low sustainable food or drink product with a high environmental impact. furthermore, the traffic light label approach would be in line with other food labelling policies already implemented in the eu with respect to dietary recommendations, aiming to demonstrate in an understandable way how healthy and nutritious a food product is. for this reason, the traffic light label would be the most successful approach seeking to make an informed choice among consumers. contrastingly, the carbon footprint approach van asselt, e., elamin, a., gonzález sánchez, c., kalesi, a. & majoor, e. incorporating sustainability into food based dietary guidelines by traffic light ecolabelling (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4687 p a g e 9 | 12 would require an advanced knowledge in sustainability and in the greenhouse gas emission levels that would be desirable for a food product to be considered sustainable. for this reason, it scores to be less consumer friendly than the traffic light, as this type of label would lead to more misunderstanding and confusion among consumers. the “do nothing” alternative is, however, the least consumer friendly due to its lack of transparency and lack of seeking sustainability goals. positive environmental impact moreover, the traffic light labels can easily educate consumers about the environmental attributes of these products, and, thus, incentivize the marketplace for more green products by increasing consumer demand for environmentally friendly products. those companies whose food products are identified as non-sustainable with a red label, might be exposed to reputational harm and will, therefore, tend to change their product formulation and process pursuing an orange or green label (20). although extensive research is still needed to decipher biases in consumer decision-making, one cannot argue that consumers will respond in a more positive way to a clear and intuitively understandable traffic light label as well as one that comes from a respected evaluation scheme such as the eu ecolabel (12). considering the positive environmental impact, the traffic light label approach scores the highest positive impact on human and planetary health and wellbeing, as it comprises not only the greenhouse gas emissions, but also the energy, water, land and other resources consumption, the generation of waste, the eutrophication, the biodiversity and the animal welfare, throughout the whole life cycle of food products (11). in contrast, the carbon footprint label approach would only consider the total amount of greenhouse gas emissions, such as carbon dioxide or methane, produced likewise throughout the life cycle of food products (12). discussion according to the results obtained from the policy options analysis, as represented in the comparison graph (figure 2), the use of the traffic light label approach is recommended to incorporate sustainability into food and drink products labels, as in general, it scored the best in terms of our evaluation criteria. the “do nothing” policy option scored the best in terms of time and cost of implementation. nevertheless, more significance was given in this study to the consumer friendliness and the possible positive impact on the human and planetary health and wellbeing that the traffic light label option would create, as these are more relevant aspects to public health. important to mention as well is the role that stakeholders and governments play on these policy options by facilitating or limiting its implementation. key players, such as the food industry, retailers, farmers associations, may be against the implementation of the carbon footprint and traffic light labels policy options. some actors expect that producers and service suppliers working in a nonsustainable way would be disadvantaged by the introduction of food in the eu ecolabel. due to the high frequency of innovation in the ingredients used by the food industry, recipes, and formulations, that result in frequent changes in their environmental characteristics, establishing sustainable criteria for food and drink products might be quite a challenge for these food manufacturers (18). on the contrary, important players such as ecolabelling advocates, consumer protection organizations (e.g., beuc, consumers international, chafea), animal welfare ngos and environmental and ecological van asselt, e., elamin, a., gonzález sánchez, c., kalesi, a. & majoor, e. incorporating sustainability into food based dietary guidelines by traffic light ecolabelling (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4687 p a g e 10 | 12 organizations may be significantly in favour of the implementation of any of these two policy options as they aim to make food products more transparent; and these same stakeholders may be considerably opposed to the “do nothing” approach. european governments and policy makers have shown during the last years a large interest in developing more sustainable and environmentally friendly policies. eventually, the implementation of sustainable labels in food products will be mandatory in most of the ms. for this reason, the prompt incorporation of labels that inform about the sustainability of food products is the best option for food producers and sellers of avoiding fines or restrictions due to not complying with future established regulations. for the previously mentioned reasons, the traffic light policy option would better meet the sustainability goals that the eu seeks to achieve. plan for change utilizing the kotter model vision: improve human and planetary health and wellbeing. mission statement: promoting sustainable diet through transparency and effective policies on fbdgs. in order to create a climate for change, firstly, it is needed to create a sense of urgency through advocacy campaigns and promoting the importance and urgency of the issue. this can be through highlighted that the current food production is destroying the environment as it accounts for 70% of all human water use; and is a major source of water pollution. it is also the leading cause of deforestation, land-use change and biodiversity loss (21). moreover, the current covid-19 pandemic exposed current food systems defects and in order for these systems to be resilient and resistant to crises, it needs to be sustainable. the next step is to establish an expert group from every stakeholder that oversees the implementation of this policy option and consists of members from environmental and consumer organisations, unions, trade, industry, crafts, communities, media, international ngos. then to plan a specialized communication strategy for each stakeholder. an example here when targeting consumers, the communication message would be to create awareness and confidence in this policy option as one of the solutions to simplify the concept of sustainability in their daily food choices as well as promoting the concept of sustainability as a whole. empowering the first actions is the subsequent step through establishing a risk assessment plan in order to identify and address the expected challenges. one challenge is the resistance to change faced by certain stakeholders and planning how to overcome this challenge is essential for the success of this policy. to successfully continue with the change, it is vital to establish the concept of creating quick wins, which can be done through incorporating the traffic light system in phases with each phase including a certain group of products. the final steps are the continuous evaluation of the traffic light ecolabeling policy impact through discussion with consumers and industry stakeholders and the promotion of the policy to be implemented widely in different international settings. conclusions knowing that up to date the ecolabelling has not been standardly implemented in food products at the eu level, three possible policy options are considered to address this problem. • the first alternative is the maintenance of the food labelling how it currently is. van asselt, e., elamin, a., gonzález sánchez, c., kalesi, a. & majoor, e. incorporating sustainability into food based dietary guidelines by traffic light ecolabelling (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4687 p a g e 11 | 12 • the second alternative is the incorporation of carbon footprint labels, which would take into account the total amount of greenhouse gas emissions, including carbon dioxide and methane, produced throughout the whole life cycle of food products. • the third alternative is a traffic light colour pattern symbol, that will use the colours green, orange and red to demonstrate low, medium, and high environmental impact respectively. it will take into account the greenhouse gas emissions, as well as many other sustainability indicators, such as water, land, and energy consumption, generation of waste, use and release of hazardous substances, or animal welfare, throughout the whole life cycle of food products. after evaluating certain criteria, such as time of implementation, cost of implementation, ease of implementation, consumer friendliness and positive environmental impact of the three policy options previously proposed, it is strongly recommended to implement the traffic light colour pattern label, as it scored the best in the analysis. lastly, it is recommended that the ecolabel is incorporated into the already existing eu ecolabel, in an effort to increase consumer knowledge and understanding of this novel ecolabel. the implementation of the eu ecolabelling for food products should be also accompanied by a campaign for raising awareness, both about food sustainability and the new label itself, since it has been shown that there is a correlation between the knowledge a consumer has of a label and his/her preference for the product carrying the label. references 1. efsa, 2010. food-based dietary guidelines in europe. retrieved from: 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https://www.icis.com/explore/resources/news/2020/07/17/10531480/carbon-footprint-labelling-a-growing-trend-among-consumer-goods-companies https://www.icis.com/explore/resources/news/2020/07/17/10531480/carbon-footprint-labelling-a-growing-trend-among-consumer-goods-companies https://www.icis.com/explore/resources/news/2020/07/17/10531480/carbon-footprint-labelling-a-growing-trend-among-consumer-goods-companies http://www.fao.org/3/y2789e/y2789e06.html http://www.fao.org/3/y2789e/y2789e06.html simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 review article the role of health service delivery networks in achieving universal health coverage in africa knovicks simfukwe1, yusuff adebayo adebisi2, amos abimbola oladunni3, salma elmukashfi eltahir mohammed4, don eliseo lucero-prisno iii5 1the university of zambia, school of veterinary medicine, lusaka, zambia 2 university of ibadan, faculty of pharmacy, ibadan, nigeria 3 ahmadu bello university, faculty of pharmacy, nigeria 4uppsala university, department of public health and caring science, uppsala, sweden 5global health focus-africa corresponding author: knovicks simfukwe; address: the university of zambia, school of veterinary medicine, great east road, lusaka, zambia; email: knovicks26simfukwe@gmail.com abstract mailto:knovicks26simfukwe@gmail.com simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 most countries in africa are faced with health system problems that vary from one to the next. countries with a low human development index (hdi) seem to be more prone to challenges in health service delivery. to mark its 70th anniversary on world health day, the world health organization (who) selected the theme “universal health coverage (uhc): everyone, everywhere” and the slogan “health for all. ”uhc refers to ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation, and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial hardship. uhc is a who’s priority objective. most governments have made it their major goal. this paper provides a perspective on the challenges of achieving uhc in sub-saharan africa (ssa). it also endeavors to spotlight the successful models of health service delivery networks (hsdns) that make significant strides in making progress towards achieving uhc. hsdns propose models that facilitate the attainment of affordability and accessibility while maintaining quality in delivering health services. additionally, it brings up to speed the challenges associated with setting up hsdns in health systems in ssa. it then makes propositions of what measures and strategic approaches should be implemented to strengthen hsdns in ssa. this paper further argues that uhc is not only technically feasible but it is also attainable if countries embrace hsdns in ssa. keywords: health systems, human development index, universal health coverage, sub-saharan africa, health service delivery networks, world health organization. simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 introduction achieving universal health coverage (uhc) is a core target of the sustainable development goals (sdgs) (1). the world health organization (who) defined uhc as ensuring that all people have access to needed health services of “sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial hardship.” (2). in low and middle-income countries (lmics), uhc has become an integral aspect of health reforms (3). unfortunately, many people in developing countries do not have access to quality health services, especially those living in poor and marginalized communities (4). in most countries, challenges towards achieving this target range from reaching all population groups (coverage and accessibility) to the accommodation of all needed services (readiness) and achievement of a reasonable proportion of health service delivery covered (health financial security) (2). health outcomes in african countries remain poor despite commitments and efforts towards achieving uhc. there are expansive shortcomings across all building blocks of health, and progress has been slow in lmics. this is complicated by inadequate resources, inequitable access to health services, and weak health system governance. other challenges such as poverty, unemployment, climate change, conflict, insecurity, among others, have created distractions that make prioritizing health difficult (5). thus, health outcomes tend to correlate with donor support. strengthened preventable maternal and child deaths, strong resilience to public health emergencies, reduced financial insecurity and strengthened the foundation of long-term economic growth will be discerning attributes of countries that achieve uhc by 2030 (11). unfortunately, the increasing population growth rates of countries in africa pose a significant threat to long-term inclusive growth (6). this is further complicated by the double burden of communicable and non-communicable diseases (7). population distribution and geography constitutes substantial challenges to delivering quality health services in africa (8), and accessibility, as well as coverage of essential health services, are very low in africa. there is a lack of a sufficient health workforce to meet the demand of the growing population (13), with a health workforce density of 2.3 healthcare workers per 1000 population (9). other studies from africa have also confirmed that wealth is also closely related to the place of delivery, i.e., the poorest women are least likely to use facility delivery services. out of pocket expenditure on health has been attributed to limited access to health care in the under-served population (11). concerning the shortage of skilled health workers, insufficient resource expenditure on training, poor working environment, difficult living expenses, and poor career path (12) are implicating factors. therefore, there is need to secure greater access to skilled health workers that meet population demands, especially in underserved communities. momentum for uhc in africa is building, and many african countries have already integrated uhc into their national health strategies. but with about 11 million africans pushed into extreme poverty each year because of out-ofpocket health expenses, how can africa achieve uhc, which delivers a quality package of care for people living in africa? to answer this question of significant importance, global health think-tanks and relevant stakeholders such as world bank, who, etc., are not looking any further from health service delivery networks (hsdns) as the prime solution. uhc requires well-functioning health systems that provide high-quality, affordable, accessible, and efficient health services. as such, hsdns provide these strategies aimed at achieving uhc. simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 what are health service delivery networks? it has become obvious to note that networks of collaborating organizations have become critical mechanisms for the effective delivery of healthcare (13). “the rise in network popularity has come largely from the recognition that money alone cannot sufficiently improve the quality of health systems, and that the major health problems facing societies are unlikely to be successfully addressed by individual organizations acting in isolation.” (14, 15). population health may improve only if resources, talents, and strategies are pooled from across a range of actors and organizations (16). networks are defined ‘as a set of nodes and the set of ties representing some relationship, or lack of relationship, between the nodes’ (16). relationships between nodes are typically non-hierarchical and may be founded on many and varied factors, including formal or informal flows of resources, information, people, or ideas (17). the pan american health organization (paho) defines health service delivery networks (hsdns) or organized health services systems, or clinically integrated systems, or integrated health organizations, “as a network of organizations that provides, or makes arrangements to provide, equitable, comprehensive, integrated, and continuous health services to a defined population and is willing to be held accountable for its clinical and economic outcomes and the health status of the population served” (14). this would include referrals between services and is based on the need to provide comprehensive services (18). the final aim is to improve health outcomes, and health services are the most proximate to that end. additionally, health services include infrastructure, human resources, and supplies and technologies necessary to provide care to patients (19). hsdns can be characterized as vertical, i.e., between different levels of service delivery from the community level to the clinic and hospital level, or horizontal, i.e., with providers or organizations working at the same level of service delivery (20). considering the wide range of health system contexts, it’s extremely difficult to prescribe a single organizational model for hsdns in africa. each country’s policymakers must design a model that meets each system’s specific organizational needs. below is an illustration outlining the four domains of the attributes of hsdns. figure 1: pan american health organization. integrated health services delivery networks concepts, policy options and a road map for implementation in the americas. (series: renewing primary health care in the americas no.4) washington, dc, 2010, pp. 32-33) simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 methods a tt r ib u te s o f h e a lt h s e r v ic e d e li v e r y n e tw o r k s financial allocation and incetives adquate funding and financial incetives aligned with network goals. organizati on and manageme nt result based management an integrated network system that links all network members with data dissagregated by sex,place of residence ethnic origin and other partinent variables. sufficient, committed and competent human resources for health that are valuable by the network integrated management of clinic, administrative and logistical support system governance and strategy a unified system of governace for the entire network broad social participation intersectorial action that addresses wider determinant of health and equity in healthy mode of care clear definition of the population territory covered and extensive knowledge of the health needs and preferences of this population, which determines the supply of health services extensive network of health facilities that offers health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation and palliative care and that engages program targeting specific diseases, risk and populations as well as personal and public health needs a multi-disciplinary first level of care that covers the population, serves as a get way to the system and integrate and coordinates first level of care in additon to meeting most of the population health needs existence of mechanism to co-ordinate health care throughout the health service continuum delivery of specialized services of the most appropriate location, preferably in nonhospital settings care that is person, family and community centered and that takes into account cultural and gender related characteristics and delivery simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 eligibility criteria for studies included in the review we considered studies on uhc with or without ssa. in this paper, we considered hsdns as the exposure variable and uhc as the outcome variable. only published articles in peered reviewed journals were considered. articles in languages other than english weren’t considered. in duplicate publications, the article with more complete data was included. pubmed, medline, google scholar, and google search served as sources for these articles. other articles we identified from reference lists of related studies from the included study. dates of coverage were specified. search terms that were used employed the use of boolean operators “and,” “or,” and “not” to refine searches by limiting or combining terms. the key terms to search for articles were “universal health coverage,” “health service delivery networks,” “health systems,” and “sub-saharan africa”. abstract information served was the screening basis and the cochrane risk of bias tool was used to assess the risk of bias. results challenges of setting up health service delivery networks in africa hsdns are distinct from a conventional organizational structure that is devoid of shared commitments to meet the health care needs of the population (21). therefore, organizations establishing hsdns must be aware of potential challenges (22). these challenges form foundations of disadvantages that potentially undermine the establishment of health system models that are compatible with hsdns in africa: the model of hospital care and management, personnel training, governance, financing strategies, and use of technologies. health care processes in africa are fragmented and are not integrated with other levels of care which generates a lack of quality and consistency in health (23). although there is a wide distribution of public health sectors in africa, patients prefer to seek health care in the private sector predominantly due to the perception of confidentiality and quality service delivery in private health establishments compared to the public health sector. private healthcare provision at the primary health care (phc) level has been an independent set of service providers varying significantly in quality of health services with few linkages with a structured health system (24). the implication of this is that it establishes a negative perception of incompetency and mistrust in public health hospitals among users of health care, thereby promoting health-seeking behavior in private establishments and contributing to high out-of-pocket spending. figure 2: health systems in africa simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 perceptions and perspectives (who, 2012. who regional office for africa, 2012). the imbalance between health service needs and health service utilization also constitutes a potential challenge to health hsdns in africa. this creates a deficit and inadequate response capacity at the first level of care in terms of resources (health workforce, medication, and lab supplies) and a weak public hospital network (referral, counter-referral, and feedback system). the exclusive tendency of an international organization to determine health priorities limits the participation of member states in the decision-making process (25,26). this focuses on health intervention projects on the specific disease (vertical programming) rather than communityoriented primary health care intervention (horizontal programming) (24). this situation poses a challenge to the implementation of hsdns due to a lack of shared responsibility among multilateral organizations, ngos, governments, communities, the private sector, medical professionals, and other stakeholders (23). for this reason, there is a need to develop a mechanism that promotes the development of primary health care and improve collaborative network across healthcare levels in an integrated system context that improves accessibility, affordability, availability, and quality of care for the underresourced population. africa has the highest population growth rate (27) and lacks a sufficient health workforce to meet the demand of the growing population (28). this creates shortcomings in the distribution of skilled 0.10% 0% 1.50% 69% 54.90% 67% 30.90% 45.10% 31.50% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% central africa0.1% east & southern africa west africa don't know dissatfisfied satisfied simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 health workforce across the different levels of health care and constitutes a serious challenge to establishing hsdns. a review of the health workforce in five african countries (mali, sudan, uganda, botswana, and south africa) revealed that a minority of doctors, nurses, and midwives are working in primary health centers (phc) and shortage of skilled health personnel are the greatest in rural areas (29). a greater number of doctors trained in mali, uganda, and sudan do not stay to work in government health establishments in their countries, let alone in primary health care, due to inadequate resource expenditure on recruiting or training, poor working environment, difficult living expenses, and poor career path (30). these imbalances in the health workforce model can create a huge gap in health service readiness towards establishing sustainable hsdns in africa. population distribution and topography in ssa present many challenges for health care delivery (31) and hsdns. a geocoded inventory of hospital services across 48 countries in africa reveals that only 16 countries met the international recommendation of more than 80% of the population within a 2-h time of travel to a hospital (32). this situation creates a considerable gap between the demand and supply of health care services among a geographically marginalized population which potentially limits the implementation of hsdns in affected african countries. innovative approaches for integrated hsdns in healthcare delivery in africa are required in specific geographical locations, including improvement of ambulatory services, transportation modes, communication systems, and the number of quality health service centers. information and communication technology (ict) is integral in operationalizing hsdns. although technology in health has a potential beneficial impact on hsdns, high implementation cost and lack of technical skills (33), security and confidentiality concerns (33,34) are barriers to implementation of both in africa. the major barrier to e-health adoption and one that can potentially affect the implementation of hsdns in africa is the lack of cooperativeness between health information systems (hiss) (35). the presence of varying standards in hiss often creates a conflict of interest which makes it quite difficult to establish cooperative governance that offers quality health services in a coordinated and timely fashion. figure 3: access to emergency hospital care simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 ouma et al. access to emergency hospital care provided by the public sector in sub-saharan africa in 2015: a geocoded inventory and spatial analysis. lanc glob health. 2018. vol 6, issue 3, e342-e350. https://www.thelancet.com/journals/langlo/article/piis2214-109x(17)30488-6/fulltext discussion examples of successful models of health service delivery networks the referral pathway model referral systems in healthcare are processes in which a health worker at one level of the health system with insufficient resources (drugs, equipment, skills) to manage a clinical condition seeks the assistance of a betterresourced facility at a higher level to assist him/her, or take over the management of, the client’s case (36). clients/patients in ghana, just like in other african countries such as mozambique, south africa, and zambia, among others, are expected to access services from primary services incrementally (e.g., the community-based health planning services, chps, and health centers), through to secondary facilities (e.g., district hospitals) and if required to the highest services (regional and tertiary hospitals) (37). 36.90% 23.30% 23.30% 46.90% 4.30% 17.40% 6.60% 51.50% 53.10% 3.40% 27.70% 34.40% 46.30% 16.70% 24.20% 57.40% 49.30% 16.40% 13.80% 38.50% 7.10% 43.30% 38.50% 53.40% 7.20% 36.20% 61.40% 49.90% 23.20% 57.20% 7.70% 11.20% 2.70% 39.70% 39.60% 39.60% 5.20% 77.20% 53.80% 6.10% 24.90% 14.70% 17.50% 40.10% 2.70% 20.70% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% % p o p u l a t io n countries https://www.thelancet.com/journals/langlo/article/piis2214-109x(17)30488-6/fulltext#figure simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 figure 4: the referral pathway model amoah p.a, philips d.r. 2017. strengthening the referral system through social capital: a qualitative inquiry in ghana. healthcare 2017, 5, 80. social marketing model the marketing strategies used by the majority of these organizations include both promotion of these services to the poor and the design of these services to meet the needs of this group. social marketing refers to the application of marketing techniques to achieve behavioral changes (38). the population services international (psi) in africa has been making use of this concept for many years. psi runs programs that offer educational programs on reproductive health for urban youth in africa. magazines, television spots, call-in radio shows, and radio drama serve as avenues to address the taboo subject of safe sexual behavior (39). studies have shown that youths have been responsive to these programs, and this resulted in increased contraceptive use and hiv testing (40). in a nutshell, this concept has largely contributed to making health services accessible. simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 contracting out model this involves the delegation of a health-related responsibility by the state to a private partner, and this can be a philanthropic or commercial basis (4,42). the private partner usually includes mining companies in zambia and south africa and faith-based based hospitals in tanzania. these private partners tend to provide subsidized health services to the community, sometimes even those not covered in the contract. type specificity, quantity, quality, and duration of services delegated are outlined in a contract (42). antenatal care, delivery and postnatal services, and the prevention of mother to child transmission of hiv (pmtct) are among the services that are contracted out by the state to private partners. because of the very nature of this model, there has been overwhelming evidence that it improves access to health services and some evidence on improved equity in access (43). foreign-aided model global public-private partnership (gppp) is a collaborative, three-way partnership, including international donors and recipient governments, usually funded by multinational health initiative through a substantial disbursement of funds, in which both government and non-governmental entities participate in decision-making through a mutually agreed upon and well-defined division of labor (44). most of the gppp in african countries such as botswana, malawi, zambia, etc. is aimed at hiv prevention and care-such as the african comprehensive hiv/aids partnership (achap), and detection and treatment of women’s cancers -pink ribbon, red ribbon (with pepfar and the gates foundation). with regards to botswana, gppp has provided the urgently needed infrastructure, equipment, human resources, and training of healthcare providers (45). consequently, gppp cuts the cost of health services on national budgets while improving the access, coverage and, quality of health services being delivered to the people. lower operating costs through simplified medical services “operating costs were lowered by simplifying the medical services provided and using less than fully qualified providers.” (46). for example, east africa and some parts of southern africa have introduced a diploma in clinical medicine. these clinical officers have contributed heavily to hiv/aids prevention and treatment initiatives in africa (47). the use of community health workers (chws) is an excellent catalyst in providing “basic health promotion and healthcare within the communities in which they live” (48). chws are laypeople of varied background, coming from, or based in the communities they serve, who have received brief training on a health problem they have volunteered to engage with have been “cited as part of the solution to the shortage of health workers and lack of universal access to healthcare in low-income” (49, 50) and feature prominently in the who’s workforce 2030 strategy for human resources for health (50). ultimately, this model of hsdns improves the accessibility of health services to poor people. high volume and low unit costs this model is very effective at improving the affordability of healthcare services through maximizing the use of infrastructure, and health personnel, and alternate use of cheaper medical procedures and equipment (51). hospitals that implement this model tend to be located in high-density areas and target low-income groups requiring basic medical care. since the available services are limited, there’s high patient throughput (100 patients per day per doctor). the high productivity of simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 health personnel helps to make the services affordable. r-jolad hospital in nigeria, nsambya hospital in uganda, and selian lutheran hospital in tanzania are examples of successful case studies (52). human resource optimization healthcare organizations have expanded the use of laypeople who are then equipped with skills and help in the distribution of oral contraceptive pills or eye exams. aravind eye system trains high school graduates into paramedical staff like patient flow managers, providers of simple diagnostic procedures, etc. (53). another example is the kisumu medical, and educational training (kemt) model in kenya embarks on improving the quality of care by leveraging human resources. kemt trains existing health workers in a safe procedure (54). these models trek miles in improving access, coverage, and quality of health services. increasing practice in rural areas model ssa experiences a disproportionate burden of access to health services. in its quest to reach the poor, narayarana hrudayala (nh) heart hospital provides health camps in rural areas of india. healthcare workers in these camps provide a cardiac diagnosis with transportation to the hospital for patients who require it (55). this model enhances accessibility to health services. recommended measures that can be implemented to strengthen health service delivery networks in sub-saharan africa.  empowering and engaging people and communities: this strategy allows for skill acquisition and places resources to people as a means of making them become empowered users of health services and advocates for a reformed health system. this is achieved through health education, engaging laypeople as community health workers. empowering and engaging people is also about reaching the underserved and marginalized groups of the population to guarantee universal access to and benefit from quality services that are co-produced according to their specific needs.  strengthening governance and accountability: the requirements for strengthening governance include a participatory approach to formulating policies, decision-making, and performance evaluation at all levels of the health system, from policy-making to the clinical intervention level. the need for good governance in ensuring the best possible results cannot be over-emphasized. this demands that transparency, inclusiveness, reduced vulnerability to corruption which facilitates the best use of available resources and information, become the norm in hsdns.  reorienting the model of care: this strategic approach prioritizes primary and community care services and the co-production of health. this brings about a shift in inpatient to outpatient and ambulatory care and from curative to preventive care. it requires investment in holistic and comprehensive care, including health promotion and illhealth prevention strategies that support people’s health and well-being. reorienting the model of care ensures efficient healthcare services.  coordinating services within and across sectors: the needs and demands of people serve as the basis for coordinating services within and across sectors. for this to be achieved, health care providers within and across health care settings, development of referral systems and networks among levels of care, and the creation of linkages between health and other sec simfukwe k, adebisi ya, oladunni aa, mohammed eltahir se, lucero-prisno iii de. the role of health service delivery networks in achieving universal health coverage in africa (review articles). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4470 tors should be integrated. this approach improves the delivery of care through the alignment and harmonizing of the processes and information among the different services.  creating an enabling environment: this complex strategy aims at effecting transformational change in leadership and management, information, methods to improve quality, reorientation of the workforce, legislative frameworks, financial arrangements, and incentives. the attainment of the above-captioned strategies largely depends on how favorable the environment is in allowing all stakeholders to effect transformational change.  creation of global and regional professional and/or academic networks: these academic networks coupled with mentorship helps in transferring skills and knowledge across regions and generations, respectively. integrating quality of care in healthcare and medical curricula and establishing open access repository for grey literature to share experiences helps make progress to uhc. global networks such as health systems action network (hsan) is committed to strengthening health systems through effective involvement of diverse stakeholders, spreading of actionable knowledge, and better management of resources that is guided by evidence. references 1. kieny mp, bekedam h, dovlo 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2 department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 3 institute of public health, faculty of health sciences, jagiellonian university, krakow, poland; 4 association of schools of public health in the european region (aspher), av de tervueren 153, 1150 brussels, belgium; 5 school of health professions education, maastricht university, maastricht, the netherlands. corresponding author: hilke mansholt, m.sc.; department of new public health, osnabrück university; address: barbarastraße, 22c 49076 osnabrück, germany; telefon: +49 (0)541 969-2078; email:hilke.mansholt@uni-osnabrueck.de mailto:email:hilke.mansholt@uni-osnabrueck.de mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 2 | 16 abstract introduction: public health is continuously challenged by a shortage of workforce. there are various reasons for this: 1) public health is less visible than traditional health professions and people may be unfamiliar with the nature and opportunities involved in entering this career field; 2) lack of official recognition of public health as a professional category; and 3) no umbrella organization that supports its members and governs professional standards as is the case of other more established professions. to adequately address the challenges of public health for the 21st century, a key policy element will need to focus on adequately cultivating, training and growing the future workforce of professionals in the field. the aim of this study was to examine why professionalization of public health in europe is not as robust as it deserves to be and what steps can be taken to assure an adequate supply of professionals with the proper education and training background, and career guidance to tackle the public health needs of the future. method: a case study approach was used collecting data via a scoping literature review, a focus group with public health students and interviews with public health experts for convergence. data was analysed using directed content analysis and pattern matching logic. results: public health fulfilled five out of seven attributes of a profession, such as skills, training and education, certification and an altruistic service. recognition of public health as multidisciplinary and multi-professional field, derived from the interviews as an additional characteristic. a code of ethics and professional conduct and a formal organization were missing. conclusion: public health professionals and organisations that govern best practices in this field should consider introducing a shared code of ethics and professional conduct as well as establishing a coordinated body to help advance the public status as a the profession to increase interest in studying and specializing in this area. keywords: professionalization, public health workforce, qualitative study conflicts of interest: none declared. mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 3 | 16 introduction healthcare is one of the largest economic sectors in the european union (eu) – accounting for around 17 million jobs (1). most of these jobs are done by the public health workforce (phw),“people who are involved in protecting, promoting and/or restoring the collective health of whole or specific populations” – and thus distinct from other medical practices (2). the phw is multidisciplinary and multi-professional in character (3), encompassing a core phw that identifies with a primary public health role and a wider phw including health professionals and others who impact on population health (4-5). according to czabanowska et al. the main task of public health professionals is to focus on the provision of essential public health operations (ephos) and thus display a more focused set of skills while providing leadership that ensures networking, coherence, synergy and strategic impact. the authors further perceive the public health workforce not only as “professionals in traditional public health occupations (such as medical doctors specialized in preventive medicine and public health, food safety inspectors, environmental health officers, communicable disease control staff, etc.) […] but also a range of “new” practitioners working in the broad field of public health protection, prevention, promotion, service delivery and quality assurance, such as those involved in projects and programmes (e.g., the healthy cities and healthpromoting schools movements)” (6). today, europe is faced with a shortage of phw due to many factors, such as low fertility rates and aging population leading to an imbalance between patients/overall population size and public health staff (7). further, the inconsistency in defining the phw has an impact on the shortage of workforce, demonstrating a significant challenge for european health systems. but the declining interest in the profession among young people is to be expected given the informal and fragmented nature of the public health profession, underlining the importance of a clear definition. cioffi et al. (8) claim that, “the fact that the public health workforce is not a single profession, but rather a fabric of many professions dedicated to a common endeavour, creates challenges to any singular approach to workforce development”. when following the definition of cruess et al. (9) who define a profession as “an occupation whose core element is work based upon the mastery of a complex body of knowledge and skills”, public health seems to be a profession. however, compared to medicine or pharmacy, public health does not enjoy the benefits of the directive 2005/36/ec (10) such as: recognition of professional qualifications by the eu member states, professional mobility or the assimilation of workers in the single market which apply only to regulated professions (11-12). the lack of professional categorisation and recognition at the regulatory level becomes apparent in the context of attracting prospective employees or students to pursue this field of study. bjegovic-mikanovic et al. (13) see an additional problem in the existence of many different study programmes that focus on individual aspects of public health rather than providing a broader and basic knowledge. this makes it difficult to state what the public health discipline really is, and where decision-makers can seek advice. therefore, there is a need for an authorised public health profession founded on graduation from comprehensive public health education (13). the establishment of public health as a profession follows with regulation and formal recognition as a “category” among the “listed” professions of europe and their taxonomy. the purpose of the taxonomy is to facilitate the systematic mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 4 | 16 characterisation of the public health workforce. currently, the international standard classification of occupation (isco-88), has two sub-major groups (health professionals and health associate professionals) within which only a few occupational titles refer explicitly to public health (14). there are several pathways to establishing a profession. professional status can be achieved via training and education resulting in a specific degree. in this respect public health follows the bologna process, an initiative that adjusts and harmonizes study programmes. moreover, there are social processes that transform an occupation into a profession, empowered by either employees and service users (bottomup process) or employers and government (top-down process) (15). for the employers, the professional status of an occupation means that they can require a diploma or certificate, which ensures, that the applicant possesses specific skills and knowledge. for the government, professionalization can require the development of educational standards and a unified curriculum. moreover, a professional status requires a code of professional conduct, which can help to enhance the quality and security of and for employees. additionally, degrees and diplomas can function as an assurance for customers, increasing their trust and confidence in making use of a service (16). although professionalization and formal recognition of the public health field may be a way to elevate the status of the public health profession and stir international interest, little has been done in the european region to address this pressing need. the current exploratory case study aims to find out hoand why public health is understood and recognised as a profession using multiple data sources: literature, public health experts and students of public health in view of the theory of professionalization (17). methodology this study uses a case study approach which investigates a contemporary phenomenon, in this case “professionalization”, within its real-life context, in particular when the boundaries between the phenomenon and the context are not clearly evident. it relies on multiple sources of evidence to converge in a triangulating fashion. it assumes a relativist orientation acknowledging multiple meanings, which are observant dependent (18). the study uses the theoretical propositions of the theory of professionalization to guide data collection and analysis (19-20). the propositions which represent the characteristics of a profession include: • skills based on abstract knowledge which is certified/licensed and credentialed; • provision of training and education, usually associated with a university; • certification based on competency testing; • formal organization, professional integration; • adherence to a code of conduct; • altruistic service. the data were collected using: 1) a scoping literature review, 2) a focus group with public health students and 3) individual interviews with public health experts for convergence. the data were analysed using directed content analysis (21) and pattern matching logic (20, 22). if empirical patterns appear to be similar, the results can help a case study to strengthen its internal validity (20). scoping review the scoping review (23-24) included articles which: 1) focus on the process of professionalization in relation to public health occupations; 2) are published in english and german; and 3) cover the period from 1st of january 1920 – 1st of july 2017. the following key words and their combinations were used: mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 5 | 16 professionalization, profession, skills, education, training, certificate, formal organization, professional integration, altruism, professional code of conduct, public health, workforce, health occupations and europe. the study made use of the following databases: pubmed, psychinfo, eric, springer, biomed central, science direct, google scholar and the websites of the european commission (ec) and world health organization (who). the information obtained guided the focus group and expert interviews. focus group the focus group (fg) aimed to get a deeper understanding of how the missing professional status of public health might affect future workforce expectations and how graduate students perceive this issue (25). in total, ten students (males n=4, females n=6) of the bachelor (b-eph) and master of european public health (m-eph) at maastricht university (nl) participated, representing two levels of higher education. thereby, the beph programme mainly focuses on the determinants of health and concrete health issues and how they are tackled in different countries. in comparison, the m-eph approaches public health from a perspective of collective action for sustained population-wide health improvement and reduction of inequalities within the institutional, legal and administrative boundaries of health systems. both programmes have a strictly public health focus and an international student population. students were selected on a voluntary basis via the electronic learning environment. during the fg, the moderator led the discussion following an interview guide referring to the awareness and recognition of the professionalization dimensions in relation to public health profession (table 1). the questions were open, in-depth and semistructured, meaning that they were adapted or added with the progress of the fg. further, the 90-minute fg, was audio-taped expert interviews four in-depth interviews were carried out at the association of schools of public health in the european region (aspher) deans and directors’ retreat in may 2017. experts were selected, representing leading ph organisations (world health organization (who), european centre for disease prevention and control (ecdc), agency for public health education accreditation (aphea) and a university providing ph educational programmes). the interviewer followed an interview protocol with openended, in-depth and semi-structured questions (table 2). each interview took about forty-five minutes and was audio-taped. both the students and the experts signed the informed consent and were offered to review the analysed results for validation. they were assured of the ethical principles including anonymity and confidentiality to increase honest answers. mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 6 | 16 table 1. focus group guiding questions examples of questions for students why did students choose a bachelor or master in public health? what are future job perspectives of public health students? how do studies in public health prepare students for the job market? how can studies in public health be improved? how necessary is a specialization in public health? what are characteristics of a profession? is public health a profession? which characteristics are missing? how is the public health workforce supported? what are concerns regarding the future of public health? table 2. individual interview guiding questions examples of questions for public health experts is public health a profession? which characteristics of a profession is public health missing? how can studies in public health be adapted to the job market? how can public health students be supported (to enter the job market)? will public health at the european level change in the future? is public health prepared to keep up with changes in knowledge and practices? is public health taken seriously on the european level or by the population? how to raise the importance of public health? directed content analysis and pattern matching the data of the fg and interviews were analysed using a directed content analysis based on predetermined codes representing the constructs from the attribute models and one additional code public health as a profession, which was derived from the data (18). the fg and interview data were matched with the results of the literature review to “provide predictions about the variables of interest, which helped to determine the initial coding scheme” (20), and to assure credibility and pattern matching, which is a strategy for aligning data to the theoretical propositions (22) and finally, providing theoretical explanations and developing the research outcome. the analysis and interpretation of the results were discussed among the researchers until consensus was reached to reduce a potential bias. mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 7 | 16 results scoping review comparison of the literature with the predicted pattern shows that both patterns match only partly. similarities and differences are explained hereafter. regarding a defined set of skills, major work was done by aspher, starting with defining a system of core competencies which could be applicable to public health education, research and practice throughout europe (26). since the start of the programme in 2006, much consideration was given to whether the skills taught in schools and programmes of public health reflect what is needed in reality (14, 27-29). that lead to further analyses and the development of the latest edition of the “european list of core competences for the public health professional” (30). the most recent “who-aspher competency framework for public health workforce in the european region” (31) is an example of a tool to support public health workforce development, professional self-assessment and staffing. regarding education and training, effective pedagogy and a public health curriculum that balances theoretical and practical education is essential to enable core competencies for future professionals. the seventh out of the ten ephos aims to “ensure that there is a relevant and competent public health workforce sufficient for the needs of the population it is designed to serve” (32). ephos self-assessment tools were developed and answered by public health services in 41 countries, to detect issues regarding the public health workforce and to give recommendations with respect to training, curriculum, core competencies, accreditation or continued professional development (34). in the following, aspher established the european degrees in public health project group to design a european master programme in public health (emph). the aim of this project was training harmonization, a recognition of degrees without restrictions and thus free movement of specialists within the european union; public health schools and programmes were invited to apply this curriculum and adapt their education (35). although further numerous initiatives took place to strengthen public health education and training (36-37), it illustrates a quite heterogeneous topic (34). therefore, public health follows other harmonizing frameworks like the bologna process or the european higher education area. thus, the basic education and training offer in public health is in place; further effort is required to ensure its comprehensiveness, including strong continuous professional development (cpd) – essential for the professional status. after successful finalisation of the studies in public health, schools of public health have to deliver a certificate that acknowledges the completion of the programme (38). further, certificates help to test the competencies and reveal whether a person, based on his or her skills and education, can be seen as a professional in the field and fulfils the requirements needed for the position. however, since programmes are not harmonized, certificates are not always comparable and may have a varying degree of significance. this makes the job application process more difficult for both employers and applicants. therefore, some initiatives, for instance by the us national board of public health examiners or the uk faculty of public health, are being undertaken to support academic certification with professional credentialing systems in public health. many organizations play a role and contribute to the european public health agenda representing different groups of stakeholders. mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 8 | 16 there is the european public health association (eupha) – an umbrella organisation for national public health associations (39), and the european group within the international association of national public health institutes (ianphi) (40). there are also the following networks: the european public health alliance (epha) – consisting of nongovernmental organisations and focusing on a wide range of advocacy efforts (41), the eurohealthnet – another not for profit partnership –of organisations, agencies and statutory bodies working to contribute to a healthier europe by promoting health and health equity between and within european countries (42), and aspher, “a key independent european organisation dedicated to strengthening the role of public health by improving education and training of public health professionals for both practice and research” (43). this is only a selection of five out of many organizations striving to improve and support different functions of public health in europe. however, one formal organization that covers and combines all aspects of public health and is responsible as well as representative to achieve a professional integration was missing. several attempts have been made to create guidelines and frameworks for the phw. nevertheless, a strict code of conduct that employees as well as employers working in the field of public health have to obey and follow when conducting their job, was lacking. this constitutes a problem because public health illustrates the need to “guide the behaviour of practitioners in the field, especially when it comes to morally or ethically ambiguous activities” (15). conversely, for epidemiological research, which is inter-related to public health, the declaration of helsinki is mandatory (44). consequently, with respect to the professionalisation of public health, foldspang (45) argued that “in each country, we should discuss the shaping of an authorised profession and about what that means in concrete terms, including, for example, the development of agreed public health professional standards and ethical rules”. concerning altruistic service, people within a profession should strive for the same goal and thus put the interest of the society over their own personal gain which is often described as a paradox, double role of professions as officers and servants of society. literature that described this altruism specifically in connection with public health was not found. however, according to yach and bettcher (46), in public health altruism was intersecting with self-interest. one example for this is globalization and the fact that “in a world of shared global problems, the moral imperatives of addressing these problems also bring mutual benefits” because nowadays poor and wealthy countries affect each other more and more and should therefore build “knowledge partnerships” to support as well as profit from each other (47). focus group similarity was found in the fact that students agreed that a certain set of skills is required for a professional status. they found that public health provides an insight into a broad range of topics, sectors and stakeholders having an effect on health and the width of public health made a career more accessible and attractive but also caused uncertainty since in an academic setting practical knowledge is often missing. the students feared not getting an adequate position or that some parts of the studies might change in the future or the degree might become less relevant. while a master degree in public health is perceived to have high relevance by the students, a bachelor degree seems to be less important and mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 9 | 16 vague. nevertheless, the students concur that the degree offers flexibility and the opportunity to switch between various careers. according to the students, a representing, professional body or organization is a requirement for a profession but it is missing in public health. the field of public health is emerging but is also lacking appreciation since outcomes are often not linked to the field. thus, the students emphasised the need for establishing a formal organization which could provide guidance for and promotion of the expanding field of public health and enforce awareness by the society. the students mentioned that a profession is characterized by a set of rules and guidelines one needs to follow when working in this field. however, none of the participants was aware of a specific code of conduct for public health. when studying public health, students have a certain way of thinking and the shared goal to improve the health and well-being of other humans, creating some kind of identity. although outcomes are not immediately visible and are often not linked to the work of public health professionals, they still continue and try to improve the health of a population. expert interviews the characteristics described by the experts are similar to the proposition of a public health profession with respect to four characteristics (skills, education/training, certification, and altruism). experts mentioned the need for a variety of skills and the need to use this broad knowledge to show flexibility. also, experts stressed the usefulness of a degree in public health, demonstrating knowledge in many fields that graduates, as well as employers, should see as a positive characteristic. further, increasing numbers of courses offered in public health is leading to younger generations that will be trained in public health and ensuring that the importance of a degree is rising and that jobs handling public health issues are occupied by professionals with an educational background in the field. a more specified job within public health will add, adjust or deepen certain skills, going beyond the basic education. further, experts recommended the involvement of major stakeholders in public health (e.g. employers, alumni) to connect education and work life. experts consequently recommended job fairs and improved career services within study programmes. public health education is a very fragmented system. the experts indicated that public health schools are often small departments within a large medical faculty, causing constant pressure to prove their usefulness. thus, collaboration between medicine and public health on an equal level should be achieved. additionally, experts felt it was necessary that public health schools develop more independently, not as small sections of a large medical faculty and with freedom to collaborate with other departments. public health is changing continuously and therefore education and training should be updated by increasing communication, also including younger generations. moreover, the ongoing changes that public health is confronted with, clarified that education has to be adjusted on a constant basis, illustrating the importance of continuous professional development. further, education in public health should focus more on public communication and leadership skills, making professionals more flexible and adaptable to future changes. in the opinion of the experts, studying and working in the field of public health clearly demonstrates an altruistic service. from their point of view, people in public health look out for the interest of others by preventing, mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 10 | 16 promoting and enhancing health and welfare more than for a high income or appreciation. regarding professional organisation and the code of conduct, the pattern found amongst experts differed from the proposition. experts agreed that a professional association and advocacy are necessary prerequisites to increase awareness about the field. however, when public health services are provided efficiently in a country, they become invisible and often go unnoticed by the population giving the impression that services lack importance and appreciation, making it difficult to promote public health. although a failure in public health can have huge impact on other sectors (e.g. economy), public health ranks low within the political context. therefore, much clearer guidance is needed on how to advocate for the evidence-based importance of public health, by e.g. demonstrating the cost-effectiveness of interventions. the question whether there is a code of conduct public health professionals can follow, caused uncertainty for the experts, who perceived it as a challenge. so far, no one was aware of a specific code of conduct, but they referred to ethics and the altruistic service that are present in public health. table 3 presents the excerpts of data assigned to the constructs of the professionalization theory. table 3. excerpts from the focus groups and expert interviews assigned to the six theoretical constructs related to professionalization advanced with a new derived category constructs citation skills “…once you have your basic academic profession there is a common ground, there are competencies that are common in public health and of course depending on what area of public health you are working in, it may look different. […] i think it is important too, within each domain of a larger public health, to define what are the competencies and then make sure that each of the professions that are working in that segment of public health have those additional competencies that go beyond their basic profession.” training & education “in many places, departments of public health are just a small piece of a much larger medical faculty and they are constantly under pressure to prove a usefulness. […] so yes, in several european countries, more needs to be done in structural terms to keep public health independent.” “this master […] is based on networking and connections that it should be super easy for them to have like a job fair, specifically for public health students […]. at least if not a job they can just give us connections for us to go forward.” certificate “there are two ways to look at it. one is to say that the glass is half empty […] i would say the glass is half full or at least three quarters full, because the advantage that you as public health graduates have is that you have some knowledge in a lot of fields. if i were an employer, not knowing what the future actually brings, i would rather have graduates who are able to think in various fields rather than graduates who are focused on a very narrow field but have some in depth knowledge.” formal organization “definitely, we need a strong professional association and strong institution, we need strong advocates. and there are strong advocates from the eu level or ngos working in the public health arena but not maybe doing that much public health work themselves but are lobbying and supporting.” “advocacy that is taking a strong role in the public debate. i think as a public health profession, we are very good at talking and communicating within a bubble. but we are less good at talking outside the bubble.” code of conduct “i think this is an interesting topic to pursue. so i take this as a challenge.” “i mean to my knowledge there is no formal code of conduct, at least i haven't seen one. i mean it might be that it is out there but, no visible to me.” altruistic service “…those who chose public health do it because there is an adherence involved of making something good for the society.” “i think that only because you have a degree in public health for example that just shows for me at least that you have a certain way of thinking.” recognition of public health as multidisciplinary and multi-professional “i think that there is a public health profession. but i recognize the risk of excluding people and the definition of public health should be about inclusion. […] that places us in this unique position to have a broad leadership role in the whole system.” “to me, i think it would be hard to say that it is one profession. i see it more as a coalition of various professions, […] different competencies working together.” mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 11 | 16 discussion by using pattern matching and directed content analysis we attempted to triangulate multiple data sources to describe the extent to which public health can be considered a true profession. the findings coming from the three sources (literature review, student focus group, and expert interviews) were overlapping and consistent with each other. they indicate that public health, as a profession, is not yet fully developed although various aspects required for a profession are fulfilled. the validation of the results against the theoretical model shows that four out of six professionalization dimensions (18) including: skills, education and training, certification, and altruistic service are fulfilled by public health, while formal organization and a professional code of conduct are lacking. however, the results reveal a separate category: recognition of public health as a multi-disciplinary and multi-professional field. while the majority of the participants did not perceive public health as a single profession but more as a job field or a coalition of different professions and multiple agencies, they still argued that it would be beneficial if the field were precisely defined. the fact that public health is very broad leads to uncertainty among the students who may sometimes doubt whether they are well prepared for later jobs as well as fear that they can be replaceable and disadvantaged compared to the students from more defined health fields. on the contrary, the experts considered the broad range of skills students are equipped with, as a benefit enabling students to be flexible and adaptable to new situations and challenges instead of being “stuck” in a narrow field. since today’s careers develop more horizontally, such an optimistic approach should be advertised in relation to public health study programmes to eliminate the fear in current and future students and present public health as a secure future. bjegovic-mikanovic et al. (14) state that the curriculum and skills have to be adapted to real work-life by the involvement of stakeholders, employers, and alumni. this was confirmed by the student respondents, who stated that experiences during their practical placements made it clear that focus on some skills should have been made more comprehensive within their classroom studies. it means that public health also needs to balance the scientific and social/relational aspects and enhance training in public communication and leadership. regarding education and training, many public health schools follow initiatives leading to the harmonization of study programmes. this enables easier application and recognition processes and thus increases the flexible movement of professionals. it is worth noting that all participants of the study agreed that altruistic service is a feature of public health, indicating that a person who works in public health aims to improve the health and well-being of other humans and puts the interests of others as their first priority rather than appreciation or financial gains. while on one hand the results of the study proved that there is no specific formal organization for the public health profession that the interviewees were aware of except for the united kingdom (uk faculty of public health or public health england), on the other they stressed the importance of such an organization for public health. it could help to ensure professional integration, increase advocacy and enhance the significance of public health within the political context to enable compliance with regulatory or legal requirements as well as issues related to salary, high quality study programmes, core mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 12 | 16 competencies and skills; consequently increasing the significance of public health degrees. moreover, a formal organization could promote public health and help to raise the awareness of the field within society thus building public trust and confidence. although the presented study is direction setting, there are limitations and it remains only exploratory. this is owing to a small sample size of the focus group and expert interviews although the focus group and the interviews were in-depth, providing rich descriptions and using more than one data source contributed to increasing the validity of the study (48). this study used two theoretical models often related to as “traits” theories. theorising of the professions, for many years, has been strongly shaped by twentieth century professional developments and societies. these approaches have highlighted universal ‘traits’ and functions of the professions (17, 49). however, the scholarly discussion on professionalization shows many different views concerning the professionalization process (49) and the “traits” approaches seem to be less adequate to describe contemporary processes of professionalization. more recently, the studies of professions have paid greater attention to the diversity of professional groups and to a wider range of factors that may promote successful professionalization. several authors have illustrated the benefits of a governance approach, as defined by who and others, and applied in cross-country comparison to health workforce research, thereby bringing health systems-based factors into view. for instance, cross-country comparative research shows that health systems vary in how they shape and target both organisations-based and professions-based reform strategies (7). the results of this study can be useful for educationalists, employers, accreditation agencies and public health schools to realise that putting public health into a clearer and more defined context will help to improve european public health systems and services and increase its importance and recognition as well as resources. conclusion the feeling of uncertainty and lack of trust as to whether public health is seen as a legitimate profession can be ameliorated by making public health more attractive. thereby, the interest in public health can be enhanced to convince the future workforce that it is a field with a secure future, worth studying, working and to staying in. public health professionals and organisations that govern best practices in this field should consider introducing a shared code of ethics and professional conduct as well as establishing a coordinated body to help advance the public status as a the profession to increase interest in studying and specializing in this area. acknowledgement we would like to thank the public health experts for their time and reflection on the issue of professionalization thus contributing to the interviews. the interviewees represented some aspher member schools and collaborating organisations such as who regional office for europe, ecdc, and aphea. furthermore, we would also like to thank the students of the bachelor and master of european public health from maastricht university for their very communicative and honest participation during the focus group. mansholt h, czabanowska k, otok r, de nooijer j. professionalization of public health – an exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 13 | 16 appendix the directed content analysis of the focus group and the expert interviews, as well as the informed consents of the participants, can be delivered upon request. references 1. european commission. health workforce, brussels, belgium. available from: https://ec.europa.eu/health/workforce/overview_en (accessed: december 2, 2019). 2. rotem a, walters j, dewdney d. the public health workforce education and training study. aust j public health 1995;19:437-8. 3. martin-moreno jm, harris m, jakubowski e, kluge h. defining and assessing 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exploratory case study (original research). seejph 2020, posted: 28 september 2020. doi: 10.4119/seejph-3845 p a g e 16 | 16 45. foldspang a. towards a public health profession: the roles of essential public health operations and lists of competences. eur j public health 2015;25:361-2. doi:10.1093/eurpub/ckv007. 46. yach d, bettcher d. the globalization of public health, ii: the convergence of self-interest and altruism. am j public health 1998;88:738-44. 47. kuhlmann e, lynn bourgeault i. gender, professions and public policy: new directions. equal oppor int 2008;27:5-18. doi:10.1108/02610150810844901. 48. leung l. validity, reliability, and generalizability in qualitative research. j family med prim care 2015;4:324-7. doi:10.4103/22494863.161306. 49. dent m, bourgeault il, denis jl, kuhlmann e. introduction: the changing world of professions and professionalism. in: dent m, bourgeault il, denis jl, et al., editors. the routledge companion to the professions and professionalism. london: routledge; 2016:1-10. ________________________________________________________________________________ © 2020 mansholt; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited orellana garcía lpo, kaur k, brand h, schröder-bäck p. scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 (original research). seejph 2021, posted: 06 april 2021. doi: 10.11576/seejph-4312 p a g e 1 | 11 c original research scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 laura patricia orellana garcía1, kiranjeet kaur2, helmut brand1,3, peter schröder-bäck1 1 department of international health, care and public health research institute (caphri), maastricht university, the netherlands; 2 chitkara school of health sciences, chitkara university, punjab, india; 3 prasanna school of public health, manipal academy of higher education, manipal, india. corresponding author: laura patricia orellana garcía; address: department of international health, maastricht university, duboisdomein 30, 6229 gt, maastricht, the netherlands; email: l.orellanagarcia@student.maastrichtuniversity.nl orellana garcía lpo, kaur k, brand h, schröder-bäck p. scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 (original research). seejph 2021, posted: 06 april 2021. doi: 10.11576/seejph-4312 p a g e 2 | 11 abstract aim: antimicrobial resistance (amr) is one of the major health challenges of the future, but the concrete impact of counteracting measures is still unclear. to study possible outcomes within the european union, a scenario analysis for the year 2050 was performed on the possible influence of the european commission (ec). methods: scenario planning and development of strategies based on different scenarios. results: rational use of antimicrobials in animals and humans, surveillance and monitoring, new antimicrobial therapies, travel and globalization, exposure to the environment, and awareness were recognized as the main driving elements. four scenarios were developed: an efficient and implicated ec sorts out amr; an implicated but unsuccessful ec withstands amr; amr is managed regardless of the ec disinterest; and a neutral and inefficient ec fails to manage amr. conclusion: all the strategies developed on the basis of the four scenarios probe for an increase in european union's dedication to achieve positive outcomes. these include the development of effective legislation and international coordination. keywords: antimicrobial resistance, european commission, one health, scenario planning, strategies. acknowledgment: peter schröder-bäck, helmut brand and kiranjeet kaur’s contribution is cofunded through a grant of the european commission within the erasmus+ programme (project: prevent it. project reference: 598515-epp-1-2018-1-in-eppka2-cbhe-jp). conflict of interests: none declared. orellana garcía lpo, kaur k, brand h, schröder-bäck p. scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 (original research). seejph 2021, posted: 06 april 2021. doi: 10.11576/seejph-4312 p a g e 3 | 11 introduction since time immemorial, mankind has struggled with the control of infectious diseases which are one of the leading causes of death worldwide (1). the covid-19 pandemic has brought infectious diseases as top priority on the global health agenda, but in general, most of the infections are caused by non-viral agents the bacteria. luckily, the development of antimicrobial agents has remarkably helped for treating these infectious diseases: antimicrobials can kill or inhibit the growth of bacteria by disrupting one or more of their essential functions. however, the indiscriminate and prolific use of antibiotics ensued a selection pressure that led to the emergence of “antibiotic resistant” organisms, resulting in antimicrobial resistance (amr) (2). it has become a major problem given the slow pace at which new antibiotics are discovered (3). effective antimicrobial drugs are especially needed for preventive and curative measures such as ensuring complex procedures (surgeries, cancer treatment, transplants) or protecting patients from fatal diseases (2,4). in 2019, amr has been named as one of the top ten threats to global health by the world health organization (who) (5). apprehensions are rampant that amr may follow similar patterns as seen in case of epidemic outbreaks developing into pandemics (6). amr associated burden can be described as its impact on health or on the economy (7). at present, amr is estimated to cause 700,000 deaths in the world per year and a cumulative loss of over 88 trillion euros by 2050 (2,8). hence, global efforts have been organized to face this challenge. the 2015-who global action plan and 2016-united nations political declaration on amr are some of the latest undertaken actions worldwide (9). in the european union (eu) 25,000 patients die annually and 1.5 billion euros are expended each year due to amr (8). consequently, the eu reinforced the 2001 community strategy against amr through the 2011 commission action plan. with its “one health” approach, this action plan addresses amr in humans and animals. based on previous approaches, the european commission (ec) also developed guidelines for the prudent use of antimicrobials in human health (9). amr prevention is also a topic for research and educational projects of the ec, as for example the prevent it project (risk management and prevention of antibiotics resistance) that established a collaboration between european and indian universities and ngos for mutual learning (10). to introduce policy interventions, evaluations of amr burden are performed through morbidity/mortality and economic indicators (11). nevertheless, these indicators are the result of amr rather than the factors which currently influence it. thus, to ascertain the best approaches in the eu, it is imperative to acknowledge the factors that will influence amr by 2050. the present paper aims to determine the driving forces of amr and establish useful strategies through the development of a series of scenarios. these scenarios will concern the influence of the eu in combating amr by the year 2050. methods scenario planning is a technique used for anticipating alternative futures. it was originally founded by economic experts to predict large-scale changes. in fact, it is particularly convenient in circumstances with high uncertainty. this method is progressively expanding in the public health sector since it takes apart the complexity of most public health concerns (12). accordingly, scenario planning was employed in this study to address amr intricacy and enhancing key strategies from the eu perspective. moreover, this method has been applied successfully in the context of eu policies earlier as well. for in orellana garcía lpo, kaur k, brand h, schröder-bäck p. scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 (original research). seejph 2021, posted: 06 april 2021. doi: 10.11576/seejph-4312 p a g e 4 | 11 stance, the white paper on the future of europe shows five scenarios for how europe could evolve by 2025 (13). to execute scenario planning, the process described by neiner et al (12) was followed. according to the authors, four steps are needed to develop scenario planning in public health: (i) define the sense of purpose; (ii) understand driving forces, key patterns and trends; (iii) develop scenario plots; and (iv) plot strategy, rehearse and converse. briefly, first of all a relevant objective needs to be established to define the sense of purpose. in this matter, the impact of amr on public health was considered, as it has motivated the need for action (14). after all, the ec has recognized amr threat and works closely with who and other partners to accomplish amr global action plan (15). besides, it aims the eu to set best example globally (16). secondly, predetermined and unpredictable forces shaping the objective need to be determined. for this purpose, a literature review was carried out. as a result, key factors, previous actions and current involvement of the eu in amr were exposed. next, alternative futures ought to be developed in conformity with the forces formerly established. hereby, four scenarios were developed based on amr progress and ec support considering the factors ascertained from the literature review. lastly, valuable strategies should be settled irrespective of the scenario contemplated. and so, these strategies were ultimately included and argued in the discussion section (12). results driving forces, key patterns and trends the development of resistance basically involves three major determinants: humans, animals, and the environment. resistant bacteria arising in humans, animals, or the environment may spread from one to the other, and from one place to another. it spans inappropriate antibiotic prescription, uncontrolled over-the-counter sale of antibiotics, disproportionate use of antibiotics in the food for animals (e.g. livestock, aquatic, pets), and poor sanitation and hygiene (17). of these, the rational use of antibiotics has a major influence on amr outcomes. common infections such as cold, flu are responsible for the majority of antibiotic prescriptions, however in reality, most of these infections are caused by viral agents against which antibiotics are ineffective (18). the use of antibiotics in these cases is not appropriate, rather it enhances the risk of amr. antibiotics also prevail as a prophylactic measure for minimizing the consequence of poor farming conditions and as a growth accelerator (18). to prevent misuse, the eu has published guidelines for the prudent use of antimicrobials (19). in this regard, the european parliament and the council of the eu issued the eu 2019/6 regulation that prohibits the use of antimicrobial as prophylactic agent or growth promoter in animals (20). rational use of antibiotics is a predetermined force since it has become a priority for health professionals (21). surveillance and monitoring are key elements of national action plans on amr (18). for instance, at eu level, several agencies are involved in amr surveillance: the european centre for disease prevention and control (ecdc), the european medicines agency (ema), and the european food safety agency (efsa). basically, ecdc is responsible for coordinating two surveillance networks (ears-net and esac-net), while ema and efsa publish annual reports on amr (18). these are predetermined forces since these agencies are expected to continue with their responsibilities. public awareness is another key element in combating amr. the results of price et al (22) substantiated poor understanding of orellana garcía lpo, kaur k, brand h, schröder-bäck p. scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 (original research). seejph 2021, posted: 06 april 2021. doi: 10.11576/seejph-4312 p a g e 5 | 11 amr in the general population. as a matter of fact, the 2018 eurobarometer indicated 57% of europeans were uninformed that antibiotics are ineffective against viruses (18). this unawareness endorses antibiotics’ misuse and so amr. hence, ecdc established the european antibiotic awareness day (eaad) which aims to support the correct use of antibiotics through national campaigns (16). though raising amr awareness perhaps entail a predictable force, its effectiveness is certainly unpredictable. the discovery of new antimicrobials and diagnostic techniques will significantly impact amr (23), therefore more investment is needed in basic science (18). for this reason, one of the main pillars of one health action plan focus on boosting research, development and innovation (9). in this regard, the eu is developing in coordination with industry for development of new antibacterial agents under the combacte-magnet project (24). despite the investment, it is unpredictable when new antimicrobials will be ready and if so, what will be their efficacy against amr strains. the relevance of the interaction between chemicals (antimicrobials, heavy metals, and biocides) and pathways (industrial wastewater, animal manure) has also been emphasized in contributing to the spread of amr. it seems that strict environmental regulations are needed in the development of amr national action plans (25). the eu acknowledges that strong evidence is needed to counteract the incomprehension of the environment role in amr. to fill this knowledge gap, specific actions (such as strengthening the role of the scientific committee on health and environmental risks (scher) on amr matters) have been included in the eu one health action plan (9). despite the ec engagement in the environmental area, the success of this approach is yet unpredictable. lastly, travel and globalization have allowed newer opportunities for cross-transmission of amr (23). visitors from developed countries such as usa often show colonization or infections with kpc-, vim-, oxa-48and especially ndm-producing enterobacteriaceae, upon travel to countries such as greece, israel, turkey and morocco and the indian subcontinent (26). amongst various categories of visits, medical tourism is specifically linked to the spread of amr. people from developed countries usually undergo several types of surgical procedures in developing countries such as india and china due to relatively low treatment costs and shorter waiting times for surgeries. travel and globalization are unpredictable driving forces since their course and trends are likely uncertain. scenario plots four scenario plots have been developed, based on the anticipated futures resulting from amr progress and ec support. the different scenario plots are presented in table 1 and 2. the first two scenarios (‘an efficient and implicated ec sorts out amr’ and ‘an implicated but unsuccessful ec withstands amr’) assumed a strong ec involvement, whereas in the last two (amr is managed regardless of the ec disinterest and a neutral and inefficient ec fails to manage amr) indicates that there is no engagement of the ec to encounter amr. despite the level of support provided by the ec, in the first and third scenario (an efficient and implicated ec sorts out amr and amr is managed regardless of the ec disinterest) it is assumed amr has been addressed appropriately. on the contrary, the second and fourth scenario (an implicated but unsuccessful ec withstands amr and a neutral and inefficient ec fails to manage amr) assumed an inefficient management of amr. orellana garcía lpo, kaur k, brand h, schröder-bäck p. scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 (original research). seejph 2021, posted: 06 april 2021. doi: 10.11576/seejph-4312 p a g e 6 | 11 table 1. scenario planning for amr in view of the ec table 2. scenario planning for amr in view of the ec an efficient and implicated ec sorts out amr an implicated but unsuccessful ec withstands amr amr is managed regardless of the ec disinterest a neutral and inefficient ec fails to manage amr u n p r e d ic ta b le f o r c e s a m r a w a r e n e ss the ec encouraged ms to raise effective awareness among the population through the increase of national campaigns. people are conscious of the use of antibiotics and follow accurately healthcare professionals’ instructions. the ec supported ms in developing multiple national campaigns to raise amr mindfulness. even so, the interventions did not have the desired impact and the public still use antimicrobials indiscriminately. the ec did not encourage ms to increase the number of national campaigns to raise amr awareness. however, the general public is more conscious about the amr problem and they use antibiotics less indiscriminately, although misuse still exists. the ec failed to encourage and support ms to raise amr awareness through sufficient and effective national campaigns. citizens misuse antibiotics which have increased the number of resistant pathogens. an efficient and implicated ec sorts out amr an implicated but unsuccessful ec withstands amr amr is managed regardless of the ec disinterest a neutral and inefficient ec fails to manage amr p r e d e te r m in e d f o r c e s r a ti o n a l u se i n a n im a ls a n d h u m a n s the ec extended the guidelines and introduced stricter measures regarding the use of antimicrobials. the broad use of antimicrobials decreased and they are uniquely provided when indicated in guidelines. the ec extended the guidelines and introduced stricter measures for antimicrobials use. still, professionals do not follow the guidelines and measures established. antimicrobials are used irrationally which has resulted in an increase of amr. the ec did not extend the guidelines and measures regarding the use of antimicrobials. despite this, professionals are following outdated guidelines. amr has slightly increased but not as much as it was expected. the ec did not extend the guidelines and measures regarding the use of antimicrobials. besides, professionals are not following the guidelines and measures. s u r v e il la n c e a n d m o n it o r in g surveillance and evaluation of amr have been performed correctly. useful information has been gathered which allowed to develop appropriate strategies to confront amr. surveillance and evaluation of amr have been performed correctly and more agencies have been involved to complete this task. despite the information gathered, it has not been used appropriately to developed useful strategies to approach amr. surveillance and evaluation of amr have failed to provide useful information. however, policymakers have been able to use the little information gathered to improve some strategies and developed useful interventions. surveillance and evaluation of amr have failed to provide useful information. the ec has lost interest in monitoring amr, there is no pressure from the european parliament or the ec. the real status of the amr situation is not known. orellana garcía lpo, kaur k, brand h, schröder-bäck p. scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 (original research). seejph 2021, posted: 06 april 2021. doi: 10.11576/seejph-4312 p a g e 7 | 11 n e w a n ti m ic r o b ia l th e r a p ie s the ec has constantly been investing in amr research. the investment has provided good results, new antibiotics have been discovered and new diagnostic technologies developed. amr exists but there are effective resources to deal with it. the ec has constantly been investing in amr research. however, the development of new antimicrobials and diagnostics has not improved considerably. new advances have been made but not sufficiently to solve the problem. the ec decreased the investment in research in amr. the development of new therapies and diagnostics has slowed down. despite this, new technologies developed for other health problems have been useful to deal with amr and reduce its impact. the ec stopped the investment in research, and no new development has been achieved. old antimicrobials are still used as first and second-line treatments. health professionals have to deal with new amr pathogens. a m r e x p o su r e t o t h e e n v ir o n m e n t the ec has been working to involve environmental regulators in amr national action plans. also, their coordination with stakeholders has improved. the degradation of antimicrobials in wastewater is strictly controlled and treated. no antimicrobials are released to the environment. the ec has been working to get environmental regulators to be more involved in amr national action plans. however, their coordination with stakeholders is still insufficient. new regulations are considered to be implemented regarding wastewater, but no steady action has been yet taken. the ec did not boost the involvement of environmental regulators in amr national action plans. nonetheless, there is coordination between environmental regulators and other stakeholders. they achieved to develop strategies to minimize amr impact in the environment. the ec did not boost the involvement and coordination between environmental regulators and stakeholders. national action plans did not include amr's impact on the environment. antimicrobials are constantly released to the environment since there is no regulation to control it. t r a v e l a n d g lo b a li z a ti o n tourism increased in the last years. the ec has been working to endorse early screening and control measures to tourist arriving from amr endemic areas. these measures have been successfully applied and so, fewer amr pathogens have been spread. the ec encouraged new control measures and provided additional guidance on early screening for tourists returning from amr endemic areas, yet they were not strongly followed, and several amr strains have been locally spread. the ec has not considered the need of new guidelines regarding early detection or additional measures in tourists. nonetheless, healthcare professionals have been able to detect certain carriers and limit the spread of imported amr strains. there ec ignored tourism as a amr threat and consequently, no measures have been considered nor proposed to supervise the transit of tourist arriving from amr endemic areas. this situation has boosted the spread of amr strains to different regions. discussion the ongoing covid-19 pandemic has taught us a big lesson that how devastating nontreatable infectious diseases can be (27). on similar league, amr bears the proficiency of attacking us as an epidemic or pandemic. an estimate by who suggests that approximately 10 million deaths will happen due to amr by 2050. although just a forecast, some of the scenarios described could be associated with this number of deaths. to decrease the odds of these deaths becoming a reality, actions must be taken on priority. therefore, the potential influence of driving forces has been described in the scenario orellana garcía lpo, kaur k, brand h, schröder-bäck p. scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 (original research). seejph 2021, posted: 06 april 2021. doi: 10.11576/seejph-4312 p a g e 8 | 11 plots to better understand the ways to combat amr. encouraging legislators to introduce standards and procedures to assure sensible use of antimicrobials will be useful (19). antibiotics could be restricted with a similar approach narcotics and psychotropics are controlled (regulated by the single convention on narcotic drugs of 1961 and the convention on psychotropic substances of 1971). the development of these “antibiotic conventions” could shift the prescription of antibiotics as a first-line treatment to every possible infection. nevertheless, to achieve this type of covenant a high level of international agreement is required. stakeholders would clearly benefit from this consensus and of these, society also plays a fundamental role. public awareness is an influential factor on amr. thus, further efforts should be considered to increase population’s consciousness about amr threat: diversification of amr campaigns in diverse channels such as tv, radio, or social media that could successfully raise public awareness. in light of newer antibiotics, the development of effective antibiotics against resistant strains is the need of the hour. a fixed amount of money provided by the ec to industry could be established as funding to foster new antibiotics discoveries. promoting partnership with industries will also improve the likelihood of developing better diagnostics to determine the etiologic agents of the diseases and, consequently, prescribe antibiotics only when necessary. likewise, the use of artificial intelligence in amr surveillance and monitoring would allow to analyze existing data more precisely and consequently improve outcomes through strategies adapted to each circumstance. tourism also represents a relevant threat to the spread of amr strains: tourists may acquire amr pathogens in their journeys and subsequently spread them in their country of origin. early detection of carriers and control measures, in combination with international cooperation are strategies which could be beneficial, if they are successfully applied (23,28). on the other hand, it is necessary to emphasize the connection between amr and the environment. on this ground, legal measures could be established to control wastewater treatment, followed by regular inspections to assure that legislation is properly applied. in general, the strategies developed from each scenario imply that the outcomes would likely be beneficial if there is an increase of commitment and coordination between stakeholders, especially from the ec. some of the strategies established have been compared with conventions already applied to other health challenges, such as the psychotropic and narcotic drug conventions. nonetheless, to achieve these methods, further collaboration and coordination are needed not only among member states but also at international level. the eu-india collaboration contributing to this global perspective (10). the global position also emphasizes the important role the eu plays in this global health challenge and the advantageous outcomes that could be achieved if the eu is fully involved in slowing down amr. on the other hand, the results have shown that the ec could address the driving forces of surveillance and monitoring, environmental amr, treatment innovation, and tourism by introducing new legislation. eu legislation can have a significant impact, not only within the member states but also outside its borders. in fact, the eu is currently endorsing amr measures in third countries through different actions, like promoting amr-related standards in its bilateral free trade agreements (ftas) (9). these actions underpin the role of the eu as a global actor in the orellana garcía lpo, kaur k, brand h, schröder-bäck p. scenario planning: an alternative approach to european commission for combating antimicrobial resistance by 2050 (original research). seejph 2021, posted: 06 april 2021. doi: 10.11576/seejph-4312 p a g e 9 | 11 amr challenge and highlights, again, the importance of developing and reinforcing international collaboration. limitations: the initial inquiry necessary for determining the trends and driving forces was not based on a systematic literature review. scenario planning is a method based on assumptions and therefore subject to bias, yet the non-systematic research of driving forces increases the risk of bias. besides, some of the driving forces, though acknowledged, were not included in the scenario planning as per the scope of this paper. for instance, the use of vaccination has shown positive effects in reducing amr, although its success has been historically under-recognized so far (29). lastly, the mutual influence between driving forces were not considered since none of the driving forces would uniquely impact amr but also influence one another. therefore, further scenarios and strategies should be developed in the future, including additional driving forces along with their reciprocal interaction/s. references 1. devasahayam g, scheld wm, hoffman ps. newer antibacterial drugs for a new century. expert opin investig drugs 2010;19:215-34. 2. european commission. 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mobility, globalization, and antimicrobial drug resistance. emerg infect dis 2009;15:1727-31. 29. jansen ku, knirsch c, anderson as. the role of vaccines in preventing bacterial antimicrobial resistance. nat med 2018;24:10-9. ____________________________________________________________________________ lopes h, middleton j. learning from the pandemic, building increased international cooperation. (position paper). seejph 2021, posted: 26 september 2021. doi: 10.11576/seejph-4760 p a g e 1 | 9 position paper learning from the pandemic, building increased international cooperation henrique lopes1, john middleton2 1 institute of health sciences, universidade católica portuguesa, lisbon, portugal; 2 association of schools of public health in the european region, um campus brussels, av de tervuren 153,1150 brussels, belgium. corresponding author: prof. henrique lopes; address: institute of health sciences, universidade católica portuguesa, lisbon, portugal; email: henrique.lopes@ucp.pt lopes h, middleton j. learning from the pandemic, building increased international cooperation. (position paper). seejph 2021, posted: 26 september 2021. doi: 10.11576/seejph-4760 p a g e 2 | 9 abstract the covid-19 pandemic highlighted a fragile preparation by countries and regions for epidemic events, exposing exacerbated nationalisms in pandemic mitigation and control actions. both conditions decisively compromise the effectiveness and efficiency of pandemic control capacity. it is important to develop frameworks that help overcome frailties in response to epidemics. based on a thematic literature review and discussions with multiple national and international entities an attempt was made to build a tool for responding to future epidemics, the pandemic preparation framework (2pf). the proposed 2pf tool is aligned with the sendai framework for disaster risk reduction and with international bodies, such as the european health emergency preparedness and response authority (hera). it aims to be a framework for operationalizing these agreements. the response to pandemics must be based essentially on international action and closer collaboration between countries and regions. keywords: crisis management, framework, internationalization, strategic management, pandemic. acknowledgments: the authors acknowledge diogo franco of the usp-ics/ucp scientific secretariat for his support in this article. authors’ contribution: the authors contributed equally to this article. conflict of interest: none declared. sources of funding: none declared. lopes h, middleton j. learning from the pandemic, building increased international cooperation. (position paper). seejph 2021, posted: 26 september 2021. doi: 10.11576/seejph-4760 p a g e 3 | 9 background although the appearance of a pandemic such as the one caused by the sars-cov2 virus has been alerted since 2007 (1) and the center for disease control and prevention (cdc) warned in 2013 (2) about the risks of accidents with laboratories at levels 3 and 4 of 0.2%/year, the frameworks and necessary reactions were not developed so that one could not act with full preparedness. the very nature of the current pandemic’s origin is not yet definitively identified as stated recently (https://covid19commission.org/). pandemics and epidemics will undoubtedly return in the current century. all the conditions for increased circulation of individuals, goods, climate change, contact with wildlife and devastation of ecosystems previously untouched by humans are currently gathered and will worsen in the predictable horizon. the latter conditions are estimated to generate around 60-70% of new diseases and epidemics (3). therefore, we must prepare so that the public health catastrophe of covid-19 will not be repeated. the countries judged to be most well-prepared for pandemic in 2018, often performed poorly. many of the failures were attributable to political positions and indecision (4). we identified at least seven weaknesses in western countries: • passive, indecisive and slow. • bureaucratic-normative. • without conceptual preparation for surveillance, preparation, or coordination of actions. • without strategic reserves of protective personal equipment (ppe) material norsignificant hospital reserves (facilities and capacity). • lacking pandemic response tools at the macro, meso and micro level. • nationally centered, paying little attention to who or other international authorities. • low knowledge management and knowledge transfer. in our reading, much of this result is due to consecutive years of disinvestment in health, especially in the last decade and because public health is usually the poor branch of health, the one in which little is invested, where little space is given to the preparation of people and logistics (5,6). this cycle should be reversed placing public health as a strategic tool for national and international cooperation. much can be done without relevant effort if the lessons of covid-19 and the accumulated experience of decades in the surveillance and mitigation of effects caused by natural risks are considered. therefore, we propose the creation of a framework for approaching biological risk with pandemic danger–the pandemic preparation framework (2pf). the proposed pandemic preparation framework (2pf) with the 2pf, we propose a way of dealing with future epidemics/pandemics that can at least partially address the difficulties and problems of the seven weaknesses in western countries’ health response during the covid-19 crisis, as summarized above. − pandemics and major epidemics are overcome in the prevention phase. − when it is no longer possible to maintain either situation with very high certainty in the preventive phase, there must be a planning and preparation phase for a concrete risk. − proactive response to the pandemic when it is already installed on the field. − the identification, prevention, planning of preparation and combating a pandemic or major epidemic can only be successful through intensive international cooperation. https://covid19commission.org/ lopes h, middleton j. learning from the pandemic, building increased international cooperation. (position paper). seejph 2021, posted: 26 september 2021. doi: 10.11576/seejph-4760 p a g e 4 | 9 the strategic idea is that the coordination of the response to an epidemic/pandemic must be essentially achieved at a supranational level, through adequate prior preparation and based on knowledge management. the need for this paradigm shift was recently addressed at the european union level, with the regulation entity proposal entitled “european health emergency preparedness and response authority” (hera) (4). however, with emerging diseases having the potential of becoming a global threat, a more global approach was reinforced by the signature of a global pandemic preparedness treaty by 24 world leaders and the world health organisation (who) (5). during the twentieth century, the world has progressed from national to supranational entities whenever the common good is to the parties' advantage, of which the ultimate example will be the united nations (un). countries have also learned that major crises are faced by cooperation and have created mechanisms for that purpose within supranational organizations. in addition, there is an increasingly globalized world where everything tends to occur almost simultaneously. only international solutions based on cooperation will be able to respond to major issues since what affects a country can quickly become a global threat. therefore, it is in the direct interest of all nations to participate in the elimination or mitigation of a risk in any country in the world. for example, since 2005, with the signing of the un hyogo framework (6) for response actions to disasters, and later with the sendai framework for disaster risk reduction (7), global targets were defined towards reducing disaster consequences such as: mortality, affected people, economic loss in gdp, infrastructural damage and service disruption, national/local risk reduction strategies, international cooperation, availability and access to multihazard warning systems. the covid-19 pandemic has shown beyond a reasonable doubt that the capacity to control a pandemic is something that goes beyond the national dimension, as declared by many politicians (8) and scientists (9). only through the highest international cooperation is it possible to find appropriate solutions, supply equipment volumes at an adequate time and acceptable prices, with universal standards and applicability, and exchange experiences to debug national procedures. international cooperation in a pandemic state has immense scope for progression in all fields (10). the degrading spectacle of government officials redirecting clinical equipment at airports should not be acceptable (11). many national strategies have sought only to concentrate the maximum level of resources with those who can afford them. for example, in the case of worldwide vaccine distribution there is the need of international agreement on its optimal and adequate allocation instead of being focused in profits (12) and realpolitik (13). interna lopes h, middleton j. learning from the pandemic, building increased international cooperation. (position paper). seejph 2021, posted: 26 september 2021. doi: 10.11576/seejph-4760 p a g e 5 | 9 tional authority is needed to ensure resources go to areas where they can be globally most useful and effective in combating the pandemic (14). the absolute need for knowledge management was verified, proving to be the central element for an adequate fight against the pandemic. this element can only be appropriately developed in a wide-ranging, fully internationalized way and with the greatest transparency. finally, it should not happen again that the strengthening of local response capacities through international means is minimal and appears as an insufficiency of the local political response. in the covid-19 pandemic, the international reinforcements that existed were vestigial (14,15) concerning the means deployed in each country and always with difficulties articulating with the local structures that led to situations in which even the smallest help made available was not used: language, local procedures and other complexities (15). only the creation of automatisms can change this framework for the integration of health services. the tactical-operational idea is that national/local actions must be part of an articulated whole composed of three dimensions: prevention, planning and preparedness, proactive response to the pandemic. this means that there must also be a high level of international operational cooperation, presenting the great challenge of requiring mutual knowledge and preparation work. things as simple as consolidating new positive cases or the lethality of a disease among countries can, in practice, be an impossibility when each country works in its own way. consistency in case definitions and ascertainment is needed, for example, to secure cross border intelligence and enable accurate inter-country comparisons. with the ongoing covid-19 pandemic threat, it must not be forgotten that there are other biological threats still emerging, as seen recently with avian influenza (h5n8) in russia (16) and the african swine fever in poland (17). these examples and other situations have been mainly dealt with by the national structures in which the threat emerges, a context that, despite being local, may reach the planetary scale if not controlled and for which there is little to no international response. it is important to note that every nation has a responsibility in preventing and reducing disaster risk, surpassing the national-level interventions, including cooperation with other nations and regions (18). following this approach, reacting promptly to a threat requires having previously allocated, trained, certified resources in sufficient quantity and the capacity to travel to another part of the planet, if accepted and allowed, to immediately integrate the national structures in an environment of full informational transparency. pandemic preparedness investment is beyond almost all countries' capabilities, which greatly reinforces the need to be thought out globally. structures such as the who, ecdc, cdc and fema (national level) did not have the resources that would have been desirable at the beginning of the pandemic, capable of being sufficient to mobilize countries with the needed tenacity and resources (19,20). namely, the who is the organization naturally dedicated to having the above mentioned global competencies. however, to be able to address this issue, it is essential to have a great reinforcement of human, financial and technological resources. in western countries, the main cooperation bodies are the who, the european centre for disease prevention and control (ecdc) or the federal emergency management agency (fema) of cdc. these coordinating organisations need to have their skills and resources strengthened to be able to deal proactively and appropriately with the epidemic/pandemic risk. proposal of an operational mesostructured in addition to strengthening international bodies whose nature leads them to a macro health policies approach, we propose the creation of a new entity, on a continental lopes h, middleton j. learning from the pandemic, building increased international cooperation. (position paper). seejph 2021, posted: 26 september 2021. doi: 10.11576/seejph-4760 p a g e 6 | 9 scale, with national representation in each country for connection to health systems. therefore, it has a different nature and is complementary to the existing bodies with a vocation for field action in biological risk situations and the capacity to strengthen local structures designed to deal with disruptive health situations such as pandemic contexts. considering the pandemic/epidemic generating factors strongly related to contacts with wildlife, this entity should also integrate and consolidate veterinary and agricultural knowledge within the public health dimension. it is possible to capacitate this entity for action regarding other health threats besides pandemics (18): large-scale earthquakes, large industrial accidents as happened in bhopal (21), or others that by nature exceed the country's response capacity in the healthcare action sphere. similar to the other risks already covered with this type of response, aid must not be read as a weakness in a given country but as a collective response to a common threat. biohazard plans must be directly linked to the preparation for action on the field. the entity must know the concrete field where the threat occurs, the existing and missing resources, and the hierarchy of supply priorities for a given risk in a given location when the event occurs. the entity must also have the first materials available to support risk mitigation. to properly perform its functions, the entity needs two fundamental competencies: knowledge management and emergency logistics (heavy materials as modular hospitals fully equipped with devices, personnel and light materials as ppe/medicines stocks). in addition to being guided by the latest scientific evidence and who advising, it must have the capacity to analyze risk and advise policymakers before substantial evidence is gathered, whenever the need to act is more pressing than the evidence available at that time. the difficulty of many governments and authorities in providing clear directives was evident in the absence of scientific evidence, which resulted in numerous delays (22). countries that opted for the proposed forms of decision that were sometimes more crisis management than scientific, ended up having better results as happened in south korea and new zealand. 2pf-strategy-operations concept knowledge management the international body should have knowledge management competencies for the proactive monitoring of potential risks, anticipating as far as possible which biological agents have pandemic capacity while designing strategic and tactical response plans that help containing the threat in early stages. the entity should promote training to national and international agents to interconnect, in case of a biological threat, and field exercises to test the respective systems' weaknesses and provide them with tactical tools. we propose that the entity works on an association between risk and probability (table 1). this will result in each continental zone having a biohazard letter that will allow governments to prepare conveniently, or at least have that opportunity. table 1. risk identification and action priority rankings risk probability high medium low high 1 2 3 medium 2 3 4 low 3 4 5 note: the intersection of each risk level is identified as a scale from 1 to 5, in which 1 represents a primary priority and 5 represents a lesser priority. lopes h, middleton j. learning from the pandemic, building increased international cooperation. (position paper). seejph 2021, posted: 26 september 2021. doi: 10.11576/seejph-4760 p a g e 7 | 9 the creation of data quality assurance tools about the threat must also encompass knowledge management work, such as ensuring easy consolidation of data and semantic sharing. logistics another competence of this supranational entity is to have a minimum reserve of protective materials (field hospitals, critical medical devices, ppe and other equipment) that enable the first action against a pandemic, at least in the early days, until industrial supply chains are adapted to the new reality. under this view, time is critical for prompt action and efficient crisis management. all threats contained in a first moment will be much easier to deal with than after spreading to large areas, as happened with covid-19. the set of procedures deployed in countries should also be worked on towards the greatest harmony possible, at least at a level that allows for the reinforcement teams not to spend several days studying local procedures before starting to work (23). it must also be ensured that at least critical medical devices can interconnect. furthermore, there is a need to respond to another point that has failed in the current pandemic data management. the entity should be responsible for previously defining the metrics of morbidity and mortality, systems of data collection, registration, and consolidation, to prevent information cacophony recurrence in countries with different data collection times, metrics, and regional data, among other aspects. whatever the data, it must be possible to consolidate with sufficient quality to be elements itself in combating the pandemic. the entity’s nature is essentially national, but it should not be exhausted. for example, it must provide for the capacity to reinforce other similar national branches when necessary. again, there is a need to strengthen international cooperation. still, for it to be effective, the types of action must be aligned between countries. for example, materials are compatible, procedures are acceptable elsewhere, national laws and rules are not overlapped. another critical point in creating an entity of this nature is to support information management/literacy of the populations/literacy of journalists/literacy of politicians about the pandemic through specific and specialized communication tools. this set of proposals represents a significant investment. however, no more than millionths of the cost that has been incurred so far. the current century is likely to be the century of pandemics. conclusions we must start preparing for the next pandemic. the proposal aims to present an organizational alternative for improvements in many points that went wrong in the covid-19 pandemic: international cooperation, scientific reading, prompt action, transmission mitigation, critical materials supply chains, decision-making processes, preventive action. most western action comprised waiting and acting with hospital facilities until exhaustion and accepting successive pandemic waves as something natural, which is not. covid19 was worse enough not to repeat without having learned anything. the countries judged to be most well-prepared for a pandemic in 2018, in many cases performed poorly. much of the failures were attributable towards political positions and indecision. there is no more room for national approaches. if politicians are able to commit to these new international mess structures, and an expanded and enhanced role for the world health organisation, it will be a demonstration of a willingness to pool sovereignty and recoil from the narrow-minded nationalism that has cost so many lives in this pandemic. the world will be a safer place, and humanity will have stepped back from the cliff edge. references 1. cheng vc, lau sk, woo pc, yuen ky. severe acute respiratory lopes h, middleton j. learning from the pandemic, building increased international cooperation. (position paper). seejph 2021, posted: 26 september 2021. doi: 10.11576/seejph-4760 p a g e 8 | 9 syndrome coronavirus as an agent of emerging and reemerging infection. clin microbiol rev 2007;20:660-94. 2. klotz lc, sylvester ej. the consequences of a lab escape of a potential pandemic pathogen. front public health 2014;2:116. 3. almond re, grooten m, peterson t. living planet report 2020bending the curve of biodiversity loss. switzerland: world wildlife fund; 2020. 4. european comission. european health emergency preparedness and response authority (hera) [internet]. 2021. available from: https://ec.europa.eu/info/law/betterregulation/have-yoursay/initiatives/12870-europeanhealth-emergency-preparednessand-response-authority-hera_en (accessed: march 30, 2021). 5. the telegraph. no government can address the threat of pandemics alone – we must come together [internet]. 2021. available from: https://www.gov.uk/government/sp eeches/no-government-canaddress-the-threat-of-pandemicsalone-we-must-come-together (accessed: march 30, 2021). 6. un, isdr. hyogo framework for action 2005–2015: building the resilience of nations and communities to disasters [internet]. kobe, japan; 2005. available from: https://www.unisdr.org/2005/wcdr/ intergover/official-doc/ldocs/hyogo-framework-for-actionenglish.pdf (accessed: march 30, 2021). 7. unisdr. sendai framework for disaster risk reduction 2015 2030 [internet]. geneva; 2015. available from: https://www.preventionweb.net/file s/43291_sendaiframeworkfordrren. pdf (accessed: march 30, 2021). 8. un. covid-19 impacting global security with heightened volatility, increased threats to united nations personnel, secretary-general says in new report [internet]. 2020. available from: https://www.un.org/press/en/2020/ org1711.doc.htm (accessed: january 15, 2021). 9. braithwaite j, tran y, ellis la, westbrook j. the 40 health systems, covid-19 (40hs, c-19) study. int j qual health care 2020;33:mzaa113. 10. gaub f, boswinkel l. covid-19: the geopolitical implications of a global pandemic [internet]. european parliament’s committee on foreign affairs. 2020. available from: https://www.europarl.europa.eu/re gdata/etudes/stud/2020/603511/exp o_stu(2020)603511_en.pdf (accessed: march 30, 2021). 11. the guardian. us accused of “modern piracy” after diversion of masks meant for europe [internet]. 2020. available from: https://www.theguardian.com/worl d/2020/apr/03/mask-warscoronavirus-outbidding-demand (accessed: may 5, 2021). 12. the guardian. the world needs a patent waiver on covid vaccines. why is the uk blocking it? [internet]. 2021. available from: https://www.theguardian.com/com mentisfree/2021/apr/18/patentwaiver-covid-vaccines-ukvariants?cmp=share_iosapp_other (accessed: april 19, 2021). 13. wong blh, delgrange m, martinmoreno jm, manfred s green, middleton j. covid-19 vaccines: a game of power jabs [internet]. 2021. available from: https://blogs.bmj.com/bmj/2021/04 /16/covid-19-vaccines-a-game-of lopes h, middleton j. learning from the pandemic, building increased international cooperation. (position paper). seejph 2021, posted: 26 september 2021. doi: 10.11576/seejph-4760 p a g e 9 | 9 power-jabs/ (accessed: april 19, 2021). 14. herlitz a, lederman z, miller j, fleurbaey m, venkatapuram s, atuire c, et al. just allocation of covid-19 vaccines. bmj glob health 2021;6:e004812. 15. euractive. germany, austria, spain, commission to help portugal deal with third covid-wave [internet]. 2021. available from: https://www.euractiv.com/section/p olitics/short_news/germanyaustria-spain-commission-to-helpportugal-deal-with-third-covidwave/ (accessed: march 10, 2021). 16. who. human infection with avian influenza a (h5n8) – the russian federation [internet]. 2021. available from: www.who.int/csr/don/26-feb-2021influenza-a-russian-federation/en (accessed: march 30, 2021). 17. ter beek v. asf poland: virus hits farm in the west with 16,000 pigs [internet]. 2021. available from: https://www.pigprogress.net/health /articles/2021/3/asf-polandvirus-hits-farm-in-the-west-with16000-pigs-724368e/ (accessed: march 30, 2021). 18. unisdr. sendai framework for disaster risk reduction 2015 2030. geneva; 2015. 19. kuznetsova l. covid-19: the world community expects the world health organization to play a stronger leadership and coordination role in pandemics control. front public health 2020;8:470. 20. maani n, galea s. covid-19 and underinvestment in the public health infrastructure of the united states. milbank q 2020;98:250. 21. mandavilli a. the world’s worst industrial disaster is still unfolding [internet]. 2018. available from: https://www.theatlantic.com/scienc e/archive/2018/07/the-worldsworst-industrial-disaster-is-stillunfolding/560726/ (accessed: january 15, 2021). 22. abbasi k. covid-19: politicisation, “corruption,” and suppression of science. bmj 2020;371:1-2. 23. the portugal news. german team starts treating first patients today [internet]. 2021. available from: https://www.theportugalnews.com/ news/2021-02-08/german-teamstarts-treating-first-patientstoday/58152 (accessed: march 10, 2021). _________________________________________________________________________ ____________________________________________________________________ © 2021 lopes et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.theatlantic.com/author/apoorva-mandavilli/ 2pf-strategy-operations concept knowledge management logistics conclusions references 1. cheng vc, lau sk, woo pc, yuen ky. severe acute respiratory syndrome coronavirus as an agent of emerging and reemerging infection. clin microbiol rev 2007;20:660-94. 2. klotz lc, sylvester ej. the consequences of a lab escape of a potential pandemic pathogen. front public health 2014;2:116. 3. almond re, grooten m, peterson t. living planet report 2020-bending the curve of biodiversity loss. switzerland: world wildlife fund; 2020. 4. european comission. european health emergency preparedness and response authority (hera) [internet]. 2021. available from: https://ec.europa.eu/info/law/better-regulation/have-your-say/initiatives/12870-european-health-emergency-preparedness-and-re... 5. the telegraph. no government can address the threat of pandemics alone – we must come together [internet]. 2021. available from: https://www.gov.uk/government/speeches/no-government-can-address-the-threat-of-pandemics-alone-we-must-come-together (a... 6. un, isdr. hyogo framework for action 2005–2015: building the resilience of nations and communities to disasters [internet]. kobe, japan; 2005. available from: https://www.unisdr.org/2005/wcdr/intergover/official-doc/l-docs/hyogo-framework-for-actio... 7. unisdr. sendai framework for disaster risk reduction 2015 2030 [internet]. geneva; 2015. available from: https://www.preventionweb.net/files/43291_sendaiframeworkfordrren.pdf (accessed: march 30, 2021). 8. un. covid-19 impacting global security with heightened volatility, increased threats to united nations personnel, secretary-general says in new report [internet]. 2020. available from: https://www.un.org/press/en/2020/org1711.doc.htm (accessed: jan... 9. braithwaite j, tran y, ellis la, westbrook j. the 40 health systems, covid-19 (40hs, c-19) study. int j qual health care 2020;33:mzaa113. 10. gaub f, boswinkel l. covid-19: the geopolitical implications of a global pandemic [internet]. european parliament’s committee on foreign affairs. 2020. available from: https://www.europarl.europa.eu/regdata/etudes/stud/2020/603511/expo_stu(2020)60... 11. the guardian. us accused of “modern piracy” after diversion of masks meant for europe [internet]. 2020. available from: https://www.theguardian.com/world/2020/apr/03/mask-wars-coronavirus-outbidding-demand (accessed: may 5, 2021). 12. the guardian. the world needs a patent waiver on covid vaccines. why is the uk blocking it? [internet]. 2021. available from: https://www.theguardian.com/commentisfree/2021/apr/18/patent-waiver-covid-vaccines-uk-variants?cmp=share_iosapp_other (ac... 13. wong blh, delgrange m, martin-moreno jm, manfred s green, middleton j. covid-19 vaccines: a game of power jabs [internet]. 2021. available from: https://blogs.bmj.com/bmj/2021/04/16/covid-19-vaccines-a-game-of-power-jabs/ (accessed: april 19, 2021). 14. herlitz a, lederman z, miller j, fleurbaey m, venkatapuram s, atuire c, et al. just allocation of covid-19 vaccines. bmj glob health 2021;6:e004812. 15. euractive. germany, austria, spain, commission to help portugal deal with third covid-wave [internet]. 2021. available from: https://www.euractiv.com/section/politics/short_news/germany-austria-spain-commission-to-help-portugal-deal-with-third-cov... 16. who. human infection with avian influenza a (h5n8) – the russian federation [internet]. 2021. available from: www.who.int/csr/don/26-feb-2021-influenza-a-russian-federation/en (accessed: march 30, 2021). 17. ter beek v. asf poland: virus hits farm in the west with 16,000 pigs [internet]. 2021. available from: https://www.pigprogress.net/health/articles/2021/3/asf-poland-virus-hits-farm-in-the-west-with-16000-pigs-724368e/ (accessed: march 30, 2021). 18. unisdr. sendai framework for disaster risk reduction 2015 2030. geneva; 2015. 19. kuznetsova l. covid-19: the world community expects the world health organization to play a stronger leadership and coordination role in pandemics control. front public health 2020;8:470. 20. maani n, galea s. covid-19 and underinvestment in the public health infrastructure of the united states. milbank q 2020;98:250. 21. mandavilli a. the world’s worst industrial disaster is still unfolding [internet]. 2018. available from: https://www.theatlantic.com/science/archive/2018/07/the-worlds-worst-industrial-disaster-is-still-unfolding/560726/ (accessed: january 15, 2021). 22. abbasi k. covid-19: politicisation, “corruption,” and suppression of science. bmj 2020;371:1-2. 23. the portugal news. german team starts treating first patients today [internet]. 2021. available from: https://www.theportugalnews.com/news/2021-02-08/german-team-starts-treating-first-patients-today/58152 (accessed: march 10, 2021). alderslade r, kokeny m, tsouros a. the health of the public: what has gone wrong? (review article). seejph 2020, posted: 07 december 2020. doi: 10.4119/seejph-3996 p a g e 1 | 10 review article the health of the public: what has gone wrong? richard alderslade1, mihaly kokeny2, agis tsouros3 1 st. georges hospital university of london, london, united kingdom; 2 global health centre, the graduate institute of international and development studies, geneva, switzerland; 3 visiting professor, institute for global health innovation, imperial college, london. corresponding author: richard alderslade; address: st. georges hospital university of london, london, united kingdom; telephone: +447742777465; email: richard.alderslade@gmail.com alderslade r, kokeny m, tsouros a. the health of the public: what has gone wrong? (review article). seejph 2020, posted: 07 december 2020. doi: 10.4119/seejph-3996 p a g e 2 | 10 abstract covid-19, a new pandemic, has swept the world. how could this have happened? in theory the world should have been prepared, armed as it has been since 2005 with a new set of international health regulations with universal commitment by who member states. yet disaster has struck. the authors of this paper consider that fundamental rethinking is needed, with a new review of the post-world war 2 international system for global governance for health. whilst who and its present and future actions will be scrutinized, the organization is fundamentally made up of 194 member states, which must share the responsibility for ensuring better global health protection in the future. it is clear the world needs a more effective who, but it also needs countries to support and develop their public health infrastructure to face today’s more complex health challenges, which can only grow in scope and complexity over coming years. the paper proposes several key steps to achieve these goals. keywords: covid-19, global health governance, international health regulations (2005), pandemic, public health strengthening, who strengthening. conflict of interest: none declared. alderslade r, kokeny m, tsouros a. the health of the public: what has gone wrong? (review article). seejph 2020, posted: 07 december 2020. doi: 10.4119/seejph-3996 p a g e 3 | 10 introduction a new pandemic covid 19 has swept across the world. globally as of 12 november 2020, there have been 51,547,733 million confirmed cases of covid-19, and 1,275,979 deaths, reported to who (1). how did this happen? could it have been prevented? we have all had to realize that the world is much more dangerous place than we thought. what lessons do we learn? what should we do in the future? in theory the world should have been prepared. it has happened before, for example during the 1918-19 influenza pandemic which is estimated to have killed some 50 million people worldwide (2). after the sars outbreak in 2003, which was globally contained, a new international legal instrument-the international health regulations (2005) (3) was agreed, putting in place new legal obligations on countries, to be open and honest about any new outbreak of communicable disease, and the cooperate fully with who in terms of management and containment. countries agreed to put in place a series of health system and laboratory “core capacities” to promote for preparedness and capacity, as well as outbreak surveillance and response. the mild h1n1 influenza pandemic of 200910 was a first challenge to the ihrs (2005). assessments suggest that country response was variable (4), whilst who was criticized for overestimating the threat (5). in the ebola outbreak in west africa in 2014 the criticism of who was the reverse, that is had not reacted with sufficient alacrity (6), and after internal and external review the organization reformed and reinvigorated its emergency response capacity (7). it worked to help countries develop their own capacities and systems, and to provide immediate support and global oversight to countries in case of an outbreak and necessary global response. over the next years since 2005, in a world of nation states, it became clear that implementation of the ihrs (2005) was patchy and incomplete. countries were not always open and immediate in the information they provided to who, and evaluations (8) revealed large gaps in core public health capacity and preparedness across a range of indicators. then, in late 2019, a new coronavirus mutation occurred, setting in train the worst human pandemic since the 1918 influenza pandemic. since then we have thought that the development of virology, and the advent of antibiotics and vaccines, meant that such a devastating outbreak could not happen again. we know better now. this paper will try to look behind what has gone wrong with our capacity to protect and secure the health of people-public health in our professional terminologyand to suggest what needs to be done now to safeguard the global population from such devastating events in the future. the characteristics of the pandemic whilst the virus first emerged in china, it spread quickly to south east asia, then to europe, then to the usa and canada, and later to south america. india and russia have been severely affected. until very recently the virus seemed better under control in most of europe, although now flare ups are being observed and new control restrictions introduced. this picture reflects however a moment in time, and the pandemic continues to expand both globally, and in individual countries e.g. the united states and across europe. whilst the virus is highly infectious, its population burden is hard to estimate. globally alderslade r, kokeny m, tsouros a. the health of the public: what has gone wrong? (review article). seejph 2020, posted: 07 december 2020. doi: 10.4119/seejph-3996 p a g e 4 | 10 there have been few population-based surveys of prevalence. recent research suggests that prevalence and mortality are substantially underestimated, and that across countries where data is available estimated cumulative covid cases may be underreported by several orders of magnitude. in addition, for every two covid-19 deaths counted, a third may be misattributed to other causes (9). the indications are that a significant proportion of those infected do not have symptoms yet can transmit the virus to others. it is also now clear that the virus seems largely transmitted through the airborne route, and transmission is much more likely in crowded places indoors than outdoors (10). these two characteristics of the virus make global control difficult and challenging. in the absence of a vaccine or definitive treatment, control measures rely on social distancing, wearing masks or face coverings, and avoided crowded and poorly ventilated places indoors. if these measures fail, either generalized or localized lockdowns remain the only control mechanism available. there is increasing evidence (11) that such restrictions are associated with severe adverse economic consequences, particularly for poor and disadvantaged groups, are characterized by adverse health consequences, and interfere with normal health system functioning. in response to the virus, there remain significant uncertainties. previously assumed knowledge and experience may be overwritten by new observations. for example, the previous assumption that mostly old people were affected has been shaded by recent experience where a greater proportion of the younger and the chronically ill have been affected (12). it is not clear why the infection appears to have spread faster in some countries than others. everywhere the return and maintenance of children at school is an urgent priority (13). also uncertain is the eventual effective management of the virus, through the development of a vaccine, the availability of effective antiviral treatments, and more widely available tests backed up by effective contact chasing and quarantine measures. there is a substantial global effort towards producing a safe and effective vaccine, with some concerns. safety must be assured, using usual scientific methods and judgements. the early distribution of a vaccine which proved not to be safe could have devastating negative consequences, for the recipients, and globally for public acceptability and willingness to take the vaccine. another concern is global production capacity, and the mechanism for global distribution. hopefully disruptive “vaccine nationalism” will be avoided. the global response in responding to the pandemic as it evolved, a main question is why the world’s previous arrangements with a focus on the international health regulations (2005) did not work as expected. at the world health assembly in may 2020 who member states agreed (14) that an enquiry should take place in due course. for that reasons present day questions must be presumptive, and open to later refinement. for who there are some compelling questions. was there a delay in the chinese government alerting who to the new and threatening viral mutation? did who respond appropriately and with alacrity? was who too close to the chinese government and if so, did this interfere with necessary operational responses? on the other hand, who clearly did engage in effective and high-quality public communication, issuing urgent warnings at an early alderslade r, kokeny m, tsouros a. the health of the public: what has gone wrong? (review article). seejph 2020, posted: 07 december 2020. doi: 10.4119/seejph-3996 p a g e 5 | 10 stage. did countries take sufficient and urgent notice, and necessary action? it must be said that throughout who acted as asked and authorized to do by its member states. yet should who have a stronger mandate and some capacity of enforcement when countries drag their heels. why were some countries’ reactions different to others? why did some countries delay or implement only half-heartedly the who-advised regime of testing, contact tracing and isolation? was the threatening nature of the disease misunderstood by some countries, basing judgements perhaps on the normal course of influenza outbreaks? what was the “herd immunity” model seemingly pursued by some countries, and not others? why were movement and other restrictions imposed earlier by some countries than others? covid-19 also caused a health crisis that amplified existing global health inequalities and disruptions, and the resultant lockdown restrictions have resulted in both economic and employment crises. different countries have pursued different paths in dealing with these consequences, opening many questions about the optimum way forward. this paper does not attempt to answer these questions. yet it does make the point that taken overall, and unlike the sars epidemic, the world’s arrangements failed in preventing a global pandemic. some part of this failure may be due to the nature of the virus itself. however, it is very difficult at this stage to suggest that the world’s arrangements worked well. this paper will attempt to get behind that conclusion, to explain, and to draw presumptive lessons for the future. the challenge of the coronavirus? covid-19 is a harsh reminder of the need to anticipate, to mitigate and to respond effectively to unexpected and emerging threats and hazards that can affect and severely disrupt every aspect of human existence. the virus has demonstrated clearly how fragile is our inter-connected world. we can be certain that this virus will not be the last threatening our global health and well-being. in addition, we will certainly be threatened by environmental and man-made disasters, and wars and complex emergencies, with climate change looming as an existential pending catastrophe and a marker of a critically deteriorating and unstable planet. now, suddenly, usual geopolitical considerations are being overridden by an imperative of survival where transparency and international cooperation and solidarity are vital. so far, in dealing with this virus these requirements have not been in place. for example, better coordination between countries has certainly been needed (15). this crisis demands a total rethinking of the way the world works together in response to such events, which have the potential to cost many lives and bring countries to their knees. yet so far it is hard to be optimistic. the postworld war 2 era of international rule-based cooperation looked increasingly fragile, affected as it has been by nationalist and populist political and social influences, even prior to this coronavirus crisis. this has not been a good time for multilateralism. in terms of global health protection and promotion since ww2 the world has been dependent on the work of the geneva-based world health organization (who), which in addition to its many other global health activities acts as a prime-mover as well as secretariat for the international health regulations (2005). now who must defend itself for its actions during the crisis in a climate of vocal criticism, easily transmitted as never before by technology in general, and social media in alderslade r, kokeny m, tsouros a. the health of the public: what has gone wrong? (review article). seejph 2020, posted: 07 december 2020. doi: 10.4119/seejph-3996 p a g e 6 | 10 particular. these media are filled with stories feeding into conspiracy theories which can divert attention from the political and technical determinants that influence who’s interaction with countries, particularly at a time of crisis. who is not a well-known or understood organization, and this makes it particularly vulnerable to criticism and an easy target for being made a scapegoat. an organization like who, at the heart of the global health architecture, can be analysed from several different perspectives: technical excellence and capacity; policies, strategies, plans and procedures; ability to support countries; resources and the ability to advocate and mobilize the international community and donors; access to and support of innovation; governance and leadership and communication. ultimately, however, who is an inter-governmental organization made up of 194 sovereign member states that it cannot instruct or cajole, but must inspire and influence. who has little in the way of sanctions available if member states fail to comply. the decline of public health institutions and capacities public health services are an important component of universal health coverage (uhc) (16). yet globally public health services are low in priority for health investment. there is a clear need to close the clear gap between political commitments to public health and the increased resources needed for public health to be effective; to place more focus on development of the public health workforce; to better organize governance arrangements (including accountability mechanisms); to start the work on mitigating the environmental footprint of healthcare; and to assign stronger legislative mandates for public health and public health legislation that is properly enforced. concerns about present day public health governance reflect the difficulties of developing effective multisectoral thinking and practice across different levels of government. as said previously, financing for public health is inadequate, both in absolute terms, and in comparison, with the money allocated to health care. public health infrastructure needs to be updated and upgraded to cope with today’s new issues, to deliver effective legal regulatory frameworks and surveillance frameworks. political and social legitimacy are both critical for success. public health should have an independent authoritative voice and be able to effectively communicate and report independently. in addition, effective public health services require structures to create and sustain a workforce with appropriate skills and knowledge (17). who a future perspective the nature of the challenges exposed by the coronavirus and the present crisis is such that the authors believe that future efforts to assess the role of who at this moment should extend much further than considering only its leverage and effectiveness in handling an emergency situation. the question rather is whether who as the lead united nations technical agency can continue to be relevant in the face of tomorrow’s demographic, environmental and technological challenges. how can it position itself to fulfil its public health mandate to full potential? the authors of this paper believe that over the last 30 years or so who’s governance and ways of working have become increasingly out of tune with its strategic objectives and newly available evidence about health and well-being. today whilst inter-sectoral action; whole of government, whole of society alderslade r, kokeny m, tsouros a. the health of the public: what has gone wrong? (review article). seejph 2020, posted: 07 december 2020. doi: 10.4119/seejph-3996 p a g e 7 | 10 and health in all policies approaches should be at the core of the organizations’ strategies, the reality in countries is that who’s governing bodies and working counterparts are predominantly health ministries, and for countries health continues to be mainly limited within the health sector. in most countries, ministries of health are preoccupied with diseases, and obtain little political engagement with the structural and non -health system determinants of disease. this is despite the vast literature on the determinants of health which calls for a much broader engagement of governmental and societal stakeholders. this multiple determinant understanding of health and the role of health as an essential precondition for human social and economic development is now made even more imperative in the light of the un 2030 agenda for sustainable development and the sustainable development goals (sdgs). ultimately health must be seen as important to human development as economic progress. in fact, we know that the two are intimately entwined. this is not a new idea. in 1946 john maynard keynes famously said: “the day is not far off when the economic problem will take the back seat where it belongs, and the arena of the heart and the head will be occupied or reoccupied, by our real problems — the problems of life and of human relations, of creation and behaviour and religion (18)”. equity is at the core of such consideration. it has been at the heart of who policies since the launch of health for all in 1981. here again the reality is that political, social, economic and health inequalities in the world are growing wider (19). specifically, for health most countries do not measure health inequities, or at best address these only in terms of access to health services. more widely across the global society it is increasingly clear that negative effects on health and wellbeing and violation of human rights are the consequences of unprincipled globalization; exploitation and mistreatment e.g. of migrants and refugees; environmental degradation and pollution; and political, social, and economic conflicts and complex emergencies. politics and diplomacy are a big part of the way who as an inter-governmental organization works. should not who be redesigned to be more vocal, assertive and effective in the face of crises and inequalities and also better configured to accommodate 21st century public health concepts and principles? yet at the same time who must preserve its scientific excellence and independence. transparency, honesty, integrity, together with local preparedness, are essential prerequisites for a sound relationship between politics and science, which is vital if the world is to be able to deal effectively with emerging threats. the role of countries the importance of public health has been illustrated during the covid-19 crisis through the performance of countries whose leaders relied upon professionalization, public health experts, and who provided accurate, timely and detailed information to the public. countries such as germany, vietnam and new zealand offer positive examples here. much less successful have been those countries where populist and nationalist perspectives predominate. yet all too often public health institutions and capacities have been allowed to decline and become degraded in many, or most, countries. there is an urgent need for this trend to be reversed, with investments made in public https://en.m.wikiquote.org/wiki/religion alderslade r, kokeny m, tsouros a. the health of the public: what has gone wrong? (review article). seejph 2020, posted: 07 december 2020. doi: 10.4119/seejph-3996 p a g e 8 | 10 health organizations, institutions and capabilities at all levels of governance (20). communities and multicultural societies need to be energized and empowered for public health. it also seems clear that public health staffing and skills need transformational changes in order to respond to the complexities of present-day and future health challenges, which will exhibit inevitable complexity, ambiguity and uncertainty in planning and implementing public health responses. the way forward today as the world attempts to deal with the coronavirus crisis there exists perhaps, and hopefully, a momentum to improve the establishment and performance of global public health institutions. the authors suggest a further strengthening and re-design of who to protect and promote global public health, particularly through the prevention, detection and response of future outbreaks. also, to be considered is the possible creation of new international health regulations, with a more pronounced accountability system. the authors suggest several key developments and changes to achieve these goals, focusing on: ensuring health and equity are and remain high on the world agenda. who being protected, resourced, and given space by global leaders in becoming an advocate for fairness, equity, universal coverage and well-being. who becoming more present in global politics, for example in trade agreements. changing the composition of who’s governing bodies, to ensure representation from different sectors and levels of government, including mayors. stepping up leadership by the director general and regional directors, expressing clear expectations that countries comply with the ihrs or face consequences in the case of noncompliance. building on inter-country agreements such as the recent european parliament resolution on the eu’s post covid public health strategy: the eu’s public health strategy post covid-19. helping countries invigorate and reform public health institutions, capacities and staffing. following up aggressively preparedness and response activities in all countries to deal with communicable disease, climate change and other emerging threats. developing platforms and supporting dialogue with different sectors and civil society. conclusion this is a formidable and ambitious list. it foretells a place for who within a new world order where health, health security, health equity and sustainable development are central on the world political agendas. accordingly, and ideally, who should have more leverage, be a stronger and courageous advocate, actively engage other sectors and civil society, and have a strong leadership role in world human, social and economic development. it is also clear that the world and the international global order does not look like this today. yet changes are essential if the world is not to repeat this recent coronavirus experience and is to ensure human survival during the coming period of dramatic, and likely existential, global health challenges and crises. alderslade r, kokeny m, tsouros a. the health of the public: what has gone wrong? 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and sustainable development. in: urban health. galea s, ettman k, vlahov d, eds). oxford university press; 2019:386-93. ______________________________________________________________________ © 2020 alderslade et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.ljmu.ac.uk/~/media/phi-reports/2020-07-direct-and-indirect-impacts-of-covid19-on-health-and-wellbeing.pdf https://www.ljmu.ac.uk/~/media/phi-reports/2020-07-direct-and-indirect-impacts-of-covid19-on-health-and-wellbeing.pdf https://www.ljmu.ac.uk/~/media/phi-reports/2020-07-direct-and-indirect-impacts-of-covid19-on-health-and-wellbeing.pdf file:///c:/users/g.burazeri/downloads/available%20from:%20https:/www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-and-covid-19-younger-adults-are-at-risk-too file:///c:/users/g.burazeri/downloads/available%20from:%20https:/www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-and-covid-19-younger-adults-are-at-risk-too file:///c:/users/g.burazeri/downloads/available%20from:%20https:/www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-and-covid-19-younger-adults-are-at-risk-too file:///c:/users/g.burazeri/downloads/available%20from:%20https:/www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-and-covid-19-younger-adults-are-at-risk-too file:///c:/users/g.burazeri/downloads/available%20from:%20https:/www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-and-covid-19-younger-adults-are-at-risk-too file:///c:/users/g.burazeri/downloads/available%20from:%20https:/www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-and-covid-19-younger-adults-are-at-risk-too https://www.weforum.org/agenda/2020/07/covid19-education-lockdown-children/ https://www.weforum.org/agenda/2020/07/covid19-education-lockdown-children/ https://www.weforum.org/agenda/2020/07/covid19-education-lockdown-children/ https://apps.who.int/gb/ebwha/pdf_files/wha73/a73_r1-en.pdf https://apps.who.int/gb/ebwha/pdf_files/wha73/a73_r1-en.pdf https://apps.who.int/gb/ebwha/pdf_files/wha73/a73_r1-en.pdf https://www.tuc.org.uk/blogs/interconnected-world-coronavirus-needs-coordinated-global-response https://www.tuc.org.uk/blogs/interconnected-world-coronavirus-needs-coordinated-global-response https://www.tuc.org.uk/blogs/interconnected-world-coronavirus-needs-coordinated-global-response file:///c:/users/g.burazeri/downloads/available%20from:%20https:/www.who.int/healthsystems/universal_health_coverage/en/ file:///c:/users/g.burazeri/downloads/available%20from:%20https:/www.who.int/healthsystems/universal_health_coverage/en/ file:///c:/users/g.burazeri/downloads/available%20from:%20https:/www.who.int/healthsystems/universal_health_coverage/en/ https://www.euro.who.int/__data/assets/pdf_file/0004/380029/68wd17e_advancepublichealth_180624.pdf https://www.euro.who.int/__data/assets/pdf_file/0004/380029/68wd17e_advancepublichealth_180624.pdf https://www.euro.who.int/__data/assets/pdf_file/0004/380029/68wd17e_advancepublichealth_180624.pdf https://www.economicshelp.org/blog/613/economics/quotes-by-john-maynard-keynes/ https://www.economicshelp.org/blog/613/economics/quotes-by-john-maynard-keynes/ https://www.economicshelp.org/blog/613/economics/quotes-by-john-maynard-keynes/ laaseru. reflections on the liberian civil war, 1989-2003 (editorial). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-154 1 editorial reflections on the liberian civil war, 1989-2003 ulrich laaser 1 1 faculty of health sciences, university of bielefeld,bielefeld, germany. corresponding author: ulrich laaser address: faculty of health sciences, university of bielefeld, pob 10 01 31, d-33501, bielefeld, germany; e-mail: ulrich.laaser@uni-bielefeld.de conflicts of interest: none. laaseru. reflections on the liberian civil war, 1989-2003 (editorial). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-154 2 the generation which experienced war in europe – world war ii – is passing away and with it those who can tell ‘in their own words’ from war experience and trauma. on the other hand accelerating globalization confronts us with a series of armed conflicts all over the world. the civil war in liberia was one of these. all of the possible fuelling factors were brought to bear on it: ethnic differences, economic domination by a ruling class the progeny of the freed slaves in 1822, and the long litany of misrule by various administrations crowned by the execution of predominantly people of american descent in the 1980 coup d’état, all set the stage for a final showdown. the conflict involved eight armed factions fighting for dominance and lasted with a short interruption from 1989 to 2003. whereas, for example in germany, there is an abundance of literature describing and analyzing personal and social experience during the war[for example translated into english (1)]; it is not so in liberia. the veterans of the various rebel groups and even former members of the regular army usually live in very poor conditions and those invalidated populate begging the streets. furthermore there are thousands of civil victims and especially an estimated 10-15% of the female population raped, more than half a million (out of a population of about four million at the time) were killed (2) and close to one million dislocated. although people have generally enjoyed peace in liberia for over a decade by now that peace can still be described as fragile. every year one can observe signs of simmering instability when ex-combatants make threats on radio and in newspapers that they will disturb the peace in the country for claims of perceived benefits they have against the government in concert with left behind widows and children and their disabled comrades. the condition of those who are physically or mentally disabled is appalling, the standard of living at the edge as usually there is no income; the acquisition of a daily meal becomes a problem. they are considered by the national community to be responsible for the atrocities and the suffering of the civilian people although they were often in the child and adolescent age when entering the armed factions, hardly mature enough to discern between what was right and what was wrong to do even in a war situation (3). different from the reaction on the ebola epidemic (4) which posed a threat to themselves, the international community has rarely taken notice of the victims of the civil war in liberia and few people seem to be concerned about the abundance of psychiatric disease including posttraumatic stress disorder. even less realized is the threat of further social disruption as any organized reconciliation processinvolving ex-combatants is missing. documented experience in europe and notably germany shows war traumata handed over through several generations, from the parents experiencing war to their children and even grand-children, a threat for social stability and cohesion: ‘because of the war my parents simply did not experience that the world is a safe place where one can feel well and protected. and exactly the same feeling i ascertained in myself although there was no external inducement’ [own translation (1)]. to listen to the ostracized invalids from the civil war and take note of what they have to say is the aim of theexplorative study by aloysius taylor hoping to initiate public discussion aimed at healing the liberian society. references 1. bodes. the forgotten generation – the war children break their silence. klettcotta, stuttgart; 2004. https://www.sabine-bode-koeln.de/war-children/the-forgottengeneration/. 2. edgertonrb. africa’s armies: from honor to infamy. amazon; 2004. https://www.amazon.co.uk/africas-armies-infamy-robert-edgerton/dp/0813342775. https://www.sabine-bode-koeln.de/war-children/the-forgotten-generation/ https://www.sabine-bode-koeln.de/war-children/the-forgotten-generation/ https://www.amazon.co.uk/africas-armies-infamy-robert-edgerton/dp/0813342775 laaseru. reflections on the liberian civil war, 1989-2003 (editorial). seejph 2017, posted: 30 october 2017. doi 10.4119/unibi/seejph-2017-154 3 3. kokulofasuekoi j. a journalist’s photo diary. auto-publication, date unknown, monrovia, liberia. https://www.barnesandnoble.com/w/rape-loot-murder-jameskokulo-fasuekoi/1105497189?ean=9781468591620. 4. gostin lo, lucey d, phelan a. the ebola epidemic: a global health emergency. jama 2014;312:1095-6. __________________________________________________________ © 2017 laaser; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.barnesandnoble.com/w/rape-loot-murder-james-kokulo-fasuekoi/1105497189?ean=9781468591620 https://www.barnesandnoble.com/w/rape-loot-murder-james-kokulo-fasuekoi/1105497189?ean=9781468591620 http://jamanetwork.com/searchresults?author=alexandra+phelan&q=alexandra+phelan agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 1 | p a g e c original research improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria prince agwu1,5, obinna onwujekwe 2,5, benjamin uzochukwu3,5, modest mulenga4 1 department of social work, university of nigeria, nsukka, enugu, nigeria; 2 department of health administration and management, college of medicine, university of nigeria, enugu campus, enugu, nigeria; 3 department of community medicine, college of medicine, university of nigeria, enugu campus, enugu, nigeria; 4 tropical diseases research centre, zambia; 5 health policy research group, college of medicine, university of nigeria enugu campus, enugu, nigeria; corresponding author: prince agwu; department of social work, university of nigeria, nsukka campus, nigeria; postal code: 410001; email: prince.agwu@unn.edu.ng; mailto:prince.agwu@unn.edu.ng agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 2 | p a g e abstract background: availability of health services at the primary healthcare (phc) level is crucial to the achievement of universal health coverage (uhc). however, insecurity of phc facilities inspires unavailability of health services. from perspectives of primary health service providers, we examined the effects of insecurity at rural and urban phc facilities in enugu, nigeria. methodology: the study adopts a qualitative method using in-depth interviews and non-participant observation. the study sites were eight (8) phc facilities (rural/urban) that were purposively selected. the first author interacted with the health workers and made extensive observations on infrastructure, policing, and other security gaps affecting the facilities. findings: while health workers wish to provide services as stipulated, the fear of getting hurt or losing their properties to hoodlums scares them, especially during the dusk hours. owing to infrastructure deficits and lack of security personnel, incidents of losing phones, stolen babies and facility items/consumables, and patients being attacked were said to be recurring. the absence of power supply during the dusk hours tend to heighten their fears, hence health workers close before it gets dark, not minding the consequences on health service users. conclusion: the issue of insecurity of lives of both the health workers and their clients is paramount to the optimal use of services in the phc facilities. insecurity is a priority concern for the health workers, and if not addressed could cause them to completely shun working in certain areas, or shun their jobs completely, with dire consequences for the achievement of uhc. keywords: primary healthcare, insecurity, community policing, universal health coverage, absenteeism agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 3 | p a g e introduction the bedrock of achieving universal health coverage (uhc) is primary healthcare [1]. this was subsequently validated in what has come to be known as the “declaration of astana” [2]. primary healthcare has the advantage of geographical spread and affordability. it covers remote regions and mostly accessed by the lowand middle-income class. in nigeria, there is a phc facility in every “ward” (the least seat of government’s administration just below the local government) [3,4]. hence, it seems that the availability component of uhc is somewhat addressed, especially in terms of presence. however, presence of healthcare facilities seems not to translate into the dispensation of health services round the clock, where patients can access and get quality health services at any time. the absence of health workers in phc facilities is documented in literature, alongside several drivers [5]. insecurity of lives and properties in phc facilities is listed among the drivers. unfortunately, this issue is underexplored in literature, whereas it forms a cardinal reason for health workers’ presence at work and efficiency, especially during dusk hours. it is also implicated in the safety of the properties of the phc facilities, as well as the lives of health service users. thus, this paper is poised to address the insecurity of phc facilities in nigeria within the context of achieving uhc by 2030. the foundations of uhc are anchored on the availability of health services and prevention of financial hardship while accessing health services. uhc service coverage index ranks nigeria on a score of 39, where the highest score is ≥80 [6]. this indicates how far nigeria is away from attaining uhc. an intersection of several factors could account for nigeria’s slow pace toward uhc, of which the closure of health facilities at crucial periods ranks highly. it is a known fact that nigeria faces a myriad of insecurity issues across its geopolitical zones. cases of insurgency, farmers-herders rivalry, kidnapping, banditry, and armed robbery make the daily news headlines [7,8]. these security lapses have occasioned calls for community policing, which means that communities should devise their means of securing themselves while partnering with the mainstream security agents. fortunately, the national primary healthcare development agency (nphcda) states how compulsory it is for phc facilities to be secured, including the employment of security personnel [4]. the local governments with oversights from the state governments employ phc workers. disappointedly, they make no vacancies for security personnel. the police force which should be an instrument of security within the state is never assigned to phc facilities, while they could be assigned to protect some private citizens [7]. thus, phc facilities are forced to rely on voluntary and community-provided security guards. in a study by okoli et al. which involved several states in nigeria, the ward development commission (wdc) in anambra state was the only wdc that helped phc facilities to recruit security staff [9]. although, the recruited security staff were not strong enough, which could be attributed to deficiencies in age (older adults) and equipment. several studies highlight the presence of key security infrastructure (perimeter fence and lighting at nights), and human security as motivators for health workers to attend work, especially at nights [10,11,12,13]. unfortunately, these infrastructures are found lacking across most phc facilities in nigeria. a study by christian aid uk on phc facilities in abuja, reveals that just 24.7% of the facilities have a perimeter fence, while virtually all do not have active security guards [14]. properly illuminated facilities will at least give a feeling of safety and capable of putting away hoodlums since they could be easily spotted. agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 4 | p a g e unfortunately, studies reveal an acute shortage of power supply across phc facilities in nigeria, causing them to rely on carbon-emitting kerosene lanterns and petrolpowered generators that are disastrous to the environment or illumination from their phones or electricity-rechargeable lanterns, even when electricity is also a problem [12,13]. in some other study, alternative sources of power supply, especially petrolpowered generators and kerosene lanterns could be too expensive to maintain by the health workers, since they need to service the generators and also purchase petrol and kerosene for the generators and lanterns respectively [15]. their inabilities to meet up with such demand justifies leaving the facilities before it gets dark, citing the need to save their lives and those of the service users who could be attacked in the course of visiting the facilities [16]. in onwujekwe et al, some cases of health service users visiting facilities at nights and meeting no one are highlighted [5]. some of the cases highlight mortality scenarios as consequence. yet the health workers feel that saving their lives by leaving insecure facilities before dusk, is the best decision to make. given these series of security setbacks marring the efficiency of phc facilities, this study reflects through the rational choice theory. the theory as designed by george homans, fundamentally asserts that human actions are often premeditated to maximise benefits over losses [17]. health workers could consider it rational when they rather choose to save their lives and those of health service users by vacating facilities before the times when they are prone to be at risk. this seems a rational choice, but it is at the expense of health service delivery, and further stalling the achievement of uhc. therefore, closing the security gaps informing the said rational choice of abandoning facilities for safety reasons is important. the dearth of literature on the physical security of phc facilities inspires the need to ascertain the relationship such gap shares with the achievement of uhc. much seems to have been done on the financial security of service users and uhc. so, it makes sense to consider their physical security as well. therefore, our study objectives include: (a) to examine the state of security of phc facilities in enugu; (b) to determine the influence insecurity of phc facilities exercises on uhc; (c) to reveal grassroots generated solutions to insecurity of phc facilities in enugu state and possible implications. methods study area the study was conducted in enugu state, southeast nigeria. the state’s population predominantly comprises the igbo ethnic group and christians. enugu state has 17 local government areas (lgas), of which 14 of them are categorized as rural, and the rest 3 as urban. the population in enugu state is at 3.3 million with an annual growth rate of 2.59% [18]. about 35% of the 1,050 phc facilities in the state are public [19]. the state of security of phc facilities in southeast nigeria is discussed in etiaba et al., as suboptimal, deeply characterized by the absence of security personnel, perimeter fence, and poor infrastructure, which heighten fear during dusk hours and force the closure of facilities within such times [27]. a preliminary investigation into the state of security of phc facilities in six distinct lgas of enugu state different from those the authors have selected describes it as a “sorry condition” [28]. in addition, crime statistics in enugu state for 2017 is 2,171; 12,408 for abia; 1,623 for imo; 4,214 for ebonyi and 1,888 for anambra [8]. these five states make up the southeast region and are barely far apart with porous land borders. this means that possible infiltration of criminal elements from one state into another is quite high. therefore, the demand for vigilance and carefulness across the region cannot be overstated. agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 5 | p a g e sampling procedure the purposive sampling technique was used in selecting 8 facilities across enugu east senatorial district that lacked perimeter fence, security personnel or both. to select the 8 facilities, two lgas, nkanu west and enugu north lgas were selected and allotted 4 facilities each. enugu north was chosen because it is the hub of enugu urban, and will naturally have higher levels of crime occurrences. this is corroborated by anumba et al., who stated that enugu urban and surrounding lgas, of which nkanu west is among the closest, are endemic areas for restiveness and crime [26]. however, while nkanu west represented the rural lgas, enugu north was selected to represent urban lgas (see figure 1 for a representation of the study locations and selected facilities). of the 4 facilities selected in nkanu west, 2 had no perimeter fence and none had designated security personnel. the absence of perimeter fence for phc facilities is prevalent in rural areas. in contrast, all 4 facilities in enugu north had perimeter fence, as expected. however, none of the selected facilities in the urban lga had an employed security guard. the rationale behind picking facilities with and without perimeter fence is to identify implications for differences in security experiences. the health workers that participated in an in-depth conversation with the investigator were selected based on their availability at the health facilities at the time the researcher visited. the study was not designed to have any specific number of respondents, but to use non-participant observation and conversations with available health workers to unravel the state of security of these facilities and the implications for healthcare. figure 1: geographical information of selected facilities agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 6 | p a g e data collection a mix of non-participant observation and key informant interviews (kii) was used to collect data for this study. the investigator (first author) visited all 8 facilities within one month (june 2020). this happened during the first and second phases of easing lockdown for covid-19 pandemic in nigeria which commenced in may 2020. however, the investigator took steps to ensure safety by facemask wearing, using a private vehicle to avoid contacts, minimal close interaction with persons at facilities, had provision for extra facemasks to be given to those he interacted with, maintaining appropriate physical distancing at each point, and effective hand sanitizing when necessary. a checklist for observation was drawn by the authors to include the presence of perimeter fence, security guards and state of power supply. the investigator took extensive notes of what he observed on the spot, after introducing himself to the health worker(s) on the ground as a researcher and orally seeking their permission to proceed with the study. permission was swiftly granted owing to a working relationship the investigator shares with most phc facilities in the state. for coherence, the notes were structured to follow three key themes of (a) state of security of the facilities (b) implications for availability of health service delivery, and (c) what the grassroots are doing to secure themselves amidst weak or no intervention from the government, which we describe as horizontal-level solutions. to understand in-depth the security situation of the facilities, available health workers provided more insights. the insights were recorded with an android phone following acknowledgement by the health workers. those that interacted with the investigator were promised confidentiality and anonymity. ethical approval ethical approval was granted by the health research ethics committee of the university of nigeria teaching hospital, itukuozalla. approval no: nhrec/05/01/2008bfwa00002458-irb00002323). data analysis a phenomenological process to data analysis was applied, which implies constructing field experiences and responses into thematic meanings [20]. observations and narratives were reviewed and categorized under three thematic categories: (1) the state of security of the facilities; (2) implications for healthcare and uhc; (3) horizontal solutions. in line with padgett’s recommended observer triangulation and peer debriefing in strengthening qualitative studies [21], the thematically arranged observations and narratives were individually reviewed among the researchers. they were also handed to two peers within the fields of community health and social determinants of health to validate appropriateness. their comments benefitted the quality of the research reporting. results results are presented in three themes. the first examines the state of security of the facilities. the second considers the security concerns and influence exercised on healthcare and uhc. while the third provides horizontal-level solutions. security of phc facilities in enugu state of the eight facilities visited, six of them were fenced with functional gates. the agbani phc facility shares a compound with a police station. there were mixed reactions to the security from the police. the facility also has a perimeter fence. this was the only facility the investigator visited and got checked before entering. although, he was somewhat asked by one of the police agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 7 | p a g e officers to offer money, which he refused. a health worker in the facility said – “as you can see, we are together with the police and should be secured, but patients sometimes avoid coming to the facility because the police are here”. the rest facilities had no one who monitors anyone at the entrance. the gates and perimeter fence tend to have no security implication during the day since anyone could get into the facilities unchecked. the health workers on duty receive persons who get into the facilities, and sometimes, they could be unaware of who gets into the facility or goes out. well, we don’t have any security guard here. i get busy and sometimes, cannot tell who is coming or leaving. it is worse during immunization or antenatal when we attend to too many persons. it is not safe, but we depend on god. my colleague’s phone was stolen the other day and we could not trace who stole it (health worker, asata health centre). the narrative above is not farfetched from the experience across other facilities, except the one in agbani. such loosed security experience during the day could be instructive of what could happen at nights. a few narratives below explain further: we only have our volunteer worker living here. we don’t live here because the accommodation is small, and it could be scary at nights. the volunteer worker is usually scared to open the gate for anyone who knocks at night because you cannot tell if it is a pregnant mother or a criminal. the other day, she was taking care of a woman who went into labour, i think around 11 pm or 12 am […] on entering her room, a thief was in it. she fought with him, but the thief overpowered her and took her phone and money. thank god she was not raped […] she screamed, but no one could come to help her. even the patient and her husband had to first secure themselves. you have seen how quiet this place is […] (health worker, new haven health centre). i was delivering a woman of her baby one night. thieves broke into the facility. they robbed me and robbed the woman even while in labour. they took our phones and money. it was so terrible that night (health worker, asata health centre). a health worker in akegbe ugwu facility reported that the power-generator set they got from a programme – partnership for transformation of health systems (paths 1) was stolen. in nkanu west, the facilities except for agbani phc facility mentioned losing a few items like foodstuff, fridge, etc., to thieves. these concerns of robbery attacks and theft caused some facilities to shut down before it gets dark, health workers could stay back in fear or liaise with local and neighbouring security agents. on the issue of power supply, it is common knowledge that illumination enhances security. being off the grid is common among phc facilities, for the reason that they might lack the wherewithal to pay bills. the investigator only met two facilities with power supply (ngwo and new haven phc facilities) while on ground, and both are in the urban area, even though ngwo can be considered semi-urban. however, health workers in these facilities mentioned that the power supply is not steady and they cannot consistently fund alternative sources. what it means is that they rely on kerosene or rechargeable lanterns to function when no power and when it is dark. for the phc facilities in the rural zone, power supply remains in hopes. the respondents said that most and if not all the attacks that they have experienced and heard, happened during the dark hours, and in the absence of power. a health worker from amodu phc facility said, “if we have a big security light in front of our facility which constantly shines when it is dark, it will help chase away hoodlums because they know they can easily be seen”. other facilities with power agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 8 | p a g e supply (although the investigator met them without power) but still had issues with steadiness are akegbe ugwu phc, amodu phc, agbani phc, and asata phc. see table 1 for a complete mapping of the security features of the selected facilities and evaluation of security risks. table 1: selected phc facilities from nkanu west and enugu north lgas, security features and evaluation facilities perimeter fence stand-by security personnel power supply alternative source of power supply risk level nkanu west akegbe ugwu phc yes no yes (unsteady) no amodu phc no no yes (unsteady) no amagu phc no no no no agbani phc yes yes (although it shares a compound with the police, security is still challenging) yes (unsteady) no enugu north new haven phc yes no yes (unsteady) no ngwohilltop phc yes yes (just night) yes (unsteady) yes (but lacks fund to consistently run it) coal camp phc no no no no asata phc yes no yes (unsteady) no source: authors’ compilation legend: red – high-level risk; yellow – mid-level risk; green – no risk insecurity in phc facilities and implications for healthcare and uhc everyone who gives and receives health services wants to be safe while doing so. on the contrary, this is not the case across the visited phc facilities, as both health workers and health service users are unsatisfied with the security level, but ngwo-hilltop phc. in the coal camp facility, although agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 9 | p a g e it is fenced, it is still accessed by cult groups. the cultists come around the facility to smoke marijuana. they threaten the health workers at times and steal items from the facility. the health worker that was engaged said both patients and health workers are usually scared when the cultists are around the facility, and they get disturbed by the smell of the smoked marijuana. she also mentioned that it affects the inflow of patients they receive. a sad story of a stolen baby was reported. […] our patients could be scared and even us health workers. we fear what might happen to us. some patients have stopped coming here. i am even scared of coming to work at night. there is this story that a baby was stolen from this facility by hoodlums. the community people are still scared of that till today (health worker, coal camp health centre). a major concern the health workers expressed is that of closing the facilities during unsafe periods or refusing to open the facility for anyone in such times. on some occasions, their choices to stay safe affected healthcare seekers. a volunteer health worker recounted her experience: i have been reported to the oic severally that i locked out persons who came to use our health centre. some of them are pregnant women. this facility has been robbed during such odd hours. i am a young girl, and i do not want to be attacked or raped. that is why i stopped opening the gate when it is so late, especially during midnights. most times, i am the only one staying here (health worker, akegbe ugwu health centre). […] anyone who wants to come to this facility for the first time, especially at night, will be discouraged for the sake of the fear that it is not fenced and no security personnel. i live here, and i get scared, even with the neighbourhood watchmen around. sometimes, they might not be close to the facility because they move around […] so, you can imagine what patients will think about when coming here, especially the first-time patients who are not aware that the neighbourhood security watchmen can sometimes be of help (health worker, amodu health centre). finally, a health worker from asata health centre made mention of what the appalling news of robbery could cause. she pitiably said: the woman that was in labour who was robbed went to tell some persons what happened to her. for a while, we hardly got patients visiting at nights […] i can’t tell how they might have survived, especially those that could go into labour within such dangerous times. maybe, they might have gone to private facilities or the enugu state teaching hospital. at least those are usually secured (health worker, asata health centre). horizontal solutions to insecurity in phc facilities aside from the phc facility in agbani, the rest facilities tried to device some ways to secure themselves. some of them were beneficial and those that concern locking up facilities during dusk kept the health workers safe but deprived service users of health services. for ngwo-hilltop health centre, the head of the facility privately employed the services of a man within the 50s to help secure the facility during dusk. according to a narrative from a health worker, the employed security personnel has a main job he does during the day and reports to the facility by the late evening hours to commence his security job. he is paid n5000 ($12). for the efficacy of his service, see quote below: […] he uses a very big torch to flash around […] because of his presence, the volunteer health workers who stay in the facility feel comfortable at nights. they don’t need to attend to the gate when someone agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 10 | p a g e comes late at night. he attends to them, and verifies, before allowing the person in. patients do not have any need to be scared again […] (health worker, ngwo-hilltop health centre) in amodu health centre, there is an understanding between the facility and the neighbourhood security watch. fortunately, they have an office not so far from the facility. amidst the fears the health workers cite because of the poorly protected facility, they tend to feel a sense of hope that the neighbourhood security watch could come to their rescue if it matters. the phone contacts of key members of the security outfit are with the health workers residing in the facility. one of the health workers narrates her experience: one day, i was here at night and i sighted herdsmen. you know how herdsmen have been terrorizing the country. so, i immediately put a call across to one of the neighbourhood security men. not so long they landed at the facility and the herdsmen had to leave the area (health worker, amodu health centre). lastly, the health facilities in new haven and amagu tend to share a similar experience concerning the provision of security for their facilities. it deals with leveraging the security apparatus of neighbours who are elites. for instance, the facility in amagu is close to the chief of the community. what they have been able to do is to request that the security of the palace equally puts an eye on their facility. fortunately, the chief approved the request. the facility in new haven shares a fence with a catholic priest. they have been able to also reach a similar bargain. discussion a vital part of the uhc is to guarantee improved access to health facilities which seems suboptimal in the study area, especially during dusk hours. scholars in health systems have at different times researched and communicated findings on how access to health services can be improved. in all, a missing agenda evident because of paucity in literature is the subject of physical security of health facilities. it is common sense that no stakeholder in the giving and receiving ends of health services would want to lose his or her life to insecurity. much of financial security as a strong component of uhc is discussed extensively in literature. yet on second thought, there could be a spillover of the effects of poor physical security into financial security while accessing healthcare. we have seen how a finding in this study implied that closure of the phc facility for security concerns forced service users into considering private facilities and higher-level hospitals where the cost of healthcare is higher. these are some concerns raised in onwujekwe et al. about the need to keep phc facilities open and health workers present to effectively dispense health services [5]. efforts are made in terms of seeking to optimize human resources for primary healthcare, but they have largely focused on mainstream health services [22,23]. the neglect of the security apparatus of the primary healthcare stands remarkably high chances of causing losses to the gains from the other areas of human resources for health. three vital elements this study has identified that will boost the security of phc facilities in nigeria are perimeter fence, power supply (especially during dusk), and competent security personnel. we found a huge security gap across the studied phc facilities, which mirrors the likelihood of similar experiences all over phc facilities in nigeria. the studied facilities were lacking at least two of the vital security elements, and in some cases, all three. we discovered that a facility that shares a common compound with the nigeria police force (npf) could not boast with the expected security they should enjoy from such a privilege. rather, findings agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 11 | p a g e showed that patients avoided the facility because of the presence of the police, which could be in connection with the corrupt attitudes of most police officers in nigeria and the grave disregard of the citizens they are meant to protect. nigeria’s police force is among the five worst-performing on the globe [29]. as a result of these gaps, theft, high profile stealing of properties and even babies, harassment, and attacks on health workers and patients were reported. an investigative report by onyeji and a study from etiaba et al revealed the neglect of phc facilities in nigeria, strongly maintaining that most phc facilities are unsafe for health workers and patients [11,24]. we discovered that these concerns of insecurity were prevalent when it gets dark. this could be the pointer toward the fact that the health workers held nothing back when stating the crucial importance of power supply. they were of the view that illumination will help drive away the hoodlums. unfortunately, they neither had a stable power supply nor the resources to maintain alternative sources. we recorded cases of petrol-powered generators donated to phc facilities being stolen. such generators as explained to the investigator are of big sizes. if such can be taken away from the facility without any attempt to apprehend the culprit, it reveals how terrible the security condition of the facilities must be. as a result of poor power condition in these facilities, kerosene lanterns are mostly used, especially, since you even need power supply to charge the rechargeable lanterns. okoye et al propose the need for off-grid solutions to the power concerns of phc facilities [13]. this could form a programmatic option for the government and donors, since most of the facilities are currently off-grid because they lack the wherewithal to regularly pay light bills. with poor power condition across the phc facilities, added to the absence of perimeter fence and competent security guard, health workers and patients try to be rational about their safety. at times, it could entail shutting down facilities at dangerous times or the patronage of more secured facilities for a higher fee. although this is not good for uhc, health workers and patients might consider such choice as the best option to take. this aligns with the rational choice theory [17]. therefore, efforts must be made to address the rational justifications that are tantamount to the achievement of uhc. this is crucial, given that primary healthcare is the cornerstone to achieving uhc [1]. one major observation in this study is that the facilities with “no risk” or “mid-level risk” were seen to have more patients than those with “high-level risk” (refer to table 1). since the investigator did not stay in any of the facilities late into the nights, it was vivid from activities during the day hours that facilities with some security sense fared better in patronage than those without any security sense. this is irrespective of geographical location because the investigator also discovered that rural and semi-urban facilities like akegbeugwu and ngwo-hilltop phcs respectively, were seen to have more patronage than coal camp phc facility which is located at the heart of enugu urban. again, it could be that health service consumers continue patronage with phc facilities or any other facility that guarantee their security during odd hours. it is especially a case for pregnant women, nursing mothers or accident victims who could be in urgent need of health services. thus, these categories of service users are more likely to go back to those facilities that attended to them during distress, and importantly, under safe conditions. this explains why urban phc facilities like the one in coal camp which is centrally and strategically located, records poor patronage even during the day. in all, while vertical interventions such as providing in a standard manner the three key security elements would radically change the security face of phc facilities, in the meantime agwu p, onwujekwe o, uzochukwu b, mulenga m. improving service delivery at primary healthcare facilities for achieving universal health coverage: examining the effects of insecurity in such facilities in enugu state, nigeria (original research). seejph 2021, posted: 09 april 2021. doi: 10.11576/seejph-4319 12 | p a g e some horizontal strategies have been applied with evidence to show effectiveness. although, some of these horizontal strategies could mean that health workers spend out of their poor salaries or device informal patterns of charges on health service users to provide these security elements. such could be demotivating and could affect job satisfaction, as well as encourage corruption. for instance, engaging a willing fellow ready to offer security services to the facility only during dusk at a relatively affordable fee was applied by one of the facilities. though, there is the concern that he might not be as active as he should, given his age, and the stress of shuttling between the security job at night and his primary job during the day. other approaches we found included discussing with the elites around the facility to permit their security personnel to have an eye on the facility and leveraging the services of neighbourhood security watch. in conclusion, the security of phc facilities strongly connects with the availability of health services which enhances access and utilization that are key to the tenets of uhc. this study has brought to the fore a less researched subject, yet a vital component that will improve the safety of health providers and consumers at any time within the facility. safety will improve efficient service delivery and healthcare-seeking. this will scale up the pace of nigeria towards uhc. our study has also brought to the table the need to reform the nigeria police force, perhaps its members could at some point be deployed to man the security of phcs. interestingly, president muhammadu buhari’s agenda captures security [25]. therefore, addressing insecurity across health facilities will be vital. it will be interesting to replicate this study in other geopolitical zones since crime statistics across the geopolitical zones vary. also, it will be good to give patients the chance to speak on this subject. these two recommendations for further research are the limitations of our study. references 1. who (2017a). from primary 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(2017, december 17). investigation: the terrible state of nigeria’s primary healthcare centres (2). premium times. retrieved from https://www.premiumtimesng.com/news/headlines/252694-investigation-terriblestate-nigerias-primary-healthcarecentres-part-two.html 25. tilley-gyado, r., filani, o., morhason-bello., & adewole, i. (2016). strengthening the primary care delivery system: a catalytic investment toward achieving universal health coverage in nigeria. health systems & reform, 2(4), 277-284 26. anumba, j., ojiako, j., gbokwe, e., ejikeme, j., & nnam, v. (2018). crime mapping in enugu urban area of enugu state, nigeria using gis approach. journal of environment and earth science, 8(9), 18-36 27. etiaba, e., manzano, a., agbawodikeizu, u., ogu, u., ebenso, b., uzochukwu, b., onwujekwe, o., ezumah, n., & mirzoev, t. 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(2019). sorry condition of primary health care facilities in enugu state as government promises to overhaul the system. retrieved from http://radionigeriaenugu.com/all-news/localnews/sorry-condition-of-primaryhealth-care-facilities-in-enugustate-as-government-promises-tooverhaul-the-system/ 29. international police science association (2016). world internal security & police index. retrieved from http://www.ipsa-police.org/images/uploaded/pdf%20file/wispi%20report.pdf. https://www.premiumtimesng.com/news/headlines/252694-investigation-terrible-state-nigerias-primary-healthcare-centres-part-two.html https://www.premiumtimesng.com/news/headlines/252694-investigation-terrible-state-nigerias-primary-healthcare-centres-part-two.html https://www.premiumtimesng.com/news/headlines/252694-investigation-terrible-state-nigerias-primary-healthcare-centres-part-two.html https://www.premiumtimesng.com/news/headlines/252694-investigation-terrible-state-nigerias-primary-healthcare-centres-part-two.html https://www.premiumtimesng.com/news/headlines/252694-investigation-terrible-state-nigerias-primary-healthcare-centres-part-two.html adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria prosper adogu1, ifeoma udigwe1, achunam nwabueze1, echendu adinma1, gerald udigwe2, chika onwasigwe3 1 department of community medicine and primary health care, nauth, nnewi, nigeria; 2 department of obstetrics and gynaecology, nauth, nnewi, nigeria; 3 department of community medicine, unth, enugu, nigeria. corresponding author: dr prosper ou adogu, department of community medicine and primary health care, nauth, nnewi, nigeria; home address: ezekwuabo otolo, nnewi (opposite transformer), anambra state, nigeria; telephone: +2348037817707; e-mail: prosuperhealth@yahoo.com 1 adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 abstract aim: young people need protective information and skills in order to reduce the risk associated with unsafe sex. this study assessed and compared the sexual health knowledge, attitude and risk perception of in-school and out-of-school female unmarried adolescents in onitsha north local government area, anambra state, nigeria. methods: a comparative cross-sectional design was used in which 391 in-school female adolescents (mean age: 15.9±1.4 years) were selected from 25 private and 17 public schools in onitsha north local government area, anambra state, nigeria using multistage sampling method. a comparison group of 392 out-of school female adolescents (mean age: 15.5±2.5 years) was also selected from a major market in the same local government area using cluster sampling technique. data was collected from the respondents with pre-tested, interviewer-administered questionnaires on reproductive and sexual health knowledge, risk perception and attitude, sexual behaviour, contraceptive knowledge and sources of sexual health information. results: in-school girls demonstrated better knowledge of sexual and reproductive health compared to their out-of-school counterparts. the awareness of fertile period, contraception methods, sti and hiv transmission and prevention were all significantly better among the in-school adolescents compared to their out-of-school counterparts (p<0.05). they also had markedly higher risk perception of getting pregnant (p<0.05) or acquiring hiv infection (p<0.05) compared to their out-of-school counterparts. conclusion: about 21% of adolescents in this study area were involved in risky sexual behaviour and this was higher among the out-of-school adolescents than their in-school counterparts. all stakeholders in the state and the local government area should come together and develop interventions that would improve the sexual health knowledge and sexual risk perception of the adolescents. keywords: attitude, female adolescents, in-school, knowledge, nigeria, onitsha, out-ofschool, risk perception, sexual health. 2 adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 introduction adolescents (10-19 years), especially females, are most vulnerable to unsafe sex. they also bear the brunt of the consequences. it is estimated that nearly two-thirds of premature deaths and one-third of the total disease burden in adults are associated with behavioural factors that began in youth and unprotected sex is mentioned among these factors (1). most studies and interventions on adolescents in sub-saharan africa and nigeria target in-school adolescents because they are easily accessible, easier to organize and monitor compared to those who are not in school. however, most of the secondary school age youths in nigeria are not in school (63% of boys and 79% of girls) (2). worldwide, about 120 million school-aged children are out of school and slightly more than half of these are girls and one-third of these children are in sub-saharan africa and 10% in nigeria (3). a recent study in anambra state, nigeria, reported that 43% of pregnant girls were expelled from school and none was recalled back (4). similar studies conducted in botswana also reported that most pregnant teenagers drop out of school (5). studies have shown that most out-of-school adolescents do not live with their parents and are found most times on the street, market places or motor parks hawking or serving as shop assistants to others (6-9). this is why most are vulnerable to unsafe sex and have lower sexual health knowledge compared to their in-school counterparts. adolescents seek reproductive and sexual health information from a variety of non-formal sources that include peers, pornography and magazines. the unguided youth usually experiment with the information received and often become exposed to stis, unwanted pregnancy among others. young people need protective information and skills in order to reduce the risk associated with unsafe sex. studies in other parts of nigeria showed in-school adolescents reporting teachers and parents as their main sources of information while out-of-school adolescents reported friends and the media as their main sources of information on sexual health (10,11). the findings are consistent with studies carried out in other african countries like in uganda where as many as 69% of out-of-school adolescents receive their information from their peers compared to only 8% of their counterparts (12). research has shown that the knowledge of out-of-school adolescents on sexual health issues is poor. a study carried out in lagos reported that two-fifths of respondents did not know that pregnancy could occur during their first sexual intercourse, most felt there was no risk associated with sexual intercourse and some had misconceptions that abstinence after menarche was harmful. many of participants also felt that having sex was necessary to show love in relationships (13). in various studies, preferred sources of sexuality information include the health workers and parents (10,14-16). this is because they give reliable information unlike peers who could give wrong and misleading information. the out-of-school adolescents are not easily accessible, because they are always on the move and not available for follow-up activities (12). therefore, it is important to clarify the needs of both groups taking into consideration the social and environmental factors, peer norms, beliefs and values of the different groups in order to develop and implement successful prevention programmes for the two groups. onitsha, nigeria, holds the largest market in west africa, and second only to lagos in youth concentration. therefore, an area of large youth concentration such as onitsha is most suited for this proposed research. the objectives of this study were to assess and compare the sexual health knowledge, attitude and risk perception of in-school and out-of-school female unmarried adolescents in onitsha north local government area (lga), anambra state, nigeria. 3 adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 methods design and study area a cross-sectional, comparative study was carried out in 2012 including unmarried in-school and out-of-school female adolescents aged 10-19 years residing in onitsha north lga in anambra state, nigeria. the onitsha main market, reputedly the largest in west africa, enjoys large patronage by traders and visitors from all over nigeria and virtually all west african countries. there are other satellite markets (about 30) to relieve the enormous pressure on the main market. many out-of-school children are found in every part of the market hawking virtually anything. some are in the market as shop assistants, while some are left entirely on their own in some stores. this constitutes the setting for the out-of-school aspects of this study. also, the onitsha north lga has 25 private schools and 17 public schools, giving a total of 42 schools. there are 22 mixed schools, 12 boys’ only schools and 8 girls’ only schools. some of the schools belong to the mission, some a government-owned, while the rest are private schools. study population the study population consisted of unmarried female adolescents between the ages of 10-19 years and comprised: a) in-school adolescents and b) out-of-school adolescents. for inschool, only those in senior secondary school one to senior secondary school three (sss1sss3) were considered for the study for comparison with their counterparts. this is because most of the out-of-school adolescents are within the age range of those in these classes than the classes below. for out-of-school adolescents, those that had never been to secondary school, finished primary school but did not continue or had dropped out of secondary school were considered eligible. the exclusion criteria included, for in-school, all the post-secondary school adolescents, those with hearing, speech and mental disabilities; and for out-of-school, all adolescents employed or unemployed who had finished secondary school and those with mental, hearing or speech disabilities. minimum required sample size was determined for comparison of two independent groups (in-school vs. out-of school female adolescents) (17). based on reports from previous studies conducted in nigeria (13,18) and an anticipated response rate of 90%, a total of 236 individuals constituted the minimum sample size. however, it was decided to recruit a total sample of 800 female adolescents (400 among in-school adolescents and 400 among out-of school adolescents) in order to considerably increase the power of the study. selection of in-school adolescents consisted of a two-staged sampling technique which employed stratified sampling method in the first stage and simple random sampling method in the second stage. secondary schools in the area were stratified into four categories as follows: two female-only private, six female-only public, 17 mixed private and five mixed public schools. from each of the strata, one school was selected using stratified random sampling technique. from each selected school, 100 respondents were chosen using simple random sampling method and ensuring proportionate representation from classes sss1-sss3 reaching a total sample size of 400 respondents. out-of-school adolescents were selected using cluster sampling technique as was done in previous studies (12,19). the market is estimated to have more than 60 clusters. clusters of 30 were selected by simple random sampling from the sampling frame containing the list of all the clusters twice (13). using the who cluster sampling method, seven consenting adolescents were selected from each cluster until a total of 400 respondents was reached. since the clusters were in different directions, a bottle was spun and the direction of its mouth was used to show the starting point of the study. 4 adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 data collection the same pre-tested interviewer-administered questionnaires were used for both in-school and out-of-school adolescents to ensure uniformity. the questionnaires were pretested among 20 in-school adolescents and 20 out-of-school adolescents in nnewi north lga for suitability, reliability, acceptability and appropriateness. the questionnaires were used to collect information on variables such as: demographic characteristics, sexual health knowledge, attitude and hiv risk perception, pattern of sexual behaviour, contraceptive use and sources of sexual health information. eight hundred questionnaires were handed out, but 783 were returned (391 for in-school and 392 for out-of-school) – yielding an overall response rate of approximately 97.9%. data analysis spss version 17 was used for data entry and analysis. chi-square test was used to compare proportions of the categorical variables and t-test for comparison of mean values of the numerical variables. differences and associations yielding p-values ≤0.05 were considered statistically significant. results the mean age of in-school girls was 15.9±1.4 years and that of the out-of-school girls was 15.5±2.5 years. most respondents in both groups were catholics, though more predominant among in-school girls (59.8%) as shown in table 1. majority (57.9%) of the out-of-school girls lived most of their time with relatives, either of the two parents, friends and boyfriend compared to 77.7% of the in-school girls who lived most of their time with both parents (p=0.001). table 1. socio-demographic characteristics of the groups [numbers (column percentages)] socio-demographic characteristics in-school (n=391) out-of-school (n=392) p-value* age (in years): 10-13 14-15 16-17 18-19 9 (2.4) 135 (34.5) 204 (52.1) 43 (11.0) 84 (21.4) 91 (23.2) 118 (30.1) 99 (25.3) 0.001 religion: roman catholic protestant pentecostal islam others-sabbath, jehovah’s witness 234 (59.8) 90 (23.0) 54 (13.8) 4 (1.0) 9 (2.4) 187 (47.7) 132 (33.7) 69 (17.6) 4 (1.0) 0 (0.0) 0.001 who they live with most time? both parents relative either parent friends boyfriend other 297 (77.7) 31 (8.4) 33 (9.0) 4 (14.8) 1 (0.3) 2 (0.5) 162 ( 43.9) 133 (35.7) 55 (14.9) 23 (6.2) 9 (2.4) 0 (0) 0.001 * chi-square test. in-school girls demonstrated better knowledge of sexual health compared to their peers that were out-of-school, as shown in table 2. they had statistically significant knowledge of 5 adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 fertile period compared to their out-of-school counterparts (p=0.001). however, less than 30% of girls in both groups were aware of the fertile period in a woman’s cycle. also, the inschool respondents had better awareness of contraceptive methods, types of stis and hiv transmission and prevention than the out-of-school respondents, all of which were statistically significant. table 2. sexual health knowledge of the groups [numbers (percentages)] knowledge of sexual health in-school out-of-school p* knowledge of fertile period: during menstruation immediately after menstruation half way between two periods don’t know 45 (11.5) 124 (31.8) 108 (27.7) 109 (27.9) 76 (19.4) 95 (24.2) 40 (10.2) 181 (46.2) 0.001 knowledge/awareness of contraceptive methods:† condom abstinence oral pills safe period injectables withdrawal others none 285 (72.9) 120 (30.7) 84 (21.5) 57 (14.6) 38 (9.7) 47 (12.0) 2 (0.5) 52 (13.3) 267 (68.1) 98 (25.0) 60 (15.3) 14 (3.6) 28 (7.1) 13 (3.3) 0 (0.0) 75 (19.1) 0.001 knowledge/awareness of hiv/ aids/stis:† hiv/aids gonorrhea syphilis candidiasis chlamydia herpes others none 383 (98.0) 264 (67.5) 190 (48.6) 143 (36.6) 13 (3.3) 18 (4.6) 11(2.8) 41 (10.5) 383 (97.7) 217 (55.4) 163 (41.6) 108 (27.6) 12 (3.1) 8 (2.0) 8(2.0) 75 (19.1) 0.002 knowledge of hiv: hiv transmission can be:† by blood transfusion and sharing of sharp needles or blade through mother to child transmission by sharing food with a person with hiv through mosquito bite by witchcraft or supernatural means reduced by using condom reduced by not having sex at all 302 (77.2) 171 (43.7) 33 (8.4) 24 (6.1) 8 (2.1) 125 (32.0) 151(38.6) 315 (80.4) 97 (27.8) 64 (16.3) 66 (16.8) 30 (7.7) 47 (12.0) 36 (9.2) 0.001 * chi-square test. †multiple responses. the commonest methods of contraception known to both groups were condoms, followed by abstinence. less than 50% in both groups were not aware of other methods of contraception. almost all adolescents in both groups (98%) were aware of hiv as a type of sti, followed by gonorrhoea, syphilis and candidiasis. more than 50% of the girls in both groups knew that hiv can be transmitted by blood transfusion and sharing of sharp needles or blade. sixteen percent of out-of-school girls had the misconception that hiv can be transmitted by sharing food with an infected person and also through mosquito bites compared to less than 10% of the in-school girls. only 12% of the out-of school girls believed that hiv can be reduced 6 adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 using condoms, and a lower proportion of 9% believed it can be reduced by not having sex at all. this is in comparison to in-school girls with 32.0% and 38.6%, respectively (table 2). most of adolescents thought that a single sexual intercourse was enough for one to become pregnant or acquire hiv infection (table 3). in-school girls had better perception of risk of getting pregnant (x2=16.31, p=0.001) or acquiring hiv infection (χ2=21.98, p=0.001), following a single sexual exposure. however, a greater proportion of their out-of-school peers perceived their chance of acquiring hiv to be high (χ2=20.03, p=0.001). although most of adolescents could not rate their risk of acquiring hiv infection, most of them felt that their chance of getting the disease is nil or low. furthermore, although majority of adolescents believed that aids is real, in-school girls demonstrated better attitude. two hundred and forty five (62.7%) in-school girls compared to 36.0% out-of-school girls did not agree that girls should be sexually experienced prior to marriage. similarly, a significant proportion of adolescents agreed that unmarried couples should use condom sex (χ2=27.84, p=0.001) (table 3). table 3. knowledge, attitude and risk perception [numbers (column percentages)] attitude and risk perception in-school out-of-school p* number of sex before one can become pregnant: once 2-5 times >5 times don’t know 307 (78.5) 54 (13.8) 22 (5.6) 17 (4.4) 257 (65.6) 55 (14.0) 25 (6.4) 57 (14.5) 0.001 number of sex before one can get hiv infection: once 2-5 times >5 times don’t know 312 (79.8) 55 (14.1) 14 (3.6) 21 (5.4) 254 (64.8) 48(12.3) 26 (6.6) 64 (16.3) 0.001 perceives self at risk of acquiring hiv infection: none low moderate high don’t know 117 (29.9) 29 (7.4) 15 (3.8) 9 (2.3) 221 (56.5) 86 (21.9) 40 (10.2) 8 (2.0) 30 (7.7) 228 (58.2) 0.001 a girl should have sexual experience before marriage: agree dnk/unsure disagree 105 (26.9) 41(10.5) 245 (62.7) 89 (22.7) 162(41.3) 141 (36.0) 0.001 do you believe that aids is real? yes no don’t know 372 (95.1) 9 (2.3) 10 (2.6) 358 (91.3) 24 (6.1) 10 (2.6) 0.029 unmarried couples should use condom during sex: agree disagree don’t know 148 (37.9) 159 (40.7) 84 (21.5) 128 (32.7) 113 (28.8) 150 (38.3) 0.001 * chi-square test. discussion a major threat to health of the adolescent stems primarily from their sexual behaviour which is partly influenced by lack of knowledge of reproductive health issues. for example, only a 7 adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 small proportion of both groups knew that a woman is likely to become pregnant half way between periods and even a smaller proportion of out-of-school respondents (10%) significantly differed from in-school adolescent (28%) in this regard. this is consistent with the finding of the ndhs (2008) where only 19% of all women knew the women’s’ fertile period (20). the study conducted in the northern part of nigeria showed a lower result because only 3.1% knew when ovulation occurs (21). in south-africa (22), it is 11%, while it is higher in ethiopia (23) with 48%. this poor knowledge of fertile period amongst nigerian adolescents may be the reason why the level of unwanted pregnancies and abortions is high. currently, it is estimated that 23% of adolescents in nigeria have begun child bearing (20). this finding strengthens the need to educate adolescents on reproductive and sexual health issues. however, a large proportion of both groups in this study knew that pregnancy is likely to occur at first sexual contact. this finding is consistent with the studies carried out in three states in northern-eastern nigeria (49%) (15) and lagos (60.5%) (24), but slightly lower with that carried out in ethiopia (48%) (23). a higher percentage of the in-school girls had better awareness of contraceptive methods than the out-of-school girls. the condom is mostly known by both groups followed by abstinence and oral pills. this agrees with findings of other studies conducted among adolescents (6,2530). adolescents and most young people have high awareness of condoms than most contraceptive methods (26). this is probably due to the much publicity given to preventive measures such as the condom with the onset of hiv pandemic; sometimes it is even distributed free of charge to the sexually active individuals. ninety-eight percent of the two groups were aware of hiv/aids and this is consistent with the figures from the 2008 ndhs (20) and also with findings of studies carried out in ghana (25), malawi (27) and uganda (28). overall, the in-school adolescents significantly had better knowledge of hiv transmission and prevention than the out-of-school counterparts, 16.8% believed that mosquitoes can transmit hiv and only 9.2% believed that condom can prevent hiv transmission. this is not surprising as educational attainment is positively associated with increased awareness of hiv methods as reported in the 2008 ndhs (8) and other african countries (25,27-28). both groups had better awareness of hiv than other stis. this is common with most studies involving adolescents and is not surprising because of the pandemic nature and publicity given to hiv infection (13,16,25,27,28). it is a common finding in studies involving the youth to discover that most do not consider themselves at risk of contracting hiv (25,27,28). in this study, more than half of the respondents in both groups do not consider themselves at risk or do not know that they are at risk of acquiring hiv infection. misconceptions, ignorance, poverty, desire for pleasure and sex under the influence of alcohol amidst other factors may provide the possible explanation for the low risk perception (31). however, the in-school girls significantly had better perception of risk of getting pregnant (χ2=16.31, p<0.05), or acquiring hiv infection (χ2=21.98, p<0.05). they also had better attitude than their out-of-school counterparts. overall, most disagree that girls should have sexual intercourse before marriage. studies done in lagos (13), ethiopia (23) and portugal (32) have also reported a similar finding. ninety-nine percent of the respondents affirmed that people had talked to them on issues of sexuality. in-school respondents had received their information mainly from parents and school teachers, while out-of-school girls had received information from youth organizations, parents and friends. this is consistent with results of similar studies done in owerri (10), benin (11) and in four other african countries (16). in this study, in-school adolescents significantly had more knowledge on sexual health than out-of-school adolescents. involvement in schools and plans to attend higher education are all related to less sexual risk8 adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 taking and lower pregnancy. however, their knowledge of many sexual health issues was poor; a significant number of both groups did not know their fertile period and had some misconceptions of hiv/aids. our study may have some limitations. due to the sensitive nature of the topic, some respondents found it difficult to respond to some questions. furthermore, some of the parents were not willing to allow their adolescent children to be interviewed, especially for the outof-school girls. there was also the problem of privacy in the market. however, in order to circumvent these problems, painstaking explanations on the purpose and benefits of the study were offered to all adolescents and a good number responded positively thereafter. in addition, our findings should be interpreted with caution due to the cross-sectional nature of our study design. in conclusion, this study has revealed that in-school respondents showed higher knowledge of sexual and reproductive health issues than their out-of-school counterparts, probably because of the effect of the school environment. they had better knowledge of hiv transmission and prevention methods, stis and contraception. however, both groups had low knowledge of fertile period and other forms of contraception. the in-schools girls also had better risk perception of hiv/aids and demonstrated better attitudes than the out-of-school girls towards pre-marital sex and condom use. it is therefore recommended that out-of-school adolescents should be targeted to go through behavioural change communication (bcc) on sexual and reproductive health issues. using the findings of the study as a baseline data, the ministry of health and education, faith organizations, international and non-governmental bodies and all adolescent stakeholders should be encouraged to collaborate and cooperate with opinion leaders into impacting and improving the reproductive and sexual health knowledge of adolescents more so for the outof-school adolescents. these could also happen by training and retraining more teachers and peer educators on issues of reproductive and sexual health for impartation on their students and their out-of-school counterparts. parents are the primary sexual educators of the children. parents should be sensitized on the importance of providing a supportive home environment; maintaining strong ties with them and giving appropriate information on sexual issues according to their ages. this will bring about a level of family connectedness that will effect positive changes in the sexual behaviour of the adolescents. the responsibility of sensitizing parents can be taken up by the ministry of women affairs with cooperation from faith-based organizations, representatives of market women, parents, teachers association and other bodies. conflict of interest: none declared. acknowledgement: this report is part of the dissertation presented and successfully defended at the nigerian national postgraduate medical college, faculty of public health in april 2012. ethical consideration and permission: ethical clearance was secured from the ethics committee of the nnamdi azikiwe university teaching hospital nnewi. official permission was also obtained from anambra state education commission, onitsha north local government authorities, each selected school authority and the authorities in charge of the market. informed consents were obtained from the adolescents’ parent/guardian especially for out-of-school respondents and from all respondents after explaining the purpose, 9 adogu p, udigwe i, nwabueze a, adinma e, udigwe g, onwasigwe c. sexual health knowledge, attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 objectives and benefits of the research to them. they were assured of no harm in participation and were told that participation is entirely voluntary. references 1. world health organization. ten facts on adolescent health. geneva: who, 2008. 2. national population commission. reports on 2008 population census in nigeria, 2008. 3. egbochukwu eo, ekanem ib. attitude of nigerian secondary school adolescent towards sexual practices; implications for counseling practices. euro journals 2008;22:177-83. 4. onyeka in, miehola j, ilika al, vaskilampi t. unintended pregnancy and termination of studies among students in anambra state, nigeria. afr j reprod health 2011;15:109. 5. meekers d, ahmed g. pregnancy-related school dropouts in botswana. pop stud 1999;53:195-209. 6. sallah am. sexual behaviour and attitude towards condoms among unmarried in school and out-of-school adolescents in a high hiv prevalence region in ghana. int q community health educ 2009;29:167-81. 7. kipp w, diesfeld h, ndyanabangi b. reproductive health behaviour 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attitude and risk perception among in-school and out-of-school female adolescents in onitsha, anambra state, nigeria (original research). seejph 2014, posted: 17 june 2014. doi 10.12908/seejph-2014-25 19. national population commission (npc) and icf macro. nigeria demographic and health survey 2008. abuja, nigeria: national population commission and icf macro, 2009. 20. sallah am. sexual behaviour and attitude towards condoms among unmarried in school and out-of-school adolescents in a high hiv prevalence region in ghana. int q community health educ 2009;29:167-81. 21. adekunle la, ricketts oz, ajunwon aj, ladipo oa. sexual and reproductive health knowledge, behavior and education needs of in-school adolescents in northern nigeria. afr j reprod health 2009;13:37-9. 22. ibaya ga, amoko dh, ncagyana dj. adolescents’ sexual behaviors, knowledge and attitudes to sexuality among school girls in transkei, south-africa. east afr med j 1996;73:95-100. 23. seifu a, fantahun m, worku a. reproductive health needs of out-of-school adolescents: a cross – sectional comparative study of rural and urban areas in northwest ethiopia. ethiop journal health 2006;20:10-17. 24. ojikutu rk, adeleke ia, yusuf t, ajijola la. knowledge, risk perception and behaivour on hiv/aids among students of tertiary institutions in lagos state, nigeria. budepest: e-ledaer, 2010. 25. alan guttmacher institute. adolescents in ghana new york: alan guttmacher int, facts in brief , 2006. 26. okereke ci. sexually transmitted infections among adolescents in a rural nigeria. indian j soc sci 2010;7:32-40. 27. alan guttmacher institute. adolescents in malawi new york: alan guttmacher int, facts in brief, 2006. 28. alan guttmacher institute. adolescents in uganda new york: alan guttmacher int, facts in brief , 2006. 29. aderibigbe sa, araoye mo, akande tm, musa oi, monehin jo, babatunde oa teenage pregnancy and prevalence of abortion among school adolescent in north, central nigeria. asian social science 2011;7:20-2. 30. tripp j. sexual health contraception and teenage pregnancy. bmj 2005;330:590-3. 31. moore a, biddlecom a, zulu e. prevalence and meanings of exchange of money or gifts for sex in unmarried adolescent sexual relationships in sub-saharan africa. afr j repr health 2007;11:1-7. 32. aderibigbe sa, araoye mo. effect of health education on sexual behaviour of students of public secondary schools in llorin, nigeria. euro j 2008;24:33-41. ___________________________________________________________ © 2014 adogu et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 11 satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 1 | 15 original research how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic adhitya satyamoorthy1, helmut brand1,2, robin van kessel1,3 1 department of international health, care and public health research institute (caphri), maastricht university, maastricht, the netherlands; 2 prasanna school of public health, manipal academy of higher education, manipal, karnataka, india; 3 maastricht working on europe, studio europa, maastricht university, maastricht, the netherlands. corresponding author: prof. dr. helmut brand; address: department of international health, maastricht university, duboisdomein 30, 6229 gt maastricht, the netherlands; email: helmut.brand@maastrichtuniversity.nl satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 2 | 15 abstract aims: the article aims to analyze what can be learned from the last financial crisis from 2008 on to minimize the negative health effects in the european union due to the economic recession caused by the covid-19 pandemic. methods: systematic literature reviews were conducted to analyze the interventions taken to combat the last financial crisis and their consequences on health. parallel to this, a qualitative document analysis of the ongoing discussion about the measures taken or to be taken in the covid-19 pandemic to fight the current economic recession was conducted using institutional websites and international media. results: the main methods taken to combat the financial crisis from 2008 were, bailing out banks, austerity measures, and the european stability mechanism. there is evidence that the financial crisis had negative effects on the european health systems in general. austerity measures in some countries, led to an increase in psychological disorders. overall mortality was not affected but the decrease of avoidable mortality slowed down. various economic interventions such as bailing out essential industries e.g., the aviation sector, cash injections, tax relief, short-work salary compensation, modified esm, and the pandemic emergency purchase program (pepp) were taken during the covid-19 pandemic to help stabilize the economy. conclusion: the current recession is not caused by internal failures of the financial system as it was in the financial crisis of 2008, but by an outside event the covid-19 pandemic. measures were taken by the governments and the european union to avoid an economic crisis, and by these, the negative health effects were created during the financial crisis in 2008, but the lockdown phase seems to lead to similar negative health effects regarding psychological disorders and delay of planned screening and treatment. keywords: austerity, covid-19, economic measures, financial crisis, health, pandemic. conflict of interest: none declared. satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 3 | 15 introduction in december 2019 an outbreak of the virus, severe acute respiratory syndrome coronavirus 2 (sars-cov-2), occurred in wuhan, china, which developed into the covid-19 pandemic (1). the virus that caused covid19 spreads mainly when an infected person is in close contact with another person or small droplets and aerosols is in the air (1). at the beginning of 2020, 23 million people were infected worldwide, out of which, 800,961 people died (2). to combat the pandemic in the absence of a vaccine several non-pharmaceutical measures such as lockdowns were adapted by infected countries. this was to prevent the spread of the disease and not overload the health system with patients. a side-effect of these measures is that they had and still have a serious influence on the economies of infected countries that finally led to a worldwide recession (3). the gross domestic product (gdp) shrank by 12.1 % in the european union at end of july 2020 (4). by this, the covid-19 pandemic has the highest negative effect on the economy of all infectious disease outbreaks in the last decades (5). next to the direct burden of ill-health due to infected people, there is the risk of an indirect burden of ill-health caused by the measures taken to combat the economic recession as we learned from studies that looked into the effect of economic decline on health (6). the european union and its member states had to choose interventions to minimize these negative health effects. figure 1, originally presented by douglas and colleagues (7), visualizes the interdependencies between the different measures taken to fight the pandemic and illustrates the pathway of economic consequences leading to indirectly attributable morbidity and mortality. the last financial crisis started in august 2007 in the united states. the excessive risk taken by banks along with the bursting of the united states housing bubble caused the financial downturn in the united states (8). real estate was hit the most damaging various financial institutions globally. this was then followed by a global financial crisis in september 2008 that later developed into the great recession in 2009-2010. the financial crisis of 2008 in europe initially affected portugal, ireland, italy, greece, and spain. this led to a loss of confidence in european businesses and economies. unsustainable fiscal policies and overleveraged banks led to a sovereign debt crisis in the euro area in 2010 (8). the research objective of this article is to analyze if the measures taken to combat the last financial crisis should be applied this time too. by comparing the current economic recession with the financial crisis of 2008 and the economic measures taken then, we can theorize if the measures would work during the economic crisis caused by the covid-19 pandemic. methods ethical consideration this literature review was based on published reports and was therefore exempted from ethical approval. a systematic literature review was conducted on the measures taken to combat the financial crisis of 2008 and, on the health effects the crisis had, using databases pubmed, web of science, and econpapers from the years 2009 to 2020 using a combination of boolean operators (and/or), medical subject headings (mesh) and predefined keywords. peer-reviewed papers in english on measures taken to combat the financial crisis of 2008 and the health effects of the crisis were retrieved and independently evaluated for eligibility based on the title and abstract. thereafter, full texts of eligible papers were accessed according to the pre-defined inclusion and exclusion criteria. the preferred reporting items for systematic reviews and meta-analyses (prisma) 2009 guidelines were followed (9). satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 4 | 15 figure 1. effects of social distancing measures (7) search strategy and data collection for the review on the measure taken to combat the financial crisis in 2008 and health effects caused by the crisis, keywords were “financial crisis 2008”, “economic impact”, “eurozone crisis”, “measures”, “austerity”, “health effects”, “behavioral effects”, and “europe”. the time span of publications was from 2009 to june 2020. the great american recession 2007-2009, the measures taken during the financial crisis of 2008 in the united states of america, countries outside the european union, and published articles in other languages apart from english were excluded. parallel to this, a qualitative document analysis regarding the content of the ongoing discussion about the measures taken or to be taken in the coronavirus pandemic to fight the economic recession was conducted to watch out for evidence about indirectly attributable morbidity and mortality. sources monitored were the institutional websites, e.g., of the european commission (ec), the european centre for disease prevention and control (ecdc), the european central bank (ecb), the world bank, the european investment bank (eib), the international monetary fund (imf), the organisation for economic co-operation and development (oecd), and major international consultant companies and newspapers. for the review on how to combat the 2008 financial crisis and the health effects of the financial crisis of 2008, 668 articles could be identified via the databases searched, and 35 articles via additional sources. satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 5 | 15 after checking for relevance 36 articles were included. the qualitative document analysis of the institutional websites was included till the end of june 2020 and 13 results were used. figure 2. systematic literature review on economic measures taken during the financial crisis 2008 (9) records identified through database searching (n =407) sc re e n in g in cl u d e d e lig ib ili ty id e n ti fi ca ti o n additional records identified through other sources (n = 21) records after duplicates removed (n =378) records screened (n = 378) records excluded (n =280) full-text articles assessed for eligibility (n =98) full-text articles excluded, with reasons (n =84) studies included in synthesis (n = 14) satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 6 | 15 results measures taken to combat the financial crisis of 2008 the primary cause of the 2008 financial crisis in europe was the bursting of a property bubble in the united states of america in 2007 (10). the crisis resulted from a structural problem of the eurozone, and a combination of factors, which included the globalization of finance, easy credit system that encourage high-risk borrowing, lending practices, international trade imbalances, a real estate bubble, unsustainable fiscal policy approaches related to government revenues, and expenses and approaches used by certain nations to bail out troubled banks and private bondholders (11). the first interventions were to prevent the collapse of the banking figure 3. systematic literature review on health effects of financial crisis of 2008 (9) records identified through database searching (n =261) s cr e e n in g in cl u d e d e li g ib il it y id e n ti fi ca ti o n additional records identified through other sources (n =14) records after duplicates removed (n =246 ) records screened (n = 246 ) records excluded (n =203) full-text articles assessed for eligibility (n =43) full-text articles excluded, with reasons (n =21) studies included in synthesis (n =22) satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 7 | 15 sector and the second interventions tried to avoid a massive drop in demand (12). member states made efforts to prevent mass unemployment and made sure workers would retain their relationship with the labor market, e.g., by implementing short-time work schemes. this was one of the main reason’s governments had to raise taxes and cut back social expenditure (13). investments in jobs and government infrastructure, tax measures, and tax reliefs were implemented (12). other measures such as lowering interest rates and buying government bonds were part of the monetary policies of the eu that would help to cope with the financial crisis (14). between october 2008 and may 2009, the european central bank (ecb) lowered its interest rate to maintain price stability in the euro area. the enhanced credit system focused on commercial banks, as they were the main source of funding for businesses and households in the euro area interbank market (15). public debt increased, national credit ratings fell and the cost of borrowing increased. this led governments in europe to impose harsh austerity measures which would reduce public spending (13). during the crisis, unemployment increased rapidly in europe. the european central bank (ecb), the european investment bank (eib), and the international monetary fund (imf) along with leaders of european member states placed a priority to reduce the deficit (16). the majority of the deficit reduction policies by european governments involved further budget cuts rather than tax increases (16). health effects of the financial crisis of 2008 in europe the 2008 financial crisis in europe not only had an economic impact but has also a short, medium, and long-term impact on the health systems and the health of individuals (16,17). economic growth, democratization, and improved living conditions have contributed to better population health in most european countries, but health inequalities are still prevalent (18). these inequalities are mainly caused by daily living conditions, inequalities in available money, and resources which affect individuals during a financial crisis due to loss of employment. this leads to a change in lifestyle which may include smoking, alcohol consumption, and nutrition intake (19,20). in times of an economic crisis, households will also limit their spending on health (21). the financial crisis of 2008 caused, in some countries, severe psychological disorders which included depression, anxiety, and suicidal behavior (22). over time suicides and psychological disorders increased by 7% because of unemployment, loss of income, and housing instability e.g. (in some southern european countries) (23). countries such as greece started to reduce their health care budget during the financial crisis in 2008. the tight restrictions of budgets on the health care system worsened the health system performance and also led to a slowdown in the reduction of avoidable mortality (24). impact of the covid-19 pandemic on the economy in europe the impact of covid-19 pandemic on the economy is severe (25). the manufacturing sector was affected due to lockdown measures as e.g., it depends on the physical presence of the workers. the travel and tourism sector experienced great difficulties as the movement of people was restricted. the closing of public places led to a supply chain disruption. educational institutions had to shift to online education. the entertainment industry experienced a total standstill as gatherings were forbidden. all of this resulted in the loss of jobs and income and also reduced demand and supply (25-27). this influenced the consumers’ confidence as they hesitate to buy products in the face of possible job loss satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 8 | 15 or reduced income. in summary both, supply and demand were reduced in the pandemic (3,28). some of the currently discussed economic measures to solve the crises are already implemented (25,29,30). they focus either on individuals by offering temporary cash for vulnerable households, expand short-time work schemes, and increasing resources for health care (27,31). for the industry, the reduction or delay of paying taxes for affected sectors is discussed (32). at the state level, fiscal consolidation is needed to expand liquidity and availability of credit to firms (32,33). regulations on reporting bankruptcy have been delayed. regarding macroeconomic policies, the expansion of liquidity to banks is discussed (30). further, it should be ensured that monetary policy can respond to extreme market conditions (32). the european union (eu) agreed upon a recovery fund and a long-term budget that supports its citizens and business from the economic crisis caused by covid -19. the european union’s long-term budget called the multiannual financial framework (mff), of 1,100 billion euros for the year 2021 to 2027 can be considered vital in the recovery of the economy (27). the eu has also sanctioned temporary funding of 750 billion euros called the pandemic emergency purchase program (pepp) (30,33). the pepp program would help the member states in supporting their citizens and businesses. this included compensation on employees’ wages, supporting small and medium-sized enterprises (sme), and supporting businesses with tax reliefs or delayed taxes (25,27,31). the effect of the measures is still unknown due to the recent implementation. some european member state governments have started to bail out national airlines (34) as the aviation and the travel sector were one of the most affected sectors during the lockdown. but not all sectors were affected equally. the it sector for example is expected to double its revenue in the second quarter compared to the first quarter in march 2020. companies such as apple and google even saw an increase in their share price from the beginning of february to the first week of august by 8.26% and e-commerce companies such as amazon and ebay saw an increase in their share price by 29.64% from the first week of march to the first week of august (35). the increase in growth of online sales has helped the e-commerce industry because consumer confidence has increased in online sales. this in return helped increase business and industry confidence. the supply chain for certain products from china had come to a standstill. as china today is seen as the workbench for europe this had major implications for the availability of most goods. this was very eminent in the discussion about missing ppe due to the import from china. therefore, many countries are encouraging companies to relocate production in their own country and have committed to support this with dedicated investments into manufacturing through programs such as the escalar (35). health effects of economic recession 2020 in europe the mortality impact of covid-19 has been of major concern in europe and the rest of the world. as of the beginning of august 2020, there were a total of 216,478 deaths (32). the impact of lockdowns adopted by the member states can have unintended health effects (36). lack of social contact can result in mental health issues, limiting physical activity can result in obesity and a rise in domestic violence. the current financial situation can cause uncertainty and stress that would result in a negative health effect in the short term (37). due to lockdown, people are not traveling and by this, the number of traffic accidents is supposed to go down (38,39). there have been concerns that the measures taken to mitigate the covid-19 pandemic satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 9 | 15 could increase the number of deaths from other diseases. one of the major issues is that people hesitate to go for treatment as they fear they would be infected by the covid19 virus. or, that they do not like to burden the healthcare system when it is already under pressure due to the pandemic (37,40). hospitals are delaying the treatment of noncovid-19 patients as they are trying to prioritize the cases related to the pandemic (40). therefore, apart from the official covid-19 deaths, there are additional deaths that may be directly or indirectly related to it. due to the lockdown and social distancing measures about 2.1 million people missed out on cancer screening. there have also been up to 290,000 people with suspected symptoms that have not been referred to any hospital or any treatments (37). this is because during the lockdown health systems focused on patients with covid-19 and other services like cancer screening were postponed. due to this, there might be around 230,000 cases of cancer gone undetected. cancer requires prompt diagnosis and treatment; hospitals can’t do so because they are over capacitated by covid-19 patients. this would increase the number of cancer cases over the long term (41). discussion the rapid spread of covid-19 prompted many governments to impose serious and strict lockdown measures. these measures have made many businesses shut down temporarily, led to restrictions on free movement and travel, financial market going turmoil, and decreased consumer confidence (42). the measures taken in europe to help and boost the economy are relatively large compared to those measures taken during the financial crisis in 2008. the magnitude of the impact of these measures on the growth of gdp is still unknown due to their recent implantation. data on the economic effect of the pandemic are not yet available or accessible since some statistics are produced on a quarterly or yearly basis. as there are different reasons for the origin of the crisis, some macro-economic effects might be different so the actions to be taken might not be the same. table 1 compares the reasons for the two crises, the effects on the economy, the measures taken, and their effects. table 1. comparison of the financial crisis of 2008 with the economic recession 2020 financial crisis 2008 economic recession 2020 reason for crises from inside the financial system (bursting of a property bubble) from outside of the financial system (sars-cov-2) effects on the economy global recession, credit crunch. global recession, no demand and no supply. measures taken bailing out banks, austerity measures, european stability mechanism (esm) introduced. bailing out essential industries e.g. the aviation sector, cash injections, tax relief, short-work salary compensation, modified esm, pandemic emergency purchase program (pepp). effect of measures taken the economy recovered over time. short-term economic recovery, long-term economic recovery is unclear. satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 10 | 15 the reasons for the shock and impact on the world economy are different in 2020 when compared to the financial crisis in 2008. in 2008, the problem was a banking crisis which was the result of too much “bad debt”. now it is the supply chain shock having a knockout effect on the market (43). various leading economists have urged governments to bring out measures to fight the economic downfall. they suggest reducing personal and corporate bankruptcies, ensure people keep spending even though they are not working, increase public investment, increase healthcare spending, and using an unconventional policy called the helicopter money where the governments print new money and distribute it among the public during a recession (44). stock markets fell about 33% from march compared with 55% during the 2008 financial crisis. but this comparison is for the short period of the economic crisis in 2020 with a much longer period of the financial crisis of 2008. the shock on the economy in 2020 is different since the lockdown has severely hampered every sector from the beginning when compared to the financial crisis of 2008 where mostly the banks were affected first. this shows that the economic outcome of the covid-19 pandemic seems worse when compared to the financial crisis in 2008 in a short term. one can compare the fall of the stock markets to the post-collapse of lehman brothers which stands at 33% and 19% respectively. if income is held up for even four months, it will drive firms into insolvency which will result in unemployment, loss of income, reduced consumer confidence. consumer confidence slumped to a level that has not been seen since the financial crisis in 2008. this shows that the pandemic has a serious toll financially and economically (45). the consumer confidence indicator fell to minus -15.6 points during the covid-19 economic crisis compared to 11.2 points during the financial crisis in 2008 (46,47). unemployment, loss of income, lack of supply or production which lead to increased prices have all severely decreased consumer confidence. this also shows that most of the people are unsure and pessimistic that the covid-19 pandemic will have a lasting impact on the economy, and this would be a lengthy recession (43). financial markets and the economy already bounced back, but the question is if this will be in the form of a sharp “v”, a prolonged “u” or even an up and down in the form of a “w” (48). in general, it is hard to attribute adverse health effects to a single cause in a situation of economic downturn. the available literature on the health consequences of the financial crisis 2008 is (surprisingly) still scarce and prone to bias from an epidemiological viewpoint. the results for the health effects of the financial crisis in 2008 and assumed health effects of the economic recession in 2020 are summarized in table 2. the hypothetic health effects of the current pandemic are marked by “(?)” satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 11 | 15 table 2. health effects of the financial crisis in 2008 compared to observed and hypothetic health effects of the economic recession in 2020. hypothetic effects marked by “(?)” financial crisis 2008 economic recession 2020 short health systems experienced financial stress, increase of hiv infections (due to the decrease of preventive measures), less road traffic accidents. covid related mortality increased, increase of alcohol consumption and violence in families, increase in depression and anxiety disorders, reduced physical activity during the lockdown, less traffic and work-related (?) accidents, less cardio-vascular diseases due to better air quality (?). medium access to and coverage of care decreased in some countries, unmet need in health increased in countries with high co-payment, increase of depression, suicide, and other psychological disorders, increase in homicide and alcohol-related death. increase of non-covid related mortality, increase of cardio-vascular mortality (stroke, myocardial infarction) due to delay in treatment because of corona fear and unemployment (?), psychological stress for younger people because of delay in schooling, graduation, and first-time employment (?). long increase of health inequalities, lower self-rated health in unemployed, no effect on overall mortality, decrease of household spending on health, decrease of avoidable mortality slowed down, no change in birth weight, fetal death, or infant mortality, small but significant increase in overall morbidity. more cancer cases due to low uptake of screening and delayed treatment (?), no increase in overall mortality (?). this take-away summary shows, in general, no surprises in the expected events. mental disorders occur when societies are under stress. the consequences of this are higher rates of alcoholism and violence in families. these “predictable” consequences give the possibility to prepare for them before they run out of control. this is especially important if further lockdowns would be necessary. indirect consequences of a lockdown as fewer road and work accidents are positive side effects but not in the focus of discussion. delayed treatment of acute diseases might lead to a higher disease burden later. at the moment there are no clear answers to this question. new is the situation of missed education for children. here indirect health consequences might occur in form of psychosocial stress with long-term effects (49). as we do not know if these health-related problems are temporary or permanent, there is the need to monitor them to be aware of their prevalence. only by this, one can shift necessary resources to the area of need. there are already clear signs that the austerity measures which followed the financial crisis of 2008 will not be applied by governments and the eu this time. in opposition, it is the first time that the eu is willing to go into debt itself. by this, further concerted actions regarding health issues become more, probably which will help to avoid the negative health effects of the recession. satyamoorthy a, brand h, van kessel r. how to minimize negative health effects in the european union due to the economic recession caused by the covid-19 pandemic (original research). seejph 2021, posted: 03 june 2021. doi: 10.11576/seejph-4492 p a g e 12 | 15 references 1. world health organization. who europe; 2020. available from: http://www.euro.who.int/en/home (accessed: march 3, 2021). 2. world health organization. coronavirus disease dashboard. who; 2020. available from: https://covid19.who.int (accessed: march 3, 2021). 3. politico. coronavirus in europe. available from: https://www.politico.eu/coronavirus-in-europe/ (accessed: march 3, 2021). 4. european commission. 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10.4119/seejph-3441 p a g e 1 | 12 original research aflatoxin b1 as an endocrine disruptor among miller flour workers safia beshir1, weam shaheen1, amal saad-hussein1, yuosra saeed2 1environmental and occupational medicine department, national research centre, giza, egypt; 2air pollution research department, national research centre, giza, egypt. corresponding author: weam shaheen; address: national research centre, dokki, giza, egypt. el-buhouth st., 12622; telephone: 01118983587; email: weamshaheen@gmail.com mailto:weamshaheen@gmail.com beshir s, shaheen w, saad-hussein a, saeed y. aflatoxin b1 as an endocrine disruptor among miller flour workers (original article). seejph 2020, posted: 04 may 2020. doi: 10.4119/seejph-3441 p a g e 2 | 12 abstract aim: aflatoxin в1 has been stated to inhibit the function of different endocrine glands. this study was proposed to clarify the possible effects of aflatoxin b1 as an endocrine disruptor on pituitary gland, thyroid gland and gonads among miller flour workers, and to evaluate its effects on human male sexual function. methods: a case-control study was conducted in a flour mill in helwan district cairo, egypt in 2019. the study included 42 exposed flour milling male workers from the grinding department which showed the highest level of aspergillus flavus in the air sampling of airborne fungi and 40 non-exposed males. serumaflatoxin в1/albumin, luteinizing hormone, follicle stimulating hormone, testosterone, 17-beta-estradiol, free triiodothyronine, free thyroxin and thyroid stimulating hormone were measured for the studied groups. results: sampling of airborne fungi revealed that aspergillus flavus and penicillum were the predominant fungal types in the flour mill. indoor/outdoor ratios for aspergillus flavus were ≥ 1 in all the locations indicating presence of indoor sources. serum aflatoxin в1/albumin, luteinizing hormone and follicle stimulating, the existence of various types of sexual disorders (decreased libido, impotence and premature ejaculation) were higher while testosterone was lower in the miller flour workers compared to non-exposed. however, there was no significant difference regarding 17-beta-estradioland thyroid hormone levels between both studied groups. conclusion: aflatoxin b1creates possible human male reproductive health distresses in miller flour workers. keywords: aflatoxin в1, egyptianflour workers, lh and fsh, sexual disorders, testosterone, thyroid hormones. acknowledgement: the authors are grateful to the national research centre for funding this research. funding: this study was funded by the national research centre, egypt. conflicts of interest: none declared. beshir s, shaheen w, saad-hussein a, saeed y. aflatoxin b1 as an endocrine disruptor among miller flour workers (original article). seejph 2020, posted: 04 may 2020. doi: 10.4119/seejph-3441 p a g e 3 | 12 introduction worldwide, human fertility is deteriorating; a state that cannot be referred only to the increase in contraception usage (1). many environmental factors, industrial and occupational compounds, dietary contaminants, lifestyle factors and medications were suggested to be other causes to this deterioration (1). male infertility causes may be pre testicular, testicular and post testicular. the pre testicular and the testicular causes are chiefly endocrine disorders that originate from the hypothalamic-pituitary-gonadal axis that have opposing effects on spermatogenesis (2). male reproduction is controlled by the hypothalamo-hypophyseal testicular axis: hypothalamic gonadotropin releasing hormone, pituitary luteinizing hormone (lh) and follicle stimulating hormone (fsh) and the gonadal steroid, principally, testosterone. it was proved that thyroid hormones have a changeable effect on this axis and thus affect the sexual and spermatogenic function of man (3). effects of thyroid hormones occur through binding to certain thyroid hormone receptors which are extensively spread in the testis (4). endocrine disrupting chemicals (edcs) may be of synthetic (pesticides, industrial chemicals, bisphenols) or natural origin (mycotoxins, phytoestrogens). some mycotoxins can act as probable endocrine disruptors and cause changes in hormone production (5). endocrine disruptors may simulate the action of sex hormones, affect reproduction (6), cause reproductive anomalies (morphological and functional gonadal dysfunction, e.g. infertility and decreased libido) and congenital malformations (altered embryonic and foetal intrauterine development) (7). egypt is one of the countries with high wheat consumption (8). fungi can produce varied types of mycotoxins under environmental conditions which are favourable to growth. aflatoxins are naturally occurring mycotoxins produced by certain fungi, mainly aspergillus flavus and aspergillus parasiticus. aflatoxins b1 (afb1) is one of the main aflatoxin types (9). afb1 has been stated to inhibit the function of different endocrine glands by disturbing the enzymes and its substrate that are responsible for the synthesis of different hormones (10). aflatoxins have the ability to generate hormonal dysfunction inducing cell toxicity which directly affects reproduction (11). previous studies stated that afb1 disturbs the hypothalamo-pituitary testicular axis resulting in production of malfunctioning spermatozoa (12,13). uriah and his colleagues (14), proved that aflatoxin levels in the blood and semen of infertile nigerians men were significantly higher than in the fertile men, suggesting that aflatoxin might be an influential factor in occurrence of men infertility. afb1 lower sensitivity of thyroid receptors by enhanced generation of reactive oxygen species, aggravating lipid peroxidation concentrations (15). mycotoxins could be raised in animal and human biological fluids after feeding of contaminated food products. however, nowadays contamination through inhalation of mycotoxins in indoor air has been taken in consideration (16). this study was proposed to clarify the possible effects of aflatoxin b1 as an endocrine disruptor on pituitary gland, thyroid gland and gonads among miller flour workers, and to evaluate its effects on human male sexual function. beshir s, shaheen w, saad-hussein a, saeed y. aflatoxin b1 as an endocrine disruptor among miller flour workers (original article). seejph 2020, posted: 04 may 2020. doi: 10.4119/seejph-3441 p a g e 4 | 12 methods study design this was a case-control study. the exposed workers were considered as cases compared to the non-exposed subjects (controls). the variable fertility/sub-fertility in this study was measured through estimation of the sex hormones as high lh and fsh and low testosterone and rate of occurrence of sexual male function disorders among the exposed workers compared to their non-exposed can affect the fertility of the exposed workers. study population and sampling this study included all the miller flour exposed male workers (42 workers) from the grinding department (which showed the highest level of aspergillus flavus in the air sampling of airborne fungi). forty male non exposed subjects were included in the study (they were all the available employees working in the area surrounding the flour mill). data collection written informed consent was obtained from all the included subjects. questionnaire was filled during personal interview with the participating groups. the questionnaire included (personal data, detailed occupational history, marital, sexual and medical history, types and use of personal protective equipment). available personal protective equipment included masks, protective goggles and gowns. exclusion criteria were obesity, history of diabetes, hypertension and thyroid diseases, which may be considered differential causes for infertility. sampling of airborne fungi the samples were taken during the normal working days, between 9.00 am to 2.00 pm to determine peak exposures inside the flour mill. the air sampler was positioned at a height of ~ 1.5 m (breathing zone) above the floor level in the middle of the sampling location. the control(comparison) samples were taken 10 m outside the building. andersen one-stage viable cascade impact or sampler (te-10-160, tisch environmental cleves, oh, usa) was used. it collects particles with aerodynamic diameter of < 2.5 µm. particles < 2.5 µm penetrate deeply into lungs. the sampler was operated at flow rate of 28.3 l/min for 5 min. malt extract agar (mea) were used to collect airborne fungi (bd biosciences, sparks, maryland, usa). three consecutive samples were taken during each sampling event (3 plates/location). fungal plates were incubated at 28 °c for 57 days and checked daily. the resultant colonies were counted and positive hole correction was conducted on all counts prior to the calculation of the colony forming units per cubic meter of air (cfu/m3) (17). fungal isolates were purified and identified by direct observation on the basis of micro and macro morphological features. identification was performed on the basis of reverse and surface coloration of colonies on sabouraud dextrose agar, czapekdoxagar, potato dextrose agar and malt extract agar. fungal isolates were identified to the genus or species level (18). laboratory investigations -the blood samples were collected in sterile dry tubes, left to clot for 30 min and then centrifuged at 3000 r/min for 10 min. the separated sera were kept at -20 ˚c for the laboratory investigations. -afb1 and serum alb:  aflatoxin b1 was firstly extracted using easiextract1 aflatoxin immune affinity column (scotland). afb1 concentrations of the samples were analyzed by micro-titer plate enzyme-linked immune-sorbent assay beshir s, shaheen w, saad-hussein a, saeed y. aflatoxin b1 as an endocrine disruptor among miller flour workers (original article). seejph 2020, posted: 04 may 2020. doi: 10.4119/seejph-3441 p a g e 5 | 12 (elisa) method using ridascreen1afb1 30/15 elisa, made in germany.  serum albumin (alb) was determined by colorimetric method according to doumas and biggs (19). -serum concentrations of lh,fsh, testosterone, free triiodothyronine (ft3), free thyroxin (ft4) and thyroid stimulating hormone (tsh) were measured using elisa kit by drg international, inc., (usa) at the research laboratory, 17-beta-estradiol (e2) using kit by biosource. ethical approval number (10142) was obtained from the research ethics committee of the national research centre, egypt, before the beginning of the study. data analysis statistical analysis was done through spss package version 20. quantitative data were expressed as mean ± sd. two independent sample t-test and chi-square test were used to assess statistical differences in the quantitative and qualitative data (for distribution of sexual disorders among the studied groups) respectively between the exposed and the non-exposed groups. pearson's correlation coefficient was calculated for exposure duration, aflatoxin в1 and studied hormones among the exposed workers. p-values were two-tailed and considered statistically significant at ≤0.05. results both studied groups were between 40 to 50 years, with mean age 45 ± 8.9 years for the exposed workers and 44± 9.2 years for the non-exposed group; without significant difference. there was no significant difference between both studied groups regarding smoking habits; number of smokers was 26 among the exposed group and 24 among the non-exposed group. the mean of duration of exposure of the miller flour workers was 15 ± 5.2 years. none of the workers in the flour mill used personal protective equipments. penicillium and aspergillus were the common airborne fungi in the flourmill. penicillium and aspergillus flavus concentrations ranged within39– 577 cfu/m3 and 12– 205 cfu/m3, respectively. penicillium and aspergillus flavus were found in the highest concentrations in the grinding unit. aspergillus niger concentrations ranged from 19– 180 cfu/m3, with the highest concentration found in garbling unit. table 1 shows indoor/outdoor (i/o) ratio, "a relative standard" used to document the presence or absence of indoor biologically derived contamination and differences between sampling sites (20). in the present study, i/o ratios for penicillium and aspergillus niger were ≤ 1 in almost all locations; suggesting that outdoor air was the main contaminant source. however, i/o ratios for aspergillus flavus were ≥ 1 in all the locations indicating presence of indoor sources table 1. i/o ratios of the common airborne fungi at the flourmill units locations penicillium species aspergillus flavus aspergillus niger aspergillus species* storage 0.07 6.68 0.5 garbling 0.2 6.67 0.75 0.42 beshir s, shaheen w, saad-hussein a, saeed y. aflatoxin b1 as an endocrine disruptor among miller flour workers (original article). seejph 2020, posted: 04 may 2020. doi: 10.4119/seejph-3441 p a g e 6 | 12 grinding 1.12 17.83 0.12 0.42 packaging 0.26 1.86 1.16 0.57 *aspergillus species include: aspergillus parasiticus, aspergillus terreus and aspergillus ochraceus. table 2 shows that afb1-albumin (afb1alb) level among the exposed group was significantly higher compared to the non-exposed. lh and fsh were significantly higher and testosterone was significantly lower among the exposed workers compared to the non-exposed. there was no significant difference regarding e2 and the thyroid hormones between the two studied groups. data in table 3 shows that among the exposed workers, afb1/alb is significantly positively correlated with lh and negatively correlated withft4 & ft3. ft4 is significantly negatively correlated with the duration of exposure. tsh was significantly negatively correlated with lh and fsh, and positively correlated with testosterone. lh was positively correlated with fsh on one side and negatively correlated with testosterone on the other side. twenty-five percent (10/40) of the non-exposed and 45.2% (19/42)of the exposed group complain of sexual disorders. fifteen percent (6/40) of the non-exposed versus 7.1% (3/42) of the exposed workers complained of one sexual disorder. while 10% (4/40) of non-exposed versus 38.1% (16/42) of the exposed workers complained of more than one sexual disorder. table 4 shows the distribution of various types of sexual disorders (decreased libido, impotence, premature ejaculation) which was higher in the exposed workers. table 2. comparison of afb1-albumin (afb1-alb) level, the male sex hormones, e2 and thyroid hormones between the two studied groups non-exposed (=40) exposed (=42) independent t-test mean sd mean sd t-test p-value afb1/alb ng/g 0.04 0.01 0.06 0.02 4.658 p< 0.001 lh (3-12miu/ml) 5.763 .1469 7.542 .3271 4.960 p< 0.001 fsh (2-10miu/ml) 6.442 .2644 30.542 3.9841 6.036 p< 0.001 testosterone (0.083 – 16ng/ml) 5.5268 .19092 4.0593 .47891 2.846 p= 0.006 17β-estradiol e2 (11.2-43.2pg/ml) 29.6789 1.96325 31.8016 2.70151 0.636 0.527 ft4 (0.93-1.7ng/dl) 1.33 0.17 1.32 0.22 1.52 0.880 ft3 (2-4.4pg/ml) 2.75 0.36 2.92 0.60 1.51 0.135 tsh (0.5-8.9uiu/ml) 1.89 0.55 2.11 0.67 1.59 0.117 beshir s, shaheen w, saad-hussein a, saeed y. aflatoxin b1 as an endocrine disruptor among miller flour workers (original article). seejph 2020, posted: 04 may 2020. doi: 10.4119/seejph-3441 p a g e 7 | 12 afb1-albumin (afb1-alb), lh= luteinizing hormone, fsh= follicle stimulating hormone, e2 =17β-estradiol, ft4= free thyroxin, ft3= free triiodothyronine, tsh= thyroid stimulating hormone. table 3. relation between exposure duration, aflatoxin в1 and studied hormones among the exposed workers exposure duration afb1/alb lh fsh testosterone e2 exposure duration r= 0.2 -.121 -.053 .200 .060 lh r= -.121 0.3* .779** -.322* -.067 fsh r= -.053 0.1 .779** -.294 -.110 testosterone r= .200 -0.1 -.322* -.294 -.051 e2 r= .060 -0.03 -.067 -.110 -.051 ft4 r= -.336* -0.3* .073 .097 -.020 .163 ft3 r= -.066 -0.3* .096 .004 -.050 .088 tsh r= -.063 -0.01 -.507** -.334* .342* -.161 ** p<0.01, * p<0.05, r= pearson's correlation;afb1-albumin (afb1-alb), lh= luteinizing hormone, fsh= follicle stimulating hormone, e2 =17β-estradiol, ft4= free thyroxine, ft3= free triiodothyronine, tsh= thyroid stimulating hormone. table 4. distribution of sexual disorders among the studied groups sexual symptoms non-exposed (40) exposed (42) chi-square number % number % p-value decreased libido 3 7.5 10 23.8 0.04 * impotence 5 12.5 12 28.6 0.07 premature ejaculation) 7 17.5 17 40.5 0.02* infertility 2 5 3 7.1 0.6 * p<0.05. discussion in the present study, sampling of airborne fungi revealed that aspergillus flavus & penicillum were the predominant fungal types in the flour mill. indoor/outdoor ratios for aspergillus flavus were ≥ 1 in all the locations indicating presence of indoor sources. serum afb1/alb, lh and fsh, existence of various sexual disorders (decreased libido, impotence and premature ejaculation) were higher while testosterone was lower in the miller flour workers compared to non-exposed. however, there was no significant difference regarding 17-beta-estradiol e2 and thyroid hormone levels between both studied groups. beshir s, shaheen w, saad-hussein a, saeed y. aflatoxin b1 as an endocrine disruptor among miller flour workers (original article). seejph 2020, posted: 04 may 2020. doi: 10.4119/seejph-3441 p a g e 8 | 12 afb1/alb is significantly positively correlated with lh and negatively correlated with ft4 & ft3. ft4 is significantly negatively correlated with the duration of exposure. the results in the present study agree with awad study (21) which found that aspergillus and penicillium were the dominant airborne fungi in flourmill buildings. the concentrations of aspergillus flavus inside the different flour mill units exceeded outdoor ones. the dominance of aspergillus flavus is an indication of inadequate storage conditions and high water content of grains (21). contamination of different grains by aspergillus niger, aspergillus flavus and fusariumoxysporium occurred due to poor environmental conditions during pre and postharvest of grains (22). in the present study, indoor/outdoor (i/o) ratios of penicillium, aspergillus niger and other aspergillus species almost did not exceed 1, meaning that outdoor was the main source. however, i/o ratio of aspergillus flavus exceeded 1, reached 17.83 (in grinding) indicating the presence of inside generative sources (23). afb1, have great effect on the endocrine glands and reproductive system both in humans and in experimental animals. however, literature on the effect of aflatoxin on human reproduction is scarce (24). serum afb1-albadduct level was significantly higher among the miller flour workers compared to the non-exposed in the present study. afb1-alb level detection in serum is a reliable indicator of long-term exposure to aflatoxin (25). so, the rise of afb1-alb level among the workers could be attributed to their occupational exposure to relatively high concentrations of aspergillus flavus through inhalation by handling flour dust which represents an additional exposure risk to those subjects than the general population, which was confirmed by the high i/o ratio of aspergillus flavus. the present study showed decreased serum testosterone and increased serum level of fsh and lh among the miller flour workers compared to the non-exposed. moreover, there is positive correlation between lh &afb1/alb in the exposed group. these findings may be due to increase level of afb1-alb among the exposed workers than the non-exposed, which could be due to the high concentration of aspergillus flavus in the air environment of the flour mill in the present study. previous studies (26,27) showed that concentrations of serum fsh, lh and testosterone were reduced in afb1 treated rats. another study (28) found similar results in male chicken fed on different concentrations of dietary aflatoxin. results showed decreased serum testosterone levels and lh in the aflatoxin treated groups compared to the control group. another author (29) administered afb1orally in male rats for 48 days at different doses. the concentrations of serum lh and testosterone were lower, but on the other hand serum fsh was higher in the treated groups. after the administration of different doses of afb1, the concentration of serum testosterone was significantly reduced, in a dosedependent manner in rabbit (30); in japanese breed quails (31); in white leghorn male chicken (32) and in goats (33). the diversity of results of various experimental animal studies could be due to species variances or due to difference in route of exposure, potency or the dose of afb1and the duration of exposure. in a previous study (34), the serum testosterone concentration was significantly lower while the levels of serum fsh and lh increased significantly in adult rats exposed to afb1 compared to non-exposed. these findings agreed with the results of the present study. beshir s, shaheen w, saad-hussein a, saeed y. aflatoxin b1 as an endocrine disruptor among miller flour workers (original article). seejph 2020, posted: 04 may 2020. doi: 10.4119/seejph-3441 p a g e 9 | 12 verma and his colleague (35) supported that reduced serum testosterone concentration is attributed to mitochondria dysfunction, to inhibition in protein synthesis or enzyme activity or to membrane changes of leydig cells. they added that increased level of lh along with decreased level of serum testosterone in experimental rats exposed to afb1 reflect decreased steroidogenic ability of the testes suggesting permanent changes in leydig cell function. the degenerative effect of the aflatoxin on germinal epithelium of the seminiferous tubules would breakout into sertoli cells, leading to decrease in inhibin b1 level thus reducing its inhibitory effect on secretion of fsh leading to its elevation (36). direct effect of afb1on leydig cells and sertoli cells in the testes leading to reduction of the gonadal hormones; testosterone and estradiol may be due to the action of afb1 on binding of dna to form complexes and inhibition of nucleic acid synthesis (32). in the current study, 45.2% of the exposed group versus 25% of the non-exposed group complained of sexual disorders. the distribution of different types of sexual disorders (decreased libido, impotence, premature ejaculation) was higher among the miller flour workers compared to non-exposed. this might be due to increase of (afb1-alb) level in the exposed group than in the non-exposed as some mycotoxins can act as probable endocrine disruptors and cause changes in hormone production (5) and can cause reproductive anomalies (morphological and functional gonadal dysfunction, e.g. infertility and decreased libido) (7). also, the decrease of testosterone in the exposed group might be the cause of decreased libido, and potency in this group, as testosterone is necessary to maintain male secondary sex characteristics, libido, and probably potency. thus patients with endocrine abnormalities may present with variety of symptoms, elevated levels of the gonadotropins, fsh and lh in the presence of decreased testosterone levels indicating primary testicular dysfunction (37), which agreed with the results of the present study. in the present study, although there was no significant difference between the exposed and the non-exposed groups regarding the levels of the thyroid hormones, yet, there was negative correlation between ft4 and duration of exposure, and between ft3, ft4 and afb1-alb. these findings might suggest thyroid gland affection by aflatoxin on the long run. moreover, there was a negative correlation between tsh and both lh, fsh, and positive correlation between tsh and testosterone, which means that decrease of tsh level occurred with lowering of testosterone and elevating lh & fsh levels indicating intact hypothalamo-pituitary-thyroid axis. limitation of the study information on sexual health was assessed using self-reporting which is a source of information bias. further studies are needed to be done on a larger scale. conclusion our results showed that afb1 causes alterations in the serum concentrations of the gonadotropic (fsh and lh), as well as gonadal (testosterone) hormones in the form of significant increase in the serum concentrations of lh and fsh, as well as significant decrease in testosterone levels among exposed workers. the lowered levels of testosterone with elevated levels of fsh and lh indicate intact pituitary testicular axis in afb1 exposed workers. these findings may confirm the ability of afb1as endocrine disruptor to affect human male reproductive health. that is why it is highly recommended to estimate the levels of both gonadotropic (fsh and lh) beshir s, shaheen w, saad-hussein a, saeed y. aflatoxin b1 as an endocrine disruptor among miller flour workers (original article). seejph 2020, posted: 04 may 2020. doi: 10.4119/seejph-3441 p a g e 10 | 12 hormones 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profiles of gonadotropic (fsh and lh), steroid (testosterone and 17β-estradiol) and prolactin hormones in adult male rat. iran j vet res 2011;12:332-36. 30. salem mh, kamel ki, yousef mi, hassan ga, el-nouty fd. protective role of ascorbic acid to enhance semen quality of rabbits treated with sublethal doses of aflatoxin b1. toxicology 2001;162:209-18. 31. eraslan g, akdoğan m, liman bc, kanbur m, delibaş n.effects of dietary aflatoxin and hydratesodium calcium aluminosilicate on triiodothyronine, thyroxine, thyrotrophinand testosterone levels in quails. turk j vet anim sci 2006;30:41-5. 32. bbosa gs, kitya d, lubega a, ogwal-okeng j, anokbonggo ww, kyegombe db. review of the biological and health effects of aflatoxins on body organs and body systems. aflatoxins. recent advances and future prospects 2013;12:239-65. 33. ewuola eo, jimoh oa, bello ad, bolarinwa ao. testicular biochemicals, sperm reserves and daily sperm production of west african dwarf beshir s, shaheen w, saad-hussein a, saeed y. aflatoxin b1 as an endocrine disruptor among miller flour workers (original article). seejph 2020, posted: 04 may 2020. doi: 10.4119/seejph-3441 p a g e 12 | 12 © 2020 beshir; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. . 2 bucks fed varied levels of dietaryaflatoxin. animreprod sci 2014;148:182-7. 34. supriya c, reddy ps. prenatal exposure to aflatoxin b1: developmental, behavioral and reproductive alterations in male rats. sci nat 2015;102:26. 35. verma rj, nair a. effect of aflatoxins on testicular steroidogenesis and amelioration by vitamin e. food chem toxicol 2002;40:669-72. 36. jensen tk, andersson am, jørgensen n, andersen ag, carlsen e, skakkebæk ne.body mass index in relation to semen quality and reproductive hormones among 1,558 danish men. fertil steril 2004;82:863-70. 37. beshir s, ibrahim ks, shaheen w, shahyem. hormonal perturbations in occupationally exposed nickel workers.open access maced j med sci2016;4:307-11. ___________________________________________________________ norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 1 original research geophagia: a cultural-nutrition health-seeking behaviour with no redeeming psycho-social qualities ishmael d. norman 1 , fred n. binka 2 , anthony h. godi 3 1 institute for security, disaster and emergency studies; 2 university of health and allied sciences, ho, vr, ghana; 3 department of biostatistics, school of public health, university of ghana, legon, accra, ghana. corresponding author: dr. ishmael d. norman, president and ceo, institute for security, disaster and emergency studies; address: sandpiper place no: 54/55, langma, cr, cantonments, accra, ghana; telephone: +233243201410; email: ishmael_norman@yahoo.com mailto:ishmael_norman@yahoo.com norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 2 abstract aim: we investigated if geophagia is restricted to only pregnant and lactating women in ghana. we also investigated if the key driver of geophagia is poverty and other sociocultural factors. methods: this analysis was part of a broader national study of resilience among the population of ghana (n=2,000). regional comparisons were made possible due to the stratified and random selection of representations that were similar in characteristics such as being urban or rural, ethnicity, religion and gender. results: it was found that geophagia was present among both females and males and was not restricted to pregnant and lactating women. geophagia was not driven by poverty or the lack of formal education or the presence of gainful employment. geophagia was practiced by both urban and rural residents irrespective of religious proclivities and devotion. the assertion that geophagia was an instinctive primordial response to gastro-intestinal disturbances was not sustained by the data in this study, although the literature review suggested such in calves and lambs. conclusion: in order to address the potential health threats posed by geophagia, the key cultural drivers need to be studied and understood. we also need to appreciate the shocks and stresses that create such desires. it is not a case of mental illness and it cannot be concluded that geophagia is driven by a psychiatric disorder. this paper would be disseminated to inform policy in ghana and beyond. keywords: food security, geophagia, ghana, poverty, psychiatric disorder, resilience, vulnerability. conflicts of interest: none. norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 3 introduction geophagia is the deliberate ingestion of soil or non-food substances (1,2). it is also known as pica (3). there are other types of the practice including pagophagia (ice eating), or coprophagia (feces eating) (4). it is practiced in the united states of america (5,6), in germany (7), turkey and other parts of asia (8-10), and in australia among the aborigines (11), as well as eastern africa (12), west africa (13) and in southern africa (14,15). the practice is now common in many nations of the world, irrespective of economic status due to migration and subsequent transfer of culture from one part of the world to the other (13). in other literature, geophagists are considered to have a psychiatric disorder (16). there are many studies on geophagia as a cultural-nutrition health-seeking behaviour for pregnant and lactating women. it may also be an instinctive response to gastro-intestinal disturbances (14). karaoglu et al. (2010) assessed nutritional anaemia in 823 pregnant women in an east anatolian province of turkey. in that study, they found anaemia (hb <11.0 gr/dl) prevalence in 27.1% of the respondents. of the anaemic cohort, 50% were deficient in iron, with another 35% being deficient in b12 (8). in a south african study conducted on calves and lambs on farms in the barkley west, postmasburg and vryburg districts of the northern cape and northwest province of the republic of south africa, geophagia had no relationship to pregnancy or lactation. the study found that suckling calves displayed an insatiable appetite for the mn rich soil and sometimes licked iron poles, which lead to severe constipation, dehydration and even death within a relatively short time. it was found that “lesions in the liver of the subjects can be attributed to a sub-acute to chronic form of manganese poisoning” from the soil eaten by the subjects. “the calves were situated in an area known as the ghaap plateau and have superficial outcrops of manganese-rich dolomitic or carboniferous rock of the reivilo formation. the soil on the affected farms contains numerous small round-to-ovoid black-grey mn rich carboniferous concretions ca. 1-10mm in diameter” (1). abraham, davies, solomon et al., (2013:1) have informed us that: “a review of the literature clearly indicates that geophagia is not limited to any particular age group, race, sex, geographic region or time period, though today the practice is most obviously common amongst the world‟s poorer or more tribally-oriented people and is therefore extensive in the tropics.” (13). in ghana, we are also informed by other researchers of the presence of geophagists (2,17). in the case of ghana, since vermeer’s research on geophagia in the 1970’s, not much appears to have been done on the topic. in almost three decades, only one paper appears to have been published on the topic by taye and lartey in 1999, although the focus was not entirely on the prevalence and incidence of the practice in the nation. that study researched “pica practice among pregnant ghanaians with particular emphasis on infant birth-weight and maternal haemoglobin level”. again, tayie in 2004, considered “the motivational factors and health effects of pica” in a select site (14). since then, other studies have been conducted elsewhere including that of kawai et al., 2009 and also young et al., 2010 which were carried out in tanzania, east africa. the kawai study considered “geophagy (soil-eating) in relation to anaemia and helminths infection among hiv-infected pregnant women in tanzania”. young focused on the “association of pica with anaemia and gastrointestinal distress among pregnant women in zanzibar, tanzania” (5,6). these studies, however, were conducted on selected communities in tanzania and did not truly represent the entire nation. although geophagia is a cultural-nutrition habit among pregnant and lactating women in many emerging economies, it appears that this is a common phenomenon among communities in sub-sahara africa and it is not limited to pregnant women. we seek to assess and document the prevalence of geophagia in a sample of 2,000 inhabitants in the population norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 4 of ghana in all of its ten administrative regions and to attempt to isolate the cultural underpinnings of this phenomenon. we would not delve into the medical, toxicological and psychiatric inquiry of geophagia on any particular group. none of the researches referred to, concentrated on the prevalence and incidence of the practice in the nations in which those researches were conducted. due to its originality, our work would contribute immensely in understanding the practice of geophagia, at least in ghana and the sub-region. the outcome would be truly representational of the nation, and would provide the baseline data for further research. the results would be analyzed and disseminated to inform policy on nutrition, mother to child transmission of lead and other substance poisoning, mother to child transmission of helminthes and other bacteria with the proximate cause to geophagia. methods sampling we were confronted with the difficulty of knowing beforehand the communities in ghana that practice geophagia. thus, targeting only the commonly known ones was not enough in determining the prevalence nationwide. targeting only pregnant women might also give a higher prevalence rate and limit the study just to them due to the practice’s wide association to pregnancy. we decided to target women of reproductive age in order to estimate the prevalence for a wider group. we also expanded this to include men since very little is known about the practice in men, although the practice is common in the generally known sites in ghana. in the end, we targeted pregnant women, women in general and men in order to estimate the prevalence for a wider group. we assumed 20% of persons in ghana practiced geophagia based upon a pilot study conducted in ashaiman, near tema municipality, ghana. this was part of a broader study on assessing the resilience of four communities within ghana and to identify the coping mechanisms to the observed effects of climate variability. this was done by asking respondents if they had ever willingly eaten earth or clay. the proportion who answered positively was used to estimate the prevalence. this yielded a sample size of 1,710 with 90% power to detect an effect size of 30% at 5% significance level. a sample size of 2,000 gave a reasonable degree of security against the effects of decline in response and a prevalence level closer to 50%. we randomly selected one or more district, municipality or metropolitan area from each of the ten regions (18). we randomly selected one or more communities from each of that and then used the random walk method to evaluate households within each community till the quota for the region was met (19). regional comparisons were made possible due to the stratified and random selection of representations. literature review and internet search for national standards on nutrition we searched through national legislation and grey paper to identify national food and nutritional guidelines or standards to evaluate if there is a nexus to geophagia. due to the paucity of literature on the subject, we were only able to access the food and drug act, the standards board act and the national nutritional policy. we also reviewed newspaper reports on geophagia as part of the build-up for the design of the study instrument. we conducted internet searches at sites such as biomed central, national institute of health, british medical council and accessed journals papers on the topic. the documentary search on the internet was conducted using carefully designed phrases like, “geophagia, a cultural nutritional artifact,” “geophagia in ghana, benefits and risks,” “typology of geophagia, pica, pagophagia (ice eating), coprophagia (feces eating),” “cultural beliefs, red earth eating and well-being”, “incidence and prevalence of geophagia, ghana only”. we summarized the findings into their respective units, and interpreted them based upon our norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 5 skills, knowledge and specialization in public health, risk communication and health promotion. statistical analysis data was entered into microsoft excel 2007, checked for accuracy and consistency to reduce errors. this was then transferred into stata version 11.0 mp for analysis. summary statistics such as frequencies, percentages, means and standard deviations were then estimated to compare the prevalence of geophagia across the various groups and backgrounds. chi-square and fisher’s exact tests were used to assess the associations between the prevalence of geophagia and background characteristics, history and its practice as well as differences between males and females in terms of experience with the practice. significant factors from the tests of association were then used in logistic regression to estimate the relative odds of such practice. ethical approval we applied for ethical approval to conduct the study for which approval was granted by the institutional review board of the ghana health service in protocol dated ghs-erc 01/11/13. study limitations many of the papers used in this write-up were the results of research conducted on small groups of people. a key aspect of this study was to document the practice of geophagia nationwide. despite, due to limited funds, we met several operational challenges. the most difficult of such challenges was the lack of comparison between urban and rural areas for each region. urban-rural comparison was done at the national level. despite this observation, we believe that the methodology used in this study was sound. we also covered the entire ten administrative regions of ghana and believe the sample size is large enough to allow us to generalize the outcome in as far as ghana is concerned. nevertheless, in order to assess the true prevalence of geophagia in west africa, a much bigger study needs to be undertaken in the future. results overall, mean (±sd) age of study participants was 33.3±12.8 years (among individuals, who ever practiced geophagia, mean age was: 35.2±13.0 years). basic demographics of geophagists from the basic demographics of the respondents, the overall finding is that geophagia was present in both females and males; in both rich and poor; in both urban and rural residents; and in both the educated and the non-educated individuals. the practice of geophagia was the highest (21.5%) within the 50-59 year age-group and the lowest (9.8%) within the under-20 year olds and this finding was statistically significant (p<0.05). it can also be seen that the practice was more predominant among females (26.2%) and this was also highly significant (p<0.001) as shown in table 1. it is interesting to show through this data that geophagia was not restricted to females, or pregnant and lactating women, but it was also evident among males. geophagia was also practiced by persons from different socio-economic groups distinguished with respect to education, marital status, religion, and employment. ethnicity and geophagia practice among the various ethnic groups in ghana, geophagia was highest in the akan-other with a figure of 26.4% (p<0.001). the akan-other would include the indigenous inhabitants of the norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 6 brong ahafo, eastern, central and western regions of ghana. in terms of regions, the eastern region has the highest geophagists among all the other regions with 35.7% followed by the upper west region with 22.8% (p<0.001). type of residence did not have an influence on the practice of geophagy (p=0.138). wealth was not a significant factor in the practice of geophagia (p=0.082) (table 1). table 1. background of respondents and the practice of geophagia characteristic number of individuals ever practised geophagia [n (%)] p-value * age-group (years): <20 20-29 30-39 40-49 50-59 ≥60 244 697 461 377 144 72 24 (9.8) 108 (15.5) 72 (15.6) 67 (17.8) 31 (21.5) 12 (16.7) p=0.005 sex: female male 1,049 948 275 (26.2) 39 (4.1) p<0.001 marital status: never married married/cohabiting divorced/separated/widowed 840 1127 29 94 (11.2) 209 (18.5) 11 (37.9) p<0.001 religion: none christian muslim traditional african 93 1409 416 73 25 (26.9) 212 (15.1) 58 (13.9) 19 (26.0) p<0.001 education: none primary secondary tertiary 75 565 1074 282 26 (34.7) 145 (25.7) 135 (12.6) 8 (2.8) p<0.001 employment status: not employed employed 375 1619 43 (11.5) 270 (16.7) p=0.005 occupation: unskilled labour agricultural clerical/secretarial professional/managerial sales and services skilled craftsmanship 82 167 53 274 454 589 13 (15.9) 31 (18.6) 7 (13.2) 8 (2.9) 126 (27.8) 85 (14.4) p<0.001 ethnicity: akan-ashanti akan-fante akan-other ewe ga-dangbe mole-dagbani grussi/gur nzema 438 208 265 206 138 252 155 140 57 (13.0) 23 (11.1) 70 (26.4) 33 (16.0) 28 (20.3) 28 (11.1) 31 (20.0) 27 (19.3) p<0.001 norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 7 other 148 16 (10.8) type of residence: urban rural 1546 451 233 (15.1) 81 (18.0) p=0.138 current residence: <5 years 5-9 years ≥10 years 920 605 466 115 (12.5) 99 (16.4) 99 (21.2) p<0.001 current community: <5 years 5-9 years ≥10 years 366 386 1239 43 (11.8) 48 (12.4) 221 (17.84) p<0.001 wealth quintile: lowest second middle fourth highest 12 286 401 664 622 3 (25.0) 47 (16.4) 63 (15.7) 119 (17.9) 79 (12.7) p=0.082 ever had biological children: no yes 924 1071 84 (9.1) 230 (21.5) p<0.001 related to people who practice geophagia: no yes 388 1195 14 (3.6) 300 (25.1) p<0.001 total 2000 314 (15.7) * p-values from chi-square test and fisher’s exact test in cases when the expected cell frequencies were <5. although the practice was highest within those with no formal education and those engaged in sales and service providers, this was not significant in determining familiarity with geophagia, or the lack of it. we also asked whether geophagia was a commonly known phenomenon (table 2). it was found that, of the respondents who had ever practiced geophagia, 19.3% of them had heard of geophagia elsewhere and another 19.8% had witnessed this practice. history and practice of geophagia among the sexes we also considered the history and practice of geophagia. the data showed that females had started the practice at a much earlier age compared to males (p<0.001). the practice being a social conduct, many of the users learned the habit from family members and friends. cultural nutrition health-seeking behaviour the data in table 2 also seems to suggest that geophagia is a culturally sanctioned activity between relatives, husbands and wives, as well as the children. geophagia was not driven by poverty, the lack of formal education, or the presence of gainful employment. in table 2 respondents who had ever been pregnant and practiced geophagia before, provide interesting insights into the social conduct. only a small fraction of the respondents (19.3%) accepted or agreed with the notion that geophagia is practiced by only pregnant women. while 92% of the respondents stated that their desire to eat dirt is stronger when pregnant, (42%) reported that they had strong desire to eat earth even when not pregnant. we did not see any evidence that supported the notion that geophagia was an instinctive primal response to gastronorman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 8 intestinal disturbances, although in the literature review, a study conducted in the cape region of south africa among calves and lamps on a farm supported this notion (1). that study also found that when the farmer withdrew the older calves from the mn rich soil, they did not demonstrate signs of withdrawal but fed normally without the display of appetite for the mn rich soil. table 2. history and practice of geophagia by sex of survey participants history and practice number (percentage) p-value * female male total age when geophagia started: <20 years 20-29 years ≥30 years do not remember 138 (50.2) 128 (46.6) 3 (1.1) 4 (1.5) 22 (56.4) 5 (12.8) 11 (28.2) 0 160 (51.0) 133 (42.4) 14 (4.5) 4 (1.3) p<0.001 last time of eating earth: <1 month 1-12 months >1 year 103 (37.5) 55 (20.0) 114 (41.5) 7 (18.0) 4 (10.3) 26 (66.7) 110 (35.0) 59 (18.8) 140 (44.6) p<0.001 frequency of eating earth: daily weekly monthly yearly 227 (82.6) 36 (13.1) 5 (1.8) 1 (0.4) 5 (12.8) 19 (48.7) 8 (20.5) 3 (7.7) 232 (73.9) 55 (17.5) 13 (4.1) 4 (1.3) p<0.001 geophagia hidden from others: no yes 191 (69.5) 81 (29.5) 16 (41.0) 21 (53.9) 207 (65.9) 102 (32.5) p<0.001 geophagia hidden from: partner/spouse parents siblings other family friends 39 (14.2) 47 (17.1) 10 (3.6) 27 (9.8) 13 (4.7) 4 (10.3) 13 (33.3) 6 (15.4) 10 (25.6) 6 (15.4) 43 (13.7) 60 (19.1) 16 (5.1) 37 (11.8) 19 (6.1) p=0.200 learnt geophagia from: no one family friends both 60 (21.8) 139 (50.6) 53 (19.3) 3 (1.1) 1 (2.6) 36 (92.3) 1 (2.6) 0 61 (19.4) 175 (55.7) 54 (17.2) 3 (1.0) p<0.001 ever had a health problem due to geophagia: no yes 249 (90.6) 25 (9.1) 38 (97.4) 0 287 (91.4) 25 (8.0) p=0.055 desire to eat earth stronger than food sometimes: no yes 197 (71.6) 77 (28.0) 38 (97.4) 0 235 (74.8) 77 (24.5) p<0.001 desire to eat earth heightens after rain: no yes 233 (84.7) 41 (14.9) 34 (87.2) 4 (10.3) 267 (85.0) 45 (14.3) p=0.624 reason: smell 40 (14.6) 4 (10.3) 44 (14.0) p=0.676 earth collected by self: p=0.648 norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 9 no yes 261 (94.9) 10 (3.6) 36 (92.3) 2 (5.1) 297 (94.6) 12 (3.8) other usual ways of acquiring earth: buying from family from friends 249 (90.6) 8 (2.9) 3 (1.1) 20 (51.3) 15 (38.5) 0 269 (85.7) 23 (7.3) 3 (1.0) p<0.001 mode of consumption: chewed licked as a drink 215 (78.2) 58 (21.1) 0 28 (71.8) 7 (18.0) 3 (7.7) 243 (77.4) 65 (20.7) 3 (1.0) p<0.001 additives added to earth before consumption: no yes 266 (96.7) 8 (2.9) 37 (94.9) 1 (2.6) 303 (96.5) 9 (2.9) p=1.000 time of day earth is normally eaten: before meals after meals no particular time 2 (0.7) 23 (8.4) 248 (90.2) 0 1 (2.6) 37 (94.9) 2 (0.6) 24 (7.6) 285 (90.8) p=0.486 total 275 (100.0) 39 (100.0) 314 (100.0) * p-values from chi-square test and fisher’s exact test in cases when the expected cell frequencies were <5. relative odds of practising geophagia based on demographics it was also noticed that females were more likely than males to practice geophagia: or=8.28, 95%ci=5.84-11.74, p<0.001 (table 3). this was still significant at almost the same level after adjusting for the other variables in the model, i.e. after taking those other characteristics into account. among different age-groups, 50-59 year olds were most likely (2.51 times) to practice geophagia compared to the under-20 year olds. however, this was not significant after adjusting for the other variables although they were still the most likely group to do so (or=2.90, 95% ci=0.88-9.58, p=0.555). the odds were against the divorcee, widowed and separated persons who were 4.85 times more likely to find comfort in eating earth than the married, cohabiting and those who had never married; this was however not significant after adjustment. table 3. relative odds of practising geophagia based on background characteristics characteristic crude adjusted or (95% ci) p-value or (95% ci) p-value age (years): <20 20-29 30-39 40-49 50-59 ≥60 1.00 (reference) 1.68 (1.05, 2.69) 1.69 (1.03, 2.77) 1.98 (1.20, 3.26) 2.51 (1.41, 4.49) 1.83 (0.87, 3.88) p=0.005 1.00 (reference) 2.34 (0.85, 6.45) 2.32 (0.79, 6.86) 2.68 (0.89, 8.08) 3.06 (0.94, 9.94) 3.00 (0.73, 12.33) p=0.558 sex: male female 1.00 (reference) 8.28 (5.84, 11.74) p<0.001 1.00 (reference) 7.73 (4.99, 11.96) p<0.001 norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 10 marital status: never married married/cohabiting divorced/separated/widowed 1.00 (reference) 1.81 (1.39, 2.35) 4.85 (2.22, 10.58) p<0.001 1.00 (reference) 1.34 (0.88, 2.06) 1.87 (0.44, 8.03) p=0.348 religion: none christian muslim traditional african 1.00 (reference) 0.48 (0.30, 0.78) 0.44 (0.26, 0.75) 0.96 (0.48, 1.92) p<0.001 1.00 (reference) 0.59 (0.32, 1.12) 0.44 (0.23, 0.86) 0.91 (0.38, 2.20) p=0.005 education: none primary secondary tertiary 1.00 (reference) 0.65 (0.39, 1.09) 0.27 (0.16, 0.45) 0.06 (0.02, 0.13) p<0.001 1.00 (reference) 0.87 (0.44, 1.70) 0.50 (0.24, 1.03) 0.17 (0.05, 0.59) p<0.001 employment status: not employed employed 1.00 (reference) 1.54 (1.10, 2.18) p<0.001 omitted due to collinearity occupation: unskilled labour agricultural clerical/secretarial professional/managerial sales and services skilled craftsmanship 1.00 (reference) 1.21 (0.60, 2.46) 0.81 (0.30, 2.18) 0.16 (0.06, 0.40) 2.04 (1.09, 3.82) 0.90 (0.47, 1.69) p<0.001 1.00 (reference) 0.96 (0.42, 2.20) 1.08 (0.34, 3.42) 0.64 (0.20, 2.03) 1.37 (0.69, 2.75) 1.33 (0.65, 2.73) p=0.512 discussion in this study we have been able to show that geophagia was not caused by food scarcity or insecurity. even in the farming communities of ghana, particularly in western, brong ahafo, ashanti and eastern regions where the average household has access to food grown on their own farms, geophagia was practiced all year round irrespective of food availability or harvest. in order to address the potential health threats posed by geophagia, the key cultural drivers need to be studied and understood. we also need to appreciate the shocks and stresses that create such desires. but first, we need to get the scientific data right without co-mingling it with social analyses. anything short of this would prolong the debate about whether geophagia is a cultural-nutrition health-seeking behaviour, or just a mere cultural imperative without redeeming psycho-social qualities (1,15,16). from the published papers accessed in this paper, we have noticed that, part of the reasons for the debate is that it appears many of the researchers try to explain the outcome of a purely laboratory investigation of the substances involved in geophagia within the cultural context (13). at other times, they attempt to explain the outcome of their social investigation of the behaviour, such as knowledge and attitude associated with the practice, with scientifically oriented language supported by laboratory measurements and equivalencies (14,16,17). there is a mixture of purposes and, therefore, the literature on geophagia is replete with claims and counter-claims or findings by the same researchers within the same studies (3,13,21). an example of a purely scientific research which was reported as such was conducted by dreyer et al. in 2004 (21). they conducted biochemical investigations into geophagia among certain ethnic group in southern africa and concluded that eating black earth among pregnant women in southern africa may be beneficial to them and may retard norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 11 the loss of iron and other properties. they reported that: “absorbent properties for sodium of black earth, though notable, were not homoeostatically significant. intake was estimated at only 7.5% of dietary guidelines, yet the serum concentration was normal. the same applies to magnesium. this was liberated from black earth in quite large amounts, dietary intake exceeded the rda (120%) and yet the serum concentration again was normal. intake of calcium was below the rda (43.5%), while the serum concentration was normal. possibly, the calcium liberated from black earth actually functioned as a dietary supplement.” on the basis of the outcome of their study, dreyer cautioned that before attributing adverse or beneficial outcomes to geophagia, the ion-exchange capacity of the substance in question should be evaluated. dreyer et al. did not attempt to extend their findings to any other issue except what they investigated. however, neser, de vries, et al. (2000) also conducted a purely scientific inquiry into „enzootic geophagia of calves and lambs‟ in the cape region of south africa and concluded among other laboratory findings that: “the cause of geophagia may not be completely understood”. the inquiry was not a cause-effect study (1). woymodt and kiss (2002:143) took the historical approach to understand the practice. in their review of the history of geophagia, they suggested that geophagia was an artifact of poverty, that “where poverty and famine are implicated, earth may serve as an appetite suppressant and filler” (3). that is to say, geophagia was an aspect of resilient building or adaptive capacity against food insecurity and food scarcity (16). although woymodt and kiss had previously maintained that geophagia was associated with poverty, they made immediate reversal of opinion that “geophagia is often observed in the absence of hunger”, but that it is “environmentally and culturally driven” (3). in the conclusion of their paper, they reversed themselves again that “the re-emergency of geophagia might be triggered by famine, cultural-change and psychiatric diseases”. to underscore geophagia as a psychiatric disease, woymodt and kiss quote from gabriel garcia marquez’s „one hundred years of solitude‟, in which one of the novel heroines: ‘rebecca got up in the middle of the night and ate handfuls of dirt in the garden with a suicidal drive, weeping with pain and fury, chewing tender earthworms and chipping her tooth on snail shells‟. researchers accorded and inured geophagia with neurosis or psychiatric disorder as exemplified in the apparently hysterical manner the apparently already crazy rebecca was „chewing tender earthworms and chipping her tooth on snail shells‟ (20). even though she was in pain, rebecca continued to chew the dirt, perhaps due to her apparent pre-existing mental disorder. such conclusions were reached in other scientific publications long before the cultural dimensions of the practice were subjected to empirical investigations (17). granted, rebecca is a fictitious character created out of a fertile, probably, male-centric mind (16,20). despite this statement, the thought that geophagia is a primal response to psychosomatic episode lingers on. for researchers to conclude that geophagia is a psychiatric disorder there has to be empirical studies to confirm this suspicion. without a contextual and clinical evaluation of a particular geophagist, it cannot be said that geophagia is driven by a psychiatric disorder. it appears the outcome reported in this study, debunks the thinking that geophagia is a sign of psychiatric condition. conclusion in this study, we have provided evidence that geophagia is not restricted to pregnant and lactating women and that it is a general practice among certain groups of people in ghana, west africa. we have proffered that, at least in ghana, geophagia is a cultural-nutritional, health-seeking behaviour. it is not a conduct which is practiced because of famine or food insecurity, but because of the utilitarian value derived from it. there is also no study on the norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 12 phenomenon on this level that has been published on ghana. therefore, this study brings to light all the findings associated with the practice of geophagia. in order not to confuse good laboratory investigation with the cultural impetus that drives the practice of geophagia, researchers of this behaviour need to focus their research questions on specific issues of the conduct. where there is comingling of cultural analyses with laboratory results, a great deal of confusion may be created, which may lead to the wrong inferences or interventions if need be. references 1. neser ja, de vries ma, de vries m, van der merwe aj, loock ah, smith hjc, van der vyver fh and elsenbrock jh. enzootic geophagia of calves and lambs in northern cape and northwest and the possible role of chronic manganese poisoning. s afr j anim sci 2000;30:105-6. 2. tayie f. pica: motivating factors and health issues. afr j food agr nut dev 2004; vol. 4, no.1. 3. woywodt a, kiss a. geophagia: the history of earth-eating. j r soc med 2002;95:143-6. 4. griffiths, m. international gaming research unit, nottingham trent university, nottingham, uk: http://en.wikipedia.org/wiki/geophagy (accessed: february 7, 2015). 5. kawai k, saathoff e, antelmam g, masamanga g, fawzi ww. geophagy (soileating) in relation to anemia and helminths infection among hiv-infected pregnant women in tanzania. am j trop med hyg 2009;80:36-43. 6. young sl, khalfan ss, farag th, kavle ja, ali sm, hajji h, et al. association of pica with anemia and gastrointestinal distress among pregnant women in zanzibar, tanzania. am j trop med hyg 2010;83:144-51. 7. menge h, lang a, cuntze h. pica in germany: amylophagia-associated iron deficiency anemia. j gastroenterol 1998;36:635-40. 8. karaoglu l, pehlivan e, egri m, deprem c, gunes g, genc mf, temel i. the prevalence of nutritional anemia in pregnancy in an east anatolian province, turkey. bmc public health 2010;10:329. doi: 10.1186/1471-2458-10-329 9. arcasoy a, cavdar ao, babacan e. decreased iron and zinc absorption in turkish children with iron deficiency and geophagia. acta haematol 1978;60:76-84. 10. ashworth m, hirdes jp, martin l. the social and recreational characteristics of adults with intellectual disability and pica living in institutions. res dev disabil 2008;30:512-20. 11. beteson em, lebroy t. clay eating by the aboriginals of the northern territory. med j aust 1978;1:51-3. 12. geissler pw, shulman ce, prince rj, mutemi w, mzani c, friis h, lowe b. geophagy, iron status and anaemia among pregnant women on the coast of kenya. trans r soc trop med hyg 1998;92: 549-53. 13. abrahams pw, davies tc, solomon ao, trow aj, wragg j. human geophagia, calabash chalk and undongo: mineral element nutritional implications. plos one 2013;8:e53304. doi: 10.1371/journal.pone.0053304 14. tayie fak, lartey a. pica practice among pregnant ghanaians: relationship with infant birth-weight and maternal haemoglobin level. ghan med j 1999;33:67-76. 15. kreulen da, jager t. herbivore nutrition in the tropics and subtropics. the science press: craighall; 1984; p. 204-221. norman id, binka fn, godi ah. geophagia: a cultural-nutrition health seeking behaviour with no redeeming psycho-social qualities (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph2014-38 13 16. bisi-johnson ma, obi cl, ekosse ge. microbiological and health related perspectives of geophagia: an overview. afr j biotech 2010;9:5784-91. doi: 10.5897/ajb09.018. 17. vermeer de. geophagy among the ewe of ghana. ethnology 1971;10:56-72. 18. davis rh, valadez jj. improving the collection of knowledge, attitude and practice data with community surveys: a comparison of two second-stage sampling methods. health policy plan 2014;29:1054-60. doi: 10.1093/heapol/czt088. 19. milligan p, njie a, bennett s. comparison of two cluster sampling methods for health surveys in developing countries. int j epidemiol 2004;33:469-76. doi: 10.1093/ije/dyh096. 20. gabriel garcia marquez. one hundred years of solitude. translated by gregory rabassa, harper-collins publishers, ny; 1967. 21. dreyer mt, chaushev pg, gledhil rf. biochemical investigations in geophagia. j roy soc med 2004;97:48-53. ___________________________________________________________ © 2015 norman et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed/?term=davis%20rh%5bauthor%5d&cauthor=true&cauthor_uid=24281698 http://www.ncbi.nlm.nih.gov/pubmed/?term=valadez%20jj%5bauthor%5d&cauthor=true&cauthor_uid=24281698 ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 1 | 16 original research women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 agima ljaljevic1, helmut wenzel2, ulrich laaser3 1 university of podgorica, montenegro; 2 freelance consultant, konstanz, germany; 3 faculty of medicine, belgrade, serbia. corresponding author: prof. dr. med. ulrich laaser, section of international health, faculty of health sciences, bielefeld university, bielefeld, germany; address: pob 10 01 31, d-33501 bielefeld, germany; e-mail: ulrich.laaser@uni-bielefeld.de. ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 2 | 16 abstract aim: montenegrin government is increasingly aware of the key role of women in the society and attempts to improve social cohesion among montenegrin people. precondition is a high degree of life satisfaction and happiness. methods: we used the multiple indicator cluster survey (mics) of 2018 to analyse the distribution and interaction of 22 potential determinants out of 383 variables available. the participation rate was 77.7 or 2,276 women aged 15-49 years out of 2,928 invited. as data quality turned out to be limited, we employed a data mining approach, i.e. an interactive classification and regression tree (c&rt). happiness was measured ranging from very happy to very unhappy on a categorical scale of 5 steps results: of all montenegrin women 70.7% declared themselves as very happy. likewise, a 10point scale of life satisfaction classifies 82.0% of the sample in the top ranks 8-10. furthermore, 73.6% of the women expect the next year to be even better. wealth, younger age, and marriage or living in union determine the status of happiness. conclusion: women in montenegro exhibit a high degree of self-reported happiness and life satisfaction. montenegrin policies should continue to support the role of women in the society. keywords: happiness, life satisfaction, mics, montenegro, women. conflicts of interest: none declared. ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 3 | 16 introduction building up its own institutions and services, montenegro is striving to advance human capital development and increase internationalization and visibility (1). during the last years, montenegrin government became increasingly aware that the role of women in the society has to get priority in order to develop successful strategies to improve the social cohesion in the montenegrin society (2). inclined to diener et al., (3) a positive social web may have three components, happiness related to moods, but frequently a consequence of life satisfaction (evaluative happiness (4)) or in other words subjective (and objective) success in life including social acknowledgement, and well-being as a consequence of both (5) and feeling secure as related to the social environment. we prefer to follow this use of the terminology although some authors understand happiness and life satisfaction as synonyms (6). others make a clear distinction (7,8). for nemati et al. (9) life satisfaction is a factor that influences both happiness and resilience. resilience on its part has an influence on happiness. determinants that possibly contribute to happiness according to e.g. galletta (10) or graham (11) are mostly seen in the categories of socio-demography, location of birth/residence, and wealth (12). as montenegro is a small country of less than one million inhabitants and limited resources, the last multiple indicator cluster survey, executed by the statistical office of montenegro (13) provides a good opportunity to interpret the information available regarding the position and role of women in the montenegrin society. our paper therefore tries to identify politically meaningful determinants of “happiness” and “life satisfaction” of the female population which would allow the government to further improve their stabilising role in the montenegrin society. methods the database of the multiple indicator cluster survey montenegro in (mics) (13) includes the file ‘wm.sav’ referring to 2018 with 2,928 women 15-49 years of age. the response rate was 77.7% or 2.276 women who participated in the highly standardized interview employed, 99.8% of the interviews executed from october to december 2018. however, in the protocols of the interviews several variables show a very high rate of non-response and therefore had to be eliminated from further consideration (we decided on a minimum response level of >=50% for a variable to be included). from the 383 variables available in the data file n = 22, listed in table 1, part i remained as relevant to have a potential impact on “happiness” respectively “life satisfaction” in other words are of “cultural relevance” and have a sufficiently high response rate. the 4 variables referring to happiness and life satisfaction (together understood as well-being) are listed in table 1, part ii. because of their high potential relevance we employed for two variables with a relatively high percentage of missing values (m7 married or lived with a man once or more than once and wagem age at first marriage/union of woman) a md imputation using a k-nn approach (14) to estimate missing values. the k-nearest neighbours is an algorithm that is used for simple classification. the algorithm uses ‘feature similarity’ to predict the values of any new data points. this means that the new point is assigned a value based on how closely it resembles the points in the training set (15). several other indicators of high interest as for example “age at ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 4 | 16 first sexual intercourse” could not be used, either because of an identified non-response rate of mostly >80% or because of a monocategorical formulation of the interview question (a complete table with all variables considered including those eliminated is attached as annex). nevertheless, the 26 variables selected in table 1 cover the categories mentioned above but their quality does not fully satisfy the suitability requirements for further statistical processing like multiple regression techniques. therefore, we employ a data mining approach, i.e. an interactive classification and regression tree (ic&rt) (14). this tree allows to analyse what-if-scenarios either by automatic splitting or manually according to specific research questions. in 1984 breiman (16) used a c&rt algorithm to identify high-risk patients, today it is also used to identify specific customers. the result of the analysis is then shown as a tree. at the various levels and nodes of the tree selected variables are used to split the data pool. a c&rt approach uses automatic (algorithmic) methods, user-defined rules and criteria specified with the help of a highly interactive graphical user interface (brushing tools). with this approach it is possible to provide an interactive environment for building classification or regression trees (via classic c&rt methods or a chi-square automatic interaction detector (chaid)) to enable users to try various predictors and split criteria. this allows to bring in expert knowledge of the researchers, instead of following only an automatic procedure. to evaluate the quality or appropriateness of the classification outcomes, several tools can be applied (14,15). table 1. selection of the 26 most relevant variables from the mics database (unicef 2019) having a sufficiently high response rate, at least bi-categorical answers, and missing values below 50% (full list in annex) part i: potential determinants of happiness and life satisfaction line numbers variable code long name variable format missing values 11 wm6m month of interview 2019 cat. none 30 wb4 age of woman quant. 22.26% missing values 32 wb6a highest level of school attended cat. 23.4% missing values 42 wb15 duration of living in current place quant. 22.26% missing values 45 cm1 ever given birth cat. 22.27% missing values 46 cm2 any sons or daughters living with you cat. 45.28% missing values 49 cm5 any sons or daughters not living with you cat. 45.29% missing values 191 cp3 ever used a method to avoid pregnancy cat. 34.4% missing values 229 un17 availability of private place for washing during last menstrual period cat. 26.33% missing values 234 dv1c if she argues with husband: wife beating justified cat. 22.26% missing values ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 5 | 16 235 dv1d if she refuses sex with husband: wife beating justified cat. 22.26% missing values 236 dv1e if she burns the food: wife beating justified cat. 22.27% missing values 259 vt20 feeling safe walking alone in neighbourhood after dark cat. 22.27% missing values 260 vt21 feeling safe at home alone after dark cat. 22.27% missing values 268 ma1 currently married or living with a man cat. 22.27% missing values 272 ma7 married or lived with a man once or more than once cat. 42.69% missing values 294 ha1 ever heard of hiv or aids cat. 22.27% missing values 325 ha31 children living with hiv should be allowed to attend school with other children cat. 26.47% missing values 331 ia1 do any vaccines cause serious adverse reactions after vaccination cat. 22.27% missing values 351 wage age-class 15-19, 20-24… quant. & cat. 22.27% missing values 353 wagem age at first marriage/union of woman quant. 42.69% missing values 369 hh7 region cat. none 373 windex10 wealth index decile quant. & cat. mixture of category and numbers part ii: happiness and life satisfaction 345 ls1-cat estimation of overall happiness quant. & cat. 22.27% missing values/ no response as category 346 ls2 satisfaction with ladder step quant. & cat. 22.27% missing values / no response as category 347 ls3 life satisfaction in comparison with last year cat. 22.27% missing values / no response as category 348 ls4 life satisfaction expectation one year from now cat. 22.27% missing values / no response as category results the descriptive table 2 shows the distribution of the selected variables potentially determining happiness and life satisfaction. with the exception of variables 5, 6, 9, 16, and 18 in table 2, missing values count for <800 or <27.3% out of a grand total of n = 2.928. variable 3 covering the ‘highest level of school attended’ points to a relatively well educated population with 55.1% having attended the secondary level and 33.1% levels higher than that, together 88.2%. this corresponds to a stable population where only 23.6% live at the present location for less than 15 years (variable 4); likewise, 98.1% indicate children living in the same household (variable 5), however, with a high number of missing answers, presumably being due to a large part of women without children as 29.6% indicate to have never given birth (variable 8). households seem to be well established as almost all women (97.7%) indicate that they have a private place for washing during the last menstrual period (variable 7). for a relatively traditional society speaks that 87.9% deny or may be too reluctant to admit to have used birth control methods ever (variable 9). however, if it comes to violence in the family the position is very clear: more than 98.4%% of females do not accept ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 6 | 16 to be beaten by the husband (variables 10, 11 and 12). although only 39.2% live in rural areas (variable 13) 86.0% feel safe walking alone in the neighbourhood after dark (variable 14) and 94.7% feel safe alone at home (variable 15). in 64.4% age at first marriage is between 15 and 25 years of age (variable 16) and 69.3% are currently married or live with a man (variable 17); almost all (96.1%) live in marriage or union only once (variable 18). almost all (variable 19) have heard of hiv/aids (95.0%), however, regarding the question, whether children with hiv should be allowed to attend school (variable 20) 32.7% say “no”. likewise, the opinion about vaccines (variable 21) is somewhat divided as 19.8% believe that vaccines could cause serious adverse reactions. the wealth index potentially of considerable impact – distributes quite evenly throughout the montenegrin population (variable 22). table 2. distribution of the variables listed in table 1, part i (n=22) name of variable and categories* number percentage missing women 15-49, grand total 2.928 1) month of interview 2019 (wm6m) january 5 0.2 october 1212 41.4 november 1219 41.6 december 492 16.8 2928 100.0 none 2) age (wb4) 15-24 501 22.0 25-34 769 33.8 35-49 1,006 44.2 15-49 2276 100.0 652 3) schooling (wb6a) primary 264 11.8 secondary 1,235 55.1 higher 743 33.1 2.242 100.0 686 4) residence (wb15) since birth 1.370 60.2 >15 years 370 16.3 <15 years 536 23.6 2.276 100.0 652 5) children who are living with you (cm2) yes 1.572 98.1 no 30 1.9 1.602 100.0 1326 6) children who are not living with you (cm5) yes 170 10.6 no 1,432 89.4 1,602 100.0 1326 7) private place for washing (un17) yes 2,102 97.7 no 50 2.3 ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 7 | 16 2,152 100.0 776 8) ever given birth (cm1) yes 1,602 70.4 no 674 29.6 2,276 100.0 652 9) ever used birth control methods(cp3) yes 230 12.1 no 1.675 87.9 1.905 100.0 1.023 10) beating by husband justified if she refuses sex (dv1d) yes 21 0.9 no 2.232 99.1 2.253 100.0 675 11) beating by husband justified if she burns food (dv1e) yes 20 0.9 no 2,239 99.1 2,259 100.0 669 12) beating by husband justified if she argues(dv1c) yes 37 1.6 no 2,210 98.4 2,928 100.0 681 13) area living (hh7) urban 1779 60.8 rural 1149 39.2 2,928 100.0 0 14) feeling safe walking alone (vt20) yes 1.952 86.0 no 319 14.0 2.271 100.0 657 15) feeling safe at home alone (vt20) very safe 1,123 49.9 safe 1,008 44.8 unsafe 119 5.3 2,250 100.0 678 16) age at first marriage (wagem) 10-14 21 1.3 15-24 1.081 64.4 25-34 527 31.4 35-49 49 2.9 1.678 100.0 1.250 17) currently married or living with a man (ma1) yes 1.575 69.3 no 699 30.7 2.274 100.0 654 18) married or lived in union (ma7) only once 1,623 96.9 more than once 52 3.1 1,675 100.0 1,250 19) ever heard of hiv/aids (ha1) yes 2153 95.0 no 114 5.0 2267 100,0 661 ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 8 | 16 20) children with hiv should attend school (ha31) yes 978 45.9 no 698 32.7 depends 457 21.4 2.133 100.0 795 21) vaccines cause serious adverse reactions (ia1) yes 449 19.8 no 1.360 60.0 no opinion 456 20.1 2.265 100.0 663 22) wealth index deciles (windex10) 1. decile 199 8.7 2. decile 217 9.6 3. decile 240 10.5 4. decile 218 9.6 5. decile 237 10.4 6. decile 235 10.3 7. decile 237 10.4 8. decile 262 11.5 9. decile 225 9.9 10. decile 206 9.1 2.276 100.0 652 * names of variables abbreviated, codes in brackets. life satisfaction was asked with a retrospective and a prospective projection of one year. life satisfaction relates to criteria like ranking according to income and social status whereas happiness has an emotional connotation. table 3 classifies life satisfaction in the upper third of a 10-point scale (ranks 8, 9, and 10) with n = 1.773 or 82.0%. however, with regard to the foregoing year only 46.8% or 1062 women consider it as better than the present one but on the other hand even 73.6% expect that regarding the next year. table 3. frequency distribution of life satisfaction (ls2-4) present levels number percentage 0-4 34 1.2 5-7 463 16.8 8-10 (highest) 1.773 82.0 total 2.270 100,0 levels last year worse 82 3.6 about the same 1.124 49.6 better 1.062 46.8 total 2.268 100.0 levels next year worse 14 0.6 about the same 580 25.8 better 1656 73.6 total 2250 100.0 ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 9 | 16 happiness was measured in the survey on a categorical scale with 5 steps (variable ranging from very happy to very unhappy). the interviewers asked to tick the appropriate category in the questionnaire. according to the data in table 4, 96.7% of females 15-49 in montenegro are very or somewhat happy. table 4. frequency distribution of happiness (ls1) categories number percentage very happy 1609 70.7 somewhat happy 592 26.0 neither nor 57 2.5 somewhat unhappy 10 0.4 very unhappy 3 0.1 no response 5 0.2 total 2276 100.0 the result of the c&rt analysis of likely determinants of happiness is shown in figure 1 below. from this tree we can induce general rules to predict who is likely to be very happy. the splitting process creates three levels of splitting. at each level the starting pool of the survey population is divided by predictors, i.e., variables that allow to break down the rating of happiness by expected variables of influence. at the first level 70.7% of the interviewed women according to their answers are very happy and 26.1% are somewhat happy. these figures seem to be relatively high, but change when breaking down the numbers by splitting variables. the 2,276 interviewees are split first according to their level of wealth. this level of wealth (windex10) groups the interviewees into deciles. in the tree 893 women belong to the category of lower wealth. for splitting the following categories of lower wealth were used according to their relevance in this specific population: 2nd, 5th, 3rd and 1st deciles. the variable level of wealth contributes most to the grouping of the interviewees; nevertheless, the remaining variables were also taken into account, but with less importance. in this group of lower wealth 61.3% are very happy and 32.9% somewhat happy. in the richer category with 1,383 women, 76.8% are very happy and 21.6% somewhat happy. if one splits then the group of lower wealth further by the age of women (wb4), from the 582 women in the age of 38 or younger 67.0% are very happy and 28.4% are somewhat happy, whereas in the group of 311 women that are older than 38 years 50.5% are very happy and 41.5% are somewhat happy. to characterise the better off group of 1,383 women, which is according to relevance described by 6th, 4th, 9th, 10th, 7th and 8th wealth deciles, the software splits it according to marital status respectively living in union: 383 women not living in union 66.8% are very happy. they split according to age into 200 women <=24 (74.5% very happy) and 183 women >24 (58.5% very happy). of those 1,000 women living in union 80.6% are very happy. they split into 144 women of (relatively) lower wealth 70.1% of them being very happy and into 856 of higher wealth and 82.4% of them very happy. ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 10 | 16 figure 1. c&rt graphic of selected variables with impact upon happiness* tree graph for ls1_cat num. of non-terminal nodes: 5, num. of terminal nodes: 6 model: c&rt id=1 n=2276 very happy 70.69% id=2 n=893 very happy 61.25% id=3 n=1383 very happy 76.79% id=6 n=383 very happy 66.84% id=7 n=1000 very happy 80.60% id=4 n=582 very happy 67.01% id=5 n=311 very happy 50.48% id=8 n=200 very happy 74.5% id=9 n=183 very happy 58.47% id=16 n=144 very happy 70.14% id=17 n=856 very happy 82.36% w index10 lower wealth higher wealth age <= 38 > 38 marital status = not in union = in union age <= 24 > 24 windex10 = lower wealth (1) = higher wealth (1) very happy somewhat happy neither happy nor unhappy somewhat unhappy no response very unhappy * for the variables m7 (‘in marriage or union once or more’) and wage (‘age at first marriage/union’) the missing values have been estimated (tibco software inc. 2017). discussion the strength of this study is the fact that it is one of the very first which tries to make use of the available data and analyses how women in montenegro think about their life. the optimistic view of the future, i.e. the expectation to be even happier next year, underlines that positive feelings dominate in the montenegrin culture. the c&rt analysis shows for montenegro that in all sub-groupings the category “very happy” dominates with percentages between 55.5 and 82.4% in any of the subgroups, bypassing e.g. the global spectrum between north america with 49% being very happy at the upper end and sub-saharan africa at the lower end with only 7% (4). hart et al. (17) found positive relations between happiness and the areas of living as well as social relations, determinants which are not dominant in our study, partly because not sufficiently covered in the mics dataset. this is a drawback of many studies in that the focus on individual-level strategies leaves out contextual factors. ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 11 | 16 the c&art analysis we employed identifies only 3 predictors (or splitting variables) as most important, namely wealth, living in union, and age. education, residence or the experience of violence and discrimination seem to have a lower impact on the dominant feeling of being happy or at least somewhat happy. this is supported by the equally prevalent indication of high satisfaction with life, reaching 82.0% at present, 76.6% expecting even higher levels next year. the high level of well-being in montenegro may be plausible looking at available data at national level and compare montenegro with the neighbouring countries: its national gdp reached with 21,470 usd ppp in 2019 the highest level whereas e.g. serbia ranges lowest with 18,233 usd ppp (18). likewise, female life expectancy in 1919 reaches in montenegro 79.3 years vs. serbia with 78.4 years and north macedonia in between with 78.8 years. last but not least, in montenegro 49.9% of females share the labour force as compared to serbia with 47.1 and north macedonia with 44.9%. taken together this seems to support the relatively high level of happiness and life satisfaction. another variable, not included in the c&art analysis because of the high number of missing values (45.3%), is the fact that 98.1% answer that they live together with their children in the same household, which indicates a healthy social family context. upbringing and parenting may define to a large degree later happiness and satisfaction with life (19). this would support the montenegrin policy to advance the societal status and role of women to strengthen social cohesion in the montenegrin society. however, we did not include in our analysis the perceived service quality of maternal care, available as antenatal care, delivery assistance and postnatal care as it would be relevant only for a smaller group of women. yet, it would be interesting to relate our results to the mortality patterns in montenegro as the impact of a reduced health status and of death on happiness has been looked at (20) but especially the reverse relationship lacks sufficient consideration. the british million women study (21) analysed both options but did not find an impact of happiness on mortality. the difficulties of research in this field are well analysed by viswanath et al. (22) pointing especially to the lack of a well-acknowledged definition of happiness. limitations of our study are in the first place the varying and for several variables very high number of missing information which led to their exclusion from the analysis. secondly, answers may be more positive than is true because of traditional elements in the montenegrin culture which lead women to hide weaknesses as others do not need to recognize them. on the other hand, the scales from 1-10 used in the survey are closed at both ends although personal experience may go far below or beyond. likewise, it is not clear how reliable is the information about wealth, especially as women often do not oversee all incomes created by their husband and facilities/household equipment as used in the survey may not correspond to the actual wealth. finally, to get the full picture a retrospective analysis as well as a comparative study in the region of south eastern europe should follow also including similar analyses of other family members i.e. fathers and children. conclusion montenegrin policies support the societal role of the family and of women in general. this analysis indicates a high degree of happiness and life satisfaction in montenegro also of women at older age, not living in marital union, and at lower levels of wealth. ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 12 | 16 montenegrin policies should continue to support the role of women in the society. references 1. united nations development programme (undp). national human development report: people are the greatest wealth of a country. how rich is montenegro? 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mortality? the prospective uk million women study. lancet 2016;387:874-81. available from: https://doi.org/10.1016/s01406736(15)01087-9 (accessed: november 15, 2020). 22. viswanath k, kubzansky ld. the science of happiness: the view from one research center. am j health promot 2019;33:1210-11. available from: https://doi.org/ 10.1177/0890117119878277b (accessed: november 15, 2020) __________________________________________________________________________ https://onlinelibrary.wiley.com/action/dosearch?contribauthorstored=ferrer-i-carbonell%2c+ada https://onlinelibrary.wiley.com/action/dosearch?contribauthorstored=frijters%2c+paul https://doi.org/10.1111/j.1468-0297.2004.00235.x https://doi.org/10.1111/j.1468-0297.2004.00235.x http://mics.unicef.org/surveys https://www.tibco.com/ https://data.worldbank.org/indicator/ny.gdp.pcap.pp.kd https://data.worldbank.org/indicator/ny.gdp.pcap.pp.kd https://doi.org/10.1016/s0140-6736(15)01087-9 https://doi.org/10.1016/s0140-6736(15)01087-9 https://pubmed.ncbi.nlm.nih.gov/31672052/ https://pubmed.ncbi.nlm.nih.gov/31672052/ https://pubmed.ncbi.nlm.nih.gov/31672052/ ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 14 | 16 annexed data annex: categorisation of all variables of potential relevance line variable code long name level of measurement missing values or coding problems suitable for analysis 10 wm6d day of interview i none no 11 wm6m month of interview cat. none yes 12 wm6y year of interview i none yes 29 wb3y year of birth of woman i 22.26% missing values yes 30 wb4 age of woman i 22.26% missing values yes 31 wb5 ever attended school cat. 22.26% missing values no 32 wb6a highest level of school attended cat. 23.4% missing values yes 33 wb6b highest grade attended at that level cat. 23.46% missing values no 34 wb7 ever completed that grade/year cat. 23.4% missing values no 35 wb9 attended school during current school year cat. 83% missing values no 36 wb10a level of education attended current school year cat. 89.2% missing values no 37 wb10b grade attended at that level during current school year i 89.2% missing values no 38 wb11 attended school previous school year cat. 83% missing values no 39 wb12a level of education attended previous school year cat. 88% .25% missing values no 40 wb12b grade attended at that level during previous school year cat. 88% .25% missing values no 41 wb14 can read part of the sentence cat. 97.78% missing values no 42 wb15 duration of living in current place i 22.26% missing values yes 43 wb16 place of living prior to moving to current place cat. 69.057% missing values no 44 wb17 region prior to moving to current place cat. 69.057% missing values no 45 cm1 ever given birth cat. 22.27% missing values yes 46 cm2 any sons or daughters living with you cat. 45.28% missing values yes 47 cm3 sons living with you i 46.31% missing values no 49 cm5 any sons or daughters not living with you cat. 45.29% missing values yes 50 cm12 confirm total number of children ever born cat. 22.26% missing values /1 code only "yes" no ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 15 | 16 58 cm15y year of last birth i 42.29% missing values yes 60 cm16by year of first birth i 54.04% missing values yes 75 cm32b no wish to have a child/another child cat. 97.13% missing values no 77 cm32d preferring to have a boy, while a girl was expected cat. 97.13% missing values no 78 cm32e preferring to have a girl, while a boy was expected cat. 97.13% missing values no 81 cm32h the parents were unmarried cat. 97.13% missing values no 93 mn4au weeks or months pregnant at first prenatal care unit cat. 85.42% missing values no 96 mn6a blood pressure cat. 85.42% missing values no 101-106 mn19a etc. assistance at delivery: doctor etc. cat. 97% and more missing values/ 1 code only no 111 mn23 after the birth, baby was put directly on the bare skin of mother's chest cat. 85.24% missing values no 116 mn32 size of child at birth cat. 85.24% missing values no 119 mn34 weight at birth (kilograms) i 85.38% missing values no 121 mn36 ever breastfeed cat. 85.24% missing values no 140 pn5 mother's health checked before leaving health facility cat. 85.31% missing values no 148-154 pn13n etc. how long after delivery did the first check of baby happen number etc. i& cat. 86% to 100% missing values no 181 un12d reason: hysterectomy cat. 98.9% missing values no 183 cp0i heard of: diaphragm cat. 98.9% missing values no 191 cp3 ever used a method to avoid pregnancy cat. 34.4% missing values yes 229 un17 availability of private place for washing during last menstrual period cat. 26.33% missing values yes 234 dv1c if she argues with husband: wife beating justified cat. 22.26% missing values yes 235 dv1d if she refuses sex with husband: wife beating justified cat. 22.26% missing values yes 236 dv1e if she burns the food: wife beating justified cat. 22.27% missing values yes 239 vt3 number of times victimisation happened in the last year cat. 99.96% missing values no 251 vt13 number of people involved in committing the offence cat. 99.6% missing values no 259 vt20 feeling safe walking alone in neighbourhood after dark cat. 22.27% missing values yes ljaljevic a, wenzel h, laaser u. women in montenegro exhibit a high degree of happiness and life satisfaction: data from the multiple independent cluster survey 2018 (original research). seejph 2021, posted: 27 january 2021. doi: 10.11576/seejph-4116 p a g e 16 | 16 260 vt21 feeling safe at home alone after dark cat. 22.27% missing values yes 268 ma1 currently married or living with a man cat. 22.27% missing values yes 270 ma5 ever married or lived with a man cat. 77.13% missing values no 271 ma6 marital status cat. 96.6% missing values no 272 ma7 married or lived with a man once or more than once cat. 42.7% missing values yes 284 sb1 age at first sexual intercourse i& cat. 22.7% missing values/ mixed coding no 290 sb7 sex with any other person in the last 12 months cat. 36.68% missing values yes 294 ha1 ever heard of hiv or aids cat. 22.27% missing values yes 325 ha31 children living with hiv should be allowed to attend school with other children cat. 26.47% missing values yes 331 ia1 do any vaccines cause serious adverse reactions after vaccination cat. 22.27% missing values yes 345 ls1 estimation of overall happiness i 22.27% missing values/ no response extra category yes ls1_cat estimation of overall happiness (categories) cat. 22.27% missing values yes 346 ls2 satisfaction with ladder step i& cat. 22.27% missing values / no response as category yes 347 ls3 life satisfaction in comparison with last year cat. 22.yesyes27% missing values / no response as category yes 348 ls4 life satisfaction expectation one year from now cat. 22.27% missing values / no response as category yes 353 wagem age at first marriage/union of woman i 42.69% missing values yes 361 welevel education cat. 22.7% missing values yes 364 migration length of stay in current place of residence cat. 22.27% missing values yes 369 hh7 region cat. none yes 373 windex5 wealth index quintile i& cat. mixture of category and numbers yes younis wy, abdalrahim ms, zeilani rs, albusoul r, alosaimi d, hamdan-mansour am. feasibility and clinical utility of bates-jensen wound assessment tool among nurses caring of patients having pressure ulcers (original research). seejph 2022, posted: 10 january 2022. doi: 10.11576/seejph5084 p a g e 1 | 12 original research feasibility and clinical utility of bates-jensen wound assessment tool among nurses caring of patients having pressure ulcers wejdan y. younis1, maysoon s. abdalrahim1, ruqayya s. zeilani1, randa albusoul1, dalyal alosaimi2, ayman m. hamdan-mansour1 1 school of nursing, the university of jordan, amman, jordan; 2 college of nursing, king saud university, riyadh, kingdom of saudi arabia. corresponding author: wejdan y. younis; address: school of nursing, university of jordan, amman 11962, jordan; email: w_younes@ju.edu.jo younis wy, abdalrahim ms, zeilani rs, albusoul r, alosaimi d, hamdan-mansour am. feasibility and clinical utility of bates-jensen wound assessment tool among nurses caring of patients having pressure ulcers (original research). seejph 2022, posted: 10 january 2022. doi: 10.11576/seejph5084 p a g e 2 | 12 abstract aims: one of the vital roles of nurses is to perform pressure ulcer risk assessment that enables them to appropriately assess and track healing progress of wound and pressure ulcers among patients. our aim was to assess the feasibility and clinical utility of the bates-jensen wound assessment tool (bwat) among nurses caring of patients with pressure ulcer. methods: a descriptive cross-sectional design used to collect data from 177 registered nurses caring of patients who developed or have a risk of developing pressure ulcers working in three hospitals in jordan. results: the mean feasibility score of the bwat was 28.3 out of 36 (sd=3.4) with a median score of 29. most of nurses reported that the bwat was easy to use on a scale of 1-4 (best) (m=3.40/4, sd=0.62) and can successfully assess wound characteristics (m=3.40/4, sd=0.59). the mean utility score of the bwat was 21.3 out of 28 (sd=2.7) with a median of 21. nurses had a perception that using the bwat enhances care of patients with wounds (m=3.36/4, sd=0.61) and makes communication easier between nurses and physicians. conclusion: this study provided evidence that support the use of the bates-jensen wound assessment tool for patients with pressure ulcer. nurses perceived bwat as easy to use, understandable, and relevant for assessing patients with pressure ulcers. keywords: bates-jensen wound assessment tool, clinical utility, feasibility, wound assessment. funding statement: this work was supported by supported and funded by the deanship of scientific research at the university of jordan, amman, jordan [number1953/2017/19]. conflicts of interest: the authors declare no potential conflicts of interest with respect to the research, authorship and publication of this study. younis wy, abdalrahim ms, zeilani rs, albusoul r, alosaimi d, hamdan-mansour am. feasibility and clinical utility of bates-jensen wound assessment tool among nurses caring of patients having pressure ulcers (original research). seejph 2022, posted: 10 january 2022. doi: 10.11576/seejph5084 p a g e 3 | 12 introduction pressure ulcer (pu) is a damage to an area of skin which covers a bony prominence (1). pressure ulcers may cause several bio-psychosocial complications that include depression, pain, and infection of muscles and bones (2). such complications of pu might lead to more serious forms of poor quality of life, morbidity, and mortality (3,4). the literature is showing that pu is affecting 6% to 10% of patents in the acute care settings causing wide range of significant problems such as pain, delayed recovery, and poor healthcare outcomes (5). globally, pu is almost affecting 2.1 million people in acute care facilities and the cost of treatment may exceed $26.8 billion (6,7). the critical influence of pu on the patient's biopsychosocial wellbeing is alarming nurses and other healthcare professionals to be attentive to intervene appropriately through assessing and minimizing its negative consequences. therefore, nurses caring of patients at risk of pu need to be equipped with knowledge and skills that best enable them to detect and manage pu. a systematic review of the literature showed that pus are considered predictable, and the prevention of such events is considered as a quality indicator (7). in particular, the increased number of older people and their high vulnerability to pu due to longer periods of hospitalization did make management of pu a priority and indicator of quality of care (8,9). therefore, nurses, have a primary responsibility in maintaining proper skin integrity and preventing skin injury and ulcer complications (10). one of the vital roles of nurses is to perform pu risk assessment that enables them to appropriately intervene to prevent pu and manage it effectively (10-12). this would suggest that feasibility of using the pu risk assessment has to be addressed as priority. feasibility is defined as the ease with which the clinicians can apply the tool in the clinical setting, while clinical utility is the ability to use the results of the tool in a useful or informative manner in clinical settings (10,13,14). one proposed tool that can be used and assist nurses working in medical-surgical units is bates-jensen wound assessment tool (bwat) (15). although the tool is proposed for nurses and other healthcare professionals and strong evidence reported to support the usefulness of the tool, few studies have been conducted, globally, to assess the feasibility and clinical utility of the bwat (15). the purpose of this study is to assess the feasibility and clinical utility of the bates-jensen wound assessment tool (bwat) in the experience of nurses caring of patients with pressure ulcer. ethical consideration: approval to use the feasibility and clinical utility tool was obtained from the original author. ethical approval obtained from irb of xyz university (approval number 1953/2019/19). methods a descriptive cross-sectional design was used to assess the feasibility and clinical utility of the bwat among nurses caring of patients. data are collected using a self-administered questionnaire. a liaison has been assigned to invite nurses to participate in the study. those who expressed interest in participation were directed to the research team who was available to address purpose and significance of the study and ensure voluntary participation. after having all their questions answered, the package including a cover letter that indicated returning the survey is considered as consenting to participate in the study. the package also included a booklet about the technique of wound assessment using the bwat. nurses were directed where to return younis wy, abdalrahim ms, zeilani rs, albusoul r, alosaimi d, hamdan-mansour am. feasibility and clinical utility of bates-jensen wound assessment tool among nurses caring of patients having pressure ulcers (original research). seejph 2022, posted: 10 january 2022. doi: 10.11576/seejph5084 p a g e 4 | 12 the survey in the given sealed envelope to ensure anonymity and confidentiality. sample and setting a convenience sampling technique was used to recruit nurses from three major hospitals in jordan representing the three healthcare sectors: governmental, educational, and military hospitals. inclusion criteria: 1) has at least three month of experience to ensure knowledge regarding protocol and guidelines of practice, and 2) caring for patients who developed or are at risk of developing pu in the selected hospitals. no exclusion criteria have been indicated. using g*power computer software program version 3.0.10, using exact test a medium effect size of 0.20 was determined, a significance level of α = 0.05 was set, and at a power of 0.80. the yielded sample was 177 participants. the tools employed are: − the bates-jensen wound assessment tool (bwat) has been developed in 1990 and revised in 2001. it aims to monitor the healing process of pressure ulcers (15,16). the bwat contains 13 items that facilitate nurses’ role in evaluating wound characteristics such as the depth, size, edges, undermining, necrotic tissue type and amount, exudates, granulation tissue, epithelialization, peripheral tissue indurations, peripheral tissue edema, and skin color surrounding the wound. each item in the bwat is graded on a scale from 1 to 5, where a score of 1 indicates improvement toward healing, and a score of 5 indicates lack of healing or wound deterioration. the total scores range from 13 to 65 (15,16). the bwat has reasonable reliability and validity, with sensitivity of 61%, a cronbach’s alpha of 0.90, positive predictive value of 65%, and specificity of 52% (15). − the feasibility and clinical utility (fcu) tool has been developed to test bates-jensen wound assessment tool feasibility and clinical utility (appendix a) (17). this tool consists of 16 questions with two subscales. the first subscale measures the feasibility and comprises nine questions while the second subscale measures the clinical utility and comprises seven questions. nurses are asked to make their responses on a 4pointscale ranging from of 1-4 (1=not relevant, 2=somewhat relevant, 3=quite relevant, 4=highly relevant). the tools have good reliability and validity with cronbach's alpha of 0.88. in addition, the questionnaire included a profile for socio-demographic data regarding including age, gender, and years of experiences (see table 1). the association between the sample characteristics and feasibility and utility scores was tested using t-test or one-way anova for variables with three categories or more. a value of p≤0.05 was considered statistically significant. results nurses' characteristics a total of 200 registered nurses expressed their interest, 177 nurses which filled and returned the survey represented the final sample of the study with a response rate of 88.5%. the mean age of nurses was 31.8+6.4 ranging from 21 to 50 years. the majority of the nurses were females (n=111, 62.7%), having a bachelor degree (n=165, 93.2%) and were working as a registered nurses (n=137, younis wy, abdalrahim ms, zeilani rs, albusoul r, alosaimi d, hamdan-mansour am. feasibility and clinical utility of bates-jensen wound assessment tool among nurses caring of patients having pressure ulcers (original research). seejph 2022, posted: 10 january 2022. doi: 10.11576/seejph5084 p a g e 5 | 12 77.4%). the mean years of experience was 9.5+6.0, and the majority of them were from the military hospital (n=117, 66.1%), see table 1. table 1. characteristics of the participants (n= 177) characteristics frequency percentage gender male female 66 111 37.3 % 62.7 % educational level bachelor degree master degree 165 12 93.2 % 06.8 % position in nursing staff nurse in charge nurse supervisor 137 21 19 77.4 % 11.9 % 10.7 % hospital sector governmental military university affiliated 22 117 38 12.4 % 66.1 % 21.5 % already using bwat* in the hospital no yes 59 118 33.3 % 66.7 % nurses experience** surgical conditions acute conditions medical conditions critical conditions oncology patients palliative conditions 70 48 116 84 78 65 39.5 % 27.1 % 65.5 % 7.5 % 44.1 % 36.7 % * bwat: bates-jensen wound assessment tool; ** more than one option acceptable. feasibility of the bates-jensen wound assessment tool the mean feasibility score of the bwat (see table 2) was 28.3 +3.4 out of 36.0 with a median score of 29, and range of 17-35. the interquartile range (iqr) classification system was utilized to categorize the feasibility scores into three categories; low (25th iqr), moderate (50th iqr), and high (75th iqr). accordingly, the results revealed that 32.2% (n=57) of the nurses fell in the low category, 41.8% (n=74) in the moderate category, and 26.0% (n=46) in the high category. younis wy, abdalrahim ms, zeilani rs, albusoul r, alosaimi d, hamdan-mansour am. feasibility and clinical utility of bates-jensen wound assessment tool among nurses caring of patients having pressure ulcers (original research). seejph 2022, posted: 10 january 2022. doi: 10.11576/seejph5084 p a g e 6 | 12 table 2. classification of the feasibility and clinical utility of the bwat category classification range frequency (%) feasibility of bwat* low moderate high (28 and below) (29-30) (31 and above) 57 (32.2%) 74 (41.8%) 46 (26.0%) clinical utility of bwat* low moderate high (20 and below) (21-23) (24 and above) 60 (33.9%) 72 (40.7%) 45 (25.4%) *bwat: bates-jensen wound assessment tool regarding feasibility, most nurses (>70%) reported that the bwat was easy to use indicated by the 4-point scale (m=3.40+0.62), and can successfully assess wound characteristics (m=3.40+.59). nurses reported that they received sufficient training on using bwat (m=3.30+0.65), and can easily understood the tool's directions (m=3.35+0.56). the responses that had low mean scores less than 3.0 were, eventually, reported for the items that have structured negatively and those are: “i use the bwat just because it is required by the hospital administration” (m=2.37+.80) and “using the bwat takes too much time from my work” (m=2.32+.69). clinical utility of the bate-jensen wound assessment tool the mean utility score of the bwat (see table 2) was 21.3+2.71 out of 28 with a median of 21, and range of 11-28. the interquartile classification system was utilized to categorize the utility scores into three categories; low (25th iqr), moderate (50th iqr), and high (75th iqr). the analysis showed that 33.9% (n=60) of nurses fell in the low category, 40.7% (n=72) in the moderate category, and 25.4% (n=45) in the high category. nurses reported that using the bwat in their daily practice will enhance the nursing care of patients with wounds (m=3.36+.61). according to the nurses, the bwat makes communication of a patient’s wound healing process easier for both nurses (m=3.26+0.57) and physicians (m=3.31+0.59). most nurses (>60%) reported that they will recommend using the bwat for wound assessment (m=3.28+0.63). the lowest mean item score was for the item “the tool is not connected to wound management guidelines in most of the hospitals” (m=2.68+0.98). in addition, a relatively low score was reported also to “the physician asks nurses frequently about the bwat scores for patients with ulcer before managing wound (m=2.78+.86). differences in feasibility and clinical utility of the bwat related to sample characteristics the results (see table 3) indicated that there is a significant difference in feasibility and clinical utility mean scores between the military hospital and other hospitals (private and governmental). nurses from the military hospital had higher mean scores in both feasibility and clinical utility (28.5±2.7, 22±2.7; respectively). younis wy, abdalrahim ms, zeilani rs, albusoul r, alosaimi d, hamdan-mansour am. feasibility and clinical utility of bates-jensen wound assessment tool among nurses caring of patients having pressure ulcers (original research). seejph 2022, posted: 10 january 2022. doi: 10.11576/seejph5084 p a g e 7 | 12 table 3. association between sample characteristics and the bwat feasibility and clinical utility variable feasibility m ± sd p utility m ± sd p gender male (n = 66) 28.4±3.90 .751 21.4 ± 2.81 .621 female (n = 115) 28.2 ± 3.31 21.2 ± 3.10 educational level bsc (n = 171) 28.2 ± 3.41 .672 21.4 ± 2.90 .045 msn (n = 10) 28.7 ± 4.61 19.5 ± 2.90 hospital sector governmental (n = 21) 26.6 ± 2.11 20.7 ± 2.01 military (n = 117) 28.5 ± 2.70 < .001 22.0 ± 2.01 .022 teaching (n = 38) 26.4 ± 5.31 20.7 ± 4.10 nursing position staff nurse (n = 142) 27.7 ± 3.40 .301 21.0 ± 2.41 .501 in-charge nurse (n = 21) 28.5 ± 3.20 21.8 ± 2.60 supervisor (n = 18) 28.5 ± 3.20 28.5 ± 3.20 caring for medical conditions no (n = 61) 27.6 ± 3.21 .091 21.5± 2.90 .401 yes (n = 120) 28.6 ± 3.51 21.1 ± 2.90 caring for acute conditions no (n = 133) 28.1 ± 3.41 .240 21.3 ± 2.90 .991 yes (n = 48) 28.8 ± 3.61 21.3 ± 3.01 caring for critical conditions no ( n= 97) 27.4 ± 3.20 < .001 21.0 ± 3.10 .181 yes (n =84) 29.3 ± 3.41 21.6 ± 2.81 caring for surgical conditions no (n = 111) 28.2 ± 3.20 .921 21.2 ± 2.80 .821 yes (n= 70) 28.3 ± 3.71 21.3 ± 3.20 caring for the condition with cancer no (n =103) 27.4 ± 3.20 < .001 21.4 ± 3.00 .521 yes (n= 78) 29.4 ± 3.41 21.1 ± 2.90 younis wy, abdalrahim ms, zeilani rs, albusoul r, alosaimi d, hamdan-mansour am. feasibility and clinical utility of bates-jensen wound assessment tool among nurses caring of patients having pressure ulcers (original research). seejph 2022, posted: 10 january 2022. doi: 10.11576/seejph5084 p a g e 8 | 12 caring for palliative patients no (n = 116) 27.6 ± 3.30 < .001 21.4 ± 2.90 .520 yes (n = 65) 29.5 ± 3.41 21.1 ± 3.00 previous educational program on wound assessment no (n = 106) 28.6 ± 3.30 .160 21 ± 2.90 .220 yes (n = 75) 27.8 ± 3.61 21.6 ± 2.91 previous use of assessment tools no (n = 59) 26 ± 4.10 <.001 19.8 ± 3.30 .003 yes (n = 117) 29.4 ± 2.51 21.9 ± 2.50 besides, higher mean scores of feasibility and clinical utility were reported among nurses that used the tool previously (had an experience in using the tool at other settings and with other patients: 29.4±2.5 and 21.9±2.5). the work experience affected participants’ perception of utility and feasibility of bwat; nurses who provided care for palliative or cancer patients, and for critical patients had significantly higher mean feasibility scores than other nurses (29.5±3.4; 29.4±3.4; 29.3±3.4). however, there was no significant difference in clinical utility mean scores among nurses in relation to work experience. nurses with graduate level of education had higher mean scores on the bwat clinical utility than nurses with undergraduate level. nurses' age and their years of experience in nursing were positively correlated with feasibility and clinical utility of bwat (p-value <0.001). discussion positive healing progress of pressure ulcer is a core indicator for quality of nursing care. therefore, nurses who assume the responsibility to assess and manage care for pressure ulcers need to be equipped with knowledge and skills to improve quality. in particular, nurses working in general wards such as medical and surgical ones caring for patients occupied to bed are challenged with high load of work and simultaneously struggle to keep high quality of nursing care (21). in our study, we found on the one hand that a considerable number of nurses indicated low levels of perception of feasibility and clinical utility of bwat although were using the tool competently. such findings partially disagree with previous reports who reported good feasibility and utility of bwat among health staff (7,18,19) whereas in our study about one third of nurses are categorized at low level. one explanation could be related to the nurses' belief that using bwat is only for the purpose of adherence to hospitals' protocol rather than their clinical and scientific judgment and practice. nurses were using the bwat just to get satisfactory reports from their supervisors which may influence the core principle of safe and quality nursing practices. such findings support previous studies that nurses found to perform bwat to get management appraisals rather than for its clinical and quality importance for patients and care outcomes (20). moreover, younis wy, abdalrahim ms, zeilani rs, albusoul r, alosaimi d, hamdan-mansour am. feasibility and clinical utility of bates-jensen wound assessment tool among nurses caring of patients having pressure ulcers (original research). seejph 2022, posted: 10 january 2022. doi: 10.11576/seejph5084 p a g e 9 | 12 nurses were not well-oriented about such advanced measure as they described bwat as easy to understand, while their scores on the items of the scale do not reflect such perception. this is one limitation of this study as we have used a self-reported format of data, while using an observational approach through assessing direct skills and outcomes would have revealed more informative results. one significant contribution of this study is, however, that nurses considered bwat as a helpful tool for documentation which enhances the feasibility and utility of bwat in different health care settings. nurses reported that using bwat made the communication of the patient’s wound healing progress easier between and among nurses and physicians which sustains what triantafyllouet al. (7) reported that bwat helped the nurses to establish meaningful communication and accurate tracking of wound healing process for both nurses and physicians (7). most nurses advocated using the bwat for wound assessment; however, they asserted also that bwat has not been integrated into the hospitals’ policies which may also explain the low to moderate scores of feasibility and utility. another significant contribution is related to the effect of training and years of experience in nursing on the willingness to use bwat. we have found that nurses with more years of experience and those who received training on wound assessment and management did have higher scores of feasibility and clinical utility of bwat. this indicates that nursing training is required and the notion that nurses should rely on their self-training and education is not valid. those with better training are capable to provide higher levels of quality of nursing care. conclusions this study found that bwat is a sufficiently valid and reliable tool used to assess and monitor progress of pu among patients in different clinical settings. the study shows also that nurses have only a low to moderate perception of feasibility and clinical utility of the bwat tool in pu assessment and monitoring. therefore, qualified training is needed to ensure nurses' competency to use the tool. furthermore, policies need to be revised to ensure integrating bwat into protocols, and a monitoring system should be created to ensure nurses' adherence to use bwat. conducting a longitudinal observational study with larger sample size would reveal more informative results regarding competency and willingness of nurses to use bwat and its outcome on patients' skin integrity. references 1. national pressure ulcer advisory panel, european pressure ulcer advisory panel and pan pacific pres/sure injury alliance. prevention and treatment of pressure ulcers: quick reference guide. emily haesler (ed.). epuap / npuap / pppia; 2019. 2. mcginnis e, briggs m, collinson m, wilson l, dealey c, brown j, et al. pressure ulcer related pain in community populations: a prevalence survey. bmc nurs 2014;13:1-10. 3. carlsson m, gunningberg l. predictors for development of pressure ulcer in end-of-life care: a national quality register study. j palliat med 2017;20:53-8. 4. mervis js, phillips tj. pressure ulcers: prevention and management. j am acad dermatol 2019;81:893902. younis wy, abdalrahim ms, zeilani rs, albusoul r, alosaimi d, hamdan-mansour am. feasibility and clinical utility of bates-jensen wound assessment tool among nurses caring of patients having pressure ulcers (original research). seejph 2022, posted: 10 january 2022. doi: 10.11576/seejph5084 p a g e 10 | 12 5. alderden j, zhao yl, thomas d, butcher r, gulliver b, cummins m. outcomes associated with stage 2 pressure injuries among surgical critical care patients: a retrospective cohort study. crit care nurse 2019;39:13-9. 6. mahyudin f, edward m, basuki mh, basrewan y, rahman a. modern and classic wound dressing comparison in wound healing, comfort and cost. jurnal ners 2020;15:31. 7. triantafyllou c, chorianopoulou e, kourkouni e, zaoutis te, kourlaba g. prevalence, incidence, length of stay and cost of healthcare-acquired pressure ulcers in pediatric populations: a systematic review and metaanalysis. int j nurs stud 2021;115:103843. 8. hamdan-mansour a. sociodemographic correlates of somatic symptoms of older persons in jordan. jordan med j 2017;51:119-30. 9. khatib ah, hamdan-mansour am, ratrout hf, alenezi a, chahien tr. testing the effectiveness of integrated elderly care model on quality of care and health outcomes among hospitalized elderlies in west bank. malaysian j public health med 2020;20:82-9. 10. institute for healthcare improvement. [internet]. relieve the pressure and reduce harm. available from: http://www.ihi.org/resources/pages/improvementstories/relievethepressureandreduceharm.aspx (accessed: february 27, 2021). 11. al khatib a, hamdan-mansour a, bani hani m. theoretical perspectives of hospitalized older patients and their health-related problems and quality of care: systematic literature review. open public health j 2017;10:215-25. 12. soban lm, kim l, yuan ah, miltner rs. organisational strategies to implement hospital pressure ulcer prevention programmes: findings from a national survey. j nurs manag 2017;25:457-67. 13. duhn lj, medves jm. a systematic integrative review of infant pain assessment tools. adv neonatal care 2004;4:126-40. 14. afridi a, rathore f. are risk assessment tools effective for the prevention of pressure ulcers formation?: a cochrane review summary with commentary. am j phys med rehabil 2020;99:357-8. 15. bates-jensen bm, mccreath he, harputlu d, patlan a. reliability of the bates‐jensen wound assessment tool for pressure injury assessment: the pressure ulcer detection study. wound repair regen 2019;27:38695. 16. bates-jensen b. the pressure sore status tool a few thousand assessments later. adv wound care 1997;10:65-73. 17. gélinas c. nurses’ evaluations of the feasibility and the clinical utility of the critical-care pain observation tool. pain manag nurs 2010;11:115-25. 18. alves df, almeida ao, silva jl, morais fi, dantas sr, alexandre nm. translation and adaptation of younis wy, abdalrahim ms, zeilani rs, albusoul r, alosaimi d, hamdan-mansour am. feasibility and clinical utility of bates-jensen wound assessment tool among nurses caring of patients having pressure ulcers (original research). seejph 2022, posted: 10 january 2022. doi: 10.11576/seejph5084 p a g e 11 | 12 © 2022 younis et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. the bates-jensen wound assessment tool for the brazilian culture. texto contexto enfer 2015;24;826-33. 19. shukla u, kumar a, anushapreethi s, singh sp. evaluation of the efficacy of hyperbaric oxygen therapy in the management of diabetic ulcer using bates-jensen wound assessment tool. anesth essays res 2020;14:335. 20. hamdan a, hamdan-mansour a. community versus hospital acquired pressure injuries: an assessment of predisposing risk factors. malaysian j med health sci 2020;16:170-6. 21. christopher k. a double bind of relational care: nurses’ narratives of caregiving at work and at home. gender issues 2021;1-16. _____________________________________________________________________________________________ younis wy, abdalrahim ms, zeilani rs, albusoul r, alosaimi d, hamdan-mansour am. feasibility and clinical utility of bates-jensen wound assessment tool among nurses caring of patients having pressure ulcers (original research). seejph 2022, posted: 10 january 2022. doi: 10.11576/seejph5084 p a g e 12 | 12 appendix a: bwat feasibility and clinical utility questionnaire question 1 2 3 4 strongly not agree not agree agree strongly agree feasibility 1. i understand the bwat directions. 2. i found the bwat is easy to use. 3. the bwat can successfully assess level of pain for mechanically ventilated patients. 4. i received sufficient training about the use of bwat. 5. using the bwat takes too much time from my work. 6. the bwat rating scores accurately reflect patients’ pain level. 7. the bwat measurement is quick to use. 8. the score of bwat is easy to document. 9. i use the bwat just because it is required by the hospital administration. clinical utility 10 the use of bwat makes communication of patients’ pain easy with other nurses. 11 the use of bwat makes communication of patients’ pain easy with physicians in the icu. 12 i recommend the use of bwat in assessing mv patients’ pain. 13 using the bwat will enhance caring of mv patients. 14 the bwat scores are often used to manage mv patients’ pain in our icu. 15 physicians ask nurses frequently about the bwat scores for mv patients before managing pain. 16 the bwat is not connected to pain management guidelines and policy of pain management in our hospital. appendix a: bwat feasibility and clinical utility questionnaire angoumis, k., langston, a., mosler, k., rialland, c., veys, m. &neicun, j. reducing the burden of hiv and hcv among sex workers who use drugs in france (policy brief). seejph 2023. posted: 09 april 2023 page113 policy brief reducing the burden of hiv and hcv among sex workers who use drugs in france konstantinos angoumis1, amanda langston1, kristin mosler1, clémentine rialland1, mathilde veys1, jessica neicun1,2 1 department of international health, governance and leadership in european public health master, faculty of health medicine and life sciences, maastricht university, maastricht, the netherlands. these authors contributed equally to this work; 2research centre, centre hospitalier de l'université de montréal (chum), montréal, qc, canada. corresponding author: konstantinos angoumis, address: brouwersweg 100, 6216eg maastricht (nl) email: k.angoumis@student.maastrichtuniversity.nl angoumis, k., langston, a., mosler, k., rialland, c., veys, m. &neicun, j. reducing the burden of hiv and hcv among sex workers who use drugs in france (policy brief). seejph 2023. posted: 09 april 2023 page114 abstract context: the far-reaching effects of the covid-19 pandemic exacerbated the adverse working and living conditions of sex workers (sws) in france. these consequences, coupled with illicit drug use, and reduced access to prevention measures raise concerns for the transmission of the human immunodeficiency virus (hiv) and hepatitis c virus (hcv) among sex workers who use drugs (swwud), creating an urgent call for targeted interventions. there is an acute need for accessible, ongoing care for swwud to prevent hiv and hcv infections and mitigate adverse health effects. current french health services such as harm reduction and hiv/hcv prevention services often operate separately and seldom address sws and people who use drugs (pwud) simultaneously. given the compounding set of challenges that swwud face, a holistic approach to policy interventions must be considered. policy options: firstly, integrated services are particularly effective in promoting harm reduction and improving the health of their users. when these services include substance use care and hiv services, uptake of these interventions and primary care utilisation increases due to enhanced accessibility. secondly, pre-exposure prophylaxis (prep) and needle and syringe programs (nsp) are clinically effective prevention methods that, when coupled with point-of-care-testing (poct), can reduce the prevalence of hiv and hcv and improve the monitoring of these viruses. finally, willingness to engage with health services is impacted by the attitudes of healthcare staff. sensitisation training can promote trauma-informed care, a nonjudgemental approach in health workers, encouraging swwud to seek care and achieve better health outcomes. recommendations: a three-pronged approach to implementing integrated services is recommended. first, facilitating access to care can be attained through the linkage of patients to treatment, primary care, sexual and reproductive health, and social services. existing service providers can be supported with interdisciplinary teams and telemedicine to reduce care fragmentation. additionally, prevention and testing measures can be enhanced through the coordinated provision of needle and syringe programs, point-of-care testing, prep, and harm reduction supplies. these services should be linked to established integrated service centres to ensure a continuum of care. finally, peer leaders may deliver sensitisation training for service providers to reduce stigma and improve understanding of the unique health needs of swwud. integrated service providers should further employ peer leaders as peer navigators to promote the vision of community empowerment and inclusion. keywords: hepatitis c virus, human immunodeficiency virus, injection drug use, integrated care, prevention, sex workers who use drugs, stigmatisation, treatment angoumis, k., langston, a., mosler, k., rialland, c., veys, m. &neicun, j. reducing the burden of hiv and hcv among sex workers who use drugs in france (policy brief). seejph 2023. posted: 09 april 2023 page115 introduction the covid-19 pandemic has significantly impacted the working and living conditions and health of sex workers (sws) worldwide. this crisis has made apparent the socioeconomic challenges most sws face due to systematic discrimination and societal exclusion (1). various lockdown rules and mobility restrictions resulted in the loss of income for many sws, creating a dangerous cycle of vulnerability (2). laws governing sex work in france contribute to the ongoing health challenges faced by those who work in the industry (3). in 2016, the nordic model was introduced, which criminalises the purchase of sws services and positions them as victims (3). this criminalisation is linked to adverse health among sws, namely, sexually transmitted infections, violence, poor access to health care, and risks of homelessness (4). criminalising the purchase of sex services has resulted in fewer clients and, therefore, a smaller client pool for sws (5). with a decreased bargaining power, sws who use drugs (swwud) are at increased risk of adverse health outcomes (3, 4). further, sws have to work longer hours and change location regularly to avoid law enforcement (5). these changes coupled with an increase in social stigmatisation, have a direct negative impact in accessing healthcare for swwud (5). under the nordic model, sws, sws may feel pressured to accede to clients’ requests to maintain their income and may engage in activities they previously would not have consented to (5). swwud are particularly vulnerable, as the use of drugs while working with unaccommodating clients can diminish their perception of danger and increase their likelihood of engaging in risky behaviors (5, 6). interviews with sws in france indicate that substance use has increased to cope with the stress of reduced income and worsened living conditions (5). as displayed in figure 1, drug use and risky sexual behaviour are linked to increased human immunodeficiency virus (hiv) and hepatitis c virus (hcv) prevalence in sws (6, 7, 8). these challenging circumstances result in complex health and social needs (9). a review of studies conducted in 50 countries found that female sws face 13.5fold higher odds of acquiring hiv in comparison to the general population of angoumis, k., langston, a., mosler, k., rialland, c., veys, m. &neicun, j. reducing the burden of hiv and hcv among sex workers who use drugs in france (policy brief). seejph 2023. posted: 09 april 2023 page116 reproductive age (10). hcv is primarily transmitted through injection drug use and sexual intercourse, posing a dual risk of transmission for swwud (7, 8). therefore, there is an urgent demand for targeted interventions to mitigate adverse health outcomes for swwud in france. figure 1: framework of the relationship between sex work policy and hiv/hcv prevalence among sex workers (adapted from reeves et al. (6)) context the nordic model has so far only been implemented in smaller northern european countries (iceland, norway, sweden, ireland) where the tradition of outside sex work is less widespread because of the cold weather. even if considering france as a southern country is debatable, the french context remains different from that of the countries where the nordic model has been implemented so far and the transferability of these policies is questionable (11). the implementation of the 2016 law is therefore a unique case in this european region where neighbouring countries have for the most part decriminalised and/or regulated sex work (belgium, germany, spain, switzerland) (11). despite the intention to protect sws with this law, a decrease in the use of condoms and increased difficulties continuing treatment for those who are hiv positive have been observed since the angoumis, k., langston, a., mosler, k., rialland, c., veys, m. &neicun, j. reducing the burden of hiv and hcv among sex workers who use drugs in france (policy brief). seejph 2023. posted: 09 april 2023 page117 introduction of the nordic model (5). some associations working with sws even reported an increase in hiv prevalence as a result of this law (11). the introduction of the nordic model in france, combined with restricted services during covid-19, made it difficult for sws to access health services, continue testing and treatment for hiv and hcv, and engage with harm reduction services for illicit drug use (12). since hiv and hcv prevention and care services operated in fragmented and deficient forms before covid-19, the restriction or suspension of these standalone services exacerbated access barriers during the pandemic (13). there is a pressing need for continuous and accessible care for swwud to prevent infections with hiv and hcv and to mitigate resulting adverse health effects (12, 13). these needs are further highlighted by goals set by the world health organization (who) and thejoint united nations programme on hiv/aids (unaids). the who has an established global goal of eradicating hcv by 2030 via a reduction of 90% in new chronic infections and reducing mortality by 65% (14). unaids’ established “95-95-95” targets for hiv foresees that by 2030, 95% of people infected know their status, 95% of diagnosed people are in treatment, and 95% of people in treatment have a suppressed viral load (15). in 2022, 120,000 people were found to be hcv positive by the french health system, which is less than 0.3% of the french population. the distribution of hcv prevalence in france is uneven, disproportionately affecting people in highrisk groups, such as swwud (16). likewise, swwud experience higher rates of hiv than the general population, with an estimated total of 172,700 people in france were living with hiv in 2018 (17). it is imperative to prioritise health interventions for sws, as the prevalence of these infections are especially high among this population (7, 8, 10). therefore, this policy brief recommends developing and strengthening health services for swwud through integrated care, prioritising hiv/hcv testing, access to preexposure prophylaxis (prep), primary and reproductive health care, providing safe facilities, and empowering communities. angoumis, k., langston, a., mosler, k., rialland, c., veys, m. &neicun, j. reducing the burden of hiv and hcv among sex workers who use drugs in france (policy brief). seejph 2023. posted: 09 april 2023 page118 policy options given the complex challenges that swwud face, a holistic approach to policy interventions must be considered. healthoriented interventions must be accessible, person-centred, context-specific, and efficiently allocate resources based on areas of greatest need (18). target-populationendorsed forms of hiv and hcv testing have been recommended to increase the monitoring and surveillance of infectious disease prevalence in this underserved population (19). needle and syringe programs (nsps) and regular access to prep have been proposed as clinically-effective hiv prevention methods for at-risk persons (20, 21). additionally, linking diseasespecific health services to primary care enables sws to receive multidisciplinary health services without requiring multiple appointments (21). finally, willingness to take up health services and the quality of services is profoundly influenced by the demeanour and sensitivity of care providers interacting with swwud (22). thus, sensitisation training has been proposed to meet this need (18, 23). point-of-care testing and prevention point-of-care testing (poct) is a sexual and reproductive health practice of providing testing and treatment for certain infections within one visit (19). this practice improves hiv and hcv control, prevention, and surveillance while maintaining affordability (19). poct in the form of mobile, streetbased hiv and hcv rapid testing has proven effective in european countries in increasing testing and treatment in difficultto-reach populations (24-26). mobile units equipped to test for hiv, and hcv can be situated in different locations and offered at off-peak hours to reach the target population (24, 25). poct can be coupled with prep to enhance hiv prevention care. prep is a clinicallyrecommended prevention strategy for key at-risk populations (21). prep enables swwud to have more control over transmission protection by reducing the occupational risk of acquiring hiv (27, 28). strict adherence to prescription guidelines is necessary to maintain drug efficacy (29). to assist in maintaining efficacy, poct can be offered to measure prep adherence and provide swwud with an improved understanding of whether their regimens are angoumis, k., langston, a., mosler, k., rialland, c., veys, m. &neicun, j. reducing the burden of hiv and hcv among sex workers who use drugs in france (policy brief). seejph 2023. posted: 09 april 2023 page119 in compliance to maintain protection against hiv (21). nsps are a third prevention measure for reducing drug risk-related harms such as hiv and hcv infection, as sharing needles is the leading risk factor for hiv/hcv among people who inject drugs (pwid) (30). in the case of hcv, the cochrane collaboration concluded that nsps might reduce the risk of hcv acquisition by 76% in europe (30). next to fixed sites, mobile approaches such as street outreach or vending machines are suitable for targeted hiv/hcv prevention (20). integrated healthcare services integrated healthcare services offer wholeperson care to swwud, addressing intersecting needs related to the social determinants of health (31). swwud often have high rates of comorbidities and coexisting psychosocial needs (32), and these services increase accessibility by providing multidisciplinary care simultaneously, allowing providers to address all needs during one appointment (31). many facilities also employ peer leaders or peer navigators with shared lived experiences to provide compassionate care and reduce stigma among staff (31). telemedicine can also enhance existing services for people who use drugs (pwud) by providing technical support and building rapport with patients to encourage ongoing engagement (33-36). low-threshold service models offer interdisciplinary care at no or low cost and increase accessibility by providing convenient locations and operating hours suitable for the target population, as well as removing eligibility requirements such as the need for government identification or sobriety (37). these services provide harm reduction supplies, drug treatment, sexual and reproductive health care, and primary health care (38, 39), and aim to be clinical, confidential, and non-judgmental (39). adapted models of low-threshold services, in conjunction with integrated primary care, can effectively meet the complex needs of swwud by providing ongoing, collaborative care (40). sensitisation training of caregivers stigma from healthcare providers is one of the most significant barriers to accessing care for sws (22). this stigma can go as far as denial of care but most often takes the form of discomfort with treating sws and angoumis, k., langston, a., mosler, k., rialland, c., veys, m. &neicun, j. reducing the burden of hiv and hcv among sex workers who use drugs in france (policy brief). seejph 2023. posted: 09 april 2023 page120 reduced quality of care after disclosing their occupation (22, 41). thus, sws are increasingly reluctant to discuss their occupation or to seek health services for fear of stigma (41). the stigma regarding hiv or sexually transmitted infections (stis) status can perpetuate fear of occupation disclosure, placing swwud at risk of underdiagnosis and delayed treatment (38). to address this stigma and provide adequate care, international guidelines on drug use and stis recommend adequate sensitisation training for health workers (18, 23). education for these caregivers should include knowledge of specific needs and associated risks of swwud, as well as the importance of being non-judgmental (18, 38, 23). peer navigators, also called peer leaders, are those with lived experience of the targeted population; they can share significant knowledge and promote traumainformed care (38). peer navigators should facilitate this training, as peer-led trainings would enable caregivers to better understand the impact of stigma and other specific issues affecting the health of swwud (42). recommendations based on the outlined policy options, a three-pronged approach to implementing integrated health services is recommended. integrated services support the provision of both primary care and sex work-specific health services at target population-focused health centres.the three recommendations for overcoming fragmentation and promoting swwud health include: [1] hiv/hcv testing and prevention, [2] facilitating access to holistic care, and [3] sensitising health service staff to the unique needs of this population. figure 2 displays an overview of the three components required to facilitate implementing the recommendation of integrating health services, with each component described in greater detail below. testing and prevention prep counselling and prescriptions are integral to hiv-specific prevention measures. the who has developed the prep implementation tool consisting of several modules which aim to support different stakeholders in planning, introducing, and implementing oral prep angoumis, k., langston, a., mosler, k., rialland, c., veys, m. &neicun, j. reducing the burden of hiv and hcv among sex workers who use drugs in france (policy brief). seejph 2023. posted: 09 april 2023 page121 (43). healthcare workers can be trained in prep prescription recommendations and equipped to disseminate the who’s prep implementation tool module tailored to prep users. figure 2: funnel diagram of integrated health services components (authors’ work) this will allow swwud to be empowered in taking control of their health. secondly, testing is an important gateway to care, so establishing and expanding mobile hiv and hcv point-of-care testing complementary to health-centre-based testing sites is particularly important (24). thirdly, nsps should be promoted as a combined prevention measure for hiv and hcv. integrating nsps into existing healthcare centres will encourage the uptake of this service (20). finally, the continued and more coordinated on-site distribution of harm reduction supplies at primary care centres will further the proposed prevention strategies. the implementation of this recommendation, using a combination of these different components, seeks to reduce the transmission of hiv and hcv. facilitate access to care adequate access to healthcare and social services is vital to ensuring a cohesive patient pathway for treating communicable diseases and managing comorbidities (31). thus, integrated care centres should be implemented in geographical areas where the sw community is well established. to reduce the fragmentation of services, primary care services already providing care angoumis, k., langston, a., mosler, k., rialland, c., veys, m. &neicun, j. reducing the burden of hiv and hcv among sex workers who use drugs in france (policy brief). seejph 2023. posted: 09 april 2023 page122 to this target population should be further equipped with interdisciplinary medical teams to provide sexual and reproductive health care linkages and linkages to social services (31). using telemedicine services on-site is recommended to enhance the capacity of integrated health centres (33-36). however, low levels of digital health literacy among patients must be anticipated by training peer leaders in assisting patients with navigating these services (35). mobile hiv and hcv testing services, organisations providing prep, and nsps must be brought into united networks to ensure the whole patient pathway for holistic care is considered. integrated care facilities foster collaboration between social service bodies and harm reduction organisations to provide in-house harm reduction supplies and services, point-of-care testing, peer navigators, and linkages to additional services when on-site provision is not possible (31). staff sensitisation integrated care facilities need to be considered safe spaces by swwud to have a real impact. this requires strategies to combat stigma and discrimination by caregivers. these efforts can be realised by employing peer leaders at integrated care centres to build trust with service users and share expertise through the facilitation of staff sensitisation training (44). these trainings would discuss a variety of scenarios that may be expected when working with this population and should address how to best respond to patients in a sensitive manner (44). peer leaders are commonly recommended for delivering sensitisation training, as they help normalise the experiences of swwud and improve power relationships within the primary care practice (44). furthermore, social events and platforms that encourage engagement between peer leaders and non-drug-using staff will support informal methods of reducing stigma and increasing understanding of the unique experiences of this population (44). stakeholder considerations given the complexity of this health challenge and the comprehensive set of solutions, the involvement and collaboration of a wide range of stakeholders is required. this collaboration must be vertical, between the different levels of the state, and horizontal, integrating public and private actors. angoumis, k., langston, a., mosler, k., rialland, c., veys, m. &neicun, j. reducing the burden of hiv and hcv among sex workers who use drugs in france (policy brief). seejph 2023. posted: 09 april 2023 page123 governmental ministries requiring varying degrees of consultation, support, and oversight include the ministry for gender equality, diversity and equal opportunities (minge), the ministry of health and prevention (minhp), and the ministry of secondary education and research (minser). minge and minhp hold overlapping responsibilities for promoting and protecting the well-being of swwud, so increasing opportunities for collaboration encourages the identification of current gaps in care and recognising areas to improve resource efficiency. minser’s consultation will support the development and implementation of sensitisation training by examining existing curriculums for suitability and areas requiring adaptation to suit the french context. the french health system already comprises various care structures specific to sexual and reproductive health (cegidd) and to substance-use-related services (caarud, csapa). these facilities are managed by public hospitals and/or associations through partnerships. nonetheless, fragmentation presents a central challenge for these care structures. proposed recommendations aim to reinforce and improve the coordination among these facilities while strengthening linkages to existing community-based services. consultation from health associations and unions will provide insight into anticipated facilitation challenges for recommendations and will create a feedback platform to recognise strengths and weaknesses for each step of implementation. community-based services and associations must be pursued and strengthened to encourage a seamless network of service provision. these local or national associations (i.e., gaïa paris, médecins du monde, french red cross) have direct contact with swwud and are most capable of providing consultation for recommendation implementation strategies. however, these associations need public actors' coordination, funding, and support. international institutions and organisations (i.e., unodc, unaids, nswp) can support national associations in providing continued advocacy pressure on their behalf. these organisations have placed pressure on actors to meet hiv and hcv reduction goals and are positioned to continue pressing for this aim through awareness campaigns, research, and informal demands. angoumis, k., langston, a., mosler, k., rialland, c., veys, m. &neicun, j. reducing the burden of hiv and hcv among sex workers who use drugs in france (policy brief). seejph 2023. posted: 09 april 2023 page124 support from public authorities at the local level is necessary to ensure community-level feedback is received by national actors. these authorities, including municipal offices and regional health agencies, will facilitate the coordination of local activities and support them through material, human, and financial resources. finally, it is important to include representatives of the sws communities, particularly those who belong to the swwud community. through regular and thoughtful engagement, they should be encouraged to provide their insights for helping to shape this strategy in a way that addresses their specific needs and concerns. including all listed stakeholders and fostering collaboration are prerequisites to implementing an effective and sustainable strategy. appendices a and b display the varying degrees of interest and influence each stakeholder holds concerning this health challenge. limitations a first limitation of this paper is that the information on which the policy options and recommendations are based is not the result of a systematic literature search, but only a selective representation of the current evidence. in addition, although the context was derived from reports and literature, the recommendations derived are not expert opinions. this could ultimately lead, for example, to inappropriate policy options being proposed, stakeholders not being fully captured, or inappropriate recommendations being made. moreover, the needs of swwud could only be roughly identified through the existing reports and was not supported by a profound empirical data base. finally, the actual feasibility of the recommendations was not thoroughly examined. conclusion swwud are frequently exposed to behavioural and structural violence, a situation exacerbated by the covid-19 pandemic and the introduction of the nordic model in france. illicit drug use combined with difficult working conditions has contributed to increased hiv and hcv risks posed to swwud. insufficient access to holistic and non-judgemental care combined with discrimination and societal exclusion angoumis, k., langston, a., mosler, k., rialland, c., veys, m. &neicun, j. reducing the burden of hiv and hcv among sex workers who use drugs in france (policy brief). seejph 2023. posted: 09 april 2023 page125 endanger this population’s health through underdiagnosis and delayed treatment. such barriers threaten the achievement of hiv and hcv targets set by the who and unaids. a strategy based on integrating health services embodied in this policy brief may advance change in current trajectories and improve the well-being of swwud. looking forward, other measures focusing on macro-level structural change, such as decriminalising the purchase of sex services and population-wide anti-stigma campaigns, should be developed and combined with the health-service-oriented approaches developed in this policy brief. disclaimer: for the purpose of this policy brief, the operational definition of sex workers is provided by the joint united nations programme on hiv and aids (unaids) guidance note on hiv and sex work (45), whichdefines sex workers as “female, male and transgender adults, over the age of 18, who receive money or goods in exchange for sexual services, either regularly or occasionally, and who may or may not selfidentify as sex workers” p(5). conflicts of interest none declared. references 1. unaids. sex workers must not be left behind in the response to covid19 [internet]. geneva: unaids; 2020 [cited 2022 dec 5]. available from:https://www.unaids.org/en/resour ces/presscentre/pressreleaseandstatem 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nswp. prevention and treatment of hiv and other sexually transmitted infections for sex workers in lowand middle-income countries: recommendations for a public health approach. geneva: world health organization; 2012. 40. kim sr, goldenberg sm, duff p, nguyen p, gibson k, shannon k. uptake of a women-only, sex-workspecific drop-in center and links with sexual and reproductive health care for sex workers. int j gynaecol obstet. 2015;128(3):201-5. 41. benoit c, jansson sm, smith m, flagg j. prostitution stigma and its effect on the working conditions, personal lives, and health of sex workers. j sex res. 2018;55(45):457-71. 42. zoe duby, francisco fong-jaen, busisiwe nkosi, benjamin brown and andrew scheibe. we must treat them like all the other people’: evaluating the integrated key populations sensitivity training programme for healthcare workers in south africa. sajhivmed. 2019 apr 30;20(1):1– 7. 43. world health organization. who implementation tool for pre-exposure prophylaxis (prep) of hiv infection: module 13: integrating sti services. geneva: world health organization; 2022 2022. angoumis, k., langston, a., mosler, k., rialland, c., veys, m. &neicun, j. reducing the burden of hiv and hcv among sex workers who use drugs in france (policy brief). seejph 2023. posted: 09 april 2023 page129 44.international hiv/aids alliance. good practice guide for employing people who use drugs. guide. hove: international hiv/aids alliance; 2015. 45. unaids. unaids guidance note on hiv and sex work. geneva; 2009. appendices appendix a: matrix influence-interest for stakeholders angoumis, k., langston, a., mosler, k., rialland, c., veys, m. &neicun, j. reducing the burden of hiv and hcv among sex workers who use drugs in france (policy brief). seejph 2023. posted: 09 april 2023 page130 appendix b: stakeholder composition, interest, and influence levels types of stakeholders stakeholders interest influence international international institutions committee on the elimination of discrimination against women (cedaw), united nations office on drugs and crime (unodc), european monitoring centre for drugs and drug addiction (emcdda), who, unaids medium high international organisations nswp, european sex workers’ rights alliance (eswra), red umbrella fund, international network for people who use drugs (inpud) high medium national national institutions ministère de la santé et de la prévention (ministry of health and prevention (minhp); ministère chargé de l’égalité entre les femmes et les hommes, de la diversité et de l’égalité des chances (ministry for genderequality, diversity and equalopportunities (minge)); medium high angoumis, k., langston, a., mosler, k., rialland, c., veys, m. &neicun, j. reducing the burden of hiv and hcv among sex workers who use drugs in france (policy brief). seejph 2023. posted: 09 april 2023 page131 ministère de l’enseignement supérieur et de la recherche (ministry of secondaryeducation and research (minser)) national associations french red cross, médecins du monde, medical associations and unions high high local local public authorities municipalities, regional agencies of health; departmental commission for the fight against prostitution, pimping and human trafficking high high community based health services caarud, csapa, cegidd high high local associations gaïa paris, les lucioles high medium community community members, sex workers representatives, peer-navigators, pwwud, swuds high medium _____________________________________________________________________________________________ © 2023 angoumis et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. bishaw t. covid -19 pandemic increasing the african access to vaccination (editorial.). seejph 2020, posted: 24 july 2021. doi: 10.11576/seejph-4608 p a g e 1 | 5 editorial covid -19 pandemic increasing the african access to vaccination a strategy to curb the global spread of infection tewabech bishaw1 member of the lancet covid-19 commission africa task force, june 30, 2021 1) african federation of public health association –wfpha; hon. ass prof. public health, jimma university ethiopia; alliance for brain gain and innovative development, md, addis ababa, ethiopia. e-mail: bishawtewabech@yahoo.com corresponding author: dr. tewabech bishaw, bsc.ph; hlt ed. dip, mph, dr. hsc; address: african federation of public health association –wfpha; hon. ass prof. public health, jimma university ethiopia; alliance for brain gain and innovative development, md, addis ababa, ethiopia; e-mail: bishawtewabech@yahoo.com mailto:bishawtewabech@yahoo.com mailto:bishawtewabech@yahoo.com bishaw t. covid -19 pandemic increasing the african access to vaccination (editorial.). seejph 2020, posted: 24 july 2021. doi: 10.11576/seejph-4608 p a g e 2 | 5 africa recorded the first case of covid-19 on february 14, 2020, a global pandemic, the response to which continues to challenge known public health measures to effectively and sustainably curb the spread and magnitude of the epidemic. early in the epidemic, responses in most african countries were led by national governments. national emergencies were declared, and systems for multisectoral response were put in place. strengthened ministries of health remained responsible for guiding and coordinating national and subnational level responses. human, financial and material resources were leveraged and mobilized to equip national public health institutes and other national entities to ensure health workforce training, strengthen diagnostic capabilities, public information, and disease surveillance systems, including expansion of non-pharmaceutical interventions (npis). over the last two years, the unprecedented social, economic, and political impact of covid-19 negatively affected many countries. school closures, negative impact on businesses, reduced household income, increased inflation, and logistics restraints (global, regional, and national level) created significant blows to the life of millions of africans. the pandemic also disrupted social activities, including banning religious gatherings and other social events disrupting the life of communities. the covid19 pandemic is expected to have devastating health and socioeconomic consequences in many countries in africa, partly because of weak health systems plagued with inadequate surveillance and laboratory capacities. additionally, insufficient health workforce to effectively respond to the pandemic and the lack of vaccines could worsen the situation further. the challenge for many african countries remains to strike a balance between the gains on covid-19 prevention, management, and control with impacts on essential health services and its bearing on other nonhealth impacts (social, economic, and political). cognizant of this and as covid-19 is expected to remain a public health threat for the foreseeable future and the rapidly changing epidemiology of covid-19 variants, many countries are putting in place surveillance systems. these are expected to help monitor status that could guide decisionmaking in emergency preparedness and response by implementing effective mitigating strategies. in this regard, the african center for the prevention and control of communicable diseases the african cdc, a newly established center for disease control under the african union (au). according to reports by the african cdc it is playing an essential role in supporting african countries: training in emergency management and providing technical assistance and technology transfer for establishing disease surveillance systems at a continental level. such new procedures are intended to link with national systems to identify potential global health threats to prepare and respond effectively. through alliances with us cdc, academia, scientific organizations, and other partners, africa cdc developed and released training to address priority national response needs; as a result, covid-19 laboratory testing capacity grew from two countries early in the outbreak to all 55 au member states by august 2020. covid-19 pandemic remains a major concern at the continental and country levels. targeting high-risk populations and improving early diagnosis and treatment capacity are strategic approaches used to control rapidly increasing mortality rates. a new norm of integration of covid-19 services within the essential health services system would reduce morbidity and mortality that are directly and indirectly linked to covid19. however, with its weak health infrastructure and resources, the strategy of choice to combat the pandemic in africa remains early prevention of the spread in communities. key bishaw t. covid -19 pandemic increasing the african access to vaccination (editorial.). seejph 2020, posted: 24 july 2021. doi: 10.11576/seejph-4608 p a g e 3 | 5 to this has been the efforts by all countries to implement non-pharmaceutical interventions (npis) through increased public awareness and strict adherence to the npi norms and standards until vaccines are made accessible to the population. nonetheless, due to various socio-cultural and related factors, sustained adherence to the npi standards by populations in most african communities has increasingly become difficult. hence to combat the spread of infection, urgently calls for accessibility of vaccines to a reasonable proportion of the population in high-risk countries and communities. factors including the socio-political-economy of vaccine availability to countries in africa become both a global public health concern and an ethical consideration. while different companies in different countries produce vaccines, actual availability to countries in africa has become increasingly difficult, calling for more active international solidarity. according to the recent appeal by the lancet covid-19 commission taskforce for africa, the continent is currently experiencing the third and deadliest wave of the covid-19 epidemic. despite africa’s support to covax, africa has not been supplied with the required vaccines so far. while the us now has 46% of its population fully vaccinated as of june 2021, and the eu has 31 % of its population covered, africa has only1.2% of its population fully vaccinated. in total, africa has received just 1.6% of the vaccine doses administered worldwide, only 49 million doses out of the 2.9 billion doses worldwide. one could safely conclude that the global fight to curb the spread of covid-19 could only be realized with equitable global access to the vaccine. vaccine coverage in africa will benefit the entire global community. would you please let me know any advice you may have on how to go about getting this very urgently needed vaccine to the needy populations in africa? urgent appeal for 300 million doses of covid-19 vaccines for africa. the lancet covid-19 commission africa task force june 30, 2021: bishaw t. covid -19 pandemic increasing the african access to vaccination (editorial.). seejph 2020, posted: 24 july 2021. doi: 10.11576/seejph-4608 p a g e 4 | 5 urgent appeal for 300 million doses of covid-19 vaccines for africa the lancet covid-19 commission africa task force june 30, 2021 on behalf of the people of africa, we appeal urgently to the vaccine-producing nations for emergency donations and shipments of at least 300 million doses of vaccines to enable every country in africa to fully immunize at least 20 percent of its adult population by end of august 2021.1 africa is currently experiencing the third and deadliest wave of the covid-19 pandemic, driven by the highly contagious delta variant that was responsible for the recent devastating surge of disease and deaths in india. but africa lacks vaccine protection. it has the lowest vaccine coverage in the world, having received just 1.6 percent of the vaccine doses administered worldwide until june 26 (49 million doses out of 2.9 billion doses worldwide). while the u.s. now has 46 percent of its population fully vaccinated (as of june 30), the european union has about 33 percent, china around 40 percent, and russia around 12 percent, africa has only 1.1 percent of the population fully vaccinated. in absolute numbers, the us and european union have fully vaccinated 299 million individuals compared with just 15 million in all of africa, despite an african population (1.34 billion) that is 73 percent larger than the combined population of the us and european union (776 million). another 20 million africans have received one dose. we note that the scale of current production worldwide makes it now feasible to provide africa with 300 million doses in the next 9 weeks on an urgent and expedited basis. we also note that the us has reached a near saturation in vaccine uptake, meaning that us-based production is now available for shipments to the rest of the world. we emphasize that vaccine coverage in africa is not only for the benefit of africa, but for the entire globe. cases of covid-19 spill across national borders, as do instability and suffering from unabated epidemics. moreover, in regions with surging infections, there are greater opportunities for the emergence of new and dangerous variants of the virus, as has already happened on several occasions. 1we assume that 300 million doses would enable 270 million doses successfully administered. of those, 20 million would constitute the second dose of the current partially immunized individuals, and 250 million doses would be for individuals not yet immunized, resulting in an additional 125 million fully immunized individuals. in total, 160 million africans would be fully immunized, accounting for 20 percent of the 800 million population aged 15 and over. in addition to the provision of vaccines, the international community should provide urgent financial and technical support to the africa cdc and to national covid-19 control programs to support non-pharmaceutical interventions, disease surveillance, diagnostics, vaccination infrastructure for cold chain and vaccination stations, data management systems, and genomic bishaw t. covid -19 pandemic increasing the african access to vaccination (editorial.). seejph 2020, posted: 24 july 2021. doi: 10.11576/seejph-4608 p a g e 5 | 5 surveillance of breakthrough infections. several partner countries have existing programs in africa to support infectious disease control efforts (e.g., for hiv/aids, malaria, and tuberculosis). such programs should be provided with supplemental funding to enable them to extend coverage of covid-19 control, including the rapid scale-up of vaccination programs. members of the africa task force of the lancet covid-19 commission: prof. salim s. abdool karim, co‐chair of the africa task force, caprisa professor for global health in epidemiology, mailman school of public health prof. miriam khamadi were, co‐chair of the africa task force, vice chair, the champions of aids-free generation kenya dr. muhammad pate, co‐chair of the africa task force, global director for health, nutrition and population, the world bank dr. naphtali agata, chair of kemri board of management; health sector consultant at japan international cooperation agency dr. gordon awandare, director of west african center for cell biology of infectious pathogens prof. yanis ben amor, executive director, center for sustainable development in the earth institute; assistant professor of global health and microbiological sciences | secretariat of the lancet covid‐19 commission: yba2101@columbia.edu dr. tewabech bishaw, founder and managing director of alliance for brain‐gain and innovative development (abide prof. abderrahmane maaroufi, director of the institut pasteur maroc (national public health institute) dr. john n. nkengasong, director of the africa centres for disease control and prevention dr. francis omaswa, executive director, african center for global health and social transformation prof. amadou sall, director of the institut pasteur senegal prof. jeffrey sachs, chair of the lancet covid‐19 commission; university professor and director of the center for sustainable development, columbia university, and president of the un sustainable development solutions network dr. michel sidibe, african union special envoy for the african medicines agency (ama); former minister of health and social affairs for mali and executive director of unaids, former under-secretary‐general of the united nations © 2021 bishaw et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. mailto:yba2101@columbia.edu leufak am, ndwandwe d. applying innovative strategies to achieve universal health coverage in the african region. (position paper). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4447 1 position paper applying innovative strategies to achieve universal health coverage in the african region arlette mouako leufak1, duduzile ndwandwe2 1department of global health, stellenbosch university, francie van zijl drive, tygerberg 7505, cape town, south africa 2cochrane south africa, south african medical research council, francie van zijl drive, parow valley 7501, cape town, south africa corresponding author: arlette mouako leufak; address: 6 robyn court, 9 steenbras street parow, cape town, 7500, south africa; email: arlettemouako@gmail.com leufak am, ndwandwe d. applying innovative strategies to achieve universal health coverage in the african region. (position paper). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4447 2 abstract universal health coverage is defined as ensuring that all people have access to needed health services of sufficient quality to be effective while ensuring that these services do not expose the user the financial hardship. universal health coverage includes three related objectives: equity in access to health services (everyone who needs services should get them, not only those who can pay for them); the quality of health services should be good enough to improve the health of those receiving services; and people should be protected against financial risk, ensuring that the cost of using services does not put people at risk of financial harm. africa still has a long way to go to achieve these objectives. many barriers limit the progress of the african region towards building the robust health systems needed for universal health coverage. such barriers include poor infrastructure, high out-of-pocket payments and catastrophic health expenditures, shortages and inequitable distribution of qualified healthcare workers, poor quality of care delivery, high cost of quality medicines, and lack of innovative technologies appropriate to the range of settings where care is delivered, health financing and governance. this paper aims to propose innovative strategies that could be applied to improve health systems in the africa region, which progress towards the continent attaining universal health coverage. keywords: innovative strategies, universal health coverage, african region leufak am, ndwandwe d. applying innovative strategies to achieve universal health coverage in the african region. (position paper). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4447 3 introduction the desire of all communities is to receive good quality healthcare service at an affordable price and to live in good conditions. to fulfil this desire, in 2015 the united nations (un) adopted 17 lifechanging goals, known as sustainable development goals (sdgs) to improve the planet and the lives of all communities by 2030 (see figure 1) (1). goal 3, which is sdg 3 includes 9 targets to be achieved by 2030 (2). of these targets is sdg 3.8, which seeks to achieve universal health coverage (uhc) (2). uhc is comprised of ensuring financial risk protection, access to quality essential healthcare services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all (3). recently, the world health organisation (who) reported that achieving uhc by 2030 may not be achievable (3). at least half of the world’s population still do not have full coverage of essential health services (3), approximately 100 million people further pushed into extreme poverty due to having to pay for health care (3). this is seen in around 930 million people globally spend at least 10% of their household budgets to pay for health care (3). thus, the first un high-level meeting on uhc was held in september 2019 to renew the movement towards uhc (4). member states adopted a political declaration, “universal health coverage: moving together to build a healthier world,” to show their commitment to achieving uhc and reached the sustainable development goal 3 (sdg3) by 2030 (4). the declaration encourages each country to prioritise and implement its national uhc package, tailored to patient needs and considering current health system capacities (4). the who defines uhc as a condition where all people who need health services (prevention, promotion, treatment, rehabilitation, and palliative care) receive them without incurring financial hardship (5). uhc allow everyone to access the health services that address the most important causes of disease and death and ensures that the quality of those services is adequate to improve the health of the people receiving them (3). protecting people from the financial consequences of paying for health services out of their own pockets avoids pushing poor people to extreme poverty (3). many countries, including japan, france, thailand, brazil, turkey, have made significant progress towards uhc (6). in african countries, people continue to experience undue financial hardship while receiving health services (7). the unwarranted financial burden is a result of weak healthcare systems. the african region faces unique challenges that slow the progress of building robust healthcare systems for uhc. such challenges include poor infrastructure; high out-of-pocket payments and catastrophic health expenditures; shortages and inequitable distribution of qualified healthcare workers; poor quality of care delivery; high cost of quality medicines; lack of innovative technologies appropriate to the range of settings where care is delivered; health financing; gaps in governance, leadership, and management (8). this begs the question of which innovative strategies should we apply to drive the african region towards uhc attainment? leufak am, ndwandwe d. applying innovative strategies to achieve universal health coverage in the african region. (position paper). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4447 4 figure 1: sustainable development goals leufak am, ndwandwe d. applying innovative strategies to achieve universal health coverage in the african region. (position paper). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4447 5 findings lack of adequate or modern infrastructure and equipment remains a major concern in africa. most africans health facilities still relying on old equipment, which sometimes are not very effective. even with old equipment, some health facilities, especially those in rural and remote areas, face challenges in providing health services to patients. therefore, patients are usually referred to a health facility in the city to receive better healthcare. even in the city, some are referred to as a developed country where they can find complete access to first-class tools and excellent technology required for treatment. in our opinion, each african government needs to conduct a health infrastructure survey in each province of their countries to identify which infrastructures to innovate, which first-class equipment to implement. the survey should include health professionals, health policymakers, and patients/population. additionally, out-of-pocket spending on healthcare by households continues to be high in africa, contributing to the causing poverty in the continent (3, 9). some african countries like ghana, nigeria, have implemented national medical insurance schemes to reduce out-of-pocket spending on health, yet this scheme covers only a minority (9). only a third of the population receives medical insurance under the country’s national health insurance scheme in ghana. nigeria’s national scheme covers less than 3% of its citizens. given that only a few people are covered in the african continent and poverty is widespread, reducing out-of-pocket payments in africa might help ameliorate health conditions and eliminate or prevent poverty. we suggest that to reduce out-ofpocket health payments in africa, each african government should revise its health policies to establish a national health insurance system that will provide free health care to all citizens or cover at least all the leading communicable diseases (hiv/aids, tuberculosis, malaria) and non-communicable diseases (hypertension, heart disease, diabetes), and all preventable childhood illness. the national health insurance system should not leave anyone behind. besides high out-of-pocket health payments in africa, human resources for health is limited in africa. over half of africa’s population lacks access to essential health services, and the continent’s population is estimated to reach 2.5 billion by 2050 (3, 7). the lack of access to essential health services is attributable to the limited human resources for healthcare and their poor distribution in most african countries. the shortage of human resources for healthcare crucially affects healthcare service delivery in the african region (9). many health professionals have left africa overseas because of low wages, poor working conditions, and insecurity (9). according to who, africa bears more than 24% of the global burden of disease but has access to only 3% of health workers (9). to improve the number of health professionals, we proposed that each african government first assess the number of his health professionals and then see how many are needed to fill the gap. the next step should be to subvention the training of the required health professionals for some time. once the training is done, trainees should be recruited, and their salaries should be considerable. we further suggest that remote and rural areas should not be left behind while planning for training and recruiting. most of remote and rural areas lack highly qualified health professionals. consequently, people living in such areas do not benefit from some of the important health services. to achieve this, public sector should work together with the private sector. the public sector should provide leufak am, ndwandwe d. applying innovative strategies to achieve universal health coverage in the african region. (position paper). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4447 6 opportunities or encourage the private sector to invest in the training of health professionals and the construction of medicals health centres in each province. there should be at least two public faculty of health science and medicine in each area in the african countries. we believe that this might help increase the number of health workers and the quality of health care service delivery in the region. further, our proposition might limit the emigration of health professionals overseas. in the others hand, many people are still dying in africa due to a lack of access to medicine. the key to the three leading causes of death (malaria, tuberculosis and hiv/aids) in africa remain scarce or expensive (9). the scarcity or the high cost of medicines is a result of most medicines being imported to africa. many african countries do not have the technical, financial or human resources required for high–scale drug production. from our perspective, if african governments make an effort to invest more in pharmaceutical research and development and local production, the access to medicine will increase, and the cost will be reduced. however, this cannot be successful without adequate infrastructure, innovative technology, training and retaining of africans scientists. most healthcare settings, especially primary healthcare settings, lack innovative technology that might be useful for increasing healthcare service delivery. for instance, a life-saving device such as mobile vscan ultrasound is not very wellknown in many healthcare facilities in africa (10). vscan ultrasound is a noninvasive device with the size of a smartphone, which provides real-time highresolution images that can be used in medical fields such as cardiology and obstetrics and gynaecology. mobile vscan has been proven to diagnose health conditions and diseases more efficiently and accurately than current practices using standard equipment (10). given the high rate of maternal and new-born mortality overall in the african region, such a device might be useful to prevent deaths of newborns and children under 5 years of age and reduce neonatal and maternal mortality, especially in settings where access to healthcare service is difficult. to our mind, african governments should consider including the budgets for innovative technologies in their agenda. innovative technologies will thus play a vital role in changing african health. researchers suggest that to improve health financing in africa, each african government should increase its revenues mainly through efficient and progressive taxation and increase spending on health, considering long-term fiscal space (11). expand pooling arrangements progressively to reorient private spending into pooled financing arrangements; avoid the fragmentation of financing systems into separate schemes with different levels of funding and benefits for different population groups; target resources to the removal of financial barriers facing the poor and most vulnerable to access priority services (11). manage public funds transparently for better accountability; allocate resources toward inputs and services that generate better results at a lower cost; develop and implement policies and regulations that ensure the efficient use of resources and use incentives in provider payment mechanisms and strengthen provider autonomy and facility management (11). authors proposed that to ameliorate african governance, african governments should introduce mechanisms of voice and community empowerment in health service delivery and establish citizens’ platforms to formulate and review national health policies, strategies and plans, and priority setting and decisions on resource allocation (11). ensure citizens’ access to data and information on uhc freely and adopt a core set of indicators formally to monitor uhc progress and incorporate them in national leufak am, ndwandwe d. applying innovative strategies to achieve universal health coverage in the african region. (position paper). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4447 7 monitoring and evaluation systems (11). provide and enforce fair, transparent, and effective regulatory frameworks and accreditation systems to maximise the reach, affordability, and quality of health services for all (11). develop national whole-of-government multisectoral plans, establish mechanisms for community mobilisation and coordinate across ministries and other stakeholders, and engage with the private sectors effectively to address health risks and promote health (11). initiate, organise and finance collective action on research, tool development, norms and standards, and mutual learning and sharing of experiences on health system strengthening across countries regardless of development status (11). deliver relevant products with an effective interaction of r&d between public and private sectors and strengthen regulatory systems and a skilled workforce to use technology transfer effectively (11). conclusions not much is known about which innovative strategies to employ in the african region to drive the goals of sdgs and uhc. this paper seeks to inform policymakers, african leaders on strategies to apply to improve health systems in the african region and drive the continent towards uhc attainment. there is a gap in knowledge about achieving uhc in africa. we anticipate that the proposed approaches will contribute to filling the knowledge gap on how to achieve uhc in african countries and tailored interventions that could be applied to improve health conditions and services delivery in african communities. however, the proposed strategies might not be applicable to all african countries as each country has its own context even if the challenges faced might be similar. to achieve uhc in the african region, health needs to remain a top priority for all african countries. we have no doubt that if african governments strongly invest in their health system, progress will be made towards uhc in the african region. reinforcing health systems will demand to mobilize more resources for health. such resources might come from gross domestic product (gdp). increasing the annual health budget will help strengthen the health sector. strong health systems are the key factor to achieve uhc and sdgs by 2030. references 1) sustainable development goals. available from:https://www.sightsavers.org/poli cy-and-advocacy/globalgoals/?gclid=cjwkcajw1cx0brbme iway9tkhuufpzr4n92tmvarbb8by ddsulvyy9xchkgbhi__jynojz88i zn5drocpl4qavd_bwe (accessed 06 april 2020). 2) world health organisation. sustainable development goal 3. available from: https://www.who.int/topics/sustainable -development-goals/targets/en/ (accessed 06 april 2020). 3) world health organisation. universal health coverage. 2019. available from: https://www.who.int/newsroom/fact-sheets/detail/universalhealth-coverage-(uhc) (access 07 august 2020). 4) united nation general assembly. moving together to build a healthier world, 2019. available from: https://www.uhc2030.org/. (accessed 16 july 2020). https://www.who.int/topics/sustainable-development-goals/targets/en/ https://www.who.int/topics/sustainable-development-goals/targets/en/ https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc) https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc) https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc) https://www.uhc2030.org/ leufak am, ndwandwe d. applying innovative strategies to achieve universal health coverage in the african region. (position paper). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4447 8 © 2021 leufak et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 5) world health organisation. universal coverage and health financing. available from: https://www.who.int/health_financing/ universal_coverage_definition/en/ (accessed 10 june 2020). 6) maeda a, araujo e, cashin c, harris j, ikegami n, reich mr. universal health coverage for inclusive and sustainable development. a synthesis of 11 country case studies. washington d.c: the world bank; 2014. 7) world health organisation and world bank. universal health coverage “a framework for action”, 2016. 8) world health organisation regional office for africa. sixty-ninth session of the who regional committee for africa, 2019. available from: https://www.afro.who.int/aboutus/governance/sessions/sixty-ninthsession-who-regional-committeeafrica. (accessed, 15 july 2020). 9) africarenewal. health care systems “time for a rethink”, 2017. available from: www.un.org/africarenewal. 10) dawn m. becker, chelsea a. tafoya, soren l. becker, grant h. kruger, matthew j. tafoya, torben k. becke. the use of portable ultrasound devices in lowand middle income countries. int j trop med. 2016:21(3):294–311. 11) universal health coverage advocacy guide 2030 “a guide to promote health systems strengthening to achieve universal health coverage”, 2018. _______________________________________________________________________ https://www.who.int/health_financing/universal_coverage_definition/en/ https://www.who.int/health_financing/universal_coverage_definition/en/ https://www.afro.who.int/about-us/governance/sessions/sixty-ninth-session-who-regional-committee-africa https://www.afro.who.int/about-us/governance/sessions/sixty-ninth-session-who-regional-committee-africa https://www.afro.who.int/about-us/governance/sessions/sixty-ninth-session-who-regional-committee-africa https://www.afro.who.int/about-us/governance/sessions/sixty-ninth-session-who-regional-committee-africa ulrich laaser, wfpha lifetime achievement award for excellence in global health. (short report). seejph 2023. posted: 05 may 2023 page 1 short report wfpha lifetime achievement award for excellence in global health speech at the award ceremony ulrich laaser1 1section of international health, faculty of health sciences, university of bielefeld, bielefeld, germany. corresponding author: professor dr. med. ulrich laaser, dtm&h, mph address: university of bielefeld, school of public health, pob 10 01 31, d 33501 bielefeld, germany email: ulrich.laaser@uni-bielefeld.de ulrich laaser, wfpha lifetime achievement award for excellence in global health. (short report). seejph 2023. posted: 05 may 2023 page 2 dear colleagues, i am extremely honoured to receive this award today from the president of the world federation of public health associations (wfpha), prof. luis eugenio de souza. my involvement with wfpha dates back to 2002, or even a bit earlier, when i became a member of the governing council those times long ago! when i was elected as president for the period 2010-12, the first issue i wanted to solve was to move the secretariat of wfpha from washington dc to geneva, the who centre. the transfer would not have been possible without the selfless support of georges benjamin, executive director of the american public health association (apha). it was about the same year that, happily, i could welcome prof. bettina borisch as the executive director in geneva, where she is acting since untiredly in this role. these years, i also travelled to the far east, china, japan, and indonesia to enlarge our membership. last, certainly not least, with dr. tewabech bishaw, i could support creating the african public health association (afpha) and having our 13th 1 the city of al-quds, yerushalayim, jerusalem is common to all three monotheisms as a holy place world congress organised in 2012 in addis ababa an absolute highlight. with great satisfaction, i observed a recent drive to better integrate the advisory board into the work of wfpha, which was, for some years, a missing link. to many more colleagues, i feel obliged, but i want to speak in the remaining minutes about my present engagement: global dynamics accumulate in the awareness of urgency because the fallout of merging trajectories becomes unpredictable, and the roof term for these concerns became one health. this complex amalgam of expertise predominantly focuses on four interrelated concepts: global, public, planetary, and environmental health. one health keeps these views on the destiny of humankind together. the atmosphere, the oceans, plants and animals – and the human existence on this planet are at stake our civilisation is at stake! the old testament is common to all three global monotheisms. islam, mosaic faith, and christianity1 tell us in genesis 6 about noe and the ark, and almost all religions carry the ulrich laaser, wfpha lifetime achievement award for excellence in global health. (short report). seejph 2023. posted: 05 may 2023 page 3 heritage of a devastating global event – maybe a swarm of meteorites. experts date it to about 8.000 before christ. we can expect a similar catastrophe – this time human-made already before twenty-one-thousand. we are the only species capable of destroying our earth; let us join efforts so that we do not need another ark. i am delighted that the one health commission (ohc) also gets an award today. finally, i am obliged to prof’s luis eugenio de souza and walter ricciardi for the opportunity to address this honourable assembly thank you all! ______________________________________________________________________________ © 2023 ulrich laaser; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1 jacobs publishing house south eastern european journal of public health special volume no. 2, 2022 young indonesian scientists write on public health a collection of spotlights 2 executive editor prof. dr. genc burazeri phd faculty of medicine, st. dibres, no. 371, tirana, albania, and caphri, faculty of health, medicine and life sciences, maastricht university, 6200 md, maastricht, the netherlands email: genc.burazeri@maastrichtuniversity.nl and: gburazeri@gmail.com volume editor prof. dr. med. ulrich laaser dtm&h, mph section of international public health school of public health, bielefeld university pob 10 01 31, d-33501 bielefeld, germany e-mail: ulrich.laaser@uni-bielefeld.de orcid: http://orcid.org/0000-0001-5889-4471?lang=en assistant executive editor kreshnik petrela ba tirana, albania email: kreshnikp@gmail.com technical editor meri roshi ba tirana, albania email: meriroshi90@gmail.com publisher jacobs publishing house hans c. jacobs phd am prinzengarten 1 d 32756 detmold, germany email: info@jacobs-publishing.com the publication of the south eastern european journal of public health (seejph) is organized in cooperation with the bielefeld university library. https://www.seejph.com/index.php/seejph/management/settings/context/mailto:genc.burazeri@maastrichtuniversity.nl https://www.seejph.com/index.php/seejph/management/settings/context/mailto:genc.burazeri@maastrichtuniversity.nl mailto:ulrich.laaser@uni-bielefeld.de http://orcid.org/0000-0001-5889-4471?lang=en https://www.seejph.com/index.php/seejph/libraryfiles/downloadpublic/126 https://www.seejph.com/index.php/seejph/management/settings/context/mailto:kreshnikp@gmail.com https://www.seejph.com/index.php/seejph/libraryfiles/downloadpublic/127 https://www.seejph.com/index.php/seejph/management/settings/context/mailto:urankurtishi@gmail.com mailto:info@jacobs-publishing.com https://www.ub.uni-bielefeld.de/ 3 seejph south eastern european journal of public health www.seejph.com/ special volume 2, 2022 publisher: jacobs publishing house germany issn 2197-5248 4 issn2197-5248 doi 10.4119/unibi/10.11576/seejph-5333. bibliographic information published by die deutschebibliothek. die deutsche bibliothek lists this publication in the deutsche nationalbibliografie; detailed bibliographic data is available on the internet at http://dnb.ddb.de south eastern european journal of public health (open access journal). copyright 2022 by jacobs publishing house: am prinzengarten 1, d 32756 detmold, germany copyright cover picture: wordpress foundation: http://wordpressfoundation.org/gnu general public license http://dnb.ddb.de/ 5 editorial the contributions assembled in this special volume have been selected from a large number of contributions to the international seminar and workshop on public health action (iswopha) 2021, organized by the department of public health, faculty of health science, universitas dian nuswantoro, semarang, indonesia. the important issues treated range from juridical questions around patient records subject of the developing legislation to adolescent pregnancies in nepal and reproductive health literacy, deal with diabetes mellitus and tuberculosis, investigate farmers handling pesticides, and last but not least argue for health protocols at the workplace, urgent in the pandemic situation of today. in the present global situation, we, the workshop organizers, want to underline the essential role of digital health together with improved health literacy. digital technology has the potential to unlock capacities otherwise sealed off, especially in the developing world. the digitalization of our world, however, looks like a two-sided coin: first, reaching the marginalized with essential information on how to protect is an extremely valuable achievement; second, the net also carries infodemic and even purposely wrong information not discernible by the recipients. hopefully, the findings published here will be used to generate better public health policy and better health care resulting in a higher quality of human life. the selected eight contributions of our young scientists demonstrate convincingly: indonesia is on the move. committee iswopha faculty of health science universitas dian nuswantoro semarang, indonesia e-mail: swopha@dinus.id mailto:swopha@dinus.id 6 table of contents rano indradi sudra, sarsintorini putra, inge hartini legal protection of the patient's right to access medical records in indonesia. retno astuti setijaningsih, suyoko, mellinia sukamto, arinimar shaffa wijayanti, brissa gustaviar vaninda, eva nur rochmah, ngesti wahyuni, sabrina hayatun nufus, slamet isworo management of medical record unit services for covid-19 patients in type c hospitals: a study of legal aspects. sweta mahato, sanjeev younjan, anamika mahato fetal outcome of adolescent pregnancy in a tertiary care center in western nepal: a case-control study. eti rimawati, tri nur kristina, sri achadi nugraheni, ani margawati assessing reproductive health literacy: terms of sex genital among caregiver in semarang city. roshan kumar mahato, wongsa laohasiriwong, rajendra koju the role of diabetes mellitus comorbidity on tuberculosis treatment outcomes in nepal: a prospective cohort study. kismi mubarokah, nurjanah, sri handayani, hermin rhema astarini, adelia wahyuningtyas maharani, dewi masitoh, merisha dea salisa, sri dian yulianah tuberculosis literacy and stigma: female activists in five areas with the lowest treatment success rate in semarang, indonesia. eni mahawati effect of safety and hygiene practices on lung function among indonesian farmers exposed to pesticides. mg catur yuantari, enny rachmani, edi jaya kusuma, amelia devi putri ariyanto implementation of health protocols in the workplace during the covid-19 pandemic in indonesia. executive editor volume editor assistant executive editor technical editor meri roshi ba tirana, albania email: meriroshi90@gmail.com publisher adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 1 original research factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria david ayobami adewole1, temitope ilori2 1department of health policy and management, college of medicine, university of ibadan, nigeria; 2family medicine unit, department of community medicine, college of medicine, university of ibadan, nigeria; corresponding author: david ayobami adewole; address: department of health policy and management, college of medicine, university of ibadan, nigeria; telephone: +234 8034052838; email: ayodadewole@yahoo.com mailto:ayodadewole@yahoo.com adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 2 abstract aims: factors that influence the personal choice of a health care facility among health care consumers vary. currently, what influences the choice of health facilities among enrollees under the national health insurance scheme (nhis) is not known. this study aimed to assess what influences the choice of facilities in the nhis of nigeria. methods: this was a descriptive cross-sectional study conducted among enrollees in selected nhis facilities in the 11 local government areas (lgas) of ibadan, nigeria. a total of 432 enrollees were selected and were interviewed. a who-usaid semi-structured intervieweradministered questionnaire was used to obtain relevant data. data collection was between october and december 2019. data were analyzed using stata version 12.0 (α =0.05). results: at unadjusted or, older respondents (or 3.24, ci = 2.52-4.18, p = <0.0001), and those who had attained the tertiary level of education (or 3.30, ci 2.57-4.23, p <0.0001) were more likely to make a personal choice of health care facilities. a similar pattern was observed among respondents who were in the high socioeconomic group (or 4.10, ci 3.015.59, p = <0.0001). however, at adjusted or, only high socio-economic status was a predictor of personal choice of health care facility (or 1.92, ci 1.21-3.05, p = 0.005). conclusion: this study is suggestive that a need for and the ability to afford the cost of care influence the choice of health facilities. policies that promote health literacy in the general populace will enhance the capability of individuals to make a personal choice of health facilities. stakeholders should prioritize this for policy. recommended citation: david a. adewole, temitope ilori. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria keywords: choice, national health insurance scheme, personal, health facility, enrolees acknowledgments: the authors wish to acknowledge study participants for permission to interview them in the course of the data collection of this study. authors' contributions: david adewole conceived and designed the study. temitope ilori did data collection and analysis. both authors contributed equally to the manuscript write-up. the two authors also read through the manuscript draft the second time and agreed to the final manuscript. conflict of interests: none declared. adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 3 introduction while some studies suggest that patients actively choose healthcare facilities evidenced by a significant level of health literacy (1), a substantial proportion of patients do not consider the choice to be very important (2). many factors have been ascribed to influence the choice of healthcare facilities. reliance on physician advice/referrals, advice of friends and relatives, and patronizing the nearest health care facilities are some of the means of choosing health care facilities. socio-demographic factors such as age, sex, educational status and socioeconomic status, cost of care, the severity of illness, existence of multiple morbidities/comorbidity, and past experiences with a facility all influence choice in different ways. cost of care and the ability to pay to play a role in the active choice of facilities (3). however, for those who are on a health care plan, the cost of care may not necessarily be an incentive in the choice of a preferred health care facility as health insurance organizations partly determine the facilities that are available to patients (4). the national health insurance scheme (nhis) of nigeria is a social health insurance program established in the year 2005. currently, the total population coverage is 4 million lives, of which the formal sector constitutes 64% compared with the informal sector. major stakeholders in the scheme are the nhis (government) officials, which provide policy guidelines, the health maintenance organizations (hmos) who are the insurers, and health care providers. by the act that established the scheme, enrolment in the scheme is voluntary. a principal enrollee is entitled to register a spouse and four children below the age of eighteen years under the scheme. the principal enrollee chooses a health care facility to receive care (5). presently, it’s not clear what factors influence the choice of health care facilities among enrollees in the scheme. the present study aimed to determine this. findings would be useful to understand better the level of health literacy of enrollees under the scheme. this will provide an avenue to addressing any existing deficiency in the process of choice of facilities. this could serve as a guide in similar schemes and settings. methods study design and area: this is a descriptive cross-sectional study. it was conducted in the 11 local government areas (lgas) of ibadan, nigeria. the 11 lgas were made up of 5 urban and 6 semi-urban areas. the semi-urban lgas formed an outer ring of the inner 5 lgas (6). the estimated population of the 11 lgas was about 3 million based on the projection using the figure from the 2006 nigeria population census as the base year (7). there were several health care facilities at the primary, secondary, and tertiary care levels in the study area. sample size estimation in this study, factors that influence the choice of health care facilities are the main outcome variable. satisfaction with services is known to influence the choice of facilities, the proportion of the enrollees who were satisfied with the choice of a facility in a previous study in nigeria was 40.7% (8). using the leslie-kish formula, (9) calculated minimum sample size was 420. sampling strategy: a list of all health care facilities within the study area (11 lgas); primary, secondary, and tertiary care level facilities was obtained from the oyo state ministry of health. next, a list of all nhis accredited facilities within the study area was obtained from the nhis office in ibadan. for the choice of enrolees, eleven (11) nhis accredited health facilities, one (1) facility in adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 4 each of the 11 lgas were selected by simple random sampling. the selected facilities were visited and the number of enrollees in each of these facilities was verified. proportional allocation of the estimated sample size (420) was done based on the number of enrollees across the selected nhis accredited facilities. profile of selected facilities there are three levels of care in the health system of nigeria. these are the primary, secondary, and tertiary levels. the primary is the first level of care and entry point of individuals to the health system. the secondary serves as the referral centre for the primary, while the tertiary is the referral centre for the secondary level. the secondary provides general medical and laboratory services, as well as specialized health services, such as surgery, pediatrics, obstetrics, and gynecology to patients referred from the primary health care level, and this is generally uniform. ownership of these facilities cuts across the private and the public (government). ownership in the private sector is either private profit-based or non-for-profit faith-based organizations (10). in the nhis arrangement, the primary level of care is not engaged to provide services. there is only one (1) tertiary level facility within the study area. only the secondary and the tertiary levels do. in this study, only the secondary level of care facilities was selected. due to the small number (only one [1] in the study area) compared to nhis accredited secondary health care facilities, and also because of better infrastructural facilities and human resources availability compared to secondary health care facilities, the only available tertiary health care facility in the study area was not selected. all faith-based health care facilities in the study area (three – 3) were however purposefully selected into the study, while others (non-faith-based private) were selected using stratified systematic sampling to allow for a representation method of sampling. participants’ selection a list of nhis enrolees waiting to receive care in the outpatient unit of a selected health facility was obtained from the medical records department of the facility. eligible individuals were the principal enrolees or spouses (excluding dependents under the age of 18 years) and had enrolled in the facility for at least one year before the commencement of the study. this was to increase the possibility that study participants had an appreciable level of interaction with the health system under the scheme that will enable appropriate responses from them (8). among this population, enrollees who began using the selected facilities before the commencement of the health insurance scheme, as well as enrollees who were health care workers in these facilities were excluded from the study. a sampling frame was generated, a sampling interval was determined, and systematic random sampling was used to select eligible participants. systematic sampling was chosen because it eliminates the phenomenon of clustered selection and a low probability of data contamination. the disadvantage of using a systematic sampling technique is noted and is considered a study limitation. the hospital card numbers of the enrollees who were interviewed were documented and kept safe. data collection selected enrolees (n = 420) in the selected nhis accredited health facilities were interviewed with the aid of an adapted whousaid demographic and health survey semi-structured interviewer-administered questionnaire (united states agency for international development. the demographic and health surveys). enrolees who had earlier been interviewed during the study but came back to the clinic for care adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 5 were deliberately identified and excluded. this was done so as not to interview such individuals a second time, and it was carried out by cross-checking the hospital number of the prospective interviewee (enrolee) in the list of hospital numbers that were earlier documented for safekeeping. this exercise was repeated daily until the allocated number of enrollees in each of the facilities was interviewed. quantitative data analysis choice of health care facilities was categorized into personal and choice-based on advice. while personal choice is the one made by the individual enrolee, a choice based on advice was the one made with the assistance of other individuals and entities such as friends and colleagues, referral physicians, family members, and insurers. quantitative data were analyzed using stata. a chisquare test was used to determine the association between socio-demographic characteristics and the choice of health care facility. following this, statistically significant variables (α = 5%) were entered into multiple logistic regression models to determine the strength of association between the dependent and independent variables (predictors). results the data as shown in table 1 depicts that more than three-quarters, 331(76.6%) of the respondents were at least 35 years of age. about three-fifths, 263 (60.9%) of the respondents were females, while 344 (79.6%) had tertiary level of education, 319 (73.8%) were civil servants. those who were in the high socio-economic status were more, 255(59.0%) compared to those who were in the low group. about one-third of 134 (31.0%) claimed to have multiple morbidities, and 219 (67.4%) sought information about the quality of service in the facility before enrolment. almost three-quarters, 320 (74.1%) of the study participants claimed to have personally chosen health care facilities where current care is received under the scheme. the total number of respondents eventually interviewed was 432 (2.8% above the minimum estimated sample size). table 1: sociodemographic characteristics of respondents socio-demographic characteristics frequency n = 432 percent age group < 35 years 101 23.4 35 and above 331 76.6 sex male 169 39.1 female 263 60.9 marital status married 415 96.1 others 17 3.9 level of education less than tertiary 88 20.4 tertiary 344 79.6 adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 6 table 2 below shows the distribution of respondents by socio-demographic characteristics and by sector. the majority, 319 (73.8%) were civil servants. overall, on the choice of health care facilities, the proportion of those who made a personal choice of facilities among civil servants compared with those who were from the private sector was much higher. however, this was not statistically significant: χ2 = 0.06, p = 0.94. however, choice of facilities was significant across age groups, χ2 28.33, p <0.001, level of education χ2 10.6, p = 0.001, and status of co-morbidities χ2 12.2 p <0.001. table 2: distribution of respondents by socio-demographic characteristics and by place of work socio-demographic characteristics public n(%) private n(%) χ2 (p-value) age group 28.33(<0.001) < 35 years 54 (53.5) 47(46.5) 35 and above 265(80.1) 66(19.9) sex 2.1 (0.11) male 132(78.1) 37(21.9) female 187(71.1) 76(28.9) marital status married 305(73.5) 110(26.5) others 14(82.4) 3(17.6) level of education 10.6 (0.001) less than tertiary 53(60.2) 35(39.8) tertiary 266(77.3) 78(22.7) socio-economic status 0.13(0.71) low 129(72.9) 48(27.1) occupation civil servant 319 73.8 private 113 26.2 socio-economic status low 177 41.0 high 255 59.0 presence of multiple morbidities absent 298 69.0 present 134 31.0 prior information about quality of care in facility yes 291 67.4 no 141 32.6 method of choice of facility personal choice 320 74.1 choice based on advice 112 25.9 adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 7 high 190(74.5) 65(25.5) presence of multiple morbidities 12.2 (<0.001) absent 235(78.9) 63(21.1) present 84(62.7) 50(37.3) prior information about quality of care in facility 0.01(0.98) yes 215(73.9) 76(26.1) no 104(73.8) 37(26.2) method of choice of facility 0.06 (0.94) personal choice 236(73.8) 84(26.2) choice based on advice 83(74.1) 29(25.9) table 3 below shows the pattern of choice of health care facilities among nhis enrollees. generally, respondents claimed the health care facilities where they enrolled for care under the scheme were chosen by personal choice. however, older respondents, married individuals, and those who attained a tertiary level of education were significantly more likely to do so than their respective counterparts ( 2  4.11, p = 0.043; 2  6.73, p = 0.01; 2  6.27, p = 0.012) respectively. also, choice of health care facilities was statistically significant among respondents who were in high socioeconomic status compared with those who were in the low group, ( 2  12.94, p = <0.00001) and as well among those who had multiple morbidities compared with those who were otherwise ( 2  4.30, p = 0.038). table 3: percentage distribution of the enrolees according to choice of health care facilities by socio-demographic characteristics personal choice choice based on advice total 2  p-value socio-demographic characteristics age group 4.11** 0.043 < 35 years 67(66.34) 34(33.66) 101 35 and above 253(76.44) 78(23.56) 331 sex 0.034 0.855 male 126(74.56) 43(25.44) 169 female 194(73.76) 69(26.24) 263 marital status 6.73*** 0.01 married 312(75.18) 103(24.82) 415 others 8(47.06) 9(52.94) 17 level of education 6.27** 0.012 less than tertiary 56(63.64) 32(36.36) 88 tertiary 264(76.74) 80(23.26) 344 occupation 0.0055 0.941 civil servant 236(73.98) 83(26.02) 319 private 84(74.34) 29(25.66) 113 adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 8 at adjusted or, while the presence of multiple morbidities was weakly significantly associated with a personal choice of health care facility (or 1.63, ci 0.97-2.74, p = 0.063, being in the high socio-economic class was highly significantly associated with a personal choice of health care facility (or 1.92, ci 1.21-3.05, p = 0.005). table 4 (below). table 4: logistics regression model of predictors of personal choice of facilities among respondents socio-economic status 12.94*** <0.00001 low 115(64.97) 62(35.03) 177 high 205(80.39) 50(19.61) 255 multiple morbidities absent 212(71.14) 86(28.86) 298 4.30** 0.038 present 108(80.6) 26(19.4) 134 information on quality 0.69 0.405 yes 212(72.85) 79(27.15) 291 no 108(76.60) 33(23.40) 141 closer facility 2.01 0.157 yes 115(78.23) 32(21.77) 147 no 205(71.93) 80(28.07) 285 socio-demographic characteristics unadjusted or adjusted or or 95% c.i p-value or 95% c.i p-value age group < 35 years (ref.) 35 and above 3.24*** 2.52-4.18 <0.0001 1.56 0.89-2.73 0.123 sex male 2.93*** 2.07-4.14 <0.0001 0.88 0.56-1.40 0.601 female (ref.) marital status married 3.03*** 2.42-3.78 <0.0001 0.86 0.42-1.79 0.691 others (ref.) level of education less than tertiary (ref.) tertiary 3.30*** 2.57-4.23 <0.0001 1.47 0.88-2.48 0.145 occupation civil servant (ref.) private 2.90*** 1.90-4.42 <0.0001 1.08 0.63-1.84 0.781 socio-economic status low (ref.) high 4.10*** 3.01-5.59 <0.0001 1.92*** 1.21-3.05 0.005 multiple morbidities adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 9 discussion the older age group respondents were more than double the younger ones. this is at variance with the 2013 ndhs and other reports that the age distribution of nigeria population and similar other countries in the sub-saharan african countries (ssa) characteristically have (5, 11, 12). the observation in this study may be partly due to a long embargo on employment in the formal sector that has resulted in the population of the current formal sector employees, the majority of whom constituted the study respondents, has grown to older age without a concomitant younger population for a gradual replacement. another factor could be that the study population (nhis enrolees) was restricted to a select privileged few unlike if the selection were to be from a more representative general population. however, the population distribution of respondents by sex and by enrolment under the nhis, and by marital status reflects the latest ndhs reports (11, 13). the higher proportion of female respondents may be a reflection of the known better health-seeking behaviour among women compared to that of men (14). it is an expected observation that the majority of the respondents’ attained tertiary level education as enrollees under the nhis are mainly individuals in the formal sector employment of the federal government of nigeria (5). in this study, respondents who were civil servants were almost three times those who were from the private sector. this is in order with credible sources that only a handful of the present enrollees under the nhis were voluntary/private contributors (5, 15). this is also similar to the general pattern observed in some other countries, such as in ghana (16) and kenya, in these countries as it is common in other poor developing ssa countries, the design of social health insurance schemes tends to be unfavourable for the informal sector population who, compared with those in the formal sector, are usually burdened with low and inconsistent income (4). as a result, the majority of the people in this category are compelled to pay health care costs through of pocket method which is associated with the inequity of access to health care and poor health outcomes (17). contextually designed strategies to addressing these challenges will assist in turning around the picture and minimize the likely inequity of access among the informal sector population. several factors interplay differently in different health situations in the same individual to influence the choice of health care facilities. these factors cut across both the consumer and facility sides of the health care market. literature on the choice of health care facilities generally agrees that health care consumers hardly make an active choice of facilities/facilities (2), and, that they more often than do not consider the choice of health facilities to be important. as a result, consumers mostly rely absent (ref.) present 4.30*** 2.71-6.37 <0.0001 1.63* 0.97-2.74 0.063 prior information about quality of care in facility yes (ref.) no 3.27*** 2.22-4.83 <0.0001 1.12 0.69-1.82 0.642 knowledge of nhis facility closer to residence yes 3.59*** 2.43-5.32 <0.0001 1.21 0.75-1.98 0.432 no (ref.) adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 10 on the assistance of others for the choice of health facilities (2, 18). for that purpose, friends, family members, and general practitioners are the usual sources of influence (18, 19). in addition to these, the presence or absence of a health insurance policy also influences the choice of facilities since in most cases, insurers determine the specific facilities that are available to health care consumers (2, 20). in addition, a knowledge of the quality of the care, (21) and the dimensions of care, functional and technical (22) available in health care facilities play a role in the choice of health facilities especially when individuals are well informed about such (1). health care consumers’ attributes such as age, sex, marital status, level of education, and type of occupation are also some of the factors that influence the choice of facilities (2, 20). others are the socio-economic status as well as the presence or absence of comorbidities and perceived severity of illness in individuals (23, 24). there are contrary opinions about the younger age group, while some claimed that this group of people make an active choice of facilities, (2), some are of the contrary view, and that passive choice is more common among them (20, 25). female sex was reported to be associated with passive choice in a previous study in nigeria (26). highly educated individuals and those in the high socioeconomic group have been reported to be more likely to actively choose health care facilities (24, 27). in this study, the personal choice of health care facilities was more likely with more vulnerable individuals such as being married, older individuals, and the presence of multiple morbidities. findings from previous studies corroborate these findings that this category of people is less likely to tolerate the risk of uncertainties and thus, are less favourably disposed to accepting the choice of health care facilities through a third party (2, 20, 23, 28). also, the acquisition of tertiary education and being in the high socio-economic class was associated with the active choice of health care facilities. in this environment, the tertiary level of education is a factor of employment in the formal sector (civil service), who characteristically enjoy a consistent and higher level of income compared with those in the informal sector (4). the synergy of higher income and education could be a strong factor in exposure to better access to beneficial health-related information. this inadvertently enhances the health literacy of such individuals and the tendencies to obtain, process, and compare different health care facilities and services while making a choice (1). it is noteworthy that, when health care consumers have the privilege to choose health care facilities and insurers, it encourages healthy competition, which in turn enhances efficient delivery of quality health services (2, 18, 29, 30). however, of all the factors associated with a personal choice of health facility, high socio-economic status and the presence of multiple morbidities had more influence in the choice of health facilities. it should be noted that the number of those who claimed personal choice of a health facility was almost three times the number of those who claimed a choice based on advice. this finding was in disagreement with the generally held pattern of passive selection of health care facilities by the majority of consumers compared to a few who do active selection (2, 18, 19). again, high socioeconomic class and level of education among the respondents in this study could be contributory factors. in conclusion, this study shows that various socio-demographic factors influence the choice of health facilities among individuals. however, a need for and the ability to afford the cost of care influences the choice of health facilities the most, as demonstrated by the presence of multiple morbidities and a high socio-economic class. it should also noteworthy that the majority made a personal choice of health facilities. this may not be unconnected with a high level of general literacy which may have had a direct impact adewole da, ilori t. factors influencing the choice of facilities among enrolees of a prepayment scheme in ibadan, southwest nigeria (original research). seejph 2021, posted: 12 may 2021. doi: 10.11576/seejph-4430 11 on health literacy. stakeholders should note this for policy purposes. as an emphasis on the benefits of personal choice of health facility, it is recommended that health literacy is promoted in the general populace. this will promote healthy competition among health care facilities and providers and enhance the efficient delivery of quality health care. the limitation of this study is the weakness associated with the systematic sampling technique. findings from a bigger study would have been more representative. it is recommended that a larger more representative study is conducted. it is recommended that a larger more representative study is conducted. this should include rural and remote populations to better differentiate especially education and income levels and the effect of these on the choice 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(accessed 2019 january 21). available from: https://projects.worldbank.org/en/projects-operations/project-detail/p163969?lang=en. (accessed: april 25, 2021). ___________________________________________________________________ https://www.ncbi.nlm.nih.gov/pubmed/?term=patterns+of+hiv%2c+tb%2c+and+non-communicable+disease+multi-morbidity+in+peri-urban+south+africa-a+cross+sectional+study. https://www.ncbi.nlm.nih.gov/pubmed/?term=a+cross-sectional+and+spatial+analysis+of+the+prevalence+of+multimorbidity+and+its+association+with+socioeconomic+disadvantage+in+south+africa%3a+a+comparison+between+2008+and+2012. https://projects.worldbank.org/en/projects-operations/project-detail/p163969?lang=en https://projects.worldbank.org/en/projects-operations/project-detail/p163969?lang=en https://projects.worldbank.org/en/projects-operations/project-detail/p163969?lang=en https://projects.worldbank.org/en/projects-operations/project-detail/p163969?lang=en haque s., terêncio i., stankutė i., bikniūtė i., staišiūnaitė a. towards harmonisation of public health master education based on who-aspher competency framework for public health workforce in the european region (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph4684 p a g e 1 | 17 policy brief towards harmonisation of public health master education based on whoaspher competency framework for public health workforce in the european region sharmi haque1, inês terêncio marques1, ieva stankutė1, inesa bikniūtė1, agnė staišiūnaitė1, katarzyna czabanowska1 1 department of international health, faculty of health, medicine, and life sciences, maastricht university, the netherlands corresponding author: name: sharmi haque email: sharmi.haque@student.maastrichtuniversity.nl address: duboisdomain 30. 6229 gt, maastricht, the netherlands haque s., terêncio i., stankutė i., bikniūtė i., staišiūnaitė a. towards harmonisation of public health master education based on who-aspher competency framework for public health workforce in the european region (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph4684 p a g e 2 | 17 abstract the absence of harmonisation in public health curricula between schools of public health is a possible root cause of the ability to effectively address future public health problems in the european region. increased cross-border mobility enables public health higher education institutions to become transnational actors in the direction of competency-based education. four public health master’s programmes were compared: management of public health in lithuanian university of health sciences (luhs), governance and leadership in european public health in maastricht university (um), public health in national (portuguese) school of public health (ensp) and public health in the university of sheffield (sh). the who-aspher competency framework was used to compare the four public health master programmes. inconsistencies were found among these masters. content and context which includes core public health disciplines appears to be the most consistent element. relations and interactions focus appeared diminished in the four schools examined. performance and achievement varied within the evaluated curricula. (1) the who-aspher competency framework served as a reference to assess the core programme elements for the partial harmonisation of public health masters in relation to the competency, values covered and inter-professional orientation. recommendations: • increase competency-based education • introduce leadership and communication skills in the public health curricula; • increase the network of schools of public health in the european region; • use a competency framework towards partial harmonisation of public health programmes. keywords: curriculum, competency framework, harmonisation, master programme, public health, workforce acknowledgments: we would like to thank prof. kasia czabanowska for the considerate feedback. likewise, we thank julien goodman, director of the agency for public health education accreditation (aphea) secretariat, dr. richard cooper, deputy director of public health section of the university of sheffield, john middleton, aspher president and robert otok, director of aspher secretariat for insightful expert comments. authors’ contributions: all authors contributed equally to this work. conflicts of interest: none declared funding: none declared haque s., terêncio i., stankutė i., bikniūtė i., staišiūnaitė a. towards harmonisation of public health master education based on who-aspher competency framework for public health workforce in the european region (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph4684 p a g e 3 | 17 context population health demands public health professionals (php) to respond to increasingly imminent and global communicable disease outbreaks in the future. (2) the covid-19 pandemic has presented an unprecedented challenge to both the public health field and its professionals. (3) the evolving public health problems require a prepared php for a future that is both variable and unknown. public health education needs to adapt to prepare these professionals for these demands. congruency between public health curriculum and practice is pivotal in allowing php to execute the public health activities they need to undertake. the absence of harmonisation in public health curricula between schools of public health is a possible root cause of the ability of php to effectively address future public health challenges. (4) in addition, php are not regulated health professionals when compared to their counterparts such as medical professional counterparts in the 2005/36/ec directive amended by 2013/55/eu directive, which substantiates the recognition of professional qualifications. (5) the notion of public health differs between the various member states (ms) in europe and the definition is incoherent and poses limitations in translating and ascertaining into the various european languages. (6) its contemporary term is defined as “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society”. (7) there is a growing consensus in europe – on the key competence areas in academic public health curricula (8) and a demand for an equally competent public health workforce (phw) across the ms. (1) to better prepare the phw, education, and performance, workforce planning and investment in capacity-building must be improved. (9) close partnerships between educational institutions and employers are essential to ensure the future employment of php. (10) educational institutions should invest in training to cope with the demands of the public health challenges that their graduates must face. hence public health competencies and values need to be promoted through the harmonisation of the curricula. (10) a comprehensive and integrative approach to competency development is required in order to better understand the needs of ms to build a phw capacity. the association of schools of public health in the european region (aspher) together with the world health organization (who) regional office for europe coalition of partners to strengthen public health services in the european region developed the who-aspher competency framework for the public health workforce in the european region. (1) the framework focuses on three core categories: content and context including science and practice of public health, promoting health, law, policies, and ethics, and one health and health security. relations and interactions including leadership and systems thinking, collaboration partnerships, and communication, culture and advocacy, and performance and achievement including governance and resource management, professional development and reflective ethical practice, and organizational literacy and adaptability. under these categories, ten domains are explored, given a total of 84 relevant public health competencies. annex 1. we evaluated four public health schools in different european countries in order to make recommendations. as a result, we took a sample of some programmes and selected the interviewees who were the best in the field. purpose haque s., terêncio i., stankutė i., bikniūtė i., staišiūnaitė a. towards harmonisation of public health master education based on who-aspher competency framework for public health workforce in the european region (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph4684 p a g e 4 | 17 the aim of this policy brief is to propose recommendations that can contribute to the partial harmonisation of public health master programmes using the who-aspher framework. more specifically, we assessed four public health masters from lithuanian university of health sciences (luhs), maastricht university, national (portuguese) school of public health (ensp), and the university of sheffield in relation to the competency areas included in the who-aspher framework. approaches a narrative literature review and expert consultations were conducted concerning the core areas of public health masters. pubmed and web of science databases were employed in the search for publications related to competencies underlying public health education. keywords such as “public health” “public health education” and “harmonisation” were used as search entries. the narrative literature review permits the examination of emerging evidence and facilitates sufficient literature to be assessed given the focus of the topic (11) the who-aspher competency framework was used as a reference point to establish convergence and divergence between four public health masters. we assessed how the given modules of each school of public health have been aligned to the competency in the framework using both the summary of modules and learning objectives of the curricular unit. tables and graphs were formulated in order to display the comparative results on the public health core competencies of each school of public health. expert consultations were held to provide further perspective into the key competency areas covered by public health education and provide their opinion on the potential need for the harmonisation of public health programmes. the director of the agency for public health education accreditation secretariat, deputy director of public health section of the university of sheffield, the president of association of the schools of public health in the european region (aspher), and the director of aspher secretariat were consulted for a better insight into the public health programmes in the eu. policy recommendations were developed in favour of partial harmonisation of public health master programmes in the european region, particularly with respect to the core public health competencies. limitations the findings were based solely on four different public health programmes and may not be applicable to all academic programmes in europe region. studies that explore a larger number of public health programmes will be profitable in understanding disparities. further analysis would need to be conducted and to get a better overview of the effectiveness of theoretical and practical learning delivery. the assessment of the competencies was performed objectively in alignment with the syllabus information. in order to avoid researcher bias, the further revision would be needed from the course director in order to validate the results. the access to module information was limited at the university’s website. direct communication with the university staff was needed to obtain the necessary information on modules that were inaccessible. findings our findings (figure 1) demonstrate that maastricht university programme in governance and leadership in european public health has 38% of content and context, 33% haque s., terêncio i., stankutė i., bikniūtė i., staišiūnaitė a. towards harmonisation of public health master education based on who-aspher competency framework for public health workforce in the european region (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph4684 p a g e 5 | 17 relations and interaction, and 28% of performance and achievement. the curriculum ap pears balanced with anincreased focus on content and context. in contrast, the national(portuguese) school of public health constitutes a largely content and contextbased course (53%) with a much lesser focus on relations and interaction. however, it has a significant portion of the course within performance and achievement. similarly, the university of sheffield harnesses a content and context-based course (45%) that still highlights the importance of both performance and achievement. in comparison to the other three schools of public health, it presented a broader range of elective modules and fewer core modules when compared to the other three schools of public health. it contributes to the variability of the programme and allows further specialization of the professionals into their topics of interest. however, this poses limitations when the ratio of the core modules and elective modules is fairly equal. lithuanian university of health sciences characterizes a balanced course with a slightly higher focus on performance and achievement. however, the proportion of relations and interactions was only 20%. content and context which is related to more traditional, core public health disciplines appear to be the most consistent element when considering public health programmes. it underpins the concepts of science, knowledge, and theory that explain public health practice. it is essential to further deepen the knowledge for public health graduates as it provides the foundations of understanding public health issues and problems. however, there is an increasing concern as to what extent these public health schools are adequately preparing graduates to contribute towards population health. figure 1 core competencies distribution among the schools of public health evaluated. haque s., terêncio i., stankutė i., bikniūtė i., staišiūnaitė a. towards harmonisation of public health master education based on who-aspher competency framework for public health workforce in the european region (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph4684 p a g e 6 | 17 the focus on relations and interactions appears diminished in all four schools of public health and further work needs to be done. increased collaboration across stakeholders needs to be addressed to ensure that today’s public health curriculum is relevant. covid19 has shown that a shift in focus in reinforcing intersectoral, interdisciplinary, and coordinated international collaboration needs to be implemented and facilitated to ensure an effective response to future possible outbreaks. furthermore, the role of leadership and system thinking does not appear to be fully covered in all four schools of public health. in fact, maastricht university is the only one having a strand that directly approaches leadership. conversely, the national (portuguese) school of public health revealed no incorporation of these competencies within its curricula. leadership revolves around vision, mission, strategy, and inspiration; it establishes direction and leads to change. its integration under public health programmes contributes to the development of a strong and competent phw that is prepared to overcome the constant changes and challenges that characterize the public health sector. (10, 12) identifying strategies to engage with government leaders in integrating community interests and concerns with government priorities during the emergency response is needed. (12) in times of crisis, the emphasis on developing the communication and interactions competency can harbor an effective response to future public health issues. clear communication channels are important to ensure public health compliance and increase trustworthiness. in light of the covid-19 crisis, this would prove invaluable for future pandemic preparedness and should not be exempt from php’s education and training. within the evaluated maastricht university national (portuguese) school of public health the university of sheffield lithuanian university of health sciences content and context relations and interactions performance and achievement haque s., terêncio i., stankutė i., bikniūtė i., staišiūnaitė a. towards harmonisation of public health master education based on who-aspher competency framework for public health workforce in the european region (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph4684 p a g e 7 | 17 curricula, performance and achievement is presented between 28 % to 41 % competencies provide a framework for workforce development planning and actions. competency-based education facilitates what graduates are able to demonstrate learning for a workforce-related need. it is apparent that the schools of public health did not successfully integrate the role of professional development and reflective ethical practice in the education process. according to the experts, ethics and code of conduct were some of the competencies that, although briefly mentioned on the curricula, need more attention. both ethical aspects of individual versus societal and national versus international rules for data protection and data storage should be clearly discriminated in the syllabus. (13) moreover, the ability to self-assess professional development based on the required competency and the willingness to pursue lifelong learning in public health needs should be a part of the education process. (1) overall, the experts agreed on the benefits of a partial harmonisation of public health programmes. it was mentioned that some frameworks were already developed by some countries, such as the uk, and the aspher list of european public health competencies and who-aspher competency framework at a european level. experts stated that funding, cultural backgrounds, and lack of resources are major barriers to achieving harmonisation. moreover, the needs of different health systems can determine the different outcomes of public health master programmes. recommendations 1. increase competency-based education. competency-based education is the present and future of public health education. (14) such education would form the basis of the public health leaders’ professional development, which would enable the workforce to meet the diverse and evolving expectations to improve population health. (15) more traditional educational frameworks often focus on what the student should know, whereas competency-based education focuses on the students’ performance after he graduates and enters the job market. (16) as some programmes of public health have already adopted competency-based education, many have struggled and continue to struggle with the actual implementation and curricular redesign. (14) competency-based education needs to be introduced in public health training to achieve harmonisation among public health curricula and close the gap between public health educational content and the competencies required in practice. (15) 2. introduce leadership and communication skills in the ph curricula. currently, the role of php is constantly changing. leadership skills must be harnessed including the ability to connect with various stakeholders in different sectors and deal with issues in the health system. (17) based on our research, there is a deficiency of leadership and communication skills integration in ph curricula. integration of these skills in the ph curricula will harmonise the professional development of all php in different universities and increase their ability to tackle health problems equally. (18) awareness of how to interact with various parties such as doctors, policymakers or soci haque s., terêncio i., stankutė i., bikniūtė i., staišiūnaitė a. towards harmonisation of public health master education based on who-aspher competency framework for public health workforce in the european region (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph4684 p a g e 8 | 17 ety is critical for php. the knowledge delivery to individuals with various levels of understanding and education, also comprehension and applying cultural awareness and sensitivity in communication with diverse populations is very important. (19) improved communication and leadership skills in public health programmes will harbor new perspectives and opinion exchange in order to facilitate project collaboration and implementation of policy change in the vital public health areas. 3. increase the network of schools of public health in the eu. the advancement of partnerships joining forces in public health preparation has proved useful at the european level. (8) networking between schools of public health is pivotal in strengthening the basis for comprehensive, interdisciplinary, dynamic, and coherent public health education. (20) it would demonstrate a shift towards achieving excellence, knowledge brokering, and the exchange of experience concerning best practices in public health. (20) information exchange among public health schools can contribute to better public health and achieve harmonisation of public health in all european countries. 4. use a competency framework towards partial harmonisation of public health programmes. core competency frameworks for public health education exist in different structures across national and european regions. (1) according to our expert consultations, it would be beneficial for one framework to be agreed upon and move towards harmonisation of public health curricula. through this common framework, the public health graduates can work towards the same core competencies creating an affinity amongst the future european phw, addressing academic gaps, redundancies, and misalignment. the whoaspher competency framework for the public health workforce in the european region can be a starting point to strengthen the education and performance of future phw. (1) conclusions there are disparities between the four european public health masters, which suggest that partial harmonisation based on core competency assessment can prove to be beneficial in educating and preparing phw to combat current and future public health problems such as covid19 pandemic. the who-aspher competency framework is a starting point for competency-based education development. furthermore, the establishment of a comprehensive network among the schools of public health has shown to be useful in achieving partial harmonisation of public health in european countries. references 1. world health organization. whoaspher competency framework for the public health workforce in the european region 2020. 2020;1– 73. available from: http://www.euro.who.int/pubrequest 2. maeshiro r, carney jk. public health is essential: covid-19’s learnable moment for medical education. acad med. 2020; http://www.euro.who.int/pubrequest haque s., terêncio i., stankutė i., bikniūtė i., staišiūnaitė a. towards harmonisation of public health master education based on who-aspher competency framework for public health workforce in the european region (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph4684 p a g e 9 | 17 3. world health organization. impact of covid-19 on people’s livelihoods, their health and our food systems [internet]. 2020 [cited 2020 dec 6]. available from: https://www.who.int/news/item/1310-2020-impact-of-covid-19-on-people’s-livelihoods-their-health-andour-food-systems 4. czabanowska k, rethmeier ka, lueddeke g, smith t, malho a, otok r, et al. public health in the 21st century: working differently means leading and learning differently. eur j public health. 2014; 5. directive 2005/36/ec of the european parliament and of the council of 7 september 2005 on the recognition of professional qualifications [2005] oj l 255/22. 6. european observatory on health systems and policies. public health in europe facets of public health in europe. 2014. 255–266 p. 7. world health organization regional committee for europe. european action plan for strengthening public health capacities and services [internet]. regional committee for europe. 2012. available from: https://www.euro.who.int/__data/assets/pdf_file/0005/171770/rc62wd1 2rev1-eng.pdf 8. bjegovic-mikanovic v, jovicvranes a, czabanowska k, otok r. education for public health in europe and its global outreach. glob health action. 2014; 9. goodman j, overall j, tulchinsky t. public health workforce capacity building lessons learned. assoc sch public heal eur reg [internet]. 2008 [cited 2021 feb 9]; available from: https://www.aspher.org/download/49/aspher_book_final_04-0408.pdf 10. bjegovic-mikanovic v, czabanowska k, flahault a, otok r, shortell s, wisbaum w, et al. addressing needs in the public health workforce in europe [internet]. vol. 10, who regional office for europe. 2014 [cited 2020 oct 25]. available from: https://www.euro.who.int/__data/assets/pdf_file/0003/248304/addressing-needs-in-the-public-health-workforce-in-europe.pdf 11. munn z, peters mdj, stern c, tufanaru c, mcarthur a, aromataris e. systematic review or scoping review? guidance for authors when choosing between a systematic or scoping review approach. bmc med res methodol. 2018; 12. ayeleke ro, dunham a, north n, wallis k. the concept of leadership in the health care sector. in: leadership. 2018. p. 83–90. 13. foldspang a, birt ca. aspher’s european list of core competences for the public health professional. scand j public health. 2018;46(23):1–52. https://www.who.int/news/item/13-10-2020-impact-of-covid-19-on-people%e2%80%99s-livelihoods-their-health-and-our-food-systems https://www.who.int/news/item/13-10-2020-impact-of-covid-19-on-people%e2%80%99s-livelihoods-their-health-and-our-food-systems https://www.who.int/news/item/13-10-2020-impact-of-covid-19-on-people%e2%80%99s-livelihoods-their-health-and-our-food-systems https://www.who.int/news/item/13-10-2020-impact-of-covid-19-on-people%e2%80%99s-livelihoods-their-health-and-our-food-systems https://www.euro.who.int/__data/assets/pdf_file/0005/171770/rc62wd12rev1-eng.pdf https://www.euro.who.int/__data/assets/pdf_file/0005/171770/rc62wd12rev1-eng.pdf https://www.euro.who.int/__data/assets/pdf_file/0005/171770/rc62wd12rev1-eng.pdf https://www.aspher.org/download/49/aspher_book_final_04-04-08.pdf https://www.aspher.org/download/49/aspher_book_final_04-04-08.pdf https://www.aspher.org/download/49/aspher_book_final_04-04-08.pdf https://www.euro.who.int/__data/assets/pdf_file/0003/248304/addressing-needs-in-the-public-health-workforce-in-europe.pdf https://www.euro.who.int/__data/assets/pdf_file/0003/248304/addressing-needs-in-the-public-health-workforce-in-europe.pdf https://www.euro.who.int/__data/assets/pdf_file/0003/248304/addressing-needs-in-the-public-health-workforce-in-europe.pdf https://www.euro.who.int/__data/assets/pdf_file/0003/248304/addressing-needs-in-the-public-health-workforce-in-europe.pdf haque s., terêncio i., stankutė i., bikniūtė i., staišiūnaitė a. towards harmonisation of public health master education based on who-aspher competency framework for public health workforce in the european region (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph4684 p a g e 10 | 17 14. bennett cj, walston sl. improving the use of competencies in public health education. am j public health [internet]. 2015 mar 1 [cited 2021 feb 10];105(suppl 1):s65–7. available from: /pmc/articles/pmc4339999/ 15. czabanowska k, smith t, könings kd, sumskas l, otok r, bjegovicmikanovic v, et al. in search for a public health leadership competency framework to support leadership curriculum-a consensus study. eur j public health. 2013; 16. gruppen ld, mangrulkar rs, kolars jc. the promise of competencybased education in the health professions for improving global health. hum resour health [internet]. 2012 nov 16 [cited 2021 feb 10];10(1):43. available from: https://human-resources-health.biomedcentral.com/articles/10.1186/1478-4491-10-43 17. tulchinsky th, varavikova ea. what is the “new public health”? public health reviews. 2010. 18. azzopardi-muscat n, kluge hhp. public health in the eye of the storm: what can we learn from the covid19 pandemic experience to strengthen public health services in europe? eur j public health. 2020; 19. ratna h. the importance of effective communication in healthcare practice. harvard public heal rev [internet]. 2019;23. available from: http://harvardpublichealthreview.org/healthcommunication/ 20. otok r, czabanowska k, foldspang a. public health educational comprehensiveness: the strategic rationale in establishing networks among schools of public health. scand j public health. 2017; https://human-resources-health.biomedcentral.com/articles/10.1186/1478-4491-10-43 https://human-resources-health.biomedcentral.com/articles/10.1186/1478-4491-10-43 https://human-resources-health.biomedcentral.com/articles/10.1186/1478-4491-10-43 http://harvardpublichealthreview.org/healthcommunication/ http://harvardpublichealthreview.org/healthcommunication/ haque s., terêncio i., stankutė i., bikniūtė i., staišiūnaitė a. towards harmonisation of public health master education based on who-aspher competency framework for public health workforce in the european region (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph4684 p a g e 11 | 17 haque s., terêncio i., stankutė i., bikniūtė i., staišiūnaitė a. towards harmonisation of public health master education based on who-aspher competency framework for public health workforce in the european region (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph4684 p a g e 12 | 17 appendices table 1 core categories and respective domains. content and context relations and interactions performance and achievement science and practice leadership and systems thinking governance and resource management promoting health collaboration partnerships professional development and reflective ethical practice law, policies and ethics communication, culture and advocacy organizational literacy and adaptability one health and health security haque s., terêncio i., stankutė i., bikniūtė i., staišiūnaitė a. towards harmonisation of public health master education based on who-aspher competency framework for public health workforce in the european region (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph4684 p a g e 13 | 17 table 2 maastricht university. content and context relations and interactions performance and achievement science and practice promoting health law, policies and ethics one health and health security leadership and systems thinking collaboration partnerships communication, culture and advocacy governance and resource management professional development and reflective ethical practice organizational literacy and adaptability introduction to governance and leadership in european public health x x x x x public health leadership strand x x x x measuring and comparing health in europe quantitative and qualitative approaches x x x identifying and assessing good and best practices in health x x x x europe as one zoneeuropean health law and policies x x x x x diffusion, implementation and quality assurance of health innovations in europe x x x x x public health law and governance x x x x x the eu, enlargement and public health x x x x research methods x x x x haque s., terêncio i., stankutė i., bikniūtė i., staišiūnaitė a. towards harmonisation of public health master education based on who-aspher competency framework for public health workforce in the european region (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph4684 p a g e 14 | 17 table 3 national (portuguese) school of public health. content and context relations and interactions performance and achievement science and practice promoting health law, policies and ethics one health and health security leadership and systems thinking collaboration partnerships communication, culture and advocacy governance and resource management professional development and reflective ethical practice organizational literacy and adaptability fundamentals of public health x x x x x statistics x x health action and planning strategies x x x health economics x x x health promotion principles and strategies x x x x evidence-based health programs x x x x x epidemiology x x x health law and ethics x x social research methods in health x x x occupational and environmental health x x x health policy and management x x x x haque s., terêncio i., stankutė i., bikniūtė i., staišiūnaitė a. towards harmonisation of public health master education based on who-aspher competency framework for public health workforce in the european region (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph4684 p a g e 15 | 17 table 4 the university of sheffield. content and context relations and interactions performance and achievement science and practice promoting health law, policies and ethics one health and health security leadership and systems thinking collaboration partnerships communication, culture and advocacy governance and resource management professional development and reflective ethical practice organizational literacy and adaptability epidemiology x x x health needs assessment, planning and evaluation x x x x x introduction to research methods x x x x introduction to statistics and critical appraisal x x key issues in global public health x x x x x x x table 5 lithuania university of health sciences. content and context relations and interactions performance and achievement science and practice promoting health law, policies and ethics one health and health security leadership and systems thinking collaboration partnerships communication, culture and advocacy governance and resource management professional development and reflective ethical practice organizational literacy and adaptability public health and health care x x x x x x management and organisational and governance x x x haque s., terêncio i., stankutė i., bikniūtė i., staišiūnaitė a. towards harmonisation of public health master education based on who-aspher competency framework for public health workforce in the european region (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph4684 p a g e 16 | 17 health ethics and human relations x x x x health policy and strategy x x x x x research work x x x health impact assessment x x x leadership and management of changes x x x x applied epidemiology biostatistics and qualitative research x x x research work x x x x health information management x x x x heath economics and applied finances x x x health law x x health care organisation and practice x x x x x x haque s., terêncio i., stankutė i., bikniūtė i., staišiūnaitė a. towards harmonisation of public health master education based on who-aspher competency framework for public health workforce in the european region (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph4684 p a g e 17 | 17 expert consultations interview guide 1what is your opinion on the harmonisation of public health master programmes in european union countries? • what can be possible barriers? 2according to you, what are the most important competencies or competency areas that should be covered by public health master programmes? 3is harmonisation of public health programmes needed? why and how can we move towards the harmonisation of public health education? 4drawing from the results of our research in which we compared ph master curricula in lithuania university of health sciences (luhs), maastricht university (um), national (portuguese) school of public health (ensp) and the university of sheffield (sh) it is evident that leadership is not incorporated in most of the available public health programmes. • why do you think it is the case? • how and to what extent can both leadership and collaboration be further integrated into the public health programmes? 5some public health programmes include elective modules. on one hand these seem to contribute to the variability to the programme, on the other they allow further specialization of the professionals into their topics of interest. until what point can this choice benefit the programmes or be a barrier to harmonisation? 6finally, are you familiar with the who-aspher competency framework for public health workforce in the european region? yes/no • if yes: what do you think, which are the competency areas included in the framework that are mostly reflected in public health programmes. can you give some examples? • if no: explain who-aspher tool and vision and where to find it. 7do you think there is a need for a standard competency framework to support the structure and content of public health master curriculum? if so, are you familiar with other framework © 2021 haque et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. kayacan zc, akgul o. climate change and its extensions in infectious diseases: south eastern europe under focus (review article). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5111. p a g e 1 | 12 review article climate change and its extensions in infectious diseases: south eastern europe under focus. zeynep cigdem kayacan1, ozer akgul1 1 department of medical microbiology, faculty of medicine, istanbul aydin university, istanbul, turkey corresponding author: prof. dr. zeynep cigdem kayacan. istanbul aydin university, faculty of medicine, department of medical microbiology, istanbul, turkey. e-mail: zeynepkayacan@aydin.edu.tr mailto:zeynepkayacan@aydin.edu.tr kayacan zc, akgul o. climate change and its extensions in infectious diseases: south eastern europe under focus (review article). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5111. p a g e 2 | 12 abstract climate change results from natural processes and human-made activities influencing the atmosphere. many infectious diseases are climate-sensitive, and their nature and epidemiology are changing in parallel with the change in climatic conditions and global warming. increased replication rates of pathogens at higher temperatures, extended transmission seasons, migration of vectors or human populations are some outcomes of the changing climate to trigger new concerns, including new epidemics with old or new pathogens. climate change is presenting itself today as an urgent global health threat, and it requires immediate international action with high priority. infectious diseases in relation to changing climatic conditions are reviewed with predominating current examples, focusing on europe with particular emphasis on south eastern european and eurasian regions. keywords: climate change, communicable diseases, disease reservoirs, europe, vectorborne diseases kayacan zc, akgul o. climate change and its extensions in infectious diseases: south eastern europe under focus (review article). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5111. p a g e 3 | 12 background the united nations framework “convention on climate change (unfccc)”, signed in 1992, defines climate change as a change of climate which is attributed directly or indirectly to human activity that alters the composition of the global atmosphere and which is in addition to natural climate variability observed over comparable time periods (1). in fact, the climate discussions had given way much earlier to gathering of the first world climate conference in geneva in 1979, sponsored by the world meteorological organization (wmo) and attended by scientists from a wide range of disciplines. the first evidence of human interference in climate was presented and plans made to establish a world climate programme under the joint responsibility of the wmo and the united nations environment programme (unep) at this same meeting to “prevent man-made changes in climate” that might harm the well-being of humanity (2, 3). in 1988, the un decided to establish the intergovernmental panel on climate change (ipcc) in collaboration with wmo for providing the scientific basis of climate change and its environmental, economic and social impacts as well as its future risks, and for developing possible response strategies (3). following, the before mentioned unfccc was established in 1992 as the first intergovernmental convention and 195 countries signed it but it remained as a goodwill act since it had no sanctions. the unfccc declared the dangerous effects of man-made environmental pollutions on climate and the aim to decrease the levels and sustain the negative effects of the atmospheric greenhouse gases. the kyoto protocol, which was constituted as an operational tool of the unfccc in 1997 but came into force not before 2005, recognized that the developed countries are largely responsible for the high levels of atmospheric greenhouse gas, and it obliged the parties to decrease their emissions. addendum 1 – annex b of the kyoto protocole stated the parties separately as “industrialized countries” such as the oecd members and eu countries and as “economies in transition”, placing a heavier burden on the industrialized and developed countries according to their higher responsive capabilities and greater contributions to high emission levels (4). being an oecd member, turkey was included in the unfccc but did not immediately sign the convention and had not yet become a party in unfcc when the kyoto protocol was accepted in 1997, having, therefore, no listed responsibility to decrease its emission levels (4, 5). later, turkey became a unfccc party in 2004 and of the kyoto protocole in 2009. as the strongest health agreement of this century, the paris agreement was launched at the united nations climate change conference (cop21) in 2015. the agreement came into force in 2016 after 196 countries adopted and signed it. it was a legally binding international treaty concerning climate change, with a specific goal to limit global warming to at least 1.5°c below the pre-industrial levels (6). turkey signed the paris agreement in 2016 but did not approve it at its parliament till october 2021, which in fact was a “must”. the coal-based energy policies of turkey have to change now for decreasing emissions. cop25 was held in madrid and was most talked about all over the world, due to the on-site performance of a group of young activists led by greta thunberg. beyond all other warnings and complaints, greta and the 15 activists aged between 8 and 17, complained about five countries to the un-unicef for neglecting the struggle against climate change. these countries were france, germany, brazil, argentina, and turkey (7). kayacan zc, akgul o. climate change and its extensions in infectious diseases: south eastern europe under focus (review article). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5111. p a g e 4 | 12 greenhouse gases, global warming and extreme weather events the greenhouse gases surround the globe like a blanket and inhibit energy escape from the surface and atmosphere, giving way to extreme warming. sources of human-induced greenhouse gas increases are mainly the use of carbon-containing fossil fuels for energy and production, as well as deforestation, population increase and mobility, planless urbanization and unsuitable agriculture. due to all of these, the arctic ice mass is melting by 2.7% per decade, the sea level is rising by 1.8 mm per year, and extreme weather events are getting more frequent. the ipcc predicted a global average temperature rise of 1.5– 5.8°c for the 21st century, accompanied by increased abnormal weather events (8-10). unless preventive measures are taken, the global temperature will continue to rise, rain patterns will change to cause floods in some regions and droughts in others, and the health effects of climate change are expected to be particularly adverse (11). el niño southern oscillation (enso) is an extreme weather event defined as the hot water wave arising from the pacific ocean and a climate pattern resulting from the aquatic and atmospheric temperature differences. it has a hot phase called el niño and a counter cold phase called la niña. since the pacific ocean is the greatest water mass in the world, every change in its temperature affects the weather and the climate. there are 33 el niño events since 1900, and three of them in 1982, 1997 and 2015 are called super el niños when temperature peaks were recorded. during the 1997 el niño, an area of oceanic water as large as the usa warmed up and pumped a large volume of heat into the atmosphere, changing the weather patterns all over the world. hurricanes, regional floods and droughts resulted in many health problems and thousands of deaths. the 1997 el niño was followed by la niña in 1998-1999, having similar effects in different regions than el niño. the 2015-16 el niño was followed by la niña in 2017-2018, as expected. the enso events always had influence on climate. global warming is strengthening their influences, as well as increasing their frequency. all these occur as the inevitable results of the increase in atmospheric greenhouse gases, influencing in return the global weather events and climate (12, 13). climate change and infectious diseases a pathogen, a host or a vector, and suitable transmission conditions are fundamental for infectious diseases. nearly 75% of the emerging infections are zoonoses hosted by domestic or wild animals and 30% are caused by vector-borne pathogens. zoonoses are sensitive to climate conditions and environment. appropriate climate and weather conditions are necessary for survival, growth, distribution and transmission of pathogens, and geographic expansion of vectors and hosts. most vector-borne and particularly insect-borne infections are linked directly or indirectly to the climate factors such as rainfall, moisture, wind and temperature. global warming changes the habitats of the vectors, pushing them to northern and higher new locations where non-immune people live and get infected more readily. this means new epidemics with the old pathogens (1416). deforestation also causes animals and vectors to lose their habitats and pushes them to search for new ones, getting sometimes closer to humans and increasing the vector-borne human infections (17). global warming favors the spread of infectious diseases, while extreme weather events enhance disease outbreaks at nontraditional places at unexpected times and intensities. climate change has the potential to enhance development of epidemics and probable emergence of new pathogens and new threats. (14-18). kayacan zc, akgul o. climate change and its extensions in infectious diseases: south eastern europe under focus (review article). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5111. p a g e 5 | 12 climate-sensitive infections climate-sensitive infections are handled in three categories in general: vector-borne, water-borne, and air-borne. the climatesensitive vector-borne infections include viral infections such as dengue, zika and hantavirus infections; or bacterial infections such as lyme disease, plague and tularemia; or parasitic infections such as malaria and leishmaniasis. the climatesensitive water-borne pathogens may also be viral such as norwalk virus; or bacterial such as salmonella, vibrio cholerae, noncholera vibrios, legionella or campylobacter; or parasitic such as giardia and cryptosporidium. the major climatesensitive air-borne infections are mainly viral such as influenza and respiratory syncytial virus, in addition to the meningococcic meningitis which is bacterial (17, 18). when temperature increases and rainfall and moisture also increase, water-borne infections such as cholera, as well as leptospirosis and weil’s disease or leishmania infections are more frequent in the relevant regions and mosquitos get more abundant to transmit infections such as malaria or dengue fever. when temperature increases but rainfall and moisture decrease, meningococcal meningitis and west nile virus infection can get more frequent. two million deaths due to diarrheas, one million to malaria and thousands due to meningitis are recorded each year, and there are approximately 50 millions of dengue patients globally. if, however temperature decreases but moisture increases, influenza infections and even epidemics are enhanced (17, 18). la niña had preceded the 1918, 1957, 1968 and 2009 influenza pandemics. the primary reservoirs of influenza-a virus are birds. the migrating birds are affected by the weather and ecosystem changes induced by enso events. not the epidemia-causing ones but the pandemia-causing viral strains are emerging as a result of viral reassortment processes. the enso events change the flight routes and stopover times of the migrating birds, thereby changing the pathogens they carry. under these conditions, different influenza virus subtypes make simultaneous multi-agent infections and therefore reassortments in birds. then, new viruses emerge, infecting animals and humans, making new pandemics from time to time (19). particularly in eastern and south-eastern asia, the population increase, agriculture types and changing routes of migrating birds induced by frequent extreme weather events have provoked the evolution of new influenza virus strains easily extending into far regions (11). vector-borne infections a) tick-borne infections the ixodes ricinus tick is the primary vector in europe (annex fig.1a) for lyme borreliosis and tick-borne viral encephalitis (tbe). caused by the ixodes-transmittedbacterium borrelia burgdorferi, lyme borreliosis loades the eu with the largest disease burden with 65,000 cases per year and is linked to warm winters and high summer temperatures. tbe was detected to be more prevalent in eastern and northern europe with 2,057 cases in 2014 (annex 1b), indicating a four-fold increase of reported cases in european endemic areas during the last 30 years (20, 21). since global warming pushes the tick-vectors to higher altitudes and northern parts, the tbe risk is expected to diminish in southern europe while lyme disease is being surveyed currently to predict its future spread (22). crimean-congo hemorrhagic fever (cchf) is caused by nairovirus transmitted to humans by hyalomma ticks. difficult to prevent and treat with a case fatality ratio of up to 40%, cchf is endemic in most of africa, asia, as well as the balkans and the middle east (annex kayacan zc, akgul o. climate change and its extensions in infectious diseases: south eastern europe under focus (review article). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5111. p a g e 6 | 12 fig. 2a, 2b) (23). bosnia and herzegovina, albania, croatia, serbia, montenegro, slovenia, bulgaria, north macedonia, greece, armenia, georgia, azerbaijan, and russia are endemic for cchf. turkey was affected by cchf outbreaks with more than 12,000 cases but with a case fatality ratio of only 5% in 2002-2019 (23-25). b) mosquito-borne infections the vector-borne infections were endemic to tropical and subtropical regions until recently. due to the long-term changes in temperature and rainfall patterns with global warming, the northern movement of the vectors will put the temperate countries into a greatest threat for emergence and reemergence of the vector-borne diseases, and mosquito-borne diseases may become more epidemic (26). malaria is transmitted to humans through the vector anopheles mosquito. the causative parasite is plasmodium and its most deadly species is plasmodium falciparum. more than 200 million malaria cases and one million deaths per year worldwide were recorded in 2010 (18). control efforts dropped malaria mortality to 409,000 in 2019. the anopheles mosquito survives in environments above 16°c and global warming would support its survival. even though malaria’s current main location is africa, it is projected by the european environment agency (eea) that different countries including turkey and some of south eastern europe will be affected due, among other factors, to the changing climate (18, 27, 28). dengue fever is a vector-borne viral hemorrhagic fever transmitted by aedes aegypti and aedes albopictus mosquitos. the pathogen carried by these vectors is the dengue virus which is an rna virus of the flaviviridae family. rainfall and moisture together with temperature increase enhance the vector survival and spread which may be very rapid. during epidemics, the infection easily spreads into cities and urban life. the infection was limited to tropical and subtropical areas until recently and was the cause of 50-100 millions of cases with 15,000 deaths per year in roughly 100 countries. the vector aedes albopictus (the asian tiger mosquito) which is the most invasive mosquito species in the world gained access to europe by 2010 and cases in croatia, southern france, germany, italy and much of the mediterranean coastal region got acquainted with the dengue fever. aedes aegypti exists more on the black sea coast of europe and in portugal (annex fig. 3), and dengue fever mortality is increasing in the affected regions (18, 29). in 2012-2013, madeira province of portugal reported the first european outbreak with more than 2,000 cases, via aedes aegypti. more than 390 million cases worldwide are estimated currently and it is known that many travelers from dengue-affected areas enter europe (18, 20, 30, 31). the first case in turkey was an imported one, detected in a traveler in 2013 (32). dengue is currently the most widely spread mosquito-borne disease in who's eastern mediterranean region and is actively surveyed for keeping the blood transfusion safety measures under control (31). chikungunya is a viral disease transmitted by aedes mosquitoes to humans. it is manifest with fever, arthralgia and rash, with a probability to end up with chronic arthritis. there is no antiviral treatment or licensed vaccine. although all index cases were imported to europe by travelers from endemic regions, the autochthonous transmission of the infection via local aedes albopictus produced two large outbreaks of chikungunya with a total of 550 confirmed and probable cases in italy in 2007 and 2017. more than 30 cases in france between 2010 and 2017 were also recorded. the risk of the chikungunya virus spread in eu is high due to importation through infected travelers, population susceptibility and presence of the specific vectors particularly around the mediterranean coast (33). kayacan zc, akgul o. climate change and its extensions in infectious diseases: south eastern europe under focus (review article). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5111. p a g e 7 | 12 west nile virus (wnv) infection is transmitted to humans by the vector culex mosquito. human wnv infection had entered europe in 1950. an increased number of outbreaks have been observed over the last twenty years. in 20% of infected cases, the virus develops the west nile fever (wnf), a febrile illness with symptoms similar to those of influenza or dengue. high temperatures in summer have been associated with a west nile fever epidemic in 2010 in southeast europe and following outbreaks have followed the same trend. the largest outbreak of human wnv infections in the european union/european economic area (eu/eea) was in 2018, with 11 countries reporting 1,548 locally acquired mosquito-borne infections. the most affected countries were serbia (126 cases), italy (123), greece (75), hungary (39) and romania (31). the number of wnv cases dropped considerably in 2019, except in greece (34, 35). during the 2020 transmission season from june 1st till mid-november, eu/eea countries reported through the european surveillance system a total of 315 human cases of wnv infection, including 22 deaths. the affected countries were again mostly in central and southern europe: greece (143 cases), spain (77), italy (66), germany (13), romania (6), the netherlands (6), hungary (3) and bulgaria (1) (35). in the 2021 transmission season and as of 21 october 2021, 135 human cases of wnv infection have been reported from eu/eea countries including greece (55), italy (54), hungary (7), romania (7), spain (6), austria (3) and germany (3), with 9 deaths in greece (7), spain (1) and romania (1). eu-neighboring countries had 18 human cases of wnv infection and 3 deaths in serbia (36). the past and present distribution of wnv infection cases in europe are shown in annex fig. 4a and 2025 and 2050 projections for its future distribution are shown in fig. 4b and 4c, respectively. wnv is transmitted also through blood transfusion or organ transplantation (16). hantavirus infection is a rodent-borne, climate-sensitive zoonosis transmitted to humans by different hantaviruses to cause three different clinical syndromes. also referred to as epidemic nephropathy, hemorrhagic fever with renal syndrome by puumala virus is the most prevalent (98%) type in europe with 4,046 cases in 2019 (38, 39). candida auris is an antifungal-resistant yeast preferring mainly the healthcare settings and making difficult-to-control outbreaks of invasive healthcare-associated infections. after its first identification in 2009, centers for disease control and prevention announced it as a catastrophic risk when its infections appeared in three continents simultaneously. within a decade, it spread to 23 countries in five continents, also entering greece and turkey (40, 41). the explanation or hypothesis was its adaptation to global warming. more heat-resistant microbes are being selected while those heat-sensitive are being eliminated. fungi are favored under these trends. the surviving more heat-resistant microbes will also resist endothermic regulations in humans and high fever, which is a defense mechanism for eliminating infectious agents, and serve for insistent infections (42). conclusions climate change brings up complicated health issues already. infectious diseases, many of which are sensitive to the climatic and environmental conditions, may occupy a considerable place in the global agenda for a long time with probable new pathogens, new diseases, new epidemics and pandemics. due to the nature of the climatesensitive infections, the steps leading to solutions can only be within a one-health frame, but legally binding intergovernmental precautions should be followed and monitored in the first place by paris agreement signatory parties, as well as all the remaining public who sincerely kayacan zc, akgul 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130(2): 559-561. 41. kömeç s, karabıçak n, ceylan an, gülmez a, özalp o. türkiye i̇stanbul’dan bildirilen üç candida auris olgusu. mikrobiyol bul. 2021; 55(3): 452-460. 42. johns hopkins researchers. climate change threatens to unlock new microbes and increase heat-related illness and death. available from: https://www.hopkinsmedicine.org/new s/newsroom/news-releases/johnshopkins-researchers-climate-changethreatens-to-unlock-new-microbesand-increase-heat-related-illness-anddeath (accessed: october 10, 2021). 43. abed y, sahu m, ormea v, mans l, lueddeke g, laaser u, hokama t, goletic r, eliakimu e, dobe m, seifman r. south eastern european journal of public health (seejph), the global one health environment, special volume no. 1, 2021. doi: 10.11576/seejph-4238. https://www.ecdc.europa.eu/en/publications-data/climatic-suitability-dengue-transmission-continental-europe https://www.ecdc.europa.eu/en/publications-data/climatic-suitability-dengue-transmission-continental-europe https://www.ecdc.europa.eu/en/publications-data/climatic-suitability-dengue-transmission-continental-europe https://www.ecdc.europa.eu/en/all-topics-z/chikungunya-virus-disease/surveillance-threats-and-outbreaks/autochthonous https://www.ecdc.europa.eu/en/all-topics-z/chikungunya-virus-disease/surveillance-threats-and-outbreaks/autochthonous https://www.ecdc.europa.eu/en/all-topics-z/chikungunya-virus-disease/surveillance-threats-and-outbreaks/autochthonous https://www.ecdc.europa.eu/en/all-topics-z/chikungunya-virus-disease/surveillance-threats-and-outbreaks/autochthonous https://www.euro.who.int/en/countries/italy/news/news/2018/8/west-nile-virus-infections-spike-in-southern-and-central-europe https://www.euro.who.int/en/countries/italy/news/news/2018/8/west-nile-virus-infections-spike-in-southern-and-central-europe https://www.euro.who.int/en/countries/italy/news/news/2018/8/west-nile-virus-infections-spike-in-southern-and-central-europe https://www.euro.who.int/en/countries/italy/news/news/2018/8/west-nile-virus-infections-spike-in-southern-and-central-europe https://www.ecdc.europa.eu/en/publications-data/west-nile-virus-infection-annual-epidemiological-report-2019 https://www.ecdc.europa.eu/en/publications-data/west-nile-virus-infection-annual-epidemiological-report-2019 https://www.ecdc.europa.eu/en/publications-data/west-nile-virus-infection-annual-epidemiological-report-2019 https://www.ecdc.europa.eu/sites/default/files/documents/aer-hantavirus-2019.pdf https://www.ecdc.europa.eu/sites/default/files/documents/aer-hantavirus-2019.pdf https://www.ecdc.europa.eu/sites/default/files/documents/aer-hantavirus-2019.pdf https://www.hopkinsmedicine.org/news/newsroom/news-releases/johns-hopkins-researchers-climate-change-threatens-to-unlock-new-microbes-and-increase-heat-related-illness-and-death https://www.hopkinsmedicine.org/news/newsroom/news-releases/johns-hopkins-researchers-climate-change-threatens-to-unlock-new-microbes-and-increase-heat-related-illness-and-death https://www.hopkinsmedicine.org/news/newsroom/news-releases/johns-hopkins-researchers-climate-change-threatens-to-unlock-new-microbes-and-increase-heat-related-illness-and-death https://www.hopkinsmedicine.org/news/newsroom/news-releases/johns-hopkins-researchers-climate-change-threatens-to-unlock-new-microbes-and-increase-heat-related-illness-and-death https://www.hopkinsmedicine.org/news/newsroom/news-releases/johns-hopkins-researchers-climate-change-threatens-to-unlock-new-microbes-and-increase-heat-related-illness-and-death https://www.hopkinsmedicine.org/news/newsroom/news-releases/johns-hopkins-researchers-climate-change-threatens-to-unlock-new-microbes-and-increase-heat-related-illness-and-death kayacan zc, akgul o. climate change and its extensions in infectious diseases: south eastern europe under focus (review article). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5111. p a g e 11 | 12 annex figure 1. tick-borne encephalitis. (a) distribution of ixodes ricinus ticks in europe, march 2021. available from: https://www.ecdc.europa.eu/en/publications-data/ixodes-ricinuscurrent-known-distribution-march-2021 (accessed: october 10, 2021). (b) number of confirmed tick-borne encephalitis cases in eu/eea, 2014. available from: https://www.ecdc.europa.eu/en/publications-data/figure-1-number-confirmed-tbe-caseseueea-2014 (accessed: october 10, 2021). figure 2. crimean-congo hemorrhagic fever (cchf). (a) distribution of hyalomma marginatum ticks as the major vector for cchf, september 2021. available from: https://www.ecdc.europa.eu/en/publications-data/hyalomma-marginatum-current-knowndistribution-september-2021 (accessed: october 10, 2021). (b) endemic areas for cchf. available from: https://www.cdc.gov/vhf/crimean-congo/outbreaks/distribution-map.html (accessed: october 10, 2021). https://www.ecdc.europa.eu/en/publications-data/ixodes-ricinus-current-known-distribution-march-2021 https://www.ecdc.europa.eu/en/publications-data/ixodes-ricinus-current-known-distribution-march-2021 https://www.ecdc.europa.eu/en/publications-data/figure-1-number-confirmed-tbe-cases-eueea-2014 https://www.ecdc.europa.eu/en/publications-data/figure-1-number-confirmed-tbe-cases-eueea-2014 https://www.ecdc.europa.eu/en/publications-data/hyalomma-marginatum-current-known-distribution-september-2021 https://www.ecdc.europa.eu/en/publications-data/hyalomma-marginatum-current-known-distribution-september-2021 https://www.cdc.gov/vhf/crimean-congo/outbreaks/distribution-map.html kayacan zc, akgul o. climate change and its extensions in infectious diseases: south eastern europe under focus (review article). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5111. p a g e 12 | 12 © 2022 kayacan et al. this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. figure 3. distribution of aedes mosquitos in europe. (a) aedes albopictus, march 2021. available from: https://www.ecdc.europa.eu/en/publications-data/aedes-albopictus-currentknown-distribution-march-2021 (accessed: october 10, 2021). (b) aedes aegypti, january 2019. available from: https://www.ecdc.europa.eu/en/publications-data/aedes-aegypticurrent-known-distribution-january-2019 (accessed: october 10, 2021). figure 4. west nile virus epidemiology. (a) wnv in europe with human cases compared to previous seasons, updated 21 october 2021 (37) (accessed: october 24, 2021). (b) 2025 prediction (16). (c) 2050 prediction (16). https://www.ecdc.europa.eu/en/publications-data/aedes-albopictus-current-known-distribution-march-2021 https://www.ecdc.europa.eu/en/publications-data/aedes-albopictus-current-known-distribution-march-2021 https://www.ecdc.europa.eu/en/publications-data/aedes-aegypti-current-known-distribution-january-2019 https://www.ecdc.europa.eu/en/publications-data/aedes-aegypti-current-known-distribution-january-2019 9. altizer s, ostfeld rs, johnson ptj, kutz s, harvell cd. climate change and infectious diseases: from evidence to a predictive framework. science 2013; 341: 514-519. 10. ipcc, 2001. climate change 2001: synthesis report. in: watson, r.t., team, c.w. (eds.), a contribution of working groups i, ii, and iii to the third assessment report of the integovernmental panel on climate change. cambridge university press, cam... 12. lindsey r. global impacts of el niño and la niña. available from: https://www.climate.gov/news-features/featured-images/global-impacts-el-ni%c3%b1o-and-la-ni%c3%b1a (accessed: may 09, 2021). 13. noaa national oceanic and atmospheric administration. what are el nino and la nina? available from: https://oceanservice.noaa.gov/facts/ninonina.html (accessed: may 09, 2021). 40. ahima rs. global warming threatens human thermoregulation and survival. j clin invest. 2020; 130(2): 559-561. 42. johns hopkins researchers. climate change threatens to unlock new microbes and increase heat-related illness and death. available from: https://www.hopkinsmedicine.org/news/newsroom/news-releases/johns-hopkins-researchers-climate-change-threatens-... 43. abed y, sahu m, ormea v, mans l, lueddeke g, laaser u, hokama t, goletic r, eliakimu e, dobe m, seifman r. south eastern european journal of public health (seejph), the global one health environment, special volume no. 1, 2021. doi: 10.11576/seejp... figure 2. crimean-congo hemorrhagic fever (cchf). (a) distribution of hyalomma marginatum ticks as the major vector for cchf, september 2021. available from: https://www.ecdc.europa.eu/en/publications-data/hyalomma-marginatum-current-known-distributio... figure 4. west nile virus epidemiology. (a) wnv in europe with human cases compared to previous seasons, updated 21 october 2021 (37) (accessed: october 24, 2021). (b) 2025 prediction (16). (c) 2050 prediction (16). 1 south eastern european journal of public health special volume no. 3, 2022 leading policy change in public health a collection of policy briefs jacobs publishing house 2 executive editor prof. dr. genc burazeri phd faculty of medicine, st. dibres, no. 371, tirana, albania, and caphri, faculty of health, medicine and life sciences, maastricht university, 6200 md, maastricht, the netherlands email: genc.burazeri@maastrichtuniversity.nl and: gburazeri@gmail.com skype: genc.burazeri volume editor prof. dr. kasia czabanowska department of international health, care and public health research institute (caphri), faculty of health, medicine and life sciences, maastricht university, 6200 md, maastricht, the netherlands email: kasia.czabanowska@maastrichtuniversity.nl assistant executive editor kreshnik petrela ba tirana, albania email: kreshnikp@gmail.com technical editor meri roshi ba tirana, albania email: meriroshi90@gmail.com publisher dr. hans jacobs jacobs publishing house am prinzengarten 1 d 32756 detmold, germany email: info@jacobs-verlag.de phone: +49 5231 6161885 the publication of the south eastern european journal of public health (seejph) is organised in cooperation with the bielefeld university library. https://www.seejph.com/index.php/seejph/management/settings/context/mailto:genc.burazeri@maastrichtuniversity.nl https://www.seejph.com/index.php/seejph/management/settings/context/mailto:genc.burazeri@maastrichtuniversity.nl https://www.seejph.com/index.php/seejph/libraryfiles/downloadpublic/126 https://www.seejph.com/index.php/seejph/management/settings/context/mailto:kreshnikp@gmail.com https://www.seejph.com/index.php/seejph/libraryfiles/downloadpublic/127 https://www.seejph.com/index.php/seejph/management/settings/context/mailto:urankurtishi@gmail.com mailto:info@jacobs-verlag.de 3 seejph south eastern european journal of public health www.seejph.com/ special volume 3, 2022 publisher: jacobs/germany issn 2197-5248 https://www.ub.uni-bielefeld.de/ 4 issn2197-5248 doi 10.11576/seejph-5672/unibi/seejph-2016106 bibliographic information published by die deutschebibliothek. die deutsche bibliothek lists this publication in the deutsche nationalbibliografie; detailed bibliographic data is available on the internet at http://dnb.ddb.de south eastern european journal of public health (open access journal). copyright 2022 by jacobs publishing house: am prinzengarten 1, d 32756 detmold, germany copyright cover picture: wordpress foundation: http://wordpressfoundation.org/gnu general public license http://dnb.ddb.de/ 5 table of contents editorials developing a new generation of public health leaders katarzyna czabanowska policy brief policy brief on revising the tb action plan for the who european region 2016-2020: what amendments are needed to reach the un sdg3 to eliminate tb epidemics by 2030? willa serling, volodymyr lotushko, nick bocken, lisa gietz, martina paric autism and inclusive education: recommendations for improvement during and after covid-19 anne petronella maria reijnders, sanne quérine van den eijnde, ruben renerus martin janssen, robin van kessel advancing the diversity and inclusion agenda in healthcare organizations: the case of german university hospitals mariam gobianidze, jordan hammond, kira jürgens, katharina reisser, valia kalaitzi the covid-19 pandemic and the right to health of people who use drugs donata eick, océane aubert, kendra dempsey, momone ozawa, eveline van eerd, jessica neicun impact: ideal measures for participation and awareness of climate change: stronger together citizen participation in achieving the european green deal in the meuse-rhine euroregion issam moussa alsamara, stefanie felicitas beinert, jeanne catelijne de jong, maaike jeannette barbara klappe, viktoria sirkku marewski, rana orhan professionalize european public health workforce: the need for a minimum dataset and skills passport benedikt kurtz, deirdre norris hennenberg, lea supke, thi yen chi nguyen proposing a code of ethics for public health professionals in europe sylvia agarici, darin elabbasy, anja hirche, royina saha, jente witte, james c. thomas centralized vaccine procurement in the postcovid-19 european union agata jagusiewicz, cyril onwuelazu uteh, janphilipp götz, jule robertz, minke anna zijlman, ines siepmann increasing fruit and vegetable consumption in ireland alisa c. m. tamminen, gaetan duport, rocío atienza serrano, suzanne m. babich 1_sdgs_policybrief_revisions_new (2)_removed table of contents (1) bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 1 review article what we need to improve the public health workforce in europe? vesna bjegovic-mikanovic 1 , katarzyna czabanowska 2 , antoine flahault 3 , robert otok 4 , stephen m. shortell 5 , wendy wisbaum 6 , ulrich laaser 7 1 university of belgrade, faculty of medicine, centre school of public health and management, belgrade, serbia; 2 department of international health, school for public health and primary care (caphri), faculty of health, medicine, and life sciences, maastricht university, maastricht, the netherlands; 3 institut de santé globale, faculté de médecine de l‘université de genève, switzerland; 4 association of schools of public health in the european region (aspher), brussels office, brussels, belgium; 5 school of public health, haas school of business uc-berkeley, usa; 6 european observatory on health systems and services, who-euro, copenhagen, denmark; 7 faculty of health sciences, university of bielefeld, bielefeld, germany. corresponding author: prof. ulrich laaser, section of international public health, faculty of health sciences, university of bielefeld; address: faculty of health sciences, university of bielefeld, pob 10 01 31, d-33501, bielefeld, germany; e-mail: ulrich.laaser@uni-bielefeld.de bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 2 abstract with the growth and complexity of current challenges such as globalization, health threats, and ageing society, financial constraints, and social and health inequalities, a multidisciplinary public health workforce is needed, supported by new skills and expertise. it has been demonstrated that public health education needs to include a wider range of health related professionals including: managers, health promotion specialists, health economists, lawyers and pharmacists. in the future, public health professionals will increasingly require enhanced communication and leadership skills, as well as a broad, interdisciplinary focus, if they are to truly impact upon the health of the population and compete successfully in today‘s job market. new developments comprise flexible academic programmes, lifelong learning, employability, and accreditation. in europe‘s current climate of extreme funding constraints, the need for upgrading public health training and education is more important than ever. the broad supportive environment and context for change are in place. by focusing on assessment and evaluation of the current context, coordination and joint efforts to promote competency-based education, and support and growth of new developments, a stronger, more versatile and much needed workforce will be developed. keywords: public health competences, public health education, public health workforce. conflict of interest: none acknowledgement: this text has been prepared originally in the context of the policy summary 10 1 by the european observatory on health systems and policies and is published slightly modified and updated in the south eastern journal of public health with the kind permission of the european observatory. 1 bjegovic-mikanovic v, czabanowska k, flahault a, otok r, shortell s, wisbaum w, laaser u (2014) policy summary 10: adressing needs in the public health workforce in europe. european observatory on health systems and policies, who-euro: copenhagen, denmark. bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 3 introduction the bologna process and the who regional office for europe‘s new european policy for health – health 2020 – support the apparent move from interest in the traditional public health worker, a specialist physician, to a more generic worker who will be expected to work across organizational boundaries with a vast array of professionals to promote the public health agenda. new emphasis has been put on further developing public health systems, capacities and functions and promoting public health as a key function in society (1). to do this, public health education needs to include a wider range of health related professionals, including managers, health promotion specialists, health economists, lawyers, pharmacists etc. (2). in the future, public health professionals will increasingly require interdisciplinary and interagency team working and communication skills if they are to truly impact upon the health of the population. but how do we get there? how can this need and the favourable supportive context actually be translated into a better equipped public health workforce? first we need to work together to better understand the current situation. next we need to develop and agree upon core and emerging competences for a well-equipped work force. following this, we need to translate those competences into competency based training education. finally, we need to assess public health performance to determine how we are doing. the steps in figure 1 summarise this process. figure 1. from core public health functions to core competences, teaching curricula and public health performance competence based education and training public health competences may be defined as a “…unique set of applied knowledge, skills, and other attributes, grounded in theory and evidence for the broad practice of public health” (3). who defines competence even more precisely as the combination of technical knowledge, skills and behaviours (4). there is growing recognition that to adequately prepare public health students to meet the challenges of today, the schools must go beyond training in the traditional areas of biostatistics, epidemiology, environmental health sciences, health policy and management, ccoorree ppuubblliicc hheeaalltthh ffuunnccttiioonnss ccoorree ppuubblliicc hheeaalltthh ccoommppeetteenncceess ccoommppeetteennccee bbaasseedd eedduuccaattiioonn aanndd ttrraaiinniinngg eeffffiicciieenntt aanndd aaccccoouunnttaabbllee ppeerrffoorrmmaannccee bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 4 and the social and behavioural sciences. these areas provide the student with a specific set of knowledge and and/or skills in a particular content area. while necessary, they are not sufficient for effective public health practice because they do not equip students with the contextual and integrative competences required to adapt to the new challenges that they will face in practice. thus, in recent years, growing interest can be observed in competence-based medical education due to its focus on outcomes, an emphasis on abilities, a de-emphasis of time-based training, and the promotion of learner-centeredness (5). this method trains graduates in problem solving skills applied to reality-based situations or real time problems in cooperation with institutions in the field (6). competency-based education (cbe) is organized around competences, or predefined abilities, as outcomes of the curriculum. ‗‗competences‘‘ have become the units of medical educational planning (2). cbe has also been introduced in public health training and education to close the bridge between teaching methods and the competences required in practice. in an era of insecurity, educators should make sure that every graduate is prepared for practice in every domain of their future practice. a first step in cbe is the identification of key competences that graduates need in order to perform adequately when entering the public health labour market. box 1 below provides recommendations on developing competences. the professional development of public health leaders requires competence based instruction to increase their ability to address complex and changing demands for critical services (7). determining necessary competences provides a foundation for standards development that can be used to operationalise teaching objectives and design impact and outcome evaluation methods. measuring programme outcome and impact satisfies all stakeholders: providers, practitioners, consumers, and other relevant bodies. clusters of competences, aptitudes, or ability achieved may be indicative of the potential for future achievement. public health workforce development has resulted in pressure for competence-based programming and performance measurement to demonstrate quality and accountability. to support competence-based medical education, many frameworks have been developed: canmeds (8), and the outcome project of the (us) accreditation council for graduate medical education (9). these frameworks form the basis of training for the majority of medical learners in the western world (5). however, based on the results of a systematic literature review, frank et al. observe that competence-based medical education still needs to identify and clarify controversies, proposing definitions and concepts that could be useful to educators across various educational systems (10). still little is known about approaches to cbe in public health, its effectiveness and efforts made for educational quality assurance. therefore, it is important to explore future directions for this approach to prepare health professionals. among the current challenges facing schools of public health is how best to translate these competences into specific learning objectives with measurable outcomes. the role of employers in determining competences in order to assure that the schools of public health adequately address the skill needs of the employment market, close partnerships are needed between employers and educators, both of which are essential components of a ‗knowledge triangle‘ based around the interaction of education, research and innovation (11). many of the competences valued by employers are really enduring qualities, and the need is to find new and better ways for educators to develop them in students, so that they can then be applied in modern workplaces. in fact, the most important skill that europe‘s workers will need in order to adapt to the demands of the future is the ability to be lifelong learners irrespective of the discipline. bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 5 to determine competences, it is of utmost importance to ask public health employers. specifying competences needed by the public health labour market can result in a benchmark approach to competence-based education. the selected competences serving as benchmarks would standardize the criteria for change in education of public health professionals. the benchmarks are relevant, because there is a need for a rapid reform of the educational system as a result of economic and political changes or previous failures to meet employment market needs. moreover, the benchmarks will provide a framework for evaluating the effects of various educational strategies on competence-based education. therefore, there is a need to specify competence requirements for different types and levels of public health employers. thus, the question arises: what do employers consider as most important? some studies suggest that employers value tacit knowledge, generic skills and work-based attitudes more than academic or technical knowledge which they take for granted employing graduates holding an mph degree (12). they look for employees who are motivated, take responsibility and are willing to learn. in view of the contemporary public health employment market worldwide, it is important to acquire the right mix of general and specific skills that fits a certain job. further distinction between skills can be made between ―hard skills‖ and ―soft skills‖. the former refers to rather technical, knowledge-related skills, while the latter includes competences such as communication and team work (13). these ―people skills‖ are essential in order to make the workforce more adaptable. the reason for this might be that these set of competences will not only prepare people for change emotionally and mentally, but they will also have an easier time adapting to a new environment. ―people skills‖ seem to matter in both daily private life and at work. for example, it was found that nurses have higher level of patient satisfaction than doctors because of their better interpersonal skills identification of competences in the us and europe there is growing consensus in the u.s. and europe on the key competence areas in academic public health curricula. influential documents have been produced by the public health foundation, i.e. the tier 1, tier 2 and tier 3 core competences for public health professionals (adopted may 3, 2010) (14). the following key public health competences are stated: epidemiology and biostatistics; environmental health sciences; health policy, management of health services and health economics; health promotion and education; and orientation to public health. additionally, generic competences, like analytical skills, communication skills, financial planning and management skills, and cultural skills are recognized as important for every academic public health professional. in the united kingdom, a public health skills and career framework (15) was developed, which is an attempt to define competences for seven levels of public health employment. in addition, through a year-long process, the association of schools of public health in the european region (aspher) developed six main domains of public health competences (16, 17). there are also many other projects worldwide which aim at the development of more specific lists of competences e.g.: core competences framework for health promotion (18), core competences for public health epidemiologists (19) or competences in the area of public health leadership. the latter are especially of pivotal importance given the repeatedly stated need to develop strong leadership skills in public health professionals (1). bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 6 box 1. recommendations on competence development 1. agree on common definitions, concepts and approaches related to competences, competence standards and cbe. 2. review the existing lists of public health competences with the aim of finding synergies, common understanding, universality or individual health care system specificity as well as selecting best practice examples. 3. agree on the underpinning quality criteria. 4. develop public health educational competence framework comprising core and emerging defined competences (which could be accepted by educators and public health professionals worldwide irrespective of the system they work in), values and convictions. 5. ensure that adequate training is provided and help to develop the workforce in terms of career progression and staff recruitment and retention through such a framework. this should include quality assurance and solid accreditation mechanisms (16). 6. carry out studies on cbe (a limitation of these studies thus far is that they mainly use qualitative approaches, like delphi group rounds, panel studies and focus groups. while these approaches are very useful in identifying the perceptions of key competences, they preclude firm conclusions and have limited representativeness) (12). based on the developed lists of competences, surveys should be given to public health employers, graduates and educators to prioritize key competences and their level of importance. 7. use simple and comprehensive language and define competences as measurable units. 8. make training and research relevant to practice and community service to revitalize the key role of schools of public health in this endeavour (16). 9. study the effects of cbe on public health practice to make it evidence-based and see whether it makes a difference. table 1 illustrates the main emerging competences identified by the european commission for 19 economic sectors. as can be seen, these represent skills related to innovations (e-skills, green skills), ―people skills‖ (intercultural skills and team work) and management (entrepreneurship, intercultural management). moreover, it is emphasized that multi skilling and skill-mix of these factors will be common and necessary. table 1. emerging competences social/cultural technical managerial  intercultural skills  team work  self management  entrepreneurship and innovativeness  ict and e-skills (both at user and expert level)  skills/knowledge related to new materials and new processes  health and green skills (related to health and climiate and environmental solutions)  intercultural management  international value chain management  international financial management  green management (implementing and managing climate and environmental friendly policies and solutions). adapted from: european commission. (2010). transversal analysis on the evolution of skills needs in 19 economic sectors (13) in addition, a set of ―cross-cutting‖ competences has been developed by the association of schools of public health (asph) in the u.s. these include: 1) communication and informatics; 2) diversity and culture; 3) leadership; 4) professionalism; 5) programme planning; and 6) systems thinking (20). bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 7 in regard to communication and informatics, it is important that graduates have an understanding of and ability to use the newly emerging information technologies and social media tools (e.g. i-pads, i-phones, facebook, twitter, etc.) in designing and implementing health interventions and in communicating messages. these tools will become even more important in developing greater public health preparedness to deal with natural disasters, continuing infectious disease outbreaks, and the ongoing threat of bioterrorism. on a different but related note, they are also central to reaching new groups of potential public health professionals through online and distance learning technologies. providing training in the competences associated with diversity and culture is particularly germane to addressing the continued inequalities in health by socioeconomic status and race/ethnicity both within and across countries, and for addressing the health issues associated with increased migration. such skills are essential to understanding and empowering communities to improve health and to adapting public health interventions to local cultures and contexts. it is becoming increasingly evident that in public health, as in other areas of public service and in the private sector, leadership matters (see case study 1 annexed). little is accomplished without it. the fundamental understanding is that no public health problem in history has been successfully met with technical skills alone. while many public health students may not think of themselves as leaders and may not aspire to leadership positions, they should be exposed to different approaches and skills associated with exerting leadership whenever and wherever their careers may take them. investment should be made in the development of innovative and creative management and leadership programmes informed by systems thinking, information science and transformational change principles to strengthen public health leadership. moreover, the particular type of leadership required is not of a traditional command and control variety, but rather akin to what has been termed ―adaptive‖ leadership: leading in contexts where there is considerable uncertainty and ambiguity. these environments often contain imperfect evidence and an absence of agreement about both the precise nature of the problem and the solutions to it. in the future, much of the authority of public health leaders will not come from their position in the health system but rather from their ability to win over and convince others through influence rather than control (21). more schools of public health are placing increased emphasis on the development of leadership competences. in sum, the importance of cross-cutting core and emerging competences for adapting and adequately equipping academic programmes in schools of public health in europe merits further exploration. clearly, these competences will need to be adapted to local contexts associated with different historical, cultural, political and economic circumstances. understanding the different settings involved is of great importance for accountable performance in public health. public health practitioners are expected to be effective in different environments. effective public health practitioners have to work with many different partners and paradigms. along with determining core and emerging competences to in order to develop competence based education in public health, it is important to make an overall strategic plan for public health training and education. box 2 below outlines a strategic framework for capacity building in public health training and education that should be articulated. this should be based on needs, with concrete objectives and targets. bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 8 box 2. strategic framework for capacity building in public health education and training 1. a strategic plan for capacity building in public health education and training in europe should start from a swot analysis and should define specific capacity building objectives and targets (with minimum set of indicators for monitoring and evaluation), which will be linked to european public health needs as well as to the new european policy for health ―health 2020‖ and european public health operations as a public health framework for action; 2. the targets for a strategy to strengthen public health education and training should cover all areas of current conceptual models of public health capacity building within the bologna process as follows: organizational development and resource allocation; degree and curriculum reforms; quality assurance; qualification frameworks; international recognition of degrees and mobility within the european higher education area (ehea) and the rest of the world; policies on widening access to and increasing participation in higher education; attractiveness of european higher education and the global dimension of the bologna process; 3. workforce development in public health should be considered among the highest priorities at national and european level; 4. perspectives on public health and expectations in public health from representatives of other sectors and policy areas should be included to enrich capacity building and lay out a basis for health in all policies; 5. ―public health identity‖ needs to be strong, reflecting the diversification of professional functions in public health and reconciling them with a shared identity: 6. both public health generalists and specialists are needed, as well as "horizontal" public health workers who consider health issues in other key sectors policy areas;  education and training of public health professionals focuses on health incorporated into development policies and tackling the socioeconomic determinants of health;  public health education and training requests to be recognized and developed in other key sectors. public health topics, views and experiences should be included in medical studies and spread through curriculum from the very beginning, as an example: 10-15% proportion of overall medical teaching should become a target. 7. the strategy for capacity building in public health education and training needs to consider horizontal and vertical aspects: it must address all levels of government and administration (supranational to local), as well as in other domains (private, civil society, public, etc). 8. the pace of strategy development for capacity building in public health education and training must fit with the national and international context. one should proceed in a measurable way. new developments in public health education and training as we have seen, the articulation of and consensus on core and emerging competences can inform competency based education and training, leading to a better equipped public health workforce. at the same time, several areas are emerging in the field of public health in europe:  development of broader, more flexible academic public health programmes, based on mobility of students and professionals in the ehea;  expansion of lifelong learning (lll), which involves extending knowledge and gaining skills –acquisition of competences – in the sphs, and application of innovation in training, particularly with regard to information technology (internet and mobile technologies, opencourseware on selected topics, and supportive elements of distance learning in general); and  increased potential of higher education programmes, based at all levels on state of the art research fostering changes by innovation and creativity. regarding the first area, in this section we discuss the move towards joint degrees and collaborative approaches with other schools. with respect to the second, we describe the importance of lifelong learning for growth and especially, increased employability, a new bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 9 development of its own. finally, we explain the new accreditation agency in europe, supporting and bringing about increased possibilities, improved accountability and better performance for public health education. broader, more flexible academic public health programmes although public health has always been ―global‖, under the rubric of ―international health‖, recent efforts have been underway to redefine ―international‖ health as ―global health‖ and think of it as a new and somewhat different field. this movement is being led primarily by medical schools, arguing that the new global health challenges require skills and approaches not typically found in ―traditional‖ schools of public health (22), pointing to the need for greater problem solving based field work, leadership development, and exposure to other disciplines such as engineering, business, law, and public policy. while many schools of public health have provided such training for years (23), there is no doubt that more could be done. the challenges of global health concerns could provide an opportunity for closer relationships between schools of public health and schools of medicine in addition to the other health science professional schools. as we have illustrated, public health is interdisciplinary, drawing on many fields, including biology, mathematics and statistics, law, business, economics and numerous other social science disciplines. however, there is only limited inter-professional education in public health. despite recent renewed interest in inter-professional training – among medicine, dentistry, pharmacy and public health – relatively little is occurring (2). among the reasons are protection of professional turf; the lack of top academic leadership and resources; lack of time and alignment of academic calendars; lack of faculty training and incentives; and lack of recognition by accrediting bodies that inter-professional competences are important (24). however, the most limiting factor in the current conception of inter-professional training is the relative exclusion of the major focus of public health; namely, the health of populations and communities. when most people refer to inter-professional education, they are primarily talking about creating effective patient care centered teams. for example, a recent influential report defines ―inter-professionality‖ as involving “…continuous interaction and knowledge sharing between professionals, organized to solve or explore a variety of education and care issues all which seek to obtain the patient’s participation.” (25). thus, to the extent that inter-professional education gains traction, one of the challenges for schools of public health is to define its role within this area. three possible approaches to inter-professional education include concurrent degrees, joint degrees, and ―embedded‖ degrees that could be given by schools of public health and other health science professional schools, such as medicine, nursing, dentistry, and pharmacy. a concurrent degree involves the admission of students to two schools (e.g. medicine and public health) from the start of the programme with a defined sequencing and pathway of interrelated courses. upon successful completion of requirements, students are simultaneously awarded both degrees. for example, at the university of california at berkeley (usa) such programmes exist between public health and business, public policy, social welfare, city and regional planning, and journalism. however, this is not yet offered with the health science professional schools perhaps because they are not located on the berkeley campus. a joint degree, on the other hand, consists of students receiving two degrees, but typically not at the same time and with relatively little overlapping course work. usually the medical or nursing degree is completed first and then students enrol for their mph degree. in most cases, bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 10 the mph degree is considered ―secondary‖ to the students´ primary clinical degree. many schools of public health in the united states offer such joint degrees. finally, a new and different approach exists which is called an embedded degree. this is offered as an arrangement between the university of california at berkeley school of public health and stanford university´s school of medicine. in this arrangement, up to five stanford medical students interrupt their medical school education during the second year to participate in an intensive one year 42 credit hour set of courses at berkeley´s school of public health. the stanford students then complete their medical training. upon completion of a jointly overseen berkeley-stanford thesis project, students are awarded both their md and mph degrees. the embedded approach is perhaps the most innovative of the three approaches in that it involves placement of a medical degree programme inside a school of public health while still in collaboration with a medical school. in addition to the stanford arrangement ucberkeley school of public health and uc san francisco school of medicine offer a combined ―joint medical programme‖, in which students spend their first three years on the berkeley campus. instruction focuses on case-based individual and team-based problem solving, assessing patients and their illness within the larger context of the community and the social environment in which patients live. upon completion of the three years, students complete their medical training and board exams at the uc san francisco medical school campus. the extent to which these, and possibly other examples of inter-professional training, might be relevant to europe and other parts of the world is a topic worthy of further discussion. lifelong learning and the importance of employability we live in the era of learning, witnessing new educational policy discourse with neo-liberal tenets (26). policies of the eu support the ―learning drive‖. it can be stated that we are observing a shift from competitiveness, growth and employment to employability – the ability to become employed. currently, 21st century competences are on the front page of educational reforms in europe and worldwide. a green paper from the eu commission calls for greater investment in workforce planning, while the eu council has called for greater priority to be given to lifelong learning as ‗a basic component of the european social model‘ (27). in line with the establishment of lifelong learning programme (llp) (decision no 1720/2006/ec amended by 1357/2008 decision), and the "new skills for new jobs" communication, the need to anticipate and match future skills has been developed. with regards to knowledge and skills, there are several systems and frameworks set up on the eu level, especially the european reference framework that defines the eight main competences needed for any person to be able to function successfully in their job and in society. the advantage of using this reference tool is that it actually reflects on the learning outcome of a person instead of only using length of time in the educational system 2 . a classification structure called ‗european skills, competences and occupations‘ (esco) is another example of ongoing work from the eu. this system is planning to bring together the most relevant skills and qualifications for numerous jobs into one network 3 . the european commission supports the development of lifelong skills and competences both formally and informally and opens many financial instruments aiming to promote the development of european educational know how, including the use of modern technology to 2 information retrieved 16/08/2011 from http://ec.europa.eu/education/lifelong-learning-policy/doc44_en.htm. 3 information retrieved 16/08/2011 from http://www.cedefop.europa.eu/en/news/16575.aspx. bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 11 support learning. it has to be noted that effective use of the ec financial instruments contributes to the development of collaborative learning, exchange of good practices and rise of new forms of teaching and learning, ranging from problem-based, active, self-directed, student-centred approaches to blended or hybrid learning, which is a combination of face to face and online learning. a broad range of options exist, such as the principle of mutual recognition of programmes and diplomas through the erasmus mundus grant or simply individual mobility throughout europe. these programmes are not only restricted to european countries, but allow for wider global participation, an important factor to be considered by public health educators. moreover, programmes offered by the european commission support the learning of foreign languages, increasing intercultural understanding, raising awareness of the potential of languages, and calling on decision makers to ensure efficient language education. it should be recognized that public health does not have specific a continuing professional development programme, unlike other health professions, and uses courses from other health care fields. however, as has been illustrated, many possibilities exist that can support the development of continuing education in public health and can help give rise to the still underdeveloped area of lifelong learning in the field. european accreditation accreditation is an important step to help ensure or enhance the level and quality of public health curricula and improve the standardization of a core curriculum in public health education. recently, along with developing lists of competences for public health professionals and for master education, aspher has taken the initiative, together with partners – eupha, the european public health alliance (epha), the european health management association (ehma), and eurohealthnet – and in consultation with who europe and the eu commission, to establish a european agency for accreditation of public health educational programmes and schools of public health. the accreditation agency has become an independent body, the agency for public health education accreditation (aphea), assuring its credibility and gaining approval by international agencies in charge of accrediting bodies and entry into international quality assurance registers. the european accreditation process for master of public health (mph) programmes is now under way. all participant organizations and individuals who contributed to this process are confident that this process will set new and improved standards for mph training in europe. this will ultimately help to improve the competences and employability of those graduating from public health programmes and entering the workforce, thereby contributing to the advancement of the field of public health across the vast european region. membership in the aphea board of directors includes representatives from all five partner organizations, while guidelines require that the chair of the board of accreditation is an individual highly distinguished in the field, but not directly associated with any of the organizations in the consortium. the curriculum required by aphea is based on the core subject domains from the list developed in the european public health core competences programme, although slightly regrouped (table 2). the agency adopted a ―fitness for purpose‖ approach to assess an academic institution based on the premise that an academic institution will set its mission for education and research within the context of a specific regional or national environment. this approach requires institutions to be orderly in developing programme aims, in carrying out ongoing assessments, and in using this information to direct and revise final qualifications, bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 12 curriculum modules, strategies and operations. ongoing assessment is intended to lead to programme improvement as part of this approach. for purposes of determining conformity with aphea accreditation criteria, the board of accreditation will consider current developments and planned changes as they relate to the ―fitness for purpose‖ process. this approach takes into account the diversity of the european schools of public health, but simultaneously sets certain curriculum standards for high quality education and training in public health in europe. the call for commitment circulated to aspher members in october of 2010 indicates that there is great interest among aspher member institutions to undergo accreditation of their public health or equivalent programmes at the european level. the agency started with three accreditations in 2011 and hopes to reach a capacity of ten per year by 2015. table 2. aphea core subject domains for mph curricula core subject areas curriculum content ects * credit ranges** introduction introduction to public health 2 methods in public health epidemiological methods, biostatistical 18-20 methods, qualitative research methods, survey methods population health and environmental sciences (including physical, 18-20 its determinants chemical and biological factors), communicable and noncommunicable disease, occupational health, social and behavioural sciences, health risk assessment, health inequalities along social gradient health policy, economics, healthcare systems planning, 16-18 economics, and organization and management, health policy, management financing health services, health programme evaluation, health targets health education and health promotion, health education, health 16-18 promotion protection and regulation, disease prevention cross-disciplinary biology for public health, law, ethics, ageing, 21-23 themes nutrition, maternal and child health, mental (mandatory and/or health, demography, it use, health informatics, elective courses) leadership and decision-making, social psychology, global public health, marketing, communication and advocacy, health anthropology, human rights, programme planning and development, public health genomics, technology assessment internship/final project supervised by faculty (full time and/or 24-26 resulting in thesis/ adjunct) dissertation/memoire * european credit transfer and accumulation system (or equivalent). ** the subject areas and credit ranges above are recommended; the accreditation process will assess the credit division among subject areas for a given programme. aphea – http://www.aphea.net ceph http://ceph.org/pg_about.htm bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 13 conclusions public health is rapidly gaining prominence in the various public policy domains in europe. the increasing importance of preparedness towards major health threats, the growing recognition of the fact that health is an important resource for economic growth and sustainability, and the heightened awareness of important health inequalities in europe are powerful driving forces in this regard. however, many eu member states and candidate countries have insufficient institutional and professional capacity for public health and the process of reforming the relevant services is slow. compared to the united states and other industrialized countries, as well as some emerging economies (e.g., brazil), the relative lack of public health capacity in the eu is striking (28). in addition, the situations within countries differ a great deal. as stated in the european action plan: current public health capacities and arrangements of public health services vary considerably across the who european region. these differences reflect variations in political prioritization and organizational models of public health services, as well as the distribution of functions and responsibilities across different administrative levels. however, there are many similarities across the european region, mainly in basic needs for public health information, knowledge and competences. there are often continuing problems of under-resourcing, skill shortages, insufficient capacity, poor morale and low pay. competency frameworks for a public health workforce, as well as career pathways, remain under-developed. public health functions are fragmented and sections of the workforce may work in an isolated way. while research capacity is well established in some countries, effective facilitation of research capacities to support policy development and programmes still lags behind (21). as an essential element of good governance, the european ministers of health in the council of europe request that a competent post-graduate training institution is available at national level, as well as in large regions, with links to both academic and health administrations (29). the schools and departments of public health are the main structure to provide education and training for public health professionals, as well as consultation and applied research for health administrations. the public health services, comprised of qualified and certified public health professionals, have to address the four main deficits of information, prevention, social equity and a weak regulatory framework. it is estimated that an additional 22,000 public health professionals are required per year for the european union alone to maintain an appropriate level of services. almost three times the present educational capacity is needed to provide these numbers. however, in order to meet population health needs, significant efforts are required not only to increase the number of public health professionals, but also their quality and relevance to public health (21). traditional disciplinary, sectoral approaches are no longer sufficient to resolve complex health problems and provide different perspectives (30). investing in a multidisciplinary public health workforce is a prerequisite for current challenges. in fact, as stated in the european action plan for strengthening public health capacities and services “a sufficient and competent public health workforce constitutes the most important resource in delivering public health services.” (21). the european schools and departments of public health have widely adopted the bologna format of teaching, as 47 countries are committed to joint action for strengthening a european higher education area (ehea). in spite of this, and as we have indicated, inequalities and the need for harmonization still exist. therefore, agreement is sought especially on bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 14 standardized lists of competences required in order to perform specified service functions. the education and training of public health professionals in europe has to be interdisciplinary and multi-professional, comprising the medical as well as the social sciences. in addition to core competences, cross-cutting competences are important to consider, including broader, multidimensional areas, such as leadership and diversity and culture. these competences should inform and shape public health education and training programmes, leading to competence-based education. this approach closes the bridge between traditional teaching methods and the competences actually required in practice. moreover, it is recognized that education and training for public health should be continuously evaluated and updated by use of performance measurement in everyday public health practice. employability is one of the key criteria for successful training of public health professionals. therefore, two key questions have to be answered: 1) who employs the public health professionals and what are their agendas? 2) what is the performance of public health professionals? it is of utmost importance to measure preferences of public health employers with respect to the competences required by graduates of public health studies at bachelor and master degree levels. specifying competences required by the public health labour market can result in a benchmark approach to competence-based education. the selected competences serving as benchmarks would standardize the criteria for change in education of public health professionals (31). the european union has recognized the importance of developing the field of public health with its et2020 strategy and both the eu and who (health 2020) are cooperating. however, each country should develop a strategic plan for capacity building in public health education and training, starting from a swot analysis and defining specific capacity building objectives and targets with a minimum set of indicators for monitoring and evaluation (see case study 2 annexed). new developments are heading in the direction of broader approaches to training, employability, and better performance of public health professionals. the focus is on defining the underlying competences needed for students to become effective global health professionals and leaders. in the age of innovation, the most valuable knowledge will be tacit, and universities and business must create environments that promote imagination, inspiration, intuition, ingenuity, initiative, a sense-of-self, self-assurance, self-confidence and selfknowledge. in the future, the public health professional will increasingly require skills such as interdisciplinary and interagency team working and communication skills. to the extent that inter-professional education gains traction, one of the challenges for schools of public health is to define its role. three possible approaches include development of concurrent degrees, joint degrees, and ―embedded‖ degrees that could be implemented between schools of public health and other health science professional schools such as medicine, nursing, dentistry, and pharmacy. during recent years, the relevance of a concept of lifelong learning has been recognized by all actors, particularly the european union. supported by blended or hybrid learning and employing online technology, these developments will change the educational landscape for all professionals and help make professionals more employable. in addition, accreditation agencies can help raise the quality and standardization of a core curriculum in public health education. the recent development of the agency for public health education accreditation (aphea) in europe will support and promote improvements in training. finally, it should be recognized that for the public health workforce to truly be equipped to tackle current public health challenges, genuine leadership should exist at all levels. bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 15 leadership that is transformational and collaborative, not top-down, needs to be in place at the policy level, to bring about educational reform; at the teaching level, to implement change; and at the level of public health professionals, to put into practice the new skills. references 1. jakab z. opening ceremony medipol university istanbul, turkey, 18 october 2010. http://www.euro.who.int/__data/assets/pdf_file/0006/124593/rdspeech1810turmedipol-university.pdf (accessed: march 15, 2014). 2. frenk j, chen l, bhutta za, cohen j, crisp n, evans t, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376:1923-58. 3. asph, association of schools of public health: demonstrating excellence in practice-based teaching for public health, 2004. www.asph.org (accessed: march 15, 2014) 4. who: regional committee for europe eur/rc61/inf.doc./1 sixty-first session: baku, azerbaijan, 12–15 september 2011. http://www.euro.who.int/en/who-weare/governance/regional-committee-for-europe/sixty-firstsession/documentation/information-documents/inf-doc-1-strengthening-public-healthcapacities-and-services-in-europe-a-framework-for-action (accessed: march 15, 2014) 5. frank jr, snell ls, cate ot, holmboe es, carraccio c, swing sr, et al. competence-based medical education: theory to practice. med teach 2010;32:638-45. 6. steele re. the cdc/hrsa public health faculty agency forum: creating recommendations and guidelines for competence based public health education. internet j public health educ 2001;3:1-5. 7. wright k, rowitz l, merkle a, reid, wm, robinson g, herzog b et al. competence development in public health leadership. am j public health 2000;90:1202-7. 8. frank jr, editor. the canmeds 2005 physician competence framework: better standards, better physicians, better care. ottawa: the royal college of physicians and surgeons of canada, 2005. 9. swing sr. the acgme outcome project: retrospective and prospective. med teach 2007;29:648–54. 10. albanese ma, mejicano g, mullan p, kokotailo p, gruppen l. defining characteristics of educational competences. med educ 2008;42:248–55. 11. european university-business cooperation thematic forum. new skills for new jobsthe role of higher education institutions and business cooperation. report (october 2009). http://www.eurireland.ie/_fileupload/2010/final%20report%209%20dec%2009.pdf (accessed: march 15, 2014). 12. biesma rg, pavlova m, vaatstra r, van merode gg, czabanowska k, smith t, groot w. generic versus specific competences of entry-level public health graduates: employers perceptions in poland, the uk, and the netherlands. adv health sci educ theory pract 2008;13:325–43. 13. european commission, dg employment. transversal analysis on the evolution of skills needs in 19 economic sectors. european commission, 2010. http://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&ved=0cd sqfjad&url=http%3a%2f%2fec.europa.eu%2fsocial%2fblobservlet%3fdocid% 3d4689%26langid%3den&ei=ew0tu_kcdoirtaa4kibi&usg=afqjcnfvmup_v aqmihpm-4cc5ae1ahfr7w&bvm=bv.62286460,d.yms (accessed: march 15, 2014). http://www.ncbi.nlm.nih.gov/pubmed?term=frenk%20j%5bauthor%5d&cauthor=true&cauthor_uid=21112623 http://www.ncbi.nlm.nih.gov/pubmed?term=chen%20l%5bauthor%5d&cauthor=true&cauthor_uid=21112623 http://www.ncbi.nlm.nih.gov/pubmed?term=bhutta%20za%5bauthor%5d&cauthor=true&cauthor_uid=21112623 http://www.ncbi.nlm.nih.gov/pubmed?term=cohen%20j%5bauthor%5d&cauthor=true&cauthor_uid=21112623 http://www.ncbi.nlm.nih.gov/pubmed?term=crisp%20n%5bauthor%5d&cauthor=true&cauthor_uid=21112623 http://www.ncbi.nlm.nih.gov/pubmed?term=evans%20t%5bauthor%5d&cauthor=true&cauthor_uid=21112623 bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 16 14. public health foundation tier 1, tier 2 and tier 3 core competences for public health professionals. council on linkages between academia and public health practice. washington dc, 2010. 15. rao m. public health skills and career framework. england: department of health in england (public health skills and career framework), 2008. http://www.sph.nhs.uk/sphfiles/phskillscareerframework_launchdoc_april08.pdf/v iew (accessed: march 15, 2014). 16. aspher, association of schools of public health in the european region. provisional lists of public health core competences. brussels: 2008. 17. aspher, association of schools of public health in the european region. aspher‘s european public health core competences programme (christopher birt, anders foldspang): publication no. 5: european core competences for public health professionals (eccphp); publication no. 6: european core competences for mph education (eccmphe); publication no. 7: philosophy, process and vision. brussels, 2011. 18. iuhpe, 2011. http://www.iuhpe.org/index.php/en/global-working-groups-gwgs/wgon-competencies-and-workforce-development-cwdg (accessed: march 15, 2014). 19. ecdc, european centre for disease prevention and control: core competences for public health epidemiologists working in the area of communicable disease surveillance and response in the european union. stockholm, 2008. 20. asph, association of schools of public health. masters degree in public health core competence development project, version 2.3. asph education committee, washington, dc: 2006. 21. who. regional committee for europe, european action plan for strengthening public health capacities and services eur/rc62/conf.doc./6 rev.2, sixty-second session: malta, 10-13 september, 2012. 22. koplan jp, bond tc, merson mh, reddy ks, rodriguez mh, sewankambo nk, et al. towards a common definition of global health. lancet 2009;373:1993-5. 23. fried lp, bentley me, buekens p, burke ds, frenk jj, klag mj, spencer hc. global health is public health. lancet 2010;375:535-7. 24. interprofessional education collaborative: core competences for interprofessional collaborative practice, washington, dc: may 2011. 25. d‘amour d, oandasan. interprofessionality as the field of interprofessional practice and interprofessional education: an emerging concept. j interprof care 2005;suppl 1:8-20. 26. brine j. lifelong learning and the knowledge economy: those that know and those that do not—the discourse of the european union. brit educ res j 2006; 32:649-65. 27. european commission. communication from the commission to the european parliament, the council, the european economic and social committee and the committee of the regions. european commission: 2008. 28. bjegovic-mikanovic v, vukovic d, otok r, czabanowska k, laaser u. education and training of public health professionals in the european region: variation and convergence. int j public health 2013;58:801-10; doi: 10.1007/s00038-012-0425-2. 29. council of europe. committee of ministers, 2012. https://wcd.coe.int/viewdoc.jsp?ref=cm%282010%2914&language=lanenglish&s ite=cm&backcolorinternet=c3c3c3&backcolorintranet=edb021&backcolorlog ged=f5d383 (accessed: march 15, 2014). http://www.ncbi.nlm.nih.gov/pubmed?term=koplan%20jp%5bauthor%5d&cauthor=true&cauthor_uid=19493564 http://www.ncbi.nlm.nih.gov/pubmed?term=bond%20tc%5bauthor%5d&cauthor=true&cauthor_uid=19493564 http://www.ncbi.nlm.nih.gov/pubmed?term=merson%20mh%5bauthor%5d&cauthor=true&cauthor_uid=19493564 http://www.ncbi.nlm.nih.gov/pubmed?term=reddy%20ks%5bauthor%5d&cauthor=true&cauthor_uid=19493564 http://www.ncbi.nlm.nih.gov/pubmed?term=rodriguez%20mh%5bauthor%5d&cauthor=true&cauthor_uid=19493564 http://www.ncbi.nlm.nih.gov/pubmed?term=sewankambo%20nk%5bauthor%5d&cauthor=true&cauthor_uid=19493564 http://www.ncbi.nlm.nih.gov/pubmed?term=fried%20lp%5bauthor%5d&cauthor=true&cauthor_uid=20159277 http://www.ncbi.nlm.nih.gov/pubmed?term=bentley%20me%5bauthor%5d&cauthor=true&cauthor_uid=20159277 http://www.ncbi.nlm.nih.gov/pubmed?term=buekens%20p%5bauthor%5d&cauthor=true&cauthor_uid=20159277 http://www.ncbi.nlm.nih.gov/pubmed?term=burke%20ds%5bauthor%5d&cauthor=true&cauthor_uid=20159277 http://www.ncbi.nlm.nih.gov/pubmed?term=frenk%20jj%5bauthor%5d&cauthor=true&cauthor_uid=20159277 http://www.ncbi.nlm.nih.gov/pubmed?term=klag%20mj%5bauthor%5d&cauthor=true&cauthor_uid=20159277 http://www.ncbi.nlm.nih.gov/pubmed?term=spencer%20hc%5bauthor%5d&cauthor=true&cauthor_uid=20159277 bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 17 30. choi bc, pak aw. multidisciplinarity, interdisciplinarity and transdisciplinarity in health research, services, education and policy: 1. definitions, objectives, and evidence of effectiveness. clin invest med 2006;29:351-64. 31. vukovic d, bjegovic-mikanovic v, otok r, czabanowska k, nikolic z, laaser u. which level of competence and performance is expected? a survey among european employers of public health professionals. int j public health 2014;59:15-30; doi: 10.1007/s00038-013-0514-x. http://www.ncbi.nlm.nih.gov/pubmed/17330451 http://www.ncbi.nlm.nih.gov/pubmed/17330451 http://www.ncbi.nlm.nih.gov/pubmed/17330451 bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 18 annex case study 1: public health leadership in europe (katarzyna czabanowska) in october 2010, ‗leaders for european public health‘ (lephie) was developed, a european erasmus multilateral, curriculum development project in the lifelong learning (lll) format. this is a collaborative effort between maastricht university (nl), the sheffield hallam university (uk), lithuanian university of health sciences (lt), medical university of graz (at) and the association of schools of public health in the european region (aspher), and resulted from an aspher and eupha on-line survey 4 that highlighted the need for online, problem-based leadership courses. this module aims to develop leadership competences through the following:  examining the key debates around leadership in public health.  introducing key theoretical frameworks that underpin leadership learning, and applying theory to actual practice.  developing the ability to analyse the public health leadership role and development needs of individuals.  stimulating self-assessment of leadership competences to identify knowledge gaps and further training needs. the competence-based programme focuses on a variety of situations related to public health risks with special attention paid to ageing and chronic diseases, as reflected by identified priorities. the public health leadership content is aimed to be applicable to performance in diverse european public health practices and contexts, and reflects the priorities and objectives of the european health programme. 5 based on an extensive literature review and expert review panels, a framework was developed to support the curriculum and facilitate self-assessment. the module uses innovative training methods, such as problem-based and blended learning formats (a combination of face-to-face and online learning), and students are active participants in the process. thus, students have a common goal, share responsibilities, are mutually dependent on each other for their learning needs, and are able to reach agreement through open interaction (suzuki et al. 2007). such an educational approach proves to be successful in the lll context. the participants are offered interactive lectures, tutorial group meetings and other collaborative sessions at a distance. the course is delivered via an intranet, such as blackboard or moodle, and course material can be directly downloaded. after being successfully piloted in the uk, a mutually recognized international blended learning leadership course worth seven ects will be delivered by the international consortium. it is believed that the integration of modern learning technology with collaborative learning techniques, supported by interdisciplinary competence-based education transcending institutional boundaries, will result in transformative learning, which is about developing leadership attributes (frenk et al. 2010). this constitutes a small step towards inter-professional and trans-professional education. 4 available from: http://www.old.aspher.org/pliki/pdf/lll_liane.pdf. 5 http://ec.europa.eu/health/programme/policy/2008-2013/index_en.htm. bjegovic-mikanovic, czabanowska, flahault, otok, shortell, wisbaum, laaser. what do we need to improve the public health workforce in europe? (review article). seejph 2014, posted: 1 may 2014. doi 10.12908/seejph-2014-20. 19 case study 2: regional cooperation – the development of a regional public health strategy in south eastern europe (vesna bjegovic-mikanovic) a regional public health strategy for south eastern europe was developed during a public health expert seminar in august 2004, belgrade, organised in the framework of the forum for public health in south eastern europe (fph-see). strengths, weaknesses, opportunities, threats and their interactions were defined based on a swot analysis. within this, a framework for a regional public health strategy, including strategic goals and objectives, was determined based on priorities identified by nominal group techniques. one of the identified goals was ―strengthening human resources in public health‖, and, within this was the objective of ―ensuring sustainable development of human resources.‖ activities included:  developing common curricula for public health on different academic levels.  providing a common glossary and terminology in public health. based on this process, there are the following proposed exercises: task 1: students split up into groups to discuss the draft strategic framework. they analyse strengths and weaknesses, considering a) the development process; b) the draft framework with its goals and objectives; and c) recommendations for improvement. each group prepares a summary report on strengths, weaknesses and their recommendations, and presents them in plenary. task 2: students compare the national public health strategy of their own country (or health policy if no specific public health strategy exists) with the draft framework for a regional strategy and compare them by highlighting similarities and differences. task 3: students experience participatory and consensus building methods: a swot analysis on the public health situation in their country (or province, district, community, or city) is conducted and subsequently, a priority setting method is applied so that a list of public health priorities can be identified in the selected setting. source: public health strategies: a tool for regional development. a handbook for teachers, researchers and health professionals. isbn 3-89918-145-x, lage, germany: hans jacobs, 2005: 583-647. ___________________________________________________________ © 2014 bjegovic-mikanovic et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 1 | 30 original research exchange and coordination: challenges of the global one health movement a pilot study exploring options to increase cooperation and coordination with systemic strategies to improve the impact on people and politics. ulrich laaser1, cheryl stroud2, vesna bjegovic-mikanovic3, helmut wenzel4, richard seifman5, carter craig6, bruce kaplan7, laura kahn8, rohini roopnarine9 1) school of public health, bielefeld, germany 2) one health commission, usa 3) faculty of medicine, belgrade, serbia 4) consultant, konstanz, germany 5) united nations association, national capital area 6) one health initiative autonomous pro bono team, lexington, ky (usa) 7) one health initiative autonomous pro bono team, sarasota, fl (usa) 8) one health initiative autonomous pro bono team, new york, ny (usa) 9) faculty of vet med; adjunct public health and preventive medicine, school of medicine, sgu, grenada corresponding author: prof. dr. med. ulrich laaser dtm&h, mph past president aspher and wfpha section of international public health school of public health, bielefeld university pob 10 01 31, d-33501 bielefeld, germany e-mail: ulrich.laaser@uni-bielefeld.de mailto:ulrich.laaser@uni-bielefeld.de laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 2 | 30 abstract1 current economic, social, and environmental trajectories within most world regions are unsustainable. interaction between bottom-up initiatives and top-down good governance is essential to change them. the one health movement, made up of many organizations, groups, and individuals from diverse backgrounds and disciplines, seeks to redress the present trajectories but has lacked coordination and cooperation, limiting its effectiveness to date. we take a snapshot of groups/organizations working to promote one health, explore options to increase cooperation and coordination among global one health stakeholders, and propose systemic strategies that could positively impact animals, people, the planet, plants, and politics. methods: through a review of the compilation of who’s who in one health organizations on the one health commission’s (ohc) website and the list of organizations that have pledged support for one health listed on the one health initiative (ohi) website, 289 organizations were identified (as of 29 july 2022: 126 civil society organizations, 133 academic and 30 governmental organizations). a stratified sampling approach and maxqda 2022 were used in a mixed-methods analysis to select a sample (n=50) of organizations to evaluate with 10 questions on purpose & focus, structure & transparency, cooperation & implementation, and publications. results: the words “one health” appeared in the organizations’ names on 62.0% (n=31) of websites examined, most often those in academic settings (78.2%). as regards transparency of the organizational structures, membership was defined in 70.0% (n=35), again most often by academic organizations (82.6%). members of the governing structures were named on 34.0% of organizational websites. projects led in the last two years were described on 32.0%, and cooperation with other organizations was indicated on 64.0% of websites examined. relevant publications and annual reports were listed on 46.0% and 24.0% of probed websites, respectively. ranking the number of positive findings for each of the 50 organizations examined revealed that full information for all ten questions was provided by only 4 academic and 1 governmental organization. the ohc website was used as a starting point and thus was not included in the n=50 samples. it was therefore examined as an example of a non-profit / cso working to support bottom-up one health leadership. since 2014 the ohc has supported a global one health community listserv of individuals from around the globe. the analysis revealed a dominance of directors from the us and a high proportion of organizations included on the ohc who’s who in one health organizations webpage were located in north america. the social sciences sociology and economics in particular – were underrepresented among in its leadership. conclusion: these 10 questions may not have been fully appropriate for all organizations examined in academic or government settings versus stand-alone non-profit or civil society organizations. however, an examination of the 50 selected websites of organizations working 1 presented orally at the 7th world one health congress 2022 in singapore: https://tinyurl.com/yy767vmy https://tinyurl.com/yy767vmy laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 3 | 30 to implement one health and/or framing their projects and purpose in one health revealed the global one health movement to be fragmented and uncoordinated. the authors propose to form a more unified voice for one health across the international one health movement, a fully networked, informal global one health alliance or community of practice that can coordinate sharing of information among the networks and with the general public, and that is able to seek synergies and joining of hands in collective/collaborative actions to effectively and efficiently promote and support bottom-up efforts. keywords: one health movement; trajectories, globalization; global health; organizational deficits; interaction; global one health alliance. laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 4 | 30 ultimately, the survival, not only of other life forms on this planet but also of our own, will depend upon humanity’s ability to recognize the oneness of all that exists and the importance and deeper significance of compassion for all life (wiebers & feigin, 2020 (1)) , introduction we have transgressed several planetary boundaries that regulate the stability of earth systems and ultimately a stable state of the planet. the world in 2050 (twi 2050) (2) initiative identified in 2018 specific pathways on how we can achieve a sustainable future, and, in a more recent reformulation, sachs et al. (3) outlined 6 transformations to achieve the united nations sustainable development goals: 1) education, gender, and inequality 2) health, well-being, and demography 3) energy, de-carbonization, and sustainable industry 4) 4) sustainable food, land, water, and oceans 5) 5) sustainable cities and communities 6) 6) digital revolution for sustainable development the timing how can the world progress along these six pathways? first, we must realize that there is not much time left; the last decades of this century may be too late. as outlined by the united nations' seventeen goals (4) and twi 2050 initiative (2), which target 2030 and 2050 respectively, action is required ‘now’. this is exemplified by the fact that, e.g., since 1970 the abundance of all vertebrates has declined by 60% (5). yet, resistance to the necessary change is strong2 (2). politics may be too slow as seen at the glasgow summit 2021 (6) and “current health governance remains segregated in local, national and international institutions, which lack the authority and tools to prevent emerging health threats at various scales” as stated by kevin queenan et al. in 2017 (7). 2 vested interests: a) owners of fossil fuels resisting the move to zero-carbon energy, and beneficiaries of unsustainable land and ocean practices as e.g. land clearing and deforestation, overfishing the oceans. b) major wealth owners avoid successfully taxation. c) limited capacity of governments to plan and implement policies with time scales of decades because of the short political business cycle and the lack of strong planning units supported by universities, and think tanks. d) the difficulty of a suitable balance in public private partnerships (successful lobbying vs. strangulation of initiative). e) an ill-informed public develops fear and resistance to change leading to 'status quo biases’. laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 5 | 30 threats of the future or today? the historical perspective in western countries, advancements in human health were critical to and resulted from the human "great escape" out of poverty over the past 250 years (8). however, many recent health gains resulted from the exploitation of natural resources, particularly for food and energy provision. the required correction of this unsustainable path must be based on the most important asset of good governance, the public's confidence, and trust: if lost, the costs can be very high. this applies also to the public's confidence in scientific conclusions. the starting point is public awareness, often initiated by civil movements or farsighted authors3 whose 3 e.g. rachel carlson’s book of 1962: “silent spring” initiating the environmental movement in the us writings have often preceded governmental action by decades (e.g., nelson mandela for civil rights). admitting that a de-growth scenario is at least for the moment impossible, instead, we must try to mitigate the consequences of our current trends (9). an example is carbon dioxide (co2) mitigation. can we extend it to other fields and what would it take scientifically, politically, and economically? the real danger is that a collision between several non-linear tipping points will generate unpredictable disruptions, leading to a period of global chaos, accelerated by rapid technological change, such as the fast internet. the lake chad basin, situated in the subsaharan region of africa, is facing one of the world’s greatest humanitarian crises. between 1973 and 2017 the lake shrank by 90%: from a surface area of 25,000km2 in 1963 to less than 2,500km2 in 2021. more than seven million people suffer from severe food insecurity and more than two million have been displaced by the intractable conflict fueled by the diminishing livelihood. the region’s recent history provides an illuminating snapshot of how climate change is already driving social tensions, conflict and migration, and threatens to do so on a much larger scale over the next decades. laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 6 | 30 bottom-up and top-down a dynamic one health framework of leadership and management will require both bottom-up (10) and top-down (11) structural elements, interacting based on scientific reasoning and guiding long-term one health advancement. innovative ideas and subsequent initiatives are often initiated bottom-up, as is the societal dimension of one health and its social dynamism. on the other hand, supportive leadership carrying forward and stabilizing initiatives is mandatory to secure an enduring long-term perspective and permanent progress: the flowers rising their heads are going to dry and die without rain4. science and policy yet policymaking in the 21st century is dealing with uncertainty and the process has become even more complex as it attempts to address systemic risks confronted with multiple possible futures. decision-making today includes many players and stakeholders, various processes (politics), and related structures (polity) to reach an agreement on courses of action, bottom-up and top-down. exacerbating policymaking is the fact that the amount of evidence is always increasing, and it is rarely final. this difficulty to forecast the effects of action with a sufficient degree of reliability constitutes a major problem for political and administrative decision-makers. consequently, they are hesitant to make decisions in a state of uncertainty and have no incentive to go beyond their field. not to mention that they are usually elected for a limited time and have to be concerned about 4 poetic wording, ul their professional future. addressing complex social issues based on separate responsibilities and not on teamwork across sectors does not pay justice to 'the interactions between causal factors, conflicting policy objectives and disagreement over the appropriate solution.' (12). already in 2010, the world bank called for a permanent system of international surveillance and control instead of prevailing temporary arrangements and uncoordinated duplication of efforts (13). an additional fundamental element is a complex amalgam requiring expertise from natural and social sciences, oriented on three interconnected concepts: i) global health, which underlines the steep gradients in human health between rich western countries and, e.g., impoverished sub-saharan countries in africa. ii) public health, which targets population health and the essential service infrastructure required in addition to individual curative medicine by. iii) planetary health which targets the ecosystem as an interdependent and interactive system of air, water, land, plants, animals, and humans. multi-professionality practice on the ground – represented by the activities of non-profit or civil society organizations (csos) should help to influence, bottom-up, the governing level and induce changes toward more responsive and inclusive governance. on the other hand, governance should secure the initiation and support of an active and wellinformed, bottom-up community of practice laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 7 | 30 thus widening its scope and coverage. this process includes multiple professional sectors, inter alia: mechanical engineering, pharmaceutical industry, forestry, education, and professional specialists: e.g. economists, agriculturalists, veterinarians, physicians, political advocates, and journalists. also, the multiple professional sectors' involvement must include the oftenneglected areas of jurisprudence, sociology, and ethics in which we need to go beyond the bioethics and include the issues of environmental and biodiversity ethics, social science ethics, and aspects of rights (human, animal, ecosystem). to this end, legal experts, sociologists, and experts in ethics should be included in the implementation of one health (14). as demand increases from the scientific community, from policymakers, and other stakeholders for quantitative projections of future climate change, the involvement of professionals with expertise in systems modeling is a must (15). indeed, though many writings have outlined core competencies5 required for one health practitioners (16), consensus across the global one health movement on a set of required competencies has not yet been reached. global interaction “one health” has been recently defined by four global institutions6 joined together as a one health quadripartite: 5 https://www.onehealthcommission.org/en/why_one _health/one_health_core_competencies/ 6 the food and agriculture organization of the united nations (fao), the world organisation for animal health (oie), the united nations environment programme (unep) and the world health organization (who): https://www.who.int/news/item/01-12-2021one health is an integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals, and ecosystems. it recognizes the health of humans, domestic and wild animals, plants, and the wider environment (including ecosystems) are closely linked and interdependent. the approach mobilizes multiple sectors, disciplines, and communities at varying levels of society to work together to foster well-being and tackle threats to health and ecosystems while addressing the collective need for clean water, energy, and air, safe and nutritious food, taking action on climate change, and contributing to sustainable development. nevertheless, one health has struggled to gain a firm institutional foothold despite growing support for this framework most recently at the g7 and g20 2021 and 2022 summits7. lee and brumme observed in 2013 that, beyond meetings, there had been few attempts (so far) “…to create a single designated global level institution for one health” (17). they continued that an integrated approach to one health is hindered by “institutional proliferation, fragmentation, competition for scarce resources, lack of an overarching authority, and donor-driven vertical programs”. leboeuf (18) called it “soft global health governance” based on meetings and declarations, dominated by veterinarians and characterized by a high degree of reductionism and fragmentation (19). streichert et al. (20) in their study on participation in one health networks (ohns) and involvement in the covid-19 tripartite-and-unep-support-ohhlep-s-definition-ofone-health 7 https://www.iges.or.jp/en/projects/g7-g20-2022; https://www.woah.org/en/g20-ministers-of-healthreaffirm-the-urgent-need-to-address-global-healthunder-a-one-health-approach/ http://www.g20.utoronto.ca/2021/210906health.html https://www.onehealthcommission.org/en/why_one_health/one_health_core_competencies/ https://www.onehealthcommission.org/en/why_one_health/one_health_core_competencies/ https://www.who.int/news/item/01-12-2021-tripartite-and-unep-support-ohhlep-s-definition-of-one-health https://www.who.int/news/item/01-12-2021-tripartite-and-unep-support-ohhlep-s-definition-of-one-health https://www.who.int/news/item/01-12-2021-tripartite-and-unep-support-ohhlep-s-definition-of-one-health https://www.iges.or.jp/en/projects/g7-g20-2022 https://www.woah.org/en/g20-ministers-of-health-reaffirm-the-urgent-need-to-address-global-health-under-a-one-health-approach/ https://www.woah.org/en/g20-ministers-of-health-reaffirm-the-urgent-need-to-address-global-health-under-a-one-health-approach/ https://www.woah.org/en/g20-ministers-of-health-reaffirm-the-urgent-need-to-address-global-health-under-a-one-health-approach/ http://www.g20.utoronto.ca/2021/210906-health.html http://www.g20.utoronto.ca/2021/210906-health.html laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 8 | 30 response found that of 1050 questionnaire responses globally, 75.0% considered themselves to be part of an ohn. 44.6% came from the united states and 42.7% from academia but only 15.6% from nonprofit organizations and only 7.6% from social sciences. khan et al. in 2018 published (21) a systematic analysis of ohns. khan et al. in 2018 published a systematic analysis of ohns (21), defined a network as engagement between two or more discrete organizations and investigated whether duplication of efforts was occurring, which stakeholders were being engaged in one health networks, and how frequently monitoring and evaluation of investments were being reported. they identified "specific gaps in the coverage of activities, limitations in stakeholder representation, apparently absent or ambiguous accountability structures, and potential areas of duplication." less than 15% of ohns reported activities targeting the "…community level impact of ongoing investments in one health, engagement with target populations, and research to aid adaptation of interventions to the local context." in this paper, we consider a global orientation – potentially best termed ‘globalism’ – as a decisive dimension. although each country or group of countries must find its priorities, direction, pace, and agenda (the traditional scenario), each such choice today has global implications in terms of conditional determinants and global effects. therefore, they must be discussed and decided considering the global context. people become increasingly 'place-less' with other, non-territorial modes of organization emerging. globalism supports our understanding of an interdependent world but can also undermine societal cohesion, the multidimensional value systems that keep communities together (22) with the consequence of unrest and even rampant fanatism unlocked. the targets of this paper since 2010 (13) there have been multiple calls for permanent systems of sustained one health implementation on many fronts, (especially for disease surveillance and response) instead of temporary arrangements and uncoordinated duplication of efforts. yet, the one health movement has appeared as a conglomeration with many different players and often uncoordinated actions. in part i of this paper, we identify and analyze the websites of a representative sample of non-profit, civil society organizations (csos), university-based organizations (academia), and governmental organizations (government) that are embracing, promoting, and operating within a one health framework. we examine their websites with 10 questions on purpose & focus, structure & transparency, cooperation & implementation, and publications. in part ii we analyze the comprehensive website of the one health commission to provide an imperfect but positive model. finally, we explore options to increase cooperation and coordination among global one health stakeholders and propose systemic strategies that could positively impact people, animals, plants, the environment, and politics. laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 9 | 30 part i: the website analysis methods starting from the websites of the one health commission (ohc)8 and the one health initiative (ohi)9, we identified (as of 29 july 2022) 289 organizations working to promote and implement one health (126 non-profit civil society organizations (cso), 133 academic organizations, and 30 governmental). to ensure the most efficient evaluation, we decided to work with a random sample of n = 50 organizations. this number seemed to be both large enough and the evaluations achievable within a reasonable amount of time. stratified sampling was used to account for the different sizes of the three categories “civil, academic and governmental”. one approach for stratified sampling is proportionate stratification. with proportionate stratification, the sample size of each stratum is proportionate to the population size of the stratum according to the formula (23): nh = ( nh / n ) * n the organizations were selected using random numbers per sample stratum. this resulted in 22 civil, 23 academic, and 5 governmental organizations, n = 50 in total. for a description of the organizations, 10 questions were formulated (see table 1 and figure 1) to be checked on their websites for positive/negative findings (also short: yes/no classification). table 1: the ten questions 1) is one health part of the organization’s name? 2) are the work objectives listed? 3) is membership defined? 4) is a governing structure (executive board) described? 5) are members of the governing structure named? 6) are projects indicated for the period 2020/2021? 7) is cooperation with other organizations/projects indicated? 8) are names of cooperation partners provided? 9) are publications (any media) listed on the website? 10) is an annual report published? 8 https://www.onehealthcommission.org the answers to these questions, taken from the websites of the selected organizations, should clarify (figure 1): i. what is the purpose and focus (1, 2)? ii. is the organization’s structure transparent (3-5)? iii. are cooperation and implementation described on the website (6-8)? iv. are there publications (9, 10)? 9 https://onehealthinitiative.com/ laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 10 | 30 figure 1: the four domains of questions on the practice of one health organizations. results table 2 shows the basic account of the 50 relevant websites of civil, academic, and governmental organizations identified, and randomly selected from 289 organizations (for more details see annex a). though they were included in a listing of who’s who in one health organizations, the words “one health” appeared in the organizations’ names on 62.0% (n=31) of websites examined, most often those in academic settings (78.2%) and governmental organizations (80.0%). as regards transparency of the organizational structures, membership was defined in 70.0% (n=35), again most often by academic organizations (82.6%). members of the governing structures were named on 34.0% of organizational websites. an annual budget was found on only one cso website. one health projects led in the last two years were described on 32.0%, and cooperation with other organizations was indicated on 64.0% of websites examined. relevant publications and annual reports were listed on 46.0% and 24.0% of probed websites, respectively. laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 11 | 30 table 2: summary of the resulting classifications of one health organizations (percentages in bold) note: the total number of possible yes/no classifications is 500 (10 questions checked for 50 organizations) of the 50 websites examined, full information for all ten questions was provided only by 4 academic and 1 governmental organization (none of the governmental ones, together 5 organizations or 10%), almost one-third answered positively on less than 5 questions. a ranking of the number of positive findings (yes classifications) for csos and academic organizations is demonstrated in figure 2. figure 2: comparison of positive findings (yes classification) for the ten questions per organization: here csos and academia. 0 2 4 6 8 10 ai ab aa ak an at ar aj al ao ad ap ah ag au ac am as ae af uv aq cso: number of yes classifications by organization i. purpose & focus ii. transparency of structure iii. cooperations iv. publications question no. 1 2 3 4 5 6 7 8 9 10 sum of yes classifications a. csos (n=22) 9 40.9 18 81.8 13 59.1 9 40.9 8 36.4 8 36.4 13 59.1 10 45.5 10 45.5 7 31.8 105 47.7 b. academia (n=23) 18 78.2 18 78.2 19 82.6 7 30.4 8 34.8 7 30.4 16 69.6 15 68.2 10 43.5 4 17.4 122 53.0 c. government (n=5) 4 80.0 3 60.0 3 60.0 2 40.0 1 20.0 1 20.0 3 60.0 3 60.0 2 40.0 1 20.0 23 46.0 sum of yes classifications 31 62.0 39 78.0 35 70.0 18 36.0 17 34.0 16 32.0 32 64.0 28 56.0 22 44.0 12 24.0 250 50.0 laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 12 | 30 the pattern of positive or yes classifications is similar for all three organizational groupings (figure 3). insignificant differences were shown for csos on one side and academic and governmental organizations on the other also by principal component analysis. figure 3: percentage of yes classifications by question and categories line plot of all three categories cso academic government q 1 q 2 q 3 q 4 q 5 q 6 q 7 q 8 q 9 q 10 question number 10 20 30 40 50 60 70 80 90 % o f y e s -a n s w e rs 0 2 4 6 8 10 ba bc bk bv be bl bn bm bu bp bt bq bo bw bh bd bf br bb bi bj bs bg academia: number of yes classifications by organization laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 13 | 30 part ii: analysis of the website of the one health commission (ohc) the one health commission’s website was used as one starting point for this pilot study and thus was not included in the random sample selected from its website. it may therefore be examined as a potential positive example of a non-profit / cso working to support bottom-up one health leadership. since 2014 the ohc has supported a global one health community listserv that had grown to over 17,200 individuals (at the time of this publication) from around the globe actively sharing information through its monthly ‘one health happenings’ newsletter.7 the website presents a comprehensive and well-organized collection of information, an extensive catalog of activities mainly programs / working group activities, extensive resources (online one health opportunities bulletin board, one health educational resources for public health educators, national one health strategic action plans, one health tools/toolkits, relevant newsletters, social media links, webinars and presentations) as well as a library of relevant books and articles, and a list of who’s who in one health organizations. annual reports for 2020 and 2021 were presented under ‘why support the one health commission?’. consequently, all 10 questions could be answered positively. of special interest is the list of projects and organizational collaborations (annex b). however, a more detailed analysis of the ohc website revealed that all but one member of the board of directors was from the us and that approximately 50% of organizations included on the who’s who in one health organizations webpage were located in north america in the us and canada. individuals listed as directors were almost exclusively veterinarians and physicians. while the ohc supports a one health social sciences initiative and working groups, the social sciences sociology and economics in particular – were underrepresented as of july 2022 among its leadership. (see the discussion). figure 4 reveals a map of 'all' groups and organizations (non-profit/cso, academia, government) identified so far in an ohcled global one health community joint effort as working to promote one health or framing their work in one health. laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 14 | 30 figure 4: global map (july 2022) of identified groups and organizations working to promote one health or framing their work in one health permission to use granted by the one health commission table 3 reveals dominance of us-american organizations identified as working to promote one health. a global list-serv10 10https://www.onehealthcommission.org/en/resourc esservices/join_the_global_oh_community_listser/ indicates a community of followers of plus 17.000 actively served with information through the monthly newsletter "one health happenings". https://www.onehealthcommission.org/en/resourcesservices/join_the_global_oh_community_listser/ https://www.onehealthcommission.org/en/resourcesservices/join_the_global_oh_community_listser/ laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 15 | 30 table 3: who is who in one health11,12 the structure of the one health commission13 can be summarized as follows: the board of directors consists of 13 members: 7 with a veterinarian education, 4 with medical education, and 1 with medical public health education (one cv is not accessible), all members are us american. the council of advisors (non-voting) comprises 15 members: 13 veterinarians and 1 with medical public health education, all us american. one member lives in england. among the council of advisors, the one health initiative (ohi)14 (autonomous pro bono team) lists 7 active members, thereof 2 veterinarians, 2 physicians, and 3 members of related pharmaceutical companies. a student representation is dated 2015/2017 and continued as the international student one health alliance (isoha15). the lists of 5 corporate financial donors/sponsors, ca. 25 institutional financial donors, and ca. 55 individual donors appear to be almost exclusively usamerican donors. 11 https://www.onehealthcommission.org/en/resourcesservices/whos_who_in_one_health/ 12 the figures may not be fully precise and differ by one or two units because of unclarity of information. 13 at: https://www.onehealthcommission.org/en/leadership__board_of_directors/ (visited 18 september 2022) 14 the one health initiative autonomous pro bono team (ohi) was co-founded originally by physician laura h. kahn, md, mph, mpp view bio, veterinarian bruce kaplan, dvm view bio, and physician thomas p. monath, md view bio in 2006-2007 for the sole purpose of promoting the one health concept nationally and internationally. the ohi team was expanded to include health research scientist *jack woodall, phd read more about jack woodall in february 2009 and *lisa a. conti, dvm, mph view bio in january 2012. 15https://www.onehealthcommission.org/en/leadership__board_of_directors/students_for_one_health_soh_news/ organizations civil society organization, not for profit academic governmental private forprofit organizations total africa 5 5 10 asia (incl. au/nz) 11 (1/1) 10 (2/0) 2 2 25 europe 13 6 5 2 26 north america (incl. canada) 22 (1) 30 7 6 65 south america 4 3 7 total 55 54 14 10 133 https://www.onehealthcommission.org/en/leadership__board_of_directors/ https://onehealthinitiative.com/wp-content/uploads/2020/05/dr.-laura-h.-kahn-short-biography-may-2020.pdf https://onehealthinitiative.com/wp-content/uploads/2020/11/dr.-bruce-kaplan-short-bio.pdf https://onehealthinitiative.com/wp-content/uploads/2020/05/tom-monath-biography-april-2018.pdf https://www.archive.onehealthinitiative.com/news.php?query=extraordinary+scientist%2c+admired+one+health+supporter-activist-leader+dies+ https://www.archive.onehealthinitiative.com/news.php?query=extraordinary+scientist%2c+admired+one+health+supporter-activist-leader+dies+ https://onehealthinitiative.com/wp-content/uploads/2020/05/lisa-conti-biography-august-2017.pdf https://www.onehealthcommission.org/en/leadership__board_of_directors/students_for_one_health_soh_news/ laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 16 | 30 discussion if we continue failing to address the wide gaps revealed in poverty, social inequality and the environmental injustice – failing to acknowledge and act on the linkages between environment and human and animal well-being then negative trajectories may exponentially grow and endanger civility. how to enhance civility? is it sufficient to get citizens to adopt a convention on decent behavior? it seems that in most if not all societies there is a potential for indecent behavior only waiting for an opportunity to exercise aggressive communication and even physical attack. this potential may be smaller in more equal societies but will be unlocked by steepening social gradients or, for example, by a pandemic like covid-19 and the restrictions coming with it. the german history of the last 150 years is a good example of unlocked aggression. starting from kaiser wilhelm ii's immature personality and almost absolute power on the last decisions, to the unbalanced treaty of versailles, and the financial crash of 1929 the stage was set for extremist groupings to take over. today the largely uncontrolled social media make it even easier to form extremist cocoons growing fast in times of general hardship when people look desperately for an exit. nevertheless, a deeply disturbing question arises: why could the great, humanizing traditions of german history duerer, lutherbibel, bach, the enlightenment, goethe's faust, the bauhaus, and very many more not prevent the total moral collapse of 1933-1945. 16 https://sdgs.un.org/goals today, on a global scale, we see large sections of our societies being deprived of a decent living and health equity e.g., in the big cities, in the former german democratic republic (gdr), in england, and especially in the us, not to mention the global south. how can we expect that they behave decently? if we do not get better at equalizing social gradients (even vaccines are unequally distributed (24)), a huge reservoir of non-civility will remain (25). many people see the one health way of thinking and living as a ray of hope for the future never more desperately and urgently needed. implementation of one health, truly making it the default way of thinking at all levels of academia, research, government and policy, will help us fully achieve the un 2030 sustainable development goals16. achieving those goals will go a long way toward global security by addressing the social, public health and ecological inequities that can drive the unlocked aggression mentioned above. it is urgent that the global community of one health stakeholders and advocates succeed in helping the world understand and adopt the one health paradigm shift. in the introduction to this paper we referred to the necessity, for one health to be fully realized, of a bottom-up and top-down strategy as outlined also in the special volume of the south eastern european journal of public health on the global one health environment (26). action from both sides and a supportive array of environmental, social, and health sciences are essential to secure sustainable, https://sdgs.un.org/goals laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 17 | 30 codified, institutionalized, long-term implementation. innovative ideas are often conceptualized bottom-up. and supportive leadership from the top is mandatory to stabilize and carry initiatives forward for secure, permanent, sustainable progress. yet the one health movement has struggled for 20 years to get these coordinated bottom-up/top-down actions happening simultaneously from both directions. there are many differing opinions about why we have not been able to sustainably put one health programs in place even on the most obviously needed fronts like zoonotic disease surveillance and control. some advocates think we have tried too much from the top down via government programs that don’t draw from deep knowledge and expertise ‘in’ local communities to discern what ‘they’ think their priorities need to be and how ‘they’ think they should be addressed. that is the way to get true support and ‘buy-in’ from the grassroots communities needed to implement one health thinking at ground level. the challenges likely lie at both ends of this spectrum. if we think for the moment just about the ‘bottom-up’ challenges, what the community of global one health stakeholders, i.e. the global one health movement, needs is a way to better ‘connect, communicate and coordinate’ our actions across all categories of players in the global one health community: • so organizations working for one health can find each other, discover their commonalities, overlaps, strengths, and synergies, join hands, and work ‘together’ • to share news from all global regions, and all professions – so the right hand of the one health movement knows what the left is doing – so we can ‘support’ each other’s efforts and become ‘force multipliers’! • to speak in a unified voice to the public, to governments, lawmakers, and policymakers urging a focus on ways to ‘prevent’ infectious disease outbreaks and environmental contamination and degradation. • to share educational, job, and volunteer opportunities • to engage more social scientists and many other disciplines there is, already in place, a lot of what is needed for effective bottom-up and topdown actions. it just lacks connection, communication, and coordination. bottom-up:  we have a global army of individuals willing and able to lead for one health as revealed by annual one health day events since 2016 (https://tinyurl.com/oh-dayhome).  we have many powerful one health tools and toolkits (https://tinyurl.com/ohc-ohtoolkits).  we have grassroots networks for communications like the ohc’s one health happenings newsletter (https://tinyurl.com/ohc-ohhappening) and the ohi’s one health news webpages (https://onehealthinitiative.com/one -health-initiative-news/).  we have a network of networks of https://tinyurl.com/oh-day-home_ https://tinyurl.com/oh-day-home_ https://tinyurl.com/ohc-oh-toolkits https://tinyurl.com/ohc-oh-toolkits https://tinyurl.com/ohc-oh-happening https://tinyurl.com/ohc-oh-happening https://onehealthinitiative.com/one-health-initiative-news/ https://onehealthinitiative.com/one-health-initiative-news/ laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 18 | 30 one health groups and organizations (https://tinyurl.com/ohc-ww) that can share information and get it out deeply across and into their networks. (example: the ohc’s global one health community listserv has grown to >17,200 since 2014 (https://tinyurl.com/ohclistserv). the needed communications just aren’t currently happening efficiently because those working in the one health space often don’t even know each other exists. top-down:  we have the newly expanded quadripartite and its advisory one health high-level expert panel (ohhlep) that has given us a more unifying definition of one health to guide us. https://tinyurl.com/whoohhlep-oh-definition  we have the newly released quadripartite one health joint plan of action https://tinyurl.com/quadri-oh-jpa with its elegant theory of change and unifying message.  we have a growing number of countries that have formally adopted national one health strategic action plans and one health framed antimicrobial resistance strategic action plans (https://tinyurl.com/ohc-ohstratact). 17 https://multilateralism.org/the-alliance/ 18 https://multilateralism.org/actionareas/berlinprinciples-on-one-health/ all that is needed is the collective, grassroots ‘will’ to ‘be’ a more coordinated community of practice to provide collaborative leadership in both directions. thus, we are calling for an informal global one health alliance. not another nonprofit organization, but a global community of practice that is well-connected and coordinated among its members. formation of an informal global alliance is not an unprecedented idea. indeed the “alliance for multilateralism”17 launched by the french and german foreign ministers is an informal network of countries united in their conviction that a rules-based multilateral order is the only reliable guarantee for international stability and peace and that our common challenges can only be solved through cooperation. that alliance has embraced one health with a posting about the berlin one health principles18 stating “international cooperation in this field [one health] must be intensified and existing structures strengthened. in this sense, the “berlin principles”, the outcome document of the conference on „one planet, one health, one future“ held in october 2019 in berlin by the federal foreign office in cooperation with the wildlife conservation society can serve as a point of departure, calling for a “unity of approach that is achievable only through convergence of human, domestic animal, wildlife, plant, and environmental health”. we call for an informal global one health alliance. https://tinyurl.com/ohc-ww https://tinyurl.com/ohc-listserv https://tinyurl.com/ohc-listserv https://tinyurl.com/who-ohhlep-oh-definition https://tinyurl.com/who-ohhlep-oh-definition https://tinyurl.com/quadri-oh-jpa https://tinyurl.com/ohc-oh-stratact https://tinyurl.com/ohc-oh-stratact https://multilateralism.org/the-alliance/ https://multilateralism.org/actionareas/berlin-principles-on-one-health/ https://multilateralism.org/actionareas/berlin-principles-on-one-health/ laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 19 | 30 the one health commission19 was not included in the random sample of organizations selected from its website for the pilot study reported here; thus it was further examined as a potential positive though imperfect example of a cso working to support bottom-up one health leadership. at the 7th world one health congress 2022 in singapore20, the ohc presented this call21 for a global one health alliance, pledged its support for collaborative, coordinated, communication partnerships with ohhlep and the quadripartite and urged that mechanisms be devised for the whole community of one health stakeholders to get actively involved, to help us become better aware of who is doing what, who has what strengths and how we can synergize our efforts to raise a collective voice. in their article one health, one welfare, one planet (july 2019), stroud and lindenmayer (27) explain a critical need to push the boundaries of the one health framework toward 'one health and one welfare for one planet' which implies that the real sustainability challenge is primarily and essentially societal and individual! health and well-being are both preconditions and outcomes of sustainable development. but the needed changes cannot be driven by any one country, one profession, or any individual. it will take the collective will of the whole global community of one health stakeholders, working both bottom-up and top-down. we call for an informal global one health alliance, an informal community of practice. 19 https://www.onehealthcommission.org/ 20 https://worldonehealthcongress.org conclusions and recommendations motto: to save the planet our arch in space requires political, economic, and sociologic analysis and coordinated intervention. limitations of the pilot study this pilot study is limited because of the small sample size from two selective lists, available at the ohc and ohi websites, and the missing operability of advanced statistical analysis. additionally, though the information has been gathered and compiled on the who’s who maps on the ohc website for the past 8 years, we know that those maps are still incomplete because many critical players in the one health space are not yet aware of and have not yet joined in the effort to help identify each other and be better connected for collaborations and sharing of information. it will require full participation by the global community of one health advocates to make those maps more complete, though they will hopefully be ever-evolving as more and more organizations, individuals and governments move into a one health way of thinking and living. to achieve full representation, a global one health stakeholders survey of related organizations and their activities is proposed for the network of networks to collectively push it out to all players. among few, ohc/ohi has the potential and the intention to support a common agenda for the one health-oriented csos 21 https://tinyurl.com/yy767vmy https://www.onehealthcommission.org/ https://worldonehealthcongress.org/ https://tinyurl.com/yy767vmy laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 20 | 30 as well as academic organizations if not also administrative bodies. the horizon for further expansion the most recent announcements of the world bank and un agencies signal heightened attention and promise a turnaround of focus to the one health concept and framework (28). in our call for an informal global one health alliance, a community we recommend: 1) as a first step a central information hub should be installed to allow for multilateral contacts and information exchange perhaps with circulating administration by interested one health organizations. 2) through that hub, an agreement should be reached on the minimum information on the websites of participating organizations modifying where appropriate the catalog of ten questions used in this paper for a basic analysis. 3) delegates solicited from the global community of one health stakeholders should be on the organizing committee and contribute to the preparation of the next world one health congress in 2024 in cape town africa22. 4) a community driven one health information newsletter is needed to orient specifically on global one health developments, initiatives and proposals as well as on publications regarding specific one health topics. for example, the established monthly one health happenings newsletter, edited by the one 22 https://www.facebook.com/hashtag/wohc2024 health commission, could be further funded and supported by the community of one health stakeholders, expanded and disseminated across and deeply into one health networks and beyond. in summary, there is an urgent need to form a coordinated voice for one health, an informal global one health alliance,, a community of practice that is connected in a communications network and able to speak in one voice, enhance synergy and collaboration, and further bottom-up efforts. the best format would be to act in partnership with the quadripartite organizations (29, 30). reminder earth is a home for animals, plants, and mankind in a common environment of air, water, and land the planet earth as noah’s ark, told in the heritage of mankind (genesis 6,12,13 & 1920): “god saw how corrupt the earth had become, for all the people on earth had corrupted their ways. so, god said to noah: ...you are to bring into the ark two of all living creatures, male and female, to keep them alive with you. two of every kind of bird, of every kind of animal, and of every kind of creature that moves along the ground will come to you to be kept alive”. references: 1) wiebers do, feigin vl. editorial. what the covid-19 crisis is telling humanity. neuroepidemiology 2020;54: 283– 286. doi: 10.1159/000508654 2) twi2050 -the world in 2050. transformations to achieve the sustainable development goals. laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. 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(original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 24 | 30 annex a: information on the ten questions provided by the n = 50 sampled organizations on their websites. note 1: missing data was assessed and counted as no since no information is equal to a negative answer. these 39 values are marked in italics. note 2: the analysis of the websites according to the 10 questions was done by hw and ul with mutual control. group of questions i. purpose & focus ii. transparency of structure iii. cooperations iv. publications summary questions & answers 1 2 3 4 5 6 7 8 9 10 a. csos y n y n y n y n y n y n y n y n y n y n sum yes sum no total aa 1 0 1 0 0 1 1 0 1 0 0 1 1 0 1 0 0 1 1 0 7 3 10 ab 1 0 1 0 0 1 1 0 1 0 0 1 1 0 1 0 1 0 1 0 8 2 10 ac 0 1 1 0 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 1 9 10 ad 0 1 1 0 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 1 9 10 ae 1 0 1 0 1 0 0 1 0 1 1 0 1 0 1 0 1 0 1 0 8 2 10 af 0 1 0 1 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 8 2 10 ag 0 1 1 0 1 0 1 0 1 0 0 1 0 1 0 1 1 0 1 0 6 4 10 ah 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 10 10 ai 0 1 1 0 1 0 1 0 1 0 0 1 0 1 0 1 0 1 0 1 4 6 10 aj 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 10 10 ak 0 1 1 0 1 0 1 0 0 1 1 0 1 0 1 0 1 0 0 1 7 3 10 al 0 1 1 0 1 0 0 1 1 0 1 0 1 0 1 0 1 0 0 1 7 3 10 am 0 1 1 0 0 1 0 1 0 1 0 1 0 1 0 1 1 0 1 0 3 7 10 an 1 0 1 0 1 0 1 0 0 1 1 0 1 0 1 0 1 0 1 0 9 1 10 laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 25 | 30 ao 1 0 1 0 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 2 8 10 ap 1 0 0 1 0 1 0 1 0 1 0 1 1 0 0 1 0 1 0 1 2 8 10 aq 0 1 1 0 1 0 1 0 1 0 0 1 1 0 0 1 1 0 0 1 6 4 10 ar 1 0 1 0 1 0 0 1 0 1 0 1 1 0 1 0 0 1 0 1 5 5 10 as 1 0 1 0 1 0 0 1 0 1 0 1 0 1 0 1 0 1 0 1 3 7 10 at 1 0 1 0 1 0 0 1 0 1 1 0 1 0 0 1 1 0 0 1 6 4 10 au 0 1 1 0 1 0 0 1 0 1 1 0 1 0 1 0 0 1 0 1 5 5 10 av 0 1 1 0 1 0 1 0 1 0 1 0 1 0 1 0 0 1 0 1 7 3 10 sum 9 13 18 4 13 9 9 13 8 14 8 14 13 9 10 12 10 12 7 15 105 115 220 laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 26 | 30 questions & answers 1 2 3 4 5 6 7 8 9 10 b academia y n y n y n y n y n y n y n y n y n y n sum yes sum no total ba 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 10 0 10 bb 1 0 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 1 9 10 bc 1 0 1 0 1 0 0 1 0 1 0 1 1 0 1 0 0 1 0 1 5 5 10 bd 1 0 1 0 1 0 0 1 0 1 0 1 1 0 1 0 0 1 0 1 5 5 10 be 1 0 1 0 1 0 1 0 1 0 0 1 1 0 1 0 1 0 0 1 8 2 10 bf 1 0 1 0 1 0 0 1 1 0 0 1 0 1 0 1 1 0 0 1 5 5 10 bg 0 1 1 0 1 0 0 1 0 1 1 0 1 0 1 0 1 0 0 1 6 4 10 bh 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 10 10 bi 0 1 1 0 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 1 9 10 bj 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 10 0 10 bk 1 0 0 1 0 1 0 1 0 1 0 1 1 0 1 0 0 1 0 1 3 7 10 bl 1 0 1 0 1 0 0 1 0 1 0 1 0 1 0 1 0 1 0 1 3 7 10 bm 1 0 1 0 1 0 0 1 0 1 1 0 1 0 1 0 1 0 0 1 7 3 10 bn 1 0 0 1 1 0 0 1 0 1 0 1 1 0 1 0 1 0 0 1 5 5 10 bo 1 0 1 0 1 0 0 1 0 1 0 1 1 0 1 0 0 1 0 1 5 5 10 bp 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 10 0 10 bq 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 0 1 0 1 8 2 10 br 0 1 0 1 1 0 0 1 0 1 0 1 1 0 1 0 0 1 0 1 3 7 10 bs 0 1 1 0 1 0 0 1 1 0 0 1 1 0 1 0 1 0 0 1 6 4 10 bt 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 10 0 10 bu 1 0 1 0 1 0 0 1 0 1 0 1 0 1 0 1 0 1 0 1 3 7 10 sum 18 5 18 5 19 4 7 16 8 15 7 16 16 7 15 8 10 13 4 19 122 108 230 laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 27 | 30 questions & answers 1 2 3 4 5 6 7 8 9 10 c gov y n y n y n y n y n y n y n y n y n y n sum yes sum no total ca 1 0 1 0 1 0 0 1 0 1 0 1 1 0 1 0 0 1 0 1 5 5 10 cb 1 0 1 0 1 0 1 0 0 1 0 1 1 0 1 0 1 0 0 1 7 3 10 cc 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 10 10 cd 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 10 0 10 ce 1 0 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 1 9 10 sum 4 1 3 2 3 2 2 3 1 4 1 4 3 2 3 2 2 3 1 4 23 27 50 laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 28 | 30 annex b: projects and cooperations of the one health commission, listed on their website, information regarding questions 6-8 question 6: are projects indicated for the period 2020/2021?  creation/leadership of global one health day  creation/leadership of global one health awareness month https://tinyurl.com/ohoh-awareness  creation/production/dissemination of monthly one health happenings https://tinyurl.com/ohc-oh-happening (since 2015)  creation of o one health social sciences work group https://conta.cc/3il5buy https://www.onehealthcommission.org/en/progra ms/one_health_social_sciences_initiative/ o bat rabies education work group https://www.onehealthcommission.org/en/programs/bat_rabies_educ ation_initiative/ o related projects at: https://conta.cc/2k1noc9  creation/launch of the following recent web pages: o mapping countries that have formally adopted national one health strategic action plans https://tinyurl.com/ohc-oh-stratact o mapping countries that have formally adopted national one health amr plans https://tinyurl.com/ohc-oh-amr o one health toolkits webpage https://tinyurl.com/ohc-oh-toolkits o one health education resources for public health educators https://tinyurl.com/ohc-oh-ph-ed questions 7 and 8: is cooperation with other organizations/projects indicated? are names of cooperation partners provided?  partnership with global alliance for rabies control call for project submissions https://conta.cc/3stbs1c  partnership (advisory and promotional) with cabi in the launch of its one health initiatives (journal, case studies) o https://conta.cc/3g1ubgl o https://conta.cc/3miiyx2 https://tinyurl.com/oh-oh-awareness https://tinyurl.com/oh-oh-awareness https://tinyurl.com/ohc-oh-happening https://conta.cc/3il5buy https://www.onehealthcommission.org/en/programs/one_health_social_sciences_initiative/ https://www.onehealthcommission.org/en/programs/one_health_social_sciences_initiative/ https://www.onehealthcommission.org/en/programs/bat_rabies_education_initiative/ https://www.onehealthcommission.org/en/programs/bat_rabies_education_initiative/ https://conta.cc/2k1noc9 https://tinyurl.com/ohc-oh-stratact https://tinyurl.com/ohc-oh-amr https://tinyurl.com/ohc-oh-toolkits https://tinyurl.com/ohc-oh-ph-ed https://conta.cc/3stbs1c https://conta.cc/3g1ubgl https://conta.cc/3miiyx2 laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 29 | 30  partnership with georgia aquarium (atlanta, georgia) to create/lead gregory bossart one health scholarship o https://conta.cc/3et1ulo o https://www.onehealthcommission.org/en/programs/one_health_scholarships/  partnership with onehealthlessons.com to get the word out https://conta.cc/3shcu4n  partnership with the national academies of sciences, engineering, and medicine, in partnership with the wilson center and the smithsonian's national museum of natural history, to lead one health in the us webinar o https://conta.cc/3secwfl o https://www.onehealthcommission.org/en/events_since_2001/one_health_in_t he_us_webinar_series/  after supporting its creation continued partnership with the international student one health alliance (isoha) one of many examples https://conta.cc/3pijbqx  partnership with who goarn and one health european joint program in a survey of one health professional participation in the pandemic response: o https://conta.cc/2wvulmr o streichert lc, sepe ludovico p, jokelainen p, stroud cm, berezowski j, del rio vilas vj., participation in one health networks and involvement in the covid-19 pandemic response: a global study, frontiers in public health, vol. 10, 2022, doi=10.3389/fpubh.2022.830893  partnership with who goarn in call for professional volunteers for pandemic response https://conta.cc/2vpq0xk  creation of us informal coalition of one health organizations: o https://conta.cc/2dcntbe o https://www.onehealthcommission.org/documents/filelibrary/oh_news/9420_ coalition_partners_146384b46dfd8.pdf  cooperative / collaborative project with one health academy in washington dc providing a webinar platform for all their monthly seminars since 2014: o http://www.onehealthacademy.org/ scroll to the bottom of the page... o and also click on all their 'previous talks' http://www.onehealthacademy.org/previous-talks.html  list of ohc financial sponsors (they are 'all' partners) o https://www.onehealthcommission.org/en/sponsorship/ https://conta.cc/3et1ulo https://www.onehealthcommission.org/en/programs/one_health_scholarships/ https://conta.cc/3shcu4n https://conta.cc/3secwfl https://www.onehealthcommission.org/en/events_since_2001/one_health_in_the_us_webinar_series/ https://www.onehealthcommission.org/en/events_since_2001/one_health_in_the_us_webinar_series/ https://conta.cc/3pijbqx https://conta.cc/2wvulmr https://www.frontiersin.org/articles/10.3389/fpubh.2022.830893/full?&utm_source=email_to_ae_&utm_medium=email&utm_content=t1_11.5e2_editor&utm_campaign=email_publication&journalname=frontiers_in_public_health&id=830893 https://www.frontiersin.org/articles/10.3389/fpubh.2022.830893/full?&utm_source=email_to_ae_&utm_medium=email&utm_content=t1_11.5e2_editor&utm_campaign=email_publication&journalname=frontiers_in_public_health&id=830893 https://conta.cc/2vpq0xk https://conta.cc/2dcntbe https://www.onehealthcommission.org/documents/filelibrary/oh_news/9420_coalition_partners_146384b46dfd8.pdf https://www.onehealthcommission.org/documents/filelibrary/oh_news/9420_coalition_partners_146384b46dfd8.pdf http://www.onehealthacademy.org/ http://www.onehealthacademy.org/previous-talks.html https://www.onehealthcommission.org/en/sponsorship/ laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 30 | 30 o https://www.onehealthcommission.org/en/sponsorship/list_of_sponsors/ yo u have to click on the links to see the lists...  it takes quite a bit of 'cooperation' to create and lead the who's who in one health organizations webpages and in the process, an incredible network of colleagues all over the world has been developed. https://tinyurl.com/ohc-ww (at the time of publication the global one health community listserv is over 17,200 and has increased by over 7,000 since the onset of the pandemic)  other 'cooperation' projects o synergizing oh collaborations online meeting https://conta.cc/3txyodc o ohc us epa partnership on national pet health survey: https://conta.cc/3yvsiti and:  https://www.onehealthcommission.org/index.cfm?nodeid=93484&au dienceid=1&preview=1  https://conta.cc/3etb8kf o supporting the creation of international student one health alliance: https://conta.cc/3cqo3w1 o online one health education conference https://conta.cc/3yune8e and: https://www.onehealthcommission.org/en/events_since_2001/one_health_edu cation_online_conference/ o 2016 launch of annual global one health day https://conta.cc/3evigkp and: https://conta.cc/3escqlx and: https://conta.cc /3coccaf and: https://www.onehealthcommission.org/en/events_since_2001/2nd_intl_whos_ who_in_oh_webinar_2016/ o letter from ohc to obama white house https://conta.cc/3tioev5 and: https://www.onehealthcommission.org/en/events_since_2001/1st_intl_whos_w ho_in_oh_webinar_201 https://www.onehealthcommission.org/en/sponsorship/list_of_sponsors/ https://tinyurl.com/ohc-ww https://conta.cc/3txyodc https://conta.cc/3yvsiti https://www.onehealthcommission.org/index.cfm?nodeid=93484&audienceid=1&preview=1 https://www.onehealthcommission.org/index.cfm?nodeid=93484&audienceid=1&preview=1 https://conta.cc/3etb8kf https://conta.cc/3cqo3w1 https://conta.cc/3yune8e https://www.onehealthcommission.org/en/events_since_2001/one_health_education_online_conference/ https://www.onehealthcommission.org/en/events_since_2001/one_health_education_online_conference/ https://conta.cc/3evigkp https://conta.cc/3escqlx https://conta.cc/3coccaf https://conta.cc/3coccaf https://www.onehealthcommission.org/en/events_since_2001/2nd_intl_whos_who_in_oh_webinar_2016/ https://www.onehealthcommission.org/en/events_since_2001/2nd_intl_whos_who_in_oh_webinar_2016/ https://conta.cc/3tioev5 kusters, j.; millner, m.a.; omelyanovskaya, k.; tangerli, m.m.; laszewska, a.; van kessel, r. addressing ableism in inclusive education policies: a policy brief outlining italy, poland, the netherlands and the united kingdom (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4681 p a g e 1 | 11 policy brief addressing ableism in inclusive education policies: a policy brief outlining italy, poland, the netherlands and the united kingdom joni kusters1, mareike annemarie millner1, karina omelyanovskaya1, mehmet mikail tangerli1, agata laszewska2, robin van kessel1 1department of international health, faculty of health, medicine, and life sciences, maastricht university, the netherlands 2department of health economics, center for public health, medical university of vienna, austria corresponding author: robin van kessel, phd r.vankessel@maastrichtuniversity.nl mailto:r.vankessel@maastrichtuniversity.nl kusters, j.; millner, m.a.; omelyanovskaya, k.; tangerli, m.m.; laszewska, a.; van kessel, r. addressing ableism in inclusive education policies: a policy brief outlining italy, poland, the netherlands and the united kingdom (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4681 p a g e 2 | 11 abstract context: access to education is a fundamental right that should be realised to the degree that every child can develop their talents to the fullest potential. therefore, children with special education needs and disabilities (send) have the right to claim resources and aid to function in schools and should not be excluded from any level of mainstream education. however, the process towards executing this fundamental right is slowed down by existing ableist structures. policy options: this policy brief analyses inclusive education policies from the perspective of four different european countries (italy, the netherlands, poland, and the united kingdom). the data was synthesised using four types of ableism that are addressed in this policy brief. the gaps within definitions and argumentation were identified and discussed to provide recommendations concerning education for people with send. recommendations: the evaluation provided three significant recommendations towards inclusive education systems by addressing ableist structures. firstly, it is crucial to reduce the linguistic gaps between national educational policies and the underlying national laws. secondly, it is necessary to include the target group and raise awareness for send to reinforce societal and scientific perspectives, and influence policy decision-making. lastly, it is important to address the discrepancies between the inclusive education policies and the structural capacity. the synergy between these two key factors is crucial for an effective implementation of inclusive education. keywords: send, sen, disabilities, ableism, policy, autism, inequality acknowledgments: we thank robin van kessel, our senior advisor, and dr katarzyna czabanowska for the opportunity to explore this topic as part of the leadership track in the master governance and leadership in european public health. authors’ contributions: all authors contributed equally to this work. conflict of interest: none declared source of funding: none declared kusters, j.; millner, m.a.; omelyanovskaya, k.; tangerli, m.m.; laszewska, a.; van kessel, r. addressing ableism in inclusive education policies: a policy brief outlining italy, poland, the netherlands and the united kingdom (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4681 p a g e 3 | 11 introduction autism is a neurodevelopmental condition that mainly manifests in language comprehension and behavioral differences (1). it is a part of the neurodiversity framework, which advocates that individuals with biological differences do not necessarily “need a correction” (1). just as the perception of autism and other developmental conditions has changed over time from an impairment, a disorder, or a disability, national and international policies and laws targeting these conditions have changed accordingly. the latest international cornerstone of this change is found in the convention on the rights of persons with disabilities (2). it adopted a broad categorization of special educational needs and disabilities (send) and indicated that— irrespectively of the type of send—every individuals’ human rights should be enforced and respected (2). article 24 of the crpd declares that access to education is a fundamental right that should be realized to the degree that every child can develop their talents to the fullest potential and effectively participate within society. it specifies that children with send have the right to claim resources and aid to function in schools, and that they may not be excluded from any level of mainstream education (2). however, discrepancies continue to exist for people with send in accessing education, such as lack of resources and lack of appropriate infrastructure (3). these discrepancies stem from various sources, one of which is a lack of uniformity in terminology regarding send, which is rooted in the everyday use of ableist language when drafting policies for people with send (4,5). ableism is prejudice towards individuals with send. this prejudice can manifest itself through (6): affective emotions, behavioral actions and practice, and cognitive beliefs and stereotypes. the expression of ableist attitudes through these three attitude categories does not necessarily consist of blatantly negative attitudes towards people with send. nario-redmond describes that “prejudice often occurs between individuals interacting at the interpersonal level”, and “represents beliefs and motivations that derive from belonging to particular groups – groups of ‘us’ and ‘them’ – groups often motivated to maintain their status difference” (6). this ‘us’ versus ‘them’ mentality is one of the main barriers in equity-related issues concerning inclusion (6,7). people with send are not only affected by aggression targeted towards their send. they are also exposed to pity or paternalistic attitudes from the general population. these attitudes are based on the assumption that atypical people might require ‘help’ from abled people to function and flourish within society (6). however, this can lead to the infantilization of people with send or to various degrees of ostracism. this ostracism should be a public concern as ableism does not only affect a minority consistently but may impact the majority of the population intermittently/temporarily at some point during their lifetime (8). according to the theory of social constructivism, there is a discrepancy between send’s societal and individual perspective (9). just as terminology and perception of racial minorities and gender change, so can the societal perspective on send. this continuous process requires ableism to be addressed and acknowledged to prevent an environment where outsiders are privileged, and insiders are disadvantaged (9). the four main types of ableism addressed within this policy brief are academic-, institutional-, cultural, and language ableism as presented in appendix i. kusters, j.; millner, m.a.; omelyanovskaya, k.; tangerli, m.m.; laszewska, a.; van kessel, r. addressing ableism in inclusive education policies: a policy brief outlining italy, poland, the netherlands and the united kingdom (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4681 p a g e 4 | 11 all these types refer to insufficient recognition of send, the existence of pervasive and archaic policies that disadvantage individuals based on their abilities, and the application of non-inclusive language, furthering the dualistic thinking of normal and abnormal (10– 12). a potential response to these types of ableism can be found in inclusive education education in which children with send participate alongside typical students in education (13). inclusive education impacts students both with and without send (13). generally, inclusive education had a positive impact on academic efforts and social attitudes and beliefs in children without send (13). five significant positive effects of attending class alongside children with send were: 1. reduced fear of human differences, complemented by comfort and awareness 2. increase of social cognition, such as increased tolerance and effective communication 3. self-improvements in the form of increased self-esteem, perceived status, and sense of belonging 4. advancement in morality and ethical principles 5. caring friendships children with send benefited socially (e.g. forming and maintaining positive peer relationships and better social skill development) and academically (e.g. increasing years of completed education) from being included in mainstream education (13). context the policy brief aimed to map ableism within four european countries (italy, poland, the netherlands, and the united kingdom) by exploring the use of language in their send and inclusive education policies. these four countries have all signed the salamanca statement 1994 and therefore have a common ground in their goals regarding an inclusive education system for children with send (14). the brief focused specifically on the inclusion practices regarding people on the autism spectrum, as one policy brief would not be able to adequately address the full range of neurodiversity. the policy brief will serve as a call to action to the authorities within the medical, social and educational fields of european countries’ contexts. it will give recommendations to further inclusion and decrease ableist structures. policy options italy the italian government started integrating persons with send in mainstream education in the 1970s (15). an important example of italian integration is the implementation of law 517/77. it aimed to address institutional ableism by eradicating the idea that send should be seen as an ailment instead of a dimension of diversity (16). however, the assessment by d’alessio shows that policies after 1977 seemed to digress from using inclusive language (17). law no. 104/1992, which was supposed to remove barriers to include people with send within mainstream education, heavily relied on the medical perspective. the same pattern could be observed in the update of the national guidelines on autism (17). the heavy inclusion of the medical model re-linked send and defect (institutional ableism) and re-established the ‘they versus us’ mentality (cultural ableism) and language non-inclusion (18). moreover, ferri reports that the most apparent ableist structures could be observed in the gaps within the practical implementation of current inclusive values (19). the main complaints concerned alleged discrimination/exclusion in schools, kusters, j.; millner, m.a.; omelyanovskaya, k.; tangerli, m.m.; laszewska, a.; van kessel, r. addressing ableism in inclusive education policies: a policy brief outlining italy, poland, the netherlands and the united kingdom (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4681 p a g e 5 | 11 challenges against the level of support school’s offer, and lack/incorrect implementation of inclusion strategies (15,19). in the european court of human rights a case of a primary school pupil (g.l.) on the autism spectrum, italy did not successfully provide tailored support or adequate, equal conditions to continue primary school education. the italian government blamed the poor enforcement of inclusive rights on a lack of financial resources (20). the european courts of the human rights’ case revealed that ableist structures remain in place, hindering inclusive education within the italian system (9,20). d’alessio contests that financial resources are the main problem. the author believes that the poor implementation of inclusion strategies within schools is a consequence of substantial decentralization and power imbalances between the state and educational facilities. in educational institutions, ministerial documents tend to be treated as recommendations and guidelines instead of legislation (18). the lack of consistency in implementing inclusion strategies and the resulting access barriers for people with send showed recognizable patterns of academic ableism (10). poland pogodzińska defined four education options for children with sen: (1) regular schools without any programs for pupils with send, (2) regular schools, with a focus on providing inclusive education, (3) integration schools for pupils with send, and (4) special schools and special residential schools (21). polish education is based on the rule that all individuals with send will be provided with sufficient aid to participate within society (22). compared to the 1990s, the inclusion of children with send in mainstream education has significantly improved. according to plichta the number of children with send who attended special schools has decreased fourfold due to the implementation of integration classes in the last 25 years: in 1990-1991, the number of children with send was 84.317, whereas it was only 24.303 in 2015-2016 (23). however, research of the european parliament demonstrated that there is still a lack of understanding of how to implement inclusive education policies in practice (20, 22) moreover, the supreme audit office observed that only half of the audited institutions had met the criteria for implementing inclusive education. in seven out of ten audited schools, no educational strategies for the pupils with send were implemented (24). the lack of inclusive education policies was ascribed to a wrong interpretation of send (21). students with send were often still perceived as disabled and advised to follow education in special schools. pogodzińska argued that send should not equate to a necessity of sending individuals to special schools but that pupils with send should have the choice to receive guidance within the same educational environment as students that do not have send (21). the netherlands the inclusion of people with send in the netherlands is grounded in the law of ‘equal treatment on the grounds of disability and chronic illness’, and intends further equal social participation and offer protection against discrimination based on ‘disabilities or chronic illnesses’ (25,26). in this legal document, the meaning of ‘disabilities or chronic illnesses’ was not specified and used as an overarching term. from secondary sources, it became evident that the terms ‘disabilities and chronic illnesses were defined as longterm physical, mental, and psychological disorders (26,27). the use of overarching terms kusters, j.; millner, m.a.; omelyanovskaya, k.; tangerli, m.m.; laszewska, a.; van kessel, r. addressing ableism in inclusive education policies: a policy brief outlining italy, poland, the netherlands and the united kingdom (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4681 p a g e 6 | 11 and the lack of specificity are examples of institutional ableism. additionally, a report on the crpd implementation from the netherlands institute of human rights stated that the law ‘equal treatment on the grounds of disability and chronic illnesses’ and the appropriate education act, the legal basis of the “education that fits “a policy which aimed to find the best fitting educational context per individual, were not designed to achieve inclusive education (3,28). mainstream schools were, more often than not, not properly equipped to accommodate send children. therefore, these children ultimately had to attend separate special schools (3). the available legislation gave the impression of inclusion in different contexts, including education, but in practice, barriers remained. despite the existence of the law, many people still experience discrimination in educational institutions. for instance, autism-related discrimination posed difficulties which can be seen in the denied access to higher education institutions of 55 students on the autism spectrum (29). the united kingdom the equality act 2010 in the united kingdom (uk) stated that that a person has a disability if (a) they have a physical or mental impairment, and (b) the impairment has a substantial and long-term adverse effect on the person’s ability to carry out normal dayto-day activities (30). however, the uk department for education defined sen as “a child or young person has sen if they have a learning difficulty or disability which calls for special educational provision to be made for him or her” (31). besides, a child of compulsory school age or a young person has a sen if they (a) have significantly greater difficulty in learning than the majority of others of the same age, or (b) have a disability which prevents or hinders them from making use of facilities of a kind generally provided for others of the same age in mainstream schools or mainstream post-16 institutions (31).this stands in stark contrast to the definition by equality act 2010, as stated above. the differences in the definitions were linked to a pupil’s biological diversity (e.g., physical or mental impairment) versus their ability to learn (e.g., relative learning difficulties). additionally, the department education stated that sen knows four dimensions; health, behavioral, social, and emotional needs (32). these different dimensions had little to no description and were not mentioned in the equality act 2010 (30). as the equality act 2010 focuses on pupils with disabilities, it assumes that children with sen can be considered disabled in practice. the statement of the department for education on comparability and feasibility of provisions for children with send confirmed this finding: “children and young people with such conditions do not necessarily have sen, but there is a significant overlap between disabled children and young people and those with sen. where a disabled child or young person requires special educational provision, they will also be covered by the sen definition” (31). this discrepancy between the definitions provided by the statutory guidance by the department for education and the equality act (2010) was an example of issues related to language ableism (10). this could eventually result in a continuation of how children with sen are medicalized and perceived as disabled (10). recommendations this policy brief aimed to address ableism and the discrimination against people with kusters, j.; millner, m.a.; omelyanovskaya, k.; tangerli, m.m.; laszewska, a.; van kessel, r. addressing ableism in inclusive education policies: a policy brief outlining italy, poland, the netherlands and the united kingdom (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4681 p a g e 7 | 11 send, hindering the implementation of inclusive education. in order to create an overview of the extensiveness of ableism, we distinguished four specific types of ableism: academic, institutional, cultural, and language ableism. to illustrate the possible ways ableism could manifest, we explored the educational policy environments of four european countries (italy, the netherlands, the united kingdom, and poland) due to the close association that education policy has had with send-related measures. all these countries have ratified the crpd and signed the salamanca statement, stating that they would improve the inclusion of people with send within their educational systems. significant improvements towards inclusive educational systems included integrating special education and mainstream education, and additional provisions for children and individuals with send. however, more improvements need to be made. we have identified three critical improvements based on our findings. firstly, the analysis on policy documents showed that there are discrepancies concerning definitions within the policy documents and the underlying laws. whereas the policy documents addressed send as an overarching theme within educational policies, the underlying laws leaned towards defining send as disabilities, thus reinforcing the ableist thinking. during the implementation of inclusive education policies, we would recommend to rely on a consistent manner of defining and addressing send. when addressing send in educational policies, public health professionals need to be aware of the differences in the medical and social perspectives of send to improve inclusive education. this would require a certain degree of representation of send population groups, as will be discussed in recommendation two. secondly, to prevent further discrimination and stigmatisation of individuals with sen, it is crucial to develop awareness to address societal and cultural perceptions of ableism. if the limited knowledge about send is not increased, stigmatisation of individuals will be maintained. therefore, individuals with send and sen-oriented professionals should more often be at the forefront of the inclusive education discussion. institutions or educational facilities could integrate individuals on a volunteer basis to improve the modern perception of ableism. in order to raise awareness about inclusive education, we would suggest familiarising inclusive education professionals with their target group and involving send individuals in political decision-making to prevent further stigmatisation of these specific population groups. this could be achieved by engaging with stakeholders and interested parties advocating send inclusion in decision-making processes to reinforce the actual target group’s perspectives in policies concerning them. lastly, we want to emphasise the need for inclusive infrastructures, such as equipped playgrounds, study halls, libraries, food areas, and elevators to increase mainstream school access for students with send. our analysis of the european countries concluded that a synergy needs to be in place between inclusive education policies and the infrastructural capacity in practice. having inclusive education policies in place would not directly result in the effective implementation of inclusive education, as structural barriers could inhibit the effectiveness of these specific policies. including infrastructural capacity within national contexts would be a critical factor in ensuring that children with send have the freedom to choose between different types of schools without fear of being discriminated against and excluded by their peers. in general, children in schools kusters, j.; millner, m.a.; omelyanovskaya, k.; tangerli, m.m.; laszewska, a.; van kessel, r. addressing ableism in inclusive education policies: a policy brief outlining italy, poland, the netherlands and the united kingdom (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4681 p a g e 8 | 11 should more often be introduced to the idea of having a diverse circle of peers as it will contribute to both their personal development, as the dismantling of societal ableism. conclusions the equal access to education for people with send has progressed positively since the crpd. perspectives have changed concerning the inclusion of people with send within educational policies, aiming for a less segregated approach and opting for more inclusive policies towards these population groups. this process is valuable, but it is important that inclusive education is a continuous process subject to societal perspectives and norms which are to this day influenced by medical perspectives, and the infrastructure to include people with send in what we still call ‘mainstream education’. references 1. baron-cohen s. editorial perspective: neurodiversity – a revolutionary concept for autism and psychiatry. j child psychol psychiatry allied discip. 2017;58(6):744–7. 2. united nations. united nations convention on the rights of persons with disabilities (crpd). 2006; 3. van kessel r, roman-urrestarazu a, ruigrok a, holt r, commers m, hoekstra ra, et al. autism and family involvement in the right to education in the eu: policy mapping in the netherlands, belgium and germany. mol autism. 2019 dec 9;10:43. 4. united nations. rights of persons with disabilities: report of the special rapporteur on the rights of persons with disabilities. 2019. 5. smyth f, shevlin m, buchner t, biewer g, flynn p, latimier c, et al. inclusive education in progress: policy evolution in four european countries. eur j spec needs educ. 2014;29(4):433–45. 6. nario-redmond mr. ableism: the causes and consequences of disability prejudice. hoboken: john wiley & sons, ltd; 2020. 7. united nations. united nations human rights declaration. 1948;2. 8. world health organisation. world report on disability. disability and rehabilitation. 2011. 9. bogart kr, dunn ds. ableism special issue introduction. j soc issues. 2019;75(3). 10. dolmage j. academic ableism. ann arbor, mi: university of michigan press; 2017. 11. chaney p. institutional ableism, critical actors and the substantive representation of disabled people: evidence from the uk parliament 1940–2012. j legis stud. 2015;21(2):168–91. 12. darrow a-a. ableism and social justice. oxford handb soc justice music educ. 2015;204. 13. hehir t, grindal t, freeman b, lamoreau r, borquaye y, burke s, et al. a summary of the evidence on inclusive education. inst alana. 2016;1–34. 14. united nations. salamanca statement and framework in action. 1994; 15. ianes d, demo h, zambotti f. integration in italian schools: teachers’ perceptions regarding day-to-day practice and its effectiveness. int j incl educ. 2014;18(6):626–53. 16. calder-dawe o, witten k, carroll p. being the body in question: young people’s accounts of everyday ableism, visibility and disability. disabil soc. 2020;35(1):132–55. kusters, j.; millner, m.a.; omelyanovskaya, k.; tangerli, m.m.; laszewska, a.; van kessel, r. addressing ableism in inclusive education policies: a policy brief outlining italy, poland, the netherlands and the united kingdom (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4681 p a g e 9 | 11 17. autism europe. italy updates national guidelines on autism. 2018. 18. d’alessio s. inclusive education in italy a critical analysis of the policy of integrazione scolastica simona. vol. 3, society. integration. education. proceedings of the international scientific conference. 2011. 19. ferri d. inclusive education in italy: a legal appraisal 10 year after the signature of the un convention on the rights of persons with disabilities. ric di pedagog e didatt – j theor res educ. 2017;12(2). 20. autism europe. the european court of human rights condemns italy for discrimination against an autistic pupil. 2020. 21. pogodzińska p. country report on poland for the study on member states’ policies for children with disabilities. 2013. 22. constitutional committee of the national assembly. the constitution of the republic of poland of 2nd of april, 1997. dz ustaw. 1997;78(483). 23. plichta p. edukacja dzieci i młodzieżywybrane wyzwania i obszary nierówności [education of children and youth selected challenges and areas of inequality]. dziecko krzywdzone teor badania, prakt. 2017;16(1):146–71. 24. supreme audit office. wsparcie osób z autyzmem i zespołem aspergera w przygotowaniu do samodzielnego funkcjonowania [support for people with autism and asperger syndrome to prepare them to live a self-determined life]. 2020; 25. european agency for special needs and inclusive education. country policy review and analysis: netherlands. brussels; 2020. 26. college of human rights. onderwijs met een beperking. available from: https://mensenrechten.nl/nl/subpage/onderwijs-met-een-beperking 27. council of state. wet gelijke behandeling op grond van handicap of chronische ziekte. 2003. 28. holtmaat r. autism-related discrimination in the field of education. 2013; 29. schuman h. passend onderwijs: pas op de plaats of stap vooruit. tijdschr voor orthop. 2007;46(6):266–78. 30. parliament of the united kingdom. equality act. 2010. 31. department for education. special educational needs and disability code of practice: 0 to 25 years. 2015. 32. department for education. ensuring a good education for children who cannot attend school because of health needs. 2013. 33. smith l, foley pf, chaney mp. addressing classism, ableism, and heterosexism in counselor education. j couns dev. 2008;86(3):303–9. 34. mclaughlin j. the medical reshaping of disabled bodies as a response to stigma and a route to normality. med humanit. 2017;43(4):244–50. https://mensenrechten.nl/nl/subpage/onderwijs-met-een-beperking https://mensenrechten.nl/nl/subpage/onderwijs-met-een-beperking kusters, j.; millner, m.a.; omelyanovskaya, k.; tangerli, m.m.; laszewska, a.; van kessel, r. addressing ableism in inclusive education policies: a policy brief outlining italy, poland, the netherlands and the united kingdom (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4681 p a g e 10 | 11 appendices appendix 1 the four main types of ableism academic ableism: educational institutions fail to recognize the specific needs of people with send and assume they will thrive in mainstream education without specific having these needs met (10). individuals with send are regarded as study and research objects rather than students, teachers and even policymakers–as a result, marginalized groups are even more stigmatized (10). structural ableism creates barriers for people with send, such as lack of access to resources as well as participation in society. it thus contributes to further institutionalization of ableism (10). institutional ableism: the existence of systematic, pervasive and habitual policies that disadvantage individuals based on their abilities (11). the reality of unconscious ableism plays a significant role on different societal levels, and it is a social construct which many people are unaware of (11). the dominant perspective of modern society sees send statutes as a defect, rather than a dimension of difference (11,33,34). therefore, in a societal context, health and wellbeing are strongly associated with the absence of conditions. being unhealthy or unwell, in turn, is determined by the presence of developmental needs, which are generally described as disabilities, impairments, and disorders (16). this results in a belief that people with developmental conditions need to be fixed to be a full member of society (16,33). in a health care context, this results in the urge towards medicalizing behavior of people with send (16). cultural ableism: the persistent way of binary social organization which is closely related to the western traditions of dualistic thinking (34). this results in the classification of people in everyday life as being either abnormal or normal (34). this day-to-day classification which we enact, both consciously and subconsciously, is referred to as everyday ableism (16). language ableism: application of non-inclusive language which furthers the dualistic thinking of normal and abnormal (12). the correct use of language is essential, as language is a crucial factor in how the perception of others can be influenced. the main reason for send-related, inappropriate terminology is often the lack of awareness (12). appendix ii. methods and search strategy the data was collected based on four identified key forms of ableism (academic, institutional, cultural, or language ableism) and consequently analyzed within the policy mapping procedure. the data synthesis process for the four selected countries consisted of four consecutive steps: (1) identifying, screening and assessing educational policies on their inclusion towards people with send. relevant educational policies concerning children with send were extracted from national sources. (2) identifying, screening and assessing relevant academic articles on their inclusion towards people with send. these articles were used in addition to national policies when language-related barriers occurred. the search strategy appendix ii was executed using pubmed and scopus. the content of the articles was screened for inclusion of student populations with send and the implementation of national send-related policies. (3) coding of documents based on the four ableism types. content from national policy documents was evaluated on the presence of ableist reasoning, definitions, and discrepancies. the content of the policy documents was reviewed for argumentation gaps and definitions that rely on the medical perspective rather than the social dimension of send. definitions concerning send kusters, j.; millner, m.a.; omelyanovskaya, k.; tangerli, m.m.; laszewska, a.; van kessel, r. addressing ableism in inclusive education policies: a policy brief outlining italy, poland, the netherlands and the united kingdom (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4681 p a g e 11 | 11 © 2021 kusters et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. were extracted from these policies. underlying laws were analyzed to attain complete definitions of send and to analyse discrepancies between the documents. in addition, academic articles were analysed using the framework, e.g., arguments on national policies concerning send definitions and practical implementations. (4) synthesising and reporting the data. the results of the evaluations of the policies and additional papers were discussed for each respective country, highlighting discrepancies in definitions, theory, and practice. search domain definition key words population group children with send (children or students or pupils) and (send or sen or disabilit* or ableis* or impairment* or “special education need*”) policy domain educational policies (education* or school* or policy or polcies) national context italy, the netherlands, poland, and the united kingdom (ital* or netherlands or dutch or polish or poland or “united kingdom” or uk) countries search queries italy (children or students or pupils) and (send or sen or disabilit* or ableis* or impairment* or “special education need*”) and (education* or school* or policy or polcies) and (ital*) the netherlands (children or students or pupils) and (send or sen or disabilit* or ableis* or impairment* or “special education need*”) and (education* or school* or policy or polcies) and (netherlands or dutch) poland (children or students or pupils) and (send or sen or disabilit* or ableis* or impairment* or “special education need*”) and (education* or school* or policy or polcies) and (polish or poland) theunited kingdom (children or students or pupils) and (send or sen or disabilit* or ableis* or impairment* or “special education need*”) and (education* or school* or policy or polcies) and (“united kingdom” or uk) italy poland the netherlands the united kingdom brauneis s, sorrentino e, di lisa v, galluccio g, piras b, carella f, et al. assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy (original research). seejph 2021, posted: 17 march 2021. doi: 10.11576/seejph4240 p a g e 1 | 13 original research assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy stefano brauneis1, enza sorrentino1, vincenza di lisa1, gabriella galluccio1, barbara piras2, francesca carella3, edoardo palozzi3, carmela generali3, simona maggiacomo3, silvia d’aurelio3, insa backhaus3, filippo la torre4, ciro villani5, giuseppe la torre3 1 pain center, "policlinico umberto i” hospital, sapienza university of rome, rome, italy; 2 casilino hospital, rome, italy; 3 department of public health and infectious diseases, sapienza university of rome, rome; 4 surgical sciences and emergency department, policlinico umberto i/sapienza university of rome, rome, italy; 5 department of orthopaedic and traumatology, policlinico umberto i hospital sapienza university of rome, rome, italy. correspondending author: prof. giuseppe la torre; address: piazzale aldo moro 5 – 00185, rome, italy; telephone: +39(0)649694308/+39(0)649970978; email: giuseppe.latorre@uniroma1.it brauneis s, sorrentino e, di lisa v, galluccio g, piras b, carella f, et al. assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy (original research). seejph 2021, posted: 17 march 2021. doi: 10.11576/seejph4240 p a g e 2 | 13 abstract aim: the aim of this study was to assess the prevalence of low back pain (lbp) among health professionals and the possible risk factors. methods: the study was carried out from april 2018 to october 2018 among all health workers of the orthopaedic clinic and the emergency department of “policlinico umberto i” in rome. lbp was assessed using the nordic questionnaire musculoskeletal disorders in the section on lumbar pain. the type of physical activity carried out as prevention was investigated by use of the international physical activity questionnaires. the overall state of health and lifestyle was determined by the short form 12-item health survey. job satisfaction and perceived work stress were assessed through the 15-questions of karasek’s questionnaire. the intensity of the low back pain was assessed using a numerical rating scale. a univariate analysis was conducted to assess the associations between socio-demographic and working variables. multiple logistic regression models were used to assess independent correlates of lbp. results: one hundred thirteen subjects were enrolled, 52 women and 61 men. the annual periodprevalence of lumbar musculoskeletal disorder was found on 79.6% of participants with lbp. mean value evidence of nrs was 2.66. the highest lbp risk over the 12 months was found in groups with high job demand (or = 1.18; 95%ci: 1.01 – 1.38), low decision-making opportunities (for decision latitude or = 0.87; (0-76 – 1.0), and low levels of physical activity (or = 0.75; 95%ci: 0.64 – 0.89). conclusion: the working environment is a potential risk factor for the development of lbp and is suitable for prevention programmes. the protective effect of physical activity and work-related stress management indicate room for improvements for the prevention of lbp in these hcws. keywords: health workers, low back pain, occupational low back pain, operating room health professionals, prevention. conflicts of interest: none declared. brauneis s, sorrentino e, di lisa v, galluccio g, piras b, carella f, et al. assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy (original research). seejph 2021, posted: 17 march 2021. doi: 10.11576/seejph4240 p a g e 3 | 13 introduction low back pain’s incidence in adult population is 10-30% every year and the lifetime prevalence in adults is as high as 65-80% in usa (1,2). people in working age, from 26 to 60 years, are affected by low back pain at least once in their lifetime (3). occupational low back pain (lbp) has become an emerging health issue in recent years (4,5). in italy a review found that lbp prevalence in healthcare workers varied from 33% to 86% (6). among health care workers, nurses and surgeons are the working categories with the highest risk of experiencing pain related to musculoskeletal disorders (msds) during their working life. this risk is related to a broad range of factors such as incorrect postures, exposure to heavy physical loads, muscle strain, whole-body vibrations (wbv), patient treatment activities (3,7-10) and may affect the ability and the efficiency of health care workers in the performance of their tasks (10). awkward postures, carrying and repositioning patients, prolonged standing, and working without sufficient breaks represent risk factors for the developing of lbp in nurses (11). among physicians the prevalence of lbp is higher among surgeons (37%) than other specialties (9,12,13). the inappropriate positioning, posture during surgery, and prolonged standing are possible cause (14,15). persistent low back pain comes along with several consequences and can cause temporary work disability with sick leave (16). work-related msds are the number one cause of absenteeism among the health care workers. the us department of labor estimates that msds are the cause of 62% of all worker injuries and 32% of missed days from work, and an estimated economic impact of $13 to $20 billion every year (9). it is essential to promote new prevention programmes based on vocational training and physical activity to provide benefits and reduce the incidence of lbp in these professional categories since it’s been demonstrated that muscle strength is a protective factor against physical fatigue and msds (12,17). due to the prolonged activity and the burden of workload on spine and shoulders of operating room health workers, as detected during the occupational health visit, the aim of the study was to assess the prevalence of lbp related to the work activity in a group of health workers, from the orthopaedic clinic and the emergency department, and the associated risk factors. methods this observational study was led by the pain therapy center “enzo borzomati” – hub lazio region, in collaboration with occupational medicine and medical radiation protection service of the university hospital "umberto i" in rome. approval to conduct this study was obtained from the ethical committee of our university hospital (5030/18). all study participants gave informed written consent and the research was conducted in accordance with the helsinki declaration. data were collected from april 2018 to october 2018 among health workers of the orthopaedic clinic and the emergency department of “policlinico umberto i” in rome participation in the study was voluntary and anonymous. setting and population all healthcare professionals who were working in the operational unit of orthopaedic surgery and emergency department (dea) at brauneis s, sorrentino e, di lisa v, galluccio g, piras b, carella f, et al. assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy (original research). seejph 2021, posted: 17 march 2021. doi: 10.11576/seejph4240 p a g e 4 | 13 the “policlinico umberto i” in rome (italy) were invited to participate. they were approached by telephone and an appointment for the interview was fixed. admission criteria: i) healthcare professionals in the operational unit of orthopaedic surgery and emergency surgery; ii) candidates of both sexes and over the age of 18 and under 70 years old. exclusion criteria: i) participants in other studies; ii) subjects with serious local or systemic physical occurring pathologies that can interfere in the investigator’s judgment with pain assessment; iii) subjects with recent surgical procedure. data collection data were collected using standardised validated questionnaires in italian. the presence of low back pain was assessed using the italian version of the nordic questionnaire musculoskeletal disorders in the section on lumbar pain (18,19). the type and quality of physical activity carried out as prevention and/or therapy has been investigated with international physical activity questionnaires (ipaq) (20,21). the overall state of health and lifestyle was determined by short form 12-item health survey (sf-12 standard v1) (22-23). job satisfaction and perceived work stress were assessed through the 15-questions karasek questionnaire (24). the intensity of the low back pain was assessed using a numerical rating scale (nrs) (25). statistical analysis quantitative and qualitative variables were examined and their frequency was calculated: years of work, years of work in the company ("policlinico umberto i" university hospital in rome), type of permanent/occasional contract with continuous/split hours and fixed/rotation on several shifts. particular attention was paid to the body mass index (bmi, calculated considering the weight and height of the subject under examination) and the hours of work spent standing or sitting. a univariate analysis was conducted to assess the association between socio-demographic factors and working variables with the following variables derived from the nordic questionnaire musculoskeletal disorders: have you ever had low back pain disorders in the last few months? during the last 12 months, have your musculoskeletal disorders ever prevented you from performing your normal activities both at home and outside? have these disorders manifested themselves in the last seven days? have you ever had any lower back problems in your life? have you ever suffered any lower back trauma as a result of an injury? logistic regression models have been built for the variables “lumbar pain in the last 12 months” and “lumbar pain in the last 7 days” in order to verify the associated variables with a multiple regression approach. we built full model and stepwise models with a backward elimination procedure. the results are presented as odd ratio (or) and 95% confidence interval (95%ci). goodness of fit of the models was assesses using the hosmerlemeshow test. the level of significance was set at p≤0.05. the spss statistical package, version 25.0, was used. results one hundred thirteenhealth professionals (response rate 100%) completed the study. contingency tables have been elaborated to describe and analyse the relationships between two or more variables and to define the frequency tables, the results of which have brauneis s, sorrentino e, di lisa v, galluccio g, piras b, carella f, et al. assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy (original research). seejph 2021, posted: 17 march 2021. doi: 10.11576/seejph4240 p a g e 5 | 13 been graphically represented by histogram, box-plot, dot-plot. socio-demographic and clinical data were obtained by the nordic questionnaire musculoskeletal disorders, in relation to the lumbar section, which were identified as quantitative and qualitative variables associated with lbp. 52 women (46%) and 61 men (54%), were enrolled, aged between 26 and 68 years (average age = 42.76 years, st. dev. = 12; median = 44 years; mode = 29 years). participants were divided into different groups on the basis of qualification and recoded as follows: specialist medical surgeon: no. 18/113 15.9%; specialist medical personnel: n° 33/113 29.2%; nursing staff: no. 49/113 (4 nursing coordinators, 44 nurses) 43.4%; technical operator (ot): n° 7/113 6.2%; socio-medical caregiver (in italian medical system distinguished in two professional figures having ass and oss as acronyms) and technical caregiver (in italian medical acronyms ota): n° 6/85 (3ass, 2oss, 1ota) 5.3%. table 1 shows the characteristics of the study participants. out of 113 subjects examined: 111 subjects have permanent employment and only 2 occasional; 107 subjects have a full-time job and 6 subjects have a part-time job; 14 subjects work the morning shift, 39 in the morning and afternoon, 36 work the multishift rotation. table 1. characteristics of the study participants variable n (%) or median (range) gender female male 52 (53.8) 61 (68.9) age 44 (26 – 68) years of work 11.4 (0.3 – 40.3) hours of work standing up 6 (3-10) hours of work sitting 1.5 (0-20) continuous working hours no yes 12 (66.7) 101 (61.4) job role nurses other health professions technicians doctors in training structured doctors 49 (51) 6 (83.3) 7 (57.1) 33 (66.7) 18 (77.8) bmi (body mass index) 24 (18.1 – 36.2) met (metabolic equivalent of task) 3483 (0 – 79140) pcs (physical component summary) 49.5 (24.5 – 63.7) mcs (mental component summary) 46.4 (20.1 – 62.8) low back pain lifetime in the last 12 months in the last week 99 (87.6) 90 (79.6) 43 (38.1) decision latitude 68 (52 90) job demand 35(25 – 48) job strain 0.82 (0.49 – 1.29) brauneis s, sorrentino e, di lisa v, galluccio g, piras b, carella f, et al. assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy (original research). seejph 2021, posted: 17 march 2021. doi: 10.11576/seejph4240 p a g e 6 | 13 based on the analysed data, it was possible to calculate the prevalence of lbp with time intervals of one week, one year, over a lifetime and the percentage of subjects who have never had lbp experience. subsequently, the annual periodic prevalence of lumbar musculoskeletal disorder was quantified on the total of 79.6% of subjects with lbp. the intensity of lumbar pain in the last 7 days was evaluated using the numerical rating scale (nrs) with a mean value evidence, on a scale from 0 to 10, of 2.66. a predictive factor for persistent low back pain seems to be the presence of neuropathy in the lower limbs, with an incidence of 11.7% on the lifetime prevalence of lbp (table 2). table 2. lumbar pain in the last 12 months variable no yes p gender female male 9 (17.3) 14 (23) 43 (82.7) 47 (77) 0.458 age 47 (27 – 68) 43.5 (26 64) 0.343 years of work 10 (0.3 – 40) 12 (0.3 – 40.3 0.795 continuous working hours no yes 5 (41.7) 18 (17.8) 7 (58.3) 83 (82.2) 0.05 job role nurses other health professions technicians doctors in training structured doctors 12 (24.5) 1 (16.7) 1 (14.3) 6 (18.2) 3 (16.7) 37 (75.5) 5 (83.3) 6 (85.7) 27 (81.8) 15 (83.3) 0.914 bmi 23.4 (18.1 – 36.2) 24 (18.2 – 36.2) 0.559 job strain 0.79 (0.59 – 1.01) 0.82 (0.49 – 1.29) 0.290 met 2670 (495 17790) 3483 (0 79140) 0.392 mcs 48.3 (20.6 – 58.8) 48.8 (22.1 – 63.9) 0.746 pcs 55 (34.1 – 63.3) 50.6 (23.8 – 61.2) < 0.001 legend: bmi= body mass index; met = metabolic equivalent of task; mcs =mental component summary; pcs =physical component summary the 15-question karasek questionnaire provided data on psychosocial conditions at work and perceived work stress, i.e. it was possible to assess the worker's autonomy in making decisions concerning his or her job. this model suggests that the relationship between high job demand (job demand, jd) and low decision-making freedom (decision latitude, dl) defines a condition of "job strain" or "perceived job stress", which can explain the levels of chronic stress and the increased risk in this case of manifesting lbp (table 3). the two main working dimensions (jd vs dl) are considered independent variables and placed on orthogonal axes. the job demand refers to the work effort required, in terms of: work rhythms; taxing nature of the organization; number of working hours; any inconsistent requests. decision latitude, on the other hand, is defined by two components: skill discretion; brauneis s, sorrentino e, di lisa v, galluccio g, piras b, carella f, et al. assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy (original research). seejph 2021, posted: 17 march 2021. doi: 10.11576/seejph4240 p a g e 7 | 13 decision authority. on the one hand, the first identifies conditions characterized by the possibility to learn new things, the degree of repetitiveness of tasks and the opportunity to enhance one's skills; on the other hand, the second basically identifies the level of control of the individual on the planning and organization of work. table 3. lumbar pain in the last 7 days variable no yes p gender female male 28 (53.8) 42 (68.9) 24 (46.2) 19 (31.1) 0.102 age 47 (27 – 68) 43.5 (26 64) 0.993 years of work 10 (0.3 – 40) 12 (0.3 – 40.3 0.599 continuous working hours no yes 8 (66.7) 62 (61.4) 4 (33.3) 39 (38.6) 0.722 job role nurses other health professions technicians doctors in training structured doctors 25 (51) 5 (83.3) 4 (57.1) 22 (66.7) 14 (77.8) 24 (49) 1 (16.7) 3 (42.9) 11 (33.3) 4 (22.2) 0.204 bmi 23.4 (18.1 – 36.2) 24 (18.2 – 36.2) 0.316 job strain 0.79 (0.59 – 1.01) 0.82 (0.49 – 1.28) 0.562 met 2670 (495 17790) 3483 (0 79140) 0.224 mcs 48.3 (20.6 – 58.8) 48.8 (22.1 – 63.9) 0.668 pcs 55 (34.1 – 63.3) 50.6 (23.8 – 61.2) 0.001 legend: bmi= body mass index; met = metabolic equivalent of task; mcs =mental component summary; pcs =physical component summary through this tool it was possible to identify the classic four working conditions, defined as: high strain, high demand with low freedom of decision; passive, low demand with low decision making (work that does not encourage individual skills with marked levels of dissatisfaction); active, high demand with high decision (job with a high degree of learning and responsibility); low strain, low demand with high decision (optimal work situation, in which the individual can manage his working time independently). in accordance with this model and by including the most significant variables, including the task performed, the highest lbp risk over the 12 months was found in groups with high labour demand and low decision-making opportunities, represented in this case by health care personnel in training. the information on the physical activity performed was obtained by using the short form of the international physical activity questionnaire (ipaq), in which weekly frequency and average duration of physical activity (intense, moderate, walking) are required, regardless of whether during work or leisure time, and the number of hours per day spent sitting. in addition, to assess the degree of physical activity exercised and classify it as good / moderate / poor, the ipaq uses mets (metabolic equivalent of task), which have a different value depending on the effort brauneis s, sorrentino e, di lisa v, galluccio g, piras b, carella f, et al. assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy (original research). seejph 2021, posted: 17 march 2021. doi: 10.11576/seejph4240 p a g e 8 | 13 practiced, allowing to add up activities of different intensity. by combining the main characteristics in a multivariate analysis and recoding the data for the task performed, the results show that ass+oss+ota staff practice a good level of physical activity and are less at risk of developing lbp in the last 12 months. through the summary of the scores obtained from the 12 questions of the short form health survey (sf-12 standard v1 questionnaire), the general state of health was investigated using two synthetic indices, the physical component summary (pcs) for the physical state and the mental component summary (mcs) for the mental state. the values of the synthetic indices vary, on the observed sample, from 23.8 to 63.3 for the pcs and from 20.59 to 60.15 for the mcs index, indicating that their growth indicates better psychophysical health conditions (table 1). considering qualitative and quantitative variables and sample averages, the most relevant data acquired from all the questionnaires (gender, age, years of work, years of work in the company, days worked per week, continuous working hours, broken hours, daily standing hours, daily sitting hours, role, bmi, pcs, mcs, mets, job demand and decision latitude) were associated with the incidence of lumbar pain in the last 12 months and the last 7 days (tables 2 and 3). there are significant variables associated with lumbar pain over the last 12 months: continuous working hours (p = 0.05); high pcs scores, in protective terms (the higher the pcs level, the lower the probability of having had lumbar pain in the last 12 months). the only variable associated with lumbar pain in the last 7 days was pcs, with higher values of pcs indicating a protective effect. the multivariate analysis shows different results for the two dependent variables (table 4). firstly, lumbar pain in the last 12 months is directly associated with years of work (or = 1.16) and job demand (or = 1.18), and inversely associated with age (or = 0.81), decision latitude (or = 0.87) and pcs (or = 0.75). on the other hand, lumbar pain in the last 7 days is directly associated to being a nurse (or = 2.55) and inversely associated pcs (or = 0.91). table 4. results of the multiple logistic regression analyses. dependent variables: lumbar pain in the last 12 months lumbar pain in the last week variable lumbar pain in the last 12 months lumbar pain in the last 7 days full model backward elimination model full model backward elimination model gender female male (ref.) 1.66 (0.30 – 9.31) 1 0.73 (0.21 – 2.49) 1 age 0.80 (0.69 – 0.92) 0.81 (0.71 – 0.92) 0.94 (0.85 – 1.04) years of work 1.21 (1.04 – 1.41) 1.16 (1.03 – 1.32) 1.01 (0.92 – 1.10) continuous working hours yes no (ref.) 0.20 (0.04 – 1.03) 1 0.17 (0.04 – 0.81) 1 0.89 (0.23 – 3.41) 1 job role nurses doctors 0.60 (0.06 – 6.08) 0.95 (0.09 – 9.8) 1 3.37 (0.69 – 16.4) 1.28 (0.22 – 7.21) 1 2.55 (1.0 – 6.49) 1 brauneis s, sorrentino e, di lisa v, galluccio g, piras b, carella f, et al. assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy (original research). seejph 2021, posted: 17 march 2021. doi: 10.11576/seejph4240 p a g e 9 | 13 other health professions (ref.) bmi (body mass index) 0.84 (0.69 – 1.03) 0.98 (0.84 – 1.13) job demand 1.19 (1.01 – 1.40) 1.18 (1.01 – 1.38) 0.98 (0.87 – 1.10) decision latitude 0.86 (0.733 – 1.01) 0.87 (0-76 – 1.0) 1.02 (0.92 – 1.12) met 1.001 (0.99 – 1.003) 1.002 (1.00 – 1.003) 1.002 (1.00 – 1.003) mcs 1.07 (0.99 – 1.16) 0.99 (0.94 – 1.05) pcs 0.74 (0.62 – 0.88) 0.75 (0.64 – 0.89) 0.91 (0.85 – 0.97) 0.91 (0.86 – 0.96) discussion lbp is a very common health problem. in this study we found that in hcws that work in operating theatre have a prevalence of lbp of almost 80% and 38%, in the last year and the last week, respectively. results show that 14 out of 113 candidates (12.4% of the total) had never experienced lumbar pain in their lifetime, while 99 (87.6%) had experienced lbp at least once in their life. these data do not differ from what is stated in scientific literature (26-27). based on the data we can assume that: lbp’s incidence shows peaks in particular age groups characterized by intense work activity (28 to 32 yearsold and 40 to 45 years-old). there is no significant difference in lbp’s incidence between male and female population. high bmis are statistically associated with lbp. a sedentary lifestyle and low physical activity levels are risk factors and aggravating factors for lbp. an adequate muscle mass tone significantly reduces lbp’s occurrence. excessive working hours, especially with insufficient recovery time between activities, increase the incidence of lbp. lbp’s incidence is lower in nurses and higher in trainees, mainly because of the above-average number of continuous working hours for trainees. a high physical effort and an excessive mechanical load or an inadequacy of the load in relation to the physical competence of the subject increase the risk of experimenting lbp. the etiopathogenesis of lumbar pain therefore involves countless variables, including biophysical factors, genetic factors, psychological factors, social factors and comorbidities (1,2). most surgeons are usually subjected to physical and mental stress and suffer from msds (physical fatigue, stiffness and pain) involving different body areas, arising during or after surgery (17). there is an association between risk factors and musculoskeletal disorders most frequently due to static positions and extreme postures that require sustained effort in the absence of breaks or with inadequate recovery timing between surgeries (28). each surgical specialty has its own ergonomic characteristics (position and height of the operating table, position of monitors, design of laparoscopic instrument handles, etc.) and this evidence suggests that particular groups of surgeons may be at higher risk of having symptoms related to their profession. in addition, the affected body area varies according to the surgical specialty (29-31). previous works show that many health care workers complain of generalized pain (17.2%) and physical fatigue (36.2%) and experience msds more than once in their working life. the areas of the body most affected brauneis s, sorrentino e, di lisa v, galluccio g, piras b, carella f, et al. assessment of the prevalence and risk factors of low back pain in operating room health workers: an observational study in italy (original research). seejph 2021, posted: 17 march 2021. doi: 10.11576/seejph4240 p a g e 10 | 13 by skeletal muscle disorders, in descending order of incidence, are (32,33): lumbar region of the spine (66.9%); cervical area of the spine (with associated headache) (65.4%); dorsal area of the spine (22.4%); lower extremities (leg and foot) (12.1%); wrist and right hand (8.6%); shoulder and right arm (8.6%). many health professionals report that pain, particularly lbp, interferes with quality of life, mental and physical health, quality of sleep and social relationships (34). persistent low back pain comes along with several consequences and can cause temporary work disability with sick leave. moreover, recurrent or persistent musculoskeletal disorders may affect the ability and efficiency of the surgeon to perform his or her work by encouraging him or her to favour the open surgical approach rather than minimally invasive surgery (mis) and/or to reduce the number of procedures or to discontinue surgery early (15, 35). from the prevention point of view, one of the most interesting results seems to be the protective effect on both dependent variables of the physical composite score, indicating that hcws involved in operating room are a perfect target of preventive programs based on regular physical activity. this result is supported by a recent systematic review and meta-analysis of rcts focused on prevention of lbp that indicates physical exercise as a protective factor against the risk of episodic lbp and sick leave due to lbp in general population (36). physical activity programs among professional health care workers could be recommended in order to prevent lbp, and this activity could be intended as part of a disability management program (15,17,37-39). another interesting point from a public health perspective is related to the association between job demand and decision latitude (as indicators of work-related stress) and lbp. our results are in agreement with those coming from the scarce literature on this issue on hcws (40,41), but according to our knowledge it is the first study that demonstrates the association between work-related stress items and lbp in operating room hcws. some limitations in this study must be acknowledged. first of all, the study carried out has a cross-sectional design, and the casual relationship between risk or protective factors and lbp cannot be completely clear. another possible limitation could be related to the settings involved, in terms of external validity. we involved only two settings (orthopedics and emergency room) and the validity of the results can be considered for these. we cannot be sure to obtain the same results on other operating wards. in conclusion, future research needs to go more deeply into the effects of physical activity experienced by health care 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indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5325 p a g e 1 | 9 original research legal protection of the patient's right to access medical records in indonesia rano indradi sudra1,2, sarsintorini putra2, inge hartini3 1 politeknik rukun abdi luhur, kudus, indonesia; 2 universitas 17 agustus 1945, semarang, indonesia; 3 universitas katolik soegijapranata, semarang, indonesia. corresponding author: rano indradi sudra; address: universitas 17 agustus 1945, semarang, indonesia. e-mail: rano.indradi@gmail.com sudra ri, putra s, hartini i. legal protection of the patient's right to access medical records in indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5325 p a g e 2 | 9 abstract background: patient access rights to medical records are related to the retention period because they can only be accessed as long as they have not been destroyed. the study aims to identify the corresponding regulations to assess the legal protection of the patient's right to access her/his medical record. methods: tracing and identifying primary legal sources in regulatory content related to patient rights of access. an analysis was conducted on the clarity and consistency of the contents identified. results: regulations identified regarding patients' rights to access their medical records are law number 29 of 2004, government regulation number 47 of 2021, and minister of health regulation number 269 of 2008. the regulations governing the retention period of medical records are law number 11 of 2008, law number 44 of 2009, government regulation number 46 of 2017 and number 71 of 2019, minister of health regulation number 269 of 2008, number 82 of 2013, and number 46 of 2017. conclusions: the condition of disharmony and inconsistency among regulations governing patient access rights and the retention period of medical records creates uncertainty for patients to access their medical records. keywords: indonesia, legal protection, medical records, patients' rights. conflicts of interest: none declared. sudra ri, putra s, hartini i. legal protection of the patient's right to access medical records in indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5325 p a g e 3 | 9 background health as a human right must be realized by offering various health efforts to the entire community through the implementation of quality and affordable health development by the community (1). health service facilities are required to provide the necessary services in administering and keeping adequate medical records. the international federation of health information management associations (ifhima), in its 2019 edition of 'learning module-1' defines medical records as "a collection of written information about patients since the patient arrived at the hospital, clinic or primary healthcare. the medical record is a record of all procedures performed on a patient, containing the patient's past medical history, including opinions, investigations, and other details relevant to the patient's health". medical records contain notes and documents about the patient's identity, examination, treatment, action, and other services that have been provided to the patient (2). the medical record, as stated in the medical record manual of the world health organization (who), must contain sufficient data to be used to identify the patient, support the diagnosis or state the main reason the patient came to the health care facility, validate the reason for offering the procedure and document all the results accurately (3). patient access rights in indonesia: chapter viii, article 29 paragraph 1 (h) in law number 44 of 2009 concerning hospitals in indonesia states that "every hospital has an obligation to maintain medical records." the explanation of the paragraphs states that "what is meant by the administration of medical records in this paragraph is carried out in accordance with standards that are gradually revised to reach international standards." the hospital accreditation commission (kars) in the national hospital accreditation standard (snars) edition 1.1 of 2019 states that "medical records are written evidence (paper/electronic) that record various patient health information such as assessment findings, care plans, details of care implementation and treatment, integrated patient progress records, and discharge summaries prepared by the care professional (ppa)" (4). article 7 of law number 36 of 2009 concerning health states that "everyone has the right to get information and education about balanced and responsible health." furthermore, in article 8, it is stated that "everyone has the right to obtain information about his health data including actions and treatments that have been or will be received from health workers." in this provision, it is also explained that health information in the context of this provision is private health information so that only those entitled have access, especially the patient concerned (5). article 12 paragraph (3) of the regulation of the minister of health number 269 of 2008 concerning medical records states that the contents of the medical record belong to the patient in the form of a summary of the medical record which can then be given, recorded, or copied by the patient or person who is authorized or has written consent from the patient or the patient's family (2). article 47 paragraph (1) of law number 29 of 2004 concerning medical practice also states that the contents of the medical record are the patient's property. article 52 (e) states that the patient has the right to obtain the contents of the medical record and not only in the form of a summary of the medical record (1). as the owner of the information in the medical record, the patient has the right to obtain his/her information and determine the parties who are authorized to participate in accessing the information in his/her medical record (2). if the health service facility already uses electronic medical records, then the technique for obtaining information in the medical record is realized by accessing the electronic medical record system. access to an electronic system, including electronic medical records, can only be done if a person is authorized by the electronic medical record system (given the right to access). present regulations for storage in order for something to be accessible, it must exist. the existence of medical records is related to the arrangement of the shelf life or retention. regulations regarding the retention sudra ri, putra s, hartini i. legal protection of the patient's right to access medical records in indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5325 p a g e 4 | 9 period of medical records are contained in articles 8 and 9 of the regulation of the minister of health number 269 of 2008 concerning medical records, circular (se) of the director-general of medical services no. hk.00.06.1.5.01160 dated march 21, 1995, concerning technical instructions for procurement of record forms basic medical and destruction of medical record archives in hospitals, article 55 of the republic of indonesia law number 44 of 2009 concerning hospitals, and article 21 paragraph (5) of government regulation of the republic of indonesia number 46 of 2014 concerning health information systems. the regulations related to the retention period of medical records mentioned above still do not harmoniously regulate the period of storage (retention), types of medical records (paper or electronic), active/inactive medical record groups, and which data/sheets are stored/destroyed. actual regulatory developments consistent regulation of patient access rights to medical records is essential and urgent considering the strategic plan of the ministry of health for 2020-2024 as stated in minister of health regulation number 21 of 2020. the plan targets all hospitals in indonesia to apply integrated electronic medical records. if medical records "can" be destroyed after a retention period of 10 years, patients will lose their access rights. this study aims to identify patient access rights to medical records and regulations related to the retention period of medical records to assess the legal protection for patients' rights to access their medical records. methods this research is empirical juridical research using secondary data collected through document studies on various legal materials and non-legal materials that support the focus of this study. the data and information obtained in this study will be presented and developed comprehensively in descriptive narratives to support the conclusion. results the author's initial survey of 50 hospitals participating in the readiness assessment and development of electronic medical records in 2018-2019 (divided into six training batches) showed that none of these hospitals provided patients with access to electronic medical records and did not even plan to provide these features. although it has been stated in the minister of health regulation number 269 of 2008 concerning medical records and law number 29 of 2004 concerning medical practice that the patient is the owner of the contents of the medical record and has the right to access his property, the regulation does not contain the patient's access rights. a complete and good medical record must include all information about the patient's health and treatment during the period of service and be easily accessible. medical records must be kept for a predetermined period so that they can be used for: a. communication needs between service providers and patients and between service providers, b. source of continuity of service and patient care data, c. evaluation of patient care, d. medicolegal needs, e. the need for health service statistics, f. sources of research and education data, and g. history-related needs (6). article 46 paragraph (1) of law number 29 of 2004 concerning medical practice states that what is meant by "medical record" in the situation of indonesia: it is a file containing records and documents regarding patient identity, examination, treatment, action, and other services that have been provided to patients. regarding the manufacture of medical records, regulation of the minister of health number 269 of 2008 concerning medical records article 2 paragraph (1) states that "medical records must be made in writing, complete and clear or electronically." a good medical record is a medical record that contains all the required information, whether sudra ri, putra s, hartini i. legal protection of the patient's right to access medical records in indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5325 p a g e 5 | 9 obtained from the patient, the doctor's thoughts, examinations, and actions of the doctor, communication between medical/health personnel, informed consent, and other information that can be evidence in the future, which arranged sequentially (chronologically). medical records also show what health service providers have done, which can be compared with what should be done as stated in professional standards and standard operating procedures, which is proof of whether or not there is a violation of obligations and the presence or absence of losses resulting from it (7). medical record ownership as a document containing notes about the patient's medical history, ownership of medical records is regulated in article 47 paragraph (1) of law number 29 of 2004 concerning medical practices and article 12 of regulation of the minister of health number 269 of 2008 concerning medical records which states that the medical record file belongs to the health service facility and its contents belong to the patient in the form of a summary of the medical record, this summary of medical records can be provided, recorded, or copied by the patient or person authorized or written consent of the patient or patient's family who is entitled to it. access to electronic data and information in the kamus besar bahasa indonesia (kbbi), data is defined as: 1) true and real information; and 2) real information or material that can be used as the basis for a study (analysis or conclusion). meanwhile, information is defined as "the whole meaning that supports the message seen in the parts of the message." article 1 paragraph (1) of law number 19 of 2016 concerning amendments to law number 11 of 2008 concerning electronic information and transactions states that "electronic information is one or a set of electronic data, including but not limited to writing, sound, images, maps, designs, photographs, electronic data interchange (edi), electronic mail (electronic mail), telegram, telex, telecopy or the like, letters, signs, numbers, access codes, symbols, or processed perforations that have meaning or can understood by those who can understand it." in paragraph (4), it is stated that "electronic document is any electronic information that is created, forwarded, sent, received, or stored in analog, digital, electromagnetic, optical, or similar forms, which can be seen, displayed, and/or heard through a computer or electronic systems, including but not limited to writing, sounds, pictures, maps, designs, photographs or the like, letters, signs, numbers, access codes, symbols or perforations that have a meaning or can be understood by people who are able to understand them." article 1 of law number 14 of 2008 concerning disclosure of public information states that what is meant by information is "…information, statements, ideas, and signs that contain values, meanings, and messages, both data, facts, and explanations that can be seen, heard, and read which is presented in various packages and formats in accordance with the development of information and communication technology electronically or non-electronically. "from this understanding, electronic medical records meet electronic documents and information criteria. in the concept of national law, health information is one type of public information that is formulated in several statutory provisions, one of which is formulated in the law on public information disclosure as described above (8). regulations regarding access to medical records in the fourth amendment to the 1945 constitution of the republic of indonesia, the provision of articles on human rights (ham) as a form of guarantee for their protection is stated in a separate chapter, namely in chapter xa with the title "human rights." regarding the protection of personal rights, it is regulated in the 1945 constitution of the republic of indonesia article 28g paragraph (1), which states that "everyone has the right to the protection of his personal, family, honor, dignity, and property under his control, and has the right to a sense of security and protection from the threat of fear to do or not do sudra ri, putra s, hartini i. legal protection of the patient's right to access medical records in indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5325 p a g e 6 | 9 something which is a human right." data protection laws such as the european union data protection directive (eu dp directive) distinguish data based on the level of harm that will be felt to individuals in the event of unauthorized processing of data into "sensitive data" and "non-sensitive data. "sensitive" data usually get better legal protection. for example, consent must be explicitly stated in a written statement. the european union data protection directive prohibits the processing of sensitive data unless express consent has been obtained from the data owner. the data includes information regarding ethnicity, political opinions, religion and beliefs, membership of trafficking organizations as well as data related to a person's health and sex life (9). the protection of the patient's medical history is contained in article 57 paragraph (1) of law number 36 concerning health which recognizes the right of everyone to the confidentiality of his personal health condition that has been presented to the health service provider. furthermore, article 57 paragraph (2) regulates the provisions for the exception to the confidentiality of personal health conditions which do not apply in terms of 1. statutory orders; 2. court order; 3. the permit in question; 4. public interest; or 5. the interest of the person. discussion a right is a claim that one person can make to another up to the limits of the exercise of that right. rights contain protection and interests and will. meanwhile, rights are protected by law, while interests are individual, or group demands expected to be fulfilled. interest essentially contains the power guaranteed and protected by law in carrying it out. rights are normative elements inherent in every human being, and their application is within the scope of equal rights and freedoms related to their interactions between individuals or institutions (10). rights are something that must be obtained. there are two theories about this. the first theory, which states that granting rights is to be done, owned, enjoyed, or has been done. the second theory states that granting full rights is an integral part of a valid claim (the benefits obtained from the exercise of rights accompanied by the implementation of obligations). thus, benefits can be obtained from the exercise of rights when accompanied by the implementation of obligations (11). there is an interaction between service providers and health service recipients (patients) in health services. article 32 of law number 44 of 2009 concerning hospitals, in letter (i), regulates patients' right to obtain privacy and confidentiality of the illness they suffer, including their medical data. letter (l) in this article requires hospitals to provide true, clear, and honest information regarding the rights and obligations of patients. whereas in letter (m) this article requires hospitals to respect and protect patients' rights. this medical secret is further regulated in the regulation of the minister of health number 36 of 2012 concerning medical secrets. this regulation of the minister of health was prepared to comply with article 48 paragraph (1) of law no. 29 of 2004 concerning medical practice and article 38 paragraph (3) of law no. 44 of 2009 concerning hospitals. article 4 of this regulation of the minister of health confirms that all parties involved in medical services must maintain patients' medical confidentiality using data and information about patients. the obligation to keep medical secrets applies forever, even if the patient has died (12). in article 52, paragraph (e) of law number 29 of 2004 concerning medical practice, it is stated that patients have the right to obtain the contents of the medical record in receiving services in medical practice. the health insurance portability and accountability act (hipaa) states that patients have the right to view and obtain copies of their medical records. in this regard, hipaa allows healthcare providers to charge a reasonable fee to provide these copies. such costs may include only the costs of labor and materials required to copy and transmit and may not include the costs of locating and retrieving the information. supporting and facilitating patient access to health information through patient portals is perhaps the most significant cultural shift for the health sudra ri, putra s, hartini i. legal protection of the patient's right to access medical records in indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5325 p a g e 7 | 9 information management (mik) profession since the emergence of prospective health care payment methods and drg (13). the right of access to electronic medical records requires terms and conditions in its implementation, including (but not limited to): a. access subject b. access permission policies and procedures c. how to access d. place and means of access e. accessed data area f. access time limitation g. activity restrictions on access h. access activity audit trail ownership is defined as "the ability to exercise complete sovereignty over information, to disclose, sell, destroy, alter, or determine who will have access to the information." given this potential complexity, it is necessary to redefine the concept of "ownership" regarding access, use, and control of health data by each entity that creates, produces, or stores health information. the question of "who can do what for what data and under what circumstances" is the main question that must be asked in determining the rights and responsibilities of each stakeholder (14). the definition of access is an activity to interact with an electronic system that is stand-alone or in a network. access activities may include (but are not limited to) open, view, add, crop/reduce, edit, delete, copy, cut, paste, move, send / forward, and print. this access activity is associated with ownership of the thing being accessed, for example, information in electronic medical records. as the owner of the contents of the medical record, the patient has the right to access his electronic medical record. access to electronic medical records can be set individually, time, duration, area accessed access method, the time limit for access. the system developed should record and track access activities to the system (audit trail), including (but not limited to) access date, access hours, accessor identity, information area accessed, activity during access (15). interoperability is one of the keys to access to electronic medical records. in addition to interoperability, patient education and additional tools that can help make it easier for patients to coordinate their information and care are also very important (16). when they leave the health facility, treatment plan sheets, discharge summaries, and data transfers should be provided to patients. other information should be accessible to the patient within a few days, and when requested during admission and care, upto-date information should be shared with the patient (17). there needs to be harmonization and equalization (standardization) to provide patient health information in electronic standards that are easy for patients to use. greater access to usable electronic health information in standardized formats could improve health literacy, communication between patients and health care providers, coordination of care, and overall quality of care (18). the regulation that regulates the contents of medical records as belonging to patients is article 12 paragraph (3) of the regulation of the minister of health number 269 of 2008 concerning medical records, which states that the contents of medical records belong to the patient in the form of a summary of medical records which can then be given, recorded, or copied. by the patient or person authorized or written consent of the patient or patient's family who is entitled to it. it should be noted here that a summary of medical records is made at the end of the service episode. this summary is only available after the patient has finished undergoing his service episode. this can create uncertainty regarding ownership of medical records when patients are undergoing service episodes. does it mean that the patient is considered not to have the contents of the medical record while undergoing an episode of service? if at the time of undergoing an episode of service, the patient is placed not as the owner of the contents of the medical record (because the summary sheet of the medical record has not been made and will only be made after the episode of service is completed), does it mean that the patient does not have the right to access the contents of his medical record before the episode of service is sudra ri, putra s, hartini i. legal protection of the patient's right to access medical records in indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5325 p a g e 8 | 9 completed? if so, then who is the owner of the contents of the medical record at that time? this condition is different from what is stated in article 47 paragraph (1) of law number 29 of 2004 concerning medical practice, which states that the contents of the medical record are the property of the patient, and article 52 (e) states that the patient has the right to obtain the contents of the medical record and not mentioned in the form of a summary of the medical record. referring to this article means that the patient has been the owner of the contents of the medical record since the medical record was made. the inconsistency between the regulations mentioned above can create legal uncertainty regarding the ownership and access rights of patients to their medical records. with a retention period of 10 years for the discharge summary sheet (which is also a summary of the medical record), it means that this sheet can be destroyed after being stored for ten years from the date the sheet was made (regulation of the minister of health number 269 of 2008 concerning medical records article 8). after this sheet is destroyed, how is the patient's right to the contents of the medical record which according to article 12 paragraph (3) of the regulation of the minister of health number 269 of 2008 states that this patient's right is given in the form of a summary of the medical record? does it mean that the patient no longer has the right to access his medical records after the discharge summary sheet is destroyed? conclusions present regulations in indonesia governing ownership and access rights of patients to their medical records have not clearly and firmly defined all necessary aspects of access to medical records in writing or electronic. the disharmony and inconsistency of regulations can create uncertainty in the legal protection of patients' rights to access their medical records. the electronic medical record system that has been developed and/or implemented does not yet provide a feature that allows patients to access their electronic medical records so that the patient's access rights to the electronic medical record cannot be realized. hospitals as medical record managers (paper-based and electronic-based) need to improve their understanding of the implementation of regulations related to the retention of medical records and the rights of patients to access medical records. references 1. law of the republic of indonesia n. 29 of 2004 regarding the medical practice; 2004. 2. regulation of the minister of health of the republic of indonesia number 269/menkes/ per/iii/2008 concerning medical records; 2008. 3. world health organization. medical records manual: a guide for developing countries. manila: who regional office for the western pacific; 2006. 4. kars. national standard for hospital accreditation (snars) edition 1.1. jakarta: kars; 2019. 5. law on health (law no. 36/2009). jakarta; 2009. 6. sudra ri. medical records, 3 ed. tangerang selatan: universitas terbuka; 2020. 7. ifhima. learning-modulenumber-1-the-health-recordfrom-paper-to-electronic; 2019. [online]. available from: https://ifhima.org/wpcontent/uploads/2019/03/learningmodule-number-1-the-healthrecord-from-paper-to-electronic.pdf (accessed: december 10, 2021). 8. sampurno b. final report of the health law compendium preparation team, jakarta: national legal system research and development center, national legal development agency, ministry of law and human rights; 2011. 9. tanner a. harvard professor reidentifies anonymous volunteers in dna study. forbes; 25 april 2013. [online]. available from: sudra ri, putra s, hartini i. legal protection of the patient's right to access medical records in indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5325 p a g e 9 | 9 © 2022 sudra et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.forbes.com/sites/adamtann er/2013/04/25/harvard-professor-reidentifies-anonymous-volunteers-indna-study/?sh=755fd12992c9 (accessed: december 10, 2021). 10. wahyat e. the right to public information and the right to medical confidentiality: human rights problems in health care. j ilmu huk 2014;1. 11. waller aa, alcantara ol. ownership of health information in the information age. j ahima 1998;69:28-38. 12. indonesian medical council. medical record manual; 2006. 13. murphy-abdouch k. patient access to personal health information: regulation vs. reality. perspect health inf manag 2015;12. 14. burrington-brown j, hjort b, washington l. health data access, use, and control. j ahima 2007;78:63-6. 15. wiedermann la. understanding patient access and amendments. ahima convention proceedings; 2011. 16. butler m. access to health information: it takes a village. j ahima 2015. 17. rode d. enabling patient access: data stewardship involves more than data use and disclosure. j ahima 2011;82. 18. world health organization. electronic health records: manual for developing countries. who regional office for the western pacific; 2006. references of the legislation cited: 1. law number 44 of 2009 concerning hospitals. 2. law number 36 of 2009 concerning health. 3. regulation of the minister of health of the republic of indonesia number 269/menkes/per/iii/2008 concerning medical records, 2008. law number 29 of 2004 concerning medical practice. 4. circular (se) of the director-general of medical services no. hk.00.06.1.5.01160 dated march 21, 1995, concerning technical instructions for procurement of record forms basic medical and destruction of medical record archives in hospitals. 5. government regulation of the republic of indonesia number 46 of 2014 concerning health information systems. 6. minister of health regulation number 21 of 2020 concerning the strategic plan of the ministry of health 20202024. 7. law number 19 of 2016 concerning amendments to law number 11 of 2008 concerning electronic information and transactions. 8. law number 14 of 2008 concerning disclosure of public information. 9. fourth amendment to the 1945 constitution of the republic of indonesia. 10. regulation of the minister of health number 36 of 2012 concerning medical secrets. ________________________________________________________________________________________________ keywords: indonesia, legal protection, medical records, patients' rights. for training purpose only, please do not quote. mahato rk, laohasiriwong w, koju r. the role of diabetes mellitus comorbidity on tuberculosis treatment outcomes in nepal: a prospective cohort study. (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5329 p a g e 1 | 13 original research the role of diabetes mellitus comorbidity on tuberculosis treatment outcomes in nepal: a prospective cohort study roshan kumar mahato1, wongsa laohasiriwong1, rajendra koju2 1 faculty of public health, khon kaen university, khon kaen, thailand; 2 kathmandu university school of medical sciences, department of internal medicine, dhulikhel hospital, kathmandu university hospital, nepal. corresponding author: assist prof. dr. roshan kumar mahato; address: faculty of public health, khon kaen university, khon kaen, thailand; e-mail: mahatoroshank@kusms.edu.np mahato rk, laohasiriwong w, koju r. the role of diabetes mellitus comorbidity on tuberculosis treatment outcomes in nepal: a prospective cohort study. (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5329 p a g e 2 | 13 abstract aim: the objective of this study was to assess the effect of diabetes mellitus (dm) on treatment outcomes of tuberculosis (tb) patients in the central development region of nepal. methods: a prospective cohort study was conducted in central nepal. the study population of n=408 was consecutively recruited from treatment centers of all 19 districts of central nepal. the tb cases (n=306) and tb with dm (n=102) cases were followed up for the estimation of blood glucose level, hba1c level, and sputum examination on 2, 5, and 6 months after tb treatment started. the generalized estimating equation (gee) was performed to identify the risk ratio among tb and tb with dm cases on treatment outcome. results: our study identified that the magnitude of treatment failure among the tuberculosis cases was 19.7% (95% ci: 17.44-21.95). the gee analysis observed that factors associated with the treatment failure had uncontrolled dm (hba1c ≥7 %) (adj.rr=5.24, 95% ci: 2.58-10.62, p value <0.001), aged ≥ 45 (adj.rr= 6.13, 95% ci: 2.55-14.76, p value <0.001), had inadequate financial status (adj.rr= 2.33, 95% ci: 1.07-5.06, p value 0.033) and had prior tb (adj.rr=2.33, 95% ci: 1.09-4.97, p value 0.028) respectively. conclusion: the prevalence of worsening tb treatment among patients with tb and dm was significantly higher than those who had tb only. poor glycaemic control, increasing age, inadequate financial status, and previous history of tuberculosis were strong predictors of worsening tuberculosis treatment outcomes. keywords: central nepal, generalized estimating equation, glycaemic control, tuberculosis with diabetes mellitus. conflict of interest: none declared. ethical approval: the ethics committee in human research of khon kaen university, khon kaen, thailand (he612209), the nepal health research council (2640) and institutional review committee (protocol approved number 01/18), kathmandu university school of medical sciences, dhulikhel, nepal had approved to conduct this study. acknowledgment: the author wishes to thank the national tuberculosis centre, nepal, for providing the approval to conduct this study. we would like to express our sincere gratitude to the faculty of public health, khon kaen university, for their sincere guidance and support during the study period. mahato rk, laohasiriwong w, koju r. the role of diabetes mellitus comorbidity on tuberculosis treatment outcomes in nepal: a prospective cohort study. (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5329 p a g e 3 | 13 introduction nepal is passing through a phase of epidemiological transition from a higher prevalence of communicable diseases to noncommunicable diseases (ncds). it is currently suffering from a double burden of diseases. various small studies from different parts of the country on diverse populations have shown varying prevalence rates of type 2 diabetes mellitus ranging from 6.3 to 8.5%. however, a systematic review and metaanalysis from 2000 to 2014 illustrate that the prevalence of type 2 diabetes reached a minimum of 1.4% to a maximum of 19.0%. the pooled prevalence of type 2 diabetes was 8.4% (95% ci: 6.2-10.5%). in addition, prevalence of type 2 diabetes in urban and rural populations was 8.1% (95% ci: 7.38.9%) and 1.0% (95% ci: 0.7-1.3%), respectively (1). tb patients beginning tb treatment with diabetes comorbidity experience tardy regain of body mass and haemoglobin (2,3), which are essential for the profound recovery from both diseases (4). in addition, previous studies have revealed that diabetes may weaken sputum conversion (2,5-7), cure and increase the risk of relapse (4,8,9), and raise the risk of anti-tb drug resistance as well (10,11). furthermore, a recent study observed that tb with dm was associated with some critical sociodemographic factors, including age, unemployment, literacy, and polluted environment (12). a study from nepal has also illustrated the prevalence of diabetes among tuberculosis patients, which was 9.1% among older age tb patients, tobacco users, people with high-income status, and a history of high blood pressure (8,13). therefore, this present study aimed to identify the role of dm on the treatment response among tb patients in the central development region of nepal. methods a prospective cohort study was conducted by administrating a structured questionnaire among the tb and tb with dm cases. in addition, we examined their blood glucose level, hba1c level, and sputum grade 2, 5, and 6 months after starting treatment of tb to identify the treatment outcome of tb. study population a total sample of 408 patients was estimated to be required by taking reference of risk ratio 2.93 of non-cure rate (28.65%) among the tb dm cases from a previous study (5). 408 tb cases were collected from the national tuberculosis centre and treatment centers of all 19 districts of the (central development region) cdr, nepal, and were examined for a blood glucose level. after that, 102 tb patients with diabetes were considered cases, and 306 non-diabetes tuberculosis patients were considered controls. since six patients died and one got severe cancer during the study period, finally, 401 tb cases were followed up to identify treatment outcomes. simultaneously, body mass index (bmi) and blood glucose level were measured, and the sputum status was checked to determine treatment outcomes in two, five, and six months after starting treatment. the respondents who met the essential requirement for their family within the year of treatment were considered to have a good financial status. data collection the data was collected by using a structured questionnaire (annex i). in addition, signs and symptoms of the tuberculosis cases were documented before the beginning of tb treatment, and additional history was obtained for the presence of dm or dm treatment, previous tb treatment, tb contacts, other comorbidities, and medication used. similarly, the patients were followed monthly during the intensive phase and bi-monthly after that. history, physical examination, blood testing, and microscopic examination were repeated after the intensive phase (at two months), five months, and at the end of treatment (at six months). tb programspecific definitions were used to classify mahato rk, laohasiriwong w, koju r. the role of diabetes mellitus comorbidity on tuberculosis treatment outcomes in nepal: a prospective cohort study. (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5329 p a g e 4 | 13 treatment response and outcome. tb registerswere cross-checked to ensure the quality of collected data. statistical analysis all collected data were entered in epi-data (version 3.1) and transferred to stata (version 13, stata corporation, college station, tx usa) for analysis. the data collected after the respondents' follow-up in 2, 5, and 6 months were analysed using gee to identify the risk ratio amongst the tb and tb with dm cases on treatment outcomes. results table 1 illustrates the characteristics of tb and tb with dm patients at 2, 5, and 6 months of the treatment period. the respondents (tb and tb with dm) aged ≥ 45 years old seemed to raise the non-curing rate from 43.30% at two months, 45.88% at five months, and 51.90% at six months of treatment. in addition, the tuberculosis patients living in rural areas were observed to fail sputum conversion at six months of treatment compared with two months of treatment, i.e., 12.50% to 11.49%, respectively. table 1. characteristics of tb patients at 2, 5 and 6 months of treatment (n=401) characteristics 2 months 5 months 6 months cured not cured cured not cured cured not cured gender male 185 (60.86) 64 (65.98) 192 (60.76) 57 (67.06) 192 (59.63) 57 (72.15) female 119 (39.14) 33 (34.02) 124 (39.24) 28 (32.94) 130 (40.37) 22 (27.85) age (years) <45 204 (67.11) 55 (56.70) 213 (67.41) 46 (54.12) 221 (68.63) 38 (48.10) ≥ 45 100 (32.89) 42 (43.30) 103 (32.59) 39 (45.88) 101 (31.37) 41 (51.90) marital status single 106 (34.87) 26 (26.80) 109 (34.49) 23 (27.06) 114 (35.40) 18 (22.78) married 198 (65.13) 71 (73.20) 207 (65.51) 62 (72.94) 208 (64.60) 61 (77.22) place of residence urban 266 (87.50) 81 (83.51) 278 (87.97) 69 (81.18) 285 (88.51) 62 (78.48) rural 38 (12.50) 16 (16.49) 38 (12.03) 16 (18.82) 37 (11.49) 17 (21.52) employment unemployed 69 (22.70) 27 (27.84) 71 (22.47) 25 (29.41) 70 (21.74) 26 (32.91) employed 235 (77.30) 70 (72.16) 245 (77.53) 60 (70.59) 252 (78.26) 53 (67.09) financial status adequate 216 (71.05) 66 (68.04) 225 (71.20) 57 (67.06) 223 (72.36) 49 (62.03) inadequate 88 (28.95) 31 (31.96) 91 (28.80) 28 (32.94) 89 (27.64) 30 (37.97) history of prior tb no 243 (79.93) 69 (71.13) 247 (78.16) 65 (76.47) 256 (79.50) 56 (70.89) yes 61 (20.07) 28 (28.87) 69 (21.84) 20 (23.53) 66 (20.50) 23 (29.11) treatment category cat i 254 (83.55) 73 (75.26) 262 (82.91) 65 (76.47) 272 (84.47) 55 (69.62) cat ii & cat iii 50 (16.45) 24 (24.74) 54 (17.09) 20 (23.53) 50 (15.53) 24 (30.38) drug resistant status none 274 (90.13) 82 (84.54) 284 (89.87) 72 (84.71) 291 (90.37) 65 (82.28) any or multi drug resistance 30 (9.87) 15 (15.46) 32 (10.13) 13 (15.29) 31 (9.63) 14 (17.72) initially screened for dm no 285 (93.75) 88 (90.72) 298 (94.30) 75 (88.24) 307 (95.34) 66 (83.54) yes 19 (6.25) 9 (9.28) 18 (5.70) 10 (11.76) 15 (4.66) 13 (16.46) history of smoking never 166 (54.61) 53 (54.64) 174 (55.06) 45 (52.94) 183 (56.83) 36 (45.57) ever smoke but now quitted 138 (45.39) 44 (45.36) 142 (44.94) 40 (47.06) 139 (43.17) 43 (54.43) mahato rk, laohasiriwong w, koju r. the role of diabetes mellitus comorbidity on tuberculosis treatment outcomes in nepal: a prospective cohort study. (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5329 p a g e 5 | 13 characteristics 2 months 5 months 6 months cured not cured cured not cured cured not cured history of alcohol consumption never 186 (61.18) 52 (53.61) 195 (61.71) 43 (50.59) 204 (63.35) 34 (43.04) ever drunk but now quitted 118 (38.82) 45 (46.39) 121 (38.29) 42 (49.41) 118 (36.65) 45 (56.96) type of house cement 250 (82.24) 76 (78.35) 261 (82.59) 65 (76.47) 268 (83.23) 58 (73.42) mud/brick 54 (17.76) 21 (21.65) 55(17.41) 20 (23.53) 54 (16.77) 21 (26.58) type of the floor cement 265 (87.17) 80 (82.47) 276 (87.34) 69 (81.18) 284 (88.20) 61 (77.22) mud/brick 39 (12.83) 17 (17.53) 40 (12.66) 16 (18.82) 38 (11.80) 18 (22.78) type of wall cement 250 (82.24) 76 (78.35) 261 (82.59) 65 (76.47) 269 (83.54) 57 (72.15) mud/brick 54 (17.76) 21 (21.65) 55 (17.41) 20 (23.53) 53 (16.46) 22 (27.85) blood glucose level < 200 mg/dl 240 (78.95) 66 (68.04) 246 (77.85) 60 (70.59) 254 (78.88) 52 (65.82) ≥ 200mg/dl 64 (21.05) 31 (31.96) 70 (22.15) 25 (29.41) 68 (21.12) 27 (34.18) blood glucose level of tb dm only < 200 mg/dl 46 (71.88) 18 (58.06) 55 (78.57) 9 (36.00) 54 (79.41) 10 (37.04) ≥ 200mg/dl 18 (28.13) 13 (41.94) 15 (21.43) 16 (64.00) 14 (20.59) 17 (62.96) hba1c level of tb dm only < 7% 52 (81.25) 22 (70.97) 63 (90.00) 11 (44.00) 60 (88.24) 14 (51.85) ≥7% 12 (18.75) 9 (29.03) 7 (10.00) 14 (56.00) 8 (11.76) 13 (48.15) bmi (kg/m2) of tb dm only <18.5 28 (43.75) 15 (48.39) 30 (42.86) 13 (52.00) 28 (41.18) 15 (55.56) ≥18.5 36 (56.25) 16 (51.61) 40 (57.14) 12 (48.00) 40 (58.82) 12 (44.44) the increasing blood glucose levels among the tb with dm cases at 2, 5, and 6 months of the treatment period revealed a curing failure with 41.94%, 64.00%, and 62.96%, respectively. similarly, an uncontrolled hba1c level is also responsible for increasing the no-curing rate from 2 months (29.03%) to 5 months (56.00%). on the other hand, a raising bmi (body mass index) level from low to normal was observed that enhanced the tb curing rate from 2 months (56.25%) to 6 months (58.82%) (table 1). risk factors of the failure of treatment outcome: using the generalized estimating equations model (gee) in this study, we analysed the risk factors for failure in treatment outcomes using the gee model for repeated measures of the outcomes. it could identify that uncontrolled diabetes during the treatment period (≥7 %) was one of the major risk factors of failure in tb treatment outcome (adj.rr=5.24, 95% ci: 2.58-10.62, p-value <0.001) as well as other risk factors including; age ≥ 45 yrs. (adj.rr=6.13, 95% ci: 2.55-14.76, p-value <0.001), inadequate financial status (adj.rr=2.33, 95% ci: 1.07-5.06, p-value 0.033) and history of prior tuberculosis (adj.rr=2.33, 95% ci: 1.09-4.97, p-value 0.028) respectively (table 2). table 2. risk factors of failure of treatment outcome among tb patients using the generalized estimating equations model factors 2 months 5 months six months adj. (rr) 95% ci p-value n % * n % * n % * hba1c level <0.001 < 7 % 22 70.97 11 44.00 14 51.85 1 1 ≥7 % 9 29.03 14 56.00 13 48.15 5.24 2.58-10.62 mahato rk, laohasiriwong w, koju r. the role of diabetes mellitus comorbidity on tuberculosis treatment outcomes in nepal: a prospective cohort study. (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5329 p a g e 6 | 13 factors 2 months 5 months six months adj. (rr) 95% ci p-value n % * n % * n % * age (years) <0.001 <45 55 56.70 46 54.12 38 48.10 1 1 ≥ 45 42 4330 39 45.88 41 51.90 6.13 2.55-14.76 financial status 0.033 adequate 66 68.04 57 67.06 49 62.03 1 1 inadequate 31 31.96 28 32.94 30 37.97 2.33 1.07-5.06 history of prior tb 0.028 no 69 71.13 65 76.47 56 70.89 1 1 yes 28 28.87 20 23.53 23 29.11 2.33 1.09-4.97 discussion the prevalence of dm with tb will continue to increase, given the projected global expansion of dm. however, to our knowledge, this is the first study on this region that has been performed to identify the treatment outcomes of tuberculosis cases associated with dm. the data presented in this prospective cohort study show that a total of 401 respondents from both tb and tb with dm cases were observed until the last month of the tuberculosis treatment period, of which 79 or 19.7% (95% ci: 15.79-23.61) were not cured. a study conducted in taiwan observed similarly 17.0% of treatment failure (14). a study conducted in the urban setting of indonesia revealed that 22.2% of the dm patients with tb had positive sputum smears after the treatment period (15). in pakistan, nearly one-third (33.6%) of study participants who had a previous history of tuberculosis was not cured (16). in addition, more than two-thirds of the respondents were delayed in seeking treatment (≥ 7 days). in addition, most of the respondents who failed to cure visited more than two health facilities for their diagnosis. this might be due to some health providers being unable to diagnose tb as well as diabetes in the same place. in our setting, we determined the role of dm and other risk factors on tb treatment outcome 2, 5 & 6 months of comprehensive treatment of our tuberculosis cohort. the sputum conversion guides the duration of tb treatment and infectivity of the patient but delayed conversion is also associated with an increased risk of relapse. while most studies outside the middle east (16) have shown no relationship between dm and conversion at the end of 2 months, we considered a more extended observation period of 6 months. up to one-third of the world's population is infected with mycobacterium tuberculosis; however, not all of those infected develop active tb because, usually, the immune system contains the germ. however, in some people, the bacteria remain dormant. they could become active, causing disease at later stages, especially those with risk factors such as old age, diabetes, and other immunosuppressive treatments (7). so, after controlling the confounding factors, uncontrolled dm and five more risk factors showed an effect on the failure of tb treatment. the respondents who had uncontrolled dm with ≥7 % of hba1c on two months of treatment were more than five times at risk of failing therapy. a systematic review found that uncontrolled dm (hba1c ≥7) was a significant risk factor for positive sputum culture after two months (17). another multicentre study conducted in south korea revealed similar findings (18). therefore, close monitoring of blood glucose and clinical conditions of tb patients with dm during the treatment period is crucial (19). respondents aged ≥ 45 years had a greater risk of deteriorating tb treatment outcomes. a similar result has been observed by studies conducted in indonesia (15), taiwan (14), and malaysia (2). similarly, mahato rk, laohasiriwong w, koju r. the role of diabetes mellitus comorbidity on tuberculosis treatment outcomes in nepal: a prospective cohort study. (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5329 p a g e 7 | 13 inadequate financial status was also associated with failure of treatment. however, a study conducted in kuala lumpur, malaysia, revealed no significant difference in the economic situation between both groups (2). furthermore, history of prior tuberculosis is doubling the effect of the non-curing rate of tuberculosis, supported by a study conducted in malaysia: the authors observed that patients with a previous history of tuberculosis treatment were found to be three times more likely to have sputum smear nonconversion compared with those without prior exposure to tuberculosis (2). so, the reason might be a previous infection may induce initial cavitation and increase the extent of residual lesions of the lung (20). conclusion this study outcome was a stepping-stone towards getting free of tb despite being diabetic. our study observed that poorly controlled dm, increasing age, inadequate financial status, and previous history of tuberculosis were strong predictors of tuberculosis treatment failure. therefore, a regular dm screening program would enhance tb control and reduce the burden of tb in nepal. the national tuberculosis program (ntp) should establish a policy on collaboration with the private sector by setting up a referral system and providing basic knowledge on tuberculosis and diabetes. references 1. gyawali b, sharma r, neupane d, mishra sr, van teijlingen e, kallestrup p. prevalence of type 2 diabetes in nepal: a systematic review and meta-analysis from 2000 to 2014. glob health action 2015;8:29088. 2. shariff nm, safian n. diabetes mellitus and its influence on sputum smear positivity at the 2nd month of treatment among pulmonary tuberculosis patients in kuala lumpur, malaysia: a case control study. int j mycobacteriol 2015;4:323-9. 3. lee ph, lin hc, huang as, wei sh, lai ms, lin hh. diabetes and risk of tuberculosis relapse: nationwide nested case-control study. plos one 2014;9:e92623. 4. faurholt-jepsen d, range n, praygod g, kidola j, faurholt-jepsen m, aabye mg, et al. the role of diabetes comorbidity for tuberculosis treatment outcomes: a prospective cohort study from mwanza, tanzania. bmc infect dis 2012;12:165. 5. jimenez-corona me, cruz-hervert lp, garcia-garcia l, ferreyra-reyes l, delgado-sanchez g, bobadilladel-valle m, et al. association of diabetes and tuberculosis: impact on treatment and post-treatment outcomes. thorax 2013;68:214-20. 6. park sw, shin jw, kim jy, park iw, choi bw, choi jc, et al. the effect of diabetic control status on the clinical features of pulmonary tuberculosis. eur j clin microbiol infect dis 2012;31:1305-10. 7. wu z, guo j, huang y, cai e, zhang x, pan q, et al. diabetes mellitus in patients with pulmonary tuberculosis in an aging population in shanghai, china: prevalence, clinical characteristics and outcomes. j diabetes complications 2016;30:23741. 8. harries ad, kumar am, satyanarayana s, lin y, zachariah r, lonnroth k, et al. addressing diabetes mellitus as part of the strategy for ending tb. trans r soc trop med hyg 2016;110:173-9. 9. lee mr, huang yp, kuo yt, luo ch, shih yj, shu cc, et al. diabetes mellitus and latent tuberculosis infection: a systemic review and metaanalysis. clin infect dis 2017;64:71927. 10. baghaei p, tabarsi p, javanmard p, farnia p, marjani m, moniri a, et al. impact of diabetes mellitus on mahato rk, laohasiriwong w, koju r. the role of diabetes mellitus comorbidity on tuberculosis treatment outcomes in nepal: a prospective cohort study. 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(original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5329 p a g e 9 | 13 annex i: questionnaire for participants “the role of diabetes mellitus co-morbidity on tuberculosis treatment outcomes in nepal: a prospective cohort study” general information: crf number: date of the interview: |……..| …......| ………...| [day | month | year] name of district: _____________________ part a: socio-demographic characteristics code a1 gender ☐ 1. male ☐ 2. female a1 a2 your age ………….. years old (full year) what is your date of births? |……..| …......| ………...| [day | month | year] a2….... a3 number of household members in your family?................... a3…… a4 marital status ☐ 1. single ☐ 2. married ☐ 3. separated ☐ 4. divorced a4 a5 place of residence ☐ 1. urban ☐ 2. rural ☐ 3. homeless/displaced a5 a6 what is your educational attainment? ☐ 1. no formal education ☐ 2. primary ☐ 3. secondary ☐ 4. high school or equivalence ☐ 5. bachelor or equivalence ☐ 6. higher than bachelor degree a6 a7 what is your main occupation? ☐ 1. none ☐ 2. housewife ☐ 3. student ☐ 4. farmer ☐ 5. unskilled worker ☐ 6. employee ☐ 7. business ☐ 8. government officer ☐ 9. other please specify ………………… a7 a79xxx a8 what is your average family monthly income ………………. npr a8…… a9 what is your average monthly income ……………………… npr a9…… a10 what is your average monthly expense ………………………npr a10…. a11 what is your financial situation? ☐ 1. not enough ☐ 2. not enough with debt a11 mahato rk, laohasiriwong w, koju r. the role of diabetes mellitus comorbidity on tuberculosis treatment outcomes in nepal: a prospective cohort study. (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5329 p a g e 10 | 13 part a: socio-demographic characteristics code ☐ 3. enough with no saving ☐ 4. enough with saving part b: health status and history of disease b1 height ………… cm b1…... b2 weight …………kg b2…... b3 systolic blood pressure …….mmhg b3…... b4 diastolic blood pressure …….mmhg b4…... b5 what are the signs/ symptoms that make you to see the health personnel? (can choose more than one options) ☐ 1. cough ☐ 2. fever ☐ 3. loss of weight ☐ 4. haemoptysis ☐ 5. chest pain ☐ 6. other please specify ………………… b51 b52 b53 b54 b55 b65xx b6 history of prior tb ☐ 1. no ☐ 2. yes b6 b7 if yes, where did you get the initial tb diagnosis? ☐ 1. public centre ☐ 2. private centre b7 b8 who made your initial tb diagnosis? ☐ 1. paramedic's ☐ 2. medical officer ☐ 3. chest specialist ☐ 4. other please specify ………… b8 b9 family history of tb ☐ 1. no ☐ 2. yes b9 b10 date of first tb diagnosis? |……..| …......| ………...| [day | month | year] b10 b11 how long does it take to get diagnosed with tb since having signs/ symptoms of tb………….(days) b11…. b12 number of health facilities visited before initial tb diagnosis …….. b12…. b13 which of the following investigations was performed to diagnose tb? (can choose more than one options) ☐ 1. sputum examination ☐ 2. x-ray ☐ 3. gene-xpert ☐ 4. pcr ☐ 5. mountex test ☐ 6. other please specify ………………… b13 1 b132 b133 b134 b135 b136x b14 sputum grade ☐ 1. + ☐ 2. ++ ☐ 3. +++ b14 b15 type of tb ☐ 1. positive sputum ☐ 2. negative sputum ☐ 3. extra pulmonary b15 mahato rk, laohasiriwong w, koju r. the role of diabetes mellitus comorbidity on tuberculosis treatment outcomes in nepal: a prospective cohort study. (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5329 p a g e 11 | 13 part b: health status and history of disease b16 treatment of category ☐ 1. cat i ☐ 2. cat ii ☐ 3. cat iii b16 b17 stage of treatment period |……..| …......| [day | month] b17 b18 in addition to tuberculosis, what other disease(s) has the patient been diagnosed? (can choose more than one options) ☐ 1. none ☐ 2. hypertension/ cardiovascular ☐ 3. diabetes ☐ 4. diabetes ☐ 5. hiv/aids b181 b182 b183 b184 b185 b19 do you have any type of drug resistant? ☐ 1. none ☐ 2. any drug resistance ☐ 3. multi drug resistance b19 b20 have you been screened for diabetes till date? (if no, then jump to q c1) ☐ 1. no ☐ 2. yes b20 b21 if you have dm, which type of dm you have? ☐ 1. type 1 ☐ 2. type2 b21 b22 do you have any type of diabetic comorbidity? (can choose more than one options) ☐ 1. none ☐ 2. hypertension/ cardiovascular ☐ 3. tb ☐ 4. cancer ☐ 5. hiv/aids ☐ 6. any other diseases, please specify ………………… b221 b222 b223 b224 b225 b226x b23 do you have any type dm complication? (can choose more than one options) ☐ 1. none ☐ 2. cvd ☐ 3. nephropathy ☐ 4. neuropathy ☐ 5. retinopathy ☐ 6. hearing impairment ☐ 7. any other diseases, please specify ………………… b231 b232 b233 b234 b235 b236 b237x b24 if, previously diagnosed date of first dm diagnosis? |……..| …......| ………...| [day | month | year] b24 b25 if you have dm since how long you are getting treatment? ……………… months b25…. b26 mode of dm treatment? (can choose more than one options) ☐ 1. dietary control ☐ 2. oral glycaemic control ☐ 3. insulin injection ☐ 4. health education ☐ 5. health counselling ☐ 6. exercise b261 b262 b263 b264 b265 b266 mahato rk, laohasiriwong w, koju r. the role of diabetes mellitus comorbidity on tuberculosis treatment outcomes in nepal: a prospective cohort study. (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5329 p a g e 12 | 13 part b: health status and history of disease ☐ 7. any other diseases, please specify ………………… b267x part c: behavioural and environmental factors c1 history of smoking ☐ 1. never ☐ 2. currently ☐ 3. ever smoke but now quitted c1 c2 if smoke, since how long …………months c2 c3 if quit, since how long …………months c3 c4 if currently smoke, specify amount of daily consumption …………. (number of cigarettes/day) c4…. c5 history of alcohol consumption ☐ 1. never ☐ 2. currently ☐ 3. ever drunk but now quitted c5 c6 if currently drink, since how long …………months c6…. c7 if quit, since how long …………months c7…. c9 what type of house do you have? ☐ 1. cement ☐ 2. mud/brick ☐ 3. other please specify ………………… c33 c10 what is the type of the floor? ☐ 1. cement ☐ 2. mud/brick ☐ 3. other please specify ………………… c34 c11 what type of wall do you have? ☐ 1. cement ☐ 2. mud/brick ☐ 3. other please specify ………………… c35 mahato rk, laohasiriwong w, koju r. the role of diabetes mellitus comorbidity on tuberculosis treatment outcomes in nepal: a prospective cohort study. (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5329 p a g e 13 | 13 chart assessment tool date of assessment: |……..| …......| ………...| [day | month | year] name of the dots centre: _____________________ description initial 2 months 5 months 6 months blood glucose level fasting random hba1c level sputum grade weight height sbp dbp la torre g. recovery and resilience plan and health: the italian experience (editorial). seejph 2021, posted: 16 august 2021. doi: 10.11576/seejph-4674 `` p a g e 1 | 3 editorial recovery and resilience plan and health: the italian experience giuseppe la torre1 1 department of public health and infectious diseases, sapienza university, rome, italy. corresponding author: giusepe la torre; address: piazzale aldo moro 5 – 00185 rome, italy; email: giuseppe.latorre@uniroma1.it mailto:giuseppe.latorre@uniroma1.it la torre g. recovery and resilience plan and health: the italian experience (editorial). seejph 2021, posted: 16 august 2021. doi: 10.11576/seejph-4674 p a g e 2 | 3 at the end of april 2021, the italian parliament approved the “the recovery and resilience plan: next generation italia” (in italian ‘piano nazionale di ripresa e resilienza’, pnrr), which foresees reforms and investments that need to be implemented in the period 2021-2025 (1). why is this plan important from a public health point of view? at the international level italy is recognized as one of the best countries for ability and quality of healthcare in relationship to the resources invested. however, at the national level there is the need of improving the effectiveness of the health governance system with the aim of developing better quality of care (2). the covid-19 pandemic has underlined some criticisms of the national health system (nhs) and, in particular, the increasing levels of the regional disparities, the excessive dependence on large hospitals and, on the other hand, a shortage of several key professional figures, among which public health professionals, and of intensive care unit beds. the objective of the pnrr is to address these issues by promoting a more diffused model of care, as well as modernising hospital equipment and implementing the training of more healthcare professionals. globally speaking, italy is prepared to use the full financing capacity of nextgenerationeu, and even more: the plan accounts for a total of €235 billion, that represents the largest recovery and resilience plan in europe. concerning the 6th mission, “health”, more than € 20 billion have been allocated for strengthening the healthcare system, with actions on two different sides, i.e., the development of a local network more close to people and patients and the modernisation of the nhs's technological equipment. regarding the first component, the so called “proximity assistance and telemedicine”, with a budget of almost € 8 billion, the objective is to strengthen and reorient the nhs towards a model centred on local areas and social and healthcare networks. this will be important to surmount the fragmentation of the different regional healthcare systems and ensure the real implementation of the essential levels of assistance, and to strengthen prevention and local assistance with the mission of increasing the integration the main stakeholders in healthcare, such as hospitals, local healthcare and social services. moreover, the first component has also the objective to develop a healthcare model in connection with environmental safety, for contributing to the mitigation of the impact of polluting factors. in relation with the second component, the so called “healthcare innovation, research and digitisation”, which accounts for almost € 12 billion, it has the objective of disseminating telemedicine tools and activities, as well as of strengthening the healthcare system's information and digital tools. so, the modernisation of equipment and the creation of safe, sustainable, cutting-edge hospitals are crucial elements to take into account. the main actions to be developed will be concerning (1): almost 1300 community homes and 400 community hospitals for proximity assistance; home care for 10% of people aged 65 or more; more than 600 new local operational centers for remote assistance; more than 3000 new large pieces of equipment for diagnostic and care. on 22-6-2021 the european commission endorses italy's recovery and resilience plan. looking at the explanation of the endorsement of the commission, one element needs to be recognized and is that related to effectively contribute to the digital transition of the health sector. according to the plan, the effective implementation of these measures will be important to build future-proof digital infrastructure, to reinforce and to make the la torre g. recovery and resilience plan and health: the italian experience (editorial). seejph 2021, posted: 16 august 2021. doi: 10.11576/seejph-4674 p a g e 3 | 3 © 2021 la torre; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited health sector more efficient, resilient and close to citizens/patients. the full implementation of the plan will be a crucial challenge for modernising the country and for letting the nhs more efficient and equitable. covid-19 has caused a massive disruption to health services all over the world, and we need to consider long term solutions, including the reduction of the waiting lists, the increasing number of general practitioners and community nurses, a plan for recruiting healthcare professionals in the nhs (4), with a vision that only a public health and epidemiological approach can assure (5). with the recovery plan, the european union has changed its scope and is looking at the implementation of long-term tools for action. this new approach can be considered a great progress, that witnesses the union’s concrete usefulness to its citizens and the confirmation of the role of europe as a key actor at the international level (6). references 1. ministry of economy and finance. the national recovery and resilience plan (nrrp). available from: https://www.mef.gov.it/en/focus/t he-national-recovery-andresilience-plan-nrrp/ (accessed: june 15, 2021). 2. la torre g, federici a. how to not detonate the bomb: the case of the italian national health service. public health 2017;153:178-80. 3. european commission. european commission endorses italy's €191.5 billion recovery and resilience plan. available from: https://ec.europa.eu/commission/pr esscorner/detail/en/qanda_21_3128 (accessed: june 15, 2021). 4. murray r. the nhs needs a comprehensive plan for recovery. bmj 2021;373:n1555. 5. maffei cm. epidemiology in the italian recovery and resilience plan: that desire for hub. epidemiol prev 2021;45:142-3. 6. vieilledent c, drevet jf. the european economic recovery plan, a historic breakthrough: sustainability without funding is unsustainable. futur anal prospect 2021;441:85-94. ___________________________________________________________________________ £ rip £ rip £ rip making a difference: investing in sustainable health and well-being for the people of wales executive summary 2016 scho ol £ rip isbn 978-1-910768-32-7 © 2016 public health wales nhs trust material contained in this document may be reproduced under the terms of the open government licence (ogl) www.nationalarchives.gov.uk/doc/open-government-licence/version/3/ provided it is done so accurately and is not used in a misleading context. acknowledgement to public health wales nhs trust to be stated. copyright in the typographical arrangement, design and layout belongs to public health wales nhs trust. design: jenney creative www.jenneycreative.co.uk about this report this report offers research evidence and expert opinion in support of preventing ill health and reducing inequalities to achieve a sustainable economy, thriving society and optimum health and well-being for the present and future generations in wales. public health wales has developed this report as part of its mission to protect, improve and promote the health and well-being of the people in wales and reduce health inequalities. the report also reflects public health wales’ responsibility to inform, support and advocate for wider health policy and cross-sector approaches and interventions offering benefits to the people, health system, society and the economy. the report has been informed by: ■ research evidence ■ professional guidance and expertise in public health, policy, social studies, equity and economics ■ welsh priorities for health and wellbeing ■ current welsh policy and health context the report consists of three parts published separately: 1 making a difference: investing in sustainable health and well-being for the people of wales executive summary (this document); 2 making a difference: investing in sustainable health and well-being for the people of wales – supporting evidence; and 3 series of 8 infographics focusing on key health challenges for wales and suggested evidence-based solutions. this is not an exhaustive public health review but presents selected summarised research evidence, data and contextual information available at the time of the report development. http://www.nationalarchives.gov.uk/doc/open-government-licence/version/3/ http://www.jenneycreative.co.uk 1 making a difference: investing in sustainable health and well-being for the people of wales executive summary we have made great strides in improving the health of the population. we are living longer, fewer of us are dying from infections and chronic diseases and we have better health services. however, we still face significant challenges in how we reduce the poverty and health inequalities that exist in some parts of wales. we also face challenges in how to support better our growing older population to stay healthy and independent for as long as possible; how to best prevent and manage chronic conditions and how to prepare ourselves and manage new epidemics and global threats to our security. this is also set within an environment of fiscal and economic challenges that require us to shift, even more so, to a more informed and targeted approach to investing in what will have the maximum impact to improve health and well-being and enable health, wealth and growth to thrive in wales. now we know more than ever that prevention saves lives and money and brings multiple benefits to the people, communities and the economy – this is a significant opportunity for us. an extensive body of evidence already exists to support the types of interventions and policies which address the root causes of ill health and inequalities and lead to better mental, physical and social well-being together with enhancing resilience, employment and growth. this report provides the most up-to-date supporting research and expertise on effective and sustainable solutions that are worth investing in to optimise health in wales. now is the time to act together. through a systems approach sharing our collective assets, following the principles of sustainability and prudent healthcare and complying with our unique legislation, the well-being of future generations (wales) act, we have the opportunity and responsibility to work united across sectors and organisations. it is essential to listen to and empower our people and to appreciate the assets of our communities, allowing them an equal part in all decisions and plans for their life, health and happiness. with this timely report, public health wales would like to be part of the solution, to inform and support decisions and policies and to join an allwales commitment and action to make a positive change towards a healthier, happier and more sustainable future for our people in wales. dr tracey cooper chief executive, public health wales foreword the momentum is accelerating to focus our efforts on making a difference to the health and well-being of the present and future generations living and working in wales. public health wales 2 authors and contributors the development of this report has been led by mariana dyakova*. it has been written by mariana dyakova*, teri knight** and sian price** with the help of sumina azam*, elodie besnier*, alisha davies*, nathan lester**, isabel puscas** and malcolm ward*. mark a bellis* and chrissie pickin** provided advice and guidance for the development of the report. high level expert group we are grateful to the national and international experts in public health, policy, social studies, equity and economics who met in january 2016 to discuss key messages and recommendations and to advise on the report structure and contents. they also provided additional evidence and feedback during the report development. eva elliott, cardiff institute of society, health and wellbeing (cishew), cardiff university school of social sciences robin ireland, health equalities group marcus longley, welsh institute for health and social care, university of south wales martin o’neill, cardiff institute of society, health and wellbeing (cishew), cardiff university school of social sciences john wyn owen, bevan commission aaron reeves, london school of economics and political science sarah simpson, equiact ted schrecker, centre for public policy and health, durham university stephen wright, independent consultant in health economics acknowledgements many thanks for providing additional evidence and comments to: julie bishop, huw brunt, nicola gordon, ashley gould, christian heathcote-elliott, rosemary fox, ciaran humphreys, dyfed huws, adam jones, angela jones, craig jones, sarah jones, carolyn lester, sue mably, tracy price, richard roberts, janine roderick, quentin sandifer, rob sage, hannah show, josie smith, robert smith, daniel thomas, angela tinkler and holly walsh from public health wales as well as to phill chick, abertawe bro morgannwg university health board; stephen macey, ash wales and clare bambra, durham university. *policy, research and international development and **health and wellbeing directorates, public health wales making a difference: investing in sustainable health and well-being for the people of wales 3 we know the economic, social and natural environment in which we grow up, live and work is a major determinant of our health and well-being and that of our children – directly, and through the ways in which we are living. there is strong evidence to support a preventative approach prevention removing the causes of poor health and inequalities (rather than addressing the consequences) offers good value for money. preventive policies and interventions save lives, money and improve peoples’ mental, physical and social well-being. they show both short and long-term benefits far beyond the health system across communities, society and the economy. wales is in a unique position to make a difference a favourable legislation and policy context, with the groundbreaking well-being of future generations (wales) act 2015, presents key opportunities to work differently across sectors and with communities to address the increasing health, social and economic challenges in a more effective and sustainable way. why now? the public health offer for wales current globalisation and demographic trends, the rising human and financial costs of illness and inequalities in health, and the ever more limited economic and natural resources threaten sustainability, and the health and well-being of the people living and working in wales. a change in the status quo is urgently needed with new, more effective and efficient solutions informed by evidence, expertise and sound judgement, to address the challenges of the current austerity climate and to achieve future health and economic gains for wales. public health can be a part of the answer together with public policy and public financing. who needs to act? public health wales suggests three priority areas for preventive action: 1 building resilience across the lifecourse and settings 2 addressing harmful behaviours and protecting health 3 addressing wider economic, social and environmental determinants of health ■ decision-makers and policy-makers in national and local governmental roles ■ senior leaders across all public services, those with public health responsibilities, planners and managers ■ all professionals whose role has an impact on people’s health and well-being ■ local communities, third sector and private organisations achieving sustainable health and well-being for the people in wales is everybody’s business. it requires dialogue, shared responsibility and agreement on harnessing action and investment between: public health wales 4 public health wales has defined three priority areas for action (figure. 1) where challenges and health needs in wales are growing and costeffective preventive interventions exist. these areas are interrelated and interdependent, sharing common determinants and solutions. solutions are enabled by the unique well-being of future generations (wales) act1 and its sustainable development principle2 as well as other legislation and approaches, such as the social services and well-being (wales) act3, the active travel (wales) act4, the prudent healthcare principles5 and the concept of systems working (building partnerships and synergies across sectors and stakeholders). the on-going devolution process has the potential to bring more positive developments and unlock key levers (e.g. taxation) to reduce inequalities and benefit people’s well-being. the public health offer for wales figure 1. priority areas for action, enabled by systems working, legislation and key principles enabling legislation systems working addressing wider economic, social and environmental determinants of health prevention long-term view integration collaboration involvement sustainable development principle prudent healthcare principles reduce variation only do what is needed greatest need first co-production do no harm only do what only you can do use evidence 1 http://gov.wales/topics/people-and-communities/people/future-generations-act/?lang=en 2 http://thewaleswewant.co.uk/ 3 http://gov.wales/topics/health/socialcare/act/?lang=en 4 http://gov.wales/legislation/programme/assemblybills/active-travel-act/?lang=en 5 http://www.prudenthealthcare.org.uk/ addressing harmful behaviours and protecting health building resilience across the life-course and settings http://gov.wales/topics/people-and-communities/people/future-generations-act/?lang=en http://thewaleswewant.co.uk/ http://gov.wales/topics/health/socialcare/act/?lang=en http://gov.wales/legislation/programme/assemblybills/active-travel-act/?lang=en http://www.prudenthealthcare.org.uk/ making a difference: investing in sustainable health and well-being for the people of wales 5 for each priority area a summary of key messages is presented, supported by examples from the evidence. more detailed information and references are provided in the supporting evidence document. ensuring good maternal health and a safe and caring environment for children, as well as reducing poverty and deprivation, are essential for a good start in life. deaths among infants (0-28 days) in the most deprived areas in wales are one and a half times more than those in the least deprived. what works? investing in early years6 universal (population wide) interventions along with additional resource proportionate to need for vulnerable children is cost-effective and essential to ensure a healthy and productive wales. investing in targeted interventions and universal child care and paid parental leave could help address as much as £72 billion worth of the cost of social problems such as crime, mental ill health, family breakdown, drug abuse and obesity for wales7. mental ill health is associated with worse physical health, increased health risk behaviours, poor education and unemployment. it accounts for a substantial burden of ill health and disability in wales with high costs to the nhs, the society and the economy. inequality is a key determinant of mental ill health and mental ill health leads to further inequality. in wales, 24% of those who are long term unemployed or have never worked, report a mental health condition compared with 9% of adults in managerial and professional groups. early life experiences, such as bullying or abuse, may have long-term consequences for the development of children and young people, with associated costs to society and public services. in wales, in 2013/14, over a third of pupils reported bullying at school in the previous two months. priority areas for preventive action building resilience across the life-course and settings in wales, 13% of adults reported a mental health condition in 2015 compared to 9% in 2003/4. the estimated cost of mental ill health to society is £7.2 billion per year. the most potential for action is in the first 1000 days from conception to the second birthday. in wales, adverse childhood experiences (aces), such as child maltreatment and/or living in a household affected by parental separation, domestic violence, mental ill health, alcohol, drug abuse or the incarceration of a parent, are associated with: over ½ of the violence and drugs abuse over of teenage pregnancies nearly ¼ of current adult smoking 1. ensuring a good start in life for all 2. promoting mental wellbeing and preventing mental ill health 6 early years defined as 0 to 7 years of age 7 estimated from uk data on unadjusted per capita basis public health wales 6 what works? investing to increase access to early intervention mental health services could lead to considerable savings for other public services. interventions for children and young people, especially the most vulnerable, could lead to long-term savings by reducing the risk of health and social problems and by improving employment prospects. ‘best buys’8 to prevent mental ill health can include interventions and policies to support parents and young children; to improve workplaces; to change lifestyles; to provide social support and to support communities through environmental improvements. violence is a major cause of poor physical and mental health. it impacts on society, the health service and the wider economy. violence affects deprived communities the most. according to the welsh aces survey, 16% of participants reported witnessing domestic violence and abuse; 17% experienced physical abuse and 10% sexual abuse, while they were growing up. admission to hospital for assaults is 3.7 times more likely in the most deprived areas compared to the least deprived areas in wales. what works? reducing violence and abuse could result in substantial savings to health and social care. effective interventions include focusing on children and young people; preventing domestic violence, abuse and violence against women; reducing harmful use of alcohol; and multi-agency approaches. implementing the nice9 guidance on domestic violence and abuse could save £4,700 per month per person on longer-term costs associated with treating and supporting someone experiencing post-traumatic stress disorder as a result of violence and abuse. in wales, domestic violence and abuse costs public services £303.5 million per year. human and emotional costs are an additional £523 million. preventing adverse childhood experiences (aces) and improving resilience and protective factors for children could reduce acts of violence in adults by 60%. anti-bullying interventions in schools can return £15 for every £1 spent; parenting programmes to prevent conduct disorder return £8 over six years for every £1 invested. 3. preventing violence and abuse 8 taking into account cost effectiveness, implementation costs and feasibility 9 uk national institute for health and care excellence improving mental health in the workplace, including prevention and early identification of problems, could produce annual savings of £250,607 for an organisation with 1000 employees. making a difference: investing in sustainable health and well-being for the people of wales 7 smoking is the largest single preventable cause of ill health and death in wales with high costs to the nhs, society and the economy. childhood exposure to tobacco smoke is of specific concern. two in three smokers start before the age of 18 years; one in five children aged 10-11 years are exposed to second hand smoke. deprivation is a risk factor for smoking. in wales, nearly 1/3 of the people in the most deprived fifth of the population smoke (29%), compared to 11% in the least deprived fifth. the health of babies born into lower income households is disproportionately affected by second hand smoke. what works? cost-effective interventions to reduce smoking include enforcing bans on tobacco advertising; raising taxes on tobacco; offering counselling to smokers and others. helping smokers to quit could reduce healthcare costs. each 25 year old smoker who cuts down on smoking would save the nhs in wales £882 over the course of their lifetime, and this would increase to £1,592 if they quit. in wales, 1 in 5 adults smoke causing 18% of adult deaths and costs of £386 million per year to the nhs and £791 million per year to the overall economy. 4. reducing prevalence of smoking 5. reducing prevalence of alcohol misuse alcohol misuse remains a major threat to public health in wales. it is a major cause of death and illness with high costs to the nhs, society and the economy. alcohol is associated with more than 6000 cases of domestic violence and more than £1 billion cost of harm to society each year. heavy drinking increases the risk of unemployment and could account for more than 800,000 working days lost due to absences from work10 and nearly 1 million working days lost due to job loss and reduced employment opportunities in wales. alcohol hurts the poorest the most. alcohol related deaths are more in the most deprived areas in wales. what works? “best buys”11 to reduce alcohol misuse include interventions and policies, such as a minimum unit price (mup) of 50 pence/unit; limiting availability (i.e. reducing outlet density, hours and days of sale); and better control of advertising. brief motivational interviewing in primary care is a cost-effective intervention. every £1 spent on motivational interviewing and supportive networks for people with alcohol dependence returns £5 to the public sector in reduced health, social care and criminal justice costs. 10 estimated from uk data on unadjusted per capita basis 11 taking into account cost effectiveness, implementation costs and feasibility addressing harmful behaviours and protecting health public health wales 8 scho ol many people in wales are not physically active12 enough to protect their health. the burden of physical inactivity is rising13 with significant costs to the health system and the wider economy. physical inactivity is related to social disadvantage. in wales, 40% of adults in the most deprived fifth reported physical activity for less than 30 minutes in the previous week, compared with 23% in the least deprived fifth. increasing physical activity can: improve physical and mental well-being; help prevent and manage many illnesses; and reduce the risk of early death. what works? “best buys”14 to increase physical activity include interventions and policies, such as mass media campaigns; active transport strategies i.e. moving from driving to walking or cycling, promoting physical activity in work places, schools and communities, and providing advice and support in primary care. primary care brief interventions are more cost-effective than prescribing drugs to lower cholesterol levels. over half of welsh adults and a large proportion of children are overweight or obese13. the burden of overweight and obesity is rising with significant costs to the health system and the economy. overweight and obesity are related to social disadvantage. what works? “best buys”14 to reduce levels of unhealthy diet include interventions and policies, such as restricting the marketing of unhealthy food and beverages to children; raising public awareness of healthy diets; increased taxes of unhealthy foods; promoting healthy eating in schools and workplaces and providing counselling in primary care. introducing a 10% tax on sugar sweetened drinks elsewhere resulted in decrease in drinks purchased by an average of 6% and by 9% in more deprived households. offering counselling to obese people in primary care could provide an additional 5,700 years of life in good health per year in wales15. increasing cycling and walking in urban areas could save £0.9 billion for the nhs in wales over 20 years16. if rates of overweight and obesity continue to rise, by 2050, this will cost the nhs in wales £465 million per year, with a cost to society and the economy of £2.4 billion. each year physical inactivity costs £51 million to the nhs and £314 million to the overall economy in wales. 6. promoting physical activity 7. promoting healthy diet and preventing obesity in wales, 28.4% of children in the most deprived areas are overweight or obese, compared to 20.9% in the least deprived areas. 12 physically active for 150 minutes or more a week. 13 for ‘overweight’ and ‘obesity’ definitions, see supporting evidence document 14 taking into account cost effectiveness, implementation costs and feasibility 15 estimated from england and wales data on unadjusted per capita basis scho ol making a difference: investing in sustainable health and well-being for the people of wales 9 infectious diseases are still a major health and economic burden in wales. rates of hiv and other sexually transmitted and some bloodborne infections are increasing. the estimated hiv-related life time costs for diagnosed individuals ranges between £280,000 and £360,000 in the uk. each unplanned hospital admission for flu treatment was estimated to cost the nhs between £347 and £774. inequalities exist for some communicable diseases. 60% of tuberculosis cases are found in people in black and other minority ethnic groups. cancer is a major cause of ill health and premature death in wales with the number of new cases continuing to rise both in men and women. deprivation is linked to poorer uptake of all adult screening programmes. for 2014/15, bowel screening uptake in wales was 41.5% in the most deprived areas compared to 57.1% in the least deprived areas. the uptake of abdominal aortic aneurysm screening was lower in men living in the most deprived areas (67.7%) compared to men living in the least deprived areas (79.5%). what works? vaccination provides a return on investment. the estimated cost of measles treatment was between £159 and £356 per case, while the cost of measles vaccination and control ranged from £0.13 to £0.74 per person in 2003 across europe. early diagnosis of infections saves lives and costs. if 1% of patients with hiv are diagnosed at an earlier stage of disease this could save around £12,114 a year for men who have sex with men and £15,143 a year for black africans in wales16. cancer screening can be cost-effective and early identification could lead to patients living longer and to fewer hospital emergency admissions and diagnostic tests. if the proportion of cancer diagnosed at early stages increased by 10% between 7000 and 9000 more people would survive cancer for 5 years in the uk. colorectal cancer alone accounted for 1,327 new cases and 528 deaths in men and 1,008 new cases and 399 deaths in women in 2014 in wales. the total number of new cases of any cancer in 2014 was 19,118, a 14% increase since 2005. the number of new hiv diagnoses reported from across wales has increased since 2012, with the highest annual number in the last 15 years in 2014 (189 new cases). 8. protection from disease and early identification 16 estimated from england and wales data on unadjusted per capita basis £1.35 would be returned for every £1 spent on targeted flu vaccination. savings would increase to £12 per vaccination when health care workers are included. public health wales 10 economic and social inequalities persist in wales with multi-generational negative impacts on health and wellbeing, triggering and sustaining health inequalities, unhealthy behaviours and influencing future generations and their life prospects. children from disadvantaged households die more often than average as babies and are more likely to have lower income or live in poverty as adults, thus perpetuating a vicious circle. a greater proportion of adults in the most deprived areas of wales die as a result of smoking and alcohol misuse compared to those in the least deprived areas. social inequality is a barrier to sustainable growth. the detrimental effects of austerity are felt greatest by those less resilient; such as those with less economic security or poor physical and mental health. babies living in fuel poor homes (cold and damp) are more likely (by 30%) to be admitted to hospital or to attend primary care. what works? tackling the causes of social and economic inequalities that drive health inequalities is likely to be most effective. this may include interventions to ensure a living wage, reduce unemployment, improve the physical environment and provide universal services (accessible to all) while also investing additionally to support vulnerable groups. a living wage is associated with improvements in life expectancy, mental health, alcohol consumption, and a fall in mortality. preventing ill health across the population is generally more effective at reducing health inequalities than a focus on clinical interventions. minimum unit pricing for alcohol reduces alcohol consumption among the lowest income group by 6% and reduces mortality among the heavy drinkers in routine/manual occupations by 8%. investing in insulation and heating to address cold and damp housing could return savings of nearly £35 million for the nhs in wales17. treating public finances as a public health issue could mitigate austerity measures, i.e. monitoring the impact of all economic and welfare reforms on the public services and public health. this could be done through using health impact assessment18. addressing wider economic, social and environmental determinants of health 9. reducing economic and social inequalities and mitigating austerity estimated costs of inequalities to the welsh economy are £1.8 to £1.9 billion per year due to productivity losses and £1.1 to £1.8 billion per year due to welfare payments and lost taxes17. 17 estimated from england and wales data on unadjusted per capita basis 18 assessing systematically the potential influences of policies, plans and projects in different non health sectors on health and well-being almost a quarter (20-25%) of the deaths among unemployed people over the 10 years following the loss of job could be prevented if they were employed. £ rip 11 environmental risks include occupational risks, urban outdoor air pollution, unsafe water, indoor smoke from solid fuels, lead exposure and global climate change. a triple jeopardy of air pollution, impaired health and social deprivation could increase ill health, disabilities and death disproportionately between and within regions in wales. breathing polluted air causes premature death. it increases the risk from heart disease, stroke, respiratory disease and lung cancer and imposes a considerable cost to society. poor quality housing, including issues such as mould, poor warmth and energy efficiency, infestations, second-hand smoke, overcrowding, noise, lack of green space and toxins, is linked to physical and mental ill health. it impacts the individual, as well as costs to the individual, society and the nhs in terms of associated higher crime, unemployment and treatment costs. injury is a leading cause of death and disability in wales. what works? although there are serious gaps in the economic evidence due to the complexity of environmental hazards and long lag of visible effect (i.e. disease), the world health organisation suggests approaches with health, social, economic and environmental benefits. these are shown to be cost-effective with potential returns on investment and include active transport, safe green spaces, low emission zones, speed management, heat wave plans, chemical regulation and removal of lead and mercury. introducing a traffic congestion charge in london has resulted in 9% reduction in bronchiolitis (lung condition) hospital stays. investing in housing improvements provides a cost-effective way of preventing ill health and reducing health inequalities. it could lead to less time off from school or work, increased use of the home for study and leisure, and improved relationships between household members. 10. ensuring safe and health promoting natural and built environment in wales, around 1,320 deaths and 13,549 years of life are lost due to small particles in the air. the financial, individual and societal costs of air pollution are estimated at nearly £1 billion per year 19. 1100 deaths, 42,000 in-patient admissions and 445,000 emergency department attendances were due to injuries in 2009 in wales. making a difference: investing in sustainable health and well-being for the people of wales 19 estimated from uk data on unadjusted per capita basis £ rip public health wales 12 the unique welsh policy context, especially the well-being of future generations (wales) act 2015, has the potential to enable positive change and secure sustainable solutions for the present and future generations. the five sustainable development principles, agreed with the welsh population are: prevention, long-term view, integration, collaboration and involvement. they are in part complemented by the four prudent healthcare principles: ‘do no harm and only do what’s needed’, ‘coproduction’, ‘reduce inappropriate variation and use evidence’ and ‘care for those with the greatest health need first’. a key enabler for all health interventions is ‘systems working’ to improve the public’s health, i.e. taking a whole systems approach which aligns public policies, financial flows and accountability with local public, private and third sector delivery and shared outcomes. a collaborative approach with an emphasis on prevention and public health will help address the current and future health, social and economic challenges in wales. drawing on recommendations from national and international experts in public health and policy, social studies, equity and economics, we have brought together recommendations on how to embed these principles into practice. enabling principles 1 prevention invest in preventive interventions which are based on evidence and offer value for money. this report has highlighted potential ‘solutions’ and approaches in some key public health areas. 2 long-term view adopt a long-term investment and prioritisation framework (on national and local level) to protect, improve and promote the health and well-being of people and communities in wales. 3 integration utilise health impact assessment across welsh government, local government and the public sector in order to consider the impact of any decision and intervention on health, well-being and inequalities, i.e. assessing the potential influences of policies, plans and projects in different non health sectors. 4 collaboration and ‘systems working’ working in partnership and synergy across sectors on national and local level, including governmental, public, private and third sector organisations. 5 involvement and ‘co-production’ ensure communities and people in wales are given a voice, involved in decisions about their health and well-being and listened to through ‘knowledge forums’ to facilitate the engagement of the public, professionals, policy makers and academic experts. 6 minimise and mitigate harms to health ensure impacts on health, well-being and equity are known and harms are minimised and mitigated through adopting a ‘health in all policies’ approach across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts, to improve population health and health equity. 7 reduce variation and address the greatest population health need first ensure a ‘proportionate universalism’ approach, i.e. all decisions and interventions which benefit health and well-being are implemented for all people but delivered at scale proportionate to need. about us public health wales exists to protect and improve health and wellbeing and reduce health inequalities for people in wales. we are part of the nhs and report to the minister for health and social services in the welsh government. our vision is for a healthier, happier and fairer wales. we work locally, nationally and, with partners, across communities in the following areas: health protection – providing information and advice and taking action to protect people from communicable disease and environmental hazards. microbiology – providing a network of microbiology services which support the diagnosis and management of infectious diseases. screening – providing screening programmes which assist the early detection, prevention and treatment of disease. nhs quality improvement and patient safety – providing the nhs with information, advice and support to improve patient outcomes. primary, community and integrated care – strengthening its public health impact through policy, commissioning, planning and service delivery. safeguarding – providing expertise and strategic advice to help safeguard children and vulnerable adults. health intelligence – providing public health data analysis, evidence finding and knowledge management. policy, research and international development – influencing policy, supporting research and contributing to international health development. health improvement – working across agencies and providing population services to improve health and reduce health inequalities. further information web: www.publichealthwales.org email: generalenquiries@wales.nhs.uk twitter: @publichealthw facebook: www.facebook.com/#!/publichealthwales http://www.publichealthwales.org mailto:generalenquiries@wales.nhs.uk http://www.facebook.com/#!/publichealthwales public health wales hadyn ellis building maindy road cathays cardiff cf24 4hq tel: 02921 841 933 this report, including the executive summary, supporting evidence and infographics can be found on the public health wales website www.publichealthwales.wales.nhs.uk £ rip http://www.publichealthwales.wales.nhs.uk ndejjo r, musinguzi g p, musoke d, wanyenze rk. unlocking the power of communities to achieve universal health coverage in africa (position paper). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4382 p a g e 1 | 11 position paper unlocking the power of communities to achieve universal health coverage in africa rawlance ndejjo1, geofrey musinguzi1, david musoke1, rhoda k. wanyenze1 1 department of disease control and environmental health, school of public health, college of health sciences, makerere university, kampala, uganda corresponding author: rawlance ndejjo; address: department of disease control and environmental health, school of public health, college of health sciences, makerere university, kampala, uganda email: rndejjo@musph.ac.ug source of funding the author(s) received no specific funding for this work. conflict of interest statement the authors declare that they have no competing interests authors’ contributions rn conceptualised and wrote the first draft of the manuscript. gm, dm and rkw supported the literature review and critically revised the manuscript. all authors read and approved the final manuscript. acknowledgments the authors wish to acknowledge prof. augustino ting mayai for his support in the manuscript development process. mailto:rndejjo@musph.ac.ug ndejjo r, musinguzi g p, musoke d, wanyenze rk. unlocking the power of communities to achieve universal health coverage in africa (position paper). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4382 p a g e 2 | 11 abstract africa is at a critical time undergoing demographic, epidemiological, political and socio-economic transitions and faced with repeated outbreaks of emerging and remerging diseases. the continent also faces other broader challenges of climate change, environmental degradation and pollution testing the resilience of its health systems and hindering progress to achieve health for all. five years into the journey towards sustainable development goals (sdgs), the continent – similar to the rest of the world – has been gripped with the corona virus disease pandemic that has caused significant morbidity and mortality as well as severely disrupted health systems and the underlying socioeconomic determinants of health. one of the most significant sdg targets is the achievement of universal health coverage (uhc) where all people have access to quality health services they need without inflicting a financial hardship on them. however, progress towards this target has been slow on the continent and requires rethinking current approaches employed. we argue that africa’s key strength lies in the communities whose potential should be unlocked to build cost effective and sustainable bottom-up health systems founded on primary health care (phc). such systems should be founded on community-based services, designed around individuals, families and the community, involving community health workers and other actors, and capitalising on health promotion and disease prevention approaches. a strong community health system should be adequately linked to district, regional and national levels working together to empower and serve populations to make health for all a reality. keywords: community health, disease prevention, health for all, health promotion, primary health care ndejjo r, musinguzi g p, musoke d, wanyenze rk. unlocking the power of communities to achieve universal health coverage in africa (position paper). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4382 p a g e 3 | 11 introduction the central promise in the 2030 agenda for sustainable development is to leave no one behind as countries make progress to achieve the sustainable development goals (sdgs) (1). although all goals contribute to health, sdg 3 specifically aims to ensure healthy lives and promote well-being for all ages (2). among the goal targets, target 3.8 purposes to achieve universal health coverage (uhc) for all (2). uhc seeks to ensure that all people have access to health services they need of sufficient quality from prevention, promotion, treatment, rehabilitation and palliative care with the use of such services not inflicting a financial hardship on them (3). uhc has great potential to drive achievement of sdg 3 and the 2030 agenda (2, 3). based on africa’s unique context and needs, a health system rooted and operationalised within the community holds the promise to achieving uhc for its population. the context: a continent undergoing change and prone to emergencies the corona virus disease that originated from china in the late 2019 (4-6) has further put a spotlight on the strain of health services delivery and tested the resilience of health systems across african countries. as of 19th january 2021, the continent had registered 3,284,451 covid-19 cases, 3.5% of all cases globally, and 79,633 deaths (cfr: 2.4%) in africa union’s 55 member states (7). never in the world has the importance of strengthened, resilient and responsive health systems and uhc been more important (811). moreover, africa has a high prevalence of infectious diseases including malaria, hiv, tuberculosis among others (12, 13) and is prone to epidemics of emerging and reemerging diseases including of ebola, marburg, yellow fever and cholera (14, 15). indeed, the continent was in 2014 gripped with its deadliest ebola disease outbreak that greatly affected west africa (guinea, sierra leone and liberia) leading to 28,616 cases and 11,310 deaths (16). some parts of east africa including the democratic republic of congo (drc) and uganda have also suffered repeated outbreaks of haemorrhagic fevers especially ebola and marburg (14, 17). these conditions pose threats to health security on the continent and their emergence back rolls progress made in improving health outcomes. for example, the early interventions due to covid-19 were associated with negative impacts on malaria, hiv, maternal mortality, sexual and reproductive health. the african continent is undergoing several transitions in its demography, disease epidemiology, political and socio-economic context (18). the continent is experiencing a surge in its young population and with increasing life expectancy, the elderly are also increasing. between 1990 to 2019, the continent has seen the greatest burden of disease shift from communicable, maternal and neonatal conditions to non-communicable diseases and injury. conflict, political processes and competing interests across african countries and its institutions continue to impact health in terms of funding and prioritisation, increase vulnerable groups and further health inequities. these political determinants of health further impact the socio-economic context including the poor living conditions, education, unemployment, unplanned urbanisation and inadequate access to healthy foods among others which further impact health outcomes. moreover, the covid-19 pandemic has further negatively impacted these socio-determinants of health reversing gains in education, employment and poverty across the continent. another challenge that the continent faces is environmental with environmental ndejjo r, musinguzi g p, musoke d, wanyenze rk. unlocking the power of communities to achieve universal health coverage in africa (position paper). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4382 p a g e 4 | 11 degradation, pollution, and climate change increasing risk of natural disasters such as drought, flooding, and landslides, food insecurity and vulnerability to infectious diseases (19). these challenges continue to negatively impact the health of africans, its health systems, populations, economy, and progress towards uhc. health systems in africa although africa has a fair share of health and environmental challenges, access to health services in most parts of the continent occurs amidst several impediments including fragile, weak and inadequately funded health systems (20, 21). a health system comprises all organizations, institutions and resources that produce actions whose primary purpose is to improve health (22). the world health organization proposed six building blocks of a health system (23): service delivery; health workforce; health information systems; access to essential medicines; financing; and leadership/governance and deficiencies among these have been shown in africa for several years. service delivery on the continent is characterised by challenges including in health worker availability and capacity, and availability of required equipment and drugs (20, 21, 24). the continent also has the least health workforce per capita (24-26). for example, in 2007, africa had an average of 2.3 health workers of all categories per 1000 population compared to 18.9 in europe and 24.8 for americas (25). to meet the basic healthcare needs of its population, africa requires at least one million more health workers (27, 28), however, the current growth rate of the workforce is not at par with recommended targets (29). in 2001, african union countries pledged to allocate 15% of their annual budget to health to strengthen their health system and ensure disease preparedness and response, however, although most countries have increased the proportion of public expenditure allocated to health, only a handful have met the abuja target (30). africa’s per capita expenditure on health stood at $160 in 2014 far lower than any other continent (30). across the continent, there have been demonstrated gaps in health systems leadership and governance, health information systems and access to essential medicines (20, 21, 24). these gaps impact the quality of care provided and the resilience of the health system to respond to shocks and stresses hindering progress towards uhc. the promise in community health uhc aims to achieve universal access to strong, resilient and people-centred health systems founded on primary health care (phc) (3). high quality health systems should be for the people, equitable, resilient and efficient, focussed on both preventing and treating disease and illness, and helping to improve well-being and quality of life (3, 21). amidst the challenges that africa faces, it is critical for the continent to generate innovative strategies to advance the health of its population to achieve uhc. one potential lies in unlocking the power of its communities as a basis for organising and structuring bottom-up health systems. communities are a group of people with diverse characteristics linked by social ties, share common perspectives, and engage in joint action in geographical locations or settings (31). a community health system is “the set of local actors, relationships, and processes engaged in producing, advocating for, and supporting health in communities and households outside of, but existing in relationship to, formal health structures” (32). an effective community health system should: be all inclusive for community members, involve various stakeholders, utilize community structures, and have a functional phc system. african communities are characterised by a sense of culture, togetherness, harmony, and respect and ndejjo r, musinguzi g p, musoke d, wanyenze rk. unlocking the power of communities to achieve universal health coverage in africa (position paper). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4382 p a g e 5 | 11 consist of community members – adolescents, young people, and elderly – leaders and community groups among others. individuals, families and communities have the ability to promote and maintain health, prevent disease, and cope with illness and disability with or without the support of a healthcare provider, a concept termed selfcare (33). self-care interventions includes health promotion, disease prevention and control; selfmedication; providing care to dependent persons; seeking hospital/specialist/primary care if necessary; and rehabilitation, including palliative care (34) and has had wider applicability in health. in sexual and reproductive health, self-care has been successful in improving antenatal, delivery, postpartum and new-born care and combating sexually transmitted infections, including hiv, reproductive tract infections, cervical cancer and other gynaecological morbidities (34). in management of chronic conditions, positive outcomes for chronic condition are registered when patients and families, community partners, and health care teams are informed, motivated, prepared and working together (35). reviews have demonstrated the potential of community health programmes in improving health outcomes including for malaria, tuberculosis and maternal and child health indicators (36-40). moreover, countries in africa including ethiopia, malawi and rwanda have showcased several benefits from scaling up their community health programmes (41). the key elements for successful community health programmes have been national stewardship, embeddedness and integration, cadre and role definition, human resource management and support, and financing (42). the role of communities in health promotion and disease prevention most health problems in africa stem from poor hygienic and living conditions, food insecurity and poor nutrition as well as emerging and re-merging infectious agents expounded by poverty, lack of health information and poor health seeking behaviours (43, 44). the continent is also faced with a ‘triple burden of disease’ consisting of already existing communicable, emerging and re-emerging, and non-communicable diseases. in line with this, the astana declaration recognises the need for prioritizing health promotion and disease prevention so that people’s needs across the life course are met through comprehensive preventive, promotive, curative, rehabilitative services and palliative care (45). unfortunately, far so often and in many african countries, the health system is focused on provision of curative services at the expense of health promotion and disease prevention which is not in sync with the continent’s disease burden. in 2010, it was noted that whereas in low-income countries, 70 to 80% of the disease burden was attributable to preventable infectious diseases, less than 10% of national expenditures were directed to public population services (46). the contributory factors are the limited funding available for health care leading to prioritisation of short team goals compared to long term objectives, traditional emphasis on direct medical services and development, and limited capacity for health promotion and disease prevention (46). fineberg et al in discussing the dilemma of why prevention is often overlooked for treatment noted that it is often invisible, requires persistent behaviour change and its results may be delayed in addition to influence of commercial interests and other cultural or personal beliefs (47). to bridge the observed gaps in health promotion, the who regional office for africa passed the health promotion strategy for the african region in 2012 whose aim is to “strengthen the capacity of member states to develop, implement, monitor and evaluate health promotion strategies, policies, and regulatory ndejjo r, musinguzi g p, musoke d, wanyenze rk. unlocking the power of communities to achieve universal health coverage in africa (position paper). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4382 p a g e 6 | 11 and legislative frameworks” (48). the risk factors and determinants of focus were communicable and non-communicable diseases, violence and injuries, maternal and child health conditions, and new and re-emerging threats to health” (48). communities are key resources to take lead in health promotion and disease prevention initiatives and contribute to addressing these risk factors. the covid-19 pandemic has been another reminder of how important individual and community actions are to maintenance of health and wellbeing. indeed, individual and community behaviours such as handwashing, social distancing, avoiding spreader events, protecting the most vulnerable and community resilience, peer and social support and self-management have all been key determinants of disease response and its impact. primary health care as the foundation for universal health coverage phc is one of the strong pillars of uhc which should be based on community-based services delivery and health promotion and disease prevention. the 1978 who alma ata declaration recognised health as a fundamental human right and noted the need for action by various sectors beyond health to achieve health for all (49). in the declaration, phc was defined as “essential healthcare based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination” (49). although phc should be country and context specific, it should comprise key services for health improvement. these services include: health education on usual health problems and their prevention and control measures; an adequate supply of safe water and basic sanitation; maternal and child care including family planning, immunisation against major infectious diseases; prevention and control of endemic diseases; treatment of common diseases and injuries; and provision of essential drugs (49). phc recognises health as multisectoral bringing together other sectors such as agriculture, education, housing among others to contribute to health efforts (49). furthermore, the need for individual and community participation in planning and organising phc is paramount with emphasis on use of local resources and the system supported by trained and lay health workers including physicians, nurses, midwives, community health workers (chws) and traditional practitioners who respond to community needs (49). phc should be sustained by integrated, functional, and mutually supportive referral systems. the need for the principles and values espoused in the alma ata declaration are now more important than ever and continue to be relevant especially in africa which should strive to build health systems that capitalise on midlevel professionals and chws and recognise the relevance of social determinants of health. owing to the continued relevance and importance of phc 40 years later, the astana declaration reaffirmed the need for phc efforts to ensure that everyone is able enjoy the highest possible attainable standard of health regardless of where they are (45). phc involves the provision of a broad range of preventive and curative services to meet the needs of the population served and remains a cost-effective approach for many lowand middleincome countries (49). building sustainable phc driven by knowledge and capacity-building, human resources for health, technology and financing thus remains one of the proven approaches to achieve uhc (45). the strong platform of phc should overarchingly be based on community-based services and health promotion and disease prevention ndejjo r, musinguzi g p, musoke d, wanyenze rk. unlocking the power of communities to achieve universal health coverage in africa (position paper). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4382 p a g e 7 | 11 (3). this however should be contextualised to the current context acknowledging the major shifts in disease conditions and risk factors, technological advancement, and latest evidence. restructuring for universal health coverage: from bottom up “health is made at home, hospitals are for repairs” has been a common phrase in discussions to reform health systems. there is agreement on the importance of health promotion that starts with the individual, families and the community as a central point for building people-centred health systems. these should be equipped with health promotion and disease prevention information so that they are empowered and actively engaged in maintaining their health and not mere passive bystanders. to achieve uhc, health systems should reach all communities no matter the context. recognised as the first point of contact with the health system in many communities, chws have an important role to play in community mobilisation, education, dialogue, empowerment and basic health services provision (50). chws have so far contributed to several health gains in immunisation, maternal and child health and sexual and reproductive health services provision across several countries (38, 51). the who has provided guidance to optimize chw programmes stipulating ways to improve the design, implementation, performance and evaluation of programmes to contribute to the progressive realisation of uhc (52). these guidelines cover several areas of chw programmes including training, supervision, remuneration and career progression among others aimed to bridge persistent gaps across programmes (52). these guidelines should inform the scale-up and sustainability of well designed, responsive and impactful chw programmes. within communities, community action and outcomes go beyond the chw as the most visible cadre with a notable contribution of wider community actors and health system factors and thus the need to embrace community health systems (32, 53). chws are part of the community health system which in itself is an integral part of phc and district health systems (53). the other actors at the community level such as local political, religious and cultural leaders, health committees, community groups and faith-based organisations all have important roles to play in advancing community health (32, 54). these actors work without formal bureaucracies relying on trust, acceptability and support of the formal health system influenced by local histories, economic and political systems, and social–cultural norms (32). phc systems support community health with well-trained health workers, drugs, equipment, health information systems, and proper referral systems and should be well financed and governed. with more investment in health promotion and disease prevention at the community level, the disease burden on the phc system is reduced providing room for health workers to improve their capacity to better support communities including through routine outreaches and screening activities reaching the underserved. the phc system should then link with the district health system across the referral pathway to support management of complicated cases or their subsequent referral to the next level (53). the functionality and integration of the health system is paramount right from the chws, community health systems, phc and the overall district health system. this integration should include aspects of joint ownership and design, collaborative supervision and feedback, incentives, and monitoring systems incorporating data from communities and the health system (54). the district health system should then link with the regional / provincial and national health sys ndejjo r, musinguzi g p, musoke d, wanyenze rk. unlocking the power of communities to achieve universal health coverage in africa (position paper). seejph 2021, posted: 26 april 2021. doi: 10.11576/seejph-4382 p a g e 8 | 11 tems providing clear pathways for referral and integration. conclusions to make health for all a reality in africa, there is need for individuals, families and communities to take charge of their own health. these should be supported by a robust community health and primary health care system providing quality, people-centred care with adequate linkage to the district and national health systems. these measures should accelerate the progress towards achieving the sdgs. references 1. general assembly. united nations: transforming our world: the 2030 agenda for 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integrating community roles into health systems frameworks to achieve health for all. bmj global health. 2019;3(suppl 3):e001384. 54. naimoli jf, perry hb, townsend jw, frymus de, mccaffery ja. strategic partnering to improve community health worker programming and performance: features of a community-health system integrated approach. human resources for health. 2015;13(1):113. ________________________________________________________________________ donev dm. pay-for-performance and tools for quality assurance in health care (reviw article). seejph 2022, posted:21 january 2022. doi: 10.11576/seejph-5115 p a g e 1 | 14 review article pay-for-performance and tools for quality assurance in health care doncho m. donev1 1 institute of social medicine, faculty of medicine, ss. cyril and methodius university, skopje, north macedonia corresponding author: professor doncho m. donev, md, ph.d. address: institute of social medicine, faculty of medicine, ss. cyril and methodius university, skopje, north macedonia phone: +38970244760 e-mail: dmdonev@gmail.com donev dm. pay-for-performance and tools for quality assurance in health care (reviw article). seejph 2022, posted:21 january 2022. doi: 10.11576/seejph-5115 p a g e 2 | 14 abstract ongoing health care reforms in the countries of southeast europe (see) to modernise and promote the health sector include the introduction of innovative payment methods for health care providers in hospitals and outpatient services. the idea of remunerating health workers according to the work they do and the results they achieve has been present in the countries of see for more than four decades. this includes the need to develop and implement objective measures and criteria to regulate the work of health facilities and health professionals. implementing the "pay-for-performance" (p4p) model is a major challenge with the risk of compromising the quality of health services in all countries, and positive experiences for quality assurance have been modest in many countries around the world. standards and norms (s/n), clinical pathways (cpw) and checklists (cl) are necessary regulatory tools that complement each other to protect the quality of health services and implement the "payment for success" (p4s) model. the absence of s/n, cpw and cl in the implementation of the p4p model leads to inefficiencies, inadequate/unrealistic numbers, and poor quality of health services, as well as more frequent medical errors. with the development, introduction and implementation of s/n, cpw and cl in the application of the p4s model, everyone benefits: patients, healthcare organisations and their employees, health insurance companies, ministries of health and the state. keywords: checklist; clinical paths, clinical pathways; patient safety, pay for performance; quality assurance, healthcare; quality of health care; standardisation, standards conflicts on interest: none donev dm. pay-for-performance and tools for quality assurance in health care (reviw article). seejph 2022, posted:21 january 2022. doi: 10.11576/seejph-5115 p a g e 3 | 14 introduction ongoing health sector reforms in the western balkans region and, in a broader context, in the countries of south eastern europe (see) and beyond, aimed at joining the european union (eu) and modernising and promoting the health sector over the last twenty or more years, include several fundamental trends and activities: 1) increasing the transparency, efficiency and sustainability of the health system; 2) introducing professional management in health facilities; 3) payment based on health services provided, known as pay-forperformance (p4p) in inpatient and outpatient care; and 4) improving the quality, safety and availability of health services through evidence-based medicine (1-5). p4p is an innovative remuneration method to motivate and reward healthcare providers in hospitals and outpatient settings (individual physicians and clinicians or clinical teams, organisational units, services or hospitals) according to the work invested and the results achieved. the p4p method has been applied for more than two decades in most countries of the see and beyond in europe and the world (1, 6-12). p4p can be defined as "a strategy for improving health care delivery that relies on the use of market or purchasing power, with incentives that reward providers for achieving a number of payer goals, including efficiency of service delivery, submission of data to the payer, and improvement in quality of care and patient safety" (13). in developing countries, there is a great deal of heterogeneity in the design of p4p schemes for providers and their autonomy, in the motivational criteria and the way performance and outcomes are monitored and reported, and in the number of financial bonuses and sanctions (1-4, 6-10). according to the agency for healthcare research and quality, the p4p method "is intended to provide financial incentives to doctors and other healthcare providers to achieve defined quality, efficiency or other goals. the collective goal of the p4p approach is to reduce the costs of the health system while improving quality by changing the behaviour of doctors, patients and hospital staff through a system of rewards and punishments" (11, 13). however, the incentives of the p4p system have significant flaws and can be counterproductive neither reducing the costs of the health system nor improving the quality of health services and care. punishing participants for poor performance can further reduce individual performance, especially when motivation and commitment are required (11-13). the initial enthusiasm and success in implementing variants of the p4p model are often questioned because there is no clear and repeated evidence of their success and there is no clear and dominant successful p4p model. a key policy dilemma remains: will p4p improve the quality of health care and nursing? (1, 4, 6-10). the idea of rewarding health personnel according to performance and success has been known in see countries for more than four decades, and with it the need to develop and apply objective measures, criteria and benchmarks against which health facilities and health workers must be measured. the implementation of p4p methods is a major challenge because there is insufficient evidence that the use of financial incentives contributes to improving the quality of health care. there is also a risk that the quality of health services will be compromised, and positive experiences are modest in many countries around the world (4, 7, 9). standards and norms (s/n), clinical pathways (cpw) and checklists (cl) are necessary regulatory tools that are complemented to ensure consistent application of p4p methods and protection of the quality of health services and patient safety (14-22). so far, several attempts have been made in macedonia and other see countries to develop and implement s/n, cpw and cl donev dm. pay-for-performance and tools for quality assurance in health care (reviw article). seejph 2022, posted:21 january 2022. doi: 10.11576/seejph-5115 p a g e 4 | 14 and to apply the p4p method in health care, but without satisfactory results: in 1977-80, s/n in primary health care (phc), specialist consultative services, and in some preventive medicine/ public health activities were prepared and adopted (14); in the 1980s and after, there were attempts in several see countries, such as slovenia, croatia, serbia, macedonia etc., to develop s/n and cpw in inpatient care; at the end of the 1980s, at the request of the sfr yugoslavia health care trade union, "regulations for the variable part of the salary depending on performance" were elaborated and adopted, which in practise provided for rewards or penalties of 1020% of the salary; in the last decade, the introduction of cl in certain health care sectors (surgery, paediatrics, obstetrics and neonatology) has started, but the experience so far is modest. objective: the focus and aim of this paper is to clarify the approaches and tools to protecting the quality of health care services when applying p4p methods in health care, especially in hospitals, to present the macedonian experience and the experience of some other countries in the see region and broader in terms of remuneration of health personnel according to the work done and the results of the work (outcome), as well as international experiences, observations and guidelines on the protection of the quality of health services and patient safety towards improvement in the application of models from pay for performance (p4p) to pay for success (p4s). the importance of standards and norms, clinical pathways and checklists for the implementation of the pay-forperformance model in health care the experience in the countries of see and beyond in europe and other countries teaches us that standardisation of health care and health services still has a long way to go. implementing the p4p model is a major challenge with the risk of compromising the quality of health services and jeopardising patient safety, and positive experiences are modest in many countries around the world (7, 9, 18). s/n, cpw and cl are necessary tools that complement each other to ensure quality of health care and good clinical practise in the application of the p4p model. according to the institute of medicine in the united states (since 2015 the national academy of medicine), quality of health care is defined as "the extent to which health care services provided to individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge" and "patient safety is no different from the provision of quality health services and care" (10, 21). donabedian describes health service delivery as a continuum of structure, process, and outcomes and argues that quality of care is an end product when structures are translated into outcomes through processes (23). in the continuum of service delivery, each of the above aspects of quality is given equal importance. the quality of structure consists of human and important material resources such as infrastructure, equipment, medicines and supplies, communication and transport. sufficiently trained and motivated staff is a prerequisite for optimal quality of health care and nursing. the process simply means whether services are delivered optimally and safely according to service delivery standards through technical and nontechnical performance (23). technical performance means that scientifically proven services are delivered at an appropriate time. for example, a routine antenatal examination should measure the woman's weight, check blood and urine samples for infections and signs of preeclampsia, palpate the abdomen and measure blood pressure and abdominal circumference. non-technical performance relates to interpersonal relationships, provider behaviour, privacy and confidentiality (10, 23, 24). donev dm. pay-for-performance and tools for quality assurance in health care (reviw article). seejph 2022, posted:21 january 2022. doi: 10.11576/seejph-5115 p a g e 5 | 14 outcomes are the key consequences of service delivery, such as morbidity, mortality, readmissions and transfers, hospital infections and complications, outof-pocket costs and customer satisfaction (8, 23, 24). the most complex and probably simplest definition of quality is used by proponents of total quality management: "do the right thing right, right away". quality assurance refers to a systematic, ongoing process aimed at improving performance, using implicit or explicit data. essentially, quality assurance is a set of activities carried out to set standards and monitor and improve performance so that health services and care are delivered as efficiently and safely as possible. the absence of minimum standards can compromise quality and safety, lead to patient dissatisfaction and reduce demand for services in the long term (2, 10). the absence of s/n, cpw and cl leads to inefficiency, inappropriate/unrealistic numbers and poor quality of health services, as well as more frequent medical errors (2, 3, 8, 10, 21). the benefits of s/n, cpw and cl are multiple, both for health institutions and staff and for health policy and decisionmakers (ministries of health, health insurance funds) and, above all, for patients and the population as a whole (box 1). box 1. multiple benefits from the use of standards and norms, clinical pathways and checklists (2, 10, 17, 18, 20, 21-23) 1. benefits for patients and the population improved quality and safety of health services and clinical work; better multidisciplinary teamwork in inpatient treatment; uniform criteria for referral to a specialist, admission and discharge from hospital; standardisation of services and a uniform therapeutic approach; precise recording of interventions, surgical procedures and prognostic parameters; faster treatment with better outcomes, fewer complications, reduced hospital mortality; lower personal costs for the patient (fewer visits, more rational treatment, shorter sick leave); protection of rights and strengthening of cooperation and active role of patients. 2. benefits for health institutions and staff a higher level of accountability of health personnel for good clinical practise; easier assessment of the volume and quality of work and the workload of health personnel; risk reduction and "management" of health services and procedures; localisation of specific liability for errors and negative outcomes in health care; reducing the costs of unnecessary procedures, analyses and medications; shortening the duration of hospital treatment and reducing readmissions; aligning the quality of work of health personnel; better internal quality and cost control for health services; support for learning/training and transfer of new knowledge into daily work; a reduced number of legitimate medical error claims; a unique approach to pricing medical services; identification of actual needs for health facility financing; control and evaluation of contractual obligations and plans of health institutions. 3. benefits for health policy and decision makers (moh, hif) provision of high quality, efficient and economic health care; setting standard costs for health services and treatment of a particular disease; agreeing the number and price of health services for health institutions and staff; appropriate allocation of funds for financing health care; appropriate distribution of the work of health care institutions and staff by levels of health care system; rational use of the capacities of the health system; reduction of irrational consumption and slower growth of costs in the future; donev dm. pay-for-performance and tools for quality assurance in health care (reviw article). seejph 2022, posted:21 january 2022. doi: 10.11576/seejph-5115 p a g e 6 | 14 collection of "online" data for quality control and external monitoring of the work of health care institutions; promotion of good clinical practise and evidence-based medicine; realistic health care planning and programming. objectives of standardisation of procedures and processes in the provision of health services and standardisation of time the main objective of standardising procedures, the order in which health services are delivered and standardising the time required to perform certain services is to increase the level of accountability of doctors and other health care providers and to improve the quality of health care services in order to achieve better outcomes and thus reduce morbidity and premature mortality. however, it is difficult to attribute morbidity and mortality only to the quality of services provided, as several other factors can influence these outcomes, such as severity of illness and pre-existing other diseases, delays in seeking health interventions and care, and non-adherence to treatment regimens (10, 17, 18, 20, 23). at the same time, it is very important to have an optimal workload and to realistically assess how many and what kind of services a doctor and other health personnel can and should provide during regular working hours (14, 18, 20). from an economic point of view, the goal is to determine the real prices of health services and the real costs of health institutions for normal/optimal work through the financial possibilities of the health system as well as to equalise price differences standardisation of health services between health institutions. standardisation of health services also prevents deviations from basic principles and procedures in the execution of health services (18, 20). what are health standards and norms, clinical pathways and checklists? s/n, cpw and cl stand for a prescribed or agreed set and sequence of medical steps and standardised clinical procedures that constitute a health care service or episode of hospital care and that must be performed according to medical science to achieve a specific positive medical outcome (14, 18, 21-28). the clinical pathway and checklists make it possible to record all relevant procedures or to record the reasons why the procedure was not performed (21, 24-30). s/n, cpw and cl have a dual function: 1) they regulate relations in the health facility with established professionalmethodological norms and rules for the behaviour of health personnel in the delivery of health care; and 2) they set the stage for the regulation of socio-economic relations between health care providers and health care users mediated by the health insurance fund (hif) and the ministry of health (moh) (14, 18). standards and norms in health care standards and norms refer to the minimum and appropriate mix of personnel by profile and number, health system infrastructure, equipment and supplies required to deliver specific health services efficiently, fairly and sustainably to the expected population at different levels of the system (14, 20, 31). a health care service standard is a prescribed or agreed set of medical procedures that constitute a health care service and that, according to medical science, must necessarily be performed to achieve a specific medical outcome. the standard of performance includes the preparatory and the final procedure as well as the content of the service as a whole, for the performance of which a time norm is specified (14, 18, 20). clinical standards are donev dm. pay-for-performance and tools for quality assurance in health care (reviw article). seejph 2022, posted:21 january 2022. doi: 10.11576/seejph-5115 p a g e 7 | 14 measures or quality statements. they are established on the basis of evidence-based best practise guidelines to ensure safe and high-quality care. therefore, standards would imply an absolute limit below which the quality of health services and care must not fall (minimum standards), while norms represent a consensus on the quality goals to strive for (aspirational norms). clinical standardisation is the process by which standards and protocols for health professionals and trainees are identified, adopted and applied in practise. the basic effects and benefits of clinical standardisation are as follows: 1) it supports patient safety and ensures consistency in care; 2) it ensures care for patients and families; 3) it increases efficiency and optimises health care resources; and 4) it improves health outcomes and accountability for physicians and trainees (16, 18-20, 31). the time norm for physician activity is the agreed time required to provide a particular health service or procedure in a manner determined by the standard of health care, taking into account an average level of technical equipment, an average level of professional knowledge and work experience of doctors/teams and other health personnel, and an average level of work intensity and workload. the time norm for the doctor and his/her team includes the time required by mid-level and high-school level nursing staff to perform work in their domain, such as sterilisation of instruments and supplies, maintenance of medical equipment, requesting and handling materials and medicines, medical documentation and records, etc. (14, 18, 20). the technical-methodological approach and process of developing standards and norms in health care goes through several phases. first, it is necessary to create a unified nomenclature of health care services, which is systematised by the individual branches of medicine, i.e. health care activities, through the law. several methods are used in the development of s/n in health care, namely: the statistical method of work, the method of expertise, the experimental method and the field method (14, 20). previous experiences and already prepared s/ns for specific activities in the country, as well as materials from other countries, domestic and foreign literature, should be used as materials for the preparation of s/ns, with the necessary adaptation to the existing conditions in the given environment/country (14, 18, 20). review of the s/n by experts in the field is necessary to make adjustments based on comments, opinions and suggestions from peers and heads of departments/services. the final correction of the s/n is done after a 'broad public debate' where opinions, comments and suggestions are sought from health facilities in the country, hif, moh and others (14, 15, 18). translating clinical standards into practise means: 1) engaging clinicians and physicians to promote a high level of clinical acceptance; 2) consulting existing best practises and evidence for guidelines; 3) using existing standardised clinical content; 4) gathering local input to ensure that standards fit a particular context; 5) optimising the time of staff and physicians who serve on boards and working groups; and 6) establishing clear documentation standards and approval procedures (16, 18, 31). clinical pathways clinical pathways (cpws) are tools that guide evidence-based health care. their aim is to translate clinical practise guideline recommendations into clinical care processes within a single culture and health facility. the clinical pathway is a structured multidisciplinary care plan with the following characteristics: 1) it serves to translate guidelines or evidence into local structures; 2) it describes in detail the steps during treatment or care in a plan, pathway, algorithm, guideline, protocol or other "action inventory"; and 3) it aims to standardise care for a specific clinical problem, procedure or health episode in a donev dm. pay-for-performance and tools for quality assurance in health care (reviw article). seejph 2022, posted:21 january 2022. doi: 10.11576/seejph-5115 p a g e 8 | 14 specific population. cpw is an evidencebased practise or way in which a particular group of patients with a predictable clinical course or disease or condition should be managed/treated, i.e. that the various tasks (interventions) of professionals involved in patient care are defined, optimised and sequenced in writing in terms of minutes/hours (emergencies), days (for acute care) or home visits (home treatment ), including the expected protection and care process. in doing so, procedures should be guided by best practise (18, 21, 22, 26, 27). cpw has been applied internationally since the 1980s. the use of cpw in european countries has increased since the 1990s, starting with the united kingdom, and currently pathways are used in most european countries. in some european countries (e.g. belgium, germany, the netherlands, slovenia and bulgaria) there is increasing activity in the development and application of cpw (21, 22, 24, 26). the european pathway association (epa), the world's largest professional organisation for cpw, was established in 2004 to support the development, implementation and evaluation of cpw/care pathways in europe. in 2018, the epa had registered members in more than 50 countries (26, 27). checklists a checklist (cl) is a tool that helps not to forget any step during the process, to perform tasks in the established order, to check the fulfilment of a set of requirements or to systematically collect data for their later analysis. it helps to improve the efficiency of teamwork, promote communication, reduce variability, standardise care and increase patient safety. the purpose of cl is to provide guidance, i.e. to help health workers manage treatments, to provide the best and most reliable care, e.g. during childbirth in different settings, to reduce adverse events due to negligence and treatment errors (2830). in the last 10 years, cl has been increasingly used as a list of procedures and interventions performed within individual health services in almost all specialties (2729). it is particularly widespread in paediatrics, obstetrics and surgery, starting with the most common safety messages cl for paediatric and adult surgery, safe birth, cl in neonatal intensive care units, highrisk interventions, paediatric intensive care and time-dependent pathologies, e.g. paediatric trauma, etc. (24, 29, 30). clinical studies have shown that cl helps to reduce mortality and morbidity rates in many specialties (24, 28-31). measuring the performance of healthcare staff and the quality of health care in hospitals clinical effectiveness performance and evaluation are based on clinical standards, clinical indicators and clinical audits. clinical standards include clinical guidelines, clinical pathways and local practise protocols. clinical indicators are benchmarks that allow comparison of health services, institutions, and departments, and the staff there, with similar ones (18, 27, 31). clinical audits are methods for evaluating and improving clinical practise. they can be defined as "systematic measurement and evaluation of the efficiency and effectiveness of organisational systems and processes". clinical audits analyse the quality of clinical care and outcomes, including the procedures used for diagnosis and treatment, the use of resources, and the adequacy of assessment of clinical outcomes and patient quality of life (18, 31). clinical control includes methods to improve clinical practise by systematically measuring and evaluating the efficiency and effectiveness of organisational systems and processes for: 1) analysis of the quality and outcomes of clinical care, including procedures used for diagnosis and treatment; 2) use of resources; and 3) donev dm. pay-for-performance and tools for quality assurance in health care (reviw article). seejph 2022, posted:21 january 2022. doi: 10.11576/seejph-5115 p a g e 9 | 14 adequacy of methods for assessing clinical outcomes and patient quality of life. the basic elements for good clinical practise with performance measurement and the potential barriers to quality and performance monitoring are presented in box 2. box 2. elements for good clinical practise and possible barriers to quality of health services and performance monitoring (18, 22, 23, 27-31) basic elements for good clinical practice and performance measurement: strengthening individual, team and organisational awareness and responsibility for good clinical practise and enhancing the safety and quality of health care; organisational policies and strategies and the clinical practise that implements them; provision of human and material resources for good clinical practise; information and communication with staff, relevant factors and the public for good clinical practise; training and professional development to support good clinical practise; performance indicators to be developed at all levels of the institution to measure and demonstrate the effectiveness of the good clinical practise strategy and policy. potential barriers to health service quality and performance monitoring: a long tradition of professional autonomy, collegiality and self-regulation, creating an organisational culture that hides weaknesses and in which it is difficult to point out and punish mistakes; lack of close collaboration with all professional groups in introducing changes/reforms; lack of standards/clinical pathways to improve the quality and control of health professionals' work; lack of support and commitment from health professionals for successful implementation of good clinical practise and p4p; lack of equipment and medicines required for the standard/clinical pathway; lack of data on treatment outcomes/effects in general; high interdependence of health systems and many external factors that weaken the link between actual and measured performance, case mix and variability. demotivation of health personnel due to penalties, audits and trials, inadequate conditions and insufficient funding for safety and quality; speed in introducing superficial changes without preparation, motivation and collaboration; shortage of staff and overload of health professionals; insufficiently developed health information system; insufficient professionalism, autonomy and support for management. all hospitals should participate in the measurement and evaluation process and have their clinical practises monitored externally on a regular basis to ensure safe and quality health care. they should also report on factors relevant to the outcome of the assessment process and take action to improve (18, 22, 23, 31). reforms to overcome barriers to quality monitoring and performance measurement can only be successful if health professionals are informed and motivated to change their behaviour through positive approaches and collaboration in implementing change. overcoming barriers is neither quick nor easy and therefore requires a systematic approach that includes education and continuous professional development, professionalism and autonomy of health institution management, and acceptance of standards/clinical pathways and work norms (18, 27, 31). discussion the evaluation of performance payments (p4p) has not kept pace with the haste with which it was introduced. the limited number of evaluations is typically small in donev dm. pay-for-performance and tools for quality assurance in health care (reviw article). seejph 2022, posted:21 january 2022. doi: 10.11576/seejph-5115 p a g e 10 | 14 scope and design, making it difficult to draw general conclusions. as a result, the empirical basis for p4p in health care is rather weak, despite the enthusiasm of its proponents (4, 7-10, 12). there are numerous criticisms and challenges when it comes to p4p models in health care. p4p schemes also reduce clinicians' job satisfaction and intrinsic motivation and tempt doctors and administrators to cheat the system. in addition, clinicians may align their treatment plans too closely with p4p processes and practises and move away from providing care tailored to individual patient needs. finally, but not comprehensively, it is difficult to accurately attribute performance outcomes to a single clinician, as patients often receive care from multiple providers (6, 7). in macedonia, the p4p model was officially introduced on 1 july 2012, with the obligation for each doctor to report online to the ministry of health on the procedures/ interventions performed during the month, with a monthly salary variation per doctor of +/20%. the model measures the individual workload of doctors as the number of procedures performed in a month, rather than the performance of a clinical team or hospital, without an established system for assessing the team, doctors' skills, professional experience and titles, the complexity and quality of procedures and care, and the outcomes of inpatient treatment and care. thus, the macedonian p4p model is a simple form of payment for reporting (p4r), subjective and prone to error and manipulation. despite doctors' voices and strikes until the end of 2012 against the health policy proposed by the ministry of health, the p4p model was implemented with strong political influence and without sufficient transparency and quality measures, leading to widespread dissatisfaction among doctors in the public health sector. this has led to conflicts within clinical teams and departments, as well as an exodus of doctors to private hospitals and outpatient clinics (4). with s/n, cpw and cl, potential side effects of p4p models can be prevented and overcome, such as tunnel vision, onesidedness, and superficiality, or a focus on quantitative aspects of clinical performance that can be easily measured, and neglect of unmeasured areas of health service quality, adverse selection or incentives to avoid the most difficult patients, undermining or potentially reducing the internal/intrinsic motivation of professionals as a key feature of quality health care, inequity creating perverse incentives to exclude disadvantaged groups, overcompensating or rewarding providers who already meet or exceed the target threshold, and misreporting, gaming or cheating (11, 12). international interest in p4p in health care is growing and debates are shifting from ideological justification to technical implementation, although the long-term impacts and risks of p4p are unknown and preliminary assessments of the quality and outcomes framework show both benefits and negative consequences (12, 13). p4p programmes are implemented in a variety of ways, and there are many factors that can influence the potentially positive or negative impacts of these programmes. direct evidence is not sufficient to draw firm conclusions, but collaboration, provider motivation and acceptance, and alignment of measures with organisational goals can be important in maintaining effective programmes. interventions that are developed transparently from the evidence base and aim to improve clinical processes and patient outcomes are more likely to be effective (9, 12). the ideal p4p model, according to social science research, is a programme design that sets the standard for excellence and offers a reward for anyone who achieves a certain level of performance. in such a design, everyone who reaches the standard is rewarded and no one is punished for not reaching the standard. the disadvantage of this 'ideal' p4p strategy is that it is difficult to budget for, as it is never known in donev dm. pay-for-performance and tools for quality assurance in health care (reviw article). seejph 2022, posted:21 january 2022. doi: 10.11576/seejph-5115 p a g e 11 | 14 advance how many individuals will reach the standard required for the reward (13). the main barriers to implementing s/n, cpw and cl are negative staff attitudes and resistance, hierarchy, poor design, inadequate training, overlap with other worksheets, work overload, cultural barriers, lack of replication, etc. (30, 31). conclusion p4p is an insufficiently precise instrument whose implementation is complicated to implement due to unexpected difficulties and consequences, and the advantages and disadvantages should be consciously and fairly assessed by managers and policymakers. optimal p4p systems should allow all participants to be rewarded for adhering to and achieving standards and improving quality, tending to reduce costs. s/n, cpw and cl are only approximate and average values with possible variations when other elements are taken into account (cultural level and structure of the population, spatial and working conditions, frequency of diseases and specificity of pathology of certain areas, etc.). it is necessary to emphasise the role of leadership in the implementation of s/n, cpw and cl in each area of medicine and health care with adequate staffing, to lead the implementation and evaluation of the results, to inform the rest of the team and to modify the process as necessary according to the problems identified. s/n, cpw and cl are dynamic indicators and it will not be possible to completely solve all problems in providing health care, but it will certainly help to improve and standardise the quality of health care, determine the real and clear prices for services and successfully implement the p4p model, and achieve complete, efficient and rational health care for the entire population. with the application of s/n, cpw and cl as tools for professional regulation, monitoring and implementation of the p4p model, health care costs will be reduced and the saved funds can be used to reward some of the staff with p4p. the basic requirements for the practical implementation of s/n, cpw and cl are legislative and it support and a balance between the professional, technical and administrative autonomy of health workers and managers on the one hand and the political dimensions and influences in health institutions, on the other. by setting parameters to evaluate performance and success, the p4p model can be elevated to a higher level in the p4s model if 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detailed bibliographic data is available on the internet at http://dnb.ddb.de south eastern european journal of public health (open access journal). copyright 2022 by jacobs publishing house: am prinzengarten 1, d 32756 detmold, germany copyright cover picture: wordpress foundation: http://wordpressfoundation.org/gnu general public license table of contents original research factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates maryam alawadhz, khadija alhumaid, sameeha almarzooqi, shaima aljasmi, ahmad aburayya, said a. salloum, waleid almesmari the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals shaima aljasmi, ihssan aburayya, sameeha almarzooqi, maryam alawadhi, ahmad aburayya, said a. salloum, khalid adel predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach khaled mohammad alomari an empirical study into factors that influence e-learning adoption by medical students in uae afrah alsharafi review article the impact of covid-19 lockdowns on air quality: a systematic review study butros m. dahu, ahmad aburayya, beenish shameem, fanar shwedeh, maryam alawadhi, shaima aljasmi, said a. salloum, hamza aburayya, ihssan aburayya tamminen, a.c.m. ; duport, g. ; atienza serrano, r. ; babich, s.m.. increasing fruit and vegetable consumption in ireland (policy brief). seejph 2022, 23 june 2022. doi : 10.11576/seejph-5604 policy brief increasing fruit and vegetable consumption in ireland alisa c. m. tamminen+1, gaetan duport+1, rocío atienza serrano+1, suzanne m. babich*2 1 department of international health, care and public health research institute – caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands 2 school of public health, indiana university-purdue university indianapolis (iupui), united states + these authors contributed equally to this work * senior advisor corresponding author: alisa tamminen, email: a.tamminen@student.maastrichtuniversity.nl, address: bourgognestraat 5b, 6221bv, maastricht, the netherlands mailto:a.tamminen@student.maastrichtuniversity.nl tamminen, a.c.m. ; duport, g. ; atienza serrano, r. ; babich, s.m.. increasing fruit and vegetable consumption in ireland (policy brief). seejph 2022, 23 june 2022. doi : 10.11576/seejph-5604 abstract context: following recommended dietary guidelines, ireland has since 2010 implemented a 0% value added tax (vat) on fruits and vegetables to increase consumption. eleven years after policy implementation, the irish still do not meet recommended intake for fruit and vegetable consumption, consuming 3.9 portions a day compared to 7 daily portions recommended. policy options: four alternatives for improvement were assessed and compared: 1) retain the status quo of reduced vat for healthy foods, 2) vat only for locally produced fruits and vegetables, 3) increased vat for salty and sweet foods with a subsidy for fruits and vegetables, and 4) an education-based policy. four evaluation criteria were applied for the comparison: economic feasibility, effectiveness, political feasibility, and equity. recommendations: the status quo remains the best option for ireland. however, further assessment of this 0% vat policy on fruits and vegetables is warranted, pending the availability of additional data to enable an in-depth understanding of policy implementation. keywords: tax and nutrition policy, dietary guidelines, global health policy analysis, nutrition policy analysis tamminen, a.c.m. ; duport, g. ; atienza serrano, r. ; babich, s.m.. increasing fruit and vegetable consumption in ireland (policy brief). seejph 2022, 23 june 2022. doi : 10.11576/seejph-5604 introduction the current state of affairs based on the current situation described in the healthy ireland report (1), consumption of fruits and vegetables which are essential for a healthy diet (2) is suboptimal in ireland. according to the bord bia thinking house study (3) from 2017 to 2020, daily consumption of fresh vegetables increased by 7% to 58% in ireland. the irish are still only eating 3.9 portions of fruits and vegetables per day, on average. this falls short of recommendations of the healthy eating guidelines (4), the irish fbdg, of up to 7 daily servings. moreover, only 51% of irish eat fruits daily, and 58% eat daily servings of vegetables (3). currently, consumption of fruits and vegetables is encouraged with a financial incentive of 0% value added tax (vat) on purchases of fruits and vegetables, as stated in vatca2010 (5). with regards to the effects of vat policy on diet, it is essential to mention that whereas vatca2010 incentivises fruit and vegetable consumption, it does not simultaneously discourage consumption of commonly consumed unhealthy foods such as cakes and biscuits (1, 6), which are taxed at a standard rate (23%) (7). the current vat policy falls short in successfully increasing fruit and vegetable consumption. when looking at the vatca2010 policy in the context of the bardach policy framework (8), it appears to lack an important component necessary for understanding whether or not the policy achieves its intended goal. there is no publicly available information on the evaluation of the performance of the policy. thus the effectiveness of the policy itself is unknown. additionally, consultations with relevant stakeholders were not feasible within the timeframe of the study, and no data were available to assess the level of public awareness of the policy. overall, more data are needed to enable a full assessment and recommendations for policy improvement. fruits and vegetables are included within food-based dietary guidelines (fbdgs) as essential to healthy diets (2) because of their vitamin, mineral and fibre contributions. low consumption of fruits and vegetables increases human health risks and indirectly harms the environment when people eat proportionately more foods of animal origin. low-quality diets with insufficient plant matter promote micronutrient deficiencies, such as vitamin and mineral deficiencies, excessive intakes of salt, sugar, animal fats and animal protein, and decreased intakes of healthsupporting phytochemicals and dietary fibre, with a concomitant increase in morbidity and mortality (9). broader consequences the production of animal products may adversely impact the environment due to high emissions of greenhouse gasses and land modifications (9). research from willett et al. (9) shows that plant-based foods, in contrast, produce the lowest environmental impact per serving. therefore, the promotion of greater consumption of plant foods is needed. the urgent need for action is related to global demographic trends. population growth will require greater food production (9). unhealthy lifestyles and ageing populations (10) are increasing the prevalence of non-communicable diseases (ncds) (11). the current situation is already concerning, as 88.41% of the dalys in the european union are ncdrelated (12). public health strategies to increase fruit and vegetable consumption are in line with the sustainable development goals (sdgs) of the united tamminen, a.c.m. ; duport, g. ; atienza serrano, r. ; babich, s.m.. increasing fruit and vegetable consumption in ireland (policy brief). seejph 2022, 23 june 2022. doi : 10.11576/seejph-5604 nations (9). those most relevant include sdg 3, development of good health and well-being, sdg 11 construction of sustainable cities and communities and sdg 13 climate action (13). in addition, there may be indirect benefits for goal 8 (13), increasing decent work and economic growth in agriculture. in ireland, a 0% vat policy has been in place for fruits and vegetables since 2010. the intended effect is to lower consumer prices for these foods, providing an economic nudge encouraging beneficial behaviour change and greater consumption of fruits and vegetables (11). as vat is included in every stage of food production and distribution, it presents a cumulative effect on all the services involved in food production (9). this policy brief describes the existing policy and potential options to strengthen it. context ireland has a population of 4.977 million people (14), with a gdp of 95 513 usd per capita (15) of which 22.66% is tax revenue (16). 39% of irish are overweight, and 23% are classified as obese (1). currently, fewer than 40% of irish people meet the recommended daily intakes of fruits and vegetables (1). irish initiatives such as healthy ireland (17) and sláintecare (18) seek to improve national health status, and healthcare systems. in ireland, the parliament, and the taoiseach, also known as the head of state, are important policy keepers. parliament consists of two houses: the senate and the house of representatives. the house of representatives (dáil éireann) have the power to initiate or revise legislation, and the senate (seanad éireann) can reject proposed legislation or amendments. the taoiseach consists of the prime minister, or tanáiste (19), and divisions (20). taxation is organised by the irish tax and customs office, called revenue (21). fruit and vegetable consumption is financially incentivised in ireland, with the most recent vat regulation enacted in 2010 (5, 22). fruits have a 0% vat, with glazed or crystallised fruits taxed at the standard rate (5). fresh and frozen vegetables also enjoy a 0% vat in ireland (5). statistics on fruit and vegetable consumption in ireland before and after the vatca2010 are not readily available. policy options four potential policy alternatives (modifications) were assessed by applying four evaluation criteria consistently. each was rated from 1 (+) worst to 5 (+++++) best based on likely outcomes, as it is shown in table 1, and further described in appendix a. the criteria were defined as follows: ‘economic feasibility’ refers to the estimated impact on the irish economy of implementation of the policy option. ‘effectiveness’ refers to the estimated success of the policy option in modifying purchasing behaviour with regard to fruits and vegetables. ‘political feasibility’ refers to the estimated willingness of stakeholders to support the option. lastly, ‘equity’ regards the ethical and societal concerns in the implementation of each option. comparisons among the options are shown in table 1. tamminen, a.c.m. ; duport, g. ; atienza serrano, r. ; babich, s.m.. increasing fruit and vegetable consumption in ireland (policy brief). seejph 2022, 23 june 2022. doi : 10.11576/seejph-5604 table 1. policy alternatives assessment. policy alternatives economic feasibility effectiveness political feasibility equitabilty (1)status quo: reduced vat for healthy foods i.e. fruits and vegetables and not for unhealthy foods (ireland) + + + + + + + + + + + (2) super vat reduction for local fruits & vegetables + + + + + + + + + + + (3) vat increase for salt and sugar and subsidy for fruits & vegetables + + + + +++ + + + (4) health promotion by education + + + + + + + + + + + + + + policy option 1: status quo “do nothing” is one potential option for policy change. with regards to assessing the functioning of the current policy, vatca2010 in ireland, fruit and vegetable consumption statistics are not readily available, and no evaluation of the policy was found. the high rates of overweight and obesity in ireland (1) demonstrate a need for policies that support healthy dietary choices. the current policy, as implemented, appears to have not done enough to encourage sufficient consumption of fruits and vegetables (1). had they been available, stakeholder consultations about the vatca2010 policy may have provided additional information and insights about opportunities to refine and improve the current policy. additionally, the tamminen, a.c.m. ; duport, g. ; atienza serrano, r. ; babich, s.m.. increasing fruit and vegetable consumption in ireland (policy brief). seejph 2022, 23 june 2022. doi : 10.11576/seejph-5604 effectiveness of the current vat policy remains unclear due to an apparent lack of publicly available evaluation data. the effect of the policy on changing behaviour over time remains uncertain, as does an understanding of what aspects of the vat reduction result in a difference in fruit and vegetable consumption and/or production. consumption. lastly, as mentioned earlier, the most commonly consumed unhealthy foods amongst the irish ‘cakes and biscuits’ (if not covered in or decorated with chocolate or similar products) (1) belong to a reduced vat tax category. other sweets have a standard vat (22). at present, there is no vat disincentive for cakes and biscuits to reduce their consumption. policy option 2: locally produced fruit and vegetable vat reduction in latvia, the standard rate of vat is 21% with a reduced rate of 12% applied to some goods and services. from 1 january 2018, a 5% vat applies to supplies of fresh fruits, berries and vegetables that are locally grown. the aim of this policy was to reduce the level of vat avoidance and share of the informal economy in the sector and to support local producers in terms of financial flows. initially, for a period of three years, the policy has been extended in 2021. the consumption of local fruit and vegetables has grown by 10% in 2018 and 9% in 2019 (23). this reduction encourages local production so sustainability with a lower footprint. policy option 3: fruit and vegetable vat reduction in combination with unhealthy food taxation policy. fruit and vegetable vat reduction policy combined with unhealthy food taxation policy have shown influence in consumption behaviours (24). indeed, fruits and vegetables are a great option to eat between meals, instead of sweets, cakes and biscuits or salty snacks, which are the unhealthiest foods consumed as analysed in the ipsos mrbi (1). products can be perceived as cheaper when other options increase their cost (11). sugar and salt taxation will increase the price of unhealthy alternatives. therefore, economic incentives and disincentive effects on the prices will increase motivation and accessibility to choose fruit and vegetables. policy option 4: education on healthy and sustainable diets and awareness about the vat reduction for fruits and vegetables. according to willet et al. (9) consumption behaviour change could be reinforced by increasing awareness about nutrition and knowledge about the vat reduction for fruits and vegetable policy and its intention to increase the intake of these goods. despite the implementation of reduced vat in ireland since 2010, the policy is unknown by a big part of the population. through mass public information campaigns from the government, the general population can be informed. moreover, the integration of nutrition and sustainability in schools by programmes and workshops with the parents' involvement may increase concern in the moment of life when it is easier to modify habits during childhood. recommendations status quo is the best option for now, as it has been resilient to change over time the current policy has remained unchanged for more than 10 years. this may demonstrate the policy’s acceptability politically and socially. however, it must be recognised that there may have been tamminen, a.c.m. ; duport, g. ; atienza serrano, r. ; babich, s.m.. increasing fruit and vegetable consumption in ireland (policy brief). seejph 2022, 23 june 2022. doi : 10.11576/seejph-5604 calls or attempts for revision of the policy which failed. outcome data are needed to document the impact of 0% vat on fruits and vegetables in ireland an integral part of any policy is an evaluation of its impact. in order to understand the impact of this policy on the consumption of fruits and vegetables amongst the irish, outcome data should be made publicly available. conclusion assessment of the current vat reduction policy and alternatives to promote greater consumption of fruits and vegetables resulted in our recommendation to retain the status quo. the conclusion is a preliminary finding in light of the lack of data that would make a more nuanced assessment possible. however, there is good reason to support a 0% vat policy for fruits and vegetables in ireland. the strongest point is the guarantee of affordability of fruits and vegetables, hence accessibility to these essential goods in a healthy diet. the policy implementation since 2010 without modifications hasconfirmed its political feasibility. regardless of 11 years of decreased tax revenue from the vat reduction, the government budget remains unaffected, demonstrating the economic feasibility of the policy in ireland. because neither evaluations nor consultations are available, the weakest aspect of the status-quo alternative is its effectiveness with regards to shaping behaviours towards higher fruit and vegetable intake. in conclusion, 0% vat for fruit and vegetables should be maintained to promote a healthier and more sustainablefood system in ireland. however, a consistent policy evaluation system may address the impact of the policy and the possibility if not already to establish a clear objective. conflicts of interest the authors declare no conflict of interest. funding the authors received no funding for this project. acknowledgements the team of authors received integral support throughout the project from the team’s senior supervisor suzanne babich. her support helped foster the development of skills and understanding in the policy creation process, as well as raised the spirits of the team. additionally, the project team would like to thank the course coordinator katarzyna czabanowska more generally for being granted the opportunity to assess a policy situation and develop policy options for a topic in the field of nutrition and sustainability. references 1. healthy ireland survey 2017. ipsos mrbi, irish department of health. ; 2017. report no.: isbn 978–14064-2965-7. 2. food-based dietary guidelines.: the food and agriculture organization of the united nations; n.d. 3. fresh produce report july 2020. the board bia thinking house; 2020. 4. healthy eating guidelines. health service executive (hse.ie.); 2012. 5. value added tax consolidation act 2010., (2010). 6. tax and duty manual: vat treatment of food and drink supplied by wholesalers and retailers. in: customs ta, editor. revenue.ie: revenue; 2010. tamminen, a.c.m. ; duport, g. ; atienza serrano, r. ; babich, s.m.. increasing fruit and vegetable consumption in ireland (policy brief). seejph 2022, 23 june 2022. doi : 10.11576/seejph-5604 7. current vat rates [internet]. revenue. 2021 [cited 09.12.2021]. available from: https://www.revenue.ie/en/vat/vatrates/search-vat-rates/current-vatrates.aspx 8. engelman a, case b, meeks l, fetters md. conducting health policy analysis in primary care research: turning clinical ideas into action. family medicine and community health. 2019;7(2):e000076. 9. willett w, rockström j, loken b, springmann m, lang t, vermeulen s, et al. food in the anthropocene: the eat–lancet commission on healthy diets from sustainable food systems. the lancet. 2019;393(10170):447-92. 10. ageing and health. world health organization; n.d. 01.09.2021. 11. healthy diet.: world health organization; 2020 29.04.2020. 12. gbd results tool. [internet]. global health data exchange ihme. 2019 [cited 01.10.2021]. available from: http://ghdx.healthdata.org/gbdresults-tool 13. sustainable development goals: united nations development programme; n.d. [available from: https://www.undp.org/sustainabledevelopment-goals. 14. population (indicator). [internet]. oecd. 2021 [cited 11.11.2021]. 15. gross domestic product (gdp) (indicator). [internet]. oecd. 2021 [cited 11.11.2021 ]. 16. tax revenue (indicator) [internet]. oecd. 2021 [cited 11.11.2021]. 17. healthy ireland. . 04.04.2019 ed. gov.ie: government of ireland; 2019. 18. sláintecare. gov.ie: government of ireland; 2018. 19. irish politics and government : irish political system. eu2013.ie irish eu presidency; 2013 [available from: http://eu2013.ie/ireland-and-thepresidency/aboutireland/irishpoliticsandgovernment/ irishpoliticalsystem/ 20. about the department of the taoiseach. gov.ie: government of ireland; 2018. 21. welcome to revenue.ie. [internet]. revenue. n.d. [cited 08.12.2021]. available from: https://www.revenue.ie/en/home.a spx 22. notes for guidance – vat consolidation act 2010. . in: customs ta, editor. revenue.ie: revenue; 2019. 23. nipers a, upite, i., pilvere, i., stalgiene, a., viira, a.h. . effect of vat rate reduction for fruits and vegetables in latvia: ex-post analysis. . journal of agricultural science 2019. 24. thow am, downs sm, mayes c, trevena h, waqanivalu t, cawley j. fiscal policy to improve diets and prevent noncommunicable diseases: from recommendations to action. bulletin of the world health organization. 2018;96(3):201-10. https://www.revenue.ie/en/vat/vat-rates/search-vat-rates/current-vat-rates.aspx https://www.revenue.ie/en/vat/vat-rates/search-vat-rates/current-vat-rates.aspx https://www.revenue.ie/en/vat/vat-rates/search-vat-rates/current-vat-rates.aspx http://ghdx.healthdata.org/gbd-results-tool http://ghdx.healthdata.org/gbd-results-tool https://www.undp.org/sustainable-development-goals https://www.undp.org/sustainable-development-goals http://eu2013.ie/ireland-and-the-presidency/about-ireland/irishpoliticsandgovernment/irishpoliticalsystem/ http://eu2013.ie/ireland-and-the-presidency/about-ireland/irishpoliticsandgovernment/irishpoliticalsystem/ http://eu2013.ie/ireland-and-the-presidency/about-ireland/irishpoliticsandgovernment/irishpoliticalsystem/ http://eu2013.ie/ireland-and-the-presidency/about-ireland/irishpoliticsandgovernment/irishpoliticalsystem/ https://www.revenue.ie/en/home.aspx https://www.revenue.ie/en/home.aspx tamminen, a.c.m. ; duport, g. ; atienza serrano, r. ; babich, s.m.. increasing fruit and vegetable consumption in ireland (policy brief). seejph 2022, 23 june 2022. doi : 10.11576/seejph-5604 appendices appendix a: rationales of rating policy options policy alternatives economic feasibility effectiveness political feasibility equitability 1 status quo = reduced vat for healthy foods i.e. fruits & vegetables and not for unhealthy foods (ireland) (15/20) this is economically feasible as it has been shown by the previous 11 years, after the financial reform in 2019 it was not changed. however, reduced vat decreases tax revenues for governmental budgets, and no other vat is raised to compensate. 3/5 there is no data available on the current effectiveness of the policy on increasing fruits and vegetable consumption upon implementation. under half of the population are consuming 5 portions of fruits and vegetables per day, but it is hard to say which other factors contribute to this. 1/5 it was implemented and it remains in effect. however, stakeholders’ consultation on vatca2010 were not readily available for assessment, thus some stakeholders’ perspectives may be dismissed. 3/5 reduction of vat for fruits and vegetables is ethically valid, as it promotes access to healthy foods. however, unhealthy foods, such as cakes and biscuits have normal vat, so there are no financial disincentives, but no financial incentive either. 4/5 2 super vat reduction for local fruits & vegetables (latvia) (11/20) vat reduction for local production is narrower than option 1. impact on the budget is lower. may decrease incentive for national producers. with regards to the main objective stated, it is not clear if this policy positively or negatively impacts consumption. however, it would help lower gas emissions, so this would be a good policy in regard to sustainability and sustainable food systems. give incentive to local production = national protectionism. this promotes different food sources / production (food system diversification driver) in the long term, which increases domestic food system resilience. not having the 0% vat for non-domestic fruits and vegetables (sometimes available at low price point e.g. bananas) may mean low income family consumption of fruits and vegetables is reduced by this option.vat reduction should apply to f&v regardless of their origin to ensure affordability of these goods, hence accessibility regardless of the financial status. tamminen, a.c.m. ; duport, g. ; atienza serrano, r. ; babich, s.m.. increasing fruit and vegetable consumption in ireland (policy brief). seejph 2022, 23 june 2022. doi : 10.11576/seejph-5604 4/5 2/5 4/5 1/5 3 vat increase for salt and sugar + subsidy for fruits & vegetables (evidence based) (10/20) yes. revenue from salt and sugar taxation.it is important to come up with a detailed strategy to respond to the likely concerns of the industry. 4/5 yes. taxation and subsidies affect prices, which influence consumers’ behaviour. however, existing vat policy has not necessarily guaranteed meeting suggested fruits and vegetables consumption in ireland. 3/5 suboptimal. sugar and salt taxation present difficulties to be implemented because of the number of stakeholder's opposition. 1/5 suboptimal. ethically low-income groups may consume salty snacks to ensure sufficient caloric intake. population acceptance may be low: high willingness to consume unhealthy foods & maybe lack of nutrition knowledge. however, the health promotion nature of these efforts would make this more acceptable. 2/5 4 health promotion (evidence based) (14/20) yes. there are already ongoing projects to promote healthy lifestyles. although money and resources are needed to develop communication and education campaigns, this approach can be integrated into the ongoing projects. yes. previous studies associated increasing awareness as the first step to bring about change. however, whether this translates to behaviour cannot be assured. the audience needs to be studied to accurately deliver the message for all demographics. yes. the policy proposal may benefit how politicians are perceived as they promote healthy dietary patterns. yes. the measure is ethical if the communication reaches all the groups of the society and not only privileged richer areas. social feasibility would depend on previous background and the individual willingness to learn, as well as adequate design of the communication materials. tamminen, a.c.m. ; duport, g. ; atienza serrano, r. ; babich, s.m.. increasing fruit and vegetable consumption in ireland (policy brief). seejph 2022, 23 june 2022. doi : 10.11576/seejph-5604 4/5 3/5 4/5 3/5 czabanowska k, laaser u, stjernberg l. shaping and authorising a public health profession (short report). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-23 short report shaping and authorising a public health profession katarzyna czabanowska1,2, ulrich laaser3,4, louise stjernberg5 1 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 2 institute of public health, faculty of health sciences, jagiellonian university medical college, krakow, poland; 3 faculty of health sciences, university of bielefeld, germany; 4 centre school of public health, faculty of medicine, university of belgrade, serbia; 5 department of health, blekinge institute of technology, karlskrona, sweden. corresponding author: prof. ulrich laaser, faculty of health sciences, university of bielefeld; address: pob 10 01 31, d-33501 bielefeld, germany; email: ulrich.laaser@uni-bielefeld.de 1 czabanowska k, laaser u, stjernberg l. shaping and authorising a public health profession (short report). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-23 abstract the aim of this short report is to stimulate a discussion on the state of a public health profession in europe and actions which need to be taken to authorise public health professionals based on their competencies. while regulated professions such as medical doctors, nurses, lawyers, and architects can enjoy the benefits of the 2005/36/ec directive amended by 2013/55/eu directive on the recognition of professional qualifications, public health professionals are left out from these influential (elite) professions. firstly, we use the profession traits theory as a framework in arguing whether public health can be a legitimate profession in itself; secondly, we explain who public health professionals are and what usually is required for shaping the public health profession; and thirdly, we attempt to sketch the road to the authorisation or licensing of public health professionals. finally, we propose some recommendations. keywords: profession, professionalization, public health, recognition of professional qualifications. 2 czabanowska k, laaser u, stjernberg l. shaping and authorising a public health profession (short report). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-23 introduction there are many professionals within the european union (eu) that are still waiting for the recognition of their qualifications. contrary to regulated professions such as doctors, nurses, midwives, pharmacists and architects, the public health (ph) profession being so multidisciplinary and system-dependent is still not clearly defined in the european states, which hinders professional mobility, rights to an automatic recognition and integration of public health professionals in the single market. the survey carried out by the association of the schools of public health in the european region (aspher) identified a profound need to develop clear-cut professional qualification models which would allow for the certification and licensing of the profession (1). the aim of this short communication is to stimulate debate on the state of a public health profession in europe and measures and actions which need to be taken to authorise public health professionals based on their competencies. the eu directives the eu introduced the directive 2005/36/ec (2) and adopted directive 2013/55/eu (3) on the modernisation of directive 2005/36/ec on the recognition of professional qualifications on the 20th of november 2013. this document was an attempt to provide a basic legislative framework of the recognition of qualifications. however, there are still many issues left unresolved by the directive. the directive 2005/36/ec was formulated to facilitate the mobility of professionals within the eu (4). depending on the national legislation and the profession in question, the document provides three different legal approaches to the recognition of a qualification. foster (2012) explained that the automatic recognition is the first possible procedure that is restricted to a limited number of regulated professions (5). in this case, the host country should recognize automatically the qualification. a second approach is the mutual recognition of qualification that is meant for the recognition of a “general system” profession. this procedure works on a case-by-case basis. in general, it establishes that an individual should undergo compensatory measures only when the education or the minimum required years of practice diverge drastically from the receiving country’s regulation. finally, the third approach is for individuals who establish themselves in another member state (ms) by working or providing a service on a temporary or occasional basis (5,6). the legislation might allow them to work without a prior recognition from the receiving country. however, article 7 of the directive is representing a restriction to this model (4). the article states that if there is a considerable difference between the individual’s qualification and/or the training required by the ms in particular in a profession having public health or safety implications, a prior check or compensation measures may be maintained (7). there are many controversial aspects within the directive: it is excluding a part of professionals from the mutual recognition by creating an inequality between the regulated and the unregulated professionals. moreover, the insecurity for the recognition of the qualification of non-regulated professionals, especially in the health sector, will contribute to a decline in the number of applications for this field (8). consequently, for a discipline such as public health there may be a shortage of labour force in the following years. these issues need to be solved to determine the needs of the job market. however, fortunately, the amendment to the 2005/36/ec directive article 16(a) states that: “the mobility of healthcare professionals should also be considered within the broader context of the european workforce for health” (2), thus, leaving room for public health professionals to be considered. therefore, there is a call for action directed to the public health community to shape the public health profession. 3 czabanowska k, laaser u, stjernberg l. shaping and authorising a public health profession (short report). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-23 shaping a profession different countries have their specific way of looking at public health, and shaping this profession is complex as public health is a very heterogeneous interdisciplinary composite with many different fields involved. however, the leadership should be provided by a highly trained professional workforce, specialised in the core areas of public health and formally recognized as a defined profession based on academic degrees. our focus is not on the role of medical staff covering also public health aspects in their work environment, neither on nonhealth professions adding to the assurance and advancement of public health. in order to discuss the shaping of a public health profession, a significant question relates to the extent that public health profession exhibits the characteristics of a profession. there are many sociological theories which describe the concept of a profession, the professional, and professionalization. while the precise content of these models varies, there are several characteristics that distinguish the professions from other occupations. the most commonly cited traits (9) include: i. skills based on abstract knowledge which is certified/licensed and credentialed; ii. provision of training and education, usually associated with a university; iii. certification based on competency testing; iv. formal organization, professional integration; v. adherence to a code of conduct; vi. altruistic service. firstly, we will use these traits as a framework in arguing whether public health can be a legitimate profession in itself; secondly, we will explain who public health professionals are and what usually is required for shaping a public health profession; and thirdly, we will attempt to sketch the road to the authorisation or licensing of ph professionals. finally, we will propose some recommendations and stimulate the debate with open questions. public health as a profession applying the trait framework to a public health profession, one can immediately observe that the first three characteristics are fulfilled. although public health is a multidisciplinary field, it encompasses abstract knowledge which can be reflected in public health competencies (aspher) when it relates to science, and in the essential public health operations (epho) when it relates to the art. both can serve as a strong base for licensing and certification of educational and practice qualifications. public health education is provided by higher educational establishments in the form of bachelor and master programmes with specialisation in public health, or a phd in public health (referring to the three cycles of the bologna system). public health programmes are in the majority of cases competency-based and, if not, their reform has been encouraged by the aspher competency project initiative (10,11). concerning the formal organisation and professional integration, contrary to what we observe in regulated professions such as medical doctors, nurses, midwives, lawyers, and architects, public health professionals do not have a specific organisation or chamber which would safeguard their rights and privileges. with respect to the specific code of conduct which would apply to the whole profession, we do not have many examples to follow (12,13). finally, considering an altruistic service as something what distinguishes public health professionals from other professions, we may state that the whole ethos of public health is based on altruistic principles of serving and protecting for the benefit of public and individual health. based on this short inventory we are able to prove that public health can be considered a profession if we put some effort in formalising and strengthening its professional integration. 4 czabanowska k, laaser u, stjernberg l. shaping and authorising a public health profession (short report). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-23 who are public health professionals? unlike the medical profession, defining public health professionals is more elusive. for example, beaglehole and dal poz define the public health workforce as “a diverse workforce whose prime responsibility is the provision of core public health activities, irrespective of their organizational base” (14), highlighting that public health workforce can be located both inside and outside the health sector (15). whitfield provides a theoretical conceptualization of public health activities and the related workforce. according to this concept, the public health workforce can be divided into three groups: i) “public health specialists”; ii) “people indirectly involved in public health activities through their work”; and iii) “people who should be aware of public health implications in their professional life” (16). distinguishing between these three categories of the public health workforce emphasizes the multidisciplinary and diverse character of public health itself. despite many differences among countries, public health professionals in europe often are physicians and have a medical public health/social medicine specialization, although there has been a shift towards more multidisciplinary teams since the 1990s and 2000s, with finland, ireland and the united kingdom among the first countries in europe in which professionals with different backgrounds were educated in public health (14). however, the multi-professionalism of the future public health profession is not represented in many european countries. for the purpose of this paper the public health workforce – whether actual or potential – consists of three main categories: i. public health professionals – professionals with sufficient public health competences at master level for public health services and/or doctor of philosophy (phd) for public health research. a bachelor degree can be considered as an entrance level, leading to a master in public health (mph)/phd degree, independent of working inor outside the health system, or: inor outside the public health services. ii. health professionals – health staff with more restricted public health competences and functions inor outside organised public health services; their main education would basically be a medical or other health-related programme with limited public health aspects – e.g., health promotion, or screening. iii. other staff with job functions bearing on the population’s health. examples would be teachers or policemen. we focus here on the first group, the public health professionals, which include: a. general public health professionals – individuals with a bachelor or master degree in public health. thus, they can be younger persons with no previous professional experience. they hold the academic degree, but not necessarily a licence for a profession. the content of the education provided by the university programmes shapes general public health professionals. needless to say, it should follow the aspher competency lists (10,11). b. public health specialists, i.e. general public health professionals who have added special competences to their general public health education and training from the areas such as: epidemiology, management and administration, health promotion, environmental health, public health genomics, or global public health which go beyond a selected specific track covered during their mph programme, or ideally accomplished a phd. what is usually required for shaping a profession? firstly, there are specific legal and regulatory steps which need to be taken in order for the profession to get a legitimate recognition. therefore, a specific national public health 5 czabanowska k, laaser u, stjernberg l. shaping and authorising a public health profession (short report). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-23 legislation should be granted to national public health councils or their equivalents, giving them the regulatory authority to protect the public’s health and including provisions on: a) public health positions, especially those related to leadership posts; b) second (mph) and third (phd) cycle academic degrees, and; c) an independent national public health chamber with the mandate to safeguard the right to enter and execute the profession, certify and license [including the mandatory minimum credits from accredited continuing education (ce)]. the support of who-int is needed here to provide a model public health law as well as the support of ce to allow for mutual recognition of academic degrees, certification, and licensing in order to enhance mobility. formal professional certification is a national prerogative. although some attempts have been made in some eu countries e.g. the uk qualification register (17), these are highly country-specific and do not necessarily fit the diverse ph systems in europe. secondly, formalized ce programmes (including an official statement on required credits), accredited at the national level by either a separate administration or a professional chamber should be made available for public health professional development. agency for public health education accreditation should provide the quality criteria for ce and offer to accredit the national accreditation procedures. thirdly, systematic development and adaptation of the existing public health competency models to meet the needs of continuing professional development, professional appraisal, and development of public health job profiles, should constitute the ongoing improvement process. this should be followed by the translation of the competency profiles to public health operations, thus, creating various competency-based job descriptions fitting possible eu public health qualification schemes. finally, the cooperation between all sectors of education, training, and the world of work is needed to improve sectoral identification and anticipation of skill and competence needs. potential conclusions and recommendations based on our analysis we see a potential in mobilizing the efforts of the public health professional community to build on the strengths and achievements of the profession so that it can join the elite of regulated professions. we strongly believe that no effort should be spared in identifying the possibilities in the eu regulatory documents and exerting influence on changing their content so that they are more inclusive in view of the common european market. above all, we should make sure that the public health profession fulfils all the necessary criteria to be considered a regulated profession and is supported by a strong formal organization at the national and european level (18)1. therefore, we recommend the following: i. strong lobbying of the professional public health community at the eu level to support the introduction of adequate legislation. ii. implementation of the professional qualification directive with broader mention of the recognition of public health professional qualifications. iii. advocating for public health laws to establish the requirements for leadership positions (see who database planned). iv. assuring that national qualifications are recognized eu-wide and beyond (european-wide recognition required for enhanced professional mobility). v. developing clear differentiating criteria related to academic (bologna cycles) and professional certification and re-licensing based on continuous professional development credits. 1we are obliged to prof. anders foldspang for the aspher concepts and policy brief on the classification of the public health workforce as an additional source for the publication. 6 czabanowska k, laaser u, stjernberg l. shaping and authorising a public health profession (short report). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-23 vi. provision of certification and licensing for all public health professionals. vii. acceptance of the national responsibility for certification and licensing. viii. advocating for the establishment of professional public health self-government (chamber) at the national level. acknowledgement the paper was presented at the deans’ & directors’ meeting in zagreb, croatia 30 may 2014, during session 5, organised by prof. anders foldspang. references 1. bjegovic-mikanovic v, vukovic d, otok r, czabanowska k, laaser u. education and training of public health professionals in the european region: variation and convergence. int j public health 2013;58:801-10. doi: 10.1007/s00038-012-0425-2. 2. european parliament, strassbourg: directive 2005/36/ec of the european parliament and of the council of september 2005. available from: http://eurlex.europa.eu/lexuriserv/lexuriserv.do?uri=oj:l:2005:255:0022:0142:en:pdf (accessed: april 28, 2014). 3. european parliament, strassbourg: directive 2013/55/eu of the european parliament and of the council of november 2013. available from: eur-lex.europa.eu/lexuriserv/lexuriserv.do?uri=oj:l:2013:354:0132:0170:en:pdf (accessed: april 28, 2014). 4. den exter a, hervey t. european union health law: treaties and legislation. antwerpen: haklu, 2012. 5. foster n. eu treaties and legislation. oxford: oxford university press, 2012. 6. dixon m. 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framework for public health. am j public health 2001;91:177682. doi: 10.2105/ajph.91.11.1776. 13. stapleton g, schroeder-baeck p, laaser u, meershoek a, popa d. global health ethics: an introduction to prominent theories and relevant topics. glob health action 2014;7:23569. doi: 10.3402/gha.v7.23569. 14. beaglehole r, dal poz m. public health workforce: challenges and policy issues. hum resour health 2003;1:4. 15. aluttis ca, maier cb, van den broucke s, czabanowska k. developing the public health workforce: chapter 15. in: rechel b, mckee m (eds.). facets of public health 7 czabanowska k, laaser u, stjernberg l. shaping and authorising a public health profession (short report). seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-23 in europe. european observatory on health systems and policies. copenhagen: world health organisation, 2014. 16. whitfield m. public health job market. in: czabanowska k, włodarczyk c (eds.). employment in public heath in europe. zatrudnienie w zdrowiu publicznym w europie. kraków: jagiellonian university press, 2004. 17. united kingdom public health register. available from: http://www.publichealthregister.org.uk/sites/default/files/practitioner_introduction_pac k_april2011.pdf (accessed: april 30, 2014). 18. foldspang a, otok r, czabanowska k, bjegovic-mikanovic v. developing the public health workforce in europe. the european public health reference framework (ephrf): it’s council and online repository. concepts and policy brief. brussels: aspher, 30 april 2014. ___________________________________________________________ © 2014 czabanowska et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 8 houghton f, o’mahony c. an examination of the diversity of beer and cider products sold in irish supermarkets in the context of health promotion advice (short report). seejph 2022, posted: 11 july 2022. doi: 10.11576/seejph-5720 short report an examination of the diversity of beer and cider products sold in irish supermarkets in the context of health promotion advice frank houghton 1, cáitlín o’mahony2 1frank houghton, school of applied sciences & information technology, technological university of the shannon, limerick, ireland orcid id: 0000-0002-7599-5255 2cáitlín o’mahony, school of medicine, university college cork, cork, ireland corresponding author: dr. frank houghton, school of applied sciences & information technology, technological university of the shannon, limerick, ireland email: frank.houghton@tus.ie mailto:frank.houghton@tus.ie houghton f, o’mahony c. an examination of the diversity of beer and cider products sold in irish supermarkets in the context of health promotion advice (short report). seejph 2022, posted: 11 july 2022. doi: 10.11576/seejph-5720 abstract aim: current health promotion advice relating to the consumption of beer and cider in ireland is very firmly based on nominal pints and half pints of beer. this study sought to determine if the assumed alcohol strength of beer and cider available in a sample of mainstream supermarkets was appropriate. this study also sought to examine if the assumed size of containers of beer and cider was accurate. methods: all beer and cider products in a purposive sample of irish mainstream supermarkets was examined. data was input into spss and examined. results: there is a substantial level of variation in the container size and alcohol content of beer available in mainstream supermarkets in ireland. discussion: current health promotion advice in ireland is out of date and does not enable people to easily monitor their drinking and follow healthy drinking guidelines. the obvious answer is the enactment of the public health (alcohol) act, 2018, that has already been passed requiring alcohol containers to display the number of grams of alcohol contained. however, this element of the legislation, despite being passed into law, has yet to be either enacted, or even given a date for enactment. keywords: alcohol, ireland, size, strength, warnings, standards, health promotion authors’ contributions: all authors contributed equally. conflict of interest: none declared. source of funding: no funding was received for this project. compliance with ethical standards: ethical approval was not required for this study. houghton f, o’mahony c. an examination of the diversity of beer and cider products sold in irish supermarkets in the context of health promotion advice (short report). seejph 2022, posted: 11 july 2022. doi: 10.11576/seejph-5720 an examination of the diversity of beer and cider products sold in irish supermarkets in the context of health promotion advice ireland has a substantial alcohol problem. although there has been a significant decline in average alcohol consumption in ireland since the height of the celtic tiger boom, it remains an intensely problematic issue. ample evidence exists of its negative impact on both the mental and physical health of drinkers, as well as on their families and communities. the negative impacts on already stretched health services are also considerable (1-5). evidence clearly demonstrates that a substantial proportion of the population are not heeding either weekly or daily low risk drinking guidelines. the national alcohol diary study indicates that over 1.33 million people in ireland are harmful drinkers, with heavy episodic (‘binge’) drinking being a particular issue (2). the mainstay of alcohol health promotion advice and guidelines in ireland is currently focused around detailing and limiting the consumption of units of alcohol (6-8). a unit of alcohol is usually considered half a pint of beer or cider, one glass of wine, or a shot of spirits. in ireland a unit of alcohol is equal to 10 grams of alcohol (9). in recent years the advised level of safe alcohol consumption in ireland has decreased from 21 units a week for men and 14 units a week for women to 17 and 11 units respectively. current irish health advice suggests that no more than 6 units of alcohol should be consumed in a day, this is also a reduction from previous advice. in relation to units of alcohol mongan & long suggest that ‘beer is the easiest for drinkers to estimate as beer is the most standardised and most beer is sold in single serve containers’ (10). figure one: screenshot example of a health services executive’s (hse) online selfassessment tool for alcohol utilising the standard drink concept (8) however, the concept of a unit of alcohol is highly problematic. it must be noted that there is considerable variation internationally on what constitutes a standard drink. this variation exists both within europe and outside of it. in the uk for example a unit of alcohol is 8g of ethanol. in ireland, as in many other european countries including poland, estonia, france & spain, a unit of alcohol houghton f, o’mahony c. an examination of the diversity of beer and cider products sold in irish supermarkets in the context of health promotion advice (short report). seejph 2022, posted: 11 july 2022. doi: 10.11576/seejph-5720 is 10g of ethanol. however, in some other european countries, particularly the nordic states, a unit of alcohol is 12g of ethanol. this includes norway, sweden, denmark and finland (10). it is even higher in some countries, such as canada and the usa, where a unit of alcohol is 13.6g and 14g of ethanol respectively. the potential causes of confusion for people attempting to adhere to safe drinking guidelines for alcohol in ireland are many. the reduction in the safe drinking guidelines mentioned above is an important factor, and the geographical variation in definitions also seems likely to foster confusion. it must be remembered that as well as the considerable number of uk citizens living in ireland, many more irish citizens have lived and worked in countries such as the usa and uk, where definitions of a unit of alcohol are different. further complexity may arise from the widespread use of both imperial and metric systems of measurement, which is reflected in the variation of alcohol container sizes. further confusion is also possible as alcohol containers may contain information on both the alcohol by volume (abv) percentage, and the more historical proof measurement of alcohol. although phased out by many countries in the 1070s and 80s, alcohol proof also measures alcohol content. the measure was originally developed in england in the sixteenth century and was the equivalent about 1.8 times the percentage of alcohol by volume. it only serves to confuse matters further that alcohol proof is defined differently in the us, it being double the percentage of alcohol by volume there. in evaluating people’s ability to calculate and understand healthy drinking advice it is also vital to appreciate the significant proportion of the population that routinely struggle with even relatively basic mathematics. evidence suggests that in ireland approximately 25% of the population have less than or equal to the most basic, level 1 numeracy skills, as measured on the programme for the international assessment of adult competencies (piaac) (11). this puts ireland 19th out of 24 participating countries. these results suggest that ‘754,000 irish people struggle with everyday maths, and may be unable to do a simple maths calculation such as subtraction’ (12). these factors may, in part, explain why evidence suggests that just 2% of adults know the low-risk healthy drinking guidelines (13). at present alcohol warning labels are not required by law in ireland. however, section 12 of ireland’s public health (alcohol) act, 2018 includes provision for the introduction of alcohol warning labels, including a specific requirement regarding the warning detail ‘the quantity in grams of alcohol contained in the container concerned’. however, there is currently no date of enactment for this section of the legislation. in the absence of mandatory alcohol warning labels in ireland it is important to examine how relevant the standard health promotion advice on alcoholic beverages actually is. specifically, around a half pint of beer or cider being equivalent to one (irish) unit of alcohol. health service executive (hse) reports discussing alcohol content routinely describe beer as a nominal 4.3% alcohol, with strong beers being rated at either 5% or 5.6% (9). speciality and micro-breweries have a long history of creating extra potent beers and ciders. however, adopting a more public health-oriented approach, this research aimed to explore the strength of beer and cider available in mainstream irish supermarkets, and their associated container sizes. method all beers and ciders on sale in a purposive sample of 8 mainstream supermarkets in the houghton f, o’mahony c. an examination of the diversity of beer and cider products sold in irish supermarkets in the context of health promotion advice (short report). seejph 2022, posted: 11 july 2022. doi: 10.11576/seejph-5720 munster region of ireland were examined, in total 359 beers and 80 ciders. the name, volume and alcohol content of each was recorded. non-alcoholic beers and ciders were excluded from this analysis. data was input into spss and descriptive statistics calculated. results three of the supermarkets examined (centra, londis and costcutter) only sold non-alcoholic beer or cider, and as such are excluded from this study. as can be seen from table 1, the beer examined across the remaining five supermarkets ranged in strength from 3.0% to 8.5%. all five supermarkets sold also beers with an alcohol content of 7.5% or more. the alcohol content of the cider was narrower, ranging from 4.0% to 6.0%. the mean strength of beer on sale ranged from 4.7% to 5.1%, while the mean for cider across the five supermarkets ranged from 4.5% to 4.9%. table one: alcohol content & container size of beer & cider for sale in irish supermarkets supermarket supervalu aldi lidl tesco dunnes stores beer alcohol contact % n 114 51 30 92 72 mean (sd) 4.7 (0.74) 5.1 (1.) 5.0 (0.87) 5.0 (0.94) 4.9 (0.89) median 4.55 4.8 4.85 4.8 4.8 minmax 3.0 7.5 3.8 7.9 4.0 8.0 3.0 8.5 3.0 8.0 beer size ml mean (sd) 473.2 (72.2) 483.5 (59.2) 483 (51.9) 456.0 (79.3) 539.8 (538.3) median 500 500 500 500 500 min max 330 660 250 660 330 500 330 660 250 5000 cider alcohol content % n 22 5 8 20 25 mean (sd) 4.9 (0.78) 4.4 (0.22) 4.6 (0.5) 4.5 (0.64) 4.7 (0.76) median 4.5 4.5 4.5 4.5 4.5 min – max 4 6 4 – 4.5 4 – 5.3 4 6 4.5 6 cider size ml mean (sd) 639 (458.6) 500 (0) 687.5 (530.3) 575 (335.4) 493.2 (34) houghton f, o’mahony c. an examination of the diversity of beer and cider products sold in irish supermarkets in the context of health promotion advice (short report). seejph 2022, posted: 11 july 2022. doi: 10.11576/seejph-5720 median 500 500 500 500 500 min max 330 2000 500 500 500 2000 500 2000 330 500 substantial variation exists in the alcohol content of both the beer and cider available. 35 different strengths of alcoholic beer were noted and 9 different strengths of alcoholic cider. similarly, there was considerable variation in the container volumes of beer and cider available. beer was sold in 12 different size containers (250 ml; 284 ml; 300 ml; 330 ml; 350 ml; 355 ml; 440 ml; 500 ml; 620 ml; 650 ml; 660 ml; 5 litres), while cider was sold in 5 different size containers (330ml, 500 ml, 568 ml, 1litre & 2 litres). discussion given the need for clear and easy to interpret health advice it is understandable that ireland has adopted the simple metric of a half pint of beer or cider equalling a unit of alcohol. however, it is very clear from this examination that mainstream irish supermarkets are routinely selling both beer and cider that is considerably more potent than the nominal 4.3% assumed in hse advice. beer of 7.5% alcohol or more was available in all five supermarkets, while cider of 6% strength was available in 3 supermarkets. the mean strength of beer and cider available in each was also marginally above the hse’s nominal 4.3%. it is clear therefore that the hse’s standard health promotion guidance may substantially under-estimate the volume of alcohol, and hence the danger, in beer and cider that is routinely for sale in ireland. the variety in strengths of alcoholic beer (35 different strengths) and cider (9 different strengths) on sale in just five supermarkets is also highly problematic. when combined with the substantial diversity in container size of the alcohol available (12 for beer and 5 for cider), even the most mathematically adept individuals might struggle to calculate an accurate measure of their unit alcohol consumption. mongan & long’s assertion that beer is the easiest for drinkers to calculate may be misplaced (10). there is therefore an urgent need for the irish government to demonstrate stronger leadership (14), and enact the remaining sections of the public health (alcohol) act, 2018, including section 12 which deals with alcohol warning labels, including provision for the introduction of information on the grams of pure alcohol contained in drinks. it must be acknowledged that the current warnings in the public health (alcohol) act, include significant gaps, and revisions are required (15). however, as an interim measure they should be enacted immediately. the extensive delays in enactment to date may well be the result of pressure exerted by the alcohol industry, which has long had a strong influence on governmental lawmaking in ireland. it is known, that in the year in which the public health (alcohol) bill was evolving, drinks industry lobbyists met government members and officials 361 times (16). drawing parallels between the alcohol industry and the tobacco industry, it is worth noting that a recent 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(epha), 2021. https://corporateeurope.org/sites/default/fil es/2021-03/epha-report.pdf (27 december 2021, date last accessed). ____________________________________________________________________ © 2022 , houghton et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://corporateeurope.org/sites/default/files/2021-03/epha-report.pdf https://corporateeurope.org/sites/default/files/2021-03/epha-report.pdf ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 1 of 16 original research digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health coverage jameel ismail ahmad1, murtala jibril2, barroon isma’eel ahmad3, abdurrahman suleiman4, nasir sani inuwa5, abdullahi garba ali6, salihu ibrahim ismail7 1. department of surgery, faculty of clinical sciences, bayero university kano/ aminu kano teaching hospital, kano, nigeria. 2. department of pharmacology and therapeutics, faculty of pharmaceutical sciences, bayero university, kano, nigeria 3. department of computer science, ahmadu bello university, zaria, nigeria 4. hubuk technology, zoo road, kano, nigeria 5. first monument city bank (fcmb), nigeria. 6. faculty of computer science and information technology, bayero university, kano, nigeria. 7. department of biochemistry, federal university dutse, jigawa state, nigeria corresponding author: jameel ismail ahmad mbbs, fwacs, mba; address: department of surgery, faculty of clinical sciences, bayero university kano, aminu kano teaching hospital, kano, nigeria; email: iajameel@yahoo.com ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 2 of 16 abstract introduction: the covid-19 pandemic highlighted the need for evolving an integrated healthcare ecosystem that will connect patients to digital and home healthcare to achieve universal health coverage. the survey aims to assess perceptions and preferences about digital and home healthcare services and develop an integrated healthcare ecosystem. methods: a survey of 254 nigerians was conducted to assess their awareness, preferences, and willingness to pay for digital and home healthcare services using electronic questionnaires, and the data were analysed using spss 16.0. results: males constituted 70.9%, and 61.4% were aged ≤35 years. two-third were clients, and a third were healthcare providers. although about 71% patronized public hospitals, there was poor satisfaction (31.7%) than those attending private hospitals that were more satisfied. the male gender, private hospital utilization, and age of ≤35 years were associated with the satisfaction with or 1.19 (95% ci 0.69-2.05), or 1.22 (95% ci 0.73-2.04), and or 2.41 (95% ci 1.384.20) respectively. thirty minutes was the acceptable delay in receiving care by most respondents. only 39.4% were aware of digital health, and 52.8% were aware of home healthcare. male gender was associated with dh awareness, while being a healthcare provider was associated with both dh and home healthcare awareness. the respondents' median amount was willing to pay for dh and hh respondents is $1.64 $6.56 and $3.28 – $6.56, respectively. conclusion: in response to the survey result, we designed an integrated hospital, digital, and home healthcare project named edokta, to leapfrog the attainment of universal health coverage in nigeria. keywords: digital health, home healthcare, universal health coverage, healthcare ecosystem ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 3 of 16 introduction nigeria is the most populous country in africa and is poised to become the third most populous in the world by 2050 (1). poverty, inequality, and poor access to health have kept the citizens' life expectancy low. the nigerian healthcare system is bedeviled with a lack of human resources, infrastructural and system challenges, which threaten the attainment of universal health coverage (uhc). to ameliorate that, nigeria developed a national health information communication technology (ict) strategic framework 2015-2020 with the vision: "by 2020 health ict will help enable and deliver universal health coverage in nigeria" (2). this strategic framework provides for the identification, prioritization, and application of appropriate icts that can strengthen the national health system. poor implementation of the framework led to poor results by 2020. one of the most essential strategies for improving the provision of quality health care to attain uhc in resource-constrained settings is the effective utilization of digital health (dh). digital health is defined as a system that connects and empowers people and populations to manage health and wellness, augmented by accessible and supportive provider teams working within flexible, integrated and interoperable, and digitally-enabled care environments that strategically leverage digital tools, technologies, and services to transform care delivery (3). it is also defined as the application of ict to advance health services delivery." the term dh is also used interchangeably with ehealth. the world health assembly (wha) recognized the role of dh in healthcare delivery in resolution wha 58.28 (2005): "ehealth is the cost-effective and secure use of ict in support of health and health-related fields including healthcare services, health surveillance, health literature, and health education, knowledge and research. mhealth is a subset of ehealth and involves providing health services and information via mobile technologies such as mobile phones, tablet computers, and personal digital assistants. dh is a tool for the achievement of goal 3 of the sustainable development goals by 2030, which is to "ensure healthy lives and promote well-being for all at all ages," particularly its article 8 to "achieve universal health coverage (uhc)" in ensuring people access quality healthcare without falling into financial catastrophes (4,5). the role of dh cut across healthcare financing, health service delivery, human resources training, health system support, and health information system. despite these potentials, dh implementation has taken a slow course, especially in many african countries. some of the challenges hampering its scaleup in many developing countries are issues bordering on usability, technology integration and interoperability, data security, and privacy, reliability, network access, affordability, acceptability, illiteracy, funding, trained human capacity, policy, and regulation (6,7). the application of dh in africa has gained momentum over the past decade, essentially due to the digital revolution brought about by the increasing penetration of mobile technology and internet use, which stood at 80.8% and 25.1% as of 2018. this is further enhanced by the proliferation of affordable smartphones, particularly from china (5). these factors have afforded a great opportunity, which could improve the ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 4 of 16 smooth launching of various dh platforms, but there is a need to understand enablers for their effective utilization. a feasibility survey was conducted to develop a sustainable dh platform that will facilitate the attainment of sdgs. the objectives of the study are to assess the respondents' perceptions about conventional hospital-based care; set awareness and preferences of dh and home healthcare; determine the willingness to pay for dh and hh services; and then develop an integrated healthcare ecosystem that will incorporate hospital-based, digital and home healthcare services to achieve uhc. methods an online survey to assess the awareness, preferences, and willingness to pay for nigerians' dh and home healthcare services was conducted in december 2019 electronically using google forms. (8) the data was automatically received, and a microsoft excel spreadsheet version of the data was generated. the data was then transferred and analysed using statistical product and service solutions (spss) 16.0. basic information, perceptions, and awareness of hospital based, digital, and home healthcare and their association to age, sex, status, and hospital being utilized was analyzed. results two hundred and fifty-four (254) respondents electronically filled the online questionnaire representing a response rate of 84.7%. the respondents include those living in all 36 states and the capital of nigeria. however, 69.7% were living in kano state. males constituted 70.9%, while 61.4% and 38.6% were aged ≤35 years and >35 years, respectively. the respondents include civil servants (40.2%), medical doctors (31.5%), traders/businesspersons (8.3%) and 11.4% were unemployed. others include other health workers, bankers, engineers, and software developers. healthcare providers constituted 36.2%, while clients were 63.8%. (table 1) table 1: respondents’ baseline characteristics over-all percentage % (n=254) age (years) ≤35 61.4(156) >35 38.6(98) sex female 29.1(74) male 70.9(180) status clients 63.8(162) providers 36.2(92) hospital being utilised private 28.7(73) ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 5 of 16 public hospitals were the most utilized by 71.3% of the respondents. the level of satisfaction is better with the private hospitals as 60.3% of the respondents were satisfied in contrast to only 31.7% who were satisfied with the public hospitals. younger age ≤35 years, male gender, and private hospital patronage were associated with reasonable satisfaction with or 1.22 (95% ci 0.73-2.04), or 1.19 (95% ci 0.69-2.05), and or 2.41 (95% ci 1.38-4.20) respectively. only a quarter of the respondents considered lack of trained staff, while delay in receiving care and poor staff attitude featured prominently by 74% and 63% of the respondents. lack of feedback from hospitals and health workers and lack of quality branded drugs are reasons for dissatisfaction by nearly a third of the respondents. thirty minutes was the acceptable delay in receiving care when sought for by 80% of the respondents. the dh awareness of the respondents was relatively low (39.4%) and male gender and being a healthcare provider associated with the awareness or 1.40 (95% ci 0.80-2.47) and or 1.40 (95% ci 0.83-2.36) (table 2). virtual booking for medical consultation, health education, and remote patient monitoring was the commonest dh services needed (figure 1). nearly two-thirds of the respondents preferred online dh services over mobile dh services, and 90.9% use android phones, while 8.3% use ios phones. more than half (52.8%) of the respondents were aware of home healthcare services which were significantly associated with respondents' status as healthcare providers, or 3.25 (95% ci 1.90-5.60) (table 3). approximately three-quarters (74.8%) of respondents believe it was operational, and 93.3% were willing to utilize the services. the home healthcare (hh) services needed include home consultation (81.3%), home delivery of purchased drugs (66.3%), and simple investigations (64.7%). other services include sample collection and delivery of results and nursing care. public 71.3(181) type of phone used ios 8.3(21) others 0.8(2) ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 6 of 16 figure 1: preferred digital health services by the respondents table 2: awareness of digital health and home healthcare digital health home healthcare awar e n=10 0 unaware n=154 or (95% ci) p-value awar e n=13 4 unaware n=120 or (95% ci) pval ue age (years) ≤35 57 99 0.74 (0.44-1.23) 0.291 78 78 0.75 (0.45-1.25) 0.3 02 >35 43 55 56 42 sex male 75 105 1.40 (0.80-2.47) 0.261 94 86 0.93 (0.54-1.60) 0.8 90 female 25 49 40 34 status provider 41 51 1.40 (0.80-2.47) 0.230 65 27 3.25 (1.90-5.60) 0.0 00 client 59 103 69 93 hospital patronized private 25 48 0.74 (0.42-1.30) 0.322 26 47 0.37 (0.21-0.66) 0.0 01 public 75 106 108 73 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% booking for medical consultation digital medical consultation digital health education remote patients monitoring ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 7 of 16 there is a remarkable willingness to pay for the dh and hh services. the median amounts the respondents were willing to pay for the digital booking for consultation, digital booking and physical consultation, digital booking and virtual consultation, and digital health education were $3.28 ($4.92), $6.56 ($6.56), $6.56 ($13.12) and $1.64 ($5.90) respectively. the median amounts (and interquartile range) the respondents were willing to pay for a home consultation, simple investigations, sample collection/results delivery, nursing care, and pharmaceuticals delivery were $6.56 ($13.12), $3.28 ($4.92), $3.28 ($4.92), $6.56 ($6.56) and $4.92 ($6.56) respectively. (table 3). table 3: willingness to pay for digital and home healthcare services in usd digital health services booking booking and physical consultation booking and remote consultation health education median (interquartile range) $ 3.28 (4.92) 6.56 (6.56) 6.56 (13.12) 1.64 (5.90) mean (sd)/$ 5.75 (±7.12) 8.98 (±9.06) 8.62 (±8.82) 5.60 (±21.90) home health services consultation basic investigations sample taking and results delivery nursing care pharmaceuticals delivery median (interquartile range) $ 6.56 (13.12) 3.28 (4.92) 3.28 (4.92) 6.56 (6.56) 4.92 (6.56) mean (sd)/$ 9.58 (±9.83) 6.76 (±32.05) 5.61 (±5.14) 8.64 (±12.03) 7.58 (±10.60) those younger than ≤35 years were more to pay a higher amount for digital booking, digital booking and physical consultation and health education with or:1.39, or:1.05, and or:1.38, respectively. at the same time, those patronizing private hospitals were more willing to pay for the digital booking and health education. females and those patronizing private hospitals were more willing to pay higher for all types of home healthcare services. at the same time, those older than 35 years were more willing to pay higher amounts for a home consultation, sample collection and results of delivery, nursing care, and pharmaceutical products. compared with the clients' willingness to pay for the services, healthcare providers were more willing to pay higher for all digital and home healthcare ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 8 of 16 services. (table 4). the healthcare providers' willingness to pay higher was more when the services involve consultation such as digital booking and physical consultation, digital booking and remote consultation and home consultation with or 2.31 (95% ci 1.363.91), or 2.21 (95% ci 1.30-3.78 ) and or 2.29 (95% ci 1.36-3.89) respectively. table 4: respondents willingness to pay higher than medium (wtph) and willingness to pay the medium and lower (wtpl) between healthcare providers and clients digital health services booking booking and physical consultation booking and remote consultation health education wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) providers 39(53) 1.51 (0.892.57) 46(46) 2.31 (1.36-3.91) 43(49) 2.21 (1.30-3.78) 43(49) 1.07 (0.641.79) clients 53(109) 1.00 49(113) 1.00 46(116) 1.00 73(89) 1.00 home healthcare services consultation basic investigations sample taking and results delivery nursing care pharmaceuticals delivery wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) wtph (wtpl) or (95% ci) providers 54(38) 2.29 (1.363.89) 46(46) 1.95 (1.153.28) 54(38) 1.49 (0.892.50) 41(51) 1.44 (0.862.43) 52(40) 1.12 (0.671.88) clients 62(100) 1.00 55(107) 1.00 79(83) 1.00 58(104) 1.00 87(75) 1.00 discussion the nigerian healthcare industry is pluralistically shared by the public and private sectors. although the public sector owns about 66% of the health facilities in nigeria, the private sector accounts for 70-75% of the total health expenditure (9). the public healthcare system is organized into primary comprising of primary healthcare services at the rural and community level, secondary consisting of general and specialist hospitals, and tertiary healthcare having the teaching hospitals and specialized medical centers. the private hospitals and clinics contribute significantly to nigeria's healthcare delivery all over the country (10). the healthcare budget is abysmally low as only 3.6% of nigeria's gdp was ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 9 of 16 spent on health, which translates to $14.6 billion in 2016. there is a considerable healthcare infrastructural gap and a massive brain drain of healthcare workers (11). it is estimated that about 3,000 new medical doctors are registered in nigeria annually. currently, nearly 2,000 doctors migrate from nigeria to other countries yearly, leaving a net of 1000 doctors and further widening doctors' deficit to about 260,000. nigerians spend an average of $1 billion on medical tourism annually abroad. nigeria has five hospital beds per 10,000 population (9,12). public hospitals' patronage remains high, with 71% of the respondents despite its poor satisfaction level (32%) when compared to private hospitals likely due to affordability factors. there is a higher satisfaction level (60%) among those who patronize private hospitals. there is evident worsening satisfaction of hospital services over the years compared to kano reports a decade ago by iliyasu et al. when the satisfaction level was 83% (13). the satisfaction level is lower than reports from different parts of nigeria and ethiopia (14–19). this could be attributable to infrastructural and personnel deficits despite an increasing population, bureaucracy, and ongoing disruption of healthcare services due to industrial actions by health workers. based on the perceived reasons for dissatisfaction, any intervention that will shorten the duration to receiving care within the first 30 minutes, teach an empathic and memorable staff attitude, provide access to quality drugs and ensure appropriate feedback will significantly improve clients' satisfaction. there is a need to enhance the satisfaction level, especially to the older respondents and females. the differential satisfaction between the public and private hospitals calls for studying and emulating the delivery of services in private hospitals so that the public hospitals could equally improve the satisfaction. digital health and home healthcare have the potential of filling these gaps. digital technology can facilitate healthcare delivery at different levels (system, center, professional and patient levels). supply chain management and an integrated platform for booking and payment can be facilitated at the system level. at the same time, the availability of remote patient monitoring and remote diagnostics can be improved at the center level. similarly, education/training and data collection and reporting will be relevant at an individual professional level. at the same time, health and wellness information and medical advice will affect patients' levels (20). the world health organization (who) classified dh interventions into interventions for clients, interventions for healthcare providers, interventions for a health system or resources management, and interventions for data services (21). dh improves access to health, quality of care and reduces healthcare costs through many applications that can contribute to sustainable development goals. these applications include electronic health records (ehr), telemedicine/telehealth, mhealth, elearning, the connection of medical devices via the internet of things (iot), and personal health using wearable devices (20,22,23). there is an unprecedented rise in teledensity, internet penetration, and social media usage globally, but more phenomenal in africa. there are 1.049 billion mobile users, 473 million internet users, and 216 million active social media users, representing 80%, 36%, and 17% pene ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 10 of 16 tration in africa (24). the available dh services in africa include mhealth, social media, telemedicine/telehealth, elearning, ehr, and big data analytics in order of preference (4,5). nigeria is strategically located to benefit from the digital economy. it accounts for about 47% of the west african population, and a half (about 100 million) of its population is under 30 years and is leading the continent in the economy (25). the country is also experiencing this trend of increasing mobile, internet, and social media penetration. according to the nigerian communications commission (ncc), the number of mobile phone subscriptions in nigeria was 176, 897, 879 (92.7% teledensity), while internet subscriptions were 122, 975, 740 (56% penetration) as of august 2019 (26). the number of smartphone users in nigeria is estimated to be 36 million (18.37% penetration). this could be attributed to an influx of low-priced smartphones (the average cost of smartphones decreased from $216 in 2014 to $95 in 2018). there are 24 million (12% penetration) social media users, and in 2018, 44% and 4% of mobile users use 3g and 4g technology, respectively, and the number keeps increasing (26,27). despite these potentials, nigeria was ranked 143rd among 176 countries on the ict development index (idd) in 2017. it did not feature among the top 16 countries on the ehealth priority ranking of sub-saharan african countries and is ranked 15th among the top 17 countries on the ehealth regulating readiness index. this is due to barriers such as infrastructure and device access challenges, funding, human resources capacity, and policies and government leadership (28,29). to establish sustainable digital health and other digital services, there is a need to build critical digital pillars such as digital infrastructure, digital platforms, digital financial services, digital entrepreneurship, and digital skills and literacy (25). covid-19 has brought the role of telehealth during the pandemic and beyond all over the world to the fore. mckinsey conducted covid-19 consumer surveys in april and may 2020, which showed an apparent increase in the adoption of telehealth services in the usa. telehealth usage was 11% in 2019, which increased, and 76% were interested in using telehealth with a 50-175 times increase in the number of telehealth visits and 80 new telehealth services approved by the centers of medicare and medicaid. precovid-19, the total annual revenue of telehealth players was estimated at $3 billion and postulated that up to $250 billion of current us healthcare spending could be virtualized (30,31). the dh awareness of the respondents was low (39.4%), even though this level of awareness could have improved after the covid-19 pandemic when some dh services were used to provide virtual medical care. the result calls for creating more awareness amongst females and clients. access to booking for consultation is a challenge, especially for rural dwellers. a window for remote booking for a medical consultation is needed, as indicated by the respondents, in addition to virtual medical consultation, health education, and remote patient monitoring. the preference for online over mobile dh services point to an interesting scenario despite mobile technology penetration being better than internet penetration. this and the preponderance of android phones should guide any dh platforms in software development and technology deployment. currently, most ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 11 of 16 home healthcare services are offered at the individual and informal level, and there is a need to coordinate the services to ensure quality, reliability, and interoperability with other dh services. home antenatal care, immunizations, management of chronic diseases including hiv-aids are low-hanging fruits to consider for hhs. there is a need for a massive hhs awareness campaign targeted at clients and those patronizing private hospitals. our findings show that there is a notable willingness to pay for the dh and hhs. although the amount the respondents were willing to pay for both services in this study seems low, it is significant when related to the prevailing minimum wage of $50 per month. it might increase after experiencing their value and advantages. the potential early adopters of dh with the willingness to pay higher will be the healthcare providers, younger clients, and those patronizing private hospitals and should be the first marketing targets. gradual engagement of older respondents and public health users will expand the dh market base. females will likely adopt hhs early, especially since they attend hospitals more frequently to seek care for themselves or their children and hence face the challenges more. healthcare providers' willingness to pay higher for the digital and healthcare services could likely be due to their exposure to healthcare delivery and challenges, bias because they were potential beneficiaries for the payment, and possible higher disposable income than the clients. in response to the above data, a team (comprising two medical specialists, a biochemist, three it experts, and a financial expert) developed an integrated (hospital-based, digital, and home healthcare) healthcare ecosystem and named it edokta. it was designed to provide hospital-based care, telemedical care, home healthcare, diagnostic and pharmaceutical services, remote patient monitoring, health education, medical education, and universal medical identity services. it is aimed at removing barriers to accessing healthcare by providing virtual access to healthcare providers using mobile and internet technology for personalized, seamless, and quality care by patients and expand the providers' customer base and returns. the critical disruptions are the local content via the inclusion of local languages and the onestop health solution nature of our services. it has a potential for facilitating dh innovations such as drones (for delivery of medical supplies to difficult terrains), big data (for managed care, disease prediction, and more accurate treatment), artificial intelligence-ai (for workflow management, precision in diagnosis and treatment aid) and iot (for remote patients monitoring). some of our key partners include specialists, hospitals, diagnostic centers, pharmaceutical shops, mobile telecommunication companies, governments, and non-governmental agencies. the telemedicine software is developed, and more than 1,000 patients benefit from free consultation during the covid-19 lockdown. the entire edokta project will be launched in may 2021. conslusion the digital and home healthcare ecosystem is a new frontier for healthcare globally and is gradually being applied in africa especially following the covid-19 pandemic. ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 12 of 16 the growing dissatisfaction with the current hospital-based healthcare system, the massive health workers' brain drain, and the unequal distribution of health personnel and infrastructure threaten the attainment of universal health coverage in nigeria and thus pave the way for introducing dh and home healthcare services. our attempt at translating dh and home healthcare survey to real life (edokta) is on the verge of debuting, gal vanizing the triple helix collaboration between government, research institutes, and industry to develop a sustainable healthcare ecosystem by utilizing digital technology to leapfrog the attainment of uhc in africa. acknowledgement i, jameel ismail ahmad, acknowledge the mentorship offered to me by professor modest mulenga, chair of the tdr joint coordinating board. references 1. united nations. world population prospects 2019 highlights [internet]. newyork; 2019. available from: https:/population.un.org/wup/publications/files/wup 2018-key facts.pdf 2. federal ministry of health. national health ict strategic framework: 2015-2020 [internet]. 2016. available from: https://www.who.int/goe/policies/nigeria_health.pdf?ua=1 3. himss unveils the digital health indicator to measure health system progress toward a digital health ecosystem [internet]. [cited 2020 nov 21]. available from: https://www.himss.org/news/himssunveils-digital-health-indicatormeasure-health-system-progress-toward-digitalhealth?_ga=2.187911660.512109590 .16059468541216353937.1605946854 4. tran ngoc c, bigirimana n, muneene d, bataringaya je, barango p, eskandar h, et al. conclusions of the digital health hub of the transform africa summit (2018): strong government leadership and public-private-partnerships are key prerequisites for sustainable scale up of digital health in africa. bmc proc [internet]. 2018 aug 15;12(s11):17. available from: https://bmcproc.biomedcentral.com/articles/10.1186/s12919-018-0156-3 5. w h o global observatory for ehealth. global diffusion of ehealth: making universal health coverage achievable: report of the third global survey on ehealth [internet]. world health organization; 2016. available from: https://www.who.int/goe/publications/global_diffusion/en/ 6. sam ajadi. digital health a health system strengthening tool for developing countries [internet]. 2020. available from: www.gsma.com/mobilefordevelopment 7. nsor-anabiah s, udunwa u ms. review of the prospects and challenges ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 13 of 16 of mhealth implementation in developing countries. int j appl eng res. 2019;14(12):2897–903. 8. googleform questionnaire. available from: https://docs.google.com/forms/d/e/1f aipqlsflnezi0yt_v_87zftbmmz7mvkr2zftwfvrlxm94yalpdoba/viewform?usp=sf_link 9. corporation if. the role of the private sector in expanding health access to the base of the pyramid. 2010; 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available from: https://healthmarketinnovations.org/sites/default/files/chmi 21. world health organization. classification of digital health interventions [internet]. 2018. available from: https://www.who.int/reproductivehealth/publications/mhealth/classification-digital-health-interventions/en/ 22. olu oo, muneene d, bataringaya je, nahimana m-r, ba h, turgeon y, et al. how can digital health contribute to sustainable attainment of universal health coverage in africa? a perspective. front public heal. 2019;7:341. 23. fowkes j, fross c, gilbert g, harris a. virtual health : a look at the next frontier of care delivery. mckinsey insights [internet]. 2020;(exhibit 1):1–11. available from: https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/virtual-health-alook-at-the-next-frontier-of-care-delivery#%0ahttps://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/virtual-health-a-look-at-the-n 24. kemp s. digital 2019: global internet use accelerates [internet]. 2019 [cited 2020 nov 17]. available from: https://wearesocial.com/blog/2019/01/digital-2019global-internet-use-accelerates 25. nigeria digital economy diagnostic report [internet]. washington, dc; 2019. available from: https://www.google.com/search?q=n igerian+digital+economy+diagnostic+report+2019+world+bank&rlz =1c1okwm_enng893ng893&oq =nigerian+digital+economy+diagnostic+report+2019+world+bank&aqs =chrome..69i57.23968j0j7&sourceid =chrome&ie=utf-8# 26. nigerian communications commission. industry statistics [internet]. [cited 2019 jul 19]. available from: https://www.ncc.gov.ng/statistics-reports/industry-overview 27. kolawole o. nigeria mobile report 2019 [internet]. 2019 [cited 2020 nov 17]. available from: https://www.jumia.com.ng/sp-mobile-report/ 28. ict development index 2017 [internet]. 2018. available from: https://www.itu.int/net4/itud/idi/2017/index.html 29. strategic partnership digital africa. digital health ecosystem for african countries: a guide for public and private actors for establishing holistic digital health ecosystems in africa [internet]. 2018. available from: https://www.bmz.de/en/publications/topics/health/materilie345_digital_health_africa.pdf 30. united states agency for international development. trends in digital health in africa : 2016;(september):1–7. available from: http://www.africanstrategies4health.org/uploads/1/3/5/3/13538666/trends_in_di gital_health_in_africa_brief_final.pdf ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 15 of 16 © 2021 ahmad; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 31. bestsennyy o, gilbert g, harris a, rost j. telehealth: a quarter-trillion-dollar post-covid-19 reality? mckinsey company publ may [internet]. 2020;29. available from: https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality __________________________________________________________________________ ahmad ji, jibril m, ahmad bi, suleiman a, inuwa ns, ali ag, ismail si. digital and home healthcare survey among nigerians: assessing awareness, preferences, and willingness to pay for an integrated healthcare ecosystem to achieve universal health cover-age (original research). seejph 2021, posted: 27 may 2021. doi: 10.11576/seejph-4471 page 16 of 16 berisha m, ramadani n, basholli fm, jerliu n, humolli i, tahirukaj a, et al. self-assessment of essential public health operations in kosovo (original research). seejph 2022, posted: 11 may 2022. doi: 10.11576/seejph-5458 p a g e 1 | 13 original research self-assessment of essential public health operations in kosovo merita berisha1,2, naser ramadani1,2, florie miftari basholli1,2, naim jerliu1,2, isme humolli2,3, ardita tahirukaj3, maria maraokuli4, jose m. martin-moreno5 1 national institute of public health of kosovo, prishtina, kosovo; 2 medical faculty, university of prishtina “hasan prishtina”, prishtina, kosovo; 3 who pristina office, pristina, kosovo; 4 consultant, health systems and public health, who regional office for europe; 5 dep. of preventive medicine and public health, medical school and incliva, university of valencia, spain; senior adviser, health systems and public health, who regional office for europe. corresponding author: naser ramadani, md, msc, phd; address: national institute of public health of kosovo, str. instituti shëndetësor, nn., 10000 prishtina, kosovo; e-mail: naser.ramadani@uni-pr.edu berisha m, ramadani n, basholli fm, jerliu n, humolli i, tahirukaj a, et al. self-assessment of essential public health operations in kosovo (original research). seejph 2022, posted: 11 may 2022. doi: 10.11576/seejph-5458 p a g e 2 | 13 abstract aim: the national institute of public health of kosovo (niphk) considered the challenge of assessing the availability and performance of critical public health services in kosovo. to this end, support was requested from the world health organization (who) european regional office, through the who office in pristina, for an action-oriented process. the systematic process of the self-assessment of public health operations aimed to generate sufficient empirical evidence to identify the strengths and weaknesses of the country’s health services and functions to provide recommendations for future public health actions in kosovo. methods: the niphk team followed the systematic self-assessment methodology of the essential public health operations (epho) model that the who’s regional office for europe developed. the appraisal was conducted throughout 2018 and the first quarter of 2019 and involved a broad spectrum of public health actors. it also followed a participatory, interdisciplinary, and inter-sectoral approach. it was developed in three phases: preparation and collection of information, analysis and interpretation of the data, and critical recommendations for the kosovo health authorities’ consideration. results: the assessment resulted in an overall score of 48% sufficiency for the set of public health operations (core and enablers). the most in need of development were epho 6, which is related to governance (only 20% of what is needed in this dimension as a whole), followed by epho 3, which considers vital aspects of health protection (35%), and epho 10, which is related to research capacities (40%). based on the epho assessment results, the specialized teams developed a set of priority recommendations to strengthen the implementation of the ephos in kosovo. conclusion: the self-assessment revealed that, despite ongoing initiatives and measures to strengthen public health, the application of ephos has much room for improvement. we believe that decisionmakers can use this method and the findings that it reveals to implement the most effective interventions to protect and promote the population’s health. in addition, the methodology and experience can be used for educational and training purposes. keywords: disease prevention, epho, health promotion, health protection, kosovo, participatory approach, public health. acknowledgments: we acknowledge the work of the national working group, participating experts, and institutions in the epho assessment process, without which the self-assessment exercise would not have been possible. we thank the members of the who’s regional office for europe and the who’s office in pristina for assisting in the work of the national working group by providing expertise and logistical support. we also thank professor laura e. cruz for her contribution to the english editing of this paper. sources of funding: work regarding the self-assessment was funded by the who’s regional office for europe, the who’s office in pristina, the national institute of public health, and the ministry of health of kosovo. berisha m, ramadani n, basholli fm, jerliu n, humolli i, tahirukaj a, et al. self-assessment of essential public health operations in kosovo (original research). seejph 2022, posted: 11 may 2022. doi: 10.11576/seejph-5458 p a g e 3 | 13 conflicts of interest: the authors of this article were part of the national working group for the selfassessment process. the first author (mb) received a consultancy fee from the who for coordinating, collecting, and analyzing the data required for the assessment reported in this article. the co-author (mm) received a consultancy fee through a professional assignment from who. the last author (jmm) also played a consulting role through a professional assignment from who. disclaimer: the authors alone are responsible for the views expressed in this publication, and they do not necessarily represent the decisions or policies of the who. berisha m, ramadani n, basholli fm, jerliu n, humolli i, tahirukaj a, et al. self-assessment of essential public health operations in kosovo (original research). seejph 2022, posted: 11 may 2022. doi: 10.11576/seejph-5458 p a g e 4 | 13 introduction kosovo has the youngest population in europe, with an average age of 30.2 years (1) and a life expectancy of 76.7 years (74.1 years for men and 79.4 years for women). furthermore, the overall unemployment rate is very high (reaching 27.5%), with youth unemployment reaching 52.4%. kosovo also has the highest female unemployment rate in europe at 31.8%. kosovo’s healthcare system is divided into three levels: primary healthcare (phc), secondary healthcare (shc), and tertiary healthcare (thc) services. the phc portfolio includes health promotion, prevention, early detection, diagnosis, treatment, and rehabilitation and deals with diseases, disorders, and injuries. shc services, on the other hand, include hospital care services and out-of-hospital services covering diagnosis, therapy, rehabilitation, and emergency transport, as well as public health coordination and protection services. finally, thc services are provided by health institutions that offer the most organized health activities, university teaching, undergraduate and postgraduate training, and research activities (2). the national act 06/l-133 on budget allocations for 2019 shows that the health sector received 10% of the total government budget, with the largest allocation (51%) given to the hospital and university clinical service of kosovo (hucsk). overall, the total budget allocated for public health in kosovo is comparable to other countries with similar gdp levels. environmental pollution has had a significantly negative impact on the population’s health in kosovo, and it is estimated that its cost is higher than all investments made for health in kosovo each year (3). for example, the prevalence of smoking is relatively high compared to other eastern european countries, with 25.7% of the population reported as smokers according to the steps survey (2019, kosovo), which outlines the expected impact of increased incidences of smoking-related diseases (4). during the last decade, several significant improvements have been achieved in kosovo, including decrease of infant mortality (10.6‰ in 2018) and perinatal mortality (11.2‰ in 2018), decrease in prevalence of infectious diseases, especially tuberculosis, eradication of poliomyelitis and other (5). nevertheless, the analysis provided in the health sector strategy (hss) of the ministry of health, but also other recent analyses, highlight that kosovo, needs to tackle a number of fundamental challenges before the health sector becomes a comprehensive system of preventive, diagnostic and treatment services attuned to the needs of the population and supporting the citizens in obtaining a health status comparable to the eu populations. to address these public health challenges in an operational manner, approaches based on models that systematically structure essential public health functions and services have been followed in different regions and countries of the world (6). specifically, the framework provided by the socalled “essential public health operations” (ephos), designed and adapted to the needs of the european region with world health organization (who) leadership and support, have proven to be practical instruments for promoting a harmonized understanding of public health, both within and outside of the health sector (7). this tool can strengthen the dialogue regarding the advantages and disadvantages present in public health, help to generate health policy options and recommendations for public health reform, and contribute to the development of public health policies, while it can also be used for educational purposes. the process of assessing the ephos serves as a tool for renewing public health services in line with the precepts of health 2020 (9) and the european action plan for strengthening public health capacities and services (14). the national institute of public health of kosovo (niphk) considered the challenge of berisha m, ramadani n, basholli fm, jerliu n, humolli i, tahirukaj a, et al. self-assessment of essential public health operations in kosovo (original research). seejph 2022, posted: 11 may 2022. doi: 10.11576/seejph-5458 p a g e 5 | 13 assessing the availability and performance of critical public health services in kosovo. to this end, in 2017, support was requested from the world health organization (who) european regional office, through the who office in pristina, for an action-oriented process. the systematic process of the self-assessment of public health operations aimed to generate sufficient empirical evidence to identify the strengths and weaknesses of the country’s health services and functions to provide recommendations for future public health actions in kosovo. the specific objectives of this first epho assessment process in kosovo were to: achieve a shared understanding of what services are encompassed by “essential public health operations”; generate the empirical evidence necessary to identify strengths and weaknesses and substantiate key recommendations for future action; and foster a consensus on priority recommendations and translate the output of the process into actionable recommendations. methods the process of assessing the ephos in kosovo involved a broad spectrum of public health actors, including representatives of the niphk and other governmental and non-governmental institutions, referred to as the specialized teams for each epho, as well as other consultants. further, it followed a participatory and systematic approach. it was comprised of three phases: preparation, data gathering and analysis, and key recommendations. the constitutive meeting of the steering committee was held on december 1, 2017, followed by a three-day workshop on the selfassessment epho process held from december 6 to 8, 2017. relevant ministries and institutions nominated the specialized team members, who performed the epho self-assessment process. in kosovo, the niphk led the process in close coordination with the who office, and the process ran from december 2017 through to july 2019. once the data had been entered into the online self-assessment tool, a long process of meetings, workshops, and coordination per who methodology and principles ensued, following which recommendations were formulated. the next step was to organize the recommendations in terms of priority and achieve consensus thereupon, a process that took place in may 2018. led by a team of international experts from the who regional office, a series of workshops took place with each of the epho specialized teams. following this series of focus workshops, the facilitators chose to convene a two-day final prioritization workshop with the members of the oversight committee to organize the top recommendations in terms of priority across all ephos. the group also agreed on the next steps in the process toward action planning. the final workshop with all specialized teams, members of the steering committee, and relevant stakeholders was held on november 21 and 22, 2018, to prepare a final draft of the outcomes and discuss the conclusions from the assessment process with high-level officials who played key roles in implementing the priority recommendations across various sectors. partnership meetings to discuss the niphk’s plan for strengthening public health services were held in prishtina on december 6 and 7, 2018. the final draft was compiled in 2019 (see figure 1). during this period, numerous meetings and workshops were held with ten sub-working groups of epho, including all relevant stakeholders, partners, and governmental and non-governmental organizations (see figure 1). during the launch workshop, members of the specialized teams have performed a “first pass” assessment, where they filled the online tool (the respective sections of the questionnaire that the specialized team members were nominated for completion). berisha m, ramadani n, basholli fm, jerliu n, humolli i, tahirukaj a, et al. self-assessment of essential public health operations in kosovo (original research). seejph 2022, posted: 11 may 2022. doi: 10.11576/seejph-5458 p a g e 6 | 13 for the self-assessment process, the electronic version of the self-assessment tool for the evaluation of essential public health operations in the who european region (7) was used. during the completion of the questionnaire (electronic self-assessment tool) participants had the possibility to answer with yes or no, in certain questions. otherwise, the answer should be a brief description of the item in question, with pertinent details as required. whenever possible, quantitative data should be provided, but qualitative responses are also possible. other ways to answer the questions were as follows: “idu”: i do not understand the question; “idk”: i understand the question but do not know the answer; “n/a”: not applicable to the national context. scoring system each suboperation contained in the list of ephos contained one or more scoring fields, in which evaluators can note the score (0–10) achieved and recommend areas for improvement (“g”: governance; “f”: financing; “rg”: resource generation, including human resources, medicines and technology and/or information and technological research; “sd”: service delivery). the scores should be assigned from 0 to 10 based on the following criteria. 0. we are unable to evaluate the performance of this operation based on the information currently available. 1. no activity: this operation/service is completely undeveloped at this time. 2. rudimentary work has been performed to improve the effectiveness of this operation, but a stronger framework and/or mandate is necessary to develop the basic foundations and to implement the programme or activity effectively. 3. there is an explicit commitment in a formal strategy document expressing the will to further develop this operation, but no practical developments have been carried out yet. 4. there are some antecedents for actions to improve this operation, but they have been inconsistent and require a better approach. 5. there is a conceptual framework to improve this operation, with some actions that can be considered adequate, but these are preliminary and still require development. 6. we have specific experience and evidence that allows us to identify a few strong points, as well as other areas in need of improvement. 7. the performance of this operation is reasonably acceptable, based on accumulated experience, but there are still some areas in need of particular work. 8. the performance of this operation is solid and well developed within the area of public health, although there are isolated areas that could still be improved. 9. a body of evidence shows that this operation is particularly effective; no significant problems need correction as performance is quite positive. 10. the development of this operation is excellent, based on independent and objective evidence. we believe that it could be a useful model for other countries; there may be international benchmarking studies that support its status to be proposed as a best practice for the who european region. the designated areas for improvement are based on the four health system framework functions, but may be further broken down into the following building blocks: “g”: governance; “f”: financing; “rg”: resource generation, including human resources, medicines and technology and/or information and technological research; “sd”: service delivery. this field is included to spark a preliminary reflection on which areas are most in need of concerted action to improve performance of the operation. the item is systematically included under all suboperations, with the understanding that all these functions may play a role, even in operations that initially seem to be concentrated under only one function (for example, one challenge related to governance may be that the berisha m, ramadani n, basholli fm, jerliu n, humolli i, tahirukaj a, et al. self-assessment of essential public health operations in kosovo (original research). seejph 2022, posted: 11 may 2022. doi: 10.11576/seejph-5458 p a g e 7 | 13 ministry of health does not receive enough funding to carry out its duties). the specialized team members were able to exchange with each other on the spot about difficulties/dilemmas they encounter, raise issues, share perspectives, and receive coaching. figure 1. timeline of the self-assessment process in kosovo results the country scored 48% overall on the selfassessment (see figure 2). the assessment indicated that kosovo’s health system scored the lowest in governance, as described in epho 6 (20%), followed by the risk factors described in epho 3 (35%) and research in the field of public health described in epho 10 (40%). observation of the population’s health and wellbeing, as described in epho 1, falls under the responsibility of several institutions in kosovo. however, the health information system (his) is highly fragmented; data and documentation regarding the population, minorities, regional areas, and the private sector are lacking, and the country does not have a universal electronic medical record system. resulting from the assessment of epho 1, the primary recommendations were to review and update the health information strategy and establish population-based registries for noncommunicable diseases (diabetes, cardiovascular diseases). the primary goal of epho 2 is to enable health institutions to monitor and strengthen responses to public health emergencies, evaluate postemergency actions at an organization or systemwide levels, and take corrective action to ensure that competent health service delivery is available for people directly affected by an emergency. the specialized teams found that it is necessary to have a response plan that outlines the coordination of activities and sharing of tasks among the relevant institutions at all levels of health care and includes the development of a risk communication guide for emergency situations. kick off • steering committee, december 2017 • workshop launch of ehpo process, december 2017 prioritiza -tion • prioritization workshop with who experts, may 2018 • final workshop on epho outcomes, november 2018 policy dialogue • policy dialogue, december 2018 action plan • action plan initiated, february 2019 • action plan finalized, july 2019 berisha m, ramadani n, basholli fm, jerliu n, humolli i, tahirukaj a, et al. self-assessment of essential public health operations in kosovo (original research). seejph 2022, posted: 11 may 2022. doi: 10.11576/seejph-5458 p a g e 8 | 13 figure 2. results of the epho self-assessment process in kosovo epho 3 aims to supervise the enforcement and control of activities for the minimization of exposure to health hazards to protect the population, including ensuring environmental, occupational, toxicological, food, and other safety measures in the country. the ministry of health, in close coordination with the niphk, the ministry of environment and spatial planning, the ministry of transport, the food and veterinary agency, and other relevant stakeholders, found that an inter-ministerial committee for health protection, including environmental, occupational, food, and other safety measures, should be established to address the current deficiencies in this area. the development of a strategy for health protection, including environmental, occupational, food, road, patient, and consumers’ safety, should incorporate definitions of the roles and responsibilities of each institution and evidencebased data for direct intervention and prevention activities and a commitment to monitoring and evaluating tools for its implementation. the implemented strategy should enhance the sustainability of health protection by focusing on environmental, occupational, and food safety and related factors. epho 4 aims to develop programs that address challenges regarding healthy eating and food control systems. this assessment area relies on 48% 40% 54% 78% 46% 20% 45% 53% 35% 45% 67% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 11. all ephos 10. advancing public health research to inform policy and practice 9. information, communication and social mobilization for health 8. assuring organizational structures and financing 7. assuring a competent public health workforce 6. assuring governance for health 5. disease prevention, including early detection of illness 4. health promotion, including action to address social determinants and health inequity 3. health protection, including environmental, occupational and food safety and others 2. monitoring and response to health hazards and emergencies 1. surveillance of popullation health and wellbeing berisha m, ramadani n, basholli fm, jerliu n, humolli i, tahirukaj a, et al. self-assessment of essential public health operations in kosovo (original research). seejph 2022, posted: 11 may 2022. doi: 10.11576/seejph-5458 p a g e 9 | 13 the vision that all of kosovo’s future population will be physically active and will live, work, and play in environments that both promote and support healthy lifestyles and mitigate diseases, injuries, and negative behaviors. an important element of promoting healthy lifestyles in kosovo is limiting tobacco consumption. the ministry of health drafted kosovo’s law on tobacco control 04/l-156, which was implemented in 2013. the global youth tobacco survey (gyts), conducted in 2004 and repeated in 2016, showed a decrease in the number of people aged 13–15 years who smoke, although the implementation is incomplete. to implement the health promoting schools program aimed at maintaining the health of pupils and creating a healthy lifestyle, the drafting of an administrative instruction for healthy nutrition in educational institutions of pre-university was initiated. the introduction of the concept of “healthy settings” derived as a priority action from the assessment process. a healthy setting refers to a social context in which a range of individuals with distinct roles engage with, in their daily activities (8). further to this, under epho 5, the two primary recommendations were to develop a national screening program for rare diseases and the early detection of congenital malformations and certain specific diseases and develop a national plan for a palliative care system. the national screening program’s main goal was to build a system for the early detection of congenital anomalies, as well as to propose and take specific measures to address these (surgical correction, early treatment of functional problems, etc.). an inter-institutional collaboration between public health institutions and healthcare facilities exists concerning population-based information campaigns, but it is not permanent. the assessment process identified several significant gaps: there are targeted activities related to health promotion, but there is no information system to monitor either disease burden patterns or access to and quality of health services for migrants, ethnic minority populations, and homeless people. there is no legislation in place that protects the financial and social rights of informal caregivers, nor are their interventions in place to address the stress that formal and informal caregivers experience. unfortunately, there are also no training programs in place for training volunteers and family caregivers. in prisons, which act as primary healthcare providers for incarcerated populations, health promotion activities for specific communicable diseases are present, but there are no services available for the stress management of prison workers. the process of rehabilitation within personalized patient care plans has not been developed and is not functional yet. the development of health policies to support tertiary rehabilitation is, thus, an urgent need. in the context of palliative care, no institution offers services for pain management, nor is health care linked with psychosocial services or related health services (e.g., nutritional counseling, smoking cessation therapies). the ministry of health launched the health sector strategy 2017–2021 in march 2017. the health sector strategy 2017–2021 was designed to develop a vision and strategic approach in the context of the ongoing health sector reforms in kosovo (epho 6). in this assessment area, the ministry of health is encouraged to enhance its participation and active involvement in international health initiatives regarding the public health agenda of the country. the goal of the recommendation for epho 7 is to enable the proper planning, analysis, and berisha m, ramadani n, basholli fm, jerliu n, humolli i, tahirukaj a, et al. self-assessment of essential public health operations in kosovo (original research). seejph 2022, posted: 11 may 2022. doi: 10.11576/seejph-5458 p a g e 10 | 13 distribution of the public health workforce as per population needs. the focus is on empowering primary healthcare providers, decentralizing services at the local level, and legalizing the private sector. although kosovo has the youngest population in europe, there are no recruitment or retention strategies to prevent younger generations from leaving the country to pursue better opportunities outside kosovo. the goal of epho 8 is to enable the proper planning, analysis, and implementation of public health insurance that offers accessible and quality healthcare services in the country. public health insurance will then insure the population against the costs of health care. however, the health insurance law has still not been implemented in kosovo. good communication with the public at the right time and the right place is linked with epho 9. lack of a comprehensive action plan for communication activities that incorporates the use of multiple channels and low-cost media outlets was found. epho 10 covers research, which is fundamental to informing policy development and service delivery, including research to expand the knowledgebase that supports evidence-based policymaking at all levels; the development of new research methods, innovative technologies, and solutions in public health; and the establishment of partnerships with research centers and academic institutions to conduct timely studies that support decision-making at all levels of public health. within the niphk, the epidemiologic surveillance system collects data on communicable diseases. existing evidence (epidemiologic and health system data) is then used for decision-making regarding health system priorities. non-communicable chronic diseases are surveilled as well. there is a legal framework for scientific research activities in kosovo (act no. 04/l-135 on scientific research activities), which regulates the establishment, activity, organization, governance, rights, and obligations of scientific workers and researchers; the position of the national science council and the approval and implementation of the national science program; the financing of the bases of scientific research activity; and other issues regarding scientific research activities in kosovo. at the conclusion of the epho assessment process in kosovo, in line with the implementation of the health sector strategy 2017–2021, as well as the who’s health 2020 objectives (9), the action plan was developed. the self-assessment process in kosovo resulted in the prioritization of ten top recommendations (out of twenty) for priority actions derived from the assessment process: review and update the health information strategy. develop an action plan for emergency healthcare services and public health, which is the 8th function of the national reaction plan. establish an inter-ministerial committee for health protection, including environmental, occupational, food, and other safety measures, which also protects people from air pollution by, for example, reducing air pollution from transport in the municipality of prishtina. introduce the concept of “healthy settings”. develop a national action plan for noncommunicable diseases. begin the governmental implementation and enforcement of laws and strategies regarding tobacco, drugs, reproductive and sexual health, mental health, etc., related to the health of the population. begin strategic planning regarding human resources in the health sector. revise and implement the law for health insurance. draft the new communication strategy for public health. develop a national strategy regarding mainstream of public health research. berisha m, ramadani n, basholli fm, jerliu n, humolli i, tahirukaj a, et al. self-assessment of essential public health operations in kosovo (original research). seejph 2022, posted: 11 may 2022. doi: 10.11576/seejph-5458 p a g e 11 | 13 discussion the self-assessment revealed that, despite ongoing initiatives and measures to strengthen public health, kosovo still faces significant challenges in implementing the ephos and the application of ephos has much room for improvement. the assessment process generated the empirical evidence necessary to identify strengths and weaknesses and substantiated key recommendations for future action. following the self-assessment process, an action plan was developed, focusing mainly in addressing the priority actions derived from it. in regard to specific priority recommendations, i.e. the assessment process revealed that it is crucial to establish a strong his to enable the systematic and timely collection of data, as well as the analysis of health-related data, required for the planning, implementation, and evaluation of the health status of the population. a his capable of generating the information required for monitoring the population’s health and with strong inter-institutional cooperation, can monitor trends and track indicators that need to be reported to the who, cdc, eurostat, and other related entities. in order to monitor and strengthen responses to public health emergencies the development of a specific action plan for emergency healthcare services and public health, the 8th function of the national emergency plan, is needed. further to this, the introduction of the concept of “healthy settings” which include schools, work sites, homes, markets, hospitals, villages and cities, would serve to the engagement of a wide range of individuals with distinct roles, in their daily activities. this social context is shaped by a variety of factors, such as environmental, organizational, and personal, which interact with each other to affect overall health and wellbeing (8). the national program on nutrition for children aged 5–18 years and the national plan on physical activity in kosovo are also identified as priority recommendations from the epho. the development of a national screening program for rare diseases and development of a national plan for a palliative care system are considered very important to build a system for early detection of congenital anomalies, as well as efficiently response to the rising burden of chronic diseases and the aging population in the country. encouragement of the ministry of health to enhance its participation and active involvement in international health initiatives regarding the public health agenda of the country will take guide toward improvement in the general population’s health, which depends on the quality and preparedness of the public health workforce too. this last is, in turn, dependent upon access to high-quality education and training. therefore, investing in the continuous professional development of the public health workforce is a basic factor in the delivery and implementation of public health services. this is an especially compelling issue in kosovo. compared to the european region, the country has an insufficient number of doctors and nurses. the number of doctors per 100,000 inhabitants in kosovo is the lowest in the region. in 2009, kosovo had around 111 doctors compared to the eu’s 320, albania’s 115, macedonia’s 255, montenegro’s 199, and serbia’s 204 (13). strengthening new profiles for degree specializations in public health is needed per eu directives, and these changes need to be reflected and supported with new curricula at the university level, i.e., in the faculty of medicine. strong financial support and operationalization of the public health insurance system in kosovo, combined with a good communication plan and strong strategy regarding public health research will support needed evidence-based policymaking at all levels. considering the findings of the epho assessment process in kosovo, it can be concluded that almost similar challenges were also identified with the self-assessment ephos, berisha m, ramadani n, basholli fm, jerliu n, humolli i, tahirukaj a, et al. self-assessment of essential public health operations in kosovo (original research). seejph 2022, posted: 11 may 2022. doi: 10.11576/seejph-5458 p a g e 12 | 13 in macedonia, the first country in the region where this type of self-assessment process was performed. many improvements are needed, including addressing the lack of inter-sectoral cooperation and coordination, as well as considering and developing further responsibilities for all parties involved in public health. even though the developed strategies and documents are in line with international global health development objectives, there is a lack of quantitative and qualitative indicators (health metrics) or published papers, as well as a lack of information flow, which are needed for public health policy formulation and evaluation this kind of experience could also contribute to strengthening the collaboration and partnerships among south-eastern european (see) countries to improve the health of the population in the region (10). in another country in the eu, slovakia, the selfassessment of the public health system provided a positive example of collaboration between the who’s regional office for europe and a member state. the final self-assessment report has laid the foundation for major changes in the slovakian public health system (11). to understand the value of investing in this public health exercise, one only needs to consider how the "essential public health operations" framework has proven to be determinant in tackling the challenge of the covid-19 pandemic (12). conclusions the self-assessment revealed that, despite ongoing initiatives and measures to strengthen public health, the application of ephos has much room for improvement. we believe that decision-makers can use this method and the findings that it reveals to implement the most effective interventions to protect and promote the population’s health. although the final selfassessment report has not yet led to major changes in the public health system, it does serve as a foundation for future evidence-based changes. it is the most comprehensive evaluation report of the existing healthcare system, and it should be used by all relevant health and nonhealth stakeholders to implement the proposed changes. in addition, the methodology and experience can be used for educational and training purposes. the self-assessment of the public health system of kosovo, also, provides a positive example of collaboration between the who’s regional office for europe and relevant health and non-health stakeholders in kosovo. references 1. kosovo agency of statistics (kas). statistical yearbook of the republic of kosovo 2020. prishtina: kosovo agency of statistics; 2020. available from: https://ask.rksgov.net/media/5641/vjetari-2020-finalper-web-ang.pdf (accessed: february 8, 2022). 2. arënliu qf, koçinaj bm. kosovo transition in health and health care in prishtina. kosovo: kosovo school of public health; 2010. 3. world bank. kosovo: country environmental analysis. washington, dc. world bank; 2013. available from: https://openknowledge.worldbank.org/h andle/10986/13216 (accessed: february 8, 2022). 4. gashi s, berisha m, ramadani n, gashi m, kern j, dzakula a, et al. smoking behaviors in kosova: results of steps survey. zdr varst 2017;56:158-65. doi: 10.1515/sjph-2017-0021. 5. national institute of public health of kosovo. perinatal situation report in kosovo. prishtina, niphk; 2018. 6. martin-moreno jm, harris m, jakubowski e, kluge h. defining and assessing public health functions: a global analysis. annu rev public health 2016;37:335-55. doi: 10.1146/annurev-publhealth-032315021429. berisha m, ramadani n, basholli fm, jerliu n, humolli i, tahirukaj a, et al. self-assessment of essential public health operations in kosovo (original research). seejph 2022, posted: 11 may 2022. doi: 10.11576/seejph-5458 p a g e 13 | 13 7. world health organization. selfassessment tool for the evaluation of essential public health operations in the who european region. copenhagen: who regional office for europe; 2015. available from: https://www.euro.who.int/__data/assets/ pdf_file/0018/281700/self-assessmenttool-evaluation-essential-public-healthoperations.pdf (accessed: february 8, 2022). 8. world health organization. health promotion. healthy settings. available from: https://www.who.int/teams/healthpromotion/enhanced-wellbeing/healthysettings (accessed: february 8, 2022). 9. world health organization. health 2020: a european policy framework supporting action across government and society for health and well-being. copenhagen: who regional office for europe; 2013. available from: https://www.euro.who.int/__data/assets/ pdf_file/0006/199536/health2020short.pdf (accessed: february 8, 2022). 10. stikova e. new challenges and opportunities of public health. int med j medicus 2016;21:131. 11. sedlakova d, katreniakova z, kollarova j, gulis g. self-evaluation of the public health system in slovakia. public health panorama 2016;2:575-80. 12. martin-moreno jm. facing the covid19 challenge: when the world depends on effective public health interventions (editorial). seejph 2020;xiv. doi: 10.4119/seejph-3442. available from: https://www.seejph.com/index.php/seej ph/article/view/3442/3583 (accessed: february 8, 2022). 13. oecd/european union. health at a glance: europe 2018: state of health in the eu cycle (summary). oecd publishing: paris; 2018. doi: 10.1787/52181165-en. 14. who regional office for europe. european action plan for strengthening public health capacities and services. 2012. available from: http://www.euro.who.int/__data/assets/p df_file/0005/171770/rc62wd12rev1eng.pdf (accessed: february 8, 2022). ___________________________________________________________________________________________________ © 2022 berisha et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://doi.org/10.1787/52181165-en https://doi.org/10.1787/52181165-en goodman j. the history of european public health education accreditation in perspective (review article). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-39 review article the history of european public health education accreditation in perspective julien d. goodman 1 1 agency for public health education accreditation (aphea). corresponding author: julien d. goodman, director, agency for public health education accreditation (aphea); address : avenue de l’armée / legerlaan 10, 1040 brussels, belgium; telephone: +3227350890; e-mail: julien.goodman@aphea.net 1 goodman j. the history of european public health education accreditation in perspective (review article). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-39 abstract aim: the aim of this paper is to investigate the history of accreditation of academic public health education and understand why there is a 65 year gap between the first system in america and the uptake of accreditation in europe. the paper intends to search for parallels and dissimilarities between the development in america and europe and then consider if any parallels could be used for determining the future role of accreditation in europe. methods: the paper draws heavily upon a literature review and analysis and the examination and interpretation of primary and secondary sources. firstly there is an exploration of the american development which is complemented by an evaluation of the developments in europe. results: the paper demonstrates that there are two key features required for the development of accreditation: interstate collaboration and a liberalisation or opening up of the education market. conclusions: since the second world war, europe has embraced interstate collaboration which has led to a liberalisation of certain economic markets. the future for sector based accreditation of public health education will be determined by the extent europe pursues liberalisation and whether a competitive environment will bring into question the transparency and trust in state sponsored accreditation agencies. keywords: european public health education accreditation. conflict of interest: none. 2 goodman j. the history of european public health education accreditation in perspective (review article). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-39 the accreditation of higher education programmes and institutions has its roots in american higher education (1) and the history of accreditation of public health education is no exception. however histories do differ in the role of the state in education. in 18th and 19 th century europe, education was taken away from the church and placed under state control to reinforce the legitimacy of the emerging, and competing, european nation states (2). american political development differed from the european model and when the states came together to form the us, education was not among the functions specifically expressed as a federal responsibility (3). europe continues to develop and embrace individual nation states with an increasing trend for laissez faire deregulation as a route to diminish barriers to free trade but it is yet unclear how this will affect the future of education and accreditation at a nation state level. the research is based around a literature review and search of key websites including the american journal of public health, pubmed and google scholar. the reviews took place between july and october 2014 based upon the search terms of “public health education accreditation”. the analysis of key themes highlighted mainly american development and this was complemented for european development, by the use of the physical archives from the association of schools of public health in the european region (aspher). the searches delivered over 150 separate books and articles covering the subject to varying degrees. together these allowed for a demonstration and reflection of the origins of public health accreditation in both europe and america. the american laissez faire approach to federal governmental responsibility toward education was not without its detractors especially when combined with a comparable economic approach. in 1910 abraham flexner criticised the free market nature of medical education in america, “overproduction of ill trained men is due in the main to the existence of a very large number of commercial schools” (4) and that, “the schools were essentially private ventures, money-making in spirit and object” (5). as a result, flexner recommended that 120 of the 155 medical schools should close. flexner was to become soon after the head of the general education board within the rockefeller foundation (6). five years after flexner’s report, wycliffe rose and william welch submitted their views on the development of schools of public health to the rockefeller foundation. given the utter calamitous state of contemporary medical education it was no surprise that the authors recommended that schools of public health should not be part of medical schools. apart from the notion that the public health worker was not identical with that of a practitioner of medicine no other reason for the independence of schools of public health was given in the report (7). institutionally splitting public health from medical education did not however allay concerns about the quality of public health training. in 1920, the american public health association (apha) established a committee on the standardisation of public health training and one year later it reported on what it saw: “the most serious defect in the whole system at present, however, lies in the fact that certain institutions give not only the certificate in public health but even the doctorate in public health for a course of a few weeks, while others require a period of almost three years, and it seems most desirable to effect some form of standardization in this field” (8). similar to the findings of flexner, there were also complaints of profit-making public health training programmes of questionable quality offering public health degrees (9). an editorial in the american journal of public health in 1924 noted that, “as far as the medical end of this scandal goes the matter can be left to the strictly medical journals but unfortunately public health is also involved” (10). this situation continued for the next twenty years with some schools being recognised as, “merely seeking to attract students by deliberately and grossly misleading prospectuses” (11). it took 26 years from the origins of the committee on standardisation until the adoption of an accreditation system in 1946 which coincided with the committee for professional education within apha taking on the responsibility for monitoring standards. this committee was headed by william shepard who strove for the recognition of public health as a profession, “whether we fully 3 goodman j. the history of european public health education accreditation in perspective (review article). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-39 realize it or not, public health has become a profession” (12). accreditation would play a role in producing well trained individuals and supplying relevant data on the needs of the national public health, as shepard noted, “to my knowledge this is the first occasion in modern times that a learned profession has kept its educational house in order as it developed. since becoming a recognized profession, we have been spared the developmental blight of having our ranks flooded with pseudotrained people” (12). in 1946 there were 11 criteria which comprised the minimum requirements of institutions to be accredited to the master of public health (13). the criteria had been developed by another member of the rockefeller board and pioneer of modern public health, charles-edward wilnslow, who had deliberately kept the criteria flexible and small enough to allow time for schools to comply and maintained that too much standardisation was undesirable (12). the basis for winslow’s criteria came from the notion that “public health is not a branch of medicine or of engineering, but a profession dedicated to a community service which involves the cooperative effort of a dozen different disciplines” (14). accreditation at this point consisted of seven criteria which looked at the institution and a further four criteria which were course specific (13). out of these latter four, one criterion stipulated the content, see table 1. by 1974, when accreditation became housed within the council on education for public health (ceph) (15), these criteria had evolved to express a mixture of educational and practical competencies (16), which saw the retraction of elements such as economics and parasitology but the addition of health systems. these criteria are kept in place into the modern period (17), albeit more succinctly phrased as biostatistics and epidemiology were included as part of investigation, measurement, and evaluation (18). the one omission is focussed on the biological features of the curriculum. table 1. changes in american accreditation compulsory curricula contents 1946 to 2014 apha 1946 ceph 1974 ceph 2014 1. the nature functioning of 1. biological, physical, and social 1. biostatistics, human organisms; factors; 2. epidemiology, 2. the nature behaviour of 2. social and behavioural sciences; 3. environmental health various forms of parasitic life; 3. health service delivery systems, sciences, 3. the physical environment; 4. community health needs; 4. health services 4. social and economic factors; 5. information collection, storage, administration 5. the major source of retrieval, analysis, and 5. social and behavioural quantitative information and dissemination; sciences. its numerical presentation and 6. environmental monitoring, analysis. analysis, and management. the history of american accreditation therefore took root at a time when public health was beginning to find its feet as a profession and against a laissez faire backdrop, which saw many schools geared toward profit making above quality and this is perhaps a situation which continues in a sense today with the growth of unrecognized, illegitimate degree and accreditation mills that “sell” (19). against these developments, were the architects of an alternative and earnest public health movement based on the research focus of the german schools and the practical training methods on the english schools (20). this period of development can be seen as 1916 to 1946, from the first rockefeller school of public health to the implementation of a fully functioning accreditation scheme. this period directly coincides with an epoch engrossed in war. although initially the criteria had been kept flexible to allow more schools to participate, the arithmetic growth of accreditation in the u.s. was not overwhelming until around the turn of the twenty first century (21) see figure 1. in 1946, there were nine schools of public health accredited in america (13). nearly 30 years later, in 1975 after the move to the ceph there were 19 schools 4 goodman j. the history of european public health education accreditation in perspective (review article). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-39 (22). this had risen to 27 in 2000 (23) and by 2014 there were over 50 schools accredited and over 100 programmes of public health accredited (17). figure 1. accredited american sphs by decade (compiled by rosenstock, l. et al) after the second world war, europe began a process of reconciliation culminating in the present union enshrined through the 1992 maastricht treaty where, under article 126, the role of union in education was to “encourage cooperation”. it is in these post war collaborative movements where european accreditation, like its american counterpart, found its foothold. as one commentator phrased, “there was an intensified development of accreditation during the 1990s in various european countries. this trend is parallel with the rapid growth in international and trans-national organisations after the second world war” (24). moreover, the first large scale appearance of accreditation was a direct result of competition and the post communist transformation in the central and eastern european region where the markets were opened up to private and foreign providers (25). this european movement of the 1980s and 1990s was to create a fertile environment for international collaborations at a public health school level with examples being, the european training consortium in public health (etc-ph) (26), brimhealth (27) and the european masters of public health (emph). the latter of these, the emph was a collaboration between aspher and the world health organisation (who) to develop a european master's degree in public health based on the who’s 38 health for all (hfa) principles (28). this followed from a momentum in european public health created by the elaboration of these principals into practice which was given the title of “new public health” (29). although this term was not new, it was first coined in 1913 as a bacteriological approach (30) and again in 1923 as health promotion (31), it did reflect the more comprehensive view of public health which still resounds today. the emph embraced three distinct areas: a) it should be concerned with the masters level, b) it should reflect the philosophy of the whos hfa and c) students should be exposed to a european perspective (32). it was enthusiastically anticipated that the emph would raise the standards of education and training across the european region and would provide a “gold standard” of which other schools and programmes would eagerly follow (33). alas, attempts to realise the programme failed. the failure of the emph was a product of several reasons: credit transfer mechanisms were poorly developed; systems didn’t accept qualifications from other institutions; the programme was too inflexible and did not respect the diversity and traditions of the countries; european content didn’t need to be all encompassing as it could be could be integrated into existing courses; and moreover, given the heterogeneity of public health training programmes in europe it was not possible to introduce a rigorous quality assessment and assurance (34). as a result of these failures the introduction of accreditation was seen as a necessary and fundamental step. however, accreditation 5 goodman j. the history of european public health education accreditation in perspective (review article). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-39 was not introduced but rather a process of mutual recognition of courses, modules, programmes and institutions was established entitled the public health education european review, more commonly known as the peer review (35). the three central principals of this review were a reflection of its emph foundations (33):  the course/module/programme/institution should be concerned with postgraduate training in public health.    the course/module/programme should be based on the philosophy of the health for all policy.   the students should be exposed to a european perspective.  the peer review was established by 1994 but it differed from accreditation as it was devised primarily as a quality improvement tool conducted through academic peers in a collegial manner. although the initial anticipation was for a multi-agency quality assurance approach this did not materialise until the advent of accreditation proper which was proposed and accepted in 2001. this was exactly the same time that aspher began to use the peer review for the establishment and quality improvement of new schools and programmes of public health in the central and eastern european region (36). this project gave valuable insights for accreditation (37) and also showed how peer could be used as a framework for development. in 2011, the accreditation agency was established and consisted of aspher and four other public health based ngos, european public health association (eupha), european public health alliance (epha), european health management association (ehma) and eurohealthnet. at the time of its establishment european accreditation focused solely upon the accreditation of postgraduate (so-called second cycle) public health degrees. similar to the american model, the processes also contained specific criteria on core curricula content: introduction, methods, population health and its determinants, health policy, economics and management, health education and promotion, cross-disciplinary themes and culminating experiences. these areas were based on the core subject domains developed through earlier aspher work on public health core competencies (38). in 2014, following a two-year review of its processes, aphea introduced two new aspects in addition to programme accreditation. the first was a curriculum validation process which replaced its initial eligibility criteria by ensuring that curricula contain the basic structure and core content expected from a modern comprehensive public health offering. the second addition was to focus on institutional accreditation which would assess the relationship of an institution, in terms of education, research and service, to the specific local, national, regional or international environments in which they serve, their so-called “social accountability” (39). this development represents a reversal of the american model which started with institutional accreditation followed by programme level accreditation. so far, the remit of aphea was in keeping with the first and third central principals of the earlier peer review. however, for future development, the postgraduate focus was also brought into question with proposals to develop accreditation for bachelor and phd programmes, thus covering the whole spectrum of school based education in public health. aphea also began consultations on the development of training accreditation which would cover smaller units from continuous personal development (cpd), moocs through to summer schools which can be delivered outside of school settings. finally, the role of using the accreditation criteria as a framework for quality improvement and development also requires future scrutiny as the peer review had worked exceptionally well in this regard (36). the second central principle of the previous peer review is based upon the health for all policies of the 1970s which has been superseded of late by the development of the whos essential public health operations (ephos) (40). an encompassing definition given for these is, “a set of fundamental actions that address determinants of health, and maintain and protect population 6 goodman j. the history of european public health education accreditation in perspective (review article). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-39 health through organized efforts of society” (41). the potential therefore lies in the ability to change the older hfa targets for these later ephos, for example, by translating the operations in to a series of competences and then assessing how these competences are integrated into the education of the workforce. however, care will need to be taken so that any system will be flexible enough to respect the diversity and traditions of different countries and thus, hopefully avoiding some of the reasons for the failure of the emph whilst learning the lessons from charles-edward winslow’s introduction of accreditation in america. all of these activities however are predicated on the future potential for sector based professional accreditation and there are two areas within the history of public health accreditation which may help determine its future trajectory. the first area is one of collaboration and second, the liberalisation of the education sector. the origins of both the american and european models of accreditation appeared as a result of interstate or supranational collaboration and an opening up of markets in education. the realisation of europe has installed significant economic liberalisation, especially in the service markets. many services in europe are now no longer a state responsibility but rather a subject of the free market and how far this free market extends remains to be seen. for example, what will be the influence of the mooted agreements between the north american free trade area (nafta) and the european union on the liberalisation of the educational market? in many ways perhaps the free movement of people already enshrined in the european project has created a quasi liberalised market with students being free to study in any country. this freedom of movement is often liberally extended to international students travelling the globe. equally important for the forthcoming years will be the influence of technologies in teaching which allow for students to receive a foreign based education without the need or hindrance of travel. the result of these present and future changes is conceivably then one of burgeoning competition above that of collaboration where education systems both within and between states increasingly compete for students and their own subsequent economic survival. the origins of the bologna declaration and the resultant european higher education area is a cooperation based on mutual trust between education systems of the member states (42) but the reason why america had accreditation before europe is because accreditation is not best suited to centralised governments (1). the question must then be raised, if collaboration turns in to competition, will the national state accreditation agencies be seen as a credible guardian of trust or will they be seen as protective of their national systems, anti-competitive and riddled with conflicts of interest? references 1. maassen pa. 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public health rev 2011;33:134-47. 39. boelen c, woollard b. social accountability and accreditation: a new frontier for educational institutions. med educ 2009;43:887-94. 40. world health organization (who). european action plan for strengthening public health capacities and services. world health organization, 10-13 september 2012. report no.: eur/rc62/conf.doc./6 rev.2. 41. bjegovic-mikanovic v, vukovic d, otok r, czabanowska k, laaser u. education and training of public health professionals in the european region: variation and convergence. int j public health 2013;58:801-10. 42. chauvigné c, ottenwaelter m. accreditation of public health training programs in europe: mapping and analysis of quality assurance and accreditation systems in public health education. rennes, france: working package 2 report, leonardo da vinci programme, 2006. ___________________________________________________________ © 2015 goodman; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 9 ylli a, jurgutis a, burazeri g, bejtja g, artykova n, sentell t. preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt (original research). seejph 2021, posted: 17 april 2021. doi: 10.11576/seejph-4352 p a g e 1 | 10 original research preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt alban ylli1,2, arnoldas jurgutis3, genc burazeri1, gazmend bejtja4, nazira artykova4, tetine sentell5 1 faculty of medicine, university of medicine, tirana, albania; 2 institute of public health, tirana, albania; 3 world health organization, european centre for primary health care, almaty, kazakhstan; 4 world health organization, office in albania, tirana, albania. 5 university of hawai‘i at mānoa, usa. corresponding author: alban ylli, md, phd; address: faculty of medicine, rr. “dibres”, no. 371, tirana, albania; telephone: 355672052674; email: albanylli@yahoo.co.uk mailto:albanylli@yahoo.co.uk ylli a, jurgutis a, burazeri g, bejtja g, artykova n, sentell t. preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt (original research). seejph 2021, posted: xx april 2021. doi: p a g e 2 | 10 abstract non-communicable diseases (ncds) in albania are increasing, yet the country has a low number of outpatient visits per inhabitant per year. a primary health care (phc) based programme of medical check-ups, with a focus on prevention, was set up in the country in 2015 aiming to address this issue, among others. this manuscript describes the development and status of the programme at key time points after its implementation, and considers some of its outcomes. the current analysis was based on data gathered from the check-up programme information system and the registry of diseases at phc centres, and guided by the european framework for action on integrated health services delivery. based on phc registered cases, a 13% and 34% increase in the prevalence of elevated blood pressure and diabetes were observed in 2015 respectively, following the introduction of the check-up programme compared to the previous year. three years after implementation, about 60% of the population aged 35–70 years old had used the programme at least once, with 61% of the total 954 667 visits provided to women. overall, the check-up programme in albania has identified a substantial number of new cases of ncd as well as their associated risk factors in its population. the early detection of ncds is expected to contribute to the prevention of complications, premature mortality and their associated costs. albanian politicians and decision-makers should regularly revise and introduce appropriate changes to the check-up programme in the future. in particular, the issue of sustainability and longterm resource mobilization is of particular concern and warrants careful consideration. keywords: albania, check-up programme, prevention, primary health care. conflict of interests: none declared. ylli a, jurgutis a, burazeri g, bejtja g, artykova n, sentell t. preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt (original research). seejph 2021, posted: xx april 2021. doi: p a g e 3 | 10 background in albania, non-communicable diseases (ncds) are estimated to account for 89% of all deaths, with cardiovascular diseases accounting for 57%, cancer 20%, chronic respiratory diseases 3%, diabetes 1% and other ncds 12% (1). the probability of dying between the age of 30 and 70 years old from a ncd in albania is 17% (1), and ncds as a percentage of total disability-adjusted lifeyears (dalys) increased considerably from 67% in 2000 to 80% in 2012 (2). furthermore, lifestyle factors account for more than 70% of the total disease burden in albania. during the past two decades, the total mortality rate related to being overweight or obese has more than doubled, and the death rate from ischaemic heart disease and diabetes have more than doubled and tripled respectively (3). despite the increases in ncds in albania, the country was reported as having the fewest outpatient visits per inhabitant per year out of the eight countries in south-eastern europe in 2013, at 2.5 per inhabitant per year, with the average in the who european region at 7.5 (2). this low attendance rate, and consequent delays in addressing health problems, were assumed to be a result of the lack of state funded health care, low population coverage of health insurance and high out-of-pocket payments, which comprised 55% of the total albanian national expenditure on health in 2014 (4,5). in response to these issues, the government of albania, in addition to introducing national intersectoral policies targeting the determinants of ncds, developed and implemented a national medical check-up programme in 2015, aiming to improve the early detection and management of ncds, and to increase access to and trust in the primary health care (phc) sector (6-8). the objective of this study was to describe the development and status of the programme at key time points after its implementation, and to quantify some of its outcomes. methods and approach each of the following factors were initially assessed: the scope/selection of services for the check up programme; the system’s delivery capacities; design of patient pathways; organization of providers at the phc centres; screening management; and the mechanisms in place to ensure performance improvement. subsequently, the outcomes and impact of the programme were analysed by focusing on indicators such as the early detection of health conditions/metabolic risk factors and changes in the registered prevalence of ncds as a result of the programme. two main data sources were used in our analysis: the checkup programme documentation and information system and the registry of diseases at phc centres. the check-up programme information system, managed by the ministry of health and social protection (mhsp), is a fully computerized case-based registry, which employs a state-of-the-art bi (business intelligence) system and provides timely information about the result of each patient visit. the registry of diseases, which was set up twelve years ago, contains all prevalent cases of disease diagnosed by a general practitioner (gp) and confirmed by a specialist, within a phc centre’s catchment area. each phc centre reports the data periodically to the compulsory health insurance fund (chif) and the aggregated database is shared with the institute of public health. along with the check-up information system, these registries are considered reliable sources of information as they have frequently (i.e., every three months updated core documentation and are also periodically checked by chif supervisors. the current analysis and presentation of findings were guided by the principles put forward by the european framework for action on integrated health services delivery and its approach to transforming the delivery of health services (9). it ylli a, jurgutis a, burazeri g, bejtja g, artykova n, sentell t. preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt (original research). seejph 2021, posted: xx april 2021. doi: p a g e 4 | 10 includes among others the people-centred approach, which recognizes that before people become patients, they need to be informed and empowered in promoting and protecting their own health. results and discussion scope of the check-up programme based on the changing health needs of the population resulting from the increasing burden of ncds, the albanian government put forward a national health programme with the primary goal of increasing life expectancy by preventing premature deaths. following international evidence on the role of phc in addressing ncd-related health needs, the government put priority on improving phc performance. during 2013/2014 the government conducted detailed preparatory work before launching a primarily preventive programme in 2015 officially named the essential medical evaluation, but announced under the logo ‘how are you?’ for all albanian citizens aged 40–65 years. this was initially set to run over three years, but has subsequently been expanded until 2024. in addition, the target age group was expanded to cover all citizens between 35–70 years at the end of 2016. the size of the initial target group in 2015 was around 1 160 000 inhabitants, which constituted 41% of the total resident population in albania. the programme, considered by the government as a major step towards universal health coverage, targeted all albanian residents regardless of their insurance status. the scope of the programme was to assess health status of eligible individuals on a yearly basis in six priority areas highlighted as high priority by the albanian institute of public health (10) and included several tests (such as blood sugar level and lipid profile, as well as assessment of other key cardiovascular risk factors) to be performed throughout the target population (table 1). table 1. tests provided in six priority areas of the check-up programme (source: reference number 10) areas tests risk factors tobacco use harmful use of alcohol unhealthy diet physical inactivity hypertension blood pressure measurement diabetes fasting plasma glucose test glucose tolerance test (2-hour plasma glucose) cardiovascular risk score (systematic coronary risk evaluation) family history ecg mental health and depression patient health questionnaire key laboratory tests complete blood count complete urine analysis faecal occult blood test liver enzymes: aspartate aminotransferase and alanine aminotransferase blood lipid analysis creatinine and urea (since 2016) ylli a, jurgutis a, burazeri g, bejtja g, artykova n, sentell t. preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt (original research). seejph 2021, posted: xx april 2021. doi: p a g e 5 | 10 the included screening tests were more comprehensive than those previously available in phc services in albania (notably the inclusion of laboratory tests) (11), and went beyond evidence-informed recommendations to include areas of priority to the government, including liver enzymes tests, electrocardiogram (ecg) etc. (10,12,13). furthermore, at the end of 2016, in addition to expanding the age group eligible for screening, the government increased the scope of the check-up programme by increasing the number of laboratory tests, (creatinine and urea tests were added). as of yet, there have been no attempts to reduce the frequency of some of the current tests, despite evidence to do so, but there is a willingness to consider the inclusion of cervical and breast cancer screening as recommended by who (12), although this has yet to be implemented. capacity for implementing the check-up programme the mhsp and chif implemented the programme through a contract with an external company, which was responsible for purchasing and maintaining equipment and the information technology system in all 380 albanian phc centres, training the staff involved in the screening, transporting samples, organizing mobile units to provide screening in remote areas and carrying out all laboratory tests. the government-funded phc centres were themselves obliged to provide: (i) suitable premises for receiving people coming for a check-up; (ii) a list of the people eligible for screening in their designated catchment area; (iii) a computer for registering and transferring data; (iv) maintaining equipment provided by the contractor; and (v) nurses responsible for check-ups. larger phc centres appointed nurses solely responsible for the check-ups, whereas smaller phc centres usually just expanded the role of the family nurse. this was reflected in higher attendance rates in larger phc centres due to their larger capacity, whereas smaller centres encountered several challenges in conducting the programme tasks. all phc doctors and nurses responsible for check-up processes were trained for the task and equipped with an accompanying manual (14) and clinical algorithms, both of which provided guidance on when further investigations and referrals were recommended. preventive check-up procedures, referrals and follow-ups the mhsp clearly defined the processes for the check-ups. all necessary steps involved, as well as the responsibilities of the contractor, phc centre and secondary health care consultants were clearly stated in a written manual. the check-up appointment itself consisted of an initial briefing on the programme by the nurse, followed by the completion of questionnaires on behavioural risk factors, body mass index calculations based on measured weight and height, an ecg, and the taking of blood samples. laboratory tests were collected by the contractor on a daily basis. if behavioural risk factors were identified, the patient received a brief intervention consisting of advice and guidance by the nurse. in addition to the 380 phc centres, mobile units visited 35 remote villages with limited health services, twice a year. the contractor provided the laboratory tests results to each phc centre and, in case of abnormalities, the stationed gp provided health advice and suitable prescriptions, or referred the patient to a secondary health care clinic, following the well-defined clinical pathways. a check-up programme referral guaranteed free and easy access to secondary health care regardless of the patient’s insurance status, with short waiting times to see a consulting ylli a, jurgutis a, burazeri g, bejtja g, artykova n, sentell t. preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt (original research). seejph 2021, posted: xx april 2021. doi: p a g e 6 | 10 specialist and for any necessary further clinical investigations, as confirmed elsewhere (15). the check-up process was deemed completed after the gp sent the contractor a report with the results of the check-up describing any identified or suspected clinical conditions. these reports were filed before any feedback from subsequent specialists and therefore rarely included a final clinical diagnosis. if the person did not require a referral to a gp, the report was filed by the nurse. identification of new cases and changes in registered morbidity the analysis of check-up programme data determined the extent to which check-ups identified new cases of ncds, and risk factors associated with ncds, but also the number of referrals to a specialist. in 2016, of the 329 576 people that underwent a check-up in albania, 36% had elevated blood pressure (systolic at 140 mmhg or higher and/or diastolic at 95 mmhg or higher); 21% were suspected of having depression; 15% had blood glucose levels higher than 5.5 mmol/l; 9% higher than 7.0 mmol/l; and 1% had a positive faecal occult blood test (table 2). table 2. distribution of selected medical conditions among 329,576 individuals undergoing a medical check-up in albania in 2016 condition number percentage percentage not previously aware of their condition depression 69211 21% 76% high blood pressure 118647 36% 49% high blood glucose 49436 15% 42% positive occult blood in faeces 2637 0.8% 99% in 2016, there were 39 213 referrals to specialists as a result of the check-ups, although there is no data regarding follow-ups and final diagnoses. a large proportion of people identified as having a medical problem as a result of the check-up had not previously been aware of their condition, with 49% unaware of their high blood pressure status and 42% unaware of their diabetic status in 2016. according to the phc registries, there was a marked increase in the prevalence of diabetes mellitus, depression and arterial hypertension (34%, 30% and 13% respectively) following the introduction of the check-up programme in 2015 compared to the previous year (fig. 1). previous annual increases had only been at around 1% for diabetes, hypertension and depression. despite the observed increase in the prevalence of phc registered hypertension, the overall prevalence actually remained low compared to the expected population levels based on who ncd country profiles in 2014, where more than 36% of the population (over 25 years old) had hypertension (3,9). almost three years after the introduction of the check-up programme, at the end of 2017, the prevalence of phc registered arterial hypertension was only 15%. similarly, the registered prevalence of diabetes mellitus was lower than expected at 3.8%. it seems that program has yet to diagnose and register all cases of hypertension and diabetes in community. ylli a, jurgutis a, burazeri g, bejtja g, artykova n, sentell t. preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt (original research). seejph 2021, posted: xx april 2021. doi: p a g e 7 | 10 figure 1. number of cases of hypertension, diabetes and depression in ncd registries of phc centres, from 2011-2017 f outcomes and impact up until february 2018, 54% of all 954 667 check-up visits were carried out in rural areas, which was a strong point of the programme, as one of its objectives was to tackle geographical differences in accessing phc. it is also worth noting the gender difference in the programme participation, with 61.3% of the check-ups provided to women, in line with the fact that programme compliance was lowest among younger middle-aged men (aged 35–44 years), an issue that deserves future attention. beyond informing and managing patients suspected of having a ncd, the check-up programme also brought about a number of key changes in the albanian health sector: (i) it changed traditional attitudes that health services should only be used for perceived and disturbing health problems, with healthy people now attending check-ups aimed at the prevention and early detection of severe health problems, as described elsewhere (16); (ii) it increased trust and utilization of phc services; and (iii) it increased the accessibility of health services for socially disadvantaged population groups, although more data are needed to confirm the extent of this (17). the perception among health professionals was that albanian population place a higher value on objective measurements of health, such as laboratory and diagnostic tests, over questionnaires for assessment of behaviour risk factors (16). therefore, in order to make the intervention more attractive and to increase participation, more laboratory tests were included in the check-up programme in 2016. overall, the check-up programme raised the awareness of the population for the need of preventive check-ups, with 60% of the people eligible for the checkups attending at least once in the period march 2015–march 2018. about half of the people screened in 2015 attended a second check-up in 2016. data on check-ups from the first quarter of 2017 indicated that about one third of the eligible population participated in the check-up programme for the first time, one third for the second time and one 229.519 231.396 233.71 236.047 267.28 269.077 281.857 45.606 48.05 48.53 48.966 65.55 71.414 72.926 7.614 7.489 7.564 7.64 9.905 10.154 10.448 0 50 100 150 200 250 300 2011 2012 2013 2014 2015 2016 2017 n um be r o f c as es (t ho us nd s) year hbp diabetes depression ylli a, jurgutis a, burazeri g, bejtja g, artykova n, sentell t. preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt (original research). seejph 2021, posted: xx april 2021. doi: p a g e 8 | 10 third of them for the third time. the phc centres were encouraged to invite eligible individuals through all channels they considered appropriate. this included both advertising campaigns and individual letters sent out to each subject, but some barriers still remain both in communication logistics between phc centres and their communities, and in the low awareness of the importance of the check-up programme in certain population groups, especially young males in the cities. only 8% of the young middle age (35–44 years) urban male population responded to the invitation. this low level of attendance may reflect different priorities in this population than preventive health, a concern in men’s health (18). it may also reflect challenges in accepting a shift from the more traditional role of the albanian phc services, which focused on illness and maternal and child health. hence, the programme still needs to be adapted to the needs and preferences of the male population, especially given that a higher prevalence of several ncds and their risk factors are expected among men. at the end of 2016, the government extended the check-up programme and from the beginning of 2017 free phc visits for the entire population, covering all health conditions, were introduced, along with easy access to specialized services, targeting this overall aim of providing universal health coverage. conclusions the check-up programme has been an important intervention in strengthening the phc service in albania. it has helped improve access to, and build more awareness about preventive care among the albanian population. there is a general consensus among professionals that the program has created the basis for better service attendance and improved health seeking behaviour in albanian adults, as well as restoring trust and communication between health professionals and communities (16). yet, there are areas to be addressed within the programme in the future. notably, the programme needs to focus on encouraging men to also attend check-ups, and needs to assess potential differences in participation rates between different socioeconomic population subgroups. this information is currently not available. overall, the check-up programme in albania has identified a substantial number of new cases of ncds and risk factors associated with chronic disease. the early detection of a ncd is expected to reduce the development of related complications, as well as premature mortality rates, which in turn should reduce the associated costs. however, policy makers need to continue to support and shift more resources to phc services to cover the increase in workload for phc gps and nurses. to ensure the effectiveness of the check-up programme and improvements in the overall health status of the population, however, it is not sufficient to have a well-funded check-up programme if it is based in the framework of low-resource phc facilities, with a limited capacity for the follow-up and management of patients with ncds. the check-up programme needs to be accompanied by a more advanced primary health care model that would include ncd management by well-trained family doctors and phc nurses, supported by other members of a multidisciplinary team (for example psychologists, health educators, public health specialists), as required. in addition, the programme should be further optimized by revising the scope of tests, the targeted age groups, and the frequency of the tests according to age and health status. for example, a number of tests including in the check-up programme, including ecg, liver enzyme tests and complete urine analysis, among others, have not been shown to be effective in population based screening (19), and should therefore only be used for opportunistic ylli a, jurgutis a, burazeri g, bejtja g, artykova n, sentell t. preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt (original research). seejph 2021, posted: xx april 2021. doi: p a g e 9 | 10 screening of patients at risk for a particular disease. this would optimize resources within the programme potentially allowing for the introduction of other evidence-based tests, including the screening of some cancers, as well as the better follow up of detected cases. overall, a better financial optimization is required to encompass both the costs of further investigation and specialist consultations, which are currently covered by health insurance, in addition to the cost of the check-ups. the check-up programme has also helped raise the professional profile of phc nurses, by transferring to them some essential tasks previously carried out by physicians. the check-up programme could gradually introduce phc nurses responsible for a particular district, so that every individual would receive a more comprehensive service from their own nurse, including check-ups, behaviour change counselling, and followups for patients with ncds. such a model should be supported by clear clinical guidelines and should include some form of both performance measurement and accountability for health personnel – along with supporting incentives (for example the revision of remuneration schemes) – with patients reaping the benefits. user-friendly and culturallysensitive information campaigns aimed at all levels of society each at an individual, family, and community-based level will be important for the future of the programme. in addition, measures to enhance the responsibility of citizens themselves to participate in the checkup programme should be gradually introduced, and incentives towards this aim need to be considered. in conclusion, the current case study is an example of how a country in the who european region with limited resources was able to make prompt resource mobilization and to strengthen the role of phc in ncd control. however, albanian politicians and decision-makers need to be able to regularly revise and introduce appropriate changes to the check-up programme in the future. in particular, the issue of sustainability and long-term resource mobilization is of particular concern and deserves careful consideration. references 1. world health organization. noncommunicable diseases country profiles 2018. country profile for albania. geneva: who; 2018. available from: http://www.who.int/nmh/countries/2018/alb_en.pdf (accessed: november 21, 2020). 2. world health organization. european health for all database. copenhagen: who regional office for europe; 2017. available from: https://gateway.euro.who.int/en/hfaexplorer (accessed: november 29, 2020). 3. institute of public health. national health report. tirana, albania; 2014. 4. world health organization. albania: scoping mission on phc needs assessment. copenhagen: who regional office for europe; 2014. 5. world bank. albania: world bank group partnership program snapshot. washington (dc): world bank; 2014. 6. national programme for prevention and control of ncds in albania 2016–2020. tirana and copenhagen: ministry of health of albania and who regional office for europe; 2017. 7. ministry of health and social protection of the republic of albania. albanian national health strategy 2016–2020. tirana, albania; 2016. ylli a, jurgutis a, burazeri g, bejtja g, artykova n, sentell t. preventive check-up programme for strengthening people-centred primary health care services in albania: case study and lessons learnt (original research). seejph 2021, posted: xx april 2021. doi: p a g e 10 | 10 © 2021 ylli et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 8. health insurance fund. focus magazine 2015;31. available from: http://www.fsdksh.com.al/images/stories/publikimet/revista/revista_fokus_dhjetor/draft_fokus_shqip_18_dhjetor.pdf (accessed: may 29, 2020). 9. world health organization. strengthening people-centred health systems in the who european region: framework for action on integrated health services delivery. copenhagen: who regional office for europe; 2016. available from: http://www.euro.who.int/__data/assets/pdf_file/0004/315787/66wd15e_ ffa_ihsd_160535.pdf?ua=1 (accessed: november 21, 2020). 10. world health organization. assessment report on implementation of the screening programme “primary care for citizens aged 40–65 in albania”. copenhagen: who regional office for europe; 2015. 11. ministry of health of albania. the basic package of primary health care services. tirana, albania; 2009. 12. world health organization. evaluation of screening in albania. copenhagen: who regional office for europe; 2016. 13. ylli a, xinxo s, lakrori j. parandalimi i semundjeve kardiovaskulare ne kujdesin paresor. [in albanian]. institute of public health; 2015. 14. ministry of health of albania. healthy, we are all equal. primary care for citizens aged 40–65. checkup programme manual. tirana, albania; 2013. 15. health consumer powerhouse. euro health consumer index, 2016. available from: https://healthpowerhouse.com/media/ehci-2016/ehci2016-report.pdf (accessed: june 20, 2020). 16. sentell tl, ylli a, pirkle cm, qirjako g, xinxo s. promoting a culture of prevention in albania: the "si je?" program. prev sci 2021;22:2939. doi: 10.1007/s11121-018-09675. 17. arora vs, kühlbrandt c, mckee m. albania: an examination of unmet health needs as perceived by roma in central and eastern europe. eur j public health 2016;26:737-42. 18. editorial. raising the profile of men's health. lancet 2019;394:1779. doi: https://doi.org/10.1016/s01406736(19)32759-x. 19. us preventive services task force. available from: https://www.uspreventiveservicestaskforce.org/browserec/index (accessed: november 21, 2020). ____________________________________________________________________________ http://www.fsdksh.com.al/images/stories/publikimet/revista/revista_fokus_dhjetor/draft_fokus_shqip_18_dhjetor.pdf http://www.fsdksh.com.al/images/stories/publikimet/revista/revista_fokus_dhjetor/draft_fokus_shqip_18_dhjetor.pdf http://www.fsdksh.com.al/images/stories/publikimet/revista/revista_fokus_dhjetor/draft_fokus_shqip_18_dhjetor.pdf http://www.fsdksh.com.al/images/stories/publikimet/revista/revista_fokus_dhjetor/draft_fokus_shqip_18_dhjetor.pdf http://www.fsdksh.com.al/images/stories/publikimet/revista/revista_fokus_dhjetor/draft_fokus_shqip_18_dhjetor.pdf https://doi.org/10.1016/s0140-6736(19)32759-x https://doi.org/10.1016/s0140-6736(19)32759-x panteli m, delipalla s. market and welfare valuation of the economic burden of diseases attributable to air pollution exposure in the western balkans (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5479 p a g e 1 | 13 original research market and welfare valuation of the economic burden of diseases attributable to air pollution exposure in the western balkans maria panteli1, sofia delipalla1 1 department of balkan, slavic and oriental studies, university of macedonia, thessaloniki, greece. corresponding author: maria panteli; address: university of macedonia, egnatia 156, thessaloniki 54636, greece; telephone: +306948940170; email: panteli@uom.edu.gr panteli m, delipalla s. market and welfare valuation of the economic burden of diseases attributable to air pollution exposure in the western balkans (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5479 p a g e 2 | 13 abstract aim: the population in the western balkans is exposed to high air pollution concentrations, among the highest in europe, causing death and disability. research, however, on the resulting economic cost in the region is still limited. we estimate the economic cost of the adverse health effects from air pollution exposure, including fine particulate matter (ambient and household) and ambient ozone air pollution in the region. methods: we employ both market and welfare-oriented methods. according to the cost-ofillness (coi) approach, we estimate both the direct (healthcare expenditure) and indirect cost (mortality and morbidity cost). against the shortcomings of a market-based valuation, the willingness to pay (wtp) approach is also used. the most recent data from the global burden of disease study 2019 are used. results: under the coi approach, total economic cost is estimated at ppp$ 6.3 billion. equivalently, it ranges from 0.8% of gdp in croatia to 2.39% of gdp in bosnia and herzegovina. the wtp methodology yields a significantly higher estimate, equal to ppp$ 76.7 billion. the monetary amount associated with the disease burden of air pollution is significant. conclusion: public health policies should include monitoring of the adverse health effects of air pollution. abatement policies should aim at reducing ambient air pollution as well as the dependence on polluting household energy usage. the reduced economic cost can be accompanied by benefits associated with climate change mitigation and an overall improvement in population’s health status, an important aspect given the current covid-19 pandemic. keywords: air pollution, economic cost, health cost, western balkans. authors’ contribution: maria panteli: conceptualization; data curation; formal analysis; methodology; software; writing original draft; writing review and editing. sofia delipalla: conceptualization; methodology; supervision; writing review and editing. source of funding: no funds, grants or financial support were received for conducting this study. conflicts of interest: none declared. panteli m, delipalla s. market and welfare valuation of the economic burden of diseases attributable to air pollution exposure in the western balkans (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5479 p a g e 3 | 13 introduction over the last years, the problem of increased air pollution has drawn a lot of attention in the western balkans region. air pollution is the fourth leading health risk factor causing death, while it is among the first seven risk factors for disability (1). despite the clear epidemiological evidence on the adverse health effects of air pollution in the region, research on the associated economic cost is still limited. most of the relevant studies focus on mortality cost, with willingness to pay (wtp) being the valuation method most frequently employed (2-6). only one of these studies offers estimates under the cost-of-illness (coi) approach as well, albeit albania and montenegro are not included in the analysis (3). research on morbidity cost and/or healthcare expenditure due to air pollution is also limited for individual countries in the western balkans (7-10). finally, a couple of studies estimate healthcare costs due to air pollution induced from coal-fired electricity plants (10,11). the aim of the present study is to estimate the economic cost of air pollutionattributable health effects in all six countries in the western balkans region, albania, bosnia and herzegovina, croatia, montenegro, north macedonia, and serbia, in 2019. our estimates include not only the economic cost of the health effects from ambient air pollution (fine particulate matter (pm2.5) and ozone), but also from household pm2.5 air pollution. we employ two different valuation methodologies, namely coi and wtp, examining the economic cost of air pollution from both a market and a welfare perspective. within a market or incomebased framework, the burden of disease from air pollution can be seen as a disinvestment in the human capital stock of a country. this disinvestment must be valued as in the case of other forms of capital degradation (12). on the other hand, wtp is more closely related to the concept of economic welfare and has become a mainstream approach in valuing pollutionrelated mortality risks. the use of both methods can be seen as an attempt to offer an upper (wtp) and lower (coi) bound of economic losses due to air pollution exposure. under the coi approach, all cost components are taken into account. to the best of our knowledge, this is the first study estimating healthcare expenditure and indirect morbidity cost due to air pollution in the western balkans. we use the most recent data on the disease burden (1). methods cost-of-illness according to coi, the economic cost of air pollution is divided into annual direct and indirect cost (13,14). direct cost includes healthcare expenditure incurred due to air pollution-related diseases. direct costs can be health care costs resulting from the use of health care services (hospitalization, physician services, medication) and nonhealthcare expenditure (transportation to health care providers, informal care for the sick, replacement expenses for sick workers, cost of cleaning up polluted air). in our analysis, direct cost includes government health spending, out-of-pocket health spending, prepaid private spending and for some countries development assistance for health. non-healthcare expenditure is not taken into account due to lack of data, as in most coi studies. for the three categories of air pollution under examination and their joint effect (total air pollution), the attributable healthcare expenditure is estimated as: 𝑨𝑷𝑨𝑬𝒊𝒋 = 𝑨𝑷𝑨𝑭𝒊𝒋 × 𝑻𝑯𝑬𝒋 (𝟏) where 𝐴𝑃𝐴𝐸𝑖𝑗 is the air pollution attributable healthcare expenditure by air pollution subcategory 𝑖 and country 𝑗, 𝐴𝑃𝐴𝐹𝑖𝑗 is the air pollution attributable fraction (mean value) based on data on death numbers by pollution subcategory 𝑖 and country 𝑗, and 𝑇𝐻𝐸𝑗 is total health spending by country 𝑗. panteli m, delipalla s. market and welfare valuation of the economic burden of diseases attributable to air pollution exposure in the western balkans (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5479 p a g e 4 | 13 indirect cost is related to productivity losses due to premature mortality and morbidity resulting from air pollution attributable illnesses. the quantification of the resulting economic losses is done using the human capital (hc) method (3). indirect morbidity cost, attributable to air pollution 𝐴𝑃𝐴𝐼𝐶, is calculated as: 𝑨𝑷𝑨𝑰𝑪𝒊𝒋𝒌𝒔 = 𝑨𝑷𝑨𝑭𝒊𝒋𝒌𝒔 × 𝒀𝑳𝑫𝒊𝒋𝒌𝒔 × 𝑬𝒋𝒔 × 𝑷𝑹𝑶𝑫𝒋 (𝟐) where 𝐴𝑃𝐴𝐹𝑖𝑗𝑘𝑠 is the air pollution attributable fraction of indirect morbidity cost by air pollution subcategory 𝑖, country 𝑗, disease 𝑘 and population subgroup 𝑠 (mean value), 𝑌𝐿𝐷 is the number of years lived with disability, 𝐸 is employment to population ratio by country 𝑗 and population subgroup 𝑠 and 𝑃𝑅𝑂𝐷 is gross domestic product (gdp) per worker by country 𝑗. it should be mentioned that the use of gdp per worker is only an imperfect proxy for measuring lost productivity due to air pollution-induced morbidity (and mortality below). a better measure would have been the use of mean annual earnings by population subgroup, as suggested by max et al. (15). however, in the absence of such detailed wage data by gender and age, we opt for the use of a second-best option, i.e., gdp per worker. the population subgroups of interest are males and females ages 15-19 years to 75-79 years. indirect mortality cost includes present and future foregone income due to premature mortality from air pollution-related illnesses. air pollution attributable indirect mortality cost 𝐴𝑃𝐴𝑀𝐶 for pollution subcategory 𝑖 and country 𝑗, resulting from premature death from disease 𝑘 in the population subgroup 𝑠 is calculated as: 𝑨𝑷𝑨𝑴𝑪𝒊𝒋𝒌𝒔 = 𝑨𝑷𝑨𝑭𝒊𝒋𝒌𝒔 × ∑ (𝑫𝑬𝑨𝑻𝑯𝒊𝒋𝒌𝒔𝒂 𝒎𝒂𝒙 𝒂=𝒎𝒊𝒏 × 𝑷𝑽𝑳𝑬𝒋𝒔𝒂) (𝟑) where 𝐴𝑃𝐴𝐹 is the air pollution attributable fraction of death (mean value), 𝐷𝐸𝐴𝑇𝐻 is the total number of deaths, 𝑃𝑉𝐿𝐸 is the present discounted value of lifetime earnings and 𝑚𝑖𝑛 𝑚𝑎𝑥 represent the minimum and maximum age groups, respectively. note that the population attributable fractions used in the analysis originate from the gbd 2019 study (1) and form a part of a complex framework developed for human health comparative risk assessment. this framework consists of six steps, including the evaluation of various risks and the formation of risk-outcome pairs to be included in the study, the estimation of exposure, the collection of sources related to the “theoretical minimum risk exposure level” (tmrel), the decision on tmrel and related uncertainty, the estimation of population attributable fractions, the estimation of summary exposure values, the collection and assessment of mediation effects and finally the estimation of the attributable health burden (16). due to the complexities present in calculating the population attributable fractions (renamed as pollution attributable fractions in the present analysis), the reader is referred to appendix 1 (section 2, pp. 39-40 and section 4, pp. 78-137) (16) of the gbd 2019 study (1) for the related methodology and formulae. in calculating the present value of productivity over all future years that a person would have worked had they not died prematurely, we take into account life expectancy for the different age groups and genders, and the percentage of people participating into the labour force by age group and gender, respectively (15). that is, 𝑷𝑽𝑳𝑬𝒂𝒈 = ∑ (𝑷𝑺𝒂𝒈 (𝒏)) 𝒎𝒂𝒙 𝒏=𝒂 × [𝑷𝑹𝑶𝑫 × 𝑬𝒈 (𝒏)] × (𝟏 + 𝝁)𝒏−𝒂/(𝟏 + 𝒓)𝒏−𝒂 (𝟒) where 𝑃𝑉𝐿𝐸 is the present discounted value of lifetime earnings, 𝑎 represents the age of a person at present and 𝑔 the gender. 𝑃𝑆 is the probability that a person of gender 𝑔 dying at age 𝑎 would have survived at age 𝑛, 𝑃𝑅𝑂𝐷 is gdp per worker, 𝐸𝑔(𝑛) is the panteli m, delipalla s. market and welfare valuation of the economic burden of diseases attributable to air pollution exposure in the western balkans (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5479 p a g e 5 | 13 employment to population ratio at age 𝑛 and gender 𝑔, 𝜇 is the labor productivity growth rate and 𝑟 is the discount rate. we assume 1% annual increase in productivity and no discounting (0%) for human life. this decision is based on a world health organization (who) technical report (17), according to which there is no inherent justification to evaluate a year of healthy life less just because it is a future year of life. the decision for no time discounting is adopted by the report for quantifying the loss of health. nevertheless, since our major goal is to assign a monetary value to life loss, we adopt this viewpoint and apply a 0% discount rate. a sensitivity analysis is performed, in which a 3% discount rate is applied instead (17). the maximum age group for which indirect mortality cost is calculated is 75-79 years, as in morbidity cost calculation. with respect to minimum age, an adjustment is made so that children below age 15 are not assigned with zero values. finally, total economic cost is the sum of direct and indirect costs. all monetary values are in 2019 ppp adjusted international dollars. willingness to pay the coi approach has been criticized on the basis that human life is valued through the stream of present and future market earnings disrupted by morbidity and premature mortality (15). to overcome the shortcomings of market-based valuation, the wtp approach has been suggested. this method reflects welfare costs as it captures the things that are “ordinarily” valued by individuals, such as leisure, consumption, health and life itself (2). under wtp, the economic cost of the mortality impact of air pollution is calculated using the value of statistical life (elicited by a primary wtp survey) multiplied by the aggregate number of early deaths in a specific setting and in a particular time interval. in the absence of primary wtp surveys for the countries under examination, an oecdrecommended vsl “base” value can be employed, equal to us$ 3 million. this vsl is a product of a meta-analysis of 92 published vsl studies and must be adjusted for income differences between the “original” and the new policy context (18). for calculating the western balkans country-specific vsls, we use the oecdrecommended formula (18,19): 𝑽𝑺𝑳𝑪,𝟐𝟎𝟏𝟗 = 𝑽𝑺𝑳𝑶𝑬𝑪𝑫,𝟐𝟎𝟎𝟓 × (𝒀𝑪,𝟐𝟎𝟎𝟓/𝒀𝑶𝑬𝑪𝑫,𝟐𝟎𝟎𝟓) 𝜷 × (𝟏 + %𝜟𝑷 + %𝜟𝒀)𝜷 (𝟓) where 𝑉𝑆𝐿𝑐,2019 is the vsl for country 𝐶 in 2019, 𝑉𝑆𝐿𝑂𝐸𝐶𝐷,2005 is set equal to us$ 3 million, 𝑌𝐶,2005 is 2005 gdp per capita for country 𝐶 in ppp terms, 𝑌𝑂𝐸𝐶𝐷,2005 is the 2005 value of average gdp per capita of oecd member states (in ppp terms), %𝛥𝑃 and %𝛥𝑌 are the percentage change in consumer price and in real per capita gdp growth from 2005 to 2019, respectively. finally, 𝛽 is the income elasticity of the vsl. the income elasticity is set equal to 1.2 in all countries except for croatia. this decision is based on the oecd recommendation for transferring vsls from high-income to non-oecd and noneu countries (18), and following the wbihme work (3). in the case of croatia, the income elasticity is set equal to 0.8, following oecd (19). data sources for the coi approach, health data are taken from ihme’s gbd 2019 (1). total national healthcare expenditure is taken from ihme’s global expected health spending 2018-2050 dataset (20). employment to population ratios by age and gender and total number of workers by country are retrieved from the international labour organization’s (ilo) statistical database (21). gdp figures refer to nominal gdp in ppp international dollars and are taken from the international monetary fund’s (imf) world economic outlook database (22). survival probabilities are calculated panteli m, delipalla s. market and welfare valuation of the economic burden of diseases attributable to air pollution exposure in the western balkans (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5479 p a g e 6 | 13 using country-specific life tables from the who (23). all data are for 2019. for the wtp calculations, data are retrieved from the world bank’s world development indicators database (24). results cost-of-illness in the western balkans, total mean healthcare expenditure related to diagnosis and treatment of air pollution attributable diseases were estimated at ppp$ 3.13 billion in 2019. direct cost due to ambient pm2.5 air pollution comprised the largest share of direct cost due to total air pollution. healthcare cost due to household pm2.5 air pollution was also significant in the region (figure 1). healthcare expenditure due to air pollution also comprise a significant share of total healthcare spending. in croatia, 6.5% of total healthcare expenditure is related to air pollution attributable illnesses. in albania, serbia and montenegro this share is 10%, 10.8% and 10.9%, respectively. the countries with the largest share of healthcare expenditure (out of total) due to air pollution are bosnia and herzegovina (12.9%) and north macedonia (13.7%). . figure 1. healthcare expenditure due to air pollution by country, 2019 sources: authors’ calculations based on data from the gbd 2019, the global expected health spending 2018-2050 dataset (ihme) and the imf mean indirect morbidity cost due to air pollution in the western balkans was estimated at ppp$ 1.22 billion in 2019. in all countries, the largest share of indirect morbidity cost resulted from diseases attributed to ambient pm2.5 air pollution exposure. this share was particularly high in croatia (94.5%), while in serbia and north macedonia it was 84% and 83.6%, respectively. in bosnia and herzegovina and montenegro, the share of morbidity cost attributed to ambient pm2.5 air pollution was significantly lower compared to the other countries (around 76%), indicating that household pm2.5 air pollution exposure has been a significant problem responsible for almost 25% of total air pollution morbidity cost. finally, in 287.4 619.3 518.0 111.4 376.5 1,214.3 193.5 463.9 469.5 85.2 313.8 1,017.2 91.4 147.0 25.8 25.4 61.0 188.6 3.0 11.3 26.2 1.0 2.3 10.7 0 200 400 600 800 1000 1200 1400 albania bosnia & herzegovina croatia montenegro north macedonia serbia d ir e ct c o st ( 2 0 1 9 u s $ , m ill io n s, p p p -a d ju st e d ) total air pollution ambient pm2.5 household pm2.5 ambient ozone panteli m, delipalla s. market and welfare valuation of the economic burden of diseases attributable to air pollution exposure in the western balkans (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5479 p a g e 7 | 13 albania, 33.5% of morbidity cost resulted from household pm2.5 air pollution exposure. indirect mean mortality cost was estimated at ppp$ 1.95 billion in the whole region. again, in all countries, ambient pm2.5 air pollution has been the most significant contributor to mortality cost from total air pollution, with a share ranging from 93.3% in croatia to 68.3% in albania. household pm2.5 air pollution has been the second largest contributor to mortality cost due to total air pollution. from the countries under examination, only croatia had a significantly small share of mortality cost resulting from exposure to household pm2.5 air pollution (4.6%). the pollutant with smallest contribution to mortality cost was ozone. the shares of mortality, morbidity and direct cost in total cost are presented by country in figure 2. it is worth noting that more than 45% of total cost from air pollution attributable diseases was due to healthcare expenditure (direct cost), while mortality cost ranges from 23.7% of total cost in croatia to 36% of total cost in albania. figure 2. share of mortality, morbidity and direct cost in total cost by country, 2019 sources: authors’ calculations based on data from the gbd 2019 (ihme), imf and ilo in the whole region, mean total cost from air pollution was estimated at ppp$ 6.3 billion in 2019, with estimates ranging from ppp$ 218.7 million in montenegro to ppp$ 2.6 billion in serbia. when we take into account the lower and upper estimated values of the disease burden of air pollution, the lower and upper bounds of total cost are estimated at ppp$ 4.7 billion and ppp$ 8.2 billion, respectively (table 1). in terms of cost as a percentage of gdp, the countries more heavily affected are bosnia and herzegovina, north macedonia and serbia. in bosnia and herzegovina, the share of total cost from air pollution in gdp was 2.39% (the highest in the region), while total cost per capita was ppp$ 373. in north macedonia, total cost was found to be equal to 1.99% of the country’s gdp and total cost per capita was estimated at ppp$ 344. in serbia, air pollution costed 1.97% of gdp, while total cost per capita was ppp$ 375 (the highest in the region). regarding the rest of the countries, the share of total cost from air pollution in gdp was smaller, 51.5 50.2 53.4 50.9 52.5 46.7 36.0 29.4 23.7 32.3 30.9 33.2 12.5 20.4 22.9 16.8 16.6 20.1 0 10 20 30 40 50 60 albania bosnia & herzegovina croatia montenegro north macedonia serbia p e rc e n t (o f to ta l co st ) direct cost mortality cost morbidity cost panteli m, delipalla s. market and welfare valuation of the economic burden of diseases attributable to air pollution exposure in the western balkans (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5479 p a g e 8 | 13 but nevertheless it exceeded 1% of gdp, with the exception of croatia (see, figure 3 and table 1). for lower and upper estimated total cost bounds, see table 1. figure 3. total cost from air pollution as a percentage of gdp by country, 2019 sources: authors’ calculations based on data from the gbd 2019 (ihme), imf and ilo assuming a 3% discount rate, mortality cost is (as expected) lower, while the decrease ranges from 20.9% in serbia to 33.6% in albania. total cost is also affected with estimates ranging from 2.24% of gdp in bosnia and herzegovina to 0.76% of gdp in croatia. table 1. direct, indirect and total cost from air pollution, western balkans, 2019 a lb a n ia b o sn ia & h e r z e g o v in a c r o a ti a m o n te n e g r o n o r th m a c e d o n ia s e r b ia w e st e r n b a lk a n s direct cost value a 287.4 619.3 518 111.4 376.5 1.21b 3.13b % gdp 0.69 1.2 0.43 0.8 1.05 0.92 0.79 % total cost 51.5 50.2 53.4 50.9 52.5 46.7 49.7 % total health exp. 10.0 12.9 6.5 10.9 13.7 10.8 10.2 morbidity cost value a 69.8 251.5 222 36.6 119.4 523 1.22b % gdp 0.17 0.49 0.18 0.26 0.33 0.4 0.31 % total cost 12.5 20.4 22.9 16.8 16.6 20.1 19.4 % indirect cost 25.8 41 49.1 34.1 35 37.7 38.5 mortality cost value a 201.1 362.1 230.4 70.7 221.3 864 1.95b % gdp 0.48 0.7 0.19 0.51 0.61 0.65 0.49 % total cost 36 29.4 23.7 32.3 30.9 33.2 30.9 % indirect cost 74.2 59 50.9 65.9 65 62.3 61.5 value a 558.3 1.23b 970.4 218.7 717.2 2.6b 6.3b 1.34 2.39 0.80 1.57 1.99 1.97 0.90 1.81 0.74 1.21 1.67 1.66 0.43 0.56 0.04 0.35 0.32 0.30 0.01 0.03 0.03 0.01 0.01 0.01 0 0.5 1 1.5 2 2.5 3 albania bosnia & herzegovina croatia montenegro north macedonia serbia p e rc e n t (o f g d p ) total air pollution ambient pm2.5 houshold pm2.5 ambient ozone panteli m, delipalla s. market and welfare valuation of the economic burden of diseases attributable to air pollution exposure in the western balkans (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5479 p a g e 9 | 13 total cost lower bound 389.9 939.1 708.5 160.2 547.1 1.97 b 4.7b upper bound 772.8 1.58b 1.29b 287.3 913.8 3.37b 8.2b % gdp 1.34 2.39 0.8 1.57 1.99 1.97 1.59 lower bound 0.94 1.82 0.58 1.15 1.52 1.49 1.19 upper bound 1.85 3.06 1.06 2.06 2.54 2.55 2.07 a monetary amount in 2019, 2019 us$, millions, ppp-adjusted b monetary amount in 2019, 2019 us$, billions, ppp-adjusted sources: authors’ calculations using data from the gbd 2019 (ihme), imf and ilo. willingness to pay the cost of premature mortality due to exposure to air pollution is much higher when estimated with the wtp method. it is equal to ppp$ 45.9 billion for the whole western balkans, using data for the same age group for which mortality cost has been estimated with the coi method (<1-79). the share of mortality cost in gdp has been found to be equal to 5.1% in albania, 5.4% in croatia, 7% in bosnia and herzegovina, 8.2% in montenegro, 11.4% in north macedonia and 20.4% in serbia. when we take into account mortality estimates for the whole population, mortality cost is estimated at ppp$ 76.7 billion. mortality cost as a percentage of gdp is found to be equal to 8.4% (of gdp) in albania, 10.2% in croatia, 11.2% in bosnia and herzegovina, 12.3% in montenegro and 16% in north macedonia. an exceptionally high estimate is obtained for serbia, equal to 34.2% of gdp. this very high difference between the estimated mortality costs, resulting from the two alternative approaches employed, reflects the difference in the underlying logic of the two methods. the coi method is an income-based methodology, which takes into account forgone output from the working age population dying prematurely from exposure to air pollution. on the other hand, under the wtp methodology, the same value (vsl) is applied for each life lost, regardless of working status. the vsl is meant to capture intangible disutility costs, thus measuring total welfare loss resulting from a statistical case of mortality (4). in this sense, these results have been expected. discussion we estimate both direct healthcare cost and indirect morbidity and mortality cost using data on the burden of disease from ambient and household air pollution exposure. our cost estimation is more inclusive than previous studies in which only mortality impact is usually taken into account. this is important because, although morbidity cost does not have the largest share in indirect cost, it is nevertheless significant, ranging from 25.8% in albania to 49.1% in croatia (table 1). furthermore, the share of morbidity cost in total cost exceeds 10% in all countries (table 1). at the same time, direct cost is the largest component of total cost, while healthcare expenditure due to air pollution amounts a significant share of total healthcare spending. a limitation in the calculation of direct cost is that pollution attributable fractions used in the analysis are based on mortality estimates. this may bring about either an overestimation or an underestimation of healthcare expenditure due to air pollution. a further limitation of the current analysis is related to the productivity measure employed in estimating mortality and morbidity cost. in the absence of detailed data pertaining to the level of average annual earnings by gender and age, we decided to use gdp per worker as the best alternative option available. we believe that a possible overestimation of mortality and morbidity cost is not substantial and can be outweighed by other cost components that were not included in the analysis due to lack of available data, such as the value of lost household production (19). panteli m, delipalla s. market and welfare valuation of the economic burden of diseases attributable to air pollution exposure in the western balkans (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5479 p a g e 10 | 13 under coi, our estimates are higher than the ones in previous literature. a frequent criticism towards the coi method is that the valuation of human life is done through the calculation of pvle in the case of mortality and foregone income due to disability. thus, people not participating in the labour market are excluded from the analysis (19). this is an important limitation in the case of the examination of the economic cost of air pollution, since the burden of disease is particularly high among the elderly. we calculated the economic cost for a wider age range (<1-79) than is usually included in similar analyses (e.g., <1-65). nevertheless, under the assumption of no participation in the labour market, people of 80 years of age and above are excluded. moreover, for people in the 65-79 age group, the calculated economic cost was low, despite the fact that the burden of disease is higher in comparison to younger ages. this result is again linked to labour force participation, as the rates are low compared to rates in previous age groups. finally, it should be also noted that intangible disutility costs are not taken into account (22). as a result, the economic cost of the air pollution-attributable health burden is most probably underestimated within a market-oriented framework. on the other hand, the wtp method is more suitable for the valuation of the economic cost in welfare terms in the society as a whole. as expected, it has yielded significantly higher mortality cost estimates. these estimates are in line with results from other studies using the wtp method. in comparison to the wb-ihme report (3), our estimates are significantly higher, due to the fact that in the current round of gbd 2019 (1) air pollutionattributable mortality estimates have been revised upwards compared to estimates from older versions. in comparison to the who-oecd report (2), our estimates are lower in all countries with the exception of serbia. apart from the fact that we used more recent health data, we have also employed a higher value of the income elasticity of the vsl, more suitable for transferring the base vsl from high to middle and low-income economies (19). a shortcoming in using the oecd recommended base vsl is that this value has been mainly proposed to be transferred to other policy contexts within the oecd group of countries. although the use of the base vsl is a common practice in studying the welfare cost of the disease burden of air pollution in policy contexts in which we lack primary wtp information, it is possible that a primary wtp survey would uncover a different vsl. conclusions addressing the health and economic consequences of air pollution in an effective manner, in the western balkans and elsewhere, is a multifaceted task. from the three air pollution subcategories examined here, the one with the largest impact in terms of total economic cost is ambient pm2.5 air pollution. however, exposure to household pm2.5 air pollution also results in a significant economic cost. these findings have wider policy implications. they indicate that efforts on meeting air quality standards should not be targeted at limiting only ambient air pollution, but also at limiting the dependence on polluting household energy use. especially in the case of albania (and to a lesser extent in north macedonia and bosnia and herzegovina), efforts on reducing energy poverty would result in a reduced child mortality rate and an improved health in adults. addressing the problem of air pollution in an effective manner requires a combination of policies, regarding the efficiency of heating systems, energy use and fuel management, to reduce emissions from both industry and households. the policy framework, among others, needs to provide economic incentives for consumers and industry to make the necessary adjustments and investments for air quality, to improve public health and the economy. public panteli m, delipalla s. market and welfare valuation of the economic burden of diseases attributable to air pollution exposure in the western balkans (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5479 p a g e 11 | 13 health policies should include monitoring of the adverse health effects of exposure to air pollution. reform in the major sectors contributing to air pollution levels that are harmful for human health 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tegration/research/newsalert/pdf/he alth_costs_environmental_pollutio n_fb21_en.pdf (accessed: february 15, 2021). 26. tung nt, cheng p, chi k, hsiao t, jones t, berube k, et al. particulate matter and sars-cov2: a possible model of covid-19 transmission. sci total environ 2021;750:1-3. doi: 10.1016/j.scitotenv.2020.141532. __________________________________________________________________________________________ © 2022 panteli et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://databank.worldbank.org/source/world-development-indicators https://databank.worldbank.org/source/world-development-indicators https://doi.org/10.1016/j.scitotenv.2020.141532 gobianidze, m., hammond, j., jürgens, k. & reisser, k. advancing the diversity and inclusion agenda in healthcare organizations: the case of german university hospitals (policy brief). seejph 2022, posted: 23 june 2022. . doi: 10.11576/seejph-5600 p a g e 1 | 14 policy brief advancing the diversity and inclusion agenda in healthcare organizations: the case of german university hospitals mariam gobianidze1+, jordan hammond1+, kira jürgens1+, katharina reisser1+, valia kalaitzi² 1department of international health, care and public health research institute – caphri, faculty of health, medicine, and life sciences, maastricht university, the netherlands +these authors contributed equally to this work 2senior advisor; department of international health, faculty of health, medicine, and life sciences, maastricht university, the netherlands; department of global health, richard m. fairbanks school of public health, indiana university, usa corresponding author: mariam gobianidze email: m.gobianidze@student.maastrichtuniversity.nl address: duboisdomain 30, 6229 gt, maastricht, the netherland mailto:m.gobianidze@student.maastrichtuniversity.nl gobianidze, m., hammond, j., jürgens, k. & reisser, k. advancing the diversity and inclusion agenda in healthcare organizations: the case of german university hospitals (policy brief). seejph 2022, posted: 23 june 2022. . doi: 10.11576/seejph-5600 p a g e 2 | 14 abstract introduction: diversity and inclusion (d&i) challenges in the hospital workforce continue to pose threats to an inclusive work environment. acknowledging the benefits of a diverse and inclusive healthcare workforce, the association of german university hospitals signed the german diversity charter to encourage its member hospitals to apply policies to cultivate such a workplace. this policy brief explores the implementation of d&i policies aligned with the charter in six university hospitals in germany, aiming to identify the policy gaps and provide recommendations for improvement. policy options: the charter´s commitments include a shared organizational vision of d&i as a source of great potential and the significant support of the senior management. it also includes d&i in employment processes, open communication about policies, and active employee engagement. overall, a comprehensive d&i strategy has been shown to be vital for sustainable change. however, not all the hospitals have signed it, nor do all fully adhere to its policies. therefore, recommendations are provided for the association to support their constituents in working toward comprehensive d&i policies. recommendations: most importantly, the association should further promote d&i awareness, enhance the support to the hospitals to improve d&i activities, and lead and monitor the implementation and outcomes of the adopted d&i strategies and policies. the comprehensive approach includes transparency; measurement and evaluation to assess the successes and failures of the strategies; the commitment by senior management to d&i efforts; and bottom-up involvement for employees to share their concerns and get involved. keywords: diversity, inclusion, diversity charter, university hospitals, germany, health workforce acknowledgements: we would like to thank our senior advisor, valia kalaitzi, phd, for the considerate feedback and heart-warming support. authors’ contributions: all authors contributed equally to this work. conflicts of interest: none declared. funding: none declared. gobianidze, m., hammond, j., jürgens, k. & reisser, k. advancing the diversity and inclusion agenda in healthcare organizations: the case of german university hospitals (policy brief). seejph 2022, posted: 23 june 2022. . doi: 10.11576/seejph-5600 p a g e 3 | 14 introduction numerous studies show that workforce diversity improves both the effectiveness and performance of an organization (1). this is no different in the field of healthcare. a diverse and inclusive healthcare workforce is the key to better patient-centred care. the diverse patient population has the right to be treated with inclusive and quality care, and a diverse healthcare workforce is a perfect facilitator to achieve this goal. these efforts are generally initiated at university hospitals as these organizations are the powerhouses of health advancement. germany is in a unique situation as it has been experiencing a sharp increase of foreign physicians from 5,3% in 2010 to 13,7% in 2020. by 2030, it will need another predicted 160,000 (3). the association of german university hospitals acknowledges the importance of fostering a diverse healthcare workforce along with the accompanying challenges. they aimed to address these challenges by signing the diversity charter. however, not all the hospitals within the association have signed it. this charter, launched in 2006 by four german companies, provides the main building blocks for the cultivation of a diverse and inclusive workplace (4). this policy brief aims to identify potential policy gaps in broad acceptance and compliance of the diversity charter by all german university hospitals. recommendations on how to further promote and integrate the charter’s tenets into the hospitals’ overarching strategies are also provided. to accomplish this, this policy brief focuses on six of the largest university hospitals in germany: uniklinik rwth aachen, klinikum der universität münchen, universitätsklinikum hamburgeppendorf, universitätsklinikum carl gustav carus dresden, universitätsklinikum frankfurt am main, and charité berlin. it focuses on the dimensions of diversity and inclusion (d&i), associated challenges, and current strategies. it then provides a checklist to assess to what extent the aforementioned institutions adhere to the charter. in the end, this policy brief provides recommendations to the senior management of the association of german university hospitals on how to improve the acceptance and compliance with the diversity charter; how to promote current d&i policy options; and how to fully integrate these into their d&i strategies. context as the world continues its quest for globalization, entire societies and cultures are seeing a population shift to more heterogeneous in terms of ethnicity, origin, languages spoken, and many other dimensions of diversity. d&i work as a team. diversity is “the mixture of attributes within a workforce that in significant ways affect how people think, feel, and behave at work” along with “their acceptance, work performance, satisfaction, or progress in the organization”, whereas inclusion “focuses new attention on the policies, practices, and climate of the workplace—the workplace culture—that shapes the experiences of employees with those characteristics” (5). inclusion is the key to successfully leveraging diversity through the empowerment of others by respecting, appreciating, and valuing differences (6). the dimensions of diversity wheel is a common way to illustrate the intertwining nature of diversity (figure 1). it shows some of the key dimensions and the importance of understanding this intersectionality across the multiple dimensions that influence an individual’s identity (7). gobianidze, m., hammond, j., jürgens, k. & reisser, k. advancing the diversity and inclusion agenda in healthcare organizations: the case of german university hospitals (policy brief). seejph 2022, posted: 23 june 2022. . doi: 10.11576/seejph-5600 p a g e 4 | 14 figure 1: dimensions of diversity wheel: a common way to illustrate the complexity of the concept of diversity. core, secondary, and organizational dimensions are inextricably linked and impact one another. empty spaces in the figure indicate that different components of dimensions are not set and can be changed depending on an individual (7) core dimensions are central to one’s personal experience and have a long-term, direct impact on our lives. they are the dimensions with which we identify ourselves most strongly. many of these aspects are more difficult to consciously modify (8). though some of them may naturally evolve and be altered throughout our lives, the way we interpret them is frequently established during childhood and has a lasting impact on one’s perceptions of identity (7). a greater degree of self-determination to change accompanies secondary dimensions. core dimensions and secondary dimensions are inextricably linked (7). for instance, one’s country of origin can have an impact on earnings. in 2021, the median wage of a full-time employee with german citizenship was 3,541€ per month. however, foreigners in germany earned significantly less than german citizens, which was an average of 2,638€ (9). organizational dimensions are also linked to core and secondary dimensions. they influence how employees approach their work and interact with people in the working environment (7). the presented approach shows that d&i dimensions are cross-cutting. as the population continues to diversify, the ever-growing demand for a diverse healthcare workforce grows (8). d&i in the healthcare workforce is gobianidze, m., hammond, j., jürgens, k. & reisser, k. advancing the diversity and inclusion agenda in healthcare organizations: the case of german university hospitals (policy brief). seejph 2022, posted: 23 june 2022. . doi: 10.11576/seejph-5600 p a g e 5 | 14 important for three main reasons. first, it is representative of population composition and, as such, it helps expand access to and quality of care for all population groups. second, by enriching the team of stakeholders and policymakers by including more diverse viewpoints, it offers a fertile context for further exploring ways for improving the performance and quality of healthcare services at both workforce and patient levels. third, it helps to cultivate a more equitable healthcare landscape by improving trust and empathy while strengthening the connection with patients and communities (10). organizations that foster a diverse and inclusive workplace are more adaptable, innovative, and promising in terms of career advancement for employees (11). however, incorporating d&i into the workplace is not easy. it needs thorough consideration to address potential biases. one major challenge to d&i is that it is difficult to define in objective and quantitative terms. as d&i have so many different dimensions, it is challenging to know exactly what to measure. many facets of diversity are intertwined with one’s identity. prioritizing certain components of diversity and measuring them incorrectly might be inherently dangerous if it is perceived that some aspects of identity are more valuable than others (12). another challenge to d&i is internal resistance, which is mainly caused by the employees’ reluctance to change the status quo (13). hospitals are taking tangible steps towards diversifying their personnel by expanding recruitment to groups that have previously been under-represented. this is driven by a need to account for talent shortages. even in nations with diverse workforces, members of demographically dominant groups tend to have more influence and face fewer barriers to recruitment and advancements than newcomers. due to cultural hurdles and a general lack of support, diversity has made limited gains (14). the complexity of d&i in the healthcare workforce has been acknowledged in many hospitals and this is no different in germany. to assess the status of d&i strategies in german university hospitals and identify potential room for improvements at policy and implementation levels, an extensive search of the hospital websites was conducted. the current policies of the researched hospitals were then compared to the commitments of the german diversity charter signed by the association of german university hospitals. although only published data on hospitals’ official websites were used to inform the proposed recommendations, and potential internal information was not possible to access, the recommendations are considered relevant and applicable. existing policy options policy options for a d&i-friendly workplace in german university hospitals should build on existing legal requirements. in germany, discrimination is prohibited by the “grundgesetz”, the german equivalent of a constitution. this requires employers to have a no-tolerance policy for discrimination of any kind, such as race, ethnicity, gender, religion, disability status, or sexual identity (15). moreover, it establishes the obligation to dedicate at least one equal opportunities officer for confidential complaints about discrimination in each company. solely adhering to legal requirements does not assure inclusion. the diversity charter, formalized in 2010, is an open commitment to d&i without legal bindingness, and more than 4,000 http://graphics.eiu.com/upload/eb/diversityandinclusion.pdf gobianidze, m., hammond, j., jürgens, k. & reisser, k. advancing the diversity and inclusion agenda in healthcare organizations: the case of german university hospitals (policy brief). seejph 2022, posted: 23 june 2022. . doi: 10.11576/seejph-5600 p a g e 6 | 14 companies have signed it (4). it establishes six main commitments. the charter calls for the creation of an environment where everyone shares the value of mutual respect; recommends an evaluation of the inclusion of diversity in the workforce recruitment and development processes; emphasizes the shared understanding of diversity as a source of great potential; enables both internal and external dialogue about d&i strategy; supports open communication about d&i activities and progress, and reinforces the idea that companies must actively engage employees in their d&i strategy. much of the literature shows that the formation of a comprehensive strategy, instead of disjointed measures, is most crucial for a successful and sustainable change towards integration (16, 17). daya (18) highlighted that definitive support from the senior management is also important to the success of the d&i strategy. another essential factor is the bottom-up involvement of employees, as it empowers and increases internal acceptance of the d&i policies (17). this has been successful at the universitätsklinikum hamburgeppendorf. the selected hospital in dresden is an example where a comprehensive strategy for inclusion of all genders has led to success. according to “medical women on top” by the deutsche ärztinnenbund in 2016, this hospital had the highest rate of female physicians in senior positions with 43% compared to the german mean of 31% (19). another important aspect of a comprehensive strategy for d&i is transparency. transparency consists of communicating the hospitals’ d&i policies both openly and accessibly (18). klingler and marckmann (3) show that foreign physicians often did not receive transparent information about their future tasks, requirements, and support in the recruitment process. making the change visible requires regular evaluation of the hospital's d&i performance. winter (20) presents employee engagement surveys as a useful tool to assess inclusion in the workplace and proposes that unit managers should take the responsibility for the survey results to initiate improvements in their unit. the d&i policies of the six chosen german university hospitals identified after a comprehensive website search are presented in table 1 below. in this table, the corresponding policy for each hospital is shown. hospitals are coloured green if they have signed the charter and red if they have not. the table also illustrates the institutional representative and the involvement of the management level in the strategic approaches. gobianidze, m., hammond, j., jürgens, k. & reisser, k. advancing the diversity and inclusion agenda in healthcare organizations: the case of german university hospitals (policy brief). seejph 2022, posted: 23 june 2022. . doi: 10.11576/seejph-5600 p a g e 7 | 14 table 1: d&i policies of the university hospitals in aachen, munich, hamburg, dresden, frankfurt am main, and berlin: analysis of adherence to the diversity charter, current d&i policies, current d&i institutional representative and involvement of hospital leadership name of hospital charter signed? diversity & inclusion approach or strategy institutional representative management/ leadership involved? uniklinik rwth aachen (21) only the university gender & diversity imbalances – the rtg 2610 innoretvision gender and diversity concept research-oriented equality standards for designing & establishing suitable measures for equality of women & men at all qualification levels creating a space for a social and academic variety implementing gender equality/equal opportunities offices: promote gender-related & diversity topics & give support at all levels infrastructure for a family-friendly environment, which includes childcare facilities on the campus equal opportunities officer no information – d&i is not included in hospital vision klinikum der universität münchen (22) only the university no strategy uploaded from the hospital: contribution in the association of university clinics for diversity, but the university has a strategy published interview with the medical director: 20% of the staff have a non-german passport equal opportunities officer no information universitätsklinikum hamburg-eppendorf (23) signed in 2012 uke inside: part of the strategic goals & human resources department: established infrastructure to communicate the strategy with all employees via newsletter, flyer, information office, e-book vision: d&i is always a work in progress goals of the strategy: participation of all employees; established structure for communicating changes; the connection between bottom-up & top-down communication; transparency & communication possibilities; the possibility of participation for relevant themes for all employees; changes will be evaluated equal opportunities department yes universitätsklinikum carl gustav carus dresden (24) only the university tu dresden (associated university) has a detailed d&i plan, but the hospital does not have a comprehensive strategy established service for international patients gender-neutral speech in official documents guideline on sexual harassment & stalking in the workplace; training for board members, information for employees, classes for students and apprentices, contact persons participation in diversity days office for support in solving conflicts equal opportunities officer focuses mainly on women & matters concerning severely handicapped persons yes universitätsklinikum frankfurt am main (25) only the university university has a detailed diversity concept, but the hospital does not have a strategy mentions internationality of healthcare workforce in vision plan for equal opportunities for women (derived from the anti-discrimination law) with qualitative & quantitative aims & reports activities by equal opportunities office: women development plan, enhancing family-friendly working, mentoring for women, leadership in part-time, facilitating come-back after parenting time, girls’ and boys’ day, retainment, and training of employees, participated in the diversity day of the university hospital alliance, apprentice officers equal opportunities officer no information gobianidze, m., hammond, j., jürgens, k. & reisser, k. advancing the diversity and inclusion agenda in healthcare organizations: the case of german university hospitals (policy brief). seejph 2022, posted: 23 june 2022. . doi: 10.11576/seejph-5600 p a g e 8 | 14 charité berlin (26) signed in 2013 special website on diversity and inclusion (diversity network) gender: in 2014 on place 4 of the best employers for gender equity: frauen-karriere-index (quantitative index for promotion for women’s career mentoring competence center (female scientists) gender-equitable teaching (gender in medicine curriculum) sexual diversity: queernetwork ethnic diversity: “inter-professional training in the health care professions” program aims to develop, trial, & evaluate inter-professional and intercultural teaching modules for the medical, nursing, & social professions at charité finished project on language skills & professional orientation for refugees interested in nursing age: project “over 60 – working in the health care professions”: exhibition, presentations, activities internationalization: charité welcome center charité international cooperation equal opportunities committee; office for women's affairs & equal opportunities; disability support officers yes as shown, only two out of the six hospitals have signed the diversity charter. all the selected hospitals have at least one equal opportunities officer, as required by law in germany. however, only three have further staff dedicated to d&i. the selected hospitals in hamburg and berlin have a more developed strategy, including a department dedicated to d&i. however, for the hospitals in aachen, munich, and frankfurt it was not possible to find information about the role of management whereas the other three hospitals state full support from the management level. in aachen, frankfurt, munich, and dresden, the universities have a d&i strategy, but the associated hospitals do not. it is uncertain to what extent the respective hospitals are integrated into the universities’ strategies. table 2 compares the published d&i policies of the six hospitals to the commitments from the german diversity charter. these commitments have been divided into six categories, written categories 1-6 in table 2 (4). categories 0, 7, and 8 were included additionally for a more detailed understanding and to account for the central role of a comprehensive approach identified in the literature (16). gobianidze, m., hammond, j., jürgens, k. & reisser, k. advancing the diversity and inclusion agenda in healthcare organizations: the case of german university hospitals (policy brief). seejph 2022, posted: 23 june 2022. . doi: 10.11576/seejph-5600 p a g e 9 | 14 table 2: d&i policy adherence: extend to which the selected university hospitals adhere to the d&i policies as proposed by the german diversity charter as can be seen above, the selected hospitals adopted d&i policies to a different extent and with a focus on different diversity dimensions (see figure 1). a clear commitment to diversity was only found on the websites of the hospitals in hamburg, berlin, and dresden. inclusive human resource management is legally required in germany through the federal equal treatment act (15), so all hospitals are considered in adherence to this even if no explicit information could be found. however, it must be noted that human resource processes might not discriminate openly while still not being inclusive (27). external communication of d&i efforts is especially developed at charité berlin, where the hospital has a website on all its d&i activities, topics, and representatives. similarly, universitätsklinikum carl gustav carus dresden communicated its commitment to stop gender-related and sexual harassment in easily accessible leaflets on its website. the involvement of employees in the d&i strategy was explicitly mentioned only in hamburg and berlin (28). as visualized in figure 1, diversity is complex. however, even the hospitals that presented the most extensive strategies, hamburg and berlin, did not explicitly mention many of these dimensions. for example, none of the hospitals mentioned a focus on faith. good practice examples show that diverse religious backgrounds can be valued, for instance, by providing inter-religious praying rooms and by taking scheduled religious practices into account, such as fasting and holidays, when planning schedules (29). from the secondary and organizational dimensions, only parental status was addressed by most of the hospitals as they offer flexible working time and support after coming back from parental leave. the secondary and tertiary dimensions certainly influence the internal working atmosphere and are important to consider while designing diversity strategies. however, explicit strategies and actions focus more on the core dimensions, being the most personal of the dimensions. gobianidze, m., hammond, j., jürgens, k. & reisser, k. advancing the diversity and inclusion agenda in healthcare organizations: the case of german university hospitals (policy brief). seejph 2022, posted: 23 june 2022. . doi: 10.11576/seejph-5600 p a g e 10 | 14 recommendations this policy brief aims to provide the association of german university hospitals with recommendations on how to promote the d&i and to enhance support to its member hospitals to better endorse and implement the d&i policies. tables 1 and 2 show that all six selected hospitals have already built a base for d&i. however, to achieve strong and sustainable change towards not only diversity but also genuine, long-lasting inclusion, broader measures must be taken. to accomplish this stated goal, the following policy options, presented in table 3, are recommended. table 3: policy recommendations: a comprehensive, holistic d&i approach with a particular focus on transparency, measurement, and evaluation, a commitment by senior management, and bottom-up involvement of employees the association of german university hospitals can support the university hospitals in germany and lead the process of application of d&i strategies. a comprehensive approach, which includes the following recommendations: transparency ● strategies should be easily accessible ● processes should be transparent measurement and evaluation of strategies ● measure the success of strategies through surveys and feedback forms ● comparison of the results with other hospitals commitment by senior management ● inclusion of the senior management in the guiding coalition bottom-up involvement of employees ● employees should share their suggestions or concerns ● establishing support and exchange networks gobianidze, m., hammond, j., jürgens, k. & reisser, k. advancing the diversity and inclusion agenda in healthcare organizations: the case of german university hospitals (policy brief). seejph 2022, posted: 23 june 2022. . doi: 10.11576/seejph-5600 p a g e 11 | 14 comprehensive strategy: as a first step towards commitment and transparency, all university hospitals should sign the german diversity charter. even if the corresponding universities have already signed, signing explicitly as a hospital would emphasize their commitment to improving their d&i policies. for successful and sustainable change towards integration, a comprehensive, strategic approach instead of disjointed single measures is essential and should be supported by a strong vision and commitment (16, 17). such a comprehensive approach could face internal resistance coming from several sources, including the management since it requires more effort than occasional activities focused on individual dimensions. however, only a comprehensive strategy will lead to sustainable change (16). the association of german university hospitals should take the lead to align the university hospitals into creating a strong d&i vision to move toward sustainable change strategies among the whole organization. transparency: the hospitals should communicate their d&i strategy, along with their actions, in an easily accessible way on their websites. the workforce recruitment and development processes shall follow transparently communicated criteria. the equal opportunities officers of the hospitals should be responsible for publishing the hospital’s d&i policy, responsible contact persons, and d&i activities. the management needs to provide adequate time and resources. the human resources department should also be responsible for communicating requirements, tasks, and possible support in a transparent way to all job candidates. measurements and evaluation: the association of german university hospitals should urge all university hospitals to measure the success of their d&i policies in several ways, for example, through employee engagement surveys, publishing a yearly report on d&i activities and progress concerning the diversity charter's objectives. in this way, the association should establish a benchmarking system to compare the hospitals' performances, and to allow them to learn from best practice examples as well as to inform the public. the visibility and comparability through this benchmarking system will further motivate the hospitals to improve d&i performance. a well-developed d&i program makes hospitals more attractive for aspiring health professionals (29). commitment by senior management: the senior management should be the main players in the guiding coalition. if they already envision the hospitals’ d&i policy, their further support will be easy to obtain. if not, convincing them to adopt a vision of d&i and to show commitment and leadership to it is essential for the success of a further change (18). leveraging the benefits of d&i in the argument, for instance by highlighting its positive impact on the hospital’s attractiveness to patients, the most talented health workforce, and the overall performance of the hospital helps sell the management that the development of a d&i policy is a valuable investment. employee engagement: employees of all levels should be encouraged to share their suggestions and concerns. this way, employees feel part of the change (17). hence, broad internal acceptance of d&i policies will grow and gobianidze, m., hammond, j., jürgens, k. & reisser, k. advancing the diversity and inclusion agenda in healthcare organizations: the case of german university hospitals (policy brief). seejph 2022, posted: 23 june 2022. . doi: 10.11576/seejph-5600 p a g e 12 | 14 employees can experience self-efficacy and satisfaction in their workplace. establishing networks as places of exchange and empowerment is especially valuable for employees of minority populations. internal opposition against d&i from employees is one of the greatest challenges for inclusion as this creates resistance towards employees belonging to minority groups and jeopardizes d&i activities. this can be combated by being transparent in the d&i policies and by communicating that diversity values everyone for their differences, not only minorities. german university hospitals have already started on the road towards a diverse and inclusive working environment. however, to achieve considerable and sustainable success in creating an inclusive workplace, and to attract and retain an excellent healthcare workforce, a comprehensive d&i strategy is needed. this strategy should be based on the principles of transparency, regular measurements, and evaluations, a strong commitment by the senior management as well as bottom-up involvement of employees. the association of german university hospitals has the position to lead the hospitals in this process. conclusion a compliance gap 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blob=pub licationfile&v=3 29. aagaard, e. m., julian, k., dedier, j., soloman, i., tillisch, j., & pérez-stable, e. j. factors affecting medical students' selection of an internal medicine residency program. journal of the national medical association, 2005; 97(9), 1264–1270. pmid: 16296217; pmcid: pmc2594785. ______________________________________________________________________________ © 2022 gobianidze, m et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.klinikum.uni-muenchen.de/med-internationalhttp://www.klinikum.uni-muenchen.de/med-internationalhttp://www.klinikum.uni-muenchen.de/med-internationalhttp://www.charta-der-vielfalt.de/ueber-uns/diehttp://www.charta-der-vielfalt.de/ueber-uns/diehttp://www.uniklinikum-dresden.de/de/presse/aktuelle-medienhttp://www.uniklinikum-dresden.de/de/presse/aktuelle-medienhttp://www.uniklinikum-dresden.de/de/presse/aktuelle-medienhttp://www.antidiskriminierungsstelle.de/shareddocs/downloads/de/publikationen/experti http://www.antidiskriminierungsstelle.de/shareddocs/downloads/de/publikationen/experti http://www.antidiskriminierungsstelle.de/shareddocs/downloads/de/publikationen/experti houghton f. the athena swan process to promote gender equity in third-level education in ireland. (position paper). seejph 2021, posted:12 october 2021. doi: 10.11576/seejph-4799 1 position paper the athena swan process to promote gender equity in third-level education in ireland frank houghton1 1 department of applied social sciences, limerick institute of technology, limerick, ireland. corresponding author: dr frank houghton; address: department of applied social sciences, limerick institute of technology, limerick, ireland. email: frank.houghton@lit.ie houghton f. the athena swan process to promote gender equity in third-level education in ireland. (position paper). seejph 2021, posted:12 october 2021. doi: 10.11576/seejph-4799 2 abstract introduction: sexism and misogyny remains an ongoing threat to optimal health and medical services. an important factor in health and medical services is the education and training pipeline into these careers. a substantial body of literature demonstrates the impacts of sexism in third-level education and training institutions developing future health service staff. athena swan accreditation is a benchmark designed to counter such institutional and individual sexist practices in education settings to foster equality. in recent years the athena swan process has expanded to include professional and administrative staff, as well as academics. this process has also evolved to move beyond a narrow focus on gender, to also include other crucial issues such as race, sexuality and gender identity. methods: this examination is based on the author’s role as a participant observer and critiques the athena swan process in an institute of technology in ireland. results: this examination identifies a substantial number of deficits in the athena swan process, as well as also identifying institutional resistance strategies to such gender equality work. conclusion: the current athena swan process in ireland is critically flawed. suggested strategies for those engaged in such work into the future are outlined. keywords: athena swan, education, gender equity, ireland. conflict of interest: none declared. houghton f. the athena swan process to promote gender equity in third-level education in ireland. (position paper). seejph 2021, posted:12 october 2021. doi: 10.11576/seejph-4799 3 introduction ‘nothing is more obscene than inertia. more blasphemous than the bloodiest oath is paralysis’ (1) as we start to emerge from the shadow of covid19 and it variants, the future of healthcare provision in europe is faced with a number of significant challenges. one important challenge is that of confronting sexism and its impact on the future pipeline of health service workers. sexism in the health field ample evidence exists demonstrating the pervasive nature of sexism in the health services and in university level institutions involved in medical/ health and social care training and research. at their most blatant sexist environments can enable sexual assaults, sexual coercion and physical assault, sexual harassment and active strategies to undermine women (2). the full gambit of sexism in health, medicine and science environments also extends to: macho attitudes, behaviours, and cultures in the workplace, differential pay, promotions, and research and mentoring opportunities for women, as well as an implicit and unconscious bias based on outdated patriarchal stereotypes (3). although health professionals in training are at particular risk (4), gender based abuse is by no means limited to those in training and continues throughout the careers of many health professionals (2). tackling such systemic sexism is particularly difficult and complex (5). the medical/ health/ stem pipeline the adverse impact of sexism on the workforce pipeline into the medical field, the allied health and caring professions, and the stem (science, technology, engineering & mathematics) sector generally is a particular concern, and may be described as critically fractured (6). as well as being an issue in general nursing and medicine, specific gender based pipeline issues for the future health service workforce have been observed in many fields, including: dental care (7); radiology (8); palliative care (9); plastic surgery (10); anaesthesiology (11); communication and speech therapy (12); biomedical engineering (13); academic surgery (14); and orthopaedic surgery (15). athena swan different european countries have responded to this issue in a variety of ways. a notable response to these issues has been the athena swan benchmarks, which were developed in the uk. the athena swan gender equality accreditation scheme was launched in 2005 by the equality challenge unit (ecu) (16). this initiative combined two former elements, the athena project, and the scientific women’s academic network (swan) (17). in the following years athena swan grew dramatically, from involving just 10 institutions in 2005 to 140 in 2017. in 2015 it was extended to include ireland and australia, and variations of the charter have also since been established in both canada and the us (16,18). sexism in irish third-level education the focus in this analysis is ireland, and this examination is based on the author’s role as a participant in, and experience of, an irish higher education institution’s application for athena swan bronze award accreditation. it is important to note that ‘ireland’s constitution envisages a restricted role for women’ and ireland’s first gender discrimination laws were only introduced after it joined the european community (19). despite the subsequent introduction of legislation outlawing gender-based discrimination in ireland (employment equality acts 1998-2015), gender disparities in employment in the irish higher education sector only started to be taken seriously by the irish government in the aftermath of the high profile 2014 legal cases of sheehy houghton f. the athena swan process to promote gender equity in third-level education in ireland. (position paper). seejph 2021, posted:12 october 2021. doi: 10.11576/seejph-4799 4 skeffington v national university of irelandgalway and dempsey v national university of ireland galway (20). in both cases the university was found guilty of gender based discrimination (21), with four more female lecturers also denied advancement subsequently being promoted after a long legal battle (22). in response to such blatant discrimination former european commissioner (research, innovation & science portfolio), máire geoghegan-quinn, was appointed to lead an expert group to explore this issue in 2015. the report of this expert group identified significant under-representation of women at senior levels among both academic and professional, management and support staff (pmss) (23). the gender equality taskforce, which was subsequently established by the then minister for higher education, mary mitchell, noted only miniscule improvements and this inertia led to the launch of a gender action plan (24). in the following year a centre for excellence in gender equality in the higher education authority (hea) was established. it is important to note that prior to these developments the position of women in academia in ireland had actually deteriorated in the preceding decades (25). a hea funded gender equality unit was closed in 2002, and from 2004 to 2012 the hea did not publish a gender equality breakdown of the higher education sector (25). figures 1 and 2 detail the percentage of women by academic grade (whole time equivalents) in irish universities and institutes of technology respectively. the linear gradient is particularly stark in ireland’s universities, with only 23% of professors being women. it is notable that in the latest report on this issue ireland had never had a female president at any of its seven universities, while there were currently two female presidents in the institute of technology sector which encompassed 11 institutions. figure 1. percentage of women by academic grade in the irish university system 23 32 38 51 professor associate professor senior lecturer lecturer universities in ireland % of women (wte) houghton f. the athena swan process to promote gender equity in third-level education in ireland. (position paper). seejph 2021, posted:12 october 2021. doi: 10.11576/seejph-4799 5 figure 2. percentage of women by academic grade in the irish institute of technology sector critiques of the athena swan process it is important to note that perceptions of the impact of athena swan are often overwhelmingly positive (26), and particular improvements have been noted among those institutions that have obtained more advanced silver accreditation (18). the following assessment by schmidt et al. is fairly typical: ‘athena swan is the single most comprehensive and inclusive gender equality scheme in europe’ (27). critiques of the athena swan process are rare. however, a small number of discordant voices questioning the athena swan project do exist and they reveal a number of significant issues of concern. some of the negative issues associated with athena swan include the administrative burden it places on institutions (17), as well as observations that women are undertaking the majority of athena swan work, often at a cost to their own career and research (16,17,27-29). other issues for concern include opposition to perceptions of positive discrimination (30), and critiques that family friendly policies aimed at women simply serve to reinforce an ideology that women’s role is caring work (17). other critiques include econometric analysis that suggests that although there have been improvements in women’s representation in many athena swan accredited organisations, this may not be the result of athena swan initiatives (31). some commentators have also suggested that the link between athena swan accreditation and access to research funding has resulted in the process becoming simply a box ticking exercise (18,28,32), with little or no engagement with wider inequalities, such as social class (28). critiques of gender equality work wider critiques of gender equality work are also relevant. the concept has often been criticised as ‘tinkering’ and having too strong a focus on data, monitoring, and evaluation (33). it is has been suggested for example that bureaucratic norms hinder moves towards gender equality (34). prügl 31 40 33 45 49 senior lecturer 3 senior lecturer 2 senior lecturer 1 lecturer assistant lecturer institutes of technology in ireland % of women (wte) houghton f. the athena swan process to promote gender equity in third-level education in ireland. (position paper). seejph 2021, posted:12 october 2021. doi: 10.11576/seejph-4799 6 discusses such managerialist discourses and approaches that are complicit in neoliberal forms of governance using the term ‘governance feminism’(35). such approaches focus on the ‘technicalization and professionalization’ of gender equity work with its statistical data and implicit ‘acceptance of… positivist and managerial forms of knowledge’(36). this quandary is perhaps best summed up by ahmed’s statement ‘you end up doing a document rather than doing the doing’ (37). a major critique is that feminist knowledge and subjectivities are changed through involvement in such work (33,35,36). ikävalko & kantola also emphasise the focus in gender equity work on dialogue, rather than goals, and insightfully state that ‘action that emphasises dialogue generates an impression of change although nothing transforms in power relations’(36). questions have been asked whether an organisations overt engagement with gender equality work really stems from a commitment principles of corporate social responsibility (csr) around this issue, or are really a form of ‘femvertising’ (38). this research sought to critique the athena swan accreditation process and to further develop and expand the critical literature around this form of gender equality work. such evaluations are crucial in university level institutions in order to better understand critical issues in the pipeline into careers in stemm (science, technology, engineering, mathematics & medicine) subjects. the health of the health services themselves requires an end to overt and covert sexism and discrimination in education, the workplace, and in wider societal settings. method this exploration of the athena swan bronze award accreditation process is based on a participant-observer approach involving an examination of limerick institute of technology (lit), a university level education institution in ireland. many elements of the issues examined are based on the author’s active involvement in the accreditation process. the author was a member of the athena swan selfassessment team (sat), and was also member of the data sub-group. as a member of the data sub-group he was responsible for construction and analysis of the online staff survey (using survey monkey for data collection and spss v.26 for quantitative data analysis), which formed the basis of the institute’s selfassessment. the author was also one of three academics involved in thematic analysis of the open-ended questions involved in the self-assessment survey. this analysis is based on observation of the accreditation process, the results of the quantitative and qualitative examination conducted as part of the institute’s selfassessment are reported elsewhere (39). a particular focus of this analysis is an examination of notions of power, resistance, and power relationships. this work is informed by the work of the french philosopher michel foucault (40,41). as ikävalko & kantola note ‘feminist resistance is always intertwined with and in interplay with resistance to feminism’ and that a focus on this ‘sheds light on the possibilities and challenges involved in transforming gender relations through this kind of work’ (36). sharing this information is vital, as a series of equality minimisation tactics and strategies were observed by the author that critically undermined substantive moves towards gender equality. on the basis that ‘forewarned is forearmed’ these findings are outlined in-depth to inform and better prepare readers and future participants in athena swan, and similar, accreditation processes. site overview: limerick institute of technology is a multicampus university level education institution in ireland offering training ranging from apprenticeship level to phd level. it has approximately 7000 students houghton f. the athena swan process to promote gender equity in third-level education in ireland. (position paper). seejph 2021, posted:12 october 2021. doi: 10.11576/seejph-4799 7 and is currently based on five sites across three counties (co. clare, co. limerick & co. tipperary). as an institute of technology (iot) it has an explicit regional focus and is also tasked with widening access to higher education. traditionally iots have been very vocationally oriented, but in recent years, their focus has broadened. lit is currently in a consortium with a similar organisation, athlone institute of technology (ait), and is expected to be re-designated as a technological university (tu) within the next six months (42). in relation to the health and medical staff pipeline it is worth noting that universities are generally seen as more prestigious than iot’s and all medicine and dental programs in ireland are taught there. the universities also teach all of the pharmacy, speech & language therapy (slt), occupational therapy (ot), physiotherapy courses, dental hygiene, and emergency medical science courses, as well as the vast majority of courses in psychology, midwifery and social work. the institutes of technology, being more applied and vocationally oriented, are unfortunately generally perceived as being the less prestigious sector in irelands binary higher education system (43). as such they teach all of the social care work, and pharmaceutical science/ analysis courses, and approximately half of the nursing courses in ireland. results a significant number of crucial issues emerged throughout the accreditation process, many of which appear absent in much of the athena swan literature to date. the following sub-sections explore issues of: leadership, sat membership, consultation, coverage, diversity, engagement, pressure, dissemination, links to funding, issues in time and space, whistleblowing, and burnout. perfunctory leadership/ management evidence suggests that effective interventions to combat gender discrimination require the very highest levels of management in an organisation to be ‘highly invested in the project or… taking on a leadership role’ (16). unfortunately, this was not apparent in the organisation in question. engagement by the organisation’s most senior leadership appeared minimal and perfunctory towards the athena swan accreditation process. there is a significant academic literature in the field of business which neatly outlines the crucial differences between leadership and management (see table 1). table 1. the differences between management & leadership (43) management produces order and consistency leadership produces change and movement planning and budgeting • establish agendas • set timetables • allocate resources establishing direction • create a vision • clarify big picture • set strategies organizing and staffing • provide structure • make job placements • establish rules and procedures aligning people • communicate goals • seek commitment • build teams and coalitions controlling and problem solving • develop incentives • generate creative solutions • take corrective action motivating and inspiring • inspire and energize • empower subordinates • satisfy unmet needs houghton f. the athena swan process to promote gender equity in third-level education in ireland. (position paper). seejph 2021, posted:12 october 2021. doi: 10.11576/seejph-4799 8 on the basis of table 1 it is therefore undoubtedly true to say that the athena swan process was managed, rather than led, in the organisation in question. this served to critically undermine any impetus towards substantive change. membership (who is in and who is out) a crucial element of control is undoubtedly suppression (45,46). a crucial element of suppression is entry to key groups such as the self-assessment team (sat) in a process such as athena swan. in the selection process at least one vocal, committed feminist and activist who applied was excluded from membership of the sat. further, informal discussions with other colleagues potentially interested in involvement in the athena swan accreditation process revealed that many had no faith in such a process within the organisation and so declined to become involved. others resisted participation in the process as they felt alienated and damaged by the organisation and hence wanted to restrict their interaction with it to the absolute minimum. such opting out of the process is an understandable and an important defence mechanism in an organisational culture where bullying and intimidation is widespread (39). however, the impact of such self-selection bias on the inclusiveness of the accreditation process should not be underestimated. consultation (who is in and who is out) one notable feature of the athena swan accreditation process is the absence of any direct communication between the wider community in the organisation being assessed and the panel reviewing the application. the review process is essentially a paper-based examination, with all documents examined by the panel being carefully prepared and forwarded by the senior member of executive management leading the accreditation process on behalf of the applicant organisation. this rather limited and closed process is in stark contrast to other consultations in the irish higher education sector, such as the international review panel, whose visits are associated with institutes of technology merging and working towards technological university status. in these visits it is standard for ireland’s higher education authority to establish a unique email address, external to the applicant organisations, inviting confidential comments that are carefully anonymised before being passed to the panel. this email address is then shared with all staff. the paper based format of the athena swan review with no consultation email prevents staff on the ground from voicing and protesting their concerns. concerns that may well be ignored, side-lined, or minimised by organisational management (47). coverage (who is in and who is out) there have been two significant expansions in the types of staff covered by athena swan. although initially targeted at stemm disciplines, it was subsequently extended to all academic disciplines, and further expanded once again to include professional and managerial staff. although these are obviously important and worthwhile developments, significant numbers of staff working within the organisation are still not covered by athena swan reporting. neo-liberal influences have led to the sub-contracting of vital campus services, notably in relation to cleaning, catering, parking, and security services, as well as in the supply of temporary clerical and administrative personnel (48,49). none of these personnel, many of whom are undoubtedly employed on near minimum wage contracts, are covered by the athena swan process and associated accreditation. diversity (who is in and who is out) historically the athena swan process was rooted in the experiences of women battling for careers in stemm subjects. the focus houghton f. the athena swan process to promote gender equity in third-level education in ireland. (position paper). seejph 2021, posted:12 october 2021. doi: 10.11576/seejph-4799 9 of athena swan also includes race/ ethnicity and more recently a focus on gender identity and sexuality. however, although there is an acceptance of intersectionality, a focus on the crucial factor of social class is wholly lacking in the athena swan project (28). the absence of this vital dimension is often routine, and yet continues to critically weaken any systematic attempts to combat inequality (50). this is an ideological blind-spot that reflects neo-liberal attitudes towards poverty, those of blame, shame and stigma. limited engagement the athena swan process involved a self-assessment team (the sat) and a number of sub-groups. attendance at all elements declined throughout the process. heavy teaching loads (vis-à-vis the university sector), the bureaucratic processes involved, and widespread staff alienation and distrust undoubtedly had much to do with this. equally, there was very limited engagement from the wider institutional community in the process. suggestions by sat members to promote wider staff engagement went unheeded. for example, figure 3 details a proposed poster to promote staff engagement with the athena swan process that was never adopted. figure 1. example of a proposed poster to promote wider staff engagement with the athena swan process that was never used (reproduced with permission of the artist, ken coleman) houghton f. the athena swan process to promote gender equity in third-level education in ireland. (position paper). seejph 2021, posted:12 october 2021. doi: 10.11576/seejph-4799 10 subtle pressures to edit results following the staff survey and its analysis three members of the data group of the sat, including the author, produced a report on the findings. the self-assessment report detailed extensive concerns over sexism, bullying, a lack of trust in management, and fears over reporting such issues. pressure was subsequently subtly applied to try and encourage the authors to change certain aspects of the report. ostensibly credible reasons were generally given for such revisions. however, as this editing process developed and further requests to change things were made, the author and at least one colleague stated that any further revisions would necessitate their resignation from the sat. limited dissemination as noted above the results contained in the sat report were damning. assurances of wider dissemination of the results of the self-assessment by the institute throughout its five campuses were never honoured. dissemination of the results of the selfassessment was minimal. a seminal moment that laid bare the lack of institutional commitment to athena swan principles was the release of the overview of findings of the athena swan survey (39). links to this report and associated data files were released on tuesday 17th december 2019. this date is highly significant in terms of seeking to minimise the uptake and impact of the findings from the staff survey, a key component of the accreditation process. the autumn term finished on the preceding friday, at the end of exam week. as exam boards are held early in the new year, any staff not already having decided to take a break and focus on christmas were in all probability marking exams, assignments, or chasing students for missing coursework. this may be described as a ‘black report moment’ for the organisation (51), a term referencing attempts by margaret thatcher’s conservative government in the uk to bury unwelcome findings about the existence of significant health inequalities by, among other nefarious tactics, releasing a report late on the friday of a bank holiday weekend (52,53). commitment & funding engagement in the athena swan process was clearly driven by the linkage between accreditation and research funding. three key funders of research in ireland: science foundation ireland, the irish research council, and the health research board, have made future funding conditional on athena swan gender equality accreditation. european union horizon 2020 funding also includes a distinct gender equity dimension and achievement of athena swan awards will undoubtedly help ensure that the organisation remains eligible for such funding. although this ‘strategic stick’ (32) was undoubtedly essential in jump-starting the organisation’s involvement in the athena swan accreditation process, it quickly became apparent that this was the sole driving force behind what passed for the ‘engagement’ of wider management in the process. it became clear that attaining athena swan accreditation was a simple hurdle to be overcome, without any fundamental attempts to change institutional culture. critiques of athena swan as a box-ticking exercise have been noted above (18,28,32). however, as the athena swan process progressed it became transparent that continued access to such funding was really the true extent of institutional ‘commitment’ to the process. this was extremely unfortunate as numerous respondents had specifically noted in their responses to the staff survey that the athena swan process had to be more than bureaucratic ‘box ticking’. houghton f. the athena swan process to promote gender equity in third-level education in ireland. (position paper). seejph 2021, posted:12 october 2021. doi: 10.11576/seejph-4799 11 appearances can be deceptive: the space/ time paradox two additional issues of concern were observed throughout the athena swan process and subsequent reflection. the first of these deals with time. the first sat meeting was held on 19th june 2018 (54). it is notable that the academic year for institutes of technology in ireland is very rigid and begins on the 1st of september each year and finishes on the 20th of june (55). the institutes of technology largely operate a secondary school based annual calendar, with most academic staff on holiday throughout the summer period. the end of term meeting was nothing more than a cynical attempt to make the consultation process appear longer than it was. this was little more than a perfunctory meet and greet session, followed by a break of almost 3 months. this manipulation of ostensible timelines was an important element in managing the optics of the consultation process to facilitate the illusion of deeper, more-prolonged engagement. a related issue is that of space to discuss deficits in the athena swan process. the author noted deficits and issues in the process and then explored the athena swan ireland site looking for an opportunity to raise such concerns. it appeared that an ideal opportunity was forthcoming in the form of the first athena swan conference in ireland on the 10th of june 2021: the next steps for equality, diversity and inclusion: advance he's inaugural conference in ireland. however, upon closer examination, rather than a standard conference in which academics and practitioners generally had an opportunity to apply to speak, this conference was a pre-packaged information event, and not a typical conference as many would understand it. appeals/ whistleblowing related to the issue of limited consultation outlined above are a number of critical deficits in the appeals/ whistleblowing process associated with athena swan. table 2 details wording from advance he’s guide to processes outlining information relating to the withdrawal of an award. table 2. withdrawal of accreditation in advance he's guide to process (56) advance he will not consider information from anonymous sources or which requires further investigation. if requested, advance he will not name the source when communicating to the applicant, but anonymity cannot be guaranteed as – depending on the objection – identities may be inferred. it must be acknowledged that such flimsy protections would make the most ardent whistle-blower circumspect about initiating a complaint (57,58). this deficit is crucial as ample evidence exists in the health and medical arena outlining the negative impacts of whistleblowing on the physical and mental health of those reporting the issue (59,60,61). the flimsy protections for challenging athena swan accreditation are particularly pertinent in ireland given high profile cases in both the irish health (61-63) and policing spheres (64,65) where whistle-blowers were significantly compromised because of their reporting. the requirement for non-anonymous communications seeking to contest athena swan accreditation is at odds with legal practice in ireland in relation to other issues, such as child sexual abuse. tusla, the state child protection agency in ireland, encourages reporting from named individuals, but will accept anonymous reporting. burnout in his classic text the art of war sun tzu suggests that ‘to fight and conquer in all our battles is not supreme excellence; supreme excellence consists in breaking the enemy’s resistance without fighting’. it is an unfortunate reality that, given the lack of houghton f. the athena swan process to promote gender equity in third-level education in ireland. (position paper). seejph 2021, posted:12 october 2021. doi: 10.11576/seejph-4799 12 substantive change to date and the lack of feedback to staff on the findings of the survey, the principles behind athena swan have been further undermined. with most staff alienated, distant and distrustful of this initiative, those still keen to be involved were either excluded from the process, or left due to burn-out. similarly, it seems unlikely that even those staff that voluntarily opted for involvement in the bronze application would do so again. from an institutional perspective of maintaining the status quo, this may be a success. the bronze award therefore has provided the perfect corporate camouflage for a continuation of ‘business as usual’. discussion the current athena swan process is critically flawed. there are currently a significant number of deficits in the process which clearly need to be redressed moving forward. the expansion of athena swan to include administrative and professional staff is important, but in modern higher education institutions operating in a neoliberal environment the current athena swan process continues to ignore those engaged in jobs that would once have been integral to the organisation (e.g. catering, cleaning), but which have now been subcontracted out. the irony in the exclusion of these roles from the athena swan process, many of which are parttime, minimally paid roles, predominantly performed by women is painful. similarly, the expansion of athena swan into examining issues such race, ethnicity, sexuality, gender identity and intersectionality is welcome. however, the exclusion of social class from such analysis is unforgivable. the athena swan accreditation process needs to include wider avenues of contact and consultation with the community being examined. a manicured document produced for limited consultation with hand-picked groups and finally submitted without oversight can be a poor gauge of wider concerns. the athena swan process around whistleblowing and challenging accreditation is also unfit for purpose. ample evidence exists demonstrating the physical, psychological and career harm that often accompanies whistleblowing (45,46). space and time also needs to be built into athena swan activities and structures, such as their conference program to facilitate the ‘airing of dirty laundry’ to facilitate robust discussions and critiques. conclusion and recommendations this examination demonstrates how an organisation can successfully resist moves to counter sexism and misogyny. such actions may be termed gender equality minimisation strategies. they include perfunctory leadership that is really only concerned with box-ticking to meet standards for funding applications. such strategies also include exclusion, limited engagement, pressure to amend unwelcome findings and limiting dissemination. ensuing staff weariness and burnout from engagement in such gender equality work processes is an added bonus to maintaining the status quo. it is surprising that more analysis of the organisational cultures of the iot/ technological university (tu), and university sector in ireland has not been conducted. further examination of cultures that facilitate bullying, intimidation, mistrust and misogyny are required. a useful start in this field would be a project synthesising the findings from the athena swan surveys conducted in each iot/ tu and university in ireland. in order to avoid some of the issues identified in this examination hindering gender equality work in the future, it is suggested that academics and practitioners engaged in similar roles consider adopting the following strategies: • sat members take full ownership of the accreditation process; houghton f. the athena swan process to promote gender equity in third-level education in ireland. 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(position paper). seejph 2021, posted:12 october 2021. doi: 10.11576/seejph-4799 17 ______________________________________________________________________________________ © 2021 houghton; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. finucane a, stritch jm. connecting the person by removing the stigma: why ireland should follow the portuguese model of drug decriminalisation (position paper). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5768 p a g e 1 | 7 position paper connecting the person by removing the stigma: why ireland should follow the portuguese model of drug decriminalisation aisling finucane1, jennifer moran stritch1 1) technological university of the shannon, limerick, ireland corresponding author:aisling finucane, technological university of the shannon, limerick, ireland. e-mail: jennifer.stritch@lit.ie mailto:jennifer.stritch@lit.ie finucane a, stritch jm. connecting the person by removing the stigma: why ireland should follow the portuguese model of drug decriminalisation (position paper). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5768 p a g e 2 | 7 abstract the decriminalisation of drugs and how it can impact addiction, crime and mental health is a subject that inspires global interest and debate. much has been written about the positive outcomes of decriminalisation from a public health perspective, including the elimination of aggressive policing and community oversight and the shift to offering treatment and social supports for those affected by addiction. ireland has yet to move to a model of decriminalisation, although a system similar to the one employed in portugal has been suggested. this article briefly outlines reasons why a paradigm shift is vital if progress is to be made in reducing addiction in contemporary ireland. the potential benefits could include a reduction in the pervasive social stigma connected with substance abuse, leading to less social exclusion within the irish population. keywords: drug decriminalisation, stigma, ireland finucane a, stritch jm. connecting the person by removing the stigma: why ireland should follow the portuguese model of drug decriminalisation (position paper). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5768 p a g e 3 | 7 it is widely accepted that struggles with addiction can keep individuals trapped in an ongoing maelstrom of social exclusion, poverty and poor health. this cycle may be made intractable by exposure to the criminal justice system and incarceration, which is a predominant response across the globe to the possession, use and distribution of most illegal drugs. these punitive policies, centred on policing and prison, may in fact exacerbate social and personal issues for those mired in addiction (1,2). however, the decriminalisation of drugs has been mooted as a public health solution to the web of addiction, arrest, incarceration and reincarceration. decriminalisation, or the legalisation of certain illegal activities that were formerly punishable by law (3,4) raises many complex issues. as of this writing, the possession of illegal substances for the purpose of sale or supply remains a crime in ireland. decriminalisation would create a policy framework that would allow a public health response to drug addiction rather than a punitive justice system approach. this piece discusses the impact of stigma linked to criminalisation for the individual struggling with substance abuse and addiction, and sets out our brief argument for decriminalisation in ireland. a move to this approach would require a definitive change in the way we think about substances, criminality, drug treatment and mental health, but we believe it is the best way forward for irish society. according to the 2021 world drug report, persons convicted of drug offenses account for 18% of the global jail population (5). over 80% of reported drug offences in european countries included possession for personal use, with the remainder involving trafficking (6). apart from the social and economic implications, worldwide drug policy has been chastised for decades for being shaped by political and moralistic approaches, positioned as "tough on crime" or fighting the "war on drugs." negative public perceptions of drugs and drug users have encouraged political leaders to maintain stringent control measures, as it is generally a comfortably conservative and politically safe alternative to meet the public desire for strict enforcement (7). prohibition and criminal sanctions against the possession and use of substances is a public health quandary. an increased risk of overdose death, spurred on by secret and hurried episodes of use and lack of inspection or regulation, has been linked to aggressive policing and enforcement techniques (8). it is commonly acknowledged that heavier sanctions have a limited deterrent effect on drug use, while inadvertently harming users more than the substances themselves (9). in many countries, racial, ethnic, and socially marginalised minorities are disproportionately affected by tough drug policies. research suggests that law enforcement officers in the field tend to implement rules in a discriminatory manner, causing disadvantaged groups in the community to be subject to more frequent arrests and incarceration due to drug possession (10). in ireland, drug-related hazards are a major worry, with concerns ranging from increased overdose rates to the negative influences of violent and organised crime which are part and parcel of the illegal drug trade. research indicates a rate of nearly two drug-related deaths every day in ireland in 2015 (11). drug-induced mortality rates in ireland are at finucane a, stritch jm. connecting the person by removing the stigma: why ireland should follow the portuguese model of drug decriminalisation (position paper). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5768 p a g e 4 | 7 the higher end of the range in the european union (12). drug policy approaches in ireland over the last four decades have shifted to targeting individual drug-using behavior. a greater emphasis on individual responsibility, power centralisation, and a public management system focused on measuring outputs, effectiveness, and value for money – all of which are completely disconnected from the needs of people and communities affected by addiction – are just a few examples of this focus (13). furthermore, studies undertaken in irish jails have revealed a prevalent drug culture that potentially encourages drug use (14,15,16) suggesting that most inmates have serious drug addiction concerns. clearly, the interplay of addiction, policing and incarceration does not solve, and in fact may exacerbate, the problem of illegal drugs in irish society. the label of addiction, with the negative connotations of secrecy and criminality, creates almost insurmountable difficulties for those affected by it. the term "stigma" can be traced back to the ancient greeks, indicating "a blemished person, ritually defiled, to be avoided, particularly in public places"(17). goffman (17) provides a detailed explanation in his seminal work of how stigmatised people interact with others, and how their encounters are negatively affected by their mutual awareness of stigma. many drug users experience stigma, compounded by the exclusion created by incarceration and ongoing involvement in the criminal justice system (18,19). removing the punitive aspects of policing, legal sanctions and imprisonment may lessen the stigma and create more pathways for treatment and positive social connection for the chronically addicted. from a public health perspective, the portuguese model of decriminalization could provide some answers for ireland, reorienting the approach from punishment and isolation to treatment and support. this reorientation could also result in a reduced level of stigma around drugs and drug use. the success of decriminalization in portugal is evidenced by population drug use rates well below the european norm and far below those in the united states (20). following the enactment of decriminalisation, the number of people arrested and referred to the portuguese courts for drug offenses decreased by more than 60% each year (20). the number of individuals incarcerated in portugal for violating drug laws has also dropped considerably, from 44% in 1999 to 24% in 2014 (21). there is some evidence that portugal's 2001 decriminalisation of all illicit substances resulted in lessened stigma around substance use, with positive public health consequences (22, 23). in 2015, the oireachtas (irish parliament) joint committee backed the decriminalisation of drugs for personal use, emphasising the utility of the portuguese model of decriminalisation (24). this is a positive development which, we argue, should be fully resourced and implemented as soon as possible. decriminalisation, aimed at harm reduction and supporting therapeutic responses to addiction rather than a punitive criminal justice approach, could have huge public health benefits for ireland and many other countries. references 1. buchman. j.& young. l. 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[accessed 1 february 2022] ________________________________________________________________________________ https://www.citywide.ie/assets/files/pdf/cdatf_outcome_report_drug_harms.pdf https://health.gov.ie/wp-content/uploads/2019/08/report-of-working-group-alternatives-possession-of-drugs.pdf https://health.gov.ie/wp-content/uploads/2019/08/report-of-working-group-alternatives-possession-of-drugs.pdf https://health.gov.ie/wp-content/uploads/2019/08/report-of-working-group-alternatives-possession-of-drugs.pdf https://health.gov.ie/wp-content/uploads/2019/08/report-of-working-group-alternatives-possession-of-drugs.pdf finucane a, stritch jm. connecting the person by removing the stigma: why ireland should follow the portuguese model of drug decriminalisation (position paper). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5768 p a g e 7 | 7 © 2022 finucane et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1 south eastern european journal of public health special volume no. 4, 2022 health status of the populations and health sector reforms in albania and kosovo 2 executive editor prof. dr. genc burazeri phd faculty of medicine, st. dibres, no. 371, tirana, albania, and caphri, faculty of health, medicine and life sciences, maastricht university, 6200 md, maastricht, the netherlands email: genc.burazeri@maastrichtuniversity.nl and: gburazeri@gmail.com skype: genc.burazeri volume editor dr. naim jerliu faculty of medicine, university of prishtina and national insitute of public health of kosovo, str. insituti shëndetësor, nn. 10000, prishtina, kosovo email: naim.jerliu@uni-pr.edu assistant executive editor kreshnik petrela ba tirana, albania email: kreshnikp@gmail.com technical editor meri roshi ba tirana, albania email: meriroshi90@gmail.com publisher dr. hans jacobs jacobs publishing house am prinzengarten 1 d 32756 detmold, germany email: info@jacobs-verlag.de phone: +49 5231 6161885 the publication of the south eastern european journal of public health (seejph) is organised in cooperation with the bielefeld university library. mailto:genc.burazeri@maastrichtuniversity.nl mailto:gburazeri@gmail.com mailto:naim.jerliu@uni-pr.edu https://www.seejph.com/index.php/seejph/libraryfiles/downloadpublic/126 mailto:kreshnikp@gmail.com https://www.seejph.com/index.php/seejph/libraryfiles/downloadpublic/127 mailto:meriroshi90@gmail.com mailto:info@jacobs-verlag.de https://www.ub.uni-bielefeld.de/ 3 seejph south eastern european journal of public health www.seejph.com/ special volume 4, 2022 publisher: jacobs/germany issn 2197-5248 http://www.seejph.com/ 4 issn2197-5248 doi 10.11576/seejph-5761 10.4119/unibi/seejph-2016 106 bibliographic information published by die deutsche bibliothek. die deutsche bibliothek lists this publication in the deutsche nationalbibliografie; detailed bibliographic data is available on the internet at http://dnb.ddb.de south eastern european journal of public health (open access journal). copyright 2022 by jacobs publishing house: am prinzengarten 1, d 32756 detmold, germany copyright cover picture: wordpress foundation: http://wordpressfoundation.org/gnu general public license http://dnb.ddb.de/ http://wordpressfoundation.org/gnu 5 table of contents original research epidemiological profile and incidence of brain tumors in kosovo sefedin muçaj, naser ramadani, serbeze kabashi-muçaj, naim jerliu, albiona rashitibytyci1, sanije hoxha overview on epidemiological and clinical manifestation of covid-19 in albanian adults najada çomo, esmeralda meta, migena qato, nevila gjermeni, entela kolovani, pellumb pipero, arjan harxhi, dhimiter kraja technical efficiency of kosovo public hospitals emiljan karma, silvana gashi level of satisfaction and sociodemographic correlates among users of primary health care services in kosovo haxhi kamberi, vanesa tanushi, muhamet kadrija, safete , kamberi, naim jerliu assessment of mother-to-child hiv prevention program in albania enkeleda prifti, enxhi vrapi, marjeta dervishi, aldo shpuza, justyna d kowalska, arjan harxhi review articles overview on health status of the albanian population iris mone, bledar kraja, enver roshi, genc burazeri policy brief improving nutrition and health among albanian schoolchildren jolanda hyska case studies nonoperative management for major blunt hepatic trauma in a 3-year-old child dritan cela, valmira abilaliaj, aldo shpuza prof. dr. genc burazeri phd dr. naim jerliu kreshnik petrela ba dr. hans jacobs copyright 2022 by jacobs publishing house: am prinzengarten 1, d 32756 detmold, germany table of contents cela d, abilaliaj v, shpuza a. nonoperative management for major blunt hepatic trauma in a 3-yearold child (case report). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5925 p a g e 1 | 6 case study nonoperative management for major blunt hepatic trauma in a 3-year-old child dritan cela1, valmira abilaliaj1, aldo shpuza2 1 department of surgery, university trauma hospital, tirana, albania; 2 department of public health, faculty of medicine, university of medicine, tirana, albania. corresponding author: dritan cela, md university trauma hospital, tirana, albania telephone: +355674939333; email: dritan.cela@yahoo.com cela d, abilaliaj v, shpuza a. nonoperative management for major blunt hepatic trauma in a 3-yearold child (case report). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5925 p a g e 2 | 6 abstract introduction: based on hemodynamic stability, non-operative management of lowand highgrade liver injury is the first treatment choice over surgical treatment. small clinics are still preferring primary operative approach instead of nonoperative one. presentation of the case: we are presenting a case (3-year-old male child) of nonoperative treatment of a grade iv blunt liver trauma (lacero-contusive injury of v, vi and vii segments) with massive hemoperitoneum. the patient was put into a conservative treatment with antibiotics, fluids and ½ unit of blood. the results of computed tomography showed significant amounts of perihepatic and periileal fluid between the bowels and in the douglas pouch, which persisted for five days. laboratory alterations of serum glutamic pyruvic transaminase, serum glutamic-oxaloacetic transaminase, and total bilirubin reached their maximum values on third day, persisting in decline until fifth day and returned to normal after tenth day. the hospital stay was 11 days, the length of time necessary for the complete conservatory treatment and full recovery of the trauma. discussion: more than 80%-90% of liver injuries are managed with nonoperative intervention. early and late complication can be managed by interventional radiology procedures when it is possible. success rate of conservative treatment is over 80%. conclusion: if no other abdominal injuries are evident and patient is hemodynamically stable nonoperative management for major blunt hepatic trauma in children is the best choice of treatment. keywords: nonoperative, hepatic trauma, hospital stay cela d, abilaliaj v, shpuza a. nonoperative management for major blunt hepatic trauma in a 3-yearold child (case report). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5925 p a g e 3 | 6 introduction operative management of severe blunt liver trauma (as the abdominal organ most commonly injured) is often associated with significant morbidity and mortality (1). despite the difficulty of choosing the right management, nonoperative management of blunt liver injury is currently the treatment modality of choice for hemodynamically stable patients, regardless of the degree of injury or age of the patient (2). thus, even in paediatric age, surgical interventions for liver injuries are almost history (3). the choice of trauma management is facilitated when the environment offers clinical monitoring and serial exam capabilities and an operating room available for emergency laparotomy (2,4). university trauma hospital is the only centre providing tertiary healthcare in trauma management, so it offers all of the aforementioned capabilities. in this context, a presentation of a case with major blunt liver trauma under non-operatory hospital management conditions was presented. presentation of the case a 3-year-old male child was presented in severe condition in the emergency department of the university trauma hospital, tirana, albania, after a car accident. after the emergency ultrasound was performed, at the time of admission, a considerable amount of perihepatic and periilenal fluid was found between the bowels and in the douglas pouch. according to laboratory tests, the results showed relevant values: white blood cells (wbc) 18.5k/ul, haematocrit (hct) 27%, red blood cells (rbc) 3.200 000, haemoglobin (hb) 9.2 g/dl, serum glutamic pyruvic transaminase (sgpt) 198u/l, serum glutamic-oxaloacetic transaminase (sgot) 178u/l, and total bilirubin 1.40mg/dl. regarding hemodynamic, the parameters appear to be stabilized: arterial pressure 100/60 mm hg, v=136 min, and oxygen saturation (sat o2) 99%. abdominal computed tomography (ct) reinforces the findings of considerable abdominal perihepatic and periilenal fluid between the bowels and in the douglas pouch, with a large contusion area of segments v-vi-vii of the liver (image 1). the patient was put into a conservative treatment with antibiotics, fluids and ½ unit of blood. image 1:ct image, day 1 cela d, abilaliaj v, shpuza a. nonoperative management for major blunt hepatic trauma in a 3-yearold child (case report). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5925 p a g e 4 | 6 after two days, the patient presented with flatulence and painful abdomen. however, the patient continued to have a stable hemodynamic status, while laboratory values are presented as follows: total bilirubin 2.4, sgpt 1490 u/l, sgot 1400 u/l, amylase 17 u/l, lipase 7 u/l, wbc 15.2, rbc 3.800 000 and hb 10.4. in this context, a contrast-enhanced ct of the abdomen was performed, the findings of which showed significant amounts of perihepatic and periileal fluid between the bowels and in the douglas pouch. no active bleeding and no other obvious damage in the abdomen were observed (image 2). image 2: ct image, day 2 after the third day, the clinical condition remained the same, with the patient having also a sub-febrile temperature of 38 degrees celsius and the laboratory alterations persisted with the following values: total bilirubin 8.7, direct bilirubin 5.1, sgpt 2240 u/l, sgot 198000 u/l, amylase 17 u/l, lipase 7 u/l, wbc 18.2, rbc 3.900 000, and hb 11.0. during the ultrasound, a diminutive quantity of perihepatic and perilenal blood were observed, with a minimum of liquid in morison, and a considerable amount between the bowels and in the douglas pouch. after the fifth day, the patient was cannulated, active and fed enterally. the temperature was 37.5 degrees celsius, the hemodynamic remained stable and laboratory values began to drop to the following values: creatinine 0.37mg/dl, total bilirubin 5.2, direct bilirubin 3.0, sgpt 1710 u/l, sgot 16440 u/l, amylase 23u/l, lipase 8 u/l, wbc 15.2, rbc 3.800 000, and hb 10.4 in the i/v contrast ct abdomen, a small amount of liquid was found between the bowels and in the douglas pouch and also a minimum of bilateral pleural liquid (image 3). cela d, abilaliaj v, shpuza a. nonoperative management for major blunt hepatic trauma in a 3-yearold child (case report). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5925 p a g e 5 | 6 image 3: ct image, day 5 after the tenth day, the patient was afebrile, without clinical complaints. nutrition was enteral, laboratory results returned to normal, and imaging tests indicated that there was no free fluid in the abdomen. the hospital stay was 11 days, the length of time necessary for the complete conservatory treatment of the hepatic trauma and full recovery. discussion the most common cause of traumatic liver damage identified in some studies was car accidents (5,6). this factor may be the ethology of injury even in children, as is the case in our study. studies have demonstrated that severe liver injury (grade iii, iv and v) is associated with increased morbidity and mortality (7). the 3-year-old patient had a grade iv blunt liver trauma (lacero-contusive injury of v, vi and vii segments) with massive hemoperitoneum and severe clinical condition. it has been demonstrated that nearly 80% of patients with liver injury are successfully treated with conservative management (8). in this context, the patient was treated conservatively and, after 11 days in hospital, was able to recover completely. the study of approximately 40,000 patients with liver injury from 405 trauma centres showed that the likelihood of operative therapy for successful treatment of complicated liver trauma was less than 40% (9). thus, contrary to the surgical treatment’s choice, on the side of old scholar surgeons in particular in small clinics, the basis of modern nonoperative management is based on the patient's stable hemodynamic. the main potential drawbacks of non-surgical care in managing blunt liver injury may be delayed bleeding and the omission of related injuries that require surgery (10). by providing the right environment that offers clinical follow-up and the possibility of rapid interventions through interventional radiology of possible complications, nonoperative management remains an effective solution even for major blunt hepatic trauma in children. cela d, abilaliaj v, shpuza a. nonoperative management for major blunt hepatic trauma in a 3-yearold child (case report). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5925 p a g e 6 | 6 conclusion if no other abdominal injuries are evident and patient is hemodynamically stable nonoperative management for major blunt hepatic trauma in children is the best choice of treatment. follow-up in appropriate hospital conditions enables the full recovery of the patient and the reduction of hospital stay. references 1. croce ma, fabian tc, menke pg, waddle-smith l, minard g, kudsk ka, et al. nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients. results of a prospective trial. ann surg. 1995 jun;221(6):744–55. 2. stassen na, bhullar i, cheng jd, crandall m, friese r, guillamondegui o, et al. nonoperative management of blunt hepatic injury: an eastern association for the surgery of trauma practice management guideline. j trauma acute care surg. 2012 nov;73(5 suppl 4):s288-293. 3. koyama t, skattum j, engelsen p, eken t, gaarder c, naess pa. surgical intervention for paediatric liver injuries is almost history a 12-year cohort from a major scandinavian trauma centre. scandinavian journal of trauma, resuscitation and emergency medicine. 2016 nov 29;24(1):139. 4. alonso m, brathwaite c, garcia v, patterson l, scherer t, stafford p, et al. practice management guidelines for the nonoperative management of blunt injury to the liver and spleen. 2003;32. 5. park kb, you dd, hong th, heo jm, won ys. comparison between operative versus non-operative management of traumatic liver injury. korean j hepatobiliary pancreat surg. 2015 aug;19(3):103–8. 6. scollay jm, beard d, smith r, mckeown d, garden oj, parks r. eleven years of liver trauma: the scottish experience. world j surg. 2005 jun;29(6):744–9. 7. zago tm, tavares pereira bm, araujo calderan tr, godinho m, nascimento b, fraga gp. nonoperative management for patients with grade iv blunt hepatic trauma. world journal of emergency surgery. 2012 aug 22;7(1):s8. 8. raza m, abbas y, devi v, prasad kvs, rizk kn, nair pp. non operative management of abdominal trauma – a 10 years review. world journal of emergency surgery. 2013 apr 5;8(1):14. 9. yu wy, li qj, gong jp. treatment strategy for hepatic trauma. chin j traumatol. 2016 jun;19(3):168–71. 10.norrman g, tingstedt b, ekelund m, andersson r. non-operative management of blunt liver trauma: feasible and safe also in centres with a low trauma incidence. hpb (oxford). 2009 feb;11(1):50–6. __________________________________________________________________________________________ © 2022 cela et al; this is an open access article distributed under the terms of the creative commons attribution license (http:// creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. poirier mjp, hard j, holst j. covid-19 pandemic providing a window of opportunity for higher education: case study of a three-country teaching-learning experience. (origianl research). seejph 2021, posted: 15 november 2021. doi: 10.11576/seejph-4924 p a g e 1 | 12 original research covid-19 pandemic providing a window of opportunity for higher education: case study of a three-country teaching-learning experience mathieu jp poirier1, julie hard2, jens holst3 1 school of global health, york university, toronto, canada; 2 faculty of health, york university, toronto, canada; 3 department of nursing and health sciences, fulda university of applied sciences, fulda, germany. corresponding author: jens holst; address: leipziger str. 123, 36037 fulda, germany; e-mail: jens.holst@pg.hs-fulda.de poirier mjp, hard j, holst j. covid-19 pandemic providing a window of opportunity for higher education: case study of a three-country teaching-learning experience. (origianl research). seejph 2021, posted: 15 november 2021. doi: 10.11576/seejph-4924 p a g e 2 | 12 abstract aim: since march 2020, the covid-19 pandemic has been causing unprecedented challenges to higher education by disrupting traditional face-to-face teaching as well as international mobility of students, faculty and staff. the factual knock-out of established modes of teaching and learning and the restriction of international travel called for rapid action and a shift towards remote learning and teaching. methods: within the framework of a pragmatic approach, global health faculty from fulda university of applied sciences in germany and york university in canada, including a small group of public health students from cluj in romania, established a globally networked learning environment. between november and december 2020, a total of 147 students participated in joint virtual lectures and international collaborative group projects. to capture the acceptance and effectiveness of the innovative didactic experience, a semi-structured student survey was conducted directly after the last session. results: the overall rating of internet-based cross-university teaching-learning was positive: students reported benefits of an enriched learning experience through the sharing of different perspectives, approaches and debates with international professors and peers. success and overcoming challenges for collaboration among students depended strongly on the level of coordination relating to time differences and expectations. conclusion: the covid-19 pandemic has revealed that transnational inter-university teaching-learning is feasible, provides a beneficial pedagogic option and points promising ways to the future. keywords: covid-19, higher education, learning, teaching. conflict of interest: none declared. acknowledgements: we gratefully acknowledge the contributions of prof. dr. kai michelsen and prof. dr. marius i. ungureanu to the development of the three-country teaching-learning experience. poirier mjp, hard j, holst j. covid-19 pandemic providing a window of opportunity for higher education: case study of a three-country teaching-learning experience. (origianl research). seejph 2021, posted: 15 november 2021. doi: 10.11576/seejph-4924 p a g e 3 | 12 background the outbreak of the covid-19 pandemic led to physical closures of higher education institutions around the world. the sudden pivot from in-person to online education disrupted usual procedures of university education. the global suspension of traditional ways of lecturing posed unprecedented challenges to both teachers and students. at the same time, it opened a window of opportunity for innovative pedagogic approaches and techniques, including realtime cross-university exchange and active student cooperation. these pandemic measures have significantly intensified efforts and reduced reservations about the cost implications of cross-border teachinglearning and joint education. without a doubt, the near universal shift to online learning also lowered the barriers to interuniversity teaching and exchange. previously, sharing in-person teaching by coordinating sessions taking place in two or more classrooms with students physically present required the classes to be connected using one or more remote lecture halls where groups of students were present. the physical distance tended to cause different learning conditions between students physically attending the lecture and those who were connected via video stream, because the latter had more indirect contact to the teachers and limited possibilities to interact with them (1). mobility and internationalisation have been heavily affected by the pandemic and the measures taken to prevent the spread of the virus. as early as march 2020, almost twothirds of european universities observed a negative impact on their outgoing student mobility (2). internationalisation as an objective and strategic agenda has certainly not diminished in importance, but its implementation has clearly transformed in the shortto medium-term (3). these impacts have affected york university in toronto, canada, and, fulda university of applied sciences in fulda, germany in different ways. the following paragraphs describe the impacts with reference to examples from bachelor of public health programmes. the pandemic posed some structural challenge for york university’s (yu) newly established school of global health, but the opportunities for internationalisation and expansion of experiential education proved to be powerful incentives to embracing new pedagogic approaches. students in york university’s bachelor’s programme in global health that choose to enrol in the specialized honours degree options have the possibility to participate in an international internship placement, but most students either refrain from participating in this programme or select domestic options for practical, financial, or academic reasons. once all courses were transitioned to an online format as of march 2020 and subsequent restrictions on travel were put in place, students that had hoped to participate in an international internship placement faced the possibility of being prevented or even prohibited from doing so, and students from all degree options raised concerns that online learning would reduce experiential learning opportunities. in fact, a november 2020 poll conducted by the ontario confederation of university faculty associations indicated that the quality of educational experience was the top concern of students in ontario, even outranking other financial, mental health, and safety concerns (4). covid-19 turned out to be a bit more challenging for fulda university of applied sciences (fuas) because it hit the university in two recent development areas. the first lockdown occurred during the initial phase of the implementation of a publicly funded internationalisation project. in october 2019, the university’s department of nursing and health sciences (pg) had ob poirier mjp, hard j, holst j. covid-19 pandemic providing a window of opportunity for higher education: case study of a three-country teaching-learning experience. (origianl research). seejph 2021, posted: 15 november 2021. doi: 10.11576/seejph-4924 p a g e 4 | 12 tained considerable funding from the german academic exchange service (daad) for promoting the internationalisation of the department and the university as a whole. the majority of funds were planned for and assigned to the exchange of students, faculty, and other staff from and to fulda in order to build a network of university and practice partners in europe and worldwide. as traveling became widely impossible from march 2020 onwards, the project staff had to look for other possibilities and pathways towards an enhanced international partner network and increased international exchange opportunities and facilities. simultaneously, covid-19 restrictions of in-person teaching of all courses and particularly the wide-ranging limitations of travel were put in place just as the first cohort of the newly established bachelor’s programme international health sciences (ihs) was preparing and embarking on their compulsory semester abroad, which is regularly scheduled in the third year of the degree programme. approximately 75% of the students had to postpone their semester abroad, leading faculty to provide the content of the subsequent semesters half a year earlier than foreseen in the curriculum. the need to offer international education, training and internships under the conditions of covid-19 called for action to minimise the negative consequences of lockdowns and travel restrictions and take advantage of the potential positive opportunities for international exchange. developing, setting up and testing innovative teaching and learning methods became an urgent need in order to allow students to finalise their study programmes within the standard period and reduce the negative impact of the pandemic on their training and education. institutional support is obviously required but increasingly taken into account by pertinent organisations (5). this paper describes the process of developing, piloting, and evaluating a globally networked learning environment between two universities in germany and canada, with the participation of some guest students from romania. method building on cooperation between fuas and yu since 2019, faculty from both universities started to explore options of collaborative teaching approaches for selected courses. it should be noted that the two universities offer quite similar bachelor’s programmes on international health sciences (fuas) and global health (yu), respectively. student exchange was initiated with canadian students conducting an internship in germany and extended student exchange was planned for 2020 and beyond but had to be put on hold under the covid-19 pandemic. the above-mentioned change in the timing of semester programming at fulda university resulted in a possibility to collaborate in the field of global health policy courses. specifically, a fulda course called “global health policy and politics” and a york course “global health policy: power and politics” exhibited concordance and consistency in course learning outcomes and content. this led the faculty to explore the potential to include joint lectures and learning opportunities for students from both universities. months of regularly scheduled calls over the summer of 2020 resulted in an agreement to establish jointly delivered virtual lectures in a three-week span of overlapping weekly courses. in addition, students were invited to work collaboratively in joint working groups dealing with “hot” topics related to the policy response to covid-19. at a later stage, a small group of public-health students from babeș-bolyai university (bbu) in clujnapoca, romania, joined the international group exercise of the german-canadian inter-university teaching-learning project. cross-cohort and -university teaching took place in november and december 2020 poirier mjp, hard j, holst j. covid-19 pandemic providing a window of opportunity for higher education: case study of a three-country teaching-learning experience. (origianl research). seejph 2021, posted: 15 november 2021. doi: 10.11576/seejph-4924 p a g e 5 | 12 with a total of 147 students 93 from yu, 36 from fuas, and 18 from bbu. three topics covered were deemed highly relevant for global health and global health policy: “global trade policies and international cooperation regarding health” and “european union health and social policies”, both delivered by fulda faculty (jh1& km), and “policy process: democracy, activism, and the battle of interests”, taught by york university faculty (mp). these topics were not countryor region-specific, but provided excellent opportunities to point out different focuses and perspectives. the international group project consisted of matching students between universities to collaboratively develop a policy brief and supporting podcast, narrated presentation or any other multimedia product comparing policy responses to covid-19 and proposing policy solutions to a range of pressing issues such as mitigating the medical, social, and economic impact of the pandemic, analysing social, economic, racial, ethnic, and gender inequities, and implementing protective measures in schools, businesses, and public spaces. to keep things manageable, only binational working groups were established. due to the different cohort sizes, the allocation resulted in nine canadian-german and four canadian-romanian working groups consisting of between 10 and 12 students each. table 1. list of potential topics for collaborative student group projects acceptance (and denial) of covid19 measures to what degree has the public accepted governments’ and scientists’ response to the pandemic, and how has this evolved since the start of the outbreak? decentralisation and the covid-19 response what level of government has taken the lead in the response to the pandemic? have there been conflicts between local, state/provincial/regional, and federal governments? employment opportunities / unemployment how severe have changes in employment been? what existing, new, and expanded programs have been implemented to reduce unemployment? global health effects of the pandemic outbreak on global health and global health politics. how has the corona crisis influenced the prevailing globalhealth debate? impact on education what policies have schools implemented to protect students, teachers, and staff at the primary, secondary, and university levels? protective measures what measures have been implemented to protect public health or public’s health, and how have these measures been relaxed or strengthened throughout the pandemic? public information / media who is responsible for communicating government public health and policy information to the public, and what is the role of media in disseminating this information? regulation of mobility what measures have been put in place to monitor and restrict international and domestic travel? social impact and inequality what social, economic, racial, ethnic, or gender inequities have emerged or widened? social protection has social protection proven to be able to mitigate the medical, social and/or economic impact of the pandemic? socioeconomic inequalities when, by whom and to which extent have inequities/inequalities been addressed during the covid-19 crisis? poirier mjp, hard j, holst j. covid-19 pandemic providing a window of opportunity for higher education: case study of a three-country teaching-learning experience. (origianl research). seejph 2021, posted: 15 november 2021. doi: 10.11576/seejph-4924 p a g e 6 | 12 choose your own topic if you are passionate about a global health topic not listed above, you can propose your own (must be approved by course director) the array of tasks ranged from analysing measures to control covid-19 in the health sector to their impact in other policy areas (see table 1). the organisation and facilitation of the inter-university group work relied heavily on the students themselves who had the chance to choose between different internet-based communication and social media platforms. york university students were prepared for the project by developing a group project plan to actively anticipate barriers to effective collaboration such as language, cultural difference, and time zones, and prepare a plan for how to overcome those barriers. student group work was also supported by faculty feedback provided to each mixed student group in scheduled video calls. due to the staggered course schedule, fulda students had the opportunity to present their jointly developed products with canadian students within their own group, to discuss them critically and to obtain feedback from the teachers. finally, student perceptions were gathered in the final weeks of cooperation by york university international relations (jh2) as an independent third party to motivate unbiased and honest feedback. results in the overall view of lecturers involved, inter-university and cross-country teaching offers an excellent opportunity to broaden the scope of content, reach a more diverse student audience, and learn from inter-cultural differences. particularly in the field of health policy, and even more in international and global (health) policy, exchange between different country perspectives turned out to be enlightening and provided the courses with extraordinary added value for all participants. students pointed out that they had learned how to collaborate and organise group work with a larger number of people. canadian students particularly appreciated the opportunity to get an insight into other healthcare systems and how other governments tackled the covid-19 issues from a first-hand experience perspective. regarding didactic requirements, staff experiences gathered during the relatively short phase of interuniversity teaching underpinned the need to provide students with timely feedback, including online video tutoring and email guidance after and between classes and to adopt measures to improve the degree and depth of students' class participation described elsewhere (6). another critical determinant of student engagement appeared to be whether participation and contribution to the collaborative group project was required and marked for course credit. students indicated a greater willingness to attend guest lecture exchange and actively contribute to group work if they knew the work would be formally evaluated. for ensuring that all students communicate with each-other and start working on their assignment, students expect all professors to clearly express the conditions and requirements of the joint teaching-learning project. and of course, the individual student experience depended very much on the group constellation and the commitment of peers and other group members. fulda and york university found ways to integrate the jointly taught course elements into their grading systems. for fulda students, the incentive was twofold: faculty informed the students before the inter-university sessions that about 25% of the term paper to be submitted at the end of the semester were dedicated to a brief description as well as a critical analysis and evaluation of the joint group work; in addition, the active and proven participation in the joint group work was rewarded with a poirier mjp, hard j, holst j. covid-19 pandemic providing a window of opportunity for higher education: case study of a three-country teaching-learning experience. (origianl research). seejph 2021, posted: 15 november 2021. doi: 10.11576/seejph-4924 p a g e 7 | 12 0.3 bonus of the final grade (based on the german grading systems between 1 (best) and 5 (failed) with one-third steps. york university students were first required to prepare a group project plan worth 5% of the final mark, anticipating and planning to overcome barriers to effective collaboration prior to the start of the exchange. the international collaborative project was evaluated on a group-by-group basis out of a total of 21% of the final mark, with adjustments based on individual contributions reported in a group progress report. finally, a writing activity completed at the end of term prompted students to reflect on challenges and areas of growth spurred by the exchange, and the final exam contained questions based on lectures delivered in all three weeks of shared teaching. after finalising the inter-university lectures and the mixed working groups, students were invited to participate in an anonymous survey conducted by a third party (york international) to explore the impact of the innovative learning experience. approximately 41% of the students participated in the survey, with 4 out of 18 bbu students, 20 out of 36 from fuas and 36 out of 93 from yu participating, for a total of 60 out of 147 students who attended the sessions. students were asked about overall impressions of the course, challenges to overcome, and ways their learning was enriched. figure 1. student ratings of various aspects of the globally networked learning environment divided by university of respondent all in all, 55 out of the 60 students surveyed indicated that they would be interested to participate in a similar experience in the future. figure 1 summarises the ratings of the overall intercontinental networked learning approach, inter-university working groups, working with fellow students, inter-university lectures, and lectures delivered by poirier mjp, hard j, holst j. covid-19 pandemic providing a window of opportunity for higher education: case study of a three-country teaching-learning experience. (origianl research). seejph 2021, posted: 15 november 2021. doi: 10.11576/seejph-4924 p a g e 8 | 12 teachers from other universities. student satisfaction was consistently high, ranging from a low of 73% for lectures of teachers from other universities and a high of 88% for inter-university lectures and the interuniversity working groups. students particularly welcomed the variety of teaching and the opportunity to meet new people as a nice change after having started feeling fatigue over the redundancy of online schooling. students were asked to comment on areas they felt the learning format and experience worked well. recurring comments revealed student appreciation for the online lecture format provided by different professors, the opportunity to hear different perspectives on topic areas, and the process of collaboration with international students. personalised feedback and assignments reportedly allowed for enjoyable and creative opportunities to develop teamwork and organizational skills in a virtual international context. students appreciated the chance to meet with the professors, discuss the progress of group works and get personalised feedback. the combination of the policy brief and a more creative multimedia product as group work result was highly appreciated. some notable limitations included overcoming the time difference of 6-7 hours between toronto and germany / romania, respectively. time differences challenged students to find mutually agreeable times to coordinate international group work on assignments. students were additionally critical of the size of each working group indicating groups were too large, further compounding coordination challenges, and reportedly permitted variability in participation among its members. one of the greatest challenges derived from the need to work with students in different time zones and make sure everyone is able to attend meetings and carry their weight of the work. lecture duration and delivery times were felt to be too long, inconvenient, and too late in the evening for some students. in the future challenges related to time and time differences could be overcome by recording asynchronous sessions; however, this would reduce the interactivity and liveness of lectures that were highly valued by students who also expressed the desire to apply cross-university approaches when school move back to face-to-face teaching in order to be able to further benefit from inputs of lecturers and students from other universities. issues related to coordinating over several platforms for video conferencing (webex, zoom) and communication and file sharing (email, whatsapp, slack, google) were relatively minor, with lectures being held over webex and leaving other communications and file sharing decisions to each student group. some students complained that particularly in the beginning it was a bit challenging organising how to work together and where to share findings and contributions; however, it turned out to be really easy to connect directly and stay in contact, as well as working together on a document or presentation via whatsapp, zoom, shared google docs, etc. even though students were unable to meet physically with their international peers, several expressed that the online experience helped with providing a "real-life" simulation of what it may feel like to collaborate with international colleagues. the process simulated the very real challenges related to coordinating between different time zones, technologies, languages, and cultures that is inherent to working in the field of global health. this intercultural exchange was also highlighted as one of the most rewarding aspects of the experience, with different approaches to teaching, learning, collaborating, and policy analysis ultimately enriching the collaborative experience of working with students around the same age group, poirier mjp, hard j, holst j. covid-19 pandemic providing a window of opportunity for higher education: case study of a three-country teaching-learning experience. (origianl research). seejph 2021, posted: 15 november 2021. doi: 10.11576/seejph-4924 p a g e 9 | 12 understanding how life after covid-19 has changed for young people and learning the differences and similarities between their experiences in school and life in general. the experience of meeting new people and communicating with them was evaluated as pleasant because students perceived themselves mutually as very open. discussion covid-19 has been a huge challenge for higher education, and universities were forced to develop strategies for safeguarding adequate learning and teaching. interuniversity and cross-border had already been implemented earlier in various settings and generated an overwhelmingly positive reception among lecturers and faculty (7). prior research has shown both opportunities and barriers of inter-university cooperation arising from the heterogeneity of the participants and different perspectives on the topics covered beyond group dynamics issues, trust, and technical as well as facilitation challenges (8). recent evidence suggests that under covid-19 restrictions, online and remote teachinglearning helps students follow the lessons outside the classroom and create an alternative to in-class teaching for completing the syllabus (9). it turned out to be helpful that students did not face major issues in terms of communication and level of knowledge, although some did differ in discipline with regards to punctuality in research and scheduled meetings. online learning requires higher than usual commitment from students, and both students and lecturers are required to develop and implement innovative approaches for making higher education successful. at the same time, online teaching opens unprecedented opportunities for students to co-design activities and assessments, creating improved opportunities to making them co-producers of their learning. the fact that it is easier to shape the format of live sessions according to students’ needs and regular feedback can help universities make students participate more proactively in directing the course of their learning. students were able to directly and mutually explore how policies and norms in daily life differ between countries, and some of the even perceived a bit of a culture shock. of course, this case study has certainly some limitations. due to the rapid and unforeseeable development of external circumstances during the covid-19 pandemic, our cooperation had to be planned and organised at very short notice. under these conditions, the participating lecturers had to opt for a pragmatic approach without a prior test run or in-depth planning. likewise, the survey to explore the impact of the innovative learning experience, which was conducted shortly after the lectures and joint group work, was descriptive in nature and applied without a pre-test. the fact that the lecture periods of the participating universities only partially overlapped put additional timely pressure on the implementation of the internet-based cross-university teaching-learning experience. moreover, the fact that this case study is limited to two global health courses and a relatively small number of participants reduces the generalisability of the described teaching-learning experiment under pandemic conditions. while the potential to make students act increasingly as partners in their education looks tempting, it should not be overstretched. even in online teaching via video chat, the commitment and active enrolment in the education depends more on individual conditions than in face-to-face teaching. it is easier and less risky for students to (partly) pull out of the sessions and hide behind the anonymity of online teaching. this applies mainly to larger cohorts which do not allow a direct supervision of all participants at the time. moreover, concurrent experience shows that the ability of students poirier mjp, hard j, holst j. covid-19 pandemic providing a window of opportunity for higher education: case study of a three-country teaching-learning experience. (origianl research). seejph 2021, posted: 15 november 2021. doi: 10.11576/seejph-4924 p a g e 10 | 12 to follow lectures, to actively work on the material and, above all, to actively participate in the lessons, shows even greater differences in online teaching than in face-toface teaching. inter-university online teaching does not only have to take into account this general condition but be aware of greater differences within and between the different cohorts. in the teaching experience of york and fulda universities, the attitude, commitment and participation did not show discernible differences between students enrolled in canadian and german higher education; however, romanian students were less visible what might be attributable to their low number and the role of guest students. students noticed differences in the teaching and research focus and priorities. for example, canadian students were more focused on statistics whereas students from germany were more focused on a holistic understanding of the topic. nonetheless it has to be stressed that the more different teaching-learning habits and cultures are, the more challenging it will be to assure equal possibilities and opportunities for all participants. online learning has certainly an equalising potential, as both lecturers and all students attend online sessions from their homes in order to adjust to the realities imposed by the pandemic outbreak. however, inequality remains an important issue for concern. availability of adequate hardware equipment, internet connectivity, supportive social integration and individual contacts remain critical topics that challenge equality of opportunities for students. hence, for preparing joint interuniversity sessions and working groups, the faculty of the academic institutions involved are strongly recommended to exchange about teaching-learning strategies, didactic approaches and practical experiences in order to be prepared and capable to adequately respond to the needs and habits of the different student cohorts. as a matter of fact, differences in language fluency have to be taken into account for preventing misunderstandings as well as insecurities in joint group works. online teaching-learning relies heavily on internet connectivity and the technical equipment available to teachers and especially students. although coverage of reliable internet connections varies in germany and offer room for improvement particularly in rural areas, technical problems on students’ side were negligible. in the toronto region internet connectivity is very good overall and allowed students to follow the joint sessions and perform in the joint group work. for romanian students, the technical conditions were also sufficient and did not cause major problems. however, one has to be aware that online interuniversity teaching learning is likely to be more challenging with academic partners located in low-income or other countries where internet connectivity is unstable; additional challenges might arise if power supply is unreliable. beyond the general framework conditions, differences in technical equipment are also very likely to play a role. if students depend on smart phones instead of computer or laptops, knowledge transfer via presentations is seriously hampered, and participation severely limited. hence, reliable power and internet supply as well as adequate technical equipment are indispensable for making inter-university higher education effective, enjoyable and successful. making all lecture recordings available is considered crucial for crossuniversity teaching-learning as it allows students repeating innovative or complicated topics; copyright issues have to be sorted out, and teachers are highly recommended to make their inputs accessible for students living in time zones where it is difficult to follow the live session and for all others who want to work the topic more in depth. one of the challenges which is highly relevant for students is the question of how to poirier mjp, hard j, holst j. covid-19 pandemic providing a window of opportunity for higher education: case study of a three-country teaching-learning experience. (origianl research). seejph 2021, posted: 15 november 2021. doi: 10.11576/seejph-4924 p a g e 11 | 12 include inter-university learning-teaching into the regular schedule and especially the given grading and assignment conditions, which may differ from one university to another. it is worth mentioning that most students were motivated to attend the interuniversity lectures and committed to contribute to the mixed working groups, although the impact of the joint sessions and working groups as part of the course assignment and grading was limited. this suggests that the primary motivation can be sufficiently strong for students at the different universities involved to broaden their perspectives and get to know other faculty and students. moreover, compared to traditional examinations with a focus on recalling information rather than exploring a topic, putting together policy briefing papers, and recording podcasts, videos, narrated powerpoint presentations or other multimedia products require and reward curiosity and academic inquiry. in a nutshell, inter-university online teaching-learning modes adopted by york and fulda university, with partial involvement of babes-bolyai university during the covid-19 adversity have proven to be very promising for both, intellectually enriched opportunities particularly on the field of global health and for further future academic cooperation. in fact, they are already being replicated in similar formats, and further online teaching-learning activities are being prepared. institutional conditions and arrangements are increasingly being adjusted to the new needs and promising to lower the barriers of implementing fruitful cross-university teaching-learning cooperation (5). these promising approaches help overcome the persisting restrictions in real-life internationality and globality due to the ongoing and prolonged pandemic. if one of the lessons to be learned from covid-19 is a critical validation of physical travel needs, online interuniversity teaching and learning exercises have the potential to anticipate the future and prepare students for the working conditions in the field of global health in the next decades. references 1. lamba p. teleconferencing in medical education: a useful tool. australas med j 2011;4:442-7. doi: 10.4066/amj.2011.823. 2. european university association. european higher education in the covid-19 crisis. brussels: 2020. available from: https://eua.eu/downloads/publications/briefing_european%20higher%20education%20in%20the%20covid19%20crisis.pdf (accessed: august 5, 2021). 3. de wit h, altbach pg. internationalization in higher education: global trends and recommendations for its future. policy rev high educ 2020;5:28-46. doi: 10.1080/23322969.2020.1820898. 4. ontario confederation of university faculty associations. ocufa 2020 study: covid-19 and the impact on university life and education. toronto; 2020. available from: https://ocufa.on.ca/assets/ocufa-2020-faculty-student-survey-opt.pdf (accessed: august 17, 2021). 5. german rectors’ conference (hrk). effective framework conditions for teaching and learning. resolution of the 147th senate of the hrk on 16 march 2021. berlin; 2021. available from: https://www.hrk.de/fileadmin/redaktion/hrk/02-dokumente/02-01-beschluesse/2021-03 poirier mjp, hard j, holst j. covid-19 pandemic providing a window of opportunity for higher education: case study of a three-country teaching-learning experience. (origianl research). seejph 2021, posted: 15 november 2021. doi: 10.11576/seejph-4924 p a g e 12 | 12 16_hrk-s-entschliessung_eckpunktepapier_en.pdf (accessed: july 20, 2021). 6. bao w. covid‐19 and online teaching in higher education: a case study of peking university. hum behav emerg tech 2020;2:113-5. doi:10.1002/hbe2.191. 7. poulová p, šimonová i. borderless education: interuniversity study – tutors’ feedback. procedia soc behav sci 2015;171:1185-93. doi:10.1016/j.sbspro.2015.01.230. 8. činčera j, mikusiński g, binka b, calafate l, calheiros c, cardoso a, et al. managing diversity: the challenges of inter-university cooperation in sustainability education. sustainability 2019;11:5610. doi:10.3390/su11205610. 9. mishra l, gupta t, shree a. online teaching-learning in higher education during lockdown period of covid-19 pandemic. int j educ res open 2020;1:100012. doi: 10.1016/j.ijedro.2020.100012 . __________________________________________________________________________________________ © 2021 poirier et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. taryam m, alawadhi d, aburayya a, mubarak s, aljasmi m, salloum sa, et al. factors affecting the uptake of covid-19 vaccine among dubai airport's professionals (original research). seejph 2022, posted: 11 january 2022. doi: 10.11576/seejph-5091 p a g e 1 | 14 original research factors affecting the uptake of covid-19 vaccine among dubai airport's professionals manal taryam1, dhoha alawadhi1, ahmad aburayya1, sara mubarak1, maryam aljasmi2, said a. salloum3, talal mouzaek4 1 dubai health authority, dubai, uae; 2 mohammed bin rashid university of medicine and health sciences, dubai, uae; 3 school of science, engineering, and environment, university of salford, uk; 4 sheikh khalifa general hospital, umm al quwain, uae. corresponding author: dr. ahmad aburayya; address: dubai health authority, dubai, uae; email: amaburayya@dha.gov.ae taryam m, alawadhi d, aburayya a, mubarak s, aljasmi m, salloum sa, et al. factors affecting the uptake of covid-19 vaccine among dubai airport's professionals (original research). seejph 2022, posted: 11 january 2022. doi: 10.11576/seejph-5091 p a g e 2 | 14 abstract aim: comprehending the elements that influence covid-19 vaccination acceptability and recognizing expediters for vaccination decisions are critical components of developing effective ways to increase vaccine coverage in the general population. this study aims to investigate the main factors affecting covid-19 vaccination uptake among dubai 'airport's employees. in addition, it seeks to explore the main signs and symptoms that appeared on vaccinated employees after taking the covid-19 vaccination, hence, track the vaccine's safety. methods: employees at dubai's airport in the united arab emirates (uae), mainly in dubai, provided data. to gather data online utilising the google forms platform, a questionnaire was used as the main quantitative tool. as 2000 questionnaires got distributed, 1007 employees participated in the survey, yielding a 50.4% response rate. results: the results show that employees overwhelmingly agree with the assertion that the factors of accessibility and affordability have a significant effect on their decision to receive the covid19 vaccine, followed by a trust in vaccine, knowledge, vaccine safety, advice and information, and beliefs on the vaccine. in this study, the agreement level on factors affecting the covid-19 vaccine uptake was found significantly to be higher in females (88.6%) who were married (91.6%) and those aged over 60 years (89.2%) at p <.05. in addition, the results show that 53.7% of vaccinated staff was found to have one or more side effects of the vaccine, where none of them was hospitalized after immunization. the binary logistic regression analysis in this study shows that females were two times more likely to have 'vaccine's symptoms after vaccination than males (exp (b): 1.6; 95%ci: 1.127 2.351, p< .01). it further reveals that participants in the age group over 50 were three times more likely to have 'vaccine's symptoms after vaccination than participants in the age group 20-29 (exp (b): 2.9; 95%ci: 2.497-9.681, p< .001). finally, it indicates that individuals with previous sars-cov-2 infection were 2 times more likely to have 'vaccine's symptoms after vaccination than those without known past infection (exp (b): 1.9; 95%ci: 1.272 2.542, p< .01). conclusion: there are several factors that playing a significant role in population’s decision to receive the covid-19 vaccine, where the accessibility and affordability factors were found to have the greatest effect on their decision to uptake the vaccine. the current study concluded that covid-19 vaccination is safe and that adverse effects from a vaccine are usually modest and affected by several factors such as age, gender, and covid-19 infection history. keywords: adverse effects, binary logistic regression model, covid-19 pandemic, dubai airport, uptake vaccine. conflicts of interest: none declared. taryam m, alawadhi d, aburayya a, mubarak s, aljasmi m, salloum sa, et al. factors affecting the uptake of covid-19 vaccine among dubai airport's professionals (original research). seejph 2022, posted: 11 january 2022. doi: 10.11576/seejph-5091 p a g e 3 | 14 introduction since the global pandemic was declared, various corporations and research centres throughout the world have invested in the development of viable covid-19 vaccination projects (sars-cov-2). in this regard, there is now an enormous toolkit of potential vaccines available. by july 2021, there were 184 covid-19 vaccine candidates in pre-clinical development, 105 in clinical development, and 18 vaccines approved for emergency use by at least one regulatory authority (1). notably, the developed covid-19 vaccines are particularly essential to control covid-19 as immunization is one of the best influential and cost-effective healthcare policies for impeding and controlling communicable diseases (2-5). in addition, to terminate the pandemic, a considerable portion of the population must be immune to the virus (5), with vaccination being the safest option. vaccines are a method that humanity has used in the past to lessen the number of people who die as a result of infectious diseases (2,3,6). the united arab emirates (uae) has licensed four covid-19 vaccines for emergency use, including one from sinopharm cnbg, another from pfizer-biontech, a third from sputnik v, and the most recent from oxfordastrazeneca (6). most recently, the uae registered hyat-vax, a cooperative venture between sinopharm cnbg and abu 'dhabi's g42. the uae offers its residents vaccines free of charge and on a non-compulsory basis after safeguarding that the individual is eligible for vaccination. nursing moms, pregnant women, and children as young as 12 years old are included in the eligibility criteria, with the sinopharm cnbg vaccine given safely to younger children aged 5 years old (7). indeed, the uae government's and health officials' concerted efforts, as well as public participation, have resulted in the country's national vaccination programme's early success. worldwide, the uae is first regarding vaccine administration rates to its residents, according to who and ‘'our world in data’' data' websites (8) that track vaccination rates track by researchers at the university of oxford. the data shows that as of october 19th 2021, the covid-19 vaccination has been administered to at least 48.7% of the world's population. globally, 6.87 billion doses have been administered, with 25.76 million doses being administered every day (8). the uae registered 86% of the population fully vaccinated and 96% who received at least one dose (8), followed by portugal at 88%; chile at 85%; spain 82%; singapore 80%; uruguay 79%; canada 78% (8). apart from the concern of a disappointing acceptance rate, the real uptake rate of pandemic immunizations may be significantly lower than the acceptance rate once the vaccine has been released and mass immunization programmes advocated (5,9). recent articles have revealed certain influential variables on vaccination acceptance to aid in the explanation of vaccination reluctance or delay behaviour, and cultural, socioeconomic, and political differences between countries ought to be taken into consideration during the decisionmaking process of vaccination (10). in essence, vaccine safety has been cited as a major obstacle to vaccination coverage for new vaccines against developing pandemics, including the 2009 h1n1 pandemic (5,9), while attitudes and past routine immunization history, particularly influenza vaccination history, were the most significant predictor of pandemic vaccination coverage (11). because the current pandemic is more severe in terms of transmissibility and death than previous influenza pandemics, nations all over the world, including the uae, are under immense insistence to contain the present pandemic and avoid future devastating epidemic waves. understanding the factors that influence covid-19 vaccination acceptability taryam m, alawadhi d, aburayya a, mubarak s, aljasmi m, salloum sa, et al. factors affecting the uptake of covid-19 vaccine among dubai airport's professionals (original research). seejph 2022, posted: 11 january 2022. doi: 10.11576/seejph-5091 p a g e 4 | 14 and discovering enablers for vaccination decisions are key components of designing successful strategies for increasing vaccination coverage among the public at large (12,13). therefore, this piloting study aims to investigate the main factors affecting covid-19 vaccination uptake among dubai 'airport's employees. in addition, it seeks to explore the main signs and symptoms that appeared on vaccinated employees after taking the covid-19 vaccination, hence, track the safety of the accepted vaccine. methods in january 2021, a cross-sectional survey was applied selecting dubai 'airport's employees using a systematic sampling method. notably, systematic sampling is defined as a probability sampling method where the researcher chooses elements from a target population by selecting a random starting point and selects sample members after a fixed ‘sampling interval’ (14). therefore, the researchers in this study selected the first participant in the sample frame as a random starting point where the sampling interval was fixed at 23. in this study, due to the availability of the sample frame, systematic sampling is more applicable than other sampling approaches (14-17). in addition, the financial plan of the study is tenuous and necessitates plainness in accomplishment and comprehending the consequences of a survey. the online poll was performed utilising the google forms platform, and the survey url was distributed and publicised via official emails and social media sites like whatsapp. the survey was executed between january 10th to 24th, 2021. the survey was open to all dubai international airports employees who were covid-19 vaccinated, living in the uae, and aged 20 and older. a sample size of 370 was computed utilising raosoft sample size calculator, in which we used 5% as a margin of error, 95% as a confidence level. to minimize the sampling error allied with the systematic sampling strategy and increase the accuracy of the sampling consequence including its predictive validity, the present investigation planned for a larger sample size (18). therefore, out of 46000 vaccinated staff, 2000 respondents were systematically selected at 23 sampling intervals. a total of 2000 questionnaires were distributed, and 1007 employees participated, yielding a 50.4% response rate. the questionnaire was developed using the 5a model "taxonomy for vaccine uptake determinants" that was self-administered (19) and based upon studies which have been previously conducted and frameworks to observe factors contributing to the vaccine uptake in the case of newly discovered infectious diseases such as covid-19, h1n1, and ebola (5,20-25). the contents of the questionnaire included (1) socio-demographic characteristics (6 items), such as age, gender, marital status, educational level, nationality, history of diagnosing for covid-19; (2) perceived factors affecting the vaccinated participants' decision to receive the covid-19 vaccine (24 items); (3) main signs and symptoms that appeared on vaccinated staff after immunization (1 item). all of the questions were closed-ended, with response options in the form of tick boxes. questions related to socio-demographic characteristics and immunization symptoms were treated as categorical variables. questions related to main factors affecting 'participants' vaccination decision making against covid-19 included 6 factors and were assessed on a five-point likert scale (1) perceived knowledge on covid-19 vaccination (5 items); (2) perceived beliefs on covid-19 vaccination (4 items); (3) perceived vaccination safety (3 items); (4) perceived accessibility and affordability on vaccination (4 items); (5) perceived advice and information related to covid-19 vaccination (4 items); (6) trust on vaccination (4 items). the perceived factors in this study taryam m, alawadhi d, aburayya a, mubarak s, aljasmi m, salloum sa, et al. factors affecting the uptake of covid-19 vaccine among dubai airport's professionals (original research). seejph 2022, posted: 11 january 2022. doi: 10.11576/seejph-5091 p a g e 5 | 14 were scored on a 5-point likert scale, with 1 representing "strongly disagree" and 5 representing "strongly agree," and a score of 3.41 or higher indicating that the identified factor strongly influences respondents' decisions to obtain the covid-19 vaccine. in essence, the length of each scale that built on a fivepoint likert scale can be calculated by dividing the scale extension on the total scale points (18,26). in this study, the scale extension is determined by 5-1= 4, and then the length of each scale is calculated by 4/5=0.8. accordingly, 0.8 was added to the each scale which resulted in adopting 3.41 as threshold for identifying factors affecting respondents' decisions to obtain the covid-19 vaccine. a descriptive content analysis was performed in this study utilising frequency percentages and distribution to analyze 'respondents' socio-demographic characteristics and immunization symptoms in the data. to find any possible associations, the socio-demographic data of respondents was cross tabulated with factors influencing their decision on the adoption of the covid-19 vaccine. to explore if age, gender, and covid-19 infection history variables were playing a role in the probability of having adverse effects after covid-19 vaccination, we used a binary logistic regression model. reliability was assessed using cronbach's alpha value, while construct validity was assessed using component loading analysis. in this study, 'cronbach's alpha coefficient with a value of 0.60 and above will be accepted (26). in terms of factor loading, the principle component analysis (pca) was used, and the construct loading value of 0.50 was established as the typical cut-off point (26). the statistical package for social sciences (spss) version 25.0 was used to analyse the data. results participants’ description the characteristics of respondents are presented in table 1. in total, 1,007 employees took part in the current investigation, with 79.9% of them being male and the remaining 20.1% being female. the age groups of (2029) and (30-39) reported for over two-thirds of the sample (79.7%). table 1 shows that 53.2% of respondents hold diplomas and bachelor's degrees, and 12% had postgraduate degrees; married staff accounted for over half of the sample (57.2%). regarding nationality, the sample consisted of 31.7% emirati, 23.5% indian, 27.3% arab, and 17.5% from other countries. furthermore, 12.8% of vaccinated employees reported previous infection with covid-19. analysis of factors affecting covid-19 vaccine acceptability the research conducted analyses in accordance with the extracted elements in this study, and the findings revealed that with a mean of 4.4, employees overwhelmingly agree that the factor of accessibility and price has a significant impact on their decision to obtain the covid-19 vaccine. the influence was followed by the trust in vaccine factor (4.3). the employees also noted that aspects related to their knowledge on the covid19 vaccine (4.2) also contributed significantly to their decision to get the covid-19 vaccine, followed by vaccine safety, advice and information related to the covid-19 vaccine, and beliefs on vaccine factors with means of 4.1, 4.0, and 3.8; respectively. with an overall mean of 4.1, the targeted employees determined the six criteria as key reasons influencing their decision to obtain the covid-19 vaccine (table 2). taryam m, alawadhi d, aburayya a, mubarak s, aljasmi m, salloum sa, et al. factors affecting the uptake of covid-19 vaccine among dubai airport's professionals (original research). seejph 2022, posted: 11 january 2022. doi: 10.11576/seejph-5091 p a g e 6 | 14 table 1. the characteristics of respondents frequency percent (%) gender male 805 79.9 female 202 20.1 age 20-29 239 23.7 30-39 564 56.0 40-49 180 17.9 50-59 15 1.5 over 60 9 0.9 marital status single 379 37.6 married 576 57.2 widow 7 0.7 divorced 45 4.5 education level high school 351 34.9 diploma 186 18.5 bachelor degree 349 34.7 master degree 109 10.8 doctorate degree 12 1.2 nationality uae 319 31.7 indian 237 23.5 pakistan 57 5.7 arab 275 27.3 western 18 1.8 other 101 10.0 diagnosed for covid19 yes 129 12.8 no 878 87.2 total 1007 100.0 taryam m, alawadhi d, aburayya a, mubarak s, aljasmi m, salloum sa, et al. factors affecting the uptake of covid-19 vaccine among dubai airport's professionals (original research). seejph 2022, posted: 11 january 2022. doi: 10.11576/seejph-5091 p a g e 7 | 14 table 2. mean analysis of vaccine acceptability factors factors n mean std. deviation ranking perceived knowledge on vaccine 1007 4.20 .846 3 perceived beliefs on vaccine 1007 3.82 .989 6 perceived safety on vaccine 1007 4.10 .946 4 accessibility & affordability 1007 4.42 .678 1 advice & information 1007 4.03 .942 5 perceived trust on vaccine 1007 4.31 .899 2 overall mean 4.14 in a bid to interpret the results, employee’s demographic data was cross-tabulated with factors influencing their decision to get the covid-19 vaccine. the x2 tests listed in table 3. table 3 indicated significant results (p<0.05) for gender, age, marital status, educational level, nationality, and known infection with covid-19. the overall agreement was 82.8% (11.7% not sure; 5.5% disagree). table 3. cross-tabulation of factors affecting the covid-19 vaccine acceptability with employees' demographical data characteristics of participants disagree (0.00-2.60) not sure (2.61-3.40) agree (3.41-5.00) chi square p overall agreement 5.5% 11.7% 82.8% na gender male 5.7% 17.3% 77% 753.305 (.001) female 5.3% 6.1% 88.6% age 20-29 7.6% 16% 76.4% 837.596 (.000) 30-39 1.6% 15.6% 82.8% 40-49 8% 11.7% 80.3% 50-59 7.1% 7.8% 85.1% over 60 3.4% 7.4% 89.2% marital status single 6.6% 19.4% 74% 767.987 (.002) married 4.4% 4% 91.6% widow 6.1% 10.2% 83.7% divorced 4.9% 13.2% 81.9% education level high school 7.1% 18.6% 74.3% 872.589 (.000) diploma 6.2% 12% 81.8% bachelor 6.5% 17.5% 76% master 2.9% 4.7% 92.4% doctorate 4.8% 5.6% 89.6% nationality uae 6.1% 5.5% 88.4% 425.431 (.043) taryam m, alawadhi d, aburayya a, mubarak s, aljasmi m, salloum sa, et al. factors affecting the uptake of covid-19 vaccine among dubai airport's professionals (original research). seejph 2022, posted: 11 january 2022. doi: 10.11576/seejph-5091 p a g e 8 | 14 indian 4.9% 3.8% 91.3% pakistan 7.5% 15.3% 77.2% arab 3.5% 2.8% 93.7% western 4.8% 23.3% 71.9% other 6.2% 19.5% 74.3% diagnosed for covid-19 yes 2.8% 3% 94.2% 613.556 (.003) no 8.2% 20.4% 71.4% analysis on signs &symptoms which appeared after immunization the results show that 53.7% of vaccinated staff was found to have one or more side effects of the vaccine, where 0% of them were hospitalized after immunization (table 4). moreover, the table below reveals that 23.1% of them had symptoms related to the injection site, such as shoulder soreness. the table further shows that 18.5% of them had headaches, where close to 1% had mild allergic reactions such as hives, wheezing, shortness of breath, and tachycardia (table 4). table 4. main signs & symptoms reported after immunization sign & symptoms n frequency percentage (%) signs related to injection site 541 125 23.1% body aches 541 56 10.4% full-body rash 541 16 2.9% fever 541 45 8.3% dizziness or fainting 541 8 1.5% numbness 541 5 .9% difficulty walking 541 54 9.9% headache 541 100 18.5% allergic reactions 541 7 1.3% body aches & fever 541 21 3.9% fever & headache 541 49 9.1% dizziness, fever & headache 541 36 6.7% headache & allergic reactions 541 9 1.6% to further analyse the association between the sociodemographic representation (gender, age, and covid-19 infection history) of the sample and the main symptoms that appeared after vaccination, a multivariate analysis using binary logistic regression analysis was performed. table 5 shows multivariate results of factors associated with the main symptoms that appeared after vaccination. it reveals that the gender of participants had a significant association with the main symptoms that appeared after vaccination. in this regard, the analysis shows that females were two times more likely to have vaccine's symptoms after dosage than males (exp (b): 1.6; 95%ci: 1.127 2.351, p< .01). age is another variable that was found to significantly affect the vaccine's symptoms occurrence. participants in the age group over 50 were 3 times more likely to have vaccine's taryam m, alawadhi d, aburayya a, mubarak s, aljasmi m, salloum sa, et al. factors affecting the uptake of covid-19 vaccine among dubai airport's professionals (original research). seejph 2022, posted: 11 january 2022. doi: 10.11576/seejph-5091 p a g e 9 | 14 symptoms after vaccination than participants in the age group 20-29 (exp (b): 2.9; 95%ci: 2.4979.681, p< .001). finally, the logistic regression analysis indicates that the covid-19 infection history of participants had a significant association with the main symptoms that appeared after vaccination. the analysis shows that participants with covid-19 infection history were twice more likely to have vaccine's symptoms after vaccination than the group who do not have any infection history of covid-19 (exp (b): 1.9; 95%ci: 1.272 2.542, p< .01). in other words, having a history of covid-19 is significantly associated with vaccine's signs and symptoms occurrence. table 5. logistic regression analysis of factors associated with reported symptoms after vaccination sociodemographic factor exp (b) 95.0% c.i. for exp(b) p gender male ref (1.00) 1.127 2.351 p< .01 female 1.637** age 20-29 ref (1.00) .471 1.962 .462 2.640 1.997 5.681 ---------- ---------- p< .001 30-39 .973 40-49 .998 over 50 2.9423*** diagnosed for covid-19 no ref (1.00) 1.272 2.542 p< .01 yes 1.879** *p<0.05; **p<0.01; ***p<0.001. discussion vaccine uptake is determined by the vaccine's accessibility and pricing. this topic is about whether the public can get to the clinic (logistics) and how much the vaccine costs (affordability). in line with this study's results, previous studies show that accessibility and affordability were associated with uptake of the vaccines (5,27). vaccine uptake necessitates a high level of faith in the vaccine, the country of origin, the provider (particularly healthcare experts), and the policymaker. in regression analysis of much research that looked at the correlation between trust and vaccination uptake, trust in the vaccine, healthcare providers, and the health system were found to reliably predict vaccine uptake or was found to be significantly associated with retrospective reports of vaccine uptake (28). not believing or knowing that a vaccine is necessary or recommended was one (and sometimes the most important) cause for vaccine non-adoption (25). notably, vaccination non-uptake was linked to the belief that covid-19 is not hazardous. the willingness to get a vaccination is also influenced by a person's perception of or understanding of certain signs of infectious disease. after reading about the symptoms of pertussis in the elderly, for example, more adults aged 65 and up (54 percent) agreed to get the vaccine (21). the belief that herpes zoster causes only temporary pain, on the other hand, was linked to a lower likelihood of vaccination. the ability to understand the properties of a vaccine has an impact on whether or not to get vaccinated. the most common cause provided for the vaccine's taryam m, alawadhi d, aburayya a, mubarak s, aljasmi m, salloum sa, et al. factors affecting the uptake of covid-19 vaccine among dubai airport's professionals (original research). seejph 2022, posted: 11 january 2022. doi: 10.11576/seejph-5091 p a g e 10 | 14 limited adoption was a lack of knowledge about its effectiveness and safety (21). in our study, "perceived vaccine safety" was the fourth factor playing a substantial role in up taking the covid-19 vaccine. in essence, vaccine safety has been identified as a basic impediment to vaccination choices, particularly for newly launched vaccinations that have not been adequately evaluated in the real world (5). the sixth theme in this study that affected vaccine uptake was advice and information. healthcare practitioners had a positive impact on the population's vaccination rate, as well as their vaccination intentions and commitment. for example, older individuals who got a proficient recommendation had much greater vaccination rates than those who did not. according to one research, government and media information can help people become vaccinated (29). finally, the participants weighed the apparent benefits and drawbacks before deciding to take the vaccination. vaccination was viewed as a preventative measure to enhance their health in several studies (4). consideration of vaccination as smart, vital, or useful were similar ideas that clearly affected or anticipated vaccine acceptance. other predictors as noted by tuite et al. (29) included things like safeguarding others and living with others who could be exposed. vaccine uptake was inversely correlated with perceptions that immunization impairs one's natural defenses, is unpleasant, causes sickness, or is unrelated to one's health (4). in this study, the agreement level on factors affecting the covid-19 vaccine uptake was found significantly to be higher in females (88.6%) than males (77%) who are married (91.6%), and aged over 60 years (89.2%), while holding a master’s degree (92.4%). although the results in this study don't match previous studies findings (30), during the spread of covid-19, women were put under more stress and had a larger physiological load than males, and they were also exposed to a greater risk of infection, which compelled them to be vaccinated. furthermore, women have a greater immunological response to vaccinations than males, which may assist women lessen the long-term consequences of covid-19 (31). a higher proportion of older participants perceived factors affecting covid-19 vaccine uptake, which could be related to the fact that they are most at-risk of morbidity and mortality; older people who become ill have more complex medical conditions and higher healthcare needs than younger people who become ill. the findings in this study showed that 53.7% of vaccinated staff was found to have one or more side effects of the vaccine, where 0% of them were hospitalized after immunization. moreover, the results revealed that 23.1% of them had symptoms related to injection site, where close to 1% had mild allergic reactions. the findings of this study are consistent with who recommendations, which said that covid-19 vaccination is safe and that adverse effects from a vaccine are usually modest and transient, such as a sore arm, headache, or moderate fever, on december 30, 2020. more adverse side effects are possible but extremely rare (13). however, the findings of previous studies match our study findings, as the most common side effect that appeared on vaccinated staff was symptoms related to injection site (23.1%). in a population-based study, the estimated relative incidence of vaccination allergic reactions during the primary risk interval (weeks 2–7) was 1.45 (95% confidence range, 1.05–1.99; p =.02) compared to the control interval (weeks 20–43). this study discovered that influenza vaccination is connected to a small risk of hospitalization due to the vaccine's side effects (32). this result is consistent with our research, which found that following inoculation, 0% of dubai airport employees were hospitalised. the results in this study indicated that females who are taryam m, alawadhi d, aburayya a, mubarak s, aljasmi m, salloum sa, et al. factors affecting the uptake of covid-19 vaccine among dubai airport's professionals (original research). seejph 2022, posted: 11 january 2022. doi: 10.11576/seejph-5091 p a g e 11 | 14 aged more than 50 years are more likely to have side effects after immunization compared to male and young persons. this result was supported by several studies. analysis by gender of 14 studies has revealed that elderly females report significantly more local reactions (13). in healthy young adults, placebocontrolled trials demonstrated that inactivated influenza vaccination does not result in greater frequencies of systemic symptoms (e.g., fever, malaise, myalgia, and headache) when compared to placebo injections (33). systemic adverse effects were more likely in those over 65 years old when a vaccination with a high dosage of 180 mcg of ha antigen (36 per 100 vaccinees) was compared to a usual dose of 45 mcg (24 per 100 vaccinees). the majority of the participants' symptoms were minor and temporary, and they went away within 3 days. (34). finally, this study indicated that having a history of covid-19 is significantly associated with vaccine's symptoms occurrence. several recent studies are in line with the findings of this study. menni et al. 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s, aljasmi m, salloum sa, et al. factors affecting the uptake of covid-19 vaccine among dubai airport's professionals (original research). seejph 2022, posted: 11 january 2022. doi: 10.11576/seejph-5091 p a g e 14 | 14 © 2022 taryam et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 35. menni c, klaser k, may a, polidori l, capdevila j, louca p, et al. vaccine side-effects and sars-cov-2 infection after vaccination in users of the covid symptom study app in the uk: a prospective observational study. lancet infect dis 2021;21:939-49. doi: 10.1016/s1473-3099(21)00224-3. _____________________________________________________________________________________________ adedeji oj, babatunde yo, ibrahim ad, adebisi ya, lucero-prisno iii de. towards universal health coverage in africa: relevance of telemedicine and mobile clinics (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4448 1 | p a g e review article towards universal health coverage in africa: relevance of telemedicine and mobile clinics oluwakorede joshua adedeji1, yusuf olalekan babatunde1, abdulmumin damilola ibrahim1, yusuff adebayo adebisi2,3, don eliseo lucero-prisno iii3 1 faculty of pharmaceutical sciences, university of ilorin, ilorin, nigeria 2 faculty of pharmacy, university of ibadan, ibadan, nigeria 3 global health focus africa corresponding author: oluwakorede adedeji; address: faculty of pharmaceutical sciences, university of ilorin, ilorin, nigeria; email: oluwakorede2017@gmail.com mailto:oluwakorede2017@gmail.com adedeji oj, babatunde yo, ibrahim ad, adebisi ya, lucero-prisno iii de. towards universal health coverage in africa: relevance of telemedicine and mobile clinics (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4448 2 | p a g e abstract access to essential healthcare services is limited in africa, resulting in preventable mortalities. telemedicine, which can be defined as the use of information and communication technologies in the delivery of healthcare services, is applied in various fields of medicine and at multiple times. some telemedicine projects have been implemented in different african countries. some successes were recorded, as well as failures. despite challenges, such as high cost, that inhibit telemedicine coverage, telemedicine still presents excellent opportunities in increasing access to basic healthcare and expert services. mobile clinics provide the opportunity to expand access to health services across a region. they can be implemented as an extension of fixed1hospitals that are often situated away from remote villages, serve in the heart of communities, and aid in preventive screenings and epidemiological monitoring. africa has limited resources but leveraging these existing resources most cost-effectively is key to achieving universal health coverage in the region. keywords: universal health coverage, telemedicine, information and communication technology, mobile clinic, africa source of funding: none conflicting interest: the authors declare no conflict of interest. authors' contributions: oluwakorede joshua adedeji conceptualized the study. oluwakorede joshua adedeji, yusuf olalekan babatunde and abdulmumin damilola ibrahim acquired, analysed and interpreted the data for the work. yusuff adebayo adebisi and don eliseo lucero-prisno iii revised it critically for important intellectual content. all authors agree to be accountable for all aspects of the work in ensuring that all questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. adedeji oj, babatunde yo, ibrahim ad, adebisi ya, lucero-prisno iii de. towards universal health coverage in africa: relevance of telemedicine and mobile clinics (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4448 3 | p a g e introduction accessibility to basic promotive, preventive, curative, rehabilitative, and palliative health services of adequate quality without incurring financial hardship encompasses the concept of universal health coverage (1). universal health coverage (uhc) enables all population members to easily obtain primary health services without being pushed to poverty or debt. health is a fundamental right of all, and access to it should not be difficult or impossible for anyone. globally, about 100 million people are pushed into extreme poverty because they have to pay for healthcare (2). this is particularly worse in africa as 11 million africans are pushed to poverty each year due to out-of-pocket expenditure (3). uhc is not just about health financing. it encompasses all other components, such as health technologies, health service delivery, health workforce, health facilities and communication networks, information systems, quality assurance mechanisms, governance, and legislation (2). several african nations are moving slowly towards universal health coverage (4), but particular challenges threaten the actualization of the "health for all" reality. such challenges include the lack of political commitment, lack of coherent health financing policies, weak health systems, and weak information systems to monitor uhc progress (1). africa harbours over 90% of global malaria cases (5), almost two-thirds of the global total of new hiv cases (6), and over 25% of tuberculosis deaths (7). many deaths can be prevented and reduced with effective health coverage in the region. attaining the third sustainable development goal (good health and wellbeing for all) requires country-specific actions towards achieving universal health coverage (1). each country's ability to translate plans and policies into concrete actions will determine the reduction in mortality rates and overall wellness of the population, thus affecting the level of growth. this paper aims to elucidate the roles and relevance of the dual implementation of telemedicine and mobile clinics as a tool for ensuring adequate health coverage in africa. telemedicine, or telehealth, can be referred to as "the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for the diagnosis, treatment, and prevention of diseases and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities" (8). the use of telemedicine can be classified as either clinical (diagnostic and therapeutic), educational or administrative (9). mobile clinics are an essential part of the health system that can help deliver basic health services to remote areas (10) predominantly rural communities that lack access to health centres. they are instrumental in accessing vulnerable populations (10). mobile clinics contain necessary equipment for temporary treatment of patients in critical situations and can help increase access to essential health services (11). implementation of telemedicine and mobile clinics provide significant advantages and challenges that inhibit full implementation and utilisation, especially in the african region. however, the dual performance may provide substantial benefits and increased access to health services of sufficient quality. this paper assesses the impact of existing telehealth platforms and mobile clinics and the effect of a dual implementation. method we conducted a narrative review of published articles on telemedicine and mobile clinics in africa. search for relevant medical literature in biomedical databases (google scholar and pubmed) was con adedeji oj, babatunde yo, ibrahim ad, adebisi ya, lucero-prisno iii de. towards universal health coverage in africa: relevance of telemedicine and mobile clinics (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4448 4 | p a g e ducted using the following key terms: "telemedicine", "mobile clinics", "africa", "telehealth", "electronic health", "ehealth" and "e-health". papers were selected based on the country (only african countries were selected), quality, and relevance to the scope of the study by reviewing their abstract and title. we also used supplementary references listed under the papers. implemented telemedicine projects in africa were selected and analysed for successes and/or reasons for failures. results in the use of telecommunication technologies to advance citizens' health and wellbeing in the state, africa is still in its infancy compared to developed countries; nevertheless, various telemedicine projects have been implemented in different african countries, as seen in table 1. these telemedicine projects were implemented for various purposes across different countries, and some successes were recorded for some projects while some other projects might have failed. table 1: various telemedicine projects and approaches and impact towards achieving universal health coverage in africa authors telemedicine project country roles and impact on healthcare towards uhc lessons antoine geissbuhler et al [22] keneyan blown mali (2001) tele-education for physicians and students and teleconsultation to follow up with patients operated in geneva and returned to mali. improved education of physicians for better healthcare delivery and post-discharge care is enhanced. problems identified include poor internet connectivity and poor infrastructure required to support telemedicine coverage t. mpunga et al. [28] static-image telepathology program at butaro cancer centre of excellence rwanda (2013) the use of static-imaging telepathology enhanced the diagnosis and interpretation of specimen samples and, overall, improved care and diagnosis for cancer patients in the country. limited bandwidth and internet instability limited the choice for dynamic real-time readings. also, the varying time zones serve as a limitation to synchronous communication. n.d montgmorey et al. [29] clinicopathologic conferences between clinicians and pathologists in kamuzu central hospital (kch) and pathologists in the university of north carolina, chapel hill (unc) malawi (2011) improved diagnosis of lymphoproliferative disorder in resource-limited settings on a modest investment and a collaborative academic environment for malawian pathologists. telemedicine can play an influential role in advancing care to millions while leveraging on existing resources and investment. maurice mars [19] drug resource enhancement against aids and malnutrition (dream) project tanzania, malawi, mozambique telecardiology training, the establishment of telecardiology centres, and remote reporting of ecgs from italy. telemedicine can cut across different countries and thus facilitate intercultural and international collaboration. cheick-oumar bagayoko et al [31] equi-reshus mali (2011) task shifting of medical imaging in obstetrics and the use of telemedicine for training and networking of health adedeji oj, babatunde yo, ibrahim ad, adebisi ya, lucero-prisno iii de. towards universal health coverage in africa: relevance of telemedicine and mobile clinics (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4448 5 | p a g e cardiology in remote locations and provision of cme (continuing medical education) professionals can help reduce the isolation of these professionals working in remote areas. cheick-oumar bagayoko et al [32] réseau afrique francophone de télémédecine (raft) project madagascar, rwanda, mali, morocco, mauritania, etc. distance learning, teleconsultations, and digital collaboration within africa and between africa and europe. the development of large-scale telemedicine projects involves the inclusion of participating countries in the development of the project. discussion overview of telemedicine coverage and application to various fields of medicine the use of information and communication technologies (ict) in healthcare has gained ground. its application spans radiology, especially teleradiology, i.e., using ict to transmit radiographic images from one location to another, usually for diagnosis and interpretation (12, 13). teleradiology often involves a store-and-forward or asynchronous form of telemedicine. the patient data is generated, stored, and transmitted to a receiver which responds at a later time (13). in psychiatry, telepsychiatry is used to diagnose, educate, treat, consult, transfer medical data, research, and other healthcare activities between a patient and the healthcare provider (14). telepsychiatry usually involves real-time or synchronous communication between the patient and a healthcare provider in which both individuals at either end of the communication link are simultaneously present and actively engaged ); dermatology (teledermatology includes both store-and-forward communication and real-time synchronous communication between patient and clinician (15).); pathology (telepathology (13)the application of telecommunication technologies in microscopic imaging and pathology (16)), etc. the use of telemedicine in real-time video consultations with off-site specialists cuts across various fields such as oncology, rheumatology, etc.(17); thus, almost every area in medicine has a potential telemedicine application. telemedicine also plays vital roles in managing chronic illnesses, emergency and trauma care, medication prescribing, counselling, stroke intervention, and post-discharge coordination (17). pharmacy practice is not left out in the application of telemedicine. the use of telemedicine can provide great advantages in remote dispensing and supervision in community pharmacies. use of mobile clinics mobile health clinics are designed from vans, trucks, or buses and, depending on use, are fitted with equipment and facilities essential in carrying out the design purpose. mobile clinics are used for various purposes in emergency cases, primary healthcare delivery, preventive screenings, etc. carried out by quite a small number of healthcare professionals. in humanitarian emergencies, mobile clinics are often common in delivering health services (24). in the united states of america, mobile health clinics serve an essential role in providing healthcare to vulnerable populations (25). the use of mobile health clinics for primary healthcare delivery is not quite established in africa. globally, more than half of the world's population lives in urban areas. however, in africa, about 57% in rural areas (26). among these countries, about 41% in lower-middle-income-countries and 32% in low-income countries live in urban areas. due to the presence of most hospitals adedeji oj, babatunde yo, ibrahim ad, adebisi ya, lucero-prisno iii de. towards universal health coverage in africa: relevance of telemedicine and mobile clinics (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4448 6 | p a g e in the cities, the use of mobile clinics presents an effective framework for health delivery to those in need in these rural areas.the ratios of the number of hospital beds to the population in most african countries is quite low and below standard values with most african countries having less than 15 beds per 10,000 population (27) and most of these beds often remain inaccessible to the majority of the population. the adoption of mobile clinics may present great benefits in eradicating preventable endemic diseases such as malaria and reducing the high mortality rate that results from such diseases in the region. mobile clinics have also been used for massive immunization programmes and ante-natal care. mobile clinics might even reduce the high mortality rate associated with the region due to certain factors such as the absence of a health professional at the time of child delivery, probably as a result of distance from hospitals. the accessibility of mobile clinics to rural and vulnerable communities greatly benefits attaining uhc in africa. stakeholders involved in the implementation of a possible framework modern telemedicine systems and mobile clinics involve a wide range of stakeholders, each having their responsibility. the key stakeholders that have important roles for successfully implementing telemedicine and mobile clinics include system designers and developers, (33) healthcare professionals like physicians, nurses, pharmacists, and community healthcare professionals (34). also, internet service providers, information technology support staff, policymakers, and end-users (35) have essential roles to play to get the required satisfaction from telemedicine projects. a proper evaluation of telemedicine and mobile clinics is essential to convince various stakeholders of its importance and as a means to come to a rational implementation in various health sectors across african countries. there is a need to establish roles of additional stakeholders that could be an important addition to the novel telemedicine and mobile clinics systems to achieve equal access to health by everyone everywhere in africa. the central role of nurses can be seen in telemedicine systems adopted in-home care settings, where patients have to be introduced to the use of new technology and empowered to perform self-management. moreover, nurses are often responsible for daily patient control through remote monitoring systems (36). also, pharmacists are increasingly acquiring a front-line role in many public health initiatives (37), (38) with the possibility of being supported by teleconsultation when needed. implementation of telemedicine and mobile clinics as a means to achieve universal health coverage in africa requires a multidisciplinary approach. firstly, the core of any telemedicine intervention would be technology. technical issues like quality, robustness need to be taken into account and integral to any telemedicine implementation. given the complexity and novelty of telemedicine applications, appropriate training to relevant stakeholders regarding the use is necessary for a successful implementation. secondly, acceptance by the users (patients and healthcare providers) is required. the users must be satisfied with the system operation and effectiveness. therefore, as suggested by berg (39), users should be involved in the early stages of the development process. thirdly, implementing telemedicine and mobile clinics will influence the financial situations of various parties in the health sector (40). the telemedicine financing will be different from the normal non-telemedicine (traditional) approach, affecting the distribution of cost and revenue amongst stakeholders. therefore, there is a need to design a sustainable business model so that all participants benefit from telemedicine. finally, there have been discussions on telemedicine systems' legal and ethical impli adedeji oj, babatunde yo, ibrahim ad, adebisi ya, lucero-prisno iii de. towards universal health coverage in africa: relevance of telemedicine and mobile clinics (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4448 7 | p a g e cations on different levels (i.e. international, national, regional) by regulatory bodies (41). commonly needed policies are related to the protection of the patient's privacy and the patient's safety. moreover, there is a need for standards to ensure the conformance of telemedicine implementations at (42) the technical level and (43) the organizational level; to guarantee the quality of the telemedicine development (44) effects of single and dual implementation of telemedicine and mobile clinics in africa ensuring successful implementation of telemedicine requires satisfying the following factors: governance, policy or strategy, scientific development and evaluation (13). an international collaboration between participating countries in a telemedicine project to stipulate guidelines and conduct that regulate the utilisation of the project is necessary for governance to ensure smooth implementation. since many telemedicine projects cut across state borders, the promulgation of guidelines can help harmonize country practices. most countries in the african region do not have a defined policy or strategy for achieving telemedicine (13), hence the low coverage in the region. as seen from other telemedicine projects in various institutions and countries, the effects of telemedicine in africa are diverse. in some projects, telemedicine enhances access to specialty services from experts. some other projects improve diagnostic services and reduce the time often spent in obtaining diagnostic results. furthermore, telemedicine has been of great advantage in enhancing interprofessional collaboration, networking and reducing isolation of professionals working in remote areas (31). despite the immense advantages telemedicine presents to numerous fields particularly in reducing the burden of distance and travel, some projects are often short-lived. improving the chances of success of a telemedicine project involves careful planning based on local resources and community setting, observing the results produced, expanding on evidence-based effectiveness, and ensuring adaptability to the local region. there is no "one-size-fits-all" strategy in achieving universal health coverage (45), every country needs to adopt a policy or strategy that achieves the best results. despite the need for the variability of approach to ensure adaptability to the region, the influence of telemedicine cuts across various processes. it can be modified to adapt to the needs of a region, state, or country. telemedicine, as a means to strengthen and support the healthcare system in africa, and not as a separate entity or competitor to the existing means of healthcare, can help improve healthcare coverage and maximise the use of existing resources either among clinicians and healthcare providers or between patients and healthcare providers. the use of mobile clinics successfully reaches vulnerable populations (10), especially in remote communities, offering urgent and emergency care reduces barriers to healthcare such as transportation, time and complexity and providing preventive services and screenings (25). mobile clinics can be implemented and utilised in catering to a particular region or location. an effective model involves dividing a state into regions and assigning a mobile clinic to each region. even in urban slums, mobile clinics may even provide health services to urban residents who may not afford the expenses of a hospital. a dual implementation of telemedicine and mobile clinics in africa combines the advantages and strengths of each approach while minimising their challenges. for example, mobile clinics present the disadvantage of isolation of health professionals, telemedicine can help bridge that gap and provide a medium for collaboration and connection with other health professionals. telemedicine presents a disadvantage of adedeji oj, babatunde yo, ibrahim ad, adebisi ya, lucero-prisno iii de. towards universal health coverage in africa: relevance of telemedicine and mobile clinics (review article). seejph 2021, posted: 18 may 2021. doi: 10.11576/seejph-4448 8 | p a g e limited infrastructure such as mobile sensors and appropriate camera technology for data collection from patients. mobile clinics can serve as a point of collection of patient information such as blood pressure, body temperature, and other vitals that may be needed to provide a clinical diagnosis. the concept of a dual implementation of telemedicine and mobile clinics is not new in africa, similar projects like "the virtual doctor project" in zambia (46) aim to take medical expertise to remote locations, hence, reshaping and improving primary healthcare for all (46). a powerful combination of telemedicine and mobile clinics can endeavour to provide services to communities where neither the infrastructure nor health facilities exist (46). limitations the study focused more on the implementation and responsibilities of relevant stakeholders in telemedicine systems and less on mobile clinics. they were very few interventions of mobile clinics in african countries. recommendations the emergence of telemedicine and mobile clinics should be seen as an opportunity to renew knowledge for medical policy-making and actions in response to the need to improve health care services for rural and remote communities. additional stakeholders to the already considered patient and physician also need to be factored in the implementation of telemedicine and mobile clinic projects: nurses, pharmacists, knowledge engineers, hardware vendors, communication service providers. it is recommended to have a quantitative study on the general public's perspective so that more factors relating to the perception of the public are uncovered and any issues are addressed in the planning and development of telemedicine projects. stakeholders need to be made aware of standardized project management practices after evaluation. this will contribute to overall improvements in planning, managing, organizing, sustaining, and monitoring of telemedicine and mobile clinics. business models need to be adapted in the national context for successfully implementing telemedicine systems. this is to avoid any financial situations amongst certain stakeholders in terms of the distribution of cost and revenue. more research and studies are needed to be conducted on how the incorporation of mobile clinics can be a great step to achieve universal health coverage in africa. conclusion innovative approaches such as telemedicine and mobile clinics can speed up the attainment of universal health coverage in africa (47). a combination of telemedicine tools and mobile clinics in africa will allow the most remote and vulnerable populations to receive quality care while strengthening health systems across the continent. implementing these approaches, on the other hand, is not without challenges. successful implementation of these initiatives will require that the african health and ict stakeholders embrace the transformative capacity they offer (47). some of the challenges and barriers facing the implementation include an inadequate legal framework, capacity for addressing ethical issues, unreliable infrastructure, long-term feasibility, and funding (10),(47). if these challenges are addressed and stringent measures put in place, these initiatives will go a long way in achieving uhc. references 1. world health organization (who), african union (au). universal health coverage in africa: from concept to action. 1st african ministers of health meeting convened by who and au (2014). adedeji oj, babatunde yo, ibrahim ad, adebisi ya, lucero-prisno iii de. towards universal health coverage in africa: relevance of telemedicine and mobile clinics (review article). seejph 2021, posted: 18 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josefine hirschler1, filip karan1, raika kugel1, elena romancenca1, jessica neicun1 1faculty of health, medicine, and life sciences, maastricht university, the netherlands corresponding author: flora argyrou, f.argyrou@student.maastrichtuniversity.nl, duboisdomein 30, 6229 gt, maastricht, the netherlands. mailto:f.argyrou@student.maastrichtuniversity.nl argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j.. committed collaboration to address homelessness in the netherlands (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4688 page 2 | 26 abstract context: in the netherlands, the number of homeless people increased from 17.800 in 2009 to 39.300 in 2018. due to the covid-19 pandemic and its socioeconomic consequences, the needs of marginalized people have increased worldwide in terms of access to services and relevant information. in the netherlands, along with the red cross, other humanitarian organizations such as the salvation army, the rainbow foundation, and the foundation for the homeless are already providing people in need with primary needs such as food and housing, but also with healthcare and legal support. cooperation between services for the homeless is also gaining attention. however, collaboration between relevant stakeholders is still insufficient and urges to be expanded. moreover, centralized monitoring is challenging as different services are provided (shelters, assisted housing) by different stakeholders and there is no central data collection system or pre-defined indicators. recent, comprehensive data on homelessness figures are needed to understand the needs and how these may have changed, given the exacerbated consequences of covid-19 pandemic on those in socioeconomic vulnerability, in order safeguard the health, safety and dignity of homeless people. policy options: to address the needs of homeless people, innovation is needed to overcome sectoral boundaries and to work collaboratively. at the level of service provision, as shown by some successful global experiences (e.g. homeless individuals and families information system (hifis), housing first, les infirmières de la rue), new partnerships and collaborations are a central dimension of many effective innovative initiatives relating to homelessness. the target of collaboration is to improve health and social outcomes in the most appropriate and efficient manner. to improve case management at the local level, in canada, the homeless individuals and families information system (hifis) provides a single platform for homogeneous data collection on clients among service providers that facilitates referrals between services. recommendations: approaches to improve cross-sectoral collaboration and communication at two levels should be identified. firstly, establishing a coordinated and comprehensive cross-sectoral network among organizations in the field and secondly, improving data collection. keywords: collaborative network, cross-sectoral collaboration, service coordination, homeless acknowledgments: the authors would like to express their sincere thanks to j. neicun and k. czabanowska for their support in preparing and revising the policy brief. authors’ contributions: all authors contributed equally to this work. conflicts of interest: none declared funding: none declared argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j.. committed collaboration to address homelessness in the netherlands (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4688 p a g e 3 | 26 introduction in the netherlands, the total number of adult homeless people has more than doubled in the past decade; it has increased from around 18.000 in 2009 to 39.300 in 2018, representing 0.23 % of the total dutch population (statistics netherlands (cbs), 2019). while an internationally recognized definition of homelessness does not exist, the netherlands considers all people without a roof to sleep under and without a registered home address as homeless. therefore, the official dutch figures on homelessness include all individuals who are sleeping in the open air, in sheltered public spaces (such as stations and cars), or in temporary housing (european federation of national organisations working with the homeless (feantsa), 2018). it is important to note that people residing in the netherlands illegally, i.e. without a government-issued residence permit, are excluded from official statistics on homelessness (oecd, 2020). the novel coronavirus pandemic is likely to further exacerbate the problems faced by the homeless communities in the netherlands for several reasons. firstly, homeless people are more likely to suffer from co-morbidities associated with increased risk for severe forms of covid-19, hence making them particularly vulnerable to the disease (lewer et al., 2020). secondly, living in shared accommodations (such as homeless shelters) puts them at a higher risk of transmission of coronavirus (lewer et al., 2020; rogers & power, 2020). lastly, poverty and homelessness rates in the netherlands are expected to increase in the near future as a result of the pandemic due to the loss of employment and income for many individuals, putting additional pressure on existing social programs and services working with the homeless populations in the country (chorus et al., 2020). there are several organizations in the netherlands working with and providing services to the homeless. some of the most notable of these organizations include the red cross netherlands, the salvation army, the feantsa, and the rainbow railroad. they are supporting the homeless population by satisfying their primary needs such as food and housing, but also by providing them with access to healthcare, advocacy, and legal support. while these organizations offer valuable programming to the homeless, they work independently and seldom collaborate for the provision of goods and services. in addition to work done by non-governmental organizations (ngos), various dutch municipalities have implemented their own programs that offer housing to people in need. this is particularly important in the four biggest dutch municipalities (amsterdam, rotterdam, the hague and utrecht) where the size of the homeless communities is the largest in the netherlands (cbs, 2019). the dutch national government has also recognized the need to address the housing situation of homeless people. the dutch national housing agenda 2018-2021 sets the tone for an increase in the availability of housing as well as better use of existing housing facilities (ollongren, 2019). it allows municipalities to determine the specific actions and budget allocations to integrate housing with other services, such as healthcare, debt assistance, and social inclusion (ollongren, 2019). while the governments, both national and local, have at times partnered with housing agencies and ngos to tackle the issue of homelessness in the netherlands, the collaboration between relevant stakeholders is still insufficient and needs to be expanded in the netherlands. according to anecdotal evidence coming from the ground, the lack of collaboration among organizations (as well as between organizations and government institutions) working with and offering services to the homeless people residing in the country has argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j.. committed collaboration to address homelessness in the netherlands (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4688 p a g e 4 | 24 been specifically identified as a major challenge in effectively tackling the problem of homelessness. having a fragmented network of service providers rather than a connected one has several disadvantages: different organizations that provide services to homeless people might be unaware of the existence of other services provided by other organizations, leading to inefficient use of resources, while different organizations which provide similar services to the homeless might be competing for the same source of funding, potentially leading to an inefficient distribution of resources among relevant partner organizations. in light of this, under the aegis of the red cross netherlands, our working group is proposing the establishment of a national collaborative network of service providers to tackle homelessness in the netherlands. the principal targets of this initiative and therefore its key stakeholders would be all organizations and government institutions working with and providing services to the homeless people residing in the netherlands. a full list of all stakeholders identified can be found in the appendix. the overall aim of this initiative is to improve cross-sectoral collaboration and communication among relevant stakeholders through the creation of a collaborative network, the development of a shared mission and vision based on reciprocal trust, and the belief that a wellbalanced investment of partners will produce positive outcomes for all of them. this collaborative national network will be in charge of collecting and disseminating relevant data among partners while aligning service provision to improve their efficacy and efficiency. context particularities of homelessness in the netherlands as in other part of the world, there is a large imbalance in the gender composition of the homeless population in the netherlands; men account for about 84 % of all homeless people. the homeless population in the netherlands is divided into three age groups for official statistics: 18-29 years old, 30-49 years old, and 50-64 years old. the latter age group accounts for only a small proportion. the number of homeless people in the 30-49 age group has decreased over the years, but this group still makes up the largest share of homeless people in the netherlands (cbs, 2019). however, the number of young homeless people (18-29 years) has increased and almost tripled between 2009 (4.000) and 2018 (12.600) (cbs, 2019). youths leave homes where they were usually dependent on adult caregivers (parents or relatives) and which were defined by intimate relationships. a high percentage of young people affected by homelessness were also in the care of child protection services. 77.50 % of this subgroup affected by homelessness stated that their inability to cope with their parents played an important role in why they left home (homeless hub, n. d.). it is necessary to point out that young homeless people have specific needs. these include in particular the satisfaction of basic needs, navigation through housing and income support systems, access to education/training, and obtaining support for mental health or drugrelated issues (buchnea, mckitterick, & french, 2020). to avoid homelessness among young people it is essential to strengthen families and take their needs into account (homeless hub, n. d.).of all homeless people in the netherlands, about 57 % had a migrant background, which indicates that foreigners, such as refugees or labor migrants, constitute a large subgroup of homeless people. almost half of all homeless people have a non-western background. similar to the proportion of young homeless people, the share of migrants without a western background tripled from 6.500 argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j.. committed collaboration to address homelessness in the netherlands (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4688 p a g e 5 | 24 (2009) to 18.300 (2018) (cbs, 2019). the main reasons why people migrate are economic or humanitarian and reasons for family reunification. the reasons for homelessness among these people are workrelated, such as lack of regular and secure employment, often caused by discrimination in access to the labor market and to fair and equal working conditions. secondly, the discrimination in the housing market, lack of residence status, insufficient availability of accommodation in reception centers for asylum seekers, lengthy administrative procedures is another cause for homelessness among foreigners. these immigrants have special needs that differ from those of the dutch homeless. this includes administrative advice, language services, legal assistance, and specialized employment services. capacity building is necessary to provide adapted services that meet the accommodation and support needs of homeless migrants (feantsa, 2013). but also, the proportion of native dutch homeless has almost doubled between 2009 (9.600) and 2018 (16.900), which means that native dutch are a large subgroup of the homeless in the netherlands (cbs, 2019). a study assessing the needs of homeless people in the netherlands showed that, in general, physical security, training, transport, affordable housing, medical/dental care, health information, vocational training/employment services were considered to be the most important (acosta & toro, 2000). however, this homeless population is very heterogeneous due to different demographic characteristics and circumstances as well as different risk factors. there are therefore major differences with regard to the needs, priorities, and customs of each subgroup of the homeless population, which should be taken into account when providing services, such as social support or legal advice (linn & gelberg, 1989; peressini, 2009). in addition, service providers should take into consideration that homelessness, in general, is associated with higher rates of mental health problems and substance use problems (fazel et al., 2008). migrants, asylum seekers and refugees in particular may be at increased risk of suffering from mental health problems, as they are likely to have experienced human rights violations, persecution, poverty, and conflict in their home country and face substandard conditions, insecurity and instability in their country of immigration (world health organization (who), 2017). policy options social innovations to reduce homelessness social innovations in the field of homelessness are important approaches to reduce homelessness (feantsa, 2012). the promotion of evidence-based social innovation in the field of homelessness is also supported by the european union (eu) in the framework of the europe 2020 agenda for "smart, sustainable and inclusive growth" (european commission, 2010). there are many projects developed in different countries around the world dealing with social innovation in the field of homelessness. in this policy brief, social innovations in the area of data collection, housing, and cross-sectoral working are of particular interest. data collection to better apprehend homelessness, an understanding of its magnitude and nature is essential. this goal can be achieved through innovative partnerships and cross‑sectoral working methods which can improve data collection on homelessness and thereby enhance the development of effective homelessness policies (feantsa, 2012). an example of a "data collection and case management system" is the homeless argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j.. committed collaboration to address homelessness in the netherlands (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4688 p a g e 6 | 24 individuals and families information system (hifis) applied in canada. this system enables several service providers in the same municipality to access data and work together. in addition, with the introduction of hifis, municipalities use identical terminology to define homelessness. based on the collected data, the client can be referred to the suitable services at the right time. furthermore, local communities can improve their understanding of homelessness situations and their needs. it also provides a detailed picture of homelessness in canada to inform policy-making processes (government of canada, 2020). housing in 2010, the european consensus conference recognized housing as an essential area for social innovations for homeless people focusing on the "housing first" model (european consensus conference on homelessness, 2011). it emphasizes the search for sustainable housing solutions as a first reaction to homelessness (feantsa, 2012). the european commission also encourages countries to implement the “housing first” approach (european parliament, 2020). some countries in the eu have already implemented this approach, including finland. the finnish strategy is to substitute short-term housing for long-term rental accommodation for homeless people (y-foundation, 2017). this approach follows the core philosophy of considering home as a human right (pleace, culhane, granfelt & knutagård, 2015). in 2008, the program “paavo i” (2008-2011) was introduced with the aim of buying and building affordable housing. the project was initially launched in the ten cities in finland having the largest problems with homelessness. after “paavo i” was finished, the program “paavo ii” (2012-2015) was introduced. with "paavo ii", the cities recommitted to the program and issued new declarations of intent. in addition, another city joined the program. in 2016, an action plan was published with reducing homelessness in finland as the main goal and preventing relapses into homelessness as the general objective. within the finish “housing first” model, different stakeholders work together, including the government, municipalities, cities, service providers, employees, and others (y‑foundation, 2017). cross-sectoral working to improve access to health services for homeless people and to overcome barriers, partnerships across sectors are important social innovations. in order to work across sectors, experts from different areas must work together. to ensure holistic care, they must identify where homeless people have needs (e.g. "health, social and housing services"; feantsa, 2012). an example of a cross-sectoral working organization is "les infirmières de la rue'' (“the street nurses”) which is a group of nurses taking care of homeless people in the streets and shelters in brussels. their objective is to bring health care directly to the homeless and to draw attention to health and hygiene problems. they also offer treatment when necessary and a link to common primary healthcare services. the organization creates a network with the objective of monitoring and helping homeless people. hereby, all relevant actors around them should be involved, e.g. medical and social staff, etc. (feantsa, 2012; les infirmières de la rue, n. d.). potential for successful cross-sectoral collaboration in the netherlands collaboration between services for homeless in the netherlands service integration is being promoted in the netherlands by the national strategy on argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j.. committed collaboration to address homelessness in the netherlands (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4688 p a g e 7 | 24 homelessness that was written collectively by all stakeholders involved. this strategy provides municipalities the freedom to formulate action plans based on local needs, working with ngos and care organizations. thus, inter-sectoral work has emerged at the local level, including between municipalities and housing associations that agree on annual strategies for social housing, aiming to reduce the number of evictions (oostveen, 2019). in the municipality of amersfoort, to prevent long-term homelessness, coalitions between service providers are formed aiming to provide sustainable solutions such as organized access to services, tailor made services and focus on recovery and independence of users. in amsterdam, the departments of debt assistance, work, income, and housing jointly provide financial help to homeless people in their search for structural housing, preventing the relapse to homelessness through a continuity of services (rijksoverheid, 2020). the home again action plan 2017, initiated by the associations of municipalities, housing, and care providers, made it possible to set collective targets locally and pilot common strategies. the continuation of this program was decided given its positive outcomes including knowledge sharing and dissemination of good practices but also upstream advocacy for local needs not covered by national legislation (oostveen, 2019). specifically, in groningen, homeless people were supported to address unemployment or debts. in north limburg, coordination from housing associations facilitated reserving places for people that reside in assisted housing and are ready to move into independent housing. also, in eindhoven, transferring the accommodation lease from the care organization to individuals that had completed a year of stay without disturbance had a 97 % success rate. among healthcare providers in the netherlands, already established effective networks include the care sector organizations (boz) that as of 2017 facilitates collective management of and transparency between health institutions and the dutch mental health services that, since march 2020, aims to expand local providers’ networks to develop a joint, communitybased strategy (denerdenlandseggz, n. d.). also, the housing first program is a network that spans across sectors and runs in the netherlands since 2016, being one of the most developed in europe. data collection various definitions of homelessness are used in the netherlands as in many countries in europe. the term ‘homeless’ may refer to people receiving housing support and ambulatory care, people staying in night shelters with no fixed address or hosted by friends or family or lastly, people staying in shelters, being roofless, or staying in insecure housing. the official definition has an impact on homelessness figures. numbers of homelessness measured by statistics netherlands (cbs) refer to registered homeless people receiving benefits under the work and social assistance act (wwb), people that have applied for low-threshold (night) shelter, as registered in the personal records database (brp), and some selected people from the national drug and alcohol information system (ladis) (rutenfransstupar, 2019). though, these sources exclude those homeless that sleep rough or those that are not eligible for social support services (those without dutch nationality or those that have an income that is higher than a certain threshold) and thus figures of homelessness are extrapolated estimates. this is illustrated in 2016 figures as 30.500 people were homeless in the netherlands according to cbs, but 60.120 people were registered in argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j.. committed collaboration to address homelessness in the netherlands (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4688 p a g e 8 | 24 the dutch federation of shelters (federatie opvag), that measures in addition those receiving ambulatory care from shelter facilities (rutenfrans-stupar, 2019). existing data should be interpreted with further scrutiny as some groups are not included in data systems, known as “hidden homeless” that have differentiated trajectories through homelessness. homeless youth is a group that may hide in parks or stations, may remain in abusive households, or use couchsurfing, an online platform of hospitality that connects travelers who seek a place to stay with local people that wish to provide such a place without compensation (feantsa, 2019a). women and female lone parents that are in need of housing and financial support, they instead tend to exhaust other support options such as from relatives, friends or domestic violence services, and thus are not visible to housing services (bretherton, 2017). in denmark and in a german region that report extensive homelessness statistics, people temporarily living with friends or family were 28 % and 37 % of all homeless (rutenfrans-stupar, 2019). in the netherlands, legislation is being drafted to allow an exchange of data between municipalities for people not paying rent that may allow for a clearer picture of “hidden homelessness” (oostveen, 2019). although homelessness is accepted as an urgent issue that no agency can tackle alone, and collaboration has been endorsed and proven effective in the netherlands, services for homeless people either work in parallel in an unintegrated manner, or they form small distinct networks that are not linked together in a core network. also, services are undermined by the unavailability of a data collection system (boesveldt, 2018). positively, during the pandemic, services for shelter are being expanded through the provision of more single rooms, reception of people otherwise not eligible for shelter under the social support act, and the expansion of childcare options (muusse, 2020). it is crucial to ensure that service provision is coordinated and responds to existing and emerging needs. recommendations the rising magnitude and complexity of homelessness can be understood and addressed nationwide through an interagency network, which must be flexible to adjust to emerging needs of heterogeneous homeless profiles and enable quick access to support through referral networks. the proposed strategy and specific recommendations aim to unify efforts by creating a collaborative network of organizations working within the field of healthcare, social assistance and legal advice for the socially vulnerable people within the netherlands. such stakeholder collaboration will highlight the methods by which groups with similar or different perspectives can exchange viewpoints and search for solutions that go beyond their own vision, with the aim of working synergistically to improve the lives of vulnerable people.the success of the strategy depends upon collaboration with a wide range of stakeholders, including donors, government institutions, service providers (homeless-serving organizations), and other people affected by homelessness – based on the best available information and evidence. in an integrated systems response, programs and service delivery systems should be organized at every level – from policy, to implementation, to service provision, to client flow, and offer support in a personcentered way. through coordinated and collaborative engagement at all levels, strategic and planned approaches to end homelessness can be supported. responses must involve cost-effective strategies bringing together organisations offering services on the sectors of health, criminal argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j.. committed collaboration to address homelessness in the netherlands (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4688 p a g e 9 | 24 justice, housing, education, child welfare, and other sectors that homeless people come into contact with. lastly, to be effective, the collaboration must be inclusive in its process, strategic in its objectives, set real and measurable targets for change that are clear to all stakeholders, and lead to real changes in the target group (larson et al., 2000). recommendation 1: creation of a collaborative network of relevant stakeholders we are calling on national policymakers, ngos, donors, etc. to support the creation of a comprehensive collaborative network, through a system-based approach to address homelessness problem in the netherlands. therefore, service providers that share the same challenges in day to day operations will be the core of this network such as housing providers, non-governmental organisations and civil society organizations. moreover, to facilitate service coordination, stakeholders from the local authorities and public institutions shall be invited and academia to support research. the collaborative network will have the aim to identify common objectives, clarify controversial issues, gather and analyse information. it will also be responsible for regularly meeting with network partners to present the initiative's results to all parties, thus ensuring that they have proper access to information while consolidating their common interests. the collaboration must improve cross-sectoral collaboration and communication among relevant stakeholders, develop a shared mission and vision based on reciprocal trust, and the belief that a well-balanced investment of partners will produce positive outcomes for all parties and overall, for vulnerable people. it is essential that collaboration is based on trust, inclusion, and constructive engagement to achieve a proposed common purpose. for this, the dialogue should be as open and participatory as possible, encouraging stakeholders from a variety of backgrounds and perspectives to contribute to the identification and framing of collaboration goals and objectives. to ensure that the most appropriate communications mechanisms are used to support collaboration efforts, it is important to work using all possible communication tools: meetings and roundtable discussions, workshops, joint initiatives, mediation, training, awarenessraising and education, and joint fact-finding. to improve communication and collaboration between stakeholders, five steps were defined: 1. the identification of relevant stakeholders working with vulnerable populations (a preliminary identification has been completed: see appendix tab. 1-3) 2. the creation of a list of correspondents across the netherlands 3. the set up a collaborative committee 4. the search for best networking practices across europe to improve the quality of collaboration 5. the design of a permanent coordination plan aimed at making collaboration as easy and efficient as possible (e.g., online meetings), particularly during the covid-19 pandemic. working together to reach a common goal involves teamwork, good communication, and problem-solving. in the end, the collaboration will add a mutually beneficial relationship between two or more parties who work towards common goals, conduct needs assessment, set priorities, and advocate for new policies and regulations, in order to decrease the magnitude of homelessness, through shared argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j.. committed collaboration to address homelessness in the netherlands (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4688 p a g e 10 | 24 responsibility, authority, and accountability in the achievement of results. recommendation 2: develop a baseline assessment of clients’ profiles, needs, and services provision to improve the efficacy and efficiency of healthcare and social services provision, the availability and exchange of information are crucial. the collaborative network will facilitate data collection, analysis and reporting on the figures, needs of homeless populations but also on the capacities available to facilitate referrals between services and inform about demand and need for capacity building. responsibilities between partners on data use and protection shall be agreed and an agreement signed. sharing of data from client registers shall strictly abide by the general data protection regulations. encryption software, need for client consent and data anonymization from client registers should be ensured. for data to be operational, it is important that the organizations that are collecting data on homeless people agree on specific definitions. this should be the first aim of the collaborative network, to agree on a required format for data collection and provide a tool to partners to develop comparable data collection systems. the ethos typology is proposed by feantsa (2005) to classify different types of homelessness; living rough or in a night shelter is defined as ‘rooflessness’, ‘houselessness’ applies to stay in shelter accommodation or supported accommodation, ‘insecure housing’ refers to temporary stay with family or friends or when living under threat of violence and, ‘inadequate housing’ to living in extreme overcrowding or unfit housing. different sources for data on homelessness have different values (feantsa, 2002). firstly, surveys should be available at national, regional and local levels and include a representative profiling of the homeless population. secondly, the social service sector for homeless people can contribute through an integrated, standardized computer-based record keeping system for service users. thirdly, public statistics on homelessness usually refer to those registered for housing support and should be recorded every year. the design of an operational strategy on how to establish a common database will include: 1. characteristics of clients: identification of the number and sociodemographic characteristics of people in need of help in the netherlands. 2. assessment of needs: identification of the essential needs (water, food, clothes, etc.) and non-essential needs (condoms, healthcare, legal support, etc.). 3. healthcare and social service mapping: elaboration on the number of places and types of services provided at local and national level. for an overview of the activities and the time scheduled proposed see appendix tab. 4. to measure, improve and demonstrate the value of this collaborative network, and maintain the focus of its mission, it is important to set and achieve short-term goals. given that achieving progress on the ultimate goal (improving quality of life for homeless people) will take substantial time, an example of indicators could be helping homeless people get access to healthcare and measuring their number of primary care visits in a period of six months or helping those who are able to work and unemployed find employment. demonstrating short-term successes will be crucial in maintaining argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j.. committed collaboration to address homelessness in the netherlands (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4688 p a g e 11 | 24 cross-organizational support for the collaborative network, and will also help recruit more organizations into the future (appelbaum, 2012). quality improvement overall network quality improvement standards can be collectively developed and disseminated in the network to ensure efficient functioning and collaboration. according to the european quality assurance for social services such key principles are: leadership, rights, ethics, partnership, participation, person-centered, comprehensiveness, continuous improvement, and result orientation (feantsa, 2012). individual organizations’ quality improvement at a service provider’s level, dissemination of quality standards used among providers can allow for continuous improvement and innovation. common general quality standards can be suggested to ensure transparency, continuous professional development for the staff, engagement of service users and equality in access to services. importantly, standards should be decided collectively to ensure they can be integrated to provider systems, including smaller service providers. given the inherent risk of dependency on homeless in services, an overall criterion of quality of services in the homeless sector should be reaching a level of independence and autonomy, by a rapid re-housing process for the client to personal housing. suggested indicators for individual providers to assess the quality of their services and users’ engagement can be found in figure 1. figure 1. indicators proposed for individual service providers that wish to assess the quality of their services and the engagement of service users. service users are important stakeholders that can take responsibility and actively participate in evaluation of the services. a participative audit methodology for quality improvement was initiated in amsterdam. paja! empowered young service users to conduct peer to peer assessments by interviewing service users, analyzing the outcomes in an objective way and prioritizing areas for improvement along with workers (feantsa, 2015). indicators for provider/ agency 1) eligibility for services and access requirements are clearly defined 2) strategies to engage service users are clearly established 3) staff is trained 4) extent of service utilization and number of service users are recorded in a data system 5) outcomes of services received including satisfaction of the service users 6) assessment of relationships between staff and service users 7) service users progress towards independent housing and autonomous living measurement of engagement of service users 1) attendance to follow-up appointments; frequency access a community service per year 2) overall health outcomes improvement 3) awareness about at least one local health service they are eligible for 4) application for general healthcare insurance argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j.. committed collaboration to address homelessness in the netherlands (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4688 p a g e 12 | 24 conclusion homelessness, being too complex to be addressed by any organization on its own, collective action is needed, in a way that resources available are allocated according to need and do not result in overlap and intense competition between providers. the rising figures of homelessness in the netherlands are alarming and require comprehensive data collection and action. the covid-19 pandemic has shed light on how inequalities created by social, cultural, and economic power dynamics are being further exacerbated in times of crisis at both national and global level. its impact on the homeless population in the dutch context has yet to be assessed and although in many municipalities momentum is built among service providers for the need to collaborate, a comprehensive nation-wide system is not in place. the formation of a collaborative network can facilitate synchronization of activities and expertise transfer to provide more synergistic and effective support for homeless people in the netherlands, thereby improving their quality of life. this is the way to progress towards recovering dignity and overcoming homelessness, responding to the call to “end homelessness in the eu by 2030” (european parliament, 2020, p.1). conflicts of interest argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j. state that there is no conflict of interest. funding there was no funding for this project. references 1. acosta, o. & toro, p.a. 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(2015). the finnish homelessness strategy. retrieved from: https://helda.helsinki.fi/bitstream/han dle/10138/153258/ymra_3en_2015. pdf?sequence=5&isallowed=y (12.02.2021). 32. rijksoverheid (2020). lees mee hoe gemeenten dakloosheid terugdringen. retrieved from: https://www.iedereenondereendak.nl/ aanpak-dakloosheid/dit-doengemeenten (12.02.2021). 33. rogers, d. & power, e. (2020). housing policy and the covid-19 pandemic: the importance of housing research during this health emergency. international journal of housing policy, 20(2), 177-183 34. rutenfrans-stupar, m.t.j. (2019). social participation of homeless people: evaluation of the intervention. "growth through participation". ridderprint bv. 35. muusse, c., planije m., & kroon, h. (2020). dakloos in coronatijden. trimbos-instituut. retrieved from: https://www.trimbos.nl/docs/9a2fc67 d-2834-432d-80a76f244f130544.pdf (12.02.2021). 36. world health organization (who) (2017). migrant populations, including children, at higher risk of mental health disorders. retrieved from: https://www.euro.who.int/en/healthtopics/healthdeterminants/migration-andhealth/news/news/2017/04/migrantpopulations,-including-children,-athigher-risk-of-mental-healthdisorders (12.02.2021). 37. y-foundation (2017). a home of your own. retrieved from: https://ysaatio.fi/assets/files/2018/01/ a_home_of_your_own_lowres_spr eads.pdf (12.02.2021) https://helda.helsinki.fi/bitstream/handle/10138/153258/ymra_3en_2015.pdf?sequence=5&isallowed=y https://helda.helsinki.fi/bitstream/handle/10138/153258/ymra_3en_2015.pdf?sequence=5&isallowed=y https://helda.helsinki.fi/bitstream/handle/10138/153258/ymra_3en_2015.pdf?sequence=5&isallowed=y 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https://www.euro.who.int/en/health-topics/health-determinants/migration-and-health/news/news/2017/04/migrant-populations,-including-children,-at-higher-risk-of-mental-health-disorders https://www.euro.who.int/en/health-topics/health-determinants/migration-and-health/news/news/2017/04/migrant-populations,-including-children,-at-higher-risk-of-mental-health-disorders https://www.euro.who.int/en/health-topics/health-determinants/migration-and-health/news/news/2017/04/migrant-populations,-including-children,-at-higher-risk-of-mental-health-disorders https://ysaatio.fi/assets/files/2018/01/a_home_of_your_own_lowres_spreads.pdf https://ysaatio.fi/assets/files/2018/01/a_home_of_your_own_lowres_spreads.pdf https://ysaatio.fi/assets/files/2018/01/a_home_of_your_own_lowres_spreads.pdf https://ysaatio.fi/assets/files/2018/01/a_home_of_your_own_lowres_spreads.pdf https://ysaatio.fi/assets/files/2018/01/a_home_of_your_own_lowres_spreads.pdf argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j.. committed collaboration to address homelessness in the netherlands (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4688 p a g e 16 | 24 appendix table 1: organizations collecting data on the homeless and other vulnerable groups in the netherlands organization methods of data collection organization type aedes database support the functioning of social housing private providers aggregated data on: vulnerable groups, affordability of housing, availability etc national organization federation of national organizations working with the homeless (feantsa) monitoring of national and eu statistical developments on homelessness ngo international homo/lesbian information center and archive (ihlia) collects, preserves and presents to the public all kinds of information in the field of lgbt ngo statistics netherlands (cbs) gathers statistical information about the netherlands governmental institution the salvation army qualitative study: interviews of undocumented nigerian, ghanaian victims ingo (christian) https://www.legerdesheils.nl/onderzoek-finding-a-way-out https://www.legerdesheils.nl/onderzoek-finding-a-way-out argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j.. committed collaboration to address homelessness in the netherlands (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4688 p a g e 17 | 24 table 2: services existing to tackle homelessness and offer support to vulnerable groups in the netherlands organization provided services organization type stichting zwerfjongeren nederland (szn) independent advocate for homeless young: lobbying, connecting parties, research/ dissemination include homeless youth voices (conversation tool). ngo chance fund (kansfonds) hilversum corona crisis emergency aid, young people, elderly, refugees trust fund the salvation army access to primary health care, prevention and quality improvement. access to basic wash facilities and prevention (including additional facilities for girls) empowerment of women and girls ingo (christian) coc netherlands supports lgbti communities globally implementing ngo, advocacy ngo aedes database support the functioning of social housing private providers aggregated data on: vulnerable groups, affordability of housing, availability etc. national organization afew connects the network with international donors and ensures all policies, procedures, and reports meet international expectations and the standards of international donors. ngo cordaid emergency aid & poverty of a particularly vulnerable group of people, help to bridge their gap to the labor market and allow them to be part of society again, support social cooperatives for two years. ngo federation of national organizations working with the homeless monitoring of national and eu statistical developments on homelessness, exchanging good practice on homelessness measurement, and creating links with the academic field as well as with european and international bodies. ngo https://zwerfjongeren.nl/nieuwsbericht/samen-in-gesprek-over-woonbehoeftes/ argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j.. committed collaboration to address homelessness in the netherlands (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4688 p a g e 18 | 24 (feantsa) housing first europe hub model for systemic change providing and maintaining housing; improving health and well-being; promoting social integration ngo van den santheuvel foundation funding support to shelters of various target groups foundation valente 3 basic networks: protected housing, women shelter, social care priorities: advocacy, prevention, tackle stigmatization work both bottom up and top down shelter atlas: online map with all organizations for homelessness, violence, exploitation, departure from care institution/ prison. trade organization. represents institutions and agencies from all over the country, connects thousands of professionals ensuring a continuous dialogue between industry, politics and society. lgbti+ asylum support links to other organizations, provides guidance. social support dutch ngo international organization for migration (iom) supports migrants across the world, developing effective responses to the shifting dynamics of migration and, as such, is a key source of advice on migration policy and practice works in emergency situations, developing the resilience of all people on the move, and particularly those in situations of vulnerability, as well as building capacity within governments to manage all forms and impacts of mobility intergovernmental organization council for the environment and infrastructure (rli) advises the dutch government and parliament on strategic issues concerning the sustainable development of the living and working environment. independent advisory group proud dutch union for sexworkers proud is the interest group for and by sex workers in the netherlands. ngo the rainbow group (de regenboog stimulates participation and development of people in (social) poverty, so that they can actively participate in society. established in amsterdam, it includes various walk-in foundation https://www.opvangatlas.nl/ argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j.. committed collaboration to address homelessness in the netherlands (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4688 p a g e 19 | 24 groep) centers. rooms with attention offer a room for young people in youth care collaborative initiative between 11 (youth) care organizations in 12 municipalities amnesty international evaluates the human rights situation in countries around the world ngo everyone’s shelter (iedereen onder een dak) central municipalities of social care have mapped out how many homeless people they have in the region and what housing and care needs there are 21 of the 43 central municipalities have submitted concrete plans with additional measures until 2021 governmental institution nunn (night shelter from noodzaak nijmegen) night shelter facility where the care is in-house for the homeless. shelter provider optimal life patient-centred care for people with psychological problems collaboration between healthcare institutions, gps, municipalities the intermediate facility reception, (assisted) living, budget management & debt assistance, daytime activities & activation has a housing cluster and a reception cluster (outreach, guidance) housing organization utrecht credo huizen safe house for young people charity, cooperative kerk in actie program for missionary and diaconal work of the protestant church of the netherlands charity (christian) wilde ganzen raises funds to combat poverty and provides support to organizations in terms of technical knowledge and expertise ngo (christian) table 3: municipalities that participate in the “everyone under one roof” (iedereen onder een dak) governmental initiative. https://kamersmetaandacht.nl/ https://www.iedereenondereendak.nl/ argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j.. committed collaboration to address homelessness in the netherlands (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4688 p a g e 20 | 24 municipality contact details oss anne de vries email: a.de.vries@oss.nl deventer, midden-ijssel lauris van eekeren, email: lgj.van.eekeren@deventer.nl mirjam jansen, email: mc.jansen@deventer.nl breda natasja van meer, email: npj.van.meer@breda.nl amsterdam josé welsink, email: j.welsink@amsterdam.nl darjalha bourgui, email: d.bourgui@amsterdam.nl amersfoort matthijs van leur, email: m.vanleur@amersfoort.nl alkmaar mirjam hartog, email: mhartog@alkmaar.nl femke zuidgeest, email: fzuidgeest@alkmaar.nl mailto:a.de.vries@oss.nl mailto:lgj.van.eekeren@deventer.nl mailto:mc.jansen@deventer.nl mailto:npj.van.meer@breda.nl mailto:j.welsink@amsterdam.nl mailto:d.bourgui@amsterdam.nl mailto:m.vanleur@amersfoort.nl mailto:mhartog@alkmaar.nl mailto:fzuidgeest@alkmaar.nl argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j.. committed collaboration to address homelessness in the netherlands (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4688 p a g e 21 | 24 table 4: recommended time schedule and implementation plan for cross-sectoral collaboration and data collection networks. category № name deliverables responsible main activity 1. create a collaborative committee of organisations working on homeless in the netherlands 1st month and 2nd month specific activities 1.1 identify the working group. responsible persons for initiation of technical activities identified (3-4 persons). initiative group 1.2. identify the office for the working group and initiate the activities. office identified office spaces arranged working group 1.3. identify stakeholders/ partners working with and collecting data on homeless and socially vulnerable people in the netherlands. list of core stakeholders identified and their contacts recorded. working group (consult list at appendix a) 1.4 identify the responsible person from each stakeholder. official nomination of responsible persons from each stakeholder received. working group all stakeholders 1.5 identify the platform of the discussion and working and the way of the collaboration. platform of discussion identified and agreed. list of topics to be discussed agreed. period of meeting agreed. 1.6 create a collaborative committee of homeless in netherlands status of committee developed, disseminated, agreed with all stakeholders. list of members developed, agreed. organogram of the committee and responsibilities developed, agreed. argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j.. committed collaboration to address homelessness in the netherlands (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4688 p a g e 22 | 24 1.7 strengthen the organizational capacities of the collaborative committee to coordinate the resources, efforts of civil society and institutional partners in the implementation of the national strategic plan of homeless. collaboration with other international partners established. round tables conducted. training of responsible persons conducted. main activity 2 develop the database and data collection indicators. 1st month-3rd month specific activities 2.1 to agree on which data should be collected, monitored and maintained. list of data created and approved. working group 2.2 to identify the indicators to be monitored for program evaluation. list of indicators developed and agreed (for different periods of the time/semester/years). source of collection agreed all stakeholders main activity 3 update the registration systems of partner organisations based on defined format 3rd month 4 conduct survey regarding the cartography of the existing current situation (existing places and number of homeless people) 3rd month4th month 5 conduct a survey to evaluate risk factors and behaviours associated with homeless people 3rd month-4th month argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j.. committed collaboration to address homelessness in the netherlands (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4688 p a g e 23 | 24 6 identify, prioritize the main problems and gaps related to homelessness in the netherlands 5th month 7 synergize efforts and continue to address the urgent primary needs of homeless people by mobilization of all possible stakeholders during the next cold period. 5th month 9 strengthen the institutional and organizational capacities of ngos/partners working with key groups of homeless people. 6th month 10 support advocacy, communication and social mobilization of civil society by strengthening the community system regarding the homeless problem. 6th month 11 identify needs and propose actions to strengthen the legal framework for homeless people and national action plans 7th month 12 develop and implement an awareness and communication campaign regarding homeless group 7th month 13 identify actions to strengthen and maintain activities for inclusion of homeless based on a person-centred approach (long term housing, workplaces, vocational and professional training and schooling). advocate to inform national strategy. 8th month 14 identify actions for diminishing and preventive risk factors related to homeless (harm reduction, family planning). advocate to inform national strategy. 9th month argyrou, f., hirschler, j., karan, f., kugel, r., romancencoa, e., & neicun, j.. committed collaboration to address homelessness in the netherlands (policy brief). seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4688 p a g e 24 | 24 15 to establish a process of the monitoring and evaluation of the activities of the collaborative network 10th month specific activities 15.1 to elaborate and publicize an analytical report, based on monitoring the main indicators measuring service provision quarterly analytical report based on key monitoring indicators conducted. working group 15.2 to conduct a periodical analysis regarding the efficiency of inclusion and integration services for homeless. semestrial analyses conducted. external consultant 15.3 to conduct an annual audit of activities conducted by the collaborative committee of homeless in the netherlands in order to find good and weak parts. evaluation conducted. report submitted and analysed external auditor 15.4 to develop corrective and preventive measures in term to improve the activity of the working group and collaborative committee of homeless in the netherlands. preventive actions developed. a new improved action plan elaborated. working group all partners. © 2021 argyrou et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. statistics netherlands (cbs) table 2: services existing to tackle homelessness and offer support to vulnerable groups in the netherlands lirussi f, ziglio e. circular health: a needed approach to promote health and prevent pandemics and other health hazards (position paper). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5112 p a g e 1 | 9 position paper circular health: a needed approach to promote health and prevent pandemics and other health hazards flavio lirussi1, erio ziglio2 1 padua university, padua, italy 2 health university of applied science, austria corresponding author: professor flavio lirussi; address:via dei rogati 6, 35122 padova, italy; email: lirussif@gmail.com mailto:lirussif@gmail.com lirussi f, ziglio e. circular health: a needed approach to promote health and prevent pandemics and other health hazards (position paper). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5112 p a g e 2 | 9 abstract sars-cov-2 is a perfect example of the intimate relationship between human, animal and environmental health. circular health goes beyond the biomedical concept of health, operating on the interface between individuals, microorganisms and ecosystems. the world health organization endorses this concept and stresses the importance of protecting the environment and addressing and reversing the negative impact of climate change. the application of circular health to the governance for population health is based on protection of all forms of life, interdisciplinarity, involvement of all of society, big data, artificial intelligence, and correct scientific information. it also considers a combination of health, environmental, social and economic problems caused by the synergistic interaction between the acute diseases in this case caused by sars-cov-2, and a number of non-transmittable chronic pathologies. disinformation and misuse of social media could be more dangerous for the pandemic's development than the virus itself. the adoption of circular health is an urgent necessity in restructuring development policies and making them more effective and sustainable, and protecting and promoting individual and collective health. within public health, circular health should urgently become the mainstream approach to prevent pandemics and other health hazards. given the many social, economic, and cultural changes undergoing in the countries of the south eastern european network the conceptual and policy framework related to circular health could be of great value in further advancing progress in this part of europe. keywords: covid-19, one health, pandemics, sars-cov-2, syndemic, world health organization lirussi f, ziglio e. circular health: a needed approach to promote health and prevent pandemics and other health hazards (position paper). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5112 p a g e 3 | 9 introduction in may 2020, the director-general of the world health organization (who) has declared: “the pandemic is a reminder of the intimate and delicate relationship between people and planet. any efforts to make our world safer are doomed to fail unless they address the critical interface between people and pathogens, and the existential threat of climate change that is making our earth less habitable” (1). his strong warning has been, unfortunately, unheeded. one and a half years later, we are still mourning more than 5 million people worldwide. the sars-cov-2 pandemic is the greatest global shock the world has experienced in recent decades. in any part of the world, humanity was totally unprepared to tackle a tsunami-like this. of the many reasons responsible for this unpreparedness, at least two have been overlooked by the stakeholders involved in the decision-making process: 1) sarscov-2 pandemic is not just a pandemic, is more than that; and 2) lack of awareness that we are all components of a single ecosystem that determines health in all its components which include humans, animals, plants and the environment. the syndemic approach in an editorial in the lancet, richard horton used the term “syndemic” in preference to a current pandemic of covid19 (2). the term syndemic was first introduced by the physician and anthropologist merrill singer in the mid1990s. he stated that “syndemics are the concentration and deleterious interaction of two or more diseases or other health conditions in a population, especially because of social inequity and the unjust exercise of power”(3). thus, the concept of syndemic refers to a combination of health, environmental, social and economic problems caused by the synergistic interaction between two or more diseases. the example here is the interaction between the acute respiratory infection caused by the sars-cov-2 virus and a series of nontransmittable chronic illnesses (obesity, hypertension, diabetes, cardiovascular disease, chronic respiratory illnesses, and cancer). horton argues that the approach to managing the spread but especially the pathology of covid-19 is incorrect, because the health crisis has been approached as though it were caused by the infectious illness alone, without considering socioeconomic inequalities of the most vulnerable sectors of society (older people, the low-paid, ethnic minorities). “unless governments devise policies and programmes to reverse profound disparities, our societies will never be truly covid-19 secure”. horton concludes that what is needed is an integrated approach, indeed a synergistic vision that encompasses different determinants of health such as education, employment, housing, diet, and the environment. horton's editorial accords completely with the views and concerns of the who during the current pandemic. the who has shown that, as infections spread, the lack of universal healthcare coverage leaves billions of people without safe access to medical treatment, and how huge inequalities and socioeconomic status have a profound impact both on mortality and the loss of the means to survive. who also stresses the importance of protecting the environment and addressing and reversing the negative impact of climate change. to this end, it put forward a manifesto for a “green and healthy” recovery from covid19 (4). it included six recommendations: (i) protect nature; (ii) guarantee access to clean water; (iii) ensure a quick healthy energy transition; (iv) promote healthy, sustainable food systems; (v) build healthy, livable cities; and (vi) stop giving incentives for fossil fuel use. the last recommendation is one of the commitments made by cop26 delegates from nearly 200 countries: “… accelerating efforts towards the phase lirussi f, ziglio e. circular health: a needed approach to promote health and prevent pandemics and other health hazards (position paper). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5112 p a g e 4 | 9 down of inefficient fossil fuel subsidies” (5). in addition, the manifesto’s “prescriptions” are in line with the sustainable development goals of agenda 2030 (6). the concept of circular health the second element that jeopardised, or made rather ineffective, the prevention of and the response to the sars-cov-2 pandemic is the non-recognition that health is one. it means that the factors determining the health of humans, animals and plants are strictly dependent on each other’s. hence, the factors to reduce the risk of new pandemics are the same as those needed to protect biodiversity and safeguard the health of animals and improve the environment. the virologist ilaria capua, director of the one health center of excellence at the university of florida, explains that the only path we can follow to never experience these types of pandemics again is to understand that we live within a system in which all living things are immersed. so, there are not just individuals and communities. the human species is not the only one that needs to be protected and preserved. the health of the planet and all its inhabitants must have equal dignity if we want to create an ecosystem that is sustainable, resilient, healthy, and durable (7). capua also specifies what the difference between one health and circular health is. while one health recognizes the interconnections and interdependencies of the health of humans, animals, plants, and the environment, circular health is a broader integrated approach to promoting the health of humans, animals, plants, and the environment together. this model requires an expanded multidisciplinary convergence of efforts encompassing economic and financial, technological, societal and cultural, and international policies around one goal: the co-advancement of the health as a system in a circular manner, where no single part is dominant over the others (8). the south eastern europe health network (seehn) recognizes the importance and the raising need in the see countries for better coordinated actions towards the one health/circular health approach and has the one health strategy on to the agenda through its regional health development centers on communicable diseases (secid) hosted by albania and the one on antimicrobial resistance hosted by bulgaria [personal communication by dr mira jovanovski dasic, head, seehn secretariat]. as it was explained above, the holistic vision of circular health represents a model of health based on the integration of different disciplines. the starting point is biomedical interdisciplinarity: human health, animal health, environmental health. but it also includes psychology, economics, engineering, chemistry, political science and social science. the circular health model is perfectly aligned with the “wholeof-society approach” and the “whole-ofgovernment approach” promoted by the who in several health strategy european documents (9,10). translating the concept of circular health into action and make change happen requires the involvement and commitment of different development sectors of society and the participation of civil society. it also requires a breaking down of the disciplinary barriers between the physical sciences and life sciences. depending on the problem to be addressed, this means improving the coordination, cooperation and integration levels of the measures that need to be taken to promote development and protect and promote collective health. thus, alongside the integration of different disciplines we need to invest – and add “more health”, in every social sphere: from farming to science, from education and training to politics, from information to the economy. there is also an urgent need for an open lirussi f, ziglio e. circular health: a needed approach to promote health and prevent pandemics and other health hazards (position paper). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5112 p a g e 5 | 9 access to information and knowledge and an innovative use and development of appropriate technologies. open access implies the sharing and the convergence of all data from different disciplines, while technology can be exploited in all its forms: artificial intelligence, big data, cloud, internet of things, up to quantum computing. according to a recent review, artificial intelligence has so far been used in at least four areas of healthcare systems in the fight against covid-19: diagnosis, treatment, clinical decision-making processes and public health. it could potentially be used in four more areas: surveillance, combination with big data, reorganisation of operations and medicosurgical services, and management of patients with covid-19 (11). the study concludes that, faced with increasing pressure on limited healthcare resources, the use of artificial intelligence-guided techniques in the prevention, diagnosis, monitoring, research into treatments and vaccines, and decision-making processes of public health can help improve the efficiency and efficacy of efforts to combat this (and future) pandemics. the core principle here is to benefit citizens and the survival of life on the planet. it should not be underestimated, for example that thanks to the new technologies pharmaceutical companies were able to produce anti covid19 vaccines in less than a year. other very promising examples come from the ethical and innovative use of big data and artificial intelligence the authors have described in other articles (12,13). whether ai can advance the interests of patients and communities depends on a collective effort to develop and implement ethically laws, policies and ethically designed ai technologies (14). to this end, who has recently published a guidance document entitled “ethics and governance of artificial intelligence for health” addressed especially to three sets of stakeholders: ai technology developers, ministries of health and health-care providers. needless to say, the implementation of the guidance will require collective action. in other words, ethical considerations and human rights must be placed at the centre of the design, development, and application of ai technologies for health (15). interestingly, a national survey of the italian young medical doctors association including 382 participants, showed that only 13% had experience in big data during clinical or research activities, 13% in -omics technology and predictive models, 13% in artificial intelligence, 6% had experience in internet of things, 22% experienced at least one telemedicine tool and 23% of the participants declared that during their clinical activities data collection was paperdriven. thus, there is an urgent need for integration of preand post-graduation training in digital health to provide adequate medical education (16). the issue of governance for health all these potentially positive development needs to be facilitated and overseen by a much stronger governance that we have today (17). principles sustaining the new governance for health should be open, sustainable, collaborative, and ethical. two basic elements are also needed to strengthen governance and practice for health, development, and inequality reduction. the first relates to a vision of the future that can influence decision making in all areas of policy, not just healthcare. here the circular health perspective is both scientifically and strategically fundamental. the second element obviously involves political will and the active participation of civil society to transform that vision into daily practice. indeed, this is the real challenge in the years to come: understanding how to realize in practical terms this new approach to health, so that it is reflected on a new governance for health, inclusive and circular. luckily, there are positive signs in this direction: the recent report of the who pan-european lirussi f, ziglio e. circular health: a needed approach to promote health and prevent pandemics and other health hazards (position paper). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5112 p a g e 6 | 9 commission on health and sustainable development entitled “drawing light from the pandemic. a new strategy for health and sustainable development” calls for the full implementation of the concept of one health in all settings where health policies are developed and urges to operationalise one health at all levels (18). circular health and information health education, training and governance cannot take place without correct information. the theme of adequate information and communication is rightly included in the circular health perspective. the distribution and amplification of inaccurate information across different platforms has demonstrably negative effects, often leading people to behave in harmful ways. the factors that might undermine appropriate communication include 1) the exponential increase of covid-19-related publications, often including biases in the peer-review and editorial process; 2) the role of traditional media; 3) politicization of the virus; and, above all, 4) the impact of social media (19). it is individuals and their behaviour that create the conditions in which an epidemic can be brought under control in the course of a few months (sars, avian flu, mers) or, conversely, cause it to explode and spread as in the current pandemic. just consider how, with all the means of transport that we have at our disposal today, we have ourselves become highly effective “vehicles” for the spread of the virus. paradoxically, “virtual” entities like (dis)information and social media could be the main drivers of a “real” pandemic. in other words, they could have far greater influence over its development than the virus factor (viral load, contagiousness, lethality) and even the human factor (genetic makeup, immune response) combined. by contrast, during emergencies, accurate scientific communication should be able to provide clear messages to improve understanding and bring about changes in behaviour over a short period of time (20). if this approach is applied systematically, it has the potential to prevent future emergency situations from arising in the first place. conclusions as we said above, the conceptual framework of circular health must be followed up with new innovative practices and supported by consistency of political will that have been lacking in the past. circular health requires a new way of thinking and acting for individual, collective and global health. as such it can be of great value in shaping further progress of sustainable health and development in the seehn countries as well as elsewhere. a further point relates to the updating of educational curricula, so that future generations can absorb this new integrated mode and improve practice. training in this area is essential to ensure that those currently responsible for taking political decisions fully understand that every choice they make in relation to human, animal and plant health as well as the health of the overall environment has impacts on all others. this is the birth of a new and important science offering a wealth of new opportunities to maximise impacts on sustainable development and health (21,22). the challenge is to put circular health into practice through the governance that truly protects and promotes health, and that is no longer myopically restricted to human health alone. the involvement of civil society in this process of change is indispensable. circular health represents an essential approach to the integrated management of public health. in other words, circular health takes account of and lirussi f, ziglio e. circular health: a needed approach to promote health and prevent pandemics and other health hazards (position paper). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5112 p a g e 7 | 9 includes the whole range of socio-economic and environmental determinants of health. these determinants characterise the potential to protect and promote health and decrease the inequalities that exist in this area. to this end, we must create a culture for health that more integrally involves society in all its different components (the voluntary and charity sectors, but also business and private enterprise). fundamentally, health is universal and remains a common good. given the many social, economic, and cultural changes undergoing in the countries of the south-eastern european network, the conceptual and policy framework related to circular health could be of great value in further advancing progress in this part of europe. in the light of the lessons we are learning from the covid-19 pandemic, the adoption of a circular health perspective is a necessity and an opportunity that can no longer be delayed. nb: the 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an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 10.11576/seejph-4238. 22. curbelo perez d, ziglio e. fortaleciendo la resiliencia en tiempos de la covid-19: una prioridad para la salud y para el progreso hacia los ods. revista iberoamericana de bioética 2020;14:2-14. 43. _______________________________________________________________________ petrela k, roshi m, laaser u, burazeri g. survey exploring the opinion of corresponding authors of articles published in the south eastern european journal of public health during 2014-2021 (short report). seejph 2021, posted: 09 july 2021. doi: 10.11576/seejph-4585 p a g e 1 | 6 short report survey exploring the opinion of corresponding authors of articles published in the south eastern european journal of public health during 2014-2021 kreshnik petrela1, meri roshi1, ulrich laaser1, genc burazeri1 1 south eastern european journal of public health. corresponding author: prof. dr. med. ulrich laaser dtm&h, mph; faculty of health sciences, bielefeld university address: pob 10 01 31, d-33501 bielefeld, germany; e-mail: ulrich.laaser@uni-bielefeld.de mailto:ulrich.laaser@uni-bielefeld.de petrela k, roshi m, laaser u, burazeri g. survey exploring the opinion of corresponding authors of articles published in the south eastern european journal of public health during 2014-2021 (short report). seejph 2021, posted: 09 july 2021. doi: 10.11576/seejph-4585 p a g e 2 | 6 abstract the aim of this survey was to assess the intentions of corresponding authors for publishing again in the south eastern european journal of public health (seejph), the aspects that they like most about the journal, and things which can be improved by seejph in order to be more attractive to potential contributors. a three-item questionnaire was sent out by email to all corresponding authors (n=89) who published in the 16 volumes of the seejph journal between 2014 and 2021. among 84 eligible corresponding authors, we collected 26 answers, or 31%. there were generally favourable and constructive comments, which is encouraging. the wide array of countries of the corresponding authors represents the successful global orientation of seejph. also, more than half of all related articles are classified as original papers, and the average of four authors per represented paper is satisfying. furthermore, all corresponding authors would publish again in seejph (“definitely”, or “probably”), and their numbers are almost equally distributed throughout 2014-2021. keywords: author survey, corresponding author, scientific journal, south eastern european journal of public health (seejph). acknowledgments: we express our gratitude to our publisher dr. hans jacobs, sebastian wolf, and all our supporters in the university of bielefeld/germany, our boards of editors, and our authors, friends, and colleagues. petrela k, roshi m, laaser u, burazeri g. survey exploring the opinion of corresponding authors of articles published in the south eastern european journal of public health during 2014-2021 (short report). seejph 2021, posted: 09 july 2021. doi: 10.11576/seejph-4585 p a g e 3 | 6 introduction in the past few years, there is evidence of an intensive proliferation and competition of many online scientific journals including also health sciences (1). hence, perceptions and practices of researchers regarding the current state of play and the future of scholarly publishing is important to be assessed and is actually subject to ongoing research (2). in 2014, the first volume of a new open access journal was published by jacobs company (3). the south eastern european journal of public health (seejph) is an open access international peer-reviewed journal involving all areas of the health sciences and public health (4). seejph welcomes submissions of scientists, researchers, and practitioners from all over the world, but particularly pertinent to transition countries (4). after six years of release of the journal, we aimed at exploring the opinions of all corresponding authors of the articles published in seejph. more specifically, we aimed at assessing the intentions of corresponding authors for publishing again in seejph, the aspects that they liked most about the journal, and things which can be improved by the journal in order to be more attractive to potential contributors. methods a three-item questionnaire was sent out by email twice (in february and april 2021) to all corresponding authors (n=89) who published in the 16 volumes of the seejph journal between 2014 and 2021. two emails of corresponding authors turned out to be not functional, whereas one of the corresponding authors was deceased. in addition, two other corresponding authors (co-authors of this short report) were excluded from the current analysis. overall, among 84 eligible corresponding authors, we collected 26 answers, or 31% (the complete excel database is annexed). results addressees responded from the following countries: albania, croatia, england, ethiopia, germany, ghana, greece, india, ireland, italy, ivory coast, kosovo, netherlands, north macedonia, poland, serbia, sweden. out of the represented publications, 14 studies (53.8%) were classified as original articles. the other 12 papers are distributed between reviews (n=3), reports (n=4), case studies (n=2), commentaries (n=1), and editorials (n=2). altogether, 104 scientists co-authored these papers, i.e. on average 4 authors per publication. the 26 corresponding authors participated during the period 2014-2021 in 10 additional articles, a total of 36 papers distributed over the years almost evenly with 6 publications in 2017, 2019, and 2020, and a minimum of 3 in 2015 and 2 in 2021 (only the first volume of the two planned in 2021). we addressed the corresponding authors per email as follows: “you have published in the south eastern european journal of public health (seejph) as the corresponding author. to develop the journal, we would like to ask you three short questions about your experience with seejph (please send your short answers as a reply to this email to kreshnikp@gmail.com):” question 1: would you publish again in seejph? (a. definitely, b. probably, c. unlikely, d. no) regarding the answers: 22 or 84.6% of the corresponding authors answered “definitely” and 4 authors answered “probably”. mailto:kreshnikp@gmail.com) petrela k, roshi m, laaser u, burazeri g. survey exploring the opinion of corresponding authors of articles published in the south eastern european journal of public health during 2014-2021 (short report). seejph 2021, posted: 09 july 2021. doi: 10.11576/seejph-4585 p a g e 4 | 6 question 2: what did you like about seejph (free wording)? answers (the favorable core terms underlined and listed in alphabetical order) include: open access; coverage of balkan (2 times); public health content; reasonable cost; format; innovative (new ideas); excellent organization; orientation; fast and helpful peer-review (19 times); global perspective; good quality; global readership; serious and correct; supportive; registered in scopus. question 3: what should be improved in seejph (free wording)? answers (core terms underlined and listed in alphabetical order) include: technical improvement of layout (2 times), copyediting (1 time), and website (4 times); orcid numbers; inform mainstream providers and provide volumes free of charge e.g. to elsevier, academic search ultimate, sciencedirect, emerald insight, proquest etc.; register with pubmed/medline; link to services (public health, medicine, health promotion, ministries of health); use of social media; more special volumes; more volumes per year. discussion the generally favorable and constructive comments are encouraging. the wide array of countries of the corresponding authors represents the successful global orientation of seejph. also, more than half of all related articles are classified as original papers, and the average of four authors per represented paper is satisfying given the widespread misuse of co-authorships (5). furthermore, all corresponding authors would publish again in seejph, definitely or probably, and their numbers are almost equally distributed throughout the years 2014-2021. most importantly, quality, organization, and fast peer-review are perceived as very positive, especially the fast and supportive peer review at the top with 19 out of 26 possible judgments (only one author perceived a delayed peer-review process). even more critical, and the primary purpose of the survey, are the suggestions for possible improvements: proactive information of mainstream providers, intensified use of social media, more publications per year (three or four partly special volumes per year), linkage to orcid, and improvement of the website layout and copyediting (together, seven times, or 26.9%). references 1. gasparyan ay, yessirkepov m, voronov aa, maksaev aa, kitas gd. article-level metrics. j korean med sci 2021;36:e74. doi: 10.3346/jkms.2021.36.e74. 2. gupta l, gasparyan ay, zimba o, misra dp. scholarly publishing and journal targeting in the time of the coronavirus disease 2019 (covid 19) pandemic: a cross-sectional survey of rheumatologists and other specialists. rheumatol int 2020;40:2023-30. doi: 10.1007/s00296-02004718-x. 3. the south eastern european journal of public health (seejph), published by jacobs verlag, hellweg 72, d-32791 lage, germany. 4. holst j, breckenkamp j, burazeri g, martinmoreno jm, schröder-bäck p, laaser u. five years of the south eastern european journal of public health (seejph): focusing on health systems in transition and global health. seejph 2018 (vol x). doi: 10.4119/seejph-1870. petrela k, roshi m, laaser u, burazeri g. survey exploring the opinion of corresponding authors of articles published in the south eastern european journal of public health during 2014-2021 (short report). seejph 2021, posted: 09 july 2021. doi: 10.11576/seejph-4585 p a g e 5 | 6 © 2021 petrela et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 5. zimba o, gasparyan ay. scientific authorship: a primer for researchers.reumatologia 2020;58:345-9. doi: 10.5114/reum.2020.101999. __________________________________________________________________________ petrela k, roshi m, laaser u, burazeri g. survey exploring the opinion of corresponding authors of articles published in the south eastern european journal of public health during 2014-2021 (short report). seejph 2021, posted: 09 july 2021. doi: 10.11576/seejph-4585 p a g e 6 | 6 annex. detailed answers of all corresponding authors who participated in the survey (excel database) the excel file is attached to this pdf. laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 1 review article the rise and fall of the “massively open online courses” wolfram laaser 1 1 self-employed consultant and external staff member of wwedu/austria, germany. corresponding author: dr. wolfram laaser address: milly-steger-str. 1, d-58093 hagen, germany; e-mail: wolframlaaser@googlemail.com laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 2 abstract the paper summarizes the actual debate about “massive open online courses” (mooc), a concept that swept over like a “tsunami” to european educators and universities since its first development in 2008. the definition of the so-called moocs, also referred to as a “disruptive educational innovation”, however, is not very precise and has led to some irritations and scepticism. therefore, the ideas moocs rely on, will be described and the pedagogical and technological background will be explained by detailed descriptions of concrete examples. after setting the scene, the factors responsible for the initial hype about moocs will be analyzed as well as the upcoming criticism raised against the arguments of the mooc proponents. the model of the gartner hype cycle serves as a useful illustration of the ups and downs of expectations related to the introduction of educational innovations. the discussion will be supplemented by a brief flash back on prior developments in distance education. furthermore, some recent empirical data retrieved from google trends are presented to underline that moocs are already on the descent. finally, the conditions for a survival of some specific applications of moocs at “the plateau of the cycle of expectations” will be outlined. in conclusion, moocs seem to have promoted, especially in the us, the use of online teaching and learning as well as the reflection about open educational resources. however, the blurred definition of the term mooc combined with exaggerated expectations turned down the initial hype about a “disruptive innovative concept of teaching and learning” to a more modest consideration of its potential. keywords: connectivism, hype cycle, massive open online courses, mooc, online learning. conflict of interest: none. laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 3 definition and origin of “massively open online course” (mooc) mooc stands for “massively open online course”. hence, there are four criteria: massive, open, online and course. it all began with the offers of two young canadian researchers, who tutored in 2008 a course about “connectivism and connectivist knowledge” at manitoba university. the young researchers were george siemens and steven downes, both not having a phd at that time with a very mixed study background, but often called the founders of moocs. however, two other researchers namely david wiley and alec couros were a little bit faster in running an mooc (1). the idea was to supply the students with the basic framework for the course and then lead from behind. the students were not confined to a prescribed online learning platform; they were encouraged to figure out what environment suited them. some spanish-speaking students even created places in “second life”, a virtual world, where they could hold discussions in their own language. the course, called “connectivism and connectivist knowledge”, ended up attracting about 2,300 non-paying, non-credit students in addition to the 25 students who took it for credit through the university of manitoba. the learning theory that pretends to back up their approach was called “connectivism” and is described by siemens (2) as being composed by the following key features:  learning and knowledge rest in diversity of opinions.  learning is a process of connecting specialized nodes or information sources.  learning may reside in non-human appliances.  the capacity to know more is more critical than what is currently known.  nurturing and maintaining connections is needed to facilitate continual learning.  the ability to see connections between fields, ideas, and concepts is a core skill. however, to call connectivism a “learning theory” has been criticised by many researchers as not fulfilling the requirements of a learning theory and for neglecting the work of previous scientists (3-6). different types of moocs the connectivist background of moocs disappeared to some extent when in 2011 a second type of mooc emerged, namely the xmoocs. these courses were primarily based on interactive media, such as lectures, videos and text. the xmoocs adopted a more behaviourist pedagogical approach, with the emphasis on individual learning, rather than on learning through peers. a number of companies were launched in the us to run xmoocs, such as: udacity, edx and coursera. the courses tend to be offered by prestigious institutions, such as harvard and stanford. the emphasis is on delivery of content via professors from these institutions (7). actually, there are different types of moocs and a number of additional abbreviating letters. to make a difference, the connective moocs were called then cmoocs. if moocs are imbedded into traditional classroom activities in a blended learning mode, the respective moocs are labelled bmoocs, which increases the variety of the “mooc alphabet”, but not the clarity of the meaning of mooc. figure 1 summarizes the mooc types, however, without reference to the blended settings. in the meantime, a new variant came from harvard university: spocs (small, private online courses). the different concepts of moocs mentioned are not clearly defined and overlap to a great extent with both, traditional terminology of distance education and definition of teaching environments in classroom-based conventional teaching. laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 4 similar to the invention of the new theory of learning “connectivism”, the concept of moocs created a lot of repercussions in academic debates. before going into details, the pedagogical concepts and technical settings of past moocs will be briefly described. figure 1. different types of moocs (source: delta initiative: evolutioncombine20120927) pedagogical settings of cmoocs in 2012, the university of frankfurt ran one of the first moocs in germany about “trends in eteaching” (8,9). the participation was free of charge and all interested participants were admitted. at the beginning of each two weeks, interval participants could listen to a video streaming lecture of one hour duration with subsequent discussion. to prepare for the expert lectures, participants received some bibliographic references related to the respective topics. as the mooc was not part of an academic curriculum, participants could ask at the end of the course for badges that characterize their contribution and role across the entire course. three types of badges were available: observer (following discussions and video lectures), commentator (giving at least three comments related to different topics by blog, video, audio, or other media), and curator (contributing significantly to the organization and content production of the course, e.g. summing up discussions, leading subgroups etc.) (9). an example of detailed differentiation of badges is shown in figure 2. mozilla offers also workflows to design individual digital badges (10). except of the certification by badges, no exams could be taken during or at the end of the mooc. participants were asked to aggregate the content offered, to remix information, to contribute by writing down own ideas and to share their knowledge. they could use the tools of their own personal learning environment such as blogs, wikis, twitter posts, or facebook. the organizers summarized the main discussion threads at the end of the two weeks rhythm and let students access them via the course website. laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 5 figure 2. example of badge design (source: http://beuthbadges.files.wordpress.com/2012/12/ple-badges1.png?w=560&h=930) (modified by: wolfram laaser) technical requirements of cmoocs which are the technical requirements to run this type of comic, which kind of programs support students and organizers in their activities to create, to certify, to assess, to collaborate, to deploy and to analyze? in a slideshare presentation of the software used in his mooc, downes listed the following software components (11):  a course wiki on the project website provided general information about participation, topics and other general issues.  a course blog (to motivate discussion and give additional inputs by the tutors).  a moodle forum (to run common discussions).  pageflakes (to add widgets for rss (rich site summary) feeds to a web page).  elluminate (group video conferencing tool).  ustream (live streaming of contributions).  twitter (to tweet with an identifying course tag).  grsshopper (harvesting content input coming from rss feeds).  ltc (language translation software). furthermore, students could subscribe to a newsletter with rss feed and use additional software for infographics (e.g. wordle), formation of working groups (google groups), storytelling (word of mouth), music integrator (orchard), virtual worlds (second life), social bookmarking, tags (11), or to create student‟s blogs (wordpress). this selection of software tools is based on available tools during the years of running the course in 2007-2008. laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 6 currently, in many cases, different tools can be used for the various purposes mentioned (12). comparing cmoocs with xmoocs among the most active mooc providers today is coursera, a start-up that offers some 200 online courses to 1.5 million students. it does so by providing a technical platform to 33 educational institutions, including the university of pennsylvania. according to daphne koller, “coursera is still a hugely interactive experience in terms of working with the material, which is not just video. there are a lot of exercises and assessments. furthermore, an educational community is created based on students interacting with each other.” (13). however, when the author (wl) picked just randomly an economics course offered by columbia university via coursera to look at the course description with respect to pedagogical design, it was found to resemble a traditional distance education course. the course description says: “the class will consist of lecture videos, shot live in the classroom but then edited down into digestible segments, with integrated quiz questions and animated slide videos added. there will also be weekly quizzes and a final exam.” (14). but, there is no mention of interaction with teachers or tutors. the only difference is that anybody is admitted; there is no fee and that there is no recognized degree available. usually, only short courses on relatively specific topics are offered. they have to be selected independently of any curriculum. just some general remarks about necessary pre-knowledge are mentioned. daphne koller (coursera), continuing her interview responses, states: “i think that it‟s wonderful for students around the world to have access to content from those universities as well. this arrangement between institutions provides economies of scale, since a single platform is an expensive and complicated thing to develop. we have almost 200 courses right now and more coming up on this hub. that‟s why we have 1.5 million students, and the population is growing.” (13). opposing to the setting of the xmoocs, one of the cmooc protagonists, downes, commented on xmoocs as follows: “look what they‟ve done to my mooc: as deployed by commercial providers they resemble television shows or digital textbooks with – at best – an online quiz component.” (15). the hype about moocs so, why those types of course setting became so popular and much discussed during the last six years? there are a number of reasons to explain this phenomenon. first of all, the young researchers did not hesitate to give a label in abbreviated form to their experiment “massively open online courses” equal to mooc to make it sound already a widely known course concept. abbreviations are known for chatting among young people and tend to hide a clear definition of what the terms exactly mean, e.g. elearning, and mlearning. furthermore, they related their concept to another newly invented label called “connectivism”, which they claimed to offer a learning theory for the 21 st century. buzz words are mostly part of a marketing strategy. by contrast, the effort to ground the concept and theoretical background on prior research is kept quite limited. a second important factor might be the proximity to the spread of the open educational resources movement, as moocs are actually free of matriculation fees and open to anybody regardless of the academic background. thus, at the same time it shares the problem of covering costs with the open educational resources. as a third point, movements such as the “edupunk” and “do it yourself university” (16), or “p2p university”(17) can be mentioned. all these ideas claim that peers learn best from laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 7 each-other according to their specific interests and needs. the expert teacher becomes obsolete (18). a fourth argument lies in the economic interests of multinationals to market educational content to a worldwide audience. multinationals try to overcome cultural and national borders by introducing their courses at zero prices in an initial phase. therefore, it is not surprising that mooc development was supported by the us and canadian government as well as by organizations like bill gates and linda gates foundation or the hewlett packard foundation. another interesting source of hidden revenue is the selling of student data to advertising companies or potential employers (19). finally, as economic pressure and new models of education are bringing competition to the traditional models of higher education, institutions are looking for ways to control costs while still providing a high quality of service. hence, participating in accreditation of moocs as part of their curriculum, economic cost reductions are expected. the necessity to economize resources on a worldwide level is also stressed by m. waldrop (20): “bricks-and-mortar campuses are unlikely to keep up with the demand for advanced education: according to one widely quoted calculation, the world would have to construct more than four new 30,000-student universities per week to accommodate the children who will reach enrolment age by 2025, let alone the millions of adults looking for further education or career training. colleges and universities are also under tremendous financial pressure, especially in the us, where rocketing tuition fees and ever-expanding student debts have resulted in a backlash from politicians, parents and students demanding to know what their money is going towards”. expectations and forecasts “moocs have gained public awareness with a ferocity not seen for some time. worldrenowned universities, as well as innovative start-ups such as udacity jumped into the marketplace with huge splashes, and have garnered a tremendous amount of attention and imitation. designed to provide high quality online learning, offered to people regardless of their location or educational background, moocs have been met with enthusiasm because of their potential to reach a previously unimaginable number of learners. the notion of thousands and even tens of thousands of students participating in a single course, working at their own pace, relying on their own style of learning, and assessing each other‟s progress has changed the landscape of online learning. this statement was given under the heading: “moocs on the move: how coursera is disrupting the traditional classroom” (13). though the term mooc was hardly a thought bubble for the new media consortium (nmc) during the discussions in 2012, the opinion of the experts changed already in their 2013 report (21). in the horizon report 2013, it is assumed that the time for global adoption of moocs in higher education (20% of all national educational institutions) will be a year or less (20). however, the methodology of the nmc horizon reports and the yearly revisions of previous forecasts have been heavily criticized by jon baggaley (3,4). the british open university suggested in its innovation report a timeframe of one to two years (22). other forecasters were more cautious and commented more in detail the factors that influence medium term trends (23). hence, are we in the rising part of the hype cycle? norway, recently announced proudly a national initiative for mooc development to promote online education and to develop a national mooc platform (24). laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 8 critical views about moocs g. siemens according to parr 2013 (15) believes that attitudes towards moocs are in a period of flux and that criticism is mounting because of what he calls the “biggest failing of the big mooc providers”; from this point of view, they are simply repackaging what is already known rather than encouraging creativity and innovation: “there has been a growing backlash against moocs over the past year. if 2012 was the „year of the mooc‟, 2013 is shaping up as the „year of the anti-mooc.‟ schulmeister, a german pedagogue, after participation in several xmoocs summed up the following critical points (19):  lack of feedback and low interaction.  high drop-out rates.  no reliable checking of learning outcomes and peer reviews.  many different subjects, but no curriculum. to these points, the information overload in terms of quality and structure might be added especially for cmoocs. it is not really surprising that nmc experts did not provide correct orientations of future mooc perspectives. according to a study of the babson survey research group (25), only a very small segment of higher education institutions in the us are now experimenting with moocs with a somewhat larger number in the planning stages. most institutions remain undecided. according to them, only 2.6% of higher education institutions in the us currently have a mooc, and another 9.4% which report moocs are in the planning stages. the majority of institutions (55.4%) report they are still undecided about moocs, while less than one-third (32.7%) state that they have no plans for an mooc. academic leaders are not concerned about mooc instruction being accepted in the workplace, but do have concerns that credentials for mooc completion will cause confusion about higher education degrees (problem of recognizing badges). in a recent paper, the conference of german university‟s rectors stressed, that the use of external mooc platforms may reduce the “visibility” of the educational institution and that the fragmentation of educational offers could lead to a “mac donaldization” of teaching (26). though, no clear cut position is taken, mainly “pros” and “cons” are discussed. as a final quotation we will mention sebastian thrun, who, after his first optimism about the tremendous enrolment rates for his udacity course on “artificial intelligence” states later with resignation: “we were on the front pages of newspapers and magazines, and at the same time, i was realizing, we don‟t educate people as others wished, or as i wished. we have a lousy product.” (27). since udacity was one of the first mooc companies, and sebastian thrun its founder, his admission came as a shock. it signalled the decline of the mooc empire: from 2012 when the new york times declared it “the year of the mooc” to now, when its very champions, who had built their reputation and companies around the theory that free, huge, online college classes were the way to fix education, were conceding failure. thrun retained that moocs were a bad product because less than ten percent of the mooc students managed to complete each class. “how can classes revolutionize education if no one is finishing them?”. the first hype about moocs is somehow difficult to follow as in pedagogical terms the early application of televised courses 30 years back in the us did not differ much from today‟s xmoocs. about that time, the author of this paper wrote, that “in 1984, the national technological university began to offer courses for upgrading engineers. a consortium of 22 universities distributed their courses through the system. classes are given as live lectures by staff of the associated universities in especially equipped classrooms and transmitted via satellite. the student at his workplace has options to pose questions via direct http://www.nytimes.com/2012/11/04/education/edlife/massive-open-online-courses-are-multiplying-at-a-rapid-pace.html?pagewanted=all&_r=0 laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 9 telephone links.” (28). the question remains whether moocs represent really a disruptive innovation (see also 29). so, is the position of moocs on the hype cycle rather like the one indicated in figure 3? figure 3. the tentative position of moocs in the hype cycle if we use the frequency of searches in google as an indicator using google trends, we can observe that the interest in moocs started in germany with a delay compared to the us and after reaching its highest values declines faster than in the us. the interest in moocs in general seems to be still declining in contrast to all exaggerated expectations and forecasts. remaining perspectives of moocs there are a number of aspects relevant for the future survival and usefulness of moocs. first of all, an economic solution has to be found to finance moocs if they are offered free of charge. however this is a problem that moocs have in common with any open educational resource. as our economic system is based on private property rights, it will always be difficult to offer private goods for free, or as the american economist milton friedman expressed: “there is nothing like a free lunch”. so far, several business models have been developed to charge not the course, but the connected services or certifications (coursera charges now for the certificate). udacity will charge in the future for tutoring support. the remaining possibilities are the financing by donations or membership contributions. “obviously, if sustainable models for the support of open content initiatives cannot be found in the relatively near future, most are doomed to be left by the wayside when their initial funding ceases.” (30). laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 10 figures 4a and b. frequency of searches in google trends in the us and germany, generated in june 2014 laaser w. the rise and fall of the “massively open online courses” (review article). seejph 2014, posted: 11 november 2014. doi 10.12908/seejph-2014-33 11 secondly, the unique possibility to dispose about “big data” by using moocs is of great relevance to research projects. moocs represent by their huge international clientele a fantastic field for research studies such as learning analytics, collaboration formats and automated support of large student numbers, spontaneous formation of groups and communities of practice, behaviour of peers in online environments and analysis of intercultural communication patterns. actual research experiences and best practise “in and around moocs” are presented in a special edition of elearning papers (31). another relevant source for mooc research are the proceedings of the european mooc stakeholder summit 2014 (32). research topics dealt with are models, built to forecast drop-out rates, eye tracking studies, or analysis of video usage and design patterns. to date, moocs have been offered usually for small courses with special content areas selected. in the future, complete degree courses will be probably offered and this will be affordable mainly for institutions that can invest huge amounts of money in attractive course presentation and marketing. this holds primarily true for xmoocs. the future of cmoocs seems to be even more uncertain, but future developments might 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distribution, and reproduction in any medium, provided the original work is properly cited. bimczok, s. p., godynyuk, e. a., pierey, j., roppel, m. s., & scholz, m. l. how is excellence and trust for using artificial intelligence ensured? evaluation of its current use in eu healthcare (policy brief). seejph 2021, posted: 18 april 2021. doi: 10.11576/seejph-4685 p a g e 1 | 14 policy brief how are excellence and trust for using artificial intelligence ensured? evaluation of its current use in eu healthcare simon paul bimczok1, elizabeth alexandra godynyuk1, joris pierey1, malin siv roppel1, mirjam lisa scholz1 1faculty of health, medicine, and life sciences, maastricht university, the netherlands corresponding author: elizabeth alexandra godynyuk email: l.godynyuk@student.maastrichtuniversity.nl address: inthealth department: duboisdomein 30, 6229 gt, maastricht, the netherlands mailto:l.godynyuk@student.maastrichtuniversity.nl bimczok, s. p., godynyuk, e. a., pierey, j., roppel, m. s., & scholz, m. l. how is excellence and trust for using artificial intelligence ensured? evaluation of its current use in eu healthcare (policy brief). seejph 2021, posted: 18 april 2021. doi: 10.11576/seejph-4685 p a g e 2 | 14 abstract context: artificial intelligence (ai) could be a key driver in different healthcare dossiers, ranging from preventive to diagnostic and treatment purposes. the establishment of the artificial intelligence high-level expert group in the european commission, as well as their white paper, show first attempts of creating policies in the domain of artificial intelligence in the eu. despite these policy approaches, there is a need for a coherent regulatory framework that enables the efficient use of ai in the field of health. the aim of this policy brief is to evaluate current legislative gaps in terms of the introduction of ai in healthcare, focusing on the domains of data protection, liability & transparency, as well as robustness & accuracy. policy options: this policy brief identified a high degree of ehealth infrastructure fragmentation on member state level and limited action towards a structured and coherent framework for ai in healthcare, under the domains of data protection, liability & transparency, and robustness & accuracy. recommendations: a unified approach at eu-level, based on proposed recommendations and merged into the form of a directive, is advised. the development of the health-ai-directive will bring progress and improvement to legal certainty in the european ai-landscape. the introduction of the health-ai-directive is recommended to ensure trust and excellence in the use of ai in healthcare. keywords: artificial intelligence (ai); european public health; trustworthiness; health policy; digital health acknowledgments: the authors of this policy brief would like to thank all our tutors, lecturers and professors of the m.sc. governance and leadership in european public health, with special thanks to kasia czabanowska and rok hržič, for enabling and encouraging us in the creation of this policy brief. authors’ contributions: all authors contributed equally to this work conflict of interest: none declared source of funding: none declared bimczok, s. p., godynyuk, e. a., pierey, j., roppel, m. s., & scholz, m. l. how is excellence and trust for using artificial intelligence ensured? evaluation of its current use in eu healthcare (policy brief). seejph 2021, posted: 18 april 2021. doi: 10.11576/seejph-4685 p a g e 3 | 14 introduction: pointing artificial intelligence in the right direction artificial intelligence (ai) is frequently described as one of the promising technologies that could guide crucial societal and technological change in the upcoming years (1). in the field of public health, ai could be a key driver in different domains, ranging from preventive to diagnostic purposes. especially, the implementation of medical imaging practices through aiimaging is likely to revolutionise public health practices (2). in the european commission’s (ec) work programme for 2021, the european union’s (eu) “fit for the digital age” will be attained through the creation of legislative developments of safety, liability, fundamental rights, and data safety of ai (3). this is particularly important, given the fact that the eu lacks a legal framework on the use of ai as there is no legal basis available that regulates the use of ai in healthcare. with respect to the current amendments in different healthcare dossiers, including the expected amendments of the medical devices regulation (4), the creation of a stringent legislative environment of ai in public health is evident. already in 2018, the ec acknowledged the need for policy action on ai, and established the high-level expert group on artificial intelligence (ai-hleg) (5). as a consequence, the white paper “on artificial intelligence a european approach to excellence and trust” was published (6) and opened to consultations with relevant stakeholders including civil society, industry, and academics from 19 february to 14 june 2020. additionally, the ec issued a communication on building trust in human centred artificial intelligence (7) and thus defined seven characteristics of trustworthy ai, namely (i) human agency and oversight, (ii) technical robustness and safety, (iii) privacy and data governance, (iv) transparency, (v) diversity, nondiscrimination and fairness, (vi) societal and environmental well-being as well as (vii) accountability. trust and excellence in ai are key requirements for ai-applications in the medical field, since sensitive data is processed. against this background, the use of ai in healthcare is categorised as high-risk ai-applications. despite these policy approaches, the eu currently lacks a coherent legally binding regulatory framework that would enable the efficient use of ai in the field of healthcare. specifically, the perspectives on data protection, liability and transparency as well as robustness and accuracy should be addressed in such a coherent framework. as such, the following policy brief aims to identify and evaluate current gaps and needs in the respective regulatory framework. the guiding question and corresponding subquestions are therefore: q: which regulatory legislations are necessary for enabling an adequate use of ai in healthcare? sq (1): which existing policies address the domains “data protection”, “liability & transparency”, and “robustness & accuracy” for healthcare-ai? sq (2): what are the current gaps in legal regulations regarding ai in healthcare? the overarching vision is to improve patientcentred healthcare and prevention for all european citizens by ensuring faster, more effective, and more efficient use of ai in healthcare. as such, this policy brief proves its relevance in presenting policy recommendations on the creation of a legal framework for ai-applications in the field of healthcare to the ec’s ai-hleg and other relevant stakeholders. bimczok, s. p., godynyuk, e. a., pierey, j., roppel, m. s., & scholz, m. l. how is excellence and trust for using artificial intelligence ensured? evaluation of its current use in eu healthcare (policy brief). seejph 2021, posted: 18 april 2021. doi: 10.11576/seejph-4685 p a g e 4 | 14 context: identification of gaps in policies and regulations this report assessed current gaps and limitations in policies and regulations, based on six requirements highlighted in the ‘white paper on artificial intelligence’ (6), established by the ec. the white paper outlines the necessity of elaborating on such topics towards further development in future regulatory frameworks in ai. these requirements include training data, keeping of records and data, information provision, human oversight, as well as robustness and accuracy. a literature search regarding policies in each of the six requirements was conducted to identify the current situation. the framework was further delineated into three overarching domains: data protection, liability & transparency, and robustness & accuracy. the resulting search yielded current policies and frameworks in use. findings were established and assembled under ‘solutions’, which can be found in table 1. current gaps in each domain and requirements are addressed, and framework recommendations are described and elaborated in table 1. infobox 1 – glimpse of the possibilities: ai in healthcare nowadays, ai is getting more and more presence in healthcare. for example, in ophthalmology, the widespread availability of optical coherence tomography (oct) and a lack of expert interpreting results produced by oct poses a problem. for such medical image analysis and referral, ai presents a potential solution. if deep learning (dl) combined with the results the oct produces promising outcomes. the ai has an accuracy of 94,5% when identify the type of eye disease (8). in mammography, ai is also on the rise. mammography’s of 60,886 patients diagnosed with breast cancer were used to train a dl model. after this model was introduced, it detected women at high risk of breast cancer. it put 31% of all patients in the top risk category for potential breast cancer (9). figure 1: infobox 1 glimpse of the possibilities: ai in healthcare bimczok, s. p., godynyuk, e. a., pierey, j., roppel, m. s., & scholz, m. l. how is excellence and trust for using artificial intelligence ensured? evaluation of its current use in eu healthcare (policy brief). seejph 2021, posted: 18 april 2021. doi: 10.11576/seejph-4685 p a g e 5 | 14 table 1: current policies, frameworks, and current gaps based on domains *citations refer to the general data protection regulation (17), declaration on ethics and data protection in ai (20), charter of fundamental rights of the european union (21), and cybersecurity act (34) domains solutions current policy instruments & frameworks* current gaps/needs data protection training data: assurance that use of products and services are safe tackle discrimination protection of personal and private data gdpr: art. 5 (1)(f) art. 6 (1)(d&f) art. 9 (1) art. 32 art. 35 medical device regulation (2017/745): art. 5 (2) declaration on ethics and data protection in ai: 4 (a) 6 (a-d) charter of fundamental rights of the eu: art. 8 (2) art. 21 no specific regulation for training data in healthcare with ai in general data protection guidelines, and for medical devices. keeping of records and data: records of dataset development to use for training data and testing methodologies for programming, training, building, testing & validating ai gdpr: art. 5 (1)(e) art. 30 no ai-specific verifiability and compliance measures. no data retention framework; policies only at national level. liability & transparency information provision: information about ai’s capabilities and limitations inform citizens, when they interact with an ai system gdpr: art. 13 (2)(f) need for clearer transparency guidelines about the functionality of ai-systems. human oversight: output reviewed and validated by a human ensure human intervention after ai output impose operational constraints on ai system gdpr: art. 22 governance mechanism of how to implement the safeguards is not defined. robustness & accuracy robust and accurate during all life cycles phases reproducible outcomes adequately able to deal with errors inconsistencies during all life cycle phases resilient against cyberattacks cybersecurity act gdpr european cybersecurity certificate. bimczok, s. p., godynyuk, e. a., pierey, j., roppel, m. s., & scholz, m. l. how is excellence and trust for using artificial intelligence ensured? evaluation of its current use in eu healthcare (policy brief). seejph 2021, posted: 18 april 2021. doi: 10.11576/seejph-4685 p a g e 6 | 14 policy options: identification of needs and recommendations for ai-requirements ai poses great opportunities for healthcare. to lead this development in a direction that mitigates potential risks, regulations are required. in the following sections the current gaps are discussed, followed by recommendations to address these gaps. data protection this domain is differentiated into the parts “training data” and “keeping of records and data”. these parts go into depth on how ai training data should be regulated and how it should be stored. training data training data in ai is the personal data that is used to direct the programme to recognise patterns and use the technology (e.g., neural networks) accurately and accordingly (1315). training data sets the basis for the functioning of the whole ai-process and system. therefore, sufficient training data is fundamental for a sufficient ai-system (13). several challenges regarding training data arise that have not yet been sufficiently addressed in mandatory legal requirements (6). assurance of safety of the products and services used by the ai-system, according to the standards of the eu, is necessary (6). a regulation for safety of medical devices can be found in art. 5(2) of the regulation (eu) 2017/745 on medical devices (16). the general data protection regulation (gdpr) regulates the general security of processing personal data in art. 32 (17). additionally, measures should be addressed which ensure that the use of ai does not lead to discrimination (6). the training dataset is often smaller and differs from the targeted population (18). for this reason, a regulation to detect, avoid, and counteract discrepancies between the target population and the training data is crucial to avoid bias in the output of ai in healthcare (19). avoidance of bias in ai is mentioned in the declaration on ethics and data protection in ai (20). universal laws protecting people against discrimination can be found in art. 21 of the charter of fundamental rights of the eu (cfr) (21) and in art. 9(1) of the gdpr (17). lastly, regulations for adequate protection of personal data, used in the context of ai in healthcare, is needed (6). regulations for protection of personal data can be found in art. 8(2) of the cfr, as well as in the art. 5(1)(f), art. 6(1)(d+f), and art. 35 of the gdpr (17). additionally, the declaration on ethics and data protection in ai mentions the need for protection of personal data during the development of ai (20). figure 2: infobox 2 biased ai infobox 2 – biased ai ai that contains existing prejudices of the developers, resulting in discrimination or lack of fairness in automated decision-making. biases in ai mostly occur through unrepresentative or incomplete training data, especially the underrepresentation of minority groups resulting in disadvantages (11, 12). groups mostly affected by ai biases are people of black race, people from the asian continent, woman and disabled (10, 12). bimczok, s. p., godynyuk, e. a., pierey, j., roppel, m. s., & scholz, m. l. how is excellence and trust for using artificial intelligence ensured? evaluation of its current use in eu healthcare (policy brief). seejph 2021, posted: 18 april 2021. doi: 10.11576/seejph-4685 p a g e 7 | 14 even though the stated aspects are generally regulated in several legislative documents, there is no specific regulation addressing aitraining data in healthcare. noted, general regulations apply for ai-training data in healthcare. nevertheless, the specificity for a sufficient execution of the stated solutions in healthcare with ai in regard to training data is missing. therefore, a separate legislative regulation addressing the processing of aitraining data in the context of healthcare is advisable. keeping of records and data under the data protection domain, there is a need for verification in compliance within algorithm development and programming. this requires recordand data-keeping within entities that intend to utilise ai-technology at multiple levels, from design to development to implementation, and continuous execution. art. 30 of the gdpr requires maintenance of records used in dataprocessing to determine each activity that involves the use of personal data (17). aispecific measures in record-keeping compliance in healthcare are limited, though. furthermore, one of the principles in art. 5(1)(e) of the gdpr states that data, under legal obligations, is to be kept for the shortest time that is applicable (17). also, data generated in ai-algorithms merges to form an output, making it difficult to find a solution to track or delete inputted data. at eu-level, no data retention policy appears to exist since the removal of directive 2006/24/ec (22). national level policies have been implemented instead (23).current methods to respond to this need revolves around ‘verifiable ai’. verifiable ai aims to certify each step in the process of aidevelopment for auditing, prior to deployment (24). this would provide mechanisms whereby entities would exercise better practices in retaining data and datasets for the purpose of traceability and to promote compliance. to further propagate a sound regulatory framework and strategy towards recordand data-keeping, audited trails are valuable for accountability (25). ai4eu, a consortium sponsored by the ec, specifies a toolbox called ‘verifai’ with the aim to verify steps in design and run time (26). therefore, an eu-wide policy in ai-specific data retention is recommended, due to the novel risk this type of data poses. this would also have to comply with the cfr. liability & transparency under the data protection domain, there is a this domain is divided into “information provision” and “human oversight”. this part is an elaboration on how information of the functioning of ai should be regulated. afterwards, the supervision of ai-systems will be discussed. information provision in terms of providing information on the development and use of ai in healthcare, a lack of transparency can be described as the main issue. to achieve transparency, it is important to deal with the so-called "black box" of an ai-application. this means understanding the aspects of an ai that influence the decision-making process. therefore, it is important to strive for transparency, not only regarding the algorithms themselves, but also regarding the data and the automated decision making (adm) processes, as well as transparency within the conceptual business model. the ai-hleg identified transparency as a key requirement for ai-applications in healthcare in order to count as trustworthy (7). in their white paper, a lack of transparency regarding the current legislation was described as a major problem (6). moreover, the call for transparency and accountability is not only present in the eu, but also in the usa (27). there are two necessary requirements when bimczok, s. p., godynyuk, e. a., pierey, j., roppel, m. s., & scholz, m. l. how is excellence and trust for using artificial intelligence ensured? evaluation of its current use in eu healthcare (policy brief). seejph 2021, posted: 18 april 2021. doi: 10.11576/seejph-4685 p a g e 8 | 14 providing information to achieve transparency, which are 1) clear information regarding the ai-system’s capabilities and limitations and 2) clear information to citizens on the fact that they are interacting with an ai-system and not with a human. the latter is covered to some extent in art. 13(2)(f) of the gdpr, where it is stated that “controllers must, at the time when the personal data are obtained, provide the data subjects with further information necessary to ensure fair and transparent processing about the existence of automated decisionmaking and certain additional information” (17). to close the regulatory gap of clear transparency guidelines on the functionality of an ai-system, the introduction of mandatory self-identification of these systems is recommended. this particularly applies to the purpose and conditions under which they are planned to function and their estimated level of accuracy (28). additionally, detailed documentation of the decisions made by the ai-systems and the entire process (including business model transparency) is required (7). the information that is provided needs to be objective, concise, and easily understandable. in order to provide appropriate information about the application of ai-systems, policy makers need to consider the circumstances within their particular context of decisionmaking. human oversight within the domain of liability and transparency, the aspect of human oversight of ai’s decision making plays a crucial role. ai presents an undeniable potential to assist health professionnels (e.g radiologists) performance (35) in medical diagnostics. however, human oversight ensures that ai does not undermine human autonomy, whilst defining the liability of decisions made. human oversight is determined by four main characteristics: (i) output reviewed and validated by a human, (ii) ensuring human intervention after ai-output, (iii) aimonitoring and the ability to intervene, as well as (iv) imposing operational constraints on ai-systems (29). against this background, art. 22 of the gdpr defines the legal basis for automated, individual decision making and aims to implement safeguarding measures to the data subject’s interests. according to art. 22 of the gdpr, autonomous decisions must always be contested by humans (17). nevertheless, a gap in the current policy framework shows no information on how to practically implement the mechanism of human oversight. this is especially important to address in the sense of ai's use in the field of (public) health. hereby, three governance mechanisms are available. firstly, human-in-the-loop (hitl), which refers to the introduction of human intervention in every step of the decisionmaking process. secondly, human-on-theloop (hotl), which considers the capability of human oversight within the design-cycle as well as the monitoring of the ai’s decision-making. thirdly, the human-incommand (hic) approach that allows human oversight of the overall activity of the aisystem, taking into account the economic, societal, legal, as well as ethical perspective (6). with respect to the use of ai in the health sector, the mechanism of human-incommand (hic) can be identified as the most desirable one. this governance mechanism covers the cluster of public health holistically, considering the economic, societal, legal, and ethical points of view. in addition to that, the approach is favoured by high eu civil servants, such as commissioner for innovation, research, culture, education, and youth, mariya gabriel (30). nevertheless, effective use of this governance approach entails certain implications, such as sufficiently trained bimczok, s. p., godynyuk, e. a., pierey, j., roppel, m. s., & scholz, m. l. how is excellence and trust for using artificial intelligence ensured? evaluation of its current use in eu healthcare (policy brief). seejph 2021, posted: 18 april 2021. doi: 10.11576/seejph-4685 p a g e 9 | 14 personnel capacities and corresponding financial capacities. robustness & accuracy in order to be trustworthy, ai-systems, particularly high-risk ai-systems, must be technically robust and accurate. some airequirements need to be ensured to prevent problems according to the ec (6). aisystems need to be (i) robust and accurate during all life cycle phases, (ii) have reproducible outcomes, (iii) be able to adequately deal with errors or inconsistencies during all life cycle phases, for example through control algorithms, and (iv) be resilient against cyberattacks (6). in a report by hamon, junklewitz & sanchez (31), the reliability of outcomes, data-protection, and transparency of ai-models to prevent issues is stressed. accuracy and transparency have a difficult interdependence within aiapplications. it is often the case that the more accurate a model is, the lower the transparency. this raises the question on whether the ability to describe how data is obtained may be less important than the ability to generate those results and validate their accuracy empirically (32).currently, efforts are being made to provide policies on cybersecurity. this has implications for the robustness of ai-applications. the cybersecurity act, adopted in 2019, gives the eu a mandate on cybersecurity as the european union agency for cybersecurity is making european cybersecurity certification schemes, which all the member states have to comply with once implemented. hamon et al. (31), propose designing a framework, using the gdpr, to make an evaluation that assesses the impacts of ai-systems on society. they also recommend the introduction of systematic methodologies to test the robustness of ai-models. finally, sharing identified ai-model vulnerabilities and technological solutions to fix them among ai-practitioners is stressed. the gdpr generally provides meaningful indications for data protection in the context of ai-applications and could be used as a foundation to create a regulatory framework for ai in healthcare (33). recommendations: roadmap for the implementation process with respect to the identified gaps within the regulatory framework, as stated in the previous section, the following policy recommendations (table 2) are directed towards the ai-hleg. hereby, it is emphasised that there are overlaps in the current framework that are thus mirrored within the recommendations. bimczok, s. p., godynyuk, e. a., pierey, j., roppel, m. s., & scholz, m. l. how is excellence and trust for using artificial intelligence ensured? evaluation of its current use in eu healthcare (policy brief). seejph 2021, posted: 18 april 2021. doi: 10.11576/seejph-4685 p a g e 10 | 14 table 2: policy recommendations for each domain domains solutions policy recommendations data protection training data to introduce a legislative regulation specifically addressing safety, avoidance of bias, and protection of private and personal data in training data of ai in healthcare. keeping of records and data to provide legislation for compliance and verifiability of ai, particularly audit trails and data tracing, and regulate such practices with ai-specific data retention policies. liability & transparency information provision to ensure transparency by introducing a mandatory self-identification and documentation of ai-systems in healthcare as well as their business models by addressing 1) their exact purposes and ways of automated decision-making, 2) the conditions under which they are planned to function and 3) their estimated level of accuracy. human oversight to implement the human-in-command governance approach to ai applications, this implies to train and accumulate personnel capacities able to oversee the ai application (background in governance, health, and life science as well as digitization and its implications). robustness & accuracy to implement and enforce a framework, based on the gdpr, that would set rules for ai-cybersecurity across the eu e.g. promoting transparency. within the framework, a platform to share knowledge of aivulnerabilities and technological solutions should be incorporated. overall recommendation to implement one overall legislative regulation for ai in healthcare addressing all three domains of data protection, liability and transparency, and robustness and accuracy. bimczok, s. p., godynyuk, e. a., pierey, j., roppel, m. s., & scholz, m. l. how is excellence and trust for using artificial intelligence ensured? evaluation of its current use in eu healthcare (policy brief). seejph 2021, posted: 18 april 2021. doi: 10.11576/seejph-4685 p a g e 11 | 14 from recommendation to implementation through legislation: a health-aidirective? the need for a framework dealing with ai in healthcare has been highlighted in the previous sections. the urgency of implementing this framework could also be shown by pointing out current gaps of airelated regulations in the gdpr and other eu law, since the gaps within the framework allow space for further policy actions. with respect to the actual implementation of the suggested recommendations, several governance perspectives must be taken into consideration. this is particularly true given the involvement of multi-faceted stakeholders and their interests in the field of healthcare. debates are likely to arise, questioning the competence of the eu in terms of creating legislation in the field of healthcare. however, in order to compete with and even exceed other global players in the realm of ai in healthcare, such as the usa and china, the eu needs to act unified and develop an accurate ai-framework. at the eu-level, a unified approach, guided by the ai-hleg, to transfer the current considerations from the white paper into the form of a directive, is advised. the development of this directive would provide a basis for a legal framework, and merge into national law of the member states. additionally, this process would ensure a legally binding basis for a unified policy approach among the eu member states concerning the use of ai in the field of healthcare. in practice, this means that political decisionmakers must always incorporate the aspects of data protection, accountability and transparency, as well as robustness and accuracy, into any decision-making-process on the use of ai in their specific context. against this background, a health-aidirective is the most favourable instrument. on the one hand it allows the member states a certain degree of flexibility to adapt the regulations on the use of ai in line with the specific conditions of their national healthcare system. on the other hand, a common path in the eu can be fostered by ensuring compliance with the key objectives in the context of ai. hereby, the contextual national frameworks and differing national priority setting, as well as the urgency of a unified approach, are taken into consideration. conclusions the development and establishment of the health-ai-directive as a regulatory eu-wide ai-framework, based on the recommendations above, constitutes one way to bring progress and improvement to legal certainty in the ai-landscape of the eu. it will counteract the fragmentation of the ai infrastructures among the member states and contribute to the objectives of the ai-hleg of “trust, legal certainty and market uptake” (6). this will strengthen the eu to pave the way for a trustworthy usage of high-quality ai in healthcare. references 1. eit health and mckinsey & company. transforming healthcare with ai. the impact on the workforce and organisations.: eit health, european union; 2020. 2. oren o, gersh bj, bhatt dl. artificial intelligence in medical imaging: switching from radiographic pathological data to clinically meaningful endpoints. the lancet digital health. 2020;2(9):e486-e8. 3. european commission. communication from the commission to the european bimczok, s. p., godynyuk, e. a., pierey, j., roppel, m. s., & scholz, m. l. how is excellence and trust for using artificial intelligence ensured? 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[accessed 23 november 2020] 34. european parliament and council of the european union. regulation (eu) 2019/881 of the european parliament and of the council of 17 april 2019 on enisa (the european union agency for cybersecurity) and on information and communications technology cybersecurity certification and repealing regulation (eu) no 526/2013 (cybersecurity act) 2019. available from: https://eurlex.europa.eu/eli/reg/2019/881/oj [accessed 04 december 2020] 35. allen b, jr., seltzer se, langlotz cp, dreyer kp, summers rm, petrick n, et al. a road map for translational research on artificial intelligence in medical imaging: from the 2018 national institutes of health/rsna/acr/the academy workshop. journal of the american college of radiology. 2019;16(9):1179-89. 36. challen r, denny j, pitt m, gompels l, edwards t, tsaneva-atanasova k. artificial intelligence, bias and clinical safety. bmj quality &amp; safety. 2019;28(3):231-7. https://ec.europa.eu/futurium/en/ai-alliance-consultation/guidelines/1 https://ec.europa.eu/futurium/en/ai-alliance-consultation/guidelines/1 https://www.euractiv.com/section/digital/news/digital-brief-tech-biopower/ https://www.euractiv.com/section/digital/news/digital-brief-tech-biopower/ https://www.euractiv.com/section/digital/news/digital-brief-tech-biopower/ https://www.europarl.europa.eu/regdata/etudes/stud/2020/641530/eprs_stu(2020)641530_en.pdf https://www.europarl.europa.eu/regdata/etudes/stud/2020/641530/eprs_stu(2020)641530_en.pdf https://www.europarl.europa.eu/regdata/etudes/stud/2020/641530/eprs_stu(2020)641530_en.pdf https://eur-lex.europa.eu/eli/reg/2019/881/oj https://eur-lex.europa.eu/eli/reg/2019/881/oj data protection liability & transparency under the data protection domain, there is a this domain is divided into “information provision” and “human oversight”. this part is an elaboration on how information of the functioning of ai should be regulated. afterwards, the supervision of ai-syst... table 2: policy recommendations for each domain from recommendation to implementation through legislation: a health-ai-directive? an empirical study into factors that influence e-learning adoption by medical students in uae (original research), posted:29 september 2022. doi: 10.11576/seejph-5902 original research an empirical study into factors that influence e-learning adoption by medical students in uae afrah alsharafi1 1. faculty of business and law, the british university in dubai, uae corresponding author: afrah alsharafi faculty of business and law, the british university in dubai, uae 21002516@student.buid.ac.ae an empirical study into factors that influence e-learning adoption by medical students in uae (original research), posted:29 september 2022. doi: 10.11576/seejph-5902 abstract aim: the global higher education sector has shown an inclination towards the adoption of technology-based learning for introducing innovation in teaching and learning activities. however, this e-learning environment can only be effective if students have positive perceptions of e-learning. hence, educational personnel is required to consider how students perceive this concept. this research intends to serve this purpose by identifying factors affecting students' acceptance of e-learning as well as their intention toward the use of e-learning for their learning activities. methods: the technology acceptance model (tam) was used in this re-search to formulate a theoretical framework. this research will employ online questionnaires as a data collection tool while the international students enrolled at united arab emirates universities will serve as study participants. results: the research outcomes indicated the most crucial role played by the predictors of “accessibility" “perceived enjoyment", “social influence”, “perceived usefulness”, and "perceived ease of use" in shaping students’ intention to resort to e-learning platforms for learning purposes. conclusion: the research indicated that the extended tam model is applicable in the uae educational context. the research outcomes also showed the possibility for policymakers in the educational sector to make effective use of e-learning platforms both as a technological solution and as an e-learning platform to support distance learning. the research also highlights the practical implications for the concerned educational developers in the educational sector to help them develop and apply a competent e-learning system. keywords: e-learning; higher education; international students; uae. acknowledgment: this work is a part of a project undertaken at the british university in dubai conflicts of interest: none declared. an empirical study into factors that influence e-learning adoption by medical students in uae (original research), posted:29 september 2022. doi: 10.11576/seejph-5902 introduction innovation has introduced the use and application of digital technologies in all walks of life particularly the digital learning and teaching processes. the global higher education sector has shown an inclination towards the adoption of technology-based learning for introducing innovation in teaching and learning activities. in this innovative world, student needs are also evolving and the educational sector specifically the academic institutions have to keep pace with these developments through continuous modification of their courses and mode of education delivery. presently, the educational sector is shifting towards elearning as a new mode of education delivery to cater to the needs of distant students. due to the extraordinary benefits of e-learning like lower cost, ease of use, and flexibility, the global education system is showing an inclination towards the integration of elearning as part of their teaching and learning strategy. e-learning adoption is being observed in various higher education institutions to offer better learning experience to students in the form of easy accessibility free from temporal and spatial limitations. the uae government’s commitment to promote online learning and distance education is evident from its implementation of e-learning as part of their innovation-promoting campaign in education sector. the concept of distant learning gained popularity in march 2020 during the spread of covid-19 when learning from home was applied by all higher edu-cation institutions and schools across the uae. as part of this movement, training programs were conducted to equip school teachers with the essential knowledge of using distance learning programs effectively. private schools were also encouraged to apply individual distance learning system for supporting the learning and teaching activities during the pandemic. the smart learning plat-forms were also initiated by the uae government. the teachers using distant learning programs for conducting classes were provided with guidelines by the uae government for proper supervision of their students’ behavior. the uae government ensured easy internet accessibility to all the students across the country. in this regard, remote areas with low or no internet connectivity were provided with free-of-cost satellite broadband services. moreover, students were also provided with free-of-cost home internet connection. the uae is committed to implement the e-learning system in all educational institutes in the country due to the strategic significance of such systems in accomplishment of the uaes in-novation-promotion campaign. e-learning systems allow easy access to learning activities by greater number of students besides facilitating the delivery of professional education leading to higher rate of qualification and attracting students beyond the traditional area of student influx. e-learning supports innovative teaching and learning process by revolutionizing the education sector through the modification of traditional education systems and methods as indicated in earlier studies. eventually, educational and learning system yields better quality. other benefits offered by e-learning system are improvement in educational curriculum and reputation of the institute, cam-pus space utilization and optimization of resources for better learning; e-learning encourages the enrolment of greater number of students leading to higher student diversity and higher income (1). but, adoption of elearning systems is not as easy as it seems. it involves various obstacles, such as improper infrastructure (2), inadequate ict support (3) and public fear and reluctance towards adoption of technology (4) among others. even the institutions fear the adoption of technology and are reluctant to switch to e an empirical study into factors that influence e-learning adoption by medical students in uae (original research), posted:29 september 2022. doi: 10.11576/seejph-5902 learning and prefer to adopt a middle way method of blended learning; in this method, e-learning tools are employed to complement the traditional classes instead of fully replacing them with online learning methods (1). positive student perception and expectations about e-learning are extremely important for the successful implementation of e-learning and development of e-learning environment. however, students’ perceptions about e-learning and the factors that motivate e-learning adoption among international student community have been fully ignored. fortunately, this study identified the factors influencing intention of students studying in higher education institutes towards using e-learning system. these factors were “accessibility", “perceived enjoyment", and “social influence”. moreover, the effect of each of these factors on international students’ perception and intention to accept the elearning platforms were also discussed. according to the literature, there is limited empirical research on how e-learning is utilized in the uae institutions and limited awareness of the factors that influence students' actual use. in the perspective of methodology, most technological acceptance researches asses, theoretical models, using the “structural equation modeling (plssem)” technique. as a result, there are two folds to this study. to begin, tam (5) and external variables were combined to assess students' actual use of e-learning. second, employing the pls-sem tool, verify the constructed theoretical model. this study starts with the literature review of the selected studies related to e-learning systems. in the next step, hypotheses are developed. after this, an ex-planation of the method is given. in the end, the study present the results and discussion, elaborates the limitations and offers recommendations for future re-search. literature review distance learning has become much convenient in the previous 10 years with the introduction of world wide web, or web which serves as a platform for con-ducting online teaching and learning activities for distant students. web is assessed by a number of users at the same time for communication and collaboration purposes; it is also accessed by many learners to obtain information. learners also get a chance to use various learning tools available on the internet for acquiring new knowledge or exploit the available knowledge. various terms associated with internet and webbased teaching and learning activities are web-based learning, e-learning and online learning among others. e-learning is a virtual classroom where different learners and teachers located remotely use inter-net for developing a connection with each other and conduct teaching and learning activities. internet acts as a mode of imparting education to students. internet allows students to involve in repetitive learning activities and access course materials irrespective of the time and place constraints (6). internet acts as a life-saver for students of all ages and levels who do not have physical access to educational centers or educational content to acquire advanced degrees otherwise. besides the educational purposes, there has been an inclination towards implementing e-learning for commercial purposes (6). e-learning has helped the educational sector specifically the higher education and corporate training institutes to overcome the obstacles experienced in learning and teaching activities (6). this situation calls for more research on e-learning which is become one of the most important developments in is industry due to the present situation where physical classes have been abandoned due to covid-19. e-learning research is essential for allowing schools and higher education institutes and students to understand this an empirical study into factors that influence e-learning adoption by medical students in uae (original research), posted:29 september 2022. doi: 10.11576/seejph-5902 technology and make best use of it while conducting e-learning courses (7). proper knowledge and implementation of e-learning in the current knowledge-based economy allows financial institutes and organizations to gain information and exploit the available information to outshine their competitors. the learning environment in organizations is also being incorporated with e-learning technology for equipping the workers with latest information and proper training. however, it must be comprehended that student acceptance of the technology is critical factor for effective implementation of online learning in educational institutes. students are the ones who are exposed to technology use in learning activities on daily basis, therefore their acceptance behavior towards that technology is extremely important to consider. before taking any decision about incorporating technology in learning processes or bringing about a change in learning behavior, students’ disposition and acceptance to adopt the change must be taken into account. the empirical evidence also depicted that user acceptance was imperative for effective implementation of technology (8). re-searchers have shown keen interest in identifying factors affecting the acceptance of information technology; in this regard, they have formulated and tested many relevant models like the “theory of reasoned action (tra)” (9) and the “technology acceptance model (tam)” (10). out of all these models, the most effective one is known to be tam since it has been validated, executed and simulated extensively and is also found to be much robust and predicative than other models (11). tam has been formulated on the basis of technology adoption literature and is a significant innovation in the domain of is. this research mainly intends to investigate the factors that affect the acceptance of elearning by students studying in higher education institutes. the research specifically focuses on how “perceived usefulness and perceived ease of use” are affected by the elearning external factors of “accessibility", “perceived enjoyment", and “social influence”. additionally, the impact of these factors on students' intention to-wards adoption of e-learning is studied. this research contributes to the domain of elearning by allowing the formulation of effective e-learning programs and conducting e-learning courses. the conceptual model and hypotheses 3.1 accessibility (acs) alshammari et al (12) defines system accessibility as the degree of ease of student access to e-learning system and the degree of student’s adoption of this system for continued learning. students find the elearning system as easy to use if the elearning system offers accessibility to them (13). it has been indicated by (14), that “perceived ease of use” associated with a website expresses its system accessibility. additionally, (15,16) also conveyed the idea that perceived ease of use of e-learning system is significantly dependent on the accessibility of that system. previous research showed same outcomes about the significant effect of perceived accessibility of an e-learning system on both its “perceived ease of use” (17) and “perceived usefulness” (18). an easily accessible e-learning sys-tem sounds more appealing to the student as the student perceives such a system to offer more usefulness and greater ease of use (15,16). thus, it is hypothesized that: h1a: accessibility (acs) has a significant influence on perceived usefulness (pu). h1b: accessibility (acs) has a significant influence on perceived ease of use (peou). an empirical study into factors that influence e-learning adoption by medical students in uae (original research), posted:29 september 2022. doi: 10.11576/seejph-5902 3.2 perceived enjoyment (pe) another intrinsic variable of ‘enjoyment’ was investigated by many researchers due to its significant relevance to technologyacceptance studies. enjoyment associated with the use of a new system has a positive influence on user perception (19). when a new system feels enjoyable, the user automatically ignores the complexities experienced during its use and perceives it to be convenient and easy-to-use (20). thus, the factor of perceived enjoyment in using elearning systems has a positive effect on elearning adoption or acceptance. similarly, previous research revealed that like any technology, for e-learning systems, perceived ease of use (21–23) and perceived usefulness (21–23) significantly de-pends on the user perception about the enjoyment offered by the e-learning sys-tem. an enjoyable e-learning system sounds more appealing to the student as the student perceives such a system to offer more usefulness and greater ease of use (6). as a result, we obtain two hypotheses: h2a: perceived enjoyment (pe) has a significant influence on perceived usefullness (pu). h2b: perceived enjoyment (pe) has a significant influence on perceived ease of use (peou). 3.3 social influence (sol) social influence is defined as the perception of influential people regarding the use of a system (24). sometimes, people’s decision to adopt or use a system is based on this social influence which means that they are willing to adopt a sys-tem to follow others and not because of their personal beliefs or emotions (25). a number of research works have investigated the impact of subjective norms on the adoption or acceptance of e-learning. (22) also revealed a significant association of subjective norm with the “perceived usefulness” of an e-learning system (22,23,26) and “perceived ease of use” (22,23,26,27). hence the hypothesis giv-en below is postulated: h3a: social influence (sol) has a significant influence on perceived usefulness (pu). h3b: social influence (sol) has a significant influence on the perceived ease of use (peou). 3.4 the technology acceptance model (tam) the “perceived usefulness and perceived ease of use” lead to the acceptance of new technology. the users’ behavioral intention to use a technology is also significantly dependent on the “perceived ease of use and perceived usefulness”; this has been indicated in tam as well as relevant studies. perceived ease of use depicts the degree of willingness of a user towards the adaption to a new technology (5). a significant association between the two aspects of “perceived ease of use (peou) and perceived usefulness (pu)” was revealed in previous research works (28–30). moreover, the two aspects of the “behavioral intention to use elearning system (iu) and perceived ease of use (peou)” were also found to have a positive direct and indirect link. a corresponding finding by (31) indicates that the user’s intention to employ an e-learning system and to show direct and indirect willingness to accept and adjust to such a system is affected by “perceived usefulness (pu)”. another study revealed a significant positive association be-tween “perceived usefulness (pu) and intention to use the elearning system (iu)” (32,33). hence, this research identifies that iu, pu and peou are positively linked. the relevant literature was reviewed leading to postulation of the hypotheses stated below: an empirical study into factors that influence e-learning adoption by medical students in uae (original research), posted:29 september 2022. doi: 10.11576/seejph-5902 h4. perceived ease of use (peou) has a positive effect on the perceived usefulness (pu). h5. perceived usefulness (pu) positively affects the intention of international student to accept an e-learning platforms (bi). h6. perceived ease of use (peou) positively affects the intention of international student to accept an e-learning platforms (bi) figure 1 illustrates that these hypotheses are employed to propose the research model. a structural equation model is developed on the basis of the theoretical model and is subsequently tested. fig. 1. theoretical framework. research methodology data collection the data collection for this study was conducted throughout the month of november 2021. an online survey was used as a data collection instrument. the international students studying in public or private universities in the uae were selected as the study participants. besides appealing the tourists from around the world, the uae has also been the center of attention for students worldwide to pursue their education and career. the abu dhabi and dubai are the two most significant destinations that house most of the higher education institutions in the uae. the web link of the survey was sent to the respondents through college website. this survey was then filled by the respondents. the link also contained a cover letter that elaborated the survey objectives; the cover letter also affirmed that the identities and personal data of the study participants will be kept confidential and not publicized. the cover letter also gave indications about how long will it take to complete the research. in this research, the traditional face-to face physical classroom settings were used; however, the college used the online platforms like college website, teachers’ blog and school intranet to give students the access to course materials uploaded online. the students were asked to obtain the study material available online before each class through their pcs or through the computers at the college laboratory. findings and discussionhypothesis testing using sem-pls the partial least squares-structural equation modeling (pls-sem) was used to analyze the data for this research with the assistance of smartpls v.3.2.7 software. the collected data was evaluated using a two-step assessment approach that included a structural model and a measurement model. pls-sem was used for this research for a myriad of purposes. primarily, pls-sem is thought to be the ideal option when the goal an empirical study into factors that influence e-learning adoption by medical students in uae (original research), posted:29 september 2022. doi: 10.11576/seejph-5902 of the study is to develop an established notion. second, the pls-sem may be used to effectively manage exploratory research with complex models. third, rather than breaking the model into bits, pls-sem analyses the entire model as a single entity. pls-sem, which delivers accurate computations sequentially, provides concurrent analysis for both measurement and structural model. the structural equation model was used in conjunction with smart pls and maximum likelihood estimation to determine the interdependence of several structural model theoretical constructs. table 1 shows the beta (β) values, t-values, and p-values for each of the hypotheses made using the pls-sem technique predicated on the obtained findings. all the hypotheses were strongly supported by all the researchers. the empirical data supported hypotheses h1a, h1b, h2a, h2b, h3a, h3b, h4, h5, and h6 relying on the data analysis. table 1. hypotheses-testing of the research model (significant at p** < = 0.01, p* < 0.05). h relationship path t-value p-value direction decision h1a acs -> pu 0.352 3.066 0.035 positive supported* h1b acs -> peou 0.617 15.485 0.000 positive supported** h2a pe -> pu 0.359 12.572 0.000 positive supported** h2b pe -> peou 0.587 17.815 0.002 positive supported** h3a sol -> pu 0.665 13.876 0.001 positive supported** h3b sol -> peou 0.632 9.154 0.003 positive supported** h4 peou -> pu 0.354 10.362 0.005 positive supported** h5 pu -> bi 0.458 3.426 0.033 positive supported* h6 peou -> bi 0.725 16.630 0.000 positive supported** conclusion this study intends to extract the factors influencing the perception of the international students about the adoption of electronic learning (e-learning) for their educational activities. the research model will be proposed and the hypothesis for testing the behavioral intention of learners to use e-learning platforms will be postulated on the basis of data analysis results. the research applies structure equation modeling (pls-sem) for evaluation of research hypotheses. it is found that the behavioral intention of students to use e-learning platforms is positively influenced by the factors of “accessibility" “perceived enjoyment", “social influence”, “perceived usefulness”, and "perceived ease of use". the study also suggested that e-learning systems hold significance and are considered as competent online learning platforms by students. an empirical study 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understanding the impact of social media practices on e-learning systems acceptance. 2019; _________________________________________________________________________ çomo n, meta e, qato m, kraja dh, pipero p, fico a. measles, a re-emerging disease in albania: epidemiology and clinical presentations (original research). seejph 2022, posted: 04 february 2022. doi: 10.11576/seejph-5198 p a g e 1 | 8 original research measles, a re-emerging disease in albania: epidemiology and clinical presentations najada çomo1, esmeralda meta1, migena qato1, dhimiter kraja1, pellumb pipero1, albana fico2 1 service of infectious diseases, university hospital centre “mother teresa”, tirana, albania; 2 institute of public health, tirana, albania. corresponding author: najada çomo, md, phd; address: rr. “dibres”, no. 371, tirana, albania; telephone: +355692492756; email: nadacomo@yahoo.com çomo n, meta e, qato m, kraja dh, pipero p, fico a. measles, a re-emerging disease in albania: epidemiology and clinical presentations (original research). seejph 2022, posted: 04 february 2022. doi: 10.11576/seejph-5198 p a g e 2 | 8 abstract aim: measles is a highly contagious disease caused by the measles virus. albania is one of many european countries that have successfully interrupted endemic transmission of this disease. however, during the years 2018-2019, an outbreak of measles occurred in albania. the aim of this study was to describe the clinical features and complications of hospitalized measles patients in tirana, albania, as related to age-group and risk factors. methods: all patients hospitalized for over 24 hours from january 2018 to december 2019 at the service of infectious diseases, university hospital centre “mother teresa” in tirana were included in this study. we included patients over 14 years old as this is an infectious diseases service for adult patients only. clinical and laboratory data were analysed. results: of the 318 hospitalized patients (139 females), about 35%, 26%, 17%, 14%, and 7% were 15-24, 25-34, 35-44, 45-54, and over 55 years old, respectively. females constituted 37% of the total number of patients. the average and median ages were 30.9 years and 28.5 years, respectively. average time from the first symptom to the hospital presentation was 3.8 days. contact with other patients with measles was noted in 21% of the patients. body rashes were identified as maculopapular in 96% of the patients. pathognomonic enanthema or koplik spots and conjunctivitis were detected in 62% and 52% of the patients, respectively. measles-related complications were noted in 53% of the patients; pneumonia/pneumonitis, hepatitis, neurological complications were presented by 24%, 26%, and 3% of the patients, respectively. average duration of hospitalization was 5.4 days, whereas mortality was 0.3%. conclusion: this study provides valuable evidence about the distribution and clinical features of measles in albania. measles is a highly contagious disease and, as long as the measles virus is circulating, the risk of transmission remains high. keywords: albania, fever, koplik spots, maculopapular, measles. conflicts of interest: none declared. çomo n, meta e, qato m, kraja dh, pipero p, fico a. measles, a re-emerging disease in albania: epidemiology and clinical presentations (original research). seejph 2022, posted: 04 february 2022. doi: 10.11576/seejph-5198 p a g e 3 | 8 introduction the widespread use of safe and cost-effective measles vaccines in national immunization programs globally since 1974 has resulted in a marked decrease in measles cases. in line with this, all regions of the world health organization (who) had established goals to eliminate measles by 2020 which, at first sight, seemed achievable (1). yet, over the last decade, measles outbreaks have been widely reported throughout europe, but not in albania. in albania, measles has been a mandatory reportable disease since 1945. the main epidemic spread of measles in albania occurred in 1955, followed by another between the years 1970–1971 with 48,156 reported cases, and then in april 1989 and 1990 with a total of 168,636 reported cases and 44 reported deaths. several cases were reported by the institute of public health (iph), albania from 1990-2000. in 2000, the ministry of health of albania endorsed the national plan for measles elimination 2000-2007, and in the last two decades the cases have been almost inconspicuous (2). so true was it, that young doctors almost forgot about measles. the reemergence of measles in populations with insufficient vaccine coverage has changed its epidemiology from its past pattern of seasonal epidemics in young children to susceptible individuals. clinically, measles is a highly contagious human infectious disease. it can lead to serious complications and often requires hospitalization (3,4). most people with measles recover uneventfully after approximately 1 week of illness characterized by fever, malaise, coryza, conjunctivitis, cough, and a maculopapular rash (5). although measles is often a mild disease, it can lead to serious complications such as pneumonia, hepatitis, keratoconjunctivitis, and encephalitis (24,6,7). the objectives of this study were to provide an update on measles hospitalizations reported in albania during 2018-2019 and describe the clinical presentations and complications of this re-emerged infectious disease. methods all patients hospitalized for over 24 hours from january 2018 to december 2019 at the service of infectious diseases, university hospital centre “mother teresa” in tirana were included in this study. measles patients who were presented in the emergency room of the infectious diseases service were excluded. all patients included were ≥14 years old because this infectious diseases service is only for adult patients. case definition for measles was based on clinical presentation, epidemiological data, and serologically confirmed diagnosis. more specifically, a clinical case of measles was defined as fever with the presence of maculopapular rash, koplik spots, conjunctivitis, cough, and malaise. serological diagnosis was based on igm antibody positivity for measles. demographic, clinical, epidemiological, and laboratory data were collected from patients’ files. results during the study period, more than 2000 people were presented in the emergency room with measles-like symptoms. from these, 1747 tested positive for measles, of whom, 318 patients were hospitalized. tirana city was the most affected area; of note, tirana hosts more than one-third of all albanian citizens. of 318 patients, 139 (43.7%) were females and 179 (56.3%) were males. the majority of hospitalized patients, 61.7%, were 15-34 years old, of whom females were 36.8%. çomo n, meta e, qato m, kraja dh, pipero p, fico a. measles, a re-emerging disease in albania: epidemiology and clinical presentations (original research). seejph 2022, posted: 04 february 2022. doi: 10.11576/seejph-5198 p a g e 4 | 8 more specifically, about 31% of the patients were 15-20 years old. the distribution of patients by 5-year age bands is presented in figure 1. figure 1. distribution of patients with measles by 5-year age bands about 13% of the patients were unemployed; 44% were employed; 2% were retired; and the remaining 41% were pupils (30%) or students (11%) (figure 2). figure 2. distribution of patients with measles by social category 31.3% 13.5% 9.4% 19.8% 6.3% 3.1% 6.3% 5.2% 3.1% 0.0% 2.1% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 15-20 20-25 25-30 30-35 35-40 40-45 45-50 50-55 55-60 60-65 65-70 p e rc e n ta g e o f th e p a ti e n ts age-group (years) 30.0% 11.3% 44.0% 12.7% 2.0% pupils students employed unemployed retired çomo n, meta e, qato m, kraja dh, pipero p, fico a. measles, a re-emerging disease in albania: epidemiology and clinical presentations (original research). seejph 2022, posted: 04 february 2022. doi: 10.11576/seejph-5198 p a g e 5 | 8 the average time from the first symptom to the hospital presentation was 3.8 days. the major indicators for hospitalization were high fever, respiratory symptoms, head ache, and in a few cases patient isolation. rash and fever were the most important complaints. other significant complaints were conjunctivitis and cough. conjunctivitis was a constant complaint, and was detected in 51.6% of patients. koplik spots were confirmed in 198 (62.2%) patients. pulmonary involvement, determined by a chest x-ray, was found in 23.8% of all patients. overall, mean oxygen saturation in admission was 92.3%; oxygen saturation was <90% in 16 (5%) patients. two patients developed acute respiratory distress syndrome (ards). leucopenia was detected in 63.5% of patients; deep leukopenia less than 1000/mm3 was detected in only 13 (4%) of the patients. platelet counts less than normal value were detected in 113 (40.15%) of cases. hepatitis was present in 84 out of 318 (26.4%) patients. the intensive care unit admitted four patients. antibiotic therapy was used in 143 (44.9%) cases. antiinflammatory steroid (prednisolone) was used in 105 (33%) cases. the average duration of hospitalization was 5.04 days, and mortality was 0.3% (1 out of 318). discussion every abrupt outbreak of infection presents a huge problem not only for the hospital administration, but also for public health. in this study, we described the demographic, clinical, hospital course, and outcomes of patients with measles hospitalized at the service of infectious diseases, university hospital centre in tirana, albania from january 2018 to december 2019. in our service, we only attend to non-paediatric cases and patients over the age of 14 years old. as shown in figure 1, the majority of cases belonged to the age group of 15-34 years. this means that lack of vaccination during a certain time has created a gap. maybe this can be explained by the demographic changes that occurred after the year 1990. during 1990-2010, the demographics of albania changed as a result of uncontrolled population movement. in the 1990s, albania experienced political changes, and during this period people frequently moved without registering their addresses. as a result, it must have been difficult for the health agencies to track the vaccination routines of the children born during this period and at least some must have remained unvaccinated. another explanation is the lack of vaccination during 1989-1992 and the measles vaccination coverage of 66%-95% during 1994-2000 (2). the ratio of male/female during 1994-2000 was 2:1 (201:117). it may not be a strong explanation for this situation, but in some infectious diseases, the role of gender is an important determinant (8). the clinical presentations, the same signs and complaints, were as described in literature (3,4,6,7,9-15). in this study, fever was presented during the emergency room presentations or during the first 24 h in 98.7% of cases. typically, morbilliform exanthema appeared 3-4 days after the onset of fever and peaked with the appearance of exanthema, which consists of blanching, erythema, macules, and papules that classically begin on the face and then cover all the body (14). in this study, rash was present in 100% of patients. it can appear 3– 4 days after fever onset. this data is consistent with our findings, because the time of hospitalization from the time of fever onset was 3.8 days. koplik spots, which are pathognomonic for measles infection, were detected in 62.3% of patients. they appear on the buccal mucosa opposite the molars and usually last 12-72 hours (10,12,14). conjunctivitis, as a constant complaint, was detected in 51.6% of patients. the eyes were çomo n, meta e, qato m, kraja dh, pipero p, fico a. measles, a re-emerging disease in albania: epidemiology and clinical presentations (original research). seejph 2022, posted: 04 february 2022. doi: 10.11576/seejph-5198 p a g e 6 | 8 infected around the 4th day and progressively reddened over subsequent days. a total of 27 out of 164 (16.5%) patients developed subconjunctival haemorrhages. the patients with severe conjunctivitis had photophobia and intense watering of eyes and required treatment by an ophthalmologist. in accordance with previous publications, the main indications for hospitalization were pulmonary involvement and high/continuous fever (4,11,16-19). lobar or interstitial pneumonia was reported in 24.2% cases. pneumonitis in measles patients takes two forms: primary by viral measles infection and secondary by bacterial or other viral coinfections. chest x-ray findings were not specific and included ground glass opacities, consolidation, interlobular septal thickening, and bronchial or bronchiolar wall thickening (11,14,15,19,20). as previously noted, patients with pneumonia often need oxygen therapy in combination with prednisolone use. because of a lack of microbiological documentation, the proportion of bacterial superinfections may have been overestimated and this explains the use of antibiotics. hepatitis, another finding in this study, occurred in 84/318 (26.4%) of patients. hepatitis in measles in adult patients can be explained by direct viral infection or by hypoxemia during pneumonitis. therefore, hepatitis should be regarded as a usual symptom rather than a complication of measles infection in adults (21). leukopenia was found in 63.5% of patients. deep leukopenia less than 1000/mm3 was detected in only 13 (4%) patients. lymphopenia is common during the acute stage of measles and lasts for about 1 week (22). infection with the measles virus induces transient immunosuppression. in classical measles cases, infected lymphocytes detected as a minor population during the incubation period disappeared soon after the onset of rash whereas in the cases of serious illness, the infected cells persisted longer after the rash (22,23). platelet counts less than the normal value were detected in 113 (40.15%) cases. sometimes thrombocytopenia can correlate with measles complications, but there were no haematological complications in this study (24). four patients were hospitalized in the intensive care unit. all of them requested intensive care support and two of them showed the complication of acute respiratory distress syndrome. average duration of hospitalization was 5.04 days, and mortality was 0.3% (1/318). fortunately, mortality rate was low and this can be explained by the non-grave complicated cases and the supportive therapy available. a limitation of our study was that it could not estimate the actual incidence rates of the disease; incidence rates were estimated only for hospitalized patients. excluding cases of mild measles that did not require hospital care may have led to a slight overestimation of the complication of the incidence. in conclusion, measles still represents a serious public health problem worldwide. the clinical findings of this study of measles in 318 albanian adults highlight the poor tolerance of people to measles but the absence of severe complications of the disease. references 1. o’connor p, jankovic d, muscat m, ben-mamou m, reef s, papania m, et al. measles and rubella elimination in the who region for europe: progress and challenges. clin microbiol infect dis 2017;23:50410. 2. bino s, kakarriqi e, xibinaku m, ion-nedelcu n, bukli m, emiroglu n, et al. measles-rubella mass immunization campaign in albania, november 2000. j infect dis 2003;187:s223-9. çomo n, meta e, qato m, kraja dh, pipero p, fico a. measles, a re-emerging disease in albania: epidemiology and clinical presentations (original research). seejph 2022, posted: 04 february 2022. doi: 10.11576/seejph-5198 p a g e 7 | 8 3. fiasca f, necozione s, fabiani l, mastrodomenico m, mattei a. measles-related hospitalizations in italy, 2004-2016: the importance of high vaccination coverage. ann glob health 2019;85. 4. ben-chetrit e, oster y, jarjou'i a, megged o, lachish t, cohen mj, et al.measles-related hospitalizations and associated complications in jerusalem, 2018-2019. clin microbiol infect 2020;26:637-42. 5. paules ci, marston hd, fauci as. measles in 2019 going backward. n engl j med 2019;380:2185-7. 6. lee sh, kim s, park sc, kim mj. cytotoxic activities of leptospira interrogans hemolysin sphh as a pore-forming protein on mammalian cells. infect immun 2002;70:315-22. 7. strebel pm, orenstein wa. measles. n engl j med 2019;381:349-57. 8. puca e, pipero p, harxhi a, abazaj e, gega a, puca e, et al.the role of gender in the prevalence of human leptospirosis in albania. j infect dev ctries 2018;12:150-5. 9. barbosa jr, martins as, ruivo j, carvalho l. fever and rash: revisiting measles. acta med port 2018;31:341-5. 10. zenner d, nacul l. predictive power of koplik’s spots for the diagnosis of measles. j infect dev ctries 2012;6:271-5. 11. albarello f, cristofaro m, rizzi eb, giancola ml, nicastri e, schininà v. pulmonary measles disease: old and new imaging tools. radiol med 2018;123:935-43. 12. premaratna r, luke n, perera h, gunathilake m, amarasena p, chandrasena tgan.sporadic cases of adult measles: a research article. bmc res notes 2017;10:38. 13. tu b, zhao jj, hu y, fu jl, huang hh, xie yx, et al. clinical and immunological analysis of measles patients admitted to a beijing hospital in 2014 during an outbreak in china. epidemiol infect 2016;144:2613-20. 14. leung ak, hon kl, leong kf, sergi cm. measles: a disease often forgotten but not gone. hong kong med j 2018;24:512-20. 15. suter c, buergi u, eigenmann k, franzen d. severe acute measles pneumonitis: virus isolation in bronchoalveolar lavage fluid. bmj case rep 2015;bcr2015210826. 16. berti e, sollai s, orlandini e, galli l, de martino m, chiappini e. analysis of measles-related hospitalizations in tuscany from 2000 to 2014. epidemiol infect 2016;144:2605-12. 17. bassetti m, schenone e, calzi a, camera m, valle l, ansaldi f, et al. measles outbreak in adults in italy. infez med 2011;19:16-9. 18. caseris m, houhou n, longuet p, rioux c, lepeule r, choquet c, et al. french 2010-2011 measles outbreak in adults: report from a parisian teaching hospital. clin microbiol infect 2014;20:o242-4. 19. schoini p, karampitsakos t, avdikou m, athanasopoulou a, tsoukalas g, tzouvelekis a. measles pneumonitis. adv respir med 2019;87:63-7. 20. forni al, schluger nw, roberts rb. severe measles pneumonitis in adults: evaluation of clinical characteristics and therapy with intravenous ribavirin. clin infect dis 1994;19:454-62. çomo n, meta e, qato m, kraja dh, pipero p, fico a. measles, a re-emerging disease in albania: epidemiology and clinical presentations (original research). seejph 2022, posted: 04 february 2022. doi: 10.11576/seejph-5198 p a g e 8 | 8 21. dinh a, fleuret v, hanslik t. liver involvement in adults with measles. int j infect dis 2013;17:e1243-4. 22. laksono bm, grosserichterwagener c, de vries rd, langeveld sag, brem md, van dongen jjm, et al. in vitro measles virus infection of human lymphocyte subsets demonstrates high susceptibility and permissiveness of both naive and memory b cells. j virol 2018;92:e00131-18. 23. okada h, kobune f, sato ta, kohama t, takeuchi y, abe t, et al. extensive lymphopenia due to apoptosis of uninfected lymphocytes in acute measles patients. arch virol 2000;145:905-20. 24. kumar d, sabella c. measles: back again. cleve clin j med 2016;83:340-4. _________________________________________________________________________________________ © 2022 çomo et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. dobe m, sahu m, taklikar c, dutta s. a study on risk perception, cognitive awareness and emotional responses to identify unmet training needs of frontline health care workers (flhcws) for covid-19 containment in india (original research). seejph 2022, posted: 29 october 2022. doi: 10.11576/seejph-5976 p a g e 1 | 10 original research a study on risk perception, cognitive awareness and emotional responses to identify unmet training needs of frontline health care workers for covid-19 containment in india madhumita dobe1, monalisha sahu1, chandrashekhar taklikar1, shibani dutta1 1 all india institute of hygiene and public health, kolkata, india. corresponding author: dr. monalisha sahu address: 110, chittaranjan avenue, kolkata – 700073, india; telephone: +919873927966; e-mail: drmonalisha@outlook.com mailto:drvikaspsm@gmail.com dobe m, sahu m, taklikar c, dutta s. a study on risk perception, cognitive awareness and emotional responses to identify unmet training needs of frontline health care workers (flhcws) for covid-19 containment in india (original research). seejph 2022, posted: 29 october 2022. doi: 10.11576/seejph-5976 p a g e 2 | 10 abstract aim: frontline health care workers (flhcws) are the key workforce in the fight against ongoing covid-19 pandemic. they hail from the community and are responsible for supporting the health system in generating awareness, implementing preventive strategies, contact tracing and isolating potential cases. in their job responsibilities, flhcws thus may perceive heightened risk of exposure to the virus, leading to overwhelming emotional response and psychological distress. the objective of this study was to investigate risk perception, cognitive awareness and emotional responses among flhcws trained to deal with covid 19, to identify unmet needs of this training in india. methods: a cross-sectional study was conducted in a total of 131 frontline workers selected by a multistage sampling process from two states (odisha and himachal pradesh) of india. the flhcws were interviewed personally (when feasible) with the help of a predesigned pretested semi-structured questionnaire. results: the findings suggested that majority (90%) of the flhcws perceived that they are susceptible to ncov-19 infection and 77.1% of flhcws felt high probability of them getting infected with the ncov-19. almost 90% of them responded that it is something they think about all the time and 41% of flhcws admitted that they feel helpless in the situation. about 63% of flhcws perceived that the ncov-19 infection was a severe illness and 35% perceived it to be very severe and life threatening. although most of them had received some unstructured and non-uniform training on preventive measures against covid-19, yet only 38% felt that the knowledge was adequate to protect themselves from the ncov-19 infection. the training sessions lacked psychological component for capacitating them with coping skills to address their emotional and psychological responses. conclusion: the flhcws experienced heightened risk perception and symptoms of emotional distress in significant numbers even after trainings. a more inclusive public health policy dialogue to address the emotional and psychological coping skills is needed for capacitation of these frontline workers to address the challenges of pandemic response now and in future. keywords: capacity building, covid-19, emotional response, flhcws, pandemic, social support. conflicts of interests: none declared. acknowledgments: we would like to thank all participants to our study, whose time is even more precious in this difficult situation for all the country, who participated. dobe m, sahu m, taklikar c, dutta s. a study on risk perception, cognitive awareness and emotional responses to identify unmet training needs of frontline health care workers (flhcws) for covid-19 containment in india (original research). seejph 2022, posted: 29 october 2022. doi: 10.11576/seejph-5976 p a g e 3 | 10 introduction the novel coronavirus 2019 (ncov-19) pandemic has caught the health systems off-guard and countries are struggling to control the galloping rates of transmission (1). the role of frontline health care workers (flhcw) in generating awareness and promoting preventive methods to limit further transmission of ncov-19 in the communities is critical. with 13,36,861 confirmed cases and 31,358 total deaths, india presently has the third highest number of confirmed ncov19 cases and the eighth highest number of deaths due to ncov-19 worldwide (2). the government of india has launched a massive operation to engage lakhs of flhcws in form of accredited social health activists (ashas) to contain the spread of ncov-19 in the rural areas of different states of the country (3). they serve as an important link between community and the health facilities and are particularly indispensable to reach out to populations in remote and rural parts of india for dealing the ncov-19 pandemic. the job responsibilities of flhcws fighting ncov-19 in india involves (4):  generating awareness in the community through inter-personal communication about (a) uptake of preventive and control measures including regular handwashing, practicing respiratory hygiene, maintaining social distance (b) addressing myths and misconceptions;  supporting auxiliary nurse midwives (anms)/supervisor in house-to-house active surveillance and contact tracing including (a) identification of hrg, probable cases and their contacts;  mobilizing community to ensure uptake of medical services in urban and rural areas; and  reporting and providing feedback across different phases of ncov-19 pandemic (number of cases, imported/sporadic cases, clusters and community wide transmission). in their line of duties, many flhcws had to work for longer hours with personal protective equipment (ppe) on and survey around 30 to 50 houses in a day depending on the risk levels of the area. due to ‘corona phobia’, they were often encountering stigma and physical violence during their home-to-home surveys (5). there is great fear regarding personal wellbeing secondary to community transmission of the disease. this may result in overreaction, and plethora of other psychological manifestations like excessive worry, fear of infection and death and feeling of helplessness etc. psychological preparedness of flhcws, their cognitive awareness and coping for emotional responses in these situations, have compelling relevance during this pandemic (6). perspectives on emotional and psychological preparedness especially the needs of specific populations like flhcws while working for ncov-19 are sparse. this study was conducted with the following objectives:  to assess the gaps in risk perceptions, cognitive awareness and capacity for coping with emotional responses in their job responsibilities during covid 19 pandemic;  to identify unmet needs for training and various challenges flhcws face while working in the community for covid-19 containment. methods a cross-sectional study was carried out from april 2020–june 2020 at selected 15 districts from the eastern state of odisha and northern city of himachal pradesh in india. a multistage sampling scheme was followed. the required sample size was calculated as 122 considering prevalence of dobe m, sahu m, taklikar c, dutta s. a study on risk perception, cognitive awareness and emotional responses to identify unmet training needs of frontline health care workers (flhcws) for covid-19 containment in india (original research). seejph 2022, posted: 29 october 2022. doi: 10.11576/seejph-5976 p a g e 4 | 10 fear as 80% (as quoted from another study conducted in india by parikh et al) at 10% error level and considering design effect as 2. adjusting for non-response additional 10% sample size was added to 122 making the total sample size as 134. however, three of the responses were incomplete and were omitted and finally 131 responses were included in the study. in the first stage purposive selection of districts were done to select 13 districts from odisha (puri, gajapati, keonjhar, kendrapara, jagatsinghpur, cuttack, angul, bhadrak, balasore, mayurbhanj, sambalpur, sundargarh, sonepur) and 2 districts from himachal pradesh (mandi, kangda). in the second stage fifteen health centers (14 phc and 1 chc) from each district were selected by using simple random selection technique. list of flhcw was prepared working under these centers. in the third stage the sample of 131 flhcws were randomly selected from the list and interviewed in person (when feasible) or over telephone, using a predesigned pretested semi-structured interview schedule consisting of 34 items. written informed consent was taken prior to the interviews. confidentiality and anonymity of the respondents was maintained throughout the study. data was analysed using microsoft excel and spss ver. 20. appropriate statistical tests of significance were applied as necessary. the data were analysed using descriptive and inferential statistics. results sociodemographic profile of flhcws nearly half (52%) of the flhcws were between the age group of 21-40 years old. majority of them (70%) were educated up to matric or higher level. most of them were trained for covid-19 (table 1). table 1. distribution of the flhcws according to the sociodemographic profile and training status (n=131) socio-demographic characteristics number percent age (in yrs.) 21 – 30 07 5.34 31 – 40 61 46.56 41 – 50 58 44.28 51 – 60 05 3.82 educational qualification primary 1 0.77 upper primary 39 29.78 matric 56 42.74 higher secondary 22 16.79 graduation 13 9.92 training trained 125 95.5 untrained 6 4.5 perception of risk: majority (90%) of the flhcws felt that they are susceptible to ncov-19 infection. 58% of them expressed that despite having knowledge about preventive measures it is difficult for them to avoid acquiring the infection. most of the dobe m, sahu m, taklikar c, dutta s. a study on risk perception, cognitive awareness and emotional responses to identify unmet training needs of frontline health care workers (flhcws) for covid-19 containment in india (original research). seejph 2022, posted: 29 october 2022. doi: 10.11576/seejph-5976 p a g e 5 | 10 flhcws (77.1%) felt that probability of them getting infected with the ncov-19 is likely or extremely likely. perception of severity: 63% of them feared that ncov-19 infection causes severe illness and 35% perceived it to be very severe and life threatening. table 2. distribution of flhcws according to their knowledge and risk perception (n=131) knowledge and risk perception no. flhcws % knowledge of protective measures against ncov-19 not at all 0 0.0 inadequate/some 80 61.1 adequate 51 38.9 perception regarding possibility of avoiding ncov infection extremely difficult 3 2.3 difficult 74 56.5 easy 43 32.8 extremely easy 11 8.4 total 131 100 perception of susceptibility to ncov-19 infection not at all susceptible 14 10.7 susceptible 67 51.1 very susceptible 50 38.2 perception regarding possibility of getting themselves infected with the ncov-19 extremely unlikely 1 0.8 unlikely 29 22.1 likely 83 63.4 extremely likely 18 13.7 perception about severity of ncov-19 infection not severe 2 1.5 severe 84 63.1 6 very severe and life threatening 47 35.3 4 cognitive awareness regarding effectiveness of various preventive measures and the ease of practicing them [figure 1]: cognitive awareness is the most important part of decision making and practicing a particular behaviour. when asked about their perceptions regarding the protective measures against ncov-19 infection, most of the flhcws (61.1%) reported that they have some knowledge about how to protect themselves from ncov-19 but only 38% dobe m, sahu m, taklikar c, dutta s. a study on risk perception, cognitive awareness and emotional responses to identify unmet training needs of frontline health care workers (flhcws) for covid-19 containment in india (original research). seejph 2022, posted: 29 october 2022. doi: 10.11576/seejph-5976 p a g e 6 | 10 believed that the knowledge was adequate to protect themselves from the ncov-19 infection. when asked to rank the preventive measures based on their effectivity, majority (74.8%) of the flhcws responded that washing hands frequently with soap and water was the most effective way to avoid infection followed by social distancing. very few of them mentioned measures like staying at home, registering names in govt. portals like ‘arogya setu’, using gloves and not spitting in public place as preventive measures that are important in preventing spread of ncov-19. (table 3). on applying chi-square test those who were educated up to higher secondary and above had significantly better knowledge of protective measures against ncov-19 (chi=79.56 p<0.01). their perception regarding possibility of getting themselves infected with the ncov-19 was that chances of getting infected was low if preventive measures were practised properly (chi=6.64 p<0.05). figure 1. distribution of ashas according to their cognitive awareness of preventive measures to limit spread of covid-19 infection on questioning about their ease to practice preventive measures like washing hands and wearing masks, few (1.5%) of the flhcws said that wearing mask always was very inconvenient. 46% of them reported feeling uneasy and suffocated while wearing mask all the time. some flhcws (22.1%) felt inconvenient to maintain social distancing while others (10%) found washing hands frequently with soap and water very inconvenient. capacity for coping with emotional responses in covid 19 pandemic work when asked about their emotional response to ncov-19 infection, almost all of them (99%) answered that they feel worried about the possibility of acquiring ncov-19 dobe m, sahu m, taklikar c, dutta s. a study on risk perception, cognitive awareness and emotional responses to identify unmet training needs of frontline health care workers (flhcws) for covid-19 containment in india (original research). seejph 2022, posted: 29 october 2022. doi: 10.11576/seejph-5976 p a g e 7 | 10 infection. 94% of them said that ncov-19 is causing a lot of fear amongst them. 90% of them also responded that it is something they think about all the time and 41% of flhcws admitted that they feel helpless because of ncov-19. 22% of flhcws admitted that they search for information about ncov-19 more than 10 times a day. most of them (64% reported checking covid related information more than 10 times a day due to worry. 42% of the respondents said that getting infected due to their job responsibilities, was a major concern to them; some others (5.3%) reported non availability of sufficient ppe kits as a major concern. however, 59% of flhcws felt that ncov19 infection could be combatted through their own practices. figure 2. perceptions of flhcws about ncov-19 infection and emotional response towards it (n=131) on probing about other challenges faced while doing active surveillance in the community, more than half of the flhcws reported that the stigma against the virus has also set off a chain of harassment against them, further demolishing their morale. anxieties of their family members over their possibility of getting infected and transmitting it to others in the household also affected their attitude towards work. some of them also reported feeling lonely and depressed when they stayed isolated at home due to the compulsion of maintaining physical distancing from their friends, relatives and family members. identified unmet needs for training of flhcws for effectively addressing these gaps: for performing covid-19 related work, almost 96.2% of the flhcws had received some training regarding covid-19. however, most of them said that the training sessions were unstructured and not uniform. also, the training session lacked psychological component for capacitating them with coping skills to address the psychological responses. discussion in a similar study for risk perception assessment of covid-19 among portuguese healthcare professionals (hcps) it was found that 54.9% of hcps believed there was a high probability of becoming infected. regarding the likelihood of family and friends becoming infected, about 60% of them felt there was dobe m, sahu m, taklikar c, dutta s. a study on risk perception, cognitive awareness and emotional responses to identify unmet training needs of frontline health care workers (flhcws) for covid-19 containment in india (original research). seejph 2022, posted: 29 october 2022. doi: 10.11576/seejph-5976 p a g e 8 | 10 a “moderate” probability. regarding the perceived effectiveness of the quarantine measures, more than 70% believing it to be “very effective”. most participants (60.0%) had the opinion that communication from the health authorities was “moderately adequate”. when asked about health services' preparations to manage this pandemic, 63.5% of the hcps responded to be “poorly prepared” (7). in another study conducted in italy it was found that health workers reported higher risk perception, level of worry, and knowledge as related to covid-19 infection compared to general population. psychological state, gender, and living area were found to be important predictors of these factors. instead, judgments about behaviours and containment rules were more linked to demographics, such as gender and alcohol consumption (8). in a questionnaire-based on-line survey taken by a total of 744 healthcare personnel (mostly indian) about 80% of the healthcare professionals were worried about being infected. almost 98% of healthcare professional, identified ‘difficulty in breathing” as the main symptom and more than 90% of the respondents knew and practiced different precautionary measures. a minority of the respondents (28.9%) knew that there was no known cure yet. almost all respondents from both the groups agreed on seeking medical help if breathing difficulty is involved and selfquarantine if required (9). in another cross-sectional, web-based study conducted among 529 hcws in iran, it was seen that a significant proportion of hcws had poor knowledge of its transmission (61%) and symptom onset (63.6%) but showed positive perceptions of covid-19 prevention and control. factors such as age and profession were associated with inadequate knowledge and poor perception of covid-19 (10). a cross-sectional study was performed between january 2020 and february 2020 at district hospital, ho chi minh city in 327 healthcare workers showed good knowledge with approximately two thirds of the participants well aware about the mode of transmission, isolation period and modalities of treatment and held positive attitude regarding the risk of personal and family members getting illness. there was a negative correlation between knowledge scores and attitude scores (r=-0.21, p<0.001) (11). an online cross-sectional study undertaken in a teaching hospitals (muths) in uganda through whatsapp messenger among hcws reported that hcws had sufficient knowledge, 21% (n = 29) had positive attitude, and 74% (n = 101) were following good practices toward covid19. factors associated with good practices were age 40 years or more (aor: 48.4; 95% ci: 3.1–742.9; p = 0.005) and holding a diploma (aor: 18.4; 95% ci: 1–322.9; p = 0.046) (12). findings from an online survey-based study conducted among healthcare professionals in pakistan showed hcps have good knowledge (93.2%, n=386), positive attitude and good practice regarding covid-19. hcps perceived that limited infection control material and poor knowledge regarding transmission of covid-19 are the major barriers in infection control practice. factors such as age, experience and job were significantly associated with good knowledge and practice. conclusion risk perception and fear of vulnerability to covid 19 was high among the flhcws leading to a greater chance of flhcws being unwilling to participate actively in the programs for response to pandemics in future. flhcws need to be better trained with substantial emphasis on emotional and mental wellbeing and should be provided with all the essential commodities particularly sufficient personal protective equipment, to conduct active surveillance safely. emphasis is needed during training dobe m, sahu m, taklikar c, dutta s. a study on risk perception, cognitive awareness and emotional responses to identify unmet training needs of frontline health care workers (flhcws) for covid-19 containment in india (original research). seejph 2022, posted: 29 october 2022. doi: 10.11576/seejph-5976 p a g e 9 | 10 to build capacity emotional and psychological coping skills for reducing emotional and psychological distress of flhcws deployed for work during pandemics. the community also need to be better informed and motivated to avoid stigmatization and harassment of the flhcws. references 1. world health organization. coronavirus disease 2019 (covid-19) situation report – 98. who; 2020. available from: https://www.who.int/docs/defaultsource/coronaviruse/situationreports/20200427-sitrep-98-covid19.pdf?sfvrsn=90323472 (accessed: april 28, 2020). 2. world health organization. novel coronavirus disease 2019 (covid-19) situation update report – 26. who; 2020. available from: https://www.who.int/docs/defaultsource/wrindia/situationreport/india-situation-report26.pdf?sfvrsn=a292c9c5_2 (accessed: april 28, 2020). 3. ministry of health and family welfare. covid 19-india. available from: https://www.mohfw.gov.in/ (accessed: april 28, 2020). 4. ministry of health and family welfare. covid-19 book of five response and containment measures for anm, asha, aww. available from: https://www.mohfw.gov.in/p df/3pocketbookof5_covid19_27m arch.pdf (accessed: april 28, 2020). 5. direct relief. the million women working on india’s covid-19 frontlines. available from: https://www.directrelief.org/2020/0 5/the-million-women-working-onindias-covid-19-frontlines/ (accessed: april 28, 2020). 6. aven t, bouder f. the covid-19 pandemic: how can risk science help?. j risk res 2020;23:849-54. 7. peres d, monteiro j, almeida ma, ladeira r. risk perception of covid-19 among portuguese healthcare professionals and the general population. j hospi infect 2020;105:434-7. 8. simione l, gnagnarella c. differences between health workers and general population in risk perception, behaviors, and psychological distress related to covid-19 spread in italy. front psychol 2020;11:2166. 9. parikh pa, shah bv, phatak ag, vadnerkar ac, uttekar s, thacker n, et al. covid-19 pandemic: knowledge and perceptions of the public and healthcare professionals. cureus 2020;12. 10. bhagavathula as, aldhaleei wa, rahmani j, mahabadi ma, bandari dk. knowledge and perceptions of covid-19 among health care workers: cross-sectional study. jmir public health surveill 2020;6:e19160. 11. giao h, thi n, han n, khanh tv, ngan vk, tam v. knowledge and attitude toward covid-19 among healthcare workers at knowledge and attitude toward covid-19 among healthcare workers at district 2 hospital, ho chi minh city. asian pac j trop med 2020;13:260-5. 12. olum r, chekwech g, wekha g, nassozi dr, bongomin f. coronavirus disease-2019: knowledge, attitude, and practices of health care workers at makerere university teaching hospitals, uganda. front public health 2020;8:181. https://www.who.int/docs/default-source/wrindia/situation-report/india-situation-report-26.pdf?sfvrsn=a292c9c5_2 https://www.who.int/docs/default-source/wrindia/situation-report/india-situation-report-26.pdf?sfvrsn=a292c9c5_2 https://www.who.int/docs/default-source/wrindia/situation-report/india-situation-report-26.pdf?sfvrsn=a292c9c5_2 https://www.who.int/docs/default-source/wrindia/situation-report/india-situation-report-26.pdf?sfvrsn=a292c9c5_2 dobe m, sahu m, taklikar c, dutta s. a study on risk perception, cognitive awareness and emotional responses to identify unmet training needs of frontline health care workers (flhcws) for covid-19 containment in india (original research). seejph 2022, posted: 29 october 2022. doi: 10.11576/seejph-5976 p a g e 10 | 10 13. saqlain m, munir mm, rehman su, gulzar a, naz s, ahmed z, et al. knowledge, attitude and practice among healthcare professionals regarding covid19: a cross-sectional survey from pakistan. j hosp infect 2020. available from: https://www.medrxiv.org/content/1 0.1101/2020.04.13.20063198v1.ful l.pdf 14. (accessed: april 28, 2020). __________________________________________________________________________________________ © 2022 dobe et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.medrxiv.org/content/10.1101/2020.04.13.20063198v1.full.pdf https://www.medrxiv.org/content/10.1101/2020.04.13.20063198v1.full.pdf https://www.medrxiv.org/content/10.1101/2020.04.13.20063198v1.full.pdf nurse j. the interaction council (commentaries). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5480 commentaries the interaction council joanna nurse1 corresponding author: 1dr joanna nurse: drjonurse@gmail.com nurse j. the interaction council (commentaries). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5480 © 2022 nurse; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. the interaction council held two highlevel expert meetings in march and april 2022 on “risks and solutions to global security: from the pandemic to future health threats.” https://www.interactioncouncil.org/mediacentre/strengthening-global-securitythrough-lessons-pandemic. these meetings brought together a wide range of senior leaders and experts committed to working together to find solutions for a safe end to the pandemic, as well as strengthening global security for our future. the overall aim of these meetings was to advance recommendations made by the council members during a meeting on the pandemic in december 2021. “the extreme threats posed by our planetary emergency and the pandemic, further exacerbated by the conflict in ukraine, challenge us to re-think our multilateral global security architecture to ensure that it is fit for our future wellbeing,” said bertie ahern, former prime minister of ireland and chair of the meetings. high-level updates were provided on the independent panel for pandemic preparedness and response report, and the global preparedness monitoring board, with a summary of an integrated approach to peace and human security in the 21st century. leaders commented on systemic failures combining with the wider impacts of the pandemic, and the complex interaction with other global security challenges. they reflected on potential solutions to strengthen international governance mechanisms for global goods for the right to health, including approaches to advance the concept of a global health threats council. aside from future health threats, the risk of continued pandemics emerging from new variants of covid-19 was acknowledged. experts shared experiences of successful pandemic responses, ranging from community based to global solutions and legislation to increase access to vaccines. the meeting reconvened in april to hear more about the potential solutions, including the need to finance and modernise public health systems and access to universal health coverage as an essential part of global health security. further opportunities were presented on the potential role of digital transformation for enhancing global security, including the platform for planet place and people (p4ppp). discussions recognized the significance of enhancing financing and governance systems to reinforce the existing un infrastructure including the who. furthermore, it was recognized that the design of global security mechanisms needs to incorporate health threats in order to coordinate rapid responses for emerging risks and to prevent further pandemics. learning from this pandemic has the potential to be applied to enhance our existing global security infrastructure to address our increasingly complex and interconnected challenges. approaches were explored to advance the council’s earlier recommendations, including the proposal of a taskforce with a particular focus on global governance for global health security. this initiative builds upon the dublin charter for one health and has been informed by the report: ending the pandemic – enhancing global security for people and planet, a framework for the future. we welcome further engagement with partners to advance this initiative going forward. please contact our advisor: dr joanna nurse: drjonurse@gmail.com __________________________________________________________________________________________ https://www.interactioncouncil.org/media-centre/strengthening-global-security-through-lessons-pandemic https://www.interactioncouncil.org/media-centre/strengthening-global-security-through-lessons-pandemic https://www.interactioncouncil.org/media-centre/strengthening-global-security-through-lessons-pandemic https://www.interactioncouncil.org/index.php/media-centre/omicron-shows-vaccine-inequality-must-end-says-bertie-ahern-co-chair-interaction https://www.interactioncouncil.org/index.php/media-centre/omicron-shows-vaccine-inequality-must-end-says-bertie-ahern-co-chair-interaction https://www.interactioncouncil.org/index.php/media-centre/omicron-shows-vaccine-inequality-must-end-says-bertie-ahern-co-chair-interaction https://sites.google.com/view/p4ppp/ https://sites.google.com/view/p4ppp/ https://www.interactioncouncil.org/publications/dublin-charter-one-health https://www.interactioncouncil.org/publications/dublin-charter-one-health https://www.interactioncouncil.org/sites/default/files/pandemic%20exit%20strategy%20reduced.pdf https://www.interactioncouncil.org/sites/default/files/pandemic%20exit%20strategy%20reduced.pdf https://www.interactioncouncil.org/sites/default/files/pandemic%20exit%20strategy%20reduced.pdf böbel s., bormans m., siepmann i., tirekidis i., wall k., kalaitzi v. diverse and inclusive leadership teams in public health schools: the change agents for sustainable and inclusive public health education (policy brief). seejph 2021, posted:18 august 2021. doi: 10.11576/seejph-4682 p a g e 1 | 11 policy brief diverse and inclusive leadership teams in public health schools: the change agents for sustainable and inclusive public health education simone böbel1, max bormans1, ines siepmann1, ilia tirekidis1, kristin wall1, valia kalaitzi1 1faculty of health, medicine, and life sciences, maastricht university, the netherlands corresponding author: max bormans (mlma.bormans@student.maastrichtuniversity.nl), duboisdomain 30, 6229 gt, maastricht, the netherlands böbel s., bormans m., siepmann i., tirekidis i., wall k., kalaitzi v. diverse and inclusive leadership teams in public health schools: the change agents for sustainable and inclusive public health education (policy brief). seejph 2021, posted:18 august 2021. doi: 10.11576/seejph-4682 p a g e 2 | 11 abstract context: an inclusive and diverse public health workforce maximizes health outcomes. however, little is known about the current diversity and inclusiveness profile of professionals, leaders and students of public health. to obtain a diverse and inclusive (d&i) public health workforce in the future, d&i leadership in public health schools is necessary to encourage a d&i student body. policy options: a variety of policy responses can be utilized to diversify schools of public health (sph). response types include (i) exploratory policies that instigate d&i research with the aim to increase knowledge and build hypotheses, (ii) regulatory (and financial) policies that change the environment by placing rules, restrictions, or expectations on the institution to increase and promote d&i and (iii) soft options, which are non-binding actions that aim to change the institutional culture surrounding d&i. however, policies are often not specifically tailored to their school and are therefore unsuccessful. recommendations: to understand the composition and identify gaps within the current diversity and inclusion (d&i) profile of leadership in european schools of public health (sph) an exploratory needs assessment is advised. a baseline assessment will be the much needed first step of this paper’s proposed project: the diverse and inclusive public health schools (diphs) project. a needs assessment should be seen as a baseline evaluation of the current d&i profile among leaders in european schools of public health (sph). this information should then build the basis to encourage institution-tailored policy interventions for sph to actively promote a diverse and inclusive public health workforce. keywords: diversity, inclusion, leadership, public health education, european schools of public health acknowledgments: we thank valia kalaitzi, our senior advisor, and kasia czabanowska for their thoughtful feedback. authors’ contributions: all authors contributed equally to this work. source of funding: none declared böbel s., bormans m., siepmann i., tirekidis i., wall k., kalaitzi v. diverse and inclusive leadership teams in public health schools: the change agents for sustainable and inclusive public health education (policy brief). seejph 2021, posted:18 august 2021. doi: 10.11576/seejph-4682 p a g e 3 | 11 introduction the importance of diversity workforce diversity is defined as the ‘similarities and differences among employees in terms of age, cultural background, physical abilities and disabilities, race, religion, gender, and sexual orientation’ (saxena, 2014, p. 76). inclusion means that people from a variety of backgrounds have power, a voice, and decision-making authority (kim, 2019). a diverse and inclusive workforce is an essential part of any organisation, particularly in the sectors of public health and healthcare, as it may improve project outcomes (cohen, gabriel, & terrell, 2002; saxena, 2014). improvements become visible in examples such as more appropriate program implementations among culturally diverse communities, a better understanding of inequalities in minority populations, and enrichment of attitudes, viewpoints, and experience among public health practitioners (coronado et al., 2019). diversity provokes critical thinking, promotes higher-quality work, and increases the likelihood of obtaining grants and funding for organisations (phillips, 2014; kalina, 2018). beyond quality improvements, diversity also leads to financial gains: organisations in the highest quartile of diversity are 35% more likely to generate above average financial returns. further, an increase of gender and ethnicity diversity in leadership positions by 10% resulted in an increase of up to 3,5% in earnings before interest and taxes (hunt, layton, & prince, 2015). therefore, to strengthen public health outcomes, the workforce should be diverse and inclusive. achieving this must already begin with diversifying education. thus, public health schools must optimize diversity and inclusion (d&i) in their student cohort and staff, including and prioritizing diverse leadership. schools of public health (sph) are herein defined as universities with faculties of public health. educating and promoting diverse leadership is essential in tackling emerging diverse health problems, as d&i programmes rely fundamentally on active and engaging leaders (bjegovic-mikanovic et al., 2014; european public health association, 2018, dreachslin, 2007). the need for diverse leadership is clear, and impacting these leaders requires an understanding of how diverse leadership roles are established. the sph diversity environment is cyclical: more diverse leadership invites and builds a more diverse student cohort, who then become the future leaders of public health. organisations where d&i leaders are present will function more efficiently and produce better outcomes for both the impacted community and the staff. context the knowledge gap the level of d&i currently present in sph leadership is unknown. there is limited data on this subject, despite routine calls for increased diversity (wandschneider, 2020). this gap in information prevents targeted action. the november 2019 report “diversity, equity and inclusion in european higher education institutions” surveyed 159 european institutions of higher education and found that the percentage of institutions that collected data on various diversity demographics, such as socio-economic background and cultural background, was below 50%. the only demographics for which over 50% of the institutions collected data were age and gender (table 1, claeys-kulik et al., 2019). böbel s., bormans m., siepmann i., tirekidis i., wall k., kalaitzi v. diverse and inclusive leadership teams in public health schools: the change agents for sustainable and inclusive public health education (policy brief). seejph 2021, posted:18 august 2021. doi: 10.11576/seejph-4682 p a g e 4 | 11 table 1: percent of 159 european higher education institutions collecting diversity data about profile of students or academic staff (claeys-kulik et. al, 2019) students (%) academic staff (%) gender 88 83 age 72 68 disability 60 49 educational background 57 40 socio-economic background 35 7 ethnic/cultural background 28 19 migration background 27 14 caring responsibilities 14 14 sexual identity (including lgbt+) 9 9 religious background/belief 8 11 we do not collect any of these data in a systematic way 4 4 i do not know 1 1 stakeholders effectively changing the d&i profile of sph requires multidisciplinary engagement. first and foremost, the schools must be willing to fill the knowledge gap on their leadership profile and recognize a need for more diversity. students and staff have the power to demand this, and play a crucial role in the implementation of both a needs assessment and following diversification measures (neumann, 2018). non-governmental organizations, such as the world health organization (who), the international association of national public health institutes, and the association of schools of public health in the european region (aspher), as well as governmental institutions such as the ministries of health and education, will continue to play fundamental supporting and guiding roles. these organizations can help create educational frameworks, define core competencies for public health that include diversity and leadership, and encourage best practice measures. public and private research groups can guide the needs assessment process, as well as assist in identifying methods for improvement. the media will impact the conversation, with the potential of mobilizing support, and either encouraging or pushing against the proposed d&i objectives (institute of medicine, 2002). potential opposition may arise from current leadership, lawmakers, and academic boards that either 1) do not agree with the need for diversity and inclusion, 2) feel attacked, undervalued, or misrepresented by the demands for change, or 3) do not support the resources necessary to enact change. this can be addressed through clear information dissemination about the goals and future outcomes of diversifying leadership -namely, it is proven to improve quality, quantity, and financial feasibility of outputs (phillips, 2014). policy options policies on d&i already exist in most organizations. however, many d&i policies are unsuccessful as they are nonspecific to their targets and act as ‘political placeholders’ (dobbin & kalev, 2016; llopis, 2017). typically, the following policy pathways are used to enhance d&i efforts among professionals: böbel s., bormans m., siepmann i., tirekidis i., wall k., kalaitzi v. diverse and inclusive leadership teams in public health schools: the change agents for sustainable and inclusive public health education (policy brief). seejph 2021, posted:18 august 2021. doi: 10.11576/seejph-4682 p a g e 5 | 11 (i) exploratory policies that instigate d&i research and aim to increase knowledge and build hypotheses about the relevant d&i environment, (ii) regulatory policies, with the subset of (iii) financing policies, which change the environment by placing rules, restrictions, or expectations on the institution to increase and promote diversity. these policies are vital as they are thought to be the most effective strategy for increasing diversity by setting up structures that assign organizational responsibility and accountability for change (kalev et al., 2006).; (iv) finally, soft options, which are non-binding actions with the aim to change the institutional culture surrounding d&i. for these policies to be successful, the specific needs of an organization must be known. it is thus necessary to conduct an exploratory needs assessment to gain insight and understanding about the sph leadership profile. needs assessments play an important role in both education and training (grant et al., 2002). to maintain a competent workforce, it is important to assess the gaps in the available skills and knowledge, as well as identify the available training (joly et al., 2018). this will provide data on the current environment and highlight possible barriers to d&i integration among sph leaders. therefore, needs assessment is a much needed baseline-evaluation of d&i at an institution-level. needs assessments are one of the key tools to ensure health equity and improved care, but this is only the first step to increasing d&i culture. therefore, a project is proposed to integrate d&i among leaders of public health: figure 1. proposed diphs (diversity and inclusion in public health schools) project cycle the diverse and inclusive public health schools (diphs) project (figure 1) aims to recognize the need for and build a diverse and inclusive leadership cohort within european schools of public health. the diphs project can identify d&i gaps and create the necessary change through targettailored policy options. it begins with the relatively simple but often forgotten step of assessing the needs of each school. barriers beyond the potential lack of stakeholder böbel s., bormans m., siepmann i., tirekidis i., wall k., kalaitzi v. diverse and inclusive leadership teams in public health schools: the change agents for sustainable and inclusive public health education (policy brief). seejph 2021, posted:18 august 2021. doi: 10.11576/seejph-4682 p a g e 6 | 11 investment include lack of resources for the proposed project, potentially high nonresponse rates, and the difficulty in bridging the gap between theory/ knowledge and practice. therefore, while this policy brief focuses on the first stage of the diphs project, the needs assessment, it continually reinforces the need for further action within the scope of the same project and participants. it aims to prevent a diffusion of responsibility amongst participants. addressing lack of investment and resources will require a cultural-level approach: if large scale groups, such as aspher and the who, show their support for the project, they can encourage individual schools to participate. sph networks could discuss adding an accreditation or award for participating and for making d&i improvements. additional benefits and rewards, including reputation, publications, and inclusion at conferences, may also be useful. these incentives will aid in overcoming the structural and cultural barriers including (unintentional) racism and sexism to support sph in their assessment and diversification process. recommendations the first stage of the proposed diphs is the needs assessment to understand the gaps within the current diversity profile of leadership. for this, key stakeholders will be engaged, experts and literature will be further analysed, and the assessment design process will begin. needs assessment can be done at varying levels: by institution, region, or even more broadly, and can be administered through self-assessment questionnaires based on specific constituents and observations (grant, 2002, joly et al., 2018). a robust, standardized survey must be conducted with all willing european schools of public health. the results will be analysed at the european, national, and school-specific levels. the initial phases of the diphs project will be completed within two years (appendix a). having a clear understanding of sph leadership profile is the crucial first step, and thus the exclusive focus of this first policy brief. however, it is important to not just identify an area in urgent need of improvement but further act upon it. therefore, this proposed project introduces the long-term goal of encouraging specifically tailored policy responses for individual sphs that are based on their respective needs assessment outcomes. practical examples for potential policy pathways can be found in appendix b. conclusion there is little information on the d&i profiles of the leaders in sph in europe. however, there is undeniable evidence on the benefits of a diverse and inclusive workforce, particularly for a field such as public health that aims to provide equitable care for all, including vulnerable communities. an inclusive and diverse leadership profile can enact change at sph through d&i education and representation, thus building a more aware and diverse cohort of future public health professionals. therefore, this policy brief recommends sphs to conduct needs assessments to explore the degree of d&i among leaders of sphs and, if necessary, encourage further steps to improve diversity and inclusion among public health leaders. references 1. bjegovic-mikanovic, v., czabanowska, k., flahault, a., otok, r., shortell, s., wisbaum, w., & laaser, u. (2014). addressing needs in the public health workforce in europe (10). retrieved from https://www.euro.who.int/__data/as böbel s., bormans m., siepmann i., tirekidis i., wall k., kalaitzi v. diverse and inclusive leadership teams in public health schools: the change agents for sustainable and inclusive public health education (policy brief). seejph 2021, posted:18 august 2021. doi: 10.11576/seejph-4682 p a g e 7 | 11 sets/pdf_file/0003/248304/address ing-needs-in-the-public-healthworkforce-in-europe.pdf?ua=1 2. claeys-kulik, a.-l., jørgensen, t. e., stöber, h. (2019). diversity, equity and inclusion in european higher education institutions. retrieved november 10, 2020 from: https://eua.eu/downloads/publicatio ns/web_diversity%20equity%20an d%20inclusion%20in%20european %20higher%20education%20instit utions.pdf 3. cohen, j. j., gabriel, b. a., & terrell, c. 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(2002). the future of the public's health in the 21st century. washington (dc): national academies press (us); . 7, media. https://eua.eu/downloads/publications/web_diversity%20equity%20and%20inclusion https://eua.eu/downloads/publications/web_diversity%20equity%20and%20inclusion https://eua.eu/downloads/publications/web_diversity%20equity%20and%20inclusion https://doi.org/10.1377/hlthaff.21.5.90 https://doi.org/10.1377/hlthaff.21.5.90 https://ec.europa.eu/programmes/erasmus-plus/programme-guide/part-b/three-key-actions/key-action-1/mobility-higher-education-students-staff_en https://ec.europa.eu/programmes/erasmus-plus/programme-guide/part-b/three-key-actions/key-action-1/mobility-higher-education-students-staff_en https://ec.europa.eu/programmes/erasmus-plus/programme-guide/part-b/three-key-actions/key-action-1/mobility-higher-education-students-staff_en https://ec.europa.eu/programmes/erasmus-plus/programme-guide/part-b/three-key-actions/key-action-1/mobility-higher-education-students-staff_en https://ec.europa.eu/programmes/erasmus-plus/programme-guide/part-b/three-key-actions/key-action-1/mobility-higher-education-students-staff_en böbel s., bormans m., siepmann i., tirekidis i., wall k., kalaitzi v. diverse and inclusive leadership teams in public health schools: the change agents for sustainable and inclusive public health education (policy brief). seejph 2021, posted:18 august 2021. doi: 10.11576/seejph-4682 p a g e 8 | 11 available from: https://www.ncbi.nlm.nih.gov/book s/nbk221224/ 13. joly, b. m., coronado, f., bickford, b. c., leider, j. p., alford, a., mckeever, j., & harper, e. (2018). a review of public health training needs assessment approaches: opportunities to move forward. journal of public health management and practice, 24(6), 571–577. https://doi.org/10.1097/phh.00000 00000000774 14. kalev, a., dobbin, f., kelly, e. (2006). best practices or best guesses? assessing the efficacy of corporate affirmative action and diversity policies. american sociological review; 71: 589–617 15. kalina, p. (2018). challenges to diversity and inclusion in health care. human resource management research, 8(3), 45– 48. https://doi.org/10.5923/j.hrmr.2018 0803.01 16. kim, s. j. (2019). inclusion by design: insights from design week portland. retrieved december 6, 2020, from gensler website: 17. https://www.gensler.com/researchinsight/blog/inclusion-by-designinsights-from-design-weekportland 18. llopis, g. (2017). 5 reasons diversity and inclusion fails. retrieved december 6, 2020 from: https://www.forbes.com/sites/glenn llopis/2017/01/16/5-reasonsdiversity-and-inclusionfails/?sh=70699ec150df 19. neumann, j. w. (2018). how power really works in schools. phi delta kappan. retrieved from https://kappanonline.org/neumannpower-really-works-schools/ 20. phillips, k. w. (2014). how diversity makes us smarter. scientific american, 311(4), 1–6. 21. roosevelt thomas, r. (1990). from affirmative action to affirming diversity. harvard business review, 68(2), 107–117. 22. saxena, a. (2014). workforce diversity: a key to improve productivity. procedia economics and finance, 11(14), 76–85. doi: 10.1016/s2212-5671(14)00178-6 23. self, w. t., mitchell, g., mellers, b. a., et al. (2015). balancing fairness and efficiency: the impact of identity-blind and identityconscious accountability on applicant screening. plos one; 10: e0145208 https://www.ncbi.nlm.nih.gov/books/nbk221224/ https://www.ncbi.nlm.nih.gov/books/nbk221224/ https://www.gensler.com/research-insight/blog/inclusion-by-design-insights-from-design-week-portland https://www.gensler.com/research-insight/blog/inclusion-by-design-insights-from-design-week-portland https://www.gensler.com/research-insight/blog/inclusion-by-design-insights-from-design-week-portland https://www.gensler.com/research-insight/blog/inclusion-by-design-insights-from-design-week-portland https://www.forbes.com/sites/glennllopis/2017/01/16/5-reasons-diversity-and-inclusion-fails/?sh=70699ec150df https://www.forbes.com/sites/glennllopis/2017/01/16/5-reasons-diversity-and-inclusion-fails/?sh=70699ec150df https://www.forbes.com/sites/glennllopis/2017/01/16/5-reasons-diversity-and-inclusion-fails/?sh=70699ec150df https://www.forbes.com/sites/glennllopis/2017/01/16/5-reasons-diversity-and-inclusion-fails/?sh=70699ec150df https://kappanonline.org/neumann-power-really-works-schools/ https://kappanonline.org/neumann-power-really-works-schools/ böbel s., bormans m., siepmann i., tirekidis i., wall k., kalaitzi v. diverse and inclusive leadership teams in public health schools: the change agents for sustainable and inclusive public health education (policy brief). seejph 2021, posted:18 august 2021. doi: 10.11576/seejph-4682 p a g e 9 | 11 appendices appendix a. proposed project timeline böbel s., bormans m., siepmann i., tirekidis i., wall k., kalaitzi v. diverse and inclusive leadership teams in public health schools: the change agents for sustainable and inclusive public health education (policy brief). seejph 2021, posted:18 august 2021. doi: 10.11576/seejph-4682 p a g e 10 | 11 appendix b. expanded examples of policy options level of intervention policy action goal evidence (ie, a similar example) i. regulatory options diversity committees & task forces to set up structures that assign organizational responsibility and accountability for change the university of strathclyde (uk) established a central equality, diversity and inclusion committee made up of students and staff. this committee oversees the university’s compliance with its equality and diversity obligations (claeys-kulik et al., 2019). to create a more equitable hiring process by collaborating with hr teams and ensuring standardized applications to recruit employees based on merit one study found that appointing diversity committees and full-time diversity staff raised the proportion of black women in leadership positions by an average of 30 percent and the proportion of black men by 14 percent (kalev et al., 2006). resume blinding to decrease bias and to hire based on individual qualifications rather than demographic factors a study in the u.s.a. compared hiring outcomes between a group of employers who were blind to the identity of applicants, and a group who were not blinded (self et al., 2015). this resulted in an increase in the number of women and people of color hired. targeted recruitment to actively seek and reach out to women and minority groups so there is a large qualified hiring pool freie universität berlin in germany has a formal rule that half of the members of search committees must be female scholars. to recruit a higher proportion of female professors, the university actively seeks female talent under the supervision of gender equality officers (claeys-kulik et al., 2019). ii. financing options individual grants/financial incentives for reaching certain milestones or for individuals to encourage individuals to enter in a study program or to have diversity as the topic for a thesis, phd or research article erasmus+ program for teaching and training grants (european commission, n.d.) rewards or monetary prizes bonus system (financial or nonmaterialistic) to encourage gender equality in research and innovation as well as higher professions for staff who actively promote an appreciative, unprejudiced organizational culture, e.g. through public recognition or prizes such as the eu prize for women innovators (annual recognition prize from the european commission) institutional competitive funding national provision of highly competitive funding to strategically develop universities the excellence initiative in germany where strategic objectives for equity, diversity and inclusion can be part of the application for funding (claeys-kulik et al., 2019). böbel s., bormans m., siepmann i., tirekidis i., wall k., kalaitzi v. diverse and inclusive leadership teams in public health schools: the change agents for sustainable and inclusive public health education (policy brief). seejph 2021, posted:18 august 2021. doi: 10.11576/seejph-4682 p a g e 11 | 11 diversity-related funding diversity-related indicators are part of the performance-based funding system or of performance contracts of institutions with the state in a few cases, there are quotas for students and staff from diverse backgrounds [critics: quotas do not automatically sensitize for an inclusive and diverse community] national mainstreaming of gender equality in national and european research funding programs to bring awareness and encourage equal gender distribution among staff and student body existing funding programs (horizon 2020) by the eu/ec to 104 universities and research organizations have been supported in implementing gender equality action plans through 14 projects with a total eu contribution of €33 million (european commission, 2020) iii. soft options awarenessraising activities diversity reports in the university’s intranet revelation of inequalities and power imbalances in the university and in academic careers the university of padua (italy) published its first annual gender report in 2017 (concerning the year 2016). since then it has conducted yearly monitoring of the indicators that reveal inequalities and power imbalances in the university and in academic careers (claeys-kulik et al., 2019). training of leaders on diversity and lunch and learn with regular keynote speeches on d&i institutional leadership is responsible for allocating resources and establishing structures for related activities “lunch ‘n learn” sessions at pacific blue cross https://accessibleemployers.ca/wpcontent/uploads/mediapress/members/29/88/pc-case-study-di-lunch-n-learns-final.pdf onboarding and promotion internationalisation process open up the university for international students through exchanges, double degree programs or onboarding processes silesian university of technology in opava, poland, an important strategic goal is opening up to international students including from outside europe (claeys-kulik et al., 2019). access & assigned staff barrier-free infrastructure ensuring access to buildings, job offers, documents etc. for disabled and disadvantaged persons and having staff directly responsible for this the london infrastructure group https://www.london.gov.uk/sites/default/files/infrastructure_di.pdf obligation to have gender equality officers to ensure equality in the staff recruitment process the university of osnabrück (germany) with the establishment of the first gender equality officers in 1980/1990s (gleichberechtigung or gleichstellung) and later inclusion of disabled people (claeys-kulik et al., 2019) © 2021 böbel et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. so l. utilising ‘new’ power strategies for public health education in addiction and dependency: learning from social media influencers. (editorial). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5721 editorial utilising ‘new’ power strategies for public health education in addiction and dependency: learning from social media influencers lisa o’rourke scott 1 technological university of the shannon region: midwest corresponding author: dr. lisa o’rourke scott, technological university of the shannon region: midwest e-mail: lisa.orourkescott@tus.ie https://orcid.org/0000-0003-2242-653 so l. utilising ‘new’ power strategies for public health education in addiction and dependency: learning from social media influencers. (editorial). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5721 the traditional goal of work in public health is the promotion of population health (1). within this very broad definition arise debates about the best way to target health behaviours, what is considered important, and who should be the focus of public health interventions. this paper will examine some of the current issues that arise when considering how to combat addiction and dependency though public health interventions in the context of a world dominated by information communication technologies (ict). in particular, it will argue that lessons for public health communication on addiction and dependency can be learned from the growth of anti-vaccination sentiment during the global pandemic and that public health needs to embrace the ‘new’ power of communication to effectively promote healthy behaviours. definitions of what constitutes addiction and dependency vary in different social, cultural, and historical contexts, as well as being contested in varying academic debates about the topic. for example, the diagnostic and statistical manual in the current version dsm-5-tr (march 2022), lists nine types of substance addictions in the category of ‘substance-related and addictive disorders’: alcohol; caffeine; cannabis; hallucinogens; inhalants; opioids; sedatives; hypnotics and anxiolytics; stimulants; and tobacco. the current version has also included gambling under this category. other behaviours such as excessive sexual behaviour, compulsive buying, internet use, or stealing, were not included as addictions because the research was thought to be insufficient (2). there are also debates about models of understanding and how they relate to intervention. for example, the use of the disease model and its impact on personal responsibility; combatting stigma; the biological predisposition model; the possibility of selfmedication for other issues (3-6); the relative influence of peers and family; culture and social expectations; the meaning that various substances and behaviours have in different contexts; and of course sociological explanations relating to social capital, poverty, access to healthcare, and social exclusion (7). all these debates add further complexity to those who wish to reduce addiction and dependency and the associated behaviours. once the definition debate has been negotiated, if a public health initiative is to be designed, it is then necessary to think about what kind of public health intervention is likely to be effective. although public health interventions work best when grounded in theories of behavioural change, there is no real consensus about what motivates behaviour. for example, one scoping review found 82 separate theories of behaviour referenced in public health literature (8). the majority of these focused on individual rather than social determinants. even when we narrow behavioural motivation to the determinants of addiction, the picture remains contested and unclear (9). despite the complexity of variable definitions, understandings of motivations and theories of behavioural change, public health interventions have managed to have some success in reducing unhealthy behaviours (8). work on preventing drinking and driving, for example, has operated at various levels with legal changes, enforcement, and monitoring, alongside campaigns to change how people think about the action of drinking and driving, and this has substantially reduced road deaths across the european union (10). the number of people in ireland who believe that there is no acceptable amount of alcohol that a driver can consume and be safe to drive has so l. utilising ‘new’ power strategies for public health education in addiction and dependency: learning from social media influencers. (editorial). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5721 increased from 61% in 2015 to 73% in 2017 (11). however, in addition to the absence of a clear uncontested understanding of what motivates behaviour and how to change it, there is another issue. as even the most casual observer of advertising campaigns will attest, the mechanisms for behavioural influence vary according to historical context, which is why the methods of communication used by advertisers change over time. at present, a hugely important source of influence is ict. one of the lessons that was learned during the pandemic is health advice and methods of intervention are subject to challenge and distrust. resistance to and refusal of vaccination, for example, has been a growing problem, which escalated substantially during the period of lockdown. perera et al. (12) claim that the greatest influence on this escalation of rejection of public health advice is attributable to social media. they also note that blocking content on one platform will inevitably cause it to move to another, as people who mistrust advice will share contrary information among their own networks. such is the scale of this issue that the world health organisation (who) now lists ‘vaccine hesitation’ as one of the top threats to world health (13). perera et al. argue that ict influence has changed the narratives that are used to position health advice (12). medical power is represented as an ‘old’ power, which is believed by some people to be open to various inaccuracies, dishonesty, corruption, or malice. ‘old’ power is regarded as suspect because it is believed to be part of a system of influence and power from which many feel disenfranchised. social media driven understandings, on the other hand, are perceived as a ‘new’ power. ‘new’ power acknowledges that the powerful use their power and disseminate knowledge to their advantage. it uses different ways to transmit information, most notably peer to peer sharing. this means that certain populations are more likely to trust information from this source. pintado and sánchez (14), suggest that ict social networks engage in two main areas of activity that maintain their influence: the creation of new content and development of social relationships. content is then shared among a social network. one example of the influence of this kind of ‘new’ power is in relation to the circulation of positive marijuana messages, which has been to increase the likelihood of marijuana use among young people exposed to the information (15). leaving aside debates about the veracity or otherwise of information on marijuana, or about abuse of power for the gain of a small elite, what is clear is that internet memes and information are influencing what potentially addictive substances mean to people and how they feel about them. for this reason, garcia del castillo et al. argue that ict should be used for prevention and promotion of health (16). calling for a public health agenda for social media, they argue that preventative promotional material should be disseminated for a range of public healthy lifestyle initiatives, in particular in relation to legal activities such as smoking and alcohol but also for illegal drug use. perera et al. make three suggestions about how we can learn from the so called ‘new’ and use it for health promotion (12). firstly, they argue, we need to create a context rather than specific content. using the example of the growth of anti-vaccination sentiment during the pandemic, they note that despite the disavowal of andrew wakefield’s so l. utilising ‘new’ power strategies for public health education in addiction and dependency: learning from social media influencers. (editorial). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5721 retracted research on mmr vaccinations (17), numerous groups abound on social media that discuss vaccines together (12). wakefield did not organise these groups, but he created the context for their formation. secondly, they suggest we should not attempt to use facts over narratives, as it is counterproductive to pit ‘old’ power against ‘new’ and make people choose between them. their third suggestion is that we spread narratives that resonate with a target audience and will be passed from peer to peer. the idea of counter narratives which challenge power relations are by no means new. for example, shen argues that irving welsh’s 1993 novel and 1996 film trainspotting offered representations of heroin addiction which provided a counter narrative to the individual choice discourses in post thatcherite britain, by representing heroin use as an existential choice (18). it offered a counter explanation for why people become addicted to heroin. furthermore, in the academy there have been sustained critiques of the notion of moral panic (19); the notion that the behaviours of certain people, like for example the young, indulge in substance use and misuse, and are inherently dangerous and are thus the subject of, often unjustifiable, public outrage and concern. moral panic, in this context can be regarded as a tool to justify the eradication of rights of the oppressed by the powerful. a more sustained critique of the ways in which the medical model has obtained and sustained power by the special knowledge it holds and the ability to problematize certain groups has come from foucault (20). this critique which has been extended to what rose (21) describes as the ‘psy’ disciplines. he argues that psychology, psychiatry, psychotherapy and other ‘psy’ disciplines have played a key role in ‘inventing our selves’, changing the ways in which human beings understand and act upon themselves, and how they are acted upon by politicians, managers, doctors, therapists, and a multitude of other authorities. these mutations are intrinsically linked, he claims, to recent changes in ways of understanding and exercising political power. in this tradition using foucault’s genealogical approach, johansen et al. (22), for example, trace the construction of the ‘addict’ in 19th century policy and its relationship to drug reforms and social regulation attempts and argue that the ‘addict’ was brought into being as a result of various forms of social and political power. as sedgwick (23) has observed the addict seems to be a perfect candidate for a list of identities that emerged at the end of the eighteenth century and intensified throughout the nineteenth: the hysterical woman; the malthusian couple; the masturbating child; and the perverse adult. all of these are thus argued to be identities that have been bought into being to regulate and control the populace. furthermore, the medical model itself has been subject to criticism in relation to the validity of the claims it makes when diagnosing illness (24-26). on a more prosaic level, attention has also been drawn to the relationship between academia and the alcohol industry and to who funds research and the implications of this (27), as well as the development of an addictions industry (28). so, while discussion and challenge in relation to the influence of medical power is not a new phenomenon, it has certainly been taken up enthusiastically by users of ict to the extent that ict represents a ‘new’ power that must not be ignored or dismissed when designing public health interventions. those who wish to work so l. utilising ‘new’ power strategies for public health education in addiction and dependency: learning from social media influencers. (editorial). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5721 with reducing dependency and addiction by means of public health education, would be wise to take cognizance of the advice of perera et al and create context rather than content, avoid challenging ‘new’ power with ‘old’ power, and use online peer to peer networks for dissemination (12). references 1. verweij m, dawson a. the meaning of 'public' in 'public health'. in angus dawson & marcel verweij (eds.), ethics, prevention, and public health. oxford: clarendon press; 2007. 2. grant ej, chamberlain rs. (2017). expanding the definition of addiction: dsm-5 vs. icd-11. cns spectrums. 2016;21(4): 300303. doi:10.1017/s1092852916000183 3. berkman lf, glass t. social integration, social networks, social support, and health. in l.f. berkman & i. kawachi (eds.), social epidemiology (pp. 174– 190). new york, ny: oxford university press; 2000. 4. berkman lf, glass t, brissette i, seeman te. from social integration to health: durkheim in the new millennium. social science medicine. 2000;51:843– 857. 5. krieger n. theories for social epidemiology in the 21st century: an ecosocial perspective, international journal of epidemiology. 2001;30(4):668– 677. 6. link bg, phelan j. social conditions as fundamental causes of disease. j health soc behav. 1995;spec no:80-94. 7. kawachi i, berkman l. social cohesion, social capital, and health. in: berkman, l.f. and kawachi, i. eds., pages 174-190. social epidemiology. new york: oxford university press; 2000. 8. davis r, campbell r, hildon z, hobbs l, michie s. theories of behaviour and behaviour change across the social and behavioural sciences: a scoping review. health psychology review. 2015;9(3):323-344. 9. hellmen m, majamaki m, rolando s, bujalski m, lemmens p. what causes addiction problems. substance use and misuse. 2015;50:419-438. 10. etsc. progress in reducing drink driving in europe. brussels: european transport safety council; 2018. 11. drugnet. public attitudes to drugs in ireland. dublin: health research board; 2019. 12. perera k, timms h, heimans j. new power versus old: to beat antivaccination campaigners we need to learn from them. bmj. 2019;367:l6447. 13. nejm. who releases list of 10 threats to global health. journal watch, 2019. retrieved 06 01, 2022, from https://www.jwatch.org/fw114986/ 2019/01/18/who-releases-list-10threats-global-health 14. pintado e, sanchez j. nuevas tendencias en comunicación estratégica. esic; 2017. 15. moreno ma, gower ad, jenkins mc, kerr b, grisson j. marijuana promotions on social media: adolescents’ views on prevention strategies. substance abuse, treatment, prevention and policy. 2018;13:23. so l. utilising ‘new’ power strategies for public health education in addiction and dependency: learning from social media influencers. 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(j. murphy, ed., and j. murphy, trans.) new york: routledge; 1976. 21. rose n. identity, genealogy, history. in p. du gay, j. evans, and p. redman, identity: a reader (pp. 313-326). london: sage; 2008. 22. johansen ka, vandenbroeck m, vandevelde s. on the biopolitics of humane drug policies: what can we learn from 19 century sobriety boards? nordic studies on alcohol and drugs. 2021; 38(5):498-516. 23. sedgewick e. tendencies. durham, north carolina: duke university press; 1983. 24. laing rd. the divided self: an existential study in sanity and madness. harmondsworth: penguin; 1960. 25. szastz t. the myth of mental illness: foundations of a theory of personal conduct. harper & row; 1974. 26. illich i. limits to medicine, medical nemesis: the exploration of health. harmondsworth: penguin; 1977. 27. babor tf. alcohol research and the alcoholic beverage industry: issues concerns and conflicts of interest. addiction. 2009;104(supp 1): 3447. 28. munro d. inside the $35 billion addiction treatment industry. forbes april 27th 2015. accessed on 22oth june 2016 at: https://www.forbes.com/sites/danm unro/2015/04/27/inside-the-35billion-addiction-treatmentindustry/?sh=326dd55d17dc _________________________________________________________________________________ heinzelmann w. the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii (review article). seejph 2015, posted: 18 january 2015. doi 10.12908/seejph-2014-37 1 review article the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii wilfried heinzelmann corresponding author: dr. wilfried heinzelmann address: schoeneberger straße 22, d-33619 bielefeld, germany; e-mail: wilfried.heinzelmann@uni-bielefeld.de heinzelmann w. the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii (review article). seejph 2015, posted: 18 january 2015. doi 10.12908/seejph-2014-37 2 abstract during the thirties of the twentieth century, german medical doctors immigrated to turkey. among them, was the german-jewish paediatrician albert eckstein. in this short biography, the richness of the literature, written by or about eckstein, will be presented, and altogether combined. starting from 1937 and further on, albert eckstein undertook scientific surveys on children’s state of health and health care in the most remote areas of anatolia. the value of the socialhygienic approach could be recognized, even in this early stage, starting with epidemiological analysis and followed by basic comprehensive health care. social hygiene, as a young branch of health sciences at the time, was in the position even then to model the health care system for large population groups, at least in countries actively developing health care, as was turkey of that time. albert eckstein and his co-workers, such as ihsan dogramaci, stand out as founders of the modern turkish health care system today and health sciences in this country. keywords: albert eckstein, anatolia, health sciences, ihsan dogramaci, paediatrics, public health, social hygiene. conflict of interest: none. acknowledgement: the support by prof. ulrich laaser and the translation by dr. nikola ilic are gratefully acknowledged. heinzelmann w. the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii (review article). seejph 2015, posted: 18 january 2015. doi 10.12908/seejph-2014-37 3 introduction during the great remodelling of the turkish nation under the government of kemal atatürk (1881-1938), the german-jewish physician and emigrant albert eckstein (1891-1950), also often mentioned as “architect of the modern turkish health-care system” (1), made significant efforts in lowering child mortality. at the end of 1920s, the german scientist gerhard domagk had discovered the healing effects of sulfonamide and started the era of chemotherapy. he was awarded the nobel prize in medicine in 1939. albert eckstein left his homeland under pursue from national-socialists in 1935, with domagk’s new therapeutic instruments in his luggage and headed for ankara, the emerging capital of modern turkey, which at that time was a country with high child mortality. biographical background in the years before eckstein arrived to ankara, he had finished studies in the elite german medical schools. he worked during his medical studies with johannes von kries and eugen fisher on scientific research in the freiburg institute of physiology and anatomy. after 1920, eckstein turned his interests to paediatrics and obtained a degree in this field three years later under carl noeggerath in freiburg. since 1925, eckstein worked for years as a senior medical doctor under the social-hygienist arthur schlossmann in the paediatric clinic at the medical academy in düsseldorf. the textbook on social hygiene and medical care edited by arthur schlossmann together with the most famous social-hygienists adolf gottstein and ludwig teleky in the midst of the twenties, was a milestone in developing modern health sciences (2), thus supplying young german doctors with the latest scientific findings on those newly endeavoured fields. the young researcher we are speaking of found entrance to his director’s family through marriage with his daughter dr. erna schlossmann. she led the auguste-viktoria children’s home, and was also engaged in social hygiene. in the times coming, she will be of great help as associate on his undertakings in exile. being associated professor with schlossmann since 1925, eckstein was the permanent deputy of his father in law and – after his master’s death in 1932 – he followed him both on clinical and academic positions1 basically, one can explain eckstein’s path, a paradox turn in the carrier of this 45 year old man, through two historical phenomena: anti-semitism in germany on one side, and government and community reconstruction in turkey of the period, on the other. already in 1924, kemal atatürk signed a treaty of friendship with germany and a second one followed in 1941 (4). following the “seizure of power” in 1933, eckstein managed to stay only two and a half years more at his workplace in düsseldorf. after a year of harassment and humiliation by the regime, colleagues, and students, a decree signed by hitler and göring forced him to leave germany (3). in those years, germany and turkey were working together under an agreement on helping the young (turkish) republic on rebuilding new government structures and forming the university in istanbul and a new university in ankara (4). through this programme, in which germans without jewish roots could work as well, national-socialists let high-profiled german-jewish scientists seek exile in turkey (3,8). (3-6). until 1935, eckstein worked on infective diseases and tuberculosis and wrote a chapter on smallpox for the textbook of internal medicine (7). historical background 1 erichsen r (2012) exil tuerkei: der pädiater albert eckstein – wie er aus deutschland vertrieben wurde und was er in die tuerkei mitbrachte; and: erichsen r (2012) zwei pädiater im tuerkischen exil: erna und albert eckstein halfen kindern im ländlichen anatolien und fotografierten ihre welt. deutsch-tuerkische gesellschaft (dtg), bonn 03.05.2012. heinzelmann w. the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii (review article). seejph 2015, posted: 18 january 2015. doi 10.12908/seejph-2014-37 4 eckstein was “the last jewish professor at the medical academy in düsseldorf” (4,9). within a few weeks, eckstein arranged with the turkish government that he would be assigned first as “head of the paediatric department in the city hospital nümune hastanesi in ankara” (4), the only hospital in ankara with its population of 125,000 residents (10). later, in 1945, he advanced to a full professor of paediatrics and director of the paediatric clinic in the newly formed university. eckstein developed from earlier, small-scale medical scientific projects, the largest social-hygienic project of the time – an analysis of infant and small children care in turkey with its population of then 16 million (11). research in rural anatolia after the reorganisation of the newly established university paediatric clinic in ankara (4) the couple eckstein went twice in the period from 1936 to 1938 on three-month voyages through regions of west and central anatolia, accompanied by their turkish assistant dr. salahaddin cevdet tekand (see below) (5,11). they tended especially to pass the rural areas and reach “the remotest villages” where men, mothers, wives, and children “have never seen medical doctors” (12,13). the workgroup undertook systematic scientific investigations and offered “on the spot” medical care for those in need. the procedure corresponded to a classical demographic and statistical survey, which led to an epidemiology of childhood diseases in anatolia as basis for the creation of a comprehensive paediatric health care system (4,5,11). as in some of the visited provinces survey techniques could not be fully used, the solution was found in the “monographic, exemplary description of single villages” (5,14). the mutual relationship between the state of health of the individual and the population, a typical case of the social-hygienic double perspective (15), could be found here as a model for the first time in a project on large-scale. the turkish health minister refik saydam, later also turkish prime minister, became friend with eckstein and agreed that eckstein visited first the rural areas and produced a report on illness and health among children of anatolia as a basis for reform proposals: “i would …. like you to prepare a report on …. children’s health and diseases in turkey …. however a german approach may not be suitable for our country …. visit and examine all of anatolia and (return) with your proposals” (10,16,17). according to akar (1), malaria and necrotic ulcerative stomatitis or noma were the major illnesses for the paediatrician in turkey to treat. whereas for malaria prophylaxis as well as therapy was available, noma required the treatment of the mucous membrane of the mouth in children with a weak immune system and malnutrition, sometimes showing also progressive facial necrosis, which represented a daunting therapeutic challenge (18). the list of illnesses comprised in addition: diarrhoea, malnutrition, rickets, typhoid fever, tuberculosis, gonorrhoea, ascariasis, anaemia, trachoma, measles, bronchitis, injuries, scarlet fever, and diphtheria (4,5,11). eckstein’s inquiry in locally typical disease manifestations included basic social-hygienic data as diet, quality of water, hygienic habits, care for infants, and social status. observations were recorded in “detailed daily journals” (3), as a prerequisite for developing new structures of medical care (5). the research trips led eckstein and his small team especially into the central and western regions of anatolia. during only two years, they visited altogether 188 villages in 25 provinces, interviewing almost 25.000 women (4,5,11). the examination began usually with social-hygienic and demographic, and population data gathering. furthermore, the group studied the dominating diseases and the social conditions determining the rural environment in which families in anatolia typically lived (11), with a special focus on childhood diseases. living conditions and living standards (water and milk supply, fruit and vegetable growing) of the rural population stayed regularly in focus. the so-called “centres for fighting malaria” heinzelmann w. the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii (review article). seejph 2015, posted: 18 january 2015. doi 10.12908/seejph-2014-37 5 (4,5) were transformed into health centers (dispensaires) that provided consultations for mothers and health care for infants and, as such, formed footing for the future paediatric services (4,5). diarrheic diseases were – different from western europe – predominantly of bacterial origin, therefore, diarrhoea during the summer months required antibacterial medication (sulfonamide), or serum therapy (3,4). because of eckstein’s work before he returned to germany in 1949, the mortality among children in turkey deceased from 35%-40% to 12% (4,5,10,13). however, the ecksteins themselves indicated some statistical weaknesses in this account (4,13). workday routine how a typical workday for the two ecksteins looked like, we can see from the 44 page daily journal covering their visit to anatolia in 1937, published in 2005 by buergel (19). the ecksteins needed not to get alone on the road trough undeveloped parts of the land in order to reach mothers and children who lived in villages there. for transportation they used one ford cabriolet, bus lines, railroad, taurus-express, occasionally with sleeping car. but, they also travelled “using taxi, jeep, or horse” (12). primarily, albert eckstein described the strange remains of antic architecture spread throughout an ever changing landscape, its utilization, management, climate, living conditions, the diet of the population, conditions of accommodation, occupations, and standards of living. often he used the hospitality of the population in anatolia as advantage in building his own social network in the field. there were rarely days that would end without celebrations of new friendships. almost everywhere they were received by higher health service representatives, who would take them to residential areas. first ones to come to him were children, followed by women who openly showed their empathy, and at the end came the sick. the social-hygienic research work started latest at 11:00 in the morning and lasted until late involving visits, tuberculin vaccinations and their controls, gathering data on birth rates and child mortality, after that “polyclinic consultations” for malaria treatment including quinine prophylaxis for enteritis, rickets, ascariasis, measles, and whooping cough. eckstein’s personality it is out of question that this highly engaged and charismatic paediatrician with his efficient work and approach to people also won the hearts and managed to generate deep empathy by the population eckstein worked with. even today, eckstein’s name is mentioned in ankara and istanbul (20). the extraordinary personality as observed by his turkish colleagues and patients, his energy and happiness in life, genius, and a feeling for the right moment, eidetic disposition (descriptive representation of the undertaken voyages, surprisingly changing scenery of landscapes in anatolia), incredible memory, adaptability, promptness of his thoughts and team spirit. dr. salahaddin cevded tekand pointed out in 1998 that those who spoke about eckstein always indicate his success, while he was referring always to “us” (16,17). the “enthusiastic doctor” managed to combine two things together “that made him very popular and beloved”: his “calm responsibility” and “affectionate way” in which he was treating both children and parents (21). their children along with other children in ankara were vaccinated against smallpox, measles, typhus, received therapy for malaria or prophylaxis with quinine, and sulfonamide for diarrhoea. jülide gülizar was explicit when she in the cumhuriyet magazine expressed her feelings: “he left behind a lot of research and studies about turkish children and the special throne he built in the hearts of their mothers” (10). typical for the deeply grateful turkish people was the triumphal farewell which eckstein’s fans organised in 1950 at ankara’s central train station. just before the departure of heinzelmann w. the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii (review article). seejph 2015, posted: 18 january 2015. doi 10.12908/seejph-2014-37 6 the train “hundreds of turkish people, many of them with babies and children in arms, came to the train station, one more time to wave him farewell”. as reported later in the magazine, this was one of the greatest “red carpet treatment” ankara had experienced ever (13). as turkey declared war against germany in february 1945, all germans in the country were interned, only eckstein and his family escaped this measure because of his previous remarkable services (3). eckstein’s turkish assistants the turkish state realised the contractual agreements of hiring additional hands very reluctantly and attached assistants only one by one. in their historical sequence (dr.’s): bahtiyar demirag, who from 1950 on carried forward the work of his teacher in ankara (10); neriman olgür (16,17) and sabiha cura (10), just like selahattin cevded tekand and ihsan dogramaci (see for both below). eckstein met ihsan dogramaci (1915-2010) by chance during his “anatolian voyage” in 1938. the tall young doctor grew up in the highest society, was nephew to the local governor, and lived in the governor’s palace. this is where he received and hosted eckstein with his co-workers. upon return, eckstein invited him to accompany them as a paediatrician on a five-day research trip through the province and to become a paediatrician (10,13,16,17). after this trip, the young ihsan dogramaci became the third in the row of turkish assistants; later, he worked as a clinician in ankara. ihsan stayed in this position until 1940 when he went on his way to the united states and baghdad (10). one year later, signed with both names, the essay on “treatment of summer diarrhoea with bacteriophages” was published (22), which was a result of joint research work in the new capital of turkey. after that, the turkish paediatrician stayed some more time in washington d.c. and boston for studies from which he returned in 1949 to ankara for postdoctoral studies. dogramaci obviously like other friends shared the enthusiasm of his teacher for the appropriation of his new homeland by photography and film (5)2 2 dogramaci, burzu: die aneignung der exil-heimat durch photographie und film. vortrag gehalten bei der konradadenauer-stiftung, bonn am 22. september 1968. . he played an important role as a professor in instituting the new university. he was founder of the hacettepe university clinic in 1958 (which later became part of the university baring the same name) (16) and in 1984 of the private bilkent university (10), “the first full-fledged private university in turkey” (17), both of those in ankara, a city with three universities in total (19). by the end of the fifties of the last century, the german-jewish paediatrician and his “former student” (figure 1) stood among the most prominent persons, founders of the new institutions in ankara. eckstein already tried to provide safe and sustained care for children in the entire middle east by building the powdered milk factory in eastern turkey (4). later, it was dogramaci who provided this milk distribution in turkey and thus was able to considerably decrease the infant and child mortality in his country. the friendship between the two german and turkish paediatricians went even further: in 1954, almost two decades after his first assistant position, dogramaci gave to dr. erna eckstein-schlossmann the administrative position in the new haccettepe paediatric clinic, responsible for equipping the facilities. that led to the return of eckstein’s widow erna eckstein-schlossmann to ankara where she stayed for the next five years until 1961 (4,6). the lifetime achievement award, which was awarded to dogramaci in istanbul in 2009 at the 12th world congress of public health by the world federation of public health associations (wfpha), came – after numerous earlier awards – as a last point after the extraordinary work of this great man (20). heinzelmann w. the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii (review article). seejph 2015, posted: 18 january 2015. doi 10.12908/seejph-2014-37 7 figure 1. dr. eckstein and dr. dogramaci (screenshot taken from: http://www.ep.liu.se/ej/hygiea/v7/i1/a3/hygiea08v7i1a3.pdf) eckstein’s first turkish assistant was his “travelling assistant”, namely dr. salahaddin cevdet tekand. although his professional career did not compare to dogramaci, eckstein had to rely especially during his travelling through the rural provinces on his francophone assistant (13) and gave him credit for part of his success (19), especially with regard to the establishment of easy contacts with the turkish peasants and their “warm” and “often touching” hospitality. tekand gathered over the years as a field doctor an impressive array of experiences. he became the head of the paediatric clinic in his hometown izmir and worked there on children welfare programmes until 1997 (19). the scientific work the main question we are interested in here is whether we can agree with the claim made by henry sigerist in 1947 that findings and work of social-hygienic assailants acted worldwide as an accelerator in the development of health sciences (23). the unprecedented successes of eckstein prove that the amended social-hygienic model that he used had the potential for population wide health care. using this approach experts displaced from germany triggered innovations in the health services of their host countries. the essential factor for success of the assailants in the field of social-hygiene was the developmental status of the target countries. many of these were countries under development such as turkey, palestine, and latin america, where they could use their know-how in health sciences. on the other hand, they failed to achieve the same in industrialised developed countries, mostly because of the high professional competition. two factors were predominant in decision making of the german-jewish assailants: the degree of persecution in germany and the legislation regulating the medical profession in host countries. eckstein was heinzelmann w. the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii (review article). seejph 2015, posted: 18 january 2015. doi 10.12908/seejph-2014-37 8 afraid of the lack of social security in the us, wherefrom he got an invitation, but he was not afraid of the need to learn turkish. that was a new and strange language, in which he soon wrote a textbook, the first textbook in turkish on infant diseases (3). eckstein was led by a powerful urge to write. during almost 15 years in turkey, during long working days, on the road, along with never ending planning, helping, creating new guidelines, and organising other staff, he wrote 50 publications. many of those publications are even today relevant due to their clarity and realism. many of the data in these publications originated from the comprehensive research which started in 1940. in turkey, the still undeveloped country at the gates of asia, he was always following his favourite thesis about “quite different, non-textbook conditions” of otherwise well known paediatric diseases, especially in the rural villages they visited on their trips: “diseases and their forms show partially a different course from those we can find described in our textbooks. other diseases such as the examples of malaria or necrotic ulcerative stomatitis can confront the paediatrician with the task, to find new ways as... the specificities of childhood must be taken into account” (19). insight in scientific gains made by eckstein on his voyages could be seen in his monograph “malaria in childhood” (24), published in 1946. on the front page of this publication the author and professor in ankara described himself, 11 years after his flight from germany, still as “former full professor... at the medical academy in düsseldorf”. here he dedicated a 100-page chapter of the text to arthur schlossmann. the text was written on never before systematically described forms of diseases, here “nontextbook” forms of malaria among children that eckstein learned to diagnose and treat during the decade he travelled deeply into the turkish countryside. unusual forms of malaria among children revealed occasionally just strong thirst or insomnia with strange behaviour and consciousness disorders. lethality was strangely high and made up for a large part of total mortality in the population. child mortality from diarrhoea could be largely reduced in malaria regions through “energetic treatment” with anti-malarial drugs. with 90 case reports, eckstein showed some common childhood diseases with symptoms, temperature charts, differential diagnoses, congenital illness, and malaria among infants, complications, protracted and foudroyant coma, recurrence, combinations with other diseases, especially with typhus abdominalis and tuberculosis, chronic malaria, consequences and therapy. even more, he compiled “more than 1000 clinical observations of interest” from his survey research. already in one earlier publication “encephalitis in the children’s age”, published in 1929 (25), he collected with the same objective different forms of encephalitis among children and how they were described in the literature. this was a compilation of new observations which contributed to the understanding of encephalitis among children, to be distinguished from the clinical picture in adults. as an example, during chronic encephalitis in adults, physical changes manifest as immobility and lethargy, while among children and young people different types of asocial behaviour can be found. almost all cases of acute encephalitis among children lead to incomplete healing and transfer over time into chronic forms of illness. concluding remark for 14 years, eckstein lived and worked in ankara. after 1945, for the successful assailant, the question of remigration appeared. a number of honours from post-war germany indicated that eckstein not only was remembered, but he was also needed. the medical academy in düsseldorf awarded eckstein the honourable citizenship in 1948 (9,26), and that same university as well as four other german universities offered him a full university professorship in paediatrics. at the end, eckstein accepted the sixth offer from hamburg. his inaugural lecture covered the theme “problems of paediatric care in turkey” (3,4). in 1949, heinzelmann w. the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii (review article). seejph 2015, posted: 18 january 2015. doi 10.12908/seejph-2014-37 9 albert eckstein came back to germany [no more than 5% of the german-jewish émigrés returned to the country of their origin (27)], but one year later he died at the age of 59. among the exiled german-jewish professors, eckstein was the most outstanding professional in the field of social-hygiene and early health sciences, and vice versa, he was its classical product – if one can say so. eckstein stands among the assailed scientists in turkey as “grotesque deviation of history” to those who most impressively reflected back the “shameful expulsion” (28). references 1. akar n, eckstein a. a pioneer in paediatrics in turkey. turk j pediatr 2004;46:295-7. 2. gottstein a, schlossmann a, teleky l. handbuch der sozialen hygiene und gesundheitsfuersorge. heidelberg: springer, 1925. 3. johannsen l. eric aschenheim albert eckstein julius weyl. juedische paediater im vorstand der vereinigung rheinisch-westfälischer kinderaerzte, juedische miniaturen. berlin: hentrich, 2010: (vol.) 104. 4. bürgel k, riener k. wissenschaftsemigration im nationalsozialismus. der kinderarzt albert eckstein und die gesundheitsfuersorge in der tuerkei. duesseldorf: quellen und forschungen aus dem universitaetsarchiv duesseldorf, 2005. 5. erichsen r. medizinemigration in die tuerkei. in: scholz a, heidel cp (eds.). emigrantenschicksale, einfluss der jüdischen emigranten auf sozialpolitik und wissenschaft in den aufnahmeländern. frankfurt: 2005. available at: https://www.google.de/#q=erichsen+r.+medizinemigration+in+die+tuerkei (accessed: december 22, 2014). 6. moeckelmann, r. wartesaal ankara ernst reuter: exil und rückkehr nach berlin. berlin: berliner wissenschaftsverlag, 2013. 7. wunderlich p, renner k. arthur schloßmann und die duesseldorfer kinderklinik. duesseldorf: festschrift zur feier des 100. geburtstages am 16. dezember 1967, 1967. 8. widmann h. exil und bildungshilfe. die deutschsprachige akademische emigration in die tuerkei nach 1933. bern: herbert lang, 1973. 9. griese k, woelk w. juedische aerzte und aerztinnen in duesseldorf und in der emigration. in: duewell k et al. (eds.). vertreibung juedischer kuenstler und wissenschaftler aus duesseldorf 1933-1945. duesseldorf: hentrich,1998. 10. günay-erkol c, reisman a. emigre albert eckstein’s legacy on health care modernization in turkey: two generations of students who have made major contributions. hygiea internationlis 2008;7:27-48. 11. eckstein a. probleme und aufgaben der kinderheilkunde in der tuerkei. annales pädiatrici/international review of pediatrics 1940;155:16-35,57-83,113-139. 12. moll h. emigrierte deutsche paediater: albert eckstein, werner solmitz. monatsschr. kinderheilk. 1995;143:1204-10. 13. eckstein-schlossmann, e. eigentlich bin ich nirgendwo zu hause. edited by lorenz peter johannsen, berlin: hentrich, juedische memoiren 2012;17:99. 14. eckstein, a. beitrag zu der erforschung der gesundheitlichen und hygienischen verhältnisse auf dem lande mit besonderer beruecksichtigung der kinder (bericht ueber eine studienreise in zentralanatolien 1937 (translated). anadolu klinigi 1938;6:37-76. 15. heinzelmann w. sozialhygiene als gesundheitswissenschaft. die deutsch/deutschjüdische avantgarde 1897-1933. bielefeld: transcript publishing company, 2009. 16. akar n. modernizer of turkey’s pediatrics: albert eckstein in exile. ankara: 2005. heinzelmann w. the german-jewish paediatrician albert eckstein (1891-1950) exiled to turkey: pioneering modern paediatric care and social hygiene (health sciences) during world war ii (review article). seejph 2015, posted: 18 january 2015. doi 10.12908/seejph-2014-37 10 17. akar n, reisman a, oral a. albert eckstein (1892-1950): modernizer of turkey’s paediatrics in exile. j med biogr 2007;4:213-18. 18. seidler e. kinderärzte, entrechtet/geflohen/ermordet. freiburg & basel: karger, 2007. 19. eckstein, a. reisetagebuch anatolische reise 1937. in: bürgel k, riener k. wissenschaftsemigration im nationalsozialismus. der kinderarzt albert eckstein und die gesundheitsfuersorge in der tuerkei. duesseldorf: quellen und forschungen aus dem universitaetsarchiv duesseldorf, 2005. 20. laaser u. persoenliche mitteilung. june 2014. 21. neumark f. zuflucht am bosporus. deutsche gelehrte, politiker und künstler in der emigration 1933-1953. frankfurt a. m.: amazon, 1980. 22. eckstein a, dogramaci i. über die behandlung der ‚sommerdurchfälle‘ mit bakteriophagen. in: annales pädiatrici 1941;156/2: 81. 23. sigerist he. the johns hopkins institute of the history of medicine during the academic year 1946-1947. baltimore: bulletin of the history of medicine, 1947. 24. eckstein a. malaria im kindesalter. basel & new york: karger, 1946. 25. eckstein a. encephalitis im kindesalter. ergebnisse der inneren medizin und kinderheilkunde 1929;494-662. 26. wiedemann hr. albert eckstein. eur j pediatr 1994;153:303. 27. kröner hp. die emigration deutschsprachiger mediziner im nationalsozialismus. ber wiss gesch 1989;12 (special issue 1998). 28. schwartz ph. notgemeinschaft. zur emigration deutscher wissenschaftler nach 1933 in die türkei. introduction by helge peukert. marburg: metropolis, 1995. ___________________________________________________________ © 2015 heinzelmann; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. mubarokah k, nurjanah n, handayani s, astarini hr, maharani aw, masitoh d, et al. tuberculosis literacy and stigma: female activists in five areas with the lowest treatment success rate in semarang, indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5330 p a g e 1 | 12 original research tuberculosis literacy and stigma: female activists in five areas with the lowest treatment success rate in semarang, indonesia kismi mubarokah1, nurjanah nurjanah1, sri handayani1, hermin rhema astarini1, adelia wahyuningtyas maharani1, dewi masitoh1, merisha dea salisa1, sri dian yulianah1 1 faculty of health science, universitas dian nuswantoro, 50131 semarang, central java, indonesia. corresponding author: kismi mubarokah; address: faculty of health science, universitas dian nuswantoro, 50131 semarang, central java, indonesia. e-mail: kismi.mubarokah@dsn.dinus.ac.id mubarokah k, nurjanah n, handayani s, astarini hr, maharani aw, masitoh d, et al. tuberculosis literacy and stigma: female activists in five areas with the lowest treatment success rate in semarang, indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5330 p a g e 2 | 12 abstract background: the case detection rate of tuberculosis (tb) in semarang city increased from 2014 to 2018, while the treatment success rate declined. low literacy can trigger stigma in society, especially among women, resulting in low awareness of suspect tb for treatment. objectives: the aims are to analyze the correlation between tb literacy and stigma expressed among female health and social activists. methods: cross-sectional research was conducted in five public health centers with the lowest treatment success rate (tsr). a valid and reliable self-administered online questionnaire collected data that involved 391 respondents predominantly in the urban areas. rank spearman test was used to analyze the data with a confidence interval of 95%. results: the respondents were mostly elderly (>45 years; 61.6%), health activists with high school graduation, didn't have a family with a health background and did not work. most of them showed low tb literacy (me:60; sd±6.62) and high stigma (me: 76; sd±10.36). they were also difficult to access, understand, assess, and apply information about tb. age (p.0.03; r.-0.110), being health activist (p.0.081; r.-0.088), and tb literacy (p.0.001; r.0.165) correlated significantly with stigma. conclusions: public health center's officers require inserting literacy education materials related to stigma to form a comfortable support system for persons with tb. keywords: literacy, stigma, tuberculosis. conflicts of interest: none declared. acknowledgment: many thanks and appreciation to semarang city of health governments, the 5 public health centres, the faculty of health science udinus, and ahla (asia health literacy association) indonesia country office universitas dian nuswantoro. mubarokah k, nurjanah n, handayani s, astarini hr, maharani aw, masitoh d, et al. tuberculosis literacy and stigma: female activists in five areas with the lowest treatment success rate in semarang, indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5330 p a g e 3 | 12 introduction case notification rate (cnr) per 100,000 population in indonesia from 20152018 shows an increase from year to year. over the past four years, 130 cases (2015) have increased to 139 (2016), 161 (2017), and 193 cases (2018) (1). this high cnr is one of the indicators of program success because of many cases of tb that can be identified and treated immediately. unfortunately, the treatment success rate (tsr) decreased during that period: from 85.8% in 2015 to 85.0% in 2016, 85.1% in 2017, and 80.12% in 2018 (1). this situation can impact the accumulation of people with tb, both who are still in the treatment process and those who have not started treatment. this means the general community's risk of exposure to mycobacterium tuberculosis increases even if they are disciplined and use masks. central java is one of the provinces with an increase in cnr from 118 in 2016 to 115.4 per 100,000 population in 2018 (2), whereas, at the same time, the tsr decreased from 86.0% (2016) to 83.7% (2018), far from the target of achieving a treatment success rate of 90%. among 37 public health centers in semarang city, the five with the lowest treatment success rate were kedungmundu, bangetayu, pegandan, ngemplak simongan, and purwoyoso (3). in addition to the high rates of treatment dropout due to inadequate knowledge of drug side effects, this decrease in tsr shows the inability and unwillingness of patients and suspects regarding tb due to the high stigma in the surrounding community (4). low social support emerges from stigma associated with low literacy (5). “women in the urban village” (pkk) is a voluntary organization active in the empowerment and welfare of families (pkk). as one of the leading programs of the pkk, they have an essential role in the field of health (6). in tb prevention, they should have good tb literacy to provide social support for the community in the region, especially for tb patients. health literacy is a person's ability to access, understand, assess and apply information (7). literacy is one factor that influences the occurrence of stigma in society. common public domains are social distance, traditional prejudice, exclusionary sentiments, negative affect, treatment carryover, disclosure carryover, perceptions of dangerousness (8). some of these terms need an explanation: social distance describes that someone tries to avoid a person with tb (pwtb). it is a traditional stereotype and prejudice believing all people with tb are less valuable. exclusionary sentiments tend to separate pwtb from everyone else or deny them their rights. negative affects refer to emotional reactions such as disgust or hatred toward pwtb. treatment carryover means being afraid of people knowing they were treated for tb in the past. the perceived need for secrecy may linger after a person recovers. disclosure carryover is when people are afraid of their reactions if known to have tb. perceptions of dangerousness are the idea that pwtb somehow represents a risk to society (8). materials and methods a total of 391 respondents filled out valid and reliable online questionnaires (see annex) containing questions about demographic variables, tb literacy (20 questions), and stigma (20 questions). respondents were the total number of women active in pkk in 5 public health centers. these primary data are bivariate and analyzed by the rank spearman test (95% ci). the cross-sectional design of mubarokah k, nurjanah n, handayani s, astarini hr, maharani aw, masitoh d, et al. tuberculosis literacy and stigma: female activists in five areas with the lowest treatment success rate in semarang, indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5330 p a g e 4 | 12 the study was conducted with the permission of the ethics commission no: 417/kepkfkm/unimus/2020. results respondents of this study are divided as 24% of bangetayu, 6.1% of ngemplak simongan, 23.5% of kedungmundu, 9.2% of purwoyoso, and 36.8% of pegandan. most of the respondents were elderly (>=45 years old, 61.6%) and with high school graduation (70.6%). a majority (80.1%) were health activists and didn't have a family with a health background (71.1%). only a small percentage of the respondents were teachers (11.0%), the majority housewives (71.1%), for details, see table 1. table 1. demographic summary of respondents (n = 391) variable frequency percent (%) mean; sd age middle age elderly 150 241 38.4 61.6 47.8; 9.06 education level < senior high school diploma bachelor 276 41 74 70.6 10.5 18.9 type of work health activist (cadre) non-health activist 313 78 80.1 19.9 field background health non-health 113 278 28.9 71.1 occupation housewife private employee teacher 278 70 43 71.1 17.9 11.0 good literacy is more owned by respondents with health background (43%; p=0,621) and health activists (41.5%, p=0.935). however, the health activists had low specific tb literacy (58.5%) and high stigma (56.5%). respondents with a health background had low tb literacy (56.6%) and high stigma (64.6%). the group of respondents with stigma was more elderly (59.3%; p=0.028). most of them were health activists (56.5%; p=0.214) and had high school education (51.1%; p=0.274).housewives made up for 56.1% (p=0.763). stigma was related to low tb literacy and dominated by not health activist respondents. some of the scores on tb literacy variables were low, especially in providing an assessment of littering and coughing behavior, able to spread pulmonary tb. for details, see table 2. mubarokah k, nurjanah n, handayani s, astarini hr, maharani aw, masitoh d, et al. tuberculosis literacy and stigma: female activists in five areas with the lowest treatment success rate in semarang, indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5330 p a g e 5 | 12 table 2. percent item distribution of tb literacy item % very difficult % quite difficult % quite easy % very easy 1. find information about pulmonary tb 1.2 8.2 67.8 22.8 2. find out how to prevent pulmonary tb 0.8 9.2 73.7 16.3 3. finding out where to get pulmonary tb treatment 0.3 2 74.4 23.3 4. get information about the risks of smoking against pulmonary tb 2 5.1 72.4 20.5 5. find a place to have a tb screening 0 1.8 74.2 24 6. understand information about pulmonary tb from the media 0 5.6 77.2 17.2 7. understand information about the symptoms of pulmonary tb from health workers 0 3.8 79.8 16.4 8. understand health warning information about the dangers of smoking 0 4.3 73.7 22 9. understand that pulmonary tb requires complete treatment 1.3 7.2 71.6 19.9 10. providing an assessment of the home/ living environment can help you stay healthy (e.g. keeping it damp, getting sunlight and fresh air in and clean) 0 4.6 79.3 16.1 11. provide an assessment of why immunization is necessary to prevent pulmonary tb 0.3 7.9 76.7 15.1 12. providing an assessment of littering & coughing behavior can spread pulmonary tb 1 21.5 65.2 12.3 13. provide an assessment of the signs or symptoms of pulmonary tb which requires examination at a health service 1 18.7 70.3 10 14. self-examination to confirm diagnosis of tb if needed 2.2 20.5 67.8 9.5 15. treatment for tb if needed 0.3 12 75.2 12.5 16. make the decision not to smoke 12.3 32.7 36.6 18.4 17. doing exercise regularly 2.3 16.4 63.9 17.4 18. eating nutritious foods with attention to diversity, including eating fruits and vegetables 0.5 4.6 70.3 24.6 19. maintain the living conditions (room, boarding house, cottage or house) with sufficient light, adequate ventilation and not damp 0 6.6 67 26.4 mubarokah k, nurjanah n, handayani s, astarini hr, maharani aw, masitoh d, et al. tuberculosis literacy and stigma: female activists in five areas with the lowest treatment success rate in semarang, indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5330 p a g e 6 | 12 20. drying the bedding to avoid humid conditions 0.3 4.3 70.3 25.1 (n: 391; total score’s range: 43-80; me: 60; sd: 6.618) table 3. percent item distribution of stigma item % sa % ag % nt % da % sd 1. some people do not want to eat/drink with tb patients. 17.6 40.2 6.4 31.2 4.6 2. some people stay away from tb patients. 5.7 16.6 7.4 62.9 7.4 3. some people feel uncomfortable around tb patients. 5.9 42.2 6.4 40.9 4.6 4. some people do not want to come into contact with tb patients. 2.3 21.5 6.4 63.4 6.4 5. some people do not want to talk to people with tb. 2.3 11.8 6.9 72.1 6.9 6. some people do not want tb patients to live around them. 2.3 9.5 7.2 70 11 7. if someone has tb, some people will treat others differently for the rest of their lives. 0.5 6.2 7.2 73.1 13 8. some people do not want their children to play around with tb patients. 5.4 46 4.4 37.3 6.9 9. some people think that tb patients are disgusting. 0.5 4.9 7.2 73.4 14 10. some people are afraid of tb patients. 0.8 29.2 7.7 55.2 7.1 11. some people do not want to eat/drink with family with tb. 2.3 24.3 7.7 59.5 6.2 12. tb patients are dirty. 0.5 2.6 6.4 73.1 17.4 13. tb patients are a curse. 0.3 0.5 3.6 58.3 37.3 14. tb patients are embarrassing. 0.3 0.5 4.1 69.6 25.5 15. people with tb must have their freedom limited. 0.3 9.5 4.1 72.5 13.6 16. tb patients are the result of wrong behavior and deserve punishment. 0.3 0.8 2.6 66.2 30.1 17. the tb patients must be isolated/locked up. 0.8 5.6 2.8 73.4 17.4 18. i do not want to be friends with people with tb. 0.8 5.3 2.6 72.6 18.7 19. tb patients are not allowed to mingle with the community. 0.3 2.3 4.4 75.4 17.6 mubarokah k, nurjanah n, handayani s, astarini hr, maharani aw, masitoh d, et al. tuberculosis literacy and stigma: female activists in five areas with the lowest treatment success rate in semarang, indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5330 p a g e 7 | 12 20. tb patients should not be able to work. 0.3 26.1 4.6 74.9 14.1 (n: 391; total score’s range: 31-100; me: 76; sd: 10.36) sa: strongly agree; ag: agree; nt: neutral; da: don't agree; sd: strongly disagree the stigma shown is relatively high in some items. most respondents did not want to eat/ drink with tb patients (8%), they stayed away from tb patients (22.3%), they felt uncomfortable around tb patients (48.1%), they did not want their children to play around with tb patients (51.4%). table 4. result of rank spearman bivariate test summary between variables (n = 391) variables p value cc ci age 0.030 -0.110 95% cadre status 0.081 -0.088 education level 0.986 -0.001 occupation 0.925 0.005 field background 0.059 -0.096 tb literacy 0.001 0.165 based on the spearman rank test there is an association between tb literacy and stigma (p.0.001; r.0,165). age is also positively correlated with stigma. (p.0,03; r.0,110). discussion stigma against tuberculosis is a social determinant of health (9). stigma has a potential impact on the health-seeking behavior of persons with tb, reducing the level of mask use, reducing the cure rate or increasing treatment dropouts, and rising patient stress so that the recovery rate also decreases (8). the number of elderly respondents who stigmatize a person with tb can be due to elderly's characteristics. in old age, they often experience mental problems such as patterns and attitudes to life, feeling lonely, worthless, and increasing emotions in the elderly (10). they also have more leisure time because they usually no longer work at this age. so they tend to spend time with their neighbors to talk about various issues, including a person with tb around them. a cadre is a community member who voluntarily assists in implementing health programs in the community. cadres are more active in health programs than other members of the community. according to the indonesian health department, cadres are local citizens selected and reviewed by the community and work voluntarily (6). in fact, they have a significant role in creating a supportive atmosphere for people with tb. however, this study shows that some cadre/health activists still stigmatize persons with tb. the cadre/ health activist can discover tb suspects, be drug swallow supervisors, even act as educators improving literacy and public knowledge about tuberculosis. for example, some previous studies increased knowledge significantly in homemakers with high school education (11). stigma against tb in some mubarokah k, nurjanah n, handayani s, astarini hr, maharani aw, masitoh d, et al. tuberculosis literacy and stigma: female activists in five areas with the lowest treatment success rate in semarang, indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5330 p a g e 8 | 12 areas still shows a reasonably high score, even up to 32 and more. factors significantly associated with stigma are age and married status (12). our research shows thatrespondents had difficulties finding and using information about tb. similar to the previous study (12), where most workers in semarang city found it more challenging to find information than to understand and to apply (13). today's society lives in the era of technology where everyone has a device. various information, including health information, becomes effortless to find through websites, social media, chat rooms, etc. unfortunately, this flood of information makes it difficult for the public to judge whether specific data is fact or a hoax (14). thus, health literacy is necessary to make judgments and decide in daily life regarding health care, disease prevention, and health promotion to maintain or improve the quality of life (15). the stigma by the environment ofpersons with tb, especially by their families, can affect the healing process. patients need motivation, social support, and low stigma to complete treatment (4,16). public health centers are advised to improve the tb literacy of female activists in socialgroups like pkk so that community stigma can be controlled. if activists have adequate literacy, they will jointly influence the general public to remove the stigma against persons with tb. moreover, counseling can accompanypersons with tb during treatment to stabilize their psychological condition (17).meanwhile, community leaders and religious leaders need to provide direction so that the community can have a positive atmosphere, provide a supportive social environment for persons with tb and decrease multi-drug resistance. conclusions the stigma shown towards persons withtuberculosis (tb) needs to be reduced and even eliminated to support tb patient treatment. women activists in a social group called “women in the urban village” (pkk) with adequate literacy will influence the wider community not to stigmatize persons with tb. also, counseling tb patients themselves is needed to overcome psychological pressure due to stigma in society. with the intervention from these two sides, the success of tb treatment will be faster and easier to achieve. references 1. kementerian kesehatan ri. info datin tuberculosis. kementeri kesehat ri. 2018:1. available from: https://pusdatin.kemkes.go.id/resources/download/pusdatin/infodatin/infodatin-tuberkulosis2018.pdf (accessed: december 20, 2021). 2. dinas kesehatan provinsi jawa tengah. kesehatan; 2017. 3. semarang ddkk. ansis program p2tbc; 2018. 4. syam ms, riskiyani s, rachman wa. dukungan sosial penderita tuberculosis paru di wilayah kerja puskesmas ajangale kabupaten bone tahun 2013. j kesehat 2013:110. 5. mackert m, donovan ee, mabry a, guadagno m, stout pa. stigma and health literacy: an agenda for advancing research and practice. am j health behav 2014;38:690-8. doi:10.5993/ajhb.38.5.6. 6. tim penggerak pkk pusat. rumusan hasil rakernas viii pkk. 2015:69. mubarokah k, nurjanah n, handayani s, astarini hr, maharani aw, masitoh d, et al. tuberculosis literacy and stigma: female activists in five areas with the lowest treatment success rate in semarang, indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5330 p a g e 9 | 12 © 2022 mubarokah et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. available from: https://tppkkpusat.org/wp-content/uploads/2017/11/buku-pkk-2015r2.pdf (accessed: december 20, 2021). 7. nutbeam d. defining and measuring health literacy: what can we learn from literacy studies? int j public health 2009;54:303-5. doi:10.1007/s00038009-0050-x. 8. mitchell em, van den hof. tb stigma measurement guidance. challenge tb; 2018. available from: 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handayani s. tuberculosis literacy supports preventive behaviour among workers in semarang, indonesia. ann trop med public heal 2021;24. doi:10.36295/asro.2021.24177. 14. rachmawati ts, agustine m. keterampilan literasi informasi sebagai upaya pencegahan hoaks mengenai informasi kesehatan di media sosial. j kaji inf perpust 2021;9:99-114. doi:10.24198/jkip.v9i1.28650. 15. sørensen k, van den broucke s, fullam j, doyle g, pelikan j, slonska z, et al. health literacy and public health: a systematic review and integration of definitions and models. bmc public health 2012;12:80. doi:10.1186/1471-2458-12-80. 16. pontianak um, tetap d, ilmu f, universitas k, pontianak m. 1 2 3 1. 2015. 17. sari nm, amirus k, febriani ca. pengaruh terapi konseling realitas dalam mengurangi stigma diri pada penderita tb. j dunia kesmas 2021;10:120-9. doi:10.33024/jdk.v10i1.3054. ___________________________________________________________________________ mubarokah k, nurjanah n, handayani s, astarini hr, maharani aw, masitoh d, et al. tuberculosis literacy and stigma: female activists in five areas with the lowest treatment success rate in semarang, indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5330 p a g e 10 | 12 annex: tuberculosis literacy and stigma questionnaire a. demographic variables 1. public health center : 2. community health activist : yes/ no 3. sub sub district : 4. address : 5. name : 6. gender : male/ female/ other 7. date birth : 8. age : 9. education level : 10. job status : 11. social media type : 12. health background of family : 13. if yes, who are they? : father/ mother/ sibling/ another, mention please………………….. b. source of information about tb 1. i've heard information about tb yes/ no 2. where do you get this information? 1. poster 2. phc 3. social media 4. magazine 5. newspaper 6. television 7. radio 8. health provider 9. subdistrict government 10. website 11. billboard 12. college 13. others, mention please………........ c. tb literacy 1. find information about pulmonary tb 1. very difficult 2. quite difficult 3.quite easy 4. very easy 2. find out how to prevent pulmonary tb 1. very difficult 2. quite difficult 3.quite easy 4. very easy 3. find out where to get pulmonary tb treatment 1. very difficult 2. quite difficult 3.quite easy 4. very easy 4. get information about the risks of smoking against pulmonary tb 1. very difficult 2. quite difficult 3.quite easy 4. very easy 5. find a place to have a tb screening 1. very difficult 2. quite difficult 3.quite easy 4. very easy 6. understand information about pulmonary tb from the media 1. very difficult 2. quite difficult 3.quite easy 4. very easy 7. understand information about the symptoms of pulmonary tb from health workers 1. very difficult 2. quite difficult 3.quite easy 4. very easy 8. understand health warning information about the dangers of smoking mubarokah k, nurjanah n, handayani s, astarini hr, maharani aw, masitoh d, et al. tuberculosis literacy and stigma: female activists in five areas with the lowest treatment success rate in semarang, indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5330 p a g e 11 | 12 1. very difficult 2. quite difficult 3.quite easy 4. very easy 9. understand that pulmonary tb requires complete treatment 1. very difficult 2. quite difficult 3.quite easy 4. very easy 10. providing an assessment of the home/ living environment can help you stay healthy (e.g. keeping it damp, getting sunlight and fresh air in and clean) 1. very difficult 2. quite difficult 3.quite easy 4. very easy 11. provide an assessment of why immunization is necessary to prevent pulmonary tb 1. very difficult 2. quite difficult 3.quite easy 4. very easy 12. providing an assessment of littering & coughing behaviour can spread pulmonary tb 1. very difficult 2. quite difficult 3.quite easy 4. very easy 13. provide an assessment of the signs or symptoms of pulmonary tb which requires examination at a health service 1. very difficult 2. quite difficult 3.quite easy 4. very easy 14. self-examination to confirm diagnosis of tb if needed 1. very difficult 2. quite difficult 3.quite easy 4. very easy 15. make the decision not to smoke 1. very difficult 2. quite difficult 3.quite easy 4. very easy 16. treatment for tb if needed 1. very difficult 2. quite difficult 3.quite easy 4. very easy 17. doing exercise regularly 1. very difficult 2. quite difficult 3.quite easy 4. very easy 18. eating nutritious foods with attention to diversity, including eating fruits and vegetables 1. very difficult 2. quite difficult 3.quite easy 4. very easy 19. maintain the living conditions (room, boarding house, cottage or house) with sufficient light, adequate ventilation and not damp 1. very difficult 2. quite difficult 3.quite easy 4. very easy 20. drying the bedding to avoid humid conditions 1. very difficult 2. quite difficult 3.quite easy 4. very easy d. stigma (sa : strongly agree ; ag : agree; nt : neutral; da : don't agree; sd : strongly disagree) 1. some people do not want to eat/drink with tb patients 1. sa 2. ag 3.nt 4. da 5. sd 2. some people stay away from tb patients 1. sa 2. ag 3.nt 4. da 5. sd 3. some people feel uncomfortable around tb patients 1. sa 2. ag 3.nt 4. da 5. sd 4. some people do not want to come into contact with tb patients 1. sa 2. ag 3.nt 4. da 5. sd 5. some people do not want to talk to people with tb 1. sa 2. ag 3.nt 4. da 5. sd 6. some people do not want tb patients to live around them 1. sa 2. ag 3.nt 4. da 5. sd 7. if someone has tb, some people will treat others differently for the rest of their lives 1. sa 2. ag 3.nt 4. da 5. sd 8. some people do not want their children to play around with tb patients 1. sa 2. ag 3.nt 4. da 5. sd mubarokah k, nurjanah n, handayani s, astarini hr, maharani aw, masitoh d, et al. tuberculosis literacy and stigma: female activists in five areas with the lowest treatment success rate in semarang, indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5330 p a g e 12 | 12 9. some people think that tb patients are disgusting children to play around with tb patients 1. sa 2. ag 3.nt 4. da 5. sd 10. some people are afraid of tb patients 1. sa 2. ag 3.nt 4. da 5. sd 11. some people do not want to eat/drink with a family with tb 1. sa 2. ag 3.nt 4. da 5. sd 12. tb patients are dirty 1. sa 2. ag 3.nt 4. da 5. sd 13. tb patients are a curse 1. sa 2. ag 3.nt 4. da 5. sd 14. tb patients are embarrassing 1. sa 2. ag 3.nt 4. da 5. sd 15. people with tb must have their freedom limited 1. sa 2. ag 3.nt 4. da 5. sd 16. tb patients are the result of wrong behavior and deserve punishment 1. sa 2. ag 3.nt 4. da 5. sd 17. the tb patients must be isolated/locked up 1. sa 2. ag 3.nt 4. da 5. sd 18. i do not want to be friends with people with tb 1. sa 2. ag 3.nt 4. da 5. sd 19. tb patients are not allowed to mingle with the community 1. sa 2. ag 3.nt 4. da 5. sd 20. tb patients should not be able to work 1. sa 2. ag 3.nt 4. da 5. sd title goes here setijaningsih ra, suyoko s, sukamto m, wijayanti as, vaninda bg, rochmah en, et al. management of medical record unit services for covid-19 patients in type c hospitals: a study of legal aspects (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5326 p a g e 1 | 15 original research management of medical record unit services for covid-19 patients in type c hospitals: a study of legal aspects. retno astuti setijaningsih1, suyoko suyoko1, mellinia sukamto1, arinimar shaffa wijayanti1, brissa gustaviar vaninda1, eva nur rochmah1, ngesti wahyuni1, sabrina hayatun nufus1, slamet isworo2 1 department of medical records and health information, faculty of health, dian nuswantoro university, semarang, indonesia; 2 departement of environmental health, faculty of health, dian nuswantoro university, semarang, indonesia. corresponding author: slamet isworo; address: department of environmental health, faculty of health, dian nuswantoro university, semarang, indonesia; email: slamet.isworo@dsn.dinus.ac.id mailto:slamet.isworo@dsn.dinus.ac.id setijaningsih ra, suyoko s, sukamto m, wijayanti as, vaninda bg, rochmah en, et al. management of medical record unit services for covid-19 patients in type c hospitals: a study of legal aspects (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5326 p a g e 2 | 15 abstract background: the impact of the pandemic on medical record health service procedures has induced significant changes. the duplication of covid-19 patient numbers in the patient medical record unit is an important concern. this study aims to analyze the legal aspects of managing medical record services during the covid-19 pandemic in hospitals. methods: this type of research is descriptive and quantitative with a cross-sectional approach. the key informants are 15 registration and medical record unit officers, using online interview techniques, employed in three hospitals in semarang with a focus on group discussions. the object of research includes the management of medical records and service standards for covid-19 patients as regulations in the medical record unit of the semarang city general hospital. results: policies and standards for medical record services for covid-19 patients, have not been adjusted to the provisions based on circular letter number hm.01.01/001/iii/2020 concerning procedures for work in situations of the covid-19 outbreak. the medical record service for covid-19 patients still applies paper-based or semi-electronic medical records so that errors can occur. this can cause legal problems for hospitals; therefore, medical record service standards must meet legal aspects as legal evidence that can protect the interests of various parties. conclusions: it is necessary to manage a medical resume form design that is better, complete, electronical, and in accordance with legal aspects. keywords: covid-19, design, legal information, medical resume, policies and standards, standard operating procedures. conflicts of interest: none declared. authors’ contributions: this research was conducted in collaboration of all the authors. the authors of the ras designed the study. authors ras, s, ms, asw, bgv, enr, nw and shn did the sampling and wrote the first draft. authors s, si and ras authors wrote the protocol and administered the study analysis. the ras authors and si authors managed the literature search. all authors read and approved the final manuscript. data availability: all relevant data has been registered with supporting file information. ethical approval: according to international standards or research standards in the republic of indonesia, written ethical consent has been collected and kept by the author. this research proposal has passed the ethical review from the health research ethics commission (kepk) faculty of health, dian nuswantoro university semarang on may 4, 2021 with an ethical approval certificate issued with number 024/ea/kepk-fkes-udinus/v/2021. acknowledgements: the authors are grateful for their support to the leadership gondosuwarno general hospital ungaran, ken saras hospital bawen, the permata medika general hospital semarang, and the dean of faculty of health, dian nuswantoro university, semarang indonesia. setijaningsih ra, suyoko s, sukamto m, wijayanti as, vaninda bg, rochmah en, et al. management of medical record unit services for covid-19 patients in type c hospitals: a study of legal aspects (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5326 p a g e 3 | 15 introduction the corona virus disease 2019 (covid-19) pandemic is caused by the corona virus sars-cov-2 (1), designated by the world health organization as a covid-19 pandemic on march 11, 2020 (2). transmission occurs via microdroplets or aerosol (3). common symptoms of this viral illness are fever, cough, and shortness of breath, which in case of complications can lead to pneumonia and severe acute respiratory distress (4). recommendations for prevention are frequent hand washing with alcohol or a surfactant (soap) (5) and keeping a distance of at least 1 meter from other people and wearing masks (6). the covid 19 virus can survive on medical devices, paper, and medical records (7). medical record management is an activation process that begins when the patient is admitted to the hospital, recording the patient’s medical data while receiving health services and continue with the handling of medical record files which includes storing and releasing files from the storage area to serve requests. these activities are a risk factor for disease transmission due to covid-19 (8). the patient’s medical record file of the admission will be stored according to regulations. the files are entered into a folder containing data and information on the results of services obtained by individual patients (9). however, the impact of the covid-19 pandemic has greatly affected the management of medical record documents in hospitals (10), especially the occurrence of errors in medical record service procedures, including duplication of medical record folders or medical record numbers for covid-19 patients (11). this can happen because covid-19 patients usually come back to the hospital for treatment 4-6 days after discharge. at this time the patient’s medical record is still in quarantine so that the patient gets a new medical record document. in this case continuity of medical information is not achieved, which can lead to errors. the numbering duplication that also can occur is generally caused by an inaccurate identification process that causes a patient to get more than one medical record number (12). the success of health services begins at the registration section, patients should get a medical record number, both outpatient and inpatient. numbering plays an important role in facilitating the search for medical records when patients come back for treatment (13). the purpose of this study is to analyze the management of medical record services for covid-19 patients from the point of legal aspects, including medical document management standards, procedures for protecting medical recorders and health information personnel, patient registration, and medical treatment procedures in order to prevent transmission of covid-19. methods this research is descriptive and quantitative with a cross-sectional approach (14). the key informants are the medical recorder at the patient registration area: the outpatient registration officer, the inpatient registration officer, and the emergency patient registration officer, together 15 officers and 3 triangulation informants, the heads of the medical record units of three type c hospitals, namely the gondosuwarno ungaran general hospital, the ken saras hospital bawen, and the permata medika general hospital semarang. the study uses online interviews with key informants and focus group discussions (fgd) as well as triangulation (15). the target is to identify the standard for managing medical record documents for covid-19 patients as a regulation in the medical record unit of the hospital. the measurement scale for the questionnaire follows guttman (16). the information on the collected data is summarised in annex 1. results the indonesian association of medical recorders and informatics has released the circular letter number hm 01.01./002/iii/2020 concerning procedures for medical recorders and health information (pmik) in situations of the covid-19 outbreak. only 8 of the 15 medical record officers (53%) were aware of the circular letter. setijaningsih ra, suyoko s, sukamto m, wijayanti as, vaninda bg, rochmah en, et al. management of medical record unit services for covid-19 patients in type c hospitals: a study of legal aspects (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5326 p a g e 4 | 15 the results of interviews with key informants regarding the policy on registration procedures for preventing transmission of covid-19 cases revealed that the hospital had such a policy according to 67% of the answers, while 33% stated that the hospital did not have. medical recorders wore surgical masks during working hours with an 80% compliance rate, wore surgical gloves with a 40% compliance rate, and always washed their hands with soap before completing activities in running water with a 100% compliance rate, according to interview data. (figure 1). figure 1. interview results on protection of medical and health information systems officers with personal protective equipment (ppe) the results of the interviews regarding the flow and procedure of medical record documents for new patients with covid-19 are as follows: a special computer unit with an online registration system new covid-19 patients existed in 47%, a special table for filling out new patient forms in 40%, and: screening patients by health facilities officers at the entrance to the patient registration area in 67%. 87% of medical recorders can always avoid direct contact with patients/patient s' families (figure 2). figure 2. interview results on flow and procedures for medical record document services for new patients with covid-19 cases 80 40 100 20 60 0 0 20 40 60 80 100 120 medical record and health information officers wear surgical masks during working hours medical record and health information officers wear surgical gloves during working hours medical record and health information officers always wash their hands before doing activities (either with soap and running water or with hand sanitizer) interview result medical record oficer using masks during working yes % no% 47 40 67 87 87 53 60 33 13 13 0 20 40 60 80 100 have a special computer unit with an online registration system for registration of new patients with covid19 cases have a special table for filling out new patient forms for covid-19 cases checking the patient's body temperature by health care facility staff at the entrance of patient registration medical record and health information officers officers always maintain a distance when communicating with patients/patient families medical recorders and health information officers can always avoid direct contact with patients/patient families the result of the interview regarding flow and procedure of medical record documents for new patients covid 19 yes no setijaningsih ra, suyoko s, sukamto m, wijayanti as, vaninda bg, rochmah en, et al. management of medical record unit services for covid-19 patients in type c hospitals: a study of legal aspects (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5326 p a g e 5 | 15 table 1 summarizes the procedures of handling covid-19 patients records. more than 10 yes answers out of 15 are documented only for issues f), g), n), and o). table 1. interview results on handling procedures for new patient medical record documents of covid-19 cases no. list of questions yes no total f % f % a. the patient's medical record form in the inpatient registration room is already an electronic medical record form. 6 40 9 60 15 (100%) b. paper medical record forms are available at the patient registration area. 9 60 6 40 15 (100%) c. if the answer to number b is "yes", then the patient's medical record document is entered in the check box. 4 27 11 73 15 (100%) d. for inpatients, there is a special procedure for handling covid-19 patient medical record documents before being taken to the nurse station room. 4 27 11 73 15 (100%) e. medical record documents are brought to the patient care room while the patient is being treated. 5 33 10 67 15 (100%) f. the patient's medical record document is always in the nurse station room while the patient is hospitalized. 15 100 0 0 15 (100%) g. the medical record document of the patient who will go home (recorded in the medical record unit) is given the date of receipt of the document. 15 100 0 0 15 (100%) h. medical record documents of inpatients are put in a tightly closed box for several days. 0 0 15 100 15 (100%) i. the surface of the outer cover/plastic of medical record documents is cleaned with spray sanitizer / alcohol / disinfectant. 6 40 9 60 15 (100%) j. the patient's medical record box is stored in a special room. 3 20 12 80 15 (100%) k. the filing clerk who cleans the cover of the medical record document wears medical gloves. 2 13 13 87 15 (100%) l. the sterilization procedure for medical record documents only applies to covid-19 patients who will return home after undergoing hospitalization. 0 0 15 100 15 (100%) m. medical record documents for covid-19 patients who return home from hospitalization are immediately destroyed. 0 0 15 100 15 (100%) n. the procedure for shrinking medical record documents for covid-19 patients who return home from the hospital is treated the same as general disease patients. 15 100 0 0 15 (100%) setijaningsih ra, suyoko s, sukamto m, wijayanti as, vaninda bg, rochmah en, et al. management of medical record unit services for covid-19 patients in type c hospitals: a study of legal aspects (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5326 p a g e 6 | 15 o. covid-19 patient medical record documents are classified in the general disease group in the archive retention schedule. 15 100 0 0 15 (100%) p. have a special note for the medical record document of covid-19 patients who return from the hospital. 0 0 15 100 15 (100%) the results of the survey show furthermore that 33% of key informants stated that there were still patient medical records that were left behind or mixed up in the inpatient room while the patient was being treated. this is not allowed because paper can be a medium for transmitting covid-19, even 100% of the informants answered that the medical record documents of covid-19 patients who were hospitalized were not put in a tightly closed box for several days, again not in accordance with the minimum standards set (17). interview results on flows and procedures for medical record document services, can be seen in figure 3: figure 3. interview results on flows and procedures for medical record document services discussion operational procedures for medical record services in general and specifically during the covid-19 pandemic situation, include: a) setting standards or basic controls b) measuring performance, c) comparing performance with standards and determining differences d) correcting deviations with corrective actions (18). regulations have to comprise all medical record and health information in the form of policies to apply minimum standards in accordance with se no. hm 01.01/002/iii/2020 of the indonesian association of medical recorders and informatics profession (pormiki) (19) and the standard operating procedures for handling medical records and managing information on covid-19 as outlined by who (20). the assessment of government regulation of the republic of indonesia number 46 of 2011 concerning assessment of civil servants' work performance shows that the socialization of regulations in the hospital environment is by far not complete, implying that the contents of circular letter no. hm 01.01/002/iii/2020 have not been fully implemented, possibly due to a lack of training and socialization.’ (21). the implementation of standard operating procedures must be set at 100 100 100 100 100 0 0 0 0 0 0 20 40 60 80 100 120 covid-19 survivors who come back for treatment after being hospitalized before 4-6 days will still be served with their medical record documents the new medical record document folder will be merged with the patient's old folder the medical record document folder will be given an old number medical record documents for covid-19 patients who return home after hospitalization will be stored in a general filing the patient comes for treatment before the medical record document is quarantined for 4-6 days, then the patient's medical record document will not be distributed to the service unit interview resulth on flow and procedure for medical record document service yes% setijaningsih ra, suyoko s, sukamto m, wijayanti as, vaninda bg, rochmah en, et al. management of medical record unit services for covid-19 patients in type c hospitals: a study of legal aspects (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5326 p a g e 7 | 15 minimum service standards to achieve optimal medical record services (22,23), noncompliance in hospitals can result in patient deaths and legal issues (24). our results confirm that according to 10 key informants (67%) screening of patients by officers at the entrance has not been carried out, as well as maintaining distance. hospital management is obliged to establish policies and standards for medical record services for covid-19 patients (10,25), and must have a policy on the use of standard personal protective equipment (ppe) during medical record services (26,27). in the investigated type c hospitals medical records are still paper-based or semi-electronic, which is an obstacle for the application of minimum standards referring to se no. hm 01.01/002/iii/2020. regarding a facilitated registration with an online system or provision of special computers for patients (28) we found that according to 47% of key informants the patient registration place had not an online system and 40% of the informants answered that there was no special table provided for filling in the format of identity of new patients, whereas registration officers should maintain a minimum distance of 1 m from patients and reduce direct contact with them (29). hospitals are legally responsible for the quality of care provided to patients delivered by doctors, nurses and health care professionals (30). according to article 46 paragraph 1 and paragraph 2 of law number 29 of 2004 concerning medical practice (1), every doctor or dentist in carrying out medical practice is obliged to keep medical records, which must be completed immediately after the patient has received health services (31). medical records provide evidence of all service actions, disease progression, and treatment during a patient's visit or hospitalization (32). data and information in medical records can be used for health care and treatment of patients, evidence in the process of law enforcement, educational research purposes, basic health service fee payments, and health statistical data (33). it includes a discharge resume (26,34) in accordance with the regulations of the joint commission international accreditation standards for hospitals (35). a draft discharge summary form has been designed to address problems that occur in type c hospitals if a covid-19 patient comes back for treatment before the quarantine period of medical record documents is complete (annex 2). conclusions the results of the three hospitals investigated show that 2 hospitals have not set policies and standard operating procedures for the covid19 pandemic and 1 hospital has used standard memos for medical record services during the covid-19 pandemic since 2020. all three hospitals are still implementing paper-based medical records or semi-electronic documentation. the occurrence of duplication of numbering is generally caused by an inaccurate identification process that causes patients to get more than one medical record number. the solution for covid-19 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10.11576/seejph-5326 p a g e 10 | 15 annex 1: stored data collection 1. medical record management standards for covid-19 case patients table 1. interview results on regulations for management of medical records in patients with covid-19 cases (f stands for frequency) no. list of questions yes no total f % f % a. the medical record officer is aware of the regulation of se no. hm 01.01/002/iii/2020 concerning medical recorder work procedures and health information (pmik) in covid-19 outbreak situations 8 53 7 47 15 (100%) b. medical record officers have received training on patient registration procedures for the prevention of transmission of covid19 cases 13 87 2 13 15 (100%) table 2. interview results on flow policies and procedures for medical record services for covid-19 patients no. list of questions yes no total f % f % a. have a policy on patient registration procedures for the prevention of transmission of covid-19 cases 10 67 5 33 15 (100%) b. have a policy on procedures for medical record documents for new patients for covid 19 cases 6 40 9 60 15 (100%) table 3. interview results on standard flows and procedures for medical record services for patients with covid-19 cases no. list of questions yes no total f % f % a. have standard operating procedures for patient registration for prevention of transmission of covid-19 cases 7 47 8 53 15 (100%) b. have standard operating procedures for medical record document services for new patients with covid 19 cases 4 27 11 73 15 (100%) table 4. results of focus group discussions on regulations for management of medical records of covid-19 case patients against triangulation (it) informants setijaningsih ra, suyoko s, sukamto m, wijayanti as, vaninda bg, rochmah en, et al. management of medical record unit services for covid-19 patients in type c hospitals: a study of legal aspects (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5326 p a g e 11 | 15 it 1, 2, 3 there is no special socialization of regulations in the form of circular letter no. hm 01.01/002/iii/2020 concerning medical recorder work procedures and health information in situations of the covid-19 outbreak. there has been no special training for medical record services to patients in the context of preventing the transmission of covid-19 cases or managing medical record documents for covid-19 patients. there are no policies and standard operating procedures specifically for patient medical record services in the context of preventing the transmission of covid19 cases there are no policies and standard operating procedures specifically for the management of medical record documents for covid-19 patients. it 3 there is a medical record service memo for covid-19 patients for emergency conditions in 2020 which was agreed to be carried out in the medical record unit. conclusion there are no policies and standard operating procedures for patient medical record services in the context of preventing the transmission of covid-19 cases or managing the medical record documents for covid-19 patients in 3 type c hospitals, regency and semarang city. 2. procedures for the protection of medical officers and health information systems with personal protective equipment (ppe) table 5. interview results on protection of medical and health information systems officers with personal protective equipment (ppe) no. list of questions yes no total f % f % a. medical record and health information officers wear surgical masks during working hours 12 80 3 20 15 (100%) b. medical record and health information officers wear surgical gloves during working hours 6 40 9 60 15 (100%) c. medical record and health information officers always wash their hands before doing activities (either with soap and running water or with hand sanitizer) 15 100 0 0 15 (100%) 3. patient registration procedures for prevention of transmission of covid-19 setijaningsih ra, suyoko s, sukamto m, wijayanti as, vaninda bg, rochmah en, et al. management of medical record unit services for covid-19 patients in type c hospitals: a study of legal aspects (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5326 p a g e 12 | 15 table 6. interview results on flow and procedures for medical record document services for new patients with covid-19 cases no. list of questions yes no total f % f % a. have a special computer unit with an online registration system for registration of new patients with covid-19 cases 7 47 8 53 15 (100%) b. have a special table for filling out new patient forms for covid-19 cases 6 40 9 60 15 (100%) c. checking the patient's body temperature by health care facility staff at the entrance of patient registration 10 67 5 33 15 (100%) d. medical record and health information officers always maintain a distance when communicating with patients/patient families 13 87 2 13 15 (100%) e. medical recorders and health information officers can always avoid direct contact with patients/patient families 13 87 2 13 15 (100%) table 7. results of focus group discussion regarding the flow and procedure of medical record document services for new patients with covid-19 cases against triangulation informants it 1, 2, 3 there are no computers and special desks available for registration of new patients who come at the patient reception center. have a barrier between medical record and health information officers and patients at the patient reception center counter. have an online registration application. it 3 have a non-permanent barrier (plastic or glass) between medical recorders and health information officers and patients at the patient reception center counter. have an online/whatsapp registration application for the convenience of patients via mobile phones. conclusion new patient registration services at the patient reception center counter are still served at the patient registration counter during the covid-19 pandemic. 4. procedure for management of medical record documents for prevention of transmission of covid-19 cases setijaningsih ra, suyoko s, sukamto m, wijayanti as, vaninda bg, rochmah en, et al. management of medical record unit services for covid-19 patients in type c hospitals: a study of legal aspects (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5326 p a g e 13 | 15 table 8. interview results on handling procedures new patient medical record documents for covid-19 cases no. list of questions yes no total f % f % a. the patient's medical record form in the inpatient registration room is already an electronic medical record form. 6 40 9 60 15 (100%) b. paper medical record forms are available at the patient registration area. 9 60 6 40 15 (100%) c. if the answer to number b is "yes", then the patient's medical record document is entered in the check box. 4 27 11 73 15 (100%) d. for inpatients, there is a special procedure for handling covid-19 patient medical record documents before being taken to the nurse station room. 4 27 11 73 15 (100%) e. medical record documents are brought to the patient care room while the patient is being treated. 5 33 10 67 15 (100%) f. the patient's medical record document is always in the nurse station room while the patient is hospitalized. 15 100 0 0 15 (100%) g. the medical record document of the patient who will go home (recorded in the medical record unit) is given the date of receipt of the document. 15 100 0 0 15 (100%) h. medical record documents of inpatients are put in a tightly closed box for several days. 0 0 15 100 15 (100%) i. the surface of the outer cover/plastic of medical record documents is cleaned with spray sanitizer / alcohol / disinfectant. 6 40 9 60 15 (100%) j. the patient's medical record box is stored in a special room. 3 20 12 80 15 (100%) k. the filing clerk who cleans the cover of the medical record document wears medical gloves. 2 13 13 87 15 (100%) l. the sterilization procedure for medical record documents only applies to covid-19 patients who will return home after undergoing hospitalization. 0 0 15 100 15 (100%) m. medical record documents for covid-19 patients who return home from hospitalization are immediately destroyed. 0 0 15 100 15 (100%) n. the procedure for shrinking medical record documents for covid-19 patients who return home from the hospital is treated the same as general disease patients. 15 100 0 0 15 (100%) o. covid-19 patient medical record documents are classified in the general disease group in the archive retention schedule. 15 100 0 0 15 (100%) p. have a special note for the medical record document of covid-19 patients who return from the hospital. 0 0 15 100 15 (100%) setijaningsih ra, suyoko s, sukamto m, wijayanti as, vaninda bg, rochmah en, et al. management of medical record unit services for covid-19 patients in type c hospitals: a study of legal aspects (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5326 p a g e 14 | 15 table 9. interview results on flows and procedures for medical record document services no. list of questions yes no total f % f % a. covid-19 survivors who come back for treatment after being hospitalized before 4-6 days will still be served with their medical record documents. 15 100 0 0 15 (100%) b. the new medical record document folder will be merged with the patient's old folder. 15 100 0 0 15 (100%) c. the medical record document folder will be given an old number, 15 100 0 0 15 (100%) d. medical record documents for covid-19 patients who return home after hospitalization will be stored in a general filing. 15 100 0 0 15 (100%) e. the patient comes for treatment before the medical record document is quarantined for 4-6 days, then the patient's medical record document will not be distributed to the service unit. 15 100 0 0 15 (100%) table 10. results of focus group discussion on medical record management procedures for prevention of transmission of covid-19 cases to triangulation informants (it) it 1, 2, 3 medical record documents of covid-19 patients who are treated in the isolation room remain at the nurse station, not brought into the patient isolation room. post-hospitalized covid-19 survivors who come back for treatment before 3 days will create a new drm folder with the old medical record number. medical record documents for hospitalized patients in covid-19 cases are quarantined for at least 3 days before entering the medical record unit. setijaningsih ra, suyoko s, sukamto m, wijayanti as, vaninda bg, rochmah en, et al. management of medical record unit services for covid-19 patients in type c hospitals: a study of legal aspects (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5326 p a g e 15 | 15 annex 2: discharge summary form design mr.01/rev.01/2021 heinz m. the potential of men’s sheds as a resource for men coping with mental health challenges and addiction (case study). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5766 p a g e 1 | 5 case study the potential of men’s sheds as a resource for men coping with mental health challenges and addiction melinda heinz1 1) upper iowa university, fayette, iowa, usa corresponding author: melinda heinz, phd associate professor of psychology 605 washington st. p.o. box 1857 215 liberal arts building upper iowa university fayette, ia 52142, usa email: heinzm@uiu.edu mailto:heinzm@uiu.edu heinz m. the potential of men’s sheds as a resource for men coping with mental health challenges and addiction (case study). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5766 p a g e 2 | 5 abstract men’s sheds are defined as grassroots community-based organizations comprised of men coping with mental health challenges and addiction. men in need experience the benefits of receiving support from other men and feel that their levels of loneliness and depression declined after they joined the men’s shed. men’s sheds could serve as a mental health refuge for a variety of men with diverse needs. it may be worthwhile to pilot a program investigating the efficacy of using men’s sheds to support individuals recovering from addictions. conflicts of interest: none declared source of funding: none declared heinz m. the potential of men’s sheds as a resource for men coping with mental health challenges and addiction (case study). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5766 p a g e 3 | 5 for the last four months i have been fortunate to be immersed in several men’s sheds throughout ireland including both rural and more urban settings. i received approval to do the research from the technological university of the shannon: midlands midwest (tus). men’s sheds are defined as grassroots community-based organizations comprised of men who come together to engage in discussion “shoulder to shoulder” while working on a craft (e.g., woodwork, art, gardening, etc.; (1). men’s sheds are informal networks and create welcoming and inclusive spaces for men. men’s sheds originated in australia (2) and have expanded to other parts of europe including the u.k. and ireland. although men’s sheds exist in america, they are not as widespread. currently, the u.s. has 17 men’s sheds dispersed throughout country (3). their inclusive and accepting ethos offer a wide array of benefits to their members. during my research with the men’s sheds i set out to learn more about how irish men’s sheds contributed to purpose and meaning in the lives of older men. men i interviewed spoke about the importance of having a place to gather with other men and the benefit of having a purpose when they got up each day. the men discussed the benefits of receiving support from other men and felt that their levels of loneliness and depression declined after they joined the men’s shed. after completing and reflecting on the interviews it was apparent to me that the men’s sheds could serve as a mental health refuge for a variety of men with diverse needs. for example, kelly et al.4 suggested that men’s sheds may be especially helpful for populations of men with unique needs, including addiction. as mental health concerns and addictions increase around the world (5), it is important to consider a wide array of interventions and solutions to address these challenges. men’s sheds may offer a worthwhile support framework for these men. research indicates that men are more likely to suffer from substance abuse and antisocial disorders as compared to women (6) and the world health organization (who)7 reported that men’s risk for premature mortality is higher than women’s. men are less likely to go to the doctor, more likely to engage in riskier behaviors, and imbibe higher quantities of alcohol (7). they also face greater risk of death from opioid overdose compared to women (8). given these gendered health differences, men’s sheds may provide spaces to address some of the health inequities between men and women. wilson and cordier9 explained that men’s sheds were ideal environments for promoting men’s health and wilson et al.10 reported that men’s sheds served as safe spaces where members felt comfortable talking about their health concerns. of the limited research available, it seems men who engage with men’s sheds felt that the environment positively contributed to their wellbeing. for example, findings indicate that men who participated in men’s sheds reported improved wellbeing, including better selfworth and increased ability to cope with depression (11). however, additional research is required to understand the effectiveness of men’s sheds and its usefulness in helping members cope with mental health and other challenges. likewise, it may be worthwhile to pilot a program investigating the efficacy of using men’s sheds to support individuals recovering from addictions. gendered approaches for coping with addiction are not new, but men’s sheds already possess the structure to serve as ideal support infrastructures. milligan et al.12 explained that men are reluctant to join groups if they perceive the group to be dominated by women and can struggle to make friendships, heinz m. the potential of men’s sheds as a resource for men coping with mental health challenges and addiction (case study). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5766 p a g e 4 | 5 particularly in older adulthood. the ethos and constitution of men’s sheds also appear to foster healthy environments for all men. for example, the men’s sheds constitution states that the men’s sheds spaces are designed to be substance free (1), creating safe environments for men in the early stages of recovery. robertson & nesvåg13 noted that it is best when recovery environments include social networks of individuals who do not use substances. the structure and routine of visiting a place like the men’s shed could also be beneficial for individuals focused on addiction recovery. for example, men could attend the men’s sheds throughout the week and find benefit from the comradery, support, and guidance of other men (4) and gain opportunities to learn new skills. building routine and structure into one’s life is beneficial when coping with recovery (14) and engaging in regular visits to the men’s sheds would likely be a positive outlet for these men. including rural men’s sheds for pilot interventions investigating the efficacy of men’s sheds as support resources could also be useful as mental health services and resources for addiction are less widespread in these areas (15, 16). in addition, monnat and rigg17 explained that opioid related deaths in rural areas have increased significantly in the last 20 years and that initiatives designed to combat the expanding issues in rural areas have been relatively ineffective. likewise, patel et al.18 advocated for additional treatment options for individuals with opioid addictions, particularly in rural areas. conducting interventions in australia, the u.k., or ireland would be ideal given the wide array of men’s sheds available in both rural and urban areas. if successful, interventions could be rolled out in parts of the u.s. where men’s sheds are less widely known. perhaps the number of men’s sheds would increase in america if research findings demonstrated the effectiveness of these spaces as support resources for men coping with mental health challenges and addictions. references 1. irish men’s sheds association what is a men’s shed?, dublin, ireland: https://menssheds.ie/aboutmens-sheds/ (accessed: may 3, 2022). 2. carragher l, golding b. (2015). older men as learners: irish men’s sheds as an intervention. adult education quarterly, 2015;65:152168. 3. u.s. men’s sheds find a men’s shed. https://usmenssheds.org/finda-shed/ (accessed: may 3, 2022) 4. kelly d, steiner a, mason h, teasdale s. men’s sheds: a conceptual exploration of the causal pathways for health and well-being. health and social care in the community 2019;27:1147-1157. 5. world health organization depression and other common mental disorders: global health estimates, geneva, switzerland: https://apps.who.int/iris/bitstream/ha ndle/10665/254610/who-msdmer-2017.2-eng.pdf (accessed may 11, 2022). 6. rosenfield s, smith d. (2010). gender and mental health: do men and women have different amounts or types of problems? in scheid tl, brown, tn, editors. a handbook for the study of mental health: social contexts, theories, and systems. cambridge: cambridge university press, 2010: 256-267. 7. world health organization men’s health and well-being in the who european region, geneva, switzerland: https://journals.sagepub.com/action/dosearch?target=default&contribauthorstored=nesv%c3%a5g%2c+sverre+martin https://menssheds.ie/about-mens-sheds/ https://menssheds.ie/about-mens-sheds/ https://usmenssheds.org/find-a-shed/ https://usmenssheds.org/find-a-shed/ https://apps.who.int/iris/bitstream/handle/10665/254610/who-msd-mer-2017.2-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/254610/who-msd-mer-2017.2-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/254610/who-msd-mer-2017.2-eng.pdf heinz m. the potential of men’s sheds as a resource for men coping with mental health challenges and addiction (case study). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5766 p a g e 5 | 5 https://www.euro.who.int/en/healthtopics/healthdeterminants/gender/mens-health (accessed: may 11, 2022). 8. silver er, hur c. (2020). gender differences in prescription opioid use and misuse: implications for men’s health and the opioid epidemic. preventive medicine 2020,131; 105946. 9. wilson nj, cordier r. (2013). a narrative review of men’s sheds literature: reducing social isolation and promoting men’s health and well-being. health & social care in the community 2013;21:451-463. 10. wilson nj, cordier r, doma k., misan g, vaz, s. men’s sheds function and philosophy: towards a framework for future research and men’s health promotion. health promotion journal of australia 2015;26:133-142. 11. crabtree l, tinker a, glaser, k. men’s sheds: the perceived health and wellbeing benefits. working with older people 2018;22:101-110. 12. milligan c, neary d, payne s, hanrattys b, irwin, p, dowrick c. (2016). older men and social activity: a scoping review of men’s sheds and other gendered interventions. ageing & society, 2016;36:895-923. 13. robertson ie, nesvåg sm. into the unknown: treatment as a social arena for drug users’ transition into a non-using life. nordic studies on alcohol and drugs 2019;36:248-266. 14. davies s, filippopoulos p. (2015). changes in psychological time perspective during residential addiction treatment: a mixedmethods study. journal of groups in addiction & recovery 2015;10:249270. 15. lister j l, weaver a, ellis jd, himle ja, ledgerwood dm. a systematic review of rural-specific barriers to medication treatment for opioid use disorder in the united states. the american journal of drug and alcohol abuse 2020;46:273-288. 16. ziller ec, anderson nj, coburn a f. access to rural mental health services: service use and out-ofpocket costs. the journal of rural health 2010;26:214-224. 17. monnat sm, rigg kk. university of new hampshire carsey school of public health, durham, nh). the opioid crisis in rural and small town america. carsey research national issue brief; summer 2018. report no. 135. https://scholars.unh.edu/cgi/viewcont ent.cgi?article=1342&context=carse y (accessed: may 13, 2022). 18. patel k, bunachita s, agarwal aa, lyon a, patel u k (2021). opioid use disorder: treatments and barriers. cureus 2021;13:e13173. __________________________________________________________________________________________ © 2022 heinz; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.euro.who.int/en/health-topics/health-determinants/gender/mens-health https://www.euro.who.int/en/health-topics/health-determinants/gender/mens-health https://www.euro.who.int/en/health-topics/health-determinants/gender/mens-health https://journals.sagepub.com/action/dosearch?target=default&contribauthorstored=nesv%c3%a5g%2c+sverre+martin https://scholars.unh.edu/cgi/viewcontent.cgi?article=1342&context=carsey https://scholars.unh.edu/cgi/viewcontent.cgi?article=1342&context=carsey https://scholars.unh.edu/cgi/viewcontent.cgi?article=1342&context=carsey naum a, toçi e, toçi d, burazeri g, van kessel r, czabanowska k. correlates of level of satisfaction among primary health care workers in albania (original research). seejph 2022, posted: 23 march 2022. doi: 10.11576/seejph-5346 p a g e 1 | 17 original research correlates of level of satisfaction among primary health care workers in albania alvi naum1,2, ervin toçi3,4, dorina toçi3,4, genc burazeri1,3, robin van kessel1, katarzyna czabanowska1 1 department of international health, school caphri (care and public health research institute), maastricht university, maastricht, netherlands; 2 local health care unit, korça, albania; 3 faculty of medicine, university of medicine, tirana, albania; 4 institute of public health, tirana, albania. corresponding author: alvi naum, msc; address: rr. 10 korriku, nr. 5, l. 13, 7001, korça, albania; e-mail: alvinaum@hotmail.com naum a, toçi e, toçi d, burazeri g, van kessel r, czabanowska k. correlates of level of satisfaction among primary health care workers in albania (original research). seejph 2022, posted: 23 march 2022. doi: 10.11576/seejph-5346 p a g e 2 | 17 abstract aim: the aim of this study was to explore the level of satisfaction of primary health care staff in albania and the factors associated with it. methods: a cross-sectional study was conducted in tirana city, the albanian capital, from 11 november 2020 until 25 november 2020. among all health centers (hcs) and health centers of specialties (hcss) of tirana municipality, there were selected randomly a hc in rural areas, a hc in urban areas and one hcs. all the staff (doctors and nurses) being present at the time of data collection was interviewed, using an international standardized tool (the dartmouthhitchcock medical center instrument) assessing the satisfaction with various elements of the work in phc, validated in albanian. a total of 102 phc staff were included in the study. binary logistic regression was used to assess the association of staff satisfaction with independent factors. results: the aspects of work most appreciated by phc staff (% satisfied or very satisfied) were: respectful treatment by colleagues (78.2%), staff morale and their positive attitude towards work (73.2%). the most disliked aspects of work by phc staff (% dissatisfied or very dissatisfied) were: current salary (60.8%), stress at work (38.3%), physical and medical infrastructure in the institution (27%). staff in rural hcs, older staff, females and nurses and family doctors are more likely to be satisfied compared to their respective colleagues. conclusion: our findings suggest various factors associated with the satisfaction of phc staff in albania. these findings could be guiding future efforts aiming to improve the work conditions of the professionals working in primary health care in albania. keywords: albania, cross-sectional, primary health care, staff satisfaction. conflicts of interest: none declared. acknowledgment: this study was funded by the “health for all project” in albania (hap.org.al), which is a project of the swiss agency for development and cooperation (sdc). naum a, toçi e, toçi d, burazeri g, van kessel r, czabanowska k. correlates of level of satisfaction among primary health care workers in albania (original research). seejph 2022, posted: 23 march 2022. doi: 10.11576/seejph-5346 p a g e 3 | 17 introduction primary health care (phc) is the point of entry of individuals/patients/users or clients to the health system representing the stable point of care over time (1). the function of primary health care is to coordinate health care for people and their multiple health needs throughout life and throughout the continuity of care provided both in phc institutions and communities, and for individuals and human populations; thus, phc is essential for the achievement of universal health coverage (1). phc is the most comprehensive, equitable, cost-effective and efficient approach to enhancing people's physical and mental health, as well as social welfare (2). an optimized effective phc is critical for making health systems resilient and more responsive to crisis situations or increased demand for services, such as with the covid-19 pandemic (2). an effective phc implies that users have easy and convenient access to trusted providers (3). increasing the availability of primary health care is associated with increased patient satisfaction and reduces spending on health care (4). a stronger primary health care system tends to be more pro-poor, more equal and more accessible compared to health systems based on specialist care (4). the use of primary health care reduces costs by increasing patient satisfaction without adverse effects on the quality of care or patient treatment outcomes as compared to the provision of services through specialist physicians; in addition, replacing the provision of some services from the secondary health level with those offered in phc has demonstrated to be a more cost-effective approach (4). however, the expansion of phc services may not always and necessarily be associated with cost reductions due to the risk of re-identifying unmet needs, improving access and tendencies to increase and expand service use (4), and, therefore a detailed analysis of the effects of the expansion of the phc system is needed as well as an analysis to at what extent and depth this expansion should take place. health care providers are of critical importance in assuring the quality of phc services because their contribution is essential to the effectiveness, safety, equality, and timeliness of phc services (5). therefore, in order to achieve the goals of the medical visit, in addition to the satisfaction of patients, which refers to the fulfillment of patients’ expectations with the health encounter (6), it is also important for the medical staff to be satisfied and to be able to meet the relevant expectations in terms of self-realization, personal career objectives, income from the provision of care for patients or users of the health care system, etc. international literature suggests that the satisfaction of healthcare professionals is related to both patient satisfaction and the quality of care provided and more favorable health outcomes (7-9). moreover, the way medical staff communicates with patients seems to have a significant effect on the level of patient satisfaction, as evidenced by the international literature: not applying the dominant position, being caring and committed to patients, and holding a positive attitude, have a favorable impact on the smooth running of the relationship between health personnel and patients (10). on the other hand, the characteristics of physicians working in phc (such as gender, work experience, and specialty) seem to influence their relationship with patients (11), and subsequently to the quality of phc. also, non-verbal communication seems to be very important in the doctor-patient relationship (12). the extent to which primary health care staff is satisfied is influenced by several factors, including salary, individual characteristics, infrastructure of health care institutions, time pressure, autonomy in decision making, professional relationships with colleagues, etc. (13-15). work stress also reduces the satisfaction of health personnel and the ability to have control over the schedule of visits and working hours seem to be associated with greater job naum a, toçi e, toçi d, burazeri g, van kessel r, czabanowska k. correlates of level of satisfaction among primary health care workers in albania (original research). seejph 2022, posted: 23 march 2022. doi: 10.11576/seejph-5346 p a g e 4 | 17 satisfaction (16). likewise, job satisfaction or dissatisfaction is related to doctors' plans to leave work, where younger doctors were more likely to plan to leave medical practice in the future, and then this indicator decreased with the increasing age of doctors; likewise, dissatisfaction with current salary and the surrounding community was strongly linked to physicians' plans to leave work (17). the phc staff has a very important role to play in reducing health care costs, through the implementation of the “gateway” function by which individuals in need make contact with the health care system (18). this is an issue of critical importance for every country in the world, including albania. the recently implemented reforms in phc in our country aim precisely at strengthening primary health care and increasing the ability of phc to serve as a gateway to the health system by providing quality service to people in need and, at the same time, reducing costs. in this context, it is important that staff working in phc feels satisfied when carrying out dayto-day health care activities. given that in albania the information about phc staff satisfaction and the factors associated with it is scarce, we carried out the current study in order to obtain a clearer picture and deeper analysis of these issues inextricably linked to the quality of health care in phc. methods a cross-sectional study was conducted in tirana city, the albanian capital, from 11 november 2020 until 25 november 2020. study population the target population was the phc staff, both doctors and nurses, working in the structures of primary health care in tirana, albania. the phc system in tirana is composed of health centers (hcs) and health centers of specialties (hcss). in total there are 31 hcs and 3 hcss in the tirana municipality. among 31 hcs, 11 hcs are located in urban areas and the remaining 20 hcs are located in rural areas; hcss, on the other hand cover hcs in both urban and rural areas, according to their geographic location. given that it was not possible to include all hcs and hcss in the current study, then we decided to select one phc facility from each level: urban hcs, rural hcs and hcss. among all the hscs, one of them was randomly selected (the health center of specialties no. 1); among all the urban hcs, one of them was randomly selected (health center no. 8) and among the rural hcs one of them was randomly selected (farka health center) as well. a total of 102 phc providers who were present at the included hcs and the hcs during the study timeframe, participated in the study. these 102 individuals represent more than half of the entire staff working in the selected phc facilities (n=182). data collection face-to-face interviews using a standardized instrument with the relevant phc health personnel of these health institutions were carried out to obtain the data. a questionnaire adapted from the dartmouth-hitchcock medical center instrument (19) was used to collect information on the satisfaction of health personnel working in phc. this questionnaire covers various aspects of working in primary health care, including satisfaction with the work environment, health facility, equipment, workload, salary, etc., and can be used by physicians and nurses working at this level. the primary care staff satisfaction questionnaire is also validated in albanian, through previous efforts of researchers (20). similarly, in the questionnaire used in the current study the answer options are built on the likert scale with five options available, where the extreme values (1-5) mean 1"strongly agree/very satisfied" and 5"strongly disagree/very dissatisfied". the staff questionnaire also contained some general socio-demographic questions such as age, gender, place of residence, occupation, work experience in naum a, toçi e, toçi d, burazeri g, van kessel r, czabanowska k. correlates of level of satisfaction among primary health care workers in albania (original research). seejph 2022, posted: 23 march 2022. doi: 10.11576/seejph-5346 p a g e 5 | 17 general and experience in the current workplace, and participation in various scientific and training activities. piloting of the questionnaire before being applied on a large scale, the staff satisfaction questionnaire was piloted among a limited number of 7 providers. in general, the questions were understood quite well and there were no particular problems with the instrument. this is probably because the questionnaire was previously validated in the albanian language, as mentioned earlier. regarding the reliability of the staff satisfaction questionnaire in the pilot phase, the internal consistency coefficient (cronbach’s alpha coefficient) was 0.822. ethical considerations all participants were informed about the purpose and objectives of the study. they were assured of the confidentiality and anonymity; in no case and under no circumstances would it be possible to relate the answers to the specific person and it would be impossible to disclose the identity of the participants. all study participants gave their verbal approval to participate. this study was approved by the medical ethics committee, with decision number 303/43, dated 12/10/2020. statistical analysis statistical analysis of the data was based on the type of variables used in the study. measures of central tendency (mean) and dispersion (standard deviation) were used to describe numerical data. for categorical data, absolute numbers and corresponding percentages were used. to assess the reliability of the instruments in the study, the internal consistency assessment of the questionnaire was used based on the calculation of cronbach's alpha internal consistency coefficient. to study the relationship between categorical variables, the square hi test was used. in-depth statistical analysis consisted of binary logistic regression test (where provider satisfaction score was dichotomized). a staff satisfaction summary score (including 9 questions) was calculated for each participant; then, this score was dichotomized into two categories: “satisfied” (under-the-median score) versus “dissatisfied” (over-the-median score). this categorization was then used to distinguish the percentages of staff who were satisfied (or dissatisfied) with different aspects of their work. this variable was used in binary logistic regression models to identify factors related to staff satisfaction with phc. in order to control the potential confounding effect of age and gender, binary logistic regression models controlled for these factors and reported standardized odds ratios (or) and corresponding 95% (95% ci) confidence intervals. in all cases, the correlations were considered statistically significant when if p ≤0.05. all statistical analyzes were performed using the statistical package for social sciences (spss), version 21. results table 1 presents general data on the phc staff in the study. the average age of the health staff included in the study was 42 years with about 30% belonging to the 3140 age group. more than 9 in 10 phc staff were female (93.1%). the average work experience in the profession was 16.9 years and participants had worked in the current job for 11.3 years on average. about 44% of respondents declared that they have been involved in scientific research, 33.8% had referred at national conferences and 7% at international conferences. about 6% were also engaged in writing scientific articles. naum a, toçi e, toçi d, burazeri g, van kessel r, czabanowska k. correlates of level of satisfaction among primary health care workers in albania (original research). seejph 2022, posted: 23 march 2022. doi: 10.11576/seejph-5346 p a g e 6 | 17 table 1. general information about study participants variable absolute number percentage total 102 100.0 % phc facility hcs nr. 1 hc nr. 8 hc farkë 53 40 9 52.0 % 39.2 % 8.8 % age (mean ± standard deviation) 42.0±10.6 age-group 23-30 years 31-40 years 41-50 years >50 years 17 * 30 17 30 17.2 % 30.3 % 26.3 % 26.3 % sex male female 7 95 6.9 % 93.1 % profession general practitioner family doctor specialist doctor nurse 8 16 11 67 7.8 % 15.7 % 10.8 % 65.7 % work experience in profession (mean ± standard deviation) 16.9±10.6 work experience at this work place (mean ± standard deviation) 11.3±8.6 participation in various activities scientific research publication of scientific articles presentations at national conferences presentations at international conferences all the above 31 4 24 5 7 43.7 % 5.6 % 33.8 % 7.0 % 9.9 % * any discrepancies with the total number is due to lack of information. table 2 presents data on the distribution of opinions of phc staff regarding the evaluation of various aspects of their work environment. data are presented in percentages. the aspects of work most appreciated by phc staff (percentage strongly agreeing or agreeing) were: respectful treatment by colleagues (78.2%), staff morale and their positive attitude towards work (73.2%), ease of asking others about the way the staff takes care of the patients (71%), the noticing from the others when the work is done well (61.9%), while for other aspects about half of the staff was very much satisfied or satisfied.meanwhile, the most disliked aspects of work by phc staff (percentage who reported dissatisfaction or a lot of dissatisfaction) were: current salary (60.8% were dissatisfied or very dissatisfied), stress at work (38.3% were dissatisfied or very dissatisfied), physical and medical infrastructure in the institution (27% were dissatisfied or very dissatisfied), and the fact that this institution was not a better place to work compared to 12 months ago (24.2% were dissatisfied or very dissatisfied). naum a, toçi e, toçi d, burazeri g, van kessel r, czabanowska k. correlates of level of satisfaction among primary health care workers in albania (original research). seejph 2022, posted: 23 march 2022. doi: 10.11576/seejph-5346 p a g e 7 | 17 table 2. satisfaction with different elements of the workplace please tell us how satisfied or dissatisfied you are with the following aspects related to your work or health institution in the last 12 months strongly agree and/or very satisfied 1 2 3 4 strongly disagree and/or very dissatisfied 5 1. i am treated with respect every day by everyone that works in this practice 36.6% 41.6% 18.8% 1.0% 2.0% 2. i am given everything i need— tools, equipment, and encouragement—to make my work meaningful to my life 9.0% 30.0% 34.0% 16.0% 11.0% 3. when i do good work, someone in this practice notices that i did it 32.0% 29.9% 24.7% 10.3% 3.1% 4. working in this health institution is very stressful 7.8% 14.7% 39.2% 24.5% 13.7% 5. it is very easy to ask anyone about how we care for patients 25.8% 45.4% 16.5% 9.3% 3.1% 6. the morale of the staff and their attitudes to work here are very positive 35.6% 37.6% 16.8% 6.9% 3.0% 7. this health institution is a better place to work than it was 12 months ago 15.2% 39.4% 21.2% 14.1% 10.1% 8. i would recommend this health institution as a very good place to work 26.7% 26.7% 32.7% 10.9% 3.0% 9. i am satisfied with my salary 6.2% 33.0% 37.1% 23.7% * row percentages. table 3 shows the information on phc staff satisfaction level by the characteristics of the participants. the percentage of staff satisfied with their working environment is significantly higher among employees of hc farka (88.9%) compared to much lower percentages in hcs no. 1 (42.3%) and hc nr. 8 (46.7%), p=0.035. meanwhile, the differences in the proportions of satisfied staff according to other socio-demographic characteristics were not statistically significant (p>0.05 in each case); however, clinical significance suggests that the percentage of those satisfied increases with in creasing staff age (from 40% among staff aged 23-30 years, to 68.2% among staff aged>50) and among females (48.8%) compared to males (42.9%). in terms of profession or specialty, it seems that higher percentages of nurses (57.6%) and family doctors (42.9%) are satisfied with their work while the most dissatisfied are the general practitioners of phc (only 12.5% are satisfied while 87.5% are dissatisfied) and specialist doctors working here (only 30% satisfied and the remaining 70% were dissatisfied). these differences have borderline statistical significance (p=0.053). naum a, toçi e, toçi d, burazeri g, van kessel r, czabanowska k. correlates of level of satisfaction among primary health care workers in albania (original research). seejph 2022, posted: 23 march 2022. doi: 10.11576/seejph-5346 p a g e 8 | 17 finally, higher percentages of staff who gave presentations at international scientific conferences (60% of them) and national conferences (52.4%) and staff engaged in publishing scientific articles (50% of them) seem to be satisfied with their work compared to colleagues of other categories (table 3). table 3. distribution of staff satisfaction level according to their basic characteristics variable overall score (9 items)* p-value dissatisfied satisfied phc facility hcs nr. 1 hc nr. 8 hc farkë 30 (57.7) a 16 (53.3) 1 (11.1) 22 (42.3) 14 (46.7) 8 (88.9) 0.035b age-group 23-30 years 31-40 years 41-50 years >50 years 9 (60.0) 17 (58.6) 12 (54.5) 7 (31.8) 6 (40.0) 12 (41.4) 10 (45.5) 15 (68.2) 0.211 b sex male female 4 (57.1) 43 (51.2) 3 (42.9) 41 (48.8) 0.762 b profession general practitioner family doctor specialist doctor nurse 7 (87.5) 8 (57.1) 7 (70.0) 25 (42.4) 1 (12.5) 6 (42.9) 3 (30.0) 34 (57.6) 0.053 b participation in various activities scientific research publication of scientific articles presentations at national conferences presentations at international conferences all the above 17 (65.4) 2 (50.0) 10 (47.6) 2 (40.0) 4 (57.1) 9 (34.6) 2 (50.0) 11 (52.4) 3 (60.0) 3 (42.9) 0.717 b * for each participant a summary score (including 9 questions) was calculated for the staff satisfaction level; then, the result was dichotomized into two categories: “satisfied” (below-the-median score) versus “dissatisfied” (above-the-median score). a absolute number and row percentage (in parenthesis). b p-value according to chi square test. note: any discrepancies with the total number is due to lack of information. table 4 presents data on the association of staff satisfaction level with the independent factors included in the study. after controlling the confounding effects of age and gender, no independent factor was found to be statistically significantly related to the satisfaction of phc staff with the work environment where they work. however, in terms of clinical significance, some differences are worth noting. thus, the most satisfied employees were those working in hc farka (or = 9.39) compared to the staff of hcs no.1, while the odds of satisfaction were almost similar among the staff of hcs nr. 1 and hc no. 8.on the other hand, the likelihood of satisfaction with current work increased with increasing age of health personnel (or = 3.18 in staff aged >50 years), were higher among female staff (or = 1.16), nurses (or = 6.18) and family physicians who work in phc (or = 3.57) [whereas general practitioners and specialist physicians were the least likely to be satisfied with current work in phc]. naum a, toçi e, toçi d, burazeri g, van kessel r, czabanowska k. correlates of level of satisfaction among primary health care workers in albania (original research). seejph 2022, posted: 23 march 2022. doi: 10.11576/seejph-5346 p a g e 9 | 17 each year increase of experience in the current workplace was associated with a 1.04fold increase in the likelihood of current job satisfaction at the phc. attendance at international conferences, national conferences and writing scientific articles increased the likelihood of satisfaction with the current work in phc by 2.02 times, 1.5 times and 1.5 times, respectively. table 4. association of staff satisfaction level with independent factors in the study – odds ratios (ors) by binary logistic regression variable model * or ** 95%ci § p-value† phc facility hcs nr. 1 hc nr. 8 hc farkë 1.00 1.23 9.39 reference 0.46-3.28 0.92-96.44 0.163 (2) 0.674 0.059 age-group 23-30 years 31-40 years 41-50 years >50 years 1.00 1.05 1.24 3.18 reference 0.29-3.75 0.33-4.71 0.80-12.56 0.236 (3) 0.941 0.749 0.100 sex male female 1.00 1.16 reference 0.23-5.70 0.860 profession general practitioner family doctor specialist doctor nurse 1.00 3.57 1.66 6.18 reference 0.30-43.07 0.12-22.30 0.68-56.41 0.161 (3) 0.316 0.703 0.107 experience in profession (years) 0.99 0.91-1.07 0.717 experience working here (years) 1.04 0.96-1.13 0.299 participation in various activities scientific research publication of scientific articles presentations at national conferences presentations at international conferences all the above 0.71 1.50 1.50 2.02 1.00 0.724 (4) 0.12-4.26 0.12-18.89 0.24-9.56 0.17-24.03 reference 0.718 (2) 0.709 0.752 0.669 0.578 * model: simultaneously adjusted for age and gender. adjusted ors. ** odds ratio (or: satisfied vs. dissatisfied), according to binary logistic regression test. § 95% interval of confidence (95% ci) for or. † p-value according to binary logistic regression test and degrees of freedom (in parentheses). table 5 shows the information about specific changes that, according to the opinions of the phc staff, would make the current health institution a better place for patients and a better place to work. the majority of staff (68.6%) stated that in order to improve patient care there is a need for new working facilities and better equipment, followed by 10% who think that there is a need for additional staff, 5.7% think that it is necessary increase the level of service, 4.3% suggest reducing the workload with patients, etc. unexpectedly, only 1.4% of staff suggested salary improvement. regarding the changes that would improve the work of the phc staff, 67.2% stated that there is a need for naum a, toçi e, toçi d, burazeri g, van kessel r, czabanowska k. correlates of level of satisfaction among primary health care workers in albania (original research). seejph 2022, posted: 23 march 2022. doi: 10.11576/seejph-5346 p a g e 10 | 17 new working facilities and better equipment, followed by 7.5% who think that there is a need to strengthen anti-covid protection measures and that many mentioned salary increase, etc. table 5. changes that would make the current health facility a better place for patients and staff variable absolute number percentage the kind of change that would make the institution a better place for patients new facilities and better equipment collaboration with managers more staff less work burden with patients increasing the level of service improving staff behavior better salary trainings and specializations patient awareness planning visits for the family doctor 48* 1 7 3 4 2 1 2 1 1 68.6 % 1.4 % 10.0 % 4.3 % 5.7 % 2.9 % 1.4 % 2.9 % 1.4 % 1.4 % the kind of change that would make the institution a better place for staff new facilities and better equipment anti-covid protection measure more staff better salary training better job appreciation additional services group work more medications available planning visits for the family doctor 45 5 2 5 2 1 2 1 1 3 67.2 % 7.5 % 3.0 % 7.5 % 3.0 % 1.5 % 3.0 % 1.5 % 1.5 % 4.5 % * discrepancies with the total numbers are due to lack of information. discussion the current study is one of the few studies in albania that sheds light on the level of satisfaction and related factors with various aspect of primary health care practice from the perspective of the phc staff. our findings suggest that the overwhelming majority of phc staff was satisfied with the relationship with their colleagues in work settings but much less so with the healthcare infrastructure and equipment; on the other hand, more than six out of ten phc professionals were dissatisfied with the current salary. in addition, nurses and family doctors were more likely to be satisfied working in phc compared to general practitioners and specialist doctors. a major problem for developing countries is bypassing the “gateway” function of phc and direct access to the highest levels of the health care system (secondary and tertiary care), making the phc “gateway” function often turn into something purely symbolic or dysfunctional (21). such a problem has affected albania in recent decades; so in the near past (7-8 years ago), patients had easy and free access to specialist doctors even at the tertiary level without the need for referral documents or these were intentionally bypassed or overlooked for other reasons, naum a, toçi e, toçi d, burazeri g, van kessel r, czabanowska k. correlates of level of satisfaction among primary health care workers in albania (original research). seejph 2022, posted: 23 march 2022. doi: 10.11576/seejph-5346 p a g e 11 | 17 similarly with the situation of many former communist bloc countries of the eastern bloc two decades ago (21). but the energetic interventions by the ministry of health and social protection (mshms) towards the regulation of the referral system and the implementation of the national health strategy 2016-2020 have had a considerable impact on the extraordinary minimization of this phenomenon, especially during last years. the fact that 50%-78% of phc staff in the current study is satisfied or very satisfied with the working environment in phc or its specific elements, may have contributed to improving the quality of health care and consequently to increasing of patient satisfaction with phc in our country. on the other hand, a high percentage of phc staff is dissatisfied with current salaries (61%) and stress at work (38%), implying the need for an increased attention by the authorities with regard to these elements. satisfaction of healthcare professionals is very important for the quality of services, effectiveness at work and commitment to duties in the work environment, also having an impact on healthcare costs (22). a number of factors can affect the satisfaction of health care professionals with their work, including age, gender, level of education, work experience, way of organizing work, institution and medical infrastructure, etc. (22), salary, job security (not losing the job), adequate training, adequate workload, etc. (23). regarding the factors related to the satisfaction of the staff working in phc, a study in kosovo reported that family physicians were significantly more likely to be satisfied compared to nurses (20), whereas in our study we identified the opposite trend: nurses were more likely to be satisfied and general practitioners and specialist doctors working in phc are among the most dissatisfied with the phc system in albania. such a difference can be explained by several factors:  first, general practitioners and specialist doctors working in phc in our country think that they are not in the right place of work: the former are always looking for a "better" specialization and the latter are always looking for employment in the capital's hospital centers or in structures of the highest levels of the health system.  second, family physicians feel more satisfied compared to the previous two categories as they have willingly (or not) received this specialization and consequently have "made up their minds" that they will work in primary health care, thus not being under the stress of seeking a specialization or other position at other levels of the health system.  third, phc nurses may be more underpaid than doctors, but they have more freedom in their work, especially in hcs in rural areas, they are in constant contact with the community, and may receive other benefits as a result of such close and constant contacts with the community, which doctors probably do not have.  fourth, physicians may feel less satisfied compared to nurses as they are more pressured during their work and relatively feel that they are underpaid for the work they do compared to nurses. higher satisfaction of nurses compared to physicians in primary health care has also been reported in other developing countries (24). the international literature suggests that the satisfaction of non-medical staff (nurses) has a strong impact on patient satisfaction (25,26). although the international literature suggests that it is more common to consider nurses as additional staff than as substitute staff for physician care (27), and this reality may be quite prevalent in albania based on anecdotal data, the fact that nurses have more freedom in their work, have expanded contacts with the community and benefits from these contacts, may overcome their “dissatisfaction” regarding the consideration as additional staff, resulting in a more naum a, toçi e, toçi d, burazeri g, van kessel r, czabanowska k. correlates of level of satisfaction among primary health care workers in albania (original research). seejph 2022, posted: 23 march 2022. doi: 10.11576/seejph-5346 p a g e 12 | 17 satisfied staff category with their work compared to doctors. in our study, the increase in work experience was always negatively associated with staff satisfaction with the work environment (although the differences never reached statistical significance), while in kosovo an opposite relationship was identified (20). the negative association in our study can be explained by the assumption that over time health personnel, hoping to move to a better job at the highest levels of the system, have in fact "stuck" here and consequently tend to see from a negative perspective everything that happens in the phc premises where he/she works. however, this is only an assumption and further studies are needed to confirm this hypothesis. for example, a survey of general practitioners' satisfaction in 34 european countries found that the age of general practitioners was positively correlated with their job satisfaction, explaining this with the "effect of a healthier worker": older general practitioners who feel more satisfied in phc tend to stay longer at work, whereas dissatisfied doctors may retire earlier and therefore may not be adequately represented in a particular study (28). in an attempt to explain this positive relationship between age and job satisfaction of phc staff in albania and the negative relationship between work experience and job satisfaction of phc staff (i.e. two factors closely related to each other: increasing age and increasing work experience, linked in opposite directions to job satisfaction!), we carried out an additional analysis (not presented in tables) to look in detail at the structure of phc categories within each age group in the study. and the solution laid right there! it turned out that 81% of the staff age >50 years old were nurses (remember, nurses were the most satisfied category of phc professionals in our study!) while specialist doctors and general practitioners occupied only 15.4% and 0% of professionals in this age group (specialist doctors and general practitioners turned out to be the most dissatisfied categories of phc professionals in our study!). so, although specialist doctors and general practitioners are the most dissatisfied staff with phc, the very high specific weight of the most satisfied group of phc staff (nurses) aged >50 is enough to overcome the effect of specialist doctors and general practitioners producing, overall, a positive correlation of staff satisfaction in general with increasing age. meanwhile, a survey of health personnel in rural iran reported that only 17% of them were satisfied with the work they were doing (29), and a survey of public primary health care physicians in delhi, india, reported that all staff were dissatisfied with training policies and practices, with the level of salaries and opportunities to make a career in the system (30), findings and levels that are incomparable with the findings of our study, where over half of the staff were very satisfied or satisfied with the working environment and work spirit in phc and the dimensions where dissatisfaction is relatively high were: salaries and work stress. a 2011 study on the satisfaction of public health care staff (hospitals) in serbia used some questions similar to those used in our study (for example, satisfaction with available medical equipment, personal relationships with colleagues, satisfaction with salary, availability of protocols, etc.) (22). the most important factors related to the satisfaction of health staff in this study (ranked based on the most important factor) included: obtaining clear instructions on the objectives to be achieved in the workplace, the opportunity for professional development in the workplace, good relations with colleagues, satisfactory salary, appropriate clinical tools, suitable time to perform tasks, opportunity for continuing education in the workplace, etc. (22). it can be noticed that some of these factors were also confirmed by the phc staff in our study. in our study we found that 53.4% of phc staff would recommend the current institution where they work as a very good place naum a, toçi e, toçi d, burazeri g, van kessel r, czabanowska k. correlates of level of satisfaction among primary health care workers in albania (original research). seejph 2022, posted: 23 march 2022. doi: 10.11576/seejph-5346 p a g e 13 | 17 to work. in a study of phc doctors in lithuania, 75.5% of them stated that they would not recommend their children to choose the profession of phc doctor (31). similar to our study where 78.2% of staff were satisfied with relationships with colleagues, in lithuania phc doctors rated this aspect as one of the most important factors that affects their job satisfaction (31). in our study 22.5% of phc staff agreed or strongly agreed with the fact that working in the current institution is very stressful; in lithuania also stress at work and workload were considered as an important factor of job dissatisfaction in phc (30). overall less than one fifth of phc staff in albania was dissatisfied or very dissatisfied with the working aspects of phc, while the level of dissatisfaction among phc doctors in lithuania were at much higher levels (31). similar to our study, where 60.8% of phc health personnel stated that they were dissatisfied or very dissatisfied with their current salary and 27% with the available clinical medications, a study in tanzania reported similar figures as 46% of the health staff in phc there were dissatisfied with their salaries while 34.2% were dissatisfied with the available clinical tools (24). two were the main factors related to staff satisfaction in tanzania: the right medical equipment and infrastructure to provide health care and a supportive work environment in terms of peer relationships (24). in norway gps turned out to be among the most satisfied professionals in this country, being on average more satisfied even compared to the doctors working in hospital; general practitioners were more satisfied with the ability to apply their skills, cooperation with colleagues, variation in work, and freedom to choose their method of work, while they were more dissatisfied with the official working schedule (32). these results are contrary to the findings of our study, where gps were the most dissatisfied in the phc system. we have mentioned the reasons for this dissatisfaction earlier during this discussion. the reason why general practitioners working at phc in norway are among the most satisfied health professionals is related to the fact that the norwegian health system relies on a strong primary health care system, where administrative responsibilities are delegated to 434 municipalities (local government); general practitioners in this system are highly valued and well paid, and their per-capita based salary system (capitation) has not influenced the clinical autonomy of general practitioners in phc (32). lack of time, the high number of official working hours, administrative workload, heavy workload and lack of recognition of merit for the work done are some other factors that reduce the satisfaction of general practitioners, according to literature reports (33). these factors are also present in the practice of phc in our country, based on conversations with doctors and our experience in the field with various studies in phc, therefore it is necessary that these factors be taken into account in order to address them. nevertheless, some elements identified in this study, such as the high workload of phc staff or the increase of the staff working at this level of health care is already reflected and is part of the 20212030 health care strategy. a study on job satisfaction of about 7400 general practitioners in 34 european countries between 2010-2012 reported great diversity of this indicator, where the level of satisfied general practitioners was highest in denmark and canada, scandinavian countries and the netherlands, and lower in spain, hungary, and the countries of southern europe; the ability to implement technical procedures, the provision of preventive care and health promotion, feedback from colleagues and patient satisfaction with the service received at the phc were positively associated with the satisfaction of gps at the phc and the increase in working hours was negatively related to their job satisfaction (28). however, comparing the working conditions and satisfaction of health staff with their work is very difficult naum a, toçi e, toçi d, burazeri g, van kessel r, czabanowska k. correlates of level of satisfaction among primary health care workers in albania (original research). seejph 2022, posted: 23 march 2022. doi: 10.11576/seejph-5346 p a g e 14 | 17 due to changes in health systems and different tasks of phc physicians in each country. still, salary turns out to be an important international determinant of job satisfaction of healthcare staff (31-35). study limitations there may be several potential limitations of our study: first, the cross-sectional design does not allow reaching final conclusions regarding the time sequence of events; as such, the study does not provide arguments for verifying the causal relationships between the variables and in this context, any finding of the study should be interpreted very carefully always keeping in mind its cross-sectional design. second, selection bias cannot be ruled out given the small number of health facilities included in this study. the selection bias might have been decreased given the fact that health facilities selected were representing all three kinds of health facilities: hcs in urban and rural areas and hcss. regarding the potential bias of the selection of health care staff, we think that this bias has a low probability since the study was attended by over half of all health staff in the study centers. however, limitations on the number of centers included in the study may limit the generalizability of outcomes related to health care staff as well! third, information bias cannot be ruled out as well; however, we do not think of any reason for the untrue reporting of the phc staff included in this study. fourth, the current study was conducted in the context of the partial limitations of the covid-19 pandemic and the heavy burden that this situation placed on the health system; it is possible that some aspects of the phc work might have been perceived in a more negative light by the phc staff due to the overload and/or increased work stress in this context. the actual study has some strong points as well: this is the first study shedding light on the level of satisfaction of phc staff and the factors associated with it in albania. as such, the current study can inform policymakers and decision-makers about these factors by encouraging appropriate measures to improve the satisfaction of phc staff with their work environment or other aspects of health care, leading to improving the quality of care provided. second, the current study used a standardized and validated international instrument in the albanian language, creating a unique opportunity to compare our findings with those of similar studies conducted in the international 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use, distribution, and reproduction in any medium, provided the original work is properly cited. associated factors among health care professionals working at university of gondar referral hospital, northwest ethiopia: a crosssectional study. bmc res notes 2018;11:824. 35. lima ld, pires de, forte ec, medeiros f. job satisfaction and dissatisfaction of primary health care professionals. esc anna nery 2014;18:17-24. ____________________________________________________________________ 1 meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in the republic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 1 original research estimating health impacts and economic costs of air pollution in the republic of macedonia craig meisner 1 , dragan gjorgjev 2,3 , fimka tozija 2,3 1 the world bank, washington, dc, usa; 2 institute of public health, skopje, republic of macedonia 3 medical faculty, skopje, republic of macedonia corresponding author: craig meisner, senior environmental economist, the world bank, msn mc7-720; address: 1818 h street, nw, washington, dc 20433, usa; telephone: 202-473-6852; e-mail: cmeisner@worldbank.org tel:202-473-6852 mailto:cmeisner@worldbank.org meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in the republic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 2 abstract aim: this paper assesses the magnitude of health impacts and economic costs of fine particulate matter (pm) air pollution in the republic of macedonia. methods: ambient pm10 and pm2.5 monitoring data were combined with population characteristics and exposure-response functions to calculate the incidence of several health end-points known to be highly influenced by air pollution. health impacts were converted to disability-adjusted life years (dalys) and then translated into economic terms using three valuation approaches to form lower and higher bounds: the (adjusted) human capital approach (hca), value of a statistical life (vsl) and the coi (cost of illness). results: fine particulate matter frequently exceeds daily and annual limit values and influences a person‟s day-to-day health and their ability to work. converting lost years of life and disabilities into dalys these health effects represent an annual economic cost of approximately €253 million or 3.2% of gdp (midpoint estimate). premature death accounts for over 90% of the total health burden since this represents a loss of total life-long income. a reduction of even 1μg/m 3 in ambient pm10 or pm2.5 would imply 195 fewer deaths and represent an economic savings of €34 million per year in reduced health costs. conclusion: interventions that reduce ambient pm10 or pm2.5 have significant economic savings in both the short and long run. currently, these benefits (costs) are „hidden‟ due to the lack of information linking air quality and health outcomes and translating this into economic terms. policymakers seeking ways to improve the public‟s health and lessen the burden on the health system could focus on a narrow set of air pollution sources to achieve these goals. keywords: air pollution, health and economic costs, particulate matter. conflicts of interest: none. acknowledgements: the authors would like to first acknowledge the financial support of the green growth and climate change analytic and advisory support program launched in 2011, with funding support from the world bank and the governments of norway and sweden. we would also like to thank our local macedonian counterparts at the institute of public health and the ministry of environment and physical planning for their willingness to collect and share data. we would also like to thank the finnish meteorological institute (fmi) for their guidance and suggestions on earlier drafts of this work. fmi is currently working with the moepp in strengthening their air quality monitoring network through an eu-sponsored twinning project. meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in the republic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 3 introduction according to the global burden of disease (2010) estimates (1), the crude mortality rate from ambient particulate matter (pm) pollution in macedonia was 80.6 deaths per 100,000 in 2010. in comparable neighboring states such as serbia, it was 71.8 deaths per 100,000; in croatia it was 69.4 per 100,000; in hungary 92.0 per 100,000; and 70 per 100,000 in slovakia. the total disability-adjusted life years (dalys) attributable to pm were about 1,480 per 100,000 in macedonia (but, up to 1,600 in hungary) (1). the main sources of this ambient condition were the use of solid fuel for heating households in the winter, as well as the impact of industry and traffic. uncontrolled urbanization is also a significant source of particulate matter. in 2009, an average annual concentration of 90µg/m 3 was registered in skopje. compounding the situation, poor air circulation is another reason why the capital city of skopje has one of the worse air conditions in winter. air pollution is also significant throughout the european region, with only nine of the 34 member states reporting pm10 levels below the annual who air quality guideline (aqg) of 20μg/m 3 . almost 83% of the population in these cities is exposed to pm10 levels exceeding the aqg levels (2). results from a recent project improving knowledge and communication for decision-making on air pollution and health in europe (aphekom), which uses a traditional health impact assessment method, indicated that average life expectancy in the most polluted cities could be increased by approximately 20 months if long-term pm2.5 concentrations were reduced to who guidelines (3). one recent study in macedonia found that an increase of pm10 by 10μg/m 3 above the daily maximum permitted level (50μg/m 3 ) was associated with a 12% increase in cardiovascular disease (2). methods to estimate the health impacts and economic costs of air pollution, the approach required overlaying data from multiple sources. the method used ambient air quality data [information received from the ministry of environment and physical planning (moepp)] for pm10 and pm2.5, health statistics – annual deaths by disease type; frequency of chronic bronchitis, asthma, infant mortality; and health cost data (information received from the institute of public health and health insurance fund), exposure-response functions from health studies (information from international and local literature) and population characteristics – age groups, gender, urban/rural population (information from the state statistics bureau). these data were combined for a municipal (city) level analysis. the approach to estimating health impacts and economic costs encompassed five steps:  collection of monitored, ambient concentration data on pm10 and pm2.5  calculation of exposed population  exposure-response functions  calculation of physical health impacts (mortality, morbidity, dalys)  monetizing health impacts collection of monitored data on fine particulate matter currently, the ministry of environment and physical planning (moepp) has a network of 19 automatic monitoring stations: seven in skopje, two in bitola, two in veles and one in kicevo, kumanovo, kocani, tetovo, kavadarci, village lazaropole, and two near the okta oil refinery (near the villages of miladinovci and mrsevci). stations measure so2, no2, co, pm10, pm2.5, ozone, benzene, toluene, ethyl benzene and btx – although some stations do not measure all pollutants [monitored pm2.5 measurements began in november, 2011 in meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in the republic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 4 karpos and centar. in cases where pm2.5 is not actually monitored, observed pm10 is adjusted by the ratio pm2.5/pm10. the ratio, based on recent observations, is estimated at 0.71 in the case of macedonia; and is within ranges found in other international studies. see ostro (4) for a discussion]. this information is available electronically through their air quality portal (available at: http://airquality.moepp.gov.mk/?lang=en). calculation of exposed population population information for 2010 was used focusing on the working population as well as vulnerable segments of society (for example, those under the age of five or older than 65 are considered more vulnerable to the effects of air pollution – that is more prone to develop acute or chronic respiratory ailments). exposure-response functions the selection of exposure-response functions was based on epidemiological research between pm10 and pm2.5 and mortality and morbidity. for mortality, exposure-response functions for long-term exposure to pm2.5 were (4): relative risks (rr) were calculated as: cardiopulmonary (cp) mortality: rr =[(x+1)/(x0 +1)] 0.15515 lung cancer (lc) mortality: rr = exp[0.23218 (x-x0)] alri mortality in under-five children: rr = exp[0.00166 (x-x0)] with: x = current annual average pm2.5 concentration for cp and lc among adults, and pm10 concentrations for alri among children and x0 = target or baseline pm2.5 concentration. information on the crude death rate (cdr), cp, lc and alri data were used to set the mortality baseline. for morbidity, exposure-response coefficients (annual cases per 100,000 population) for pm10 from ostro (4,5) and abbey et al. (6) were applied. ostro (4) reflects a review of worldwide studies, and abbey et al., (6) provides estimates of chronic bronchitis associated with particulates (pm10). a baseline for pm concentrations a baseline level (natural background concentration) for pm2.5 = 7.5 µg/m 3 , as suggested by ostro (4), was used (some argue that the baseline should be set at zero since the literature does not support the existence of a concentration level of which there are no observable effects. however a baseline of zero is not realistic since natural background concentrations hover between 10-15 μg/m 3 in macedonia – and one would only look at investments which could reduce ambient concentrations to this level (i.e. at least from a benefit-cost standpoint of weighing alternative investments). given a pm2.5/pm10 ratio of 0.71 using observations in macedonia, the baseline level for pm10 is 10.6 µg/m 3 . these baseline concentrations were applied to both large and medium/small urban areas. calculation of physical health impacts (mortality, morbidity, dalys) using the population information and the exposure-response functions, mortality and morbidity impacts were calculated through the conversion of impacts to dalys (dalys = sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability). the daly method weights illnesses by severity: a mild illness or disability (e.g. morbidity effects) represents a small fraction of a daly and a severe illness represents a larger fraction (e.g. mortality = 1 daly). weights used in this context were adapted from larsen (7) and are presented in table 1. meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in the republic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 5 table 1. estimated health impacts of air pollution, urban and rural, 2010 (source: world bank, 2012) health impacts dalys /10,000 cases cp mortality (pm2.5) 80,000 lc mortality (pm2.5) 80,000 alri mortality (pm10) 340,000 chronic bronchitis (pm10) 22,000 hospital admissions (pm10) 160 emergency room visits (pm10) 45 restricted activity days (pm10) 3 lower respiratory illness in children (pm10) 65 respiratory symptoms (pm10) 0.75 total monetizing health impacts to create a set of bounds three alternative valuation approaches were used: the (adjusted) human capital approach (hca) [the adjusted version avoids the issue of assigning a value of zero to the lives of the retired and the disabled since the traditional approach is based on foregone earnings. it avoids this issue by assigning the same value – per capita gdp – to a year of life lost by all persons, regardless of age], value of a statistical life (vsl) and the coi (cost of illness). the hca estimates the indirect cost of productivity loss through the value of an individual‟s future earnings. thus, one daly corresponds to one person‟s contribution to production, or gdp per capita. this method provides a realistic lower bound for the loss of one daly. the vsl measures the willingness-to-pay (wtp) to avoid death – using actual behavior on the tradeoffs between risks and money. the vsl is calculated by dividing the marginal wtp to reduce the risk of death by the size of the risk reduction. measured this way, the value of one daly corresponds to the vsl divided by the number of discounted years lost because of death. the vsl typically forms an upper bound measure of health damages. the coi approach estimates the direct treatment costs associated to different health end-points (e.g. hospitalization, restricted activity days, and doctor visits). mortality was valued using hca as a lower bound and the vsl as an upper bound. for morbidity effects the coi was estimated as a lower bound and willingness-to-pay to avoid a case of illness was applied as a higher bound of cost (wtp was assumed to be two times the coi). results air quality data support the finding that particulate matter is one of the most serious concerns in the country. ambient pm10 concentrations frequently exceeded the eu standard of 40μg/m 3 over the years (figure 1). using information on ambient pm10 and pm2.5 in conjunction with the methods outlined above, it is estimated that in macedonia 1,350 deaths occur annually from cardiopulmonary disease and lung cancer (table 2). these deaths are considered „premature‟ in the sense that air pollution contributed to their early demise – since many factors actually influence a persons‟ lifespan (e.g. smoking, exposure to the outdoors, job, etc.). particulate matter can also influence a person‟s day-to-day health and their ability to work. in 2011, levels of pm10 and pm2.5 were primarily responsible for 485 new cases of chronic bronchitis, 770 hospital admissions, and 15,200 emergency visits. meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in the republic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 6 figure 1. annual average pm10 concentration at each automatic monitoring station in μg/m 3 (source: ministry of environment and physical planning, 2012) what do these translate to in terms of a total cost to society? converting lost years of life and disabilities to dalys (or disability-adjusted life years) these health effects represent an annual economic cost of €253 million or 3.2% of gdp (table 2). note that premature death accounts for over 90% of the total health cost since the loss of life is a loss of total (future) income. people also suffer from the day-to-day consequences of respiratory diseases. it is estimated that several thousand work-years are lost annually from chronic bronchitis, asthma, hospital admissions and days of restricted activity. these estimates are consistent with other recent studies – such as kosovo where annual deaths were estimated to be in the range of 805-861 from cardiovascular disease and lung cancer (8). it should be noted that our estimates are mid-points (middle) with lower and higher ranges reflecting different assumptions made on the pm2.5/pm10 ratio and the population‟s exposure to air pollution. what are the potential benefits of reducing particulate matter? if macedonia were to lower pm10 and pm2.5 to eu limit values this would avoid over 800 deaths and thousands of days in lost productivity – representing a health cost savings of €151 million per year (table 3). a reduction of even 1μg/m 3 in ambient pm10 and pm2.5 would result in 195 fewer deaths (1,648 fewer dalys) and imply an economic savings of €34 million per year in reduced health costs. p m 1 0 c o n c e n tr a ti o n ( u g /m 3 ) skopje bitola veles tetovo kumanovo kavadarci kocani kicevo rural eu std meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in the republic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 7 table 2. number of annual cases, dalys per year and economic cost in million euros, 2011 (source: authors’ calculations) health impact annual cases * total dalys per year annual economic cost (€ million) cardiopulmonary & lung cancer mortality (pm2.5) 1,351 10,809 232.0 alri † mortality (pm10) 1 17 0.1 chronic bronchitis (pm10) 485 1,066 3.0 hospital admissions (pm10) 770 12 0.4 emergency room visits (pm10) 15,200 68 0.9 restricted activity days (pm10) 3,213,000 964 8.6 lower respiratory illness in children (pm10) 22,400 146 1.5 respiratory symptoms (pm10) 10,197,000 765 6.8 total 13,847 253.3 * mid-point estimates using a baseline for pm10 = 15 µg/m 3 and pm2.5 = 7.5 µg/m 3 † alri: acute lower respiratory infections. table 3. the potential health ‘savings’ associated with reductions in pm10 and pm2.5 (€ million) [source: authors’ calculations] level of reduction in ambient pm10 and pm2.5 (μg/m 3 ) * reduced dalys annual health savings (€ million) 0 0 0.0 1 1,648 34.1 5 4,894 98.9 10 6,636 133.6 15 8,059 161.5 20 9,275 184.9 eu standards met † 7,840 151.5 * example reductions were equally applied to both pm10 and pm2.5 at the same time. † pm10 = 40 µg/m 3 and pm2.5 = 20 µg/m 3 . discussion there is significant evidence of the effects of short-term exposure to pm10 on respiratory health, but for mortality, and especially as a consequence of long-term exposure, pm2.5 is a more robust risk factor than the coarse part of pm10 (particles in the 2.5–10 μm range). allcause daily mortality is estimated to increase by 0.2 0.6% per 10 μg/m 3 of pm10 (9). furthermore, it has been estimated that exposure to pm2.5 reduces life expectancy by about 8.6 months on average in the european region. results from the study “improving knowledge and communication for decision-making on air pollution and health in europe” (aphekom), which uses traditional health impact assessment methods, indicates that average life expectancy in the most polluted cities could increase by approximately 20 months if longterm pm2.5 concentrations were reduced to who annual guidelines (10). monitored pm10 and pm2.5 concentrations have repeatedly exceeded eu standards in republic of macedonia and have contributed to short-term and chronic respiratory disease. this study estimated an annual (mid-point) loss of approximately 1,350 lives with thousands of lost-productive days, indirectly costing the economy u p w a r d s o f €253 million or 3.2% of gdp in 2011. the specific exposure-response functions used in this study were meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in the republic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 8 borrowed from the international literature – however the orders of magnitude have been shown to be robust in many developing country applications after adjusting for local conditions (4,5,7,8). from a policy standpoint, it is important to note that these estimated costs are generally “hidden” since they are not normally quantified, and benchmarked to the value of economic activity that generated the pollution (i.e. gdp). likewise the distribution of this burden is shared between the general public and the health care system – so total costs are not transparent. the results should motivate policy makers to be more focused on preventative measures, among them, local green options to reduce particulate matter including energy efficiency, fuel switching and the adoption of cleaner technologies. the benefits from such actions should find their way into the benefit-cost analysis of associated investments since the health “savings” could offset the investment costs of greening interventions. references 1. institute for health metrics and evaluation. global burden of disease, 2010. http://www.healthdata.org/search-gbd-data?s (accessed: february 2, 2015). 2. kochubovski m, kendrovski v. monitoring of the ambient air quality (pm10) in skopje and evaluation of the health effects in 2010. jepe 2012;13:789-96. 3. world health organization (who). who air quality guidelines, particulate matter, ozone, nitrogen dioxide and sulphur oxide; geneva, switzerland; 2006. 4. ostro b. outdoor air pollution assessing the environmental burden of disease at national and local levels. environmental burden of disease, series no. 5, geneva: who; 2004 (62p). 5. ostro b. estimating the health effects of air pollution: a method with an application to jakarta. policy research working paper no. 1301, washington, d.c.: the world bank; 1994. 6. abbey de, lebowitz md, mills pk, petersen ff, beeson wl, burchette rj. longterm ambient concentrations of particulates and oxidants and development of chronic disease in a cohort of nonsmoking california residents. inhal toxicol 1995;7:19-34. 7. larsen b. colombia. cost of environmental damage: a socio-economic and environmental health risk assessment. final report prepared for the ministry of environment, housing and land development of republic of colombia; 2004. 8. world bank. kosovo country environmental analysis: cost assessment of environmental degradation, institutional review, and public environmental expenditure review, washington, dc. the world bank; 2012. http://documents.worldbank.org/curated/en/2013/01/17485553/kosovo-countryenvironmental-analysis-kosovo-country-environmental-analysis-cea (accessed: february 2, 2015). 9. samoli e, peng r, ramsay t, pipikou m, touloumi g, dominici f, et al. acute effects of ambient particulate matter on mortality in europe and north america: results from the aphena study. environ health perspect 2008;116:1480-6. 10. world health organization (who) – regional office for europe. health effects of particulate matter: policy implications for countries in eastern europe, caucasus and central asia. copenhagen, denmark; 2013. ___________________________________________________________ © 2015 meisner et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 1 | 12 original research contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. nathalie ambounda ledaga 1, robertine mamche 1, sylvain honore woromogo 1, jesse saint saba antaon 1, fatou sow saar 2 1interstate centre for higher public health education in central africa (ciespac), brazzaville, congo. 2 director of the gender and family institute dakar, senegal. corresponding author: nathalie ambounda ledaga; address: interstate centre for higher public health education in central africa (ciespac), brazzaville, congo; e-mail: ledagan@yahoo.com mailto:ledagan@yahoo.com ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 2 | 12 abstract aims: this study aims to assess the knowledge of people from central africa about universal health coverage and show the contribution of information-education-communication for its adoption. methods: a cross-sectional analytical study across 4 of 6 central african countries was conducted. independent variables are sociodemographic characteristics. dependent variables are knowledge about information-education-communication and universal health coverage. the questionnaire was disseminated by whatsapp images or word file or copy/paste of the text and send to the contacted and trained focal points. from the smartphone, the filmed or transferred data were entered into a cspro 5.0 input form. mean score calculations and odd ratio with 95 % confidence interval for p < 0.005 were used to make associations. results: the universal health coverage had never been heard of by 56.3% of the participants. the universal health coverage was defined as health insurance by (43.9%), free care (30.3%). respondents with secondary and higher education are more likely to have heard of the uhc than respondents with no education or those with elementary education [or = 2.95 (1.01-8.64), p = 0.021] and [or = 4.27 (1.50 – 12.16), p = 0.002] respectively. conclusion: 9.3% of the economic and monetary community of central africa (cemac) population is aware of the universal health coverage; 89.4% of these accept universal health coverage in their country, and 87.4% of them think that the information education communication could enable better adherence to the universal health communication. implemention of universal health coverage for the general population and adoption of information-education-communication to promote universal health coverage and pool efforts and affiliation procedures in the cemac zone is very important. keywords : universal health, coverage, central africa ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 3 | 12 introduction according to who's definition, universal health coverage (uhc) is achieved when ‘all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship’ (1, 2). universal health coverage « is driving the global health agenda; it is embedded in the sustainable development goals (sdgs) and is now designated by an official united nations uhc day on december 12. ‘although many sub-saharan african countries have made efforts to provide universal health coverage for their citizens, several of these initiatives have achieved little success’ (3,4). local health authorities need guidance on how they can set fair and sustainable priorities (5,6). ‘progressive realisation is invoked as the guiding principle for countries on their own path to uhc and achievement of the sdg health targets. it refers to the governmental obligations to immediately and progressively move towards the full realisation of uhc, recognising the constraints imposed by limited available resources’ (7). information-education-communication (iec) is a process for individuals, communities and societies to develop communication strategies to promote health-promoting behaviour (8). africa's population is young and the burden of non-communicable and communicable diseases is a double burden, the lack of health knowledge could become a triple burden if nothing is done for iec to move towards disease-related communication for development and universal health coverage to prevent, detect and treat diseases early and cheaply (9, 10). within the economic and monetary community of central africa (cemac) countries, university health coverage seems to be unknown to the population despite the commitments made by the states to move towards it (11-14). the objective of this work was to study the contribution of iec in the adoption of universal health coverage by the populations in the cemac zone in 2020. methods study design: this was a cross-sectional, analytical, interventional study conducted from july 15 to july 30 2020 in the major cities of the cemac countries as cameroon, central african republic (car), congo, gabon, equatorial guinea (eg) and chad. study population: residents of the cemac countries, whose general population is estimated at 55 781 513, constituted the target population studied (15). residents under 15 years of age and those who refused to answer the questionnaire were not included. sampling: probabilistic and exhaustive type of sampling was chosen. the sample size, to ensure representativeness, was calculated using daniel schwartz's formula (16): n= p(1-p)(z(α/2) ) 2/ i², where n is the minimum sample size, p is the prevalence of uhc in africa (50%), z(α/2) = is the confidence level of the study at risk α = 95%, i.e. 1.96, i is the accepted printing error on either side of the result, i.e. 5%. we obtained n = 403. sample size by country : the general population by country was 23 779 022 (cameroon), 5 745 135 (car), 5 279 517 (congo), 2 074 656 (gabon), 2 015 334 (eg) and 15 162 044 (chad). to obtain the sample per country, we used the following formula n = (country population x 403) / general population for the 6 countries. thus, we obtained 182 for cameroon, 42 for car, 40 for ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 4 | 12 congo, 16 for gabon, 15 for eg and 110 for chad. data collection tool and collection procedure: we used a questionnaire with two sections, a definition and concepts. the questionnaire was disseminated by whatsapp images or word file or copy/paste of the text and send to the contacted and trained focal points. through relationships with ngos adolescence et santé, exit gate from gabon, whatapps contacts were made in the capitals of the countries; volunteer interviewers were trained and deployed in the city respecting the barrier gestures also those who could fill in numerically did so. in the end, there was one principal interviewer in each country except cameroon where there were two. the questionnaires were filled in and collected in the community face to face in focus groups of less than 5 people and through the whatsapp network on the questionnaire sent online. for the digital responses, questionnaires were sent by whatsapp to the country correspondents who collected the responses via whatsapp before transmitting them via the same channel or internet. variables independent variables : sociodemographic characteristics (age, gender, level of education, marital status, occupation. dependent variables : knowledge of iec and uhc, attitudes towards iec and uhc, adoption of iec and uhc. data entry and analysis: from the smarthphone, the filmed or transferred data were entered into a cspro 5.0 input form, imported and analysed using spss. mean score calculations and or with 95 % ci for p < 0.05 were used to make associations. ethical considerations: requests for authorisation were sent to the ministries of health of the 6 countries with acknowledgement of receipt. informed consent file submitted to participants who read and agreed before participating in the interview. results a total of 403 questionnaires, of which 100 were on hard paper and 303 on digital, were submitted and transferred to the population. only 302 responded, i.e. a participation rate of 74.94% (302/403). out of 6 countries, 4 returned the questionnaires. cameroonian participation represented 37.7%, congolese 34.2%, gabonese 18.5% and central african 9.6% (table 1). sociodemographic characteristics : the mean age was 31.29 ± 10.74 years. the 2534 age group accounted for 39.1%; the 15-24 and 35-44 age groups for 29.1 and 18.9% respectively. the female and male sex represented 46% and 54% respectively, sex ratio: 1.17 (163/139). higher education was found in 52% of the participants. the marital status revealed 65.9% of single people. unemployed participants represented 47.7% (table 1). ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 5 | 12 table 1. sociodemographic characteristics of participants variables number percentage (%) country participation rates cameroon 114 37.7 central african republic (rca) 56 18.5 congo 103 34.2 gabon 29 9.6 age (years) : mean/sd 31.29 (10.74); min/max 15/74 15-24 88 29.1 25-34 175 58.0 45-54 39 12.9 sex sex ratio : 1.17 female 139 46.0 male 163 54.0 education no education 22 7.3 primary 21 7.0 secondary 101 33.4 university 158 52.3 marital status single 199 65.9 married 86 28.5 divorced 14 4.6 widowed 3 1.0 sector of activities public 51 16.9 private 64 21.1 liberal 38 12.6 without 149 49.4 knowledge of uhc and iec: the uhc had never been heard of by 56.3% of the participants. the information sources mentioned by the participants were television (25.8%) and social networks (28%). the uhc was defined as health insurance by (43.9%), free care (30.3%) participants. the concept of iec was not known by 63.6% of participants. social networks, health structures and television represented 24.1%, 24.1% and 15.7% respectively. the participants who acknowledged not having received iec on uhc represented 59.3% (table 2). ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 6 | 12 table 2. knowledge of participants about uhc and iec knowledge number percentage n = 302 % have you heard about uhc ? yes 132 43.7 no 170 56.3 what is the uhc ? health insurance 58 43.9 mutual insurance 4 3.0 free care 40 30.3 dont’t know 24 18.2 other 3 2.3 not specified 3 2.3 you heard through which channel? tv 34 25.8 radio 18 13.6 social networks 37 28.0 health structure 20 15.2 other 18 13.6 not specified 5 3.8 have you heard about iec ? yes 108 35.7 no 192 63.6 not specified 2 0.7 you heard through which channel? tv 17 15.7 radio 16 14.8 social networks 26 24.1 health structure 26 24.1 other 22 20.4 not specified 1 0.9 was there an iec on uhc? yes 39 36.1 no 64 59.3 not specified 5 4.6 ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 7 | 12 attitudes towards the iec and uhc: the uhc was accepted in their country by 89.4% of participants; 81.8% were willing to enrol and 88.4% accepted the iec on uhc. participants without uhc represented 89.4%; of the 9.3% with insurance 42.9% had full coverage (table 3). the origin of the uhc fund was not known for 28.8%. 80.5% of the participants were willing to practice iec. iec on uhc does not exist in their country according to 55.6% of the participants. 87.4% of the participants felt that uhc is necessary for the population; 74.8% had not been trained on iec and 87.4% thought that iec can improve adherence to uhc. table 3. attitudes of participants towards uhc and iec attitudes number percentage n =302 % do you agree with the uhc in your country ? yes 270 89.4 no 30 9.9 not specified 2 0.7 are you ready to subscribe to the uhc ? yes 247 81.8 no 55 18.2 would you accept the iec on uhc ? yes 267 88.4 no 29 9.6 not specified 6 2.0 have you subscribed to an uhc ? yes 28 9.3 no 270 89.4 not specified 4 1.3 if yes total or partial ? total 2 7.1 partial 12 42.9 not specified 14 50.0 are you willing to practice iec ? yes 243 80.5 no 56 18.5 not specified 3 1.0 in your country has there been iec on uhc ? yes 30 9.9 enough 23 7.6 not enough 78 25.8 no 168 55.6 not specified 3 1.1 ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 8 | 12 have you ever been trained on iec ? yes 75 24.8 no 226 74.8 not specified 1 0.4 does iec lead to better adherence to uhc ? yes 264 87.4 no 36 11.9 not specified 2 0.7 influences of socio-demographic factors on the level of knowledge: respondents with secondary and higher education are more likely to have heard of the uhc than respondents with no education or those with elementary education [or = 2.95 (1.01-8.64), p = 0.021] and [or = 4.27 (1.50 – 12.16), p = 0.002] respectively. public, private and liberal sector workers are more likely to have heard of the uhc than non-employees [or = 8.67 (4.26-17.66), p < 0.001], [or = 2.39 (1.29 – 4.44), p = 0.00] and [or = 2.34 (1.11 4.91), p = 0.013] respectively. workers are more likely to have heard of the iec than non-workers (table 4). table 4. influences of sociodemographic factors on the level of knowledge sociodemographic factors yes no or (95% ci) p knowledge: heard about uhc education without education 05 17 primary 9 12 2.55 (0.68 – 9.54) 0.090 secondary 47 54 2.95 (1.01 – 8.64) 0.021 university 88 70 4.27 (1.50 12.16) 0.002 sector of activities public 42 14 8.67 (4.26 – 17.66) < 0.001 private 29 35 2.39 (1.29 – 4.44) 0.003 liberal 17 21 2.34 (1.11 – 4.91) 0.013 without 37 107 144 (100) knowledge: heard about iec sector of activities public 30 26 2.89 (1.53 – 5.48) < 0.001 private 28 36 1.95 (1.06 – 3.60) 0.017 liberal 21 17 3.10 (1.49 – 6.47) 0.001 without 41 103 143 (100) ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 9 | 12 discussion the most represented age group was 25-34. the young african population may explain the predominant age ranges. more than half of our respondents were men and university education was more represented as well as the private sector of activity. the period of containment may explain the higher participation rate of men as they are more out of the home and also as workers in the private sectors have many more work constraints than those in the public sector. knowledge: we assessed participants' knowledge of universal health coverage and iec and the ways in which they acquired this knowledge. more than half of the participants had never heard of universal health coverage and the concept of iec, although we found that more than half of the respondents were employees or had attended university. our findings clearly show the low level of knowledge and perception of universal health coverage among the urban population of the cemac zone countries. taking into account the expectations of the populations of the districts of certain countries, which notably show that ‘respondents seek improvements in the quality of care, community engagement activities, expansion of the range of services to include emergency referral services, and enhancement of clinical health insurance coverage to include preventive health services’ (17), it is important for the countries of the cemac zone to initiate perspectives aimed at strengthening the implementation of the uhc by taking into account the actions recommended by the who and certain studies (7,18). the case of nepal and ghana which illustrates the role and contribution of community health worker counseling family is prominent (8, 19, 20, 21). almost half of the respondents defined the uhc as health insurance. one of the paths for strengthening the practice of uhc is therefore health insurance. in the cemac zone, only gabon has adopted this policy; countries are encouraged to have their population subscribe to health insurance, considering that the role of insurance in the achievement of universal coverage within a developing country context has been demonstrated (22) as well as that of the iec (18, 23). health services are expected to play an important role in the implementation of the uhc as more than half of the respondents mentioned these health services. finally, we noted that knowledge of the uhc and iec is related to the respondents' level of education as well as their business sector. cemac member states are encouraged to use different methods to sensitise the population on the uhc as we have noted that correspondents have mentioned social networks and television as the main sources of information on the uhc. it can be seen today that there is an increase in the number of people using social networks and television as sources of information. attitudes : the uhc was accepted in their country by 89.4% of participants; 81.8% were willing to enrol and 88.4% accepted the iec on uhc. we noticed that people are willing to embrace the uhc and the concept of iec, which many have found to be innovative. governments can build on this to boost the uhc. but before that it would be useful to go through a situational analysis at different levels of the community and business sector as proposed by some studies (7,18). study limitations : for this study, covid-19 imposed digital communication and this ledaga na, mamche r, woromogo sh, saba antaon js, saar fs. contribution of information-education-communication in the adoption of universal health coverage by the populations in the economic and monetary community of central africa in 2020. (original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 10 | 12 seemed to be little used by the populations for the surveys; the high penetration rates and costs of the internet seemed to reduce the enthusiasm of the investigators and the surveyed population. the spanish language in malabo obstructed the data collection process. in ndjamena, the investigator did not adopt the digital tool. the rainy season in bangui and the expensive and poorly penetrating internet were reported by the investigator to explain the low participation rate. conclusions less than 10%of the cemac population is aware of the uhc; 89.4% of them accept universal health coverage in their country and 87.4% of them think that the iec could enable better adherence to the uhc. only 30% have an uhc. in view of these results, the following suggestions are proposed to the cemac states: implemention of uhc for the general population, adoption of iec as a means of promoting uhc and to pool efforts and affiliation procedures in the cemac zone is very important. references 1. verrecchia r, thompson r, yates r. universal health coverage and public health : a truly sustainable approach. lancet 2019 ; 4(1) : e10-e11 2. who. what is health financing for universal health coverage ? geneva : world health organization. http://www.who.int/health_financial/universal_coverage_definition (accessed april 04 2021) 3. mclntyre d, garshong b, mtei g, meheus f, thiede m, akazili j, ally m, aikins m, mulligan ja, goudge j. beyong fragmentation and towards universal coverage : insights from ghana, south africa and the united republic of tanzania. bull world health organ 2008 ; 86(11) :871-6 4. chukwuemeka au. challenges toward achieving universal health coverage in ghana, kenya, nigeria, and tanzania. int j health plann manage 2018 ; 33(4) : 794-805 5. jansen mpm, bijlmakers l, baltussen r, rouwette ea, broekhuizen h. a sustainable apporach to universal health coverage. lancet glob health 2019 ; 7(8) : e1013 6. sakolsatayadorn p, chan m. breaking down the barriers to universal health coverage. bull world health organ 2017 ; 95(2) :86 7. who consultative group on equity and universal health coverage. making fair choices on the path to uhc. geneva 2016 8. schwarz r, thapa a, sharma s, kalaunee sp. at a crossroads : how can nepal enhance its community health care system to achieve sustainable development goal 3 and universal health coverage ? j glob health 2020 ; 10(1) :010309 9. sanofi [internet]. the rise and rise of chronic diseases in africa. 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(original research). seejph 2021, posted: 29 may 2021. doi: 10.11576/seejph-4477 p a g e 12 | 12 © 2021 ledaga et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 22. van der heever am. the role of insurance in the achievement of universal coverage within a developing country context : south africa as a case study. bmc public health 2012 ; 12(1) : s5 23. kushitor mk, biney aa, wright kj, phillips jf, awoonor-williams jk, bawah aa. a qualitative appraisal of stakeholders' perspectives of a community-based primary health care program in rural ghana. bmc health serv res 2019 ; 19(1) : 675 __________________________________________________________________________ houghton f. researching gambling: have we learned nothing from big tobacco’s overt manipulation of science? (commentary). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5769 commentary researching gambling: have we learned nothing from big tobacco’s overt manipulation of science? frank houghton1 1) school of applied sciences & information technology, technological university of the shannon, limerick, ireland corresponding author: dr.frank houghton, school of applied sciences & information technology, technological university of the shannon, limerick, ireland. email: frank.houghton@tus.ie houghton f. researching gambling: have we learned nothing from big tobacco’s overt manipulation of science? (commentary). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5769 the global gambling industry was estimated to be worth us$711.4 billion in 2020, with projections of its worth to reach us$876 billion by 2026 (1). however, behind such headline grabbing statistics lies the reality of the extremely negative impacts gambling can have on physical, psychological and social functioning (2,3). although estimates vary as to the level of gambling addiction in populations, evidence suggest that between 0.5–3.0% of the population are problem gamblers, with up to four times as many people reporting subclinical problems (4). an issue of particular concern is the significant growth of the online gambling industry during the covid-19 pandemic (5). davies has recently examined gambling from a neuropsychological perspective, outlining the reinforcement prompts that perpetuate gambling (6,7). however, as well as looking at this individual level, it is also vital to look at how the industry works as a whole. a useful primer to understand the machinations of the gambling industry is to examine how big tobacco operates. such a focus is appropriate in light of the strong history of the gambling and tobacco industries working together (8). big tobacco has been described as akin to the hydra of greek mythology, wherein two heads sprout to replace each that is cut-off (9-10). this analogy is used to describe the industry’s continuous attempts to circumvent and subvert health-oriented legislation designed to curtail and restrict their activities (11,12). the global tobacco industry has a documented history of engaging in a wide range of nefarious activities designed to undermine tobacco control, overcome negative health concerns, and promote their products (13). their activities range what might be described as mild manipulation to outright and deliberate and blatant subversion of science and the law (13-16). for example, some of their less overt activities have included strategies such funding of the arts, health interventions, and numerous other ostensibly philanthropic interventions (13,14). in recent times they have also engaged in pseudo pro-environmental greenwashing, faking a pro-environment stance, to present the industry as socially aware, and thereby distract from other health issues (15-22). however, these activities are mild compared to other documented activities of big tobacco, which include openly lying to the us congress, targeting minority groups, and deliberately subverting scientific investigations (13-15). it is this last aspect of the activities of big tobacco that are of particular interest here. tobacco industry documents have revealed how strategies evolved to deliberately undermine scientific studies highlighting the negative impact of first hand and later second hand smoking (23-29). later, as pro-tobacco scientists routinely accepting big tobacco money became identified and discredited, the industry began funding scientists with whom they had no prior connection, to explore other potential causes that would obscure and muddy the relationship between tobacco and disease (13-15). table one details six tobacco industry strategies to manipulate risk data identified by bero (30). table one: tobacco industry strategies to manipulate data on risk (30) 1. fund research that supports the interest group position. 2. publish research that supports the interest group position. 3. suppress research that does not support the interest group position. 4. criticize research that does not support the interest group position. houghton f. researching gambling: have we learned nothing from big tobacco’s overt manipulation of science? (commentary). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5769 5. disseminate interest group data or interpretation of risk in the lay press. 6. disseminate interest group data or interpretation of risk directly to policy makers. fiscal malfeasance in relation to gambling has an extremely long history in ireland. the most infamous example is the irish hospital sweepstakes which ran for over 50 years and was only wound up after dramatic evidence of deep rooted and longstanding corruption and collusion emerged (31,32). in more recent times evidence suggests that national lottery sports lottery funding distributions demonstrate a clear bias towards areas represented by the ministers for arts, sports and tourism and the ministers for finance (33). attempts at manipulation by the gambling industry in ireland are blatant, as evidenced by the recent attendance by irish politicians at corporate hospitality tents funded by the irish bookmakers association (iba) at punchestown race course (co. kildare, ireland) . this rather transparent and obvious attempt to influence irish politicians occurred when longpromised and overdue regulation of the gambling industry by the oireachtas (irish parliament) is both overdue (34,35), and imminent (36,37). it is vital that lessons are learned from the machinations of big tobacco when assessing how to respond to the growing power of, and damage caused by, the gambling industry. funding should not be accepted from the gambling industry. many journals and funders have taken a lead here, and now proscribe research and researchers funded by big tobacco (38). it is an issue of serious concern for example that a major recent report on the impact of gambling in ireland was funded by the gambling awareness trust (39). the gambling awareness trust is ostensibly an independent charity ‘set up to establish and operate a charitable fund which will fund gambling addiction counselling, prevention, education, research and awareness services in ireland’ (40). however, further examination of the gambling awareness trust website reveals that it is funded by over 30 individual bookmakers (41; see note 1). in future all researchers should decline funding from the gambling industry. if they do not, independence and integrity are at risk of erosion. if industries such as gambling and tobacco are allowed to fund research into their own activities, it stands to reason that the recipient of the funding is under an obligation to publish findings that they favour. finally, it is also important to note a fact that is seldom mention in any circles; the intrinsic role of organized crime in the gambling industry (42). the gambling industry is a routine avenue for money laundering (43,44), often including the washing of money gained through the production and sale of illicit narcotics (45). therefore, research money which comes from this industry could potentially originate from organised crime. in order to maintain their professional integrity researchers exploring the gambling industry and its impacts must avoid accepting funding from it, or its allies and affiliates. the lessons learned from the manipulative activities of big tobacco should be read as a template for tactics and strategies adopted by the gambling industry. to accept such funding in future is not just naïve, but a serious error of judgement that may be seen as collusion. notes 1. funders lister in 2020 were: bar one racing; bet365; betdaq; betway; boyle sports; bwin; casumo; celton; chieftain houghton f. researching gambling: have we learned nothing from big tobacco’s overt manipulation of science? (commentary). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5769 bookmakers; coral; fox bookmakers; foxy casino; gala; irish greyhound board; ladbrokes; mintbet; mr green; paddypower betfair; party casino; partypoker; quinn bet; redbet; roncol sports; sbobet; sean graham; sportingbet; sportpesa; the stars group; the track; 32 red; +o+e; tully bookmakers; william hill; winners enclosure; winning room. references 1. cision pr newswire. global gambling market to reach $876 billion by 2026. accessed on 20th june 2022 at: https://www.prnewswire.com/news -releases/global-gambling-marketto-reach-876-billion-by-2026301305923.html 2. condron i, lyons s, carew am. gambling in ireland: profile of treatment episodes from a national treatment reporting system. ir j psychol med. 2022:1-8. doi:10.1017/ipm.2022.20 3. murphy, m. "an investigation of problem gambling and young sports players in an irish amateur sporting organisation." (2019). dept. of management & enterprise conference material [online]. available at: https://sword.cit.ie/dptmecp/1 4. abbott mw. the changing epidemiology of gambling disorder and gambling-related harm: public health implications. public health. 2020;184:41-45. 5. mcgarry p. numbers seeking help for gambling problems rises during pandemic. the irish times 25th march 2021. accessed 20th june 2022 at: https://www.irishtimes.com/news/s ocial-affairs/numbers-seeking-helpfor-gambling-problems-risesduring-pandemic1.4520358?mode=amp 6. davies r. jackpot. london: faber & faber; 2021. 7. davies r. what gambling firms don’t want you to know – and how they keep you hooked. the guardian 12th february 2022. accessed on 20th june 2022 at: https://www.theguardian.com/socie ty/2022/feb/12/what-gamblingfirms-dont-want-you-to-know-andhow-they-keep-you-hooked 8. mandel ll, glantz sa. hedging their bets: tobacco and gambling industries work against smoke-free policies. tobacco control 2004;13:268–276. doi: 10.1136/tc.2004.007484 9. european commission. tobacco or health in the european union past, present and future. brussels: directorate-general for health and consumer protection. european commission; 2004. 10. amarasekera n. restraining tobacco--the hydra headed monster. ceylon med j. 2014;59(2):72. doi:10.4038/cmj.v59i2.7071 11. houghton f, o'doherty d, duncan b, meaney c. combatting the big tobacco hydra in sport: another case of alibi marketing through false flag advertising. international medicine review. 2020; 28(113):199-204. 12. henriksen l. comprehensive tobacco marketing restrictions: promotion, packaging, price and place. tobacco control. 2012;21(2):147-153. doi:10.1136/tobaccocontrol-2011050416. 13. glantz s, slade j, bero l, et al. cigarette papers. berkeley, california: university of california press; 1996. 14. proctor rn. golden holocaust: origins of the cigarette https://www.prnewswire.com/news-releases/global-gambling-market-to-reach-876-billion-by-2026-301305923.html https://www.prnewswire.com/news-releases/global-gambling-market-to-reach-876-billion-by-2026-301305923.html https://www.prnewswire.com/news-releases/global-gambling-market-to-reach-876-billion-by-2026-301305923.html https://www.prnewswire.com/news-releases/global-gambling-market-to-reach-876-billion-by-2026-301305923.html https://sword.cit.ie/dptmecp/1 https://www.irishtimes.com/news/social-affairs/numbers-seeking-help-for-gambling-problems-rises-during-pandemic-1.4520358?mode=amp https://www.irishtimes.com/news/social-affairs/numbers-seeking-help-for-gambling-problems-rises-during-pandemic-1.4520358?mode=amp https://www.irishtimes.com/news/social-affairs/numbers-seeking-help-for-gambling-problems-rises-during-pandemic-1.4520358?mode=amp https://www.irishtimes.com/news/social-affairs/numbers-seeking-help-for-gambling-problems-rises-during-pandemic-1.4520358?mode=amp https://www.irishtimes.com/news/social-affairs/numbers-seeking-help-for-gambling-problems-rises-during-pandemic-1.4520358?mode=amp https://www.theguardian.com/society/2022/feb/12/what-gambling-firms-dont-want-you-to-know-and-how-they-keep-you-hooked https://www.theguardian.com/society/2022/feb/12/what-gambling-firms-dont-want-you-to-know-and-how-they-keep-you-hooked https://www.theguardian.com/society/2022/feb/12/what-gambling-firms-dont-want-you-to-know-and-how-they-keep-you-hooked https://www.theguardian.com/society/2022/feb/12/what-gambling-firms-dont-want-you-to-know-and-how-they-keep-you-hooked houghton f. researching gambling: have we learned nothing from big tobacco’s overt manipulation of science? (commentary). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5769 catastrophe and the case for abolition. berkeley, california: university of california press; 2012. 15. white l. merchants of death: the american tobacco industry. new york: beech tree books; 1988. 16. pollock d. denial and delay. the political history of smoking and health, 1951-1964: scientists, government and industry as seen in the papers at the public records office. london: action on smoking and health; 1999. 17. world health organization. talking trash: behind the tobacco industry’s “green” public relations. geneva: who; 2022. 18. world health organization. tobacco and its environmental impact: an overview. geneva: who; 2017. 19. lc friedman. tobacco industry use of corporate social responsibility tactics as a sword and a shield on secondhand smoke issues. j law med ethics. 2009;37(4):819-827. doi: 10.1111/j.1748720x.2009.00453.x 20. zafeiridou m, hopkinson n, voulvoulis n. cigarette smoking: an assessment of tobacco’s global environmental footprint across its entire supply chain. environ. sci. technol. 2018; 52:15. 21. houghton f, houghton s, o’doherty d. mcinerney d, duncan b. greenwashing tobacco attempts to eco-label a killer product. journal of environmental studies and sciences. journal of environmental studies and sciences 2019;9(1): 82-85. doi: 10.1007/s13412-018-0528-z 22. houghton f, houghton s, o’doherty d, mcinerney d, duncan b. ‘greenwashing’ tobacco products through eco and social/equity labelling: a potential threat to tobacco control. tobacco prevention and cessation. 2018;4: 37. doi: 10.18332/tpc/99674 23. michaels d. doubt is their product: how industry's assault on science threatens your health. oxford: oxford university press; 2008. 24. muggli me, forster jl, hurt rd, repace jl. the smoke you don’t see: uncovering tobacco industry scientific strategies aimed against environmental tobacco smoke policies. am j public health. 2001;91:1419-23. 25. muggli m, hurt r, blanke d. science for hire: a tobacco industry strategy to influence public opinion on secondhand smoke. nicotine tob res. 2003;5:303–14. 26. chapman s. tobacco industry memo reveals passive smoking strategy. bmj 1997;314:1569. 27. samet jm, burke ta. turning science into junk: the tobacco industry and passive smoking. am j public health. 2001 nov;91(11):1742-4. 28. ong ek, glantz sa. tobacco industry efforts subverting international agency for research on cancer's secondhand smoke study. lancet. 2000 apr 8;355(9211):1253-9. 29. world health organisation. tobacco industry interference with tobacco control. geneva: who; 2009. 30. bero la. tobacco industry manipulation of research. public health reports. 2005;120: 200208. 31. coleman m. the irish sweep: a history of the irish hospitals sweepstake, 1930-87, dublin: houghton f. researching gambling: have we learned nothing from big tobacco’s overt manipulation of science? (commentary). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5769 university college dublin press; 2009. 32. corless d. the greatest bleeding hearts racket in the world: irish hospitals sweepstakes. dublin: gill & macmillan; 2010. 33. considine j, crowley f, foley s, o’connor m. irish national lottery sports capital grant allocations, 1999–2007: natural experiments on political influence. economic affairs 2008;28(3):38-44. 34. o'gara c. the gambling control bill: time for action. ir j psychol med. 2018;35(4):269-271. doi:10.1017/ipm.2017.77 35. subramanian n. gambling: an irish perspective. ir j psychol med. 2014;31(3):153-158. doi:10.1017/ipm.2014.29 36. mcgee h, bray j. politicians accepting hospitality at horseracing festival ‘deeply concerning’ the irish times 26th may 2022. accessed on 20th june 2022 at: https://www.irishtimes.com/politic s/2022/05/26/politicians-acceptinghospitality-at-horse-racing-festivaldeeply-concerning/ 37. clerkin m. politicians leave themselves open when they take bookmakers’ hospitality. the irish times 30th may 2022. accessed on 20th june 2022 at: https://www.irishtimes.com/sport/r acing/2022/05/30/politicians-leavethemselves-open-when-they-takebookmakers-hospitality/ 38. nature. tobacco money and medical research. nat med. 1999;5: 125. https://doi.org/10.1038/5472 39. kerr a, o’brennan j, vazquezmendoza l. gambling trends, harms, and responses: ireland in an international context. maynooth, co. kildare: maynooth university; 2021. 40. gambling awareness trust. about us. accessed on 20th june 2022 at: https://gamblingcare.ie/aboutus/#mission 41. gambling awareness trust. gat subscribers. accessed on 20th june 2022 at: https://gamblingawarenesstrust.ie/g at-contributors/ 42. banks j, waugh d. a taxonomy of gamblingrelated crime. international gambling studies. 19(2):339-357. 43. pepi k. an exploratory study into the money laundering threats, vulnerabilities, and controls within the uk bookmaker sector, with a specific focus on fixedodds betting terminals. unlv gaming research & review journal; 22(1): 1-27. 44. brooks g. online gambling and money laundering: “views from the inside’. journal of money laundering control. 15(3):304-31. 45. schneider f, windischbauer u. money laundering: some facts. economics of security working paper 25. berlin: department of international economics, german institute for economic research; 2010. _________________________________________________________________ © 2022 houghton; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.irishtimes.com/politics/2022/05/26/politicians-accepting-hospitality-at-horse-racing-festival-deeply-concerning/ https://www.irishtimes.com/politics/2022/05/26/politicians-accepting-hospitality-at-horse-racing-festival-deeply-concerning/ https://www.irishtimes.com/politics/2022/05/26/politicians-accepting-hospitality-at-horse-racing-festival-deeply-concerning/ https://www.irishtimes.com/politics/2022/05/26/politicians-accepting-hospitality-at-horse-racing-festival-deeply-concerning/ https://www.irishtimes.com/sport/racing/2022/05/30/politicians-leave-themselves-open-when-they-take-bookmakers-hospitality/ https://www.irishtimes.com/sport/racing/2022/05/30/politicians-leave-themselves-open-when-they-take-bookmakers-hospitality/ https://www.irishtimes.com/sport/racing/2022/05/30/politicians-leave-themselves-open-when-they-take-bookmakers-hospitality/ https://www.irishtimes.com/sport/racing/2022/05/30/politicians-leave-themselves-open-when-they-take-bookmakers-hospitality/ https://gamblingcare.ie/about-us/#mission https://gamblingcare.ie/about-us/#mission https://gamblingawarenesstrust.ie/gat-contributors/ https://gamblingawarenesstrust.ie/gat-contributors/ burazeri g, laaser u, martin-moreno jm, schröder-bäck p. growing up the south eastern european journal of public health (editorial). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-89 1 editorial growing up the south eastern european journal of public health genc burazeri 1,2 , ulrich laaser 3 , jose m. martin-moreno 4,5 , peter schröder-bäck 2,6 1 school of public health, university of medicine, tirana, albania; 2 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life science, maastricht university, maastricht, the netherlands; 3 faculty of health sciences, university of bielefeld, bielefeld, germany; 4 department of preventive medicine and public health, university of valencia, spain; 5 incliva research institute, university of valencia clinical hospital, valencia, spain; 6 faculty of human and health sciences, university of bremen, bremen, germany. corresponding author: genc burazeri, md, phd; address: rr. “dibres”, no. 371, tirana, albania; e-mail: genc.burazeri@maastrichtuniversity.nl conflicts of interest: none. burazeri g, laaser u, martin-moreno jm, schröder-bäck p. growing up the south eastern european journal of public health (editorial). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-89 2 the south eastern european journal of public health (seejph) is an online, open-access, international, peer-reviewed journal, which was launched in 2013 (1). it covers all areas of health sciences, with a main focus on public health. seejph is a journal originating from the ten years of the stability pact for south eastern europe (2001-2011), but aiming to provide a forum for all countries in transition worldwide, whose research work would otherwise be hardly visible. from this point of view, this journal strives to promote particularly an area referred to as “health transition research” (1). time is passing, though, and our “baby”, the seejph, is already two years old by now, or more precisely four volumes “old” – volumes with excellent peer-reviewed contributions from many parts of the world and fascinating discussions e.g. on a view back to the maastricht treaty on european union by the leading negotiators of the time (2); “endorsement” of a public health profession (3); the south east european health network (seehn) (4); the european public health education accreditation system (5); public health ethics (6); as well as several other outstanding original research and review articles tackling a wide range of public health issues. time to prepare for preschool furtherance? yes, indeed! we moved to the open journal system (ojs), kindly hosted by the university of bielefeld in germany. ojs provides all the necessary technical facilities including online submission and review process. but, not only that! in addition, we are now registered in index copernicus and are currently under consideration by several other electronic databases. our executive editorship remains in tirana, albania, but we are happy to have engaged now regional editors covering the globe:  samir n. banoob, president, intenational health mangement, tampa, florida, usa, for the middle east.  evelyne de leeuw, editor-in-chief of health promotion international, , sydney, australia, for the western pacific region.  damen haile mariam, university of addis ababa, ethiopia, for the african region.  charles surjadi, faculty of medicine, atmajaya university, jakarta, indonesia, for the south east asian region.  laura magana valladares, secretaria académica, instituto nacional de salud pública, mexico, mexico, for latin america. however, the journal will grow only upon a firm and long-term commitment of experts and researchers worldwide who believe in the pprofessionalisation of public health in order to advance public health education, training, research and practice. we learned from many sides that seejph is considered a valuable contribution to public health in south eastern europe and transitional countries worldwide. we look forward to applying for an impact factor as soon as it looks promising. your high level contributions will help a lot. thus, no time to celebrate but to grow up our little child to adolescence and adulthood! recommended citation: burazeri g, laaser u, martin-moreno jm, schröder-bäck p. growing up the south eastern european journal of public health (editorial). seejph 2016: vol. v. doi 10.4119/unibi/seejph-2016-89 burazeri g, laaser u, martin-moreno jm, schröder-bäck p. growing up the south eastern european journal of public health (editorial). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-89 3 burazeri g, laaser u, martin-moreno jm, schröder-bäck p. growing up the south eastern european journal of public health (editorial). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-89 4 references 1. burazeri g, jankovic s, laaser u, martin-moreno jm. south eastern european journal of public health: a new international journal. seejph 2014;1. doi 10.12908/seejph-2013-01. 2. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives. seejph 2015;1. doi 10.12908/seejph-2014-36. 3. czabanowska k, laaser u, stjernberg l. shaping and authorising a public health profession. seejph 2014;2. doi 10.12908/seejph-2014-23. 4. ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health. seejph 2015;1. doi 10.12908/seejph2014-34. 5. goodman j. the history of european public health education accreditation in perspective. seejph 2015;1. doi 10.12908/seejph-2014-39. 6. schröder-bäck p, maeckelberghe e, royo-bordonada má. the ethics effect. seejph 2014;2. doi 10.12908/seejph-2014-31. ___________________________________________________________ © 2016 burazeri et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. henke k-d. the effectiveness of the health economy: a case study of the federal republic of germany (position paper). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5113 p a g e 1 | 6 position paper the effectiveness of the health economy: a case study of the federal republic of germany klaus-dirk henke1 1 fakultät vii wirtschaft und management, technical university berlin, berlin, germany corresponding author: prof. dr. klaus-dirk henke address: fakultät vii wirtschaft und management, technical university berlin, straße des 17. juni 135, 10623 berlin, germany email: klaus-dirk.henke@outlook.de mailto:klaus-dirk.henke@outlook.de henke k-d. the effectiveness of the health economy: a case study of the federal republic of germany (position paper). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5113 p a g e 2 | 6 usually, the population associates the health care system with providing medical care and health care for patients. stereotypically, this image includes excessively high costs and the need to curb them. completely disregarded is the fact that the health care system is not only a cost factor but also a growing industry. its economic importance is impressively demonstrated by its contribution to employment value-added, and exports. 16.6% of the labor market, 12.0% of gross value-added, and 8.3% of exports in the overall economy in 2019 are already impressive figures that other industries do not have (1).1 the german federal ministry for economic affairs and energy regularly publishes facts and figures on the core and extended sectors of the healthcare industry and the associated collectively and individually financed healthcare services. these reliable data are available nationally and at the regional level down to the individual county (2). for example, it can be seen that the health economy in mecklenburg-western pomerania and schleswig-holstein makes a particular contribution to regional employment and gross value-added, while in southern germany, the industrial locations of the health economy are in the foreground. thus the data refer to the state's economy, in particular employment. the northern states profit a lot from tourism, while the industry is in the foreground in the south (3). the figures do not refer to health needs and demands between different regions.the economic importance of health care is also reinforced by the fact that healthy aging increases the population's productivity and triggers a growing demand for services and goods (4). it can be seen that healthcare is not only a cost factor but also an economic sector that makes a stable long-term contribution to the national product and, above all, to employment, alongside tourism, the education sector, the energy 1 all data in the entire article are for germany, except the three tables for a few see countries in the appendix. industry, and the automotive industry. the described economic footprint is further strengthened because this economic sector stabilizes the national economic power due to the low input ratio. finally, it can be shown that the industry grows one percent faster over time than the german economy as a whole (5). despite the regular and systematic statistical coverage of the health economy by the german federal ministry for economic affairs and energy and the independent economic research institute wifor (wirtschaftsforschung, https://www.wifor.com/en/), additional aspects require further investigation. for example, the question arises as to whether a healthier society also generates savings. however, there are hardly any reliable calculations on this assumption. there is a lack of meaningful medical results. this requires calculations for specific disease patterns for different population groups and, if possible, differentiated by region. therefore, a frequent question relates to the health benefit, somewhat superficially also referred to as the "health dividend" of the health care system. in germany, we have taken a major step forward with institutionalized benefit measurement through the german medicines market reorganization act (gmmra) and the associated institutes for quality assurance, efficiency, and evaluation of medical interventions. nevertheless, there are increasing complaints about the associated increase of bureaucracy in the selfadministration and thus in the healthcare system. increasing transparency seems to be increasing bureaucratization even more. it is a pity that competition hardly plays a role in this context. the health insurance funds mainly manage themselves, and the sgb v does not allow them to organize health care entrepreneurially. the health benefits of the health economy are not equally apparent, as is the case with calculations of value-added, employment, and exports based on the statistical basis for all of these figures are from an article published in 2019 by henke et al. (1) henke k-d. the effectiveness of the health economy: a case study of the federal republic of germany (position paper). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5113 p a g e 3 | 6 standardized national accounts. on the way to more transparency, comprehensibility and an evaluation of the benefits of the health care industry, attention should therefore be drawn to only a few selected and easily comprehensible ways as examples. new tasks include suitability for everyday life and the elderly as a care goal that is gaining in importance. the health economy includes medical devices and prosthetics, combined with sports and fitness equipment, weight and blood pressure measurement, home emergency call systems, and the measurement of irregular body states (digital health). in these more medical-technical areas, given their economic benefits here and there, they can even be expected to be self-financing. another path is more strongly oriented toward individual physical functioning in ophthalmology, using the example of highly successful cataract operations. the healthcare industry contributes a great deal to a better quality of life in this area. accidents in the home, in sports, or traffic, completely different segments can also be isolated in the context of the health economy and analyzed in terms of their health benefits. often overlooked is that these small-seeming sectors include many medium-sized companies that have turned healthcare into an industry. more than 45 million people are wearing spectacles in germany. more than 800,000 cataract operations (6) also have to be managed technically, even if the focus is on vision, hearing, or mobility for the individual. assisted living and age-appropriate assistive technologies also contribute to better health or everyday fitness in the familiar and neighborhood environment. accessible health is not just a buzzword but a prerequisite for open access to healthcare services (7). in the case of chronic illnesses, the focus is on new technologies that are often initially paid for individually before they come into widespread use as standard services. the progress usually starts with 2 the author thanks jadranka božikov for the information about this background. the consumption of expensive goods by people who can afford them. increasing demand may reduce the prices and, together with empirically-based benefits, will be used by the sickness funds to support their use by larger insured groups. an example of the automobile industry is similar in that rich people buy expensive cars and use technical equipment earlier and more often. still, after a certain period, the average population can use the goods and services because the prices went down. in the case of interventions that can be scheduled, special clinics with their particularly sophisticated medical equipment play a unique role. elective surgery is essential for health tourism, i.e. export, particularly in some countries in central and south eastern europe, including croatia. especially it applies to procedures and services financed out-of-pocket (e.g. dental care and the already mentioned cataract surgery). plastic surgery and aesthetic treatments are another rising part, and cross–border health care could be mentioned in this context, as well.2 during the covid pandemic another issue came up concerning the elective surgical procedures. to increase the capacity of intensive care, elective surgery was postponed in many cases to a later period of time. last but not least, reference should be made to medical services and aids, medications, and the rapid medicaltechnical progress in general and especially in university hospitals. here, too, the public rarely perceives the healthcare system as a sui generis branch of industry. yet, the healthcare industry is an indispensable prerequisite for the provision of healthcare to the population. this is particularly true for the pharmaceutical industry and indirectly included through expenses for drugs that are usually included in health spending in which over-the-counter drugs are not always included. the benefits of those mentioned above and other treatments result from the products and services of the health economy, which must be available henke k-d. the effectiveness of the health economy: a case study of the federal republic of germany (position paper). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5113 p a g e 4 | 6 millions of times in terms of type and scope. thus, the population's health care and its health assistance belong inseparably together with the health economy. of course, one should never forget that ethical and humanitarian principles have to be respected (8,9). supporting everyday competence combined with the skills and abilities of older people, i.e., successful aging, remains an ongoing challenge in aging societies. new ways in the health economy contribute significantly to this and are still underestimated in their importance for the aging population's health care (10). references 1. henke k-d, legler b, claus m, ostwald da. health economy reporting: a case review from germany, international journal of business and social science, 2019; 10 (3):50-64, doi: 10.30845/ijbss.v10n3p5. 2. bundesministerium für wirtschaft und energie, hrsg., gesundheitswirtschaft, fakten und zahlen, ausgabe 2019, berlin 2020:8. 3. henke k-d. von der gesundheitsökonomie zur gesundheitswirtschaft. perspektiven der wirtschaftspolitik 2019; 20(1):23-41 ibid. p.36. 4. henke k-d, martin k, health as a driving economic force. in: kickbusch i. (editor). policy innovation for health, berlin 209; 95-124 https://de.statista.com/statistik/daten/ studie/673391/umfrage/preis. 5. henke k-d, fachinger u, eberhardt b. better health and ambient assisted living (aal) from a global, regional and local economic perspective. in: international journal of behavioural and healthcare research, 2010; bd. 2, h. 2, 172-192. 6. marstein e, babich sm. global health in transition. the coming of neoliberalism. south eastern european journal of public health, 2018; 9:1-7, doi: 10.4119/unibi/seejph-2018-179. 7. marstein e, babich sm. the corporatization of global health: the impact of neoliberalism. south eastern european journal of public health, 2018; 10:1-8, doi: 10.4119/unibi/seejph-2018-191. 8. henke k-d, ostwald da. health satellite account: the first step, in: behavioural and healthcare research. 2012; bd.3, h.1., s. 91105. henke k-d. the effectiveness of the health economy: a case study of the federal republic of germany (position paper). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5113 p a g e 5 | 6 appendix the role of health economy in some see countries (croatia, montenegro and slovenia) based on empirical data and in comparison with the eu is presented in tables 1-3 bellow. source: henke, k-d, legler b. the economic importance of the healthcare sector. health economy reporting in the balkan states – empirical data for croatia, slovenia and montenegro, opatija, september 2018. health expenditures, share of health expenditures in gdp, gross value-added (gva) of health economy, and share of health economy in gdp are documented in table 1 for 2015. the figures stem from own calculations based on eurostat (2018) and who (2018). table 2 refers in the long run from 2011 to 2015 and includes the growth rate of the labor force in the health economy. the sources are the same as in table 1. a comparison with other sectors (tourism and finance) is shown in table 3. the health economy is a key segment of the croatian and slovenian economy in 2016 compared with tourism and finance. these data stem from eurostat (2018). what are the benefits of the health economic accounts? • established and continuous monitoring of the health economy. • facts and figures as a basis for political decision-makers. • early warning tool for special developments. (anomalies in growth dynamics, value-added losses, employment declines). • comparability with other major sectors of the economy. table 1: measurements of the health economy: expenditures and shares of health economy in the overall economy in croatia, slovenia and montenegro compared to the european union (eu). source: wifor calculations based on eurostat (2018) and who (2018) source: wifor calculations based on eurostat (2018), who (2018). euslovenia montenegro 5.9 %8.6 %share of health expenditures in gdp 216 ml.eur3.3 bn.eurhealth expendituresin 2015 9.9 % 1,470 bn.eur 7.3 % 3.2 bn.eur croatia 5.3 %8.5 %share of health economy in gva 9.9 %6.7 % 209 ml.eur3.4 bn.eurgva of health economyin 2015 1,312 bn.eur3.1 bn.eur henke k-d. the effectiveness of the health economy: a case study of the federal republic of germany (position paper). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5113 p a g e 6 | 6 © 2022 henke. this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. table 2: health economy reporting also includes time series analyses and thus enables statements to be made on economic dynamics. data for croatia, slovenia and montenegro compared to the european union (eu). source: wifor calculations based on eurostat (2018) and who (2018) table 3: comparison of the health economy with other sectors (tourism and finance): shares of gross value-added (gva) and labor force in the overall economy in croatia and slovenia are shown. source: wifor calculations based on eurostat (2018) ________________________________________________________________________ source: wifor calculations based on eurostat (2018), who (2018). euslovenia montenegro 1.8 %1.5 %growth rateof health expenditure (2011 – 2015, p.a.) 1.1 % croatia 3.7 %1.7 %growth rateof health economy gva (2011 – 2015, p.a.) 2.5 %1.3 % source: wifor calculations based on eurostat (2018). finance 6.0 % 4.7 % 1.1 % 4.1 % tourism 3.1 bneur 155.500 gross value added in 2016 labor force in 2016 croatia 4.1 % 2.4 % 1.2 % 2.5 % slovenia 3.4 bneur 119.500 gross value added in 2016 labor force in 2016 gva share of overall economy labor force share of overall economy 8.6 % 8.1 % gva share of overall economy labor force share of overall economy 12.2 % 9.8 % pampuri o, czabanowska k, hysa b, roshi e, burazeri g. public health leadership competency level among health professionals in a south eastern european country (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-40 1 original research public health leadership competency level among health professionals in a south eastern european country orjola pampuri 1 , katarzyna czabanowska 2,3 , bajram hysa 4 , enver roshi 1,4 , genc burazeri 2,4 1 institute of public health, tirana, albania; 2 department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 3 institute of public health, faculty of health sciences, jagiellonian university, medical college, krakow, poland; 4 faculty of public health, university of medicine, tirana, albania. corresponding author: orjola pampuri, institute of public health; address: rr. “aleksander moisiu”, no. 88, tirana, albania; telephone: +355672066183; e-mail: o.pampuri@yahoo.com pampuri o, czabanowska k, hysa b, roshi e, burazeri g. public health leadership competency level among health professionals in a south eastern european country (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-40 2 abstract aim: the aim of this study was to describe the current and the required leadership competency level of health professionals in albania, employing a recently established international instrument. methods: a nationwide cross-sectional study was conducted in albania in july-december 2014 including a representative sample of 267 health professionals (162 men and 105 women; mean age: 44.7±10.3 years; overall response rate: 89%). a structured questionnaire was administered to all health professionals aiming at self-assessing the current level of leadership competencies and the required (desirable) level of leadership competencies for their current job position. the questionnaire included 52 items grouped into eight subscales/domains. answers for each item of the tool ranged from 1 (“minimal competency level”) to 5 (“maximal competency level”). an overall summary score (range: 52-260) and a subscale summary score for each domain were calculated for both the current and the required leadership competency levels. wilcoxon signed ranks test was employed to compare the overall scores and the subscale scores of the current and the required level of leadership competencies among health professionals. results: mean value of the overall summary score for the 52 items of the instrument was significantly lower for the current leadership competency level compared with the required leadership competency level (138.4±11.2 vs. 159.7±25.3, respectively; p<0.001). most of the subscales’ scores were significantly higher for the required than for the current leadership competency level. conclusion: our study provides useful evidence about the current and the required level of leadership competencies among health professionals in transitional albania. findings of this study may help policymakers in albania to identify the gap between the required and the current level of leadership competencies among health professionals. furthermore, findings of this study should be expanded in the neighbouring countries of the south eastern european region and beyond. keywords: albania, competency level, health professionals, public health leadership, south eastern europe. acknowledgement: the authors thank colleagues and partners from the lephie project and the members of the aspher’s wgigp. conflicts of interest: none. pampuri o, czabanowska k, hysa b, roshi e, burazeri g. public health leadership competency level among health professionals in a south eastern european country (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-40 3 introduction to date, there have been developed a few competency frameworks in order to assess public health leadership and medical leadership competencies (1-4). these instruments have basically included the key principles and concepts of leadership (5,6). establishment and refinement of these tools is due to the urgent need to develop strong leadership skills and competencies among public health professionals at large (7). hence, these leadership frameworks are deemed useful for professional training and continuous medical education in particular, but also for continuous professional development in general (5,6). competencies in the area of public health leadership are regarded as a crucial element for the performance and activities of health professionals operating at all levels of health care services (public health, primary health care services, as well as hospital care) in different settings and cultures (7). a key driver in improving leadership within public health is that the nature of the challenges faced by such professionals is evolving. developing effective leadership is essential as many european countries are putting health systems under significant financial pressures and forcing them to deliver more with diminishing resources (8). notwithstanding the current progress towards development of leadership competencies in the area of medicine and public health, the existing frameworks are – on the face of it – too generic and not satisfactorily detailed for a proper assessment of the leadership competency level of health professionals operating in different levels of health care. it has been convincingly argued that a proper identification and assessment of the level of leadership competencies is a basic prerequisite for adjustment of the educational curriculum and training models for health professionals in different european countries (7). for this very reason, fairly recently, it has been developed a specific public health leadership competency framework with the aim to significantly foster the competency-based european public health leadership curriculum (7). as acknowledged earlier, this competency framework was designed in the context of the leaders for european public health (lephie) erasmus multilateral curriculum development project, supported by the european union lifelong learning programme (7). the information about public health leadership is scarce for albania, a former communist country in southeast europe, which is characterized by a rapid political and socioeconomic transition associated with deleterious health effects (9,10). the particularly rapid process of transition in albania over the past twenty five years has been associated with an intensive process of migration, both internal (from rural areas to urban areas of the country) and external (mainly to the neighbouring countries including greece and italy) (11). this has also affected the workforce, at least to some extent. indeed, regardless of the international financial crisis, the relatively poor economic situation and the lack of rapid economic expansion due to limited domestic resources continue to encourage albanian adults to emigrate (12). in 2013, it was established in albania a national school of public health under the auspices of the university of medicine. nevertheless, the curriculum of both undergraduate and postgraduate public health programs does not sufficiently promote leadership skills and competencies for future health professionals in albania. the new leadership competency framework was cross-culturally adapted in albania in may 2014 in a sample of health professionals operating at different levels of health care services (13). pampuri o, czabanowska k, hysa b, roshi e, burazeri g. public health leadership competency level among health professionals in a south eastern european country (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-40 4 in this context, the aim of our study was to describe the current and the required leadership competency level of health professionals in albania, employing this recently established international instrument, which was previously validated. methods a cross-sectional study was conducted in albania in july-december 2014 targeting a nationwide representative sample of 300 health professionals working at different health institutions all over the country (primary health care services, regional hospitals, university hospital centre “mother teresa”, institute of public health, and health insurance fund). of 300 targeted health professionals, 33 individuals refused to participate. the study sample consisted of 267 health professionals (162 men and 105 women; mean age: 44.7±10.3 years; overall response rate: 89%). a structured questionnaire was administered to all health professionals aiming at selfassessing the current level of leadership competencies and the required/desirable level of leadership competencies for their current job position. as reported previously, the questionnaire consisted of 52 items grouped into eight competency domains (subscales) including (7): i) systems thinking; ii) political leadership; iii) collaborative leadership: building and leading interdisciplinary teams; iv) leadership and communication; v) leading change; vi) emotional intelligence and leadership in team-based organizations; vii) leadership, organizational learning and development, and; viii) ethics and professionalism as explained elsewhere, each domain (subscale) of the instrument corresponds to one educational session within public health leadership curriculum (7,14). answers for each item of each subscale of the instrument ranged from 1 (“minimal competency level”) to 5 (“maximal competency level”). an overall summary score (range: 52-260) and a subscale summary score for each domain were calculated for both, the current level of competencies and the required level of competencies. the instrument was previously validated (cross-nationally adapted in the albanian context) in a sample of 53 health professionals in tirana in may 2014 (13), after a careful process of translation and back-translation of the original english version of the leadership competency questionnaire, following strict methodological rules (15). furthermore, the questionnaire included demographic information (age and sex of health professionals), place of work (urban areas vs. rural areas), type of diploma obtained (dichotomized into: health sciences vs. other diploma), years of working experience, as well as current job position (trichotomized into: high, middle and low managerial level). measures of central tendency and dispersion (mean values and standard deviations) were used to describe the distribution of age and working experience among male and female participants. conversely, absolute numbers and their respective percentages were used to describe the distribution of place of work, diploma obtained and the job position of health professionals. cronbach’s alpha was used to assess the internal consistency for both the current level of competencies and the required level of competencies (16,17). on the other hand, wilcoxon signed ranks test was used to compare the overall scores and the subscale scores of the current level of competencies and the required level of competencies among health professionals included in this study. pampuri o, czabanowska k, hysa b, roshi e, burazeri g. public health leadership competency level among health professionals in a south eastern european country (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-40 5 results mean age in the male sample of health professionals (n=162) was 44.9±10.6 years, whereas in females (n=105) it was 44.4±9.9 years (table 1). about 75% of health professionals were working in urban areas and 25% in rural areas of albania. around 87% (n=233) of participants had received a diploma in health sciences (medicine, public health, nursing, pharmacy, or dentistry), whereas 13% (n=34) had other backgrounds (law, economics, social sciences, or engineering). overall, mean working experience was 19.6±10.1 years. about 21% (n=55) of health professionals were working in high-level managerial positions compared with 32% (n=84) who were operating in low-level positions. table 1. baseline characteristics in a nationwide representative sample of health professionals in albania, in 2014 variable men (n=162) women (n=105) total (n=267) age (years) 44.9±10.6 * 44.4±9.9 44.7±10.3 place of work: urban areas rural areas 111 (68.5) † 51 (31.5) 90 (85.7) 15 (14.3) 201 (75.3) 66 (24.7) diploma: health sciences other 142 (87.7) 20 (12.3) 91 (86.7) 14 (13.3) 233 (87.3) 34 (12.7) working experience (years) 20.0±10.4 19.0±9.6 19.6±10.1 job position: high managerial level middle managerial level low managerial level 33 (20.4) 70 (43.2) 59 (36.4) 22 (21.0) 58 (55.2) 25 (23.8) 55 (20.6) 128 (47.9) 84 (31.5) * mean values ± standard deviations. † numbers and column percentages (in parentheses). the internal consistency of the overall scale (52 items) was cronbach’s alpha=0.86 for the current competency level and cronbach’s alpha=0.96 for the required competency level (table 2). for the current competency level, cronbach’s alpha was the lowest for the “ethics and professionalism” domain (0.49) and the “leadership, organizational learning and development” subscale (0.55) and the highest for the “political leadership” domain (0.94). similarly, for the required competency level, cronbach’s alpha was the lowest for the “ethics and professionalism” domain (0.65) and the highest for the “political leadership” domain (0.91). mean value of the overall summary score for the 52 items of the instrument was significantly lower for the current competency level compared with the required competency level (138.4±11.2 vs. 159.7±25.3, respectively; p<0.001) (table 3). all the subscales’ scores were significantly higher for the required competency level than for the current competency level, except for the “emotional intelligence and leadership in team-based organisations” and “leading change” domains (table 3). pampuri o, czabanowska k, hysa b, roshi e, burazeri g. public health leadership competency level among health professionals in a south eastern european country (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-40 6 table 2. internal consistency of the leadership competency instrument administered in a representative sample of health professionals in albania (n=267) domain (subscale) cronbach’s alpha current competency level required competency level overall scale (52 items) 0.86 0.96 systems thinking (7 items) 0.82 0.78 political leadership (8 items) 0.94 0.91 collaborative leadership: building and leading interdisciplinary teams (5 items) 0.89 0.85 leadership and communication (7 items) 0.62 0.87 leading change (6 items) 0.64 0.77 emotional intelligence and leadership in team-based organizations (6 items) 0.83 0.83 leadership, organizational learning and development (7 items) 0.55 0.79 ethics and professionalism (6 items) 0.49 0.65 table 3. summary score of each domain (subscale) of the leadership competency instrument for the current and the required competency level of albanian health professionals (n=267) domain (subscale) mean values ± standard deviations p-value * current competency level required competency level overall scale (52 items) 138.4±11.2 159.7±25.3 <0.001 systems thinking (7 items) 21.1±2.8 21.8±3.4 <0.001 political leadership (8 items) 20.1±5.0 20.9±5.4 <0.001 collaborative leadership: building and leading interdisciplinary teams (5 items) 11.7±2.9 12.9±3.6 <0.001 leadership and communication (7 items) 16.5±2.2 17.9±4.3 <0.001 leading change (6 items) 17.1±2.1 16.7±3.2 0.005 emotional intelligence and leadership in team-based organizations (6 items) 18.1±2.4 17.3±3.6 <0.001 leadership, organizational learning and development (7 items) 16.5±2.1 17.7±3.6 <0.001 ethics and professionalism (6 items) 17.2±2.0 17.6±2.7 0.018 * wilcoxon singed ranks test. discussion this study provides useful evidence about the level and distribution of leadership competencies among health professionals in transitional albania, based on a recently established international instrument, which was previously validated (cross-culturally adapted) in the albanian context. this measuring international instrument exhibited satisfactory internal consistency especially for assessment of the required (desirable) leadership competency level. during the previous pampuri o, czabanowska k, hysa b, roshi e, burazeri g. public health leadership competency level among health professionals in a south eastern european country (original research). seejph 2015, posted: 10 february 2015. doi 10.12908/seejph-2014-40 7 validation exercise, the tool had also displayed a high stability over time (i.e., a high testretest reliability for the overall scale and for each of the subscales of the instrument) (13). main findings of this survey include a higher self-perceived level of the required leadership competencies than the current (existing) level of leadership competencies among health care professionals in post-communist albania. interestingly, most of the subscale scores were significantly higher for the required competency level compared with the current competency level in this nationwide representative sample of health professionals in albania. findings of this study may help policymakers in albania to identify the gap between the required and the current level of leadership competencies among health professionals. as already reported elsewhere, the public health leadership competency-based curriculum was established in the framework of the lephie project (7). similarly, as czabanowska et al. point out that a starting point is to identify the competency capacities of future leaders in relation to population health and well-being and apply the study results to inform education, training and culture change throughout the workforce (14), we considered that the description of the competencies supports the curriculum design and it can be used as a self-assessment instrument for students and public health professionals, helping them to reflect and identify gaps in their knowledge, skills and competencies (7). the teaching of leadership is still not common in public health training programmes around the world and seems particularly rare in countries experiencing intensive public health reforms. there is a need for substantial investment in leadership training for public health professionals (18). in conclusion, we provide important evidence about the level and distribution of the leadership competency level among health professionals in albania, a country embarked in the long journey towards accession into the european union. our survey informs about both the self-perceived leadership competency level and the required/desirable level of leadership competencies for the respective job positions of health care professionals in albania. findings of our survey should be expanded further in large representative samples of health care professionals in the neighbouring countries in the western balkans and beyond. similar to albania, this type of survey will help to identify potential gaps in the level of existing leadership competencies and the required/desirable level of leadership competencies, which will ultimately inform the public health curricula about necessary content adjustments. references 1. maintenance of certification competencies and criteria. american 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reliability. j nurs scholars 2007;39:155-64. 18. czabanowska k, smith t, stankunas m, avery m, otok r. transforming public health specialists to public health leaders. lancet 2013;381:449-50. ___________________________________________________________ © 2015 pampuri et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed?term=czabanowska%20k%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=smith%20t%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=k%c3%b6nings%20kd%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=sumskas%20l%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=otok%20r%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=bjegovic-mikanovic%20v%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed?term=brand%20h%5bauthor%5d&cauthor=true&cauthor_uid=24121098 http://www.ncbi.nlm.nih.gov/pubmed/24121098 http://www.ncbi.nlm.nih.gov/pubmed/?term=czabanowska%20k%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=rethmeier%20ka%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=lueddeke%20g%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=smith%20t%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=malho%20a%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=otok%20r%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=stankunas%20m%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=stankunas%20m%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/pubmed/?term=stankunas%20m%5bauthor%5d&cauthor=true&cauthor_uid=24709511 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=retrieve&dopt=abstractplus&list_uids=17436387&query_hl=1&itool=pubmed_docsum http://www.ncbi.nlm.nih.gov/pubmed/?term=czabanowska%20k%5bauthor%5d&cauthor=true&cauthor_uid=23399070 http://www.ncbi.nlm.nih.gov/pubmed/?term=smith%20t%5bauthor%5d&cauthor=true&cauthor_uid=23399070 http://www.ncbi.nlm.nih.gov/pubmed/?term=stankunas%20m%5bauthor%5d&cauthor=true&cauthor_uid=23399070 http://www.ncbi.nlm.nih.gov/pubmed/?term=avery%20m%5bauthor%5d&cauthor=true&cauthor_uid=23399070 http://www.ncbi.nlm.nih.gov/pubmed/?term=otok%20r%5bauthor%5d&cauthor=true&cauthor_uid=23399070 ahmed p, eaty m, alam n, anthony l, yasmin n. respiratory symptoms among urban traffic policemen in bangladesh: a cross-sectional study (original research). seejph 2022, posted: 19 june 2022. doi: 10.11576/seejph-5534 p a g e 1 | 13 original research respiratory symptoms among urban traffic policemen in bangladesh: a cross-sectional study parvez ahmed1, mahim eaty2, nazmul alam3, leela anthony4, nawzia yasmin1 1 state university of bangladesh, dhaka, bangladesh; 2 plan international, bangladesh; 3 asian university for women, chittagong-4000, bangladesh; 4 aimst university, kedah, malaysia. corresponding author: dr. parvez ahmed mbbs mph ph.d.; address: state university of bangladesh, 77 satmasjid road, dhanmondi, dhaka -1205, bangladesh; telephone: +88 01713 485394; email: parvez.epidemiology@gmail.com ahmed p, eaty m, alam n, anthony l, yasmin n. respiratory symptoms among urban traffic policemen in bangladesh: a cross-sectional study (original research). seejph 2022, posted: 19 june 2022. doi: 10.11576/seejph-5534 p a g e 2 | 13 abstract aim: there is accumulating evidence that roadside pollution is detrimental to health. this study aims to compare the risk of adverse respiratory symptoms in different categories of traffic police including traffic constables, sergeants, and inspectors working in the polluted environment. methods: the study population consisted of 369 randomly selected traffic police personnel from the city of chittagong in bangladesh. information on their occupation and respiratory health symptoms were collected. the health outcomes were coughing, coughing sputum, coughing up blood, shortness of breathing, wheezing, and chest pain with deep breathing. results: the risk of coughing [adjusted odds ratio (aor) = 4.469, 95% ci=1.265-15.793], coughing sputum [aor= 3.687, 95% ci= 1.004 -13.540], coughing up blood [aor=1.040, 95% ci=0.227-6.162], shortness of breathing [aor=3.937, 95% ci=1.069-14.500], wheezing [aor= 2.464, 95% ci= 0.613-9.906] and chest pain with deep breathing [aor=2.163,95% ci= 0.5608.349] was higher in traffic constables on comparison to inspectors. in sergeants odds increased for coughing up blood [aor=1.102, 95% ci= 0.283-4.286] and wheezing [aor=1.260, 95% ci= 0.304-5.229]. conclusion: there was a substantial difference in the risk of studied respiratory symptoms between different categories of traffic police jobs. keywords: bangladesh, epidemiology, occupational and environmental health, respiratory symptoms, traffic police. conflicts of interest: none declared. ahmed p, eaty m, alam n, anthony l, yasmin n. respiratory symptoms among urban traffic policemen in bangladesh: a cross-sectional study (original research). seejph 2022, posted: 19 june 2022. doi: 10.11576/seejph-5534 p a g e 3 | 13 introduction environmental exposures during work activities can affect health. traffic police personnel spend a long duration of time by roadside due to the nature of their job and are exposed to roadside vehicular emissions that can cause both longand short-term health problems. previously conducted epidemiological studies reported the association of occupational health hazards such as environmental pollution due to vehicular emission and adverse respiratory health outcomes in traffic police personnel (1,2). road traffic generates volatile organic compounds, suspended particulate matter, oxides of nitrogen, sulfur oxides, and carbon monoxide which impose a wide range of adverse health effects on the exposed population (3). vehicular emission-related deterioration in air quality has been shown to produce significant morbidity and mortality by affecting multiple organs and systems (4). these pollutants cause respiratory morbidities, reduced lung function, and chronic exposure may even cause lung cancers and copd (5,6). bangladesh, one of the most densely populated countries in the world, is going through economic transition and rapid urbanization in recent years. major cities of bangladesh, particularly chittagong and capital city dhaka is congested with a large number of motor vehicles, including local transport buses, long route buses, diesel-run local passenger vans, passenger cars, commercial vans, private cars, compressed natural gas (cng)-run auto-rickshaws, and heavy-duty diesel-powered lorry trucks for the shipment of garment products to the chittagong port. most of these vehicles are run by high-sulfur diesel (7). the air quality of dhaka is considered to be one of the most polluted in the world, at 82 µg/m3 annual average pm2.5 concentration from a variety of pollution sources and ranked as the third most polluted city among the megacities with at least 14 million people (8). according to the bangladesh road and transport authority (brta), there were 504,130.000 registered motor vehicles in 2019 in bangladesh, most of which were decades old and unfit for the road, polluting the environment severely (9). exhaust and fumes of these vehicles are a major source of no2 emissions and co emissions in chittagong and dhaka, accounting for some 58.6% of the total annual no2 emissions and 40.5% of the total co emissions (10). the concentration of pm particles, so2, ozone, carbon monoxide in some cities of bangladesh including chittagong city has been found well above the recommended level of the world health organization (who) (11,12). despite the high pollution and vulnerability of the traffic police of bangladesh, there are hardly any studies that have been done on them. therefore, this study aims to assess the risk of adverse respiratory health outcomes in different categories of traffic police including constables, sergeants, and inspectors of bangladesh. methods study setting a cross-sectional study was conducted in chittagong city of bangladesh. the data collection process was carried out from june 1st, 2018 to august 31st, 2018. study population and work environment study participants were traffic police personnel working in different areas in the city of chittagong of bangladesh. in bangladesh, traffic police constables, by job definition are assigned in traffic control and management at traffic junctions, traffic inspectors coordinate scheduled service within assigned territory of streetcar, bus, or railway transportation system with the periodical investigation in schedule delays for accidents, equipment failures, complaints ahmed p, eaty m, alam n, anthony l, yasmin n. respiratory symptoms among urban traffic policemen in bangladesh: a cross-sectional study (original research). seejph 2022, posted: 19 june 2022. doi: 10.11576/seejph-5534 p a g e 4 | 13 and files written report, and sergeants perform patrol duties to address traffic infringement or violation and is responsible for the initial scene management of incidents. the road traffic is very dense at most of the traffic junctions in chittagong city either because of nonfunctional traffic lights or due to traffic snarl-ups. traffic police personnel aged 20 years or over were invited for the study. determination of sample size the sample size for the prevalence of the respiratory disease among traffic police was determined using single proportion formula with the following assumptions: level of significance (α) =5%, (at a confidence level of 95%), p= 68% (according to a study done in india, 68% traffic police personnel had frequent coughing and other complications with various percentages due to occupational exposure. india was considered for expectation prevalence for this study since india and bangladesh are located in the same geographical region and both countries share similar types of exposures) (13). z value=1.96, marginal error d=7% of p, n= z2 * p * (1-p)/d=369 a simple random sampling technique was used to collect police personnel following strobe guidelines. variables the survey about respiratory symptoms in traffic policemen was based on a questionnaire adapted from the standard respirator medical evaluation questionnaire (14). the questionnaire covered the following respiratory symptoms: coughing, coughing sputum, wheezing, coughing up blood, shortness of breathing, and chest pain with deep breathing. respiratory symptoms were recorded as being present if a participant answered, "yes", to a relevant question. the participants were provided with explanations about each respiratory symptom. the questionnaire also included socio-demographic information of the participants including age, height, weight, marital status, job information including job title, preventive measures such as using the face mask, information about behavioral factors including smoking and workout habit (exercise), and history of a previous respiratory disease diagnosed by a doctor including asthma, tuberculosis, chronic bronchitis, emphysema, pneumonia, pneumothorax, cancer, tuberculosis, chest injury or surgery, broken ribs, allergic reaction interfering with breathing. three trained data collectors went to the site with the questionnaire after obtaining approval from the local police authority and conducted face-to-face interviews. validation of respiratory symptoms was done by a registered medical doctor (first author). research approach the research approach of the present study was the identification of the type of industries where there is an excess risk of adverse health outcomes. focus on workers in this occupation can lead to recognition of one or several factors, which may have independent or synergic effects (15). data management and analysis all data were recorded and analyzed in statistical package for the social sciences (spss) version 22. traffic inspectors were used as a reference category to compare the risk of respiratory health outcomes among traffic police as traffic inspectors are considered least exposed to roadside pollution. to determine the risk of respiratory outcomes among traffic police, a two-step statistical model approach was undertaken. first, the prevalence of adverse respiratory health outcomes in different traffic police by job title was measured. second, the risk of adverse respiratory outcomes was compared ahmed p, eaty m, alam n, anthony l, yasmin n. respiratory symptoms among urban traffic policemen in bangladesh: a cross-sectional study (original research). seejph 2022, posted: 19 june 2022. doi: 10.11576/seejph-5534 p a g e 5 | 13 to different traffic jobs by job title. odds ratio with 95% confidence interval (ci) was the measure of association. logistic regression analysis was conducted to estimate adjusted odds ratio where covariates such as age, bmi, education, smoking status, use of mask, workout (exercise), previous respiratory disease were adjusted for each of the other. ethical considerations the study was approved by the research and ethics committee of the asian university for women, bangladesh. informed verbal consents of the participants were obtained before data collection. results table 1 describes the sample characteristics according to the job title. out of a total of 369 traffic police personnel, 25 (6.7%) were inspectors, 145 (39.3%) were sergeants, and 199 (53.9%) were constables. there was a substantial difference was in the distribution of socio-demographic determinants, which could be partly explained by relatively small numbers in some groups. for example, the prevalence of using masks at the workplace was 16.0% in traffic inspectors, 34.5% among sergeants, and 13.6% among constables. however, the distribution of workout habits and smoking status was found almost the same in all the occupational groups. table 1. characteristics of participants according to job title (n=369) variable job title inspector (n/%) sergeant (n/%) constable (n/%) total (n/%) age (years) <30 0 (0.0%) 4 (2.9%) 21 (23.6%) 25 (6.8%) 30-40 48 (33.8%) 86 (62.3%) 11 (12.4%) 145 (39.3%) >40 94 (66.2%) 48 (34.8%) 57 (64.0%) 199 (53.9%) x2 =101.019, df=4, p<0.001 education school 9 (36.0%) 0 (0.0%) 25 (12.6%) 34 (9.2%) high school 9 (36.0%) 0 (0.0%) 141 (70.9%) 150 (40.7%) undergraduate and higher 7 (28.0%) 145 (100.0%) 33 (16.6%) 185 (50.1%) bmi underweight 0 (0.0%) 2 (1.4%) 3 (1.5%) 5 (1.4%) normal 4 (16.0%) 81 (55.9%) 113 (56.8%) 198 (53.7%) overweight 16 (64.0%) 62 (42.8%) 79 (39.7%) 157 (42.5%) obese 5 (20.0%) 0 (0.0%) 4 (2.0%) 9 (2.4%) x2 =101.019, df=6, p<0.001 marital status single 4 (16.0%) 12 (8.3%) 63 (31.7%) 79 (21.4%) married 21 (84.0%) 133 (91.7%) 136 (68.3%) 290 (78.6%) x2= 27.723, df=2, p<0.001 physical exercise (workout) yes (always) 3 (12.0%) 11 (7.6%) 14 (7.0%) 28 (7.6%) no 4 (16.0%) 83 (57.2%) 72 (36.2%) 159 (43.1%) sometimes 18 (72.0%) 51 (35.2%) 113 (56.8%) 182 (49.3%) workplace yes 4 (16.0%) 50 (34.5%) 27 (13.6%) 81 (21.9%) sometimes 14 (56.0%) 60 (41.4%) 124 (62.3%) 198 (53.7%) no 7 (28.0%) 35 (24.1%) 48 (24.1%) 90 (24.4%) x2 =24.168, df=4, p<0.001 no 25 (100.0%) 125 (86.2%) 189 (95.0%) 339 (91.9%) ahmed p, eaty m, alam n, anthony l, yasmin n. respiratory symptoms among urban traffic policemen in bangladesh: a cross-sectional study (original research). seejph 2022, posted: 19 june 2022. doi: 10.11576/seejph-5534 p a g e 6 | 13 smoking status yes 0 (0.0%) 20 (13.8%) 10 (5.0%) 30 (8.1%) x2 = 11.007, df=2, p=0.004 table 2 shows the prevalence of present respiratory symptoms and previous respiratory illness diagnosed by a doctor according to the job title. there was a substantial difference in the prevalence of all present respiratory symptoms according to the job title. for example, the prevalence of coughing was 24% in the inspectors, 7.6% in the sergeants, and 21.6% in constables while corresponding estimates for cough sputum were 24.0%, 7.6%, and 19.1% respectively. table 2. prevalence of respiratory symptoms according to the job title (n=369) respiratory symptoms job title inspectors (n/%) sergeants (n/%) constables (n/%) total (n/%) coughing 6 (24.0% 11 (7.6%) 43 (21.6%) 60 (16.3%) coughing sputum 6 (24.0%) 11 (7.6%) 38 (19.1%) 55 (14.9%) coughing up blood 5 (20.0%) 11 (7.6%) 41 (20.6%) 57 (15.4%) shortness of breathing 6 (24.0%) 11 (7.6%) 39 (19.6%) 56 (15.2%) wheezing 4 (16.0%) 11 (7.6%) 39 (19.6%) 54 (14.6%) chest pain with deep breathing 12 (48.0%) 12 (8.3%) 41 (20.6%) 65 (17.6%) table 3 shows the distribution of previous respiratory illnesses in the traffic police personnel according to the job title. the participating traffic inspectors, sergeants, and constables were found to have almost no history of previous respiratory diseases, which could be partly explained by the recruitment of personnel with no history of a previous disease or chronic illness in the police service including the traffic police service of bangladesh. table 3. distribution of previous respiratory illness according to the job title (n=369) respiratory symptoms job title inspectors (n/%) sergeants (n/%) constables (n/%) total (n/%) history of pneumonia 0 1 (0.7%) 1 (0.5%) 1 (0.3%) history of tuberculosis 0 0 0 0 history of chronic bronchitis 0 0 1 (0.5%) 1 (0.3%) history of asthma 0 0 0 0 history of pneumothorax 0 0 0 0 history of lung cancer 0 0 0 0 history of chest injury or surgery 0 0 0 0 history of broken ribs 0 0 0 0 allergic reaction interfering with breathing 0 1 (0.7%) 1 (0.5%) 2 (0.5%) table 4 shows logistic regression analysis of respiratory symptoms according to job title (duty type). constables were found at risk for all the studied respiratory symptoms in comparison to the reference group for coughing (adjusted odds ration=4.469, 95% ahmed p, eaty m, alam n, anthony l, yasmin n. respiratory symptoms among urban traffic policemen in bangladesh: a cross-sectional study (original research). seejph 2022, posted: 19 june 2022. doi: 10.11576/seejph-5534 p a g e 7 | 13 ci = 1.265-15.793), coughing sputum (adjusted odds ratio=3.687, 95% ci= 1.004 13.540), shortness of breathing (adjusted odds ratio = 3.937, 95% ci=1.069-14.500). risk also increased for wheezing (adjusted odds ratio=2.464, 95% ci=0.613-9.906), chest pain with deep breathing (adjusted odds ratio=2.163, 95% ci=0.560-8.349), and coughing up blood (adjusted odds ration=1.040, 95% ci=0.227-6.162), however, the risk was not significant statistically. risk moderately increased in sergeants for coughing up blood [aor=1.102, 95% ci= 0.283-4.286] and wheezing [aor=1.260, 95% ci= 0.304-5.2 on comparison to traffic constables, however, the risk was not significant. table 4. logistic regression analysis of respiratory symptoms according to job title outcomes job title crude odds ratio adjusted odds ratio* pe 95% ci pe 95% ci coughing inspector reference sergeants 1.429 0.299-6.817 0.841 0.230-3.075 constables 3.358 1.665-6.771 4.469 1.265-15.793 coughing sputum inspector reference sergeants 1.727 0.467-29.761 0.573 0.151-2.169 constables 2.875 1.415-5.843 3.687 1.004 -13.540 coughing up blood inspector reference sergeants 1.038 0.367-2.932 1.102 0.283-4.286 constables 3.161 1.563-6.392 1.040 0.227-6.162 shortness of breathing inspector reference sergeants .772 0.289-2.061 0.612 0.163-2.291 constables 2.969 1.464-6.024 3.937 1.069-14.500 wheezing inspector reference sergeants 1.280 0.415-3.942 1.260 0.304-5.229 constables 2.969 1.464-6.024 2.464 0.613-9.906 chest pain inspector reference sergeants 0.281 0..119-0.662 0.741 0.302-1.821 constables 2.876 1.452-5.696 2.163 0.560-8.349 * logistic regression analysis adjusting for age, bmi (body mass index), education, marital status, smoking, use of mask and work out (exercise), history of respiratory disease. discussion air pollution in bangladesh is a major public health hazard, especially among those who live and work in cities. the growing number of vehicles is one of the contributing factors for the deteriorating air quality. traffic police personnel who are continuously exposed to air pollutants are at high risk. the present study was designed to assess the prevalence and risk of respiratory symptoms between traffic police personnel. the study explored a high prevalence of respiratory symptoms in different categories of traffic police. this finding corroborates with the result of studies conducted before among traffic police personnel in thailand and india (16,17). the use of a questionnaire was useful to take into account a large number of potential confounders in the current study. after adjustment of potential covariates, constables were found at risk of coughing, cough sputum, coughing up blood, shortness of breath, wheezing, and chest pain in ahmed p, eaty m, alam n, anthony l, yasmin n. respiratory symptoms among urban traffic policemen in bangladesh: a cross-sectional study (original research). seejph 2022, posted: 19 june 2022. doi: 10.11576/seejph-5534 p a g e 8 | 13 comparison to the inspectors. similar to the present study, an epidemiological study conducted before in italy also reported that traffic police personnel assigned for traffic control and management by the roadside are at high risk of adverse respiratory symptoms including coughing, wheezing, shortness of breathing in comparison to traffic police personnel assigned for administrative duties at the office (18). the elevated risk of studied respiratory symptoms in constables could be explained by direct and continuous roadside exposure to roadside pollution which has been shown to be a direct correlate in studies conducted before (19,20). a recently conducted comparative study in malaysia explored that traffic police personnel who work by the roadside are at high risk of adverse respiratory outcomes in comparison to unexposed occupational groups due to continuous and direct exposure (21). continuous and direct exposure to toxic chemicals and gases of vehicular emission cause irritation and allergy in the lungs and airways, airway obstruction, and increased mucus production leading to obstructive lung diseases (22,23). although the human bronchopulmonary tract has multiple protective mechanisms, such as the air-blood barrier and mucosal cilia, air pollutants can accumulate in or pass through lung tissues depending on the size and chemical nature of pollutants (24). the vapor of air pollutants is prone to be absorbed by human tissues or dissolved in body fluids, relying mostly on hydrophilicity and hydrophobicity. the ultrafine particles are capable of translocation through blood circulation to distal organs and tissues, such as liver tissue for detoxification (25). particles deposited in the respiratory tract in sufficient amounts can induce pulmonary inflammation. controlled human and animal exposure studies have demonstrated increased markers for pulmonary inflammation following exposure to a variety of different particles (26). airway inflammation increases airway responsiveness to irritants such as particle pollution, allergens, and gases reducing lung function by causing bronchoconstriction. at the cellular level, inflammation may damage or kill cells and compromise the integrity of the alveolar-capillary barrier. repeated exposure to particle pollution aggravates the initial injury and promotes chronic inflammation with cellular proliferation and extracellular matrix reorganization (27). as regards to subjective symptoms of the current study, investigated by means of the questionnaire, positive results were more prevalent among the constables than inspectors, this difference being a statistically significant agreement with what was observed by a study conducted before in china which showed an increase in respiratory symptoms in road traffic workers (28). regarding the research approach of the study, the identification of the type of industries and occupations where there is an excess risk of adverse respiratory health outcomes is in agreement with a study done before in italy (29). this study, to the best knowledge of the authors, is the first of its kind that measures the risk of adverse respiratory health outcomes among traffic police personnel in bangladesh. however, there are some limitations in the present study. given the cross-sectional design of the study, it has limited capability to infer causality, and the relatively small number in the reference group can affect the validity of the outcome. further epidemiological studies, on larger samples and environmental air quality data provided, are required to better understand and define the pollution-related respiratory outcomes in traffic police personnel. the finding of this study suggests a valuable need for targeted occupational health interventions such as the use of protective masks at the workplace and periodic medical surveillance ahmed p, eaty m, alam n, anthony l, yasmin n. respiratory symptoms among urban traffic policemen in bangladesh: a cross-sectional study (original research). seejph 2022, posted: 19 june 2022. doi: 10.11576/seejph-5534 p a g e 9 | 13 to prevent respiratory morbidity and mortality in traffic police personnel working in polluted environments. references 1. han x, naeher lp. review of trafficrelated air pollution exposure assessment studies in the developing world. environ int 2006;32:106-20. doi: 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https://www.osha.gov/lawsregs/regulations/standardnumber/191 0/1910.134appc (accessed: june 1, 2021). 15. ahmed p, jaakkola jj. maternal occupation and adverse pregnancy outcomes: a finnish population-based study. occup med (lond) 2007;57:417-23. doi: 10.1093/occmed/kqm038. 16. karita k, yano e, tamura k, jinsart w. effects of working and residential location areas on air pollution related respiratory symptoms in policemen and their wives in bangkok, thailand. eur j public health 2004;14:24-6. doi: 10.1093/eurpub/14.1.24. 17. ranganadin p, chinnakali p, vasudevan k, rajaram m. respiratory health status of traffic policemen in puducherry, south india. int j curres rev 2013;5:87-91. 18. detoni a, fillon lf, finotto l. respiratory diseases in a group of traffic police officers: results of a 5year follow-up. g ital med lav ergon 2005;27:380-2. 19. kumar m, shaker i, kann n. the study of frequency domine analysis of hrv in traffic police. int j bioassays 2012;1:64-7. doi: 10.21746/ijbio.2012.10.004. 20. jung th. respiratory diseases in firefighters and fire exposers. j korean med assoc 2008;51:1087-96. doi: https://doi.org/10.5124/jkma.2008.51. 12.1087. 21. chean ky, abdulrahman s, chan mw, tan kc. a comparative study of respiratory quality of life among firefighters, traffic police and other occupations in malaysia. int j occup environ med 2019;10:203-15. doi: 10.15171/ijoem.2019.1657. 22. d'amato g, liccardi g, d'amato m, cazzola m. the role of outdoor air pollution and climatic changes on the rising trends in respiratory allergy. respir med 2001;95:606-11. doi: 10.1053/rmed.2001.1112. 23. beverland ij, cohen gr, heal mr, carder m, yap c, robertson c, et al. a comparison of short-term and longterm air pollution exposure associations with mortality in two cohorts in scotland. environ health perspect 2012;120:1280-5. doi: 10.1289/ehp.1104509. 24. d'amato g, cecchi l, d'amato m, liccardi g. urban air pollution and climate change as environmental risk factors of respiratory allergy: an update. j investig allergol clin immunol 2010;20:95-102. 25. falcon-rodriguez ci, osornio-vargas ar, sada-ovalle i, segura-medina p. aeroparticles, composition, and lung diseases. front immunol 2016;7:3. doi: 10.3389/fimmu.2016.00003. 26. he f, liao b, pu j, li c, zheng m, huang l, et al. exposure to ambient particulate matter induced copd in a rat model and a description of the underlying mechanism. sci rep 2017;7:1-15. doi: 10.1038/srep45666. 27. berend n. contribution of air pollution to copd and small airway dysfunction. respirology 2016;21:237-44. doi: 10.1111/resp.12644. . 28. gao zy, li pk, zhao jz, jiang rf, yang bj, zhang mh, et al. effects of airborne fine particulate matter on human respiratory symptoms and pulmonary function. chin j industr hyg occup dis 2010;28:748-51. ahmed p, eaty m, alam n, anthony l, yasmin n. respiratory symptoms among urban traffic policemen in bangladesh: a cross-sectional study (original research). seejph 2022, posted: 19 june 2022. doi: 10.11576/seejph-5534 p a g e 11 | 13 29. proietti l, mastruzzo c, palermo f, vancheri c, lisitano n, crimi n. prevalence of respiratory symptoms, reduction in lung function and allergic sensitization in a group of traffic police officers exposed to urban pollution. med lav 2005;96:24-32. _____________________________________________________________________________________________ © 2022 ahmed et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ahmed p, eaty m, alam n, anthony l, yasmin n. respiratory symptoms among urban traffic policemen in bangladesh: a cross-sectional study (original research). seejph 2022, posted: 19 june 2022. doi: 10.11576/seejph-5534 p a g e 12 | 13 annex. questionnaire respiratory health outcomes among traffic police in bangladesh: a cross-sectional study face sheet serial number : site : date of interview : interviewed by : sl. no questions coding category direction code section a: socio-demographic characteristics 1 name ……………………… 2 age (to the nearest year) ……………. 3 sex male/ female 3 your height …………ft………. inch = ….. m…cm 4 your weight …………….kg 5 religion muslim....................................................1 hindu......................................................2 buddhist.................................................3 christian.................................................4 others (specify).....................................5 6 what is your job title inspector………………………………1 sergeant……………………………….2 constable………………………………3 7 what is your relationship status: single…………………………………1 married……………………………….2 divorced/ separated………………….3 section b: respiratory heath status ahmed p, eaty m, alam n, anthony l, yasmin n. respiratory symptoms among urban traffic policemen in bangladesh: a cross-sectional study (original research). seejph 2022, posted: 19 june 2022. doi: 10.11576/seejph-5534 p a g e 13 | 13 sl. no questions coding category direction code 8 do you currently have any of the following respiratory heath condition? a. shortness of breath: yes/no b. shortness of breath when walking fast on level ground or walking up a slight hill or incline: yes/no c. shortness of breath when walking with other people at an ordinary pace on level ground: yes/no d. have to stop for breath when walking at your own pace on level ground: yes/no e. shortness of breath when washing or dressing yourself: yes/no f. shortness of breath that interferes with your job: yes/no g. coughing that produces phlegm (thick sputum): yes/no h. coughing that wakes you early in the morning: yes/no i. coughing that occurs mostly when you are lying down: yes/no j. coughing up blood in the last month: yes/no k. wheezing: yes/no l. wheezing that interferes with your job: yes/no m. chest pain when you breathe deeply: yes/no n. any other symptoms that you think may be related to lung problems: yes/no multiple response possible section c: history of previous respiratory illness 9 have you ever had the following lung disease diagnosed by a doctor? asthma ……………………………..1 chronic bronchitis …………………2 tuberculosis………………………...3 pneumonia………………………….4 pneumothorax………………………5 lung cancer………………………..6 chest injury or surgery.……………7 broken ribs…………………………8 multiple response possible 10 have you ever had any allergic conditions? allergic reactions that interfere with your breathing: yes/no section d: behavioural information 11 what is your smoking status? yes …………………1 no ………………….2 12 do you regularly do exercise (workout)? yes……………………………………1 no…………………………………….2 sometimes ……………………………3 13 do you use mask at workplace duty time? yes (always)………………………...1 no…………………………………… 2 sometimes……………………………3 božikov j. the population's health: could south eastern europe do better? (editorial). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5471 p a g e 1 | 9 editorial the population's health: could south eastern europe do better? jadranka božikov1 1 andrija štampar school of public health, school of medicine, university of zagreb, croatia (retired) corresponding author: prof. dr. jadranka božikov address: university of zagreb, school of medicine, andrija štampar school of public health rockefeller st. 4, zagreb, croatia orcid: 0000-0002-1159-9675 email: jadranka.bozikov@snz.hr skype: jadranka.bozikov mailto:jadranka.bozikov@snz.hr božikov j. the population's health: could south eastern europe do better? (editorial). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5471 p a g e 2 | 9 the south eastern european journal of public health (seejph) was launched in 2014 with a welcome address by professor vesna bjegović-mikanović, then president of the association of schools of public health in the european region (aspher), and an introductory editorial by the founding editors with professor genc burazeri, then and since then executive editor, as first author (1,2). in eight years, seventeen regular volumes have been published, accompanied by half a dozen special volumes and many more books available in digital form free of charge on the journal's website (https://seejph.com/index.php/seejph). the establishment and successful development of seejph is primarily the result of its editors' enthusiastic efforts and dedication. it is also an achievement of the longstanding collaboration of scholars from academic institutions in south eastern european (see) countries gathered together in the network "forum for public health in south eastern europe" under the able leadership of professor ulrich laaser from the school of public health, faculty of health sciences, university of bielefeld (germany). the collaboration started in the early 2000s and involved faculty and public health professionals from eleven see countries, namely albania, bosnia and herzegovina, bulgaria, croatia, kosovo, macedonia (now north macedonia), moldova, montenegro, romania, serbia, and slovenia. the national school of public health from athens (greece) also participated, at the time, as the only institution from the european union (eu) besides the bielefeld school of public health. the results can be seen mainly in numerous book volumes with thousands of pages and hundreds of public health teaching modules. dozens of conferences have been organized as well, along with other activities that brought a wealth of unforgettable shared moments, priceless experiences, and lifelong friendships. i am very proud to have been part of this network, together with my colleagues from the andrija štampar school of public health, school of medicine, university of zagreb (croatia). seejph has grown into a respectable academic journal, indexed on scopus and attracting a wider international audience thanks to the efforts and contributions of its editorial board and the broader support of regional and advisory editors. it is my honour and pleasure to serve as guest editor of this particular volume. i want to thank professors ulrich laaser and genc burazeri for their trust. my sincere thanks also go to jeffrey levett, professor emeritus of the national school of public health, athens (greece), for his support in soliciting contributions. i hope that the result will justify the confidence of the editors and also arouse the interest of readers, who will find here excellent reviews and position papers on global issues and challenges of interest to the see region, as well as reports of original research conducted in the region. over the past three decades, health systems in see countries have undergone many reforms triggered by the search for more efficient management of health care and new sources of revenues able to answer cost pressures related to new technologies. all this took place with the transition from a socialist to a market economy in the background. the economic collapse triggered by the transition in the early 1990s led to a deterioration in the population health with a decline in life expectancy in several see countries and was accompanied by the effects of conflicts and war in the yugoslav successor states, which led to a failure in basic health services (3). the health system of the former yugoslavia was established in the 1920s together with health insurance organisations under the progressive leadership of andrija štampar. it was based on a network of community health centres staffed by mixed teams of general practitioners and nurses, including community nurses, and linked to other socio-medical institutions focusing on common health problems of the time (e.g. https://seejph.com/index.php/seejph božikov j. the population's health: could south eastern europe do better? (editorial). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5471 p a g e 3 | 9 dispensaries for tuberculosis, venereal diseases, and mother and child care), as well as hygiene institutes. the role of specialists in these community health centres increased in the socialist period after the second world war when primary health care was provided by seven different functions (general medicine, occupational medicine, pre-school paediatrics, school medicine, gynaecology and obstetrics, and hygiene and epidemiology). nevertheless, general practitioners continued to play the most crucial role, including the gate-keeping one, and a specialisation in family medicine was also introduced in 1960, the first in the world. the specialists became more important over time, and by the 1980s, they prevailed over the general practitioners. gradually, the orientation of health centres towards preventive and social medicine weakened, while curative medicine became more and more important (3). at the same time, health care systems in the countries behind the iron curtain (albania, bulgaria, moldova, and romania) developed differently according to the soviet-style "semashko model" based on central planning and state ownership and command. health care was provided in hospitals, polyclinics, outpatient clinics for primary care, and, in rural areas, by individual physicians or feldshers (medical assistants). the systems were generally dominated by specialists and hospital-based care, with no clear role for district physicians as gatekeepers. health care was provided on the basis of a general entitlement to care but was characterised by bottlenecks and queues. resource allocation was based on planned services, such as beds or staff, rather than patients and community needs (3). the turbulent beginning of the 1990s and the disintegration of the former multinational state of yugoslavia was followed not only by a terrible and bloody war, but also by a political and social transition from a one-party socialist system to democracy and a free-market economy, which also took place in other see countries, from albania to countries that up to 1991 used to be part of the warsaw pact (bulgaria and romania) or part of ussr (moldova). as already mentioned above, the collapse of the health system started a decade earlier, at least as far as the former yugoslavia is concerned, as excellently described by stephen kunitz (4) in his article "the making and breaking of yugoslavia and its impact on health", which also provides a brief and concise historical background. as a result, the health status of the population deteriorated, which was reflected in a sharp decline in health indicators and even in a further divergent development. the same was observed in some, but not all, independent states established after the collapse of the ussr (e.g. the baltic states, which used to be soviet socialist republics. kunitz argued that the individual and social modernisation processes of the early 1980s did not lead to irreversible improvements in health and well-being, but the impact of the transition on population health was profound. despite huge differences between the republics and autonomous provinces in the former yugoslavia, the improved and converging mortality and morbidity rates that existed before the collapse gave way to increasing disparities afterward (4). today, 30 years after the collapse of communism/socialism and twenty years after public health researchers and professionals from 11 see countries started their collaboration in the forum for public health in south eastern europe, four of these countries are european union (eu) member states (bulgaria, croatia, romania, and slovenia) and four others are already eu candidate countries (albania, north macedonia, montenegro, and serbia). health disparities in the population remain large, due to insufficient investment in health and never-ending reforms of the health system, but also to other circumstances, notably undesirable božikov j. the population's health: could south eastern europe do better? (editorial). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5471 p a g e 4 | 9 demographic changes due to population aging. the labour force drain from the see countries to the more developed eu member states, which typically starts immediately after the accession to the eu, combined with low birth rates, has led to an ageing population and slower economic growth and caused a demographic deficit. two countries with the most aged populations, bulgaria and croatia, conducted their censuses in 2021 and found a significant population decline of almost 10 percent compared to the last census ten years ago, while some other countries are also experiencing population declines (romania and serbia). on the other hand, countries with an advantageous younger age structure, such as kosovo, north macedonia, and albania, are experiencing a severe economic, social and political crisis and high emigration rates, particularly of health care workers. a democratic deficit that persists in many of these countries is hindering the economic and social development sought and expected during the transition period and deserved by their people. in general, the crisis of health systems in the see countries began forty years ago, and health reforms have not stopped since. it can be said that we are constantly in a circulus viciosus of crises and reforms. a crisis requires reform, and reform never ends but gives birth to a new crisis. in the present seejph special volume, readers will find several articles on the performance of health systems, their reforms, and their economic impact. an article contributed by romanian authors silvia gabriela scintee and christian vladescu gives an excellent example of how to evaluate the implementation of the national health strategy when it is realised gradually through incremental reforms and no official evaluation has been done. the authors assessed small health reforms into five main clusters and analysed their results from the perspective of the main strategic goals. professor doncho donev contributed a review about a new payment method of health care providers and institution known as “pay-for-performance”. as it brings also the risks of compromising the quality of health services, it requires addition regulatory tools that complement it. professor klaus-dirk henke draws the readers’ attention to the fact that the health care system not only generates high and constantly growing costs but that it must also be seen as a growing industry of great economic importance. the role and contribution of the healthcare industry to the labour market, gross value-added and exports are well documented for germany at the national level, but can also be broken down to the regional and even county level. the well-documented situation in a highly developed western european federal country could be a model and guide for the see countries on how to monitor and promote the role of the health industry in their economies. in addition, the appendix provides data on the expenditures and shares of the health economy in the overall economy for three see countries (croatia, slovenia, and montenegro) compared to the corresponding eu 2018 averages. the approach used in this interesting position paper gives a challenge for analogous analyses of the contributions and importance of health industries to national economies in see region. monitoring and comparison of health indicators are important for the selection of problems to be addressed when setting priorities at the population level. in this regard, the global burden of disease (bod) indicators provide a tool for quantifying health loss due to hundreds of causes of death, diseases, injuries, and risk factors. the inclusion of the disability-adjusted life years (dalys) indicator and its components, years of life lost (ylls) and years lived with disability (ylds), made disability criteria as important as incidence, prevalence and mortality. it has made it possible to quantify the burden of diseases božikov j. the population's health: could south eastern europe do better? (editorial). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5471 p a g e 5 | 9 whose consequences manifest them mainly in disability and which have been neglected in the past. an excellent contribution by a group of slovenian authors led by professor lijana zaletel-kragelj can serve as a model for analyses of health indicators and their comparisons between two points in time or between different countries. the authors analysed changes in slovenian bod indicators (all four dimensions, i.e. deaths, dalys, ylls and ylds) across several causes groups over five years. they also compared slovenian indicators with those for the western european and central european countries. the authors utilised bod indicators available from the open international databases and demonstrated the power of original and inventive data visualisation. three more original studies were done in the region: burnout and optimism among health workers during the period of covid-19 was assessed by two psychometric tools in a research study done in greece while the knowledge, experience and behaviour regarding reproductive and sexual health among medical students were examined by the serbian authors using a questionnaire designed by the world health organization for adolescent sexual and reproductive health. slovenian authors contributed a study protocol that represents a tool developed for a learning needs assessment of professional workers in community mental health centres. at the same time as the covid-19 pandemic hit the whole world in the last two years, europe was hit by other disasters, too. in 2020, croatia experienced two destructive series of earthquakes. first, the capital zagreb was hit by an earthquake, and nine months later, another one hit a rural area. no one can predict or prevent these natural disasters. in such situations, we can only rely on good disaster preparedness and solidarity between people and countries to repair the damage. however, environmental disasters, such as the extreme and deadly weather conditions that were commonplace in the summer of 2021 can also be a result of human activity. in europe, it began in the centre and west with excessive rain, flooding, and landslides that left more than 240 people dead and many more homeless. it continued in the south with unbearable heat, fires, and suffocating environmental conditions after forests, woodlands and parklands burned. summer is becoming increasingly dangerous as the heat rises, while little is being done for climate adaptation. the call for papers for this seejph special volume was circulated during the summer of 2021, at the very time of these environmental disasters and the continuation of the pandemic. that makes the issue of climate change and its relationship with the environment and emerging diseases even more important. the article by professors zeynep cigdem kayacan and ozer akgul from turkey aims to raise awareness of the relationship between climate change, the environment, and emerging diseases. it focuses on climate change and climatesensitive infections, their nature and epidemiology, which are changing in parallel with global warming. climate change could trigger new problems, including new epidemics with old or new pathogens. the paper provides an overview of examples of infectious diseases related to changing climatic conditions, focusing on europe and, in particular, on the south eastern european and eurasian regions. at the end of october, right at the time of manuscript submission, the 26th un climate change conference of the parties (cop26) began in glasgow (scotland). it brought together around 120 world leaders in addition to delegates from almost 200 countries, both the major emitting countries and those most vulnerable to climate change, for face-to-face negotiation how to halve emissions by 2030 and boost green recovery from the pandemic. it follows on from the previous cop25 conference held two years ago in madrid, which was the most talked-about conference globally due to the appearance on the scene of a group of young activists led by greta thunberg. božikov j. the population's health: could south eastern europe do better? (editorial). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5471 p a g e 6 | 9 among all the other warnings and complaints, greta and the 15 activists, aged between 8 and 17, complained to ununicef about five countries neglecting the fight against climate change. greta became known worldwide by her speech given a few months earlier at the united nations climate action summit in new york city, which included her alarming message, "we are in the beginning of mass extinction, and all you can talk about is money and fairy tales of eternal economic growth. how dare you!" after more than two years of the pandemic, it is still not known how sars-cov-2 emerged and whether its spread was driven by environmental changes. however, the awareness of the importance of environmental issues, global interdependence, and solidarity has risen up. relatively new concepts and ideas in public and environmental health known as one health, planetary health, global health, circular economy, and circular health are receiving more attention. the world health organisation (who) endorses those concepts and emphasises the importance of protecting the environment and combating the negative effects of climate change. this volume contains a much-appreciated contribution on circular health written by the experts in the field, professors flavio lirussi and erio ziglio, who had promoted this concept as former consultant and former head of the european office for investment in health and development at the who regional office for europe (5). it is worth mentioning that seejph dedicated one of its 2021 special volumes to the global one health environmental concept and published an extensive (more than 200 pages) learning module on continuing environmental education for postgraduate scholars (6). today, it is clear that a biomedical approach alone was not sufficient for the pandemic control. social scientists are very much needed to deal with public health problems. a mixture of health, environmental, social, and economic measures is crucial to prevent and combat probable future pandemics and other public health threats. we wonder how to understand the phenomenon observed last year in the see region when resistance to epidemiological measures and hesitant attitudes towards vaccination emerged in certain population groups. it was unexpected and even shocking for me as a senior public health scholar to observe the extent of vaccine reluctance in the republic of croatia, especially considering that preventive medicine and epidemiological services, including vaccination, had a long and fruitful tradition in the past. despite the efforts of health care professionals and the government's financial support for businesses, unreasonable resistance seems to be inherent even though in some population groups. the vaccination campaign officially started on 27 december 2020 in all eu member states and continued progressively in early 2021, extending vaccination coverage to the elderly and chronically ill and gradually to other adult age groups. in the beginning, the response was excellent. there was a struggle to get vaccinated, but in the summer, when the available vaccine doses became sufficient to cover the entire adult population, the interest dropped dramatically and reluctance became visible. a similar or even worse situation occurred in the other countries in the see region. the question arises as to the causes of this phenomenon. despite the all possible organisational and logistical shortcomings of the vaccination campaigns, the impression is that the cause has to be found in the mentality and even resistance to what the state offers and organises, unlike in stable western democracies. it is therefore not surprising that the see countries have suffered the most deaths from covid-19, although the mortality rate during the first wave was minimal, partly due to a strict lockdown and partly due to the fact that sars-cov-2 initially broke out in western and northern europe. the božikov j. the population's health: could south eastern europe do better? (editorial). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5471 p a g e 7 | 9 death toll which followed after the vaccines supply became sufficient for adult residents is particularly surprising. high mortality could be only partly attributed to the older population structure in some see countries. although we can also observe a hesitancy to vaccinate and resistance to nonpharmaceutical containment measures in the highly developed countries of western europe, we see a shocking difference when it comes to the percentage of people vaccinated. this brings us back to the point made by kunitz that social and economic changes (modernisation, globalisation) have an instantaneous negative impact on the population. we can conclude that favourable economic and social opportunities and regional (eu) integration processes, which have undoubtedly brought about the desired progress, have a confidence-lacking effect on people and reduce their trust in science and health. the who european region includes 53 countries, 50 without the three mini-states (andorra, monaco, and san marino). excluding all the ussr successor states except moldova and the three baltic states who are eu members (estonia, latvia and lithuania), and adding kosovo, which is not yet a who member, we have 39 countries altogether. figure 1 shows the share of the population fully vaccinated against covid-19 on 1 january 2022 in those 39 countries. the lower third includes all eleven see countries plus slovakia and poland, with the lowest share of the population fully vaccinated in moldova, bosnia and herzegovina and bulgaria (range from 24,41% to 27,77%), and the highest in slovenia (57,21%). the share of the population fully vaccinated in the upper third spans from 70% up to almost 90% in portugal (7). the ideas elaborated in the paper on circular health might help us understand those phenomena. the authors pointed out the toxic effects of disinformation spreading through social networks and media and opt for a collective effort to develop and implement ethical laws and policies. referring to the current pandemic, they stated: "paradoxically, "virtual" entities like (dis)information and social media could be the main drivers of a "real" pandemic. in other words, they could have far greater influence over its development than the virus factor (viral load, contagiousness, lethality) and even the human factor (genetic makeup, immune response) combined." (5). they concluded that the adoption of circular health concepts is an urgent necessity in restructuring development policies and making them more effective and sustainable in the protection and promotion of individual and collective health. it must be followed up by new innovative practices and supported by consistent political will that has been lacking in the past. the challenge is to put these principles into practice through the educational curricula for the future generations and training of those currently responsible for political decisions which must fully understand that every choice they make in relation to human, animal, and plant health as well as for the overall environment has impacts on all others. it requires a new way of thinking and acting for individual, collective and global health. to this end, great opportunities are seen in the innovative use of big data and artificial intelligence for health. who has recently published a document entitled "ethics and governance of artificial intelligence for health" aimed at guidance addressing especially three sets of stakeholders: all technology developers, ministries of health, and healthcare providers (5). extreme weather events caused by climate change and the sars-cov-2 pandemic that marked the last two years, have taken a heavy toll in human lives and worsened the population health. there is a fear that an epidemic of non-communicable diseases, particularly malignant and mental illnesses, is yet to come. science and biomedical researchers achieved a spectacular result božikov j. the population's health: could south eastern europe do better? (editorial). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5471 p a g e 8 | 9 with the development of new vaccines in less than a year. at the same time, it became evident how social and economic policies are crucial and how much damage could be done by the spread of misinformation. let us make all the efforts to choose the right decisions and to improve the health status of individuals and communities because south eastern europe deserves better and can do better. figure 1. share of the population fully vaccinated against covid-19 as of 1 january 2022 (link to ourworldindata) (7) references 1. bjegović-mikanović v. wellcome address. south eastern european journal of public health (seejph) 2013;1. available at: https://www.seejph.com/index.php/see jph/article/view/1768, doi: 10.4119/seejph-1769 2. burazeri g, jankovic s, laaser u, martin-moreno jm. south eastern european journal of public health: a new international journal. seejph 2013;1:1-4. posted: 31 october 2013. available at: https://www.seejph.com/index.php/see jph/article/view/1769, doi: 10.4119/seejph-1769. 3. bartlett w, božikov j, rechel b. health reforms in south east europe: an introduction. in: bartlett w, božikov j. rechel b, editors. health https://ourworldindata.org/explorers/coronavirus-data-explorer?zoomtoselection=true&time=2022-01-01&facet=none&pickersort=asc&pickermetric=location&metric=people+fully+vaccinated&interval=cumulative&relative+to+population=true&color+by+test+positivity=false&country=gbr~deu~ita~alb~aut~bih~hrv~cyp~cze~grc~hun~isl~isr~lva~mne~mkd~nor~pol~prt~rou~srb~svn~svk~mda~mlt~owid_kos~ltu~lux~che~tur~bgr~fin~fra~dnk~bel~est~irl~swe~esp https://www.seejph.com/index.php/seejph/article/view/1768 https://www.seejph.com/index.php/seejph/article/view/1768 https://www.seejph.com/index.php/seejph/article/view/1769 https://www.seejph.com/index.php/seejph/article/view/1769 božikov j. the population's health: could south eastern europe do better? (editorial). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5471 p a g e 9 | 9 © 2022 božikov; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. reforms in south east europe. new perspectives on south east europe series. basingstoke (uk): palgrave macmillan, 2012, pp. 3-28. 4. kunitz sj. the making and breaking of yugoslavia and its impact on health. american journal of public health 2004; 94(11):1894-1904. available at: https://ajph.aphapublications.org/doi/f ull/10.2105/ajph.94.11.1894 doi: 10.2105/ajph.94.11.1894 5. lirussi f, ziglio e. circular health: a needed approach to promote health and prevent pandemics and other health hazards. south eastern european journal of public health (seejph) 2022; (special issue 1), pp. 1-9, available at: https://www.seejph.com/index.php/see jph/article/view/5112, doi:10.11576/seejph-5112 6. abed y, sahu m, ormea v, mans l, lueddeke g, laaser u, hokama t, goletic r, eliakimu e, dobe m, seifman r. the global one health environment. south eastern european journal of public health (seejph) 2021; (special issue 1), pp. 1-206, available at: https://www.seejph.com/index.php/see jph/article/view/4238, doi: 10.11576/seejph-4238. 7. our world in data. share of people who completed the initial covid-19 vaccination protocol, jan 1, 2022. available at: https://ourworldindata.org/explorers/c oronavirus-dataexplorer?zoomtoselection=true&time =2022-0101&facet=none&pickersort=asc&pick ermetric=location&metric=people+ful ly+vaccinated&interval=cumulative& relative+to+population=true&color+ by+test+positivity=false&country=gb r~deu~ita~alb~aut~bih~hrv ~cyp~cze~grc~hun~isl~isr~l va~mne~mkd~nor~pol~prt~ rou~srb~svn~svk~mda~mlt ~owid_kos~ltu~lux~che~tu r~bgr~fin~fra~dnk~bel~est ~irl~swe~esp. (accessed: january 31, 2022). ________________________________________________________________ https://www.seejph.com/index.php/seejph/article/view/5112 https://www.seejph.com/index.php/seejph/article/view/5112 https://ourworldindata.org/explorers/coronavirus-data-explorer?zoomtoselection=true&time=2022-01-01&facet=none&pickersort=asc&pickermetric=location&metric=people+fully+vaccinated&interval=cumulative&relative+to+population=true&color+by+test+positivity=false&country=gbr~deu~ita~alb~aut~bih~hrv~cyp~cze~grc~hun~isl~isr~lva~mne~mkd~nor~pol~prt~rou~srb~svn~svk~mda~mlt~owid_kos~ltu~lux~che~tur~bgr~fin~fra~dnk~bel~est~irl~swe~esp 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https://ourworldindata.org/explorers/coronavirus-data-explorer?zoomtoselection=true&time=2022-01-01&facet=none&pickersort=asc&pickermetric=location&metric=people+fully+vaccinated&interval=cumulative&relative+to+population=true&color+by+test+positivity=false&country=gbr~deu~ita~alb~aut~bih~hrv~cyp~cze~grc~hun~isl~isr~lva~mne~mkd~nor~pol~prt~rou~srb~svn~svk~mda~mlt~owid_kos~ltu~lux~che~tur~bgr~fin~fra~dnk~bel~est~irl~swe~esp vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi 10.12908/seejph-2014-48 1 original research public expenditure and drug policies in bulgaria in 2014 toni yonkov vekov 1 , silviya aleksandrova-yankulovska 1 1 department of medical ethics, management of health care and information technology, faculty of public health, medical university – pleven. corresponding author: prof. toni yonkov vekov, medical university, pleven; address: 1 sv kliment ohridski st., 5800 pleven, bulgaria; telephone: +35929625454; e-mail: t.vekov.mu.pleven@abv.bg vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi 10.12908/seejph-2014-48 2 abstract aim: the objective of this study was to provide an analysis of the factors which have a significant impact on the growth of public expenditure on medical products in bulgaria. methods: this research work consists of a critical analysis of the data reported by the national health insurance fund in bulgaria on the stability of the healthcare insurance model and the implementation of the budget for 2014. results: the results from the current analysis indicate that the growth of public expenditure is directly proportional to the number of reimbursed medical products and that the pattern of prescriptions including the innovative medical products mainly for the treatment of oncological and rare diseases has a significant impact on it. conclusion: the reasons for the increase of public expenditure in bulgaria include the nontransparent decisions in pricing and reimbursement of the products, the lack of guidelines for presenting pharmacological evidence and the lack of legislatively-defined drug policies for the management and control of the patterns of medical prescriptions. key words: bulgaria, drug policies, reimbursement, public expenditure. conflicts of interest: none. vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi 10.12908/seejph-2014-48 3 introduction healthcare in the european union (eu) countries including bulgaria is funded by the healthcare systems and/or through general taxation. the main objective of the healthcare systems is the protection of public health, based on the principles of solidarity and universal access. the drug policy in every country is part of the healthcare policy and adopts the same objectives and principles (1). the expenses on medical products are an important component of the healthcare budgets of all the eu member states. there is an increasing necessity to limit the escalating expenses on healthcare including those on medical products, as well as the effective spending of the financial resources (2). the good european practice on drug policy implies the determining of positive drug lists (pdl) provided by the healthcare system, and the regulation of the drug prices in a certain order. the main focus of the approaches to drug policies includes the rational use of medical products, which contributes to the control of public expenditure (3). considering the fiscal impact of the economical and financial crisis, as well as the expected healthcare expenses for the aging population, these policies are of an increasing interest to the institutions which pay for the public expenses in healthcare (4). the contemporary views of the european healthcare policies are that through the correct regulation of the pharmaceutical markets economies can be achieved, without having an impact on the provision of care (5). the drug policy in bulgaria is legally established by the ministry of health and practically applied by the national council on prices and reimbursement of medical products (ncprmp). this is the authority which regulates the prices and makes decisions regarding the reimbursement of the medical products with public funds. the control on prices is based on external and internal reference pricing and regressive margins for distributors and pharmacies. the reimbursing decisions are formally based on pharmaco-economic valuations, but the experts’ reports are not available to the public and the objectivity of these decisions cannot be established. in this context, the aim of this study was to analyze the public fund expenses on medical products in bulgaria in 2014 in order to determine the impact of the legislative approaches to drug policies and their possible impact on public health. methods this article is a critical analysis of data from the report of the national health insurance fund (nhif) in bulgaria on the stability of the healthcare insurance model and the implementation of the budget for 2014 (6). a commentary is provided concerning the existing prescribing patterns, national policies for the inclusion of medical products in pdl and their impact on the increasing public expenses. a detailed analysis of the expenses by disease groups and the pattern for the prescription of medicines is also provided. all graphs and tables included in this article are created on the basis of the data derived from the report of the nhif in bulgaria on the stability of the healthcare insurance model and the implementation of the budget for the year 2014 (6). the difference of costs and amount of reimbursed products in the pdl for the period under investigation is presented as a percentage and is calculated with a mathematical method based on the determination of proportionality coefficients. when trying to predict the future value, one follows the following basic idea: future value = present value + change from this idea, we obtain a differential, or a difference equation by noting that: vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi 10.12908/seejph-2014-48 4 change = future value – present value the growth of public expenses is influenced by a number of factors discussed in the report of the nhif in bulgaria on the stability of the healthcare insurance model and the implementation of the budget for 2014 (6). all prices are given in bgn with current exchange rates of: 1.95583 bgn = 1 eur. results the review of the development of the pdl in bulgaria in the past three years (2011-2014) from the viewpoint of quantitative indicators shows a big volume (1997 medical products) and a list with frequent changes (every 15 days). in 2011, the pdl included 1382 medical products, in 2012 it included 1673 products, and in 2014 there were 1997 products. during this three-year period, the number of reimbursed medical products increased by 45%. the proportion of public expenditure and the number of reimbursed medical products is presented in figure 1. the established relationship is directly proportional, whereas the cost of public expenses increased by 25%. figure 1. reimbursed medicines for home treatment and the cost of public expenses (both in bgn) in bulgaria; data for 2014 consists of estimates (source: nhif report for june 2014) the other factor which has a marked impact on public expenditure is the pattern of prescription of the medical products. the presented results (figure 2) of the average cost of public expenditure for the treatment of non-insulin diabetes in 2013 are indicative – the cost of the expense differs doubly in the various regions, considering that the list of the medical products, their prices and the reimbursed amounts are the same for all the regions of bulgaria. the different cost of public expenses in the various regions of bulgaria directly depends on the level of prescribing of dpp-4 inhibitors and glp-1 receptor antagonists. these are the two groups of innovative medical products for the oral therapy of diabetes, which are rather recommended as a second and a third line of treatment, due to unclear data for the long-term cost effectiveness and doubts about the safety profile (7). 1000 1500 2000 400 450 500 550 600 2011 2012 2013 2014 n u m b e r n u m b e r cost quantity vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi 10.12908/seejph-2014-48 5 figure 2. average cost per patient (in bgn) for the treatment of non-insulin dependent diabetes in bulgaria in 2013 (source: nhif report for june 2014) the analysis of public expenses by groups of diseases outlines the clear tendencies for an abrupt increase in the expenses for the treatment of rare diseases and oncological diseases. the expenses for the treatment of rare diseases increased by 36% in 2013 compared to 2012 and reached 59 million bgn, which constitutes 10.7% of all public expenses for medical products (table 1). this points to a pronounced imbalance of solidarity in the insurance system, because these public costs are absorbed by only 0.15% of the insured individuals. at the same time, public expenses for socially significant diseases such as the cardiovascular disease, diseases of the neural system and diseases of other systems are decreasing (6). these results are an expression of the flaws in the drug policy, part of which are the application of internal reference pricing without a system for the control of medical prescriptions (8), the lack of transparency in the decisions on pricing and reimbursement, based on an expert evaluation of pharmaco-economical evidence, the lack of a defined limit of public expenses for one gained quality-adjusted life year (qaly), and the like (9). table 1. expenses for the treatment of rare diseases in 2013 (source: nhif report for june 2014) disease public expense average annual cost per patient in bgn number of patients haemophilus 20 009 544 5290 3783 beta-thalassemia 8 323 230 3692 2254 gaucher disease 8 196 183 32 795 250 blonhopulmonal dysplasia 4 245 087 2828 1501 mukopolizaharoidosis 3 294 574 68 637 48 hereditary amyloidosis with neuropathy 1 625 885 27 098 60 pompe disease 477 953 47 795 10 0 100 200 300 400 500 600 700 rousse gabrovo sliven bourgas smolyan average cost vratsa shoumen silistra haskovo pernik n u m b e r vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi 10.12908/seejph-2014-48 6 the analysis of the expenses on the medical therapy for oncological diseases, paid outside the cost of clinical pathways emphasizes several main facts:  the expanding of the indications for innovative medicines, mainly for monoclonal antibodies and tyrosine kinase inhibitors. however, there is no data on the evaluation of the efficacy, benefits and costs of the new indications.  the addition of monoclonal antibodies to the target therapies, which increases the cost of the therapy more than 30 times, while the benefits, expressed as final health outcomes, are minimal. the willingness of society to pay such a high price for the gain of a qaly remains uncertain.  the inclusion of new international non-proprietary names in the pdl without a clear evaluation of their differential cost-effectiveness as compared to the existing therapies. as a result of all these factors, the public expenditure on oncological medical products significantly exceeded the settled budgets for the past years, as indicated in table 2. table 2. expenses of the medical therapy for oncological diseases, paid outside the costs of clinical pathways (source: report on the implementation of the budget of nhif, 2013-2014) year year 2013 2014 budget in bgn 90 000 000 145 000 000 public expenditure in bgn 172 443 480 203 472 732 * relative share of the overspending (%) 91,60 40,30 * data for 2014 consists of estimates. discussion several main factors have been identified which have an impact on the annually increasing public expenses on medical products in bulgaria:  non-transparent decisions for the inclusion of medical products in the pdl with unclear cost-effectiveness compared to the existing drug alternatives. there is no data on the recommendations of ncprmp for the pharmaceutical industry and set out denials for reimbursement justified by the lack of sufficient evidence of effectiveness and/or high prices. the practice in the economically developed countries is different. for example, the committee for the evaluation of medicinal products in canada refused to reimburse pemetrexed for the treatment of malignant pleural mesothelioma, because the product does not provide added value for the price difference compared to the existing alternatives (10). another canadian solution sets to reimburse sunitinib for the treatment of metastatic renal cell carcinoma only after negotiating the price because of poor costeffectiveness, despite the improved efficacy over the existing therapeutic alternatives. many similar negative decisions regarding the reimbursement of medical products for a specific diagnosis can be found in the scientific literature. their aim is both to facilitate the access of patients to therapies which give them additional therapeutic value and use, as well as to protect patients from health risks connected to severe adverse drug reactions (11,12). vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi 10.12908/seejph-2014-48 7  the lack of legally defined public expenditure related to one gained qaly. this is a widely used instrument for limiting public expenditure and for the control of the innovative medical therapies (13).  lack of legal control on the patterns of prescribing medicines. the eu states have a number of measures in working order for improving the patterns of prescribing medicines. most often they entail the monitoring of the prescriptions, recommendations and guidelines of advisory/obligatory nature regarding the prescriptions, including the requirements to prescribe an international non-proprietary name, a maximum limit on the prescribed medicines, prescription quotas, financial incentives, as well as educational and informational approaches (14-16). the aim of all enumerated policies is to promote the rational use of medical products for the benefit of public health. the combinations of diverse measures, as electronic monitoring in prescription and in guidelines, connected with electronic systems which support the process of decision-making and give feedback to the physician, are an effective way to improve the patterns in prescribing medicines (17). in addition, educational and informational instruments should be activated. the prescription of international non-proprietary names and prescription quotas, if possible in combination with target budgets and financial incentives, seem to be effective tools for the purpose of regulating public expenditure. conclusion the effectiveness of public expenditure in bulgaria will improve when it becomes the main objective in medical policy, i.e., when medical therapies are evaluated in a real and transparent way as a ratio of expenses and use as compared to the existing alternatives. it is necessary that the first steps are aimed at developing a control system of the prescription and evaluation of medicines’ pharmaco-economical evidence, as well as determining public expenditure of the medical therapy at the level of one gained qaly. references 1. adamski j, godman 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passport (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5601 p a g e 1 | 11 policy brief professionalize european public health workforce: the need for a minimum dataset and skills passport benedikt kurtz1*, deirdre norris hennenberg1*, lea supke1*, thi yen chi nguyen1,2* 1 department of international health, care and public health research institute – caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands 2 school of health and related research, the university of sheffield, sheffield, united kingdom *these authors contributed equally to this work senior advisor: prof. czabanowska, kasia., department of international health, care and public health research institute – caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands corresponding author: thi yen chi nguyen, email: nguyen.yen.chi123@gmail.com / tyc.nguyen@student.maastrichtuniversity.nl address: department of international health, care and public health research institute – caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands mailto:nguyen.yen.chi123@gmail.com mailto:tyc.nguyen@student.maastrichtuniversity.nl kurtz, b; hennenberg, d.n; supke, l.; nguyen, t.y.c. professionalize european public health workforce: the need for a minimum dataset and skills passport (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5601 p a g e 2 | 11 key messages ● public health workforce is difficult to define. the use of a minimum dataset and a skills passport should be considered to help strengthen professionalization. ● more workforce data is important for policy-making decisions, forecasting capacity management, and workforce development for a rapidly changing health environment. ● information provided by the minimum dataset and skills passport will allow public health education institutions to adapt their curricula to the workforce’s needs. introduction this policy brief aims is to inform deliberations amongst stakeholders such as the european commission, directorate general for health and food safety, public health educational institutions, public health policymakers, public health civil society organisations, and health or education ministries of european member states to provide context for advancing the professionalism of the public health workforce (phw), by introducing the concept of a minimum dataset and skills passport. in 2021, the european union health policy platform emphasized the need to have phw ready for unprecedented health and social challenges (1). the covid-19 pandemic has shown that delivery and coordination of public health is essential to national and global health and highlighted the problems of long-standing underfunding and underdevelopment of the phw (2). developing a competent phw with skills to adapt to rapidly-changing health challenges is not possible without knowing the workforce compositions. historically, the phw has been difficult to accurately define due to its multidisciplinary, various occupational categories, unclear boundaries in the field of public health, and the absence of credential requirements for many of the disciplines involved. in most of the countries within europe, there is no single system that enumerates phw or registers the composition of key skill sets (3). no clear definition of phw despite a long history of public health training, the phw has not been clearly defined at the international level due to its complexity and diversity. in 2003, beaglehole defined phw as “a diverse workforce whose prime responsibility is the provision of core public health activities, irrespective of their organizational base”(4). however, the complex nature of public health involves a wide range of professionals, leading to the definition of wider phw as all people engaged in work that creates the conditions within which people can be healthy (5,6). in addition, the challenges of defining the phw are complicated by the different understandings and terminologies across europe concerning the role and meaning of “public health”. in 2008, for example, the medical specialties in public health were recognized in 21 european member states under different titles, such as "preventive medicine" in italy, "social medicine" in sweden, and "community medicine" in denmark. (7,8). no data on phw kurtz, b; hennenberg, d.n; supke, l.; nguyen, t.y.c. professionalize european public health workforce: the need for a minimum dataset and skills passport (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5601 p a g e 3 | 11 efforts to enumerate the phw have faced major challenges, due to the lack of a clear professional licensing system and central registries in most countries, except united kingdom and poland, where registration of public health professionals is optional (9– 11). until now, most efforts to enumerate the phw are based on existing data sources with various limitations (3). different job titles for the same type of public health employment are a hindrance, and not all job titles are appropriately classed as 'public health' in different data sources. registers use different definitions of public health employees. some specific disciplines (nursing, medical professions) have their registers and not all are represented in the databases. taxonomy is a useful tool to describe and classify a workforce (12). some efforts to develop taxonomies for the phw narrowly focus on those contributing to the essential public health operations or working in governmental agencies (12,13). furthermore, current taxonomies do not clearly distinguish between positions that require formal public health education and those that do not, nor do they establish connections between those occupations and required public health competencies. the need to match public health professions and required competencies is calling for the development of a tool to gather deeper insights into phw, as well as specify the needed skills and qualifications for each profession within the phw. the objective of this policy brief is to propose the development of a minimum dataset and skills passport to support the professionalism of the phw within the european union. more specifically, this policy brief will present minimum dataset and skills passport, suggest their visualisation, discuss their potential benefits and barriers to their implementation, and will propose recommendations that can contribute to creating a sustainable impact on the development of the phw. policy option 1. minimum dataset to ensure the population's health, the determination of employment availability is central (14). as stated by the world health organization, "no health workers, no care."(15), professional training, recruitment and retention of workers, and training investment are priorities for the public health sector to tackle present and future difficulties. therefore, there is an urgent need for phw data to describe the supply and distribution. due to the contextual nature of the public health sector, a gold standard is not available, as planning tools should be individually adapted to national and local needs and country characteristics. therefore, countries should consider a minimum dataset as advised by the joint action on health workforce planning (16). definition a minimum dataset, in epidemiology, is defined by a list of names, definitions, and data sources to support a specific purpose (17). as there is no unified data on the health workforce on a european level and the available data is context-sensitive due to different planning methods and tools (18), there is no appropriate concept of a minimum dataset on a european union level. how a minimum dataset could look like? data collection on the phw differs in the member states with various indicators and data resources. some countries have central statistics, others use information from kurtz, b; hennenberg, d.n; supke, l.; nguyen, t.y.c. professionalize european public health workforce: the need for a minimum dataset and skills passport (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5601 p a g e 4 | 11 health insurance companies, registration offices, and employers collected by surveys. the use of a category system is needed to harmonize available data with its original collection method and definitions of the public health employee (19). to close the gap of missing data, information can be obtained according to a predetermined standard, for example, through questionnaires. a minimum dataset should guide critical variables in health workforce surveys, including demographic, educational, and practice characteristics (20). existing taxonomy can be adapted to collect specific information. country-specific trends and comparisons between countries can be seen. additionally, it can be possible to calculate country-specific workforce demand. this could be used to assess the gaps currently within the workforce and strengthen workforce knowledge for future capacity planning and allow valid comparisons across countries. the minimum dataset can be used by national and european employers and policymakers and an example is provided in figure 1. fig. 1. example of a minimum dataset what are the benefits of a minimum dataset? by analysing, monitoring, and reporting the phw, the gaps and requirements can be examined (21). on a european level, it could help identify the public health workers' migration from low/middleincome to higher-income countries. strategies and policies on a local and european level can be developed to minimise the resulting lack of professionals in low-income countries. additionally, inefficient organisational structure can be identified and processes can be improved (22). the dataset can help evaluate trends of age distribution, emigration, and immigration of the workforce. as a result, countries will have an indicator of where to allocate resources and focus on training phw to fulfil capacity demand. this benefit is illustrated by the local example of a minimum dataset as used in queensland (23) (see box 1). the european commission carried out a feasibility study on eu-level cooperation on health workforce needs. this is a step towards a minimum dataset within the european union, highlighting the five critical elements of the health workforce planning process. these key elements include goals, forecasting model, data, link to policies, and organisation (16). since kurtz, b; hennenberg, d.n; supke, l.; nguyen, t.y.c. professionalize european public health workforce: the need for a minimum dataset and skills passport (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5601 p a g e 5 | 11 data is linked to every element, the harmonisation and availability of data is a step towards the professionalization of the healthcare workforce (20). what are the barriers to implementing a minimum dataset? at the european level, the coordination between the member states for data collection could be challenged by the heterogeneity of member states. in addition, demand forecasting is influenced by demographic change, and advances in medicine and policy, such as the retirement age of health professionals. thus, european-level data collection would require the involvement of a centralized statistical agency (i.e eurostat) (24) to coordinate between stakeholders, facilitate resources, and monitor the collection process. data harmonization is another barrier to implementing a minimum dataset. the integration and analysis of multi-resource data could be time-consuming and requires developing new frameworks and tools to assist data compilation, as well as network infrastructure to enable data sharing between stakeholders. furthermore, the use of data needs to be in line with the general data protection regulation (25) (gdpr) to minimize ethical concerns related to privacy, data protection, and surveillance. lastly, the constantly growing and changing phw (14) would require a simulated update of job titles and required competencies, as well as societal demands to promote professionalism and the value of the workforce. box 1. example of minimum dataset implementation an annual survey of general practices and general practitioners is used to keep an up-to-date database of the general practitioner workforce in remote, rural, and regional queensland. the data gathering is based on the remoteness areas (ra) system of the australian standard geographical classification and census by a mix of strategies. the minimum dataset aims to optimize the health care resources and create a sustainable framework which also feeds the need of rural areas to guarantee an adequate access to the healthcare system. in the published healthcare report, they provide information about the number of medical practitioners, gender, number of average working hours per week by gender, working status (solo or collocate practice with at least one other gp), working location (inner regional/ outer regional/ remote/ very remote). employment through monitoring, proactive planning is possible so that a shortage of specialists, especially in rural areas, can be minimized (23). policy option 2. skills passport definition currently the european union defines a skills passport as: “a tool or document allowing people to record their skills, competencies, and knowledge. these can result from formal, informal or non-formal learning” (26). one example is the “europass” provided by the european union. this passport shows academic credentials and certificates and is valid among all member states. unfortunately, for the phw it has limitations as it is not linked to a competency framework. former public health england (replaced by uk health security agency and office for health improvement and disparities) described the skills passport as an https://ec.europa.eu/esco/portal/escopedia/skill https://ec.europa.eu/esco/portal/escopedia/competence https://ec.europa.eu/esco/portal/escopedia/competence https://ec.europa.eu/esco/portal/escopedia/knowledge kurtz, b; hennenberg, d.n; supke, l.; nguyen, t.y.c. professionalize european public health workforce: the need for a minimum dataset and skills passport (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5601 p a g e 6 | 11 interactive digital platform, which can “enable users to keep a record of their public health credentials – all in one place that can be accessed by individuals irrespective of their employer, or employment status.” (27). it identifies the qualifications of the phw and provides the possibility of transferability among employers and registration bodies. for better categorization and recognition of qualifications, the skills passport is aligned to a public health skills and competency framework (phskf) (28). how could a skills passport look like? our concept inspired by the idea of a skills passport by public health england (28), is an interactive digital platform that includes all career data and diplomas certificates, and continued professional development courses for the public health employees. once the data is uploaded, an artificial intelligence algorithm can analyse the data and subsequently match the competencies within a competency framework. these are visible in the passport so that administrative bodies, employers and employees have a clearer understanding of the qualifications and competencies of the workforce (figure 2). in this policy brief, we propose to link the skills passport to the who-aspher competency framework which has three main categories (“content & context”, “relations & interactions”, and “performance & achievements”), which are linked to competency subcategories. the single competencies are assessed on three levels: level 1expert, level 2, proficient, level 3-competent (29). in addition, this skills passport can be linked to the existing “europass” of the european union. figure 2. model of a skills passport what are the benefits of a skills passport? linking to the benefits of the competency framework (29), the skills passport would kurtz, b; hennenberg, d.n; supke, l.; nguyen, t.y.c. professionalize european public health workforce: the need for a minimum dataset and skills passport (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5601 p a g e 7 | 11 bring similar impacts and help to push forward a clear definition and terminology for phw. this can help with the planning and forecasting the phw. data collection can be improved through categorisation and registration of the phw can be more workable. it is the basis for analysing the distribution of the workforce and for drawing up concrete development plans and forecasting future needs and investments. moreover, a skills passport can provide orientation to develop a european standard of education for the phw. this would raise the education and performance level of the workforce and ensure quality. in addition, a clear categorization of competencies would contribute to increasing value and respect for the profession. needed skills and qualifications would be defined to achieve a specific rank. advantages such as european mobility, easier professional recognition of education, as well as registration and revalidation among member states could be a result. on the other hand, it would close gaps between countries through a higher level of collaboration (29). what are the barriers? the main barrier will be the acceptance and usage of the passport in the phw. the design of the framework and passport could be too complicated. as public health england's evaluation of their competency framework showed, some adaptations were necessary to improve manageability. utilization of stakeholder consultations is a helpful tool to overcome these challenges. promotion of the skills passport is vitally important and commitment from employers and employees will be necessary for its success. otherwise, it is quite possible that many will not use it or know about its existence. significant efforts must be undertaken to implement it. in the united kingdom, the competency framework was initiated in july 2014 and was implemented in 2016. the development of the skills passport still seems to be ongoing. in 2019, only the second of four stages for implementing a skills passport was reached. this illustrates the challenges of such an implementation (c.f. box 2). kurtz, b; hennenberg, d.n; supke, l.; nguyen, t.y.c. professionalize european public health workforce: the need for a minimum dataset and skills passport (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5601 p a g e 8 | 11 box 2. example of skills passport implementation in 2016, a skills passport is being developed in england which is linked to a public health skills and knowledge framework (30). the framework is shown as the basis. the skills passport should represent the conversion into a digital interactive platform. the design of the framework is a functional map showing public health functions and competencies (27). there, phw is assessed in three different levels: a=technical functions, b=contextual functions, c=delivery functions, which are categorised in four levels, that refer to different key areas of public health which is aligned with existing national occupational standards (30). in 2019, an evaluation of the framework was conducted and determined that slightly ¼ of respondents have never used the framework and 87% of previous users rated it as useful. barriers to using it were primarily encouragement from senior levels in the organisations. suggestions for improvement such as the creation of an online community, better communication about its usefulness, a link to other competency frameworks, or includingmore evaluation options were made. there are several development phases for this, whereby phase two of four has been completed so far (31). the next phase (phase 3) reviews the security and performance of the previous product until it can then be fully implemented (phase 4) (30). recommendations with the importance and overwhelming benefits of workforce data, it is rational to start the first steps of phw professionalization with the minimum dataset to enumerate and characterise the workforce in a unified taxonomy system. there are multiple career paths within public health disciplines, which call for financial and capacity support from multiple stakeholders. in order to overcome the challenges, we urge for following action steps: for policymakers ● continue support for research to better characterize the phw, as well as the development of a data framework and network infrastructure for data collection and sharing between stakeholders ● collaborate and build consensus among public health stakeholders led by key eulevel agencies toward the development of a consistent taxonomy for describing public health occupations, functions, core competencies, and required training. those core competencies and training need to be recognized at the european union level. ● involve a centralized statistical agency (for example eurostat) to coordinate, monitor, and harmonize obtained data into an accessible database, as well as ensure compliance with gdpr regarding data privacy and protection. for educational institutes and public health professionals ● collaborate / consult with policymakers to come to a unified definition of phw, conduct further research to characterize the workforce, provide evidence to advocate for the importance of professionalizing phw, and support the policy-making process. kurtz, b; hennenberg, d.n; supke, l.; nguyen, t.y.c. professionalize european public health workforce: the need for a minimum dataset and skills passport (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5601 p a g e 9 | 11 ● develop a common method to track the career path of ph graduates, and develop an educational framework to standardize the education for phw, which can be recognized across the region. for public health employers ● take part in the survey on workforce characteristics and provide insights on career path and required competencies for particular ph professionals. ● evaluate and consult the use of minimum dataset as a tool to assess actions and tasks within ph disciplines, as well as the workforce gap and capacity planning for the future. ● promote the use of minimum dataset as a guideline for career development for ph professionals. ● ● authors’ contributions: bk, dnh, ls, and tycn conceptualised the paper, sl designed the illustrations of minimum dataset, bk developed a sample model of skill passport. all authors contributed equally to writing the paper. all authors reviewed the final version and agreed on the submission. references 1. european health policy platform joint statement: profiling and training the health care workers of the future [internet]. 2021 [cited 2021 dec 8]. available from: https://ehma.org/wpcontent/uploads/2021/02/hpp-coverstatement.png 2. czabanowska k, kuhlmann e. public health competences through the lens of the covid‐19 pandemic: what matters for health workforce preparedness for global health emergencies. int j health plann mgmt. 2021 may;36(s1):14–9. 3. jambroes m, van honschooten r, doosje j, stronks k, essink-bot ml. how to characterize the public health workforce based on essential public health operations? environmental public health workers in the netherlands as an example. bmc public health. 2015 dec;15(1):750. 4. beaglehole r, dal poz mr. public health workforce: challenges and policy issues. hum resour health. 2003 dec;1(1):4. 5. tilson h, gebbie km. the public health workforce. annu rev public health. 2004 apr 1;25(1):341–56. 6. sim f. maximizing the contribution of the public health workforce: the english experience. bull world health organ. 2007 dec 1;85(12):935–40. 7. westerling r. the harmonization of the medical speciality in public health in the eu countries--a challenge for the profession. the european journal of public health. 2009 jun 1;19(3):230–2. 8. european medical association. medical specialties in europe [internet]. 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[cited 2021 dec 9]. available from: https://www.gov.uk/government/publica tions/public-health-skills-andknowledge-framework-phskf/publichealth-skills-and-knowledgeframework-august-2019-update __________________________________________________________________ © 2022 kurt et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 1 original research population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe mihajlo jakovljevic1, ulrich laaser2 1 faculty of medical sciences, university of kragujevac, kragujevac, serbia; 2 section of international public health (s-iph), faculty of health sciences, university of bielefeld, bielefeld, germany. corresponding author: assoc. prof. mihajlo jakovljevic, md, phd, health economics and pharmacoeconomics graduate programme, faculty of medical sciences, university of kragujevac; address: svetozara markovica 69, 34000, kragujevac, serbia; telephone: +38134306800; e-mail: sidartagothama@gmail.com mailto:sidartagothama@gmail.com� jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 2 abstract aim: population aging has profoundly reshaped demographic landscapes in all south eastern european (see) countries. the aim of this study was to provide a thorough comparative intercountry assessment on the speed of population aging in the entire see region for the period 1950-2010. methods: descriptive observational analysis of long-term trends on core primary and composite indicators of population aging across seventeen countries of the wider see region, with panel data sets at a national level. results: during the past six decades, the entire see region has experienced a rapid increase in the median age (from 25.2 years in 1950 to 37.9 years in 2010), with a simultaneous fall of fertility rates for two children per woman (from 3.55 children per each childbearing woman in 1950 to 1.49 in 2010), coupled with significant rise in the population of elderly citizens. the speed of population aging has vastly accelerated (with a 2.5 fold increase) over the past three decades. the percentage of individuals over 65 years has doubled from 7% in 1950 to 14% in 2010. conclusion: complex national strategies are needed to cope with the shrinking labour force coupled with the growing proportion of the older population. with all likelihood, population aging will further accelerate in the near future. this profound long-term demographic transition will threaten financial sustainability of current health systems in all see countries. keywords: aging, demography, population; primary indicators; south eastern europe; syncretic indicators, trend. source of funding: the ministry of education, science and technological development of the republic of serbia has funded this study through grant oi 175014. publication of results was not contingent to ministry’s censorship or approval. conflicts of interest: none. jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 3 introduction according to the most realistic official forecasts scenario, global population aging will accelerate. the profound demographic transformation of contemporary societies started almost a century and a half ago in most of the developed nations (1). surprisingly, this phenomenon is currently moving from rich industrial north to the most emerging markets of the southern hemisphere. the aging of developing nations occurs at a far greater speed. for increasing the proportion of people over 60 years from 7% to 14%, it will take china only 26 years, whereas the same process in france occurred over 115 years (2). to date, most of global aging in absolute terms, by far and large, has occurred in more developed regions with enormous social and economic consequences (3). the wider south eastern europe (see) presents a myriad of societies in diverse ethno-religious traditions, prevailing lifestyle patterns and income levels (4). for the purpose of providing a comprehensive insight into the evolution of population aging in this region, a total of seventeen countries were examined in the region’s broadly accepted geographical boundaries. there is a significant gap in regional knowledge on population aging and its consequences in the broader eastern european region including the balkan peninsula (5). the aim of this study was to describe the long-term aging trends and identify the serious agingrelated public health challenges in the upcoming decades. the main hypothesis was that speed of population aging and stages of demographic transition differ substantially among the individual nations. methods this was a descriptive retrospective trend analysis conducted on complex national level datasets within 1950-2010 time spans. the data collection consisted of official release of medium range estimates on core population aging indicators provided by the united nations (un), department of economic and social affairs, population division issued within the report entitled: “world population prospects: the 2012 revision related to the period 1950-2010” (6). countries selected were the ones whose territory lies within geographic boundaries of see partially or in its entirety and which are covered by the un’s department of economic and social affairs official demographic reports. the countries observed included: albania; bulgaria; hungary; republic of moldova; romania; bosnia and herzegovina; croatia; italy; fyr macedonia; montenegro; serbia; slovenia; slovakia; cyprus; greece; turkey; and ukraine. transitional balkan countries were observed as a subgroup of economies whose territories reside entirely or in large parts within the geographic boundaries of the balkan peninsula, but were centrally planned economies during the cold war era (1945-1989): albania, bosnia and herzegovina, bulgaria, croatia, montenegro, the republic of moldova, romania, serbia and the former yugoslav republic of macedonia (excluding of greece and turkey which were free market economies prior to 1989). the time period 1950-2010 was selected for two reasons: extensive data availability as well as the fact that most local nations actually entered severe population aging in the early post world war ii decades, or at the end of the 20th century (7). for the purpose of this analysis there were no missing data, because un referral bodies provided comprehensive assessments for each nation during the observation period. jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 4 selected indicators of population aging were defined according to the list provided in anex i of the united nation’s department of economic and social affairs official projections entitled: “world population ageing: 1950-2050”. of the indicators listed, the vast majority were applied in this analysis with few minor exceptions of less relevant compound indicators. authors had at their disposal complete availability of data for all the seventeen countries and all relevant years/five year periods within the 1950-2010 time span. results due to the rapid population growth rates in the initial decades of global demographic explosion, many nations of the wider see region exhibited bold gains in population size, most prominent in large countries such as romania, italy, ukraine and turkey. top performers in terms of population growth were turkey and albania which even succeeded to triple their populations within these six decades (table 1). however, the entire region has recorded profound population aging trends in terms of all the relevant indicators. table 1. ground demographic indicators of population aging: medium range estimates by the united nations department of economic and social affairs population division for 1950 and 2010 country total population (both sexes, as of 1 july (millions) total fertility rate (children per woman) population growth rate (% of average annual rate of population change) median age of the total population (years) percentage of people aged 65+ years 1950 2010 19501955 2005 2010 19501955 2005 2010 1950 2010 1950 2010 albania 1.2 3.2 6.1 1.8 2.7 -0.29 20.9 31.9 5.9 10.1 bosnia 2.7 3.8 4.8 1.2 2.5 -0.2 20.0 38.6 4.0 15.1 bulgaria 7.3 7.4 2.5 1.4 0.8 -0.8 27.3 42.4 6.7 18.3 croatia 3.9 4.3 2.8 1.4 0.7 -0.2 27.9 41.9 7.9 17.5 cyprus 0.5 1.1 3.7 1.5 1.4 1.3 23.7 34.2 6.0 11.6 greece 7.6 11.1 2.3 1.5 1.0 0.1 26.0 41.8 6.8 19.0 hungary 9.3 10.0 2.7 1.3 1.0 -0. 2 30.1 39.9 7.8 16.7 italy 46.4 60.6 2.4 1.4 0.7 0.6 28.6 43.3 8.1 20.3 montenegro 0.4 0.6 4.0 1.7 2.2 0.1 21.6 36.3 7.4 12.5 moldova 2.3 3.6 3.5 1.5 2.3 -1.1 26.6 35.2 7.7 11.2 romania 16.2 21.9 2.9 1.3 1.4 -0.2 26.3 38.5 5.7 14.8 serbia 6.7 9.6 3.2 1.4 1.5 -0.6 25.8 37.8 7.6 13.7 slovakia 3.4 5.4 3.5 1.3 2.1 0.2 27.0 37.2 6.6 12.3 slovenia 1.5 2.1 2.6 1.4 0.8 0.5 27.7 41.5 7.0 16.7 fyr macedonia 1.3 2.1 4.0 1.5 1.8 0.1 21.8 36.1 7.1 11.7 turkey 21.2 72.1 6.6 2.2 2.7 1.3 19.7 28.3 3.0 7.1 ukraine 37.3 46.1 2.8 1.4 1.4 -0.5 27.6 39.4 7.6 15.8 transitional* mean ± sd range 4.7±4.9 0.4-16.2 6.3±6.4 0.6-21.9 3.8± 1.1 2.5-6.1 1.5±0.2 1.2-1.8 1. 8±0.7 0.7-2.7 -0.3±0.4 -1.1-0.1 24.2±3.1 20.0-27.9 37.6±3.3 31.9-42.4 6.7±1.3 4.0-7.9 13.9±2.81 0.1-18.3 wider see mean ± sd range 10.0±13.4 0.4-46.4 15.6±22.1 0.6-72.1 3.6± 1.3 2.3-6.6 1.5±0.2 1.2-2.2 1.6± 0.7 0.7-2.7 0.01±0.6 -1.1-1.3 25.2±3.3 19.7-30.1 37.9±4.0 28.3-43.3 7.0±1.0 3.0-8.1 14.0±4.0 7.1-20.3 * transitional balkan countries were considered the following countries: albania, bosnia and herzegovina, bulgaria, croatia, montenegro, the republic of moldova, romania, serbia and the former yugoslav republic of macedonia. jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 5 all countries have experienced rapid increase in median age (from 25.2 in 1950 to 37.9 in 2010), with a simultaneous fall of fertility rates for two children per woman (from 3.55 children per each childbearing woman in 1950 to 1.49 in 2010). population growth rate decreased steadily even among the youngest nations of the region from 1.6 in 1950 to 0.01 in 2010. crude death rates followed the general pattern of improved mortality-based indicators in all countries with a decrease from 13 (per 1000 population) in 1950 to 11 in 2010. old-age dependency ratio increased from 10.6 in 1950 to 20.9 in 2010. furthermore, the potential support ratio decreased from 9.9 in 1950 to 5.1 in 2010. life expectancy increased substantially: at birth (about 15 years 1950-2010) and ages over 60 (four years increase during 1950-2010) and 80 (1.8 years increase during 1950-2010) (table 2). table 2. dependency and support indicators of population aging and life expectancies in key age groups: medium range estimates by the united nations department of economic and social affairs population division for 1950 and 2010 country old-age dependency ratio (individuals 65+ per 100 people aged 15-64 years) potential support ratio (individuals aged 15-64 per population 65+ years) life expectancy at birth [both sexes combined (years)] life expectancy at age 60 [both sexes combined (years)] 1950 2010 1950 2010 1950 -1955 2005 -2010 19501955 20052010 albania 10.8 15.1 9.3 6.6 55.3 76.3 17.5 20.4 bosnia 6.9 22.3 14.5 4.5 53.7 75.5 13.9 19.7 bulgaria 10.1 26.8 9.9 3.7 62.1 72.9 17.4 18.5 croatia 12.1 26.1 8.3 3.8 61.3 76.1 14.4 20.0 cyprus 10.1 16.4 9.9 6.1 66.7 79.0 17.6 21.4 greece 10.5 28.6 9.5 3.5 65.8 79.78 16.4 22.9 hungary 11.6 24.4 8.6 4.1 64.0 73.8 16.0 19.4 italy 12.4 30.9 8.1 3.2 66.3 81.5 17.2 24.1 montenegro 13.2 18.3 7.6 5.5 59.8 74.2 15.5 18.9 moldova 12.0 15.5 8.3 6.5 59.0 68.2 14.2 16.0 romania 8.7 21.2 11.5 4.7 61.1 73.1 15. 8 19.0 serbia 11.9 19.8 8.4 5.1 59.1 73.3 15.4 18.3 slovakia 10.3 17.0 9.8 5.9 64.5 74.7 16.7 19.4 slovenia 10.7 24.0 9.3 4.2 65.6 78.6 15.4 22.2 fyr macedonia 12.5 16.4 8.0 6.1 54.9 74.4 14.5 18.6 turkey 5.2 10.6 19.3 9.4 41.0 73.4 13.3 20.0 ukraine 11.7 22.4 8.6 4.5 61.8 67.9 16.9 17.2 transitional* mean ± sd range 10.9±2.0 6.9-13.2 20.2±4.3 15.1-26.8 9.5±2.2 7.6-14.5 5.2±1.1 3.7-6.6 58.5±3.1 53. 7-62.1 73.8± 2.4 68.3-76.3 15.4± 1.3 13.9-17.5 18.8±1.3 16.0-20.4 wider see mean ± sd range 10.6±2.1 5.2-13.2 20.9±5.5 10.6-30.9 9.9±2.9 7.6-19.3 5.1±1.5 3.2-9.4 60.1± 6.4 41.0-66.7 74.9±3.6 67.9-81.5 15.7±1.4 13.3-17.6 19.8±2.0 16.0-24.1 * transitional balkan countries were considered the following countries: albania, bosnia and herzegovina, bulgaria, croatia, montenegro, the republic of moldova, romania, serbia and the former yugoslav republic of macedonia. jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 6 there was evidence of a significant rise in the elderly population, where the percentage of individuals aged over 60 years increased from 9.8% in 1950 to 19.6% in 2010, whereas the percentage of individuals aged over 80 years increased from 0.9% in 1950 to 3.1% in 2010. speed of aging was assessed independently in two thirty-year periods (1950-1980 and 19802010) using the percentage of individuals aged over 60 years in line with the methodology employed by the un population division in the world population ageing report issued in 2013. according to the official un estimates based on national data, the speed of population aging has vastly accelerated over the past three decades (with a percentage point increase of people over 60 years of 2.8% during 1980-2010) compared to the previous three decades (7.0% during 19501980). during the same period, transitional balkan countries aged considerably faster, from 1.4% increase in the early three decades to 8.1 % increase in the past three decades. extensive details on national estimates in five-year periods or single years during 1950-2010 time span, depending on the variable considered, are listed in tables 1-2. discussion in the early post ward war ii decades, many of populations in the wider see region were young, with high fertility rates and a rather modest longevity (8). the latter was determined by a modest literacy level and unhealthy lifestyle/behavioural factors attributable to the low socioeconomic levels of most of the countries. higher income levels and standards of living were initially observed in italy followed by greece and former yugoslavia (9) in the course of 1960s and 1970s. these countries had higher capabilities and capacities in terms of national health systems and better coverage of rural areas regarding the provision of health care services. we should revoke the fact the urbanization of balkan societies was still developing rapidly during the second half of the 20th century. most of the inhabitants were still living in rural communities and therefore reach of extended network of medical facilities increased the percentage of births attended by skilled personnel. in addition, the increase of youth vaccination rates and improved hygiene and availability of antibiotics significantly improved survival in the early childhood. such changes are clearly visible in the official data provided by regional governments to the various who offices including the european health for all database. these positive developments were initially visible among the semashko-type (10) health systems and much later in turkey (11). after the “baby boom” of post world war ii generations, a few health policymakers anticipated the scale of the population aging that was about to come. complex socio-cultural changes, as well as economic limitations gradually led to decreasing fertility rates among all of the nations of the region (figure 1). an essential event giving impetus to the changes was the massive absorption of female labour force into most of the world economies. women were getting easier access to education and consecutively had higher chances to build up a professional career path. this, in turn, led to governmental financial incentives to women for giving birth to fewer children and, instead, contribute to the community as employed citizens (12). jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 7 figure1. total fertility rate evolution 1950-2010 (above) and median age evolution 1950-2010 (beneath) in the wider south eastern europe, transitional balkan countries and four largest countries of the region (italy, romania, turkey and ukraine) 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 total fertility rate italy romania turkey ukraine transitional balkan countries wider south east europe 15.0 20.0 25.0 30.0 35.0 40.0 45.0 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 median age italy romania turkey ukraine transitional balkan countries wider south east europe jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 8 in historical terms, nations were at different stages of this demographic transition at the starting point of our observation (in 1950). albanian and turkish populations were quite young at the time with fertility rates above six (per woman), in bosnia almost five, while macedonia and montenegro over four. all the other nations were significantly above the simple population replacement level of 2.1. currently, after six decades, we have quite an opposite landscape across europe. turkey and ireland remain among the few nations with 2.1 fertility levels. legalized abortion procedures performed by gynaecologists had a profound impact on vulnerable fertility of eastern european nations (13). these changes coupled with a significant rise in longevity of almost fifteen years on average in the wider see region have ultimately led to dramatic changes of population pyramids in all nations (14). median age, broadly regarded as one of the most reliable indicators of population aging, has also increased as much as fifteen years (the four largest nations in the region are illustrated in figure 1). speed of population aging is another core issue in this research work. long-term perspective of six decades has allowed us to split it into two periods to observe the pace of the process across the local nations. during the initial three decades in the so called “take off” stage, there was a very slow pace and, in some countries, it has not even began before 1980s. but, in the latter stage, the scale of the process became much more intensive providing insight into evident acceleration in most countries of the region (15) (figure 2). population aging is about to remain a landmark change of our time in almost all regions of the world, with the exception of sub-saharan africa and a few mena countries – including a total of eighteen countries so-called “demographic outliers” (16). this global fact is constantly increasing the workload and economic burden to the national health systems. grounds are demanding medical needs of the elderly population (17) joined with significantly longer life expectancies among citizens aged over 60 and 80 years. the worsening of demographic balance of working age population and the elderly throughout the entire region is clearly present. old age dependency ratio has substantially increased, whereas the potential support ratio has heavily decreased in all countries within the 1950-2010 time span. this means that dwindling tax-base of employees is about to sustain even a heavier layer of retired citizens whose pension contributions to the national social insurance funds has to be supported by the current budget revenues. the most obvious and extreme example of this phenomenon is observed in the world’s oldest large nation of japan (18). universal health coverage that effectively functions in the second largest global health care market has contributed to the highest attainable longevity. most national health systems of the region ranked substantially lower in terms of patient satisfaction, quality and accessibility of medical care in the last who ranking of 2000. severe financial constraints throughout the region are worsened by macroeconomic crisis such as the case of italy (19), greece and serbia (20). such developments hampered national capacities to expand medical spending (21) and reimbursement of medicines for the retired to cover the needs of aging societies (22). among the few truly successful options to contain the sky rocketing costs of health care without severe trade-off for quality consists of the generic replacement of brand name drugs. governmental strategies targeted to give financial incentives to prescribers, dispensers and patients to use “copy cat” pharmaceuticals were already successfully implemented in major global markets such as the japanese one (23). innovative industrial manufacturers were at the same time protected from their revenue losses in order to compensate for their research and development expenses across the globe (24). jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 9 figure 2. speed of population aging expressed as proportion of people aged over 60 years in the entire population (percentage point increase) in two three-decade periods (1950-1980 and 19802010) providing clear evidence of a several-fold acceleration in most of the wider see countries another highly visible trend in regional pharmaceutical market transformation includes the prevailing domination of medicines used to treat non-communicable diseases which are very prevalent in the older age. this is the case with copd (chronic obstructive pulmonary disease) cancer, diabetes and cardiovascular disorders whose growing share of the market size both in terms of unit dose prescription as well as value-based was recently evidenced in a regional example (25). interestingly, the most expensive medical care is actually attributable to the patient’s last year of life which is most obvious in the case of malignant disorders (26). only a minor part of these costs might be partially contained by diverse screening and prevention strategies. national authorities have adopted different policies to cope with growing budget impacts of aging with various success stories. regardless of an almost unbearable burden imposed by this demographic transition, some promising developments in the emerging rapidly evolving economies such as turkey, might pose an excellent example on promising perspectives for the improved medical care for the elderly (27). 17.9 11.6 10 9.8 9.2 8.1 7.8 7.6 7.6 7.4 7.3 7.0 6.9 6.7 5.6 5.2 4.7 4.4 3.6 3.2 2.5 5.1 2.1 2.5 5.5 5.3 1.4 -0.6 1 4 7.5 -0.1 2.8 -1.5 4.2 5.2 -0.4 4.5 3.3 1.2 4 0.6 -5 0 5 10 15 20 25 japan bosnia croatia bulgaria italy transitional balkan countries fyr macedonia serbia slovenia greece montenegro wider south east europe albania romania hungary moldova ukraine slovakia turkey cyprus world 1980-2010 percentage point increase of citizens aged ≥ 60 1950-1980 percentage point increase of citizens aged ≥ 60 jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 10 study limitations the far reaching process of aging of human populations in europe dates back much earlier than 1950. actually, earliest roots of falling fertility levels might be tracked back almost two centuries ago (28). the process itself in some balkan nations such as serbia began much earlier, even a century ago (29). therefore, a minor study weakness could be considered the very time span of this study when taking into account long-term historical processes. nevertheless, in most of the nations, population aging becomes visible in demographic statistics only during 1980s. official data worldwide are lacking for most of the countries before 1950. thus, authors consider the selected time horizon to be the broadest attainable within this methodological framework. one political entity was omitted from the analysis because of lack of availability of official data although its territory resides within geographic boundaries of the wider see. kosovo (unsc 1244/99) was exempted from the analysis due to the fact that it is absent from the un registries during the period under observation. un estimates bear the minor risks of underor overestimating the real life population data. nevertheless, such assessments rely on a sound methodological framework and are most likely to reflect properly hidden demographic trends even in cases of missing data for some countries and some periods (30). of the overall un department of economic and social affairs list of core indicators of population ageing, a few of them were omitted based on partial or complete lack of such data or grounds for their calculation in the un’s public demographic registries. these indicators include: the illiteracy rate, labour force participation rate, the parent support ratio and the survival rate to a specific age. although they present a minor setback of the study design, the authors considered that these indicators would not change the demographic landscape of the aging process in any significant manner. inclusion of large countries such as italy, ukraine and turkey whose territories rely mostly outside strict geographical boundaries bears the risk of bias. national level extrapolations refer to the entire populations of these countries living in apennine peninsula, eastern europe and asia minor. regardless of this fact, the aim of the paper was to depict a comprehensive image of regional population fluctuations and describe the long-term demographic transition of the respective nations. conclusion accelerated pace of population aging across the globe will have a profound echo among the rapidly developing see markets. some of these nations have entered this demographic transition only in recent decades such as e.g. albania. other countries stand at the borderline of simple replacement fertility rates such as turkey, which is the region’s largest nation. italian, greek, romanian, hungarian and all the remaining slavic populations have undergone these changes many decades earlier. these trends will put an additional pressure to the national health systems and the entire regional economy. the balance between working age population and the retired citizens is worsening, thus, leading to a shrinking base of tax payers. at the same time, increased longevity will increase demands for medical care and the burden to families still supporting their elderly people. complex socioeconomic and health policy strategies will have to be adopted by regional governments to cope with probably the largest single long-term public health challenge of the 21st century. jakovljevic m, laaser u. population aging from 1950 to 2010 in seventeen transitional countries in the wider region of south eastern europe (original research). seejph 2015, posted: 21 february 2015. doi 10.12908/seejph-2014-42 11 references 1. ogura s, tachibanaki t, wise da (eds.). aging issues in the united states and japan. university of chicago press, 2007. 2. united nations. the world population ageing 2013 un report. http://www.un.org/en/development/desa/population/publications/ageing/worldpopulation ageingreport2013.shtml (accessed: february 18, 2015). 3. ogura s. the cost of aging: public finance perspectives for japan. in aging in the united states and japan: economic trends. university of chicago press, 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___________________________________________________________ © 2015 jakovljevic et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. houghton f, o’rourke ls. condemning the war in ukraine & the need for peace (editorial). seejph 2022, posted: 23 march 2022. doi: 10.11576/seejph-5349 p a g e 1 | 2 editorial condemning the war in ukraine & the need for peace frank houghton1, lisa scott o’rourke1 1technological university of the shannon, moylish, limerick, ireland corresponding author: dr frank houghton director of social sciences connexions address: room 12b13, department of applied social sciences, technological university of the shannon, moylish, limerick, ireland. email: frank.houghton@tus.ie houghton f, o’rourke ls. condemning the war in ukraine & the need for peace (editorial). seejph 2022, posted: 23 march 2022. doi: 10.11576/seejph-5349 p a g e 2 | 2 © 2022 houghton et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited we and our colleagues call for an immediate ceasefire in ukraine. we wholeheartedly condemn the russian federation’s recent invasion of ukraine, which began on 24th february 2022. this attack is an unprovoked and unacceptable breach of international law and the un charter. we further call on the russian federation to withdraw its forces back to international borders as agreed and operated as of 2013. the russian invasion has already resulted in significant loss of life, as well as the wholescale destruction of crucial elements of ukraine’s infrastructure. we are extremely alarmed at the number of people, including civilians, killed to date, as well as the number that has been injured both mentally and physically. the impacts of the war will be felt for decades to come. the trauma of those enduring the conflict and those who have been forced to flee will undoubtedly result in adverse health outcomes that will be felt across generations. we anticipate significantly higher rates of anxiety, depression, addiction, self-harm, and suicide across impacted populations. war is anathema to health, health protection, and health improvement. we understand that the russian invasion will have further harmed the health of the ukrainian people through adversely impacting those with chronic health conditions, as well as those currently requiring treatment and those in need of diagnostic services. we are appalled at the targeting of ukraine’s health infrastructure by invading forces, as evidenced by the russian federation’s attack on the maternity hospital in mariupol. we are equally appalled by the systematic bombardment of civilian areas in ukraine by invading russian forces and their targeting of civilians attempting to flee the conflict. we further condemn the russian federation’s targeting of vital civil infrastructures such as water plants, power stations, and transportation systems. such infrastructure is vital to health and health services and will take many years to repair. the environmental damage in ukraine has also been significant, as has the impact on industry and business. we understand that in addition to the direct impact of the war, almost all factors associated with the determinants of health have been adversely affected. we are equally cognisant of the negative physical and mental impacts of the conflict upon invading russian federation forces and call on them to lay down their arms and refuse to continue to participate in this illegal and unprovoked war. we are concerned that the recent invasion by the russian federation will lead to increased militarism and military spending across europe. the opportunity cost of such defence related expenditure may well be less spending on essential health and social programs. we admire and applaud the courage of individuals within the russian federation in speaking out and protesting against the war. in the increasingly authoritarian state that is the russian federation, such protestors are risking their lives. we call upon all eu countries to continue to work for a diplomatic solution to the conflict and continue to support ukrainians forced to flee because of the conflict. dr frank houghton phd mphe ma msc ma cgeog (gis) fhea frgs dr lisa scott o’rourke phd, msc, ma, hdip, hcert, cert coun, bs ____________________________________________________________________ mone i, kraja b, roshi e, burazeri g. overview on health status of the albanian population (review article). seejph 2022, posted: 02 october 2022. doi: 10.11576/seejph-5913 p a g e 1 | 6 review article overview on health status of the albanian population iris mone1, bledar kraja1, enver roshi1, genc burazeri1,2 1 faculty of medicine, university of medicine, tirana, albania; 2 department of international health, school caphri (care and public health research institute), maastricht university, maastricht, the netherlands. corresponding author: iris mone, university of medicine, tirana; address: rr. “dibres”, no. 371, tirana, albania; telephone: 00355692149301; email: iris_mone@yahoo.com mone i, kraja b, roshi e, burazeri g. overview on health status of the albanian population (review article). seejph 2022, posted: 02 october 2022. doi: 10.11576/seejph-5913 p a g e 2 | 6 abstract the albanian population is rapidly aging (in 2020, almost 15% of the population was ≥65 years) as a result of a steady increase in life expectancy (74.4 years in men and 78.7 years in women in in 2021), a gradual decrease in fertility rate (1.6 children per woman of childbearing age in 2020), and emigration of particularly young adults. this demographic transition experienced in the past three decades has inevitably led to a significant change in the epidemiological profile of the albanian population, characterized by a remarkable shift towards non-communicable diseases (ncds), particularly cardiovascular diseases (cvd), cancer, chronic respiratory diseases, and diabetes. the main risk factors in the albanian population consist of high blood pressure (top risk factor, accounting for about 34% of the overall mortality), nutritional-related risks (second, constituting about 25% of the overall mortality), and smoking (third risk factor, accounting for about 20% of the overall mortality). the national “health strategy, albania 2021-2030” is a political document of the albanian government that aims to define and achieve the objectives of the program for the protection and improvement of the health of the albanian population. following the national “health strategy, albania 2021-2030”, two new action plans were recently developed: the “action plan on ncds, albania 2021-2030” and the “action plan on health promotion, albania 2022-2030”. keywords: albania, demographic transition, epidemiological transition, health profile, western balkans. mone i, kraja b, roshi e, burazeri g. overview on health status of the albanian population (review article). seejph 2022, posted: 02 october 2022. doi: 10.11576/seejph-5913 p a g e 3 | 6 demographic characteristics of the albanian population as of january 2022, the population of albania consists of about 2.8 million inhabitants (1), displaying a gradual decrease in the past decade due to a decrease in fertility rate and emigration. as a matter of fact, fertility rate in albania has decreased steadily in the past few decades, exhibiting a level of 1.6 children per woman of childbearing age in 2020 (2), which is only slightly higher than the average in the european union countries (1.5 live births per woman in 2020) (3). according to the official figures provided by the national institute of statistics, in 2021, life expectancy in albania was 74.4 years in men and 78.7 years in women (4), representing a significant decrease compared with the pre-covid-19 pandemic (in 2019, life expectancy in men was 77.6 years, whereas in women it was 80.6 years). seemingly, there is evidence of a considerable excess death due to covid-19, especially among adult men in albania during the period 2020-2021. nevertheless, covid-19 aside, there is evidence of a steady increase in life expectancy in albania in the past three decades (4). in the past three decades following the breakdown of the communist regime, albania has experienced an unprecedented level of emigration, which continuous unabated. the net migration rate in albania is estimated to be between -5% to -10%, which involves a loss of more than 300,000 people only due to emigration in the past two decades (5). only during 2019-2020, the net migration rate in albania was about -40 thousand individuals (5). as a consequence of a gradual increase in life expectancy in the past few decades, the decrease in fertility rate, and the massive emigration of especially young adults, there is evidence of a significant demographic transition of the albanian population, with a substantial increase in the proportion of older individuals (≥65 years): from about 4% in 1990 to almost 15% in 2020 (4). mortality indicators of the albanian population in the past two decades, the age-standardized mortality rates in albania have declined more rapidly than in most of the other countries of the european region including especially the neighbouring countries of the western balkans (6). the overall mortality rate (number of deaths per 100,000 population) in albania in 2021 was 1,085, with cardiovascular diseases comprising about 53% of proportional mortality (7). according to the global burden of disease (gbd) estimates, the age-standardized overall mortality in albania in 2019 was about 575 (95%ci=460-714) deaths per 100,000 population, whereas in 1990 it was 830 (95%ci=813-849) deaths per 100,000 population (6). consistent with the overall increase in life expectancy in albania, infant mortality and child mortality, on the whole, have both decreased in the past three decades, a trend which was nevertheless interrupted in the past few years (2019-2021). in 2021, infant mortality rate was 8.4 deaths per 1,000 live births, whereas under-5 mortality rate was 9.2 deaths per 1,000 live births (4). the plateau or even worsening of child indicators in the past few years should be a cause of concern to policymakers and decisionmakers in albania, pointing to lack of sufficient attention in strategies and interventions targeting traditional mother and child health care programs and probably budget shifts toward other healthcare services. conversely, maternal mortality ratio in albania in 2020 was 3.6 deaths per 100,000 livebirths, indicating a decrease in the past decade (in 2012, it was 5.6 deaths per 100,000 livebirths) (4). of note, there has been a significant change in the mone i, kraja b, roshi e, burazeri g. overview on health status of the albanian population (review article). seejph 2022, posted: 02 october 2022. doi: 10.11576/seejph-5913 p a g e 4 | 6 epidemiological profile of the population in the past few decades with a remarkable transition towards non-communicable diseases (ncds), characterized by an increase of cardiovascular diseases (cvd), cancer, chronic respiratory diseases, and diabetes (8). the age-standardized mortality rate from all ncds in 2019 was estimated at 520 (95%ci=413-649) deaths per 100,000 population, whereas in 1990 it was estimated at 673 (95%ci=657-705) deaths per 100,000 population (6). in 2019, about 93% (95%ci=92%-94%) of all deaths in albania (all ages) were caused by ncds, as opposed to only about 71% (95%ci=69%-76%) in 1990 (6). cvd mortality in 2019 was estimated at 474 (95%ci=374-596) deaths per 100,000 population, constituting 57% (95%ci=52%60%) of the overall mortality in the albanian population (6). furthermore, mortality from neoplasms in 2019 was estimated at 173 (95%ci=131-223) deaths per 100,000 population, accounting for 21% (95%ci=19%-23%) of the overall mortality (6). in addition, mortality rate from chronic respiratory diseases in 2019 was 30 (95%ci=22-39) deaths per 100,000 population, comprising 3.6% (95%ci=3.1%4.2%) of the overall mortality (6). mortality rate from diabetes mellitus in 2019 was 6.4 (95%ci=4.8-8.5) deaths per 100,000 population, comprising 0.8% (95%ci=0.7%0.9%) of all-cause mortality (6). on the other hand, in 2019, mortality rate from communicable diseases, maternal, neonatal and nutritional disorders altogether was estimated at 27 (95%ci=22-33) deaths per 100,000 population, comprising 3.2% (95%ci=2.8%-3.8%) of all-cause mortality (6). in turn, mortality rate from injuries in 2019 was 31 (95%ci=24-39) deaths per 100,000 population, comprising 3.7% (95%ci=3.5%3.9%) of all-cause mortality (6). based on this rapid epidemiologic transition (from infectious diseases toward ncds), there is a pressing need for an effective strategy for control and prevention of ncds, which has been a core component of the health sector reform in albania, culminating with the fairly recent development of the “national plan on ncds, albania 20212030” (document pending official endorsement by the albanian ministry of health and social protection). disease burden and the main risk factors in the albanian population regarding the burden of disease (mortality and disability combined), in 2019, ncds accounted for 82% (95%ci=81%-84%) of all disability-adjusted life years (dalys) (6). cvds only constituted 29% (95%ci=25%33%) of the overall disease burden in the albanian population (6). conversely, neoplasms, chronic respiratory diseases, and diabetes accounted respectively for 15%, 2.6% and 2.1% of the overall burden of disease in the albanian population (6). the ncd burden in albania is caused by a wide range of health determinants, but, particularly, due to a high prevalence of high blood pressure (top risk factor for the albanian population according to the most recent gbd estimates, accounting for about 34% of the overall mortality); nutritional related risks (second, constituting slightly more than 25% of the overall mortality); smoking (third risk factor, accounting for about 20% of the overall mortality), as well as overweight and obesity, high plasma sugar level and physical inactivity (6). regarding the trends in the main conventional risk factors, the prevalence of smoking has slightly decreased in albanian men in the past few years, whereas in women it remains low (as a matter of fact, the lowest mone i, kraja b, roshi e, burazeri g. overview on health status of the albanian population (review article). seejph 2022, posted: 02 october 2022. doi: 10.11576/seejph-5913 p a g e 5 | 6 in the region) (9). in 2019, mortality attributed to smoking comprised about 50% of chronic respiratory diseases deaths, 31% of deaths from neoplasms, and 17% of cvd deaths (6). on the other hand, the average alcohol consumption has increased by half a litter (per capita) in the past few years. in 2019, mortality attributed to alcohol consumption comprised about 5% of deaths from neoplasms, and 1.7% of cvd deaths (6). as for the high blood pressure, which is the main risk factor in the albanian population, its attributable mortality in 2019 accounted for more than 57% of cvd deaths (6). of note, there is evidence of a considerable increase in the prevalence of obesity in both men and women in albania in the past decade (overall, 28% increase) (9). in 2019, mortality attributed to high body mass index constituted about 43% of deaths from diabetes mellitus, more than 19% of cvd deaths, and about 5% of deaths from neoplasms (6). current strategies and policies to address disease burden in the albanian population the national “health strategy, albania 20212030” is a political document of the albanian government that aims to define and achieve the objectives of the program for the protection and improvement of the health of the albanian population (10). this policy document defines the main objectives for improving health and healthcare for the period 2021-2030, although the vision presented in the strategy will also be suitable for the period after the official implementation of this strategy (10). the drafting of the national “health strategy, albania 2021-2030” was led by the ministry of health and social protection through an inter-institutional technical working group, which was established by a special order of the minister of health and social protection and was supported with technical assistance of local and international experts (10). following the national “health strategy, albania 2021-2030”, two new action plans were recently developed: the “action plan on ncds, albania 2021-2030” and the “action plan on health promotion, albania 20222030”. both documents are still pending official approval by the albanian ministry of health and social protection. nonetheless, the new action plans are based on positive developments and progress of albania in general and reforms in the health sector in particular. the documents take into consideration the updated legislation and the regulatory framework adopted in albania during the last decade, in close cooperation and with the technical assistance of various partner organizations and international agencies. also, both action plans address the actual public health challenges and the priorities defined by the albanian government, focusing especially on major noncommunicable diseases, such as cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases. references 1. institute of statistics, albania. key data, 2022. http://www.instat.gov.al/al/statistika/ t%c3%ab-dh%c3%abnaky%c3%a7e/ (accessed: september 26, 2022). 2. the world bank. fertility rate, albania. https://data.worldbank.org/indicator/ sp.dyn.tfrt.in?locations=xk.al&name_desc=false (accessed: september 26, 2022). 3. eurostat. fertility statistics. https://ec.europa.eu/eurostat/statistics explained/index.php?title=fertility_s tatistics#:~:text=the%20total%20fer https://data.worldbank.org/indicator/sp.dyn.tfrt.in?locations=xk.-al&name_desc=false https://data.worldbank.org/indicator/sp.dyn.tfrt.in?locations=xk.-al&name_desc=false https://data.worldbank.org/indicator/sp.dyn.tfrt.in?locations=xk.-al&name_desc=false https://ec.europa.eu/eurostat/statistics-explained/index.php?title=fertility_statistics#:%7e:text=the%20total%20fertility%20rate%20is,in%202019%20%2d%20figure%202 https://ec.europa.eu/eurostat/statistics-explained/index.php?title=fertility_statistics#:%7e:text=the%20total%20fertility%20rate%20is,in%202019%20%2d%20figure%202 https://ec.europa.eu/eurostat/statistics-explained/index.php?title=fertility_statistics#:%7e:text=the%20total%20fertility%20rate%20is,in%202019%20%2d%20figure%202 https://ec.europa.eu/eurostat/statistics-explained/index.php?title=fertility_statistics#:%7e:text=the%20total%20fertility%20rate%20is,in%202019%20%2d%20figure%202 mone i, kraja b, roshi e, burazeri g. overview on health status of the albanian population (review article). seejph 2022, posted: 02 october 2022. doi: 10.11576/seejph-5913 p a g e 6 | 6 tility%20rate%20is,in%202019%20 %2d%20figure%202) (accessed: september 26, 2022). 4. institute of statistics, albania. population data, 2022. http://www.instat.gov.al/al/temat/tre guesit-demografik%c3%ab-dhesocial%c3%ab/popullsia/#tab2 (accessed: september 26, 2022). 5. institute of statistics, albania. migration and integration of migrants. http://www.instat.gov.al/al/temat/tre guesit-demografik%c3%ab-dhesocial%c3%ab/migracioni-dheintegrimi-imigrant%c3%abve/#tab2 (accessed: september 26, 2022). 6. institute for health metrics and evaluation (ihme). global burden of disease estimates. https://vizhub.healthdata.org/gbdresults/ (accessed: september 26, 2022). 7. institute of statistics, albania. causes of death in albania, 2021. http://www.instat.gov.al/al/temat/kus htetsociale/sh%c3%abndet%c3%absi a/publikim et/2022/shkaqet-evdekjeve-2021/(accessed: september 26, 2022). 8. institute of public health, albania. health status of the albanian population. tirana, 2014. http://seehn.org/web/wpcontent/uploads/2015/02/albanianhealth-report_download.pdf (accessed: september 26, 2022). 9. institute of statistics, institute of public health and icf. albania demographic and health survey; 2018. https://www.ishp.gov.al/wpcontent/uploads/2015/04/adhs2017-18-complete-pdf-finalilovepdf-compressed-1.pdf (accessed: september 26, 2022). 10. government of albania, ministry of health and social protection. health strategy, albania 2021-2030. tirana, 2022. https://konsultimipublik.gov.al/kons ultime/detaje/434 (accessed: september 26, 2022). _____________________________________________________________________________________________ © 2022 mone et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://ec.europa.eu/eurostat/statistics-explained/index.php?title=fertility_statistics#:%7e:text=the%20total%20fertility%20rate%20is,in%202019%20%2d%20figure%202 https://ec.europa.eu/eurostat/statistics-explained/index.php?title=fertility_statistics#:%7e:text=the%20total%20fertility%20rate%20is,in%202019%20%2d%20figure%202 http://www.instat.gov.al/al/temat/treguesit-demografik%c3%ab-dhe-social%c3%ab/popullsia/#tab2 http://www.instat.gov.al/al/temat/treguesit-demografik%c3%ab-dhe-social%c3%ab/popullsia/#tab2 http://www.instat.gov.al/al/temat/treguesit-demografik%c3%ab-dhe-social%c3%ab/popullsia/#tab2 http://www.instat.gov.al/al/temat/treguesit-demografik%c3%ab-dhe-social%c3%ab/migracioni-dhe-integrimi-i-migrant%c3%abve/#tab2 http://www.instat.gov.al/al/temat/treguesit-demografik%c3%ab-dhe-social%c3%ab/migracioni-dhe-integrimi-i-migrant%c3%abve/#tab2 http://www.instat.gov.al/al/temat/treguesit-demografik%c3%ab-dhe-social%c3%ab/migracioni-dhe-integrimi-i-migrant%c3%abve/#tab2 http://www.instat.gov.al/al/temat/treguesit-demografik%c3%ab-dhe-social%c3%ab/migracioni-dhe-integrimi-i-migrant%c3%abve/#tab2 http://www.instat.gov.al/al/temat/treguesit-demografik%c3%ab-dhe-social%c3%ab/migracioni-dhe-integrimi-i-migrant%c3%abve/#tab2 http://www.instat.gov.al/al/temat/kushtet-sociale/sh%c3%abndet%c3%absia/publikim http://www.instat.gov.al/al/temat/kushtet-sociale/sh%c3%abndet%c3%absia/publikim http://www.instat.gov.al/al/temat/kushtet-sociale/sh%c3%abndet%c3%absia/publikim http://www.instat.gov.al/al/temat/kushtet-sociale/sh%c3%abndet%c3%absia/publikim http://seehn.org/web/wp-content/uploads/2015/02/albanian-health-report_download.pdf http://seehn.org/web/wp-content/uploads/2015/02/albanian-health-report_download.pdf http://seehn.org/web/wp-content/uploads/2015/02/albanian-health-report_download.pdf https://www.ishp.gov.al/wp-content/uploads/2015/04/adhs-2017-18-complete-pdf-final-ilovepdf-compressed-1.pdf https://www.ishp.gov.al/wp-content/uploads/2015/04/adhs-2017-18-complete-pdf-final-ilovepdf-compressed-1.pdf https://www.ishp.gov.al/wp-content/uploads/2015/04/adhs-2017-18-complete-pdf-final-ilovepdf-compressed-1.pdf https://www.ishp.gov.al/wp-content/uploads/2015/04/adhs-2017-18-complete-pdf-final-ilovepdf-compressed-1.pdf https://konsultimipublik.gov.al/konsultime/detaje/434 https://konsultimipublik.gov.al/konsultime/detaje/434 south eastern european journal of public health special volume no. 6, 2022 addiction & dependency contributions to a major health problem jacobs publishing house executive editor prof. dr. genc burazeri phd faculty of medicine, st. dibres, no. 371, tirana, albania, and caphri, faculty of health, medicine and life sciences, maastricht university, 6200 md, maastricht, the netherlands email: genc.burazeri@maastrichtuniversity.nl and: gburazeri@gmail.com skype: genc.burazeri volume editors dr. frank houghton email: frank.houghton@tus.ie section co-editor dr. lisa o’rourke scott email: lisa.orourkescott@tus.ie section co-editor assistant executive editor kreshnik petrela ba tirana, albania email: kreshnikp@gmail.com technical editor meri roshi ba tirana, albania email: meriroshi90@gmail.com publisher dr. hans jacobs jacobs publishing house am prinzengarten 1, d 32756 detmold, germany email: info@jacobs-verlag.de the publication of the south eastern european journal of public health (seejph) is organised in cooperation with the bielefeld university library. https://www.seejph.com/index.php/seejph/management/settings/context/mailto:genc.burazeri@maastrichtuniversity.nl https://www.seejph.com/index.php/seejph/management/settings/context/mailto:genc.burazeri@maastrichtuniversity.nl mailto:frank.houghton@tus.ie mailto:lisa.orourkescott@tus.ie https://www.seejph.com/index.php/seejph/libraryfiles/downloadpublic/126 https://www.seejph.com/index.php/seejph/management/settings/context/mailto:kreshnikp@gmail.com https://www.seejph.com/index.php/seejph/libraryfiles/downloadpublic/127 https://www.seejph.com/index.php/seejph/management/settings/context/mailto:urankurtishi@gmail.com mailto:info@jacobs-verlag.de https://www.ub.uni-bielefeld.de/ seejph south eastern european journal of public health www.seejph.com/ special volume 6, 2022 publisher: jacobs/germany issn 2197-5248 issn2197-5248 doi 10.11576/seejph-5770 bibliographic information published by die deutsche bibliothek. die deutsche bibliothek lists this publication in the deutsche nationalbibliografie; detailed bibliographic data is available on the internet at http://dnb.ddb.de south eastern european journal of public health (open access journal). copyright 2022 by jacobs publishing house: am prinzengarten 1, d 32756 detmold, germany copyright cover picture: wordpress foundation: http://wordpressfoundation.org/gnu general public license table of contents editorials utilising ‘new’ power strategies for public health education in addiction and dependency: learning from social media influencers lisa o’rourke scott case study the potential of men’s sheds as a resource for men coping with mental health challenges and addiction melinda heinz review article tribal communities and opioids margo hill position papers connecting the person by removing the stigma: why ireland should follow the portuguese model of drug decriminalization aisling finucane, jennifer moran stritch commentary researching gambling: have we learned nothing from big tobacco’s overt manipulation of science? frank houghton harizi (shemsi) e, rroji a, cekaj e, gabrani s. anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania (original research). seejph 2014, posted: 20 december 2014. doi 10.12908/seejph-2014-35 1 original research anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania edlira harizi (shemsi)1,2, arben rroji3, elton cekaj1, sazan gabrani2 1 regional hospital, durres, albania; 2 university of medicine, tirana, albania; 3 neuro-radiology service, university hospital centre “mother teresa”, tirana, albania. corresponding author: dr. edlira harizi; regional hospital, durres; address: lagjia no. 8, rruga “aleksander goga”, durres, albania; telephone: +355676092814; e-mail: edliraharizi@hotmail.com harizi (shemsi) e, rroji a, cekaj e, gabrani s. anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania (original research). seejph 2014, posted: 20 december 2014. doi 10.12908/seejph-2014-35 2 abstract aim: the purpose of this study was twofold: i) in a case-control design, to determine the relationship between anatomical variations of the circle of willis and cerebrovascular accidents; ii) to assess the association between anatomical variations of the circle of willis and aneurisms among patients with subarachnoid hemorrhage. methods: a case-control study was conducted in albania in 2013-2014, including 100 patients with subarachnoid hemorrhage and 100 controls (individuals without cerebrovascular accidents). patients with subarachnoid hemorrhage underwent a ct angiography procedure, whereas individuals in the control group underwent a magnetic resonance angiography procedure. binary logistic regression was used to assess the association between cerebrovascular accidents and the anatomical variations of the circle of willis. conversely, fisher’s exact test was used to compare the prevalence of aneurisms between subarachnoid hemorrhage patients with and without anatomical variations of the circle of willis. results: among patients, there were 22 (22%) cases with anatomical variations of the circle of willis compared with 10 (10%) individuals in the control group (p=0.033). there was no evidence of a statistically significant difference in the types of the anatomical variations of the circle of willis between patients and controls (p=0.402). in ageand-sex adjusted logistic regression models, there was evidence of a significant positive association between cerebrovascular accidents and the anatomical variations of the circle of willis (or=1.87, 95%ci=1.03-4.68, p=0.048). within the patients’ group, of the 52 cases with aneurisms, there were 22 (42.3%) individuals with anatomical variations of the circle of willis compared with no individuals with anatomical variations among the 48 patients without aneurisms (p<0.001). conclusion: this study provides useful evidence on the association between anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania. furthermore, findings from this study confirm the role of the anatomical variations of the circle of willis in the occurrence of cerebral aneurisms. keywords: albania, aneurism, cerebrovascular accidents, circle of willis, subarachnoid hemorrhage. conflicts of interest: none. harizi (shemsi) e, rroji a, cekaj e, gabrani s. anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania (original research). seejph 2014, posted: 20 december 2014. doi 10.12908/seejph-2014-35 3 introduction there is convincing evidence linking the anatomical variations of the circle of willis with the development and harshness of cerebrovascular accidents including aneurysms, infarctions, or other vascular disorders which bear a significant negative health impact (1-3). normally, the circle of willis consists of a symmetrical arterial circle, with a single anterior communicating artery and bilateral posterior communicating arteries (4-6). however, different types of anatomical variations of the circle of willis have been described (1,4) including hypoplasia (of the posterior communicating artery, the circular part of the posterior cerebral artery, the circular part of the anterior cerebral artery, or the anterior communicating artery); accessory vessels (which are manifested as duplications or triplications of one of the components of the polygon); anomalous origin (persistence of the embryonic derivation of the posterior cerebral artery from the internal carotid); or absent vessels (of one or other posterior communicating arteries) (1,4). research has indicated that anatomical variations of the circle of willis may be genetically determined and develop in early embryonic stage, persisting in postnatal life (1,7). in addition to development of cerebrovascular accidents, there has been suggested a possible link between the anomalies of the circle of willis and mental illnesses and cerebrovascular catastrophe (1,8). the available evidence about the prevalence and distribution of the anatomical variations of the circle of willis in the adult population of albania is scarce. after the collapse of the communist regime in early 1990s, albania experienced a particularly rapid political and socioeconomic transition, which was associated with tremendous behavioral/lifestyle changes that have a significant health impact (9,10). currently, almost twenty five years after the breakdown of its stalinist regime, albania remains one of the poorest countries in south eastern europe. in this context, the aim of our study was twofold: i) in a case-control design, to determine the relationship between anatomical variations of the circle of willis and cerebrovascular accidents; ii) to assess the association between anatomical variations of the circle of willis and aneurisms among patients with subarachnoid hemorrhage. methods a case-control study was conducted in albania in 2013-2014, including 100 patients with subarachnoid hemorrhage (hospitalized at the university hospital centre “mother teresa”) and 100 controls (individuals who showed up at the university hospital centre “mother teresa” without cerebrovascular accidents, but with signs of tension-type headache, or vertiginous syndrome). all patients with subarachnoid hemorrhage underwent a ct angiography procedure. on the other hand, all individuals in the control group underwent a magnetic resonance angiography procedure either in tirana, or at the regional hospital in durres (second largest city in albania). based on these respective examinations, the presence of cerebrovascular accidents was determined, in addition to the presence and type of anatomical variation of the circle of willis. among patients with subarachnoid hemorrhage, the presence of aneurisms was additionally determined. data on age and sex of participants were also collected. fisher’s exact test was used to compare the prevalence and types of anatomical variations between cases and controls, and the prevalence of aneurisms between subarachnoid hemorrhage patients with and without anatomical variations of the circle of willis. conversely, mann-whitney u-test was used to compare the age distribution between patients harizi (shemsi) e, rroji a, cekaj e, gabrani s. anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania (original research). seejph 2014, posted: 20 december 2014. doi 10.12908/seejph-2014-35 4 and controls. binary logistic regression was used to assess the association between cerebrovascular accidents and the anatomical variations of the circle of willis. odds ratios (ors), their respective 95% confidence intervals (cis) and p-values were calculated. initially, crude (unadjusted) ors were calculated. subsequently, ageand-sex adjusted ors were calculated in a simultaneous multivariable-adjusted logistic regression model. the overall goodness-of-fit of the multivariate model was formally assessed through the hosmerlemeshow test. for all the statistical tests, a p-value of ≤0.05 was considered as statistically significant. statistical package for social sciences (spss, version 17.0) was used for all the data analyses. results table 1 describes the demographic characteristics of the patients and controls included in this case-control study. mean age was significantly higher among patients (53.4±9.8 years) compared with the control group (36.8±12.6 years) (mann-whitney u-test: p<0.001). there were 18 (18%) controls aged 50 years or older, compared with 47 (47%) individuals in the sample of patients. as for the sex distribution, 41 (41%) individuals in the control group were males and 59 (59%) were females, whereas in the sample of the patients there were 46 (46%) males and 54 (54%) females. table 1. demographic characteristics of the patients with subarachnoid hemorrhage and the control group characteristic cases (n=100) controls (n=100) p-value age (years): mean (sd) median (interquartile range) range 53.4±9.8 55.0 (8.0) 24-74 36.8±12.6 35.5 (20.0) 16-63 <0.001* age-group: <50 years ≥50 years 53 (53.0)† 47 (47.0) 82 (82.0) 18 (18.0) <0.001‡ sex: male female 46 (46.0) 54 (54.0) 41 (41.0) 59 (59.0) 0.568‡ * mann-whitney u-test. † absolute numbers and column percentages (in parentheses). ‡ fisher’s exact test. table 2 presents the anatomical variations of the circle of willis in the sample of patients and in the control group. in the sample of the patients, there were 22 (22%) cases with anatomical variations of the circle of willis compared with 10 (10%) individuals in the control group, with a statistically significant difference between the two groups (fisher’s exact test: p=0.033). in the sample of patients with any type of anatomical variation (n=22), there were 10 (45.5%) cases with aca (a1 segment) anomaly, 7 (31.8%) cases with a.com.a. variation (anterior communicant artery), 3 (13.6%) case with p.com.a. anomaly (posterior communicant artery) and 2 (9.1%) cases with pca (p1 segment) variation. the distribution of these anomalies among individuals in the control group who presented any type of harizi (shemsi) e, rroji a, cekaj e, gabrani s. anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania (original research). seejph 2014, posted: 20 december 2014. doi 10.12908/seejph-2014-35 5 anatomical variations of the circle of willis (n=10) was as follows: 3 (30.0%), 2 (20.0%), 4 (40.0%) and 1 (10.0%), respectively – with no evidence of a statistically significant difference with the sample of the patients (fisher’s exact test: p=0.402) (table 2). table 2. anatomical variations of the circle of willis in patients with subarachnoid hemorrhage and the control group characteristic cases controls p-value† circle of willis: normal variation total 78 (78.0)* 22 (22.0) 100 (100.0) 90 (90.0) 10 (10.0) 100 (100.0) 0.033 variation type: aca (a1 segment) a.com.a. p.com.a. pca (p1 segment) total 10 (45.5) 7 (31.8) 3 (13.6) 2 (9.1) 22 (100.0) 3 (30.0) 2 (20.0) 4 (40.0) 1 (10.0) 10 (100.0) 0.402 * absolute numbers and column percentages (in parentheses). † fisher’s exact test. table 3 presents the relationship between cerebrovascular disorders with the anatomical variations of the circle of willis. in unadjusted logistic regression models, there was evidence of a strong positive association between cerebrovascular accidents and the anatomical variations of the circle of willis, which was statistically significant: or=2.54, 95%ci=1.135.69, p=0.024) (table 3, model 1). findings were attenuated upon simultaneous adjustment for age and sex, but the significant positive association between cerebrovascular disorders and the anatomical variations of the circle of willis was still evident (or=1.87, 95%ci=1.034.68, p=0.048; table 3, model 2). table 3. association of cerebrovascular accidents with the anatomical variations of the circle of willis; odds ratios (ors) from binary logistic regression model or 95%ci p-value model 1* anatomical variations normal circle 2.54 1.00 1.13-5.69 reference 0.024 model 2† anatomical variations normal circle 1.87 1.00 1.03-4.68 reference 0.048 * crude (unadjusted) models (or: cases vs. controls). † ageand-sex adjusted models. within the patients’ group, the prevalence of aneurisms was 52% (n=52). of these, there were 22 (42.3%) cases with anatomical variations of the circle of willis compared with no harizi (shemsi) e, rroji a, cekaj e, gabrani s. anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania (original research). seejph 2014, posted: 20 december 2014. doi 10.12908/seejph-2014-35 6 cases with anatomical variations among the 48 patients without aneurisms – a finding which was highly statistically significant (p<0.001) (table 4). table 4. anatomical variations of the circle of willis by presence of aneurisms among patients with subarachnoid hemorrhage characteristic without aneurisms with aneurisms p-value† circle of willis: normal variation total 48 (100.0)* 48 (100.0) 30 (57.7) 22 (42.3) 52 (100.0) <0.001 * absolute numbers and column percentages (in parentheses). † fisher’s exact test. discussion this study informs about the link between anatomical variations of the circle of willis and cerebrovascular accidents consisting of subarachnoid hemorrhage in albanian adults. in addition, this study provides important evidence on the association between anatomical variations of the circle of willis and presence of aneurisms among patients with subarachnoid hemorrhage. the main finding of this study relates to a positive association between the anatomical variations of the circle of willis and subarachnoid hemorrhage. furthermore, among individuals who experienced subarachnoid hemorrhage, there was a positive association between anatomical variations of the circle of willis and the presence of aneurisms. our findings are compatible with previous international studies which have linked the anomalies of the circle of willis with the development and severity of symptoms of different cerebrovascular accidents including infarctions, aneurysms, and several other vascular disorders (1,3). based on the available scientific evidence, it is recommended to assess comprehensively the form of the circle of willis in order to determine the capacity of the brain circulation in operations for cerebral aneurysms, as well as in interventions involving the internal carotid artery (1). in this regard, magnetic resonance angiography displays the functional morphology of the arterial circle (2,4,11-13) and additionally provides a useful means for hemodynamic assessment of blood flow and direction through different techniques and procedures (3,4,14). in particular, detailed information about the anatomical variations of the circle of willis is rather valuable to surgeons for a suitable and rational planning of their operations, which involve complex situations associated with other serious co-morbid conditions (1). in our study, all patients with anatomical variations of the circle of willis had also aneurisms, a finding which confirms the evidence about the role of arterial variations of the circle of willis as a leading factor for cerebral hemodynamic disorders which cause aneurisms (1-3). these, in turn, are a risk factor for cerebrovascular accidents. indeed, in this sample of albanian patients, aneurisms were involved in the occurrence of subarachnoid hemorrhage. this study may have some limitations due to the relatively small sample size and the selection of the control group. during a two-year period, we included all consecutive patients harizi (shemsi) e, rroji a, cekaj e, gabrani s. anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania (original research). seejph 2014, posted: 20 december 2014. doi 10.12908/seejph-2014-35 7 with subarachnoid hemorrhage hospitalized at the university hospital center “mother teresa”, which is the only tertiary health care facility in albania. however, the relatively small sample size may have influenced the stability of the estimates. on the other hand, we cannot entirely exclude the possibility of selection bias in the control group. nonetheless, we included in the control group only individuals who did not had evidence of cerebrovascular disorders. in any case, if there is a positive link between cerebrovascular accidents and the anatomical variations of the circle of willis and if there were a few cases of unnoticed negligible cerebrovascular disorders in the control group, these possibilities would tend to diminish the strength of the association observed instead of producing a spurious finding. in conclusion, our study provides useful evidence on the association between anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania. furthermore, findings from this study confirm the role of the anatomical variations of the circle of willis in the occurrence of cerebral aneurisms. as reported from previous studies on this topic, the anomalies of the circle of willis play an important role in the occurrence, manifestation of symptoms, treatment options and recovery process of several cerebrovascular disorders (1). larger studies should be carried out in the future in albania and other countries in order to confirm and extend the findings of the current case-control study. references 1. iqbal s. a comprehensive study of the anatomical variations of the circle of willis in adult human brains. j clin diagn res 2013;7:2423-7. 2. miralles m, dolz jl, cotillas j, et al. the role of the circle of willis in carotid occlusion; assessment with phase contrast mr angiography and transcranial duplex. eur j vasc endovasc surg 1995;10:424-30. 3. marks mp, pelc nj, ross mr, enzmann dr. determination of cerebral blood flow with a phase-contrast cine mr imaging technique: evaluation of normal subjects and patients with arteriovenous malformations. radiology 1992;182:467-76. 4. hartkamp mj, van der grond j. investigation of the circle of willis using mr angiography. medicamundi 2000;44:20-7. 5. riggs he, rupp c. variation in form of circle of willis. the relation of the variations to collateral circulation: anatomic analysis. arch neurol 1963;8:8-14. 6. alpers bj, berry rg, paddison rm. anatomical studies of the circle of willis in normal brain. ama arc neurol psychiatry 1959;81:409-18. 7. crompton mr. the pathology of ruptured middle cerebral aneurysms with special reference to the differences between the sexes. lancet 1962;2:421-25. 8. kamath s. observations on the length and diameter of the vessels forming the circle of willis. j anat 1981;133:419-23. 9. nuri b, tragakes e. health care systems in transition: albania. european observatory on health care systems. copenhagen: denmark, 2002. 10. rechel b, mckee m. healing the crisis: a prescription for public health action in south eastern europe. new york, usa: open society institute press, 2003. 11. hoogeveen rm. vessel visualization and quantification by magnetic resonance angiography. thesis, university of utrecht, 1998. isbn: 90-393-1769-0. 12. stock kw, wetzel s, kirsch e, bongartz g, steinbrich w, radue ew. anatomical evaluation of the circle of willis: mr angiography versus intraarterial digital subtraction angiography. ajnr 1996;17:1495-9. http://www.ncbi.nlm.nih.gov/pubmed?term=iqbal%20s%5bauthor%5d&cauthor=true&cauthor_uid=24392362 http://www.ncbi.nlm.nih.gov/pubmed/?term=journal+of+clinical+and+diagnostic+research.+2013+nov%2c+vol-7%2811%29%3a+2423-2427 harizi (shemsi) e, rroji a, cekaj e, gabrani s. anatomical variations of the circle of willis and cerebrovascular accidents in transitional albania (original research). seejph 2014, posted: 20 december 2014. doi 10.12908/seejph-2014-35 8 13. patrux b, laissy jp, jouini s, kawiecki w, coty p, thiébot j. magnetic resonance angiography (mra) of the circle of willis: a prospective comparison with conventional angiography in 54 subjects. neuroradiology 1994;36:193-7. 14. ross mr, pelc nj, enzmann dr. qualitative phase contrast mra in the normal and abnormal circle of willis. ajnr 1993;14:19-25. ___________________________________________________________ © 2014 harizi (shemsi) et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. aigbokhaode aq, isah ec, isara ar. health seeking behaviour among caregivers of under five children in edo state, nigeria (original research). seejph 2015, posted: 18 february 2015. doi 10.12908/seejph-2014-41 1 original research health seeking behaviour among caregivers of under-five children in edo state, nigeria adesuwa q. aigbokhaode 1 , essy c. isah 1 , alphonsus r. isara 1 1 department of community health, university teaching hospital of benin, benin city, nigeria. corresponding author: dr. alphonsus r. isara; address: university teaching hospital, p. m. b. 1111, benin city, nigeria; telephone: +2348034057565; email: mansaray2001@yahoo.com mailto:mansaray2001@yahoo.com aigbokhaode aq, isah ec, isara ar. health seeking behaviour among caregivers of under five children in edo state, nigeria (original research). seejph 2015, posted: 18 february 2015. doi 10.12908/seejph-2014-41 2 abstract aim: timely and appropriate healthcare seeking behaviours if practiced by caregivers of under-five children can have a significant impact on child survival. this study assessed the knowledge of, and general health seeking practices among mothers of under-five children in nigeria. methods: this descriptive cross-sectional study was carried out among caregivers of underfive children in edo state, nigeria, in 2013. a multi-staged sampling technique was used to recruit respondents. data collection was done by means of a structured intervieweradministered questionnaire adapted from unicef/imci household baseline survey questionnaire. results: a total of 370 caregivers (mean age: 31.1±5.9 years) participated in the study. almost all of them were females 368 (99.5%), 234 (63.2%) had secondary education and 283 (76.5%) were in the unskilled social class. over 70%, 76%, 72%, 76% and 82% of participants did not know that being unable to eat/drink, fast breathing, blood in stool and convulsion, respectively, were symptoms of a child not feeling well. the place of primary care of children by caregivers was at home 142 (38.4%), chemist shop 91 (24.6%) and health facility 80 (21.6%). cost and long waiting time were major reasons for not seeking care in health facilities. conclusion: this study showed poor health seeking practices among caregivers of under-five children in edo state, nigeria. there should be continuous education of caregivers on recognition of danger signs in children and the need to seek appropriate medical care in health facilities. keywords: caregivers, health seeking behaviour, nigeria, under-five children. acknowledgement: the authors wish to appreciate the contribution of the network on behavioural research for child survival in nigeria to the success of this research. we also thank the pan african thoracic society’s methods in epidemiological, clinical and operational research (pats mecor) programme for the training imparted on researchers from africa. we appreciate the role of the 2014 pats mecor level 3 faculty; prof. stephen gordon, prof. nigel bruce and prof. john balmes in developing this paper. conflicts of interest: none. aigbokhaode aq, isah ec, isara ar. health seeking behaviour among caregivers of under five children in edo state, nigeria (original research). seejph 2015, posted: 18 february 2015. doi 10.12908/seejph-2014-41 3 introduction nigeria is facing huge challenges in meeting the millennium development goal (mdg) 4 (1), due to high morbidity and mortality rates among under-five year old children. although households and communities have a major responsibility in recognizing when children need treatment outside the home, a recent national survey found that this has not been the case due to poor health seeking knowledge and practices in households (2). generally, the poor health seeking practices among caregivers of under-five children, which is a consequence of poor knowledge among other factors such as poverty, lack of family support and competing work demands of carers, is one of the leading causes of the high infant and under-five mortality rates of 69/1,000 live births and 128/1000 live births respectively (2). in edo state, nigeria, infant and under-five mortality rates are reported to be higher (at 100/1000 and 191/1000 live births respectively) (3). the major causes of underfive morbidity and mortality in nigeria are diseases like malaria (24%), pneumonia (20%), diarrhoea (16%), measles (6%), hiv (5%), neonatal conditions (26%), malnutrition and injuries (4,5). diseases and deaths due to these causes are preventable through application of community-oriented cost-effective interventions in the households/communities, such as the unicef/who key household practices (1,4). in nigeria, according to the national demographic and health survey (ndhs) of 2013, slightly more than one-third (35%) of children with symptoms of acute respiratory infections (ari) were taken for treatment to a health facility, 29% of children with diarrhoea were taken to a health facility, whereas 38% of the children with diarrhoea were treated with oral rehydration therapy (ort) (2). the edo state strategic health plan assessment found that only 2% owned insecticide treated nets (itns), only 6% of children under-five slept under a mosquito net and only 13% of children aged 12-23 months had received the recommended course of immunization (3). the nigerian experience is part of wider problem, with a majority of child deaths in (developing countries) continuing to occur at home, often with no contact with a health care facility (6). it has been documented in some sub-saharan africa countries that factors such as lack of money, distance to health facility and perception of the illness not being serious were the major reasons why mothers and caregivers of under-five children do not seek care for their ill children (6,7). studies from india and mexico have reported poor knowledge and practice of health seeking among mothers and caregivers of children less than five years mainly due to careers and not recognizing signs of childhood illness for seeking care immediately for common childhood diseases such as diarrhoea, respiratory tract infections and fevers (8,9). a study in guatemala revealed that 63%-83% of mothers relied on home care the last time their children under the age of five suffered from diarrhoea, fever, cough, and the use of health services (western or traditional) was consistently low among them (10). the resultant effect of this is an increased morbidity and mortality among under-five children. however, a qualitative study carried out in germany among 11 mothers with turkish background and nine mothers with german background showed that mothers had good knowledge of childhood fever and good practice of seeking care for their children’s fever. the mothers perceive their child’s fever not merely as elevated temperature, but as a potentially dangerous event. a deeply rooted urge to protect the child from harm was central to all participants’ experience (11). this good knowledge and practice will make room for prompt and appropriate action thus reducing complications and mortality. studies have shown that timely and appropriate healthcare seeking behaviours can have a significant impact on child survival, if practiced by the majority of caregivers of children less than five years of age (2,3,6). aigbokhaode aq, isah ec, isara ar. health seeking behaviour among caregivers of under five children in edo state, nigeria (original research). seejph 2015, posted: 18 february 2015. doi 10.12908/seejph-2014-41 4 in this framework, our study sought to assess the knowledge of, and general health care seeking practice among mothers of under-five children in edo state, nigeria, with the aim of improving their health practices through the design of appropriate interventions. methods study design a descriptive cross-sectional study using a questionnaire survey method was done. setting the study was carried out in edo state, nigeria, in july 2013. edo state, which is made up of 18 local government areas, is located in the heart of the tropical rain forest and it lies between longitudes 5 o e and 6 o 42" e and latitudes 5 o 45" n and 7 o 35" n of the equator (12). the state has a total population of 3,233,366 with 1,633,946 males and 1,599,420 females, and a total land area of 19,819,277 square kilometres (13). study population the study population consisted of caregivers of under-five children in edo state, nigeria. inclusion criteria: caregivers of under-five children who were presently caring for an underfive child (the biological parents, or the primary caregivers). sampling method: a multi-staged sampling technique was used in selecting the respondents for this study:  stage one: three local government areas was selected by balloting from the three senatorial districts in edo state.  stage two: from the three selected local government areas, one ward in each was selected by simple random sampling using a table of random numbers from a list of all the wards in the selected local government areas.  stage three: from the wards selected, one community in each was selected by simple random sampling using a table of random numbers from a list of all the communities in the selected wards.  stage four: in the three selected communities, a systematic sampling method was then used to select the houses corresponding to the total number of respondents allocated to the respective communities. the sampling interval was determined by dividing the total number of houses in the community with the sample size allocated to the community. the starting point was chosen by simple random sampling of the houses within the sampling interval starting for the house of the community head. the study unit was households with the informant being the primary caregiver. where there was more than one household in a house, a single household was selected by simple random sampling. where a caregiver was responsible for more than one under-five child, the youngest was selected as the index child for the study. sample size calculation: the sample size for this survey was calculated using the cochran’s formula (14) for sample size determination in a cross-sectional study (n=z 2 pq/d 2 ). using a prevalence of 68% (0.68) being the percentage of caregivers with poor knowledge of schedules of childhood immunization and diseases preventable by vaccines given to children in kano state, nigeria (15), and accounting for a 10% non response, the calculated sample size for this study was 370. the sample size was proportionately allocated to the three selected local government areas according to their respective sizes. data collection aigbokhaode aq, isah ec, isara ar. health seeking behaviour among caregivers of under five children in edo state, nigeria (original research). seejph 2015, posted: 18 february 2015. doi 10.12908/seejph-2014-41 5 a structured interviewer-administered questionnaire adapted from unicef/imci household baseline survey questionnaire (16) and the imci pictorial counselling and community practices for maternal, newborn and child health booklet (17) were used for data collection. the questionnaire covered caregivers’ general knowledge and practice of health seeking including recognition of a sick child, symptoms of illness in a child, recognition of when a child needs treatment outside the home and the primary care services for a sick child. ethical considerations: ethical approval was obtained from the research ethics committee of the university teaching hospital of benin. permission was also sought from the administrators of the three selected local government areas and the traditional heads. confidentiality and privacy of the respondents was assured and respected during the interviews. a written informed consent was obtained from each respondent before conducting the questionnaire interviews. health education on the various components of the key household practices was carried out at the end of the study. data analysis the questionnaires were screened for completeness by the researcher, coded and entered into the statistical package for social sciences, version 16.0 (spss inc. chicago, illinois, usa). categorical data such as occupational and educational statuses were presented as percentages. results a total of 370 respondents participated in the study. all the eligible respondents selected consented to the interview giving a response rate of 100%. majority of the respondents (230, or 62%) were in the age-group of 25-34 years. mean age of the respondents was 31.1±5.9 years. almost all the respondents were females 368 (99.5%). greater than four-fifths of the respondents (325, or 88%) were married, 38 (10%) were cohabiting, while 2 (0.5%) were single. majority 338 (91%) of the respondents were christians and 32 (9%) were muslims. a greater proportion 234 (63%) had secondary education, 76 (21%) had primary education, 55 (15%) had tertiary education, while 5 (1%) had no education (data not shown in the tables). over three quarters (283, or 77%) of the respondents were in the unskilled social class, 79 (21%) were in the middle level social class and 8 (2%) were in the professional social class. respondents of esan, afemai and benin ethnicity made up 109 (29%), 92 (25%) and 76 (21%), respectively. more than a third 137 (37%) of children were in the age-group 12-23 months, followed by 88 (24%) in the 0-11 age-group. mean age of the children was 21.8±1.5 months. more than half (209, or 57%) of the children were boys and 161 (43%) were girls. over 70%, 76%, 72%, 76% and 82% of respondents did not know that being unable to eat/drink, fast breathing, blood in stool and convulsion, respectively, were symptoms of a child not feeling well (table 1). table 1. respondents’ correct knowledge of symptoms of illness in children symptoms number (n= 370) percent not playing normally 269 72.7 fever for more than 24 hours 170 45.9 vomiting 147 39.7 fast breathing 103 27.8 blood in stool 90 24.3 unable to eat or drink 89 24.1 convulsion 68 18.4 drinks poorly 63 17.0 aigbokhaode aq, isah ec, isara ar. health seeking behaviour among caregivers of under five children in edo state, nigeria (original research). seejph 2015, posted: 18 february 2015. doi 10.12908/seejph-2014-41 6 over three quarters of the respondents (279, or 75%) were aware of the importance of consultation of medical personnel for advice for a sick child. health personnel known to respondents that can be consulted were patent medicine dealer (115, or 41%), nurses (71, or 26%), and doctors (22, or 8%). a little below one third of the respondents (109, or 29%) knew the recommended distance to the nearest health facilities of less than 5 km (table 2). table 2. knowledge of primary care services among respondents variables number percent aware of the importance of consulting the health personnel (n=370): yes no 279 91 75.4 24.6 categories of health personnel that can be consulted (n=279): patent medicine dealer nurses community health workers doctors traditional birth attendants 115 71 60 22 11 41.2 25.5 21.5 7.9 3.9 knowledge of the recommended distance to the nearest health facility (n=370): <5 km 5-10 km >10 km do not know 109 28 5 228 29.4 7.6 1.4 61.6 almost all of the respondents (354, or 96%) had heard of antenatal care. respondents’ major sources of information about antenatal care were from hospital/health workers (304, or 86%), television (31, or 9%), and from relatives (10, or 3%). the majority of the respondents (335, or 95%) knew the meaning of antenatal care and 19 (5%) reported that it was the use of concoctions and herbs during pregnancy. over four-fifths (66%) of respondents who had heard of antenatal care were of the opinion that antenatal visits should take place as many times as possible, while only 28 (8%) of the respondents knew that antenatal care visits should be 3-4 times, and further 38 (11%) individuals did not know. the major symptoms that prompt immediate treatment among respondents were vomiting 279 (75%), frequent stooling 261 (71%), fever 252 (68%), while fast breathing came forth with a little above half (189 or, 51% of respondents). major reasons by respondents for not seeking treatment for children were child’s condition not being serious (184, or 50%) and cost of treatment (154, or 41%) (table 3). the place of primary care by more than a third of the respondents (142, or 38%) was at home, followed by the chemist shop (91, or 25%), whereas the use of health facility was reported by less than a quarter of the respondents (80, or 22%). sixty nine (86%) of the respondents did not carry out instructions of the health workers and the major reasons for caregivers not complying with instructions of health workers were the cost of treatment (53, or 77% of respondents) and the distance to the health facility (42, or 61% of participants) (table 4). aigbokhaode aq, isah ec, isara ar. health seeking behaviour among caregivers of under five children in edo state, nigeria (original research). seejph 2015, posted: 18 february 2015. doi 10.12908/seejph-2014-41 7 table 3. symptoms that prompt care seeking and reasons for not seeking immediate treatment among respondents variables number (n=370) percent symptoms of ill health in a child that will prompt immediate treatment * : drinks poorly fever vomiting frequent stooling fast breathing skin rashes playing poor oral hygiene scalp infection not eating well 74 252 279 261 101 11 5 9 7 4 20.0 68.1 75.4 70.5 27.3 3.0 1.4 2.4 1.9 1.1 reasons for not seeking immediate treatment * : condition not serious unavailability of nearby health provider cost long waiting time long distance dissatisfaction with medical care discouragement by family member competing domestic duties social traditions and values 184 74 154 18 16 6 5 5 2 49.7 20.0 41.4 4.9 4.3 1.6 1.4 1.4 0.5 * multiple responses. table 4. health seeking practices among respondents variables number percent respondents place of first treatment when child is ill (n=370): home chemist shop health facility health care provider church traditional birth attendant (tba) 142 91 80 53 3 1 38.4 24.6 21.6 14.3 0.8 0.3 compliance to health workers instructions (n=80): yes no 11 69 13.8 86.2 reasons for non compliance of health workers instructions * (n=69): cost distance fear of bigger hospitals not sure of the health workers 53 42 26 7 76.8 60.8 37.7 10.1 * multiple responses. aigbokhaode aq, isah ec, isara ar. health seeking behaviour among caregivers of under five children in edo state, nigeria (original research). seejph 2015, posted: 18 february 2015. doi 10.12908/seejph-2014-41 8 discussion in this study, there was poor knowledge of caregivers concerning recognition of children who were ill and when to seek medical care. health personnel most known to caregivers that could be consulted were patent medicine dealers, whereas the major reasons by caregivers for not seeking treatment for ill children were child’s condition not being serious, cost of treatment and long waiting time. in our study, over two third of the respondents were in their mid twenties to early thirties, this is within the reproductive age group for women. the act of care giving for children is mainly the responsibility of females in nigeria and other sub-saharan african countries. hence, it was not surprising that almost all the under-five caregivers in this study were females. a greater proportion of the caregivers had a secondary level of education, which is consistent with findings from the 2013 ndhs where a greater proportion of the respondents from edo state had secondary education (2). this information will be helpful when it comes to health education of caregivers in order to improve their health care seeking knowledge and practice. the finding of poor knowledge of caregivers concerning recognition of children who were ill was surprising. they could recognise vomiting and fever but could hardly recognise fast breathing and drinking poorly as symptoms for which to seek immediate medical care for their children. this is probably due to the fact that caregivers’ knowledge of symptoms of danger sign for the different diseases differed, but it is expected that fast breathing in a child should be of great concern to a mother. another possible reason could be that health care workers pay more attention to diseases like malaria and diarrhoea at the clinics during routine antenatal attendance since the major source of information for the caregivers was from the health care workers and the health centres. therefore, healthcare professional need to pay more attention to other life threatening childhood conditions such as febrile convulsion and pneumonias in the health facilities during health education. this finding of poor knowledge on recognition of disease symptoms by the respondents was similar to findings from studies carried out in mexico (9) and in nigeria (18-20), and also consistent with findings from the multiple indicator cluster survey (mics) (21), in which only 10% of women knew of the two danger signs of pneumonia (fast and difficult breathing) that could prompt them seeking immediate care for their children. appropriate knowledge and recognition of danger signs and symptoms in ill children by caregivers is necessary in seeking immediate and an appropriate management of disease conditions, thereby reducing complications and deaths in these children. in our study, the health seeking practices of the caregivers with regards to using identified symptoms was also poor. the most commonly identified symptoms for taking a child to a health facility/health care provider were vomiting, fever and frequent stooling, whereas drinking poorly and fast breathing were less common. this finding is in agreement with the health seeking practice found in the mics in which fever was the most commonly identified symptom for taking children to health facility by their caregivers and only 19% and 23% of mothers identified fast breathing and difficult breathing respectively as symptoms for taking children immediately to a health care provider (21). this could be a result of poor knowledge of the caregivers with regards to recognizing the dangers signs of ill health in these children and also taking for granted that these symptoms were not serious enough to warrant immediate treatment or intervention. this may also explain the reason why the first place of treatment by a greater proportion of the caregivers was at home and patent medicine stores rather than the hospitals/health facilities. mothers’ knowledge of the danger signs is an important determinant of care seeking behaviour and the secondary level of education of most of the caregivers in the study can be exploited to improve their health seeking practices. aigbokhaode aq, isah ec, isara ar. health seeking behaviour among caregivers of under five children in edo state, nigeria (original research). seejph 2015, posted: 18 february 2015. doi 10.12908/seejph-2014-41 9 although majority of the respondents were aware of the importance of consulting medical personnel when their children were ill, only 14.3% of them consulted a health care provider for an ill child. the poor knowledge danger signs in a child that should necessitate health care seeking demonstrated by caregivers in this study may have contributed to this practice. this poor health seeking practice could also be due in part to the poor economic situation in nigeria and by extension edo state and the long waiting time in health facilities. the main reason for not seeking immediate treatment by a greater proportion of respondents in this study was that the condition was not serious, followed by cost of treatment and unavailability of nearby health provider. this was compounded by the fact that most of the respondents who visited the health facilities do not carry out the instructions of the healthcare providers. this poor health seeking behaviour by the respondents will result in delays in obtaining proper treatment for the children and an increase in cases of complications from different disease conditions that are preventable. this ultimately will result in morbidities and mortality in the children, thereby hindering the attainment of mdg 4. this poor health seeking behaviour is consistent with findings from a study in anyigba, north-central, nigeria where the major reason for the delay in seeking treatment by more than half of respondents was the thought that they would get over the ailment without treatment, about a quarter of respondents delayed because of lack of money for treatment, while about one fifth of the respondents delayed seeking treatment due to the far distance to the health facility (18). it, however, contrasted the findings from a study in igbeagu community in south-east nigeria where the health centre was the most preferred choice for treatment (19). good health seeking behaviour will reduce complications, morbidities and mortality in the households and promote family health especially maternal and child health. in conclusion, this study showed poor health seeking practices among caregivers of underfive children in edo state, nigeria. the major factors associated with this poor health seeking 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properly cited. http://www.ncbi.nlm.nih.gov/pubmed?term=p%c3%a9rez-cuevas%20r%5bauthor%5d&cauthor=true&cauthor_uid=9203789 http://www.ncbi.nlm.nih.gov/pubmed?term=guiscafr%c3%a9%20h%5bauthor%5d&cauthor=true&cauthor_uid=9203789 http://www.ncbi.nlm.nih.gov/pubmed?term=romero%20g%5bauthor%5d&cauthor=true&cauthor_uid=9203789 http://www.ncbi.nlm.nih.gov/pubmed?term=rodr%c3%adguez%20l%5bauthor%5d&cauthor=true&cauthor_uid=9203789 http://www.ncbi.nlm.nih.gov/pubmed?term=guti%c3%a9rrez%20g%5bauthor%5d&cauthor=true&cauthor_uid=9203789 http://www.population.gov.ng/factssand%20figures%202006 http://scialert.net/asci/author.php?author=tanimola&last= http://scialert.net/asci/author.php?author=tanimola&last= http://scialert.net/asci/author.php?author=tanimola&last= http://scialert.net/asci/author.php?author=tanimola&last= http://scialert.net/asci/author.php?author=julius%20o.%20owoyemi&last= qirjako g, qosja a, draçini x, çomo n, hyska j, fico a, bukli m, burazeri g. infection prevention and control in healthcare facilities in albania (original research). seejph 2021; posted: 20 august 2021. doi: 10.11576/seejph-4702 p a g e 1 | 13 original research infection prevention and control in healthcare facilities in albania gentiana qirjako1,2, alketa qosja1, xheladin draçini1, najada çomo1, jolanda hyska1,2, albana fico1,2, mariana bukli3, genc burazeri1,4 1 faculty of medicine, university of medicine, tirana, albania; 2 institute of public health, tirana, albania; 3 united nations children’s fund, tirana, albania; 4 department of international health, school caphri (care and public health research institute), maastricht university, maastricht, the netherlands. corresponding author: gentiana qirjako, md, phd; address: faculty of medicine, rr. dibres, no. 371, tirana, albania; telephone: +355674027657; e-mail: gentaqirjako@gmail.com qirjako g, qosja a, draçini x, çomo n, hyska j, fico a, bukli m, burazeri g. infection prevention and control in healthcare facilities in albania (original research). seejph 2021; posted: 20 august 2021. doi: 10.11576/seejph-4702 p a g e 2 | 13 abstract aim: the objective of this study was to assess the current status regarding infection prevention and control (ipc) in selected healthcare facilities in albania in light of the ongoing covid-19 pandemic which continues unabated. methods: a cross-sectional study was conducted in april 2021 including a nationwide representative sample of 505 health professionals working mostly in primary health care centres in albania (84 men and 421 women; response rate: 95%). a structured questionnaire developed by the world health organization was administered online to all participants inquiring about a wide range of measures and practices employed at health facility level for an effective ipc approach. fisher’s exact test was used to assess potential urban-rural differences in the distribution of characteristics regarding ipc aspects reported by survey participants. results: about 47% of health facilities did not have a designated focal point for ipc issues; the lack of one patient per bed standard was evident in more than one-third of health facilities (37%); and the lack of an adequate distance between patient beds was reported in a quarter of health facilities (which was twice as high among health facilities in urban areas compared to rural areas). furthermore, water services were always available only in about two-thirds of health facilities (63%), whereas an adequate number of toilets (at least two) was evident in slightly more than half of the health facilities surveyed (53%). also, one out of four of the health facilities did not have functional hand hygiene stations and/or sufficient energy/power supply. a completely adequate ventilation was evidenced in slightly more than half of the health facilities (51%). four out of five health facilities had always available materials for cleaning and about half (49%) had always available personal protective equipment. functional waste collection containers were available in nine out of ten health facilities, of which, four out of five were correctly labelled. conclusion: this study informs about the existing structures, capacities and available resources regarding ipc situation in different health facilities in albania. policymakers and decision-makers in albania and in other countries should prioritize investments regarding ipc aspects in order to meet the basic requirements and adequate standards in health facilities at all levels of care. keywords: albania, epidemiology, healthcare related infections, infection prevention and control. qirjako g, qosja a, draçini x, çomo n, hyska j, fico a, bukli m, burazeri g. infection prevention and control in healthcare facilities in albania (original research). seejph 2021; posted: 20 august 2021. doi: 10.11576/seejph-4702 p a g e 3 | 13 introduction in response to the covid-19 situation at a global level, the world health organization (who) developed a self-assessment monitoring tool about “infection prevention and control health-care facility response for covid-19” (1). the aim of this instrument is to assess infection prevention and control (ipc) capacities to respond to covid-19 and other infections in health facilities at all levels of care. this self-assessment tool was developed mainly for acute health-care facilities, but can also be adapted for use in long-term care facilities (1,2). the who instrument reflects and considers other useful tools developed by the centre for disease prevention and control (cdc) in usa (3) and the european centre for disease control and prevention (ecdc) (4). regardless of the level of care, the instrument developed by who supports health facilities to identify, prioritize and address the gaps in ipc capacities, structures and resources in order to respond adequately to covid-19 and other infectious diseases (1). following the who guidelines and recent developments, this instrument was recently translated and adapted into the albanian context. albania has experienced a considerable demographic change and epidemiologic transition in the past three decades (5,6), following the breakdown of the communist regime in 1990. according to the most recent estimates from the national institute of statistics, the proportion of the population aged ≥65 years was 15% in january 2021 (7), compared with only about 4% in early 1990s. this particularly rapid aging of the population is associated with a significant shift toward non-communicable diseases. according to the most recent estimated provided by the institute for health metrics and evaluation, the mortality rate from infectious diseases, maternal, neonatal and nutritional diseases in albania in 2019 was estimated at 27 per 100,000 population comprising only 3% of the overall mortality, whereas in 1990 it accounted for more than 20% of the all-cause mortality (8). however, there is no specific information about the healthcare-related mortality or burden of infectious diseases in albania. in april 2021, following the translation and adoption into the albanian context of the who self-assessment instrument regarding ipc aspects at health facility level (9), many health professionals (both physicians and nurses) were trained about an array of issues and dimensions pertinent to effective and adequate implementation of safety measures related to ipc. the training was carried out online with technical support from the university of medicine in tirana and technical and financial support from unicef, office in albania. in this framework, the aim of this study was to assess the current status regarding ipc aspects in selected healthcare facilities in albania in light of the ongoing covid-19 pandemic. we hypothesized that many health facilities in albania would meet the basic ipc standards, based on the grey literature and reports mainly available from the albanian ministry of health and social protection website (https://shendetesia.gov.al/). methods a cross-sectional study was conducted in albania in april 2021 including a nationwide representative sample of health professionals in albania who were trained online during the period march-april 2021 about different aspects regarding healthcare-related ipc. study population in the framework of the partnership of the university of medicine with unicef office in albania, thorough march-april 2021, there were trained online 1593 health professionals from all districts of albania (585 physicians and 1008 nurses) operating qirjako g, qosja a, draçini x, çomo n, hyska j, fico a, bukli m, burazeri g. infection prevention and control in healthcare facilities in albania (original research). seejph 2021; posted: 20 august 2021. doi: 10.11576/seejph-4702 p a g e 4 | 13 mainly in primary health care centres (n=1411, of whom 550 physicians and 861 nurses), or in maternity services (n=182, of whom 35 physicians and 147 nurses). the survey conducted in april 2021 included a representative sample of 505 health professionals (84 men and 421 women) working in primary health care centres (n=453, or 32% of the overall trained personnel), or maternity services (n=52, or 29% of the overall trained personnel) in different districts of albania. the survey form was sent to one-third of training participants (n=531). of these, only 505 survey forms were returned back and provided valid information. therefore, the response rate was: 505/531=95%. data collection an adopted version of the infection prevention and control assessment framework (ipcaf) developed by the who (9) was employed. the data collection consisted of a structured questionnaire administered online (through the platform jotform: https://www.jotform.com/) inquiring about the environment, materials and equipment available at the health facility level for healthcare-related ipc. more specifically, the online questionnaire included the following dimensions: ipc focal points at health facility level; presence of microbiological laboratory at health facility; ipc training; ipc funding; water availability; hand hygiene and sanitation facilities; power supply, ventilation and cleaning; patient placement and personal protective equipment; medical waste management and sewage; and decontamination and sterilization (9). a full version of the questionnaire administered to all study participants is presented in annex 1. the survey was approved by the scientific committee of the national institute of public health, tirana, albania. statistical analysis measures of central tendency and dispersion were calculated and reported for the numerical variables (age, and work experience of study participants). on the other hand, frequency distributions (absolute numbers and respective proportions) were reported for categorical variables (gender, workplace, type of health facility, job profile, and work position of study participants). fisher’s exact test was used to assess potential urban-rural differences in the distribution of a wide range of characteristics regarding ipc aspects reported by survey participants (focal points, microbiological laboratory, ipc training, ipc funding, water, hand hygiene and sanitation facilities, power supply, ventilation, cleaning, patient placement, personal protective equipment, medical waste management, as well as decontamination and sterilization). statistical package for social sciences (spss, version 22) was used for all the statistical analyses. results table 1 presents the distribution of sociodemographic characteristics among study participants. overall, 421 (about 83%) of survey participants were women and 84 (17%) were men. mean age in the whole sample was 40±11 years. about 70% worked in urban health care facilities. almost 90% of interviewees worked in primary health care centres and the remaining 10% in maternities (paediatric services). two-thirds were nurses, whereas one-third were physicians. on average, participants had a working experience of about 15 years. almost one in four participants was the manager/director of the health facility (table 1). https://www.jotform.com/ qirjako g, qosja a, draçini x, çomo n, hyska j, fico a, bukli m, burazeri g. infection prevention and control in healthcare facilities in albania (original research). seejph 2021; posted: 20 august 2021. doi: 10.11576/seejph-4702 p a g e 5 | 13 table 1. distribution of socio-demographic characteristics in a nationwide sample of health professionals in selected healthcare facilities in albania (n=505) characteristic number percentage gender: men women 84 421 16.6 83.4 workplace (residence): urban areas rural areas 352 153 69.7 30.3 type of health facility: primary health care centre maternity 453 52 89.7 10.3 job profile: physician nurse 168 337 33.3 66.7 manager/director of facility: no yes 385 120 76.2 23.8 characteristic mean (sd) median (iqr) age (years) 40.0±10.6 38.0 (31.0-49.0) work experience (years) 14.5±10.8 11.0 (5.0-25.0) table 2 presents the distribution of individual profile regarding ipc aspects, as well as health facility characteristics pertinent to selected ipc issues. overall, about half of the health facilities included in this survey (47%) did not have a designated focal point (either part-time, or full-time) regarding ipc aspects, and only a third of them (33%) reported to have a dedicated focal point about these issues. there were no rural-urban differences. surprisingly, one out of five interviewees did not know whether there was a focal point in their respective health facilities in charge of ipc issues. the source of funding for ipc aspects consisted mainly of health facility funds (62%), or a mix of funds that is health facility and donors’ funding (about 28%). less than a quarter of health facilities included in the survey had a functional microbiological laboratory, with a remarkable difference between urban areas and rural areas (around 30% vs. 5%, respectively; p<0.001). on the whole, 60% of participants had received several training courses on ipc aspects, and further 31% were just trained. there were no urban-rural differences in the trainings received (table 2). conversely, the proportion of cleaners pertinent to the respective health facilities was significantly higher in health facilities pertinent to urban areas compared to rural areas (16% vs. 5%, respectively; p<0.001). of note, a significantly higher proportion of new staff working in rural health facilities were trained about ipc aspects upon recruitment compared with their urban counterparts (49% vs. 35%, respectively; p<0.001). almost two-thirds of the interviewees considered sufficient the number of staff working at their respective health facilities, with a borderline statistically significant difference by place of residence (p=0.08). remarkably, more than one-third (37%) of the overall health facilities did not meet the standard of one patient per bed, with no evidence of significant urban-rural qirjako g, qosja a, draçini x, çomo n, hyska j, fico a, bukli m, burazeri g. infection prevention and control in healthcare facilities in albania (original research). seejph 2021; posted: 20 august 2021. doi: 10.11576/seejph-4702 p a g e 6 | 13 differences (table 2). on the other hand, an adequate distance of at least 1 meter between patient beds was respected significantly more among health facilities (with beds) in rural areas than those in urban areas (70% vs. 56%, respectively; p=0.01). table 2. distribution of individual profile and health facility characteristics regarding infection prevention and control (ipc) according to survey participants’ perspective characteristic total urban rural p† focal point for infection prevention and control (ipc): yes no don’t know total 166 (32.9)* 237 (46.9) 102 (20.2) 505 (100.0) 120 (34.1) 160 (45.5) 72 (20.5) 352 (100.0) 46 (30.1) 77 (50.3) 30 (19.6) 153 (100.0) 0.576 source of funding for ipc: health facility funds donors both don’t know 313 (62.0) 11 (2.2) 143 (28.3) 38 (7.5) 215 (61.1) 7 (2.0) 97 (27.6) 33 (9.4) 98 (64.1) 4 (2.6) 46 (30.1) 5 (3.3) 0.118 microbiological laboratory: yes no 113 (22.4) 392 (77.6) 105 (29.8) 247 (70.2) 8 (5.2) 145 (94.8) <0.001 personal training regarding ipc: several courses once upon recruitment once long after recruitment just trained 286 (60.1) 16 (3.4) 28 (5.9) 146 (30.7) 202 (61.4) 12 (3.6) 20 (6.1) 95 (28.9) 84 (57.1) 4 (2.7) 8 (5.4) 51 (34.7) 0.624 ipc training received by the cleaners at the health facility: yes no no cleaners at health facility don’t know 65 (12.9) 97 (19.3) 183 (36.4) 158 (31.4) 57 (16.2) 84 (23.9) 74 (21.1) 136 (38.7) 8 (5.3) 13 (8.6) 109 (71.7) 22 (14.5) <0.001 training of new staff about ipc: yes, all new staff yes, but only some of the new staff no don’t know 198 (39.4) 57 (11.4) 140 (27.9) 107 (21.3) 124 (35.4) 50 (14.3) 89 (25.4) 87 (24.9) 74 (48.7) 7 (4.6) 51 (33.6) 20 (13.2) <0.001 is the number of staff sufficient at your health facility? yes no don’t know 328 (65.7) 118 (23.6) 53 (10.6) 225 (64.7) 79 (22.7) 44 (12.6) 103 (68.2) 39 (25.8) 9 (6.0) 0.079 one patient per bed at facility: yes, always yes, but not always 188 (38.4) 121 (24.7) 131 (38.5) 78 (22.9) 57 (38.3) 43 (28.9) 0.307 qirjako g, qosja a, draçini x, çomo n, hyska j, fico a, bukli m, burazeri g. infection prevention and control in healthcare facilities in albania (original research). seejph 2021; posted: 20 august 2021. doi: 10.11576/seejph-4702 p a g e 7 | 13 no 180 (36.8) 131 (38.5) 49 (32.9) >1 meter between patient beds: yes, always yes, but not always no 284 (60.2) 73 (15.5) 115 (24.4) 183 (56.0) 51 (15.6) 93 (28.4) 101 (69.7) 22 (15.2) 22 (15.2) 0.006 water services at health facility: yes, always yes, partially no 309 (62.7) 138 (28.0) 46 (9.3) 232 (67.6) 90 (26.2) 21 (6.1) 77 (51.3) 48 (32.0) 25 (16.7) <0.001 number of toilets at facility: none 1 2 ≥3 7 (1.4) 225 (45.3) 152 (30.6) 113 (22.7) 4 (1.2) 137 (39.5) 104 (30.0) 102 (29.4) 3 (2.0) 88 (58.7) 48 (32.0) 11 (7.3) <0.001 functioning hand hygiene stations at health facility: yes, fully equipped yes, but partially equipped no 175 (35.6) 193 (39.2) 124 (25.2) 113 (32.9) 136 (39.7) 94 (27.4) 62 (41.6) 57 (38.3) 30 (20.1) 0.109 sufficient energy/power supply at health facility: yes, adequate voltage yes, but low voltage no 371 (75.3) 104 (21.1) 18 (3.7) 256 (74.4) 76 (22.1) 12 (3.5) 115 (77.2) 28 (18.8) 6 (4.0) 0.696 ventilation at health facility: yes, completely adequate yes, but only partially adequate no 251 (51.2) 170 (34.7) 69 (14.1) 170 (50.1) 122 (36.0) 47 (13.9) 81 (53.6) 48 (31.8) 22 (14.6) 0.665 materials for cleaning: always available partially available no 399 (80.4) 84 (16.9) 13 (2.6) 284 (81.6) 56 (16.1) 8 (2.3) 115 (77.7) 28 (18.9) 5 (3.4) 0.563 personal protective equipment: always available partially available no 241 (48.7) 213 (43.0) 41 (8.3) 176 (50.6) 144 (41.4) 28 (8.0) 65 (44.2) 69 (46.9) 13 (8.8) 0.432 sterile equipment at facility: always partially no don’t know 199 (40.4) 179 (36.3) 90 (18.3) 25 (5.1) 138 (40.1) 111 (32.3) 73 (21.2) 22 (6.4) 61 (40.9) 68 (45.6) 17 (11.4) 3 (2.0) 0.002 functional waste collection containers at health facility: yes no 452 (91.7) 33 (6.7) 318 (92.7) 19 (5.5) 134 (89.3) 14 (9.3) 0.289 qirjako g, qosja a, draçini x, çomo n, hyska j, fico a, bukli m, burazeri g. infection prevention and control in healthcare facilities in albania (original research). seejph 2021; posted: 20 august 2021. doi: 10.11576/seejph-4702 p a g e 8 | 13 don’t know 8 (1.6) 6 (1.7) 2 (1.3) waste collection containers labelled: yes no don’t know 396 (80.5) 80 (16.3) 16 (3.3) 279 (81.3) 53 (15.5) 11 (3.2) 117 (78.5) 27 (18.1) 5 (3.4) 0.754 * number and column percentages (in parentheses). discrepancies in the totals are due to missing covariate values. † p-values from fisher’s exact test. as expected, water services (for personal hygiene, medical activities, decontamination, cleaning and laundry) were more prevalent in urban health facilities than in rural ones (68% vs. 51%, respectively; p<0.01). similarly, the number of toilets was significantly higher in health facilities in urban areas compared with those in rural areas (p<0.001). fully equipped functioning hand hygiene stations were more prevent in rural areas than in urban areas (42% vs. 33%, respectively), but this difference was not statistically significant (p>0.1). on the whole, about three-quarters of health facilities had sufficient energy/power supply with adequate voltage, a finding which was similar in both urban and rural areas. slightly more than half of health facilities (51%) had completely adequate ventilation, with no significant urban-rural differences. in addition, about 80% of health facilities had always available materials for cleaning. personal protective equipment was always available in slightly less than half of health facilities (49%). also, about 40% of health facilities had always sterile equipment available. furthermore, about 92% of health facilities had functional waste collection containers and four out of five of such containers were properly labelled (table 2). discussion this study included a nationwide representative sample of health professionals informing about the current status, the existing structures, capacities and available resources regarding ipc situation in different health facilities across albania. main findings of this survey include the absence of a designated focal point for ipc issues in almost half of health facilities included in the study (47%); the lack of one patient per bed standard in more than one-third of health facilities (37%); and the lack of an adequate distance between patient beds in a quarter of health facilities (which was twice as high among health facilities in urban areas compared to rural areas). furthermore, water services were always available only in about two-thirds of health facilities included in the survey (63%), whereas an adequate number of toilets (at least two) was evident in slightly more than half of the health facilities surveyed (53%). also, one out of four of the health facilities did not have functional hand hygiene stations and/or sufficient energy/power supply. a completely adequate ventilation was evidenced in slightly more than half of the health facilities (51%). four out of five health facilities had always available materials for cleaning and about half (49%) had always available personal protective equipment. functional waste collection containers were available in nine out of ten health facilities, of which, four out of five were correctly labelled. this survey conducted fairly recently in albania was based on the ipcaf instrument which is a structured, closed-ended questionnaire (9), particularly easy and user-friendly to administer. this instrument is mainly meant to be self-administered as a valuable selfassessment tool (9) for health facilities at different levels of care (primary health care, qirjako g, qosja a, draçini x, çomo n, hyska j, fico a, bukli m, burazeri g. infection prevention and control in healthcare facilities in albania (original research). seejph 2021; posted: 20 august 2021. doi: 10.11576/seejph-4702 p a g e 9 | 13 and hospital care). as such, the tool can be periodically used by the health personnel at facility level. at the same time though, this instrument may also be used for assessment of health facilities by different key stakeholders including central level institutions such the ministry of health and its affiliated agencies, who, or other relevant actors, also at local level. according to who guidelines, the ipcaf instrument is envisioned for acute health care facilities, but it can be also used in other inpatient health care settings (2,9), which was the case of the current study conducted in albania. the who has convincingly demonstrated that several indicators of the ipcaf tool are valid and useful at a global scale for assessment of ipc standards in any country (9). therefore, the present survey carried out in albania provides valuable evidence on the situation of primary health care centres and maternity services in different districts of albania with regard to ipc aspects, in the midst of covid-19 pandemic. the evidence provided by the current study regarding the ipc activities and resources at health facility level enable prompt identification of strengths and limitations which should inform policy and feed into the future planning of health facilities in all districts of albania. from this point of view, administration of the ipcaf instrument should be deemed as a pretty valid analytical tool for health facilities at all levels of care in order to identify important issues, drawbacks and bottlenecks which should be adequately addressed in order to prepare regional and facility based ipc action plans and meet the required ipc standards (revised and approved by order of the albanian ministry of health and social protection no. 156 on 10.03.2021) (2,9). findings from this study are also important in light of the ongoing reforms in the albanian health sector which, among other things, consist of a governance reform of primary and secondary health care institutions (10). hence, starting from 2018, a new central institution referred to as the “general operator of health care services” with four regional branches (“regional operators”) has already assumed most of the responsibilities from the albanian ministry of health and social protection regarding planning and management of public health services, primary health care services, as well as hospital services (10). study limitations generalization of the findings of the current survey may be limited to some extent due to sample representativeness, potential information biases, as well as its crosssectional design. this study included a fairly large sample of health professionals (both physicians and nurses) working in primary health care centres and maternity services in different districts of albania. as such the sample included in this survey is deemed nationwide representative. yet, extrapolation of the findings to all health professionals and/or the overall health facilities in albania should be done cautiously. the instrument of data collection consisted of a wellstandardized international questionnaire developed by who (9). however, the degree of validity depends on the self-perceptions, objectivity and accuracy of responses delivered by interviewees. also, findings from cross-sectional studies do not infer causality and, therefore, no firm conclusions should be drawn unless future prospective studies are conducted. conclusion this is one of the very first reports informing about the current status, the existing structures, capacities and available resources regarding ipc situation in a nationwide sample of health facilities in albania. the administration of self-assessment tools combined with direct monitoring and supervision at facility level may further qirjako g, qosja a, draçini x, çomo n, hyska j, fico a, bukli m, burazeri g. infection prevention and control in healthcare facilities in albania (original research). seejph 2021; posted: 20 august 2021. doi: 10.11576/seejph-4702 p a g e 10 | 13 contribute to the creation of an enabling environment for the implementation of national ipc standards. policymakers and decision-makers in albania and in other countries should prioritize investments regarding ipc aspects in order to meet the basic requirements and adequate standards in health facilities at all levels of care. conflicts of interest: none declared. acknowledgment: this study was supported by the united nations children’s fund (unicef), office in albania. references 1. world health organization. infection prevention and control health-care facility response for covid-19. interim guidance. october 20, 2020. https://www.who.int/publications/i/it 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http://www.instat.gov.al/al/temat/treguesit-demografik%c3%ab-dhe-social%c3%ab/popullsia/#tab2 http://www.instat.gov.al/al/temat/treguesit-demografik%c3%ab-dhe-social%c3%ab/popullsia/#tab2 http://ghdx.healthdata.org/gbd-results-tool http://ghdx.healthdata.org/gbd-results-tool https://www.who.int/infection-prevention/tools/core-components/ipcaf-facility.pdf https://www.who.int/infection-prevention/tools/core-components/ipcaf-facility.pdf https://www.who.int/infection-prevention/tools/core-components/ipcaf-facility.pdf qirjako g, qosja a, draçini x, çomo n, hyska j, fico a, bukli m, burazeri g. infection prevention and control in healthcare facilities in albania (original research). seejph 2021; posted: 20 august 2021. doi: 10.11576/seejph-4702 p a g e 11 | 13 10. roshi d, burazeri g, schröder-bäck p, toçi e, italia s, ylli a, brand h. understanding of medication information in primary health care: a cross-sectional study in a south eastern european population. front public health; 2020;8:388. doi: 10.3389/fpubh.2020.00388. https://pubmed.ncbi.nlm.nih.gov/32903804/ https://pubmed.ncbi.nlm.nih.gov/32903804/ https://pubmed.ncbi.nlm.nih.gov/32903804/ https://pubmed.ncbi.nlm.nih.gov/32903804/ qirjako g, qosja a, draçini x, çomo n, hyska j, fico a, bukli m, burazeri g. infection prevention and control in healthcare facilities in albania (original research). seejph 2021; posted: 20 august 2021. doi: 10.11576/seejph-4702 p a g e 12 | 13 annex 1. questionnaire administered to study participants • socio-demographic characteristics: gender; age. • position and job profile: position (physician vs. nurse); years of working experience; head of unit/facility (yes vs. no). • characteristics of health facility: district and municipality; area (urban vs. rural areas); type (primary health care centre vs. hospital). • is there a focal point in your institution in charge (fulltime or part-time) of implementation and monitoring of infection control and prevention programs/measures? (possible answers: yes, no, don’t know). • have you been trained for infection control and prevention? (possible answers: yes, several times, yes, upon recruitment, yeas, once but a long after being recruited, yes, just trained). • have the cleaners in your health facility been trained about infection control and prevention? (possible answers: yes, no, there are cleaners in our health facility, don’t know). • are the newly appointed staff trained regarding the infection control and prevention? (possible answers: yes, all new staff, yes, some of them, no). • how have the safety measures applied in your facility been purchased? (possible answers: health facility funds, different donors, both). • is there a laboratory in your health facility which is routinely used for microbiological testing? (yes vs. no). • does your health facility have informational materials regarding the following topics (circle all that apply): hand hygiene, disinfection and sterilization, antibiotic-resistance, personal safety measures (masks, gloves, etc.), safe injections, waste management. • which of the following procedures is monitored in your health facility: (circle all that apply): hand hygiene, wound changes, cleaning, disinfection and sterilization of instruments, use of soap and alcohol-based solutions, waste management. • do you consider sufficient the number of personnel in your health facility? (possible answers: yes, no, don’t know). • is the standard of one patient per bed fulfilled in your health facility? (possible answers: always, sometimes, no, don’t know). • is adequate spacing of >1 meter between patient beds ensured in your facility? (possible answers: always, sometimes, no, don’t know). • are water services available at all times and of sufficient quantity for all uses (e.g., hand washing, drinking, personal hygiene, medical activities, sterilization, decontamination, cleaning and laundry? (possible answers: always, partially, no). • how many toilets are available at your health facility? • are functioning hand hygiene stations (that is, alcohol-based handrub solution or soap and water and clean single-use towels) available at all points of care? (possible answers: always, partially, not at all). qirjako g, qosja a, draçini x, çomo n, hyska j, fico a, bukli m, burazeri g. infection prevention and control in healthcare facilities in albania (original research). seejph 2021; posted: 20 august 2021. doi: 10.11576/seejph-4702 p a g e 13 | 13 • in your health care facility, is sufficient energy/power supply available for all uses? (possible answers: sufficient and with adequate voltage, sufficient but mostly with inadequate voltage, not at all). • in your health care facility, is adequate ventilation available? (possible answers: adequate ventilation, only partially adequate, not at all). • are appropriate and well-maintained materials for cleaning (for example, detergent, mops, buckets, etc.) available at your health facility? (possible answers: always, partially, not at all). • is ppe (personal protective equipment) available at all times and in sufficient quantity for all uses for all health care workers? (possible answers: always, partially, not at all). • do you reliably have sterile and disinfected equipment ready for use? (possible answers: always, partially, not at all). • do you have sufficient functional waste collection containers? (possible answers: yes, no, don’t know). • are the waste collection containers labelled according to their content, i.e. for noninfectious (general) waste, infectious waste and, sharps waste? (possible answers: yes, no, don’t know). ___________________________________________________________________________ © 2021 qirjako et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. laci i, spahiu a. concurrent validity of radiography and ultrasound examination for the diagnosis of aortic aneurisms in albanian patients (original research). seejph 2016, posted: 25 march 2016. doi 10.4119/unibi/seejph-2016-98 1 original research concurrent validity of radiography and ultrasound examination for the diagnosis of aortic aneurisms in albanian patients ilirian laci 1 , alketa spahiu 2 1 radiology and nuclear medicine service, university hospital center “mother teresa”, tirana, albania; 2 statistics service, university hospital center “mother teresa”, tirana, albania. corresponding author: dr. ilirian laci address: rr. “dibres”, no. 370, tirana, albania; telephone: +355672072668; e-mail: ilirianlaci@yahoo.com laci i, spahiu a. concurrent validity of radiography and ultrasound examination for the diagnosis of aortic aneurisms in albanian patients (original research). seejph 2016, posted: 25 march 2016. doi 10.4119/unibi/seejph-2016-98 2 abstract aim: the aim of our study was to assess the concurrent validity of radiography and ultrasound examination among patients diagnosed with aortic aneurisms in albania, a transitional country in south eastern europe. methods: this study included 75 consecutive patients diagnosed with aortic aneurisms (thoracic and/or abdominal) admitted at the university hospital centre “mother teresa” in tirana during 2012-2014 (56 men and 19 women). for each patient, computerized tomography (ct) scan with contrast was used to confirm the diagnosis of aortic aneurisms. in addition to the ct scan (“gold standard” for the diagnosis of aneurisms), in 37 patients, radiography and ultrasound examination were simultaneously performed in order to assess the validity of these techniques. furthermore, demographic data and other relevant clinical information were collected for each study participant. results: in 18 patients with thoracic aneurisms pertinent to ascendant aorta where radiography and ultrasound were simultaneously performed, ultrasound was able to diagnose 5 (27.8%) cases which were not detected through radiography (p=0.038). conversely, in 16 patients with abdominal aneurisms where radiography and ultrasound were simultaneously performed, ultrasound was able to diagnose 4 (25.0%) cases which were not detected through radiography (p=0.034). the remaining three patients diagnosed with thoracic-abdominal aneurisms were not detected either by ultrasound examination or radiography. conclusions: in this sample of albanian patients diagnosed with aortic aneurisms (n=75), overall, 9 (24.3%) subjects were detected through ultrasound examination but not radiography (p<0.001). findings from this study provide valuable clues about the concurrent validity and predictive value of these two key examinations for the diagnosis of aortic aneurisms. keywords: albania, aneurism, ct scan, predictive value, radiography, ultrasonography, ultrasound, validity. conflicts of interest: none. laci i, spahiu a. concurrent validity of radiography and ultrasound examination for the diagnosis of aortic aneurisms in albanian patients (original research). seejph 2016, posted: 25 march 2016. doi 10.4119/unibi/seejph-2016-98 3 introduction aortic aneurysms are defined as enlargements (dilations) of the aorta which is caused by a chronic weakness (thinness) of the arterial wall. under these conditions, there is a high risk for ruptures, as well as for other unfavourable cardiovascular events in subjects with aortic aneurisms (1-3). in the united kingdom, in patients with aortic aneurisms of a size about 40-55 mm, only 16% of deaths have been linked to surgical interventions or ruptures, whereas 50% of deaths have been linked to other cardiovascular events including myocardial infarction and stroke (4). aortic aneurisms affect about 8% of men aged 65 years and above, but the occurrence of this condition is increasing in women too (5,6). data available from the centre for disease control and prevention (cdc) in usa indicate that aortic aneurisms constitute the fifteenth leading cause of death in american men and women aged 60-84 years old (7). as aortic aneurisms remain one of the major causes of morbidity and mortality especially among older men, its prevalence is expected to increase gradually in parallel with population aging in most countries of the world. aortic aneurisms are usually asymptomatic and are often detected upon radiological examinations performed for other reasons. based on the radiological evidence, surgical or endovascular interventions are performed. especially under emergency conditions, radiography and ultrasound examinations are very important in order to identify aortic aneurisms and aortic dissections (8). in principle, however, the diagnosis of aortic aneurisms is made through the following techniques: ultrasound, ct scan without contrast and/or with intravenous contrast (cta), radiography, angiography (aortography) and magnetic resonance imaging (mri) (8). the risk for rupture of aneurisms is related to the level of dilation. several studies have convincingly argued that ultrasound may be a suitable method for the diagnosis of aortic aneurisms given the fact that it is a non-invasive technique, without radiation and relatively cheap (8). the sensitivity and specificity of ultrasound examination for detection of aortic aneurisms have been estimated at 87.4%-98.9% and 99.9%, respectively (9). nevertheless, the accuracy of ultrasound examination may be far lower in obese individuals and in those with intestinal meteorism (9). as a matter of fact, it is possible to assess only the ascendant thoracic aorta through trans-thoracic ultrasound examination, whereas assessment of the descendent thoracic aorta is possible only through trans-oesophageal ultrasound (10). in post-communist albania, there has been an increase in cardiovascular diseases in the past two decades (11). in particular, the death rate from ischemic heart disease in albania is the highest in south eastern europe (11), in line with the rapid changes in dietary patterns characterized by an increase in processed foods and an increase in the prevalence of smoking (12). in addition, albania is the only country in south eastern europe which has experienced an increase in the mortality rate from ischemic heart disease and cerebrovascular diseases in the past two decades (11,12). however, specific information about the frequency and distribution of aortic aneurisms in the albanian population is scant. in this framework, the aim of this study was to assess the concurrent validity of radiography and ultrasound examination among patients diagnosed with aortic aneurisms in albania, a transitional country in south eastern europe which, among other reforms, is also undergoing a deep reform in the health care sector. methods this study included 75 consecutive patients diagnosed with aortic aneurisms (thoracic and/or abdominal) admitted at the university hospital centre “mother teresa” in tirana (the only tertiary care facility in albania) for the period from january 2012 to december 2014 (56 men and 19 women). https://en.wikipedia.org/wiki/aorta laci i, spahiu a. concurrent validity of radiography and ultrasound examination for the diagnosis of aortic aneurisms in albanian patients (original research). seejph 2016, posted: 25 march 2016. doi 10.4119/unibi/seejph-2016-98 4 for each patient, computerized tomography (ct) scan with contrast was used to confirm the diagnosis of aortic aneurisms. in addition to the ct scan (which is considered as the “gold standard” for the diagnosis of aneurisms), radiography was performed in 56 (74.7%) patients, whereas ultrasound examination was conducted in 45 (60.0%) patients (table 1). table 1. examinations performed in a sample of albanian patients diagnosed with aortic aneurisms during 2012-2014 (n=75) radiography ultrasound ct scan with contrast number percent number percent number percent 56 74.7% 45 60.0% 75 100.0% on the other hand, in 37 patients, radiography and ultrasound examination were simultaneously performed in order to assess the validity of these techniques. in principle, radiography and ultrasound examination were performed in patients admitted at the emergency unit who were residents in tirana. ultrasound in emergency conditions consisted of trans-thoracic or trans-abdominal examination, but not trans-oesophageal examination, because such a procedure involves a careful preparation and is not recommended under emergency conditions. on the other hand, patients from other districts of albania for whom there was prior suspicion for aneurisms underwent directly ct scan examination. furthermore, other relevant clinical information and demographic data were collected for each study participant. mann-whitney u-test was used to compare mean age and mean duration of hospitalization between male and female participants. on the other hand, fisher’s exact test was used to compare the proportions of place of residence, smoking, hypertension and other chronic diseases between men and women. conversely, cramer’s v test (a measure of association between two nominal variables) was used to compare the concurrent validity of radiography and ultrasound examination. in all cases, a p-value of ≤0.05 was considered as statistically significant. statistical package for social sciences (spss, version 19.0) was used for the data analysis. results this study involved 75 patients with a confirmed diagnosis of aortic aneurism according to ct scan with contrast (“gold standard”). demographic characteristics and clinical data of the patients included in this study are presented in table 2. overall, 56 (74.7%) patients were men and 19 (25.3%) were women (male-to-female ratio about 3/1). mean age in women was higher than in men, a difference which nevertheless was not statistically significant (62.5±13.8 vs. 58.0±15.7 years, respectively, p=0.41). on the whole, 31 patients were residents in tirana compared with 44 patients who were residents in other districts of albania. mean duration of hospitalization was 7.4±8.9 days, with no statistically significant sex-difference (p=0.261), notwithstanding a longer duration in men (10.3±9.5) compared to women (6.4±8.6). the overall prevalence of smoking was 32/75=43%; it was considerably higher in men than in women (52% vs. 16%, respectively, p=0.007). the overall prevalence of hypertension was 55/75=73%, with no significant difference between men and women (p=0.249). overall, 60% (45 out 75) of the patients had other pre-existing chronic conditions, which were evenly distributed between men and women (table 2). https://en.wikipedia.org/wiki/association_%28statistics%29 https://en.wikipedia.org/wiki/nominal_data#nominal_scale laci i, spahiu a. concurrent validity of radiography and ultrasound examination for the diagnosis of aortic aneurisms in albanian patients (original research). seejph 2016, posted: 25 march 2016. doi 10.4119/unibi/seejph-2016-98 5 table 2. demographic data and clinical characteristics of the patients diagnosed with aortic aneurisms characteristic women (n=19) men (n=56) total (n=75) age (years) 58.0±15.7 * 62.5±13.8 59.1±15.3 place of residence: tirana other districts total 8 (25.8) † 11 (25.0) 19 (25.3) 23 (74.2) 33 (75.0) 56 (74.7) 31 (100.0) 44 (100.0) 75 (100.0) length of hospitalization (days) 6.4±8.6 10.3±9.5 7.4±8.9 smoking: yes no 3 (9.4) 16 (37.2) 29 (90.6) 27 (62.8) 32 (100.0) 43 (100.0) hypertension: yes no 16 (29.1) 3 (15.0) 39 (70.9) 17 (85.0) 55 (100.0) 20 (100.0) other chronic diseases: yes no 11 (24.4) 8 (26.7) 34 (75.6) 22 (73.3) 45 (100.0) 30 (100.0) * mean ± standard deviation. † number and row percentages (in parenthesis) radiography was able to detect 20 patients with a confirmed diagnosis of aortic aneurism. hence, 35.7% of suspected cases (20 out of 56 patients who underwent this procedure) were detected through radiography. it should be noted that radiography played a major role in thoracic aortic aneurisms, but less so for abdominal aortic aneurisms, except for old abdominal aneurisms with wall calcifications which enabled a prompt diagnosis upon radiography. conversely, trans-thoracic and trans-abdominal ultrasound examination was able to detect 36 patients with a confirmed diagnosis of aortic aneurism. thus, 80.0% of suspected cases (36 out of 45 patients who underwent this procedure) were detected through ultrasound examination (data not shown in the tables). it should be emphasized that complications such as ruptures, dissections, hematomas, or clots could not be detected either through radiography or by ultrasound examination. table 3 presents findings from radiography and ultrasound examination performed simultaneously in a sub-sample of 37 patients. in this sub-sample of patients diagnosed with aortic aneurisms (n=37), overall, 9 subjects (or, 24.3% of them) were detected through ultrasound examination but not radiography (cramer’s v=0.609, p<0.001). table 3. findings from radiography and ultrasound examination performed simultaneously in a sub-sample of 37 patients radiography ultrasound total yes no yes 14 (100.0%) 0 (0%) 14 (100.0%) no 9 (39.1%) 14 (60.9%) 23 (100.0%) total 23 (62.2%) 14 (37.8%) 37 (100.0%) laci i, spahiu a. concurrent validity of radiography and ultrasound examination for the diagnosis of aortic aneurisms in albanian patients (original research). seejph 2016, posted: 25 march 2016. doi 10.4119/unibi/seejph-2016-98 6 overall, 23 (or, 62.2%) of the cases in this sub-sample (n=37) were detected by one of the two examination methods (radiography or ultrasound). conversely, 14 (37.8%) of the cases in this-sample were not detected either by radiography or ultrasound examination (table 2). in 18 patients with thoracic aneurisms pertinent to ascendant aorta where radiography and ultrasound were simultaneously performed, ultrasound was able to diagnose 5 (27.8%) cases which were not detected through radiography (p=0.038) (not shown in the tables). conversely, in 16 patients with abdominal aneurisms where radiography and ultrasound were simultaneously performed, ultrasound was able to diagnose 4 (25.0%) cases which were not detected through radiography (p=0.034). the remaining three patients diagnosed with thoracic-abdominal aneurisms were not detected either by ultrasound examination or radiography. discussion this may be the first report from albania informing about clinical characteristics of a consecutive sample of patients diagnosed with aortic aneurisms according to ct scan with contrast examination which is regarded as the gold standard for the confirmation of the diagnosis of this condition. main findings of this study include a higher sensitivity of ultrasound examination compared to radiography. hence, of the 37 patients who underwent both of these procedures, 9 (24.3%) subjects were detected through ultrasound examination but not radiography (p<0.001). radiography in emergency conditions is feasible and is considered as a straightforward procedure (8). in our study, radiography was able to detect about 36% (20/56) of the cases with aortic aneurisms. in particular, radiography played a major role for detection of thoracic aortic aneurisms, whereas in cases of abdominal aortic aneurisms it was less effective (valid). similarly, trans-thoracic and trans-abdominal ultrasound examination is also feasible in emergency conditions (8,9). in our study, ultrasound examination was able to detect 80% (36/45) of the cases with aortic aneurisms. the remaining 9 (or, 20%) of the cases were not detected through ultrasound probably due to the inability of the examiners (lack of proper training) involved in this procedure. notwithstanding the higher detection rate of ultrasound examination compared to radiography, it was not possible in our study to assess the complications of aneurisms such as dissections, ruptures, fistulisation with other organs, involvement of blood vessels stemming from the respective aneurisms, or calcifications. on the other hand, in our study, hematomas were partly assessed through ultrasound examination. our findings related to radiography are generally in line with previous reports from the international literature (13). hence, according to a previous study, aortic aneurisms were confirmed in about 50% of the cases (13). in any case, it is argued that chest radiography has a limited value for the diagnosis of aortic aneurisms (8,13). radiography plays an important role only in cases of aortic aneurisms with wall calcifications. in all suspected cases of aortic aneurisms though, ct scan with intravenous contrast should be promptly conducted (8,13). this study may have several limitations. our study included all consecutive patients diagnosed with aortic aneurisms over a three-year period at the university hospital centre “mother teresa”, which is the only tertiary care facility in albania. based on this recruitment approach, our study population involved an all-inclusive sample for the three-year period under investigation. furthermore, the diagnosis of aortic aneurisms was based on the state-ofthe-art clinical protocols and up-to-date examination techniques employed in similar studies conducted in other countries. in any case, the self-reported information which was collected through semi-structured interviews may have been prone to different types of information laci i, spahiu a. concurrent validity of radiography and ultrasound examination for the diagnosis of aortic aneurisms in albanian patients (original research). seejph 2016, posted: 25 march 2016. doi 10.4119/unibi/seejph-2016-98 7 bias. this may have been the case of self-reported smoking, hypertension and other preexisting conditions. in conclusion, this study provides useful evidence about the detection rate of radiography and ultrasound examination among patients diagnosed with aortic aneurisms in albania, a transitional country in south eastern europe. findings from this study provide valuable clues about the concurrent validity and predictive value of these two key examinations for the diagnosis of aortic aneurisms. references 1. lederle fa, johnson gr, wilson se, chute ep, littooy fn, bandyk d, et al. prevalence and associations of abdominal aortic aneurysm detected through screening. aneurysm detection and management (adam) veterans affairs cooperative study group. ann int med 1997;126:441-9. 2. sakalihasan n, limet r, defawe od. abdominal aortic aneurysm. lancet 2005;365:1577-89. 3. thompson mm. 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2014. http://www.ishp.gov.al/wpcontent/uploads/2015/01/health-report-english-version.pdf (accessed: march 3, 2016). laci i, spahiu a. concurrent validity of radiography and ultrasound examination for the diagnosis of aortic aneurisms in albanian patients (original research). seejph 2016, posted: 25 march 2016. doi 10.4119/unibi/seejph-2016-98 8 13. von kodolitsch y, nienaber ca, dieckmann c, schwartz ag, hofmann t, brekenfeld c, nicolas v, berger j, meinertz t. chest radiography for the diagnosis of acute aortic syndrome. am j med 2004;116:73-7. ___________________________________________________________ © 2016 laci et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed/?term=von%20kodolitsch%20y%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=nienaber%20ca%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=dieckmann%20c%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=schwartz%20ag%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=hofmann%20t%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=hofmann%20t%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=hofmann%20t%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=brekenfeld%20c%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=nicolas%20v%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=berger%20j%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=meinertz%20t%5bauthor%5d&cauthor=true&cauthor_uid=14715319 http://www.ncbi.nlm.nih.gov/pubmed/?term=11.%09von+kodolitsch+y%2c+nienaber+ca%2c+dieckmann+c%2c+schwartz+ag%2c+hofmann+t%2c+brekenfeld+c%2c+nicolas+v%2c+berger+j%2c+meinertz+t mahato s, younjan s, mahato a. fetal outcome of adolescent pregnancy in a tertiary care center in western nepal: a case control study (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/ seejph-5327 p a g e 1 | 6 original research fetal outcome of adolescent pregnancy in a tertiary care center in western nepal: a case control study sweta mahato1, sanjeev younjan2, anamika mahato3 1 department of ob/gyn, dhulikhel hospital, kathmandu university hospital, nepal; 2 department of ob/gyn, devdaha medical college, kathmandu university hospital, nepal; 3 department of pediatrics, dhulikhel hospital, kathmandu university hospital, nepal. corresponding author: dr. sweta mahato; address: department of ob/gyn, kathmandu university school of medical sciences dhulikhel, nepal. e-mail: swetakusms@gmail.com mahato s, younjan s, mahato a. fetal outcome of adolescent pregnancy in a tertiary care center in western nepal: a case control study (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/ seejph-5327 p a g e 2 | 6 abstract background: the incidence of adolescent pregnancy is decreasing in developed countries, whereas developing countries like nepal still report a high incidence. aims: to compare the fetal outcomes of adolescent pregnancies with those of the optimal reproductive age group in a country that accounts for 95% of teenage pregnancies, in contrast to 11% worldwide. method: a hospital-based case-control study was conducted with 150 pregnant women with singleton gestation admitted to kathmandu university hospital. an adolescent pregnancy (<19 yrs.) was considered a case, and pregnant women of the optimal age group (20-35 yrs.) were considered the control. the data were collected from jan 5, 2018, to jan 5, 2019. the control group was selected by matching the parity of the cases in the study groups during the same study period. respondents were interviewed and examined with a pre-structured tool. odds ratio (or) and 95% confidence interval (ci) were calculated using conditional logistic regression (p<0.05 considered significant). results: the mean age of adolescent mothers was 17 years, the majority being primigravida. this study identified that fetal complications were higher in adolescent pregnancies (61% vs. 40%). the fetal complications like low birth weight (or 2.42, 95%ci :1.044-5.43, p=0.03), nicu admission (or 3.27, 95%ci:1.48-7.25, p=0.003), low apgar score (or 2.32, 95%ci:1.05-5.11, p=0.034) and neonatal death (or 3.72, 95%ci:1.15-12.01, p=0.04) were associated with the adolescent pregnancies respectively. conclusion: adolescent pregnancies are at increased risk of fetal complications compared to pregnancies in the optimal reproductive group. adolescent pregnancies were at increased risk of low birth weight, neonatal death, low apgar score, and higher admission in nicu. therefore, an adequate antenatal visiting program for early detection and timely management likely will reduce the fetal complications during adolescent pregnancy. keywords: adolescent pregnancy, complications, nepal. conflicts of interest: none declared. mahato s, younjan s, mahato a. fetal outcome of adolescent pregnancy in a tertiary care center in western nepal: a case control study (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/ seejph-5327 p a g e 3 | 6 introduction motherhood is a very precious moment in a woman’s life. maternal age remains an independent factor influencing obstetric outcomes. the biologically optimal childbearing age for a woman is between 20 and 35 years. women at the extremes of reproductive age groups, i.e., below 20 years and above 35 years, are considered a risk factor for adverse obstetric outcomes (1). adolescent pregnancy is defined as an adolescent girl becoming pregnant within the ages of 13-19 years (2). teenage pregnancy is a significant social and public health problem worldwide. in developing countries, early marriages, traditional gender roles, lack of education, and poverty are the major factors contributing to adolescent pregnancy. in contrast, teenage pregnancy is usually seen out of marriage in developed countries. young age at first intercourse, lack of use, or incorrect use of contraceptive methods are the factors resulting in a pregnancy in adolescence (3,4). worldwide, adolescent pregnancy rates range from 143 per thousand in some sub-saharan african countries to 2.9 per thousand in south korea (5). according to a report published by who in 2008, about 16 million adolescent girls aged 15-19 years give birth each year, representing 11% of all deliveries worldwide, and almost 95% of these births occur in developing countries. moreover, it is estimated that half of the adolescent births occur in just seven countries: bangladesh, brazil, the democratic republic of congo, ethiopia, nigeria, india, and the united states (6). within south asia, the recorded adolescent pregnancy is highest in bangladesh (35%) followed by nepal (21%) and india (21%) (7). however, with proper sexual education programs and increasing rates of contraception use, there is a decreasing trend towards adolescent pregnancy rates. according to demographic health surveys, adolescent pregnancy rates have fallen in 35 out of 40 countries since 2000. this range varies from an average decline of 16% in eastern and southern africa to 50% in north africa, west asia, and europe (8). methods this hospital-based, observational, case-control study was undertaken in kathmandu university hospital, nepal. the sample size considered for this study was 150, including the study and control groups. all pregnant women with a singleton pregnancy, below 20 years, and fulfilling inclusion and exclusion criteria were enrolled in this study from the admission room. they were considered as the study group. for each study group, there was a separate control group which was taken from the age group 20-34 years, meeting the inclusion and exclusion criteria. in each group, parity was matched. after enrolling a case in the study group, the subsequent first case with matched parity was taken for comparison. the time of admission of each case was recorded. however, if any patient in either group was discharged without being delivered, lost to follow up, or missing medical records, this woman and her control were excluded from the study. only the patients who freely consented to participate were enrolled and interviewed on admission. data collection: at admission, baseline information regarding age, address, ethnicity, religion, education level, gravidity, and detailed medical and surgical history, obstetric and menstrual history was recorded in a proforma after taking verbal and written consent. maternal age was ascertained by the patient’s account of her age at marriage and age at first childbirth. the last menstrual period (lmp) and regularity of the previous menstrual cycle were asked regarding menstrual history. gestational age was calculated from the lmp if the patient was sure of her date and her previous cycles were regular. suppose the patient does not remember her lmp, we used the earliest available ultrasound reports. all the patients were examined, and relevant investigations were sent. every case was followed thereafter. the delivery was attended, and for those cases whose delivery could not be attended, the details were obtained from the records. the neonates were assessed: the fetal outcome was recorded in terms of apgar scorei at 1 minute and 5 mahato s, younjan s, mahato a. fetal outcome of adolescent pregnancy in a tertiary care center in western nepal: a case control study (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/ seejph-5327 p a g e 4 | 6 minutes, birth weight, neonatal deaths, and admission in neonatal intensive care unit (nicu) stay and its indications. all the enrolled cases were followed up regularly throughout the hospital stay. these patients were discharged according to the hospital protocol. at discharge, every patient and their neonates were examined, counseled regarding family planning, breastfeeding, and immunization of the newborn. data entry and analysis: data were entered into a microsoft excel spreadsheet. data analysis was made using the statistical package for the social sciences (spss-21) and was depicted in tables. odds ratio and its 95% ci was calculated by using conditional logistic regression. a p-value of <0.05 was considered significant. during the study period, 150 cases were enrolled, 75 as case (<=19years) and 75 as controls. (20-34 years). parity was matched for each patient. results table 1 shows the age of adolescent mothers ranged from 15 to 19 years with a mean age of 17.29 ± 1.19. the women in the control group had a mean age of 26 ± 4.76 years. table 1. mean, maximum, minimum, and median age of case and control groups mean±sd max min median adolescent pregnant 17.29 ± 1.19 19 15 17 orag 26 ± 4.76 34 20 27 in this study, 25 teens (33%) were illiterate, 28 (37.3%) had completed the primary level of education, and 22 teens (29.3%) had completed the secondary level of education. in the control group, 40% had completed primary level of education, while 29.3% were illiterate. similarly, 50 teens were housewives (66.7%), while only 6 were students. in the control group, 54.7% were housewife while 5.3% was a student. thus, in both the case and control group majority was a housewife, and the minorities were students, and the results were not statistically significant. table 2. demographic and menstrual characteristics of the study population * p-value highly significant at the level < 0.001 characteristics adolescent pregnancy n (%) orag n (%) p-value* age < median (17) 18 (24%) ≥ median (17) 57 (76%) <0.001* < median (27) 36 (48%) ≥ median (27) 39 (52%) education level illiterate 25 (33%) 22 (29.3%) 0.915 primary level 28(37.3%) 30 (40%) secondary level 22 (29.3%) 23 (30.7%) occupation housewife 50 (66.7%) 41 (54.7%) 0.237 service 9 (12%) 11 (14.7%) student 6 (8%) 4 (5.3%) no job 10 (13.3%) 19 (.3%) menstrual cycle irregular 19 (25.3%) 18 (24%) 0.85 regular 56 (74.7%) 57 (76%) mahato s, younjan s, mahato a. fetal outcome of adolescent pregnancy in a tertiary care center in western nepal: a case control study (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/ seejph-5327 p a g e 5 | 6 this study identified that fetal complications were higher in adolescent pregnancy (61%vs 40%). the fetal complications like low birth weight (or 2.42, 95% ci:1.044-5.43, p=0.03), nicu admission (or 3.27, 95%ci:1.48-7.25, p=0.003), low apgar score (or 2.32, 95%ci:1.05-5.11, p=0.034) and neonatal death (or 3.72, 95%ci:1.15-12.01, p=0.04) were associated with the adolescent pregnancies respectively. table 3. fetal outcomes between teen pregnancy and orag pregnancy * p-value statistically was significant at the level < 0.05. nicu=neonatal icu discussion adolescent pregnancy is an important global health issue in developing and developed countries due to their physiological and anatomical immaturity and various socioeconomic barriers. although multiple studies have shown different results, most have demonstrated an increased frequency of adverse pregnancy complications in adolescent pregnancy, resulting in a less favorable maternal and fetal outcome. in this study, most of the adolescent mothers, i.e. 54% were primipara and 13% with previous one viable pregnancy; clearly, this is due to the young age of adolescent mothers. several studies have shown that birth asphyxia results in low apgar scores in the newborns of adolescent mothers. mukhobadhya et al. (9) and kumar et al. (10) reported a significantly higher rate of birth asphyxia in newborns of adolescent mothers. similarly, higher rates of low apgar score in infants of adolescent mothers as shown in retrospective studies indicated birth asphyxia as one of the complications associated with adolescent pregnancy (11,12). in this study, the overall incidence of low birth weight of adolescent mothers was 22% which was significantly higher than in the control group (11%) with a pvalue of 0.03. when further stratified into preterm and term, low birth weight (lbw) babies showed that most of the lbw was due to preterm births associated with adolescent pregnancy. this result is consistent with various other studies. two large population-based studies conducted in ireland and the united states revealed a strong association between young maternal age and the rate of lbw infants (13,14). similarly, studies performed by cy et al. in hongkong (11), aquino-cunha et al. in brazil (15), and chutadip tantayakom et al. in thailand (16) found that adolescent mothers were about 1.7-2.99 times at increased risk of delivering an lbw infant as compared to the reference population. chutatip tantayakom et al. (16) showed that the rate further increased in young adolescents by up to 3.98 times (16). this study showed that about 27% of the neonates of adolescent mothers were admitted to nicu, which was significantly higher than 11% in the control population (p-value=3.27). the higher incidence of nicu admission was attributed to a greater incidence of prematurity and corresponding low birth weight associated with a higher death rate (16 vs. 7%). conclusion adolescent girls have a higher rate of medical and obstetric complications during pregnancy and a higher rate of neonatal complications: low birth weight due to prematurity and admission in nicu. this study concludes that pregnancy at adolescent age is at high risk and needs adequate antenatal visits for timely detection of risk factors and management to optimize the pregnancy outcome in this group. complications adolescent pregnancy (n) orag (n) or p-value low birth weight 22 (29.30%) 11 (14.70%) 2.42 (1.07-5.43) 0.03* apgar at 5 min ≤6 23 (30.70%) 12 (16%) 2.32 (1.05-5.11) 0.034* nicu admission 27 (36%) 11 (14.70%) 3.27 (1.48-7.25) 0.003* neonatal death 16 (21.40%) 7 (9.30%) 3.72 (1.15-12.01) 0.041* mahato s, younjan s, mahato a. fetal outcome of adolescent pregnancy in a tertiary care center in western nepal: a case control study (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/ seejph-5327 p a g e 6 | 6 © 2022 mahato et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. references 1. cunningham fg, leveno kj, bloom sl, hauth jc, rouse dj, spong cy. parturition. williams obstetrics, 23rd edition. mcgraw-hill; 2010;180-1. 2. unicef. young people and family planning: teenage pregnancy. fact sheet: plan you family plan your future. unicef: malaysia; 2008. 3. unicef. a league table of adolescent births in rich nations. innocenti report card 2001;3. 4. moore ka, miller bc, sugland bw, morrison dr, glei da, blumenthal c. beginning too soon: adolescent sexual behavior, pregnancy and parenthood. a review of research and interventions. aspe; 1995. 5. treffers pe. adolescent pregnancy, a worldwide problem. ned tijdschr geneeskd 2003;147:2320-5. 6. world health organization. adolescent pregnancy. maternal, newborn, child and adolescent health: adolescent pregnancy fact sheet. who; 2014. available from: https://apps.who.int/iris/bitstream/handl e/10665/112320/who_rhr_14.08_en g.pdf (accessed: november 20, 2021). 7. acharya dr, bhattaria r, poobalan as, van teijlingen e, chapman gn. factors associated with adolescent pregnancy in south asia: a systematic review. health sci j 2010;4:3-14. 8. spitz am, ventura sj, koonin lm, strauss lt, frye a, heuser rl, et al. surveillance for pregnancy and birth rates among adolescentrs, by state -united states, 1980 and 1990. morbidity and mortality weekly report: cdc surveillance summaries 1993:1-27. 9. markovitz bp, cook r, flick lh, leet tl. socioeconomic factors and adolescent pregnancy outcomes: distinctions between neonatal and postneonatal deaths? bmc public health 2005;5:1-7. 10. kumar a, singh t, basu s, pandey s, bhargava v. outcome of adolescent pregnancy. indian j pediatr 2007;74:927-31. 11. liu rc, cheung k. obstetric characteristics and outcomes of teenage pregnancies. j gynaecol obstet midwifery 2011;11:79-84. 12. naz s, parveen r, bhatt a, baloch r, hanif m. teenage pregency: (are teenagers a high risk group?). med channel 2010;16. 13. mcavoy h, sturley j, burke s. inequalities in the occurrence of low birthweight babies in ireland. dublin: institute of public health in ireland; 2006. 14. chen xk, wen sw, fleming n, demissie k, rhoads gg, walker m. adolescent pregnancy and adverse birth outcomes: a large population based retrospective cohort study. int j epidemiol 2007;36:368-73. 15. aquino-cunha m, queiroz-andrade m, tavares-neto j, andrade t. pregnancy in adolescence: relation to low birth weight. rev bras ginecol obs 2002;24:513-9. 16. tantayakom c, prechapanich j. risk of low birth weight infants from adolescent mothers: review case study in siriraj hospital. thai j obstet gynaecol 2008;103-8. __________________________________________________________________________________________ eick, d., aubert, o., dempsey, k., ozawa, m., van eerd, e., & neicun j. the covid-19 pandemic and the right to health of people who use drugs (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5605 policy brief the covid-19 pandemic and the right to health of people who use drugs donata eick1, océane aubert1, kendra dempsey1, momone ozawa1, eveline van eerd1 and jessica neicun1,2 1 department of international health, care and public health research institute – caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands. 2research centre, centre hospitalier de l'université de montréal, montréal, qc, canada corresponding author: jessica neicun, email: jessicaneicun@gmail.com, ph.d. (c) eick, d., aubert, o., dempsey, k., ozawa, m., van eerd, e., & neicun j. the covid-19 pandemic and the right to health of people who use drugs (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5605 abstract context: according to the european monitoring centre for drugs and drug addiction (emcdda) people who inject drugs (pwid) make up a significant part of the population that needs to be looked after to eliminate infectious diseases such as those caused by hiv and hcv. this situation has been exacerbated by the covid-19 pandemic. as covid-19 rapidly spread across the globe, governments implemented various prevention measures which not only caused an increase in problem drug use (pdu) because of their negative impact on mental health and socioeconomic conditions but also prompted a decrease in drug services provided. therefore, new challenges appeared, such as increased demand for drugs and diversification of clients, and new needs. nevertheless, in clear contradiction to what was needed, the emcdda’s initial reports suggested that there was a decline in european drug services both in providing treatment and harm reduction interventions. covid-19 increased the need to access drug services, healthcare, and support services creating an increased demand for opioid substitution therapy and other medication. thus, comprehensive, and sustainable policies are needed to combat the public health threats associated with these challenges and to ensure the continuity of care. policy options: the challenging circumstances brought by the covid-19 pandemic require policymakers need to take action to build capacity and resiliency for those facing drug-related health and social problems. these should include the adoption of integrated strategies that combine drug consumption rooms, substance-specific therapies, provision of free needles and naloxone, primary healthcare, and social support. recommendations: the creation of an integrated drug policy framework addressed to european union member states is necessary to create robust drug services capable of surviving a crisis. this is guided by a relevant policy design and implementation framework, alongside tangible action principles in line with lowthreshold service provision. keywords: high-risk drug use, integrated drug policy, harm reduction, drug treatment, healthcare, and social support acknowledgments: the authors would like to sincerely thank j. neicun and k. czabanowska for their support in preparing, editing, and revising the policy brief. authors’ contributions: all authors contributed equally to this work. conflicts of interest: none declared funding: none declared eick, d., aubert, o., dempsey, k., ozawa, m., van eerd, e., & neicun j. the covid-19 pandemic and the right to health of people who use drugs (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5605 p a g e 3 | 22 list of abbreviations emcdda european monitoring centre for drugs and drug addiction covid-19 – sars-cov-2 eu – european union eea – european economic area ms – member state(s) pwid – people who inject drugs hiv human immunodeficiency virus hcv – hepatitis c hbv – hepatitis b pdu – problem drug use ost – opioid substitution treatment oat – opioid agonist treatment dcrs – drug consumption rooms edpqs – european drug prevention quality standards, nsp – needle and syringe programmes lts – low-threshold services introduction as in any other realm of life, drug use has been impacted by the covid-19 pandemic. over two years, drugs typically prevalent in recreational settings like mdma or cocaine decreased in popularity during lockdown periods, while a general increase in consumption of cannabis, crack cocaine, dissociative drugs as well as in non-medical use of some pharmaceutical drugs (ex. tramadol, benzodiazepines, barbiturates) has been observed (1)(2). the covid-19 pandemic’s global impact has been particularly felt by vulnerable populations, such as high-risk drug users. the latter are more exposed to covid-19 infection due to drug consumption practices such as the sharing of drug use equipment (pipes, syringes & needles) but also to their deteriorated health status (including comorbidities such as hiv/hcv infection and mental health problems) and often precarious living conditions (homelessness and unstable housing) (3). this has been reflected in an increasing number of visits to hospitals and calls to mental health services, alongside a rise in problem drug use (pdu) (4) with subsequent increases in demand for harm reduction and drug treatment options (5). in particular, the covid-19 pandemic saw a significant rise in high-risk drug use, alongside a convergence of homeless populations where drug services were offered, and increased demand for social support and low-threshold opioid substitution treatment during regional lockdowns (5), which was largely assumed to be due to disruptions in heroin supply in some countries (6). eick, d., aubert, o., dempsey, k., ozawa, m., van eerd, e., & neicun j. the covid-19 pandemic and the right to health of people who use drugs (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5605 p a g e 4 | 22 figure 1: the impact of covid-19 on drug use in europe. (6) context marginalization of populations with pdu becomes increasingly prevalent in public health crises, yet adequate healthcare is often not provided accordingly (3)(6). drug-related issues further exacerbated by the covid-19 pandemic include changes in types and quality of drugs used; substance use relapse for individuals previously in recovery; and reuse of drug/medical materials which contributes to the spread of conditions such as hiv or viral hepatitis (2)(7). despite disparities between countries across europe, reports from the european monitoring centre for drugs and drug addiction (emcdda) suggest an overall decline in drug treatment and harm reduction services provided during the first stages of the covid-19 pandemic (5). access to necessary harm reduction services was disrupted by the covid-19 measures and has thus caused additional challenges for people who use drugs (pwud) and the whole society (7). for example, hiv testing and treatment services have also significantly decreased globally throughout the covid-19 pandemic, with estimates from the united kingdom showing a 33% fall in new hiv diagnoses (8)(9). as a result of the disturbance of harm reduction services, people who inject drugs also face an increased spread of infectious diseases like hcv and hiv, contributing to a higher burden of disease in the population (5)(10). those trends present new challenges for public health policy traditional harm reduction approaches. with an estimated 10 million people living with chronic hepatitis in the european union (eu) and european economic area (eea) in 2016, improved disease prevention and treatment access are vital. to this aim, a key element is the strengthening of harm reduction systems, many of which were weakened during the covid-19 pandemic (2). broadly, in the context of health or political crisis, it is necessary to protect marginalized communities and the whole society (10). in particular, the protection of harm reduction services is vital for both direct and indirect drug-use-related health problems. it is therefore imperative for drug services and eick, d., aubert, o., dempsey, k., ozawa, m., van eerd, e., & neicun j. the covid-19 pandemic and the right to health of people who use drugs (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5605 p a g e 5 | 22 harm reduction facilities to be considered essential services and thus remain operational even under restricted or crisis conditions (5). overall, harm reduction must be considered an essential service for it promotes respect for basic human rights (11). policy options drug-related activities have been evolving since the outbreak of the covid-19 pandemic. while no definitive patterns may be defined so far, some common trends in drug use emerged across the world with changing social circumstances (1)(3). changes were also observed in the interventions addressed to people who use drugs, as countries had to alter their treatment services to new standards. many started to prioritize outreach and home delivery services, and reduced opening hours of dropin centers where social distancing measures were implemented. concomitantly, a general increase in food, water, and hygienic supplies was reported, while the provision of opioid substitution treatment (ost) expanded in some places (12). considering the challenging circumstances brought by the covid-19 pandemic, policymakers may promote capacity building and resiliency among those facing intertwined health and social problems. as problem drug users are usually among the most vulnerable groups in society (13) resiliency and efficacity may be possible through the adoption of multisectoral approaches combining harm reduction strategies, primary and specialized health care including drug services – as well as social support. to this aim existing harm reduction services, including drug consumption rooms, substance-specific therapies, provision of naloxone and clean needles, and continuity in health care and social services must be strengthened and incorporated into a comprehensive, sustainable drug service provision. to promote such an initiative, we propose the introduction of an eu-wide integrated drug policy framework that reinforces existing innovative responses and linkage to care. we also provide some concrete actions aimed at facilitating the implementation of that public health-focused drug policy. 1. safe injection sites: drug consumption rooms (dcrs) drug consumption rooms (dcrs) are facilities that provide legally sanctioned, professional care to allow safe and hygienic drug consumption for people who inject drugs (pwid) in a supervised setting (12). the objectives for dcrs include overall reductions in overdose deaths and emergency service callouts, prevention of disease transmission from repeated needle usage, and a better connection with healthcare workers and social services (14)(15). in the eu, there are currently 17 countries that are in the process of implementing these facilities, with 11 countries where dcrs are already in active execution (14). dcrs are effective at not only reducing overdose deaths and risky behaviors in their service area but also in reaching the most vulnerable and problematic drug user populations – like those experiencing homelessness – to access appropriate social support, healthcare, and drug treatments (16)(17). in addition to providing safe spaces for hygienic drug consumption, an important aspect of dcrs is the provision of healthcare, drug treatment, and linkage to social services. around 60-70% of dcrs provide access to primary healthcare, breaking down the barriers to treatment often experienced by marginalized populations (15). moreover, essential services and goods such as food, water, shower, clean clothing, and the eick, d., aubert, o., dempsey, k., ozawa, m., van eerd, e., & neicun j. the covid-19 pandemic and the right to health of people who use drugs (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5605 p a g e 6 | 22 use of a phone are also provided in many dcrs (15). during the covid-19 pandemic, the services provided at dcrs had to adapt to unprecedented situations. although most of the dcrs were able to stay open in the eu, changes in service delivery such as opening hours, social distancing rules, limited client numbers, mandatory masking and hand washing, and client checks for entering dcrs were implemented to fit the changing conditions (18). as dcrs can provide not only drug consumption safety but also a more comprehensive approach to drug use disorders, a continuation of services for vulnerable populations during these crisis times is crucial. 2. substance-specific therapies (ost/oat) in 2017, there were over 1.3 million high-risk opioid users in the eu (19). although the prevalence of opioid use varies by country, it is considered one of the most pressing issues of illicit drug use. opioid substitution treatment (ost) / opioid agonist treatment (oat) is the most common form of treatment approach for opioid dependence offered in outpatient settings (20). ost/oat are pharmacological treatments that use substances similar to morphine, most commonly either methadone or buprenorphine, that mimic the effects of opioids to tackle opioid dependence (20). currently, it is considered as best practice for opioid dependence to combat overdose risk, mortality, as well as other risky behaviors leading to the spread of blood-borne infections (notably hiv/hcv) (21). this treatment is crucial in tackling opioid dependence, overdose, and mortality as around 80% of all overdose deaths associated with illicit drugs in the eu involved opioids in 2017 (19). however, difficulties in treatment approaches arose during the covid-19 pandemic. high-risk drug users were faced with disruptions to care during the pandemic, with over 91% experiencing some form of disruption such as cancellation of group activities, reduced opening hours, and complete closures of treatment facilities due to restriction measures (12). this is detrimental to the process of treatment as ost/oat requires long-term outpatient care and pharmacological maintenance for better effectiveness (13). vulnerable populations such as people experiencing homelessness were hit especially hard by these disruptions. to confront these challenges, contingency strategies such as the outreach to enable takehome ost/oat delivery, as well as increased flexibility in dispensing services, were strongly recommended (22). this aimed to increase the availability of and/or the maintenance of ost/oat while addressing the societal barriers of stigmatization in accessing those services (12). 3. provision of clean needles and naloxone the sharing of previously used syringes is associated with the transmission of bloodborne viruses. needle sharing causes pwid to be at higher risk for acquiring or transmitting various communicable diseases (23)(24). as recommended by the emcdda, needle and syringe programmes (nsp) are key to preventing and controlling many harms associated with injecting drug use (25)(26). in addition to minimizing injecting-related risks, nsp also aims to decrease the presence of used equipment and associated wastes in public areas (27). along with clean needles and syringes provision, a supply of naloxone administrable through an intranasal spray is an eick, d., aubert, o., dempsey, k., ozawa, m., van eerd, e., & neicun j. the covid-19 pandemic and the right to health of people who use drugs (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5605 p a g e 7 | 22 essential part of the « take-home kit » needed for pwid to reduce harms associated with their consumption and to prevent fatal overdose. used in treating opioids overdoses, this medication is effectively used to reverse opioid-related mortality (28). the provision of such services also constitutes an appropriate time to facilitate education, counseling, and referral services (29). during the covid-19 pandemic, several countries reported problems with the provision and distribution of packs with sufficient supply (5). also, as their effectiveness is coverage-dependent, lockdowns and social distancing have impacted their access and availability (30). to be effective, those services need to be available in settings that are accessible to pwud, either on fixed sites such as drug treatment services, community pharmacies, emergency departments, or even through mobile units (30)(31). the implantation of automatic dispensing machines (32), the encouragement of peer-to-peer distribution, and even the development of options for supplies delivery or posting (33) have proven to be successful in certain settings and may mitigate the barriers that some populations especially women and lgbtq+ people – sometimes encounter in accessing those services (34). 4. primary healthcare & social support pdu is more than a health-related concern, as populations who develop drug use disorders are often exposed to higher rates of poverty, unemployment, and homelessness while having a decreased access to vital resources (35)(36)(37)(38)(39). therefore, essential services covering basic human needs such as housing, food, hygiene, education, and employment support for those in need must be provided (40). social activities, as well as access to technologies, also contribute to the reintegration of the most isolated people into society. access to legal support is also an essential aspect of a comprehensive service, considering the heavy burden of criminalization illicit drug users are faced with (41) to comply with the right to the highest attainable standard of health described by the international guidelines on human rights and drug policy rights (42), general health considerations would also need to be integrated through the treatment of underlying chronic medical conditions, and the prevention of sexually transmitted infectious diseases through information campaigns on safe sex practices and screening. moreover, the monitoring of the ongoing physical and mental health of drug service users would allow the arrangement of appropriate care where needed (43). in this regard, service providers have identified several specific challenges related to the covid-19 pandemic. this crisis has exacerbated the tensions that a large number of high-risk drug users were already facing (unstable economic status, precarious housing situation, etc.). moreover, the health and social situation of the most precarious problem drug users has been degrading because of the stop or reduction of numerous services, only increasing the various vulnerabilities (44). as an example, during the lockdown, the interruption of infectious disease testing and treatment among drug users with high-risk behavior could be, in a near future, associated with outbreaks of hiv, hcv, or hbv (6). the provision of continued health care and social services would help deal with all the aspects that are intertwined with the problem of drug use issue. this will not work unless those eick, d., aubert, o., dempsey, k., ozawa, m., van eerd, e., & neicun j. the covid-19 pandemic and the right to health of people who use drugs (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5605 p a g e 8 | 22 services are implanted where populations are facing this problem and unless an effort of outreach to the most vulnerable and isolated individuals is made. 5. designing and implementing an integrated drug policy framework to tackle the issues amplified during the covid-19 pandemic, there is an immediate need to develop and maintain a more holistic approach that does not only encompass the drug-specific health problem. for this purpose, the adoption of the inclusion health approach – a service, research, and policy agenda that aims to “prevent and redress health and social inequities among the most vulnerable and excluded populations” (45) – may be fruitful. with this goal in mind, policymakers need to build strategies that would ensure access to drug-specific health services with dcrs, osts/oats, nsps – while integrating primary healthcare & social support. this is only possible with the creation of an inclusive environment, implanted in areas that face those specific health and social problems. given that such issues are multidimensional, a multidisciplinary team of professionals from complementary fields is required. thus, the establishment of cross-sectoral cooperation between healthcare professionals such as medical doctors, nurses, and psychologists along with social workers, educators, police officers, and local/governmental representatives is needed to enable the implementation of a comprehensive strategy that tackles all the intertwined issues associated with problem drug use. in parallel, such integrated services would also help reinforce the monitoring of trends in illicit drug markets, while providing a framework to understand the social determinants that influence problem drug use in a particular setting. ultimately, at a european policy level, we recommend the establishment and joint adoption of an integrated framework to guide drug policy decisions outlining the general and specific healthcare provisions and support needed by high-risk drug users. this framework should capitalize on wellestablished processes and principles while remaining flexible enough so that future policies can be adjusted to reflect the needs and characteristics of different geographical contexts and populations. to aid in the creation of this integrated drug policy framework, we recommend reviewing and combining principles from the six harm reduction principles outlined by hawk et al (46); the alberta health service's lowthreshold service model (47); and the emcdda's five factors of drug problem response implementation (48). taken together, these principles and approaches can yield an innovative drug policy framework intended to promote cross-sectoral engagement within the eu and beyond. in this section, we will explain the relevant principles and approaches guiding the proposed integrated drug policy framework. subsequently, we will present a set of tangible actions intended to facilitate the implementation of the proposed policy framework. evidenced-based policy frameworks supporting harm reduction approaches are already used to tackle highrisk drug use through a public health lens. key elements from such frameworks can be examined and learned from to facilitate the creation of an innovative drug policy framework. successfully implemented harm reduction policies and programs can be quite sustainable and cost-effective, thus promoting lasting change among targeted populations (11). in a eick, d., aubert, o., dempsey, k., ozawa, m., van eerd, e., & neicun j. the covid-19 pandemic and the right to health of people who use drugs (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5605 p a g e 9 | 22 public health crisis such as the covid-19 pandemic, these policy orientations are crucial to protect already vulnerable populations. 5.1. general guiding principles according to the six harm reduction principles outlined by hawk et al (46), acting guided by the principle of humanism, we would ensure user-friendly services and responses that are focused on the patient's needs. while taking pragmatism into account, we can provide a range of supportive approaches knowing that substance abstinence is neither prioritized nor assumed to be the goal of every drug treatment patient. moreover, as every human being possess a unique skill set, their level of harm and receptivity to treatment should be seen as a spectrum to which proposed intervention options need to cater (individualism). through the promotion of autonomy care negotiations will be based on the needs and wishes of the patient, thus strengthening the provider-patient relationship. incrementalism encompasses the idea that any positive change is a step in the right direction towards improving the patients' health and stresses the importance of having a plan for dealing with backward movements. finally, by recognizing the responsibility of the patient in their behavior without penalizing them for not achieving goals we can help them understand the impact of their choices. figure 2: hawk et al. (2017) harm reduction principles for healthcare settings (46) 5.2. integrated drug policy framework: core components the innovative policy framework we propose must include considerations for sustainable integrated services (including drug services, primary healthcare, and social support) considering a public health crisis such as the covid-19 pandemic. nevertheless, from a public health perspective, the implementation of integrated services for high-risk drug users must also be showcased in normal times. regardless of the specific context, a successfully integrated drug policy framework must include the following core components presented in table 1. eick, d., aubert, o., dempsey, k., ozawa, m., van eerd, e., & neicun j. the covid-19 pandemic and the right to health of people who use drugs (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5605 p a g e 10 | 22 table 1: the four core components of an integrated drug policy framework recognition of drug services as essential healthcare services tools to protect a safe drug supply improved strategies to monitor drug composition and sale must be deployed to ensure a safe drug supply, thus reducing the likelihood of overdose and other related complications (49). alongside this, protection of services like ost, at-home drug screening kits and naloxone provision must be guaranteed. this includes contingency plans to protect the production of such resources, and the ability for end-users to continually access them. this may include allowing end-users to create a personal "stockpile" of such tools to avoid the increased frequency of social interaction/infection exposure (50). flexibility in access to such resources is critical. continuous end-user engagement and reflection a variety of stakeholders must be engaged in the coordination of successfully integrated drug policies. importantly, to ensure the pertinence and coherence of such policies, engagement with end-users and drug service workers must be prioritized and frequently evaluated (51). policies and services must not simply be designed for pwud but in close collaboration with them, along with other key stakeholders such as service providers. flexibility in the consideration of demographic, social, and structural issues while the adoption of integrated drug policy allows for continuity and cohesion in the provision of drug services, primary healthcare, and social support, means to deal with demographic, social, and structural differences between countries and regions must be available. this will allow for some flexibility in how integrated drug services are designed and implemented. 5.4 action principles for implementation alongside the four core components comprising our proposed integrated drug policy framework, several concrete actions will contribute to the implementation of services under such framework. in this regard, the alberta health service proposes the “low-threshold services” (lts) model for the delivery of harm reduction services, which is focused on the patient and removal of barriers to improving access to care (alberta health services, 2019). based on the lts model we describe in table 2 action principles are intended to help successfully implement drug services under the guidance of an integrated drug policy framework. eick, d., aubert, o., dempsey, k., ozawa, m., van eerd, e., & neicun j. the covid-19 pandemic and the right to health of people who use drugs (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5605 p a g e 11 | 22 table 2: action principles for the successful implementation of integrated drug policies and services, derived from alberta health service’s low-threshold services action principles description accessible to allow drug services facilities to operate at increased hours so support is available throughout the day accepting to create a drug services training program geared towards recruiting, training, and maintaining skilled workers with lived experience of drug use (either personal or familial) affordable to approve increased cross-national and supranational funding to offer integrated drug services for free under local/national/supranational health schemes accommodating to create mobile ost/oat delivery service to improve access and protect the continuity of ost/oat provision during public health crises like pandemics removing barriers to care create a permanent coalition between other social support and healthcare services to ensure continuity of care from a holistic approach 5.4.1 other considerations for implementation to implement the proposed innovative policy framework and make the provision of integrated drug services feasible and sustainable over time, an effort must be made to consider the different stakeholders involved with the project. as their interest, power, and position on the issue may vary, their engagement in the design and implementation of the responses needs to be defined accordingly (appendix 1). the main stakeholder which needs to be involved is the population directly faced with problem drug use. to this end, this specific group needs to be consulted, as they can contribute by providing insights into the different practical dimensions that are associated with the implementation of integrated drug policies and services. similarly, the implementation of integrated drug services might get drawbacks from the local communities living in the immediate surroundings, which is a substantial endeavor to effectively communicate with about services' main features (aims & components, target populations, opening hours, legal and institutional framework). addressing communities’ concerns is a prerequisite to ensuring the sustainability of integrated drug services. some local communities may be concerned that services will attract more high-risk drug users to the area, or that service user will openly engage in drug use and drug dealing. thus, it is eick, d., aubert, o., dempsey, k., ozawa, m., van eerd, e., & neicun j. the covid-19 pandemic and the right to health of people who use drugs (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5605 p a g e 12 | 22 important to address these concerns before the response can be implemented. moreover, the successful implementation of integrated policy responses to drug-related health and social problems must also consider other factors as presented in table 3 (48). table 3: factors to consider for the successful implementation of integrated policy responses to drug-related health and social problems. enlisting policy and public support by promoting the policymaker and the public recognition and comprehension of drug-related health and social problems, the need for a response can be better communicated and accepted by these stakeholders. persuasion may be required in some cases to press the need for a public health approach. having well-prepared staff to deliver services it may be necessary to hire and/or train additional personnel to provide the intended integrated drug response. finding appropriate facilities where the services can be delivered proper facilities are required to provide adequate treatment. such facilities need to be geographically accessible through a variety of means, to limit barriers to access for various groups. potential facilities must be able to adequately house necessary supplies, staff, and service users. centrally located facilities will likely reduce many barriers to accessibility. interand intra-coordination of health services to ensure the efficient coordination of different agencies working on the proposed integrated response, management systems are needed. this may necessitate the constitution of an advisory board consisting of a range of key stakeholders. to incorporate socioeconomic factors and mental health issues into the services program, proper coordination between drug services and other healthcare provisions is also required. importantly, these must be addressed simultaneously. ensure the use of quality standards for service supply the eu has issued basic quality requirements (european drug prevention quality standards, edpqs) in the areas of drug demand reduction, which also includes risk and harm reduction. the edpqs emphasizes the importance of training, developing skills of staff, the reintegration into society of drug treatment patients, and the necessity to consider the readiness for change. eick, d., aubert, o., dempsey, k., ozawa, m., van eerd, e., & neicun j. the covid-19 pandemic and the right to health of people who use drugs (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5605 p a g e 13 | 22 conclusion protecting the right to health for people who use drugs is a complex issue, particularly in the context of the covid-19 pandemic. collaborative, sustainable, and robust integrated responses to drug-related problems are necessary to reduce health and social inequities, to ultimately improve health outcomes in vulnerable populations. the adoption and implementation of an eu-wide integrated drug policy framework is one crucial step in this pathway. these policy solutions are primarily geared toward injecting drug use of opioid-based substances, as there are known successful harm reduction options and users in this group are often the most vulnerable in public health crises. strengthening services listed in this policy brief such as drug consumption rooms, substance-specific therapies, needles, and naloxone distribution, along with primary healthcare and social support plays an important role in mitigating structural barriers to health of high-risk drug users. however, this cannot, unfortunately, address all the drug-related problems that might have been yielded or exacerbated by the covid-19 pandemic. addressing issues associated with cocaine use via harm reduction is challenging. there is no recognized alternative substance therapy for cocaine (like there is ost for opioids). additionally, due to supply chain issues with substances like heroin, some individuals have turned to cocaine use (6). moreover, the adoption of an integrated drug policy framework across europe may be very challenging as it requires a paradigm shift towards a more progressive human rightscentered approach to problem drug use. this involves the attainment of a broad political consensus at national and supranational levels, as well as the allocation of additional public funding to support the effective implementation of innovative responses to health and social responses associated with problem drug use. nevertheless, we encourage national health authorities to take the time to rethink their approach to drugrelated health and social problems through the lens of the integrated drug policy framework we propose. despite the financial and political costs such an endeavor may involve, available scientific evidence suggests that these changes need to be seen as an investment for a more effective and efficient national drug-related strategy in the future. an integrated drug policy framework such as the one we propose will significantly enhance the quality of drugrelated services – including prevention, harm reduction, and drug treatment which in turn will improve health outcomes for high-risk drug users (decrease in drug-related problems such as hiv/hcv transmission, poisoning, and fatal overdoses; higher rates of drug treatment maintenance, lower the risk of relapse). as the emcdda’s main objective is to combat drug-related health and social harms by informing eu and national drug policies, it may have a crucial role in providing specific guidelines together with evidence-based recommendations that facilitate the design and implementation of integrated drug policies and services. to this aim, one first action would be the creation of an eu task force with representation from all relevant stakeholders (see appendix 1 & 2 for details) to ensure the provision of relevant responses. within this context, eu member states could be responsible for the appropriate provision of funding and practical support for local actors in the set-up of these responses. additionally, local authorities would oversee capacitybuilding to achieve adequate coverage of the target population. finally, obtaining support from national authorities must rely on a common goal: finding a suitable balance between public health, social cohesion, and public security eick, d., aubert, o., dempsey, k., ozawa, m., van eerd, e., & neicun j. the covid-19 pandemic and the right to health of people who use drugs (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5605 p a g e 14 | 22 appendix 1: stakeholder mapping name of stakeholder influence/ power high/mediu m/low interest/ stake in the issue high/mediu m/low lightly position in relation to the issue (i.e., positive, against) engagemen t priority high/mediu m/ low emcdda medium high positive medium eu member state governments / policymakers (federal, regional, local) high high positive / against high persons who use drugs low high positive high community members living in areas where harm reduction services are offered low medium initially against low harm reduction workers high high positive high health care professionals high high positive high eick, d., aubert, o., dempsey, k., ozawa, m., van eerd, e., & neicun j. the covid-19 pandemic and the right to health of people who use drugs (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5605 p a g e 15 | 22 law enforcement officials medium low positive / against medium eick, d., aubert, o., dempsey, k., ozawa, m., van eerd, e., & neicun j. the covid-19 pandemic and the right to health of people who use drugs (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5605 p a g e 16 | 22 appendix 2: importance of stakeholders from a power and leadership perspective group 1: influence & interest high group 2: influence or interest medium but other high group 3: engagement high eu member state governments / policymakers (federal, regional, local) emcdda eu member state governments / policymakers (federal, regional, local) harm reduction workers persons who use drugs health care professionals harm reduction workers health care professionals eick, d., aubert, o., dempsey, k., ozawa, m., van eerd, e., & neicun j. the covid-19 pandemic and the right to health of people who use drugs (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5605 p a g e 17 | 22 references 1. unodc. covid-19 and drugs: impact outlook. united nations : office on drugs and crime [internet]. 2021 na [cited 2022 apr 10]; available from: https://www.unodc.org/res/wdr2021/ field/wdr21_booklet_5.pdf 2. emcdda. spotlight on… health and social responses to drug problems during the covid-19 pandemic. european monitoring centre for drugs and drug addiction [internet]. 2021 oct 18 [cited 2022 apr 3]; available 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______________________________________________________________ kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 1 | 11 original research level of satisfaction among primary health care workers in kosovo haxhi kamberi1,2, vanesa tanushi2, muhamet kadrija2,3 1 regional hospital “isa grezda”, gjakova, kosovo; 2 faculty of medicine, university of gjakova “fehmi agani”, gjakova, kosovo; 3 family medicine center, gjakova, kosovo. corresponding author: vanesa tanushi, faculty of medicine, university of gjakova “fehmi agani”, gjakova, kosovo; address: str. "sabrije vokshibija", n.n., 50 000 gjakova, kosovo; telephone: +383 45686337; email: vanesa.tanushi@uni-gjk.org kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 2 | 11 abstract aim: the objective of this study was to assess the extent and selected corelates of work satisfaction among primary healthcare professionals in kosovo. methods: a cross-sectional study was conducted in selected regions of kosovo during the period may-june 2022 including a representative sample of 500 primary healthcare workers (209 men and 291 women; overall mean age: 42.0±12.3 years). a structured 9-item questionnaire was administered to all participants aiming at assessing the level of satisfaction among primary healthcare workers (each item ranging from 1 [high] to 5 [low]). a summary score was calculated for all 9 items related to satisfaction level ranging from 9 (the highest satisfaction level) to 45 (the lowest satisfaction level). binary logistic regression was used to assess the association of satisfaction level (dichotomized into “satisfied” vs. “unsatisfied”, based on median value of the summary score) with selected demographic factors and work characteristics of primary healthcare workers. results: mean summary score of the 9 items related to the satisfaction level of primary healthcare workers was about 23±5; median score was 23 (interquartile range: 20-26). in multivariableadjusted logistic regression models, the level of satisfaction was not significantly related to any demographic factor, but positively associated with the years of working experience of primary healthcare workers [or(for 1 year increment in the work experience)=1.03, 95%ci=1.00-1.05] . conclusion: the evidence from this study conducted in kosovo indicates no significant relationships of the level of satisfaction with demographic factors of primary healthcare workers, but a strong association with their working experience. policymakers in kosovo and in other countries should be aware of the importance of working conditions and working environment in order to gradually increase the level of satisfaction of the staff, which is a basic prerequisite for quality improvement of service delivery at primary healthcare level. keywords: epidemiology, family physicians, kosovo, nurses, primary health care, satisfaction, staff, work characteristics. kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 3 | 11 introduction the health indicators in kosovo are worse than most of the european union countries including, in particular, life expectancy (1). furthermore, almost 15 years after declaring its independence, kosovo is still struggling to shifting its formerly semashko healthcare system toward social health insurance, in line with the trends observed in many former communist countries in central and eastern europe (2). however, primary health care services in kosovo are currently well-regulated and standardized in all regions of the country. according to the most recent information, there were registered about 3.2 million visits at primary health care services in 2021 (3). according to an assessment of the world health organization, in alignment with the regulatory framework, primary health care in kosovo provides quality and safe health services, based on the principles of family medicine and led by the needs and requirements of individuals, families and communities with the final aim at promoting, preserving and improving health for all (4). however, primary health care payment schemes need to be revised to encourage higher performance (4). the available evidence about the level and determinants of satisfaction of primary healthcare workers in kosovo is scant. of note, assessment of satisfaction level of primary healthcare workers constitutes an important component of the overall assessment of health care services regarding quality and health care system responsiveness (5,6). the international literature suggests that the satisfaction of healthcare professionals is related to both patients’ satisfaction and the quality of care provided and also to more favourable health outcomes (7-10). moreover, the way medical staff communicates with patients seems to have a significant effect on the level of patients’ satisfaction, as evidenced by international literature: not applying a dominant position, being caring and committed to patients, and positive attitudes have a favorable influence on the functioning of the relationship between health personnel and patients (11,12). conversely, the degree to which primary healthcare staff is satisfied is influenced by several factors, including salary, individual characteristics, infrastructure of health care institutions, time pressure, autonomy in making decisions, professional relationships with colleagues, and the like (13-15). stress at work also affects the reduction of satisfaction of health personnel, while the possibility of having control over the schedule of visits and working hours seems to be related to a greater satisfaction at work (16). likewise, job satisfaction or dissatisfaction seems to be related to physicians’ plans to leave work (with younger physicians being more likely to plan to leave medical practice in the future), and dissatisfaction with remuneration and with the work environment (17). in this framework, the objective of this study was to assess the level of satisfaction and selected demographic and work characteristics correlates among primary healthcare workers in kosovo, a country in the western balkans which is currently undergoing profound reforms in all sectors including health sector. methods a cross-sectional study was conducted during the period may-june 2022 including a representative sample of primary healthcare workers in selected regions of kosovo. kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 4 | 11 the study was carried out in three regions of kosovo: gjakova, peje, and prizren, which are among the main regions of the republic of kosovo. more specifically, this study included a random sample of 500 primary healthcare workers aged 18 years and above in the regions of gjakova, peje and prizren (209 men and 291 women; overall response rate: 97%). the level of satisfaction of primary healthcare workers was based on an adapted version of the dartmouth-hitchcock medical center instrument (17). this instrument covers nine different aspects (work characteristics) relevant to primary healthcare staff including: respect at the workplace; availability of equipment and instruments; work recognition by colleagues and authorities; stress at workplace; access to information about different aspects of the work; moral and attitudes of the colleagues; continuous improvement of the environment at the workplace; overall perceived quality of healthcare facility; and staff remuneration (18). potential answers for each question are arranged in a 5-point likert scale from 1 (“highest satisfaction” level) to 5 (“lowest satisfaction” level). this questionnaire has been already validated in the context of primary healthcare workers in kosovo (19). a summary score was calculated for all 9 items related to the level of satisfaction among primary healthcare workers ranging from 9 (highest level of satisfaction) to 45 (lowest level of satisfaction). in the analysis, the summary score was dichotomized into “satisfied” vs. “unsatisfied’ based on its median value. furthermore, information about demographic factors (age, gender, place of residence) and work characteristics (profession, work experience, years in the current job position, and engagement in continuous professional education) were collected for all study participants. of note, the study was approved by the ethics commission and council of the faculty of medicine, university of gjakova. fisher’s exact test was used to compare differences in selected demographic factors and work characteristics (age-group, place of residence, region, profession and continuous professional education) between male and female participants. similarly, fisher’s exact test was employed to compare differences in demographic factors and work characteristics between satisfied and unsatisfied primary healthcare workers. conversely, student’s ttest was used to compare gender differences in mean values of work experience and years in current job position. binary logistic regression was used to assess the association of the summary score of the satisfaction (9item instrument, dichotomized in the analysis into “satisfied” vs. “unsatisfied” based on median value of the summary score) with demographic factors and work characteristics of study participants. initially, crude (unadjusted) odds ratios (ors), their respective 95% confidence intervals (95%cis) and p-values were calculated. subsequently, multivariable-adjusted binary logistic regression models were run controlling simultaneously for all demographic factors and work characteristics of study participants (age-group, sex, place of residence, region, profession, continuous professional education and work experience). multivariable-adjusted ors, their respective 95%cis and p-values were calculated. in all cases, a p-value ≤0.05 was considered as statistically significant. statistical package for social sciences (spss, version 19.0) was used for all the statistical analyses. results mean age (±sd) of primary health care workers included in this study was 42.0±12.3 years; median age was 42 years (interquartile range: 32-53 years); the age range was: 19-64 kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 5 | 11 years (data not shown in the tables). table 1 presents the distribution of demographic factors and work characteristics of study participants (n=500), separately in men and in women. overall, about 23% of individuals were aged ≤30 years, whereas 28% of participants (24% in men vs. 30% in women; p=0.04) were 51 years and above. about 32% of primary healthcare professionals worked in rural areas (38% in men vs. 28% in women; p=0.02). about 33% of individuals were resident in prizren region (40% in men vs. 28% in women; p=0.01). around 17% (25% in men vs. 12% in women) were family physicians, 13% (14% in men vs. 11% in women) were general practitioners, and 67% (57% in men vs. 74% in women) were nurses (overall p<0.01). more than 2/3rd of participants (68%) was actively engaged in continuous professional education (73% in men vs. 65% in women; p=0.07). on average, the staff included in this survey had about 16 years of work experience and about 12 years in the current job position, without evidence of any gender differences (table 1). table 1. distribution of demographic factors and work characteristics in a sample of primary health care workers in kosovo in 2022 (n=500) demographic factors and work characteristics total (n=500) men (n=209) women (n=291) p† age-group: ≤30 years 31-50 years ≥51 years 114 (22.8)* 247 (49.4) 139 (27.8) 41 (19.6) 117 (56.0) 51 (24.4) 73 (25.1) 130 (44.7) 88 (30.2) 0.044 place of residence: urban areas rural areas 339 (67.8) 161 (32.2) 129 (61.7) 80 (38.3) 210 (72.2) 81 (27.8) 0.015 region: gjakove peje prizren 171 (34.2) 165 (33.0) 164 (32.8) 58 (27.8) 67 (32.1) 84 (40.2) 113 (38.8) 98 (33.7) 80 (27.5) 0.005 profession: family physician general practitioner nurse other 87 (17.4) 63 (12.6) 335 (67.0) 15 (3.0) 53 25.4) 30 (14.4) 120 (57.4) 6 (2.9) 34 (11.7) 33 (11.3) 215 (73.9) 9 (3.1) <0.001 continuous professional education: no yes 160 (32.0) 340 (68.0) 57 (27.3) 152 (72.7) 103 (35.4) 188 (64.6) 0.065 work experience (years): mean (sd) median (iqr) 15.6±11.7 14 (4-24) 15.6±10.7 15 (5-24) 15.6±12.3 14 (3-24) 0.985 years in current position: mean (sd) 12.3±10.4 12.2 ±9.5 12.4±11.0 0.798 kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 6 | 11 median (iqr) 10 (3-20) 10 (4-17) 10 (2-20) * absolute numbers and column percentages (in parenthesis). † p-values from fisher’s exact test (for comparison of age-group, place of residence, region, profession and continuous professional education) and student’s t-test (for comparison of work experience and years in current job position). a summary score was calculated for all 9 items of the satisfaction level of primary healthcare workers ranging from 9 (indicating the highest level of satisfaction of primary healthcare workers) to 45 (indicating the lowest level of satisfaction of primary healthcare workers). mean summary score of the 9 item-instrument of the level of satisfaction of primary healthcare workers was 22.9±4.6; median score was 23 (interquartile range: 20-26) [data not shown in the tables]. the summary score was subsequently dichotomized into “satisfied” vs. “unsatisfied” staff based on its median value. table 2 presents the distribution of the level of satisfaction (dichotomized into “satisfied” vs. “unsatisfied”) by selected demographic factors and work characteristics of primary healthcare workers. the proportion of men was slightly higher among the satisfied staff as compared with the unsatisfied individuals (about 43% vs. 40%, respectively), but this small gender difference was not statistically significant. furthermore, the percentage of staff aged 51 years and above was higher among the satisfied workers compared with their unsatisfied counterparts (about 32% vs. 23%, respectively), a difference which was statistically significant (p=0.04). there was a borderline statistically significant association with place of residence (p=0.1), with a higher proportion of urban residents among the satisfied workers than among the unsatisfied ones (about 70% vs. 65%, respectively). in addition, the proportion of family physicians was higher among the satisfied workers compared with the unsatisfied staff (20% vs. 15%, respectively; p=0.05). conversely, there was no association of the level of satisfaction with region, or engagement in continuous professional education (table 2). table 2. distribution of the level of satisfaction by selected demographic factors and work characteristics of primary healthcare workers demographic factors and work characteristics unsatisfied (n=226) satisfied (n=274) p† gender: men women 90 (39.8)* 136 (60.2) 119 (43.4) 155 (56.6) 0.466 age-group: ≤30 years 31-50 years ≥51 years 61 (27.0) 113 (50.0) 52 (23.0) 53 (19.3) 134 (48.9) 87 (31.8) 0.037 place of residence: urban areas rural areas 146 (64.6) 80 (35.4) 193 (70.4) 81 (29.6) 0.098 region: gjakove peje prizren 69 (30.5) 79 (35.0) 78 (34.5) 102 (37.2) 86 (31.4) 86 (31.4) 0.291 kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 7 | 11 profession: family physician general practitioner nurse other 33 (14.6) 37 (16.4) 147 (65.0) 9 (4.0) 54 (19.7) 26 (9.5) 188 (68.6) 6 (2.2) 0.045 continuous professional education: no yes 72 (31.9) 154 (68.1) 88 (32.1) 186 (67.9) 0.998 * absolute numbers and column percentages (in parenthesis). † p-values from fisher’s exact test. table 3 presents crude (unadjusted) and multivariable-adjusted association of the level of satisfaction (dichotomized into “satisfied” vs. “unsatisfied”) with demographic factors and work characteristics of primary healthcare workers, according to results obtained from binary logistic regression. in crude models, there was evidence of a positive association of the level of satisfaction with age of primary healthcare workers (overall p=0.04). there was no signification association with gender, or place of residence, albeit higher odds of males and especially urban residents among the satisfied staff compared with their unsatisfied counterparts. on the other hand, there was a graded positive relationship with age-group: the odds of satisfaction were significantly lower among younger participants compared with their older counterparts (or=0.5, 95%ci=0.3-0.9). in addition, the odds of family physicians were considerably higher (about 2.5 times) among satisfied vs. unsatisfied workers, a finding which was, overall, statistically significant (p=0.05). notably, the odds of satisfaction increased by 3% for an increment of one year in the work experience of study participants (p<0.01). in multivariable-adjusted logistic regression models controlling simultaneously for all demographic factors and work characteristics presented in table 3, the association with profession was no longer statistically significant, whereas the positive relationship with work experience persisted [or(for 1 year increment in the work experience)=1.03, 95%ci=1.00-1.05], albeit borderline significant (p=0.08). table 3. association of the level of satisfaction with demographic factors and work characteristics of primary healthcare workers – results from binary logistic regression socio-demographic factors unadjusted models multivariable-adjusted models or* 95%ci* p* or 95%ci p gender: men women 1.16 1.00 0.81-1.66 reference 0.416 1.24 1.00 0.84-1.81 reference 0.281 age-group: ≤30 years 31-50 years ≥51 years 0.52 0.71 1.00 0.31-0.86 0.46-1.08 reference 0.038 (2)† 0.011 0.112 1.30 1.17 1.00 0.52-3.24 0.62-2.18 reference 0.855 (2) 0.578 0.628 place of residence: kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 8 | 11 urban areas rural areas 1.31 1.00 0.90-1.90 reference 0.165 1.26 1.00 0.85-1.87 reference 0.245 region: gjakove peje prizren 1.34 0.99 1.00 0.87-2.07 0.64-1.52 reference 0.292 (2) 0.184 0.954 1.40 0.99 1.00 0.89-2.21 0.63-1.54 reference 0.241 (2) 0.150 0.955 profession: family physician general practitioner nurse other 2.46 1.06 1.92 1.00 0.80-7.52 0.33-3.32 0.67-5.51 reference 0.048 (3) 0.116 0.928 0.226 1.76 0.90 1.55 1.00 0.55-5.68 0.28-2.89 0.53-4.55 reference 0.222 (3) 0.341 0.856 0.427 cpe: no yes 1.01 1.00 0.69-1.48 reference 0.951 1.03 1.00 0.70-1.53 reference 0.874 work experience (years) 1.03 1.01-1.04 0.001 1.03 1.00-1.05 0.078 * odds ratios (or: “satisfied” vs. “unsatisfied”), 95%ci and p-values from binary logistic regression. range of the summary score (dichotomized into satisfied vs. unsatisfied based on its median value) was from 9 (the highest level of satisfaction) to 45 (the lowest level of satisfaction among primary healthcare workers). † overall p-values and degrees of freedom (in parentheses). discussion this study provides valuable evidence about the level of satisfaction of primary healthcare workers in kosovo, a country which is presently emerged into deep political and socioeconomic reforms including also the health sector. in our study, upon multivariable-adjustment for a range of characteristics, there was no evidence of independent associations of satisfaction level with demographic factors of primary healthcare workers. on the other hand, there was evidence of a strong and significant relationship with working experience of the primary healthcare staff. our finding on a positive association of satisfaction level with working experience of primary healthcare staff is compatible with a previous report from kosovo (19). a study among health personnel in rural areas of iran reported that only 17% were satisfied with their work (20), whereas a study among public primary healthcare physicians in delhi, india, reported that all personnel were dissatisfied with training policies and practices, with the level of wages and opportunities to make a career in the system (21), findings which are not in line with the results of our study, where the personnel was generally satisfied with the working environment and working “spirit” in primary healthcare services and the dimensions where dissatisfaction was relatively high included wages (remuneration) and stress at work. a recent study conducted in saudi arabia reported that none of the sociodemographic variables had significant association with job satisfaction (22). according to this report, about two thirds of the primary health care workers were not satisfied with their job (22). on the other hand, a job satisfaction survey with nhs employees reported that, despite the evident limitations placed by the environment, a significant degree of job satisfaction was evidenced among primary health care workers, with 58% of respondents kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 9 | 11 expressing they looked forward to going to work and 65% saying they enjoyed being at work (23). also, a majority of 62% had no plans to change employers (23). a fairly recent study conducted in turkey reported that primary health care workers were generally dissatisfied with their working conditions and they declared that they were not sufficiently qualified to work in primary care. their overall satisfaction was found to be moderate and the most important predictor for job satisfaction was found to be “liking the workplace” (24). conversely, a study on the satisfaction of public healthcare (hospital) staff in 2011 in serbia used some questions similar to those used in our questionnaire (for example, satisfaction with available medical equipment, personal relationships with colleagues, satisfaction with salary, availability of available protocols) (25). the most important factors related to health staff satisfaction in this study (ranked from the most important factor) included: receiving clear instructions regarding the objectives to be achieved in the workplace, the opportunity for professional development in the workplace, good relations with colleagues, satisfactory salary, adequate clinical tools, adequate time to carry out tasks, opportunity for continuing education in the workplace, and the like (25). of note, some of these factors were also affirmed by the health personnel in our study conducted in kosovo. nonetheless, there may be several limitations of the current study conducted in kosovo. our study included only three regions of kosovo and, notwithstanding the fact that the regions included are fairly representative of the whole country, findings may not be generalizable to all the primary healthcare workforce in kosovo. in addition, although the sample size included in this study was sufficient to assess the satisfaction level among primary healthcare workers, it may have not allowed to detect small differences in the satisfaction level between different demographic groupings. the instrument used in our study for assessment of satisfaction level has been previously validated in primary healthcare workers in kosovo (18) but, nevertheless, the possibility of information bias cannot be entirely excluded. also, associations observed in this type of study (cross-sectional survey) are not assumed to be causal. regardless of these potential limitations, this study provides useful evidence about the level of satisfaction among primary healthcare workers operating in three regions of kosovo. this study indicates no significant relationships of the level of satisfaction with demographic factors of primary healthcare workers, but a strong association with their working experience. in all cases, policymakers in kosovo and in other countries should be aware of the importance of working conditions and working environment in order to gradually increase the level of satisfaction of the staff, which is a basic prerequisite for quality improvement of service delivery at primary healthcare level. references 1. the world bank. life expectancy at birth in kosovo. https://data.worldbank.org/indicator/ sp.dyn.le00.in?locations=xk (accessed: 29 october, 2022). 2. pavlova m, tambor m, stepurko t, merode g, groot w. assessment of patient payment policy in cee countries: from a conceptual framework to policy indicators. soc econ. 2012;34:193-220. 3. the world bank. total fertility rate in kosovo. https://data.worldbank.org/indicator/ kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 10 | 11 sp.dyn.tfrt.in?locations=xk (accessed: 29 october, 2022). 4. who regional office for europe. primary health care in kosovo: rapid assessment; 2019. https://www.who.int/docs/librariespr ovider2/default-documentlibrary/kos-phc-report-web090519.pdf#:~:text=4%20primary% 20health%20care%20in%20kosovo %3a%20rapid%20assessment,with %20united%20nations%20security %20council%20resolution%201244 %20%281999%29%29 (accessed: 29 october, 2022). 5. agency of statistics, republic of kosovo. health statistics, 2020. pristina, 2021. https://ask.rksgov.net/media/6320/statistikat-eshendetesise-2020.pdf (accessed: 29 october, 2022). 6. bleich sn, özaltin e, murray cj. how does satisfaction with the health-care system relate to patient experience? b world health organ 2009;87:271-8. 7. pagán ja, balasubramanian l, pauly mv. physicians’ career satisfaction, quality of care and patients’ trust: the role of community uninsurance. health econ policy law 2007;2(pt 4):347-62. 8. devoe j, fryer ge jr, straub a, mccann j, fairbrother g. congruent satisfaction: is there geographic correlation between patient and physician satisfaction? med care 2007;45:88-94. 9. goetz k, campbell s, broge b, brodowski m, steinhaeuser j, wensing m, szecsenyi j. job satisfaction of practice assistants in general practice in germany: an observational study. fam pract 2013;30:411-7. 10. patel i, chapman t, camacho f, shrestha s, chang j, balkrishnan r, feldman sr. satisfied patients and pediatricians: a cross-sectional analysis. patient relat outcome meas 2018;9:299-307. 11. schmid mast m, hall ja, roter dl. disentangling physician sex and physician communication style: their effects on patient satisfaction in a virtual medical visit. patient educ couns 2007;68:16-22. 12. schmid mast m, hall ja, roter dl. caring and dominance affect participants' perceptions and behaviors during a virtual medical visit. j gen intern med 2008;23:5237. 13. williams es, konrad tr, linzer m, mcmurray j, pathman de, gerrity m, schwartz md, scheckler we, douglas j. physician, practice, and patient characteristics related to primary care physician physical and mental health: results from the physician worklife study. health serv res 2002;37:121-43. 14. devoe j, fryer jr ge, hargraves jl, phillips rl, green la. does career dissatisfaction affect the ability of family physicians to deliver highquality patient care? j fam pract 2002;51:223-8. 15. glymour mm, saha s, bigby j. society of general internal medicine career satisfaction study group. physician race and ethnicity, professional satisfaction, and workrelated stress: results from the physician worklife study. j natl med assoc 2004;96:1283-9. 16. keeton k, fenner de, johnson tr, hayward ra. predictors of physician career satisfaction, worklife balance, and burnout. obstet gynecol 2007;109:949-55. kamberi h, tanushi v, kadrija m. level of satisfaction among primary health care workers in kosovo (original research). seejph 2022, posted: 07 november 2022.. doi: 10.11576/seejph6026 p a g e 11 | 11 17. pathman de, konrad tr, williams es, scheckler we, linzer m, douglas j. career satidfaction study group. physician job satisfaction, dissatisfaction, and turnover. j fam pract 2002;51:593. 18. trustees of dartmouth college, godfrey, nelson, batalden, institute for healthcare improvement. assessing, diagnosing and treating your outpatient primary care practice (page 12). adapted from the original version, dartmouthhitchcock, version 2, february 2005. https://clinicalmicrosystem.org/uploa ds/documents/2.5.21_pdf_outpatien t-primary-care_-workbook.pdf (accessed: 29 october, 2022). 19. tahiri z, toçi e, rrumbullaku l, pulluqi p, roshi e, burazeri g. socio-demographic correlates of satisfaction level of primary health care personnel in gjilan, kosovo. mac j med sciences 2012;5:202-4. 20. arab m, pourreza a, akbari f, ramesh n, aghlmand s. job satisfaction on primary health care providers in the rural settings. iran j public health 2007;36:64-70. 21. kumar p, khan am, inder d, sharma n. job satisfaction of primary health-care providers (public sector) in urban setting. j family med prim care 2013;2:227-33. 22. aljumail e, rabbani u. job satisfaction among primary health care workers in buraidah, qassim, saudi arabia. world family medicine 2021;19:27-33. doi: 10.5742/mewfm.2021.94173. 23. campden health. job satisfaction survey; 2013. https://www.cogora.com/wpcontent/uploads/2016/11/jobsatisfaction.pdf (accessed: 29 october, 2022). 24. bucaktepe pge, celik sb, celik f. job satisfaction in primary care after the health reform in a province of turkey. eur rev med pharmacol sci 2022;26:2363-72. 25. janicijevic i, seke k, djokovic a, filipovic t. healthcare workers satisfaction and patient satisfaction where is the linkage? hippokratia 2013;17:157-62. © 2022 kamberi et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3. 0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. alomari km. predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach (original research). seejph 2021, posted:20 august 2022. doi: 10.11576/seejph5827 p a g e 1 | 12 original research predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach khaled mohammad alomari1 1) academic programs for military colleges, abu dhabi university, uae corresponding author: khaled mohammad alomari; academic programs for military colleges, abu dhabi university, uae e-mail: khaled.alomari@adu.ac.ae, orcid (0000-0001-6677-6301) alomari km. predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach (original research). seejph 2021, posted:20 august 2022. doi: 10.11576/seejph5827 p a g e 2 | 12 abstract aim: the volume of research being conducted on the acceptance of social media platforms is rising. but the factors influencing the acceptance for academic reasons are still not properly identified. this study's goal is two-fold. initially, by including technology acceptance model (tam) and external variables, analyze the students' intention to use social media networks. secondly, to employ machine learning (ml) algorithms and partial least squares-structural equation modeling (pls-sem) to verify the proposed theoretical model. methods: the focus of this research is to create a conceptual model by supplementing tam with a subjective norm to assess students' adoption of social media in the classroom. students currently at one private university in the united arab emirates (uae) provided a sum of 627 acceptable questionnaire surveys out of 700 distributed corresponding to 89.6%. the collected data were evaluated using ml and pls-sem. results: according to the research findings, students' intention to utilize social media networks for learning is significantly predicted by “subjective norms, perceived usefulness, and perceived ease of use”. these findings illustrated how crucial it is for students to feel capable and secure using social networks in their academic work. for validation using machine learning classifiers, the results showed that j48 (a decision tree) typically outperformed other classifiers. conclusion: according to the empirical findings, "subjective norm," "perceived usefulness and ease of use" all significantly increase students' intention to use social networks for learning. these results were in line with earlier research on social network acceptability. lawmakers and managers of social media platforms in education must therefore concentrate on those factors that are crucial to promoting education and enhancing students' capacity for developing and implementing successful social media applications. keywords: social media networks; acceptance; technology acceptance model; pls-sem. conflicts of interest: none declared. alomari km. predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach (original research). seejph 2021, posted:20 august 2022. doi: 10.11576/seejph5827 p a g e 3 | 12 introduction facebook and twitter are social media networking platforms that was originally invented keeping college students in mind. a social network is an online community where members post their images, news, videos, and happenings to bring people their shared opinions, likes, experiences, and pursuits (1–3). users can communicate with one another on the internet via email and instant messaging via these online communities (4–6). on facebook, users build profiles for themselves and add images, videos, and personal information. facebook is a one-way communication tool that is effective for information sharing (7,8). additionally, it enables students to work remotely with their classmates. individuals can also join facebook groups, where individuals do not need to be friends (2,9,10). these groups' users have free access to instantaneous upload and share of a file, article, link, information, and video (11,12). the widespread usage of social media is largely due to technological developments, such as the expansion of broadband service accessibility, improved software applications, and the creation of more robust computers and mobile phones (13,14). in truth, this type of media has spread widely and has become a crucial component of the daily lives of many individuals all over the globe (15). since instructors and learners make up most internet users, social media appears to have had a significant role in how we instruct and study (16,17). the acceptance of social media in academia could be affected by many factors. finding these factors continues to be difficult and varies from one region to the next. the majority of technology acceptance research typically evaluates the theoretical models using the structural equation modeling (sem) methodology. in keeping with the body of current literature, there is limited empirical research on the usage of social media in schools in the united arab emirates (uae) and knowledge of the factors influencing students' actual use. consequently, this study's goal is two-fold. initially, by including the technology acceptance model (tam) (18) and external variables, analyze the students' intention to use social media networks. secondly, to employ plssem and ml algorithms to verify the proposed theoretical model. research hypotheses the research model is shown in figure 1. the main goal of the present research is to develop a conceptual model centered on the tam. the correlations between the constructs in the model are described in the ensuing subtopics. 1. subjective norm (sj) sj, defined as "the degree of belief associated with the improvement in his or her job performance likely to be brought about by the use of a specific system by any person," was shown to have a positive influence on social media usage (18). a significant determinant of user intent to use social media networks, according to the study, is the aspect of the subjective norm. thus, it is evident that: h1: subjective norm (sj) would predict the perceived usefulness (pu). h3: subjective norm (sj) would predict the intention to use social media sites (ism). 2. tam constructs pe indicates "the degree to which the person believes that adopting a given system will be effortless" (19). the term "degree to which the individual believes that employing a particular system would improve his/her job performance" is pu (19) and alludes to this belief. it is thought that pu and the perceived ease of use (peou) make it easier for people to accept new technology. the behavioral intention to use social networks is significantly positively influenced by these two factors, according to a study (20,21). pe was also alomari km. predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach (original research). seejph 2021, posted:20 august 2022. doi: 10.11576/seejph5827 p a g e 4 | 12 thought to have a significant positive effect on pu. as a result, we propose the following: h2: perceived usefulness (pu) would predict the perceived ease of use (peou). h4: perceived usefulness (pu) would predict the intention to use social media sites (ism). h5: perceived ease of use (peou) would predict the intention to use social media sites (ism).these hypotheses form the foundation of the proposed research model, as shown in figure 1. a structural equation model is initially used to represent the theoretical model, and it is then evaluated employing machine learning methods. figure 1. the research model. alomari km. predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach (original research). seejph 2021, posted:20 august 2022. doi: 10.11576/seejph5827 p a g e 5 | 12 methodology context and subjects the data was collected between january and april of 2022 using self-administered surveys. students studying at one private university in the united arab emirates (n = 1.500) make up the original study population. the survey participants volunteered to participate, and they received no remuneration for doing so. the data for this study were collected using a convenience sampling method. students who are interested in participating in the research have received an e-mail with the research's goal and a link to the survey. the survey link was also shared on the university's respective facebook and whatsapp groups to increase response rates. the students' participation was entirely voluntary. out of the 700 surveys that were sent, 627 students satisfactorily completed the whole survey, yielding an 89.6 percent response rate (22). the total quantity of proper responses of 627 was an appropriate sample size for the research, as stated by krejcie & morgan (1970) because the required sample size for a population of 1500 would be n=306 respondents. there were 297 men and 330 women in the sample, 73% of the participants were between the ages of 18 and 29. in addition, 64% of participants were pursuing a bachelor's degree, while 24% a master's, 9% a ph.d., and 3% were pursuing a diploma. study instrument the first section will focus on gathering participant demographic data, while the second is intended to get feedback on the factors of the conceptual model. this study's research instrument is divided into two parts as mentioned. the second section's elements were measured employing a "5-point likert scale." the peou and pu measurement items were adapted from choi & chung, davis, and venkatesh (18,23,24). the items employed to measure social media usage intentions and the items for the subjective norm were modified accordingly (18,23) . table 1 contains a listing of the constructs and the underlying items for each. the 11 items) will be assessed using a five-point likert scale, which includes the following weights: strongly disagree (1), disagree (2), neutral (3), agree (4), and strongly agreed (5). table 1. constructs, indicators, and their sources. construct items instrument source “intention to use social media sites “ ism1 facebook and twitter both encouraged networking and the growth of social bonds. (18,23) ism2 twitter and facebook help individuals build stronger social bonds. “perceived ease of use” peou1 i have been able to communicate clearly and easily using twitter and facebook. (18,23,24) peou2 twitter and facebook's userfriendly interfaces make communication quick and easy without taxing the brain. peou3 i find it simple to learn how to navigate facebook or twitter. “perceived usefulness” pu1 information can be found more readily on twitter or facebook. (18,23,24) pu2 i will keep using twitter and facebook. alomari km. predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach (original research). seejph 2021, posted:20 august 2022. doi: 10.11576/seejph5827 p a g e 6 | 12 pu3 i will utilize twitter and facebook for purposes other than information research. “subjective norm” sn1 individuals think twitter or facebook is necessary and inescapable. (23,25) sn2 almost all my friends and colleagues assume that i frequently use facebook or twitter. sn3 if i stop using twitter or facebook, i might face opposition from others. results data analysis this research takes advantage of the smartpls software with partial least squares-structural equation modeling (pls-sem) (26,27). the primary justification for using pls-sem in this work is that it offers contemporaneous evaluation for both the measurement and structural model, which yields more precise results (28). the second technique is used in this research to predict the dependent variables in the conceptual model by employing machine learning algorithms via weka (29). the developed theoretical model is evaluated in this research using these two mentioned separate techniques. measurement model assessment the “cronbach's alpha and composite reliability (cr)” measures were employed for reliability analysis. each of these measurements should have a value of ≥ 0.70 (30). the reliability is corroborated by the findings in table 2, which show that both measures' numbers are satisfactory. the validity and reliability of the measurement model are evaluated (30). the “average variance extracted (ave)” and factor loadings were evaluated for convergent validity. while the numbers of factor loadings ought to be ≥ 0.70 (31), the values of ave must be ≥ 0.50 (32). the convergent validity is established based on the findings in table 2 and the acceptable numbers for both measures. table 2. convergent validity. constructs items factor loading cronbach's alpha cr ave “intention to use social media sites” ism1 0.887 0.896 0.824 0.609 ism2 0.721 “perceived ease of use” peou1 0.767 0.882 0.786 0.621 peou2 0.780 peou3 0.889 “perceived usefulness” pu1 0.756 0.774 0.860 0.732 pu2 0.751 pu3 0.706 ‘subjective norm’ sn1 0.747 0.898 0.774 0.674 sn2 0.779 sn3 0.868 alomari km. predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach (original research). seejph 2021, posted:20 august 2022. doi: 10.11576/seejph5827 p a g e 7 | 12 1.1 hypotheses testing and coefficient of determination each path's variance description (r2 value) and each connection's path relevance in the research model were evaluated. figure 2 and table 3 show the formalized path coefficients and path significance. the combination assessment of the nine stated hypotheses was conducted using the structural equation modeling (sem) method. all hypotheses were validated by the data. according to figure 2, “the perceived usefulness, perceived ease of use, and intention to use social media networks” all had r2 values that varied from 0.756 to 0.863. as a result, these constructs seem to have high predictive power (33). all the constructs from earlier studies were confirmed in the model (sn, pu, peou, and ism). the empirical data supported hypotheses h1, h2, h3, h4, and h5, according to the data analysis. the findings supported hypothesis h1 by demonstrating that pu greatly impacted sn (β= 0.648, p<0.001). the finding that perceived ease of use (peou) significantly influences pu (β= 0.651, p<0.001) validates hypothesis h2. consequently, h3, h4, and h5 are validated since “the intention to use social media networks (ism)” greatly impacts sn (β= 0.418, p<0.01), pu (β= 0.758, p<0.001), and peou (β= 0.575, p<0.01). table 3. test results. h relationship path t-value p-value direction decision h1 sn -> pu 0.648 18.528 0.000 + s** h2 pu -> peou 0.651 15.546 0.000 + s** h3 sn -> ism 0.418 12.651 0.002 + s** h4 pu -> ism 0.758 15.743 0.000 + s** h5 peou -> ism 0.575 10.715 0.001 + s* note:+, positive; s, supported. “p**=<0.01, p* <0.05significant at p**=<0.01 , p* <0.05”. figure 2. the structural model of the study. alomari km. predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach (original research). seejph 2021, posted:20 august 2022. doi: 10.11576/seejph5827 p a g e 8 | 12 1.2 hypotheses testing using machine learning algorithms the “bayesnet, adaboostm1, lwl, logistic, j48, and oner” classifier-based predictive model was employed using weka (version 3.8.3) (34). to predict the correlations in the proposed theoretical model, this study utilizes machine-learning classification algorithms by employing a variety of methodologies, such as “bayesian networks, decision trees, if-then-else rules, and neural networks”. the 10-fold cross-validation showed that the decision tree algorithm j48 successfully predicted the pu with an accuracy of 92.2 percent. as can be seen from the findings in table 4, j48 outperforms the other classifiers in estimating the pu of social media networks. h1 is therefore supported. in comparison to the other classifiers, this one performed higher in regard to tp rate (.921), precision (.919), and recall (.920). table 4. predicting the pu by sn. classifier cci1 (%) tp2 rate fp3 rate precision recall f-measure bayesnet 85.31 .853 .320 .854 .851 .854 logistic 85.44 .854 .381 .855 .853 .859 lwl 86.36 .863 .334 .865 .866 .867 adaboostm1 86.38 .864 .431 .868 .862 .866 oner 87.30 .873 .476 .875 .874 .874 j48 92.19 .921 .895 .919 .920 .921 1cci: “correctly classified instances, 2tp: true positive, 3fp: false positive”. j48 predicted the peou with a 79.90% accuracy rate utilizing the criteria of perceived usefulness (pu). the results also showed better classifier performance by j48 when predicting the peou when opposed to other classifiers, as seen in table 5 as a result, h2 received support. table 5. predicting the peou by pu. classifier cci1 (%) tp2 rate fp3 rate precision recall f-measure bayesnet 79.25 .793 .536 .794 .794 .798 logistic 80.31 .803 .565 .810 .805 .807 lwl 81.19 .811 .595 .819 .812 .812 adaboostm1 82.35 .824 .598 .835 .829 .828 oner 84.64 .846 .624 .849 .847 .848 j48 89.83 .898 .679 .899 .897 .895 the classifier j48 in table 5 predicted the intention to use the social media networks (ism) system with a 90.4 percent accuracy rate. according to the results presented in table 6, j48 performed better than other classifiers in estimating the intention to use social media networks (ism) utilizing attributes of sn, pu, and peou. therefore, h3, h4, and h5 had support. alomari km. predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach (original research). seejph 2021, posted:20 august 2022. doi: 10.11576/seejph5827 p a g e 9 | 12 table 6. predicting the ism by sn, pu, and peou. classifier cci1 (%) tp2 rate fp3 rate precision recall f-measure bayesnet 84.30 .843 .624 .844 .845 .844 logistic 85.37 .853 .644 .856 .852 .852 lwl 85.69 .857 .647 .858 .855 .856 adaboostm1 86.17 .862 .732 .864 .861 .863 oner 88.31 .883 .719 .887 .884 .885 j48 90.35 .903 .772 .909 .903 .912 2. discussion because this research is one of the rare efforts (give references here again) to implement machine learning algorithms in predicting the actual use of social media, it is hoped that the adoption of a parallel multi-analytical approach would bring a new addition to the literature on information systems (is). this research employed “pls-sem and machine learning classification algorithms” in a parallel manner to assess the proposed model. it is significant to remember that pls-sem can be utilized for both dependent variable prediction and conceptual model validation depending on the extension of an existing theory (35-38). similar to this, supervised machine learning algorithms can be implemented to predict a dependent variable by relying on independent variables (29). these methods have a pre-defined dependent variable. it is also intriguing to see how many varied classification algorithms with distinct methodologies, including “decision trees, bayesian networks, association rules, neural networks, and if-then-else rules”, were used in the research. more particular, the results showed that j48 (a decision tree) typically outperformed other classifiers. it is important to note that the sample was divided into homogeneous sub-samples depending on the most important independent variable, and the decision tree (nonparametric) was adopted to classify both continuous (numerical) and categorical variables (29). on the other side, pls-sem (a nonparametric procedure) was applied to generate a large number of subsamples at random and verify the significant coefficients with substitutes from the sample. there has been a thorough investigation in the current research to assess the external variables associated with user’s behavioral intention to use social media sites among uae students namely the “subjective norm, perceived usefulness, and perceived ease of use”. however, it is also imperative to investigate and validate the technology acceptance by user with respect to the individual and organizational factors affecting technology. this calls for conducting a similar study with greater number of external variables which will help generalize the study outcomes. after this, we can use a longitudinal study to test the proposed argument. it is also possible to use a longitudinal study to comprehend the potential adoption of social media sites by education workplaces in developing countries. this will require comparative analysis of the current research model at different time periods. conclusion and future works the tam was used and extended by "perceived playfulness" to accomplish this goal. from the students studying at reputable universities in the united arab emirates, a alomari km. predicting the intention to use social media among medical students in the united arab emirates: a machine learning approach (original research). seejph 2021, posted:20 august 2022. doi: 10.11576/seejph5827 p a g e 10 | 12 record of 627 acceptable questionnaire surveys were gathered. by use of the “plssem and machine learning approaches”, the suggested model was verified. according to the empirical findings, "subjective norm," "perceived usefulness," and "perceived ease of use" all significantly increase students' intention to use social networks for learning. these results were in line with earlier research on social network acceptability (15,16,23,39,40). these findings illustrated how crucial it is for students to feel capable and secure using social networks in their academic work. the primary goal of this research was to explore the variables influencing students' acceptance of social networks in the classroom. lawmakers and managers of social media platforms in education must therefore concentrate on those factors that are crucial to promoting education and enhancing students' capacity for developing and implementing successful social media applications. the statistics were only gathered from one private university in the uae as a restriction. the findings might not generalize to other higher education schools in the uae. to evaluate the commonalities and differences 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1998;295(2):295–336. 34. frank e, hall m, holmes g, kirkby r, pfahringer b, witten ih, et al. weka-a machine learning workbench for data mining. in: data mining and knowledge discovery handbook. springer; 2009. p. 1269–77. 35. alsharhan a, salloum s, aburayya a. technology acceptance drivers for ar smart glasses in the middle east: a quantitative study. int j data netw sci. 2022;6(1):193–208. _________________________________________________________________________ study instrument hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 1 | 9 review article tribal communities and opioids margo hill1 1) eastern washington university corresponding author: margo hill, associate professor, department of urban and region planning eastern washington university email: mhill86@ewu.edu hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 2 | 9 abstract american indians/ alaskan natives (ai/an) experience overdose rates higher than any other ethnic/ racial group in the us. in recent decades the opioid epidemic has had a particularly negative impact on ai/an populations. to respond effectively to this issue, it is vital to understand its root cause. a range of factors are responsible, with some dating back hundreds of years. the main factors are the impact of colonization and exclusion; forced migration to peripheral areas; forced removal of children and attempts at cultural genocide; poor social environments; poverty and unemployment; adverse childhood experiences; and inadequate and under-funded federal health services. particular blame can be attributed to the pharmaceutical industry and its active over-promotion of opioid use. a number of strategies for tackling this scourge are outlined. keywords: tribal communities, opioids, north america, pharmaceutical industry hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 3 | 9 in 2015, american indian and alaskan natives (ai/an) had the highest drug overdose rates of any population in the united states (1). the opioid mortality rates from ai/an populations have risen almost continuously for nearly two decades and are comparable to the mortality rates of nonhispanic whites that are often cited as the highest ethnic or racial group (2). as we look at the data, experts believe that the ai/an drug overdose rates may be underestimated by as much as 35% due to race, ethnicity, and misclassification on death certificates (1). according to the northwest portland area indian health board, the death rate from drug overdose among american indian & alaska natives (ai/an) in washington state was 43.1 per 100,000 people in 2016 (3). this rate was almost 3 times the national ai/an rate and the washington state average. while the overall overdose death rate in washington state has remained relatively stable since 2007, the rates for ai/an in washington has increased 36% since 2012, and almost 300% since 2000. in terms of polysubstance deaths of ai/an in washington state in 2014-16, almost half of the drug overdose deaths involved more than one drug, and a third involved more than one opioid. common combinations included deaths involving cocaine and an opioid. in 74% of deaths from overdose the deceased had used a deadly combination of cocaine and opioids (3). moreover, 59% of deaths involving methamphetamine (‘meth’) involved an opioid, and 17% of deaths involving heroin also involved a prescription opioid (3). what are the underlying causes of this disproportionate impact of opioid abuse and substance abuse on ai/an? in our tribal communities we know the reasons why tribal people struggle with substance abuse and particularly opioids. the united states government inflicted colonization and federal indian policies that were devastating to tribal communities. brave heart and debruyn discuss how the u.s. government enacted a range of punitive policies such as: removing native children from native homes to boarding schools; forced assimilation through relocation to urban centers; and termination of tribal governments (4). all such policies have had long lasting negative impacts on american indians and disrupted tribal family systems. for american indians the united states was the ‘perpetrator’ of their holocaust (4). ai/an continue to deal with historical trauma and loss of culture which lends itself to substance abuse disorders. unresolved historical grief and trauma that ‘...contributes to the current social pathology of high rates of suicide, homocide, domestic violence, child abuse, alcoholism, and other social problems among american indians’ (4). these government inflicted policies have placed tribal communities in disadvantaged circumstances such as the geographic location of american indian reservations. the european white settlers moved onto and claimed the most fertile lands, and reservations were created in remote, geographically less viable locations. leonard, parker and anderson found that land designations were not randomly selected and instead were chosen to avoid conveying highvalue agricultural land to native americans (5). this contributes to high rates of poverty, unemployment and lack of opportunity (6). ai/an still struggle to gain a foothold in mainstream america. although some members of tribal communities successfully navigate society and gain education and employment, many members still struggle. according to a recent survey by adamsen et al. one-in-four ai/ans live in poverty, and tribal communities report the lowest hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 4 | 9 employment rate nationally (7). the policies of the united states government such as boarding schools and welfare systems that continued to remove children from ai/an homes until the late 1970s were particularly hard on tribal families and disrupted family systems of child rearing. native american children were forced to go to boarding schools, ai/an culture was seen as a problem and the purpose of these schools was forced assimilation (4) as a result of forced assimilation and relocation, we have broken families that often lead to relationship difficulties. the federal governments’s indian policies disrupted tribal cultural systems, took children away from their families, and often resulted in historical trauma, leading to an increased prevalence of substance abuse. why are there higher rates of substance use disorders (sud) amongst ai populations? brave heart & debruyn unequivocally outline the causes as ‘...an outcome of internalized aggression, internalized oppression, and unresolved grief and trauma’ (4). there are many root causes of substance abuse disorders and all tribal communities are different, depending on their history, location and resources. however, one leading cause is our social environment: social influences; peer influence; social policies; availability of illicit substances; and family systems. in much of the country, the counties with the lowest levels of social capital have the highest overdose rates (8). these are all mechanisms that are responsible for the adoption maintenance and maintenance of addictions in our communities. we also see in our tribal communities that our young people start alcohol and substance abuse at a relatively young age. swaim and stanley note that early initiation for american indian youths include increasing rates of use in early and later adulthood, higher risk of developing a substance use disorder (9). for our tribal communities, social influence, our families, our cousins and friends, are very powerful influences. another indicator of substance abuse are adverse childhood experience (aces), such as exposure to alcoholism, drug abuse, domestic violence, emotional neglect, incarceration of a parent, physical or sexual abuse (10). toxic stress from aces can change brain development and affect how body responds to stress and are linked to substance misuse in adulthood (11). these adverse childhood experiences lead to higher risk of addiction. again, many of these issues can be traced back to lack of control, and lower levels of certainty, as a result of government policies that dominated the lives of american indians and alaskan natives. as a result of loss of ancestral lands and loss of cultural identity, we often see that life on reservations can result in dire poverty and hopelessness (12). decker discusses the chaos of many american indian families that can lead to addiction, mental health issues, domestic violence and suicide (12). these issues are passed from generation to generation, leading to an intense need to escape the pain and loss. often substances provide an escape by numbing the pain (12). opioids have been described as providing an escape and a euphoria that washes over you, taking away both physical and emotional pain (13). opioids disrupt the natural reward system by flooding the brain with large amounts of dopamine. when people are addicted to opioids and do not have the opiates, they experience uncontrollable cravings which persists even after they stop taking the opioid (13,14) opioid drugs target the brain’s pleasure center, where we have a natural source of dopamine. this is usually triggered by things that we enjoy such as hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 5 | 9 food, sex or music; ‘dopamine triggers a surge of happiness. when the dopamine rolls into amygdala, the brain’s fear center, it relieves anxiety and stress. both of these events reinforce the idea that opioids are rewarding’ (15). it has been described to this author as being like ‘fireworks going off’. how does opioid abuse start? prescription painkillers like hydrocodone, oxycodone, percocet, vicodin, morphine, codeine, and fentanyl are all substances that have been overprescribed by doctors and led to dependency and abuse (16) for tribal elders, perhaps they were prescribed oxycodone after a heart attack, such as in my dad’s case. for younger people, like my nephew in his 20s, the first time they were prescribed opiates may have been after a simple dental procedure. we know that pharmaceutical companies were marketing the right to be pain free. purdue pharma’s sales reps ‘fanned out to evangelized doctors and dentists with a message: prescribing oxycontin for pain was the moral, responsible and compassionate thing to do’ (17). drug companies targeted primary care doctors and ads promoted long-term pain relief. they falsely stated that the risk of addiction was rare. purdue pharma’s david haddox claimed that oxycontin was safe with addiction rates less that 1 percent (17). prescribing doctors were encouraged to use pain as the fifth vital sign and seek to improve pain management (17,18). this led to a dramatic overprescribing of pain pills (17). often expensive surgeries that are needed by tribal members are not funded by the indian health service (his), and hence people have little alternative but to mask their pain with opioids. american indian tribes ceded their lands to the united states government with two primary promises: healthcare and education (4). by ceding their land they essentially prepaid for their healthcare. the united states government has a legal obligation to provide health services for native people. this obligation is the result of treaties between the federal government and native nations, as well as federal statute (19). however, the indian health service (ihs) is never adequately funded. many the specialized healthcare needs and surgeries needed are not funded and people have little option therefore but to mask their pain and discomfort with medications, such as opioids. opioids are also more likely to be prescribed in counties with more uninsured people (20), and those that have insurance may find that prescription narcotics are more reliably covered than other medical interventions (21). in the us surgery is often considered too costly for economically depressed and low density populations (22). insurance companies often disapprove medical procedures and approved prescribed pain medications. compounding these factors, indian health clinics are severely underfunded (19). tribal clinics are placed on priority one status which means you can only get coverage for a procedure only when life and limb are at immediate risk. this means when local ihs facilities cannot provide needed services for patients, they may contract out to private health care centers through the contract health services (chs) program. it should be noted that only american indians who live on the reservation are eligible for contract health services. sick or injured patients with contract health who are not covered for treatment of the cause of pain instead receive options to manage it, and are often prescribed opioids. indian health service physicians, like many american physicians, were also sold the right to be ‘pain free’ concept, and thus readily dispensed opioid prescriptions to patients. in hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 6 | 9 indian country it is cheaper to prescribe pain pills than to get the necessary surgery for a back injury or a knee injury. we see opioid significant levels of misuse in rural areas. health care challenges are compounded due to a shortage of primary care providers and thus opioids are again prescribed more commonly in rural areas (18,19,22,23). as well as the impact of social environments, the impacts of genetics and physiology on addiction cannot be ignored. the role of genetics is clear in alcoholism is clear. there is a higher risk ratio for individuals when a high number of their relatives have alcohol abuse issues. (24). other traditional markers that we consider in looking at substance abuse are severity and tolerance. the need for more of the substance is an indicator that there is a problem. you need more of the substance to get the same affect. a commonly used term for opioid withdrawal is ‘dopesick’ (17). one us law firm filing a class action stated ‘long-term opioid use changes the way nerve cells work in the brain. opioids create artificial endorphins in the brain, which bind the brain’s opioid receptors producing euphoric effects and providing pain relief. opioids trick the brain into stopping production of endorphins. when this happens, users experience excruciating withdrawal symptoms’ (25) . an addict will tell us that the physiological pain of not having the pills is unbearable and leads to intense drug seeking behavior. in opiate withdrawal, when a dose is not taken, the body experiences painful symptoms such as vomiting, sweating, nausea, runny nose, dilated pupils, watery eyes, anxiety, insomnia, physical pain and constipation (26). what does the opioid do to your body? it has many effects and is similar to heroin or the morphine molecule, especially when taken in ways other than prescribed by the doctor. opioid pills can be melted down, smoked, or injected intravenously. many addicts started by snorting the pills, before moving on to ‘routinely injecting the liquified crushed-up powder with livestock syringes they bought (or stole) from local feed stores’ (17). there have been three waves of drug use in recent years; first, prescriptions like oxycontin became widespread and abused. tribal leaders and health care providers became aware of the opioid abuse and began restrictive policies controlling prescriptions. they monitored opioid prescriptions via databases on nearby reservations and offreservation (27). second, once access and prescriptions were restricted addicts turned to illicit street drugs like heroin. around 2013, there was an increase in synthetic opioids like fentanyl. a particular danger with such drugs is that people can overdose when they start ‘using’ again after having experienced a period of abstinence, due to factors such as treatment or jail time (23). how do we stop opioid abuse in tribal communities? (28) in my experience as a tribal attorney for 10 years, it often comes in the form of providing consequences to those abusing drugs. consequences include going to jail, the removal of children, job loss, and being ordered to attend treatment. the hope is that once the addict is not using they will be able to detox and get out of the cycle of addiction and drug seeking behaviors. if abusers are not able to get out of the cycle of addiction they will likely end up in jail, or overdose, or end up dead. however, even when people want to get clean and sober the continuing challenges of finding employment, housing and accessing outpatient treatment programs can be significant barriers (28). however, we are now seeing illicit opioids like heroin becoming more accessible. in tribal communities, there are numerous stressors, including distress, sadness and hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 7 | 9 poverty. our tribal governments struggle to provide treatment that combines holistic tribal cultural healing practices, alongside western biomedical science and treatment grounded in evidence-based practices. the social determinants of addiction are significant and include: economic opportunity; poverty level; substance availability; genetic predisposition; mental health condition;self-image; substance use among family and friends; family conflict/abuse; and level of supervision. it is an unfortunate reality that all of these factors are significant issues in tribal communities (29,30). the environmental factors of stress, trauma and pain often lead to experimentation with opioids, and later to cycles of dependence. tribal governments, like states, counties and cities have expended millions of dollars of precious resources towards addressing the opioid epidemic. as judge polster, of n.d. ohio federal district court stated ‘everyone shares some of the responsibility, and no one has done enough to abate it. this includes the manufacturers, the distributors, the pharmacies, the doctors, the federal government and the state government, local governments and hospitals’ (31). references 1. mack ka, jones cm, ballesteros mf. illicit drug use, illicit drug use disorders, and drug overdose deaths in metropolitan and nonmetropolitan areas—united states. am j transplant. 2017;17:3241–3252. 2. tipps rt, buzzard gt, mcdougall ja. the opioid epidemic in indian country. j law med ethics. 2018;46:422–436. 3. northwest portland area indian health board. american indian & alaska native opioid & drug overdose data brief. accessed on 22nd june 2022 at: https://www.nihb.org/docs/04092020 /washington%20opioid%20&%20d rug%20overdose%20data%20brief. pdf 4. brave heart my, debruyn lm. the american indian holocaust: healing historical unresolved grief. american indian and alaska native mental health research. 1998;8(2):56–78. 5. leonard, b., parker, d. and anderson, t., land quality, land rights, and indigenous poverty november 2018. accessed june 21, 2022 at: https://aae.wisc.edu/dparker/wpcontent/uploads/sites/12/2018/11/le onard-parker-anderson-11-1318.pdf 6. 2005 bureau of indian affairs american indian population & labor force report. accessed june 21st at: https://www.bia.gov/sites/default/file s/dup/assets/public/pdf/idc001719.pdf. 7. adamsen c, schroeder s, lemire s, carter p. education, income, and employment and prevalence of chronic disease among american indian/alaska native elders. preventing chronic disease. 2018;15:e37. https://doi.org/10.5888/pcd15.17038 7 8. zoorob mj, salemi jl. bowling alone, dying together: the role of social capital in mitigating the drug overdose epidemic in the united states. drug alcohol depend. 2017;173:1–9. 9. swaim rc, stanley lr. substance use among american indian youths on reservations compared with a https://www.nihb.org/docs/04092020/washington%20opioid%20&%20drug%20overdose%20data%20brief.pdf https://www.nihb.org/docs/04092020/washington%20opioid%20&%20drug%20overdose%20data%20brief.pdf https://www.nihb.org/docs/04092020/washington%20opioid%20&%20drug%20overdose%20data%20brief.pdf https://www.nihb.org/docs/04092020/washington%20opioid%20&%20drug%20overdose%20data%20brief.pdf https://aae.wisc.edu/dparker/wp-content/uploads/sites/12/2018/11/leonard-parker-anderson-11-13-18.pdf https://aae.wisc.edu/dparker/wp-content/uploads/sites/12/2018/11/leonard-parker-anderson-11-13-18.pdf https://aae.wisc.edu/dparker/wp-content/uploads/sites/12/2018/11/leonard-parker-anderson-11-13-18.pdf https://aae.wisc.edu/dparker/wp-content/uploads/sites/12/2018/11/leonard-parker-anderson-11-13-18.pdf https://www.bia.gov/sites/default/files/dup/assets/public/pdf/idc-001719.pdf https://www.bia.gov/sites/default/files/dup/assets/public/pdf/idc-001719.pdf https://www.bia.gov/sites/default/files/dup/assets/public/pdf/idc-001719.pdf https://doi.org/10.5888/pcd15.170387 https://doi.org/10.5888/pcd15.170387 hill m. tribal communities and opioids (review article). seejph 2022, posted: 26 july 2022. doi: 10.11576/seejph-5767 p a g e 8 | 9 national sample of us adolescents. jama network open. 2018; 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understanding addictions among indigenous people through social determinants of health frameworks and strength-based approaches: a review of the research literature from 2013 to 2016. curr addict rep. 2016;3:378–386. 30. park-lee e, lipari rn, bose j, et al. substance use and mental health issues among u.s.-born american indians or alaska natives residing on and off tribal lands. cbhsq data review. 2018; july:1-40. 31. dayton daily news, the federal judge handling the mdl, judge dan aaron polster in the northern district court of ohio, https://www.daytondailynews.com/n ews/butler-county-opioid-lawsuitpart-global-effort-endepidemic/pht0r5tkyfw5iohpcgllxo ____________________________________________________________________________________ © 2022 hill; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://skikos.com/the-opioid-crisis/ a comprehensive understanding of the children’s and women’s health as a state of complete physical, mental and social wellbeing , is essential to the health of current and future generations jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 1 original research health and health status of children in serbia and the desired millennium development goals aleksandra jovic-vranes 1 , vesna bjegovic-mikanovic 1 1 institute of social medicine, medical faculty, belgrade university, serbia. corresponding author: aleksandra jovic-vranes, belgrade university, serbia; address: dr subotica 15, 1100 belgrade, serbia; telephone: +381112643830; e-mail: aljvranes@yahoo.co.uk mailto:aljvranes@yahoo.co.uk jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 2 abstract aim: children represent the future, and ensuring their healthy growth and development should be a prime concern of all societies. better health for all children is one of the leading objectives of the national plan of action for children and a key element of the tailored millennium development goals for serbia. methods: our analysis was based on relevant literature and available information from the primary and secondary sources and databases. we analyzed health status of children that can be illustrated by indicators of child and infant mortality, morbidity, and nutritional status. results: there has been a significant reduction in the mortality rates at the national level, particularly with regard to infants and children under five years of age. however, the current mortality rate of roma children is still three times as high as the millennium goal set at the national level for serbia. most deaths of children under the age of five are due to preterm birth complications, congenital anomalies, birth asphyxia and trauma, pneumonia and sepsis. the rate of malnourished children among the poor and in roma settlements is twice as high as in the general population of serbian children. a growing number of obese children was also noted in the roma population. conclusion: political awareness, commitment and leadership are required to ensure that child health receives receive the attention and the resources needed to accelerate the progress of serbia. keywords: children, health status, millennium development goals, serbia. conflicts of interest: none. jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 3 introduction a comprehensive understanding of the children’s and women’s health as a state of complete physical, mental and social wellbeing (1) is essential to the health of current and future generations. almost every culture holds that a society has a responsibility to ensure a nearly equal start in life for children, which implies developing their full health potential (2). however, there are still significant ethnical and regional differences that need to be considered while developing the global health policy framework. the differences in people health are determined by their exposures to health risks, which are, in turn, the social determinants of health (3). the prevention of disease requires overall investment in the social determinants of health and reduction of inequalities and unfairness in health. the foundations for adult health and, indeed, the health of future generations are laid in early childhood and even before birth. therefore, better health for all children is one of the leading objectives of the national plan of action for children (4) and a key element of the tailored millennium development goals for serbia. progress in the reduction of child mortality is one of the leading public health challenges in all countries (1). reducing child mortality is also one of the millennium development goals, and the first of the total of 27 goals adopted at the world summit for children. it has also been incorporated into many national plans of action for children. in spite of major improvements, national reports on progress in attaining the millennium development goals, even in countries in which child mortality has been reduced by two thirds on the average, highlight that the problem is still present in rural areas, among people living below the accepted poverty line and – as regards southeastern europe – in particular, among roma subpopulations (1,5). child mortality due to preventable causes is further compounded by poverty, unfavorable living conditions, low educational level of mothers, social exclusion, neglect, violence against children and insufficiently accessible antenatal and postnatal health care (6,7). deaths among children under the age of five years represent one of the most serious challenges currently faced by the international community. to address this challenge, it is necessary to measure accurately the levels and causes of mortality among this population group (8). major causes of under-five mortality remain the same globally; their relative importance varies across regions of the world. while in low-income countries infectious diseases account for a large proportion of under-five deaths, the main killers of children in high-income countries are non-communicable diseases such as congenital anomalies, prematurity, injuries and birth asphyxia (9). monitoring of the nutritional status plays an important role in the analysis of the health of children, particularly when health risks and preventive actions need to be assessed and considered. irregular and insufficient nutrition during infancy and later can significantly impair the growth and development of children and have adverse health effects (physical fitness, mental functions, immune system). at the same time, excessive food intake and an imbalanced diet may also result in obesity and negative health consequences (10). the aim of our study was to analyze children mortality rates in serbia, leading causes of death, differences in mortality rates between the average population of children and roma children and diet and nutritional status of children under the age of five years. jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 4 methods this situation analysis has been done on the basis of relevant literature and available information from the following primary and secondary sources and databases: published documents including strategies, policies, programs, plans, laws and other regulations of the government of the republic of serbia, health regulations and guidelines of the ministry of health, published reviews, scientific and professional articles on health and health status of the serbian population in national and international journals, national surveys and project reports of international organizations (unicef, who, eu, world bank) that deal with issues of children’s and women’s health in serbia; publications in the area of routine health statistics, national e-databases (institute of public health of serbia, dr. milan “jovanović batut”, statistical office of the republic of serbia and international e-databases (who/eurostat) for comparison purposes. this statistical information often is only available in aggregated sets of data which do not allow for detailed analyses. health outcomes and health status of children are illustrated by the following indicators: infant mortality rate (deaths of children in the first year of life), perinatal mortality rate (fetal deaths from the 22 nd week of gestation or achieved 1000g in intrauterine development and deaths by the seventh day of life), neonatal mortality rate (deaths in the first 27 days of life only), and morality of children under five years of age (deaths before children turn five years); morbidity, nutritional status and comparisons with relevant national and international benchmarks and objectives. a special focus was placed on disparities and social inequalities in health among population groups within serbia, which are considered unfair, unjust, avoidable and unnecessary. the results were presented in tables and graphs. results in serbia, there has been a significant reduction in the mortality rates at the national level, particularly with regard to infants and children under five (figure 1), while the reduction of the mortality rate in the prenatal period was somewhat more limited. figure 1. children mortality rates in serbia: situation analysis and the desired millennium goal by 2015 i-infant mortality rate; ii-perinatal mortality rate; iii-neonatal mortality rate; iv-children under 5-year mortality rate. 10.6 11.2 7.7 12.7 8.0 9.3 5.8 9.2 6.3 8.8 4.7 7.1 4.5 6.5 3 5 0 2 4 6 8 10 12 14 i ii iii iv 2000 2005 2011 mdg 2015. jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 5 mortality among roma children remains high, the rate has almost halved over the last five years bringing the number closer to the national millennium goal of reducing roma under-five child mortality to 14 and infant mortality to 12. however, the current mortality rate of roma children is still three times as high as the millennium goal set at the national level for serbia (figure 2). figure 2. differences in mortality rates between the average population of children and roma children in 2005 and 2010 in serbia figure 3 presents the leading causes of death in serbian children under-five years. most deaths of under-five children are due to preterm birth complications, congenital anomalies, birth asphyxia and trauma, pneumonia and sepsis. figure 3. distribution of the leading causes of death of children under-five in serbia 25.9 29 14 15 12 14 8 9.2 6.7 7.9 4.5 5 0 5 10 15 20 25 30 35 infant mortality under 5 years mortality roma children roma children2 2015: mdg for roma children 2005: average population 2010:average population 2015: mdg for serbia roma settlements roma settlementsserbia serbia rate per 1000 live births 29 32 31 30 30 28 31 36 35 36 41 5 4 3 6 6 6 4 7 5 6 4 0 5 10 15 20 25 30 35 40 45 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 consequences of pre-term birth congenital anoma other diseases asfixia during birth pneumonia injuries sepsis jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 6 the indicators of diet and nutritional status of children under-five years of age are presented in table 1. the rate of malnourished children among the poor and in roma settlements is twice as high as in the general population of serbian children. surprisingly, a growing number of obese children were also noted in the roma population, from 6.7% to 12.8%, which points to irregular nutrition. the corresponding millennium development goal in serbia aims to bring the share of obese children down to 9.1% by 2015. breastfeeding habits have not substantially changed, except in the roma population where the number of exclusive breastfeeding up to the age of six months has decreased. the rate of exclusive breastfeeding is still only half of the desired millennium development goal in serbia (30% of exclusively breastfed children from birth until the six month of age). table 1. diet and nutritional status of children under five years of age in 2005 and 2010 in serbia indicator serbia the poor roma settlements mdg 2005 2010 2005 2010 2005 2010 2015 live births with low birth weight 4.9 4.8 8.6 8.3 9.3 10.2 percent of children first breastfed within a day after birth 68.8 61.9 71.7 69.1 72.5 70.3 percent of children with exclusive breastfeeding for the first six month 14.9 13.7 15.4 19.5 18.0 9.1 30.0 percent of children 6-23 months who receive the minimum number of meals na 84.3 na 80.0 na 71.9 prevalence of malnourishment among children under-five (body weight for the given height ≤2sd) 3.2 2.3 3.8 5.2 4.1 5.2 prevalence of obesity among children under-five (body weight for the given height ≤2sd) 15.6 12.7 15.5 12.5 6.7 12.8 9.1 discussion this situation analysis covers the health status of serbian children that can be illustrated by indicators of child and infant mortality, morbidity and nutritional status which are compared with relevant national and international benchmarks and objectives. a special focus was placed on disparities and social inequalities in health among population groups within serbia, which are considered unfair, unjust, avoidable and unnecessary since they open a systematic burden on vulnerable population groups. it is believed that the unfair differences in health of children result from social structures and political, economic and legal relations: they are derived from the system, and are result of the social system (so that they can be changed) and they are unjust (11). marmot insists that they are not a natural phenomenon by any means; instead, they are a combination of poor conditions and low standards of living, poverty, risky life-styles, social exclusion, scarcely formulated, inappropriate health programs and sometimes toxic national and local policies (12). infant mortality is generally regarded as a basic indicator of population health and a measure of long-term consequences of perinatal events. this parameter is particularly jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 7 important for monitoring and assessing health outcomes in high risk groups such as pre-term children and children with developmental difficulties. trends show that serbia has made significant progress towards the millennium development goal relating to infant mortality (13,14). an analysis of routine statistical data, although infant mortality is still above the european union–27 average (for example, in 2010, the eu-27 infant mortality average was 4.1 vs. 6.7 in serbia), suggests that serbia may achieve the proposed national millennium goals in 2015: an infant mortality rate of 4.5 and an under-five mortality rate of 5 per 1000 live births. earlier comparisons of infant mortality revealed rates in serbia two times higher than the eu rates, but this difference has been substantially reduced to date (15,16). recent studies conducted by unicef and other organizations indicate that the majority of the roma population face social disadvantage and exclusion, and most of them live in poverty (17). many roma individuals are also unemployed, have limited education, as well as insufficient access to information, which combined with a lack of trust in institutions often prevent them from using healthcare services in case of need. the multiple indicator cluster surveys (mics), which have been conducted periodically in serbia since 1996 with the help of unicef, have been extremely valuable in gaining a better understanding of the challenges involved. from 2005, these surveys have provided assessments of child mortality in the roma population using the brass method for estimating child mortality taking into account the risk of death to which the children are exposed to (18). although mortality among roma children remains high, the rate has almost halved over the last five years bringing the number closer to the national millennium goal of reducing roma under-five child mortality to 14, and infant mortality to 12. however, the current mortality rate of roma children is still three times as high as the millennium goal set at the national level for serbia (15). according to the world health organization, most deaths of children under the age of five years are due to a small number of diseases and conditions. forty-three per cent of these deaths occur among babies aged 0-28 days (newborns) and are mainly due to preterm birth complications, birth asphyxia and trauma, and sepsis. after the first 28 days until the age of five years, the majority of deaths are attributable to infectious diseases such as pneumonia (22%), diarrhoeal diseases (15%), malaria (12%) and hiv/aids (3%) (8,9). while international efforts to address mortality among children under the age of five have resulted in significant reductions globally, persistent inequities between and within countries exist. these are not only driven by poverty, but are intrinsically linked to social exclusion and discrimination. therefore, continued efforts to eliminate under-five mortality must take into consideration both direct causes and underlying determinants. this requires a comprehensive and holistic approach, which must explicitly recognize human rights’ standards as essential and integral elements. also, poor nutritional status in children is strongly correlated with vulnerability to diseases, delayed physical and mental development, and an increased risk of dying. while, between 1990 and 2011, the proportion of children under the age of five years who were underweight declined by 36%, under-nutrition is still estimated to be associated with 45% of child deaths worldwide. in 2011, there were 165 million children under the age of five years who were stunted, and 52 million who were wasted (10,19,20). low birth weight is closely associated with increased risks of neonatal mortality, cognitive problems and chronic diseases in later life (20). our jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 8 analysis shows that the national average share of live births with low birth weight (under 2,500 grams) has remained constant in serbia in the last decade. the share of low birth weight is significantly higher for roma and poor children. more preventive approaches and consistent efforts for improvement are needed in serbia, to ensure that child health receives the attention and resources needed and secure the benefits that children and families require. identifying the health outcomes that matter most for the children, and set out the contribution that each part of the health system needs to make in order that desired health outcomes are achieved, would be an effective way to reach 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action on social determinants of health. bull world health org 2011;89:702. http://www.childinfo.org/files/mics4_serbia_finalreport_eng.pdf http://www.ncbi.nlm.nih.gov/pubmed/?term=black%20re%5bauthor%5d&cauthor=true&cauthor_uid=23746772 http://www.ncbi.nlm.nih.gov/pubmed/?term=victora%20cg%5bauthor%5d&cauthor=true&cauthor_uid=23746772 http://www.ncbi.nlm.nih.gov/pubmed/?term=walker%20sp%5bauthor%5d&cauthor=true&cauthor_uid=23746772 http://www.ncbi.nlm.nih.gov/pubmed/?term=bhutta%20za%5bauthor%5d&cauthor=true&cauthor_uid=23746772 http://www.ncbi.nlm.nih.gov/pubmed/?term=christian%20p%5bauthor%5d&cauthor=true&cauthor_uid=23746772 http://www.ncbi.nlm.nih.gov/pubmed/?term=de%20onis%20m%5bauthor%5d&cauthor=true&cauthor_uid=23746772 jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 9 13. institut za javno zdravlje srbije “dr milan jovanović batut”. zdravlje stanovnika srbije. analitička studija 1997-2007. beograd: institut za javno zdravlje srbije; 2008. 14. institut za javno zdravlje srbije „dr milan jovanović batut“. republikasrbija.odabranizdravstvenipokazateljiza 2011. godinu. beograd: izjzs; 2012. 15. vlada republike srbije. nacionalni milenijumski ciljevi razvoja u republici srbiji. beograd vs; 2006. 16. vlada republike srbije. progres u realizaciji milenijumskih ciljeva razvoja u republici srbiji. beograd: vs i undp; 2009. 17. unicef. serbia. multiple indicator cluster survey 2005. monitoring the situation of children and women. belgrade: unicef belgrade; 2007. 18. unicef. srbija. istraživanje višestrukih pokazatelja 2010. praćenje stanja i položaja dece i žena. beograd: unicef beograd; 2012. 19. united nations children’s fund/world health organization/world bank. levels and trends in child malnutrition: report 2012; 2012. http://www.who.int/nutgrowthdb/jme_unicef_who_wb.pdf (accessed: may 16, 2015). 20. united nations children’s fund/world health organization. low birth weight: country, regional, and global estimates. unicef: new york; 2004. ___________________________________________________________ © 2015 jovic-vranes et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.who.int/nutgrowthdb/jme_unicef_who_wb.pdf title goes here mahawati e. effect of safety and hygiene practices on lung function among indonesian farmers exposed to pesticides (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5331 p a g e 1 | 11 original research effect of safety and hygiene practices on lung function among indonesian farmers exposed to pesticides eni mahawati1 1environmental health department, faculty of health, universitas dian nuswantoro, indonesia. corresponding author: eni mahawati; addeess: environmental health department, faculty of health, universitas dian nuswantoro, indonesia; e-mail: eni.mahawati@dsn.dinus.ac.id mahawati e. effect of safety and hygiene practices on lung function among indonesian farmers exposed to pesticides (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5331 p a g e 2 | 11 abstract aim: this study aimed to detect lung function impairment in farmers exposed to pesticides related to safety and hygiene practices in pesticide application. methods: this was a cross-sectional study with respondents are 200 farmers who were exposed to pesticides in grobogan, the main agricultural center in central java, indonesia, which has 95.75% agricultural workers. data were collected by a questionnaire-based interview, observation, and spirometry measurement. chi-square and multinomial regression were used for the statistical test. results: the survey results of all respondents showed that 12% had restriction lung function, 32% had obstruction lung function, and 56% had normal lung function. there was a significant effect between work period, pesticide spraying hour per day, spraying against wind direction, changing clothes directly after exposure to pesticides, taking a bath directly after exposure to pesticides with "farmer's lung function" based on statistical test results. conclusion: the safety and hygiene practices of farmers exposed to pesticides could affect their lung function. it is suggested that to improve management and regulation control of pesticide application, educational programs and reinforcement of "safety and hygiene practices" in the workplace as effective approaches for preventing respiratory disorders related to pesticide exposures. keywords: farmer's lung function, hygiene, pesticide, safety. conflicts of interest: none declared. mahawati e. effect of safety and hygiene practices on lung function among indonesian farmers exposed to pesticides (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5331 p a g e 3 | 11 introduction pesticides have been widely utilized in numerous occupational settings, including agriculture, fisheries, forestry, and food (1). occupational pesticide exposure occurs when pesticides are manufactured, transported, and used in the workplace (2,3). agricultural employees are frequently exposed to pesticides even when performing duties unrelated to pesticide application (4-6). pesticides' harmful characteristics constitute a possible threat to human health (7). people exposed to pesticides frequently have respiratory symptoms such as coughing, wheezing, and airway irritation (8). the correlation between occupational pesticide exposure and chronic respiratory disorders such as asthma, chronic obstructive pulmonary disease (copd), and lung cancer has been investigated in epidemiological research (8-10). by 2020, copd is expected to be the third major cause of death (2). appropriate community-based methodologies that assist the optimum development of prevention strategies are essential in preventing and early detection of copd. screening for pulmonary function exams in employees exposed to risk factors is one of the early detection methods for copd. farmers who are exposed to pesticides are one of the workers that are at risk for copd. the objectives of this study were early detection of lung function impairment in farmers exposed to pesticides related to safety and hygiene practices in pesticide application. the hypothesis in this research is safety and hygiene practices of farmers exposed to pesticides could affect their lung function. methods this cross-sectional study was conducted in grobogan, central java, indonesia, in 2015. data were collected by interview with a questionnaire, observation, and measurement of lung function by spirometry. total samples of 200 male farmers in grobogan, central java, indonesia, participated in this research. samples were selected through spirometry measurement and medical records in hospital / primary health centers with the help of local people and health officers. the research area was selected because it is one of the largest agricultural centers in central java, indonesia. inclusion criteria of samples were: i) have a livelihood as farmers ii) age more than or equal to 40 years old iii) gender male iv) willing to be a respondent v) able to communicate well for interviews. exclusion criteria are as follows i) the health condition does not allow the interview or had died during the study period; ii) medical record can not be found. lung function tests of the participants were done by bkpm (lung health centres community) semarang with mir spirolab iii as an instrument for measurement. data were analyzed by a univariate and bivariate statistical test: univariate analysis to describe the frequency distribution of each variable, and the bivariate analysis using chi-square test to determine the correlation. a multinomial regression test was used statistically to assess the effect of safety and hygiene practices onlung function. results based on the data results, the analysis showed that there was farmer's impaired lung function, which consists of restriction and obstruction disorder. there were 112 respondents (56%) with normal lung function, 24 respondents (12%) with restriction, and 64 respondents (32%) with obstruction. it means that almost 50% of respondents showed impaired lung function. mahawati e. effect of safety and hygiene practices on lung function among indonesian farmers exposed to pesticides (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5331 p a g e 4 | 11 table 1. lung function based on spirometry measurement results category of spirometry measurement result σ % normal lung function obstruction restriction 112 64 24 56.0 32.0 12.0 total 200 100.0 table 2. descriptive analysis of lung function parameters based on spirometry test parameter fvc fvc/pred fev1 fev1/pred fev1/fvc mean 2,762.76 95.28 2,143.20 90.27 76.49 median 2,825.00 97.75 2,275.00 94.59 78.02 mode 2,380.00 97.75 2,510.00 100.00 100.00 standard error 55.71 1.90 54.75 2.13 1.11 standard deviation 787.87 26.83 774.23 30.10 15.71 range 3,830.00 131.55 3,310.00 158.20 64.14 minimum 750.00 32.60 390.00 19.63 35.86 maximum 4,580.00 164.15 3,700.00 177.83 100.00 count of sample 200 200 200 200 200 based on interviews and observations on farmers' hygiene and safety practices in spraying pesticides, the following data description is obtained. table 3. safety and hygiene farmer's practices of pesticide application no. safety and hygiene practices aspects % 1. work period as farmer • less than 5 years • 5-10 years • more than 10 years 2.0 4.0 94.0 2. pesticide spraying hour per day • less than 5 hours per day • more than or equal to 5 hours per day 31.0 69.0 3. checking hygiene personal protective equipment before used • never • sometimes • always 8.0 18.0 74.0 4. cleaning personal protective equipment after used • never • sometimes • always 8.0 15.0 77.0 5. eating/drinking while pesticide spraying • never • sometimes • always 97.0 3.0 0.0 mahawati e. effect of safety and hygiene practices on lung function among indonesian farmers exposed to pesticides (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5331 p a g e 5 | 11 no. safety and hygiene practices aspects % 6. smoking while pesticide spraying • never • sometimes • always 2.0 18.0 80.0 7. using the direct pesticide mixing hand • yes • no (using the tools mixer) 7.0 93.0 8. eating/drinking/smoking while mixing pesticide • never • sometimes • always 66.0 28.0 6.0 9. blowing clogged nozzles direct using mouth • yes • no (using a needle / tools ) 16.0 84.0 10. wiping sweat with fabric / clothes exposed to pesticides • never • sometimes • always 57.0 6.0 37.0 11. wash hands after exposure to pesticides • in the river • in the well 55.0 45.0 12. change clothes direct after exposure to pesticides • never • sometimes • always 20.0 18.0 62.0 13. washing clothes direct after exposure to pesticides • never • sometimes • always 90.0 10.0 0.0 14. take a bath direct after exposure to pesticides • never • sometimes • always 20.0 78.0 0.0 the results of hypothesis testing with bivariate and multivariate using "chi-square and multinomial regression test" obtained the following results. table 4. results of data analysis using chi-square statistical test (correlation between safety and hygienic practices with lung function) variables of safety and hygienic practices on pesticide application p-value or 95% ci 1. work period <0.05 4.148 1.798-9.573 2. pesticide spraying hour per day <0.05 3.165 1.176-8.518 3. doing spraying without pay attention to n.s. 1.362 0.289-6.426 mahawati e. effect of safety and hygiene practices on lung function among indonesian farmers exposed to pesticides (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5331 p a g e 6 | 11 wind direction 4. doing spraying againts wind direction <0.05 4.750 2.008-11.236 5. doing spraying when strong wind n.s. 1.417 0.624-3.218 6. checking hygiene personal protective equipment before used n.s. 3.273 0.627-17.071 7. cleaning personal protective equipment after used n.s. 2.136 0.503-9.068 8. eating/drinking while pesticide spraying n.s. 1.285 0.480-3.437 9. smoking while pesticide spraying n.s. 1.285 0.480-3.437 10. using the direct pesticide mixing hand n.s. 1.362 0.289-6.426 11. eating/drinking/smoking while mixing pesticide n.s. 1.195 0.522-2.737 12. blowing clogged nozzles direct using mouth n.s. 1.348 0.460-3.956 13. wiping sweat with fabric / clothes exposed to pesticides n.s. 0.922 0.417-2.035 14. wash hands after exposure to pesticides n.s. 0.556 0.255-1.254 15. change clothes direct after exposure to pesticides <0.05 3.857 1.278-11.638 16. washing clothes direct after exposure to pesticides n.s. 0.392 0.095-1.613 17. take a bath direct after exposure to pesticides <0.05 6.469 2.000-20.917 table 5. results of data analysis using multinomial regression statistical test (effect of safety and hygienic practices on lung function) safety and hygiene practices on pesticide application p-value 1. work period <0.05 2. pesticide spraying hoursper day <0.05 3. doing spraying against wind direction <0.05 4. change clothes directly after exposure to pesticides <0.05 5. take a bath directly after exposure to pesticides <0.05 based on results analysis in tables 4 and 5 above, we can see that there are five aspects of hygiene and safe pesticide spraying practices that are significantly related as a risk factor and influence farmers' impaired lung function. discussion people who work with pesticides directly and frequently are at the most significant risk of exposure in the workplace (3). chemical substances are usually absorbed into the systemic circulation through an external or interior body surface (e.g., skin, mucosa, and respiratory tracts). the concentration of a toxic agent at the absorbing surface, which depends on the rate of exposure and dissolution of the chemical, is connected to the absorption rate of a poisonous agent. it is linked to the exposed site's size, the epithelium layer's features, and the toxicant's physicochemical properties. one of the most significant influences on absorption rate is lipid solubility. lipid-soluble chemicals are more easily absorbed (11). in addition, agricultural workers and their family members are frequently exposed to pesticides at work (4-6), and they can be exposed to significant amounts of pesticides (12). occupational pesticide exposures, whether acute or chronic, are generally at relatively high doses compared to environmental exposures, where levels of exposure tend to be relatively low (2). the major causes of occupational pesticide exposures are accidental pesticide spills, leaks, inappropriate equipment use, and noncompliance with safety rules (3). in occupational settings, respiratory inhalation and cutaneous absorption are the principal routes of pesticide exposure (2,13). when spraying extremely mahawati e. effect of safety and hygiene practices on lung function among indonesian farmers exposed to pesticides (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5331 p a g e 7 | 11 volatile pesticide chemicals, respiratory exposures are common, especially for people working without respiratory protection equipment or in a poorly ventilated working environment (14). according to the findings of this study, farmers had reduced lung function in 12% cases of restriction and 32% cases of obstruction on farmer's lung function. we found that safety and hygiene practices of farmers exposed to pesticides could affect their lung function. the respiratory route accounts for around 10% of overall pesticide exposure in agricultural jobs, with the rest coming from cutaneous absorption or digestion (15). inhalation of pesticidecontaminated aerosols or particulate particles can potentially cause respiratory exposure (pm). gas exchange, which includes perfusion, ventilation, and diffusion, is the lung's primary function. the lung's primary function is to deliver o2 to the body's target organs and tissues while also removing co2, an abundant waste product. figure 1 depicts the responses of the respirometry systems to hazardous substances (11). figure 1. responses of the respirometry system to toxic agents (11) several studies have linked pesticides as hazardous agents in industrial contexts to reduced lung function. for example, a crosssectional study on ethiopian state farms of 102 pesticide sprayers and 69 non-sprayers found that pesticide sprayers aged 15–24 years had significantly lower fev1 and fvc than nonsprayers (16). a similar study conducted among agricultural pesticide sprayers in spain suggested that short-term pesticide exposure was associated with a reduction in fev1. in contrast, long-term pesticide exposure was associated with a reduction in fef25 percent–75 percent (17). cholinesterase inhibition caused by organophosphate or carbamate insecticides was also linked to decreased lung function. exposure to organophosphate and carbamate pesticides was linked to lower fvc, fev1, fev1/fvc ratio, fef25 percent-75 percent, and peak expiratory flow rate (pefr), which was also linked to cholinesterase inhibition, in a matched case-control study of agricultural laborers in india (18). furthermore, a cross-sectional investigation of pesticide sprayers in indian mango plantations found a link between reduced acetylcholinesterase activity and poorer lung function (19). occupational pesticide exposure has been linked to obstructive and restrictive problems in the lungs. the fev1/fvc ratio was lower (but not significantly lower) among farm pesticide sprayers in the spanish study (19), implying an obstructive anomaly. long-term exposure to cholinesterase-inhibiting pesticides was similarly linked to a significant reduction in the fev1/fvc ratio among agricultural laborers in india (20). seasonal low-level exposure to mahawati e. effect of safety and hygiene practices on lung function among indonesian farmers exposed to pesticides (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5331 p a g e 8 | 11 organophosphate pesticides among farmers in sri lanka was linked to a normal fev1/fvc ratio but a decrease in both fvc and fev1 (21), implying a restrictive anomaly. the author of a study of pesticide spraying workers in mango plantations in india suggested that exposure to organophosphate and organochlorine insecticides was linked to a restrictive kind of lung function impairment (22). pesticide poisoning was also linked to reduced fvc and fev1 among current smokers in a study of farm operators and their spouses in colorado, indicating a restrictive defect. the study's findings also revealed that most farmers had compromised lung function, including limitation and obstruction disorders. another cohort study of 364 smallholder farmers in uganda found that exposure to organophosphate and carbamate insecticides can deteriorate lung function (23). according to the research of pesticide exposures among farmworkers, workplace safety and hygiene habits are crucial for preventing pesticide exposures in the workplace (24). safe pesticide application procedures, showering after work, wearing and changing clean clothes between work shifts, and often washing hands at work are all examples of safety and hygiene behaviors in the workplace (25). furthermore, a study of farmers in rural indonesia who used pesticides, including organophosphates, found that those who did not wear a mask/respirator wore wet clothing, wore short-sleeved shirts, had more skin contact with pesticides. those who smoked while spraying had the highest risk of developing health problems (26). unlike other studies, we discovered that the length of daily exposure and the suitability of pesticide spraying direction is the pesticide application practices that have been demonstrated to affect farmers' compromised lung function in the indonesian environment. the requirement for the socialization of safe working methods for farmers in using pesticides and perfecting pesticide application techniques effectively and correctly in copd prevention has implications for public health. pesticide exposure should be limited to 5 hours per day, and pesticides should not be sprayed towards the wind. in this research, we found that farmers do not yet understand the consequences of spraying without regard for wind direction, which will increase chemical exposure in farmers' bodies. one element that farmers often overlook is contact toxicity. if there are abnormalities on the skin and/or sweat, pesticides will be absorbed more effectively through the skin. the accumulation of pesticide exposure on the responders can be of high intensity related to spraying hours per day. spraying time is the number of hours per day that pesticides are used to spray plants. poisoning from pesticides can be reduced if farmers keep their spraying time within the safe range of 1-5 hours. because the longer a person is exposed to pesticides, the greater the danger of poisoning, spraying should be limited to no more than 4-5 hours each day. it was wise to spray pesticides on the respondents in this study at various times during the day, especially in the morning and evening. spraying during the day with high temperatures causes the body's metabolism to speed up, resulting in a larger absorption of pesticides into the body. the environment's temperature is harmful to pesticide spraying farmers if it is higher than the temperature of the human body, which is 37°c. if the ambient temperature is high, the body temperature rises as well. blood vessels dilate to bring them closer to the skin (external environment), allowing heat to escape and more blood in the skin to facilitate heat release by irradiation and sweating. sweat glands have a particular temperature that allows them to collect much heat and release it into the environment when the sweat evaporates. an increase in the effects of harmful compounds in the air can be caused by an increase in temperature combined with sunshine and the development of reactions from one or more secondary pollutants. a hot climate or working environment will significantly impact the pace of chemical reactions in the air, particularly in the employees' bodies, which are constantly exposed. farmers frequently underestimate the mahawati e. effect of safety and hygiene practices on lung function among indonesian farmers exposed to pesticides (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5331 p a g e 9 | 11 hazards of pesticides in pesticide application procedures, resulting in non-compliance with pesticide safety regulations. pesticide poisoning, particularly chronic poisoning, is generally undetectable and has unpredictable results. as a result, most farmers who have been using pesticides in their way for decades have been unaffected. it is widely assumed that the pesticide management procedures used by indonesian farmers are highly hazardous to both themselves and the environment. similarly, the results of this study demonstrate that the pesticide application strategy has not been applied correctly in a safe operating manner and has been shown to impact lung function impairment. pesticide regulations and management, educational programs on safety precautions, and reinforcement of safety behaviors, particularly hygienic and safety practices at work, have been effective approaches for preventing respiratory disorders linked to occupational pesticide exposures in studies. pesticide applicators who were given educational interventions to inform them about the risks of using pesticides and how to reduce pesticide exposure showed changes in perceptions of vulnerability and effectiveness measured by surveys before and after the intervention to determine the sustainable effect, according to rohlman et al. (27). pesticides are increasingly being viewed as a long-term health concern by a growing number of people, and participants' attitudes toward proper pesticide application hygiene are improving (27). this intervention is an example of a low-cost approach that can enhance the pesticide application and personal hygiene practices of teenagers and young adults during and after pesticide application. the strategy could be replicated in other nations with a comparable pesticide application safety culture. another study by bagheri et al. (28) found that continuing education should improve farmers' intentions and behavior toward safe handling of pesticides, i.e., improve hygiene and occupational safety practices (28). farmers' attitudes and behavior control in the safe use of pesticides can be integrated into various interprogram and cross-cutting initiatives. conclusions people exposed to pesticides at work generally had impaired lung function, including limitation and obstruction issues. in conclusion, ongoing education and training programs on the potential health risks of pesticide exposures and the enforcement of "safety and hygiene behaviors" during pesticide handling effectively prevent pesticide exposures and related respiratory disorders. controlling risk factors or early prevention of chronic obstructive pulmonary disease in the community is proposed. references 1. food and agriculture organization. database on pesticides consumption. [internet]. available from: https://www.fao.org/waicent/faoinfo /economic/pesticid.htm (accessed: october 8, 2021). 2. damalas ca, eleftherohorinos ig. pesticide exposure, safety issues, and risk assessment indicators. int j environ res public health 2011;8:1402-19. 3. maroni m, fanetti ac, metruccio f. risk assessment and management of occupational exposure to pesticides in agriculture. med lav 2006;97:430-7. 4. bradman a, salvatore al, boeniger m, castorina r, snyder j, barr db, et al. community-based intervention to reduce pesticide exposure to farmworkers and potential take-home exposure to their families. j expo sci environ epidemiol 2009;19:79-89. 5. coronado gd, thompson b, strong l, griffith wc, islas i. agricultural task and exposure to organophosphate pesticides among farmworkers. environ mahawati e. effect of safety and hygiene practices on lung function among indonesian farmers exposed to pesticides (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5331 p a g e 10 | 11 health perspect 2004;112:142-7. 6. quandt sa, arcury ta, rao p, snively bm, camann de, doran am, et al. agricultural and residential pesticides in wipe samples from farmworker family residences in north carolina and virginia. environ health perspect 2004;112:382-7. 7. calvert gm, plate dk, das r, rosales r, shafey o, thomsen c, et al. acute occupational pesticide‐related illness in the us, 1998–1999: surveillance findings from the sensor‐pesticides program. am j ind med 2004;45:14-23. 8. sanborn md, cole d, abelsohn a, weir e. identifying and managing adverse environmental health effects: 4. pesticides. can med assoc j 2002;166:1431-6. 9. hoppin ja, umbach dm, london sj, henneberger pk, kullman gj, coble j, et al. pesticide use and adult-onset asthma among male farmers in the agricultural health study. eur respir j 2009;34:1296-303. 10. hoppin ja, valcin m, henneberger pk, kullman gj, umbach dm, london sj, et al. pesticide use and chronic bronchitis among farmers in the agricultural health study. am j ind med 2007;50:969-79. 11. klaassen cd. casarett and doull’s toxicology: the basic science of poisons. new york: mcgraw-hill; 2013. 12. pearce m, habbick b, williams j, eastman m, newman m. the effects of aerial spraying with bacillus thuringiensis kurstaki on children with asthma. can j public heal 2002;93:215. 13. proudfoot at, bradberry sm, vale ja. sodium fluoroacetate poisoning. toxicol rev 2006;25:213-9. 14. keifer mc, firestone j. neurotoxicity of pesticides. j agromedicine. 2007;12(1):17–25. 15. hoppin ja, adgate jl, eberhart m, nishioka m, ryan pb. environmental exposure assessment of pesticides in farmworker homes. environ health perspect 2006;114:929-35. 16. zuskin e, mustajbegovic j, schachter en, kern j, deckovic-vukres v, trosic i, et al. respiratory function in pesticide workers. j occup environ med 2008;1299-305. 17. sprince nl, lewis mq, whitten ps, reynolds sj, zwerling c. respiratory symptoms: associations with pesticides, silos, and animal confinement in the iowa farm family health and hazard surveillance project. am j ind med 2000;38:455-62. 18. mekonnen y, agonafir t. lung function and respiratory symptoms of pesticide sprayers in state farms of ethiopia. ethiop med j 2004;42:261-6. 19. hernández af, casado i, pena g, gil f, villanueva e, pla a. low level of exposure to pesticides leads to lung dysfunction in occupationally exposed subjects. inhal toxicol 2008;20:839-49. 20. fareed m, pathak mk, bihari v, kamal r, srivastava ak, kesavachandran cn. adverse respiratory health and hematological alterations among agricultural workers occupationally exposed to organophosphate pesticides: a cross-sectional study in north india. plos one 2013;8:e69755. 21. chakraborty s, mukherjee s, roychoudhury s, siddique s, lahiri t, ray mr. chronic exposures to cholinesterase‐inhibiting pesticides adversely affect respiratory health of agricultural workers in india. j occup health 2009;51:488-97. 22. peiris-john rj, ruberu dk, wickremasinghe ar, van-der-hoek w. low-level exposure to organophosphate pesticides leads to restrictive lung dysfunction. respir med 2005;99:131924. 23. hansen mrh, jørs e, sandbæk a, mahawati e. effect of safety and hygiene practices on lung function among indonesian farmers exposed to pesticides (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5331 p a g e 11 | 11 sekabojja d, ssempebwa jc, mubeezi r, et al. organophosphate and carbamate insecticide exposure is related to lung function change among smallholder farmers: a prospective study. thorax 2021;76:780-9. 24. quandt sa, hernández-valero ma, grzywacz jg, hovey jd, gonzales m, arcury ta. workplace, household, and personal predictors of pesticide exposure for farmworkers. environ health perspect 2006;114:943-52. 25. jensen hk, konradsen f, jørs e, petersen jh, dalsgaard a. pesticide use and self-reported symptoms of acute pesticide poisoning among aquatic farmers in phnom penh, cambodia. j toxicol 2011;639814. 26. sekiyama m, tanaka m, gunawan b, abdoellah o, watanabe c. pesticide usage and its association with health symptoms among farmers in rural villages in west java, indonesia. env sci 2007;14:23-33. 27. rohlman ds, davis jw, ismail a, rasoul gma, hendy o, olson jr, et al. risk perception and behavior in egyptian adolescent pesticide applicators: an intervention study. bmc public health 2020;20:1-10. 28. bagheri a, emami n, damalas ca. farmers’ behavior towards safe pesticide handling: an analysis with the theory of planned behavior. sci total environ 2021;751:141709. ___________________________________________________________________________________________________ © 2022 mahawati; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. muçaj s, ramadani n, kabashimuçaj s, jerliu n, rashiti-byyci a, hoxha s. epidemiological profile and incidence of brain tumors in kosovo (original research). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5708 p a g e 1 | 10 original research epidemiological profile and incidence of brain tumors in kosovo sefedin muçaj1,2, naser ramadani1,2, serbeze kabashi-muçaj1,3, naim jerliu1,2, albiona rashiti-bytyci1,2, sanije hoxha1,2 1 faculty of medicine, university of prishtina, prishtina, republic of kosovo; 2 national institute of public health of kosovo, prishtina, republic of kosovo; 3 radiology clinic, university clinical center of kosovo (ucck), prishtina, republic of kosovo. corresponding author: naser ramadani, md, phd, national institute of public health of kosovo and faculty of medicine, university of prishtina, prishtina, kosovo; address: rr. “instituti shëndetësor”, 10000, prishtina, republic of kosovo; telephone: +38138541432; e-mail: naser.ramadani@uni-pr.edu muçaj s, ramadani n, kabashimuçaj s, jerliu n, rashiti-byyci a, hoxha s. epidemiological profile and incidence of brain tumors in kosovo (original research). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5708 p a g e 2 | 10 abstract aim: brain tumors (bt) are neoplasms developed in intracranial tissues and the meninges. the purpose of this study was to describe the epidemiological features of brain tumors diagnosed and treated at the university clinical center of kosovo (ucck), the only healthcare institution in kosovo that diagnosis and treats malignancies. methods: a 3-year retrospective study (2019-2021) was carried out in the neurosurgical clinic, radiology clinic, and institute of pathology, of ucck. mann-whitney test was used to compare age distribution between males and females. results: a total of 227 patients were treated for bt at the ucck during the three-year period under investigation (that is 2019-2021). there were 119 males (52.4%) and 108 (47.6%) females. the incidence rate of bt for the year 2021 was 4.7/100,000 inhabitants. bt were most common in the age groups: >50 years (n=178, 78.4%), 25-50 years (n=33, 14.6%), whereas 13 cases (5.7%) were children from the age-group ≤14 years. almost one third of the patients (33.9%) were from prishtina region, followed by peja region (18.5%) and mitrovica region (13.2%). from the overall number of cases (n=227), 31.3% (n=71) were benign and 66.1% (n=150) were malignant tumors. the average age of brain tumor patients was 58.4±18.3 years. the most prevalent histological type of bt was meningioma who gr. i (n=57, 25.1%) followed by glioblastoma who gr. iv (n=43, 18.9%) with similar appearances in both genders. most often, tumors had supratentorial/intra-axial localization (63.4%). conclusion: adults over 50 years old represent the most affected age-group for bt in kosovo. meningioma, and glioblastoma were the most frequent bt in kosovo adults. further studies are needed to assess the long-term outcome of patients with bt in kosovo. keywords: brain tumors, epidemiology, kosovo, incidence. muçaj s, ramadani n, kabashimuçaj s, jerliu n, rashiti-byyci a, hoxha s. epidemiological profile and incidence of brain tumors in kosovo (original research). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5708 p a g e 3 | 10 introduction cancer is listed as the leading cause of death and a major obstacle for increasing life expectancy in every country all over the world (1). according to the world health organization (who) data, based on the publications of globocan (international agency for research on cancer), tumors are a major global public health problem, as they are the leading cause of deaths worldwide, causing 7.6 million deaths (13% of all deaths in 2008), while according to a who projection, cancer deaths represent a new increase in mortality, with an estimate of 13.1 million deaths in 2030 (1,2). brain tumors (bt) are a diverse group of neoplasms that grow from intracranial tissues (1,2). brain tumors are classified into two types: primary and metastatic. primary brain tumors form and grow in the brain. metastatic brain cancers develop in other parts of the body and spread to the brain. primary brain tumors can be classified as benign or malignant based on their capacity to penetrate surrounding tissue. in 2015, the global yearly incidence of primary brain tumors was projected to be 3.7 and 2.6 per 100,000 men and women, respectively, with developed countries (5.1/100,000) having a higher rate than developing countries (3.0/100,000) (3,4). brain tumors make up 1.4% of all cancers and 2.4% of all cancerassociated deaths (3,4). the incidence of brain tumors varies in different parts of the world, with a variable course. according to global burden of disease study 2016 (5), there were 330 000 (95% ui 299 000 to 349 000) incident cases of cns cancer and 227 000 deaths globally; east asia was the region with the most incident cases of cns cancer for both sexes (108 000 [95% ui 98 000 to 122 000]), followed by western europe (49 000 [37 000 to 54 000]), and south asia (31 000 [29 000 to 37 000]) (5). the top three countries with the highest number of incident cases were china, the usa, and india. (5) the annual global incidence standardized by the age of primary malignant brain tumors is ~ 3.7 per 100,000 for males and 2.6 per 100,000 for females (6,7). rates appear to be higher in more developed countries (males, 5.8 and females, 4.1 per 100,000) than in less developed countries (males 3.0 and females 2.1 per 100,000). according to the latest statistical reports, the overall incidence of brain tumors for benign and malignant tumors combined is 18.71 per 100,000 persons/year. the most common benign brain tumor in adults is meningioma, with a higher incidence in women, and the most common malignant tumor is glioblastoma, with a higher incidence in adult men (8,9). cancer disease is an increasingly important factor in the global burden of disease in the decades to come, with around 60% of all new cases that occur in developing countries all over the world (8.9). aspects of cancer control should be seen in the context of a systemic and comprehensive approach, such as a cancer control plan or strategy. bt incidence assessment as well as the clinical benefits of early detection of bt are important considerations for policymakers (10,11), considering a bt screening program (12-15). prevention and control of cancer, and in particular bt are among the most important scientific and public health challenges at present. commitment needs to be made in each country to prevent, cure and alleviate cancerous diseases. in kosovo, there is a scarce data and limited studies on cancers (16-18), and especially on bt (18). through this research we aim to contribute to informing policy making and responsible authorities regarding the course, incidence, and epidemiological profile of brain tumors in kosovo. more specifically, this study aimed to determine the epidemiological features of bt diagnosed and treated at the university clinical center of kosovo (ucck), the only tertiary care muçaj s, ramadani n, kabashimuçaj s, jerliu n, rashiti-byyci a, hoxha s. epidemiological profile and incidence of brain tumors in kosovo (original research). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5708 p a g e 4 | 10 institution in the country, according to several variables: years, age, gender, place of residence, and according to the type of tumor, anatomical localization, as well as the comparison of the course of bt over different time periods. methods study design this was a 3-year retrospective study (20192021) carried out in the radiology clinic, institute of pathology and neurosurgical clinic of the university clinical center of kosovo (ucck). all patients hospitalized for the diagnosis of bt throughout the research period were included in the study. more specifically, this study included patients with bt examined and interpreted by magnetic resonance at the radiology clinic, with histopathological confirmation at the institute of pathology, and treated at the neurosurgery clinic at the ucck in prishtina, the only healthcare institution in the country that diagnoses and treats malignancies. we estimate that ucck covers the vast majority of newly diagnosed patients with bt; therefore, the data collected may be considered representative for kosovo. data collection due to deficiencies in the kosovo health reporting system, patients’ registers (hospitalization and outpatient registers) and records of the ucck were used as the data source to identify the patients and then to obtain the data collection from their files. the data obtained included socio-demographic data (age, sex, residence and diagnosis), clinical presentation of each tumor type, histological type, who grading, and localization. the reports of malignant diseases in the national institute of public health of kosovo (niphk), were used as well, for the purpose of the further analysis. this research was carried out in line with the helsinki declaration. according to kosovo legislation only bio-medical studies on human subjects require ethical permission and agreement to participate (19), but the use of personal data for research purposes requires no prior consent from the individual participants provided the data are anonymized before processing (20) which was the situation in this study. personal data processing authorization was received from the ucck’s personal data protection office. statistical analysis descriptive data for 227 bt patients identified between 2019 and 2021 are presented. for this particular period, annual incidence crude rates per 100,000 people were estimated. annual incidence rates at the kosovo level were determined for accuracy by utilizing population data based on the 2011 census. data were analyzed using spss 23.0. categorical variables were presented as frequency (n) and percentages (%). continuous variables were expressed as mean ± standard deviation (sd). mannwhitney test was used to compare age distribution between males and females. the course of new cases over years is presented through the respective equation and trend line. results a total of 227 (n=227) patients were treated for bt at the ucck during the three-year period under investigation (2019-2021). there were 119 males (52.4%) and 108 (47.6%) females. bt were most common in age groups: >50 years (n=178, 78.4%), 25-50 years (n=33, 14.6%), whereas 13 cases (5.7%) were children from the age group <14 years. almost one third of the patients (33.9%) were from prishtina region, followed by peja region (18.5%) and mitrovica region (13.2%) (table 1). muçaj s, ramadani n, kabashimuçaj s, jerliu n, rashiti-byyci a, hoxha s. epidemiological profile and incidence of brain tumors in kosovo (original research). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5708 p a g e 5 | 10 table 1. general characteristics of the study population variables n % age (years) <14 13 5.7 15-24 3 1.3 25-50 33 14.6 >50 178 78.4 gender female 108 47.6 male 119 52.4 regions of kosovo ferizaj 24 10.6 gjakova 16 7.0 gjilan 11 4.8 mitrovica 30 13.2 peja 42 18.5 prishtina 77 33.9 prizren 21 9.3 unknown 6 2.6 out of the total number of new cases of brain tumors reported (n=227), according to the years of diagnosis, the highest number was recorded in 2021 with 81 cases (35.7%), while the lowest number was recorded in 2020 with 67 cases (29.5 %). the highest incidence rate was recorded in 2021 (4.7/100,000 inhabitants), while the lowest incidence rate was in 2020 (3.9/100,000 inhabitants). the average incidence rate for this period of time was 4.4/100,000 inhabitants (table 2). table 2. incidence of brain tumors by years, 2019-2021 years n (%) incidence / 100,000* 2019 79 (34.8) 4.5 2020 67 (29.5) 3.9 2021 81 (35.7) 4.7 total 227 (100) 4.4 * number of inhabitants in kosovo according to the kosovo agency of statistics (ask 2011), approximately 1.74 million residents. the course of linear trend of bt in kosovo during the period 2019-2021 is presented in figure 1. muçaj s, ramadani n, kabashimuçaj s, jerliu n, rashiti-byyci a, hoxha s. epidemiological profile and incidence of brain tumors in kosovo (original research). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5708 p a g e 6 | 10 figure 1. the course of linear trend of brain tumors, according to the years 2019-2021 according to gender, the highest number was recorded in males with 119 cases (52.4%), to 108 cases (47.6%) among women (table 3). table 3. average age and gender of patients with brain tumors, 2019-2021 parameter gender total female male number 108 119 227 mean 57.5 59.1 58.4 sd 18.5 18.2 18.3 min 5 3 3 max 92 87 92 mann-whitney test: p=0.317 the average age by gender of the patients with bt in kosovo during the period 20192021 is also exhibited in figure 2. the average age of patients with bt for the period 2019-2021 was 58.4±18.3 years. the youngest patient was 3 years old, and the oldest one was 92 years old. the average age of female patients was 57.5±18.5 years. the average age of male patients was 59.1±18.2 years. mann-whitney test did not indicate a significant difference in the distribution of age by gender (p=0.317) (table 3 and figure 2). regarding malignant and benign tumors by gender, there was shown a significant difference (chi-square test: p=0.001). malignant tumors are more common in men and benign tumors are more common in women. 79 67 81y = x + 73.667 0 10 20 30 40 50 60 70 80 90 2 0 1 9 2 0 2 0 2 0 2 1 cases linear (cases) muçaj s, ramadani n, kabashimuçaj s, jerliu n, rashiti-byyci a, hoxha s. epidemiological profile and incidence of brain tumors in kosovo (original research). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5708 p a g e 7 | 10 figure 2. average age by gender of patients with brain tumors, 2019-2021 according to the type of tumors, age groups, and gender, the highest number is recorded in the age group 55-59 years with 30 cases (13.2%), with more malignant tumors 20 cases, than benign tumors 10 cases, among them. the lowest number was recorded in the age groups 0-4 years, 20-24 years, and 25-29 years with only 1 case (0.4%) per each age group (table 4). according to the type of tumors (benign/malignant), the highest number was recorded as malignant tumors (n=150, 66.1%), with the most affected being the age group 65-69 years with 27 cases. the lower number was recorded in benign tumors with 71 (31.3%), with the most affected being the age group 70-74 years with 12 cases (table 4). table 4. types of tumors (benign / malignant), by age group and gender, 2019-2021 (malignant and benign tumors by gender: chi-test = 10.24, p = 0.001). regarding their localization, diagnosed brain tumors most often had supratentorial/intraaxial localization (63.4%), followed by supratentorial/extra-axial localization (22.5%), infratentorial/ intra-axial localization (6.6%), infratentorial / extraaxial localization (4.4%) and fewer were cases with supratentorial / intra-axial – extraaxial localization (2.2%). the ratio between supratentorial brain tumors and infratentorial 0 10 20 30 40 50 60 70 80 90 f m ag e ye ar (m ea n ± sd ) 0 4 5 9 1 0 1 4 1 5 1 9 2 0 2 4 2 5 2 9 3 0 3 4 3 5 3 9 4 0 4 4 4 5 4 9 5 0 5 4 5 5 5 9 6 0 6 4 6 5 6 9 7 0 7 4 7 5 7 9 8 0 + n % 1 3 1 1 5 1 1 7 5 10 5 10 12 6 3 71 31.3 2 1 1 6 4 8 3 6 9 4 1 45 19.8 1 1 1 1 4 1 1 1 2 2 4 3 2 2 26 11.5 4 1 1 1 2 4 5 7 17 20 21 27 12 19 9 150 66.1 2 1 2 2 1 6 9 6 6 11 6 3 4 59 26.0 male 2 1 1 2 4 1 8 14 15 16 6 16 5 91 40.1 unknown 3 1 1 1 6 2.6 female 2 1 1 4 1.8 male 1 1 2 0.9 n 1 10 2 2 1 1 7 5 6 14 23 30 26 37 24 25 13 227 100.0 % 0.4 4.4 0.9 0.9 0.4 0.4 3.1 2.2 2.6 6.2 10.1 13.2 11.5 16.3 10.6 11.0 5.7 100.0 malignant total type of tumors by gender and age groups age-groups total female benign female male muçaj s, ramadani n, kabashimuçaj s, jerliu n, rashiti-byyci a, hoxha s. epidemiological profile and incidence of brain tumors in kosovo (original research). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5708 p a g e 8 | 10 brain tumors was 89% to 11% (report 8:1) (table 5). table 5. patients by tumor localization and gender, 2019-2021 gender female male grand total brain tumors by localization total (n=108) total (n=119) (n=227) infratentorial /intra-axial 9 (8.3%) 6 (5.0%) 15(6.6%) infratentorial/extra-axial 7 (6.5%) 3 (2.5%) 10 (4.4%) supratentorial/extra-axial 33 (30.6%) 18 (15.1%) 51 (22.5%) supratentorial/ intraaxial 57 (52.8%) 87 (73.1%) 144 (63.4%) supratentorial/intra-axial – extra-axial 1 (0.9%) 4 (3.4%) 5 (2.2%) unknown 1 (0.9%) 1 (0.8%) 2 (0.9%) without statistical significance between genders and tumor location (infratentorial/ supratentorial), (chi test=0.235, p=0.125). from the overall number of tumors classified according to the who grades (146 cases), the most common was meningioma who gr. i with (n=57, 25.1%) followed by glioblastoma who gr. iv (n=43, 18.9%) with similar appearances in both genders. about 35.7% of the cases remained unclassified with respect to who grading (table 6). table. 6. brain tumors according to who grading and gender, 2019-2021 discussion this study aimed to determine the epidemiological features of bt diagnosed and treated at the ucck, the only tertiary care institution in kosovo, according to an array of characteristics including time period, age, gender, place of residence, and according to the type of tumor, anatomical localization, as well as the comparison of the brain tumors according to who grading and gender total= n (%) n= 108 (%) n= 119 (%) n= 227 (%) adenomae hypophysae 2 1.9 0.0 2 0.9 astrocytoma who gr.i 1 0.9 2 1.7 3 1.3 astrocytoma who gr.ii 0.0 1 0.8 1 0.4 astrocytoma who gr.iii 2 1.9 1 0.8 3 1.3 astrocytoma who gr.iv 0.0 1 0.8 1 0.4 ciste 0.0 1 0.8 1 0.4 craniopharyngioma who gr. i 1 0.9 0.0 1 0.4 ependymoma who gr. i 1 0.9 2 1.7 3 1.3 ependymoma who gr. iv 2 1.9 0.0 2 0.9 glioblastoma who gr.ii 0.0 2 1.7 2 0.9 glioblastoma who gr.iii 2 1.9 1 0.8 3 1.3 glioblastoma who gr.iv 12 11.1 31 26.1 43 18.9 glioma who gr ii 1 0.9 1 0.8 2 0.9 hemangioblastoma who gr.i 0.0 1 0.8 1 0.4 hemangioblastoma who gr.iii 1 0.9 0.0 1 0.4 hemangioma 1 0.9 0.0 1 0.4 medulloblastom who ii 0.0 1 0.8 1 0.4 medulloblastoma who iv 0.0 1 0.8 1 0.4 meningeoma who gr.ii 0.0 1 0.8 1 0.4 meningioma who gr.i 38 35.2 19 16.0 57 25.1 meningioma who gr.iii 1 0.9 4 3.4 5 2.2 neurinoma who gr. i 1 0.9 0.0 1 0.4 oligodendroglioma who gr. ii 3 2.8 3 2.5 6 2.6 primitive neuro-ectodermal tumors (pnet) 3 2.8 1 0.8 4 1.8 unknown 36 33.3 45 37.8 81 35.7 female male total muçaj s, ramadani n, kabashimuçaj s, jerliu n, rashiti-byyci a, hoxha s. epidemiological profile and incidence of brain tumors in kosovo (original research). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5708 p a g e 9 | 10 course of brain tumors over different time periods. our study is in line with previous studies conducted in other countries (21,22) and complies with the recommendations of the american association of neurological surgeons (23). yet, several potential limitations of this study should be mentioned including the time period under investigation (only three years), as well as the possibility of information bias (in particular, recording of cases and the diagnosis). however, the ucck covers the absolute majority of newly diagnosed patients with bt in kosovo thereby providing generalizability of the findings for the whole country. nonetheless, further studies are needed to assess particularly the long-term outcome of patients with bt in kosovo. the cancer registry is an essential part of any reasonable cancer control program and serves to report malignant diseases through the relevant malignancy application form (1618). the cancer registry is an information system designed to collect, manage, and analyze data on people diagnosed with a malignant disease or malignant neoplasms (cancer). currently, the main headquarters of the population cancer registry in kosovo are located at the niphk and constitute the only population cancer registry in kosovo, but there is seemingly an underreporting from healthcare institutions. the installation of the new software canreg5 at the niphk is done in order to increase the quality of analysis and data management for malignant neoplasms. conclusions adults over 50 years old represent the most affected age-group with bt in kosovo. meningioma, and glioblastoma were the most frequent brain tumors in adults. strengthening resources for central cancer registries, collecting and properly reporting data, that is timely, specific, and widely consistent across kosovo is needed to lay the ground for evidence-based research, as well as to advance the prevention of the bt and other central nervous system tumors, through early detection tumors as a future public health intervention. references 1. world health organization (who). global health estimates 2020: deaths by cause, age, sex, by country and by region, 2000-2019. who; 2020. https://www.who.int/data/gho/data/them es/mortality-and-global-healthestimates/ghe-leading-causes-of-death (accessed april 27, 2022). 2. international agency for research on cancer (iarc), 2020. globocan. https://gco.iarc.fr/. 3. american cancer society. cancer facts and figures 2012. atlanta: american cancer society; 2012. 4. cbtrus. statistical report: primary brain and central nervous system tumors diagnosed in the united states in 2004-2008 (march 23, 2012 revision). hinsdale, il: central brain tumor registry of the united states; 2012. 5. patel, anoop p et al. global, regional, and national burden of brain and other cns cancer, 1990-2016: a systematic analysis for the global burden of disease study 2016. the lancet neurology 2019;18:376-93. 6. cancer net (2022). https://www.cancer.net/cancertypes/brain-tumor/ statistics (accessed april 26, 2022). 7. inskip pd, linet ms, heineman ef. etiology of brain tumors in adults. epidemiol rev 1995;17:382414. 8. bondy ml, scheurer me, buffler pa. brain tumor epidemiology: consensus https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death https://gco.iarc.fr/ muçaj s, ramadani n, kabashimuçaj s, jerliu n, rashiti-byyci a, hoxha s. epidemiological profile and incidence of brain tumors in kosovo (original research). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5708 p a g e 10 | 10 from the brain tumor epidemiology consortium (btec). cancer 2008;113(7 suppl):1953-68. 9. who, “global action plan for the prevention and control of ncds 20132020,” 2013a. [online]. available: http ://www.who.int/nmh/events/ncd_action_ plan/en/. 10. ramadani n. epidemiologjia moderne. shkolla kosovare e shëndetësisë publike, prishtinë, maj 2005. 11. national institute of public health of kosovo (niphk), department of his. health statistics reports in kosovo for the years 2019-2021. 12. ramadani n, berisha m, muçaj s, hoxha s, hoxha r, and hatashi m. cancer registry, manual for presenting cases of malignant diseases. niphk, 2017. 13. national institute of public health of kosovo (niphk), department of epidemiology, unit of chronic noncommunicable diseases. reports of health statistics in kosovo, 2019-2021. 14. national program for cancer control in kosovo (npcck). national board for cancer control in kosovo and ministry of health, prishtina, 2017. 15. kabashi s, muçaj s, gashi s, dreshaj s, shala n. radiological imaging detection of tumors localized in fossa cranii posterior. med arh 2008;62:271-4. 16. ramadani n, dedushi k, muçaj s. radiologic diagnosis of spondylodiscitis, role of magnetic resonance. acta inform med 2017;25: 54-7. 17. ramadani n, kreshnike kd, muçaj s, kabashi s, hoxhaj a, jerliu n, bejiçi r. mri verification of a case of huge infantile rhabdomyoma. acta inform med 2016; 24:146-8. 18. berisha m, miftari-basholli f, ramadani n, gashi s, hoxha r, kocinaj d. impact of the national population register in improving the health information system of malignant diseases in kosova. acta inform med 2018;26:62-6. 19. administrative instruction no.05/2012 supervision of professional ethics [internet]. https://msh.rks-gov.net/wpcontent/uploads/2013/11/udhezimadministrativ-05-2012.pdf (accessed april, 30, 2022). 20. kosovo rk. 27. law no. 03/l-172 on protection of the personal data. (03):144. 21. meel m, choudhary n, kumar m, mathur k. epidemiological profiling and trends of primary intracranial tumors: a hospital-based brain tumor registry from a tertiary care center. j neurosci rural pract 2021;12:145-152. doi:10.1055/s-0040-1721622 22. motah m, massi dg, bekolo ff, nju na, ndoumbe a, moumi m, et al. epidemiological profile of brain tumors in cameroon: a retrospective study. egypt j neurol psychiatry neurosurg 2021;57:126. 23. american association of neurological surgeons. brain tumors. https://www.aans.org/en/patients/neuros urgical-conditions-andtreatments/brain-tumors (accessed april, 30, 2022). __________________________________________________________________________________________ © 2022 muçaj et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://pubmed.ncbi.nlm.nih.gov/?term=mu%c3%a7aj+s&cauthor_id=19469268 https://pubmed.ncbi.nlm.nih.gov/?term=gashi+s&cauthor_id=19469268 https://pubmed.ncbi.nlm.nih.gov/?term=dreshaj+s&cauthor_id=19469268 https://pubmed.ncbi.nlm.nih.gov/?term=shala+n&cauthor_id=19469268 https://pubmed.ncbi.nlm.nih.gov/27147810/ https://pubmed.ncbi.nlm.nih.gov/27147810/ https://msh.rks-gov.net/wp-content/uploads/2013/11/udhezim-administrativ-05-2012.pdf https://msh.rks-gov.net/wp-content/uploads/2013/11/udhezim-administrativ-05-2012.pdf https://msh.rks-gov.net/wp-content/uploads/2013/11/udhezim-administrativ-05-2012.pdf https://www.aans.org/en/patients/neurosurgical-conditions-and-treatments/brain-tumors https://www.aans.org/en/patients/neurosurgical-conditions-and-treatments/brain-tumors https://www.aans.org/en/patients/neurosurgical-conditions-and-treatments/brain-tumors djuric p, stevanovic a, rajovic n, todorovic j, laaser u. reproductive health of medical students: exploring knowledge, experiences, and behaviors (original research). seejph 2021, posted: 22 may 2022. doi: 10.11576/seejph-5481 p a g e 1 | 14 original research reproductive health of medical students: exploring knowledge, experiences, and behaviors petar djuric1, aleksandar stevanovic2, nina rajovic3, jovana todorovic2, ulrich laaser4 1 institute of public health of serbia dr. milan jovanovic batut 2 institute of social medicine, faculty of medicine, university of belgrade 3 institute for medical statistics and informatics, faculty of medicine, university of belgrade 4 faculty of health sciences, university of bielefeld, germany corresponding author: prof. ulrich laaser, faculty of health sciences, university of bielefeld, pob 100131, d-33501 bielefeld, germany. e-mail: ulrich.laaser@uni-bielefeld.de djuric p, stevanovic a, rajovic n, todorovic j, laaser u. reproductive health of medical students: exploring knowledge, experiences, and behaviors (original research). seejph 2021, posted: 22 may 2022. doi: 10.11576/seejph-5481 p a g e 2 | 14 abstract introduction: sexually transmitted infections (stis) along with unintended pregnancies, genderbased violence, and gender inequality represent a serious risk to reproductive health in adolescent age. comprehensive sexual education (cse) plays a central role among public health interventions designed to prepare young people for these challenges. the aim of our research was to examine knowledge, experience, and behaviors regarding reproductive and sexual health among the population of medical students, as well as the possible connection between reproductive health, information, and study success. material and methods: a total of 186 second-year and 214 fifth-year medical students were included in the study as a convenient sample taken by random selection. we used a questionnaire of the world health organization designed for adolescent sexual and reproductive health. data were analyzed with the imb spss 25 software. results: for the second-year students, primary source of information about sex are conversations with their family and friends (37.6%), while for the fifth-year students it is the faculty curriculum (34.7%). students with personal experience of stis showed higher average level of knowledge about stis and reproductive health (p=0.011). significant positive correlation between the average grade and the level of knowledge about reproductive health was found (r=0.150; p=0.03). conclusion: this study has shown the diverse sexual life of young medical students in serbia, combined with risky habits and attitudes, also similarly represented in the world. further research is needed in order to formulate public health policies adjusted to the needs of the serbian youth. keywords: reproductive health, sexual health, students, medical; knowledge, behavior. djuric p, stevanovic a, rajovic n, todorovic j, laaser u. reproductive health of medical students: exploring knowledge, experiences, and behaviors (original research). seejph 2021, posted: 22 may 2022. doi: 10.11576/seejph-5481 p a g e 3 | 14 introduction world health organization (who) defines reproductive health as "a state of complete physical, mental and social well-being, not merely the absence of infirmity, in all matters concerning the reproductive system, its functions, and processes. reproductive health implies that people can have a satisfying and safe sex life, to be able to reproduce and to have the freedom to decide whether, when, and how often to do so"(1). acknowledging that people don't partake in sexual relations merely for reproduction, who recognized the need for defining fundamental sexual rights. in its geneva report in 2002 (2), ten fundamental sexual rights were drafted, which are shown in table 1: table 1. ten fundamental sexual rights according to the geneva report in 2002.  highest attainable standard of sexual health, including access to sexual and reproductive health care services  seek, receive and impart information related to sexuality  sexuality education  respect for bodily integrity  choose their partner  decide to be sexually active or not  consensual sexual relations  consensual marriage  decide whether or not, and when, to have children  pursue a satisfying, safe, and pleasurable sexual life as part of a vulnerable population group of young people, students face specific challenges maintaining their reproductive health and well-being. in line with who recommendations on adolescent sexual and reproductive health and rights, we emphasize djuric p, stevanovic a, rajovic n, todorovic j, laaser u. reproductive health of medical students: exploring knowledge, experiences, and behaviors (original research). seejph 2021, posted: 22 may 2022. doi: 10.11576/seejph-5481 p a g e 4 | 14 the need for comprehensive sexuality education (cse), counseling and contraception, safe abortion care, sexually transmitted infections (stis) prevention, and care. instead of being a solid instrument for strengthening individual control over health, there is growing evidence that social media negatively influences sexual habits, behaviors, and knowledge (3,4). pornography and unmoderated online content give a distorted picture of optimal sexual practices and deprive young people of the necessary knowledge to maintain their reproductive health and well-being (5,6). this is why many studies are focused on the sexual habits of young people, especially adolescents, exploring their knowledge, attitudes and practices (7-10). furthermore, specific public health intervention programmes are designed to tackle the growing challenges in maintaining the youth's reproductive health, such as increasing stis in the student population (1113). according to previous research, determinants such as demographic characteristics, socioeconomic status, and sexual orientation are significantly correlated with the student population's level of knowledge about reproductive health, sexual education, and sexual habits (3-5, 15). comprehensive sexuality education (cse) "aims to equip children and young people with knowledge, skills, attitudes, and values that will empower them to maintain their reproductive and sexual health" (16). as future health care providers and medical professionals with scientific knowledge in this field, medical students could be a role model for their peers. in addition to the standard ways of informing themselves about sexual and reproductive health (family, friends, media, internet), medical students also learn about these topics during the medical school curriculum, as well as in different extracurricular activities (workshops, seminars, elective courses). our research aimed to examine knowledge, experience, and behaviors regarding reproductive and sexual health among a population of medical students at the university in belgrade and the potential association between reproductive health knowledge and overall success in higher education. material and methods this cross-sectional study was conducted at the faculty of medicine, university of belgrade, in november 2019. the respondents included in our research were students of the second and fifth years of medical studies. our convenient sample of students was created by randomly selecting classes on two randomly selected days of the week. our research instrument was designed as a questionnaire based on previous work published by john cleland in cooperation with who (17). the questionnaire consisted of 71 multiple-choice questions divided into four segments: sociodemographic characteristics, social and sexual practices, questions on reproductive health, and knowledge assessment. the last segment of the questionnaire was reduced to a series of djuric p, stevanovic a, rajovic n, todorovic j, laaser u. reproductive health of medical students: exploring knowledge, experiences, and behaviors (original research). seejph 2021, posted: 22 may 2022. doi: 10.11576/seejph-5481 p a g e 5 | 14 ten questions, with each correct answer being scored by one point. a maximum of 10 points was given to a student who answered all ten questions correctly (table 2). table 2. test questions on stis and reproductive health knowledge 1. do you think that women can get pregnant during their menstrual bleeding? 2. does hiv mean the same as aids? 3. does an hiv positive person look sick and exhausted? 4. how much time does it take for an hiv test to be certainly positive or negative after a risky sexual intercourse? 5. do you think that hbv infection is common? 6. do you think that hbv can be easily transmitted through sexual intercourse? 7. do you think that hcv can be easily transmitted through sexual intercourse? 8. is syphilis common in our country? 9. which virus causes genital herpes? 10. which microorganisms are often associated with the inability to conceive? statistical analysis the data were processed using the imb spss 25 software. descriptive statistics used were: measures of central tendency, measures of variability and relative numbers, and methods of inferential statistics: a) methods for assessing the significance of difference: chi-square test for categorical data and student's t-test for numerical data, and b) methods for estimation significance of association, spearman rank correlation coefficient. p<0.05 was considered statistically significant. results demographic data the study included 400 subjects, students of the second and the fifth year of integrated academic studies of medicine (186 and 214 students, respectively), of which 105 (26.3%) were male, and 295 (73.7%) were female. the mean age of the subjects in the second year of medical studies was 20.3 ± 1.12 years, in the fifth year, 23.7 ± 1.41 years. no statistically significant difference in age was observed between male and female subjects (p = 0.469). there was a statistically significant difference in the average grade during the study between the secondand fifth-year medical students (p<0.001), i.e., in the second-year students, the average grade was 8.3 ± 0.8, and in the fifth-year students 8.6 ± 0.8. regarding origin, 87% of respondents came from urban areas in serbia and reported that they lived with their parents. students who moved to belgrade mostly lived in rented apartments (33.8%), homes (13.5%), or apartments (9.5%). in terms of work history, 5.2% of fifth-year college students reported being once employed. a more detailed sociodemographic profile of the respondents included in the study is shown in table 3. djuric p, stevanovic a, rajovic n, todorovic j, laaser u. reproductive health of medical students: exploring knowledge, experiences, and behaviors (original research). seejph 2021, posted: 22 may 2022. doi: 10.11576/seejph-5481 p a g e 6 | 14 table 3. sociodemographic profile of second and fifth-year medical students variable in total group p 2nd year 5th year sex, n (%) male 105 (26.3) 52 (28) 53 (24.8) 0.469 female 295 (73.8) 134 (72) 161 (75.2) age (years), mean ± sd 20.3±1.12 23.7±1.41 average grade, mean ± sd 8.5±0.8 8.3±0.79 8.6±0.76 < 0.001* origin village 52 (13) 20 (10.8) 32 (15) 0.206 city 347 (87) 166 (89.2) 181 (85) current accommodation rented apartment 135 (33.8) 62 (33.3) 73 (34.3) 0.073 dorm for students 54 (13.5) 17 (9.1) 37 (17.4) with parents 160 (40.1) 85 (45.7) 75 (35.2) other 12 (3) 4 (2.2) 8 (3.8) own apartment 38 (9.5) 18 (9.7) 20 (9.4) employment yes 15 (3.8) 4 (2.2) 11 (5.2) 0.186 no 384 (96.2) 182 (97.8) 202 (94.8) sd – standard deviation *statistically significant difference if p<0.05 djuric p, stevanovic a, rajovic n, todorovic j, laaser u. reproductive health of medical students: exploring knowledge, experiences, and behaviors (original research). seejph 2021, posted: 22 may 2022. doi: 10.11576/seejph-5481 p a g e 7 | 14 student lifestyle, communication, and ways of informing about sex regarding tobacco products, 115 respondents reported that they were consuming tobacco products, of which 48 (25.8%) of the secondyear students and 67 (31.5%) five-year students. alcoholic beverages are consumed by 276 subjects, 129 of them (69.4%) from the second, and 147 (69.0%) from the fifth year of study. there was no statistically significant difference in the consumption of tobacco products (p=0.214) or alcoholic beverages (p=0.941) between secondand fifth-year students. n=166 (41.6%) state that they go out several times a month, and 42 (10.5%) every weekend. no statistically significant difference was found between the secondand fifth-year respondents regarding the frequency of "a night out" (p=0.576). more than 40%, i.e., 162 (40.9%) mostly talk about sex with family members or relatives, while 234 (59.1%) talk with friends or other people in the area. regarding sources of information for medical students about sex, 37.6% of second-year students are informed about sex through conversations with family and friends, and 18.3% through teaching programmes. in comparison, teaching programmes are the primary source of information for fifth-year students (34.7%), followed by a conversation with family and friends (29.7%). detailed information is presented in table 4. table 4. lifestyles, communication, and ways of informing medical students about sex variable in total group p 2nd year 5th year tobacco consumption, n (%) 115 (28.8) 48 (25.8) 67 (31.5) 0.214 alcohol consumption, n (%) 276 (69.2) 129 (69.4) 147 (69.0) 0.941 amount of alcohol consumption, n (%) 1-2 drinks 137(34.3) 58 (31.2) 79 (37.1) 0.576 3-4 drinks 124 (31.1) 62 (33.3) 62 (29.1) 5 or more drinks 62 (15.5) 28 (15.1) 34 (16) i do not consume alcohol 76 (19) 38 (20.4) 38 (17.8) nightlife, n (%) several times of year 67 (16.8) 30 (16.1) 37 (17.4) 0.943 several times of month 166 (41.6) 76 (40.9) 90 (42.3) every weekend 42 (10.5) 22 (11.8) 20 (9.4) i rarely go out 110 (27.6) 51 (27.4) 59 (27.7) i'm not going out 14 (3.5) 7 (3.8) 7 (3.3) communication about sex, n (%) with family/relatives 162 (40.9) 81 (44) 81 (38.2) 0.241 friends/other 234 (59.1) 103 (56) 131 (61.8) < 0.001* djuric p, stevanovic a, rajovic n, todorovic j, laaser u. reproductive health of medical students: exploring knowledge, experiences, and behaviors (original research). seejph 2021, posted: 22 may 2022. doi: 10.11576/seejph-5481 p a g e 8 | 14 informing about sex, n (%) faculty 108 (27.1) 34 (18.3) 74 (34.7) < 0.001* media 113 (28.3) 61 (32.8) 52 (24.2) physician 26 (6.5) 16 (8.6) 10 (4.7) youth counseling 10 (2.5) 1 (0.5) 9 (4.2) family or friends 132 (33.1) 70 (37.6) 62 (29.1) other 10 (2.5) 4 (2.2) 6 (2.8) extracurricular activities, n (%) 65 (16.3) 26 (14) 39 (18.3) 0.242 *statistically significant difference if p<0.05 basic parameters of sexual (reproductive) health of medical students out of the total number of respondents included in the study, 96.2% of the secondyear students and 91.5% of the fifth-year students stated that they were heterosexual, and 7 (3.8%) and 18 (6.5%) were nonheterosexual orientation (p = 0.052). our respondents most often had their first sexual intercourse at 18. there was a statistically significant difference in the initiation of sexual activity (p = 0.001) in favor of younger students, who, on average, engage in first sexual intercourse almost a year earlier than their older counterparts did (17.54 vs. 18.32, respectively). there is a growing trend in the total number of sexual partners during life, with 25 (14.5%) second-year students having a total of more than three partners, while this is the case for 47 (23.4%) fifth-year students. also, 39 (22.5%) second-year students did not yet have sexual intercourse compared to 21 (10.4%) fifth-year students (p = 0.002). regarding the use of contraceptives and protection against stis, looking at the total number of sexually active fifth-year students, 121 (65.8%) use a condom, while this is the case with 102 (74.5%) second yearsexually active students. detailed information on medical students' sex life and habits is presented in table 5. table 5: basic parameters of sexual and reproductive life variable group p 2nd year 5th year sexual orientation, n (%) number of responses 186 (100) 214 (100) heterosexual 179 (96.2) 194 (91.5) 0.052 non-heterosexual 7 (3.8) 18 (8.5) first sexual intercourse (age in years), mean ± sd 17.54 ±1.25 18.32±2.12 0.001* djuric p, stevanovic a, rajovic n, todorovic j, laaser u. reproductive health of medical students: exploring knowledge, experiences, and behaviors (original research). seejph 2021, posted: 22 may 2022. doi: 10.11576/seejph-5481 p a g e 9 | 14 total number of sexual partners, n (%) number of responses 173 (100) 201 (100) no one 39 (22.5) 21 (10.4) 0.002* one 57 (32.9) 52 (25.9) two 27 (15.6) 39 (19.4) three 25 (14.5) 42 (20.9) more than three 25 (14.5) 47 (23.4) number of emotional partners, median (range) 2 (0-9) 3 (0-20) type of contraception, n (%) number of responses 144 (100) 187 (100) condom 102 (70.8) 121 (64.7) 0.163 oral contraceptive pills 19 (13,2) 26 (13.9) tracking fertile and infertile days 4 (2.8) 5 (2.7) interrupted intercourse method 12 (8.3) 18 (9,6) i don’t use protection 7 (4.9) 17 (9.1) pregnancy, n (%) 3 (1.7) 5 (2.4) 0.661 abortion, n (%) 3 (1.9) 7 (3.4) 0.357 sd – standard deviation *statistically significant difference if p<0.05 the level of reproductive health knowledge and safe and risky sexual practices a statistically significant difference in reproductive health knowledge was found between those with and without previous experience of stis (p=0.011) showing that those who experienced stis have higher level of knowledge. students aware that condom is not an effective method for protection of all sexually transmitted infections have shown statistically higher level of knowledge on reproductive health (p<0.001). no difference was found in number of correct/incorrect answers and other respondents' risky attitudes and practices. furthermore, a slight positive significant correlation between the average grade during the study and the level of knowledge about stis, could be identified (spearman rank correlation r=0.150; p=0.03). discussion the results of our study indicate that a significant number of medical students at the university of belgrade consume tobacco products (28.8%), which does not match the results of the similar research in hungary reported last year (18), where is a higher prevalence of consumption of smokeless tobacco forms, as well as among medical students at saint louis university in missouri 6.6% (19). this speaks in favor of the fact that tobacco consumption is more represented in our area than in other developed countries (20-22). djuric p, stevanovic a, rajovic n, todorovic j, laaser u. reproductive health of medical students: exploring knowledge, experiences, and behaviors (original research). seejph 2021, posted: 22 may 2022. doi: 10.11576/seejph-5481 p a g e 10 | 14 when it comes to alcohol consumption, our students consume alcohol to a similar extent as students in the world, which is confirmed by the mentioned studies (23, 24). it is essential to emphasize that alcohol is an independent risk factor for risky sexual habits, such as promiscuity and sexual aggression (23,25), and is also associated with a higher prevalence of hiv infection among the general and especially student population (26-28). interestingly, the sources of information on sex and reproductive health differ concerning the year of study and emphasize the positive impact of teaching at the faculty, where we notice that fifth-year students acquire information and necessary knowledge through lectures (34.7%), unlike their younger colleagues. the latter reach them first through conversations with relatives and friends (37.6%) or the media (32.8%). this is also confirmed by the swiss study from 2019 and turkey (29,30). however, nursing and medical students from madrid university (31) most often access information about sex and contraception through the internet. in our study, there was a statistical trend to more openly express personal sexual orientation among older students (8.5%), which is very important because homosexuality has been associated for years with more unrestrained sexual habits, as well as a higher prevalence of stis, primarily hiv infection and aids (32) and especially such students in foreign schools have been the subject of stigmatization and harassment (32,33). additionally, one of the reasons for this population's reproductive and sexual health vulnerability could be the provision of poor-quality service by health workers (34). similar results were obtained by quetta and co-workers in their study with the population of chinese medical students from 2016 (35), but also in a survey conducted in bosnia and herzegovina in 2017 (36). when we examined the contraception and sti prevention method among our students, we found that the dominant instrument of protection was a condom in both groups of respondents, younger (70.8%) and older (64.7%). however, it was noticed that 9.1% of fifth-year students do not use any protection. if we take into account that the practice of interrupting intercourse mainly implies not using protection, it can be said that 18.7% of our sexually active fifth year students do not use protection. in a greek study among medical students, dinas and colleagues showed that a condom is the main instrument for protection against unwanted pregnancy (45.1%). still, oral contraceptive pills are more common (4.9%), and 4.9% of female students stated they did not use protection (37). in 17 % of cases, spanish students declared that they don't use contraception (38). the study results also indicate that students of the younger generation (second year of study) entered the first sexual intercourse on average a year earlier than their older colleagues from the fifth year of study. these results coincide with the results of other studies (39,40). conclusions the results of our study show the diverse sexual life of young medical students in djuric p, stevanovic a, rajovic n, todorovic j, laaser u. reproductive health of medical students: exploring knowledge, experiences, and behaviors (original research). seejph 2021, posted: 22 may 2022. doi: 10.11576/seejph-5481 p a g e 11 | 14 serbia, combined with risky habits and attitudes, which are similarly represented in the world. however, there is still not enough knowledge and awareness about the importance of stis, the development of healthy lifestyles, and within that, sexual habits and attitudes. thus, we could ensure the preservation of the reproductive health of the generative population of our country, and first of all, medical students who are future providers of health and educational services. it would be interesting to conduct a similar national study among younger adolescents and high school pupils to design and implement more effective prevention programs at the beginning or before the start of sexual activities of young people. references 1. 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(editorial). seejph 2021, posted: 11 november 2021. doi: 10.11576/seejph-4882 editorial the editors of the south eastern european journal of public health (seejph) proudly present a collection of papers authored by young african scientists in honor of dr. hideyo noguchi (1876‒1928), the famous japanese bacteriologist (see the introductory editorial information). although the publication is in english, it also collects contributions from several francophone countries in subsaharan africa. as the authors may go for the hideyo noguchi competition, we did not modify the submitted papers’ content to not interfere with the selection process. however, we invite minor corrections e.g. of misspellings etc. if later detected. we are, nevertheless, highly impressed by the quality, engagement, and originality of the contributions examining the status of universal health coverage in one of the most disadvantaged regions of the world, with insufficient health infrastructure and investment, aggravated by the permanent outmigration of qualified personnel and the current covid19 pandemic. the editors are very grateful for the permanent and effective support of prof. flavia senkubuge, chair who/afro african advisory committee on research and development and president colleges of medicine of south africa, vice-president african federation of public health associations. genc burazeri meri roshi ulrich laaser executive director technical editor board of editors alaze a.,coomans s., dimitsaki p., mol m., smith-cornwall m.. time for action towards a sustainable future: α policy brief for “green supermarkets”. seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4686 p a g e 1 | 12 policy brief time for action towards a sustainable future: a policy brief for “green supermarkets” anita franziska alaze1, saskia karina coomans1, persefoni dimitsaki1, maud alline mol1, matilda smith-cornwall1 1faculty of health, medicine, and life sciences, maastricht university, the netherlands corresponding author: s.k. coomans, s.coomans@student.maastrichtuniversity.nl mailto:s.coomans@student.maastrichtuniversity.nl alaze a.,coomans s., dimitsaki p., mol m., smith-cornwall m.. time for action towards a sustainable future: α policy brief for “green supermarkets”. seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4686 p a g e 2 | 12 abstract context: climate change is considered to be the greatest threat to global public health. it affects our food and water sources, the air we breathe and the weather we experience. climate change is equally harmful to supermarkets: 95% of the current food supply is at risk from climate change. as fewer products become available, costs will increase not only for consumers but also for purchasers. the european green deal functions as a secure foundation to create a business that is focused on the protection of the environment. the aim of this policy brief is to guide industry leaders on how to transform supermarkets to function in a more sustainable way and mitigate negative environmental impacts. policy options: three policy options are presented for discussion: reduction of food waste, reduce energy efficiency, reduce plastic packaging. supermarkets are a major factor in climate change contributing to food waste, high energy use and plastic pollution, each with negative effects. we see an urgent need and opportunity for supermarket chains to act. these policy options are presented in conjunction to allow for maximum effect of action. recommendations: supermarkets should reduce fossil fuel use in transport, storage, and delivery, incorporating sustainable design into practice. landfill and food waste should be minimised by an improved supply chain management. harmful packaging should be diminished or replaced by alternative materials providing customers with more sustainable options. keywords: climate change, european green deal, energy waste, food waste, sustainability acknowledgments: the authors would like to acknowledge and thank john middleton (aspher) for his help and support in the development of this policy brief and his insight into the field of public health during this process. special thanks to katarzyna (kasia) czabanowska for her guidance and assistance throughout all the stages of the policy brief development. authors’ contributions: all authors contributed equally to this work. conflicts of interest: none declared funding: none declared alaze a.,coomans s., dimitsaki p., mol m., smith-cornwall m.. time for action towards a sustainable future: α policy brief for “green supermarkets”. seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4686 p a g e 3 | 12 introduction global greenhouse emissions output declined briefly because of covid-19, but this is not sufficiently slowing down the process of climate change (mcsweeney & tandon, 2020). covid has shown how quickly the climate began to recover from the damage done by human actions. we need to act immediately and start changing the design of key industries, such as supermarkets. supermarkets are a focal point in society but are insufficiently maintained and contribute heavily to food waste, plastic consumption, and energy loss. food production produces greenhouse gas emissions along the entire food supply chain, and those emissions are produced in vain if food is wasted (scholz et al., 2015). by changing current practice, supermarkets will make a large difference in the fight against climate change, avoid carbon taxes newly proposed by the european commission, and help to improve population health. with this policy brief, we want to guide the supermarkets and their managers towards a more sustainable way and mitigate negative environmental impacts, in line with the european green deal (2019). supermarkets can act as drivers by serving as an example of best practice towards sustainability and lead the way for other supermarkets to act (baig et al., 2020). three areas of improvement will be outlined in this brief to inspire managers to become leaders who are committed to promoting affordable, environmentally friendly, and ethical food provisions. we aim to secure a safe and sustainable future. climate change is defined as a long-term change in the average weather patterns that have come to define earth’s local, regional, and global climates (shaftel, n.d.). it is one of the major concerns in the 21st century and is considered the greatest threat to global health (poursafa et al., 2015; world health organization, 2020a). climate change affects our food and water sources, the air we breathe and the weather we experience, increasing the frequency and intensity of heatwaves, droughts, and extreme rainfalls (crimmins et al.,2016; leonard, 2020). this presents challenges to agriculture and food security, impacting nutrition and human health. climate change is due, in large part, to human activities. known, avoidable, environmental risks cause about one-quarter of all deaths and disease burden worldwide, amounting to thirteen million deaths each year (world health organization, 2020b). context climate change is defined as a long-term change in the average weather patterns that have come to define earth’s local, regional, and global climates (shaftel, n.d.). it is one of the major concerns in the 21st century and is considered the greatest threat to global health (poursafa et al., 2015; world health organization, 2020a). climate change affects our food and water sources, the air we breathe and the weather we experience, increasing the frequency and intensity of heatwaves, droughts, and extreme rainfall (crimmins et al.,2016; leonard, 2020). this presents challenges to agriculture and food security, impacting nutrition and human health. climate change is due, in large part, to human activities. known, avoidable, environmental risks cause about one-quarter of all deaths and disease burden worldwide, amounting to thirteen million deaths each year (world health organization, 2020b). climate change is not only a serious threat to public health; it is also threatening the economy. adverse impacts of climate change are already being felt across europe. extreme weather is causing economic losses for farmers and for the eu’s agriculture sector (european environment agency, 2019). without alaze a.,coomans s., dimitsaki p., mol m., smith-cornwall m.. time for action towards a sustainable future: α policy brief for “green supermarkets”. seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4686 p a g e 4 | 12 reducing greenhouse gas emissions – the primary cause of global warming – some of the most common food products will no longer be available or affordable (world wide fund for nature, 2015). in fact, 95% of the food supply is at risk from climate change. many regions will experience declines in crop and livestock production from increased heat (hatfield et al., 2014). moreover, climate change has driven up food prices by twenty per cent over the past decade. as fewer products will be available, the costs will increase not only for consumers but also for purchasers, with knock-on effects on customer satisfaction, store offering and market value (carrington, 2018). a fifth of the food that is produced in europe becomes waste (condamine, 2020). if we continue without change, food prices and supply-chain instability will rise further (carrington, 2018). supermarkets are in a position to make a difference. if supermarkets take action against climate change, now they can solve these issues and protect their business. the green deal, resolved in 2019, intends to address climate change and environmental challenges by promoting climate neutrality and reducing carbon dioxide emissions by compensating for any remaining emissions, such as removing carbon from the atmosphere or supporting sustainable projects (european commission, 2019; european council & council of the european union, n. d.). furthermore, the primary aims of the green deal are to promote citizen health and a resource-efficient economy while developing economic growth, sustainability and inclusiveness. the role of supermarkets in climate change is taken up in the european green deal through the ‘farm to fork’ strategy which includes the following steps: sustainable food production, sustainable food processing and distribution, sustainable food consumption, food loss and waste prevention. additionally, the green deal aims to introduce carbon taxes in alignment with climate objectives (european commission, 2019). for this reason, developing a sustainable supermarket that reduces carbon dioxide emissions will also reduce long-term expenditures for supermarkets. the european green deal offers the window of opportunity to create a business that is supported both politically and economically. it gives an incentive to protect the environment without fear of economic loss. the european green deal functions, therefore, as a secure foundation to create a business that is focused on the protection of the environment. conforming to this legislation provides supermarkets with the first steps of becoming sustainable. energy, food waste, and plastic packaging have a high negative contribution to climate change. large changes can be made in these areas, with low opportunity cost to supermarkets. this policy brief, therefore, focuses on these three important areas for change. policy options due to the complex nature of climate change, we are addressing several policy areas within this brief. these are energy efficiency, food waste, and packaging. these three sectors have the greatest opportunity to reduce environmental impact directly. supermarkets are energy-intensive buildings due to the equipment necessary to preserve fresh food and the regulation of temperature for customers, but this energy use can be both sourced and managed more sustainably. unnecessary food waste both pollutes and places strain on land use and can be managed through changes to supply management, and supermarket packaging can be rethought to reduce landfill contributions. furthermore, supermarkets can contribute to the eu ‘energy roadmap 2050’, prioritising the implementation of energy efficiency measures and the reduction of emissions (lopez-menendez et al., 2014). alaze a.,coomans s., dimitsaki p., mol m., smith-cornwall m.. time for action towards a sustainable future: α policy brief for “green supermarkets”. seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4686 p a g e 5 | 12 energy efficiency in and outside supermarkets, and transport providing sustainable energy as well as reducing energy consumption are key factors in tackling climate change (lópez-menéndez et al., 2014). improving energy efficiency is the cheapest and usually, the most immediate way to reduce greenhouse gas emissions that negatively impact health (environmental and energy study institute, n.d.). there are great opportunities for efficiency improvements in supermarkets. merely by adjusting the current energy consumption to specifically fit customer’s needs, up to fifteen per cent can be reduced without a need for capital investment (zhang et al., 2014).first, improvements can be achieved in refrigeration systems and heating, ventilation, and air conditioning systems (hvac). supermarkets are energy-intensive buildings because of the equipment necessary to keep food fresh and temperature regulated. the largest consumption of energy inside supermarkets occurs in hvac and lighting (timma et al., 2016). by reducing the relative humidity in the supermarket by as little as 5%, the total store energy load can be reduced by 4.84%, leading to significant energy and cost savings (bahman et al., 2012). secondly, an energy management system can help to identify failures in a timely manner and help to reduce excessive energy consumption (timma et al., 2016). moreover, solar panels as a renewable energy source have elicited the most positive attention because of their low pollution and the endless supply of solar energy. they represent an important energy source for a supermarket (qi & zhang, 2017).transport is another area to reduce energy as it accounts for a quarter of the greenhouse gas emissions in europe. to achieve climate neutrality by 2050, 90% of the transport emissions must be avoided (european commission, 2019). transport from the food production site to the final supermarket can include road, rail, aviation, and waterborne transport (european commission, 2019), which must all be considered when aiming to reduce co2. a shift to local produce or shorter supply chains strengthens the economy through supporting local farmers but also decreases transport emissions which contribute to air pollution. reducing the weight of the products through intelligent packaging also contributes to the reduction of greenhouse gases. energyefficient vehicles such as plug-in hybrids and fully electric vehicles generates fewer emissions and could be incorporated into current practise (environmental and energy study institute, n.d.).as stated in the european green deal, the construction of new buildings requires a large amount of energy. therefore, the renovation of energyinefficient buildings should be a priority (european commission, 2019). changes in existing buildings can be made to reduce energy usage and costs. these may include small actions, such as choosing led light bulbs and energy-efficient technologies, or greater efforts such as upgrading insulation and weatherization (environmental and energy study institute, n.d.). food waste food waste is defined as the avoidable or unavoidable waste of food items intended for consumption. food waste occurs at different stages in the production chain and results from decisions and actions by retailers, food service providers and consumers (food and agriculture organization of the united nations, n. d.; tonini et al., 2018). twenty per cent of all the food that is produced in europe becomes waste (condamine, 2020). with the population projected to increase to nine billion by 2050, it is urgent to reduce food waste and promote sustainability in order to preserve land use and food supply (bond et al., 2013). additionally, reducing food waste is one of the cheapest options for supermarkets to become more sustainable. alaze a.,coomans s., dimitsaki p., mol m., smith-cornwall m.. time for action towards a sustainable future: α policy brief for “green supermarkets”. seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4686 p a g e 6 | 12 supermarkets, who are or would be affected by this in the future, have the interest to contribute as little as possible to climate change and use the available food in the best possible way. this section addresses two policy options for combating food waste within supermarkets: supply chain management and cosmetic standards. chain management the agricultural sector, the food processing industry and the distribution sectors are connected through the food supply-chain (deloitte, n.d.). the supply-chain includes food production, processing, distribution, consumption, and disposal (european union., 2017). to achieve a sustainable food supply chain within a supermarket, the following options need to be considered (baig et al., 2020). high levels of waste are present in the food, water, packaging, and energy sectors (bond et al., 2013). there is a lack of awareness regarding the economic costs of food waste within the food production process (bond et al., 2013). more importantly, within food supply-chains food waste is normalized and seen as collateral damage. these costs can be eliminated through management practices which consider consumer’s expectations and act to make a difference (mena & whitehead, 2008). supermarkets need to focus on improving their sustainability by enhancing the impact of supply-chain management within this process (bond et al., 2013). whenever the supply-chain management applies adaptable forecasting methods, they are able to predict food demands and adjust the number of orders, preventing food waste and land strain through overproduction. more adaptable forecasting methods will eventually lead to saving costs. the consumer plays a key role in forecasting production. when the consumer makes sustainable demands, this leads to a supply of sustainable products and a sustainable foodsupply chain (welch et al., 2018). cosmetic standards cosmetic food standards regulate the appearance, weight, and colour of food items, setting a ‘standard’ that is not limited to the nutritional quality or food safety (de hooge et al., 2018). current, strict cosmetic standards that streamline attractive products to customers contribute to food waste further down the supply chain by limiting the amount of edible produce that reaches stores. rejected produce cannot enter the market as readily, often being ploughed back into the ground, used as animal feed, or simply wasted (de hooge et al., 2018). this promotes food insecurity through increased yield demand on farmers and arable land. rejection can affect up to 40% of total yields (bond et al., 2013). customers are shown to have become more willing to accept ‘ugly’ products due to growing concern for the environment (bond et al., 2013). with a shift in a consumer mentality and greater climate awareness occurring, an adaptation of the cosmetic limitations of saleable produce may increase consumer satisfaction and the brand image of retailers. relaxing cosmetic standards also offers the opportunity to provide consumers with cheaper options, compared to products with higher aesthetic ratings. by utilising the full extent of edible food produced, supermarkets are able to reduce food waste and increase the amount of food on offer to their customers, often with a lower associated cost. this has the added benefit of making healthy and high-quality foods more affordable and helps people with a lower socioeconomic status, reducing nutritional poverty. packaging food packaging intends to preserve nutrition and shield commodities from external alaze a.,coomans s., dimitsaki p., mol m., smith-cornwall m.. time for action towards a sustainable future: α policy brief for “green supermarkets”. seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4686 p a g e 7 | 12 degradation factors. glass, metal, paper, and plastic are substances that are mostly utilized to produce packaging (marsh & bugusu, 2007). constancy, adaptability, and costeffectiveness are some of the characteristics that qualify plastic as one of the most popular raw materials in the manufacturing industry (napper et al., 2020). research has shown that the weight of the products and thus the manufacturing costs would quadruple if the industry were to use materials other than plastic and double energy use (association of plastics manufacturers in europe, 2001). however, extensive utilization of plastic generates crucial ecological issues, such as waterway pollution. between five to thirteen tons of plastics leak into the oceans annually, contaminating our planet (wijngaard et al., 2020; rhein & schmid, 2020). in 2020, 330 million tonnes of plastic packaging was used, a significant proportion of which is nonrecyclable and single-use (napper et al., 2020; hatzidakis & ioannidou, 2018; rhein & schmid, 2020). universally 84% of packaging waste is not recycled (hatzidakis & ioannidou, 2018). the recycling industry cannot process current plastic volumes. much of this packaging uses mixed materials or coloured plastics that cannot be easily separated and are not easily recycled (association of plastics manufacturers in europe, 2001). packaging which is manufactured from blended materials offsets the ecological benefit of recycling due to the immense demands of energy needed. instead of relying on recycling alone to solve the problem, supermarkets need to reduce the amount of plastic that is used and shift to alternatives where this is not possible. removal of unnecessary packaging and adoption of cardboard, clear recyclable plastics, and food-safe bio-plastics such as pla will reduce the amount of packaging sent to landfill and help to reduce the impacts of the food industry (van den oever et al., 2017). recommendations from the policy options discussed above, the following six recommendations are suggested. these recommendations are proposed on the basis that they promote a sustainable future in line with the vision of the european green deal, providing guidance for action and considering the economic concerns of stakeholders. energy • measures to reduce energy wastage and greenhouse gas emissions should be implemented in all retail and corporate spaces and phase out the use of fossil fuels in transport, storage, and delivery: use of solar or wind energy and sustainable refrigeration, heating, and lighting systems. integrate an energy management system. a focus on the redesign of existing heating, refrigeration, and lighting systems should be made a priority as this is a primary source of energy and cost inefficiency with great scope for improvement, e.g., adapted defrosting and lighting control technologies like energy management systems to save energy. switch to electric vehicles and local delivery services and fuel-free options such as bikes. maximize the efficiency of transport through better utilization of container space. • incorporate sustainable design practices into the design, construction and maintenance of all new retail and corporate spaces. include heat recovery systems in design and place fruits or vegetables next to cooling areas (kauko et al., 2016). use stand-alone supermarkets with optimal size, shape, and proper insulation for the highest energy efficiency. avoid many windows and, if alaze a.,coomans s., dimitsaki p., mol m., smith-cornwall m.. time for action towards a sustainable future: α policy brief for “green supermarkets”. seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4686 p a g e 8 | 12 practical, introduce solar panels. heat recovery (from refrigeration) is the most energy-efficient method (karampour et al., 2016) as it can cover a great share of the heating demand. the size, shape, and insulation of a supermarket are critical for the highest possible energy efficiency. food waste and supply chain management • reduce store contributions to landfill and food wastage at all levels of the supply chain. supermarket chains should monitor and order more wisely. adaptable ordering and control systems increase the accuracy of demand forecasting and reduce unnecessary waste. supermarkets should invest in artificial intelligence and more sophisticated monitoring algorithms. furthermore, unsold food still fit for human consumption should be donated to homeless shelters, and food banks to reduce hunger and landfill contributions. adopting food donation schemes also has the benefit of positive publicity at negligible cost. for example, in the netherlands arrangements can be made with ‘leger des heils’ to pick up food that is still fit for human consumption that would end up in trash otherwise. • invest in sustainable supply chain management and abolish cosmetic standards of fresh products. supermarkets should invest in sustainable methods and adopt shorter supply chains. retailers have bargaining power within the supply chain and should engage suppliers through the promotion of sustainable practices, such as promoting organic and sustainably sourced products and adopting proceeds schemes where a portion of the profit is invested in the local agricultural infrastructure. nutrition and sustainable practices should be considered over aesthetic ideals. ‘ugly’ fruit and vegetable options should be made available to maximize usable product and decrease pressure on production systems. packaging • promote a culture of minimizing unnecessary packaging materials and diminish plastic consumption. although packaging, in general, prolongs the life span of products, the food industry and supermarkets should focus on more sustainable solutions. many products are packaged deliberately and for cosmetic reasons. supermarkets should implement a strategy of essential packaging; in other words, products should be packaged for utility reasons with the most eco-friendly material and not for commercial aims. • give clients greener options! educate customers and sensitize them to the results of extensive waste, especially regarding plastic waste footprint to our planet. give information and tips for proper recycling procedures in supermarkets. most plastic waste is unable to be recycled due to inappropriate disposal. supermarkets should ensure that all packaging materials are clearly labelled by type, giving information on recycling options. providing recycling waste containers in store for plastics that are not collected kerbside, with clear instructions to customers specified through signs and digital media. conclusions we need industry leaders who are committed to a sustainable future. the effects of climate change are now visible across europe with alaze a.,coomans s., dimitsaki p., mol m., smith-cornwall m.. time for action towards a sustainable future: α policy brief for “green supermarkets”. seejph 2021, posted: 18 august 2021. doi: 10.11576/seejph-4686 p a g e 9 | 12 the action proposed through the european green deal to introduce carbon taxes and other measures. if retailers implement ambitious “green” measures, now, they will stay ahead of change and ahead of their competitors. supermarkets and shareholders that promote the sustainable practice and act on climate change are better situated to serve and retain customers, today and in the long run. taking action now will not only protect the health of the citizens but will contribute to creating a viable future in a changing world. references 1. association of plastics manufacturers in europe, (2001) retrieved from 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https://wwf.panda.org/wwf_news/?256679/impact-of-climate-change-on-global-food-supply-chains-starting-to-be-visible--wwf-report https://wwf.panda.org/wwf_news/?256679/impact-of-climate-change-on-global-food-supply-chains-starting-to-be-visible--wwf-report https://wwf.panda.org/wwf_news/?256679/impact-of-climate-change-on-global-food-supply-chains-starting-to-be-visible--wwf-report https://doi.org/10.1016/j.cie.2014.05.002 https://doi.org/10.1016/j.cie.2014.05.002 https://doi.org/10.1016/j.cie.2014.05.002 https://doi.org/10.1016/j.cie.2014.05.002 chain management the agricultural sector, the food processing industry and the distribution sectors are connected through the food supply-chain (deloitte, n.d.). the supply-chain includes food production, processing, distribution, consumption, and dis... cosmetic standards cosmetic food standards regulate the appearance, weight, and colour of food items, setting a ‘standard’ that is not limited to the nutritional quality or food safety (de hooge et al., 2018). current, strict cosmetic standards that s... packaging food packaging intends to preserve nutrition and shield commodities from external degradation factors. glass, metal, paper, and plastic are substances that are mostly utilized to produce packaging (marsh & bugusu, 2007). constancy, adaptability, and cost-effectiveness are some of the characteristics that qualify plastic as one of t... recommendations south eastern european journal of public health special volume no. 1, 2022 the population's health: could south eastern europe do better? jacobs publishing house p a g e 1 | 4 executive editor prof. dr. genc burazeri phd faculty of medicine, st. dibres, no. 371, tirana, albania, and caphri, faculty of health, medicine and life sciences, maastricht university, 6200 md, maastricht, the netherlands email: genc.burazeri@maastrichtuniversity.nl and: gburazeri@gmail.com skype: genc.burazeri volume editor prof. dr. jadranka bozikov university of zagreb, school of medicine, andrija štampar school of public health rockefeller st. 4, zagreb, croatia orcid: 0000-0002-1159-9675 email: jadranka.bozikov@snz.hr skype: jadranka.bozikov assistant executive editor kreshnik petrela ba tirana, albania email: kreshnikp@gmail.com technical editor meri roshi ba tirana, albania email: meriroshi90@gmail.com publisher dr. hans jacobs jacobs publishing house am prinzengarten 1 d 32756 detmold, germany email: info@jacobs-verlag.de phone: +49 5231 6161885 the publication of the south eastern european journal of public health (seejph) is organised in cooperation with the bielefeld university library. https://www.seejph.com/index.php/seejph/management/settings/context/mailto:genc.burazeri@maastrichtuniversity.nl https://www.seejph.com/index.php/seejph/management/settings/context/mailto:genc.burazeri@maastrichtuniversity.nl https://www.seejph.com/index.php/seejph/libraryfiles/downloadpublic/126 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general public license http://dnb.ddb.de/ p a g e 4 | 4 editorials the population's health: could south eastern europe do better? jadranka božikov original research health of the slovenian population: where do we stand? lijana zaletel-kragelj, kaja batista, marusa bertoncelj, aljaz brlek, tanja carli, manja grasek, martina horvat, ines kebler, ana mavric, matija mozetic, denis opresnik, mirjam rozic, anja strmsek, nastja sivec, vesna smarcan, blaz vurzer, kristina zadravec, rok zaletel, andreja kukec, ivan erzen learning needs assessment among professional workers in community mental health centres in slovenia: study protocol anja kragelj, majda pahor, lijana zaletel-kragelj, irena makivic reproductive health of medical students: exploring knowledge, experiences, and behaviors petar djuric, aleksandar stevanovic, nina rajovic, jovana todorovic, ulrich laaser overview of the main incremental health care reforms introduced between 2014 and 2020 in romania silvia gabriela scintee, cristian vladescu burnout and optimism among health workers during the period of covid-19 paraskevi theofilou, charalampos platis, konstantina madia, ioannis kotsiopoulos review articles climate change and its extensions in infectious diseases: south-eastern europe under focus zeynep cigdem kayacan, ozer akgul pay-for-performance and tools for quality assurance in health care doncho donev position papers circular health: a needed approach to promote health and prevent pandemics and other health hazards flavio lirussi, erio ziglio the effectiveness of the health economy: a case study of the federal republic of germany klaus-dirk henke table of contents fourth-volume executive editor volume editor prof. dr. kasia czabanowska assistant executive editor technical editor meri roshi ba tirana, albania email: meriroshi90@gmail.com publisher editorials dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 1 | 22 review article the impact of covid-19 lockdowns on air quality: a systematic review study butros m. dahu1, ahmad aburayya2 , beenish shameem 2 , fanar shwedeh2 , maryam alawadhi3 , shaima aljasmi 3, said a. salloum4 , hamza aburayya5 , ihssan aburayya6 1 institute of data science and informatics, university of missouri, columbia, usa; 2 assistant professor, business administration college, city university college of ajman, ajman, uae; 3 senior specialist registrar, primary health care sector, dubai health authority, dubai, uae; 4 school of science, engineering, and environment, university of salford, uk; 5faculty of medicine, jordan university of science & technology, irbid, jordan; 6faculty of medicine, university of constantine 3, constantine, algeria; corresponding author: dr. ahmad aburayya. assistant professor, business administration college, city university college of ajman, ajman, uae. address: city university college of ajman, ajman, uae. email: a.aburrayya@cuca.ae mailto:a.aburrayya@cuca.ae dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 2 | 22 abstract background: the purpose of this article was to review the published literature and evaluate the association between air quality/air pollution and the lockdown/stay-at-home orders during covid-19 pandemic. our goal is to identify the various environmental factors, such as urban and rural air quality, which were affected by the lockdown during the coronavirus disease (covid-19) pandemic. methods: we searched pubmed (2000–2021) for eligible articles using the following: (1) aerosol[title/abstract], and (2) air quality[title/abstract] or air pollution[title/abstract] and (3) covid-19[title/abstract]. a total of 39 articles were identified through the search conducted in pubmed. we first screened the title and the abstract of those 39 articles for eligibility. a total of 24 articles did not meet the eligibility criteria and were excluded based on the title and the abstract review. the 15 remaining articles were assessed in full text for eligibility and data extraction. after a full-text review, 3 articles were excluded. finally, a total of 12 selected articles were confirmed for data extraction. results: among the 12 studies, 5 articles focused on the effect of the air pollution, fine particulate matter, and air pollutants of covid-19 pandemic’s lockdown, while 1 article targeted the relationship between the weather/air quality and covid-19 death rate during lockdown. in addition, 5 papers focused on the association between the environmental factors, air pollution and air quality and covid-19 mortality rate. finally, 1 research study paper aimed to study the covid-19 positivity rate and the effect of air quality during the stay-at-home order or the lockdown which was occurred in march 2020. it is important to note that it has been found that an increase in the average pm2.5 concentration was correlated with a relative increase in the covid-19 test positivity rate. this explains the increase in the number of covid cases during the period of the wildfire smoke from august to october 2020 (1). conclusion: the findings indicate that the covid-19 lockdown has significant impact on the air quality across the world. the lockdown significantly reduces the air pollutants such as no2, co, o3 and particulate matter pm2.5 and pm10. this reduction led to a much healthier and safer outdoor air and hence improved the air quality during the lockdown/stay-at-home orders. more research is needed to validate that the air pollutants (no2, co, o3, pm2.5 and pm10) have a significant impact on the covid-19 mortality and fatality rates. keywords: covid-19; lockdowns; air quality; air pollution; environmental factors dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 3 | 22 introduction the coronavirus disease (covid-19) is an infectious disease caused by the sars-cov2 virus. the covid-19 pandemic has infected more than 262 million people and killed more than 5.2 million lives worldwide. the coronavirus pandemic has also caused an enormous economic, public health, and social damages. it is important to note that the risk factors of covid-19 are still under investigations, but some environmental factors, such as urban and rural air pollution and air quality play a vital role in increasing the population sensitivity to covid-19 pathogenesis (2). the united states national oceanic and atmospheric administration stated almost 30% decrease in nitrogen oxides (no2) emissions in the urban northeast during april 2020. in addition, there was a huge reduction in the volatile organic compound concentrations (3). research studies have proven that exposure to the fine particulate matter pm2.5 may cause a major harmful health effect. those effects include cardiovascular, respiratory, diabetes, kidney disease mortality and morbidity (4). additionally, ecological studies indicate that living in areas with higher levels of ambient fine particulate matter air pollution (pm2.5) increase the chance of having a higher risk of adverse covid-19 outcomes (5). the covid-19 restrictions have reduced the emission of the primary air pollutants worldwide in general and in the united states particularly due to the decrease in industrial activities and transportation (6). the coronavirus disease (covid-19) pandemic has created so many challenges to the united states government to balance economy and public safety. president donald trump declared a national emergency on march 13, 2020, where all municipalities and states issued different degrees of stay-athome and/or lockdowns policies matching the local specific conditions.(7). these local policies have impacted the air quality through decreasing the non-necessary energy consumption and transportation. according to the u.s. environmental protection agency (epa), the air pollutants and the national emissions contains 59% of carbon monoxide (co), and 74% of nitrogen oxides (nox, sum of nitrogen dioxide [no2] and nitric oxide [no]) as well as emissions from electric generation and the on-and-off road traffic (7). in addition, the ambient levels of the two pollutants pm2.5 and pm10 (particulate matter with aerodynamic diameters below 2.5 and 10 μm, respectively) might be the most affected by the lockdown (l. w. a. chen et al., 2020). it is important to mention that the ozone (o3) is developed in the atmosphere through the photochemical reaction of the volatile organic compounds (vocs) and nox. also, reducing the vocs and nox emissions could either lower or lift the ozone (o3) concentrations depending on the local photochemical regime (7). our aim is to estimate the association between air quality/air pollution and the lockdown/ stay-at-home orders during covid-19 pandemic. we sought to identify changes that were made to the air gases, air pollutants and particular matters during the covid-19 pandemic lockdown. in addition, our goal is to identify the various environmental factors, such as urban and rural air quality, which were affected by the lockdown during the coronavirus disease (covid-19) pandemic. finally, we will evaluate whether there was a uniform improvement in air quality during the covid-19 lockdown. we will also estimate the association between the covid-19 fatality rate and air quality by dragging our dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 4 | 22 attention on the direct relationship between the air quality and the covid-19 mortality across the world. furthermore, the changes in mobility were correlated with the relevant air quality parameters, such as no2, which in turn was highly correlated to o3. the study provides data and analysis to support future planning and response efforts in sharjah (united arab emirates) (8,9). also, previous studies show the large impact of human activities on the quality of air and present an opportunity for policymakers and decision-makers to design stimulus packages to overcome the economic slow-down, with strategies to accelerate the transition to resilient, low-emission economies and societies more connected to the nature that protect human health and the environment (9,10). methods data sources we searched pubmed (2000–2021) for eligible articles using combinations of the following search terms: (1) (aerosol[title/abstract])), (2) and (air quality[title/abstract])) or (3) (air pollution[title/abstract])) and (4) (covid19[title/abstract])). we also systematically searched the reference lists of the included studies and relevant reviews. we found 39 eligible articles on pubmed. inclusion and exclusion criteria the researchers reviewed the titles and abstracts of the identified citations and identified eligible articles based on the following criteria. the inclusion criteria included any randomized controlled trial, quasi-experimental study, or pre–post study evaluating the effect of the lockdown on the air quality. the included studies measured health outcomes, processes of care and the effect of the lockdown on the pollution rates in the united states major cities. in addition, we excluded studies published in a language other than english was excluded. furthermore, data that is not related to covid-19 were excluded (no other disease). study selection and data extraction the process of selection was performed in two steps. in the first step, we read the titles and abstracts of the citations by the search query to screen the articles based on the inclusion/exclusion criteria mentioned above. in the second step, we read the full text of the citations selected by the first step and based on that we decide if the paper is eligible for inclusion. the search criteria did not limit by publication date; due to recency of the field, the earliest eligible article was published in 2020. in addition, the researchers collected the following information from each article that was eligible: author and year, study objective, methods/tools, geographic location, particulate, and gases measured, source of data, samples collected for analysis and major findings and results. figure 1. shows, a total of 39 articles were identified through the search conducted in pubmed. we first screened the title and the abstract of those 39 articles for eligibility. a total of 24 articles did not meet the eligibility criteria and were excluded based on the title and the abstract review. the 15 remaining articles were assessed in full text for eligibility and data extraction. after a fulltext review, 3 articles were excluded. finally, a total of 12 selected articles were confirmed for data extraction. dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 5 | 22 figure 1. prisma flow diagram we summarize the basic information of the selected papers. for each paper, we evaluated the main aspects which include but are not limited to the following: 1) descriptions of the study design, 2) sample size, 3) air particles, 4) duration of study, 5) covid-19 mortality rate, 6) control groups, 7) process and outcome measures, 8) statistical significance, 9) effect of the ambient ozone, 10) ambient air pollutants, 11) urban air pollution, 12) ambient pm2.5 and pm10, 13) disparities in nitrogen dioxide pollution and 14) covid-19 fatality rate. results among the 12 studies, 5 articles focused on the effect of the air pollution, fine particulate matter, and air pollutants on covid-19 pandemic’s lockdown, while 1 article targeted the relationship between the weather/air quality and covid-19 death rate during lockdown. in addition, 5 papers focused on the association between the environmental factors, air pollution and air quality and covid-19 mortality rate. finally, 1 research study paper aimed to study the covid-19 positivity rate and the dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 6 | 22 effect of air quality during the stay-at-home order or the lockdown which was occurred in march 2020. one of the study results shows that the covid-19 lockdown reduced the disparity in air quality between the census tracts with low and high segments of nonwhite population in some of the rural areas of the united states (for example new york city). on the other hand, the racial gap in air quality remained the same with no notable change in urban areas (3). additionally, some research findings which have massive environmental policy relevance, indicating that mobility reductions by itself may be insufficient to reduce and decrease the particulate matter pm2.5 uniformly and substantially (4). it is important to note that it has been found that an increase in the average pm2.5 concentration was correlated with a relative increase in the covid-19 test positivity rate. this explains the increase in the number of covid cases during the period of the wildfire smoke from august to october 2020 (1). our results show that counties with higher air pollutants (no2, o3, co, pm2.5 and pm10) rates were found to be significantly associated with higher rates of covid-19 mortality rates. additionally, counties with higher average daily particulate matter (pm2.5) tend to have a significantly higher covid-19 mortality rate (11). on the other hand, counties with higher average temperatures are significantly associated with much lower mortality rates for covid19 (12). during the covid-19 lockdown the ozone (o3) concentration decreases which caused a decrease in the air pollution and improve the air quality. this makes the outdoor air much healthier and safer for the human lungs. it has been noticed that the ozone levels are negatively correlated with the covid-19 death rates (13). the lockdown reduced the concentration of the particulate matter pm2.5 which improves the air quality. our findings showed that an increase in pm2.5 would cause an increase in the risk of hospitalization caused by covid19 (12). it is important to mention that the association of pm2.5 and risk of hospitalization among covid-19 patients was present in each wave of the pandemic. also, our study analysis suggested that there was higher risk of hospitalization associated with pm2.5 in black people compared to white people and in those who living in socioeconomically disadvantaged neighborhoods (5). the covid-19 lockdown reduced the two air toxicants (i.e., nitrogen dioxide or no2, and benzidine), which caused an improvement in the air quality. our results proved that there is a relationship between the covid-19 lockdown and the air quality. it also confirmed the previously reported environmental factors associated with covid-19 mortality rate (14). our systematic review results show that the no2 (one of the air pollutants) concentrations were positively associated with covid-19 mortality and fatality rates (15). additionally, after adjusting for co-pollutants, per interquartile-range (iqr) increase in no2, the covid-19 case mortality rate and fatality rate were associated with an increase as well. we should note that we did not notice or observe any significant association between the long term exposure to o3 or pm2.5 and covid-19 mortality and fatality rates per iqr increase (2,11,16). the reductions of co and no2 are statistically significant with the covid-19 pandemic lockdown. it is also significant at two thirds of the sites and tend to increase with local population density. additionally, the lockdown has a significant reduction on particulate matter (pm2.5 and pm10), which also has a significant impact on the air quality (l. w. a. chen et al., 2020). the air pollution levels did not significantly change, compared with historical trends (5). in summary, our dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 7 | 22 results showed that the covid-19 locked down which occurred in march 2020 has affective the air quality positively. it has improved the air quality by decreasing the pollution rate. it also helps in decreasing the polluted gases such as no2, co, o3, pm2.5 and pm10. additionally, the air quality affected the covid-19 testing and positivity rates. this systematic review study has shown that the covid-19 testing, and positivity rates are higher in the areas with high pollution rates. the lockdown has improved the air quality, decreased the pollution rates, and decreased the covid-19 mortality and fatality rates. table 1. summary of the results analysis study objective methods/tools geographic location particulate & gases measured samples collected for analysis air pollution and the risk of hospitalization adjusted poisson regression united states pm2.5 with risk of hospitalization national cohort of 169,102 covid19 to evaluate the air quality to estimate the confidence interval & bootstrapping northeast and california/nevada metropolises, united states (no2), (co), (o3) & (pm2.5, pm10) six weeks or 42 days between march 15 and april 25, 2020 impacts of covid-19 lockdowns on pm2.5 regression model & synthetic control method” (scm) 455 pm2.5 monitoring sites across the united states the level of pm2.5 in air 455 monitors association of covid19 mortality multivariable regression model county-level united states no2 and benzidine 337 variables to estimate the association between weather and covid19 fatality rates models included state-level social distancing measures county-level longitudinal design across the united states min & max daily temperature, precipitation, o3, pm2.5 concentrations & u.v. light index time-constant factors at the county level, and linear and nonlinear timevarying factors examine whether wildfire smoke associated with an increased rate of covid time-series analysis western united states, in reno, nevada ambient pm2.5 hourly beta attenuation monitors with a very sharp cut cyclone estimate the association between no2, pm2.5 and o3 & covid-19 mortality conducted a cross-sectional nationwide study county level – united states no2, pm2.5 and o3 3141 us counties estimate the association between no2, pm2.5, and o3 and county-level covid-19 casefatality and mortality rates a cross-sectional nationwide study united states counties average no2 concentrations, and long-term exposure to pm2.5 or o3 monitors were hourly beta attenuation monitors with a very sharp cut cyclone (vscc) and temperature and humidity data. evaluate the association between opioid-related mortality & covid-19 mortality a multivariable negative-binomial regression model counties across the u.s. pm exposure estimate within each county data from 3142 counties across the u.s. identify changes in pediatric asthmarelated health care utilization viral transmissions were enacted in philadelphia philadelphia, united states pollution data for 4 criteria air pollutants changes in encounter characteristics, viral testing patterns, and air pollution before and after mar 17, 2020 investigated whether long-term average exposure to (pm 2.5) is associated with an increased risk of covid-19 death in the united states included a random intercept by state to account for potential correlation 3,000 counties in the united states particulate matter pm 2.5 negative binomial mixed models using county-level covid-19 deaths to investigate causality between the economic lockdown and changes in air quality triple difference-indifferences model high and low shares of non-white population in rural new york the change in pm2.5 pollution three samples: aod, pm2.5-atmonitor, and aod-at-monitor dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 8 | 22 discussion our findings suggested that the urban combustion sources such as traffic, may increase susceptibility to severe covid-19 outcomes due to the long-term exposure to no2. this is independent from the long term exposure of o3 and pm2.5. our results also support directed public health actions to protect the highly polluted regions with prominent levels of no2. the lockdown lowers the traffic emissions and ambient air pollution which will improve the air quality and reduce the risk of covid-19 case mortality and fatality (11). it is worth noting that exposure to higher levels of the particulate matter pm2.5 plays a very vital and direct role in increasing the risk of hospitalization among covid-19 infected patients. our results show that black race and people who are living in disadvantaged neighborhoods have a higher risk of hospitalization in the setting of covid-19 due to the untoward effect of pm2.5 (11). we have also found that wildfires cause an increase in air pollution due to the elevated pm2.5 (13). this will increase the covid19 test positivity rate. our research findings have indicated that pm2.5 from other sources, such as industry and vehicle traffic increase the susceptibility of covid-19 (1). lockdown reduces the emissions of pm2.5 coming from industries and vehicle traffic and hence reduce the air pollution and improve the air quality (1). there is also a direct relationship between weather changes and the us covid-19 fatality rates. it only appeared with the ozone levels and the minimum temperature. our study analysis showed an increase in the minimum daily temperature during the lockdown period which also associated with higher covid-19 fatality rates. in addition, fewer covid-19 deaths were associated with higher ozone levels (13). the methodology used in previous studies can be applied to evaluate the impacts of covid-19 or similar events on people’s mobility, air quality and utility consumption at other geographical locations (17)(10). particulate matter concentrations show a quite different pattern from the rest of pollutants examined and with substantial week-to-week variations (10)(17)(8). the current study concludes that due to declining automobile and industrial emissions in the northern emirates of the united arab emirates (neuae), the lockdown initiatives lowered no2, aod, and surface urban heat island intensity (suhii). in addition, the aerosols did not alter significantly since they are often linked to the natural occurrence of dust (10). our study has various limitations that are worth noting. in some of the eligible articles used in this literature review, the health care, demographic, utilization, and viral testing data were taken from a single institution and collected as part of routine care (18-25). additionally, the electronic health record (ehr) data is subject to bias and error. these errors are hard to be controlled and do not allow us to observe significant changes. lastly, future studies are necessary to refine our findings and improve our understanding of the effects of the covid-19 pandemic lockdown on the air quality (6). conclusion the findings indicate that the covid-19 lockdown has significant impact on the air quality across the world. the lockdown significantly reduces the air pollutants such as no2, co, o3, and particulate matter pm2.5 and pm10. this reduction led to a much healthier and safer outdoor air and dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 9 | 22 hence improved the air quality during the lockdown/stay-at-home orders. more research is needed to validate that the air pollutants (no2, co, o3, pm2.5 and pm10) have a significant impact on the covid-19 mortality and fatality rates. the lockdown during the covid-19 pandemic improved the air quality as well as decreasing the exposure and the emissions of the particulate matter pm2.5. this will help decrease the risk of hospitalization among covid-19 infected individuals. lastly, this study indicates the need for public health efforts during the hard hit of covid-19. it also improves the advantage of the lockdown on the air pollution and air quality. references 1. kiser d, elhanan g, metcalf wj, schnieder b, grzymski jj. sarscov-2 test positivity rate in reno, nevada: association with pm2.5 during the 2020 wildfire smoke events in the western united states. j expo sci environ epidemiol [internet]. 2021 sep 1 [cited 2021 nov 7];31(5):797–803. available from: https://pubmed.ncbi.nlm.nih.gov/34 257389/ 2. liang d, shi l, zhao j, liu p, schwartz j, gao s, et al. urban air pollution may enhance covid-19 case-fatality and mortality rates in the united states. medrxiv [internet]. 2020 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springer international publishing; 2021: 795–806. _________________________________________________________________________________ dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 12 | 22 appendix 1 table 2. data analysis of the impact of the covid-19 lockdown on air quality author & year study objective methods/ tools geographic location particulate & gases measured source of data samples collected for analysis major findings & results bowe et al., 2021 air pollution and the risk of hospitaliz ation among covid-19 positive individual s adjusted poisson regression united states pm2.5 with risk of hospitalizati on the us department of veterans affairs national healthcare databases and va corporate data warehouse (cdw) outpatient and inpatient encounters national cohort of 169,102 covid-19 positive united states veterans there were 25,422 (15.0%) hospitalizatio ns; 5,448 (11.9%), 5,056 (13.0%), 7,159 (16.1%), and 7,759 (19.4%) were in the lowest to highest pm2.5 quartile, respectively. in models adjusted for state, demographic and behavioral factors, contextual characteristic s, and characteristic s of the pandemic a one interquartile range increase in pm2.5 (1.9 µg/m3) was associated with a 10% (95% ci: 8%12%) increase in risk of hospitalizatio n. the association of pm2.5 and dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 13 | 22 risk of hospitalizatio n among covid-19 individuals was present in each wave of the pandemic. models of non-linear exposureresponse suggested increased risk at pm2.5 concentratio ns below the national standard 12 µg/m3. formal effect modification analyses suggested higher risk of hospitalizatio n associated with pm2.5 in black people compared to white people (p = 0.045), and in those living in socioeconom ically disadvantage d neighborhoo ds (p < 0.001). chen et al., 2020 to evaluate the air quality response to reduced economic activities. to estimate the confidence interval of δi%, a bootstrappi ng procedure northeast and california/ne vada metropolises , united states nitrogen dioxide (no2) and carbon monoxide (co), ozone (o3), particulate matter (pm2.5 and pm10) epa national core (ncore) network, and airnowtech & epa airdata website six weeks or 42 days between march 15 and april 25, 2020, was designated as the firstphase lockdown period (p1). a reference period deemed business as the reductions, up to 49% for no2 and 37% for co, are statistically significant at two thirds of the sites and tend to increase with local population density. significant dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 14 | 22 usual between january 25 and march 7, 2020 (p0) was selected reductions of particulate matter (pm2.5 and pm10) only occurred in the northeast and california/ne vada metropolises where no2 declined the most, while the changes in ozone (o3) were mixed and minor. chen et al., 2021 impacts of covid-19 lockdown s on pm2.5 regression model & synthetic control method” (scm) 455 pm2.5 monitoring sites across the united states the level of pm2.5 in air epa air quality system (aqs), epa air now system, & google earth engine 455 monitors remain to be used in our analyses the findings have immense environment al policy relevance, suggesting that mobility reductions alone may be insufficient to reduce pm2.5 substantially and uniformly. hu et al., 2021 associatio n of covid-19 mortality multivariab le regression model county-level united states nitrogen dioxide or no2, and benzidine nationwide county-level covid-19 mortality data in the contiguous us 337 variables characterizi ng the external exposome from 8 data sources were integrated, harmonized , and spatiotemp orally linked to each county all the 4 variables that were significant in both sets in phase 1 remained statistically significant in phase 2, including two air toxicants (i.e., nitrogen dioxide or no2, and benzidine), one vacant land measure, and one food environment dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 15 | 22 measure. this is the first external exposome study of covid-19 mortality. it confirmed some of the previously reported environment al factors associated with covid19 mortality, but also generated unexpected predictors that may warrant more focused evaluation. karimi et al., 2021 to estimate the associatio n between weather and covid-19 fatality rates models included state-level social distancing measures county-level longitudinal design across the united states primary measures included minimum and maximum daily temperature , precipitation , ozone concentratio n, pm2.5 concentratio ns, and u.v. light index. analyzed covid-19 deaths from public health departments’ daily reports models included state-level social distancing measures, census bureau demographic s, daily weather information, and daily air pollution. timeconstant factors using fixed effects at the county level, and linear and nonlinear timevarying factors, and serial correlation, social distancing measures 3141 us counties a 1 °f increase in the minimum temperature was associated with 1.9% (95% ci, 0.2% to 3.6%) increase in deaths 20 days later. an ozone concentratio n increases of 1 ppb (part per billion) decreased daily deaths by 2.0% (95% ci, 0.1% to 3.6%); ozone levels below 38 ppb negatively correlated with deaths. kiser et al., 2021 examine whether wildfire smoke from the time-series analysis using generalize western united states, in ambient pm2.5 environment al protection agency’s (epa’s) internet monitors were hourly beta attenuation monitors they found that a 10 µg/m3 increase in the 7-day dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 16 | 22 2020 wildfires associate d with an increased rate of sarscov-2 infections d additive models reno, nevada database, from four air quality monitors located in reno and sparks. temperature and humidity data were obtained from the krno weather station (via mesowest.ut ah.edu) (met one bam 1020s) with a very sharp cut cyclone (vscc) and temperatur e and humidity data. average pm2.5 concentratio n was associated with a 6.3% relative increase in the sarscov-2 test positivity rate, with a 95% confidence interval (ci) of 2.5 to 10.3%. this corresponde d to an estimated 17.7% (ci: 14.4-20.1%) increase in the number of cases during the period most affected by wildfire smoke, from 16 aug to 10 oct. dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 17 | 22 liang et al., 20 to estimate the associatio n between long-term (20102016) countylevel exposures to no2, pm2.5 and o3 and countylevel covid-19 casefatality and mortality rates in the us conducted a crosssectional nationwide study using zeroinflated negative binomial models county level – united states no2, pm2.5 and o3 from three databases: the new york times, usafacts, and 1point3acres .com between long-term (20102016) county-level exposures to no2, pm2.5 and o3 and county-level covid-19 case-fatality and mortality rates 1,027,799 covid cases and 58,489 deaths were reported in 3,122 us counties from january 22, 2020, to april 29, 2020, with an overall observed case-fatality rate of 5.8%. spatial variations were observed for both covid death outcomes and longterm ambient air pollutant levels. county-level average no2 concentratio ns were positively associated with both covid-19 case-fatality rate and mortality rate in single-, bi & tri-pollutant models (pvalues<0.05) . per interquartile range (iqr) increase in no2 (4.6 ppb), covid-19 case fatality rate and mortality rate were associated with an increase of 7.1% (95% ci 1.2% to 13.4%) and dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 18 | 22 11.2% (95% ci 3.4% to 19.5%), respectively. no observe significant associations between long-term exposures to pm2.5 or o3 and covid19 death outcomes (pvalues>0.05) , although per iqr inc in pm2.5 (3.4 ug/m3) was marginally associated with 10.8% (95% ci: 1.1% to 24.1%) increase in covid-19 mortality rate liang et al., 2020 to estimate the associatio n between long-term (20102016) countylevel exposures to no2, pm2.5, and o3 and countylevel covid-19 casefatality and mortality rates in a crosssectional nationwide study using zeroinflated negative binomial models used both singleand multipollutant models and controlled for spatial trends and a comprehe nsive set of potential united states counties average no2 concentratio ns, and long-term exposure to pm2.5 or o3 obtained the number of daily countylevel covid19 confirmed cases and deaths that occurred from january 22, 2020, the day of the first confirmed case in the united states, through july 17, 2020, in the united states from three databases: the new york times,2 usafacts,3 3,076 us counties from january 22, 2020, to july 17, 2020, 3,659,828 covid-19 cases and 138,552 deaths were reported in 3,076 us counties, with an overall observed case-fatality rate of 3.8%. county-level average no2 concentratio ns were positively associated with both covid-19 dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 19 | 22 the united states confounde rs and 1point3acres .com case-fatality rate and mortality rate in single-, bi-, and tripollutant models. when adjusted for co-pollutants, per interquartilerange (iqr) increase in no2 (4.6 ppb), covid-19 case-fatality rate and mortality rate were associated with an increase of 11.3% (95% ci 4.9%18.2%) and 16.2% (95% ci 8.7%24.0%), respectively. we did not observe significant associations between covid-19 case-fatality rate and long-term exposure to pm2.5 or o3, although per iqr increase in pm2.5 (2.6 μg/m3) was marginally associated, with a 14.9% (95% ci 0.0%-31.9%) increase in covid-19 mortality rate when adjusted for co-pollutants. dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 20 | 22 qeada n et al., 2021 to evaluate the associatio n between opioidrelated mortality and covid-19 mortality a multivariab le negativebinomial regression model counties across the u.s. pm exposure estimate within each county johns hopkins university center for systems science and engineering coronavirus site cdc wonder data from 3142 counties across the u.s. were used after controlling for covariates, counties with higher rates of opioidrelated mortality per 100,000 persons were found to be significantly associated with higher rates of covid-19 mortality (amrr: 1.0134; 95% ci [1.0054, 1.0214]; p = 0.001). counties with higher average daily particulate matter (pm2.5) exposure also saw significantly higher rates of covid-19 mortality. analyses revealed rural counties, counties with higher percentages of nonhispanic whites, and counties with increased average maximum temperatures are significantly associated with lower mortality rates from covid-19. dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 21 | 22 taquec hel et al., 2020 sought to identify changes in pediatric asthmarelated health care utilization, respirator y viral testing, and air pollution during the covid-19 pandemic viral transmissi ons were enacted in philadelphi a, were assessed, and compared with data from 2015 to 2019 as a historical reference philadelphia, united states pollution data for 4 criteria air pollutants data were extracted from children's hospital of philadelphia electronic health records, and pollution data for 4 criteria air pollutants were extracted from airnow changes in encounter characterist ics, viral testing patterns, and air pollution before and after mar 17, 2020 after march 17, 2020, inperson asthma encounters decreased by 87% (outpatient) and 84% (emergency + inpatient). video telemedicine, which was not previously available, became the most universally used asthma encounter modality (61% of all visits), and telephone encounters increased by 19%. concurrently, asthmarelated systemic steroid prescriptions and frequency of rhinovirus test positivity decreased, although air pollution levels did not change, compared with historical trends. wu et al., 2020 investigat ed whether long-term average exposure to fine particulate matter (pm 2.5) is included a random intercept by state to account for potential correlation in counties within the same state & 3,000 counties in the united states particulate matter pm 2.5 collected for more than 3,000 counties in the united states (representing 98% of the population) up to april 22, 2020, it negative binomial mixed models using county-level covid-19 deaths as the outcome and countythey found that an increase of only 1 μg/m 3 in pm 2.5 is associated with an 8% increase in the covid19 death rate (95% dahu bm, aburayya a, shameem b, shwedeh f, maryam a, aljasmi sh, salloum sa, aburayya h, aburayya i. the impact of covid-19 lockdowns on air quality: a systematic review study (review article). seejph 2022, posted: 09 october 2022. doi: 10.11576/seejph-5929 p a g e 22 | 22 associate d with an increased risk of covid-19 death in the united states conducted more than 68 additional sensitivity analyses from johns hopkins university level longterm average of pm 2.5 as the exposure confidence interval [ci]: 2%, 15%). the results were statistically significant and robust to secondary and sensitivity analyses. zhang et al, 2021 to investigat e causality between the economic lockdown and changes in air quality triple differenceindifferences model high and low shares of non-white population in rural new york the change in pm2.5 pollution nasa’s satellite imagery data, aerosol optical depth (aod), environment al protection agency’s (epa) & moderate resolution imaging spectroradio meter three samples: aod, pm2.5-atmonitor, and aodat-monitor the lockdown narrowed the disparity in air quality between census tracts with high and low shares of non-white population in rural new york, whereas the racial gap in air quality remained unchanged in urban new york. aljasmi sh, aburayya i, almarzooqi s, alawadhi m, aburayya a, salloum as, adel k. the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals (case studies). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph-5758 p a g e 1 | 13 original research the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals shaima aljasmi1, ihssan aburayya2, sameeha almarzooqi1, maryam alawadhi1, ahmad aburayya1, said a. salloum3, khalid adel4 1dubai health authority, dubai, uae; 2faculty of medicine, university of constantine 3, constantine, algeria; 3school of science, engineering, and environment, university of salford, uk; 4 rak medical & health sciences university, ras al khaimah, uae; corresponding author: dr. ahmad aburayya; assistant professor, business administration college, jefferson international university, california, usa; address: dubai health authority, dubai, uae; email: amaburayya@dha.gov.ae; q5110947@tees.ac.uk. mailto:amaburayya@dha.gov.ae mailto:q5110947@tees.ac.uk aljasmi sh, aburayya i, almarzooqi s, alawadhi m, aburayya a, salloum as, adel k. the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals (case studies). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph-5758 p a g e 2 | 13 abstract aim: maintaining service quality and value using quality and management tools is crucial in any organization. in essence, improving service quality boosts both efficiency of organizations and consumer pleasure. the deployment of quality development programs such as total quality management (tqm) is one technique that businesses may employ to deliver exceptional customer service. the health sector, in particular, is one of the industries that require tqm adoption due to its complexity and the need for constant service improvement. tqm helps to improve service quality in health facilities through advanced clinical and administrative procedures. this research comprehensively assesses tqm levels and the impact of hospital demographics on its implementation process in hospitals in the united arab emirates (uae). methods: the study used a quantitative research strategy based on a survey study design. questionnaires were used to gather primary data from respondents deployed a self-administered technique. 1850 questionnaires were delivered to the hospital's senior staff based on their number in each hospital. of the 1850 questionnaires distributed, 1238 usable questionnaires were analyzed, yielding a response rate of 66.9%. the study used a binary logistic regression model to determine if hospital demographics affected tqm implementation. the study data were examined and analysed using version 25.0 of the spss software. results: the results show that most of the health facilities with an overall tqm between 4.12 and 4.82 were utilized, governmental, accredited and utilized and large hospitals, while the hospitals with a mean between 2.91 and 3.45 were small, unaccredited private, and non-specialised. thus, large hospitals have a higher tqm utilization rate than small hospitals. in addition, the findings of the t-test revealed that a high tqm is represented by means of 4.68, 4.67, 4.43, and 4.12 for accredited, utilized, governmental and large hospitals. the binary regression analysis also reveals similar results: large, governmental, utilized and accredited hospitals have greater chances of tqm adoption than other categories of hospitals (exp (b): 1.2; 95%ci: 1.001 – 1.421, p< .05); (exp (b): 1.3; 95%ci: 1.012 – 1.721, p< .05); (exp (b): 1.5; 95%ci: 1.127 – 2.051, p< .01); and (exp aljasmi sh, aburayya i, almarzooqi s, alawadhi m, aburayya a, salloum as, adel k. the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals (case studies). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph-5758 p a g e 3 | 13 (b): 1.5; 95%ci: 1.102 – 2.012, p< .05); correspondingly. another observation from the results is that hospitals that implemented technological tools had a greater chance of successfully executing the tqm program than hospitals that did not utilize advanced technologies due to the limited availability of resources (exp (b): 1.7; 95%ci: 1.332 – 2.187, p< .01). conclusion: even though health facilities need to adopt tqm, its implementation depends on the hospital size and demographics that significantly influence the adoption of tqm programs. however, this study will help bridge the current gap on the usage of tqm in the health context by examine the influence of demographic factors on adopting tqm in hospitals. hence, provide adequate information to help the uae hospital administrators appropriately execute the tqm program in the hospitals and enhance the efficacy of their operations. keywords: total quality management, quality improvement strategy, hospital service quality, hospital size, hospital demographic factors, binary logical regression model. conflict of interest: none declared. aljasmi sh, aburayya i, almarzooqi s, alawadhi m, aburayya a, salloum as, adel k. the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals (case studies). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph-5758 p a g e 4 | 13 introduction healthcare system quality has become a major societal concern, as pointed out in several reports such as ‘the state of health care quality’, and ‘to err is human: building a safer health system’ (1,2). on the contrary, studies (1-4) based on the institute of medicine (iom) report indicate that the absence of quality care leads to human error, which causes around 98,000 deaths yearly. another factor that raises the mortality rate is unnecessary hospital admissions, responsible for as many as 81,000 deaths and 3.6 billion usd in yearly expenditures. also, johns hopkins university school of medicine conducted research on a similar issue in 2016 and discovered that over 250,000 americans die annually due to avoidable medical mistakes (5). however, aburayya et al. (1,2) also reported that if the entire healthcare system provided quality services, especially total quality management (tqm), many of these deaths and expenses could be avoided. tqm helps minimise the number of future medical error-related fatalities by streamlining the hospital processes and operations. the application of tqm in the healthcare context has followed the effective trial studies which showed that the model could work in the healthcare. the national demonstration project on quality improvement in healthcare (ndpqih) which has approximately 20 specialists on healthcare from diverse establishments detailed that the tqm strategy could be practically applied in the healthcare setting (6,7). likewise, tqm was also found to have the power to improve patient satisfaction, reduce medical mistakes, and increase the safety of patients (8). furthermore, lashgari et al. (9) agreed that the tqm model improved customer experience, staff morale, and productivity in various industries. the implementation of comprehensive management programs such as tqm is dependent on several factors such as the size of the organisation, organization’s type (government or private), organization’s accreditation profile, organization’s functionality (specialised and non specialised), and technology adoption (1,2,8,10-15). however, several studies (8,13,14,16) indicate that smaller businesses find it more difficult to develop due to the lack of adequate resources, inability to reach suppliers, ineffective leadership, insufficient analytical tools and the inability to track and adjust to their processes. this is proven by other results from the above studies, which reveal that tqm approaches were first utilised in major and large companies in japan and the united states. as a result, research indicates the importance of attaining specific standards and necessities to gain the ability to integrate tqm into their operations among small organisations (13). moreover, study (17) notes that the deployment of tqm in small and large companies is different as the former is less formal and more absorbed by people, while the latter is based on certain procedures. on the converse, sila (18) offers a contradicting opinion that tqm execution in both small and large firms shows no significant difference. thus, more research is required on how factors such as size determine tqm implementation in several organisations. attitude towards quality has also been a huge determinant in tqm. for example, considerable researchers (1, 2, 7) have reported that private companies value tqm implementation compared to government organisations. in contrast, large organisations tend to invest significantly more in training and education to encourage the adoption of tqm processes. studies (1, 8, 10,14) support the above research by showing that tqm approaches have greater importance and can be more easily implemented in firms that have earned quality accreditation. the companies also ought to have embraced aljasmi sh, aburayya i, almarzooqi s, alawadhi m, aburayya a, salloum as, adel k. the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals (case studies). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph-5758 p a g e 5 | 13 technology as the process requires adequate resources, which many small companies with no specialisation lack. the impact of size or scale on quality has dominated the research for a long time, following the desire to improve patient outcomes through tqm. numerous studies (1, 10, 19) report a significant relationship between a hospital's size and its capacity to deliver high-quality medical treatment. the quality of services a hospital supply depends on its size, kind, and operation. this is due to the high level of collaboration in large hospitals. studies (20-23) explains that closeness and teamwork facilitate collaboration, eventually increasing the quality of services delivered. also, the health facilities can integrate various digital solutions into their processes to improve health outcomes. for instance, accredited hospitals have adequate resources to afford an electronic medical record system (emr), which helps the health providers to pursue advanced quality improvement programs and interventions (21-23). there exists insufficient research on the tqm adoption in the uae. specifically, a literature search has revealed that the demographic parameters associated with the successful implementation of tqm in uae hospitals were under-discussed (2). thus, following insufficient research on the topic, this study will help bridge the gap and provide adequate information to help the uae hospital administrators and healthcare providers appropriately execute the tqm program in the hospitals. the research is also committed to determining the effect of such traits and variables on the level of medical care delivered by uae hospitals in terms of patient outcomes. in addition, the healthcare industry needs to investigate the connection between the demographic features of hospitals and the implementation of tqm. this will help locate suitable strategies for utilising the approach because previous attempts (1-2, 6-8,24-26) have examined the application of tqm in the medical business and have presented no adequate answers to the many implementation issues. another aim is to fill the gap that most studies have discovered on the lack of understanding of the implementation of tqm in the gulfstream area, notably in the uae (1,2,10,26-28). as a result, the research explores tqm using scientific and practical ways to compensate for this deficit. this is the first research of its type to look into the tqm adoption rate and level in uae health facilities (uae). according to this study, tqm deployment in hospitals is linked to the demographic features of hospitals, which is achieved through research aims and current literature in assembling the findings. tqm implementation level was also evaluated for its efficacy in addition to this. after providing sufficient information on the topic, the health experts can use the findings and suggestions of this study to implement better hospital quality management standards in uae hospitals. as a result, the study is committed to investigating the tqm level in the uae hospitals, considering the opinions of executive hospital staff. another method of how the study plans to fill the research gap is by examining whether the hospital size and demographic differences affect tqm being used in those facilities. methods and materials the research looked at how hospital size and demographic characteristics affected the adoption of tqm in uae health facilities using quantitative research and survey techniques. the primary data were derived from respondents who self-reported and responded to surveys they supplied to themselves. all administrative and clinical hospital directors in dubai make up the sample unit or the staff, which is a great source of knowledge about quality procedures (29). the study was carried out in aljasmi sh, aburayya i, almarzooqi s, alawadhi m, aburayya a, salloum as, adel k. the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals (case studies). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph-5758 p a g e 6 | 13 dubai between october 15, 2019, and february 12, 2020, covering hospitals in the uae. convenience sampling was used in this study since it was challenging to get a sample frame list from these organisations. according to (30), convenience sampling is the most suitable for this study because it can cut costs and time involved in the research process and gives quick access to the right sample size. additionally, the sampling method is frequently used for research since it is convenient, cheap and can access large data (30). for instance, this study utilised a larger sample size to lower the chances of committing errors associated with the type of sampling. employing a huge sample in the research also helped boost the accurateness and predictive validity of the sampling findings. likewise, with a 95% confidence level and a margin of error of 5%, the raosoft sample size calculator used in the research managed to generate 975 samples. for this investigation, hospital administrators received 1,850 questionnaires. out of the 1,850 questionnaires distributed, 1,238 valid surveys were returned, yielding a response rate of 66.9%. furthermore, the research led to the creation of exceptional items of tqm building measurement instruments. thirty-two different items were used to computing tqm elements published in various studies (1,2,6,8,17). this study utilised a five-point likert scale to record people's views, with one point meaning "strongly disagree" and five points denoting "strongly agree". the contents of the questionnaire included (1) socio-demographic characteristics (7 items), such as age, gender, hospital size, hospital type, hospital accreditation profile, hospital functionality, technology adoption; (2) perceived factors affecting the implementation of tqm (32 items). checkboxes serve as symbols for different answers to the closed-ended questions for the study. questions related to sociodemographic characteristics were treated as categorical variables. questions related to main factors affecting the implementation of tqm treated as continuous variables. the researcher asked the participants to express their views and opinions on whether they agreed or disagreed with the statements they were provided with. a study conducted by diamond and jefferies (31) shows that a fivepoint likert scale's extension is divided by the sum of scale points to determine the length of the scale. as a result, the extension of each scale is calculated in this investigation by subtracting five from one to get four, then dividing the total length of each scale by four to get 0.80. consequently, 0.8 was added to each scale code which resulted in adopting 3.41 as threshold for identifying factors affecting the success implementation of tqm. in order to compare the means of two groups for a similar variable, the study employed an independent t-test for the groups. this enabled the researchers to determine whether there were significant differences between the tqm components in various hospital types. furthermore, the study used a binary logistic regression model to determine if hospital demographics affected the chance that tqm deployment would have an impact. the study data were examined and analysed using version 25.0 of the spss software. results participants and hospitals profile table 1 displays the features of the participants in the study. in this research, 1,238 participants participated, where 58% were men and 42% were women. additionally, two-thirds of the sample belonged to the designated age ranges; 3039 and 40-49, who reported 65%, equivalent to two-thirds of the sample. three of the six hospitals that comprise this study's sample are large, operated by the government, specialised, accredited by joint commission aljasmi sh, aburayya i, almarzooqi s, alawadhi m, aburayya a, salloum as, adel k. the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals (case studies). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph-5758 p a g e 7 | 13 international (jci), and equipped with cutting-edge technology. of the 1238 respondents, 76% (945) worked for large hospitals, whereas 293 (24%) worked for smaller ones. additionally, more than twothirds of the respondents worked for government or institutions in different specialisations. regarding hospital accreditation and technology adoption, 80% of respondents who worked in accredited hospitals stated their facilities regularly employ various technological tools effectively. table 1. the characteristics of respondents demographic factors frequency percent (%) gender male 724 58 female 514 42 age 20-29 138 11 30-39 412 34 40-49 388 31 over 50 300 24 hospital size large 945 76 small 293 24 hospital type government 854 69 private 384 31 hospital functionality specialised 799 65 non-specialised 439 35 accreditation certification yes 1002 81 no 236 19 technology adoption yes 998 80 no 240 20 hospitals’ demographic factors and overall tqm implementation in this study, eight tqm elements were identified. the researcher deals with each of these elements together to determine the level of overall tqm implementation in the targeted hospitals. findings from table 2 show that a mean tqm implementation score of 4.82 was recorded in most hospitals that effectively employ diverse technical solutions, which positions them at the top of the list. in addition, the overall averages of 4.68, 4.67, 4.43, and 4.12 imply that accredited, specialist, government and large hospitals implemented tqm at a greater rate than small, private, non-accredited, and nonspecialised hospitals. at the .05 levels of significance, the t-test demonstrates a aljasmi sh, aburayya i, almarzooqi s, alawadhi m, aburayya a, salloum as, adel k. the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals (case studies). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph-5758 p a g e 8 | 13 significant difference between the small hospital's mean tqm implementation and the large hospital's mean tqm implementation, suggesting large discrepancies between accredited, specialist, government, and technology-adopted hospitals and the means of other types of hospitals. consequently, it is realistic to anticipate that tqm adoption in large, accredited, government-specialised, and technology-adopted hospitals is substantially greater than in hospitals of other categories. the link between sample demographics and hospital tqm implementation was evaluated utilising multivariate research applying binary logistic regression analysis. there is a link between hospital size and successful tqm adoption, as evidenced by the multivariate data given in table 2 results. the findings imply that large hospitals were more likely than small hospitals to have a substantial degree of tqm application (exp (b): 1.2; 95 percent ci: 1.001 1.421, p 0.05). the type of hospital has also been proven to be a significant factor in adopting tqm in health facilities. government hospitals have greater chances of utilising tqm extensively (exp (b): 1.3; 95 percent ci: 1.012 1.721, p 0.05). it is also considered that hospital functionality affects tqm adoption. furthermore, tqm use is stronger in specialised hospitals than in nonspecialist hospitals (exp (b): 1.5; 95 percent ci: 1.127 2.051, p.01), while the hospital's accreditation profile greatly influences tqm adoption, as illustrated in table 2. the results reveal that hospitals with quality accreditation certificates have a higher ability to adopt tqm than non-accredited hospitals (exp (b): 1.5; 95 percent ci: 1.102 2.012, p 0.05). moreover, hospitals that possessed the ability to utilise the digital tools successfully had a greater chance twice in adopting the tqm models (exp (b): 1.7; 95 percent ci: 1.332 2.187; p.01). thus, the results confirm the proposition that the demographic aspects and size of the hospital considerably affect the tqm implementation's efficacy. table 2. t-independent test &logistic regression analysis of factors predicting the overall tqm implementation among hospitals demographic factors overall tqm t-test p-value exp (b) 95.0% c.i. for exp(b) p hospital size large 4.12 1.654 .021* ref (1.00) 1.194* 1.001 1.421 p< .05 small 3.45 hospital type government 4.43 1.801 .013* ref (1.00) 1.326* 1.012 1.721 p< .05 private 3.34 functionality specialised 4.67 1.127 aljasmi sh, aburayya i, almarzooqi s, alawadhi m, aburayya a, salloum as, adel k. the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals (case studies). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph-5758 p a g e 9 | 13 non-specialised 3.07 1.986 .002** ref (1.00) 1.521** 2.051 p< .01 accreditation yes 4.68 1.889 .007** ref (1.00) 1.505* 1.102 2.012 p< .05 no 3.11 technology adoption yes 4.82 2.954 .000*** ref (1.00) 1.657** 1.332 2.187 p< .01 no 2.91 note: *p<0.05; **p<0.01; ***p<0.001. discussion and conclusion this study investigates senior hospital personnel’s perspectives on adopting and implementing tqm in the healthcare industry. according to the results of multiple regression analysis, tqm has a large and beneficial effect on the quality of hospital service. the research also evaluated the link between hospital demographic characteristics and tqm implementation in different hospitals in dubai and the influence of hospital size, hospital type, hospital functioning, accreditation profile, and technology adoption on tqm implementation in healthcare. according to the study findings, large, government, specialist, accredited, and technologyadopting hospitals in the uae had a comparatively high degree of tqm adoption compared to the smaller heath facilities. consequently, hospitals in the uae became aware of the advantages and aims of implementing tqm to boost the value of services. also, the results, which have also been consistent with previous research (1, 2, 7, 10), confirm that the administration of these hospitals also supports the value of tqm in boosting patient satisfaction and institutional performance. however, the results of this research are in agreement with a considerable body of past studies. the study contained a significant variance in the mean of tqm components between small and large hospitals at the .05 significance level, with large hospitals implementing tqm more successfully. correspondingly, elfaituri’s study (13) further confirms that when successful management methods become mainstream, large organisations are often the first to embrace them. on the other hand, studies (8, 16, 17) indicate that small enterprises deal with a lack of information infrastructure, insufficient leadership, and supplier concerns, among other barriers. in addition, the absence of statistical tools and process control is still a huge barrier to tqm implementation among small enterprises, and numerous studies continue to prove that the adoption of tqm in government and accredited hospitals is much larger than in private and non-certified facilities. accreditation of a government hospital confirms that its performance fulfils nationally established criteria based on government rules. moreover, many hospitals have their assessment and self-improvement process, which, ideally, leads to adherence to the standard of care and improved results. aljasmi sh, aburayya i, almarzooqi s, alawadhi m, aburayya a, salloum as, adel k. the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals (case studies). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph-5758 p a g e 10 | 13 seelbach et al. (32) conducted a study on quality management to examine whether joint commission hospital accreditation had an impact on patient outcomes compared to health facilities with other accreditation. the researchers discovered that large facilities inspire better trust among the general public, indicating higher client satisfaction. the findings further showed that specialized and technologically equipped hospitals are among those that apply tqm management efficiently. the study confirms studies’ (1,8,10,17) that hospitals with high levels of specialization and technology usage invest much more in management leadership, training, and education to support tqm implementation than hospitals with low specialization and technology adoption. studies (1,6-9,17,21) added that these hospitals majorly focus on comparing their tqm processes and have greater operationquality relationships than hospitals with lesser specialism and technology usage. thus, hospital functioning corresponds with the quality of care services (8,11,17,24). the teamwork ability, closeness and employing various tools or technology, such as an emr system, according to almarzouqi et al. (20) and hamadneh et al. 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https://smex-ctp.trendmicro.com/wis/clicktime/v1/query?url=https%3a%2f%2fdoi.org%2f10.1145%2f3423336.3429349&umid=2e3f612b-8e7f-4a5f-a65c-ff7ae973d780&auth=2e67fbfa2fb6c049f414ed817d22962c1dec540f-d1d9e7139bd2cad112236731f36f6e4ddb9fe337 https://smex-ctp.trendmicro.com/wis/clicktime/v1/query?url=https%3a%2f%2fdoi.org%2f10.1145%2f3423336.3429349&umid=2e3f612b-8e7f-4a5f-a65c-ff7ae973d780&auth=2e67fbfa2fb6c049f414ed817d22962c1dec540f-d1d9e7139bd2cad112236731f36f6e4ddb9fe337 the impact of hospital demographic factors on total quality management implementation: a case study of uae hospitals theofilou p, platis c, madia k, kotsiopoulos i. burnout and optimism among health workers during the period of covid-19 (original research). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5114 p a g e 1 | 11 original research burnout and optimism among health workers during the period of covid-19 paraskevi theofilou1, charalampos platis2, konstantina madia3, ioannis kotsiopoulos1 1 ministry of health, athens, greece 2 greek d.r.g. institute sa, athens, greece 3 aegean college, athens, greece corresponding author: paraskevi theofilou address: 12 eratous, 14568, athens, greece email: pardrothe@gmail.com https://www.scirp.org/journal/articles.aspx?searchcode=greek+d.r.g.+institute+sa%2c+athens%2c+greece&searchfield=affs&page=1 mailto:pardrothe@gmail.com theofilou p, platis c, madia k, kotsiopoulos i. burnout and optimism among health workers during the period of covid-19 (original research). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5114 p a g e 2 | 11 abstract aim: the investigation of the level of burnout and optimism as well as the effect of sociodemographic and other factors on the above two variables among health workers during the period of covid-19. methods: the following two psychometric tools were used to collect the research data: the maslach burnout inventory to assess burnout and the revised life orientation test (lot-r) to assess the level of optimism. results: in the present study 10 men (24.4%) and 31 women (75.6%) participated. the majority of them were between 36-45 years (36.6%), married and unmarried (48.8% and 48.8% respectively), holding bachelor degree (61.0%) and with 11-25 years of work experience (53.7%). very high levels of exhaustion and especially emotional exhaustion and depersonalization were observed with also a high degree of personal achievement. the levels of optimism were high. there were statistically significant differences between the two genders in terms of burnout (only the dimension of emotional exhaustion) with women showing higher rates. employees aged 25-35 years and those who had 1-10 years of work seemed to have higher levels of emotional exhaustion (all differences were considered statistically significant for p<0.05). finally, a statistically significant correlation took place between burnout and optimism (p<0.05). conclusions: the level of burnout among health workers seems to be high during the period of covid-19. in addition, various socio-demographic and occupational factors appear to influence burnout. keywords: burnout, professional; burnout, psychological; optimism; covid-19; health personnel; psychological tests; psychometrics. conflicts of interest: none. theofilou p, platis c, madia k, kotsiopoulos i. burnout and optimism among health workers during the period of covid-19 (original research). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5114 p a g e 3 | 11 introduction burnout may be defined as a state of physical, emotional and mental exhaustion that results from long-term involvement in work situations that are emotionally demanding. a great deal of research has been devoted to the understanding of factors contributing to burnout and to its consequences for individuals and their health. research indicates that stress and burnout are significant factors in the development of both physical and psychological illness (1). further research findings show that burnout is correlated with numerous self-reported measures of personal distress (2,3). the first time that the term burnout was used by healthcare provider was back in 1975 by herbert freudenberger in his effort to describe the physical and emotional state that he, and his colleagues, were experiencing. this group of people was working intensively in the free clinic movement of the late 1960s and early 1970s (4). according to freudenberger the term burnout is used in order to define the state of fatigue or frustration brought about by devotion to a way of life, or relationship that has failed to produce the expected reward (5). since then and up to time there have been conducted researches regarding burnout and the effects that can have in a variety of professions as teachers (6), doctors (7), and nurses (8). the nursing profession is considered to be one of the harder professions globally and is characterized by great workloads, fast pace and intensity of work. nurses occupy a central role in the delivery of health care in all countries, though countries may have different health care systems and methods of payment options. unfortunately, studies of the work experiences and satisfactions of nurses in several countries indicate that the satisfaction of nurses is modest. many of them report negative attitudes and diminished psychological and physical well-being, and several would like to leave the profession (8). according to researches so far burnout does not occur in the short term, but gradually escalating, thereby creating long-term problems, such as feelings of hopelessness, distress and failure to work requirements, which have an impact on all areas of human life (9). in the process of time, many demographic varieties have been investigated in order to get fully aware about burnout such as age, gender, working experience. furthermore, the differences between various wards of the hospitals such as psychiatric wards, intensive care units and operating rooms which are considered to be high demanding wards, have been studied in association with burnout several times (10). the health care profession is always physically and emotionally demanding, sometimes requiring decision-making on life and death issues in a very short space of time with limited resources. during disasters such as terror attacks, war or natural catastrophes this situation intensifies since these medical teams must manage the scenario in a state of overall chaos. the health care teams are faced with enormous challenges and are endangered by emotional upheaval. there are human strengths that reinforce mental fortitude acting as buffers against mental illness, such as courage, future-mindedness, optimism, interpersonal skills, faith, work ethics, hope, honesty, perseverance and capacity for flow and insight (10). in general, researchers have proved that optimism has the power to improve morbidity outcomes, and enhance team and organization performance during crisis (11). according to seligman, optimism is ‘the way we explain events and outcomes to ourselves, and it is a learnable approach to life and an invaluable motivator’ (12). people who see desired outcomes as attainable continue to strive toward those outcomes, even when progress becomes difficult or slow (13). weinstein used the term ‘unrealistic optimism’ to describe a theofilou p, platis c, madia k, kotsiopoulos i. burnout and optimism among health workers during the period of covid-19 (original research). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5114 p a g e 4 | 11 cognitive bias which lays in early perceptions of personal vulnerability to health threatening situations (14). knowing the potential benefit of optimism, the world health organization (who) included recommendations providing social and psychological support for health care workers (hcws), patients and communities (15). also, the centers for disease control and prevention (cdc), pointed out the importance of strengthening psychological resources such as coping abilities, selfefficacy, mastery, perceived control, selfesteem, hope and optimism before and during a disaster (16). according to seligman a clear set of coping skills, including how to think optimistically and how to approach problems and adversities can help the hcws. gaining the skill of optimism can assist in confronting stress or setback, can help to overcome failure in particular events, and strengthen selfefficacy and resilience. this will increase the hcw’s overall sense of well-being, helping them to be more beneficial to their society (12). aim the aim of the present study was to investigate the level of burnout and optimism as well as the effect of sociodemographic and other factors on the above two variables among health workers during the period of covid-19. apart from the fact that several studies have been conducted regarding the assessment of burnout, there is a limited number of studies in greece investigating the relation between burnout and optimism as well as the impact of specific variables on the level of them (burnout and optimism). methods this is a cross sectional study including the variables of burnout, optimism and sociodemographic factors (e.g. gender, age, education, marital status etc). the dependent variables are burnout and optimism while the independent are all the sociodemographics. a sample of 50 healthcare workers was recruited. from this set, 41 healthcare workers provided full data on the variables studied, while the remaining 9 healthcare workers were excluded, having incomplete data. in the present study 10 men (24.4%) and 31 women (75.6%) have participated working in two public general hospitals. the inclusion criteria included the characteristics of the sample presented below: 1. >18 of age 2. ability to communicate in greek 3. working in the health sector the data were obtained with a greek version of the maslach burnout inventoryhuman services survey (mbi-hss) (17). the questionnaire consists of twenty two items that provide a measure of perceived burnout. the response format of frequency was used. items can be answered on a seven-point likert scale, ranging from 1 (never) to 7 (everyday). according to maslach et al. (22) the instrument is made up of three subscales: personal accomplishment (pa) (8 items), emotional exhaustion (ee) (9 items), and depersonalization (dp) (5 items). it is preferred to examine relationships with subscale scores as continuous variables and outcomes. scale scores are calculated by averaging the item scores. higher score of these 3 subscales shows more personal accomplishment, emotional exhaustion and depersonalization respectively. the life orientation test (lot) is a standard psychological tool for measuring optimism. initially created by michael scheier and charles carver in 1985, this test underwent a few revisions, and eventually, the improved version of the lot, known as lot-revised or lot-r gained more popularity for personal and professional purposes. the first version of the life theofilou p, platis c, madia k, kotsiopoulos i. burnout and optimism among health workers during the period of covid-19 (original research). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5114 p a g e 5 | 11 orientation test had twelve questions, each measuring optimism and pessimism objectively. the respondents needed to answer each item on a 5-point likert scale where – 0 means ‘strongly disagree‘ and 4 implies ‘strongly agree.’ the lot uses questions that are relatable to all individuals irrespective of their age or background and investigates simple elements of life that we all contemplate at some point in life. the life orientation test includes (18): • statements about how we feel about ourselves, others, and life in general. • statements about how we feel about ourselves, others, and life under stress. • statements about how we feel about ourselves, others, and life during happy times. the questions, however simple, are deep and probe the individual to explore parts of the mind that are sometimes untouched and unheard. the interpretation and analysis of the scores provide valuable understanding of where we are standing in life and how we can overcome pessimistic or negative contemplations to move ahead. due to such criticisms, a modified version of the lot, called the lot-r or life orientation testrevised was created by scheier and carver 1994. the lot-r is a shorter version of the lot but is more objective and specialized than the original test. there are only ten questions that are evaluated in the questionnaire with a response system that is similar to the original version of lot (5point likert scale). a written consent statement for voluntary participation was taken. the survey was done between september and november 2020. all valid data was entered into a spreadsheet format, and analyses were performed using statistical package for social sciences, version 25.0. the results indicated that the variables examined showed normality according to kolmogorov – smirnov test which was conducted. results in the present study 10 men (24.4%) and 31 women (75.6%) participated. the majority of them were between 36-45 years (36.6%), married and unmarried (48.8% and 48.8% respectively), holding a bachelor degree (61.0%) and with 11-25 years of work experience (53.7%). all the characteristics of the sample are presented in table 1. table 1. sociodemographic and working characteristics of the sample n 41 gender (men) n (%) 10 24.4 (women) n (%) 31 75.6 education secondary n (%) 4 9.8 university bachelor n (%) 25 61.0 master degree 7 17.1 phd degree 5 12.2 age theofilou p, platis c, madia k, kotsiopoulos i. burnout and optimism among health workers during the period of covid-19 (original research). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5114 p a g e 6 | 11 25-35 n (%) 9 22.0 36-45 n (%) 15 36.6 46-55 n (%) 12 29.3 >55 n (%) 5 12.2 marital status single n (%) 20 48.8 married n (%) 20 48.8 divorced n (%) 1 2.4 professional affiliation nursing staff n (%) 19 46.3 medical staff n (%) 10 24.4 administrative staff n (%) 7 17.1 μedical laboratory technologists etc n (%) 1 2.4 other n (%) 4 9.8 years of work 1-10 n (%) 14 34.1 11-25 n (%) 22 53.7 >25 n (%) 5 12.2 table 2. descriptive statistics of the participants n minimum maximum mean std. deviation optimism total 41 13 30 21.68 4.62 depersonalization 41 5 32 13.87 7.40 personal achievement 41 14 56 42.76 9.86 emotional exhaustion 41 12 59 30.95 12.95 based on the results in table 2, the mean values of the optimism and burnout were 21.68 (optimism), of depersonalization 13.87, of personal achievement 42.76 and of emotional exhaustion 30.95. theofilou p, platis c, madia k, kotsiopoulos i. burnout and optimism among health workers during the period of covid-19 (original research). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5114 p a g e 7 | 11 tables 3. cut-off points for optimism and three dimensions of burnout frequency (n) percent (%) meaning optimism cut-off points ≤ 13 1 2.4 low 14-18 15 36.6 moderate ≥ 19 25 61.0 high total 41 100.0 depersonalization (dp) cut-off points ≤ 6 6 14.6 low 7-12 15 36.6 moderate ≥13 20 48.8 high total 41 100.0 personal achievement (pa) cut off points ≥ 39 24 58.5 low 22-38 16 39.0 moderate ≤ 21 1 2.4 high total 41 100.0 emotional exhaustion (ee) cut off points ≤ 16 5 12.2 low 17-26 13 31.7 moderate ≥ 27 23 56.1 high total 41 100.0 as seen in table 3, the majority of the participants presented high level of optimism (n=25, 61%) while 15 participants (36.6%) indicated moderate optimism. the majority of the participants presented high level of depersonalization (n=20 or 48.8%) while 15 participants (36.6%) indicated moderate level of depersonalization. the majority of the participants presented high level of personal achievement (24, 58.5%) while 16 participants (39.0%) indicated moderate personal achievement. the majority of the participants presented high level of emotional exhaustion (23, 56.1%) while 13 participants (31.7%) indicated moderate emotional exhaustion. table 4. correlations between optimism and burnout depersonalization personal achievement emotional exhaustion optimism total pearson correlation -0.359 0.555 -0.369 * sig. (2-tailed) 0.027* <0.001** 0.022* n 41 41 depersonalization pearson correlation -0.068 0.588 theofilou p, platis c, madia k, kotsiopoulos i. burnout and optimism among health workers during the period of covid-19 (original research). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5114 p a g e 8 | 11 sig. (2-tailed) 0.684 <0.001** n 41 41 personal achievement pearson correlation -0.209 sig. (2-tailed) 0.207 n 41 * correlation is significant at the p=0.05 level (2-tailed) ** correlation is significant at the p=0.01 level (2-tailed) as seen in table 4, a positive and statistically significant correlation took place between optimism and personal achievement (r= 0.555, p<0.001). a negative and statistically significant correlation was observed between optimism and depersonalization (r= -0.359, p=0.027) as well as with emotional exhaustion (r= 0.369, p=0.022). table 5. t-test showing differences between males (n=10) and females (n=31) in optimism and burnout scores gender mean std. deviation p-value optimism total female 21.52 4.87 0.695 male 22.22 3.90 depersonalization female 14.38 7.86 0.452 male 12.22 5.76 personal achievement female 42.79 8.53 0.974 male 42.67 13.97 emotional exhaustion female 33.62 13.10 0.020* male 22.33 8.06 * t-test is significant at p=0.05 level (2-tailed) as seen in table 5, females presented more burnout and specifically emotional exhaustion in comparison to males (33.63 vs. 22.33, p=0.020). there was no other statistically significant difference between these two groups. regarding the effect of age, the results indicated that individuals of 25-35 years old showed higher scores of emotional exhaustion (38.77) in comparison to 36-45 (34.86), 46-55 (22.77) and >55 years old (19.80) (p=0,004). regarding the effect of the years of working experience, the results indicated that individuals working 1-10 years showed higher scores of emotional exhaustion (35.21) in comparison to those working 1125 (31.31) and >25 years (17.60) (p=0.028). no statistically significant differences were observed regarding marital status, education level and category of personnel. discussion the aim of the present study was the investigation of the level of burnout and optimism as well as the effect of sociodemographic and other factors on the above theofilou p, platis c, madia k, kotsiopoulos i. burnout and optimism among health workers during the period of covid-19 (original research). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5114 p a g e 9 | 11 two variables among health workers during the period of covid-19. the concept of burnout has been under investigation frequently especially in the social sciences who are dealing with the structure society; moreover, experts in administration and organization became fully aware of the importance of the syndrome and the effects which has to the individual, the economy and general production as well. through years, burnout syndrome has been in the center of research among health care professionals due to the impacts on their lives. very high levels of exhaustion and especially emotional exhaustion and depersonalization are observed in the present study with also a high degree of personal achievement. this is a result which corresponds to previous findings but we must point out that in previous studies most participants suffered from emotional exhaustion, although at a low level (19). this could be explained that our study took place during the period of covid-19 providing the health workers with more burden. the levels of optimism are observed to be high in the context of the current study. this is also a result which is in agreement with other studies showing that all of the participants had high expectations that fulfilling the recommended measures could mitigate the impact of the pandemic (20). moreover, there is a close relation between burnout and optimism. suñer-soler et al. (21) in spain in their research compared the levels burnout, quality of life and mental health among nursing and healthcare personnel and had the same associations between the levels of burnout and mental health. there are also differences between the two genders in terms of burnout (dimension of emotional exhaustion) with women showing higher rates. this finding is in agreement with other similar results indicating that women present a worse mental wellbeing compared to males in health population or chronic disease patients (22,23). employees aged 25-35 years and those who had 1-10 years of work seem to have higher levels of emotional exhaustion. the research conducted by douvanas and associates in 2011 among nursing personnel in greece had indicated the above factors to be related to burnout (24). the same demographic factors had been indicated and in other researches in greece (25-29). further, there is a close relation between the variables of optimism and burnout indicating a positive association of optimism with personal accomplishment, which is a term with a positive meaning. on the other hand, the findings show a negative relation of optimism to the subscales of emotional exhaustion and depersonalization which are two terms with a negative meaning. burnout is related to the work environment, but its effects extend into the personal lives of health professionals. the physical, psychological, and interpersonal/social effects of stress and burnout among these professionals can vary from those felt in the general workforce. professional consequences of burnout have serious implications not only for the health and well-being of health workers but also for the health and safety of patients. therefore, a well supportive social network can affect positively in the work life of them and those positive effects can expand to health and quality of life in general. limitations limitations of the research should be noted to put the findings into a broader context. the sample of the health workers in this study was small. it was impossible to determine the representativeness of those individuals that participated. future research needs to involve a larger and representative sample of health providers drawn from several different hospitals. declaration we confirm that this manuscript has not been published elsewhere and is not under consideration by another journal. theofilou p, platis c, madia k, kotsiopoulos i. burnout and optimism among health workers during the period of covid-19 (original research). seejph 2022, posted: 21 january 2022. doi: 10.11576/seejph-5114 p a g e 10 | 11 references 1. firth-cozens j, payne r. stress in health professionals. psychological and organisational causes and interventions. new york: john wiley & sons, 1999. 2. belcastro pa, gold rs. teacher stress and burnout: implications for school health personnel. j sch health. 1983 sep;53(7):404-7. 3. greenglass er, julkunen j. cookmedley hostility, anger, and the type a behavior pattern in finland. psychol rep. 1991 jun;68 (3pt 2):1059-66. 4. daley mr. burnout: smoldering problems in protective services. social work. 1979; 24(5): 375-9. 5. freudenberger hj. the staff burnout syndrome in alternative institutions. psychol psychother theor res pract. 1975; 12(1):73-82. 6. barutçu e, serinkan c. burnout syndrome of teachers: an empirical study in denizli in turkey. procedia soc behav sci. 2013; 89:318-22 7. ptacek r, celedova l, kuzelova h, cevela h, kebza v, solcova i. stress and burnout syndrome in medical professions in the czech republic. eur psychiatry. 2011;26(suppl 1): 1598. 8. kalandyk h, penar-zadarko b. a perception of professional problems by nurses. prog health sci. 2013;3(2):100-9. 9. bakker ab, killmer ch, siegriest j, schaufeli wb. effort-reward imbalance and burnout among nurses. j adv nurs. 2000; 31:884-91. 10. sahraian α, fazelzadeh α, mehdizadeh αr, toobaee sh. burnout in hospital nurses: a comparison of internal, surgery, psychiatry and burns wards. int nurs rev. 2008 mar;55(1):62-7. 11. seligman mep. positive health: an international review. appl psychol. 2008;57:318. 12. seligman m. authentic happiness: using the new positive psychology to realize your potential for lasting fulfillment. new york: the free press; 2004. 13. scheier me, carver cs. effects of optimism on psychological and physical well-being: theoretical overview and empirical update. cognitive ther res. 1992;16:20128. 14. weinstein nd. unrealistic optimism about future life events. j pers soc psychol. 1980;39:80620. 15. world health organization. global influenza program, whole-of-society pandemic readiness [internet]. geneva; may 2009. available from: http://www.unpic.org/web/documents/ english/who%20wos%20pandemic %20 readiness%202009-05-05.pdf (accessed: june 20, 2010). 16. center for disease control and prevention (cdc). crisis and emergency risk communication: pandemic influenza. 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relationship with the patients? a qualitative analysis. international journal of caring sciences, 2016; 9(2), 534-41. ________________________________________________________________________ jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 1 original research pharmaceutical expenditure changes in serbia and greece during the global economic recession mihajlo b. jakovljevic 1 , kyriakos souliotis 2,3 1 health economics and pharmacoeconomics, faculty of medical sciences, university of kragujevac, kragujevac, serbia; 2 university of peloponnese, corinth, greece; 3 the centre for health services research, medical school, university of athens, greece. corresponding author: mihajlo (michael) jakovljevic, md, phd, head of graduate health economics & pharmacoeconomics curricula, faculty of medical sciences, university of kragujevac; address: svetozara markovica 69, 34000 kragujevac, serbia; telephone: +38134306800 (ext. 223); email: sidartagothama@gmail.com jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 2 abstract aim: clarity on health expenditures is essential for the timely identification of risks that jeopardize the democratic provision of health services and the credibility of health insurance systems. furthermore, observing health outcomes with geographical scope is essential for making multilateral associations. this study aimed at conveying information on the variability of important economic parameters of the health sector of serbia and greece from 2007 to 2012, when the most serious financial crisis in the post-war economic history hit the global economy. methods: exchange rates, purchase-power-parities (ppp) and price indices were used for the bilateral review of health and pharmaceutical expenditure dynamics during 2007-2012. prescription and dispensing changes were also studied taking into account the anatomical therapeutic chemical (atc) structure of drugs consumed. results: greece was forced to cut down its total health care and pharmaceutical expenditure and mainly its out-of-pocket payments were more seriously affected by the recession. surprisingly, emerging market of serbia, although severely damaged by global recession, succeeded to maintain 19% growth of its per capita health expenditure and even 25% increase of its per capita spending on pharmaceuticals. innovative pharmaceuticals showed an upward trend in both countries. conclusions: these two countries might serve as an example of two distinct pathways of mature and emerging health care markets during financial constraints caused by global recession. our findings show that producing disease-based feedback, in the long run, may empower the assessment of the return on investment on medical technology and healthcare systems’ cost-effectiveness. keywords: economic crisis, expenditure, greece, pharmaceutical global recession, serbia. conflict of interest: none. source of funding: the ministry of education, science and technological development of the republic of serbia has funded this study through grant: oi 175014. in any case, publication of results of this study was not contingent on ministry’s censorship or approval. jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 3 introduction studying the cost of services in healthcare over multiple periods is a challenging task taking into account the coalescence of explicit and implicit parameters of change in the service products provided; namely, the changes in the commodities’ price and quality (1). pharmaceutical care is, ‘par excellence’, a dynamic part of health sector. firstly, pharmaceutical products are dominated by continual change due to the unstoppable technological improvement; secondly, the public sector has a role of payer and hence the power to regulate market prices. financial fluctuations can thus act as tidal waves affecting providers, users and, ultimately, the population’s health. the following paragraphs attempt to delineate key changes in the serbian and greek healthcare sector covering the period from 2007 onwards, when the global economy was hit by the most serious financial crisis in the post-war economic history (2). serbia, the largest market of the western balkans region, has experienced bold growth of domestic public and private health care sector. its total health expenditure grew from 7.7% of gdp in 2000 to 10.5% in 2009, well above the eu average. its total public health expenditure increased enormously (from €1,175 million in 2004 to €1,847 million in 2012). at the same time, public spending on pharmaceuticals doubled, reaching a level of €742 million (3). unfortunately, like all the surrounding balkan and eastern european transitional post-socialist markets, the serbian health system suffered heavily from several consecutive waves of global recession. after sustaining these impacts and introducing severe cost-cutting policies (some of which introduced only recently in 2014), the national market of serbia began its slow recovery. the greek health sector experienced a period of significant growth during the first decade of the millennium, with a total health expenditure rising from 8.7% of gdp in 2003 to 10% in 2009, which was above the eu average (4). this growth was very pronounced particularly in the pharmaceutical sector where total expenditure more than doubled during the same period (from €3.2 billion in 2003 to €6.6 in 2009), rising from 1.9% to 2.8% of the gdp, with more than 78% being public expenditure (5). specifically, public pharmaceutical expenditure increased by €0.5 billion per year between 2004 and 2009, reaching €5.2 billion in 2009 (4). yet, following the signing of the memorandum of understanding (mou) (6) in 2010, a series of extraordinary cost-containment measures and structural reforms were imposed on the greek health sector, and on the pharmaceutical sector in particular, a sector regarded as a major contributor to both the deficit and the public debt due to the excessive public spending resulting from lack of control over both volume and cost of prescribing. thus, since may 2010, the pharmaceutical sector has been placed at the centre of fiscal consolidation, becoming one of the key areas of intervention in order to reduce public pharmaceutical expenditure to 1% of gdp, thereby approaching the european average (7). as a result, public pharmaceutical expenditure has dropped by 44% between 2009 and 2012, reaching €2.8 billion and corresponding to 1.5% of the gdp in 2012 (iobe, 2014). methods setting serbian and greek national pharmaceutical sectors assessments grounded in official data released by the respective national medicines’ agencies and national health insurance funds. jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 4 study design consisted of a retrospective database analysis conducted from the first party payer’s perspective with a six-year long time horizon. health outcomes regarding values, prices and the quality of the services provided were observed for serbia and greece. the time domain of the analysis covers the time interval 2007-2012. any information fissures caused by lack of data in health accounts are glossed over by more recent data. differences in price levels between the two countries are measured with the official exchange rates into us dollars. the purchasing power parity (ppp) was additionally used as a real expenditure change survey tool (8). the presented ppps are in 2011 us dollars (9). the price index of the comparative price level (cpl) was also computed according to the algebraic expression shown below (10): cpl = rateexchange ppp the relevant outcomes are presented in table 1. other measures of bilateral comparability are also included in table 1, such as the gdp and the gdp per capita which are based on ppps in us dollars. population magnitudes as the size of the population, the percentage of people aged 65 and over, and the crude birth and death rates per 1000 people are also appended. table 1. basic macroeconomic and demographic magnitudes in serbia and greece in 2012/2013 economy serbia greece gross national income (ppp billions us$, 2012) 82.6 290.3 gross national income per capita (ppp us$, 2012) 11 430 26 170 indices ppp* (1 us$=1.000) 37.29 0.69 exchange rate (1 us$=1.000) 73.34 0.72 cpl price index (us prices=100) 16.22 37.00 demographics resident population (millions, 2013) 7.3 11.3 population ≥65 years (%, 2013) 14 20 crude death rate per 1000 people (2012) 14 11 crude birth rate per 1000 people (2012) 9 9 unemployment % of total labour force (2008-2012) 24 24 * sources: 2014 world development indicators. 2014 international bank for reconstruction and development, the world bank purchasing power parities and the real size of world economies. a comprehensive report of the 2011 international comparison program. 2015 international bank for reconstruction and development, the world bank. table 2 includes health expenditure values and changes based on ppps. annual percentage changes depicted in the last column of the table are yielded according to the harmonic mean of annual changes within the period 2007-2012. national total and pharmaceutical health expenditure per capita trends in serbia and greece during 2007-2012 are analytically presented (in ppp$ values) in figure 1. jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 5 national health expenditures as percentage of gdp in serbia and greece during the period 2007-2012 are also depicted in figure 2. table 2. health expenditure values and their increase: serbia and greece, 2007-2012 healthcare outcome 2007 2012 change (%) annual change (%) health expenditure per capita, ppp$ serbia 1 047 1 250 19.39 3.44 health expenditure per capita, ppp$ greece 2 727 2 346 -13.95 -3.28 health expenditure, private (% of gdp) serbia 4 4 1.62 0.28 health expenditure, private (% of gdp) greece 4 3 -16.39 -3.88 health expenditure, private (% of total health expenditure -the) serbia 39 39 0.55 0.10 health expenditure, private (% of total health expenditure-the) greece 37 32 -11.53 -2.84 health expenditure, public (% of gdp) serbia 6 6 0.72 0.12 health expenditure, public (% of gdp) greece 6 6 7.09 1.06 health expenditure, public (% of government expenditure) serbia 14 13 -3.37 -0.72 health expenditure, public (% of government expenditure) greece 12 11 -7.10 -1.56 health expenditure, public (% of total health expenditure) serbia 61 61 -0.34 -0.07 health expenditure, public (% of total health expenditure) greece 60 68 13.32 2.42 health expenditure, total (% of gdp) serbia 10 10 1.07 0.19 health expenditure, total (% of gdp) greece 10 9 -5.50 -1.20 health expenditure, total (current us$, millions) serbia 4 035 4 030 -0.13 -1.00 health expenditure, total (current us$) greece 29 964 23 080 -22.97 -5.58 pharmaceutical expenditure per capita, ppp$ serbia 305 382 * 25.25 0.64 pharmaceutical expenditure per capita, ppp$ greece 676 673 * -0.44 -1.16 * sources: data from database: health nutrition and population statistics. the world bank. 2011. who global health expenditure database 2007–2012 and european health for all database (hfa-db) 2007–2012. tables 3 and 4 illustrate respectively the maximum and minimum absolute changes in the available outcomes of the two countries’ pharmaceutical sector, classified according to the atc4 level of the anatomical therapeutic chemical classification system of drugs (11). direct bilateral ppp comparisons were conducted for the gdp per capita and the pharmaceutical expenditure per capita, simplifying the paasche price index. in the algebraic expression (2), serbia is the base country and the pgs expresses greece’s “p” values (i.e., the p.c. gdp or the p.c. pharmaceutical expenditure) in serbian terms. “s” and “g” initials denote “serbia” and “greece”, respectively, and “q” is the general population of greece. pgs = σpgqg / σpsqg (2) jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 6 jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 7 figure 1. national total and pharmaceutical health expenditure trends in serbia and greece during the period 2007-2012 (expressed in current ppp $ per capita) * source: who global health expenditure database 2007-2012 and european health for all database (hfa-db) 2007-2012. figure 2. national health expenditure trends in serbia and greece during the period 2007-2012 (expressed as a percentage of disposable gross domestic product, gdp) jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 8 * source: who global health expenditure database 2007-2012 and european health for all database (hfa-db) 2007-2012. table 3. top 20 atc drug classes based on turnover growth, 2007-2012 atc classes serbia * atc classes greece † c09ba ace inhibitors and diuretics € 2 246 511 l01xc monoclonal antibodies € 11 287 179 l01xc monoclonal antibodies € 1 890 961 l01xe protein kinase inhibitors € 9 001 287 b01ac platelet aggregation inhibitors excluding heparin € 1 662 525 l04ab tumor necrosis factor alpha (tnf-α) inhibitors € 8 711 090 c10aa hmg coa reductase inhibitors € 1 560 979 l04aa selective immunosuppressants € 4 954 700 r03ak adrenergics in combination with corticosteroids or other drugs, excl. anticholinergics € 1 430 330 l02bx other hormone antagonists and related agents € 4 405 048 c09ca angiotensin ii antagonists, plain € 1 180 464 l04ax other immunosuppressants € 4 155 810 l01xe protein kinase inhibitors € 1 000 095 s01la antineovascularisation agents € 3 530 581 a10ad insulins and analogues for injection, intermediateor long-acting combined with fastacting € 863 908 l04ac interleukin inhibitors € 2 756 671 c07ab beta blocking agents, selective € 789 919 a16ab enzymes € 2 440 854 v08ab water-soluble, nephrotropic, low osmolar x-ray contrast media € 635 129 j05ab nucleosides and nucleotides excluding reverse transcriptase inhibitors € 2 396 560 n04bc dopamine agonists € 600 260 b03xa other antianemic preparations € 2 354 249 g04ca alpha-adrenoreceptor antagonists € 589 965 c01eb other cardiac preparations € 2 238 049 j05ar antivirals for treatment of hiv infections, combinations € 581 846 c09dx angiotensin ii antagonists, other combinations € 2 001 835 n02be anilides € 562 326 a10bd combinations of oral blood glucose lowering drugs € 1 902 922 c05ba heparins or heparinoids for topical use € 541 038 r03dx other systemic drugs for obstructive airway diseases € 1 760 418 l01cd taxanes € 493 830 l01xx other antineoplastic agents € 1 758 626 n06da anticholinesterases € 438 968 b01ae direct thrombin inhibitors € 1 606 684 g04be drugs used in erectile dysfunction € 432 442 l01ba folic acid analogues € 1 597 243 r01aa sympathomimetics, plain € 418 995 l03aa colony stimulating factors € 1 411 531 a10ba biguanides € 415 132 l01bc pyrimidine analogues € 1 368 591 * sources: medicines and medicinal device agency of serbia annual reports on turnover and consumption of pharmaceuticals; national health insurance fund of serbia. jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 9 † greek national organisation for health care services provision-eopyy. jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 10 table 4. bottom 20 atc drug classes based on turnover growth 2007-2012 atc classes serbia * atc classes greece † c09aa ace inhibitors, plain -€ 1 643 854 c10aa hmg coa reductase inhibitors -€ 31 679 014 g03ga gonadotropins -€ 1 330 919 c09da angiotensin ii antagonists and diuretics -€ 13 420 269 j01fa macrolides -€ 1 197 082 b01ac platelet aggregation inhibitors excluding heparin -€ 8 526 396 j01dd third-generation cephalosporins -€ 1 059 188 c09ca angiotensin ii antagonists, plain -€ 7 929 987 m01ab acetic acid derivatives and related substances -€ 1 040 177 n03ax other antiepileptics -€ 7 071 604 c01da organic nitrates -€ 935 780 a02bc proton pump inhibitors -€ 6 745 836 a02ba h2-receptor antagonists -€ 896 631 n06ab selective serotonin reuptake inhibitors -€ 6 399 987 m01ae propionic acid derivatives -€ 846 670 n06da anticholinesterases -€ 5 199 056 j01db first-generation cephalosporins -€ 691 096 n05ax other antipsychotics -€ 5 119 251 l01cb podophyllotoxin derivatives -€ 577 411 m05ba bisphosphonates -€ 4 794 650 b03xa other antianemic preparations -€ 566 477 c08ca dihydropyridine derivatives -€ 4 165 272 c04ad purine derivatives -€ 563 692 n06ax other antidepressants -€ 3 810 668 l04aa selective immunosuppressants -€ 438 147 c09aa ace inhibitors, plain -€ 3 275 530 j01ca penicillins with extended spectrum -€ 433 257 r03dc leukotriene receptor antagonists -€ 3 182 560 j01dc second-generation cephalosporins -€ 417 805 n05ah diazepines, oxazepines, thiazepines and oxepines -€ 2 894 838 b05ba solutions for parenteral nutrition -€ 390 852 a10bg thiazolidinediones -€ 2 860 150 r03ac selective beta-2adrenoreceptor agonists -€ 376 303 r03ba glucocorticoids -€ 2 455 708 j01cr combinations of penicillins, including betalactamase inhibitors -€ 374 335 c09ba ace inhibitors and diuretics -€ 2 195 843 r03da xanthines -€ 340 329 a10bb sulfonamides, urea derivatives -€ 2 137 085 b05aa blood substitutes and plasma protein fractions -€ 328 794 l02bg aromatase inhibitors -€ 2 007 464 * sources: medicines and medicinal device agency of serbia annual reports on turnover and consumption of pharmaceuticals; national health insurance fund of serbia. jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 11 † greek national organisation for health care services provision-eopyy (estimations based on 2010-2012 data). results aside from minor differences in their aging populations, serbia and greece were spending similar amounts on health as percentage of the gdp, in the beginning of the recession. the recession, however, resulted in decreases in the amounts allocated for health in both countries, with greece reducing mainly its private expenditure on health (from 37% to 32% of the). in per capita terms, pharmaceutical expenditure recorded bold 25% growth in serbia, whereas marginal decreases (0.4%) were jotted down for greece, during the recession. greece’s more intense recession effects on the pharmaceutical sector were also reflected on the values of the pgs price index. greece’s p.c. gdp in ppp$ was 2.29 times the p.c. gdp of serbia in 2012 (pgs = 26,170/11,430). similarly, the pharmaceutical expenditure per capita of greece was 2.22 times the pharmaceutical expenditure per capita of serbia in 2007 (pgs = 676/305), whereas in 2012 it reduced to 1.76 (pgs = 673/382). the pharmaceutical market internal structure of prescription and sales has in some cases moved in the same direction in the two countries. specifically, within some therapeutic categories, pharmaceutical expenditure continued to grow despite the depression. these categories included the l01xc monoclonal antibodies, the l01xe protein-kinase inhibitors, the a10b blood glucose lowering drugs, excluding insulins and the j05a direct acting antiviral drugs. continuing rise of share of innovative biological medicines is evident despite the financial constraints. few important differences in adaptive responses to the economic crisis induced weaknesses were noticed between emerging and mature health market. while health expenditure per capita (ppp$) in serbia still succeeded to grow for 19.4%, the greek one felt almost 14% during these six years. the total health expenditure (the) in serbia decreased marginally by 0.13%, whereas during the same time, the greek the fell abruptly by even 23%. health expenditure percentage of gdp in serbia grew 1% while greek one decreased almost 5.5%. a similar pattern was noticed with private health care expenditure expressed either as percentage of the or gdp: the greek one decreased by 16.4% and 12% respectively, while serbian private health expenditure recorded minor growth in crisis’ years. governmental share of health expenditure has fallen dramatically in both countries although more prominently in greece. opposed to all the aforementioned recessional changes, public health expenditure was rising much faster in greece compared to serbia both on grounds of gdp proportion and the proportion which reached 13.3% increase. at the same time, in serbia, these values were slightly up and down, but only marginally (see table 2). discussion to date, all countries of the broader south eastern europe have found themselves in different stages of profound demographic transition outsourcing from increased longevity and falling fertility rates (12). greece’s population is ageing faster considering its lower crude death rates and its higher proportion of old ages in the general population. population aging in serbia has deep historical roots and is likely to pose severe challenge on the national health system financing in the upcoming decades (13). this inevitable demographic change will be shaping growing needs for pharmaceuticals and the landscape of their consumption in both countries in the long run. jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 12 observing much shorter time horizon of six recent years of global economic recession, emerging serbian pharmaceutical market has undergone complex changes in terms of valuebased medicines prescription and dispensing. regardless of significant difficulties and slower growth, national public expenditure on pharmaceuticals has doubled since 2004. innovative cardiovascular, anti-diabetic agents, combined adrenergic and corticosteroid preparations and targeted immunotherapies dominated the landscape. economic crisis induced package of policy measures provided temporary relief for the ongoing financial difficulties. nevertheless, shortages of pharmaceuticals continued to occur more frequently compared to the period before 2008. these shortages occasionally refer even to the essential medicines and are primarily caused by the substantial public debt toward major multinational pharma companies supplying the eastern european markets. contemporary market access and reimbursement policies by regional authorities in most of balkans peninsula limit patient access to the expensive innovative medicines to narrowly defined diagnoses related groups (14). it is essential to be aware of the boomerang effect created by these restrictive policies. individuals, who are denied primary care preventive or screening services, ultimately end up in late severe stages of illness requiring expensive and complex inpatient treatment. a higher presence of clinically evolved conditions in transitional eastern european countries has already been proven in the case of copd (15), alcohol abuse (16) and cancer (17). these health system inefficiencies inherited from the socialist era create significant costs to the system, as well as worse health outcomes. high consumption of medicines indicated to treat some of key “prosperity” diseases such as diabetes (18), copd, risky pregnancies (19,20), addiction disorders, hepatitis (21) and cancer (22) serves as the evidence of such vulnerabilities within the system (20). these major illnesses should also present core targets for more responsible, evidence-based national resource allocation strategies (23). in greece, the pharmaceutical industry has traditionally represented an important sector of the economy and has been a major employer in the production, research and development, as well as distribution wholesale and retail. however, the greek pharmaceutical market has been long characterized by significant overspending (24), with public pharmaceutical expenditure reaching unprecedented levels in 2009 and thus being blamed as one of the main contributors of public deficit and debt. between 1990 and 2010, the applied pharmaceutical policy has focused mostly on price regulations in order to control expenditure, while no real effort was made to contain the volume of prescribed medicines, determined by the prescribing habits of physicians and by patients’ demand (25,26). as a result, public pharmaceutical expenditure continued to rise during this period, while the introduction of measures such as pharmaceutical pricing according to the lowest ex-factory european price and the positive list, had only a temporary effect on reducing expenditure, ultimately leading to the replacement of old products with new, more expensive ones and to the switching to more expensive medicines of the same therapeutic category (27,28). in light of the above and in the context of fiscal consolidation, a comprehensive health care reform was implemented after the signing of the mou in 2010 and is still on-going, aiming, among other things, to reduce waste, control expenditure and increase the accountability and efficiency of the greek pharmaceutical sector. the mou defined a number of costcontainment measures that had to be implemented within very tight timelines, targeting the reduction of both cost and volume of prescribed medicines. these measures included interim flat decreases of pharmaceutical prices, a new pharmaceutical pricing system according to jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 13 which prices are determined based on the average of the three lowest prices in the eu-27, introduction of positive, negative and over-thecounter (otc) medication lists, reduction in the profit margins of pharmacists and wholesalers, collection of rebate and claw-back from pharmaceutical companies, changes in the distribution of high-cost medicines, increase in the use of generics in the national health system, introduction of electronic prescriptions for medicines, publication of clinical guidelines and prescribing protocols, as well as monitoring of physicians’ prescribing habits (29). following the implementation of the mou, the greek government has primarily focused on applying cost-containment measures such as flat decreases of pharmaceutical prices and the collection of the rebates from pharmaceutical companies in order to achieve a fast reduction of pharmaceutical expenditure, while the measures and structural reforms aiming at the rationalization of the prescribing behaviour of physicians, such as e-prescribing and monitoring of physicians’ behaviour progressed at a slower pace. by 2012, public pharmaceutical expenditure shrunk by 44% since 2009, reaching 1.5% of gdp, while in 2013 it was reduced to €2.4 billion (53% decrease). the recent changes in pharmaceutical policy which have been implemented in greece in the context of its economic adjustment program have created turmoil in the pharmaceutical sector challenging its growth prospects and its long-term sustainability, thus resulting in instability in the market. this led to temporary drug shortages, hampering access to timely and effective therapy for the patients (30). at the same time, the policy of continuous reductions in pharmaceutical expenditure after a certain level and the substantial downsizing of the market, led to significant losses in public income resulting from the layoffs in the pharmaceutical sector and the subsequent lost of tax revenues and social contributions from pharmaceutical companies and pharmacies. the above demonstrate that even though in 2010 there was a real, urgent need for rationalization of the greek pharmaceutical market and for the implementation of a number of structural reforms, currently, several years after the eruption of the fiscal crisis and while the health care reform is still on-going, there is a need to adopt a more multi-factorial approach in policy-making, i.e., an approach which will account for the potential impact of applied policies on: i) patient access; ii) insurance contributions, employment and gdp, as well as; iii) the benefits brought by the strengthening of scientific research and development, when estimating the net financial result of these policies. conclusions these two countries might serve as an example of two distinct pathways of mature and emerging health care markets during financial constraints caused by global recession. apart from the ostensible differences in their composition of health and pharmaceutical expenditure, serbia and greece both cut down on their pharmaceutical expenditure during the financial crisis, even though greece was more seriously affected by the recession. surprisingly, the emerging market of serbia, although severely damaged by the global recession, succeeded to maintain 19% growth of its per capita health expenditure and even 25% increase of its per capita spending on pharmaceuticals. the recession left unaffected certain pharmaceutical expenditure trends in both countries dictating inelastic areas in the curve of pharmaceutical needs. specifically, an increasing expenditure was documented for the l01xc monoclonal antibodies, the l01xe proteinkinase inhibitors, the a10b blood glucose lowering drugs, excluding insulins and the j05a direct acting antiviral drugs. jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 14 the current results show that studies in the direction of producing disease-based feedback could empower the assessment of return on investment on medical technology, enhance the process of pharmaceutical expenditure estimations, predictions and projections and, in the long run, increase health outcomes’ predictability and the european healthcare systems’ costeffectiveness. jakovljevic mb, souliotis k. pharmaceutical expenditure changes in serbia and greece during the global economic recession (original research). seejph 2016, posted: 06 april 2016. doi 10.4119/unibi/seejph2016-101 15 references 1. oecd/eurostat. main pricing methods for service producer price indices, in eurostat-oecd methodological guide for developing producer price indices for services: second edition, oecd publishing; 2014. 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___________________________________________________________ © 2016 jakovljevic et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. czabanowska k. developing a new generation of public health leaders (editorial). seejph 2022, posted:20 august 2022. doi: 10.11576/seejph-5828 p a g e 1 | 3 editorial developing a new generation of public health leaders katarzyna czabanowska1,2 1 department of international health, care and public health research institute caphri, fhml, maastricht university, maastricht, the netherlands; 2 department of health policy management, institute of public health, faculty of health sciences, jagiellonian university, krakow, poland. corresponding author: katarzyna czabanowska, maastricht university; address: duboisdomein 30, 6229 gt maastricht, the netherlands; e-mail: kasia.czabanowska@maastrichtuniversity.nl czabanowska k. developing a new generation of public health leaders (editorial). seejph 2022, posted:20 august 2022. doi: 10.11576/seejph-5828 p a g e 2 | 3 one of the challenges of teaching and developing the new generation of public health leaders is to meet the needs of health systems in the twenty-first century. competent leaders are increasingly important across all health professions and “as a learned skill; the topic of leadership is gathering momentum as a key curriculum area” (1). effective leadership is a complex and highly valued component of public health education. it consists of a learnable set of competencies that can be developed by fostering interdisciplinary, collaborative learning and communication around current and urgent public health problems such as for example: antimicrobial resistance, climate change, diversity and inclusion, health inequalities or communicable and non-communicable diseases, or conflict. learning how to advance existing health policies, which are not effective or proposing new ones in a facilitated group setting, can assist students in leadership development and can be viewed as a practical technique for orchestrating change and achieving performance in the practitioner’s world (2). public health leadership course, which is a part of the governance and leadership in european public health master’s at maastricht university instils a competency of political savvy in the future public health professionals, who have to propose a plan for policy change or policy development in relation to a specific public health challenge in the process of six leadership tutorials. the result of such collaborative process facilitated by public health or leadership experts is a collection of policy briefs that we present in this special issue. these policy briefs developed by the public health students contribute to both the development of new generation of public health leaders with a policy-making acumen and to the development of public health policy field from the perspective of young generation of public health professionals. the importance of this work is summarised below by some of the expert tutors who took part in this educational experience. “the field urgently needs public health practitioners who understand how to look at big, complex problems, dissect and analyse them, and craft creative, evidence-based ideas about how to solve them with better policies. it's an essential skill in advancing change to improve the public's health." sue babich "the policy brief on participation and awareness of climate change shows which issues are most important to tackle (climate change), what populations need extra attention in policies (citizens in crossborder regions are most often neglected) and which tools are necessary to ensure broad support and sustainable measures (by citizen participation). these are aspects that every public health leader should take into account when working towards health for all." rana orhan "during the covid-19 pandemic, harm reduction services appeared as front-line public health interventions that quickly adapted and innovated to respond to the needs of those already stigmatised and criminalised by their drug use behaviour, but also to provide basic care to vulnerable populations including migrants, homeless and impoverished people. as the war on ukraine recently showed, beyond the prevention of fatal overdoses and bloodborne diseases such as hiv/hcv among people who use drugs through the provision of opioid substitution treatment and needle & syringe exchange, harm reduction services may also play a role in providing antiretroviral therapy and other life-saving medication to solve health issues affecting refugees. therefore, this policy brief explains the importance of harm reduction services in engaging the most vulnerable populations in society, while highlighting why they are essential public health services that must be recognised and protected by governments and policymakers, especially in current times of crisis." jessica neicun. czabanowska k. developing a new generation of public health leaders (editorial). seejph 2022, posted:20 august 2022. doi: 10.11576/seejph-5828 p a g e 3 | 3 © 2022 czabanowska; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. "the european region was on track to eliminate tuberculosis (tb) epidemics by 2030, which is one of the targets developed by the united nations in sustainable development goal 3 (sdg3). however, due to the covid-19 pandemic, resources intended for tb have shifted away. additionally, the who tb action plan for the european region 2016-2020 needs to be updated and a new action plan should be developed. this policy brief explores how the who tb action plan should be updated, taking into consideration lessons learned from the pandemic." martina paric. references 1. van diggele, c., burgess, a., roberts, c. et al. leadership in healthcare education. bmc med educ 20, 456 (2020). https://doi.org/10.1186/s12909020-02288-x. 2. yphantides n, escoboza s and macchione n (2015) leadership in public health: new competencies for the future. front. public health 3:24. __________________________________________________________________________________________ https://doi.org/10.1186/s12909-020-02288-x https://doi.org/10.1186/s12909-020-02288-x qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and selfperceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi 10.12908/seejph-2014-50 1 original research reaction to political and socioeconomic transition and self-perceived health status in the adult population of gjilan region, kosovo musa qazimi 1 , luljeta cakerri 2 , zejdush tahiri 2 , genc burazeri 3 1 principal family medicine centre, gjilan, kosovo; 2 faculty of medicine, tirana university, tirana, albania; 3 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands. corresponding author: dr. musa qazimi address: rr. “avdulla tahiri”, p.n. 60000, gjilan, kosovo telephone: +381280323066; e-mail: micro_dental@hotmail.com qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and selfperceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi 10.12908/seejph-2014-50 2 abstract aim: the objective of our study was to assess the association of reaction to political and socioeconomic transition with self-perceived general health status in adult men and women in a region of kosovo, a post-war country in the western balkans which has proclaimed independence in 2008. methods: this was a cross-sectional study carried out in gjilan region of kosovo in 2014, including a representative sample of 867 primary health care users aged ≥35 years (419 men aged 54.3±10.9 years and 448 women aged 54.0±10.1 years; overall response rate: 87%). reaction to political and socioeconomic aspects of transition was assessed by a three-item scale (trichotomized in the analysis into positive attitude, intermediate attitude, and negative attitude towards transition), which was previously used in the neighbouring albania. selfreported health status was measured on a 5-point scale which was dichotomized in the analysis into “good” vs. “poor” health. demographic and socioeconomic data were also collected. binary logistic regression was used to assess the association of reaction to transition with self-rated health status. results: in crude/unadjusted models, negative attitude to transition was a “strong” predictor of poor self-perceived health (or=2.5, 95%ci=1.7-3.8). upon multivariable adjustment for all the demographic factors and socioeconomic characteristics, the association was attenuated and was only borderline statistically significant (or=1.6, 95%ci=1.0-2.6, p=0.07). conclusion: our findings indicate an important association between reaction to transition and self-perceived health status in the adult population of the newly independent kosovo. policymakers and decision-makers in post-war countries such as kosovo should be aware of the health effects of attitudes towards political and socioeconomic aspects of transition, which is seemingly an important psychosocial factor. keywords: attitude to transition, gjilan, kosovo, psychosocial factors, reaction to transition, self-perceived health, self-rated health. conflicts of interest: none. qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and selfperceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi 10.12908/seejph-2014-50 3 introduction in several post-communist countries including russia, negative attitudes towards the political transition and socioeconomic reforms have been linked to poor self-perceived health among adult men and women (1,2). similarly, a negative or a pessimistic reaction to transition has been more recently linked to development of acute coronary syndrome in albania (3), a country which shares the same language and culture with the nowadays republic of kosovo. according to this previous study conducted in albania, a plausible mechanism linking pessimism, or negative attitude with excess coronary risk was deemed the stressor effect of inadequate coping with change in this transitional society (3). nonetheless, the evidence from many former communist countries of southeast europe, including kosovo, is scarce. after a long war against serbia and its proclaimed independence in 2008, kosovo has been undergoing a very difficult process of political and socioeconomic transition (4) associated with a particularly high unemployment rate and a rather poor socioeconomic situation of the general population (5), which leads to an intensive process of emigration to different european union countries and beyond (6). given this particularly difficult socioeconomic situation, the attitudes and perceptions of the adult population in kosovo towards the political reforms and socioeconomic aspects of transition are considered to have been negatively affected notwithstanding the lack of systematic documentation (6). as a matter of fact, regardless of its natural resources, kosovo is one of the poorest countries in europe (4-6). current evidence suggests an increase in the morbidity and mortality rates from non-communicable diseases in adult men and women in kosovo (7,8), which is explained by an increase in unhealthy behaviours (9) and presumably psychosocial factors (9). according to a recent review, alongside with unhealthy lifestyle including dietary patterns and physical inactivity, unfavourable socioeconomic and psychosocial conditions are considered as important determinants of the excess morbidity and mortality from chronic diseases in kosovo including diabetes and cardiovascular diseases (9). notably, it has been argued that changes in behavioural patterns may have unevenly affected different population subgroups, especially the vulnerable and the marginalized categories who are unable to cope with the dramatic changes of the rapid transition occurring in post-communist societies including kosovo (6,9,10). nonetheless, the negative health effects of psychosocial factors in the adult population of kosovo have not been scientifically documented to date. in this context, our aim was to determine the association of reaction to political and socioeconomic aspects of transition with self-perceived general health status among adult men and women in a region of post-war kosovo. based on a previous report from albania (3), we hypothesized a negative health effect of pessimistic attitudes towards transition, suggesting inadequate coping with change, independent of (or, mediated through) demographic factors and socioeconomic characteristics. methods this was a cross-sectional study which was carried out in gjilan region, kosovo, in 2014. study population this study included a representative sample of primary health care users of both sexes aged 35 years and above. a minimum of 740 individuals was required for participation in this study, based on the initial sample size calculations. nevertheless, it was decided to invite 1000 individuals in order to increase the study power accounting also for non-response. therefore, 1000 consecutive primary health care users aged 35 years and above who were resident in gjilan region were invited to participate in this study. qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and selfperceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi 10.12908/seejph-2014-50 4 of 1000 individuals who were invited to participate, 62 primary health care users were ineligible (individuals aged <35 years and/or very sick to participate), whereas 71 individuals refused to participate. hence, the final study population included 867 individuals (419 men and 448 women) with an overall mean age of 54.2±10.5 years (54.3±10.9 years in men and 54.0±10.1 years in women). the overall response rate in this study was: 867/1000=87%. data collection a structured questionnaire was administered to all participants including information on demographic and socioeconomic characteristics, reaction to political and socioeconomic transition in kosovo and self-perceived health status. reaction to political and socioeconomic aspects of transition among study participants was assessed by a three-item scale which was previously used in the neighbouring albania (3). this scale employed in albania was adapted from an instrument originally used in russia (1,2,11). in the current study conducted in kosovo, all participants were asked to rate their agreement/disagreement about the following three statements: a) “overall, the current economic system in kosovo is better than the old system” [range from 0 (strongly agree) to 3 (strongly disagree)]; b) “the transition toward the new system in kosovo is difficult; however, it’s worthwhile in view of the forthcoming prosperity” [range from 0 (strongly agree) to 3 (strongly disagree)], and; c) “compared with the previous system, most of the people in kosovo are poorer now” [range from 0 (strongly disagree) to 3 (strongly agree)]. a summary score was calculated for each individual (referred to as “overall reaction to transition”) ranging from 0 (most positive or optimistic attitude towards political and socioeconomic aspects of transition) to 9 (most negative or pessimistic reaction to transition). cronbach’s alpha of the three-item scale in our study conducted in kosovo was 0.94, which was slightly lower than a previous study conducted in albania (3). in the statistical analysis, the summary score of attitudes to transition was categorized into three groups [positive attitude (score: 0-3), intermediate attitude (score: 4-6), and negative attitude (score: 7-9)]. in addition, all participants were asked to rate their general health status: “overall, during the past year, how would you rate your general health status: excellent, very good, good, poor, or very poor?”. in the analysis, the self-perceived health status was dichotomized into: “good” vs. “poor”. demographic factors included age of study participants (in the analysis grouped into: 35-44 years, 45-54 years, 55-64 years and ≥65 years), sex and marital status (in the analysis, dichotomized into: married vs. not married), whereas socioeconomic characteristics consisted of educational attainment (categorized into: low, middle and high), employment status (trichotomized into: employed, unemployed and retired), income level (categorized into: low, middle and high) and social status (similarly trichotomized into: low, middle and high). statistical analysis measures of central tendency [mean values (± standard deviations) and median values (with their respective interquartile ranges iqr)] were used to describe the distribution of reaction to transition scores separately in male and female study participants. on the other hand, the distribution of different categories of the reaction to transition scores (positive, intermediate and negative) was expressed in absolute numbers together with their respective percentages separately in men and in women. chi-square test was used to assess the crude (unadjusted) association of reaction to transition scores (trichotomized into: positive, intermediate, negative) with the socio-demographic characteristics and self-perceived health status of study participants. qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and selfperceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi 10.12908/seejph-2014-50 5 conversely, binary logistic regression was used to assess the crude (unadjusted) and subsequently the multivariable-adjusted associations of self-reported health status (outcome variable dichotomized into: “good” vs. “poor” health status) and reaction to transition (independent variable) of study participants. initially, crude (unadjusted) odds ratios (ors) and their respective 95% confidence intervals (95%cis) were calculated. next, the logistic regression models were adjusted for age of participants. subsequently, the other demographic factors (sex and marital status) were entered simultaneously into the logistic regression models. finally, socioeconomic characteristics (educational attainment, employment status, income level and social status) were entered simultaneously into the logistic regression models. in all logistic regression models, the self-perceived health status was the outcome variable and reaction to transition (introduced in three categories: positive, intermediate and negative) was the main independent variable. multivariable-adjusted ors and their respective 95%cis were calculated. hosmer-lemeshow test was used to assess the overall goodness-offit of the logistic regression models (12). in all cases, a p-value of ≤0.05 was considered as statistical significant. statistical package for social sciences (spss, version 17.0) was used for all the statistical analyses. results overall mean (sd) summary score of reaction to transition was 4.2±2.8 (4.1±2.8 in men and 4.2±2.7 in women) [table 1]. furthermore, median (iqr) was quite similar in men and in women [sex-pooled median (iqr): 3.0 (3.0)]. overall, 494 (57%) of participants reported a positive attitude towards the political and socioeconomic transition in kosovo, as opposed to 181 (21%) of individuals who had a negative reaction to transition. the negative attitude to transition was higher in men than in women (23% vs. 19%, respectively) [table 1]. table 1. distribution of reaction to political and socioeconomic transition scores in a representative sample of primary health care users in gjilan region, kosovo, in 2014 reaction to transition score men (n=419) women (n=448) total (n=867) mean (standard deviation) 4.1±2.8 4.2±2.7 4.2±2.8 median (interquartile range) 3.0 (4.0) 3.0 (3.0) 3.0 (3.0) positive (score: 0-3) intermediate (score: 4-6) negative (score: 7-9) 243 (58.0) 79 (18.9) 97 (23.2) 251 (56.0) 113 (25.2) 84 (18.8) 494 (57.0) 192 (22.1) 181 (20.9) table 2 presents the distribution of demographic factors, socioeconomic characteristics and self-perceived health status by reaction to transition scores (trichotomized into: positive, intermediate and negative scores) among study participants. as noted above, the prevalence of negative attitudes to transition was significantly higher in men compared to women (p=0.05). furthermore, older individuals (65 years and above) displayed the most negative (pessimistic) attitudes to transition compared with their younger counterparts (p<0.001). similarly, the prevalence of a negative reaction to transition was the highest among the retirees (p<0.001), given the aging of this population subgroup. there was no significant association with marital status. remarkably, low-educated participants had a significantly higher prevalence of negative attitudes to transition compared with their highly educated counterparts (40% vs. 7%, respectively, p<0.001). likewise, albeit with smaller differences, low-income individuals and those with a lower social status displayed a higher prevalence of negative reaction to transition compared to high-income participants (33% vs. 18%, qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and selfperceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi 10.12908/seejph-2014-50 6 respectively, p<0.001), and individuals with a higher social status (29% vs. 12%, respectively, p<0.001). participants with a poor self-perceived health status had a significantly higher prevalence of negative reaction to political and socioeconomic transition compared with individuals who reported a good health status (34% vs. 18%, respectively, p<0.001) [table 2]. it should be noted that, on the whole, there were 696 (80.5%) participants who reported a “good” health status compared with 169 (19.5%) individuals who perceived their health status as “poor”. table 2. distribution of socio-demographic characteristics and self-perceived health status by reaction to transition scores in the study population (n=867) variable positive (score: 0-3) [n=494] intermediate (score: 4-6) [n=192] negative (score: 7-9) [n=181] p † sex: men women 243 (58.0) * 251 (56.0) 79 (18.9) 113 (25.2) 97 (23.2) 84 (18.8) 0.047 age-group: 35-44 years 45-54 years 55-64 years ≥65 years 132 (69.8) 171 (68.7) 131 (52.8) 60 (33.1) 37 (19.6) 56 (22.5) 59 (23.8) 40 (22.1) 20 (10.6) 22 (8.8) 58 (23.4) 81 (44.8) <0.001 employment: employed unemployed retired 272 (71.0) 129 (62.0) 93 (33.8) 78 (20.4) 52 (25.0) 62 (22.5) 33 (8.6) 27 (13.0) 120 (43.6) <0.001 marital status: not married married 63 (49.2) 431 (58.4) 31 (24.2) 161 (21.8) 34 (26.6) 146 (19.8) 0.116 educational level: low middle high 101 (30.5) 246 (69.9) 145 (80.1) 96 (29.0) 73 (20.7) 23 (12.7) 134 (40.5) 33 (9.4) 13 (7.2) <0.001 income level: low middle high 46 (35.7) 118 (47.0) 330 (68.2) 40 (31.0) 85 (33.9) 66 (13.6) 43 (33.3) 48 (19.1) 88 (18.2) <0.001 social status: low middle high 40 (40.0) 318 (55.4) 136 (71.6) 31 (31.0) 128 (22.3) 32 (16.8) 29 (29.0) 128 (22.3) 22 (11.6) <0.001 self-perceived health: good poor 416 (59.8) 78 (46.2) 158 (22.7) 33 (19.5) 122 (17.5) 58 (34.3) <0.001 * absolute numbers and their respective row percentages (in parentheses). discrepancies in the totals are due to the missing values. † p-values from the chi-square test. table 3 presents the association of reaction to transition with self-perceived health status of study participants. in crude (unadjusted) logistic regression models (model 1), there was qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and selfperceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi 10.12908/seejph-2014-50 7 evidence of a strong positive association between negative reaction to transition and poor self-rated health: or(negative vs. positive scores)=2.5, 95%ci=1.7-3.8. adjustment for age (model 2) attenuated the findings (or=1.8, 95%ci=1.2-2.8). additional adjustment for sex and marital status (model 3) did not affect the findings (or=1.8, 95%ci=1.2-2.8). further adjustment for socioeconomic characteristics including education, employment, income level and social status (model 4) attenuated the strength of the association which, in fully-adjusted models, was only borderline statistically significant (or=1.6, 95%ci=1.0-2.6, p=0.07). on the other hand, there was no difference in the odds of self-perceived health status between participants with intermediate scores and those with positive scores of reaction to transition, even in crude (unadjusted) logistic regression models (table 3, models 1-4). table 3. association of reaction to transition with self-perceived health status in a representative sample of primary health care users in gjilan region, kosovo model or * 95%ci * p * model 1 † positive attitude (score: 0-3) intermediate attitude (score: 4-6) negative attitude (score: 7-9) 1.00 1.11 2.54 reference 0.71-1.74 1.71-3.76 <0.001 (2) ‡ 0.636 <0.001 model 2 ¶ positive attitude (score: 0-3) intermediate attitude (score: 4-6) negative attitude (score: 7-9) 1.00 0.99 1.81 reference 0.63-1.56 1.18-2.78 0.014 (2) 0.958 0.007 model 3 § positive attitude (score: 0-3) intermediate attitude (score: 4-6) negative attitude (score: 7-9) 1.00 0.97 1.84 reference 0.62-1.53 1.20-2.83 0.011 (2) 0.897 0.005 model 4 ** positive attitude (score: 0-3) intermediate attitude (score: 4-6) negative attitude (score: 7-9) 1.00 0.88 1.58 reference 0.54-1.43 0.96-2.61 0.079 (2) 0.605 0.072 * odds ratios (or: “poor health” vs. “good health”), 95% confidence intervals (95%cis) and p-values from binary logistic regression. † model 1: crude (unadjusted). ‡ overall p-value and degrees of freedom (in parentheses). ¶ model 2: adjusted for age (35-44 years, 45-54 years, 55-64 years and ≥65 years). § model 3: adjusted for age, sex (men vs. women) and marital status (married vs. unmarried). ** model 4: adjusted for age, sex, marital status, educational level (low, middle, high), employment status (employed, unemployed, retired), income level (low, middle, high) and social status (low, middle, high). discussion the main finding of this study consists of a positive association of pessimistic reaction towards political reforms and socioeconomic transition with poor self-rated health among adult men and women in post-war kosovo, a country characterized by dramatic and rapid changes in the past few years. the association of poor self-perceived health with negative reaction to transition was strong, but upon multivariable adjustment for a wide array of demographic and socioeconomic characteristics the relationship was only borderline qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and selfperceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi 10.12908/seejph-2014-50 8 statistically significant. our findings are largely compatible with previous reports from former communist countries including russia (1,2,11) and albania (3). overall, the prevalence of negative reaction (score 0-3) towards socioeconomic aspects of transition in our study population was 21%, which is higher than a previous study carried out in albania which reported a sex-pooled prevalence of 13% (3). nevertheless, the prevalence of pessimistic reaction in our sample is much lower than in russia, where 49% of a representative sample of the adult population reported a nostalgic reaction to political and socioeconomic changes (disapproving the new system and approving the old system) according to a previous study (2). it should be pointed out that, in russia, it was considered that the attitudes towards the political and socioeconomic reforms in 1990s were significantly more negative than in other post-communist countries in europe (2,3). in our study, there was no evidence of a graded relationship with pessimistic or negative attitudes to transition. hence, the association was evident only between negative vs. positive attitude groups, with no differences between neutral (intermediate) and positive attitude categories (table 3). on the other hand, a previous study conducted in albania reported a graded relationship between acute coronary syndrome and negative attitudes towards socioeconomic transition consistent in both sexes and irrespective of demographic and socioeconomic characteristics and a wide range of conventional risk factors (3). potential mechanisms of psychosocial factors including reaction towards political and socioeconomic aspects of transition have been suggested to operate either directly through the neuro-endocrine system (13), or indirectly through induction of unhealthy behaviour such as smoking, excessive alcohol consumption, unhealthy diet and sedentary lifestyle (3,13). furthermore, regarding the negative effect of psychosocial factors on cardiovascular risk, it has been suggested that psychological distress may act chronically through pathological modifications of the cardiovascular system, such as changes in lipid profile and elevation of arterial blood pressure (3,14). in our study, the mechanism of excess self-perceived poor health among pessimists may be related to poor adaptation to critical circumstances associated with the particularly rapid transition in kosovo, as suggested by previous research on this field (3), where obvious differences in coping strategies between optimists and pessimists have been convincingly demonstrated (3,15,16). conversely, negative reaction towards political and socioeconomic aspects of transition may also serve as a marker of depression (17,18), which may lead to poor health status in general. this study may suffer from several limitations including its design, representativeness of the study population and the possibility of information bias. firstly, findings from cross-sectional studies do not imply causality and, therefore, future prospective studies should robustly assess and establish the directionality of the relationship between self-reported health status and attitudes to political and socioeconomic transition in kosovo and other transitional settings. secondly, we cannot exclude the possibility of selection bias in our study sample notwithstanding the inclusion of a fairly large sample of consecutive primary health care users of both sexes in gjilan region. in addition, we obtained a very high response rate (87%), which is reassuring. yet, we cannot generalize our findings to the general adult population of gjilan region given the fact that our study population was confined merely to primary health users. more importantly, findings from this study cannot be generalized to the overall adult population of kosovo, as our survey was conducted only in gjilan region. thirdly, the instrument used for measurement of reaction to transition may be subject to information bias, regardless of the fact that this tool was previously validated in albania (3). in our study population, the measuring instrument of reaction to transition exhibited a very qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and selfperceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi 10.12908/seejph-2014-50 9 high internal consistency and discriminated well between population subgroups distinguished in their educational attainment, income level and social status – similar to previous reports including the neighbouring albania (3). in conclusion, regardless of these potential limitations, our findings indicate an important association between reaction to transition and self-perceived health status in the adult men and women of post-war kosovo. health professionals and policymakers in developing countries and transitional populations should be aware of the negative health effects of psychosocial factors including also the general attitude towards political and socioeconomic aspects of transition, as evidenced in the current study conducted in kosovo. references 1. rose r. new russia barometer vi: after the presidential election. studies in public policy, no. 272. glasgow: center for the study of public policy, university of strathclyde; 1996. 2. bobak m, pikhart h, hertzman c, rose r, marmot m. socio-economic factors, perceived control and self-reported health in russia. a cross-sectional survey. soc sci med 1998;47:269-79. 3. burazeri g, kark jd. negative attitudes to transition in post-communist albania and acute coronary syndrome. health psychol 2009;28:779-86. doi: 10.1037/a0015987. 4. international labour organization. profile of the social security system in kosovo (within the meaning of unsc resolution 1244 [1999]); 2010. available from: http://www.ilo.org/wcmsp5/groups/public/---europe/---ro-geneva/---srobudapest/documents/publication/wcms_168770.pdf (accessed: june 25, 2015). 5. the world bank. europe and central asia region. poverty reduction and economic management unit. statistical office of kosovo. consumption poverty in the republic of kosovo, in 2009. western balkans programmatic poverty assessment; 2011. 6. jerliu n, toci e, burazeri g, ramadani n, brand h. socioeconomic conditions of elderly people in kosovo: a cross-sectional study. bmc public health 2012;12:512. doi: 10.1186/1471-2458-12-512. 7. world health organization, regional office for europe. european health for all database. copenhagen, denmark; 2015. 8. jerliu n, toçi e, burazeri g, ramadani n, brand h. prevalence and socioeconomic correlates of chronic morbidity among elderly people in kosovo: a population-based survey. bmc geriatr 2013;13:22. 9. jerliu n, ramadani n, mone i, brand h. public health in kosovo after five difficult years of independence. seejph 2013, posted: 31 october 2013. doi 10.12908/seejph-2013-02. 10. burazeri g, goda a, sulo g, stefa j, roshi e, kark jd. conventional risk factors and acute coronary syndrome during a period of socioeconomic transition: populationbased case-control study in tirana, albania. croat med j 2007;48:225-33. 11. bobak m, pikhart h, rose r, hertzman c, marmot m. socioeconomic factors, material inequalities, and perceived control in self-rated health: cross-sectional data from seven post-communist countries. soc sci med 2000;51:1343-50. 12. hosmer d, lemeshow s. applied logistic regression. new york: wiley & sons; 1989. 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http://www.ncbi.nlm.nih.gov/pubmed/?term=the+clinical+impact+of+negative+psychological+states%3a+expanding+the+spectrum+of+risk+for+coronary+artery+disease. department of health sciences increasing funding for global mental health by drawing lessons from the case of hiv/aids bachelor thesis submitted by: eva patrizia r. sander matriculation number: 1210772 in the study course: b.sc. international health sciences winter semester 2022/23 supervisor: prof. dr. dr. jens holst co-supervisor: prof. dr. kai michelsen cologne, march 2023 i abstract objective: global mental health (gmh) is the field of global health dealing with the spectrum of mental, neurological and substance use disorders (mns disorders), often with a focus on lowand middle-income countries (lmics). while mns disorders constitute a considerable burden of disease, investments in the field lag behind, creating a severe funding gap. in contrast, the human immunodeficiency virus/acquired immunodeficiency syndrome (hiv/aids) epidemic has seen unprecedented commitment, especially in terms of funding. consequently, this paper examines the research question: “how can the increase in global funding for hiv/aids over the past three decades serve as an example to draw lessons for increasing gmh funding in lmics?”. methods: based on the ‘theory of lesson-drawing’ by rose (1991) two programs, the joint united nations programme on hiv/aids (unaids) and the global fund to fight aids, tuberculosis and malaria (the global fund), were analyzed, and a conceptual model created for each program. the conceptual model, in addition to a comprehensive literature review were the base to draw learnings from the fight against the hiv/aids epidemic and its funding. learnings from hiv/aids were applied to gmh by giving a prospective evaluation of the transferability and desirability of the analyzed programs and their outcomes. results: a concrete next step that should be taken in order to increase funding and implementation of high-quality mental health care in lmics includes the establishment of a gmh partnership which represents diverse constituencies and expertise. among other things, emphasis should be put on promoting strong civil-society and community involvement. additionally, a multi-facetted advocacy and awareness campaign to increase traditional donor contributions, innovative financing mechanisms and domestic resources for gmh should be launched. conclusion: lessons from the increase in global funding for hiv/aids and how it was achieved can be drawn in the areas of funding generation, raising political and social commitment and multi-stakeholder collaboration. yet, the analysis has also shown the potential pitfalls when overall health system strengthening efforts and primary health-care integration are not sufficiently addressed. acknowledgments: this paper was produced as a final thesis to acquire the academic degree bsc international health sciences at fulda university of applied sciences. i would like to extend my gratitude to prof. dr. dr. jens holst for his support throughout my studies and this thesis supervision, together with prof. dr. kai michelsen. moreover, i would like to thank eric daniel sander for his invaluable thoughts and input during the writing process, as well as those who supported me with corrections and proof-reading. ii content 1 introduction ............................................................................................................. 1 1.1 introduction and problem statement ................................................................ 1 1.2 history and funding of the hiv/aids response ............................................... 4 1.3 objective and development of research question ........................................... 5 2 theory of lesson-drawing...................................................................................... 6 2.1 lesson-drawing and programs ....................................................................... 6 2.2 stimulus of dissatisfaction............................................................................... 6 2.3 steps of lesson-drawing ................................................................................. 8 3 methodology .......................................................................................................... 10 3.1 identification and choice of hiv/aids programs ........................................... 10 3.2 literature search and appraisal .................................................................... 11 4 results ................................................................................................................... 12 4.1 the joint united nations programme on hiv/aids ...................................... 12 4.1.1 background and history of unaids establishment ............................ 12 4.1.2 objectives, governing structure, and budget ...................................... 13 4.1.3 development and achievements by unaids .................................... 16 4.2 the global fund to fight aids, tuberculosis and malaria............................ 19 4.2.1 background and establishment .......................................................... 19 4.2.2 objective, governing structure, and budget ........................................ 20 4.2.3 development and achievements of the global fund .......................... 24 4.3 learnings ...................................................................................................... 27 4.3.1 conceptual model and learnings from unaids ................................. 27 4.3.2 conceptual model and learnings from the global fund...................... 30 4.3.3 general learnings from hiv/aids funding .......................................... 32 5 discussion ............................................................................................................. 36 iii 5.1 prospective evaluation ................................................................................. 36 5.2 consequences for gmh ............................................................................... 40 5.3 limitations and research demand ................................................................. 43 6 conclusion ............................................................................................................. 45 list of tables.................................................................................................................. 46 list of figures ................................................................................................................ 47 list of abbreviations ..................................................................................................... 48 bibliography .................................................................................................................. 50 list of appendices ........................................................................................................ 59 appendix .......................................................................................................................... i introduction 1 1 introduction “i challenge global leaders to build upon these lessons learned from the hiv/aids response and apply it positively to the challenge of mns disorders. we must no longer overlook the deleterious effects that the lack of quality mns services has upon our communities.” – agnes binagwaho, minister of health, rwanda (2008-2016) (patel et al. 2015: xi). 1.1 introduction and problem statement global mental health (gmh) is the interdisciplinary field that aims to reduce inequalities in mental health care in and between countries by scaling up mental health services, particularly in lowand middle-income countries (lmics) (patel et al. 2018: 1556; rajabzadeh et al. 2021: 9). according to rajabzadeh et al. the term “global mental health” is used in different ways with varying understandings. the most cited understandings found were conceptualized as: “globalised mental health research”, “global mental health is implementation”, “improving the mental health landscape” and lastly “learning from and supporting lmics” (rajabzadeh et al. 2021:6). in all four concepts the role of interdisciplinary involvement and shifting away from western perspectives, towards a strong inclusion of perspectives from lmics, were emphasized. additionally, over time, a shift from a biomedical approach to a more convergent approach of mental health has occurred. this approach recognizes the “complex interplay of psychosocial, environmental, biological, and genetic factors across the life course, but in particular during the sensitive developmental periods of childhood and adolescence” (patel et al. 2018: 1556) in the prevention and development of mental health issues. gmh combines research from various disciplines, such as anthropology and epidemiology, and other fields of action, such as advocacy, policy and program development and service delivery for mental health (rajabzadeh 2021: 4). further, while promoting a global approach, a lot of gmh activities focus on lmics and improving their mental health infrastructure, care delivery and the situation of persons affected (rajabzadeh et al. 2021). gmh deals with a variety of diseases and diagnoses including psychiatric and mental (e.g. depression, bipolar disorder, schizophrenia), neurological (e.g. dementia, parkinson’s) and substance use disorders. mns disorders are non-communicable disease (ncds) with no one clear underlying cause. however, research has shown a strong interdependence between social determinants and their significant role as risk factors in association to onset, severity, and duration of mns disorders (patel et al. 2018: 1557). this puts already vulnerable groups, for example due to low socio-economic status, low education level, living in poor environmental conditions or people seeking refuge at high risk for developing mns disorders. hereby, especially the sensitive developmental phases of childhood and introduction 2 adolescence are crucial for mental well-being. over their life-course approximately one in four people are affected by mental disorders (lions head global partners (lhgp) 2018: 6). in addition, many mns disorders are chronic, multimorbid and have comorbidities such as cardiovascular diseases. as a result, mns disorders constitute a substantial burden of disease, a trend which has increased by almost 50% from 1990 until 2019 (gbd 2019 mental disorder contributors 2022: 141). prevalence is estimated to be at roughly 970.1 million cases of mental disorders worldwide. the corresponding number of disability-adjusted life-years (dalys) due to mental disorders are estimated at 125.3 million, which accounted for 4.9 % of global dalys in 2019 (gbd 2019 mental disorder contributors 2022: 141). people often suffer from mns disorders over a long period of time throughout their life-course. this results in 125.3 million years lived with disability (ylds) due to mns disorders in 2019, representing 14.9 % of the global ylds in the respective year (gbd 2019 mental disorder contributors 2022: 142). mns disorders combined are the seventh leading cause for dalys. they are prevalent in all age groups with the highest prevalence found in persons between 25 and 34 years, for both genders (gbd 2019 mental disorder contributors 2022: 144). therefore, a large share of people affected suffer from mns disorders during their most productive years, leading to loss of human capabilities with severe microand macroeconomic effects estimated to reach global economic losses of approximately 16.1 trillion us$ for the timespan between 2010 and 2030 (bloom et al. 2011: 5; patel et al. 2018: 1560). a vast treatment and care gap for mns disorders persists worldwide. in lmics, around 90% of patients with severe mental disorders receive no treatment at all. where treatment and care are available quality is often low, especially for severe mental disorders. (lhgp 2018: 13; patel et al. 2018: 1558). in addition, people suffering from mns disorders are at high risk for abuse and violation of their fundamental human rights, for example through unjust incarceration or physical violence (patel et al. 2018: 1558). in the past years, the field of gmh is said to have ‘come of age’. it has become a respected discipline in the field of global health (patel et al. 2018: 1555; patel et al. 2015; lhgp 2018; patel et al. 2018; who 2021b). the advancement from the millennium development goals (mdgs) to the sustainable development goals (sdgs) in 2015 was an essential step for the inclusion of mental health indicators and the recognition of mental health to be a crucial part for achieving overall health and wellbeing (patel et al. 2018: 1554). moreover, meaningful engagement came from the world health organization (who), through the launch of its mental health gap action programme (mhgap) (who 2022) in 2008, the who comprehensive mental health action plan (2013-2020) (who 2013) and who comprehensive mental health action plan 2013-2030 (who 2021a) respectively. this has resulted in important investments, mainly into research for care delivery. furthermore, since 2007, introduction 3 development assistance for mental health (damh) has doubled in absolute numbers. yet, despite recent gains in the recognition of the field, challenges persist. regardless of the increase of funding in absolute numbers, damh has never exceeded 1% out of total global development assistance for health (dah). in 2015, damh was as low as 0,4 % of total dah (lhgp 2018: 6). more so, despite the importance of prevention and attention to child and adolescent mental health, allocations to this matter seem particularly neglected (patel et al. 2018: 1560). while this important age group is bearing a quarter of the mns disorder dalys, allocations were at 12.5% of damh, making up no more than 0.1% of the total dah (lu et al. 2018: 1). moreover, domestic spending for mental health exhibits similarly low. low-income countries (lics) spend approximately 0.5% of their annual health budgets on mental health (lhgp 2018: 6). where funding is available for mental health in lmics, roughly 80% are spend on major institutions and mental hospitals instead of communitybased services (lhgp 2018: 35). in 2013, investment per daly caused by mns disorders was only 0,85 us$, compared to 144 us$ per daly caused by hiv/aids (charlson et al. 2017: 5). this is despite an estimated 4 us$ return for every dollar invested (lhgp 2018: 14). from 1995 until 2015, damh funding experienced a six-fold increase, from 18 million us$ to 132 million us$, out of a total of 36 billion us$ of dah. what might seem like a considerable increase is comparably low, when looking at other health areas, hiv/aids for example. from 1995 onward, hiv/aids funding experienced an 18-fold increase (charlson et al. 2017: 3f.). in 2018, the lions head global partners group, with contributions from gmh researchers, advocates, and affiliated organizations (lhgp 2018: 57), published a paper, outlining the current funding situation and expected funding needs for different scenarios for varying levels of mental health service coverage (lhgp 2018). depending on the target spend per person, ranging from 1 us$ to 3 us$ per person per annum (pppa), estimates for the funding needed range between 3.74 billion us$ and 11.22 billion us$ per year (lhgp 2018: 25). this leaves gmh with a substantial funding gap, that in order to avoid the considerable economic losses and leverage on the return of investment ratio, in addition to providing people with their basic human right to access quality health services to attain their best health possible, must be closed as soon as possible through concerted efforts of the global community. in their conclusion, the lhgp authors find that, in order to close the funding gap and to reach the goals and ambitions set out by the sdgs and the lancet commission on global mental health and sustainable development (patel et al. 2018), a combination of increased domestic resource mobilization and the establishment of “one or more ‘new’ financing mechanism(s)” will be needed (lhgp 2018: 6). introduction 4 1.2 history and funding of the hiv/aids response after the first cases of aids were reported in the us in 1981 the hi virus was discovered and determined to be the cause for the syndrome in 1983 (schmid 2018). the first cases of hiv and aids had been reported among homosexual men, or men who have sex with men (msm), and injecting drug users. additionally, persons who had received blood products were identified to be affected. however, soon after, women and children who did not exhibit any of the previous characteristics were reported to be infect with hiv as well, suggesting heterosexual as well as mother-to-child transmission of the virus (hofer 2018). moreover, increasing numbers of cases of hiv and aids were recorded on the african continent, with researchers suggesting that the disease had been spreading on the continent for decades (ferhervari 2018). this explained the rapidly increasing number of cases, transforming into the global epidemic of hiv/aids. by 1996, the who and the joint united nations programme on hiv/aids (unaids) estimated “that more than 4.6 million people had died from aids since the beginning of the epidemic” (knight 2008: 7), and 20.1 million people worldwide were living with hiv (knight 2008: 7). according to unaids, in 2021, an estimated total of 40.1 million people had died from hiv/aids and approximately 38.4 million people were living with hiv (unaids 2022b). as mentioned previously, since the discovery of hiv and aids, the amount of funding allocated to this field has been unprecedented. funding for hiv/aids is spent on research, prevention, and treatment programs, as well as health system strengthening. common prevention programs include condom use programs, education campaigns, abc campaigns (abstinence, be faithful, use a condom if a and b fail) and needle exchange programs. after advancements in research pre-exposure prophylaxis (prep) for high-risk populations became available in addition to anti-retroviral treatment (art) in the course of the 1990s and early 2000 years (piot et al. 2015: 179f.). over the past 30 years, funding for the aids response in lmics has risen from 612 million us$ to approximately 11 billion us$ in 2015 and up to 19 billion us$ today. furthermore, “[t]hrough coordinated advocacy by a coalition of diverse stakeholders, the challenge of aids was met with unprecedented scientific, medical, political, and economic force within two decades of its emergence“ (vigo et al. 2019: 351). growth in funding, despite the 200809 financial crises, was also possible due to increases in domestic funding spent on hiv/aids, in addition to the external investments from traditional donors (piot et al. 2015: 201). in recent years, funding levels have remained relatively flat at this level. yet, to reach the goals set for hiv/aids in the sdgs and the 90-90-901 target by unaids to be reached by 2030 a funding gap of roughly 7 billion us$ persists (bekker et al. 2018: 323; piot et al. 2015: 201). 1 90% of people living with hiv are aware of their status, 90% of people diagnosed with hiv receive art, at least 90% of those receiving art are virally suppressed (kazanjian 2017 :409) introduction 5 1.3 objective and development of research question although aids is a single disease with a definite etiology and gmh constitutes a broad set of mns disorders with a much less clearly defined cause, both fields of global health action share important characteristics, such as “stigma, human rights abuses, and a sluggish initial global response despite the evidence of transformative interventions” (vigo et al. 2019: 351). furthermore, both fields of action operate in low-resource setting, primarily lmics. for both, hiv/aids and mns disorders, vulnerable groups include the lgbtq+ community (lesbian, gay, bisexual, transgender, queer and all other gender identities and sexual orientations), people experiencing adverse living conditions (e.g. experiencing homelessness) and persons with low socio-economic status as well as low educational attainment (patel et al. 2018: 1556f.; 1567). there is consensus among researchers and advocates for the large need for funding for gmh. however, the question on how to raise and distribute these funds proves to be more difficult and harder to reach consensus on. there is a lot of knowledge and experience in gathering large amounts of funding in the case of hiv/aids which could provide beneficial lessons to be learned for gmh. against this backdrop, this paper aims to look at the different strategies and drivers for this increase in funding made available for the global fight against hiv/aids since 1995, as well as other potential influences that impacted the resource allocation to this cause. by taking into consideration criticism directed towards the global fight against hiv/aids, this thesis is not limited to ‘positive’ lessons (dos) to be learned but also ‘do not’s’ to be considered in this context. thus, the following research question was formulated: how can the increase in global funding for hiv/aids over the past three decades serve as an example to draw lessons for increasing gmh funding in lmics? this thesis expands the knowledge on the topic through its in-depth analysis of programs established in the response to hiv/aids (see chapter 3.1.) and the examination of their results relationship on funding generated. a similar approach of organizational learning from hiv/aids as well as maternal and newborn health for successful scale-up of gmh was performed by vigo et al. (2019). however, the analysis was based on a different selection of programs, with the exception of the global fund to fight aids, tuberculosis and malaria (global fund). the findings will be carefully considered in the discussion of this thesis. theory of lesson-drawing 6 2 theory of lesson-drawing this thesis uses richard roses’ (1991) lesson-drawing approach to draw lessons from the programs established for the global fight against hiv/aids and apply them to commitments for gmh. according to rose „lesson-drawing addresses the question: under what circumstances and to what extent can a programme that is effective in one place transfer to another.” (rose 1991: 3)2. 2.1 lesson-drawing and programs programs are established as an instrument to achieve policy intentions (rose 1991: 6) by bringing together the interests of different groups, e.g., public officials, experts, interest groups, and those who benefit from the program (rose 1991: 7). a program is defined through a statute which declares its “purposes and the conditions under which it operates” (rose 1991: 6). additionally, the resources it operates on are defined by a budget which is administered through a public agency and defined personnel. all these characteristics make programs specific and concrete, in contrast to the intentions of politicians who formulate and establish them (rose 1991: 6). in accordance with rose, lesson-drawing does not just evaluate a program active in one place or in the case of hiv/aids in one thematic setting. moreover, it goes further by attempting a prospective judgement on its performance in a new setting, in this case being gmh (rose 1991: 7, 19). therefore, the lesson is not just the judgement of the program in place but rather the critical assessment of its transferability to a new setting (rose 1991: 7). the conclusion of effectiveness in the new setting is what makes lesson-drawing special compared to other social science comparisons (rose 1991: 8). the motivation for policy makers to look outside for lessons usually does not stem from the success a foreign program has demonstrated, but rather comes from a place of dissatisfaction with the status quo in their own setting or area of responsibility. hence, there is need for change (rose 1991: 5). therefore, rose calls dissatisfaction with status quo the “stimulus to search for lessons” (1991: 10). 2.2 stimulus of dissatisfaction as long as everyone is satisfied the most efficient strategy for policy makers is to do nothing, since inaction is the most preserves resources. however, disruptions in the routine create dissatisfaction with the status quo and doing nothing is no longer an option for the way forward (rose 1991: 10). for both cases, hiv/aids and gmh, the stimulus of 2 the theory by rose is written in british english; however, this thesis is written in american english. to remain stringent the author will use the spelling ‘program’ as the equivalent term for ‘programme’ used by rose. theory of lesson-drawing 7 dissatisfaction is the increasing disease burden both create, and inadequate amounts of resources allocated to the causes. additionally, for hiv/aids another stimulus was the potential security risk which forced policy makers to act (knight 2008: 106f.). in both cases it was the policy environment which changed and created dissatisfaction, rather than the program producing negative results (rose 1991: 12), simply because no programs were or are in place yet. therefore, the change does not originate from a place of learning of better alternatives but from the realization that inaction is unsustainable (rose 1991: 12). not least inaction of policy makers is sanctioned in case of dissatisfaction, as it would result in an increasing disease burden and cost of disease. moreover, dissatisfaction of the status quo paired with inaction of policymakers can also quickly lead to dissatisfaction with the policymakers themselves. thus, the “cost of inaction” (rose 1991: 12) is estimated to be higher than the cost of action and potential gain from the investment. consequently, policy makers search for satisfaction because “’[they] can’t afford not to’” (rose 1991: 13). in their search for satisfaction policymakers can look across time and space for programs operating in other places and settings or programs proven effective in the past. the proximity in which they search is determined by what is already known to policy makers as what is known will always be favored over what is unknown (rose 1991: 13). when searching across space, policy makers will search in areas where they feel they have similarities. hence, local community policymakers are more likely to search for programs in other local communities nearby (rose 1991: 13). yet, subjective identification will play a more critical role in where policy makers choose to look than geographic proximity (rose 1991: 14). therefore, international policymakers are likely to search for programs on an international level where the baseline issue and starting point were similar, for example the spatial dimension of countries affected, which in case of hiv/aids and gmh were foremost lmics. however, due to the functional interdependence of countries because they are mutually affected, they cannot ignore actions of other countries which influence the problem at hand. this is especially true for issues that in their nature transcend national borders, for example environmental, or as seen most recently with the covid-19 pandemic, health issues (rose 1991: 17). theory of lesson-drawing 8 2.3 steps of lesson-drawing in his 1991 publication rose outlines four steps for lesson drawing (see table 1) (rose 1991: 19ff.). table 1: four steps of lesson drawing step 1 search for programs addressing similar problems step 2 produce a conceptual model step 3 comparison of different models and the program currently in place step 4 prospective evaluation (source: own presentation after rose 1991: 19ff.) “the first step in lesson-drawing is to seek information about programmes of public agencies elsewhere that have addressed a similar problem.” (rose 1991: 19). the focus lies on programs which have potential to be successful when imported, even though this might require some adaptions as the overall goal is to gain transferrable knowledge that is generic and applicable (rose 1991: 19f.). in this thesis, program selection is explained and justified in chapter 3.1. in the second step the goal is to produce a conceptual model of the program, with an accurate, yet generic description. the description should be stripped to the basic elements which show how the program works, defining the relationships between cause and effect and identifies the programs outputs. this model, however, has no expressive power about desirability of the program yet (rose 1991: 20). accordingly, the production of conceptual models for the programs chosen will be established in the results part of this paper (chapter 4). thirdly, the model or models produced are compared with the program or action currently in place, which initially caused the dissatisfaction. this comparison aims to look at different factors, such as differences between the programs in dimension or kind, as well as political acceptability and resources needed and available (rose 1991: 20f.). finally, the last step of lesson-drawing, described in the discussion (chapter 5), is the prospective evaluation of the likely success of the program when transferred to the new place or setting (rose 1991: 22). consequently, the judgement whether a program will or will not work needs to be justified, taking into consideration the observed characteristics of the effective program in comparison with the conditions in the setting it should be transferred to. yet, this judgment can never be entirely free of speculation (rose 1991: 23). prospective evaluation stands out from conventional evaluation based on retrospective empirical examination, by offering an ex-ante estimate on the success of a program. this offers unique opportunities for policymakers forced to make decisions under time pressure since it can help to give a forewarning in case necessary conditions for success cannot be met in the new setting (rose 1991: 23f.). theory of lesson-drawing 9 “the ideal programme is both practical and desirable.” (rose 1991: 24). this is the situation before dissatisfaction arises and should be the goal for the introduction of a new program. therefore, for the prospective evaluation two different kinds of feasibility of the program should be taken into consideration, namely technical feasibility to assess practicality and political feasibility estimating desirability (rose 1991: 25). consequently, four different judgements are possible resulting from the prospective evaluation: a program is deemed neither technically nor politically feasible, meaning that the outcomes are not desirable for politicians and the program is expected to fail when transferred. a program could be judged desirable but not practical or vice versa. lastly, the most anticipated result is that technical expertise judges a program practical, and politicians are attracted by the desirable results (rose 1991: 26). different results can come from a successful lesson. when adapting a program to a new setting some adaptions are likely needed to accommodate the new circumstances. simple ‘copying’ is possible when the circumstances are almost the same and the introduction of the program does not require any or only small adaptations. ‘emulation’ is the process of adopting the desired program, however, by adjusting for the circumstances of the new setting to enhance likelihood of success. ‘hybridization’ happens when elements of two different programs are combined and introduced in the new setting. this also happens when the lesson drawn is a ‘synthesis’ of elements from three or more programs in effect somewhere else. lastly, lesson-drawing can serve as an ‘inspiration’ when no program or elements of one are adapted, yet the process has inspired and served as an intellectual stimulus for a new program to be created (rose 1991: 21f.). hence, lesson-drawing is not merely ‘copy and paste’-ing but should be considered “a creative act” (rose 1991: 21). methodology 10 3 methodology 3.1 identification and choice of hiv/aids programs during the preliminary research multiple programs, initiatives and organizations involved in funding the global fight against hiv/aids were recognized, including unaids, the world bank multi-country aids program in africa (africa map), the global fund to fight aids, tuberculosis, and malaria (the global fund) and the u.s. president’s emergency plan for aids relief (pepfar)3. despite being the largest funder for hiv/aids within the un system, contributions by world banks africa map are comparably low to overall contributions (oomman n.y.), as is the scope and reach of the program compared to the others listed. africa map was therefore not chosen for the analysis. in contrast, pepfar is recognized to be one of the largest donors focused on hiv/aids, funding approximately 22 % of the global hiv/aids response in 2021 (own calculation after unaids 2022a). pepfar was established in 2003 to distribute funding from the us congress, earmarked specifically for hiv and aids. however, pepfar and the us government face regular criticism for the high level of ‘strings attached’ to their funding (knight 2008: 170f.) as they act bilaterally. since the research question is focused on “global funding” pepfar was also excluded from the program analysis. the establishment of unaids, which is tightly embedded into the unite nations organizational structure, was an important prerequisite leading to the founding of the various funding organizations mentioned above. in addition, despite not being a funding organization per se, unaids is critical to the general funding generation for hiv/aids. the issue cannot be discussed without considering the wide range of achievements made by unaids. therefore, unaids was the first organization chosen for an in-depth analysis to draw lessons from. the global fund on the other hand is a multilateral hybrid organization which is focused on providing funding for three focus diseases by combining public and private partnerships (ppps) (vigo et al. 2019: 351). it provides the highest levels of contributions for hiv/aids among multilateral donors (unaids 2022a). furthermore, the global fund offers a variety of innovative organizational and funding features, offering a spectrum of lessons to be drawn for gmh. consequently, the global fund was chosen for the second program analysis. 3 listed in order of establishment methodology 11 3.2 literature search and appraisal the analysis and critical discussion of unaids and the global fund are based on a comprehensive literature search. for this purpose, the databases medline (pubmed), cinahl, embase, wiley online library, web of science were searched, with access to databases and publications provided through fulda university of applied sciences. moreover, databases from the various united nations organizations and agencies were considered. in addition, primary literature and referred sources from adequate publications were obtained through the snowball principle, using google scholar. according to the research question and chosen programs keywords for the literature search are: “unaids”, “global fund”, “hiv/aids fund*” or “hiv/aids financ*”, “development assistance for health”, and “global mental health fund*”. keyword searches in title and abstracts yielded high numbers of results with a high share of publications unrelated to the research question. however, publications focusing on either program or hiv/aids usually specifically mentioned them in the title. therefore, searches were limited to titles and were abstracts excluded from the advanced search. no time limits were applied to the search terms “unaids” and “global fund”, since the historical development of the programs is an important factor in their analysis and the judgement on their performance of funding generation over time. for the remaining keywords a time limit of five years was set. furthermore, articles included were published in english or german language. detailed search results can be found in the appendix (see appendix 1: keyword searches). in addition to the literature search program websites were used for understanding the functions of each program. for disease data on hiv/aids and mns disorders, the author searched for the most recent data available, usually not older than five years. however, due to the covid-19 pandemic collection and reporting of some data was disrupted. therefore, in some cases exceptions to the 5-year range may occur. following the analysis, lesson-drawing as described by richard rose (rose 1991; evans 2006) was performed for the two programs. a prospective evaluation of the applicability and replicability of these programs for the case of gmh was done and critically discussed. finally, conclusions were drawn and an outlook on further research needs given. results 12 4 results 4.1 the joint united nations programme on hiv/aids unaids coordinates the hiv/aids response of all eleven cosponsoring un organizations4, sets out global principles and priorities for the response to the hiv/aids pandemic and has been especially active in moderating the alignment of donor efforts and national priorities of recipient countries (lisk et al. 2013: 128) 4.1.1 background and history of unaids establishment the hiv/aids epidemic and its impact on a social, demographic, economic, cultural, and political level was firstly recognized by the un general assembly in 1987. accordingly, the need for a coordinated response by a multitude of un agencies was identified. consequently, in 1988 the global programme on aids (gpa) was established as part of who, to organize the uns response to the hiv/aids epidemic. despite its success in advocating and exchanging information on hiv/aids, gpa lacked the inter-agency coordination which had been recognized to be needed (knight 2008: 15 ff.). therefore, in 1993, a joint and cosponsored program was proposed: a coordinating body that brings together the multitude of stakeholders involved, including advocacy groups and people living with hiv/aids, while ensuring ownership of the “broad set of un agencies” (knight 2008: 20f.). this coordinating body is supposed to serve as a global focal point for the response to hiv/aids. in the following months the design of the program and the role and power of its secretariat were heatedly discussed. while most un organizations preferred a rather small secretariat with a focus on information exchange donors generally supported a strong secretariat. despite the initial proposal for the new program to act as a funding agency, this was met with strong opposition from some un agencies (knight 2008: 21ff.). finally, in fall of 1993, the un secretary-general expressed his support of a program with a strong secretariat, granting it a “high level of coordinating control over the cosponsors” (knight 2008: 22), but without explicit funding powers. the request for endorsement from the economic and social council (ecosoc) followed for the new joint program, cosponsored by initially six organizations, which had already been represented at gpa (who, unicef, unfpa, undp, unesco, world bank). the final decision was made on july 26th, 1994. yet, cosponsoring un agencies were reluctant to agree to the new program, but the uncoordinated requests for funding 4 cosponsoring organizations: united nations development programme (undp), united nations children’s fund (unicef), united nations population fund (unfpa), world health organization (who), united nations educational, scientific and cultural organization (unesco), world bank, united nations office on drugs and crime (unodc), international labor organization (ilo), world food programme (wfp), office of the united nations higher commissioner for refugees (unhcr), united nations entity for gender equality and the empowerment of women (un women) results 13 from multiple agencies and the lack of coordination had left donors unsatisfied. as a result, they threatened to pull funding altogether if no cosponsored agency would be established (knight 2008: 22f.). although the establishment of the new joint programme had already been decided by the ecosoc it took another two years for it to start operating as a result of interagency rivalries between different un entities. in addition, the form and functions of the new program had to be worked out (knight 2008: 24). finally, the new cosponsored joint united nations programme on hiv/aids – unaids – started operating in 1996 and was the first of its kind within the un body. 4.1.2 objectives, governing structure, and budget with the endorsement by the ecosoc the six objectives (see table 2) of the new program were formulated, defining the areas of work for unaids and serving as its guiding framework. table 2: unaids objectives objective 1 provide leadership in the global response to hiv/aids objective 2 mediate consensus on global hiv/aids policies and programs objective 3 strengthen monitoring capacities and implement appropriate strategies at countrylevel objective 4 support national governments in developing and implementing comprehensive strategies and effective hiv/aids activities objective 5 political and social mobilization for hiv/aids response and prevention objective 6 advocating on global and local level for adequate resource mobilization and allocation (source: own presentation after knight 2008: 29) programme coordinating board (pcb) unaids is guided by the programme coordinating board, consisting of 22 member states with a specific distribution of seats5, with strong representation of traditionally receiving countries. additionally, five non-governmental organizations (ngos) serve as non-voting pcb members, as well as the cosponsors (unaids 2020: 16ff.). the pcb is the governing and decision-making body of unaids (knight 2008: 34; unaids 2020: 16). its responsibilities include reviewing and approval of unaids policies, plans of action and financial plans. this is to be done in consideration of the executive directors’ and committee of cosponsoring organizations (cco) input and recommendations (unaids 2020: 15ff.). for the pcb to work up to its best potential it can establish working groups and subcommittees to work on specific topics (unaids 2020: 20; unaids 2022d). the unique composition of the 5 five seats for africa and asia each, three seats for latin america and the caribbean combined, two seats for eastern europe, and the remaining seven seats for ‘western europe and other states’ results 14 pcb makes unaids the only un body that has active representatives of ngos on their governing body (knight 2008: 34). in addition, this kind of governing structure enables active participation of civil society and people infected and most affected (lisk et al. 2013: 127f.). committee of cosponsoring organizations (cco) in addition to the pcb, the conglomerate of six agencies who had previously been on the gpa management committee were formalized into the joint programme’s committee of cosponsoring organizations (cco). the initial six cosponsors have since been joined by multiple other un bodies. as of february 2023, there are eleven cosponsoring un organizations (unaids 2022f). the cco is composed of the heads of each cosponsoring organization. all decisions made by the pcb are taken to the cosponsoring organizations respective boards through the cco, to ensure unaids policies are incorporated into cosponsors activities and result frameworks (unaids 2022c). the cco responsible for providing input from the cosponsoring agencies to unaids strategies and policies. furthermore, the cco reviews the budgetary and workplan proposals by the executive director as well as the pcb. moreover, cco members review the activities of the cosponsoring organizations and their level of consistency with unaids policy and targets. additionally, it is the responsibility of the cco members to give technical advice according to the mandate of their respective organization (unaids 2020: 22). unaids secretariat and executive director the unaids secretariat consists of the executive director, appointed by the uns’ secretary-general, together with all administrative and technical staff necessary for the program to run smoothly. the executive director is by office the secretary to both the pcb and cco (unaids 2020: 23f.). un theme groups on hiv/aids in addition to the organizational structures on the global level unaids has established ‘un theme groups on hiv’, to extend its work on the country level (see figure 1). the theme groups comprise the head of each cosponsoring organization of the respective country/region, likewise the organization of the cco. in addition, the group is joined by the country programme adviser (cpa), employed by unaids (knight 2008: 50). furthermore, theme groups offer civil society an opportunity for a seat at the table and help manage the relationship between national governments and local civil society organizations (csos) through unaids mediation (knight 2008: 52). these theme groups were intended as the link between the un body and the country’s national hiv/aids coordinating institution, for example ministries of health. aligned with unaids objectives the implied task is to formulate national hiv strategies according to local needs (knight 2008: 50). in addition, the theme results 15 groups are an important tool to streamline activities of multiple agencies and organizations in the same country, competing for funding and creating duplicates (knight 2008: 51). figure 1: governing structure – unaids (source: own presentation) funding and resources unlike its predecessor, unaids itself is not a funding agency but supports the global aids strategy through its advocacy and technical advisory work. through this work, the organization played and still plays an incremental role in the mobilization of resources for the response to hiv/aids (lisk et al. 2013: 129f.; knight 2008: 22). yet, this means, that unaids itself relies on outside funding, which, in large parts, is channeled through the eleven cosponsoring un organizations (unaids 2021a: 81). unaids operates on a budget, which decided on in a biennial rhythm, in line with the biennial work plan (knight 2008: 56 ff.; lisk et al. 2013: 130). for the years 2022-2026, the budgets and work plans are embedded into the strategic directions set out by the 2022-2026 unified budget, results and accountability framework (ubraf) (unaids 2021a: 5). unaids funds are separated into core and non-core funds. core funds are used to fund the secretariat itself with all its functions, as well as the hiv/aids related work of the eleven cosponsoring organizations. in contrast, non-core funds are mostly earmarked for specific purposes and support additional initiatives and programs beyond the work of the secretariat. therefore, they cannot be used as flexible as core funds and are seen as supplementary (unaids 2023a). the majority of unaids funds, both core and non-core funds, are mobilized on the global level (unaids 2017: 8). donations are made either on an ad hoc basis or are based on results 16 multi-year commitments, which ensure more predictable funding for unaids. these contributions are supplemented by donations from biand multilateral aid agencies and development partners, as well as foundations and the private sector. (unaids 2023a). additionally, unaids regional and country offices raise money locally, through a mix of domestic funding, private sector donations and international donors (unaids 2017: 8). moreover, a large share of funds mobilized by unaids cosponsors mainly flows as non-core funds into the various unaids strategy areas (unaids 2023d), e.g. testing and treatment, prevention or mother to child transmission (unaids 2023e). in 2021, unaids held its first structured funding dialogue with donors, with the goal to strongly position unaids and its work in the global aids strategy, create momentum for its priorities and invigorate more predictable and flexible funding for the future (unaids 2021b: 2). during this event, it was highlighted that in recent years, unaids funding had been relatively stable (unaids 2021b: 7). however, funding gaps remained and are to be expected to increase in the upcoming years if the donor community does not step up. for the 2022-23 funding period, a 35 million us$ funding gap is expected just for core funds. in addition to the general funding gap, the mixture of funding available has changed drastically. while core, non-earmarked funds amounted to 174 million us$ in the 2016-17 funding period, they have lowered down to just 44 million us$ in 2020-21. this leaves unaids without its much-needed flexibility to direct funds to key issues (unaids 2021b: 8). 4.1.3 development and achievements by unaids despite substantial reluctance of un agencies to collaborate and to ‘being coordinated’ by unaids, the organization managed to gain momentum over the first five years of its operation. an essential factor promoting unaids’ role as an important resource was the focus on collecting and publishing reliable and comprehensive data on the extend and impact of the epidemic (knight 2008: 59ff.). in january 2000, the un security council discussed hiv/aids as a major security concern and a hindrance to development efforts. this was a premiere for the security council, to consider a health issue as a threat to global security. these considerations were the result of close collaboration between the united states ambassador to the un and security council member, richard holbrooke, with unaids. during the security council meeting light was shed on various effects of the epidemic, from its overwhelming impact on health systems to socioeconomic crises and its threat to political stability (knight 2008: 106f.). this was especially important, as many african leaders had been resistant to acknowledge the severity of the situation, despite being most affected by its consequences (knight 2008: 1007). later that year, the united nations millennium declaration was adopted by the 2000 millennium summit, declaring the uns eight millennium development goals (mdgs), set to results 17 be achieved by 2015 (un 2015). particularly important for unaids work was goal 6: “combat hiv/aids, malaria and other diseases” (unaids 2020: 143), with sub-targets focusing on halting and reversing the spread of hiv/aids by 2015 and increasing access to arts (unaids 2020: 143). “with three of the eight mdgs specifically focused on health, the mdg agenda catalyzed a remarkable increase in official development assistance for health” (bekker et al. 2018: 318). following the debate in the security council, the un general assembly had passed a resolution to hold a un general assembly special session on aids (ungass) the following year (knight 2008: 110). in 2001, the world’s leaders came together for three days to discuss hiv/aids and demonstrate commitment at the highest level. the goal of ungass was a declaration of commitment on hiv/aids, which came with considerable challenges. topics such as the balance between prevention and treatment, as well as more sensitive issue such as cultural and religious barriers rendered substantial discussion (knight 2008: 132ff.). however, ungass offered a stage for unaids to show its capabilities in coordinating and bringing together different agencies and stakeholders and brokering joint commitment (knight 2008: 134f.). by the beginning of the new millennium, through major contribution by unaids, the attitude towards hiv/aids had changed majorly. starting out as a denied and talked-down epidemic it now became a broadly recognized issue, needing attention from the entirety of global organizations and leaders (knight 2008: 105). in 2002 and 2003, the global fund to fight aids, tuberculosis and malaria (global fund) and the u.s. president’s emergency plan for aids relief (pepfar) started operating. as a result, a vast increase of funding for the fight against hiv/aids was pledged and disbursed. according to the first u.s. global aids coordinator randall tobias “the existence of unaids ha[sd] been very critical to the development of pepfar” (knight 2008: 170), which in turn would generate additional 10 billion us$ for the next five years (knight 2008: 169). besides, to make the global fund and pepfar work, the already established country networks of unaids were imperative (knight 2008: 170; brugha et al. 2004: 97). in 2004, unaids leveraged on its well-established partnership with mtv and together they launched the global media aids initiative (gmai), in collaboration with 20 major media corporations to help raise awareness through a variety of educational and entertainment productions focusing on hiv/aids. one year later already 130 media companies worldwide were involved (knight 2008: 182f.). other milestones in the work of unaids and the fight against hiv/aids during the first years of the 21st century included the launch of various partnerships, e.g. the international partnership against aids in africa (ipaa) (knight 2008: 118) and the pan caribbean partnership against hiv/aids (pancap) (knight 2008: 130f.). furthermore, the world bank recognized the magnitude of the epidemic and launched its own multi-country hiv/aids programme for africa (map) to channel funding (knight 2008: results 18 117f.). in addition, achievements in lowering art prizes and increasing treatment rates were made (knight 2008: 121ff.). by 2006, more than 100 countries had established national hiv/aids strategies and national hiv/aids coordinating bodies that put monitoring and evaluation systems in place (lisk et al. 2013: 128). having such strategies and coordinating bodies helped to accumulate additional domestic and donor funding and monitor progress and targets. furthermore, the un general assembly held another high-level meeting in hiv/aids in june 2006, to recognize the achievements made but also reiterate the continued need for action and their commitment to fighting hiv/aids (united nations 2006). in 2008, unaids’ first executive director, peter piot stepped down after eleven years in this position. unaids’ achievements until 2008 were widely recognized to be a closely tied to his persona, and result of his strong leadership and advocacy work. however, this raised questions on how to differentiate the program from his person, in addition to criticism regarding unaids passive attitude towards ideology driven policies and programs (das/ samarasekera 2008: 2100f.). discussions arose whether unaids could function with a new executive director and who he or she could be, or, if unaids was outdated and should be shut down all together. ultimately, there was consensus that the work of unaids is still needed, although reforms would be necessary in some areas, for example regarding the scrutiny of unaids estimates and in invigorating coordination within and outside of uanids (das/ samarasekera 2008: 2102). michel sidibé followed into peter piots footsteps and became the new executive director, staying this position from 2009-2019 (unaids 2023b). in june of 2011, hiv/aids was once more recognized for its detrimental effects on human and country development and the need for sustained action reiterated by the 2011 un security council resolution (un 2011a) and the 2011 political declaration on hiv and aids (un 2011b). in this general assembly resolution member states re-pledged their commitment to sustaining progress in the fight against hiv/aids. further political declarations followed, focusing on ending the aids epidemic by 2030, in 2016 (unaids 2016) and again in 2021, with the “political declaration on hiv and aids: ending inequalities and getting on track to end aids by 2030” (unaids 2021c). the target to end the aids epidemic as a public health threat by 2030 had been set as part of the sdgs, which were introduced in 2015, following the mdgs (bekker et al. 2018: 320). especially ‘goal 3 – good health and well-being’, target 3.3 focuses on fighting communicable diseases and ending the aids, tb and malaria epidemics by 2030. it has since become an important focal point for global health action (joint sdg fund n.y.). additionally, in 2013, in contemplation of the 2015 mdg deadline, unaids set the 90-90-90 target to be reached by 2020 (bekker et al. 2018: 320). results 19 after allegations of harassment became loud in 2018, findings by an independent expert panel were damning. the panel attested unaids “a work culture of fear, lack of trust and retaliation” (horton 2018: 2536), with employees almost used to bullying, sexual harassment and abuse of power (horton 2018: 2536, wise 2018). furthermore, the panel made executive director michele sidibé responsible, by enabling a culture of autocratic and patriarchal leadership, far off from unaids’ commitment to good governance and non-discrimination (horton 2018: 2536). “unaids secretariat was in crisis, and the evidence of a broken organisational culture was overwhelming“ (wise 2018). the publication of the findings opened the door back up for critics to question the continued need for unaids’ existence (headley et al. 2019: 381f.). yet, similar to the situation ten years earlier, critics were met by a number of voices demonstrating the continued need for unaids as an organization. however, it was clear that a change in leadership was necessary to follow through with much needed reforms and a cultural change within unaids (headley et al. 2019: 382). following the leadership crisis and reputational loss for unaids, sidibé stepped down and was superseded by todays unaids executive director winnie byanyima, who has put an emphasis on the situation of women and girls in her work at unaids (unaids 2019). since 2020, reaching unaids and sdg targets has been heavily impacted by the covid-19 pandemic (jiang et al. 2022). 4.2 the global fund to fight aids, tuberculosis and malaria the global fund to fight aids, tuberculosis and malaria was introduced in 2002 as ppp (hanefeld 2014: 54) with the goal “to attract, manage, and disburse additional resources worldwide to control the[se] three” priority diseases (brugha et al. 2004: 95). hereby, the focus lies on the generation of additional resources and not just channeling the already available funding from donors (brugha 2005: 623). 4.2.1 background and establishment the first discussion about a funding mechanism to fight the epidemics of hiv/aids, tuberculosis (tb) and malaria was at the first group of eight (g8) meeting in 2000, and later reiterated in a follow-up meeting the same year (knight 2008: 116f.). the rationale for establishing the global fund had also been discussed at ungass, in form of a special fund for hiv/aids through which countries could make sustainable contributions to reach the goals of the mdgs, with an annual budget between seven to ten billion dollars (maciocco/stefanini 2007: 482). in 2001, discussions by donors and un organizations continued (knight 2008: 157). civil society hoped for a balanced private-public distribution, with recipients and donors having a seat at the table, next to the un, csos, and ngos. this was results 20 also supported by unaids, who fought for implementing countries to have an equal voice in the global fund (knight 2008: 158). the decision for the establishment of the global fund was endorsed by the g8 in july 2001. the actual establishment was managed by a transitional working group, and only six months later, in january 2002, the global fund started its work (the global fund 2023f). 4.2.2 objective, governing structure, and budget the global fund was explicitly designed to be a funding mechanism without the mandate to act as an implementing or technical agency (poore 2004: 52). upon its introduction, the global fund was perceived as highly innovative. firstly, this was due to its ambitious goal to tackle the three most important and devastating diseases for the health and development of lmics. secondly, the short time in which it was decided on and set up was a novum, and lastly, its pledge to far-reaching transparency was very attractive to donors. furthermore, the global fund marketed a quick disbursement mechanism (brugha 2005: 623) in contrast to the usual time-consuming biand multilateral donor negotiations (brugha et al. 2004: 98f.). board the global fund itself only operates in its main offices in geneva, switzerland, and does not have any country-offices itself (zühr et al. 2014: 7). it is governed by the board, which consists of 20 voting members equally representing donor countries, implementing countries, the private sector, private foundations, ngos, and communities affected by the diseases. additionally, eight non-voting members, including the chair and vice-chair of the board, representatives of the supporting organizations (unaids, who, world bank) as well as other public donors, are part of the board (the global fund 2023b). each of the members represent their constituency in all board functions. these include strategy development, governance oversight and performance assessment, resource commitment to receivers, risk management as well as engagement with partners focusing on advocacy and resource mobilization (the global fund 2023b). the board delegates some of its work to three standing committees: the audit and finance committee, the ethics and governance committee, and the strategy committee. committee members are also representatives of their constituencies. seat distribution is done with respect to the balance of donors and implementers (the global fund 2023c). secretariat and other operational structures there are additional structures reporting to the board, which are significant for the global fund. the secretariat, located in geneva, represents approximately 700 staff members who carry out the funds daily operations. these include among others grant and risk results 21 management, finance and accounting, coordination of the grant application process, engagement with donors, private sector, and advocacy groups, as well as legal affairs (the global fund 2023m). “the secretariat is headed by the executive director of the global fund” (zühr et al. 2014: 7), who is appointed by the board. the technical review panel receives all proposals and requests for funding and evaluates each, before making a recommendation to the board, which then makes the final decision on funding approval (the global fund 2023n). experts serving on the technical review panel do not represent any constituency but themselves and their professional opinion (the global fund 2023o). the office of the inspector general holds a special role within the global funds system, as it is independent from the secretariat. the inspector general is granted special access to all books and records concerning global fund funding as well as all implementation and program sites. “through audits, investigations and consultancy work, the office of the inspector general promotes good practice, reduces risk and reports on abuse.” (the global fund 2023h). the office of the inspector general is an eminent part of the global funds pledge to thorough transparency and accountability to its donors and recipients. country coordinating mechanism (ccm) as mentioned before, the global fund is unique in its structure as is has no own country offices and therefore relies on support from in-country partners (zühr et al. 2014: 8), such as unaids or who (knight 2008: 159). implementing countries have to establish a country coordinating mechanism (ccm) in order to develop and submit a grant proposal to the global fund. ccms should include representatives from the government, ngos, biand/or multilateral organizations, academia, the private sector, civil society and people most affected or living with the priority diseases. according to the global fund, civil society should make up around 40% of representatives of the ccm, although this number is far from being met so far (sands 2019: 101). in their proposal, ccms must demonstrate its basis on national strategies and on “an inclusive multi-stakeholder process” (zühr et al. 2014: 10). after a grant proposal is approved by the global fund the ccm is then responsible for overseeing the implementation and success of the activities. in addition, one or more principal recipients (prs) must be appointed by the ccm. the pr is the country organization which receives the funds, “implements and monitors programmes, and is accountable for how funds are used” (brugha et al. 2004: 95). this can, for example, be the ministry of health or csos. after grant approval, the global fund signs a grant agreement with every pr listed in the proposal individually, which are then authorized to pass on parts of their funds to other implementing organizations (sub-recipients) (zühr et al. 2014: 8). furthermore, to oversee and verify the implementation and progress, and to further ensure in-country financial accountability, the global fund contracts an results 22 independent organization to act as local fund agent (brugha et al. 2004: 95). this is usually an accounting firm, which is also tasked with verifying the progress reports submitted by prs (zühr et al. 2014: 9). organizational structures on the global level and country level are connected and work together as can be seen in figure 2. figure 2: governing structure – the global fund (source: own presentation) funding and resources the world bank has another important role in the global funds system, as it serves as the funds trustee (knight 2008: 158). therefore, funding pledged by donors is collected and disbursed to recipients through world bank (see figure 2) (the global fund 2022a: 30). funding for the global fund is mobilized through a multitude of donor pledges, private partnerships, and innovative financing mechanisms. the global funds most important tool to generate funding are ‘replenishments’, which were introduced in 2005 to establish more predictable funding. replenishments are three-year funding cycles which are preceded by a fundraising period, during which donor governments, private foundations, and the private sector pledge donations in an effort to reach the global funds predicted needs (the global fund 2023l). however, actual contributions often lack behind the amount of funding pledged during the fundraising period (the global fund 2022a: 28f.; the global fund 2023e). in the seventh replenishment 2022, covering the resource needs for the 2024-26 implementation period, the global fund estimated a global funding need of 130 billion us$ for all three priority diseases worldwide. to reach this number, the global fund asked its donors for at least 18 billion us$ in its latest investment case (the global fund 2022b), to stay on track results 23 with its current activities and make up for the losses resulting from the covid-19 pandemic (the global fund 2022b: 12). the majority of global fund resources come from public sources, “with 94% of […] funding coming from donor governments” (the global fund 2023k), as can be seen in figure 3. figure 3: budget development, including funding for tb and malaria – the global fund (source: own presentation after the global fund 2023i) however, until january 2022, private contributions made up more than 3.5 billion us$ out of overall global fund budgets (the global fund 2023j). this funding was mobilized by foundations and other nongovernmental groups, as well as faith-based organizations (the global fund 2023k). in addition to direct pledges, the global fund promotes a variety of innovative financing mechanisms. for instance, some countries offer ‘dept2health swaps’ (the global fund 2023g). in this scenario, creditor countries cancel dept owed by a beneficiary country in exchange for it to transfer a negotiated share of the original dept to the global fund. this funding is then earmarked and reinvested into health programs in the beneficiary country through a global fund grant (cassimon et al. 2008: 1188). another innovative financing mechanisms, (red), was introduced in 2006. (red) is a retail marketing initiative that collaborates with popular brands such as apple, nike, jeep, or starbucks. together with (red) they develop (red) products as part of their own product-lines. with the purchase of a (red) product consumers trigger a corporate donation to the global fund, earmarked for investments towards hiv/aids (the global fund 2023a). this form of collaboration is a good example for the global funds’ strong position in brokering ppps. however, the private sector is not only important in leveraging financial resources, but also for implementation and delivery processes. many private partners are active on the ground, sometimes by serving on ccms or as prs or sub-grant recipients, for example providing supply-chain support. furthermore, private sector partners have a lot of in-kind resources $0 $2,00,00,00,000 $4,00,00,00,000 $6,00,00,00,000 $8,00,00,00,000 $10,00,00,00,000 $12,00,00,00,000 $14,00,00,00,000 $16,00,00,00,000 2001-2005 2006-2007 2008-2010 2011-2013 2014-2016 2017-2019 2020-2022 public sector contributions (in us$) private sector and nongovernmental contributions (in us$) total, including dept2health (in us$) results 24 to offer, such as valuable technical expertise and technologies, supporting data management and digitalization (for example mastercard and coca cola) (the global fund 2023d). funding from the global fund is disbursed through different schemes, for example resultsbased financing, where funding disbursement is tied to achieving pre-agreed results. this is also known as ‘cash on delivery’ (the global fund 2023g). another disbursement method is outcome-based financing, for example in the form of social impact bonds. this means, that investors provide funding upfront and are repaid once pre-defined outcomes are achieved, for example with the cost-savings accumulated by reducing the cost for governments to deal with a social issue (australian housing and urban research institute 2021). in contrast to unaids, the global fund has a slim body of staff, operating in geneva only. by not having their own country-offices the global fund was able to keep operation costs relatively low (zühr et al. 2014: 7), at approximately 326 million us$ in 2021 (the global fund 2022a). however, this is not without mentioning that opportunity costs to manage funds and keep reporting up are then outsourced to the implementing countries (hanefeld 2014: 55). when talking about funding and resources in the context of the global fund another important aspect is how money is distributed among implementing countries. however, since the focus of this thesis lies on the resource generation rather than the distribution, this aspect will not be further highlighted. yet, this is not without mentioning the importance of these issues in achieving equity and effectiveness in program delivery. 4.2.3 development and achievements of the global fund the rapid establishment of the global fund did not come without its initial challenges. in the early 2000 years, a multitude of donors focusing on hiv/aids, namely the global fund, the world bank multi-country aids program (map), pepfar, and the clinton initiative were all acting simultaneously in the same countries (brugha 2005: 625). this put significant pressure on recipient countries governments to interact and negotiate with all donors and keep their expectations satisfied (brugha et al. 2004: 98f.). therefore, it was important to clarify the global funds’ role within this already complex global health initiative structure. additionally, the requirement for countries to establish a ccm proved challenging, not least because it was unclear how ccms should be located within already existing country structures, for example national aids councils (brugha 2005: 624), especially with the additional focus on tb and malaria. moreover, in some countries power imbalances between government, ngos, civil society and private sector representatives were reported, which limited some parties to voice their opinions. collaboration in the ccm was further hampered by the unclear role definition and lack of regular participation of representatives (brugha et al. results 25 2004: 97f.). on the other hand, the global fund was welcomed by some recipient countries because it offered previously unknown autonomy to recipient countries in formulating their own country proposals (brugha et al. 2004: 96) instead of just doing what external donors and advisors saw fit. this promoted country ownership and alignment with national strategies (hanefeld 2014: 55). once grants had been approved, the global fund had high expectations on frequent reporting from implementing countries, and the prs specifically. however, it became evident quickly that prs were lacking skills and/or capacity to keep up with such close monitoring and reporting requirements. in some cases, different reporting standards and frequencies had already been implemented by other donors, yet they did not match global fund requirements, posing a risk of creating duplication of reporting systems (brugha et al. 2004: 99). satisfying all the different reporting requirements was especially difficult in sector-wide approaches with pooled resources from multiple donors (brugha et al. 2004: 96f.). in the case of global fund funding, inability to keep up reporting and meet indicator goals slowed down fund disbursement (results-based financing), as it was linked to regular implementation monitoring and prs showing value for money (vfm) (brugha et al. 2004: 98). this created a dilemma for the global fund early on: the global fund had advertised transparency and accountability by establishing high monitoring and reporting expectations. this was also necessary to demonstrate good performance and vfm to donors to attract future funding pledges (brugha et al. 2004: 100). on the other hand, it proved unsustainable for many implementing countries and slowed down progress. as a result, the global fund had to demonstrate its willingness to adapt. after two years, reporting requirements were redesigned with more flexibility to reduce the strain on the countries with highest disease burdens and the weakest health (reporting) systems (brugha 2005: 624f.). this was also a necessary reform for the global fund, as it was and still is competing with many other initiatives for funding. this emphasized the need for the global fund to establish, demonstrate and keep up its role as a quick and reliable partner to donors (brugha 2005: 625). in addition, the global fund still needed to make a case for its ability to “actively harmoniz[eing] its systems and process with recipient countries” (brugha 2005: 625). adding to the challenges regarding reporting, weak and undersourced health systems in recipient countries also exhibited limited capacities to absorb huge amounts of money in a short time, as the global fund was ready to offer and disburse (brugha et al. 2004: 99). this exacerbated criticism from some donors and scholars on the global funds vertical program approach by focusing on three diseases only, thereby disregarding the need for general health system strengthening through a sector-wide approach (brugha et al. 2004: 96f.; maciocco/stefanini 2007: 485). as a result, in 2005, the global fund allowed proposals focusing on health system strengthening, to mitigate those results 26 difficulties and support absorption abilities of grant recipients (maciocco/stefanini 2007: 485). despite initial difficulties, by mid-2006 efforts by the global fund had contributed substantially to the mdg targets for health (komatsu et al. 2007: 805). in 2010, partially because of the financial crisis, donor pledges fell short in reaching the projected needs of the 2011-2013 replenishment round. the estimated need of at least 13 billion usd to sustain the existing grants in addition to funding new proposals fell short, with only 11.7 billion usd being pledged (the lancet 2010: 1274). additionally, in 2011, allegations that global fund money was being mismanaged became loud and irregularities had been discovered in internal audits. as a result, the global fund further suffered loss of trust from donors. despite only small amounts of money being misused by a small number of countries, some donors blocked their funding to the global fund as a result (hanefeld 2014: 55). subsequently, the board took the decision to suspend the already announced funding round because of lack of funds and in order to focus work on reforming the global fund. in 2012, the board approved the new funding model (nfm), which enabled significant changes to the funding system. this included adjustments in the funding period to improve funding predictability (zühr et al. 2014: 1), and the introduction of country dialogues to increase interaction between the secretariat and ccms to support proposal preparation and improve proposal quality (zühr et al. 2014: 10). furthermore, the nfm formulated an explicit funding allocation methodology, accounting for disease burden and the ability to pay of affected countries, which had not been consistently measured before (fan et al. 2014: 2240). until 2016, the global fund spent more than 17 billion us$ for hiv/aids programs in over 100 countries (bekker et al. 2018: 323). for the funding period between 2017-19, the global fund managed to get back on track in terms of fulfilled replenishments, when of the 13 billion us$ the fund asked for, about 99,3% were pledged. this was partially due to upped commitments from major donors such as the usa, japan and germany. but even more remarkable were record numbers of commitments from african countries (usher 2016: 1265). as of 2020 there was a 50% decline in the combined mortality of aids, tb and malaria in countries where the global fund had funded programs. about half of the 38 million people living with hiv were on art sponsored by the global fund (olufadewa et al. 2021: 284). by 2022, the global fund saved 44 million lives (the lancet 2022: 787). in its latest replenishment in september 2022 the global fund asked for at least 18 billion us$, remaining focused on the goals of sdg3, fighting against the three priority diseases and strengthening health systems, which had rendered even more fragile in the eye of the covid-19 pandemic. therefore, 6 billion us$ are planned to go to pandemic preparedness and health system strengthening specifically (the lancet 2022: 787). results 27 4.3 learnings in this section general learnings that can be drawn from the key components of the conceptual model of each program in addition to the establishment, history, and achievements of unaids and the global fund will be presented. furthermore, learnings are depicted on the basis of the comprehensive literature search for both programs and the general fight against the hiv/aids epidemic. they will later serve as the basis for the prospective evaluation. 4.3.1 conceptual model and learnings from unaids the conceptual model for unaids (see figure 4) depicts its most basic elements and identifies the programs output for the fight against and funding for hiv/aids, by defining their cause-effect relationships. additionally, the conceptual model differentiates on the activities and outcomes on the global and country-level. the conceptual model is based on the information in chapter 4.1. figure 4: conceptual model – unaids (source: own presentation) one of the six objectives of unaids, which was prominent in establishing the programs role as an important resource was the focus on collecting and publishing reliable and comprehensive data on the extend and impact of the epidemic (knight 2008: 59ff.). the introduction of a broad set of indicators and data publications by unaids delivered a muchneeded basis for the work and response to the hiv/aids epidemic. having one place to look for up-to-date and reliable data on the development of the epidemic and the indicators set was crucial for monitoring the epidemic. additionally, it provides a basis to hold leaders and governments accountable and to inform further required action, as well as program and funding needs (piot et al. 2015: 182; sridhar 2012: 22; knight 2008: 181). unaids demonstrated a vital role in bringing stakeholders together on global and country level, in the pcb and the un theme groups on hiv/aids. by engaging various un organization, civil society and activist groups as well as government officials the multitude of results 28 stakeholders were forced to recognize different perspectives. furthermore, unaids innovatively engaged with stakeholders such as major corporations and the pharmaceutical industry (knight 2008: 57ff.; 65ff.). through its original organizational structure, unaids ensured an integrated response from various perspectives by drawing on the mandates of multiple un agencies and coordinating their response (lisk et al. 2013: 127). furthermore, including perspectives of governments and civil society alike helped to inform local needs and national aids strategies. in turn, this promoted country-ownership for aids activities and strategies. the idea that “nobody’s too rich not to need support or too poor not to offer support” (knight 2008: 84) further promoted horizontal collaboration within spatial proximity through unaids “technical resource networks”. these networks were another good example for country-ownership and the limited need for external actors to step in, as was traditionally the case. on the contrary, unaids, in line with other un agencies, is criticized for having become an expensive bureaucracy machine with little actual control and real power over the cosponsor’s participation and execution of pcb decisions (sridhar 2012: 22, graham 2017: 59). moreover, unaids faced similar challenges as many other development efforts, which was operating within a fragmented donor landscape. with various reporting requirements from different donors and donor delegations visiting program sites frequently, they were overpowering receiving governments and their capacities. while implementation and absorption capacities in receiving countries were already limited, they were further strained visiting delegations and donor negotiations, instead of working on national hiv/aids strategies and their implementation (knight 2008: 183 ff.). another issue was the lack of accountability of donors to their beneficiaries and alignment of programs with the country’s needs (knight 2008: 186, 188s). unaids’ mandate includes the coordination of donor activities to reduce duplication and transaction costs, not just on the global level, but also in support of national efforts. yet, despite honest efforts from unaids and various declarations on aid effectiveness and harmonization signed by hics and lmics alike during the first years of the 21st century, effective coordination of funds and programs in implementing countries is still insufficient and program duplication persists (knight 2008: 185ff.; piot et al. 2015: 182). further, the literature points out that the level of intrinsic motivation and incentives for those being coordinated is very important to make coordination possible and mitigate struggles for status, autonomy and political turf as were seen during the establishment and first years of unaids (graham 2017: 58f). therefore, navigating inter-agency rivalries and defining roles and responsibilities between cosponsors and other stakeholders are crucial in the early stages of the program establishment. nonetheless, the pcbs organizational structure was breaking new ground and still is unique in the un system, especially in the sense that results 29 for the first time civil society and people most affected were given a seat at the table and a voice on the highest level. this further broadened the perspective on the topic, as well as it demonstrated the importance of inclusion of civil society on all levels, for example in the composition of national aids councils and formulation of national aids strategies. another strength of unaids and its position within the un is its ability to broker versatile partnerships in many different domains, for example between countries (e.g. ipaa, pancap), with different industries (e.g. the pharmaceutical industry, the media), different funding organizations (the global fund, pepfar) and civil society. this characteristic helped to spark innovation and tackle the variety of issues accompanying hiv/aids from many different angles and with fresh ideas (knight 2008: 81f.). furthermore, unaids collaborated with the un security council members and brokered the discussion of hiv/aids in the council’s session. framing the pandemic as a security threat catalyzed immense momentum for the fight against hiv/aids and pushed it to the top of the agenda for many, particularly african leaders (knight 2008: 106f.). additionally, it helped generate funding challenged through security strategies (shadyab et al. 2017: 80f.) however, framing the disease as a security threat can easily be misinterpreted and translated into infected persons to be perceived as a threat, which heightened stigma and discrimination. despite not being a funding organization itself, unaids contributed enormously to the increase in funding (knight 2008: 169; 181) by lobbying for the cause with key decision-makers and placing hiv/aids on top of the global agenda (sridhar 2012: 22). its advocacy was not just successful in promoting hiv/aids as a priority disease, but also a priority social and political topic, requiring action from all angles and the multitude of cosponsoring un organizations (sridhar 2012: 22). among other things, unaids advocacy work amplified the urgency of the situation and helped to create the stimulus for the creation of funding organizations such as the global fund and pepfar. results 30 4.3.2 conceptual model and learnings from the global fund equal to the unaids conceptual model the global funds most basic elements and program outputs on the global and country-level, with regard to their cause-effect relationship, are depicted in figure 5 based on the information from chapter 4.2. figure 5: conceptual model the global fund (source: own presentation) the level of transparency about funding and grant progress in the global fund is unique and highlighted by researchers. this characteristic is invaluable not just in terms of creating accountability but also in offering a basis for scrutiny and critical assessment for researchers and policymakers (lu et al. 2006 :487). like unaids, the global fund brings governments, civil society, the private sector, affected communities, and technical and development partners to the table at both local and global levels. this governance approach increases trust and ensures the inclusion and effective implementation of diverse perspectives (the global fund 2022b: 11). furthermore, by forming ccms and having them formulate the grant proposals in line with local needs and national strategies, and based on the diverse perspectives of constituencies represented, country-ownership is strengthened. yet, despite efforts to design the board democratically, some still criticize that implementing nations are marginalized, and representatives of donor nations and their preferences predominate the decision-making process (adeboye 2018: 339). therefore, scholars have pointed out, that “in this era of decolonizing health” further action should be taken to counter “neocolonial imbalance[s] in country representation” on the board, where currently only two out of 20 voting members represent the african region (the lancet 2022: 787). among the most affected groups by hiv/aids are sex workers, msm, injecting drug users and adolescent girls. these groups are also highly marginalized and likely to experience results 31 stigma and discrimination. executive director, peter sands, himself highlights the need to have strong representation of those groups in form of civil society representatives on the board, but especially in ccms, to support program design in ways it can practically and genuinely reach those most affected (sands 2019: 101f.). another way the role of civil society is strengthened in hiv/aids programs is their introduction as prs and service-providers. this further promotes that the groups most vulnerable can be reached through global fund funding. the fight against hiv/aids, with the global fund on the forefront, pioneered different innovative financing strategies, such as the (red) retail shopping campaign and dept2health swaps. these were an important addition to traditional donor schemes that also informed funding generation for other major health topics. in addition, they offer inspiration to develop new innovative financing schemes in the future (hecht et al. 2009: 1601f.). however, there are also critical views on dept2health swaps, as their impact is easily overestimated by simply disregarding the lack of beneficiaries’ fiscal space to invest large amounts of money into hiv/aids programs at once (cassimon et al. 2008: 1189ff.). the global fund took a vertical approach, by focusing on three priority diseases. however, despite the vast improvements there remains criticism that the focus on specific diseases often forgets “the fundamental indicators of health“ (maciocco/stefanini 2007: 485), for example infant and maternal mortality. adding to this, social determinants of health, such as socio-economic status or discrimination are not adequately addressed through vertical programs, although some exceptions might exist. to reach the high goals set, especially for the fight against hiv/aids, narrow-focused programs appear insufficient. adding on to the criticism, shifting priorities to the global fund evidently led to the neglect of other health priorities, such as maternal and child health, for example through the global fund’s competitive recruitment, often paying higher wages than other health programs had to offer. subsequently, while hiv/aids targets were getting closer to being met, other health indicators were declining where the global fund was active (maciocco/stefanini 2007: 484f.). this was also the case within the realm of hiv/aids, as many experts in the field have point out that after the introduction of the global fund, “prevention fell through the cracks” (knight 2008: 126), with focus shifting heavily to treatment (knight 2008: 126). results 32 4.3.3 general learnings from hiv/aids funding the hiv/aids epidemic constituted a new challenge to the world, forcing the need to transform the usual approach of development aid, for health specifically. one way how this was done was the unprecedented inclusivity of boards and decision-making bodies on global and country-level. uniting government representatives with non-government representation (ngos, civil society, private sector), as well as un organizations and agencies with a variety of focuses and mandates in the governing and decision making-bodies was innovative in the hiv/aids response and an incremental factor to its successes (piot et al. 2015: 181f.). in addition, it fostered accountability, country-ownership and good relationships with civilsociety and the private sector (sridhar 2012: 22). in both, and virtually all organizations handling such large amounts of money, there is a high need for strong leadership and compliance to mitigate and combat misuse of funds and corruption. moreover, both, unaids and the global fund, have undergone different crises and significant restructuring since their establishment. here as well, literature often highlights the need for strong leadership, which is also visible through the extensive body of literature dealing with questions of failed leadership and unclear leadership continuance in unaids and the global fund (zühr et al. 2014: 12; horton 2018; wise 2018; headley et al. 2019). the need for strong country-ownership was frequently highlighted by unaids and the global fund. however, since the global fund has no country offices itself, their work relies heavily on in-country structures, such as unaids country theme groups, which in some cases had already established national strategies that global fund grant proposals could be based on. consequently, some form of country structures with strong representation of civil society and ngos is critical to transport global advocacy to the ground. one striking difference between unaids and the global fund is the amount of money needed to run each organization, which is partly due to the global funds lean organization structure relying on others on country level. generally, operational costs have to be kept to a minimum to ensure that resources are directed to where they are needed most instead of seeping away in the united nations and global health initiatives bureaucracy. furthermore, one has to keep in mind, that unaids and the global fund, in line with virtually all other global health initiatives, compete for the same donor funds (sridhar 2012: 22) which makes them highly donor dependent. this in turn translates to donor-dependency of recipient countries. however, especially with view on stagnant or even declining donor contributions a revived effort from recipient countries to free domestic funding for hiv/aids and health in general, for example by aiming for the abuja target spent of 15% for health, could ease both the high reliance on donors and general decrease in funding (hecht et al. 2009: results 33 1603; yu et al. 2008: 7). this would also support the move from ‘upward accountability’, from recipients being accountable to donors, misguiding agenda setting and dismissing local priorities, which is a general problem in development aid. with a rise in domestic funding, there is a shift to ‘downward accountability’, from national governments to their citizens and beneficiaries on the ground, with more power of national governments to shape their programs according to their need. despite domestic funding increases in many countries, this development is unevenly distributed. while some countries that were previously donor-dependent are now able to fully fund their own programs (e.g. botswana and south africa), others remain heavily donor-dependent and therefore suffer from their upward accountability (oberth et al. 2016: 2f.). the hiv/aids response is broadly based on human rights frameworks and the right to health. this helped to progress legislation in many countries and dismantle discriminatory judicial rulings (piot et al. 2015: 182). furthermore, it serves as precedent and has opened the door for other global health issues to achieve successes by challenging policies and courts on the human rights basis. as mentioned for the global fund, hiv/aids activism and funding generation took an exceptionalist and vertical approach, focusing ‘just’ on hiv/aids. however, the need for health system strengthening to build up capacities and establish functioning health systems with well-trained staff, infrastructure, management and documentation was widely overlooked, especially in the beginning (cassimon et al. 2008: 1193f.; bekker et al. 2018: 323). as a result, early hiv/aids prevention and treatment programs were weakened by the lack of health system capacities to deliver (hanefeld 2014: 55). additionally, the focus on a biomedical approach to hiv/aids left other structural issues inadequately addressed. this includes a vast need for efforts in the realm of gender-based violence, stigma reduction and changes in inappropriate legislature and policy environments (piot et al. 2015: 183). shifting funding to hiv/aids left other health issues, for example reproductive health, with less resource, leading to a decline of services provided in some areas (yu et al. 2008: 3f.). moreover, as mentioned before, funding for prevention fell short behind funding for treatment. resultingly, the number of people in need of treatment has risen, driving up the need for even more funding (piot et al. 2015: 183). on the other hand, the outpour of resources towards hiv/aids was also beneficial for other health areas and helped to indirectly strengthen health systems in some places, as a result of infrastructure improvements (e.g. laboratory systems, telecommunication, buildings, water, electricity). successes in the hiv/aids response highly relied on scientific progress in the development of prep and art, and the ongoing search for vaccines (piot et al. 2015: 182). the introduction of art opened hospital beds back up, since before its introduction results 34 people with hiv/aids occupied between 50-80% of hospital beds and service resources in many sub-saharan countries (yu et al. 2008: 2ff.). therefore, despite broad criticism on the vertical, disease-specific approach, successful gains were made in many areas, including funding, multi-stakeholder collaboration, emphasizing civil-society inclusion, scientific innovations as well as political commitment and awareness (bekker et al. 2018: 323). furthermore, a 2015 lancet commission on defeating aids, chaired by former unaids executive director peter piot, attested that for hiv/aids the combination of prevention and treatment, in line with social and political commitment as well as structural interventions, has proven powerful, despite not being ‘a magic solution to all problem’ (piot et al. 2015: 179). the aforementioned lancet commission, on the other hand, criticizes that the need for a quick response to the rising numbers of people infected with hiv in the 1990s led to ineffective use of resources. what was understandable in the beginning, given lack of information and data, has however, continued far into today. despite a strong focus on coordination and harmonization by unaids, there are distinct shortcomings in this field, resulting in duplication and parallel structures regarding funding, monitoring and reporting and lack of harmonization with national strategies (piot et al. 2015: 182f.). inadequate management of funds and other resources, lacking cost and duplication reduction strategies, as well as corruption and misappropriation of funding have been frequently criticized (piot et al. 2015: 183). moreover, funding for hiv/aids programs was often focused on delivering short-term goals. this was to the disadvantage of long-term and sustainable funding and investment, despite the need for life-long treatment and interventions and the need for structural changes (piot et al. 2015: 182). consequently, there is need for the hiv/aids fight (prevention, treatment and care) to be integrated into existing health systems and services, to be treated like the chronic disease it now is instead of managing it like the emergency it was at the end of the 20th century (yu et al. 2008). therefore, the consequence should be a shift in how funding for hiv/aids and health system strengthening is generated and disbursed. looking beyond unaids and the global fund, ample criticism exists on the level of conditionalities attached to funding. a prime example for this is the case of pepfar, ruling that 33% of its resources must be spend on abstinence and fidelity programs. because of their strained position, most african countries were not able to reject this conditionality-soaked funding. however, this made it quite difficult for funding recipients to tailor programs to their local needs. instead, it further imposed western donor ideologies, also going beyond pepfar, on african countries (adeboye 2018: 338f.). despite the global fund and unaids both strongly advocating for country-ownership and alignment with national strategies, one results 35 has to recognize that this was still not the case for all donors. furthermore, criticism has been voiced about the celebration of achievements made, which widely focus on the attitudes and perspectives of international donors and the global health community, but largely dismisses the fact that the situation of those on the ground and most affected remains largely unchanged (adeboye 2018: 339). in practice this means that despite declining infection rates in some areas, there are still a high number of new infections occurring every day, stigma persists, and children and women are still more vulnerable to the virus. according to adeboye (2018), this is a result of insufficiently addressing the social circumstances mentioned above, in which the epidemic still exists and persists. to her it appears that, in addition to health investments, “africans also need a ‘social pill’” (adeboye 2018: 339). other researchers agree that the persisting epidemic toady is “driven by marginalisation, stigma, and discrimination, resulting in poor health care, insufficient access to treatment, and substantial power imbalances” (headley et al. 2019: 382). finally, despite the achievements made in the hiv/aids fight, efforts have to be kept up to secure sustainable commitment and financing in the future and stay on track for the ambitious goals of the agenda 2030 and the sdgs. at the moment, funding commitments of traditional donors as well as political commitment in some of the countries most affected are decreasing. accordingly, there is increasing recognition of the need to integrate the hiv/aids response more strongly into broader health system strengthening efforts and primary health care (phc), in order to sustain the achievements of the past decades and achieve the ambitious goals set for the fight against hiv/aids (bekker et al. 2018: 323). important development: funding from external donors is increasingly mirrored by “substantially increasing investments from domestic governments” (piot et al. 2015: 182) discussion 36 5 discussion 5.1 prospective evaluation as seen in the previous chapter, the fight against hiv/aids offers a variety of learnings with positive as well as negative outcomes one should consider in the establishment of new programs. in this next chapter we will attempt a prospective evaluation of the programs and outcomes discussed and their desirability, practicality, and transferability to gmh. the prerequisite for unaids’ and later the global fund’s establishment was the recognition of hiv/aids to be the ‘disease of the time’, with great potential to harm development efforts worldwide. hiv/aids was a new phenomenon, with an unknown etiology and no practical guidelines in place yet. consequently, the need for a multisectoral response with broad stakeholder inclusion was established, as inaction would have hindered development of lmics substantially, and it justified the surge in programs and funding. while a similar awareness for gmh and its importance for human and country development would be desirable and the gmh field has made major steps towards this in recent years, it is unlikely to reach comparable levels to hiv/aids. on the one hand, this is induced by the increasing competition of health affairs with the multitude of other pressing issues, including forced migration, climate change and environmental degradation, social justice, terrorism as well as armed conflict. this development can also be observed in the transition from mdgs to sdgs. while health “occupied three of the eight mdgs, health is specifically addressed in only one of 17 sdgs and ten of 169 sdg targets” (bekker et al. 2018: 315). on the other hand, gmh also competes with a myriad of health priorities, such as mother and child health, reproductive health and often mentioned health system strengthening efforts, in addition to pandemic preparedness. additionally, gmh and mns disorders have been known for quite some time and do not have the ‘surprise momentum’ like hiv/aids had in the 1980s and 90s. moreover, physical diseases are often perceived as ‘more important’ than mental diseases, even by those affected. however, experiences of the covid-19 pandemic have catapulted health to the top of decision-makers’ agenda and questions about the mental health impact of the pandemic have fostered momentum and awareness for the cause. to give a prospective evaluation a good starting point is to reconsider the fundamental tasks of unaids and the global fund. while unaids offers technical assistance and serves as knowledge base, but does not act as a funding organization, the opposite is true for the global fund, with no merit in implementation or technical assistance. as one main lesson was the need to minimize fragmentation the leading question should be if two separate organizations or programs with divided tasks are necessary, especially because it has discussion 37 shown to create confusion about their respective role. additionally, by avoiding duplication and keeping the organizational structure lean operational costs can be avoided and funding channeled to where it can create the greatest impact. furthermore, one might look around at what tasks are already covered by existing organizations, for example by the who. as mentioned in chapter 1.3 vigo et al. performed a similar analysis of scale-up potential for gmh by drawing from the global fund, who’s partnership for maternal, newborn and child health (pmnch) and the world bank’s global financing facility (gff) (2019: 351). they argue against the establishment of another organization focused on advocacy, stewardship and capacity-building, such as unaids, as this would lead to further fragmentation and create unnecessary competition with who (vigo et al. 2019: 352). they too find that reliance on who for advocacy and stewardship will likely not render as strong results as were seen from unaids’ efforts for hiv/aids, especially in fund mobilization. however, who should be the primary provider of highly reliable data on mns disorders and gmh in general, as it is already mandated with monitoring outcomes and capacity-building in the realm of mental health, for example through its mhgap programs. moreover, this way, data collection and methodology, as well as epidemiological estimation procedures are under scrutiny of more diverse experts. in turn, this reduces the risk of overand underestimation, which has been criticized in the case of some unaids estimates (das/samarasekera 2017: 2102). in line with the argument of fragmentation, vigo et al. make the point that the embedment of a new organization into the un landscape leads to a high dependency on the un, for example regarding procedures and goals. although vigo et al. cite another program (pmnch) for their case, this argument also applies here, for example in terms of dependency on cosponsors to cooperate (2019: 353). therefore, in spite of the desirability of many of the outcomes unaids produced, transferability of the organization as a whole does not appear given or practical. in their findings vigo et al. agree with this viewpoint as they see the main task of a new program for gmh only in the field of funding, pooling and disbursement. yet, they endorse who to be a strong partner in a gmh focused organization (2019: 353). consequently, in their assessment of the global fund, vigo et al. rate its characteristics of autonomy from pre-existing bureaucracies as well as inclusive and diverse representation of stakeholders as highly desirable for gmh. however, in terms of transferability of the entire organizational structure, it is deemed rather unfeasible and unsustainable. this is due to expected high costs of establishing and operating such a new and autonomous organization, which poses a high risk of failure (vigo et al. 2019: 352). adding to this, the creation of another organization following the global fund model would mean creating another vertically focused and disease(group)-specific organization at risk of losing sight of the need for system discussion 38 strengthening and consideration of other determinants for mental health. this factor might be even more critical for gmh, since treatment for mns disorders is much more complex than for hiv/aids. this is especially true, since mental well-being and mental disorders exist on different levels of the continuum and are less definite as an hiv infection (infected vs. not infected). moreover, administration of medication for mns disorders is more multifaceted and therefore bound to regular modification and monitoring and does not ‘fix it’ as much as one could argue is the case for hiv/aids. therefore, successes in the hiv/aids response resulting from the introduction of prep and art are highly desirable but not directly transferable to gmh due to the non-communicable nature of mns disorders. consequently, focusing on an integrated, whole system approach including psychosocial interventions is necessary, right from the beginning. while the establishment of a ‘second unaids’ and a similar ‘global fund for gmh’ is not practical or sustainable, transferring elements of the unaids and global fund structure could be. uniting government representatives with non-government representation (ngos, civil society, private sector), as well as un organizations and agencies with a variety of focuses and mandates in the governing and decision-making bodies was innovative in the hiv/aids response and an incremental factor to its successes (piot et al. 2015: 181f.). it brought attention to hiv/aids in different areas of activity and simultaneously leverages on expertise of different stakeholders. this kind of multistakeholder involvement renders results that are highly desirable for gmh and should, although in an adapted form, be transferred to a new program outside the un system. adding to this, there is a great need for strong civil society engagement and ‘grassroot energy’ as was present in the hiv/aids movement for the global mental health field (bekker et al. 2018: 323), to push the issue to the top of the agenda and work against stigma and marginalization. consequently, some form of country representation, with the same strong representation of civil society and ngos is important to transport global advocacy to the ground. this is equally important for the case of gmh as it was for hiv/aids, as this a promising tool to bridge cultural barriers and stigma by including for example faith-based organizations on country and community level. adding to the point, having some form of country-level working group is crucial to develop programs that follow local needs and national strategies, and are not imposed by donors from ‘outside’. criticism that western agendas overpower lmics and do not take the culture, context and experience of those most affected into consideration exist in close to all fields of development aid and cooperation. gmh is no exception and already being accused of such tendencies (rajabzadeh et al. 2021: 4). therefore, actively working against this bias by establishing country-ownership and advocacy for their own needs should be prioritized for a gmh discussion 39 program. fortunately, strong community participation is already endorsed by the gmh research and advocacy community, following the credo “nothing about us without us” (patel et al. 2018: 1557). however, activism of people living with mns disorders and those most affected might fall short in some places, due to the limitations living with mns disorders can have. moreover, in contexts where civil society participation is not as common and csos less established additional efforts should be made to strengthen these structures. therefore, it is important to encourage those affected and give room for their stories. the high level of community participation needs to be represented in program design and policy making on local, national and global level (rajabzadeh et al. 2021: 7). hence, transferability of promoting country-ownership and civil society engagement seems practical and promises highly desirable outcomes. adding on to this, strong community and civil society involvement is also crucial because the voice of activism is an important medium to express dissatisfaction with the status quo and can be an important driver urging political leaders to act (piot et al. 2015: 181). moreover, following the precedent of hiv/aids and coming back to the fundamental understanding that health is a human right gives civil societies and activist groups an arena to challenge countries’ responsibility to provide healthcare without restrictive and/or marginalizing limitations of the law. (maciocco/ stefanini 2007: 480). this could promote countries to evoke a stronger human rights basis in mental health care and help reduce stigma of persons affected by reducing punishing laws. this is also an important factor, as mental health care still opens a lot of doors for human right violations (patel et al. 2018: 1558) and has to be carefully considered in program design and funding disbursement. in many low-income countries quality mental health services have to be built up from the bottom. consequently, including mental health services in community and primary health care from the beginning would be an accessible and realistic way to reduce system fragmentation further, not just in terms of funding but also in terms of care delivery. in contrast, in middle-income countries, where domestic funding is already available for gmh, it is currently spent on specialized hospitals with a small reach. here, funds “need to be redirected to strengthen primary care and community services” (vigo et al. 2019: 352) to be capable to manage physical as well as psycho-social and psychiatric needs. the point of redirection of funds assumes domestic funding is available to some extent. however, an important factor which is not sufficiently addressed through activities of the global fund and unaids for hiv/aids is heightening the effort of countries to create fiscal space for health and to direct domestic funding to mental health. despite all funding channeled from donors, this is essential to the effort of reaching any of the treatment packages and 1 us$ to 3 us$ investment pppa scenarios as proposed by the lhgp group (lhgp 2018: 27ff.; 35). discussion 40 furthermore, it supports country-ownership and helps diminish donor, and especially western ideologies on lmics, or recipient communities in general. one of the key elements supporting the increase of resources contributed to the global fund was its pledge to transparency and the systems embedded into the organizational structure to ensure this. effective corruption and fraud countermeasures have to be in place to make sure the huge sums of money end up where donors intended to put them. especially in the establishment of a new funding program those in charge should go beyond standard measures of compliance and emphasize this topic, also in terms of leadership choice, to generate credibility and trust from donors. 5.2 consequences for gmh in order to increase funding for gmh and to scale up mental health services in lmics an innovative, diverse and well-resourced funding program is necessary. this new program needs to be a credible partner for donors and investors, ensuring transparency in fund management and vfm. moreover, this program will face challenges of fragmentation and must be ready to manufacture an integrated response from all relevant stakeholder and constituencies to overcome current inconsistencies. this includes priority setting in regard to populations, countries and disorders, in close collaboration with who. the core task of the program must be developing various funding mechanisms and financial instruments to attract, pool and disburse funds for gmh. moreover, the new program needs to build capacities in the realm of implementation and evaluation, as well as establishing accountability mechanisms. vigo et al. agree, that “the time is ripe for establishing a multipolar and inclusive partnership to address the challenge of financing a global scale-up of mental health services” (2019: 351). in order to avoid undesirable features such as dependency on dominant partners like the un or high costs for establishment and operations of the new gmh funding program, they suggest an “autonomous partnership with a secretariat housed […] in an expert organisation” (2019: 352), instead of a multilateral organization. the supporting secretariat could be embedded in an academic institute, but the program itself would be governed by a board representing diverse constituencies. constituencies must include hic and lmic representatives alike, academia and implementers, especially strong representation of csos and people with lived experiences, the private sector, as well as affiliated un organizations and those who hold expertise in relevant issues. these would for example include world bank as expert on generating and disbursing funds, and potentially as trustee, or unicef, as expert on reaching the highly vulnerable group of children and adolescents. discussion 41 additionally, in the previous chapter it was established that efforts in collecting epidemiological data and publishing estimates as well as creating awareness and establishing gmh as a high-priority item on the global agenda should stay with who. consequently, who must take a strong role in the new gmh partnership, without overpowering other constituencies. moreover, it is now up to who to launch a timely and multi-facetted advocacy and awareness campaign, addressing various audiences, from regular people and those potentially affected to local, national and global decision-makers. whos advocacy work must be brought into various forums where the work has touching points with gmh on global and country-level, for example the un general assembly, ilo or world bank, as well as national ministries of health, csos and the private sector and should be supported by the expertise on gmh accumulated in the diverse board of the gmh partnership. an additional feature of the gmh partnership program must be a form of country-level forum on gmh, which is connected to the global partnership. the country-level forum should consist of similar constituencies as the global board, in addition to other locally important entities, for example faith-based organizations. in this context, community participation should be given special attention. tasks of country forums need to be defined in accordance with priorities set by the gmh partnership and might vary depending on the priorities set for different geographical areas or focus on diseases within the mns disorder spectrum. moreover, the state of mental health services in each respective country needs to be considered. where no national strategies for mental health are in place yet, country forums on gmh should start off with creating those, drawing on the expertise of the various constituencies. this offers an important basis for quality care, especially where services have to be built up from the bottom. further, national strategies attract funding from ‘outside‘, but also serve as grounds for increasing domestic funding. additionally, writing proposals for gmh grants could be another task, however, this depends on the financial instruments implemented by the gmh partnership. country forums on gmh should be able to work as autonomously as possible, within the frameworks of the gmh partnership, in order to foster country-ownership and limit the influence of foreign ideologies which have a tendency of disregarding local needs and cultural and ethnic customs. this plays an especially important role in gmh as the perception of mns disorders is susceptible to religious or other cultural beliefs. while who should take the hat in initiating a global awareness campaign it is critical to involve country forums to reach local communities and translate the aspects of the campaign in a culturally sensitive manner. taking away from the hiv/aids story that prevention should not suffer from a focus on treatment, this should also be emphasized in gmh activities, be it advocacy work as well as implementation. it is important to promote prevention, especially through communitydiscussion 42 support, to keep the number of patients in need of treatment and consequently the costs of treatment and loss of productivity as low as possible. moreover, increasing attention should be given to fighting stigma and discrimination. this requires adaptions of national legal frameworks and the revision of discriminatory and punishing legislature for mental disorders and must continue into the most basic levels of care provision. further, this is a crucial part in ensuring that health care, and mental health care specifically, are provided to everybody, as every person holds the human right to health. moreover, persons suffering from mns disorders are highly vulnerable to have their basic human rights violated when seeking treatment, which has to be addressed in programs financed through the global gmh partnership and within each countries’ forum. the agenda for sustainable development, which brought forth the 17 sdgs, has been driving efforts towards universal health coverage (uhc) with increasing momentum created through the understanding of the health to right as a human right (bekker et al 2018: 315). this offers an important entry point for gmh advocacy, since universal health care must undeniably include mental health care. including gmh in uhc advocacy is also in line with the need to embed gmh efforts into general health system strengthening, with focus of integration of mental health services into primary health care delivery. furthermore, especially in low-resource settings special attention should be given to strengthening community-based care. another lesson from hiv/aids is the need for flexible, non-earmarked funding to ensure that the gmh partnership can tailor funding offers to local needs. increased donor commitments for gmh are needed, to come anywhere close to closing the funding gap. however, in view of great competition for donor funding among health and other development issues, the general decrease of donor funding for all development areas due to increasing nationalist tendencies of many high-income nations and resultingly unpredictability of funding, as well as efforts to decrease donor-dependency of implementing countries, other funding sources will have to play an increasingly important role. consequently, more innovative funding mechanisms are needed. the global fund championed two examples, the (red) campaign and dept2health swaps, which offer a good baseline and inspiration for the development of new mechanisms. further ideas include, for example, luxury or ‘sin taxes’ on harmful products for health, such as tobacco or alcohol, or social impact bonds as mentioned before. with the establishment of funding mechanisms, the focus cannot only be on how funds can be generated and pooled, but one must not lose sight of how those funds are spent and disbursed most effectively. the global fund pursued the path of distribution tied to grants, mainly with result-based money disbursement. yet, new ways of channeling money to beneficiaries in the most effective and equitable way should be considered discussion 43 concurrently. lastly, as mentioned previously, increases in domestic funding are dearly needed to scale-up mental health services. growing national gross domestic products (gdp) of long-time low-income countries are promising. however, within those growing resources fiscal space has to be created for matters of health systems strengthening and gmh, so that the populations can benefit from the increasing prosperity of their countries. it is important to note that no singular approach to funding generation will be sufficient, but a combination of all three, traditional donors, innovative financing mechanisms as well as domestic resource generation is needed to tackle the gmh funding gap. 5.3 limitations and research demand the literature search was limited to title searches in order to make the exhaustive body of literature surrounding hiv/aids and funding more accessible. yet, it cannot be ruled out that significant publications to this topic did not show up in the results through this method of choice. moreover, differences between hiv/aids, and even the extension to tb and malaria as a collection of communicable diseases and gmh as part of the ncd disease group are substantial and limit the direct comparison of programs. while there is a multitude of organizational designs within the international governance landscape from which lessons could be drawn, this analysis only looks at a very limited selection and is by far not exhaustive. the increase in funding is not attributable only to the two programs depicted in the results section. considerable amounts of funding were also spent by pepfar, the bill and melinda gates foundation in addition to other bilateral and multilateral development agencies, private foundations and global health initiatives. however, the lion share of money was pledged and disbursed after the year 2000, after unaids had put substantial work into bringing hiv/aids to the top of the global health agenda, into the security council, as well as the mdgs and sdgs. without advocacy work and creating political commitment to the cause it is likely that the response from donors would have been delayed by many, crucial years. this thesis looked at the global fund to assess ways how funding for the fight against hiv/aids was generated. however, when pledging funding to the global fund, donors do not earmark the money for one of the priority diseases. therefore, one must be careful that funds pledged to the global fund cannot automatically be fully attributed to funding against hiv/aids, especially where pledges have not been honored yet and the final spending target is not yet determined. it is not clear how bringing together these three diseases in one fund influenced donor decisions in pledging more or less money and there is no evidence whether pledges would have reached similar amounts if the global fund had focused on hiv/aids only. discussion 44 the prospective evaluation was performed by one person alone with a background in international health sciences. however, the topic of funding generation in general, but especially in a global health and development context involves many more disciplines, e.g. economics, political science and development studies. therefore, the prospective evaluation on desirability and transferability of the analyzed programs is limited to the perspective of one researcher from one discipline. yet, this evaluation would profit from more diverse perspectives and judgements. further research need exists on how funds are best spent with regard to gmh, by generating the greatest impact for the people most affected through effective disbursement mechanisms. additionally, research is needed in the realm of culturally appropriate communitybased service delivery in low-resource setting. moreover, mechanisms for successful coordination and harmonization are dearly needed and research should focus on examining various existing structures and their effectiveness, before the establishment of a new program or partnership, to integrate this important aspect from the beginning of its establishment. moreover, emphasis on how to practically realize gmh integration into overall care delivery is needed and further research should focus on this aspect. conclusion 45 6 conclusion while speaking about funding generation, pooling and disbursement for causes such as hiv/aids and gmh it is important not to lose sight of the human suffering, disguised behind numbers and technicalities. moreover, health and well-being should be at the center and cannot get lost in discussions focusing only on productivity increase and economic fitness. drawing lessons from the two proposed programs is by far not an exhaustive selection of possible models, as the global architecture of funding initiatives offers many more examples of how funding generation and coordination could be accomplished. however, it can be concluded that the increase in global funding for hiv/aids and how it was achieved offers many valuable lessons in terms of funding generation, raising political and social commitment and multi-stakeholder collaboration. the analysis of unaids has unmistakably shown the great impact of advocacy and the right framing of an issue. all this has played an important role in the creation of multiple funding mechanisms and sustained commitment by the global community. another great learning from the fight against hiv/aids is the need for inclusion of civil society and those most affected, by any disease, in decision-making bodies on global and country-level, as well as in the creation of national strategies. adding on, the fight against hiv/aids has shown the great importance of strong leadership and transparency, to establish trust from donors but also from those affected. yet, despite being a positive example in terms of overall outcomes, lessons to be learned from hiv/aids are not exclusively positive. for example, disregarding the need for overall health system strengthening and continuous struggles for coordination have held up progress and effectiveness. consequently, hiv/aids serves as a negative example too, and the lessons learned should focus on how to do it better next time. this also entails the broader consequences for health systems and other health indicators that have to be considered when applying a vertical approach and carefully weighed before taking hasty, unthoughtful action. finally, the history of funding hiv/aids in the past three decades offers important lessons. these lessons can be drawn and applied for gmh, to inform necessary actions as next steps. 46 list of tables table 1: four steps of lesson drawing .............................................................................. 8 table 2: unaids objectives............................................................................................ 13 47 list of figures figure 1: governing structure unaids ......................................................................... 15 figure 2: governing structure the global fund ........................................................... 22 figure 3: budget development, including funding for tb and malaria the global fund 23 figure 4: conceptual model unaids ........................................................................... 27 figure 5: conceptual model the global fund............................................................... 30 48 list of abbreviations aids acquired immunodeficiency syndrome arv anti-retroviral treatment cco committee of cosponsoring organizations cso civil society organization dah development aid on health dalys disability-adjusted life-years g8 group of eight (japan, canada, italy, france, germany, united kingdom, united states of america, russia) gbd global burden of disease gdp gross domestic product gff world bank’s global financing facility gmh global mental health gpa global programme on aids (who) hic high-income country hiv human immunodeficiency virus ilo international labor organization ipaa international partnership against aids in africa lgbtq+ lesbian, gay, bisexual, transgender, queer and all other gen der identities and sexual orientations lhgp lions head global partners lmics lowand middle-income countries map africa multi-country hiv/aids programme for africa mdgs millennium development goals mhgap mental health gap action plan mns disorders mental, neurological, and substance-use disorders msm men who have sex with men ncd non-communicable disease 49 nfm new funding model (the global fund) oda official development assistance pancap pan caribbean partnership against hiv/aids pcb programme coordinating board pepfar u.s. president’s emergency plan for aids relief pmnch who’s partnership for maternal, newborn, and child health ppp public-private partnership pppa per person per annum prep pre-exposure prophylaxis sdgs sustainable development goals tb tuberculosis the global fund the global fund to fight aids, tuberculosis, and malaria ubraf unified budget, results and accountability framework uhc universal health coverage un women united nations entity for gender equality and the empowerment of women unaids the joint united nations programme on 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(2014): evidence to policy initiative. partnership profile: the global fund. about the global fund to fight aids, tuberculosis and malaria. san francisco: the global health group. https://www.who.int/teams/mental-health-and-substance-use/treatment-care/mental-health-gap-action-programme#:~:text=the%20who%20mental%20health%20gap,low%2d%20and%20middle%2dincome https://www.who.int/teams/mental-health-and-substance-use/treatment-care/mental-health-gap-action-programme#:~:text=the%20who%20mental%20health%20gap,low%2d%20and%20middle%2dincome https://www.who.int/teams/mental-health-and-substance-use/treatment-care/mental-health-gap-action-programme#:~:text=the%20who%20mental%20health%20gap,low%2d%20and%20middle%2dincome https://www.who.int/teams/mental-health-and-substance-use/treatment-care/mental-health-gap-action-programme#:~:text=the%20who%20mental%20health%20gap,low%2d%20and%20middle%2dincome 59 list of appendices appendix 1: keyword searches...................................................................................... i keyword search in medline (pubmed) ...................................................................... i keyword search in cinahl ............................................................................................ i keyword search in embase ............................................................................................ i keyword search in wiley online library...................................................................... ii keyword search in web of science core collection ................................................. ii appendix i appendix appendix 1: keyword searches keyword search in medline (pubmed) search date search term filters results 04.01.2023 unaids [title] not 90-90-90 [title] 213 12.01.2023 the global fund [title] 185 15.02.2023 hiv/aids [title] and (fund* [title] or finance* [title]) publication year: 2018-2023 22 15.02.2023 development assistance for health [title] publication year: 2018-2023 35 15.02.2023 global mental health [title] and (fund*[title] or (financ*[ [title]) publication year: 2018-2023 6 keyword search in cinahl search date search term filters results 04.01.2023 unaids [title] not 90-90-90 [title] 109 12.01.2023 the global fund [title] 247 15.02.2023 hiv/aids fund* [title] or hiv/aids financ* [title] publication year: 2018-2023 7 15.02.2023 development assistance for health [title] publication year: 2018-2023 33 15.02.2023 global mental health fund* [title] or global mental health financ* [title] publication year: 2018-2023 2 keyword search in embase search date search term filters results 03.01.2023 unaids [title] not 90-90-90 [title] 208 12.01.2023 the global fund [title] 202 15.02.2023 hiv/aids [title] and (fund* [title] or finance* [title]) publication year: 2018-2023 27 15.02.2023 development assistance for health [title] publication year: 2018-2023 34 15.02.2023 global mental health [title] and (fund*[title] or (financ*[ [title]) publication year: 2018-2023 4 appendix ii keyword search in wiley online library search date search term filters results 04.01.2023 unaids [title] 19 12.01.2023 the ‘global fund’ [title] 17 15.02.2023 hiv/aids and (fund* or finance*) [title] publication year: 2018-2023 3 15.02.2023 development assistance for health [title] publication year: 2018-2023 2 15.02.2023 global mental health and (funding or financing) [title] publication year: 2018-2023 4 keyword search in web of science core collection search date search term filters results 04.01.2023 unaids [title] not 90-90-90 [title] 162 12.01.2023 the global fund [title] 428 15.02.2023 hiv/aids [title] and (fund* or finance*) [title] publication year: 2018-2023 24 15.02.2023 development assistance for health [title] publication year: 2018-2023 37 15.02.2023 global mental health and (funding or financing) [title] publication year: 2018-2023 3 scintee sg and vladescu c. overview of the main incremental health care reforms introduced between 2014 and 2020 in romania. (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5477 p a g e 1 | 13 original research overview of the main incremental health care reforms introduced between 2014 and 2020 in romania silvia gabriela scintee1 and cristian vladescu1,2 1 national school of public health, management and professional development, bucharest, romania 2 titu maiorescu university, faculty of medicine, bucharest, romania corresponding author: silvia gabriela scintee national school of public health, management and professional development 31 vaselor str., 21253 bucharest, romania e-mail: sscintee@snspms.ro mailto:sscintee@snspms.ro scintee sg and vladescu c. overview of the main incremental health care reforms introduced between 2014 and 2020 in romania. (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5477 p a g e 2 | 13 abstract aim: on 2014 the government of romania has committed to improving health and health system through the implementation of the 2014–2020 national health strategy: health for prosperity. an official evaluation of the strategy implementation is not publicly available yet. this paper aims to provide an overview of the main incremental reforms taken during this period in romania and to analyse the results from the perspective of the main strategy goals. methods: information was collected from legislative documents, statistical and scientific publications. the main implemented or initiated incremental reforms, during the assessed period, were assigned to five main clusters: ”governance”, “resources for health”, “coverage and access”, “organization of health care”, “quality of care” and were analysed in accordance with the aim, the type, the implementation stage and the corresponding objectives of the strategy. results: the 2014–2020 national health strategy has definitely not reached all its objectives, but one sign of prosperity, is that based on 2019 per capita income (of $12,630) world bank classified romania, for the first time, as a high-income country. the health status of the population has increased in many aspects, yet romanians’ health has still remained among the poorest in the european union (eu). conclusion: incremental reforms might be successful, but the small steps should be taken in a holistic approach, and should be tailored to specific needs. previous strengthening health systems resilience and plans for overcoming possible risks and obstacles might ensure successful implementation. assessments of the reforms might draw lessons that help policymakers in shaping further health policies and designing of next strategies. keywords: health care reform, health planning, health resources, quality of health care, romania conflict of interest: none declared. scintee sg and vladescu c. overview of the main incremental health care reforms introduced between 2014 and 2020 in romania. (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5477 p a g e 3 | 13 introduction under the perspective of signing the 2014–2020 partnership agreement with the european commission on funding through the european structural and investment funds, the government of romania approved the 2014–2020 national health strategy ”health for prosperity”, as one of the ex-ante conditionalities to ensure the effective and efficient use of these funds. the strategy development was based on the european commission’s country-specific recommendations for the health sector and a functional review of the romanian health sector performed by the world bank (wb). besides following the aims of the european commission growth strategy ”europe 2020”, the document is aligned with the who health policy framework for the european region ”health 2020” (1). as well, even if not mentioned in the strategy substantiation note, it fits the main principle of the south eastern european 2020 strategy that integrates health as part of the broader economic growth strategy (2), pursuing the achieving of a healthy and productive nation through improving equity in health; strengthening human resources for health; and improving intersectoral cooperation and governance. the national health strategy 2014–2020 provide a framework for improving the health of the population in romania, ensuring equitable access to quality and cost-effective health services, and also highlights cross-cutting measures for ensuring health system sustainability and predictability (3). each of the three main areas of intervention has general and specific objectives with subsequent strategic measures. the measures concerning improvements in population health are targeted to the main public health concerns in romania: health and nutrition of mother and child, communicable diseases (including tuberculosis, hiv/aids, hepatitis b and c) and non-communicable diseases (including cardiovascular diseases, cancer, diabetes, mental health, rare diseases). the scope of the envisaged measures is wide, ranging from prevention and control to disease registries, treatment and rehabilitation. the measures in the area of health services are directed mainly towards shifting the balance of health care services from inpatient to ambulatory and community care, increasing access to quality health care and tailoring services to the needs. the cross-cutting measures include: strengthening planning capacity at all levels (national, regional, local), ensuring sustainability by mobilizing sufficient resources, increasing efficiency in the health system through e-health and reducing inequities in access by developing the health care infrastructure. the strategy is accompanied by an action plan which focuses on results and includes the estimated budget, financing sources, responsibilities and monitoring indicators (4). reporting was due annually for the most of indicators, though the only publicly available implementation report is the one for 2015, which is too early to draw any conclusion on the strategy results. the analysis of the strategy implementation could support the shaping of further health policies and the design of the next strategies. the evaluation of the national health strategy 2014–2020 and the development of the national health strategy 2021– 2027 are planned within a larger structural funds financed project on ”developing the strategic and operational framework for planning and reorganization of health services at scintee sg and vladescu c. overview of the main incremental health care reforms introduced between 2014 and 2020 in romania. (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5477 p a g e 4 | 13 national and local levels” run over 2019– 2022 (5). the current paper is not an evaluation of the implementation of the national health strategy 2014 2020, but it aims to provide an overview of the main incremental reforms implemented over the same period, framing each of them within the objectives of the national health strategy and its expected results. methods the methodology was inspired by the one used by the european observatory on health systems and policies in a study comparing the 2018-2019 reforms in 31 high-income countries, but much simplified, given that it concerns only one country (6). the implemented or initiated incremental reforms, during 2014 2020, were listed, then assigned to five main clusters: ”governance”, “resources for health”, “coverage and access”, “organization of health care”, “quality of care”. ”governance” refers to the changes at the decision making level, either concerning governing bodies or the governance process in healthcare. “resources for health” category includes reforms that attempt to increase the general level of financial, physical and human resources for health, but also to ensure better allocation and efficient spending. “coverage and access” category refers to the reforms aiming to increase the number of people covered with services, or to the increase of the types or number of services provided. this category includes also coverage and access of people to the public health services (health promotion, disease prevention and other interventions aiming at improving health and prolonging life). “organization of health care” category refers to changes in the model of service delivery including the interface between outpatient/inpatient care, primary/specialized care, rehabilitation/palliative care, continuity of care and any other dimensions of health care provision. “quality of care” includes all the changes introduced with the aim of providing more effective, peoplecentred, timely, equitable, integrated, efficient and safer health services. for each cluster were chosen five reforms (see table 1). each reform was described as content, aim, type (e.g. legislation, plan, implemented project) and implementation status and it was matched to one of the objectives under the three main strategic directions of the national health strategy 2014–2020, respectively: improving the health of the population, ensuring equitable access to quality and cost-effective health services, and ensuring health system sustainability and predictability (see box 1). the reforms were then analysed in terms of common characteristics regarding the aim, the type and the implementation stage, the extent to which they replied to the objectives of the national health strategy 2014–2020 and, were data available, the possible impact on the expected results of the strategy. information on the incremental reforms during the assessed period was collected from the legislative documents published in the official gazette, documents on planned changes and funded programmes and projects from the official websites of the ministry of health (www.ms.ro), national health insurance house (www.casan.ro), and the national institute of public health (www.insp.ro). information on current population health status and health services were collected scintee sg and vladescu c. overview of the main incremental health care reforms introduced between 2014 and 2020 in romania. (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5477 p a g e 5 | 13 from the world bank and eurostat databases, as well as from other reports and publications listed in references. the limitation of the study is given by the data collection based on publicly available data only, not taking any deeper investigation on the way the reforms were put on the policy agenda, the implementation process and resources, the major obstacles or the impact evaluation. box 1 the national health strategy 2014 2020 general objectives. priority strategic areas intervention strategic area 1: “public health” go 1. improving the health and nutrition of mother and child go 2. decreasing morbidity and mortality due to communicable diseases, and their impact at individual and social level go 3. reducing the rate of increase in morbidity and mortality from non-communicable diseases and reducing their burden on the population through national, regional and local preventive health programs intervention strategic area 2: “health services” go 4. ensuring equitable access to all citizens, especially to vulnerable groups, to quality, cost-effective health services intervention strategic area 3: “cross-cutting measures for a sustainable and predictable health system” go 5. an inclusive, sustainable and predictable health system through the implementation of priority cross-cutting policies and programs go 6. increasing efficiency of the health system through e-health solutions results the incremental reforms were considered for this study, as there was no major change to existing institutions, organizational structures and management systems that define structural reforms over the assessed period (7). the predominant type of reform was a legislative change (88%), while 22% of reforms were initiated through wb or european union (eu) structural funds financed projects. some 32% of reforms were mixing legislation with project implementation. most of the reforms (60%) responded to the third strategic direction of the national health strategy 2014–2020, which includes measures aiming at ensuring health system sustainability and predictability. fewer reforms were oriented towards the other two directions of the strategy: ensuring equitable access to health services (24%) and improving the health of the population (16%). the reforms contributing to the third strategic direction were concentrated scintee sg and vladescu c. overview of the main incremental health care reforms introduced between 2014 and 2020 in romania. (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5477 p a g e 6 | 13 mainly on improving the quality of health services, strengthening planning capacity, ensuring sufficient financial and human resources for health and developing the infrastructure of the hospital and ambulatory care. reforms oriented towards improving the quality of health services, consisted either of measures stated by the strategy, as implementing health technology assessment (hta) and fighting nosocomial infections, or measures not specified by the strategy, but leading to the specific objective of assurance and monitoring of health services quality. strengthening planning capacity consisted mainly in training and learning by doing through technical assistance within eu structural funds financed projects. the development of health care infrastructure has also been beneficiating by these funds. mobilization of resources was done through specific legislation that mainly increased the budget for health, including the threefold increase of health personnel salaries. the reforms corresponding to the health services development strategic direction, consisted in measures over the governance of some sectors of care (palliative and home care), organizational measures in other sectors (primary health care, community care) and measures to increase the coverage and access to health services. the reforms in this category listed under the governance and organization of healthcare clusters can be found as specific measures in the plan of action for the implementation of the 2014–2020 national health strategy, while the measures for better coverage and improved access to health services are not specified in the strategy, but contribute to the achievement of the general objective of this strategic direction – ensuring equitable access to quality, cost-effective health services to all citizens. the reforms related to the improvements in population health strategic direction included also governance measures through addressing the incomplete legislation to ensure better intersectoral collaboration for controlling environment-related risk factors and better transplant services and measures to increase coverage and access such as improving screening and treatment for cancer and ensuring access to the innovative treatment of chronic hepatitis c. most of the reforms (64%) are still ongoing. they consist of projects still under implementation or main legislation that need subsequent implementation norms development. several legislative measures have been already implemented: increase of health financing and health personnel salaries, the establishment of new institutions or organizational structures (the national authority for quality management in health care, the national centre for human resources) or provisions related to coverage and access. in what concern the changes in the state of health, the 2014 data were compared to 2019. the period 2020–2021 was not eligible for comparison due to covid-19 pandemics that influenced the trend of most indicators. scintee sg and vladescu c. overview of the main incremental health care reforms introduced between 2014 and 2020 in romania. (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5477 p a g e 7 | 13 table 1. incremental reform clusters, 2014-2020 s ta r ti n g y e a r reform content aim of the reform type of reform s tr a te g ic d ir e c ti o n * im p le m e n ta ti o n s ta tu s* * governance 2016 setting specific tasks and responsibilities on the management of the risks for health; setting the national register for environmentrelated risks factors for health intersectoral collaboration for controlling the risks for health government decision (2016) government decision (2019) 1 o 2016 improving moh capacity for strategic planning and management of the national health programmes better implementation and increased impact of the national health programmes eu structural funds financed project (2016) 3 o 2016 reorganization of organ transplantation services addresses the incomplete legislation in the field of organ transplantation, the lack of registries, guides, protocols and a transplant code additions and modification of existing legislation (2016) eu structural funds financed project (2019) 1 o 2017 development of national coordinated palliative and home care services development of national policies in palliative and home care area, development of implementing capacity and development of proper legislation wb financed project (2017) legislation (2018) eu structural funds financed project (2020) 2 o 2019 developing the strategic and operational framework for planning and reorganization of health services at national and local levels development of the national health strategy 2021 – 2027 and of the regional health masterplans eu structural funds financed project (2019) 3 o resources for health 2015 over threefold increase in the salaries of health personnel measures to alleviate the shortage of human resources in the romanian health system emergency ordinance to increase the salaries of health personnel by 25% (2015) emergency ordin ance to the salaries of health personnel during 2018 to the value projected for 2022 (2017) 3 f 2016 first centralized procurement for drugs (antibiotics and for treatment of cancer) reducing costs emergency ordinance appointing moh as centralized procurement unit (2012) moh order establishing the list of 3 o scintee sg and vladescu c. overview of the main incremental health care reforms introduced between 2014 and 2020 in romania. (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5477 p a g e 8 | 13 items that can be centrally procured (2013) 2017 increased budget for health ensuring financial sustainability in the health sector the budget law (2017) 3 f 2017 establishment of a national centre for human resources better human resources for health planning government decision (2017) 3 f 2018 employer shi contributions abolished increased collection of health insurance contributions by eliminating the problem of employers not paying shi premiums for their workers emergency ordinance (2017) to amend that fiscal code law 3 f coverage and access 2014 pensioners living in eu/eec countries; eu/eec citizens not insured in another member state; cross border workers (at own request) covered by health insurance extension of nhih coverage amended law 95/2006 (2014) 2 f 2015 interferon-free treatment of chronic hepatitis c access to new innovative treatments moh and nhih order (yearly updated) 1 o 2016 improving screening and treatment for cancer decreasing the burden of cancer by early detection and better treatment national cancer plan (2016) eu structural funds financed project (2018) 1 o 2018 reimbursement of new services (home care, speech therapy, psychological counselling, kinesitherapy, breast reconstruction after cancer surgery) provided to specific vulnerable people (under palliative care, people with autism) extension of nhih benefits government decision setting the terms under which health services are provided under nhih (2018, 2020) 2 f 2018 removal of referral from the family physician to hospital oncology services for people enrolled in the national cancer treatment programme; new exemptions from copayments: victims of human trafficking; detainee, arrested and imprisoned people without income; telemedicine 2020 improving access to health services government decision setting the terms under which health services are provided under nhih (2018) amended law 95/2006 for co-payment exemptions and telemedicine (2019, 2020) 2 f organization of health care 2014 building 8 regional hospitals reorganization of hospitals on level of care and redistribution of extra acute beds as long-term care beds government decisions (2014) wb and eu structural funds financed projects (2014) 3 o 2014 improving the infrastructure of ambulatory, community and phc increasing the use of outpatient services government decisions (2014) wb and eu structural funds financed projects (2014) 3 o scintee sg and vladescu c. overview of the main incremental health care reforms introduced between 2014 and 2020 in romania. (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5477 p a g e 9 | 13 *1improving the health of the population, 2ensuring equitable access to quality and cost-effective health services, 3ensuring health system sustainability and predictability **f-finalized, o-ongoing a sign of prosperity, the ultimate goal of the strategy, that might have been influenced, among other factors, by the incremental reforms taken during 2014–2020, was the increase of per capita income from $10,044 in 2014 to $12,630 in 2019, thus world bank classified romania, for the first time, as a high-income country (8). unfortunately, the economic impact of the coronavirus crisis pushed back romania, in 2020, among the upper-middle-income countries with a per capita income of $12,570. life expectancy at birth increased from 75.0 years in 2014 to 75.6 years in 2019 but fell to 74.2 in 2020 (9). 2016 development of regional masterplans for health services tailoring provision of health services to the needs government decision (2016) eu structural funds financed project (2019) 3 o 2017 increased financing for continuity care centres ensuring delivery of primary health care an ongoing basis moh order to increase provider payment (2017) emergency ordinance on increasing budget for continuity of primary health care (2018) 2 f 2017 implementing community care developing community care services emergency ordinance (2017) inter-institutional collaboration protocol (2017) government decision (2019) eu structural funds financed project (2019) 2 o quality of care 2014 hta was introduced to inform the selection of benefits improved quality of services by practising evidence-based medicine government decision (2014) wb financed projects (2016, 2020) 3 o 2015 establishment of the national authority for quality management in health care ensuring quality of health services governmental decision 629/2015 3 f 2016 strategic plan for prevention and fighting of nosocomial infections; setting a multisectoral national committee to control antibiotic resistance improving the control and surveillance of nosocomial infections and reducing antimicrobial resistance strategic plan for prevention and fighting of nosocomial infections 2016–2018 government decision (2017) 3 o 2017 more specialization opportunities for nurses increasing quality of care through better training of health personnel moh order (2017) 3 o 2019 improving quality and performance of hospital services through costs evaluation and standardization updating the drg system and developing tools for ensuring increased quality and performance of hospital services eu structural funds financed project (2019) 3 o scintee sg and vladescu c. overview of the main incremental health care reforms introduced between 2014 and 2020 in romania. (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5477 p a g e 10 | 13 the healthy life years at birth increased from 59.0 in 2014 to 60.2 in 2019 (9). infant mortality had a spectacular decrease over 2014–2019, from 8.2 to 5.8 deaths per 1000 live births (9). the preventable mortality decreased from 310 to 306 deaths per 100,000 population over the 2016–2018 period, while treatable mortality increased from 208 to 210 deaths per 100,000 population over the same period (10, 11). despite the highest annual average growth rate in per capita health spending in the eu, 7.8 over the 2013–2019 period, romania still had the lowest health expenditure per capita, of 1,292 eur ppp, almost half of the eu average of 2,572 eur (12). considering that the main vision of the strategy is to shift the balance of health care services from inpatient to ambulatory and community care, from the services utilization perspective there were some achievements: the hospital discharges per 1000 population decreased slightly from 213 in 2014 to 211 in 2018, but the number of outpatient consultations also decreased from 5.3 to 5.2 (12, 13). the self-reported unmet medical care needs also decreased from 9.4% in 2014 to 4.9% in 2018 (12, 13). the share of hospital expenditure has increased from 39% to 46% of total health expenditure, but the increase might have been due to the increase of day-care provision (12, 13). as well, an important and costly measure aiming to alleviate the shortage of human resources was the threefold increase in health personnel salaries. this could be also related to the increase in the availability of both doctors and nurses per 1000 population, from 2.7 to 3.1, respectively from 6.2 to 7.2 over 2014– 2018 (12, 13). discussion reforming the health system in romania has started in the early 1990s once with the general social and political restructuring after the fall of communism. the main structural reforms consisted of the introduction of the social health insurance system and the purchaser-provider split (14). their implementation was a lengthy (1994-1999) and difficult process and they were followed by many incremental reforms. there were also reform initiatives that were abandoned. comparing the implementation of the reforms in different periods in romania, a first observation is that the eu support, which for the assessed period represented the programming and accession of 2014–2020 structural investments funds, was an important driver for change. besides the commitments represented by the signature on the programming documents, adequate financial resources were available. some reforms were favoured by eu legislation that applies to all member states. one example is the implementation of hta that after several unsuccessful attempts was introduced into romanian law following the european union directive 2011/24/ on the application of patients' rights in cross-border health care (15). other reforms were initiated by the eu policy agenda, such as the use of digital technologies and online services (16). increasing efficiency of the health system through e-health solutions was included as the general objective of the strategy, but until 2020 there have been only several isolated projects on telemedicine covering emergency services in remote areas and on the further development of electronic solutions such as electronic health records (17). real big steps in the implementation of e-health were taken when this turned into a ”must” by the covid-19 pandemics. it is difficult to say if the strategy objectives have all been reached since they are not accompanied by measurable targets and performance monitoring (18). the health status of the population has been improved in many aspects, including the self-reported unmet medical care needs, yet romanians’ health has remained among the poorest in the eu. scintee sg and vladescu c. overview of the main incremental health care reforms introduced between 2014 and 2020 in romania. (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5477 p a g e 11 | 13 by and large, better health could be related to better living, as shows the increase of per capita income in 2019. the question is how equitable were the health and wealth distributed knowing that, in 2019, 23.8% of romanians were at risk of poverty (9). the strategy’s main vision of shifting the balance of health care by increasing the volume of services provided in primary and community care settings and rationalizing the use of hospital services is still far away from its achievement. this will take as long as it needs for implementing the necessary changes not only in the health sector but also in other sectors, knowing that among the factors that prevent the use of ambulatory services are poor road infrastructure, lack of public transport and high travel costs. the 2019 increased indicators showing slight improvements in health status and health services provision were reversed by the covid-19 pandemics. this reflects the need for further reforms toward ensuring a more resilient, sustainable and predictable health system. a great opportunity for this is the european commission recovery and resilience facility key instrument that aims to support member states to mitigate the economic and social impact of the coronavirus pandemic (19). romania’s recovery and resilience plan, with a total budget of €14.2 billion in grants and €14.9 billion in loans, includes three main reforms in the health sector: increased capacity for the management of public health funds; increased capacity to undertake investments in health infrastructure; and increased capacity for health management and human resources in health. these build on the 20142020 health strategy achievements, having available by 2026, as specific examples, €470 million for developing an integrated e-health system, connecting over 25,000 healthcare providers and telemedicine systems, and €2 billion to strengthen the resilience of the health system: investing in modern hospital infrastructure to ensure patient safety and reduce the risk of healthcare-associated infections in hospital settings (20). the main factor slowing down the reforms has been the political environment, characterised by high instability (changing 8 ministers of health during 2014-2020) and lack of consensus reaching. this led to delays in passing the necessary legislation, implementation of projects or reaching consensus among different stakeholders. conclusions even if no structural major reform was implemented during 2014-2020, the incremental reforms undertaken over this period could make a difference in health and wellbeing, as some indicators have shown. this reveals that not always radical structural changes are needed to improve health status, but rather to take small steps in a holistic approach. as well, reforms tailored to solving problems in specific populations, areas or regions could have a greater impact than the ones oriented towards the whole population, health sector or to the entire country. the resilience of health systems is an important aspect that should be taken into account, together with any other risk factor that might constitute an obstacle for health reform. as a consequence, strengthening health systems resilience should be a precondition for any planned reform together with all the necessary diligence for ensuring human, financial and political resources and adequate plans for overcoming possible risks and implementation obstacles. as well, milestones and targets should be set up to be used for a proper reform implementation assessment, from which to draw lessons and to build evidence for further reforms. references 1. guvernul romaniei [government of romania], nota de fundamentare la hotararea guvernului nr. 1028/2014 scintee sg and vladescu c. overview of the main incremental health care reforms introduced between 2014 and 2020 in romania. 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(original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5477 p a g e 13 | 13 systems and policies, brussels, doi: 10.1787/f345b1db-en. 11. oecd/european observatory on health systems and policies (2021), romania: country health profile 2021, state of health in the eu, oecd publishing, paris, doi: 10.1787/74ad9999-en. 12. oecd/european union (2020), health at a glance: europe 2020: state of health in the eu cycle, oecd publishing, paris, doi: 10.1787/82129230-en. 13. oecd/european union (2016), health at a glance: europe 2016: state of health in the eu cycle, oecd publishing, paris, doi: 10.1787/9789264265592-en. 14. scintee sg, vladescu c. recent issues of the romanian health financing system. j public health 2006; 14: 237– 45, doi: 10.1007/s10389-006-0045-5. 15. scintee sg, ciutan m. development of health technology assessment in romania. int j technol assess health care. 2017; 33(3):371-5. doi: 10.1017/s0266462317000095. 16. bozikov, j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health, south eastern european journal of public health (seejph). 2015; vol.4:1-7. doi: 10.4119/seejph-1807. 17. vladescu c, scintee sg, olsavszky v, hernández-quevedo c, sagan a. romania: health system review. health systems in transition, 2016; 18(4):1– 170. 18. donev, d. (2022) “pay-for-performance and tools for quality assurance in health care”, south eastern european journal of public health (seejph). doi: 10.11576/seejph-5115. 19. european commission business, economy, euro recovery from the coronavirus recovery and resilience facility, https://ec.europa.eu/info/businesseconomy-euro/recoverycoronavirus/recovery-and-resiliencefacility_en (accessed: january 11, 2022) 20. european commission, factsheet: romania’s recovery and resilience plan, #nextgeneu | september 2021, https://ec.europa.eu/info/sites/default/fil es/factsheet-romania_en.pdf (accessed: january 11, 2022) _______________________________________________________________________ © 2022 scintee et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://ec.europa.eu/info/business-economy-euro/recovery-coronavirus/recovery-and-resilience-facility_en https://ec.europa.eu/info/business-economy-euro/recovery-coronavirus/recovery-and-resilience-facility_en https://ec.europa.eu/info/business-economy-euro/recovery-coronavirus/recovery-and-resilience-facility_en https://ec.europa.eu/info/business-economy-euro/recovery-coronavirus/recovery-and-resilience-facility_en https://ec.europa.eu/info/sites/default/files/factsheet-romania_en.pdf https://ec.europa.eu/info/sites/default/files/factsheet-romania_en.pdf rimawati e, kristina tn, nugraheni sa, margawati a. assessing reproductive health literacy: terms of sex genital among caregiver in semarang city (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5328 p a g e 1 | 7 original research assessing reproductive health literacy: terms of sex genital among caregivers in semarang city eti rimawati1,2, tri nur kristina3, sri achadi nugraheni2, ani margawati3 1 faculty of health, university of dian nuswantoro, semarang, indonesia; 2 faculty of public health, university of diponegoro, semarang, indonesia; 3 faculty of medicine, university of diponegoro, semarang, indonesia. corresponding author: eti rimawati; address: faculty of public health, university of diponegoro, semarang, indonesia: e-mail: eti.rimawati@dsn.dinus.ac.id rimawati e, kristina tn, nugraheni sa, margawati a. assessing reproductive health literacy: terms of sex genital among caregiver in semarang city (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5328 p a g e 2 | 7 abstract introduction: taboos, filth, and shame are moral values resulting from cultural construction that limit names, leading to inappropriate sexuality. these values will impact the practice of caregivers in communicating reproductive health to their children. this study aims to describe the terms used for the names of reproductive organs and examine the connotations built in the marking of these names. methods: the research design was a case report study. the sample comprised 224 caregivers to early childhood who were selected by stratified random sampling in the city of semarang. data analysis was carried out by description and basic quantification. results: researchers found 27 language terms for the names of male and female genital organs. the name's connotation was built because of inheritance, similarity to certain animals, and texture of the organs. conclusion: the use of the connotation of reproductive organs in communicating to children will continue to reduce the culture of taboo and shame continuously. it is necessary to increase the ability of parents to say the correct name for the genital organs. keywords: health literacy, reproductive health, sex education, term of sex organs. conflicts of interest: none declared. ethical approval: this research has received ethical approval from the faculty of public health, the university of diponegoro, number 223/ea/kepk-fkm/2020. rimawati e, kristina tn, nugraheni sa, margawati a. assessing reproductive health literacy: terms of sex genital among caregiver in semarang city (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5328 p a g e 3 | 7 background in the last five years, the number of cases of children in conflict with the law (abh) as victims of sexual violence has shown an increase in indonesia. currently, in the last year alone, the number has shown a sharp increase from 190 cases (2019) to 419 patients (2020) (1). some of the causes of sexual violence against children are the attraction of adult sexual orientation to children (pedophilia), the influence of mass media porn, and children's lack of understanding of sexuality issues (2). children's lack of understanding of sexual problems is due to communication between parents and their children. communication between parents and their children is essential for children's development (3). poor parenting practices can be one of the causes of reproductive health problems in adolescents (4). parents' experiences in obtaining information about reproductive health (sex education) and sexual experiences experienced as adults influence them in teaching reproductive health (sex education) to their children. they consider it too medical, and there are difficulties delivering sex education to children (5). health literacy is "the degree to which individuals can obtain, process, and understand basic health information and services needed to make appropriate health decisions” (6). this study aimed to find the terms used for naming genital organs. it was known that mothers' knowledge of the names of genital organs would impact their practice in providing sex education (reproductive health) to their children. methods the qualitative research design was conducted in the city of semarang. the research sample was 224 early childhood caregivers selected by stratified random sampling. the data was collected by filling out the male and female genital names and discussing the argument. data analysis was carried out descriptively to classify the terms of sex organs. results from the survey results on questions about male and female genitalia names, the terms in tables 1 and 2 appeared. each caregiver wrote down a genital name that they usually use when communicating with their child. most of them can explain the reasons for the term, but some cannot because they got it from generation to generation. table 1. terminology of the male genitalia terms of male sex genital n % penis 134 59.8 titit (a local term for penis) 45 20.1 burung (bird) 23 10.3 sontong/sotong (cuttlefish) 4 1.8 don't know 4 1.8 gajah (elephant) 3 1.3 alat kelaminlaki-laki (male sex genital) 2 0.9 testis 2 0.9 male 1 0.5 nanuk/manuk (local term for bird) 1 0.5 seli (n/a) 1 0.5 sombosamalase (n/a) 1 0.5 totot (a local term for penis, bigger than female’s) 1 0.5 untuk pipis (for pee) 1 0.5 vagina 1 0.5 total 224 100 rimawati e, kristina tn, nugraheni sa, margawati a. assessing reproductive health literacy: terms of sex genital among caregiver in semarang city (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5328 p a g e 4 | 7 table 1 shows that the respondents expressed language by eleven terms of the male genitalia (others are marked italic). most of them have correctly said that ‘penis’ is the correct name of the male genitalia (59.8%). the research found the most widely used local language expressions are: "titit" (a local term for sex genital), "burung" (bird), "sotong or sontong" (cuttlefish), and “gajah” (elephant). in table 2 are listed sixteen linguistic expressions to describe the female genitalia as indicated in the survey, although most respondents said that ‘vagina’ is the correct name (68.3%). table 2. terms of female genitalia terms of female sex genital n % vagina 153 68.3 gembus (one of the typical dishes in java) 16 7.1 memek (whining) 12 5.4 nunuk (javanese term for vagina) 11 4.9 sempuk (javanese term for vagina) 11 4.9 don't know 6 2.7 pepek/pipik/pipit (sumatra term for pee) 2 0.9 untuk pipis (for pee) 2 0.9 bebek (duck) 1 0.5 female 1 0.5 kupu-kupu (butterfly) 1 0.5 mentul (soft and supple) 1 0.5 pipis (pee) 1 0.5 saru (taboo) 1 0.5 senuk (female sex worker) 1 0.5 sombolase (n/a) 1 0.5 tempe (one of the typical dishes in java) 1 0.5 titit (local term for vagina, smaller than male’s 1 0.5 zeweh (n/a) 1 0.5 total 224 100 based on the respondents’ arguments, the team of researchers classified the terms in table 3 by paying attention to the reasons for mentioning the specific names . table 3. classification and connotation of language expressions classification (based on the argument) connotation language expression scientific context  penis terms for sex genital  “titit” (a local term for penis)  alat kelaminlaki-laki (male sex genital)  testis (testicle)  male  vagina rimawati e, kristina tn, nugraheni sa, margawati a. assessing reproductive health literacy: terms of sex genital among caregiver in semarang city (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5328 p a g e 5 | 7  “nunuk” (javanese term for vagina)  “sempuk” (javanese term for vagina)  female the resemblance to animal shape  burung (bird) terms for genitals that are similar to specific shapes and characteristics of animals  sontong/sotong (cuttlefish)  gajah (elephant)  nanuk/manuk (local term for bird)  bebek (duck)  kupu-kupu (butterfly) referring to the function  pepek/pipik/pipit (sumatra term for pee) terms of the genitals according to their function  untuk pipis (for pee)  pipis (pee) refer to size  totot (a local term for penis, bigger than female’s) terms of genitals based on size  titit (local term for vagina, smaller than male’s the resemblance to the shape of the food  gembus (one of the typical dishes in java) the term for female genitalia is similar to the shape and texture of local food  tempe (one of the typical dishes in java) referring to the character memek (whining) the term genitals according to character in women referring to texture mentul (soft and supple) nunuk (stand out) the term genitalia according to its soft shape and texture refers to the type of work senuk (female sex worker) a term that refers to a particular profession blur interpretation saru (taboo) a term that indirectly refers to the genitals discussion the respondents named language terms for the genital organs due to consideration of animallike shape/function/size, resemblance to the shape of food, character, texture, type of work, and blur interpretation. respondents remembered that when they were taught the correct names of the genitals, they were ashamed and considered it taboo to mention penis and vagina to their children. they argued that the teacher at the school should convey the information. a taboo is still the opinion of most people and parents regarding sex. they think that sex will always be associated with pornographic, dirty, perverted, and the like. in contrast, sex education is an effort to raise awareness and explain sex, instinct, and marriage (7). meilani et al (8) describes that most mothers have not been able to provide sexual education properly, where 66.3% have not communicated openly about sexuality, 52.2% use other terms in mentioning reproductive organs, and 83.3% have a perception of feeling inadequate to provide sexual education. they think that saying the correct name of the genitals is taboo, dirty, has rimawati e, kristina tn, nugraheni sa, margawati a. assessing reproductive health literacy: terms of sex genital among caregiver in semarang city (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5328 p a g e 6 | 7 no morals, and is uneducated. this may be why things that refer to sexuality are inappropriate (9-11). parental fears and cultural taboos will hinder effective parent-child communication regarding sexual health (12). they forbid children to ask questions, consider sexual education unnecessary, and feel uncomfortable (taboo) when mentioning penis and vagina (13) and assume children will know by themselves (13) thus making it difficult for them to communicate with their children, the next generation (14). appropriate sex education involves getting informationand forming positive beliefs, values, and attitudes (15). conclusions our results show that reproductive health literacy in early childhood is still hindered by shame and cultural taboos in mentioning the name of the genitals. this will affect decisionmaking in providing reproductive health education to children who are repeating themselves like their parents. the use of the connotation of reproductive organs in communicating to children will continue to reduce the culture of taboo and shame continuously. it is necessary to increase the ability of parents to say the correct name for the genital organs. the readiness of parents to provide open-minded reproductive health education for their children will help protect children from becoming victims of sexual violence. the lack of accurate knowledge about the risks and indicators of child sexual abuse will negatively influence prevention and detection (16). references 1. indonesian child protection commission (kpai). data kasus pengaduan anak (case data on child complaints) 2016 – 2020 [internet]. available from: https://bankdata.kpai.go.id/tabulasidata/data-kasus-pengaduan-anak2016-2020 (accessed: october 9, 2021). 2. fauzi’ah s. faktor penyebab pelecehan seksual terhadap anak (factors causing sexual harassment of children). an-nisa 2016;9:81-101. 3. ackard dm, neumark-sztainer d, story m, perry c. parent-child connectedness and behavioral and emotional health among adolescents. am j prev med 2006;30:59-66. 4. parkes a, henderson m, wight d, nixon c. is parenting associated with teenagers’ early sexual risk-taking, autonomy and relationship with 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2011;6:7181. 14. allen i. education in sex and personal relationships. policy studies institute; 1987. 15. walker j. parents and sex education— looking beyond ‘the birds and the bees.’ sex educ 2004;4:239-54. 16. marriage nd, blackley as, panagiotaros k, seklaoui sa, van den bergh j, hawkins r. assessing parental understanding of sexualized behavior in children and adolescents. child abus negl 2017;72:196-205. ___________________________________________________________________________________________ jagusiewicz a, uteh c, götz jp, robertz j, zijlman ma. centralized vaccine procurement in the postcovid-19 european union (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5599 p a g e 1 | 16 policy brief centralized vaccine procurement in the post-covid-19 european union agata jagusiewicz¹⁺, cyril onwuelazu uteh¹⁺, jan-philipp götz¹⁺, jule robertz¹⁺, minke anna zijlman¹⁺ and ines siepmann²* 1department of international health, care and public health research institute – caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands ² rpp group (rohde public policy), brussels, belgium +these authors contributed equally to this work *senior advisor corresponding author: jule robertz, email:j.robertz@student.maastrichtuniversity.nl; address: heideweg 22 47447 moers germany. mailto:j.robertz@student.maastrichtuniversity.nl jagusiewicz a, uteh c, götz jp, robertz j, zijlman ma. centralized vaccine procurement in the postcovid-19 european union (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5599 p a g e 2 | 16 abstract introduction: the covid-19 pandemic has confronted healthcare systems worldwide with societal, psychological, and economic burdens. the widespread use of the developed covid-19 vaccines has been generally pursued to stop the spread, decrease mortality rates, and lift the economic burden of healthcare systems. however, it became apparent that the demand for vaccines outnumbers the supply provided by pharmaceutical manufacturers. this policy brief explores the use of centralized procurement globally to formulate recommendations on how the european union (eu) and its member states can benefit from such an approach. policy options: globally, different models with varying levels of collaboration on procurement are implemented. the collaboration can be limited to information sharing or extend towards centralized procurement of medical goods. however, during the covid-19 pandemic, countries collaborated at an unprecedented scale, pooling together resources and expertise to ensure access to scarce vaccine supplies. the resulting centralized approach witnessed in the united states (us), eu, african union (au), or through covax highlighted the benefits of centralized procurement in the state of crisis. recommendations:  an independent institution for pandemic preparedness and response: o focuses on transparent and timely access to vaccines o supports strengthening of national capacities and healthcare systems through periodic monitoring and evaluation.  a centralized procurement system for all eu member states under the independent institution.  the development of comprehensive and efficient emergency preparedness plans. keywords: covid-19, vaccination, centralized procurement, hera, eu, emergency response acknowledgments: we thank ines siepmann, our senior advisor, and kasia czabanowska for the opportunity to explore this topic as part of the leadership track in the master governance and leadership in european public health. authors’ contributions: all authors contributed equally to this work. conflict of interest: none declared source of funding: none declared jagusiewicz a, uteh c, götz jp, robertz j, zijlman ma. centralized vaccine procurement in the postcovid-19 european union (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5599 p a g e 3 | 16 introduction in march 2020, the world health organization (who) declared the covid19 outbreak a pandemic. globally, the virus has cost more than five million lives, and infection rates have been continuously in flux since the first cases of the virus were reported (1,2). the contagiousness of the disease has confronted healthcare systems worldwide with the question of how to stop its spread most effectively (3). in the early stages of the pandemic, it quickly became apparent that the containment of the virus was nearly impossible without taking drastic measures. countries implemented mitigation and suppression strategies to slow down disease spread, such as social distancing and lockdowns (4–6). such strategies contributed to the overarching goal of flattening the curve, in which the number of cases is spread over a longer period of time to not overwhelm healthcare systems’ capacity and resources (2). however, it cannot be neglected that despite their effectiveness, such measures carried extensive economic costs and wideranging social and psychological costs. additionally, since their effectiveness depended heavily on individual adherence, standing alone, they were inadequate to contain the virus (7). therefore, the development of vaccines for covid-19 was anticipated with great interest as an effective strategy to end the pandemic and alleviate the above-mentioned burdens from nations and inhabitants (4). the health benefits of vaccinating against covid-19 include the reduction in mortality and morbidity for those most at risk. additionally, it reduces further cases and often averts severe disease cases. the economic benefits of vaccination include a reduction in treatment costs, fewer absenteeism rates in the workforce, and hopefully the expedition of a return to normal social and economic functioning (8). a recent study states that covid-19 vaccination for individuals above 60 years has already averted 469,000 deaths globally, highlighting the importance of vaccination in the ongoing pandemic (9,10). the european commission (ec) has declared covid-19 vaccines as the best way out of the pandemic, presupposing high vaccination rates (11). therefore, high availability of safe and effective vaccines in an equitable and timely manner is crucial (3,10). context the existence of vaccines does not mean that countries have the infrastructure and resources to effectively distribute them, nor that individuals will accept them. in the eu, access and availability failed to meet demand when vaccination campaigns started in march 2021. thus, despite the availability of the needed technology, the eu was and remains unable to distribute enough vaccines in an equitable way across its member states (ms) (12). the eu took a common approach in securing and facilitating distribution. presented in june 2020, the objectives of the vaccines strategy were to ‘accelerate the development, manufacturing and deployment of vaccines against covid-19’ (11). however, actions taken to meet the objectives have been widely criticized and were subject to much scrutiny (12,13). some of the flawed aspects of the strategy included, as stated by ec president von der leyen, being too optimistic regarding the ability to mass-produce vaccines, acting too late in granting authorization, and not preparing ms equally to distribute vaccines (12,14). moreover, lack of transparency, lengthy negotiation processes which ended only after a possible threat of monopolizing by the us, and suboptimal vaccine rollout with no regard to national capacities led to inequitable and less than timely access jagusiewicz a, uteh c, götz jp, robertz j, zijlman ma. centralized vaccine procurement in the postcovid-19 european union (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5599 p a g e 4 | 16 (12,14). the delay in procurement also led various groups to negotiate with manufacturers on their own (14). acknowledging the weaknesses of the vaccine strategy, the ec launched the european health emergency preparedness and response authority (hera) in september 2021 (11). it is a key pillar of the new european health union, aiming to fill gaps in the eu’s health emergency response and preparedness capabilities. hera combines the power of the european centre for disease prevention and control (ecdc) and the european medicines agency (ema), and it has already been challenged for having various flaws. for example, hera is not an independent agency, and key european institutions such as the european parliament are not involved. furthermore, according to the treaties (teu and tfeu), the eu only holds limited competency to actually translate hera’s vision into action. the pandemic has demonstrated that the current strategies to tackle health emergencies at the european level are insufficient. even though the development of hera could be a first step in the right direction, the accelerated momentum of the pandemic must be utilized to work towards a comprehensive strategy. therefore, the aim of this policy brief is to develop a new strategy for vaccine procurement in the eu, built upon and informed by previous strategies throughout the world. policy options in november 2020, the ec adopted the ‘pharmaceutical strategy for europe’. the initiative aims to ensure access to affordable medicines, enhance the crisis preparedness and response mechanisms, and diversify and secure supply chains whilst promoting a strong united eu voice in the world (15). yet, as witnessed during the pandemic, inefficiencies in the supply chain, procurement capacity constraints, and limited financial resources can hinder access to lifesaving medicines. to be well-prepared for the possible occurrence of similar scenarios as the covid-19 pandemic, we argue that a new, revised procurement strategy, which ensures equitable and timely access to vaccines for all, is needed. we consider centralized procurement, by aggregating demand, increasing bargaining power, and improving procurement management, as a useful tool to comprehensively address flaws in previous strategies. the who defines it as the combination of ‘several buyers into a single entity that purchases (...) on behalf of those buyers’ (13). figure 1 illustrates factors influencing the feasibility of a centralized procurement approach. based on the characteristics of different procurement models (as displayed in table 1), governments and organizations choose the best option for them. examples include informed buying, where only information on prices and suppliers is shared, or coordinated informed buying, where members additionally conduct joint market research. in the group contracting model, members enter joint negotiations with selected suppliers; however, the procurement can be done individually, in contrast to the central contracting and procurement scheme. some strategy choices are discussed below, focusing firstly on general procurement mechanisms and secondly on covid-19 specific procurement approaches, which provide the basis for the development of our conclusive recommendations. https://www.zotero.org/google-docs/?9g5cvx https://www.zotero.org/google-docs/?1kqhft jagusiewicz a, uteh c, götz jp, robertz j, zijlman ma. centralized vaccine procurement in the postcovid-19 european union (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5599 p a g e 5 | 16 table 1: swot analysis of possible collaboration information sharing models pooled procurement models informed buying coordinated informed buying group contracting central contracting and procurement characteristics information sharing on prices and suppliers procurement conducted individually information sharing on prices and suppliers procurement conducted individually joint market research joint price negotiations joint selection of suppliers procurement conducted individually joint tenders and contract awarding through a representative organization central procurement unit pools the resources and conducts the purchase on behalf of ms strengths least costly, less complex than joint procurement reduced administrative and horizon scanning costs reduction of risks associated with the choice of supplier savings due to bulk purchasing lower prices more efficient supply chain improved accountability, transparency, and costefficiency weaknesses lack of economies of scale factor may not contribute to lower price purchase complexity – requires a reliable governance system high setup cost opportunities development of standardized methods for manufacturers and medicine development assessments may contribute to further political integration improved international collaboration improved harmonization of the drug registration process improved reliability and accountability of suppliers pooled resources and expertise greater involvement of local manufacturers creation of a single market promotion of international trade threats unwillingness of ms to share the information limited impact of the reference pricing differing needs among member states lack of involvement of bigger ms lack of political will and commitment jagusiewicz a, uteh c, götz jp, robertz j, zijlman ma. centralized vaccine procurement in the postcovid-19 european union (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5599 p a g e 6 | 16 procurement pre-covid 19 prior to the pandemic, collaboration on procurement was utilized by international organizations such as the paho revolving fund and unicef (16–19). within europe, such activities before the pandemic were often justified by insufficient individual markets of the participating countries (20); this is particularly true for the procurement of small-volume products, such as orphan drugs and innovative medicine. appendix a provides an overview of european collaborations in place before the pandemic. however, such pre-existing structures were not equipped to deal with a large-scale health crisis like covid-19. centralized procurement eu however, during the pandemic, due to the scarce supplies, and state of emergency, many countries decided to cooperate on an unprecedented scale. governments were entering into advance purchase agreements (apas) with vaccine companies to secure access to vaccine doses. meaning they were committing to purchasing products that were yet to enter the market. most of these agreements were between private manufacturers and intergovernmental organizations (i.e., eu, covax, african union). the eu negotiated apas with vaccine manufacturers as part of their vaccination strategy (21). this followed an unusual approach as vaccines’ safety, quality, and efficacy were previously assessed at the eu level by the ema, while price negotiations and subsequent reimbursement decisions were commonly taken at the national level (22). the legal basis for pooling competencies at the eu level was the council regulation eu 2016/369 (23), which set up the emergency support instrument under the principle of solidarity to respond to the pandemic. figure 1 illustrates some of the general factors influencing centralized procurement embedded into the broader context of pandemic preparedness. it underlines the complex interplay of various factors. https://www.zotero.org/google-docs/?a6a7ts https://www.zotero.org/google-docs/?kmx0i7 https://www.zotero.org/google-docs/?cn1oqw https://www.zotero.org/google-docs/?izfykg https://www.zotero.org/google-docs/?epgl2q jagusiewicz a, uteh c, götz jp, robertz j, zijlman ma. centralized vaccine procurement in the postcovid-19 european union (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5599 p a g e 7 | 16 centralized procurement africa in africa, by february 2020, the africa joint continental strategy for covid-19 outbreak was adopted. managing the continental-level coordinated response required the leadership of the african cdc, which birthed two main operational units; the africa task force for coronavirus and africa cdc’s incident management system (24). to pool resources, strengthen the supply chain, and improve coordinated actions against covid-19, an african coronavirus fund was established, which has aided the au to procure and distribute essential medical equipment and supplies, thereby strengthening mobilization and response rates (24). procurement us to coordinate the acceleration of development, procurement, and distribution of pandemic countermeasures, the united states government started operation warp speed (ows) (25). this collaboration between the department of defense and the department of health and human services consisted of services like the center for disease control and prevention, the national institutes of health, and the biomedical advanced research and development authority (barda), which served as the basis for the development for its european counterpart hera. whilst the focus of ows included therapeutics and diagnostics, most financial resources were spent on developing vaccines (25). barda’s approximately 18 billion us dollar investment in various manufacturers made ows the greatest global effort to develop covid-19 vaccines (26). the vaccine tracking system by the cdc allowed states to place weekly orders, however, states had no say in which vaccines were delivered (27). centralized procurement covax globally, in april 2020, covid-19 vaccines global access (covax) was set up to ensure equitable access to covid-19 tests, treatments, and vaccines (28). covax has two modalities of participation. firstly, low and middle-income countries participate through the advance market commitment (amc) instrument (29). after confirming participation, supported by who and partners, countries develop national deployment and vaccination plans before signing indemnity and liability agreements. participants can request additional technical assistance and cold chain support. secondly, self-funded participants indicate the share of the population to be covered (10%-50%), whereupon covax negotiates and enters agreements with manufacturers on their behalf (30). countries then receive vaccines through optional or committed purchase arrangements, both requiring up-front payment. participating countries sequentially receive enough doses to cover 20% of the population. once all reach the 20% threshold, further doses are allocated according to vulnerability and risk criteria. a comprehensive overview of key mechanisms for the different procurement approaches can be found in table 2, whereas their swot analysis is presented in table 3. analysis the described policy options show a general tendency in international organizations and states to explore more centralized approaches to tackle emergency health crises. this trend in pooling further powers at the eu level becomes apparent in the recent call to establish a european health union. the pandemic has shown the need for timely and coordinated responses in the procurement of https://www.zotero.org/google-docs/?zadvqr https://www.zotero.org/google-docs/?sdpvbw https://www.zotero.org/google-docs/?1xbd3o https://www.zotero.org/google-docs/?wzfeuo https://www.zotero.org/google-docs/?ffgbgw https://www.zotero.org/google-docs/?ok4js0 https://www.zotero.org/google-docs/?jloamp https://www.zotero.org/google-docs/?dgvucl https://www.zotero.org/google-docs/?j6a2bh jagusiewicz a, uteh c, götz jp, robertz j, zijlman ma. centralized vaccine procurement in the postcovid-19 european union (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5599 p a g e 8 | 16 vaccines for the general population. table 3 highlights that the benefits of centralized procurement outweigh its shortcomings. equitable and timely access to vaccines in a transparent manner seems to be its core strength derived from the procurement policies. the lack of procurement legislation and limited financial resources seem to be recurring themes in the policies of paho, unicef, and covax, which hinder their effective use. additionally, the complexity of setting up such systems, currently one of the main challenges and contributions to a lackluster covid-19 response, could be overcome by utilizing the already high level of harmonization of the eu and involved institutions such as ema and the ecdc and potentially hera. questions as to the extent to which ms will give up autonomy over vaccine purchases might need to be clarified. to counter discordance, it should be considered to apply centralized procurement only in a health crisis through the emergency support instrument of the eu. we argue that the opportunities of centralized procurement presented in table 3 can be harnessed by the eu, while the threats can be overcome through already existing structures in the eu. the application of apas under a centralized procurement scheme in the eu demonstrated some pitfalls that must be addressed. extended price negotiations with vaccine manufacturers led to a delay in vaccine procurement. consequently, ms stopped relying on eu efforts to procure vaccines. the observed delays ultimately resulted in a shortfall in the number of vaccines available to eu residents. however, the eu was able to negotiate a price lower than the u.s., possibly attributing to a lengthier negotiation process (31). the formulated policy options built upon the pharmaceutical strategy for europe, which addresses crisis preparedness and securing supply chains in pharmaceutical products. the examples of centralized procurement given in section 3 shall guide the implementation of the eu procurement system. stakeholders improving eu vaccine procurement requires the involvement and alignment of various stakeholders. the ec, parliament, council of ministers, individual ms, and pharmaceutical industry hold high interest and power. the eu institutions would most likely favor a centralized procurement system as this can increase their negotiation power. on the other hand, pharmaceutical companies are less inclined to support a centralized procurement system as it potentially limits their influence on pricing. another challenge is aligning ms interests to agree on how this new procurement system should look. the integration of stakeholders with high interest but low power, for example, the ecdc, who, ema, and more, must also be regarded. considering the above analysis, the following recommendations were developed, aiming to produce comprehensive guidance on how to procure vaccines in a crisis through a pooling mechanism whilst aligning the majority of stakeholder interests. in anticipation of a future crisis, we want to generate fruitful cooperation and collaboration at all levels and across borders and act as an undivided eu. https://www.zotero.org/google-docs/?jew9ao jagusiewicz a, uteh c, götz jp, robertz j, zijlman ma. centralized vaccine procurement in the postcovid-19 european union (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5599 p a g e 9 | 16 table 2: policy option characteristics eu unicef´s supply division paho revolving fund operation warp speed covax amc covax facility au covid-19 response fund model central contracting and procurement central contracting and procurement group contracting n/a central contracting and procurement central contracting and procurement ownership eu member states unicef paho member states us government gavi, the coalition for epidemic preparedness innovations, who gavi, the coalition for epidemic preparedness innovations, who africa cdc financing mechanism emergency support instruments national budgets mainly donor funding, a few countries pay in full for the vaccine purchases + administrative fee (3-6%) national budgets (price of the vaccines + 3,5% recapitalization fee) national budget and additional funds allocated through barda mainly donor funding national governments donor funding procurement activities centralized centralized left to the states centralized centralized centralized centralized timeframe covid-19 pandemic permanent permanent 15.05.2020 – 24.02.2021 then responsibilities transferred to the white house covid-19 response team covid-19 pandemic covid-19 pandemic covid-19 pandemic range of products or services involved covid-19 vaccines routine vaccination vaccines, syringes, and related supplies covid-19 therapeutics, diagnostics, and vaccines covid-19 vaccines covid-19 vaccines covid-19 vaccines purchasing mechanism direct procurement: advance purchase agreement multi-year tender annual tender direct procurement: other transaction agreement direct procurement: advance market commitment direct procurement: optional/ committed purchase arrangements direct procurement: advance purchase agreement jagusiewicz a, uteh c, götz jp, robertz j, zijlman ma. centralized vaccine procurement in the postcovid-19 european union (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5599 p a g e 10 | 16 table 3: swot overview of procurement policies strengths weaknesses opportunities threats eu higher negotiation power compared to single member states (lower pharmaceutical prices) ensures access to promising vaccines in a timely manner for all ms risk-sharing between the pharmaceutical manufacturers and the eu transparency of the negotiated conditions exploration of more centralized and multinational efforts to purchase and distribute medicinal products apas cause the possibility of purchasing ineffective or unsafe vaccines, or vice versa risk of a pharmaceutical contractor not adhering to predetermined conditions unicef provides equitable and efficient access to vaccines resource pooling ensures equal access for ms guided by an experienced partner initial capitalization and management of funds national procurement legislation lower unit prices, eventually generating cost savings greater stability in vaccine supplies reporting and evaluation according to harmonized external standards rather than national ones reliance on external bodies (a risk that country capacities will not be developed accordingly, creating a long-term dependence on external bodies) paho global recognition of paho high level of accountability promoting equity and encouragement of collaboration between local agencies limited financial resources very bureaucratic and rigid in processes partnerships for resource mobilization ms unable to meet the annual requirements for the revolving funds financial and operational stability of the ms us guarantee of enough vaccines for the citizens of the us other countries were also able to close deals with the vaccine manufacturers and had more vaccine doses per capita than the us ordering system for vaccinations can be seen as an example of a system for the eu states have no say in which vaccines will be delivered, causing relegation of the vaccines covax amc & facility expertise of partners (translating into broad manufacturer portfolios and strong bargaining power) insufficient funding severe demand-supply gap lack of transparency in concluded contracts promotion of health equity and the benefits of multilateralism vaccine hoarding in high-income countries few countries offer vaccine donations (if so, they often arrive last-minute and in small numbers) slow process, leading participants to enter into bilateral agreements undermining covax efforts african union aid in the procurement and distribution of essential covid-19 medical equipment and supplies reinforcement of au ms response to the covid-19 challenge vaccine shortage low vaccination rates legal, operational, and institutional autonomy of the africa cdc from the african union commission sustained close collaboration at the national, regional, and continental levels encouraging vaccine manufacturing on the african continent delays in accessing covid-19 vaccines jagusiewicz a, uteh c, götz jp, robertz j, zijlman ma. centralized vaccine procurement in the postcovid-19 european union (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5599 p a g e 11 | 16 recommendations the discussed policy options demonstrated the necessity of establishing a designated institution charged with the ownership and control of a centralized crisis response, which presents an entirely independent body (hereinafter referred to as the institution) as opposed to the recently developed hera under the ec. this allows the institution to act detached from other key eu players. its mandate must ensure not only transparent negotiations and timely access to vaccines but also establish continuous efforts and support to strengthen national capacities and healthcare systems through periodic monitoring and evaluation. this guarantees that when vaccinations are procured, ms are equipped to utilize them efficiently according to national needs. the institution shall function as the overarching and coordinating emergency response body and, more specifically, should build on the approach of centralized procurement taken by the eu in the covid-19 pandemic, of which advantages have been discussed above. since health is a ms competence, this strategy requires ensuring that ms interests are aligned, to then be transferred to the supranational level. it is apparent that such an endeavor requires will and political commitment. therefore, the momentum created by the covid-19 pandemic must be utilized to bring together european institutions, ms, and relevant stakeholders, to initiate negotiations that will facilitate the streamlining of interests. such congregations create room for copious deliberation, helping all parties to agree on the institution's exact scope and modus operandi. similarly to hera, the institution must aim to collaborate closely with the ecdc and ema, incorporating their advice in the development of the pandemic response. regular meetings with representatives of all three institutions, preand during a pandemic, allow for monitoring of disease threats and medicinal products. a sufficient amount of resources must be invested to set up a resilient technical infrastructure that allows for continuous data sharing. this data exchange provides an evidence base for the institution's negotiations with vaccine manufacturers. widely criticized in the covid-19 was the lack of transparency. hence, content of negotiation processes should be made available to citizens in an easily accessible, comprehensive manner, on a designated part of the institution's website. since public money is spent, we need to be aware of agreements made at the supranational level. the existence of comprehensive and efficient emergency preparedness plans which enable ms to effectively respond to and manage future pandemics must be ensured, as this allows strategies, such as the abovementioned centralized procurement, to function smoothly. to sustain emergency preparedness across the eu, adequate resources need to be dedicated toward interdisciplinary proactive pandemic preparedness and response planning, following the cycle depicted in figure 1. common standards for participating countries shall be developed, adhered to by participating ms, transferring competencies to the eu, where insufficient national capacities to respond to a pandemic are present. there is an urgent need to evaluate ms infrastructure and pandemic response to identify shortcomings. once identified, the institution can direct resources and support towards ms in greatest need. as the name entails, a pandemic affects the whole world. covid-19 has distinctly demonstrated how interconnected the globe is, where european public health is highly influenced by global public health. jagusiewicz a, uteh c, götz jp, robertz j, zijlman ma. centralized vaccine procurement in the postcovid-19 european union (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5599 p a g e 12 | 16 therefore, it should not be neglected that the eu must internally strengthen the centralized approach and further foster international partnerships to promote timely and swift emergency responses, comprehensive information, and evidence sharing, all helping to mitigate international public health emergencies. conclusion in conclusion, vaccine procurement policies in the eu hold great potential for improvement. during covid-19, the lack of transparency in lengthy negotiation processes, and lack of unity and solidarity were considered problematic. by setting up a centralized procurement mechanism under a novel independent body for emergency and pandemic response, the procurement of vaccines in a future health crisis will run smoothly. embedding this in elaborate emergency preparedness planning, the eu will be able to react timely and in ms and citizens’ best interest. references 1. johns hopkins university & medicine. covid-19 map [internet]. johns hopkins coronavirus resource center. [cited 2021 dec 6]. available from: https://coronavirus.jhu.edu/map.html 2. who thailand. coronavirus disease 2019 (covid-19) who thailand situation report [internet]. 2020 mar [cited 2021 dec 6]. available from: https://www.who.int/docs/defaultsource/searo/thailand/2020-03-19tha-sitrep-26covid19.pdf?sfvrsn=6f433d5e_2 3. chung jy, thone mn, kwon yj. covid-19 vaccines: the status and perspectives in delivery points of view. adv drug deliv rev. 2021 mar;170:1–25. 4. girum t, lentiro k, geremew m, migora b, shewamare s, shimbre ms. optimal strategies for covid19 prevention from global evidence achieved through social distancing, stay at home, travel restriction and lockdown: a systematic review. arch public health. 2021 dec;79(1):150. 5. saez m, tobias a, varga d, barceló ma. effectiveness of the measures to flatten the epidemic curve of covid-19. the case of spain. sci total environ. 2020 jul 20;727:138761. 6. abouk r, heydari b. the immediate effect of covid-19 policies on social distancing behavior in the united states [internet]. 2020 apr [cited 2021 dec 6] p. 2020.04.07.20057356. available from: https://www.medrxiv.org/content/10. 1101/2020.04.07.20057356v2 7. moosa ia. the effectiveness of social distancing in containing covid-19. appl econ. 2020 dec 13;52(58):6292–305. 8. bloom de, cadarette d, ferranna m. the societal value of vaccination in the age of covid19. am j public health. 2021 jun 1;111(6):1049–54. 9. meslé mm, brown j, mook p, hagan j, pastore r, bundle n, et al. estimated number of deaths directly averted in people 60 years and older as a result of covid-19 vaccination in the who european region, december 2020 to november 2021. eurosurveillance. 2021 nov 25;26(47):2101021. 10. randolph he, barreiro lb. herd immunity: understanding covid jagusiewicz a, uteh c, götz jp, robertz j, zijlman ma. centralized vaccine procurement in the postcovid-19 european union (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5599 p a g e 13 | 16 19. immunity. 2020 may 19;52(5):737–41. 11. european commission. eu vaccines strategy [internet]. european commission european commission. [cited 2021 dec 6]. available from: https://ec.europa.eu/info/live-worktravel-eu/coronavirusresponse/public-health/eu-vaccinesstrategy_en 12. hyde r. von der leyen admits to covid-19 vaccine failures. lancet lond engl. 2021;397(10275):655–6. 13. the world bank, gavi alliance. brief 12: the vaccine market pooled procurement [internet]. 2010 [cited 2021 dec 6]. available from: https://www.who.int/immunization/p rogrammes_systems/financing/analy ses/brief_12_pooled_procurement.p df 14. deutsch j, wheaton s. how europe fell behind on vaccines. politico [internet]. 2021 jan 27 [cited 2021 dec 6]; available from: https://www.politico.eu/article/europ e-coronavirus-vaccine-strugglepfizer-biontech-astrazeneca/ 15. european commission. a pharmaceutical strategy for europe [internet]. public health european commission. 2020 [cited 2021 dec 5]. available from: https://ec.europa.eu/health/humanuse/strategy_en 16. dubois p, lefouili y, straub s. pooled procurement of drugs in low and middle-income countries. eur econ rev. 2021 feb 1;132:103655. 17. paho. paho revolving fund paho/who | pan american health organization [internet]. [cited 2021 dec 6]. available from: https://www.paho.org/en/revolvingfu nd 18. deroeck d, bawazir sa, carrasco p, kaddar m, brooks a, fitzsimmons j, et al. regional group purchasing of vaccines: review of the pan american health organization epi revolving fund and the gulf cooperation council group purchasing program. int j health plann manage. 2006;21(1):23–43. 19. unicef supply division. scaling vaccine procurement [internet]. [cited 2021 dec 6]. available from: https://www.unicef.org/supply/storie s/scaling-vaccine-procurement 20. vogler s, haasis ma, van den ham r, humbert t, garner s, suleman f. european collaborations on medicine and vaccine procurement. bull world health organ. 2021 oct 1;99(10):715–21. 21. european commission. eu strategy for covid-19 vaccines [internet]. 2020 [cited 2021 dec 6]. available from: https://eur-lex.europa.eu/legalcontent/en/txt/?uri=celex%3a5 2020dc0245 22. european medicines agency. authorisation of medicines [internet]. european medicines agency. 2018 [cited 2021 dec 6]. available from: https://www.ema.europa.eu/en/about -us/what-we-do/authorisationmedicines 23. the council of the european union. council regulation (eu) 2016/ 369 of 15 march 2016 on the provision of emergency support within the union. official journal of the european union. :6. 24. african union. africa’s governance response to covid-19 [internet]. 2020 [cited 2021 dec 6]. available jagusiewicz a, uteh c, götz jp, robertz j, zijlman ma. centralized vaccine procurement in the postcovid-19 european union (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5599 p a g e 14 | 16 from: https://au.int/sites/default/files/docu ments/38893-doccovid_19_final_english.pdf 25. siddalingaiah sv. operation warp speed contracts for covid-19 vaccines and ancillary vaccination materials. congressional research service. 2021 mar 1;4. 26. kim jh, hotez p, batista c, ergonul o, figueroa jp, gilbert s, et al. operation warp speed: implications for global vaccine security. lancet glob health. 2021 jul 1;9(7):e1017– 21. 27. cdc. covid-19 vaccination [internet]. centers for disease control and prevention. 2020 [cited 2021 dec 6]. available from: https://www.cdc.gov/coronavirus/20 19-ncov/vaccines/distributing.html 28. usher ad. covid-19 vaccines for all? the lancet. 2020 jun 13;395(10240):1822–3. 29. gavi covax amc [internet]. [cited 2021 dec 5]. available from: https://www.gavi.org/gavi-covaxamc 30. who. covax facility explainer [internet]. 2021 sep [cited 2021 dec 5]. available from: https://www.who.int/publications/m/i tem/covax-facility-explainer 31. dyer o. covid-19: countries are learning what others paid for vaccines. bmj. 2021 jan 29;372:n281. 32. jaime espín, joan rovira, antoinette calleja, natasha azzopardi-muscat, erica richardson, willy palm, et al. policy brief 21: how can voluntary cross-border collaboration in public procurement improve access to health technologies in europe? [cited 2021 dec 7]; available from: https://www.euro.who.int/__data/ass ets/pdf_file/0009/331992/pb21.pdf %3fua%3d1 jagusiewicz a, uteh c, götz jp, robertz j, zijlman ma. centralized vaccine procurement in the postcovid-19 european union (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5599 p a g e 15 | 16 appendices appendix a table 1: european collaborations in the procurement of health technologies start date countries involved scope aspects of procurement covered central eastern european and south eastern european countries initiative november 2016 romania, bulgaria, croatia, latvia, poland, serbia, slovakia, slovenia, republic of moldova, fyr macedonia pharmaceuticals price negotiation southern european initiative june 2016 greece, bulgaria, spain, cyprus, malta, italy, portugal innovative medicines information sharing on prices and markets, collaboration on r&d declaration of sofia june 2016 bulgaria, croatia, estonia, hungary, latvia, fyr macedonia, romania, serbia, slovakia, slovenia pharmaceuticals information sharing on prices and markets, with potential for joint purchasing in the future nordic pharmaceuticals forum june 2015 denmark, iceland, norway, sweden pharmaceuticals horizon scanning, information sharing on prices and markets romanian and bulgarian initiative june 2015 romania, bulgaria innovative medicines joint negotiations in purchasing to get lower prices for pharmaceuticals and cross-border exchange of medicines in short supply to ensure continuity of access beneluxa april 2015 belgium, netherlands, luxembourg, austria pharmaceuticals and medical devices hta, horizon scanning, information sharing on prices and markets, joint negotiation for purchasing to ensure affordability baltic partnership agreement may 2012 latvia, lithuania, estonia innovative medicines centralized joint purchasing (tenders, negotiation, payment, and distribution) to reduce expenditure and ensure continuity of access adapted from (32) jagusiewicz a, uteh c, götz jp, robertz j, zijlman ma. centralized vaccine procurement in the postcovid-19 european union (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5599 p a g e 16 | 16 _________________________________________________________________________ © 2021 jagusiewicz et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. kalaitzi v. the mark of women’s leadership on solutions to global health problems (editorial). seejph 2016, posted: 07october2016. doi: 10.4119/unibi/seejph-2016-131 1 editorial the mark of women’s leadership on solutions to global health problems valia kalaitzi 1 1 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life science, maastricht university, maastricht, the netherlands. corresponding author: valia kalaitzi, msc, phdc; address: 25 vas sofias, 10674 athens greece; telephone: +30 6932285055; e-mail: valiakalaitzi@maastrichtuniversity.nl kalaitzi v. the mark of women’s leadership on solutions to global health problems (editorial). seejph 2016, posted: 07october2016. doi: 10.4119/unibi/seejph-2016-131 2 “man is the measure of all things”, stated protagoras in 485 bc (1). maybe it’s time to add women to that equation and adapt protagoras’ saying into:“women who are leaders are the measure of global health challenges”. what protagoras meant, of course, was that man is the point of reference, the centre of universe; he adjusts his world to fit his needs. in other words, man has the ability to shape his living conditions, the environment and solutions to the challenges in life. in that sense, the challenges are managed according to the terms and conditions of man. indeed, global health challenges of the 21 st century are widespread. they are many, and they are of great magnitude. world health leaders are challenged by crises such as polio, zika virus, and h1ni, to mention a few. many health systems around the world have been challenged to respond effectively to these crises, spotlighting major gaps in worldwide surveillance, disease control, resources, and infrastructure required to protect and support the public’s health. the economic crisis that affected europe has been linked to several infectious disease outbreaks including tb and hiv, compounded by recent waves of migration, although the links between these events remain unclear (2). debates ensue about the value and feasibility of universal health coverage, the increasing role of the private sector in the global health landscape and the subsequent changing roles of global health actors that shape the new health economy. these are complex times, and they require skilful players if we hope to translate public and private sector investments in health into both economic growth and equitable improvements in health. such goals require inspired, inclusive, and effective leadership. these very traits are the hallmark of women’s leadership. women have been observed to possess certain traits and characteristics that may accelerate effective and sustainable solutions to challenging global health problems. it is widely accepted that women who are leaders act as a normative agent of change and developmental processes (3-8). they practice people-centred, inclusive leadership and balance strategic priorities with collective dynamics. in this regard, they may exhibit greater mastery as compared to men in relation to key competencies required to make progress. one may argue that we experience a collision of worlds in respect of the old and the new tradition of gender-based roles in global health governance, and the implications for our freshly made, globalized world. however, the balance of global gender roles in our contemporary world is the outcome of politics and power. that balance can be changed to benefit global health. if the collective political community “aims at some good and the community which has the most authority of all and includes all the others aims highest”(9), then, our current, turbulent suffering societies expect global leaders to practice the quality of leadership as described by plato (10). that form of leadership combines the following components:  wisdom, as the knowledge of the whole including both knowledge of the self and political prudence;  civic courage, in the sense of preserving rights and standing in defence of such values as friendship and freedom on which a good society is founded, and;  moderation, a sense of the limits that bring peace and happiness to all. global health leadership falls behind in providing the opportunities and motivation to female leaders to unfold their talents and give their touch to new health challenges. the huge reservoir of talented women remains mostly untapped. the transformative attributes of female leaders to create opportunities out of a web of complexity, to promote systematic preparedness and to create a starting point for change out of chaos have been underestimated and sacrificed to stereotypes and social constraints. kalaitzi v. the mark of women’s leadership on solutions to global health problems (editorial). seejph 2016, posted: 07october2016. doi: 10.4119/unibi/seejph-2016-131 3 of course, numerous notable initiatives have been introduced; important foundations have been established and contribute considerably towards this end. nonetheless, the relative lack of women who are leaders in top decision-making positions in global health should be looked upon like a well-diagnosed, but mistreated disease. what kind of politicians and leaders do we need to provide the proper room for experiencing the mark of women on global health challenges? maybe politicians and decision-makers should be wise enough to adapt the saying of protagoras (1). from now on, let’s call loudly for women who are leaders to be “the measure of global health challenges”! conflicts of interest: none. references 1. sholarin ma, wogu iap, omole f, agoha be."man is the measure of all things": a critical analysis of the sophist conception of man. res human socsci2015;5:178-84. 2. kentikelenis a, karanikolos m, williams g, mladovsky p, king l, pharris a, et al. how do economic crises affect migrants’ risk of infectious disease? a systematicnarrative review.eur j public health 2015;25:937-44. doi:10.1093/eurpub/ckv151. 3. eaglyah, chin jl. diversity and leadership in a changing world. am psychol2010;65:216-24. doi: 10.1037/a0018957. 4. northouse pg.leadership: theory and practice (5 th ed.). sage publications; 2010. 5. silverstein m, sayre k. the female economy. harvard business review2009;87:4653. https://hbr.org/2009/09/the-female-economy (accessed: october 5, 2016). 6. mckinsey global institute. the power of parity: how advancing women’s equality can add $12 trillion to global growth;2015. http://www.mckinsey.com/globalthemes/employment-and-growth/how-advancing-womens-equality-can-add-12trillion-to-global-growth (accessed: october 5, 2016). 7. world economic forum. the global gender gap report; 2014. http://reports.weforum.org/global-gender-gap-report-2014/(accessed: october 5, 2016). 8. world health organization. health in 2015 from sdgs to mdgs; 2015. http://apps.who.int/iris/bitstream/10665/200009/1/9789241565110_eng.pdf(accessed: october 5, 2016). 9. aristotle. political theory. stanford encyclopedia of philosophy (online). http://plato.stanford.edu/entries/aristotle-politics/#polview (accessed: october 5, 2016). 10. plato. political philosophy. internet encyclopedia of philosophy (online). http://www.iep.utm.edu/platopol/ (accessed: october 5, 2016). __________________________________________________________ © 2016 kalaitzi; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.ncbi.nlm.nih.gov/pubmed/?term=kentikelenis%20a%5bauthor%5d&cauthor=true&cauthor_uid=26318852 https://www.ncbi.nlm.nih.gov/pubmed/?term=karanikolos%20m%5bauthor%5d&cauthor=true&cauthor_uid=26318852 https://www.ncbi.nlm.nih.gov/pubmed/?term=williams%20g%5bauthor%5d&cauthor=true&cauthor_uid=26318852 https://www.ncbi.nlm.nih.gov/pubmed/?term=mladovsky%20p%5bauthor%5d&cauthor=true&cauthor_uid=26318852 https://www.ncbi.nlm.nih.gov/pubmed/?term=king%20l%5bauthor%5d&cauthor=true&cauthor_uid=26318852 https://www.ncbi.nlm.nih.gov/pubmed/?term=pharris%20a%5bauthor%5d&cauthor=true&cauthor_uid=26318852 https://www.ncbi.nlm.nih.gov/pubmed/?term=how+do+economic+crises+affect+migrants%e2%80%99+risk+of+infectious+disease%3f+a+systematic-narrative+review la torre g, dorelli b, lia l, grassucci d, gelardini m, ardizzone c, et al. smoking e-cigarette and heat-not-burn products: the secrhet study, a large observational survey among young people in italy (original research). seejph 2021, posted: 26 december 2021. doi: 10.11576/seejph-5043 p a g e 1 | 15 original research smoking e-cigarette and heat-not-burn products: the secrhet study, a large observational survey among young people in italy giuseppe la torre1, barbara dorelli1, lorenza lia1, daniele grassucci2, marcello gelardini2, carla ardizzone2, maria caterina grassi3, alice mannocci4 1 department of public health and infectious diseases, sapienza university, rome, italy; 2 skuola.net; 3 department of physiology and pharmacology “v. erspamer”, sapienza university, rome, italy; 4 universitas mercatorum, rome, italy. corresponding author: giuseppe la torre address: department of public health and infectious diseases, sapienza university, rome, italy; telephone: +39.06.49694308; email: giuseppe.latorre@uniroma1.it la torre g, dorelli b, lia l, grassucci d, gelardini m, ardizzone c, et al. smoking e-cigarette and heat-not-burn products: the secrhet study, a large observational survey among young people in italy (original research). seejph 2021, posted: 26 december 2021. doi: 10.11576/seejph-5043 p a g e 1 | 15 abstract aim: electronic cigarettes (ecig) and heated tobacco products (htp), that heat a solution (eliquid) to create vapour and tobacco at a temperature below the point of combustion, respectively, are emerging forms of smoking device widely diffused. the aim of this study was to investigate knowledge, attitudes and behaviour toward htp among young people in italy. methods: the smoking e-cigarette and heat-not-burn products (secrhet) study was an online survey carried out in april 2019 using the platform skuola.net, a platform where 2.5 million students are registered. questions were related to knowledge about new generation smoking products, such as “do you know what happens to tobacco when you use a heat-notburn product?”, “do you think electronic cigarettes create addiction?”, “are products that use heated tobacco harmful to health?”, “are electronic cigarettes harmful to health?”, “have you ever heard of products that use heated tobacco?”, “is nicotine present in products that use heated tobacco?” results: a total of 13882 people completed the questionnaire, of which 8056 (58%) were females. regarding smoking habits, 3393 (24.4%) declared to be current cigarette smokers, while 802 (5.8%) and 3173 (22.9%) were current and former e-cigarette smokers, respectively. moreover, 715 (5.2%) and 1148 (8.3%) declared to be current and former heat-notburn cigarette smokers. the variables associated to both ecig and htp use were current smoking, age over 18 years, male gender, and residence in central and southern regions. concerning knowledge issues, almost half of respondents believe that electronic cigarettes are addictive and are harmful to health. moreover, most of respondents do not know what happens to tobacco when using a heated tobacco device and if heated tobacco products are harmful to health. conclusion: the prevalence of ecig and htp use is higher among young people in italy compared to adults and older people, and requires adequate public health interventions. keywords: electronic cigarettes, heat not burn tobacco products, italy, smoking, young people. conflicts of interest: none declared. funding: this research received no external funding. acknowledgments: the authors are grateful to the personnel of skuola.net. la torre g, dorelli b, lia l, grassucci d, gelardini m, ardizzone c, et al. smoking e-cigarette and heat-not-burn products: the secrhet study, a large observational survey among young people in italy (original research). seejph 2021, posted: 26 december 2021. doi: 10.11576/seejph-5043 p a g e 2 | 15 introduction new next generation nicotine-containing products, i.e. electronic cigarette (ecig) and partial tobacco combustion devices (heat tobacco products, htps, sometimes referred to by the tobacco industry as heat not burn, hnb), are widely used at the international level with a current use ranged from 0% in zambia to 17.2% in england (1), in particular among adolescents and young people (2). in italy, 1.4% of the population aged ≥15 years tried htp in 2017. more specifically, 1.0% of never-smokers, 0.8% of ex-smokers and 3.1% of current cigarette smokers had tried htp, and 2.5% and 2.8% were current or former e-cigarette smokers (3). the evidence on health implications and safety reported in the scientific literature is not conclusive. concerning the use of ecig, a systematic review carried out in 2014 highlighted that no firm conclusions can be drawn on their safety, and it is difficult to consider them harmless (4). e-cigarettes do not contain tobacco and their liquid is heated so there is no partial combustion. a united kingdom (uk) government review concluded that ecigarettes are 95% less harmful then smoking (5). moreover, there is inconsistent scientific evidence on the health risk characterization that is linked to the use of ecig (6). a more recent systematic review underlined that the passive exposure to ecig vapour has the potential to cause adverse health effects in bystanders (7). htp products produce lower levels of toxic chemicals, even if not considered risk-free (8). however, htps, unlike e-cigarettes, contain tobacco which has many harmful chemicals and may include some partial combustion which makes chemicals more harmful (9). htps may reduce exposure to some harmful chemicals but, as they are new products, it is not known whether they reduce the risk of disease (10). in this context, many health authorities and scientific societies have raised questions concerning safety issues and effectiveness for smoking cessation of next generation products (11). nevertheless, little is known concerning the use of these devices among the youth population. the global youth tobacco survey conducted in italy estimated e-cigarettes' vaping prevalence among adolescents aged 13–15 and found that use doubled between 2010 and 2018 for both boys (11.0-21.9%) and girls (5.9-12.8%) (12). in this framework, the aims of this study were: i) to assess knowledge, attitudes and behaviour toward htps among young people in italy, and; ii) to assess the prevalence and selected correlates of htp. methods study design and participants an online self-administered anonymous survey was carried out, using a questionnaire (appendix 1) previously validated (13), between april 5th and 12th 2019, using the website of “skuola.net”, an italian network for information and insights for high school and university students (5 million visits per month and 2.5 million students registered). during this week, the students and other young people not attending school or university but registered on the website had the opportunity, on a voluntary basis and free of charge, to complete the survey by answering the questionnaire through a dedicated link published on the homepage (www.skuola.net). hence, the sample for this survey was self-selected and therefore non probabilistic, avoiding the use of protocols to quantify invitations and response rates, as suggested by the american association for public opinion research (aapor) reporting guideline (14). la torre g, dorelli b, lia l, grassucci d, gelardini m, ardizzone c, et al. smoking e-cigarette and heat-not-burn products: the secrhet study, a large observational survey among young people in italy (original research). seejph 2021, posted: 26 december 2021. doi: 10.11576/seejph-5043 p a g e 3 | 15 the questionnaire a. the questionnaire was divided into four main sections for a total of twenty items: – the first section was on demographic characteristics (age, gender, region of residence, type of school); – the second part was related to the lifestyle and to the personal relationship with smoking (“do you practice sports?”, “in your family, except you if you are a smoker, does someone smoke?”, “how many times have you smoked in the last 30 days?”, “have you ever vaped electronic cigarettes?”, “have you ever used heat-not-burn products (hnb)?”); – the third part concerned knowledge about next generation products (“do you know what happens to tobacco when you use a heat-not-burn product?”, “do you think electronic cigarettes create addiction?”, “are products that use heated tobacco harmful to health?”, “are electronic cigarettes harmful to health?”, “have you ever heard of products that use heated tobacco?”, “is nicotine present in products that use heated tobacco?”); – the fourth section was concerning measures of susceptibility established for hnb (“if one of your best friends were to offer you a heat tobacco product, would you try it?”, “would you recommend using products that use heated tobacco to a person who wants to stop smoking?”). students were classified as non-smokers if they answered “never” to the question “how many times have you smoked in the last 30 days?” and smokers in all other cases. regarding the questions “have you ever vaped electronic cigarettes?” and “have you ever used heat-not-burn products?”, students could choose one of the following answers: never; occasionally (i emptied less than 50 electronic cigarettes/hnb in my life); formerly (i’ve emptied at least 50 electronic cigarettes/hnb in my life but i haven’t done it for at least 30 days); habitually (i have emptied at least 50 electronic cigarettes/hnb in my life including the last 30 days). based on their answers, students were classified as non-smokers (never), former smokers (occasionally and in the past) and smokers (habitually). statistical analysis the descriptive analysis of categorical variables consisted of absolute frequencies and percentages. differences between groups for percentages of categorical variables were tested using the chi-square test. moreover, four logistic regression models were computed, estimating odds ratios (ors) with 95% confidence intervals (95% cis): the dependent variable in the models was each question concerning current and ever use of ecig and htp, and the independent variables were age, sex, type of school, geographic area and traditional tobacco smoking. possible interactions between demographics and smoking status were tested in the multivariate analysis. multicollinearity was checked using a matrix of correlation coefficients. due to the non probabilistic sampling, the analysis was weighted using a frequency variable derived from age and gender distribution of the sample. the overall goodness of fit for the multivariable-adjusted models was checked using the hosmer-lemeshow test. the statistical significance was set at p≤0.05. the statistical analysis was carried out using ibm spss for windows (statistical package for the social sciences, version 25; spss, inc., chicago, il). results description of the study sample 15149 students took part in the survey and a total of 13882 people completed the questionnaire (completeness rate 91.6%), of which 8056 (58%) were females and 5552 (40%) were males. the distribution of sociodemographic characteristics (age, attended la torre g, dorelli b, lia l, grassucci d, gelardini m, ardizzone c, et al. smoking e-cigarette and heat-not-burn products: the secrhet study, a large observational survey among young people in italy (original research). seejph 2021, posted: 26 december 2021. doi: 10.11576/seejph-5043 p a g e 2 | 15 school, regional macroarea) of the sample is shown in table 1. table 1. selected demographics characteristics of the respondents variables n=13882 (%) italian census data (%)* gender female 8056 (58) 48.7 male 5552 (40) 50.3 age, years 11-13 1619 (11.7) 14-15 3232 (23.3) 8.9 16-17 3457 (24.9) 8.8 18-19 2500 (18.0) 9.1 20-21 579 (4.2) 9.2 22-23 309 (2.2) 9.2 24-25 440 (3.2) 9.3 >25 1746 (12.6) 45.5 attended school junior high school 2700 (19.7) senior high school 8351 (61.0) university 1165 (8.5) not attending school/university 1471 (10.7) macroarea of italy north 5950 (43.4) 47.4 center 3143 (22.9) 22 south 4628 (33.7) 30.6 * data from giovani. stat, updated to 2020. regarding smoking habits, 3393 (24.4%) declared to be current cigarette smokers, while 802 (5.8%) and 3173 (22.9%) were current (at least 50 electronic cigarettes in their life including the last 30 days) and former (less than 50 electronic cigarettes in their life or at la torre g, dorelli b, lia l, grassucci d, gelardini m, ardizzone c, et al. smoking e-cigarette and heat-not-burn products: the secrhet study, a large observational survey among young people in italy (original research). seejph 2021, posted: 26 december 2021. doi: 10.11576/seejph-5043 p a g e 2 | 15 least 50 electronic cigarettes in their life but never done it for at least 30 days) e-cigarette smokers. moreover, 715 (5.2%) and 1148 (8.3%) declared to be current and former heat-not-burn cigarette smokers based on the same response modalities as electronic cigarettes. 269 (1.9%) were simultaneously ecigarette and heat-not-burn smokers. univariate analysis – knowledge questions five questions concerned knowledge about next generation products. to question “do you think electronic cigarettes are addictive?” answered yes especially respondents aged under 18 (48.4%), females (48.0%), smokers (48.9%), middle school students (51.5%) and people from north of italy (48.8%) (table 2). similar results came from question 2 “are electronic cigarettes harmful to health?”. to the remaining questions, “do you know what happens to tobacco when using a heated tobacco device?”, “is nicotine contained in heated tobacco products?” and “are heated tobacco products harmful to health?”, most of the participants answered “i don't know” (table 2). univariate analysis – behaviour questions three questions concerned behaviour. about question “have you ever vaped electronic cigarettes?” answered never most respondents aged under 18 (75.6%), females (75.8%), those who practiced physical activity (72.1%), current smokers (83.7%), who attending middle school (87.1%) and was from north of italy (73.1%) (table 3). about question “have you ever used heated tobacco products?” 4796 (86.4%) males, 7103 (88.2%) females, 6504 (89.3%) who practiced physical activity and 5515 (83.6%) who did not practiced, 9632 (93.8%) current smokers, 2546 (94.3%) who attending middle school, 7432 (89.0%) who attending high school, 905 (77.7%) who attending university, 1056 (71.8%) who not attending any school, 5347 (89.9%) from north, 2649 (84.3%) from center, 3962 (85.6%) from south, 5247 (81.7%) with family smokers and 6772 (90.8%) without family smokers say that they have never used those products. about the question “if you have never used these products, would you try them?” 6430 (83.7%) males, 3591 (82.3%) females, 5515 (84.8%) who practiced physical activity and 4506 (81.3%) who did not practiced, 8497 (88.1%) current smokers, 2219 (87.0%) who attending middle school, 6104 (82.1%) who attending high school, 774 (85.5%) who attending university, 866 (80.8%) who not attending any school, 4401 (82.9%) from north, 2230 (84.1%) from center, 3299 (83.1%) from south, 4217 (80.0%) with family smokers and 5804 (85.7%) without family smokers answered no (table 3). multivariate analysis the logistic regression analysis revealed different results for current and ever e-cigarette or hnb smokers (table 4). being current cigarette smoker was the strongest predictors of both current e-cigarette (or = 7.95; 95%: 7.93 – 7.97) and hnb smokers (or = 6.41; 95%ci: 6.39 – 6.43). being male and aged more than 18 were predictors of both current e-cigarette and hnb smokers. concerning the attended school, interestingly, junior high school students showed higher odds of both being current e-cigarette and hnb smokers compared to senior high school students. moreover, higher odds were also for university students and young people not attending school. la torre g, dorelli b, lia l, grassucci d, gelardini m, ardizzone c, et al. smoking e-cigarette and heat-not-burn products: the secrhet study, a large observational survey among young people in italy (original research). seejph 2021, posted: 26 december 2021. doi: 10.11576/seejph-5043 p a g e 7 | 15 table 2. univariate analysis (knowledge questions) variables do you think electronic cigarettes are addictive? are electronic cigarettes harmful to health? do you know what happens to tobacco when using a heated tobacco device? is nicotine contained in heated tobacco products? are heated tobacco products harmful to health? yes n (%) no n (%) i don’t know n (%) yes n (%) no n (%) i don’t know n (%) right answer n (%) wrong answer n (%) i don’t know n (%) yes n (%) no n (%) i don’t know n (%) yes n (%) no n (%) i don’t know n (%) 6405 (46.8) 2646 (19.3) 4633 (33.9) 6875 (50.3) 2240 (16.4) 4549 (33.3) 2619 (19.2) 2298 (16.8) 8748 (64) 5288 (38.8) 757 (5.6) 7593 (55.6) 638 (4.7) 7143 (52.3) 5871 (43) age <18 years 3990 (48.4) 1600 (19.3) 2650 (32.2) 4303 (51.8) 1425 (17.2) 2515 (30.3) 1348 (16.3) 1369 (16.6) 5546 (67.1) 3174 (38.5) 360 (4.4) 4718 (57.2) 278 (3.4) 4603 (55.8) 3368 (40.8) ≥ 18 years 2415 (44.4) 1046 (19.2) 1983 (36.4) 2572 (46.1) 815 (14.6) 2034 (36.5) 1271 (23.5) 929 (17.2) 3202 (59.3) 2114 (39.2) 397 (7.4) 2875 (53.4) 360 (6.7) 2540 (47.0) 2503 (46.3) sex male 2490 (45.3) 1356 (24.7) 1647 (30.0) 2605 (47.4) 1217 (22.2) 1669 (30.4) 1352 (24.6) 1044 (19.0) 3106 (56.5) 2348 (42.8) 366 (6.7) 2775 (50.6) 335 (6.1) 3024 (55.0) 2138 (38.9) female 3816 (48.0) 1238 (15.6) 2899 (36.5) 4195 (52.7) 971 (12.2) 2787 (35.0) 1232 (15.4) 1197 (15.0) 5550 (69.6) 2867 (35.9) 373 (4.7) 4737 (59.4) 278 (3.5) 4053 (50.8) 3644 (45.7) physical activities yes 3568 (49.5) 1440 (20.0) 2205 (30.6) 3788 (52.5) 1215 (16.9) 2206 (30.6) 1419 (19.7) 1225 (17.0) 4569 (63.3) 3006 (41.8) 364 (5.1) 3830 (53.2) 288 (4.0) 4108 (57.1) 2800 (38.9) no 2837 (43.8) 1206 (18.6) 2428 (37.5) 3087 (47.8) 1025 (15.9) 2343 (36.3) 1200 (18.6) 1073 (16.6) 4179 (64.8) 2282 (35.4) 393 (6.1) 3763 (58.4) 350 (5.4) 3035 (47.0) 3071 (47.6) current smoker yes 4970 (48.9) 1642 (16.2) 3553 (35.0) 5241 (51.6) 1456 (14.3) 3458 (34.1) 1409 (13.9) 1646 (16.2) 7088 (69.9) 3403 (33.6) 500 (4.9) 6230 (61.5) 363 (3.6) 5163 (50.9) 4612 (45.5) no 1343 (40.4) 959 (28.9) 1021 (30.7) 1527 (46.2) 746 (22.6) 1034 (31.3) 1162 (35.0) 609 (18.3) 1548 (46.6) 1788 (54.2) 244 (7.4) 1267 (38.4) 258 (7.8) 1863 (56.4) 1183 (35.8) school middle school 1374 (51.5%) 415 (15.6%) 877 (32.9) 1451 (54.1) 420 (15.7) 809 (30.2) 250 (9.3) 547 (20.4) 1883 (70.3) 984 (36.8) 144 (5.4) 1546 (57.8) 152 (5.7) 1506 (56.2) 1024 (38.2) la torre g, dorelli b, lia l, grassucci d, gelardini m, ardizzone c, et al. smoking e-cigarette and heat-not-burn products: the secrhet study, a large observational survey among young people in italy (original research). seejph 2021, posted: 26 december 2021. doi: 10.11576/seejph-5043 p a g e 8 | 15 high school 3905 (47.1) 1722 (20.8) 2665 (32.1) 4280 (51.7) 1429 (17.3) 2571 (31.1) 1843 (22.2) 1263 (15.2) 5186 (62.5) 3444 (41.6) 365 (4.4) 4479 (54.0) 242 (2.9) 4606 (55.7) 3428 (41.4) university 562 (49.0) 224 (19.5) 360 (31.4) 582 (51.0) 172 (15.1) 388 (34.0) 347 (30.2) 229 (19.9) 574 (49.9) 501 (43.8) 131 (11.4) 513 (44.8) 127 (11.1) 583 (51.0) 433 (37.9) not attending school/university 497 (35.1) 246 (17.4) 671 (47.5) 500 (35.5) 188 (13.3) 721 (51.2) 153 (10.8) 222 (19.9) 1039 (73.5) 315 (22.2) 104 (7.3) 997 (70.4) 98 (6.9) 394 (27.7) 928 (65.4) macroarea north 2876 (48.8) 1057 (17.9) 1962 (33.3) 3152 (53.4) 891 (15.1) 1856 (31.5) 1072 (18.2) 940 (15.9) 3883 (65.9) 2300 (39.1) 283 (4.8) 3304 (56.1) 237 (4.0) 3171 (53.8) 2490 (42.2) center 1440 (46.3) 652 (21.0) 1017 (32.7) 1495 (48.2) 576 (18.6) 1029 (33.2) 759 (24.4) 535 (17.2) 1820 (58.4) 1278 (41.1) 262 (8.4) 1570 (50.5) 216 (7.0) 1700 (55.0) 1176 (38.0) south 2031 (44.7) 910 (20.0) 1604 (35.3) 2183 (48.1) 743 (16.4) 1617 (35.6) 773 (16.9) 787 (17.3) 3001 (65.8) 1674 (36.8) 200 (4.4) 2679 (58.8) 170 (3.7) 2227 (48.8) 2165 (47.5) family smokers yes 2838 (45.1) 1358 (21.6) 2095 (33.3) 3084 (49.1) 1177 (18.7) 2017 (32.1) 1445 (23.0) 1160 (18.5) 3682 (58.6) 2704 (43.2) 386 (6.2) 3170 (50.6) 346 (5.5) 3375 (53.8) 2555 (40.7) no 3567 (48.2) 1288 (17.4) 2538 (34.3) 3791 (51.3) 1063 (14.4) 2532 (34.3) 1174 (15.9) 1138 (15.4) 5066 (68.7) 2584 (35.0) 371 (5.0) 4423 (59.9) 292 (4.0) 3768 (51.1) 3316 (45.0) table 3. univariate analysis (behaviour questions) variables have you ever vaped electronic cigarettes? have you ever used heated tobacco products? if you have never used these products, would you try them? > 50 cigarettes n (%) <50 cigarettes n (%) never n (%) > 50 cigarettes n (%) <50 cigarettes n (%) never n (%) yes n (%) no n (%) i don’t know n (%) 802 (5.8) 3173 (22.9) 9907 (71.4) 715 (5.2) 1148 (8.3) 12019 (86.6) 848 (7) 10021 (83.2) 1178 (9.8) age <18 years 283 (3.4) 1745 (21.0) 6280 (75.6) 152 (1.8) 476 (5.7) 7680 (92.4) 548 (7.1) 6430 (83.7) 705 (9.2) la torre g, dorelli b, lia l, grassucci d, gelardini m, ardizzone c, et al. smoking e-cigarette and heat-not-burn products: the secrhet study, a large observational survey among young people in italy (original research). seejph 2021, posted: 26 december 2021. doi: 10.11576/seejph-5043 p a g e 9 | 15 ≥ 18 years 519 (9.3) 1428 (25.6) 3627 (65.1) 563 (10.1) 672 (12.1) 4339 (77.8) 300 (6.9) 3591 (82.3) 473 (10.8) sex male 384 (6.9) 1502 (27.1) 3666 (66.0) 269 (4.8) 487 (8.8) 4796 (86.4) 324 (6.8) 4102 (85.6) 368 (7.7) female 368 (4.6) 1584 (19.7) 6104 (75.8) 386 (4.8) 567 (7.0) 7103 (88.2) 513 (7.2) 5828 (81.8) 782 (11.0) physical activities yes 315 (4.3) 1716 (23.6) 5253 (72.1) 238 (3.3) 542 (7.4) 6504 (89.3) 444 (6.8) 5515 (84.8) 547 (8.4) no 487 (7.4) 1457 (22.1) 4654 (70.5) 477 (7.2) 606 (9.2) 5515 (83.6) 404 (7.3) 4506 (81.3) 631 (11.4) current smoker yes 246 (2.4) 1431 (13.9) 8588 (83.7) 233 (2.3) 400 (3.9) 9632 (93.8) 388 (4.0) 8497 (88.1) 762 (7.9) no 542 (16.0) 1658 (48.9) 1192 (35.1) 459 (13.5) 707 (20.8) 2226 (65.6) 444 (19.8) 1395 (62.3) 400 (17.9) school middle school 111 (4.1) 236 (8.7) 2353 (87.1) 73 (2.7) 81 (3.0) 2546 (94.3) 153 (6.0) 2219 (87.0) 178 (7.0) high school 314 (3.8) 2394 (28.7) 5643 (67.6) 215 (2.6) 704 (8.4) 7432 (89.0) 586 (7.9) 6104 (82.1) 747 (10.0) university 112 (9.6) 273 (23.4) 780 (67.0) 115 (9.9) 145 (12.4) 905 (77.7) 55 (6.1) 774 (85.5) 76 (8.4) not attending school/university 235 (16.0) 197 (13.4) 1039 (70.6) 272 (18.5) 143 (9.7) 1056 (71.8) 42 (3.9) 866 (80.8) 164 (15.3) macroarea north 235 (3.9) 1367 (23.0) 4348 (73.1) 182 (3.1) 421 (7.1) 5347 (89.9) 396 (7.4) 4441 (82.9) 517 (9.7) center 202 (6.4) 748 (23.8) 2193 (69.8) 170 (5.4) 324 (10.3) 2649 (84.3) 182 (6.9) 2230 (84.1) 239 (9.0) south 338 (7.3) 1003 (21.7) 3287 (71.0) 332 (7.2) 334 (7.2) 3962 (85.6) 260 (6.5) 3299 (83.1) 412 (10.4) la torre g, dorelli b, lia l, grassucci d, gelardini m, ardizzone c, et al. smoking e-cigarette and heat-not-burn products: the secrhet study, a large observational survey among young people in italy (original research). seejph 2021, posted: 26 december 2021. doi: 10.11576/seejph-5043 p a g e 10 | 15 family smokers yes 523 (8.1) 1867 (29.1) 4035 (62.8) 455 (7.1) 723 (11.3) 5247 (81.7) 469 (8.9) 4217 (80.0) 585 (11.1) no 279 (3.7) 1306 (17.5) 5872 (78.7) 260 (3.5) 425 (5.7) 6772 (90.8) 379 (5.6) 5804 (85.7) 593 (8.8) all p values are <0.05. la torre g, dorelli b, lia l, grassucci d, gelardini m, ardizzone c, et al. smoking e-cigarette and heat-not-burn products: the secrhet study, a large observational survey among young people in italy (original research). seejph 2021, posted: 26 december 2021. doi: 10.11576/seejph-5043 p a g e 11 | 15 table 4. results of the logistic regression analysis variables e-cigarette* heat-not-burn* current or (95%ci) ever or (95%ci) current or (95%ci) ever or (95%ci) gender female (reference) 1 1 1 1 male 1.85 (1.84-1.85) 1.92 (1.92-1.93) 1.20 (1.20-1.21) 1.38 (1.38-1.39) age, years < 18 (reference) 1 1 1 1 ≥ 18 1.21 (1.21-1.22) 1.08 (1.08-1.09) 2.25 (2.24-2.26) 1.61 (1.60-1.61) attended school junior high school 1.97 (1.96-1.98) 0.44 (0.44-0.44) 2.01 (2.00-2.02) 0.85 (0.85-0.86) high school (reference) 1 1 1 1 university 1.87 (1.86-1.88) 0.76 (0.76-0.77) 2.16 (2.15-2.17) 1.45 (1.44-1.45) not attending school 4.85 (4.83-4.87) 0.93 (0.93-0.93) 6.37 (6.34-6.40) 3.57 (3.56-3.58) macroarea of italy north (reference) 1 1 1 1 center 1.35 (1.35-1.36) 1.01 (1.01-1.01) 1.36 (1.35-1.36) 1.36 (1.36-1.37) south 1.36 (1.35-1.36) 0.99 (0.99-0.99) 1.41 (1.400-1.41) 0.99 (0.99-0.99) current smoking no (reference) 1 1 1 1 yes 7.95 (7.93-7.97) 8.92 (8.91-8.93) 6.41 (6.39-6.43) 7.34 (7.32-7.35) hosmer-lemeshow test (p) 13.8 (0.085) 31.8 (<0.01) 29.1 (<0.01) 43.3 (<0.01) * the results are related to a logistic regression model in which the outcome variables where being a current or an ever smoker of e-cigarette or heat-not-burn tobacco products. a full model was carried out. the results in bold are statistically significant. concerning the geographical macroarea, center and southern italy showed higher odds of being current e-cigarette and hnb smokers compared to northern italy. the interaction between demographics and smoking status did not add any insight into the la torre g, dorelli b, lia l, grassucci d, gelardini m, ardizzone c, et al. smoking e-cigarette and heat-not-burn products: the secrhet study, a large observational survey among young people in italy (original research). seejph 2021, posted: 26 december 2021. doi: 10.11576/seejph-5043 p a g e 12 | 15 multivariate analysis. no multicollinearity between variables was found. discussion our survey demonstrated that the prevalence of current use of ecig and htp is around 5%6% among the young population in italy. this finding is in line with the results of the global youth tobacco surveys conducted in italy among adolescents (13-15 years old) (12). the data provided by the health behaviour in school-aged children study (hbsc) involving students aged 11, 13 and 15 years in all italian regions show that in 2018, the year of the last survey, the share of children who declare that they have smoked cigarettes at least one day in the last 30 days significantly increases with age, in both boys and girls, with a marked gender difference at 15 years (24.8% in boys, 31.9% in girls) (15). interestingly, the ever use of ecig is high not only in young people older than 18 years old (almost one third) but also in adolescents (almost one fourth). on the other hand, the use of hnb tobacco products is threefold in older young people if compared to adolescents’ use (one fourth vs one twelfth). these results indicate a higher use of both ecig and htp when comparing to similar studies carried out in other countries both in asia, such as in japan (16,17) and in korea (18), as well as in europe (germany) (19). considering the risk and harm associated with their use in adolescents and young adults, a coordinated effort from policy makers, public health agencies, parents, educators, health practitioners and researchers is essential to mitigate harms from e-cigarette use in this vulnerable population. concerning strengths, our survey was large (almost tenfold of the previous study in italy)and comprises also older young people, including university students.on the other hand, we need to recognize some limitations. first of all, the issue concerning the access to the website, since not all students have access to the "skuola.net" site to acquire information on a specific topic. secondly, the study is based on self-reported data of students smoking status and reporting bias cannot be excluded at all. finally, the sampling was non-probabilistic, but the number of people that entered the survey can be sufficient to draw some interesting conclusions, even if the external validity could be questionable. non-probabilistic sampling can be a reasonable approach for online sample, and according to some authors inferences from this type of samples may also be possible and appropriate (20-22). in conclusion, the prevalence of use of ecig and htp is higher among young people in italy and this requires adequate public health interventions. first of all, as suggested by the world health organization, marketing of htps should not be permitted unless there is conclusive evidence that, compared to conventional cigarettes, the product reduces exposure to harmful and potentially harmful components and reduces health risks. in addition, htps should be taxed similarly to other tobacco products, following the recommendations of the conference of the parties to the who framework convention on tobacco control. furthermore, comprehensive smoke-free regulations prohibiting smoking in all public places and workplaces should be apply also to hnbs and finally advertising and promotions should be banned also for these new products. references 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proceedings 59th isi world statistics congress, 25-30 august 2013, hong kong. available from: http://2013.isiproceedings.org/files/ips064-p1-s.pdf (accessed: august 24, 2021). _________________________________________________________________________ https://www.aapor.org/ https://www.aapor.org/ la torre g, dorelli b, lia l, grassucci d, gelardini m, ardizzone c, et al. smoking e-cigarette and heat-not-burn products: the secrhet study, a large observational survey among young people in italy (original research). seejph 2021, posted: 26 december 2021. doi: 10.11576/seejph-5043 p a g e 15 | 15 appendix 1 – the questionnaire used in this survey • gender (f, m) • age (continuous variable) • attended school (junior high school; high school; university; not attending) • macro-area (north; center; south) • current tobacco smoking (yes; no) • e-cigarette user (yes, actually; yes, in the past; no) • have you ever vaped electronic cigarettes? (> 50 cigarettes; < 50 cigarettes; never) • heat-not-burn (yes, actually; yes, in the past; no) • have you ever used heated tobacco products? (> 50 cigarettes; < 50 cigarettes; never) • if you have never used these products, would you try them? (yes; no; i do not know) • do you think electronic cigarettes are addictive? (yes; no; i do not know) • are electronic cigarettes harmful to health? (yes; no; i do not know) • do you know what happens to tobacco when using a heated tobacco device? (yes; no; i do not know) • is nicotine contained in heated tobacco products? (yes; no; i do not know) • are heated tobacco products harmful to health? (yes; no; i do not know) * the results are related to a logistic regression model in which the outcome variables where being a current or an ever smoker of e-cigarette or heat-not-burn tobacco products. a full model was carried out. the results in bold are statistically signi... discussion references title goes here fani t, saptorini kk, anggreani ad. the willingness of covid-19 vaccination and associated factors: a systematic review (review article). seejph 2022, posted: 09 may 2022. doi: 10.11576/seejph-5454 p a g e 1 | 11 review article the willingness of covid-19 vaccination and associated factors: a systematic review tiara fani1, kriswiharsi kun saptorini1, aprilia diah anggreani1 1 associate degree of medical record and health information program, faculty of health science, dian nuswatoro university, semarang city. indonesia. corresponding author: tiara fani; address: faculty of health science, dian nuswatoro university, semarang city, indonesia; e-mail: tiara.fani@dsn.dinus.ac.id fani t, saptorini kk, anggreani ad. the willingness of covid-19 vaccination and associated factors: a systematic review (review article). seejph 2022, posted: 09 may 2022. doi: 10.11576/seejph-5454 p a g e 2 | 11 abstract aim: vaccination is an effective approach to avoid infection and reduce morbidity and mortality of infectious diseases. however, in previous infectious disease vaccination programs, some people were hesitant to get vaccinated. to develop an effective vaccination program or policy, the government or public health officials need to understand the factors that influence the willingness of covid-19 vaccination from the various studies. methods: between 1-18 december 2020, articles were searched from pubmed and sciencedirect with the following key terms: willingness, acceptance, acceptability, covid19 vaccine, and covid-19 vaccination. eligibility for article inclusion criteria was determined by prisma. results: 20 studies were included in this review. all studies were conducted in the early days of the covid-19 pandemic. the willingness of covid-19 vaccination ranged from 60-97% among the general population, 28-63% among healthcare workers, 56-65% among parents or caregivers, and 73% among factory workers. the common factors that affected the willingness of covid-19 vaccination: gender, age, education, individual perception about diseases and the vaccine, trust in the government, statements of public health officials and health providers. conclusion: concerns about disease risk, effectiveness, and side effects are important factors associated with vaccination willingness. to avoid vaccination hesitancy in the community, public health officials need to disseminate detailed information about the vaccines like efficacy level and side effects, and continue to provide information about the risks of covid19 for personal health and others through various online media to avoid vaccination hesitancy. keywords: covid-19, determinants, vaccination willingness. conflicts of interest: none declared. fani t, saptorini kk, anggreani ad. the willingness of covid-19 vaccination and associated factors: a systematic review (review article). seejph 2022, posted: 09 may 2022. doi: 10.11576/seejph-5454 p a g e 3 | 11 introduction until the end of 2020, there was no cure or herd immunity for the covid-19 outbreak. the pandemic is a serious threat to public health and welfare (1). vaccination is an effective approach to stop and prohibit infection and reduce morbidity and mortality of infectious diseases (2). in 2020, several countries had developed and distributed covid-19 vaccines to reduce and eradicate the covid-19 outbreak (3). during a disease pandemic such as the covid-19 pandemic, vaccines must be developed and distributed effectively and efficiently. some people were still hesitant to get vaccinated in previous infectious disease vaccination programs (2). therefore, it is necessary to formulate a vaccination program or policy that can encourage people to get vaccinated. to develop an effective vaccination program or policy, the government or public health officials need to understand the factors that influence people's decisions to accept or reject vaccines. in 2020, several surveys have examined the acceptance or willingness of the covid-19 vaccine and the determinant factors. therefore, this systematic review of published articles combined data from related surveys and identified factors that influence covid-19 vaccination willingness in the general and specific populations. methods search strategy we searched for articles indexed in the electronic databases of pubmed and sciencedirect with the following key terms: willingness, acceptance, acceptability, covid-19 vaccine, and covid-19 vaccination. articles were searched 1-18 december, 2020. the search terms were combined with the boolean operator as follows: “(willingness or acceptance or acceptability) and (covid-19 vaccine or covid-19 vaccination)”. furthermore, relevant articles had extracted from the references section of the manuscripts found in the initial search. selection criteria we searched articles that examine the willingness or acceptance of covid-19 vaccination. we included observational research articles; research on the prevalence of willingness to take the covid-19 vaccine, and covid-19 vaccination willingness/acceptance factors. we excluded articles: systematic reviews, narrative reviews, data articles, letters to editors, and published on pre-print or pre-proof servers; articles published in languages other than english; information about covid-19 vaccination acceptance or hesitancy was unclear. eligibility for article inclusion and exclusion criteria determined by preferred reporting items for systematic reviews and meta-analyses (prisma) according to the diagram in figure 1. results study selection 822 articles were found in the electronic database pubmed and sciencedirect. from the search results, 20 articles met the selection criteria for further analysis (figure 1). study characteristics the studies included in the analysis observed general populations (70%) (4-17) healthcare workers (15%) (18-20) parents and caregivers (10%) (11,21) and factory workers (5%) (22). all surveys in reviewed articles were self-administered (based on online surveys), and the sample size ranged from 613 to 13,426 respondents. the studies mostly surveyed in china, us and european countries and were mostly conducted in the early days of the pandemic before the covid-19 vaccine availability in the respective countries. 40% articles were published in journals on vaccines (table 1). fani t, saptorini kk, anggreani ad. the willingness of covid-19 vaccination and associated factors: a systematic review (review article). seejph 2022, posted: 09 may 2022. doi: 10.11576/seejph-5454 p a g e 4 | 11 vaccination willingne the reported willingness to participate in the covid-19 vaccination ranged from 60.0% to 97.0% among general population respondents (4-7,9,10,12-17,23), 27.7% to 63.0% among healthcare workers (18-20), 55.8%-65.0% among parents or caregivers (11,21), and 72.6% among factory workers (22). figure 1. prisma diagram of studies selected records identified through database searching sciencedirect and pubmed (n = 822) articles excluded duplicates (n = 8) articles screened by the abstract (n = 814) full-text articles assessed for eligibility (n=32) studies included (n = 20) articles excluded • irrelevant (n = 705) • full-text not available (n=55) • articles not in english (n=3) • preprints, preproof, review articles (n= 19) articles excluded • did not report percentages of covid-19 vaccination acceptance (n=10) • did not report study population (n=1) • data article (n=1) fani t, saptorini kk, anggreani ad. the willingness of covid-19 vaccination and associated factors: a systematic review (review article). seejph 2022, posted: 09 may 2022. doi: 10.11576/seejph-5454 p a g e 5 | 11 table 1. study characteristics study journal year country n time of study data collection method characteristic of participants covid-19 vaccination willingness kwok, kin on et al (18) international journal of nursing studies 2020 china 1205 mid-march and late april 2020 online survey nurses with mean age = 40.79, mostly female nurses (90%). 63% bell, sadie et al (21) vaccine 2020 england 1252 april 19 and may 11, 2020 online survey and structure interview parent or guardian of a child aged ≤18 months, england residents, and aged above 16 years. definitely accept: 55.8%; unsure but leaning towards yes: 34.3% guidry et al (4) american journal of infection control 2020 us 788 jul-20 online survey general populations above 18 years 60% definitely or probably willing to take covid-19 vaccine. karlsson et al (5) personality and individual differences 2020 finland 1325 3rd and 17th of april 2020 online survey general populations whose facebook users ¾ of respondents (21.83% likely, 51.1% very likely) malik et al (10) eclinical medicine 2020 us 672 may-20 online survey general populations above 18 years 67% goldman et al (11) vaccine 2020 canada, usa, japan, spain, switzerland, israel. 1541 march 26may 31, 2020 online survey caregivers and their children arrive to 16 pediatric emergency departments (ed) 65% sarasty et al (12) vaccine 2020 ecuador 1,050 april 2 to 7, 2020 online survey general populations 97% detoc et al (23) vaccine 2020 france 3259 march 26 to april 20,2020 online survey general populations above 18 years and adult patients in france. 77.6% (general populations) 81.5%, (healthcare workers) 73.7% (non-healthcare workers) leng et al (13) vaccine 2020 china 1883 not reported online survey general population in some chinese provinces. 84.77% reiter et al (14) vaccine 2020 united states 2,006 may-20 online survey us general populations aged ≥18 years 69% wang k. et al (19) vaccine 2020 china 806 26 february and 31 march 2020 online survey nurses 40.0% wang j. et al (15) vaccine 2020 china 2058 mar-20 online survey general populations above 18 years in china 91.3% harapan et al (16) frontiers in public health 2020 indonesia 1,359 march 25 and april 6, 2020 online survey general population in indonesia 93.3% (95% effective vaccine), 67.0% (50% effectiveness) lazarus et al (17) nature medicine 2020 19 countries 13,426 jun-20 online survey general populations in 19 countries 46.8% and 24.7% completely and somewhat agree. palamenghi et al (6) european journal of epidemiology 2020 italy 968 not reported online survey general populations 59% al-mohaithef et al (7) journal of multidisciplinar y healthcare 2020 saudi arabia 992 not reported online survey general population in 4 major cities (dammam, jeddah, riyadh, and abha) in saudi arabia 642 have an interest to accept the covid-19 vaccine salali et al (8) cambridge university press 2020 uk and turkey uk: 1088 turkey: 3936 may-20 online survey general populations above 18 years not reported nzaji et al (20) pragmatic and observational research 2020 congo 613 march to april 30,2020 online survey hcws in some referral hospital and university hospital in lubumbashi, mbuji-mayi, and kamina towns 27.7% zhang et al (22) jmir pediatrics and parenting 2020 china 1052 september 1 to 7, 2020 online survey factory workers in shenzhen who had at least 1 child under 18 years 72.6% neumannböhme, sebastian et al (9) the european journal of health economics 2020 germany, italy, denmark, france, portugal, the netherlands, uk 7664 2 and 15 april, 2020 online survey general populations 73.9% fani t, saptorini kk, anggreani ad. the willingness of covid-19 vaccination and associated factors: a systematic review (review article). seejph 2022, posted: 09 may 2022. doi: 10.11576/seejph-5454 p a g e 6 | 11 socio-demographic factors several studies have reported that sociodemographic factors influence a person's decision to take the covid-19 vaccine. most studies show that men were more interested to participate in the covid-19 vaccination than women, both in the general populations and among healthcare workers (4,8-11,14,15,17,19,20,23). several studies have shown that age is related to the decision to take the covid-19 vaccine. people in the older age groups (=>40years) were more willing to take the covid-19 vaccine (5-7,9-11,13,17,20,23), but one study showed the opposite (18). meanwhile, in the young and middle age groups, there was no consistency, several studies reported that the younger (<24 years) (6,18) or middle age groups (24-<40 years) (17) were more willing to take the vaccine, other studies reported opposite results (6,17). four articles reported that the education level is associated with the willingness to participate in covid-19 vaccination, but there was inconsistency in the results. three articles reported that people showed more willingness with higher education (4,10,17) to get covid-19 vaccine, while one article reported this for people with lower education (13). other demographic variables related to willingness to participate in vaccination against covid-19 are being married, marital status (7,15), working as a healthcare workers (20,23), working in private services (19), and household income (13,14,17,21). determinant of willingness the factors or reasons that influence the general population's willingness to participate in covid-19 vaccination vary considerably. common factors or reasons to accept covid-19 vaccination are perceptions to contract more likely covid19 (5,7,8,13-15) and covid-19 as a severe/dangerous disease (5,14,23), those who had a higher perceived-risk level of covid-19 infection (10,14,16,23), those who had been vaccinated against influenza (11,15,19), those who had higher trust that the vaccine is safe (5,6,13,20), living in a country or place with a higher number of covid-19 cases (14,15,17) or if vaccine was free, cheap, or convenient (13,15,16), other factors are less frequently named in the selected literature. among parents or caregivers, the factors that influence the willingness to get covid-19 vaccination for their children were: age of the child (11,22), family support, perceived behavioral control about covid-19 vaccination in children, had a higher exposure to positive information about covid-19 vaccination, avoiding social gatherings with other people or crowded places (22), having children that were up-todate on their vaccines and had no chronic illness; caregiver/parents that have concerns about their child and others (11), and having 2-3 children (21). several factors that make people refuse to be vaccinated are: those who are concerned about the vaccine safety and side effects (9,11,13-15,17,19), concerns related to vaccines that are new or developed rapidly (11,19), concerns about the effectiveness of vaccines to prevent transmission of covid-19 (16,19), if vaccines have a short protection duration (≤2 years), and required higher doses (13). discussion before the covid-19 vaccine was available, all affected countries found it difficult to control the spread of covid-19 by enforcing quarantine, lockdowns, social distancing, and mandatory use of face masks while in public places, and travel restrictions. the current pandemic has caused tremendous physical and psychosocial health impairments for society and has driven massive problems in the global economy. therefore, various fani t, saptorini kk, anggreani ad. the willingness of covid-19 vaccination and associated factors: a systematic review (review article). seejph 2022, posted: 09 may 2022. doi: 10.11576/seejph-5454 p a g e 7 | 11 countries have started to develop vaccines. vaccines are an effective way to control the transmission of communicable disease outbreaks (24). there has been a lot of research to determine the vaccine acceptance/willingness and its associated factors. based on this review, the willingness to get the covid-19 vaccine varies considerably among general populations and healthcare workers. most studies report a willingness to be vaccinated in the range of 50-70%. these results need essential consideration to support vaccination programs in the general populations and particular groups. socio-demographic factors that most frequently affected the decision-making regarding covid-19 vaccination were gender, age, and education in the general population and certain sub-groups. men were more likely willing to get the covid19 vaccine than women. several systematic reviews reported that during the 2009 ph1n1 pandemic, pertussis, hepatitis b, and influenza vaccination met a consistently higher acceptance in males than females worldwide (2,25,26). women were more concerned about vaccine side effects and getting infected by the novel disease. therefore, women were more willing to use protective measures during epidemics or pandemics (27,28). older age and higher educated people were more likely to have vaccine intentions. older age groups had more willingness because they had higher incidence and mortality than a younger age. in addition, comorbidity as a higher covid 19 risk factor is common among older people (29). even though age, education, occupation, and household income were associated with covid 19 vaccine uptake intentions, the results were still inconsistent between the selected studies. other factors and category differences in the selected studies may affect these inconsistent results. personal perception regarding the risk of disease and the covid-19 vaccine is an essential factor in vaccine acceptance. in previous vaccination programs, vaccine side effects and efficacy were the main considerations for vaccine acceptance (2,27,30). vaccination acceptance was relatively high when people perceived that the vaccine has very high effectiveness, safety, and no adverse side effects. this review also found that vaccine acceptance was affected by personal perceptions of the severity, adverse effects (5,14,23), and disease transmission risks of covid-19 (5,8,14-16,23,31,32). concerns related to vaccine side effects and safety (6,9,11,13– 15,17,19,20), the effectiveness of the covid-19 vaccine (14-16,19), vaccines that were new or developed rapidly (11,19) affected covid-19 vaccine uptake. some studies reported the duration of vaccine protection and vaccine doses also affected the willingness of covid-19 vaccination (13). several countries have distributed vaccines to the community. several types of vaccines have an efficacy >90%, like pfizerbiontech (95%), moderna (94.5%), russia's sputnik v vaccine (92%). several vaccines with an efficacy rate <90% also were distributed in countries. for example, astrazeneca with 70% average from a combination of two analyses. sinovac biotech (based on late-stage clinical trials in brazil) a vaccine efficacy rate of 50.4%. however, recently other tests conducted by butantan institute, brazil showed a 78% efficacy rate of sinovac biotech in mild cases and 100% in moderate and severe cases (33). after distribution, there were reports of vaccine side effects in patients after vaccine injection. apart from the typical side effects of vaccines (muscle pain, headache, and fatigue), some cases reported severe/rare effects after vaccination. uncommon reported side effects include fani t, saptorini kk, anggreani ad. the willingness of covid-19 vaccination and associated factors: a systematic review (review article). seejph 2022, posted: 09 may 2022. doi: 10.11576/seejph-5454 p a g e 8 | 11 anaphylactic shock, facial paralysis, and even death after a few days of being injected with certain types of vaccines. even so, it still needs further exploration (34). people were more likely to uptake the covid-19 vaccine if the vaccines were free, cheap, or convenient (3,15,16). in this review, several studies reported healthcare provider recommendations on vaccination (14,15), people who trusted their government (8,17), and the health system in their respective country (7,35) affected vaccination acceptance. nowadays, people access health information from various sources, including social media platforms that gain popularity globally. social media popularity grows public health concerns regarding the impacts of anti-vaccination or conspiracy theory contents (36). a study showed that about 50% of the population has little evidence of conspiracy thinking about coronavirus. the conspiracy beliefs lead to mistrust, less compliance with government guidelines, and unwillingness to participate in future tests or treatment. the holders of coronavirus conspiracy beliefs were more likely to share their opinions with others (37). therefore, misinformation about covid-19 and vaccines will spread in the community. misinformation about the efficacy and side effects of the vaccine lead to vaccine hesitancy. public health officials should disseminate complete information about the vaccines like efficacy level and side effects through various online media. providing detailed information about vaccines to the public is essential to avoid vaccine hesitancy due to widespread misinformation. the government and health providers also need to follow up on the widespread of misinformation about the vaccine. limitations hardly any studies with specific populations (health workers, parents or child caregivers, and factory workers) were selected in this review. several factors and reasons related to the willingness of covid-19 vaccination were inconsistent because the questions regarding the determinants in the selected studies varied. in addition, the article selection process did not consider the reported study bias in the reviewed articles. conclusion the factors that consistently affected the willingness of covid-19 vaccination include gender, age, and educational level, individual perception about the disease and the vaccine, as well as trust in the government, public health officials, and health providers. concerns about disease risk, effectiveness, and side effects are the most important factors. therefore, to avoid vaccination hesitancy in the community public health officials need to disseminate detailed information about the vaccines like efficacy level and side effects and continue to provide information about the risks of covid-19 for personal health and others through various online media. the government and health providers also need to follow up on the widespread misinformation about the vaccine. further research needs to explore health promotion methods in the vaccination program and health literacy in general populations. references 1. world health organization. who director-general’s opening remarks at the media briefing on covid-19 [internet]. available from: https://www.who.int/directorgeneral/speeches/detail/whodirector-general-s-opening-remarksat-the-media-briefing-on-covid-19--12-october-2020 (accessed: 2020 december 29, 2020). 2. nguyen t, henningsen kh, brehaut jc, hoe e, wilson k. acceptance of fani t, saptorini kk, anggreani ad. the willingness of covid-19 vaccination and associated factors: a systematic review (review article). seejph 2022, posted: 09 may 2022. doi: 10.11576/seejph-5454 p a g e 9 | 11 a pandemic influenza vaccine: a systematic review of surveys of the general public. infect drug resist 2011;4:197-207. 3. oxford martin school. statistics and research: coronavirus (covid-19) vaccinations [internet]. available from: https://ourworldindata.org/covidvaccinations (accessed: december 29, 2020). 4. guidry jpd, laestadius li, vraga ek, miller ca, perrin pb, burton cw, et al. willingness to get the covid-19 vaccine with and without emergency use authorization. am j infect control 2021;49:137-42. 5. karlsson lc, soveri a, lewandowsky s, karlsson l, karlsson h, nolvi s, et al. fearing the disease or the vaccine: the case of covid-19. pers individ dif 2021;172:110590. 6. palamenghi l, barello s, boccia s, graffigna g. mistrust in biomedical research and vaccine hesitancy: the forefront challenge in the battle against covid-19 in italy. eur j epidemiol 2020;35:785-8. 7. al-mohaithef m, padhi bk. determinants of covid-19 vaccine acceptance in saudi arabia: a webbased national survey. j multidiciplinary healthc 2020;13:1657-63. 8. salali gd, uysal ms. covid-19 vaccine hesitancy is associated with beliefs on the origin of the novel coronavirus in the uk and turkey. psychol med 2020;(i):26-8. 9. neumann-böhme s, varghese ne, sabat i, barros pp, brouwer w, van exel j, et al. once we have it, will we use it? a european survey on willingness to be vaccinated against covid-19. eur j heal econ 2020;21:977-82. 10. malik aa, mcfadden sam, elharake j, omer sb. determinants of covid-19 vaccine acceptance in the us. e clinical medicine 2020;26:100495. 11. goldman rd, yan td, seiler m, cotanda cp, brown jc, klein ej, et al. caregiver willingness to vaccinate their children against covid-19: cross sectional survey. vaccine 2020;38:7668-73. 12. sarasty o, carpio ce, hudson 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willingness of covid-19 vaccination and associated factors: a systematic review (review article). seejph 2022, posted: 09 may 2022. doi: 10.11576/seejph-5454 p a g e 10 | 11 wong sys, lee ss. influenza vaccine uptake, covid-19 vaccination intention and vaccine hesitancy among nurses: a survey. int j nurs stud 2021;114:103854. 19. wang k, wong ely, ho kf, cheung awl, chan eyy, yeoh ek, et al. intention of nurses to accept coronavirus disease 2019 vaccination and change of intention to accept seasonal influenza vaccination during the coronavirus disease 2019 pandemic: a crosssectional survey. vaccine 2020;38:7049-56. 20. nzaji mk, ngombe lk, mwamba gn, ndala dbb, miema jm, lungoyo cl, et al. acceptability of vaccination against covid-19 among healthcare workers in the democratic republic of the congo. pragmatic obs res 2020;11:103-9. 21. bell s, clarke r, mounier-jack s, walker jl, paterson p. parents’ and guardians’ views on the acceptability of a future covid-19 vaccine: a multi-methods study in england. vaccine 2020;38:7789-98. 22. zhang kc, fang y, cao h, chen h, hu t, chen yq, et al. parental acceptability of covid-19 vaccination for children under the age of 18 years: cross-sectional online survey. jmir pediatr parent 2020;3:e24827. 23. detoc m, bruel s, frappe p, tardy b, botelho-nevers e, gagneuxbrunon a. intention to participate in a covid-19 vaccine clinical trial and to get vaccinated against covid-19 in france during the pandemic. vaccine 2020;38:7002-6. 24. lin y, hu z, zhao q, alias h, danaee m, wong lp. understanding covid-19 vaccine demand and hesitancy: a nationwide online survey in china. plos negl trop dis 2020;14:e0008961. 25. klein sl, pekosz a. sex-based biology and the rational design of influenza vaccination strategies. j infect dis 2014;209s114-9. 26. pulcini c, massin s, launay o, verger p. factors associated with vaccination for hepatitis b, pertussis, seasonal and pandemic influenza among french general practitioners: a 2010 survey. vaccine 201320;31:3943-9. 27. lin c, tu p, beitsch lm. confidence and receptivity for covid-19 vaccines: a rapid systematic review. vaccines 2020;9:16. 28. moran kr, del valle sy. a metaanalysis of the association between gender and protective behaviors in response to respiratory epidemics and pandemics. plos one 2016;11:e0164541. 29. li x, xu s, yu m, wang k, tao y, zhou y, et al. risk factors for severity and mortality in adult covid-19 inpatients in wuhan. j allergy clin immunol 2020;146:110-8. 30. newman pa, logie c. hiv vaccine acceptability: a systematic review and meta-analysis. aids 2010;24:1749-56. 31. malik aa, mcfadden sm, elharake j, omer sb. determinants of covid-19 vaccine acceptance in the us. e clinical medicine 2020;26:100495. 32. al-mohaithef m, padhi bk. determinants of covid-19 vaccine acceptance in saudi arabia: a web fani t, saptorini kk, anggreani ad. the willingness of covid-19 vaccination and associated factors: a systematic review (review article). seejph 2022, posted: 09 may 2022. doi: 10.11576/seejph-5454 p a g e 11 | 11 based national survey. j multidiscip healthc 2020;13:1657. 33. terry m. updated comparing covid-19 vaccines: timelines, types and prices. biospace [internet]. available from: https://www.biospace.com/article/co mparing-covid-19-vaccines-pfizerbiontech-moderna-astrazenecaoxford-j-and-j-russia-s-sputnik-v/ (accessed: january 25, 2021). 34. freund a. covid-19: risks and side effects of vaccination. dw; 2021 [internet]. available from: https://www.dw.com/en/covid-19risks-and-side-effects-ofvaccination/a-56136620 (accessed: january 25, 2021). 35. larson hj, clarke rm, jarrett c, eckersberger e, levine z, schulz ws, et al. measuring trust in vaccination: a systematic review. hum vaccines immunother 2018;141599-609. 36. puri n, coomes ea, haghbayan h, gunaratne k. social media and vaccine hesitancy: new updates for the era of covid-19 and globalized infectious diseases. hum vaccin immunother 2020;16:2586-93. 37. freeman d, waite f, rosebrock l, petit a, causier c, east a, et al. coronavirus conspiracy beliefs, mistrust, and compliance with government guidelines in england. psychol med 2020;1-13. _____________________________________________________________________________________________ © 2022 fani et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. conflicts of interest: none declared. we searched articles that examine the willingness or acceptance of covid-19 vaccination. we included observational research articles; research on the prevalence of willingness to take the covid-19 vaccine, and covid-19 vaccination willingness/acceptan... results gjorgji p, kruja j. trends and demographic characteristics of hemorrhagic stroke in albania during the period 2004-2015 (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-123 1 original research trends and demographic characteristics of hemorrhagic stroke in albania during the period 2004-2015 petrit gjorgji 1 , jera kruja 2 1 university hospital centre “mother teresa”, tirana, albania; 2 faculty of medicine, university of medicine, tirana, albania. corresponding author: petrit gjorgji, md; address: university hospital center “mother teresa”, rr. dibres, no. 371, tirana, albania; telephone: 00355685175790; e-mail: gjorgji19@yahoo.com mailto:g@yahoo.com gjorgji p, kruja j. trends and demographic characteristics of hemorrhagic stroke in albania during the period 2004-2015 (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-123 2 abstract aim: our aim was to describe the trend over time and the demographic distribution of hemorrhagic stroke in albania in the past decade. methods: this study included all patients diagnosed with hemorrhagic stroke and admitted during the period 2004-2015 at the university hospital center “mother teresa” in tirana (988 cases overall; 34% women; overall mean age: 57.8±19.3 years). information about selected demographic characteristics was also collected for all study participants. results: the proportion of older patients (≥70 years) was slightly, but not significantly, higher in women than in men (32% vs. 27%, respectively; p=0.163). furthermore, the proportion of tirana residents was similar in both sexes (47% in men vs. 45% in women). overall, there was evidence of a significant linear trend over time (mann-kendall test: p<0.01), indicating a gradual increase in the number of hemorrhagic stroke cases in albania for the period 2004-2015. conclusion: this study provides useful information about the increasing trend of hemorrhagic stroke in albania, a transitional country in southeastern europe which is characterized by rapid changes including unhealthy dietary habits. keywords: albania, cerebrovascular disease, hemorrhagic stroke, time trend, western balkans. conflicts of interest: none. gjorgji p, kruja j. trends and demographic characteristics of hemorrhagic stroke in albania during the period 2004-2015 (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-123 3 introduction it has been shown that the sudden appearance of acute ischemic stroke is a consequence of a hasty interruption of blood flow to a part of the brain (1). it is argued that in most of the circumstances this situation occurs from embolic or thrombotic arterial vascular occlusion (1,2). in addition, lacunar strokes, arteritis, arterial dissections, and cortical venous occlusions constitute some other vascular events which may result in stroke syndromes (1,2). intraparenchymal intracranial hemorrhage from a variety of causes (including the spontaneous or hypertensive hemorrhages, vascular malformations, or aneurysmal origin) are observed fairly frequently in the clinical practice. normally, these additional conditions are involved in the initial differential diagnosis of stroke. actually, these different conditions have been referred to as stroke subtypes and are considered in the classification of this major disease. according to the first national health report for albania which was published in 2014, there is evidence of an increase in the mortality rate from cerebrovascular diseases in the past two decades in this post-communist country (3,4). as a matter of fact, albania is the only country in the southeastern european region that exhibits an increase in the death rate from cerebrovascular diseases (3,4), which raises serious concerns for health professionals and policymakers in this transitional country. the increase in the death rate from cerebrovascular diseases has been bigger in males (from about 85 per 100,000 population in 1990 to 157 per 100,000 population in 2010) compared to females (100 and 169 per 100,000 population, respectively) (3,4). it has been argued that this increase in the mortality rate of cerebrovascular diseases in albania indicates an early evolutionary stage of these conditions, a trend which was evident several decades ago in the western countries (3). in any case, accurate information on the extent of cerebrovascular diseases in albania is scant. as a matter of fact, there is no scientific information about the incidence or prevalence of cerebrovascular diseases in the albanian adult population. in this framework, we aimed to describe the distribution and the demographic characteristics of hemorrhagic stroke in albania, a transitional country in southeastern europe which has been undergoing a rapid change in the past decades including also drastic changes in lifestyle/behavioral factors. methods we conducted a case-series study which included all patients with hemorrhagic stroke admitted during the period 2004-2015 at the university hospital center “mother teresa” in tirana. it should be noted that this is the only tertiary care hospital in albania. overall, during the 12-year time period under investigation, there were hospitalized 988 patients (66.1% men and 33.9% women). for all cases included in this study, the diagnosis of stroke and differentiation of its subtype was done with magnetic resonance imaging (mri) and magnetic resonance angiography (mra) (5). data on selected demographic characteristics (age, sex and place of residence) of all study participants was also collected. age was categorized in the analysis into four groups: <50 years, 50-60 years, 61-70 years and >71 years. place of residence was dichotomized into: tirana vs. other districts of albania. the time period under investigation was treated as a discrete variable (for the purpose of time trend analyses), but it was also dichotomized into: 2004-2009 vs. 2010-2015. t-test was used to compare mean age between male and female stroke patients. on the other hand, fisher’s exact test was used to compare the sex-differences related to age-groups, place of residence and time period under investigation (2004-2009 vs. 2010-2015). conversely, gjorgji p, kruja j. trends and demographic characteristics of hemorrhagic stroke in albania during the period 2004-2015 (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-123 4 mann-kendall test was used to assess the linear trend in the distribution of the number of hemorrhagic stroke cases in albania for the period 2004-2015. in all cases, a p-value of ≤0.05 was considered as statistically significant. statistical package for social sciences (spss, version 15.0) was used for all the statistical analyses. results overall, mean age of study participants was 57.8±19.3 years, whereas median (interquartile range) was 61.0 years (51.5-71.3 years). mean age in men was slightly higher than in women (58.4±17.8 years vs. 56.6±21.9 years, respectively), but this difference was not statistically significant (p=0.174). the distribution of ischemic stroke cases by selected demographic characteristics of the study participants is displayed in table 1. on the whole, 29% of hemorrhagic stroke cases were 70 years or older; 24% were 61-70 years; 25% were 50-60 years; and 22% were less than 50 years of age. overall, 46% of the hemorrhagic stroke cases were residents in tirana, whereas the remaining 54% of the patients were residents in other districts of albania. notably, most of the hemorrhagic stroke cases (70%) occurred during the period 2010-2015 compared with only 30% of the cases registered in the period 2004-2009. table 1. distribution of hemorrhagic stroke cases by selected demographic characteristics in albania during the period 2004-2015 characteristic number percentage sex: men women total 653 335 988 66.1 33.9 100.0 age-group: <50 years 50-60 years 61-70 years >70 years 222 243 237 286 22.5 24.6 24.0 28.9 residence: tirana other districts 456 532 46.2 53.8 time period: 2004-2009 2010-2015 298 690 30.2 69.8 table 2 presents the distribution of selected demographic characteristics by sex of the hemorrhagic stroke cases. the proportion of older patients (70 years and above) was somehow higher in women than in men (32% vs. 27%, respectively), but this difference was not statistically significant (p=0.163). furthermore, the proportion of tirana residents was similar in both sexes (47% in men vs. 45% in women, p=0.638). also, there was no statistically significant difference between male and female hemorrhagic stroke cases regarding the time period under investigation dichotomized into 2004-2009 vs. 2010-2015 (p=0.213). gjorgji p, kruja j. trends and demographic characteristics of hemorrhagic stroke in albania during the period 2004-2015 (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-123 5 table 2. demographic distribution of hemorrhagic stroke cases by sex characteristic men (n=653) women (n=335) p-value * number (percentage) number (percentage) age-group: <50 years 50-60 years 61-70 years >70 years 142 (21.7) 165 (25.3) 168 (25.7) 178 (27.3) 80 (23.9) 78 (23.3) 69 (20.6) 108 (32.2) 0.163 residence: tirana other districts 305 (46.7) 348 (53.3) 151 (45.1) 184 (54.9) 0.638 time period: 2004-2009 2010-2015 188 (28.8) 465 (71.2) 110 (32.8) 225 (67.2) 0.213 * p-values from fisher’s exact test. figure 1 presents the overall and the sex-specific distribution of hemorrhagic stroke cases for each year included in the study (from 2004 to 2015). overall, the number of hemorrhagic stroke cases increased from 20 (in 2004) to 44 (in 2005) and, in the next couple of years, remained quite stable. from 2008 to 2012, the number of cases ranged from a minimum of 66 (in 2010) to a maximum of 85 (in 2011). next, there was a steep increase to 191 cases in 2013, and even more so in the following year (229 cases). conversely, in 2015, there was a sharp decrease, where there were registered only 47 cases of hemorrhagic stroke. the trend over time was more or less similar in both sexes, notwithstanding the generally higher number of cases in men for each year under investigation. figure 1. trend of hemorrhagic stroke cases in albania during the period 2004-2015 overall, there was evidence of a significant linear trend over time (mann-kendall test: p<0.01), indicating a gradual increase in the number of hemorrhagic stroke cases in albania for the period 2004-2015 (figure 1). 20 44 41 47 75 71 66 85 72 191 229 47 0 50 100 150 200 250 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 overall men women linear (overall) gjorgji p, kruja j. trends and demographic characteristics of hemorrhagic stroke in albania during the period 2004-2015 (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-123 6 discussion this study provides evidence on the distribution and demographic characteristics of hemorrhagic stroke cases hospitalized in tirana, the albanian capital for the period 20042015. the proportion of older patients was slightly but not significantly higher in women than in men. furthermore, the proportion of tirana residents was similar in both sexes. on the whole, there was evidence of a significant linear trend over time, which points to a steady increase in the number of hemorrhagic stroke cases in albania in the past decade. the reasons for the sharp decline of hemorrhagic stroke cases in albania in 2015 are difficult to explain. one reason may be the incomplete reporting for this particular year, pointing to quality deficits in the albanian health reporting system. another explanation may relate to the reduction of transferred stroke cases from other districts to tirana, the albanian capital, where the only tertiary health care facility is located. in any case, such considerable fluctuations in the number of hemorrhagic stroke cases in albania deserve further investigation. we have previously reported about the distribution and demographic characteristics of ischemic stroke in albania for the same period of time (from 2004 to 2015) (6). according to this previous report, the proportion of older women (70 years and above) with a diagnosis of ischemic stroke was significantly higher compared to men (55% vs. 41%, respectively, p<0.001). on the other hand, there was evidence of a higher proportion of men residing in tirana compared to women (35% vs. 30%, respectively, p=0.002). contrary to the current study involving hemorrhagic stroke patients, there was no evidence of a statistically significant trend over time for ischemic stroke for the period 2004-2015, notwithstanding a sharp increase in 2014 (6). the official reports from the albanian institute of statistics (instat) regarding the death rate from cerebrovascular disease are substantially lower than the global burden of disease (gbd) estimates for both men and women (4). from this point of view, instat reports that mortality rate from cerebrovascular disease in 2009 was about 100 and 120 (per 100,000 population) in males and females, respectively – values which are 57% lower in males and 41% lower in females compared with the gbd estimates for the year 2010 (4). regarding the age-standardized mortality rate from cerebrovascular disease, in albania, in the year 2010 it was about 147 deaths per 100,000 population – which constitutes the second highest rate in the region after macedonia (which, in turn, shows a particularly high mortality rate from this condition, with about 203 deaths per 100,000 population) (3). it should be noted that, among countries of southeastern europe, slovenia has achieved a remarkable decrease in the mortality rate from cerebrovascular accidents (from about 124 to 54 per 100,000 population in 1990 and 2010, respectively). as a matter of fact, all countries except albania have experienced various degrees of decline in the mortality rates from cerebrovascular disease due to effective treatment, as well as effective primary prevention measures introduced in several (routine) national health programs (3,7). in the clinical practice, the diagnosis of acute stroke is straightforward in most of the circumstances. from this perspective, the unexpected onset of a focal neurologic deficit in an identifiable vascular distribution with a common presentation (including hemiparesis, facial weakness and aphasia) indicates a common syndrome of “acute stroke” (6,8). however, there are several manifestations which are similar and very difficult to distinguish from an ischemic stroke syndrome (8,9). these are referred to as “stroke mimics” and include both processes occurring within the central nervous system and systemic events (8). taking into consideration the various treatment regimens of stroke which are currently very complex and gjorgji p, kruja j. trends and demographic characteristics of hemorrhagic stroke in albania during the period 2004-2015 (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-123 7 also bear the risk of undesirable effects, it is very important to differentiate these noncerebrovascular “stroke mimics” from real strokes, as argued elsewhere (8,9). this study may suffer from several limitations. stroke patients included in this study may not be fully representative of all stroke cases in albania. in any case, we included in our study all patients hospitalized in tirana during more than a decade, regardless of their place of residence (tirana, or other districts of albania). furthermore, the clinical diagnosis and discrimination of the stroke subtype was based on modern technology and scientific protocols employed in similar studies. demographic information for all patients was based on the medical charts and consisted of hard data such as age, sex and place of residence. given the administrative requirements, such demographic information is completed accurately and, therefore, there is no evidence of any kind of information biases in this regard. in conclusion, this study provides useful information about the increasing trend of hemorrhagic stroke in albania, a transitional country in southeastern europe which is characterized by rapid changes including unhealthy dietary habits. nevertheless, further studies should be conducted in albania at a national level in order to obtain valuable information about the extent, distribution and the main risk factors of both ischemic and hemorrhagic stroke. references 1. brott t, bogousslavsky j. treatment of acute ischemic stroke. n engl j med 2000;343:710-22. 2. allder sj, moody ar, martel al, morgan ps, delay gs, gladman jr, fentem p, lennox gg. limitations of clinical diagnosis in acute stroke. lancet 1999;354:1523. 3. albanian institute of public health. national health report: health status of the albanian population. tirana, albania; 2014. 4. institute for health metrics and evaluation (ihme). global burden of disease database. seattle, wa: ihme, university of washington; 2014. 5. weisberg la, nice cn. intracranial tumors simulating the presentation of cerebrovascular disease. am j med 1977;63:517-24. 6. gjorgji p, kruja j. ischemic stroke during the period 2004-2015 in transitional albania. management in health 2016;xx/2:16-8. 7. burazeri g, achterberg p. health status in the transitional countries of south eastern europe. seejph 2015;1. doi: 10.4119/unibi/seejph-2015-48. 8. kothari ru, brott t, broderick jp, hamilton ca. emergency physicians: accuracy in diagnosis of stroke. stroke 1995;26:2238-41. 9. norris jw, hachinski vc. misdiagnosis of stroke. lancet 1982;1:328-31. __________________________________________________________ © 2016 gjorgji et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://doi.org/10.4119/unibi/seejph-2015-48 karma e, gashi s. technical efficiency of kosovo public hospitals (original research). seejph 2022, posted: 27 july 2022. doi: 10.11576/seejph-5771 p a g e 1 | 11 original research technical efficiency of kosovo public hospitals emiljan karma phd1, dr. silvana gashi 2 1 research centre on developing economies, faculty of economic, political and social sciences, catholic university our lady of good counsel, tirana, albania 2 management department, faculty of business, university “aleksandër moisiu”, durrës, albania corresponding author: emiljan karma, phd. address: univ. katolik zoja e keshillit te mire, rruga d. hoxha, 23, tirana (albania) telephone: 00355695639061 email: e.karma@unizkm.al karma e, gashi s. technical efficiency of kosovo public hospitals (original research). seejph 2022, posted: 27 july 2022. doi: 10.11576/seejph-5771 p a g e 2 | 11 abstract aim: the goal of this paper is to evaluate the technical efficiency of kosovo public hospitals and to propose ways to improve the situation. methods: an input-oriented data envelopment analysis model with a constant return to scale was applied for a 3-year period from 2018 to 2020. input variables of number of beds, number of specialists and how they are used to produce outputs of inpatient discharges and surgical operations, are examined. results: the analysis highlights the marked hospital technical inefficiencies. this study clearly points out the greater attention of public healthcare institutions toward production efficiency. results illustrate that at least half of kosovo public hospitals operate inefficiently compared to their counterparts. inefficient, compared to efficient hospitals, on average utilize at least (depending on scenarios analysed) 30% more beds and specialists. conclusions: the resources available for public health services in kosovo are the lowest in europe and the challenge remains to secure financial resources and use them effectively. the study illustrates that most of kosovo public hospitals run inefficiently. productivity is low, efficiency needs to be improved, especially in terms of introducing modern treatment methods such as daycare. based on this research, it seems advisable to decrease the number of beds while rationalizing the number of specialized physicians with respect to the special requirements of therapeutic and diagnostic processes in the individual hospitals. keywords: dea, efficiency; kosovo, public health; tobit regression. karma e, gashi s. technical efficiency of kosovo public hospitals (original research). seejph 2022, posted: 27 july 2022. doi: 10.11576/seejph-5771 p a g e 3 | 11 introduction healthcare services in kosovo are provided through a network of health institutions organized at three levels: primary(kpsh), secondary(kdsh) and tertiary level (ktsh). healthcare services are organized and provided by healthcare providers such as hospital services, home health care services and emergency ones. these services are provided in public and private health institutions. based on the law on health 04 / l-125 (1), the ministry regulates, supervises, and controls the health care implementation in public and private institutions at all three levels of health care. the resources available for public health services in kosovo are the lowest in europe and the challenge remains to secure financial resources and use them effectively (2). over the past decade, kosovo has experienced a rise in health care spending. during the 11-year period covering 2010 to 2021, kosovo's per capita health care spending (in u.s. dollars) increased 1,9 times from $49 in 2010 to $141 in 2021 (3,4). kosovo’s total health expenditure, as a percentage of gross domestic product, rose from 1.6% in 2010 to 3.5% in 2021 (3,4). this study on the health system of kosovo seeks to identify the technical inefficiencies present in public hospitals in kosovo considering the necessary interventions to improve cost – effectiveness. hospitals are the key resource units in a health care system. they consume the majority of a country's health expenditures, and the important role they play in the delivery of health care services place them at the root of many pressing issues. because of their importance, hospitals strongly influence their health care system's efficiency (5). performance in the production theory refers to an optimal combination of inputs to achieve maximum outputs, thereby reducing waste (6). regarding efficiency, we refer to the way that public hospitals allocate (allocative efficiency) and utilize their inputs (productive efficiency) to produce outputs in terms of specialized services. efficiency refers to the use of an input to generate output; previously defined as the output-toinput ratio, such as cost per unit or production per hour of labour (7). literature (8 10) has shown that a traditional method (ratio analysis) is not relevant in measuring the overall performance of a dmu (decision making unit). ratios are based on a single input and single output and measure the performance on a single indicator, which does not serve the purpose of measuring the hospital efficiency. the modern efficiency method can be extended to more inputs and outputs and can be used to measure the dmus performance. the study proposes relative effectiveness as a metric that can be used relatively to assess the success of dmus in terms of social and financial aspects. to our knowledge, this is the first study that directly investigates the kosovo public hospitals’ efficiency using a nonparametric method like dea. there are studies that use the traditional method (parametric and ratio analysis) in evaluating indirectly but partially the efficiency in health care institutions. lleshi (11) conducted a study using the parametric model to evaluate the quality assurance concerning the quality based management system. bytyqi et al. (12) use a quantitative approach, with an explorative-descriptive design to examine the leadership profile and quality in primary, secondary and tertiary public health institutions in kosovo. tahiri et al. (13) conducted a study using the traditional method to evaluate the patient satisfaction with the primary health care service in gjilan region, kosovo. hoxha et al. (14) conducted a study using multiple linear regression analysis to assess predictive factors for patient satisfaction with healthcare services as a measure of the quality of hospital care in public and private hospitals in kosovo. kosovo agency of statistics (15-17) periodically reports the efficiency indicators of public hospitals activity in kosovo (indicators which are based on a single input and single output). karma e, gashi s. technical efficiency of kosovo public hospitals (original research). seejph 2022, posted: 27 july 2022. doi: 10.11576/seejph-5771 p a g e 4 | 11 methods the evaluation of health services has been addressed by a number of authors worldwide. multi-criteria methods are widely used for the evaluation as tools that are able to assess the efficiency of inputs and show the opportunities for the improvement of inefficient units, but also to identify exemplary units. one of the tools able to determine the rate of technical efficiency of production units is the data envelopment analysis (dea) model. dea is a non-parametric method that evaluates the relative technical efficiency of decision-making units (dmus) in terms of input / output combination. dea analyzes the efficiency with which dmu (in this study, hospital) uses inputs to produce its outputs. this method identifies the optimal input/output combination and represents it with the "best practice frontier," or data envelope. dmus that compose this frontier are assigned an efficiency score of one and are technically efficient relative to their peers (18). all other dmus are assigned a score of between less than one, but greater than zero (18,19). the first dea model was formulated in the study published by charnes, cooper, rhodes (20). this model is based on the assumption of constant returns to scale and maximizes the efficiency of the evaluated production unit under the condition that the efficiency of all other units is less than or equal to one. the modelling of technical efficiency was performed using the inputoriented model that expects that inefficient units should reduce their inputs with respect to the outputs attained. however, it is also a well-known fact that reductions in key human resources (physicians, general nurses, and midwives) have a negative impact on the quality of the services provided in both public health and social services (21,22). the two basic dea models are the ccr model of charnes, cooper, rhodes (20) and the bcc model of banker, charnes, cooper (23). ccr assesses technical efficiency under a constant return to scale (crs) condition (20). considering that this is often not the case, banker et al. (23) introduced the variable return to scale (vrs) condition, so that an institution will be compared to a similarly sized institution that has similar return to scale (24). in the basic dea model, there are two approaches that can be used, the input-oriented approach, which maximizes proportional input reduction by holding outputs constant, and the output-oriented approach, which maximizes proportional output increase while keeping inputs constant (20). our analysis only uses the input-oriented approach with its crs model: θ * =min 𝜃𝑘 , subject to ∑ 𝜆𝑗 𝑛 𝑗=1 𝑦𝑟𝑗 ≤ 𝑦𝑟𝑘 𝑟 = 1, 2, … , 𝑠 ∑ 𝜆𝑗 𝑛 𝑗=1 𝑥𝑖𝑗 ≥ θ * 𝑥𝑖𝑘 𝑖 = 1, 2, … , 𝑚 𝜆𝑗 ≥ 0 ∀ 𝑗 = 1, 2, … , 𝑛 dea show an exponential growth in its use in academic research over the last forty years (25). technical efficiency is analysed in two stages. first, we calculated the relative technical efficiency using the basic outline of the input-oriented dea model with crs (constant returns to scale). in the second stage, a regression analysis is performed to relate efficiency scores to contextual factors for investigating their influence on the relative efficiency in the provision of hospital services. the karma e, gashi s. technical efficiency of kosovo public hospitals (original research). seejph 2022, posted: 27 july 2022. doi: 10.11576/seejph-5771 p a g e 5 | 11 description of the production units evaluated public hospitals (dmus), the inputs and outputs, and evaluation models are specified below. statistical analyses are performed using stata 16 software. dmus in the context of the health system as of 31 december 2020, a total of 8 public hospitals operated in kosovo, with a total capacity of 3872 beds: university clinical centre kosovo (qkuk) and seven public hospitals (regional hospitals). according to the ministry of health (26), the expenses of public health for inpatient and outpatient care in secondary and tertiary health care providers increased during the period 2010 – 2018 (passing from 45% to 70% of the kosovo health budget). the hospital network comprises both public and private hospitals, while public hospitals are unambiguously dominant. significant changes implemented in the last 20 years were aimed at making the public health system more efficient, whether from the perspective of the hospitals’ operation or in terms of hospital care funding changes. although much was accomplished, reforms largely failed due to the discrepancy between the identification of internal needs and external priorities that drove health reform process (world bank and other donors). secondly, the weak state capacities and the political instability contributed to slowing down the implementation of reforms (2). this research focuses on public hospitals that provide comprehensive acute inpatient care. inputs and outputs there is no clear guideline on how to select among a variety of indicators. the articles specified below demonstrate the combination input/output changes in various studies. medarević et al. (27) conducted a study to evaluate the efficiency and productivity of public hospitals in serbia between 2015 – 2019. their method was the input – oriented method and the proposed dea model comprises the number of beds, the number of health workers (without physicians), the total number of physicians. the output variables included the number of inpatient episodes and the number of outpatient episodes. torabipur et al. (28) aimed to measure the hospital productivity using a cross sectional study in which the panel data comprised a 4-year period from 2007 to 2010. the input measures included are the number of nurses, number of beds and number of physicians. the output measures included are number of the outpatients and inpatients, average of hospital stay, and number of surgeries. kundurjiev et al. (29) focused on the efficiency in healthcare and especially technical efficiency in psychiatric hospital care. the proposed dea model includes as inputs hospital beds, physicians, nurses, and as outputs inpatients and bed – days. pirani et al. (30) focused on the evaluation of the efficiency of public hospitals between 2012 and 2016. their method was the output-oriented dea model positing variable returns to scale, while the input variables comprised the number of hospital admissions, the number of nurses, and the number of available beds. the output variables included the average length of stay and the bed turnover interval. ghahremanloo et al. (31) point to the importance of performance evaluation as a relevant tool for hospital management. the proposed dea model includes the evaluation of the overall hospital efficiency. the model’s input indicators comprise the number of healthcare professionals, the number of other staff, and the number of beds. the output indicators include the bed occupancy rate and the bed turnover rate. varabyova et al. (32) focused their research on applying the non-parametric methods (such as dea and fdh) to evaluate certain italian and german hospitals. their input indicators were the number of beds, the number of physicians and the number of https://pubmed.ncbi.nlm.nih.gov/?term=medarevi%c4%87%20a%5bauthor%5d karma e, gashi s. technical efficiency of kosovo public hospitals (original research). seejph 2022, posted: 27 july 2022. doi: 10.11576/seejph-5771 p a g e 6 | 11 nurses (the personnel data are specified in a full-time equivalent), while the output indicators were the selected inpatient adjusted and day cases. however, to use dea correctly, the number of dmus must be high enough: the larger the number of variables used, the larger the number of dmus (33). given that the number of dmus in kosovo is only eight, two inputs indicators and two output indicators were chosen to fulfil the objective of the article. secondly, after conducting a review of the available literature (34, 35) we decided to use these inputs and outputs: x1 number of hospital beds available in public hospitals (input); x2 – number of specialized physicians (input); y1 – number of hospitalized patients by year (output); y2 – number of surgeries by year (output). the performance estimation of efficiency according to the dea model is implemented using four specific models. the first two models contain two outputs and one input and estimate the efficiency with constant returns to scale (crs) method. these models are indicated as x1crs (x1; y1-y2) and x2-crs (x2; y1 – y2). consequently, the partial efficiency is estimated from the perspective of the individual inputs (x1, x2). the other two models contain two inputs and one output and estimate the efficiency with crs method. these models are indicated as y1crs (x1-x2; y1) and y2-crs (x1-x2; y2). consequently, the partial efficiency is estimated from the perspective of the individual outputs (y1, y2). results the distribution of the results between the individual inefficiency levels (mild, moderate, strong) confirms that models x1 crs attain the worst results, while the best results are attained by y1 – crs. of the 8 general hospitals included in the study, the average efficiency rate fluctuates from 70% to 91% depending on the model applied. according to this analysis, the best performance, in all models, is obtained by the public hospital of vushtrri. on the other side, considering these input – output indicators, the worst performance is obtained by the public hospital of gjilan. dmus efficiency ranking, the means of input and output variables, for both efficient and inefficient hospitals, are presented in table 1. table 1. hospital efficiency results dmu efficiency ranking (by model) x1 crs x2 crs y1 crs y2 crs prizren 4 1 1 2 peje 6 4 5 5 gjilan 8 7 7 8 vushtrri 1 1 1 1 mitrovice 2 6 1 4 gjakove 6 1 1 7 ferizaj 3 8 8 6 qkuk 5 5 6 3 the efficiency rate of 8 general hospitals by models mean 0,70 0,87 0,91 0,72 mean (%) 70 87 91 72 st. deviation 0,17 0,24 0,33 0,48 efficient hospitals are using fewer inputs to produce more outputs compared to inefficient hospitals. the extent of the inefficiency changes according to the karma e, gashi s. technical efficiency of kosovo public hospitals (original research). seejph 2022, posted: 27 july 2022. doi: 10.11576/seejph-5771 p a g e 7 | 11 models used. the presence of inefficiencies indicates that a hospital has excess inputs or insufficient outputs compared to those hospitals on the efficiency frontier. the distribution of dmus based on the efficiency score is presented in figure 1. for the efficiency comparison over time, a mann-whitney test is used (36-39). this non-parametric test identifies whether the efficiency scores from one year to another have a significant difference. following the results (see table 2), we can conclude that there are no significant differences in all models with the exception of model y2 – crs: in this case, it can be seen a statistically significant efficiency improvement during 2019 and 2020 compared with the year 2018. the selected tobit model (40, 41) for explaining the observed hospital inefficiencies contains the following variables: hospital size (size), average length of stay (alos) and bed occupancy rate (bor). the tobit model was performed for the four scenarios (x1-crs; x2-crs; y1-crs; y2-crs). table 2. results of the mann – whitney test (year efficiency comparison). x1 crs x2 crs y1 crs y2 crs 18/19 18/20 19/20 18/19 18/20 19/20 18/19 18/20 19/20 18/19 18/20 19/20 u value 15,5 15 24 20 28 27 19 27 25 11.5 12 30 z – value -1,68 -1,73 -0,78 -1,2 -0,36 0,47 -1,31 -0,47 0,68 -2,1 -2,04 0,15 p value 0,09 0,08 0,43 0,23 0,71 0,63 0,19 0,64 0,49 0,04* 0,04* 0,87 note: p* = 0.05 (significance level) table 3 presents the tobit regression model results. results from the regression analysis indicate that the coefficient for bed occupancy rate has a positive coefficient in all efficiency models indicating that the higher the bed occupancy rate the higher the efficiency score (in x1 – crs model, 1% increase in bed occupancy rate increases the 1 3 4 1 2 1 3 1 2 3 1 5 3 1 1 0 1 2 3 4 5 6 7 8 9 x1 crs x2 crs y1 crs y2 crs figure 1. distribution of dmus by efficiency score efficiency mild inefficiency moderate inefficiency strong inefficiency note: [0-0,5[ score: strong-inefficiency; [0,5 – 0,7[ score: moderate inefficiency; [0,7-0,99[ mild-inefficiency; [1] score: efficiency karma e, gashi s. technical efficiency of kosovo public hospitals (original research). seejph 2022, posted: 27 july 2022. doi: 10.11576/seejph-5771 p a g e 8 | 11 efficiency score by 0,0143054 all other factors remaining constant. the score coefficient is statistically significant at the 1% level). the coefficient for the hospital size is positive in all efficiency models but significant only for x2 – crs and y1 – crs models. the coefficient for alos has a negative and significant coefficient in all models indicating that the higher the average length of stay the lower the technical efficiency score. table 3. results of tobit model efficiency model variable coefficient t p > |t| x1 crs size -0,0082051 -0,50 0,640 bor 0,0143054 22.99 0,000** alos -0,1625514 -15.23 0,000** cons 0,6849855 20.51 0,000** sigma .0094139 **p < 0,01 *p < 0,05 n. observations 8 lr chi2 45,13 prob > chi2 0,0000 log likelihood 25,973067 pseudo r2 -6,6161 x2 crs size 0,5481224 4,07 0,010* bor 0,0204997 4,04 0,010* alos -0,2820566 -3,24 0,023* cons 0,7138949 2,62 0,047* sigma 0,0767903 **p < 0,01 *p < 0,05 n. observations 8 lr chi2 10,06 prob > chi2 0,018 log likelihood 9,1819099 pseudo r2 -1.2127 y1 crs size 0,3574446 3,48 0,018* bor 0,0125095 3,23 0,023* alos 0,2419334 -3,64 0,015* cons 1,115265 5,36 0,003** sigma 0,00586798 **p < 0,01 *p < 0,05 n. observations 8 lr chi2 8,39 prob > chi2 0,0387 log likelihood 11,33377 pseudo r2 -0,5873 y2 crs size 0,2358457 2,35 0,065 bor 0,0244741 6,48 0.001** alos 0,1787922 -2,76 0,040* cons 0,1009707 0,50 0,640 sigma 0,0571663 **p < 0,01 *p < 0,05 n. observations 8 lr chi2 16,24 prob > chi2 0,0010 log likelihood 11,542818 pseudo r2 -2,3711 karma e, gashi s. technical efficiency of kosovo public hospitals (original research). seejph 2022, posted: 27 july 2022. doi: 10.11576/seejph-5771 p a g e 9 | 11 discussion this study is one of the first attempts at analyzing technical the efficiencies of public hospitals in kosovo by using dea methodology. the study illustrates that the large majority of kosovo public hospitals run inefficiently. these results are not surprising and are further support of the conventional beliefs that the kosovo health and hospital systems are not effective and efficient (42). because the hospital system is the largest component of the health system, it can be said that to a great degree, the efficiency of the hospital system determines the health system efficiency. as shown in table 1, inputs are wasted and not utilized in the production of hospital services. the above results may indicate—within the context of the evaluation logic according to the input-oriented dea model—those inefficient hospitals should primarily consider reducing the number of beds and secondly discuss the number of specialized physicians. however, this recommendation must be considered individually in the hospital conditions, especially those showing an extensive inefficiency degree, even if this includes at least 50% of all the public hospitals. the evaluation of the technical efficiency results according to hospital size shows that big hospitals are not necessarily the leaders within the set analysed (e.g., the hospital of vushtrri is a small structure with only 63 beds.). based on this research, it seems advisable to decrease the number of beds while rationalizing the number of specialized physicians with respect to the special requirements of therapeutic and diagnostic processes in individual hospitals. in the case of physicians, any interference in their numbers should only be made based on special evaluation processes, because a reduction in the number of physicians is likely to decrease the quality of healthcare (21, 22). with this information, policymakers and managers will be able to make educated choices in which path to take to increase efficiency. since hospital managers generally have more control over their inputs, they may devote more attention to the examination of total inefficiencies generated by excessive input usage. however, examinations of output inefficiencies can also provide strategic direction for the hospital by indicating where to increase its efficiency. by analyzing output inefficiencies and excess inputs, policymakers and managers can attempt to make hospital and health systems more efficient. references 1. kosovo assembly. law on health no. 04/l-125. available from: https://msh.rks-gov.net/wpcontent/uploads/2020/03/law-onhealth.pdf (accessed: 03/05/2022). 2. percival v, sondorp e. a case study of health sector reform in kosovo. conflict and health 2010;4:1-14. 3. world bank database. gdp per capita kosovo. available from: https://data.worldbank.org/indicator/n y.gdp.pcap.cd?locations=xk (accessed 03/05/2022) 4. instituti gap. shpenzimet buxhetore kosove. available from: https://www.institutigap.org/ spendings /#/~ /klasifikimi-institucional (accessed 03/05/2022). 5. vrabkova i, vankova, i. efficiency of human resources in public hospitals, an example from the czech republic. int. journal of environmental. research and public health 2021;18:4711-35. 6. chase rb, jacobs rf, aquilan jn. operations management nella produzione e nei servizi. mcgraw-hill education, 2012. 7. cooper ww, seiford ml, tone k. data envelopment analysis: a comprehensive text with models, applications, references, and dea-solver software. new york:springer, 2007. https://msh.rks-gov.net/wp-content/uploads/2020/03/law-on-health.pdf https://msh.rks-gov.net/wp-content/uploads/2020/03/law-on-health.pdf https://msh.rks-gov.net/wp-content/uploads/2020/03/law-on-health.pdf https://www.institutigap.org/%20spendings%20/#/~ /klasifikimi-institucional https://www.institutigap.org/%20spendings%20/#/~ /klasifikimi-institucional karma e, gashi s. technical efficiency of kosovo public hospitals (original research). seejph 2022, posted: 27 july 2022. doi: 10.11576/seejph-5771 p a g e 10 | 11 8. diamond am, medewitz jn. use of data envelopment analysis in an evaluation of the efficiency of the deep program for economic education. journal of economic education 1990;21:337-54. 9. sexton rt. the methodology of data envelopment analysis. in silkman rh editor. measuring efficiency: an assessment of data envelopment analysis. san francisco: jossey-bass, inc., 1996:73 – 105. 10. wei zh, zeshui x. an overview of the fuzzy data envelopment analysis research and its successful applications. international journal of fuzzy systems 2020;22:1037-1055. 11. lleshi s. the effectiveness of qms implementation in 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f. the specification of a hospital cost function. a comment on the recent literature. journal of health economics 1987; 6:147-57. 35. kohl s, schoenfelder j, fuegener a, brunner jo. the use of data envelopment analysis (dea) in healthcare with a focus on hospitals. health care management science 2019;22:245-86. 36. chilingerian ja. exploring why some physicians’ hospital practices are more efficient: taking dea inside the hospital. in charnes a, cooper w, lewin ay, seidorf lm editors. data envelopment analysis. kluwer academic publishers 1994:167-94. 37. valdmanis v. sensitivity analysis for dea models: an empirical example using public vs. n.f.p hospitals. journal of public economics 1992; 4:185-205. 38. ley e. eficiencia productiva: un estudio aplicado al sector hospitalario. investigaciones economicas 1991; 15:71-88. (with a summary in english) 39. grosskopf s, valdmanis v. measuring hospital performance. a nonparametric approach. journal of health economics 1987; 6:89-107. 40. chilingerian ja. evaluating physician efficiency in hospitals: a multivariate analysis of best practices. european journal of operational research 1995;80:548-74. 41. amore md, murtinu s. tobit models in strategy research: critical issues and applications. global strategy journal 2021;11:331-55. 42. qosaj fa, froeschl g, berisha m, bellaqa b, holle r. catastrophic expenditures, and impoverishment due to out‑of‑pocket health payments in kosovo. cost effectiveness and resource allocation 2018; 16:1-12. __________________________________________________________________________________________ © 2022 karma et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.researchgate.net/journal/engineering-management-in-production-and-services-2543-912x https://www.researchgate.net/journal/engineering-management-in-production-and-services-2543-912x reijnders, a.p.m.; van den eijnde, s.q.; janssen, r.r.m.; van kessel r. autism and inclusive education: recommendations for improvement during and after covid-19 (policy brief). seejph 2022, 23 june 2022. doi: 10.11576/seejph-5602 page1 | 12 policy brief autism and inclusive education: recommendations for improvement during and after covid-19 anne petronella maria reijnders1, sanne quérine van den eijnde1, ruben renerus martin janssen1, robin van kessel1 1 department of international health, care and public health research institute (caphri), faculty of health, medicine, and life sciences, maastricht university, netherlands corresponding author: robin van kessel, phd email: r.vankessel@maastrichtuniversity.nl mailto:r.vankessel@maastrichtuniversity.nl reijnders, a.p.m.; van den eijnde, s.q.; janssen, r.r.m.; van kessel r. autism and inclusive education: recommendations for improvement during and after covid-19 (policy brief). seejph 2022, 23 june 2022. doi: 10.11576/seejph-5602 page2 | 12 abstract context: covid-19 has disproportionately affected the autism community yet also provided an opportunity to improve education delivery. there are several policies to ensure education for autistic children, but there are still gaps that need to be filled. policy options: this policy brief analyses several interventions designed to create a more inclusive education environment for autistic children. the four policy options described and analyzed are: teacher assistants focussing on children with special education needs, peer mentoring interventions (pmi), digitalization of education, and gamification. recommendations: the analysis concludes that pmi and gamification would be the most feasible to implement. pmi can improve the dynamic between autistic children and their neurotypical peers. gamification enables personalization to educational needs and fluid transition to at-home education. subsequently, the european union already invests in gamification, making the step smaller to invest in gamification for inclusive education. keywords: autism, special education needs (sen), policy, education acknowledgments: we thank prof dr katarzyna czabanowska for the opportunity to explore this topic as part of the leadership track in the master governance and leadership in european public health. authors' contributions: all authors contributed equally to this work. conflict of interest: none declared source of funding: none declared reijnders, a.p.m.; van den eijnde, s.q.; janssen, r.r.m.; van kessel r. autism and inclusive education: recommendations for improvement during and after covid-19 (policy brief). seejph 2022, 23 june 2022. doi: 10.11576/seejph-5602 page3 | 12 introduction autism autism spectrum condition (henceforth autism) is a neurodevelopmental condition characterized by impairments in social communication and inconsistent restrictive or repetitive behavior (1,2). the global prevalence of autism is estimated at around 1%, with the condition affecting 2 to 3 times more men than women (3–5). about 70% of autistic people experience co-occurring conditions, such as intellectual disabilities and depression (4). autistic people show a wide variety of characteristics associated with the autism diagnosis and with a wide range of severity from very mild to severe (6). consequently, there is a lot of variation in the kind and amount of support they need to achieve relative independence (2). autistic children are shown to benefit from inclusive education and interaction with neurotypical peers in general (7,8). current framework there are two international policies in place to ensure the rights of people with disabilities and education: the united nations in the universal declaration of human rights (udhr) and the convention on the rights of persons with disabilities (crpd). the udhr promotes and protects the rights of autistic children. it states that education is a fundamental human right and is "directed to the full development of the human personality" (9). the crpd was the first international, legally binding treaty that focused on the human rights of people with disabilities specifically. when signed, member states are obliged to respect the needs of people with disabilities, including autism, such as the right to education (10). the disability rights in education model (derm) offers a guidance tool that provides a multilevel framework for evaluating aspects of inclusive education at international, national, and local levels. it also provides an overview of key domains relevant to the development of inclusive education (8). covid-19 and social inclusion social inclusion is defined as improving the terms of participation in society, particularly for disadvantaged groups, through enhancing opportunities, access to resources, voice, and respect for rights (11). whereas a socially inclusive society is seen as a society where people feel valued, differences are respected, and basic needs are provided so that each individual can live with dignity. moreover, social exclusion is defined as the process of being left out from the social, economic, political and cultural systems which contribute to the integration of a person into the community (12). apart from the given opportunity covid-19 provides us to alter the current position of social inclusion, it must be stated that social inclusion is also one of the clear objectives of the european union and their agenda set during the lisbon convention in 2000. this highlights the need for a proper strategy to achieve social inclusion and eventually their relation to inclusive education. this has been on the european agenda for more than twenty years. being on the european agenda for over twenty years and not being fully achieved yet indicates the challenges the society experienced before covid-19 imposed on achieving social inclusion (8). context it is essential to ensure education for autistic children because education is a human right (10). many frameworks, guidelines, and policies are already in place, usually regarding children with special education needs and not specific for autistic children (13–18). there is still a gap between the current and desired situation. in the next chapter, several policy options will be discussed to tackle the issue. the covid-19 https://www.zotero.org/google-docs/?k6nxnf https://www.zotero.org/google-docs/?cewceu https://www.zotero.org/google-docs/?gjpmy6 https://www.zotero.org/google-docs/?93ww50 https://www.zotero.org/google-docs/?zlp6d5 https://www.zotero.org/google-docs/?v9wft8 https://www.zotero.org/google-docs/?0cigpo https://www.zotero.org/google-docs/?h62zcg https://www.zotero.org/google-docs/?f2fkjy https://www.zotero.org/google-docs/?iypkqa https://www.zotero.org/google-docs/?pxpbf3 https://www.zotero.org/google-docs/?rkmsxt https://www.zotero.org/google-docs/?qsas0o https://www.zotero.org/google-docs/?nsripe reijnders, a.p.m.; van den eijnde, s.q.; janssen, r.r.m.; van kessel r. autism and inclusive education: recommendations for improvement during and after covid-19 (policy brief). seejph 2022, 23 june 2022. doi: 10.11576/seejph-5602 page4 | 12 pandemic presents a unique opportunity for change and opens up a policy window. the pandemic has afforded glimpses of how quickly the world could change (19), for example, the speed and extent of some of the responses by governments (20,21), like the switch to online education and hybrid learning (19,22). since covid-19 changed how our society could operate, this provides us an opportunity to put social inclusion higher on the european agenda and address inclusive education accordingly. three political streams contribute to whether an issue will gain entrance onto the agenda: the problem, the policy, and the politics. the policy streams model of kingdon argues that each of the three streams runs independently from the others, and it is only when all three streams converge that a window of opportunity opens for a given issue (23). the window of opportunity is when a given initiative is most likely to be acted upon and passed. policy windows rarely present themselves, and advocates must capitalize during this time because the potential of another opportunity is uncertain (23). in this context, the problem stream refers to the substandard education delivery to the autism community. the policy options presented below represent possible approaches that the policy stream can take to improve education delivery. policy options based upon the kingdon model, we formulated the following policy options. we evaluated the possibilities of children with special education needs (sen), of which autistic children are part. therefore, policy options that would work for children with sen should also positively affect autistic children and vice versa. option 1: teaching assistants focus on sen children one of the recommendations to improve the quality of inclusive education while maintaining a high level of individual focus for children with sen is using teaching assistants (tas) next to a teacher in classrooms. in this context, a ta is seen as school staff in pupil and classroom-based support roles while working mainly with individuals with sen. the focus of a ta lies specifically upon having more paraprofessional experience with children needing special attention; therefore, this can be potentially helpful to increase the quality of inclusive education (24). tas have a seemingly positive impact on learning outcomes; however, evidence remains somewhat inconsistent (25). when the tas are explicitly trained to deliver these programs, studies show that this has a beneficial outcome on the learning results of children with sen (26). in other words, positive learning outcomes are strongly associated with teachers and tas working together effectively next to the quality of preparation and training they are given. one of the main arguments for using tas is their ability to reduce the workload and stress a teacher experiences. teaching a classroom with inclusive education creates an opportunity to maintain a high quality of educational services to individuals with specific needs and individuals without specific needs (27). the arguments given for the use of tas in classrooms show that it is crucial for future research to focus on international research, such as the perspectives of this role and the impacts tas might have on inclusive education. moreover, research should focus on finding the most appropriate type of training for tas and seeing how teachers and tas can work together effectively. different methodological approaches should be used in order to facilitate research more efficiently. an example of a well-developed implementation to use teaching assistants in inclusive education can be found in the national policies of latvia. one of their https://www.zotero.org/google-docs/?stplng https://www.zotero.org/google-docs/?h8zb6n https://www.zotero.org/google-docs/?cejuod https://www.zotero.org/google-docs/?fewpvc https://www.zotero.org/google-docs/?wg6bqy https://www.zotero.org/google-docs/?igcssy https://www.zotero.org/google-docs/?44zme5 https://www.zotero.org/google-docs/?avi5t9 https://www.zotero.org/google-docs/?8ht7tc reijnders, a.p.m.; van den eijnde, s.q.; janssen, r.r.m.; van kessel r. autism and inclusive education: recommendations for improvement during and after covid-19 (policy brief). seejph 2022, 23 june 2022. doi: 10.11576/seejph-5602 page5 | 12 strategies entails the use of certain conditions. as an example, assistant services were introduced next to specific requirements for persons wanting to deliver these services. however, latvia failed to address the definition of inclusive education in its entity; thus, some minor limitations might occur (28). option 2: peer mentoring interventions to improve social skills one type of intervention that has shown promising results in inclusive educational settings and is already widely used is peer mentoring intervention (pmi) (7). within pmi, one or multiple peers are connected to the autistic child to help with practice and learn social behaviors within a typical social setting. it may be well-suited for implementation in the school setting as autistic children can have more active time within the intervention without the intervention putting a lot of responsibilities on the teacher. however, it may put extra pressure on the peer chosen to participate (7). it is important to evaluate how intensive the intervention needs to be and how many peers will be pmi encourages more interaction between autistic children and their peers and has shown to be effective in teaching autistic children social skills (7,29). there are different pmi strategies, which strategy will have the most effect depending on the child's characteristics (29). when looking for school-based interventions, generalizability is essential (30). through interventions aimed at achieving high levels of generalizability, the possibility of transferring the interventions to broader settings is more likely. this would improve the quality of the presented policy options, and thus the chances of successful implementation to a wider extent would increase. most studies with good generalizability had similar criteria, with fitting characteristics of the children (29). other interventions possible, including different technological interventions that positively affect social skills. moreover, pmi has the benefit that it can be incorporated in daily activities (29,31). it is also possible to make use of multicomponent pmis, which combine indirect strategies like technological interventions with pmi (7). these multicomponent pmis show substantial gains in communication and reduction in isolation to no treatment. option 3: digitalization to improve inclusive education digital education has gained massive popularity since the covid-19 pandemic (22,32). the need for online education had never been this demanding in the short timeframe available. huge changes were made and after 1.5 years, we are all familiar with hybrid working or education. but even before the covid-19 pandemic, the interest in online education was present. for example, a meta-analysis found technology and online learning valuable for all children when the teaching strategies are diverse, such as tutorials, simulations, and word processing (33). on top of that, collaboration between peers should be encouraged, the child itself should be in control of their learning speed, and consistent feedback should be given. children with sen also benefit from these interventions, and research found multimodal learning to be especially helpful, which offers education in the forms of images, videos, animations, and recordings. this helps children with sen engage in technology in their learning (34–36). other benefits found by research are mentioned in box 1. however, children with sen have individual needs and learning difficulties that need to be taken into account to achieve the best outcome. repetition and consistency of used methods are required to keep these children https://www.zotero.org/google-docs/?7qpjrn https://www.zotero.org/google-docs/?vfiqd6 https://www.zotero.org/google-docs/?f1on0d https://www.zotero.org/google-docs/?gdoazb https://www.zotero.org/google-docs/?jd0wau https://www.zotero.org/google-docs/?mglnn0 https://www.zotero.org/google-docs/?apj1ht https://www.zotero.org/google-docs/?xuuems https://www.zotero.org/google-docs/?eny81k https://www.zotero.org/google-docs/?qfb3u0 https://www.zotero.org/google-docs/?xhxuvk https://www.zotero.org/google-docs/?z31mug reijnders, a.p.m.; van den eijnde, s.q.; janssen, r.r.m.; van kessel r. autism and inclusive education: recommendations for improvement during and after covid-19 (policy brief). seejph 2022, 23 june 2022. doi: 10.11576/seejph-5602 page6 | 12 engaged in online learning, and improve the personal experience of online education (37). box 1. examples of benefits of digital education the combination of audio, video, text and other means to convey meaning has the potential to provide children greater access to curricula and learning opportunities and additional ways to demonstrate their understanding (38) individual pace of learning, lack of distractions, better meaningful social contact (39) option 4: games and education: the perfect fit one form of digital education is gamification. gamification uses game elements and design techniques to teach skills in a playful way (40). it is crucial to keep the users engaged on intrinsic motivation instead of for rewards given by the game. this can be done with the right balance of mechanics, dynamics, and aesthetics, as seen in the mde model (see table 1; (41). gamification is already in use in educational settings (42). it shows a lot of potential in the educational background to empower neurotypical children as children with sen and impact their motivation and academic skills (40,43). an advantage of gamification is that there are options to personalize the software to the child's needs, whether this is on the graphics or difficulty of the content (44). due to this, it should be possible to make one gamification program customizable to both the needs of neurotypical and special needs children. autistic people tend to have an interest in computerized learning (31,43). however, it is unclear whether they can apply the learned skills to real-life situations (44). table 1. mde model term explanation term explanation examples mechanics actions offered to players in the game draw cards attack trade dynamics behaviors players show during the run-time of mechanics socializing bluffing attention aesthetics sensory formation of the game in order to evoke desired emotional responses in the players. challenge: obstacle course narrative: drama fellowship: social framework policy recommendations based on the kingdon model, we assessed the three policy streams and regarding the policy options mentioned previously. we discovered that the lack of resources and trained professionals is one of the main https://www.zotero.org/google-docs/?sqeu5n https://www.zotero.org/google-docs/?szmzbo https://www.zotero.org/google-docs/?ve6vp8 https://www.zotero.org/google-docs/?00r37e https://www.zotero.org/google-docs/?guielg https://www.zotero.org/google-docs/?awwbjn https://www.zotero.org/google-docs/?ouhbng https://www.zotero.org/google-docs/?8it4gt https://www.zotero.org/google-docs/?za7ono https://www.zotero.org/google-docs/?086vqn reijnders, a.p.m.; van den eijnde, s.q.; janssen, r.r.m.; van kessel r. autism and inclusive education: recommendations for improvement during and after covid-19 (policy brief). seejph 2022, 23 june 2022. doi: 10.11576/seejph-5602 page7 | 12 reasons interventions have a smaller chance of success. based on assessments, we recommend pmi or gamification as the most feasible interventions to improve inclusive education for autistic children. pmi settings in inclusive education benefit for implementing as policy recommendation: generally, pmi settings focus on a particular targeted approach, whereas peers of the target children (primarily children with sen) receive training which enables them to provide necessary tutoring and guidance for children with educational, social, or behavioral concerns (45). through pmi, the peers can demonstrate "appropriate" behavior themselves, which might be an incentive for people with special needs to act accordingly. mostly, the peers are chosen from the specific classrooms themselves, after which they receive the appropriate training. during peer intervention, these peers are also closely observed when they perform assistance to individuals in sen settings. some studies argue that implementing pmi settings is timeconsuming and may oppose some challenges, such as demonstrating the appropriate techniques to peers. however, it is shown that pmi settings are beneficial for improved inclusion of target children in their peer group. more specifically, pmi settings are an effective technique to improve education for autistic people (45). whilst chan et al. (42) argue that implementing pmi settings is more likely to be an effective intervention for autistic children; there are more arguments which favor this policy option. as this option requires the use of people within the same age group, this automatically demonstrates that there is never a shortage of peers. therefore, once this setting is appropriately implemented, it is highly likely that this option will be an automatic ongoing process. secondly, observational learning through peers likely positively influences children with difficulties, they are less intimidated by peers than teachers. this is potentially effective for autistic people as instruction and feedback from peers are more likely to be followed. moreover, pmi research has been done in multiple settings, including autism, problematic behavior, and adhd conditions, and in all these settings, pmi is shown to be effective. therefore, pmi is potentially effective in multiple settings, making them more cost-effective considering their relatively expensive implementing costs (46,47). gamification due to the current changes towards online education hybrid learning due to covid-19, there is now a window of opportunity to implement gamification. gamification is offered digitally and can thus also be implemented if, for any reason, online education would come back in the future, ensuring a smaller shift in an educational setting than what happened in the current situation. gamification and digital education show positive results for both neurotypical children and children with sen, including autistic children (31,33,37,43). as gamification can be personalized to a certain extent, it would be possible to use the same gamification software for both neurotypical children autistic children (44,48). some of these personalization styles could be manually adjusted by the children, teachers, or parents, while difficulty generally is personalized based on algorithms. it is not clear whether the same gamification program can be used for both neurotypical and autistic children, even with personalization. this would generally also depend on the level of personalization possible. if a program has different settings focused on neurotypical children or various types of sen children, it could be a promising program for implementation (48). the eu also already https://www.zotero.org/google-docs/?25klju https://www.zotero.org/google-docs/?t4d3gr https://www.zotero.org/google-docs/?yd26fa https://www.zotero.org/google-docs/?btwams https://www.zotero.org/google-docs/?xkf0yv https://www.zotero.org/google-docs/?8irmzc reijnders, a.p.m.; van den eijnde, s.q.; janssen, r.r.m.; van kessel r. autism and inclusive education: recommendations for improvement during and after covid-19 (policy brief). seejph 2022, 23 june 2022. doi: 10.11576/seejph-5602 page8 | 12 invests in gamification in education. there is a possibility to widen the use of the investment in gamification also to address the need for improved inclusion of autistic children in education (49). conclusions due to the rapid digital transformations resulting from covid-19 (50), improvements in inclusive education for children with sen are vital. based on kingdon's policy streams theory, a policy window is currently making to change the current status quo of education delivery for children with sen – also known as the problem stream in this context. multiple options that can fit in the paradigm of kingdon's policy stream were identified in this policy brief. the use of pmi and gamification turned out to be the most promising. key advantages of pmi entail the inclusion of peers as mentors, which creates a positive dynamic between autistic children and their peers and can positively affect the educational outcome of autistic children if implemented properly. key advantages of gamification entail its versatility and the option to personalize it according to individual needs. covid-19 has significantly influenced our systematic search, as research on this topic has increased in popularity since the pandemic's start. many of the interventions addressed are in the early stages, which raises the question of how transferable these interventions are. the outcome presented within this policy brief might be different in a few years due to the rapid developments of the covid-19 pandemic or the long-term evaluation of interventions. subsequently, with regards to the kingdon streams model, addressing the politics stream does not apply within the scope of this policy brief. as a future large-scale public health threat is likely to occur, gamification enables a more fluid transition to at-home education. generally, existing research shows no adverse outcome to the use of gamification. subsequently, the european union already invests in gamification, making the step smaller to invest in gamification for inclusive education. references 1. american psychiatric association. diagnostic and statistical manual of mental disorders [internet]. 5th ed. 2013 [cited 2021 dec 7]. available from: https://dsm.psychiatryonline.org/doi/ab s/10.1176/appi.books.9780890425596 2. campisi l, imran n, nazeer a, skokauskas n, azeem mw. autism spectrum disorder. british medical bulletin. 2018 sep 1;127(1):91–100. 3. elsabbagh m, divan g, koh y-j, kim ys, kauchali s, marcín c, et al. global prevalence of autism and other pervasive developmental disorders. autism research. 2012;5(3):160–79. 4. lai m-c, lombardo mv, baron-cohen s. autism. lancet. 2014 mar 8;383(9920):896–910. 5. roman-urrestarazu a, van kessel r, allison c, matthews fe, brayne c, baron-cohen s. association of race/ethnicity and social disadvantage with autism prevalence in 7 million school children in england. jama pediatrics. 2021 jun 7;175(6):e210054. 6. lord c, elsabbagh m, baird g, veenstra-vanderweele j. autism spectrum disorder. lancet. 2018 aug 11;392(10146):508–20. 7. dueñas ad, plavnick jb, goldstein h. https://www.zotero.org/google-docs/?xmgk1t https://www.zotero.org/google-docs/?eiokzr https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv reijnders, a.p.m.; 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[piraeus]: university of piraeus; 2021. available from: https://dione.lib.unipi.gr/xmlui/bitstrea m/handle/unipi/13800/khattari_17015. pdf?sequence=1&isallowed=y 50. kessel r van, hrzic r, o’nuallain e, weir e, wong blh, anderson m, et al. digital health paradox: international policy perspectives to address increased health inequalities for people living with disabilities. journal of medical internet research. 2022 feb 22;24(2):e33819. __________________________________________________________________________ © 2022 reijnders et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv https://www.zotero.org/google-docs/?vr4tqv bjegovic-mikanovic v, matovic-miljanovic s, seitalieva c, makarova t, murzalieva g, kozhokeev k. assessment of the training needs and interests among directors of health care services in the kyrgyz republic. (original research). seejph 2021, posted: 05 september 2021. doi: 10.11576/seejph4728 p a g e 1 | 13 original research assessment of the training needs and interests among directors of health care services in the kyrgyz republic vesna bjegovic-mikanovic1,2, sanja matovic-miljanovic2, chinara seitalieva3, tatyana makarova3, gulgun murzalieva3, kanatbek kozhokeev3 1 faculty of medicine, university of belgrade, belgrade, serbia; 2 euro health group, denmark / regional office belgrade, serbia; 3 sdc funded project‚ health facilities autonomy project phase ii (exit phase), kyrgyzstan. corresponding author: prof. vesna bjegovic-mikanovic, md, msc, phd; address: dr subotica 15, 11000 belgrade, serbia; e-mail: vesna.bjegovic-mikanovic@med.bg.ac.rs bjegovic-mikanovic v, matovic-miljanovic s, seitalieva c, makarova t, murzalieva g, kozhokeev k. assessment of the training needs and interests among directors of health care services in the kyrgyz republic. (original research). seejph 2021, posted: 05 september 2021. doi: 10.11576/seejph4728 p a g e 2 | 13 abstract aim: an assessment of the training needs and interests of health managers working in the health care facilities of the kyrgyz republic was conducted, aiming to tailor and shape future training interventions. methods: a rapid assessment was organized among directors of health care services in the kyrgyz republic, using a web-based questionnaire. due to the pandemic situation (covid-19), it was impossible to involve all healthcare facilities as initially planned. therefore, a convenient sample of 75 directors was drawn with a response rate of 77.3%, or 58 filled-in questionnaires. results: among respondents, 60.3% were female and 39.7% male managers, with an average age of 53.5 years. most of the respondents (89.7%) came to a managerial position by direct appointment, while only 10.3% were appointed through competitive process. more than half of health managers (63.8%) do not have any managerial category, and only 25.7% indicated that they have membership in the association of health administrators of kyrgyzstan1. all respondents reported the need to develop computer skills. discussion: there is a high demand in all aspects of the management of health organizations. the respondents are deciding about involvement in management training based on (a) the full range of training' topics, (b) the quality of the training content, and (c) the focus on developing practical skills. the most cited training needs are digital health (e-health), financing management, planning, and quality control; the interest in distance learning courses is excellent. almost twothirds of managers reported that the ministry of health and social development (mohsd kr) did not evaluate their work. conclusion: the main implications derived from this assessment are related to the culture of lifelong learning among the population of kyrgyz health managers. keywords: health management, kyrgyz republic, lifelong learning, training needs. authors’ contributions: all authors contributed equally. conflict of interest: none declared. source of funding: the project is financed by the government of switzerland. the opinions expressed in this publication are the views of the authors and do not necessarily reflect the opinion of the government of switzerland. 1 ассоциация организаторов здравоохранения кыргызстана bjegovic-mikanovic v, matovic-miljanovic s, seitalieva c, makarova t, murzalieva g, kozhokeev k. assessment of the training needs and interests among directors of health care services in the kyrgyz republic. (original research). seejph 2021, posted: 05 september 2021. doi: 10.11576/seejph4728 p a g e 3 | 13 “good leadership and management are about providing direction to, and gaining commitment from partners and staff, facilitating change and achieving better health services through efficient, creative and responsible deployment of people and other health resources.” who/eip/health systems/2005 introduction modern management is creating and maintaining an environment in which people working together may accomplish predetermined objectives. it occurs in a formal organizational setting through the utilization of human and other resources. the provision of specific services fulfills health and medical care demands to individual consumers, organizations, and communities. as a universal and complex process, management in health care services, open towards its environment, consists of five essential components: planning, organizing, staffing, leadership, and controlling. an effective manager's activities imply basic and advanced skills that balance these interrelated components and competencies in evidencebased management (1,2). besides basics in health services management, information and health legislation, performance, quality, and financial management are essential elements of a coherent strategy for health care management training. the multiprofessionalism within health management teams and the corresponding interdisciplinarity should provide an institutional environment where knowledge, skills, and experience are adequately implemented – in a participatory and supportive system representing a flat hierarchy. the kyrgyz republic recently approved a new state health program 2019-2030 “program of the kyrgyz republic government on public health protection and health care system development for 2019-2030 healthy person – prosperous country”. the program aims to protect the health, ensure access to essential quality services, strengthen primary health care, and decrease financial hardship for all people and communities in pursuit of universal health coverage and sustainable development by 2030. also, the program underlines the importance of qualified managers in health care services. since 2013, the kyrgyz republic is implementing the legislation with a description of responsibilities for health facilities managers and their hiring on a contractual basis (3). the den sooluk programme of health sector reform in the kyrgyz republic (lasting from 2011 to 2016 with extension up to 2018) opened direct opportunities through legislation and pilot initiatives for advancements in health care management to achieve better performance with existing resources. today, the ministry of health and social development (mohsd kr), in close collaboration with international and national partners, considers the changing context of the kyrgyz republic becoming a lowermiddle-income country with the necessity to increase performance in the health sector. an example of the recent positive development is an orientation towards continuous quality improvement in health care, which requests better health services management (4). also, positive initiatives were in pilots aiming to improve the health services management health facilities autonomy project and bjegovic-mikanovic v, matovic-miljanovic s, seitalieva c, makarova t, murzalieva g, kozhokeev k. assessment of the training needs and interests among directors of health care services in the kyrgyz republic. (original research). seejph 2021, posted: 05 september 2021. doi: 10.11576/seejph4728 p a g e 4 | 13 health results-based financing initiative. nevertheless, the need for strategic management improvement in the health sector is still visible. a brief overview of the literature has pointed to the recent history of health management strengthening in the kyrgyz republic, but the lack of information on their effectiveness, training focus, with emphasis on individual managers not on team development, except rare practices and country-wide efforts to develop planning, monitoring, and reporting system together with financial management. these efforts jointed with multiple initiatives through several projects, often not coordinated, poorly institutionalized, and therefore not sustained. as a particular challenge, the recent reviews stressed the weaknesses of "formal management training, lack of incentives for performance improvement and lack of overall accountability of managers." one of the main problems noticed through the literature in the kyrgyz republic was typical for all transitional countries. with health sector decentralization, doctors and nurses are often asked to take up new responsibilities, i.e., to fulfill leadership and managerial functions for which they have not been well prepared and trained (5). at the same time, they are usually not aware that their professions (doctors and nurses) do not qualify them to hold management positions. besides, managers' incentives are not present at a small scale, bringing low motivation for improvements. financial incentives are weak, salaries and allowances compared broadly with similar posts in the public sector (no significant financial incentives for excellent performance). non-financial incentives are not recognized: status of managers within their community, degree of autonomy (very little control of resources under limited funds), learning and sharing opportunities – few; lack of a "managers' forum" (despite of the existence of health managers association), opportunities for career progression – limited, recognition – mainly through the appraisal system and monitoring and supervision by the central authority within the ministry of health and social development. challenges for leadership and management development include defining what it is and why it is necessary, measuring the difference that better leadership and management makes, integrating into traditional health and health care models and frameworks, institutionalization—where and how, and the need for long-term partnerships and commitments. within the inception phase of the health facilities autonomy (hfa) phase ii project, financed by the government of switzerland, an assessment of the training needs and interests of health managers working in the health care facilities of the kyrgyz republic was conducted, aiming to tailor and shape future training interventions. methods the rapid assessment was organized among directors of health care services in the kyrgyz republic utilizing a web-based questionnaire. due to the epidemiological situation regarding covid-19 in the kyrgyz republic and the additional work burden imposed on managers with the organization of health services under emergency conditions, it was not possible to involve all health care facilities, as initially planned. therefore, a convenient (6) sample of 75 directors replaced the whole population of health services managers (354 directors). the response rate was 77.3%, or 58 respondents (23 male and 35 female health managers). by the level of the managed health organization, five respondents were from the tertiary health care institutions situated in bishkek city, 17 from secondary and 36 from primary health bjegovic-mikanovic v, matovic-miljanovic s, seitalieva c, makarova t, murzalieva g, kozhokeev k. assessment of the training needs and interests among directors of health care services in the kyrgyz republic. (original research). seejph 2021, posted: 05 september 2021. doi: 10.11576/seejph4728 p a g e 5 | 13 care facilities (family medicine centres and general medicine centres with beds). the distribution of responders by the administrative level of health organizations and regions is presented in table 1. table 1. distribution of respondents by the level of health organizations and by regions region no. of respondents tertiary level secondary level primary level / (family medicine centers) primary level (general practice сenters with beds) total in the kr* no. of surveyed total in the kr* no. of surveyed total in the kr* no. of surveyed total in the kr* no. of surveyed batken 2 7 4 6 2 chui 12 11 4 8 4 4 4 issyk-kul 18 7 4 6 11† 2 3† jalalabad 4 17 3 10 9 1 naryn 1 6 1 6 1 osh 1 23‡ 8‡ 1 4 talas 12 6 5 3 5 2 2 bishkek city 8 11 5 10 19 3 total 58 5 17 24 12 * data for 2016. † respondents are directors and their deputies. ‡ data include osh oblast and osh city. the questionnaire (in russian) developed for data collection comprises three parts: 7 questions to collect general information about health organizations, ten inquiries related to the characteristics of health managers, and 26 questions about their needs and interests. results profile of the responding health services managers in the kyrgyz republic among respondents, 60.3% were female and 39.7% male managers, with an average age of 53.5 years. the youngest manager was 29 years old, while the oldest one had 65 years (sd=7.786). all of the surveyed health managers have a medical background, and all use computer software for their work on an everyday basis. on average, they belong to experienced staff with 39.5 years of overall working experience (sd=8.595). however, their managerial experience is not short, being 12.3 years (including positions of deputy directors), with significant variations among respondents (sd=9.364). for example, the youngest manager has only eight months of managerial experience and only four years of overall working experience, which is the minimum legal request in the kyrgyz republic. on the other hand, the most extensive managerial experience in different executive positions has one of the directors – in total 38 years, assuming that he started to work in an administrative role immediately after completing medical studies. at the time of this assessment, the average appointment duration was 7.3 (sd=6.665), with the minimum being two months and the maximum 22 years (see figure 1 for details). most of the respondents (89.7%) came to a bjegovic-mikanovic v, matovic-miljanovic s, seitalieva c, makarova t, murzalieva g, kozhokeev k. assessment of the training needs and interests among directors of health care services in the kyrgyz republic. (original research). seejph 2021, posted: 05 september 2021. doi: 10.11576/seejph4728 p a g e 6 | 13 managerial position by direct appointment, while only 10.3% were appointed through competitive process. almost two-thirds of health managers who responded (63.8%) do not possess any specific managerial category. concerning the participation in health management training, more than half of the respondents completed some training after their appointments (53.4%), while 29.3% took this opportunity before their appointments. ten managers avoided answering this question . figure 1. duration of the managerial experience 39.7 15.5 10.3 19 15.5 54.4 19.3 7 14 5.3 0 10 20 30 40 50 60 up to 5 years 6 to 10 11 to 15 16 to 20 21 and above overall experience experience at this position percent years belonging to a professional association is an essential feature of each health care manager; however, only 25.7% indicated that they hold a membership in the association of health administrators in the kyrgyz republic 2 . even fewer of them take an active role in the events of the association – only 21.2% responded positively to this question. key barriers faced by health managers in their performance this rapid assessment aimed to explore the key barriers that health managers face in their performance (table 2). based on the respondents' opinion, the most challenging 2 the new association of health managers of kyrgyz republic (ассоциация руководителей организаций здравоохранения кыргызской managerial activity is to perform quality management. however, in the reviewed literature, it was evident that the highest priority during recent years in the kyrgyz republic was to improve different aspects of management for continuous quality improvement in health care. two-thirds of assessed managers found that they have barriers to perform quality management. the subsequent prominent difficulties are coming in two fields: health organization performance and remuneration optimization and staff incentives. in both areas, more than half of the managers experience barriers or difficulties. through optimization of the республики) was founded only after this study was conducted. bjegovic-mikanovic v, matovic-miljanovic s, seitalieva c, makarova t, murzalieva g, kozhokeev k. assessment of the training needs and interests among directors of health care services in the kyrgyz republic. (original research). seejph 2021, posted: 05 september 2021. doi: 10.11576/seejph4728 p a g e 7 | 13 health organization performance is directly interconnected, the manager found fewer problems with this activity. in essence, only one-third think that there are some barriers in this area of their work. remuneration and staff incentives are difficult to achieve in an environment of fiscal constraints. a similar finding is with human resource management – only 13.8% of respondents indicated barriers in this critical area of their work. as expected, in the fourth place are obstacles related to financial planning, accounting, analysis, and control with 62.1% of managers indicated those barriers and difficulties. taking into account the above mentioned problems with the optimization of health organizations, remuneration, and staff incentives, we found interesting that the least problematic areas of work for the respondents are human resources management and analysis of staff performance (13.8% and 12.1% respectively). table 2. key barriers faced by health managers in their performance no barriers / difficulties number of respondents percent 1 optimization of health organization performance 38 65.5 2 financial planning, accounting, analysis and control 36 62.1 3 human resource management 8 13.8 4 remuneration and staff incentives 38 65.5 5 information system and reporting (internal/external) 25 43.1 6 analysis of health organization performance 17 29.3 7 analysis of staff performance 7 12.1 8 quality management 41 70.7 9 procurement, supply and management of materials (stocks) 32 55.2 10 other (please, specify)* 4 6.9 * respondents specified two other barriers related to their specific health facilities: (a) revision of salaries in psychiatric services; (b) equipment and their technical assistance. though answers could be subjective, almost two-thirds of managers reported that the ministry of health did not evaluate their work individually following order no 724 of june 25, 2019. nevertheless, most managers (75.0%) agreed with the overall results of the latest assessment by the ministry of health and social development. besides, 62.5% considered that a regular individual evaluation of the leader's activity is necessary. training needs and interests the respondents confirmed their need for advanced training in health management. the most requested topics for skills improvement are e-health (79.6%), finance management (70.4%), planning (66.7%), the basics of management and quality management (64.8%), while office work, public relations, and presentation skills (the art of performance) are considered by respondents as areas with the least need for improvement in their work (see figure 2). the respondents believe that health management training will help them to improve their theoretical knowledge (77.6%) and practical skills (70.7%). all respondents reported the need to develop computer skills. only 33 out of 48 respondents reported that bjegovic-mikanovic v, matovic-miljanovic s, seitalieva c, makarova t, murzalieva g, kozhokeev k. assessment of the training needs and interests among directors of health care services in the kyrgyz republic. (original research). seejph 2021, posted: 05 september 2021. doi: 10.11576/seejph4728 p a g e 8 | 13 they received certificates that prove their participation in health management training, while 20 out of 33 respondents used those certificates to confirm their managerial category. according to the assessment results, only 20.8% of health managers expressed satisfaction with the quality of the existing programmes/modules on health management in the kyrgyz state medical institute on retraining and continuous medical education (ksmirce), while 60.4% were only partially satisfied. the majority of respondents took training in the kmirsce (87.2%). the most frequent topic of the training was "actual issues of modern management in health care," followed by "basics in health care management." other issues of attended pieces of training included "medical legislation," "human resources management," "rights and obligations," "modern issues of management and marketing.” even though they expressed the highest need for improvement in digital health technologies, only one respondent mentioned participation in a course with the topic "innovative technologies. "in most cases, the received courses were full-time in the classroom of the educational institution (72.9%). the usual duration of the sessions varied from 2 to 4 weeks. seventeen respondents (29.3%) participated in health management training during 20182019; others participated before 2018, or not at all. the respondents indicated the average number of hours allocated annually to their continuous skills development. for 21.6% of respondents, this education lasted 50 hours and more, 45.1% dedicated 25-50 hours, 27.4% reserved less than 25 hours, while other indicated that they did not have continuing education. figure 2. needs for improvement of managerial knowledge and practical skills 0 10 20 30 40 50 60 70 80 90 100 basics of management healthcare management organization management planning monitoring and evaluation analysis of the institution human resources management quality control financial management materials and medicines management, incl. procurement health care reform in the kyrgyz republic e-health health legal issues office work public relations art of performance presentation skills practical skills knowledge note: the rays in the spider web indicate the percentage. the majority of respondents (86.5%) are planning to participate in programmes of bjegovic-mikanovic v, matovic-miljanovic s, seitalieva c, makarova t, murzalieva g, kozhokeev k. assessment of the training needs and interests among directors of health care services in the kyrgyz republic. (original research). seejph 2021, posted: 05 september 2021. doi: 10.11576/seejph4728 p a g e 9 | 13 continuing education, particularly skills development; 70.6% can initiate alone the entrance to the advanced training for managers. the respondents also mentioned the request of the ministry of health and social development (19.6%) as the initiating factor for involvement in the management training, followed by the submission of oblast coordinators (7.8%). as the most important factors to choose the particular program/module the respondents indicated (figure 3): • the possibility to improve their practical skills; • the format of training (equally preferable formats are daytime and distance learning); and • topics and quality of the training program. among two-thirds of respondents, participation in programmes of continuing education is self-initiated. as a source of funding for paying courses fees, 25,0% of respondents cite state budget, 65.4% budget of health organization, while 17.3% cite external sources such as international donors/sponsors/projects. a considerable number of respondents reported their investment in training, especially for travel expenses (38.5%). figure 3. factors in the selection of management training 13.46 23.08 23.08 26.92 48.08 51.92 57.69 73.08 78.85 82.69 0 10 20 30 40 50 60 70 80 90 the ability to teach after this training cost of education class time (daytime, evening time, weekends) expenses in addition to training (transport, accommodation) training location opportunities for professional growth, promotion training duration training program (topics, content, modules) form of study (full-time, distance learning) the opportunity to gain practical skills percent more than half of assessed health managers (57.7%) expressed interest in being part of the trainers' team, participating in the training of trainers (tot), and contributing to the process of continuing skills development for other health managers. worthwhile to mention is that 35% of respondents reported that they have innovations to share with others, and 11.8% of health managers already had some teaching experience. discussion and conclusions the conducted assessment showed that the bjegovic-mikanovic v, matovic-miljanovic s, seitalieva c, makarova t, murzalieva g, kozhokeev k. assessment of the training needs and interests among directors of health care services in the kyrgyz republic. (original research). seejph 2021, posted: 05 september 2021. doi: 10.11576/seejph4728 p a g e 10 | 13 surveyed health managers at all levels of the health care system are usually appointed to their managerial positions directly (not on a competitive basis). all of them are specialists with a medical background. only one-third of respondents had some form of training in health management before taking their managerial responsibilities. the rest of them have received training after their appointments or didn't receive it at all.the majority of those who participated in the existing health management training offered by the ksmirce expressed partial satisfaction. usually, participation in the health management training is self-initiated (despite official rules/requirements reflected in the regulatory documents of the mohsd kr). health managers use different financial sources to cover training fees and travel expenses (state/organization budgets, international donors/projects, personal resources).according to the assessment results, there is a high demand in all aspects of the management of health organizations. the respondents are deciding about involvement in management training based on (a) the full range of training' topics, (b) the quality of the training content, and (c) the focus on developing practical skills. the most cited training needs are digital health (e_health), financing management, planning, and quality control. more than half of the respondents expressed their interest in distance learning courses. one-third of health managers in this assessment reported innovations implemented in their health organizations to share with others. therefore, there is a possibility to identify potential candidates for a pool of trainers among the surveyed health managers. the main implications derived from this assessment are related to the culture of lifelong learning among the population of kyrgyz health managers, which have broad state support expressed in several strategic documents (7). following the actual trends in health management education, the competencebased training development and the application of instructional innovation through applied management learning have to inspire training teams in each country. this participatory approach allows follow-up of the training impact in real life – on organizational behavior and performance improvement, both in quality and efficiency. based on the results of this assessment, the advantage of a step-wise approach for capacity development of kyrgyz health managers is the following: i. after discussion of the training needs assessment with a broader population of health managers and stakeholders from the mohsd, centre of health system development and medical technologies (chsd&mt), educational institutions (particularly ksmirce), and other relevant partners, the process of renewal of competences' list becomes crucial. during the assessment, we find it necessary for highly qualified performance within health care management. the importance of managerial competencies in monitoring and improving the performance of organizational leaders and managers are well accepted. different processes have been used to identify and develop competency frameworks or models for healthcare managers worldwide to meet different contextual needs (8)."today's healthcare executives and leaders must have management talent sophisticated enough to match the increased complexity of the healthcare environment. executives are expected to demonstrate measurable outcomes and bjegovic-mikanovic v, matovic-miljanovic s, seitalieva c, makarova t, murzalieva g, kozhokeev k. assessment of the training needs and interests among directors of health care services in the kyrgyz republic. (original research). seejph 2021, posted: 05 september 2021. doi: 10.11576/seejph4728 p a g e 11 | 13 effectiveness and to practice evidence-based management. at the same time, academic and professional programs emphasize the attainment of competencies related to workplace effectiveness. the shift to evidencebased management has led to numerous efforts to define the competencies most appropriate for healthcare" (9). the basis for the intended delphi process (10) in achieving consensus about the kyrgyz list of managerial competencies, besides the results of this assessment, will be the international list "leadership competencies for healthcare services managers." ii. the training strategy should rely on modular training of trainers, applied management improvement projects, and recognition of the best performers of pilot projects (11,12). a training strategy should be developed to cover the recommended competencies through several coherent modules. modules should have clearly defined learning objectives, expected outcomes and competencies, module prerequisites, content, recommended readings, teaching methods, means of evaluating participants' performance, and training schedule. in cooperation with kyrgyz partners (designated to health management education), the curricula development should involve a combination of management training in different areas including process improvement, project management, and program management. the new curricula could combine courses to address the skills needed to work with and supervise people effectively. the initial focus has to be on the capacity building of kyrgyz trainers after the selection of the national trainers' team. also, the proposal of educational events has to request national and international accreditation (either within the european union of medical specialists – uems and its european accreditation council for cme eaccme® (13) or preferably to agency for public health education accreditation – aphea and its board for ce) (14). iii. as several previous reviews pointed to the necessity of better strategic and operational (business) planning in the kyrgyz health care institutions, particular attention has to to be given to training related to strategic management in health care. using the advantage of instructional innovations and applied management learning, empowered kyrgyz trainers in health management should follow up training (managerial teams) participants in the application of gained competencies. each managerial team could be responsible for developing the strategic plan and business plan for their health organization using the logic of strategic planning (defining mission, vision, and the smart objectives of the health care organization, précising activities and indicators for monitoring and evaluation, and assigning responsibilities with wbswork breakdown structure and budget). iv. under the health programme (20192030), the kyrgyz republic continues to invest in the programme for continuous quality improvement, requiring competent managers. managerial teams will also pay bjegovic-mikanovic v, matovic-miljanovic s, seitalieva c, makarova t, murzalieva g, kozhokeev k. assessment of the training needs and interests among directors of health care services in the kyrgyz republic. (original research). seejph 2021, posted: 05 september 2021. doi: 10.11576/seejph4728 p a g e 12 | 13 attention to capacity building to apply useful managerial tools, such as total quality management (tqm). training in tqm tools will allow health care managers to use a systematic data-based method for improving the quality of specific work processes and therefore contribute to the overall improvement of performance. health care managers will be competent to go through a fantastic seven-step improvement process and experience progress in their healthcare organizations within 5 to 6 months. educated trainers of the kmirsce and chsd&mt has to follow up (monitor and evaluate) the whole applied management learning. v. in evaluating and monitoring, educated trainers can use the kirkpatrick method (15). vi. in the end, applied leadership and management skills, not just theoretical knowledge, has to be overall objective. applied management improvement projects will reinforce classroom learning, empower local groups to identify and manage their improvement opportunities, multiply training benefits, and generate products that have a measurable impact on health care organization goals and stakeholders. health care managers will be capable of including others from the organization in transferring managerial skills. strengthening the management skills of health managers in the kyrgyz republic involved in the integrated interventions can be accomplished by combining management training on technical management areas in project management and process improvement, combined with training directed at addressing the skills needed to work with and supervise people adequately. the health facilities autonomy phase ii project, financed by the government of switzerland is seen as a platform for improvement of health management training in the kyrgyz republic that applies the above described step-wise approach for capacity development of the kyrgyz health managers. “remember, training is not what is ultimately important…performance is.” marc rosenberg president of the society for performance and instruction references 1. bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments. review article. seejph 2016. doi:10.4119/unibi/seejph-201694. 2. bjegović v. health management: theory and practice. in: bjegović v, donev d, ed. health systems and their evidence-based development. a handbook for teachers, researchers and health professionals. lage, germany: hans jacobs publishing company; 2004:241-62. 3. jakab m, smith b, sautenkova n, abdraimova a, temirov a, kadyralieva r, et al. better noncommunicable disease outcomes: challenges and opportunities for health systems. kyrgyzstan country assessment: focus on cardiovascular disease. copenhagen: who bjegovic-mikanovic v, matovic-miljanovic s, seitalieva c, makarova t, murzalieva g, kozhokeev k. assessment of the training needs and interests among directors of health care services in the kyrgyz republic. (original research). seejph 2021, posted: 05 september 2021. doi: 10.11576/seejph4728 p a g e 13 | 13 regional office for europe; 2014. available from: http://www.who.int/iris/handle/1066 5/153905 (accessed: april 11, 2021). 4. who europe. quality of care review in kyrgyzstan. copenhagen: who regional office for europe; 2018. available from: http://www.euro.who.int/__data/asse ts/pdf_file/0004/383890/kgz-qoceng.pdf (accessed: april 11, 2021). 5. giz. developing capacity for health services management in kyrgyzstan. policy brief. bishkek: giz; 2019. 6. saunders m, lewis p, thornhill a. research methods for business students. 6th edition. new york: pearson education limited; 2012. 7. ministry of education, science and youth. education development strategy of the kyrgyz republic for 2012-2020. bishkek; 2014. available from: https://planipolis.iiep.unesco.org/en/ 2014/education-developmentstrategy-kyrgyz-republic-2012-20206620 (accessed: april 11, 2021). 8. liang z, howard pf, leggat s, bartram t. development and validation of health service management competencies. j health organ manag 2018. doi:10.1108/jhom-06-2017-0120. 9. stefl me. common competencies for all healthcare managers: the healthcare leadership alliance model. j health manag 2008;53:360-74. 10. brill tm, bishop mj, walker ae. the competencies and characteristics required of an effective project manager: a webbased delphi study. educational technology research and development 2006;54:115-40. 11. centers for disease control and prevention. sustainable management development program. the health of people is directly related to effective health systems. atlanta: cdc; 2012. 12. parviainen hm, halava h, leinonen ev, kosunen e, rannisto ph. successful curriculum change in health management and leadership studies for the specialist training programs in medicine in finland. front public health 2018;6:271. doi: 10.3389/fpubh.2018.00271. 13. european accreditation council for cme eaccme®. available from: https://www.uems.eu/areas-ofexpertise/cme-cpd/eaccme (accessed: april 11, 2021). 14. agency for public health education accreditation – aphea. available from: https://www.aphea.be/pages/a1a.ct ee/ctee_accreditation.html (accessed: april 11, 2021). 15. heydari mr, taghva f, amini m, delavari s. using kirkpatrick's model to measure the effect of a new teaching and learning methods workshop for health care staff. bmc res notes 2019;12:388. doi: 10.1186/s13104-019-4421-y. _____________________________________________________________________________________________ © 2021 bjegovic-mikanovic et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. yuantari c, rachmani e, kusuma ej, ariyanto adp. implementation of health protocols in the workplace during the covid-19 pandemic in indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5332 p a g e 1 | 9 original research implementation of health protocols in the workplace during the covid-19 pandemic in indonesia catur yuantari1, enny rachmani2, edi jaya kusuma2, amelia devi putri ariyanto3 1 public health study program, faculty of health dian nuswantoro university semarang central java, indonesia; 2 health information medical record study program faculty of health dian nuswantoro university semarang, central java, indonesia; 3 department of informatics engineering, faculty of electrical and intelligent information technology, sepuluh nopember institute of technology surabaya, east java, indonesia. corresponding author: mg catur yuantari; address: nakula i/5, semarang, central java, indonesia. email: mgcatur.yuantari@dsn.dinus.ac.id yuantari c, rachmani e, kusuma ej, ariyanto adp. implementation of health protocols in the workplace during the covid-19 pandemic in indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5332 p a g e 2 | 9 abstract background: covid-19 is a new disease for which no cure has been found; prevention of disease transmission is an alternative to reducing cases. the workplace is one of the places that have the potential for information of covid-19 because workers will have direct contact in one place with other workers. this study aims to analyze the characteristics and availability of health protocol facilities on worker compliance in the workplace during the covid-19 pandemic. methods: the research method uses quantitative methods with a cross-sectional approach. the population in this study are workers who work in formal and informal sectors in indonesia, with a sample of 217 respondents. data collection used a survey method and obtained as much as 217 data. for data processing, we used the rank spearman test. results: the results showed that there was a relationship between years of service (p-value 0.008; rho: 0.148), educational level (p-value 0.000; rho: 0.363), number of employees (p-value 0.000; rho: 0.488), and the availability of health protocol facilities (p-value 0.000; r: 0.498) at the workplace. as for age and the level of compliance with the application of health protocols, there was no relationship (p-value 0.044). discussion: the level of compliance with suitable health protocols at the workplace can help suppress the spread of covid-19. there are still workplaces where workers do not comply with health protocols, such as workers who do not practice social distancing and lower masks to their chins when talking to colleagues. keywords: compliance, covid-19, health protocols, workplace. conflicts of interest: none declared. acknowledgments: the researcher would like to thank lppm and the faculty of health at dian nuswantoro university for providing financial support for this research. yuantari c, rachmani e, kusuma ej, ariyanto adp. implementation of health protocols in the workplace during the covid-19 pandemic in indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5332 p a g e 3 | 9 introduction the world health organization has declared the covid-19 outbreak as a global pandemic. it spread to more than 200 countries and infected about 4.5 million people. the epidemic is alarming people worldwide and has resulted in several million deaths (1,2). indonesia is one of the countries affected by the covid-19 pandemic. according to the data site of the covid-19 task force as of march 14, 2021, the number of cases in indonesia was 1,419,455 and the number of deaths 38,426 (3). who recommends always maintaining hand hygiene and a distance of at least 1 meter from other people to avoid covid-19 (4,5). the government's role is very decisive in reducing the spread of covid-19. it is necessary to develop a systematic covid-19 control protocol (6,7). many countries worldwide have implemented health protocols. for example, the government in korea has enforced physical distancing, maintaining proper cough etiquette, and using personal sanitation such as face masks, face shields, and sanitizers (8). in indonesia, the government has implemented physical distancing policies, regional lockdowns, and maintaining hand hygiene (9). governments are also responsible for protecting workers' health at their workplaces (10,11). based on research conducted by alanezi et al., more than 60% of health workers in seven selected hospitals in saudi arabia ignore health protocol regulations (12). the same was found in india, although there are regulations governing health workers at the workplace (13). just below 50% of the health workers have not been able to maintain distance while talking to colleagues. also, they work with used protective equipment because they do not have time to replace it (13). therefore, our study aims to analyze the characteristics and applications of health protocols concerning workers' compliance at the workplace during the covid-19 pandemic in indonesia. methods we use a cross-sectional design based on an online questionnaire implemented over one month in this study. the questionnaire has been prepared based on the decree of the directorgeneral of labor, supervision and occupational safety, and health number 5/151/as.02/xi /2020 concerning guidelines for occupational safety and implementation of workforce health checks duringthecovid-19 pandemic. the distribution of respondents' workplaces covers the following indonesian provinces: south kalimantan, west kalimantan, central kalimantan, north kalimantan, banten, diy, central java, east java, west java, riau, ntt, dki jakarta, and papua. we obtained 217 questionnaires. data processing used the spearman rank test because data distribution is not normal. the study was approved by the health research ethics commission of the state university of semarang with no. 015/kepk/ec/2020. results the respondents are workers from various work units, both informal and formal. of the 217 respondents analyzed in table 1, more than half, i.e., 59.9%, are aged 21 to 40. the tenure of service is predominantly in the range of 1-10 years (63.6%); about two-thirds (66.8%) have education in tertiary institutions. one-third work at workplaces with <10 employees (34.1%). table 1. characteristics of respondents (n=217) characteristics of respondents category f % age ≤20 5 2.3 21-40 130 59.9 ≥41 82 37.8 tenure 1-10 138 63.6 yuantari c, rachmani e, kusuma ej, ariyanto adp. implementation of health protocols in the workplace during the covid-19 pandemic in indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5332 p a g e 4 | 9 11-20 44 20.3 21-30 26 12.0 ≥31 9 4.1 education elementary school 15 6.9 junior high school 11 5.1 senior high school 46 21.2 college 145 66.8 number of employees ≤10 74 34.1 11-50 53 24.4 51-100 31 14.3 ≥101 59 27.2 table 2 shows that almost all workplaces have issued regulations on health protocols. to increase the success of regulations, a socialization effort is to be implemented so that employees pay more attention to the health protocols. figure 1 explains that the most widely used media at the workplace are banners. in addition, some workplaces use posters, safety talks, and circulars. several health protocols require employees to wash their hands before entering the workspace, providing hand sanitizers and a sink with running water and soap. more than 70% of workplaces have provided personal protective equipment during the pandemic, taking temperature measurements before entering the workplace, keeping distance during work, and preventing crowds in specific workplace facilities such as places of worship, canteens, and rest areas. in addition, several workplaces have also established sanctions if employees do not wear masks and regularly spray disinfection to reduce the spread of covid19. however, there are still many workplaces where safety or health officers do not monitor their employees' health and do not carry out preventive engineering such as installing barriers or glass screens for workers who serve customers. table 2. availability of health protocol facilities at the workplace no availability of health protocol facilities in the workplace yes (%) 1 regulations for implementing health protocols in the workplace 93.1 2 workplaces provide ppe during the covid-19 pandemic 75.1 3 there is a temperature measurement 75.1 4 there are sanctions if you don't wear a mask 63.1 5 availability of sink 84.8 6 sufficient number of sinks/hand washers 87.1 7 there is running water and soap at the sink 87.1 8 employees are required to wash their hands before entering the workspace 70.5 9 hand sanitizer available 78.3 10 there are rules to keep your distance while working 73.3 11 the workplace has been sprayed with disinfection 79.7 12 workplace restricts attendance of employees 43.8 13 there are arrangements for the use of workplace facilities to 74.2 yuantari c, rachmani e, kusuma ej, ariyanto adp. implementation of health protocols in the workplace during the covid-19 pandemic in indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5332 p a g e 5 | 9 figure 1. forms of socialization in applying health protocols at the workplace table 3. frequency distribution of compliance level implementing health protocols at the workplace no questions always (%) often (%) sometimes (%) never (%) 1 i implement complete health protocols at work 62.2 15.7 22.1 0 2 i wash my hands with soap before work 57.6 15.2 27.2 0 3 i wash my hands with soap after work 60.4 14.7 24.9 0 4 i use hand sanitizer after work 49.8 20.7 28.1 1.4 5 i wear a mask at work except when eating 70.0 7.4 22.6 0 6 i did not change my mask for more than one day 9.7 9.2 30.9 50.2 7 i lower my mask to my chin/neck when talking at work 0.9 6.5 55.3 37.3 116 145 91 56 2 1 1 9 0 20 40 60 80 100 120 140 160 poster banner safety talk workplace policy zoom whatsapp group e-mail nothing form of socialization prevent crowds (facilities of worship, canteens, rest areas) 14 safety or health officers monitor the health of their employees 59.0 15 your workplace carries out transmission prevention engineering such as installing barriers or glass screens for workers serving customers and so on 54.8 16 17 have you ever taken the covid-19 rapid test at work? the supervisor where you work guides workers who do not implement the covid-19 prevention and control protocol 58.1 69.1 yuantari c, rachmani e, kusuma ej, ariyanto adp. implementation of health protocols in the workplace during the covid-19 pandemic in indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5332 p a g e 6 | 9 8 i keep a distance of 1 meter from my co workers 34.6 24.9 38.7 1.8 9 i immediately went to the nearest polyclinic or health service if i had a cough/flu/fever 38.7 17.5 35.5 8.3 10 i still go to work even though i have a cough/flu/fever 6 6.9 38.7 48.4 the results of the frequency distribution of compliance levels in implementing health protocols in the workplace are shown in table 3. it demonstrates that many employees do not change masks the latest after one day and lower the mask to their chin or neck when talking to other people. this maybe s o because sanctions are often applied only to those not wearing masks, not if somebody wears the mask incorrectly, such as not changing masks or lowering masks while talking. many employees do not maintain a distance of one meter as per the regulations set by who, government regulations, and workplace regulations. in addition, some employees still go to work even though they have a cough/flu/fever, possibly a covid-19 infection. moreover, many employees lack the self-awareness to immediately go to the nearest polyclinic or health service if they have a cough/flu/fever. table 4. bivariate analysis of respondent characteristics and the application of health protocols at the workplace variable p-value r age .442 .044 tenure .008 .148** education .000 .363** number of employees .000 .488** availability of health protocols at the workplace .000 .498** table 4 shows that except for age, the respondents' characteristics are related to the protocol: tenure, education, number of employees, and essentially the availability of protocols. discussion three categories of measures are employed to strengthen the protection of workers during the covid-19 pandemic, namely organizational, environmental and individual factors. organizational factors are usually a safety culture and climate that lead to particular policies or procedures employed in the workplace (14). according to our findings, almost all workplaces in indonesia have issued regulations to implement health protocols at the workplace. based on research conducted by fernardo (15), providing banners or posters with high threat and efficacy as a medium of socialization can increase compliance in implementing health protocols and seeing high threat posters can evoke the memory of workers to remember the closest people, family, and relatives who have been affected by covid-19. the use of social media and social influencers also needs to be considered because the research of yousuf et al. (16) stated that socialization media were effective in promoting health protocols. furthermore, for environmental factors, the study results show that most workplaces in yuantari c, rachmani e, kusuma ej, ariyanto adp. implementation of health protocols in the workplace during the covid-19 pandemic in indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5332 p a g e 7 | 9 indonesia have provided a sink or sanitizer to maintain hand hygiene, provide personal protective equipment, and take temperature measurements before entering the workspace. however, most of the safety or health officers in the workplace still do not routinely check the health of their workers. a study conducted by sunandar et al. (17) concludes that the most critical aspect in preventing the transmission of covid-19 is to carry out regular health checks as a form of preventive service to workers. regular check-ups can also be used to further assess comorbidities of covid-19, for example, obesity, kidney disease, diabetes mellitus, and hypertension. workers who have these comorbidities are at higher risk of complications. therefore, companies or job providers must pay more attention to their workers by setting policies for workers who have comorbidities of covid-19, e.g., to work from home. finally, individual factors usually consist of knowledge, beliefs, behaviour, risk perception, and sociodemographic characteristics of the workers themselves (14). from our study results, it turns out that some workers still go to work even though they are sick with cough/flu/fever. therefore, it is necessary to have a weekly or monthly evaluation of the regulations. in addition, it is essential to have health education held regularly to make workers more aware of the importance of consistently implementing health protocols correctly and adequately and the dangerous consequences of ignoring them. a study conducted by zhong et al. (18,19) found that age was a determining factor for risky behavior against covid-19 and that compliance with health protocols would increase with age. in this study, we found that education relates to compliance. research conducted by muklis et al. (20), labban et al. (21), and bawazir et al. (22) stated that the educational background of workers could determine the level of vigilance against the spread of covid-19. employers or companies with 100 or more workers will have a higher risk of spreading covid-19, including the risk of later being forced to reduce the company's productivity. conclusion compliance with the application of health protocols in the workplace supports successfully suppressing the spread of covid-19. many workplaces still do not practice social distancing and lower masks to their chins when talking to colleagues. in addition to the lack of application of health protocols in the workplace, numerous younger people constitute a high risk of workers being infected with covid-19 because younger workers feel they will be more immune and more robust if they have to fight covid-19. references 1. kandeğer a, aydın m, altınbaş k, cansız a, tan ö, tomar bozkurt h, et al. evaluation of the relationship between perceived social support, coping strategies, anxiety, and depression symptoms among hospitalized covid-19 patients. int j psychiatry med 2021;56:240-54. doi:10.1177/0091217420982085. 2. sulistyawati s, rokhmayanti r, aji b, wijayanti sp, hastuti sk, sukesi tw, et al. knowledge, attitudes, practices and information needs during the covid-19 pandemic in indonesia. risk manag healthc policy 2021;14:163-75. doi:10.2147/rmhp.s288579 3. veranda covid-19. available from: https://covid19.go.id/ (accessed: december 10, 2021). 4. shaikh ss, jose ap, nerkar da, vijaykumar kvm, shaikh sk. covid19 pandemic crisis—a complete outline of sars-cov-2. futur j pharm sci 2020;6:1-20. doi:10.1186/s43094-02000133-y. 5. azuma k, yanagi u, kagi n, kim h, ogata m, hayashi m. environmental factors involved insars-cov-2 yuantari c, rachmani e, kusuma ej, ariyanto adp. implementation of health protocols in the workplace during the covid-19 pandemic in indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5332 p a g e 8 | 9 transmission: effect and role of indoor environmental quality in the strategy for covid-19 infection control. environ health prev med 2020;25:1-6. doi:10.1186/s12199-020-00904-2. 6. pandey a, saxena nk. effectiveness of government policies in controlling covid-19 in india. int j heal serv 2022;52:30-7. doi:10.1177/0020731420983749. 7. fellows of the collegium ramazzini, italy. 24th collegium ramazzini statement prevention of work-related infection in the covid-19 pandemic. int j occup med environ health 2020;33:538-57. 8. kim ea. social distancing and public health guidelines at workplaces in korea: responses to coronavirus disease-19. saf health work 2020;11:275-83. doi:https://doi.org/10.1016/j.shaw.202 0.07.006. 9. roziqin a, mas’udi syf, sihidi it. ananalysis of indonesian government policies against covid-19. public adm policy 2021;24:92-107. doi:10.1108/pap-08-2020-0039. 10. dyal jw. covid-19 among workers in meat and poultry processing facilities. morb mortal wkly rep 2020;69:557-61. 11. michaels d, wagner gr. occupational safety and health administration (osha) and worker safety during the covid-19 pandemic. jama 2020;324:1389-90. doi:10.1001/jama.2020.16343. 12. alanezi f, aljahdali a, alyousef sm, alshaikh w, mushcab h, al thani b, et al. investigating health care practitioners' attitudes towards the covid-19 outbreak in saudi arabia: a general qualitative framework for managing the pandemic. inform med unlocked 2021;22:100491. doi:https://doi.org/10.1016/j.imu.2020. 100491. 13. agarwal a, ranjan p, saraswat a, kasi k, bharadiya v, vikram n, et al. are health care workers following preventive practices inthe covid-19 pandemic properly? a cross-sectional survey from india. diabetes metab syndr 2021;15:69-75. doi:https://doi.org/10.1016/j.dsx.2020. 12.016. 14. surya pa, mustikaningtyas mh, thirafi szt, pramitha ad, mahdy lt, munthe gm, et al. literature review: occupational safety and health risk factors of healthcare workers during covid-19 pandemic. indones j occup saf heal 2021;10:144-52. doi:10.20473/ijosh.v10i1.2021.144152. 15. fernardo e. experimental study to improves covid-19 health protocol compliance with high threat and high efficacy poster. j komun 2021;13:18499. 16. yousuf h, corbin j, sweep g, hofstra m, scherder e, gorp ev, et al. association of a public health campaign about coronavirus disease 2019 promoted by news media and a social influencer with self-reported personal hygiene and physical distancing in the netherlands. jama netw open 2020;3:1-12. doi:10.1001/jamanetworkopen.2020.14 323 17. sunandar h, ramdhan dh. preventing and controlling covid-19: a practical-based review in offshore workplace. kesmas 2021;16:97-101. doi:10.21109/kesmas.v0i0.5226. 18. zhong bl, luo w, li hm, zhang qq, liu xg, li wt, et al. knowledge, attitudes, and practices towards covid-19 among chinese residents during the rapid rise period of the covid-19 outbreak: a quick online cross-sectional survey. int j biol sci yuantari c, rachmani e, kusuma ej, ariyanto adp. implementation of health protocols in the workplace during the covid-19 pandemic in indonesia (original research). seejph 2022, posted: 20 march 2022. doi: 10.11576/seejph-5332 p a g e 9 | 9 © 2022 yuantari et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 2020;16:1745-52. doi:10.7150/ijbs.45221. 19. padidar s, liao sm, magagula s, mahlaba tam, nhlabatsi nm, lukas s. assessment of early covid-19 compliance to and challenges with public health and social prevention measures in the kingdom of eswatini, using an online survey. plos one 2021;16:1-28. doi:10.1371/journal.pone.0253954. 20. mukhlis h, widyastuti t, harlianty r, susanti s, kumalasari d. study on awareness of covid-19 and compliance with social distancing during covid-19 pandemic in indonesia. j community psychol 2020. doi:10.31234/osf.io/c9rme. 21. labban l, thallaj n, labban a. assessing the level of awareness and knowledge of covid 19 pandemic among syrians. arch med 2020;12:8. doi:10.36648/1989-5216.12.3.309. 22. bawazir a, al-mazroo e, jradi h, ahmed a, badri m. mers-cov infection: mind the public knowledge gap. j infect public health 2018;11:8993. doi:10.1016/j.jiph.2017.05.003. ________________________________________________________________________________________________ hyska j. improving nutrition and health among albanian school children (policy brief). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5709 p a g e 1 | 9 policy brief improving nutrition and health among albanian schoolchildren jolanda hyska1,2 1 department of public health, faculty of medicine, university of medicine, tirana, albania; 2 department of food and nutrition, institute of public health, tirana, albania. corresponding author: jolanda hyska; address: rr. aleksander moisiu, no. 88, tirana, albania; telephone: +355672052972; email: lhyska@yahoo.it hyska j. improving nutrition and health among albanian school children (policy brief). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5709 p a g e 2 | 9 abstract nutrition is a critical part of health and development. better nutrition is related to improved infant, child and maternal health, stronger immune systems, safer pregnancy and childbirth, lower risk of non-communicable diseases and longevity. prevention of malnutrition among adolescents and improvement of the nutritional status of children are considered important targets in albanian health system efforts to achieve benefits in the population’s health. key approaches for improving nutritional status and nutrition-related knowledge, attitude and practices among school-children in albania (based on the main findings from the in-depth analysis of three nationwide surveys conducted in albania between 2015 and 2018 on nutritional status and nutrition-related knowledge, attitudes and practices among schoolchildren in albania and other findings) consist ofprevention and promotion from an early age, focus on knowledge, attitudes and practices, limit exposure to less healthy foods and increase parental awareness and involvement. these studies findings and respective recommendations can support the development of a national school food and nutrition education programme in albania. while there is evidence for the need to intervene at the national level, the stratified analysis at regional and district levels points to the need for the design and implementation of specific interventions at the local level. it is also very crucial to strengthen and improve anthropometric nutrition and surveillance systems for nutritional risk factors for children and adolescents, and use the data obtained by these systems effectively and appropriately. keywords: albania, attitude, nutrition, nutritional status, school-age children. conflicts of interest: none declared. acknowledgment: this document is based on the in-depth analysis of three nationwide surveys conducted recently in albania regarding ‘nutritional status and nutrition-related knowledge, attitude and practices among school-children in albania”carried out by ass. prof jolanda hyska in the framework of the project "improving the nutritional status of children in schools in albania", a project developed by the albanian center for economic research (acer), funded by unicef albania. the views and opinions expressed in this publication are those of the author and do not necessarily represent the official opinion of acer nor of unicef. hyska j. improving nutrition and health among albanian school children (policy brief). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5709 p a g e 3 | 9 the impact of nutrition on health nutrition is a critical part of health and development. better nutrition is related to improved infant, child and maternal health, stronger immune systems, safer pregnancy and childbirth, lower risk of noncommunicable diseases (such as diabetes and cardiovascular disease), and longevity (1). two of the major challenges of our times are malnutrition in all its forms and the degradation of environmental and natural resources. both are happening at an accelerated pace (2). the state of food security and nutrition in the world report (sofi 2019) shows that the number of the undernourished has been slowly increasing for several years in a row, and at the same time the number of overweight and obese people all over the world is increasing at an alarming rate. poor diets are a major contributory factor to the rising prevalence of malnutrition in all its forms. moreover, unhealthy diets and malnutrition are among the top ten risk factors contributing to the global burden of disease. in addition, the way we produce and consume food is taking a toll on the environment and natural resource base. food production accounts for the use of 48 percent and 70 percent of land and fresh water resources respectively at the global level (2). the health effects of poor nutritional practices and habits are manifested from early childhood and have implications for health status in adulthood (who, 2018). it is well established that poor nutrition for children has negative effects for their health, growth and development, school performance and, consequently, for their productivity in adulthood (3). both undernutrition and overweight and obesity among children reflect poor nutritional practices. adequate and healthy nutrition is essential for children to reach their full potential at every stage of their development. what children eat today and their understanding of how food affects their health are crucial for tackling the problem of obesity (4) and other health problems resulting from poor dietary practices. prevention of malnutrition among adolescents and improvement of the nutritional status of children are considered important targets in albanian health system efforts to achieve benefits in the population’s health by increasing the proportion of people who have access to adequate, safe and nutrient-rich food, eat a balanced diet and maintain a healthy body weight (5). as the linkages between childhood nutrition and health, and development and productivity in adulthood have become increasingly evident, it is clear that addressing malnutrition is central to improving individual development and well-being, improving the overall economic and social development of families and communities and supporting societal development (6). given the high human and economic returns that investments in child and adolescent nutrition bring and the growing recognition of the right to adequate food, the global commitment to addressing malnutrition has intensified. it now features prominently on the international agenda, including the sustainable development goals (sdgs), the rome declaration and framework for action adopted by the second international conference on nutrition (icn2), and the un decade of action on nutrition 2016–2025, among others (7,8). the role of school-based food and nutrition education more and more, schools have become a focus for policies and programmes that aim to address malnutrition and other health problems related to poor nutrition and unhealthy diets. schools reach the majority of school-age children (9) in non-crisis contexts over a prolonged period of time, and can extend benefits to families, the hyska j. improving nutrition and health among albanian school children (policy brief). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5709 p a g e 4 | 9 whole school community and to the surrounding community. school-based food and nutrition education (sfne) consists of coherent and mutuallyreinforcing educational strategies and learning activities which, supported by a healthy food environment, help schoolchildren, adolescents and their communities improve their food choices and diets. when implemented successfully, sfne helps schoolchildren, along with school staff and parents, achieve lasting improvements in their diets, food practices, outlooks and knowledge, build their capacity to change and adapt to external change, and to pass on their learning to others. essential elements of sfne are: 1) a healthy food environment and safe and nutritious school food; 2) food and nutrition education; 3) inclusive food procurement (including local production) and nutritionsensitive value chains; and 4) enabling policy, legal and institutional environments. successful sfne involves a holistic approach with explicit linkages, interactions and coherence between each of these elements. school food and nutrition approach is a direct response to the international call for improved nutrition and food systems, and supports sdgs 2 (zero hunger), 3 (good health and well-being), 4 (quality education), 5 (gender equality) and 12 (responsible consumption and production) (10). sfne also plays an important role in complementing global efforts to improve food environments, and in empowering children and adolescents to become active participants and future leaders in shaping food systems that are better able to deliver healthy and sustainable diets. key approaches for improving nutritional status and nutritionrelated knowledge, attitude and practices among school-children in albania (based on the main findings from the indepth analysis of three nationwide surveys conducted in albania between 2015 and 2018 on nutritional status and nutritionrelated knowledge, attitudes and practices among school-children in albania and other findings) (11,12) 1. prevention and promotion from an early age prevention is the best cost–benefit method to control overweight and obesity in children and thus future adults. children are considered a priority population for prevention strategies because weight loss is difficult for adults and there are more interventions available for children than for adults. some of these potential strategies for intervention in children can be implemented by targeting schools as a natural development zone for nutrition education (13).  prevention can be achieved through various interventions that target the school environment, physical activity and diet, such as: high importance of physical activity; healthy foods in cafeteria, ban on sweetened beverages and energydense junk food; training of teachers regarding health education; incorporation of more knowledge about nutrition and physical activity and nutrition-related diseases in school curriculum, etc. (14).  as eating patterns and dietary habits are established early in life, and behaviour change later in life is more difficult, it is most effective to help children form good habits at an early age by improving their everyday skills in making good food choices, planning and preparing healthful meals, protecting the quality and safety of the foods they eat and in establishing healthful hyska j. improving nutrition and health among albanian school children (policy brief). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5709 p a g e 5 | 9 personal habits and lifestyles, based on activity-approaches with less emphasis on reading and more on learning by doing, with a variety of activities, exercises, investigations and analysis that can be done in groups or individually (12). data showed that: two-thirds of children say they know only an average amount or less about food, health and nutrition. two out of five children (40%) are more concerned about how much they eat than what kind of food they eat. only one-third (36.7%) of children believe it is important for their growth and health for them to have three main meals and in between snacks. only one in three children believes that without breakfast they “can’t learn as much”. only about half of children indicate meat and chicken as very good foods and one-third are uncertain about fat intake and health. about half of the children (47%), believe also that skipping breakfast can result in being less able to follow the lessons.  in albania a holistic and integrated approach is imperative to develop health promotion programs for children in the fight against childhood obesity, which aim to change behaviour rather than simply providing information alone (which often has little impact on what people do) as: the prevalence of overweight and obesity is still a public health problem in the country, with a rising trend among children 6-15 years old (from 21.7% in 2016 to 27.9% in 2018); overweight/obesity level is about 30% lower among children with good knowledge compared with children who exhibited poor knowledge about food, health and nutrition, the likelihood of consuming breakfast was 30% higher among normal weight children compared to their overweight/obese counterparts; this prevalence is higher in children from urban areas compared with rural areas, and among boys compared to the girls; moreover, obesity is a multifactorial disease where preventive interventions should address all causal factors. 2. focus on knowledge, attitudes and practices good nutrition education helps children to become “nutritionally literate”. children educated in this way will come to know how to make good foodand lifestylechoices and develop good eating habits for themselves and for others. nutritionally literate adults will know where to get answers to questions about food, diet and health. the value of nutrition education to the long-term development of a society is plain to see (15). nutrition education has the best chance of making a real impact if it involves action, direct experience and participation by the children; stimulates all their faculties; takes learning outside the classroom into real-life situations (15).  there is a need to promote healthy nutrition in school-aged children by focusing on behaviour, in addition to knowledge, especially regarding the consumption of those foods most important for children’s growth and development. while virtually all children recognize the importance of breakfast, on the measurement day only three out of five of hyska j. improving nutrition and health among albanian school children (policy brief). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5709 p a g e 6 | 9 children reported they had eaten breakfast. breakfast consumption in children (selfreported) is lower than the other main meals (71%, compared with 89% for lunch and 87% for dinner). there is a considerable proportion of children who do not consume milk on a daily basis, with a range 47%-65% (11). children’s positive attitudes toward healthy foods, healthy nutritional habits and health benefits do not often correlate with their nutritional practices (behaviours); they seem to know the benefits of eating fresh fruits and vegetables, with almost all of them saying that fruit is very good for their health (92%), actually less than three in five children consume fruits on a daily basis whereas vegetable consumption is far too lower (with a range: 20%30% in all three surveys). the tv is switched on during meals every day in 43% of the families. one third of children eats their dinner while watching tv, using a mobile phone, or tablet (37%) every day, or almost every day. 3. limit exposure to less healthy foods food marketing has a huge effect on children’s health. limiting the advertising of unhealthy foods to the maximum possible has been assessed as a very effective intervention to improve the food environment, promote good eating habits and reduce the problems caused by malnutrition.  it is important to assess the need for specific arrangements related to the advertising of unhealthy foods and to make recommendations that adequately address the prohibition of advertising of unhealthy food in the premises of basic education educational institutions, as: children in albania are a target group from unhealthy food advertisements (12). even some public schools (both urban and rural) allow some form of food and beverage advertisements in the school building or on the school grounds. although the legal framework in force has widely regulated the issue of food marketing, the standard regulation lacks regulations dedicated to food and nutrition of children (12).  it is crucial that schools provide food for children at school and control foods that are being bought by children to eat at school, limit exposure to less healthy food options, improve the nutritional quality of any foods sold in schools’ environments, and ensure that the healthy option is always available and the easier option, as: only one in three children (33%) takes food from home to eat at school every day or almost every day, much more frequent among children in the 4th grade and in those with a better family income. more than half of the children (58%) carry money to school for buying food, beverages, or lunch every day or almost every day, and one-fifth (22%) sometimes do; most schools have some kind of food shop, cafeteria or vending machine in the school vicinity or on the premises, from which adults and children can purchase foods. however, the quality of the foods offered is poor, consisting primarily of candies, hyska j. improving nutrition and health among albanian school children (policy brief). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5709 p a g e 7 | 9 chips, chocolates, or peanuts (81%), pies, pizza, or sandwiches (78%), and sweetened or fizzy beverages (73%). very few of these vendors offer fresh fruit, vegetables, milk or yoghurt. about half of schools do not provide children with access to drinking water, either free or for purchase. very few schools provide some form of meal or snack. only about 5% of parents confirm that their children eat food provided by the school. 4. increase parental awareness and involvement  it will be important to increase parental awareness and involvement that enables sustainable changes in support of healthy lifestyles, which could make poor nutrition prevention interventions more effective as: there were a significant association between breakfast consumption and the relationship with caregiver’s education: children of highly educated caregivers reported a higher prevalence of breakfast consumption compared with children with low-educated caregivers (16). the parental perception of the body image of their children was different from the actual nutritional status for all three conditions namely children who were thin, overweight, or obese in both studies. the parental perception gets marginalized for those who have overweight and especially obese children. consumption of fresh fruit and vegetables was significantly higher among children with highly educated parents. conclusions prevention policies focused on key factors such as healthy diet and regular physical activity are among the best investments in the personal well-being of a young european generation in good health (17).  these studies findings and respective recommendations can support the development of a national school food and nutrition education (sfne) programme in albania,  while there is evidence for the need to intervene at the national level, the stratified analysis at regional and district levels points to the need for the design and implementation of specific interventions at the local level.  it is also very crucial to strengthen and improve anthropometric nutrition and surveillance systems for nutritional risk factors for children and adolescents, and use the data obtained by these systems in effectively and appropriately. references 1. world health organization. nutrition. available from: https://www.who.int/healthtopics/nutrition (accessed: april 12, 2022). 2. food and agriculture organization of the united nations & world health organization. sustainable healthy diets guiding principles. fao 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fao; 2005. 16. institute of public health of albania. iniciativa e survejancës së obezitetit në moshën fëminore hyska j. improving nutrition and health among albanian school children (policy brief). seejph 2022, posted: 06 july 2022. doi: 10.11576/seejph-5709 p a g e 9 | 9 (cosi) në republikën e shqipërisë: rezultatet e vitit; 2016. [in albanian]. available from: http://ishp.gov.al/wpcontent/uploads/2015/04/raport i-obeziteti-tek-femijet.pdf (accessed: april 12, 2022). 17. council of the european union. healthy nutrition for children: the healthy future of europe 2018/c 232/01. available from: https://eur-lex.europa.eu/legalcontent/en/txt/pdf/?uri=cele x:52018xg0703(01)&from=en) (accessed: april 12, 2022). __________________________________________________________________________________________ © 2022 hyska; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 1 original research influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study helmut wenzel 1 , edgar unger 1 1 bodensee campus gmbh, kostanz, germany; corresponding author: helmut wenzel, m.a.s. address: d78464 konstanz, germany; e-mail: hkwen@aol.com wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 2 abstract aim: to assess the feasibility and effectiveness of resistance training on glycaemic control in adults with type 2 diabetes, the additional risk factors including low physical activity, measured by hba1c, body weight, cholesterol and triglycerides. methods: we conducted a pilot study as a pre-and-post study with no control group. participants had to meet the following inclusion criteria: type 2 diabetic person, 45-75 years old, duration of diabetes <10 years, no experience with resistance training within the last ten years, willingness to attend regularly the training sessions (two training units per week, with 45 minutes of duration each). furthermore, a certificate from the treating physician (diabetologist) was requested, testifying that there were no medical reasons against participation. patients with severe accompanying diseases, high blood pressure, heart failure (nyha iii), or retinopathy were excluded. eighteen persons (10 men, 8 women), aged 46-71 years could be included. due to dropouts, the pre-post-evaluation was based on 13 individuals only. mean age of this group (6 men, 7 women) was 63.6±5.5 years. mean body mass index at the beginning was 29.8±4.9. mean hba1c was 7.5%±0.6%; the triglycerides were in the range between 134 mg/dl and 335 mg/dl with an average value of 195.8±50.9 mg/dl. cholesterol level was between 149 mg/dl and 262 mg/dl, which corresponded to an average of 206.6±34.8 mg/dl. the training took place in a fitness centre under the supervision of a certified sports scientist between april 2010 and october 2010 for 28 weeks. during the training period, the patients were asked to report whether they changed their level of general physical activity during this period, as a potential confounder. possible treatment adaptations had to be recorded. results: at the end of the study, the average hba1c dropped from 7.5%±0.6% to 7.1%±0.8%. mean cholesterol level dropped from 206.6±34.8 mg/dl to 191.3± 30.85 mg/dl. mean triglycerides were lowered from 195.8±50.9 mg/dl to 144±30 mg/dl. these changes were all statistically significant (p<0.05). the dose-response curve was not significant, probably due to the small number of participants. conclusions: there is now suggestive evidence supporting the use of resistance training for improving glycaemic control and insulin sensitivity in type 2 diabetes. however, this has not been perceived clearly enough to date. it is also not in the focus of economic evaluations of diabetes preventing strategies. activating diabetic patients to perform resistance training is an effective and efficient way to reduce the burden of diabetes and, even more, to prevent this disease. keywords: cholesterol, hba1c, pilot study, triglycerides, type ii diabetes. conflicts of interest: none. wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 3 introduction diabetes affects patients and their families, health insurance and society. diabetes lowers average life expectancy of the patient increasing cardiovascular disease risk two to four fold, and is the leading cause of kidney failure, lower limb amputations, and adult-onset blindness. the disease puts a significant economic burden on society and healthcare programmes (1) and leads to considerable stagnation of national economies. the costs of caring for patients that are suffering the consequence of complications are four times higher than those without complications (2). as the international diabetes federation emphasizes, complications due to diabetes are a major cause of disability, reduced quality of life and death (3). just over 8.3% of the global population between 20 and 79 years has diabetes, which was about 415 million in 2015; by 2040, this figure will rise to 642 million (4). the number of people with diabetes in 2013 in europe was estimated at 56.3 million, which is 8.5% of the adult population. turkey has the highest prevalence (14.8%) and the russian federation has the greatest number of people with diabetes (10.9 million). by contrast, azerbaijan has an estimated prevalence of diabetes of just 2.4%. after turkey, the countries with the highest prevalence are montenegro (10.1%), macedonia (10.0%), serbia (9.9%), and bosnia and herzegovina (9.7%) (3). diabetes imposes a large economic burden on individuals and families, national health systems, and countries. according to a report of the international diabetes federation (3), health spending on diabetes accounted for 10.8% of total health expenditure worldwide in 2013. most of the money has to be spent for treating the complications. it is not diabetes or its management that causes most costs; rather, it is the consequences of the complications (4,5). at present, type 1 diabetes cannot be prevented. the environmental triggers that are thought to generate the process that results in the destruction of the body’s insulin-producing cells are still under investigation. but, there is significant evidence that lifestyle changes (achieving a healthy body weight and moderate physical activity) can help prevent the development of type 2 diabetes (6). obesity, particularly abdominal obesity, is linked to the development of type 2 diabetes. weight loss improves insulin resistance and reduces hypertension. people who are overweight or obese should therefore be encouraged to achieve and maintain a healthy body weight (6,7). a reduced capability of insulin to boost muscle blood flow is typical for insulinresistant obese individuals and individuals with type 2 diabetes. exercise training, however, has been found to help improve this problem, and substantially improve the control of insulin over blood glucose (8,9). implementing inexpensive, easy-to-use interventions can reduce the huge economic burden of diabetes. many of these interventions are cost-effective and/or cost saving, even in developing countries. vijgen et al. (10) provide a detailed overview on various approaches in primary, secondary and tertiary prevention. prospective studies and clinical trials have shown that moderate to high levels of physical activity and an increase in physical activity levels can prevent type 2 diabetes (11), or at least after onset slow down progression (12). consequently, diabetologists and others recommend physical activity (13-15). interestingly, the plea for physical activities in the treatment of persons with diabetes is not quite new. the importance of physical activity was already recognised at the beginning of the 20 th century. allen (16, p. 495) very early became aware of the possible impact of physical activity on the glucose metabolism. recent research shows the favourable impact of resistance training and/or aerobic training (17-22). there are also studies that show how type 2 diabetes can cause bone dysfunction and how resistance training positively impacts bone functioning (23). wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 4 in this context the purpose of this pilot study was to determine the feasibility and effectiveness of resistance training on glycaemic control in adults with type 2 diabetes, the additional risk factors including low physical activity, measured by hba1c, body weight, cholesterol and triglycerides. methods we conducted a pilot study as a pre-and-post study with no control group. four diabetologists/internists were asked to name eligible participants from their patients. the participants had to meet the following inclusion criteria: type 2 diabetic person (t2d), 45-75 years old, duration of diabetes less than 10 years, no experience with resistance training within the last ten years, willingness to attend regularly the training sessions (two training units per week, with 45 minutes of duration each). furthermore, a certificate from the treating physician (diabetologist) was requested, testifying that there was no medical reason against participation. patients with severe accompanying diseases, high blood pressure, heart failure (nyha iii), or retinopathy were excluded. eighteen persons (10 men, 8 women), in the age between 46 and 71 years, could be included. due to dropouts, the pre-and-post evaluation was based on 13 persons, only. the average age of this group (6 men, 7 women) was 63.6 (sd 5.5) years. mean body mass index (bmi) at the beginning was 29.8±4.9; the range was between 22.5 and 41.4. mean hba1c level was 7.5%±0.6%, ranging from 6.2% to 8.6%; the triglycerides were in the range between 134 mg/dl and 335 mg/dl, with an average value of 195.8±50.9 mg/dl. cholesterol level was between 149 mg/dl and 262 mg/dl, which corresponded to an average level of 206.6±34.8 mg/dl. according to the current guidelines, this group was likely to fall into the category “high risk” (24,25). the training took place in a fitness centre under the supervision of a certified sports scientist for 28 weeks. during the training period, the patients were asked to report whether they changed their level of general physical activity during this period, as a potential confounder. possible treatment adaptations had to be recorded. intervention the circuit programme consisted of two sessions per week. each session lasted 45 minutes, and was executed at eight different stations. the level of difficulty and the progression were determined individually with the intention not to surpass 60% of the maximum possible intensity of an untrained person. intensity was defined as a combination of weight moved, the number of repetitions, and the duration of the workout. twenty repetitions are approximately 60% of maximum intensity (26, p 229); depending on the individual situation of the test, person eighteen to twenty repetitions were carried out. this graduation was set because the study population was in relatively poor health and had to be protected against overloading. the workload was increased by 2.5 kg every two weeks until the final maximum possible capacity was reached. the only exception was the leg press where, for technical reasons, the increase steps were 5 kg. furthermore, the exercises were planned in such a way that both agonists and antagonists were trained likewise. the training started with a warm-up exercise on a stationary bicycle ergometer for 10 minutes. the strength training was made up of the following exercises: vertical traction, shoulder press, leg press, abductor training, low row, chest press, lower back and abdominal crunch. two cycles per machine and up to 20 repetitions were applied. the performance of the exercises was recorded with the help of a “training key” (i.e. workload), number of repetitions, speed, and extend of the movements. wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 5 we measured weight, height, hba1c, cholesterol, and triglycerides at baseline and weight, hba1c cholesterol, and triglycerides at the end of the intervention. statistical analysis for statistical analysis, we used the wilcoxon matched pairs test. the wilcoxon matched pairs test is a nonparametric alternative to the t-test for dependent samples, which fits with the pre-and-post comparison design (i.e., repeated observations of the same person). the application does not require a gaussian distribution of data. the variables must be measured in such a way that will allow the rank ordering of the observations (ordinal scale). we considered a p-value below 0.05 to be statistically significant (two-tailed test). statistics were calculated with xlstat 2009, version 4.07. results at the end of the study, mean hba1c dropped from 7.5%± 0.6% to 7.1%±0.8%. figure 1 and figure 2 provide overviews and show also the minimal and maximal values. figure 1. comparison of hba1c * * the red cross represents the mean, the box stands for the 1 st and 3 rd quintile, the line in the middle is the median. the whiskers represent the minimum and maximum value, the asterisks symbolize outliers. the height of the box is the interquartile range. the differences were significant (p<0.05); n=13. for type 2 diabetic patients the target range of hba1c is currently set between 6.5% and 7.5%; hence, participants were close to treatment recommendations. the average cholesterol level dropped from 206.6±34.8 mg/dl to 191.3±30.85 mg/dl, ranging from 150 mg/dl to 230 mg/dl. mean triglycerides were lowered from 195.8±50.9mg/dl to 144±30 mg/dl, with a maximum value of 182 mg/dl and a minimum of 87 mg/dl. these changes were all significant (p<0.05). figure 1 and 2 indicate that in the case of hba1c and total cholesterol, the interquartile range (height of the boxes) after intervention was lower than that of the initial hba1c hba1c(1) 0.06 0.065 0.07 0.075 0.08 0.085 0.09 0.095 comparison t0 t1 wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 6 starting point. this means that the data are less widely spread; the minimum and maximum values are also closer to the box. figure 2. comparison of triglycerides and total cholesterol * * the red cross represents the mean, the box stands for the 1 st and 3 rd quintile, the line in the middle is the median. the whiskers represent the minimum and maximum value, the asterisks symbolize outliers. the height of the box is the interquartile range. the differences were significant (p<0.05); n=13. dose-response smidt hansen and colleagues pointed out that there must be a dose-response relationship between physical activity and glucose metabolism (27). this means that, the higher the workload, the higher the reduction of hba1c. we therefore compared the cumulated size of the weight that was moved during the training period by all participants with the corresponding changes in hba1c achieved. we expected, in accordance with the principle of “diminishing marginal returns in production curves” (28), a rather s-shaped curve. the fitted curve of our data showed the expected incremental effect. the curve starts with a steep incline at the beginning and flattens towards the end. this is in accordance with the law of diminishing marginal returns. however, due to the small number of participants the explained variance was only 18%. therefore, it was not possible to identify the optimum of the doseresponse relationship. discussion we started the training with a relatively low workload despite the recommendations how to prevent, delay, or reverse the process of losing muscle power (29-31). to increase muscle mass a training intensity of 60% to 85% of the individual maximum possible intensity is triglycerides triglycerides (1) cholesterol cholesterol (1) 50 100 150 200 250 300 350 comparison t0 t1 wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 7 proposed, and for forcing the muscle development mayer et al. even advise more than 85% of maximum intensity (30). to influence sarcopenia, i.e. the age-related loss of muscle mass and function (32), this will be appropriate in a non-diabetic elderly population. to our knowledge, we have currently no training plans that are specially adapted to the needs of diabetic patients. it is also still under discussion whether it is more effective to increase the workload or the number of repetitions, mainly in the case of diabetic patients at higher ages. to determine the maximum possible intensity, the “one repetition maximum strength test [1-r]” is used mostly (30). applying a [1-rm] strength test is somewhat critical “because of the high stress on the musculoskeletal system and the high injury risk, especially for sportspersons involved in recreational sport” (33, p 1). this is even more valid for our study population. moreover, studies allow the assumption that the [1-rm] test is inappropriate for intensity control. compared with the “multiple repetition maximum test [m-rm]”, its reliability is questionable (33,34). therefore, we applied our multiple repetition test. persons with diabetes are at a higher risk to develop sarcopenia. among other things, decreased physical activity is also complemented by metabolic impairment (35); possible interactions are quite complex, and the underlying mechanism between sarcopenia and type 2 diabetes mellitus have not been clarified completely [36]. however, the baltimore longitudinal study of aging showed that hyperglycaemia is associated with lower muscle strength (37). with our restraint, we took into account that our participants were untrained for many years and that they even manifested sarcopenia in advanced stages, also in combination with obesity (39% of participants were obese). insofar, the effectiveness of our training concept might be at the lower end of a possible dose-response relationship. on the other hand, our results are consistent with the findings of healy and colleagues, who show that even small increments in physical activities are associated with improved metabolic control (38). smidt hansen and colleagues conclude that “for persons, increasing the amount of light physical activity might be a more realistic approach rather than increasing physical activity of moderate-to-vigorous character” (27). according to the ukpds and the dcct studies, improving the hba1c by 1% of a person with type 1 or type 2 diabetes reduces the risk of microvascular complications by 25% (39). the changes of the other risk factors are also substantial. the investigation was planned as a pilot study; nevertheless, the improvement of hba1c found here is compatible with the outcomes of other studies (21,40). according to könig et al. (40), meta-analyses show average changes of hba1c between 0.5 percentage points and 0.6 percentage points; mean changes in our study were 0.35 percentage points (sd: 0.4). sigal et al. report changes of 0.38 percentage points when applying resistance training alone (21). depending on the composition of the sample under examination and the training scheme, hba1c changes of >1 percentage points were also reported – actually, 18 percentage points in the case of a progressive resistance training over 10 weeks (41, p 5). cauza (42) observed a 28% reduction of cholesterol. baseline levels of total cholesterol significantly decreased in the training group from 205.5±14.1 mg/dl to 177.5±13.3 mg/dl. in our study, the average value dropped from 206.6±9.7 mg/dl to 191.3±8.6 mg/dl. in their strength training group, the triglyceride levels were reduced from 229±25 mg/dl to 150±15 mg/dl (42). our respective data showed a reduction from 188.8±14.12 mg/dl to 145.7±8.6 mg/dl. previous analyses have demonstrated that structured supervised training is more effective than unsupervised training at home (43-45). in a new meta-analysis, randomised studies with supervised training were analysed which directly compared aerobic training, resistance training and a combination of both. combination training (ct) led to a 0.6 percentage points wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 8 improvement of hba1c compared to resistance training. similarly, beneficial results were found for fasting glucose, triglycerides and systolic blood pressure (43). schwingshackel and colleagues conclude that ct might be the most effective exercise modality to improve glycaemic control and blood lipids (44). nevertheless, they recommend cautious interpretation, due to limited information on adverse outcomes of exercise. the outcomes of our pilot are statistically significant. however, are they significant from a medical/epidemiological viewpoint too? to assess further the health effect of the training and to evaluate the relevance of the changes, it would be worthwhile to extrapolate the changes of the risk factors to events like myocardial infarction and/or stroke. there are several risk functions available, for example the euro score (46), or the framingham risk function (47) and the like. the algorithms are mostly based on blood pressure, cholesterol, ldl, hdl and triglycerides. diabetes is coded as “yes/no” only. therefore, as a compromise, we used the framingham risk function to estimate in an exemplary manner the cardiovascular risk and its reduction. one of the participants in the age of 68 years with cholesterol level of 188 mg/dl, and an hba1c of 8%, reduced the total cholesterol level to 153 mg/dl and the hba1c level to 7.4%. if we assume that, the blood pressure (conservative) is at 140 mm hg and hdl at 40 mg/dl (also conservative), the 10 years risk of general cardiovascular events is about 24.22%. the reduction in cholesterol reduces his risk to 19.44%. if we further could assume here that the reduction of hba1c from 8% to 7.4% is equivalent to “no diabetes” coding, then the new 10-year risk would be 10.26%. looking at all 13 patients, the cholesterol dropped from 206.6 mg/dl on average to 191.3 mg/dl. based on the conservative assumptions on blood pressure and hdl, the risk would drop from 23.65% to 11.59%. admittedly, these calculations can only give a rough estimate of the training’s health impacts, especially because the improvement of hba1c can be modelled insufficiently only. however, the benefits for various stakeholders are obvious. the patient improves his quality of life and life expectancy, the health insurance saves money, employers have less sick days, and so on. at a first glance, it looks like a win-win situation. unfortunately, the “investment” has to be done by the individual. it is not only expenditures, but it is also the “cost of motivation”. to keep diabetic patients at it, sophisticated measures have to be introduced. they have to be based on a concept of motivation and identified barriers, which in turn possibly impede maintenance of training (48). special attention must be given to the peculiarities and possible differences in t2d and t1d (49). this pilot study, regardless of the small study population, is compatible with the respective literature. nevertheless, there are some weaknesses. first of all, the pre-and-post design cannot provide “class one evidence”; controlling for confounders was difficult. secondly, the small number of participants does not yield a high statistical power. on the other hand, there are many other studies involving small numbers too (41,50). thirdly, more sophisticated statistical analysis is not possible due to the small number of participants. a study with more participants and the collection of all health parameters that are needed to calculate health outcomes would be required. conclusions there is evidence supporting the use of resistance training for improving glycaemic control and insulin sensitivity in type 2 diabetes. however, this has not been perceived clearly enough to date. it is also not in the focus of economic evaluations of diabetes preventing strategies, i.e., lifestyle changes that were economically assed did not include resistance training. the fact that in many studies the participants had individually supervised training sessions requires larger, population-based (effectiveness) studies to ensure that these findings can be generalised. also, further research is needed to identify the efficiency of dose-response wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 9 relationship by describing frequency and intensity of training and the sustainability of the effects, i.e. the duration of acute and chronic improvements. activating diabetic patients to perform resistance training is an effective and efficient way to reduce the burden of diabetes, and, even more, to prevent diabetes. wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 10 references 1. world health organisation. diabetes: the cost of diabetes, fact sheet number 236. 2014 [21.11.2015]. available from: http://www.who.int/mediacentre/factsheets/fs236/en/ (accessed: march 11, 2016). 2. liebl a, neiss a, spannheimer a, reitberger u, wagner t, gortz a. 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[10.11.2015]. available from: http://euroscore.org/index.htm (accessed: march 11, 2016). 47. medscape. framingham 10 year risk of general cardiovascular disease (2008 paper) 2008 [12.11.2015]. available from: http://reference.medscape.com/calculator/framingham-cardiovascular-disease-risk (accessed: march 11, 2016). 48. jekauc d, völkle m, wagner mo, mess f, reiner m, renner b. prediction of attendance at fitness center: a comparison between the theory of planned behavior, the social cognitive theory, and the physical activity maintenance theory. front psychol 2015;6:121. wenzel h, unger e. influence of a six-month strengthening programme on hba1c, cholesterol and triglycerides in type ii diabetics: a pilot study (original research). seejph 2016, posted: 23 march 2016. doi 10.4119/unibi/seejph-2016-96 13 49. plotnikoff rc, lippke s, courneya ks, birkett n, sigal rj. physical activity and social cognitive theory: a test in a population sample of adults with type 1 or type 2 diabetes. appl psychol 2008;57:628-43. 50. marcus rl, smith s, morrell g, addison o, dibble le, wahoff-stice d, et al. comparison of combined aerobic and high-force eccentric resistance exercise with aerobic exercise only for people with type 2 diabetes mellitus. phys ther 2008;88:1345-54. ___________________________________________________________ © 2016 wenzel et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 1 | 8 review article syndromic surveillance in early detection of outbreaks of infectious diseases eugena tomini1, artan simaku1, elona kureta1, adela vasili1, silva bino1 1 institute of public health, tirana, albania. corresponding author: eugena tomini, md, phd; address: rr. “aleksander moisiu”, no. 88, tirana, albania; telephone: 00355672052938; email: genatomini@yahoo.com tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 2 | 8 abstract aim: motivated by the threat of infectious diseases and bioterrorism, syndromic surveillance systems are being developed and implemented around the world. the aim of the study was to describe the early warning surveillance system in albania. methods: syndromic surveillance is a primary health care-facilityand emergency room (er)based syndromic surveillance system aiming at detecting outbreaks and undertaking public health actions. it is based on weekly notifications of nine syndromes by over 1,600 general practitioners (gps) in the 36 districts of albania. data is aggregated by district epidemiologists (de) and centralized by the national institute of public health. results: a syndrome is “a set of symptoms or conditions that occur together and suggest the presence of a certain disease or an increased chance of developing the disease.” in the context of syndromic surveillance, a syndrome is a set of non-specific pre-diagnosis medical and other information that may indicate the release of a bioterrorism agent or natural disease outbreak. since its inception, syndromic surveillance has mainly focused on early event detection: gathering and analysing data in advance of diagnostic case confirmation to give early warning of a possible outbreak. conclusion: the system is useful for detecting and responding to natural disease outbreaks such as seasonal and pandemic flu, and thus they have the potential to significantly advance and modernize the practice of public health surveillance. keywords: albania, early event detection, public health, situational awareness. tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 3 | 8 introduction the epidemiology of infectious diseases is one of the major crises facing human society. following the course of epidemic outbreaks of diseases such as sars (severe acute respiratory syndrome), a health emergency that shocked the world at the end of 20022003 or of the influenza pandemic caused by the ah1n1 virus in 2009 to arrive at covid19 pandemic, the appropriate management of crises health issues that exceed borders, takes an important role (1-3). human cases of ah5n1 influenza are still being reported in asia, and the emergence of new infectious disease epidemics is still a major concern. early detection of outbreaks of infectious diseases is essential for taking measures against the disease. in recent years, "syndromic surveillance" has attracted attention as a new technology that meets these needs. the term "surveillance" is used when observing the trends of an infectious disease (4-6). it refers to the systematic collection, analysis and interpretation of data necessary for the planning, implementation and evaluation of measures against diseases, due to the continuous monitoring of the situation and the trend of disease occurrences, thus making it possible to take effective measures based on timely results and continuous feedback evaluations of decision-making bodies (7,8). syndromic surveillance focuses on the patient's symptoms such as fever, diarrhoea, etc. syndromic surveillance takes less time than diagnosis-based surveillance, so it enables an early investigation of infectious disease epidemics and taking measures to prevent their spread. in the situation where "improvement and reinforcement of surveillance" is at the top of the list for measures to be taken for the prevention of infectious diseases, including new subtypes of influenza viruses and sars-cov-2 variants, expectations for syndromic surveillance are high, as was discussed at the international conference maintained by the world health organization (who) (9,10). in syndromic surveillance, the technologies of epidemic intelligence, epidemiological analysis of information about the patient's symptoms thanks to statistical methods, as well as the technologies of efficient collection, processing and distribution of information, play a very important role. this article focuses on the role of syndromic surveillance in taking measures against infectious diseases in humans. what is syndromic surveillance? description and objectives of surveillance the research, development and practical application of syndromic surveillance has been promoted since the anthrax cases that occurred after the september 2001 attacks in the united states of america, as well as after the sars epidemic in 2002-2003, with the aim of developing measures against bioterrorism, early detection of the emergence and re-emergence of epidemics from infectious diseases, especially unknown or rare ones (11). the us centres for disease control and prevention proposed the following definition of syndromic surveillance as the most appropriate and acceptable: syndromic surveillance is an investigative approach by which health department staff, assisted by data from automated and the construction of comparative statistics, monitors disease indicators in real or near-real time, in order to detect disease epidemics earlier than was possible with traditional public health methods (12-16). in other words, syndromic surveillance is an action that captures disease outbreaks in real or near-real time, focusing on symptoms that serve as disease indicators, collecting information automatically, and analysing tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 4 | 8 information from an epidemiological point of view thanks to the use of statistical methods. syndromic surveillance is an early investigation of the epidemic of an infectious disease, thanks to the rapid and early identification of the growing number of patients with specific symptoms, before the diagnosis is confirmed by the doctor. it is a "surveillance of syndromes", with the aim of quickly engaging in the "early dictation" of new epidemics, especially those of reappearing diseases, of unknown or rare infectious diseases, a description that also explains the objective of syndromic surveillance. if all the above points are summed up, it can be said that syndromic surveillance "collects information about the patient's symptoms, analyses the information from an epidemiological point of view using statistical methods, notifies family physicians and government organizations about the results, and quickly takes measures for public health" as and "an effective action that prevents the epidemic spread of infectious diseases caused by humans (bio-terrorism) or by nature" (17-20). system organization and action views the operative process of syndromic surveillance consists of three steps:  selection of information source and data collection;  analysing the information collected and based on the results of judgment about the chances of an epidemic;  notifying health professionals and government organizations responsible for taking measures against infectious diseases. these steps are the same for all types of syndromic surveillance. but since epidemics of infectious diseases vary in form based on the microbiological characteristics of the pathogen and the area of the outbreak, and since syndromic surveillance uses different sources of information, the collection and analysis algorithms are different. the main goal of syndromic surveillance is to establish these algorithms and the various research results. the inability of different countries to detect and contain epidemic outbreaks, identify an infectious agent and understand the dynamics of its transmission in time, has contributed to the spread of infectious diseases in the past (21-24). the international health regulations (ihr) were revised to meet the risks and challenges of the emergence or re-emergence of diseases in the 21st century (25). according to this regulation, all states must report as soon as possible all public health events that have a potential international impact, so that control and prevention measures can be implemented as soon as possible (26). this is achieved by strengthening syndromic surveillance of infectious diseases as a function of the early warning and response of the public health surveillance system, which also helps to collect important data on the epidemiology of endemic diseases. this early warning system was implemented in albania during the influx of kosovar refugees in april 1999 (27,28). this was carried out in collaboration with the institut de veille sanitaire (invs) and the world health organization (who). after the departure of kosovar refugees in july 1999, the system was redesigned to meet the needs of the national health system. the system of early warning and response to infectious diseases alert, was established in september 1999, as part of the national surveillance system coordinated by the institute of public health (iph). the goal of the alert system is the early detection of epidemic outbreaks. it is a syndromic surveillance system based on health centers and emergency departments tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 5 | 8 that produces information for action. the participation of general practitioners in surveillance and preventive activities is mandatory and is included in their employment contract with the institute of health insurance. the system also includes the emergency departments in the hospitals of 36 districts of the country. at the end of each week, gps report the syndrome cases they have examined during the week, including reporting zero cases. the system includes nine infectious syndromes. data are reported to infectious disease information system which is a web-based integrated platform. after visual verification of the data for any outbreak signal, the data are analysed and a weekly bulletin is prepared on the epidemiological situation all over the country. the information produced by the pih is distributed to the epidemiological service of the districts in the form of weekly and quarterly bulletins. the verification of the alert signal and the epidemiological investigation is also carried out at the district level with the help of the pih if necessary. the district epidemiology service is responsible for distributing the weekly newsletter to general practitioners. in some cases, general practitioners are informed in the form of alert data summaries during their monthly meetings with the administration of the institute of health insurance and the directorate of the primary health service (29,30). the "alert" system is integrated and complementary with the mandatory routine reporting system of diagnosed diseases the major disease-based surveillance system, along with other case-based surveillance systems. table 1. type of syndromes and target diseases syndromes clinical definition disease(s) target diarrhoea without blood more than 3 loose stools in 24h salmonellosis… diarrhoea with blood more than 3 loose stools with blood in 24h shigellosis… upper respiratory infections fever, and at least one of the following: rhinitis, cough, sore throat influenza … lower respiratory infections fever and fast breathing (= 50 breathing/min) and at least one of the following: cough, dyspnoea bacterial or viral pulmonary infections sars… avian influenza rash (exanthema) with fever rash with fever measles, rubella, varicella, … jaundice yellow eyes and skin hepatitis virus infection … tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 6 | 8 congenital anomalies structural or functional anomalies that occur during intrauterine life congenital rubella syndrome (crs), congenital syphilis, congenital cytomegalovirus (ccmv) infection and congenital zika syndrome (czs) acute conjunctivitis in neonates conjunctival inflammation occurring within the first 30 days of life chlamydia, bacteria, viral diseases syndromes are broken down by age-group and different automated reports and graphs are produced by epidemiological triad timeplace-person. integration of different surveillance system aiming at maximizing case detection and fast control actions within infectious disease information system is shown in figure 1. figure 1. scheme of integration of different surveillance systems conclusion the alert component of the surveillance of infectious diseases in albania is one of the few systems in the world spread over the entire territory of the country. it can be improved by re-examining the case definition and the disorders under surveillance, and its integration with routine surveillance at the district level. re-structuring, training, feedback to family doctors can be more frequent, increasing the acceptability of the system. the alert system remains very useful, and complements other surveillance systems in a timely and effective manner. tomini e simaku a, kureta e, vasili a, bino s. syndromic surveillance in early detection of outbreaks of infectious diseases (review article). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5930 p a g e 7 | 8 choices made in building the system—such 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2004;53:1-14. 22. centers for disease control. framework for evaluating syndromic surveillance systems for bioterrorism preparedness. mmwr morb mortal wkly rep 2004;53(rr-5):1-14. 23. grein tw, kamara kb, rodier g, plant aj, bovier p, ryan mj, et al. rumors of disease in the global village: outbreak verification. emerg infect dis 2000;6:97-102. 24. world health organization. regional office for europe. the dubrovnik pledge on surveillance and prioritization of infectious diseases: report on a who meeting, bucharest, romania 21-23 november, 2002. 25. the albanian center for economic research (acer). un common country assessment: albania; 2002. 26. nuri b. health care systems in transition – albania; 2002. 27. valenciano m, bergeri i, jankovic d, milic n, parlic m, coulombier d. strengthening early warning function of surveillance in the republic of serbia: lessons learned after a year of implementation. euro surveill 2004;9:24-6. 28. valenciano m, pinto a, coulombier d, hashorva e, murthi m. surveillance of communicable diseases among the kosovar refugees in albania, april-june 1999. euro surveill 1999;4:92-5. 29. kakarriqi e. survejanca e shendetit publik. leksion per specializantet pasuniversitare te fakultetit te mjekesise (universiteti i tiranes); 2003 (in albanian). 30. kakarriqi e. epidemiologjia e semundjeve infektive ne shqiperi (1960-2001) dhe kontrolli e parandalimi i tyre ne kontekstin: fatkeqesite natyrore dhe semundjet infektive. tiranë; 2003 (in albanian). _____________________________________________________________________________________________ © 2022 tomini et al; this is an open access article distributed under the terms of the creative commons attribution license (http:// creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. prifit e, vrapi e, dervishi m, shpuza a, kowalska jd, harxhi a. assessment of mother-to-child hiv prevention program in albania (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5921 p a g e 1 | 12 original research assessment of mother-to-child hiv prevention program in albania enkeleda prifti1, enxhi vrapi2, marjeta dervishi3, aldo shpuza4, justyna d kowalska5, arjan harxhi6 1 department of obstetrics and gynecology, university of medicine, tirana, albania; 2 university hospital of obstetrics and gynecology ‘koço gliozheni’, tirana, albania; 3 national aids program, institute of public health, tirana, albania; 4 department of public health, university of medicine, tirana, albania; 5 department of adults' infectious diseases, hospital for infectious diseases, medical university of warsaw, poland; 6 department of infectious disease, university of medicine, tirana, albania. corresponding author: enkeleda prifti, msc, phd university hospital of obstetric-gynaecology, tirana, albania telephone: +355692087257; email: enkeledaprifti@yahoo.com prifit e, vrapi e, dervishi m, shpuza a, kowalska jd, harxhi a. assessment of mother-to-child hiv prevention program in albania (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5921 p a g e 2 | 12 abstract aim: mother-to-child transmission (mtct) is one of the recognized routes of hiv transmission. this study aims to assess mctc among hiv positive pregnant women in albania. methods: this was a retrospective study that included a case series of 14 pregnant women in albania diagnosed with hiv between 2014 and 2020 who were enrolled in hiv care ambulatory centre. the following variables were analysed: epidemiological characteristics (age, hiv diagnoses in regard to pregnancy), clinical characteristics such as use of antiretrovirals, adherence to treatment, cd4 cell count, viral loads, mode of delivery, gestational age at delivery) and the hiv status of the infant. descriptive statistics were used to summarise the variables in the data sample. results: eight women (57.2%) were aware of their hiv status prior to the pregnancy, while for the other 6 women (42.8%) an hiv diagnosis was done during the pregnancy as part of the antenatal testing. only two women (14.28%) had a viral load of >1000 copies/ml before delivery. the mean time from diagnosis to initiation of antiretroviral therapy was 3.83 weeks +2.4 sd (range 1-7 weeks). adherence was calculated to be good, with 92.9% of women reporting taking the medication precisely as directed. no mother to child transmission cases were reported among the women in our cohort. conclusion: gaps in prenatal screening for hiv and viral load measurements were identified in this study conducted in albania. thus, educating the providers, in this case the obstetricians, to offer first trimester hiv screening to all pregnant woman and to enhance testing, would reduce vertical transmission. keywords: albania, hiv, mother-to-child transmission, prevention, screening. prifit e, vrapi e, dervishi m, shpuza a, kowalska jd, harxhi a. assessment of mother-to-child hiv prevention program in albania (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5921 p a g e 3 | 12 introduction about 1.5 million women living with hiv become pregnant each year (1). mother-tochild transmission (mtct) is one of the routes of virus transmission and therefore protocols are constantly updated in this regard (2). diminishing mtct through treatment of pregnant women is key in achieving global health goals such as unaids 90-90-90, as well as those that directly target the reduction of new paediatric infections (3,4). despite a steady rise of newly diagnosed hiv cases, albania remains a low prevalence country (5). according to institute of public health of tirana, there were a cumulative total of 1402 hiv infections (23% female) reported until 2020. the main mode of reported transmission is heterosexual in more than 95% of the cases, with a cumulative total of 179 women diagnosed between 2014 till 2020 (out of 706 diagnosed in total) the national institute of health reports 37 documented cases of mother to child transmission since the beginning of epidemic in albania. the purpose of the study is to evaluate mother to child prevention (mtcp) effectiveness and pregnancy outcomes in albania. methods this is a retrospective, observational case series study which aims to evaluate mother to child hiv prevention program in albania. fourteen hiv positive pregnant women, enrolled to care and followed at the hiv ambulatory center, university hospital center of tirana and university obstetric hospital in tirana during the period 2014 to 2020 were included in the study. the hiv ambulatory center serves as the only specialized care center at a national level (5). during the same period, there were 7 newly diagnosed women following the hiv diagnoses of their new-borns, but these cases were considered as missed diagnosis during pregnancy and were not included in the analysis. the following variables were analysed: epidemiological characteristics (age, parity, hiv diagnoses in regard to pregnancy), clinical characteristics such as use of antiretrovirals, adherence to treatment, cd4 cell count, viral loads, mode of delivery, gestational age at delivery) and new-born characteristics such as birth weight, neonatal morbidity and the use of postpartum prophylaxis. new-borns exposed to hiv were managed accordingly by the paediatricians. in order to determine the hiv status of new-borns, hiv confirmatory antibody test was performed at 15-18 months of age. data was compiled in a secured database. the absolute numbers and their respective percentages were calculated to describe the category variables, while for continuous variables, the mean and standard deviation were calculated. this study was approved by the ethical committee of the medical university of tirana. results between 2014 and 2020 there were a total of 14 hiv pregnant women which were followed at our center. the mean maternal age was 28.7 years ± 5.8 sd (range 22-39 years) (table1). table 2 shows that eight women (57.2%) were aware of their hiv status prior to the pregnancy, while for the other 6 women (42.8%) an hiv diagnosis was done during the pregnancy as part of the antenatal testing. three patients (50%) were diagnosed during the first trimester. two women (33.3%) were made aware of their hiv status during the second trimester and only one patient (16.7%) failed to know until the third trimester when she was diagnosed prior to delivery. the mean gestational age at diagnoses was 18.6 weeks ± 9.4 sd (range 11-36 weeks). viral load testing was performed, at least once, for 13 out of 14 patients in our series (92.85%). measurements, first at the time prifit e, vrapi e, dervishi m, shpuza a, kowalska jd, harxhi a. assessment of mother-to-child hiv prevention program in albania (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5921 p a g e 4 | 12 of diagnoses and/or at the beginning of pregnancy, and then, repeated again before delivery were available for 8 patients (61.5%). these enabled the evaluation of antiretroviral treatment effects, by which viral suppression was achieved in 7 out of 8 cases (87.5%). two women (15.38%) sreached delivery bearing a high viral burden. one of them was only diagnosed in the third trimester, prior to delivery. table 1. baseline characteristics of cases baseline characteristics descriptive statistics maternal age at hiv diagnoses (years) 28.7 ± 5.8* living in tirana yes no 6 (42.8) † 8 (57.2) married not-married 11 (78.6) 3 (21.4) education level university or higher high school or lower not declared 2 (14.3) 5 (35.7) 7 (50.0) working yes no 4 (28.6) 10 (71.4) serodiscordant couples yes no unknown 5 (35.7) 7 (50.0) 2 (14.3) reason for testing pregnancy partner positive status symptomatic disease positive child from prior pregnancy other 6 (42.8) 2 (14.3) 3 (21.4) 2 (14.3) 1 (7.2) * mean and standard deviation. † absolute numbers and their respective column percentages. the mean time from diagnoses to starting therapy was 3.83 weeks ± 2.4sd (range 17 weeks). only 5 (62.5%) out of the 8 hiv+ women diagnosed prior to pregnancy were already receiving antiretroviral therapy. of the 3 women who had not been receiving antiretroviral therapy, 2 manifested negative viral loads and the other had a cd4+ count of 889 cells. nine patients (64.2%) started antiretroviral therapy during pregnancy (mean gestational age 21.6 ± 7.4 weeks, range 1336 weeks of gestation), with the majority of them (7 patients, 77.8%) only started taking the medication during the second trimester. by the moment of delivery, all the patients in our cohort were receiving antiretroviral therapy. eight patients (57.1%) received a combination of two nucleoside reverse transcriptase inhibitors (nrti) and one boosted protease inhibitor (pi) while 6 patients (42.9%) received a combination of two nrti and one non-nucleoside reverse transcriptase inhibitor (nnrti). adherence was reported to be good, with 92.9% of women reporting that they took prifit e, vrapi e, dervishi m, shpuza a, kowalska jd, harxhi a. assessment of mother-to-child hiv prevention program in albania (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5921 p a g e 5 | 12 the medication precisely as directed (table 2). table 2. clinical characteristics clinical characteristics n (%)* parity nulliparous pluriparous 4 (28.6) 10 (71.4) hiv status at entry into antenatal care previously known hiv diagnosed during antenatal care 8 (57.2) 6 (42.8) gestational age at diagnoses 1st trimester 2nd trimester 3rd trimester 3 (50.0) 2 (33.3) 1 (16.7) on art prior to pregnancy yes no 5 (35.7) 9 (64.3) gestational age at art initiation 1st trimester 2nd trimester <20 weeks 20 28 weeks 3rd trimester 1 (11.1) 7 (77.8) 2 (28.6) 5 (71.4) 1 (11.1) art scheme used 2 nrti + pi 2 nrti + nnrti 8 (57.1) 6 (42.9) adherence to treatment yes no 13 (92.9) 1 (7.1) viral load at beginning of pregnancy undetectable < 1000 copies > 1000 copies undetermined 3 (21.4) 8 (57.1) 3 (21.4) viral load during pregnancy/near delivery undetectable < 1000 copies > 1000 copies undetermined 9 (64.3) 2 (14.3) 2 (14.3) 1 (7.1) cd4+ counts during pregnancy > 500 500 350 200 350 < 200 8 (72.7) 3 (27.3) *absolute numbers and their respective percentages. delivery was mainly done by means of an elective caesarean section in 10 cases (71.4%). emergency caesarean section was performed on 2 patients (16.6%), indicated prifit e, vrapi e, dervishi m, shpuza a, kowalska jd, harxhi a. assessment of mother-to-child hiv prevention program in albania (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5921 p a g e 6 | 12 by signs of foetal compromise (table 3). 2 women (14.3%) delivered vaginally despite them being aware of their hiv status and the recommendation of c-section. one pluriparous patient showed at the maternity unit with advanced dilation, thus performing c-section was not possible, while the other case failed to attend the prenatal counselling and follow up sessions. premature delivery complicated only 14.2% (2 cases) of pregnancies of hiv positive women, though both were categorized as being late premature births. no other obstetrical complications were observed in our cohort. no mother to child transmission cases were reported among the women in our cohort (table 3). table 3. obstetrical characteristics obstetrical characteristics n (%)* mode of delivery vaginal delivery cesarean section 2 (14.3) 12 (85.7) elective c-section emergency c-section 10 (83.3) 2 (16.7) gestational age at delivery <37 weeks > 37 weeks 2 (14.3) 12 (85.7) neonatal hiv status positive negative 14 (100) *absolute numbers and their respective percentages. infants born to these women received prophylaxis with oral zidovudine for 6 weeks. formula milk was given to all newborns, as breastfeeding was not encouraged. discussion this is the first study assessing the pmtct program in albania. between 2014 and 2020, there were no registered mother to child transmission among hiv diagnosed women who were followed during their pregnancy. this demonstrates the importance of the implementation of prophylactic measures that incorporates and follows international guidelines in the matter of reducing vertical transmission of hiv. mother to child transmission remains an important contributing factor in the spread of hiv (2). introduction of better care sees the increase of women of reproductive age infected with hiv and the increase of pregnancies among hiv positive patients. the average age of women in our study is 28.3 years ± 5.4 sd. factors to blame for increased risk of mother to child transmission are advanced disease, late diagnoses, elevated viral load, route of delivery and low cd4 counts among others (6-9). most of the above mentioned would be preventable if access to care and initiation of antiretrovirals was done early in the course of pregnancy (10,11). this highlights the necessity to offer and sustain care access to women (3). in high income countries transmission is reduced to 1-2% since 2000 while in lowand middle-income countries rate as low as 5% have been achieved. who 2015 recommendation of lifelong art despite the cd4 counts (option b+) was adopted by 83% of low-and middle-income countries (12) contributing to better neonatal outcomes (13-16). this strategy was also incorporated in our country, offering prifit e, vrapi e, dervishi m, shpuza a, kowalska jd, harxhi a. assessment of mother-to-child hiv prevention program in albania (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5921 p a g e 7 | 12 therapy to all patients, regardless of their cd 4 count. there are no recent robust data on implementation of antenatal screening program in albania. late initiation of art is another factor that may increase vertical transmission. studies demonstrate that duration of less than 15 days correlates with higher risk of transmission. french perinatal cohort found a 2.2% transmission rate among women who start therapy late in pregnancy as opposed to 0.2% in the entire cohort (18,19). only one woman in our cohort was diagnosed late at term, thus preventing her to be exposed to art for an adequate time. a national guideline on hiv testing of pregnant women is approved since 2015. although the establishment of an antenatal screening program is feasible since most women attend at least one gynaecological/obstetrician appointment during the course of their pregnancy, the data from institute of public health (iph) shows a low rate of hiv testing among pregnant women, with only 1430 hiv tests offered in 10 months (28561 live births are reported during 2019 in albania) (20). based on the demographic and health survey 2017-2018 , only 11% of women aged 15-49 years who gave birth in the 2 years before the survey received counselling on hiv during antenatal care (anc), and 9% were tested and received results either during an antenatal visit or during labour (21). iph reports that between 2014 and 2020, there were 7 cases of vertical transmission diagnosed after birth, which shows the existing gaps in the hiv screening program in albania. strengthening of hiv screening of pregnant women program should be accompanied by a training program of medical staff to certify that testing and associated counselling are performed professionally. another barrier to overcome is the nonadherence to treatment, defined as missing more than one dose of medication per month. despite a multidisciplinary approach to managing pregnancies in hiv positive women, some of them fail to adhere to treatment as for fear of possible medication side effects on the foetus (22,23). a cluster randomized controlled trial in mozambique (24) noted a 23% adherence. adherence is measured according to the women reporting that they have taken the medication as prescribed when they show to pick up the monthly therapy at the hiv ambulatory clinic in tirana, thus leaving this measurement up to subjectivity with lack of a proper objective test to quantify the adherence. measuring drug concentrations in plasma is not performed in our settings. only one woman resulted to be non-adherent, but despite this, her viral load remained undetectable prior to delivery. viral load monitoring is the gold standard in monitoring treatments efficacy and predicting possible mtct (25). levels of maternal viremia are found to be directly proportional to the risk of transmission (26,27). monitoring is recommended to continue postpartum, as half of mtct occur during breastfeeding (28). viral load values, also dictate the decision regarding mode of delivery. in the presence of undetectable hiv-arn vaginal delivery is encouraged despite theories postulating the presence of viral concentration in vaginal fluids (29). american college of obstetrics and gynaecology recommends a scheduled pre-labour caesarean section at 38th week of gestation, in the presence of hiv rna > 1000 copies/ml near delivery (30). this threshold is largely based on findings of the women and infants transmission study cohort in 1999, where no cases of transmission were reported among 57 women viral loads lesser than 1000 copies/ml (31). access to viral load testing is one of the barriers to achieving a better hiv care, especially evident among lower-and middle-income countries (25). alongside a gap in the screening programs, there is also prifit e, vrapi e, dervishi m, shpuza a, kowalska jd, harxhi a. assessment of mother-to-child hiv prevention program in albania (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5921 p a g e 8 | 12 an evident gap in the access for viral burden testing not only for the pregnant subjects, but for all hiv positive patients (5). thus, the inability to recognize the near delivery viral load in most cases has conditioned the decision of doctors to recommend and perform caesarean section for all hiv positive pregnant women. similarly, breastfeeding is not encouraged. on one hand, caesarean section rates, a preferred mode of delivery among obstetricians, are on the rise in albania, with unicef reporting a nationwide rate of 31%. this number was as high as 40.35% at obstetrical university hospital in 2017 (32). on the other hand, caesarean section is requested by women, who feel safer if the baby is delivered surgically. only 2 women in our study group delivered vaginally. the presence of active progressed labour in the first case made performing a c-section impossible. it was the lack of adherence to proper antenatal care that prevented the second women to be informed of the need of having a caesarean section. in such cases the use of parenteral zidovudine (zdv) as evidence implies, especially in women with high viral loads of >1,000 copies/ml, would have been necessary to further reduce risk of transmission. it is also recommended in women primarily diagnosed with hiv during labour and with unknown viral load status. the national pmtc protocol should be revised according to the international guidelines. the french perinatal cohort of >11,000 pregnant women with hiv on art (72% receiving triple arv regimens) evaluated the role of intravenous zidovudine use. 95% received intravenous zdv. in woman bearing high viral loads, mtct was significantly higher in women where iv zidovudine was not applied (10.2%) as opposed to women receiving zdv (2.5%, p<0.01) (18, 19, 33). this protocol is not embraced by our obstetrical institutions, where this drug is not readily available. once, based on pactg 076 study, monotherapy with intrapartum zidovudine was the gold-standard of care reducing mtct from 25.5% to 8%, now combination antiretroviral therapy, or haart took over as the most effective mean of prevention further reducing transmission to the above-mentioned rates published by who (14). who guidelines in 2018 recommend fixed dose combination of tenofovir with either emtricitabine or lamivudine and efavirenz (34). 4 women were treated accordingly in our study. efavirenz, taken by these patients, was initially blamed for neural tube defects. such correlation was ruled out by recent studies, which found no increased risk of such defects in women exposed to efavirenz (35-37). updated recommendations list dolutegavir as the first line therapeutic agent, even in women of child bearing potential (38). shahin lockman et al report that dolutegavir containing regimens show better virologic efficacy compared to efavirenz, emtricitabine and tenofovir disoproxil fumerate regimens as of the data received from impaact 2010/vested multicenter, randomised controlled phase 3 trial (39). in our country, this drug, although used as a first line in the general hiv-positive population, has not yet been implemented in the schemes offered to pregnant women. regardless of advances made in managing hiv positive pregnant women to further reduce mtct, controversy still exists when it comes to pregnancy related side effect such as preterm birth, low birth weight and small for gestational age. a meta-analysis of 11 studies describes a significantly higher risk among women who conceive while receiving antiretrovirals as opposed to women initiating therapy during pregnancy (40). there were only two late preterm births among our cohort of women, both of whom had initiated therapy during the second trimester of pregnancy. prifit e, vrapi e, dervishi m, shpuza a, kowalska jd, harxhi a. assessment of mother-to-child hiv prevention program in albania (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5921 p a g e 9 | 12 despite the introduction of a range of antiretrovirals, zidovudine remains the prophylactic drug of choice for the newborn since the paediatric aids clinical trials group protocol 076 (actg 076) (10). it should be administered every 6 hours for at least 6 weeks starting 8 hours after delivery. earlier initiation of prophylaxis reduces the chance of a hiv positive infant. when it comes to defining the hiv status of an infant, we should bear in mind that maternal igg cross the placenta and may false positively show up on the new-born blood samples thus we can only definitely rule out infection with a negative assay at 18 months of age. on the other hand, virologic tests may be more useful for an earlier definite diagnosis of hiv. three consequent negative virologic tests (at birth, at one month and four months), translate into a 95% chance that the newborn is not hiv infected (41). one limitation of this study is the impossibility of multivariate analysis due to the limited number of cases. thus, the data can only be interpreted in a crude way. however, we can draw conclusions about the efficiency of the prevention program. issues such as gaps in prenatal screening for hiv, viral load measurement paucity and unavailability of intrapartum zidovudine were identified. in the context of these discussions, where the importance of early recognition of disease status was emphasized several times, we conclude the necessity to make hiv screening tests more accessible, while simultaneously educating the providers, in this case the obstetricians, to request hiv evaluation in the first trimester screening. conflicts of interest: none. references 1. unaids. 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2018. https://www.ishp.gov.al/wpcontent/uploads/2015/04/adhs2017-18-complete-pdf-finalilovepdf-compressed-1.pdf (accessed: 24 september 2022). 22. desai n, mathur m. selective transmission of multidrug resistant hiv to a newborn related to poor https://www.ishp.gov.al/wp-content/uploads/2015/04/adhs-2017-18-complete-pdf-final-ilovepdf-compressed-1.pdf https://www.ishp.gov.al/wp-content/uploads/2015/04/adhs-2017-18-complete-pdf-final-ilovepdf-compressed-1.pdf https://www.ishp.gov.al/wp-content/uploads/2015/04/adhs-2017-18-complete-pdf-final-ilovepdf-compressed-1.pdf https://www.ishp.gov.al/wp-content/uploads/2015/04/adhs-2017-18-complete-pdf-final-ilovepdf-compressed-1.pdf prifit e, vrapi e, dervishi m, shpuza a, kowalska jd, harxhi a. assessment of mother-to-child hiv prevention program in albania (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5921 p a g e 11 | 12 maternal adherence. sex transm infect 2003;79:419-21. 23. yeganeh n, kerin t, ank b, et al. hiv antiretroviral resistance and transmission in mother-infant pairs enrolled in a large perinatal study. clin infect dis 2018;66:1770-7. doi:10.1093/cid/cix1104. 24. pfeiffer jt, napua m, wagenaar bh, et al. stepped-wedge cluster randomized controlled trial to promote option b+ retention in central mozambique. j acquir immune defic syndr 2017;76:27380. 25. peter t, ellenberger d, kim aa, et al. early antiretroviral therapy initiation: access and equity of viral load testing for hiv treatment monitoring. lancet infect dis 2017;17:e26-e29. doi:10.1016/s14733099(16)30212-2. 26. myer l, essajee s, broyles ln, et al. pregnant and breastfeeding women: a priority population for hiv viral load monitoring. plos med 2017;14:e1002375. doi:10.1371/journal.pmed.1002375 . 27. tubiana r, le chenadec j, rouzioux c, mandelbrot l, hamrene k, dollfus c, et al. factors associated with mother-tochild transmission of hiv-1 despite a maternal viral load <500 copies/ml at delivery. clin infect dis 2010;50:585-96. 28. unaids. get on the fast track: the life cycle approach to hiv. geneva: unaids, 2016. 29. garcía-bujalance s, ruiz g, de guevara cl, peña jm, bates i, vázquez jj, gutiérrez a. quantitation of human immunodeficiency virus type 1 rna loads in cervicovaginal secretions in pregnant women and relationship between viral loads in the genital tract and blood. eur j clin microbiol infect dis 2004;23:111-5. doi: 10.1007/s10096-003-1058-4. 30. american college of obstetricians and gynecologists. acog committee opinion no. 751: labor and delivery management of women with human immunodeficiency virus infection. obstet gynecol 2018;132:e131-7. 31. garcia pm, kalish la, pitt j, et al. maternal levels of plasma human immunodeficiency virus type 1 rna and the risk of perinatal transmission. women and infants transmission study group. n engl j med 1999;341:394-402. 32. zijaj l, shtylla a, kerpaci j, dajti i. the analysis of caesarean section rate based on 10 groups robson’s classification. j gynecol res obstet 2021;7:32-5. 33. briand n, warszawski j, mandelbrot l, et al. is intrapartum intravenous zidovudine for prevention of mother-to-child hiv1 transmission still useful in the combination antiretroviral therapy era? clin infect dis 2013;57:90314. 34. who. consolidated guidelines on the use of antiretroviral drugs for treating and preventing hiv infection: recommendations for a public health approach—second edition. world health organization, geneva; 2016. 35. ford n, mofenson l, shubber z, et al. safety of efavirenz in the first trimester of pregnancy: an updated systematic review and metaanalysis. aids 2014;28(suppl 2): s123-31. 36. watts dh. teratogenicity risk of antiretroviral therapy in pregnancy. curr hiv/aids rep 2007;4:13540. prifit e, vrapi e, dervishi m, shpuza a, kowalska jd, harxhi a. assessment of mother-to-child hiv prevention program in albania (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5921 p a g e 12 | 12 37. antiretroviral pregnancy registry steering committee. [cited 2017 february 02] the antiretroviral pregnancy registry international interim report 1 january 1989 through 31 july 2016. 2016. www.apregistry.com (accessed: 24 september 2022). 38. who. who recommends dolutegravir as preferred hiv treatment option in all populations. july 22, 2019. https://www.who.int/newsroom/det ail/22 (accessed: 24 september 2022). 39. lockman s, brummel ss, ziemba l, et al. efficacy and safety of dolutegravir with emtricitabine and tenofovir alafenamide fumarate or tenofovir disoproxil fumarate, and efavirenz, emtricitabine, and tenofovir disoproxil fumarate hiv antiretroviral therapy regimens started in pregnancy (impaact 2010/vested): a multicentre, openlabel, randomised, controlled, phase 3 trial. lancet 2021;397:1276-92. 40. uthman oa, nachega jb, anderson j, kanters s, mills ej, renaud f, essajee s, et al. timing of initiation of antiretroviral therapy and adverse pregnancy outcomes: a systematic review and meta-analysis. the lancet hiv 2016;4:e-21-30. 10.1016/s23523018(16)30195-3. 41. american academy of pediatrics. committee on pediatric aids. evaluation and medical treatment of the hiv-exposed infant. pediatrics 1997;99:909-17. __________________________________________________________________________________________ © 2022 prifti et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.who.int/newsroom/detail/22 https://www.who.int/newsroom/detail/22 ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 1 review article the south eastern europe health network: a model for regional collaboration in public health maria ruseva 1 , snezhana chichevalieva 1,2 , meggan harris 3 , neda milevska kostova 4 , elke jakubowski 5 , hans kluge 6 , jose m. martin-moreno 3,7 1 executive committee, south eastern europe health network, skopje, republic of macedonia; 2 head of who country office in the former yugoslav republic of macedonia, skopje, republic of macedonia; 3 department of preventive medicine and public health, university of valencia, spain; 4 centre for regional policy research and cooperation ―studiorum‖, skopje, republic of macedonia; 5 public health services, division of health systems and public health, who regional office for europe, copenhagen, denmark; 6 division of health systems and public health, who regional office for europe, copenhagen, denmark; 7 incliva research institute, university of valencia clinical hospital, valencia, spain. corresponding author: maria ruseva, md address: bellmansgade 23, 7 tv., 2100 copenhagen ø, denmark; telephone: +4522500664; e-mail: rusevamaria33@gmail.com ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 2 abstract inter-country alliances, articulated through regional approaches, have increasingly been used to drive economic development and social progress in the past several decades. the south eastern europe health network (seehn) stands out among these types of initiatives for the tangible improvements it has achieved in regional governance for health, with several important lessons for public health leaders worldwide. this review paper, written by several key participants in seehn operation, follows the main milestones in network development, including its foundation under the stability pact’s initiative for social cohesion and the three ministerial forums that have shaped its evolution, in order to show how it can constitute a model for regional collaboration in public health. herewith we summarise the main accomplishments of the network and highlight the keys to its success, drawing lessons that both international bodies and other regions may use in their own design of collaborative initiatives in health and in other areas of public policy. keywords: collaborative networks, health systems, public health, regional cooperation, south eastern europe. conflict of interest: none. ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 3 introduction inter-country alliances, articulated through regional approaches, have increasingly been used to drive economic development and social progress in the past several decades. the european union (eu), with its common currency, open borders and well-established governing institutions, is the most consolidated regional political alliance, but many other blocs have been established across the globe as a way to catalyse development and cooperation. although founded primarily to promote free trade – not social cohesion or justice – their leaders have gradually begun to understand that social and economic development are inextricably linked. the charter of fundamental rights (part of the treaty of lisbon) set the stage for dozens – if not hundreds – of eu-led initiatives in public health and education, including the black sea cooperation and the union of the mediterranean. other regions have taken steps to articulate a common approach to public health as well, for example in asia (1) and south america (2). the south eastern europe health network (seehn) stands out among these types of initiatives for the tangible improvements it has achieved in regional governance for health, with several important lessons for public health leaders worldwide. this paper follows the main milestones in seehn development, including its founding and the ministerial forums that have shaped its evolution (http://www.myhistro.com/story/seehnfounding-story/147935/), in order to show how it can constitute a model for regional collaboration in public health. herewith we highlight the keys to success and draw lessons that both international bodies and other regions may use in their own design of collaborative initiatives, in health and in other areas of public policy, paying due attention to the specific context of the region. the roots of seehn development: public health as a bridge to peace, reconciliation and development in the decade following the disintegration of the soviet union and the neighbouring yugoslavia, the south eastern european (see) region plunged into a long period of turmoil, transitioning rapidly from a state-command to market economy amidst the violent combustion of ethnic tensions in the former yugoslavia. the consequent financial instability, decline in social expenditures and inadequate organisational structures (3,4) led to a breakdown of already tenuous health and social care systems. when albania, bosnia and herzegovina, bulgaria, croatia, the republic of macedonia, romania and yugoslavia signed the stability pact for south eastern europe in 1999, the health indicators in these regions reflected that crisis. as just one example, infant mortality in the see region nearly tripled that of the eu-15, at 13.9 deaths per 1000 live births (5). although the ―non-productive‖ social sector was deemed by the states as a consumer of income rather than as a producer of value (6), investing in public health was nevertheless considered a worthy way to maintain social unity. it was also considered as a particularly appropriate area for regional cooperation; after all, the tradition of public health in see dates back to one of the key architects in the creation of the world health organization (who), dr. andrija štampar, a fitting symbol of how health can function as a force of peace and cooperation between otherwise fractious governments. in 2001, the seehn was established as part of the stability pact’s initiative for social cohesion, under the leadership of the council of europe, the council of europe development bank and the who regional office for europe. at the same time, the need to reconstruct the training programmes for public health professionals, especially in the successor states of the former yugoslavia, became obvious. ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 4 therefore the german sponsored section of the european stability pact agreed to fund the forum for public health in south eastern europe (fph-see) (7) from 2000-2008 with the following main objectives: i. to develop up-to-date teaching materials for public health sciences; ii. to determine and analyse comparable health indicators for south eastern europe; iii. to support the institution building for public health, especially with regard to schools of public health, institutes of public health and public health associations; iv. to organise professional meetings, workshops and conferences in the south eastern european region. during this period, six volumes with more than 3500 pages of teaching materials were published (8) and their utilisation analysed (9) with a 2 nd online edition in 2014 (10); a revised shortlist of indicators was published in 2006 (11), and new schools of public health were established in belgrade, bucharest, chisinau, novi sad, pleven, skopje, sofia, tirana, and varna. by 2008, more than 25 conferences and summer schools had been organised and more than 50 articles been published, beginning with kovacic & laaser in 2001 (12). public health thus became the common denominator of both a political and academic movement to improve the health and wellbeing of the see populations. the strong commitment of the ministries of health in the region surfaced as an urge to address the emerging changes across the societies; together with the strategic guidance of seehn’s external partners and burgeoning academic communities, the ministers of health of seven countries 1 planted the seed for an exemplary initiative of regional cooperation. learning by doing: forging partnerships in public health to protect the most vulnerable populations (2001–2005) the who regional office for europe, along with the council of europe and the council of europe development bank, eleven donor states (belgium, france, greece, hungary, italy, norway, the netherlands, slovenia, sweden, switzerland and the united kingdom) and the health ministers of the founding member states themselves, worked to shape an institutional model capable of empowering national leadership as well as regional collaboration. the achievement of this goal is a testament to member states’ commitment to seehn’s goals, particularly that of professional exchange and regional partnership, but it is also a result of the wisdom of external leaders and donors, who knew how to make their role redundant in just seven years. the founding dubrovnik pledge committed the states to mobilising human and financial resources to meet the needs of their most vulnerable citizens. seven priorities were laid out: (i) enhanced access to quality health and public health services; (ii) development of community health services; (iii) regional self-sufficiency in the provision of safe blood and blood products; (iv) integrated and universal healthcare; (v) better surveillance and control of communicable diseases; (vi) food safety and security, and; (vii) regional exchange of social and health information (13). this first health minister’s forum set the political vision for seehn policy, but technical policy and implementation also had to be developed. at the beginning, the technical side was also led by experts from the council of europe, the council of europe development bank 1 the founding dubrovnik pledge included signatories from albania, bosnia and herzegovina, bulgaria, croatia, romania, the republic of macedonia and yugoslavia. however, the republic of moldova joined a year later (2002), and in 2006, two independent countries (montenegro and the republic of serbia) from the former yugoslavia formally pledged their adherence. finally, israel joined the network in 2011, bringing current seehn membership to ten countries. ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 5 and the who regional office, together with the national health coordinators (high-level officials designated by each member state). by 2004, however, this structure had given way to a rotating presidency, held personally by health ministers for a six-month term. these leaders, along with representatives of the regional office and donors, would hold a regional meeting of the national health coordinators, high-level officials designated by each member state. the regional meetings would forge the technical policy through consensus among all participants. as for implementation, regional project offices were established in the lead country for each technical area. since then, these offices have managed and coordinated technical work at a regional level, fostering a collaborative network of professionals region-wide. member states have chosen the project areas they led from the start, thereby cultivating ownership and leadership in one area and providing a natural incentive to collaborate and learn from initiatives led by other countries (14). the first major seehn project, on mental health, was led by bosnia and herzegovina (15). initially planned for just two years, its success led to a four-year extension, which has now been consolidated and given continuity through the transformation of the sarajevo regional project office into the network’s first regional health development centre, or rhdc (box 1). the mental health project also provided an excellent model on which to base subsequent initiatives during the first period of seehn development, which have successfully tackled blood safety (16), food safety (17), tobacco (18) and other challenges. box 1. tangible achievements in mental health through seehn three million euros from external donors provided the resources that experts within see needed to implement seehn’s flagship project, which started by establishing a regional project office in sarajevo as well as national offices and teams in all of the member states. these professionals worked together to analyse existing mental health policies in their countries and to set a common vision and strategy for the region; this work led to the endorsement of new national mental health strategies and laws in all member states. the second phase began in 2005 and saw the establishment of pilot mental health centres in every country, which provided a practical basis for the development of a regional model of service provision, including firsthand and collaborative experience in developing care standards, leadership modules and case management systems. a monitoring and evaluation system was also established, facilitating the exchange of data that would prove crucial to external consultants and regional partners in the refinement of policy and practice. eleven centres, serving a catchment area of over one million citizens, were fully integrated into the countries’ primary health care system, contributing greatly to the de-institutionalisation of people with mental health disorders. the final phase focused on training and advocacy programmes, which seeded the reform movement for mental health policy in the region. when see health ministers released a joint declaration on mental health in 2007 (19), all member states responded by revising their mental health policy in line with its recommendations. today, dozens of mental health centres operate in every see country, supported by a clearly articulated national policy and a coherent regional framework, which are all in line with current european recommendations (20). moving forward: reforming health systems and public health services (2005–2011) by the second health minister’s forum in 2005 in skopje, a reservoir of regional trust, expertise and leadership had accumulated. in recognition of the enhanced regional capacity for managing the network, an executive committee was established to oversee implementation of the decisions made during the ministerial forums, facilitate regional action ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 6 and monitor progress. the skopje pledge (21) also saw the assumption of seehn ownership over all regional projects, marking a decisive turning point towards a pro-active leadership. in 2008, and coinciding with the replacement of the stability pact by the regional cooperation council, seehn’s self-governance was consolidated through a memorandum of understanding. this document set new terms for network organization (figure 1) and operation included by means of a formal secretariat in skopje (inaugurated in 2013) and a number of regional health development centres (rhdcs) across see. starting in 2010, these were established to give continuity to the results achieved and to provide ongoing services and policy advice in particular areas of action. this structural configuration has allowed each country to benefit from the concentration of expertise in other member states, without having to maintain national centres in all the technical areas at anything close to the same level. by pooling the resources, member states all have access to world-class institutions in a variety of technical fields. these developments set the stage for see member states to take full control of the network, although the who regional office and other partners would continue to provide technical input and guidance. figure 1. governance of the see health network in 2014 the policy focus of seehn also shifted during this period. without abandoning the strategic launch of individual projects in specific technical areas (indeed, the goals pursued in dubrovnik were reiterated and affirmed), participants in skopje pledged to apply the efforts of the seehn towards a comprehensive reform of public health capacities and services. systematic problems in these areas had been identified during a study by the council of europe development bank and the regional office (22), including low levels of investment, poor workforce capacity, under-developed primary care services, and suboptimal follow-up and implementation of formal agreements. at the same time, the report highlighted the cascading effects of ill health on economic development, engaging the interest of the region’s finance ministers. together, the ministers of health and finance in see recognised health as a vital part of the economic development and regional integration processes; they committed ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 7 to further regional collaboration, advocacy for intersectoral policy and empowerment of health professionals, in order to optimise the full economic potential of health as a means to increase productivity and decrease public expenditures related to ill-health. the project that best illustrates this new focus was the evaluation of public health services in south eastern europe. a regional project manager in the republic of macedonia, along with the national focal points in other see states, collaborated at a technical level with the who regional office, which commissioned the development of an innovative web-based self-assessment tool to evaluate the delivery of ten essential public health operations. assessments were carried out in all member states in conjunction with technical experts from the who regional office, revealing a somewhat antiquated approach to public health services, which was still primarily focused on sanitation and hygiene rather than on a holistic integration of public health concepts throughout the health system and beyond. the final report (23) concluded with 11 specific recommendations for all see countries, as well as individual profiles on all member states. these recommendations and observations have constituted the basis for sweeping reforms to public health services and capacities in the see region, which are still ongoing today. likewise, the experience established see as a pioneer in efforts to strengthen public health services through a regional approach, setting an important precedent for the european action plan for strengthening public health capacities and services (24), which would be eventually adopted by the 53 member states of the who european region in 2012. connecting the dots: towards a whole-of-government, whole-of-society approach to public health (2011– present) after conceptually consecrating public health’s role as a pillar of the health system, the next milestone in the development of the network was to introduce a societal perspective. given the social and economic diversity in the region and the rapidly changing national, european and global landscape, the seehn ministers of health sought to make health a priority on the agendas of all sectors and in all policies. the third ministerial forum in 2011 brought the signing of the banja luka pledge (25), with the ministers’ unanimous commitment to sustain and strengthen the regional cooperation in public health in see; achieve equity and accountability in health; strengthen public health capacities and services; and foster intersectoral collaboration within national governments, with regional and international partners, and among all stakeholders interested in promoting sustainable health and wellbeing for the population. banja luka marked the first ministerial forum in which the see countries had full control over the finances, policy direction and technical agenda, but rather than cut ties with international partners, the network strengthened them. the role of the regional cooperation council was reaffirmed, and partnerships with almost all the important players from the international health and development scene were broadened. indeed, this period has even seen a geographical expansion of seehn membership through the acceptance of israel as a tenth member state, a decision made to deepen the existing collaboration with that country, which had supported seehn since its inception. likewise, the banja luka pledge explicitly supported the vision of the who regional office and its main projects for strengthening public health, namely health 2020 (26), the european action plan for strengthening public health capacities and services (24), and the european strategy for the prevention and control of non-communicable diseases (27). at a technical level, the consolidation of managerial control and implementation structures in the hands of see experts has been very positive. the establishment of rhdcs has taken off, ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 8 and today, ten centres focus on mental health, antibiotic resistance, organ transplantation, human resources for health, blood safety, health care accreditation and quality improvement, public health services, communicable diseases, non-communicable diseases and healthy ageing. together, the rhdcs represent a coherent, integrated, increasingly comprehensive response to the major public health challenges faced in the see region in the twenty-first century (14), both in the health sector and in the broader developmental agenda. likewise, and thanks to seehn action, the recently adopted south eastern europe growth strategy 2020 (28) saw the incorporation of the health dimension as an integral part of inclusive growth, economic development and prosperity of the region. this politically important move has helped seehn follow through on its commitment to work for better health side-by-side with other sectors, including other government ministries, academia, civil society, and the private sector, to truly realize a whole-of-government, whole-of-society approach to public health. regional learning, global lessons among the many regional initiatives that give life to cooperation in south eastern europe, the ever-changing seehn, now in its second decade of life, emerges as an outstanding example of one that has implemented a wide range of successful initiatives with positive results in the realm of public health (table 1). its founding documents planted the seed for success, while strong political commitments from members and partners cemented its effectiveness and influence in the region. meanwhile, the political direction was shaped by local, regional, and global trends, especially those promoted by who, from the health for all policy framework of 1998 (29) to the health 2020 programme, currently under implementation. isolated events (e.g., the 2014 floods affecting see, the h1n1 swine flu scare) have enabled a more mature understanding of the power the network embodies and of the moral obligation to cooperate for the benefit of the population. in the see context, a network approach has a particular added value. the fact that member states are relatively small, with limited leverage on the world stage, means that a unified position—in health or in health-related policies—amplifies their individual influence and power. this fact can be seen in international fora such as the who regional committee, where see countries speak with one voice. at the same time, the small size of these states may also constitute an advantage for governance, as involving relevant stakeholders and maintaining close links with the population is more straightforward than it would be in larger countries. indeed, several countries were able to quickly mobilise assistance where it was most needed in response to the 2014 floods thanks to close connections with national social media networks (30). this lesson is relevant for other coalitions composed of small countries, for example the incipient sub-regional network of countries with less than one million inhabitants in the who european region (still under development). ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 9 table 1. main accomplishments of the south eastern europe health network technical area main accomplishments mental health  establishment of ten pilot community mental health centres covering more than one million inhabitants as the basis for an entirely new mental health communityoriented system for see.  decreased stigmatisation of mental health patients and increased acceptance in the community.  establishment of information systems for community health services. antibiotic resistance  implementation of system for exchanging knowledge and expertise on antibiotic resistance and molecular diagnostics in see member states. non-communicable diseases  ratification of the who framework convention on tobacco control and approval of tobacco control laws in all see states.  passage of food safety laws and regulations to protect consumers. communicable diseases  development of regional hub for communicable diseases with online information portal and exchange platform (www.secids.com).  strengthening of communicable diseases surveillance and response in see.  support for implementation of the international health regulations, surveillance of communicable diseases and preparedness for disease threats and pandemics. organ donor and transplant medicine  establishment of regional centre of excellence for exchange of knowledge in organ donor and transplant medicine.  expert missions for transfer of knowledge and skills in transplantation medicine (to romania, macedonia, montenegro and albania).  bilateral collaboration in transplantation surgeries, with joint teams performing in montenegro (deceased donor transplantation) and macedonia (deceased donor and live kidney transplantations). accreditation and continuous quality improvement of healthcare  narrowing the gap with eu standards: promoting quality of care standards and patient safety in see.  regular training of professionals on patient safety and accreditation procedures for hospitals and maternity wards. blood safety  increase in regional self-sufficiency of safer blood and blood components.  narrowing the gap with eu standards: increasing blood availability and providing the highest donor and patient safety in transfusion therapy in emergency special circumstances. human resources in health  integrative and intersectoral approaches to provide excellence in human resources in health.  leadership in profiling human resources in health across the region. public health services  expanded integration of public health services and increased outreach for health promotion and disease prevention.  completion of a round of self-assessments of public health services of member states as coordinated sub-regional action.  development and updates of national strategies to improve maternal and neonatal health. healthy aging  work on participatory and empowering approaches, which include advocacy and stimulating activities for and with elderly people that result in ―healthy living/active aging‖.  enhance the ability of see countries and communities to identify and implement effective strategies and programs to promote and protect the health of elderly.  promotion of health and preservation of health-related quality of life for the elderly. although no regional public health alliance can be copy-pasted into a different geopolitical and socioeconomic context, there are a number of lessons for other coalitions, both in public health and in other areas of policy (table 2). http://www.secids.com/ ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 10 table 2. keys to success in the south eastern europe health network seehn strengths description structure  decision-making structures aligned with regional leadership capacity.  balance of power among regional partners; countries lead in some areas and are led in others.  continuity; project offices transformed into sustainable regional health development centres. promotion of ownership among national and local stakeholders  strong political commitment from national stakeholders required to move forward.  political direction for network decided by national leaders.  technical areas led by local/national stakeholders (with specific guidance solicited from external experts).  explicit recognition of leaders and good practices, supported by excellent monitoring and evaluation of programmes. utilization of regional assets  good governance practices through pooling of human and financial resources.  strong historic tradition in public health. adaptive capacity  dynamic organisation, with new decision-making structures emerging as experience accumulates.  policies are responsive to regional needs.  new partnerships emerging on a continuous and ad hoc basis, without compromising regional ownership.  proactive capitalisation on investments made over the course of the network.  continuous efforts to mitigate challenges and limit the role of special interests. alignment with european and global movements  close collaboration with who regional office for europe, including in implementation of european and global policy and programmes.  common commitment among see countries to the political goal of integration into the european union.  effective synergy between political and technical spheres of the network. intersectoral action  evidence-based arguments tying health gains to economic development and security for the see region.  integration of health into a broader agenda for growth. the most decisive strength of the network, perhaps, has been the positive role of see’s political institutions. although the countries making up the region had limited experience in government (indeed, many of the member states had only just achieved independence), their leaders still demonstrated a key quality necessary for good governance: the commitment to accomplish both political and technical objectives through collaborative learning. external donors and partners had an important role in guiding the network development at its inception, but it was the national stakeholders who knew how to take advantage of the guidance and achieve operational ownership of the initiative. today, both new and old challenges await the incoming seehn secretariat. to strengthen network operation, the skopje office must lead the renewal of political and financial commitments from see member states as well as initiate contacts with other regional initiatives and partnerships as part of the regional cooperation council, including with the who regional office and the european commission. in the same way, the network itself must be renewed by engaging new talents and allies within see and beyond. the official seehn website (http://studiorum.org.mk/seehn/) will see further development as a platform to disseminate network achievements, and the secretariat will also work to integrate seehn action into the daily work, not only of ministries of health, but also the authorities in charge of international affairs and trade. this new line of work in health diplomacy is incredibly http://studiorum.org.mk/seehn/ ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 11 timely, as globalisation has increased interdependence in human and economic development as well as internationalising public health emergencies. imminent projects to tackle these new challenges will be the formation of an emergency coordination aid task force and the development of a strategy to address health professional mobility, as the network continues to pave new roads for regional cooperation in public health. by strengthening the bonds among seehn member states through trust and shared governance for health, these countries will themselves become stronger and more capable of achieving common objectives. in essence, seehn exemplifies a positive policy cycle, in which population health, regional cooperation and economic development have mutually fed into each other for the benefit of everyone, from the most vulnerable populations all the way up to their highest elected officials. references 1. association of southeast asian nations. regional action plan on healthy asean lifestyles. http://www.asean.org/communities/asean-socio-culturalcommunity/item/regional-action-plan-on-healthy-asean-lifestyles (accessed: july 08, 2014). 2. south american institute of government in health. health council. http://www.isagsunasursalud.org/interna.asp?lang=2&idarea=37 (accessed: july 08, 2014). 3. shkolnikov v, mckee m, leon da. changes in life expectancy in russia in the mid1990s. lancet 2001;357:917-21. 4. atun ra, ibragimov a, ross g, editors. review of experience of family medicine in europe and central asia. vol. 1. world bank report no. 32354-eca. washington, dc: the world bank, 2005. 5. health for all database [internet]. who regional office for europe. http://data.euro.who.int/hfadb/ (accessed: october 08, 2014). 6. orosz e. hungary. in johnson n, 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germany: hans jacobs publishing company, 2 nd edition, volume i and ii, 2013. available at: http://www.seejph.com/wp-content/uploads/2013/10/volume-i-health-systemslifestyle-policies.pdf and http://www.seejph.com/wpcontent/uploads/2013/12/volume-ii-health-investigation.pdf (accessed 26 november 2014). 11. bardehle d, laaser u, kragelj l: selected indicators on health care resources and health care utilization and costs compared between the countries collaborating in the ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 12 ―public health in south eastern europe (ph-see) network. slovne journal of public health – zdravstveno varstvo 2006;45:67-80. 12. kovacic l, laaser u: public health training and research collaboration in south eastern europe. med arh 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[online] 2013. www.rcc.int/pubs/20/south-east-europe2020-strategy (accessed: october 20, 2014). http://coebank.org/upload/infocentre/brochure/en/health_in_see.pdf ruseva m, chichevalieva s, harris m, milevska kostova n, jakubowskie e, klugef h, martin-moreno jm. the south eastern europe health network: a model for regional collaboration in public health (review article). seejph 2014, posted: 12 december 2014. doi 10.12908/seejph-2014-34 13 29. who regional office for europe. health 21: an introduction to the health for all policy framework for the who european region. copenhagen: who, 1998. 30. ivankovic i. new instruments, methods and systems of diplomacy. presentation at: global health diplomacy course; 2014 october 15-17; chisinau, republic of moldova. ___________________________________________________________ © 2014 ruseva et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 1 review article governance and management of health care institutions in serbia: an overview of recent developments vesna bjegovic-mikanovic 1 1 faculty of medicine, belgrade university, belgrade, serbia. corresponding author: prof. vesna bjegovic-mikanovic, md, msc, phd; address: dr subotica 15, 11000 belgrade, serbia; email: bjegov@med.bg.ac.rs mailto:bjegov@med.bg.ac.rs bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 2 abstract in order to promote awareness of factors that affect social services, their quality, effectiveness and coverage, the term “governance” is frequently used. however, there is no agreement on definitions, frameworks and how it relates to the health sector. in this overview, two interrelated processes in serbia will be analyzed: governance and management at the macro-, meso-, and micro level. key messages are as follows: i) continue decentralization and support to an effective national decision-making body (health council of serbia) with all relevant stakeholders; ii) reduce the well-known implementation gap and agree on a binding time frame for reforms, and; iii) establish obligatory schemes for education and training of managers and support sustainability of state institutional capacity to teach, train and advise on a scientific basis. keywords: governance, health sector, management, serbia. conflict of interest: none. bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 3 introduction governance and management of health care institutions encompass a series of regulatory measures undertaken for planning, organizing, functioning and evaluation of all the numerous and interrelated system elements by which the set objectives are brought into effect (1). although it is considered as a multidimensional and interdependent process, there are differences between governance and management. how to apply in particular the term “governance” to the health sector? in order to promote awareness of factors that affect social services, their quality, effectiveness and coverage, the term “governance” is frequently used. however, there is no agreement on definitions, frameworks and how it relates to the health sector (2). in general, governance relates to decisions on the framework that defines expectations, grants power, or verifies performance. the debate over this terminology began in the early nineties when the world bank defined governance as: “the exercise of political authority and the use of institutional resources to manage society’s problems and affairs” (3). in recent years, the avenues towards effective governance are described in more detail: good governance in health systems promotes efficient delivery of health services. critical are appropriate standards, incentives, information, and accountabilities, which induce high performance from public providers (4). the united nations led a debate on the understanding of good governance. referring to the world bank definition, good governance entails sound public sector management (efficiency, effectiveness, and economy), accountability, exchange and the free flow of information (transparency), and a legal framework for development (justice, respect for human rights and liberties) (5). who summarizes it as follows: “the leadership and governance of health systems, also called stewardship, is arguably the most complex but critical building block of any health system. it is about the role of the government in health and its relation to other actors whose activities impact on health. this involves overseeing and guiding the whole health system, private as well as public, to protect the public interest. it requires both political and technical action because it involves reconciling competing demands for limited resources, in changing circumstances” (6). governance represents the owners, or the interest group of people, who represent an organization or any institution (7,8). the governing body, on the other hand, appoints personnel for the (executive) management. while governance is relevant for the vision of an organization, and translation of the vision into policy, management is related to making decisions for implementing the policies. governance also includes the relationships among the many players involved (the stakeholders) and the corporate goals. the principal players include the shareholders, the board of directors, and the management. other stakeholders include employees, suppliers, customers, regulators, the social environment and the community as a whole. management comes only second to the governing body, and it is bound to strive as per the wishes of the governing body. aim of this review in this overview, two interrelated processes in serbia will be analyzed: governance and management. to summarize the terminology, which will be used in the overview, as an official translation from serbian, “macro,” “meso” and “micro” levels are discussed. at the “macro” level, (usually at the state level) governance of health care system in serbia is performed by government, ministry of health and republic fund of health insurance. in addition, some governance functions in serbia (without kosovo and metohija) are also at the level of (9,10): bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 4  autonomous province of vojvodina and its six cities and 39 municipalities; governing bodies are “province government of vojvodina”, “province secretariat for health social policy and demography” and “province fund of health insurance”.  city of belgrade and its 17 municipalities; governing bodies are “city council with the mayor, deputy mayor and members” and “city secretariat for health care”, and 23 cities (including those in vojvodina with its 28 urban municipalities) and 150 municipalities (including those in vojvodina); governing bodies are the city and municipality authorities. at the “meso” level (at the facility/institutional level), governance is performed by the managerial board of each facility/institution (in serbian: “upravni odbor”). also, some governance functions with very weakly defined tor (terms of references) at the institutional level are performed by the supervisory board (in serbian: “nadzorni odbor”). at the “meso” level management is performed by the director and his/her management team. at the “micro” level, we can observe only management processes. a framework for assessing governance and management of health institutions in serbia is based on a set of criteria to cover assessment of institutional, financial and accountability arrangements, together with decision-making capacity and responsibility during the last decade (11,12). besides the “macro” level determining the basic structure, organization and finance of all publicly owned health institutions in the serbian context, this overview particularly deals with the description of the “meso” level: the functions/responsibilities of health managers at primary, secondary and tertiary care level of organization (see figure 1). however, the “micro” level dealing with operational management of staff and services inside the organization is also highlighted. this overview is prepared based on the following sources of information (data):  published health policy and legal documents in serbia, health legislation and guidelines from the ministry of health (moh), published papers in the serbian and international health management literature, internationally funded project reports (eu and wb projects’ reports dealing with health management, financing (capitation), quality improvement and local governance), health management conferences in the country and the region, training curricula and programmes of work;  published general health statistics, national electronic databases and who/eurostat database for comparison, and;  results of national survey of all health institutions’ directors and matron nurses done by the health council of serbia in 2010 and 2011. i. governance and management at macro level the essential characteristics of the external environment in which today’s governance and management of health service organizations in serbia are taking place include population aging, costly medical technologies, lifestyle intervention, and advance health promotion and prevention. also, the health care system, as in some other transitional countries, is faced with ethical and economic crises of unpredictable outcome. political, social and, predominantly, professional groups attempt to introduce changes in health legislation and functioning of health service organization, however, with variable success. at the macro level of governance, the most important was the adoption of the health policy document (13) by the serbian government. no similar document has ever been adopted in serbia, hence the process of bringing health in serbia closer to the relevant policy of the bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 5 european union was at this moment initiated. the health policy document defined the main directions of development of the health care system. as such, it was essential as a foundation of laws and bylaws conducive to the reforms of the health care system, including governance and management at all levels. according to this document, the reform of the health care system in serbia, being a continuous process of the transition of the entire socio-economic system, presupposes the implementation of the following goals of the health policy: a) safeguarding and improving the status of health of the population in serbia and strengthening of the health potential of the nation; b) a just and equal accessibility to health care for all the citizens of serbia and improvement of the health care for vulnerable populations; c) putting the beneficiaries (patients) into the centre of the health care system; d) sustainability of the health care system while ensuring transparency and a selective decentralization in the field of resource management, and diversification of sources and methods of financing; e) improvement in functionality, efficiency and quality of the health care system and definition of specialized national programs to advance human resources, corporate networks, technologies, and provision of medical supplies; f) defining the role of private sector in provision of medical services to the population; g) improvement of the human resources for health care. however, more than a decade after the adoption of this document, achievements of the health policy proves still to be variable in the sense of governance and implementation, due to the lack of specific objectives and priorities adopted by all parties. in practice, the implementation of the proposed framework of health policy of serbia presupposes consensus thereon of all the key actors in the health care system (beneficiaries, providers of services and mediators in the provision of health care – health insurance and ministry). following the adoption of the new system laws in 2005 (health care law and health insurance law), intended decentralization has been considered to play a major role in the portfolio of possible activities to improve governance and management of health care organizations in serbia. the actual organizational structure of the health care system in serbia as a framework for governance and management at “macro level” is presented in figure 1. serbia, as other parts of former yugoslavia, inherited a centralized state health system financed by compulsory health insurance contributions. the system was intended to provide access to comprehensive health services for all citizens with an extensive network of health institutions. at the end of 2013, the publicly owned health care system in serbia employed 112.202 persons in a total of 354 institutions (14). currently, in serbia, looking at the governance at “macro” level as the process by which authority is exercised, still many functions related to strategic directions/planning, legislation, and financing are at the national – republic level (ministry of health and health insurance fund, see figure 1). however, with the beginning of the process of decentralization, important players at “macro level” could also be seen at vojvodina province level, within its provincial secretariat for health care, social policy and demography (15), city belgrade secretariat for health care (16), and the respective provincial health insurance agency (17). social care for health at the level of an autonomous province, a municipality, or a city, includes measures for the provision and implementation of health care according to the interest of the citizens in the territory, as follows (article 13 of health care law) (18): bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 6 i. monitoring of the state of health of the population and the operation of the health service in their respective territories, as well as looking after the implementation of the established priorities in health care; ii. creating of conditions for accessibility and equal use of the primary health care in their respective territories; iii. coordination, encouraging, organization, and targeting of the implementation of health care, which is exercised by the activity of the authorities of the local self-government units, citizens, enterprises, social, educational, and other facilities and other organizations; iv. planning and implementation of own program(s) for preservation and protection of health from polluted environment, which is caused by noxious and hazardous matters in air, water, and soil, disposal of waste matters, hazardous chemicals, sources of ionizing and non-ionizing radiation, noise and vibrations in their respective territories, as well as by carrying out systematic tests of victuals, items of general use, mineral drinking waters, drinking water, and other waters used for production and processing of foodstuffs, and sanitary and hygienic and recreational requirements, for the purpose of establishing their sanitary and hygienic condition and the specified quality; v. providing of the funds for assuming of the foundation rights to the health care facilities it is the founder of in compliance with the law and with the plan of the network of health care facilities, and which includes construction, maintenance, and equipping of health care facilities, and/or capital investment, capital-current maintenance of premises, medical and non-medical equipment and means of transport, equipment in the area of integrated healthcare information system, as well as for other liabilities specified by the law and by the articles of association; vi. cooperation with humanitarian and professional organizations, unions and partnerships, in the affairs of health care development. decentralization implies a transfer of authority and competencies, as well as responsibilities from higher to lower levels. the transfer of authority from the central administration to smaller and local communities does not necessarily deprive the central government from all authority and power. the central administration should retain some control along with essential tasks in the sense of governance, such as legislative, financial, and regulatory duties. any excess, whether it refers to total centralization or total decentralization, can harm the health care process (19). in the health insurance act of 2005 (articles 208 et seq.), the serbian government (20) admitted that the reorganization of the serbian health care system has to take into account the following key issues: “the compulsory health insurance is provided and implemented by the republic fund of health insurance, with its official seat in belgrade” (article 208), and: “the republic fund is managed by the insured that are equally represented in the board of directors of the republic fund in proportion to the type and number of the insured established by this act” (article 209). according to the serbian legislation, health care facilities with funds in state ownership (hereinafter referred to as: state owned health care facility) are funded in accordance with the plan of the network of health care facilities, which is adopted by the government. health care facilities that provide emergency medical care, supply of blood and blood derivative products, taking, keeping, and transplantation of organs and parts of human body, production of serums and vaccines and patho-anatomical and autopsy activity, as well as the healthcare activity in the area of public health, shall be funded exclusively in state ownership. bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 7 figure 1. organizational structure of the health care system in serbia institutes institutes of public health general hospitals private specialist practices primary health care centers “dz” private general offices of physicians private pharmacies health stations health ambulances clinical centers clinical hospital centers special hospitals professional commissions republic government health insurance fund health council ministry of health f in a n ci n g p o li cy republic parliament pharmacies clinics, institutes ethical board otherwise, health care facilities can be established by legal or natural persons at any level. the complex interrelationships between the macro-, meso-, and micro level are illustrated in figures 2 and 3. however, governance at the level of municipalities predominantly has been exercised only regarding appointments of the directors, deputy director, the members of the management board (board of directors), and the supervisory board of health care institutions, at the same time with low capacity/competencies to exercise the decision making process at the local level and use responsibilities in the decision making space. execution of financial functions at the local/municipality level could be observed within some municipalities and their annual programme budget planning, which engages resources mainly to meet infrastructure needs of primary health care at the local level. besides the adopted law on local self-governance (23) which is providing decision space for local authorities to exercise more responsibility in governance at the local level, decision capacity stays limited. therefore, the main objective of the recent international projects, such as: dils – “delivery of improved local services” [managed by ministries of health, education, labour and social policies (24)] and “support to local self-government in decentralization” [managed by standing conference of towns and municipalities (25)] are meant to increase decision capacity of multidisciplinary teams at municipality level, both in governance and management. bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 8 figure 2. overview of the governance process source: original copy from: lewis w, pettersson g. governance in health care delivery: raising performance. policy research working paper 5074. washington: the world bank development economics department & human development department 2009 (21). figure 3. the long and short routes of accountability source: world bank. world development report 2004: making services work for poor people, washington, dc: world bank 2004 (22). bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 9 several factors contributed to this type of evolvement of governance at “macro” level. firstly, serbia is still in economic crisis, inherited from the past and aggravated by the world economic crisis. the poor performance of economy has a deep negative impact on the social sectors, including the health sector. political involvement at almost all administrative levels has also affected in a negative way the proper governance and management of the health system. it induced changes in the human resources structure (especially top managers) affecting the continuity of governance at “macro” level and strategic thinking (26,27). besides financial and legislative problems, many other weaknesses in the area of organization and functioning of the health care sector are present at “macro” level governance:  rigid normative regulation of the health care system;  centralized and bureaucratized management with limited autonomy of managers lacking necessary management skills;  still not fully developed and operational health information system and up-to-date information as basis for decision-making processes;  undeveloped “market” in the health sector with deprivation of private health care providers and still “passive” approach to privatization in the health care system;  development of health facilities beyond economic possibilities, their duplication, lack of coordination of activities according to levels of health care organization, poor maintenance of equipment and buildings, lack of sufficient operational budgets;  low professional satisfaction of health workers caused by low salaries with the consequence of bad motivation for providing efficient and quality health services;  dehumanised relationships between medical personnel and patients followed by absence of citizens’ responsibility for their own health;  curative orientation of the health care system with priority in development of secondary (hospital) and tertiary (sub-specialized) levels of care, despite formal support to primary health care orientation;  unrealistic objectives for prevention with formal and non-effective programs and activities in health promotion despite widespread risk behaviour and numerous environmental hazards;  lasting postponement of implementation of legal and administrative decisions, with lack of swaps (sector wide approaches) as necessary for development and implementation of regulations connected to the authority of other ministries, such as those dealing with economic affairs and regional development. however, certain achievements of “macro” level governance during the last decade have to be acknowledged, such as the introduction of the health council of serbia as advisory body to the ministry of health, development of a transparent process for continuous quality improvement in health care and the agency for accreditation, trying out new payment mechanisms in primary health care (“performance-based payment” as a step towards capitation), preparation for more efficient financing of hospitals by development of a drg system, and the like. ii. governance and management at meso-level institutional arrangements a review of health service legislation and the regulatory environment related to governance and health management shows weak areas that should be addressed and opportunities that bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 10 exist to make governance and management the mainstay of health sector reform in serbia. contrary to a typical business organization, the authority structure in managing a health services organization is divided among three authority and responsibility centres: board of directors, doctors, and administration represented by the director and his management team (28,29). the managerial board is legally responsible for the organization as a whole, including provision of health care, public relations and assistance in supply of resources for its functioning. if basic social roles of a health service are under consideration, it is the managerial board that most commonly reflects the profile of the community and its health services organization. it means that the former consists of delegates from various social groups of certain educational level and experience and in this way is executing governance at the “meso” level. doctors, comprising a medical board, but others as well, have a powerful role in management, since they are hold responsible for the majority of cost rendering decisions made. administration, composed of director, heads of departments and chiefs of assisting services, is the third and last authority centre in managing health services organizations, responsible for operational management. the authority and responsibility structure in managing the health services organization in serbia is defined in the health care law and bylaws together with the role and current and expected function of health managers at “meso” level. according to the health care law (article 130), a typical health care organization in serbia has the following management structure: the director, the managerial board (corresponding to the board of directors), and the supervisory board. it may also have a deputy director, who is appointed and relieved under the same conditions and according to the same procedure, which is specified for appointment and relieving of the director of the health care organization. the director, deputy director, the members of the management board, and the supervisory board of health care organisations are appointed and relieved by the founder. as an example, the director, deputy director, the members of the management board, and the supervisory board of an institute, clinic, institute, and clinical center, or the health care of employees institute of the ministry of interior affairs, the founder of which is the republic, are appointed and relieved by the government. the director, deputy director, the members of the management board, and the supervisory board of health care facilities the founder of which is the republic, except for the specifically mentioned institutions, are appointed and relieved by the minister. the director of a health care facility is appointed on the basis of a vacancy publicly announced by the management board of the health care organisation. the management board of a health care organization makes selection of the candidate and submits the proposal to the founder, which then makes the appointment. however, should the management board of a health care organization fail to elect the candidate for the director of the health care facility, or should the founder of a health care facility fail to appoint the director of the health care facility, in accordance with the provisions of the law, the founder shall appoint the acting director for a period of six months. in practice, it was not unusual that “acting director” stays for couple of years; whereas the law (article 135) also prescribed criteria for appointment, as well as conditions in which the director of a health care organization should be replaced. furthermore, the same health care law defines responsibilities and duties of the respective managerial bodies. the director is organizing the work and managing the process of work, representing and acting as proxy of the health care facility and is responsible for the legality of work of health care facility. in this way, contrary to established theory and practice, it seems that in serbia the director has also some governance function. if the director does not bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 11 have medical university qualifications, the deputy, or assistant director shall be responsible for the professional and medical work of the health care facility. the director shall submit to the management board a written quarterly, and/or six-monthly report about the business operations of the health care organization. the director shall attend the meetings and participate in the work of the management board, without the right to vote. contrary to the position of the director, the law does not prescribe such detailed instructions as regards who should be appointed for management board and supervisory board. it is only stated (article 137) that the management board in primary health care centres dz, pharmacies, institutes (see table 1 for details), and the national public health institute have five members of whom two members are from the health care organization, and three members are the representatives of the founder, whereas the management board in a hospital, clinic, institute, clinical hospital, and clinical centre has seven members of whom three members are from the health care facility, and four members are the representatives of the founder. responsibilities of the management board are the following: i) adopt the articles of association of the health care organization with the approval of the founder; ii) adopt other bylaws of the organization in compliance with the law; iii) decide on the business operations of the health care organization; iv) adopt the program of work and development; v) adopt financial plan and annual statement of account of the health care organization in compliance with the law; vi) adopt annual report on the work and business operations of the health care organization; vii) decide on the use of resources of the health care organization, in compliance with the law; viii) announce vacancy and implement the procedure of election of the candidates for performing the function of the director; ix) administer other affairs specified by the law and the articles of the association. a supervisory body as the third centre of authority is appointed in a similar way as the management board (with three members for less complex health care organizations and five for those at secondary and tertiary level of organization). contrary to the management board, the law does not prescribe in detail responsibilities of the supervisory board, except for the following (article 138): “the supervisory board of health care organization shall exercise supervision over the work and business operations of a health care organization”. in practice, such formula is producing a rather passive role for this body. a recent survey of all directors of health care organizations conducted by the health council of serbia in 2010 and 2011, pointed to some general and some specific characteristics of management at “meso-level”. the study used a questionnaire designed on the basis of similar studies in serbia, which comprises five groups of questions: general characteristics that define the manager profile, the problems of management, assessment of the importance of motivational factors, carrying out the management goals and self-evaluation of managerial skills. according to this survey, the managers of health care organizations in serbia are mostly experienced specialists, slightly more often males than females, who usually have some form of management education (table 1). in comparison with the period of the nineties, the structure of health organizations’ managers in serbia improved in terms of management training and gender sensitivity. bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 12 table 1. general profile of directors of health care organizations in serbia characteristics directors of outpatient institutions (n=140) directors of hospital institutions (n=90) p number percent number percent gender 0.032 male 76 54.3 61 68.5 female 64 45.7 28 31.5 age (years) 0.033 <35 3 2.1 1 1.1 35-45 14 10 11 12.5 46-55 92 65.7 42 45.7 56-65 31 22.1 34 38.6 occupation <0.001 physician with specialization 104 76.3 87 96.7 physician without specialization 6 4.3 0 0 dentist 8 5.7 0 0 pharmacists 19 13.6 1 1.1 economists, lawyers, other 3 2.1 2 2.2 working experience 0.135 up to 15 8 5.9 7 8.1 15-19 21 15.4 7 8.1 20-24 44 32.4 20 23.3 25-29 38 27.9 27 31.4 over 30 25 18.4 25 29.1 managerial experience (years) 0.265 <1 21 15.2 7 8 1-2 43 31.2 28 31.8 3-4 25 18.1 10 11.4 5-6 18 13 14 15.9 7-9 24 17.4 23 26.1 over 10 7 5.1 6 6.8 education in management 0.047 yes 110 79.1 60 67.4 no 29 20.9 29 32.6 type of education 0.212 self-empowerment 13 11.2 12 18.2 courses 73 62.9 43 65.2 master programmes 30 25.9 11 16.7 satisfaction with social status 0.959 very satisfied 99 70.7 65 72.2 moderate satisfaction 35 25 21 23.3 not satisfied 6 4.3 4 4.4 member of a political party 0.003 yes 85 63 37 42.5 no 50 37 50 57.5 source: health council of serbia survey of directors of health care organizations 2010-2011 (30). a situation analysis performed within a recent eu project found that given the opportunity, some health workers would choose management roles in the health services. they may also choose project-based work with international organisations and ngos, and when the funding for such projects ends may seek to return to the health services in management positions. bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 13 there are also managers in legal services, human resources, utilities management and other professional categories. the issues of general management and non-medically trained managers are complex and have not yet been addressed in serbia as a debate about health management has only recently started. the need for new management skills is being partially met by existing institutions and universities, on the job training, projects funded by international organisations and ngos, and, in a very limited way, education programmes by newly emerging private providers. a large boost is required to create a cadre of managers who can bring about change in the health services. responsibilities of managers in serbia will request change with decentralisation, requiring more knowledge and skills at municipal level. private/public partnerships are likely to develop within the next five years, requiring more skills in contracting out. as of now, there is no clear career structure or progression pathway for health managers. however, this is likely to be mapped out within the next five years and will increase demand for formal training and accredited courses. it is expected that the old style bureaucratic and very hierarchical structure will change and for this managers with change management skills will be required. the following have been identified by key informants as priority areas for the introduction of change management: team working will enable a more effective approach to cross-disciplinary tasks. better use of information technology is likely to produce information that is more relevant to decision-making. financial tracking will shift to output-based methods and efficiency will be measurable. individual accountability, currently weak, will be required to increase; there will be a shift to benchmarking rather than a reliance on blame and, therefore, criteria for positive results will become more transparent and measurable. transparency in decision making and better planning and consultation processes. prioritizing of scarce resources while protecting access to services for the poor and uninsured. project management skills will be applied within the health service. there will be a shift from development support from the international community towards loans and credits; managers who understand how to use such funds will be required. there will also be a shift towards contracting out services. increased individual accountability and managers who understand client-focused services will be required. this will require a cadre of managers with a very new set of skills. by producing large numbers of change managers it is also expected that they will be able to support each other in a system that is currently quite hostile to change. this has been a positive experience from the ear funded and carl bro implemented project, where team-based working and problem solving has also provided professional support for the managers involved. there is a frequently expressed belief in the health services that hospital management is very different to general management of other organizations. there is likely to be little acceptance of general managers in the health system; actually, this has not been tried out in serbia to date, but it should not be excluded. there is also a practice that amongst health professionals, only senior specialist doctors have the authority required for senior management and leadership positions in the health services; again, this should be questioned and tested (27). bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 14 financial arrangements besides the main financial arrangements in serbia and implementation of ongoing changes in the financial management system, particular attention is given to the managerial aspects of decision making related to capital investment, adjustment of capital and operational expenses and ability to incur debt, sometimes considered by managers (directors and management teams) as deficit carried over from the last fiscal year and due to introduction of a new budget system for reporting based on the new law on budget system, which is ongoing from 2009 and adopted in the serbian parliament each year (31). according to real practice examples, strengths and weaknesses are obvious in planning and reporting on institutional financial flows. typically, the managerial board (“upravni odbor”) is responsible for the adoption of financial reports and annual budget plans at the beginning of each calendar year, after which a report and a plan is processed to the republic fund of health insurance for approval and serves as a base for contracting with the health care organization. those institutions which have also financing directly through the republic budget (such as institutes of public health) are obliged to send their plan of activities including a budget in the foregoing calendar year for the next calendar year. although it should be activity-based costing, very often the correlation between activities and budget lines is not clear and visible. examples from practice indicate that the managerial board (“upravni odbor”) does not have always direct responsibilities in financial arrangements, as sometimes changes in contractual agreements with the republic fund of health insurance, as well as with the ministry of health during the year are reported by directors only post factum. this is also an indication of the relatively weak role (responsibility) of the managerial board within health care organizations of serbia regarding governance. accountability arrangements health managers are not defined as a separate profession in serbia. senior staff in the health services has management functions and responsibilities, and these are noted under the health law of 2005 and under various other procedural documents in the legislation. with very few exceptions, senior health services managers in the country are doctors, there is more variety at middle management level, although the two levels have not till now been clearly defined. in the study of managing health services organizations in serbia over the last decade, apart from the triple power and authority distribution between management and supervisory board, administrative director with his collegiums, workforce particularly doctors, specific accountability and responsibilities include the following: accountability and responsibility for the patient, above all, within the scope of modern medicine and health promotion movement, with provision of the best possible health care, with minimal costs. only recently in serbia within the development of different patient ngo’s; accountability is increasing in this regard, apart also from recently established the socalled “protector” of patients’ rights in each institution. reports about patients’ complaints are regularly presented both to directors and managerial boards. however, regular monitoring during five years within the reporting about quality indicators has pointed to a low level of complaints and consequently few actions by management for corrections; accountability and responsibility for the employed workforce by recognizing their sensible requirements for safety in terms of wages, appropriate working conditions, bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 15 promotions, but also identifying their fears caused by uncertainty regarding positive effects of their work (outcomes concerning the treated patients’ health). usually, this is exercised through trade unions, sometimes several per one health care organization; accountability and responsibility for a financier and different social groups (donors, sponsors) supplying resources for functioning of the institution; accountability and responsibility for the community (public) in determining means for meeting the population health care needs, and; accountability and responsibility for oneself by making efforts to perfect one’s knowledge and skills related to management as well as readiness to make effective responses under conditions of continuing changes and threats. the national survey of directors is offering assessment of the last bullet point referring to managerial skills (table 2). there are no differences between outpatient and hospital managers in this regard, however, this is a very subjective assessment indicating surprisingly high competences, which should be further investigated and verified. table 2. self-assessment of managerial skills (on a 5-point scale) skill directors of outpatient institutions (n=140) directors of hospital institutions (n=90) p average sd average sd evidence based situation analysis 4.39 0.862 4.37 0.788 0.859 application of swot analysis 3.59 1.293 3.42 1.277 0.350 development of mission and vision 4.20 1.052 4.30 0.866 0.450 development of flow-charts for specific work process 3.28 1.227 3.25 1.199 0.833 development of smart objectives 3.57 1.290 3.39 1.216 0.322 development of diagrams 3.15 1.321 3.10 1.234 0.805 development of wbs 3.46 1.332 3.23 1.180 0.217 assessment of employees 4.26 0.930 4.17 0.865 0.476 public relations skills 4.30 0.852 4.25 0.918 0.700 change management skills 4.29 0.862 4.30 0.714 0.944 project management skills 4.26 0.864 4.33 0.769 0.536 conducting effective meeting 4.45 0.704 4.54 0.724 0.374 searching through internet 4.14 0.928 4.17 0.950 0.811 communications with employees 4.60 0.560 4.51 0.642 0.222 fund raising and donor searching 4.10 1.046 3.84 1.127 0.087 source: health council of serbia survey of directors of health care organizations 2010-2011 (30). decision-making capacity versus responsibility this section is based mainly on the national health management survey executed among directors of health care institutions and matron nurses. there are few exclusive health service managers, as it is an insecure profession. often doctors take up a management role but continue to wear their “clinical hats” and keep a base in their clinical work. this gives them a safety net in the event that they do not keep their management posts, the most senior of which are subject to political appointment. according to the national survey results in serbia, priority objectives for managers are: improving health care quality, increasing patient bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 16 satisfaction and professional development, as well as improving employee satisfaction and work organization (table 3). significant differences were found between managers of primary healthcare organizations and hospitals: outpatient facilities’ managers are much more likely to improve in the areas of management, are significantly more often members of a political party and more frequently state that the problem of management is the lack of coordination in health care institutions. the major objectives for hospital managers are familiarizing new employees with the work process, introducing new technologies and developing scientific research. table 3. assessment of importance of institutional objectives by directors (on a 10-point scale) objective directors of outpatient institutions (n=140) directors of hospital institutions (n=90) p average sd average sd improvement of work organization 73.17 26.59 78.30 21.88 0.132 decreasing of operational costs 63.31 31.10 64.77 31.28 0.733 increasing staff satisfaction 76.26 23.38 75.17 24.82 0.740 increasing consumer satisfaction 79.14 22.89 80.80 24.08 0.603 multidisciplinary team work 69.78 26.80 74.89 24.02 0.148 empowering of newly employed staff 57.55 30.30 65.34 26.78 0.050 continuing education 78.06 23.68 77.84 25.12 0.948 introduction of new technologies 71.09 28.40 78.60 24.02 0.042 research and development 52.07 33.61 68.50 32.20 0.001 source: health council of serbia survey of directors of health care organizations 2010-2011 (30). considering the main player in the setting of institutional objectives, the situation is very interesting pointing to very low authority of managerial boards in this process, which is mainly governance function. according to the national survey conducted in 2010-2011, the situation is as follows:  ministry of health 7.4%  director alone 2,6%  director after discussion with collaborators and staff 65,7%  management team and its discussion 22,6%  other players 0.4%  without answer 1,3% managerial problems (table 4) are grouped into factors, based on which it is possible to define future interventions such as improvement of work organization and coordination, control systems and working discipline. strategic management comprises drafting, implementing, and evaluating cross-functional decisions that enable an organization to achieve its long-term objectives together with solving strategic and operational daily problems of management. in this process, a strategic plan is laid out that encompasses the organization’s mission, vision, objectives, and action plans aimed at achieving these objectives. bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 17 table 4. assessment of management problems (on a 4-point scale) type of problems directors of outpatient institutions (n=140) directors of hospital institutions (n=90) p prosečna vrednost sd prosečna vrednost sd planning 2.78 0.942 2.65 0.871 0.314 work organization 2.79 0.832 2.72 0.750 0.514 coordination of services 3.17 0.731 2.85 0.847 0.003 replacement of staff 2.75 0.884 2.63 0.949 0.363 professional development 3.06 0.923 2.93 0.997 0.329 procurement of equipment 2.09 1.062 1.84 0.931 0.067 keeping of equipment 2.39 1.036 2.21 0.935 0.199 financing 1.86 0.938 1.76 0.905 0.413 system of control 2.90 0.851 2.84 0.838 0.589 information system 2.46 0.992 2.38 1.053 0.598 working discipline 2.96 0.734 2.80 0.733 0.108 cooperation with ministry of health 2.80 1.105 2.87 1.120 0.664 cooperation with health insurance fund 2.70 1.057 2.63 1.083 0.658 source: health council of serbia survey of directors of health care organizations 2010-2011 (30). a recent study of 40 hospital management teams in serbia proved capacity of managers who are trained to improve strategic management competences and accept clear responsibility in strategic management. during the workshop done with the same 40 general hospitals managers they did a swot analysis and possible strategic options for development of their organizations. examples are presented in table 5. continuing education on health care management is being offered in serbia at an increasing scale, in response to the health care system’s well-known deficits. recently, at the belgrade school of medicine, a postgraduate master’s program in health care management was established. however, in serbia, such programs have been evaluated very rarely if at all. exceptions are the results of the training programme for hospital and primary health care managers, offered by the centre school of public health and management in belgrade, with providing evidence, for the first time in serbia, of effective support to the directing managerial teams with respect to their strategic planning abilities. during those studies, the measurement and evaluation of hospital performance were recognized as essential, partly as a consequence of the recently established reporting system of quality indicators and partly due to recognition of the usefulness for benchmarking. only a few stakeholders, e.g., the ministry of health, the republic health insurance fund, and project agencies, were considered relevant for the hospitals. those key partners directly affect hospital services and financial flows and, therefore, were highly correlated to hospital managers’ ability to plan strategically. this demonstrates that the managerial teams were predominantly oriented toward the fulfilment of legal obligations and contracts. the second independent component was a detailed analysis of the internal environment (staff, their training and development, management, information system, equipment, customers and their satisfaction, and kind and quality of health services). the hospital’s internal environment was included in the government’s health reform initiatives (32). in serbia, defining a hospital’s mission, vision, action plan, and especially its bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 18 smart objectives (33) seems to be dependent on the political environment and the existing legislation. table 5. strategic management thinking in serbian general hospitals example of vision and mission statement: “we are here to provide optimal methods in health care services with respect to the demands of our patients and to apply new technological accomplishments for the faster and more efficient treatment of our customers.” examples of goals: development of quality and efficiency of health care services establishing new diagnostic and therapeutic methods implementation of procedures for ambulatory surgery examples of strengths: highly educated staff introduction of clinical guidelines renovation of some parts of our facilities good relationship with the media examples of weaknesses: medical staff holding second jobs in private practice medical equipment out of date low motivation of staff negative financial balance examples of opportunities: rationing of hospital staff and facilities support from the local community and from ngos participation in international projects examples of threats: lack of treatment standards and protocols high number of refugees and internally displaced people lack of effective gatekeeper function in primary health care proposals of strategic options comparative advantage (strength/opportunity): widen the spectrum of services to gain additional income investment/divestment (weakness/opportunity): promotion of cooperation with local authorities mobilisation (strength/threat): improvement of communication with customers damage control (weakness/threat) note: the teams could not or did not want to imagine this scenario source: workshop with 40 general hospital teams done in 2009 by the school of public health and health management university of belgrade, within an eu project (see also terzic-supic et al. (32). in order to increase further management capacity to deal with management problems, numerous training have been organized since 2007 supported by several projects which resulted in the development of strategic plans: “capacity building of hospital management teams”, supported by eu project (result: 40 hospitals developed strategic plans); “programme for management development in primary health care institutions of belgrade” project funded by the city secretariat of health care belgrade, 2007-2009 (result: 14 primary health care centres in belgrade developed strategic plans); working group of serbian basic health project – ministry of health (wb) – education of 7 primary health care managers (result: 9 primary health care centres in belgrade developed strategic plans); “politics of primary health care in balkans”, project managed by cida (result: 7 primary health care centres developed strategic plans); bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 19 “support to the implementation of capitation payment in primary health care in serbia”, eu financed and managed project (result: 29 primary health care centres developed strategic plans); dils – “delivery of improved local services” (managed by piu of ministries of health, education, labour and social policies (result: 28 primary health care centres developed strategic plans). looking at primary health care organizations up to 2012, in total, 78 out of 157 have developed strategic plans based on this capacity building (predominantly with the support of the school of public health and management, faculty of medicine, university of belgrade). in addition, strategic plans for capacity building of management teams in primary health care as support to the new method of payment of providers in primary health care are developed since 2010. it is also proven (34-37) that the training courses offered to management teams in serbia by the centre school of public health and management in belgrade had positive effects on the teams’ ability to formulate their organizational mission and vision, strategic objectives, and action plan as learning outcomes and to implement monitoring and adjustment of their strategies. nevertheless, the research evidences in serbia also demonstrates that improving strategic planning practices can be effective, but many health care organizations have difficulties in translating their strategic plan into actions that result in successful performance. iii. management at micro-level as physicians and to a lesser extend nurses regularly execute management functions at micro-level, it is of great relevance for a smooth operation of services as well as for the satisfaction of patients and staff, that these functions are not only performed with good will but also with knowledge and skills. the example of gaps in management competence before and after training for physicians and nurses illustrated in figures 4 and 5 highlight a key problem at the micro-level: training! female managers in our studies, here following santric-milicevic (36), developed higher competency levels after training in communication skills and problem solving. managers rated assessing performance of higher importance, while chief nurses emphasized the importance of leading. before training, the estimated competency gap was generally the highest in assessing performance, followed by team building and planning and priority setting. terzic et al. (35) came to similar conclusions but added the analysis of predictors: “the biggest improvement was in the following skills: organizing daily activities, motivating and guiding others, supervising the work of others, group discussion, and situation analysis. the least improved skills were: applying creative techniques, working well with peers, professional self-development, written communication, and operational planning. identified predictors of improvement were: shorter years of managerial experience, type of manager, type of profession, and recognizing the importance of the managerial skills in oral communication, evidence-based decision making, and supervising the work of others.” bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 20 figure 4. core management competences of top managers (physicians): competence gap before and after training (the confetti pattern of radar indicates the area of improvement after training) source: santric milicevic m, bjegovic-mikanovic v, terzic-supic z, vasic v. competencies gap of management teams in primary health care. the european journal of public health 2011; 21(2):247-53 (36). figure 5. core management competences of chief nurses: competence gap before and after training (the confetti pattern of radar indicates the area of improvement after training) source: santric milicevic m, bjegovic-mikanovic v, terzic-supic z, vasic v. competencies gap of management teams in primary health care. the european journal of public health 2011; 21(2):247-53 (36). bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 21 challenges and recommendations for possible improvements of governance and management of health care institutions in serbia challenges ahead for the governance and management of health institutions in serbia are derived from the situation analysis and recommendations are made based on actual examples of good practices in europe and the world and in the light of management opportunities/threats and strengths/weaknesses in serbia. the serbian health system is by tradition highly centralized. however, providing health services of high quality on a regular basis requires a high degree of complexity and interaction between various levels of management and different stakeholders. keeping all relevant decisions at the national level and organizing complex tasks centrally cannot be perceived without establishing a highly trained, numerous and well-paid central bureaucracy. this does not seem to be a realistic option for serbia and many other countries as well. therefore, the issue of far reaching and effective decentralization is on the table which at the same time introduces a certain degree of competition between service institutions. the term “horizontal, not vertical management” has been introduced in this context. however, each country coming from a specific historical background has to find its own way forward. the concept of decentralization according to bossert (38-41) comprises three elements at the macro-level, namely allowing for “decentralist decision space”, “corresponding institutional capacity”, and “local accountability” (towards the community). at the managerial meso-level this has to be translated into operational planning, budgeting, human resources management, and service organization, where this last element is considered to be a matter of the microlevel. in order to strive for the implementation of this concept in serbia, the following activities are recommended to be carried out timely and successfully: macro-level: i. the ministry of health should revise the valid legislation allowing for a stepwise transfer of more decision making powers within a limited time period to the “decentralist level”, defined as municipality authorities. ii. the republic fund of health insurance is to become fully independent and has likewise to defer financial powers to the lower levels – branches. however, there should be a compensation mechanism between poorer and richer municipalities in serbia, maybe supported from tax money allocated by the budget or by the ministry of finance, or through the ministry of health. iii. the service facilities (hospitals and others) within a district (= region = “okrug”) negotiate their service profile and budget directly with the local partners – the branch of the republic fund of health and municipal authority. iv. insured patients can select a chosen physician wherever they want. v. in order to harmonise the various elements of the health system in terms of a horizontal management, a national decision making body composed of the hif and the representation of the service providers together with the professional chambers should meet chaired by the ministry of health in order to adapt permanently the governance. the package of basic health services is to be defined at this level, as well as the care to be provided to uninsured persons. vi. the number of institutional managers required nationwide has to be determined and trained accordingly in postgraduate programmes for public health and management bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 22 (based on defined competences required to provide good performance). otherwise, they will not be able to make use of the larger decision space provided. vii. likewise, short-courses in community health management for mandated civil servants and politicians at the community level should be regularly offered. meso-level: i. standard models of terms of references for all management staff categories have to be developed and harmonised to correspond to the new legislation and practice in educational sector and linked to corresponding programmes of continuous professional development (cpd) offered by the four serbian medical/health faculties in close cooperation with the faculties of management and organization. ii. satisfaction of patients and employees which is measured by standard instruments every year at the institutional level should be improved both in the way of assessment and tools for improvement. iii. development of a guideline on change management and decentralist accountability towards the local elected community representatives. iv. promotion of the employment of non-medical managers and managers coming from non-medical environments. micro-level: i. allowance of intra-institutional opportunities for increased decision space of staff, especially nurses, and encouragement of training options up to postgraduate levels. ii. regular negotiations with the trade union representatives to agree on payment schemes which correspond to the qualification and position of staff, especially nurses. key messages  continue decentralization and support to an effective national decision making body (health council of serbia) with all relevant stakeholders.  reduce the well-known implementation gap and agree on a binding time frame for reforms.  establish obligatory schemes for education and training of managers and support sustainability of state institutional capacity to teach, train and advise on a scientific basis. references 1. world bank. world development report 2004: making services work for poor people, washington, dc: world bank, 2004. 2. savedoff wd. governance in the health sector: a strategy for measuring determinants and performance. policy research working paper 5655. washington d.c: the world bank, human development network office of the chief economist: may 2011. 3. world bank. managing development the governance dimension. washington 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bossert t. decentralisation of health system: decision space, innovations and performance: boston: harvard university, 1997. bjegovic-mikanovic v. governance and management of health care institutions in serbia: an overview of recent developments (review article). seejph 2016, posted: 17 february 2016. doi 10.4119/unibi/seejph-201694 25 39. bossert t, baernighausen t, mitchell a, bowser d. assessing financing, education and management for strategic planning for human resources in health: geneva: who, 2007. 40. brune n, bossert t. building social capital in post-conflict communities: evidence from nicaragua. soc sci med 2009;68:885-93. 41. bossert tj, mitchel ad. health sector decentralisation and local decision-making: decision space, institutional capacities and accountability in pakistan. soc sci med 2011;72:39-48. ___________________________________________________________ © 2016 bjegovic-mikanovic; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. merkel b. a growing competence: the unfinished story of the european union health policy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-2015-15 1 commentary a growing competence: the unfinished story of the european union health policy bernard merkel1 1 visiting research fellow, london school of hygiene and tropical medicine, london, uk. corresponding author: dr. bernard merkel address: dg sante, european commission, brussels; email: merkebe@gmail.com mailto:merkebe@gmail.com� merkel b. a growing competence: the unfinished story of the european union health policy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-2015-15 2 a few months ago, the south eastern european journal of public health (seejph) published a lengthy article by hans stein on the importance of the maastricht treaty of 1992 and how the european union (eu) health policy has developed since then (1). undoubtedly, dr. stein made a major contribution to this story himself and in his paper he sets out his own viewpoint on key events and trends, offering us a wealth of historical detail and many real insights. but, like all good commentators who try to condense and make sense of a tortuous and convoluted sequence of events spanning more than two decades and involving very many players, he inevitably omits parts of the story, and his interpretations can sometimes give rise to more questions than answers. in this review, i will entirely leave aside his general discussion of the overall evolution of the eu and its future prospects, and instead concentrate on a few specific points about the development of eu health policy to date. it is a truism, and the beginning of perceived wisdom on the history of eu health policy, that the maastricht treaty introduced the first explicit ec (european community) legal competence for public health, devoting an article to it (article 129). it is also true, as dr. stein mentions, that there was much health-related activity in the ec well before the advent of the maastricht treaty. such actions, in fact, go back many years. for instance, there was an ec directive on pharmaceuticals in 1971 and in the same year a regulation on coordination of social security systems providing rights to health care to workers in other ec countries. moreover, various public health programmes on cancer, aids and drugs also predate maastricht. yet, article 129 represented the first explicit framework for public health. however, dr stein makes the more interesting point that this competence was “often but never substantially changed in the subsequent treaties”. and, again, “the main components of article 129 were slightly reworded in the following treaties, but essentially are still valid”. in saying this he is implying that it was and remains after several treaty changes, a very weak competence which results from the “defensive and negative position of ms” (eu member states) and reflects their position “to keep the eu as far away as possible from influencing their health policy”. there is no doubt that the health ministries of the older ms, and most, if not all, of the newer ones, have never wanted the eu to tell them how to run their healthcare systems, or to subsume their health policies into an eu-wide policy as has been done in areas such as trade or agriculture. and it is certainly the case, as dr. stein emphasizes, that the article 129 competence is a weak one – as well as being very ill-defined. but, this raises some further issues. as he says, it was ms, not the commission or the european parliament, that dominated the process of negotiating and agreeing the maastricht treaty. the question then must arise of why did these very ms decide to put into the treaty a new competence in public health at all if they did not want the ec (eu as it has become) to do anything of significance in this field? later in his paper, dr. stein quotes approvingly from an article by scott greer who says that article 129 “was the harbinger of more effective promotion of health issues within eu policy-making. in time, however, the internal market and the single currency have had the biggest health consequences”. and then, dr. stein adds the interesting comment that: “this was not really what the ms had in mind when they established a specific eu public health mandate”. of course, in 1992, the ms could not really have been thinking about the impact of the single currency which was not introduced until 1999! it is true that the treaty did set out some clear steps towards achieving an economic and monetary union. but, it seems far merkel b. a growing competence: the unfinished story of the european union health policy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-2015-15 3 fetched, to say the least, to suppose that those involved in designing a new public health competence would have given any thought to the potential impact on health of such a theoretical eventuality. similarly, how likely is it that many of them were envisaging the creation of some kind of protective instrument to counter the single market’s potential impact on public health? this may have been on the mind of one influential player: hans stein, at least according to what he wrote in an article some years later (2). in this he states that: “single market regulations are sure to have an impact on health and health policy.....the full consequences of the internal market in the field of health and health care are as yet unknown. to analyse, to support or to counteract them can be done effectively only on an eu scale”. but, it is doubtful that others were so far-sighted. moreover, if ms had really wanted to establish a health competence that could act as a bastion to promote and defend the interests of public health against the possible negative consequences of the single market, why did they make the public health competence so feeble that it ‘is the weakest legal base possible’? what seems more plausible is that ms (most of them in any case) saw some advantages in european cooperation in some health areas either where they faced common health problems such as aids, and tobacco, and on some apparently non-contentious topics, such as improving health information, and health education, where they could exchange experience and expertise. in doing so it is arguable that they were trying to achieve two objectives: first to show that the ec was not just about markets and economics but could play a valuable role in other policy spheres. this indeed was a general underlying thread of the maastricht treaty. it is noteworthy in this context that article 129 is sandwiched by two rather similar articles, 128 on culture, and 129a on consumer protection. the second aim could be seen as being perhaps a more cynical one: it was to give the ec a formal competence to take some actions in health, which they had in any case been doing for some time in fields such as cancer, aids and drugs, while reducing the potential for any future action in areas where ms did not wish to see ec involvement by defining the scope of the ec’s public health activities and explicitly limiting its competence in this field. this view was common among commission officials involved in health policy, including this reviewer, who expressed it in an article in 1995 (3). a second contestable point is the claim that the treaty competence on public health has remained essentially the same over the last two decades. on the face of it, this cannot really be the case. indeed what is particularly striking about this competence is how greatly the legal provisions have changed from treaty to treaty. unlike many other policy areas where the treaty provisions have remained largely unchanged, the wording about health has been greatly amended and the provisions have become more and more detailed. in the treaty of amsterdam of 1997, for example, the public health article (article 129 of the maastricht treaty) was significantly lengthened and the new article (article 152), among other things, included for the first time the power to make binding eu legislation in a few specific areas, in relation to blood and organs, and in some veterinary and phytosanitary areas. a quick look at the current health article, (article 168 of the lisbon treaty) will show that it is again substantially different from the ones agreed in previous treaties, as well as being very much longer. the areas of binding legislative powers introduced in 1997 are retained and there is a further one: medicinal products and medical devices, additionally, the scope for taking legal measures is increased, and now also includes cross-border threats to health, merkel b. a growing competence: the unfinished story of the european union health policy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-2015-15 4 tobacco and alcohol; and the article includes soft law provisions similar to those of the so called ‘open method of coordination’ used in social and employment policy. the article also concedes for the first time that the eu in the framework of its public health competence may have a role in relation to health services, saying that the eu: “shall in particular encourage co-operation between the ms to improve the complementarity of their health services in cross-border areas”. finally, of course, in addition to article 168, the treaty of lisbon also incorporates the charter of fundamental rights of the eu. article 35 of this promulgates a right in respect of health care: “everyone has the right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices. a high level of human health protection shall be ensured in the definition and implementation of all the union’s policies and activities”. hence, clearly, the eu’s legal competence has considerably evolved since the maastricht treaty. but perhaps dr. stein is making a deeper point, that regardless of the specific textual amendments in successive treaties, the underlying scope of and limitations on the eu’s public health competence have not fundamentally changed. there is some strength in this argument. but the position is not as clear-cut as he maintains. the first point to be considered is similar to the one we have made in connection with the article 129 of the maastricht treaty. if ms wanted to preserve the eu’s public health power weak and nebulous, why did they not simply keep it as it was? why did they keep changing it (and adding to it!) in each treaty revision? we can advance several reasons. first, there was never unanimity among the ms about the extent of the eu’s role in public health, and in fact a diminishing degree of consensus as more ms joined the eu. some of them, notably the newer ms, actively welcomed a greater eu involvement not only in developing national public health policies but even in respect of the functioning of their health systems. second, the treaty reformulations represent (to some extent) responses to developments in europe and beyond. gradually, even against their basic instincts, most, if not all, ms came to appreciate that the eu could be of use in helping tackle some health problems that would be difficult to deal with by individual countries acting separately. these include for example • responding effectively to health threats from communicable diseases and man-made and natural disasters, • tackling various health determinants, • developing a framework for regulating health goods and related items that circulate in europe, and • responding to global health problems. thirdly, the ms were not negotiating in a vacuum; they had to take into account public opinion and, in particular, the views of the other eu institutions, notably the european parliament (ep) and the commission which both pressed at various points for the eu to be given additional powers in particular health fields. in relation to the maastricht treaty, for example, the commission may have had a limited role in the actual negotiations, but it made proposals for what it wanted to see, it liaised with ms about how texts were worded and certainly followed the negotiations extremely closely. the final draft of the new public health article therefore came as no surprise to the commission. and directly after the treaty had been ratified on 1 november 1993, it published a detailed communication setting out how it intended to implement the new provisions (4). similarly the ep played a very forceful role in the bse crisis which led both to a substantial shake–up in the organization of the commission services to separate agriculture from food safety and also to pressure to merkel b. a growing competence: the unfinished story of the european union health policy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-2015-15 5 strengthen the treaty provisions on the protection of public health. this resulted in the inclusion in article 152 of the amsterdam treaty of provisions allowing for binding measures to be taken in the veterinary and phytosanitary fields in relation to public health, and the extension of the overall scope of ec public health action to “preventing human illness and diseases, and obviating sources of danger to human health”. certainly, dr. stein is right in his contention that the health ministries of many ms have never been the warmest advocates of increasing eu competence in health. yet despite this the fact remains that it has increased, is increasing and seems likely to continue to increase. paradoxically, it is arguable that the prime movers of this growth in eu power have not generally been those in the health field, but rather those in charge of other policy areas who have never been so zealous about national prerogatives in relation to health. decades ago it was heads of government who pushed for action on the single market which led ultimately led to eu action on pharmaceuticals, mutual recognition of health professionals and reciprocity of health insurance coverage. later those same heads of government called for eu action on cancer and aids. in the last few years it has again been heads of government and finance ministers who have set up a new eu system of economic governance which has led to direct interventions in ms’s budgetary and economic policies and through those means intrusion into their national health care policies. today, as part of this system, we have an eu instrument, the semester, which enables the eu to give every ms specific (non-binding but very influential) recommendations on the main issues confronting their healthcare systems, their health spending and the reforms they should make. we have obviously travelled a very long way indeed from the arguments about whether the eu had a significant role in public health policy, let alone that it could have anything to do with the functioning of national health systems. dr. stein has written a thought-provoking article which helps us to trace the path that has been followed and offers us some pointers to what may come in the future for european health policy. as he wrote in 1995: “it may take some time, but i have little doubt that when the range of possibilities inherent in the new treaty provisions are really used, their impact on public health will be greater than anybody expects today” (5). now, twenty years and several treaties later, we can see just how prescient he was. references 1. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives. seejph 2014; posted: 23 december 2014. doi 10.12908/seejph-2014-36. 2. stein h. experiences of the german presidency: small steps towards integrating public health. eurohealth 1995;1:19-20. 3. merkel b. the public health competence of the european community. eurohealth 1995;1:21-2. 4. european commission. communication on the framework for action in the field of public health. com(93)559 final. 5. stein h. experiences of the german presidency: small steps towards integrating public health. eurohealth 1995;1:19-20. © 2015 merkel; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0)� commentary bernard merkel1 references alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 1 | 14 original research factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates maryam alawadhi1, khadija alhumaid2, sameeha almarzooqi1, shaima aljasmi1, ahmad aburayya1, said a. salloum3, waleid almesmari4 1dubai health authority, dubai, uae; 2 rabdan academy, abu dhabi, uae; 3school of science, engineering, and environment, university of salford, uk; 4 ministry of defence, uae airforce and airdefence office, abu dhabi, uae; corresponding author: dr. ahmad aburayya; assistant professor, business administration college, jefferson international university, california, usa; address: dubai health authority, dubai, uae; email: amaburayya@dha.gov.ae; q5110947@tees.ac.uk. mailto:amaburayya@dha.gov.ae mailto:q5110947@tees.ac.uk alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 2 | 14 abstract aim: medical training activities have been disrupted in many regions following the outbreak and rapid spread of the coronavirus disease 2019 (covid-19) across the globe. the most affected areas include organizations’ process of leveraging high-tech medical equipment from abroad to facilitate a practical approach to learning. also, as countries implemented covid-19 safety regulations, it became difficult for organizations to conduct face-to-face training. consequently, non-face-to-face learning methods have been introduced in the medical field to enable instructors to remotely engage with learners. the current research investigated the students' perceptions of the use of metaverse systems in medical training within the medical community of the united arab emirates (uae). methods: a conceptual model comprising the adoption properties of personal innovativeness, perceived enjoyment, and technology acceptance model concepts was utilised. the current research targeted students in uae medical universities. data was obtained by conducting online surveys that were implemented in the winter semester of 2021/2022 between 15th february and 15th may 2022. 500 questionnaires were issued to students following their voluntary participation and 435 questionnaire responses were obtained i.e. an 87% response rate. the research team tested the measurement model employing structural equation modeling using smart partial least squares version (3.2.7). results: statistically significant associations were confirmed to exist between personal innovativeness (pi) influenced by both the perceived ease of use (peou), and perceived usefulness (pu) (β= 0.456) and (β= 0.563) at p<0.001. the statistically significant associations involving perceived enjoyment (ej) and peou and pu (β= 0.554, p<0.05), (β= 0.571, p<0.05) were further confirmed. additionally, peou had a relationship with pu (β= 0.863, p<0.001). eventually, peou and pu significantly influenced the participants’ inclination to use the metaverse technology with (β= 0.745, p<0.001) and (β= 0.416, p<0.001), respectively. alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 3 | 14 conclusion: conclusions made during the research add to the existing literature regarding technology adoption by demonstrating how adoption properties, perceived enjoyment, and personal innovativeness influence students’ perceptions concerning innovational technologies used in education. keywords: metaverse; covid-19 pandemic; medical training; medical students; technology acceptance model; sem based analysis. conflicts of interest: none declared. alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 4 | 14 introduction with the rapidly increasing demand for digital products and services in the contemporary world, computer scientists and researchers develop ideas to improve the experiences of computer users. among the most recent innovations in the digital world is the use of three-dimensional virtual environments (1,2). metaverse is a term commonly used to refer to virtual and augmented reality. the term was invented in 1992 (3) where a science fiction novel was composed to describe the future of immersive 3-dimensional virtual reality technologies. virtual reality allows users to experience diverse digital mirrors of their world and aspects that do not exist in the real world (1,4–6). multiple research studies have been conducted in universities and other learning institutions to investigate the effectiveness of metaverse as a learning tool. such studies focus on the implementation of metaverse through a problem-based approach where different stakeholders in the learning environment can submit queries and obtain feasible solutions to diverse problems using the three-dimensional classes and the avatar (7–10). similarly, a study (11) confirmed that a metaverse platform constitutes a useful tool for increasing motivation and immersion among learners. through such a learning platform, students develop real feelings toward the innovative learning strategy and benefit from self-guided learning experiences. therefore, the metaverse has been praised to contribute to a positive learning experience. metaverse has also been observed to contribute to research in diverse fields. multiple studies (7,8,12) investigate key benefits of using metaverse systems in diverse fields of research. the studies predominantly focused on real-life experiments where virtual or augmented reality is used to develop solutions to various problems. with respect to inferences from the various studies, it is important to develop a conceptual framework that takes into consideration the influential role of metaverse systems in education. adopting such a conceptual framework could help to determine the effectiveness of the metaverse system by studying how students perceive it. through this study, a model will be developed to describe the crucial factors for an effective learning strategy, which include perceived enjoyment (ej) and personal innovativeness (pi). pi is influenced by two factors that include perceived usefulness (pu) and its perceived ease of use (peou) (13,14). therefore, this study will investigate how innovativeness of medical students who use the metaverse system is influenced by peou and pu of the technology. the general objective is to study key factors that determine the implementation of the metaverse in the united arab emirates (uae) medical education system and establish whether the peou and pu are depicted in the current metaverse system. the study will also describe how the technology impacts an individual’s enjoyment and pi following the implementation of the metaverse system. consequently, findings from the current study will summarise the key factors surrounding students’ perceptions regarding the implementation of metaverse systems. unlike similar past studies that have utilised the structural equation modeling (sem) strategy to develop theoretical models, the current study will integrate technology acceptance model (tam) to examine learners’ inclination to adopt metaverse as a learning tool (15). eventually, the study will validate the developed theoretical model by utilizing the partial least squares -sem (pls-sem) approach. alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 5 | 14 the innovation theory will be used to guide the research methodology. the theory classifies consumers of technological innovations as innovative members of society who actively seek information and innovational ideas (16,17). users of technology are often forced to overcome their uncertainty and develop a positive inclination to use technology. their innovativeness helps them to shape their beliefs and attitudes towards achieving greater innovation through the use of technology. pi has been observed to cause a substantial impact on a person’s ability to cognitively interpret information technology which symbolises the risk-taking inclination to use technology (18,19). tam describes how individuals’ innovativeness in the use of technology is influenced their perceptions regarding its usefulness and userfriendliness (15). therefore, the basic aspects of the proposed model comprise the perceived user-friendliness and the pu of the system. pu refers to the extent to which a user of technology believes that it will positively influence their ability to compete certain tasks. on the other hand, peou refers to how much a person is convinced that a technology would improve their experiences by reducing the effort required to complete certain tasks. significant associations have been confirmed to exist involving an individual’s behavioral intentions and the level of satisfaction with their use of the technology. therefore, the conceptual model suggests that the pu and perceived userfriendliness of technology are dependent on pi, which indicates the need to leverage the metaverse system in medical education (20,21). considering the identified assumptions, the current study theorises that: h1: pu is positively affected by pi. h2: peou is positively affected by pi. the study defines ej as the degree to which an individual feels enjoyment and is satisfied by their performance in certain tasks. it is often perceived as the extent to which consumers of technology gain satisfaction with the virtual reality technology. past studies have evaluated ej as a qualitative factor that influences the users’ sense of pleasure, disgust, or hate resulting from the use of technology, which further influences their behavior (22–24). as convenience and enjoyment enable users to develop positive perceptions, the ej of technology influences a user’s inclination to use technology, which determines their level of comfort in the long run (24,25). as such, the current study hypothesises that; h3: pu is positively affected by ej. h4: peou is positively affected by ej. the tam theory describes how the perceived user-friendliness and usefulness of technology influences the users’ inclination to accept and adopt it. the perceived userfriendliness is considered to be level of effectiveness and comfort that individuals experience after using an innovative technology. in contrast, pu refers to the effort-free experience that positively impacts the user’s performance (26). the current study theorises that; h5: pu is positively affected by the peou. h6: an individual’s intention to use metaverse system in medical training (in) is positively affected by the pu of the technology. h7: an individual’s intention to use metaverse system in medical training (in) is positively affected by the peou of the technology. based on the above, the study seeks to measure the acceptance and implementation of the metaverse system by analyzing the ej and pi relative to other independent variables. the proposed research model relies on the earlier identified hypotheses as depicted in figure 1 below. alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 6 | 14 figure 1. research model. methodology the current research targeted learners in uae universities. data was obtained by conducting online surveys that were conducted in the winter semester of 2021/2022 between 15th february and 15th may 2022. a link to the survey as well as details regarding the research objectives were emailed to members of the target population. the information was also shared across the students’ social media groups to maximise the response rate and gather a sufficient number of individuals to participate in the study. 500 questionnaires were issued to students following their voluntary participation and 435 questionnaire responses were obtained, which constituted an 87% response rate. the exclusive inclusion of students was since students are the most affected group of stakeholders who use the metaverse systems in the university setting. whenever technology presents challenges to students, universities consider leveraging more efficient tools to stimulate students' performance. as instructors possess vast experience and diverse competencies, they can contribute to the university’s process of leveraging new technologies that could provide better user experiences to students. the selected sample size was sufficient enough to provide the desired information during the study. as (27) suggests, a population of 1500 members ought to have an estimated number of at least 306 respondents taking part in a study. on that account, a sample size of 435 is considered large enough to meet the current research objectives. to validate its hypotheses, the study utilised a survey to collect the desired information. the survey comprised 14 items that helped to evaluate the five major constructs that the research sought to analyse. questions used in preceding studies were restructured to concur with the needs of the current study and facilitate the applicability of conclusions. the collected data was assessed using a fivepoint likert scale based on 5 statistics that ranged between strongly agreed (5) and strongly disagree (1). an evaluation using a alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 7 | 14 sem is efficient for the current study’s sample size, which would help to test the study hypotheses (28). although preestablished theories were used to develop the hypotheses, they focused on the implementation of the metaverse systems in the medical education setting. the research team tested the measurement model using smartpls version (3.2.7) while further assessments were conducted using the path model. the construct of reliability and validity was considered when assessing the measurement model. the strategy was recommended by (29) where construct reliability was confirmed by assessing composite reliability (cr), dijkstrahenseler's alpha (pa), and cronbach’s alpha (ca). additionally, validity was determined by establishing both the discriminant and convergent cogency. results participants’ description as demonstrated in table 1, the proportion of male and female participants was 53% and 47% respectively. the age distribution of the participants was generally even with 72% of the respondents ranging between 18 years and 29 years while 28% had surpassed the age of 29. a larger proportion of the respondents were seeking university degrees with 11% having doctoral degrees, 33% having master's degrees, and 56% of them having bachelor's degrees. a purposive sampling strategy was utilised in the study due to its effectiveness in studies where respondents are willing to volunteer (30). table 1 . demographic data of the respondents. criterion factor frequency percentage gender male 232 53% female 203 47% age between 18 to 29 314 72% between 30 to 39 78 18% between 40 to 49 35 8% between 50 to 59 8 2% education qualification bachelor 244 56% master 145 33% doctorate 46 11% convergent and discriminant validity as demonstrated in table 2, construct reliability was confirmed as ca ranged between 0.801 and 0.857, which were higher than the standard value of 0.7 (31). the assessment also revealed that the cr ranged between 0.812 and 0.859, which is greater than the standard threshold of 0.7 (32). therefore, it was necessary to consider evaluating and reporting cr using pa to check for the reliability of the research data (33). dijkstra-henseler's alpha ought to present values greater than 0.07 in investigative studies and values that exceed 0.8 for other types of research (31,34). as depicted in table 2 below, the reliability coefficients for all measurements exceed 0.70, which confirms the construct reliability. consequently, the constructs considered in the study were reported to be unbiased by the end of the study. the average extracted value (ave) and factor loading were also alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 8 | 14 tested during the study. such analyses facilitate the confirmation of convergent validity, which determines the overall reliability of research conclusions (29). as depicted in table 2, the factor loadings exceeded the standard value of 0.7 while ave values ranged between 0.625 and 0.755, which exceeds the standard value of 0.5. therefore, convergent validity was confirmed for all constructs. the heterotrait-monotrait ratio (htmt) is measured as the primary strategy to determine discriminant validity (29). the htmt values for all constructs were less than the standard value of 0.85 (35), which indicates the conformity of the htmt ratio as presented in table 3. as such, the discriminant validity was confirmed. as such, no significant inconsistencies related to validity and reliability were observed when conducting the assessment. findings from the analysis confirmed feasibility of the structural model in analyzing the research data. table 2. convergent validity results (factor loading & cronbach’s alpha,). constructs items factor loading cronbach's alpha cr pa ave perceived enjoyment ej1 0.815 0.851 0.85 3 0.85 0 0.62 5 ej2 0.829 ej3 0.836 personal innovativeness pi1 0.854 0.857 0.85 9 0.85 3 0.70 5 pi2 0.798 pi3 0.792 perceived ease of use peou1 0.841 0.826 0.83 2 0.82 1 0.65 9 peou2 0.836 peou3 0.856 perceived usefulness pu1 0.790 0.825 0.81 9 0.82 3 0.75 5 pu2 0.799 pu3 0.810 users’ intention to use the ms in1 0.822 0.801 0.81 2 0.80 2 0.70 2 in2 0.840 table 3. heterotrait-monotrait ratio (htmt). ej pi peou pu in ej pi 0.765 peou 0.369 0.632 pu 0.756 0.619 0.531 in 0.335 0.577 0.605 0.768 alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 9 | 14 hypotheses testing results key variables of the study had percentages of variance of 72%, 76%, and 70% respectively as presented in figure 2 and table 4. beta (β) values, t-values, and p-values presented in table 5. the empirical data used in the study confirmed the hypotheses h1, h2, h3, h4, h5, h6, and h7. statistically significant associations were confirmed to exist between pi was observed to be influenced by both the peou and pu (β= 0.456) and (β= 0.563) at p<0.001, which confirms hypotheses h1 and h2. the statistically significant associations involving ej, peou and pu (β= 0.554, p<0.05), (β= 0.571, p<0.05) confirmed the hypotheses h3 and h4. additionally, peou had a considerable relationship with pu (β= 0.863, p<0.001), which confirmed the validity of hypothesis h5. eventually, peou and pu significantly influenced the participants’ inclination to use the technology with (β= 0.745, p<0.001) and (β= 0.416, p<0.001), respectively, which confirmed the hypotheses h6 and h7. table 4. r2 of the endogenous latent variables. construct s r2 results in 0.698 high peou 0.724 high pu 0.762 high table 5. hypotheses-testing of the research model (significant at p** < = 0.01, p* < 0.05). h relationship path tvalue pvalue direction decision h1 pi -> pu 0.563 10.217 0.002 positive supported** h2 pi -> peou 0.456 8.302 0.005 positive supported** h3 ej -> pu 0.571 6.557 0.015 positive supported* h4 ej -> peou 0.554 5.689 0.018 positive supported* h5 peou -> pu 0.863 15.083 0.000 positive supported** h6 pu -> in 0.416 18.226 0.000 positive supported** h7 peou -> in 0.745 17.119 0.000 positive supported** alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 10 | 14 figure 2. path coefficient of the model (significant at p** < = 0.01, p* < 0.05). discussion and conclusion this study investigated the students' perceptions of the use of metaverse systems in medical training within the medical community in the uae. in essence, the metaverse system constitutes one of the technologies that will cause a meaningful impact on medical education. the innovative technology facilitates various educational practices in the contemporary world. the technology is likely to replace the internet and introduce greater innovation to transform teaching and learning. having investigated the perceptions among university students regarding the implementation of the metaverse technology in education within the uae, the current study found that pi, ej, pu, and peou factors are significantly affecting the learners’ perceptions concerning the use of metaverse in medical education at p<0.001. the current study found that there exists a close association between the learners’ perceptions concerning the use metaverse and their levels of innovativeness. indeed, this finding from the study concurred with past research works (15,18-21). users of technology are often forced to overcome their uncertainty and develop a positive inclination to use technology. their innovativeness helps them to shape their beliefs and attitudes towards achieving greater innovation through the use of technology. pi has been observed to cause a substantial impact on a person’s ability to cognitively interpret information technology which symbolises the risk-taking inclination to use technology (18,19). furthermore, the basic aspects of the tam model comprise the perceived userfriendliness and the pu of the system. in addition, the study findings revealed the ej factor has positive effects on pu and peou (p<0.001). past studies have evaluated ej as a qualitative factor that influences the users’ sense of pleasure, disgust, or hate resulting from the use of technology, which further influences their behavior (22–24). as convenience and enjoyment enable users to develop positive perceptions, the ej of technology influences a user’s inclination to use technology, which determines their level of comfort in the long run (24,25). the students’ perceptions regarding the technology were further influenced by alawadhi m, alhumaid k, almarzooqi s, aljasmi sh, aburayya a, salloum sa, almesmari w. factors affecting medical students’ acceptance of the metaverse system in medical training in the united arab emirates (original research). seejph 2022, posted: 25 july 2022. doi: 10.11576/seejph5759 p a g e 11 | 14 perceptions regarding the peou and eventual pu of the metaverse system in the education setting. findings from the study concurred with past research works as it describes students’ experiences with innovational technology used in the contemporary education sector. certainly, several technology theories describe how the perceived user-friendliness and usefulness of technology influences the users’ inclination to accept and adopt it. the perceived userfriendliness is considered to be level of effectiveness and comfort that individuals experience after using an innovative technology. in contrast, pu refers to the effort-free experience that positively impacts the user’s performance (26). however, the study had several limitations that included its exclusive reliance on two variables that include pi and ej. additionally, the tam constructs only used two constructs of peou and pu to make the process of measurement easier and focus the research process on the key factors that influence the participants’ innovativeness. as the survey link was shared on social media, 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modeling. j acad mark sci [internet]. 2015;43(1):115–35. available from: http://dx.doi.org/10.1007/s1174014-0403-8 ______________________________________________________________________________ http://dx.doi.org/10.1016/j.csda.2014.07.008 http://dx.doi.org/10.1016/j.csda.2014.07.008 http://dx.doi.org/10.2753/mtp1069-6679190202 http://dx.doi.org/10.2753/mtp1069-6679190202 http://dx.doi.org/10.1007/s11747-014-0403-8 http://dx.doi.org/10.1007/s11747-014-0403-8 agarici, s.; elabassy, d.; hirche, a.; saha, r.; witte, j.; thomas, j.c. proposing a european public health code of ethics. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph5606 p a g e 1 | 18 policy brief proposing a code of ethics for public health professionals in europe sylvia agarici1+, darin elabbasy1+, anja hirche1+, royina saha1+, jente witte1+, james c. thomas* 1faculty of health, medicine, and life sciences, maastricht university, the netherlands +these authors contributed equally to this work *senior advisor corresponding author: sylvia agarici, email: sy.rici@yahoo.com address: universiteitssingel 60 6229 er maastricht, the netherlands agarici, s.; elabassy, d.; hirche, a.; saha, r.; witte, j.; thomas, j.c. proposing a european public health code of ethics. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph5606 p a g e 2 | 18 abstract context: public health practitioners are involved in a wide array of contexts. local and national government public health agencies; domestic and international nongovernmental organizations (ngos); and academic institutions are just a few examples of the settings where public health practitioners work. acting ethically and meeting ethical commitments in a practical and transdisciplinary endeavor as complicated as public health necessitates careful consideration. ethical practice ensures that public health institutions work properly and that individual public health practitioners maintain their integrity. there is little debate about the importance of ethics in public health professional practice and, as a result, the necessity for a corresponding professional code of ethics. policy options: only an us-american code of public health ethics has been created so far. since ethical considerations in public health are heavily dependent in contexts, the aim of this document is to initiate a discussion surrounding the establishment of a code of ethics for public health professionals in europe. recommendations:  stimulate the discussion on a european code of public health ethics.  make a clear distinction between public health ethics and medical ethics.  recognize public health as a profession and not just a medical specialty.  recognize the need for a common code of ethics among public health professionals in europe.  use kotter's model based on the theory of change as a roadmap when creating the european public health code of ethics.  treat the european code of ethics as a "living document".  encourage further research on a european code of ethics. keywords: code of public health ethics, european code of public health ethics, public health, public health values, public health ethics acknowledgements: we thank professor james c. thomas for his guidance and support in developing this paper, as well as professor kasia czabanowska for her help and for providing the opportunity to have explore this special project. we also thank all the interviewees for their time and contributions. contributions: all authors contributed equally to this work. conflict of interest: none declared source of funding: none declared agarici, s.; elabassy, d.; hirche, a.; saha, r.; witte, j.; thomas, j.c. proposing a european public health code of ethics. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph5606 p a g e 3 | 18 introduction in early november 2021, the austrian authorities announced that about two million people who had not been fully vaccinated against covid-19 would be placed in lockdown. shortly after, germany introduced the same restrictions. unvaccinated individuals were only allowed to leave their premises for limited reasons, such as working or grocery shopping (1). meanwhile, protesters against covid restrictions are dispersed using water cannons and tear gas in belgium and italy (2). these events demonstrate how reactions to protecting public health (ph) at the expense of individual moral rights and frustrated desires are not novel. they lead to the emergence of diverse ethical questions, such as the limits to individual freedom (3). this is where ethical codes are useful, as they are concerned with providing guidelines to answer such questions in formally written documents (4). based on the idea that health professions are more than just special interest groups entrusted with serving the community, codes represent a societal pledge for the profession, which is part of a unique commitment and a second identity for the individual with values and norms relating to this society (4). since different professions operate in different contexts with different societal expectations and values to attend to, each profession needs its code of ethics (5). for instance, biomedical codes of ethics might not be entirely applicable to ph (6). in europe however, ph is yet to be recognized as a unique profession recognizing its multidisciplinary, instead of a medical specialty, as pointed out by ph experts during interviews for this policy brief (see table 4, appendix 2). there is no doubt about the relevance of ethics in ph professional practice and therefore, the need for a corresponding professional code of ethics. so far, only an american code of ph ethics was developed (7,8). however, since ph is extensively based on social contexts, having a code of ph ethics for different regions would be more relevant to the unique ethical dilemmas related to ph interventions and the nature of societies historical backgrounds and values in each region. currently, no european ph code of ethics exists, but there have been previous efforts to initiate the discussion around the creation of one (9,10). a plausible assumption is that the covid19 crisis could lead to significant measures to mitigate the recent shortcomings witnessed in national responses within europe (11). part of this crisis and its aftermath might lead to better redistribution of resources, considerations being given to ph as its own profession, and most importantly, a recognized document or code which underpins the values, roles, and ethics of european ph decision-making. hence, this policy brief calls for the establishment of a european ph code of ethics and suggests a framework that could possibly guide the development of a european code of ethics using kotter’s model of change. context medical ethics and public health ethics first, for the purpose of developing a european ph code of ethics, it is important to make the distinction between medical ethics and ph ethics. according to conti (12), medical ethics is focused primarily on individual health and cases, concerning itself with topics such as aspects relating to the desire for parenthood, changes of sex, or agarici, s.; elabassy, d.; hirche, a.; saha, r.; witte, j.; thomas, j.c. proposing a european public health code of ethics. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph5606 p a g e 4 | 18 organ replacement. in essence, the values of autonomy, beneficence, non-maleficence, and justice are integral to the medical ethics approach (13). in contrast, ph ethics is concerned with a societal view of ethics (13,14). issues regarding distributional differences, health inequalities across society, and other diverse topics, are of major concern and can be directly linked to the social determinants of health (13). the use of biometrics during hiv surveillance for example, highlights complex ph issues around privacy, the exposure of participants to risks of legal action or violence, the potential biassing of surveillance results, and the undermining of trust in the health care system, which are relevant for healthcare and ph professionals alike (15,16). this calls for action to clearly address the role of professionals in ethical dilemmas relating to ph and provide guidance for such matters. public health ethics in the united states and europe there remains the question of why a different code of ethics in europe is needed, and the work of the american ph code of ethics should not merely be copied. in the united states, the ph code of ethics provides guidance on ethical analysis and action in policy and practice. it also highlights the importance of transparency, accountability, respect, and reciprocity. furthermore, policy and practice guidance for twelve areas of ethical action is elaborated upon within the document, giving clear direction to ph ethics work (4). in contrast to the american ph code of ethics, the complexity of europe requires special thought and consideration. certain political realities, such as the french revolution or nazi germany and the resulting nuremberg code, were responsible for the development of different value systems and thus to more solidarity-based health systems within europe compared to the us (17). while current policy ideas headed by the eu such as commitments to minimize socioeconomic disparities and the promotion of a health-inall-policies approach exist, ph remains a topic largely governed by the member states. despite the different need for codes of ethics in europe and the united states, european ph professionals should not completely step away from the american code of ethics. camps et al. (17) have stressed that establishing ph ethics in europe should incorporate the american code of ethics, as the fundamental key ideas do not differ significantly. however, innovations and even some adaptations regarding moral values in european societies should be made. regardless of the universalities of moral obligations, the values that govern the ph decision-making of societies are different and therefore need to be regarded (17). codes are based on values that relate to the contexts they will be applied to. europe’s health values are based on a unique set of beliefs about health rights and duties which reflects the identity and the history of europe. therefore, the ph field in europe is more likely to benefit from a code that is tailored based on european values than just adopting existing codes. although it cannot be assured that all of europe would fully adopt the document, it would allow european ph professionals to have a reference document which can guide and support ph decision-making. values to be considered in european public health ethics as ph ethics evolves, a broader and more in-depth set of arguments regarding which agarici, s.; elabassy, d.; hirche, a.; saha, r.; witte, j.; thomas, j.c. proposing a european public health code of ethics. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph5606 p a g e 5 | 18 values are at the core of ph practice in europe will be seen. these values will be contrasted with the ones reflected in the american public health (ph) code of ethics while considering the differences between both societies (4). justice and equity lundgren & etheredge (18) advocate for justice, i.e., the notion for people to be treated equally. in ph ethics, the principles of justice advocate for people to be treated in a like manner and the health of the collective is prioritized. the american ph code of ethics states that all ph actions aimed at reducing health inequalities should be rooted in the values of justice and ethics (4). here, equality implies that each person or group of people has the same access to resources and opportunities, while equity recognizes that circumstances for each person is different and gives the precise resources and opportunities required to achieve an equal result (19). health justice encompasses not only the equitable allocation of scarce resources, but also the elimination of structural and institutional domination resulting from other disparities. the american ph code of ethics claims that it is difficult for ph to promote health justice at the transactional level unless it also works to promote it at structural and institutional levels (4). similarly, european literature equally highlights the importance of equity as a health determinant, however, from the view of the european system, health equality refers to the commitment to diminish and eventually eradicate inequities in health and its determinants (20). the new code of ethics could further the value of equity from the groundwork laid by the american ph code of ethics into a health dimension that goes beyond individual factors and encompasses the socioeconomic, cultural, and environmental determinants of health (4). autonomy: right to self-determination embedded within the social context the american ph code of ethics states that it is imperative for ph professionals to implement measures that respect the privacy and autonomy of all individuals and do the needful to minimize infringement upon personal liberties or adverse social and health outcomes (4). however, it is argued that european citizens tend to think of moral or social dilemmas on a more societal level due to the narrative surrounding the civic and cultural ‘european identity’ which is one of the underlying principles of the ‘european project’ (21). nonetheless, mah and timmings (22) suggested that the role of ph ethics should be the notion that ph interventions, as mechanisms for operationalizing long-term health equity goals, should attempt to actively shift existing social norms. the existing deliberation between autonomy and broader population health continues to be one of great importance within ph ethics. owens and cribb (23) emphasize that freedom of choice does not equate to a policy that provides all people with the capability to be healthy. more attention should be drawn to the trade-offs between the right of self-governance and maximizing public health in a broadened discussion, addressing issues related to the intersection of individual-level factors and the social inequalities causing health disparities, including the question of added interference posed by this (23,24). according to kavanagh et al. (15), justifications for activities that infringe on liberty and privacy must be based on considerations such as effectiveness of an intervention towards a legitimate ph goal, whether the benefits outweigh the harms, whether infringement is necessary to achieve agarici, s.; elabassy, d.; hirche, a.; saha, r.; witte, j.; thomas, j.c. proposing a european public health code of ethics. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph5606 p a g e 6 | 18 the goal, whether the activity represents the least infringing option, and whether these actions have been publicly explained and communities consulted (15). a clear distinction between american and european ideological perspectives relating to autonomy can be recognized. according to ellemers et al. (21), the pursuit of one’s health goals without state ph interference is central to an american perspective, whereas more europeans agree that a certain extent of state interference is acceptable to guarantee that no citizen is in need. this could be owed to a higher degree of accountability that europeans attribute to their governments, as well as the european ideology that the right to good health for everyone directly translates into better economic productivity (20). this could be a key area where the european code of ethics deviates from the american code of ethics by striking a more fitting balance between autonomy and interdependence, given the changing sociocultural dynamics post the covid-19 pandemic. solidarity and interdependence solidarity is the moral ideal that best describes the european concept of ph as a common good, mutual help, and shared responsibility for population health (25). it was pointed out during ph expert interviews (see table 4, appendix 2) that solidarity in the ph context should not only be recognized from a medical perspective, but rather in a holistic approach, accounting for the moral complexity in people’s relationships with one another, with nonhumans and with the environment, and broadening the remit of ph ethics which may result in analyses that are more sensitive and useful (26). focus should also be given to the inseparable association between solidarity and society. solidarity should be practiced in a way that the scale or degree of institutionalization does not determine the moral worth or the ultimate importance of its enactment (26). syrett (27) highlights that, while rearranging rights in a relational direction is not simple, it is not impossible. as such a development is based on conceptions of interconnection, it would considerably increase the potential of the right to health to be used in pursuit of community health goals and determinants of health (27). this would allow for a shift in moral focus from personal accountability to broader social issues and the pursuit of the common good. in the european context, solidarity permeates all dimensions of society: from healthcare, to economy, to politics. the structure and functioning of the european legislature discourage making hierarchical divisions that place one country higher than the others based on any parameter (28). furthermore, interstate solidarity between european countries and interpersonal solidarity between european citizens are two key values which determine the dynamism and influence of europe. therefore, it is justified for a new european ph code of ethics to put more emphasis on solidarity and interdependence as essential determinants of good health. legitimacy and trust dawson and verweij (29) strongly advocate for three uses of legitimacy in the form of a normative concept, mandating an assessment of the legitimacy of actions. first, legitimacy should be seen related to the authority to make certain decisions and enact certain policies, second, legitimacy should be used as an angle to view fair agarici, s.; elabassy, d.; hirche, a.; saha, r.; witte, j.; thomas, j.c. proposing a european public health code of ethics. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph5606 p a g e 7 | 18 processes and procedures in decisionmaking, and third it should be viewed differently than moral justification as it is concerned with what decides morally right or wrong. schmidt (30) argues that the ability to gain normative legitimacy and trust is essential to the success of any ph intervention, highlighting the importance of this as a ph value. the american ph code of ethics recognizes that legitimacy and trust in public institutions can be enhanced by boosting public participation, but only touches upon it moderately. europe thrives on strong social connections, shared customs, and a high level of public trust. political legitimacy is regarded as a basic condition for good governance, and an authority not viewed as legitimate is regarded as ineffective in making decisions. the same notion, when stretched to the health of the public, clarifies why the legitimacy of health systems and ph professions are crucial within europe. a new european code could use this as a starting point to advocate for further public participation with the objective to build legitimacy and trust in health systems (4). policy options to ensure the practical feasibility of creating a code of ethics for ph in europe, a roadmap for creating this code is deemed necessary. kotter’s 8-step model of change can be used as this roadmap to create change. kotter's (31) eight-stage process for implementing major change has been acknowledged as one of the most wellknown approaches to transformation, as the mainstream wisdom for leading change, and as the most compelling formula for success in change management (32–34). creating a climate for change 1. create urgency the first step that needs to be taken is creating a sense of urgency among ph organizations in europe (35). there are several recent events that can stimulate this sense of urgency. an important example is the recent g26 meeting that took place in glasgow, scotland (36). the meeting concerning climate change confirmed the current high urgency for taking action and creating largescale change. climate change poses a large threat to the environment, biodiversity, and human-animal interaction, and consequently ph, adding to already existing ph ethical dilemmas this calls for immediate action to create a code of ethics for europe, to have guidance and tactics to govern these dilemmas. furthermore, the covid-19 pandemic resulted in ethical questions, for example in relation to disease transmission and isolation mandates serving the purpose of protecting vulnerable groups within the population, posing an ethical dilemma of autonomy and freedom versus population health. according to thomas and miller (37), most ethical issues in ph arise from interactions between agencies, such as a local health department, and the population the agency is serving, like in the previous example (37). these are several reasons as to why specifically a guiding code of ethics can be an asset in ph. a european code of ethics can also be a basis for shaping guiding principles of national ph organizations, and additionally, it can serve as a basis for codes of ethics for a variety of disciplines within ph. moreover, a european code of ethics can facilitate coordination and consistency among european countries. to have this consistency, the code must include decisionmaking processes and how they are communicated in the context of ph emergencies. this makes the code accessible and serves as a resource primarily for ph agarici, s.; elabassy, d.; hirche, a.; saha, r.; witte, j.; thomas, j.c. proposing a european public health code of ethics. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph5606 p a g e 8 | 18 practitioners and all ph community members. therefore, a sense of urgency is the first building block in creating change and initiating the discussion. this needs to be done among several stakeholders. image 1. stakeholder analysis image 1 shows a rough stakeholder map to guide agencies and institutions that hold high-level individuals who can be at the front of leading the steps towards creating urgency. collaboration must be actively sought out, sharing the common view of the urgency behind writing a european code of ethics. in the next section, the aspect of the collaboration will be elaborated on. 2. form a powerful coalition creating coalitions is an essential step in leading change; the key element of any successful process that creates change is collaboration (35,38). especially in challenging times like these, it is important to stand together as ph professionals through common goals and shared values. climate change, the covid-19 pandemic, humanitarian disasters, increasing inequalities are only some examples of major challenges ph professionals are facing, and outlines the increasing importance and urgency of collaborating as a coalition on ethically dealing with forementioned crises. when creating a code of ethics for all european ph professionals, it should be a primary institution that takes the lead in collecting a group of stakeholders that come from a variety of institutions. this primary institution should be both high in interest and influence on the stakeholder map, such as aspher, epha or eupha, as it will be a key player in leading a collected group of stakeholders. this would be similar to how the first version of the american ph code of ethics was created, where fellows from the public health leadership institute, based in the us, took the lead in writing a first version of the american code of ethics (7). another important stakeholder to include in this coalition would be national ph associations, organized in the world federation of public health associations (wfpha), joining in taking the lead in writing a european code of ethics (39). in essence, it is ph professionals with some credibility that should be leading this process. a proposed list, in addition to the stakeholder map proposed above, can be found in the appendix. 3. create a vision for change public health leaders must craft a vision that is compelling for the future; a story that illustrates the power of a vision. this will be the vision that can be shared with the european ph community, and which provides the following according to kaufman (40):  a clear sense of direction for the code of ethics and a foundation for what this code should be based on, agarici, s.; elabassy, d.; hirche, a.; saha, r.; witte, j.; thomas, j.c. proposing a european public health code of ethics. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph5606 p a g e 9 | 18  a sense of engagement, purpose, and direction for european ph professionals, empowerment, emotion, enthusiasm, and long-term motivation regarding the code of ethics among all european ph professionals,  alignment between this vision and the strategy that will be the code of ethics,  a strong foundation for addressing competing priorities among ph professionals and ethical dilemmas (40). visions are essential when creating change (35). the coalition mentioned in the previous step is the body responsible for creating a clear vision that meets the five requirements indicated above. engaging and enabling the organization 4. communicate the vision for communicating the vision that was established in the previous step, every opportunity possible to continuously communicate the change must be employed (35). a code of ethics that equips ph professionals with the tools needed to practice in an ethical manner still has to be written. the vision – a world where this code is already existing and employed – must be communicated clearly to the entire european ph community; be it ph professionals working in the field, large ph institutions or national bodies. key elements that include effectively communicating the vision are explanation, repetition, use of multiple platforms and leading by example. the leading coalition is responsible for this effort, by walking the talk and setting the example (35). specifying this to the code of ethics, communication about the code can take place in three different types of settings where the vision of an existing and employed code of ethics can be shared:  through written word in the form of publications in academic journals, editorials, or influential online blogs.  in large settings such as conferences, events, or lectures.  on the personal level through strategic selection of influential ph professionals that can be invited to more informal settings to discuss a ph code of ethics. the code of ethics should not be written in stone, but rather be a living document, which will increase the likelihood of keeping the topic of a code of ethics on the agenda (39). ultimately, this serves as an important step that ensures ethical practices which are worthy of public trust within ph (37). when communicating the vision, an effective way of doing this is through a compelling story (40). a story that celebrates the history of european ph ethics and that demonstrates the need for change, or, in other words, the need for a european code of ethics. three drivers of needing change are essential points in a compelling story: crises, crises of confidence between the public and the ph professionals, and lastly, the story and code of ethics must respond to the 21stcentury needs in the ph profession (40). 5. empower action for this step, others must be empowered to act on the vision (35). for clarification purposes, the elements of the statement above should be adapted to the context of ph. in this case, “others” would include ph professionals and/or agencies who operate and influence decision-making in ph. the action is writing the code of ethics, and the vision would be the code of ethics being widely recognized but also practically applied. agarici, s.; elabassy, d.; hirche, a.; saha, r.; witte, j.; thomas, j.c. proposing a european public health code of ethics. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph5606 p a g e 10 | 18 in order to empower action, one ought to get rid of any obstacles to change. an example of such an obstacle was mentioned by schmidt (30), when discussing problems related to ph. effective ph measures, must sometimes be implemented even though they might not, at least initially, be equally accepted by everyone. the potential reluctance may then cause problems to the general good, as populations may not comply voluntarily. a code of ethics would also struggle to reach unanimity, even after multiple drafts have been created. understanding but also accepting the fact that such a document will face resistance, is the very first step that needs to be taken to tackle any future obstacles. thus, the first and most crucial step in order to empower action is acknowledging that the european code of ethics for ph will be faced with controversy; just like any major ph policy seeking to create change. 6. planning for and creating short-term wins writing a code of ethics is a time-consuming process. the completion of such a task would be highly affected by a potential loss of momentum. to avoid this, the ph community and other stakeholders need to remain invested and willing to facilitate the process. motivation may be lost if there is no tangible evidence of the success of the work conducted thus far. hence, it is crucial to plan for visible improvements and recognize the importance of the work conducted by those involved. an example of a short-term win with long-lasting effects would be introducing ph ethics in public health education. while changing the entire curriculum of numerous professions is not a “short-term” process, there are ways to quickly integrate ph ethics through extracurricular activities. such activities include, but are not limited to, conferences, seminars and even competitions organized with the scope of increasing awareness in the field of ph ethics. implementing & sustaining for change 7. build on the change this step entails consolidating achievements and generating additional change. "do not declare triumph too soon," urges kotter (31). it may take years for change to permeate profoundly into a culture. henceforth, writing a european code of ethics for ph is not enough. the document has no credibility unless it becomes recognized and enforced by important ph stakeholders, such as the european union. it is essential that the eu is to be involved in acknowledging first public health as an interdisciplinary public health profession, as well as a future code of public health ethics. additionally, the code has the potential to be used as educational material for both existing and emerging ph professionals. 8. anchor the change the final step regards instituting new approaches. when something becomes "the way we do things around here," it persists (31). there are two things that must be considered for the changes to become part of the culture. the first step is to demonstrate how the adjustments have improved performance. the second step is to guarantee that future ph professionals believe in and embrace the new practices. for example, in all communications addressed to ph professionals there should be a reminder of the ethical responsibility and values professionals need to attend to. recommendations  stimulate the discussion on a european code of public health ethics. agarici, s.; elabassy, d.; hirche, a.; saha, r.; witte, j.; thomas, j.c. proposing a european public health code of ethics. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph5606 p a g e 11 | 18  make a clear distinction between public health ethics and medical ethics.  recognize public health as a profession and not just a medical specialty.  recognize the need for a common code of ethics among public health professionals in europe.  use kotter's model based on the theory of change as a roadmap when creating the european public health code of ethics.  treat the european code of ethics as a "living document".  encourage further research on a european code of ethics. conclusion public health crises are becoming more frequent and with them come ethical dilemmas. this calls for ethical guidelines that can be used in all ph practices and a code of ethics that is specific to european values. a wide variety of professions have adopted codes of ethics that are specified to those professions and their context. however, ph is extensively based on social contexts, therefore, a worldwide generalization of one code of ethics, such as the adoption of the american code of ethics in europe, would be inappropriate. european history and the wide variety of cultures requires attention to different historical aspects, as well as to different values. moreover, cultural differences between european countries are essential to be considered as well to include all of europe. many current real-life problems that european ph professionals face daily urge a code to be developed as soon as possible. with a european code of ethics, ph professionals are empowered and equipped to make important decisions ethically. furthermore, it could re-establish trust in ph decision-making among the public. to guide the development of a code, kotter’s eightstep model to change is proposed as a guiding tool for creating a european code of ethics. this commentary suggests a starting point for developing a european ph code of ethics and calls upon influential ph organizations such as eupha, epha and aspher, to start the writing process for ph professionals to be equipped with fitting ethical strategies to stand ready for any current and future ph crises. conflicts of interest the authors declare no conflict of interest. funding this research received no grant from any funding institution in the public, private, or not-for-profit sectors. acknowledgments first and foremost, the authors want to thank professor james c. thomas for his guidance and support in developing this paper. in addition, they would like to thank professor kasia czabanowska for her help and for providing the authors with the opportunity to have taken on this special project. the authors would also like to thank the interviewees dr. habil peter schröder-bäck, prof. john middleton, and dr. farhang tahzib, who took the time to provide us with their insight and knowledge on the topic. references 1. reuters. tens of thousands march in vienna against covid measures before lockdown [internet]. euronews. 2021 [cited 2022 apr 22]. available from: https://www.euronews.com/2021/11/ 21/uk-health-coronavirus-austria agarici, s.; elabassy, d.; hirche, a.; saha, r.; witte, j.; thomas, j.c. proposing a european public health code of ethics. 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(policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph5606 p a g e 14 | 18 31. kotter jp. leading change. boston: harvard business school press; 1996. 32. mento a, jones r, dirndorfer w. a change management process: grounded in both theory and practice. j change manag. 2002 mar 1;3(1):45–59. 33. nitta ka, wrobel sl, howard jy, jimmerson-eddings e. leading change of a school district reorganization. public perform manag rev. 2009 mar 1;32(3):463– 88. 34. phelan mw. cultural revitalization movements in organization change management. j change manag. 2005 mar 1;5(1):47–56. 35. richesin al. assessing the implementation of a non-profit organizational change initiative using kotter’s (1995) 8 step change model [internet] [undergraduate honours thesis]. east tennessee state university; 2011. available from: https://dc.etsu.edu/honors/10/ 36. cop26 the glasgow climate pact [internet]. presentation slides presented at: un climate change conference; 2021 [cited 2022 apr 22]; glasgow. available from: https://ukcop26.org/wpcontent/uploads/2021/11/cop26presidency-outcomes-the-climatepact.pdf 37. thomas jc, miller r. codes of ethics in public health. in: quah sr, editor. international encyclopedia of public health (second edition) [internet]. oxford: academic press; 2017. p. 71–4. available from: https://www.sciencedirect.com/scien ce/article/pii/b978012803678500079 5 38. javidi m. collaborative change management: a systematic approach. intercult commun stud. 2003;12(2):1–12. 39. schröder-bäck p. carrying the vision of a european public health code of ethics. 2021. 40. kaufman b. collaboration at the heart of successful change initiatives. acad lead [internet]. 2012 [cited 2022 apr 22];28(9). available from: https://d1224169db0e-4296-b514a58769039e00.filesusr.com/ugd/399f 8a_a0b2afc6010148e29063cc711b56 0e44.pdf agarici, s.; elabassy, d.; hirche, a.; saha, r.; witte, j.; thomas, j.c. proposing a european public health code of ethics. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph5606 p a g e 15 | 18 appendices appendix 1: organizations and contacts reached for the purposes of this project to carrying the vision of a european ph code of ethics forward, several contacts and organizations were identified, and are outlined in table 1. it must be advised that this is not an exhaustive list. table 1: organizations and contacts who may provide guidance name title and affiliated organisation interviewed? dr habil. peter schröder bäck (p.) professor for ethics and sociology at the hochschule für polizei und öffentliche verwaltung nrw yes, via zoom prof. john middleton ffph, frcp president, association of schools of public health in the european region (aspher) yes, via zoom dr farhang tahzib public health physician and chair of the ethics committee, uk faculty of public health yes, via zoom assoc. prof. dr hab. katarzyna czabanowska ffph maastricht university public health leadership and workforce development, leadership & governance in european public health , department of international health, care and public health research institute yes, via zoom european public health alliance (epha) public health university wolverhampton (uk) agarici, s.; elabassy, d.; hirche, a.; saha, r.; witte, j.; thomas, j.c. proposing a european public health code of ethics. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph5606 p a g e 16 | 18 appendix 2: methodology literature review first, the literature review was used to examine the state of existing codes of ph ethics in europe. second, it allows the placement of the present document within the context of existing literature making a case for why further study is needed. both objectives were fulfilled by reviewing existing literature and conducting short interviews, the details of which are presented below. inclusion and exclusion criteria the information extracted from the literature was subjected to several inclusion and exclusion criteria. all the publications included in this paper were published from 2002 to 202. with regards to the topic of the literature screened, the search was limited to publications related to public health ethics and/or existing codes of ethics in public health. furthermore, to create a european framework, literature enlisting and describing european values was screened. for this parameter, literature relevant to bioethics was excluded. with respect to the types of literature considered, the research included several types of academic theoretical and empirical research (see table 2). on that aspect, non-peer reviewed publications and anonymous articles were disregarded. finally, documents not written or available in the english language were not taken into account. table 2: search inclusion & exclusion criteria parameter inclusion criteria exclusion criteria topic literature relevant to:  public health ethics  codes of ethics  european values literature relevant to:  bioethics type of literature academic theoretical and empirical research including:  journal articles  research notes  papers and abstracts from conference proceedings  phd theses  opinion pieces  non-peer reviewed journals  unpublished theses  anonymous publications agarici, s.; elabassy, d.; hirche, a.; saha, r.; witte, j.; thomas, j.c. proposing a european public health code of ethics. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph5606 p a g e 17 | 18  governmental archives  professional reports  peer-reviewed articles year of publication published from 2002 to 2021 published before 2002 language publications written or available in english publications not written or available in english search strategy to thoroughly examine all of the available literature in a timely manner, a literature review was conducted. the two databases used for the literature extraction were pubmed and embase. table 3 below is a documentation of the search strategies used. table 3: search strategy database research strategy results pubmed (((public health[title]) and ((ethic*[title]) or ((professional[title]) and (ethic*[title])) or ((decision making[title] and (ethic*[title])) or ((decision making[title]) and (ethic*[title])) or ((professional[title]) and (standard*[title]))) and (code[title]))) 9 embase (‘ph’:ti and ethics:ti or ‘professional standard’:ti) and [embase]/lim not ([embase]/lim and [medline]/lim) and [humans]/lim and [english]/lim 66 interviews conducted furthermore, four interviews were conducted to gain an understanding of the views of public health professionals who worked within ethics. table 4 shows the names, dates, and methods by which the interview was conducted. table 4: interviews conducted name date of interview method assoc. prof. dr hab. katarzyna czabanowska ffph 6th of october 2021 via zoom dr habil. peter schröder bäck (p.) 12th of november 2021 agarici, s.; elabassy, d.; hirche, a.; saha, r.; witte, j.; thomas, j.c. proposing a european public health code of ethics. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph5606 p a g e 18 | 18 prof. john middleton ffph, frcp 24th of november 2021 dr. farhang tahzib 7th of december 2021 ________________________________________________________________________ © 2022 agarici et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 1 original research adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria mariela stefanova kamburova 1 , petkana angelova hristova 1 , stela ludmilova georgieva 1 , azhar khan 1 1 department of public health sciences, faculty of public health, medical university, pleven, bulgaria. corresponding author: dr. mariela kamburova, medical university, pleven; address: 1, st. kliment ohridski, str, pleven, 5800, bulgaria telephone: +359887636599; email: mariela_kamburova@yahoo.com kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 2 abstract aim: this paper aims to study the relationship between mothers’ age, body mass index (bmi), gestational weight gain (gwg) and smoking and the risk for premature birth in pleven, bulgaria. methods: a case-control study was conducted in pleven in 2007. the study was comprehensive for all premature children (n=58) and representative for full-term infants (n=192, or 10.4% of all of the 1827 full-term children) born in 2007 at the university hospital of pleven and resident in the city of pleven. retrospective data on determinants under study were collected from all the mothers included in this study (n=250). results: mothers of premature children were more likely to be above 35 years old (27.6%), with a bmi ≥25 kg/m² (23.1%), gwg below the recommended value (38.5%) and to smoke during pregnancy (37.9%). the odds of being a smoker during pregnancy were five times higher among mothers with low birth weight (lbw) newborns compared with their counterparts with normal birth weight newborns (or=5.1, 95%ci=2.4-10.6). there was a positive association between bmi and lbw in infants whose mothers were overweight (or=2.1, 95%ci=1.0-4.0). the risk of lbw increased when gwg was less than recommended (or=1.8, 95%ci=1.0-3.1). conclusion: our results indicate that pre-pregnancy bmi ≥25 kg/m², less than recommended gwg and smoking during pregnancy are risk factors for premature birth in pleven region. findings from this study suggest the need for active health and educational actions by health professionals in order to avoid premature births in bulgaria. keywords: bulgaria, lifestyle, pleven, premature birth, risk factors. conflicts of interest: none. acknowledgements: the authors are very grateful to the staff of the obstetric clinic at university hospital in pleven, bulgaria, for their continuous support for the whole duration of this study. kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 3 introduction premature birth (pb) is a major public health problem worldwide (1). furthermore, pb is rated as one of the most important single causes of the global burden of diseases in neonatal period (2). it is associated with increased infant mortality, short and long-term negative effects on health and additional costly care needs (3). the interest of researchers in personal characteristics and lifestyle factors of the mothers is due to the fact that they are modifiable and they affect the incidence of premature birth. the challenge is to accurately measure the impact of these factors because of their complexity (4). several studies have shown young maternal age as a significant risk factor for premature birth (5,6). it has not been established with certainty yet, whether this risk is associated primarily with the biological immaturity of young mothers, or an increased incidence of certain risk factors associated with socioeconomic status such as age-appropriate educational level, parity, smoking status, prenatal care utilization and poverty status (7,8). women over the age of 35 years are also at increased risk of pre-term birth. astolfi and zonta (2002) found a 64% increase in the probability of giving premature birth for women over 35 years after controlling for educational status, birth order, and sex of the newborns (9). low or high pre-pregnancy body mass index (bmi) and inadequate or excess gestational weight gain (gwg) are linked to an increased risk of adverse neonatal outcomes (10,11). the weight of a woman before the pregnancy is related to her diet, quantity and quality of food (4). studies have shown that low weight of women before pregnancy is associated with an increased risk of preterm birth (12). campbell et al. (2012) found a link between low prepregnancy bmi and the birth of a premature baby, with a relative risk of >2.5 (6). a study conducted in 2010 in bulgaria on the role of some risk factors for preterm birth failed to establish a statistically significant difference in the weight of women bearing preterm children and those with to term births (13). smoking is defined as one of the most common and preventable causes of adverse outcomes of pregnancy (14,15). many chemicals in maternal smoking pass from the pregnant woman to the fetus through the placenta (16). smoking is associated with placental abruption and inadequate weight gain during pregnancy, but this relationship with the birth of a premature baby is not conclusive and is not proven in all studies. the probable reason for this is that the impact of smoking depends on its duration and intensity, and decreases in women who stop smoking at the beginning of pregnancy (17). some studies have found a strong causal association between smoking and pb of a child (18). a large number of studies have found a moderate influence of smoking in relation to pb of a baby (14,16,17). bulgaria is a country that is characterized by one of the highest indicators of age-specific fertility rate (above 40 per 1000) in europe in the age-group 15-20 years, which is a risk factor for giving birth to a premature baby (19). according to manolova (2004), 42.3% of women in bulgaria smoked during pregnancy (20). however, prematurity as a public health issue has not been subject to scientific inquiry in bulgaria in the past two decades. yet, there are a small number of scientific publications in terms of risk factors for pb in bulgarian children (21). in this context, there is a need to determine the lifestyle characteristics of mothers as important factors for pb in bulgaria. this paper aims at studying the relationship between mothers’ age, bmi, gwg and smoking during pregnancy and the risk for pb in the city of pleven, bulgaria. we hypothesized a positive association between pb and younger or older age and smoking habits of the mothers. furthermore, we assumed a positive link between low bmi and low weight gain during pregnancy and pb. kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 4 methods study design a case-control study was carried out in 2007 in the city of pleven, bulgaria. pleven is a typical township, located in central north bulgaria. at the beginning of the study (in 2007) the size of the population of the city was 139,573 people. in the same year, the birth rate was 8.96‰. maternal care was carried out only by the university hospital. there were 2004 children born at the university hospital, of whom, 1981 were live births. the proportion of preterm infants among all live births was 7.7%. study population the anticipated sample size for inclusion in this study consisted of 250 newborns. the study was comprehensive for all premature children (n=58) and representative for full-term infants (192, or 10.4% of all 1827 full-term children) born in 2007 at the university hospital of pleven and resident in the city of pleven. cases: 58 premature infants weighing 2500 g or less at birth. their gestational age was 37 weeks or less, and they resided in pleven. controls: 192 term infants who were matched to premature infants by date of birth. they were selected randomly among preterm children born on the same date. they weighed more than 2500 g. their gestational age was more than 37 weeks and they also resided in pleven. data collection document analysis: the information on birth weight, gestational age and home addresses of newborns was derived from medical records in a neonatal clinic at the university hospitalpleven. interview: the information for mother’s age, weight of women before the pregnancy, weight gain during pregnancy and smoking habits was gathered retrospectively by interviewing mothers during home visits. such information was not available in the records of mothers in the obstetrics ward, and not all women retained documents from antenatal visits. special questionnaires were designed for the purpose of the study. they were part of a larger study on risk factors for premature birth in the region of pleven, bulgaria. the questionnaire used for the documents’ analysis contained 39 questions, four of which were related to demographic and socio-economic status of the mother. the questionnaire for the interview comprised 92 questions, nine of which were about the lifestyle factors of the mother. for the validation of the questionnaires, a pilot study was conducted. before and after the pilot study questionnaires were discussed and approved by experts, pediatricians, obstetricians and public health professionals. all included mothers answered the questionnaire in the process of an interview. all data in this study were based on women’s reports during the survey interviews. ethical considerations the study was conducted under the supervision of the chair of the irb (institutional review board). the right of privacy of the studied subjects was guaranteed. only the leading investigator had access to the identifying information. mothers expressed their free will for participation and signed an informed consent before the interview. outcomes we studied two outcomes: preterm birth (pb<37 weeks completed gestation and birth weight <2500 g) and low birth weight (lbw: birth weight <2500 g). kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 5 determinants age of the mothers was determined as: ≤24 years, 25-29 years, 30-34 years and ≥35 years. pre-pregnancy bmi was categorized according to the world health organization (who) as either being underweight (bmi<18.5kg/m²), normal weight (18.5≤ bmi≤ 24.9), overweight (25≤bmi≤29.9), or obese (bmi≥30). we utilized the 2009 institute of medicine guidelines on gwg to categorize women’s weight gain for their bmi as below, within, or above the recommended value (22). smoking during pregnancy was determined based on the question “did you smoke during pregnancy?”. women who responded “yes” or “rarely” were categorized as “regular smokers” and “occasional smokers”. statistical analysis the survey data was processed with the statistical software packages spss (statistical package for social sciences), version 11.5, statgraphics and excel for windows. the results were described using tables. percentages were used to report the observed distribution of age of the mothers, bmi, gwg, smoking during pregnancy and other maternal characteristics. parametric tests for hypotheses testing at normal and near to normal distribution of cases: ttest, anova with post hoc tests (lsd, tukey, scheffe, bonferroni, newman-keuls, duncan) and nonparametric tests in other than normal distribution of cases pearson χ²-test, mann-whitney, kruskal-wallis h-test were applied. regression models for modeling and predicting of correlations and multiple logistic regression analyses controlled for covariates estimated the odds ratios with 95% confidence intervals of pb and lbw were used. using multivariable linear regression we assessed the relationships of studied determinants with outcomes (pb, lbw). odds ratios (or) were calculated to determine the effect of the age, weight and smoking during pregnancy, as factors for preterm birth. in all cases, a value of p≤0.05 was considered as statistically significant. results table 1 presents the distribution of basic characteristics of the participants by pb status. the distribution of maternal characteristics varied across mothers with pb and term birth. overall, 17.2% of women were above 35 years old. the share of older mothers was two times higher among those with pb compared to women with term-birth. overall, 23.3% of women were underweight and 12.5% were either overweight or obese. the proportion of overweight was more than two times higher among mothers with pb (19.2%) compared to mothers with term-birth (9.6%). around half (48.8%) of women gained above than the recommended weight for their bmi and a quarter (24.6%) gained less than the recommended weight. about 39% of women with pb compared to 21% of mothers with term-birth gained less than the recommended weight. smoking was reported by 38% of women: 16% of them were regular smokers and 22% occasional smokers. the proportion of mothers with pb who smoked (38%) was about four times higher compared to smoking women with term-birth (10%). compared to mothers with term-born infants, mothers of premature children were more likely to be above 35 years (27.6%), have a bmi≥25 (23,1%), have a gwg below the recommended value (38.5%), smoke during pregnancy (37.9%) and deliver pb children after the third delivery (17.2%). significant differences among mothers with pb were identified for maternal age, pre-pregnancy bmi, gwg, maternal smoking during pregnancy and birth order. conversely, there was no significant difference between groups with regard to their income level. kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 6 table 1. distribution of maternal characteristics characteristics all women (n=250) mothers with premature birth (n=58) mothers with term birth (n=192) p maternal age ≤24 years 25-29 years 30-34 years ≥35 years 25.8 27.4 29.1 17.2 10.4 37.9 24.1 27.6 30.5 24.2 30.5 14.8 0.001 0.049 ns 0.047 pre-pregnancy bmi <18.5 kg/m 2 18.5-24.9 kg/m 2 25.0-29.9 kg/m 2 ≥30 kg/m 2 23.3 64.2 11.7 0.8 15.4 61.5 19.2 3.9 25.5 64.9 9.6 ns ns ns gestational weight gain <recommended = recommended > recommended 24.6 26.7 48.8 38.5 26.9 34.6 20.7 26.6 52.7 0.010 ns 0.020 smoking during pregnancy regularly occasionally no 16.1 21.8 62.1 37.9 10.3 51.8 9.5 25.3 65.2 0.001 0.002 ns per capita income lowest (0-125 euro) middle (126-250 euro) highest (>250 euro) 36.0 46.4 17.6 41.4 41.4 17.2 34.4 47.9 17.7 ns ns ns birth order 1 2-3 ≥4 52.4 41.2 6.4 41.4 41.4 17.2 55.8 41.1 3.1 0.050 ns 0.005 table 2. maternal characteristics correlated with normal birth-weight and low birth-weight (g) characteristics linear regression logistic regression all (n=250) low birth weight (n=58) normal birth weight (n=192) low birth weight p mean±se p mean±se p mean±se p or (95%ci) maternal age 25-29 ≤24 30-34 ≥35 3120±85 3219±69 3168±71 2790±127 ns ns 0.007 2297±45 2256±47 2361±43 1876±88 ns ns 0.001 3491±46 3318±62 3318±53 3312±71 ns ns 0.005 reference 0.22 (0.08-0.58) 0.50 (0.23-0.99) 1.19 (0.54-2,65) 0.001 0.048 0.600 pre-pregnancy bmi 18.5-24.9 <18.5 25.0-29.9 ≥30 * 3185±59 3124±72 2844±101 2400±0 ns 0.040 0.010 2149±90 2163±72 2296±45 2400±0 ns ns ns 3427±41 3284±56 3148±96 ns 0.001 reference 0.64 (0.27-1.48) 2.12 (1.02-4.03) 0.280 0.049 gestational weight gain = recommended <recommended > recommended 3158±84 2955±74 3191±66 0.020 ns 2300±44 2307±40 1971±146 ns 0.002 3347±64 3287±61 3402±46 ns ns reference 1.83 (1.04-3.08) 0.65 (0.30-1.41) 0.048 0.270 smoking during pregnancy no regularly occasionally 3192±60 2666±72 3162±66 0.001 ns 2065±92 2328±29 2333±58 0.030 ns 3437±40 3080±86 3265±58 0.001 0.001 reference 5.05 (2.41-10.58) 0.52 (0.20–1.32) 0.001 0.160 * only two children weighing 2400 g were born from mothers with bmi≥30. kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 7 table 2 shows that maternal age at delivery, gwg and smoking during pregnancy were significantly associated with lbw. mothers who smoked regularly had a significant fivefold increase in lbw risk compared with nonsmoking mothers (or=5.05, 95%ci=2.41-10.58, p=0.001). the association between bmi and lbw was evident among infants whose mothers’ were overweight (or=2.12, 95%ci=1.02=4.03, p=0.049). we did not assess obesity as a risk factor for lbw, because there were no mothers of children with normal birth weight who had a bmi≥30. the risk of lbw increased when gwg was less than the recommended value (or=1.83, 95%ci=1.043.08, p=0.048). age of the mothers upon delivery less than 24 years (or=0.22, 95%ci=0.080.58, p=0.001) and between 30-34 years (or=0.50, 95%ci=0.23-0.99, p=0.048) was found as a protective factor for lbw. table 3 shows the results of fitting a multiple linear regression model to describe the relationship between prematurity and three independent variables: pre-pregnancy bmi, gwg and maternal age. the model explains 93% of the variability in pb. the equation of the fitted model was as follows: pb = 87.6117*bmi + 41.0981*gwg + 9.6293*maternal age table 3. multiple regression analysis: pre-pregnancy bmi, gwg and maternal age correlated with premature birth dependent variable: premature birth parameter estimate standard error t statistic p pre-pregnancy bmi gestational weight gain maternal age 87.6117 41.0981 19.6293 12.4486 7.13523 8.4454 7.03787 5.75988 2.32426 0.001 0.001 0.021 analysis of variance source sum of squares df mean square f-ratio p-value model residual 2.30485e9 1.70403e8 3 235 7.68283e8 725119.0 1059.53 0.001 total 2.47525e9 238 r-squared = 93.1157 %; r-squared (adjusted for d.f.) = 93.0571 %; standard error of est. = 851.539; mean absolute error = 646.141; durbin-watson statistic = 1.04712. discussion this study provides useful evidence about pb and lbw in the region of pleven, bulgaria. our results indicate that pre-pregnancy bmi, gwg related with personal bmi and smoking during pregnancy are important characteristics for pb in this population. the age of the mother is essential for normal pregnancy and delivery with a favorable outcome. from a biological point of view, the best age for childbirth is 20-29 years (8). the average age of women in our study was 26.3±5.8 years which was non-significantly lower than the average age for childbirth established in bulgaria (27.9 years of age) (23) and also lower than that established by yankova and dimitrov (2010) who stated an average age of 28 years at birth (24). the results for more than a twofold increased risk of premature birth to mothers aged under 20 years were reported by branum and schoendorf in 2005 (25). the association between the risk of a preterm labor and mother’s age is reported to be inverse (21,26), but we did not establish this. we found the age of the mothers at delivery less than 34 years as a protective factor for lbw. kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 8 we did not find a significant difference between the mean weight of mothers of premature (55 kg) and to term infants (54 kg) before pregnancy. we found a more than two times higher risk for lbw among mothers with pre-pregnancy bmi 25.0-29.9 kg/m², but there was no effect found of pre-pregnancy bmi<18.5 kg/m². the results of our study are compatible with the findings of a recent meta-analysis on the existence of a weak association or lack of association between low bmi before pregnancy and the birth of a premature baby (27). according to our results, the probability of giving birth to a premature baby in women who have had gwg less than recommended is around two times higher compared with mothers with recommended gwg. the insufficient weight gain during pregnancy increases the risk of having a premature baby, especially amongst women with low bmi before pregnancy: rr=1.5-2.5 (27). our results are similar to those of schieve la et al. (2000), who found out a three times higher risk of giving birth to a premature baby in women with a normal bmi, but not enough weight gain during pregnancy compared with women of normal weight and with adequate weight gain during pregnancy (28). our results concerning smoking during pregnancy (around 40% of all mothers) are close to a previous study from bulgaria conducted by manolova (2004), which reported that about 42% of all women smoked during the whole pregnancy (20). yet, the proportion of smoking mothers in our study was higher than a previous study conducted in bulgaria in 2007, which reported a prevalence of 33% (23). smoking is regarded as one of the most common and preventable causes of poor pregnancy outcomes (17). there is variability in the reported results for the relationship between smoking and pb, but a large number of studies establish an rr=1.2-1.5 when daily consumption of cigarettes is 10-20, and an rr=1.5-2.0 when more than 20 cigarettes are smoked per day. the same results were obtained by andriani and kuo for smoking mothers who lived in urban areas (17). our survey revealed a greater than fivefold increase in the risk of lbw among mothers who smoked during pregnancy, a finding which is in line with previous reports about the influence of smoking on the pb risk (14,17). study limitations this study may have several limitations. firstly, reports of the characteristics of mothers were retrospective after the child was born. additionally, self-reported data on bmi, gwg and smoking are highly correlated with pb and lbw, but they tend to underestimate these measures. women who smoked were categorized into three groups based on qualitative variables, and not according to the number of cigarettes smoked per day. the dissemination of information on adverse outcomes of smoking may have discouraged some mothers from disclosing it. secondly, because the place of study was an urban area we did not find enough mothers less than 19 years old. the result was that we did not establish the association between young maternal age and pb. thirdly, we utilized the institute of medicine guidelines to categorize women’s weight gain as below, within, or above recommended value (22), which maybe is not appropriate for bulgaria, but there are no other recommendations to be used. finally, we excluded from the analysis some women with either missing information on the principal determinants of interest (age, bmi, gwg, smoking), or missing information on gestational age and birth weight (needed for outcome variables), but the number of missing values was small. kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 9 obviously, there is a need for prospective studies from the registration of the pregnancy, in pleven and in other regions of bulgaria, in which such data should be collected in a standardized manner and the number of mothers and their children should be higher. conclusion our results confirm our research hypothesis that pre-pregnancy bmi>25 kg/m², less than recommended gwg related with their personal bmi and smoking during pregnancy are risk factors for pb. age of the mothers at delivery <34 years was a protective factor for lbw. this analysis was part of a study on the risk factors for pb and their impact on development and health status of children <3 years in bulgaria. our findings highlight the public health importance of promoting a healthy lifestyle of mothers in order to reduce the level of pb in bulgaria. references 1. blencove h, cousens s, oestergaard m, chou d, moller ab, narwal r, et al. national, regional and worldwide estimates of preterm birth in the year 2010 with time trends for selected countries since 1990: a systematic analysis and implications. lancet 2012;379:2162-72. 2. wang h, liddell ca, coates mm, mooney md, levitz ce, 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kamburova et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed/?term=sijtsma%20a%5bauthor%5d&cauthor=true&cauthor_uid=24510962 http://www.ncbi.nlm.nih.gov/pubmed/?term=sauer%20pj%5bauthor%5d&cauthor=true&cauthor_uid=24510962 http://www.ncbi.nlm.nih.gov/pubmed/?term=land%20ja%5bauthor%5d&cauthor=true&cauthor_uid=24510962 http://www.ncbi.nlm.nih.gov/pubmed/?term=laopaiboon%20m%5bauthor%5d&cauthor=true&cauthor_uid=24641534 http://www.ncbi.nlm.nih.gov/pubmed/?term=lumbiganon%20p%5bauthor%5d&cauthor=true&cauthor_uid=24641534 http://www.ncbi.nlm.nih.gov/pubmed/?term=zhang%20j%5bauthor%5d&cauthor=true&cauthor_uid=24641534 arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 1 original research an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity luz arenas-monreal1, lilian e pacheco-magana1, celina rueda-neria1, josue carrilloestrada1, margarita marquez-serrano1, laura magana-valladares2, marta riverapasquel3 1 centre for research in health systems, national institute of public health, cuernavaca, méxico; 2 academic secretariat, national institute of public health, cuernavaca, méxico; 3 centre for research in nutrition and health, national institute of public health, cuernavaca, méxico. corresponding author: luz arenas-monreal address: ave universidad 655 santa maría ahuacatitlán, cuernavaca, morelos. méxico cp 62100; telephone: (777)3293000 (ext: 5223); e-mail: luz.arenas@insp.mx arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 2 abstract aim: to present the results of a community initiative focused on strengthening physical activity and the consumption of fruits, vegetables and natural water while discouraging the use of highly energetic food and sugary drinks in public schools of morelos. methods: a quasi-experimental study with an educational initiative focused on the school community of two primary schools and two junior high schools. preand-post initiative measurements were made. the study took place in the municipality of yautepec, morelos, mexico, in a rural area and an urban area, from august 2010 to july 2011. results: water consumption among school-aged children increased from 15.1% to 20.1% and soda consumption decreased from 21.4% to 13.2%. a slight increase in the consumption of fruits and vegetables was also measured (oranges, jicamas, bananas, tomatoes, prickly pear pads, lettuces), that are accessible in the region. it was found that the supply of fresh food is limited and that high energy density foods have an oversupply in both study areas. physical activity increased with actions such as football and dancing, in accordance with the baseline measurement. no changes were observed in the nutritional condition of school-aged children (n=150; 13.3% with overweight and 7.3% with emaciation), or in adults who presented a body mass index higher than normal, 60.2% to 88.4%. conclusion: in addition to educational activities, schools need to implement strategies to improve the access and availability of fresh foods while limiting the access of high energydensity foods. keywords: diet, educational initiative, mexico, nutritional condition, school-aged children. conflicts of interest: none. arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 3 introduction currently, the number of mexican children and adolescents with overweight and obesity (o/o) is a public health problem (1), which has increased in school-aged children aged from 5 to 11 years. according to the national nutrition survey (enn in spanish) in 1999, the increase was of 19.5%. the national survey of health and nutrition (ensanut in spanish) in 2006 reached 26%, and the ensanut 2012 went up to 34.4%, representing an increase of over 80% (1-3). the “health in the world 2002” report of the world health organization (who), has pointed out health risks in different continents. in latin america, addictions, blood pressure, low weight, together with overweight and obesity, represent one sixth of the morbidity burden. in this report, different cost-effective actions are mentioned to reduce the risks, such as decreasing salt and saturated fats intake to diminish the risks associated with cardiovascular diseases. it also states that one of the priority actions is to promote healthy environments for children (4). strategies for healthy communities and schools consider that cities, towns and schools are the most adequate spaces to promote healthy lifestyles for the entire population and specifically for school-aged children. since children and young people are in a formative stage of life, schools become an ideal place for educational initiatives, so that they can incorporate knowledge, skills and health practices that not only circumvent risk behaviours, but improve health (5). various studies report educational initiatives aimed at school-aged children in their educational atmosphere. some of these studies focus on increasing the knowledge of schoolaged children in relation to healthy food (6,7). there are also researches about school-aged children’s food intake preferences, which indicate that vegetables are not the food of their choice (8). other initiatives are aimed at increasing school-aged children consumption of fruits, vegetables and reduce the consumption of beverages and high-energy density products and increase physical activity (9-13). some authors mention that in the educational initiatives they have carried out, they focus on the entire school community (school-aged children, parents and teachers) in order to obtain better results and because parents and teachers help shape school-aged children behaviour (9-11). the objective of this manuscript is to present the results of an educational initiative focused on strengthening physical activity and the consumption of fruits, vegetables and natural water, while discouraging the intake of highly energetic food and sugary drinks in the school community of public schools in morelos, mexico. methods a quasi-experimental study through an educational initiative focused on the school community of elementary and junior high schools was implemented. previous and postinitiative measurements were made. the study was conducted in the municipality of yautepec, morelos, in a rural area and an urban area, from august 2010 to july 2011. we employed a convenience sampling (n=150 students and n=178 adults) across rural and urban areas, and applied a pre-post test design based on quantitative and qualitative data. the educational initiative was carried out with students of the 4th, 5th and 6th grades of elementary school, and the 1st, 2nd and 3rd grades of junior high school located within the localities. in addition to school-aged children, teachers, managers and administrative staff of the schools, arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 4 as well as parents were included in order to strengthen the changes proposed for school-aged children and make them sustainable (9-11). tools and techniques for data collection school-aged children the following measurements were taken at the beginning and at the end of the study: weight and height using a standardized anthropometric methodology (14). the weight was measured with an electronic scale (tanita brand, model 1583, tokyo, japan) with capacity of 140 kg and accuracy of 100g. height was measured using a wooden stadiometer with capacity of 2 meters and precision of 1 mm. the ages and dates of birth were provided by the school-aged children and corroborated by their teachers or mothers. anthropometric measurements were taken by the research team, which was previously trained according to standard techniques (15). the anthropometric indicators used to assess the nutritional condition of school-aged children were weight/height and height/age. length and weight data were transformed into zscores by using the who/anthroplus (16). a cut-off of -2.0 sd was used for classifying children as stunted based on individual height-for-age z-scores. a cut-off of +2 sd was used to classify children as overweight or obese, based on individual weight-forheightage-z-scores (bmi)-for-age, according to international standards, sexand agespecific. questionnaires applied at the beginning and at the end of the study included (17): i) dietary information: food frequency questionnaire (ffq). this questionnaire was taken from the school-aged children section of the 2006 national health and nutrition survey, which is validated and was applied in all the regions of mexico. the information was obtained using a 7-day semi-quantitative ffq. for each food item, the number of days of intake per week, times-a-day, portion size (very small, small, medium, large, and very large), and number of portions consumed were asked. the food groups were as follows: milk and dairy, fruits, vegetables, sugar sweetened beverages and sugar-free beverages, water and sweets and candy, as well as consumption of fruits and vegetables; ii) physical activity questionnaire for school-aged children. adults initially, measurements of weight, height and waist and hip circumferences were made. the applied technique was in agreement with lohman and martorell and standardization was according to habicht (6,7). weight and height were measured with the same instruments used with school-aged children. adults’ waist was measured at the midpoint between the lower rib and upper margin of the iliac crest; it was taken with a rigid tape brand “seca” with capacity of 2 meters and precision of 1mm. hip circumference was measured horizontally at the widest portion of the buttocks. the indicators used to assess the nutritional status of adults were the body mass index (bmi) and waist-to-hip ratio (whr) circumference index. the classification used to categorize the bmi was taken from the who standards (18), which identifies four categories: malnutrition (<18.5kg/m2) normal bmi (18.5 to 24.9kg/m2), overweight (25.0 to 29.9 kg/m2), and obesity (≥30.0kg/m2). the classification of the international diabetes federation was used as a reference for the waist circumferences, which defines as cut-off waist circumference of >80 cm for women and >90 cm for men (19). whr was calculated as waist circumference divided by the hip circumference, and a whr ≥0.90 in men or a whr ≥0.85 in women was classified as that representing abdominal obesity (20). arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 5 schools and communities in schools and communities there were carried out: i) observation guides for the ethnographic record; ii) guided focus-group interviews, and; iii) community mapping. arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 6 description of educational activities the educational initiative was based on the paulo freire’s empowerment education theory, which departs of the knowledge, practices and circumstances of the population involved, and secondly is enriched with theory (new knowledge), so that people can make changes in their environment later on (21-23). during the educational sessions with school-aged children, participatory and playful techniques were used to promote collective reflection. the sessions were coordinated by facilitators previously trained and lasted 50 minutes. overall, 15 sessions were held once a week, in each of the school grades (4th, 5th and 6th grades of elementary school and 1st, 2nd and 3rd grades of junior high school). the sessions were divided into two axes: diet and physical activity. under the first axis, the following topics were addressed: a) the healthy eating plate (24); b) the importance of eating fresh fruits and vegetables; c) drinking natural water; d) the damage caused to the human body by high energy density foods and sugary drinks; e) personal commitments to increase the intake of fruits, vegetables and natural water, and; f) actions within their family, school and community for healthy eating. for the second axis, the following topics were addressed: a) the importance of physical activity; b) the damage caused when being sedentary; c) personal commitments to carry out physical activity, and; d) actions within their family, school and community to perform physical activity. school-aged children carried out a series of activities (mural newspaper, school radio, health fairs, community tours, poster competitions, murals, sports tournaments and races within the school and their community) to spread their knowledge and make practical actions, both in their school and in their community. at the end of the educational sessions, a school committee was established in each school in order to address nutrition and physical activity issues. it also carried out advocacy actions with the schools’ directors and local authorities to improve the type of food and beverages that are offered within the educational institutions and the community, as well as various other actions to promote physical activity. workshops with parents were conducted in eight weekly sessions (two hours per week). with teachers and school staff, the workshops were held in four monthly sessions, where each session lasted five hours long. at the end of each workshop, the groups of parents and teachers made commitments to carry out actions aimed at improving diet and physical activity in various fields such as: personal, family, school and community. data analysis quantitative component: for the anthropometric analysis, anthropometric indexes based on the measurements of weight, height and age were used. the indicator used for children, adolescents and adults was the bmi. for the classification of children in various categories, bmi distributions were used as well as the criteria proposed by the international obesity task force (iotf). this system identifies specific bmi breakpoints for each age and gender. the anthroplus program and the stata v13 statistical package were used. univariate and bivariate analyses were obtained from the questionnaires’ data. measures of central tendency were used for numerical variables, whereas frequency distributions were used for categorical variables. percentages were analyzed and described at the beginning and at the end of the arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 7 initiative. the following statistical programs were used for the analysis: stata v13, excel 2007 and winepi. qualitative component: systematization of community mapping, ethnographic records and focus groups. results the analysis was performed with 159 school-aged children with complete questionnaire data: food intake frequency, anthropometry, socio-demographic characteristics, and physical activity (preand post-intervention). mean age was 12.3±1.9 years. anthropometric data were presented with 150 school-aged children. there were no substantial changes in the nutritional condition (table 1). table 1. school-aged children anthropometry: body mass index (bmi) by community according to gender (percentages) parameter rural urban total men women men women (n=150) (n=17) (n=19) (n=59) (n=55) overweight pre 13.3 17.7 21.1 6.8 16.4 post 13.3 17.7 15.8 11.9 12.7 obesity pre 1.3 5.9 0.0 1.7 0.0 post 2.0 5.9 0.0 1.7 1.8 emaciation pre 7.3 11.8 15.8 3.4 7.3 post 7.3 11.8 15.8 3.4 7.3 the mean bmi in the pre-intervention phase was 19.4±3.8, whereas in the post-intervention phase it was 20.5±4.0. it was found that most of the adult population was above the normal range of the bmi. in the rural community (n=121), it was found that bmi was between 60.2% (community groups) and 85% (parents) above the cut-off that is considered adequate. in the urban community (n=77), bmi ranged from 69.8% (community groups) and 91.7% (parents). the results for teachers in rural schools were: bmi above normal in 88% of them. in urban schools it was 57.1% above the normal bmi. in 87% of rural schools parents, a whr≥0.85 was found and 90.5% of them had a >80 cm waist circumference. parents in urban areas showed 83.3% whr ≥0.85 and a >80 cm waist circumference (data not shown). consumption changes of drinks, fruits, vegetables and highly energetic food natural water consumption increased (not significantly) in school-aged children (from 15.1% to 20.1%) in a 2-4 day range per week. soda consumption significantly decreased in schoolaged children who consumed it daily (from 21.4% to 13.2%) and significantly increased in those who never consumed it or did it once a week (from 8.2% to 9.4% for the first case and from 30.8% to 42.2% for the second case) (table 2). arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 8 the consumption for at least once a week of some fruits and vegetables, increased regarding products that are common in the area, or inexpensive in certain periods of the year (jicama, apples, pineapples, lettuces, prickly pear pads, cucumbers, squashes and chayote). the intake of oranges, mangos and melons increased from once a week to 2-4 times per week. there was no increase in the consumption of broccoli, cauliflower, cabbage or green beans (figures 1 and 2). no significant gender differences were found in the consumption analysis of water, soda, fruits and vegetables. table 2. beverages’ consumption of school-aged children per community according to intervention phase (percentages) type of beverage total rural urban pre post pre post pre post (n=159) (n=38) (n=121) natural water consumption per week never 3.8 0.6 7.9 0.0 2.4 0.8 1 day 13.8 10.7 21.1 7.9 11.6 11.6 from 2 to 4 days 15.1 20.1 7.9 29.0 17.4 17.4 from 5 to 6 days 15.1 15.7 7.9 18.4 17.4 14.9 7 days 50.9 51.0 52.6 42.1 50.4 53.7 did not answer 1.3 1.9 2.6 2.6 0.8 1.6 soda consumption per week never 8.2 9.4 2.6 10.5 9.9 9.1 1 day 30.8 42.2 42.1 42.1 27.3 42.1 from 2 to 4 days 30.8 23.9 34.2 34.2 29.8 20.7 from 5 to 6 days 8.8 11.3 5.3 7.9 9.9 12.4 7 days 21.4 13.2 15.8 5.3 23.1 15.7 the frequency of fried food consumption decreased slightly (81.2% vs. 79.3%), as well as the intake of industrial pastries. figure 1. school-aged children’s fruit consumption percentage per week days (n=159) arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 9 in schools, teachers promoted the accessibility of natural water for school-aged children, and also made modifications (increased the consumption of fresh food and decreased the intake of high energy density food) in the type of food offered to school-aged children. focus groups with school-aged children reported that they increased natural water and fruits intake. simultaneously, they pointed out that they decreased their sugary drinks and junk food intake. figure 2. school-aged children’ vegetables consumption percentage per week days (n=159) in addition, drinking natural water sweetened with fruits and the absence of soft drinks was observed in the ethnographic record of the rural community: 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 banana day 1 jicama day 1 mango day 1 mango days 2-4 30.8 28.3 34.0 29.6 35.2 37.7 38.4 p e r c e n t fruit/days pre post 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 tomato day 1 squash day 1 cucumber day 1 cucumber days 2-4 32.1 31.4 24.5 28.9 34.6 35.2 30.8 32.7 p e r c e n t vegetables/days pre post arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 10 “according to what was taught, did you do any changes?” –“i drink more water and eat more fruits”. –“we hardly eat junk food now”. –“i barely use valentina sauce and i add less sugar to my coffee or tea” (junior high school and rural elementary school focus group: 33-44). differences were observed in focus groups with teachers, who reported positive changes for the urban elementary school and the rural junior high school: –“did you notice any changes in the children?” –“no doubt there were changes in the children and the school in general. although, as you just said, only 4th, 5th and 6th graders participated in the educational activity, and now the children who were in 4th grade are in 6th grade. there were changes in the school: we no longer sell candy or soft drinks. there has been a change in the food that the school offers to students because of the advices and information that you gave us at the beginning of this project, along with the directions that have been implemented by the basic education institute of the state of morelos” (urban elementary school teachers’ focus group). in community mapping exercises of all groups, it was identified that there is a limited offer of fresh food, fruits and vegetables in both communities, while there is an oversupply of high energy density food and sugary drinks. physical activity and sedentary lifestyle the calculation results of the metabolic rate measurement units (met’s) of the students were as follows: mild met: mean (sd)=17.8±13.7, corresponding to cleaning, games, board games, chats, music, reading and working; moderate met: 18.2±20.2 corresponding to games or sports with a moderate wear out (skating, gym, swimming, riding bikes or motorcycles); vigorous met: 64.4±48.1 including high physical performance activities (soccer, basketball, dancing, running, tennis, and the like). weekly hours dedicated to each of the activities were as follows: mild activities: mean (sd): 6.3±5.2 hours; moderate activities: 3.96±5.1 hours; vigorous activities: 8.5±7.1. there was a significant increase in the school-aged children’s physical activity like playing soccer (14% vs. 27%), and dancing (3% vs. 7%), among other activities, regarding the baseline. sedentary activities decreased: the percentage of students who did not watch movies increased (from 23.9% to 30.8%), or played videogames (from 40.9% to 44.0%), and the hours per week children used to watch movies decreased from 6 to 7 hours per week (from 3.8% to 0.6%). discussion this study fostered changes in the eating habits of school-aged children, drinking natural water and eating more fruits and vegetables, while diminishing sedentary activities from the actions taken by the educational initiative. there were no significant changes between the two anthropometric measurements carried out at the beginning and at the end of the initiative, which happens to be consistent with a study carried out with schoolchildren in hawaii, who showed no significant changes between the measurements of bmi (25). bayer et al. have reported similar results in a longitudinal study arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 11 in which no significant changes were obtained in the bmi (26). in a literature review of research carried out in brazil, it was reported that there was an increase in the level of knowledge and food choices in school-aged children, but there were no changes in the nutritional status (27). it was found that parents and teachers have high percentages of o/o, similar to the percentage reported by ensanut in 2012. this aspect is relevant since it points out that one of the factors associated with school-aged children o/o is the high bmi of their parents (28). due to the above, it is important to incorporate parents and teachers into educational initiatives aimed at school-aged children so that dietary changes can be sustainable. in fact, the incorporation of parents and teachers has been reported in several studies (9-11), and in a study carried out in mexico, the integration of parents and teachers was recommended since the beginning of the study in order to obtain better results (29). the post educational initiative data showed an increase in water consumption and the elimination of sugary drinks at school, which is consistent with the findings of james et al. (30), who reported an increase in water consumption and a reduction of sugary drinks. other studies have reported an increase in healthy eating knowledge but without showing any changes in the nutritional condition, which is similar to the results of this research (6,31), but differs in that school-aged children made changes in their eating habits with the intake of fruits, vegetables and natural water, which was the main objective of the educational initiative. the results obtained in our study are similar to those reported in other studies (9,11-13). changes in the nutritional condition of school-aged children require the link between the educational initiative and structural social actions such as public policies addressing the type of food that is sold at schools and community environments, the production and manufacture of high-energy food and the strict regulations on food advertising aimed at this population. wijesinha-bettoni et al. have reported that, in mexico, educational and health authorities do not have strategies or actions to provide vegetables and fruits to school-age children in food programs carried out in schools (32). the information gathered from the teachers’ focus groups showed that they appreciated the changes in school-aged children involved with the educational initiative, as well as their commitment and concern for school’s diet, which is similar to what schetzina et al. have previously reported (33). sedentary activities dropped after the initiative, which coincides with veugelers et al. (34), and lawlor et al. (11), who reported similar results in their studies. the limitations of this study were: the educational initiative was targeted for the 4th, 5th and 6th graders; the implementation time was short and did not include another school for comparison. other limitations of this study are related to the context of schools and communities, since the supply of fruits and vegetables is low in contrast to the oversupply of products and drinks of high energy density, and there are no spaces to perform physical activity. due to the size of the population included in the study, the results cannot be extrapolated to other regions of the country. conclusions this study shows that, although moderate, it is possible to achieve a change in behaviour with a specific educational initiative. this study should be expanded to increase the number of arenas-monreal, pacheco-magana, rueda-neria, carrillo-estrada, marquez-serrano, magana-valladares, rivera-pasquel. an educational initiative for mexican school-aged children to promote the consumption of fruit, vegetables and physical activity (original research). seejph 2016, posted: 30 september 2016. doi: 10.4119/unibi/seejph-2016-130 12 educational sessions with school-aged children and with all members of the school community, to strengthen scientific evidence with diet and physical activity subjects that must be part of the school curriculum, to make progress on the health of this population group. educational activities that modify school-age children’s behaviours are not enough for reducing overweight and obesity. the implementation of diverse and simultaneous actions is needed, such as an increase in the supply access and availability of fresh and healthy foods. this is why the promotion of policies and regulations regarding the type of food and diet at schools and communities is essential. references 1. olaiz-fernández g, rivera-dommarco j, shamah-levy t rr, villalpandohernández s, hernández-ávila m, sepúlveda-amor j. encuesta nacional de salud y nutrición 2006. cuernavaca, méxico: instituto nacional de salud pública; 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(http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. thomas-reilly rg, tozija f, soltan v, nikovska dg, crudu v, atun r, mckee m. multidrug-resistant tuberculosis in moldova and the former yugoslav republic of macedonia: the importance of the overall governance of the health systems (original research). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-85 1 original research multidrug-resistant tuberculosis in moldova and the former yugoslav republic of macedonia: the importance of health system governance r. gregory thomas-reilly 1 , fimka tozija 2 , viorel soltan 3 , dance g. nikovska 2,4 , valeriu crudu 3,5 , rifat atun 6 , martin mckee 1 1 london school of hygiene & tropical medicine, london, united kingdom; 2 ss. cyril & methodius university, skopje, the former yugoslav republic of macedonia; 3 center for health policies & studies, chisinau, moldova; 4 ministry of health, republic of macedonia; 5 phthisiopneumology institute, chisinau, moldova; 6 harvard university, cambridge ma, usa. corresponding author: r. gregory thomas-reilly ba, bscn, mscpph, pgdip, phd; address: 331 st. patrick street, ottawa, ontario, canada, k1n 5k6; telephone: +1613-315-0900 ; email: greg.thomas-reilly@lshtm.ac.uk thomas-reilly rg, tozija f, soltan v, nikovska dg, crudu v, atun r, mckee m. multidrug-resistant tuberculosis in moldova and the former yugoslav republic of macedonia: the importance of the overall governance of the health systems (original research). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-85 2 abstract aim: multidrug-resistant tuberculosis (mdr-tb) arises where treatment is interrupted or inadequate, when patients are treated inappropriately, or when an individual has impaired immune function, which can lead to a rapid progression from infection with an mdr-strain to disease. this study examines the role of health systems in amplifying or preventing the development of mdr-tb. methods: we present two comparative studies, which were undertaken in the former yugoslav republic of macedonia (tfyr macedonia) and moldova. results: the findings reveal several health systems-level factors that contribute to the different rates of mdr-tb observed in these two countries, including: pre-existing burden of disease; organization of the health system, with the existence of parallel systems; power dynamics among policy makers and disease programmes; and the accountability & effectiveness of programme oversight. conclusions: the findings do not offer a universal template for health system reform but do identify specific factors that may be contributing to the epidemic and are worthy of further attention in the two countries. keywords: drug-resistance, europe, health systems, mdr-tb, moldova, the former yugoslav republic of macedonia, tuberculosis. conflicts of interest: none. acknowledgements: this study was funded by the global fund to fight aids, tb and malaria. rgt-r was supported by a graduate teaching fellowship from the london school of hygiene and tropical medicine. thomas-reilly rg, tozija f, soltan v, nikovska dg, crudu v, atun r, mckee m. multidrug-resistant tuberculosis in moldova and the former yugoslav republic of macedonia: the importance of the overall governance of the health systems (original research). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-85 3 introduction multi-drug resistant tuberculosis (mdr-tb) is now a major problem in parts of europe (1). resistance arises when treatment regimens are interrupted or inadequate or when treatment is blind to the sensitivity of infecting organisms, allowing bacilli resistant to a single drug to reproduce. these conditions are most often found where health systems are weak (2) or inappropriately designed (3), providing some treatment, but not in a way that ensures that it is taken appropriately. in this study we use a comparative case design to gain insights into why two otherwise similar countries, moldova and tfyr macedonia, differ significantly in their burdens of tb and patterns of drug-resistance (table 1). table 1. surveillance data from macedonia, moldova, and the european region in 2013 (source: european center for disease prevention and control) indicator macedonia moldova non-eu/eea european region new tb cases 346 4,203 194,913 success n (%) 298 (86.1) 3,205 (76.3) 146,404 (75.1) died n (%) 28 (8.1) 418 (9.9) 14,203 (7.3) failed n (%) 3 (0.9) 125 (3.0) 12,312 (6.3) lost to follow up n (%) 16 (4.6) 331 (7.9) 12,843 (6.6) not evaluated n (%) 1 (0.3) 124 (3.0) 9,151 (4.7) laboratory confirmed 188 2,695 117,802 drug sensitivity testing n (% of those confirmed) 179 (95.2) 2,317 (86.0) 108,746 (92.3) mdr-tb n (% of those confirmed) 1 (0.5) 912 (33.8) 33,686 (30.9) xdr-tb n (% of those confirmed) 0 35 (1.2) 393 (0.3) tb case notification rate / 100,000 population 15.3 144.8 12.7 the notification rate in moldova per 100,000 population is almost ten times higher than in macedonia, where it is only slightly higher than the non-eu/eea countries of europe. the treatment success rate is about ten percentage points higher in macedonia than moldova. a third of laboratory confirmed infections in moldova (n=912) in 2013 were multi-drug resistant (mdr), with only one case in macedonia. in the same year moldova had 35 cases that were extensively drug resistant (xdr), while macedonia had none. methods we undertook an in-depth comparative case study (4). data were triangulated from a range of sources including documentary evidence, such as statistical reports, action plans, and activity reports, and interviews with key informants. key informants were identified using theoretical and snowball sampling to obtain a broad range of insights and perspectives (5). interviews were semi-structured, including open-ended questions, and were recorded, with contemporaneous notes taken. interviews continued until data saturation was achieved. field notes were kept throughout the research. letters were sent to key informants outlining the purpose of the research. this sought to ensure “buy-in”, both at individual and organizational levels. an initial conceptual framework, based on a literature review, was developed to identify systems-level drivers of mdr-tb but then refined during the interviews. we interviewed 23 (100% response) informants in macedonia, and 20 (55.6% response, 11% declined or cancelled, 33% did not respond) in moldova. details of those interviewed are presented in table 2. however, data saturation was achieved in both countries, with no new thomas-reilly rg, tozija f, soltan v, nikovska dg, crudu v, atun r, mckee m. multidrug-resistant tuberculosis in moldova and the former yugoslav republic of macedonia: the importance of the overall governance of the health systems (original research). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-85 4 themes arising after about 15 interviews, although further clarification and factual information was obtained in subsequent interviews. the participants were equally open, reflective and critical in both countries. table 2. characteristics of those interviewed category macedonia (n=23) moldova (n=20) stewardship (leadership responsibilities within the health system) senior managers within the tb system vice-minister of health senior managers & directors from the ministry of health hospital directors former deputy minister of health senior administrators in the penitentiary health sector national health insurance fund government administrators / managers n= 10 n=10 service delivery (responsibility for service provision within the health system) tb physicians tb physicians hiv/aids physicians general physicians tb patronage & public health nurses tb patronage & public health nurses prison health care staff pharmacists n= 10 n=6 non-government (representatives from various non-government organisations, with a defined focus, work or interest in tb issues) non-governmental organization working with vulnerable populations community agencies working with prisoners global fund country office who country representative national physicians association academic specialist in public health n= 3 n=4 this study received approval from the ethics committee of the london school of hygiene & tropical medicine and from corresponding ethics committees in each country. informed consent was obtained from each participant, prior to the initiation of data collection. all information was made available to participants in their language of choice. results the results from each country were categorised into primary and secondary themes, according to the consistency with which respondents presented topics, the emphasis that they placed on them, and the differences observed between the two countries. the primary (emerging) themes were: (i) pre-existing burden of (tb) disease; (ii) organisation of the health system; (iii) existence of parallel health systems; (iv) degree of accountability and oversight exercised within the system; and (v) power and relationships. pre-existing burden of disease respondents felt strongly that the pre-existing burden of disease contributed to the current epidemiology. however, in the early 1990s, when each country achieved independence, incidence rates were very similar (6) (figure 1). another aspect related to disease burden, raised by some informants in moldova but not in tfyr macedonia, was migration. moldova has experienced large-scale labour migration to western europe and the former ussr. precise data are difficult to obtain because many moldovans are entitled to, or hold, either romanian, and hence european union nationality, or russian or ukrainian nationality. however, it is estimated that t he number of moldovan citizens living abroad is between 11 and 17% of those living in the country (7), but the figure is about a third for those of working thomas-reilly rg, tozija f, soltan v, nikovska dg, crudu v, atun r, mckee m. multidrug-resistant tuberculosis in moldova and the former yugoslav republic of macedonia: the importance of the overall governance of the health systems (original research). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-85 5 age (8). the challenges of controlling tb where there is large-scale labour migration, are well recognised (9,10). figure 1. trends in tb incidence in moldova and macedonia (source: world development indicators) health system organisation we define organisation as being related to the structure of health systems, from its leadership downwards. macedonia has a national health insurance system, overseen by the health insurance fund (hif). in recent years primary health care delivery has been privatized, and general practitioners are paid by a blended model of capitation and incentive payments (i.e. completing specified health examinations). general practitioners act as gate-keepers to the health system, and have become more important, particularly as the number of acute care beds has decreased (11). the national tb programme (ntp) in tfyr macedonia is coordinated centrally from the national tb institute. the ntp is the sole provider of tb services in the country, working through the national institute in the capital, skopje, but with affiliated regional hospitals and community dispensaries. the ntp also employs community nurses with responsibilities for directly observed community-based therapy. moldova also has a national health insurance programme. while less well established than in macedonia, moldova has moved toward a family practitioner model of primary health care. this said, a large stock of hospital beds remains (12), and hospital physicians exercise considerable influence on the health system. tuberculosis care in moldova is provided in several systems (e.g. prison, military and general health systems), although points of connection exist throughout. the ntp is coordinated by a manager at the phthisiopneumology institute in chisinau, the capital. services are delivered through municipal and national hospitals, along with local specialists and family physicians in the more rural parts of the country. 0 20 40 60 80 100 120 140 160 180 200 1990 1995 2000 2005 2010 in ci d e n ce /1 0 0 ,0 0 0 moldova macedonia, fyr thomas-reilly rg, tozija f, soltan v, nikovska dg, crudu v, atun r, mckee m. multidrug-resistant tuberculosis in moldova and the former yugoslav republic of macedonia: the importance of the overall governance of the health systems (original research). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-85 6 in macedonia informants spoke positively of the structure, management and clinicians within the ntp, while counterparts in moldova were critical, specifically of the structure and management of the ntp. those in moldova raised particular concerns about the current and future capacity of the ntp, given challenges experienced in recruiting and retaining qualified staff. as tb care is a separate specialty, informants felt that it is not attractive to new clinicians, given the inherent risks to practitioners and the confined scope of practice. this is in contrast to macedonia, where those providing tb care have transitioned to a broader medical specialization of respiratory medicine. as both countries have similarly structured ntps, criticisms raised in moldova would seem to reflect how the structure translates into service. on closer examination, informants in macedonia tended to personalise their praise of individuals within the ntp. in moldova, there was less personification and more reflection on the frequent transitions of individuals. moldovan informants also reflected on a disconnection between the ntp leadership and local practices and realities, particularly in rural areas. although informants framed their reflection as an organisational critique, what they were in reality commenting on was the capacity of individuals within the system to deliver the leadership and outcomes desired. parallel health systems there was a consistent narrative in both countries about challenges associated with parallel health systems. in macedonia these had been addressed by having all tb services provided through a single ntp, including those in the prison system, with prisoners referred to the general health system for treatment. in contrast, moldova has dedicated prison-based facilities for the treatment of tb, which fall within the prison directorate. while informants highlighted significant advances within the moldovan prison system, specifically in regard to the treatment of tb, there were concerns about the risk of losing individuals as they transfer into, or out of parallel systems. accountability and oversight in macedonia, informants felt that service providers were accountable for their actions, supported by training and oversight from the ntp managers. informants described substantial uniformity in care provided across the country, which they associated with the good outcomes observed. in moldova there was conflict between the hospital and community service providers. those in the acute care sector blamed the community service providers for lax practices, whilst their counterparts in the community highlighted a lack of awareness of the realities in communities, particularly in rural settings. those who are responsible for oversight of the ntp described limited capacity for monitoring and enforcing practice standards, which they believed contribute to variations in practice. power and relationships power dynamics are an important theme, although this emerged implicitly from the interviews rather than being raised explicitly. those in moldova described a persistent tension between acute care institutions and emerging community care service providers. they also spoke about the lack of consistent leadership, which arose from frequent leadership transitions, often due to changing political fortunes. in macedonia informants also described frequent political transitions, but these spared the management of the ntp, enabling institutional stability. macedonian informants further described cordial, if not pleasant working relations and communications with many of their colleagues across the country. thomas-reilly rg, tozija f, soltan v, nikovska dg, crudu v, atun r, mckee m. multidrug-resistant tuberculosis in moldova and the former yugoslav republic of macedonia: the importance of the overall governance of the health systems (original research). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-85 7 secondary themes in addition to the primary themes, several secondary ones were identified, which, while not necessarily differentiating the two countries, emerged from the literature as being of potential relevance and, in some cases, offered additional nuanced insights to their performance (table 3). these will be discussed briefly. table 3. case study themes theme macedonia moldova major themes organisation  x pre-existing burden of disease  x parallel health systems  x power  x accountability & oversight  x secondary themes political commitment   infrastructure x  historical trajectory x x institutional memory  x  positive factor  mixed x challenges political commitment: in both countries informants described a high degree of political commitment to tackling tb but, perhaps surprisingly, none believed that this had any influence on the tb programme. it could be that this was taken for granted and it would have attracted more comment if it had been lacking. however, there was also a degree of cynicism as many felt that the commitment was because of the external funding attached to it, as both countries were recipients of global fund grants at the time of the study. infrastructure: moldovan informants highlighted particular challenges in instituting uniform practices and standards in rural settings where there are difficulties recruiting and retaining health workers and where clinicians are overworked and largely disconnected from the broader health system, with its focus on larger policlinics and hospitals (13). from our observations, it was apparent that moldova was well-equipped in respect to the diagnostic capacity available, particularly in the reference laboratories. this is the direct result of capacity building funds offered by the global fund to fight aids, tuberculosis and malaria; united states agency for international development (usaid); world bank, and other donors. in contrast, macedonia did not have in-house access to high-technology equipment (e.g. polymerase chain reaction or pcr), but this seemed to have little impact on the overall system of care. this observation strengthens our initial hypothesis, in that the systems of care have a greater impact on outcomes than does technology. historical trajectory: one phenomenon that characterised moldova‟s early postindependence years was the growth of social inequality and breakdown of health services (14,15). this was exacerbated by a lack of management capacity in all post-soviet republics outside russia, in part consequent on the previously centralised system in the ussr (16). it thomas-reilly rg, tozija f, soltan v, nikovska dg, crudu v, atun r, mckee m. multidrug-resistant tuberculosis in moldova and the former yugoslav republic of macedonia: the importance of the overall governance of the health systems (original research). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-85 8 is plausible that some differences between former soviet and former yugoslav republics can be accounted for by the long history of decentralization in the latter (17,18). institutional memory: a loss of institutional memory may have played a role in moldova, with frequent leadership changes in the political realm impacting substantially on the ntp. this has ripple effects on the continuity of policy, programmes and funding, as staff operate within an environment facing continual change (19,20). discussion this study points to the importance of tackling not just the immediate causes of infection and resistance, but also the upstream factors, related to the way in which the health system is governed and organised. key factors emerging from this research are congruent with those reported from other countries, including the challenges when patients cross boundaries between parallel health systems, or from a well-developed acute care sector to the community (21-23); a lack of accountability and oversight for tb treatment (14,23); the challenges arising from a strong centralized hospital sector, with consequent power imbalances (14,2426); and the challenges of recruiting and retaining health staff in rural areas (16). consistent with the now extensive body of research on how some countries achieve good outcomes at low cost (27), we see that there is no single reason why macedonia gets better outcomes than moldova. these other studies have failed to find a single „magic bullet‟, but have identified several factors that increase the likelihood of success, such as effective governance systems and institutional continuity, both present in macedonia, but weak in moldova. informants praised leaders in macedonia, but those in moldova were seen as weak, and afflicted by frequent changes. fragmentation was a key issue, with moldova unable to integrate prison care, contrary to what was done in macedonia. this creates inevitable problems as there are well known challenges in enforcing uniform standards across multiple systems of care (28). the risk of losing patients to follow-up in such circumstances, particularly for people who are vulnerable or marginalized, is ever present (29). prison health systems are a neglected political priority globally, and often provide substandard care compared with mainstream health systems (30). this being said, the moldovan prison system is not entirely separate, maintaining some connections, as is usual in countries with parallel systems (31). weak governance can also be inferred from the problematic relationships between different providers in moldova. this study has a number of limitations. the most obvious is attribution. while it is possible to infer certain relationships between observed characteristics of the two health systems and health outcomes, it is not possible, in a non-experimental study, to determine cause and effect. however, the associations observed, with weak governance, lack of institutional stability, and the existence of parallel health systems being seen in the country with the higher burden, and not in the one with less mdr-tb, is both plausible and consistent with the evidence on health systems performance more generally. the second is that, although the two countries have many similarities, they are not identical and have different historical legacies, and policies take place in different political, social, and economic contexts. these are likely, at least to some extent, to explain the differences in governance systems. notwithstanding these limitations, this study does add to the sparse literature on the association between health systems and the development of mdr-tb and points to the need to address the overall governance of the health system, as well as more downstream measures such as the promotion of rational prescribing. thomas-reilly rg, tozija f, soltan v, nikovska dg, crudu v, atun r, mckee m. multidrug-resistant tuberculosis in moldova and the former yugoslav republic of macedonia: the importance of the overall governance of the health systems (original research). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-85 9 references 1. world health organization. anti-tuberculosis drug resistance in the world. geneva, 1997. 2. coker 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http://www.ncbi.nlm.nih.gov/pubmed/?term=dash%20u%5bauthor%5d&cauthor=true&cauthor_uid=23574803 http://www.ncbi.nlm.nih.gov/pubmed/?term=crudu%20v%5bauthor%5d&cauthor=true&cauthor_uid=23407226 http://www.ncbi.nlm.nih.gov/pubmed/?term=galusca%20i%5bauthor%5d&cauthor=true&cauthor_uid=23407226 http://www.ncbi.nlm.nih.gov/pubmed/?term=soltan%20v%5bauthor%5d&cauthor=true&cauthor_uid=23407226 http://www.ncbi.nlm.nih.gov/pubmed/?term=cohen%20t%5bauthor%5d&cauthor=true&cauthor_uid=23407226 http://www.ncbi.nlm.nih.gov/pubmed/?term=international+journal+of+tuberculosis+and+lung+disease+2013%3b+17%283%29%3a+373-80 http://www.ncbi.nlm.nih.gov/pubmed/?term=30.%09stuckler+d%2c+basu+s%2c+mckee+m%2c+king+l kragelj a, pahor m, zaletel-kragelj l, makivić i. learning needs assessment among professional workers in community mental health centres in slovenia: study protocol (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5478 p a g e 1 | 11 original research learning needs assessment among professional workers in community mental health centres in slovenia: study protocol anja kragelj1, majda pahor2, lijana zaletel-kragelj1,3, irena makivic1 1 national institute of public health, ljubljana, slovenia 2 faculty of health sciences, university of ljubljana, ljubljana, slovenia (retired) 3 chair of public health, faculty of medicine, university of ljubljana, ljubljana, slovenia corresponding author: lijana zaletel-kragelj faculty of medicine, university of ljubljana chair of public health zaloska 4, 1000 ljubljana, slovenia phone: + 386 1 543 75 40; fax: + 386 1 543 75 41 e-mail: lijana.zaletel-kragelj@mf.uni-lj.si kragelj a, pahor m, zaletel-kragelj l, makivić i. learning needs assessment among professional workers in community mental health centres in slovenia: study protocol (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5478 p a g e 2 | 11 abstract aim: this article aims to present a study protocol that represents a tool developed for a learning needs assessment. with a pilot study, based on the presented concept of a model study, we will be able to assess what mental health learning content is not yet part of formal higher education for professionals working in community mental health centres, but has been identified as necessary for inclusion. the presented tool is transferable with appropriate modifications. the goal is to conduct multiple research with the same basic tool at all levels of the educational system and in continuing professional education for all professionals who work with people. methods: the learning needs assessment study protocol presented uses both quantitative and qualitative research approaches. it is expected that the research will be conducted in several interrelated phases that holistically cover the needs assessment process. results: the pilot study will provide insight into the advantages and disadvantages of the prepared learning needs assessment tool. through the research study, the learning needs of professionals working in community mental health centres, will be identified. conclusion: professional mental health care workers must be equipped with the necessary knowledge, skills, attitudes, and values to perform their work with quality. by implementing appropriate mental health learning content in educational processes from pre-school education to higher education and further to continuing professional education, we can impact the mental health of the entire population. since this can lead to acquiring the competencies necessary to care of one’s own mental health and that of others, it can be considered an important public health intervention. keywords: needs assessment, mental health, educational programmes source of funding none declared acknowledgements the authors gratefully acknowledge maja dizdarevic, vera grebenc, kaja krajc, vesna svab, matej vinko and nika vuksa jurejevcic for their invaluable contribution when creating the methodological document. conflict of interest none declared. kragelj a, pahor m, zaletel-kragelj l, makivić i. learning needs assessment among professional workers in community mental health centres in slovenia: study protocol (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5478 p a g e 3 | 11 introduction mental disorders are one of the major public health problems. according to the world health organization (who), regional office for europe, they are one of the major public health challenges in the who european region (1). the who data for 2015 showed that mental disorders are the leading cause in terms of disability (years lived with disability ylds) and the third leading cause in terms of premature mortality and disability (disability adjusted life years dalys) (1). a similar picture is shown by the global burden of disease study (gbds) database for the year 2019 as well (second leading cause in terms of ylds, and fourth leading cause in terms of dalys) (2,3), even excluding substance use disorders and selfharm (4). moreover, the classification of alzheimer's disease, which is considered a neurological disorder in available databases, is also blurred. due to its expression in terms of mental changes, it can also be considered as a mental disorder (5-7). also, historically dementia was treated within psychiatric services because of its mental manifestations (6). therefore, the burden of disease (bod) of this group of health phenomena is often underestimated (4). in slovenia, the bod of mental disorders is highest in terms of ylds (12.3%), and it is even much higher when substance use disorders, self-harm, alzheimer disease and other dementias are included (17.5% of the total bod) (8). in 2018, slovenia adopted the resolution on the national mental health programme 2018-2028 (rnpdz), a document that defines the strategy for action in the field of mental health (9). one of the priority areas is “education, research, monitoring and evaluation” (9). an important goal of this priority area is to provide learning content about mental health in educational programmes (eps) at different levels of the educational system and in continuing professional education for all professionals who work with people (health care, social and family care, education, justice and law enforcement) (9). in order to optimally integrate learning content into educational processes, it is first necessary to assess the needs in this area. to achieve this goal, a methodological document was prepared with the design of multiple research to assess the needs for the inclusion of learning content on mental health (in short, learning needs) at different levels of the educational system and in the field of continuing professional education (10). the need reflects the gap between the current situation regarding the inclusion of learning content in educational processes and the state we want to achieve (figure 1). figure 1 also represents the targeted state, which is determined when content that is important for implementation is recognized. the methodological document presents in more detail the design of the model study, which is, after further development of the concept, presented further on. a pilot study will be conducted to test and complement currently existing phases, steps and procedures within the prepared tool. in the model study, the learning needs of professionals working in community mental health centres (cmhcs) will be assessed, based on the competencies (referring to their components such as knowledge, skills, values and attitudes (11)) they need to perform high-quality work. cmhcs are special units that address population mental health at the primary level of the health care system. their establishment has begun with the rnpdz implementation (9). cmhcs for children and adolescents provide treatment for the population aged 0-19 years, while cmhcs for adults provide care for those over 19 years of age (9). cmhc for adults consists of two teams, the regional outpatient treatment team and the regional community psychiatric treatment team (9). table 1 shows the structure of professional staff working in cmhcs (12). kragelj a, pahor m, zaletel-kragelj l, makivić i. learning needs assessment among professional workers in community mental health centres in slovenia: study protocol (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5478 p a g e 4 | 11 figure 1. relationship between need, current state, desired state and targeted state in relation to the inclusion of mental health learning content in educational processes. table 1. profiles of professionals in community mental health centres (cmhcs) in slovenia (12). cmhc for children and adolescents cmhc for adults the regional outpatient team the regional community psychiatric treatment team  physician, specialist in child and adolescent psychiatry  psychologist, specialist in clinical psychology  psychologist  special pedagogue  speech-language pathologist  speech-language pathologist, specialist in clinical speechlanguage pathology  occupational therapist  social worker  registered nurse  physician, specialist in psychiatry  psychologist, specialist in clinical psychology  psychologist  social worker  registered nurse  physician, specialist in psychiatry  psychologist, specialist in clinical psychology  occupational therapist  social worker  registered nurse design and methods research framework and design purpose and objectives the purpose of the model study is to find out if there exist a need to include learning content, identified as missing, from the field of mental health in eps for professionals working in cmhcs. the objectives of the model study are: a) to review already conducted research and findings on the topic that will be investigated; b) to assess the current state and analyse what mental health learning content already exists in formal eps for professionals working in cmhcs, to assess the desired state considering the perspective of users and professionals, and afterwards to identify the learning needs by comparing the current and desired state; c) to explore examples of good practices from slovenia or abroad, and d) through the consensus process based on the identified learning needs and the examples of good practice, to identify the target state the state, that needs to be achieved. the phases and steps to achieve the listed objectives are described below. research design both quantitative and qualitative research approaches will be used. the research will be conducted in several interrelated phases, as shown in figure 2. kragelj a, pahor m, zaletel-kragelj l, makivić i. learning needs assessment among professional workers in community mental health centres in slovenia: study protocol (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5478 p a g e 5 | 11 figure 2. schematic representation of the phases of the model study that focuses on learning needs assessment among professional workers in community mental health centres in slovenia. methods by phases phase 1 in the first phase of the model study, we will conduct a scoping review. we are interested in research and findings that focus on assessing the learning needs of mental health professionals who are also part of cmhc teams. phase 2 the identification of learning needs or the analysis of the gap between the current state and the desired state will take place in three segments (analysis of the current state, desired state and comparison between them), and within this in several steps. a) analysis of the current state: in order to assess what competencies professionals in cmhcs can acquire before they start working, we will first review the formal higher eps intended for educating these professionals. we will review first cycle (bachelor’s), second cycle (master’s), second cycle integrated master’s degree programmes and educational programmes within specializations. through document analysis, we will identify courses with mental health content and corresponding credit points. this will be followed by a detailed review of the content of the identified courses and an analysis of the learning outcomes, objectives, and competencies expected and described in the syllabus. in the second step, we will explore the experience of recent graduate students with the content identified in the first step. we will explore their experiences using a questionnaire with closed and open-ended questions. if there will be a need for an indepth assessment of the current situation based on the experiences of graduates, additional interviews or focus groups will be conducted. b) analysis of the desired state: kragelj a, pahor m, zaletel-kragelj l, makivić i. learning needs assessment among professional workers in community mental health centres in slovenia: study protocol (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5478 p a g e 6 | 11 in the first part of the first step, we will learn the perspective of professionals, who have been employed at cmhc for at least one year, on the competencies required for their work. focus groups will be conducted. in the second part of the first step, we will learn the users’ perspective on the competencies, that professionals need for their work (focusing on the interpersonal aspect). by choosing a method of data collection through semi-structured individual interviews, we want to prevent users from refusing to participate due to withdrawal from possible stigmatisation of mental conditions. individual interviews also reach those who do not wish to participate in the group for other reasons. interviews will be conducted with adult patients in cmhcs (both outpatient and community psychiatric treatment), their relatives and parents or guardians of children and adolescents. in the second step, using the nominal group technique, the participating experts will reach consensus on the desired state based on the perspective of the users and the perspective of the professionals. c) by comparing the results of the analysis of the current state and desired state, we will identify the learning needs. phase 3 in this phase, we will search for examples of good practice (from slovenia or abroad) and review appropriate existing formal eps for the education of mental health professionals, ideally in the form of multiple case study. we will collect data through document analysis. in the eps, we will identify courses with mental health content and extract the learning outcomes, learning objectives and competencies related to mental health. phase 4 based on the identified learning needs and the analysis of good practices, starting points for the application of the delphi method will be prepared. the delphi method will be used to reach a consensus on the targeted state, i.e., what content (ranked in order of importance) is needed to address the identified gaps in eps. the delphi method involves various stakeholders who can either contribute to the implementation of the identified content in formal eps (leaders of the eps), are representatives of the professional staff working at cmhcs (and at this point are the users of the “services” of the educational system), or are representatives of policy or decision-makers. ethical considerations to gain a comprehensive view of the competencies that professionals working in cmhcs need for their work, we will include different groups of participants. based on patient participation, the protocol will be submitted to the national medical ethics committee for review. discussion the protocol presented enables the identification of the learning needs of professionals working in cmhcs. the complex design of the study enables the identification of needs based on the personal experiences of professionals working in the field. however, by comparing the experiences of professionals with those reported by users, we can also identify learning needs that professionals may not be aware of. some of the learning needs may be outside the awareness of those for whom eps are or will be created – so-called unperceived learning needs (13). the experiences of the users, i.e. those for whom the professionals do their work, are thus an added value. indepth insight into the needs is only possible with a combination of quantitative and qualitative approaches, and in order to know and understand the experiences thoroughly, the protocol gives priority to the latter.the study protocol has its advantages and kragelj a, pahor m, zaletel-kragelj l, makivić i. learning needs assessment among professional workers in community mental health centres in slovenia: study protocol (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5478 p a g e 7 | 11 disadvantages, which can be reduced or eliminated by further developing the protocol after the pilot testing. first of all, we emphasise the fact that the protocol focuses only on formal forms of education as a source of competencies. formal education enables to obtain formally endorsed educational results through participation in eps (14). formal education provides the foundation from which experts acquire the necessary competencies to successfully perform their work, so we have taken this form of education as the base from which to begin exploring their learning needs. education is an organised, structured, systematic and goaloriented process (15,16), but education is only one of ways in which learning can be carried out (15). learning is any activity by which a person changes and is ongoing (17), including through incidental everyday experiences (16). professionals acquire their competencies from various sources, including non-formal forms of education or through informal learning, which includes activities that are not planned as educational (e.g. exhibitions) but imply learning (16). therefore, in the future it might be necessary to pay attention to other sources from which individuals draw their knowledge, skills and attitudes. furthermore, we would like to point to the emergence of a hidden curriculum, which explains that a person involved in the educational process does not only learn what is clearly defined in the official curriculum (18). norms, values, implicit beliefs and attitudes (19,20) can be transmitted in this hidden way. the impact of education comes from the interaction between teachers and students (18), they influence each other not only by what they do but by who they are (21). in a broader sense, life in the educational organization as a whole has its effects (18). with the phenomenon of the hidden curriculum, we could explain why changes to the official curriculum sometimes do not bring the desired results, as everyday experiences have more power than planned learning content (19). the final limitation of the study protocol presented could be that we are studying eps that are currently in use, but some of the representatives of the professionals included in the focus groups were educated according to programmes that are no longer in use. professional workers that will participate in the focus groups will share their experiences of working in cmhcs and their opinions about existing or lacking competencies they will express what they need to do quality work, but they will not be expected to pass judgement on ep that they have participated in the past. since we can only upgrade eps that are currently in use, we will compare their perspective (and users' perspective) with the learning content in the current programmes. this protocol also has important strengths. firstly, with it, slovenia has prepared a plan for the implementation of an important national survey that can be undertaken as soon as the funds are available for its implementation. secondly, experts from different fields came together to draft the protocol. this multi-professional approach ensures a high degree of coherence between the different professional fields involved in the protection of the mental health of the population. in addition, various stakeholders who are in some way connected with the education of professionals will be involved in the research. in this context, we would like to highlight the involvement of users. the importance of involving health and social service users in research is internationally recognized (22). this is because users know what it is like to be in their shoes (23) and can contribute with their views from a perspective that is different from that of the researchers. this has been found to be a positive contribution to both the research and the researchers, as well as to the users involved in the research (22,23). therefore, users should also be involved in planning and kragelj a, pahor m, zaletel-kragelj l, makivić i. learning needs assessment among professional workers in community mental health centres in slovenia: study protocol (original research). seejph 2022, posted: 21 may 2022. doi: 10.11576/seejph-5478 p a g e 8 | 11 conducting the research and in interpreting the results (23-25). in addition, the prepared protocol provides a basic research tool that can be transferred and used (with appropriate adaptations) in the design of research assessing learning needs at all levels of the educational system (from pre-school education through basic education and upper secondary education to higher and shortcycle higher vocational education) and in other forms of education (e.g. non-formal education). in this way, it will be possible to find out in a methodologically harmonised way where we currently stand in terms of the inclusion of mental health content in different educational settings and what we are missing to achieve the identified and necessary goals. the ultimate goal is a person equipped with adequate competencies not only to do professional work in the field of mental health care but also to take care of their own mental health and that of fellow human beings in the community in which they live. given that most countries in south eastern europe region have historically had similar foundations in health and educational systems, the protocol may also be relevant and very helpful in planning a similar study to the one planned in slovenia. it could also serve many european countries that are facing similar mental health issues or are in the process of reforming the mental health system similar to slovenia. the final outcome of the model study will be the list of learning content, identified by consensus of different stakeholders as important to be covered in the education of professionals working in cmhcs. the wish is that the content will be implemented according to the priority list, but the latter will no longer be the subject of research, but the effort will be in the hands of those who will lead the implementation (either at policy level or at university and faculty level). the aim is to include missing content in already existing formal eps. at the same time, we are aware that despite the efforts of those in charge, changing the programmes is not an easy process and will take time. achieving this goal will be urgent in the event of a large discrepancy between the learning outcomes that are the result of current educational processes and the competencies that are actually needed by professionals in the labour market. the necessary changes can be made in a shorter time by implementing content in formal or non-formal in-service training for professionals in cmhcs. the design of the model study presented is only the first step of a large scale-up process. conducting a pilot study based on a model study protocol will provide insight into the advantages and disadvantages of the tool used to assess learning needs. the ultimate goal is to conduct multiple research with the same basic tool at all levels of the educational system and in continuing professional education for all professional groups working with people. we see the educational system and its upgrading through the inclusion of appropriate mental health learning content in educational processes as an important factor that can impact the mental health of the whole population. therefore, we see the implementation of these multiple research, the concepts of which are presented in the methodological document (10), as a kind of public health intervention that can lead to acquiring the necessary competencies for taking care of the mental health of oneself and others, and thus influencing the mental health of individuals and, ultimately, of society. the role of public health professionals in the communication processes between different stakeholders that can enable the implementation of the necessary learning content will be pivotal (26). conclusion we presented a study protocol to assess what mental health learning content is not yet part kragelj a, pahor m, zaletel-kragelj l, makivić i. learning needs 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no.3):4684. doi:10.11576/seejph4684. ________________________________________________________________ © 2022 , zaletel-kragelj et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 1 | 23 original research health behavior, stress and obesity among working age women in myanmar win mya mya htut1, kittipong sornlom1, wongsa loahasiriwong1 1 faculty of public health, khon kaen university, thailand. corresponding author: dr. kittipong sornlom; address: faculty of public health, khon kaen university, thailand; telephone: +66-0850020225l; email: kittsorn@kku.ac.th htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 2 | 23 abstract aim: this study aimed to determine the prevalence of overweight and obesity and to investigate the association between socioeconomic factors, health behaviors, health literacy, knowledge, attitude, physical and mental health status, and overweight and obesity among working age women in myanmar . methods: a cross-sectional study was conducted among 1,094 women aged 18 to 59 years old who were recruited by using multistage random sampling from 12 townships out of 6 districts among three states/regions. a structured questionnaire was developed and applied to assess the prevalence of overweight and obesity. generalized linear mixed model (glmm) was performed to determine the association between dependent and independent variables after controlling the effects of covariates presenting adjusted or and 95% confidence interval. results: more than half of the respondents were with overweight and obesity (51.28%; 95%ci: 48.31-54.23). the multivariable analysis indicated that factors significantly associated with overweight and obesity included; aged 31-59 years (adjusted odds ratio (aor) = 1.72, 95%ci:1.222.40), living without family (aor= 2.07, 95%ci:1.20-3.57), average monthly income ≥200,000mmk (aor= 1.38, 95%ci:1.05-1.82), parity≥1 (aor= 1.61, 95%ci: 1.172.23), high fat & protein consumption ≥5-days per week (aor= 2.90, 95%ci:1.91-4.39), alcohol consumption (aor= 2.53, 95%ci:1.91-3.36) and moderate-severe stress (aor= 1.47, 95%ci:1.11-1.94). conclusion: more than half of working age women were with overweight and obesity. socioeconomic status, health behavior and stress are the factors behind over nutrition. the findings provide relevant evidence to develop the appropriate policies and public health interventions in order to minimize the burden of overweight and obesity. likewise, it is anticipated that this outcome would support the prevention of cardiovascular and other chronic diseases. keywords: alcohol consumption, generalized linear mixed model, myanmar, overweight and obesity. conflicts of interest: none declared. ethical consideration: ethical consideration was taken from khon kaen university ethics committee in human research (the approval number, he632117) and department of medical research, yangon, myanmar (approval number ethics/dmr/2020/109). a coding scheme was used and every document was destroyed on completion of research. written consent was obtained from all participants prior to participation. acknowledgement: the authors would like to express our sincere appreciation to all working age women in study areas for the data collection. special thanks to the faculty of public health, khon kaen university, thailand for the financial and technical support. htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 3 | 23 introduction globally, the prevalence of overweight and obesity have risen to nearly threefold since 1975 and as a result, more than 1.9 billion adults were overweight and over 650 million were obese (1). moreover, in the low-and middle-income countries, over 115 million people are suffering from obesity related problems including non-communicable diseases (ncds) like coronary heart disease, ischemic stroke, hypertension, diabetes mellitus and certain cancers such as endometrial carcinoma, colon cancer and breast cancer (2,3). among the various risk factors responsible for the ncds, obesity has been considered as one of the major risk factors (2,4). myanmar is among the 23 countries with high burden of ncds (4). as a result of epidemiological and socioeconomic transition in the last few decades, ncds have emerged as main public health issues in myanmar. therefore, it is now facing double burden of diseases (5,6). moreover, women are highly affected by overweight and obesity as compared to men (7). evidence shows that the prevalence of overweight and obesity is in increasing trend in myanmar, particularly among women. the trend of overweight among women in myanmar has been raised from 22% to 28.1% and obese women from 8.4% to 13.1% during the period between 2009 and 2015 (6,8). overweight and obesity have wide-range of genetic, socio-economic and behavioral factors, which consist of those who are women, urban residents, having high income, have low education, consuming high sugar daily, having deep fried foods, snacks, fatty foods, low fruits and vegetable intake, low physical activity, high stress and low health literacy level (8-15). while the general risk factors for overweight and obesity are known, the magnitude and strength of association of the factors and their significance may vary depending on socioeconomic background, ethnic groups and the place where they reside (i.e. townships/states and regions). hence, this study was conducted to assess the prevalence and the influence of socioeconomic factors, health behaviors, health literacy, knowledge, attitude, physical and mental health status on overweight and obesity among working age women (18-59 years) in mandalay region, shan state and mon state. methods study population a cross-sectional study was conducted in 2020. the study population was working age women aged 18-59 years old in mandalay region, shan state and mon state of myanmar. the sample size was calculated by using the sample size estimation formula for the logistic regression analysis of hsieh by taking references of previous study done on socio-demographic factors and overweight and obesity in india, which showed 63% proportion of overweight and obesity among those who had family history of ncd with 95% confidence interval and a margin error of 5% (16,17). so, the estimated sample size was 1,094. firstly, mandalay region, shan state and mon state were randomly selected from 15 states and regions. after that, two districts of each state/region were randomly selected from 4 states/regions and then two townships were randomly selected from each district. finally, one community was randomly selected from each township. then, simple random sampling method was applied to select 1,094 individuals on the basis of proportionate to size of the population (pps). the inclusion criteria of the respondents were: women living in the study area for at least one year, women of working age (18-59 years) and willing to participate in the study. the exclusion criteria were pregnant women, lactating women, physically and mentally ill women. the participants were requested to answer a structured questionnaire followed by interview and anthropometric measurements by trained interviewers. data collection a structured questionnaire was developed based on the research questions and relevant htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 4 | 23 literature. the questionnaire consisted of seven parts: demographic and socioeconomic characteristics; health behavior; health literacy; knowledge; attitude; physical health status; and mental health status. the questionnaires had been verified for content validation by 5 experts and revised to improve the validity. moreover, the questionnaire was tested for reliability by calculating cronbach’s alpha among 30 participants in another region. the cronbach’s alpha coefficient was 0.857. measurement of outcome: body height in centimeters (cm) and weight in kilograms (kg) were measured by using metering object and digital weighing instruments. overweight and obesity defined as bmi ≥23 kg/m2 by who (18) for asian cut-off points was the main outcome of the study. the respondents were asked to sign the written consent form if they were willing to participate in the study after obtaining ethical clearance and approval from the office of the khon kaen university ethics committee in human research (reference no. he632117). all confidentiality of data was fully assured. a structured questionnaire interview was conducted to collect the data from 1,094 respondents by 5 experienced interviewers who were trained and standardized for data collection skills. statistical analysis stata version 14 (college station, texas, usa) was used for analysis. the categorical data were presented as frequency and percentage, whereas, the continuous data as mean standard deviation, median and range. glmm was operated to model the random effects and correlations inside clusters. in the modeling, the residential area/township was set as the random effect. bivariate analysis was performed to define the association of each independent variable with overweight and obesity. the variables were significant in the bivariate analysis with p-value <0.05 were proceeded for multivariate analysis. results in the final model defined the magnitude of association with independent variables and overweight and obesity with an aor and its 95% ci. glmm was performed to control the clustering effects. results among the total of 1,094 respondents, about one third of them were in the age between 1829 years and almost all of them were buddhists (85.19%), most of the respondents were married (59.51%), 35.19% were dependent, and 39.49% had completed high school level education. the median of family size was 4 persons and 55.85% of women lived with a spouse. the median monthly income and expenditure were 150,000mmk and 100,000mmk respectively; however, 47.54% of women had enough saving and nearly half of women (44.15%) had 1-2 parity. the study revealed that 52.92% of participants did not consume fast food. however, women consuming fast food and sugar-sweetened beverage 1-4 days per week were 40.86% and 56.58% respectively. women who did vigorous-intensity activity during recreation <5 days and ≥5 days per week were53 . 9 3 % and 7.77% respectively. women who did and moderate-intensity activity during recreation <5 days and ≥ 5 d a y s per week were 53.02% and 14.17% respectively. only 8.14% were current smoker, 12.98% were current alcohol consumers, and 15.08% were current betel chewers. about one third (33.18%) of participants had sufficient to excellent health literacy however, the respondents with problematic and inadequate health literacy were 18.55% and 48.27% respectively. more than half of them had good general knowledge (64.44%) but only 0.09% had good attitudes. of the study participants, currently 92.41% of women had good health status, 68.83% did not have family history of overweight and obesity and 27.63% used contraception. more than half (61.33%) of them had moderate stress and 50.82% of women had mild depression (table 1). as high as 31.63% of the working age women were obese and 19.65 % were overweight. less than half were normal weight (44.70%) and only 4.02% were underweight (table 2). htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 5 | 23 table 1. the characteristics of respondents characteristics frequency (n) percentage (%) state/region mandalay 399 36.47 shan 330 30.16 mon 365 33.36 district ya mae thinn 189 17.28 meiktila 210 19.20 taunggyi 197 18.01 loilem 133 12.16 mawlamyaing 171 15.63 thaton 194 17.73 socio-economic status age 18-29 344 31.44 30-30 274 25.05 40-49 257 23.49 50-59 219 20.02 religion none 24 2.19 buddhism 932 85.19 christian 83 7.59 muslim 20 1. 83 hinduism 12 1.10 other 23 2.10 education level no formal education 28 2.56 primary school 103 9.41 secondary school 235 21.48 high school 432 39.49 bachelor degree 283 25.87 higher than bachelor degree 13 1.19 marital status single 334 30.53 married 651 59.51 divorced/widowed/separated 109 9.96 occupation agriculture and livestock 33 3.02 government staff 159 14.53 own business 157 14.35 private employee 139 12.71 manual labor 221 20.20 dependent 385 35.19 family members less than and equal to 3 399 36.47 4-5 550 50.27 more than 5 145 13.25 htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 6 | 23 characteristics frequency (n) percentage (%) whom they live with parents 357 32.63 spouse 611 55.85 relatives 50 4.57 alone 30 2.74 friend 17 1.55 others 29 2.65 monthly income (mmks) <100,000 373 34.10 100,000-200,000 337 30.80 ≥200,000 384 35.10 monthly expenditure (mmks) <100,000 402 36.75 100,000-200,000 431 39.40 ≥200,000 261 23.86 financial situation not enough 165 15.08 not enough with debt 174 15.90 enough with saving 520 47.54 enough with no saving 235 21.48 parity 0 395 36.11 1-2 483 44.15 >2 216 19.74 health behavior frequency of fast food consumed per week (days) nil 579 52.92 1-4 447 40.86 ≥5 68 6.22 frequency of sugar-sweetened beverage consumed per week (days) nil 142 12.98 1-4 619 56.58 ≥5 333 30.44 frequency of high fat protein consumed per week (days) nil 272 24.86 1-4 671 61.33 ≥5 151 13.80 frequency of vigorous-intensity activity during recreation per week (days) nil 419 38.30 <5 590 53.93 ≥5 85 7.77 frequency of moderate-intensity activity during recreation per week (days) nil 359 32.82 htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 7 | 23 characteristics frequency (n) percentage (%) <5 580 53.02 ≥5 155 14.17 smoking never 798 72.94 former 207 18.92 current 89 8.14 alcohol drinking never 714 65.27 former 238 21.76 current 142 12.98 betel chewing never 801 73.22 former 128 11.70 current 165 15.08 health literacy of overweight and obesity inadequate 528 48.27 problematic 203 18.55 sufficient 203 18.55 excellent 160 14.63 knowledge level of knowledge on overweight and obesity poor (0.0-5.9) <60% 156 14.26 fair (6-7.9) 60-79% 233 21.30 good (8-10) ≥80% 705 64.44 attitude level of attitude on overweight and obesity poor attitude (10-29) <60% 779 71.21 moderate attitude (30-39) 60-79% 314 28.70 good attitude (40-50) ≥80% 1 0.09 physical health status health status healthy 1,011 92.41 unhealthy 83 7.59 family history of overweight/obesity yes 341 31.17 no 753 68.83 use of contraception yes 244 27.63 no 639 72.37 mental health status stress mild (1-13) 367 33.55 moderate (14-26) 671 61.33 severe (27-40) 56 5.12 depression mild (0-16) 556 50.82 moderate (16-23) 316 28.88 htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 8 | 23 characteristics frequency (n) percentage (%) severe (24-60) 222 20.29 total 1094 100.0 table 2. overweight and obesity of women characteristics number of women (%) 95% ci underweight (<18.5 kg/m2) 44 (4.02) 3.00-5.36 normal weight (18.5-22.99 kg/m2) 489 (44.70) 41.77-47.66 overweight (23.0-24.99 kg/m2) 215 (19.65) 17.40-22.11 obesity (≥25 kg/m2) 346 (31.63) 28.93-34.45 mean ±sd 24.25 ± 4.54 median (min: max) 23.01 (14.81: 45.23) the multivariable analysis for associated factors of overweight and obesity were identified by using the generalized linear mixed model (glmm) to control the clustering effect of the sampling selection of the participants. factors that were significantly associated with overweight and obesity of participants included; age 31-59 years (adj.or=1.72; 95%ci: 1.22-2.40), living with family (adj.or= 2.07; 95%ci: 1.20-3.57), average monthly income ≥ 200,000 (adj.or= 1.38; 95%ci: 1.05-1.82), parity ≥1 (adj.or= 1.61; 95%ci: 1.17-2.23), high fat protein consumption ≥5 days per week (adj.or= 2.90; 95%ci: 1.91-4.39), did not drink alcohol (adj.or= 2.53; 95%ci: 1.91-3.36) and moderate and severe stress (adj.or= 1.47; 95%ci: 1.11-1.94) (table 3). table 3. multivariable analysis of factors associated with overweight and obesity by using the glmm characteristics no %o/b crude or adjusted or 95%ci p-value age (years) 0.002 18-30 344 38.95 1 1 31-59 750 56.93 2.07 1.72 1.22-2.40 whom you live with 0.009 with family 1018 50.00 1 1 without family 76 68.42 2.17 2.07 1.20-3.57 average monthly income (mmk) 0.023 <200,000 710 47.46 1 1 ≥ 200,000 384 58.33 1.55 1.38 1.05-1.82 parity 0.004 0 395 40.51 1 1 ≥1 699 57.37 1.98 1.61 1.17-2.23 high fat protein consumption per week (days) <0.001 <5 943 47.40 1 1 ≥5 151 75.50 3.42 2.90 1.91-4.39 alcohol consumption <0.001 yes 380 36.05 1 1 no 714 59.38 2.59 2.53 1.91-3.36 stress 0.007 low 367 41.42 1 1 htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 9 | 23 characteristics no %o/b crude or adjusted or 95%ci p-value moderate to severe 727 56.26 1.82 1.47 1.11-1.94 *as the participants were selected from different geographical areas, glmm was performed to control the clustering effect. discussion our study showed that the combined prevalence of overweight and obesity (bmi ≥ 23 kg/m2) among working age women in myanmar was 51.28 % in which overweight (bmi ≥23.0-24.99 kg/m2) was 19.65% and obesity (bmi≥25 kg/m2) was 31.63% respectively. the prevalence of overweight in this study was lower but obesity was higher as compared to 2015-16 myanmar demographic health survey (mdhs) and myanmar national step survey of risk factors for ncds conducted in 2009 (3, 19). the observed difference between this study and others in myanmar may be due to different cut-off points. in a study conducted in malaysia by using the same cut off point of bmi ≥25 kg/m2, the prevalence of overweight and obesity in women was similar to the results of the current study (20). however, compared to other studies using the same cut off point (bmi ≥ 23 kg/m2), the combined prevalence of overweight and obesity from the current study was higher than in bangladesh and india (21,22). this high prevalence of overweight and obesity among working age women in myanmar bears risks for chronic noncommunicable diseases such as ischemic heart diseases, cancer, hypertension, diabetes, stroke and reproductive health diseases (14). our multivariate analysis revealed that the factors associated with overweight and obesity were significantly associated with overweight and obesity among women aged 31-59-yearold. with the trend of increasing age, people follow sedentary lifestyle, less physical activities, not control over dietary habit and less willingness to reduce body weight regardless of their health status led to gain excessive body weight (14-24). the study demonstrated that participants who lived without family were more likely to be overweight and obese as compared to those living with family. it may be due to the women those living alone consume convenient and unbalanced dietary intake such as fast food and also is related with higher intake of high carbohydrate and fatty foods (25,26). the study revealed that average monthly income was significantly associated with overweight and obesity, as those whose monthly income was (≥ 200,000 mmk) were1.38 times more likely to be overweight and obese than those whose average monthly income was (<200,000 mmk). it can be assumed that females with high income follow sedentary lifestyle and consume more fast foods which can lead to overweight and obesity among them (27). regarding the parity, women with ≥1 pregnancy were 1.61 times more likely to be overweight and obesity than women with no parity. most of the women gain weight during and after the pregnancy and reduction in ovulation cycles in multiparous women can stimulate to accumulate more fat among them (28). moreover, the study revealed that protein with high fat consumption was significantly associated with overweight and obesity where, those who consumed ≥5 days per week were more likely to be overweight and obese as compared to those who consumed < 5 days per week. it might be that high fat foods contain cholesterol, saturated fatty acids and also dietary fat prompts the overconsumption and increase weight through high calories (29). regarding the alcohol consumption, the women who did not consume the alcohol were more likely to be overweight and obesity than those who consumed alcohol in this study. in comparison with my descriptive study, only 12.98% of women were current drinkers. light to moderate amount of alcohol consumption was less likely to be associated with overweight and obesity in this study. also, htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 10 | 23 women drinkers appear to be substitute alcohol for their daily dietary intake without increasing more calories (24). moreover, moderate and severe stress was significantly associated with overweight and obesity than those who has low stress level, and more likely to be overweight and obesity. a possible explanation for this finding could be physiologic mechanisms might play a role, such as stress-induced cortisol secretion, which increases lipogenesis, so increasing the likelihood of being obese (29). study limitations this study had some limitations. firstly, this study was conducted among working age women (18 to 59 years old) living in mandalay region, shan state and mon state. so, it cannot be generalized to all working age women in myanmar. secondly, this study was dependent on the participants’ answers to the structured questionnaires. therefore, memory recalling and interviewer relationship bias could not be excluded. finally, as this is crosssectional study it does not allow establishing the causality of association therefore further longitudinal studies are needed. in addition, covid-19 related travel restrictions have caused delayed in the data collection period. conclusion the study found a high prevalence of overweight and obesity and very low levels of good attitudes regarding excess body weight among working-age women in myanmar. socioeconomic and behavioral risk factors of overweight and obesity were identified and this finding will be used as evidence to develop the appropriate policies and public health interventions. these will address the problems in reducing overweight and obesity that can further lead to prevent non-communicable diseases. there is also a need for urgent intervention targeted to women with information, education and communication (iec). references 1. world health organization. obesity and overweight [internet]. available from: 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________________________________________________________________________________________________ htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 13 | 23 annex i questionnaires health literacy and overweight and obesity among working age women in myanmar: a cross sectional analytical study please circle the answer or fill in the blanks for explanations the truth. part 1. demographic and socioeconomic characteristics information for researcher 1 how old are you? |__|__| years (completed year) sd1 |__|__| 2 what is your ethnic? ( ) 1. barma ( ) 2. mon ( ) 3. karen ( ) 4. rakhine ( ) 5. kachin ( ) 6. shan ( ) 7. pa oh ( ) 8. other please specify -------------- sd2 |__| 3 what is your religion? ( ) 1. none ( ) 2. buddhism ( ) 3.christian ( ) 4. muslim ( ) 5. hinduism ( ) 6. ghost ( ) 7. others please specify -------------- sd3 |__| 4 what is the highest level of education you completed? ( ) 1. no formal education ( ) 2. primary ( ) 3. secondary ( ) 4. high school or equivalence ( ) 5. bachelor degree or equivalence ( ) 6. higher than bachelor degree sd4 |__| 5 what is your marital status? ( ) 1. single ( ) 2. married ( ) 3. divorced/widowed/separated sd5 |__| 6 what is your major occupation? ( ) 1. agriculture and livestock ( ) 2. government staff ( ) 3. own business ( ) 4. private employee ( ) 5. manual labor ( ) 6. dependent ( ) 7. others please specify-------------- sd6 |__| 7 what is your family type? ( )1. nuclear ( ) 2. extended f1 |__| participant id  date--------/--------/----- htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 14 | 23 information for researcher ( )3. others please specify -------------- 8 what is your family size (family members)? |__||__| persons f2 |__|__| 9 do you stay with whom? ( ) 1. parents ( )2. spouse ( )3. relatives ( )4. alone ( )5. friend ( )6. others please specify -------------- f3 |__| 10 what is your average monthly income? ---------------mmk e1 ------- 11 what is your average monthly expense? ----------------mmk e2 ------- 12 what is your average family monthly income? ---------------mmk e3 ------- 13 what is your average family monthly expense? ----------------mmk e4 ------- 14 what is your financial situation? ( ) 1. not enough ( ) 2. not enough with debt ( ) 3. enough with no saving ( ) 4. enough with saving e5 |__| 15 what is your parity? |__||__| (leave 0 if you are single) m1 |__|__| 16 how many children do you have? |__||__| m2 |__|__| part 2: health behaviors no information no 1-2 days 3-4 days 5-6 days 7 days code 2.1 dietary pattern: in 1 week, how often do you 1 consume fast food such as pizza, hamburger, sandwiches, doughnuts? 1 2 3 4 5 d1|__| 2 consume sugar-sweetened beverage such as coca cola, pepsi, coffee with milk, energy drink, and fruit juice? 1 2 3 4 5 d2|__| 3 eat sweet fruits such as durian, mango, pineapple, grapes, and banana? 1 2 3 4 5 d3|__| 4 eat fruits that not sweet such as dragon fruit, kiwi, lime, lemon? 1 2 3 4 5 d4|__| 5 eat vegetables that contain starch such as potatoes, sweet potatoes, taro, corn and pumpkin? 1 2 3 4 5 d5|__| 6 eat vegetables that not contain starch such as carrot, cabbage, cauliflower, mushrooms? 1 2 3 4 5 d6|__| 7 eat protein such as lean meat, chicken, eggs, soy products like tofu? 1 2 3 4 5 d7|__| 8 eat protein with high fat such as cheese, nuts, seeds, streaky pork? 1 2 3 4 5 d8|__| 9 eat protein from vegetable such as bean, pea, lentils, chickpeas, cauliflower, tofu? 1 2 3 4 5 d9|__| 10 eat food cooked with animal oil? 1 2 3 4 5 d10|__| 11 eat food cooked with vegetable oil? 1 2 3 4 5 d11|__| 2.2 physical activity htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 15 | 23 no information no 1-2 days 3-4 days 5-6 days 7 days code activity at work 12 how often do you do vigorous-intensity activity that causes large increases in breathing or heart rate like [carrying or lifting heavy loads, digging or construction work] for at least 10 minutes continuously at work? 1 2 3 4 5 p1|__| 13 how often do you do moderate-intensity activity that causes small increases in breathing or heart rate such as brisk walking [or carrying light loads] for at least 10 minutes continuously at work? 1 2 3 4 5 p2 |__| travel to and from places 14 how often do you walk or use a bicycle (pedal cycle) for at least 10 minutes continuously to get to and from places? 1 2 3 4 5 p3 |__| recreational activities 15 how often do you do any vigorousintensity sports, fitness or recreational (leisure) activities that cause large increases in breathing or heart rate like [running or football] for at least 10 minutes continuously? 1 2 3 4 5 p4 |__| 16 how often do you do any moderateintensity sports, fitness or recreational (leisure) activities that cause a small increase in breathing or heart rate such as brisk walking, [cycling, swimming, and volleyball] for at least 10 minutes continuously? 1 2 3 4 5 p5 |__| 2.3 leisure time 17 during the leisure time, what do you do? (remark: more than 1 answer is possible. please circle all the possible answers.) l1.a watching television 1. yes 2. no l1.b using internet 1. yes 2. no l1.c playing internet games 1. yes 2. no l1.d playing guitar 1. yes 2. no l1.e listening music 1. yes 2. no l1.f sing the songs 1. yes 2. no l1.g others(specify) ------------------------ l1a |__| l1b |__| l1c |__| l1d |__| l1e |__| l1f |__| l1g |__| 18 tv watching hours /day (self-estimated) -------------------hours l2 |__| 19 internet media watching hours /day (self-estimated) --------------hours l3 |__| 2.4 sleep pattern 20 in average how many hours per day do you sleep? ---hours sl1 |__| 21 during sleeping, do you get sound sleep? ------days per week sl2 |__| 2.5 smoking htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 16 | 23 no information no 1-2 days 3-4 days 5-6 days 7 days code 22 have you ever smoked? [ ]1. never smoke (skip to question 27 ) [ ]2. former smoking [ ]3. current smoking s1 |__| 23 what is the most common type of cigarette you use? [ ]1. cigar [ ]2. cheroot [ ]3. cigarette [ ]4. tobacco for betel quit [ ]5. others(specify)------------ s2 |__| 24 how often do you smoke? -------------days per week s3 |__| 25 how many cigarettes do you smoke per day? -------------pcs s4 |__| 26 how much do you spend for smoking per month? ------------mmk s5 |__| 2.6 alcohol drinking 27 have you ever consumed an alcoholic beverage in the past 1month? [ ] 1. never drink ( skip to question 32 ) [ ] 2. former drinker [ ]3. current drinker (drinking any alcohol product in past 30 days) a1|__| 28 how often do you drink alcohol? …………. days per week a2 |__| 29 what is the most common type of alcohol you drink? [ ]1. beer [ ]2.whiskey [ ]3. rice alcohol [ ]4.wine [ ]5. others (specify) ------------------ a3 |__| 30 drink volume per time (estimated) -----------g 1 standard drink=10 gram of pure alcohol a4 |__| 31 how much do you spend for alcohol drinking per month? ----------------mmk a5 |__| 2.7 betel chewing 32 have you ever betel chewing in the past 12 months? [ ]1. never chew ( skip to part 3 ) [ ]2. former chewer [ ]3. current chewer b1 |__| 33 have often do you chewed?...................... days/ week b2 |__| 34 what is the most common type of betel you chew? [ ]1. signal [ ] 2.92 [ ]3. tobacco leaf [ ]4.100 [ ]5. others(specify), ------------------ b3 |__| 35 how many chews in a day? ----------chews b4 |__| 36 how much do you spend for betel chewing per month? ----------------mmk b5 |__| part 3: health literacy hc = health care; dp = disease prevention; hp = health promotion please mark √ in ( ) or fill in the blanks for explanation the truth. htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 17 | 23 no. action area domain very difficult fairly difficult fairly easy very easy 1 access to information hc find information on the causes of overweight and obesity 1 2 3 4 2 find information about how to eat proper food for not to get overweight and obesity 1 2 3 4 3 find information on how to reduce your body weight if you are overweight or obesity 1 2 3 4 4 dp find out information on how to manage stress, depression that could cause overweight and obesity 1 2 3 4 5 find information about how to manage unhealthy behavior such as smoking and drinking alcohol that can cause overweight and obesity 1 2 3 4 6 hp find information on how to promote healthy activities such as exercise 1 2 3 4 7 find out how to practice at home, working place and community to stay fit and healthy 1 2 3 4 8 understand information hc understand the information on causes of overweight and obesity 1 2 3 4 9 understand the information on how to eat proper food for not to get overweight and obesity 1 2 3 4 10 understand the information on how to reduce your body weight if you are overweight or obesity 1 2 3 4 11 dp understand the information on how to manage stress, depression that could cause overweight and obesity 1 2 3 4 12 understand the information on how to manage unhealthy behavior such as smoking and drinking alcohol that can cause overweight and obesity 1 2 3 4 13 hp understand the information on how to promote healthy activities such as exercise 1 2 3 4 14 understand the information on how to practice at home, 1 2 3 4 htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 18 | 23 no. action area domain very difficult fairly difficult fairly easy very easy working place and community to stay fit and healthy 15 appraise information hc judge the causes of overweight and obesity 1 2 3 4 16 judge the correctness of the information how to eat proper food for not to get overweight and obesity 1 2 3 4 17 judge correctness of the information how to reduce your body weight if you are overweight or obesity 1 2 3 4 18 dp judge measures to manage stress, depression that could cause overweight and obesity 1 2 3 4 19 judge the correctness of the information on how to manage unhealthy behavior such as smoking and drinking alcohol that can cause overweight and obesity 1 2 3 4 20 hp justified information on how to promote healthy activities such as exercise 1 2 3 4 21 justified appropriate practice to stay fit and healthy at home, working place and community, 1 2 3 4 22 making decision hc decide to prevent overweight and obesity by yourself based on information 1 2 3 4 23 decide to eat proper food to prevent overweight and obesity 1 2 3 4 24 decide to take actions to reduce your body weight if you are overweight or obesity 1 2 3 4 25 dp decide to manage stress, depression that could cause overweight and obesity 1 2 3 4 26 decide to manage unhealthy behaviors such as smoking and drinking alcohol that can cause overweight and obesity 1 2 3 4 27 hp decide to do activities such as exercise to promote the health 1 2 3 4 htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 19 | 23 no. action area domain very difficult fairly difficult fairly easy very easy 28 decide to practice to stay fit and healthy at home, working place and community. 1 2 3 4 part 4: knowledge please mark √ in ( ) or fill in the blanks for explanation the truth. no information answer for researcher yes no 1 bmi can be used to define overweight and obesity. 1 2 d1 |__| 2 eating more vegetables could cause overweight and obesity. 1 2 d2 |__| 3 drinks soda such as coca cola, pepsi and fanta could help burning fat which is good for those with hyperlipidemia. 1 2 d3 |__| 4 animal fats are more beneficial than vegetable oil. 1 2 d4 |__| 5 overweight and obesity can be lowered by medicine only. 1 2 d5 |__| 6 reading the nutritional labeling before buying foods could help reducing overweight and obesity. 1 2 d6 |__| 7 breast cancer is related with obesity. 1 2 d7 |__| 8 overweight and obesity increases the risk of type2 diabetes but not hypertension and heart diseases. 1 2 d8 |__| 9 obesity is not related with irregular periods and infertile. 1 2 d9 |__| 10 obesity is not related with bones and joints problems 1 2 d10 |__| part 5: attitude positive items score strongly agree 5 agree 4 neutral 3 disagree 2 strongly disagree 1 please mark √ in ( ) or fill in the blanks for explanation the truth. no opinion answer for researcher strongly disagree disagree neutral agree strongly agree 1 overweight and obesity are unhealthy. 1 2 3 4 5 e1 |__| 2 obesity makes females look ugly. 1 2 3 4 5 e2 |__| 3 overweight and obesity among male is acceptable. 1 2 3 4 5 e3 |__| 4 obesity reduces self-esteem and self-confidence. 1 2 3 4 5 e4 |__| 5 it is hard to control weight. 1 2 3 4 5 e5 |__| htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 20 | 23 no opinion answer for researcher strongly disagree disagree neutral agree strongly agree 6 overweight / obese people are lazy. 1 2 3 4 5 e6 |__| 7 obesity is my serious problems. 1 2 3 4 5 e7 |__| 8 overweight and obesity is genetic, therefore we could not prevent it. 1 2 3 4 5 e8 |__| 9 medicine is the best measure to reduce obesity. 1 2 3 4 5 e9 |__| 10 behavior modification with long term monitoring is the healthiest measures to prevent and control obesity. 1 2 3 4 5 e10 |__| part 6: physical health status information for researcher 1 how do you rate your current health status? 1 2 3 4 5 6 7 8 9 10 very sick very healthy phs1 |__| 2 do you suffer any acute illness during last 2 weeks? [ ]1. no [ ]2. yes my problems is ………………….. phs 2 |__| 3 do you have any chronic diseases? [ ]1. no (if no, skip to question7) [ ]2. yes phs 3 |__| 4 what chronic diseases are you suffering? phs4.a.hypertension ( ) 1.no ( ) 2.yes phs4.b.diabetes mellitus ( ) 1.no ( ) 2.yes phs4.c.stroke ( ) 1.no ( ) 2.yes phs4.d.muscle pain ( ) 1.no ( ) 2.yes phs4.e.heart disease ( ) 1.no ( ) 2.yes phs4.f.tuberculosis ( ) 1.no ( ) 2.yes phs4.g.malaria ( ) 1.no ( ) 2.yes phs4.h.std ( ) 1.no ( ) 2.yes phs4.i.skin diseases ( ) 1.no ( ) 2.yes phs4.j.others (specify), ------------------ phs4a|__| phs4b|__| phs4c|__| phs4d|__| phs4e|__| phs4f|__| phs4g|__| phs4h|__| phs4i|__| phs4j |__| 5 do you take regular treatment for your chronic disease? [ ]1.yes [ ]2.no [ ]3. others (specify), ------------------ phs5 |__| 6 where do you get treatment for your disease? [ ]1.drug store [ ]2.health personals [ ]3.private clinic [ ]4.ngos [ ]5.uhc [ ]6.public hospital [ ]7.others (specify), ------------------ phs6 |__| 7 did you have any hospitalization during the past one year? [ ]1. yes for ------------------days phs7 |__| htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 21 | 23 information for researcher [ ]2. no 8 did you have any accidents during the past one year? [ ]1. yes [ ]2. no phs8 |__| 9 do your family have history of overweight/obesity? 1.yes 2.no if “yes” choose any of follow; (can answer more than one) fh1.a mother 1. yes 2. no fh1.b father 1. yes 2. no fh1.c grandparents 1. yes 2. no fh1.d siblings 1. yes 2. no fh1|__| fh1a |__| fh1b |__| fh1c |__| fh1d |__| 10 do your family have history of hypertension? 1.yes 2.no if “yes” choose any of follow; (can answer more than one) fh2.a mother 1. yes 2. no fh2.b father 1. yes 2. no fh2.c grandparents 1. yes 2. no fh2.d siblings 1. yes 2. no fh2 |__| fh2a |__| fh2b |__| fh2c |__| fh2d |__| 11 do your family have history of diabetes mellitus? 1.yes 2.no if “yes” choose any of follow; (can answer more than one) fh 3.a mother 1. yes 2. no fh 3.b father 1. yes 2. no fh 3.c grandparents 1. yes 2. no fh 3.d siblings 1. yes 2. no fh 3|__| fh3a |__| fh3b |__| fh3c |__| fh3d |__| 12 what is your reproductive health status? 1.not in menopause period. 2. in menopause period (if menopause, skip to part 7) rh1 |__| 13 do you use contraception? 1.yes 2. no if “yes” choose any of follow rh2.a oral contraception 1. yes 2. no rh2.b injection 1. yes 2. no rh2.c others please specify………….. rh2 |__| rh2a |__| rh2b |__| rh2c |__| htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 22 | 23 part 7: mental health status 7.1 stress relating factors by perceived stress scale (pss) the questions in this scale ask you about your feelings and thoughts during the last month. in each case, please indicate with a check how often you felt or thought a certain way. no information in the last month, never almost never sometimes fairly often very often 1 how often have you been upset because of something that happened unexpectedly? 0 1 2 3 4 2 how often have you felt that you were unable to control the important things in your life? 0 1 2 3 4 3 how often have you felt nervous and “stressed”? 0 1 2 3 4 4 how often have you felt confident about your ability to handle your personal problems? 4 3 2 1 0 5 in the last month, how often have you felt that things were going your way? 4 3 2 1 0 6 how often have you found that you could not cope with all the things that you had to do? 0 1 2 3 4 7 how often have you been able to control irritations in your life? 4 3 2 1 0 8 how often have you felt that you were on top of things? 4 3 2 1 0 9 how often have you been angered because of things that were outside of your control? 0 1 2 3 4 10 how often have you felt difficulties were piling up so high that you could not overcome them? 0 1 2 3 4 total stress score s1----------------------------- stress 1. no 2. yes s2------------------- 7.2 depression index below is a list of some of the ways you may have felt or behaved. please indicate how often you have felt this way during the past week. respond to all items. no place a check mark (!) in the appropriate column. during the past week. rarely or none of the time (less than 1 day) some or a little of the time (1-2 days) occasionally or a moderate amount of time (3-4 days) all of the time (5-7 days) 1 i was bothered by things that usually don’t bother me. 0 1 2 3 2 i did not feel like eating; my appetite was poor. 0 1 2 3 htut wmm, sornlom k, loahasiriwong w. health behavior, stress and obesity among working age women in myanmar (original research). seejph 2022, posted: 27 may 2022. doi: 10.11576/seejph-5494 p a g e 23 | 23 no place a check mark (!) in the appropriate column. during the past week. rarely or none of the time (less than 1 day) some or a little of the time (1-2 days) occasionally or a moderate amount of time (3-4 days) all of the time (5-7 days) 3 i felt that i could not shake off the blues even with help from my family. 0 1 2 3 4 i felt that i was just as good as other people. 0 1 2 3 5 i had trouble keeping my mind on what i was doing. 0 1 2 3 6 i felt depressed. 0 1 2 3 7 i felt that everything i did was an effort. 0 1 2 3 8 i felt hopeful about the future. 0 1 2 3 9 i thought my life had been a failure. 0 1 2 3 10 i felt fearful. 0 1 2 3 11 my sleep was restless. 0 1 2 3 12 i was happy. 0 1 2 3 13 i talked less than usual. 0 1 2 3 14 i felt lonely. 0 1 2 3 15 people were unfriendly. 0 1 2 3 16 i enjoyed life. 0 1 2 3 17 i had crying spells. 0 1 2 3 18 i felt sad. 0 1 2 3 19 i felt that people disliked me. 0 1 2 3 20 i could not "get going." 0 1 2 3 total score d1…………………… ………… depressive symptoms 1.no 2.yes d2…………………… ………… part 8: case record form anthropometric measurement for researcher 1. height--------------------------------centimeters a1----------cm 2. weight--------------------------------kilograms a2----------kg 3. waist circumference------------------centimeters a3----------cm 4. hip circumference------------------centimeters a4----------cm this is the end of the questionnaire, thank you for your participation. laaser u, schröder-bäck p. towards a code of conduct for the european public health profession! (short report). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-88 1 short report towards a code of conduct for the european public health profession! ulrich laaser1, peter schröder-bäck2,3 1 faculty of health sciences, university of bielefeld, bielefeld, germany; 2 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life science, maastricht university, maastricht, the netherlands; 3 faculty of human and health sciences, university of bremen, bremen, germany. corresponding author: dr. peter schröder-bäck address: postbus 616, 6200 md maastricht, the netherlands e-mail: peter.schroder@maastrichtuniversity.nl conflicts of interest: none. laaser u, schröder-bäck p. towards a code of conduct for the european public health profession! (short report). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-88 2 introduction is the group of public health professionals consistent of other professions such as physicians, nurses, social workers and the like, or should public health professionals define themselves as a distinct profession in their own rights? as of today, in europe, public health professionals do not build an own profession. czabanowska et al. (1) define and promote in this journal the formalization of the public health profession, based on the criteria which – following macdonald (2) – differentiate a profession from an occupation. these criteria include adherence to a code of conduct and altruistic service. from an ethical point of view, both elements are essentially related and both are reflected in the most famous example of a code for a health profession: the ancient hippocratic oath (3). for a public health profession we can draw only partly on the oath as public health deals with populations – not with individual patients – and, therefore, requires population ethics, not medical or bio-ethics, the latter well accepted since the 1980s at least (4). population ethics what is particularly relevant when we take a social or population ethics point of view? following e.g. laaser (5) financial means are in principle never sufficient because the health of population groups is always subject to potential improvement. therefore, efficiency or cost-effectiveness of interventions gains ethical relevance as resources can be spent only once, and are then not available for alternative use. for this reason, population ethics often adhere to the utilitarian principle. however, it is normatively important to amend the utilitarian calculus, namely that the ‘pursuit of happiness’ for the greatest number must not be achieved by reducing the benefit of any single individual (6). given the specific prevailing european value tradition of solidarity (7), an additional amendment may be considered namely, that differences between population groups should not increase by any public health measure but be minimized wherever possible. another deontological limitation of the utilitarian principle is the respect for the autonomy of persons and their rights (8). in addition, a fundamental moral issue remains in that all decisions on population health level are based on probabilities and statistical lives (9), making possible technologies of assessing interventions – and promoting the giving or withholding of interventions – based on utilitarian cost-effectiveness rationales (10). the utilitarian principle, its ethical limitations and practicability for public health decision-making requires a continuous public health ethics discourse (11). which principles could nevertheless be identified guiding a public health profession in its decisions on the population’s health? summarising the ethical literature, schröder-bäck et al. (12) proposed seven mid-level principles to be considered: maleficence, beneficence, health maximisation, efficiency, respect for autonomy, justice, and proportionality. laaser et al. (13) proposed with reference to a specific european heritage the following principles: solidarity, efficiency, participation, equity, subsidiarity, sustainability, reconciliation, and evidence, underlining in addition the component of empathy/altruism which is of essential relevance in the individual physician-patient relationship, as well as in the professional-population realm. with regard to a european dimension, the european commission published council conclusions (14) manifesting four overarching principles: equity, universality, access to good quality of care, and solidarity – critically discussed by schröder-bäck et al. (15). from this short account it seems that, in spite of different terminologies used, the following four values can be considered as core for a european framework: solidarity, equity, efficiency and respect for autonomy. the access to good quality of care describes only one of the preconditions of health and can be hardly considered as an ethical principle. laaser u, schröder-bäck p. towards a code of conduct for the european public health profession! (short report). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-88 3 a professional code? can we build a professional code on this value account? various aspects are published in volume 36 of the public health reviews (16). in its recommendation on good governance in health systems (17) in 2010, the council of europe promotes codes of conduct for stakeholders in the health sector including effective mechanisms for enforcement and specific clauses on conflict of interest. in 2002, the american public health leadership society published twelve principles of the ethical practice of public health (18) [table 1]. table 1. principles of the ethical practice of public health no. principle 1 public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes. 2 public health should achieve community health in a way that respects the rights of individuals in the community. 3 public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members. 4 public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all. 5 public health should seek the information needed to implement effective policies and programs that protect and promote health. 6 public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation. 7 public health institutions should act in a timely manner on the information they have within the resources and the mandate given to them by the public. 8 public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community. 9 public health programs and policies should be implemented in a manner that most enhances the physical and social environment. 10 public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others. 11 public health institutions should ensure the professional competence of their employees. 12 public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness. even though the values we mentioned and affirmed above are somewhat reflected in the code of the leadership society, values that seem particularly important for a european perspective on public health – namely solidarity and equity – are not explicitly mentioned. according to prainsack & buyx (19), often they are even referred to as opposed to the american thinking. prainsack & buyx define solidarity as shared practices reflecting a collective commitment to carry costs (financial, social, emotional, or otherwise) to assist others. also, the term equity has a long european tradition and has likewise a moral dimension. inequity refers to differences which are unnecessary and avoidable but, in addition, are also considered unfair and unjust (20). we propose herewith that solidarity and equity are core values that have to be reflected in a european version of a code of conduct for public health professionals, operating in a laaser u, schröder-bäck p. towards a code of conduct for the european public health profession! (short report). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-88 4 framework that is also guided by the principles of efficiency and respect for autonomy. with a transnational perspective, verkerk & lindemann (21) call in addition for more justice of resource sharing on a global scale, whereas stapleton et al. (22) talk already about a global ethics. these values would reflect a specific european value dimension in public health conduct. but, what does this mean? if we assume – what we do – that a code of conduct is important to function as an explicit normative compass for public health and to help building the public health profession for europe, then such a code of conduct should be formulated and it will help to further professionalization of public health. professionalization of public health is important to advance public health education, training, and practice. in our opinion, there is no contradiction that the profession of public health consists of members of different other professions – which also have their own values and conducts. yet, if professions work under the roof of public health, the pillars – the core values – of the house that is built are the common denominators. making the guiding norms and values explicit is important for the self-definition of the professional field/profession and giving guidance in pursuing a fair and respectful improvement of population health. references 1. czabanowska k, laaser u, stjernberg l. shaping and authorising a public health profession. seejph 2014, posted: 31 may 2014. doi 10.12908/seejph-2014-23. 2. macdonald km. the sociology of the professions. london: sage publications, 1999. 3. available in the original version at: https://www.nlm.nih.gov/hmd/greek/greek_oath.html, and in one of the modern adaptations at: http://guides.library.jhu.edu/c.php?g=202502&p=1335759 (both accessed: september 5, 2015). 4. beauchamp tl, childress jf. principles of biomedical ethics. 6th edition. oxford university press: new york, 2009. 5. laaser u. health, economics and ethical reasoning. j publ hlth (springer) 2005;13:229-30. 6. rawls j. theory of justice. harvard university press, 1971. 7. laaser u, bjegovic-mikanovic v, lueddeke g. epilogue: global health, governance, and education. in: lueddeke g (ed.) global population health and well-being in the 21st century – towards new paradigms, policy, and practice. springer: new york, 2015. 8. sass hm. introduction: the principle of solidarity in health care policy. j med philos 1992;17:367-70. 9. cohen ig, daniels n, eyal n. identified versus statistical lives: an interdisciplinary perspective (front matter and introduction). oxford university press, 2015. available at: http://ssrn.com/abstract=2571392 (accessed: september 10, 2015). 10. laaser u. ethical approach in good governance of health systems. moldovan journal of health sciences 2015;4:66-72. 11. schröder-bäck p, maeckelberghe e, royo-bordonada má. the ethics effect. seejph 2014, posted: 23 september 2014. doi 10.12908/seejph-2014-31. 12. schröder-bäck p, duncan p, sherlaw w, brall c, czabanowska k. teaching seven principles for public health ethics: towards a curriculum for a short course on ethics in public health programmes. bmc medical ethics 2014;15:73. doi:10.1186/14726939-15-73. laaser u, schröder-bäck p. towards a code of conduct for the european public health profession! (short report). seejph 2016, posted: 11 january 2016. doi 10.4119/unibi/seejph-2016-88 5 13. laaser u, donev d, bjegovic v, sarolli y. public health and peace. croat med j 2002;43:107-13. 14. council of the european union. council conclusions on equity and health in all policies: solidarity in health. 3019th employment, social policy, health and consumer affairs council meeting. brussels: 8 june 2010. available at: http://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/lsa/114994.pdf (accessed: september 10, 2015). 15. schröder-bäck p, clemens t, michelsen k, schulte in den bäumen t, sørensen c, borrett g, brand h. public health ethical perspectives on the values of the european commission’s white paper “together for health”. cent eur j public health 2012;20:95-100. 16. chambaud l, tulchinsky t (eds.). ethics. public health reviews 2015;36. available at: http://www.publichealthreviews.net/ (accessed: september 10, 2015). 17. council of europe. recommendation cm/rec(2010)6 of the committee of ministers to member states on good governance in health systems. 18. public health leadership society (phls). principles of the ethical practice of public health, version 2.2.2002. available at: http://nnphi.org/uploads/media_items/principles-of-the-ethical-practice-of-publichealth-brochure.original.pdf (accessed: september 5, 2015). 19. prainsack b, buyx a. solidarity: reflections on an emerging concept in bioethics. nuffield council on bioethics (ncob): november 2011; isbn: 978-1-904384-25-0. available at: http://nuffieldbioethics.org/wpcontent/uploads/2014/07/solidarity_report_final.pdf (accessed: september 10, 2015). 20. whitehead m. the concepts and principles of equity and health. european health for all series no. 1. who europa: copenhagen 1985 (eur/icp/rpd 414 7734r). available at: http://publicaciones.ops.org.ar/publicaciones/piezas%20comunicacionales/cursodds/ cursoeng/textos%20completos/the%20concepts%20and%20principles%20of%20equ ity%20and%20health.pdf (accessed: september 10, 2015). 21. verkerk ma, lindemann h. theoretical resources for a globalised bioethics. j med ethics 2011;37:92-6. 22. stapleton g, schroeder-baeck p, laaser u, meershoek a, popa d. global health ethics: an introduction to prominent theories and relevant topics. glob health action 2014;7: 23569. doi: 10.3402/gha.v7.23569. ___________________________________________________________ © 2016 laaser et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/lsa/114994.pdf http://www.publichealthreviews.net/ http://nnphi.org/uploads/media_items/principles-of-the-ethical-practice-of-public-health-brochure.original.pdf http://nnphi.org/uploads/media_items/principles-of-the-ethical-practice-of-public-health-brochure.original.pdf http://nuffieldbioethics.org/wp-content/uploads/2014/07/solidarity_report_final.pdf http://nuffieldbioethics.org/wp-content/uploads/2014/07/solidarity_report_final.pdf levett j. first half century of the association of schools of public health in the european region (editorial). seejph 2016, posted: 20 april 2016. doi: 10.4119/unibi/seejph-2016-113 1 editorial first half century of the association of schools of public health in the european region jeffrey levett 1 1 the national school of public health, athens, greece. corresponding author: prof. dr. jeffrey levett, national school of public health; address: ilia rogakou 2, athens, 106 72, greece; telephone: +302103641607; email: jeffrey.levett@gmail.com levett j. first half century of the association of schools of public health in the european region (editorial). seejph 2016, posted: 20 april 2016. doi: 10.4119/unibi/seejph-2016-113 2 this year, the association of schools of public health in the european region (aspher) reaches 50 years [1966-2016] and is engaged in celebration. its significant achievements on the european stage will appear in the anniversary book and tell much of its exciting story (1). the official ceremony will take place in athens, greece 25-27 may 2016 with an opening event in the acropolis museum. the celebration is hosted by the hellenic school, an institution finally launched in 1929, following heroic efforts of greek pioneers in malaria and after a bizarre pandemic of dengue fever and a little known, unique and short-lived revolution in public health, which hiccoughed its way into history (2-5). one powerful driving force was ludwik rajchman of the league of nations who described the health situation in greece as being “worse than in brazil”. aspher’s contemporary vision is expressed in its 2020 strategy, enunciated into five specific strategic objectives that reflect educational quality, research capacity and global governance. these are pivotal to present and future population health challenges and have been elaborated in a spirit of collaboration and solidarity and in concert with the international community. one fundamental goal is the continued improvement of competency training of the european workforce. appropriately trained public health practitioners are an effective link to crisis intervention such as in the current refugee crisis. aspher is a natural link and think tank for europe and can provide insights into paths towards solution for the current and horrendous set of european problems. in 1992, with the support of who-euro [jo asval, m. barberro] and the european commission, dgv [david hunter, jos draijer], a turbulent general assembly was hosted by the hellenic school. it received support from the rockefeller and goulandri foundations and from hellenic ministries of health, education and culture [melina mecouri]. in athens, i) a balkan forum for public health was conducted and facilitated eastern european schools to become a greater force within aspher thus fulfilling the aim of its first secretary-general, teodor gjurgjevic, zagreb [1968] who travelled unsuccessfully to moscow, to encourage membership; ii) aspher outlined its response to article 154 of the maastricht treaty, and; iii) an award named for andrija stampar got underway, which this year goes to richard horton, editor of the lancet (6). public health is a paradoxical entity spurned when things go well, called back by society when things fall apart. it is an essential function of society; an organized and systematic concoction for dealing with unpleasant surprises. it is an invigorating interdisciplinary cocktail, which like women’s domestic work, does not fit well into the economist’s equations of development or into business or market models. public health is an anti-hero, not unlike don quixote who tilted at windmills and hucklebury finn who knew hell awaited him, after he helped the escape from slavery. like huck and the don, public health has a nobility of spirit and purpose, wanting to right wrongs. like a woman spurned, it can take disastrous revenge when rejected by the community or by the state. think of ebola [africa]; lead in flint [usa]. social sensitivity to deprivation and the organization of public health in response to dismal outcomes from environmental miasma are both constructs and products of the enlightenment (7). its thinkers aimed to improve living conditions of the population impacted by the industrial revolution and urbanization. they embraced such powerful thoughts as: “there but for the grace of god go i, do onto others as you would have them do onto you and that the reduction of mortality had an economic value to society”. nevertheless, the danger still exists that the ship of state is operating with an insufficient ratio of lifeboats to passengers while avoidable death climbs (8). levett j. first half century of the association of schools of public health in the european region (editorial). seejph 2016, posted: 20 april 2016. doi: 10.4119/unibi/seejph-2016-113 3 aspher’s homunculus-logo depicts both heart and brain, thus echoing the ancient maxim of “healthy in body, healthy in mind”, for the individual, the community and the body politic. perhaps we should listen more to female voices; hygiene, daughter of asclepius, goddess symbol of public health; peitho goddess of persuasion. linguistically, public health suggests political tension and ideological divisions. it is a strange couplet from which the polar “public-private” surfaces. etymologically, idiocy-idiot derives from the greek word private and health lacks importance until lost. at this time of humanitarian crisis in europe, aspher calls for greater tolerance of diversity; color, creed, opinion nurtured within cultures of peace and science and within a framework of equality. public health policy must be equal in complexity to the current problem space; refugee waves, austerity measures, terrorism. it must demonstrate flexibility in approach and draw upon alternative but convergent conceptualizations as either in terms of reducing vulnerability or in terms of resilience building. as we step into the future we may be faced by health indicator decline and health determinant disasters. aspher’s 50 year legacy must be seen as a vital contributor to socio-economic progress, a bulwark against health damage and a pillar for our common european future. we say that investing in schools of public health is a good thing! schools of public health do make a difference (9)! no better gift can come from the political world than greater recognition of schools and institutions of public health in tandem with the ascendancy of public health up the political agenda. from athens, aspher’s thoughts and concerns go out to all victims of abominable terrorist attacks, those suffering the consequences of austerity and to the plight of being a refugee. we must resist the dastardly and merciless acts of terrorism and mount a more effective response to population deprivation and environmental dangers and not permit them to derail europe. with pride we draw attention to our appealing association aspher as it reaches a half century, while simultaneously, appealing to the european world of politics to make more room for public health. references 1. foldspang a, müller-nordhorn j, bjegovic-mikanovic v, otok r (eds.). fifty years of professional public health workforce development. aspher’s 50 th anniversary book. brussels: association of schools of public health in the european region, 2016 [in press]. 2. mandyla m, tsiamis c, kousounis a, petridou e. pioneers in the anti-malaria battle in greece (1900-1930). gesnerus 2011;68:180-97. 3. levett j. the athens school: lighthouse of greek public health. www.kastaniotis.com (greek only). 4. giannuli d. repeated disappointment: the rockefeller foundation and the reform of the greek public health system, 1929-1940. bull hist med 1988;72:47-72. 5. scientific foundations of public health policy in europe. editors: laaser u, de leeuw e, stock c. juventa verlag weinheim and munchen; 1995. 6. aspher. welcome to athens. http://www.aspher.org/articles,4,20.html http://www.kastaniotis.com/ http://www.aspher.org/articles,4,20.html levett j. first half century of the association of schools of public health in the european region (editorial). seejph 2016, posted: 20 april 2016. doi: 10.4119/unibi/seejph-2016-113 4 7. levett j. disaster press: public health enlightenment, greece: from the athens to the hellenic national school of public health. sunday, 20 november 2011. http://nrdisaster.blogspot.gr/2011/11/public-health-enlightenment-greece.html (accessed: april 21, 2016). 8. levett j. disaster press: blunders without apology, mistakes and their excuses. thursday, 31 march 2016. http://nrdisaster.blogspot.gr/2016/03/blunders-withoutapology-mistakes-and.html (accessed: april 21, 2016). 9. de leeuw e. european schools of public health in state of flux. lancet 1995;345:1158-60. ___________________________________________________________ © 2016 levett; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://nrdisaster.blogspot.gr/2016/03/blunders-without-apology-mistakes-and.html. http://nrdisaster.blogspot.gr/2016/03/blunders-without-apology-mistakes-and.html. serling, w., lotushko, v., bocken, n., gietz, l., paric, m. policy brief on revising the tb action plan for the who european region 2016-2020: what amendments are needed to reach the un sdg3 to eliminate tb epidemics by 2030? (policy brief). seejph 2022. 26 august 2022. doi:10.11576/seejph-5836 p a g e 1 | 15 policy brief policy brief on revising the tb action plan for the who european region 2016-2020: what amendments are needed to reach the un sdg3 to eliminate tb epidemics by 2030? willa serling1, volodymyr lotushko1, nick bocken1, lisa gietz1, martina paric1 1faculty of health, medicine, and life sciences, maastricht university, the netherlands department of international health, care and public health research institute – caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands corresponding author: willa serling, email: w.serling@student.maastrichtuniversity.nl, address: duboisdomein 30, 6229 gt maastricht, the netherlands serling, w., lotushko, v., bocken, n., gietz, l., paric, m. policy brief on revising the tb action plan for the who european region 2016-2020: what amendments are needed to reach the un sdg3 to eliminate tb epidemics by 2030? (policy brief). seejph 2022. 26 august 2022. doi:10.11576/seejph-5836 p a g e 2 | 15 abstract context: the world health organization (who) european region’s political attention shifted to the covid-19 pandemic from the start of 2020 onwards. a consequence of this shift has been decreased political attention towards combating tuberculosis (tb) in the who european region. as a result, decreasing tb data reporting, rising death rates, and increasing antimicrobial resistance (amr) have prevented the who european region from remaining on track to reach the united nations sustainable development goal 3 (sdg3) to eliminate tb epidemics by 2030. furthermore, the who tuberculosis action plan for the who european region 2016-2020 has missed opportunities to mitigate tb in this region, thus exacerbating the issue and preventing the achievement of sdg3. policy options: the who’s roadmap to implement the tuberculosis action plan for the who european region 2016-2020 provided guidance for tb management in the member states (ms), but did not sufficiently address amr, lacking promotion of new tb vaccine rollout, nor describe national tb implementation strategies. the who 2016-2020 tb action plan is now overdue and who policymakers should consider the following recommendations when creating the new tb action plan. recommendations: this policy brief addresses the urgent need for a new who tb action plan to integrate a national level implementation commitment, amr programming, and who support in creating a vaccine strategy with aims for the who european region to achieve sdg3 and eliminate tb epidemics by 2030. keywords: amr, who european region, sdg3, tuberculosis action plan, tuberculosis, who acknowledgments: we would like to thank martina parić for her support throughout the brainstorming, planning, and revision process of this project, thank you. we would also like to thank kasia czabanowksa for providing us the opportunity to partake in this project, allowing us to apply leadership insights to pertinent public health issues. authors’ contributions: all authors contributed equally to this work. conflicts of interest: none declared funding: none declared serling, w., lotushko, v., bocken, n., gietz, l., paric, m. policy brief on revising the tb action plan for the who european region 2016-2020: what amendments are needed to reach the un sdg3 to eliminate tb epidemics by 2030? (policy brief). seejph 2022. 26 august 2022. doi:10.11576/seejph-5836 p a g e 3 | 15 abbreviations: amr antimicrobial drug resistance ap action plan bcg bacillus calmette-guérin vaccine ears-net european antimicrobial resistance surveillance network ecdc european centre for disease prevention and control eea european economic area eu european union ema european medicines agency mdr tb multidrug resistance tuberculosis ms member states of the who european region tb tuberculosis tb ap tuberculosis action plan ngo non-governmental organization sdg3 sustainable development goal 3 who world health organization xdr tb extensively drug-resistant tb introduction tuberculosis (tb) is the second most infectious killer after covid-19 (1). a bacterial infection caused by the mycobacterium tuberculosis, tb, most commonly resides in the lungs as pulmonary tb but can infect any part of the body (2). this illness is highly contagious as it spreads through airborne transmission. although it is both preventable and treatable, without sufficient treatment nearly 45% of people with tb die, and this rate increases for those with compromised immune systems such as coinfection of hiv, covid-19, etc. (2). approximately one in four people in the world have a tb infection, and the european union (eu) has the highest rate of drugresistant tb in the world (3). in 2019, the who european region exceeded the 2020 milestone of reducing tb incidence by 25% instead of the targeted 20% (4). however, the covid-19 pandemic caused several setbacks, and the who european region is no longer on track to achieve the united nations sustainable development goal 3 (sdg3) of ending tb epidemics by 2030 (5). throughout the ongoing covid-19 pandemic, there has been a drop in tb diagnoses, data reports, tb incidence reporting, funding, and an increase in tb deaths (1; 6). the drop in diagnoses is believed to be attributed to unreported data and not an actual drop in cases; experts believe there has actually been a rise in cases. furthermore, tb laboratories have been burdened by social distancing measures and fewer resources (7). this is a result of resources being allocated towards covid19 control efforts, including personnel, equipment, and monetary resources. mathematical modeling suggests longlasting setbacks in tb response and an increase in deaths and incidence due to the covid-19 pandemic (6). serling, w., lotushko, v., bocken, n., gietz, l., paric, m. policy brief on revising the tb action plan for the who european region 2016-2020: what amendments are needed to reach the un sdg3 to eliminate tb epidemics by 2030? (policy brief). seejph 2022. 26 august 2022. doi:10.11576/seejph-5836 p a g e 4 | 15 another burden for tb is antimicrobial resistance (amr). this is the ability of bacteria and fungi to develop resistance against drugs that have been produced to eliminate them (8). organ transplantation, cancer chemotherapy, and major surgeries can become high-risk without an appropriate answer to antimicrobial treatment. misuse and overuse of antibiotics are the main contributors to accelerating this process (9). this is an urgent problem that affects people's lives every day and results in prolonged illness, disability, and death. this problem is especially pertinent for those with tb since antibiotics are vital to treat the infection (10). additionally, amr dramatically increases the financial burden on national governments. according to the european commission, the 3.000 deaths due to amr cost the eu €1.5 billion per year in healthcare costs and productivity losses in 2017 (11). in the who european region, we can observe that european countries have different levels of drug resistance. ears-net data for 2019 displayed wide variations in the occurrence of amr across the eu/eea depending on the bacterial species, antimicrobial group, and geographical region (12). moreover, a north-to-south and a west-to-east gradient could be observed in the eu/eea for several bacterial species– antimicrobial group combinations (12). this gradient refers to the observation that amr rates in western and northern europe are lower than in eastern and southern europe. for instance, norway is located in the north and has a lower amr rate than bulgaria, greece, and romania, situated in the east and south. as a bacterial disease, tb demonstrates a similar pattern. due to amr, in 2019 only 63.7% of tuberculosis cases were treated successfully; 43.2% for multidrug-resistant tuberculosis (mdr tb) cases at 24 months, and 34.9% among extensively drugresistant tuberculosis (xdr tb) cases at 36 months (13). countries with the highest proportion of mdr tb rates among examples with drug susceptibility (dst) results (excluding france) were estonia (21.3%) and lithuania (17.0%), which are situated in central-east europe. this fact also reflects the geographical pattern mentioned above (figure 1). for instance, in portugal, which is located in western europe, mdr tb rate was only 1% of all tb events. xdr tb was reported for 21.9% of 584 mdr tb cases tested for second-line drug susceptibility in eu/eea region (13). serling, w., lotushko, v., bocken, n., gietz, l., paric, m. policy brief on revising the tb action plan for the who european region 2016-2020: what amendments are needed to reach the un sdg3 to eliminate tb epidemics by 2030? (policy brief). seejph 2022. 26 august 2022. doi:10.11576/seejph-5836 p a g e 5 | 15 figure 1. the proportion of tb cases notified as mdr tb in 2019, eu/eea (retrieved from ecdc. tuberculosis surveillance and monitoring in europe 2021 –2019 report 13). the united kingdom health security agency warns of a ‘hidden pandemic’ of antibiotic-resistant infections after covid19 due to misuse of drugs in case of viral infections (14). considering the fact that developing new antibiotics is a difficult process with an assessed failure rate of 95% (15) and the mean cost of developing a new drug has been estimated to be between $314 million to $2.8 billion (16), further disregard of this problem will lead to critical consequences. additionally, the lack of a widespread vaccination campaign also reflects the increased number of tb cases. currently, only the bcg vaccine is available and used against tb. it does not provide 100% protection against the development of tb, but it does offer protection for the most serious forms and complications of tb at a young age. it demonstrates 80% effectiveness against severe forms of childhood tb (tb meningitis) and roughly 60% for pulmonary tb (17). the protection effect lasts for 20 years (17). the bcg vaccine is only included in 15 european countries' immunization program schedules. despite controversial data in research about the effectiveness of the bcg vaccine, another type of immunization has not been established. currently, 15 vaccines are under development; 6 of them are at the third phase of clinical trials (re-bcg included) and are serling, w., lotushko, v., bocken, n., gietz, l., paric, m. policy brief on revising the tb action plan for the who european region 2016-2020: what amendments are needed to reach the un sdg3 to eliminate tb epidemics by 2030? (policy brief). seejph 2022. 26 august 2022. doi:10.11576/seejph-5836 p a g e 6 | 15 expected to come to market soon. however, a lack of financing impedes the research of a new vaccine against tb. statistics show that governments spent an estimated us$90 billion on covid-19 vaccine research and development (r&d) in the first 11 months of the pandemic; this is nearly 82 times the us$1.1 billion the world spent on tb vaccine research in the last 11 years (18). context the who european region developed a tuberculosis action plan (ap) 2016-2020 to address tb (19). this ap was part of the policy to achieve sdg3. the ap was largely based on the framework proposed by lönroth et al. 2015. it originally consisted of 8 priority action areas; political commitment, reaching vulnerable groups, cross-border, screening, prevention, surveillance, research, and control (20). the who european region provided support to reach several goals. these goals focused on:  care of tb patients and preventing the spread of tb among vulnerable groups and hard-to-reach populations;  policies and supportive systems to address the lack of political commitment and infrastructures;  intensifying research and innovation to create tools and new vaccines to stop tb spread. in the ap, the who european region pointed out how screening programs, better monitoring, cross-border collaboration, and ensuring access to treatment have taken place. however, the ap omits some issues. for instance, the rise of amr was not explained and amr was only mentioned once in the annex of the original ap. moreover, vaccine research has been performed, but no clear strategy on how to organize distribution and infrastructure was described. furthermore, the ap stated that declining tb visibility could lead to less political commitment. this happened at the start of the ongoing covid-19 crisis when the political attention shifted to managing the pandemic. the ap did not provide a structure that ensured the above-mentioned goals would be fulfilled if an emergency occurred. the world health organization monitored the ap implementation until their final report in 2020. the most important observation that emerged from their monitoring is a persistent lack of political commitment. most reports say that politicians, policymakers, and highlevel officials are responsible for making available structural national funding for tb research and methods of measurement for tb prevention and detection. if there is no commitment, the fight against tb will be inadequate. additionally, the european centre for disease prevention and control (ecdc) produced an overview document in 2016 on why interventions for vulnerable groups are necessary. they recommended that teams should form to garner better involvement of partners to integrate services, ensure adherence to the treatment protocol, and promote tb awareness and education (21). furthermore, several studies have evaluated the ap interventions. for example, rafetery et al. (22) examined a training program for strengthening european national reference laboratories in combating tb. this program demonstrated success in developing leadership, expertise, partnerships, and networks to support tb laboratories. additionally, a european union funding for research & innovation report (23) found the serling, w., lotushko, v., bocken, n., gietz, l., paric, m. policy brief on revising the tb action plan for the who european region 2016-2020: what amendments are needed to reach the un sdg3 to eliminate tb epidemics by 2030? (policy brief). seejph 2022. 26 august 2022. doi:10.11576/seejph-5836 p a g e 7 | 15 development of tb vaccines an accomplishment towards ending tb epidemics. lastly, the who european region’s (24) final report on the implementation of the ap acknowledged their progress prior to the onset of covid-19. many ‘in-between’ goals were reached, but since the pandemic, funding, research, and diagnosis have decreased while the tb death rate has increased. despite the who european region’s accomplishments, many targets lie ahead to achieve sdg3. policy options the who roadmap for implementing the ap is addressed to those responsible for tb prevention and care in the member states (ms) (ministries of health and other government bodies, health financing, health education, non-governmental organizations (ngos), social services, and other stakeholders). according to the who, this roadmap is applicable for all eu/eea ms. nevertheless, the implementation of the ap has not been fully processed in all of the ms (25). data about the how the ap was implemented during the covid-19 pandemic is lacking. therefore, data from 2017-2019 was obtained to analyze the progress of implementation of national tb strategies and the ap. the latest survey was conducted by collin et al. (26) in 2017 and demonstrates the progress of national implementation strategies (figure 2). serling, w., lotushko, v., bocken, n., gietz, l., paric, m. policy brief on revising the tb action plan for the who european region 2016-2020: what amendments are needed to reach the un sdg3 to eliminate tb epidemics by 2030? (policy brief). seejph 2022. 26 august 2022. doi:10.11576/seejph-5836 p a g e 8 | 15 figure 2: national tb strategy implementation in eu/eea countries in 2017 (25) collin et al. (26) identified three barriers referring to vulnerable/high-risk groups that impede tb control in the majority of eu/eea countries: lack of knowledge, low motivation to adhere to treatment, and low motivation to seek treatment. countries reported that special tb training is needed for health care workers at local levels and especially for nurses in tb patient care. in some countries, the low incidence of tb led to neglecting the importance of training health care workers in adequate tb care. additionally, political commitment for better tb control seems to be low, which results in insufficient funding. it was found that general health system constraints for tb care increase gaps in tb control between the ms. on the one hand, most of the countries rated reaching vulnerable population groups, screening for active cases, and implementation of electronic tb registers as high priority areas for action. on the other serling, w., lotushko, v., bocken, n., gietz, l., paric, m. policy brief on revising the tb action plan for the who european region 2016-2020: what amendments are needed to reach the un sdg3 to eliminate tb epidemics by 2030? (policy brief). seejph 2022. 26 august 2022. doi:10.11576/seejph-5836 p a g e 9 | 15 hand, bcg vaccination and establishing or managing tb control boards were most frequently rated as low priority areas (26). table 1: who end tb strategy implementation progress in % in 2019, including data about national tb strategy implementation in 2017 from (25). in table 1, data from figure 2 was merged with data about the implementation progress of the end tb strategy in 2019 (27), stated in the who roadmap. the coloring of the national tb strategy from figure 1 (26) was applied to the implementation progress of the ap in 2019. the percentage represents the progress of implementation of the ap related to 86 areas. the ecdc (27) did not elaborate on these 86 areas, stated in their annex 4, which is a limitation. most of the orange countries without a national plan implemented under 50% of the ap, with the exception of ireland. the implementation progress of blue-marked countries, however, is varied. the majority of countries are still scoring under 50% concerning implementation progress. overall, lithuania, romania, slovenia, and estonia progressed in their implementation of the ap. however, estonia, and lithuania show rising amr rates, which confirms the north-to-south and the west-to-east serling, w., lotushko, v., bocken, n., gietz, l., paric, m. policy brief on revising the tb action plan for the who european region 2016-2020: what amendments are needed to reach the un sdg3 to eliminate tb epidemics by 2030? (policy brief). seejph 2022. 26 august 2022. doi:10.11576/seejph-5836 p a g e 10 | 15 geographical pattern described above (27) and is demonstrated in figure 3. countries with the highest level of mdr tb as a consequence of amr's geographical pattern (estonia, lithuania, and romania) have implemented a national tb strategy in 2017 and were on track with implementing the ap in 2019. figure 3: incidence of tb per 100.000 and mdr rates in % based on data retrieved from (27) the covid-19 pandemic, rising amr rates, and stagnant tb vaccination rates add to the burden of tb across the who european region and hinder efforts to achieve sdg3 to end tb epidemics by 2030. additionally, the ap contains several missed opportunities. the 2016-2020 ap must be amended, and a new ap created for the who european region to get back on track. to achieve sdg3, the new who european region tb ap should integrate the policy recommendations detailed below. recommendations our proposed upcoming 2022-2027 ap requires new guidelines that build upon existing frameworks and address pressing tb issues in order to get back on track with achieving sdg3. this new ap should integrate both who european region guidelines and country-specific national strategies to address local and regional barriers to eliminating tb epidemics. three policy recommendations below detail specific measures the who can include in the new ap in order to bolster political will and mitigate barriers that hinder reaching sdg3. who policymakers responsible for creating a new ap should therefore consider the following policy recommendations. 1. promote agenda setting and evaluated commitment at the national level the who european region ap includes helpful guidance for better tb control, e.g., the collaborative monitoring of tb data as well as guidance for screening programs. vulnerable population groups were identified, and the who recommends more awareness to make tb care and prevention serling, w., lotushko, v., bocken, n., gietz, l., paric, m. policy brief on revising the tb action plan for the who european region 2016-2020: what amendments are needed to reach the un sdg3 to eliminate tb epidemics by 2030? (policy brief). seejph 2022. 26 august 2022. doi:10.11576/seejph-5836 p a g e 11 | 15 accessible for all population groups (25). nevertheless, collin et al. (26) demonstrated that the ms set different priorities in tb control and are facing different barriers concerning the implementation of tb strategies. this leads to problems regarding the commitment and implementation of the ap and highlights the importance of clear guidance in a new plan. therefore, tb needs to be reintroduced into the political agenda with clear guidelines concerning common goals and progress evaluation. a strong commitment from all who european region countries is needed to achieve sdg3. country-specific guidance is needed for providing support for the implementation of the ap. therefore, the who european region should amend the new ap to make it applicable for all eu/eea ms tb situations and other territories, including the incidence, mortality, treatment guidelines, and vaccination rates. standardized goals applicable for all ms can prevent implementation differences through common goal setting and evaluation of progress. the new guidance should recommend educational interventions for health care workers and tb patients in ministries of health and local health services to educate physicians and nurses working in tb care settings. evaluation guidelines can promote regular monitoring and help identify gaps in the education of healthcare workers as well as communication problems between the eu/eea ms, at national and regional levels. management structures of tb care need to be implemented at national levels. this can be assured through binding guidelines that are based on the recommendations of the who and set out by health ministries. the who should also refer to the “tb strategy toolkit”, which gives recommendations on the development and implementation of national tb strategies (28). this toolkit focuses on adjusting a tb strategy to country-specific tb situations and aims to create consistency with national health policies and national health plans. guaranteed tb care resources need to be provided and should not be used for other crisis management situations. technical assistance and funding must be guaranteed in all ms, which can be planned and calculated with the “tb strategy toolkit” (28). combining the toolkit with guidance from the who for the new ap should help reintroduce tb and especially mdr tb into the political agenda of the eu/eea ms. 2. include amr into the new action plan amr issues were not deeply integrated into the previous ap. for instance, rising amr rates through eu/eea countries have become visible, and the prevalence of mdr tb forms increased as a result. therefore, this problem has to evolve into a new milestone for the who european region in combating tb. a strong engagement between ms to increase observational, informational, educational, and resilience resources in case of tb treatment needs to be established. first of all, national governments should appropriately revise and update their medical protocols for antibiotic prescription in case of bacterial infection along with tb and include novel medicines for mdr tb care. secondly, proper education and communication for the medical and public health workforce need to be established to ensure that the amr-combating strategy will be successfully implemented. thirdly, national governments should inform the medical staff about the new ap goals and how to achieve these goals (e.g., goals that serling, w., lotushko, v., bocken, n., gietz, l., paric, m. policy brief on revising the tb action plan for the who european region 2016-2020: what amendments are needed to reach the un sdg3 to eliminate tb epidemics by 2030? (policy brief). seejph 2022. 26 august 2022. doi:10.11576/seejph-5836 p a g e 12 | 15 measure amr rate decrease and mdr tb successful treatment percentage increase), and develop digital instruments for strong monitoring of antibiotic prescription according to the protocol. lastly, wideranging information campaigns about the misuse of antibiotics and the harmful consequences of their overuse need to be developed and presented for patients by national and local governments to increase population awareness of amr. these steps could decrease antibiotic consumption and provide a reduction of amr rates. therefore, an amr combating strategy needs to be part of the new ap. 3. vaccination strategy tb is a vaccine-preventable disease, and wide vaccination campaign could decrease the incidence of tb cases. however, a vaccination strategy was not included in the previous ap, and this is a lost opportunity for the who european region. the covid-19 pandemic demonstrated how european region countries could promptly arrange vaccination campaigns and immunize a considerable part of the population. therefore, tb vaccination could rely on a similar scheme once new vaccines become available. additionally, the who and national governments need to allocate funding for researching new vaccines against tb, as due to the covid-19 crisis a lot of resources were relocated. for instance, new research grants should be provided for scientists to boost clinical trials. furthermore, while new vaccines are under development, national governments should organize their own medical infrastructures to allow for quick vaccine distribution after approval is granted by european medicines agency (ema) or equivalent organizations in the region. moreover, preparations for creating a vaccination partnership for tb could make immunization affordable for the most vulnerable countries. these actions will facilitate delivering new vaccines to the most susceptible population groups and help reach sdg3. in sum, an appropriate immunization strategy against tb, sufficient funding for novel vaccine development, and adequate market distribution needs to become a part of the new ap. conclusion the who european region is no longer on track to reach sdg3 to end tb epidemics by 2030. this is a combined result of the covid-19 pandemic deviating political attention and resources away from tb, increasing amr rates, and an outdated ap with several missed opportunities to facilitate achieving sdg3. who policymakers should urgently focus on creating a new 2022-2027 ap, taking the following recommendations into account: promote agenda setting and evaluated commitment at the national level include an amr-combatting strategy promote research towards new tb vaccine development and rollout by bolstering political will towards tb with the new ap, the who can facilitate a more robust tb strategy aimed at mitigating tb epidemics in the who european region. by including the above policy recommendations, tb will hopefully be reduced and the who european region can get back on track with achieving sdg3. serling, w., lotushko, v., bocken, n., gietz, l., paric, m. policy brief on revising the tb action plan for the who european region 2016-2020: what amendments are needed to reach the un sdg3 to eliminate tb epidemics by 2030? 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https://www.euro.who.int/en/health-topics/communicable-diseases/tuberculosis/publications/2016/roadmap-to-implement-the-tuberculosis-action-plan-for-the-who-european-region-20162020.-towards-ending-tuberculosis-and-multidrug-resistant-tuberculosis-2016 https://www.euro.who.int/en/health-topics/communicable-diseases/tuberculosis/publications/2016/roadmap-to-implement-the-tuberculosis-action-plan-for-the-who-european-region-20162020.-towards-ending-tuberculosis-and-multidrug-resistant-tuberculosis-2016 https://www.euro.who.int/en/health-topics/communicable-diseases/tuberculosis/publications/2016/roadmap-to-implement-the-tuberculosis-action-plan-for-the-who-european-region-20162020.-towards-ending-tuberculosis-and-multidrug-resistant-tuberculosis-2016 https://www.euro.who.int/en/health-topics/communicable-diseases/tuberculosis/publications/2016/roadmap-to-implement-the-tuberculosis-action-plan-for-the-who-european-region-20162020.-towards-ending-tuberculosis-and-multidrug-resistant-tuberculosis-2016 https://www.euro.who.int/en/health-topics/communicable-diseases/tuberculosis/publications/2016/roadmap-to-implement-the-tuberculosis-action-plan-for-the-who-european-region-20162020.-towards-ending-tuberculosis-and-multidrug-resistant-tuberculosis-2016 https://www.euro.who.int/en/health-topics/communicable-diseases/tuberculosis/publications/2016/roadmap-to-implement-the-tuberculosis-action-plan-for-the-who-european-region-20162020.-towards-ending-tuberculosis-and-multidrug-resistant-tuberculosis-2016 https://www.ecdc.europa.eu/en/publications-data/tuberculosis-surveillance-and-monitoring-europe-2021-2019-data https://www.ecdc.europa.eu/en/publications-data/tuberculosis-surveillance-and-monitoring-europe-2021-2019-data https://www.ecdc.europa.eu/en/publications-data/tuberculosis-surveillance-and-monitoring-europe-2021-2019-data https://www.who.int/publications/i/item/97892415079 https://www.who.int/publications/i/item/97892415079 kamberi h, tanushi v, kadrija m, kamberi s, jerliu n. level of satisfaction and socio-demographic correlates among users of primary health care services in kosovo (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5922 p a g e 1 | 9 original research level of satisfaction and socio-demographic correlates among users of primary health care services in kosovo haxhi kamberi1,2, vanesa tanushi2, muhamet kadrija2,3, safete kamberi4, naim jerliu5,6 1 regional hospital “isa grezda”, gjakova, kosovo; 2 faculty of medicine, university of gjakova “fehmi agani”, gjakova, kosovo; 3 family medicine center, gjakova, kosovo; 4 center of public health, gjakova, kosovo 5 national institute of public health of kosovo, prishtina, kosovo; 6 faculty of medicine, university of prishtina “hasan prishtina”, prishtina, kosovo. corresponding author: naim jerliu, md, phd, faculty of medicine “hasan prishtina”, university of prishtina & national institute of public health of kosovo, prishtina, kosovo address: national institute of public health of kosovo, str. instituti shëndetësor, 10000, prishtina, kosovo telephone: +38338541432; email: naim.jerliu@uni-pr.edu kamberi h, tanushi v, kadrija m, kamberi s, jerliu n. level of satisfaction and socio-demographic correlates among users of primary health care services in kosovo (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5922 p a g e 2 | 9 abstract aim: the aim of this study was to assess the level and socio-demographic correlates of satisfaction with services among adult primary health care users in kosovo. methods: a cross-sectional study was conducted in kosovo during the period may-june 2022 including a representative sample of 510 adult users (238 men and 272 women) of primary health care services in kosovo (mean age: 44.6±19.2 years). in addition to socio-demographic data, a structured 23-item questionnaire aiming at assessing the level of satisfaction with primary health care services was administered to all participants (each item ranging from 1 [high] to 5 [low]). a summary score was calculated for all 23 items related to satisfaction level ranging from 23 (the highest satisfaction level) to 115 (the lowest satisfaction level). general linear model was used to assess the association between the summary score of satisfaction level with primary health care services and socio-demographic factors of study participants. results: mean summary score of the 23 items related to the satisfaction level with primary health care services was 49.8±13.0; median score was 49 (interquartile range: 41-57). in multivariable-adjusted models, the level of satisfaction with primary health care services was significantly higher among participants with a lower educational attainment, individuals with e lower income level, and ethnic albanian participants. conclusion: this study identified important socio-demographic correlates of the level of satisfaction with primary health care services in the adult population of kosovo. findings from this study should raise the awareness of policymakers and decision-makers in kosovo and elsewhere in order to improve the quality of primary health care services. keywords: epidemiology, kosovo, patients, primary health care, satisfaction, socioeconomic factors, users of services. kamberi h, tanushi v, kadrija m, kamberi s, jerliu n. level of satisfaction and socio-demographic correlates among users of primary health care services in kosovo (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5922 p a g e 3 | 9 introduction almost 15 years after declaring its independence, kosovo is still undergoing a difficult political and socioeconomic transition, striving for wider recognition in the international arena and aspiring to join european union in due time. according to the world bank data (1), life expectancy in kosovo in 2020 was 71 years (74 years in women and 69 years in men), which is substantially lower than the national report of about 76 years (which is related to a significant under-registration of deaths) (2). crude death rate in kosovo is 8 per 1,000 population, whereas crude birth rate is 15 per 1,000 people. in turn, fertility rate is 1.9 births per woman of childbearing age (3). similar to most of the central and eastern european countries, kosovo has experienced a development of health care reform that shifted its semashko health care system established during the communist era, towards social health insurance (4). primary health care services in kosovo are regulated, somehow well-organized and standardized in all communes. in 2021, overall, there were registered about 3.2 million visits at primary health care services (5), which exhibits a decreasing trend from the previous year (2020) which registered more than 4 million primary health care visits (6). the current scientific evidence about the level and determinants of satisfaction with primary health care services in kosovo is scarce. at an international level, assessment of satisfaction level among users of healthcare service is considered an essential part of the overall assessment of health care services regarding quality and health care system responsiveness (7,8). despite the wide range of the level of satisfaction with healthcare services, three key individual determinants of satisfaction have been consistently reported from previous studies conducted internationally: expectations, health status and socio-demographic characteristics (9). the associations of users’ satisfaction with age, health status and education are usually fairly consistent, whereas the relationship between satisfaction and gender has been reported to be somehow inconsistent (10). in this context, the aim of this study was to assess the level of satisfaction and selected socio-economic correlates among adult primary healthcare users in kosovo. we hypothesized a higher level of satisfaction among younger participants, male individuals, and higher socioeconomic status participants. methods a cross-sectional study was conducted in kosovo during the period may-june 2022 in a sample of primary healthcare users. the study was carried out in three regions of kosovo: gjakova, peje, and prizren, which constitute some of the main regions of the republic of kosovo. a representative sample of individuals attending primary healthcare services in the regions of gjakova, peje and prizren was included in this survey. more specifically, the study population consisted of a random sample of 510 adult individuals (91% response rate; 238 men and 272 women – all 18 years and above) attending different primary healthcare centres/facilities in the aforementioned three regions of kosovo. a structured 23-item questionnaire (11) inquiring about the level of satisfaction with primary healthcare services was administered to all study participants. assessment of satisfaction level consisted of the 23-item europep instrument (11). this instrument has been previously validated in the adult population of kosovo (12). kamberi h, tanushi v, kadrija m, kamberi s, jerliu n. level of satisfaction and socio-demographic correlates among users of primary health care services in kosovo (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5922 p a g e 4 | 9 a summary score was calculated for all 23 items related to the level of satisfaction with primary healthcare services ranging from 23 (highest level of satisfaction) to 115 (lowest level of satisfaction with primary healthcare services). furthermore, information about demographic factors (age, sex, ethnicity, marital status and place of residence) and socioeconomic characteristics (employment status, educational attainment and income level) were gathered for all study participants. the study was approved by the ethics commission and council of the faculty of medicine, university of gjakova. fisher’s exact test was used to compare differences in socio-demographic factors (age, place of residence, marital status, ethnicity, employment status, educational attainment and income level) between male and female participants. conversely, general linear model was used to assess the association between the summary score of the satisfaction level with primary healthcare services (23-item instrument) and socio-demographic factors of study participants. firstly, crude (unadjusted) mean values, their respective 95% confidence intervals (95%cis) and p-values were calculated. secondly, multivariable-adjusted models were run controlling simultaneously for all socio-demographic factors of study participants (age, sex, ethnicity, place of residence, employment, educational attainment and income level). multivariableadjusted mean values, their respective 95%cis and p-values were calculated. a p-value ≤0.05 was considered as statistically significant in all cases. statistical package for social sciences (spss, version 19.0) was used for all the statistical analyses. results mean age (±sd) of participants included in this study was 44.6±19.2 years; median age was 44 years (interquartile range: 27-59 years); the age range was: 18-88 years (not shown in the tables). table 1 presents the distribution of sociodemographic factors of study participants (n=510), separately in men and in women. overall, about 32% of individuals were aged ≤30 years, whereas 38% of participants were 51 years and above. about 50% of participants resided in rural areas, whereas about 90% were ethnic albanians. about 62% of individuals were currently married (which was more prevalent in men than in women, p=0.01). only half of study participants (51%) were currently employed (62% in men vs. 40% in women, p<0.01). around 41% of individuals had a low educational attainment (≤8 years of formal schooling), whereas 26% of them had a high educational level (with significant gender differences: p=0.01). on the whole, 49% of individuals had a lowincome level, whereas only about 7% of participants reported a high-income level. there were no statistically significant differences in the distribution of the other socio-demographic characteristics between men and women included in the study (table 1). a summary score was calculated for all 23 items of the satisfaction level with primary healthcare services ranging from 23 (indicating the highest level of satisfaction with primary healthcare services) to 115 (indicating the lowest level of satisfaction with primary healthcare services). mean summary score of the 23 item-instrument of the level of satisfaction with primary healthcare services was 49.8±13.0; median kamberi h, tanushi v, kadrija m, kamberi s, jerliu n. level of satisfaction and socio-demographic correlates among users of primary health care services in kosovo (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5922 p a g e 5 | 9 score was 49 (interquartile range: 41-57) [data not shown in the tables]. table 1. socio-demographic factors in a sample of primary health users in kosovo in 2022 (n=510) socio-demographic factors total (n=510) men (n=238) women (n=272) p † age-group: ≤30 years 31-50 years ≥51 years 164 (32.2)* 154 (30.2) 192 (37.6) 65 (27.3) 74 (31.1) 99 (41.6) 99 (36.4) 80 (29.4) 93 (34.2) 0.073 place of residence: urban areas rural areas 254 (49.8) 256 (50.2) 111 (46.6) 127 (53.4) 143 (52.6) 129 (47.4) 0.106 region: peje prizren gjakove 146 (28.6) 176 (34.5) 188 (36.9) 68 (28.6) 83 (34.9) 87 (36.6) 78 (28.7) 93 (34.2) 101 (37.1) 0.986 ethnicity: other albanian 50 (9.8) 460 (90.2) 22 (9.2) 216 (90.8) 28 (10.3) 244 (89.7) 0.403 marital status: other married 191 (37.5) 319 (62.5) 76 (31.9) 162 (68.1) 115 (42.3) 157 (57.7) 0.010 educational level: low middle high 209 (41.0) 167 (32.7) 134 (26.3) 91 (38.2) 94 (39.5) 53 (22.3) 118 (43.4) 73 (26.8) 81 (29.8) 0.008 employment status: employed unemployed retired 257 (50.5) 157 (30.8) 95 (18.7) 147 (62.0) 49 (20.7) 41 (17.3) 110 (40.4) 108 (39.7) 54 (19.9) <0.001 income level: low middle high 250 (49.1) 226 (44.4) 33 (6.5) 124 (52.3) 101 (42.6) 12 (5.1) 126 (46.3) 125 (46.0) 21 (7.7) 0.269 * numbers and column percentages (in parenthesis). † p-values from fisher’s exact test. table 2 presents the association between summary score of satisfaction level with primary healthcare services and sociodemographic factors of study participants. in crude (unadjusted) general linear models, the mean summary score of the 23-item kamberi h, tanushi v, kadrija m, kamberi s, jerliu n. level of satisfaction and socio-demographic correlates among users of primary health care services in kosovo (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5922 p a g e 6 | 9 instrument measuring the level of satisfaction with primary healthcare services was significantly higher among ethnic albanians compared to other ethnic groups: 49.3 vs. 54.8, respectively (p=0.01). furthermore, the level of satisfaction with primary healthcare services was higher among low-income participants compared to their high-income counterparts (47.5 vs. 54.9, respectively), and among low-educated individuals compared to highly educated participants (49.2 vs. 51.9). conversely, there were no differences in summary scores of the level of satisfaction with primary healthcare services between male and female participants, urban and rural residents, or between different age-groups of individuals included in this study. table 2. association between the level of satisfaction with primary healthcare services and socio-demographic factors – results from the general linear models socio-demographic factors unadjusted models multivariable-adjusted models mean* 95%ci p mean 95%ci p sex: women men 49.8 49.8 48.1-51.5 48.2-51.3 0.952 53.1 53.7 50.6-55.7 50.9-56.5 0.624 age-group: ≤30 years 31-50 years ≥51 years 50.0 49.6 49.8 48.0-52.0 47.5-51.7 47.9-51.7 0.963 (2)† 0.914 0.862 reference 53.7 52.7 53.9 50.6-56.8 49.7-55.7 51.0-56.9 0.699 (2) 0.874 0.442 reference ethnicity: albanian other groups 49.3 54.8 48.1-50.5 51.0-58.6 0.007 51.2 55.7 49.2-53.2 51.7-59.6 0.032 place of residence: urban areas rural areas 49.8 49.8 48.2-51.5 48.2-51.4 0.985 53.3 53.6 50.7-55.9 50.9-56.2 0.832 educational level: low middle high 49.2 48.9 51.9 47.5-51.0 46.9-50.9 49.6-54.1 0.111 (2) 0.073 0.054 reference 51.9 52.2 56.2 49.3-54.6 49.2-55.1 52.9-59.5 0. 019 (2) 0.012 0.011 reference employment: employed unemployed retired 50.4 49.0 49.7 48.7-51.9 47.0-51.1 47.0-52.4 0.610 (2) 0.681 0.703 reference 53.7 52.7 53.9 51.2-56.3 49.7-55.7 50.1-57.6 0.742 (2) 0.941 0.577 reference income level: low middle high 47.5 51.7 54.9 45.6-49.1 50.0-53.4 50.3-59.5 <0.001 (2) 0.003 0.196 reference 49.3 54.2 56.7 46.8-51.8 51.7-56.8 52.0-61.5 <0.001 (2) 0.004 0.321 reference * range of the summary score from 23 (the highest level of satisfaction) to 115 (the lowest level of satisfaction with primary healthcare services). † overall p-values and degrees of freedom (in parentheses). kamberi h, tanushi v, kadrija m, kamberi s, jerliu n. level of satisfaction and socio-demographic correlates among users of primary health care services in kosovo (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5922 p a g e 7 | 9 in multivariable-adjusted models, the significant association with ethnicity persisted strongly, with ethnic albanians exhibiting a significantly higher satisfaction level with primary healthcare services compared with the other ethnic groups, whereas the association with educational attainment was accentuated. in brief, upon simultaneous multivariable adjustment for all socio-demographic characteristics, mean summary score of satisfaction level with primary healthcare services was significantly higher among: low-educated individuals compared to highly educated participants (51.9 vs. 56.2, respectively); in low-income participants compared to high-income individuals (49.3 vs. 56.7, respectively); and ethnic albanian participants compared to other ethnic groups (51.2 vs. 55.7, respectively) [table 2]. discussion the main finding of this study consists of a remarkably significant relationship between satisfaction level with primary healthcare services and selected key socio-demographic characteristics including educational attainment, income level, and ethnicity. the associations with these three characteristics persisted upon adjustment for several other key socio-demographic factors including age, gender, place of residence, and employment status. our working hypotheses on a positive relationship of satisfaction level with age and male gender were not evidenced, in contrast with a previous study conducted in kosovo (12), and also a fairly recent report from the neighbouring albania (unpublished – personal communication), which both reported a higher satisfaction level among younger and male primary healthcare users. on the other hand, the association with socioeconomic level evidenced in our study is compatible with the previous reports from kosovo (12) and albania. a few studies conducted in turkey employing the same europep instrument have reported a higher level of satisfaction with primary healthcare services among the low-educated participants (13,14), a finding which is in line with our study. a factor that may be related to users’ satisfaction concerns the individuals’ expectations from health care: the lower the expectations, the higher the level of satisfaction, and vice versa (15). this may also explain the higher satisfaction level evidenced in our study among the loweducated individuals. in our study we found a lower satisfaction level with primary healthcare services among ethnic minorities. this finding is compatible with international reports which have similarly evidenced a lower satisfaction level among ethnic minorities (16-20). regarding the inverse association between satisfaction level and income status, our findings are not in line with a previous study (21), whereas several other studies have reported similar results with our study (i.e., a higher level of satisfaction among the lowincome individuals) (22,23). however, there are several limitations of this study conducted in three regions of kosovo which consist of the sample size of primary healthcare users, the sample representativeness, the odds of information bias and the issue of study design. seemingly, the sample size included in our study was sufficient to assess the extent (magnitude) of satisfaction level among primary healthcare users and the association with sociodemographic characteristics. yet, subtle differences in the level of satisfaction among patients belonging to different sociodemographic categories might have been kamberi h, tanushi v, kadrija m, kamberi s, jerliu n. level of satisfaction and socio-demographic correlates among users of primary health care services in kosovo (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5922 p a g e 8 | 9 missed, given the sample size at hand. hence, a larger sample size would allow for exploration and comparison of smaller differences in the levels of satisfaction between different socioeconomic groups. more importantly, study participants were pertinent only to three regions of kosovo and, therefore, generalizability of our findings should be interpreted with caution. the europep instrument employed in our study has been previously successfully validate in the adult population of primary healthcare users in kosovo (12), which is comforting. nonetheless, the possibility of information bias cannot be discarded. finally, associations observed in crosssectional studies do not imply causality. despite of these potential limitations and drawbacks, this study provides valuable evidence about the level of satisfaction with primary healthcare services among adult patients in three regions of kosovo. findings from this study should raise the awareness of policymakers and decision-makers in kosovo in order to improve the quality of primary health care services. references 1. the world bank. life expectancy at birth in kosovo. https://data.worldbank.org/indica tor/sp.dyn.le00.in?locations= xk (accessed: 30 september, 2022). 2. republic of kosovo: ministry of health. health strategy 20172021. pristina, 2016. 3. the world bank. total fertility rate in kosovo. https://data.worldbank.org/indica tor/sp.dyn.tfrt.in?locations =xk (accessed: 30 september, 2022). 4. pavlova m, tambor m, stepurko t, merode g, groot w. assessment of patient payment policy in cee countries: from a conceptual framework to policy indicators. soc econ. 2012;34:193-220. 5. agency of statistics, republic of kosovo. health statistics, 2021. pristina, 2022. https://ask.rksgov.net/media/7052/statistikat-esh%c3%abndet%c3%absis% c3%ab-2021.pdf (accessed: 30 september, 2022). 6. agency of statistics, republic of kosovo. health statistics, 2020. pristina, 2021. https://ask.rksgov.net/media/6320/statistikat-eshendetesise-2020.pdf (accessed: 30 september, 2022). 7. bleich sn, özaltin e, murray cj. how does satisfaction with the health-care system relate to patient experience? b world health organ 2009;87:271-8. 8. bjertnaes oa, sjetne is, iversen hh. overall patient satisfaction with hospitals: effects of patientreported experiences and fulfilment of expectations. bmj qual saf 2012;21:39-46. 9. crow r, gage h, hampson s, hart j, kimber a, storey l, & thomas h. the measurement of satisfaction with healthcare: implications for practice from a systematic review of the literature. health technol assess 2002;32. http://www.journalslibrary.nihr.a kamberi h, tanushi v, kadrija m, kamberi s, jerliu n. level of satisfaction and socio-demographic correlates among users of primary health care services in kosovo (original research). seejph 2022, posted: 06 october 2022. doi: 10.11576/seejph-5922 p a g e 9 | 9 © 2022 kamberi et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. c.uk/__data/assets/pdf_file/0008/ 64934/fullreport-hta6320.pdf (accessed: 30 september, 2022). 10. pascoe gc. patient satisfaction in primary health care: a literature review and analysis. eval program plann 1983;6:185-210. 11. wensing m. europep 2006. revised europep instrument and user manual; 2006. https://www.yumpu.com/en/docu ment/view/20032561/europep2006-topas-europe (accessed: 30 september, 2022). 12. tahiri z, toçi e, rrumbullaku l, hoti k, roshi e, burazeri g. patients’ evaluation of primary health care services in gjilan region, kosovo. j public health (oxf) 2014;36:161-9. 13. aktürk z, ateşoğlu d, çiftçi e. patient satisfaction with family practice in turkey: three-year trend from 2010 to 2012. eur j gen pract 2015;21:238-45. 14. dağdeviren n, akturk z. an evaluation of patient satisfaction in turkey with the europep instrument. yonsei med j 2004;45:23-8. 15. naseer m, zahidie a, shaikh bt. determinants of patient's satisfaction with health care system in pakistan: a criticalreview. pakistan j public health 2012;2:52-61. 16. hayek s, derhy s, smith ml, towne sd jr, zelber-sagi s. patient satisfaction with primary care physician performance in a multicultural population. isr j health policy res 2020;9:13. 17. johnson rl, saha s, arbelaez jj, beach mc, cooper la. racial and ethnic differences in patient perceptions of bias and cultural competence in health care. j gen intern med 2004;19:101-10. 18. johnson rl, roter d, powe nr, cooper la. patient race/ethnicity and quality of patient–physician communication during medical visits. am j public health 2004;94:2084-90. 19. saha s, arbelaez jj, cooper la. patient–physician relationships and racial disparities in the quality of health care. am j public health 2003;93:1713-9. 20. taira da, safran dg, seto tb, et al. asian-american patient ratings of physician primary care performance. j gen intern med 1997;12:237-42. 21. vuong qh, vuong tt, ho tm, nguyen hv. psychological and socio-economic factors affecting social sustainability through impacts on perceived health care quality and public health: the case of vietnam. sustainability (switzerland); 2017;9. 22. nguyen t, nguyen h, dang a. determinants of patient satisfaction: lessons from largescale inpatient interviews in vietnam. plos one 2020;15:e0239306. 23. alshammari f. patient satisfaction in primary health care centers in hail city, saudi arabia. am j appl sciences 2014;11:1234-40. _____________________________________________________________________________________ macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 1 | 15 original research socially responsible human resources management and stakeholders’ health promotion: a conceptual paper gloria macassa1,2, gianpaolo tomaselli3 1 department of public health and sports sciences, university of gävle, gävle, sweden; 2 epiunit – instituto de saúde pública, universidade do porto, porto, portugal; 3 department of health services management, faculty of health sciences, university of malta, malta. corresponding author: prof. gloria macassa; address: 801 76 gävle, sweden; e-mail: gloria.macassa@hig.se. macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 2 | 15 abstract the prime objective of this paper is to propose a new conceptual framework for how integrating corporate social responsibility (csr) and human resources management (hrm) can impact on stakeholders’ health and wellbeing. the proposed framework argues that integrative socially responsible hrm (sr-hrm) policies coupled with public health literacy and integrative responsible leadership can play a significant role in shaping health behaviour change of internal stakeholders, which in turn can spill over to external stakeholders (family and proximate communities). from a health promotion and population health perspective, we see human resources (hr) as a leading partner in educating employees on the value of csr and public health literacy programmes, and also as providing action plans on how to strategically and successfully implement these types of programmes. by helping to develop action plans to analyse crs and public health literacy activities, hr professionals will be promoting both corporate citizenship and health behaviour change. both of these are vital for developing a culture of social responsibility (and achieving the triple bottom line (tbl)) and sustainable population health promotion. henceforth, srhrm policies and practices could help business organizations to contribute to the achievement of the united nations’ sustainable development goals (sdgs) and specifically goals 3 and 8. this novel framework, which is especially pertinent to public health, has not yet been tested empirically. hence, future studies are warranted to empirically test the theoretical framework using field data collection. keywords: corporate social responsibility, public health literacy, responsible leadership, socially responsible human resources, stakeholders’ health and wellbeing. acknowledgements the authors would like to thank dr jesus barrena-martínez for his valuable comments and suggestions on the conceptual framework. gm is grateful for the support of the department of public health and sports science at the university of gävle, through the csr-pham programme and relesh project. conflicts of interest: none declared. macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 3 | 15 introduction in recent years, various scholars have argued that there is a need to integrate corporate social responsibility (csr) and human resources management (hrm) across business organizations in order to better advance a sustainability agenda and, ultimately, the triple bottom line (tbl) of profit, people, planet – or, differently put, economic, social and environmental sustainability (1,2). notwithstanding positive findings regarding the importance of csr as a potential strategic partner for hrm in management, there still is the need to better understand how this relationship can be understood in other disciplines such as public health. in the context of how business organizations can contribute to address society’s wicked problems, and especially the promotion of stakeholders’ health and wellbeing, it has recently been argued that integrated csr-hrm can contribute to improving population health through public health literacy (3). therefore, this paper attempts to propose a conceptual framework for how integrated csr-hrm can potentially affect stakeholders’ health and wellbeing within the context of sustainable development in terms of the tbl. the paper first discusses concepts regarding the integration of csr-hrm, then proposes a framework for how the nexus of csr-hrm can contribute to the promotion of internal and external stakeholders’ health and wellbeing, and finally identifies a future research agenda. the integration of corporate social responsibility and human resource management corporate social responsibility involves integrating social, environmental and ethical concerns, as well as respect for human rights and consumer concerns, in a business organization’s business operations and its basic strategy as a means to maximize the creation of value for its owners, stakeholders and society in the broad sense; and further identifying, preventing and mitigating their potential adverse consequences on the environment (4). for the business organization, it means the introduction of socially responsible elements in the daily management of its business that legitimize its activities across the groups with which it interacts (e.g. shareholders, partners, suppliers, customers, public institutions, non-governmental organizations, employees and their families, communities, and society in general). on the other hand, hrm is defined as the philosophy, policies, procedures and practices related to the management of an organization’s employees (1). also, hrm can be seen as a set of organizational and people-oriented functions or activities deliberately designed to influence the effectiveness of employees in the organization (5). it is suggested that hrm should be understood as concerned with all activities that are aimed to contribute to successfully attracting, developing and maintaining a high-performing workforce needed to achieve success within a business organization (5,6). however, in recent years, the hrm role appears to have transitioned from being an administrative support service within organizations to providing a strategic hrm, thus shifting focus from a narrow maintenance role to an active one in which hr strategies are employed that integrate overall business strategy, empower employees and help restructure the organization (1,5). according to some scholars, the csr-hrm nexus can be understood through a common thread, the stakeholder theory, which helps to explicate the integration of csr actions in the business organizations’ management (1,2,7). the stakeholder theory focuses on the importance of stakeholders in the course and macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 4 | 15 success of csr business activities. nonetheless, because business organizations have multiple stakeholders that are involved in their organizational activities, it is important that they differentiate these stakeholders and prioritize them (1). the literature has proposed dividing stakeholders into two groups: (i) primary stakeholders, who have a formal contract with the organization and are essential for its proper functioning (owners, shareholders, employees, unions, customers, suppliers, etc); and (ii) secondary stakeholders, who, though not directly involved in the economic activities of a company, can exercise a significant influence on its activities (employees’ families, citizens, competitors, the local community, government, public administration) (1,5,6). in this conceptual paper we consider employees as primary stakeholders, while the supply chain, consumers, local communities and society at large are considered as secondary stakeholders. corporate social responsibility cuts across different departments in any given organization and influences the way the organization conducts its business and relates with its stakeholders, both internally and externally; the hrm activities affect all units and departments in the organization. through the stakeholder theory bridge, hrm systems should take increasing responsibility in managing csr activities. this way csr would expand the hr agenda and help its effective implementation instead of the current overlap of activities which still takes place in many business organizations (5,7). furthermore, it has been argued that csr can also expand the role of hrm in supporting workplace practices that contribute to organizational efficiency and effectiveness (e.g. smart working, family-friendly policies, flexible hours) (5) and that a combined csr-hrm strategy can be the catalyst for the long-term success of business organizations (8,9). according to simmons, hrm needs to be seen both as a component and as a potential facilitator of csr (8). voegtlin and greenwood propose studying the link between csr and hrm from three theoretical perspectives: the instrumental, integrative and political perspective (10). the instrumental perspective posits that the involvement of workers in csr is instrumental in achieving greater economic outcomes for the organization. furthermore, this perspective considers the importance of profit maximization, simply said: how csr and hrm synergies can improve the business organization’s financial performance (2,10). in this perspective, csr is associated with hard hrm (e.g. focusing on the task that needs to be done, cost control, and achieving organizational goals). by contrast, the integrative, or social integrative, perspective looks at how csr and hrm can reinforce each other to create social benefit for the organization and its stakeholders. this approach bases itself in the relation between csr and soft hrm to examine how the integration of the social demands of employees can improve their wellbeing and motivation as well as overall stakeholder value (2,10). the integrative approach to csrhrm links csr strategies with soft hrm which views stakeholders (internal and external) as critical resources that are key to the business organization’s long-term business strategies (2,10). finally, the political approach to csr-hrm accommodates the power of corporations in society and the concomitant responsibilities this power implies. this perspective points to the relevance of contextual institutions (local, national and international) in csr and hrm (2,10). macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 5 | 15 there have been few studies that have investigated how the integrated csr and hrm nexus has contributed to stakeholders’ outcomes from a management perspective. for instance, a study by tekin regarding hrm dimensions in csr, which was carried out in turkey, found that csr led to improvements in recruitment to organizations and that these improvements had an impact on commitment to csr initiatives, thus making the organizations more attractive to potential employees (11). furthermore, there was a close relationship between csr and training activities that incorporated workplace policies (11). in another study, celma and colleagues analysed the effectiveness of several hrm practices that were considered socially responsible, according to internal institutions, in terms of three dimensions of wellbeing: job stress, job satisfaction, and trust in management. their results showed that higher job quality increased employees’ wellbeing at work, but some practices were more effective than others for each of the wellbeing dimensions (12). also, shao et al. found that socially responsible hr policies increased employees’ organizational citizenship behaviour while decreasing their task performance through roleambiguity mediation (13). in the same study, prosocial motivation served as a significant moderator in strengthening the positive relationship between socially responsible hr practices and organizational citizenship behaviour as well as the negative association between socially responsible hr practices and task performance (13). from lithuania, buciunene and kazlauskaite report that there is a relationship between hrm, csr and performance outcomes in an organization. in their study, organizations in which hrm was a function for csr were found to have better csr policies (14). elsewhere, a study by abdulmotaleb and saha that investigated the processes linking socially responsible hrm to employee wellbeing in egypt found that positive employee perceptions of organizational morality arising from socially responsible hr policies and practices led to an “enhanced state-based positive affect at work that ultimately increased employee vitality” (15). using insights from social exchange and social identity theories, newman and co-authors investigated the influence of three dimensions of sr-hrm, namely, legal compliance hrm, employee-oriented hrm, and general csr facilitation, on employees’ organizational citizenship behaviours in chinese organizations (16). their findings showed that, while organizational identification fully mediated the relationship between employee-oriented hrm and employees’ citizenship organizational behaviours, general csr facilitation of hrm had a direct effect on employee organizational citizenship behaviour. in addition, legal compliance hrm did not influence employee organizational citizenship behaviour either directly, or indirectly through organizational identification (16). barrena-martínez and colleagues suggest that the integrative model of hrm needs to be studied from four complementary management perspectives. the first of these is the universalistic perspective which posits that there is a common and universal successful way in which the management of human capital organizations should be done, independent of country or any other variable (7). however, this view has been criticized for ignoring the potential contribution of context as well other variables (e.g. business strategy, technology and investments). the second perspective, the contingency perspective, argues that socially responsible hr policies re macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 6 | 15 sult from a combination of contingent internal (e.g. structure, size, technology, business strategy) and external (e.g. organizational environment) variables to achieve a solid, responsible system (7). the third perspective, called the “configurational perspective”, sees socially responsible hr policies through the synergy and interactions of these policies with internal and external variables. this would mean a social orientation that is coherent with hr and csr strategies consistent practices resulting from the proposed policies. in addition, socially integrated hr policies would need to consider the potential role of institutional pressures and stakeholder requirements in the context in which the organization operates. to this end, the fourth and last perspective puts emphasis on how the identification of contextual aspects outside the organization (political, socio-economic, environmental, cultural, educational and trade union aspects) as well as inside the organization (company size, technology working environment, innovation, and different stakeholders’ interests) can be of great importance in the integration of socially responsible human resources management (srhrm) policies (7). in this paper we argue that an integrated srhrm approach that takes into account the context outside (political, socio-economic, environmental, etc; see above) and inside the organization (company size, technology working environment, innovation, etc) is best positioned to contribute to stakeholders’ health promotion. with this perspective in mind we expect sr-hrm policies within the organization to include public health literacy that might in the long term contribute to improvements in employees’ (and their families’) wellbeing. we assume that the hr component of the integration would help the messaging and implementation of initiatives aimed to improve wellbeing based on the tbl. this would occur through training of employees in matters regarding physical activity literacy, mental health literacy, and overall wellness strategies as well as environmental-related risks linked to health outcomes. this way workplaces would develop strategies that would increase health information and services aimed at employees as well as their families. according to freedman and colleagues, public health literacy is the degree to which individuals and groups can obtain, process, understand, evaluate, and act upon information needed to make public health decisions that benefit the community and all its stakeholders (17). public health literacy is seen as a challenge for public health and health promotion as it represents a new, higher level of health literacy, through which the population as a whole (and within different arenas) can better understand health information related not only to the individual, but also to the community (18). moreover, it is posited that, compared with individual health literacy, public health literacy includes a myriad of factors such as poverty, globalization and climate change that have an influence on public health. thus, public health literacy “takes into account the complex social, economic, environmental and systemic forces that affect health and wellbeing” (17). hence, public health literacy is the best synergetic partner for business organizations in their pursuit of implementing sr-hrm policies and practices for the tbl, as well as for the achievement of the united nations’ (un) sustainable development goal 3 (healthy lives and wellbeing for all at all ages) and goal 8 (decent work and economic growth). individual health literacy is considered to be a stronger predictor of individual and popula macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 7 | 15 tion health outcomes, even more than are income, ethnicity, education, employment status and age (19,20). low health literacy has been associated with less use of preventive health services; reduced ability to manage chronic conditions (e.g. diabetes, asthma, high blood pressure); and lower likelihood to follow provider orders, such as proper use of medication; as well as feelings of shame at having low skill levels, and reduced capacity to act upon health alerts. furthermore, low health literacy has been linked to poor selfreported health, and workplace injuries (1921). conceptual framework socially responsible human resources management and stakeholders’ health promotion in this paper, we posit that a socially integrated csr-hrm approach oriented through a contextual approach to management (taking into account the social, environmental, political and cultural aspects of the context in which business organizations operate) (7) will, through public health literacy at the workplace, educate employees on health and wellness. further, the employees will in turn disseminate health and wellbeing knowledge to other stakeholders (e.g. families and communities at large). the establishment of educational training with emphasis on physical activity, wellness and mental health literacy will contribute to the reduction of health care costs due to preventable diseases (including chronic disease), as well as to decreased levels of absenteeism and presenteeism (22). box 1 of the framework (figure 1) depicts the integration of the csr strategies with those from hrm within the context in which the organization operates (i.e. the local, national and/or international context). this way, as described above, hrm will become a function of csr and will help deliver public health literacy (including individual literacy) to primary stakeholders (the employees). box 2 (figure 1) of the framework displays potential intermediary variables in the business organization which can facilitate (or hinder) the implementation of an integrated csr-hrm. we suggest two potential mechanisms through which an integrated csrhrm can influence internal and external stakeholders’ health and wellbeing (physical and psychological health outcomes). figure 1. conceptual framework socially responsible human resource management and stakeholder’s health promotion (authors’ own adaptation of barrena-martinez et al. 2018 framework) macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 8 | 15 the first mechanism includes “socially responsible hrm policies” that impact employee and organizational wellbeing as well as organizational performance. barrena-martínez and colleagues identified eight srhrm policies: attraction and retention of employees; training and continuous development; management of employment relations; communication, transparency and social dialogue; diversity and equal opportunity; fair remuneration and social benefits; prevention, health, and safety at work; and work–family balance (1). empirical evidence has shown that socially responsible companies (companies that care about the tbl and sustainability in general) are likely to attract new workers (23). employees’ training and continuous development is an important part of social responsibility, and it ensures that the employees feel empowered and become motivated to change. employees are important assets and, hence, investment should be made in their training and development. it is argued that hr is the best change management partner for educating and empowering the entire workforce for change with regard to social responsibility, sustainability and the tbl. others go even further to suggest that hr has the responsibility to be proactive, thus leading the way in the establishment of a business organization-wide, csr-enabled culture (24). it is within this training and development of socially responsibility practices that we see the importance of public health literacy in contributing to the promotion of health and wellbeing. in such a context, employees will be educated about the importance of achievement of economic profit in tandem with environmental quality and social equity (25), and will also learn about how these contribute to the health and wellbeing of all stakeholders. human resource professionals are well positioned to help with the formulation, execution and monitoring of such training. strandberg argues that hr managers have not only the tools but also the opportunities to leverage commitment to, and engagement in, the business organization csr strategy (26). engagement in such strategy can enable employees to achieve physical activity, wellness and mental health literacy, which are important predictors for the achievement of positive health outcomes. the public health literacy training would include physical activity, mental health literacy and overall notions of wellness. here, “physical activity literacy” is defined as having the motivation, confidence, physical competence, knowledge and understanding to value and take responsibility for engagement in physical activities (27,28). on the other hand, “mental health literacy” goes beyond simple awareness of one’s mental health, to a place of greater understanding and skill development related to maintaining mental health and effectively coping with challenges. thus, mental health literacy becomes a fundamental element of mental health promotion, and prevention, early identification, and treatment of mental health disorders (29-31). to exemplify how an integrated csr-hrm strategy could potentially contribute to promote stakeholders’ health we can consider a “workplace wellness program”. such a program would aim to target modifiable risk factors of disease such as physical activity, nutrition, smoking cessation as well as mental and environmental literacy for employees and their families (3, 22). furthermore, these activities can extend to supply chain collaborators, thus covering both internal stakeholders (employees) and external stakeholders (family members and actors in the supply chain). however, carrying out wellness programs might pose challenges to employers and employees alike. for instance, business macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 9 | 15 organizations might be conflicted from the need to make profits as well as to motivate their employees for sustainable and healthy changes, especially in the short term. in addition, organizations might lack financial and leadership-related resources (32). mccoy and colleagues reported that regardless of company size, potential barriers to workplace wellness included cost, time, expertise and legal concerns (32). moreover, employees can be reticent to participate. for instance, a us study found that the most common barriers to employees’ participation were insufficient incentives, inconvenient locations, time limitations, lack of interest in topics presented, schedule, marketing and health beliefs (33). however, we see workplace wellness and public health literacy within it as a unique opportunity to promote health and wellbeing for all stakeholders but specifically for employees (primary stakeholders) and their families. a recent randomized clinical trial that studied the effect of a workplace wellness program on employees’ health in us found that employees exposed to the program reported significantly higher rates of some positive health behaviours (e.g. weight management and regular exercise) compared with those who were not exposed. nevertheless, the same study found no significant effects on clinical measures of health, health care spending and utilization, or employment outcomes after 18 months (34). commenting their findings, the authors argued that it was possible that behavioural change may precede improvements in other outcomes suggesting future improvements in health or reductions in health-care spending (34). this is in line with our suggested framework where we expect public health literacy policies to contribute to behavioural change in domains of healthy life style, mental health and environmental understanding conductive to improved health and wellbeing both in the workplace and society. according to mujtaba et al., a company’s investments in its employees’ health and wellness will “pay off” for the company in the long-run and will provide benefits for employees, their co-workers, families, communities, and society as a whole (35). regarding the socially responsible policy of management of employment relationship, this centres on decent work, respect for human rights, ethics, social responsibility and the labour rights of the workers. moreover, the policy encompasses employer–employee communication regarding potential changes in the organization that might alter the contractual employer–employee relationship and can contribute to employees being able to plan their careers (1). the sr-hrm policy relates to communication, and transparency in communication that promotes employee participation in the organization’s decisionmaking. it is suggested that employees feel empowered if they perceive that they can contribute with their opinions, ideas and proposals, and activities within the organization. of great importance here is the communication to employees, not only about the organization’s economic results, but also those related to its environmental and social performance (1,36). the diversity and equal opportunity policy is of importance in terms of employee motivation, creativity and commitment (37). it is a policy that argues for the promotion of equal opportunity and diversity at the workplace, in other words, a policy that ensures non-discrimination (e.g. based on age, ethnic background, disability) and fair policies in management practices. according to lee et al, if employees are aware of the social value of these practices within the organization, they macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 10 | 15 will be involved with and committed to the organization in the long term because of its system of work able to produce benefits from widespread cultures and different values (38). furthermore, the policy of “fair remuneration and social benefits” centres on the need to ensure pay equity and add value in social coverage or benefits offered to employees (1). the available evidence states that wage disparities can contribute to social conflicts between employees (39). prevention, health and safety at work is an sr-hrm policy that has an impact on internal and external stakeholders’ wellbeing. organizational health (including occupational health and wellness) is a growing concern for hrm today. workers who perform their tasks under safe physical and psychosocial working conditions contribute to long-term achievement of organizational goals (40,41). we argue that within this policy, a socially integrated csr-hrm approach will contribute to prevention because occupational health and safety, physical activity and mental health literacy will take a central stage. increased prevention knowledge will benefit not only individual employees, but also the organization and the employees’ families (which can spill over to the communities in which these employees live). improved public health literacy (including individual health literacy) is likely to contribute to a reduction in sickness absence and presenteeism, physical inactivity, obesity, diabetes type ii, cardiovascular disease, and distress which might cause depression among employees and their respective families (42-45). the work-life balance policy aims to provide conditions that have a positive impact on stakeholders’ wellbeing. employees need to have a balance between the time allocated for work and other aspects of life (e.g. family, social and leisure activities) (46). it is argued that organizations need to have in place mechanisms to facilitate changes in working hours to accommodate family needs, to provide time for parenthood for both men and women and, where possible, to grant transfers of employees who are geographically separated from their family. evidence has shown that employees who experience a greater work–life balance are likely to experience better mental outcomes (47). we argue that the policies outlined above can serve as a vehicle to deliver tbl concepts for a sustainable organization in which employees will acquire knowledge of wellness promotion (physical activity and mental health literacy), which is critical to improving health and wellbeing in and outside the walls of the organization. hence, the role of hr managers will be crucial to ensure employees’ adoption of both socially responsible and healthy behaviours. the second mechanism (see box 2 of the framework [figure 1]) is “integrative responsible leadership”, an important factor that can influence both the formulation of sr-hrm policies and the implementation of public health literacy within the organizations. according to macassa, integrative responsible leaders are well-positioned to be agents of change for the tbl, but also to take on the important role that business organizations are likely to play for all stakeholders beyond the workplace (48). according to maak and colleagues (49), integrative leaders exhibit behaviours that: (i) mobilize stakeholders; (ii) promote a high degree of stakeholder interaction (including the integration of legitimate but powerless constituencies) and inclusive decision making; (iii) consider strategic choices beyond the business case rationale; and (iv) show a proactive approach towards csr (49). we expect integrative business executives to be proactive in working with both macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 11 | 15 csr and hr managers in their organizations to provide knowledge on both sustainability and health promotion. the integrative responsibility towards all stakeholders is also expected from both csr and hr managers. integrative responsible leaders (ceo’s) will be more prone to support their csr and hr managers during the implementation of public health literacy and workplace wellness activities (made as part of their strategic csr within the organization). as pointed out, responsible leaders are more inclined to do “good” and avoid “harm” to all stakeholders especially in the contexts where their business operate (3,48,49). furthermore, as already stated these ceo’s will better understand the need to promote health and well-being beyond their workplaces. box 3 in the framework (figure 1) alludes to stakeholders’ health and wellbeing in the form of positive health behaviour changes for employees (internal stakeholders), but also for families and the communities where employees live (external stakeholders). these outcomes can range from healthy behaviour change (e.g. increased physical activity and improved mental) or improved and hedonic wellbeing, which is linked to employee happiness, satisfaction and pain avoidance, to eudaimonic wellbeing, which relates to the employee’s sense of meaning and self-realization (50). overall, the framework in this paper proposes two hypotheses which might be relevant in the relationship between sr-hrm and stakeholders’ health and wellbeing: (i) sr-hrm policies implemented within the organization that include public health literacy will be associated with behaviour change towards environmental and social aspects linked to sustainable development as well as improvement of health outcomes. public health literacy training (embedded within sr-hrm policies) will contribute to changes in health behaviour among employees (and their families), which might spill over to the communities in which they reside; and (ii) integrative responsible leadership (at the top level of the company) will positively impact the planning and implementation of sr-hrm policies, thus contributing to stakeholders’ health promotion. from a health promotion, and population health, perspective, embedding public health literacy in the strategic csr-hrm policies will not necessarily result in extra-costs for the organization; on the contrary, it might contribute to long-term profits (3). moreover, it will boost employees’ knowledge and motivate them to take decisions of importance to their health, the working environment, and the health and wellbeing of others, including the natural environment (3). however, as mentioned above, we expect that companies will adhere in different ways to an integrated csr-hrm policy and practice, depending on the (political and cultural) context in which they operate and/or on the company size, revenue and an array of other situational factors. conclusion and future research agenda this conceptual paper attempts to offer a theoretical framework for how socially responsible human resource management can help improve stakeholders’ health and wellbeing within the context of a business case for population health (and achievement of the tbl). the framework proposes two potential mechanisms: (i) socially responsible hr policies that include public health literacy (physical activity and mental health literacy); and (ii) integrative responsible leadership. although hrm has been linked to employee outcomes (e.g. job satisfaction), to our knowledge this is the first time that it has been proposed to macassa g, tomaselli g. socially responsible human resources management and stakeholders’ health promotion: a conceptual paper (original research). seejph 2020, posted: 22 december 2020. doi: 10.4119/seejph-4046 p a g e 12 | 15 link integrated csr-hrm to population health outcomes in the context of sustainable development. however, the conceptual framework proposed here has not been tested empirically anywhere, let alone within the discipline of public health to which the authors pertain. this suggests the need for future studies to test the framework empirically through field data collection. an important argument as to why it is important to make a business case for population health is that for so long business organizations have distanced themselves from the health of those outside their organizations. but, there is now agreement that un agenda 2030 will not be achieved through governmental efforts alone, giving traction to the idea that business organizations (small, medium and large) will need to be a prominent partner. from the environmental and social equity perspectives as well as the health promotion 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(http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. poštovana obitelj deželić, poštovana obitelj kušan, poštovani kolege i prijatelji the editors of the south eastern european journal of public health express their deepest sorrow about the death of one of our most prominent members of the editorial board, professor luka kovačić, founder of the stability pact’s forum for public health in south eastern europe (fph-see) in 2000/2001 and strong supporter of the creation of this journal. genc burazeri (tirana, albania and maastricht, the netherlands) ulrich laaser (bielefeld, germany) jose martin-moreno (valencia, spain) peter schröder-bäck (maastricht, the netherlands) obituary professor luka kovacic, md, phd professor luka kovačić, md, phd, specialist in social medicine and organization of health care, retired full professor of the school of medicine, university of zagreb, passed away on 21 april 2015 fatigued by incurable malignant disease. luka kovačić was born on 13 october 1940 in a small town đurđevac some 100 km north of zagreb in the area called podravina, where he attended primary school and finished gymnasium in koprivnica. he graduated from the school of medicine in zagreb in 1965, and after a few years of medical practice he joined the andrija štampar school of public health which is a part of the school of medicine, university of zagreb. there he spent practically his entire working lifetime. he earned both, msc and phd degrees from the university of zagreb, school of medicine in 1972 and 1983. in his academic career he advanced from the assistant position at the chair for hygiene, social medicine, and epidemiology through positions as assistant professor (1984) and associate professor (1988) to full professorship (2003). he completed the specialization in social medicine and organization of health care successfully in 1974. he was also trained in sweden (1964), scotland (1966), usa (1968 and 1971, when he was trained in public health, epidemiology and research methods at the johns hopkins school of hygiene and public health in baltimore), finland (university of kuopio, 1977) and alma-ata (who training in planning and management in 1985). he paid study visits or served as a consultant in the uk, the ussr, kazakhstan, sudan, cameroon, india, iran (undp), nigeria (who) and elsewhere. at the andrija štampar school of public health he used to held numerous posts and responsibilities: he was a head of the department for hygiene, social medicine and epidemiology 1993-1997 and after its dissolution in three smaller departments in 1997 he continued to chair the department for social medicine and organization of health care; he was deputy coordinator from 1984 and coordinator 1997-2000 of the who collaborating centre for primary health care. he served as an assistant to the director and deputy director (1984-2004) and finally as the director of the school from 2004 till his retirement in 2006. he served firstly as the coordinator and later as director (1990-1996) of the international 9-week course "planning and management of primary health care in developing countries" which was held 16 times between 1978 and 1996 at the andrija štampar school of public health with the support of the government of the netherlands and had altogether more than 350 participants coming form 66 countries. luka kovacic was active member of the croatian medical association, president of its section for social medicine and organization of health care (1978-1986). later the section changed its name into the society for public health with him as president (1986-1999). his activities and duties were so numerous, both within his institution and in the broader croatian and international context, that we mentioned only those mostly pronounced or internationally visible. luka was a gifted and dedicated teacher, mentor of six msc theses and one phd dissertation as well as altogether more than 200 diploma works for medical and nursing students at the school of medicine and school of applied health sciences. he was principal investigator in many domestic projects and played a leading role in several international projects and networks. he actively participated in the work of the european network of districts "tipping the balance toward primary health care" (ttb) from 1987, being also its chairman of the board and president of the assembly from 1997 to 2005, and the coordinator of the whole network and the project "ttb second decennial survey of the health needs and health care for older people in europe", which was implemented in five european countries including croatia in 20052006. he was also a member of the european society for public health and its scientific committee since 2000. the cooperation between the school of public health, university of bielefeld and public health academic institutions in ten south eastern european (see) countries started in the year 2000 under his able leadership together with professor ulrich laaser, supported by the stability pact for south eastern europe. professor luka kovačić contributed enormously to the establishment of the forum for public health in south eastern europe (fph-see) as a network of academic institutions, aiming at the reestablishment of professional cooperation between public health teachers and professionals in see. as the result of this cooperation six book volumes were prepared and published between 2004 and 2010 encompassing altogether more than 4300 pages, containing some 250 teaching modules authored by more than 200 authors. among them professor kovačić co-edited the volume “management in health care practice” and authored four modules therein. luka kovačić was retired less than 9 years ago but he continued to be active and involved in teaching, especially in postgraduate specialist programmes and the phd programme "medicine and health sciences" where he coordinated courses in research methods in public health also at the school of applied health sciences in zagreb he taught several subjects and mentored diploma works. he was a full member of the croatian academy of medical sciences where he chaired the college of public health and participated in the work of the committee for food and the committee for telemedicine to which he was previously president during two terms. professor luka kovačić has published almost 200 scientific and professional articles and edited several books, among them also a textbook in social medicine. he coordinated a number of national and international projects and networks, and has organized numerous national and international conferences in the field of public health and health care organization. condolence arrived to family kovačić and his colleagues from many institutions and individuals not only from croatia but also from abroad, especially from colleagues from the south eastern european countries. their words once again proved not only how much professor kovačić was respected as an expert, but also how he was appreciated and loved as a co-worker, colleague and teacher. professor luka kovacic will remain in our memory forever as a creative and responsible teacher, an excellent organizer, a competent expert, but above all as a colleague and a friend always ready to assume obligations and help others, a modest and friendly man. a number of colleagues, former students, associates and friends from all over croatia together with those coming from neighbouring countries joined his beloved ones, his wife marija, sons mladen and damir, brother, daughters in law and four lovely grandchildren at his funeral as well as at the commemoration held in the andrija štampar school of public health on may 12 to pay a tribute to a conscientious and gifted teacher, diligent and organized scientists but above all to the dear colleague, a man who did not have and could not have enemies, because he was gentle and always ready to help, both students and colleagues. only ten days after luka passed away the global public health curriculum was published in the south eastern european journal of public health (seejph) including two modules (2.1 and 2.8) he authored. so it happened that his last two teaching texts appeared in seejph, let there be glory and praises to luka kovačić! may he rest in peace! on behalf of the andrija štampar school of public health, school of medicine, university of zagreb prof. jadranka bozikov selected papers of professor luka kovacic: 1. schach e, bice tw, haythrone df, kovačić l, matthews vl, paganini jm, rabin dv. methodologic results of the who/international collaborative study of medical care utilization. milbank memorial fund quaerterly 1972; 5:65-80. 2. kovačić l. dogovaranje pregleda i posjeta. [appointment system in health care]. lijec vjesn 1979;101:120-1. 3. kovačić l & al. dogovaranje pregleda u primarnoj zdravstvenoj zaštiti. [appointment system in primary health care]. zagreb: jugoslavenska medicinska naklada; 1979. 97 pp. 4. lemkau pv, kulčar ţ, kesić b, kovačić l. selected aspects of the epidemiology of psychoses in croatia. am j epid 1980; 112:661-74. 5. kovačić l, stipanov i. optimal development and utilization of primary health care in zadar. european journal of public health 1992; 2:212-4. 6. kovačić l, šošić z. organization of health care in croatia: needs and priorities. croatian med j 1998;39:24955. 7. kovačić l, lončarić s, paladino j, kern j. the croatian telemedicine. in: hasman et al. (eds). medical infobahn for europe. proceedings of mie 2000 and gmds 2000. ios press vol 77: 1146-50. 8. heslin jm, soveri pj, vinoy jb, lyons ra, buttanshaw ac, kovacic l, daley ja, gonzalo e. health status and service utilisation of older people in different european countries. scan j prim health care 2001;19:218-22. 9. kovačić l, laaser u. public health training and research collaboration in south eastern europe. medicinski arhiv 2001;55:13-5. 10. laaser u, kovačić l, editors.the reconstruction of public health training in south eastern europe. lage: hans jacobs editing company; 2001. 104 pp. (international public health working papers ; 4) 11. lang s, kovacic l, sogoric s, brborovic o. challenge of goodness iii: public health facing war. croat med j 2002; 43:156-65 12. babić-banaszak a, kovačić l, kovačević l, vuletić g, mujkić a, ebling z. impact of war on health related quality of life in croatia: population study. croat med j 2002; 43:396-402. 13. iveković h, boţikov j, mladinić-vulić d, ebling z, kern j, kovačić l. electronic health center (ehc): integration of continuing medical education, information and communication for general practitioners. stud health technol inform 2002; 90:788-92. 14. ebling z, kovačić l, šerić v, santo t, gmajnić r, kraljik n, lončar j. traheal, bronhial and lung cancer prevention in the osijek municipality. med fam croat 2003; 11 (1-2):15. 15. gazdek d, kovačić l. navika pušenja djelatnika u zdravstvu koprivničko-kriţevačke ţupanije – usporedna studija 1998. i 2002. [smoking habits among health staff in the county of koprivnica-krizevci--comparative study 1998 and 2002]. lijec vjesn 2004;126:6-10. 16. vrca botica m, kovačić l, kujundţić tiljak m, katić m, botica i, rapić m, novaković d, lovasić s. frequent attenders in family practice in croatia: retrospective study. croat med j. 2004;45:620-4. 17. vrca botica m, kovačić l, kujundţić tiljak m, katić m, botica i, rapić m, novaković d, lovasić s. frequent attenders in family practice in croatia: retrospective study. croat med j. 2004; 45:620-4. 18. kovačić l, boţikov j. master programs in public health – dilemmas and challenges. european phd programmes in biomedicine and health sciences. proceedings of the european conference on harmonisation of phd programmes in biomedicine and health sciences zagreb, croatia, april 24 and 25, 2004. zagreb: medical school, 2004; 52-4. 19. bjegović v, kovačić l, laaser u. the challenge of public health transition in south eastern europe. journal of public health 2006;14:184-9. 20. kovačić l, gazdek d, samardţić s. hrvatska zdravstvena anketa: pušenje [croatian health survey: cigarette smoking]. acta med croatica 2007;61:281-5. 21. kovačić l, zaletel kragelj l (eds.). management in health care practice. lage: hans jacobs verlag; 2008. 22. majnarić-trtica lj, vitale b, kovačić l, martinis m. trends and challenges in preventive medicine in european union countries. comment on the state in croatia. period biol. 2009;111:5-12. 23. kovačić l, laaser u. ten years of public health training and research collaboration in south eastern europe (phsee). snz.hr 2010;1(1):53-4. 24. tomek-roksandić s, tomasović mrčela n, kovačić l, šostar z. kardiovaskularno zdravlje, prehrana i prehrambeni unos soli kod starijih osoba. [cardiovascular health, diet and salt in the elderly]. acta med croatica 2010;64:151-7. 25. vadla d, boţikov j kovačić l. differences in health status and well-being of the elderly in three croatian districts. eur j public health 2011; 21(suppl 1):156. 26. vadla d, boţikov j, akerström b, cheung wy, kovačić l, mašanović m, merilainen s, mihel s, nummelinniemi h, stefanaki in, stencrantz b. differences in healthcare service utilisation in elderly, registered in eight districts of five european countries. scand j public health. 2011; 39, 3:272-9. 27. zaletel kragelj l, kovačić l, bjegović v, boţikov j, burazeri g, donev d, galan a, georgieva l, pavleković g, scintea sg, bardhele d, laaser u. the use and exchange of teaching modules published in the series of handbooks prepared within the frame of the „forum for public health in south-eastern europe“ network. zdrav var 2012; 51: 237-250. 28. keenan s, hammond j, leeks d, šogorić s, kovačić l, dţakula a, ganzleben c, guarinoni m, belin a. food safety and public health situation in croatia. european parliament, directorate-general for internal policies, brussels, october 2012 (monograph, 66 pages). available at: http://www.europarl.europa.eu/studies 29. polić-viţintin m, tomasović-mrčela n, kovačić l. mortalitet od cirkulacijskih bolesti i zloćudnih novotvorina u gradu zagrebu u osoba mlađih od 65 godina – stanje za uzbunu? [mortality rates of circulatory system diseases and malignant neoplasms in zagreb population younger than sixty-five – call for alarm?] acta med croatica. 2012: 66: 357-64. 30. vadla d, boţikov j, kovačić l. are the untreated anxiety and depression in elderly unrecognized sources of increased healthcare utilisation? eur j public health 2012; 22(suppl. 2):212-3. 31. bralic i, tahirovic h, matanić d, vrdoljak o, stojanović-špehar s, kovačić v, blaţeković-milaković s. association of early menarche age and overweight/obesity. j pediatr endocrinol metab. 2012;25(1-2):57-62. 32. vadla d, boţikov j, blaţeković-milaković s, kovačić l. anksioznost i depresivnost u starijih osoba pojavnost i povezanost s korištenjem zdravstvene zaštite. [anxiety and depression in elderly prevalence and association with health care]. lijec vjesn. 2013; 135:134-8. 33. vrcić keglević m, kovačić l, pavleković g. assessing primary care in croatia: could it be moved forward? coll. antropol. 2014; 38(suppl. 2): 3–9. 34. bendeković z, šimić d, gladović a, kovačić l. changes in the organizational structure of public health nurse service in the republic of croatia 1995 to 2012. coll antropol. 2014; 38(suppl. 2):85-9. 35. šimić d, bendeković z, gladović a, kovačić l. did the structure of work in the public health nurse service of the republic of croatia change in the period 1995-2012? coll antropol. 2014; 38(suppl 2):91-5. 36. kostanjšek d, topolovec niţetić v, razum z, kovačić l. getting some insight into the home care nursing service in croatia. coll antropol. 2014; 38(suppl 2):97-103. 37. kovačić l, malik m. n2.1 demographic challenges, population growth, ageing, and urbanization. seejph 2015; available at: http://www.seejph.com/n-2-1-demographic-challenges-population-growth-aging-and-urbanisation/ 38. kovačić l. n2.8 disaster preparedness. seejph 2015; available at: http://www.seejph.com/n-2-8-kovacicdisaster-preparedness-150322/ http://www.europarl.europa.eu/studies http://www.ncbi.nlm.nih.gov/pubmed/23898693 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 1 original research ethnic differences in smoking behaviour: the situation of roma in eastern europe laetitia duval 1 , françois-charles wolff 2 , martin mckee 3 , bayard roberts 3 1 school of public health, imperial college london, norfolk place, london w2 1pg, united kingdom; 2 lemna, université de nantes, bp 52231 chemin de la censive du tertre, 44322 nantes cedex, france and ined, paris, france; 3 ecohost – the centre for health and social change, faculty of public health and policy, london school of hygiene and tropical medicine, london, united kingdom. corresponding author: laetitia duval, school of public health, imperial college london; address: norfolk place, london w2 1pg, united kingdom; e-mail: l.duval@imperial.ac.uk duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 2 abstract aim: to investigate ethnic differences in smoking between roma and non-roma and their determinants, including how discrimination faced by roma may influence smoking decisions. methods: we analysed data from the roma regional survey 2011 implemented in twelve countries of central and south-east europe with random samples of approximately 750 households in roma settlements and 350 households in nearby non-roma communities in each country. the overall sample comprises 11,373 individuals (8,234 roma) with a proportion of women of 57% and an average age of 36 years. statistical methods include marginal effects from probit and zero-truncated negative binomial estimates to explain cigarette consumption. results: we found that roma have a higher probability of smoking and are heavier smokers compared to otherwise comparable non-roma. these differences in smoking behaviour cannot purely be explained by the lower socio-economic situation of roma since the ethnic gap remains substantial once individual characteristics are controlled for. the probability of smoking is positively correlated with the degree of ethnic discrimination experienced by roma, especially when it is related to private or public health services. conclusions: by providing evidence on smoking behaviour between roma and non-roma in a large number of countries, our findings support the need to understand smoking behaviour of roma from a comparative perspective, and may ultimately contribute to more effective anti-smoking messages for roma. however, if the health disadvantage faced by roma is to be addressed adequately, this group must be involved more effectively in the policy and public health process. keywords: central and south-east europe, cigarette smoking, discrimination, ethnicity, roma. conflicts of interest: none. acknowledgements: we are indebted to one anonymous reviewer for very helpful comments and suggestions on a previous draft. funding statement: this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 3 introduction while much is now known about the determinants of smoking, relating both to individuals (such as gender, age, marital status, and socio-economic characteristics), and product characteristics (such as price, availability, and marketing) (1-9), there has been less attention to ethnic differences in smoking behaviour, even though tobacco control measures may need to take account of factors, such as health beliefs, that might influence the effectiveness of certain policies and messages (10-12). roma are the largest ethnic minority group in europe (estimated to number 10-12 million), most living in central and south-east europe (13). they suffer multiple disadvantages, with lower education, worse living conditions, and lower socio-economic status (14-17) and face discrimination in many areas of life, including barriers in accessing health services and health information (18-22). consequently, roma have worse health on many measures (15,17,19) than the majority populations in the same countries. research on the roma population has largely focused on communicable diseases and child health (18), but more recent contributions have also investigated non-communicable diseases and health care (17,23). however, there have been fewer studies on health behaviours, although those that have been conducted show increased prevalence of risk factors, including smoking (24,25). paulik and colleagues (23) report attitudes to tobacco control from a small cross-sectional survey, with only 83 roma and 126 non-roma, finding roma respondents reluctant to accept restrictions on tobacco use. petek and colleagues (26) conducted a small qualitative study of the meaning of smoking in roma communities in slovenia, but with only three women and nine men of roma origin. they reported how smoking is seen as part of the cultural identity of roma and is accepted by men, women and children, while invoking fatalism and inevitability to explain why smoking is not identified by roma interviewed as a threat to health (26). given growing recognition of the role of smoking-related disease in perpetuating or accentuating health inequalities and lack of evidence on tobacco use among roma, the aim of the present study is to investigate ethnic differences in smoking between roma and nonroma as well as their determinants, which includes how discrimination faced by roma may influence smoking. methods data and samples we use data from the roma regional survey, a cross-sectional household survey commissioned by the united nations development programme, the world bank and the european commission. further details on the survey methodology can be found at: http://www.eurasia.undp.org/content/rbec/en/home/ourwork/sustainabledevelopment/development-planning-and-inclusive-sustainable-growth/roma-in-central-andsoutheast-europe/roma-data.html the sample comprises both roma (n=9,207) and non-roma (n=4,274) households living in countries with high proportion of roma, namely albania, bosnia and herzegovina, bulgaria, croatia, the czech republic, hungary, macedonia, moldova, montenegro, romania, serbia and slovakia. the survey was conducted from may to july 2011. the intention was to include roma living in distinct settlements and compare them with non-roma living nearby. given this intention, duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 4 it would have been inappropriate to compare what are known to be very deprived roma settlements (27) with the general population, which would include many affluent groups who have little in common with those living in the settlements. consequently, 350 non-roma households living in the same neighbourhood – defined as households living in close proximity, within 300 meters, of a roma settlement – were selected. a stratified cluster random sampling design was used. thus, the first stage sampling frame comprised known roma settlements, from which those to be included were sampled at random. then nonroma settlements nearby were selected, again at random. in the second sampling stage, households were randomly chosen with equal probability within each cluster for both populations. the method of data collection was face-to-face interviews at the respondent’s household. the overall sample comprised 13,481 households corresponding to 54,660 family members. among them, 9,207 households were roma (68.3%) and 4,274 were non-roma (31.7%). we focus on the current smoking behaviour of respondents aged between 16 and 60 at the time of the survey. there is no information in the survey on past smoking decisions. this leaves us with a sample comprising 11,373 individuals, 8,234 of whom were roma (72.4%). the survey covers demographic characteristics, education, employment status, living standards, social values and norms, migration, discrimination, and health. socio-economic status is proxied using a household asset index. this aggregate index is derived from a principal component analysis of a list of household possessions following the methodology described by filmer et al. (28). the list of items included comprises radio receiver, colour tv, bicycle or motorbike, car/van for private use, horse, computer, internet connection, mobile phone or landline, washing machine, bed for each household member including infants, thirty and more books except school books, and power generator. the principal component technique was implemented on the entire sample, pooling roma and non-roma individuals. higher values of the asset index correspond to higher long-run socioeconomic status. the characteristics of respondents are summarised in table 1. table 1. descriptive statistics of the sample (n=11,373) variables (1) all respondents (2) roma respondents (3) non-roma respondents (4)p-value of (2)-(3) female 57,7% 57,8% 57,6% 0.848 age in years 36,0 35,0 38,8 0.000 in a couple 69,5% 71,4% 64,5% 0.000 divorced – separated 8,0% 7,9% 8,3% 0.473 widowed 5,0% 5,2% 4,7% 0.330 single 17,5% 15,6% 22,5% 0.000 household size (number of persons) 4,3 4,7 3,5 0.000 no formal education 18,4% 24,8% 1,6% 0.000 primary education 20,7% 26,4% 5,7% 0.000 lower secondary education 34,2% 36,9% 27,1% 0.000 upper/post-secondary education 26,7% 11,8% 65,7% 0.000 paid activity – self-employed 31,7% 25,8% 47,2% 0.000 homemaker – parental leave 19,7% 21,7% 14,2% 0.000 retired 5,2% 4,1% 8,2% 0.000 not working – other 43,4% 48,4% 30,4% 0.000 asset index (value) 0,0 -0,6 1,5 0.000 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 5 capital/district center 33,5% 33,0% 34,7% 0.103 town 26,1% 26,2% 25,8% 0.665 village/unregulated area 40,4% 40,8% 39,6% 0.238 number of respondents 11,373 8,234 3,139 source: authors’ calculations, undp/wb/ec regional roma survey 2011. about 58% are women and the average age is 36 years. on average, roma are younger than non-roma (35.0 versus 38.8). roma have lower educational attainment and are more likely to be outside the formal labour market. overall, scores on the asset index are worse for roma (-0.563 compared to 1.477 for the non-roma), although the scale of relative disadvantage varies, with the largest gaps in croatia, romania and bulgaria. for smoking behaviour, we used the two following questions. first, respondents indicated whether they smoked or not at the time of the survey: “with regard to smoking cigarettes, cigars, or a pipe, which of the following applies to you?”. possible answers were “i currently smoke daily”, “i currently smoke occasionally”, “i used to smoke but have stopped” and “i have never smoked”. second, those reporting one of the first two answers (either daily or occasionally) were asked: “on average, how many cigarettes, manufactured or hand-rolled do you smoke each day?”. note that it may be more difficult for occasional smokers to assess their daily consumption. to examine the role of discrimination, we used the three following questions: i) “does your household have a doctor to approach when needed?”; ii) “do you feel safe in regards health protection – do you have the confidence that you will receive service in case you need it?”; and iii) “were there any instances in the past 12 months when your household could not afford purchasing medicines prescribed to, needed for a member of your household?”. we also included in our regressions variables from a specific section about general discrimination and rights awareness. discrimination is defined as being treated less favourably than others because of a specific personal feature such as age, gender or minority background. selfassessed discrimination was assessed with the following question: “in the past 12 months (or since you have been in the country), have you personally felt discriminated against on the basis of one or more of the following grounds: a) because of ethnicity for non-roma, because you are a roma for roma, b) because you are a woman/man, c) because of your age, d) because of your disability, e) for another reason”. finally, we investigated the role played by access to health care system using answers to the following question: “during the last five years; have you ever been discriminated against by people working in public or private health services? that could be anyone, such as receptionist, nurse or doctor.” the reason attributed to the discrimination was specified: it could be either a discrimination on the basis of ethnic background or a discrimination because of other reasons. statistical analysis we analysed the determinants of smoking behaviour both in terms of smokers versus nonsmokers and number of cigarettes among smokers. to isolate as far as possible the role of ethnicity, we adjusted for the following individual characteristics, available for each household member: gender, age, marital status, household size, education level, asset index, occupation and location (capital or district centre, town, village or rural area). we compared the pattern of smoking not only by ethnicity, but also by country to account for the potential role of country-specific factors such as tobacco price. as an initial comparison duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 6 showed that roma were, as expected, materially worse off, we turned to an econometric analysis to explain both the decision to smoke and the consumption of cigarettes among smokers. we began with an investigation of the determinants of the probability of smoking using probit regressions, with marginal effects for various specifications (table 3). we also examined correlates of smoking intensity among smokers. since the dependent variable had non-negative integer values, we used count data models and estimated a zero-truncated negative binomial regression to account for over-dispersion as in (29,30). finally, we investigated the role of discrimination as a potential factor explaining the widespread smoking behaviour among the roma population (table 4). results determinants of cigarette consumption a comparison of cigarette consumption by ethnicity and country in table 2 shows that, while overall the proportion of smokers is 50.0%, there are substantial differences between countries. when pooling all countries, we found a much higher proportion of smokers among roma than non-roma (columns 2-4). the gap between these groups amounted to 15.5 percentage points. the prevalence differential was greatest in the czech republic (+31.4 points for roma), followed by hungary (+23.7 points), slovakia (+22.7 points) and bosnia and herzegovina (+22.6 points). conversely, there was no significant difference between roma and non-roma in bulgaria, macedonia and montenegro. the situation was a little different in terms of intensity of smoking. there were significant differences in daily number of cigarettes (among smokers) between roma and non-roma in only four countries: czech republic (+3.8 cigarettes for roma), bosnia and herzegovina (+3.1 cigarettes), slovakia (+1.6 cigarettes) and moldova (-5.1 cigarettes). table 2. cigarette consumption, by ethnicity and country country proportion of current smokers (in %) cigarette consumption among smokers (1) all (2) roma (3) nonroma (4)p-value of (2)-(3) (5) all (6) roma (7) nonroma (8)=p-value of (6)-(7) albania 33.5 36.6 26.5 0.002 17.7 17.7 17.5 0.832 bosnia and herzegovina 54.6 61.1 38.5 0.000 21.2 21.8 18.7 0.009 bulgaria 51.7 53.3 46.8 0.108 12.0 11.8 12.9 0.233 croatia 57.3 64.1 38.4 0.000 16.1 16.2 15.5 0.766 czech republic 68.7 78.0 46.6 0.000 15.1 15.9 12.1 0.000 hungary 55.2 61.3 37.6 0.000 15.5 15.4 16.1 0.469 macedonia 42.1 43.2 39.3 0.279 17.2 17.4 16.6 0.443 moldova 29.8 33.5 19.4 0.000 16.7 15.9 21.0 0.004 montenegro 42.5 42.4 42.7 0.946 22.3 22.8 21.0 0.057 romania 46.7 50.5 34.8 0.000 12.8 12.8 12.8 0.728 serbia 58.9 61.7 51.5 0.004 18.4 18.3 18.7 0.627 slovakia 57.4 64.2 41.5 0.000 14.2 14.5 12.9 0.005 all countries 50.0 54.2 38.7 0.000 16.5 16.7 16.2 0.139 source: authors’ calculations, undp/wb/ec regional roma survey 2011. we examined the role of individual characteristics in explaining differences in cigarette consumption between roma and non-roma. as shown in column 1a of table 3, we found a positive correlation between the ethnic dummy and the smoking decision. at the sample means, the probability of smoking was 16.1 percentage points higher among roma compared duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 7 to non-roma. this marginal effect accounted for the role of country heterogeneity. the country dummies in the regression captured the influence of differences in tobacco prices as well as other unobserved differences in anti-smoking policies or tobacco advertising. next, we accounted for by individual characteristics, given the demographic and socioeconomic differences in roma and non-roma respondents (column 2a). our main result was that the roma dummy was still positively correlated with the propensity to smoke at the one per cent level of significance. however, controlling for differences in respondents’ characteristics strongly reduced the marginal effect of ethnic origin. being roma was now associated with an increase of 8.5 percentage points in the probability of smoking. we also estimated separate regressions for each ethnic group (columns 3a and 4a). many covariates such as gender, age, household size or education had a similar influence on the likelihood of smoking among roma and non-roma, but we noted some differences. for instance, the marginal effect associated with the asset index was three times higher for nonroma compared to roma. similarly, having a paid activity and being homemaker were significantly correlated with probability of smoking (respectively positively and negatively) only for non-roma. in column 1b, we found a positive correlation between roma origin and cigarette consumption. in column 2b, the positive effect of roma origin was still significant (at the five percent level) once individual characteristics were controlled for. table 3. probit and zero-truncated negative binomial estimates of cigarette consumption – marginal effects variables probability of smoking cigarette consumption among smokers (1a) all (2a) all (3a) roma (4a) non-roma (1b) all (2b) all (3b) roma (4b) non-roma roma 0.161** 0.085** 0.734* 0.927* (15.15) (5.91) (2.39) (2.49) female -0.138** -0.125** -0.166** -2.784** -2.892** -2.034** (-12.69) (-9.60) (-8.64) (-9.82) (-8.76) (-3.65) age 21-30 0.090** 0.067** 0.143** 2.374** 2.123** 3.587* (ref: ≤20) (4.85) (3.26) (3.35) (4.33) (3.59) (2.37) 31-40 0.123** 0.105** 0.128** 3.214** 2.800** 4.896** (6.28) (4.86) (2.81) (5.53) (4.48) (3.01) 41-50 0.157** 0.158** 0.129** 4.168** 3.993** 5.090** (7.61) (6.87) (2.75) (6.44) (5.65) (2.98) 51-60 0.119** 0.117** 0.090 4.103** 3.485** 6.028** (5.32) (4.63) (1.85) (5.83) (4.54) (3.29) marital status divorced – separated 0.035 0.042 0.031 0.508 0.577 0.392 (ref: in a couple) (1.87) (1.93) (0.92) (1.07) (1.06) (0.41) widowed 0.032 0.035 0.004 -0.050 -0.204 1.153 (1.32) (1.26) (0.09) (-0.08) (-0.30) (0.77) single -0.031* -0.041* -0.057* -0.185 -0.724 1.205 (-2.00) (-2.19) (-2.08) (-0.47) (-1.59) (1.48) household size 0.007** 0.006* 0.015* 0.085 0.107 -0.017 (2.81) (2.09) (2.30) (1.36) (1.60) (-0.09) education primary 0.002 -0.001 -0.110 -0.958* -1.040** -0.273 (ref: no formal) (0.15) (-0.08) (-1.48) (-2.48) (-2.60) (-0.13) lower secondary -0.008 -0.028 -0.102 -1.071** -1.337** -0.688 (-0.55) (-1.68) (-1.44) (-2.77) (-3.25) (-0.38) upper/post-secondary -0.061** -0.090** -0.138 -1.459** -1.595** -0.593 (-3.17) (-3.95) (-1.89) (-3.08) (-3.04) (-0.31) activity paid activity – self-employed 0.023 0.021 0.039 0.188 0.262 0.397 (ref: not working – other) (1.81) (1.43) (1.66) (0.60) (0.72) (0.62) homemaker – parental leave -0.019 -0.013 -0.065* -0.511 -0.615 0.256 (-1.35) (-0.83) (-2.11) (-1.37) (-1.52) (0.26) retired -0.089** -0.071* -0.098* -1.098 -0.925 -1.331 (-3.58) (-2.22) (-2.56) (-1.73) (-1.21) (-1.16) asset index -0.026** -0.016** -0.048** 0.189* 0.266** -0.101 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 8 (-7.62) (-4.00) (-7.58) (2.15) (2.63) (-0.56) location town -0.040** -0.050** 0.001 -1.445** -1.570** -1.112 (ref: capital/district center) (-2.96) (-3.14) (0.03) (-4.38) (-4.19) (-1.61) village/unregulated area -0.049** -0.039** -0.059* -2.186** -2.360** -1.437* (-3.81) (-2.63) (-2.50) (-6.87) (-6.53) (-2.15) country dummies yes yes yes yes yes yes yes yes number of respondents 11,373 11,373 8,234 3,139 5,682 5,682 4,466 1,216 source: authors’ calculations, undp/wb/ec regional roma survey 2011. note: the probability of smoking is explained using a probit model, the cigarette consumption among smokers is explained using a zero-truncated negative binomial model. significance levels are p<0.01 (**) and p<0.05 (*). when comparing the estimates obtained separately on the roma and non-roma samples (columns 3b and 4b), the correlation between consumption of cigarettes and gender, age as well as location had the same sign for both ethnic groups. conversely, we observed some differences in the role of education and asset index among smokers. first, the negative correlation between education and cigarettes was only significant for roma. second, we found a positive correlation between consumption of cigarettes and the asset index only for roma. as roma are economically disadvantaged, only those with adequate resources will be able to purchase and smoke cigarettes. finally, we estimated country-specific regressions. for ease of interpretation, we presented the marginal effect associated with the roma dummy (figure 1). figure 1. the gap in smoking between roma and non-roma, by country a. probability of smoking b. cigarette consumption among smokers -5 0 5 10 15 20 25 r o m a g a p m a rg in a l e ff e c t (p ro b . in % ) bosnia and herzegovina czech republic hungary croatia romania moldova slovakia albania serbia montenegro bulgaria macedonia duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 9 source: authors’ calculations, undp/wb/ec regional roma survey 2011. the probability of smoking was 24.1 percentage points higher among roma than non-roma in bosnia and herzegovina. the gap was significant in seven other countries: by decreasing order of magnitude, the czech republic (19.7 percentage points), hungary (15.6), croatia (13.7), romania (13.7), moldova (12.5), slovakia (7.1) and albania (2.8). roma consumed 3.8 additional cigarettes per day in the czech republic compared to non-roma smokers. the situation was very similar in bosnia and herzegovina (+3.7 cigarettes), slovakia (2.7), romania (1.3) and montenegro (1.1). smoking and discrimination the proportion of respondents who felt discriminated against because of ethnicity was much higher among roma (34.6%) than non-roma (4.9%) (+29.7 percentage points). the ethnic differential was lower but still significant when considering other forms of discrimination: +6.9 points because of gender (8.3% for roma compared to 3.1% for non-roma), +1.9 points because of age (6.2% against 4.3%) and +1.8 points because of disability (3.6% against 1.8%). when pooling the various reasons, the ethnic gap amounted to 26 percentage points (36.7% against 16.7%). we added indicators of health inequalities to our previous regressions explaining smoking decisions (panel a of table 4). table 4. discrimination and cigarette consumption – marginal effects from probit and zerotruncated negative binomial models variables probability of smoking cigarette consumption among smokers (1a) all (2a) all (3a) roma (4a) nonroma (1b) all (2b) all (3b) roma (4b) nonroma panel a: roma 0.085** 0.081** 0.927* 0.920* (5.91) (5.63) (2.49) (2.47) -4 -2 0 2 4 r o m a g a p m a rg in a l e ff e c t (c ig a re tt e s ) czech republic bosnia and herzegovina slovakia romania montenegro macedonia serbia croatia hungary bulgaria moldova albania duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 10 doctor to approach when needed 0.037* 0.033 0.050 0.211 0.336 -0.826 (2.23) (1.82) (1.31) (0.50) (0.74) (-0.69) feel safe in regards health protection -0.015 -0.015 -0.012 -0.219 -0.155 -0.401 (-1.11) (-0.95) (-0.44) (-0.63) (-0.41) (-0.49) cannot afford purchasing medicine prescribed 0.032** 0.028* 0.033 0.027 0.012 0.258 (2.92) (2.34) (1.46) (0.10) (0.04) (0.40) control variables yes yes yes yes yes yes yes yes number of respondents 11,373 11,373 8,234 3,139 5,682 5,682 4,466 1,216 panel b: roma 0.085** 0.077** 0.927* 0.828* (5.91) (5.27) (2.49) (2.19) discriminated against in the past 12 months 0.041** 0.034** 0.045 0.482 0.450 0.269 (3.62) (2.80) (1.55) (1.67) (1.46) (0.32) control variables yes yes yes yes yes yes yes yes number of respondents 11,373 11,373 8,234 3,139 5,682 5,682 4,466 1,216 panel c: roma 0.085** 0.072** 0.927* 0.825* (5.91) (4.93) (2.49) (2.17) discriminated against in the past 12 months 0.059** 0.060** -0.001 0.399 0.187 1.582 because of ethnicity (4.62) (4.40) (-0.02) (1.26) (0.56) (1.23) discriminated against in the past 12 months -0.038* -0.058** 0.043 0.172 0.482 -1.376 because of other reasons (-2.30) (-3.10) (1.21) (0.41) (1.03) (-1.50) control variables yes yes yes yes yes yes yes yes number of respondents 11,373 11,373 8,234 3,139 5,682 5,682 4,466 1,216 panel d: roma 0.085** 0.079** 0.927* 0.891* (5.91) (5.46) (2.49) (2.38) discriminated against by people working in health 0.078** 0.072** 0.057 0.467 0.238 3.901 servicesbecause of ethnicity (4.29) (3.84) (0.79) (1.06) (0.53) (1.54) discriminated against by people working in health -0.053 -0.060 -0.035 -0.409 0.146 -4.160* servicesbecause of other reasons (-1.79) (-1.84) (-0.49) (-0.55) (0.18) (-2.41) control variables yes yes yes yes yes yes yes yes number of respondents 11,373 11,373 8,234 3,139 5,682 5,682 4,466 1,216 source: authors’ calculations, undp/wb/ec regional roma survey 2011. note: the probability of smoking is explained using a probit model, the cigarette consumption among smokers is explained using a zero-truncated negative binomial model. significance levels are p<0.01 (**) and p<0.05 (*). we found that people who could approach a doctor when needed has a higher probability of smoking (column 2a). this result is seemingly counterintuitive but it may be that those living in areas with access to a doctor have higher (unobserved) levels of income or can more easily buy cigarettes. however, there may also be reverse causation as smokers are likely to have more health problems and thus more frequent interactions with doctors. while feeling safe had no influence on smoking, the correlation between probability of smoking and inability to purchase medicines prescribed was positive for roma respondents only (column 3a). none of our indicators of health inequalities had an influence on intensity of cigarette consumption among smokers. in panel b of table 4, we found a positive correlation between smoking behaviour and feeling of discrimination (whatever its reason). the probability of smoking increased by 4.1 percentage points for those who felt discriminated against (column 2a). the role played by discrimination was mainly observed in terms of probability rather than intensity of smoking. the correlation between discrimination and cigarette consumption among smokers was not significant when separating roma and non-roma (columns 2c and 2d).as shown in panel c, most of the effect came from discrimination on the basis of ethnic background. indeed, the coefficient associated with ethnic discrimination was positive and significant, but it was negative for other forms of discrimination. as a final step, we explored the correlation between smoking and discrimination in access to the health care system (panel d). the probability of smoking is higher among respondents duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 11 who felt discriminated against by people working in health services on ethnic grounds (+7.8 points). conversely, the correlation is negative for the other forms of discrimination (-5.3 points) while there was no significant relationship with smoking intensity. discussion in this paper we compared the smoking behaviour of roma and those in the majority population living nearby in twelve countries of central and south-east europe. the strengths of this study lie in the use of a large study sample across multiple countries. previous research on roma health tends to be restricted to a small number of countries, mainly hungary, the czech republic and slovakia (15,16,23,26), and which often use small sample sizes which make comparisons between roma and non-roma groups of population difficult. this study is, however, subject to a number of limitations. first, by design, it does not provide a representative sample of the roma population in the countries concerned. this is an inevitable and well-known problem facing all research on roma health, reflecting problems of defining the roma population (31). there are varying degrees of assimilation in each country and estimates of the roma population vary, reflecting in part the reason why a particular survey was undertaken and thus the incentive to self-identify as roma. furthermore, in some situations there may be strong disincentives to do so, given the previous experience of this population in their dealings with authority. for this reason, much of the existing research has adopted the approach used here, focussing on the most marginalised roma groups, and the most easily and consistently identifiable. second, the sample size in each country is relatively small, limiting the power to compare sub-groups. third, there is a need for qualitative research to understand better the place that smoking occupies within roma communities and the barriers that exist to reducing smoking rates. qualitative research has found that smoking is important in cultural and ethnic identity of roma, with smoking being introduced by older family members to younger ones. even where there is awareness of health risks associated with smoking, there is little willingness to consider quitting, to reduce exposure to second-hand smoke, or to prohibit children from smoking because it is considered part of growing up (23). policies that attempt to limit tobacco access to children or eliminate smoking in public places are rejected (26). fourth, some factors that might influence smoking behaviour are missing from the roma regional survey. for instance, we could not include household income in our regressions, although we were able to use an asset index, which captures household wealth. fifth, interpretation of findings on discrimination is complex. from an individual perspective, the perception of discrimination is a sensitive topic. feeling discriminated against is subjective and may be subject to justification bias. this would occur if roma respondents report being discriminated in order to justify their smoking decision. at the same time, according to the eu-midis report on discrimination argues, discrimination against roma seems to be largely unreported (32). finally, a limitation, inherent in the cross-sectional design, is that we are unable to show a causal association between discrimination and smoking. it may be that roma decide to smoke because they feel less accepted by the rest of the population, but their higher smoking prevalence may also be perceived as a potential signal of their ethnicity, as noted above. our findings show that roma respondents are more likely to smoke and are heavier smokers on average compared to non-roma (with substantial heterogeneity in the gap between the duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 12 two groups between countries).a recent study found no genetic basis for differences in smoking among roma and non-roma in hungary (33). now, this study shows that differences in smoking behaviour cannot simply be explained by the worse socio-economic situation of roma. first, the non-roma comparison population comprises those living in close proximity to roma settlements and not the general population. thus, our data will presumably underestimate the overall gap between the roma and non-roma population in each country. second, the ethnic gap remains substantial once individual characteristics are controlled for, although of course it is possible that our indicators do not fully capture relative disadvantage. importantly, this conclusion is consistent with another study using a different data set but similar methodology in hungary (34). we also find some positive correlation between the probability of smoking and discrimination reported by roma, especially with respect to private or public health services, but not in terms of smoking intensity. our findings support other literature on the disadvantage and discrimination faced by roma in central and south-east europe (13,15,21,22,35,36) with roma considered by some as the most discriminated against group in europe (32). this reinforces the importance of developing messages through a shared process, involving roma participation, and in ways that avoid stigmatisation, as part of comprehensive policies to tackle disadvantage and discrimination (37). conclusions to the best of our knowledge, this study is the first to provide comparative evidence on smoking behaviour between roma and non-roma in a large number of countries. our findings support the need to understand smoking behaviour of roma from a comparative perspective, and may ultimately contribute to improved anti-smoking policies towards roma. if roma health vulnerability is to be addressed adequately, efforts need to be concentrated on involving roma in the policy and public health process, including measures that specifically address the factors that lead to high rates of smoking in this multiply disadvantaged 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easterling d, rogers t. smoking behaviour and attitudes of hungarian roma and non-roma population towards tobacco control policies. int j public health 2011;56:485-91. 24. kosa z, szeles g, kardos l, kosa k, nemeth r, orszagh s, et al. a comparative health survey of the inhabitants of roma settlements in hungary. am j public health 2007;97:853-9. duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph2016-132 14 25. hujova z, alberty r, paulikova e, ahlers i, ahlersova e, gabor d, et al. the prevalence of cigarette smoking and its relation to certain risk predictors of cardiovascular diseases in central-slovakian roma children and adolescents. cent eur j public health 2011;19:67-72. 26. petek d, rotar pavlic d, svab i, lolic d. attitudes of roma toward smoking: qualitative study in slovenia. croat med j 2006;47:344-7. 27. kosa k, darago l, adany r. environmental survey of segregated habitats of roma in hungary: a way to be empowering and reliable in minority research. eur j public health 2011;21:463-8. 28. filmer d, pritchett lh. estimating wealth effects without expenditure data--or tears: an application to educational enrollments in states of india. demography 2001;38:11532. 29. kilic d, ozturk s. gender differences in cigarette consumption in turkey: evidence from the global adult tobacco survey. health policy 2014;114:207-14. 30. gorman bk, lariscy jt, kaushik c. gender, acculturation, and smoking behavior among u.s. asian and latino immigrants. soc sci med 2014;106:110-8. 31. kosa k, adany r. studying vulnerable populations: lessons from the roma minority. epidemiology 2007;18:290-9. 32. european union agency for fundamental rights. eu-midis european union minorities and discrimination survey data in focus report 1: the roma. budapest: european union agency for fundamental rights; 2009. 33. fiatal s, toth r, moravcsik-kornyicki a, kosa z, sandor j, mckee m, adany r. high prevalence of smoking in the roma population seems to have no genetic background. nicotine tob res 2016;18:2260-7. 34. voko z, csepe p, nemeth r, kosa k, kosa z, szeles g, et al. does socioeconomic status fully mediate the effect of ethnicity on the health of roma people in hungary? j epidemiol community health 2009;63:455-60. 35. hajioff s, mckee m. the health of the roma people: a review of the published literature. j epidemiol community health 2000;54:864-9. 36. duval l, wolff fc, mckee m, roberts b. the roma vaccination gap: evidence from twelve countries in central and south-east europe. vaccine 2016;34:5524-30. 37. fesus g, ostlin p, mckee m, adany r. policies to improve the health and well-being of roma people: the european experience. health policy 2012;105:25-32. __________________________________________________________ © 2016 duval et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. alsamara, i.; beinert, s. f.; de jong, j. c.; klappe, m. j. p.; marewski, v. s. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5603 page1 | 15 policy brief impact ideal measures for participation and awareness of climate change: stronger together citizen participation in achieving the european green deal in the meuse-rhine euroregion issam moussa alsamara1, stefanie felicitas beinert1, jeanne catelijne de jong, maaike jeannette barbara klappe1, viktoria sirkku marewski1, rana orhan1,2* 1department of international health, care and public health research institute – caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands 2the association of schools of public health in the european region *senior advisor corresponding author: maaike klappe, email: m.klappe@student.maastrichtuniversity.nl address: universiteitssingel 60 6229 er maastricht, the netherlands mailto:m.klappe@student.maastrichtuniversity.nl alsamara, i.; beinert, s. f.; de jong, j. c.; klappe, m. j. p.; marewski, v. s. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5603 page2 | 15 abstract context: the european green deal is a tool to make europe the first climate-neutral continent by 2050. to reach this goal, action is needed on all organizational levels. at the same time, temperatures keep rising, and the meuse-rhine euroregion (emr) suffered from heavy floods in the summer of 2021and extreme weather events are expected to increase. this is an example of a cross-border issue and therefore shows the need for cross-border climate action. the emr could be a showcase for climate action and collaboration for other border regions across europe and worldwide. policy options: citizens often do not feel responsible for taking climate action; however, everyone should contribute to achieving the biggest results in tackling climate change. therefore, three policy options are presented to increase citizen participation in climate action: local climate measurements, sustainable food consumption, less food waste, and sustainable cities through urban gardening. these policy areas deserve more attention and have room for improvement. recommendations: · encourage the implementation of citizen science projects in the emr. · gather insights on the region's greenhouse gas emissions. · provide more sustainable food in institutional canteens and reduce food waste. · use social media as a tool to provide information about sustainable food. · use urban areas for urban gardening projects. · create community sustainability challenges. keywords: citizen participation; climate change; european green deal; meuse-rhine euroregion alsamara, i.; beinert, s. f.; de jong, j. c.; klappe, m. j. p.; marewski, v. s. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5603 page3 | 15 introduction climate change is one of the main challenges that encounter humanity, and its consequences will keep on affecting the current forms of life on earth for the decades and centuries to come. the human influence on warming the atmosphere is unequivocal (1). moreover, in every region across the globe, the environment is affected by humaninduced climate change. with the continuing global warming, it is projected that the global water cycle and other weather extremes will be further intensified (1, 2, 3).furthermore, the projected change in climate is expected to alter the geographic range and burden of various climate-sensitive health outcomes and affect the functioning of public health and health care systems (4). substantial increases in morbidity and mortality are expected over the coming decades if no additional actions are taken (5). figure 1 illustrates the pathways by which climate change can affect health (6). global actions to mediate and counter climate change have started taking shape since the second half of the twentieth century and kept on gaining momentum and support from growing stakeholders around the world. the paris agreement in 2015 is one of the most significant steps the international community has taken toward limiting global warming in the last two decades. it is a result of the continuing efforts of the united nations framework convention on climate change and the intergovernmental panel on climate change. besides, the latest conference of parties of the unfccc (cop26) in november 2021 set several objectives, like committing to more ambitious targets to reduce greenhouse gas (ghg) emissions by 2030 and other matters regarding adaptation measures and funds for developing countries (8). alsamara, i.; beinert, s. f.; de jong, j. c.; klappe, m. j. p.; marewski, v. s. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5603 page4 | 15 europe is a key stakeholder in humanity's fight against climate change due to several reasons. one is the historical and ongoing contribution of the european states to warming the climate. moreover, europe must deal with the severe consequences of climate change, as it threatens high temperatures, droughts and wildfires, availability of freshwater, and sea-level rise across europe (9). finally, and most importantly, there is a desperate need for a global leader who spearheads the fight against climate change. through its endeavors, the european union is claiming such a position. that is by leading by example, i.e., through adopting advanced environmental legislation, achieving its international obligations regarding its co₂ emission reduction, stepping up its goals to cut down emissions, and even making it a legal obligation through the european climate law (10, 11). those endeavors could be spotted in the objectives of the european green deal, where the member states agreed on an array of policy initiatives that set out how to make europe the first climate-neutral continent by 2050 (12). one of the main strategies of the european green deal is the farm to fork strategy (f2f), which is at the heart of the deal. this strategy addresses the challenges of sustainable food systems and recognizes the inextricable links between healthy people, healthy societies, and a healthy planet. f2f is also essential to the european commission's agenda to achieve the united nations' sustainable development goals (sdgs), in particular sdg 12 (sustainable consumption and production) and sdg 13 (climate action) (13). the f2f approach aims to ensure that agriculture, fisheries, aquaculture, and the food value chain contribute appropriately to the process of curbing the ghg emissions, as stated by the eu goals (14). according to the european environment agency, the 2019 levels of ghg emissions correspond to a higher reduction rate than the original target set for 2020 (15). moreover, bringing citizens together in the development and implementation of the european green deal is the aim of the european climate pact. that is because citizens' just and inclusive participation and engagement in all areas of the deal is essential for the transition towards a climate-neutral, sustainable europe (1). context during the summer of 2021, the european continent witnessed one of the direct effects of global warming. after the unprecedented heatwave in june, the hottest one since 1901, devastating floods hit different river basins across europe, killing hundreds of people, displacing thousands, and damaging the infrastructure and the agricultural lands, resulting in billions of euros in losses (17). these floods contributed to the truth that the effects of climate change know no borders. this fact necessitates cross-border collaboration in climate action and makes cross-border regions within europe the main stage to initiate actions and mediate changes. furthermore, the similarity in context and culture in those regions create, to an extent, a similar theme of challenges and barriers, thus, similar solutions as well. the dreadful disaster was evident in the meuse-rhine euroregion (emr), where the most intense floods occurred. the emr is a cross-border collaboration composed of three languages (french, dutch, and german) and five partner regions, including the dutch province of limburg, the german zweckverband of the aachen region, the german-speaking community of belgium, and the belgian provinces of liège and limburg (18,19). this policy brief will target the citizens of the meuse-rhine euroregion in its options due to alsamara, i.; beinert, s. f.; de jong, j. c.; klappe, m. j. p.; marewski, v. s. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5603 page5 | 15 several reasons. the emr is one of the oldest cross-border regions in europe, and it retains a high population density, numerous industrial activities, high traffic, and frequent large-scale events. therefore, it is at high risk of large-scale disasters (20,21). moreover, the environment is one of the critical subjects the emr wants to work on in the upcoming years (22). additionally, the emr could be a showcase for other border regions across europe and worldwide. this policy brief aims to provide decisionmakers in the emr with several policy options to promote climate literacy and climate action among citizens of the meuse– rhine euroregion under the umbrella of the farm to fork strategy and the european green deal policy options although a long-term strategy to mitigate climate risks is needed, research in hollands noorderkwartier in the netherlands has shown that citizens often do not feel responsible for taking climate action. even though the urgency of climate change is apparent, they do not feel like they would be the ones responsible for inducing change (23). so, to achieve the biggest results in tackling climate change and increasing citizen participation in the emr, new policy areas should get more attention. firstly, citizen participation throughout local climate measurements is an under-explored area that can play an essential role in improving the feeling of responsibility in citizens. secondly, food waste and sustainability are some of the most significant contributors to climate change, making it a relevant policy area with great opportunities. lastly, urban sustainability is needed in the increasing urban-focused communities of the emr. these broad policy options are required to achieve the biggest results for a sustainable future in the emr.. citizen participation support throughout the use of local climate measurements citizen involvement in scientific measurements, or citizen science, could be beneficial in the early detection and communication of climate events through monitoring and sharing data. the risk management for the flooding in the emr was insufficient to provide safe evacuations for all citizens in the affected areas. in these cases, early detection and risk communication could save lives by allowing for early-stage evacuation (24). for example, the emr could draw on the experiences of a citizen observatory for flood risk reduction in brenta-bacchiglione, italy (25). local climate measurements could thus be an efficient way to obtain reliable data on air quality while increasing awareness and alsamara, i.; beinert, s. f.; de jong, j. c.; klappe, m. j. p.; marewski, v. s. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5603 page6 | 15 knowledge of environmental change indicators, like air pollution. citizen science has recently gained attention in environmental monitoring projects, and communities could potentially greatly expand the scope. in the netherlands, the project 'measure together' supports citizen science locally (26). climate participation projects have efficiently increased knowledge and awareness (27). so far, similar projects have not been implemented in the emr. different types of citizen science projects exist; some are contributory, others collaborative, and some are co-created projects in which researchers and citizens design together (28). an example of an effective citizen science project is a tool for carbon calculation, which contributed to achieving the local co2 targets in various cities in austria, germany, and spain. this online tool gives insights into the carbon footprint of citizens by collecting data on several aspects of environmental factors. besides increasing awareness and knowledge of co2 impacts, the co2 emissions of participants slightly decreased during the project (29). sustainable food consumption and less food waste current food consumption patterns are neither sustainable for health nor the environment (30). besides contributing to cardiovascular diseases and death in humans, tonnes of waste and increased amounts of emissions per capita are hazardous consequences for the planet (31). in the emr, these emissions are almost twice as high as the global average (32). that is why the emr must transform the environmentally friendly choice into the easiest choice. thus, for that purpose, alternative approaches are to follow. firstly, provide information; customers often do not pay attention to storage instructions on the packaging. as a result, food is usually thrown away both because it is not consumed before it has passed its "best by" date or because many goods in retail shops remain unsold since consumers prefer to buy food with a longer shelf life (33). besides this information about food waste, education about food production and its impacts on health and the environment is needed. the arrangement of this explicit information makes it less demanding for people to select healthy and economic diets that will benefit their well-being (30). therefore, innovative ways to provide this information through other means, including digital possibilities, social media, and more regional-related announcements, are needed. alsamara, i.; beinert, s. f.; de jong, j. c.; klappe, m. j. p.; marewski, v. s. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5603 page7 | 15 secondly, creating opportunities: the emr could be a best practice example by setting minimum mandatory criteria for sustainable food procurement in institutional catering. by integrating daily vegetarian and vegan food in public canteens, a large part of the population would consume fewer animal products and eat a healthier diet (34). vegetarian and vegan food in canteens can also inspire people to change their daily lives. additionally, the third-largest source of food waste in europe is the food service industry, including school canteens (35). one of the main reasons for this plate waste is a lack of knowledge and awareness (36). cities, regions, and public authorities could assume responsibility for sourcing sustainable food for schools, universities, and local institutions. in this manner, the eu plans to enhance its commitment to feasible nourishment utilization and, specifically, reinforce informational messages on the significance of healthy nutrition, ecologic production, and diminishing food waste (30). and lastly, promote awareness; to shift the consumer's attention to the process of food production, the emr could promote the extension of nutritional labeling on the front of the packaging. in addition, origin or provenance information should become obligatory to indicate co2 and water pollution. if the product proved an appropriate balance, it could receive its own emr eco-label (32). furthermore, citizens should be more aware of the impact of customer behavior on food waste and, therefore, the environment. on the other hand, decision-makers should also be mindful of the different motivations of citizens to change behavior, such as saving money and social responsibility (37). the aim is to create awareness of food's background and strengthen regional offers related to this, and canteens could state where the products are from and how disrupting they are for the environment (32). sustainable cities through urban gardening due to the advancing climate change, urban areas are currently facing significant challenges. on the one hand, ways must be found to deal with more frequent weather extremes (38). on the other hand, urban areas should involve residents in land use, provide opportunities for them to be outdoors, be physically active, interact with each other, and learn more about our environment and the consequences of alsamara, i.; beinert, s. f.; de jong, j. c.; klappe, m. j. p.; marewski, v. s. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5603 page8 | 15 climate change. one way to get closer to these goals is to use urban spaces for community projects such as urban gardens to combine urban planning with social aspects. considering the weather extremes of recent years, areas used for urban gardening can be very beneficial because they help infiltrate large amounts of water, reducing the risk of flooding. they also support groundwater replenishment. in addition, the influence of green spaces on temperatures must be considered. unsealed surfaces such as grass or patches do not store heat as much as asphalt or pavement do and, thus, contribute to regulating the urban climate in summer (39). it has also been shown that urban green areas positively affect air quality as they absorb, e.g., carbon monoxide, ozone, nitrogen oxide, or sulfur dioxide (39, 40, 41). furthermore, this type of space increases the urban landscape's biodiversity by providing habitats for insects, birds, small mammals, and a wide range of different vegetation, both ornamental and crop plants (39, 41, 42). the social dimension of community gardening is another considerable advantage. people from all generations can contact each other and grow their food (42). physical work outdoors and social engagement can prevent or improve health-related issues such as stress, social isolation, and depression (43, 44). it has also been shown that people integrated into such projects by growing their food, consuming more fruits and vegetables, and having better food knowledge (45). furthermore, an argument for these projects within cities is the accompanying educational opportunities. children and adolescents especially can learn more about nature, conservation, sustainability, seasonality, and our food production (45). working in a community garden makes it possible to raise environmental awareness and promote citizen participation in the fight against climate change (39). recommendations the recommendations provided in this section elaborate on implementing practical solutions to promote climate literacy and climate action among citizens. to provide an integrative approach to tackling climate change, we call on policymakers and researchers to follow our holistic recommendations. ● prioritize funding of citizen science, urban gardening, and sustainable food projects in the emr internal or external money, current or new staff time, technical skills, or stakeholder buy-in may be necessary to support a project or program, depending on the goals. noteworthy, the emr is part of an eu fund for a stronger euregion (21). to reach a significant impact, it is necessary to invest in implementing the proposed projects. ● ensure equal participation options for every citizen a precondition of successful implementation is accessibility to all citizens within the emr. it must not be related to their education, age, disabilities, country of origin, or financial situation. ● empower implementation of the projects through organizational support policymakers should contribute to measures that look beyond country borders. citizens should be provided with the possibility to gain insights into climate data. early-stage participation of partners should be considered, for example, by stimulating https://www.linguee.de/englisch-deutsch/uebersetzung/accompanying.html alsamara, i.; beinert, s. f.; de jong, j. c.; klappe, m. j. p.; marewski, v. s. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5603 page9 | 15 debates, gathering information, or seeking neighbors to sign a sustainability pledge. ● stimulate the formulation of clear sustainability goals program designers should work with clearly defined goals, communicate the goals of such programs to the public, and choose specific actions to pursue. these goals should be coherent, well-designed, relevant to the community, and proactive. all measures must be evaluated to improve the value and create long-term advancements. ● encourage the implementation of citizen science projects in the emr citizen science projects aim to increase environmental awareness among citizens while simultaneously gathering valuable data on the state of the environment. reforms, as mentioned above, are needed to allow all citizens to take part in such projects. ● gather insights on the region's greenhouse gas emissions help local governments determine and track progress towards goals by better understanding activities and emission sources. ● provide more sustainable food in institutional canteens and reduce food waste a big part of the emr student population eats a few times per week in an institutional canteen. therefore, this would be a suitable place to create opportunities for citizens to include more sustainable food into their diet. ● use social media as a tool to provide information about sustainable food young citizens are progressive and openminded, and they appear to be open to receiving advice through social media and find it easy to communicate with peers about societal subjects (46). therefore, they are most likely to change their behavior more sustainably if they are aware of the importance and know-how to act. ● use urban areas for urban gardening projects urban areas should be used more intensively for urban gardening projects to promote the health of the residents, reduce environmental pollution, save biodiversity, and mitigate the effects of weather extremes in cities. furthermore, the initiators must pay particular attention to the quality of the soil to prevent harmful consequences to health. the terrain must be suitable. issues such as accessibility, water supply, and possible pollutants in the soil must be considered. the initiators have the task of ensuring this by reporting on the project as widely as possible, making it easily accessible, and ensuring that participation is free of charge. ● create community sustainability challenges creating little public challenges (such as a one-month vegetarian diet), discounts for regional offerings, accessible outreach, and education, hosting a discussion on recycling and waste reduction, building a green gardening demonstration project, and so on might all be adopted. community-based social marketing is critical, as it uses direct neighbor-to-neighbor communication and influence to encourage behavior change (47). giving people and organizations in your audience short-term action checklists with doable tasks can help them feel accomplished. such a list can offer suggestions and be a starting point for longterm behavior adjustment. the action items must be carried out in a low-key manner conclusion alsamara, i.; beinert, s. f.; de jong, j. c.; klappe, m. j. p.; marewski, v. s. (policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5603 page10 | 15 the climate is changing, and the human influence on it is unmistakable. this policy brief stresses the urgent need for leadership to tackle these changes and provide opportunities for citizen participation. implementing the suggested measures in the emr will increase the knowledge and awareness of the environment among the emr citizens and the local authorities, consequently leading to empowering people to engage in climate action. even though there is a long way to go, the recommendations of this policy brief are provided in the belief that measures to include citizens in climate action are of high necessity to tackle climate change conflicts of interest none declared. funding none declared acknowledgments the authors wish to acknowledge and thank rana orhan for her help and support in developing this policy brief. in addition, they want to thank katarzyna czabanowska for her guidance and assistance throughout the public health leadership course at maastricht university. “the content of this publication has not been approved by the united nations and does not reflect the views of the united nations or its officials or member states”. references 1. contribution of working group i to the sixth assessment report of the intergovernmental panel on climate change [massondelmotte, v., p. zhai, a. pirani, s.l. connors, c. péan, s. berger, n. caud, y. chen, l. goldfarb, m.i. gomis, m. huang, k. leitzell, e. lonnoy, j.b.r. matthews, t.k. maycock, t. waterfield, o. yelekçi, r. yu, and b. zhou (eds.)]. ipcc, 2021: summary for policymakers. in: climate change 2021: the physical science basis [internet]. 2021 [cited 2021 dec 2]. available from: https://www.ipcc.ch/report/ar6/wg1/d ownloads/report/ipcc_ar6_wgi_s pm_final.pdf. 2. smith kr, woodward a, campbelllendrum d, chadee trinidad dd, honda y, liu q, et al. human health: impacts, adaptation, and co-benefits coordinating. cambridge university press. cambridge, united kingdom and new york, ny, usa; 2014. 3. romanello m, mcgushin a, di napoli c, drummond p, hughes n, jamart l, et al. the 2021 report of the lancet countdown on health and climate change: code red for a healthy future. lancet. 2021;398(10311):1619-1662. doi:10.1016/s0140-6736(21)017876. 4. mitchell d, heaviside c, vardoulakis s, huntingford c, masato g, p guillod b, et al. attributing human mortality during extreme heat waves to anthropogenic climate change. environ res lett [internet]. 2016 [cited 2021 dec 8];11(7):074006. available from: https://iopscience.iop.org/article/10.1 088/1748-9326/11/7/074006. 5. haines a, ebi k. the imperative for climate action to protect health. n engl j med. 2019;380(3):263-273. doi:10.1056/nejmra1807873. 6. kendrovski v, schmoll oliver, matthies-wiesler f. health and climate action: policy brief [internet]. world health organization. 2019 [cited 2021 dec 8]. available from: https://www.preventionweb.net/publi https://www.ipcc.ch/report/ar6/wg1/downloads/report/ipcc_ar6_wgi_spm_final.pdf https://www.ipcc.ch/report/ar6/wg1/downloads/report/ipcc_ar6_wgi_spm_final.pdf https://www.ipcc.ch/report/ar6/wg1/downloads/report/ipcc_ar6_wgi_spm_final.pdf https://www.preventionweb.net/publication/health-and-climate-action-policy-brief alsamara, i.; beinert, s. f.; de jong, j. c.; klappe, m. j. p.; marewski, v. s. 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(policy brief). seejph 2022, posted: 23 june 2022. doi: 10.11576/seejph-5603 page15 | 15 editable graphics: bop mc, diop ct, diarra b, gueye b, ka o. determinants of low birth weight in the health district of bounkiling in senegal (original research). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5931 p a g e 1 | 9 original research determinants of low birth weight in the health district of bounkiling in senegal martial coly bop1, cheikh tacko diop1, bou diarra2, boubacar gueye1, ousseynou ka1 1 alioune diop university, bambey, senegal; 2 health district of bounkiling, sédhiou, senegal. corresponding author: dr. martial coly bop; address: unité de formation et de recherchee en santé et déveeloppement durable (ufr/sdd), université alioune diop de bambey, bp 30, sénégal telephone: 00221772550239; email: martialcoly.bop@uadb.edu.sn mailto:martialcoly.bop@uadb.edu.sn bop mc, diop ct, diarra b, gueye b, ka o. determinants of low birth weight in the health district of bounkiling in senegal (original research). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5931 p a g e 2 | 9 abstract aim: low birth weight (lbw), 9.1 million deaths per year, is a global health issue. the proportion of lbw in senegal is estimated at 12% (in 2017) and is at 11.7% (in 2017) in the region of sedhiou. in this regard, rigorous management is required to address this issue, especially in rural areas. the objective of the study was to identify the determinants of lbw. methodology: this is a case-control study which has been conducted in the district of bounkiling. socio-demographic characteristics of the mothers, their obstetrical and medical history, and information on the health status of the newborn in the case group were compared with that of the controls. bivariate and multivariate analyses are performed using epi info 7 software to identify the determinants. results: low-weights accounted for 97.05% of lbw. the sex ratio was 0.87 in favor of girls. the apgar score at birth was not good for 31.4% of newborns. teenage mothers accounted for 17.08%. the multivariate analysis showed that the determinants of lbw (p < 0.05) were the female sex of the newborn, the apgar score at birth, the maternal age <=19 years, the household income < 83.96 usd, maternal history of low birth weight and physical labor during pregnancy. conclusion: strengthening communication on early marriages and pregnancies, empowering women and improving pregnancy monitoring would be levers to counter the determinants of low birth weight. keywords: determinants, district of bounkiling, low birth weight, senegal. coflicts of interests: none declared. bop mc, diop ct, diarra b, gueye b, ka o. determinants of low birth weight in the health district of bounkiling in senegal (original research). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5931 p a g e 3 | 9 introduction infant mortality is a worldwide concern, particularly in developing countries where deaths occur more in the neonatal period (1). the efforts made by countries have led to a decrease in neonatal mortality. however, it still remains high: 36.6 per thousand in 1990 to 17.5 per thousand in 2019 (2). the high neonatal mortality rate is closely connected with the high number of deaths among low birth weight newborns. in 2015, 20.5 million children born globally weighed less than 2500 grams at birth. nearly 90% of these births took place in lowor middle-income countries, particularly in south asia and sub-saharan africa (3). according to the world health organization (who), newborns with low birth weight (lbw) account for 17% of all live births. this frequency of lbw varies from country to country, ranging from 7% in developed countries to 19% in developing countries (4). in sub-saharan africa, the prevalence of low birth weight varies between countries with 13% in cape verde, 15% in togo, 16% in benin, 19% in burkina faso and 23% in mali (3). in senegal, the proportion of low birth weights dropped from 18% (in 2000) to 12% (in 2017) and 11.7% (5) in the region of sedhiou. in the health district of bounkiling, administrative data showed that the number of children born with low birth weight in health facilities was below the data provided by demographic surveys. the proportions were 7.4% in 2019 and 10.3% in 2020 of all live births recorded in health facilities. lbw are a predictor of the quality of child survival. they also cause the deaths of 9.1 million children worldwide each year (6). various studies have shown that low birth weight newborns have higher mortality and morbidity rates than normal-weight infants (6-9). low birth weights are the cause of several very severe and sometimes irremediable disabilities (4). low birth-weight newborns and more particularly premature infants require rigorous care, especially in semi-rural and rural areas because of the under-equipment and lack of qualified personnel (10,11). based on this observation, we conducted this study in the health district of bounkiling located in the region of sedhiou, to identify risk factors and contribute to improving the health of the mothers and children. methods the study was carried out in the district of bounkiling which covers the department of the same name (bounkiling) located in the region of sedhiou. it has an area of 3,005 km2 and a population of 183,842 inhabitants, or 62 inhabitants per km². it also includes a health center and twentyfour health posts settled throughout three boroughs, namely diaroumé, bona and bogal. according to the national health developmment plan phase ii (nhdp ii) standards, the gaps in the number of health centers and health posts are four and eighteen, respectively and are characterized by the lack of personnel (doctors, nurses and midwives). we carried out a case-control study on the different factors associated with low birth weights, based on the birth records of women found in the district maternity wards in the course of the year 2020. (births taking place in maternities are under the responsibility of health professionals whereas those home birth are under the responsibility of non-professionals). the study population consisted of all the mothers who gave birth in the health facilities and the newborns resulting from these deliveries. the cases were all live newborns weighing less than 2500 grams and all women who gave birth to live newborns weighing less than 2500 grams in the district maternity bop mc, diop ct, diarra b, gueye b, ka o. determinants of low birth weight in the health district of bounkiling in senegal (original research). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5931 p a g e 4 | 9 wards during the study period (from 01 january to 31 december 2020). the controls were all live newborns weighing more than 2500 grams and all women who gave birth to live newborns weighing more than 2500 grams in the district maternity wards during the study period. all live newborns whose birth weight is not traced, women from twin pregnancies with low birth weight and low birth weight infants whose mothers were from outside the district were excluded from the study (excluded: low weight from twin pregnancies (13), low weight whose mothers lived outside the district (5) and those whose records were not complete (14). the number of discarded low birth weight newborns was 33. the sampling was exhaustive and the sample size was two hundred and thirtyseven (237) on each side: low birth weight records and records of birthweights over 2500 grams (selected low birth weights 237 were matched to 237 birth weights of 2500g or more). the data was collected using a form filled with the socio-demographic characteristics of the women, the maternal history, the pathologies related to pregnancy, and the clinical examination of the newborn. to complete the data collection, a field visit was conducted and selected women were those whose health records were used. they were recorded in the sphinx software iq then exported to epi info tm 7.2 in view of a descriptive and analytical analysis. as regards the description, the frequencies were calculated for the categorical variables. on the other hand, regarding the quantitative variables, calculation of the position and dispersion was made. in the analytical section, we performed a bivariate analysis using the statistical tests of fisher and a multivariate analysis by a logistic regression. results the average weight of newborns was 2581.1 (±561.1) grams. in the group of newborns weighing less than 2500 grams, low birth weight accounted for 97.05% and very low birth weights were 2.95%. the sex ratio was 0.87 in favor of girls. the apgar score at birth was not normal (below 7) for 31.43% of newborns. birth defects were found in 1.27% of births consisting mainly of polydactyly and microcephaly. the socio-demographic characteristics collected among the mothers surveyed showed that the average maternal age was around 25.6 (±6.2) years, teenage mothers (14 to 19 years) accounted for 17.08%, outof-school women were 71.34% and those who lived in households with a monthly income of less than 50,000 cfa francs per month were 63.71%. the history of abortions and stillbirths at birth was noted in 10.55% and 3.16% of the mothers surveyed, respectively. the delivery of a low birth weight child was found in the obstetrical history of 5.91% of the women surveyed. the maternal pathologies found during the study were essentially high blood pressure (3.38%), malnutrition (2.53%), anemia 0.84%. the behavioral factors which mothers presented during pregnancy were physical work (52.11%), tabacco via vaginal route (8.5%) and geophagia (3.80%). bivariate analysis showed that the link between the birth of a female newborn and the occurrence of low birth weight was statistically significant (p equal to 0.013). newborns with low birth weight were almost twice as likely (or=1.89) to have a low apgar score than those of normal weight. a teenage mother aged 19 and under was more likely to give birth to a low-birthweight child. the prevalence was 62.96% in this age group. teenage mothers are almost twice as likely to give birth to a low birth weight child (or=1.89 with 95% ci =1.15 3.09). women whose households was less than 77.73 usd were surveyed and they were 1.55 times more likely to give birth to a low birth weight child (or=1.55 with 0 95% ci bop mc, diop ct, diarra b, gueye b, ka o. determinants of low birth weight in the health district of bounkiling in senegal (original research). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5931 p a g e 5 | 9 =1.06 2, 26) than those with a regular income. the association was statistically significant, p = 0.01. those exposed to strenuous labor during pregnancy were almost twice more likely to deliver a low birth weight newborn compared to those who were spared from heavy labor (or = 1.69 with 95% ci = 1.17 – 2.43). the association was statistically significant with a p equal to 0.002. women with a history of low birth weight were almost 3 times more likely to give birth to an lbw child than those without a history of lbw (or=2.89 with ci=1.67 – 4.97). a statistically significant association was found between the history of lbw and the occurrence of a lbw birth (p = 0.00005). the absence of high blood pressure in mothers would be a protective factor with regard to the occurrence of a low-weight birth (p = 0.009). the birth of a low birth weight newborn is significantly related to the presence of malnutrition in the mothers (p = 0.007). this association was not found in mothers with pathologies such as anemia, diabetes, hiv infection and malaria in their pregnancy. the bivariate analysis showed the existence of risk factors for the occurrence of low birth weight among women in the health district of kolda (table 1). table 1. risk factors associated with low birth weight factors associated with lbw p value or 95% ic female 0.013 1.53 1.06 – 2.20 apgar score < 7 0.0007 1.92 1.29 – 2.85 age less than 19 years 0.007 1.89 1.15 – 3.09 monthly household income under 50000 0.01 1.55 1.06 – 2.26 mother's height less than or equal to 150 cm 0.01 4.16 1.15 – 14.93 hard work during pregnancy 0.002 1.69 1.17 – 2.43 number of anc ≤ 2 0.002 1.82 1.20 – 2.75 history of lbw deliveries 0.00005 2.89 1.67 – 4.97 maternal malnutrition 0.007 3.58 1.30 – 9.88 history of high blood pressure 0.009 4.52 1.27 – 16.09 the risk factors correlated with the occurrence of low birth weight were the female sex of the newborns, the apgar score < 7, the maternal age of less than 19 years, the monthly household income of less than 83.96 usd, the height of the mother less than or equal to 150 centimeters, heavy labor during pregnancy, the low number of prenatal visits (≤2) carried out, the existence of a history of delivery of an infant with lbw, the history of high blood pressure during pregnancy and malnutrition in the mother. these variables were under consideration in the multivariate analysis to control for possible confounding factors. thus, the multivariate analysis showed that the independently and significantly associated factors were maternal age less than 19 years (or=2.42 with ci = 1.43-4.12); p equal to 0.001, household income less than 83.96 usd, (or=1.97 with ci=1.27-3.04); p equal to 0.002, maternal history of low birth weight (or=3.62 with ic=2.02-6.50); p=0.000001, physical work during pregnancy (or=1.80 with ci=1.20 – 2.69); p = 0.004, the female sex of a newborn (or=1.59 with ic=1.07 – 2.35); p equal to 0.019 and the apgar score at birth (or=2.79 with ci=1.77 – 4.41); p equal to 0.000001 (table 2). bop mc, diop ct, diarra b, gueye b, ka o. determinants of low birth weight in the health district of bounkiling in senegal (original research). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5931 p a g e 6 | 9 table 2. results of the multivariate analysis factors associated with lbw multivariate analyze or adjusted p female 1.59 0.019* apgar score < 7 2.79 0.000001* age less than 19 years 2.42 0.001* monthly household income under 50000 1.97 0.002* mother's height less than or equal to 150 cm 3.12 0.12 physical labor during pregnancy 1.80 0.004* number of anc ≤ 2 1.42 0.08 history of lbw deliveries 3.62 0.000001* maternal malnutrition 2.83 0.06 history of high blood pressure 2.95 0.11 tabacco via vaginal route 0.67 0.28 history of abortions 1.26 0.48 birth defects 2.28 0.49 *statistically significant. discussion various limitations have been identified in this work. these were representativeness biases, information biases and biases relating to case-control studies. in view of he study carried out in 2019 (16), the representativeness biases are largely explained by the importance of home births recorded in health structures and estimated at 15% and 23% the lack of information in some birth records was a limitation in this work and justified the use of comprehensive records of mother-child pairs. control case studies which are by nature retrospective, may imply drawbacks such as selection bias (over or under-estimation of the risk factor) and information bias (missing data, memorization, interviewer subjectivity). the study focused on determinants related to newborns (sex, apgar score, birth defects) and mothers (individual, biological, socio-economic and behavioural). newborn characteristics the categorization of newborns with low birth weight shows that the majority (97.05%) weighed between 1500 and 2499 grams. based on distribution of newborns by birth weight, this same trend has been observed in other studies carried out in the health district of kolda in senegal (12) and in moroco (13). the link existing between the delivery of a female child and the low birth weight which was found in our study is similar to that found in work done in tunisia (14) and in the democratic republic of congo (15). however, this relation (13,16) was not found in other studies. the results showed that low birth weights are about five times more likely to have an apgar score under 7 which reflects a poor neurological condition of the newborn, than those of normal weight. this conclusion was observed in studies carried out in cameroon, tunisia and madagascar (1719). this relation was statistically significant in our study. however, this result was not found in kolda (12). but, it had been found that lbw are more likely to have an apgar score under 7. depending on the contexts of study and the determinants which were identified, we noted that the conclusions are not identical. however, the management of low birth bop mc, diop ct, diarra b, gueye b, ka o. determinants of low birth weight in the health district of bounkiling in senegal (original research). seejph 2022, posted: 10 october 2022. doi: 10.11576/seejph-5931 p a g e 7 | 9 weight must be rigorous with regard to the consequences of a low apgar score on newborns health. maternal characteristics and risk factors mothers under the age of 19 are 2.42 times more likely to give birth to a newborn with low birth weight. there is a statistically significant association (p<0.05) between young maternal age and the delivery of a lowweight newborn. this link can be observed given that teenage pregnancy remains a public health issue for the young mother and her newborn (21). in senegal, studies have shown that the probability for a woman to give birth to a child with low birth weight was present in adolescents (12,21) age group. these results were similar to those of studies carried out in mali (23) and cameroon (17). however, this link was not found in other studies (2325). this could be explained by the significant pace of growth and of change during this period, and especially by the context of the precocity of reproductive life. women living in families with a monthly income of less than 77.73 usd were 1.97 times more likely to give birth to a child with low birth weight (p<0.05). this significant difference was found in guédiawaye (26) and kolda (12). however, in morocco, the study did not show any statistically significant link (13). in bounkiling, the results can be explained by the fact that the region of sédhiou is one of the poorest localities in the country. this poverty has an impact on the household income and on meeting primery needs, particularly for pregnant women (27). women empowerment can help improve the management of the basic needs of this target. the prevalence of low birth weight was 3.62 times higher among women with past obstetric history of low birth weight than among those who gave birth to children with normal weight in their previous pregnancy. similar results have been found in studies conducted in senegal and burkina (12,26,29). on the other hand, the study conducted in tunisia (18) did not establish a statistically significant relation in this regard. the existence of this nonmodifiable risk factor could reflect a lack of management of pregnancy (12). women who did physical labor during pregnancy were 1.80 times more likely to give birth to a child with low birth weight than those who did not engage in physical labor. a statistically significant link was found (p equal to 0.004). similar results were found in studies conducted in senegal and in burkina (26,29). however, mangane (12) did not establish any statistically significant relation. this can be explained by the context of poverty causing women to carry out daily arduous tasks such as farming activities and trade over long distances. the lack of running water means that women also have to draw water from wells for domestic work, which is non-optional. these difficult living conditions could lead to an early onset of labor, thus, the birth of premature infants, and therefore lowweight newborns. conclusion identifying the risk factors associated with low birth weight is a prerequisite for developing prevention strategies. scaling up strategies focused on the reproductive health of adolescent 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(original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 1 | 30 original research exchange and coordination: challenges of the global one health movement a pilot study exploring options to increase cooperation and coordination with systemic strategies to improve the impact on people and politics. ulrich laaser1, cheryl stroud2, vesna bjegovic-mikanovic3, helmut wenzel4, richard seifman5, carter craig6, bruce kaplan7, laura kahn8, rohini roopnarine9 1) school of public health, bielefeld, germany 2) one health commission, usa 3) faculty of medicine, belgrade, serbia 4) consultant, konstanz, germany 5) united nations association, national capital area 6) one health initiative autonomous pro bono team, lexington, ky (usa) 7) one health initiative autonomous pro bono team, sarasota, fl (usa) 8) one health initiative autonomous pro bono team, new york, ny (usa) 9) faculty of vet med; adjunct public health and preventive medicine, school of medicine, sgu, grenada corresponding author: prof. dr. med. ulrich laaser dtm&h, mph past president aspher and wfpha section of international public health school of public health, bielefeld university pob 10 01 31, d-33501 bielefeld, germany e-mail: ulrich.laaser@uni-bielefeld.de mailto:ulrich.laaser@uni-bielefeld.de laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 2 | 30 abstract1 current economic, social, and environmental trajectories within most world regions are unsustainable. interaction between bottom-up initiatives and top-down good governance is essential to change them. the one health movement, made up of many organizations, groups, and individuals from diverse backgrounds and disciplines, seeks to redress the present trajectories but has lacked coordination and cooperation, limiting its effectiveness to date. we take a snapshot of groups/organizations working to promote one health, explore options to increase cooperation and coordination among global one health stakeholders, and propose systemic strategies that could positively impact animals, people, the planet, plants, and politics. methods: through a review of the compilation of who’s who in one health organizations on the one health commission’s (ohc) website and the list of organizations that have pledged support for one health listed on the one health initiative (ohi) website, 289 organizations were identified (as of 29 july 2022: 126 civil society organizations, 133 academic and 30 governmental organizations). a stratified sampling approach and maxqda 2022 were used in a mixed-methods analysis to select a sample (n=50) of organizations to evaluate with 10 questions on purpose & focus, structure & transparency, cooperation & implementation, and publications. results: the words “one health” appeared in the organizations’ names on 62.0% (n=31) of websites examined, most often those in academic settings (78.2%). as regards transparency of the organizational structures, membership was defined in 70.0% (n=35), again most often by academic organizations (82.6%). members of the governing structures were named on 34.0% of organizational websites. projects led in the last two years were described on 32.0%, and cooperation with other organizations was indicated on 64.0% of websites examined. relevant publications and annual reports were listed on 46.0% and 24.0% of probed websites, respectively. ranking the number of positive findings for each of the 50 organizations examined revealed that full information for all ten questions was provided by only 4 academic and 1 governmental organization. the ohc website was used as a starting point and thus was not included in the n=50 samples. it was therefore examined as an example of a non-profit / cso working to support bottom-up one health leadership. since 2014 the ohc has supported a global one health community listserv of individuals from around the globe. the analysis revealed a dominance of directors from the us and a high proportion of organizations included on the ohc who’s who in one health organizations webpage were located in north america. the social sciences sociology and economics in particular – were underrepresented among in its leadership. conclusion: these 10 questions may not have been fully appropriate for all organizations examined in academic or government settings versus stand-alone non-profit or civil society organizations. however, an examination of the 50 selected websites of organizations working 1 presented orally at the 7th world one health congress 2022 in singapore: https://tinyurl.com/yy767vmy https://tinyurl.com/yy767vmy laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 3 | 30 to implement one health and/or framing their projects and purpose in one health revealed the global one health movement to be fragmented and uncoordinated. the authors propose to form a more unified voice for one health across the international one health movement, a fully networked, informal global one health alliance or community of practice that can coordinate sharing of information among the networks and with the general public, and that is able to seek synergies and joining of hands in collective/collaborative actions to effectively and efficiently promote and support bottom-up efforts. keywords: one health movement; trajectories, globalization; global health; organizational deficits; interaction; global one health alliance. laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 4 | 30 ultimately, the survival, not only of other life forms on this planet but also of our own, will depend upon humanity’s ability to recognize the oneness of all that exists and the importance and deeper significance of compassion for all life (wiebers & feigin, 2020 (1)) , introduction we have transgressed several planetary boundaries that regulate the stability of earth systems and ultimately a stable state of the planet. the world in 2050 (twi 2050) (2) initiative identified in 2018 specific pathways on how we can achieve a sustainable future, and, in a more recent reformulation, sachs et al. (3) outlined 6 transformations to achieve the united nations sustainable development goals: 1) education, gender, and inequality 2) health, well-being, and demography 3) energy, de-carbonization, and sustainable industry 4) 4) sustainable food, land, water, and oceans 5) 5) sustainable cities and communities 6) 6) digital revolution for sustainable development the timing how can the world progress along these six pathways? first, we must realize that there is not much time left; the last decades of this century may be too late. as outlined by the united nations' seventeen goals (4) and twi 2050 initiative (2), which target 2030 and 2050 respectively, action is required ‘now’. this is exemplified by the fact that, e.g., since 1970 the abundance of all vertebrates has declined by 60% (5). yet, resistance to the necessary change is strong2 (2). politics may be too slow as seen at the glasgow summit 2021 (6) and “current health governance remains segregated in local, national and international institutions, which lack the authority and tools to prevent emerging health threats at various scales” as stated by kevin queenan et al. in 2017 (7). 2 vested interests: a) owners of fossil fuels resisting the move to zero-carbon energy, and beneficiaries of unsustainable land and ocean practices as e.g. land clearing and deforestation, overfishing the oceans. b) major wealth owners avoid successfully taxation. c) limited capacity of governments to plan and implement policies with time scales of decades because of the short political business cycle and the lack of strong planning units supported by universities, and think tanks. d) the difficulty of a suitable balance in public private partnerships (successful lobbying vs. strangulation of initiative). e) an ill-informed public develops fear and resistance to change leading to 'status quo biases’. laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 5 | 30 threats of the future or today? the historical perspective in western countries, advancements in human health were critical to and resulted from the human "great escape" out of poverty over the past 250 years (8). however, many recent health gains resulted from the exploitation of natural resources, particularly for food and energy provision. the required correction of this unsustainable path must be based on the most important asset of good governance, the public's confidence, and trust: if lost, the costs can be very high. this applies also to the public's confidence in scientific conclusions. the starting point is public awareness, often initiated by civil movements or farsighted authors3 whose 3 e.g. rachel carlson’s book of 1962: “silent spring” initiating the environmental movement in the us writings have often preceded governmental action by decades (e.g., nelson mandela for civil rights). admitting that a de-growth scenario is at least for the moment impossible, instead, we must try to mitigate the consequences of our current trends (9). an example is carbon dioxide (co2) mitigation. can we extend it to other fields and what would it take scientifically, politically, and economically? the real danger is that a collision between several non-linear tipping points will generate unpredictable disruptions, leading to a period of global chaos, accelerated by rapid technological change, such as the fast internet. the lake chad basin, situated in the subsaharan region of africa, is facing one of the world’s greatest humanitarian crises. between 1973 and 2017 the lake shrank by 90%: from a surface area of 25,000km2 in 1963 to less than 2,500km2 in 2021. more than seven million people suffer from severe food insecurity and more than two million have been displaced by the intractable conflict fueled by the diminishing livelihood. the region’s recent history provides an illuminating snapshot of how climate change is already driving social tensions, conflict and migration, and threatens to do so on a much larger scale over the next decades. laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 6 | 30 bottom-up and top-down a dynamic one health framework of leadership and management will require both bottom-up (10) and top-down (11) structural elements, interacting based on scientific reasoning and guiding long-term one health advancement. innovative ideas and subsequent initiatives are often initiated bottom-up, as is the societal dimension of one health and its social dynamism. on the other hand, supportive leadership carrying forward and stabilizing initiatives is mandatory to secure an enduring long-term perspective and permanent progress: the flowers rising their heads are going to dry and die without rain4. science and policy yet policymaking in the 21st century is dealing with uncertainty and the process has become even more complex as it attempts to address systemic risks confronted with multiple possible futures. decision-making today includes many players and stakeholders, various processes (politics), and related structures (polity) to reach an agreement on courses of action, bottom-up and top-down. exacerbating policymaking is the fact that the amount of evidence is always increasing, and it is rarely final. this difficulty to forecast the effects of action with a sufficient degree of reliability constitutes a major problem for political and administrative decision-makers. consequently, they are hesitant to make decisions in a state of uncertainty and have no incentive to go beyond their field. not to mention that they are usually elected for a limited time and have to be concerned about 4 poetic wording, ul their professional future. addressing complex social issues based on separate responsibilities and not on teamwork across sectors does not pay justice to 'the interactions between causal factors, conflicting policy objectives and disagreement over the appropriate solution.' (12). already in 2010, the world bank called for a permanent system of international surveillance and control instead of prevailing temporary arrangements and uncoordinated duplication of efforts (13). an additional fundamental element is a complex amalgam requiring expertise from natural and social sciences, oriented on three interconnected concepts: i) global health, which underlines the steep gradients in human health between rich western countries and, e.g., impoverished sub-saharan countries in africa. ii) public health, which targets population health and the essential service infrastructure required in addition to individual curative medicine by. iii) planetary health which targets the ecosystem as an interdependent and interactive system of air, water, land, plants, animals, and humans. multi-professionality practice on the ground – represented by the activities of non-profit or civil society organizations (csos) should help to influence, bottom-up, the governing level and induce changes toward more responsive and inclusive governance. on the other hand, governance should secure the initiation and support of an active and wellinformed, bottom-up community of practice laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 7 | 30 thus widening its scope and coverage. this process includes multiple professional sectors, inter alia: mechanical engineering, pharmaceutical industry, forestry, education, and professional specialists: e.g. economists, agriculturalists, veterinarians, physicians, political advocates, and journalists. also, the multiple professional sectors' involvement must include the oftenneglected areas of jurisprudence, sociology, and ethics in which we need to go beyond the bioethics and include the issues of environmental and biodiversity ethics, social science ethics, and aspects of rights (human, animal, ecosystem). to this end, legal experts, sociologists, and experts in ethics should be included in the implementation of one health (14). as demand increases from the scientific community, from policymakers, and other stakeholders for quantitative projections of future climate change, the involvement of professionals with expertise in systems modeling is a must (15). indeed, though many writings have outlined core competencies5 required for one health practitioners (16), consensus across the global one health movement on a set of required competencies has not yet been reached. global interaction “one health” has been recently defined by four global institutions6 joined together as a one health quadripartite: 5 https://www.onehealthcommission.org/en/why_one _health/one_health_core_competencies/ 6 the food and agriculture organization of the united nations (fao), the world organisation for animal health (oie), the united nations environment programme (unep) and the world health organization (who): https://www.who.int/news/item/01-12-2021one health is an integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals, and ecosystems. it recognizes the health of humans, domestic and wild animals, plants, and the wider environment (including ecosystems) are closely linked and interdependent. the approach mobilizes multiple sectors, disciplines, and communities at varying levels of society to work together to foster well-being and tackle threats to health and ecosystems while addressing the collective need for clean water, energy, and air, safe and nutritious food, taking action on climate change, and contributing to sustainable development. nevertheless, one health has struggled to gain a firm institutional foothold despite growing support for this framework most recently at the g7 and g20 2021 and 2022 summits7. lee and brumme observed in 2013 that, beyond meetings, there had been few attempts (so far) “…to create a single designated global level institution for one health” (17). they continued that an integrated approach to one health is hindered by “institutional proliferation, fragmentation, competition for scarce resources, lack of an overarching authority, and donor-driven vertical programs”. leboeuf (18) called it “soft global health governance” based on meetings and declarations, dominated by veterinarians and characterized by a high degree of reductionism and fragmentation (19). streichert et al. (20) in their study on participation in one health networks (ohns) and involvement in the covid-19 tripartite-and-unep-support-ohhlep-s-definition-ofone-health 7 https://www.iges.or.jp/en/projects/g7-g20-2022; https://www.woah.org/en/g20-ministers-of-healthreaffirm-the-urgent-need-to-address-global-healthunder-a-one-health-approach/ http://www.g20.utoronto.ca/2021/210906health.html https://www.onehealthcommission.org/en/why_one_health/one_health_core_competencies/ https://www.onehealthcommission.org/en/why_one_health/one_health_core_competencies/ https://www.who.int/news/item/01-12-2021-tripartite-and-unep-support-ohhlep-s-definition-of-one-health https://www.who.int/news/item/01-12-2021-tripartite-and-unep-support-ohhlep-s-definition-of-one-health https://www.who.int/news/item/01-12-2021-tripartite-and-unep-support-ohhlep-s-definition-of-one-health https://www.iges.or.jp/en/projects/g7-g20-2022 https://www.woah.org/en/g20-ministers-of-health-reaffirm-the-urgent-need-to-address-global-health-under-a-one-health-approach/ https://www.woah.org/en/g20-ministers-of-health-reaffirm-the-urgent-need-to-address-global-health-under-a-one-health-approach/ https://www.woah.org/en/g20-ministers-of-health-reaffirm-the-urgent-need-to-address-global-health-under-a-one-health-approach/ http://www.g20.utoronto.ca/2021/210906-health.html http://www.g20.utoronto.ca/2021/210906-health.html laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 8 | 30 response found that of 1050 questionnaire responses globally, 75.0% considered themselves to be part of an ohn. 44.6% came from the united states and 42.7% from academia but only 15.6% from nonprofit organizations and only 7.6% from social sciences. khan et al. in 2018 published (21) a systematic analysis of ohns. khan et al. in 2018 published a systematic analysis of ohns (21), defined a network as engagement between two or more discrete organizations and investigated whether duplication of efforts was occurring, which stakeholders were being engaged in one health networks, and how frequently monitoring and evaluation of investments were being reported. they identified "specific gaps in the coverage of activities, limitations in stakeholder representation, apparently absent or ambiguous accountability structures, and potential areas of duplication." less than 15% of ohns reported activities targeting the "…community level impact of ongoing investments in one health, engagement with target populations, and research to aid adaptation of interventions to the local context." in this paper, we consider a global orientation – potentially best termed ‘globalism’ – as a decisive dimension. although each country or group of countries must find its priorities, direction, pace, and agenda (the traditional scenario), each such choice today has global implications in terms of conditional determinants and global effects. therefore, they must be discussed and decided considering the global context. people become increasingly 'place-less' with other, non-territorial modes of organization emerging. globalism supports our understanding of an interdependent world but can also undermine societal cohesion, the multidimensional value systems that keep communities together (22) with the consequence of unrest and even rampant fanatism unlocked. the targets of this paper since 2010 (13) there have been multiple calls for permanent systems of sustained one health implementation on many fronts, (especially for disease surveillance and response) instead of temporary arrangements and uncoordinated duplication of efforts. yet, the one health movement has appeared as a conglomeration with many different players and often uncoordinated actions. in part i of this paper, we identify and analyze the websites of a representative sample of non-profit, civil society organizations (csos), university-based organizations (academia), and governmental organizations (government) that are embracing, promoting, and operating within a one health framework. we examine their websites with 10 questions on purpose & focus, structure & transparency, cooperation & implementation, and publications. in part ii we analyze the comprehensive website of the one health commission to provide an imperfect but positive model. finally, we explore options to increase cooperation and coordination among global one health stakeholders and propose systemic strategies that could positively impact people, animals, plants, the environment, and politics. laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 9 | 30 part i: the website analysis methods starting from the websites of the one health commission (ohc)8 and the one health initiative (ohi)9, we identified (as of 29 july 2022) 289 organizations working to promote and implement one health (126 non-profit civil society organizations (cso), 133 academic organizations, and 30 governmental). to ensure the most efficient evaluation, we decided to work with a random sample of n = 50 organizations. this number seemed to be both large enough and the evaluations achievable within a reasonable amount of time. stratified sampling was used to account for the different sizes of the three categories “civil, academic and governmental”. one approach for stratified sampling is proportionate stratification. with proportionate stratification, the sample size of each stratum is proportionate to the population size of the stratum according to the formula (23): nh = ( nh / n ) * n the organizations were selected using random numbers per sample stratum. this resulted in 22 civil, 23 academic, and 5 governmental organizations, n = 50 in total. for a description of the organizations, 10 questions were formulated (see table 1 and figure 1) to be checked on their websites for positive/negative findings (also short: yes/no classification). table 1: the ten questions 1) is one health part of the organization’s name? 2) are the work objectives listed? 3) is membership defined? 4) is a governing structure (executive board) described? 5) are members of the governing structure named? 6) are projects indicated for the period 2020/2021? 7) is cooperation with other organizations/projects indicated? 8) are names of cooperation partners provided? 9) are publications (any media) listed on the website? 10) is an annual report published? 8 https://www.onehealthcommission.org the answers to these questions, taken from the websites of the selected organizations, should clarify (figure 1): i. what is the purpose and focus (1, 2)? ii. is the organization’s structure transparent (3-5)? iii. are cooperation and implementation described on the website (6-8)? iv. are there publications (9, 10)? 9 https://onehealthinitiative.com/ laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 10 | 30 figure 1: the four domains of questions on the practice of one health organizations. results table 2 shows the basic account of the 50 relevant websites of civil, academic, and governmental organizations identified, and randomly selected from 289 organizations (for more details see annex a). though they were included in a listing of who’s who in one health organizations, the words “one health” appeared in the organizations’ names on 62.0% (n=31) of websites examined, most often those in academic settings (78.2%) and governmental organizations (80.0%). as regards transparency of the organizational structures, membership was defined in 70.0% (n=35), again most often by academic organizations (82.6%). members of the governing structures were named on 34.0% of organizational websites. an annual budget was found on only one cso website. one health projects led in the last two years were described on 32.0%, and cooperation with other organizations was indicated on 64.0% of websites examined. relevant publications and annual reports were listed on 46.0% and 24.0% of probed websites, respectively. laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 11 | 30 table 2: summary of the resulting classifications of one health organizations (percentages in bold) note: the total number of possible yes/no classifications is 500 (10 questions checked for 50 organizations) of the 50 websites examined, full information for all ten questions was provided only by 4 academic and 1 governmental organization (none of the governmental ones, together 5 organizations or 10%), almost one-third answered positively on less than 5 questions. a ranking of the number of positive findings (yes classifications) for csos and academic organizations is demonstrated in figure 2. figure 2: comparison of positive findings (yes classification) for the ten questions per organization: here csos and academia. 0 2 4 6 8 10 ai ab aa ak an at ar aj al ao ad ap ah ag au ac am as ae af uv aq cso: number of yes classifications by organization i. purpose & focus ii. transparency of structure iii. cooperations iv. publications question no. 1 2 3 4 5 6 7 8 9 10 sum of yes classifications a. csos (n=22) 9 40.9 18 81.8 13 59.1 9 40.9 8 36.4 8 36.4 13 59.1 10 45.5 10 45.5 7 31.8 105 47.7 b. academia (n=23) 18 78.2 18 78.2 19 82.6 7 30.4 8 34.8 7 30.4 16 69.6 15 68.2 10 43.5 4 17.4 122 53.0 c. government (n=5) 4 80.0 3 60.0 3 60.0 2 40.0 1 20.0 1 20.0 3 60.0 3 60.0 2 40.0 1 20.0 23 46.0 sum of yes classifications 31 62.0 39 78.0 35 70.0 18 36.0 17 34.0 16 32.0 32 64.0 28 56.0 22 44.0 12 24.0 250 50.0 laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 12 | 30 the pattern of positive or yes classifications is similar for all three organizational groupings (figure 3). insignificant differences were shown for csos on one side and academic and governmental organizations on the other also by principal component analysis. figure 3: percentage of yes classifications by question and categories line plot of all three categories cso academic government q 1 q 2 q 3 q 4 q 5 q 6 q 7 q 8 q 9 q 10 question number 10 20 30 40 50 60 70 80 90 % o f y e s -a n s w e rs 0 2 4 6 8 10 ba bc bk bv be bl bn bm bu bp bt bq bo bw bh bd bf br bb bi bj bs bg academia: number of yes classifications by organization laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 13 | 30 part ii: analysis of the website of the one health commission (ohc) the one health commission’s website was used as one starting point for this pilot study and thus was not included in the random sample selected from its website. it may therefore be examined as a potential positive example of a non-profit / cso working to support bottom-up one health leadership. since 2014 the ohc has supported a global one health community listserv that had grown to over 17,200 individuals (at the time of this publication) from around the globe actively sharing information through its monthly ‘one health happenings’ newsletter.7 the website presents a comprehensive and well-organized collection of information, an extensive catalog of activities mainly programs / working group activities, extensive resources (online one health opportunities bulletin board, one health educational resources for public health educators, national one health strategic action plans, one health tools/toolkits, relevant newsletters, social media links, webinars and presentations) as well as a library of relevant books and articles, and a list of who’s who in one health organizations. annual reports for 2020 and 2021 were presented under ‘why support the one health commission?’. consequently, all 10 questions could be answered positively. of special interest is the list of projects and organizational collaborations (annex b). however, a more detailed analysis of the ohc website revealed that all but one member of the board of directors was from the us and that approximately 50% of organizations included on the who’s who in one health organizations webpage were located in north america in the us and canada. individuals listed as directors were almost exclusively veterinarians and physicians. while the ohc supports a one health social sciences initiative and working groups, the social sciences sociology and economics in particular – were underrepresented as of july 2022 among its leadership. (see the discussion). figure 4 reveals a map of 'all' groups and organizations (non-profit/cso, academia, government) identified so far in an ohcled global one health community joint effort as working to promote one health or framing their work in one health. laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 14 | 30 figure 4: global map (july 2022) of identified groups and organizations working to promote one health or framing their work in one health permission to use granted by the one health commission table 3 reveals dominance of us-american organizations identified as working to promote one health. a global list-serv10 10https://www.onehealthcommission.org/en/resourc esservices/join_the_global_oh_community_listser/ indicates a community of followers of plus 17.000 actively served with information through the monthly newsletter "one health happenings". https://www.onehealthcommission.org/en/resourcesservices/join_the_global_oh_community_listser/ https://www.onehealthcommission.org/en/resourcesservices/join_the_global_oh_community_listser/ laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 15 | 30 table 3: who is who in one health11,12 the structure of the one health commission13 can be summarized as follows: the board of directors consists of 13 members: 7 with a veterinarian education, 4 with medical education, and 1 with medical public health education (one cv is not accessible), all members are us american. the council of advisors (non-voting) comprises 15 members: 13 veterinarians and 1 with medical public health education, all us american. one member lives in england. among the council of advisors, the one health initiative (ohi)14 (autonomous pro bono team) lists 7 active members, thereof 2 veterinarians, 2 physicians, and 3 members of related pharmaceutical companies. a student representation is dated 2015/2017 and continued as the international student one health alliance (isoha15). the lists of 5 corporate financial donors/sponsors, ca. 25 institutional financial donors, and ca. 55 individual donors appear to be almost exclusively usamerican donors. 11 https://www.onehealthcommission.org/en/resourcesservices/whos_who_in_one_health/ 12 the figures may not be fully precise and differ by one or two units because of unclarity of information. 13 at: https://www.onehealthcommission.org/en/leadership__board_of_directors/ (visited 18 september 2022) 14 the one health initiative autonomous pro bono team (ohi) was co-founded originally by physician laura h. kahn, md, mph, mpp view bio, veterinarian bruce kaplan, dvm view bio, and physician thomas p. monath, md view bio in 2006-2007 for the sole purpose of promoting the one health concept nationally and internationally. the ohi team was expanded to include health research scientist *jack woodall, phd read more about jack woodall in february 2009 and *lisa a. conti, dvm, mph view bio in january 2012. 15https://www.onehealthcommission.org/en/leadership__board_of_directors/students_for_one_health_soh_news/ organizations civil society organization, not for profit academic governmental private forprofit organizations total africa 5 5 10 asia (incl. au/nz) 11 (1/1) 10 (2/0) 2 2 25 europe 13 6 5 2 26 north america (incl. canada) 22 (1) 30 7 6 65 south america 4 3 7 total 55 54 14 10 133 https://www.onehealthcommission.org/en/leadership__board_of_directors/ https://onehealthinitiative.com/wp-content/uploads/2020/05/dr.-laura-h.-kahn-short-biography-may-2020.pdf https://onehealthinitiative.com/wp-content/uploads/2020/11/dr.-bruce-kaplan-short-bio.pdf https://onehealthinitiative.com/wp-content/uploads/2020/05/tom-monath-biography-april-2018.pdf https://www.archive.onehealthinitiative.com/news.php?query=extraordinary+scientist%2c+admired+one+health+supporter-activist-leader+dies+ https://www.archive.onehealthinitiative.com/news.php?query=extraordinary+scientist%2c+admired+one+health+supporter-activist-leader+dies+ https://onehealthinitiative.com/wp-content/uploads/2020/05/lisa-conti-biography-august-2017.pdf https://www.onehealthcommission.org/en/leadership__board_of_directors/students_for_one_health_soh_news/ laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 16 | 30 discussion if we continue failing to address the wide gaps revealed in poverty, social inequality and the environmental injustice – failing to acknowledge and act on the linkages between environment and human and animal well-being then negative trajectories may exponentially grow and endanger civility. how to enhance civility? is it sufficient to get citizens to adopt a convention on decent behavior? it seems that in most if not all societies there is a potential for indecent behavior only waiting for an opportunity to exercise aggressive communication and even physical attack. this potential may be smaller in more equal societies but will be unlocked by steepening social gradients or, for example, by a pandemic like covid-19 and the restrictions coming with it. the german history of the last 150 years is a good example of unlocked aggression. starting from kaiser wilhelm ii's immature personality and almost absolute power on the last decisions, to the unbalanced treaty of versailles, and the financial crash of 1929 the stage was set for extremist groupings to take over. today the largely uncontrolled social media make it even easier to form extremist cocoons growing fast in times of general hardship when people look desperately for an exit. nevertheless, a deeply disturbing question arises: why could the great, humanizing traditions of german history duerer, lutherbibel, bach, the enlightenment, goethe's faust, the bauhaus, and very many more not prevent the total moral collapse of 1933-1945. 16 https://sdgs.un.org/goals today, on a global scale, we see large sections of our societies being deprived of a decent living and health equity e.g., in the big cities, in the former german democratic republic (gdr), in england, and especially in the us, not to mention the global south. how can we expect that they behave decently? if we do not get better at equalizing social gradients (even vaccines are unequally distributed (24)), a huge reservoir of non-civility will remain (25). many people see the one health way of thinking and living as a ray of hope for the future never more desperately and urgently needed. implementation of one health, truly making it the default way of thinking at all levels of academia, research, government and policy, will help us fully achieve the un 2030 sustainable development goals16. achieving those goals will go a long way toward global security by addressing the social, public health and ecological inequities that can drive the unlocked aggression mentioned above. it is urgent that the global community of one health stakeholders and advocates succeed in helping the world understand and adopt the one health paradigm shift. in the introduction to this paper we referred to the necessity, for one health to be fully realized, of a bottom-up and top-down strategy as outlined also in the special volume of the south eastern european journal of public health on the global one health environment (26). action from both sides and a supportive array of environmental, social, and health sciences are essential to secure sustainable, https://sdgs.un.org/goals laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 17 | 30 codified, institutionalized, long-term implementation. innovative ideas are often conceptualized bottom-up. and supportive leadership from the top is mandatory to stabilize and carry initiatives forward for secure, permanent, sustainable progress. yet the one health movement has struggled for 20 years to get these coordinated bottom-up/top-down actions happening simultaneously from both directions. there are many differing opinions about why we have not been able to sustainably put one health programs in place even on the most obviously needed fronts like zoonotic disease surveillance and control. some advocates think we have tried too much from the top down via government programs that don’t draw from deep knowledge and expertise ‘in’ local communities to discern what ‘they’ think their priorities need to be and how ‘they’ think they should be addressed. that is the way to get true support and ‘buy-in’ from the grassroots communities needed to implement one health thinking at ground level. the challenges likely lie at both ends of this spectrum. if we think for the moment just about the ‘bottom-up’ challenges, what the community of global one health stakeholders, i.e. the global one health movement, needs is a way to better ‘connect, communicate and coordinate’ our actions across all categories of players in the global one health community: • so organizations working for one health can find each other, discover their commonalities, overlaps, strengths, and synergies, join hands, and work ‘together’ • to share news from all global regions, and all professions – so the right hand of the one health movement knows what the left is doing – so we can ‘support’ each other’s efforts and become ‘force multipliers’! • to speak in a unified voice to the public, to governments, lawmakers, and policymakers urging a focus on ways to ‘prevent’ infectious disease outbreaks and environmental contamination and degradation. • to share educational, job, and volunteer opportunities • to engage more social scientists and many other disciplines there is, already in place, a lot of what is needed for effective bottom-up and topdown actions. it just lacks connection, communication, and coordination. bottom-up:  we have a global army of individuals willing and able to lead for one health as revealed by annual one health day events since 2016 (https://tinyurl.com/oh-dayhome).  we have many powerful one health tools and toolkits (https://tinyurl.com/ohc-ohtoolkits).  we have grassroots networks for communications like the ohc’s one health happenings newsletter (https://tinyurl.com/ohc-ohhappening) and the ohi’s one health news webpages (https://onehealthinitiative.com/one -health-initiative-news/).  we have a network of networks of https://tinyurl.com/oh-day-home_ https://tinyurl.com/oh-day-home_ https://tinyurl.com/ohc-oh-toolkits https://tinyurl.com/ohc-oh-toolkits https://tinyurl.com/ohc-oh-happening https://tinyurl.com/ohc-oh-happening https://onehealthinitiative.com/one-health-initiative-news/ https://onehealthinitiative.com/one-health-initiative-news/ laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 18 | 30 one health groups and organizations (https://tinyurl.com/ohc-ww) that can share information and get it out deeply across and into their networks. (example: the ohc’s global one health community listserv has grown to >17,200 since 2014 (https://tinyurl.com/ohclistserv). the needed communications just aren’t currently happening efficiently because those working in the one health space often don’t even know each other exists. top-down:  we have the newly expanded quadripartite and its advisory one health high-level expert panel (ohhlep) that has given us a more unifying definition of one health to guide us. https://tinyurl.com/whoohhlep-oh-definition  we have the newly released quadripartite one health joint plan of action https://tinyurl.com/quadri-oh-jpa with its elegant theory of change and unifying message.  we have a growing number of countries that have formally adopted national one health strategic action plans and one health framed antimicrobial resistance strategic action plans (https://tinyurl.com/ohc-ohstratact). 17 https://multilateralism.org/the-alliance/ 18 https://multilateralism.org/actionareas/berlinprinciples-on-one-health/ all that is needed is the collective, grassroots ‘will’ to ‘be’ a more coordinated community of practice to provide collaborative leadership in both directions. thus, we are calling for an informal global one health alliance. not another nonprofit organization, but a global community of practice that is well-connected and coordinated among its members. formation of an informal global alliance is not an unprecedented idea. indeed the “alliance for multilateralism”17 launched by the french and german foreign ministers is an informal network of countries united in their conviction that a rules-based multilateral order is the only reliable guarantee for international stability and peace and that our common challenges can only be solved through cooperation. that alliance has embraced one health with a posting about the berlin one health principles18 stating “international cooperation in this field [one health] must be intensified and existing structures strengthened. in this sense, the “berlin principles”, the outcome document of the conference on „one planet, one health, one future“ held in october 2019 in berlin by the federal foreign office in cooperation with the wildlife conservation society can serve as a point of departure, calling for a “unity of approach that is achievable only through convergence of human, domestic animal, wildlife, plant, and environmental health”. we call for an informal global one health alliance. https://tinyurl.com/ohc-ww https://tinyurl.com/ohc-listserv https://tinyurl.com/ohc-listserv https://tinyurl.com/who-ohhlep-oh-definition https://tinyurl.com/who-ohhlep-oh-definition https://tinyurl.com/quadri-oh-jpa https://tinyurl.com/ohc-oh-stratact https://tinyurl.com/ohc-oh-stratact https://multilateralism.org/the-alliance/ https://multilateralism.org/actionareas/berlin-principles-on-one-health/ https://multilateralism.org/actionareas/berlin-principles-on-one-health/ laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 19 | 30 the one health commission19 was not included in the random sample of organizations selected from its website for the pilot study reported here; thus it was further examined as a potential positive though imperfect example of a cso working to support bottom-up one health leadership. at the 7th world one health congress 2022 in singapore20, the ohc presented this call21 for a global one health alliance, pledged its support for collaborative, coordinated, communication partnerships with ohhlep and the quadripartite and urged that mechanisms be devised for the whole community of one health stakeholders to get actively involved, to help us become better aware of who is doing what, who has what strengths and how we can synergize our efforts to raise a collective voice. in their article one health, one welfare, one planet (july 2019), stroud and lindenmayer (27) explain a critical need to push the boundaries of the one health framework toward 'one health and one welfare for one planet' which implies that the real sustainability challenge is primarily and essentially societal and individual! health and well-being are both preconditions and outcomes of sustainable development. but the needed changes cannot be driven by any one country, one profession, or any individual. it will take the collective will of the whole global community of one health stakeholders, working both bottom-up and top-down. we call for an informal global one health alliance, an informal community of practice. 19 https://www.onehealthcommission.org/ 20 https://worldonehealthcongress.org conclusions and recommendations motto: to save the planet our arch in space requires political, economic, and sociologic analysis and coordinated intervention. limitations of the pilot study this pilot study is limited because of the small sample size from two selective lists, available at the ohc and ohi websites, and the missing operability of advanced statistical analysis. additionally, though the information has been gathered and compiled on the who’s who maps on the ohc website for the past 8 years, we know that those maps are still incomplete because many critical players in the one health space are not yet aware of and have not yet joined in the effort to help identify each other and be better connected for collaborations and sharing of information. it will require full participation by the global community of one health advocates to make those maps more complete, though they will hopefully be ever-evolving as more and more organizations, individuals and governments move into a one health way of thinking and living. to achieve full representation, a global one health stakeholders survey of related organizations and their activities is proposed for the network of networks to collectively push it out to all players. among few, ohc/ohi has the potential and the intention to support a common agenda for the one health-oriented csos 21 https://tinyurl.com/yy767vmy https://www.onehealthcommission.org/ https://worldonehealthcongress.org/ https://tinyurl.com/yy767vmy laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 20 | 30 as well as academic organizations if not also administrative bodies. the horizon for further expansion the most recent announcements of the world bank and un agencies signal heightened attention and promise a turnaround of focus to the one health concept and framework (28). in our call for an informal global one health alliance, a community we recommend: 1) as a first step a central information hub should be installed to allow for multilateral contacts and information exchange perhaps with circulating administration by interested one health organizations. 2) through that hub, an agreement should be reached on the minimum information on the websites of participating organizations modifying where appropriate the catalog of ten questions used in this paper for a basic analysis. 3) delegates solicited from the global community of one health stakeholders should be on the organizing committee and contribute to the preparation of the next world one health congress in 2024 in cape town africa22. 4) a community driven one health information newsletter is needed to orient specifically on global one health developments, initiatives and proposals as well as on publications regarding specific one health topics. for example, the established monthly one health happenings newsletter, edited by the one 22 https://www.facebook.com/hashtag/wohc2024 health commission, could be further funded and supported by the community of one health stakeholders, expanded and disseminated across and deeply into one health networks and beyond. in summary, there is an urgent need to form a coordinated voice for one health, an informal global one health alliance,, a community of practice that is connected in a communications network and able to speak in one voice, enhance synergy and collaboration, and further bottom-up efforts. the best format would be to act in partnership with the quadripartite organizations (29, 30). reminder earth is a home for animals, plants, and mankind in a common environment of air, water, and land the planet earth as noah’s ark, told in the heritage of mankind (genesis 6,12,13 & 1920): “god saw how corrupt the earth had become, for all the people on earth had corrupted their ways. so, god said to noah: ...you are to bring into the ark two of all living creatures, male and female, to keep them alive with you. two of every kind of bird, of every kind of animal, and of every kind of creature that moves along the ground will come to you to be kept alive”. references: 1) wiebers do, feigin vl. editorial. what the covid-19 crisis is telling humanity. neuroepidemiology 2020;54: 283– 286. doi: 10.1159/000508654 2) twi2050 -the world in 2050. transformations to achieve the sustainable development goals. laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. 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(original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 23 | 30 environment, south eastern european journal of public health (seejph). doi: 10.11576/seejph4238. 27) stroud c, lindenmayer j. one health, one welfare, one planet. at: https://www.onehealthcommission. org/documents/filelibrary/homepag e_images/72419_one_health_one _welfare_one_pl_6d0f58dcfd4 f5.pdf 28) seifman r. hopeful signs for global public health? we’ve seen this before. the impacter at: https://impakter.com/hopeful-signsglobal-public-health-seen-before/ 29) the quadripartite agreement of the food and agriculture organization of the united nations (fao), the world organisation for animal health (oie), the un environment programme (unep), and the world health organization (who), signed 17 march 2022. published at: https://www.who.int/news/item/2904-2022-quadripartitememorandum-of-understanding(mou)-signed-for-a-new-era-of-onehealth-collaboration 30) fao, unep who, and woah. 2022. global plan of action on one health. towards a more comprehensive one health, approach to global health threats at the human-animal-environment interface (zero draft). rome 22 october 2022. at: https://doi.org/10.4060/cc2289en © 2022 , laaser et al.; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.onehealthcommission.org/documents/filelibrary/homepage_images/72419_one_health_one_welfare_one_pl_6d0f58dcfd4f5.pdf https://www.onehealthcommission.org/documents/filelibrary/homepage_images/72419_one_health_one_welfare_one_pl_6d0f58dcfd4f5.pdf https://www.onehealthcommission.org/documents/filelibrary/homepage_images/72419_one_health_one_welfare_one_pl_6d0f58dcfd4f5.pdf https://www.onehealthcommission.org/documents/filelibrary/homepage_images/72419_one_health_one_welfare_one_pl_6d0f58dcfd4f5.pdf https://www.onehealthcommission.org/documents/filelibrary/homepage_images/72419_one_health_one_welfare_one_pl_6d0f58dcfd4f5.pdf https://www.who.int/news/item/29-04-2022-quadripartite-memorandum-of-understanding-(mou)-signed-for-a-new-era-of-one-health-collaboration https://www.who.int/news/item/29-04-2022-quadripartite-memorandum-of-understanding-(mou)-signed-for-a-new-era-of-one-health-collaboration https://www.who.int/news/item/29-04-2022-quadripartite-memorandum-of-understanding-(mou)-signed-for-a-new-era-of-one-health-collaboration https://www.who.int/news/item/29-04-2022-quadripartite-memorandum-of-understanding-(mou)-signed-for-a-new-era-of-one-health-collaboration https://www.who.int/news/item/29-04-2022-quadripartite-memorandum-of-understanding-(mou)-signed-for-a-new-era-of-one-health-collaboration laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 24 | 30 annex a: information on the ten questions provided by the n = 50 sampled organizations on their websites. note 1: missing data was assessed and counted as no since no information is equal to a negative answer. these 39 values are marked in italics. note 2: the analysis of the websites according to the 10 questions was done by hw and ul with mutual control. group of questions i. purpose & focus ii. transparency of structure iii. cooperations iv. publications summary questions & answers 1 2 3 4 5 6 7 8 9 10 a. csos y n y n y n y n y n y n y n y n y n y n sum yes sum no total aa 1 0 1 0 0 1 1 0 1 0 0 1 1 0 1 0 0 1 1 0 7 3 10 ab 1 0 1 0 0 1 1 0 1 0 0 1 1 0 1 0 1 0 1 0 8 2 10 ac 0 1 1 0 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 1 9 10 ad 0 1 1 0 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 1 9 10 ae 1 0 1 0 1 0 0 1 0 1 1 0 1 0 1 0 1 0 1 0 8 2 10 af 0 1 0 1 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 8 2 10 ag 0 1 1 0 1 0 1 0 1 0 0 1 0 1 0 1 1 0 1 0 6 4 10 ah 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 10 10 ai 0 1 1 0 1 0 1 0 1 0 0 1 0 1 0 1 0 1 0 1 4 6 10 aj 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 10 10 ak 0 1 1 0 1 0 1 0 0 1 1 0 1 0 1 0 1 0 0 1 7 3 10 al 0 1 1 0 1 0 0 1 1 0 1 0 1 0 1 0 1 0 0 1 7 3 10 am 0 1 1 0 0 1 0 1 0 1 0 1 0 1 0 1 1 0 1 0 3 7 10 an 1 0 1 0 1 0 1 0 0 1 1 0 1 0 1 0 1 0 1 0 9 1 10 laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 25 | 30 ao 1 0 1 0 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 2 8 10 ap 1 0 0 1 0 1 0 1 0 1 0 1 1 0 0 1 0 1 0 1 2 8 10 aq 0 1 1 0 1 0 1 0 1 0 0 1 1 0 0 1 1 0 0 1 6 4 10 ar 1 0 1 0 1 0 0 1 0 1 0 1 1 0 1 0 0 1 0 1 5 5 10 as 1 0 1 0 1 0 0 1 0 1 0 1 0 1 0 1 0 1 0 1 3 7 10 at 1 0 1 0 1 0 0 1 0 1 1 0 1 0 0 1 1 0 0 1 6 4 10 au 0 1 1 0 1 0 0 1 0 1 1 0 1 0 1 0 0 1 0 1 5 5 10 av 0 1 1 0 1 0 1 0 1 0 1 0 1 0 1 0 0 1 0 1 7 3 10 sum 9 13 18 4 13 9 9 13 8 14 8 14 13 9 10 12 10 12 7 15 105 115 220 laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 26 | 30 questions & answers 1 2 3 4 5 6 7 8 9 10 b academia y n y n y n y n y n y n y n y n y n y n sum yes sum no total ba 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 10 0 10 bb 1 0 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 1 9 10 bc 1 0 1 0 1 0 0 1 0 1 0 1 1 0 1 0 0 1 0 1 5 5 10 bd 1 0 1 0 1 0 0 1 0 1 0 1 1 0 1 0 0 1 0 1 5 5 10 be 1 0 1 0 1 0 1 0 1 0 0 1 1 0 1 0 1 0 0 1 8 2 10 bf 1 0 1 0 1 0 0 1 1 0 0 1 0 1 0 1 1 0 0 1 5 5 10 bg 0 1 1 0 1 0 0 1 0 1 1 0 1 0 1 0 1 0 0 1 6 4 10 bh 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 10 10 bi 0 1 1 0 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 1 9 10 bj 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 10 0 10 bk 1 0 0 1 0 1 0 1 0 1 0 1 1 0 1 0 0 1 0 1 3 7 10 bl 1 0 1 0 1 0 0 1 0 1 0 1 0 1 0 1 0 1 0 1 3 7 10 bm 1 0 1 0 1 0 0 1 0 1 1 0 1 0 1 0 1 0 0 1 7 3 10 bn 1 0 0 1 1 0 0 1 0 1 0 1 1 0 1 0 1 0 0 1 5 5 10 bo 1 0 1 0 1 0 0 1 0 1 0 1 1 0 1 0 0 1 0 1 5 5 10 bp 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 10 0 10 bq 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 0 1 0 1 8 2 10 br 0 1 0 1 1 0 0 1 0 1 0 1 1 0 1 0 0 1 0 1 3 7 10 bs 0 1 1 0 1 0 0 1 1 0 0 1 1 0 1 0 1 0 0 1 6 4 10 bt 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 10 0 10 bu 1 0 1 0 1 0 0 1 0 1 0 1 0 1 0 1 0 1 0 1 3 7 10 sum 18 5 18 5 19 4 7 16 8 15 7 16 16 7 15 8 10 13 4 19 122 108 230 laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 27 | 30 questions & answers 1 2 3 4 5 6 7 8 9 10 c gov y n y n y n y n y n y n y n y n y n y n sum yes sum no total ca 1 0 1 0 1 0 0 1 0 1 0 1 1 0 1 0 0 1 0 1 5 5 10 cb 1 0 1 0 1 0 1 0 0 1 0 1 1 0 1 0 1 0 0 1 7 3 10 cc 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 10 10 cd 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 10 0 10 ce 1 0 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 1 9 10 sum 4 1 3 2 3 2 2 3 1 4 1 4 3 2 3 2 2 3 1 4 23 27 50 laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 28 | 30 annex b: projects and cooperations of the one health commission, listed on their website, information regarding questions 6-8 question 6: are projects indicated for the period 2020/2021?  creation/leadership of global one health day  creation/leadership of global one health awareness month https://tinyurl.com/ohoh-awareness  creation/production/dissemination of monthly one health happenings https://tinyurl.com/ohc-oh-happening (since 2015)  creation of o one health social sciences work group https://conta.cc/3il5buy https://www.onehealthcommission.org/en/progra ms/one_health_social_sciences_initiative/ o bat rabies education work group https://www.onehealthcommission.org/en/programs/bat_rabies_educ ation_initiative/ o related projects at: https://conta.cc/2k1noc9  creation/launch of the following recent web pages: o mapping countries that have formally adopted national one health strategic action plans https://tinyurl.com/ohc-oh-stratact o mapping countries that have formally adopted national one health amr plans https://tinyurl.com/ohc-oh-amr o one health toolkits webpage https://tinyurl.com/ohc-oh-toolkits o one health education resources for public health educators https://tinyurl.com/ohc-oh-ph-ed questions 7 and 8: is cooperation with other organizations/projects indicated? are names of cooperation partners provided?  partnership with global alliance for rabies control call for project submissions https://conta.cc/3stbs1c  partnership (advisory and promotional) with cabi in the launch of its one health initiatives (journal, case studies) o https://conta.cc/3g1ubgl o https://conta.cc/3miiyx2 https://tinyurl.com/oh-oh-awareness https://tinyurl.com/oh-oh-awareness https://tinyurl.com/ohc-oh-happening https://conta.cc/3il5buy https://www.onehealthcommission.org/en/programs/one_health_social_sciences_initiative/ https://www.onehealthcommission.org/en/programs/one_health_social_sciences_initiative/ https://www.onehealthcommission.org/en/programs/bat_rabies_education_initiative/ https://www.onehealthcommission.org/en/programs/bat_rabies_education_initiative/ https://conta.cc/2k1noc9 https://tinyurl.com/ohc-oh-stratact https://tinyurl.com/ohc-oh-amr https://tinyurl.com/ohc-oh-toolkits https://tinyurl.com/ohc-oh-ph-ed https://conta.cc/3stbs1c https://conta.cc/3g1ubgl https://conta.cc/3miiyx2 laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 29 | 30  partnership with georgia aquarium (atlanta, georgia) to create/lead gregory bossart one health scholarship o https://conta.cc/3et1ulo o https://www.onehealthcommission.org/en/programs/one_health_scholarships/  partnership with onehealthlessons.com to get the word out https://conta.cc/3shcu4n  partnership with the national academies of sciences, engineering, and medicine, in partnership with the wilson center and the smithsonian's national museum of natural history, to lead one health in the us webinar o https://conta.cc/3secwfl o https://www.onehealthcommission.org/en/events_since_2001/one_health_in_t he_us_webinar_series/  after supporting its creation continued partnership with the international student one health alliance (isoha) one of many examples https://conta.cc/3pijbqx  partnership with who goarn and one health european joint program in a survey of one health professional participation in the pandemic response: o https://conta.cc/2wvulmr o streichert lc, sepe ludovico p, jokelainen p, stroud cm, berezowski j, del rio vilas vj., participation in one health networks and involvement in the covid-19 pandemic response: a global study, frontiers in public health, vol. 10, 2022, doi=10.3389/fpubh.2022.830893  partnership with who goarn in call for professional volunteers for pandemic response https://conta.cc/2vpq0xk  creation of us informal coalition of one health organizations: o https://conta.cc/2dcntbe o https://www.onehealthcommission.org/documents/filelibrary/oh_news/9420_ coalition_partners_146384b46dfd8.pdf  cooperative / collaborative project with one health academy in washington dc providing a webinar platform for all their monthly seminars since 2014: o http://www.onehealthacademy.org/ scroll to the bottom of the page... o and also click on all their 'previous talks' http://www.onehealthacademy.org/previous-talks.html  list of ohc financial sponsors (they are 'all' partners) o https://www.onehealthcommission.org/en/sponsorship/ https://conta.cc/3et1ulo https://www.onehealthcommission.org/en/programs/one_health_scholarships/ https://conta.cc/3shcu4n https://conta.cc/3secwfl https://www.onehealthcommission.org/en/events_since_2001/one_health_in_the_us_webinar_series/ https://www.onehealthcommission.org/en/events_since_2001/one_health_in_the_us_webinar_series/ https://conta.cc/3pijbqx https://conta.cc/2wvulmr https://www.frontiersin.org/articles/10.3389/fpubh.2022.830893/full?&utm_source=email_to_ae_&utm_medium=email&utm_content=t1_11.5e2_editor&utm_campaign=email_publication&journalname=frontiers_in_public_health&id=830893 https://www.frontiersin.org/articles/10.3389/fpubh.2022.830893/full?&utm_source=email_to_ae_&utm_medium=email&utm_content=t1_11.5e2_editor&utm_campaign=email_publication&journalname=frontiers_in_public_health&id=830893 https://conta.cc/2vpq0xk https://conta.cc/2dcntbe https://www.onehealthcommission.org/documents/filelibrary/oh_news/9420_coalition_partners_146384b46dfd8.pdf https://www.onehealthcommission.org/documents/filelibrary/oh_news/9420_coalition_partners_146384b46dfd8.pdf http://www.onehealthacademy.org/ http://www.onehealthacademy.org/previous-talks.html https://www.onehealthcommission.org/en/sponsorship/ laaser u, stroud ch, bjegovic-mikanovic v, wenzel h, seifman r, craig c, kaplan b, kahn l, roopnarine r. exchange and coordination: challenges of the global one health movement. (original research). seejph 2022, posted: 22 november 2022. doi: 10.11576/seejph-6076 p a g e 30 | 30 o https://www.onehealthcommission.org/en/sponsorship/list_of_sponsors/ yo u have to click on the links to see the lists...  it takes quite a bit of 'cooperation' to create and lead the who's who in one health organizations webpages and in the process, an incredible network of colleagues all over the world has been developed. https://tinyurl.com/ohc-ww (at the time of publication the global one health community listserv is over 17,200 and has increased by over 7,000 since the onset of the pandemic)  other 'cooperation' projects o synergizing oh collaborations online meeting https://conta.cc/3txyodc o ohc us epa partnership on national pet health survey: https://conta.cc/3yvsiti and:  https://www.onehealthcommission.org/index.cfm?nodeid=93484&au dienceid=1&preview=1  https://conta.cc/3etb8kf o supporting the creation of international student one health alliance: https://conta.cc/3cqo3w1 o online one health education conference https://conta.cc/3yune8e and: https://www.onehealthcommission.org/en/events_since_2001/one_health_edu cation_online_conference/ o 2016 launch of annual global one health day https://conta.cc/3evigkp and: https://conta.cc/3escqlx and: https://conta.cc /3coccaf and: https://www.onehealthcommission.org/en/events_since_2001/2nd_intl_whos_ who_in_oh_webinar_2016/ o letter from ohc to obama white house https://conta.cc/3tioev5 and: https://www.onehealthcommission.org/en/events_since_2001/1st_intl_whos_w ho_in_oh_webinar_201 https://www.onehealthcommission.org/en/sponsorship/list_of_sponsors/ https://tinyurl.com/ohc-ww https://conta.cc/3txyodc https://conta.cc/3yvsiti https://www.onehealthcommission.org/index.cfm?nodeid=93484&audienceid=1&preview=1 https://www.onehealthcommission.org/index.cfm?nodeid=93484&audienceid=1&preview=1 https://conta.cc/3etb8kf https://conta.cc/3cqo3w1 https://conta.cc/3yune8e https://www.onehealthcommission.org/en/events_since_2001/one_health_education_online_conference/ https://www.onehealthcommission.org/en/events_since_2001/one_health_education_online_conference/ https://conta.cc/3evigkp https://conta.cc/3escqlx https://conta.cc/3coccaf https://conta.cc/3coccaf https://www.onehealthcommission.org/en/events_since_2001/2nd_intl_whos_who_in_oh_webinar_2016/ https://www.onehealthcommission.org/en/events_since_2001/2nd_intl_whos_who_in_oh_webinar_2016/ https://conta.cc/3tioev5 relative income and acute coronary syndrome: a population-based case-control study in tirana, albania kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 1 original research lifestyle correlates of low bone mineral density in albanian women artur kollcaku1, julia kollcaku², valbona duraj1, teuta backa1, argjend tafaj1 1 rheumatology service, university hospital center “mother teresa”, tirana, albania; ² ambulatory health service, polyclinic, tirana, albania. corresponding author: dr. artur kollcaku address: rr. “dibres”, no. 371, tirana, albania; telephone: +355674039706; e-mail: artur_kollcaku@yahoo.com kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 2 abstract aim: the aim of this study was to assess the association of lifestyle/behavioral factors with low bone mineral density in albanian women, a transitional country in the western balkans. methods: a cross-sectional study was conducted in tirana city in 2010 including a population-based sample of 549 women aged 35 years and above (response rate: 92%). low bone mineral density (osteopenia and/or osteoporosis defined as a bone mineral density tscore less than -1) was assessed with a bone ultrasound device which is simple and easy to use for screening of bone mineral density in population-based studies. binary logistic regression was used to determine the relationship of low bone mineral density with behavioral factors in this study population. results: the prevalence of low bone mineral density in this study population was 28.4% (156/549). in multivariable-adjusted logistic regression models, low bone mineral density was positively associated with smoking (or=4.1, 95%ci=2.2-7.4) and coffee consumption (or=2.3, 95%ci=1.3-4.1), but inversely related to overweight and obesity (or=0.4, 95%ci=0.2-0.7 and or=0.3, 95%ci=0.2-0.6, respectively). conclusion: this study offers useful evidence about the lifestyle/behavioral determinants of low bone mineral density among women in this transitional south eastern european population. health professionals and policymakers in albania should be aware of the major behavioral factors which increase the risk of low bone mineral density in order to provide correct treatment and control of this condition in the general population. keywords: albania, bone mineral density, bone ultrasound, bone ultrasound device, osteopenia, osteoporosis, tirana. conflicts of interest: none. kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 3 introduction low bone mineral density, especially osteoporosis, is characterized by excessive skeletal fragility and susceptibility to trauma fracture (1), particularly among older individuals (2,3). conventionally, low bone mineral density includes osteopenia and osteoporosis. osteopenia is deemed as en initial step of osteoporosis notwithstanding the fact that not every person with osteopenia may inevitably experience osteoporosis (4-6). as a rule of thumb, osteopenia is defined as a bone mineral density t-score lower than -1.0 and greater than -2.5 (7). on the other hand, osteoporosis is defined as a bone mineral density t-score of -2.5 or lower (7). it is important to note that osteopenia is an indication of normal aging, as opposed to osteoporosis which is evident in pathologic aging (1,5). the prevalence of low mineral bone density, especially osteoporosis, increases with age (2,3,8). furthermore, the prevalence of osteoporosis is higher in women, especially after menopause (1,8,9). in addition, unhealthy behavioral patterns consisting of smoking, excessive alcohol consumption and physical inactivity increase the risk of low bone mineral density and/or exacerbate the conditions of osteopenia and osteoporosis (5,10,11). on the other hand, body weight has been shown to exert a beneficial effect on increasing bone mass which, in turn, reduces the risk of osteoporosis (1). furthermore, fat mass has been described as a protective factor against osteoporosis in several studies conducted worldwide (12-14). however, the findings related to excessive fat mass are not consistent and several other studies have reported that it may not protect against decreases in bone mass (15-17). the assessment of bone mineral density is typically done with dual x-ray absorptiometry (dexa) procedure (18). at the same time, assessment of bone mineral density can be also performed with portable scanners using ultrasound, and portable machines can measure density in the heel (19,20). as a matter of fact, quantitative ultrasound is currently used worldwide due to its low cost, simplicity of performance, mobility and due to the lack of ionizing radiation (19). after the fall of the communist regime in 1990, albania, a transitional country in the western balkans, has been characterized by a particularly difficult political and socioeconomic situation associated with periodic civil unrests and high rates of unemployment (21). according to a recent report, the burden of musculoskeletal disorders has increased in albania in the past two decades (22). the overall share of musculoskeletal disorders accounted for 8.5% of the total burden of disease in 1990, whereas in 2010 it amounted to 11.0% (22,23). there is evidence of a stronger increase in females than in males. in both sexes, there was a similar moderate yet steady increase from 1990-2005 (22,23). subsequently, there was a steeper increase in females, but a smaller increase in males, which additionally accentuated the excess burden of disease explained by the musculoskeletal disorders in females compared to males (22). the burden of musculoskeletal disorders in albania was similar to most of the countries in south eastern european (see) region in both 1990 and 2010 (22,23). in 2010, the share of musculoskeletal disorders was 11.0% of the total burden of disease in several see countries including albania. essentially, musculoskeletal disorders are said to have increased in albania probably due to a higher accessibility to the health care services in addition to the ageing pattern of the albanian population (22). to date though, data on the prevalence and determinants of osteopenia and osteoporosis in the albanian population is scarce. in this framework, the aim of our study was to assess the lifestyle/behavioral correlates of low bone mineral density (osteopenia and/or osteoporosis) in tirana city, the capital of albania, a transitional country in the western balkans http://en.wikipedia.org/wiki/osteoporosis� http://en.wikipedia.org/wiki/bone_mineral_density#t-score� http://en.wikipedia.org/wiki/aging� http://en.wikipedia.org/wiki/osteoporosis� http://en.wikipedia.org/wiki/dual_energy_x-ray_absorptiometry� kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 4 characterized by an intensive process of urbanization and internal migration of the population in the past twenty five years. methods a cross-sectional study was conducted in 2010 including a population-based sample of women aged 35 years and above residing in tirana city, the capital of albania. regarding the sample size, a minimum of 540 women was estimated as the minimal number required for inclusion in this study. in order to account for potential non-response, we decided to invite 600 women to participate in our study. the inclusion criteria consisted of women aged 35 years and above residing in tirana city. of 600 eligible individuals invited to take part in this study, 549 women agreed to participate (mean age: 55.6±9.1 years; response rate: 92%). the bone mineral density among study participants was assessed with a bone ultrasound device which is simple and easy to use for screening of bone mineral density in populationbased studies (19,20). from this point of view, ultrasound is considered as a quick, cheap and non-radiating device for assessing bone quality (19,20). low bone mineral density was defined as a bone mineral density t-score less than -1 that is osteopenia and/or osteoporosis. the physical examination included also measurement of height and weight for all study participants based on which body mass index (bmi) was calculated (kg/m2) and categorized in the analysis into normal weight (bmi≤25 kg/m2), overweight (bmi: 25.1-29.9 kg/m2) and obesity (bmi≥30 kg/m2). the other lifestyle/behavioral factors were assessed through an interviewer-administered structured questionnaire including information on smoking habits (dichotomized in the analysis into: yes vs. no), alcohol intake (yes vs. no), coffee consumption (yes vs. no) and tea consumption (yes vs. no). demographic and socioeconomic data (age, marital status, educational level and employment status of study participants) were also collected for all women included in this study. binary logistic regression was used to assess the association of low bone mineral density (outcome variable) with lifestyle/behavioral factors (independent variables). initially, crude (unadjusted) odds ratios (ors) and their respective 95% confidence intervals (95%cis) were calculated. next, all the lifestyle factors (smoking, alcohol intake, coffee and tea consumption and bmi) together with demographic and socioeconomic characteristics (age, marital status, educational level and employment status) were entered simultaneously into the logistic regression models. multivariable-adjusted ors and their respective 95%cis were calculated. in all cases, a p-value of ≤0.05 was considered as statistically significant. statistical package for social sciences (spss, version 15.0) was used for all the statistical analyses. results the prevalence of low bone mineral density (osteopenia and/or osteoporosis) in this study population was 156/549=28.4% (table 1). the prevalence of smoking was significantly higher in women with low bone mineral density compared with those with normal bone mineral density (25.6% vs. 8.7%, respectively; p<0.001). there were no differences regarding the prevalence of alcohol intake. the prevalence of both coffee consumption and tea consumption was significantly higher in women with low bone mineral density than in those with normal bone mineral density (83.3% vs. 68.2%, p<0.001 and 53.8% vs. 41.2%, p=0.005, respectively). kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 5 on the other hand, the prevalence of both overweight and obesity was significantly lower in women with low bone mineral density compared with women with normal bone mineral density (30.8% vs. 40.2% and 23.7% vs. 32.2%, respectively; overall p<0.001) (table 1). table 1. distribution of lifestyle/behavioral factors in a sample of albanian women by bone mineral density status variable total (n=549) normal bone mineral density (n=393) low bone mineral density (n=156) p † smoking: no yes 475 (86.5)* 74 (13.5) 359 (91.3) 34 (8.7) 116 (74.4) 40 (25.6) <0.001 alcohol intake: no yes 514 (93.8) 34 (6.2) 369 (93.9) 24 (6.1) 145 (93.5) 10 (6.5) 0.508 coffee consumption: no yes 151 (27.5) 398 (72.5) 125 (31.8) 268 (68.2) 26 (16.7) 130 (83.3) <0.001 tea consumption: no yes 303 (55.2) 246 (44.8) 231 (58.8) 162 (41.2) 72 (46.2) 84 (53.8) 0.005 bmi: normal weight overweight obesity 179 (32.7) 205 (37.5) 163 (29.8) 108 (27.6) 157 (40.2) 126 (32.2) 71 (45.5) 48 (30.8) 37 (23.7) <0.001 * absolute numbers and their respective column percentages (in parentheses). † p-values from fisher’s exact test. table 2 presents the association of low bone mineral density with lifestyle factors of the women included in this study. in crude (unadjusted) logistic regression models, there was evidence of a strong and statistically significant association of low bone mineral density with smoking (or=3.6, 95%ci=2.2-6.0), but not alcohol intake (or=1.1, 95%ci=0.5-2.3). on the other hand, there was a strong association of low bone mineral density with coffee consumption (or=2.3, 95%ci=1.5-3.7) and tea consumption (or=1.7, 95%ci=1.2-2.4). on the contrary, the odds of overweight and obesity were lower among women with a low bone mineral density compared with their counterparts with normal bone mineral density (or=0.5, 95%ci=0.3-0.7 and or=0.4, 95%ci=0.3-0.7, respectively). in multivariable-adjusted logistic regression models, low bone mineral density was positively associated with smoking (or=4.1, 95%ci=2.2-7.4), coffee consumption (or=2.3, 95%ci=1.3-4.1) and (non-significantly) with tea consumption (or=1.4, 95%ci=0.9-2.2), but inversely related to overweight and obesity (or=0.4, 95%ci=0.2-0.7 and or=0.3, 95%ci=0.2-0.6, respectively) (table 2). kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 6 table 2. association of low bone mineral density with lifestyle/behavioral factors among women in tirana, albania variable crude (unadjusted models) multivariable-adjusted models or (95%ci)* p* or (95%ci)* p* smoking: no yes 1.00 (reference) 3.64 (2.20-6.02) <0.001 1.00 (reference) 4.07 (2.23-7.40) <0.001 alcohol intake: no yes 1.00 (reference) 1.06 (0.49-2.27) 0.880 1.00 (reference) 0.73 (0.30-1.75) 0.478 coffee consumption: no yes 1.00 (reference) 2.33 (1.46-3.74) <0.001 1.00 (reference) 2.33 (1.34-4.07) 0.003 tea consumption: no yes 1.00 (reference) 1.66 (1.15-2.42) 0.008 1.00 (reference) 1.40 (0.90-2.16) 0.134 bmi: normal weight overweight obesity 1.00 (reference) 0.47 (0.30-0.72) 0.45 (0.28-0.72) <0.001 (2)† 0.001 0.001 1.00 (reference) 0.39 (0.23-0.65) 0.32 (0.18-0.55) <0.001 (2)† <0.001 <0.001 * odds ratios (or: low bone mineral density vs. normal bone mineral density), 95% confidence intervals (95%cis) and p-values from binary logistic regression. besides the variables presented in the table, multivariable-adjusted models were additionally controlled for age, marital status, employment status and educational level. † overall p-value and degrees of freedom (in parentheses). discussion this study including a representative sample of women residing in tirana – the capital city of transitional albania which was the most isolated country in europe during the communist regime – offers useful evidence about selected lifestyle/behavioral predictors of low bone mineral density (osteopenia and osteoporosis) in the adult female population. smoking and coffee consumption were positively associated, whereas overweight and obesity were inversely related to osteopenia and osteoporosis in this sample of albanian women, after controlling for other lifestyle factors and several demographic and socioeconomic characteristics. our findings related to a positive association between low bone mineral density with smoking and coffee consumption are in line with previous reports from the international literature (5). in our study, the association of osteopenia and osteoporosis with coffee consumption was strong and remained unaffected upon simultaneous adjustment for a wide array of covariates including alcohol intake and tea consumption. furthermore, the positive relationship with smoking was even stronger after multivariable adjustment for other behavioral characteristics. in our study, overweight and obesity were strong correlates of osteopenia and osteoporosis. the negative association of overweight and obesity with low bone mineral density was accentuated in multivariable-adjusted logistic regression models. our findings regarding body mass are compatible with several reports from the international literature (1,24). from this point of view, higher body weight or higher bmi is known to be a protective factor against bone loss in both men and women worldwide (1,24-26). nevertheless, overweight and kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 7 obesity are related to a gain in fat mass as well as an increase in lean mass. therefore, identification of the specific roles that fat mass itself plays in bone mass regulation is important to establish the clinical implications of osteoporosis (24). several studies have indicated that both fat mass and lean mass can lead to an increase in bone mass which, in turn, reduces the risk of osteoporosis (13,24). on the other hand, according to some other studies, fat mass has a negative effect on bone mass after controlling for body weight (1,27). importantly, regarding total fat mass, subcutaneous fat has been reported to be beneficial for bone mass, whereas visceral fat has negative effects (24,28). this study may have some limitations. notwithstanding the representativeness of the sample of women included in this study, the possibility of selection bias, at least to some extent, may be an issue which cannot be completely excluded. in any case, tirana women are not assumed to represent the overall albanian women and, hence, findings from this study cannot be generalized to the overall female population in albania. in our survey, we employed a standardized and internationally valid instrument for assessment of low bone mineral density in population-based studies. furthermore, findings from the quantitative ultrasound measurements of bone mineral density correlate well with the dual energy x-ray absorptiometry (dxa) (19), which is one of the most widely validated tools for measurement of bmd in clinical practice (18). on the other hand, the lifestyle/behavioral data collected through the interview may have been subject to information bias. this may be the case of smoking, alcohol intake, as well as coffee and tea consumption. seemingly though, there is no plausible explanation of a differential reporting of lifestyle factors between women distinguished by the presence of osteopenia and/or osteoporosis in our study. conversely, measurement of height and weight provides little grounds for biased estimates of overweight and obesity in our study sample. in conclusion, our study provides important evidence about the lifestyle/behavioral determinants of low bone mineral density in tirana, the capital city of albania. smoking and coffee consumption were significant predictors of low bone mineral density (osteopenia and osteoporosis) in this study sample of tirana women. future studies in albania should assess the magnitude and distribution of osteopenia and osteoporosis in population-based samples of the general population. references 1. zhao lj, jiang h, papasian cj, maulik d, drees b, hamilton j, deng hw. correlation of obesity and osteoporosis: effect of fat mass on the determination of osteoporosis. j bone miner res 2008;23:17-29. 2. melton lj iii. adverse outcomes of osteoporotic fractures in the general population. j bone miner res 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dorey fj, mittelman sd. reciprocal relations of subcutaneous and visceral fat to bone structure and strength. j clin endocrinol metab 2009;94:3387-93. ___________________________________________________________ © 2015 kollcaku et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. çomo n, meta e, qato m, gjermeni n, kolovani e, pipero p, harxhi a, kraja d. overview on epidemiological and clinical manifestation of covid-19 in albanian adults (original research). seejph 2022, posted: june 2022. doi: 10.11576/seejph-5626 p a g e 1 | 11 original research overview on epidemiological and clinical manifestation of covid-19 in albanian adults najada çomo1, esmeralda meta1, migena qato1, nevila gjermeni1, entela kolovani1, pellumb pipero1, arjan harxhi1, dhimiter kraja1 1 infectious diseases service, university hospital center “mother theresa”, tirana, albania. corresponding author: najada çomo, md, phd; address: rr. “dibres”, no. 371, tirana, albania; telephone: +355692492756; email: nadacomo@yahoo.com çomo n, meta e, qato m, gjermeni n, kolovani e, pipero p, harxhi a, kraja d. overview on epidemiological and clinical manifestation of covid-19 in albanian adults (original research). seejph 2022, posted: june 2022. doi: 10.11576/seejph-5626 p a g e 2 | 11 abstract on march 9, 2020 the first two cases of sars-cov-2 were identified and hospitalized in albania. in this paper we present a retrospective analysis of 3000 consecutive covid-19 confirmed cases in albanian adults admitted at the infectious diseases service which includes three tertiary care wards, part of tirana university hospital center “mother teresa”. the period included in this analysis is from march 2020 – april 30, 2021. the paper provides a general overview including demographic distribution, symptomatic diversity and clinical signs manifested among cases, as well as the association observed with underlying pathologies. the analysis included 1944 males and 1056 females. overall, the age groups included range from 15 to 99 years (median 65 years; mean value 63.4±13.4 years). there were no statistically significant age differences between males and females (mean ages were: 63.5±13.1 in females and 63.3±13.5 in males; median ages were: 64 years in females and 65 years in males; p=0.67). there was evidence of a statistically significant difference between sexes regarding the presence of symptoms, which were more predominant in males (p<0.001). on the whole, we observed 19 cases with specific signs and symptoms, most of them (82.9%) among patients who reported the presence of such symptoms 5-14 days before hospitalization. the comorbidities encountered were ranked according to systems and organs, classifying them in 22 categories, among which the most frequent were hypertension (52%) and diabetes mellitus (26.4%). age was a strong risk factor for severe illness, complications, and death. analyzing symptom onset with total symptoms and comorbidities, it showed that some patients were affected for many days with few symptoms and few comorbidities. it seems they started as mild cases for many days unpredictably precipitating. there were also a few cases with many comorbidities, but a few symptoms upon hospital admission. keywords: adults, albania, clinical manifestations, covid-19, epidemiology. conflicts of interest: none declared. çomo n, meta e, qato m, gjermeni n, kolovani e, pipero p, harxhi a, kraja d. overview on epidemiological and clinical manifestation of covid-19 in albanian adults (original research). seejph 2022, posted: june 2022. doi: 10.11576/seejph-5626 p a g e 3 | 11 introduction it’s the second year of the pandemic, from the identification of the first cases of sarscov-2 in wuhan, hubei province of china, characterized by acute respiratory syndrome and silent hypoxemia (1-3). this new clinical syndrome was similar to sars cov and mers but with faster and much more contagious designation named covid-19. on march 11, 2020 who declared a global pandemic situation, of which our country was a part. on march 9, 2020 the first 2 cases of sars-cov-2 were identified in albania and hospitalized in infectious diseases (id) service of uhc tirana. the id service was adapted to receive patients with covid-19. from the identification and hospitalization of the first two cases and so far in this service that includes 3 covid hospitals, over 8000 patients have been hospitalized (4). facing a new syndrome in our country not encountered before with similar forms sars cov and mers, based on the initial media data or the first articles on it that focused on symptoms such as fever, dry cough, dyspnea, asthenia; we focused on each of the signs and symptoms referred by the patient, the variety of clinical forms, concomitant diseases clinical forms that appear. in the first 12 weeks, cases were hospitalized with positive rt-pcr of mild forms to severe in order to receive early medical treatment and limit the spread of the virus, through negativity in the hospital and then "self-isolation" after discharge for up to 14 days (3). as the months went by and the progressive increase of cases and the emergence of new genetic variants of covid19 we encountered as a result a wider spectrum of clinical forms, the severity of the presentation and the most affected age groups. the purpose of this study is to present a general overview of covid-19 in albanian adults including demographic distribution, symptomatic diversity and clinical signs manifested, the association with accompanying pathologies. methods we conducted a descriptive retrospective analysis of 3000 consecutive covid-19 confirmed cases hospitalized in infectious diseases hospital service which include three hospitals, part of tirana university hospital center ‘mother teresa’. all three hospitals are tertiary care institutions. cases were admitted in hospital from march 2020 to april 2021. study inclusion was based on the hospital admission criteria consisting of proved cases of non-pediatric age. covid hospitals in tirana, the capital, were the same and admissions are representative of the pandemic characteristics because there were no different filters accepting patients. demographics, symptoms and comorbidities were analyzed through counting and descriptive statistics as frequencies (and percentages) and mean and standard deviation were calculated. data were elaborated through ibm® spss® statistics 26 software (5). results based on gender; females were n=1056 (35.2%), mean (sd): 63.5±13.1 years; males were n=1944 (64.8%) mean (sd): 63.3±13.5 years. there was statistically significant difference between sexes, p<0.001 (table 1 and figure 1). epidemiological aspects: in 3,000 cases with a range from 15 years to 99 years, mean (sd) was 63.4±13.4 years, p= 0.667 (table 1). çomo n, meta e, qato m, gjermeni n, kolovani e, pipero p, harxhi a, kraja d. overview on epidemiological and clinical manifestation of covid-19 in albanian adults (original research). seejph 2022, posted: june 2022. doi: 10.11576/seejph-5626 p a g e 4 | 11 table 1. distribution of participants by age-group age group number percentage 15-19 4 0.1% 20-29 43 1.4% 30-39 150 5.0% 40-49 246 8.2% 50-59 554 18.5% 60-69 945 31.5% 70-79 760 25.3% over 80 298 9.9% total 3000 100.0% figure 1. distribution of particiaptns by gender and age-group based on the place of residence, the highest frequency was encountered in tirana, the capital city of albania (n=1348, 44.9%), due to the higher population density and testing capacities in the capital; uhc serves at the same time as a secondary and tertiary center for the capital in contrast to the districts, as well as in contrast to the regional hospitals are expected to be cases of larger age groups, and with higher gravity. clinical aspects: we identified 19 clinical signs and symptoms referring from the day of onset to the hospitalization (presented in table 2). çomo n, meta e, qato m, gjermeni n, kolovani e, pipero p, harxhi a, kraja d. overview on epidemiological and clinical manifestation of covid-19 in albanian adults (original research). seejph 2022, posted: june 2022. doi: 10.11576/seejph-5626 p a g e 5 | 11 table 2. clinical signs and symptoms frequency percent 1. sore throat 723 24.1 2. syncope 18 .6 3. weakness 2959 98.6 4. headache 1452 48.4 5. mialgia 2166 72.2 6. arthralgia 2090 69.7 7. anosmia 1553 51.8 8. anorexia 1483 49.4 9. sweats 2188 72.9 10. vomiting 332 11.1 11. diarrhea 505 16.8 12. dyspnea 2645 88.2 13. cough 2469 82.3 14. dry mouth 9 .3 15. thirst 4 .1 16. poliuria 3 .1 17. chest pain 974 32.5 18. paleness 2591 86.4 19. face congestion 72 2.4 20. fever 2769 92.3 among the most common signs and symptoms there were weakness 98.6%, fever 92.3%, paleness 86.4%, dyspnea 88.2%, cough 82.3%, myalgia 72.2%, sweats 72.9%, arthralgia 69.7%. we also monitored symptoms such as heart rate (hr), respiratory rate (rr), oxygen saturation level and at the time of hospitalization in 3000 patients were encountered (hr) with a range 19-170 and mean (sd) of 86.2±14.3; rr with a range 39 and mean (sd) of 20.8±3.3; and oxygen saturation level with a range 40-99 and mean (sd) of 82.7±11.1 (table 3). table 3. heart rate, respiratory rate and oxygen saturation level parameter n minimum maximum median mean std. deviation heart rate (/min.) 3000 19 170 85.0 86.2 14.3 respiratory rate (/min.) 3000 10 49 20.0 20.8 3.3 sato2 lying position 3000 40 99 84.0 82.7 11.1 çomo n, meta e, qato m, gjermeni n, kolovani e, pipero p, harxhi a, kraja d. overview on epidemiological and clinical manifestation of covid-19 in albanian adults (original research). seejph 2022, posted: june 2022. doi: 10.11576/seejph-5626 p a g e 6 | 11 most symptoms and signs were observed in 82.9% of patients who showed symptoms from 5-14 days before hospitalization (figure 2). figure 2. day of the symptoms onset we also analyzed the number of symptoms per patient, we identified that the predominant cases were 7-11 signs and symptoms. there was a significant positive correlation between the onset of symptoms and the total number of symptoms n=3000, r = 0.161, p <0.001 (figure 3). figure 3. number of sings and symptoms çomo n, meta e, qato m, gjermeni n, kolovani e, pipero p, harxhi a, kraja d. overview on epidemiological and clinical manifestation of covid-19 in albanian adults (original research). seejph 2022, posted: june 2022. doi: 10.11576/seejph-5626 p a g e 7 | 11 table 4. number of sings and symptoms percentile value 25 6.00 50 8.00 75 10.00 we categorized the concomitant diseases encountered according to the systems and organs and the frequency of occurrence (table 5). table 5. comorbidity diseases frequency percent dm cat. 791 26.4 hta cat. 1559 52.0 thyroid disorders cat. 55 1.8 ckd cat. 159 5.3 neoplasms cat. 78 2.6 obesity cat. 36 1.2 diseases of the respiratory system cat. 116 3.9 cardiac diseases cat. 77 2.6 cardiac arrhythmia’s cat. 74 2.5 post myocardial infarction cat. 16 .5 chf cat. 73 2.4 ischemic heart disease cat. 30 1.0 prostate cancer cat. 77 2.6 rheumatic & dermatologic cat. 57 1.9 post stroke cat. 40 1.3 hematological diseases cat. 31 1.0 diseases of the nervous system cat. 48 1.6 infectious diseases cat. 22 .7 mental disorders cat. 32 1.1 diseases of the digestive system cat. 17 .6 thrombosis cat. 8 .3 other health conditions cat. 32 1.1 in 36.3% of cases there were no comorbidity diseases up to 0.1% with 6 comorbidity pathologies (figure 4). çomo n, meta e, qato m, gjermeni n, kolovani e, pipero p, harxhi a, kraja d. overview on epidemiological and clinical manifestation of covid-19 in albanian adults (original research). seejph 2022, posted: june 2022. doi: 10.11576/seejph-5626 p a g e 8 | 11 figure 4. comorbidities in the study population the comorbidities encountered are ranked according to systems and organs, classifying them in 22 categories, among which the most frequent were hta 52% and dm 26.4%. from statistical analysis the onset of symptoms depends on age but not on gender and comorbidities. from the regression it was seen that the onset of symptoms “agerelated comorbidities were introduced into the regression model; their onset is significantly p = 0.004 for age but the onset of symptoms has nothing to do with comorbidities p = 0.229. another correlation we analyzed consisting of the frequency of symptoms according to comorbidities, patients with connective/dermatological and digestive tissue diseases had an average of 8.7 signs and symptoms, followed by the respiratory system with 8.4 and at a lower heart rate and those of the nervous system with 7.1. to assess the impact of age, sex, comorbidities and the total number of symptoms on the time of symptoms onset, a multivariate model was constructed and analyzed (table 6). table 6. multiple linear regression model unstandardized coefficients standardized coefficients t sig. 95.0% confidence interval for b model b std. error beta lower bound upper bound age .016 .006 .054 2.848 .004 .005 .027 sex -.248 .151 -.030 -1.643 .100 -.543 .048 comorbidites -.107 .089 -.023 -1.203 .229 -.282 .067 total symptoms .246 .027 .162 9.014 .000 .193 .300 çomo n, meta e, qato m, gjermeni n, kolovani e, pipero p, harxhi a, kraja d. overview on epidemiological and clinical manifestation of covid-19 in albanian adults (original research). seejph 2022, posted: june 2022. doi: 10.11576/seejph-5626 p a g e 9 | 11 discussion in our study conducted in albania, the most affected age group was between 50-79 years (comprising 75% of the overall number of participants). there was evidence of a more prevalent moderate type of disease with an increase in the age of the affected patients with sars cov 2. on the other hand, the age group over 80 years was less prevalent compared to some studies in other countries, because albania is characterized by a young population and social centers and asylums are in smaller numbers which explains the lower exposure of older people in albania (1-3,7). furthermore, in our study there was evidence of male predomination (with 64.8% of the cases). we distinguished a variety of 20 symptoms; their manifestation varied from 1-30 days, with greater predominance in the number between the day 5-11 before hospitalization. in the analysis made on their number for each patient, the most predominant ones had 7-11 symptoms. age is a strong risk factor for severe illness, complications, and death (15-17). in our study, the most frequent underlying diseases included hypertension and diabetes mellitus (52% and 26.4%, respectively). our detailed analysis indicated also the time when the symptoms started among patients affected (14-25). prediction of symptoms onset (days) was run through multiple linear regression controlling for age, sex and comorbidities. variables in equation significantly predicted symptom onset f(4, 2995) = 22.669, p<0.001. age significantly added to prediction (p=0.004) while comorbidities (p=0.229) and sex (p=0.100) did not. analyzing symptom onset with total symptoms and comorbidities indicated that some patients were affected for many days with few symptoms and few comorbidities. it seems they started as mild cases for many days unpredictably precipitating. there were also a few cases with many comorbidities, but a few symptoms upon hospital admission. in conclusion, this study provides useful evidence about covid-19 in albanian adults including its demographic distribution, symptomatic diversity and the clinical signs manifested. references 1. center for disease control and prevention. coronavirus disease 2019 (covid-19). 2020. available from: https://www.cdc.gov/coronavirus/20 19-ncov/symptomstesting/symptoms.html (accessed: march 20, 2020). 2. world health organization. coronavirus 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anymedium, provided the original work is properly cited. https://doi.org/10.1101/2020.03.17.20037572 https://doi.org/10.1101/2020.03.17.20037572 https://covid19-surveillance-report.ecdc.europa.eu/archive-covid19-reports/index.html https://covid19-surveillance-report.ecdc.europa.eu/archive-covid19-reports/index.html https://covid19-surveillance-report.ecdc.europa.eu/archive-covid19-reports/index.html https://covid19-surveillance-report.ecdc.europa.eu/archive-covid19-reports/index.html bozikov j. european and north american schools of public health – establishment, growth, differences and similarities (editorial). seejph 2016, posted: 03 june 2016. doi : 10.4119/unibi/seejph-2016-119 1 review article european and north american schools of public health – establishment, growth, differences and similarities jadranka bozikov 1 1 andrija stampar school of public health, school of medicine, university of zagreb, zagreb, croatia. corresponding author: jadranka bozikov, phd address: andrija stampar school of public health, rockefeller st. 4, zagreb, croatia; telephone: +38514590101; e-mail: jbozikov@snz.hr conflicts of interest: none. acknowledgements: the author is grateful to the editor prof. ulrich laaser for the encouragement and corrections. mailto:jbozikov@snz.hr bozikov j. european and north american schools of public health – establishment, growth, differences and similarities (editorial). seejph 2016, posted: 03 june 2016. doi : 10.4119/unibi/seejph-2016-119 2 abstract unlike european schools of public health, whose development was primarily influenced by the medical profession and was linked to the healthcare system, north american schools of public health operate as independent academic institutions engaged in research and education of public health specialists. while public health has been recognised as a distinctive profession in usa and canada for almost a century, in many european countries it is not recognized as such and, accordingly, there are no well-defined job positions for graduates. similarities and differences between the european and american schools of public health are reviewed and the importance of classification of core competences, responsibilities and scope of knowledge required for public health practice was pointed out as a prerequisite for accreditation of study curricula. for the professionalization of public health in europe further efforts are needed. keywords: competency-based education, public health, public health students, schools of public health. bozikov j. european and north american schools of public health – establishment, growth, differences and similarities (editorial). seejph 2016, posted: 03 june 2016. doi : 10.4119/unibi/seejph-2016-119 3 origins of the schools of public health schools of public health (sphs) operate either as independent institutions or as constituents of academic institutions, and vary widely in their foundation patterns, in particular if comparing north american sphs against those established in great britain and europe. the eldest institutions of this kind, those established in great britain, have evolved from various charity organisations primarily founded for provision of healthcare to seafarers and ship crews affected by numerous communicable diseases, in particular those contracted in the tropics. these institutions began to offer systematic education of healthcare professionals (mainly those willing to practice overseas), while the research conducted under their roofs was primarily focused on the pathology of tropical diseases. the london school of hygiene and tropical medicine (lshtm) and the liverpool school of tropical medicine (lstm), both founded at the very end of 19 th century (in 1899 and 1898, respectively), were not only the oldest schools of tropical medicine in the world but also leading institutions of this kind until today, well-known due to their educational excellence and scientific breakthroughs (1,2). however, the european continent accommodated only a few sphs prior to the world war two and two types of sphs have profiled – those operating under the wings of the ministries of health that are actually the constituents of public (state-governed) healthcare system involved in public health (health-related) research and education, and those operating under the wings of medical schools/universities (as their constituents or departments like for instance, department of hygiene or social medicine department or, more recently, public health or healthcare management departments, as typical examples). regardless of their status (healthcare facility, or an academic institution or department), the european sphs were dominated by medical profession from the very start, gradually also affiliating experts of other backgrounds as necessary due to the multidisciplinary nature of public health. as opposed to that, the north american model of public health education is unique due to the fact that american sphs operate independently from the healthcare system. namely, in the times of rapid industrialisation and urban growth, witnessed in the second half of the 19 th century when numerous cities were afflicted with major disease outbreaks including cholera and typhoid, city health offices or, more precisely, utility and healthcare services, were established across the us, especially in cities where, among other things, clean water supply and drainage systems of indisputable importance for the prevention of communicable diseases were established. however, this course of events facilitated the struggle for supremacy between experts of medical and non-medical profile. it is astonishing that the american public health association, established in new york by a small group of enthusiasts, was founded as early as in 1872. within this context, the key role was played by the rockefeller foundation under which the rockefeller sanitary commission for the eradication of hookworm disease started to operate as early as in 1909. the commission was established owing to the initial one million-donation and was led by wickliffe rose, a professor of history and philosophy (3). the famous flexner report released in 1910 served as the basis for the substantial reform of medical education, resulting in the cessation of operation of numerous schools of medicine in the usa and canada and the improved quality of medical tuition (4). the report set new, higher medical education standards. about the same time, in october 1914, the education board of the rockefeller foundation organised the new york conference, which further propelled the discussion on, and contributed to, the defining of tasks, responsibilities and scopes of knowledge and expertise required for public health practice. the initial ideas were further elaborated by william welch and wickliffe rose, the authors of the famous welch bozikov j. european and north american schools of public health – establishment, growth, differences and similarities (editorial). seejph 2016, posted: 03 june 2016. doi : 10.4119/unibi/seejph-2016-119 4 rose report, actually compiled in two versions and released in 1915 (5). the report became the symbol and the blueprint of evidence-based education underpinning the new profession that requires well-defined competencies. growth of sphs and their associations public health as a distinctive profession and the first sphs, operating as independent academic institutions (optionally, but not necessarily, under the wings of the universities) were established across the us, a number of them thereby being supported by the rockefeller foundation. w. welch was elected the first dean of the renowned johns hopkins school of public health (originally named the johns hopkins school of hygiene and public health, established in 1916). this school served as the model institution and several sphs were established soon after under the wings of the columbia, harvard, yale and other universities. welch was already well-known as one of the “big four” founding professors at the johns hopkins hospital established earlier (in 1889) and also the first dean of its affiliated johns hopkins school of medicine (he was pathologist and bacteriologist) (6). in 1953, the us sphs united into an organisation named the association of schools of public health (asph), currently joined by approximately 50 members and referred to as the association of schools and programs of public health (aspph). before the world war two, the “old continent” accommodated only a few sphs (excluding the institutes of hygiene that were founded in european capitals already in the 19 th and at the beginning of the 20 th century as health administrative, but not academic institutions, although often involved in teaching). one of the first schools of this kind that followed into the footsteps of the lshtm and the lstm was the school of public health in zagreb, ceremonially opened on october 3 rd , 1927. the credit for this development goes to dr andrija stampar and the rockefeller foundation that granted funds for the construction and equipping of the school’s building. in the subsequent course, the national school of public health was established in athens in 1929, followed by the ankara school of public health, founded in 1936. contrary to the american model of education, until late 1960s, in the majority of european countries one could opt for public health as a narrow field of expertise only as medical specialization although there were models of postgraduate programmes tailored for experts of various background, both medical and non-medical, mainly those already engaged in the health segment, the showcases hereby being the andrija stampar school of public health in zagreb and ehesp school of public health in rennes (today’s ehesp école des hautes études en santé publique was established in 1945 by the french government under the name ensp école des hautes études en santé publique). since, and especially after 1990s, new sphs were established either as independent high schools or faculties under the wings of universities offering professional (mainly master and post-master) degrees in health sciences (showcase is the faculty of health sciences, university of bielefeld, germany). the association of european sphs was established in 1966 in response to the initiative of who regional office for europe. the association was first given the french name and acronym airesspe – association des institutions responsables d’un enseignement supérieur en santépublique et des écoles de sp en europe, which was later changed into aspher association of schools of public health in the european region. aspher has tripled its membership during 50 years of continuing growth, which is described in more detail in this issue of seejph (7). bozikov j. european and north american schools of public health – establishment, growth, differences and similarities (editorial). seejph 2016, posted: 03 june 2016. doi : 10.4119/unibi/seejph-2016-119 5 upon the implementation of the bologna process, a number of european countries have virtually been flooded with undergraduate and graduate public health study programmes proposed and introduced, but regrettably often lacking clearly defined competencies and, unlike the us, clearly defined labour market prospects and career advancement paths. bottom-line, for almost a century, public health has been recognised as a distinctive profession both by the us and canada, a great importance thereby being given to the accreditation of the study curricula. aspph membership is allowed only to the institutions of merit, which have satisfied stringent accreditation criteria. however, it should be pointed out that aspph can be joined only by institutions that have passed the accreditation procedure entrusted with the special agency operating under the wing of the council on education of public health (the ceph), while schools having their study curricula not yet accredited may join the association only as associated members, provided that the accreditation procedure is already set in motion. from the past to the present developments one of the founding fathers of the european union, jean monnet has stated that: “nothing is possible without man, nothing is sustainable without institutions”. associations of sphs, established in europe and north america long time ago were drivers for promotion of public health education, research and service and, warranty, of high quality educational standards. aspher celebrates its half a century-long establishment in 2016. the association primarily embraces schools or departments of public health established in countries belonging to the who-euro, and has only recently opened to associated members beyond the european region. aspher membership reached 110 members in terms of schools or departments of public health established in 43 countries of the who european region, spanning from iceland to the west to kazakhstan to the east, and from norway to the north to israel to the south. on top of that, some of the schools from other continents (australia, canada, mexico, lebanon and syria) are affiliated with the association as associated members (8). aspher became a respectable european organisation in public health workforce development and collaborates with who as well as with other european and international organizations and associations such as the european public health association (eupha), the world federation of public health associations (wfpha), the european public health alliance (epha), the european health management association (ehma), the eurohealthnet (ehn) and many others. despite different patterns of establishment, sphs from both sides of the atlantic ocean have currently a lot in common; one can say they are converging having in mind that sphs in europe are currently academic institutions with multi-professional faculty. many new sphs were established after 1990 in central and eastern european (cee) countries, as well as in the newly independent states formed after dissolution of ussr. besides education and training of health professionals, sphs have the mission to inform and support the planning, development and evaluation of public health interventions, programmes and policies coming from both, governmental and non-governmental sector. in 1995, evelyne de leeuw, at that time secretary-general of apsher, published an excellent article in the lancet based on a survey performed three years earlier encompassing 54 sphs in europe in which she labelled eight types of sphs (9). two types were found to be most common in cee countries: (i) sph within medical university, and; (ii) sph which is a branch of the ministry of health (moh), while other types were more typical for western europe: (iii) sph within medical school; (iv) university (multi-school) based programme bozikov j. european and north american schools of public health – establishment, growth, differences and similarities (editorial). seejph 2016, posted: 03 june 2016. doi : 10.4119/unibi/seejph-2016-119 designated by moh, and; (v) an independent research and training institution within the university (what is in fact an equivalent of the accredited sph in us). some sphs in cee countries, particularly the newly establishing ones, were in transition towards the last type (us-type sph). it seemed that the european scene of public health education had been changing but cee countries showed to be polarized: in some countries us-type sphs had been established, whereas in the others even the new initiatives were based at the training under the umbrella of mohs, likely due to historical reasons as it was stated in the conclusion (9). twenty years later, the situation is very much the same and public health as a profession is still struggling for recognition not only in cee countries, but also in some western european countries. besides the need for integration of academic and field activities already in the educational environment, i.e. establishment of us-like academic institutions granting bachelor and/or master degrees and not only postgraduate ones, another issue is essential: availability of well-defined jobs for graduates. in many european countries, both in western and eastern europe, it is difficult to change patterns according to which job posts are defined and made available. that is why in some countries (e.g., in albania), newly established higher education programmes in public health were abolished due to non-employability of graduates, while in others after many years of successful training within a common postgraduate msc study programme in public health and epidemiology that was open to multi-professional student body (e.g., to candidates with medical as well as different non medical background), separated programmes have been currently introduced (e.g., in croatia): public health medicine as mandatory part of medical specialization (i.e. for mds only) and specialized postgraduate programme in public health designed for other professionals, mainly those already employed in the health sector or engaged in governmental or local authorities or ngos. this programme started at the andrija stampar school of public health already in 1947 followed by the opening of similar programmes in other public health disciplines: occupational medicine in 1949, mother and child care in 1953, environmental health in 1954, school medicine and hygiene in 1955, sports medicine in 1965, and two programmes started in 1984 (gerontology and medical informatics). besides these postgraduate study programmes that led to msc degree, there were two other tracks opened to mds only (family medicine introduced in 1960 and medical microbiology introduced in 1961). while some of the mentioned programmes were designed as a mandatory part of medical specialist training and enrolled exclusively mds, some others used to mix students of different backgrounds or had two or more tracks (e.g. public health and epidemiology, school medicine and hygiene, environmental health, sports medicine) and students had the option to write a thesis and earn an msc degree or to complete only the study and exams as mandatory part of medical specialization. the last two programmes were aimed for a mixed student body. all mentioned programmes were terminated in 1998 while since than there are no msc programmes anymore in croatia and two types of postgraduate programmes were put in place instead: phd study programmes as the third cycle of higher education and postgraduate specialized programmes. the later programmes are designed either as part of organized education within medical specializations or for other professionals (market-oriented) looking for expertize in a narrow field and mag. univ. degree. in many european countries, public health professionals are still trained at postgraduate level only in schools or departments of public health located within medical school/university, in educational structures of type 1 or 2 described in (9). in some other countries professionals of different backgrounds (e.g. lawyers, social workers or economists) are undergoing training in public health in institutions under the responsibility and management 6 bozikov j. european and north american schools of public health – establishment, growth, differences and similarities (editorial). seejph 2016, posted: 03 june 2016. doi : 10.4119/unibi/seejph-2016-119 7 of national health authorities, i.e. in type 5 sphs according to the referred classification. the best examples for these two forms of postgraduate training institutions were until recently two of the aspher’s founding schools, andrija stampar school of public health belonging to the school of medicine university of zagreb and the french ensp in rennes that was transformed by the public health act in 2004 into ehesp in order to provide france with an outstanding, internationally recognized sph. besides many programmes leading to civil service executive degrees for students previously recruited by government departments or local authorities as well as professional development programmes, the school offers a full range of programmes leading to academic degrees covering all three cycles (bachelor, master and phd) for international students (10). there is evidence that it is possible to build educational structures for education and training of master level public health professionals but they are not sustainable without the changes of labour market. it seems that unlike the west of europe, its east still lacks well-defined job posts for public health graduates unless they have another previously acquired “traditional” qualification. there are even worse examples: more than ten years after the majority of higher education programmes were split into two cycles (bachelor and master) with the bologna reform of higher education in croatia, we are still lacking job positions for those with bachelor degrees and more than 90% of them are continuing their studies for master degree in the same field. moreover, not only that bologna reform seems to be unnecessary, but we are already witnessing demands and examples of a backward process at the university of zagreb: integration of two cycles split previously at the time of bologna process “passion”. bottom-line, well-defined qualification standards linked to well-defined learning outcomes within the national qualification frameworks and in accordance with the european qualification framework are prerequisites for the creation of jobs, but the policy makers should take into account that changes in job definitions should be made and the labour market must be prepared in order to ensure employability of graduates. this is a necessary prerequisite for sustainability of higher education programmes but also could give an impetus to the professionalization of public health and further advancement of public health education, training, and practice. in previous issues of this journal current state of public health profession has already been described by czabanowska et al. (11) followed by an excellent apology towards formulation of a code of conduct for the european public health profession formulated by laaser and schröder-bäck (12). there are no contradictions in the fact that the profession includes, besides those graduated in public health, also members of different other professions – which also have their own values and conducts. in addition to the adherence to ethical principles of public health practice like the ones proposed by the american public health leadership society already in 2002, the european added dimension and values need to be included and obeyed such as solidarity, equity, efficiency and respect for autonomy. the way towards the european treasury of public health competences/operations and accreditation criteria the consensus on core competency model for master’s degree in public health was reached within the aspph at the beginning of the 21 st century (13). on the other side of the atlantic ocean, similar efforts were already under way. in cooperation with the open society institute (osi) public health program, apsher started a project entitled “quality development of public health teaching programmes in central and eastern europe” in the year 2000 aimed bozikov j. european and north american schools of public health – establishment, growth, differences and similarities (editorial). seejph 2016, posted: 03 june 2016. doi : 10.4119/unibi/seejph-2016-119 8 for the quality improvement of public health education in cee countries through review of their teaching programmes by the evaluators coming from the more developed european schools (14). results of this five-year project were already available and lessons learned when the programme targeted towards the european core competences started in the year 2006 and involved public health teachers, scientists and practitioners from aspher member schools in the discussion leading to the first and second list of competences (15,16). it was the base for further discussions taking into account different perspectives of teachers and practitioners, as well as the diversity of public health functions across europe and between different levels of education what resulted in the third edition of aspher’s list of competences in 2011 (17-20). finally, aspher’s lists of competences were widely recognized and endorsed as the basis for public health education by all european who member states at the regional committee for europe sixty-second session in september 2012 and included in the who european action plan for strengthening public heath capacities and services (21,22). moreover, in 2013, who europe delegated the responsibility to aspher for leading its working group concerning the assurance of a sufficient and competent public health workforce (essential public health operation [epho] no. 7). despite aspher’s and other institutions’ efforts, the educational capacity in the european region is still far from being sufficient if compared to aspired us levels (23). as public health opportunities and threats are increasingly global, higher education institutions in europe as well as in other regions have to look beyond national and even regional boundaries and participate in global networks for education, research and practice (24). aspher leaders planned and completed the survey aimed to assess the desired levels of performance by different categories of potential employers of graduates. compared to the ranking obtained from member schools, ranks were lower. it means that schools need to reconsider priorities and questions the competences’ level (i.e. learning outcomes) of their graduates in accordance with the expectations and needs of their potential employers (25). aspher made also efforts to establish criteria for accreditation of programmes in public health that ended in the establishment of the agency for public health education accreditation (aphea) launched in 2011 which has already accredited some aspher members (26,27). conclusions north american sphs operate as independent academic institutions engaged in research and education of public health specialists and public health has been recognised as a distinctive profession both by the us and canada for almost a century. in contrary, the development of the european sphs was primarily influenced by the medical profession and linked to the healthcare system. recent developments at both sides of the atlantic ocean seems to be converging towards an academic type of sph offering all three cycles of study programmes with a great importance given to the accreditation of the study curricula. the design/redesign of any study curriculum for education and training of professionals must be based on well-defined and work-related set of competences in accordance with the employers’ needs. the accreditation criteria for higher education programmes are carefully prepared and formal accreditation procedures exist not only at national, but also at international level. bozikov j. european and north american schools of public health – establishment, growth, differences and similarities (editorial). seejph 2016, posted: 03 june 2016. doi : 10.4119/unibi/seejph-2016-119 9 public health workforce in europe consists of members of different professions working under the same roof and accepting the public health professional identity by obeying not only common ethical values, but also the values determined by the european heritage. the code of conduct for the european public health profession must include european added values and is considered as an amalgam for the public health professionalization. references 1. london school of hygiene & tropical medicine. introducing our school. http://www.lshtm.ac.uk/aboutus/introducing/index.html (accessed: april 13, 2016). 2. liverpool school of tropical medicine. history. http://www.lstmed.ac.uk/about/history (accessed: april 13, 2016). 3. rockefeller foundation. 100 years of the rockefeller foundation. rockefeller sanitary commission (rsc). http://rockefeller100.org/exhibits/show/health/rockefeller-sanitary commissio (accessed: april 13, 2016). 4. flexner a. medical education in the united states and canada. a report to the carnegie foundation for the advancement of teaching with an introduction by henry s. pritchet, president of the foundation.bulletinnumberfour. new york: the carnegie foundation for the advancement of teaching, 1910. http://www.carnegiefoundation.org/sites/default/files/elibrary/carnegie_flexner_report.p df (accessed: april 13, 2016). 5. delta omega honorary public health society. the welch-rose report: a public health classic. a publication by the delta omega alpha chapter to mark the 75th anniversary of the founding of the johns hopkins universtiy school of hygiene and public health 1916-1992. http://www.deltaomega.org/documents/welchrose.pdf (accessed: april 13, 2016). 6. anonimous. william h. welch. https://en.wikipedia.org/wiki/william_h._welch (accessed: april 13, 2016). 7. bozikov j. aspher’s half century: a significant contribution to public health education. seejph 2016. doi: 10.4119/unibi/seejph-2016-115. 8. aspher. members. http://www.aspher.org/members.html (accessed: april 13, 2016). 9. de leeuw e. european schools of public health in state of flux. lancet 1995;345:1158 60. 10. ehesp. programs. http://www.ehesp.fr/en/programs/ (accessed: april 13, 2016). 11. czabanowska k, laaser u, stjernberg l. shaping and authorising a public health profession. seejph 2014. http://www.seejph.com/index.php/seejph/article/download/39/33 (accessed: april 13, 2016). 12. laaser u, schröder-bäck p. towards a code of conduct for the european public health profession! seejph 2016. http://www.seejph.com/index.php/seejph/article/view/88/65 (accessed: april 13, 2016). 13. calhoun jg, ramiah k, weist em, shortell sm. development of a core competency model for the master of public health degree. am j public health 2008;98:1598-607. 14. goodman j, overall j, tulchinsky t. 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https://en.wikipedia.org/wiki/william_h._welch http://doi.org/10.4119/unibi/seejph-2016-115 http://www.aspher.org/members.html http://www.ehesp.fr/en/programs/ http://www.seejph.com/index.php/seejph/article/download/39/33 http://www.seejph.com/index.php/seejph/article/view/88/65 bozikov j. european and north american schools of public health – establishment, growth, differences and similarities (editorial). seejph 2016, posted: 03 june 2016. doi : 10.4119/unibi/seejph-2016-119 10 15. foldspang a (ed.). provisional lists of public health core competences. european public health core competencies programme (ephcc) for public health education. phase 1. aspher series no. 2. brussels: aspher, 2007. 16. foldspang a (ed.). provisional lists of public health core competences. european public heath core competencies programme (ephcc) for public health education. phase 2. aspher series no. 4. brussels: aspher, 2008. 17. birt c, foldspang a. european core competences for public health professionals (eccphp). aspher’s european public health core competences programme. aspher publication no. 5. brussels: aspher, 2011. 18. birt c, foldspang a. european core competences for mph education (eccmphe). aspher’s european public health core competences programme. aspher publication no. 6. brussels: aspher, 2011. 19. birt c, foldspang a. philosophy, process, and vision. aspher’s european public health core competences programme. aspher publication no. 7. brussels: aspher, 2011. 20. birt c, foldspang a. the developing role of systems of competences in public health education and practice. public health rev 2011;33:134-47. 21. aspher. european public health core competencies (ephccp) and european public health reference framework (ephrf). http://www.aspher.org/european-public-health reference-framework.html (accessed: march 26, 2016). 22. who. action plan for strengthening public health capacities and services. copenhagen: who europe, 2012. http://www.euro.who.int/ data/assets/pdf_file/0005/171770/rc62wd12rev1 eng.pdf?ua=1 (accessed: april 13, 2016). 23. bjegovic-mikanovic v, vukovic d, otok r, czabanowska k, laaser u. education and training of public health professionals in the european region: variation and convergence. int j public health 2013;58:801-10. 24. bjegovic-mikanovic v, jovic-vranes a, czabanowska k, otok r. education for public health in europe and its global outreach. glob health action 2014;7:23570. doi: 10.3402/gha.v7.23570. 25. vukovic d, bjegovic-mikanovic v, otok r, czabanowska k, nikolic z, laaser u. which level of competence and performance is expected? a survey among european employers of public health professionals. int j public health 2014;59:15-30. 26. agency for public health education accreditation. aphea. http://aphea.net (accessed: april 13, 2016). 27. goodman jd, muckelbauer r, muller-nordhorn j, cavallo f, kalediene r, kuiper t, otok r. european accreditation and the future public health workforce. eur j public health 2015;25:1112-6. © 2016 bozikov; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.aspher.org/european-public-healthhttp://www.euro.who.int/__data/assets/pdf_file/0005/171770/rc62wd12rev1-eng.pdf?ua=1 http://www.euro.who.int/__data/assets/pdf_file/0005/171770/rc62wd12rev1-eng.pdf?ua=1 http://aphea.net/ http://creativecommons.org/licenses/by/3.0) bozikov j. half century of the association of schools of public health in the european region: a significant contribution to public health education (editorial). seejph 2016, posted: 23 april 2016. doi: 10.4119/unibi/seejph-2016-115 1 editorial half century of the association of schools of public health in the european region: a significant contribution to public health education jadranka bozikov 1 1 andrija stampar school of public health, school of medicine, university of zagreb, zagreb, croatia. corresponding author: jadranka bozikov, phd address: andrija stampar school of public health, rockefeller st. 4, zagreb, croatia; telephone: +38514590101; e-mail: jbozikov@snz.hr conflicts of interest: the author is the director of the andrija stampar school of public health in zagreb, croatia, which is one of the founding members of aspher. mailto:jbozikov@snz.hr bozikov j. half century of the association of schools of public health in the european region: a significant contribution to public health education (editorial). seejph 2016, posted: 23 april 2016. doi: 10.4119/unibi/seejph-2016-115 2 abstract the association of institutions responsible for advanced teaching in public health and of schools of public health in europe was established in 1966. it was in response to the initiative of the world health organization (who) regional office for europe as part of a worldwide initiative to set up regional associations of schools in every who region as a channel for initiating innovative policies. the organisation’s name was later changed into association of schools of public health in the european region (aspher). aspher has established a tradition in terms of an annual award named andrija stampar, which has become a prestigious european reward for merits in public health. a significant contribution to public health education has been made during half century and the association is today stronger than ever before. keywords: association of schools of public health in the european region (aspher), public health education, public health teaching. bozikov j. half century of the association of schools of public health in the european region: a significant contribution to public health education (editorial). seejph 2016, posted: 23 april 2016. doi: 10.4119/unibi/seejph-2016-115 3 establishment and early years in response to the world health organization (who) euro initiative, representatives of the leading schools of public health (or hygiene) including the schools for tropical medicine (and, in addition, the institutes of hygiene/healthcare) gathered together at meetings held between 1964 and 1966 in rennes (december 14-18, 1964), lisbon (february 14-16, 1966) and ankara (october 17-21, 1966). already in 1964, professor sénécal from the school of medicine in rennes was appointed to draft the statutes based on the statues of several international associations and taking into account specificities of the “old continent” and suggestions from representatives of the schools. the statutes were unanimously adopted at the meeting in ankara on the 20 th of october, 1966. the organisation was first given the french name and acronym (airesspe – association des institutions responsables d’un enseignement supérieur en santé publique et des écoles de sp en europe) and later (in 1973) the association’s name was changed into aspher (association of schools of public health in the european region). the history of the association has been already described (1-3). the article 24 of the statutes stated that its text, written in english, french and russian (the working languages of the who regional office for europe), was to be deposited in the archives of the who regional office in copenhagen accompanied with versions in spanish (also, official and working language of who euro) and german. an interim committee was elected with the task of carrying out the decisions of the ankara symposium and to convening the first general assembly of the newly established association. prof. dr. hans harmsen from hamburg was elected as president, dr. frans doeleman from leiden as vicepresident and prof. dr. jean-simon cayla as the secretary-general of the interim committee (4, preface, pp. 1-3). the statutes were signed by the president, vice-president and two rapporteurs (professor jean sénécal and dr stuart w. hinds) and it was later approved and published in english, french and russian in the bulletin no. 1-2 together with the list of member institutions with full addresses and phone numbers, delegate name and his/her alternate representing the respective member according to the article 6 of the statutes (4,5). the author of this article, currently acting in the capacity of director of the andrija stampar school of public health, takes pride from the fact that our institution hosted the first general assembly of the newly-established organisation, convened in 1968 (figure 1), on the occasion of which the statutes were approved and dr. jean-simon cayla, the director of the ėcole nationale de la santé publique (ensp; today’s ehesp) established in rennes, was elected as president; dr. christian lucasse, representing the koninklijke instituut voor de tropen (royal tropical institute from amsterdam) was elected as vice-president; whereas dr. teodor gjurgjevic, acting in the capacity of the administrative secretary of the andrija stampar school of public health, was elected as secretary-general. prior to that, dr. gjurgjevic was personal secretary of andrija stampar himself. at the time of the first general assembly, the director of the school was professor branko kesic, while prof. fedor valic was the third one who contributed significantly to the airesspe’s foundation acting in the capacity of the delegate. it was decided that a seat of the newly established organization would be at the school in zagreb as long as dr gjurgjevic was secretarygeneral. the bulletin of the association was launched and the first two double-issues were published during 1969 (no. 1-2 and no. 3-4) bringing in printed form records of all sessions thanks to the efforts of the secretary-general who wrote the respective prefaces too (4,5). according to the published lists of the members, the association counted 33 members at the time of its first general assembly and it reached 40 members by the end of 1969. interesting to mention, those 40 members represented the following 16 countries: algeria [1], belgium bozikov j. half century of the association of schools of public health in the european region: a significant contribution to public health education (editorial). seejph 2016, posted: 23 april 2016. doi: 10.4119/unibi/seejph-2016-115 4 [5], france [5], germany [2], greece [1], hungary [1], ireland [1], italy [4], portugal [1], the netherlands [6], spain [1], sweden [1], czechoslovakia [1], turkey [3], uk [4] and yugoslavia [3], where number of members is denoted in squared parentheses including one french institute that already in 1969 announced an intention to withdraw from membership (4,5). figure 1. participants of the first aspher general assembly, convened from october 7-12, 1968, in front of the andrija stampar school of public health in zagreb, croatia the school of public health in zagreb was established in 1927 by funds of the rockefeller foundation and the efforts of dr. andrija stampar as one of the oldest schools of public health in europe. at the ceremonial opening of the school’s building which took place on october 3 , 1927, speeches were delivered by the representatives of rockefeller foundation (selskar m. gunn), the league of nations (dr. ludwig rajchman and prof. léon bernard), as well as by many others including the representatives of the institutes of hygiene from warsaw, prague and budapest. the school became part of the zagreb university school of medicine after world war ii under the directorship of andrija stampar who also chaired the department of hygiene and social medicine. at the same time, stampar was preparing the constitutions and other documents for the establishment of the world health organization, chaired the interim commission and was elected by the virtue of acclamation as the president of its first assembly convened in geneva. “he was not only a founding father of the latter organization, but also one of its most stalwart bulwarks during the first and formative decade of its existence” wrote who director-general dr. mg candau in his letter to contribute as a foreword of the publication of selected papers by andrija stampar in 1965 (6). the school proudly took stampar’s name after he passed away in 1958. bozikov j. half century of the association of schools of public health in the european region: a significant contribution to public health education (editorial). seejph 2016, posted: 23 april 2016. doi: 10.4119/unibi/seejph-2016-115 5 dr. teodor gjurjevic (1909-1976) was an interesting person: educated in law in zagreb and later in international affairs in paris and haag, he was a polyglot fluent in several foreign languages (he used to speak and write in english, french, german and italian and spoke polish, russian and spanish). he had pursued the path of the career diplomat already before world war ii and was a holder of two phd degrees, one in law obtained at the university of zagreb in 1933 and the second in humanities from the university of oxford in 1956. he was an employee of the zagreb school of public health since january 1, 1948 till his death on march 20, 1976 with a 3-year break (in 1954-1957) which he used for preparation of the phd dissertation at the faculty of modern history, university of oxford (7). dr. gjurgjevic had every intention to evoke the interest of sphs established in the east europe and encourage them to join the association; to that goal, he even travelled to moscow, but was unsuccessful. moreover, in aspher written history it reads: “dr. gjurgjevic had a fatal heart attack whilst visiting libya in the pursuit of his heroic efforts to set up a world federation of schools of public health”, while in official documents it is stated that he died on 20 march 1976 in zagreb (1,7). ever since the foundation day, aspher has regularly organised its annual conferences. from 2008 on, these annual conferences have been organised in collaboration with the european public health association (eupha) and have run under the name european public health conference (eph). on top of the eph attendance, the school principals get to meet once more on the occasion of the deans’ and directors’ retreat (d&d retreat), also organised on an annual basis. since 2014, when zagreb had the privilege to host the d&d retreat, the event has become even more important, given that within its frame the annual session of the general assembly, earlier convened on the occasion of the annual conference, takes place. the prestigious andrija stampar medal aspher has made it its tradition to present an accolade (a medal) in memory of andrija stampar; the medal became a reality in 1992 and has been awarded annually since 1993 to the key opinion leaders in recognition of their international-scale achievements in the field of public health. the andrija stampar medal has become the most prestigious european award presented in recognition of one’s achievements in public health leadership and education. the credit for introducing this accolade and making it a tradition should go to prof. jeffrey levett from athens, who presided over the association in the 1992-1993 timeframe, and to his successor, prof. ulrich laaser from bielefeld, who had acted in the capacity of aspher president when it was coined and firstly awarded during the 15 th aspher annual conference held in bielefeld, germany, from november 28 to december 2, 1993. on one side of the medal, the name of the association and its logo can be found, while on the edge of its other side the following words, allegedly spoken by dr. andrija stampar, are embossed: “public health investment harvests rich rewards”. in the centre of the medal, the name of the medallist is engraved (figure 2). the awardee is selected by the aspher executive committee, and the award is presented on the occasion of the ceremony organised during the aspher annual conference. the ceremony includes the laudatio to the awardee delivered by a prominent figure, followed by the “thank you” speech given by the awardee. the very first awardee was dr. léo kaprio, who euro regional director emeritus at the time (who regional director 1966-1985), whereas the laudatio speech was delivered by prof. jeffrey levett, the dean of the athens school of public health (figure 3). it is worth mentioning that dr. kaprio, representing the world health organization in his address given at the first general assembly convened in zagreb in 1968, stated the following: “this bozikov j. half century of the association of schools of public health in the european region: a significant contribution to public health education (editorial). seejph 2016, posted: 23 april 2016. doi: 10.4119/unibi/seejph-2016-115 6 general assembly of your association can be an important milestone along the road to further progress in european public health” (4, pp 35-39). the list of the medallists, the pertaining conference venues and the names of the laudatio speakers are available at aspher’s website (8). figure 2. the andrija stampar medal * * in order to express her gratitude for the medal awarded to her in november 2011, dr zsuzsanna jakab, the who regional director for europe, gave a thank you speech in words most carefully selected which was recorded and made available through the who website (9); who regional director also took the opportunity to proudly advertise her medal awardee achievement while presenting her annual report during the 62nd session of the who regional committee convened at malta on september 10th, 2012 (10, slide 12). bozikov j. half century of the association of schools of public health in the european region: a significant contribution to public health education (editorial). seejph 2016, posted: 23 april 2016. doi: 10.4119/unibi/seejph-2016-115 7 figure 3. ceremony of the first andrija stampar medal * * the very first stampar medal award ceremony was held during the xv aspher annual conference held in bielefeld from november 28 to december 2, 1993. from left to the right: prof. ulrich laaser, aspher president, evelyne de leeuw, aspher secretary-general, awardee dr. léo kaprio accompanied by mrs. kaprio and prof. jeffrey levett, aspher immediate past-president who delivered the laudatio speech (courtesy of aspher). congratulations and best wishes for a productive and prosperous future currently, aspher has reached 110 members in terms of schools or departments of public health established in 43 countries of the who european region and, on top of that, some of the schools from other continents (australia, canada, mexico, lebanon and syria) are affiliated with the organization as “associated members” (11). this year aspher is celebrating the 50 th anniversary and the schools’ heads will meet end of may 2016 in athens, where deans’ and directors’ retreat together with the general assembly is hosted by the national school of public health under the aegis of the hellenic ministry of health (12). the fiftieth anniversary book with member schools’ profiles is already in press (13). congratulations! long live and best wishes for a successful and prosperous next 50 years! bozikov j. half century of the association of schools of public health in the european region: a significant contribution to public health education (editorial). seejph 2016, posted: 23 april 2016. doi: 10.4119/unibi/seejph-2016-115 8 references 1. landheer t, macara aw. the history of aspher 1968-1993. http://aspher.org/download/24/the_history_of_aspher_by_awmacara_and_tlandheer.pdf (accessed: march 10, 2016). 2. foldspang a, louvet t, normand c, sitko s (editors). 40 aspher anniversary 1966-2006. anniversary book. aspher series no. 1. st maurice: aspher, 2006. http://aspher.org/download/23/aspher_40_anniversary_book.pdf (accessed: march 10, 2016). 3. levett j. from leo kaprio to julio frenk – two decades of aspher's andrija stampar award. the tribute to the ever current štampar. malta, october 10, 2012. http://aspher.org/mod/file/download.php?file_guid=9548 (accessed: march 10, 2016). 4. airesspe. bulletin no 1-2, zagreb: airesspe, 1969, 139 pages. 5. airesspe. bulletin no 3-4, zagreb: airesspe, 1969, 171 pages. 6. grmek md (editor). serving the cause of public health. selected papers of andrija stampar. zagreb: andrija stampar school of public health, medical faculty, university of zagreb, 1966. p. 5 7. kovacic l. [dr teodor gjurgjevic, lawyer, diplomat, polyglot, and the collaborator of andrija stampar]. acta med hist adriat 2015; 13(suppl. 1); 21-30. http://hrcak.srce.hr/file/218055 (accessed: march 10, 2016). 8. aspher. andrija stampar medal. http://www.aspher.org/andrija-stampar-medal.html (accessed: march 10, 2016). 9. jakab z. speech “on accepting the andrija stampar medal from the association of schools of public health in the european region”. copenhagen, november 10, 2011. http://www.euro.who.int/en/who-we-are/regional-director/speeches-and-presentations-byyear/2011/speech-on-accepting-the-andrija-stampar-medal-from-the-association-of-schools-ofpublic-health-in-the-european-region 10. jakab z. report on the work of the regional office. malta, september 10, 2012. http://www.slideshare.net/slideshow/embed_code/14232316?rel=0# (accessed: march 10, 2016). 11. aspher. members. available at: http://www.aspher.org/members.html (accessed: march 10, 2016). 12. levett j. athens aspher celebration, 25-27 may, 2016 blog 2. http://www.aspher.org/articles,21.html (accessed: march 10, 2016). 13. foldspang a, müller-nordhorn j, bjegovic-mikanovic v, otok r (editors). fifty years of professional public health workforce development. aspher’s 50th anniversary book. brussels: aspher, 2016 [in press]. ___________________________________________________________ © 2016 bozikov; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://aspher.org/download/24/the_history_of_aspher_by_awmacara_and_tlandheer.pdf http://aspher.org/download/23/aspher_40_anniversary_book.pdf http://aspher.org/mod/file/download.php?file_guid=9548 http://hrcak.srce.hr/file/218055 http://www.aspher.org/andrija-stampar-medal.html http://www.slideshare.net/slideshow/embed_code/14232316?rel=0 http://www.aspher.org/members.html http://www.aspher.org/articles,21.html selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 1 original research discrimination of elderly patients in the health care system of lithuania kristina selli 1 , kasia czabanowska 2,3 , lina danusevičienė 1 , rūta butkevičienė 1 , ramunė jurkuvienė 1 , judy overall 4 1 faculty of public health, lithuanian university of health sciences, kaunas, lithuania; 2 department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 3 faculty of health sciences, jagiellonian university, krakow, poland; 4 fairbanks school of public health, indiana university, indianapolis, indiana, usa. corresponding author: assist. kristina selli, llm, department of health management, faculty of public health, lithuanian university of health sciences; address: a. mickevičiaus g. 9, kaunas, lt-44307, lithuania; telephone: +37067172620; e-mail: kristina.selli@gmail.com selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 2 abstract aim: this study aimed to explore and describe the barriers that elderly lithuanians experience with respect to going to court or other institutions to defend their right not to be discriminated regarding medical care. methods: we used a mixed methods approach due to the scarcity of information in lithuania. first, the review of laws was done using the e-tar database and court cases were searched using the e-teismai database followed by policy analysis. additional sources of information were identified searching google scholar and pubmed, as well as google for grey literature. the keywords used were: ageism in patient care, discrimination against elderly, elderly and health (english and lithuanian: 2000-2015). secondly, we conducted indepth individual interviews with 27 clients of newly-established integrated home care services: 13 elderly patients, and 14 informal caregivers. results: this study identified five groups of barriers explaining why lithuanian elderly are hesitant to fight discrimination in the health system. the results of the study disclose the following barriers that the elderly in lithuania face: i) the lack of recognition of the phenomenon of discrimination against the elderly in patient care; ii) the lack of information for complaining and the fear of consequences of complaining; iii) the deficiencies and uncertainties of laws and regulations devoted to discrimination; iv) the high level of burden of proof in court cases and lack of good practices; v) the lack of a patient (human) rightsbased approach in all policies and in education as well as the lack of intersectoral work. conclusions: this study disclosed the need to: encourage training of legists and lawyers in expanding knowledge and skills in human rights in patient care; encourage training of health care professionals – the burden of leadership for this has to be assumed by universities and public health professionals; incorporate a new article in the „law on the rights of patients and compensation for the damage to their health‟, clearly stating where to complain in case of discrimination; create a webpage and brochures with readable and understandable information for elderly persons and their families and caregivers; establish legal consultation and mediation cabinets in health care facilities; establish an older persons‟ rights protection service under the ministry of social security and labour in close cooperation with the ministry of health; promote sustainable results by incorporating a human rights-based approach regarding elderly persons in all policies. keywords: aging, discrimination against elderly patients, human rights, legislation, lithuania, patient care. acknowledgements the research was inspired by the scholars program of the association of schools of public health in the european region, human rights in patient care core network (aspher hrpc). the purpose of the scholars program is to foster research and publication on human rights in patient care (available at: http://cop.health-rights.org/scholars and http://eurpub.oxfordjournals.org/content/24/suppl_2/cku151.111). we thank prof. ulrich laaser, faculty of health sciences, bielefeld, germany, for the extensive support and careful editing. conflicts of interest: none. selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 3 introduction although ageism, i.e. stereotyping and discriminating against individuals or groups on the basis of their age, has been described already since 1969 by robert neil butler (1), it is still prevalent, and in some societies even growing (2). roots of ageism are gerontophobia and the fear of death, which are deeply embedded in people‟s minds. discrimination against the elderly exists in all spheres of life and in patient care as well (3,4). discrimination against the elderly in patient care combines two main actions: discriminating behaviour on the ground of a patient‟s age and the lack of „good behaviour‟ by someone who has a duty and responsibility for patients in the health context. this type of discriminating behaviour may occur when professional health care providers are not educated enough to question their own personal culture, views or attitudes (subjective causes), or when the state violates the legallyrecognized human rights principles by creating discriminatory policies. in one of the interviews, an over-80-year-old man said “it surprised me how children and young people show love and respect for the elderly in their family and yet disrespect and ignore the elderly outside” (5). this „outside‟ can be a hospital, hospice or elderly home or system of laws. french researchers herr et al. (6) disclosed that „socioeconomic position influenced the risk of having unmet health care needs, but the main risk factors identified were advanced age and homebound status.<...> the oldest-olds are the most affected by unmet health care needs‟. the united nations special rapporteur believes „…that the promotion and protection of human rights of older persons is not only in the interest of senior persons, but should also be of concern to everyone, because every person ages‟ (7). europe is aging and lithuania is aging twice as fast as europe on the whole (8). the main causes are low birth and high emigration rates of younger lithuanians. at the beginning of 2015, the population of lithuania was 2.9 million, including more than 650,000 (or 22.3%) of pension-age individuals (work according to a moving age-scale in 2015 ends at 61,4 years of age for women and 63,2 for men) (9). the elderly have become a significant part of society, but this does not mean in any way that they have become a privileged part of society. europe, including lithuania, has clear legal protection a convention for children (10), but does not have a convention for older persons. both are vulnerable groups and need more protection than the working age subgroup of the population. elderly are only covered indirectly, e.g. by the european charter of patients‟ rights (11), or the council of europe in its convention for the protection of human rights and dignity of the human being (12). policy makers do not seem to be very interested in an additional document specifying the elderly person‟s rights (13), but it is time to connect patient care and public health law with a human rights-based approach. according to gostin (14): “…public health law is the study of the legal powers and duties of the state, to assure the conditions for people to be healthy. the prime objective of public health law is to pursue the highest possible level of physical and mental health in the population, consistent with the values of social justice”. according to the eurobarometer survey, “discrimination eu 2012”, discrimination against old age and disability is very frequent in lithuania, respectively 59% and 45% percent (15). lithuanian research reveals a deep and ingrained discrimination in all fields of life, especially in the labour market (16). although discrimination of elderly occurs also in patient care in lithuania (17,18) there is lack of multi-facetted and comprehensive research showing how widespread the discrimination of elderly in fact is. discrimination in patient care in lithuania resembles the allegory about the three wise monkeys that hear, see, and speak no evil. but in real life an older person faces many discriminating phrases like: „what do you expect at your age?‟; „you don‟t need breast at your age‟; „come on, pensioners can wait‟…and „never tell the ambulance operator your real age, they will not hurry‟. given this situation, questions selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 4 remain as to why lithuanian elderly do not use institutions or courts to insist on their rights. after all, health issues are the most pertinent to survival. “ageist attitudes are not only hurtful; they are harmful<…> the fact is that older people get sick from disease, not old age‟ (19). „the right to health requires that facilities, goods, and services be available, accessible, acceptable, and of quality” (20). this is not only the question of a patient‟s right to health, but of the person‟s human rights per se. the research question has derived from the description of the situation in lithuania and the aim of the research was to identify the barriers preventing elderly patients from filing legal action against experienced discrimination which could be successful and, even more, would indicate the magnitude of the problem. methods in this study two main methods were employed. firstly, a review of the legislation using the e-tar database (21). court cases were searched employing the e-teismai database (22) followed by policy analysis. furthermore, google scholar and pubmed and, for grey literature, google were screened. the following key words and terms were used: „ageism in patient care‟, „discrimination against elderly‟, „elderly and health‟ (all in english and lithuanian: 2000-2015). secondly, in-depth individual interviews with elderly patients and their family members (informal care givers) were conducted to answer questions like: what is your current health care situation? what difficulties do you face concerning health care? what actions do you think you could take in order to change the situation and to receive proper medical care? the answers were analysed with the research focus on how discriminating behaviour towards elderly patients manifests in patients‟ everyday day life, and what do patients and their caregivers think of taking legal action to protect their rights of access to and receipt of proper medical care. the targeted sample of informants was the users of the newly-implemented integrated home care services from ten lithuanian municipalities (out of 21 municipalities where the services were started). the users were chosen according to their availability for an interview on the day that the interviewer was visiting the municipality. overall, 34 patients and their care-givers were visited, but seven patients were not interviewed because they were younger than 65 years. the final sample comprised 13 patients and 14 family members. the patients were present during the interview, but seven of them were not contributing significantly because of having difficulties to express their thoughts. all informants (including the family members) were older than 65 years. the elderly patients had chronic conditions and required long-term care around-the-clock. the informal caregivers were nine daughters or daughters-in-law, and five spouses (four wives and one husband). although the intention of interviewing family members was to hear about the person they take care of, the result always was that the carers additionally volunteered to provide information about their own experience in health care as patients. the interviews focused on informants‟ experiences, perceptions, and opinions concerning medical care services. all interviews were conducted by a team of authors (ld, rj, rb). the interviews took place in patients‟ homes and lasted 60-90 minutes each. all interviews were tape-recorded (audio) with the informants‟ consent, both the patient and the family member. all three interviewers/authors repeatedly read the material, selected, and coded the „meaning units‟ related to the manifestation of discriminating behaviour by health care providers and the opinions of taking legal action to protect the elderly persons‟ rights to proper medical care. the main categories were developed and reached by the team of authors after thorough discussion. selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 5 definitions: discrimination: i) the unjust or prejudicial treatment of different categories of people, especially on the grounds of race, age, or sex (23), or ii) any distinction, exclusion or preference that has the effect of nullifying or impairing equal enjoyment of rights (who) (24). the study was conducted in accordance with the declaration of helsinki (25). results examination of the lithuanian legal framework and the court practice and litigation procedure i) article 29 of the lithuanian constitution does not mention age specifically but is inclusive in regard to equality of all persons under the law and non-restriction of rights of human beings and contains a limited list of categories of persons whose rights cannot be restricted or to whom special privileges cannot be granted on specific grounds: “all persons shall be equal before the law, the court, and other state institutions and officials. the rights of the human being may not be restricted, nor may he be granted any privileges on the ground of gender, race, nationality, language, origin, social status, belief, convictions, or views” (26). ii) the main law, “law on the rights of patients and compensation for the damage to their health” (27), which describes different patient rights and establishes a particular institution to which to complain (article 23), does not mention any institution which has the authority to solve disputes regarding discrimination in lithuania. iii) the law, „law on equal treatment‟ (28), which sets up the categories of discrimination and empowers the ombudsperson to investigate alleged instances of discrimination, does not define describe discrimination in health care – whereas discrimination in the education system or labour marked is clearly mentioned. iv) regarding court practice and litigation procedure as of now (early 2016) there are no cases in the lithuanian supreme court and other courts‟ records. in 2015, lithuania still did not have an effective procedure or best practice in formulating court suits linked to discrimination of elderly persons in the delivery of patient care (29). it seems that the majority of lithuanian elderly do not use legal means. v) there is a lack of complaints in the office of the equal opportunities ombudsperson in spite of the provision 13 of the european charter of patients‟ rights is the „right to complain‟ (11). in lithuania, on 1 january 2005, a new law on equal treatment came into force, guaranteeing the right to file complaints to the equal opportunities ombudsman in cases of discrimination on grounds of age, sexual orientation, disability, race and ethnic origin, religion or beliefs (30). the ombudsman is a pre-litigation body in lithuania for discrimination cases. until now, the ombudsman service had only one case regarding age discrimination in health preventive programs (31). an analysis of the webpage of the ombudsman service revealed that almost all information, complaints and researches are devoted to age discrimination in the labour market. vi) in 2015, lithuania created an „inter-institutional operations plan for promotion of nondiscrimination‟ for the period 2015-2020, the main aim of which is to raise public awareness and foster respect for human beings. the plan recognized: “lithuanian public awareness is still too low, only a small proportion of the population knows where to go for fighting discrimination” (32). the same is demonstrated in our findings. in interviews, „i do not know what to do‟ was repeated in almost all conversations. furthermore, in the action plan there are lots of general and specific steps and recommendations to act in fighting age discrimination; but this does not ensure that educational activities will reach those persons selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 6 who discriminate against the elderly in patient care. this type of discrimination is not mentioned in the action plan, and among actors (implementing authorities) there is no inclusion of the ministry of health. implementing authorities are: ministry of social security and labor, ministry of education and science and ombudsman. vii) there is a lack of institutions and organizations that provide legal help for elderly persons in resolving disputes and defending their rights in health care facilities. we did not find elder law clinics or older persons‟ rights protection services. viii) there is a shortage of easy, understandable, and easily-obtainable information for elderly persons regarding their rights. we did not find web pages or specialized easily understandable, and obtainable information for elderly. to prove discrimination against elderly in legal cases is often challenging: a citation of the chief of the lithuanian supreme court in 2007 may serve: “there is no racial discrimination in lithuania, <…> there are some complaints for some not-equal treatment in other spheres, but then proceedings are completed and discrimination is not proven” (33). analysis of the interviews the initial idea of the study was to gather information from elderly patients who were most in need of care as they required long-term care around-the-clock. however, what the family members provided as their experience of taking care and of being patients themselves, broadened the scope of the study. thus, information about discrimination not only of the bedridden people, but also of healthier old people was gathered. in spite of all the interviewees reporting their experience as patients, the research team will further on call the two groups “patients” and “informal caregivers” according to their social roles. as concerns the discrimination because of age, there was no difference between the two groups found in what they were telling about themselves as patients, therefore, the findings about ageism are presented for both groups together. the analysis of the interviews with patients and their informal caregivers revealed manifestation of discrimination due to age. older persons very often confronted with violation of their rights as a human and as a patient to receive health care services and proper treatment. they often were ignored and were not treated seriously. their right to information was violated and their right of participation in the process of decision making regarding to their own health situation was ignored. an older person with special needs (overweight) was left without appropriate care, because hospitals and elderly homes are poorly equipped and do not even have simple hoists. the detailed manifestation of discrimination and ageist behaviour revealed in the interviews is presented in table 1. table 1. ageist behaviour and manifestation of discrimination ageist behaviour manifestation of discrimination violation of the patients‟ rights to health care because of their age "the nurse is talking [to me, the caregiver] on a phone: „87 years old! and you want our doctor to pay a home visit to such a patient!? no, he [doctor] won‟t come. and it‟s illegal for me to provide infusion therapy without a prescription of the doctor.‟ and what should i do?" (daughter, 67 years old, site 1). violation of the patients‟ rights to the information because of their age “nobody really cares to explain to you in what case you are eligible for rehabilitation services. the doctor says „you are too old to understand‟” (spouse, 82 years old, site 1). selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 7 ignored or not taken seriously because of their age “i am not able to talk with the doctor about my mother‟s condition. when i go for a consultation i get the only answer „such an age [94 years old]!‟ she even said to me, „in your seventies you want to be healthy?‟ and i got so angry at that moment. our town is small; we know each other. she is only several years younger than i am and she thinks that she is young! i tell her about my condition and she is not even listening. i never get any prescription. if not for our pharmacist, my mother would have been dead. my mother had a very bad erysipelas. and only the pharmacist told me that there is a special antibiotic, but the doctors usually do not prescribe it. i went to the doctor and insisted that she give the prescription for this medication. she was very unpleasant, but gave the prescription. and my mother got better straight away. but if i did not know about this type of medication, i would have never got it.” (daughter, 70 years old, site 6). the system serves only the interests of the system when the client is old, overweight and has special health problems “the family doctor did not even come and look at her [mother]. <…> she said she has too many patients registered! then she [doctor] wrote a referral to a hospital for treatment without seeing her. she [mother] did feel very bad, she was coughing up to suffocation. and my mom, she weighs 120 kg. <…> we went [to the hospital] to look for an illness in the lungs, and ended up in vilnius [the capital] to do a computer tomography of the intestines, because they came up with an idea that there is a tumour in the intestines. but nobody hospitalized her, and the night was approaching! so i called the nurse of the integrated care team at 8.30 pm: “what should i do? nobody hospitalizes us. and how am i supposed to take my bedridden mother who weighs 120 kg home?” everything went on through the phone: send her, bring her, go… the nurse somehow arranged that an ambulance brought us back from vilnius, so we were finally back in a district hospital at 2.30 am. and here again i hear: “we are not going to hospitalize her; she is old and her condition is too severe.” and they sent us back home. and i think to myself, what i should do now? my mother was dragged around through half of lithuania and now i have her back at home with the inflammation of the lungs on my own” (daughter, 65 years old, site 2) when the patient is old, the doctor is reluctant to visit that patient with acute disease at home. “<...> in april it happened that the doctor refused to visit my wife. over the weekend my wife had gotten even worse. on monday i went to [our] ambulatory centre to ask for a doctor‟s visit. and there i was told that “today we do not have any times free for registration; for tomorrow we also cannot register. and from the first of may our doctor leaves for the holiday”. it felt like a mockery. and in the cases of acute conditions they [personnel of primary health care centre] have to take the patient in without any registration. in the waiting room there were no patients at all. then i asked, “maybe now she [doctor] could come and examine her [my wife]? we live so close, just across the street. it would take only a few minutes to come and examine.” and her answer was, “no, i cannot leave the ambulatory“. and at the same time there were two nurses there sitting. you realize how it is? they do not care about old patients. what should we do? the fever was very high. i called for an ambulance. the ambulance took her to the hospital. and there in the hospital, she, having pneumonia and high fever, had to stay in the corridor on a transfer trolley for almost over twenty-four hours. the hospital could not refuse to selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 8 take her in with high fever… ” ( spouse, 78 years old, site 1) how do the older persons deal with the experience of ageist behaviour? as findings reveal, in most cases the older persons recognize ageist behaviour, but do not perceive it as a violation of their rights. instead of trying to change anything, the people use emotional coping and remain with the feeling of helplessness. the findings disclosed that older persons face certain barriers that prevail on taking legal action in order to protect their rights to proper medical care. among the barriers were internal barriers, health limitations, readiness and willingness of legal representatives to identify ageist and discriminatory behaviour and to represent the older person in a legal action based upon the discrimination (table 2). table 2. barriers in taking legal actions to protect the rights of older persons to proper care barriers description of the barrier health state limitations “…at this age you are not supposed to go to fight in the courts. [in order] to go to the court and to fight you ought to have good health and a lot of strength.” (woman, 75 years old, site 1). prolonged court processes “you need help here and now and not at the time when the process will be over and the court will decide. people might be in the suit for years there, and what result does it give? <...> and on the other hand, the winning of the court after half of a year or a year might be too late. by that time my husband or i myself might be below ground.” (spouse, 70 years old, site 4). “there were two court processes [about using the handicapped spouses‟ money for nursing]. the procedure seems quite simple, but it took half a year <...> and you have to live now, to buy medications and nursing items now. you have to live your life now.” (spouse 78 years old, site 1) the lack of positive experience in dealing with the courts “the old person has no chance to win the court. in our courts the justice is on the side of the one who has more money. it is as simple as that…” (man, 77 years old, site 2) “... i had already gone through the court in order to get the permission to use her money for her care. after her stroke she is not able to go to the bank or to sign [documents]. her speech is limited. <...> there were two court processes. the procedure seems quite simple, but it took a half of a year <...> and you have to live now, to buy medications and nursing items now. you have to live life now. and what the result was: the decision that i can take from her account only 1400 euro even though at the time i had already spent over 1700 euro just for her medications. if you want more money, you have to appeal to the court from the very beginning again. and they questioned my daughter and my son, and they both [daughter and son] were not against it. but still such decision.” (spouse, 82 years old, site 1) the lack of special knowledge “if you want to fight for justice in the court, you have to have selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 9 knowledge. these things are not for an old person.” (woman, 71 years old, site 2). need of other resources “you need somebody who could drive you to the court. and not once, but constantly through all the procedure. and at the moment i feel lucky that my daughter and son-in-law drive me to the doctor or to the shop, or to the church. and you would additionally ask to drive to the court? everybody is busy with their own affairs and duties.” (women, 74 years old, site 5). the lack of recognition of the discrimination even by lawyers “and regarding the court… now i think to myself. my son-in-law is a lawyer. and he has never mentioned the possibility of the court. he knew our situation in details; he saw everything. apparently he really knows that the court cannot help there. and he is really good at those things...” (spouse, 76 years old, site 10) inner barriers and fear of consequences to be left without any care researcher: “have you ever thought of looking for justice [regarding being discriminated by the doctor] or looking for another doctor?” “i have never thought about it... and when i think now, i realise that i would never do it. i would really feel uncomfortable regarding the doctor. i know her and she knows our family for so many years. and you are used to her and she knows all my health problems. somehow you cannot go into the conflict [with the doctor]” (spouse, 76 years old, site 10). “if you start to conflict, you may stay without any help. and what should one do in such an age and health condition. you completely depend on the doctor. she prescribes medications… and in our ambulatory she is the only doctor.” (woman, 78 years old, site 9). the lack of a patient (human) rights-based approach in all policies, lack of education, and the lack of intersectoral work “...i could not imagine that it would be hard to take care of your own mother? she raised us, so can't i now take care of her? it is five years now [since then]. <...> she cries day and night: mum, mum. you don't get if she has pain, or not. this cry, it seems i will get crazy. when i cannot bear it anymore, i go out, walk around with my head in my arms, and come back. i used to hire people [to nurse] <...> but nobody wants to stay with such a hard patient. they stay for a month and leave. where haven't i looked for help? <...> the answer was that we understand that it is hard for you, but it is your mother and you have to take care of her.” (daughter, 66 years old, caregiver of 91yearold mother, site 8). for the caregivers, taking care itself is already a huge emotional and physical overload. “well, when i get tired at night, i think to myself sometimes, “god, oh, god”... [...] the nursing is very difficult. you cannot leave anywhere. i step out, sit on a bench for a while and back into the house. oh, and i go to the shop. i long for the fresh air… he is sick for 8 years already. you can imagine what it means to stay with a patient for so many years” [she is moved and gets tearful, cannot talk for some time] (spouse, 74, site 16). it can be rewarding experience when you help, but there is ample research about caregivers feeling depression, somatic disorders and the like (35,36). when somebody is discriminated and does not receive proper medical care, s/he can already feel disappointed and rejected. selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 10 when you additionally do not get help with the one you take care of, the helplessness that you feel is double, because you have to see the suffering of a person close to you. the question “and what should i do?” without finding appropriate answer and with the feeling of helplessness was very often on the lips of the caregivers in the study. some participants of the study had interesting suggestions regarding how the situation could be changed to a less-ageist attitude. one of them suggested that the problem was that the fight against ageist behaviour was seen as a private matter and it has to be made into a public one. moreover, because of their homebound, bedridden situation the people are not able to take proper care of themselves; therefore it is improbable that they would additionally fight against discrimination. as concerns the carers, having to deal with the situation where the sick relative totally depends on you made them learn a lot about nursing, filling appropriate documents, achieving that help is provided and this round-the-clock job without holidays often left them exhausted, was causing health problems, and did not allow to fight for change against discrimination: there were other, more urgent problems at hand and not enough resources to deal with everything. even people with political positions could not achieve change in patient-care, in spite of writing about the situation extensively (rūta vanagaitė, active politician: she used her position in parliament to change the situation of people, who are dependent and need home care. she iniciated discussions on the topic and raised the problems in media. even wrote a book. vanagaitė r. pareigos metas [time of duty], 2014 [in lithuanian]). therefore it came as a natural suggestion, that there is a need for professionals such as social workers, who would be legally entitled to act against discrimination based on age: “i think that an older person has to have a legal representative such as a social worker. the social worker could present cases of violation of the rights of an older person. social workers should be entitled to file a suit to the court when an older person is left without care or when a patient has to take care of another patient at home without formal support and without proper attention of doctor and nurse in such cases like my situation was [when i was caring for my late husband]. me, with a heart pacemaker, had to take care of my bedridden husband for over three months. i had to wash him, to lift him, and day and night to nurse him on my own. after such an intensive care i walked wobbling. thanks god, he died in time” (78 years old women, site 5). summary of the empirical findings i) discrimination is not perceived as such and often is considered a lack of attention. ii) the fear to lose doctors‟ friendly support dominates, especially in rural areas, were only one doctor works. iii) there is no elderly-orientated or easily-operational legal information that clearly states steps to fight discrimination in patient care. iv) there is a lack of confidence in justice, courts, and institutions. v) the results of the study disclose the following barriers which the elderly in lithuania face: a) lack of recognition of the phenomenon of discrimination against the elderly in patient care; b) lack of information for complaining and fear of consequences of complaining; c) deficiencies and uncertainties of laws and regulations devoted to discrimination; d) a high level of burden of proof in court cases and lack of good practices; e) lack of a patient (human) rights-based approach in all policies and in education as well as the lack of intersectoral work. discussion selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 11 while other authors (35) often discuss how to fight hidden discrimination, we found it necessary to speak about open discrimination of elderly patients. the review of court cases, and more specifically interviews disclosed that the phenomenon of discrimination is neither perceived nor recognized. on the contrary, findings show that wide and open discrimination against elderly persons is manifest in patient care. in line with discussion by williams in „age discrimination in the delivery of health care services to our elders‟ (36), we found that the main barrier to changing practice still is the lack of recognition. in regard to the second important barrier, the lack of information and fear of consequences, clough and brazier asked similar questions in their work „never too old for health and human rights?‟(35). they cite barriers in the context of the united kingdom: the elderly patients “may not complain because of a fear of consequences, for example, that they will be evicted from their care home if they do, may not complain because they lack confidence, may feel they are „just making a fuss‟, may find there is a lack of accessible complaints, mechanisms or information about how to complain, may have particular communications/language difficulties or may face limited access to legal aid providers or be limited by the scope of legal aid, or may be put off by complex legal procedures such as conditional fee arrangements” (35). this comes close to our empirical findings: the lack of information and especially the fear of consequences are additional major barriers in lithuania. differently from the uk context, the fear of consequences can be explained in lithuania by „renter mentality and conformity that are lingering of soviet society mentality” (37) because the older generations in lithuania lived during the soviet period (1940-1990). we found that elderly persons do not trust courts and they do not see any possible real way to change the system. they do not know who can help them or who can inform them. they need health care now, not after long-lasting, expensive litigation. they believe that a doctor is the only person who could help them and that is why they do not want to risk losing their doctor‟s favour. the third barrier in lithuania is the deficiencies and uncertainties of laws and regulations devoted to discrimination. in this study we found that in 2004, when entering the european union (eu), lithuania changed or supplemented laws according to eu requirements. in most laws, non-discriminatory sentences were added. however, the implementation of laws, in general, is a real issue. perhaps it is due to a lack of brave and new practice for forming decisions of the lithuanian supreme court. lithuanian laws should be written more clearly; their examination revealed a lack of precise articles in two basic laws (27,28) that should indicate the way for complains and, ultimately, the constitution of lithuania does not pay attention to age discrimination at all. in line with the european union agency for fundamental rights finding that „interviews with legal experts, equality bodies and health ombudsmen indicate that proving that a discriminatory act has taken place is often challenging for plaintiffs and their lawyers (38), we found that the lack of court cases is the result of the difficulty to prove discrimination, and vice versa the difficulty of the burden of proof is the result of the absence of successful litigation. there is one possible solution: in lithuanian civil law court cases, the aim of averment is a court‟s reasonable belief of existence or non-existence of certain circumstances (art.176) (39). that is why anti-discriminatory policies could educate judges to see discrimination more often. also more frequent complaints (starting with civil cases) would slowly change the practice and burden of proving in civil and administrative cases (including ombudsman‟s procedures). finally, a change in policy regarding a human rights approach influencing education and fostering intersectoral coordination and cooperation in terms of health in all policies would selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 12 accelerate the already visible slow movement forward as regards the european context. tonio borg, ex-eu commissioner for health, said: “i believe health is for all. everybody should have access to good quality healthcare regardless of gender, age, race, and sexual orientation, type of condition, social status, education, or country of residence. for this to become reality, we need to fight discrimination in health” (40). unfortunately, the new lithuanian action plan for “healthy aging” (32) that derived from the strategy and action plan of healthy aging in europe, 2012-2020 (41) interprets „healthy aging‟ from a nonhuman rights perspective and is in itself discriminatory. its main focus is to inspire the elderly to be active, as a cause of healthy living, not as a consequence of healthy living. there is a policy deficiency regarding a non-active, almost-disabled or very old person who cannot be active. lithuanian „healthy aging‟ itself has to tackle discrimination and health inequalities in its approach and focus more on „strengthening health systems, in order to increase older people‟s access to affordable, high-quality health and social services‟ (41). one of the reasons for the incomplete implementation of human rights in elderly patient care is likely the non-binding character of many conventions and charters instead of binding legislation. the european charter of patients‟ rights of 2002 (4) contains 14 provisions, the second being the „right of access‟: „the health services must guarantee equal access to everyone, without discriminating on basis of financial resources, place of residence, kind of illness or time of access to services‟. it seems that lithuanian lawmakers are afraid of the word „guarantee‟ and its consequences, especially when the talk is about financial resources. this can be illustrated by the words of the secretary-general to the un general assembly: “older persons suffer discrimination in health care and tend to be overlooked in health policies, programmes and resource allocation” (42). or by the research, where aleksandrova investigating the question of financial resource allocation in her study „should age be a criterion for the allocation of health resources?‟ (43) gives different arguments „for‟ and „against‟ focusing on the usefulness of the elderly. the universal declaration on bioethics and human rights of 2005 is not legally binding either, but has expedient content such as its article 11: „no individual or group should be discriminated against or stigmatized on any grounds, in violation of human dignity, human rights and fundamental freedoms‟ (44). even binding instruments, as the international covenant on economic, social and cultural rights with its article 12 „the states parties to the present covenant (e.g. lithuania) recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health‟ do not change the situation. the crucial point, however, is the lack of successful practice in the european court of human rights (echr) (34). examples of echr cases show that lithuania has no strong outside incentive or rather pressure, different from the period of accession to the eu in 2004. the fear of sanctions/consequences for not complying with the acquis communeautaire was a powerful incentive. but later, in 2005, the protocol 12 to the european convention on human rights – devoted to the extension of prohibition of discrimination – was not signed by lithuania (45). the americas likely will become the first region in the world to have an instrument for the promotion and protection of the rights of older persons (46). if it is ratified, the member states will “adopt and strengthen such legislative, administrative, judicial, budgetary, and other measures as may be necessary to give effect to and raise awareness of the rights recognised in the present convention, including adequate access to justice, in order to ensure differentiated and preferential treatment for older persons in all areas” (47). this is a good example setting standards for a stronger legislation. selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 13 most barriers not only in lithuania seem to be concerned with policy. now it is time to ask about the place of elderly people in public health policy. first, there is an “inner level” question: what person is able to notice the discrimination and the barriers? answer: a person who is trained to notice. our study revealed a big gap between the occurrence of discrimination and fighting that discrimination in the health system. we agree with the statement by bjegovic-mikanovic et al. that: „…public health education needs to include a wider range of health-related professionals including: managers, health promotion specialists, health economists, lawyers and pharmacists. <…> investing in a multidisciplinary public health workforce is a prerequisite for current challenges‟ (48). secondly, there is an “external level” question. when asking how/where can the barriers be removed, we find that in a state, where there are appropriate and enforceable instruments and an older person-friendly scene in which to enforce them. historically, from the ancient times it was a taboo to complain about the doctor‟s work; it appears that it is still a taboo to complain about human rights violations. the state must improve the legal basis and have a strong will to help improve and protect older persons‟ rights in all spheres. thirdly, there is a question dealing with information and leadership. the need for a workforce that is educated in the needs and rights of elderly persons (lawyers, judges, health care providers, politicians, and even the church clerks) is obvious. these professionals need multidisciplinary knowledge in order to think “out of the box”. good practices from other countries for elderly legal consultation can be used, for example elder law clinics (49) and „ehelp‟ as a compilation of useful information (50). the burden of leadership is to make this a reality that belongs to everyone. however, we are aware of the limitations of our research. the narrative literature review was performed in order to show the need to solve the problem of discrimination and because of scarcity of prior research in lithuania. however, a systematic review of good practice abroad might have yielded more specific evidence. also a bigger sample size might have allowed comparing the group of patients with the caregivers. nevertheless even our small study reveals serious violations of elderly patients‟ rights and should arose the attention of politicians, stakeholders and professionals and help to initiate further studies to analyse the quantity and quality of human rights neglect in elderly patient care. conclusions in spite of the obvious limitations of our study, we were able to identify three main barriers that blockade improvements in elderly patient care:  recognition of open and hidden discrimination of elderly patients.  lack of information and fear of consequences experienced by patients and caregivers facing discrimination and considering complaint.  deficient non-binding legislation and court practice. in consequence this study disclosed the need to:  encourage training of health care professionals. the burden of leadership has to be assumed by universities and public health professionals;  encourage training of legists and lawyers in expanding knowledge and skills in human rights in patient care;  incorporate a new article in the „law on the rights of patients and compensation for the damage to their health‟, clearly stating where to complain in case of discrimination;  create a web page and brochures with readable and understandable information for elderly persons and their families and caregivers; selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system of lithuania (original research). seejph 2016, posted: 26 july 2016. doi 10.4119/unibi/seejp-2016-124 14  establish legal consultation and mediation cabinets in health care facilities;  establish an older persons‟ rights protection service under the ministry of social security and labor in close cooperation with the ministry of health;  promote sustainable results by incorporating a human rights-based approach regarding elderly persons in all policies. selli k, czabanowska k, danusevičienė l, butkevičienė r, jurkuvienė r, overall j. discrimination of elderly patients in the health care system 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organised the health council of four german eu presidencies, but also published a large number of articles mainly in international journals and books. after his retirement in 2002, dr. stein continued as a free lance consultant to a number of eu institutions and a lecturer in german, dutch, austrian, and english schools of public health. personally, i probably met hans stein the first time in 1977 when in west germany a discussion started about a “big” population study on cardiovascular health. he worked already for several years in the ministry of health (the name of the ministry at that time may have been more complex and i forgot it) but, different from many political administrators, he was fascinated by contents and not by formalities. he paved the way for the german cardiovascular prevention study (gcp) targeting five regions with together around one million population for more than a decade (1979-1994). hans stein started his long chain of contributions to population health and health policy with a presentation in my then high blood pressure department in heidelberg and i remember how difficult it was to convince him to speak in public about prevention. that changed later completely when he became a european figure representing the german government in the endless and tiring deliberations foregoing the milestone treaty of maastricht. i shall never forget how dr. stein presented a historical dialogue with his former dutch colleague jos draijer at the 25 th anniversary of the treaty at a celebration in the very city of maastricht. hans stein remained an engaged sceptic with an insurmountable enthusiasm, truly a rare mélange, obvious also from his review below of the european health policy development since maastricht. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 2 the maastricht treaty 1992: taking stock of the past and looking at future perspectives hans stein 1 1 free lance consultant, bonn, germany. corresponding author: dr. hans stein address: ministerialrat a.d. bonn, germany email: dr.hans.stein@gmx.de stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 3 abstract aim: the article contains a personal view of the history as well as the future of the european union‟s (eu) health policy. describing and evaluating the developments on the road from the treaty of maastricht to a new europe it asks and tries to answer the question if we – especially the eu member states – really know where we want to go to and how to get there. method: based on personal experiences, countless eu documents, as well as scientific publications the paper shows the impact eu health policy has had in the member states in the past. historical development: considering that the legal basis for health has been and remains to be very weak limiting eu action to support, coordinate, and supplement actions of member states – which, as a rule, still consider health to be first and foremost a national responsibility and therefore do not want interference from international institutions – the amount and content of eu health activities in the past years has been quite remarkable. health policy may not be an eu priority and as a crosscutting policy sector it is dominated by many other eu policies. however, especially the “hard law” regulations and directives of the internal market give eu the power and competence to achieve health objectives. the size of this growing influence is shown by direct interventions, made possible by the legal acts to improve economic policy coordination. health and health care in this context are considered as a key policy area for economic growth and eu macroeconomic policy. on the other hand, there is a risk that such regulations affecting health policy and population health may be dominated too much by economic institutions and their interests, whereas health authorities play only a minor role to date. conclusion: for the future of eu health policy it is essential that its position is considerably strengthened, in order to assure that health interests of the eu population are sufficiently safeguarded. keywords: european union, future perspectives, health policy, maastricht treaty. conflict of interest: none. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 4 introduction as a rule, a 20 th anniversary, especially when it concerns an event considered to be a historical landmark, is a cause for celebration. the treaty of maastricht was finally negotiated in an intergovernmental conference by the member states of the european union (eu) and signed on the 7 th of february 1992 in maastricht, the netherlands (1). it came into force on the 1 st of november 1993 after it had been ratified in all member states by national parliaments, in some cases adopted even by a population referendum. it is not only a cornerstone in the general development of the european union, comparable to the establishment of an economic and monetary union with a common currency, but it also contains for the first time a specific legal basis for health as a european issue. it is worthwhile noting that, this process was dominated by the governments of the member states. commission and european parliament participated on the side lines with very limited power to influence content and process. nevertheless, this event certainly would have deserves to be celebrated. but, surprisingly, except for some small meetings in maastricht, initiated by local institutions, there were no celebrations by the european union in brussels, or in national capitals. this situation should be a cause for concern. is it considered to be so critical that nobody wants to be reminded of how, when and where european integration started? were the experiences during the last 20 years in general, as well as with the implementation of the health mandate specifically that bad and negative? has the european vision got lost or was it just forgotten? has the european dream ended? or, is it that the eu has too big difficulties occupying the minds in adapting itself to the present situation characterized by the economic crisis and globalisation? looking back as a base for future developments it is the purpose of this article not only to describe how the eu health policy has developed in the 20 years since the maastricht treaty was signed, but also to develop concepts for the future. whether and how much it was a success story and what future perspectives are needed and realistic, cannot be judged only by looking at health issues. no eu policy field develops in isolation. especially in health with its horizontal character progress depends to a great deal on the overall eu development, its problems, and how these are solved. the present eu crisis, in many ways related to the economic situation, was not caused by health issues but health problems and even national health policies are affected by the crisis and the measures taken to improve the situation. “health in all policies” (2) is not only a mandate, but also a description of the situation. it will be shown how the newly created instruments to establish a “european economic governance” such as the european semester (3), the stability pact (4) and others not only go far beyond the existing legal base, but will influence national health systems and policies by increasing the commission‟s power to intervene at a national level. lack of interest in the past the existing lack of interest in the historic development of the european integration in general, and especially in the eu health policies may be regretted, but it can be explained by two interrelated developments: lack of positive commitment of eu citizens to european unification, and; eu enlargement implies growing economic gap between member states. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 5 lack of commitment by the citizens the project of european unification faces presently the biggest existential crisis of its history. nobody really knows when and how the crisis can be overcome or, at least, be mitigated. timothy garton ash (5) in an essay “the crisis of europe” describes in great detail how the union came together and why right now it seems to be falling apart. in his view “the project of european unification for about 40 years could rely on at least a passive consensus among most of europe‟s national publics”, today there is a lack of commitment to european integration nearly everywhere. it is obvious that a growing number of citizens in many countries do not believe anymore that the eu can at least contribute to solving their problems. even worse, they consider the eu itself to be the problem. these sceptical and critical views about the eu have existed in many countries for quite a number of years. but, eurobarometer (6) as well as national polls, especially the results of the elections 2014 for the european parliament, show that a growing number of citizens in many countries have lost confidence in the eu. surprisingly, this feeling exists even in germany or the netherlands, two signatory nations of the maastricht treaty, for a long time firm believers in european integration, including even a political union, countries that are not suffering from the present economic crisis. european integration has been rightly described as a project of elites with little even indirect participation of the citizens. they were seldom asked if they agreed to european solutions. and they were certainly never asked, if they wanted european solutions in health matters. had this been the case, a clear “no” would have been the answer, even if they could not have imagined how these solutions would look like. eu enlargement and the economic gap in 1993, only 12 member states negotiated and signed the maastricht treaty. since then, we have had three new treaties – of amsterdam, nice and the still valid one of lisbon (7) – as well as a failed attempt to establish a european constitution. more importantly, the eu has increased tremendously in size. from 1993 to 2014, altogether 16 new states have joined the eu and even more association negotiations are going on and will soon lead to even more member states (ms). at the same time some ms – especially the united kingdom – consider to leave the eu unless their special interests are taken care of. for the new ms, the date of their own accession as well as a solution of their present day problems are more important than a treaty which was signed 20 years ago. the astonishing and unexpected enlargement and expansion of the eu from original six to now 29 and possibly soon 35 member states in a few years is not a question of numbers alone. whereas eu structures and mechanisms, originally designed for only six ms have largely remained unchanged, this enormous growth combined with a financial and economic crisis has created big, yet unsolved problems. on the one hand, there is a growing small vs. big ms situation. whereas eight ms have a population of five million or less (luxemburg, malta, and cyprus being the smallest with only 0.5 million inhabitants), seven ms have a population between 6-10 million, and only 12 have more than 10 million. small size populations lead to small size economies. there are enormous differences in the present economic situation of some, often new ms. in health, this means that not all ms have sufficient financial and personal resources to offer their population all health services that are needed. this has already led to a growing „health gap‟ (8). reducing these health inequalities is essential in that it will contribute to social cohesion, i.e. reducing poverty and social exclusion. it requires a new dimension of eu solidarity including support and assistance. the classical eu instruments of cooperation and coordination are not sufficient any more to cope with the present situation. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 6 weaknesses and shortcomings of eu health policy health – an eu priority? health has never been a priority of european integration and it is highly improbable that it will ever become so in the future. despite a number of positive achievements in the past, health has not become a central objective of eu policy making. contrary to environmental policy or research – to name just two health-related similar policy areas – health has not been named in any of the various eu treaties as an eu objective. in article 3 of the treaty of maastricht, where the purpose of the various eu policy areas has been described, it states about health as follows: “a contribution to the attainment of a high level of health protection”, which is not exactly a very ambitious objective. on the contrary, whenever in the past years a reduction of eu activities and competence has been demanded by ms, health always has been a strong candidate, offered even by the commission. with this background, it is not surprising that the power and influence of the health commissioner and his general directorate has never been high. his responsibilities were always limited, and the financial and personal resources are small, especially when compared with areas like agriculture or research. it is not surprising that big member states in the usual battle to get an influential commissioner have never shown any interest to get this office. in the past twenty, years health commissioners have therefore come from smaller countries like greece, ireland, cyprus, and malta. the same applies to the new commission coming into power in september 2014. the new commissioner for health and food safety, vytenis andriukaitis, comes from lithuania, also a small country. but, differing from all his predecessors, he has experience in eu matters as well as a very convincing health background: he is a surgeon and was lithuanian minister of health and, as such, responsible for an impressive health agenda during the lithuanian eu presidency in 2013. as health remains an independent eu policy area – combined with food safety, for a long time a major eu priority – the expectation can be justified that health might become more powerful in the future. the commission has always been called the „guardian of the treaty‟ (9), from whom it was expected to work for more integration. however, as far as health is concerned, it has shown only little interest in the past to improve the status of health as a european topic. it appears that most if not all successful proposals have come from others; in 1977, for example, a belgian initiative to establish a health council and in 1985 a french proposal in the rome summit to establish „europe against cancer‟ as a european responsibility (both, by the way, many years before health was established formally as a european task in the maastricht treaty). furthermore, in 1995, the initiative of the european parliament to strengthen the eu health mandate and legal competence resulted in the amsterdam treaty 1997; and, finally, the many decisions of the european court of justice, beginning 1998 with the famous “kohll and decker” cases about patient mobility. the last phase started in 2012 with various summit decisions to establish a „european economic governance‟ with new instruments including “health care as an answer to the economic and financial crisis, going far beyond the existing eu legal base” (10). it seems that others discovered much earlier than the commission the health potential of the main eu objective, namely the internal market. health and the internal market it is often overlooked that national health systems, however differently they are organised and financed, are strongly related to and have been integrated into the internal market with its stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 7 four freedoms (11) embracing the free movement of goods (pharmaceuticals and health technology), free services (physicians, nurses), cross-border capital (e.g. investing in rehabilitation clinics), and people, i.e. patients looking for treatment outside their home country. right from the beginning, health systems have been influenced and even regulated to some extent by regulations and directives of the eu market and the competition therein. health care is, and it has always been, a central element of european and national economies. it is a big, possibly the biggest part of the internal market and it is permanently growing. about 8.5% of the national gross domestic product is, on average, spent for health. in germany, this means every year more than 250 billion euro. millions of people – especially doctors and nurses – work in the health care systems. in germany, about 12% of the working population is employed in the health sector (12). many of them, especially in the new ms, make increasingly use of their right of free movement and work in other eu countries. in the receiving countries this contributes to solving the existing shortage problems, whereas at the same time it leads to growing difficulties in their home countries. the main objective of the regulations and directives, the most effective eu tools, is to establish a functional internal market (13).they apply fully to the health systems and influence the development and content of national health policy. in addition, they are a powerful treaty base for influencing and even removing those ms policies such as health that might interfere with the aims of the internal market. scott greer (14) describes the results and consequences of the maastricht treaty in his essay „glass half empty‟: “the euro zone and the internal market overshadow the health effects of maastricht: it is comparatively easy to find the treaty authority for legislation promoting the internal market and eu law and courts are sceptical of public health or other rationales for legislation impeding the markets development”. he names as prominent examples the patient mobility decisions of the european court of justice, which culminated in the directive on patients‟ rights in cross border mobility (15). furthermore, the application of competition and the state law for health care providers, and the integration of pharmaceuticals‟ regulation around the european medicines agency. finally, he summarises his considerations about the effects of the maastricht treaty on health as follows: “the first mention of health was the harbinger of more effective promotion of health issues within eu policy making. in time, however, the internal market and the single currency have had the biggest health consequences”. this was not really what the ms had in mind when in 1992 they established a specific eu public health mandate. position and interests of member states health has always been considered to be first and foremost a national responsibility. states all over the world with hardly any exception want to keep their complete and undiminished integrity and full autonomy to organize and run their health systems the way they want it. health systems, different as they are, often are considered as a part of the national heritage and culture. countries do not want any interference from outside, be it by the eu, or be it by the who, which by the way is more accepted than eu institutions, but not more effective. for many years national governments – in full agreement with their citizens and the medical professions – have jealously and on the whole successfully prevented the transfer of any substantial health policy issues to a supra-national level, except for the indirect effects of the internal market as discussed above. they, therefore, still have a great difficulty in accepting health policy as a matter of the eu concern. it seems that health policy is one of the last realms and retreats of national policy competence which had to be defended. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 8 it seems also that health policy is a political sector which more than others absorbs and reflects national developments, traditions, and cultures. health systems are seen as the result of decades of development and the individual response to a country‟s social situation and profile. the answers given a long time ago by bismarck and later by beveridge regarding health seem to be sacrosanct even if a lot has changed since their time. safeguarding the pluralism of national health systems is considered to be a value by itself which has to be kept safeguarded at all costs against influence from outside even if the problems faced everywhere are quite identical and the solutions are at least similar. it seems to be overlooked that the eu might be a supporting strategic partner to overcome vested stakeholder interests that at the national level would not be possible. these popular but nevertheless antiquated views neglect a number of essential facts important for health. individual ms alone cannot cope sufficiently with outbreaks of infectious diseases like h1n1, food safety issues, biological or chemical terrorism and health threats from climate change. growing new health dangers and threats which „don‟t respect borders‟ is a common saying, presently ebola being an example (16). the development and evaluation of new technologies and pharmaceuticals especially combating rare diseases and the establishment of whole new areas such as e-health and telemedicine expand beyond the national level. therefore, possibly the best argument for the need of an eu health policy is the undisputed fact that health is influenced and determined to a great extent by factors and policies far outside national health care systems namely environment, work, transport, education, research and, most importantly, the economic situation of society and the individual. as all these policy areas are shaped more and more at the eu or even global level in different ways by binding regulations or international treaties. health interests have a chance of success against powerful industrial lobbies only at this international level. the essential instrument for achieving this is “health in all policies”. it is not only named in the article 35 of the eu charter of fundamental rights (17), but it is also the most important part of the eu legal base for health. even if today it is still more a vision and not a reality, there is hope that at the eu level it can become true. commissioner david byrne (18) expressed this as follows: “the future of health is not characterized by national isolation but by international cooperation, governance, and partnership. a more cooperative, integrative and proactive health policy will lead to a more healthy society characterized by enhanced economic output and reduced strain on national health care systems”. to make this hope come true, it not only needs political will, but also sufficient instruments. does the eu have them? can they be developed? the biggest obstacle is the ms‟ attitude as described below. development of health competence from maastricht 1992 to lisbon 2010 article 129, treaty of maastricht, 1992 the eu “public health” competence as laid down for the first time in article 129 of the treaty of maastricht, often but never substantially changed in the subsequent treaties, fully reflects the defensive and negative position of ms. as only a „supportive competence‟ it always was and still is the weakest legal base possible – in great contrast to the other strong categories such as exclusive or shared competences. it gives the eu no power to establish binding legal regulations or directives. its competence is limited to “carry out actions to support, coordinate or supplement the actions of the member states” according to article 6 of the treaty on the functioning of the eu (treaty of lisbon). the “protection and improvement of human health” is on the same unsatisfactory level such as culture or tourism. the establishment of a legal base for eu health policy has never been the object of an overall plan or strategy of any eu institution. right from the beginning, there have been permanent stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 9 conflicts between european activities and differing national positions on the one hand, and economic interests versus health needs on the other. in these conflicts, health interests find only little support. the europeanization of health policy and the implementation of eu health competence were “a dynamic but still rather unplanned process of policy harmonization and policy adaption. it offers an example of effective and inspired muddling through, rather than of a consistent and clear cut european concerted strategy” (19). it is worthwhile to take a look at the evolution of the legal base of the eu public health mandate, especially as today treaty changes are being discussed to reduce eu power in favour of increased national responsibility. before the treaty of maastricht in 1992, there was no specific legal base for public health activities. the first eu action program „europe against cancer‟ 1985 initiated by a summit in rome and, therefore, had to be based on a catch of legal base, in that a commission proposal could be agreed unanimously if the treaties did not provide the necessary power. this legal base still exists today in the article 352 of the lisbon treaty, but it cannot be applied to health any more, as there is a specific legal base for public health, established in the article 129 of the treaty of maastricht in 1992. the main components of article 129 were slightly reworded in the following treaties, but essentially are still valid: community action should encourage and support ms‟ cooperation in order to achieve a high level of health protection, and; community action should be directed towards preventing human illnesses, especially by promoting research into their causes, their transmission, as well as health information and education. the only instrument to achieve this, were supportive activities. consequently the only activities that took place were „action programmes‟ and „recommendations‟. any binding legal measures such as regulations or directives are impossible. health care was not even mentioned and ms, especially the new ones, watched very carefully that eu action did not go an inch beyond these agreements. quite soon, it became obvious that this very limited and weak mandate and its legal base were not sufficient to enable the eu to react appropriately to new challenges or at least to contribute sufficiently to their solution. examples for these new problems, which most ms were unable to cope with alone, included new health threats such as aids, sars or ebola, the economic crisis and its effects on health systems, as well as bio-terrorism, to name just a few. regarding one threat, the bse crisis and the jacob-creutzfeld disease, the commission handling it was paying more attention to the commercial interests of farmers than to health risks for humans, which led the european parliament to demand a strengthening of the public health legal base, which took place in a new strengthened formulation in the article 152 of the treaty of amsterdam (20), which was not only upheld, but even strengthened in all further treaty changes (nice 2003, lisbon 2010). the lisbon treaty 2010 many years later, in 2010, the lisbon treaty was agreed to and ratified. its ratification was relatively easy because it was not a completely new text but just modified the pre-existing treaty of nice. it consists of two parts (treaty of the eu containing common provisions and principals and treaty on the eu functioning) containing the strengthened competences of the commission as proposed in the failed attempt to agree on a european constitution in 2004. despite the permanently ongoing discussion about increasing or decreasing eu competences, the necessary changes of the lisbon treaty seem highly improbable because the needed unanimous agreement and ratification by 28 ms and even more in the future. as the lisbon stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 10 treaty will be the legal base of all eu action for a long time, it is appropriate to look at the changes in the health provisions to see how far future challenges could be met by eu activities. the provisions in the treaty on the functioning of the eu are peculiar, difficult to understand, and even contradictory. whereas article 4 mentions health aspects as an area of shared competence: “common safety concerns in public health matters for the aspects defined in this treaty” [2k], the article 6 also names it as the first area for supportive, coordinative and supplementary competence : (a) “protection and improvement of human health”. health is the only policy area mentioned in two different competence categories. is there a difference between public health and human health? is there a difference between common safety and protection? most likely this is a badly formulated remnant of the foregoing discussion around a constitution, where health as a whole was originally planned to be a „shared competence‟, which many ms did not want. the background for a potential shared competence was the threat of „bio-terrorism‟, which was considered to be a common safety concern to society and not just a health threat. whatever the explanation may be, as the eu-related contents of public health are described in great detail in the title xiv of article 168, it is obvious that with few exceptions public health continues to be only a supportive competence, which aims at encouraging and supporting ms cooperation. in spite of the detailed description in the article 168, this leads to less and not more clarity. in comparison to the lengthy elaboration of one page in article 168, the really important area internal market consists of involves only some lines in article 26. the well-known ms position to keep the eu as far away as possible from influencing their health policy is fully upheld. there is no harmonization of systems in any way. there still is hardly any possibility for binding hard law legislation (exceptions: article 168 no. 4 dealing with quality and safety of organs and blood, veterinary and phytosanitary fields with direct relation to public health, and quality and safety of medicinal products as well as devices). however, there are at least some small improvements. the scope and content of the commission support of cooperation, i.e. financing, is increased by naming concrete possibilities such as establishment of guidelines and indicators – both basic for the establishment of a permanent eu health information system – as well as the organisation of the exchange of best practices, periodic monitoring and evaluation. furthermore, the door for the first time is slightly opened for health care as there are positive words about improving the complementarities of health services in cross-border areas, something that has been happening for a long time in many „euregios‟ without commission participation or support. health in all policies (hiap) the most important change, however, is the new first sentence introducing article 168, also contained in article 35 of the eu charter of fundamental rights: “a high level of human health protection shall be insured in the definition and implementation of all the unions policies and activities”. this very clear statement, which gives the eu an undisputable legal right und political mandate, is quite unique as it is not contained in any national constitution or bill of human rights. it not only means that all other policies have to avoid or at least limit negative health effects, but it also provides a legal base to use all policies directly or at least indirectly for binding and obligatory “health legislation”. it gives the eu the power and the competence to establish „hard law‟, to achieve health aims and targets. the eu fight against tobacco was the biggest eu health policy success story; it was made possible because „hard law‟, based on internal market competences, was used to establish the stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 11 needed binding directives. they were disputed and fought bitterly by the active and powerful tobacco lobby, but despite of all their attempts expressively legally confirmed and even promoted by a number of european court decisions. despite of this encouraging example, health in all policies today is mainly a vision and far away from being an overall reality. it is tremendously difficult to apply and implement it, as other policies which want to achieve their own aims and health impacts, as a rule, are of little concern to them. last but not least, powerful stakeholders – not only industry but also social partners – have foremost economic and not health interests and, at a political level, it is the economy that counts. as an example, the eu strategy to „reduce alcohol-related harm‟ failed to a great extent because of the negative consequences for various other eu policies and regulations (agricultural subsidies, harmonisation of taxation and the removal of trade barriers in the internal market). it is the most prominent example of failure of the hiap principle. despite the undisputable fact that alcohol is a main cause for diseases and health, the economic interests were stronger and prevailed. the eu is worldwide the biggest alcohol producer in a growing and very profitable market which had to be safeguarded. thus, the eu market laws weakened the restrictive alcohol policy in the nordic countries with the result that drinking alcohol already in adolescence became their biggest health problem. to transform the health in all policies principle from vision to reality it is essential to be able to compete with and to influence countervailing economic and industrial powers. this requires adequate organisational structures as well as institutional mechanisms for resolving conflicts and the development and permanent use of support tools such as health impact assessment. above all, it is essential that those who are responsible for health in the commission (health commissioner and health directorate) and in the ms (health ministries and stakeholders) have the political will, as well as the power to do it. all of that is missing nowadays in the eu. achievements and impact of eu health policy after more than 20 years, it is justified to ask two simple questions: i. have eu activities led to better health in the eu? ii. have eu health actions and health-related legal regulations had a noticeable impact in the ms and on the national health policies? both questions may be simple, but are difficult to answer. a short, but honest, answer would be: we just do not know! as, up to now, no overall evaluation (health impact assessment) of eu activities has been made in the eu or in any ms, we can only give some general indications based on eu/who/oecd health information systems and health monitoring, mostly created by eu funding and networks. this enormous increase of knowledge about the health situation and health systems and their development, easily available to everyone, is possible the biggest achievement of eu health policy, to date. we know today more than ever before, but the central question remains: are eu and national policies based on this knowledge? health status european countries have achieved major gains in population health in recent decades. the situation in the eu is better than in most of the other parts of the world. “life expectancy at birth in the eu has increased by more than six years than 1980 to reach 79 years in 2010, while premature mortality has reduced dramatically. over three quarters of these years can be expected to be lived free of activity limitation” (21). on average, across the eu, life expectancy at birth for the three-year period 2008-10 was 75. 3 years for men and 81.7 years stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 12 for women. the report explains this situation by “improved living and working conditions and some health-related behaviours, but better access to care and quality of care also deserves much credit”. the question is, if and how much these factors have been influenced by eu policies. a scientific evaluation in 2003 of the eu “europe against cancer program” (22) comes to the conclusion, that this programme appears to have been associated with the avoidance of 92,573 cancer deaths in the year 2000, or a reduction of about 10% of the eu overall. these exact figures might be questioned, but the phrase „appears to have been associated‟ is applicable also to the positive eu influence on the overall improvement of the health status of eu citizens. there can be little doubt that many eu activities that have been directed at reducing risk factors to health, be it tobacco smoking, alcohol consumption or overweight, have contributed at least to some extent to their reduction. the reduction of tobacco consumption by adults in most eu member states (examples: 15% in sweden and iceland from 30% in 1980, but still over 30% in greece, bulgaria, ireland and others) would not have happened without the eu activities such as public awareness campaigns, advertising bans, and increased taxation. indeed, the reduction of smoking is the biggest eu health success story until now. by influencing mainly non-medical factors, the eu has contributed quite substantially to the present positive health status, whereas „governance of health care‟ factors such as proper access to health care, number of doctors and nurses, health care spending and the like have hardly been effected by the eu. even if the health status within the eu can be considered to have improved overall, there still is the unsolved problem of large and still growing inequalities between different countries. the gap between eu-ms with the highest and lowest life expectancy at birth is around eight years for women and 12 years for men. but, there is also a large gap within countries mainly between socio-economic groups. however, the eu has tried to reduce these gaps, where it was not successful. impact in member states the process of transforming visions into reality, of developing eu health policy and implementing it in the ms had to overcome countless barriers, was not very transparent and still is very slow. it has been described by lamping (19), a german political scientist as “discontinuing, incoherent sometimes fairly accidental and even undemocratic with little logic and rationality , self dynamic, not political but technocratic, determined by interest groups, based mainly on voluntary cooperation with little room for binding legal acts”. on the same lines, hervey and vanhercke (22) describe eu health policy as “a patch work of actors and institutions which decide and implement law, policy, and governance”. they name five different domains as components of eu health policy that ms have to improve: public health, research (both are soft law areas with no binding obligations to ms), internal market, competition, and social laws. there is no overall leadership and more competition than cooperation. whereas national health policy as a rule is the domain of one political administration (the health ministry), supported by health experts, the eu health patch work consists of institutional structures and procedures that often were developed for domains that have no health interest at all. as a consequence, eu health is not only not an eu priority but also a highly contested area with a permanent conflict between health and economic interests. also, there is only little transparency. eu health policy is mainly a field for experts with little citizens‟ participation. scott greer (15) called it a „secret garden‟ which should be turned into a „public park‟. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 13 considering the weak legal base, the lack of political commitment and interest of the ms but also within the commission, and the limited financial and personal resources available, the amount of health and health-related activities that have been developed and undertaken by this „patch work‟ is quite astonishing. starting with its first programme “europe against cancer” in 1985, a countless number of soft law activities (strategies, recommendations, programmes, projects, studies, networks, frameworks, concerted actions, establishment of agencies, platforms, and committees etc.) have taken place. the amount of binding legislations (hard law) is of course much smaller, the most important being those on tobacco issues including advertising, blood safety, pharmaceuticals, medical devices, professional qualifications, food safety and – the first small step into health care – the “patient‟s rights” directive on cross-border health care. the latter was enforced by a number of decisions of the european court of justice. there is hardly any health problem or major disease that has not been the object of eu activities. the most comprehensive overview is contained in a “welcome package public health”, prepared in 2009 by the policy department “economic and scientific policy” (23) of the european parliament, to serve as a reference tool for incoming members of the european parliament. a similar document seemingly was not produced for the new european parliament 2014. in more than 120 pages, this document, available on the internet, names and describes all past, ongoing and planned eu activities. the integration of health into other policies, however, is described on just one page and these other policies are not even named. furthermore, the document says nothing about the impact on the ms. this is to some degree understandable because there is hardly any knowledge about the actual impact of eu healthrelated activities on the ms. there is no overall evaluation, no general health impact assessment. of course the many different activities, strategies, programs, and projects, as a rule are evaluated, but these evaluations say nothing about their impact. health impact assessments of health in all policies are conducted in a small number when new policies and regulations are being prepared, not when they have been implemented. there is hope for at least a partial improvement in the future. the “patient mobility directive 2011” not only had to be implemented by the ms until the end of 2013; they also have to report to the commission about what they have done. these reports have to include detailed information about patient movements and the cooperation between ms in border regions, european reference networks, rare diseases, e-health, and health-technology assessment. as of 2015 the commission has to give an overall report to the council and the european parliament, we will then know a little more about national impact, at least in some areas. today, we still know only little, actually too little, about the impact of eu health policy. only a few documents contain information about success or failure: i. the most negative report is an evaluation conducted by the european court of auditors in 2009 of the 3 rd eu public health programme 2007-2013 (24). this report considered it a waste of money, because it contained no strategy, was badly implemented, the projects funded had little policy connection, and there was no follow up. the commission accepted this harsh criticism and promised positive changes in its future programmes, especially in the following next 4 th programme. also, from author‟s experience as a project evaluator it seems justified to say that since 1978 the many hundreds, even thousands of projects funded in the various public health as well as research programmes very rarely had relations to political activities, be it in the eu, be it in the individual ms. although it was the expressive aim of all these programmes that the funded projects should contribute to the improvement of health of the european citizens, it was never really evaluated if and how they achieved this. many of the projects improved knowledge, but only a few led to political action. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 14 ii. surprisingly the most positive document is the “review of the balance of competences between the united kingdom and the european union in health”, published 2013 by the uk government (25). it is part of a comprehensive examination of the balance of competences between the uk and the eu to analyse what uk membership means to national interest. these documents were prepared for all eu policies to serve as a base for negotiations with the eu about a reduction of eu competences, which – if not successful – might even lead to the uk to leave the eu. this health review is quite remarkable for a number of reasons. it is the only document prepared by any ms government describing and evaluating the national impact of eu health activities. it not only contains the view of the uk government, but also – this is really unique – the views of uk citizens, industry and stakeholders, who were asked to give their opinion. altogether, it was recognized that with very few exceptions the eu in health matters had a positive impact especially in public health (tobacco use, tackling obesity, alcohol abuse), as well as health security (where even more efforts were welcomed), sharing of information and data, as well as research funding. benefits were also seen in internal market health care measures including the free movement of patients and of health professionals, to reduce shortages. only in a few areas adverse consequences of cross sector eu legislation were noted: the directives on clinical trials, data protection, and working time. the current balance of competences between eu and uk were considered appropriate, but should not be extended further. considering these positive views in a country where generally the eu is looked at in a negative and critical way, it may be good to have similar surveys in other countries. iii. a midterm evaluation about the implementation and impact of the eu health strategy 2008-2013 (26) contains some key conclusions that could be applied to the eu health policy as a whole. it acknowledges that there is a high level of activities at eu and member state level, but it is uncertain if the outputs at ms level can be attributed directly or exclusively to the eu health strategy. thematic or structural similarities between eu and ms activities were identified but considered to be a reflection of similar priorities, a discernable direct of eu measures was not found, its influence an national strategies was considered limited. the main value of the eu health strategy was described as follows: “it acts as a guiding framework and to some extent as a catalyst for action”. these findings coincide with the results of a conference on “european public health, 20 years of maastricht treaty“, 2013 in maastricht (27). it names a number of positive developments as the result of eu health policies: building of a public health infrastructure (agencies & permanent networks); establishment of the eu as a reference point for policy makers/professionals, i.e. the establishment of a change agent for innovation; demand for capacity building initiating a boom of new education; development of european-oriented knowledge and skills. it seems that the highly fragmented eu health policy as it is gradually taking shape has up to now only limited, indirect, and even unintended affects often on national health systems and policies. it has, however, contributed considerably to the development of public health, an area which in many ms is underdeveloped and needs this support. health and the eu crisis stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 15 the present eu crisis was not caused by health, but it influences eu health policy and the national health systems. the crisis started as a financial and economic one, but it has led to a general eu crisis. it still is uncertain, when and how it will be solved, but very likely the measures taken to control it will change eu objectives, structures, competences and instruments. the future eu will be quite different to the one existing in 2014. as early as in april 2012, the former eu health commissioner john dalli, who later was forced to retire under still not clarified circumstances, said at a cocir conference in brussels (28): “a key challenge we are facing today is to prevent the economic crisis from triggering a health crisis. this may sound dramatic but the risk of this should not be underestimated”. largely unnoticed by the media, the public opinion, and by the public health community as well, a health crisis soon became a reality in many eu-ms, especially in those which because of their critical economic situation received financial aid through the “economic adjustment programmes”. examples of impact and extent of the health crisis are shown by the following figures in the “briefing notes” of the european public health alliance (29): rise in unemployment in the eu-28 from 7.2% in 2007 to 9.7% in 2010 and 11.0% in 2013 (greece 27.5%, spain 26.2%, and croatia 17.6%), especially the deterioration of youth employment which in 19 of the 28 ms stood at over 20% in 2013. mental health and suicides rates, which until 2007 had been consistently decreasing rose in the eu from 11.4 % in 2007 to 11.8% in 2012, alarming in some ms such as greece, spain, ireland and italy. cutting health budgets as well as other resources and frequent measures to reduce costs in nearly all ms have reduced the availability of frontline services and institutions. austerity measures concerning health professionals such as reducing salaries (pay cuts between 10-40%) have led to a growing migration which endangered health services in some countries. all these measures concerning the organisation and delivery of health services belong fully to the responsibility of ms, which the european commission has to respect. although the treaty and therefore the limited eu health competence – excluding most aspects of health care – remain unchanged, the balance of power between the eu and ms in health care is changing in favour of the eu as a number of new instruments were created since 2011. they are intended to strengthen the eu governance of economic policy but have of course an impact also in the health sector. the new instruments should enable the commission to intervene directly in national health care policies from a financial perspective and force national health systems to contribute to the achievement of the economic eu goals. these interventions concern not only “crisis states” receiving financial aid from eu, the international monetary fund, and the european central bank, but all ms in the context of a common macroeconomic policy. direct interventions by international into national health systems are not within the eu competences. in the past, this kind of interventions has been restricted to developing countries receiving financial aid. however, those countries receiving financial aid from the eu “economic adjustment programmes” are in a quite similar situation. they have been obliged to undertake a wide range of austerity health actions demanded by the so-called troika. these austerity measures are not always fully in line with widely accepted health values such as full access for everyone and good quality of medical services. there are, on the other hand, also eu initiatives that address health care reforms in all ms in the context of a common economic policy. these direct interventions are slowly turning into a systematic eu surveillance, backed by the power to issue early warnings and to apply even sanctions. the most important new legal act that makes this possible is the so-called fiscal stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 16 pact (“treaty on stability, coordination and governance in the economic and monetary union”), agreed by only 25 eu-ms as an intergovernmental agreement which does not replace the eu treaty, but is nevertheless enforced by the commission. the most important tool to improve policy coordination of macro-economic structural issues in key policy areas is the “european semester for economic policy coordination” that was launched in 2011. at that time, health was not considered to be a key policy area that had to be included. but, this changed in the same year when the ecofin council demanded the commission to include health. since 2012, health care is included and considered to be a key policy area for economic growth and a permanent part of its five components. since then, it is described in the annual growth survey (ags), presented every year by the commission, a part of strategic advice & orientations, contained in the “national reform & stability convergence programmes of the member states”, and the object of country specific recommendations given by the commission and the ecofin council (30-33). although the eu health competence as laid down in the treaty is and will remain weak and limited mainly to public health, denying any eu actions in health care and health systems, it is firmly established as a key policy area of eu macroeconomic policy. all decisions are dominated and made by economic actors and structures in all of the european institutions with mainly economic interests in mind. those responsible for health play a minor role in the decision making process. future perspectives an article about the past developments in the eu would not be complete without taking a look at future options and perspectives. there is a large number of publications describing and criticising eu health policy, but there are hardly any books or scenarios about its possible future. scenarios of the future are manifold. as far as health is concerned, three factors have to be taken into account: i. the future eu ii. new challenges and new solutions iii. the role of health in a future eu the future eu the eu is here to stay. there will be changes. the number of its members will continue to grow – there seems to be almost no limit. industrial ties and economic interests will guarantee its pertaining future existence. some countries may leave the eu, the main candidate at the moment being the united kingdom. this for many reasons would have negative effects on both sides, especially in public health, as the english public health community appears to be the strongest one. growth, however, will also continue to increase problems in two ways. on the on hand, the differences between ms such as size, population, economic situation, resources and the like, will lead to more inequality, for many aspects including health. on the other hand, the eu will have to cope with its growth with structures and instruments that were designed for a small community of six countries, all of which similar regarding their economic situation. in order to adapt the eu to be able to better master new challenges and tasks, it is essential to change not only its objectives and priorities but also its competences, structures and instruments, including a new balance of power between the three institutions the council, the commission, and the european parliament. this normally could only be done by a fundamental change of the lisbon treaty, however, that is almost impossible, not only right now, but also in a foreseeable future. it needs unanimity by all ms and ratification – partly by a national referendum – again by all ms. because of this, the debate about a new treaty, stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 17 including the establishment of a political union, has stopped. we will have to live with the treaty of lisbon for a long time. the answer possible at the moment – and for some time – can only be a europe of two speeds, in no way a new development. we already have an eu of at least two speeds in areas in which not all ms could agree on a common way forward. the schengen agreement on border regulations and the creation of a monetary union, establishing the new currency euro in most but not all countries, are the most prominent examples. lately, and more relevant for the health, is the creation of the fiscal union (treaty on stability, coordination and governance) agreed up to 2012 by only 25 ms as an intergovernmental agreement, part of a new economic governance framework. in the future, supranational and intergovernmental agreements of this kind outside the eu “acquis communautaire” and its legal base will partly replace the existing eu instruments and influence national policies more than ever before in many areas including health. the impact of this new situation on national welfare, social as well as health systems, has not been considered sufficiently yet. to date, eu and national health authorities play only a minor role in this process dominated by economic interests. there is a danger that health values and interests could be neglected, especially when they clash directly with economic interests. for the future of health it is essential, even vital, to ensure that those responsible and accountable for health policy at the eu as well as national level take part in this process with sufficient power to safeguard health interests. new challenges and new solutions presently, eu health policy is faced with two main, totally different challenges: the overall eu crisis mainly caused by economic and financial problems; the outbreak of ebola, one of the biggest health threats ever. in both cases, the eu has done too little and too late. especially in the case of ebola, the eu was badly prepared and, so far, is largely invisible (16). even the new european centre for disease control, founded in 2005, was much too weak to create a common anti-ebola policy of the european institutions and the ms. as difficult as it may be to master these problems, they are at the same time an opportunity to move forward. the development of the eu health policy has often been crisis driven. there is justified hope that the new situation will lead to new solutions, only possible in a time of crisis. in the past, the progress of eu health policy was triggered by new challenges and dangers which could not be tackled sufficiently on the grounds of the existing legal base, structures and instruments. communicable disease outbreaks (aids and hiv-blood contamination, cjd, sars, and especially bse posed severe threats to health, similar to bio-terrorism) are prominent examples enabling progress that otherwise would not had taken place: ° treaty changes strengthening the eu legal base for public health; ° the eu health strategy with strategic objectives and principles; ° new organisational structures within the eu; ° shift of competences (food, pharmaceuticals) to health institutions; ° intensification & institutionalisation of new cooperation capacities; ° creation of comprehensive databases & information systems; ° establishment of agencies in health-related areas (altogether nine); ° the new instrument of “open method of coordination (omc)”, applied to health; ° closer cooperation of the eu with who and oecd. most importantly, they brought about changes in the attitude of ms. these were influenced to some extent by the needs and expectations of new ms which considered it essential to add stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 18 health care and finance issues to the eu health agenda. ms still consider health to be, first and foremost, national responsibility but there is a slowly growing feeling “…that health policy should no longer be discussed exclusively in terms of national autonomy and sovereignty” (19). eu power and influence related to “all other policies” has already changed the environment in which national health policy takes place. as there is also a feeling that many problems, be it in health care or fighting new health threats cannot be solved effectively at the national level, it is increasingly recognized that the eu health policy is not simply a continuation of national health policies, but it is in many ways different. the legal basis a new and more precise formulation of the eu health competence (article 168) is needed, but obviously not possible as it would require a change of the treaty. however, a new consensus could and should be achieved as to how the article 168 should be interpreted and implemented. the eu should not continue to be active in every possible health arena, many of which are already sufficiently covered by national health policies. it should concentrate and limit itself to those issues, where ms need eu support, because the objectives of the action cannot be sufficiently achieved by the ms. this is not new, but simply the subsidiarity principle as laid down in the article 5 of the treaty, which in the past has been neglected too often. if this is done, there is no need to continue the permanent debate about giving eu health competences back to the ms. a renationalisation desired by many would take place automatically. internal structural reforms to be better prepared for facing future challenges, structural reforms are essential, which include but go far beyond „complementing national policies‟ and „encouraging cooperation between ms‟, without intending a harmonisation of national health systems. these should include: i. the internal reorganisation of the commission which should increase and not decrease the areas for which the health commissioner is responsible, including all those with a priority health interest. ii. increasing, stabilizing, and institutionalising the eu problem-solving capacities by establishing new health agencies (examples: health technology assessment, rare diseases, e-health, or health information systems), strengthening the administrative power of the existing ones, and creating new observatories and permanent networks in order to improve the diffusion of best practices. iii. advance, even institutionalise, a closer cooperation with who and oecd making use of their reputation, knowledge, experiences, manpower, worldwide resources and avoid double work. in the long run, this should result in a common institutionalised global health policy with many partners. the role of health in a future european union again, eu health policy is here to stay. it is no longer questioned any more that public health should remain to be an eu policy of its own. nobody is demanding any more a total renationalisation. nevertheless, the eu public health policy as such is far away from being or becoming a european priority. it is, at best, only a side issue on the european stage with little power and low resources. but, this is not even half of the story. health as an issue, not as a policy, has been transformed during the past years from a non-topic to one of the most important eu fields. in the main stream of eu politics, i.e. policy coordination on macro-economic issues, health has become stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 19 and will remain a key policy area. this elevation is fully justified considering its economic implications and its position in the four freedoms of the internal market. nevertheless, the eu health policy is and will remain a patch work consisting of many different parts and partners. it is a complex cross-cutting policy sector and is part of and regulated in a multitude of other policy sectors like environment, consumer protection, industry, research, transport, agriculture, competition, information and – most importantly – the eu internal market policy. health policy and especially health care are an intrinsic and relevant part of the european market of goods and services, which are affected and partly even harmonized via simple market compatibility. the decisions are taken issue-specific, fragmented, not very transparent, and mostly guided by economic interests. the eu is foremost an economic union and partly even a political one, but not a social union. health, contrary to social progress or environment, is not mentioned as an eu objective in the lisbon treaty. health, as a key policy area, is only of interest as long as it is part of another policy and has positive or negative economic implications. health authorities within the eu-commission, the european parliament, and the council of ms, at best, play only a minor role in the economy dominated decision making process. it is obvious that health values and interests could easily be neglected, especially when there is a clash with economic interests. it is essential and vital for the role of health in a future eu to ensure that those accountable and responsible for health at the eu and national levels take an active part in this decision making process with sufficient power to safeguard health interests. in the past, this was partly achieved by shifting more competences within the commission from agriculture (food), or the internal market (free movement of patients and professionals, pharmaceuticals) to the health directorate. this was much more than just an internal organisational act by the commission because it had consequences for the decision-making process in other eu institutions. whatever belonged to the tasks of the health directorate was automatically decided by the health council and the health committee of the european parliament. conclusion eu health policy as a whole has not been an unequivocal success story: there are weaknesses but also strengths. its main strength is that it has become a permanent part of the european integration process. hardly anyone is demanding its renationalisation anymore. considering its weak legal base, the restrictive position of the ms, and the activities of recognised international organisations such as who or oecd, it is astonishing to observe what has been achieved. a „non-topic‟ has developed into a key policy area of the eu economic policy. this is not due to a sudden discovery of the value of public health – the esteem for eu action in this area is still low – but relies entirely on its economic consequences. however, there is also the danger and even to some degree a tendency that the eu health policy might be reduced to narrow public health issues alone. therefore, public health activities should not only be continued but, in due time, considerably broadened and strengthened. in the future, the main task will be to safeguard health interests in „all areas‟ including economy, to ensure that economic interests do not precede health. this task should not be left to non-governmental groups, as valuable as their contributions will continue to be, but should be the task of health authorities within the commission and in the ms. to be successful, this requires political power as well as adequate organisational structures, giving health authorities more power instead of taking it away from them. in addition, it needs scientific evidence that could be provided by the eu-funded public health actions and research. if this happens, there is no reason to have doubts about a positive future of the eu health policy. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives (review article). seejph 2014, posted: 23 december 2014. doi 10.12908/seejph-2014-36 20 references 1. european community. treaty on european union. luxembourg: office for official publications of the european community, 1992. 2. ministry of social affairs and health. health in all policies prospects and potentials. helsinki, finland: ministry of social affairs and health, 2006. 3. european parliament. an assessment of the european semester, study 2012. european parliament, 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the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 1 original research dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem maha nubani-husseini 1,2 , elliot berry 1 , ziad abdeen 3 , milka donchin 1 1 braun school of public health, hadassah & the hebrew university-hadassah medical school, jerusalem, israel; 2 faculty of public health, al-quds university, palestine; 3 nutrition and health research institute, faculty of medicine, al-quds university, jerusalem, palestine. corresponding author: maha nubani-husseini maha, braun school of public health, hebrew university-hadassah medical school; address: p.o.box 19746, east jerusalem, israel; telephone: +972522520104; email: maha.husseini@mail.huji.ac.il. nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 2 abstract aim: this study aims to assess the palestinian girls’ dietary habits and physical activity patterns as a baseline for intervention. methods: a cross-sectional study of grade 4 and 5 pupils (mean age: 11 years) in 14 all-girl schools in east jerusalem, of four different types of school ownership (overall n=897), was conducted, using self-administered questionnaires and height and weight measurements. logistic regressions were conducted to determine predictors of healthy behaviours. results: only 36.6% of the pupils reported eating breakfast daily, with unrwa schools having the highest rate of daily breakfast consumption (42.6%). about 28% reported eating the recommended daily quantity of five portions of fruits and vegetables. only 15% of the pupils reported being active at least five days a week and more than one third of the schoolchildren viewed tv for ≥4 hours a day. the prevalence of overweight and obesity was 22.2% and 7.6%, respectively, with private schools having the highest rates, 29.6% and 12.8% respectively (p=0.001). additional predictors of overweight and obesity were: being the first child in the family, watching tv for more than four hours a day, always eating while watching tv and being physically active less than five days a week. conclusions: most palestinian pupils miss breakfast, eat less fruits and vegetables than recommended and have sedentary behaviours. these findings raise serious concerns and point to the urgent need for tailored interventions. keywords: dietary and physical activity behaviour, obesity, palestinian female schoolchildren. conflicts of interest: none. source of funding: this study is a part of ph.d. degree. maha nubani-husseini received a scholarship from joint distribution committee (jdc). she thanks nutrition and health research institute al-quds university for funding part of the research. the linda joy pollin cardiovascular wellness center for women at the division of cardiology of hadassah university medical center, directed by dr. donna zfat funded the mothers’ activities and lectures towards the end of the intervention, as well as the implementation of the programme at the control schools one year after the study ended, as they were promised when they got selected. acknowledgments: the authors thank the participating schools, the palestinian ministry of education, the unrwa office of education and jerusalem municipality for facilitating fieldwork. their gratitude also goes to mr. radwan qasrawi (al-quds university), dr. marrio baras and dr. deena jaffeh (hebrew university) for statistical support, and to mrs. suzy daher for editing. nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 3 introduction healthy nutrition and physical activity are the key factors in preventing and reducing obesity in children (1). additionally, adapting such a healthy lifestyle throughout one’s life span is essential for optimal physical growth and intellectual development (1). obesity is known to be a significant risk factor for chronic diseases including type ii diabetes mellitus, cardiovascular disease and certain types of cancer (2,3), and imposes a substantial economic burden (4). the obesity trend is especially alarming considering the increasing prevalence in children and adolescents. the need for effective preventive measures to control obesity has therefore become a major public health issue. in palestine, rapid urbanization, modernization and sedentary lifestyle have contributed to the increasing prevalence of overweight and obesity in all age groups (5). however, there are few local studies focusing on eating habits and physical activity patterns. one study was part of the health behaviour school children survey (hbsc) conducted in 2004 in the west bank and gaza strip. this survey acknowledged problems such as skipping breakfast particularly among girls, low consumption of vegetables and fruits and low intake of milk (6). such data is lacking for female schoolchildren from east jerusalem. the current study is done to fill this gap and is part of a baseline study of a school-based intervention programme in east jerusalem to promote healthy eating and physical activity among schoolchildren, their mothers and teachers. the purpose of this paper is to describe nutritional and physical activity habits and their socio-demographic determinants among palestinian girls in east jerusalem schools of different types of ownerships. methods study design and population a cross-sectional study was performed in april-june 2011 to provide the baseline data in a randomized controlled programme trial, before allocating schools into intervention and control groups. the primary target population was girls in grades 4 and 5, as those elementary schoolchildren are old enough to be able to answer the questions, however, they are not yet close to puberty when hormonal changes could have altered the results. all schoolgirls from the different types of ownership in east jerusalem were eligible for the study. this included 31 jerusalem municipality (jm) schools with 2,759 students, 23 palestinian authority (pa) schools with 2167 students, 40 private schools with 820 students and eight united nation relief and works agency (unrwa) schools with 1218 students. average number of students per class is 34, with different numbers according to school type of ownership. sampling was done in two stages: i) stratified sampling of schools according to their ownership; ii) a random selection of classes (by lottery). all students in the selected classes were included. sample size calculation was based on the estimated prevalence of healthy behaviours relating to physical activity (>5 days per week), which was estimated at 25% among girls in grade 6 in the hbsc study (6). assuming that this behaviour will increase among the intervention schools to 40%, and will remain at 25% in the control group, with a significance level of 5%, a power of 90%, intra-class correlation of 0.001 and a cluster size of 34, a sample of 14 schools was needed in order to provide 13% of the eligible population (952/6962). a random sample of schools was drawn in each of the four strata. this corresponded to six schools from the jerusalem municipality, four pa, two private and two unrwa schools, with 28 classes nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 4 and 935 students. data collection a structured self-administered anonymous questionnaire was given to the pupils based on the hbsc questionnaire (6),which in turn was based on the who format (7). it focused on dietary assessment (eating breakfast, drinking before leaving for school, consumption of fruit and vegetables, milk consumption), physical activity (mode of transport to and from school, days per week active in sport for at least one hour per day), physical inactivity (watching tv) and knowledge (recommended daily consumption of fruits and vegetables). the class teacher supervised filling the questionnaire by reading out aloud each question and then asking for an immediate response. the main researcher (mh) was present during administration of the questionnaires to clarify questions if required. respondents were informed that answering was voluntary and that information would be treated confidentially. the height and weight of each student were measured after they completed the questionnaire, students’ weights were measured in their lightweight clothes (schools’ uniform with no jackets) and without shoes before 10 o’clock break according to a standard protocol and instrument. care was taken to ensure that the measurements were done sensitively and separately in a private room with the presence of the class teacher’s supervisor. mothers’ level of education and occupation was based on the mothers’ self reported questionnaire and school files of the children for missing data. measures eating breakfast was assessed based on the question “do you always eat breakfast before you leave for school?” with response options (1) yes, every day, (2) yes, sometimes, (3) never. whereas drinking in the morning: (1) yes, always, (2) yes, sometimes, (3) never. next, both questions were categorized into yes (yes, every day) or no (sometimes or never). daily consumption and quantity of fruits and vegetables were calculated and converted to two categories <5 serving per day ≥5 servings per day. physical activity assessment was categorized into: (1) physical activity >5 days a week; (2) ≤5 days a week. bmi-for-age was computed for each child using the who software anthroplus 2007 program. this program deduced z-score and percentiles using the exact age in days (8). overweight was determined if a child’s z-score fell between ≤ + 1sd and +2 sd (85 th percentile). obesity was determined if the child’s z-score fell above and equal 2 sd (97 th percentile), while underweight was determined if z-score fell below minus 2 sd (3 rd percentile). mothers’ education was divided into three categories; (1) less than secondary, (2) secondary, (3) diploma and higher. employment was divided into two categories; (1) yes, (2) no. crowding index (the ratio between number of residents at home and number of rooms) was used as a proxy for socioeconomic status and divided into (1) less than one; (2) 1-2, (3) more than 2. statistical analysis data analysis was performed using spss version 20. chi-square tests were used to calculate associations between categorical variables by school ownership, grade, sociodemographic/economic variables. a stepwise forward logistic regression model was built for identifying independent predictors of eating breakfast daily, eating the recommended quantity of fruits and vegetables, physical activity and overweight and obesity. the variables in the final model of the stepwise forward logistic regression were tested again by entering them into the logistic regression models. ethical considerations nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 5 approval from the israeli ministry of education, palestinian ministry of education, unrwa office of education department and private school principals was obtained. the research program was approved by the hebrew university of jerusalem/authority for research students committee. results sample characteristics all 14 selected schools agreed to participate in the study. of the 935 eligible schoolchildren, 897 (95.9%) participated (49.9% children were from grade 4 and 50.1% were from grade 5). non-response was due to absence from school on the day of data collection. table 1 presents the socio-demographic characteristics of the study population by school ownership. table 1. socio-demographic characteristics of the study population by school ownership variable school type municipality (n=400) pa (n=236) unrwa (n=136) private (n=125) total (n=897) grade (%): 4 th grade 5 th grade 49.8 50.3 50.0 50.0 49.3 50.7 51.2 48.8 49.9 50.1 age: mean sd 11.02 0.70 11.00 0.78 11.10 0.87 10.98 0.71 11.02 0.71 order in the family (%): 1 2-3 4 ≥5 19.2 39.0 15.6 24.8 19.1 30.9 16.1 33.9 16.9 37.5 15.4 30.1 29.6 51.2 9.6 9.6 20.6 38.4 15.2 25.9 sibling (%): 0-2 3-4 ≥5 14.5 44.8 40.8 6.8 42.4 50.4 5.9 38.2 55.9 43.2 46.4 10.4 15.2 43.4 41.4 crowding index (%): <1 1-2 >2 9.0 54.5 36.5 6.4 66.1 27.1 8.1 51.5 40.4 17.6 62.4 20.0 9.4 58.3 32.3 religion (%): muslim christian 100.0 0.0 100.0 0.0 100.0 0.0 59.2 40.8 94.3 5.7 mother education (%): less than secondary secondary diploma & higher 45.6 40.0 14.4 49.0 34.3 16.7 52.7 36.4 10.9 7.1 38.1 54.9 42.2 37.7 20.1 mother employment (%): yes no 16.6 83.4 15.9 84.1 14.5 85.0 33.9 66.1 18.5 81.5 the age of students ranged between 9-14 years (mean: 11.02, sd±0.71). about 94% were muslims and 6% were christians, all attending private schools. the mean family size was nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 6 7.1; schoolchildren from municipality, p.a and unrwa had more siblings compared to those in private schools. schoolchildren from municipality and unrwa schools lived in higher crowding index (residents per room) compared to pa and private schools. about 81% of the mothers did not work and 20% had a diploma or higher education. dietary habits the percent of schoolchildren who reported having breakfast was 36.6%. there was a significant difference between school ownership with unrwa schools having the highest rate of daily breakfast consumption (42.6%), compared to municipality, pa and private (p=0.032) (table 2). more muslim schoolchildren (29.7%) consumed breakfast compared to christian schoolchildren (25.5%) in private schools. table 2. dietary pattern, physical activity, knowledge perception, overweight and obesity (%) by school type and crowding index behavioural characteristics school ownership crowding index jm n=400 pa n=236 unrwa n=136 private n=125 <1 (n=84) 1-2 (n=522) >2 (n=290) dietary pattern always eating breakfast 38.3 34.7 42.6 28.0 * 56.0 33.3 33.6 † always drinking in the morning 46.0 42.0 51.5 47.0 52.2 48.8 45.2 always eating vegetable at 10 o’clock break 18.3 8.5 22.8 16.0 ‡ 23.8 15.7 14.5 always eating fruits at 10 o’clock break 18.3 11.4 20.6 16.1 16.7 15.9 17.6 eating ≥5 serving of vegetables and fruits/day 35.8 22.1 14.0 27.2 ‡ 29.8 27.2 27.2 eating vegetables once or more per day 21.3 27.5 13.2 23.2 * 26.2 21.5 21.4 eating fruits once or more per day 23.3 19.6 16.9 23.2 29.8 22.2 17.0 * when thirsty water is the most used drink 69.5 90.3 79.0 68.0 ‡ 78.6 74.7 78.3 drinking milk every day 43.3 40.7 27.2 52.0 ‡ 59.5 41.8 35.5 ‡ lunch is the main meal at home 74.2 77.5 61.0 77.6 * 76.2 73.9 72.3 * eating with family or at least one parents 79.5 77.0 77.2 72.8 77.4 78.1 76.6 eating while watching tv 27.0 21.7 20.6 32.0 ‡ 28.6 24.9 25.3 eating while using computer 5.3 1.70 8.1 4.80 † 3.6 4.6 5.2 eating when bored/angry/stressed/frustrated 6.5 4.2 4.4 1.6 † 4.8 5.2 4.5 physical activity pattern walking to school in the morning 65.3 71.6 93.4 39.2 ‡ 57.1 64.4 76.2 ‡ walking back after school 73.3 76.3 97.1 40.0 ‡ 61.9 70.3 80.7 † physically active ≥5 days a week 16.8 13.6 8.1 16.0 20.2 16.5 9.30 sedentary behaviours using computer >4 hours 20.0 14.0 7.4 17.6 † 22.6 14.9 16.2 tv viewing ≥4 33.0 36.0 38.2 38.0 ‡ 33.3 33.5 34.5 knowledge acknowledge importance of breakfast 91.7 94.5 94.0 94.4 94.0 93.7 92.0 acknowledge importance of fruits & vegetables 97.7 97.0 95.6 100.0 96.4 98.1 96.9 acknowledge importance of water 98.0 95.8 100.0 99.2 * 97.6 98.1 97.9 know recommended serving vegetables/fruits 12.5 12.0 10.3 14.4 25.0 21.3 23.5 bmi overweight 24.8 14.4 21.3 29.6 29.8 19.3 25.2 obese 7.5 3.4 10.3 12.8‡ 7.1 8.4 6.2 * p<0.05; † p<0.01; ‡ p<0.001. eating breakfast daily was associated with the socio-economic status of the family, measured by crowding index. those living in a house with fewer than one person per room had a 2.4nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 7 fold increase in the likelihood of eating breakfast (or=2.38, 95%ci=1.36-4.18), controlling for school type (logistic regression, table 3). unrwa schoolchildren were more likely to eat breakfast (or=1.75, 95%ci=1.07-2.88) compared to other school types of ownership. if mothers always prepared breakfast for their daughters, there was a 4-fold increase in the likelihood of the child eating breakfast (or=3.83, 95%ci=0.82-17.96), although this finding was not statistically significant. these three determinants contributed independently to having breakfast daily (logistic regression, table 3). the mother’s level of education and employment status, beliefs, and knowledge regarding the importance of breakfast meals and birth order were found to have no effect on eating daily breakfast. “not feeling hungry” was the main reason for skipping breakfast (78.6%). table 3. determinants of eating breakfast – logistic regression models * variable number or p-value 95%ci crowding index: <1 1-2 >2 73 432 230 2.38 0.75 1.00 <0.001 (2) † 0.003 0.099 1.36-4.18 0.53-1.06 reference school ownership: jm pa unrwa private 341 193 86 115 1.00 0.91 1.75 0.55 0.004 (3) 0.640 0.030 0.018 0.62-1.34 1.07-2.88 0.34-0.90 reference mother preparing breakfast to her daughter: never sometimes always 13 235 487 1.00 1.41 3.83 <0.001 (2) 0.67 0.089 reference 0.29-6.76 0.82-17.96 * the last variables left of the stepwise forward logistic regression were entered into the logistic regression model. † overall p-value and degrees of freedom (in parentheses). the most commonly consumed food for breakfast was za’ater and oil with bread. this choice varied widely between school ownership type (p<0.001), where unrwa schoolchildren consumed the most (61.6%). other relevant variables were muslim religion (p<0.001) and mothers who had not attained secondary education (p<0.001). the proportion of schoolchildren who reported drinking in the morning before leaving for school was 46.2%. this was not found to be associated with school ownership, grade, or with socio-economic variables. about 28% of the schoolchildren reported consuming the recommended number of daily servings of fruits and vegetables (five servings a day), with a significant difference between school types of ownership (p<0.001) and the mother’s level of education (p=0.01). only 12.3% of schoolchildren reported the correct answer for the daily recommended consumption of fruits and vegetables. children of mothers with a diploma or higher level of education had a higher proportion of consuming the recommended number of servings (47.9%). school type of ownership and the mother’s level of education remained statistically significant in the final multilevel logistic regression model. being in a jm school increased the probability of consuming the recommended quantity of vegetables and fruit by 1.55 times (or=1.53, 95%ci=0.76-1.96). having a mother with a diploma or higher education increased it by 1.8 nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 8 times (or=1.80, 95%ci=1.25-2.60). the mother’s employment status, religion, and crowding index were found to have no effect. school ownership had a significant effect (p<0.001) on daily milk consumption, with private schools having the highest consumption (52%). another predictor was the crowding index, which was inversely associated (p<0.001). most of the schoolchildren had lunch as the main meal which they ate with at least one parent. physical activity the majority of schoolchildren reported walking to and from the school (67.6% and 72.9%, respectively). there was a significant difference between school ownership type (table2), with unrwa schools having the highest level (93.4% and 97.1%, respectively, p<0.001). the overall reported physical activity in schoolchildren showed that pupils were only slightly active in sport. about 14% of schoolchildren reported being active at least five days a week (table 2). this proportion was significantly inversely associated with the crowding index (20.2%, 16.5%, and 16.5% for up to one, between 1-2, and more than two, respectively, p=0.006). a positive significant association was also found with mothers’ level of education (12.9%, 13.4% and 21.5% for less than secondary, secondary and diploma or higher education, respectively, p=0.027). no other tested variables were associated with physical activity. sedentary behaviours one-third of the students (33.9%) viewed tv for ≥4 hours a day and this was significantly associated with the school ownership (p<0.001). the highest percentages reporting viewing television were found in unrwa and private schools (38.2% and 38.0%, respectively). (table 2). sedentary behaviour was not associated with the crowding index, mothers’ education or employment. no correlation was found between television viewing and being physically active. body weight the overall prevalence of overweight and obesity was 22.2% and 7.6%, respectively. the difference between school ownership types was statistically significant (p<0.001), where the highest proportion was among private schoolchildren (42.4%). more christian schoolchildren in the private schools (47.1%) were overweight and obese compared to muslim schoolchildren (39.2%). about 1% of schoolchildren were underweight, with highest rates among pa schoolchildren (3%) (table 2). a significant higher prevalence of overweight and obesity was noticed with the first child in the family. the other independent determinants of overweight and obesity (logistic regression) were: watching tv more than four hours a day (or=4.13, 95%ci=2.93-5.82); being physically inactive (less than five days a week) (or=1.95, 95%ci=1.17-3.24) and always eating while watching tv (or=3.42, 95%ci=2.27-5.13) (table 4). no association was found with crowding index, mothers’ level of education or employment. about 75% of overweight/obese children considered their weight as normal, whereas 66% of those who perceived themselves as “high weight for their age” were actually overweight/obese children (data not shown). nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 9 table 4. determinants of overweight and obesity – logistic regression models * variable number or p-value 95%ci family order: 1 2-3 4 ≥5 185 343 136 231 1.00 0.48 0.91 0.57 0.003 (3) † 0.001 0.74 0.024 reference 0.31-0.74 0.54-1.56 0.35-0.93 school ownership: jm pa unrwa private 399 235 136 125 1.00 0.38 0.90 1.71 <0.001 (3) <0.001 0.660 0.026 reference 0.24-0.59 0.56-1.45 1.07-2.75 physical activity: <5 days/week ≥5 days/week 761 135 1.95 1.00 0.010 1.17-3.24 reference tv viewing: ≤4 hours/day >4 hours/day 597 299 1.00 4.13 <0.001 2.93-5.82 reference eating while watching tv: never several times a week every day 315 534 266 1.00 0.71 3.42 <0.001 (2) 0.010 <0.001 reference 0.48-1.07 2.27-5.13 * overweight and obesity were combined. the last variables left of the stepwise forward logistic regression were entered into the logistic regression model. † overall p-value and degrees of freedom (in parentheses). discussion the aim of this study was to provide baseline information of schoolchildren living in east jerusalem as the first stage of a randomized controlled intervention programme. the results showed that most children fail to meet the international dietary and physical activity recommendations. there was a significant independent difference between school ownership and socio-economic groups, measured by the crowding index, but no significant difference was observed between grades for all the studied variables. approximately one third (36.6%) of female schoolchildren ate breakfast before school. this finding is consistent with the finding of dietary habits among palestinian adolescents where 34.7% ate breakfast (9). most of the schoolchildren reported “not feeling hungry” as the main reason for skipping breakfast, which is a growing concern worldwide, especially among females (10). in private schools, although the pupils come from higher social classes and are assumed to be in a better position to provide good food for their children, the level of skipping breakfast was the highest. za’ater and olive oil with bread is the most commonly consumed breakfast meal. this could be because of its prominent role in cultural heritage, due to the widely held belief that za’ater helps to keep mind alert especially prior to exams or school. olive oil is known to be a main component of the mediterranean diet, a rich source of monounsaturated fatty acids and an antioxidant agent, which has several beneficial biological functions for health (11). studies also have proved that olive oil intake is associated with the reduced risk of cardiovascular disease and mortality in individuals at high risk (12). nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 10 drinking milk was reported only by 40% of schoolchildren. adequate calcium intake for children is essential for the development of bone mass and mineral density (13) and in the maintenance of health and prevention of chronic diseases (14). strategies to encourage milk consumption by schoolchildren need special attention. the reported fruit and vegetable intake was lower in our study than that found in the 2004 palestinian hbsc survey (6). this could be due to rapid and progressive shifting among palestinian adults to western-style food patterns (9). less than one third of schoolchildren reached the recommended daily dietary intake of five servings of fruits and vegetables (1). this means that these children may fail to obtain appropriate nutritional intakes of vitamins, mineral and fiber to protect them from diet-related chronic diseases (15), including overweight and obesity (16,17), despite the fact that palestinian markets have a wide variety of vegetables and fruits at low prices. therefore, the need to promote the consumption of more vegetables and fruits is viable and a public health priority. regular physical activity plays an important role in improving the quality of life. although more than two thirds of schoolchildren reported walking in the morning to and from school, respondents did not engage in regular sport and physical activity in leisure time. therefore, they do not achieve the recommended level of being one hour or more physically active per day (18). in arab countries, including palestine, women are prohibited by the socio-cultural norms from participation in outdoor sports activities. therefore, there is a need to develop good physical education practices (e.g. skipping, which can be performed at home) to increase physical activities among girls. in parallel, there is an increase in sedentary behaviours among schoolchildren, which is due mainly to time spent watching television, as in many other countries (15). this is because television is so accessible and available. current recommendations are that children should spend no more than two hours watching television a day (19). the problem of obesity the prevalence of overweight and obesity is high among palestinian schoolchildren, associated with lack of physical activity and increased sedentary behaviours. childhood obesity is an increasingly worldwide problem. this study found that the prevalence of overweight is 22.2% and obesity is 7.6% which is higher than adolescents in the gaza strip (17.0% and 5.45%, respectively) (20), ramallah (18.9% and 3.3%, respectively), hebron (14.9% and 2.0%, respectively) (9), but slightly lower than a previous study conducted in east jerusalem in 2002 (24.3% and 9.9%, respectively) (21). the overweight/obese schoolchildren were found more likely to watch television for more than four hours. this is in accordance with several cross-sectional and longitudinal studies showing very strong associations between television viewing and childhood obesity (22,23). significant positive associations were found between eating while watching television and the risk of becoming overweight/obese. watching television for many hours may lead to a snacking while watching (24), which is independently associated with overweight/obesity among children (25). schoolchildren in private schools have higher standards of living. several studies have demonstrated that socioeconomic status is directly related to childhood obesity in developing countries (26), which is higher in urban areas (27,28). the discussed culture restrictions placed on girls which results in their staying at home with easy access to food, contribute to their increased risk of overweight and obesity. evidence suggests that measures should be introduced as early as possible, so that healthy lifestyle habits are learnt from childhood (29). nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 11 study limitations the study involved a cross-sectional design, and therefore cannot address causality. another limitation is using a self-reported questionnaire from schoolchildren in grades 4 and 5 which could have influenced its validity and reliability. however, studies show that results from self-administered questionnaires tend to minimize social desirability bias compared to interviewer-administered questionnaires (30). conclusion this study shows that palestinian girls miss breakfast, eat less fruits and vegetables than the recommended requirements, and have sedentary behaviours, which is associated with high prevalence of overweight and obesity. there is a need for developing effective intervention programmes to promote healthy eating and physical activity among palestinian schoolchildren. references 1. world health organization. diet, nutrition and the prevention of chronic disease. geneva: world health organization, 2003. available at: http://www.who.int/dietphysicalactivity/publications/trs916/en/ (accessed: january 16, 2016). 2. wyatt sb, winters kp, dubbert pm. overweight and obesity: prevalence, consequences, and causes of a growing public health problem. am j med sci 2006;331:166-74. 3. lobstein t, baur l, uauy r, obesity i. obesity in children and young people : a crisis in public health. obes rev 2004;5:4-85. 4. world health 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clin nutr 2007;85:355-61. 23. veldhuis l, vogel i, renders cm, van rossem l, oenema a, hirasing r a, et al. behavioral risk factors for overweight in early childhood; the “be active, eat right” study. int j behav nutr phys act 2012;9:74. 24. ouwens m a, cebolla a, van strien t. eating style, television viewing and snacking in pre-adolescent children. nutr hosp 2012;27:1072-8. 25. pate rr, mitchell ja, byun w, dowda m. sedentary behaviour in youth. br j sport med 2011;45:906-13. 26. mcdonald cm, baylin a, arsenault je, mora-plazas m, villamor e. overweight is more prevalent than stunting and is associated with socioeconomic status, maternal obesity , and a snacking dietary pattern in school children from bogota. j nutr 2009;139:370-6. nubani-husseini m, berry e, abdeen z, donchin m. dietary patterns and physical activity among palestinian female schoolchildren in east jerusalem (original research). seejph 2016, posted:15 february 2016. doi 10.4119/unibi/seejph-2016-92 13 27. mirmiran p, azizi f. childhood obesity in the middle east : a review. east mediterr heal j 2010;16:1009-17. 28. neuman m, kawachi i, gortmaker s, subramanian s v. urban-rural differences in bmi in lowand middle-income countries : the role of socioeconomic status. am j clin nutr 2013;97:428-36. 29. doak cm, visscher tls, renders cm, seidell jc. the prevention of overweight and obesity in children and adolescents : a review of interventions and programmes. obes rev 2006;7:111-36. 30. hebert jr, clemow l, pbert l, ockene is, ockene jk. social desirability bias in dietary self-report may compromise the validity of dietary intake measures. int j epidemiol 1995;24:389-98. ___________________________________________________________ © 2016 nubani-husseini et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 1 review article ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy christiane wiskow 1 , maria ruseva 2 , ulrich laaser 3 1 sectoral policies department, international labour office, geneva, switzerland; 2 executive committee, south eastern europe health network, skopje, fyr macedonia (republic of macedonia) and management board, international health partnerships association, sofia, bulgaria; 3 section of international public health, faculty of health sciences, university of bielefeld, bielefeld, germany and member, international health partnerships association, sofia, bulgaria. corresponding author: maria ruseva, md, international expert, public health member, executive committee, see health network (seehn) and founding member, international health partnerships association (ihpa); address: bellmansgade 23, 7 tv. 2100 copenhagen ø, denmark; telephone: +4539186929; e-mail: rusevamaria33@gmail.com wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 2 abstract aim: regional collaboration has continuously contributed to the development of public health in the south eastern europe (see) region since 2000 when the public health collaboration in see (ph-see) was initiated. this article looks into two frameworks for regional collaboration in the area of public health: a framework developed in 2004 by a network of public health professionals and academics, and another one developed by the see health network as integral part of the see 2020 strategy on jobs and prosperity in a european perspective, adopted in 2013. it compares the commonalities and differences of the two frameworks; considers what is still valid and relevant after ten years and which new features have emerged in the new strategy. methods: a literature review was carried out and a qualitative analysis was applied for the comparison of the two frameworks. results: notwithstanding the time gap of nearly ten years, the commonalities between the two regional health strategies are significant. major consistent goals include: improving equity in health; strengthening human resources for health; improving intersectoral cooperation and governance. the differences between the two regional strategies, including issues around social participation and regional health information systems, are partially due to their different development context. cross-border policies and quality management have emerged as new or more pronounced topics in the see 2020 strategy’s health dimension. conclusions: many aspects addressed in the 2004 framework are pertinent with regard to the see 2020 health dimension and remain relevant in the current context. the integration of health as part of the economic see 2020 strategy reflects a significant paradigm shift and important step forward for public health. keywords: public health strategy, regional collaboration, socioeconomic development. conflicts of interest: none. disclaimer: the main author of this article is a health sector specialist at the sectoral policies department of the international labour office, geneva. the views expressed in this article are those of the author and do not necessarily reflect the views of the international labour organization. wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 3 introduction in november 2013, ministers of economy of seven south eastern european (see) transition economies signed the see 2020 strategy on jobs and prosperity in a european perspective (hereafter see 2020 strategy, or strategy). the see 2020 strategy aims at socio-economic growth and underlines the importance of the european union (eu) perspective for the see region. it provides a framework for regional cooperation in specific political and economic areas with the purpose to assist governments in the achievement of common national goals. the development of the strategy has revealed a high level between regional and national agendas (1,2). while the focus of the strategy is primarily on advancing the economic development of its members, health constitutes an integral part of this strategy. as highlighted by the see health network (seehn), this is an innovative aspect reflecting a paradigm shift in recognizing that health contributes to socioeconomic growth rather than constituting just a burdening cost factor (3,4). the seehn has been mandated to assist in the implementation of the health dimension of the see 2020 strategy (5). in the context of another network, the public health collaboration in see (ph-see), a framework for a regional public health strategy had been developed and suggested as early as in 2004 (6). this article looks into two frameworks for regional collaboration in the area of public health: one framework developed in 2004 by public health professionals and academics, and another one developed by the seehn as integral part of the see 2020 strategy. it compares the commonalities and differences of the two frameworks; considers what is still valid and relevant after ten years and which new features emerged in the new strategy. it is based on a literature review and applied qualitative analysis for the comparison. background information during the past three decades, the see countries have experienced dramatic changes through the disintegration of the communist systems and the subsequent rapid transition to marketoriented economies. this shift had social and cultural implications for the societies, marked by increasing poverty, high unemployment, massive emigration, and financial downturn, further aggravated by a devastating war. as a consequence, the burden of disease in many see countries has been – and continues to be – higher than in western european highincome countries despite varieties in the region (7-9). the eu-initiated stability pact for the see (1999-2008) 1 included two major health programmes under the social cohesion pillar that resulted in two distinct public health networks, operating at political and professional levels:  the see health network (seehn), established in 2001, brought together the ministries of health of nine see countries 2 and other experts, and has since acted as an intergovernmental forum and legal platform implementing regional collaboration on health systems and public health at political level. in 2010, the see health network took ownership for the regional collaboration on health and development under the regional 1 the eu was the main initiator of the stability pact for the see. over 60 partners provided funding for the activities and programmes under the stability pact, including the wb, ebrd, ceb, coe, all un organizations and many bilateral donor countries. all health actions were financially and technically supported by ten bilateral donor countries, coe, ceb and who europe. 2 albania, bosnia and herzegovina, bulgaria, croatia, the former yugoslav republic (fyr) of macedonia (republic of macedonia), republic of moldova, montenegro, romania and the republic of serbia. israel joined seehn in 2011 as the tenth member country. wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 4 cooperation council (10), the successor of the stability pact since 2008 (11). its institutions include regional health development centres in each of its ten member states and a network of over 300 experts, with a secretariat based in skopje, fyr macedonia (12). it is one of the over 60 see regional initiatives under the broad political framework of the see regional cooperation process and the regional cooperation council.  at the academic and technical level, the public health collaboration in see (ph-see), funded by the german stability pact (2000-2008), brought together universities and institutes of public health of see countries and partner universities from european countries to develop programmes for training and research in public health and assist in the establishment of schools of public health. following the end of the stability pact, in 2008, ph-see transformed into the forum for public health in see (fph-see), a nongovernmental and non-profit consortium of public health institutions in the see region. as an affiliate of the european public health association (eupha) it aims at exchange of experience, mutual support, and common activities for a new public health (13). both networks continue to be active; it is noteworthy that they share the vision and mission to promote peace, reconciliation, and health through regional collaboration in public health. as pointed out by ruseva et al. (14), both networks together enhanced public health as a common denominator of both a political and an academic movement to improve the health and wellbeing of the see populations. the seehn achievements are numerous with significant impact on health policies, spanning the areas of mental health, non-communicable and communicable diseases, healthy aging, antibiotic resistance, organ donor and transplant medicine, blood safety, accreditation and quality improvement of health services, health workforce, and public health services. at the academic level, the ph-see by 2008 had produced six volumes of teaching materials (3500 pages), a shortlist of health indicators; organized more than 25 conferences and summer schools; and had assisted in the establishment of new schools of public health in belgrade, bucharest, chisinau, novi sad, pleven, skopje, sofia, tirana, and varna. as a lesson learnt from the seehn, ruseva et al. conclude that a network approach constitutes an added value for the region with view to the small size of most of see countries. the regional collaboration network amplifies their influence and power at international levels, as they speak with one voice; moreover, collaboration between various stakeholders has enabled the countries to rapidly resort to their respective networks to mobilize assistance in emergency events, such as the floods in 2014 (14). development of a regional public health strategy framework in 2004 3 in 2004, the public health collaboration in see programme (ph-see) (13) brought together public health professionals from seven see countries and other european countries 4 in a seminar that served as a forum for the development process of the regional strategy framework. the seminar built on previous work in the region and followed a participatory approach in several steps. hence, based on the existing national health strategies at that time, the participants jointly elaborated a situation analysis with regard to public health in the see 3 this section draws on reference no. 6: framework for a common regional public health strategy of south eastern europe, in: scintee sg and galan a (eds.). public health strategies: a tool for regional development – a handbook for teachers, researchers and public health professionals. lage: hans jacobs publishing company, 2005. 4 36 public health experts from albania; bulgaria; croatia; fyr macedonia; romania; serbia and montenegro; and slovenia; five public health experts from denmark, germany, switzerland and the uk. wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 5 region, selected priorities for a regional framework, formulated major goals and developed an operational action plan. a methodological combination of the swot 5 analysis and the nominal group technique was selected for the framework development. both methods are recognized in supporting decision-making and problem solving processes, by applying heuristic reasoning for advancing analysis and decision-making. being primarily intuitive and judgemental rather than mechanistic and measurable (15), these methods nevertheless follow rigorously disciplined regulations. in regional development as well as in strategic planning, the use of heuristic reasoning is well-established. situation analysis of public health in the see region in 2004 the situation analysis using the swot methodology aimed at describing the external and internal environment of public health in the see region and facilitating the choice of strategic options. strengths the countries in the see region could build on a strong tradition and history in public health. namely, the management of communicable diseases in conjunction with the sanitary control of water supplies and food safety had the potential for further development at regional level. the traditional system of family physicians and the focus on maternal and child health were highly relevant with regard to international trends in health. this was backed by already existing legislation and regulations like the laws on surveillance of communicable diseases, food safety and healthy nutrition, environmental health, occupational health, school children health, immunization and the like. routine health data collection was maintained in most countries. the existing public health infrastructure consisting of professionals, inspectorates and national institutes of public health represented a solid base both at country and regional levels. in 2004, a core group of public health professionals with international training and connections provided quality input into projects and institutions. nearly all countries in central and eastern europe had mature education and training systems (15), although the see region could build only on a selected number of schools of public health, such as the andrija stampar school in zagreb, croatia with its long tradition. professional associations and non-governmental organizations (ngo) reflected the continuing cooperation and communication and represented a means for empowerment of public health. national public health associations and schools of public health had been founded in romania, serbia, moldova, fyr macedonia, bulgaria and albania in recent years with the support of the open society foundations and the german funded stability pact. weaknesses weaknesses within public health in see countries were observed in the areas of legislation, organization, financing, health promotion, health information system, human resources, education and training, and ethical issues. the health sector reforms during the transition period brought about rapid changes of legislation. in addition, the unstable political situation often led to the disruption of development processes in public health, and as a consequence resulted in a lack of persistent vision and policy. at the same time, the slow transition from a centralized structure to 5 swot analysis is a structured planning process that assesses strengths, weaknesses, opportunities and threats with regard to the internal and external environment of a project or business. wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 6 decentralised systems reflected a form of inflexibility stemming from former systems. additionally, poor vertical and horizontal communication impeded the advancement of new structures and initiatives. community involvement in health development tended to be neglected. overall, the efficiency of the health information systems was questioned, as was the quality and the effective use of health information. the health financing was perceived to be insufficient. of concern were also the inappropriate allocation of funds and the low effectiveness in spending, enhanced by a lack of control mechanisms. corruption was a significant worry, as it was contributing to increasing inequalities in health care. inappropriate salaries and lack of incentives were also weakening the delivery of public health services through demotivated health personnel. furthermore, the lack of professional and social recognition and the missing formal inclusion in decision-making processes demotivated the public health professionals. at that time, a critical mass of well-trained public health professionals was not built yet and a clear shortage of management skills in public health was observed. opportunities in contrast to the 1990s, in 2004, the see region was characterized by a climate of opening and cooperation between the countries. the dubrovnik pledge of 2001 (16) had marked a firm political commitment to regional health development. the political and technical cooperation had been institutionalised in the “see health network” as the main political body for providing leadership and sustaining ownership of the countries and implementing concerted action in defined areas of mutual interest. 6 there was an enhanced trend to increased professional cooperation within and between the see countries, facilitated and sustained by the establishment of institutionalized structures, such as the seehn and the phsee networks. political changes and increasing foreign investment targeting the socio-economic development in see countries also opened opportunities for public health initiatives. a number of international agreements and regional declarations constituted important reference points for a regional public health strategy, including the united nations (un) millennium development goals (mdgs) (17). the european public health policies provided a frame for harmonizing see approaches and alignment with the european standards, including the who health 21 strategy (18); the ljubljana charter on reforming health care, 1996 (19); and the eu public health programme (20-22). other relevant international declarations were the who ottawa charter concerning health promotion and the verona initiative advocating for multi-sectoral investment in health (23). the development of information technology (it) offered new opportunities in terms of facilitating better access to the international body of knowledge in public health for professionals and politicians in the region, helping to exchange information and improving equal access to new databases, journals and other up-to-date information. the emerging national public health strategies demonstrated the relevance of a regional approach as they provided evidence on the numerous common problems and challenges that 6 in 2004, the see health network consisted of over 200 members, including representatives of nine see beneficiary countries, ten donor and neighbour countries and representatives of international organizations, such as who regional office for europe, the council of europe (coe) and the council of europe development bank (ceb). the political body of representatives of the ministers of health, called the national health coordinators of the see countries, acted as the steering committee for implementing the dubrovnik pledge. wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 7 most see countries faced. for addressing those, a regional framework through setting of goals of mutual interest, joining forces through cooperation and information exchange was considered beneficial for advancing public health in the see region. threats at the same time, political, security and socioeconomic instability in the region and at country level was perceived as a major constraint on the way forward. particularly, the political instability was of concern as every electoral mandate came along with changes in governmental strategies, institutions and agencies with effects on legislation and financing mechanisms. the lack of continuity in management, legal framework and allocation of resources throughout and across different political cycles were challenging the development of sustainable public health strategies. competing and conflicting interests of the different political groups also meant a threat to the thorough development of a long-term public health policy. despite the stability pact efforts in the follow-up of the dubrovnik pledge, the see countries at that time felt that the international community had paid limited attention to the reform of the health systems in see and health had been excluded as a regional priority in the frame of the eu cards programme (24). primary concern among the consequences of the socioeconomic instability was the high turnover of health professionals. furthermore, the lack of recognition of public health professionals compared to clinical medical staff, in terms of identity, social status and public image, hindered the evolution of public health within the health system. strategic choice and recommendations the mapping of interactions between the external and the internal environment suggested the choice of the comparative advantage strategy that matched the strengths in the public health field in see with the external opportunities. building on the potentials did not mean losing reality out of sight: maximising the strengths implied overcoming the weaknesses for a stronger position to take opportunities offered by the external environment. in this understanding, a set of key messages and recommendations were formulated:  a key priority in the see region was the reduction of health inequalities within and between the countries with a view to further socioeconomic stabilization of the region and a better use of external opportunities.  improved community involvement and social participation in the decision-making process in health activities would be important with a view to meeting the expectations of the population and making the public health strategy socially and culturally acceptable.  intersectoral collaboration (vertical and horizontal) would be indispensable for integrating public health in the agenda of all economic sectors and overall politics. it would also help to resolve competing interests in national coalitions and international partnerships.  the willingness of joining the eu could be the engine for economical and social development. the public health field should take advantage of the requirements to adapt to eu standards and regulations in order to improve legislation, professional regulations and harmonize public health practices.  regional cooperation would contribute to improving the capability of attracting international funding for multi-national projects. joining forces in obtaining international wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 8 investments in public health research, capacity building and improving infrastructure could help to mitigate the weak financing of public health in the region.  the sustainable development of a public health workforce was necessary to strengthen public health aspects in health reform and health policies. capacity building should include management of health systems and better use of existing resources.  an improved status of public health professionals would enhance their active involvement in policy development and decision making processes, thus ensuring the integration of public health knowledge and the use of data for evidence based policymaking processes. this could be operationalized in strengthening or establishing national public health associations and forming a regional umbrella organization.  professional collaboration in the form of networks would help in capacity building across see countries through mutual exchange of information and experiences and the sharing of successful national projects throughout the region. the results of the situation analysis and the recommendations informed the priority setting process for public health goals in the region. the final priorities were formulated as goals, framing the regional public health strategy. this framework of strategic goals was translated into an action plan by setting operational objectives, specifying activities, timeframe, deliverables, outcomes, indicators, and analysing potential partners, resources and risks. the see regional public health strategy framework (2004) five strategic goals build the overall framework for action to address public health priorities at a regional level (box 1). an initial five-year period for implementation was established (2005-2010). the regional strategy framework aims to complement the national public health strategies. in addition to the countries’ strategies, it provides a framework for addressing common health challenges in the region, contributing to the harmonization of public health policies between the countries and the approximation to european standards. box 1. overview of the strategic goals and objectives of the draft of see regional public health strategy framework (2004) [source: scintee sg and galan a (eds.) (2005). public health strategies: a tool for regional development, page 629] see regional public health strategy framework, 2005-2010 goals and objectives goal 1 improving equity in health 1.1: targeting vulnerable groups 1.2: ensuring adequate and safe living conditions goal 2 strengthening social participation 2.1: mapping social participation opportunities and initiatives 2.2: awareness rising and empowerment of the public 2.3: developing mechanisms to involve civil society in decision making processes goal 3 strengthening human resources in public health 3.1: ensuring sustainable development of human resources 3.2: enhancing regional professional collaboration goal 4 improving regional public health information and knowledge 4.1: establishing a regional public health information system 4.2: developing mechanisms for reporting and analysis at regional level 4.3: improving the level of public health knowledge among three key groups: the professionals, the decision-makers and the public goal 5 establishing intersectoral cooperation 5.1:establishing involvement in programmes of non-health sectors 5.2:introducing intersectoral research wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 9 see 2020 strategy – the health dimension (2013) the see 2020 strategy pursues a holistic approach of development (1, page 4). it features health as integral part of the overall socioeconomic development. the strategy aims to achieve three overall economic targets 7 building on a structure of five pillars (integrated growth, smart growth, sustainable growth, inclusive growth and governance for growth), with pillar specific targets and a set of 16 dimensions. health and employment form the two priority dimensions under the pillar inclusive growth as they were identified as the most urgent topics to be addressed and there are expectations of significant return of efforts in terms of social development. the employment dimension appears more prominent compared to the health dimension, which may reflect on the importance of employment in the strategy, as well as the commitment to create one million new jobs in the see region by 2020. yet, the inter-linkages of the employment and the health dimensions become apparent in two key goals of the strategy: fighting poverty through job creation and fighting health inequalities with a focus on low-income and vulnerable groups. the aim is to ensure that everybody benefits from growth through reduction of poverty, improved health and wellbeing, and greater social cohesion. the see 2020 labour market policies focus on the flexicurity approach to be implemented through comprehensive lifelong learning strategies, effective active labour market policies and modern social security systems (1, pages 28 & 50). according to the european commission, flexicurity is an integrated strategy that attempts to reconcile employers’ needs for a flexible workforce (flexibility) with workers’ needs for security (25). the see 2020 actions refer to the four components of flexicurity approaches: flexible and secure contractual arrangements and work organisations, both from the perspective of the employer and the employee; active labour market policies that help workers to cope with rapid changes, unemployment, reintegration and transitions to new jobs; lifelong learning systems to ensure the continuous adaptability and employability of all workers, and to enable firms to keep up productivity levels; and modern social security systems which provide adequate income support and facilitate labour market mobility (26). effective social security can be achieved through comprehensive social protection floors. this approach comprises an integrated set of social policies designed to guarantee income security and access to essential social services for all, with a focus on vulnerable groups and protecting and empowering people across the life cycle (27). social protection floors, as defined by the international labour organization (ilo), are nationally defined sets of basic social security guarantees that ensure that all in need have, as a minimum, access to essential health care and to basic income security that together secure effective access to goods and social services. the concept is part of a two-dimensional strategy aimed at the rapid implementation of national social protection floors in line with the ilo social protection floors recommendation, 2012 (no. 202), and the progressive achievement of higher levels of protection within comprehensive social security systems according to the ilo social security (minimum standards) convention, 1952 (no 102) (28). robust social protection floors are important particularly with view to the demographic transition in the see region posing challenges for both the employment and the health dimension. accelerated population aging has been observed in the region throughout the past six decades, with an increased median age, rising life expectancies and a simultaneous fall of fertility rates by more than half 7 short version: (i) increase see average gdp per capita relative to the eu average; (ii) boost total see trade in goods and services; (iii) reduce see trade deficit (1, page 5). wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 10 (from 3.55 children per childbearing woman in 1950 to 1.49 in 2010). the percentage of population aged 65 or older has doubled in the same period (from 7 to 14 per cent) as well as the old-age dependency ratio (from 10.6 to 20.9). the effect of the demographic transition on health systems consists of an increasing demand through more old-age related health care needs; the employment dimension will have to address the increasing gaps in labour, while social security systems have to struggle with the decrease of the potential support ratio. the countries in the see region will have to respond to these developments with complex and integrated socioeconomic and health policies (29). the see health network has developed the health dimension for the see 2020 strategy (12). this section of the see 2020 strategy has been based on the seehn policies expressed in the skopje (2005) and banja luka (2011) pledges, the findings and recommendations of four seehn studies (3,4,30,31), the national health and health systems policies, strategies and action plans of all seehn member states and, finally, on their cross-country analysis. a brief description of the situation within the see 2020 acknowledges the significant progress in health care in the region while pointing to several challenges. among the common health challenges identified in the region, inequalities within and between countries are a priority concern. health systems in the region have been described as still being inefficient with common weaknesses including the lack of effective access to health services; inadequate financing of health systems, but also inefficient use of available resources; fragmentation of health services; deficiencies in quality of care; inefficient management; low capacities of the health workforce and significant internal and international migration. in terms of public health needs, the burden of non-communicable diseases also suggests a lack of effective health promotion policies and preventive health services (1, page 27). in order to achieve the set objective of improving health and wellbeing of all people living in the see region, four key strategy actions have been set: i) strengthen the delivery of universal and high-quality health-promoting services. policies for improving the health status focus on low-income and vulnerable groups. ii) strengthen and improve the intersectoral governance of the health sector at all levels, including the health information structure and enhancing regional information exchange. iii) harmonise public health and public health services legislation, standards and procedures across countries in the region. this includes developing mutual recognition and trust to enable the creation of a free trade area from a public health perspective. iv) strengthen human resources in the health sector, harmonise qualifications of health professionals in the see region and monitor health workforce mobility. table 1 summarizes the objective, key strategy actions and activities, projects or instruments for implementation of the see 2020 health dimension. the responsible actors for implementation of the health dimension consist of the ministries of health at national level and the see health network at regional level. wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 11 table 1. overview of the see 2020 strategy, dimension health (source: regional cooperation council. see 2020 strategy, pages 28-29 and 50-51) objective: improve health and wellbeing of all those living in the see region timeframe 1. strengthen the delivery of universal and high-quality health-promoting services at all levels of care  adopt and implement a regional model for delivery of universal and high-quality health, promoting services at all levels of care with an emphasis on a strong primary care sector for improving the health gain in the see region, with a particular focus on low-income and vulnerable groups;  develop a baseline cross-country study on the efficiency of health systems and services;  update current health service legislation and regulations related to health care, disease prevention, health promotion and patient safety;  develop and implement quality improvement mechanisms;  introduce efficient monitoring and evaluation mechanisms in the region’s health systems to improve transparency and accountability. 2015–16 2. strengthen and improve the intersectoral governance of the health sector at all regional levels. adopt regional exchange mechanism for sharing experiences and good practices  strengthen health institutions and improve the intersectoral governance of the health sector at national, regional and community levels following the health in all policy (hiap) approach; and including capacity building for health information infrastructure and introducing ehealth;  adopt a regional information exchange mechanism for sharing experiences and good practices in cross-border public health, health care and mobility of health workforce;  review the current networks of health institutions and develop reform strategies;  review and update the existing health legislation in order to introduce hiap and hia;  implement best practice from eu countries when introducing mechanisms for the intersectoral governance of health; 2015–16 3. harmonise the cross-border public health legislation and enable a free trade area from a public health perspective  adopt multilateral and bilateral agreements to harmonise the cross-border public health and public health services legislation, standards, procedures and develop mutual recognition and trust to enable the creation of a free trade area from a public health perspective;  develop mutually agreed regional public health cross-border standards and procedures;  develop and launch an see regional information database on cross-border public health issues and best practice. 2020 4. adopt multilateral and bilateral agreements to strengthen human resources for health, harmonise and mutually recognize health professionals’ qualifications  adopt multilateral and bilateral agreements to strengthen human resources for health, harmonise and mutually recognise health professionals’ qualifications and monitor the human resources for health and their mobility;  review the current situation on forecasting and planning in respect of the health workforce, as well as on harmonising and mutually recognising the qualifications and mobility of health professionals;  establish a permanent see forum for health education institutions;  establish a regional masters programme for public health based on eu public health curricula. 2016 discussion notwithstanding the time gap of nearly ten years and the different context of their development histories, the commonalities between the two regional health strategies described above are significant. this may be owing to the common spirit in which they have been created with shared values of equity, social justice, and health as a human right as wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 12 underlying principles. another reason emerges when comparing the two situation analyses pointing to a number of persisting common problems and weaknesses, including health inequalities within countries and across the region as a primary concern. the aim to address these problems being the basis for the selection of strategic goals and implementation action may explain some of the similarities between the two strategies. in 2004, the experts of ph-see were convinced that a regional public health framework would underscore the critical role of public health for the socioeconomic development and its implementation would help enhancing social stability and peace in the region. while in 2004 it was acknowledged that the health of populations was an important factor in economic development (18,32), the potential of public health as active supporter remained underestimated. similarly, in the context of see 2020, the seehn refers to health and wellbeing as a determinant as well as a contributor to peace and economic development (12). the integration of health as part of the economic growth strategy see 2020 reflects indeed an important paradigm shift towards the full recognition of health as a contributor to economic growth as highlighted by seehn (5). both regional strategies underline the commitment to eu and who regional office for europe policies in the area of health as well as the intention to complement national health policies and support the collaboration between countries in the region to address issues of mutual interest in national health policies aiming for harmonization of policies and standards. regardless the differences in structure and wording, both strategies are consistent in the majority of their goals and strategy actions. major consistent objectives include: i) improving equity in health with a focus on vulnerable and low-income groups, hence improving health for all; ii) strengthening human resources for health and public health, respectively; iii) strengthening and improving intersectoral cooperation and governance. within those consistent goals, partially different priorities and approaches reflect the timegap and the variety of contexts. i) improving equity in health in 2004, reducing inequalities in health and in access to quality health care within and between the countries in the region was a top priority. at that time, political changes, economic breakdowns and war had resulted in the deterioration of the overall population health status, affecting most the vulnerable groups. a special challenge for some see countries in that period was the situation of internally displaced persons and refugees; those living in conflict areas under the stress of insecurity and violent threats; and those considered as ethnic minorities. these groups were considered vulnerable in terms of social exclusion and deprivation from resources influencing health such as income, education and healthy living conditions. despite the progress made to date, health inequalities within and between the countries remain of high concern; assisting governments in reducing poverty and health inequalities is the declared aim of the see 2020 inclusive growth pillar. the health objective in this regard is to ensure universal quality health services focusing on access for vulnerable groups. ii) strengthening the health workforce the concern of insufficient numbers and capacities of the health workforce has been addressed in both strategies, regardless of different perspectives. the ph-see framework emphasized the strengthening of the public health workforce capacities and status within the overall health workforce. in 2004, the emergence of the holistic approach to public health wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 13 was not mirrored in the public health workforce in see. the existing body of knowledge, institutions and professionals focused on the bio-medical aspects of public health and was complemented by the existing expertise in social medicine; however, the need for integrative approaches and inter-professional collaboration was evident. in the context of see 2020, low capacities of the health workforce have been indicated as one of the persisting weaknesses. under the objective of strengthening the health workforce, the cross-border aspect is emphasized. mobility has been mentioned in the 2004 framework strategy, but the emphasis of this aspect in see 2020 reflects the current situation characterized by significant international migration of health workers. general trends of health professional mobility flows from eastern to western europe have been persisting throughout the past decade with peaks following the eu enlargement, though at more moderate levels than expected, and with varying magnitude across countries depending on their health labour markets (33,34). on the one hand, health professional mobility is being facilitated in the context of eu policies, through harmonization and mutual recognition of qualifications; on the other hand, the intention is to improve the management of the mobility through monitoring and bilateral and multi-lateral agreements to mitigate adverse effects of outflows from vulnerable health systems that already experience workforce shortages as well as protecting migrant health workers. both regional public health strategies commonly aim for enhancing the regional professional collaboration in the area of education through harmonisation of curricula and a common forum of health education institutions. see 2020 further aims at establishing a regional public health masters programme based on the eu public health curricula. here is certainly an opportunity for enhanced collaboration between the two networks fph-see and seehn as most of the see countries have already implemented the three cycles of the bologna process including master programmes in public health. both strategies focus on the qualification and performance aspects regarding the health workforce while the importance of employment opportunities and decent working conditions in the health sector have been mentioned only marginally. yet, health provider performance and quality of care are linked with enabling and supportive work environments (35). in the context of the see 2020 strategy, the health sector is also economically important in terms of its potential for employment creation, with a view to the increasing demand for health services in times of demographic transition. iii) improving intersectoral collaboration the progress made in the past ten years is particularly evident in the aspect of achieving the integration of health across all sectors. intersectoral collaboration has become more commonly accepted with the appearance of the health impact assessment in the context of the health promotion movement. while the 2004 strategy framework (modestly) aimed at establishing the involvement of public health in the programmes of non-health sectors, the see 2020 aims to implement the integrative approach of “health in all policies” (hiap). in 2004, there was already recognition that most of the determinants of health were outside the sphere of influence of the health sector. however, at that time, the awareness of health impact of actions undertaken in other sectors was limited and neglected in practice in the see region. regular and institutionalized mechanisms of intersectoral cooperation needed to be developed and established in the region in order to promote the protection of health. such integrative and intersectoral approach, while recognized and promoted since the alma ata declaration on primary health care (in 1978) has only later been labelled as “health in all policies” (hiap), more specifically in the eu during the second finnish eu presidency in 2006 (36). in parallel, methods of health impact assessment (hia) have been developed and wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 14 implemented. furthermore, the who europe framework health policy “health 2020” develops and recommends the whole-of-government and whole-of-society approaches that were endorsed by all ten seehn members states during the who europe regional committee session in 2012 in malta (37). the see 2020 strategy takes advantage of these developments and includes in their objectives to “review and update the existing legislation in order to introduce hiap and hia” (table 1, action 2). hiap and hia reflect the important influence of health within the policies of other sectors in the overall see 2020 strategy and offers new opportunities for public health intersectoral collaboration. seehn has been mandated to monitor the health impact of the see 2020 implementation and has ensured that health targets and indicators incorporate prevention and health promotion within the hiap approach, social determinants of health and inequalities (5). in addition to the obvious commonalities, there are also apparent differences between the two strategies that are reflected in a number of objectives and issues without matching counterparts. nevertheless, some of those aspects can be found as elements or indirect intentions in the other strategy.  social participation the 2004 framework for a regional public health strategy emphasized the importance of strengthening social participation in public health and in decision-making processes. it referred to the alma ata declaration on primary health care (phc; 1978) and the health for all strategy (hfa; 1981) policies promoting public participation in health policy development. it further pointed to the responsibility and accountability of all as a prerequisite for sustainable health development, which required the involvement of all stakeholders in health policy and action, including communities. the concept of social dialogue had been suggested as a means for inclusive development processes in the health sector (38). the emphasis of social participation in the 2004 framework strategy may be explained by the historical context and situation at that time, influenced by the aftermaths of a war and in light of the political and socioeconomic instabilities in transition countries. developing trust between people and nations was seen as a priority at a time when see countries were perceived as fragile and the rapid changes involved socio-cultural incoherence. nevertheless, while social or community participation is not explicitly mentioned in the see 2020 health dimension, it emphasizes primary health care and seeks to improve transparency and accountability. both aspects take into account the community level and population interface with the health service delivery, with the aim to build up resilient communities.  regional public health information improving regional public health information and knowledge was one of the priorities and strategic goals in the 2004 framework strategy as well as one of the seven objectives of the seehn dubrovnik pledge. the health information systems at that time were considered inefficient and compounded by the ineffective use of the information in shaping health policies. the set objectives included establishing a regional public health information system and developing mechanisms for reporting and analysis at regional level with a view to improving the level of public health knowledge among professionals, decision-makers and the public. the objective referred to the dubrovnik pledge with its commitment to “establish regional networks and systems for the collection and exchange of social and health information” (16). within the see 2020 health dimension, information systems appear less prominently and in a different way. a reference is found under the objective of cross-border harmonization where the “development and launch of a see regional information database on cross-border public health issues and best practice” is one of the planned activities (table wiskow c, ruseva m, laaser u. ten years onwards: comparison of the south eastern european regional public health strategy 2004 and the south eastern european 2020 strategy (review article). seejph 2016, posted: 13 january 2016. doi 10.4119/unibi/seejph-2016-90 15 1, action 3). while the establishment of health information systems in the see region has advanced following the commitment of the dubrovnik pledge, it is still “work in progress”. thus, strengthening health information systems in the see region continues to be an important priority, as recognized by the ad-hoc meeting of the see ministers of health, 22 june 2015, in belgrade, serbia (39).  cross – border public health the see 2020 strategy includes cross-border public health as a new aspect that is not reflected in the 2004 framework. the strategy action aims at harmonizing cross-border public health legislation and to enable a free trade area from a public health perspective (table 1, action 3). to this end, multilateral and bilateral agreements shall help in harmonizing standards and procedures and, moreover, in the development of mutual recognition and trust to enable a public health free trade area. in 2004, the idea of a see regional free trade area was not foreseen given the instable situation in the region at that time.  quality improvement see 2020 explicitly addresses quality improvement of health services delivery. it aims at exploring the efficiency of health systems with a baseline study and establishing a sustainable quality management system. the aspect of quality management is missing in the 2004 strategy while it implicitly forms an underlying principle. conclusions despite the time lag of nearly ten years, the commonalities of the two strategies for regional public health collaboration are significant. many aspects addressed in the 2004 framework are pertinent with regard to the see 2020 health dimension; therefore, the main parts of the 2004 framework strategy are still relevant in the current context. the differences between the two regional strategies are partially due to the different development context, not only in terms of the different situations in the see region in 2004 and 2013, respectively, but also in terms of different angles: the 2004 framework strategy was developed from within the health system perspective by public health professionals, whereas the see 2020 strategy has been developed at a political level and implies consequently a different perspective on the issues at hand. collaboration between the two networks fph-see and seehn particularly in the area of public health education could be of mutual benefit, with a format still to be agreed upon though. similarly, collaboration between the two networks could further strengthen the improvement of regional health information. the integration of health in the see 2020 strategy with the hiap approach opens opportunities for health influencing socioeconomic development policies. this paradigm shift is an important step forward for public health. references 1. regional cooperation council. south east europe 2020 strategy – jobs and prosperity in a european perspective. sarajevo: regional cooperation council, 2013. 2. regional cooperation council. south east europe 2020 baseline report – towards regional growth. sarajevo: regional cooperation council, 2014. 3. south-eastern europe health network, who regional office for europe, council of europe 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access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. kollcaku j, kollcaku a. correlates of rheumatoid arthritis among women in albania (original research). seejph 2016, posted: 29 august 2016. doi 10.4119/unibi/seejph-2016-127 1 original research correlates of rheumatoid arthritis among women in albania julia kollcaku1, artur kollcaku2 1 ambulatory health service, polyclinic no. 3, tirana, albania; 2 rheumatology service, university hospital center “mother teresa”, tirana, albania. corresponding author: julia kollcaku, md; address: polyclinic no. 3, rr. “qemal stafa”, tirana, albania; telephone: 00355674039706; e-mail: artur_kollcaku@yahoo.com mailto:g@yahoo.com� kollcaku j, kollcaku a. correlates of rheumatoid arthritis among women in albania (original research). seejph 2016, posted: 29 august 2016. doi 10.4119/unibi/seejph-2016-127 2 abstract aim: our aim was to assess the association of rheumatoid arthritis with socio-demographic characteristics and lifestyle factors among women in transitional albania. methods: a cross-sectional study was carried out in 2012-2013 including a sample of 2198 women aged 30 years and above who attended the rheumatology services at primary health care clinics in tirana municipality (mean age: 60.2±9.7 years; overall response rate: 95%). the diagnosis of rheumatoid arthritis was based on the american college of rheumatology/european league against rheumatism (acr/eular) 2010 criteria. in addition, a structured questionnaire was administered to all study participants including information on demographic and socioeconomic characteristics and behavioral factors. binary logistic regression was used to assess the association of rheumatoid arthritis with covariates. results: overall, 437 (19.9%) women were diagnosed with rheumatoid arthritis (both incident and prevalent cases). in multivariable-adjusted models, rheumatoid arthritis was positively and significantly related to older age (or=1.8, 95%ci=1.3-2.6), a lower educational attainment (or=1.4, 95%ci=1.1-1.9), smoking (or=1.5, 95%ci=1.1-2.0), alcohol intake (or=1.9, 95%ci=1.2-3.1) and overweight and obesity (or=1.5, 95%ci=1.22.0 and or=1.6, 95%ci=1.2-2.0, respectively). conclusion: this study provides useful evidence about selected correlates of rheumatoid arthritis among women attending specialized primary health care services in albania. health professionals and policymakers in albania should be aware of the magnitude and consequences of this chronic condition in the adult population. keywords: albania, behavioral factors, rheumatoid arthritis, socio-demographic factors, western balkans. conflicts of interest: none. kollcaku j, kollcaku a. correlates of rheumatoid arthritis among women in albania (original research). seejph 2016, posted: 29 august 2016. doi 10.4119/unibi/seejph-2016-127 3 introduction rheumatoid arthritis is currently considered a clinical syndrome across several disease subsets (1), involving inflammatory flows (2), leading to an ultimate common pathway in which persistent synovial inflammation and associated damage to articular cartilage and underlying bone are present (3). overproduction of the tumor necrosis factor is the principal inflammatory process in the pathophysiology of the rheumatoid arthritis (1,4). this leads to overproduction of many cytokines such as interleukin 6, which causes persistent inflammation and joint destruction (1,5). regarding the etiology, genetic factors account for about 50% of the risk of developing rheumatoid arthritis (6,7). these factors are primarily related to either autoantibody-positive disease (acpa-positive) or acpa-negative disease (1). as for the lifestyle factors, smoking is considered the main environmental risk factor (1,8), doubling the risk for development of rheumatoid arthritis (9). rheumatoid arthritis affects 0.5%-1.0% of adults in developed countries (1). women are three times more affected than men (1). however, the prevalence of this condition is positively related to age in both men and women (1). in women, hormonal factors play an additional role as the prevalence of rheumatoid arthritis is highest among individuals over 65 years (10). regarding the incidence of rheumatoid arthritis in developed countries, it varies from 5 to 50 cases per 100,000 adults (11). on the other hand, the prevalence of rheumatoid arthritis displays significant geographical variations (12). the prevalence of this condition is higher in northern europe and north america compared to developing countries (13). such geographical variations have been linked both to different genetic inclinations as well as to different environmental factors which expose individuals from different regions to different levels of risk for rheumatoid arthritis (1). the information about rheumatoid arthritis in former communist countries of the western balkans including albania is scarce. in general, the burden of musculoskeletal disorders has increased in albania in the past few decades (14). the proportion of musculoskeletal disorders comprised only 8.5% of the total burden of disease in albania in 1990, whereas in 2010 it increased to 11.0% (14). there is evidence of a steeper increase in women than in men (3.7% vs. 2.0%, respectively) (14). in this context, the aim of our study was to assess the association of rheumatoid arthritis with demographic and socioeconomic characteristics and lifestyle/behavioral factors among women attending specialized primary health care services in transitional albania. methods this was a cross-sectional study which was carried out in 2012-2013. study population this study included a sample of 2198 women aged 30 years and over who attended the rheumatology services at primary health care clinics in tirana municipality. beforehand, the required sample size was estimated at 1870 women in order to obtain sufficient cases of rheumatoid arthritis among women who attended the rheumatology services in different polyclinics of tirana. in order to increase the study power and account for potential nonresponse, we decided to include 2500 consecutive women aged ≥30 years who attended t he rheumatology services. of these, 198 women were ineligible (too sick to participate), whereas 104 further women refused to participate. the final study sample consisted of 2198 eligible women who agreed to participate (overall response rate: 2198/2302=95%). of 2198 kollcaku j, kollcaku a. correlates of rheumatoid arthritis among women in albania (original research). seejph 2016, posted: 29 august 2016. doi 10.4119/unibi/seejph-2016-127 4 women who participated in the study, 437 (19.9%) were diagnosed with rheumatoid arthritis (both incident and prevalent cases). data collection the diagnosis of rheumatoid arthritis was based on the american college of rheumatology/european league against rheumatism (acr/eular) 2010 criteria (15). these criteria consist of joint involvement, serology, acute-phase reactants and duration of symptoms (15). in addition, a structured questionnaire was administered to all study participants including information on selected demographic and socioeconomic characteristics and lifestyle/behavioral factors. socio-demographic factors included age (which in the analysis was dichotomized into: ≤50 years vs. >50 years), marital status (dichotomiz ed into: married vs. not married), employment status (employed and/or retired vs. unemployed) and educational attainment (trichotomized into: low, middle and high). conversely, lifestyle/behavioral factors included smoking, alcohol intake, coffee consumption and tea consumption – all dichotomized into: no vs. yes), as well as the body mass index (bmi, trichotomized into: <25, 25-29.9 and ≥30). statistical analysis independent samples t-test was used to compare the mean ages between women with and without rheumatoid arthritis. conversely, fisher’s exact test was used to compare the distribution of socio-economic characteristics and behavioral factors between women with and without rheumatoid arthritis. on the other hand, binary logistic regression was used to assess the association of rheumatoid arthritis (outcome variable) with socio-economic characteristics and behavioral factors (independent variables). initially, crude (unadjusted) odds ratios (ors) and their respective 95% confidence intervals (95%cis) were calculated. subsequently, multivariable-adjusted models controlling simultaneously for all covariates were run. multivariable-adjusted ors and their respective 95%cis were calculated. in all cases, a p-value of ≤0.05 was considered as statistically significant. statistical package for social sciences (spss, version 15.0) was used for all the statistical analyses. results overall, mean age of study participants was 60.2±9.7 years; median age was 60.0 years (interquartile range: 54.0-67.0 years). on the other hand, the age range was 30-92 years. women diagnosed with rheumatoid arthritis were older than those without rheumatoid arthritis (mean age: 62.0±9.8 years vs. 59.8±9.7 years, respectively; p<0.001) [not shown in the tables]. the distribution of socio-demographic characteristics and lifestyle/behavioral factors of women by rheumatoid arthritis status is presented in table 1. as expected, the proportion of older individuals (over 50 years of age) was higher among women with rheumatoid arthritis compared with their counterparts without this condition (91% vs. 85%, respectively, p<0.001). the proportion of a lower educational level was more prevalent in women with rheumatoid arthritis than in those without rheumatoid arthritis (20% vs. 16%, respectively, p=0.02). conversely, no differences were evident for marital status or employment between the two groups of women. regarding behavioral factors, the prevalence of smoking and alcohol intake were significantly higher in women with rheumatoid arthritis than in those without rheumatoid arthritis (for smoking: 15% vs. 11%, respectively, p=0.02; for alcohol consumption: 7% vs. 4%, respectively, p=0.01). similarly, the prevalence of coffee kollcaku j, kollcaku a. correlates of rheumatoid arthritis among women in albania (original research). seejph 2016, posted: 29 august 2016. doi 10.4119/unibi/seejph-2016-127 5 consumption was higher among women with rheumatoid arthritis, but this finding was not statistically significant. the prevalence of tea consumption was similar in the two groupings. on the other hand, the prevalence of overweight and obesity were significantly higher in women with rheumatoid arthritis compared with those without this chronic condition (for overweight: 35% vs. 29%, respectively, whereas for obesity: 30% vs. 25%, respectively; overall p<0.001) [table 1]. table 1. distribution of socio-demographic characteristics and lifestyle/behavioral factors in a sample of albanian women by rheumatoid arthritis status variable total (n=2198) rheumatoid arthritis (n=437) no rheumatoid arthritis (n=1761) p † age-group: ≤50 years >50 years 298 (13.6)* 1900 (86.4) 37 (8.5) 400 (91.5) 261 (14.8) 1500 (85.2) <0.001 employment: employed and/or retired unemployed 1746 (79.4) 452 (20.6) 342 (78.3) 95 (21.7) 1404 (79.7) 357 (20.3) 0.509 marital status: married not married 1793 (81.6) 405 (18.4) 363 (83.1) 74 (16.9) 1430 (81.2) 331 (18.8) 0.408 educational level: low middle/high 364 (16.6) 1834 (83.4) 89 (20.4) 348 (79.6) 275 (15.6) 1486 (84.4) 0.021 smoking: no yes 1947 (88.6) 251 (11.4) 372 (85.1) 65 (14.9) 1575 (89.4) 186 (10.6) 0.015 alcohol intake: no yes 2105 (95.8) 93 (4.2) 407 (93.1) 30 (6.9) 1698 (96.4) 63 (3.6) 0.005 coffee consumption: no yes 758 (34.5) 1440 (65.5) 136 (31.1) 301 (68.9) 622 (35.3) 1139 (64.7) 0.103 tea consumption: no yes 1200 (54.6) 998 (45.4) 242 (55.4) 195 (44.6) 958 (54.4) 803 (45.6) 0.747 bmi: normal weight overweight obesity 971 (44.2) 655 (29.8) 572 (26.0) 155 (35.5) 151 (34.6) 131 (30.0) 816 (46.3) 504 (28.6) 441 (25.0) <0.001 * absolute numbers and their respective column percentages (in parentheses). † p-values from fisher’s exact test. table 2 presents the association of rheumatoid arthritis with demographic and socioeconomic characteristics and behavioral factors. in crude (unadjusted) models, there was a positive association of rheumatoid arthritis with older age (or=1.9, 95%ci=1.3-2.7), a lower educational attainment (or=1.4, 95%ci=1.1-1.8), smoking (or=1.5, 95%ci=1.1-2.0), alcohol intake (or=2.0, 95%ci=1.3-3.1) and overweight and obesity (or=1.5, 95%ci=1.22.0 and or=1.6, 95%ci=1.3-2.3, respectively). furthermore, there was a weak and kollcaku j, kollcaku a. correlates of rheumatoid arthritis among women in albania (original research). seejph 2016, posted: 29 august 2016. doi 10.4119/unibi/seejph-2016-127 6 borderline statistically significant relationship with coffee consumption (or=1.2, 95%ci=1.0-1.5). on the other hand, there was no association with employment, marital status, or tea consumption. table 2. association of rheumatoid arthritis with socio-demographic characteristics and lifestyle factors variable crude (unadjusted) models multivariable-adjusted models or (95%ci)* p* or (95%ci)* p* age-group: ≤50 years >50 years 1.00 (reference) 1.88 (1.31-2.70) 0.001 1.00 (reference) 1.82 (1.26-2.62) 0.001 employment: employed and/or retired unemployed 1.00 (reference) 1.09 (0.85-1.41) 0.497 1.00 (reference) 1.08 (0.84-1.43) 0.522 marital status: married not married 1.00 (reference) 0.88 (0.67-1.16) 0.369 1.00 (reference) 0.94 (0.71-1.24) 0.654 educational level: middle/high low 1.00 (reference) 1.38 (1.06-1.80) 0.017 1.00 (reference) 1.44 (1.10-1.89) 0.008 smoking: no yes 1.00 (reference) 1.48 (1.09-2.01) 0.012 1.00 (reference) 1.46 (1.07-2.00) 0.017 alcohol intake: no yes 1.00 (reference) 1.99 (1.27-3.11) 0.003 1.00 (reference) 1.93 (1.22-3.05) 0.005 coffee consumption: no yes 1.00 (reference) 1.21 (0.97-1.51) 0.099 1.00 (reference) 1.16 (0.92-1.46) 0.210 tea consumption: no yes 1.00 (reference) 0.96 (0.78-1.19) 0.714 1.00 (reference) 0.92 (0.74-1.14) 0.421 bmi: normal weight overweight obesity 1.00 (reference) 1.54 (1.23-2.02) 1.59 (1.29-2.28) <0.001 (2)† 0.001 <0.001 1.00 (reference) 1.53 (1.18-1.98) 1.57 (1.22-2.02) <0.001 (2)† 0.001 <0.001 * odds ratios (or: rheumatoid arthritis vs. no rheumatoid arthritis), 95% confidence intervals (95%cis) and p-values from binary logistic regression. † overall p-value and degrees of freedom (in parentheses). upon multivariable-adjustment for all covariates entered simultaneously into the logistic regression models, rheumatoid arthritis was positively and significantly related to older age (or=1.8, 95%ci=1.3-2.6), a lower educational attainment (or=1.4, 95%ci=1.1-1.9), smoking (or=1.5, 95%ci=1.1-2.0), alcohol intake (or=1.9, 95%ci=1.2-3.1) and overweight and obesity (or=1.5, 95%ci=1.2-2.0 and or=1.6, 95%ci=1.2-2.0, respectively) [table 2]. discussion kollcaku j, kollcaku a. correlates of rheumatoid arthritis among women in albania (original research). seejph 2016, posted: 29 august 2016. doi 10.4119/unibi/seejph-2016-127 7 this study provides evidence on selected socio-demographic and lifestyle correlates of rheumatoid arthritis among women seeking specialized primary health care in postcommunist albania. older age, low education, smoking, alcohol intake and overweight and obesity were strong and significant “predictors” of rheumatoid arthritis in this sample of adult women in albania. the positive association of rheumatoid arthritis with age which was found in our study is in line with several previous reports (1). on the other hand, the positive relationship with a lower educational attainment is appealing and deserves further investigation in populationbased samples. regarding the environmental factors, we found that, in multivariable-adjusted models, smoking was related to a 50% increase in the risk of rheumatoid arthritis. several studies have indicated that smoking is the main environmental risk factor which increases twice the risk of developing rheumatoid arthritis (9). it has been demonstrated that the effect of smoking is confined to patients with acpa-positive disease (8). nonetheless, at a population level, the risk associated with smoking is quite low and has limited clinical relevance regardless of the pathogenetic importance of this factor (1). in our study, we found a positive relationship between rheumatoid arthritis and alcohol consumption. the risk in women who reported to consume alcohol was about 90% higher than in those who did not report alcohol intake. this finding is generally compatible with previous studies conducted elsewhere (1,16). other potential environmental risk factors for development of rheumatoid arthritis may include coffee intake, vitamin d status, and oral contraceptive use (1,16). we did not assess the effect of vitamin d, or oral contraceptive use, but found a weak and borderline significant relationship with coffee consumption in unadjusted logistic regression models only. in any case, smoking excluded, the effect of environmental factors in the risk of rheumatoid arthritis is controversial (1). at present, there are many unresolved difficulties for individuals suffering from rheumatoid arthritis. yet, the constant introduction of innovative and ground-breaking treatments can overcome many of these difficulties and challenges (1). one of the main requirements involves the characterization of disease subsets in individuals with early onset of rheumatoid arthritis in order to target intensive treatment regimens for those who need them most and are also likely to respond (1). from this perspective, it is suggested that that the new direction of treatment and management of rheumatoid arthritis should be towards short intensive therapeutic courses that result in remission instead of the traditional approach which consist of long-term suppressive treatment strategies (1). this study may have several limitations. the study sample may not be representative of all women who attend rheumatology services at the primary health care level in tirana. nonetheless, we included consecutive women who fulfilled the eligibility criteria in order to ensure, to the extent possible, a representative sample of female primary health care users seeking rheumatology services in tirana municipality. yet, as our study was conducted in tirana only, the sample may not be necessarily representative of all the albanian women. assessment of rheumatoid arthritis was based on the acr/eular 2010 criteria (15), which is reassuring. however, the information related to lifestyle/behavioral factors of women included in this study may have been biased in the context of a traditional and patriarchal society such as albania. notwithstanding this possibility, there is no plausible reason to assume different reporting of behavioral factors in women with and without rheumatoid arthritis. kollcaku j, kollcaku a. correlates of rheumatoid arthritis among women in albania (original research). seejph 2016, posted: 29 august 2016. doi 10.4119/unibi/seejph-2016-127 8 in conclusion, this study provides useful information about important correlates of rheumatoid arthritis among women attending specialized primary health care services in postcommunist albania. health professionals and policymakers in albania should be aware of the magnitude and consequences of this chronic condition in the adult population. references 1. scott dl, wolfe f, huizinga twj. rheumatoid arthritis. lancet 2010;376:1094-108. 2. van der helm-van mil ahm, huizinga twj. advances in the genetics of rheumatoid arthritis point to sub-classification into distinct disease subsets. arthritis res ther 2008;10:205. 3. van oosterhout m, bajema i, levarht ew, toes re, huizinga tw, van laar jm. differences in synovial tissue infiltrates between anti-cyclic citrullinated peptidepositive rheumatoid arthritis and anti-cyclic citrullinated peptide-negative rheumatoid arthritis. arthritis rheum 2008;58:53-60. 4. feldmann m, brennan fm, maini rn. rheumatoid arthritis. cell 1996;85:307-10. 5. choy eh, isenberg da, garrood t, et al. therapeutic benefit of blocking interleukin6 activity with an anti-interleukin-6 receptor monoclonal antibody in rheumatoid arthritis: a randomized, double-blind, placebo-controlled, dose-escalation trial. arthritis rheum 2002;46:3143-50. 6. van der woude d, houwing-duistermaat jj, toes re, et al. quantitative heritability of anti-citrullinated protein antibody-positive and anti-citrullinated protein antibodynegative rheumatoid arthritis. arthritis rheum 2009; 60:916-923. 7. barton a, worthington j. genetic susceptibility to rheumatoid arthritis: an emerging picture. arthritis rheum 2009; 61:1441-1446. 8. källberg h, padyukov l, plenge rm, et al, and the epidemiological investigation of rheumatoid arthritis (eira) study group. gene-gene and gene-environment interactions involving hla-drb1, ptpn22, and smoking in two subsets of rheumatoid arthritis. am j hum genet 2007;80:867-75. 9. carlens c, hergens mp, grunewald j, et al. smoking, use of moist snuff, and risk of chronic inflammatory diseases. am j respir crit care med 2010;181:1217-22. 10. charbonnier lm, han wg, quentin j, et al. adoptive transfer of il-10-secreting cd4(+)cd49b(+) regulatory t cells suppresses ongoing arthritis. j autoimmun 2010;34:390-99. 11. pedersen jk, kjaer nk, svendsen aj, hørslev-petersen k. incidence of rheumatoid arthritis from 1995 to 2001: impact of ascertainment from multiple sources. rheumatol int 2009;29:411-5. 12. costenbader kh, chang sc, laden f, puett r, karlson ew. geographic variation in rheumatoid arthritis incidence among women in the united states. arch intern med 2008;168:1664-70. 13. kalla aa, tikly m. rheumatoid arthritis in the developing world. best pract res clin rheumatol 2003;17:863-75. 14. albanian institute of public health. national health report: health status of the albanian population. tirana, albania; 2014. http://www.ishp.gov.al/wpcontent/uploads/2015/01/health-report-english-version.pdf (accessed: march 10, 2016). 15. aletaha d, neogi t, silman aj, funovits j, felson dt, bingham co 3rd, et al. 2010 rheumatoid arthritis classification criteria: an american college of https://www.ncbi.nlm.nih.gov/pubmed/?term=funovits%20j%5bauthor%5d&cauthor=true&cauthor_uid=20872595� https://www.ncbi.nlm.nih.gov/pubmed/?term=felson%20dt%5bauthor%5d&cauthor=true&cauthor_uid=20872595� https://www.ncbi.nlm.nih.gov/pubmed/?term=bingham%20co%203rd%5bauthor%5d&cauthor=true&cauthor_uid=20872595� kollcaku j, kollcaku a. correlates of rheumatoid arthritis among women in albania (original research). seejph 2016, posted: 29 august 2016. doi 10.4119/unibi/seejph-2016-127 9 rheumatology/european league against rheumatism collaborative initiative. arthritis rheum 2010;62:256981. 16. liao kp, alfredsson l, karlson ew. environmental influences on risk for rheumatoid arthritis. curr opin rheumatol 2009;21:279-83. __________________________________________________________ © 2016 kollcaku et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 1 original research performance of the public health care sector in the republic of macedonia lolita mitevska 1 , manuela sofia stanculescu 2 , elisaveta stikova 3 1 national institute of transfusion medicine-skopje, r. macedonia; 2 research institute for quality of life, romanian academy of science, romania; 3 university “ss. ciryl & methodius”, medical faculty, institute of public health, skopje, republic of macedonia. corresponding author: prof. elisaveta stikova, university “ss. ciryl & methodius”, medical faculty, institute of public health, skopje, republic of macedonia; address: 50 divizija no 6, 1000 skopje, r of macedonia; telephone: +38970230183; e-mail: estikova@ukim.edu.mk mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 2 abstract aim: healthcare authorities constantly search for new approaches of assessing the performance of the health sector. comparative studies help for improvements in healthcare by learning from each-other. our aim was to assess the performance of the public healthcare system in the republic of macedonia, through the analysis of preparedness of institutions to fulfill the population‟s healthcare needs and expectations. methods: this study had a regional character. the national research team interviewed 175 randomly selected participants from macedonia. the research was performed in the period march 2012 – march 2013. for the research purposes there were used especially designed questionnaires for cancer, stroke, myocardial infarction, diabetes mellitus and injuries. for assessment of the performances, the appropriate techniques were developed. results: macedonians consider public healthcare system as being medium-good in all aspects: accessibility, availability, quality of health care services and population‟s confidence. the knowledgeable observers (n=125) believe that state-of-the-art treatment exist all over the country (“yes”: 33.6% and “rather yes”: 44.8%). they believe that the services are accessible to everybody, free of major charges (“yes”: 31.2% and “rather yes”: 45.6%). the individual witnesses (n=50) argued toward lack of pharmacies and proper medicines in rural areas, with a gap between the availability and quality of services in rural vs. urban areas. conclusion: the future goals for macedonia include better public healthcare financing, cost definition of health packages, improved disease prevention and effective human resources. keywords: assessment of services, availability, public healthcare system, quality of care. conflicts of interest: none. mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 3 introduction health authorities are in constant search for systematic ways and new approaches of assessing the performance of the health sector at national, or cross-national level. main arguments for the necessity of measurement include identification of the quality of healthcare service delivery, support for design of the health sector reforms, improvement of healthcare system and production of better outcomes for the patients and payers. the healthcare performance can be followed and measured by different indicators, such are: life expectancy, morbidity, or mortality. there are many determinants of health that have influence on the health status of the population, but are not considered as direct indicators (1). the performance assessment can be defined as comparing or measuring deviations of observed clinical practice from recommended practice. this assessment may range from a formal in-depth evaluation process to a much less elaborate simple review of practice. the most common performance assessment methods are: (i) audits/audit groups, (ii) peer-review groups, and (iii) practice visits (2,3). noncommunicable diseases (ncd), principally cardiovascular diseases (cvd), diabetes mellitus (dm), cancer, and chronic respiratory diseases, are the most common diseases which have caused million deaths worldwide. the scientists predict an increased number of deaths from noncommunicable diseases that are projected to further 17% over the next 10 years (4). republic of macedonia is not different in disease prevalence values compared with other european or neighboring countries. according to the data from the national public health institute in the republic of macedonia, in the year 2011, the most frequent diseases for which the patients had received treatments at out-patient services were: cardiovascular diseases (23.6%), respiratory diseases (18.2%), diseases of the muscular-skeletal system (7.7%), diseases of digestive system (7.2%), and diseases of the endocrine system (7.1%), out of 2695233 registered cases (5). for the same year, the total number of hospitalized patients was 253906 (6), out of which for: cancer 33836 (13.3%), endocrinology system diseases 6422 (2.5%) patients, musculoskeletal system diseases 11150 (4.4%), cardio-vascular diseases 38133 (15.0%) and for injuries 12955 (5.1%). the republic of macedonia has a compulsory health insurance system that provides universal health coverage for the whole population. the goal of the health sector reform in republic of macedonia is the creation of a system that is aligned to the needs of the population, which can operate efficiently within the resources available. the government and the ministry of health provide the legal framework for operation and stewardship and the health insurance fund (hif) is responsible for the collection of contributions, allocation of funds and the supervision and contracting of providers. in the year 2002, the hif has started contracting the private primary health care facilities (family doctors or general practitioners-gps), introducing a capitation-based payment system. the medical examinations by the gps are provided free of charge for all citizens. the population participates in covering the health expenditures by paying some amount of money which is calculated from hif special scales and generally is 20% of the total costs of health services. this practice was changed and even improved in the year 2012, by introduction of a law for health protection (7). free-of-charge healthcare services receive all patients with monthly salary lower than the average official salary for the previous year. from co-payments are excluded blood donors, children with special needs, persons under permanent social care, patients in mental institutions and mentally retired abandoned persons. mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 4 all citizens that do not have regular health insurance (for example: stateless persons and social care recipients), are subsidized by the state budget (8). in the year 2010, general government expenditure on health as a percentage of total government expenditure was 12.9%. the total expenditure on health (ppp in us$) in the same year was 791 $ per capita, which increased from 423 $ in the year 1995. the healthcare system in the republic of macedonia is organized at three levels: primary, secondary and tertiary level. some of these services are part only of the public healthcare sector, whereas some other services are provided in public and private healthcare facilities. in the year 2011, there were 3375 at primary level and 386 at secondary level private healthcare practices that had contracts with hif. the total number of hospital beds in 2012 was 9076, or 4.4 beds per 1000 inhabitants (9). the hospital services are organized in: 14 general hospitals, 13 special hospitals, 30 university clinics and 19 other clinical hospitals, centers and units (9). in this framework, the objective of this study was to assess the performance of the public healthcare system in the republic of macedonia, through the analysis of the expected (stateof-art treatment) and actual public health care of the patients. methods the performance of the public health care system in the republic of macedonia was analyzed trough assessment of the access of the population to health care services developed by wismar et al. (10), where “the state-of-the-art” of the healthcare system is defined as: diagnosis, treatment and recovery, which are accessible to every citizen covered by a health insurance, free of major additional charges. accessibility of the health care system is defined as “a measure of the proportion of the population that reaches appropriate health services”. the assessment of the expected and actual performances of public health care system was based on the data collected from 175 interviewed respondents: 125 knowledgeable observers (family physicians and medical specialists in hospitals or emergency centers), and 50 individual witnesses (patients or their family members who were diagnosed during the period between the 1 st of january 2010 to the 31 st of december 2011). the structured interviews were performed for those two groups of the study participants, using ten different questionnaires tailored according to the five selected health problems/diseases: cancer, stroke, myocardial infarction, diabetes mellitus (type ii) and injuries. the selection of these health problems/diseases was due to the fact that they represent the major causes of death in the country and require different approaches in the health care response (emergency versus longterm monitoring and care). we combined two different sampling methods: selective expert sampling for knowledgeable observers and non-probability convenience sampling method for the individual witnesses. the field work was carried out in the period from march 2012 to march 2013. the data obtained through interviews with knowledgeable observers and individual witnesses, for each of the five selected health problems, was organized and analyzed in relation to an adjusted 6-access-steps model based on the following sequence of themes: the extent to which the national benefit packages cover diagnostic, treatment, monitoring and rehabilitation in the specific health problem; the extent to which payments, co-payments, and out-of-pocket expenditure are involved and threaten equity of access; geographical access and availability of services; availability of public and private health-care providers; waiting lists and other aspects of system organization that can result in barriers to the health care access; and groups with limited access and risk factors related to the specific health problems. the expected performance of the health care system was assessed by measurement of four dimensions of the health care system: accessibility, availability, quality of health-care mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 5 services and the population‟s confidence in the public health system, based on the opinion of the knowledgeable observers. assessment for each dimension was made using the likert scale from 1 („very poor‟) to 5 („very good‟). results were presented as the average of the scored values for each dimension. for measurement of the general assessment of the health system, the opinions on the four dimensions were aggregated into a dominant opinion index, using the method basically developed by hofstede in 1980 (11) and the formula: (p-n) * (t-nr)*100/t*t, where p – positive answers („very good‟ or „good‟), n – negative („very poor‟ or „poor‟), nr – neutral or non-response, and t – total number of variables. this type of index varies between -100 (generalized negative attitude) and 100 (generalized positive attitude toward the issue). for assessment of the actual performance of the public health care system, the analysis of the opinions/experience of the individual witnesses and knowledgeable experts was made with a focus on the history of the health problem. the main focus was on the factors hampering the access to the health care system, as essential elements for the assessment of the actual performance of the public health care system. results health status of the population in macedonia shows many different characteristics and tendency, caused by economic, political, socio-demographic changes, as well as health care reforms which have been in process in the past 20 years. figure 1 presents the standardized death rate (sdr) of five health problems: malignant, cerebrovascular and ischemic heart diseases, diabetes and injuries in the period 1990-2010 (12). sdr of malignant neoplasms shows higher rate and increasing trends in the republic of macedonia, compared with the eu and the european region countries. hence, the sdrs of cerebrovascular diseases and diabetes are 3.5 times higher in macedonia than in the eu countries and much higher than in the countries of the european region. sdr of cerebrovascular diseases follows the similar trend as in the other european countries, but the sdr of injuries is two times lower than in the european countries. in the current research, all respondents were divided into two groups: individual witnesses (n=50) and knowledgeable observer (n=125). their distribution is presented in map 1. the demographic characteristics of the individual witnesses that have participated in the study are presented in table 1. the dominant characteristics of the respondents from the group of the individual witnesses included: patients (64%) that live in a large urban residency (48%), pensioners (34%), with high school level of education (54%) and middle income (38%). the characteristics of the knowledgeable observers are presented in table 2. according to demographic data, the dominant group of respondents from knowledgeable observers consisted of doctors (34.4% gps and 31.2% specialists), males (58.4%) that live in a large urban residency (66.4%), with a mean age of 43.3 years. the results of the assessment of the performance of public health care system in the country are presented in table 3. knowledgeable observers consider the health system as being medium/good in all four dimensions: accessibility, availability, quality of healthcare service and the population‟s confidence in the public health system, with an average score of 3.5. the scores vary from 3.4 points for the population confidence to 3.7 points for the availability of the services. the biggest part of respondents from the group of the knowledgeable observers believes that state-of-the-art treatment exists all over the country (“yes”: 33.6% and “rather yes”: 44.8%) and that they are accessible to everyone free of major charges (“yes”: 31.2% and “rather yes”: mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 6 45.6%). yet, health professionals from rural areas tend to assess the system performance with lower remarks. at the level of the overall sample, the dominant opinion index about the health care services showed an average value of 34 points in a scale from -100 to +100. this index had very little variations from 38 for diabetes mellitus, 37 for injuries, 35 for stroke and myocardial infarction, but it was significantly lowest for cancer, with only 23 points. these findings are shown in figure 2. figure 1. sdr for selected diseases in the republic of macedonia during 1990-2010 130 140 150 160 170 180 190 200 210 1990 2000 2010 mkd* european region eu sdr, malignant neoplasms, all ages, per 100 000 0 50 100 150 200 250 1990 2000 2010 mkd* european region eu sdr, cerebrovascular diseases, all ages, per 100 000 10 15 20 25 30 35 40 1990 2000 2010 mkd* european region eu sdr, diabetes, all ages, per 100 000 20 30 40 50 60 70 80 90 100 1990 2000 2010 mkd* european region eu sdr, external causes of injury and poisoning, all ages, per 100 000 10 20 30 40 50 60 70 1990 2000 2010 mkd* european region eu sdr, ischaemic heart disease, 0–64, per 100 000 mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 7 map 1. distribution of respondents table 1. demographic characteristic of individual witnesses variable category number percent type of respondent patients 32 64 family member 18 36 residence large urban 24 48 small urban 14 28 rural 12 24 ethnicity macedonian 37 74 albanian 11 22 other (roma, serbian) 2 4 age (average) cancer 54.9 ? stroke 65.3 ? aim 53.8 ? injuries 43 ? dm 61.6 ? employment status manager 1 2 clerical staff 6 12 non-manual worker 5 10 manual worker 11 22 pensioner 17 34 student 3 6 housewife or inactive 7 14 level of education none 3 6 elementary 10 20 high school 27 54 college or more 10 20 income low 10 20 middle low 13 26 middle 19 38 middle high 6 12 high 2 4 x knowledgeable observers  individual witnesses mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 8 table 2. demographic characteristic of knowledgeable observers variable category number percent type of respondent general practitioners 43 34.4 specialist doctors 39 31.2 representatives of regional or national directions of public health 7 5.6 hospital representatives 11 8.8 emergency centers representatives, 3 2.4 representatives of ngos active in the field 2 1.6 representatives of patient organizations 3 2.4 other 17 13.6 residency large urban 83 66.4 small urban 32 25.6 rural 10 8 age (average) 43.3 (min=24; max=67) gender male 73 58.4 female 52 41.6 figure 2. the value of the dominant opinion index -150 -100 -50 0 50 100 150 dominant opinion index min max average diabetes injuries infarction stroke cancer mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 9 table 3. assessment of the performance of public health care system in the republic of macedonia assessment of public health performance category number percent score (1-5) availability of health care services very poor 0 poor 11 8.8 medium 43 34.4 good 48 38.4 very good 23 18.4 average score 3.7 quality of health-care services very poor 1 0.8 poor 11 8.8 medium 52 41.6 good 44 35.2 very good 17 13.6 average score 3.5 population’s confidence in the public health-care system very poor 3 2.4 poor 14 11.2 medium 52 41.6 good 40 32 very good 16 12.8 average score 3.4 health-care services are accessible to any person who needs them, regardless their economic situation very poor 8 6.4 poor 16 12.8 medium 32 25.6 good 37 29.6 very good 32 25.6 average score 3.5 state-of-art treatment (of the respective health problem) is available? yes 42 33.6 rather yes 56 44.8 no 6 4.8 rather no 21 16.8 is the state-of-the-art treatment (including diagnostics, monitoring etc.) accessible to everybody, which means free of major charges? yes 39 31.2 rather yes 57 45.6 no 6 4.8 rather no 23 18.4 dominant opinion index (overall) 34 when analyzing which group of knowledgeable observers are most satisfied, it is remarkable to note that physicians (general practitioners and specialists) are the most satisfied observers, with a score on the dominant opinion index of 40 points, despite the ngo and representatives of the patients‟ organizations who are the least satisfied observers (approaching to the 0 point on the scale). however, it should be emphasized that the simple size and the profile of the observers influenced on the observed results of this research work. regarding the assessment of the actual performance of the public health care system, table 4 provides descriptions about the main barriers of access to services in macedonia. mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 10 table 4. main access barriers in public health care of the five selected health problems access barriers 1 2 3 4 5 iw ko iw ko iw ko iw ko iw ko delayed first contact with a doctor x x x x x poor knowledge and low level of prevention and information of population x x x x x doctor or medical services are not available in some areas x x x x x x diseases‟ related services are available only in some areas x x x rehabilitation units/ services are not available/enough in some areas x x pharmacies are not available in some areas x x x emergency services are not available in some areas or are underdeveloped x x x x x transport services are underdeveloped or too costly x the waiting time for being received by a specialist is very long x x x the waiting time for getting medication is very long x x the waiting time for rehabilitation services is very long x x lack of trust in doctors, nurses or medical staff x x x lack of interest or unprofessionalism of the doctor or medical staff x x x lack of humanness of the staff x x lack of money to pay the doctor x x lack of money to pay the needed tests lack of money for out-of-pocket payments x low quality and effectiveness of medical services x x x x x x x x high costs of medication x x x x x x x poor equipment of public clinics/hospitals x x x x x x lack of accessibility and continuity of care x x specialists of certain subspecialties are missing or insufficient legend: 1 = infarction; 2 = stroke; 3 = cancer; 4 = injuries; 5 = diabetes iw = individual witnesses; ko = knowledgeable observers there are four major aspects of the health care system that are major barriers in accessing state-of-the-art treatment, for all the selected health problems:  low quality and effectiveness of medical services; mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 11  high cost of medication;  poor equipment of public health care clinics/hospitals, and;  availability of doctors and medical services. additionally, the respondents gave high priority to the poor knowledge and the low level of information and the lack of preventive health-related behavior; availability of emergency services and lack of trust in medical staff and their unprofessionalism as possible barriers hampering state-of-the-art treatment of the patients. the respondents in this study confirmed a delayed first contact with a doctor in four of the analyzed diseases (myocardial infarction and stroke from knowledgeable observers, cancer and diabetes from individual witnesses), as well as unavailability of healthcare services in some areas (for stroke and cancer) and long waiting time for specialized care (myocardial infarction and cancer). more than 70% of participants in the study referred to a low quality of medical services, high cost of medication and poor equipment of public clinics and hospitals. despite these remarks, macedonian citizens showed a high level of trust in doctors. the trust in medical doctors or nurses in this study was pointed out for cancer (knowledgeable observers) and injuries (individual witnesses and knowledgeable observers). discussion considering the health challenges that are facing all countries in the southeastern european (see) region, a comparative qualitative study about assessment of the performance of the public health care system was performed in 2013, with participation of eight countries. this paper is focused on the research results obtained in the republic of macedonia. the main idea was to compare the actual level of health care delivery in comparison with the highest, “state-of-the-art” diagnosis, treatment and recovery, related to five deadliest health problems in the country: myocardial infarctions, stroke, cancer, diabetes mellitus type 2 and injuries. the results of the study showed that health professionals consider the macedonian health care system as being “medium/good” with no significant variations in the accessibility, availability, quality of health care service and the population‟s confidence. the overall performance of the health care system was similarly assessed as “good” with no significant differences for different health care problems/diseases. regarding the opinions of study participants, low quality and effectiveness of medical services, high cost of medication and uncommon preventive health related behavior were pointed out as the main barriers in delivery of the state-of-the-art health care treatment. there is a lot of information about the risk factors for non-communicable diseases and preventive measures in the country, but apparently they do not reach the needs and expectation of the citizens, even though the gps are obliged to make regular preventive examinations among the population, according to the national preventive programs. the strategic objective to the ministry of health (2010-2014) aimed to provide healthcare services for the population with good quality, improved availability and accessibility, as well as better primary health care services for the population (13). there are a lot activities that are conducted to meet this goal (including provision of new equipment, education of medical staff, preventive programs and the like). in 2011, the ministry of health started a project for public procurement of new equipment. with a budget of 70 million euros, there were provided over 609 new sophisticated medical devices. the research that was performed in macedonia (in may, 2012) with 531 respondents, showed that citizens expect better behavior of the medical staff, shorter waiting time for medical examination or diagnostic procedures and better hygiene (14). mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 12 in comparison with the results from the other seven countries included in the research comparative study, macedonia shares the same situation as the other see countries, where poverty, financial and geographical barriers are major factors that lead to a lack of access. in most of the countries (especially in moldova, bulgaria and kosovo), out-of-pocket payments constitute more than 40% of the total payments for health care services, in contrast with the responses from participants in macedonia, where out-of-pocket payments as a barrier is mentioned only for cancer. however, the performance of the public health care system in macedonia has differences compared with other see countries, from the point of view of knowledgeable observers, because the knowledgeable observers from croatia, montenegro and serbia tend to assess their health systems in positive terms. on the other side, representatives of romania, moldova and kosovo are rather critical in evaluating their health systems. bulgarians and macedonians consider their health systems as being “medium-good” in all respects. macedonian citizens showed a high level of trust in doctors, similar to the results from the whole study, where from a total number of 845 respondents, 70.8% reported trust in doctors, 21.4 % did not, and the remaining 7.8% were neutral (15). the future reforms in health policies in the republic of macedonia, as well as in other see countries should be oriented toward six major goals (15,16): the need to better define, and evaluate the costs of benefit packages: all eight countries provide, by national laws, comprehensive packages of health-care services. none of the studied health systems has the capacity to ensure the universal provision of such services. the need to develop prevention services: the community nursing system, considered to be the most powerful “equalizer” in the health system is still largely unutilized in most of see countries. despite efforts to develop primary care, access to adequate and holistic community, health care remains a challenge for certain segments of the population (low-income groups, residents of rural areas and small towns, rom, and the like). the need to develop rehabilitation, palliative and long-term care services: palliative, long-term and rehabilitation care are not sufficiently developed as parts of the healthcare systems in the region. most long-term care is provided in the family, and there are few resources available for informal cares. the need to improve the financing of the public health care systems: public health-care systems in the region are under-financed, primarily as a result of fiscal constraints. hence, political will is a major factor for improving the performance of public health care systems. the need for an effective human resource policy in health: in nearly all countries included in this survey, the availability of all types of medical professionals is far below the european average. shortages of some specialties and skills are also reported in the studied countries such as croatia, macedonia, kosovo and moldova, and are not necessarily related to health professional mobility. the need to address informal payments in the public health care system: the study showed that informal payments still represent an access barrier to state-of-the-art treatment, in particular in relation to chronic diseases. informal payments primarily represent a response to the poor capacity of the public health-care system to provide adequate access to basic services. in conclusion, over the last ten years, many efforts have been undertaken to establish a common conceptual framework for health system performance assessment which is defined mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 13 as the way how the individuals/patients are treated encompassing the notion of the patients‟ experience. measuring of the health care performances is a key tool in aiding decision makers to describe, analyze, compare and improve the delivery and outcomes achieved by health care systems (17). this study applied the method of measuring qualitative parameters received by structured interview to quantitative indicators. the results from the first research study performed in the country show that macedonians consider their health systems as being “medium-good” in all respects. the research methodology used in this paper has the potential to extend the applied methods to the large population taking into consideration other socioeconomic characteristics (income, education, cultural influences and the like). it would help to obtain stronger scientific evidence on health care system performances and to foster the development of measuring tools of its components. 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http://data.euro.who.int/hfadb/linecharts/linechart.php?w=1366&h=768 (accessed: november 18, 2015). 13. ministry of health. strategic plan 2012-2014. http://mz.gov.mk/wpcontent/uploads/2013/01/strateski_plan2012-14.pdf (accessed: april 12, 2016). http://hsm.sagepub.com/search?author1=tim+freeman&sortspec=date&submit=submit http://www.moh.gov.mk/ http://iph.mk/images/stories/pdf/pdf_2014/zk%20mk%20prv%20del%202012.pdf http://data.euro.who.int/hfadb/linecharts/linechart.php?w=1366&h=768 mitevska l, stanculescu ms, stikova e. performance of the public health care sector in the republic of macedonia (original research). seejph 2016, posted: 15 april 2016. doi 10.4119/unibi/seejph-2016-104 14 14. health grouper. patients experiences-how to be better? www.healthgrouper.com/mk/page/patients-experiences-2012 (accessed: april 12, 2016). 15. stanculescu ms, neculau g. the performance of public health-care systems in south east europe, friedrich ebert stiftung, belgrade; 2014. 16. stanculescu ms. analysis of the financial literacy survey in romania and recommendation. comprehensive report prepared for world bank. institute for the study of the quality of life. bucharest; 2010. 17. murray cj, evans d. health systems performance assessment. office of health economics; 2006. __________________________________________________________ © 2016 mitevska et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 1 original research the relevance of ethics in the european union’s second public health programme nelly k. otenyo1 1department of international health, school of public health and primary care (caphri), faculty of health, medicine, and life sciences, maastricht university, maastricht, the netherlands. corresponding author: nelly k. otenyo, msc address: department of international health, maastricht university, postbus 616, 6200md, maastricht, the netherlands; email: nellyotenyo@gmail.com otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 2 abstract aim: the objective of this paper was to investigate whether ethical values were explicitly identified in the second public health programme (2008-2013) of the european commission. methods: a qualitative case study methodology of exploratory nature was followed. the data used were the summaries of the project proposals and public health programme objectives and was retrieved from the publicly available consumers, health and food executive agency database. since the php was finalized during the study, the study only focused on the summaries of the fifty-five finalized project proposals while excluding the ongoing projects and those projects at the reporting stage. the full proposals for the projects are confidential and thus could not be retrieved. however, the project summaries were inarguably sufficient to conduct the study. using a table, a content analysis method in addition to the ethical framework, was applied in order to analyze and categorise the project findings. results: the results unfold that, out of the seven ethical principles, only ‘equity’ and ‘efficiency’ were explicitly considered in eighteen projects and four projects respectively. moreover, from the shared health values, eight projects identified aspects pertaining to ‘accessibility to quality health care’ while ‘solidarity’ was only discussed in one project. lastly, the ethical aspects ‘ethics’ and ‘values’ were identified in three projects and in one project respectively. conclusions: from the results, there is a limited consideration of ethical principles within the projects. therefore, future public health programmes could use this as an opportunity to emphasis on the inclusion and application of ethical principles in public health projects. keywords: accessibility for quality health care, efficiency, equity, respect for human dignity, universality. conflicts of interest: none. otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 3 introduction in the recent years, there has been an increased focus on implementing policies that promote better health, that are cost effective and use targeted strategies against targeted ill-health worldwide. this interest has sparked an even greater concern for public health practices, as well as how ethics is observed with regards to health, especially since populations continue to suffer from emerging health challenges (1). it is also commonly known that human health is greatly influenced or affected by public health practices as well as socio-economic circumstances of individuals. in a response to solve this, researchers are constantly evaluating and checking their research work against ethical aspects of public health; assessing whether the recommendations that are or can be derived from their work can be ethically justified. even though there has been a growing interest on how ethics applies to public health, it has not yet gained a prominent position in all public health research. with the increasing burden of disease and emergent public health programmes, it is important to emphasize the need for public health ethics and develop this interest into maturity in order for it to have benefits (2). ethics is an academic discipline that questions what is required to be done, what is right, fair, just and good. therefore, ethics clearly defined is the study of human values and reasoning, but also refers to the systematizing of these values or rules or moral conduct that guides human lives. through the application of ethics, policy makers are able to frame policies and make critical decisions (3). the rise in the study of how public health and ethics are connected has been gradually developing in the past last years, due to human mal-practices, actions and problems in healthcare practice. public health focuses on ways to detect and quantify factors that put the population’s health at risk, once these factors are quantified policies are formulated to tackle or reduce adverse health outcomes for the population (4). public health ethics is concerned with the dissemination of health resources in a more equitable, efficient way and protecting the society (5). numerous studies have been carried out on ethics and public health actions and these have led to normative frameworks of public health ethics. hence, one could assume that ethical aspects are considered by researchers and public health professionals to be significant in enabling a functioning plan, execution and development of various public health programs. within the european commission, the 2007 health strategy ‘together for health’ is a better example of a health policy that considers values, as it is based on shared values. moreover, founded on these values, the second php 2008-2013 was implemented (6). it therefore goes without saying that when ethics are considered, public health is safeguarded, particularly when the ethical aspects are predicted or recognized in advance through critical investigations and discussions (7). an example of how ethical values can be considered in different public health disciplines is through gostin’s work. gostin looks at public health ethics from three viewpoints. the first is ethics of public health, by which professionals need to work for the common good with regards to their public duty and trust from the society. the second, ethics in public health, involves examining the position of ethics in public health. it involves communal and individual interests in relation to the allocation of returns and harms in an equitable way, e.g. in decision making and implementation of public health policies. ethics for public health, gostin’s third point, mainly entails a healthy population where the needs of the vulnerable and marginalized populations are considered in a more practical manner (8). as outlined in gostin’s perspectives, the ethical framework applied in this paper acts as an umbrella to ascertain whether the professionals carrying out the projects are working for the good of the otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 4 public, whether the allocation and distribution of resources is fair, and whether the needs of the minorities are taken into consideration to ensure a healthy population. ethical principles and standards are not only important for public health, they are also considered important for other disciplines, institutions and they have been used in recent years to guide professional conduct and behaviour (9). the european union (eu) is an example of such organizations, it does not only fund research through its framework programmes, but also monitors how health research is done or how projects are implemented (european union, n.d). through the health programme funding, the directorate general for health and consumer affairs (dg sante) oversees the health programme which is managed by the consumers, health and food executive agency (chafea) (chafea, n.d). every year, the european commission through chafea sends a call for proposal for operating grants, conferences as well as joint actions and sets the criteria for funding options available (chafea, n.d). the european commission has so far adopted three public health programmes (hereafter referred to as php). in this work, we will focus on the second php 2008-2013 because of its significance in forming part of the commission’s execution of the eu health strategy “together for health” (10). the objectives of php 2008-2013 were directed towards improving the health information and knowledge of eu citizens. this is done so as to increase the competences of how individuals respond to health threats or how they consider various determinants to stimulate better health or obviate disease (chafea, n.d). against this background, the php 2008-2013 was also aligned with the health strategy ‘together for health’. the first principle of shared health values emphasizes overarching values of solidarity, universality, access to good quality care and equity (6). for this paper, it is interesting to see how the funded projects of the php explicitly dealt with these ethical values and whether they used them as a foundation for setting their public health priorities. it is important to note that exploring the scope and the role of values in public health actions and strategies relates to the discipline of ethics. thus, this paper explores whether ethical values, principles and aspects have been explicitly considered in the second php objectives, proposals and its finalized projects. theoretical framework in order to investigate whether ethical aspects or concerns were considered in the php objectives, projects funded by dg sante, a selection and combination of ethical appropriate principles, safeguarding and incorporating relevant values and aspects of human rights retrieved from studies addressing various aspects of public health ethics are proposed. there are five principles for public health ethics which are also known as ethical principles, these are: health maximization, respect for human dignity, social justice, efficiency and proportionality (11), the principle of respect for autonomy (1), and finally equity as a principle proposed by tannahill are also combined (12). to formulate the framework for this study, these ethical principles will be combined with the shared health values of the eu health strategy namely: ‘universality’, ‘solidarity’, ‘accessibility for quality health care’. respect for autonomy is targeted at various aspects, such as the decision-making power of individuals in relation to their health or the general public health. additionally, it focuses on individual autonomy relating to self-domination, privacy, personal choice and free will (1). respect for human dignity compliments respect for autonomy, it guards the various interests of an individual and his or her absolute value so that an individual is referred to with respect otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 5 especially for his or her liberties, such as self-control (11). it further emphasizes that an individual’s liberties should not be defiled unless it harmfully affects others (13). health maximization is applied in practices where the monetary values of various projects are considered so as to give priority to the most cost effective project but also making sure that the public takes full advantage of all health benefits. the principle social justice guards against segregation and marginalization of vulnerable individuals. it ensures that individuals are treated fairly, particularly in matters of equity and maximization of health benefits, so as to minimize and avoid inequalities related to health care services. due to the growing public health needs and the inadequate public health resources, the principle of efficiency is significant in public health ethics. it is viewed as a moral act that ensures benefits are maximized especially in the execution of public health strategies, done by promoting the dissemination of basic necessities in a resourceful way. the proportionality principle advocates for benefits to be considered and assessed alongside the harmful properties, especially when debates on individual liberty versus public good arise (11). equity seeks to ensure that, the less privileged are not secluded in key public health actions that are important to them. in response to this, interventions and strategies that analyze the unfair allocation of services across different populations are implemented to target those at risk in a way to find the influencing factors and decrease inequalities (12). from the health strategy, shared values, universality value ensures that every eu citizen has equal access to use the available healthcare and services and that no one is denied care. the value access to good quality care guarantees that the available health care and services are of high quality and no eu patient is denied any high-quality care. equity as a value ensures that every eu patient is entitled to receive health care and services irrespective of their ethnic, gender or social economic backgrounds and status. solidarity ensures that all the financial arrangements made by the respective member states will promote the accessibility of health care and services to all citizens (6). using this framework, this paper will explore whether ethical principles, values and the 2007 strategy’s shared values were sufficiently addressed in objectives, proposals and finalized projects of the second php. table 1. overview of ethical principles and health strategy values (source: references 11-13) ethical aspect description health maximization complete utilization of health benefits respect for human dignity no violation of individual liberties social justice promotes fairness and guards against discrimination efficiency promotes cost effectiveness, maximizing of benefits and limits wastefulness proportionality considers the benefits alongside harm respect of autonomy promotes individual’s free will and privacy equity supporting the fair access with reference to the need but regardless of origin, sex, age, social or economic rank universality no patient is denied access to health services and care accessibility to quality health care ensure accessibility of high quality health care for all solidarity the financial organization of a member states’ health system so as to ensure health is accessible for all. otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 6 methods a qualitative study design was carried out to gain insights into the ethical concepts and determine whether they have a role in the funding allocation of phps and in the reported project results. the search items used, relate to the seven principles and basic terms of ethics: ‘equity’, ‘autonomy’, ‘health maximization’, ‘respect’, ‘dignity’, ‘social justice’, ‘justice’, ‘efficiency’, ‘proportionality’, ‘ethics’, ‘moral’, ‘value’, ‘ethic’, ‘ethical framework’. including the shared health values ‘universality’, ‘solidarity’, ‘accessibility’ and ‘quality health care’. it is important to note that despite the fact that, a number of projects used ‘equity’ to imply the reduction of inequalities, the term ‘inequalities’ was still excluded used as a keyword. all data was retrieved from the consumers, health and food executive agency (chafea). the proposals were available as summaries which included the following sections: general objectives, strategic relevance and contribution to the public health program, methods, means and expected outcomes (chafea, n.d). the research focused on the summaries of the fifty-five finalized project proposals at the data collection time and excluded projects that were still ongoing as well as projects at the reporting stage. the study included all the projects from all the three strands of the chafea project database: health information, determinants/health promotion, and health threats/health security. for the analysis, the individual project aims, goals and principles were compared against the ethical framework principles and the shared health values so as to show the overlapping concepts and which ethical gaps still need to be addressed. moreover, the identified ethical aspects are further scrutinized to ascertain whether they were only mentioned as keywords or whether they were expected outcomes of the analyzed project. methodological and theoretical limitations including other potential challenges the results from this study will indicate whether ethical concepts and public health ethics are already a constituent part of public health projects particularly with regard to the second eu public health programme. however, since this is a qualitative research, the study may encounter some limitations. to ensure validity as proposed by bowling the researcher intends to organize, clustering the retrieved data into relevant and respective ethical themes (14). this study has looked into the php’s, assessing whether ethical aspects were explicitly considered in its objectives and the summaries of the project proposals. the study recognizes that, by focusing on the only the explicit role of ethics in php through the eyes of only the seven principles and the shared health values, other ethical relations and aspects which are still vital in phps may have been excluded. in addition, not all projects that implicitly discussed aspects related to the principles and shared values were reported due to the act that, out 55 finalized projects, ethical principles and related concepts were identified both explicitly and implicitly in 27 projects. since the researcher used the given description of the principles to decide which ethical aspects and values were related to each other, there may be some form of interpretation bias. however, as discussed in the paper, it is inarguable that there are various definitions of ethics and ethical frameworks depending on different disciplines. this has led different ethical frameworks to be defined and applied to suit certain situations. the seven ethical principles proposed for the framework may therefore be exclusive in terms of excluding other significant values and concepts. additionally, given different definitions, application and otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 7 descriptions of the principles, it is clear that some aspects may refer to various principles such as universality and accessibility to health care. the study recognizes that, by focusing on the explicit role of ethics in the php through the eyes of only the seven principles and the shared health values, other ethical relations and aspects which are still vital in phps may have been excluded. the results focusing on the project proposals show minimal external validity as they only apply to the 55 finalized projects and may perhaps not be adequately generalized to a broader setting. however, regarding the results focusing on the objectives of the php, the representativeness of the findings cannot be questioned since the objectives apply to all the projects funded during the 2008-2013 php. thus, it can be generalized to improve the projects that are yet to be finalized and even aid in the drafting of the objectives of future php’s in the case of learning from best practices. since most of the projects and proposals from the second php 2008-2013 were still in the final phase during the data collection, only the projects that were finalized by june 2014 were included and the projects submitted at any later date were excluded. the full proposals for the projects were also confidential and thus could not be retrieved. therefore, it may be likely that some ethical principles and values might have been considered elsewhere in the full proposals hence resulting in limitations on the findings of this study. however, the project summaries were inarguably sufficient to conduct this study as they included a detailed executive summary of the project objectives in relation to the php objectives. results after examining the summaries of the 55 project proposals and the eu public health programme objectives, the findings were as follows. out of the seven ethical principles from the theoretical framework, only two principles were identified. other terminologies used in the analysis included ‘ethics’ and ‘values’ which were identified in three projects and in one project respectively. since the second php was founded on values prioritized in the eu health strategy: together for health, the keywords ‘universality’, ‘access’, ‘quality health care’ and ‘solidarity’ retrieved from the first principle of the health strategy were identified differently in nine projects. eight projects identified aspects pertaining to accessibility to quality health care and solidarity was only discussed in one project. additionally, out of the four shared health values, only ‘equity’, ‘solidarity’ and ‘access to quality health care’ was identified explicitly in the objectives of the php. the projects were analysed basing on the seven ethical principles, the four shared health values and the ethical concepts ethics, morals and values. the results will be analysed and presented in the following categories. the different research questions will be answered and discussed in their respective sub-sections below. table 2. presentation of the findings categories used in analysis and how results are presented the terminologies used those identified in project proposals and/or in php objectives ethical concepts in php objectives & project proposals morals, values, ethics, ethics, values, otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 8 shared health values identified in php objectives and project proposals equity, accessibility to quality health care, universality and solidarity solidarity, universality and accessibility to quality health care ethical principles identified in php project proposals health maximization, equity, proportionality, respect for human dignity, autonomy, efficiency, social justice. efficiency and equity ethical concepts and shared health values in the php-2008-2013 objectives ethical concepts such as, ‘ethics’, ‘morals’ and ‘values’ were not identified in the php objectives. however, the shared health values equity, solidarity and access to quality health care were explicitly identified in the php objectives. from the general objectives of the php, the common goal evident is improving ways that will ensure and promote the health security of the eu citizens. this goal is in line with the shared health value of ensuring ‘accessibility to quality health care’. even though ‘accessibility’ is not explicitly mentioned in the php objectives, it is one of the main objectives of the php because through the php, the eu commission seeks to improve the member state’s capacities of responding to all kinds of health threats and ensure that the health care services, treatment and medications, for example transplant organs, are of the highest quality. the php 2008-2013 also aims to promote the health of the eu citizens while reducing health inequalities. solidarity ensures that all member states commit to working in unity while supporting each other for the growth and development of the entire eu. moreover, with regards to the solidarity value, the php was envisioned to complement, offer assistance and add value to the member state’s policies by developing, distributing and sharing all information, evidence, best practices and expertise relating to health to all member states. since solidarity ensures that less capable countries are not left out in the development or growth, the php fully supports this value as it aims to see to it that prosperity in the european union is increased, and as a counter effect public health is improved. table 3. shared health values in the php-2008-2013 objectives (source: adapted from reference no. 15) shared health values of the eu health strategy description as given in chapter 4 of this paper how the concept is used in the php objectives equity reduces inequalities among the minorities “promote health and reduce health inequalities” solidarity mutual support and commitment among the ms “it is intended to complement, support and add value to the policies of the member states and contribute to increasing solidarity and prosperity in the european union” “generate and disseminate health information and otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 9 knowledge, exchanging knowledge and best practice on health issues’’ access to quality health care safe and quality health care is made available to everybody “promoting actions related to patient safety through high quality and safe healthcare, scientific advice and risk assessment, safety and quality of organs, substances of human origin and blood” otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 10 ethical principles in the php 2008-2013 project proposals from the 55 projects, only 6 projects explicitly discussed findings that related to equity, while efficiency was only identified in four projects. • equity: the project ‘daysafeimproving patient safety of hospital care through day surgery’, recognized existing challenges health systems face while trying to ensure fair access to high quality and safe health care. the project therefore proposes to offer applicable solutions and as a result increase patient satisfaction, safety, equity and quality of health care. according to the ‘chain of trust’ project, increasing the awareness and understanding of the available recommendations regarding the perceptions, challenges and advantages resulting from the use of tele-health, will equip all the key stakeholders with knowledge and information that will add value and further promote the provision of health care equitable to all patients in the eu. the ‘healthvent’ project discusses equity under the strategic relevance and contribution to the public health programme section of their proposal. it emphasizes that, its objectives will be aligned with those of the php as it aims to tackle environmental health determinants specifically those related to the use of energy in homes, schools and various public buildings so as to prevent chronic diseases and further decrease inequalities in health. ‘crossing bridges’ builds on the execution of article no. 168 of the ec treaty to ensure that the hiap vision is accomplished for equity across the eu. moreover, ‘crossing bridges’ expects that through the project results, the respective stakeholders will be encouraged to implement policies that will result in health equity. by developing a suitable surveillance and information system for health the ‘eumusc.net’ project expects to increase and harmonise the quality of care to allow for equity in care for rheumatic illnesses and musculoskeletal disorders across the member states. through the consideration of structural aspects of gender inequality and gender stereotypes that openly affect men and women’s health, ‘engender’ project aims to ensure equity by creating an online inventory of good practice of policies and programmes that focus on promoting health. • efficiency: ‘daysafe’ expects to improve the technical efficiency of health services by ensuring that the policy-makers are well-informed and recognize the factors limiting the performance of ds, such as operational issues and incompetently designed structures. ‘healthvent’ project: through establishing a health-related ventilation guideline focussing on buildings such as schools, homes, offices and nursery buildings among others, ‘healthvent’ expects that inhabitants will utilize energy in a more reasonable manner so as to have more energy efficient buildings. bordernet project aims to improve the prevention, testing and treatment of hiv/aids/stis by reducing obstacles related to practice, policies and cooperation between border countries and among member states though a more transparent and sustainable network. this will further improve the effectiveness and efficiency capacity of organizations of various sectors responding to aids/stis. ‘engender’ expects that increasing the awareness and creating a platform for all stakeholders to be well informed through the online inventory of best practices, will result in effective, efficient policies and programs that focus on achieving gender equity in health. otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 11 table 4. efficiency aspects identified in project proposals project title aspects of efficiency/ efficient identified in the php project proposals improving patient safety of hospital care through day surgery (daysafe). "the project will enhance ds which represents a crucial strategic approach toward the improvement of health services safety and quality, including patient’s satisfaction, together with technical efficiency and, possibly, equity" health-based ventilation guidelines for europe (healthvent) the (guidelines) "will reconcile health and energy impacts by protecting people staying in these buildings against risk factors, and at the same time taking into account the need for using energy rationally and the need for more energy efficient buildings" highly active prevention: scale up hiv/aids/sti prevention, diagnostic and therapy across sectors and borders in cee and see (bordernetwork) "the improved effectiveness and efficiency on regional and cross-border level in interdisciplinary response to aids/stis and scale up of hiv/stitesting will put forward the practical implementation of hiv combination prevention" inventory of good practices in europe for promoting gender equity in health (engender) "increased awareness and knowledge for all stakeholders including: policy makers, politicians, researchers, ngos and citizens, within and outside the health sector about effective, efficient policies and programmes to achieve gender equity in health" shared values of the 2007 eu health strategy in the php 2008-2013 project proposals? out of the four shared health values, only accessibility to quality health care and equity were addressed in the summaries of the project proposals. basing on the description given for universality, the value was in a way linked to the context used to describe accessibility. from this assessment, more principles are seen to be used in association such as, ‘accessibility and universality’, ‘universality and equity’. • accessibility to quality health care: accessibility was analyzed in the projects in two parts: first, those projects that promote high quality health care services and secondly, those that ensure high quality of health care are accessible to all. ‘coorenor’, ‘daysafe’ and ‘implement’ projects discuss ‘high quality of health care’ by stating that quality assurance models are present in their projects and will ensure safe and high quality of services across the eu. ‘imp.ac. t’ and ‘promovox’ projects promote actions that particularly focus on marginalized groups and migrants. ‘imp.ac. t’ aims to ensure that access to hiv/tb testing for marginalized groups is improved, and ‘promovox’ emphasizes the facilitation of better access of immunizations among the migrant population. ‘care-nmd’ relates accessibility of healthcare to reduced inequalities. the project believes that, by improving the access otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 12 to expert care, there will be a reduction of inequalities among member states and within a member state. otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 13 table 5. accessibility to quality health care as identified in the summaries of the project-proposals project title accessibility to quality health care value as used in the php project proposals coordinating a european initiative among national organizations for organ transplantation (coorenor) "all requirements for ensure recipient safety and high quality of the treatment as well as running models for quality assurance will be considered and transferred to the eu institutions improving patient safety of hospital care through day surgery (daysafe) "the general objective of the project is to improve patient safety & quality of hospital care through the promotion of ds best practice and standards. implementing strategic bundles for infection prevention and management (implement) "aims to improve patient safety through high quality and safe healthcare". highly active prevention: scale up hiv/aids/sti prevention, diagnostic and therapy across sectors and borders in cee and see. (bordernetwork) “bordernetwork' focuses both disease causes and underlying social determinants of health, aiming to improve responses to prevention offers and accessibility of care services”. improving access to hiv/tb testing for marginalized groups (imp.ac.t) a) “improving access to hiv/tb testing for marginalized groups b) “to increase the percentage of idus and migrants having access to hiv and tb testing” promote vaccinations among migrant populations in europe (promovax) “improve migrants understanding & acceptance of immunizations and facilitate their access to immunizations by identifying a network of relevant sites”. dissemination and implementation of the standards of care for duchenne muscular dystrophy in europe (including eastern countries) (care-nmd) "improved access to specialist care for dmd and reduction of inequalities between countries & within countries due to better trained health professionals" otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 14 ethical concepts or aspects in the php 2008-2013 • ethics: under the strategic relevance and contribution to the php section, ‘chain of trust’ acknowledges that the consideration of ethical associated issues while developing recommendations related to the approval of telemedicine by patients and health professionals is important especially during the implementation of telemedicine. ‘apyn’ will assist in realizing the work plan priority 3.3.4 for preventing addiction and further contribute to the alcohol strategy. the project proposes to consider “ethically sound actions” which, according to the priority areas for 2008 as stated in the 2008 work plan, refers to the ethical aspects outlined in the charter of fundamental rights of the european union. “ethical considerations: any proposal, which contravenes fundamental ethical principles particularly those set out in the charter of fundamental rights of the european union may be excluded from the evaluation and selection process” (16). apyn’ and ‘healthy eco life’ will support the work plan actions through the “involvement of new (non-traditional) actors for health in sustained, co-operative and ethically sound actions, both at regional or local level and across participating countries” (chafea, n.d). • values: ‘active’ intends to introduce a new method that will engage children between 5-8 years of age in europe. it is evident from their title that the project aims to teach and inspire the children with values and views concerning healthy eating and physical activity‘animation for children to teach and influence values and views on healthy eating and physical activity (active)’. however, the project only mentions the term ‘values’ in its title. discussion these ethical principles ensure that the individuals or professionals governed by them align their actions and conduct with the principles in order to uphold the society’s trust. most of the ethical principles used in public health actions and research assist in making sure that researchers and public health professionals are held responsible by society. moreover, ethical principles enable researchers to develop trust with the society, which often may cause them to receive funding or financial support for their research from the public because of their reliable and excellent work. furthermore, upholding ethical principles in research will stimulate the consideration of significant moral and social values (9). therefore, it is important for public health professionals and all stakeholders to abide by ethical principles in their duties. additionally, ethical consideration is not limited to public health professionals only at a european level, it is also relevant for public health research and projects of the eu’s public health programmes. with the php 2008-2013 being aligned with the health strategy ‘together for health’, which was explicitly value based in setting priorities, ethics still plays a significant role in the explicit project proposals; yet, this role is not evident in all the phps. however, it is surprising to see that less than half of the projects considered the principle equity which is regarded as a public health and an eu strategy priority. it is clear from the projects, that the mention of equity in their objectives and expected outcomes is not a sufficient indication of ethical consideration, for example, by mentioning that project actions will promote the coordination of abilities from both eastern and western otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 15 europe, coorenor project justifies its role in reducing health inequalities. this is an example to show that the mere mention of ethical principle is not an indication for its consideration in the entire project implementation and therefore the project falls short of explicitly considering equity. in spite of this, various projects still gave relevance to ethical principles and values as they exhaustively discussed in their project summaries matters that related to ethics. ‘daysafe’ recognizes that challenges exist which cause inaccessibility to quality and safe health care, hence they progress to propose methods that will promote equity in health. in discussing ‘efficiency’, the four projects, ‘bordernetwork’, ‘healthvent’, ‘daysafe’ and ‘engender’,only discussed how their activities and methods will result in efficient services and materials. they however fail to show in their methods how this will be attained and only limit it to mention that providing of policy guidelines will promote efficiency. regarding ‘accessibility to quality health care’, the projects questioned the quality and safety of health care services offered in europe and offered to foster a high level of surveillance and monitoring to further ensure that the quality health care is accessible to all patients. they linked quality assurance strategies to high quality services. even though some projects did not explicitly mention ‘accessibility’, their objectives and method description matched the value ‘universality’ while also linking it to reduced inequalities, as they emphasized that no one particularly minorities such as, migrants, hiv/aids and tb patients, should be denied access to health care. most of the projects had implicit discussions of how best practices should be shared across the eu and coordination among all different stakeholders should be supported in order to reduce inequalities in health instead of the explicit mention of solidarity. ex-post evaluation of the health programme the aim of this evaluation was to assess the main results that were reached as well as recognize the key challenges and solutions especially after consideration of recommendations from preceding assessments. the post evaluation study was guided by four key themes that is programme management, dissemination methods, the effect of the health programme collaboration with other programmes and services. according to the assessment, the programme lacked proper management as monitoring data was not used, thus making followup a challenge. in order to increase the number of accepted and executed health programme funded actions, the main results of the health actions have to be made available to the relevant target groups. the 2nd health programme objectives were very broad, covering various significant needs of the member states as well as those of the stakeholders. it was therefore recommended that the health programme ought to introduce more specific progress analysis as they have been defined in the 3rd health programme. with regard to the 2nd health programme’s objectives, the funded actions led to significant advancements such as, promoting cross-border partnerships. it is important to note that, the administrative duties of the programme were increasingly efficient. moreover, the 2nd programme has shown major eu added value in recognizing best practices as well as networking (17). even though, the objectives of the health programme are commendable as they seek good practices and also focus on national priorities while contributing to a healthy status for the european population, they are still very broad and only focus on the relevance of the action. therefore, they may fail to explicitly address most of the ethical principles used in this study. otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 16 since the study has examined only the explicit use of ethical principles and concepts in the project summaries and the php objectives, the ethical framework may therefore exclude implicit discussions of ethical principles and other significant ethical values especially those based on ethical definitions not considered in the descriptions provided for this study. despite the fact that the ethical framework used for this assessment was based on seven principles, the study therefore doesn’t provide a full picture of this ethical role in php but provides a new mentality and platform that will enable the explicit rethinking and reconsidering of ethics and ethical aspects in public health. this new mentality and concern according to callahan and jennings will lead us to considering vital questions such as: “what are the basic ethical issues of public health? what ethical orientations are most helpful in the clarification and resolution of these issues? how are ethical principles and concepts incorporated into decision making in public health agencies and programs? how adequately are ethical dimensions of public health policy identified and debated?” this is because as public health gains more prominence, the ethical aspects regarding health issues increase too (2). conclusions this paper has presented and outlined ethical aspects that were explicitly identified in the 2008-2013 programme objectives and available project reports of the php. the projects were assessed, based on the theoretical framework consisting seven ethical principles. furthermore, the four shared health values of the eu health strategy were considered as they were more general ethical concepts. from the analysis, the principle ‘equity’ was extensively discussed and considered by some of the projects, followed by the ‘efficiency’ principle and then the value ‘accessibility to quality health care’. the study recognizes that by focusing on the role of ethics in php through the eyes of only the seven principles and the shared health values, other ethical relations and aspects which are still vital in phps may have been excluded. most commonly addressed values of the eu health strategy: ‘together for health’ by the projects were, ‘equity’, ‘accessibility’ and ‘universality’ as it seemed expected from them since the php was based on values. it is encouraging to see that most of the shared health values were discussed in most of the projects. even though vital principles such as‘respect for human dignity’, ‘autonomy’, and ‘health maximization’ were not addressed by any of the projects. it is clear from the projects, that the mere mention of a principle briefly such as ‘project will ensure equity’ in the project objectives and expected outcomes is not enough to justify that the principle will be adequately considered or that the project understands or acknowledges the significance of ethics in public health today. the project needs to consistently consider ethical aspects in its entire proposal, in this case a project summary, and not just mention it, since it is required and expected to be included under the ‘strategic relevance and contribution to public health programme’ section. this study has tried to paint a picture of the role of ethics in public health programmes. even with its prominence, ethics in public health programmes and activities still needs to be encouraged. moreover, more awareness in understanding ethics and ethical aspects in public health activities will further steer more ethical considerations not only amongst public health professionals and researchers, but also a more explicit and consistent consideration in phps and public health actions. in addition, basing on gostin’s work, ethical values ought to be otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 17 considered firstly by professionals in order to guide them in working for the common good of the society. secondly, in public health in terms of how decision making influences the balance between individual and communal interests especially in the implementation of public policies. thirdly, ethics for public health where the needs of the population are met in practical ways, such as more emphasis on training and research to improve ethical knowledge, as well as applications. this study has therefore provided a new mentality and platform that will enable the explicit rethinking and reconsidering of ethics and ethical aspects in public health. references 1. beauchamp tl, childress jf. principles of biomedical ethics: oxford university press; 2001. 2. callahan d, jennings b. ethics and public health: forging a strong relationship. am j public health 2002;92:169-76. 3. preston n. understanding ethics. the federation press; 2007. 4. mann jm. medicine and public health, ethics and human rights. hastings center report 1997;27:6-13. 5. kass ne. public health ethics from foundations and frameworks to justice and global public health. j law med ethics 2004;32:232-42. 6. commission e. white paper–together for health: a strategic approach for the eu 2008–2013; 2007. 7. coughlin ss. ethical issues in epidemiologic research and public health practice. emerg themes epidemiol2006;3:16. 8. gostin lo. public health, ethics, and human rights: a tribute to the late jonathan mann. j law med ethics 2001;29:121-30. 9. resnik db. what is ethics in research & why is it important. research triangle park, north carolina: national institute of environmental health sciences/national institute of health; 2010. 10. commission e. together for health: a strategic approach for the eu 2008–2013. white paper, ip/07/1571; 2007;23. 11. schröder-bäck p, brand h, escamilla i, davies jk, hall c, hickey k, et al. ethical evaluation of compulsory measles immunisation as a benchmark for good health management in the european union. centr eur j public health 2009;17:183. 12. tannahill a. beyond evidence—to ethics: a decision-making framework for health promotion, public health and health improvement. health promot int2008;23:380-90. 13. sørensen k, schuh b, stapleton g, schröder-bäck p. exploring the ethical scope of health literacy: a critical literature review. alban med j 2013;2:71-83. 14. bowling a. research methods in health: investigating health and health services: mcgraw-hill international; 2009. 15. council directive. decision 1350/2007ec of the european parliament and of the council of europe; 23 october 2007. 16. commission. e. guide for the evaluation for proposals for action grants and operating grants, joint actions; 2008. 17. directorate-general for health and consumers: the second health programme 20082013. http://ec.europa.eu/health/programme/policy/2008-2013_en. accessed 13 july 2015. otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 18 ___________________________________________________________ © 2017 otenyo; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. introduction in the recent years, there has been an increased focus on implementing policies that promote better health, that are cost effective and use targeted strategies against targeted ill-health worldwide. this interest has sparked an even greater concern fo... theoretical framework methods methodological and theoretical limitations including other potential challenges results ethical concepts and shared health values in the php-2008-2013 objectives ethical principles in the php 2008-2013 project proposals equity: the project ‘daysafeimproving patient safety of hospital care through day surgery’, recognized existing challenges health systems face while trying to ensure fair access to high quality and safe health care. the project therefore proposes to... efficiency: ‘daysafe’ expects to improve the technical efficiency of health services by ensuring that the policy-makers are well-informed and recognize the factors limiting the performance of ds, such as operational issues and incompetently designed s... shared values of the 2007 eu health strategy in the php 2008-2013 project proposals? ethical concepts or aspects in the php 2008-2013 ethics: under the strategic relevance and contribution to the php section, ‘chain of trust’ acknowledges that the consideration of ethical associated issues while developing recommendations related to the approval of telemedicine by patients and healt... ‘apyn’ will assist in realizing the work plan priority 3.3.4 for preventing addiction and further contribute to the alcohol strategy. the project proposes to consider “ethically sound actions” which, according to the priority areas for 2008 as stated ... apyn’ and ‘healthy eco life’ will support the work plan actions through the “involvement of new (non-traditional) actors for health in sustained, co-operative and ethically sound actions, both at regional or local level and across participating countr... values: ‘active’ intends to introduce a new method that will engage children between 5-8 years of age in europe. it is evident from their title that the project aims to teach and inspire the children with values and views concerning healthy eating and... discussion conclusions references kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 1 | 27 original research epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. laurant kollçaku1 1 pediatrics department, unit of endocrinology and diabetes, university hospital center 'mother teresa', tirana, albania. corresponding author: laurant kollçaku address: university hospital center “mother teresa”, rr. dibres, no. 371, tirana, albania; email: laurantkollcaku@gmail.com kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 2 | 27 abstract aim: diabetes mellitus is a major public health problem worldwide. type 1 diabetes mellitus (t1dm) is the most common metabolic chronic disease in genetically susceptible children and adolescents, due to an autoimmune process characterized by a selective destruction of insulin producing β-cells. the aim is to assess the epidemiological features of new-onset t1dm in children and adolescent at the national level during the period 2010-2014 in department of pediatrics, endocrine unit, university hospital center 'mother teresa', tirana, as the unique center for pediatric endocrinology and diabetology in albania. methods: the clinical and laboratory characteristics of 152 patients aged <15 years newly diagnosed with t1d from 1 january 2010 to 31 december 2014 were studied. t1d was diagnosed according to who 2006 criteria and dka was diagnosed based on ispad 2014 criteria. patients were classified into 3 sub-groups (i: 0-4 years, ii: 5-9 years, and iii; 10-14 years). statistical analysis was performed using spss 26. results: the incidence of new-onset of t1dm was 5.012/100.000/year. the mean age of children at diagnosis was 8.3 ± 3.6 years. the patients were mostly diagnosed at ages 5-9 years (40.1%), and 10-14 years (39.5%), followed by the 0-4 years age group (20.4%). mean duration of symptoms was 23.35 ± 17.16 days; longer in the subgroup 5-9 years (p= 0. 0.013). three quarters (75%) of children with t1dm live in urban areas. viral infections or other circumstance triggers were in 41.9% of children aged 0-4 years compared to other subgroups (p=0.002). most of the children were born in the spring−summer months (53.23%) compared to the autumn−winter months (46.77%). approximately 1/4 of the children were born and diagnosed with type 1 diabetes in each of the seasons of the year and 52.63% of the patients studied were first born. family history for dmt1 and dmt2 is observed in 15.8% and 17.8% of the children, respectively. polyuria (99.3%), polydipsia (99.6%) and weight loss (98.1%) were the most common symptoms and 67.8% of patients presented with diabetic ketoacidosis (dka). misdiagnosis was in 21 (13.8%) patients. mean glycosylated hemoglobin a1c (hba1c) was 11.63%; 11.9 ± 2.0 in dka positive children and 11.1 ± 2.4 in dka negative children (p= 0.195). at diagnosis and during follow up of t1dm 25% (38/152) developed associated autoimmune diseases; 68.42% at diagnosis of t1dm and 65.79% (25/38) of patients were female. during follow up children with t1dm developed associated cd and sat, 2.54, and 2.19 years, respectively. conclusion: diabetes mellitus is one of the major public health problems worldwide. albania is a country with middle incidence of t1dm and the age at onset is decreasing. the symptoms lasted significantly longer and mean hba1c levels were significantly higher in older children. the incidence of dka in children with newly diagnosed t1dm is high. keywords: autoantibodies, children, diabetic ketoacidosis, incidence, seasons, type 1 diabetes. conflicts of interest: none declared. kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 3 | 27 s introduction type 1 diabetes mellitus (t1dm) is the most common endocrine and metabolic disease in children and adolescents aged 0–14 years (1). t1dm represents 5-15% of the diabetic population; 85-95% have t2dm and less than 2% have other forms of diabetes (2). the incidence of childhood type 1 diabetes is increased worldwide more than two to three folds during the last decades, particularly in finland and sardinia (“hot spots” of the world) (3). the incidence of t1d in children < 15 years of age is increasing significantly, approximately 3% (range 2-5%) (1,4,5). from 1965 to 2012 the incidence of type 1 diabetes in pediatric population has increased significantly from 9.44% (8.22–10.66) to 19.58% (14.55–24.60) (6), with the exception of central america and the west india (4). the overall incidence of dmt1 is 11.43/100,000/year, and according to gender; 11.42 (10.23–12.61) in boys and 11.11 (9.94– 12.27) in girls (4). in many european countries the overall incidence has increased to 3.9% (ranges from 0.6% 9.3%); the increase is higher in children aged 0-4 years with 5.4%, compared to 4.3% and 2.9% for age groups 5-9 and 10-14, respectively (4). the main epidemiological characteristics of type 1 diabetes in children < 15 years old are: the large variation of incidence from 0.1 in venezuela to 62.3 per 100,000 per year in finland (7); the increasing incidence in countries with lower incidence and the trend of occurrence towards the younger age group (0-4 years) (3). variation of type 1 diabetes incidence cannot be explained by genetic factors alone (frequency of protective hladq alleles between populations) suggests the importance of environmental factors in the complex pathogenesis of dmt1. exposure to one or more environmental factors of genetically predisposed individuals, triggers an immune response that causes the selective destruction of pancreatic beta cells. among environment factors include: latitude and geographic position (811); frequent and high exposure to cow's milk and its products (12), consumption of foods high in carbohydrates (13); short-time exposure to ultraviolet radiation and insufficiency and deficiency of vitamin d; oceanic climate (cold winter and summer) (6); prenatal and postnatal viral infections (14-16); pregnancy-related factors (parental age at birth, order of birth, maternal illness, viral infections) and perinatal period (birth weight, gestational age) (17); use of pharmaceutical products (antibiotics); obesity (increased bmi) (18-20); migration; socio-economic status with high income (7); gender and age (21) as well as the month and season of birth (22) are all associated with increased risk of type 1 diabetes. this study aims to investigate the epidemiological features of t1dm in children and adolescents aged <15 years, during the period 2010-2014 in albania. patients and methods study type this study represents a series of patients (cases) newly diagnosed with type 1 diabetes mellitus presented at the specialty service, endocrinology clinic, "mother teresa" university hospital center, tirana (qsut), during the period 2010-2014. study population this prospective study from january 1, 2010 to december 31, 2014, included 152 patients who met the criteria: children diagnosed with t1d for the first time < 15 years old in albania. the number of children and adolescents aged 0-14 years old from 20102014 according to instat is 3,032,819 children (1,451,992 females and 1,580,827 males). patients are classified into 3 age kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 4 | 27 groups (i: 0-4 years, ii: 5-9 years, and iii: 1014 years). inclusion criteria: the study included 1) new cases aged < 15 years diagnosed for the first time with diabetes mellitus type 1 during the period january 2010 december 2014 resident in albania, which from a geographical point of view corresponds to the administrative borders and census; 2) individuals who received their first insulin injection before their 15th birthday and resident in albania at the time of the first insulin administration. exclusion criteria: new cases ≥ 15 years of age during the period 2010-2014, cases of diabetes mellitus from secondary causes as a result of a primary pathology (cystic fibrosis, corticotherapy, mody, etc.) were excluded from the study. data collection data for this study were collected prospectively using a standardized clinical record. information was collected on a range of demographic and laboratory data. the epidemiological data regarding the date of birth, the date of initial presentation of t1dm and age at diagnosis, the order of birth, the birth weight, the mode of delivery, and pubertal status were obtained from the patients’ clinical records. the diagnosis of t1d was determined according to who, 2006 criteria; the ispad, 2014 criteria were used to determine dka; hyperglycemia (glycemia> 200 mg/dl or > 11 mmol/l), metabolic acidosis (ph < 7.30, and /or plasma bicarbonate level < 15 mmol/l or ketones in urine (ketonuria > 2+), accompanied by history of polyuria, polydipsia, nocturia, weight loss, dehydration, nausea, vomiting, abdominal pain, respiratory signs (acetone odor, respiratory distress, dyspnea), level of consciousness (classified into 3 categories: normal, altered consciousness and coma according to the pediatric glasgow coma scoring system), and different triggers conditions. anthropometric measurements (weight, height, body mass index, bmi (kg/m2) also expressed in standard deviation (bmi-ds), stage of pubertal development according to tanner. the severity of dka was determined by the ph and concentration of plasma bicarbonates and was categorized into 3 groups: (a) mild: ph <7.30 and/or serial bicarbonate <15 mmol /l; (b) moderate: ph <7.2 and /or bicarbonate <10 mmol /l and (c) severe: ph <7.1 and /or bicarbonate <5 mmol/l (table 1). according to ispad, new-onset t1dm with ph > 7.3 and hco3 > 15 meq/l was classified as t1dm without ketoacidosis. ethics approval and consent of participate: informed written consensus was obtained from all patients' parents. it is approved by the albanian national ethics committee. statistical analysis absolute numbers and corresponding percentages were used to describe the categorical data. to describe numerical data, the reporting of the central tendency measures, in this case the mean value, and the dispersion measures, in this case the standard deviation, was used. the square hi test was used to compare categorical variables; in case the resulting table was in the size of 2x2, then the value of p was reported according to fisher's exact test, which gives a more accurate calculation of the p-value. to compare the mean values of the numerical dependent variable according to the categories of the independent variable, the non-parametric mann-whitney u test was used for two independent samples in the case where the independent variable had only two categories; otherwise, when the independent variable had >2 categories the nonparametric kruskal wallis test was used for k kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 5 | 27 independent samples. non-parametric tests were used in case the dependent variable was found to be abnormally distributed in the study population. otherwise, for normally distribute numerical variables, the student's ttest for two independent samples was used. binary logistic regression test was used to identify the associations between the presence of diabetic ketoacidosis and the independent variables. various tables depending on the information were used to present the data. graphs of different types were used to present and illustrate the study findings. in all cases, the associations between the variables were considered significant if the value of the statistical significance was ≤ 0.05 (or ≤ 5%). all statistical analyzes were performed through the statistical package for social sciences, version 26 (ibm spss statistics for windows, version 26) software program. results a total of 152 (52% male and 48% female) children age < 15 years were diagnosed with type 1 diabetes mellitus (t1dm) during the study period. the mean age at diagnosis, age, sex and residence distribution of the study population are shown in table 1. the mean age of the subjects at the time of diagnosis is 8.3 years ± 3.6 years. at the time of diagnosis, 40.1% were between ages 5-9 years, followed by 39.5% between ages 1014 years and 20.4% younger than 5 years. three quarters (75%) of children with t1dm live in urban areas and 25% in rural areas. table 1. mean age at diagnosis, age, sex and residence distribution of the study population variable frequency (%) mean age at diagnosis (mean value ± standard deviation) 8.3 ± 3.6 agegroup 0-4 years 5-9 years 10-14 years 31 (20.4%) 61 (40.1%) 60 (39.5%) gender male female 79 (52%) 73(48%) residence urban rural 114 (75%) 38 (25%) total 152 (100.0) mean duration of symptoms to the diagnosis of t1d was 23.35 ± 17.16 days. no statistically significant gender differences were observed regarding mean duration of symptoms, while the age differences were statistically significant: 17.48 days among children 0-4 years old, 28.61 days among children 5-9 years old and 21.03 days among children 10 -14 years (table 2). kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 6 | 27 table 2. duration of symptoms to the diagnosis of t1dm statistical parameter time of onset of symptoms to diagnosis of dmt1 (in days) p-value according to gender p-value according to subgroups mean average value 23.35 0.362* 0.013** the standard deviation 17.16 median 21.00 mode 30 minimum value 0 maximum value 90 the spectrum 90 * p value according to the non-parametric mann-whitney u test for two independent samples. ** p value according to the non-parametric kruskal wallis test for k independent samples. at diagnosis of t1d1, 13.8% were misdiagnosed as viral infection, gastrointestinal and respiratory airways infection and less often as surgery emergency. table 3. misdiagnosis at new onset of t1dm variable frequency (%) suspicion of diabetes at the time of admission no yes 21 (13.8%) 131 (86.2%) family history for dmt1 were in 15.8%, dmt2 in 17.8% and both types in 2.6% of the children. among children with a positive family history of dmt1, the grandfather/grandmother was most often affected (54.2%), followed in 29.2% of cases by the brother/sister. table 4. family history and t1dm and/or t2dm variable frequency (%) family history with t1dm 24 (15.8%) family history with dmt2 27 (17.8%) kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 7 | 27 figure 1a. positive family history of t1dm figure 1b. positive family history of t2dm regarding the season of birth and the season of diagnosis of type 1 diabetes of the children in the study, it is noted that approximately 1/4 of the children were born in each of the seasons of the year. however, more than half of dmt1 were diagnosed in autumn and winter (60.5%). table 5. distribution of children at diagnosis of t1dm according to the seasons of birth and seasons of diagnosis 0 2 4 6 8 10 12 mother grandfather father mother and grandfather others (aunts, uncles,causins) siblings siblings and grandfather 0 2 4 6 8 10 12 mother father & others (aunts, uncles,causins) grandfather grandfather & others (aunts, uncles,causins) father others (aunts, uncles,causins) kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 8 | 27 birth season 0-4 years 5-9 years 10-14 years spring 8 14 17 summer 6 15 15 autumn 7 21 13 winter 10 12 14 total 31 62 59 season's diagnosis spring 3 18 18 summer 5 8 8 autumn 13 20 16 winter 10 16 17 total 31 62 59 figure 2. distribution of diagnosis and frequency of birth in different seasons of year the data analysis showed that most of the children were born in the spring−summer months (53.23%) compared to the autumn−winter months (46.77%) (figure 3a). most of the children were born in december, followed by those born in november, april, august and september (figure 3a). significantly more children were diagnosed with t1dm during the colder months of the year, october−march (53.3%) compared to 46.7% during the warmer months, april−september (figure 3b). 25.7 13.8 32.2 28.3 25.7 23.7 27 23.7 spring summer autumn winter birth season season of diagnosis kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 9 | 27 figure 3. a) distribution of children according to month of birth. b) frequency of diagnosis of t1dm during the cold and warm months kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 10 | 27 table 6. birth order birth order 1 2 3 4 total 80 43 27 2 0-4 years 15 10 4 2 5-9 years 35 15 12 0 14-10 years 30 18 11 0 52.63% of the patients studied were first born, 28.3% were the second child of the family, 17.8% were the third child, 4.6% the fourth child and 1.3% were the fifth child (fig. ). the differences observed with respect to the order of birth are statistically significant (chi-squared test, p < 0.001). figure 4. a) birth order b) birth order according to the age the mean birth weight of our study group was 3325 ± 463.8 g (min: 1500 g, max: 5100 g). 1.3% of the patients had a birth weight below 2500 g, 70.4% between 2500 0 10 20 30 40 50 60 70 80 90 1 2 3 4 0 5 10 15 20 25 30 35 1 2 3 4 0-4 years 59 years 10-14 years kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 11 | 27 and 3500 g and 28.3% >3500 g. most of the patients (82%) were born by normal vaginal delivery and 18% by cesarean section. among the children diagnosed with dmt1, in 23.7% of cases the presence of viral infections (enteroviruses, hepatitis, frequent upper respiratory tract infections, gastroenteritis) and one case chest trauma were identified. psychosocial stress (divorce, death of a parent and family member) was observed in 2.6% of children. there were no statistically significant gender differences related to these indicators. the percentage of viral infections history or other trigger conditions were higher in children aged 0-4 years (41.9%) compared to children aged 5-9 years (27.9) and aged 1014 years (10%) [p=0.002] and no statistically significant age differences were observed regarding the psychosocial stress. polyuria (100%), polydipsia (100%), and weight loss (98.1%) were the most common complaints. the frequency of malaise, vomiting, enuresis nocturnal, acetone odor, dyspnea, drowsiness and confusion was higher among children with dka (p < 0.001). figure 5. the presenting clinical manifestations of children and adolescents at the time of diagnosis, the overall incidence of ketoacidosis was 67.8%. the mean age of children with dka was 7.75 ± 3.64 years, and 9.29 ± 3.39 years in children without dka (p = 0.012). there were no statistically significant differences by age subgroup and living residence; the percentage of females was higher in t1dm children with dka (54.4%) than among those without dka (34.7%) (p = 0.025). 102 49 26 96 5 5 12 25 4 15 3 56 45 35 45 36 22 4 46 18 1 36 2 0 3 3 0 3 1 3 0 0 0 1 0 0 0 20 40 60 80 100 120 p o ly u ri a a n d … a p p e ti te v a ri a ti o n n o c tu rn a l e n u re si s w e a k n e ss ,… h e a d a c h e c o n st ip a ti o n a b d o m in a l p a in v o m it in g d ia rr h e a o ra l c a n d id ia si s m o n il ia l… a c e to n e s m e ll k u ss m a u l… t a c h y p n e a /p o ly … d y sp n o e a s o m n o le n c e c o n fu si o n c e re b ra l e d e m a t1dm with dka t1md without dka kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 12 | 27 figure 6. frequency of dka at diagnosis of t1dm positive family history of type 1 diabetes increases the odds ratio (or) of the presence of dka by 1.52 times, and positive family history of type 2 diabetes decrease 1.56 (1/0.64) times the presence of dka (protective role), compared to children without family history for dmt2 but this difference is not statistically significant (p>0.05). a positive family history for both dmt1 and dmt2 increases the likelihood of the presence of kad by 8.73 times, but even these differences did not reach statistical significance (p>0.05). viral infections and other trigger conditions increase the likelihood of the presence of kad by about 1.58 times; however, there were not statistical significance difference (p> 0.05). regarding the association of psycho-social stress and presence of kad in type 1 diabetes, seems that psycho-social stress may be a risk factor for the presence of dka in diabetic children (being that 3.9% of diabetic children). table 7. association between the presence of dka in diabetic children and selected variables – odds ratio (or) by binary logistic regression test variable or § 95% ci * p-value † lower interval upper interval positive family history of t1dm 1.52 0.56 4.10 0.411 positive family history of t2dm 0.64 0.27 1.50 0.300 positive family history of t1dm or t2dm 6.00 0.60 59.80 0.127 positive family history of t1dm and t2dm 8.73 0.82 92.85 0.073 viral infections and other trigger conditions 1.58 0.68 3.68 0.290 67.8 32.2 t 1 d m w i t h d k a t 1 d m w i t h o u t d k a kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 13 | 27 female with dka 2.24 1.11 4.54 0.025 subgroup 0-4 years with kad 2.97 1.06 8.32 0.038 age (year) -0.126 †† 0.016 urban residence and dka 1.32 0.61 2.84 0.484 duration of signs and symptoms (day) 0.015 †† 0.179 § odds ratio (or) of the presence of kad in diabetic children versus its absence, according to the binary logistic regression procedure; * 95% confidence interval (95% ci) for or; † statistical significance value (p value) according to the binary logistic regression test. table 8 presents the association of the kad with symptoms and signs of children in the study. it appears that presence of nocturnal enuresis, malaise, vomiting, acetone smell and drowsiness increase the odds of the presence of dka in diabetic children by 16.21, 4.95, 4.98, 18.27 and 25.79 times, respectively, and these differences are statistically significant (p<0.05). it must be said that kussmaul respiratory distress, polypnea/tachypnea, dyspnea, confusion and cerebral edema/coma appear to be significant predictive factors of the presence of dka in diabetic children, but the absence of these signs in children without kad made binary logistic regression analysis impossible. table 8. association between the presence of dka in diabetic children and selected variables – odds ratio (or) by binary logistic regression test variable or § 95% ci * p-value † lower interval upper interval nocturnal enuresis 16.21 2.13 123.35 0.007 malaise 4.95 1.83 13.40 0.002 headache 1.20 0.22 6.41 0.832 abdominal pain 2.02 0.54 7.52 0.294 vomiting 4.98 1.42 17.41 0.012 oral candidiasis 2.61 0.72 9.49 0.144 monilial vaginitis 1.44 0.15 14.21 0.755 acetone smell 18.27 5.34 62.54 <0.001 somnolence 25.79 3.42 194.67 0.002 glycaemia 0.006 †† 0.001 ph -78.275 0.022 hco3 -0.312 0.001 triglycerides 0.009 0.009 table 9 presents the relationship between the presence of dka and some laboratory parameters of the diabetic children in the study. data analysis showed that blood glucose and triglycerides are positively related to the presence of dka, being that each additional unit of glycemia and triglycerides increases the odds of dka by 0.006 and 0.099 times, respectively, and these changes are statistically significant (p<0.05). in the meantime, ph and hco3 are negatively related to the presence of kad: kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 14 | 27 thus, one additional unit of ph and hco3 decreases the likelihood of dka by 78.275 and 0.312 times, respectively and these differences are statistically significant (p<0.05). table 9. association between dka and laboratory parameters t1dm with dka t1dm without dka p-value frequency of dka at diagnosis (%) 67.8 32.2 mean age 7.75 ± 3.64 9.29 ± 3.39 0.012 † gender (male/female) (%) 45.6/54.4 65.3/34.7 0.025** residence (urban/rural) (%) 76.7/23.3 71.4/28.6 0.549** age-groups 0-4 years 25 (24.3) * 6 (12.2) 5-9 years 43 (41.7) 18 (36.7) 0.082** 10-14 years 35 (34.0) 25 (51.0) duration of symptoms (days) 24.65 ± 17.39 20.61 ± 16.51 0.169* family history of t1dm/t2dm (%) 17.5/15.5 12.2/22.4 0.482/ 0.364** viral infections trigger 26.2 18.4 0.316** serum glucose level (mg/dl) 513.2 ± 193.2 386.5 ± 138.3 <0.001 glycated hemoglobin (hba1c) at baseline 11.9 ± 2.0* 11.1 ± 2.4 0.195 ** blood ph 7.2 ±0.1 7.4 ± 0.1 <0.001 hco3 8.7 ± 5.4 19.9 ± 4.5 <0.001 triglycerides 217.5 ± 189.9 118.2 ± 55.7 0.001 presentation with severe dka based on venous ph (<7.1) 17 (32.1) * <0.001** presentation with severe dka based on hco3 (<5) 15 (28.8) <0.001** the mean hba1c level of the total study population was 11.65±2.2%. hba1c levels did not differ by age subgroups or gender. age (years) 0-4 5-9 10 -14 mean value hba1c 11.63 ± 2.05 11.76 ± 162 11.70 ± 1.76 there were no significant differences of mean hba1c values between diabetic children with and without kad (11.9 ± 2.0% vs. 11.1 ± 2.4%, p=0.195) at diagnosis and during follow up. the average values of hba1c at diagnosis and over time in diabetic children with and without kad are presented in the following figure 7. it can be seen from the figure 7 that the progress of hba1c over time is more favorable for diabetic children without kad compared to diabetic children with kad, since in diabetic children without kad the average level of hba1c is constantly lower than in children with kad, while in children with kad the average level of this parameter remains more or less constant but at quite high levels (between 89%). kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 15 | 27 figure 7. mean hba1c level (in %) among diabetic children with and without dka, during study * mean value ± standard deviation. ** statistical significance value according to the non-parametric mann-whitney test for two independent samples. at diagnosis of t1dm, 17.10% (26/152) of the children had concomitant autoimmune diseases (ad): 14.47% (22/152) autoimmune thyroid disease (atd) and 2.63% (4/152) cd; 65.38% (17/26) were female and 34.62% (9/26) male. half of children (13/26) with autoimmune diseases were presented with dka. according to the specific age group 7.7% were in the age group 0-4 years; 57.7% in the age group 5-9 years and 34.6% belong the group age 10-15 years old. at the time of diagnosis, among children with atd, 68.2% were female, ages 8-10 were the most affected (59.09%), 23% children had tsh >5 mu/l and 77% of children were positive tpo and 80% e children with positive tpo had normal thyroid function. among children that developed concomitant cd at diagnosis of t1dm, 2 patients were female and 2 males; 2 age group 0-4 years and 1 age group 5-10 years and 1 age group 10-14 years. of these, 1 girl, age 1.4 years preceded the diagnosis of dmt1 by 4 months (table). during follow-up, 8.55% of children developed sat and cd; 8 children cd and 4 children sat. the mean age of developed of cd and sat after the diagnosis of t1d were 2.19 and 2.54 years, respectively. of these, 1 child developed sat and cd; hashimoto 1.023 years and cd 4.11 years after the diagnosis of dmt1. kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 16 | 27 table 10. concomitant autoimmune diseases (ad) in children with t1dm discussion the study included 152 children and adolescents aged 0-14 years, diagnosed with dmt1, presented to the pediatric department, "mother teresa" university hospital, tirana during the period january 1, 2010 to on december 31, 2014. to our knowledge, there are no similar studies conducted earlier in albania that illuminate the epidemiological characteristics of children with dmt1. in this context, the present study takes a greater importance. dmt1 is one of the most common autoimmune chronic metabolic diseases in children and adolescents. the incidence of childhood onset type 1 diabetes is increasing by ∼50% every 10 years (1,4). according to the data of the international diabetes federation (idf) 2017 (23), the number of children and adolescents living with diabetes during the last decades is growing rapidly, especially among younger children. in european population the incidence of type 1 diabetes varied tenfold (24); from the lowest in georgia (4.6/100,000/year) to very high in finland (62.3/100,000/year) (25). however, most european countries have intermittent incidence (5.0-9.99 per 100,000 population) (1). during the 2010-2014 study period, the incidence of t1dm among albanian children ages < 15 years was 5.012/100,000/year, places albania among countries with middle risk (1). countries that have an incidence of t1dm close to albania are belarus (5.6), romania (5.4) and macedonia (5.8) (25). besides north macedonia, bosnia-herzegovina (8.2) and croatia (9.1) (25), other countries of the southern european region, have a high incidence (10-19.99/100,000/year) (1). frequency (%) ad at diagnosis of t1dm ad post diagnosis of t1dm age (years) 0-4 5-9 10-14 12 /152 (7.89%) atd+cd 26/152 (15.79%) 1 (0.66%) female 17/26 (65.38%) 1 (5.9%) 10 (58.82%) 6 (35.3%) male 9 /26 (34.62%) 1 (11.11%) 5 (55.56%) 3 (33.3%) atd female male 22/152 (14.47%) 15/22 (68.2%) 7/22 (31.8%) 5 (3.96%) 4 1 cd female male 4/152 (2.63%) 2 2 2 1 1 8 (35%) 4 4 tsh > 5 mu/l 6 (23%) ac. anti tpo > 25 iu/ml 20 (77%) dka 13 (50%) positive tpo & normal thyroid function 16/20 (80%) mean age after diagnosis of t1dm sat cd 2.19 years 2.54 years kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 17 | 27 in general, the incidence increases with age until middle puberty, with a peak at age 10– 14 years compared to other ages is attributed the rapid hormonal changes (26,27) and decreases after puberty, particularly in females compared to young male adults (28,29). approximately 45% of children are first presented before age 10 (30). the mean age of children with t1dm included in this study was 8.3 ± 3.6 years. in our study, at the time of diagnosis of dmt1 about 40% were 10-14 years old; 40% were 5-9 years old and 20% were 0-4 years old of children with diabetes. these findings are consistent with international literature data. interestingly, in search study the distribution of children with diabetes by age group was about 21% of children 0-4 years, in the philadelphia registry, 37% were 5-9 years and 41% were 10-14 years (26), quite similar to that of our study. according to the eurodiab registry, 24% of children with type 1 diabetes were 0–4 years old, 35% were 5–9 years old, and 41% were 10–14 years old (26), these results are quite similar to the findings of our study. a study in france of 1299 children 0–14 years old at the time of t1d diagnosis reported that 26% were 0–4 years old, 34% were 5–9 years old, and 40% were 10–14 years old (31), these findings are completely similar to the age distribution of t1dm evidenced in our study. although most autoimmune diseases more commonly affect females, in the overall incidence of childhood t1dm there no gender difference. in our study, it was observed an almost equal gender distribution among children with type 1 diabetes; 52% male and 48% female. these data are also supported by international studies. the search study on diabetes in youth reported both genders are equally affected by type 1 diabetes (26). type 1 diabetes mellitus is characterized by global, modest seasonal variation, with the highest incidence in the cold months (autumn-winter) and the lowest in the warm months (spring-summer). (32) the diamond project demonstrated that the seasonality of the incidence of type 1 diabetes mellitus in children ages < 15 years is a real phenomenon. statistical differences in the seasonality of the development of type 1 diabetes have been found in populations with intermediate and high incidence compared to the general population (3,33). there is a significant tendency of younger patients to be diagnosed in the cold months. the reason for this seasonal difference is not completely understood, it may be related to the pathogenic role of various environmental triggers including infections encountered more frequently in the younger age groups, especially due to kindergarten enrollment, although there are no definitive conclusions regarding the role of specific infections in the occurrence of dmt1 (34). a study among children ages 0-14 years in bulgaria reported that a greater proportion of children with dmt1 were diagnosed during the autumnwinter period (about 62.5%) (35), a figure completely similar to the finding in our study where 60.5% of children with dmt1 were diagnosed in autumn-winter. in our study we did not observe any clear trend regarding the seasonality of the birth and diagnosis of children with dmt1, as about a quarter of children with dmt1 were born and about a quarter of them were diagnosed in each season of the year. however, 60.5% of dmt1 cases in our study were diagnosed in autumn-winter and 39.5% in spring-summer. there is a connection between the month of birth and the development of dmt1 during the later stages of life (34). children born during the spring and summer months, especially in countries with intermediate incidence such as eastern european countries, have a higher risk of developing type 1 diabetes compared to children born during the fall and winter months (36,37). it kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 18 | 27 is thought to be related to seasonal environmental factors during fetal-perinatal life and thereafter (38) which influence fetuses and children to develop islet autoimmunity (6,23,39) and the disease at different ages (34). our finding was similar to a study in greece (40), while several other studies reported the opposite (26,34). seasonal character of birth month and t1dm development in some sub-populations is related to gender, ethnicity and race, and viral infections. in some countries males born in the spring and summer months are prone to develop t1dm while in others predominate females (41). in our study, 56% (42/75) of children born in the spring summer months were boys. in homogenous populations despite incidence of type 1 diabetes children born in the spring summer months have a higher risk of developing type 1 diabetes, while this association is not in ethnically heterogeneous populations (42). the increased risk of t1dm manifestation in children born in spring-summer is also related to viral infections including enteroviruses, rotavirus, mumps virus, cytomegalovirus, rubella virus, etc. based on serological, immunological findings (43). a variety of infections play a role in the conversion of endogenous beta-cell antigens into immunogenic structures, where infiltration of the islets of langerhans, by activated autoreactive t cells is considered to be the major driver of the onset and progression of type 1 diabetes mellitus. if the pregnancy occurs during the months with the highest presence of viral infections (43) they are more likely to be infected and to transmit the virus to the fetus. consequently, given a normal gestation period of 40 weeks, children born in spring and summer are more likely to develop type 1 diabetes. the order of birth has been associated with t1dm presentation. the study by eirini kostopoulou., et al 2021 (44); chris r cardwell., et al. 2011 (45) showed increase the risk of childhood type 1 diabetes in first born children and reduction risk in secondor later born children particularly among children aged <5 years. the cause of any increase in the risk of childhood type 1 diabetes in first born children is unknown. it is possible related with younger maternal age, maternal prenatal immune response to environment exposures (46), congenital infections and use of antibiotics by mothers during pregnancy (43), reduced or delayed exposure to infections such as enteroviruses (47), household with older siblings who are exposed to infectious agents at school or day care or parents pay attention differently for their first child compared with subsequent children. our findings are consistent with international literature data. this finding may provide indirect support for the hygiene hypothesis, which suggests that the immune system requires stimulation by infections and other immune contests in early life to achieve a mature and balanced repertoire of responses (48). the higher incidence of dmt1 in western countries can be dedicated to the phenomenon of "hygiene hypothesis"; according to this hypothesis, decrease of the frequency of infections of diabetogenic viruses may lead to an increase in the incidence of dmt1 (43). however, exposure to viruses does not necessarily appear to be the cause of dmt1 but rather may be beneficial in some cases (43). regarding viral infections in our country, data is not available. a relatively low level of hygiene, especially in rural areas point toward that viruses are one of the main etiological factors of t1dm. based on the fact that in our study only 25% of diabetic patients lived in rural areas, it appears that this study supports that part of the literature that emphasizes a protective role of viral infections in the development of dmt1 in children. kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 19 | 27 in our study, three quarters of children with t1dm lived in urban areas. such finding has been evidenced into similar studies conducted in the balkan countries (35). however, other studies have evidenced a higher incidence of dmt1 among children living in rural areas (49-53) suggested that the higher incidence of dmt1 in rural areas may be related to a lower exposure of these children to protective environmental factors (53). the international literature suggests the role of psycho-social stress in the development of t1dm in children. a study among 338 children with dmt1 aged 0–14 years in sweden and 528 controls suggested that stressful life events (threats or fear of losing family members, such as divorce or death of parents) adverse psychosocial stressful events (including events with difficult adjustment, child behavioural deviations, and disordered and chaotic family functioning) 12-24 months before the diagnosis of t1dm, during the two years before t1d diagnosis in children statistically significantly increased the risk of t1d (54) and may have different impacts at with a relative risk (rr) of 1.82 in different ages (55). the stressful life events, are associated with the development of t1d in children aged 5-9, acting as a risk factor for this disease (56). in our study, we did not have a comparison group to analyse whether stressful psychosocial life events are a risk factor for t1dm in children, but psychosocial stress related to parental divorce or death was evidenced in 2.6% of children with t1dm at aged 5–9 years compared to the children aged 0–4 and 10-14 years, confirming the findings of the study in sweden. further studies can be undertaken to verify whether psychosocial stress is a risk factor for t1dm in our country. in our study, it was found that 23.7% of children with dmt1, had a history of precipitating viral infections, significantly higher among children aged 0-4 years (41.9%) compared to children aged 5-9 years (27.9) or those aged 10-14 years (10 %) [p=0.002]. more than 85% of individuals who develop type 1 diabetes have no family history, so the general population screening to identify risk in is an important goal (56). in our study we found that 15.8% of children with dmt1 had a family history of dmt1, 17.8% had a family history of dmt2, 28.3% had a family history of dmt1 or dmt2, and 2.6% had a family history of both dmt1 and dmt. the genetic component of the development of dmt1 is known. the risk of developing dm1 in first degree relatives is 8 to 15 times higher (57-59) and about twice as high in second-degree relatives compared to children with no relatives with diabetes (5760). about 10-12% of children with t1dm have a family history of diabetes at the time of diagnosis, which may increase more than 20% during their lifetime (60-63) data which are very similar to the findings of our study. a study among 1488 children aged 0–14 years in finland reported that 21.8% of them had a firstor second-degree relative with type 1 diabetes at the time of diagnosis (64). the fathers transmit dmt1 to their offspring more often than mothers (58,65). similar findings were observed to our study: 12.5% of children with dmt1 had a father and only 8.4% of them had a mother with dmt1 at the time of diagnosis. different studies have reported different data regarding the time between the appearance of symptoms and the moment of diagnosis. the duration of symptoms to the diagnosis can vary greatly, ranging from a few days to several weeks or months depending on the level of education of the parents, the fact of the presence of diabetes in other family members, level of health care, the age of the patient, etc. (66). the average duration of symptoms to the diagnosis of dmt1 in our study we was 23.35 ± 17.16 days, ranging from 0 days (immediate diagnosis) to a kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 20 | 27 maximum of 90 days (ie, 3 month). our results regarding the duration of symptoms were similar to those reported by demir f, et al (67) and usher-smith et al (68). the age of the patient is important because younger patients usually present with mild, vague symptoms, while older children usually present with the classic symptoms of the disease such as polyuria, polydipsia and weight loss (66). younger children are more likely to present in severe stages of the disease, reflecting this in a higher frequency of ketoacidosis (kad) compared to older children due to higher levels of respiratory and gastrointestinal infections in this group, which may delay diagnosis (66). it has been proven that the diagnosis of dmt1 can be established later in girls than in boys, for unknown reasons (66). there are no statistically significant gender differences regarding this parameter, but there are significant age differences where this time was longer in children 5-9 years old (28.61 days) (p = 0.013). polyuria, polydipsia and weight loss were the most common symptoms, 99.3%, 99.3% and 98.1%, receptively. the second and most serious, life-threatening presentation of t1dm is dka. although the incidence of dka in many developed countries has been reduced (69-71), various studies around the world reported a 6-fold variation of dka in presentation from 12.8% to 80% of children diagnosed with t1d for the first time (72). in our study the overall incidence of ketoacidosis was 67.8%. the mean age of children with dka was 7.75 ± 3.64 years, while that of children without dka was 9.29 ± 3.39 years (p = 0.012). the mean age at diagnosis of children with dmt1 with kad is significantly higher than that of children with dmt1 without kad (24.65 ± 17.39 vs 20.61 ± 16.51, p=0.169). in general, children with dmt1 with kad are diagnosed earlier than children with dmt1 without kad, possibly because of their more gravity of clinic. in our study we found that the frequency of dka was higher among girls (76.7%) than among boys (59.5%) and this difference was statistically significant (p = 0.025). the higher frequency of dka among girls with t1d than among boys with t1d is also reported in the international literature. the girls were stated to experience dka more frequently, possibly due to some sexrelated social or biological differences (72). our results were similar to the data of demir f., et al (67). females and ages 0-4 years were identified as factors related to the presence of kad in children with t1dm; 2.24 and 2.97 times, respectively more likely to be affected by kad compared to males and children ages 10-14 years, respectively (p<0.05). nevertheless, was evidenced a negative and statistically significant relationship between age and the presence of kad: for every year increase of the age of children, the possibility of the presence of kad decreases by 0.126 times. positive family history for dmt1 is considered a protective factor and is associated with a reduced risk of dka at t1dm diagnosis because cases are diagnosed in an earlier stage (73). our results did not reach agreement with these findings. pawlowicz et al (74) and also reported that a positive family history had no such impact. positive family history for dmt1 and dmt2 was not statistically significantly associated with the presence of kad in children with dmt1. however, children who have a positive family history of dmt1 or dmt2 were 6 times more likely to be affected by kad (p=0.127); children with a history of dmt1 and dmt2 were 8.73 times more likely to be affected by kad compared to children with dmt1 without a positive family history of dmt1 or dmt2 (p=0.073, borderline). the presence of viral infections or other precipitating conditions increased the odds of kad by 1.58 times compared to kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. (original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 21 | 27 children without these conditions, this difference did not reach statistical significance. regarding residence, children living in urban areas are 1.32 times more likely to be affected by kad compared to children in rural areas. the misdiagnosed were in 13.8% of cases, of which respiratory and gastrointestinal and infectious illnesses were the most common. almost all were presented with kad; and almost half (45.3%) were in the age group 04 years similar results were found in the study małgorzata pawłowicz et al (14.13%) (74). autoimmune diseases are more common in females. in children and adolescents with t1dm of both genders carry similar risk and have no significant differences in overall incidence (75). the gender predominance of dmt1 is thought to be influenced by race, age of diabetes diagnosis, and incidence. in certain populations the incidence of dmt1 is more frequent in males (76) and in some more frequent in females (77). in caucasians, in high-incidence countries (23/100,000/year) (78), children ages < 6 and ≥13 years of european origin (age group which is more likely to develop diabetes for the same age and geographical localization (male: female ratio 3:2) (79) men have a slightly higher incidence than females. on the other hand, the female predominance is seen in of non-caucasian origin (80), african and asian, low incidence countries (81), peripubertal age (82). age, urban residence and year of diagnosis (35) and factors are related to viruses’ infections, dietary factors such as gluten, obesity in childhood, improvement of hygienic-sanitary conditions, etc. (83) are statistically significant risk factors for the occurrence of dmt1 in children. t1dm is associated with an increased risk of developing other autoimmune diseases as a result of genetic susceptibility to autoimmune diseases (ad). the most common comorbidities include: autoimmune thyroid disease (atd) and celiac disease (cd) (84), possibly because of some common pathogenetic mechanisms including certain gene expressions (34). these ad are observed more frequently in females with t1dm (85). at diagnosis and during follow up of t1dm 19.74% (30/152) developed associated autoimmune diseases; 11.85% atd and 7.89% cd. of them, 60% at diagnosis of t1dm and 68% of patients were female. during follow up children with t1dm developed associated cd and sat, 2.54, and 2.19 years, respectively. these findings are consistent with international literature data. references 1. diamond project group. incidence and trends of childhood type 1 diabetes worldwide 19901999. diabet med 2006;23:857-66. doi: 10.1111/j.14645491.2006.01925.x. 2. international diabetes federation. diabetes atlas (4th edition). brussels, belgium: idf; 2009. 3. gale ea. the rise of childhood type 1 diabetes in the 20th century. diabetes 2002;51:3353-61. doi: 10.2337/diabetes.51.12.3353. 4. patterson cc, dahlquist gg, gyurus e, green a, soltesz g. incidence trends for childhood type 1 diabetes in europe during 1989-2003 and predicted new cases 2005-20: a multicentre prospective registration study. lancet 2009;373:2027-33. 5. search for diabetes in youth study group. the burden of diabetes mellitus among us youth: prevalence estimates from the search for diabetes in youth study. pediatrics 2006;118:1510-8. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4439892/#ref12 kollçaku l. epidemiological features of new-onset type 1 diabetes mellitus in children and adolescent during 2010-2014 in albania a unique experience. 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(original research). seejph 2022, posted: 24 november 2022. doi: 10.11576/seejph-6078 p a g e 27 | 27 85. fröhlich-reiterer ee, hofer s, kaspers s, herbst a, kordonouri o, schëarz hp, et al. screening frequency for celiac disease and autoimmune thyroiditis in children and adolescents with type 1 diabetes mellitus—data from a german/austrian multicentre survey. pediatr diabetes 2008;9:546-53. ________________________________________________________________________________________ © 2022 kollçaku; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 1 editorial comment launch of the ‘one health global think-tank for sustainable health & well-being’ – 2030 (ghw-2030) the adoption of the 17 sustainable development goals (sdgs) by the un general assembly in september 2015 opens a new era for global, regional, national and local initiatives to ensure the well-being and sustainability of the planet and people (1). the south eastern european journal of public health (seejph) published several papers (volumes 2,3,5) on the un global goals (2, 3, 4). in addition, prof ulrich laaser and prof vesna bjegovic mikanovic established together with dr george lueddeke a global think-tank on „global health, governance, and education‟ (5) to help inform the writing of the epilogue of dr lueddeke‟s recent book entitled global population health and well-being in the 21 st century – towards new paradigms, policy, and practice (6). in continuation of this process we worked with dr. joanna nurse, head of the commonwealth* secretariat health and education unit (heu) (7, 8) and collectively founded the „one health global think tank for sustainable health & well-being – 2030‟ (ghw-2030). a synopsis of the think-tank‟s remit and membership is set out below. the summary is followed by a background paper outlining the ghw-2030 rationales, particularly in light of the un 2030 agenda for sustainable development (9), and the pressing need to incorporate holistic one world, one health values, principles and practice (10, 11) as these relate to environmental, social, economic and geopolitical spheres with a view to guiding associated frameworks (12, 13), policies and enabling strategies. a listing of current ghw-2030 members and affiliations is also provided. for the ghw-2030, april 2016 professor ulrich laaser, international public health, university of bielefeld, bielefeld, germany (ulrich.laaser@uni-bielefeld.de) dr george lueddeke, think-tank convenor/chair; southampton, united kingdom (glueddeke@aol.com) dr joanna nurse, head, commonwealth secretariat health and education unit (heu), london, united kingdom (j.nurse@commonwealth.int) * the commonwealth is a voluntary association of 53 independent and equal sovereign states. it is home to 2.2 billion citizens, of which over 60% are under the age of 30” (7). laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 2 references (1) united nations. sustainable development goals, sustainable development knowledge platform, 2016. available at: https://sustainabledevelopment.un.org/sdgs (2) burazerii g, laaser u, jose m. martin-moreno jm, schröder-bäck p (eds.) complete issue. seejph 2014, vol.2: availableat:http://www.seejph.com/index.php/seejph/article/view/2/ (3) burazeri g, laaser u, martin-moreno jm, schröder-bäck p (eds.) complete issue. seejph 2015, vol.3: available at: http://www.seejph.com/index.php/seejph/article/view/3/ (4) burazeri g, laaser u, martin-moreno jm, schröder-bäck p (eds.) complete issue. seejph 2016, vol.5: available at: http://www.seejph.com/index.php/seejph/article/view/3/ (5) laaser u, bjegovic-mikanovic v, lueddeke g. et al. epilogue. in: lueddeke g. global population health and well-being in the 21st century: toward new paradigms, policy, and practice. springer publishing, new york; 2016. (6) lueddeke g. global population health and well-being in the 21 st century: toward new paradigms, policy and change. springer publishing; new york; 2016. available at: http://www.springerpub.com/global-population-health-and-well-beingin-the-21st-century-toward-new-paradigms-policy-and-practice.html. (7) the commonwealth secretariat. about us: the commonwealth; 2016. available at: http://thecommonwealth.org/about-us. (8) the commonwealth secretariat. promoting sustainable social development and well-being for all: an overview of the commonwealth secretariat‟s health and education unit. available at: file:///c:/users/george/downloads/health_and_education_unit_brochure.pdf (9) united nations. transforming our world: the 2030 agenda for sustainable development; 2016. available at: https://sustainabledevelopment.un.org/post2015/transformingourworld (10) one health commission. ohc mission; 2016. available at: https://www.onehealthcommission.org/en/why_one_health/ohc_mission/ (11) one health initiative. mission statement;2016. available at: http://www.onehealthinitiative.com/mission.php https://www.thecommonwealth-healthhub.net/ (12) nurse j. a health systems policy framework for the commonwealth to support the sustainable delivery of universal health coverage (uhc). commonwealth secretariat, health and education unit, london uk; 2015. (13) lueddeke g. achieving the un-2030 sustainable development goals through the „one world, one health‟ concept, oxford public health; 2016. available at: https://issuu.com/oxfordpublichealth/docs/oxph_magazine_issue_4_apr2016/37?e=19 297810/34461022 copyright (c) 2016 ulrich laaser, george r. lueddeke, joanna nurse http://www.seejph.com/index.php/seejph/article/view/3/ http://www.seejph.com/index.php/seejph/article/view/3/ http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html http://www.springerpub.com/global-population-health-and-well-being-in-the-21st-century-toward-new-paradigms-policy-and-practice.html http://thecommonwealth.org/about-us https://www.onehealthcommission.org/en/why_one_health/ohc_mission/ http://www.onehealthinitiative.com/mission.php https://www.thecommonwealth-healthhub.net/ https://issuu.com/oxfordpublichealth/docs/oxph_magazine_issue_4_apr2016/37?e=19297810/34461022 https://issuu.com/oxfordpublichealth/docs/oxph_magazine_issue_4_apr2016/37?e=19297810/34461022 laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 3 the one health global think tank for sustainable health & well-being – 2030 (ghw-2030) purpose, rationales, and guidance synopsis purpose to bring together global multi-sectoral and multi-disciplinary thought leaders to articulate and advocate for sustainable „planet and people‟ health and well-being. mission and method the central mission of the ghw-2030 multi-sectoral think tank is to contribute to the implementation of the un sustainable development goals (sdgs) by working toward achieving the education and health goals in cooperation with the commonwealth secretariat using an international interdisciplinary/multidisciplinary/transdisciplinary global one health approach. a major focus of the think tank will be on the health and well-being – physical, emotional, aspirational – of children and young people particularly as these relate to their personal security, physical and emotional well-being, education and employment and the sustainability of life on the planet. referencing contemporary and future-oriented developments, the activities of think tank members include:  analysing root causes with regard to key issues in environmental, social, economic and geopolitical arenas, particularly in relation to „well-being‟ goals, targets and indicators underpinning the un 2030 agenda for sustainable development;  considering and assessing future risks, such as egocentrism, demographic shifts, environmental, and public one health challenges generally – human, animal, plant, environmental – and identifying potential solutions at local, national, regional and global levels;  exploring creative and innovative approaches for informing global and national policy directions, including a „global framework for public health systems and services‟ (see background paper below, fig 4) .  publishing and disseminating knowledge and evidence-based papers articles (possibly informed by recognised research tools (e.g., cdc-authored community guide) or interviews in a creative and sustained fashion;  producing short summaries of policy options and recommendations for policy-makers and planners;  stimulating public online discussions as well as potential consortial activities, including social media; and  contributing to decision-making and policy development (government and nongovernmental) to enhance sustainable „health and well-being‟ at local, national, regional and global levels, involving existing and potential mechanisms for transformative enabling action. laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 4 in addition, along with others, think tank members will have the opportunity to engage in high level on-line policy discussions on the commonwealth secretariat‟s health and education unit hubs as well as contribute to a range of policy briefs which target policy makers and planners on key global health issues. (health:<healthhub@commonwealth.int> education:<eduhub@commonwealth.int>) terms of reference the overall aim of ghw-2030 is to explore and present evidence-based and refreshing or creative solutions through theme papers / interviews that impact on well-being or quality of life (human, animal, plant, environmental) and that go beyond silo thinking and conventional political interventions. think tank reviews will be undertaken annually with agendas set out by the secretariat and will be reported to the commonwealth secretariat health and education unit seeking its guidance for dissemination and implementation.  papers may originate with any member of the think tank and will be considered a „draft‟ subject to reviews of think tank members.  contributions from trans-disciplinary and/or multi-sectoral „primary‟ sources are essential;  the draft papers will be reviewed first by the secretariat and subsequently circulated to other members for comments through three review rounds.  draft papers should be restricted to significant contemporary global issues (e.g., involuntary migration, food safety and security, unemployment/underemployment, national governance, armed conflict, small island health, climate change, social instability, public health emergencies caused by infectious diseases such as the ebola and the zika virus, urban violence and crime).  the papers should be about 1500-2500 words in length, excluding references.  each paper should culminate with recommendations in terms of addressing the issue(s).  comments will be returned to originating author(s) for integration of feedback.  final papers will be disseminated, first, to all think tank members and, secondly, they will be submitted for consideration to global/public/clinical health and social care journals* and other fora (e.g., social media), to reach a wider audience.  up to six papers will be reviewed annually, involving on-line meetings, as required, and agreed through final on-line approval meetings of all members. organisation for the time being the group will function in association with the commonwealth secretariat health and education unit (heu), facilitated by its on-line health and education hubs. links to other think tanks or working groups addressing similar concerns will be developed wherever possible. mailto:healthhub@commonwealth.int mailto:eduhub@commonwealth.int laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 5 membership and affiliations think tank members (two year renewable term) involve those who helped to draft the epilogue „global health, education and governance,‟ for the book, global population health and well-being in the 21 st century: toward new paradigm, policy and practice and others working in diverse capacities in such areas as education, politics, health, research, journalism, economics, civil service, business, law, to name several fields. recommended affiliations include leading organisations focusing on global / national health and well-being. secretariat professor ulrich laaser, [dr. med, dtm&h, mph], international public health, university of bielefeld, bielefeld, germany (ulrich.laaser@uni-bielefeld.de) dr george lueddeke [ba, otc, med, phd] / ghw-2030 convenor/chair; consultant in higher & medical education, southampton, united kingdom (glueddeke@aol.com) dr joanna nurse, [bm, mph, msc. ffph], head, commonwealth secretariat health and education unit (heu), london, united kingdom (j.nurse@commonwealth.int) laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 6 the one health global think-tank for sustainable health & well-being -2030 (ghw-2030) purpose, rationales, and guidance the 21 st century has been marked by a rapidly accelerating globalization of cultures, religions, trade, and also of conflict. correspondingly recognition of global threats is rising with regard to environmental degradation, social divides and resulting civil war, enforced migration, and terrorism. taken together, it has become clear that global and regional governmental structures are struggling to cope effectively with emerging challenges to peace, security, basic human rights and planetary imbalances. the eight millennium development goals (mdgs) as a global average – have made considerable progress in several key areas, including increasing the net enrolment rate in primary school education in developing regions from 83 per cent in 2000 to 91 per cent in 2015 and raising official development assistance (oda) from developed countries by 66 per cent in real terms between 2000 and 2014, reaching $135.2 billion (1). however, progress has been uneven. as one example, poverty reduction, „which has declined significantly over the last two decades‟ (1) is partly due to the overachievement of countries like china and cannot be generalised across other – especially low income countries (2). and, while initiatives appear to be promising across the other seven mdgs, many targets remain unfulfilled and many more have emerged or have deepened since the mdg inception in 2000 (3). to cite a few specific examples: across 53 nations and about 2.5 billion people in the commonwealth nations „there are still approximately 23 million primary-aged children out of school‟ and „just over a third (8.5 million) are known to have access to anti-retroviral therapy‟ for those living with hiv/aids. moreover, given global socioeconomic and political polarizations, „the radicalization of young people and the underachievement of boys are emerging as challenges‟ (4). addressing the global life-threatening issues, as ban ki-moon un secretary-general highlights in the mdg final report, requires „targeted interventions, sound strategies, adequate resources and political will.‟ what has been demonstrated throughout the mdg initiative, he concludes in the introduction to the mdg final report, is that „even the poorest countries can make dramatic and unprecedented progress‟ (1). for the secretary-general the most important factor is „to tackle root causes and do more to integrate the economic, social and environmental dimensions of sustainable development,‟ thereby working toward resolving the „uneven achievements and shortfalls in many areas‟. the recently agreed un addis ababa action agenda (5), the 2030 agenda for sustainable development (6), including the 17 sustainable development goals (figure 1), as well as the framework convention on climate change (7) may be timely and catalytical in underpinning the establishment of the think tank, elaborated in the terms of reference (p. 4) laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 7 the sustainable development goals (sdgs) (2016-2030) by agreeing to the 17 sdgs on 25 september 2015 (6), the 193 member states of the un general assembly resolved to:  end poverty and hunger everywhere;  combat inequalities within and among countries;  build peaceful, just and inclusive societies;  protect human rights and promote gender equality and the empowerment of women and girls; and  ensure the lasting protection of the planet and its natural resources (6). figure 1: visual representation of the overarching elements of the sdgs source: commonwealth secretariat, health and education unit, 2015 (4) inherent in the un final report transforming our world: the 2030 agenda for sustainable development (6) are fundamental principles and values that inter alia include  adopting an overarching approach that fully integrates the social, economic and environmental dimensions of sustainable development;  committing to the intent of „leaving no one behind‟ and reflecting universality through all goals;  placing people and the planet at the centre at global, regional, national and local levels; and laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 8  supporting development cooperation commitments and means of implementation (moi) that consider finance, trade, technology, capacity-building, policy and institutional coherence, data and monitoring and multi stakeholder partnerships . jeff waage and christopher yap (editors) of thinking beyond sectors for sustainable development (figure 2) (8) grouped the sdgs into three main concentric circles and categories: natural environment, infrastructure and wellbeing , underpinned by sdg 17 which cuts across all sdgs (6). each sdg has specific targets with performance indicators, which are currently under development and are „expected to be adopted by the un economic and social council (ecosoc) and the un general assembly (unga), „preferably in june 2016‟ (9). figure 2: framework for examining interactions between sustainable development goals. (goal 17 is excluded from this framework because it is an overarching goal.) march 2016. laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 9 environmental-social sustainability and prospects for individual ‘well-being’ the central concerns of the 2030 agenda lie with ensuring sustainability of the natural environment, infrastructure while globally meeting basic human needs in order to safeguard and promote societal and individual well-being. the authors of „a vision for human well-being: transition to social sustainability‟ (10) emphasise the value of “living in ways that can be sustained because they are healthy and satisfying for people and communities.” in short, they posit that “while environmental sustainability examines living within the limits of the natural world”, social sustainability requires providing for material, social and emotional needs, avoiding behaviours that result in poor health, emotional distress and conflict, and ensuring that we do not destroy the social structures (such as families and communities), cultural values, knowledge systems and human diversity that contribute to a vibrant and thriving human community. as the authors make clear, „key components of human well-being are dependent on well-functioning ecosystems and the biosphere” and “conversely, maintaining a healthy environment and making the transition to environmental sustainability requires human societies that function well.‟ another important working hypothesis put forth is that „healthy, happy individuals with a strong sense of place, identity and hope for the future are more likely to make protection of their environment a priority‟. in this regard, a useful definition of “well-being” comes from the uk department of health which in the report confident communities, brighter futures. a framework for developing well-being‟ (11) defined „well-being‟ as „a positive state of mind and body, feeling safe and able to cope, with a sense of connection with people, communities, and the wider environment‟. according to the report, promoting mental health and well-being can be enhanced by a number of strategies or initiatives especially those that • use a life course approach to ensure a positive start in life and healthy adult and older years. with such an approach, people develop and share skills to continue learning and have positive social relationships throughout life. • build strength, safety and resilience: address inequalities and ensure safety and security at individual, relationship, community and environmental levels. • develop sustainable, connected communities: create socially inclusive communities that promote social networks and environmental engagement . • integrate physical and mental health: develop a holistic view of well-being that encompasses both physical and mental health, reduce health-risk behaviour and promote physical activity. oecd’s ‘better life’ index: an illusionary measure for the 21 st century? the comprehensive and informative global/national/regional oecd‟s better life index (12,13) indicates that australia is the „#1 place to live if all factors or criteria housing, income, jobs, community, education, environment, governance, health, life satisfaction, safety and work-life balance were treated with equal importance.‟ laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 10 figure 3: oecd better life index source: oecd, 2014 however, while „the overall level of health and wellbeing of australians is relatively high compared with other countries,‟ (14) the graph and findings may be somewhat illusory and may fall short in terms of representing a true picture of individual well-being on national scales where „there are significant disparities in the health outcomes of different populations‟ impacting mostly on the poor, the marginalised, the disadvantaged and increasingly the desperate as the european migration crisis makes clear. many past and present reviews of well-being have been and continue to be based on gross domestic product (gdp) per capita. while gdp as an average measure is “a good proxy for well-being,‟ it „ignores the asymmetrical distribution of wealth in a country‟ (10) and continues to correlate wealth and well-being as complementary and generally benign measures. research tells us that „happiness is not always closely associated with income or other objective indicators of well-being such as physical health.‟ in fact, amartya sen, acclaimed philosopher and proponent of social justice has argued that what is most important is to provide „the freedoms and capabilities that allow each person to achieve what will contribute to his or her own well-being,‟ (15) which may place less value on material wealth and shift from economic focus toward „equality in social relations, social trust in most other people, and degree of democracy; and safety of the area in which one lives‟ (10, 16). highlighting that „evidence about well-being comes from several different standpoints,‟ dr piumatti from the university of belgrade (17) reminds us that „economists laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 11 and psychologists are improving the measures of subjective well-being‟ (18) and that „questions about the influence of different determinants of psychological well-being are also being raised” (19). more specifically, he observes that researchers agree on the fact that individuals have different sources of well-being at different stages in their lives. for example, career and educational goals are highly relevant for people across the globe, particularly for young people who are transitioning into work. failing to meet one’s personal goals can result in disappointment and lower levels of well-being (20). accordingly, in order to contribute moving the measurement of subjective well being from a primarily academic activity to the sphere of official statistic and to raise awareness on this topic, we need to build bridges across disciplines. indeed, many new dimensions have already been absorbed by this field: nutritionists cooperate on defining the field of nutritional well-being (21), sociologists utilize the definition of community well-being (22), while other scientists analyze well-being in different age groups (23, 24). these works also represent a reflection of the complex and contested nature of well-being. moreover, it is noteworthy that while the meaning and application of „well-being‟ as a social construct may differ, viewed historically, „human‟ well-being has been largely defined in physical terms enabled through wealth creation and made possible especially in the past century through advancements in technology and science. in this respect well-being has become synonymous with a substantial rise in the standard of living for about a fifth of the world population totalling close to 7.4 billion at the moment. but economic growth has come at a steep price: first, it has promulgated a rather narrow – consumption –drivenconcept of „well-being‟ that is human ego-centric (vs animal, environmental – eco-centric) affecting the potential prosperity of only about 20 per cent of the human population coupled with huge losses in other species and biodiversity. and, secondly, it has created modern lifestyles that are arguably incongruous with our genetic evolution and are fast becoming a major societal dilemma affecting individuals from all groups regardless of background and increasingly all nations, high and low incomes (25, 26). as one example, considering the limitations of figure 3, obesity rates in australia are climbing faster than anywhere else in the world with about 5 million australians classified as obese (27) out of close to 24 million people. these trends are equally disturbing in the uk where, for example, a study predicts that „by 2035, 39 per cent of the population will be classed as obese, 33 per cent will be overweight and only 28 per cent will be of healthy weight or less, on current trends. (28). even close to half the staff in the uk national health service, the largest employer in the uk, –about 700,000are estimated to be overweight or obese (29). china is also experiencing a similar crisis. according to a study by the university of washington‟s institute for health metrics and evaluation, „the country is now no. 2 for obesity, with its number of obese residents outstripped only by the u.s. its obesity rate has skyrocketed over the last three decades, resulting in 46 million obese chinese adults and 300 million who are overweight (30). similarly, obesity appears to spreading across india, where its „economic boom has been accompanied by a meteoric increase in the number of people with diabetes – and those at risk for the disease. prevalence rates are up to 20% in some cities, and recent figures showed surprisingly increased rates in rural areas.‟ there are now over ‟65.1 million people with the disease, compared to 50.8 million in 2010‟ (31). http://online.wsj.com/articles/nearly-30-of-world-population-is-overweight-1401365395 http://online.wsj.com/articles/nearly-30-of-world-population-is-overweight-1401365395 laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 12 a study by the university of washington‟s institute for health metrics and evaluation focused on south asians and is generalizable to all nations trying to find a way forward to unhealthy and often unhappy lifestyles. perhaps unsurprisingly their report concluded that obesity „is primarily driven by nutrition, lifestyle and demographic transitions, increasingly faulty diets and physical inactivity, in the background of genetic predisposition‟ (32). another worrying trend likely intensified by modernism relates to mental health. research in australia found that „one in four young australians currently has a mental health condition‟ and „a quarter of young australians say they are unhappy with their lives‟ (14). these changes are also evidenced in levels of unhappiness in children in the uk, where a helpline study comparing reasons why children call childline from 1986 to the present, found that one in eight calls are now primarily related to feelings of loneliness and low self-esteem rather than sexual abuse and pregnancy which was the case 30 years ago. helpline concludes that „the pressures of modern life are „creating a generation of children plagued by low-level mental health problems,‟ causing stress attributable largely to „social media „and cyberbullying (33). exacerbating the difficulty of finding solutions in the uk and likely in other high and moderate income nations is the low priority that seems to be ascribed to mental health. as one example, the uk medical research council „spent less than 3 per cent of its budget on mental health last year,‟ (34) and local councils „spend only 1 per cent of the annual budget on mental health‟ with some spending „nothing on preventing mental illness‟ (35). nationally only £3.3 billion are allocated to public health out of a total nhs budget of about £116 billion, that is, around 3 per cent, considering that „annual cost from days at work lost and under-employment along with care and treatment is estimated at £105 billion‟ alone (34). most health funds globally are spent on treatment of physical health, not prevention of mental illness and ensuring well-being, despite non-communicable diseases, including a dramatic rise in depression, anxiety disorders, self-harming –especially among adolescents now accounting for c. 70 per cent of all mortalities and morbidities worldwide. perhaps dr stan kutcher from dalhousie university in nova scotia, canada, echoes the feelings of many distressed parents across the globe querying „why mental health services waited until young people reached crisis point before stepping in,‟ when „oncologists did not wait until a cancer was in stage 4 before treating it‟ (36). as a grieving father noted, giving young individuals who are mentally ill a „strip of pills‟ and „website names‟ is not the answer and more funded, collaborative and focused social research and system reform are urgently required (36). at the extreme opposite end of the figure 2 „well-being‟ spectrum are the non-oecd millions of children and young adults who are presently displaced or caught in conflict and war zones. syria is a cruel example of „social breakdown‟ as intolerable as any in preceding wars, reflected starkly in the unicef report, „committing to child survival: a promise renewed progress report 2015‟ (37) and reminding us that „in „2015 an estimated 5.9 million children will have died before turning 5 – and children under 5 from the poorest households are twice as likely to die as those from the richest.‟ further, the authors acknowledge „the cost of inaction at moral, economic and societal levels is too high,‟ and unquestionably must be viewed as one of the most important priorities for the united nations development program (undp) and those responsible for implementing the sdgs globally (38). laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 13 re-focusing on social and individual well-being in the 21 st century rogers et al (10) conclude their article by highlighting that unlike the natural sciences where there is general consensus „on the urgent need to reduce carbon emissions,‟ recently translated into a worldwide agreement at the paris climate conference, social science research still has a considerable distance to travel before nations agree to „replace the consumer culture with something more supportive of human and social and emotional needs…‟ in this regard, while tackling poverty, inequalities and „promoting peaceful, just and inclusive societies‟, our biggest challenge in this decade and beyond may be no longer defining “success and happiness” solely “in terms of material wealth” but accepting that “human happiness and well-being can continue to grow without exceeding sustainability limits and planetary boundaries‟ (10). writing in the times, in a piece entitled, „the search for happiness is all greek to me,‟ science correspondent oliver moody laments that “moral philosophy has all but vacated the public sphere over the last century, and, while we might blame practitioners for walling themselves up in a labyrinth of obscurities”, the truth may be “that the rest of the world is too busy upgrading its iphones and filling its tax returns to listen”. the writer‟s main point is that our seemingly „busy‟ lives make “all of us poorer” and “without a common idea of neither happiness nor “even the means to come up with one” (39). his conclusion may be confirmed by on-going deliberations that involve the draft sdg indicators by hundreds of dedicated stakeholders. the sdg indicators are certainly pointing in the right direction (9), but, by and large, the emphasis is still primarily on „conventional growth, competitiveness and personal gain‟ not on „promoting sustainable social development and well-being for all‟ (10). in short, there is little evidence that the sdgs will lead to diminishing „inequalities within and between societies‟ along with developing „economic and political policies and institutions that serve human well-being in all its dimensions.‟ the un decision to establish a ten-member group to support the technology facilitation mechanism (tfm), as part of the addis ababa action agenda (aaaa) for the period 2016-2017 to promote „technology initiatives‟ is an important step (40). it is also telling. the decision does little to respond to „the imperatives of human rights and the values of humanity and solidarity‟ (40). as success of the un 2030 agenda for sustainable development (6) depends arguably more on human than technological systems and factors, as the 20 th century and this century have already painfully demonstrated, would it not make sense to establish a parallel, authoritative „mechanism‟ for achieving humanitarian ends that value „consensus and common action, mutual respect, inclusiveness, transparency, accountability, legitimacy and responsiveness‟? (4). moody appears to be entirely justified in reminding us that it is really time „to tell us why we‟re wrong‟and the urgency „to show us a better way‟ (39). it is against this broad background that we have established the „one health global think tank for sustainable health and well-being – 2030‟ and agreed its overall rationales and guidelines. laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 14 the one health global think-tank for sustainable health & well-being -2030 (ghw-2030) purpose to bring together global multi-sectoral and multi-disciplinary thought leaders to articulate and advocate for sustainable „planet and people‟ health and well-being. mission and method the central mission of the ghw-2030 multi-sectoral think tank is to contribute to the implementation of the un sustainable development goals (sdgs) by working toward achieving the education and health goals in cooperation with the commonwealth secretariat using an international interdisciplinary/multidisciplinary/transdisciplinary “one health” approach. a major focus of the think tank will be on the health and well-being – physical, emotional, aspirational – of children and young people particularly as these relate to their personal security, physical and emotional well-being, education and employment and the sustainability of life on the planet. referencing contemporary and future-oriented developments, the activities of think tank members include:  analysing root causes with regard to key issues in environmental, social, economic and geopolitical arenas, particularly in relation to „well-being‟ goals, targets and indicators underpinning the un 2030 agenda for sustainable development;  considering and assessing future risks, such as egocentrism, demographic shifts, environmental, and public one health challenges generally – human, animal, plant, environmental – and identifying potential solutions at local, national, regional and global levels;  exploring creative and innovative approaches for informing global and national policy directions, including a „global framework for public health systems and services‟ (fig 4);  publishing and disseminating knowledge and evidence-based papers or articles* (possibly informed by recognised research tools (e.g., cdc-authored community guide) or interviews in a creative and sustained fashion;  producing short summaries of policy options and recommendations for policy-makers and planners;  stimulating public online discussions as well as potential consortial activities, including social media; and  contributing to decision-making and policy development (government and nongovernmental) to enhance sustainable „health and well-being‟ at local, national, regional and global levels, involving existing and potential mechanisms for transformative enabling action. laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 15 figure 4: public health systems and services source: commonwealth secretariat, health and education unit, 2015 (33) *potential journals (others to be added depending on theme or author preference) american journal of preventive medicine, american journal of public health, bulletin of the world health organisation, american journal of tropical medicine and hygiene, ecology letters, european journal of public health, global journal of interdisciplinary social sciences, health affairs, infection ecology and epidemiology, international journal of one health, international journal of public health, journal of the american medical association, journal of american public health, journal of international humanitarian action, journal of the veterinary medical association, journal of the united nations, lancet global health, one health journal (sweden), oxford public health magazine, plos one, south eastern european journal of public health, trends in ecology and evolution, vectorborne and zoonotic diseases, veterinary sciences (switzerland), world bank research observer…. laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 16 in addition, along with others, think tank members will have the opportunity to engage in high level on-line policy discussions on the commonwealth secretariat‟s health and education unit hubs as well as contribute to a range of policy briefs which target policy makers and planners on key global health issues (4). (health:<healthhub@commonwealth.int>( education:<eduhub@commonwealth.int>) the „one world, one health‟ concept refers to „a worldwide strategy for expanding interdisciplinary collaboration and communication in all aspects of health for humans, animals and the environment‟ (42). according to the one health initiative (ohi), „the synergism achieved will advance health care for the 21st century and beyond by accelerating biomedical research discoveries, enhancing public health efficacy, expeditiously expanding the scientific knowledge base, and improving public health education and health care.‟ the global one health commission (43) asserts that these aims can be greatly facilitated by: • connecting one health stakeholders • creating strategic networks / partnerships • educating about one health issues to support a paradigm shift in information sharing, active health interventions, collaborations, and demonstration projects. it is anticipated that „when properly implemented, the one health concept will help protect and save untold millions of lives in our present and future generations‟ (42). public health is the fundamental bridge or key coordinating mechanism to „improve health outcomes and well-being of humans, animals and plants and to promote environmental resilience…‟ (43). immediate catalysts the ghw-2030 think tank has developed based on the experience with the international group of advisors contributing to the final chapter of george lueddeke‟s book, global population health and well-being in the 21 st century – toward new paradigms, policy, and practice (25). the intention is to make use of this network of excellence and create a permanent structure inviting additional experts to work on topics of global health and wellbeing relevance. more particularly, the impetus for establishing the think tank is based on recommendations contained in the book‟s epilogue, which highlights recommendations for global decision makers, including the need to consider ‘the creation of a collective public or population health and well-being vision underpinned by global social justice, formalized structures of regional health and well-being‟; and transforming „traditional health & and social care education and training through innovative practice, focusing on prevention and health promotion’ (44). mailto:healthhub@commonwealth.int mailto:eduhub@commonwealth.int laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 17 supporting the latter, the association of schools of public health in the european region (aspher) has already recently underlined this essential in its global charter (45) and in its strategy 2020 (46). similarly, the world federation of public health associations (wfpha) has prepared “a global charter for the public‟s health: the public health system: role, functions, competencies and education requirements” (47) (in print), and the framework of a global strategic network for public health education and training has been outlined by professor vesna bjegovic-mikanovic, aspher president, et al (48). . organisation for the time being the group will function in association with the commonwealth secretariat health and education unit (heu), facilitated by its on-line health and education hubs. links to other think tanks or working groups addressing similar concerns will be developed wherever possible. membership and affiliations think tank members (two year renewable term) involve those who helped to draft the epilogue „global health, education and governance,‟ for the book, global population health and well-being in the 21 st century: toward new paradigm, policy and practice* (25) and others working in diverse capacities in such areas as education, politics, health, research, journalism, economics, civil service, business, law, to name several fields. affiliations include leading organisations focusing on global / national health and well-being. additional affiliations a number of key organizations have joined the think-tank. additional members are being sought representing inter alia: american public health association (apha), asia pacific academic consortium for public health (apacph), earth institute (tei), european public health association (eupha), global health council (ghc), india public health association (ipha), international association of public health institutes (ianph), rockefeller foundation (rf), united nations – undp, unesco, un foundation, world bank group (wbg), world health organisation (who), world veterinary association (wva), world medical association (wma). secretariat professor ulrich laaser, international public health, university of bielefeld, bielefeld, germany (ulrich.laaser@unibielefeld.de) dr george lueddeke, think-tank convenor/chair; southampton, united kingdom (glueddeke@aol.com) dr joanna nurse, head, commonwealth secretariat health and education unit (heu), london, united kingdom (j.nurse@commonwealth.int) laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 18 references (1) united nations. the millennium development goals report 2015. summary. available at: http://www.un.org/millenniumgoals/2015_mdg_report/pdf/mdg%202015%20summary% 20web_english.pdf. 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(45) association of schools of public health in the european region (aspher). the global dimension of education and training for public health in the 21st century in europe and in the world. charter of the association of schools of public health in the european region (aspher) at the occasion of the 6th european public health conference in brussels, belgium, november 13-16, 2013. available at: http://aspher.org/pg/file/read/370940/the-global-dimension-of-education-and-training-forpublic-health-in-the-21st-century-in-europe-and-in-the-world (46) association of schools of public health in the european region (aspher). strategic plan 2016-2020: aspher 2020. available at: http://aspher.org/download/20/aspher2020_outline-aga2015.pdf (47) world federation of public health associations. about wfpha. available at: http://www.wfpha.org/about-wfpha (48) bjegovic-mikanovic v, jovic-vranes a, czabanowska k, otok r: education for public health in europe and its global outreach. global health action 7/2014 . available at: http://www.globalhealthaction.net/index.php/gha/issue/current copyright (c) 2016 ulrich laaser, george r. lueddeke, joanna nurse laaser et al. for the ghw-2030; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://unictz.org/2016/02/01/secretary-general-appoints-a-10-member-group-to-support-the-technology-facilitation-mechanism/ http://unictz.org/2016/02/01/secretary-general-appoints-a-10-member-group-to-support-the-technology-facilitation-mechanism/ http://www.globalpolicywatch.org/blog/2015/07/16/civil-society-response-agenda-financing-development/ http://www.globalpolicywatch.org/blog/2015/07/16/civil-society-response-agenda-financing-development/ http://www.onehealthinitiative.com/mission.php https://www.onehealthcommission.org/en/why_one_health/ohc_mission/ http://aspher.org/pg/file/read/370940/the-global-dimension-of-education-and-training-for-public-health-in-the-21st-century-in-europe-and-in-the-world http://aspher.org/pg/file/read/370940/the-global-dimension-of-education-and-training-for-public-health-in-the-21st-century-in-europe-and-in-the-world http://aspher.org/download/20/aspher2020_outline-aga2015.pdf http://www.wfpha.org/about-wfpha http://www.globalhealthaction.net/index.php/gha/issue/current laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 21 the one health global think-tank for sustainable health & well-being -2030 (ghw-2030) (members as of 14.05.16) name affiliation e-mail country 1. dr. ibukun adepoju phd fellow, vriej university, amsterdam ladeadepoju@yahoo.com nigeria/neth erlands 2. dr. muhammad mahmood afzal ret'd global health workforce alliance, world health organization (ghwa/who), geneva, switzerland. chairman/chief editor, 'global health & medicine' magazine. drmmafzal@yahoo.com lahore, pakistan 3. dr. muhammad wasif alam director, public health and safety department, dubai health authority head quarter. malam@dha.gov.ae, wasifsuper@juno.com dubai , united arab emirates 4. prof john ashton president, uk faculty of public health . president@fph.org.uk uk 5. prof vesna bjegovicmikanovic vice dean of the faculty of medicine, university of belgrade. past president of the association of schools of public health in the european region (aspher). bjegov@med.bg.ac.rs vesna.bjegovic@aspher.org republic of serbia 6. prof bettina borisch director of the geneva office, world federation of public health associations. bettina.borisch@unige.ch switzerland 7. prof genc burazeri deputy director of the national institute of public health (albania).visiting lecturer at maastricht university; ;executive editor, south eastern european journal of public health. gburazeri@yahoo.com> albania 8. dr. sara carr clinical psychology, university of southampton. sara.carr4@nhs.net uk 9. dr. lisa conti deputy commissioner and chief science officer at florida department of agriculture and consumer services. lisa.conti@freshfromflorida.com u.s. 10. dr. katarzyna czabanowska dept of international health, faculty of health, medicine and life sciences, caphri school of public health & primary care (maastricht university) . kasia.czabanowska@maastrichtuniversit y.nl the netherlands, 11. dr. eliudi eliakimu assistant director health services inspectorate and quality assurance, health quality assurance division, ministry of health, community development, gender, elderly and children, dar es salaam eliakimueliudi@yahoo.co.uk eliakimueliudi@gmail.com tanzania 12. dr. kira fortune advisor, determinants of health (paho/who) fortunek@paho.org denmark 13. dr. luis galvão regional manager, sustainable development and environmental health (paho/who) galvaolu@paho.org brazil 14. dr. iman hakim dean of the university of arizona mel and enid zuckerman college of public health. ihakim@email.arizona.edu varelal@email.arizona.edu u.s. 15. prof n.k. ganguly former director general, indian council of medical research (icmr). coordinator and chair, policy center for biomedical research (pcbr), translational health science & technology institute (thsti). nkganguly@nii.ac.in india 16. prof joshua godwin international association of health care joshua@medicalscs.co.uk uk mailto:malam@dha.gov.ae mailto:wasifsuper@juno.com mailto:president@fph.org mailto:bjegov@med.bg.ac.rs mailto:vesna.bjegovic@aspher.org mailto:bettina.borisch@unige.ch mailto:gburazeri@yahoo.com mailto:ihakim@email.arizona.edu mailto:varelal@email.arizona.edu mailto:nkganguly@nii.ac.in mailto:joshua@medicalscs.co.uk laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 22 professionals (iahcp) joshuagodwin414@ymail.com 17. prof. james herington department of health behavior and executive director, gillings global gateway.™ unc gillings school of global public health . jimhsph@email.unc.edu u.s. 18. prof. tomiko hokama emeritus professor. executive vice president, university of the ryukyus. former president of asia pacific academic consortium for public health, (apacph). b987390@med.u-ryukyu.ac.jp japan 19. dr. howard hu dean, dalla lana school of public health, university of toronto. professor of environmental health, epidemiology and global health. professor of medicine. howard.hu@utoronto.ca canada 20. prof. ehimario igumbor extraordinary associate professor of public health, school of public health, university of the western cape, bellville, cape town, south africa. eigumbor@uwc.ac.za s. africa 21. prof. paul johnstone regional director for the north of england (public health england) paul.johnstone@phe.gov.uk uk 22. dr gretchen kaufman co-chair, education task force (one health commission). adjunct faculty, paul g. allen school for global animal health, washington state university.adjunct faculty, tufts center for conservation medicine, tufts university.co-founder and associate director, veterinary initiative for endangered wildlife. gkaufman10@gmail.com u.s. 23. dr. bruce kaplan co-founder, global one health initiative team; manager/editor, one health initiative website; former cdc eis officer and usda/fsis food safety staff officer; small animal veterinary medicine practitioner; retired bkapdvm@verizon.net u.s. 24. dr. laura kahn research scholar with the program on science and global security, princeton u. co-founder, global one health initiative (ohi). lkahn@princeton.edu u.s. 25. prof daniella kingsley international association of health care professionals (iahcp) daniella@iahcp.org.uk uk 26. prof ulrich laaser (secretariat) section of international public health (siph), faculty of health sciences, university of bielefeld. past president of the world federation of public health associations (wfpha). past president of the association of schools of public health in the european region (aspher). ulrich.laaser@uni-bielefeld.de germany 27. dr. george lueddeke (secretariat/convenor/chair) consultant education advisor, higher & medical education. co-chair, one health education task force. glueddeke@aol.com uk 28. dr. joann lindenmayer chair, one health commission (ohc) senior manager of disaster operations, humane society international jlindenmayer@hsi.org u.s. 29. prof qingyue meng professor in health economics and policy. dean of peking university school of public health. executive director of peking universitychina center for health development studies. qmeng@bjmu.edu.cn china mailto:joshuagodwin414@ymail.com mailto:jimhsph@email.unc.edu mailto:paul.johnstone@phe.gov.uk mailto:daniella@iahcp.org.uk mailto:glueddeke@aol.com laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 23 30. dr. jay maddock association of schools and programs of public health (aspph). dean of the texas a&m health science center, school of public health. maddock@tamhsc.edu kmanry@srph.tamhsc.edu u.s. 31. dr. john middleton vice president, uk faculty of public health. president-elect uk faculty of public health. honorary professor, wolverhampton university johnmiddleton@phonecoop.coop uk 32. prof getnet mitike professor of public health, addis ababa university, college of health sciences, school of public health getnetmk@gmail.com ethiopia 33. prof. geoff mccoll dean of medical education and training, university of melbourne; director of the medical journal of australia gjmccoll@unimelb.edu.au australia 34. dr. thomas monath chief scientific and chief operations officer of bioprotection systems corporation. tmonath@linkp.com u.s. 35. dr. joanna nurse (secretariat) head, commonwealth secretariat health and education unit. j.nurse@commonwealth.int jonurse66@hotmail.com m.mulholland@commonwealth.int uk 36. mr. robert otok executive director, association of schools of public health in the european region (aspher). robert.otok@aspher.org belgium 37. dr. giovanni piumatti universityof belgrade, school of public health. giovanni.piumatti@gmail.com italy 38. prof. k. srinath reddy president, public health foundation of india. ksrinath.reddy@phfi.org india 39. prof helena ribeiro former dean of the school of public health at the university of são paulo, lena@usp.br brazil 40. prof . barbara rimer dean, university of north carolina (unc) gillingsschool of global public health. brimer@unc.edu usa 41. dr. flavia senkubuge public health medicine specialist (university of pretoria). vice-president african federation of public health associations. junior vice-president of the colleges of medicine of south africa. flavia.senkubuge@up.ac.za s. africa, 42. dr. neil squires chair of global health (uk public health foundation ). neil.squires@phe.gov.uk uk 43. dr. cheryl stroud executive director, one health commission cstroud@onehealthcommission.org u.s. 44. prof charles surjadi chief technical advisor, indonesian epidemiology network. atmajaya faculty of medicine, djakarta. kotasehat@hotmail.com indonesia 45. dr. moaz abdel wadoud doctor of public health in health management and policy, college of public health, university of kentucky. previous associate researcher of public health, theodor bilharz research institute, ministry of scientific research, egypt. drmoaz@windowslive.com egypt 46. dr. john “jack” woodall professor and director (retd.), nucleus for the investigation of emerging infectious diseases at the institute of medical biochemistry, center for health sciences, federal university of rio de janeiro, brazil. co-founder and associate editor of jackwoodall13@gmail.com u.s. mailto:maddock@tamhsc.edu mailto:kmanry@srph.tamhsc.edu mailto:johnmiddleton@phonecoop.coop mailto:professor%20of%20medical%20education%20and%20training,%20univerity%20of%20melbourne,%20%20and%20director%20of%20the medical%20journal%20of%20australia,%20.ccoll@unimelb.edu.au mailto:professor%20of%20medical%20education%20and%20training,%20univerity%20of%20melbourne,%20%20and%20director%20of%20the medical%20journal%20of%20australia,%20.ccoll@unimelb.edu.au mailto:professor%20of%20medical%20education%20and%20training,%20univerity%20of%20melbourne,%20%20and%20director%20of%20the medical%20journal%20of%20australia,%20.ccoll@unimelb.edu.au mailto:jonurse66@hotmail.com mailto:m.mulholland@commonwealth.int mailto:robert.otok@aspher.org https://www.linkedin.com/company/595282?trk=prof-0-ovw-curr_pos https://www.linkedin.com/company/595282?trk=prof-0-ovw-curr_pos mailto:ksrinath.reddy@phfi.org mailto:flavia.senkubuge@up.ac.za#_blank mailto:neil.squires@phe.gov.uk http://www.linkedin.com/search?search=&company=indonesian+epidemiology+network&sortcriteria=r&keepfacets=true&trk=prof-exp-company-name http://www.linkedin.com/search?search=&company=indonesian+epidemiology+network&sortcriteria=r&keepfacets=true&trk=prof-exp-company-name http://www.linkedin.com/search?search=&company=atmajaya+faculty+of+medicine&sortcriteria=r&keepfacets=true&trk=prof-0-ovw-curr_pos http://www.linkedin.com/search?search=&company=atmajaya+faculty+of+medicine&sortcriteria=r&keepfacets=true&trk=prof-0-ovw-curr_pos mailto:kotasehat@hotmail.com mailto:jackwoodall13@gmail.com laaser u, lueddeke g, nurse j. the one health global think tank for sustainable health & well-being – 2030 (ghw-2030 (short report). seejph 2016, posted: 19 april 2016. doi 10.4119/unibi/seejph-2016114 24 promed. member of one health initiative autonomous team. 1 south eastern european journal of public health volume iv, 2015 editors: genc burazeri, ulrich laaser, jose m. martin-moreno,peter schröder bäck jacobs verlag south eastern european journal of public health volume iv, 2015 genc burazeri, ulrich laaser, jose m. martin-moreno, peter schröder-bäck executive editor genc burazeri (tirana, albania and maastricht, the netherlands) faculty of medicine rr. “dibres”, no. 371 tirana albania phone: 0035/5672071652 e-mail:gburazeri@yahoo.com skype: genc.burazeri assistant executive editors ms. florida beluli dr. ervin toci mr. kreshnik petrela editors genc burazeri (tirana, albania and maastricht, the netherlands) ulrich laaser (bielefeld, germany) jose martin-moreno (valencia, spain) peter schröder-bäck (maastricht, thenetherlands) regional editors samir banoob (tampa, florida, usa) for the middle east evelyne de leeuw (sydney, australia) for the western pacific region damen haile mariam (addis ababa, ethiopia) for the african region charles surjadi (jakarta, indonesia) for the south east asian region laura magana valladares (mexico, mexico) for latin america advisory editorial board tewabech bishaw, african federation of public health associations (afpha) (addisababa, ethiopia) helmut brand (maastricht, the netherlands) patricia brownell (new york, usa) franco cavallo (torino, italy) doncho donev (skopje, fyr macedonia) mariana dyakova (sofia, bulgaria and warwick, united kingdom) florentina furtunescu (bucharest, romania) andrej grjibovski (oslo, norway & arkhangelsk, russia) motasem hamdan (al quds, occupied palestinian territories) mihajlo jakovljevic (kragujevac, serbia) aleksandra jovic-vranes (belgrade, serbia) ilona kickbusch (geneva, switzerland) mihali kokeny (budapest, hungary) dominique kondji (douala, cameroon) giuseppe la torre (rome, italy) oleg lozan (chisinau, moldova) george lueddeke (southampton, united kingdom) jelena marinkovic (belgrade, serbia) izet masic (sarajevo, bosnia-herzegovina) martin mckee (london, united kingdom) bernhard merkel (brussels, belgium) naser ramadani (prishtina, kosovo) enver roshi (tirana, albania) maria ruseva, south east european health network (seehn) (sofia,bulgaria) fimka tozija (skopje, fyrmacedonia) theodore tulchinsky (jerusalem, israel) lijana zaletel-kragelj (ljubljana,slovenia) mailto:gburazeri@yahoo.com mailto:gburazeri@yahoo.com mailto:gburazeri@yahoo.com mailto:gburazeri@yahoo.com publisher dr. hans jacobs (lage, germany) editorial office jacobs verlag hellweg 72 d 32791 lage germany e-mail: info@jacobs-verlag.de phone: 0049/5232/979043 fax: 0049/05232/979045 value added tax identification number/umsatzsteueridentitätsnummer: de 177 865 481 instructions to authors http://www.seejph.com/instructions-to-authors mailto:info@jacobs-verlag.de mailto:info@jacobs-verlag.de http://www.seejph.com/instructions-to-authors south eastern european journal of public health volume iv, 2015 genc burazeri, ulrich laaser, jose m. martin-moreno, peter schröder-bäck jacobs verlag issn 2197-5248 doi 10.12908/seejph-2014-54 bibliographic information published by die deutschebibliothek. die deutsche bibliothek lists this publication in the deutsche nationalbibliografie;detailed bibliographic data is available on the internet at http://dnb.ddb.de south eastern european journal of public health (open access journal) copyright 2015 by jacobs publishing company hellweg 72, 32791 lage, germany copyright cover picture: wordpress foundation:http://wordpressfoundation.org/ gnu general public license http://dnb.ddb.de/ http://wordpressfoundation.org/ table ofcontents editorial page ehealth and m-health: great potentials for health and wellbeing, but also 1-7 for harmonization and european integration in health jadranka bozikov original research piloting an advanced methodology to analyse health care policynetworks: the 8-21 example of belgrade, serbia helmut wenzel, vesna bjegovic-mikanovic, ulrichlaaser estimating health impacts and economic costs of air pollution in the republic of 22-29 macedonia craig meisner, dragan gjorgjev, fimkatozija health and health status of children in serbia and the desired millennium 30-38 development goals aleksandra jovic-vranes, vesnabjegovic-mikanovic adverse effects of maternal age, weight and smoking during pregnancy in pleven, 39-48 bulgaria mariela kamburova, petkana angelova hristova, stela ludmilova georgieva, azhar khan lifestyle correlates of low bone mineral density in albanianwomen 49-57 artur kollcaku, julia kollcaku, valbona duraj, teuta backa, argjendtafaj public expenditure and drug policies in bulgaria in 2014 58-65 toni yonkov vekov, silviyaaleksandrova-yankulovska reaction to political and socioeconomic transition and self-perceived health 66-75 status in the adult population of gjilan region, kosovo musa qazimi, luljeta cakerri, zejdush tahiri, genc burazeri http://www.seejph.com/e-health-and-m-health-great-potentials-for-health-and-wellbeing-but-also-for-harmonization-and-european-integration-in-health/ http://www.seejph.com/e-health-and-m-health-great-potentials-for-health-and-wellbeing-but-also-for-harmonization-and-european-integration-in-health/ http://www.seejph.com/e-health-and-m-health-great-potentials-for-health-and-wellbeing-but-also-for-harmonization-and-european-integration-in-health/ commentary a growing competence: the unfinished story of the european unionhealth policy 7680 bernard merkel obituary professor luka kovacic, md, phd 80-85 bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph 2014-53 1 editorial ehealth and m-health: great potentials for health and wellbeing, butalso for harmonization and european integration inhealth jadranka bozikov 1 1 department for medical statistics, epidemiology and medical informatics, andrija stampar school of public health, school of medicine, university of zagreb, zagreb,croatia. corresponding author: jadranka bozikov, phd address: andrija stampar school of public health, rockefeller st. 4, zagreb, croatia; telephone: +38514590101; e-mail: jbozikov@snz.hr conflicts of interest: none. mailto:jbozikov@snz.hr bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph 2014-53 2 health has never been an european union (eu) priority like agriculture, research, ecology or food safety and still remains to be first of all, if not exclusively, the responsibility of member states (ms). from the eu perspective, health is the crosscutting policy sector dominated by many other policies, especially by the ―hard law‖ regulations of the internal market. in the preceding two volumes, the south eastern european journal of public health (seejph) published an admirable lengthy article by hans stein and equally splendid supplemented commentary by bernard merkel recounting and evaluating developments of the eu‘s health policy from the 1992 maastricht treaty (and even from earlier) to the present-day state and future perspectives (1,2). although health still has very weak basis in the eu legislation, it has evolved from ―non-topic‖ into a key area of the eu economic policy (1), but despite a growing competence ―the unfinished story of the eu health policy” is slowly moving from declarative to operational phase in developing framework for circulation of health goods and related items within europe and beyond (2). in his commentary, dr merkel has summarized changes in treaties and other regulations from 1971 (directive on pharmaceuticals and regulation on coordination of social security systems providing rights to health care to workers in other ec countries) through the following milestones: (i) the article 129 of the maastricht treaty that for the first time introduced health although in a very weak manner; (ii) the 1997 treaty of amsterdam that extended the public health article and introduced the new one (article 152) including for the first time a few specific areas related to blood and organs, some veterinary and phytosanitary areas and other things, and; (iii) finally, the 2007 lisbon treaty with inclusion of medicinal products and medical devices but also incorporating the charter of fundamental rights of the eu including the right to access health care (preventive and curative, article 35 of the charter)(3). having in mind also the common currency introduced and spreading since 1999, the conclusion that single market will finally have an impact on health and health policy stands up. on the other hand, charter of fundamental rights of the eu (proclaimed in the year 2000 but being put in the new legal environment since it became formally binding by the lisbon treaty in 2009) has declared in its article 35 in addition that ―a high level of human health protection shall be ensured in the definition and implementation of all union policies and activities‖ prior than this principle became known as health in all policies (hiap) during the finish eu presidency in 2006. according to what has been mentioned above, population health and organization of health system (including health insurance) has always been and remains a national responsibility. at the same time, the eu member states (as well as accession candidates and potential candidates) were shaping their health policies, implementing activities and monitoring systems directed by recognized international organizations such as who and oecd (and, more recently, the eu) and also used their support in responding to health threats from communicable diseases and disasters, as well as in combating the growing burden of non-communicablediseases. finally, single market principles are going to enter health sector somehow through ―back door‖ via instruments such as directive 2011/24/eu on the application of patients‘ rights in cross-border healthcare that came into force on 25 th october 2013 (4), up to now without a great success, but with potential to improve access to healthcare services and harmonize their quality within the eu member states and push them to cooperate closer in establishing of health networks in order to meet patients‘ expectations. another very important opportunity for european integration is influencing and penetrating health sector from a much broader perspective of fast developing communication technologies. bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph 2014-53 3 a digital agenda for europe initiative was selected as one of the seven flagship initiatives supposed to be crucial for obtaining the targets of europe 2020 strategy for smart, sustainable and inclusive growth (5). the adoption of europe 2020 strategy in 2010 was followed by ―e health action plan 2012-2020‖ (6), a new one after the previous adopted in 2004 (7), and ―a digital single market strategy‖ for europe which was adopted in may 2015 after the new european commission elected in 2014 set up ten priority policy areas in its agenda for jobs, growth, fairness and democratic change including the priority to create ―a connected digital single market‖ listed as no. 2 priority by jean-claude juncker in his opening statement speech before the european parliament delivered on the 15 th of july 2014 (8,9). it is expected that the creation of digital single market will enable the creation of new jobs, notably for younger job seekers, and a vibrant knowledge-based society. enhancement of the use of digital technologies and online services was proclaimed as a horizontal policy, covering all sectors of the economy, as well as the public sector including health, and common european data protection rules were seen as a necessary prerequisite. facts about the ―digital agenda for europe initiative and digital single market (dsm) strategy‖ are available at the respective web-site (10), where we can also find new information and follow developments and public consultations on selected topics ofinterest. the ―digital agenda for europe initiative‖ proposes to better exploit the potential of information and communication technologies (icts) in order to foster innovation, economic growth and progress. it consists of the following sevenpillars: i. digital single market ii. interoperability & standards iii. trust & security iv. fast and ultra-fast internetaccess v. research and innovation vi. enhancing digital literacy, skills andinclusion vii. ict-enabled benefits for eu society a ―digital single market‖ (dsm) is one in which the free movement of persons, services and capital is ensured and where individuals and businesses can seamlessly access and exercise online activities under conditions of fair competition, and a high level of consumer and personal data protection, irrespective of their nationality or place ofresidence. at (10) we can find definitions of e-health and m-health as well as information on what is going on in digital society including the public consultations launched on respectivetopics. information and communication technology for health and wellbeing (e-health) is becoming increasingly important to deliver top-quality care to european citizens and includes informatisation of health care systems at all levels (from local through institutional and regional to european and global level including use of tele-consultations and telemedicine. mobile health (m-health) is a sub-segment of e-health and covers medical and public health practice supported by mobile devices. it especially includes the use of mobile communication devices for health and wellbeing services and information purposes, as well as mobile health applications. particularly important are policies for healthy and active ageing with help of ict and use of mobile applications for health and wellbeing including home care monitoring devices (wired and mobile). there are already more than 100,000 applications for health, fitness and wellbeing obtainable for different mobile platforms, the majority of which are designed for apple ios and android smart phones. bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph 2014-53 4 the european commission often consults with stakeholders on a number of subjects and such consultations can be found on the pages of digital agenda for europe (10). the commission launched a public consultation on the green paper on mobile health (11) on 10th of april2014. the green paper on mobile health covered broad scope of m-health potential for both, healthcare and market. main potential for healthcare are seen in (i) increased prevention and quality of life approach, (ii) more efficient and sustainable healthcare, and (iii) more empowered patients. having in mind that the healthcare systems‘ organization is a national competence green paper focused on cross-border european-wide issues and on possible coordinated actions at eu level that could contribute to the scale-up of m-health in europe by putting 11 issues atstake: 1. data protection, including security of healthdata 2. big data 3. state of play on the applicable eu legal framework 4. patient safety and transparency ofinformation 5. m-health role in healthcare systems and equalaccess 6. interoperability 7. reimbursement models 8. liability 9. research and innovation in m-health 10. international cooperation 11. access of web entrepreneurs to the m-healthmarket the commission also published a staff working document on the existing eu legal framework applicable to lifestyle and wellbeing apps, aiming at providing simple guidance to application developers on eu legislation in the field (12) and invited the views of stakeholderslike:  regional and national authorities e.g. health ministries, authorities dealing withmedical devices/data protection  health professionals, carers, health practitioners, medicalassociations  consumers, users of m-health apps, patients and theirassociations  web entrepreneurs  app developers and app stores  manufacturers of mobile devices  insurance agencies  sports centres, health clubs, and the like. consultation was open for more than three months during which stakeholders responded to 23 questions on a wide range of themes: data protection, legal framework, patient safety and transparency of information, m-health role in healthcare systems and equal access, interoperability, reimbursement models, liability, research & innovation, international cooperation and web entrepreneurs‘ market access. a total of 211 responses were received and summarized in the published report (13). besides the great potential for health and wellbeing, there are some concerns, as well. the safety of mobile health solutions (and of some lifestyle and wellbeing applications, too) is a main cause for concern, explaining the potential lack of trust. there are reports pointing out that some solutions do not function as expected, and may not have been properly tested or in some cases may even endanger people‘s safety. that is why on both sides of the atlantic, regulations for medical devices including software applications are established and continuously updated (14-16). it is beyond the scope of this article to discuss the importance bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph 2014-53 5 and the need of certification of e-health and m-health devices and software, but health professionals must carefully take this issue into account and stick to guidelines and recommendations issued by regulatory agencies and bodies as thosecited. undoubtedly, e-health and m-health have a large potential for health and wellbeing through empowering of patients and enabling them to take responsibility for their own health while reducing the ever-growing healthcare costs. at the same time, health professionals and students need to be educated and trained to evaluate such applications or at least to take into account their limitations. my personal experience has shown that medical students are capable to test m health applications and understand the need for validation and certification of such applications. they successfully prepared a seminar in medical informatics using their own smart phones. within the same course students received assignments to read, understand and present eu directives, charters and other documents (e.g. 3,4,6,11,14,16) in order to become acquainted with the european integration in health. health systems in the eu are facing the common challenge of a rise in chronic diseases as a consequence of our increasingly ageing population. vytenis andriukaitis, the eu commissioner for health and food safety, entitled his column in august 2015 issue of the european journal of public health ―how the ehealth can help with europe‘s chronic diseases epidemic‖ (17). quotes from this article are presented below: ―as a former medical doctor, i am fascinated with innovative solutions that are part of today‟s medical toolbox. i would like to highlight ehealth in particular. the more i learn about ehealth, the more convinced i am that it can enable better health, better and safer care for citizens and more efficient and sustainable healthcare systems. ehealth and mhealth can deliver more tailormade, „citizen-centric‟ care, more targeted and effective therapies, andhelp reduce medical errors.” good to hear that ehealth network has adopted the guidelines on electronic prescriptions needed for their cross-border exchange and progress ininteroperability: “although the deployment of ehealth is the responsibility of member states, the eu adds value in many ways. the ehealth network set up under the cross-border health care directive provides a forum for cooperation, support and guidance for speeding up the broad use of ehealth services and solutions. facilitating interoperability and safe and efficient handling of electronic health data across national and organizational boundaries is a key issue. the ehealth network has already adopted guidelines on cross-border exchange of patient summaries and prescriptions. these guidelines encourage the adoption of ehealth applications at national level.” guidelines on eprescriptions dataset adopted by ehealth network (18) are intended to be complementary to the commission implementing directive 2012/52/eu of 20 december 2012 laying down measures to facilitate the validation of medical prescriptions issued in another member state (19), but also as another document for implementation in the nearfuture. references 1. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives. seejph 2014; posted: 23 december 2014. doi 10.12908/seejph-2014-36. 2. merkel b. a growing competence: the unfinished story of the european union health policy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-2014 49. 3. charter of the fundamental rights of the european union. 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http://ec.europa.eu/priorities/digital-single-market/docs/dsm-communication_en.pdf http://ec.europa.eu/priorities/docs/pg_en.pdf https://ec.europa.eu/digital-agenda/en/digital-agenda-europe-2020-strategy%20(2 https://ec.europa.eu/digital-agenda/news-redirect/15512 https://ec.europa.eu/digital-agenda/news-redirect/15512 http://ec.europa.eu/newsroom/dae/document.cfm?doc_id=5146 http://ec.europa.eu/newsroom/dae/document.cfm?doc_id=8382 http://www.fda.gov/downloads/medicaldevices/.../ucm263366.pdf http://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidancedocu http://ec.europa.eu/health/medicalbozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph 2014-53 7 18. guidelines on eprescriptions dataset for electronic exchange under cross-borderdirective 2011/24/eu. release 1. adopted by ehealth network. available at: http://ec.europa.eu/health/ehealth/docs/eprescription_guidelines_en.pdf (accessed: september 29, 2015). 19. commission implementing directive 2012/52/eu of 20 december 2012 laying down measures to facilitate the recognition of medical prescriptions issued in another member state. available at: http://ec.europa.eu/health/cross_border_care/docs/impl_directive_presciptions_2012_en.pdf (accessed: september 29, 2015). © 2015 bozikov; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://ec.europa.eu/health/ehealth/docs/eprescription_guidelines_en.pdf http://ec.europa.eu/health/cross_border_care/docs/impl_directive_presciptions_2012_en.pdf http://creativecommons.org/licenses/by/3.0) 8 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 original research piloting an advanced methodology to analyse health care policynetworks: the example of belgrade, serbia helmut wenzel 1 , vesna bjegovic-mikanovic 2 , ulrichlaaser 3 1 health economic consultant; 2 institute of social medicine, faculty of medicine, university of belgrade,serbia; 3 section of international health, faculty of health sciences, university of bielefeld, ger many. corresponding author: helmut wenzel, m.a.s. address: d78464 konstanz,germany; e-mail: hkwen@aol.com mailto:hkwen@aol.com 9 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 abstract aim: political decisions usually emerge from the competing interests of politicians, voters, and special interest groups. we investigated the applicability of an advanced methodological concept to determine whether certain institutional positions in a cooperating network have influence on the decision-making procedures. to that end, we made use of the institutional network of relevant health care and health governance institutions, concentrated in belgrade, serbia. methods: we used a principal component analysis (pca) based on a combination of meas ures for centrality in order to evaluate the positions of 25 players in belgrade‟s institutional network. their directed links were determined by a simulated position approach employing the authors‟ long-term involvement. software packages used consisted of visone 2.9, ucinet 6, and keyplayer 1.44. results: in our analysis, the network density score in belgrade was 71%. the pca revealed two dimensions: control and attractiveness. the ministry of health exerted the highest level of control but displayed a low attractiveness in terms of receiving links from important play ers. the national health insurance fund had less control capacity but a high attractiveness. the national institute of public health‟s position was characterized by a low control capacity and high attractiveness, whereas the national drug agency, the national health council, and non-governmental organisations were no prominentplayers. conclusions: the advanced methodologies used here to analyse the health care policy net work in belgrade provided consistent results indicating that the intended decentralization of the health care network in belgrade may be incomplete, still with low participation of civil society representatives. with the present study we set the stage for a broad-range survey based data collection applying the methodology piloted inbelgrade. keywords: belgrade‟s health care policy network, policy analysis, serbia, social network analysis, sources of power. conflicts of interest: none. acknowledgments: this work was supported by the ministry of science and technological development, republic of serbia, contract no. 175042. 10 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 introduction political decisions are not primarily the result of scientific (rational) problem solving like e.g. the illustration of the policy cycle suggests (1,2). the decisions usually will emerge from the competing interests of politicians, voters, and special interest groups. the policy literature considers this issue and suggests a variety of frameworks and analytic models for policy analysis (3). the spectrum ranges from the rather normative scientific problem solving ap proach to a more „incrementalistic‟ way (4). lindblom even calls it „muddling through‟ (5) and finally to the paradigm of „bounded rationality‟ (6,7). analyzing decision outcomes (policies) has to consider the specific organisational structure (policy) and the initiated proc esses (politics), comparable to donabedian‟s concept of structure and process as a prerequi site of outcome quality (8). related questions are: how will political decision processes pos sibly influence policy-making (6)? do certain individual or institutional positions in a coop erating network have more or less influence on the decision-makingprocedures? to explore the complex governmental portfolio of resources, hood et al. (9,10) propose a classification scheme, which gets to the point with only four important sources of power: nodality, authority, treasure and organisation. they state that nodality denotes the property of being in the middle of an information or social network (10). a high degree of nodality gives a player a strategic position from which he allocates information, and which enables him to draw in information. authority is the formal and legitimate official power (11). that is the formal power to demand, forbid, guarantee, and arbitrate. treasure gives the government the ability to exchange goods, using the coin of money or something that has a money-like property. finally, organisation gives to a government the physical ability to act directly, us ing its own forces (10). with the serbian health insurance act of 2005 (12) the serbian government aimed at reo rienting the health care system and transform it into a more decentralised organisation. these changes would hopefully offer to the insured population an opportunity for a greater self management. as most of the relevant institutions are concentrated in the serbian capital bel grade, we used this example to investigate the applicability of the aforementioned methodo logical concept. with the disclosure of the players‟ nodalities that make up belgrade‟s health care policy network, we envisaged to analyse to which degree the decentralisation of decision making has progressed since the legislation of 2005, extending our preliminary analysis (13). with the present step we focus on institutional players and their nodality only, without con sideration of potentially influential individual players. the analysis of belgrade‟s health pol icy network is a pilot project appropriate for testing the feasibility of a countrywide survey. this analysis was based on a questionnairesurvey. methods to break down the abstract notion of power and influence, different paradigms were used in sociology and political science: reputation approach, decision approach, or position approach (14). for a critical review of the approaches see domhoff (14). in our understanding, influen tial actors can be best described by the position approach, i.e. a policy network. a policy network is described by its various players public as well as non-governmental their for mal and informal connections and the specific boundary of the network under consideration. the links between the players are likely to be understood as communication channels for the exchange of information, expertise, trust and other policy resources (15). depending on the scientific disciplines, e.g. coming from community power research (14), or systems thinking (16,17), various technical approaches and measures have been used to identify, describe and 11 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 analyse formal or informal networks within organisations. necessary data can be collected by means of survey (questionnaires, interviews), observations, or by analysing secondary data. for economic reasons, a heuristic procedure as outlined e.g. by vester (16) or bryson (18) was applied and possible actors [so-called boundary specification (19, p. 77)] were enume rated in a brainstorming session listed in a ―cross-impact matrix‖ of influences (16, p. 188). finally, the strength and direction of their connections was estimated (16, p. 188) by the au thors for the purpose of this methodological study. these are ―soft data‖ (16, p. 22), but nev ertheless they are based on experience, knowledge of the health care system and observa tions. as newman points out, collecting data by directly questioning participants (or, players) does not necessarily provide a higher accuracy and is also a laborious endeavour (20). for visualisation of the network and a more in-depth analysis, we recurred to the analytic tools of social network analysis (sna). the concept of nodality corresponds well with the measures used in sna and, basically, two viewpoints are possible: primarily focusing on a specific player (ego-centred) only, and analysing and evaluating the network as a whole, taking all connections and all players into account (socio-centred)(13). on a socio-centred level, the network structure can be described by measuring density and centralization. centralization is defined as the variation in the centrality scores of the nodes or players in the network. this variation shows the extent to which there is a centre i.e., very central players and a periphery i.e., players with very low centrality scores (21). density is a basic network property that reflects the overall intensity of the connected players: the more connected the network, the greater its density. a dense network is one where a lot of activity or a large number of strong ties exist among its members (22). on an ego-centred (individual) level, we focused on the players‟ importance. importance reflects the visibility to other net work members (23) and is broken down into indices like influence andprestige. measures of centrality the concept of centrality is a crucial aspect when representing policy networks (24). central ity measures will identify the most prominent players. these are the players who are exten sively involved in relationships with other network members (25) without necessarily dis criminating between formal or informal links (depending on the data collection approach). the most frequently centrality measures used include degree centrality, betweenness central ity, and closeness centrality. they reflect the view that information is transferred along the shortest pathways (26). degree centrality is an indicator of expertise and is measured by the sum of all other players who are directly connected to a specific player (25). asymmetric networks are particular in that the distinction between indegree-centrality and outdegree-centrality has to be taken into account (13). players receiving many ties (indegree) have a high prestige (23). players with a high flow of outgoing connections (outdegree) are able to exchange with many others, or at least make others aware of their views (13). this means that players with a high outdegree centrality are said to be influential players(27). betweenness centrality counts how many times a player connects other players, who other wise would not be able to reach one-another (25). it measures the potential for control, be cause a player who shows a high betweenness degree will be able to operate as a gatekeeper by controlling the flow of resources between the other nodes that are connected through him (25) on shortest paths (28). 12 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 closeness centrality is based on the concept of distance. a player who is close to all others in the network, e.g. having a distance of no more than one, is not dependent on any other to reach everyone in the network (25). closeness centrality measures independence or efficiency (25). in the context of sna, efficiency means that the higher the closeness centrality of a node, the shorter is its average distance to any other node, thus indicating a better position for spreading information (29). further centrality measures are hub function and authority. in directed networks, players that have important resources should get a high centrality score too. newman defines it as fol lows: “authorities are nodes that contain useful information on a topic of interest; hubs are nodes that tell us where the best authorities are to be found” (30, p. 179). in the framework of sna, formal authority has to be differentiated from informal authority (11). hubs are en ablers of effective knowledge transfer (31, p. 225). a high hub player points to many impor tant authorities (high outdegree) whereas a high authority player receives ties from many im portant hubs (high outdegree). they can effectively connect different sub-groups of the net work and facilitate knowledge flows; removing them from the network can lead to its frag mentation (31, p. 225). study setting for investigating the applicability of the methodological concept we chose a position ap proach as it best describes the potential of power and influence, combined with a heuristic data collection. to that end, the authors all well informed about the serbian health care sys tem and the situation in belgrade listed 25 players, identified the links between the players and the perceived strength of their relationship together in an open process. as pointed out earlier (13), the links can point in one direction only (unidirectional), or include both direc tions (bidirectional). the strength of the relationship was rated on a scale ranging from 0 to 4. very weak links with a value of 1 were put on a level with 0 for ―no link‖ (13). the rating of the links reflects the averaged assessment of the authors. the resulting ―cross-impact matrix‖ was exported to visone 2.9 (15) for further analysis. in some cases where the analytic toolset of visone 2.9 did not provide the calculation of specific indices, we used ucinet 6 (32), and keyplayer1.44 (33) instead. to visualise the analytical findings in an easily understandable format, we chose the design of a target diagram, which is also a built-in feature of visone 2.9. in this diagram, the 25 players (nodes) are placed according to their scores. this means that the player with the high est score is positioned in the centre of the diagram; the others, according to their decreasing scores, are moved toward the periphery of the structure, correspondingly. to ensure a largely undisturbed view, the authors of visone 2.9 applied a specialized layout algorithm that aims at minimizing entanglement by reducing the number of crossing lines and occlusions deter mine the angular location. the different score levels are displayed as thin concentric circles. this allows comparing the scores of the players easily, without looking at the output table (15, p. 17). brandes et al. (15) successfully used these diagrams to analyse local health poli cies and the underlying structure of the various players, e.g. to disclose the differences in the local drug policy of two german municipalities and the networks of players that form the basis of the policy making. furthermore, to facilitate an overall perspective (holistic view) of the indices applied, we merged the results with the help of a principle component analysis (pca) diagram. pca is a multivariate data analysis method which is used to reduce complex ity by transforming a set of possibly correlated variables into a set of uncorrelated variables, 13 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 ., principal components (34,35). this approach explains best the variance of data and helps to reveal the internal structure of the data. results the network matrix was composed by 25 players and 158 directed and valued links or con nections as determined for the purpose of this methodological study by the authors. the network density was calculated as 71% realized links out of all possible ones. a density greater than 50% is considered high (36). therefore, we assumed here that the players in bel grade were well connected. for valued networks (see figure 1), the centralization score has to be calculated separately for outdegree and indegree centrality. the outdegree score here was 46.3% of all possible connections, whereas the indegree score was 19.1% (calculated with ucinet 6). this would disclose a distinct centralisation. however, the range of outdegree scores was larger than that of indegree scores, and the players showed a higher variability. the coefficient of variation was 93% for outdegree and 54% for indegree centrality, indicat ing that the network was less homogeneous with regard to outdegree centrality, or influence (27). the possible influence of the players in the network varied largely, i.e., the positional advantages were rather unequallydistributed. the most important players – identified in terms of degree centrality (figure 1a and table 1) were the national health insurance fund [1], the ministry of health [15], the national government [14], and the medical faculty, belgrade [22]. the health insurance fund [1] received most of the strongest [blue] links. the players with the highest indegree centrality or 14 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 prestige were the clinical hospital centres, belgrade [8], the institute of public health, bel grade [4], the national health insurance fund [1], and the clinical hospital centre of the republic [7]. players with the highest outdegree centrality or influence were the national government [14], the ministry of health [15], the medical faculty, belgrade [22], the state revisor [18], and the national health insurance fund [1]. table 1. ranking of players by centralityindices (based on percentages – for the numeric codes, see table 3 in theannex) indices of centrality degree centrality indegree centrality outdegree centrality betweenness closeness hub function authority 1 8 14 8 14 14 3 15 4 15 15 15 15 8 14 1 22 22 18 18 4 22 7 18 7 22 1 7 7 3 1 19 19 22 23 8 5 17 1 7 17 1 18 6 7 20 1 20 25 5 23 20 11 20 7 9 4 25 19 23 23 11 2 17 9 11 5 17 19 10 19 15 23 6 11 5 15 20 23 8 9 16 23 6 23 2 5 23 8 8 23 6 10 16 18 10 10 5 11 22 9 12 3 9 13 3 12 6 17 9 16 17 23 19 10 3 23 6 16 9 13 4 4 21 2 19 25 17 2 10 12 4 12 2 11 12 2 5 23 22 10 20 21 14 6 21 20 12 16 23 16 2 12 11 16 21 3 21 4 3 21 13 18 25 25 25 25 18 21 14 13 13 13 13 14 with respect to the betweenness centrality, the clinical hospital centres, belgrade [8] were the most central players. the ministry of health [15], the medical faculty, belgrade [22], the clinical hospital centre of serbia [7], and the serbian physicians society [19] seemed to be very close to each-other, but located more to the margin. players with a high degree of close ness were the national government [14], the ministry of health [15], the state revisor [18], the medical faculty, belgrade [22], and the serbian physicians society [19]. the picture changed when we looked at hub functions. as pointed out, hubs are enablers of effective knowledge transfer, they can effectively connect different sub-groups of the network and facilitate knowledge flows; removing them from the network can lead to its fragmentation (31, p. 225). considering the hub function, the national government [14] was in the most 15 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 favourable position (see figure 1b), followed by the ministry of health [15]. the national health insurance fund [1] moved more to the periphery indicating a loss of importance for knowledge transfer. the state revisor [18] and the mof budget inspection [17] also moved more to the centre of the diagram. as hannemann and riddle note, the question of how structural positioning implicates power is still a matter of research and debate (34). to reduce the complexity, eventually sort out redundant information and get an integral view, we applied pca which is displayed in table 2 and figure 2. table 2. contribution of centrality measures to the dimensions of the pca(percentages) centrality measures d1 (control) d2 (attractiveness) degree 22.645 3.186 indegree 0.159 40.837 outdegree 22.820 3.876 betweenness 12.246 7.907 closeness 19.822 3.205 hub function 21.654 3.607 authority 0.654 37.381 the pca provides evidence of two dimensions (figure 2); they explain 88.81% of the data. the first dimension consists of degree, outdegree, closeness, and hub function. the second dimension consists of indegree and authority. the first dimension d1 represents the capacity for ―control‖; the second dimension d2 depicts what we called―attractiveness‖. the main players: the ministry of health [15] apart from the formal aspect i.e. legal author ity and organisation was highly ranked on the first dimension of control. on the second di mension of attractiveness, it was ranked just above the average. this picture was confirmed in the classification by hub function and authority. the ministry of health was a hub as well as an authority in this analysis, whereas the hub feature was more pronounced. this would mean that it was connected to many popular players and received links from important play ers. the national government [14] was likewise highly ranked on the first dimension, but showed the lowest score on the second dimension. this means that control was high but the attractiveness was low. on the other hand, the national government [14] was also a hub, which means that it was connected to many very important players, and its influence might be based on this feature, primarily. the national health insurance fund [1] showed less poten tial of control [first dimension] than the ministry of health [15], but had a higher score on the attractiveness axis [second dimension]. the national health insurance fund [1] was a hub and an authority too. the hub score was lower than that of the ministry of health or the na tional government, but its authority score was very pronounced. this means, its authority feature receiving links from important players – in our pilot study was moreimportant. according to this analysis, effective decentralisation would require more autonomy for insti tutions like the national institute of public health [3], the national drug agency [10], the national health council [13], and non-governmental organisations [21], all ranking with the exception of the national institute of public health [3] towards the end in table 1 and low on both dimensions in figure 2. but, also the chambers of health professionals [11, 12] could play a more important role as well as the trade unions [20] and the branches of the na tional health insurance fund [2]. 16 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 figure 2. the position of players by twodimensions legend: the yellow triangles mark the national government and the ministry of health; the green diamonds signify the players focussed in the analysis; the blue circles represent the remaining players. for the numeric codes, see table 3 in theannex. the national institute of public health [3] ranked below average on the first dimension (con trol) and was positioned above average on the second dimension (attractiveness) that is play ers were seeking contact. its high authority score confirmed this, but as a hub it ranked very low (table 1). according to borgatti, such players are primarily mediators(37). discussion it is a widespread view in the literature that no single or generally accepted method for mea suring decentralization exists (38); there are many different definitions, understandings of the concepts and diverse measurement instruments (39). thus, measuring centralization or decen tralization is mostly based on analyzing the financial autonomy or regulatory mechanisms (39,40). independent of the underlying ―intellectual tradition‖ (41), disciplinary and language differences, and the way the various indices were constructed, these approaches focus on formal aspects. informal ways of influence and power are not taken into account. however, these informal relationships may superimpose the formal balance of power, supporting or even hindering structural changes or specific policy-making, and possibly will underestimate the real balance of power. the concept of nodalities, used here, is based on relationships (links). these links cannot only indicate subordination but can also stand for information observations (axes d1 and d2: 88.81 %) after varimaxrotation 2.5 2 8 1.5 7 1 4 3 24 1 25 0.5 6 9 5 15 0 2 23 10 19 22 -0.5 13 12 11 1720 -1 16 21 -1.5 18 -2 14 -2.5 -2 -1.5 -1 -0.5 0 0.5 1 1.5 2 d1 control (55.4%) 2.5 d 2 a tt r a c ti v it y ( 3 3 .4 % ) 17 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 channels. insofar, mapping the nodalities, is complementary to the approaches mentioned above and will round off the picture. compared to other european countries, serbia is among the most centralized systems (42). it ranks second on a list of thirteen countries (38). the analysis of the degree and appropriate ness of decentralization, however, is not an end in itself. it is a means to achieve a broader spectrum of goals (43) or, more generally speaking, it is an important component of good governance (38). very often it is emphasized that decentralization is a very significant step in promoting democracy (44,45). with decentralization essential goals should be achieved, such as effectiveness and efficiency, fairness, quality, financial responsibility, and respect for local preferences (43,45). decentralization is one of the most important issues on the agenda of health care reform in many countries. however, there is little information from research that can show the likely correlation between the degree of centralization and health outcomes, i.e. the health of the population (40). furthermore, observations and case studies indicate that, if inadequately planned, and implemented, i.e. too rapidly or inconsistently, decentralization can have serious consequences on the provision of health services to the population (43). for that reason, appropriate planning, and considering corresponding experiences in other coun tries, may prevent disappointment and slow-down of processes. decentralization also will shift the role of the ministry of health, from direct management and decision making toward formulating health care policies, technical counselling and assistance, as well as monitoring and evaluation of programmes andactivities. decentralization represents the transfer of authority and responsibility for public functions from the central to subordinate levels and/or to the private sector (43,45). the essential task, then, is to define the adequate level of decentralization (45) by entities, i.e., regions, districts, and municipalities, and by appropriate forms of bureaucratic autonomy, i.e. deconcentration, delegation, and devolution. any consideration on whether decentralization is necessary and how much will be feasible has to undergo a detailed examination in the context of a (rational) organisational structure (46); this is very often perceived a common place, and ignored with associated consequences. certain aspects of decentralization deserve closer attention. for example, the possibility of local authorities to adapt to local conditions should be carefully balanced against a common vision and the goals of the health care system (4). for this reason, the policy of decentralization should include mechanisms of coordination, since the local political interests grow as more responsibilities are transferred to that level (47). furthermore, decentralization bears the risk of fragmenting responsibility for different types of health care (specialist hospitals, general hospitals, primary care etc.) between the levels of regional and municipal government (43). in this context, it is indicative that the coordinative and integra tive potential of the national health council of serbia [13] seemingly is not used. this body could include non-governmental organisations [21] in the field of health, as well as trade union representatives from the most important health institutions. the limitations of our approach relate to its validity and reliability. a valid model has to be isomorphic, thus representing a true picture of the system to be modelled. the level of iso morphism can be disclosed in analogy to the revision of „validity of structure and processes‟ (48), or „expert concurrence‟ (49). however, in this study the boundaries and the linksremain to be crosschecked as a next research step, especially as the present dataset relies only on the author‟s evaluation of the situation. missing data, i.e., the absence of players and/or links can also have an important impact (50,51) on the „application validity‟. another criticism that raised concerns relates to the shortest paths-based measures as they do not take intoaccount 18 wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 diffusion along non-shortest paths (52). however, the modelling algorithms used here are consistent with validated standard computersoftware. in order to challenge the appropriate level and structure of a health care system and to control any process of reorganisation, it is essential to be fully familiar with the positive interaction of the various players. in this context, it is an important cornerstone to know the nodality of the health care network, in our example that of belgrade hosting most of the national health institutions. the network depicted would also provide a basis for what-if-scenarios to antici pate the likely effects of intended changes. furthermore, the methodology used for the net work and its description, which examines the system from a relatively high level (bird‟s eye view), can be adapted to specific decision-making situations, and tailored to support specific planning processes. conclusion the advanced methodologies used here to analyse the health care policy network in belgrade deliver consistent results indicating that the intended decentralization of the health care net work in belgrade may be incomplete, still with low participation of civil society representa tives. with the present study we hope to prepare for a broad-range survey-based data collec tion and to apply the methodology piloted in belgrade. references 1. bridgman p, davis g. what use is a policy cycle? plenty, if the aim is clear. austj pub admin 2003;62:98-102. 2. may jv, wildavsky ab. the policy cycle. beverly hills, sage publications;1978. 3. parag y. a system perspective for policy analysis and understanding: the policy process networks. systemist 2006;28:212-24. 4. hayes mt. incrementalism and public policy. new york ny u.a, longman; 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2013. p. 24-43. 52. borgatti sp. centrality and network flow. social networks2005;27:55-71. annex table 3. list of players and their correspondingcodes work code full name 1 national health insurance fund 2 nhif, belgrade branch 3 national institute of publichealth 4 institute of public health, belgrade 5 secretary for health, belgrade 6 primary health care centres (17),belgrade 7 clinical hospital centre of serbia 8 clinical hospital centres (4),belgrade 9 national accreditationagency 10 national drug agency 11 national chambers of healthprofessionals 12 chambers of health professionals, belgradebranches 13 national health council 14 national government 15 ministry of health 16 ministry of finance 17 mof budget inspection 18 state revisor 19 serbian physicians society 20 trade unions 21 non-governmental organisations 22 medical faculty, belgrade 23 council of the medical faculty,belgrade 24 special hospitals, belgrade 25 tertiary medical institutes,belgrade © 2015 wenzel et al; this is an open access article distributed under the terms of the creative commons attri bution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited. http://creativecommons.org/licenses/by/3.0) 22 meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in therepublic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 original research estimating health impacts and economic costs of air pollutioninthe republic of macedonia craig meisner 1 , dragan gjorgjev 2,3 , fimka tozija 2,3 1 the world bank, washington, dc, usa; 2 institute of public health, skopje, republic of macedonia 3 medical faculty, skopje, republic of macedonia corresponding author: craig meisner, senior environmental economist, the world bank, msn mc7-720; address: 1818 h street, nw, washington, dc 20433, usa; telephone: 202-473-6852; e-mail: cmeisner@worldbank.org mailto:cmeisner@worldbank.org 23 meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in therepublic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 abstract aim: this paper assesses the magnitude of health impacts and economic costs of fine particulate matter (pm) air pollution in the republic of macedonia. methods: ambient pm10 and pm2.5 monitoring data were combined with population characteristics and exposure-response functions to calculate the incidence of several health end-points known to be highly influenced by air pollution. health impacts were converted to disability-adjusted life years (dalys) and then translated into economic terms using three valuation approaches to form lower and higher bounds: the (adjusted) human capital approach (hca), value of a statistical life (vsl) and the coi (cost ofillness). results: fine particulate matter frequently exceeds daily and annual limit values and influences a person‟s day-to-day health and their ability to work. converting lost years of life and disabilities into dalys these health effects represent an annual economic cost of approximately €253 million or 3.2% of gdp (midpoint estimate). premature death accounts for over 90% of the total health burden since this represents a loss of total life-long income. a reduction of even 1μg/m 3 in ambient pm10 or pm2.5 would imply 195 fewer deaths and represent an economic savings of €34 million per year in reduced health costs. conclusion: interventions that reduce ambient pm10 or pm2.5 have significant economic savings in both the short and long run. currently, these benefits (costs) are „hidden‟ due to the lack of information linking air quality and health outcomes and translating this into economic terms. policymakers seeking ways to improve the public‟s health and lessen the burden on the health system could focus on a narrow set of air pollution sources to achieve these goals. keywords: air pollution, health and economic costs, particulatematter. conflicts of interest: none. acknowledgements: the authors would like to first acknowledge the financial support of the green growth and climate change analytic and advisory support program launched in 2011, with funding support from the world bank and the governments of norway and sweden. we would also like to thank our local macedonian counterparts at the institute of public health and the ministry of environment and physical planning for their willingness to collect and share data. we would also like to thank the finnish meteorological institute (fmi) for their guidance and suggestions on earlier drafts of this work. fmi is currently working with the moepp in strengthening their air quality monitoring network through an eu-sponsored twinning project. 24 meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in therepublic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 introduction according to the global burden of disease (2010) estimates (1), the crude mortality rate from ambient particulate matter (pm) pollution in macedonia was 80.6 deaths per 100,000 in 2010. in comparable neighboring states such as serbia, it was 71.8 deaths per 100,000; in croatia it was 69.4 per 100,000; in hungary 92.0 per 100,000; and 70 per 100,000 in slovakia. the total disability-adjusted life years (dalys) attributable to pm were about 1,480 per 100,000 in macedonia (but, up to 1,600 in hungary) (1). the main sources of this ambient condition were the use of solid fuel for heating households in the winter, as well as the impact of industry and traffic. uncontrolled urbanization is also a significant source of particulate matter. in 2009, an average annual concentration of 90µg/m 3 was registered in skopje. compounding the situation, poor air circulation is another reason why the capital city of skopje has one of the worse air conditions inwinter. air pollution is also significant throughout the european region, with only nine of the 34 member states reporting pm10 levels below the annual who air quality guideline (aqg) of 20μg/m 3 . almost 83% of the population in these cities is exposed to pm10 levels exceeding the aqg levels(2). results from a recent project improving knowledge and communication for decision-making on air pollution and health in europe (aphekom), which uses a traditional health impact assessment method, indicated that average life expectancy in the most polluted cities could be increased by approximately 20 months if long-term pm2.5 concentrations were reduced to who guidelines (3). one recent study in macedonia found that an increase of pm10 by 10μg/m 3 above the daily maximum permitted level (50μg/m 3 ) was associated with a 12% increase in cardiovascular disease(2). methods to estimate the health impacts and economic costs of air pollution, the approach required overlaying data from multiple sources. the method used ambient air quality data [information received from the ministry of environment and physical planning (moepp)] for pm10 and pm2.5, health statistics – annual deaths by disease type; frequency of chronic bronchitis, asthma, infant mortality; and health cost data (information received from the institute of public health and health insurance fund), exposure-response functions from health studies (information from international and local literature) and population characteristics – age groups, gender, urban/rural population (information from the state statistics bureau). these data were combined for a municipal (city) levelanalysis. the approach to estimating health impacts and economic costs encompassed fivesteps:  collection of monitored, ambient concentration data on pm10 and pm2.5  calculation of exposed population  exposure-response functions  calculation of physical health impacts (mortality, morbidity,dalys)  monetizing health impacts collection of monitored data on fine particulatematter currently, the ministry of environment and physical planning (moepp) has a network of 19 automatic monitoring stations: seven in skopje, two in bitola, two in veles and one in kicevo, kumanovo, kocani, tetovo, kavadarci, village lazaropole, and two near the okta oil refinery (near the villages of miladinovci and mrsevci). stations measure so2, no2, co, pm10, pm2.5, ozone, benzene, toluene, ethyl benzene and btx – although some stations do not measure all pollutants [monitored pm2.5 measurements began in november, 2011 in 25 meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in therepublic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 karpos and centar. in cases where pm2.5 is not actually monitored, observed pm10 is adjusted by the ratio pm2.5/pm10. the ratio, based on recent observations, is estimated at in the case of macedonia; and is within ranges found in other international studies. see ostro (4) for a discussion]. this information is available electronically through their air quality portal (available at: http://airquality.moepp.gov.mk/?lang=en). calculation of exposed population population information for 2010 was used focusing on the working population as well as vulnerable segments of society (for example, those under the age of five or older than 65 are considered more vulnerable to the effects of air pollution – that is more prone to develop acute or chronic respiratory ailments). exposure-response functions the selection of exposure-response functions was based on epidemiological research between pm10 and pm2.5 and mortality and morbidity. for mortality, exposure-response functions for long-term exposure to pm2.5 were (4): relative risks (rr) were calculatedas: cardiopulmonary (cp) mortality: rr =[(x+1)/(x0 +1)] 0.15515 lung cancer (lc) mortality: rr = exp[0.23218 (x-x0)] alri mortality in under-five children: rr = exp[0.00166 (x-x0)] with: x = current annual average pm2.5 concentration for cp and lc among adults, and pm10 concentrations for alri among children and x0 = target or baselinepm2.5 concentration. information on the crude death rate (cdr), cp, lc and alri data were used to set the mortality baseline. for morbidity, exposure-response coefficients (annual cases per 100,000 population) for pm10 from ostro (4,5) and abbey et al. (6) were applied. ostro (4) reflects a review of worldwide studies, and abbey et al., (6) provides estimates of chronic bronchitis associated with particulates (pm10). a baseline for pm concentrations a baseline level (natural background concentration) for pm2.5 = 7.5 µg/m 3 , as suggested by ostro (4), was used (some argue that the baseline should be set at zero since the literature does not support the existence of a concentration level of which there are no observable effects. however a baseline of zero is not realistic since natural background concentrations hover between 10-15 μg/m 3 in macedonia – and one would only look at investments which could reduce ambient concentrations to this level (i.e. at least from a benefit-cost standpoint of weighing alternativeinvestments). given a pm2.5/pm10 ratio of 0.71 using observations in macedonia, the baseline level for pm10 is 10.6 µg/m 3 . these baseline concentrations were applied to both large and medium/small urban areas. calculation of physical health impacts (mortality, morbidity, dalys) using the population information and the exposure-response functions, mortality and morbidity impacts were calculated through the conversion of impacts to dalys (dalys = sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability). the daly method weights illnesses by severity: a mild illness or disability (e.g. morbidity effects) represents a small fraction of a daly and a severe illness represents a larger fraction (e.g. mortality = 1 daly). weights used in this context were adapted from larsen (7) and are presented in table 1. http://airquality.moepp.gov.mk/?lang=en) 26 meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in therepublic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 table 1. estimated health impacts of air pollution, urban and rural,2010 (source: world bank, 2012) health impacts dalys /10,000 cases cp mortality(pm2.5) 80,000 lc mortality (pm2.5) 80,000 alri mortality (pm10) 340,000 chronic bronchitis (pm10) 22,000 hospital admissions(pm10) 160 emergency room visits (pm10) 45 restricted activity days(pm10) 3 lower respiratory illness in children(pm10) 65 respiratory symptoms (pm10) 0.75 total monetizing health impacts to create a set of bounds three alternative valuation approaches were used: the (adjusted) human capital approach (hca) [the adjusted version avoids the issue of assigning a value of zero to the lives of the retired and the disabled since the traditional approach is based on foregone earnings. it avoids this issue by assigning the same value – per capita gdp – to a year of life lost by all persons, regardless of age], value of a statistical life (vsl) and the coi (cost of illness). the hca estimates the indirect cost of productivity loss through the value of an individual‟s future earnings. thus, one daly corresponds to one person‟s contribution to production, or gdp per capita. this method provides a realistic lower bound for the loss of one daly. the vsl measures the willingness-to-pay (wtp) to avoid death – using actual behavior on the tradeoffs between risks and money. the vsl is calculated by dividing the marginal wtp to reduce the risk of death by the size of the risk reduction. measured this way, the value of one daly corresponds to the vsl divided by the number of discounted years lost because of death. the vsl typically forms an upper bound measure of health damages. the coi approach estimates the direct treatment costs associated to different health end-points (e.g. hospitalization, restricted activity days, and doctor visits). mortality was valued using hca as a lower bound and the vsl as an upper bound. for morbidity effects the coi was estimated as a lower bound and willingness-to-pay to avoid a case of illness was applied as a higher bound of cost (wtp was assumed to be two times thecoi). results air quality data support the finding that particulate matter is one of the most serious concerns in the country. ambient pm10 concentrations frequently exceeded the eu standard of 40μg/m 3 over the years (figure 1). using information on ambient pm10 and pm2.5 in conjunction with the methods outlined above, it is estimated that in macedonia 1,350 deaths occur annually from cardiopulmonary disease and lung cancer (table 2). these deaths are considered „premature‟ in the sense that air pollution contributed to their early demise – since many factors actually influence a persons‟ lifespan (e.g. smoking, exposure to the outdoors, job, etc.). particulate matter can also influence a person‟s day-to-day health and their ability to work. in 2011, levels of pm10 and pm2.5 were primarily responsible for 485 new cases of chronic bronchitis, 770 hospital admissions, and 15,200 emergency visits. 27 meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in therepublic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 figure 1. annual average pm10 concentration at each automatic monitoring stationin μg/m 3 (source: ministry of environment and physical planning, 2012) what do these translate to in terms of a total cost to society? converting lost years of life and disabilities to dalys (or disability-adjusted life years) these health effects represent an annual economic cost of €253 million or 3.2% of gdp (table 2). note that premature death accounts for over 90% of the total health cost since the loss of life is a loss of total (future) income. people also suffer from the day-to-day consequences of respiratory diseases. it is estimated that several thousand work-years are lost annually from chronic bronchitis, asthma, hospital admissions and days of restricted activity. these estimates are consistent with other recent studies – such as kosovo where annual deaths were estimated to be in the range of 805-861 from cardiovascular disease and lung cancer (8). it should be noted that our estimates are mid-points (middle) with lower and higher ranges reflecting different assumptions made on the pm2.5/pm10 ratio and the population‟s exposure to airpollution. what are the potential benefits of reducing particulate matter? if macedonia were to lower pm10 and pm2.5 to eu limit values this would avoid over 800 deaths and thousands of days in lost productivity – representing a health cost savings of €151 million per year (table 3). a reduction of even 1μg/m 3 in ambient pm10 and pm2.5 would result in 195 fewer deaths (1,648 fewer dalys) and imply an economic savings of €34 million per year in reduced health costs. skopje bitola veles tetovo kumanovo kavadarci kocani kicevo rural eu std p m 1 0 c o n c e n tr a ti o n ( u g / m 3 ) 28 meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in therepublic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 10 2.5 10 2.5 10 2.5 table 2. number of annual cases, dalys per year and economic cost in millioneuros, 2011 (source: authors’ calculations) health impact annual cases * total daly per year s annual economic cost (€ million) cardiopulmonary & lung cancer mortality(pm2.5) 1,351 10,809 232.0 alri † mortality(pm10) 1 17 0.1 chronic bronchitis (pm10) 485 1,066 3.0 hospital admissions(pm10) 770 12 0.4 emergency room visits(pm10) 15,200 68 0.9 restricted activity days(pm10) 3,213,000 964 8.6 lower respiratory illness in children(pm10) 22,400 146 1.5 respiratory symptoms(pm10) 10,197,000 765 6.8 total 13,847 253.3 * mid-point estimates using a baseline for pm = 15 µg/m 3 and pm = 7.5 µg/m 3 † alri: acute lower respiratoryinfections. table 3. the potential health ‘savings’ associated with reductions in pm10 and pm2.5 (€ million) [source: authors’ calculations] level of reduction in ambient pm10 and pm2.5(μg/m 3 ) * reduced dalys annual health savings (€ million) 0 0 0.0 1 1,648 34.1 5 4,894 98.9 10 6,636 133.6 15 8,059 161.5 20 9,275 184.9 eu standards met † 7,840 151.5 * example reductions were equally applied to both pm and pm at the same time. † pm = 40 µg/m 3 and pm = 20 µg/m 3 . discussion there is significant evidence of the effects of short-term exposure to pm10 on respiratory health, but for mortality, and especially as a consequence of long-term exposure, pm2.5 is a more robust risk factor than the coarse part of pm10 (particles in the 2.5–10 μm range). all cause daily mortality is estimated to increase by 0.2 0.6% per 10 μg/m 3 of pm10 (9). furthermore, it has been estimated that exposure to pm2.5 reduces life expectancyby about months on average in the european region. results from the study ―improving knowledge and communication for decision-making on air pollution and health in europe‖ (aphekom), which uses traditional health impact assessment methods, indicates that average life expectancy in the most polluted cities could increase by approximately 20 months if long term pm2.5 concentrations were reduced to who annual guidelines (10). monitored pm10 and pm2.5 concentrations have repeatedly exceeded eu standards in republic of macedonia and have contributed to short-term and chronic respiratory disease. this study estimated an annual (mid-point) loss of approximately 1,350 lives with thousands of lost-productive days, indirectly costing the economy up wa rds of €253 million or 3.2% of gdp in 2011. the specific exposure-response functions used in this study were 29 meisner c, gjorgjev d, tozija f. estimating health impacts and economic costs of air pollution in therepublic of macedonia (original research). seejph 2015, posted: 07 april 2015. doi 10.12908/seejph-2014-45 borrowed from the international literature – however the orders of magnitude have been shown to be robust in many developing country applications after adjusting for local conditions(4,5,7,8). from a policy standpoint, it is important to note that these estimated costs are generally ―hidden‖ since they are not normally quantified, and benchmarked to the value of economic activity that generated the pollution (i.e. gdp). likewise the distribution of this burden is shared between the general public and the health care system – so total costs are not transparent. the results should motivate policy makers to be more focused on preventative measures, among them, local green options to reduce particulate matter including energy efficiency, fuel switching and the adoption of cleaner technologies. the benefits from such actions should find their way into the benefit-cost analysis of associated investments since the health ―savings‖ could offset theinvestment costs of greeninginterventions. references 1. institute for health metrics and evaluation. global burden of disease, 2010. http://www.healthdata.org/search-gbd-data?s (accessed: february 2, 2015). 2. kochubovski m, kendrovski v. monitoring of the ambient air quality (pm10) in skopje and evaluation of the health effects in 2010. jepe 2012;13:789-96. 3. world health organization (who). who air quality guidelines, particulate matter, ozone, nitrogen dioxide and sulphur oxide; geneva, switzerland; 2006. 4. ostro b. outdoor air pollution assessing the environmental burden of disease at national and local levels. environmental burden of disease, series no. 5, geneva: who; 2004 (62p). 5. ostro b. estimating the health effects of air pollution: a method with an application to jakarta. policy research working paper no. 1301, washington, d.c.: the world bank; 1994. 6. abbey de, lebowitz md, mills pk, petersen ff, beeson wl, burchette rj. long term ambient concentrations of particulates and oxidants and development of chronic disease in a cohort of nonsmoking california residents. inhal toxicol 1995;7:19-34. 7. larsen b. colombia. cost of environmental damage: a socio-economic and environmental health risk assessment. final report prepared for the ministryof environment, housing and land development of republic of colombia; 2004. 8. world bank. kosovo country environmental analysis: cost assessment of environmental degradation, institutional review, and public environmental expenditure review, washington, dc. the world bank; 2012. http://documents.worldbank.org/curated/en/2013/01/17485553/kosovo-country environmental-analysis-kosovo-country-environmental-analysis-cea (accessed: february 2, 2015). 9. samoli e, peng r, ramsay t, pipikou m, touloumi g, dominici f, et al. acute effects of ambient particulate matter on mortality in europe and north america: results from the aphena study. environ health perspect 2008;116:1480-6. 10. world health organization (who) – regional office for europe. health effects of particulate matter: policy implications for countries in eastern europe, caucasus and central asia. copenhagen, denmark; 2013. © 2015 meisner et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.healthdata.org/search-gbd-data?s http://documents.worldbank.org/curated/en/2013/01/17485553/kosovo-countryhttp://creativecommons.org/licenses/by/3.0) 30 jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 original research health and health status of children in serbia and thedesired millennium development goals aleksandra jovic-vranes 1 , vesna bjegovic-mikanovic 1 1 institute of social medicine, medical faculty, belgrade university,serbia. corresponding author: aleksandra jovic-vranes, belgrade university, serbia; address: dr subotica 15, 1100 belgrade,serbia; telephone: +381112643830; e-mail: aljvranes@yahoo.co.uk mailto:aljvranes@yahoo.co.uk 31 jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 abstract aim: children represent the future, and ensuring their healthy growth and development should be a prime concern of all societies. better health for all children is one of the leading objectives of the national plan of action for children and a key element of the tailored millennium development goals forserbia. methods: our analysis was based on relevant literature and available information from the primary and secondary sources and databases. we analyzed health status of children that can be illustrated by indicators of child and infant mortality, morbidity, and nutritional status. results: there has been a significant reduction in the mortality rates at the national level, particularly with regard to infants and children under five years of age. however, the current mortality rate of roma children is still three times as high as the millennium goal set at the national level for serbia. most deaths of children under the age of five are due to preterm birth complications, congenital anomalies, birth asphyxia and trauma, pneumonia and sepsis. the rate of malnourished children among the poor and in roma settlements is twice as high as in the general population of serbian children. a growing number of obese children was also noted in the roma population. conclusion: political awareness, commitment and leadership are required to ensure that child health receives receive the attention and the resources needed to accelerate the progress of serbia. keywords: children, health status, millennium development goals,serbia. conflicts of interest: none. 32 jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 introduction a comprehensive understanding of the children‘s and women‘s health as a state of complete physical, mental and social wellbeing (1) is essential to the health of current and future generations. almost every culture holds that a society has a responsibility to ensure a nearly equal start in life for children, which implies developing their full health potential (2). however, there are still significant ethnical and regional differences that need to be considered while developing the global health policy framework. the differences in people health are determined by their exposures to health risks, which are, in turn, the social determinants of health (3). the prevention of disease requires overall investment in the social determinants of health and reduction of inequalities and unfairness inhealth. the foundations for adult health and, indeed, the health of future generations are laid in early childhood and even before birth. therefore, better health for all children is one of the leading objectives of the national plan of action for children (4) and a key element of the tailored millennium development goals forserbia. progress in the reduction of child mortality is one of the leading public health challenges in all countries (1). reducing child mortality is also one of the millennium development goals, and the first of the total of 27 goals adopted at the world summit for children. it has also been incorporated into many national plans of action for children. in spite of major improvements, national reports on progress in attaining the millennium development goals, even in countries in which child mortality has been reduced by two thirds on the average, highlight that the problem is still present in rural areas, among people living below the accepted poverty line and – as regards southeastern europe – in particular, among roma subpopulations (1,5). child mortality due to preventable causes is further compounded by poverty, unfavorable living conditions, low educational level of mothers, social exclusion, neglect, violence against children and insufficiently accessible antenatal and postnatal health care (6,7). deaths among children under the age of five years represent one of the most serious challenges currently faced by the international community. to address this challenge, it is necessary to measure accurately the levels and causes of mortality among this population group (8). major causes of under-five mortality remain the same globally; their relative importance varies across regions of the world. while in low-income countries infectious diseases account for a large proportion of under-five deaths, the main killers of children in high-income countries are non-communicable diseases such as congenital anomalies, prematurity, injuries and birth asphyxia (9). monitoring of the nutritional status plays an important role in the analysis of the health of children, particularly when health risks and preventive actions need to be assessed and considered. irregular and insufficient nutrition during infancy and later can significantly impair the growth and development of children and have adverse health effects (physical fitness, mental functions, immune system). at the same time, excessive food intake and an imbalanced diet may also result in obesity and negative health consequences (10). the aim of our study was to analyze children mortality rates in serbia, leading causes of death, differences in mortality rates between the average population of children and roma children and diet and nutritional status of children under the age of fiveyears. 33 jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 methods this situation analysis has been done on the basis of relevant literature and available information from the following primary and secondary sources anddatabases: published documents including strategies, policies, programs, plans, laws and other regulations of the government of the republic of serbia, health regulations and guidelines of the ministry of health, published reviews, scientific and professional articles on health and health status of the serbian population in national and international journals, national surveys and project reports of international organizations (unicef, who, eu, world bank) that deal with issues of children‘s and women‘s health in serbia; publications in the area of routine health statistics, national e-databases (institute of public health of serbia, dr. milan ―jovanović batut‖, statistical office of the republic of serbia and international e-databases (who/eurostat) for comparison purposes. this statistical information often is only available in aggregated sets of data which do not allow for detailed analyses. health outcomes and health status of children are illustrated by the following indicators: infant mortality rate (deaths of children in the first year of life), perinatal mortality rate (fetal deaths from the 22 nd week of gestation or achieved 1000g in intrauterine development and deaths by the seventh day of life), neonatal mortality rate (deaths in the first 27 days of life only), and morality of children under five years of age (deaths before children turn five years); morbidity, nutritional status and comparisons with relevant national and international benchmarks and objectives. a special focus was placed on disparities and social inequalities in health among population groups within serbia, which are considered unfair, unjust, avoidable and unnecessary. the results were presented in tables andgraphs. results in serbia, there has been a significant reduction in the mortality rates at the national level, particularly with regard to infants and children under five (figure 1), while the reduction of the mortality rate in the prenatal period was somewhat morelimited. figure 1. children mortality rates in serbia: situation analysis and the desired millennium goal by 2015 i-infant mortality rate; ii-perinatal mortalityrate; iii-neonatal mortalityrate; iv-children under 5-yearmortalityrate. 14 12.7 12 10.6 11.2 10 8.0 9.3 9.2 8.8 7.7 8 7.1 6.3 6.5 5.8 6 4.5 4.7 5 4 3 2 0 i ii iii iv 2000 2005 2011 mdg 2015. 34 jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 mortality among roma children remains high, the rate has almost halved over the last five years bringing the number closer to the national millennium goal of reducing roma under-five child mortality to 14 and infant mortality to 12. however, the current mortality rate of roma children is still three times as high as the millennium goal set at the national level for serbia (figure2). figure 2. differences in mortality rates between the average population of childrenand roma children in 2005 and 2010 in serbia figure 3 presents the leading causes of death in serbian children under-five years. most deaths of under-five children are due to preterm birth complications, congenital anomalies, birth asphyxia and trauma, pneumonia andsepsis. figure 3. distribution of the leading causes of death of children under-five inserbia 35 roma children rate per 1000 livebirths roma children2 30 29 2015: mdg for roma children 25.9 2005: averagepopulation 25 2010:averagepopulation 20 2015: mdg for serbia 15 14 15 14 12 10 9.2 8 7.9 6.7 4.5 5 5 0 roma settlements infantmortality serbia roma settlements under 5 yearsmortality serbia 45 41 40 36 35 36 32 35 consequences of pre-termbirth 31 30 30 31 congenitalanoma 29 30 28 25 otherdiseases 20 asfixiaduringbirth 15 pneumonia injuries 10 7 6 6 6 6 5 sepsis 5 4 4 5 4 3 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 35 jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 the indicators of diet and nutritional status of children under-five years of age are presented in table 1. the rate of malnourished children among the poor and in roma settlements is twice as high as in the general population of serbian children. surprisingly, a growing number of obese children were also noted in the roma population, from 6.7% to 12.8%, which points to irregular nutrition. the corresponding millennium development goal in serbia aims to bring the share of obese children down to 9.1% by 2015. breastfeeding habits have not substantially changed, except in the roma population where the number of exclusive breastfeeding up to the age of six months has decreased. the rate of exclusive breastfeeding is still only half of the desired millennium development goal in serbia (30% of exclusively breastfed children from birth until the six month ofage). table 1. diet and nutritional status of children under five years of age in 2005 and 2010 in serbia indicator serbia the poor roma settlements mdg 2005 2010 2005 2010 2005 2010 2015 live births with low birthweight 4.9 4.8 8.6 8.3 9.3 10.2 percent of children first breastfed within a day after birth 68.8 61.9 71.7 69.1 72.5 70.3 percent of children with exclusive breastfeeding for the first sixmonth 14.9 13.7 15.4 19.5 18.0 9.1 30.0 percent of children 6-23 months who receive the minimum number ofmeals na 84.3 na 80.0 na 71.9 prevalence of malnourishment among children under-five (body weight for the given height ≤2sd) 3.2 2.3 3.8 5.2 4.1 5.2 prevalence of obesity among children under-five (body weight for the given height ≤2sd) 15.6 12.7 15.5 12.5 6.7 12.8 9.1 discussion this situation analysis covers the health status of serbian children that can be illustrated by indicators of child and infant mortality, morbidity and nutritional status which are compared with relevant national and international benchmarks and objectives. a special focus was placed on disparities and social inequalities in health among population groups within serbia, which are considered unfair, unjust, avoidable and unnecessary since they open a systematic burden on vulnerable population groups. it is believed that the unfair differences in health of children result from social structures and political, economic and legal relations: they are derived from the system, and are result of the social system (so that they can be changed) and they are unjust (11). marmot insists that they are not a natural phenomenon by any means; instead, they are a combination of poor conditions and low standards of living, poverty, risky life-styles, social exclusion, scarcely formulated, inappropriate health programs and sometimes toxic national and local policies(12). infant mortality is generally regarded as a basic indicator of population health and a measure of long-term consequences of perinatal events. this parameter is particularly 36 jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 important for monitoring and assessing health outcomes in high risk groups such as pre-term children and children with developmental difficulties. trends show that serbia has made significant progress towards the millennium development goal relating to infant mortality (13,14). an analysis of routine statistical data, although infant mortality is still above the european union–27 average (for example, in 2010, the eu-27 infant mortality average was 4.1 vs. 6.7 in serbia), suggests that serbia may achieve the proposed national millennium goals in 2015: an infant mortality rate of 4.5 and an under-five mortality rate of 5 per 1000 live births. earlier comparisons of infant mortality revealed rates in serbia two times higher than the eu rates, but this difference has been substantially reduced to date (15,16). recent studies conducted by unicef and other organizations indicate that the majority of the roma population face social disadvantage and exclusion, and most of them live in poverty (17). many roma individuals are also unemployed, have limited education, as well as insufficient access to information, which combined with a lack of trust in institutions often prevent them from using healthcare services in case of need. the multiple indicator cluster surveys (mics), which have been conducted periodically in serbia since 1996 with the help of unicef, have been extremely valuable in gaining a better understanding of the challenges involved. from 2005, these surveys have provided assessments of child mortality in the roma population using the brass method for estimating child mortality taking into account the risk of death to which the children are exposed to (18). although mortality among roma children remains high, the rate has almost halved over the last five years bringing the number closer to the national millennium goal of reducing roma under-five child mortality to 14, and infant mortality to 12. however, the current mortality rate of roma children is still three times as high as the millennium goal set at the national level for serbia (15). according to the world health organization, most deaths of children under the age of five years are due to a small number of diseases and conditions. forty-three per cent of these deaths occur among babies aged 0-28 days (newborns) and are mainly due to preterm birth complications, birth asphyxia and trauma, and sepsis. after the first 28 days until the age of five years, the majority of deaths are attributable to infectious diseases such as pneumonia (22%), diarrhoeal diseases (15%), malaria (12%) and hiv/aids (3%)(8,9). while international efforts to address mortality among children under the age of five have resulted in significant reductions globally, persistent inequities between and within countries exist. these are not only driven by poverty, but are intrinsically linked to social exclusion and discrimination. therefore, continued efforts to eliminate under-five mortality must take into consideration both direct causes and underlying determinants. this requires a comprehensive and holistic approach,which must explicitly recognize human rights‘ standards as essential and integral elements. also, poor nutritional status in children is strongly correlated with vulnerability to diseases, delayed physical and mental development, and an increased risk ofdying. while, between 1990 and 2011, the proportion of children under the age of five years who were underweight declined by 36%, under-nutrition is still estimated to be associated with 45% of child deaths worldwide. in 2011, there were 165 million children under the age of five years who were stunted, and 52 million who were wasted (10,19,20). low birth weight is closely associated with increased risks of neonatal mortality, cognitive problems and chronic diseases in later life (20). our 37 jovi-vranes a, bjegovic-mikanovic v. health and health status of children in serbia and the desired millennium development goals (original research). seejph 2015, posted: 19 may 2015. doi 10.12908/seejph-2014-47 analysis shows that the national average share of live births with low birth weight (under 2,500 grams) has remained constant in serbia in the last decade. the share of low birth weight is significantly higher for roma and poorchildren. more preventive approaches and consistent efforts for improvement are needed in serbia, to ensure that child health receives the attention and resources needed and secure the benefits that children and familiesrequire. identifying the health outcomes that matter most for the children, and set out the contribution that each part of the health system needs to make in order that desired health outcomes are achieved, would be an effective way to reachprogress. reference 1. who constitution. http://www.who.int/governance/eb/who_constitution_en.pdf (accessed: may 16, 2015). 2. barros fc, victora cg, scherpbier r, gwatkin d. socioeconomic inequities in the health and nutrition of children in low/middle income countries. rev saude publica 2010;44:1-16. 3. marmot m, allen j, bell r, bloomer e, goldblatt p; consortium for the european review of social determinants of health and the health divide. who european review of social determinants of health and the health divide. lancet 2012;380:1011-29. doi: 10.1016/s0140-6736(12)61228-84. 4. government of serbia. national plan of action for children in serbia. http://www.arhiva.serbia.gov.rs (accessed: may 16,2015). 5. unicef (un inter-agency group for child mortality estimation). levels and trends in child mortality. report 2012. new york: unicef headquarters, 2012. 6. parekh n, rose t. 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inequities in health: levelling up. copenhagen: who regional office for europe; 2006. 12. marmot m. global action on social determinants of health. bull world health org 2011;89:702. http://www.who.int/governance/eb/who_constitution_en.pdf http://www.arhiva.serbia.gov.rs/ http://www.childinfo.org/files/mics4_serbia_finalreport_eng.pdf http://www.who.int/healthinfo/statistics/indunder5mortality/en/ http://www.ncbi.nlm.nih.gov/pubmed/?term=black%20re%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=23746772 http://www.ncbi.nlm.nih.gov/pubmed/?term=victora%20cg%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=23746772 http://www.ncbi.nlm.nih.gov/pubmed/?term=walker%20sp%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=23746772 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izjzs; 2012. 15. vlada republike srbije. nacionalni milenijumski ciljevi razvoja u republici srbiji. beograd vs; 2006. 16. vlada republike srbije. progres u realizaciji milenijumskih ciljeva razvoja u republici srbiji. beograd: vs i undp; 2009. 17. unicef. serbia. multiple indicator cluster survey 2005. monitoring the situation of children and women. belgrade: unicef belgrade; 2007. 18. unicef. srbija. istraživanje višestrukih pokazatelja 2010. praćenje stanja i položaja dece i žena. beograd: unicef beograd; 2012. 19. united nations children‘s fund/world health organization/world bank. levels and trends in child malnutrition: report 2012; 2012. http://www.who.int/nutgrowthdb/jme_unicef_who_wb.pdf (accessed: may 16, 2015). 20. united nations children‘s fund/world health organization. low birth weight: country, regional, and global estimates. unicef: new york; 2004. © 2015 jovic-vranes et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited. http://www.who.int/nutgrowthdb/jme_unicef_who_wb.pdf http://creativecommons.org/licenses/by/3.0) 39 kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 original research adverse effects of maternal age, weight and smoking during pregnancyin pleven, bulgaria mariela stefanova kamburova 1 , petkana angelova hristova 1 , stelaludmilova georgieva 1 , azhar khan 1 1 department of public health sciences, faculty of public health, medical university, pleven, bulgaria. corresponding author: dr. mariela kamburova, medical university, pleven; address: 1, st. kliment ohridski, str, pleven, 5800, bulgaria telephone: +359887636599; email: mariela_kamburova@yahoo.com mailto:mariela_kamburova@yahoo.com 40 kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 abstract aim: this paper aims to study the relationship between mothers‘ age, body mass index (bmi), gestational weight gain (gwg) and smoking and the risk for premature birth in pleven, bulgaria. methods: a case-control study was conducted in pleven in 2007. the study was comprehensive for all premature children (n=58) and representative for full-term infants (n=192, or 10.4% of all of the 1827 full-term children) born in 2007 at the university hospital of pleven and resident in the city of pleven. retrospective data on determinants under study were collected from all the mothers included in this study(n=250). results: mothers of premature children were more likely to be above 35 years old (27.6%), with a bmi ≥25 kg/m² (23.1%), gwg below the recommended value (38.5%) and to smoke during pregnancy (37.9%). the odds of being a smoker during pregnancy were five times higher among mothers with low birth weight (lbw) newborns compared with their counterparts with normal birth weight newborns (or=5.1, 95%ci=2.4-10.6). there was a positive association between bmi and lbw in infants whose mothers were overweight (or=2.1, 95%ci=1.0-4.0). the risk of lbw increased when gwg was less than recommended (or=1.8, 95%ci=1.0-3.1). conclusion: our results indicate that pre-pregnancy bmi ≥25 kg/m², less than recommended gwg and smoking during pregnancy are risk factors for premature birth in pleven region. findings from this study suggest the need for active health and educational actions by health professionals in order to avoid premature births inbulgaria. keywords: bulgaria, lifestyle, pleven, premature birth, riskfactors. conflicts of interest: none. acknowledgements: the authors are very grateful to the staff of the obstetric clinic at university hospital in pleven, bulgaria, for their continuous support for the whole duration of this study. 41 kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 introduction premature birth (pb) is a major public health problem worldwide (1). furthermore, pb is rated as one of the most important single causes of the global burden of diseases in neonatal period (2). it is associated with increased infant mortality, short and long-term negative effects on health and additional costly care needs(3). the interest of researchers in personal characteristics and lifestyle factors of the mothers is due to the fact that they are modifiable and they affect the incidence of premature birth. the challenge is to accurately measure the impact of these factors because of their complexity (4). several studies have shown young maternal age as a significant risk factor for premature birth (5,6). it has not been established with certainty yet, whether this risk is associated primarily with the biological immaturity of young mothers, or an increased incidence of certain risk factors associated with socioeconomic status such as age-appropriate educational level, parity, smoking status, prenatal care utilization and poverty status (7,8). women over the age of 35 years are also at increased risk of pre-term birth. astolfi and zonta (2002) found a 64% increase in the probability of giving premature birth for women over 35 years after controlling for educational status, birth order, and sex of the newborns(9). low or high pre-pregnancy body mass index (bmi) and inadequate or excess gestational weight gain (gwg) are linked to an increased risk of adverse neonatal outcomes (10,11). the weight of a woman before the pregnancy is related to her diet, quantity and quality of food (4). studies have shown that low weight of women before pregnancy is associated with an increased risk of preterm birth (12). campbell et al. (2012) found a link between low pre pregnancy bmi and the birth of a premature baby, with a relative risk of >2.5 (6). a study conducted in 2010 in bulgaria on the role of some risk factors for preterm birth failed to establish a statistically significant difference in the weight of women bearing preterm children and those with to term births (13). smoking is defined as one of the most common and preventable causes of adverse outcomes of pregnancy (14,15). many chemicals in maternal smoking pass from the pregnant woman to the fetus through the placenta (16). smoking is associated with placental abruption and inadequate weight gain during pregnancy, but this relationship with the birth of a premature baby is not conclusive and is not proven in all studies. the probable reason for this is that the impact of smoking depends on its duration and intensity, and decreases in women who stop smoking at the beginning of pregnancy (17). some studies have found a strong causal association between smoking and pb of a child (18). a large number of studies have found a moderate influence of smoking in relation to pb of a baby(14,16,17). bulgaria is a country that is characterized by one of the highest indicators of age-specific fertility rate (above 40 per 1000) in europe in the age-group 15-20 years, which is a risk factor for giving birth to a premature baby (19). according to manolova (2004), 42.3% of women in bulgaria smoked during pregnancy (20). however, prematurity as a public health issue has not been subject to scientific inquiry in bulgaria in the past two decades. yet, there are a small number of scientific publications in terms of risk factors for pb in bulgarian children (21). in this context, there is a need to determine the lifestyle characteristics of mothers as important factors for pb in bulgaria. this paper aims at studying the relationship between mothers‘ age, bmi, gwg and smoking during pregnancy and the risk for pb in the city of pleven, bulgaria. we hypothesized a positive association between pb and younger or older age and smoking habits of the mothers. furthermore, we assumed a positive link between low bmi and low weight gain during pregnancy andpb. 42 kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 methods study design a case-control study was carried out in 2007 in the city of pleven, bulgaria. pleven is a typical township, located in central north bulgaria. at the beginning of the study (in 2007) the size of the population of the city was 139,573 people. in the same year, the birth rate was 8.96‰. maternal care was carried out only by the university hospital. there were 2004 children born at the university hospital, of whom, 1981 were live births. the proportion of preterm infants among all live births was 7.7%. study population the anticipated sample size for inclusion in this study consisted of 250 newborns. the study was comprehensive for all premature children (n=58) and representative for full-term infants (192, or 10.4% of all 1827 full-term children) born in 2007 at the university hospital of pleven and resident in the city of pleven. cases: 58 premature infants weighing 2500 g or less at birth. their gestational age was 37 weeks or less, and they resided in pleven. controls: 192 term infants who were matched to premature infants by date of birth. they were selected randomly among preterm children born on the same date. they weighed more than 2500 g. their gestational age was more than 37 weeks and they also resided inpleven. data collection document analysis: the information on birth weight, gestational age and home addresses of newborns was derived from medical records in a neonatal clinic at the university hospital pleven. interview: the information for mother‘s age, weight of women before the pregnancy, weight gain during pregnancy and smoking habits was gathered retrospectively by interviewing mothers during home visits. such information was not available in the records of mothers in the obstetrics ward, and not all women retained documents from antenatal visits. special questionnaires were designed for the purpose of the study. they were part of a larger study on risk factors for premature birth in the region of pleven, bulgaria. the questionnaire used for the documents‘ analysis contained 39 questions, four of which were related to demographic and socio-economic status of the mother. the questionnaire for the interview comprised 92 questions, nine of which were about the lifestyle factors of the mother. for the validation of the questionnaires, a pilot study was conducted. before and after the pilot study questionnaires were discussed and approved by experts, pediatricians, obstetricians and public health professionals. all included mothers answered the questionnaire in the process of an interview. all data in this study were based on women‘s reports during the surveyinterviews. ethical considerations the study was conducted under the supervision of the chair of the irb (institutional review board). the right of privacy of the studied subjects was guaranteed. only the leading investigator had access to the identifying information. mothers expressed their free will for participation and signed an informed consent before theinterview. outcomes we studied two outcomes: preterm birth (pb<37 weeks completed gestation and birth weight <2500 g) and low birth weight (lbw: birth weight <2500g). 43 kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 determinants age of the mothers was determined as: ≤24 years, 25-29 years, 30-34 years and ≥35 years. pre-pregnancy bmi was categorized according to the world health organization (who) as either being underweight (bmi<18.5kg/m²), normal weight (18.5≤ bmi≤ 24.9), overweight (25≤bmi≤29.9), or obese(bmi≥30). we utilized the 2009 institute of medicine guidelines on gwg to categorize women‘s weight gain for their bmi as below, within, or above the recommended value(22). smoking during pregnancy was determined based on the question “did you smoke during pregnancy?”. women who responded “yes” or “rarely” were categorized as ―regular smokers‖ and ―occasionalsmokers‖. statistical analysis the survey data was processed with the statistical software packages spss (statistical package for social sciences), version 11.5, statgraphics and excel forwindows. the results were described using tables. percentages were used to report the observed distribution of age of the mothers, bmi, gwg, smoking during pregnancy and other maternal characteristics. parametric tests for hypotheses testing at normal and near to normal distribution of cases: t test, anova with post hoc tests (lsd, tukey, scheffe, bonferroni, newman-keuls, duncan) and nonparametric tests in other than normal distribution of cases pearson χ²-test, mann-whitney, kruskal-wallis h-test were applied. regression models for modeling and predicting of correlations and multiple logistic regression analyses controlled for covariates estimated the odds ratios with 95% confidence intervals of pb and lbw wereused. using multivariable linear regression we assessed the relationships of studied determinants with outcomes (pb, lbw). odds ratios (or) were calculated to determine the effect of the age, weight and smoking during pregnancy, as factors for pretermbirth. in all cases, a value of p≤0.05 was considered as statisticallysignificant. results table 1 presents the distribution of basic characteristics of the participants by pb status. the distribution of maternal characteristics varied across mothers with pb and termbirth. overall, 17.2% of women were above 35 years old. the share of older mothers was two times higher among those with pb compared to women with term-birth. overall, 23.3% of women were underweight and 12.5% were either overweight or obese. the proportion of overweight was more than two times higher among mothers with pb (19.2%) compared to mothers with term-birth (9.6%). around half (48.8%) of women gained above than the recommended weight for their bmi and a quarter (24.6%) gained less than the recommended weight. about 39% of women with pb compared to 21% of mothers with term-birth gained less than the recommended weight. smoking was reported by 38% of women: 16% of them were regular smokers and 22% occasional smokers. the proportion of mothers with pb who smoked (38%) was about four times higher compared to smoking women with term-birth(10%). compared to mothers with term-born infants, mothers of premature children were more likely to be above 35 years (27.6%), have a bmi≥25 (23,1%), have a gwg below the recommended value (38.5%), smoke during pregnancy (37.9%) and deliver pb children after the third delivery (17.2%). significant differences among mothers with pb were identified for maternal age, pre-pregnancy bmi, gwg, maternal smoking during pregnancy and birth order. conversely, there was no significant difference between groups with regard to their income level. 44 kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 table 1. distribution of maternalcharacteristics characteristics all wome (n=250) n mothers with premature birth (n=58) mothers with term p birth (n=192) maternal age ≤24 years 25.8 10.4 30.5 0.001 25-29 years 27.4 37.9 24.2 0.049 30-34 years 29.1 24.1 30.5 ns ≥35 years 17.2 27.6 14.8 0.047 pre-pregnancy bmi <18.5 kg/m 2 23.3 15.4 25.5 ns 18.5-24.9 kg/m 2 64.2 61.5 64.9 ns 25.0-29.9 kg/m 2 11.7 19.2 9.6 ns ≥30 kg/m 2 0.8 3.9 gestational weight gain <recommended 24.6 38.5 20.7 0.010 = recommended 26.7 26.9 26.6 ns > recommended 48.8 34.6 52.7 0.020 smoking during pregnancy regularly 16.1 37.9 9.5 0.001 occasionally 21.8 10.3 25.3 0.002 no 62.1 51.8 65.2 ns per capita income lowest (0-125 euro) 36.0 41.4 34.4 ns middle (126-250 euro) 46.4 41.4 47.9 ns highest (>250 euro) 17.6 17.2 17.7 ns birth order 1 52.4 41.4 55.8 0.050 2-3 41.2 41.4 41.1 ns ≥4 6.4 17.2 3.1 0.005 table 2. maternal characteristics correlated with normal birth-weight and low birth-weight(g) linear regression logistic regression characteristics all (n=250) low birth weight (n=58) normal birth weight (n=192) low birth weight p mean±se p mean±se p mean±se p or (95%ci) maternal age 25-29 3120±85 2297±45 3491±46 reference ≤24 3219±69 ns 2256±47 ns 3318±62 ns 0.22 (0.08-0.58) 0.001 30-34 3168±71 ns 2361±43 ns 3318±53 ns 0.50 (0.23-0.99) 0.048 ≥35 2790±127 0.007 1876±88 0.001 3312±71 0.005 1.19 (0.54-2,65) 0.600 pre-pregnancy bmi 18.5-24.9 3185±59 2149±90 3427±41 reference <18.5 3124±72 ns 2163±72 ns 3284±56 ns 0.64 (0.27-1.48) 0.280 25.0-29.9 2844±101 0.040 2296±45 ns 3148±96 0.001 2.12 (1.02-4.03) 0.049 ≥30 * 2400±0 0.010 2400±0 ns gestational weightgain = recommended 3158±84 2300±44 3347±64 reference <recommended 2955±74 0.020 2307±40 ns 3287±61 ns 1.83 (1.04-3.08) 0.048 > recommended 3191±66 ns 1971±146 0.002 3402±46 ns 0.65 (0.30-1.41) 0.270 smoking duringpregnancy no 3192±60 2065±92 3437±40 reference regularly 2666±72 0.001 2328±29 0.030 3080±86 0.001 5.05 (2.41-10.58) 0.001 occasionally 3162±66 ns 2333±58 ns 3265±58 0.001 0.52 (0.20–1.32) 0.160 * only two children weighing 2400 g were born from mothers with bmi≥30. 45 kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 table 2 shows that maternal age at delivery, gwg and smoking during pregnancy were significantly associated with lbw. mothers who smoked regularly had a significant fivefold increase in lbw risk compared with nonsmoking mothers (or=5.05, 95%ci=2.41-10.58, p=0.001). the association between bmi and lbw was evident among infants whose mothers‘ were overweight (or=2.12, 95%ci=1.02=4.03, p=0.049). we did not assess obesity as a risk factor for lbw, because there were no mothers of children with normal birth weight who had a bmi≥30. the risk of lbw increased when gwg was less than the recommended value (or=1.83, 95%ci=1.04 3.08, p=0.048). age of the mothers upon delivery less than 24 years (or=0.22, 95%ci=0.080.58, p=0.001) and between 30-34 years (or=0.50, 95%ci=0.23-0.99, p=0.048) was found as a protective factor for lbw. table 3 shows the results of fitting a multiple linear regression model to describe the relationship between prematurity and three independent variables: pre-pregnancy bmi, gwg and maternal age. the model explains 93% of the variability inpb. the equation of the fitted model was as follows: pb = 87.6117*bmi + 41.0981*gwg + 9.6293*maternal age table 3. multiple regression analysis: pre-pregnancy bmi, gwg and maternal age correlated with premature birth dependent variable: premature birth parameter estimate standard error t statistic p pre-pregnancy bmi 87.6117 12.4486 7.03787 0.001 gestational weight gain 41.0981 7.13523 5.75988 0.001 maternal age 19.6293 8.4454 2.32426 0.021 analysis of variance source sum of squares df mean square f-ratio p-value model 2.30485e9 3 7.68283e8 0.001 residual 1.70403e8 235 725119.0 total 2.47525e9 238 r-squared = 93.1157 %; r-squared (adjusted for d.f.) = 93.0571 %; standard error of est. = 851.539; mean absolute error = 646.141; durbin-watson statistic =1.04712. discussion this study provides useful evidence about pb and lbw in the region of pleven, bulgaria. our results indicate that pre-pregnancy bmi, gwg related with personal bmi and smoking during pregnancy are important characteristics for pb in thispopulation. the age of the mother is essential for normal pregnancy and delivery with a favorable outcome. from a biological point of view, the best age for childbirth is 20-29 years (8). the average age of women in our study was 26.3±5.8 years which was non-significantly lower than the average age for childbirth established in bulgaria (27.9 years of age) (23) and also lower than that established by yankova and dimitrov (2010) who stated an average age of 28 years at birth (24). the results for more than a twofold increased risk of premature birth to mothers aged under 20 years were reported by branum and schoendorf in 2005 (25). the association between the risk of a preterm labor and mother‘s age is reported to be inverse (21,26), but we did not establish this. we found the age of the mothers at delivery less than 34 years as a protective factor for lbw. 46 kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 we did not find a significant difference between the mean weight of mothers of premature (55 kg) and to term infants (54 kg) before pregnancy. we found a more than two times higher risk for lbw among mothers with pre-pregnancy bmi 25.0-29.9 kg/m², but there was no effect found of pre-pregnancy bmi<18.5 kg/m². the results of our study are compatible with the findings of a recent meta-analysis on the existence of a weak association or lack of association between low bmi before pregnancy and the birth of a premature baby(27). according to our results, the probability of giving birth to a premature baby in women who have had gwg less than recommended is around two times higher compared with mothers with recommended gwg. the insufficient weight gain during pregnancy increases the risk of having a premature baby, especially amongst women with low bmi before pregnancy: rr=1.5-2.5 (27). our results are similar to those of schieve la et al. (2000), who found out a three times higher risk of giving birth to a premature baby in women with a normal bmi, but not enough weight gain during pregnancy compared with women of normal weight and with adequate weight gain during pregnancy(28). our results concerning smoking during pregnancy (around 40% of all mothers) are close to a previous study from bulgaria conducted by manolova (2004), which reported that about 42% of all women smoked during the whole pregnancy (20). yet, the proportion of smoking mothers in our study was higher than a previous study conducted in bulgaria in 2007, which reported a prevalence of 33% (23). smoking is regarded as one of the most common and preventable causes of poor pregnancy outcomes (17). there is variability in the reported results for the relationship between smoking and pb, but a large number of studies establish an rr=1.2-1.5 when daily consumption of cigarettes is 10-20, and an rr=1.5-2.0 when more than 20 cigarettes are smoked per day. the same results were obtained by andriani and kuo for smoking mothers who lived in urban areas (17). our survey revealed a greater than fivefold increase in the risk of lbw among mothers who smoked during pregnancy, a finding which is in line with previous reports about the influence of smoking on the pb risk(14,17). study limitations this study may have several limitations. firstly, reports of the characteristics of mothers were retrospective after the child was born. additionally, self-reported data on bmi, gwg and smoking are highly correlated with pb and lbw, but they tend to underestimate these measures. women who smoked were categorized into three groups based on qualitative variables, and not according to the number of cigarettes smoked per day. the dissemination of information on adverse outcomes of smoking may have discouraged some mothers from disclosing it. secondly, because the place of study was an urban area we did not find enough mothers less than 19 years old. the result was that we did not establish the association between young maternal age and pb. thirdly, we utilized the institute of medicine guidelines to categorize women‘s weight gain as below, within, or above recommended value (22), which maybe is not appropriate for bulgaria, but there are no other recommendations to be used. finally, we excluded from the analysis some women with either missing information on the principal determinants of interest (age, bmi, gwg, smoking), or missing information on gestational age and birth weight (needed for outcome variables), but the number of missing values was small. 47 kamburova ms, hristova pa, georgieva sl, khan a. adverse effects of maternal age, weight and smoking during pregnancy in pleven, bulgaria (original research). seejph 2015, posted: 30 june 2015. doi 10.12908/seejph-2014-51 obviously, there is a need for prospective studies from the registration of the pregnancy, in pleven and in other regions of bulgaria, in which such data should be collected in a standardized manner and the number of mothers and their children should be higher. conclusion our results confirm our research hypothesis that pre-pregnancy bmi>25 kg/m², less than recommended gwg related with their personal bmi and smoking during pregnancy arerisk factors for pb. age of the mothers at delivery <34 years was a protective factor for lbw. this analysis was part of a study on the risk factors for pb and their impact on development and health status of children <3 years in bulgaria. our findings highlight the public health importance of promoting a healthy lifestyle of mothers in order to reduce the level of pb in bulgaria. references 1. blencove h, cousens s, oestergaard m, chou d, moller ab, narwal r, et al. national, regional and worldwide estimates of preterm birth in the year 2010 with time trends for selected countries since 1990: a systematic analysis and implications. lancet 2012;379:2162-72. 2. wang h, liddell ca, coates mm, mooney md, levitz ce, 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under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited. http://www.ncbi.nlm.nih.gov/pubmed/?term=sijtsma%20a%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24510962 http://www.ncbi.nlm.nih.gov/pubmed/?term=sauer%20pj%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24510962 http://www.ncbi.nlm.nih.gov/pubmed/?term=land%20ja%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24510962 http://www.nsi.bg/ http://www.ncbi.nlm.nih.gov/pubmed/?term=laopaiboon%20m%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24641534 http://www.ncbi.nlm.nih.gov/pubmed/?term=lumbiganon%20p%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24641534 http://www.ncbi.nlm.nih.gov/pubmed/?term=zhang%20j%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24641534 http://creativecommons.org/licenses/by/3.0) 49 kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 original research lifestyle correlates of low bone mineral density in albanianwomen artur kollcaku 1 , julia kollcaku², valbona duraj 1 , teuta backa 1 , argjendtafaj 1 1 rheumatology service, university hospital center ―mother teresa‖, tirana, albania; ² ambulatory health service, polyclinic, tirana, albania. corresponding author: dr. artur kollcaku address: rr. ―dibres‖, no. 371, tirana, albania; telephone: +355674039706; e-mail: artur_kollcaku@yahoo.com mailto:artur_kollcaku@yahoo.com 50 kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 abstract aim: the aim of this study was to assess the association of lifestyle/behavioral factors with low bone mineral density in albanian women, a transitional country in the western balkans. methods: a cross-sectional study was conducted in tirana city in 2010 including a population-based sample of 549 women aged 35 years and above (response rate: 92%). low bone mineral density (osteopenia and/or osteoporosis defined as a bone mineral density t score less than -1) was assessed with a bone ultrasound device which is simple and easy to use for screening of bone mineral density in population-based studies. binary logistic regression was used to determine the relationship of low bone mineral density with behavioral factors in this studypopulation. results: the prevalence of low bone mineral density in this study population was 28.4% (156/549). in multivariable-adjusted logistic regression models, low bone mineral density was positively associated with smoking (or=4.1, 95%ci=2.2-7.4) and coffee consumption (or=2.3, 95%ci=1.3-4.1), but inversely related to overweight and obesity (or=0.4, 95%ci=0.2-0.7 and or=0.3, 95%ci=0.2-0.6, respectively). conclusion: this study offers useful evidence about the lifestyle/behavioral determinants of low bone mineral density among women in this transitional south eastern european population. health professionals and policymakers in albania should be aware of the major behavioral factors which increase the risk of low bone mineral density in order to provide correct treatment and control of this condition in the generalpopulation. keywords: albania, bone mineral density, bone ultrasound, bone ultrasound device, osteopenia, osteoporosis, tirana. conflicts of interest: none. 51 kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 introduction low bone mineral density, especially osteoporosis, is characterized by excessive skeletal fragility and susceptibility to trauma fracture (1), particularly among older individuals (2,3). conventionally, low bone mineral density includes osteopenia and osteoporosis. osteopenia is deemed as en initial step of osteoporosis notwithstanding the fact that not every person with osteopenia may inevitably experience osteoporosis (4-6). as a rule of thumb, osteopenia is defined as a bone mineral density t-score lower than -1.0 and greater than -2.5 (7). on the other hand, osteoporosis is defined as a bone mineral density t-score of -2.5 or lower (7). it is important to note that osteopenia is an indication of normal aging, as opposed to osteoporosis which is evident in pathologic aging(1,5). the prevalence of low mineral bone density, especially osteoporosis, increases with age (2,3,8). furthermore, the prevalence of osteoporosis is higher in women, especially after menopause (1,8,9). in addition, unhealthy behavioral patterns consisting of smoking, excessive alcohol consumption and physical inactivity increase the risk of low bone mineral density and/or exacerbate the conditions of osteopenia and osteoporosis (5,10,11). on the other hand, body weight has been shown to exert a beneficial effect on increasing bone mass which, in turn, reduces the risk of osteoporosis (1). furthermore, fat mass has been described as a protective factor against osteoporosis in several studies conducted worldwide (12-14). however, the findings related to excessive fat mass are not consistent and several other studies have reported that it may not protect against decreases in bone mass(15-17). the assessment of bone mineral density is typically done with dual x-ray absorptiometry (dexa) procedure (18). at the same time, assessment of bone mineral density can be also performed with portable scanners using ultrasound, and portable machines can measure density in the heel (19,20). as a matter of fact, quantitative ultrasound is currently used worldwide due to its low cost, simplicity of performance, mobility and due to the lack of ionizing radiation (19). after the fall of the communist regime in 1990, albania, a transitional country in the western balkans, has been characterized by a particularly difficult political and socioeconomic situation associated with periodic civil unrests and high rates of unemployment(21). according to a recent report, the burden of musculoskeletal disorders has increased in albania in the past two decades (22). the overall share of musculoskeletal disorders accounted for 8.5% of the total burden of disease in 1990, whereas in 2010 it amounted to 11.0% (22,23). there is evidence of a stronger increase in females than in males. in both sexes, there was a similar moderate yet steady increase from 1990-2005 (22,23). subsequently, there was a steeper increase in females, but a smaller increase in males, which additionally accentuated the excess burden of disease explained by the musculoskeletal disorders in females compared to males (22). the burden of musculoskeletal disorders in albania was similar to most of the countries in south eastern european (see) region in both 1990 and 2010 (22,23). in 2010, the share of musculoskeletal disorders was 11.0% of the total burden of disease in several see countries including albania. essentially, musculoskeletal disorders are said to have increased in albania probably due to a higher accessibility to the health care services in addition to the ageing pattern of the albanian population (22). to date though, data on the prevalence and determinants of osteopenia and osteoporosis in the albanian population is scarce. in this framework, the aim of our study was to assess the lifestyle/behavioral correlates of low bone mineral density (osteopenia and/or osteoporosis) in tirana city, the capital of albania, a transitional country in the western balkans http://en.wikipedia.org/wiki/osteoporosis http://en.wikipedia.org/wiki/bone_mineral_density#t-score http://en.wikipedia.org/wiki/aging http://en.wikipedia.org/wiki/osteoporosis http://en.wikipedia.org/wiki/dual_energy_x-ray_absorptiometry 52 kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 characterized by an intensive process of urbanization and internal migration of the population in the past twenty five years. methods a cross-sectional study was conducted in 2010 including a population-based sample of women aged 35 years and above residing in tirana city, the capital of albania. regarding the sample size, a minimum of 540 women was estimated as the minimal number required for inclusion in this study. in order to account for potential non-response, we decided to invite 600 women to participate in our study. the inclusion criteria consisted of women aged 35 years and above residing in tirana city. of 600 eligible individuals invited to take part in this study, 549 women agreed to participate (mean age: 55.6±9.1 years; response rate: 92%). the bone mineral density among study participants was assessed with a bone ultrasound device which is simple and easy to use for screening of bone mineral density in population based studies (19,20). from this point of view, ultrasound is considered as a quick, cheap and non-radiating device for assessing bone quality (19,20). low bone mineral density was defined as a bone mineral density t-score less than -1 that is osteopenia and/or osteoporosis. the physical examination included also measurement of height and weight for all study participants based on which body mass index (bmi) was calculated (kg/m 2 ) and categorized in the analysis into normal weight (bmi≤25 kg/m 2 ), overweight (bmi: 25.1-29.9 kg/m 2 ) and obesity (bmi≥30 kg/m 2 ). the other lifestyle/behavioral factors were assessed through an interviewer-administered structured questionnaire including information on smoking habits (dichotomized in the analysis into: yes vs. no), alcohol intake (yes vs. no), coffee consumption (yes vs. no) and tea consumption (yes vs. no). demographic and socioeconomic data (age, marital status, educational level and employment status of study participants) were also collected for all women included in thisstudy. binary logistic regression was used to assess the association of low bone mineral density (outcome variable) with lifestyle/behavioral factors (independent variables). initially, crude (unadjusted) odds ratios (ors) and their respective 95% confidence intervals (95%cis) were calculated. next, all the lifestyle factors (smoking, alcohol intake, coffee and tea consumption and bmi) together with demographic and socioeconomic characteristics (age, marital status, educational level and employment status) were entered simultaneously into the logistic regression models. multivariable-adjusted ors and their respective 95%cis were calculated. in all cases, a p-value of ≤0.05 was considered as statistically significant. statistical package for social sciences (spss, version 15.0) was used for all the statisticalanalyses. results the prevalence of low bone mineral density (osteopenia and/or osteoporosis) in this study population was 156/549=28.4% (table 1). the prevalence of smoking was significantly higher in women with low bone mineral density compared with those with normal bone mineral density (25.6% vs. 8.7%, respectively; p<0.001). there were no differences regarding the prevalence of alcoholintake. the prevalence of both coffee consumption and tea consumption was significantly higher in women with low bone mineral density than in those with normal bone mineral density (83.3% vs. 68.2%, p<0.001 and 53.8% vs. 41.2%, p=0.005, respectively). 53 kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 on the other hand, the prevalence of both overweight and obesity was significantly lower in women with low bone mineral density compared with women with normal bone mineral density (30.8% vs. 40.2% and 23.7% vs. 32.2%, respectively; overall p<0.001) (table1). table 1. distribution of lifestyle/behavioral factors in a sample of albanian womenby bone mineral density status variable total normal bone mineral low bone mineral † (n=549) density (n=393) density (n=156) smoking: no 475 (86.5) * 359 (91.3) 116 (74.4) <0.001 yes 74 (13.5) 34 (8.7) 40 (25.6) alcohol intake: no 514 (93.8) 369 (93.9) 145 (93.5) 0.508 yes 34 (6.2) 24 (6.1) 10 (6.5) coffee consumption: no 151 (27.5) 125 (31.8) 26 (16.7) <0.001 yes 398 (72.5) 268 (68.2) 130 (83.3) tea consumption: no 303 (55.2) 231 (58.8) 72 (46.2) 0.005 yes 246 (44.8) 162 (41.2) 84 (53.8) bmi: normal weight 179 (32.7) 108 (27.6) 71 (45.5) overweight 205 (37.5) 157 (40.2) 48 (30.8) obesity 163 (29.8) 126 (32.2) 37 (23.7) * absolute numbers and their respective column percentages (in parentheses). † p-values from fisher‘s exact test. table 2 presents the association of low bone mineral density with lifestyle factors of the women included in this study. in crude (unadjusted) logistic regression models, there was evidence of a strong and statistically significant association of low bone mineral density with smoking (or=3.6, 95%ci=2.2-6.0), but not alcohol intake (or=1.1, 95%ci=0.5-2.3). on the other hand, there was a strong association of low bone mineral density with coffee consumption (or=2.3, 95%ci=1.5-3.7) and tea consumption (or=1.7, 95%ci=1.2-2.4). on the contrary, the odds of overweight and obesity were lower among women with a low bone mineral density compared with their counterparts with normal bone mineral density (or=0.5, 95%ci=0.3-0.7 and or=0.4, 95%ci=0.3-0.7, respectively). in multivariable-adjusted logistic regression models, low bone mineral density was positively associated with smoking (or=4.1, 95%ci=2.2-7.4), coffee consumption (or=2.3, 95%ci=1.3-4.1) and (non-significantly) with tea consumption (or=1.4, 95%ci=0.9-2.2), but inversely related to overweight and obesity (or=0.4, 95%ci=0.2-0.7 and or=0.3, 95%ci=0.2-0.6, respectively) (table 2). 54 kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 table 2. association of low bone mineral density with lifestyle/behavioral factorsamong women in tirana, albania variable crude (unadjusted models) multivariable-adjustedmodels or (95%ci) * p * or (95%ci) * p * smoking: no 1.00 (reference) <0.001 1.00 (reference) <0.001 yes 3.64 (2.20-6.02) 4.07 (2.23-7.40) alcohol intake: no 1.00 (reference) 0.880 1.00 (reference) 0.478 yes 1.06 (0.49-2.27) 0.73 (0.30-1.75) coffee consumption: no 1.00 (reference) <0.001 1.00 (reference) 0.003 yes 2.33 (1.46-3.74) 2.33 (1.34-4.07) tea consumption: no 1.00 (reference) 0.008 1.00 (reference) 0.134 yes 1.66 (1.15-2.42) 1.40 (0.90-2.16) bmi: <0.001 (2) † <0.001 (2) † normal weight 1.00 (reference) 1.00 (reference) overweight 0.47 (0.30-0.72) 0.001 0.39 (0.23-0.65) <0.001 obesity 0.45 (0.28-0.72) 0.001 0.32 (0.18-0.55) <0.001 * odds ratios (or: low bone mineral density vs. normal bone mineral density), 95% confidence intervals (95%cis) and p-values from binary logistic regression. besides the variables presented in the table, multivariable-adjusted models were additionally controlled for age, marital status, employment status and educationallevel. † overall p-value and degrees of freedom (inparentheses). discussion this study including a representative sample of women residing in tirana – the capital city of transitional albania which was the most isolated country in europe during the communist regime – offers useful evidence about selected lifestyle/behavioral predictors of low bone mineral density (osteopenia and osteoporosis) in the adult female population. smoking and coffee consumption were positively associated, whereas overweight and obesity were inversely related to osteopenia and osteoporosis in this sample of albanian women, after controlling for other lifestyle factors and several demographic and socioeconomic characteristics. our findings related to a positive association between low bone mineral density with smoking and coffee consumption are in line with previous reports from the international literature (5). in our study, the association of osteopenia and osteoporosis with coffee consumption was strong and remained unaffected upon simultaneous adjustment for a wide array of covariates including alcohol intake and tea consumption. furthermore, the positive relationship with smoking was even stronger after multivariable adjustment for other behavioral characteristics. in our study, overweight and obesity were strong correlates of osteopenia and osteoporosis. the negative association of overweight and obesity with low bone mineral density was accentuated in multivariable-adjusted logistic regression models. our findings regarding body mass are compatible with several reports from the international literature (1,24). from this point of view, higher body weight or higher bmi is known to be a protective factor against bone loss in both men and women worldwide (1,24-26). nevertheless, overweight and 55 kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 obesity are related to a gain in fat mass as well as an increase in lean mass. therefore, identification of the specific roles that fat mass itself plays in bone mass regulation is important to establish the clinical implications of osteoporosis (24). several studies have indicated that both fat mass and lean mass can lead to an increase in bone mass which, in turn, reduces the risk of osteoporosis (13,24). on the other hand, according to some other studies, fat mass has a negative effect on bone mass after controlling for body weight (1,27). importantly, regarding total fat mass, subcutaneous fat has been reported to be beneficial for bone mass, whereas visceral fat has negative effects(24,28). this study may have some limitations. notwithstanding the representativeness of the sample of women included in this study, the possibility of selection bias, at least to some extent, may be an issue which cannot be completely excluded. in any case, tirana women are not assumed to represent the overall albanian women and, hence, findings from this study cannot be generalized to the overall female population in albania. in our survey, we employed a standardized and internationally valid instrument for assessment of low bone mineral density in population-based studies. furthermore, findings from the quantitative ultrasound measurements of bone mineral density correlate well with the dual energy x-ray absorptiometry (dxa) (19), which is one of the most widely validated tools for measurement of bmd in clinical practice (18). on the other hand, the lifestyle/behavioral data collected through the interview may have been subject to information bias. this may be the case of smoking, alcohol intake, as well as coffee and tea consumption. seemingly though, there is no plausible explanation of a differential reporting of lifestyle factors between women distinguished by the presence of osteopenia and/or osteoporosis in our study. conversely, measurement of height and weight provides little grounds for biased estimates of overweight and obesity in our study sample. in conclusion, our study provides important evidence about the lifestyle/behavioral determinants of low bone mineral density in tirana, the capital city of albania. smoking and coffee consumption were significant predictors of low bone mineral density (osteopenia and osteoporosis) in this study sample of tirana women. future studies in albania should assess the magnitude and distribution of osteopenia and osteoporosis in population-based samples of the general population. references 1. zhao lj, jiang h, papasian cj, maulik d, drees b, hamilton j, deng hw. correlation of obesity and osteoporosis: effect of fat mass on the determination of osteoporosis. j bone miner res 2008;23:17-29. 2. melton lj iii. adverse outcomes of osteoporotic fractures in the general population. j bone miner res 2003;18:1139-41. 3. melton lj iii. the prevalence of osteoporosis: gender and racial comparison. calcif tissue int 2001;69:179-81. 4. world health organization. who scientific group on the assessment of osteoporosis at primary health care level. summary meeting report; 2004. 5. leslie wd, morin sn. osteoporosis epidemiology 2013: implications for diagnosis, risk assessment, and treatment. curr opin rheumatol 2014;26:440-6. 6. consensus development conference. diagnosis, prophylaxis, and treatment of osteoporosis. am j med 1993;94:646-50. 7. international osteoporosis federation. available at: http://www.iofbonehealth.org/ (accessed: april 15, 2015). http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=zhao%20lj%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=17784844 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=jiang%20h%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=17784844 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=papasian%20cj%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=17784844 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10.12908/seejph-2014-46 8. el-heis ma, al-kamil ea, kheirallah ka, al-shatnawi tn, gharaibia m, al mnayyis a. factors associated with osteoporosis among a sample of jordanian women referred for investigation for osteoporosis. east mediterr health j 2013;19:459-64. 9. spencer h, kramer l. nih consensus conference: osteoporosis. factors contributing to osteoporosis. j nutr 1986;116:316-9. 10. duncan cs, blimkie cj, cowell ct, burke st, briody jn, howman-giles r. bone mineral density in adolescent female athletes: relationship to exercise type and muscle strength. med sci sports exerc 2002;34:286-94. 11. kohrt wm, bloomfield sa, little kd, nelson me, yingling vr. american college of sports medicine position stand: physical activity and bone health. med sci sports exerc 2004;36:1985-96. 12. reid ir, ames r, evans mc, sharpe s, gamble g, france jt, lim tm, cundy tf. determinants of total body and regional bone mineral density in normal postmenopausal women—a key role for fat mass. j clin endocrinol metab 1992;75:45-51. 13. khosla s, atkinson ej, riggs bl, melton lj iii. relationship between body composition and bone mass in women. j bone miner res 1996;11:857-63. 14. douchi t, yamamoto s, oki t, maruta k, kuwahata r, nagata y. relationship between body fat distribution and bone mineral density in premenopausal japanese women. obstet gynecol 2000;95:722-5. 15. de laet c, kanis ja, oden a, johanson h, johnell o, delmas p, eisman ja, kroger h, fujiwara s, garnero p, mccloskey ev, mellstrom d, melton lj iii, meunier pj, pols ha, reeve j, silman a, tenenhouse a. body mass index as a predictor of fracture risk: a meta-analysis. osteoporos int2005;16:1330-8. 16. hsu yh, venners sa, terwedow ha, feng y, niu t, li z, laird n, brain jd, cummings sr, bouxsein ml, rosen cj, xu x. relation of body composition, fat mass, and serum lipids to osteoporotic fractures and bone mineral density in chinese men and women. am j clin nutr 2006;83:146-54. 17. janicka a, wren ta, sanchez mm, dorey f, kim ps, mittelman sd, gilsanz v. fat mass is not beneficial to bone in adolescents and young adults. j clin endocrinol metab 2007;92:143-7. 18. cummings sr, bates d, black dm. clinical use of bone densitometry: scientific review. jama 2002;288:1889-97. 19. trimpou p, bosaeus i, bengtsson ba, landin-wilhelmsen k. high correlation between quantitative ultrasound and dxa during 7 years of follow-up. eur j radiol 2010;73:360-4. 20. saadi hf, reed rl, carter ao, qazaq hs, al-suhaili ar. bone density estimates and risk factors for osteoporosis in young women. east mediterr health j 2001;7:730 7. 21. burazeri g, kark jd. hostility and acute coronary syndrome in a transitional post communist muslim country: a population-based study in tirana, albania. eur j public health 2011;21:469-76. 22. albanian institute of public health. national health report: health status of the albanian population. tirana, albania, 2014. http://www.ishp.gov.al/wp content/uploads/2015/01/health-report-english-version.pdf (accessed: april 15, 2015). http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=el-heis%20ma%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24617125 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=al-kamil%20ea%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24617125 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=kheirallah%20ka%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24617125 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=al-shatnawi%20tn%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24617125 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=gharaibia%20m%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=24617125 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http://www.ncbi.nlm.nih.gov/pubmed?term=black%20dm%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=12377088 http://www.ncbi.nlm.nih.gov/pubmed/12377088 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=trimpou%20p%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=19135327 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=bosaeus%20i%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=19135327 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=bengtsson%20ba%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=19135327 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=landin-wilhelmsen%20k%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=19135327 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/19135327 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=saadi%20hf%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=15332772 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=reed%20rl%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=15332772 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=carter%20ao%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=15332772 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=qazaq%20hs%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=15332772 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/?term=al-suhaili%20ar%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=15332772 http://www.ncbi.nlm.nih.gov.ezproxy.ub.unimaas.nl/pubmed/15332772 http://www.ishp.gov.al/wp57 kollcaku a, kollcaku j, duraj v, backa t, tafaj a. lifestyle correlates of low bone mineral density in albanian women (original research). seejph 2015, posted: 25 april 2015. doi 10.12908/seejph-2014-46 23. institute for health metrics and evaluation (ihme). global burden of disease database. seattle, wa: ihme, university of washington, 2014. http://www.healthdata.org (accessed: april 15, 2015). 24. kim jh, choi hj, kim mj, shin cs, cho nh. fat mass is negatively associated with bone mineral content in koreans. osteoporos int 2012;23:2009-16. 25. ravn p, cizza g, bjarnason nh, thompson d, daley m, wasnich rd, et al. low body mass index is an important risk factor for low bone mass and increased bone loss in early postmenopausal women. early postmenopausal intervention cohort (epic) study group. j bone miner res 1999;14:1622-7. 26. reid ir. relationships among body mass, its components, and bone. bone 2002;31:547-55. 27. zhao lj, liu yj, liu py, hamilton j, recker rr, deng hw. relationship of obesity with osteoporosis. j clin endocrinol metab 2007;92:1640-6. 28. gilsanz v, chalfant j, mo ao, lee dc, dorey fj, mittelman sd. reciprocal relations of subcutaneous and visceral fat to bone structure and strength. j clin endocrinol metab 2009;94:3387-93. © 2015 kollcaku et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.healthdata.org/ http://creativecommons.org/licenses/by/3.0) 58 vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi10.12908/seejph-2014-48 original research public expenditure and drug policies in bulgaria in2014 toni yonkov vekov 1 , silviya aleksandrova-yankulovska 1 1 department of medical ethics, management of health care and informationtechnology, faculty of public health, medical university –pleven. corresponding author: prof. toni yonkov vekov, medical university,pleven; address: 1 sv kliment ohridski st., 5800 pleven,bulgaria; telephone: +35929625454; e-mail: t.vekov.mu.pleven@abv.bg mailto:t.vekov.mu.pleven@abv.bg 59 vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi10.12908/seejph-2014-48 abstract aim: the objective of this study was to provide an analysis of the factors which have a significant impact on the growth of public expenditure on medical products inbulgaria. methods: this research work consists of a critical analysis of the data reported by the national health insurance fund in bulgaria on the stability of the healthcare insurance model and the implementation of the budget for 2014. results: the results from the current analysis indicate that the growth of public expenditure is directly proportional to the number of reimbursed medical products and that the pattern of prescriptions including the innovative medical products mainly for the treatment of oncological and rare diseases has a significant impact onit. conclusion: the reasons for the increase of public expenditure in bulgaria include the non transparent decisions in pricing and reimbursement of the products, the lack of guidelines for presenting pharmacological evidence and the lack of legislatively-defined drug policies for the management and control of the patterns of medicalprescriptions. key words: bulgaria, drug policies, reimbursement, publicexpenditure. conflicts of interest: none. 60 vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi10.12908/seejph-2014-48 introduction healthcare in the european union (eu) countries including bulgaria is funded by the healthcare systems and/or through general taxation. the main objective of the healthcare systems is the protection of public health, based on the principles of solidarity and universal access. the drug policy in every country is part of the healthcare policy and adopts the same objectives and principles (1). the expenses on medical products are an important component of the healthcare budgets of all the eu member states. there is an increasing necessity to limit the escalating expenses on healthcare including those on medical products, as well as the effective spending of the financial resources (2). the good european practice on drug policy implies the determining of positive drug lists (pdl) provided by the healthcare system, and the regulation of the drug prices in a certain order. the main focus of the approaches to drug policies includes the rational use of medical products, which contributes to the control of public expenditure (3). considering the fiscal impact of the economical and financial crisis, as well as the expected healthcare expenses for the aging population, these policies are of an increasing interest to the institutions which pay for the public expenses in healthcare (4). the contemporary views of the european healthcare policies are that through the correct regulation of the pharmaceutical markets economies can be achieved, without having an impact on the provision of care (5). the drug policy in bulgaria is legally established by the ministry of health and practically applied by the national council on prices and reimbursement of medical products (ncprmp). this is the authority which regulates the prices and makes decisions regarding the reimbursement of the medical products with public funds. the control on prices is based on external and internal reference pricing and regressive margins for distributors and pharmacies. the reimbursing decisions are formally based on pharmaco-economic valuations, but the experts‘ reports are not available to the public and the objectivity of these decisions cannot be established. in this context, the aim of this study was to analyze the public fund expenses on medical products in bulgaria in 2014 in order to determine the impact of the legislative approaches to drug policies and their possible impact on public health. methods this article is a critical analysis of data from the report of the national health insurance fund (nhif) in bulgaria on the stability of the healthcare insurance model and the implementation of the budget for 2014 (6). a commentary is provided concerning the existing prescribing patterns, national policies for the inclusion of medical products in pdl and their impact on the increasing public expenses. a detailed analysis of the expenses by disease groups and the pattern for the prescription of medicines is also provided. all graphs and tables included in this article are created on the basis of the data derived from the report of the nhif in bulgaria on the stability of the healthcare insurance model and the implementation of the budget for the year 2014 (6). the difference of costs and amount of reimbursed products in the pdl for the period under investigation is presented as a percentage and is calculated with a mathematical method based on the determination of proportionalitycoefficients. when trying to predict the future value, one follows the following basicidea: future value = present value + change from this idea, we obtain a differential, or a difference equation by notingthat: 61 vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi10.12908/seejph-2014-48 change = future value – present value the growth of public expenses is influenced by a number of factors discussed in the report of the nhif in bulgaria on the stability of the healthcare insurance model and the implementation of the budget for 2014 (6). all prices are given in bgn with current exchange rates of: 1.95583 bgn = 1 eur. results the review of the development of the pdl in bulgaria in the past three years (2011-2014) from the viewpoint of quantitative indicators shows a big volume (1997 medical products) and a list with frequent changes (every 15 days). in 2011, the pdl included 1382 medical products, in 2012 it included 1673 products, and in 2014 there were 1997 products. during this three-year period, the number of reimbursed medical products increased by 45%. the proportion of public expenditure and the number of reimbursed medical products is presented in figure 1. the established relationship is directly proportional, whereas the cost of public expenses increased by 25%. figure 1. reimbursed medicines for home treatment and the cost of public expenses (bothin bgn) in bulgaria; data for 2014 consists of estimates (source: nhif report for june2014) the other factor which has a marked impact on public expenditure is the pattern of prescription of the medical products. the presented results (figure 2) of the average cost of public expenditure for the treatment of non-insulin diabetes in 2013 are indicative – the cost of the expense differs doubly in the various regions, considering that the list of the medical products, their prices and the reimbursed amounts are the same for all the regions of bulgaria. the different cost of public expenses in the various regions of bulgaria directly depends on the level of prescribing of dpp-4 inhibitors and glp-1 receptor antagonists. these are the two groups of innovative medical products for the oral therapy of diabetes, which are rather recommended as a second and a third line of treatment, due to unclear data for the long-term cost effectiveness and doubts about the safety profile(7). cost 600 quantity 2000 550 500 1500 450 400 1000 2011 2012 2013 2014 n u m b e r n u m b e r 62 vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi10.12908/seejph-2014-48 figure 2. average cost per patient (in bgn) for the treatment of non-insulin dependentdiabetes in bulgaria in 2013 (source: nhif report for june2014) the analysis of public expenses by groups of diseases outlines the clear tendencies for an abrupt increase in the expenses for the treatment of rare diseases and oncologicaldiseases. the expenses for the treatment of rare diseases increased by 36% in 2013 compared to 2012 and reached 59 million bgn, which constitutes 10.7% of all public expenses for medical products (table 1). this points to a pronounced imbalance of solidarity in the insurance system, because these public costs are absorbed by only 0.15% of the insured individuals. at the same time, public expenses for socially significant diseases such as the cardiovascular disease, diseases of the neural system and diseases of other systems are decreasing (6). these results are an expression of the flaws in the drug policy, part of which are the application of internal reference pricing without a system for the control of medical prescriptions (8), the lack of transparency in the decisions on pricing and reimbursement, based on an expert evaluation of pharmaco-economical evidence, the lack of a defined limit of public expenses for one gained quality-adjusted life year (qaly), and the like(9). table 1. expenses for the treatment of rare diseases in2013 (source: nhif report for june 2014) disease public expense average annual cost number of per patient in bgn patients haemophilus 20 009 544 5290 3783 beta-thalassemia 8 323 230 3692 2254 gaucher disease 8 196 183 32 795 250 blonhopulmonal dysplasia 4 245 087 2828 1501 mukopolizaharoidosis 3 294 574 68 637 48 hereditary amyloidosis with neuropathy 1 625 885 27 098 60 pompe disease 477 953 47 795 10 700 600 500 400 300 200 100 0 rousse gabrovo sliven bourgas smolyan average cost vratsa shoumen silistra haskovo pernik n u m b e r 63 vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi10.12908/seejph-2014-48 the analysis of the expenses on the medical therapy for oncological diseases, paid outside the cost of clinical pathways emphasizes several mainfacts:  the expanding of the indications for innovative medicines, mainly for monoclonal antibodies and tyrosine kinase inhibitors. however, there is no data on the evaluation of the efficacy, benefits and costs of the newindications.  the addition of monoclonal antibodies to the target therapies, which increases the cost of the therapy more than 30 times, while the benefits, expressed as final health outcomes, are minimal. the willingness of society to pay such a high price for the gain of a qaly remainsuncertain.  the inclusion of new international non-proprietary names in the pdl without a clear evaluation of their differential cost-effectiveness as compared to the existing therapies. as a result of all these factors, the public expenditure on oncological medical products significantlyexceeded the settled budgets for the past years, as indicated in table 2. table 2. expenses of the medical therapy for oncological diseases, paid outside the costs of clinical pathways (source: report on the implementation of the budget of nhif,2013-2014) year ye ar 2013 2014 budget in bgn 90 000 000 145 000 000 public expenditure in bgn 172 443 480 203 472 732 * relative share of the overspending (%) 91,60 40,30 * data for 2014 consists of estimates. discussion several main factors have been identified which have an impact on the annuallyincreasing public expenses on medical products in bulgaria:  non-transparent decisions for the inclusion of medical products in the pdl with unclear cost-effectiveness compared to the existing drug alternatives. there is no data on the recommendations of ncprmp for the pharmaceutical industry and set out denials for reimbursement justified by the lack of sufficient evidence of effectiveness and/or high prices. the practice in the economically developed countries is different. for example, the committee for the evaluation of medicinal products in canada refused to reimburse pemetrexed for the treatment of malignant pleural mesothelioma, because the product does not provide added value for the price difference compared to the existing alternatives (10). another canadian solution sets to reimburse sunitinib for the treatment of metastatic renal cell carcinoma only after negotiating the price because of poor cost effectiveness, despite the improved efficacy over the existing therapeutic alternatives. many similar negative decisions regarding the reimbursement of medical products for a specific diagnosis can be found in the scientific literature. their aim is both to facilitate the access of patients to therapies which give them additional therapeutic value and use, as well as to protect patients from health risks connected to severe adverse drug reactions (11,12). 64 vekov ty, aleksandrova-yankulovska s. public expenditure and drug policies in bulgaria in 2014 (original research). seejph 2015, posted: 27 may 2015. doi10.12908/seejph-2014-48  the lack of legally defined public expenditure related to one gained qaly. this is a widely used instrument for limiting public expenditure and for the control of the innovative medical therapies (13).  lack of legal control on the patterns of prescribing medicines. the eu states have a number of measures in working order for improving the patterns of prescribing medicines. most often they entail the monitoring of the prescriptions, recommendations and guidelines of advisory/obligatory nature regarding the prescriptions, including the requirements to prescribe an international non-proprietary name, a maximum limit on the prescribed medicines, prescription quotas, financial incentives, as well as educational and informational approaches(14-16). the aim of all enumerated policies is to promote the rational use of medical products for the benefit of public health. the combinations of diverse measures, as electronic monitoring in prescription and in guidelines, connected with electronic systems which support the process of decision-making and give feedback to the physician, are an effective way to improve the patterns in prescribing medicines (17). in addition, educational and informational instruments should be activated. the prescription of international non-proprietary names and prescription quotas, if possible in combination with target budgets and financial incentives, seem to be effective tools for the purpose of regulating public expenditure. conclusion the effectiveness of public expenditure in bulgaria will improve when it becomes the main objective in medical policy, i.e., when medical therapies are evaluated in a real and transparent way as a ratio of expenses and use as compared to the existing alternatives. it is necessary that the first steps are aimed at developing 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http://www.ncbi.nlm.nih.gov/pubmed/23996108 http://onlinelibrary.wiley.com/doi/10.1002/hec.v22.7/issuetoc http://www/ http://www.ncbi.nlm.nih.gov/pubmed/?term=von%20der%20schulenburg%20f%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=22828053 http://www.ncbi.nlm.nih.gov/pubmed/?term=vandoros%20s%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=22828053 http://www.ncbi.nlm.nih.gov/pubmed/?term=kanavos%20p%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=22828053 http://creativecommons.org/licenses/by/3.0) 66 qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and self perceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi10.12908/seejph-2014-50 original research reaction to political and socioeconomic transition and self-perceived health status in the adult population of gjilan region,kosovo musa qazimi 1 , luljeta cakerri 2 , zejdush tahiri 2 , gencburazeri 3 1 principal family medicine centre, gjilan,kosovo; 2 faculty of medicine, tirana university, tirana,albania; 3 department of international health, school for public health and primary care (caphri), faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands. corresponding author: dr. musa qazimi address: rr. ―avdulla tahiri‖, p.n. 60000, gjilan, kosovo telephone: +381280323066; e-mail: micro_dental@hotmail.com mailto:micro_dental@hotmail.com 67 qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and self perceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi10.12908/seejph-2014-50 abstract aim: the objective of our study was to assess the association of reaction to political and socioeconomic transition with self-perceived general health status in adult men and women in a region of kosovo, a post-war country in the western balkans which has proclaimed independence in 2008. methods: this was a cross-sectional study carried out in gjilan region of kosovo in 2014, including a representative sample of 867 primary health care users aged ≥35 years (419 men aged 54.3±10.9 years and 448 women aged 54.0±10.1 years; overall response rate: 87%). reaction to political and socioeconomic aspects of transition was assessed by a three-item scale (trichotomized in the analysis into positive attitude, intermediate attitude, and negative attitude towards transition), which was previously used in the neighbouring albania. self reported health status was measured on a 5-point scale which was dichotomized in the analysis into ―good‖ vs. ―poor‖ health. demographic and socioeconomic data were also collected. binary logistic regression was used to assess the association of reaction to transition with self-rated health status. results: in crude/unadjusted models, negative attitude to transition was a ―strong‖ predictor of poor self-perceived health (or=2.5, 95%ci=1.7-3.8). upon multivariable adjustment for all the demographic factors and socioeconomic characteristics, the association was attenuated and was only borderline statistically significant (or=1.6, 95%ci=1.0-2.6,p=0.07). conclusion: our findings indicate an important association between reaction to transition and self-perceived health status in the adult population of the newly independent kosovo. policymakers and decision-makers in post-war countries such as kosovo should be aware of the health effects of attitudes towards political and socioeconomic aspects of transition, which is seemingly an important psychosocialfactor. keywords: attitude to transition, gjilan, kosovo, psychosocial factors, reaction to transition, self-perceived health, self-ratedhealth. conflicts of interest: none. 68 qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and self perceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi10.12908/seejph-2014-50 introduction in several post-communist countries including russia, negative attitudes towards the political transition and socioeconomic reforms have been linked to poor self-perceived health among adult men and women (1,2). similarly, a negative or a pessimistic reaction to transition has been more recently linked to development of acute coronary syndrome in albania (3), a country which shares the same language and culture with the nowadays republic of kosovo. according to this previous study conducted in albania, a plausible mechanism linking pessimism, or negative attitude with excess coronary risk was deemed the stressor effect of inadequate coping with change in this transitional society(3). nonetheless, the evidence from many former communist countries of southeast europe, including kosovo, is scarce. after a long war against serbia and its proclaimed independence in 2008, kosovo has been undergoing a very difficult process of political and socioeconomic transition (4) associated with a particularly high unemployment rate and a rather poor socioeconomic situation of the general population (5), which leads to an intensive process of emigration to different european union countries and beyond (6). given this particularly difficult socioeconomic situation, the attitudes and perceptions of the adult population in kosovo towards the political reforms and socioeconomic aspects of transition are considered to have been negatively affected notwithstanding the lack of systematic documentation (6). as a matter of fact, regardless of its natural resources, kosovo is one of the poorest countries in europe (4-6). current evidence suggests an increase in the morbidity and mortality rates from non-communicable diseases in adult men and women in kosovo (7,8), which is explained by an increase in unhealthy behaviours (9) and presumably psychosocial factors (9). according to a recent review, alongside with unhealthy lifestyle including dietary patterns and physical inactivity, unfavourable socioeconomic and psychosocial conditions are considered as important determinants of the excess morbidity and mortality from chronic diseases in kosovo including diabetes and cardiovascular diseases (9). notably, it has been argued that changes in behavioural patterns may have unevenly affected different population subgroups, especially the vulnerable and the marginalized categories who are unable to cope with the dramatic changes of the rapid transition occurring in post-communist societies including kosovo (6,9,10). nonetheless, the negative health effects of psychosocial factors in the adult population of kosovo have not been scientifically documented todate. in this context, our aim was to determine the association of reaction to political and socioeconomic aspects of transition with self-perceived general health status among adult men and women in a region of post-war kosovo. based on a previous report from albania (3), we hypothesized a negative health effect of pessimistic attitudes towards transition, suggesting inadequate coping with change, independent of (or, mediated through) demographic factors and socioeconomic characteristics. methods this was a cross-sectional study which was carried out in gjilan region, kosovo, in 2014. study population this study included a representative sample of primary health care users of both sexes aged 35 years and above. a minimum of 740 individuals was required for participation in this study, based on the initial sample size calculations. nevertheless, it was decided to invite 1000 individuals in order to increase the study power accounting also for non-response. therefore, 1000 consecutive primary health care users aged 35 years and above who were resident in gjilan region were invited to participate in thisstudy. 69 qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and self perceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi10.12908/seejph-2014-50 of 1000 individuals who were invited to participate, 62 primary health care users were ineligible (individuals aged <35 years and/or very sick to participate), whereas 71 individuals refused to participate. hence, the final study population included 867 individuals (419 men and 448 women) with an overall mean age of 54.2±10.5 years (54.3±10.9 years in men and 54.0±10.1 years in women). the overall response rate in this study was:867/1000=87%. data collection a structured questionnaire was administered to all participants including information on demographic and socioeconomic characteristics, reaction to political and socioeconomic transition in kosovo and self-perceived healthstatus. reaction to political and socioeconomic aspects of transition among study participants was assessed by a three-item scale which was previously used in the neighbouring albania (3). this scale employed in albania was adapted from an instrument originally used in russia (1,2,11). in the current study conducted in kosovo, all participants were asked to rate their agreement/disagreement about the following three statements: a) “overall, the current economic system in kosovo is better than the old system” [range from 0 (strongly agree) to 3 (strongly disagree)]; b) “the transition toward the new system in kosovo is difficult; however, it’s worthwhile in view of the forthcoming prosperity” [range from 0 (strongly agree) to 3 (strongly disagree)], and; c) “compared with the previous system, most of the people in kosovo are poorer now” [range from 0 (strongly disagree) to 3 (strongly agree)]. a summary score was calculated for each individual (referred to as ―overall reaction to transition‖) ranging from 0 (most positive or optimistic attitude towards political and socioeconomic aspects of transition) to 9 (most negative or pessimistic reaction to transition). cronbach‘s alpha of the three-item scale in our study conducted in kosovo was 0.94, which was slightly lower than a previous study conducted in albania (3). in the statistical analysis, the summary score of attitudes to transition was categorized into three groups [positive attitude (score: 0-3), intermediate attitude (score: 4-6), and negative attitude (score:7-9)]. in addition, all participants were asked to rate their general health status: “overall, during the past year, how would you rate your general health status: excellent, very good, good, poor, or very poor?”. in the analysis, the self-perceived health status was dichotomized into: ―good‖ vs. ―poor‖. demographic factors included age of study participants (in the analysis grouped into: 35-44 years, 45-54 years, 55-64 years and ≥65 years), sex and marital status (in the analysis, dichotomized into: married vs. not married), whereas socioeconomic characteristics consisted of educational attainment (categorized into: low, middle and high), employment status (trichotomized into: employed, unemployed and retired), income level (categorized into: low, middle and high) and social status (similarly trichotomized into: low, middle andhigh). statistical analysis measures of central tendency [mean values (± standard deviations) and median values (with their respective interquartile ranges iqr)] were used to describe the distribution of reaction to transition scores separately in male and female study participants. on the other hand, the distribution of different categories of the reaction to transition scores (positive, intermediate and negative) was expressed in absolute numbers together with their respective percentages separately in men and in women. chi-square test was used to assess the crude (unadjusted) association of reaction to transition scores (trichotomized into: positive, intermediate, negative) with the socio-demographic characteristics and self-perceived health status of studyparticipants. 70 qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and self perceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi10.12908/seejph-2014-50 conversely, binary logistic regression was used to assess the crude (unadjusted) and subsequently the multivariable-adjusted associations of self-reported health status (outcome variable dichotomized into: ―good‖ vs. ―poor‖ health status) and reaction to transition (independent variable) of study participants. initially, crude (unadjusted) odds ratios (ors) and their respective 95% confidence intervals (95%cis) were calculated. next, the logistic regression models were adjusted for age of participants. subsequently, the other demographic factors (sex and marital status) were entered simultaneously into the logistic regression models. finally, socioeconomic characteristics (educational attainment, employment status, income level and social status) were entered simultaneously into the logistic regression models. in all logistic regression models, the self-perceived health status was the outcome variable and reaction to transition (introduced in three categories: positive, intermediate and negative) was the main independent variable. multivariable-adjusted ors and their respective 95%cis were calculated. hosmer-lemeshow test was used to assess the overall goodness-of fit of the logistic regression models (12). in all cases, a p-value of ≤0.05 was considered as statistical significant. statistical package for social sciences (spss, version 17.0) was used for all the statisticalanalyses. results overall mean (sd) summary score of reaction to transition was 4.2±2.8 (4.1±2.8 in men and 4.2±2.7 in women) [table 1]. furthermore, median (iqr) was quite similar in men and in women [sex-pooled median (iqr): 3.0 (3.0)]. overall, 494 (57%) of participants reported a positive attitude towards the political and socioeconomic transition in kosovo, as opposed to 181 (21%) of individuals who had a negative reaction to transition. the negative attitude to transition was higher in men than in women (23% vs. 19%, respectively) [table 1]. table 1. distribution of reaction to political and socioeconomic transition scores ina representative sample of primary health care users in gjilan region, kosovo, in2014 reaction to transitionscore men (n=419) women (n=448) total (n=867) mean (standard deviation) 4.1±2.8 4.2±2.7 4.2±2.8 median (interquartilerange) 3.0 (4.0) 3.0 (3.0) 3.0 (3.0) positive (score: 0-3) 243 (58.0) 251 (56.0) 494 (57.0) intermediate (score: 4-6) 79 (18.9) 113 (25.2) 192 (22.1) negative (score: 7-9) 97 (23.2) 84 (18.8) 181 (20.9) table 2 presents the distribution of demographic factors, socioeconomic characteristics and self-perceived health status by reaction to transition scores (trichotomized into: positive, intermediate and negative scores) among study participants. as noted above, the prevalence of negative attitudes to transition was significantly higher in men compared to women (p=0.05). furthermore, older individuals (65 years and above) displayed the most negative (pessimistic) attitudes to transition compared with their younger counterparts (p<0.001). similarly, the prevalence of a negative reaction to transition was the highest among the retirees (p<0.001), given the aging of this population subgroup. there was no significant association with marital status. remarkably, low-educated participants had a significantly higher prevalence of negative attitudes to transition compared with their highly educated counterparts (40% vs. 7%, respectively, p<0.001). likewise, albeit with smaller differences, low-income individuals and those with a lower social status displayed a higher prevalence of negative reaction to transition compared to high-income participants (33% vs. 18%, 71 qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and self perceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi10.12908/seejph-2014-50 respectively, p<0.001), and individuals with a higher social status (29% vs. 12%, respectively, p<0.001). participants with a poor self-perceived health status had a significantly higher prevalence of negative reaction to political and socioeconomic transition compared with individuals who reported a good health status (34% vs. 18%, respectively, p<0.001) [table 2]. it should be noted that, on the whole, there were 696 (80.5%) participants who reported a ―good‖ health status compared with 169 (19.5%) individuals who perceived their health status as ―poor‖. table 2. distribution of socio-demographic characteristics and self-perceived health statusby reaction to transition scores in the study population(n=867) variable positive (score =494] : 0-3) [n intermediate (score: 4-6) [n=192] (sco negative 181] p † sex: men 243 (58.0) * 79 (18.9) 97 (23.2) women 251 (56.0) 113 (25.2) 84 (18.8) age-group: 35-44 years 132 (69.8) 37 (19.6) 20 (10.6) 45-54 years 171 (68.7) 56 (22.5) 22 (8.8) <0.001 55-64 years 131 (52.8) 59 (23.8) 58 (23.4) ≥65 years 60 (33.1) 40 (22.1) 81 (44.8) employment: employed 272 (71.0) 78 (20.4) 33 (8.6) unemployed 129 (62.0) 52 (25.0) 27 (13.0) retired 93 (33.8) 62 (22.5) 120 (43.6) marital status: not married 63 (49.2) 31 (24.2) 34 (26.6) married 431 (58.4) 161 (21.8) 146 (19.8) educational level: low 101 (30.5) 96 (29.0) 134 (40.5) middle 246 (69.9) 73 (20.7) 33 (9.4) high 145 (80.1) 23 (12.7) 13 (7.2) income level: low 46 (35.7) 40 (31.0) 43 (33.3) middle 118 (47.0) 85 (33.9) 48 (19.1) high 330 (68.2) 66 (13.6) 88 (18.2) social status: low 40 (40.0) 31 (31.0) 29 (29.0) middle 318 (55.4) 128 (22.3) 128 (22.3) high 136 (71.6) 32 (16.8) 22 (11.6) self-perceived health: good 416 (59.8) 158 (22.7) 122 (17.5) poor 78 (46.2) 33 (19.5) 58 (34.3) * absolute numbers and their respective row percentages (in parentheses). discrepancies in the totals are due to the missingvalues. † p-values from the chi-squaretest. table 3 presents the association of reaction to transition with self-perceived health status of study participants. in crude (unadjusted) logistic regression models (model 1), there was 6 72 qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and self perceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi10.12908/seejph-2014-50 evidence of a strong positive association between negative reaction to transition and poor self-rated health: or(negative vs. positive scores)=2.5, 95%ci=1.7-3.8. adjustment for age (model 2) attenuated the findings (or=1.8, 95%ci=1.2-2.8). additional adjustment for sex and marital status (model 3) did not affect the findings (or=1.8, 95%ci=1.2-2.8). further adjustment for socioeconomic characteristics including education, employment, income level and social status (model 4) attenuated the strength of the association which, in fully-adjusted models, was only borderline statistically significant (or=1.6, 95%ci=1.0-2.6,p=0.07). on the other hand, there was no difference in the odds of self-perceived health status between participants with intermediate scores and those with positive scores of reaction to transition, even in crude (unadjusted) logistic regression models (table 3, models 1-4). table 3. association of reaction to transition with self-perceived health status in a representative sample of primary health care users in gjilan region,kosovo model or * 95%ci * p * model 1 † <0.001 (2) ‡ positive attitude (score:0-3) 1.00 reference intermediate attitude (score:4-6) 1.11 0.71-1.74 0.636 negative attitude (score: 7-9) 2.54 1.71-3.76 <0.001 model 2 ¶ 0.014 (2) positive attitude (score:0-3) 1.00 reference intermediate attitude (score:4-6) 0.99 0.63-1.56 0.958 negative attitude (score: 7-9) 1.81 1.18-2.78 0.007 model 3 § 0.011 (2) positive attitude (score:0-3) 1.00 reference intermediate attitude (score:4-6) 0.97 0.62-1.53 0.897 negative attitude (score: 7-9) 1.84 1.20-2.83 0.005 model 4 ** 0.079 (2) positive attitude (score:0-3) 1.00 reference intermediate attitude (score:4-6) 0.88 0.54-1.43 0.605 negative attitude (score: 7-9) 1.58 0.96-2.61 0.072 * oddsratios (or: ―poor health‖ vs. ―good health‖), 95% confidence intervals (95%cis) and p-values from binary logisticregression. † model 1: crude (unadjusted). ‡ overall p-value and degrees of freedom(inparentheses). ¶ model 2: adjusted for age (35-44 years, 45-54 years, 55-64 years and ≥65 years). § model 3: adjusted for age, sex (men vs. women) and marital status (married vs. unmarried). ** model 4: adjusted for age, sex, marital status, educational level (low, middle, high), employment status (employed, unemployed, retired), income level (low, middle, high) and social status (low, middle, high). discussion the main finding of this study consists of a positive association of pessimistic reaction towards political reforms and socioeconomic transition with poor self-rated health among adult men and women in post-war kosovo, a country characterized by dramatic and rapid changes in the past few years. the association of poor self-perceived health with negative reaction to transition was strong, but upon multivariable adjustment for a wide array of demographic and socioeconomic characteristics the relationship was only borderline 73 qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and self perceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi10.12908/seejph-2014-50 statistically significant. our findings are largely compatible with previous reports from former communist countries including russia (1,2,11) and albania(3). overall, the prevalence of negative reaction (score 0-3) towards socioeconomic aspects of transition in our study population was 21%, which is higher than a previous study carried out in albania which reported a sex-pooled prevalence of 13% (3). nevertheless, the prevalence of pessimistic reaction in our sample is much lower than in russia, where 49% of a representative sample of the adult population reported a nostalgic reaction to political and socioeconomic changes (disapproving the new system and approving the old system) according to a previous study (2). it should be pointed out that, in russia, it was considered that the attitudes towards the political and socioeconomic reforms in 1990s were significantly more negative than in other post-communist countries in europe(2,3). in our study, there was no evidence of a graded relationship with pessimistic or negative attitudes to transition. hence, the association was evident only between negative vs. positive attitude groups, with no differences between neutral (intermediate) and positive attitude categories (table 3). on the other hand, a previous study conducted in albania reported a graded relationship between acute coronary syndrome and negative attitudes towards socioeconomic transition consistent in both sexes and irrespective of demographic and socioeconomic characteristics and a wide range of conventional risk factors(3). potential mechanisms of psychosocial factors including reaction towards political and socioeconomic aspects of transition have been suggested to operate either directly through the neuro-endocrine system (13), or indirectly through induction of unhealthy behaviour such as smoking, excessive alcohol consumption, unhealthy diet and sedentary lifestyle (3,13). furthermore, regarding the negative effect of psychosocial factors on cardiovascular risk, it has been suggested that psychological distress may act chronically through pathological modifications of the cardiovascular system, such as changes in lipid profile and elevation of arterial blood pressure (3,14). in our study, the mechanism of excess self-perceived poor health among pessimists may be related to poor adaptation to critical circumstances associated with the particularly rapid transition in kosovo, as suggested by previous research on this field (3), where obvious differences in coping strategies between optimists and pessimists have been convincingly demonstrated (3,15,16). conversely, negative reaction towards political and socioeconomic aspects of transition may also serve as a marker of depression (17,18), which may lead to poor health status ingeneral. this study may suffer from several limitations including its design, representativeness of the study population and the possibility of information bias. firstly, findings from cross-sectional studies do not imply causality and, therefore, future prospective studies should robustly assess and establish the directionality of the relationship between self-reported health status and attitudes to political and socioeconomic transition in kosovo and other transitional settings. secondly, we cannot exclude the possibility of selection bias in our study sample notwithstanding the inclusion of a fairly large sample of consecutive primary health care users of both sexes in gjilan region. in addition, we obtained a very high response rate (87%), which is reassuring. yet, we cannot generalize our findings to the general adult population of gjilan region given the fact that our study population was confined merely to primary health users. more importantly, findings from this study cannot be generalized to the overall adult population of kosovo, as our survey was conducted only in gjilan region. thirdly, the instrument used for measurement of reaction to transition may be subject to information bias, regardless of the fact that this tool was previously validated in albania (3). in our study population, the measuring instrument of reaction to transition exhibited a very 74 qazimi m, cakerri l, tahiri z, burazeri g. reaction to political and socioeconomic transition and self perceived health status in the adult population of gjilan region, kosovo (original research). seejph 2015, posted: 29 june 2015. doi10.12908/seejph-2014-50 high internal consistency and discriminated well between population subgroups distinguished in their educational attainment, income level and social status – similar to previous reports including the neighbouring albania(3). in conclusion, regardless of these potential limitations, our findings indicate an important association between reaction to transition and self-perceived health status in the adult men and women of post-war kosovo. health professionals and policymakers in developing countries and transitional populations should be aware of the negative health effects of psychosocial factors including also the general 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http://www.ncbi.nlm.nih.gov/pubmed/?term=weintraub%20jk%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=2926629 http://www.ncbi.nlm.nih.gov/pubmed/2926629 http://www.ncbi.nlm.nih.gov/pubmed/?term=kubzansky%20ld%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=15953792 http://www.ncbi.nlm.nih.gov/pubmed/?term=davidson%20kw%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=15953792 http://www.ncbi.nlm.nih.gov/pubmed/?term=rozanski%20a%5bauthor%5d&amp;amp%3bamp%3bamp%3bamp%3bcauthor=true&amp;amp%3bamp%3bamp%3bamp%3bcauthor_uid=15953792 http://www.ncbi.nlm.nih.gov/pubmed/?term=the%2bclinical%2bimpact%2bof%2bnegative%2bpsychological%2bstates%3a%2bexpanding%2bthe%2bspectrum%2bof%2brisk%2bfor%2bcoronary%2bartery%2bdisease http://creativecommons.org/licenses/by/3.0) 76 merkel b. a growing competence: the unfinished story of the european union healthpolicy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-2014-49 commentary a growing competence: the unfinished story of the european unionhealth policy bernard merkel 1 1 visiting research fellow, london school of hygiene and tropical medicine, london, uk. corresponding author: dr. bernard merkel address: dg sante, european commission, brussels; email: merkebe@gmail.com mailto:merkebe@gmail.com 77 merkel b. a growing competence: the unfinished story of the european union healthpolicy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-2014-49 a few months ago, the south eastern european journal of public health (seejph) published a lengthy article by hans stein on the importance of the maastricht treaty of 1992 and how the european union (eu) health policy has developed since then (1). undoubtedly, dr. stein made a major contribution to this story himself and in his paper he sets out his own viewpoint on key events and trends, offering us a wealth of historical detail and many real insights. but, like all good commentators who try to condense and make sense of a tortuous and convoluted sequence of events spanning more than two decades and involving very many players, he inevitably omits parts of the story, and his interpretations can sometimes give rise to more questions than answers. in this review, i will entirely leave aside his general discussion of the overall evolution of the eu and its future prospects, and instead concentrate on a few specific points about the development of eu health policy to date. it is a truism, and the beginning of perceived wisdom on the history of eu health policy, that the maastricht treaty introduced the first explicit ec (european community) legal competence for public health, devoting an article to it (article 129). it is also true, as dr. stein mentions, that there was much health-related activity in the ec well before the advent of the maastricht treaty. such actions, in fact, go back many years. for instance, there was an ec directive on pharmaceuticals in 1971 and in the same year a regulation on coordination of social security systems providing rights to health care to workers in other ec countries. moreover, various public health programmes on cancer, aids and drugs also predate maastricht. yet, article 129 represented the first explicit framework for public health. however, dr stein makes the more interesting point that this competence was “often but never substantially changed in the subsequent treaties”. and, again, “the main components of article 129 were slightly reworded in the following treaties, but essentially are still valid”. in saying this he is implying that it was and remains after several treaty changes, a very weak competence which results from the “defensive and negative position of ms” (eu member states) and reflects their position “to keep the eu as far away as possible from influencing their health policy”. there is no doubt that the health ministries of the older ms, and most, if not all, of the newer ones, have never wanted the eu to tell them how to run their healthcare systems, or to subsume their health policies into an eu-wide policy as has been done in areas such as trade or agriculture. and it is certainly the case, as dr. stein emphasizes, that the article 129 competence is a weak one – as well as being veryill-defined. but, this raises some furtherissues. as he says, it was ms, not the commission or the european parliament, that dominated the process of negotiating and agreeing the maastricht treaty. the question then must arise of why did these very ms decide to put into the treaty a new competence in public health at all if they did not want the ec (eu as it has become) to do anything of significance in this field? later in his paper, dr. stein quotes approvingly from an article by scott greer who says that article 129 “was the harbinger of more effective promotion of health issues within eu policymaking. in time, however, the internal market and the single currency have had the biggest health consequences”. and then, dr. stein adds the interesting comment that: “this was not really what the ms had in mind when they established a specific eu public health mandate”. of course, in 1992, the ms could not really have been thinking about the impact of the single currency which was not introduced until 1999! it is true that the treaty did set out some clear steps towards achieving an economic and monetary union. but, it seems far 78 merkel b. a growing competence: the unfinished story of the european union healthpolicy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-2014-49 fetched, to say the least, to suppose that those involved in designing a new public health competence would have given any thought to the potential impact on health of such a theoretical eventuality. similarly, how likely is it that many of them were envisaging the creation of some kind of protective instrument to counter the single market‘s potential impact on public health? this may have been on the mind of one influential player: hans stein, at least according to what he wrote in an article some years later (2). in this he states that: “single market regulations are sure to have an impact on health and health policy.....the full consequences of the internal market in the field of health and health care are as yet unknown. to analyse, to support or to counteract them can be done effectively only on an euscale”. but, it is doubtful that others were so far-sighted. moreover, if ms had really wanted to establish a health competence that could act as a bastion to promote and defend the interests of public health against the possible negative consequences of the single market, why did they make the public health competence so feeble that it ‗is the weakest legal base possible‘? what seems more plausible is that ms (most of them in any case) saw some advantages in european cooperation in some health areas either where they faced common health problems such as aids, and tobacco, and on some apparently non-contentious topics, such as improving health information, and health education, where they could exchange experience and expertise. in doing so it is arguable that they were trying to achieve two objectives: first to show that the ec was not just about markets and economics but could play a valuable role in other policy spheres. this indeed was a general underlying thread of the maastricht treaty. it is noteworthy in this context that article 129 is sandwiched by two rather similar articles, 128 on culture, and 129a on consumer protection. the second aim could be seen as being perhaps a more cynical one: it was to give the ec a formal competence to take some actions in health, which they had in any case been doing for some time in fields such as cancer,aids and drugs, while reducing the potential for any future action in areas where ms did not wish to see ec involvement by defining the scope of the ec‘s public health activities and explicitly limiting its competence in this field. this view was common among commission officials involved in health policy, including this reviewer, who expressed it in an article in 1995 (3). a second contestable point is the claim that the treaty competence on public health has remained essentially the same over the last two decades. on the face of it, this cannot really be the case. indeed what is particularly striking about this competence is how greatly the legal provisions have changed from treaty to treaty. unlike many other policy areas where the treaty provisions have remained largely unchanged, the wording about health has been greatly amended and the provisions have become more and moredetailed. in the treaty of amsterdam of 1997, for example, the public health article (article 129 of the maastricht treaty) was significantly lengthened and the new article (article 152), among other things, included for the first time the power to make binding eu legislation in a few specific areas, in relation to blood and organs, and in some veterinary and phytosanitary areas. a quick look at the current health article, (article 168 of the lisbon treaty) will show that it is again substantially different from the ones agreed in previous treaties, as well as being very much longer. the areas of binding legislative powers introduced in 1997 are retained and there is a further one: medicinal products and medical devices, additionally, the scope for taking legal measures is increased, and now also includes cross-border threats tohealth, 79 merkel b. a growing competence: the unfinished story of the european union healthpolicy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-2014-49 tobacco and alcohol; and the article includes soft law provisions similar to those of the so called ‗open method of coordination‘ used in social and employment policy. the article also concedes for the first time that the eu in the framework of its public health competence may have a role in relation to health services, saying that the eu: “shall in particular encourage co-operation between the ms to improve the complementarity of their health services in cross-border areas”. finally, of course, in addition to article 168, the treaty of lisbon also incorporates the charter of fundamental rights of the eu. article 35 of this promulgates a right in respect of health care: “everyone has the right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices. a high level of human health protection shall be ensured in the definition and implementation of all the union’s policies and activities”. hence, clearly, the eu‘s legal competence has considerably evolved since the maastricht treaty. but perhaps dr. stein is making a deeper point, that regardless of the specific textual amendments in successive treaties, the underlying scope of and limitations on the eu‘s public health competence have not fundamentally changed. there is some strength in this argument. but the position is not as clear-cut as he maintains. the first point to be considered is similar to the one we have made in connection with the article 129 of the maastricht treaty. if ms wanted to preserve the eu‘s public health power weak and nebulous, why did they not simply keep it as it was? why did they keep changing it (and adding to it!) in each treaty revision? we can advance several reasons. first, there was never unanimity among the ms about the extent of the eu‘s role in public health, and in fact a diminishing degree of consensus as more ms joined the eu. some of them, notably the newer ms, actively welcomed a greater eu involvement not only in developing national public health policies but even in respect of the functioning of their healthsystems. second, the treaty reformulations represent (to some extent) responses to developments in europe and beyond. gradually, even against their basic instincts, most, if not all, ms came to appreciate that the eu could be of use in helping tackle some health problems that would be difficult to deal with by individual countries acting separately. these include forexample  responding effectively to health threats from communicable diseases and man-made and natural disasters,  tackling various health determinants,  developing a framework for regulating health goods and related items that circulatein europe, and  responding to global health problems. thirdly, the ms were not negotiating in a vacuum; they had to take into account public opinion and, in particular, the views of the other eu institutions, notably the european parliament (ep) and the commission which both pressed at various points for the eu to be given additional powers in particular health fields. in relation to the maastricht treaty, for example, the commission may have had a limited role in the actual negotiations, but it made proposals for what it wanted to see, it liaised with ms about how texts were worded and certainly followed the negotiations extremely closely. the final draft of the new public health article therefore came as no surprise to the commission. and directly after the treaty had been ratified on 1 november 1993, it published a detailed communication setting out how it intended to implement the new provisions (4). similarly the ep played a very forceful role in the bse crisis which led both to a substantial shake–up in the organization of the commission services to separate agriculture from food safety and also to pressure to 80 strengthen the treaty provisions on the protection of public health. this resulted in the inclusion in article 152 of the amsterdam treaty of provisions allowing for binding measures to be taken in the veterinary and phytosanitary fields in relation to public health, and the extension of the overall scope of ec public health action to “preventing human illness and diseases, and obviating sources of danger to human health”. certainly, dr. stein is right in his contention that the health ministries of many ms have never been the warmest advocates of increasing eu competence in health. yet despite this the fact remains that it has increased, is increasing and seems likely to continue to increase. paradoxically, it is arguable that the prime movers of this growth in eu power have not generally been those in the health field, but rather those in charge of other policy areas who have never been so zealous about national prerogatives in relation to health. decades ago it was heads of government who pushed for action on the single market which led ultimately led to eu action on pharmaceuticals, mutual recognition of health professionals and reciprocity of health insurance coverage. later those same heads of government called for eu action on cancer and aids. in the last few years it has again been heads of government and finance ministers who have set up a new eu system of economic governance which has led to direct interventions in ms‘s budgetary and economic policies and through those means intrusion into their national health care policies. today, as part of this system, we have an eu instrument, the semester, which enables the eu to give every ms specific (non-binding but very influential) recommendations on the main issues confronting their healthcare systems, their health spending and the reforms they shouldmake. we have obviously travelled a very long way indeed from the arguments about whether the eu had a significant role in public health policy, let alone that it could have anything to do with the functioning of national health systems. dr. stein has written a thought provoking article which helps us to trace the path that has been followed and offers us some pointers to what may come in the future for european health policy. as he wrote in 1995: ―it may take some time, but i have little doubt that when the range of possibilities inherent in the new treaty provisions are really used, their impact on public health will be greater than anybody expects today” (5). now, twenty years and several treaties later, we can see just how prescient he was. references 1. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives. seejph 2014; posted: 23 december 2014. doi 10.12908/seejph-2014-36. 2. stein h. experiences of the german presidency: small steps towards integrating public health. eurohealth 1995;1:19-20. 3. merkel b. the public health competence of the european community. eurohealth 1995;1:21-2. 4. european commission. communication on the framework for action in the field of public health. com(93)559 final. 5. stein h. experiences of the german presidency: small steps towards integrating public health. eurohealth 1995;1:19-20. © 2015 merkel; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited. http://creativecommons.org/licenses/by/3.0) 81 obituary luka kovacic the editors of the south eastern european journal of public health express their deepest sorrow about the death of one of our most prominent members of the editorial board, professor luka kovačic, founder of the stability pact‘s forum for public health in south eastern europe (fph-see) in 2000/2001 and strong supporter of the creation of this journal. genc burazeri (tirana, albania and maastricht, the netherlands) ulrich laaser (bielefeld, germany) jose martin-moreno (valencia, spain) peter schröder-bäck (maastricht, the netherlands) obituary professor luka kovačic, md,phd professor luka kovačic, md, phd, specialist in social medicine and organization of health care, retired full professor of the school of medicine, university of zagreb, passed away on 21 april 2015 fatigued by incurable malignant disease. luka kovačic was born on 13 october 1940 in a small town đurđevac some 100 km north of zagreb in the area called podravina, where he attended primary school and finished gymnasium in koprivnica. he graduated from the school of medicine in zagreb in 1965, and after a few years of medical practice he joined the andrija štampar school of public health which is a part of the school of medicine, university of zagreb. there he spent practically his entire working lifetime. he earned both, msc and phd degrees from the university of zagreb, school of medicine in 1972 and 1983. in his academic career he advanced from the assistant position at the chair for hygiene, social medicine, and epidemiology through positions as assistant professor (1984) and associate professor (1988) to full professorship (2003). he completed the specialization in social medicine and organization of health care successfully in 1974. he was also trained in sweden (1964), scotland (1966), usa (1968 and 1971, when he was trained in public health, epidemiology and research methods at the johns hopkins school of hygiene and public health in baltimore), finland (university of kuopio, 1977) and alma-ata (who training in planning and management in 1985). he paid study visits or served as a consultant in the uk, the ussr, kazakhstan, sudan, cameroon, india, iran (undp), nigeria (who) and elsewhere. at the andrija štampar school of public health he used to held numerous posts and responsibilities: he was a head of the department for hygiene, social medicine and epidemiology 1993-1997 and after its dissolution in three smaller departments in 1997 he continued to chair the department for social medicine and organization of health care; he was deputy coordinator from 1984 and coordinator 1997-2000 of the who collaborating centre for primary health care. he served as an assistant to the director and deputy director (1984-2004) and finally as the director of the school from 2004 till his retirement in2006. he served firstly as the coordinator and later as director (1990-1996) of the international 9-week course "planning and management of primary health care in developing countries" which was 82 held 16 times between 1978 and 1996 at the andrija štampar school of public health with the support of the government of the netherlands and had altogether more than 350 participants coming from 66 countries. luka kovacic was active member of the croatian medical association, president of its section for social medicine and organization of health care (1978-1986). later the section changed its name into the society for public health with him as president (1986-1999). his activities and duties were so numerous, both within his institution and in the broader croatian and international context, that we mentioned only those mostly pronounced or internationally visible. luka was a gifted and dedicated teacher, mentor of six msc theses and one phd dissertation as well as altogether more than 200 diploma works for medical and nursing students at the school of medicine and school of applied health sciences. he was principal investigator in many domestic projects and played a leading role in several international projects and networks. he actively participated in the work of the european network of districts "tipping the balance toward primary health care" (ttb) from 1987, being also its chairman of the board and president of the assembly from 1997 to 2005, and the coordinator of the whole network and the project "ttb second decennial survey of the health needs and health care for older people in europe", which was implemented in five european countries including croatia in 2005-2006. he was also a member of the european society for public health and its scientific committee since2000. the cooperation between the school of public health, university of bielefeld and public health academic institutions in ten south eastern european (see) countries started in the year 2000 under his able leadership together with professor ulrich laaser, supported by the stability pact for south eastern europe. professor luka kovačic contributed enormously to the establishment of the forum for public health in south eastern europe (fph-see) as a network of academic institutions, aiming at the reestablishment of professional cooperation between public health teachers and professionals in see. as the result of this cooperation six book volumes were prepared and published between 2004 and 2010 encompassing altogether more than 4300 pages, containing some 250 teaching modules authored by more than 200 authors. among them professor kovačič co-edited the volume “management in health care practice” and authored four modulestherein. luka kovačic was retired less than 9 years ago but he continued to be active and involved in teaching, especially in postgraduate specialist programmes and the phd programme "medicine and health sciences" where he coordinated courses in research methods in public health also at the school of applied health sciences in zagreb he taught several subjects and mentored diploma works. he was a full member of the croatian academy of medical sciences where he chaired the college of public health and participated in the work of the committee for food and the committee for telemedicine to which he was previously president during two terms. professor luka kovačic has published almost 200 scientific and professional articles and edited several books, among them also a textbook in social medicine. he coordinated a number of national and international projects and networks, and has organized numerous national and international conferences in the field of public health and health careorganization. condolence arrived to family kovačic and his colleagues from many institutions and individuals not only from croatia but also from abroad, especially from colleagues from the south eastern european countries. their words once again proved not only how much professor kovačic was respected as an expert, but also how he was appreciated and loved as a co-worker, colleague and teacher. professor luka kovačic will remain in our memory forever as a creative and responsible teacher, an excellent organizer, a competent expert, but above all as a colleague and a friend always ready 83 to assume obligations and help others, a modest and friendly man. a number of colleagues, former students, associates and friends from all over croatia together with those coming from neighbouring countries joined his beloved ones, his wife marija, sons mladen and damir, brother, daughters in law and four lovely grandchildren at his funeral as well as at the commemoration held in the andrija štampar school of public health on may 12 to pay a tribute to a conscientious and gifted teacher, diligent and organized scientists but above all to the dear colleague, a man who did not have and could not have enemies, because he was gentle and always ready to help, both students and colleagues. only ten days after luka passed away the global public health curriculum was published in the south eastern european journal of public health (seejph) including two modules (2.1 and 2.8) he authored. so it happened that his last two teaching texts appeared in seejph, let there be glory and praises to lukakovačic! may he rest in peace! on behalf of the andrija štampar school of public health, school of medicine, university of zagreb prof. jadranka bozikov selected papers of professor luka kovacic: 1. schach e, bice tw, haythrone df, kovačic l, matthews vl, paganini jm, rabin dv. methodologic results of the who/international collaborative study of medical care utilization. milbank memorial fund quaerterly 1972;5:65-80. 2. kovačic l. dogovaranje pregleda i posjeta. *appointment system in health care+. lijec vjesn 1979;101:120-1. 3. kovačic l & al. dogovaranje pregleda u primarnoj zdravstvenoj zaštiti. *appointment system in primary health care]. zagreb: jugoslavenska medicinska naklada; 1979. 97 pp. 4. lemkau pv, kulčar ž, kesid b, kovačic l. selected aspects of the epidemiology of psychoses in croatia. am j epid 1980;112:661-74. 5. kovačic l, stipanov i. optimal development and utilization of primary health care in zadar. european journal of public health 1992;2:212-4. 6. kovačic l, šošid z. organization of health care in croatia: needs and priorities. croatian med j 1998;39:249-55. 7. kovačic l, lončarid s, paladino j, kern j. the croatian telemedicine. in: hasman et al. (eds). medical infobahn for europe. proceedings of mie 2000 and gmds 2000. ios press vol 77: 1146-50. 8. heslin jm, soveri pj, vinoy jb, lyons ra, buttanshaw ac, kovačic l, daley ja, gonzalo e. health status and service utilisation of older people in different european countries. scan j prim health care2001;19:218-22. 9. kovačic l, laaser u. public health training and research collaboration in south eastern europe. medicinski arhiv2001;55:13-5. 10. laaser u, kovačic l, editors.the reconstruction of public health training in south eastern europe. lage: hans jacobs editing company; 2001. 104 pp. (international public health working papers ; 4) 11. lang s, kovačic l, sogoric s, brborovic o. challenge of goodness iii: public health facing war. croat med j 2002;43:156-65 12. babid-banaszak a, kovačic l, kovačevid l, vuletid g, mujkid a, ebling z. impact of war on 84 health related quality of life in croatia: population study. croat med j 2002; 43:396-402. 13. ivekovid h, božikov j, mladinid-vulid d, ebling z, kern j, kovačic l. electronic health center (ehc): integration of continuing medical education, information and communication for general practitioners. stud health technol inform 2002;90:788-92. 14. ebling z, kovačic l, šerid v, santo t, gmajnid r, kraljik n, lončar j. traheal, bronhial and lung cancer prevention in the osijek municipality. med fam croat 2003; 11 (1-2):15. 15. gazdek d, kovačic l. navika pušenja djelatnika u zdravstvu koprivničko-križevačke županije – usporedna studija 1998. i 2002. [smoking habits among health staff in the county of koprivnica-krizevci--comparative study 1998 and 2002]. lijec vjesn2004;126:6-10. 16. vrca botica m, kovačic l, kujundžid tiljak m, katid m, botica i, rapid m, novakovid d, lovasid s. frequent attenders in family practice in croatia: retrospective study. croat med j. 2004;45:620-4. 17. vrca botica m, kovačic l, kujundžid tiljak m, katid m, botica i, rapid m, novakovid d, lovasid s. frequent attenders in family practice in croatia: retrospective study. croat med j. 2004; 45:620-4. 18. kovačic l, božikov j. master programs in public health – dilemmas and challenges. european phd programmes in biomedicine and health sciences. proceedings of the european conference on harmonisation of phd programmes in biomedicine and health sciences zagreb, croatia, april 24 and 25, 2004. zagreb: medical school, 2004; 52-4. 19. bjegovid v, kovačic l, laaser u. the challenge of public health transition in south eastern europe. journal of public health2006;14:184-9. 20. kovačic l, gazdek d, samardžid s. hrvatska zdravstvena anketa: pušenje *croatian health survey: cigarette smoking]. acta med croatica2007;61:281-5. 21. kovačic l, zaletel kragelj l (eds.). management in health care practice. lage: hans jacobs verlag; 2008. 22. majnarid-trtica lj, vitale b, kovačic l, martinis m. trends and challenges in preventive medicine in european union countries. comment on the state in croatia. period biol. 2009;111:5-12. 23. kovačic l, laaser u. ten years of public health training and research collaboration in south eastern europe (ph-see). snz.hr2010;1(1):53-4. 24. tomek-roksandid s, tomasovid mrčela n, kovačic l, šostar z. kardiovaskularno zdravlje, prehrana i prehrambeni unos soli kod starijih osoba. 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[mortality rates of circulatory system diseases and malignant neoplasms in zagreb population younger than sixty-five – call for alarm?] acta med croatica. 2012: 66: 357-64. 30. vadla d, božikov j, kovačic l. are the untreated anxiety and depression in elderly http://www.europarl.europa.eu/studies 85 unrecognized sources of increased healthcare utilisation? eur j public health 2012; 22(suppl. 2):212-3. 31. bralic i, tahirovic h, matanid d, vrdoljak o, stojanovid-špehar s, kovačic v, blažekovid milakovid s. association of early menarche age and overweight/obesity. j pediatr endocrinol metab.2012;25(1-2):57-62. 32. vadla d, božikov j, blažekovid-milakovid s, kovačic l. anksioznost i depresivnost u starijih osoba pojavnost i povezanost s korištenjem zdravstvene zaštite. *anxiety and depression in elderly prevalence and association with health care]. lijec vjesn. 2013; 135:134-8. 33. vrcid keglevid m, kovačic l, pavlekovid g. assessing primary care in croatia: could it be moved forward? coll. antropol. 2014; 38(suppl. 2):3–9. 34. bendekovid z, šimid d, gladovid a, kovačic l. changes in the organizational structure of public health nurse service in the republic of croatia 1995 to 2012. coll antropol. 2014; 38(suppl. 2):85-9. 35. šimid d, bendekovid z, gladovid a, kovačic l. did the structure of work in the public health nurse service of the republic of croatia change in the period 1995-2012? coll antropol. 2014; 38(suppl 2):91-5. 36. kostanjšek d, topolovec nižetid v, razum z, kovačic l. getting some insight into the home care nursing service in croatia. coll antropol. 2014; 38(suppl2):97-103. 37. kovačic l, malik m. n2.1 demographic challenges, population growth, ageing, and urbanization. seejph 2015; available at: http://www.seejph.com/n-2-1-demographic challenges-population-growth-aging-and-urbanisation/ 38. kovačic l. n2.8 disaster preparedness. seejph 2015; available at: http://www.seejph.com/n 2-8-kovacic-disaster-preparedness-150322/ http://www.ncbi.nlm.nih.gov/pubmed/23898693 http://www.seejph.com/n-2-1-demographichttp://www.seejph.com/n jacobs verlag modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 1 original research global health in foreign policy in south africa – evidence from state actors moeketsi modisenyane 1, flavia senkubuge1, stephen jh hendricks1 1 school of health policy and systems, faculty of health sciences, university of pretoria, south africa. corresponding author: moeketsi modisenyane bsc, bed, msc, mph; address: school of health policy and systems, faculty of health sciences, university of pretoria, south africa; telephone: +27123958833/4; e-mail: modisem44@gmail.com modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 2 abstract aim: there are currently debates about why south africa integrates global health into its foreign policy agendas. this study aimed at exploring motivation and interests’ south african policy actors pursue to advance global health and the processes that lead to such integration. methods: the study utilized a mixed-method design from a sample of state policy actors at the national department of health of south africa. participants were selected purposively and had experience of more than three years participating in various international health activities. all participants completed semi-structured questionnaires. quantitative data was analysed to determine frequencies and transcribed text was analyzed using qualitative content analysis. results: a total of 40 people were invited, of whom 35 agreed to participate. of the respondents, 89.7% (n=32) strongly argued that health should facilitate ‘free movement of people, goods and services’. majority (79.0%, n= 29) agreed that ‘development and equality’ are the main elements of foreign policy. of the respondents, majority 77.1% (n=27) agreed that ‘moral and human rights’ are the main elements of foreign policy. furthermore, 82.8% (n=29) agreed that the country should advance ‘africa regionalism and south-south cooperation’ and 85.7% (n=30) strongly argued for a ‘whole-government approach’ in addressing global health challenges. ‘hiv/aids’ and ‘access to medicines agenda’ were the main policy issues advanced. the main domestic factors shaping south africa’s involvement in global health were its ‘political leadership’ and ‘capacity of negotiators’. conclusion: it is evident that within south africa, state policy actors are largely concerned with promoting global health interest as a normative value and a goal of foreign policy, namely, human dignity and development cooperation. furthermore, south africa drives its global health through building coalition with other state and non-state actors such as civil society. hiv/aids, as a policy issue, presents a potential entry point for engagement in global health diplomacy. keywords: diplomacy, foreign policy, global health, global health diplomacy, south africa. conflicts of interest: none. acknowledgment: national department of health, south africa. modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 3 introduction global health diplomacy (ghd) has dramatically increased in the recent years in global health and international relations (1,2). amid this enthusiasm, it is apparent that the concept of ghd is an emerging concept, with new evidence and debates emerging but with clearly diverse and sometimes poorly clarified meanings ascribed to the terms (3,4). in addition, rapid increase in the number of state and non-state actors in global health is an important development. however, the main challenge for governments and non-state organizations is to develop a multisectoral and coherent approach to overcome fragmented policies (5). while the global health practitioners have welcomed this elevated political priority, there have been questions and debates about why and how south africa has conceptualized and contributed to global health diplomacy. furthermore, there has been less examination of why south africa incorporates global health into its foreign policy agenda since 1994 elections. this then raises the question: why south africa incorporates global health into its foreign policy? therefore, these questions, and the broader issue of understanding the relationship between global health and foreign policy in south africa are the focus of this study. along this pathway, the study explored in-depth information on the views of senior state policy actors with the intention of generating new explanations or theory to account for pattern of such health influenced behaviour. as such, deductive process from existing knowledge and theory will be followed which would then be further tested and refined. furthermore, the study explored the strategies, policy issues, domestic factors and diplomatic practices that would shape south africa’s involvement in global health. several authors have tried to introduce frameworks to analyse the relationship between global health and foreign policy. whichever framework of ghd is used, most of the authors have agreed that no single policy framework offers a fully comprehensive description or understanding of the integration of global health into foreign policy as each answers somewhat different questions. furthermore, some authors indicated that there are differing arguments between and within these policy frames, while others are overlapping, and can also be contradictory. in this study, labonte and gagnon framework was used to better explain why south africa incorporates global health into its foreign policy agenda. labonte and gagnon (2010) use the deductive approach using six policy frames, namely: security; development; global public good; trade; human rights and ethical/moral reasoning (6). therefore, this paper, using the framework developed by labonte and gagnon’s health and foreign policy conceptualizations, contributes to this goal by reviewing health in foreign policy through an empirical research case study of south africa. methods participants the study utilized a mixed-method design including both qualitative and quantitative methods (7). a cross-sectional study was conducted amongst state policy actors at the national department of health (ndoh), in pretoria, the capital city of south africa. purposeful sampling (8) was used to identify and recruit interviewees based on relevant peerreviewed or grey literature, as well as the lead author’s professional networks in global health and development. we then employed snowball sampling to enrol additional interviewees until we achieved theoretical saturation, that is, until successive interviews produced no new concepts. participants eligible for in-depth interviews were key informants who had extensive experience in international negotiations for improved access to medicines in each of the three cases. inclusion criteria consisted of key informants who had extensive experience and skills modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 4 (such as more than five years) in participating in international negotiations, which include bilateral, regional and multilateral activities and more than five years working in the health sector. key informants not meeting the above inclusion criteria were excluded. the reason for using semi-structured interviews was to help to reduce bias, sequence, clarity and face validity (9). the need for ‘extra’ sampling arose during the process of interviewing and preliminary theorizing or analysis. the total of eligible participants was 40, and 35 individuals participated in the study giving a response rate of 87.5%. all participants completed a semi-structured questionnaire. nevertheless, the study sample in general was limited by the number of state policy actors who normally participate in international health activities, especially in multilateral negotiations. participants provided written informed consent. the items in the questionnaire were adapted from the previously published instrument used by labonte (6,10). however, the questionnaire was adapted to fit south african context and discussed thoroughly until a consensus was reached, based on agreed criteria. in order to improve clarity, the questionnaire was pilot-tested amongst three state policy actors within the ndoh representing different areas. this pilot test provided the opportunity to refine the questions for clarity and local adaptation. data collection data for this study was gathered by using a self-administered semi-structured questionnaire. the closed questions provided an assessment of views and perspectives of state policy actors regarding what interests south africa pursue when it engages in global health issues. the first five items provided socio-economic indicators of the respondents, namely: ranks; gender; health programme or service responsible for; experience working in health sector; and experience in participating in global health activities. the following 14 items were scored on a five-point likert scale anchored at 5 as strongly agreed and 1 as strongly disagreed, with a mid-point for unsure. the structure of each question was in the following form: ‘the main motivation and/or interests used to justify why health should be a prominent element of foreign policy is that health is a global public good’. for these 14 items, participants were asked to provide a detailed narrative explanation or provide examples. by use of written individual narratives to explain their views, this process provided a validity check and complemented the findings. one item asked participants to identify the biggest challenges that south africa face in fulfilling its commitment to global health. procedures in the first stage of data collection, a semi-structured self-administered survey was given to 40 state policy actors within the ndoh who had participated in global health negotiations in various global health forums. all the potential participants were approached, and were asked if they were willing to participate in the study. in addition, the questionnaire was also given two present and previous health attachés who were willing to participate in the study. the questionnaires were delivered during lunch breaks and all potential participants were explained the purpose of the study and were asked about their willingness to participate. a register was made to record the number of questionnaires issued out. in case where participants were not in the office or were absent, appointments were made for a follow-up visit. the second stage of data collection included a review of published literature and reports on why south africa incorporates global health into its foreign policy agenda. searches were modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 5 conducted in numerous databases (pubmed, medline, social science citation index and science direct), selecting articles and reports that either directly addressed the relationship between global health and foreign policy, or were case studies of an interaction between global health and one or more of the six dimensions of foreign policy in south african context. quantitative data was entered anonymously into the database. the data editing and data capturing on spreadsheet were initially done on site by the research team as soon as the completed questionnaires became available. double data entry and validation was done by two operators at the university of pretoria using the statistical package epi-info, version 13. in the case of qualitative data from both the primary (questionnaire) and the secondary sources, the data were transcribed into microsoft word, and initial notes were written which were used during the coding cycle. the process, settings, events, as well as discussions with respondents were all meticulously recorded. the study received ethical approval from the research and ethics committee of the university of pretoria and the ndoh of south africa. in addition, participants provided informed consent to participate in the study. analysis quantitative data was exported using start transfer and analysis was done using the statistical package stata (version 12). following cleaning of the data, variables were recorded. the main outcome measure was successful participation in global health diplomacy. descriptive statistical analysis was used to compute frequency distributions and sample characteristics in order to summarize and describe data in a concise form. in the case of qualitative variables emanating from survey questionnaire, published literature and government reports on global health and foreign policy, data was analyzed for content (9). all the texts were read several times and were labelled with codes to conceptualize and categorize the respondents’ experiences. codes sharing communalities were grouped into sub-categories, which later supported the construction of categories. analysis was done concurrently with data collection, making interpretations and preliminary reports on ongoing basis. the explanations given by participants in the survey questionnaire illuminated the experiences, perspectives and views of state policy actors. a ‘thick description’ of both participants and document quotes were presented throughout the results section to contribute to the trustworthiness of the research (9). the study used a combination of emerging codes and those that fitted already predetermined codes. secondary sources were also used to support and give context to the findings. the analysis was characterized by constant comparison of the sub-categories and categories with the original text to ensure that the interpretations were grounded in the data (9). limitations a limitation is that it was not possible to examine all papers across a broad range of public health, political science and international relations literature dealing with the understanding of international networks’ ghd processes. thus, this study is not a comprehensive review of every published article related to this subject; rather, this study sought key literature that illuminates the relationship between global health and foreign policy. furthermore, this study did not interview all possible key informants. in addition, there was a potential for selection bias resulting from the purposive sampling and initial selection of documents to be analyzed. in an attempt to mitigate or overcome this problem, we expanded the analysis to examine documents from other sources. furthermore, there was a high rate of responsiveness of many modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 6 potential respondents who had knowledge and experiences in participating in negotiations for integration of health into foreign policy in south africa. the responses from the questionnaire served as a useful purpose of validating the data from the published literature and reports, and acted as a control mechanism to test the validity of the findings. results a total of 35 state policy actors completed the questionnaire, providing their views about why south africa incorporates global health into its foreign policy agendas. the response rate was 87.5%. table 1 presents the socio-demographic characteristics of the study participants. of the 35 respondents, 54.3% (n=19) were female; 45.7% (n=16) were at post level 13 (directors); 48.6% (n=17) had more than 15 years experience working in health sector; and 34.3% (n= 12) had between 5 to 10 years experience participating in global health activities. table 1. socio-demographic characteristics of study participants variable number percentage gender: male female total 16 19 35 45.7 54.3 100.0 rank: post level 15 post level 14 post level 13 post level 12 or below 2 6 16 11 5.7 17.1 45.7 31.4 experience in the health sector: >15 years 10-15 years 5-9 years <5 years 17 8 8 2 48.6 22.9 22.9 5.7 experience in the health sector: >15 years 10-15 years 5-9 years 3-4 years 6 7 12 10 17.1 20.0 34.3 28.6 analysis of the quantitative and qualitative data from the questionnaire and published literature resulted in 16 categories that correspond to four content areas, namely: motivations and interests used to advance global health agenda; strategies and approaches used to advance global health; domestic factors affecting south africa’s participation in global health discourse and policy issue(s) to be advanced in global health. motivations and interests used to advance global health agenda the responses are shown in table 2. of the respondents, the majority 89.7% (n=32) agreed that health is a global public good. conversely, only 42.8% (n=15) agreed that health is part of global security concerns. however, a significant number of respondents, 34.3% (n=12) disagreed that security concerns is the main motivation why health is an element of foreign policy. of the respondents, 45.9% (n=16) agreed that trade and economic interest are the modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 7 main elements of foreign policy. of the respondents, majority agreed 79.0% (n=29) that development assistance for health is the main element of foreign policy. furthermore, the majority 77.1% (n=27) agreed that human rights and ethical/moral reasoning are main elements of foreign policy. modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 8 table 2. motivation and interest used to advance global health variable number percentage global public good: strongly disagree disagree not sure agree strongly agree 0 0 3 8 24 8.6 22.9 68.6 security argument: strongly disagree disagree not sure agree strongly agree 0 12 8 6 9 34.3 22.9 17.1 25.7 trade and economic interest: strongly disagree disagree not sure agree strongly agree 4 8 7 9 7 11.4 22.9 20.0 25.7 20.0 development agenda: strongly disagree disagree not sure agree strongly agree 1 1 5 11 17 2.9 2.9 14.3 31.4 48.6 human rights and moral reasoning: strongly disagree disagree not sure agree strongly agree 0 2 6 11 16 5.7 17.1 31.4 45.7 in order to complement the quantitative results presented above, the qualitative analysis of the narratives from the semi-structured questionnaires, published literature and government reports regarding why health is a prominent element of foreign policy in south africa, post 1994, resulted in the following categories: free movement of people, goods and services most of the respondents believe that due to globalization, health is becoming a global public good, as indicated below: ‘globalization and movement of people into the country and out of the country due to country to country interactions, asylum seeking activities, wars that cause people to be displaced, health tourism, sports. people movement and goods may result in transfer of disease pathogens from country to country’ [respondent no 25]. human security and better health for all modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 9 most respondents have argued strongly on focusing on human security, safety and protection of the individuals more than the state security, as indicated below: ‘public health issues goes beyond bioterrorism and outbreaks of influenza. public health is about addressing inequalities and social determinants of health and therefore must be an important element of all foreign policy. health has no geographic border, it affect all people, everywhere’ [respondent no 8]. however, some respondents are of the view that acute outbreak of infectious diseases such as sars and h1n1, threaten the citizens and security of the country. as a result, there is a need to establish effective cross border disease control and management, as indicated below: ‘the world we live in has become highly permeable and an attack on one nation has got a ripple effect in term of other nations. this was evident during the h1n1 influenza outbreak’ [respondent no 26]. socio-economic development and equality most of the respondents have argued strongly that trade and commerce should not lead to reduction of the fundamental rights to health and dignity, as indicated below: ‘the issue of trade and socio-economic interest should not be at the centre stage undermining people’s rights to health and dignity’ [respondent no 26]. some of the responses from state policy actors clearly indicate tensions in the trade-andhealth relationships due to conflict between economic interests and global health goals, as indicated below: ‘again, although this is a realistic and driving force for many countries’ foreign policy, it would be better if this was discounted, but that would be regarded as naïve’ [respondent 20]. development, equality and solidarity most respondents have argued that south africa’s engagements in global health should lead to the advancement of developmental health agenda and equality, located within african solidarity, as indicated below: ‘sa in line with its foreign policy has always prioritized development and equality, such as making spaces available for training of students from sadc, assist other countries such as drc, rwanda during humanitarian situation’ [respondent no 28]. furthermore, most respondents are of the view that south africa should strengthen its international cooperation and developmental assistance, and also address issues of poverty and underdevelopment, as indicated below: ‘consolidation of the african agenda is key to the rsa’ foreign policy. to this end, the goal of this priority is for the continent to be able to resolve conflicts and building of an environment in which socio-economic development can flourish’ [respondent no 3]. rights-based structural cooperation most respondents argued that south africa’s engagements in global health should be framed within human rights, morality and democratic principles, as indicated below: ‘(sa) constitution, align with it. regional perspective in terms of our moral and human right standing in the africa continent’ [respondent no 23]. the review of the available published literature highlighted the need for south africa to use its role of peace making and institutions building in africa, as part of its continent’s renewal and advancement of interest of the developing countries (11). the literature also revealed that south africa should use its moral power, its own struggle for democracy, commitment to promoting human rights, and multilateral focus, to leverage its own sovereignty and that of weaker states, especially in the areas of access to medicines and migration of health modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 10 professionals (12). many authors argue that south africa needs a stronger and focused foreign and global health policies (12,13). this focused global health policy can include the identification of strategic global health priorities, greater institutional co-operation with agencies dealing with health and foreign policy; and the need for south africa to develop a stronger leadership role in the african continent on global health. strategies and approaches used to advance global health the responses are shown in table 3. of the respondents, majority 82.8% (n=29) agreed that south africa build coalition with other countries. table 3. strategies, approaches and domestic factors used to advance global health variable number percentage coalitions with other countries: strongly disagree disagree not sure agree strongly agree 0 3 3 13 16 8.6 8.6 37.1 45.7 capacity building for actors or negotiators: strongly disagree disagree not sure agree strongly agree 11 12 11 1 0 31.4 34.3 31.4 2.8 role of other ministries: strongly disagree disagree not sure agree strongly agree 0 0 5 13 17 14.3 37.1 48.6 role of academia and private sector: strongly disagree disagree not sure agree strongly agree 0 0 2 15 18 5.7 42.9 51.4 role of civil society: strongly disagree disagree not sure agree strongly agree 1 2 1 14 17 2.9 5.7 2.8 40.0 48.6 domestic factors: strongly disagree disagree not sure agree 1 1 9 10 2.9 2.9 25.7 28.6 modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 11 strongly agree 14 40.0 however, 65.7% (n=23) said that there is no national programme for capacity building for south african actors or negotiators on global health issues. of the respondents, 85.7% (n=30) agreed that other ministries have a role to play in addressing global health challenges. of the respondents, 94.3% (n=33) agreed that academia and private sector have a role to play in addressing global health challenges. of the respondents, 88.6% (n=31) agreed that civil society have a role to play in addressing global health challenges. to complement the quantitative results shown above, the qualitative analysis of narratives from the semi-structured questionnaires and available literature regarding strategies and approaches used to advance south africa’s involvement in global health, post 1994, resulted in the following categories: whole-government approach most respondents argued that south africa’s engagement in global health should include consistency of purpose across all government sectors, as indicated below: ‘health needs a “whole government approach”. this is very well illustrated with regards to ncds, where we need changes in eating, behavior, physical activity, etc. we cannot achieve this without changing pricing of health, foods, involvement of schools, sport, transport, etc.’ [respondent no 14]. role of non-state actors most respondents argued that south africa’s engagements in global health should use the soft power of non-state actors such as civil society, academia and private sector as a global health policy instrument, as indicated below: ‘… for example the ncd alliance played a prominent role in advocating for the unea political declaration on ncds and gave perspectives of users and experts, which was critical to the final declaration’ [respondent no 14]. african regionalism most respondents argued that south africa’s engagements in global health should be framed within africa’s socio-economic development agenda, as indicated below: ‘consolidation of the african agenda is key to the rsa’ foreign policy. to this end, the goal of this priority is for the continent to be able to resolve conflicts and building of an environment in which socio-economic development can flourish’ [respondent 3]. south-south cooperation most respondents argued that south africa’s engagements in global health should aim at advancing development socio-economic development within the developing world, as indicated below: ‘ … ibsa promotes south-south cooperation and build consensus on issues of increasingly trade opportunities amongst the three countries as well as exchange of information, technology and skills to complement each other’s strengths’ [respondent 3]. the review of the available literature highlighted that non-state actors, including civil society, universities and other academic institutions, as well as private cooperation, have contributed to the advancement of global health goals (11,12). for example, south african health activists community like treatment action campaign (tac) and cosatu, in consultation with transnational activism networks in the global south, have advocated for a broader access to affordable medicines, especially arvs. furthermore, the country was successful in modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 12 building strategic alliances with countries such as brazil, during negotiations of 2001 doha declaration on the agreement on trade related aspects of intellectual property rights (trips). modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 13 domestic factors affecting south africa’s involvement in global health the responses are shown in table 3. of the respondents, majority 68.6% (n=24) agreed that south africa’s newly assertive foreign policy and global health remains constrained by its domestic challenges. furthermore, 65.7% (n=23) indicated that south africa has no capacity building programme for its actors or negotiators. the qualitative analysis of narratives from the semi-structured questionnaires and the available literature regarding domestic factors affecting south africa’s involvement in global health, post 1994, resulted in the following categories:  high disease burden: most respondents argued that south africa’s engagements in global health should be framed within south africa disease burden or challenges, as indicated below: ‘rsa is faced with quadruple diseases that impact immensely on the economy and this is compounded by the hr scarce to meet the health needs of the people’ [respondent no 6].  political leadership: most respondents argued that south africa’s engagements in global health are shaped by the leadership that was provided recently, especially in the area of hiv and aids and recently in non-communicable diseases, as indicated below: ‘hct (hiv/aids counseling and treatment) campaign initiated by the minister of health has drawn interest globally and regionally and has had a positive influence in the global agenda’ [respondent no 8]. ‘in the past decade sa has taken a particular leadership role in hiv and aids, mdgs and now recently in ncds. also in tobacco framework and now alcohol related harm’ [respondent 14].  moderate resources: most respondents argued that south africa’s engagements in global health have been shaped by its moderate resources, especially its scientific skills, r&d and private sector, as indicated below: ‘our technical and expert knowledge will be our entry into new market in africa, south americas and asia. with expansion in develop countries to assist with global financial crises’ [respondent 30].  capacity of negotiators: most respondents indicated that there is no health diplomacy training programme for actors or negotiators, as indicated below: ‘available programmes are not specific for health, but assist in orientating health actors, like the orientation programme for ambassadors by dirco’ [respondent no 11]. the review of the literature clearly indicated that despite south africa’s increasing participation in global health discourse, it is facing several constraints in implementing its global health initiatives. these constraints are found in south africa’s socio-economic challenges and institutional capacity (13). the country faces challenges of high unemployment, poverty and inequality. on health, the country face quadruple burden of diseases, due to hiv and aids and tb, an increasing burden of chronic diseases, high rates of interpersonal violence and injuries (14). this has limited south africa’s scope and influence of its global health assistance programme. that said, literature has also highlighted that south africa has had broad influence and has provided leadership on global health, especially in terms of clinical research, advocacy and policy (15). the literature also indicated that south africa’s weak institutional capacity of its negotiators is another major challenge to its ability to deliver a robust global health policy befitting its modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 14 newly enhanced global standing. nonetheless, south african actors or key negotiators have played significant role in major negotiations, such as during negotiations of trips agreement, who fctc tobacco control and who code for ethical recruitment of health professionals. during these negotiations, south africa has demonstrated its ability to play a leadership role in the south, as a facilitator and a bridge-builder between north and south. policy issue(s) to be advanced in global health  access to medicine agenda: most respondents argued that south africa’s success in global health diplomacy has been achieved within access to medicines control, especially in ensuring availability arvs to all, as indicated below: ‘sa realizes that it will not be able to provide medical care to all unless it assists in bringing prices of medicine down. it therefore collaborate(s) with other countries and strategizes how best this can be done’ [respondent no 14].  hiv/aids: most respondents argued that south africa’s success in global health diplomacy has been achieved within area of hiv and aids, as indicated below: ‘without sa’s interventions on issues such as hiv, the world would not have moved to where it currently is’ [respondent 14].  tobacco control: most respondents argued that south africa’s success in global health diplomacy has also been achieved within the who’s fctc, as indicated below: ‘fctc is a(n) excellent example where we were proactive & prepared & followed through with active … actions & perseverance & purpose!’ [respondent no 20]. ‘sa was one of the first few countries to ratify the who fctc’ [respondent no 8]. the literature review highlighted that, given that nearly six million south african are hivpositive, the country can take up the global leadership on hiv and aids (11). the notion of niche or focused diplomacy brings the identification of ‘transnational issue networks’ that can be used to advocate for improved health outcomes (12). in addition, south africa need to use its bridge-builder and facilitation ability, to explore closer multilateral ties with brazil (via ibsa) to seek to advancement of a shared health goals (11,12,16). discussion findings from the current study reveal that south africa’s participation in global health discourse is limited by its domestic health challenges. the findings confirm other studies in that south africa is faced with challenges of epidemics such as hiv/aids and tb, an increasing burden of chronic diseases including obesity, and high rates of interpersonal violence and injuries (11). behind these epidemics, there is the continuing mortality of mothers, babies and children, which still primarily affects the poorest families. hence, the findings of the study are in line with results of other studies which have demonstrated that south africa has understandably chosen to prioritize domestic health over global health (11). the findings of this study are also in line with other studies in that south africa should use a human rights framework to position its approach to health diplomacy (11,12). south african government has used its human rights emphasis to champion for increase access to antiretroviral drugs in order to provide universal treatment to all hiv-positive people. however, studies have also revealed that south africa has experienced a palpable tension between the politics of solidarity and sovereignty on the one hand and human rights on the other, as evidenced in its voting patterns on zimbabwe to libya in the un security council and aids denialism (17). modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 15 this study, consistent with other studies, confirms that overemphasis on health security overshadow the opportunity to use health as a constructive and novel perspective to shape international, transnational and global action (17,18). the findings support other studies in that the governance of health threats should be about the search for equity, justice and well being, other than the current perspective of protection of international commerce from a freeriding epidemics (11,19). the findings of this study are also consistent with other studies in that some state policy actors still tend to focus on “high politics” of health issues, rather than on “low politics” in which health issues are seen as a reflection of human dignity (11,19). the findings of this study are consistent with many other studies that have argued that south africa should explicitly pursue issues of poverty and equality within its global health agendas and debates (11,19). furthermore, studies have highlighted that south africa’s attention on global health diplomacy should focus on global trade, as ‘trade and health linkage highlights the new prominence of health within foreign policy’ (20). the findings of this study are consistent with other studies and reports that have reported that south africa does allocate limited resources to health assistance through multilateral agencies, bilateral channels and other south-south partnerships (15,21). the findings suggest that south africa can play a more transformative role, through providing focused technical assistance for health projects, supplying medical goods and services to very poor countries in its immediate geographic neighborhood. for example, south africa has provided funding to seychelles for infrastructure rehabilitation and republic of guinea to boost rice production (21). the findings of this study are consistent with other studies in that the contribution of nonstate actors, including civil society, universities and other academic institutions, as well as private cooperation, is an important development in the advancement of global health goals (11,15). for example, south african health activists community like treatment action campaign (tac), in consultation with transnational activism networks in the global south, have advocated for broader access to affordable arvs and health care services in south africa and developing countries.15 this study is consistent with other studies, in that south africa as an emerging middle income country, should prioritize its global health efforts (17). south africa should avoid using rhetoric or ineffectual diplomacy, and try to be all and do all for everyone. for example, brazil used focused diplomacy in areas of antiretroviral drugs, using health rights framework, while cuba and china used medical diplomacy to achieve their foreign policy goals (22,23). therefore, given the current burden of diseases, south africa can use its hiv and aids diplomacy as a project of emancipating and transformation, rather than an affirmation of the world as it is (15). lastly, this study found that there is no formal training programme for actors and diplomats on global health diplomacy in south africa. other studies have also indicated the need for the development of a training programme on global health diplomacy (24,25). all these studies have clearly indicated that for health to be a sustainable lens for foreign policy thinking and agenda setting, it must be mainstreamed into the training of diplomats and health officials. this finding therefore highlights the need for south africa to take a lead in training of diplomats and health officials within the country and in the africa region. conclusion this study has showed that south africa has a limited engagement in global health diplomacy. south africa is still inward focused, and that its domestic challenges (such as especially the burden of hiv/aids and tb) will drive its engagement internationally. modisenyane m, senkubuge f, hendricks sjh. global health in foreign policy in south africa – evidence from state actors (original research). seejph 2016, posted:20 september 2016. doi 10.4119/unibi/seejph2016-129 16 furthermore, due to its domestic challenges, south africa has not taken a regional leadership role in global health diplomacy. south africa’s economic diplomacy can presents a potential entry point for engagements in global health diplomacy. non-state actors might also push the government to be more actively engage in global health diplomacy. it is therefore south africa’s approach to hiv/aids and tobacco control which might position it for engagement and a leadership role internationally. therefore, in order to take its rightful leadership role, south africa need to develop a focused global health strategy and take a lead in the training of diplomats and health officials within the country and for the africa region. references 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training across disciplines. bull world health organ 2007;85:971-3. __________________________________________________________ © 2016 modisenyane et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.ncbi.nlm.nih.gov/pubmed/?term=silberschmidt%20g%5bauthor%5d&cauthor=true&cauthor_uid=18278266 http://www.ncbi.nlm.nih.gov/pubmed/?term=alcazar%20s%5bauthor%5d&cauthor=true&cauthor_uid=18278266 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 1 original research trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood giovanni piumatti1 1 department of psychiatry, university of oxford, oxford, uk. corresponding author: giovanni piumatti, phd; address: warneford hospital, ox3 7jx, oxford, uk; telephone: +393335251387; email: giovanni.piumatti@psych.ox.ac.uk piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 2 abstract aim: the aim of this study was to examine how university students’ achievement strategies in an academic context and perceptions of criteria for adulthood relate to life satisfaction trajectories across one year. methods: a convenience sample of 143 young adults 18-28 years (mean age: 20.9±2.7 years; 109 females and 34 males) attending the university of turin in northwest italy completed questionnaires at three points with a six-month interval between each measurement. latent growth curve modelling and latent class growth analysis were used to assess longitudinal changes in life satisfaction and the related heterogeneity within the current sample. results: three trajectories of life satisfaction emerged: high stable (37%), moderate decreasing (57%), and low stable (6%). at every time point high success expectations were related to a high stable life satisfaction trajectory. in turn, those adopting achievement avoidance strategies were more likely to have low-stable or moderately decreasing life satisfaction trajectories. the perception of the criteria deemed important to be defined as adults did not change across time points or across life satisfaction trajectories’ groups. conclusion: these findings suggest that self-reported measures of achievement strategies among university students relate longitudinally to life satisfaction levels. positive and optimistic dimensions of personal striving may be protective factors against the risk of decrease of life satisfaction among university students. keywords: achievement strategies, criteria for adulthood, developmental trajectories, life satisfaction, person-oriented approach. conflicts of interest: none. note of the author: some results of the present paper have been previously presented at the 7th conference of the society for the study of emerging adulthood in miami, florida, october 14-16, 2015. piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 3 introduction according to diener, emmons, larsen, and griffin (1) life satisfaction (ls) is defined as an individual’s overall appraisals of the quality of his or her life. in the social and psychological sciences this construct has become a key variable for analyzing individuals overall subjective well-being (2). longitudinal studies have shown that after adolescence the majority of people experience stability in ls over long periods of times (3). however, depending on the length of time, one may observe short-, intermediateand long-term influences on ls (4). indeed, in the field of life-span research, the development of ls over time has become a very important baseline through which more variegated trajectories of individual development are observed (5). especially among older cohorts (i.e., aged 18 and above), given the relative stable differences in ls between observed latent growth groups in comparison with the more turbulent adolescence years, many have adopted a person-oriented approach (6,7) to describe which other characteristics unite individuals of a certain developmental trajectory of ls. for example, ranta, chow, and salmela-aro (8) have associated trajectories of ls among young adults to their self-perceived financial situation, concluding that positive ls trajectories relate to being in a positive self-perceived financial situation. röcke and lachman (3) observed how to maintain stable trajectories of positive ls individuals need intact social relations as well as a high sense of control. in addition, salmela-aro and tuominen-soini (9) and salmela-aro and tynkkynen (7) found that education achievement during and after secondary education positively correlated with high stable ls. emerging adulthood research proposes that the growing acquisition of maturity regarding adulthood-related duties and roles such as the commitment to life-long relationships or the importance attributed to forming a family are parallel to a stable ls path (10). in general, in the age range 18-30 years, perceiving oneself as an adult correlates to higher levels of ls and positive affect (11). such findings contributed to give credit to the theoretical assumption stating that among young adults the increasing acquisition of an adult identity and the endorsement of adulthood-related criteria are concurrent factors in determining positive outcomes at the individual level, as for example higher ls. at the same time, if we adopt a person-oriented approach to look at this issue, we might expect that others characteristics may define those young adults proceeding through transitions while exhibiting a mature adult identity and high ls. in an academic context, for example, the kinds of cognitive and attributional strategies individuals deploy provide a basis for their success in various situations (12), as well as for the positive development of their well-being (13). accordingly, in the present study we aimed at integrating the research literature on the relationship between the attainment of adult maturity and well-being with indicators of individual achievement strategies typical of life-span studies. more specifically, through a longitudinal approach, we questioned whether university students’ ls changes during a one year period and what kind of trajectories can be found. secondly, we examined young adults’ perception of the criteria deemed important for adulthood and achievement strategies in the academic context in relation to ls trajectories. the italian context university students account for a good proportion of the population aged 18-30 years in italy, although italian national statistics show a steady decrease in the overall university enrolment rates (14). moreover, italy reports one of the highest rates of university withdrawals among oecd members (15), with some regional differences between north and south (with dropout rates being higher in the latter), but overall widespread across the country (16). despite the considerable high social cost related to dropout rates during tertiary education and the interrelation between motivation, education attainment and well-being among young adults piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 4 (17), very few studies have examined from a longitudinal and psychological perspective how self-reported measures of well-being such as ls interact with motivational strategies in an academic context in italy (18). accordingly, the present study aimed to test the specific research hypothesis that positive motivational attitudes in an academic context relate to higher ls levels among young adults attending university and, possibly, to a higher acquisition of adulthood maturity. methods sample the empirical data of the present study were collected through the submission at three time points of an online questionnaire to a convenience sample of university students in the northwestern italian city of turin. participants were reached in various university settings of the faculty of psychology, including libraries, canteens, cafeterias and public leisure spaces. the criteria to take part in the study were being enrolled as a full-time university student, being italian and aged between 18 to 30 years. students provided their email contacts if they were interested in taking part in the study. then, they received a link to the online questionnaire through email. at time 1, 645 individuals (76% females; mean age: 22.1 years) completed the questionnaire. at time 2, six months afterwards, 252 individuals (79% females; mean age: 22.3 years) completed again the same questionnaire. finally, at time 3, twelve months after time 1, 150 individuals (77% females; mean age: 22.1 years) filled in the questionnaire. the very high dropping rate from time 1 to time 2 and time 3 can be explained by the total absence of an incentive for the participants to take part in the study (e.g., money, or school credits). therefore, it is reasonable to imagine that only those personally interested in the topic or in the research itself were willing to fill in the questionnaire. in fact, while the dropping rate from time 1 to time 2 was equal to 61%, from time 2 to time 3 it was equal to 41% (of the total number of participants at time 2), indicating a significant decline in the number of people dropping out. this may be explained by the fact that at time 2 the proportion of participants interested in the research was higher than at time 1. moreover, only the participants who filled in the questionnaire at time 2 were contacted again at time 3. measures life satisfaction ls was measured using the satisfaction with life scale (1). participants rated five items (for example, “i am satisfied with my life”, and “the conditions of my life are excellent”) on a 7point likert-type scale ranging from 1 (totally disagree) to 7 (totally agree). a mean score was calculated for all items. cronbach’s alphas ranged from 0.69 to 0.79 across the three measurement points, indicating a good level of internal consistency with respect to the ls variable. achievement strategies four different types of achievement strategies in an academic context were assessed: success expectation, (cronbach’s alphas ranged from 0.68 to 0.73), measuring the extent to which people expect success and are not anxious about the possibility of failure (4 items, e.g., “when i get ready to start a task, i am usually certain that i will succeed in it”); taskirrelevant behaviour (α from 0.76 to 0.82), measuring the extent to which people tend to behave in a social situation in ways which prevent rather than promote involvement (7 items, e.g., “what often occurs is that i find something else to do when i have a difficult task in front of me”); seeking social support (α from 0.73 to 0.77) measuring the extent to which piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 5 people tend to seek social support from other people (6 items, e.g., “it is not worth complaining to others about your worries”); and avoidance (α from 0.77 to 0.76), measuring the extent to which people have a tendency to avoid social situations and feel anxious and uncomfortable in them (6 items, e.g., “i often feel uncomfortable in a large group of people”). the scales belong to the strategy and attribution questionnaire (19). criteria for adulthood participants rated the importance of 36 criteria for adulthood (20) on their degree of importance on a scale of 1 (not at all important) through 4 (very important). based on previous research (10,20), these criteria were grouped into six categories: interdependence (α from 0.60 to 0.65; 5 items; e.g., “committed to long-term love relationship”), role transitions (α from 0.84 to 0.86; 6 items; e.g., “have at least one child”), norm compliance (α from 0.77 to 0.82; 8 items; e.g., “avoid becoming drunk”), age/biological transitions (α from 0.70 to 0.74; 4 items; e.g., “grow to full height”), legal transitions(α from 0.81 to 0.86; 5 items; e.g., “have obtained license and can drive an automobile”) and family capacities (α from 0.75 to 0.77; 8 items; e.g., “become capable of caring for children”). analysis the analyses followed three steps. first, to examine how ls changes during a one-year period, latent growth curve modelling (lgcm) (21) estimated the average initial level and slope of ls among the participants. the following indicators assessed the goodness-of-fit of the estimated lgcm: χ²-test, the comparative fit index (cfi) with a cut-off value of ≥0 .95, and the standardized root mean square residual (srmr) with a cut-off value of ≤0 .09. subsequently, to evidence whether different types of ls trajectories emerge from the total sample, the analyses of this longitudinal data set extended into latent class growth analysis (lcga) (22). lcga examines unobserved heterogeneity in the development of an outcome over time, by identifying homogeneous subpopulations that differ with respect to their developmental trajectories within the larger heterogeneous population. lcga is exploratory by nature, which means that there are no specific a priori assumptions regarding the exact number of latent classes. when testing lcga models, different class solutions are specified. the best-fitting model is then selected based on the goodness-of-fit indices and theoretical considerations. here, the following goodness-of-fit indices evaluated the models: akaise’s information criteria (aic), bayesian information criteria (bic) and adjusted bayesian information criteria (abic) of the alternative models. entropy values were also examined, with values close to 1 indicating a clear classification. following marsh, lüdtke, trautwein, and morin (18), groups of ≥ 5% of the sample were considered the smallest to give an acceptable solution. practical usefulness, theoretical justification and interpretability of the latent group solutions were also taken into consideration (23). the analyses were controlled for age, gender and self-perceived socio-economic status (participants were asked how they would rate their actual socio-economical position on a scale from 1 – not good at all to 5 – very good). both lgcm and lcga analyses were conducted with the mplus 5.0 statistical software program. at last, one-way analysis of variance (anova) examined if the ls trajectory groups differed in terms of their achievement strategies and importance attributed to criteria for adulthood. post-hoc comparisons using the games-howell test examined differences between groups. piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 6 results development of life satisfaction the specified lgcm with a linear slope for ls change across the three time points fits the data well, χ²=3.99(1), p<0.05; cfi=0.98; srmr=0.04. in particular, while the intercept indicating the initial level of ls was statistically significant, the linear slope was not (intercept m= 3.02, se=0.05, p<0.001; slope m = -0.11, se=0.02, p>0.05). in addition, while the variance of the intercept was significant the variance of the slope was not (intercept variance =0.15, p<0.001; slope variance 0.01, p>0.05). together these results indicate that first, on average, there was no significant longitudinal change in ls across the three measurement points, and second, that there was a significant individual variance in the initial levels but not in the rate of change. thus, the significant heterogeneity among individuals was analyzed further adopting the person-oriented approach of latent class growth models. more specifically, these results suggest that, rather than investigating different rates of longitudinal change in ls within the overall sample, it would be more plausible to observe latent groups exhibiting stable trajectories of ls across time while being concurrently significantly different between each-other from baseline to the last follow-up. identifying life satisfaction trajectories lcga identified three sub-groups of individuals according to their levels of ls across measurement points. table 1 shows the fit indices and class frequencies for different latent class growth solutions. the four-class solution was unacceptable given the presence of a group with zero individuals. the three-class solution was thus the most optimal given the numerical balance of the observed groups and its higher entropy value with respect to the two-class solution (i.e., values closed to zero are indicative of better fit). figure 1 displays the estimated growth curves for the different latent trajectories of ls, whereas table 1 reports lcgm results. figure 1. life satisfaction trajectories (mean values in a scale 1-7) 0 1 2 3 4 5 6 7 t1 life satisfaction t2 life satisfaction t3 life satisfaction high stable (n = 52; 37%) moderate decreasing (n = 82; 57%) low stable (n = 9; 6%) piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 7 table 1. fit indices and class frequencies based on estimated posterior probabilities for latent class growth models of life satisfaction with different numbers of latent trajectory groups number of groups bic abic aic entropy 1 766.94 751.12 752.13 2 (n1 = 69%, n2 = 31%) 684.93 659.62 661.23 .747 3 (n1 = 37%, n2 = 6%, n3 = 57%) 652.44 617.64 619.85 .827 4 (n1 = 6%, n2 = 58%, n3 = 0%, n4 = 36%) 667.33 623.03 625.85 .863 note. bic = bayesian information criteria; abic = adjusted bayesian information criteria; aic = akaike information criteria. the chosen option is marked in bold. the latent trajectories of ls were labelled high stable (37%), moderate decreasing (57%), and low stable (6%). ls mean levels of the high and the low stable trajectory groups remained stable over time. on the other hand, the moderate decreasing group exhibited a significant decrease in ls mean levels over time (see table 2). anova and chi-square tests evidenced how the three sub-groups did not differ according to age, f(2, 150)=0.01, p>0.05, gender, x2 (2, 150)=1.56, p>0.05, and self-perceived socio-economic position, x2 (2, 150)=8.13, p>0.05. table 2. estimation results of the final growth mixture model with five latent classes (unstandardized estimates; standard errors in parentheses) high stable (n=52; 37%) moderate decreasing (n=82; 57%) low stable (n=9; 6%) mean structure level 3.42 (0.05)** 2.83 (0.05)** 1.91 (0.11)** change -.09 (0.06) -.25 (0.05)** -.14 (0.20) note. variance is kept equal across the different latent groups. ** p< .001 differences in achievement strategies and criteria for adulthood the second analytical step consisted of testing whether the three observed ls trajectory groups were significantly different at each time point concerning self-reported achievement strategies outcomes in the academic context and the importance attributed to criteria for adulthood. table 2 reports all effects and pairwise mean comparisons between ls groups. since we did not observe any significant effect of ls trajectory group membership on the mean levels of the importance attributed to the criteria for adulthood, we decided not to report in a table such results for parsimony reasons. on the other hand, it appears clear how the three developmental trajectories groups consistently differed across time points regarding the types of achievement strategies they adopted in their academic activities. more specifically, from time 1 to time 3, the high stable group showed the highest levels of success expectation and the lowest levels of task irrelevant behaviour and avoidance. diametrically opposite was the performance of individuals in the low stable group who consistently showed the lowest levels of success expectation and the highest levels of task irrelevant behaviour and avoidance. finally, the moderate decreasing group reported a stable success expectation over time, but a slight increasing in avoidance. in fact, while at time 1, the avoidance did not differ between the moderate and the high stable group, from time 2 to time 3, individuals in the moderate decreasing group showed the same level of avoidance as the individuals in the low stable group. piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 8 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 9 overall, these results indicate that the types of achievement strategies in the current sample are linked to different ls development trajectories. furthermore, such measures of personal agency did not relate to different perceptions of the criteria deemed important for adulthood, nor the latter seem to correlate with ls developmental trajectories. discussion the current research focused on a longitudinal convenience sample of young adults attending university in the north-western italian city of turin. the person-oriented model tested here provided theoretical evidence of the overtime interconnection between motivational strategies in an academic context and well-being among university students. the main contribution of the present study was the adoption of a person-oriented approach (6) to focus on the issue of the perception of adulthood among young adults. indeed, to date, very few studies (24) have opted not to focus entirely on the relations between singular variables but instead to look at more elaborated systems of individual characteristics to draw a ‘picture’ of different ‘types’ of emerging adults in western societies. moreover, the longitudinal nature of the trajectory analysis contributed to test whether for emerging adults the perception of what it means to be considered adults nowadays is a stable construct over time, even if just across only one-year period. in particular, the latent curve growth analysis implemented here has represented a more fruitful way for examining young adults’ individual development (22). indeed, a single growth trajectory would have oversimplified the heterogeneity of the changes in emerging adults’ life satisfaction over time, as some experience an increase and some a decrease in life satisfaction, although the majority seem to experience a significant stability (7). in this study, it was possible to identify meaningful latent classes of individuals according to the initial levels and the longitudinal changes in their life satisfaction across the three measurement points. adopting this multiple trajectories approach resulted in a model of three developmental trajectories. overall, two major conclusions can be drawn from the present study. first, starting from the non-significant findings, it appeared that the perception of the most important criteria for adulthood (i.e., family capacities, interdependence, norm compliance) are not correlated to life satisfaction trajectories, either low or high. second, achievement strategies reflecting notions of agency were closely linked to life satisfaction, both about initial level and development. the first findings can reasonably be the result of the limited time span across which we aimed at observing developmental changes. indeed, we already know that emerging adults are more prone to change their perception of adulthood especially in correspondence with crucial life events, such as getting married, experience of parenthood, finishing the studies and start working (10,11). therefore, the impossibility to control for such events in the present study or simply the fact that the very small sample did not include a sufficient number of people going through specific transitions’ thresholds, can explain why we did not observe significant differences across developmental groups who instead remained stable in their opinions over the curse of one year. however, we were not just interested in looking at changes, but we argued for stable differences across developmental trajectory groups. again, despite the fact that we observed trajectory groups that showed significant differences in motivational strategies across time, these did not relate to adulthood self-perception. these results might confirm how the major sources of adulthood identity variation over time are significant experiences related to it. the significant differences between groups in terms of achievement strategies suggest that these measures of motivation and life satisfaction are strictly related. specifically, individuals with a high level of positive achievement approach strategies demonstrated high levels of life satisfaction. on the contrary, high levels of avoidance and irrelevant behaviours mostly piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 10 related to low levels of life satisfaction. a closer look revealed that individuals in the moderate decreasing life satisfaction trajectory maintained a more stable level of avoidance over time than the other two groups that both showed instead a decreasing in avoidance. thus, personal strivings and strategies may be protective factors against a decrease in life satisfaction. in summary, the findings from the current study are aligned with previous research work focusing on samples of young adults attending university and evidencing how individuals’ achievement strategies measured during university studies affect subjective well-being outcomes (25,26), including life satisfaction (27,28). in particular, in accordance with our results, success expectations are positively associated with higher satisfaction (29) and poor engagement relate to low well-being (27). these evidences should guide future research with the aim of further investigating the role of different types of agentic personality traits among university students in relation to positive life outcomes and health behaviours as factors strongly related to subjective well-being outcomes. study limitations and conclusions it is important to point out the main limitations of the current study. firstly, owning to the person-oriented statistical approach and despite the study longitudinal design, the analyses did not explicitly report on any causal relationship between measures of achievement strategies and overall satisfaction with life. future studies should look more specifically into cause-effect models using these types of self-reported measures of achievement strategies and various well-being outcomes. secondly, the convenience sample of university students included in this study cannot be considered representative of the entire population of university students in the context of reference (i.e., the university of turin in italy). accordingly, the generalizability of the current findings should be considered with caution while they may well represent a base to validate the theoretical framework according to which different motivational strategies among university students 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doi:10.4119/unibi/seejph-2017-140 12 28. piumatti g, rabaglietti e. different “types” of emerging adult university students: the role of achievement strategies and personality for adulthood self-perception and life and education satisfaction. int j psychol psychol ther 2015;15:241-57. 29. nurmi je, aunola k, salmela-aro k, lindroos m. the role of success expectation and task-avoidance in academic performance and satisfaction: three studies on antecedents, consequences and correlates. contemp educ psychol 2003;28:59-90. ___________________________________________________________ © 2017 piumatti; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. eliakimu es, mans l. taking up from cop26 going forward: contribution of the book “survival: one health, one planet, one future by george r. lueddeke” (commentary) seejph 2022, posted: 16 december 2022. doi: 10.11576/seejph-6119 p a g e 1 | 11 commentary taking up from cop26 going forward: contribution of the book “survival: one health, one planet, one future by george r. lueddeke” eliudi saria eliakimu1 and linda mans2,3 1health quality assurance unit, ministry of health; dodoma, tanzania 2an independent consultant and researcher in support of healthy people and a healthy planet, manskracht; nijmegen, netherlands 3policy officer science and knowledge development healthcare at the netherlands institute for health services research (nivel); utrecht, netherlands corresponding author: eliudi saria eliakimu, (md, mph) ministry of health, health quality assurance unit, nhif building 05th floor, 2 ukaguzi road, p. o. box 743, dodoma, tanzania. +255 754361400 email: eliakimueliudi@yahoo.co.uk and eliudi.saria@afya.go.tz mailto:eliakimueliudi@yahoo.co.uk mailto:eliudi.saria@afya.go.tz eliakimu es, mans l. taking up from cop26 going forward: contribution of the book “survival: one health, one planet, one future by george r. lueddeke” (commentary) seejph 2022, posted: 16 december 2022. doi: 10.11576/seejph-6119 p a g e 2 | 11 abstract since its publication in 2019, the book "survival: one health, one planet, one future", written by george r. lueddeke, has proven to be timely and useful in these uncertain and tense ("rattling" – lueddeke’s word) times we are experiencing. indeed, we have had (and still are experiencing) the covid-19 pandemic and the war between russia and ukraine that was started early 2022. in this article, we recall the urgency of climate action, the goals of cop26 (that took place from 31st october to 12th november 2021) and provide suggestions for topics that might deserve a place in a possible update of the book. these topics include (i) a critical analysis of the effects of russia and ukraine war and lessons from the perspective of one health and wellbeing; (ii) progress in various countries in using the one health approach to address issues that affect the health and wellbeing of population (equity), the environment and ecosystems in general (including global trends in non-communicable diseases and antimicrobial resistance); and (iii) look at the current global governance systems in relation to how they can better function proactively to prevent future wars (interconnected challenges). keywords: climate change, conference of parties 26, one health approach, covid-19, and russia and ukraine war. acknowledgements: we acknowledge the work of the president of cop26 and the secretariat for the draft decision document that has been one of our foundational references. we also thank all the authors of the references cited in our paper for their wonderful work. source of funding: no funding was received for this work. conflicts of interest: the authors declare that there is no any conflict of interest. disclaimer: the authors alone are responsible for the views expressed in this publication, and they do not represent views of their organisations. eliakimu es, mans l. taking up from cop26 going forward: contribution of the book “survival: one health, one planet, one future by george r. lueddeke” (commentary) seejph 2022, posted: 16 december 2022. doi: 10.11576/seejph-6119 p a g e 3 | 11 introduction the coronavirus disease 2019 (covid-19) pandemic has affected the life of populations globally both socially and economically causing deaths of millions of people globally in a way that has even challenged our capacity for deaths registration (1). the pandemic has also led to a consecutive two-years (2020-2022) retardation in the progress of implementation of the sustainable development goals (sdgs) (2); hence, affecting well-being of people in terms of mental health (3). covid-19 has also exposed vulnerabilities in health systems in high income countries (hics) (4), as well as in lowand middle-income countries (lmics) including countries in sub-saharan africa (5). as much as countries around the world have been struggling with covid-19, another challenge of climate change effects has also been reported in various countries in both hics and lmics settings such as: floods in south africa in which 400 people died, destroyed more than 12,000 houses and forced about 40,000 people from their homes (6); wild fires in united sates (7); and heat waves in india during the period of march – may, 2022 (8). all these challenges have demonstrated the need for the world to come together to put strategies that can ensure we minimize the effects of climate change (9); and also, to have health systems that are more resilient, sustainable and well prepared against future pandemics (10). sadanandan (2022) has documented lessons from the covid19 pandemic for policy makers on management of pandemics which can help decision makers to perform better in future pandemics (11). one of the key instruments for tackling climate change is “the united nations framework convention on climate change (unfccc)” which entered into force on 21st march 1994 and as of 25 june 2022, its status showed that it has 165 signatories and 197 parties. all the countries that have ratified the convention are called “parties to the convention” (12, 13). each year since 1997 the “parties to the convention” meet annually for meetings that are commonly named as “conference of parties (cop)”. on 31st october–12th november 2021 the 26th conference of parties (cop26) was held in glasgow, scotland (12). the cop26 had four goals namely “mitigation, adaptation, finance and collaboration”. from a public health perspective, a broad approach to health was discussed, which considered socio-economic and environmental determinants, health and equity (14). the cop26 draft decision proposed by the president (15), focused on the following eight key areas (as quoted from the draft decision): “(i) science and urgency importance of science for effective climate change action and policy; (ii) adaptation urged parties to further integrate adaptation into local, national and regional planning; (iii) adaptation finance – “urged developed country parties to increase their provision of climate finance, technology transfer and capacity-building, financial institutions and private sector to mobilize funds; (iv) mitigation parties to consider further actions to reduce by 2030 non-carbon dioxide greenhouse gas emissions, including methane; accelerate the development, deployment and dissemination of technologies, and the adoption of policies, to transition towards low-emission energy systems; and protecting, conserving and restoring nature and ecosystems, including forests and other terrestrial and marine ecosystems; (v) finance, technology transfer and capacity-building for mitigation and adaptation emphasizing on the importance of strengthening cooperative action on technology development and transfer for the implementation of mitigation and adaptation action; (vi) loss and damage the importance of strengthening partnerships between developing and developed countries, eliakimu es, mans l. taking up from cop26 going forward: contribution of the book “survival: one health, one planet, one future by george r. lueddeke” (commentary) seejph 2022, posted: 16 december 2022. doi: 10.11576/seejph-6119 p a g e 4 | 11 funds, technical agencies, civil society and communities to enhance understanding of how approaches to averting, minimizing and addressing loss and damage can be improved; (vii) implementation importance of protecting, conserving and restoring ecosystems in which parties need to take an integrated approach for protecting, conserving and restoring ecosystems in national and local policy and planning decisions; and to ensure just transitions that promote sustainable development and eradication of poverty; (viii) collaboration – taking up key issues that will ensure: meaningful youth participation and representation in multilateral, national and local decisionmaking processes, including under the convention and the paris agreement; important role of indigenous peoples’ and local communities’ culture and knowledge in effective action on climate change, and urges parties to actively involve indigenous peoples and local communities in designing and implementing climate action; and to increase the full, meaningful and equal participation of women in climate action and to ensure genderresponsive implementation and means of implementation, which are vital for raising ambition and achieving climate goals” (15). against that background, in addressing the climate change and other emerging challenges, we aimed to explore the contribution of the book “survival: one health, one planet, one future” by george r. lueddeke. routledge taylor and francis group abingdon – oxon, london and new york, first published 2019; ebook isbn 9780429444081. 254 pages. doi: https://doi.org/10.4324/978042944 4081. methods a narrative analysis of the content of the book was done taking into account the goals of the cop26; and reviewed literature on climate change and other issues related to content of the book. based on the analysis, highlights of some actions that need to be taken are presented in the discussion section under sub-section “going forward”. the conclusion section includes suggestions for topics that might deserve a place in a possible update of the book. results the book brings to our attention the need for “changing the way we relate to the planet and to one another and confronting how we use technology (dataism) for the benefit of both humankind and the planet”. the author george r. lueddeke (who is an educational advisor in higher and medical education and chairs the global one health education task force for the one health commission and the one health initiative) has been able to touch broadly around key topics related to protection of our environment, humanity, and the ecosystem in general, while focusing on the future with a special eye on young generations (which he refers to as generation z) in terms of their education and their relation with the fast growing technology. the author introduced the book well and organized it into three parts. part one highlighted on challenges we face as we strive to protect well-being of people and the planet including: urbanization; climate change and sdgs focusing as well on non-communicable diseases (ncds) and antimicrobial resistance (amr); technology and our lives; increasing population and the problem of overconsumption; and capitalism including issues that require attention in twenty-first century. part two delt with war and peace; projections into 2050 in terms of shifting global economic powers, automation effects to society, corruption, democracy and decision making in twentyfirst century; shaping the society for a https://doi.org/10.4324/9780429444081 https://doi.org/10.4324/9780429444081 eliakimu es, mans l. taking up from cop26 going forward: contribution of the book “survival: one health, one planet, one future by george r. lueddeke” (commentary) seejph 2022, posted: 16 december 2022. doi: 10.11576/seejph-6119 p a g e 5 | 11 sustainable future with a note on dangers such as endless new weapon systems; growing antagonism among nations; the poison in our politics; and climate change; and one health approach. part three of the book mainly focused on how to create a more just, sustainable and peaceful world touching on global education as a way of building foundations for future; detailed description of key leading global and national organizations in the area of one health and well-being initiatives; challenges faced in leadership in an era of “uncertainty, upheaval and anxiety” probably pointing to a “new world order”; and defined generation z and the challenges they are likely to face including the technological as well as socioeconomic challenges that leaders in the twenty-first century need to be aware of, and engage the generation in finding appropriate solutions that are tailored to their context and aspirations. discussion the book has pointed out broadly on many of the issues that were also focused in the cop26 meeting including: protection of nature and ecosystems with a look on effects of overpopulation and overconsumption; ensuring just transition that will enable sustainable development and eradication of poverty; meaningful participation and involvement of young generations in protection of our planet to ensure a better and safer future; and the use of technology for betterment but also potential effects of technological use if not well managed depending on how the young generation (referred to in the book as generation z) is prepared to cope with the technological era (fourth industrial revolution). the book has further looked at the topics that affect the health of population which require a multi-sectoral approach in addressing them such as ncds and amr. these are among the major challenges that are likely to overwhelm global and national health systems and ultimately affecting the life of populations. the challenge of overpopulation has also been noted by mackenbach (2022) regarding the need for using persuasive interventions on top of the usual public health interventions and family planning measures in order to address people reproductive preferences (16). the recent global report on global burden of bacterial amr in 2019 has shown that “amr is a leading cause of death around the world, with the highest burden in lowresource settings” (17). therefore, as noted by weldon, et al, (2022) it is important to strengthen governance of amr globally drawing on lessons from the paris climate agreement (18). the challenge of ncds require multisectoral actions at national and global level (19); and also, it requires incorporation of behavioural medicine strategies in policies and intervention frameworks (20). the book also touched on social, political, and economic determinants of health such as poverty, inequality, war and peace, corruption, democracy, and decision making in the twenty-first century. the ongoing war between russia and ukraine is a testimony on why we need to focus on peace and avoid wars given the fact that the war has already affected the whole world causing: exacerbation of the worsening economies that had already been weak due to the covid-19 pandemic; shortages of food supply globally pushing populations into famine; increase in oil and gas prices as well as other commodities prices; and pushing millions of ukrainian people into refugee situation (21). democracy has been shown to have impact on health outcomes. for instance: countries with democratic governance had better responses to the covid-19 leading to a decrease in “excess mortality” (22); and improvement in democracy has contributed to increase in life expectancy and decrease in infant eliakimu es, mans l. taking up from cop26 going forward: contribution of the book “survival: one health, one planet, one future by george r. lueddeke” (commentary) seejph 2022, posted: 16 december 2022. doi: 10.11576/seejph-6119 p a g e 6 | 11 mortality in the “post-communist states” (23). the one health approach is the cornerstone for addressing global health challenges that transcend the boundaries of health sector. as noted by ghebreyesus, et al, (2022), “issues beyond the health sector such as changing demographic patterns, climate change, changing land use, de-forestation and increased animalhuman proximity, coupled with increasing population density and globalization are increasing the likelihood of further pandemics or other crises. now is the time for all sectors to work together on health” (24). one health is also a critical element in surveillance of infectious diseases (25, 26), and for tackling zoonotic diseases (27). for one health to achieve this all stakeholders and various sectors need to come together and work in partnerships “accommodating competing political perspectives and include flexibility to allow multisector partnerships to respond to changing external dynamics” (28). there is a need for a more strengthened one health to expand its ethical considerations for animals and the environment for it to be more useful in addressing the current global health challenges and threats (29). one health also needs to harness and promote its growing component – “planetary health” (30); and also consider possibility of integration of principles of ecological economics and pluralist economic thinking (31). going forward the author (george r. lueddeke) has rightly put it that there is a need to put efforts in “shaping the society for a sustainable future and address the ongoing dangers such as endless new weapon systems; growing antagonism among nations; the poison in our politics; and climate change”; this is the time to stop and take concrete actions. the war between russia and ukraine is more than an alarm that our future is in great danger. ongoing wars and armed conflicts will exacerbate inequalities and affect the chances for the world (and affected countries) to achieve the sdgs. we need to keep focus on children, youths, and women by involving them in all actions for addressing climate change and achieving a green, healthy and just transition, while avoiding war and upholding peace. in this, there is a room for bringing in psychologists to assist us with “the language of the psychology of survival” in what is referred to as “planetary psychology to try to address the planetary context of the individual psyche” (32). also, community involvement, e.g., by recognising and establishing a variety of trusted community members as change agents and involving populations in marginalized positions in climate action will help to ensure we have a just transition towards sustainable development. to this end, we need to work on strengthening efforts to track effects of climate change on human health and the environment so that we can design effective strategic interventions (33). global food systems must be strengthened, and further studies need to be done drawing on lessons from various disruptions (including covid-19; and the russia and ukraine war) taking into account roles of social scientists including economists (34). there is also a need for equipping next generation of public health professionals with knowledge and skills necessary for addressing the climate challenge (as an important competency for them) (35). ministries responsible for health in various countries need to take concrete actions that will improve health and equity, following example from actions put forward by the united states’ department of health and human services after participating in the cop26 (36). growing hate behaviour in various countries leading to violence such as gun eliakimu es, mans l. taking up from cop26 going forward: contribution of the book “survival: one health, one planet, one future by george r. lueddeke” (commentary) seejph 2022, posted: 16 december 2022. doi: 10.11576/seejph-6119 p a g e 7 | 11 violence in united states of america (37), point to a gloomy future if we are not able to address the situation. also, racism is becoming a threat to wellbeing of clients of health facilities as it may affect the quality of services provided (38). as put forward by bailey, et al, (2021), there is a need for tackling racism by focusing on structural issues (such as laws, rules, and practices) in government structures at all levels, economic systems, and in social and cultural norms (39). in order to address this from the public health perspective, it requires capacitating public health professionals with knowledge and skills on the “critical race theory” to help them in preventing racism in health systems and uphold public health (40). conclusion apart from the challenge of climate change; wars, conflicts, and violence are imminent threats to the wellbeing of humanity and environment. the effects of covid-19 and the russia and ukraine war are likely to have very severe effects on the progress towards attainment of the sdgs targets and implementation of agreed actions to tackle climate change. we suggest future editions of the book to include the following three areas: (i) a critical analysis of the effects of russia and ukraine war and lessons from the perspective of one health and wellbeing approach; (ii) progress in various countries in using the one health approach to address issues that affect the health and wellbeing of population (equity), the environment and ecosystems in general (including global trends in ncds and amr); and (iii) look at the current global governance systems in relation to how they can better function proactively to prevent future wars (interconnected challenges). references 1. covid-19 excess mortality collaborators. estimating excess mortality due to the covid-19 pandemic: a systematic analysis of covid-19-related mortality, 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https://www.medpagetoday.com/surgery/generalsurgery/99022?xid=nl_mpt_dhe_2022-06-02&eun=g1334223d0r&utm_source=sailthru&utm_medium=email&utm_campaign=daily%20headlines%20evening%202022-06-02&utm_term=nl_daily_dhe_dual-gmail-definition https://doi.org/10.1016/j.hjdsi.2022.100630 https://doi.org/10.1056/nejmms2025396 https://doi.org/10.2105/ajph.2022.306846 bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph2014-53 1 editorial e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health jadranka bozikov 1 1 department for medical statistics, epidemiology and medical informatics, andrija stampar school of public health, school of medicine, university of zagreb, zagreb, croatia. corresponding author: jadranka bozikov, phd address: andrija stampar school of public health, rockefeller st. 4, zagreb, croatia; telephone: +38514590101; e-mail: jbozikov@snz.hr conflicts of interest: none. bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph2014-53 2 health has never been an european union (eu) priority like agriculture, research, ecology or food safety and still remains to be first of all, if not exclusively, the responsibility of member states (ms). from the eu perspective, health is the crosscutting policy sector dominated by many other policies, especially by the “hard law” regulations of the internal market. in the preceding two volumes, the south eastern european journal of public health (seejph) published an admirable lengthy article by hans stein and equally splendid supplemented commentary by bernard merkel recounting and evaluating developments of the eu’s health policy from the 1992 maastricht treaty (and even from earlier) to the present-day state and future perspectives (1,2). although health still has very weak basis in the eu legislation, it has evolved from “non-topic” into a key area of the eu economic policy (1), but despite a growing competence “the unfinished story of the eu health policy” is slowly moving from declarative to operational phase in developing framework for circulation of health goods and related items within europe and beyond (2). in his commentary, dr merkel has summarized changes in treaties and other regulations from 1971 (directive on pharmaceuticals and regulation on coordination of social security systems providing rights to health care to workers in other ec countries) through the following milestones: (i) the article 129 of the maastricht treaty that for the first time introduced health although in a very weak manner; (ii) the 1997 treaty of amsterdam that extended the public health article and introduced the new one (article 152) including for the first time a few specific areas related to blood and organs, some veterinary and phytosanitary areas and other things, and; (iii) finally, the 2007 lisbon treaty with inclusion of medicinal products and medical devices but also incorporating the charter of fundamental rights of the eu including the right to access health care (preventive and curative, article 35 of the charter) (3). having in mind also the common currency introduced and spreading since 1999, the conclusion that single market will finally have an impact on health and health policy stands up. on the other hand, charter of fundamental rights of the eu (proclaimed in the year 2000 but being put in the new legal environment since it became formally binding by the lisbon treaty in 2009) has declared in its article 35 in addition that “a high level of human health protection shall be ensured in the definition and implementation of all union policies and activities” prior than this principle became known as health in all policies (hiap) during the finish eu presidency in 2006. according to what has been mentioned above, population health and organization of health system (including health insurance) has always been and remains a national responsibility. at the same time, the eu member states (as well as accession candidates and potential candidates) were shaping their health policies, implementing activities and monitoring systems directed by recognized international organizations such as who and oecd (and, more recently, the eu) and also used their support in responding to health threats from communicable diseases and disasters, as well as in combating the growing burden of non-communicable diseases. finally, single market principles are going to enter health sector somehow through “backdoor” via instruments such as directive 2011/24/eu on the application of patients’ rights in cross-border healthcare that came into force on 25 th october 2013 (4), up to now without a great success, but with potential to improve access to healthcare services and harmonize their quality within the eu member states and push them to cooperate closer in establishing of health networks in order to meet patients’ expectations. another very important opportunity for european integration is influencing and penetrating health sector from a much broader perspective of fast developing communication technologies. bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph2014-53 3 a digital agenda for europe initiative was selected as one of the seven flagship initiatives supposed to be crucial for obtaining the targets of europe 2020 strategy for smart, sustainable and inclusive growth (5). the adoption of europe 2020 strategy in 2010 was followed by “ehealth action plan 2012-2020” (6), a new one after the previous adopted in 2004 (7), and “a digital single market strategy” for europe which was adopted in may 2015 after the new european commission elected in 2014 set up ten priority policy areas in its agenda for jobs, growth, fairness and democratic change including the priority to create “a connected digital single market” listed as no. 2 priority by jean-claude juncker in his opening statement speech before the european parliament delivered on the 15 th of july 2014 (8,9). it is expected that the creation of digital single market will enable the creation of new jobs, notably for younger jobseekers, and a vibrant knowledge-based society. enhancement of the use of digital technologies and online services was proclaimed as a horizontal policy, covering all sectors of the economy, as well as the public sector including health, and common european data protection rules were seen as a necessary prerequisite. facts about the “digital agenda for europe initiative and digital single market (dsm) strategy” are available at the respective web-site (10), where we can also find new information and follow developments and public consultations on selected topics of interest. the “digital agenda for europe initiative” proposes to better exploit the potential of information and communication technologies (icts) in order to foster innovation, economic growth and progress. it consists of the following seven pillars: i. digital single market ii. interoperability & standards iii. trust & security iv. fast and ultra-fast internet access v. research and innovation vi. enhancing digital literacy, skills and inclusion vii. ict-enabled benefits for eu society a “digital single market” (dsm) is one in which the free movement of persons, services and capital is ensured and where individuals and businesses can seamlessly access and exercise online activities under conditions of fair competition, and a high level of consumer and personal data protection, irrespective of their nationality or place of residence. at (10) we can find definitions of e-health and m-health as well as information on what is going on in digital society including the public consultations launched on respective topics. information and communication technology for health and wellbeing (e-health) is becoming increasingly important to deliver top-quality care to european citizens and includes informatisation of health care systems at all levels (from local through institutional and regional to european and global level including use of tele-consultations and telemedicine. mobile health (m-health) is a sub-segment of e-health and covers medical and public health practice supported by mobile devices. it especially includes the use of mobile communication devices for health and wellbeing services and information purposes, as well as mobile health applications. particularly important are policies for healthy and active ageing with help of ict and use of mobile applications for health and wellbeing including home care monitoring devices (wired and mobile). there are already more than 100,000 applications for health, fitness and wellbeing obtainable for different mobile platforms, the majority of which are designed for apple ios and android smart phones. bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph2014-53 4 the european commission often consults with stakeholders on a number of subjects and such consultations can be found on the pages of digital agenda for europe (10). the commission launched a public consultation on the green paper on mobile health (11) on 10th of april 2014. the green paper on mobile health covered broad scope of m-health potential for both, healthcare and market. main potential for healthcare are seen in (i) increased prevention and quality of life approach, (ii) more efficient and sustainable healthcare, and (iii) more empowered patients. having in mind that the healthcare systems’ organization is a national competence green paper focused on cross-border european-wide issues and on possible coordinated actions at eu level that could contribute to the scale-up of m-health in europe by putting 11 issues at stake: 1. data protection, including security of health data 2. big data 3. state of play on the applicable eu legal framework 4. patient safety and transparency of information 5. m-health role in healthcare systems and equal access 6. interoperability 7. reimbursement models 8. liability 9. research and innovation in m-health 10. international cooperation 11. access of web entrepreneurs to the m-health market the commission also published a staff working document on the existing eu legal framework applicable to lifestyle and wellbeing apps, aiming at providing simple guidance to application developers on eu legislation in the field (12) and invited the views of stakeholders like:  regional and national authorities e.g. health ministries, authorities dealing with medical devices/data protection  health professionals, carers, health practitioners, medical associations  consumers, users of m-health apps, patients and their associations  web entrepreneurs  app developers and app stores  manufacturers of mobile devices  insurance agencies  sports centres, health clubs, and the like. consultation was open for more than three months during which stakeholders responded to 23 questions on a wide range of themes: data protection, legal framework, patient safety and transparency of information, m-health role in healthcare systems and equal access, interoperability, reimbursement models, liability, research & innovation, international cooperation and web entrepreneurs’ market access. a total of 211 responses were received and summarized in the published report (13). besides the great potential for health and wellbeing, there are some concerns, as well. the safety of mobile health solutions (and of some lifestyle and wellbeing applications, too) is a main cause for concern, explaining the potential lack of trust. there are reports pointing out that some solutions do not function as expected, and may not have been properly tested or in some cases may even endanger people’s safety. that is why on both sides of the atlantic, regulations for medical devices including software applications are established and continuously updated (14-16). it is beyond the scope of this article to discuss the importance bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph2014-53 5 and the need of certification of e-health and m-health devices and software, but health professionals must carefully take this issue into account and stick to guidelines and recommendations issued by regulatory agencies and bodies as those cited. undoubtedly, e-health and m-health have a large potential for health and wellbeing through empowering of patients and enabling them to take responsibility for their own health while reducing the ever-growing healthcare costs. at the same time, health professionals and students need to be educated and trained to evaluate such applications or at least to take into account their limitations. my personal experience has shown that medical students are capable to test m-health applications and understand the need for validation and certification of such applications. they successfully prepared a seminar in medical informatics using their own smart phones. within the same course students received assignments to read, understand and present eu directives, charters and other documents (e.g. 3,4,6,11,14,16) in order to become acquainted with the european integration in health. health systems in the eu are facing the common challenge of a rise in chronic diseases as a consequence of our increasingly ageing population. vytenis andriukaitis, the eu commissioner for health and food safety, entitled his column in august 2015 issue of the european journal of public health “how the ehealth can help with europe’s chronic diseases epidemic” (17). quotes from this article are presented below: “as a former medical doctor, i am fascinated with innovative solutions that are part of today‟s medical toolbox. i would like to highlight ehealth in particular. the more i learn about ehealth, the more convinced i am that it can enable better health, better and safer care for citizens and more efficient and sustainable healthcare systems. ehealth and mhealth can deliver more tailormade, „citizen-centric‟ care, more targeted and effective therapies, and help reduce medical errors.” good to hear that ehealth network has adopted the guidelines on electronic prescriptions needed for their cross-border exchange and progress in interoperability: “although the deployment of ehealth is the responsibility of member states, the eu adds value in many ways. the ehealth network set up under the cross-border health care directive provides a forum for cooperation, support and guidance for speeding up the broad use of ehealth services and solutions. facilitating interoperability and safe and efficient handling of electronic health data across national and organizational boundaries is a key issue. the ehealth network has already adopted guidelines on cross-border exchange of patient summaries and prescriptions. these guidelines encourage the adoption of ehealth applications at national level.” guidelines on eprescriptions dataset adopted by ehealth network (18) are intended to be complementary to the commission implementing directive 2012/52/eu of 20 december 2012 laying down measures to facilitate the validation of medical prescriptions issued in another member state (19), but also as another document for implementation in the near future. references 1. stein h. the maastricht treaty 1992: taking stock of the past and looking at future perspectives. seejph 2014; posted: 23 december 2014. doi 10.12908/seejph-2014-36. 2. merkel b. a growing competence: the unfinished story of the european union health policy (commentary). seejph 2015, posted: 15 june 2015. doi 10.12908/seejph-201449. 3. charter of the fundamental rights of the european union. (2000/c 364/01). available at: http://www.europarl.europa.eu/charter/pdf/text_en.pdf (accessed: september 29, 2015). http://www.europarl.europa.eu/charter/pdf/text_en.pdf bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph2014-53 6 4. directive 2011/24/eu of the european parliament and of the council of 9 march 2011 on the application of patients’ rights in cross-border healthcare. available at: http://eurlex.europa.eu/lexuriserv/lexuriserv.do?uri=oj:l:2011:088:0045:0065:en:pdf (accessed: september 29, 2015). 5. europe 2020 a strategy for smart, sustainable and inclusive growth. available at: http://eur-lex.europa.eu/legal-content/en/txt/pdf/?uri=celex:52010dc2020 (accessed: september 29, 2015). 6. e-health action plan 2012-2020 innovative healthcare for the 21st century. available at: http://ec.europa.eu/health/ehealth/docs/com_2012_736_en.pdf (accessed: september 29, 2015). 7. e-health making healthcare better for european citizens: an action plan for a european ehealth area. available at: http://eurlex.europa.eu/lexuriserv/lexuriserv.do?uri=com:2004:0356:fin:en:pdf (accessed: september 29, 2015). 8. a digital single market strategy for europe. available at: http://ec.europa.eu/priorities/digital-single-market/docs/dsm-communication_en.pdf (accessed: september 29, 2015). 9. juncker jc. a new start for europe: my agenda for jobs, growth, fairness and democratic change. political guidelines for the next european commission, july 15, 2014, strasbourg. available at: http://ec.europa.eu/priorities/docs/pg_en.pdf (accessed: september 29, 2015). 10. digital agenda for europe. a europe 2020 initiative. available at: https://ec.europa.eu/digital-agenda/en/digital-agenda-europe-2020-strategy (accessed: october 02, 2015). 11. green paper on mobile health (“mhealth”). available at: https://ec.europa.eu/digitalagenda/news-redirect/15512 (accessed: october 02, 2015). 12. commission staff working document on the existing eu legal framework applicable to lifestyle and wellbeing apps. accompanying the document green paper on mobile health (“mhealth”). available at: http://ec.europa.eu/newsroom/dae/document.cfm?doc_id=5146 (accessed: october 02, 2015). 13. summary report on the public consultation on the green paper on mobile health. available at: http://ec.europa.eu/newsroom/dae/document.cfm?doc_id=8382 (accessed: october 02, 2015). 14. fda. mobile medical applications. guidance for industry and food and drug administration staff. document issued on february 9, 2015. available at: http://www.fda.gov/downloads/medicaldevices/.../ucm263366.pdf (accessed: september 29, 2015). 15. fda. medical devices data systems, medical image storage devices, and medical image communications devices. guidance for industry and food and drug administration staff. document issued on february 9, 2015. available at: http://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidancedocu ments/ucm401996.pdf (accessed: september 29, 2015). 16. ec. dg health and consumer. guidelines on the qualification and classification of standalone software used in healthcare within the regulatory framework of medical devices (meddev 2.1/6 january 2012). available at: http://ec.europa.eu/health/medicaldevices/files/meddev/2_1_6_ol_en.pdf (accessed: september 29, 2015). 17. andriukaitis v. how ehealth can help with europe's chronic diseases epidemic. eur j public health 2015;25:748-50. http://eur-lex.europa.eu/lexuriserv/lexuriserv.do?uri=oj:l:2011:088:0045:0065:en:pdf http://eur-lex.europa.eu/lexuriserv/lexuriserv.do?uri=oj:l:2011:088:0045:0065:en:pdf http://eur-lex.europa.eu/legal-content/en/txt/pdf/?uri=celex:52010dc2020&from=hr http://ec.europa.eu/health/ehealth/docs/com_2012_736_en.pdf http://ec.europa.eu/priorities/digital-single-market/docs/dsm-communication_en.pdf http://ec.europa.eu/priorities/docs/pg_en.pdf https://ec.europa.eu/digital-agenda/en/digital-agenda-europe-2020-strategy%20(2 https://ec.europa.eu/digital-agenda/news-redirect/15512 https://ec.europa.eu/digital-agenda/news-redirect/15512 http://ec.europa.eu/newsroom/dae/document.cfm?doc_id=5146 http://ec.europa.eu/newsroom/dae/document.cfm?doc_id=8382 http://www.fda.gov/downloads/medicaldevices/.../ucm263366.pdf bozikov j. e-health and m-health: great potentials for health and wellbeing, but also for harmonization and european integration in health (editorial). seejph 2015, posted: 06 october 2015. doi 10.12908/seejph2014-53 7 18. guidelines on eprescriptions dataset for electronic exchange under cross-border directive 2011/24/eu. release 1. adopted by ehealth network. available at: http://ec.europa.eu/health/ehealth/docs/eprescription_guidelines_en.pdf (accessed: september 29, 2015). 19. commission implementing directive 2012/52/eu of 20 december 2012 laying down measures to facilitate the recognition of medical prescriptions issued in another member state. available at: http://ec.europa.eu/health/cross_border_care/docs/impl_directive_presciptions_2012_en.pdf (accessed: september 29, 2015). ___________________________________________________________ © 2015 bozikov; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://ec.europa.eu/health/ehealth/docs/eprescription_guidelines_en.pdf wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 1 original research piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia helmut wenzel 1 , vesna bjegovic-mikanovic 2 , ulrich laaser 3 1 health economic consultant; 2 institute of social medicine, faculty of medicine, university of belgrade, serbia; 3 section of international health, faculty of health sciences, university of bielefeld, germany. corresponding author: helmut wenzel, m.a.s. address: d78464 konstanz, germany; e-mail: hkwen@aol.com wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 2 abstract aim: political decisions usually emerge from the competing interests of politicians, voters, and special interest groups. we investigated the applicability of an advanced methodological concept to determine whether certain institutional positions in a cooperating network have influence on the decision-making procedures. to that end, we made use of the institutional network of relevant health care and health governance institutions, concentrated in belgrade, serbia. methods: we used a principal component analysis (pca) based on a combination of measures for centrality in order to evaluate the positions of 25 players in belgrade‟s institutional network. their directed links were determined by a simulated position approach employing the authors‟ long-term involvement. software packages used consisted of visone 2.9, ucinet 6, and keyplayer 1.44. results: in our analysis, the network density score in belgrade was 71%. the pca revealed two dimensions: control and attractiveness. the ministry of health exerted the highest level of control but displayed a low attractiveness in terms of receiving links from important players. the national health insurance fund had less control capacity but a high attractiveness. the national institute of public health‟s position was characterized by a low control capacity and high attractiveness, whereas the national drug agency, the national health council, and non-governmental organisations were no prominent players. conclusions: the advanced methodologies used here to analyse the health care policy network in belgrade provided consistent results indicating that the intended decentralization of the health care network in belgrade may be incomplete, still with low participation of civil society representatives. with the present study we set the stage for a broad-range surveybased data collection applying the methodology piloted in belgrade. keywords: belgrade‟s health care policy network, policy analysis, serbia, social network analysis, sources of power. conflicts of interest: none. acknowledgments: this work was supported by the ministry of science and technological development, republic of serbia, contract no. 175042. wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 3 introduction political decisions are not primarily the result of scientific (rational) problem solving like e.g. the illustration of the policy cycle suggests (1,2). the decisions usually will emerge from the competing interests of politicians, voters, and special interest groups. the policy literature considers this issue and suggests a variety of frameworks and analytic models for policy analysis (3). the spectrum ranges from the rather normative scientific problem solving approach to a more „incrementalistic‟ way (4). lindblom even calls it „muddling through‟ (5) and finally to the paradigm of „bounded rationality‟ (6,7). analyzing decision outcomes (policies) has to consider the specific organisational structure (policy) and the initiated processes (politics), comparable to donabedian‟s concept of structure and process as a prerequisite of outcome quality (8). related questions are: how will political decision processes possibly influence policy-making (6)? do certain individual or institutional positions in a cooperating network have more or less influence on the decision-making procedures? to explore the complex governmental portfolio of resources, hood et al. (9,10) propose a classification scheme, which gets to the point with only four important sources of power: nodality, authority, treasure and organisation. they state that nodality denotes the property of being in the middle of an information or social network (10). a high degree of nodality gives a player a strategic position from which he allocates information, and which enables him to draw in information. authority is the formal and legitimate official power (11). that is the formal power to demand, forbid, guarantee, and arbitrate. treasure gives the government the ability to exchange goods, using the coin of money or something that has a money-like property. finally, organisation gives to a government the physical ability to act directly, using its own forces (10). with the serbian health insurance act of 2005 (12) the serbian government aimed at reorienting the health care system and transform it into a more decentralised organisation. these changes would hopefully offer to the insured population an opportunity for a greater selfmanagement. as most of the relevant institutions are concentrated in the serbian capital belgrade, we used this example to investigate the applicability of the aforementioned methodological concept. with the disclosure of the players‟ nodalities that make up belgrade‟s health care policy network, we envisaged to analyse to which degree the decentralisation of decision making has progressed since the legislation of 2005, extending our preliminary analysis (13). with the present step we focus on institutional players and their nodality only, without consideration of potentially influential individual players. the analysis of belgrade‟s health policy network is a pilot project appropriate for testing the feasibility of a countrywide survey. this analysis was based on a questionnaire survey. methods to break down the abstract notion of power and influence, different paradigms were used in sociology and political science: reputation approach, decision approach, or position approach (14). for a critical review of the approaches see domhoff (14). in our understanding, influential actors can be best described by the position approach, i.e. a policy network. a policy network is described by its various players public as well as non-governmental their formal and informal connections and the specific boundary of the network under consideration. the links between the players are likely to be understood as communication channels for the exchange of information, expertise, trust and other policy resources (15). depending on the scientific disciplines, e.g. coming from community power research (14), or systems thinking (16,17), various technical approaches and measures have been used to identify, describe and wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 4 analyse formal or informal networks within organisations. necessary data can be collected by means of survey (questionnaires, interviews), observations, or by analysing secondary data. for economic reasons, a heuristic procedure as outlined e.g. by vester (16) or bryson (18) was applied and possible actors [so-called boundary specification (19, p. 77)] were enumerated in a brainstorming session listed in a “cross-impact matrix” of influences (16, p. 188). finally, the strength and direction of their connections was estimated (16, p. 188) by the authors for the purpose of this methodological study. these are “soft data” (16, p. 22), but nevertheless they are based on experience, knowledge of the health care system and observations. as newman points out, collecting data by directly questioning participants (or, players) does not necessarily provide a higher accuracy and is also a laborious endeavour (20). for visualisation of the network and a more in-depth analysis, we recurred to the analytic tools of social network analysis (sna). the concept of nodality corresponds well with the measures used in sna and, basically, two viewpoints are possible: primarily focusing on a specific player (ego-centred) only, and analysing and evaluating the network as a whole, taking all connections and all players into account (socio-centred) (13). on a socio-centred level, the network structure can be described by measuring density and centralization. centralization is defined as the variation in the centrality scores of the nodes or players in the network. this variation shows the extent to which there is a centre i.e., very central players and a periphery i.e., players with very low centrality scores (21). density is a basic network property that reflects the overall intensity of the connected players: the more connected the network, the greater its density. a dense network is one where a lot of activity or a large number of strong ties exist among its members (22). on an ego-centred (individual) level, we focused on the players‟ importance. importance reflects the visibility to other network members (23) and is broken down into indices like influence and prestige. measures of centrality the concept of centrality is a crucial aspect when representing policy networks (24). centrality measures will identify the most prominent players. these are the players who are extensively involved in relationships with other network members (25) without necessarily discriminating between formal or informal links (depending on the data collection approach). the most frequently centrality measures used include degree centrality, betweenness centrality, and closeness centrality. they reflect the view that information is transferred along the shortest pathways (26). degree centrality is an indicator of expertise and is measured by the sum of all other players who are directly connected to a specific player (25). asymmetric networks are particular in that the distinction between indegree-centrality and outdegree-centrality has to be taken into account (13). players receiving many ties (indegree) have a high prestige (23). players with a high flow of outgoing connections (outdegree) are able to exchange with many others, or at least make others aware of their views (13). this means that players with a high outdegree centrality are said to be influential players (27). betweenness centrality counts how many times a player connects other players, who otherwise would not be able to reach one-another (25). it measures the potential for control, because a player who shows a high betweenness degree will be able to operate as a gatekeeper by controlling the flow of resources between the other nodes that are connected through him (25) on shortest paths (28). wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 5 closeness centrality is based on the concept of distance. a player who is close to all others in the network, e.g. having a distance of no more than one, is not dependent on any other to reach everyone in the network (25). closeness centrality measures independence or efficiency (25). in the context of sna, efficiency means that the higher the closeness centrality of a node, the shorter is its average distance to any other node, thus indicating a better position for spreading information (29). further centrality measures are hub function and authority. in directed networks, players that have important resources should get a high centrality score too. newman defines it as follows: “authorities are nodes that contain useful information on a topic of interest; hubs are nodes that tell us where the best authorities are to be found” (30, p. 179). in the framework of sna, formal authority has to be differentiated from informal authority (11). hubs are enablers of effective knowledge transfer (31, p. 225). a high hub player points to many important authorities (high outdegree) whereas a high authority player receives ties from many important hubs (high outdegree). they can effectively connect different sub-groups of the network and facilitate knowledge flows; removing them from the network can lead to its fragmentation (31, p. 225). study setting for investigating the applicability of the methodological concept we chose a position approach as it best describes the potential of power and influence, combined with a heuristic data collection. to that end, the authors all well informed about the serbian health care system and the situation in belgrade listed 25 players, identified the links between the players and the perceived strength of their relationship together in an open process. as pointed out earlier (13), the links can point in one direction only (unidirectional), or include both directions (bidirectional). the strength of the relationship was rated on a scale ranging from 0 to 4. very weak links with a value of 1 were put on a level with 0 for “no link” (13). the rating of the links reflects the averaged assessment of the authors. the resulting “cross-impact matrix” was exported to visone 2.9 (15) for further analysis. in some cases where the analytic toolset of visone 2.9 did not provide the calculation of specific indices, we used ucinet 6 (32), and keyplayer1.44 (33) instead. to visualise the analytical findings in an easily understandable format, we chose the design of a target diagram, which is also a built-in feature of visone 2.9. in this diagram, the 25 players (nodes) are placed according to their scores. this means that the player with the highest score is positioned in the centre of the diagram; the others, according to their decreasing scores, are moved toward the periphery of the structure, correspondingly. to ensure a largely undisturbed view, the authors of visone 2.9 applied a specialized layout algorithm that aims at minimizing entanglement by reducing the number of crossing lines and occlusions determine the angular location. the different score levels are displayed as thin concentric circles. this allows comparing the scores of the players easily, without looking at the output table (15, p. 17). brandes et al. (15) successfully used these diagrams to analyse local health policies and the underlying structure of the various players, e.g. to disclose the differences in the local drug policy of two german municipalities and the networks of players that form the basis of the policy making. furthermore, to facilitate an overall perspective (holistic view) of the indices applied, we merged the results with the help of a principle component analysis (pca) diagram. pca is a multivariate data analysis method which is used to reduce complexity by transforming a set of possibly correlated variables into a set of uncorrelated variables, wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 6 i.e., principal components (34,35). this approach explains best the variance of data and helps to reveal the internal structure of the data. results the network matrix was composed by 25 players and 158 directed and valued links or connections as determined for the purpose of this methodological study by the authors. the network density was calculated as 71% realized links out of all possible ones. a density greater than 50% is considered high (36). therefore, we assumed here that the players in belgrade were well connected. for valued networks (see figure 1), the centralization score has to be calculated separately for outdegree and indegree centrality. the outdegree score here was 46.3% of all possible connections, whereas the indegree score was 19.1% (calculated with ucinet 6). this would disclose a distinct centralisation. however, the range of outdegree scores was larger than that of indegree scores, and the players showed a higher variability. the coefficient of variation was 93% for outdegree and 54% for indegree centrality, indicating that the network was less homogeneous with regard to outdegree centrality, or influence (27). the possible influence of the players in the network varied largely, i.e., the positional advantages were rather unequally distributed. the most important players – identified in terms of degree centrality (figure 1a and table 1) were the national health insurance fund [1], the ministry of health [15], the national government [14], and the medical faculty, belgrade [22]. the health insurance fund [1] received most of the strongest [blue] links. the players with the highest indegree centrality or wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 7 prestige were the clinical hospital centres, belgrade [8], the institute of public health, belgrade [4], the national health insurance fund [1], and the clinical hospital centre of the republic [7]. players with the highest outdegree centrality or influence were the national government [14], the ministry of health [15], the medical faculty, belgrade [22], the state revisor [18], and the national health insurance fund [1]. table 1. ranking of players by centrality indices (based on percentages – for the numeric codes, see table 3 in the annex) indices of centrality degree centrality indegree centrality outdegree centrality betweenness closeness hub function authority 1 8 14 8 14 14 3 15 4 15 15 15 15 8 14 1 22 22 18 18 4 22 7 18 7 22 1 7 7 3 1 19 19 22 23 8 5 17 1 7 17 1 18 6 7 20 1 20 25 5 23 20 11 20 7 9 4 25 19 23 23 11 2 17 9 11 5 17 19 10 19 15 23 6 11 5 15 20 23 8 9 16 23 6 23 2 5 23 8 8 23 6 10 16 18 10 10 5 11 22 9 12 3 9 13 3 12 6 17 9 16 17 23 19 10 3 23 6 16 9 13 4 4 21 2 19 25 17 2 10 12 4 12 2 11 12 2 5 23 22 10 20 21 14 6 21 20 12 16 23 16 2 12 11 16 21 3 21 4 3 21 13 18 25 25 25 25 18 21 14 13 13 13 13 14 with respect to the betweenness centrality, the clinical hospital centres, belgrade [8] were the most central players. the ministry of health [15], the medical faculty, belgrade [22], the clinical hospital centre of serbia [7], and the serbian physicians society [19] seemed to be very close to each-other, but located more to the margin. players with a high degree of closeness were the national government [14], the ministry of health [15], the state revisor [18], the medical faculty, belgrade [22], and the serbian physicians society [19]. the picture changed when we looked at hub functions. as pointed out, hubs are enablers of effective knowledge transfer, they can effectively connect different sub-groups of the network and facilitate knowledge flows; removing them from the network can lead to its fragmentation (31, p. 225). considering the hub function, the national government [14] was in the most wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 8 favourable position (see figure 1b), followed by the ministry of health [15]. the national health insurance fund [1] moved more to the periphery indicating a loss of importance for knowledge transfer. the state revisor [18] and the mof budget inspection [17] also moved more to the centre of the diagram. as hannemann and riddle note, the question of how structural positioning implicates power is still a matter of research and debate (34). to reduce the complexity, eventually sort out redundant information and get an integral view, we applied pca which is displayed in table 2 and figure 2. table 2. contribution of centrality measures to the dimensions of the pca (percentages) centrality measures d1 (control) d2 (attractiveness) degree 22.645 3.186 indegree 0.159 40.837 outdegree 22.820 3.876 betweenness 12.246 7.907 closeness 19.822 3.205 hub function 21.654 3.607 authority 0.654 37.381 the pca provides evidence of two dimensions (figure 2); they explain 88.81% of the data. the first dimension consists of degree, outdegree, closeness, and hub function. the second dimension consists of indegree and authority. the first dimension d1 represents the capacity for “control”; the second dimension d2 depicts what we called “attractiveness”. the main players: the ministry of health [15] apart from the formal aspect i.e. legal authority and organisation was highly ranked on the first dimension of control. on the second dimension of attractiveness, it was ranked just above the average. this picture was confirmed in the classification by hub function and authority. the ministry of health was a hub as well as an authority in this analysis, whereas the hub feature was more pronounced. this would mean that it was connected to many popular players and received links from important players. the national government [14] was likewise highly ranked on the first dimension, but showed the lowest score on the second dimension. this means that control was high but the attractiveness was low. on the other hand, the national government [14] was also a hub, which means that it was connected to many very important players, and its influence might be based on this feature, primarily. the national health insurance fund [1] showed less potential of control [first dimension] than the ministry of health [15], but had a higher score on the attractiveness axis [second dimension]. the national health insurance fund [1] was a hub and an authority too. the hub score was lower than that of the ministry of health or the national government, but its authority score was very pronounced. this means, its authority feature receiving links from important players – in our pilot study was more important. according to this analysis, effective decentralisation would require more autonomy for institutions like the national institute of public health [3], the national drug agency [10], the national health council [13], and non-governmental organisations [21], all ranking with the exception of the national institute of public health [3] towards the end in table 1 and low on both dimensions in figure 2. but, also the chambers of health professionals [11, 12] could play a more important role as well as the trade unions [20] and the branches of the national health insurance fund [2]. wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 9 figure 2. the position of players by two dimensions legend: the yellow triangles mark the national government and the ministry of health; the green diamonds signify the players focussed in the analysis; the blue circles represent the remaining players. for the numeric codes, see table 3 in the annex. the national institute of public health [3] ranked below average on the first dimension (control) and was positioned above average on the second dimension (attractiveness) that is players were seeking contact. its high authority score confirmed this, but as a hub it ranked very low (table 1). according to borgatti, such players are primarily mediators (37). discussion it is a widespread view in the literature that no single or generally accepted method for measuring decentralization exists (38); there are many different definitions, understandings of the concepts and diverse measurement instruments (39). thus, measuring centralization or decentralization is mostly based on analyzing the financial autonomy or regulatory mechanisms (39,40). independent of the underlying “intellectual tradition” (41), disciplinary and language differences, and the way the various indices were constructed, these approaches focus on formal aspects. informal ways of influence and power are not taken into account. however, these informal relationships may superimpose the formal balance of power, supporting or even hindering structural changes or specific policy-making, and possibly will underestimate the real balance of power. the concept of nodalities, used here, is based on relationships (links). these links cannot only indicate subordination but can also stand for information 14 15 18 1 22 17 20 7 11 19 5 23 8 10 9 16 6 2 4 24 21 12 3 25 13 -2 -1.5 -1 -0.5 0 0.5 1 1.5 2 2.5 -2.5 -2 -1.5 -1 -0.5 0 0.5 1 1.5 2 2.5 d 2 a tt r a c ti v it y ( 3 3 .4 % ) d1 control (55.4 %) observations (axes d1 and d2: 88.81 %) after varimax rotation wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 10 channels. insofar, mapping the nodalities, is complementary to the approaches mentioned above and will round off the picture. compared to other european countries, serbia is among the most centralized systems (42). it ranks second on a list of thirteen countries (38). the analysis of the degree and appropriateness of decentralization, however, is not an end in itself. it is a means to achieve a broader spectrum of goals (43) or, more generally speaking, it is an important component of good governance (38). very often it is emphasized that decentralization is a very significant step in promoting democracy (44,45). with decentralization essential goals should be achieved, such as effectiveness and efficiency, fairness, quality, financial responsibility, and respect for local preferences (43,45). decentralization is one of the most important issues on the agenda of health care reform in many countries. however, there is little information from research that can show the likely correlation between the degree of centralization and health outcomes, i.e. the health of the population (40). furthermore, observations and case studies indicate that, if inadequately planned, and implemented, i.e. too rapidly or inconsistently, decentralization can have serious consequences on the provision of health services to the population (43). for that reason, appropriate planning, and considering corresponding experiences in other countries, may prevent disappointment and slow-down of processes. decentralization also will shift the role of the ministry of health, from direct management and decision making toward formulating health care policies, technical counselling and assistance, as well as monitoring and evaluation of programmes and activities. decentralization represents the transfer of authority and responsibility for public functions from the central to subordinate levels and/or to the private sector (43,45). the essential task, then, is to define the adequate level of decentralization (45) by entities, i.e., regions, districts, and municipalities, and by appropriate forms of bureaucratic autonomy, i.e. deconcentration, delegation, and devolution. any consideration on whether decentralization is necessary and how much will be feasible has to undergo a detailed examination in the context of a (rational) organisational structure (46); this is very often perceived a common place, and ignored with associated consequences. certain aspects of decentralization deserve closer attention. for example, the possibility of local authorities to adapt to local conditions should be carefully balanced against a common vision and the goals of the health care system (4). for this reason, the policy of decentralization should include mechanisms of coordination, since the local political interests grow as more responsibilities are transferred to that level (47). furthermore, decentralization bears the risk of fragmenting responsibility for different types of health care (specialist hospitals, general hospitals, primary care etc.) between the levels of regional and municipal government (43). in this context, it is indicative that the coordinative and integrative potential of the national health council of serbia [13] seemingly is not used. this body could include non-governmental organisations [21] in the field of health, as well as trade union representatives from the most important health institutions. the limitations of our approach relate to its validity and reliability. a valid model has to be isomorphic, thus representing a true picture of the system to be modelled. the level of isomorphism can be disclosed in analogy to the revision of „validity of structure and processes‟ (48), or „expert concurrence‟ (49). however, in this study the boundaries and the links remain to be crosschecked as a next research step, especially as the present dataset relies only on the author‟s evaluation of the situation. missing data, i.e., the absence of players and/or links can also have an important impact (50,51) on the „application validity‟. another criticism that raised concerns relates to the shortest paths-based measures as they do not take into account wenzel h, bjegovic-mikanovic v, laaser u. piloting an advanced methodology to analyse health care policy networks: the example of belgrade, serbia (original research). seejph 2015, posted: 27 july 2015. doi 10.12908/seejph-2014-52 11 diffusion along non-shortest paths (52). however, the modelling algorithms used here are consistent with validated standard computer software. in order to challenge the appropriate level and structure of a health care system and to control any process of reorganisation, it is essential to be fully familiar with the positive interaction of the various players. in this context, it is an important cornerstone to know the nodality of the health care network, in our example that of belgrade hosting most of the national health institutions. the network depicted would also provide a basis for what-if-scenarios to anticipate the likely effects of intended changes. furthermore, the methodology used for the network and its description, which examines the system from a relatively high level (bird‟s eye view), can be adapted to 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national health insurance fund 2 nhif, belgrade branch 3 national institute of public health 4 institute of public health, belgrade 5 secretary for health, belgrade 6 primary health care centres (17), belgrade 7 clinical hospital centre of serbia 8 clinical hospital centres (4), belgrade 9 national accreditation agency 10 national drug agency 11 national chambers of health professionals 12 chambers of health professionals, belgrade branches 13 national health council 14 national government 15 ministry of health 16 ministry of finance 17 mof budget inspection 18 state revisor 19 serbian physicians society 20 trade unions 21 non-governmental organisations 22 medical faculty, belgrade 23 council of the medical faculty, belgrade 24 special hospitals, belgrade 25 tertiary medical institutes, belgrade ___________________________________________________________ © 2015 wenzel et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. south eastern european journal of public health volume vii, 2017 genc burazeri, ulrich laaser, jürgen breckenkamp, jose m. martin-moreno, peter schröder-bäck(eds.) jacobs verlag south eastern european journal of public health genc burazeri, ulrich laaser, jürgen breckenkamp jose m. martin-moreno, peter schröder-bäck. executive editor genc burazeri (tirana, albania and maastricht, the netherlands) faculty of medicine rr. “dibres”, no. 371 tirana, albania phone: 0035/5672071652 skype: genc.burazeri assistant executive editors florida beluli, ervin toci, kreshnik petrela, all at: faculty of medicine rr. “dibres”, no. 371 tirana, albania editors jürgen breckenkamp, faculty of health sciences, university of bielefeld, germany (2016). genc burazeri, faculty of medicine, tirana, albania and department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands (2013). ulrich laaser, faculty of health sciences, university of bielefeld, germany (2013). jose m. martin-moreno, school of public health, valencia, spain (2013). peter schröder-bäck, department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands (2014). regional editors suzanne m. babich, associate dean of global health and professor, health policy and management, at the indiana university richard m. fairbanks school of public health in indianapolis, indiana, usa, for north america. samir n. banoob, president, intenational health mangement, tampa, florida, usa, for the middle east. evelyne de leeuw, free lance health consultant, sydney, australia, for the western pacific region. damen haile mariam, university of addis ababa, ethiopia, for the african region. charles surjadi, faculty of medicine, atmajaya university, jakarta, indonesia, for the south east asian region. laura magana valladares, secretaria académica, instituto nacional de salud pública, mexico, mexico, for latin america. advisory editorial board tewabech bishaw, african federation of public health associations (afpha), addis ababa, ethiopia jadranka bozikov, department for medical statistics, epidemiology and medical informatics, andrija stampar school of public health, school of medicine, university of zagreb, zagreb, croatia. helmut brand, department of international health, caphri, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands. patricia brownell, fordham university, new york city, new york, usa. franco cavallo, department of public health and paediatrics, school of medicine, university of torino, torino, italy. doncho donev, institute of social medicine, faculty of medicine, university “ss cyril and methodius”, skopje, macedonia. mariana dyakova, university of warwick, faculty of public health, united kingdom. florentina furtunescu, department of public health and management, university of medicine and pharmacy "carol davila", bucharest, romania. andrej grjibovski, norwegian institute of public health, oslo, norway and school of public health, arkhangelsk, russia motasem hamdan, school of public health, al-quds university, east jerusalem, palestine. mihajlo jakovljevic, faculty of medical sciences, university of kragujevac, kragujevac, serbia. aleksandra jovic-vranes, institute of social medicine, medical faculty, belgrade university, serbia. ilona kickbusch, graduate institute of international and development studies, geneva, switzerland. mihali kokeny, free lance consultant, budapest, hungary. dominique kondji, cameroon public health association, douala, cameroon. giuseppe la torre, department of public health and infectious diseases, university sapienza, rome, italy. oleg lozan, school of public health management, chisinau, moldova. george lueddeke, consultant in higher and medical education, southampton, united kingdom. izet masic, university of sarajevo, sarajevo, bosnia and herzegovina. martin mckee, london school of hygiene and tropical medicine, london, united kingdom. bernhard merkel, visiting research fellow, london school of hygiene and tropical medicine, london, uk. naser ramadani, institute of public health, prishtina, kosovo. enver roshi, school of public health, university of medicine, tirana, albania. maria ruseva, south east european health network (seehn), sofia, bulgaria. fimka tozija, institute of social medicine, faculty of medicine, university “ss cyril and methodius”, skopje, macedonia. theodore tulchinsky, hadassah–braun school of public health and community medicine, jerusalem, israel. lijana zaletel-kragelj, faculty of medicine, university of ljubljana, ljubljana, slovenia. publisher dr. hans jacobs (lage, germany) editorial office jacobs verlag hellweg 72 d 32791 lage germany email phone: 0049/5232/979043 fax: 0049/05232/979045 mailto:info@jacobs-verlag.de� seejph south eastern european journal of public health www.seejph.com/ volume vii, 2017 genc burazeri, ulrich laaser, jürgen breckenkamp, jose m. martin-moreno, peter schröder-bäck (eds.) publisher: jacobs/germany issn 2197-5248 jacobs verlag http://www.seejph.com/� issn2197-5248 doi 10.4119/unibi/seejph-2016-174 bibliographic information published by die deutschebibliothek. die deutsche bibliothek lists this publication in the deutsche nationalbibliografie; detailed bibliographic data is available on the internet at http://dnb.ddb.de south eastern european journal of public health (open access journal) copyright 2016 by jacobs publishing company hellweg 72, 32791 lage, germany copyright cover picture: wordpress foundation: http://wordpressfoundation.org/gnu general public license http://dnb.ddb.de/� http://wordpressfoundation.org/gnu� table of contents page editorial the mark of women’s leadership on solutions to global health problems 1-3 valia kalaitzi original research ethnic differences in smoking behaviour: the situation of roma in eastern europe 4-16 laetitia duval, françois-charles wolff, martin mckee, bayard roberts the relevance of ethics in the european union’s second public health programme 17-35 nelly k. otenyo trajectories of life satisfaction during one-year period among university students: 36-47 relations with measures of achievement strategies and perception of criteria for adulthood giovanni piumatti review articles nurses’ roles, knowledge and experience in national disaster pre-paredness and emergency 48-66 response: a literature review thomas grochtdreis, nynke de jong, niels harenberg, stefan görres, peter schröder-bäck the emerging public health legislation in ukraine 67-75 iryna senyuta short reports protecting the planet and sustainable development 76-82 laura h. kahn socio-demographic factors and selected clinical characteristics of patients with retinal 83-90 occlusions in transitional albania manushaqe rustani-batku, ali tonuzi kalaitzi v. the mark of women’s leadership on solutions to global health problems (editorial). seejph 2016, posted: 07october2016. doi: 10.4119/unibi/seejph-2016-131 1 editorial the mark of women’s leadership on solutions to global health problems valia kalaitzi1 1department of international health, school for public health and primary care (caphri), faculty of health, medicine and life science, maastricht university, maastricht, the netherlands. corresponding author: valia kalaitzi, msc, phdc; address: 25 vas sofias, 10674 athens greece; telephone: +30 6932285055; e-mail: valiakalaitzi@maastrichtuniversity.nl mailto:valiakalaitzi@maastrichtuniversity.nl� kalaitzi v. the mark of women’s leadership on solutions to global health problems (editorial). seejph 2016, posted: 07october2016. doi: 10.4119/unibi/seejph-2016-131 2 “man is the measure of all things”, stated protagoras in 485 bc (1). maybe it’s time to add women to that equation and adapt protagoras’ saying into:“women who are leaders are the measure of global health challenges”. what protagoras meant, of course, was that man is the point of reference, the centre of universe; he adjusts his world to fit his needs. in other words, man has the ability to shape his living conditions, the environment and solutions to the challenges in life. in that sense, the challenges are managed according to the terms and conditions of man. indeed, global health challenges of the 21st century are widespread. they are many, and they are of great magnitude. world health leaders are challenged by crises such as polio, zika virus, and h1ni, to mention a few. many health systems around the world have been challenged to respond effectively to these crises, spotlighting major gaps in worldwide surveillance, disease control, resources, and infrastructure required to protect and support the public’s health. the economic crisis that affected europe has been linked to several infectious disease outbreaks including tb and hiv, compounded by recent waves of migration, although the links between these events remain unclear (2). debates ensue about the value and feasibility of universal health coverage, the increasing role of the private sector in the global health landscape and the subsequent changing roles of global health actors that shape the new health economy. these are complex times, and they require skilful players if we hope to translate public and private sector investments in health into both economic growth and equitable improvements in health. such goals require inspired, inclusive, and effective leadership. these very traits are the hallmark of women’s leadership. women have been observed to possess certain traits and characteristics that may accelerate effective and sustainable solutions to challenging global health problems. it is widely accepted that women who are leaders act as a normative agent of change and developmental processes (3-8). they practice people-centred, inclusive leadership and balance strategic priorities with collective dynamics. in this regard, they may exhibit greater mastery as compared to men in relation to key competencies required to make progress. one may argue that we experience a collision of worlds in respect of the old and the new tradition of gender-based roles in global health governance, and the implications for our freshly made, globalized world. however, the balance of global gender roles in our contemporary world is the outcome of politics and power. that balance can be changed to benefit global health. if the collective political community “aims at some good and the community which has the most authority of all and includes all the others aims highest”(9), then, our current, turbulent suffering societies expect global leaders to practice the quality of leadership as described by plato (10). that form of leadership combines the following components: • wisdom, as the knowledge of the whole including both knowledge of the self and political prudence; • civic courage, in the sense of preserving rights and standing in defence of such values as friendship and freedom on which a good society is founded, and; • moderation, a sense of the limits that bring peace and happiness to all. global health leadership falls behind in providing the opportunities and motivation to female leaders to unfold their talents and give their touch to new health challenges. the huge reservoir of talented women remains mostly untapped. the transformative attributes of female leaders to create opportunities out of a web of complexity, to promote systematic preparedness and to create a starting point for change out of chaos have been underestimated and sacrificed to stereotypes and social constraints. kalaitzi v. the mark of women’s leadership on solutions to global health problems (editorial). seejph 2016, posted: 07october2016. doi: 10.4119/unibi/seejph-2016-131 3 of course, numerous notable initiatives have been introduced; important foundations have been established and contribute considerably towards this end. nonetheless, the relative lack of women who are leaders in top decision-making positions in global health should be looked upon like a well-diagnosed, but mistreated disease. what kind of politicians and leaders do we need to provide the proper room for experiencing the mark of women on global health challenges? maybe politicians and decision-makers should be wise enough to adapt the saying of protagoras (1). from now on, let’s call loudly for women who are leaders to be “the measure of global health challenges”! conflicts of interest: none. references 1. sholarin ma, wogu iap, omole f, agoha be."man is the measure of all things": a critical analysis of the sophist conception of man. res human socsci2015;5:178-84. 2. kentikelenis a, karanikolos m, williams g, mladovsky p, king l, pharris a, et al. how do economic crises affect migrants’ risk of infectious disease? a systematic narrative review.eur j public health 2015;25:937-44. doi:10.1093/eurpub/ckv151. 3. eaglyah, chin jl. diversity and leadership in a changing world. am psychol2010;65:216-24. doi: 10.1037/a0018957. 4. northouse pg.leadership: theory and practice (5thed.). sage publications; 2010. 5. silverstein m, sayre k. the female economy. harvard business review2009;87:46 53. https://hbr.org/2009/09/the-female-economy (accessed: october 5, 2016). 6. mckinsey global institute. the power of parity: how advancing women’s equality can add $12 trillion to global growth;2015. http://www.mckinsey.com/global themes/employment-and-growth/how-advancing-womens-equality-can-add-12 trillion-to-global-growth (accessed: october 5, 2016). 7. world economic forum. the global gender gap report; 2014. http://reports.weforum.org/global-gender-gap-report-2014/(accessed: october 5, 2016). 8. world health organization. health in 2015 from sdgs to mdgs; 2015. http://apps.who.int/iris/bitstream/10665/200009/1/9789241565110_eng.pdf(accessed: october 5, 2016). 9. aristotle. political theory. stanford encyclopedia of philosophy (online). http://plato.stanford.edu/entries/aristotle-politics/#polview (accessed: october 5, 2016). 10. plato. political philosophy. internet encyclopedia of philosophy (online). http://www.iep.utm.edu/platopol/ (accessed: october 5, 2016). © 2016 kalaitzi; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.ncbi.nlm.nih.gov/pubmed/?term=kentikelenis%20a%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26318852� https://www.ncbi.nlm.nih.gov/pubmed/?term=kentikelenis%20a%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26318852� https://www.ncbi.nlm.nih.gov/pubmed/?term=williams%20g%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26318852� https://www.ncbi.nlm.nih.gov/pubmed/?term=mladovsky%20p%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26318852� https://www.ncbi.nlm.nih.gov/pubmed/?term=king%20l%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26318852� https://www.ncbi.nlm.nih.gov/pubmed/?term=pharris%20a%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26318852� https://www.ncbi.nlm.nih.gov/pubmed/?term=how%2bdo%2beconomic%2bcrises%2baffect%2bmigrants%e2%80%99%2brisk%2bof%2binfectious%2bdisease%3f%2ba%2bsystematic-narrative%2breview� http://www.mckinsey.com/global-� http://reports.weforum.org/global-gender-gap-report-2014/(accessed� http://apps.who.int/iris/bitstream/10665/200009/1/9789241565110_eng.pdf(accessed� http://plato.stanford.edu/entries/aristotle-politics/#polview� http://www.iep.utm.edu/platopol/� http://creativecommons.org/licenses/by/3.0)� 4 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 original research ethnic differences in smoking behaviour: the situation of roma in eastern europe laetitia duval1, françois-charles wolff2, martin mckee3, bayard roberts3 1 school of public health, imperial college london, norfolk place, london w2 1pg, united kingdom; 2 lemna, université de nantes, bp 52231 chemin de la censive du tertre, 44322 nantes cedex, france and ined, paris, france; 3 ecohost – the centre for health and social change, faculty of public health and policy, london school of hygiene and tropical medicine, london, united kingdom. corresponding author: laetitia duval, school of public health, imperial college london; address: norfolk place, london w2 1pg, united kingdom; e-mail: l.duval@imperial.ac.uk mailto:l.duval@imperial.ac.uk� 5 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 abstract aim: to investigate ethnic differences in smoking between roma and non-roma and their determinants, including how discrimination faced by roma may influence smoking decisions. methods: we analysed data from the roma regional survey 2011 implemented in twelve countries of central and south-east europe with random samples of approximately 750 households in roma settlements and 350 households in nearby non-roma communities in each country. the overall sample comprises 11,373 individuals (8,234 roma) with a proportion of women of 57% and an average age of 36 years. statistical methods include marginal effects from probit and zero-truncated negative binomial estimates to explain cigarette consumption. results: we found that roma have a higher probability of smoking and are heavier smokers compared to otherwise comparable non-roma. these differences in smoking behaviour cannot purely be explained by the lower socio-economic situation of roma since the ethnic gap remains substantial once individual characteristics are controlled for. the probability of smoking is positively correlated with the degree of ethnic discrimination experienced by roma, especially when it is related to private or public health services. conclusions: by providing evidence on smoking behaviour between roma and non-roma in a large number of countries, our findings support the need to understand smoking behaviour of roma from a comparative perspective, and may ultimately contribute to more effective anti-smoking messages for roma. however, if the health disadvantage faced by roma is to be addressed adequately, this group must be involved more effectively in the policy and public health process. keywords: central and south-east europe, cigarette smoking, discrimination, ethnicity, roma. conflicts of interest: none. acknowledgements: we are indebted to one anonymous reviewer for very helpful comments and suggestions on a previous draft. funding statement: this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. 6 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 introduction while much is now known about the determinants of smoking, relating both to individuals (such as gender, age, marital status, and socio-economic characteristics), and product characteristics (such as price, availability, and marketing) (1-9), there has been less attention to ethnic differences in smoking behaviour, even though tobacco control measures may need to take account of factors, such as health beliefs, that might influence the effectiveness of certain policies and messages (10-12). roma are the largest ethnic minority group in europe (estimated to number 10-12 million), most living in central and south-east europe (13). they suffer multiple disadvantages, with lower education, worse living conditions, and lower socio-economic status (14-17) and face discrimination in many areas of life, including barriers in accessing health services and health information (18-22). consequently, roma have worse health on many measures (15,17,19) than the majority populations in the same countries. research on the roma population has largely focused on communicable diseases and child health (18), but more recent contributions have also investigated non-communicable diseases and health care (17,23). however, there have been fewer studies on health behaviours, although those that have been conducted show increased prevalence of risk factors, including smoking (24,25). paulik and colleagues (23) report attitudes to tobacco control from a small cross-sectional survey, with only 83 roma and 126 non-roma, finding roma respondents reluctant to accept restrictions on tobacco use. petek and colleagues (26) conducted a small qualitative study of the meaning of smoking in roma communities in slovenia, but with only three women and nine men of roma origin. they reported how smoking is seen as part of the cultural identity of roma and is accepted by men, women and children, while invoking fatalism and inevitability to explain why smoking is not identified by roma interviewed as a threat to health (26). given growing recognition of the role of smoking-related disease in perpetuating or accentuating health inequalities and lack of evidence on tobacco use among roma, the aim of the present study is to investigate ethnic differences in smoking between roma and non roma as well as their determinants, which includes how discrimination faced by roma may influence smoking. methods data and samples we use data from the roma regional survey, a cross-sectional household survey commissioned by the united nations development programme, the world bank and the european commission. further details on the survey methodology can be found at: http://www.eurasia.undp.org/content/rbec/en/home/ourwork/sustainable development/development-planning-and-inclusive-sustainable-growth/roma-in-central-and southeast-europe/roma-data.html the sample comprises both roma (n=9,207) and non-roma (n=4,274) households living in countries with high proportion of roma, namely albania, bosnia and herzegovina, bulgaria, croatia, the czech republic, hungary, macedonia, moldova, montenegro, romania, serbia and slovakia. the survey was conducted from may to july 2011. the intention was to include roma living in distinct settlements and compare them with non-roma living nearby. given this intention, http://www.eurasia.undp.org/content/rbec/en/home/ourwork/sustainable-� 7 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 it would have been inappropriate to compare what are known to be very deprived roma settlements (27) with the general population, which would include many affluent groups who have little in common with those living in the settlements. consequently, 350 non-roma households living in the same neighbourhood – defined as households living in close proximity, within 300 meters, of a roma settlement – were selected. a stratified cluster random sampling design was used. thus, the first stage sampling frame comprised known roma settlements, from which those to be included were sampled at random. then non roma settlements nearby were selected, again at random. in the second sampling stage, households were randomly chosen with equal probability within each cluster for both populations. the method of data collection was face-to-face interviews at the respondent’s household. the overall sample comprised 13,481 households corresponding to 54,660 family members. among them, 9,207 households were roma (68.3%) and 4,274 were non-roma (31.7%). we focus on the current smoking behaviour of respondents aged between 16 and 60 at the time of the survey. there is no information in the survey on past smoking decisions. this leaves us with a sample comprising 11,373 individuals, 8,234 of whom were roma (72.4%). the survey covers demographic characteristics, education, employment status, living standards, social values and norms, migration, discrimination, and health. socio-economic status is proxied using a household asset index. this aggregate index is derived from a principal component analysis of a list of household possessions following the methodology described by filmer et al. (28). the list of items included comprises radio receiver, colour tv, bicycle or motorbike, car/van for private use, horse, computer, internet connection, mobile phone or landline, washing machine, bed for each household member including infants, thirty and more books except school books, and power generator. the principal component technique was implemented on the entire sample, pooling roma and non-roma individuals. higher values of the asset index correspond to higher long-run socioeconomic status. the characteristics of respondents are summarised in table 1. table 1. descriptive statistics of the sample (n=11,373) variables (1) all (2) roma (3) non-roma (4)p-value respondents respondents respondents of (2)-(3) female 57,7% 57,8% 57,6% 0.848 age in years 36,0 35,0 38,8 0.000 in a couple 69,5% 71,4% 64,5% 0.000 divorced – separated 8,0% 7,9% 8,3% 0.473 widowed 5,0% 5,2% 4,7% 0.330 single 17,5% 15,6% 22,5% 0.000 household size (number of persons) 4,3 4,7 3,5 0.000 no formal education 18,4% 24,8% 1,6% 0.000 primary education 20,7% 26,4% 5,7% 0.000 lower secondary education 34,2% 36,9% 27,1% 0.000 upper/post-secondary education 26,7% 11,8% 65,7% 0.000 paid activity – self-employed 31,7% 25,8% 47,2% 0.000 homemaker – parental leave 19,7% 21,7% 14,2% 0.000 retired 5,2% 4,1% 8,2% 0.000 not working – other 43,4% 48,4% 30,4% 0.000 asset index (value) 0,0 -0,6 1,5 0.000 8 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 capital/district center 33,5% 33,0% 34,7% 0.103 town 26,1% 26,2% 25,8% 0.665 village/unregulated area 40,4% 40,8% 39,6% 0.238 number of respondents 11,373 8,234 3,139 source: authors’ calculations, undp/wb/ec regional roma survey 2011. about 58% are women and the average age is 36 years. on average, roma are younger than non-roma (35.0 versus 38.8). roma have lower educational attainment and are more likely to be outside the formal labour market. overall, scores on the asset index are worse for roma ( 0.563 compared to 1.477 for the non-roma), although the scale of relative disadvantage varies, with the largest gaps in croatia, romania and bulgaria. for smoking behaviour, we used the two following questions. first, respondents indicated whether they smoked or not at the time of the survey: “with regard to smoking cigarettes, cigars, or a pipe, which of the following applies to you?”. possible answers were “i currently smoke daily”, “i currently smoke occasionally”, “i used to smoke but have stopped” and “i have never smoked”. second, those reporting one of the first two answers (either daily or occasionally) were asked: “on average, how many cigarettes, manufactured or hand-rolled do you smoke each day?”. note that it may be more difficult for occasional smokers to assess their daily consumption. to examine the role of discrimination, we used the three following questions: i) “does your household have a doctor to approach when needed?”; ii) “do you feel safe in regards health protection – do you have the confidence that you will receive service in case you need it?”; and iii) “were there any instances in the past 12 months when your household could not afford purchasing medicines prescribed to, needed for a member of your household?”. we also included in our regressions variables from a specific section about general discrimination and rights awareness. discrimination is defined as being treated less favourably than others because of a specific personal feature such as age, gender or minority background. self assessed discrimination was assessed with the following question: “in the past 12 months (or since you have been in the country), have you personally felt discriminated against on the basis of one or more of the following grounds: a) because of ethnicity for non-roma, because you are a roma for roma, b) because you are a woman/man, c) because of your age, d) because of your disability, e) for another reason”. finally, we investigated the role played by access to health care system using answers to the following question: “during the last five years; have you ever been discriminated against by people working in public or private health services? that could be anyone, such as receptionist, nurse or doctor.” the reason attributed to the discrimination was specified: it could be either a discrimination on the basis of ethnic background or a discrimination because of other reasons. statistical analysis we analysed the determinants of smoking behaviour both in terms of smokers versus non smokers and number of cigarettes among smokers. to isolate as far as possible the role of ethnicity, we adjusted for the following individual characteristics, available for each household member: gender, age, marital status, household size, education level, asset index, occupation and location (capital or district centre, town, village or rural area). we compared the pattern of smoking not only by ethnicity, but also by country to account for the potential role of country-specific factors such as tobacco price. as an initial comparison 9 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 showed that roma were, as expected, materially worse off, we turned to an econometric analysis to explain both the decision to smoke and the consumption of cigarettes among smokers. we began with an investigation of the determinants of the probability of smoking using probit regressions, with marginal effects for various specifications (table 3). we also examined correlates of smoking intensity among smokers. since the dependent variable had non-negative integer values, we used count data models and estimated a zero-truncated negative binomial regression to account for over-dispersion as in (29,30). finally, we investigated the role of discrimination as a potential factor explaining the widespread smoking behaviour among the roma population (table 4). results determinants of cigarette consumption a comparison of cigarette consumption by ethnicity and country in table 2 shows that, while overall the proportion of smokers is 50.0%, there are substantial differences between countries. when pooling all countries, we found a much higher proportion of smokers among roma than non-roma (columns 2-4). the gap between these groups amounted to 15.5 percentage points. the prevalence differential was greatest in the czech republic (+31.4 points for roma), followed by hungary (+23.7 points), slovakia (+22.7 points) and bosnia and herzegovina (+22.6 points). conversely, there was no significant difference between roma and non-roma in bulgaria, macedonia and montenegro. the situation was a little different in terms of intensity of smoking. there were significant differences in daily number of cigarettes (among smokers) between roma and non-roma in only four countries: czech republic (+3.8 cigarettes for roma), bosnia and herzegovina (+3.1 cigarettes), slovakia (+1.6 cigarettes) and moldova (-5.1 cigarettes). table 2. cigarette consumption, by ethnicity and country albania 33.5 36.6 26.5 0.002 17.7 17.7 17.5 0.832 bosnia and herzegovina 54.6 61.1 38.5 0.000 21.2 21.8 18.7 0.009 bulgaria 51.7 53.3 46.8 0.108 12.0 11.8 12.9 0.233 croatia 57.3 64.1 38.4 0.000 16.1 16.2 15.5 0.766 czech republic 68.7 78.0 46.6 0.000 15.1 15.9 12.1 0.000 hungary 55.2 61.3 37.6 0.000 15.5 15.4 16.1 0.469 macedonia 42.1 43.2 39.3 0.279 17.2 17.4 16.6 0.443 moldova 29.8 33.5 19.4 0.000 16.7 15.9 21.0 0.004 montenegro 42.5 42.4 42.7 0.946 22.3 22.8 21.0 0.057 romania 46.7 50.5 34.8 0.000 12.8 12.8 12.8 0.728 serbia 58.9 61.7 51.5 0.004 18.4 18.3 18.7 0.627 slovakia 57.4 64.2 41.5 0.000 14.2 14.5 12.9 0.005 all countries 50.0 54.2 38.7 0.000 16.5 16.7 16.2 0.139 source: authors’ calculations, undp/wb/ec regional roma survey 2011. we examined the role of individual characteristics in explaining differences in cigarette consumption between roma and non-roma. as shown in column 1a of table 3, we found a positive correlation between the ethnic dummy and the smoking decision. at the sample means, the probability of smoking was 16.1 percentage points higher among roma compared country proportion of current smokers (in %) cigarette consumption among smokers (1) all (2) roma (3) non(4)p-value (5) all (6) roma (7) non(8)=p-value roma of (2)-(3) roma of (6)-(7) 10 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 to non-roma. this marginal effect accounted for the role of country heterogeneity. the country dummies in the regression captured the influence of differences in tobacco prices as well as other unobserved differences in anti-smoking policies or tobacco advertising. next, we accounted for by individual characteristics, given the demographic and socio economic differences in roma and non-roma respondents (column 2a). our main result was that the roma dummy was still positively correlated with the propensity to smoke at the one per cent level of significance. however, controlling for differences in respondents’ characteristics strongly reduced the marginal effect of ethnic origin. being roma was now associated with an increase of 8.5 percentage points in the probability of smoking. we also estimated separate regressions for each ethnic group (columns 3a and 4a). many covariates such as gender, age, household size or education had a similar influence on the likelihood of smoking among roma and non-roma, but we noted some differences. for instance, the marginal effect associated with the asset index was three times higher for non roma compared to roma. similarly, having a paid activity and being homemaker were significantly correlated with probability of smoking (respectively positively and negatively) only for non-roma. in column 1b, we found a positive correlation between roma origin and cigarette consumption. in column 2b, the positive effect of roma origin was still significant (at the five percent level) once individual characteristics were controlled for. table 3. probit and zero-truncated negative binomial estimates of cigarette consumption – marginal effects variables probability of smoking cigarette consumption among smokers (1a) all (2a) all (3a) roma (4a) non-roma (1b) all (2b) all (3b) roma (4b) non-roma roma 0.161** 0.085** 0.734* 0.927* (15.15) (5.91) (2.39) (2.49) female -0.138** -0.125** -0.166** -2.784** -2.892** -2.034** (-12.69) (-9.60) (-8.64) (-9.82) (-8.76) (-3.65) age 21-30 0.090** 0.067** 0.143** 2.374** 2.123** 3.587* (ref: ≤20) (4.85) (3.26) (3.35) (4.33) (3.59) (2.37) 31-40 0.123** 0.105** 0.128** 3.214** 2.800** 4.896** (6.28) (4.86) (2.81) (5.53) (4.48) (3.01) 41-50 0.157** 0.158** 0.129** 4.168** 3.993** 5.090** (7.61) (6.87) (2.75) (6.44) (5.65) (2.98) 51-60 0.119** 0.117** 0.090 4.103** 3.485** 6.028** (5.32) (4.63) (1.85) (5.83) (4.54) (3.29) marital status divorced – separated 0.035 0.042 0.031 0.508 0.577 0.392 (ref: in a couple) (1.87) (1.93) (0.92) (1.07) (1.06) (0.41) widowed 0.032 0.035 0.004 -0.050 -0.204 1.153 (1.32) (1.26) (0.09) (-0.08) (-0.30) (0.77) single -0.031* -0.041* -0.057* -0.185 -0.724 1.205 (-2.00) (-2.19) (-2.08) (-0.47) (-1.59) (1.48) household size 0.007** 0.006* 0.015* 0.085 0.107 -0.017 (2.81) (2.09) (2.30) (1.36) (1.60) (-0.09) education primary 0.002 -0.001 -0.110 -0.958* -1.040** -0.273 (ref: no formal) (0.15) (-0.08) (-1.48) (-2.48) (-2.60) (-0.13) lower secondary -0.008 -0.028 -0.102 -1.071** -1.337** -0.688 (-0.55) (-1.68) (-1.44) (-2.77) (-3.25) (-0.38) upper/post-secondary -0.061** -0.090** -0.138 -1.459** -1.595** -0.593 (-3.17) (-3.95) (-1.89) (-3.08) (-3.04) (-0.31) activity paid activity – self-employed 0.023 0.021 0.039 0.188 0.262 0.397 (ref: not working – other) (1.81) (1.43) (1.66) (0.60) (0.72) (0.62) homemaker – parental leave -0.019 -0.013 -0.065* -0.511 -0.615 0.256 (-1.35) (-0.83) (-2.11) (-1.37) (-1.52) (0.26) retired -0.089** -0.071* -0.098* -1.098 -0.925 -1.331 (-3.58) (-2.22) (-2.56) (-1.73) (-1.21) (-1.16) asset index -0.026** -0.016** -0.048** 0.189* 0.266** -0.101 11 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 (-7.62) (-4.00) (-7.58) (2.15) (2.63) (-0.56) location town -0.040** -0.050** 0.001 -1.445** -1.570** -1.112 (ref: capital/district center) (-2.96) (-3.14) (0.03) (-4.38) (-4.19) (-1.61) village/unregulated area -0.049** -0.039** -0.059* -2.186** -2.360** -1.437* (-3.81) (-2.63) (-2.50) (-6.87) (-6.53) (-2.15) country dummies yes yes yes yes yes yes yes yes number of respondents 11,373 11,373 8,234 3,139 5,682 5,682 4,466 1,216 source: authors’ calculations, undp/wb/ec regional roma survey 2011. note: the probability of smoking is explained using a probit model, the cigarette consumption among smokers is explained using a zero-truncated negative binomial model. significance levels are p<0.01 (**) and p<0.05 (*). when comparing the estimates obtained separately on the roma and non-roma samples (columns 3b and 4b), the correlation between consumption of cigarettes and gender, age as well as location had the same sign for both ethnic groups. conversely, we observed some differences in the role of education and asset index among smokers. first, the negative correlation between education and cigarettes was only significant for roma. second, we found a positive correlation between consumption of cigarettes and the asset index only for roma. as roma are economically disadvantaged, only those with adequate resources will be able to purchase and smoke cigarettes. finally, we estimated country-specific regressions. for ease of interpretation, we presented the marginal effect associated with the roma dummy (figure 1). figure 1. the gap in smoking between roma and non-roma, by country a. probability of smoking b. cigarette consumption among smokers 25 20 15 10 5 0 -5 bosnia and czech hungary croatia romania moldova slovakia albania serbia montenegro bulgaria macedonia herzegovina republic 12 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 source: authors’ calculations, undp/wb/ec regional roma survey 2011. the probability of smoking was 24.1 percentage points higher among roma than non-roma in bosnia and herzegovina. the gap was significant in seven other countries: by decreasing order of magnitude, the czech republic (19.7 percentage points), hungary (15.6), croatia (13.7), romania (13.7), moldova (12.5), slovakia (7.1) and albania (2.8). roma consumed additional cigarettes per day in the czech republic compared to non-roma smokers. the situation was very similar in bosnia and herzegovina (+3.7 cigarettes), slovakia (2.7), romania (1.3) and montenegro (1.1). smoking and discrimination the proportion of respondents who felt discriminated against because of ethnicity was much higher among roma (34.6%) than non-roma (4.9%) (+29.7 percentage points). the ethnic differential was lower but still significant when considering other forms of discrimination: +6.9 points because of gender (8.3% for roma compared to 3.1% for non-roma), +1.9 points because of age (6.2% against 4.3%) and +1.8 points because of disability (3.6% against 1.8%). when pooling the various reasons, the ethnic gap amounted to 26 percentage points (36.7% against 16.7%). we added indicators of health inequalities to our previous regressions explaining smoking decisions (panel a of table 4). table 4. discrimination and cigarette consumption – marginal effects from probit and zero truncated negative binomial models variables probability of smoking cigarette consumption among smokers (1a) all (2a) all (3a) roma (4a) non roma (1b) all (2b) all (3b) roma (4b) non roma panel a: roma 0.085** 0.081** 0.927* 0.920* (5.91) (5.63) (2.49) (2.47) 4 2 0 -2 -4 czech bosnia and slovakia romania montenegro macedonia serbia croatia hungary bulgaria moldova albania republic herzegovina 13 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 doctor to approach when needed 0.037* 0.033 0.050 0.211 0.336 -0.826 (2.23) (1.82) (1.31) (0.50) (0.74) (-0.69) feel safe in regards health protection -0.015 -0.015 -0.012 -0.219 -0.155 -0.401 (-1.11) (-0.95) (-0.44) (-0.63) (-0.41) (-0.49) cannot afford purchasing medicine prescribed 0.032** 0.028* 0.033 0.027 0.012 0.258 (2.92) (2.34) (1.46) (0.10) (0.04) (0.40) control variables yes yes yes yes yes yes yes yes number of respondents 11,373 11,373 8,234 3,139 5,682 5,682 4,466 1,216 panel b: roma 0.085** 0.077** 0.927* 0.828* (5.91) (5.27) (2.49) (2.19) discriminated against in the past 12 months 0.041** 0.034** 0.045 0.482 0.450 0.269 (3.62) (2.80) (1.55) (1.67) (1.46) (0.32) control variables yes yes yes yes yes yes yes yes number of respondents panel c: roma 11,373 0.085** 11,373 0.072** 8,234 3,139 5,682 0.927* 5,682 0.825* 4,466 1,216 (5.91) (4.93) (2.49) (2.17) discriminated against in the past 12 months 0.059** 0.060** -0.001 0.399 0.187 1.582 because of ethnicity (4.62) (4.40) (-0.02) (1.26) (0.56) (1.23) discriminated against in the past 12 months -0.038* -0.058** 0.043 0.172 0.482 -1.376 because of other reasons (-2.30) (-3.10) (1.21) (0.41) (1.03) (-1.50) control variables yes yes yes yes yes yes yes yes number of respondents panel d: roma 11,373 0.085** 11,373 0.079** 8,234 3,139 5,682 0.927* 5,682 0.891* 4,466 1,216 (5.91) (5.46) (2.49) (2.38) discriminated against by people working in health 0.078** 0.072** 0.057 0.467 0.238 3.901 servicesbecause of ethnicity (4.29) (3.84) (0.79) (1.06) (0.53) (1.54) discriminated against by people working in health -0.053 -0.060 -0.035 -0.409 0.146 -4.160* servicesbecause of other reasons (-1.79) (-1.84) (-0.49) (-0.55) (0.18) (-2.41) control variables yes yes yes yes yes yes yes yes number of respondents 11,373 11,373 8,234 3,139 5,682 5,682 4,466 1,216 source: authors’ calculations, undp/wb/ec regional roma survey 2011. note: the probability of smoking is explained using a probit model, the cigarette consumption among smokers is explained using a zero-truncated negative binomial model. significance levels are p<0.01 (**) and p<0.05 (*). we found that people who could approach a doctor when needed has a higher probability of smoking (column 2a). this result is seemingly counterintuitive but it may be that those living in areas with access to a doctor have higher (unobserved) levels of income or can more easily buy cigarettes. however, there may also be reverse causation as smokers are likely to have more health problems and thus more frequent interactions with doctors. while feeling safe had no influence on smoking, the correlation between probability of smoking and inability to purchase medicines prescribed was positive for roma respondents only (column 3a). none of our indicators of health inequalities had an influence on intensity of cigarette consumption among smokers. in panel b of table 4, we found a positive correlation between smoking behaviour and feeling of discrimination (whatever its reason). the probability of smoking increased by 4.1 percentage points for those who felt discriminated against (column 2a). the role played by discrimination was mainly observed in terms of probability rather than intensity of smoking. the correlation between discrimination and cigarette consumption among smokers was not significant when separating roma and non-roma (columns 2c and 2d).as shown in panel c, most of the effect came from discrimination on the basis of ethnic background. indeed, the coefficient associated with ethnic discrimination was positive and significant, but it was negative for other forms of discrimination. as a final step, we explored the correlation between smoking and discrimination in access to the health care system (panel d). the probability of smoking is higher among respondents 14 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 who felt discriminated against by people working in health services on ethnic grounds (+7.8 points). conversely, the correlation is negative for the other forms of discrimination (-5.3 points) while there was no significant relationship with smoking intensity. discussion in this paper we compared the smoking behaviour of roma and those in the majority population living nearby in twelve countries of central and south-east europe. the strengths of this study lie in the use of a large study sample across multiple countries. previous research on roma health tends to be restricted to a small number of countries, mainly hungary, the czech republic and slovakia (15,16,23,26), and which often use small sample sizes which make comparisons between roma and non-roma groups of population difficult. this study is, however, subject to a number of limitations. first, by design, it does not provide a representative sample of the roma population in the countries concerned. this is an inevitable and well-known problem facing all research on roma health, reflecting problems of defining the roma population (31). there are varying degrees of assimilation in each country and estimates of the roma population vary, reflecting in part the reason why a particular survey was undertaken and thus the incentive to self-identify as roma. furthermore, in some situations there may be strong disincentives to do so, given the previous experience of this population in their dealings with authority. for this reason, much of the existing research has adopted the approach used here, focussing on the most marginalised roma groups, and the most easily and consistently identifiable. second, the sample size in each country is relatively small, limiting the power to compare sub-groups. third, there is a need for qualitative research to understand better the place that smoking occupies within roma communities and the barriers that exist to reducing smoking rates. qualitative research has found that smoking is important in cultural and ethnic identity of roma, with smoking being introduced by older family members to younger ones. even where there is awareness of health risks associated with smoking, there is little willingness to consider quitting, to reduce exposure to second-hand smoke, or to prohibit children from smoking because it is considered part of growing up (23). policies that attempt to limit tobacco access to children or eliminate smoking in public places are rejected (26). fourth, some factors that might influence smoking behaviour are missing from the roma regional survey. for instance, we could not include household income in our regressions, although we were able to use an asset index, which captures household wealth. fifth, interpretation of findings on discrimination is complex. from an individual perspective, the perception of discrimination is a sensitive topic. feeling discriminated against is subjective and may be subject to justification bias. this would occur if roma respondents report being discriminated in order to justify their smoking decision. at the same time, according to the eu-midis report on discrimination argues, discrimination against roma seems to be largely unreported (32). finally, a limitation, inherent in the cross-sectional design, is that we are unable to show a causal association between discrimination and smoking. it may be that roma decide to smoke because they feel less accepted by the rest of the population, but their higher smoking prevalence may also be perceived as a potential signal of their ethnicity, as noted above. our findings show that roma respondents are more likely to smoke and are heavier smokers on average compared to non-roma (with substantial heterogeneity in the gap between the 15 duval l, wolff fc, mckee m, roberts b. ethnic differences in smoking behaviour: the situation of roma in eastern europe (original research). seejph 2016, posted: 14 december 2016. doi:10.4119/unibi/seejph 2016-132 two groups between countries).a recent study found no genetic basis for differences in smoking among roma and non-roma in hungary (33). now, this study shows that differences in smoking behaviour cannot simply be explained by the worse socio-economic situation of roma. first, the non-roma comparison population comprises those living in close proximity to roma settlements and not the general population. thus, our data will presumably underestimate the overall gap between the roma and non-roma population in each country. second, the ethnic gap remains substantial once individual characteristics are controlled for, although of course it is possible that our indicators do not fully capture relative disadvantage. importantly, this conclusion is consistent with another study using a different data set but similar methodology in hungary (34). we also find some positive correlation between the probability of smoking and discrimination reported by roma, especially with respect to private or public health services, but not in terms of smoking intensity. our findings support other literature on the disadvantage and discrimination faced by roma in central and south-east europe (13,15,21,22,35,36) with roma considered by some as the most discriminated against group in europe (32). this reinforces the importance of developing messages through a shared process, involving roma participation, and in ways that avoid stigmatisation, as part of comprehensive policies to tackle disadvantage and discrimination (37). conclusions to the best of our knowledge, this study is the first to provide comparative evidence on smoking behaviour between roma and non-roma in a large number of countries. our findings support the need to understand smoking behaviour of roma from a comparative perspective, and may ultimately contribute to improved anti-smoking policies towards roma. if roma health vulnerability is to be addressed adequately, efforts need to be concentrated on involving roma in the policy and public health process, including measures that specifically address the factors that lead to high rates of smoking in this multiply disadvantaged population. references 1. perez-stable ej, ramirez a, villareal r, talavera ga, trapido e, 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in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0)� 18 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 original research the relevance of ethics in the european union’s second public health programme nelly k. otenyo1 1department of international health, school of public health and primary care (caphri), faculty of health, medicine, and life sciences, maastricht university, maastricht, the netherlands. corresponding author: nelly k. otenyo, msc address: department of international health, maastricht university, postbus 616, 6200md, maastricht, the netherlands; email: nellyotenyo@gmail.com mailto:nellyotenyo@gmail.com� 19 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 abstract aim: the objective of this paper was to investigate whether ethical values were explicitly identified in the second public health programme (2008-2013) of the european commission. methods: a qualitative case study methodology of exploratory nature was followed. the data used were the summaries of the project proposals and public health programme objectives and was retrieved from the publicly available consumers, health and food executive agency database. since the php was finalized during the study, the study only focused on the summaries of the fifty-five finalized project proposals while excluding the ongoing projects and those projects at the reporting stage. the full proposals for the projects are confidential and thus could not be retrieved. however, the project summaries were inarguably sufficient to conduct the study. using a table, a content analysis method in addition to the ethical framework, was applied in order to analyze and categorise the project findings. results: the results unfold that, out of the seven ethical principles, only ‘equity’ and ‘efficiency’ were explicitly considered in eighteen projects and four projects respectively. moreover, from the shared health values, eight projects identified aspects pertaining to ‘accessibility to quality health care’ while ‘solidarity’ was only discussed in one project. lastly, the ethical aspects ‘ethics’ and ‘values’ were identified in three projects and in one project respectively. conclusions: from the results, there is a limited consideration of ethical principles within the projects. therefore, future public health programmes could use this as an opportunity to emphasis on the inclusion and application of ethical principles in public health projects. keywords: accessibility for quality health care, efficiency, equity, respect for human dignity, universality. conflicts of interest: none. 20 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 introduction in the recent years, there has been an increased focus on implementing policies that promote better health, that are cost effective and use targeted strategies against targeted ill-health worldwide. this interest has sparked an even greater concern for public health practices, as well as how ethics is observed with regards to health, especially since populations continue to suffer from emerging health challenges (1). it is also commonly known that human health is greatly influenced or affected by public health practices as well as socio-economic circumstances of individuals. in a response to solve this, researchers are constantly evaluating and checking their research work against ethical aspects of public health; assessing whether the recommendations that are or can be derived from their work can be ethically justified. even though there has been a growing interest on how ethics applies to public health, it has not yet gained a prominent position in all public health research. with the increasing burden of disease and emergent public health programmes, it is important to emphasize the need for public health ethics and develop this interest into maturity in order for it to have benefits (2). ethics is an academic discipline that questions what is required to be done, what is right, fair, just and good. therefore, ethics clearly defined is the study of human values and reasoning, but also refers to the systematizing of these values or rules or moral conduct that guides human lives. through the application of ethics, policy makers are able to frame policies and make critical decisions (3). the rise in the study of how public health and ethics are connected has been gradually developing in the past last years, due to human mal-practices, actions and problems in healthcare practice. public health focuses on ways to detect and quantify factors that put the population’s health at risk, once these factors are quantified policies are formulated to tackle or reduce adverse health outcomes for the population (4). public health ethics is concerned with the dissemination of health resources in a more equitable, efficient way and protecting the society (5). numerous studies have been carried out on ethics and public health actions and these have led to normative frameworks of public health ethics. hence, one could assume that ethical aspects are considered by researchers and public health professionals to be significant in enabling a functioning plan, execution and development of various public health programs. within the european commission, the 2007 health strategy ‘together for health’ is a better example of a health policy that considers values, as it is based on shared values. moreover, founded on these values, the second php 2008-2013 was implemented (6). it therefore goes without saying that when ethics are considered, public health is safeguarded, particularly when the ethical aspects are predicted or recognized in advance through critical investigations and discussions (7). an example of how ethical values can be considered in different public health disciplines is through gostin’s work. gostin looks at public health ethics from three viewpoints. the first is ethics of public health, by which professionals need to work for the common good with regards to their public duty and trust from the society. the second, ethics in public health, involves examining the position of ethics in public health. it involves communal and individual interests in relation to the allocation of returns and harms in an equitable way, e.g. in decision making and implementation of public health policies. ethics for public health, gostin’s third point, mainly entails a healthy population where the needs of the vulnerable and marginalized populations are considered in a more practical manner (8). as outlined in gostin’s perspectives, the ethical framework applied in this paper acts as an umbrella to ascertain whether the professionals carrying out the projects are working for the good of the 21 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 public, whether the allocation and distribution of resources is fair, and whether the needs of the minorities are taken into consideration to ensure a healthy population. ethical principles and standards are not only important for public health, they are also considered important for other disciplines, institutions and they have been used in recent years to guide professional conduct and behaviour (9). the european union (eu) is an example of such organizations, it does not only fund research through its framework programmes, but also monitors how health research is done or how projects are implemented (european union, n.d). through the health programme funding, the directorate general for health and consumer affairs (dg sante) oversees the health programme which is managed by the consumers, health and food executive agency (chafea) (chafea, n.d). every year, the european commission through chafea sends a call for proposal for operating grants, conferences as well as joint actions and sets the criteria for funding options available (chafea, n.d). the european commission has so far adopted three public health programmes (hereafter referred to as php). in this work, we will focus on the second php 2008-2013 because of its significance in forming part of the commission’s execution of the eu health strategy “together for health” (10). the objectives of php 2008-2013 were directed towards improving the health information and knowledge of eu citizens. this is done so as to increase the competences of how individuals respond to health threats or how they consider various determinants to stimulate better health or obviate disease (chafea, n.d). against this background, the php 2008-2013 was also aligned with the health strategy ‘together for health’. the first principle of shared health values emphasizes overarching values of solidarity, universality, access to good quality care and equity (6). for this paper, it is interesting to see how the funded projects of the php explicitly dealt with these ethical values and whether they used them as a foundation for setting their public health priorities. it is important to note that exploring the scope and the role of values in public health actions and strategies relates to the discipline of ethics. thus, this paper explores whether ethical values, principles and aspects have been explicitly considered in the second php objectives, proposals and its finalized projects. theoretical framework in order to investigate whether ethical aspects or concerns were considered in the php objectives, projects funded by dg sante, a selection and combination of ethical appropriate principles, safeguarding and incorporating relevant values and aspects of human rights retrieved from studies addressing various aspects of public health ethics are proposed. there are five principles for public health ethics which are also known as ethical principles, these are: health maximization, respect for human dignity, social justice, efficiency and proportionality (11), the principle of respect for autonomy (1), and finally equity as a principle proposed by tannahill are also combined (12). to formulate the framework for this study, these ethical principles will be combined with the shared health values of the eu health strategy namely: ‘universality’, ‘solidarity’, ‘accessibility for quality health care’. respect for autonomy is targeted at various aspects, such as the decision-making power of individuals in relation to their health or the general public health. additionally, it focuses on individual autonomy relating to self-domination, privacy, personal choice and free will (1). respect for human dignity compliments respect for autonomy, it guards the various interests of an individual and his or her absolute value so that an individual is referred to with respect 22 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 solidarity especially for his or her liberties, such as self-control (11). it further emphasizes that an individual’s liberties should not be defiled unless it harmfully affects others (13). health maximization is applied in practices where the monetary values of various projects are considered so as to give priority to the most cost effective project but also making sure that the public takes full advantage of all health benefits. the principle social justice guards against segregation and marginalization of vulnerable individuals. it ensures that individuals are treated fairly, particularly in matters of equity and maximization of health benefits, so as to minimize and avoid inequalities related to health care services. due to the growing public health needs and the inadequate public health resources, the principle of efficiency is significant in public health ethics. it is viewed as a moral act that ensures benefits are maximized especially in the execution of public health strategies, done by promoting the dissemination of basic necessities in a resourceful way. the proportionality principle advocates for benefits to be considered and assessed alongside the harmful properties, especially when debates on individual liberty versus public good arise (11). equity seeks to ensure that, the less privileged are not secluded in key public health actions that are important to them. in response to this, interventions and strategies that analyze the unfair allocation of services across different populations are implemented to target those at risk in a way to find the influencing factors and decrease inequalities (12). from the health strategy, shared values, universality value ensures that every eu citizen has equal access to use the available healthcare and services and that no one is denied care. the value access to good quality care guarantees that the available health care and services are of high quality and no eu patient is denied any high-quality care. equity as a value ensures that every eu patient is entitled to receive health care and services irrespective of their ethnic, gender or social economic backgrounds and status. solidarity ensures that all the financial arrangements made by the respective member states will promote the accessibility of health care and services to all citizens (6). using this framework, this paper will explore whether ethical principles, values and the 2007 strategy’s shared values were sufficiently addressed in objectives, proposals and finalized projects of the second php. table 1. overview of ethical principles and health strategy values (source: references 11-13) health maximization complete utilization of health benefits respect for human dignity no violation of individual liberties social justice promotes fairness and guards against discrimination promotes cost effectiveness, maximizing of benefits and limits wastefulness proportionality considers the benefits alongside harm respect of autonomy promotes individual’s free will and privacy supporting the fair access with reference to the need but regardless of origin, sex, age, social or economic rank universality no patient is denied access to health services and care accessibility to quality health care ensure accessibility of high quality health care for all the financial organization of a member states’ health system so as to ensure health is accessible for all. ethical aspect description equity efficiency 23 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 methods a qualitative study design was carried out to gain insights into the ethical concepts and determine whether they have a role in the funding allocation of phps and in the reported project results. the search items used, relate to the seven principles and basic terms of ethics: ‘equity’, ‘autonomy’, ‘health maximization’, ‘respect’, ‘dignity’, ‘social justice’, ‘justice’, ‘efficiency’, ‘proportionality’, ‘ethics’, ‘moral’, ‘value’, ‘ethic’, ‘ethical framework’. including the shared health values ‘universality’, ‘solidarity’, ‘accessibility’ and ‘quality health care’. it is important to note that despite the fact that, a number of projects used ‘equity’ to imply the reduction of inequalities, the term ‘inequalities’ was still excluded used as a keyword. all data was retrieved from the consumers, health and food executive agency (chafea). the proposals were available as summaries which included the following sections: general objectives, strategic relevance and contribution to the public health program, methods, means and expected outcomes (chafea, n.d). the research focused on the summaries of the fifty-five finalized project proposals at the data collection time and excluded projects that were still ongoing as well as projects at the reporting stage. the study included all the projects from all the three strands of the chafea project database: health information, determinants/health promotion, and health threats/health security. for the analysis, the individual project aims, goals and principles were compared against the ethical framework principles and the shared health values so as to show the overlapping concepts and which ethical gaps still need to be addressed. moreover, the identified ethical aspects are further scrutinized to ascertain whether they were only mentioned as keywords or whether they were expected outcomes of the analyzed project. methodological and theoretical limitations including other potential challenges the results from this study will indicate whether ethical concepts and public health ethics are already a constituent part of public health projects particularly with regard to the second eu public health programme. however, since this is a qualitative research, the study may encounter some limitations. to ensure validity as proposed by bowling the researcher intends to organize, clustering the retrieved data into relevant and respective ethical themes (14). this study has looked into the php’s, assessing whether ethical aspects were explicitly considered in its objectives and the summaries of the project proposals. the study recognizes that, by focusing on the only the explicit role of ethics in php through the eyes of only the seven principles and the shared health values, other ethical relations and aspects which are still vital in phps may have been excluded. in addition, not all projects that implicitly discussed aspects related to the principles and shared values were reported due to the act that, out 55 finalized projects, ethical principles and related concepts were identified both explicitly and implicitly in 27 projects. since the researcher used the given description of the principles to decide which ethical aspects and values were related to each other, there may be some form of interpretation bias. however, as discussed in the paper, it is inarguable that there are various definitions of ethics and ethical frameworks depending on different disciplines. this has led different ethical frameworks to be defined and applied to suit certain situations. the seven ethical principles proposed for the framework may therefore be exclusive in terms of excluding other significant values and concepts. additionally, given different definitions, application and 24 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 descriptions of the principles, it is clear that some aspects may refer to various principles such as universality and accessibility to health care. the study recognizes that, by focusing on the explicit role of ethics in the php through the eyes of only the seven principles and the shared health values, other ethical relations and aspects which are still vital in phps may have been excluded. the results focusing on the project proposals show minimal external validity as they only apply to the 55 finalized projects and may perhaps not be adequately generalized to a broader setting. however, regarding the results focusing on the objectives of the php, the representativeness of the findings cannot be questioned since the objectives apply to all the projects funded during the 2008-2013 php. thus, it can be generalized to improve the projects that are yet to be finalized and even aid in the drafting of the objectives of future php’s in the case of learning from best practices. since most of the projects and proposals from the second php 2008-2013 were still in the final phase during the data collection, only the projects that were finalized by june 2014 were included and the projects submitted at any later date were excluded. the full proposals for the projects were also confidential and thus could not be retrieved. therefore, it may be likely that some ethical principles and values might have been considered elsewhere in the full proposals hence resulting in limitations on the findings of this study. however, the project summaries were inarguably sufficient to conduct this study as they included a detailed executive summary of the project objectives in relation to the php objectives. results after examining the summaries of the 55 project proposals and the eu public health programme objectives, the findings were as follows. out of the seven ethical principles from the theoretical framework, only two principles were identified. other terminologies used in the analysis included ‘ethics’ and ‘values’ which were identified in three projects and in one project respectively. since the second php was founded on values prioritized in the eu health strategy: together for health, the keywords ‘universality’, ‘access’, ‘quality health care’ and ‘solidarity’ retrieved from the first principle of the health strategy were identified differently in nine projects. eight projects identified aspects pertaining to accessibility to quality health care and solidarity was only discussed in one project. additionally, out of the four shared health values, only ‘equity’, ‘solidarity’ and ‘access to quality health care’ was identified explicitly in the objectives of the php. the projects were analysed basing on the seven ethical principles, the four shared health values and the ethical concepts ethics, morals and values. the results will be analysed and presented in the following categories. the different research questions will be answered and discussed in their respective sub-sections below. table 2. presentation of the findings ethical concepts in php objectives & project morals, values, ethics, ethics, values, proposals those identified in project proposals and/or in php objectives categories used in analysis and the terminologies used how results are presented 25 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 shared health values identified in php objectives and project proposals ethical principles identified in php project proposals equity, accessibility to quality health care, universality and solidarity health maximization, equity, proportionality, respect for human dignity, autonomy, solidarity, universality and accessibility to quality health care efficiency and equity efficiency, social justice. ethical concepts and shared health values in the php-2008-2013 objectives ethical concepts such as, ‘ethics’, ‘morals’ and ‘values’ were not identified in the php objectives. however, the shared health values equity, solidarity and access to quality health care were explicitly identified in the php objectives. from the general objectives of the php, the common goal evident is improving ways that will ensure and promote the health security of the eu citizens. this goal is in line with the shared health value of ensuring ‘accessibility to quality health care’. even though ‘accessibility’ is not explicitly mentioned in the php objectives, it is one of the main objectives of the php because through the php, the eu commission seeks to improve the member state’s capacities of responding to all kinds of health threats and ensure that the health care services, treatment and medications, for example transplant organs, are of the highest quality. the php 2008-2013 also aims to promote the health of the eu citizens while reducing health inequalities. solidarity ensures that all member states commit to working in unity while supporting each other for the growth and development of the entire eu. moreover, with regards to the solidarity value, the php was envisioned to complement, offer assistance and add value to the member state’s policies by developing, distributing and sharing all information, evidence, best practices and expertise relating to health to all member states. since solidarity ensures that less capable countries are not left out in the development or growth, the php fully supports this value as it aims to see to it that prosperity in the european union is increased, and as a counter effect public health is improved. table 3. shared health values in the php-2008-2013 objectives (source: adapted from reference no. 15) reduces inequalities among the minorities mutual support and commitment among the ms “promote health and reduce health inequalities” “it is intended to complement, support and add value to the policies of the member states and contribute to increasing solidarity and prosperity in the european union” “generate and disseminate health information and how the concept is used in the php objectives shared health values of the eu description as given in health strategy chapter 4 of this paper equity solidarity 26 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 knowledge, exchanging knowledge and best practice on health issues’’ access to quality health care safe and quality health care is made available to everybody “promoting actions related to patient safety through high quality and safe healthcare, scientific advice and risk assessment, safety and quality of organs, substances of human origin and blood” 27 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 ethical principles in the php 2008-2013 project proposals from the 55 projects, only 6 projects explicitly discussed findings that related to equity, while efficiency was only identified in four projects. • equity: the project ‘daysafeimproving patient safety of hospital care through day surgery’, recognized existing challenges health systems face while trying to ensure fair access to high quality and safe health care. the project therefore proposes to offer applicable solutions and as a result increase patient satisfaction, safety, equity and quality of health care. according to the ‘chain of trust’ project, increasing the awareness and understanding of the available recommendations regarding the perceptions, challenges and advantages resulting from the use of tele-health, will equip all the key stakeholders with knowledge and information that will add value and further promote the provision of health care equitable to all patients in the eu. the ‘healthvent’ project discusses equity under the strategic relevance and contribution to the public health programme section of their proposal. it emphasizes that, its objectives will be aligned with those of the php as it aims to tackle environmental health determinants specifically those related to the use of energy in homes, schools and various public buildings so as to prevent chronic diseases and further decrease inequalities in health. ‘crossing bridges’ builds on the execution of article no. 168 of the ec treaty to ensure that the hiap vision is accomplished for equity across the eu. moreover, ‘crossing bridges’ expects that through the project results, the respective stakeholders will be encouraged to implement policies that will result in health equity. by developing a suitable surveillance and information system for health the ‘eumusc.net’ project expects to increase and harmonise the quality of care to allow for equity in care for rheumatic illnesses and musculoskeletal disorders across the member states. through the consideration of structural aspects of gender inequality and gender stereotypes that openly affect men and women’s health, ‘engender’ project aims to ensure equity by creating an online inventory of good practice of policies and programmes that focus on promoting health. • efficiency: ‘daysafe’ expects to improve the technical efficiency of health services by ensuring that the policy-makers are well-informed and recognize the factors limiting the performance of ds, such as operational issues and incompetently designed structures. ‘healthvent’ project: through establishing a health-related ventilation guideline focussing on buildings such as schools, homes, offices and nursery buildings among others, ‘healthvent’ expects that inhabitants will utilize energy in a more reasonable manner so as to have more energy efficient buildings. bordernet project aims to improve the prevention, testing and treatment of hiv/aids/stis by reducing obstacles related to practice, policies and cooperation between border countries and among member states though a more transparent and sustainable network. this will further improve the effectiveness and efficiency capacity of organizations of various sectors responding to aids/stis. ‘engender’ expects that increasing the awareness and creating a platform for all stakeholders to be well informed through the online inventory of best practices, will result in effective, efficient policies and programs that focus on achieving gender equity in health. 28 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 table 4. efficiency aspects identified in project proposals improving patient safety of hospital care through day surgery (daysafe). "the project will enhance ds which represents a crucial strategic approach toward the improvement of health services safety and quality, including patient’s satisfaction, together with technical efficiency and, possibly, equity" the (guidelines) "will reconcile health and energy impacts by protecting people staying in these health-based ventilation guidelines for europe (healthvent) buildings against risk factors, and at the same time taking into account the need for using energy rationally and the need for more energy efficient buildings" "the improved effectiveness and efficiency on highly active prevention: scale up hiv/aids/sti prevention, diagnostic and therapy across sectors and borders in cee and see (bordernetwork) regional and cross-border level in interdisciplinary response to aids/stis and scale up of hiv/sti testing will put forward the practical implementation of hiv combination prevention" "increased awareness and knowledge for all inventory of good practices in europe for promoting gender equity in health (engender) stakeholders including: policy makers, politicians, researchers, ngos and citizens, within and outside the health sector about effective, efficient policies and programmes to achieve gender equity in health" shared values of the 2007 eu health strategy in the php 2008-2013 project proposals? out of the four shared health values, only accessibility to quality health care and equity were addressed in the summaries of the project proposals. basing on the description given for universality, the value was in a way linked to the context used to describe accessibility. from this assessment, more principles are seen to be used in association such as, ‘accessibility and universality’, ‘universality and equity’. • accessibility to quality health care: accessibility was analyzed in the projects in two parts: first, those projects that promote high quality health care services and secondly, those that ensure high quality of health care are accessible to all. ‘coorenor’, ‘daysafe’ and ‘implement’ projects discuss ‘high quality of health care’ by stating that quality assurance models are present in their projects and will ensure safe and high quality of services across the eu. ‘imp.ac. t’ and ‘promovox’ projects promote actions that particularly focus on marginalized groups and migrants. ‘imp.ac. t’ aims to ensure that access to hiv/tb testing for marginalized groups is improved, and ‘promovox’ emphasizes the facilitation of better access of immunizations among the migrant population. ‘care-nmd’ relates accessibility of healthcare to reduced inequalities. the project believes that, by improving the access aspects of efficiency/ efficient identified in the php project proposals project title 29 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 to expert care, there will be a reduction of inequalities among member states and within a member state. 30 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 table 5. accessibility to quality health care as identified in the summaries of the project-proposals coordinating a european initiative among national organizations for organ transplantation (coorenor) "all requirements for ensure recipient safety and high quality of the treatment as well as running models for quality assurance will be considered and transferred to the eu institutions "the general objective of the improving patient safety of hospital care through day surgery (daysafe) project is to improve patient safety & quality of hospital care through the promotion of ds best practice and standards. implementing strategic bundles for infection prevention and management (implement) "aims to improve patient safety through high quality and safe healthcare". “bordernetwork' focuses both highly active prevention: scale up hiv/aids/sti prevention, diagnostic and therapy across sectors and borders in cee and see. (bordernetwork) disease causes and underlying social determinants of health, aiming to improve responses to prevention offers and accessibility of care services”. a) “improving access to hiv/tb improving access to hiv/tb testing for marginalized groups (imp.ac.t) testing for marginalized groups b) “to increase the percentage of idus and migrants having access to hiv and tb testing” “improve migrants understanding promote vaccinations among migrant populations in europe (promovax) & acceptance of immunizations and facilitate their access to immunizations by identifying a network of relevant sites”. "improved access to specialist care dissemination and implementation of the standards of care for duchenne muscular dystrophy in europe (including eastern countries) (care-nmd) for dmd and reduction of inequalities between countries & within countries due to better trained health professionals" accessibility to quality health care value as used in the php project proposals project title 31 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 ethical concepts or aspects in the php 2008-2013 • ethics: under the strategic relevance and contribution to the php section, ‘chain of trust’ acknowledges that the consideration of ethical associated issues while developing recommendations related to the approval of telemedicine by patients and health professionals is important especially during the implementation of telemedicine. ‘apyn’ will assist in realizing the work plan priority 3.3.4 for preventing addiction and further contribute to the alcohol strategy. the project proposes to consider “ethically sound actions” which, according to the priority areas for 2008 as stated in the 2008 work plan, refers to the ethical aspects outlined in the charter of fundamental rights of the european union. “ethical considerations: any proposal, which contravenes fundamental ethical principles particularly those set out in the charter of fundamental rights of the european union may be excluded from the evaluation and selection process” (16). apyn’ and ‘healthy eco life’ will support the work plan actions through the “involvement of new (non-traditional) actors for health in sustained, co-operative and ethically sound actions, both at regional or local level and across participating countries” (chafea, n.d). • values: ‘active’ intends to introduce a new method that will engage children between 5-8 years of age in europe. it is evident from their title that the project aims to teach and inspire the children with values and views concerning healthy eating and physical activity‘animation for children to teach and influence values and views on healthy eating and physical activity (active)’. however, the project only mentions the term ‘values’ in its title. discussion these ethical principles ensure that the individuals or professionals governed by them align their actions and conduct with the principles in order to uphold the society’s trust. most of the ethical principles used in public health actions and research assist in making sure that researchers and public health professionals are held responsible by society. moreover, ethical principles enable researchers to develop trust with the society, which often may cause them to receive funding or financial support for their research from the public because of their reliable and excellent work. furthermore, upholding ethical principles in research will stimulate the consideration of significant moral and social values (9). therefore, it is important for public health professionals and all stakeholders to abide by ethical principles in their duties. additionally, ethical consideration is not limited to public health professionals only at a european level, it is also relevant for public health research and projects of the eu’s public health programmes. with the php 2008-2013 being aligned with the health strategy ‘together for health’, which was explicitly value based in setting priorities, ethics still plays a significant role in the explicit project proposals; yet, this role is not evident in all the phps. however, it is surprising to see that less than half of the projects considered the principle equity which is regarded as a public health and an eu strategy priority. it is clear from the projects, that the mention of equity in their objectives and expected outcomes is not a sufficient indication of ethical consideration, for example, by mentioning that project actions will promote the coordination of abilities from both eastern and western 32 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 europe, coorenor project justifies its role in reducing health inequalities. this is an example to show that the mere mention of ethical principle is not an indication for its consideration in the entire project implementation and therefore the project falls short of explicitly considering equity. in spite of this, various projects still gave relevance to ethical principles and values as they exhaustively discussed in their project summaries matters that related to ethics. ‘daysafe’ recognizes that challenges exist which cause inaccessibility to quality and safe health care, hence they progress to propose methods that will promote equity in health. in discussing ‘efficiency’, the four projects, ‘bordernetwork’, ‘healthvent’, ‘daysafe’ and ‘engender’,only discussed how their activities and methods will result in efficient services and materials. they however fail to show in their methods how this will be attained and only limit it to mention that providing of policy guidelines will promote efficiency. regarding ‘accessibility to quality health care’, the projects questioned the quality and safety of health care services offered in europe and offered to foster a high level of surveillance and monitoring to further ensure that the quality health care is accessible to all patients. they linked quality assurance strategies to high quality services. even though some projects did not explicitly mention ‘accessibility’, their objectives and method description matched the value ‘universality’ while also linking it to reduced inequalities, as they emphasized that no one particularly minorities such as, migrants, hiv/aids and tb patients, should be denied access to health care. most of the projects had implicit discussions of how best practices should be shared across the eu and coordination among all different stakeholders should be supported in order to reduce inequalities in health instead of the explicit mention of solidarity. ex-post evaluation of the health programme the aim of this evaluation was to assess the main results that were reached as well as recognize the key challenges and solutions especially after consideration of recommendations from preceding assessments. the post evaluation study was guided by four key themes that is programme management, dissemination methods, the effect of the health programme collaboration with other programmes and services. according to the assessment, the programme lacked proper management as monitoring data was not used, thus making follow up a challenge. in order to increase the number of accepted and executed health programme funded actions, the main results of the health actions have to be made available to the relevant target groups. the 2nd health programme objectives were very broad, covering various significant needs of the member states as well as those of the stakeholders. it was therefore recommended that the health programme ought to introduce more specific progress analysis as they have been defined in the 3rd health programme. with regard to the 2nd health programme’s objectives, the funded actions led to significant advancements such as, promoting cross-border partnerships. it is important to note that, the administrative duties of the programme were increasingly efficient. moreover, the 2nd programme has shown major eu added value in recognizing best practices as well as networking (17). even though, the objectives of the health programme are commendable as they seek good practices and also focus on national priorities while contributing to a healthy status for the european population, they are still very broad and only focus on the relevance of the action. therefore, they may fail to explicitly address most of the ethical principles used in this study. 33 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 since the study has examined only the explicit use of ethical principles and concepts in the project summaries and the php objectives, the ethical framework may therefore exclude implicit discussions of ethical principles and other significant ethical values especially those based on ethical definitions not considered in the descriptions provided for this study. despite the fact that the ethical framework used for this assessment was based on seven principles, the study therefore doesn’t provide a full picture of this ethical role in php but provides a new mentality and platform that will enable the explicit rethinking and reconsidering of ethics and ethical aspects in public health. this new mentality and concern according to callahan and jennings will lead us to considering vital questions such as: “what are the basic ethical issues of public health? what ethical orientations are most helpful in the clarification and resolution of these issues? how are ethical principles and concepts incorporated into decision making in public health agencies and programs? how adequately are ethical dimensions of public health policy identified and debated?” this is because as public health gains more prominence, the ethical aspects regarding health issues increase too (2). conclusions this paper has presented and outlined ethical aspects that were explicitly identified in the 2008-2013 programme objectives and available project reports of the php. the projects were assessed, based on the theoretical framework consisting seven ethical principles. furthermore, the four shared health values of the eu health strategy were considered as they were more general ethical concepts. from the analysis, the principle ‘equity’ was extensively discussed and considered by some of the projects, followed by the ‘efficiency’ principle and then the value ‘accessibility to quality health care’. the study recognizes that by focusing on the role of ethics in php through the eyes of only the seven principles and the shared health values, other ethical relations and aspects which are still vital in phps may have been excluded. most commonly addressed values of the eu health strategy: ‘together for health’ by the projects were, ‘equity’, ‘accessibility’ and ‘universality’ as it seemed expected from them since the php was based on values. it is encouraging to see that most of the shared health values were discussed in most of the projects. even though vital principles such as‘respect for human dignity’, ‘autonomy’, and ‘health maximization’ were not addressed by any of the projects. it is clear from the projects, that the mere mention of a principle briefly such as ‘project will ensure equity’ in the project objectives and expected outcomes is not enough to justify that the principle will be adequately considered or that the project understands or acknowledges the significance of ethics in public health today. the project needs to consistently consider ethical aspects in its entire proposal, in this case a project summary, and not just mention it, since it is required and expected to be included under the ‘strategic relevance and contribution to public health programme’ section. this study has tried to paint a picture of the role of ethics in public health programmes. even with its prominence, ethics in public health programmes and activities still needs to be encouraged. moreover, more awareness in understanding ethics and ethical aspects in public health activities will further steer more ethical considerations not only amongst public health professionals and researchers, but also a more explicit and consistent consideration in phps and public health actions. in addition, basing on gostin’s work, ethical values ought to be 34 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 considered firstly by professionals in order to guide them in working for the common good of the society. secondly, in public health in terms of how decision making influences the balance between individual and communal interests especially in the implementation of public policies. thirdly, ethics for public health where the needs of the population are met in practical ways, such as more emphasis on training and research to improve ethical knowledge, as well as applications. this study has therefore provided a new mentality and platform that will enable the explicit rethinking and reconsidering of ethics and ethical aspects in public health. references 1. beauchamp tl, childress jf. principles of biomedical ethics: oxford university press; 2001. 2. callahan d, jennings b. ethics and public health: forging a strong relationship. am j public health 2002;92:169-76. 3. preston n. understanding ethics. the federation press; 2007. 4. mann jm. medicine and public health, ethics and human rights. hastings center report 1997;27:6-13. 5. kass ne. public health ethics from foundations and frameworks to justice and global public health. j law med ethics 2004;32:232-42. 6. commission e. white paper–together for health: a strategic approach for the eu 2008–2013; 2007. 7. coughlin ss. ethical issues in epidemiologic research and public health practice. emerg themes epidemiol2006;3:16. 8. gostin lo. public health, ethics, and human rights: a tribute to the late jonathan mann. j law med ethics 2001;29:121-30. 9. resnik db. what is ethics in research & why is it important. research triangle park, north carolina: national institute of environmental health sciences/national institute of health; 2010. 10. commission e. together for health: a strategic approach for the eu 2008–2013. white paper, ip/07/1571; 2007;23. 11. schröder-bäck p, brand h, escamilla i, davies jk, hall c, hickey k, et al. ethical evaluation of compulsory measles immunisation as a benchmark for good health management in the european union. centr eur j public health 2009;17:183. 12. tannahill a. beyond evidence—to ethics: a decision-making framework for health promotion, public health and health improvement. health promot int2008;23:380-90. 13. sørensen k, schuh b, stapleton g, schröder-bäck p. exploring the ethical scope of health literacy: a critical literature review. alban med j 2013;2:71-83. 14. bowling a. research methods in health: investigating health and health services: mcgraw-hill international; 2009. 15. council directive. decision 1350/2007ec of the european parliament and of the council of europe; 23 october 2007. 16. commission. e. guide for the evaluation for proposals for action grants and operating grants, joint actions; 2008. 17. directorate-general for health and consumers: the second health programme 2008 2013. http://ec.europa.eu/health/programme/policy/2008-2013_en. accessed 13 july 2015. http://ec.europa.eu/health/programme/policy/2008-2013_en� 35 otenyo nk. the relevance of ethics in the european union’s second public health programme (original research). seejph 2017, posted: 10 march 2017. doi:10.4119/unibi/seejph-2017-138 © 2017 otenyo; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0)� 36 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 original research trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood giovanni piumatti1 1 department of psychiatry, university of oxford, oxford, uk. corresponding author: giovanni piumatti, phd; address: warneford hospital, ox3 7jx, oxford, uk; telephone: +393335251387; email: giovanni.piumatti@psych.ox.ac.uk mailto:giovanni.piumatti@psych.ox.ac.uk� 37 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 abstract aim: the aim of this study was to examine how university students’ achievement strategies in an academic context and perceptions of criteria for adulthood relate to life satisfaction trajectories across one year. methods: a convenience sample of 143 young adults 18-28 years (mean age: 20.9±2.7 years; 109 females and 34 males) attending the university of turin in northwest italy completed questionnaires at three points with a six-month interval between each measurement. latent growth curve modelling and latent class growth analysis were used to assess longitudinal changes in life satisfaction and the related heterogeneity within the current sample. results: three trajectories of life satisfaction emerged: high stable (37%), moderate decreasing (57%), and low stable (6%). at every time point high success expectations were related to a high stable life satisfaction trajectory. in turn, those adopting achievement avoidance strategies were more likely to have low-stable or moderately decreasing life satisfaction trajectories. the perception of the criteria deemed important to be defined as adults did not change across time points or across life satisfaction trajectories’ groups. conclusion: these findings suggest that self-reported measures of achievement strategies among university students relate longitudinally to life satisfaction levels. positive and optimistic dimensions of personal striving may be protective factors against the risk of decrease of life satisfaction among university students. keywords: achievement strategies, criteria for adulthood, developmental trajectories, life satisfaction, person-oriented approach. conflicts of interest: none. note of the author: some results of the present paper have been previously presented at the 7th conference of the society for the study of emerging adulthood in miami, florida, october 14-16, 2015. 38 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 introduction according to diener, emmons, larsen, and griffin (1) life satisfaction (ls) is defined as an individual’s overall appraisals of the quality of his or her life. in the social and psychological sciences this construct has become a key variable for analyzing individuals overall subjective well-being (2). longitudinal studies have shown that after adolescence the majority of people experience stability in ls over long periods of times (3). however, depending on the length of time, one may observe short-, intermediateand long-term influences on ls (4). indeed, in the field of life-span research, the development of ls over time has become a very important baseline through which more variegated trajectories of individual development are observed (5). especially among older cohorts (i.e., aged 18 and above), given the relative stable differences in ls between observed latent growth groups in comparison with the more turbulent adolescence years, many have adopted a person-oriented approach (6,7) to describe which other characteristics unite individuals of a certain developmental trajectory of ls. for example, ranta, chow, and salmela-aro (8) have associated trajectories of ls among young adults to their self-perceived financial situation, concluding that positive ls trajectories relate to being in a positive self-perceived financial situation. röcke and lachman (3) observed how to maintain stable trajectories of positive ls individuals need intact social relations as well as a high sense of control. in addition, salmela-aro and tuominen-soini (9) and salmela-aro and tynkkynen (7) found that education achievement during and after secondary education positively correlated with high stable ls. emerging adulthood research proposes that the growing acquisition of maturity regarding adulthood-related duties and roles such as the commitment to life-long relationships or the importance attributed to forming a family are parallel to a stable ls path (10). in general, in the age range 18-30 years, perceiving oneself as an adult correlates to higher levels of ls and positive affect (11). such findings contributed to give credit to the theoretical assumption stating that among young adults the increasing acquisition of an adult identity and the endorsement of adulthood-related criteria are concurrent factors in determining positive outcomes at the individual level, as for example higher ls. at the same time, if we adopt a person-oriented approach to look at this issue, we might expect that others characteristics may define those young adults proceeding through transitions while exhibiting a mature adult identity and high ls. in an academic context, for example, the kinds of cognitive and attributional strategies individuals deploy provide a basis for their success in various situations (12), as well as for the positive development of their well-being (13). accordingly, in the present study we aimed at integrating the research literature on the relationship between the attainment of adult maturity and well-being with indicators of individual achievement strategies typical of life-span studies. more specifically, through a longitudinal approach, we questioned whether university students’ ls changes during a one year period and what kind of trajectories can be found. secondly, we examined young adults’ perception of the criteria deemed important for adulthood and achievement strategies in the academic context in relation to ls trajectories. the italian context university students account for a good proportion of the population aged 18-30 years in italy, although italian national statistics show a steady decrease in the overall university enrolment rates (14). moreover, italy reports one of the highest rates of university withdrawals among oecd members (15), with some regional differences between north and south (with dropout rates being higher in the latter), but overall widespread across the country (16). despite the considerable high social cost related to dropout rates during tertiary education and the interrelation between motivation, education attainment and well-being among young adults 39 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 (17), very few studies have examined from a longitudinal and psychological perspective how self-reported measures of well-being such as ls interact with motivational strategies in an academic context in italy (18). accordingly, the present study aimed to test the specific research hypothesis that positive motivational attitudes in an academic context relate to higher ls levels among young adults attending university and, possibly, to a higher acquisition of adulthood maturity. methods sample the empirical data of the present study were collected through the submission at three time points of an online questionnaire to a convenience sample of university students in the north western italian city of turin. participants were reached in various university settings of the faculty of psychology, including libraries, canteens, cafeterias and public leisure spaces. the criteria to take part in the study were being enrolled as a full-time university student, being italian and aged between 18 to 30 years. students provided their email contacts if they were interested in taking part in the study. then, they received a link to the online questionnaire through email. at time 1, 645 individuals (76% females; mean age: 22.1 years) completed the questionnaire. at time 2, six months afterwards, 252 individuals (79% females; mean age: 22.3 years) completed again the same questionnaire. finally, at time 3, twelve months after time 1, 150 individuals (77% females; mean age: 22.1 years) filled in the questionnaire. the very high dropping rate from time 1 to time 2 and time 3 can be explained by the total absence of an incentive for the participants to take part in the study (e.g., money, or school credits). therefore, it is reasonable to imagine that only those personally interested in the topic or in the research itself were willing to fill in the questionnaire. in fact, while the dropping rate from time 1 to time 2 was equal to 61%, from time 2 to time 3 it was equal to 41% (of the total number of participants at time 2), indicating a significant decline in the number of people dropping out. this may be explained by the fact that at time 2 the proportion of participants interested in the research was higher than at time 1. moreover, only the participants who filled in the questionnaire at time 2 were contacted again at time 3. measures life satisfaction ls was measured using the satisfaction with life scale (1). participants rated five items (for example, “i am satisfied with my life”, and “the conditions of my life are excellent”) on a 7 point likert-type scale ranging from 1 (totally disagree) to 7 (totally agree). a mean score was calculated for all items. cronbach’s alphas ranged from 0.69 to 0.79 across the three measurement points, indicating a good level of internal consistency with respect to the ls variable. achievement strategies four different types of achievement strategies in an academic context were assessed: success expectation, (cronbach’s alphas ranged from 0.68 to 0.73), measuring the extent to which people expect success and are not anxious about the possibility of failure (4 items, e.g., “when i get ready to start a task, i am usually certain that i will succeed in it”); task irrelevant behaviour (α from 0.76 to 0.82), measuring the extent to which people tend to behave in a social situation in ways which prevent rather than promote involvement (7 items, e.g., “what often occurs is that i find something else to do when i have a difficult task in front of me”); seeking social support (α from 0.73 to 0.77) measuring the extent to which 40 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 people tend to seek social support from other people (6 items, e.g., “it is not worth complaining to others about your worries”); and avoidance (α from 0.77 to 0.76), measuring the extent to which people have a tendency to avoid social situations and feel anxious and uncomfortable in them (6 items, e.g., “i often feel uncomfortable in a large group of people”). the scales belong to the strategy and attribution questionnaire (19). criteria for adulthood participants rated the importance of 36 criteria for adulthood (20) on their degree of importance on a scale of 1 (not at all important) through 4 (very important). based on previous research (10,20), these criteria were grouped into six categories: interdependence (α from 0.60 to 0.65; 5 items; e.g., “committed to long-term love relationship”), role transitions (α from 0.84 to 0.86; 6 items; e.g., “have at least one child”), norm compliance (α from 0.77 to 0.82; 8 items; e.g., “avoid becoming drunk”), age/biological transitions (α from 0.70 to 0.74; 4 items; e.g., “grow to full height”), legal transitions(α from 0.81 to 0.86; 5 items; e.g., “have obtained license and can drive an automobile”) and family capacities (α from 0.75 to 0.77; 8 items; e.g., “become capable of caring for children”). analysis the analyses followed three steps. first, to examine how ls changes during a one-year period, latent growth curve modelling (lgcm) (21) estimated the average initial level and slope of ls among the participants. the following indicators assessed the goodness-of-fit of the estimated lgcm: χ²-test, the comparative fit index (cfi) with a cut-off value of ≥0 .95, and the standardized root mean square residual (srmr) with a cut-off value of≤0 .09. subsequently, to evidence whether different types of ls trajectories emerge from the total sample, the analyses of this longitudinal data set extended into latent class growth analysis (lcga) (22). lcga examines unobserved heterogeneity in the development of an outcome over time, by identifying homogeneous subpopulations that differ with respect to their developmental trajectories within the larger heterogeneous population. lcga is exploratory by nature, which means that there are no specific a priori assumptions regarding the exact number of latent classes. when testing lcga models, different class solutions are specified. the best-fitting model is then selected based on the goodness-of-fit indices and theoretical considerations. here, the following goodness-of-fit indices evaluated the models: akaise’s information criteria (aic), bayesian information criteria (bic) and adjusted bayesian information criteria (abic) of the alternative models. entropy values were also examined, with values close to 1 indicating a clear classification. following marsh, lüdtke, trautwein, and morin (18), groups of ≥ 5% of the sample were considered the smallest to give an acceptable solution. practical usefulness, theoretical justification and interpretability of the latent group solutions were also taken into consideration (23). the analyses were controlled for age, gender and self-perceived socio-economic status (participants were asked how they would rate their actual socio-economical position on a scale from 1 – not good at all to 5 – very good). both lgcm and lcga analyses were conducted with the mplus 5.0 statistical software program. at last, one-way analysis of variance (anova) examined if the ls trajectory groups differed in terms of their achievement strategies and importance attributed to criteria for adulthood. post-hoc comparisons using the games-howell test examined differences between groups. 41 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 results development of life satisfaction the specified lgcm with a linear slope for ls change across the three time points fits the data well, χ²=3.99(1), p<0.05; cfi=0.98; srmr=0.04. in particular, while the intercept indicating the initial level of ls was statistically significant, the linear slope was not (intercept m= 3.02, se=0.05, p<0.001; slope m = -0.11, se=0.02, p>0.05). in addition, while the variance of the intercept was significant the variance of the slope was not (intercept variance =0.15, p<0.001; slope variance 0.01, p>0.05). together these results indicate that first, on average, there was no significant longitudinal change in ls across the three measurement points, and second, that there was a significant individual variance in the initial levels but not in the rate of change. thus, the significant heterogeneity among individuals was analyzed further adopting the person-oriented approach of latent class growth models. more specifically, these results suggest that, rather than investigating different rates of longitudinal change in ls within the overall sample, it would be more plausible to observe latent groups exhibiting stable trajectories of ls across time while being concurrently significantly different between each-other from baseline to the last follow-up. identifying life satisfaction trajectories lcga identified three sub-groups of individuals according to their levels of ls across measurement points. table 1 shows the fit indices and class frequencies for different latent class growth solutions. the four-class solution was unacceptable given the presence of a group with zero individuals. the three-class solution was thus the most optimal given the numerical balance of the observed groups and its higher entropy value with respect to the two-class solution (i.e., values closed to zero are indicative of better fit). figure 1 displays the estimated growth curves for the different latent trajectories of ls, whereas table 1 reports lcgm results. figure 1. life satisfaction trajectories (mean values in a scale 1-7) 7 6 5 high stable (n = 52; 37%) 4 moderate decreasing (n = 82; 57%) 3 low stable (n = 9; 6%) 2 1 0 t1 life satisfaction t2 life satisfaction t3 life satisfaction 42 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 table 1. fit indices and class frequencies based on estimated posterior probabilities for latent class growth models of life satisfaction with different numbers of latent trajectory groups number of groups bic abic aic entropy 1 766.94 751.12 752.13 2 (n1 = 69%, n2 = 31%) 684.93 659.62 661.23 .747 3 (n1 = 37%, n2 = 6%, n3 = 57%) 652.44 617.64 619.85 .827 4 (n1 = 6%, n2 = 58%, n3 = 0%, n4 = 36%) 667.33 623.03 625.85 .863 note. bic = bayesian information criteria; abic = adjusted bayesian information criteria; aic = akaike information criteria. the chosen option is marked in bold. the latent trajectories of ls were labelled high stable (37%), moderate decreasing (57%), and low stable (6%). ls mean levels of the high and the low stable trajectory groups remained stable over time. on the other hand, the moderate decreasing group exhibited a significant decrease in ls mean levels over time (see table 2). anova and chi-square tests evidenced how the three sub-groups did not differ according to age, f(2, 150)=0.01, p>0.05, gender, x2 (2, 150)=1.56, p>0.05, and self-perceived socio-economic position, x2 (2, 150)=8.13, p>0.05. table 2. estimation results of the final growth mixture model with five latent classes (unstandardized estimates; standard errors in parentheses) mean structure high stable (n=52; 37%) moderate decreasing (n=82; 57%) low stable (n=9; 6%) level 3.42 (0.05)** 2.83 (0.05)** 1.91 (0.11)** change -.09 (0.06) -.25 (0.05)** -.14 (0.20) note. variance is kept equal across the different latent groups. ** p< .001 differences in achievement strategies and criteria for adulthood the second analytical step consisted of testing whether the three observed ls trajectory groups were significantly different at each time point concerning self-reported achievement strategies outcomes in the academic context and the importance attributed to criteria for adulthood. table 2 reports all effects and pairwise mean comparisons between ls groups. since we did not observe any significant effect of ls trajectory group membership on the mean levels of the importance attributed to the criteria for adulthood, we decided not to report in a table such results for parsimony reasons. on the other hand, it appears clear how the three developmental trajectories groups consistently differed across time points regarding the types of achievement strategies they adopted in their academic activities. more specifically, from time 1 to time 3, the high stable group showed the highest levels of success expectation and the lowest levels of task irrelevant behaviour and avoidance. diametrically opposite was the performance of individuals in the low stable group who consistently showed the lowest levels of success expectation and the highest levels of task irrelevant behaviour and avoidance. finally, the moderate decreasing group reported a stable success expectation over time, but a slight increasing in avoidance. in fact, while at time 1, the avoidance did not differ between the moderate and the high stable group, from time 2 to time 3, individuals in the moderate decreasing group showed the same level of avoidance as the individuals in the low stable group. 43 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 44 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 overall, these results indicate that the types of achievement strategies in the current sample are linked to different ls development trajectories. furthermore, such measures of personal agency did not relate to different perceptions of the criteria deemed important for adulthood, nor the latter seem to correlate with ls developmental trajectories. discussion the current research focused on a longitudinal convenience sample of young adults attending university in the north-western italian city of turin. the person-oriented model tested here provided theoretical evidence of the overtime interconnection between motivational strategies in an academic context and well-being among university students. the main contribution of the present study was the adoption of a person-oriented approach (6) to focus on the issue of the perception of adulthood among young adults. indeed, to date, very few studies (24) have opted not to focus entirely on the relations between singular variables but instead to look at more elaborated systems of individual characteristics to draw a ‘picture’ of different ‘types’ of emerging adults in western societies. moreover, the longitudinal nature of the trajectory analysis contributed to test whether for emerging adults the perception of what it means to be considered adults nowadays is a stable construct over time, even if just across only one-year period. in particular, the latent curve growth analysis implemented here has represented a more fruitful way for examining young adults’ individual development (22). indeed, a single growth trajectory would have oversimplified the heterogeneity of the changes in emerging adults’ life satisfaction over time, as some experience an increase and some a decrease in life satisfaction, although the majority seem to experience a significant stability (7). in this study, it was possible to identify meaningful latent classes of individuals according to the initial levels and the longitudinal changes in their life satisfaction across the three measurement points. adopting this multiple trajectories approach resulted in a model of three developmental trajectories. overall, two major conclusions can be drawn from the present study. first, starting from the non-significant findings, it appeared that the perception of the most important criteria for adulthood (i.e., family capacities, interdependence, norm compliance) are not correlated to life satisfaction trajectories, either low or high. second, achievement strategies reflecting notions of agency were closely linked to life satisfaction, both about initial level and development. the first findings can reasonably be the result of the limited time span across which we aimed at observing developmental changes. indeed, we already know that emerging adults are more prone to change their perception of adulthood especially in correspondence with crucial life events, such as getting married, experience of parenthood, finishing the studies and start working (10,11). therefore, the impossibility to control for such events in the present study or simply the fact that the very small sample did not include a sufficient number of people going through specific transitions’ thresholds, can explain why we did not observe significant differences across developmental groups who instead remained stable in their opinions over the curse of one year. however, we were not just interested in looking at changes, but we argued for stable differences across developmental trajectory groups. again, despite the fact that we observed trajectory groups that showed significant differences in motivational strategies across time, these did not relate to adulthood self-perception. these results might confirm how the major sources of adulthood identity variation over time are significant experiences related to it. the significant differences between groups in terms of achievement strategies suggest that these measures of motivation and life satisfaction are strictly related. specifically, individuals with a high level of positive achievement approach strategies demonstrated high levels of life satisfaction. on the contrary, high levels of avoidance and irrelevant behaviours mostly 45 piumatti g. trajectories of life satisfaction during one-year period among university students: relations with measures of achievement strategies and perception of criteria for adulthood (original research). seejph 2017, posted: 20march 2017. doi:10.4119/unibi/seejph-2017-140 related to low levels of life satisfaction. a closer look revealed that individuals in the moderate decreasing life satisfaction trajectory maintained a more stable level of avoidance over time than the other two groups that both showed instead a decreasing in avoidance. thus, personal strivings and strategies may be protective factors against a decrease in life satisfaction. in summary, the findings from the current study are aligned with previous research work focusing on samples of young adults attending university and evidencing how individuals’ achievement strategies measured during university studies affect subjective well-being outcomes (25,26), including life satisfaction (27,28). in particular, in accordance with our results, success expectations are positively associated with higher satisfaction (29) and poor engagement relate to low well-being (27). these evidences should guide future research with the aim of further investigating the role of different types of agentic personality traits among university students in relation to positive life outcomes and health behaviours as factors strongly related to subjective well-being outcomes. study limitations and conclusions it is important to point out the main limitations of the current study. firstly, owning to the person-oriented statistical approach and despite the study longitudinal design, the analyses did not explicitly report on any causal relationship between measures of achievement strategies and overall satisfaction with life. future studies should look more specifically into cause-effect models using these types of self-reported measures of achievement strategies and various well-being outcomes. secondly, the convenience sample of university students included in this study cannot be considered representative of the entire population of university students in the context of reference (i.e., the university of turin in italy). accordingly, the generalizability of the current findings should be considered with caution while they may well represent a base 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grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 review article nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review thomas grochtdreis1,2, nynke de jong3, niels harenberg2, stefan görres2, peter schröder-bäck4,5 1 department of health economics and health services research, hamburg centre for health economics, university medical centre hamburg-eppendorf, hamburg, germany; 2 institute for public health and nursing science, university of bremen, bremen, germany; 3 department of educational development and research, school of health professions edu cation, faculty of health, medicine and life sciences, maastricht university, maastricht, the netherlands; 4 department of international health, caphri school for public health and primary care, faculty of health, medicine and life sciences, maastricht university, maastricht, the neth erlands; 5 faculty for human and health sciences, university of bremen, bremen, germany. corresponding author: thomas grochtdreis, department of health economics and health services research, hamburg centre for health economics, university medical centre ham burg-eppendorf; address: martinistr. 52, 20246 hamburg, germany; telephone: +49407410-52405; email: t.grochtdreis@uke.de mailto:t.grochtdreis@uke.de� mailto:t.grochtdreis@uke.de� mailto:t.grochtdreis@uke.de� 49 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 abstract aim: nurses play a central role in disaster preparedness and management, as well as in emergency response, in many countries over the world. care in a disaster environment is dif ferent from day-to-day nursing care and nurses have special needs during a disaster. how ever, disaster nursing education is seldom provided and a lack of curricula exists in many countries around the world. the aim of this literature review is to provide an overview of nurses‟ roles, knowledge and experience in national disaster preparedness and emergency response. methods: an electronic search was conducted using multiple literature databases. all items were included, regardless of the publication year. all abstracts were screened for relevance and a synthesis of evidence of relevant articles was undertaken. relevant information was extracted, summarized and categorized. out of 432 reviewed references, information of 68 articles was included in this review. results: the sub-themes of the first main theme (a) roles of nurses during emergency re sponse include the expectations of the hospital and the public, general and special roles of nurses, assignments of medical tasks, special role during a pandemic influenza, role conflicts during a disaster, willingness to respond to a disaster. for (b) disaster preparedness knowl edge of nurses, the corresponding sub-themes include the definition of a disaster, core com petencies and curriculum, undergraduate nursing education and continuing education pro grams, disaster drills, training and exercises, preparedness. the sub-themes for the last theme (c) disaster experiences of nurses include the work environment, nursing care, feelings, stressors, willingness to respond as well as lessons learned and impacts. conclusion: there is consensus in the literature that nurses are key players in emergency response. however, no clear mandate for nurses exists concerning their tasks during a disas ter. for a nurse, to be able to respond to a disaster, personal and professional preparedness, in terms of education and training, are central. the framework of disaster nursing competen cies of the who and icn, broken down into national core competencies, will serve as a suf ficient complement to the knowledge and skills of nurses already acquired through basic nursing curricula. during and after a disaster, attention should be applied to the work envi ronment, feelings and stressors of nurses, not only to raise the willingness to respond to a disaster. where non-existent, national directives and concepts for disaster nursing should be developed and nurses should be aware of their duties. nursing educators should prepare nurses for disasters, by adjusting the curricula and by meeting the increased need for educa tion and training in disaster nursing for all groups of nurses. the appropriateness of theoreti cal and practical preparation of disaster nursing competencies in undergraduate nursing courses and continuing education programmes should be evaluated. keywords: disasters, disaster planning, emergencies, emergency preparedness, nurses. conflicts of interest: thomas grochtdreis is a member of the german red cross and vice president of the german red cross youth. the other authors do not declare any conflicts of interest. 50 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 introduction disasters are defined by the centre for research on the epidemiology of disasters (cred) as “a situation or event, which overwhelms local capacity, necessitating a request to a na tional or international level for external assistance; an unforeseen and often sudden event that causes great damage, destruction and human suffering” (1). disasters are classified as natural, biological, geophysical, climatological, hydrological, meteorological, and techno logical (2). recent examples of major disasters are the earthquake in haiti in 2010 as an example of a natural disaster and the earthquake followed by a tsunami and the nuclear catastrophe in ja pan in 2011 as an example of a mixed natural and manmade disaster. within the countries of western europe, more than five million people have been affected by a variety of disaster types (e.g., 4,295,600 people affected by storms, 684,492 by floods, and 816 by epidemics) in the last 20 years. within this timeframe, 8,835 people were injured and 38,643 people were killed (3). in order to master a huge number of affected people due to a disaster within a short period, it is important to have well trained first-response personnel or volunteers. here, an essential role is allotted to nurses for integrating communicating efforts across these protagonists and for having role competencies in disaster preparation. it is quite probable that at some time in the future, nurses may be called upon to respond to a mass casualty event or disaster outside of the hospitals. therefore, a need for nurses, who are well trained and prepared, arises on a national as well as on an international level (4). referring to the conditions in the usa, four strengths of nurses, which are key to a central role in disaster preparedness and management, as well as in emergency response, can be stated (5): (i) nurses are team players and work effectively in interdisciplinary teams needed in disaster situa tions; (ii) nurses have been advocates for primary, secondary, and tertiary prevention, which means that nurses can play key roles at the forefront in disaster prevention, preparedness, response, recovery, and evaluation; (iii) nurses historically integrate the psychological, social support, and family-oriented aspects of care with psychological needs of patients/clients; and (iv) nurses are available and practic ing across the spectrum of health care delivery system settings and can be mobilized rapidly if neces sary. however, approximately two out of five health care professionals would not respond during health emergencies. the nurses‟ intention to respond to disasters, the needs of nurses who respond to disasters and other health emergencies, and as well as the influence of the nursing shortage and the lack of education preparing nurses for disaster response are important issues which need to be approached (6). concerning the anticipated needs of nurses during a disaster, giarratano, orlando and savage (7) report that during a disaster nurses have to live through the uncertainty of the situation and have to be prepared to adapt to the needs that arise in both patient care and self preservation situations. in order to prepare for emergency response, education within the field of disaster nursing is essential. disaster nursing curricula and preparation of nursing faculty members are distinctly needed to teach disaster nursing in order to prepare nursing students for possible disaster situations adequately in future (6). extensive work towards a comprehensive list of core competencies has been done by the who and icn in their framework of disaster nursing competencies (8). pang, chan and cheng (9) suggest that this framework should equip nurses with similar competencies from around the world while giving attention to local appli cations. 51 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 there is no comprehensive review covering all relevant fields of professional socialization: role, knowledge and experience. recent reviews do concentrate on either the nurses‟ disaster preparedness, or the response of nurses working during a bioterrorism event (10). the aim of this literature review is to provide an overview of the nurses‟ role, knowledge and experience in national disaster preparedness and emergency response within the international scientific literature. methods search strategy a database search was conducted during september-november 2012 using cinahl (eb sco), pubmed, cochrane library, and carelit. a search strategy was used utilizing the terms „disaster‟ and „nursing‟ as keyword searches or subject headings, where applicable. all study designs as well as expert opinions were included in the review. inclusion criteria were the existence of a relevant abstract on the role, knowledge and experience in the field of dis aster nursing. all results, independent of their publication year and country of publication, written in english or german language, were included. selection criteria in total, 503 articles were identified within the databases; out of these, 71 appeared in more than one database. the abstracts of all included literature (432 references) were scanned for their relevance on the topic. articles were excluded if they definitely lacked relevance, mean ing that the topic of disaster nursing did not appear at all (242 references). as a second step, the articles, which were deemed relevant (190 references), were evaluated in-depth by the first author by initial reading and appraising the relevance in relation to the aim of the litera ture review. articles were excluded if they failed to address nurses‟ role, knowledge or ex perience in national disaster preparedness and emergency response in their full text (103 ref erences) or if they were not available for evaluation (19 references) resulting in 68 included references. a flow chart of the selection process is presented in figure 1. figure 1. flow chart of the selection process 52 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 n=68 no full text avail able: n=19 n=190 double: n=71 data analysis as articles differed in their (study) design, no meta-analysis was possible. therefore, synthe sis of the written evidence was undertaken. categories for analysis, which were predefined through the aim of this literature review, included: (a) roles of nurses during emergency re sponse, (b) disaster preparedness knowledge of nurses and (c) disaster experiences of nurses. for each category, sub-themes were determined out of the different focuses of the articles on disaster nursing (11). for each article, the narratives about a particular sub-theme were ex tracted. the narratives were paraphrased and generalized, where possible. results in total, 68 relevant sources were identified from the literature search. the majority of the studies were descriptive (40%), or expert opinions/case reports (40%). furthermore, 15% of the studies were qualitative and correlational studies, whereas 3% were systematic reviews. the three categories, according to which the articles where analysed, represented also the most important themes: (a) roles of nurses during emergency response, (b) disaster prepared ness knowledge of nurses and (c) disaster experiences of nurses. most of the articles on disas ter nursing were drafted in north america. in europe, no articles concerning disaster experi ences of nurses had been published. below, each theme is divided into paragraphs, which are equivalent to the determined sub-themes. roles of nurses during emergency response the six identified sub-themes include expectations of the public and the hospital, general and special roles of nurses, assignments of medical tasks, special role during a pandemic influ enza and biological terrorism, role conflicts during a disaster and willingness to respond to a disaster. expectations of the public and the hospital: the public expects that nurses are prepared at a personal and professional level and that they have procedures in place, which enable them to pubmed: n=170 abstract not rele vant: n=242 cochrane: n=2 carelit: n=34 cinahl: n=297 article not rele vant: n=103 53 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 serve in an emergency (12). reinforcing, the public has a right to expect effective response from healthcare professional, including nurses (13). moreover, it is anticipated from the hos pitals that nurses know before a disaster what will be expected from them in such a situation, what tasks will have to be fulfilled and who is authorized to issue directives towards them and many employees in hospitals do not know what their role during a disaster will be (14). in order to develop or to optimize the field of disaster nursing nationwide, it is proposed to develop a national committee to help define the discipline, build disaster curricula, and to set disaster competencies. furthermore, nurses need to participate in disaster preparedness plan ning to become familiar with their responsibilities in disaster situations (15). general and special roles of nurses: in general, nurses will have to provide care in a very different context than in their usual practice during disasters (16,17). further, it is imperative that nurses are able to continue working to provide care to additional patients (18). different authors acknowledge that nurses are key players in emergency response (15,17-22). in other words, it can be determined that nurses are in a natural position to assist in a disaster (23), they are the most vital resources in dealing with disasters (24), they have been part of disaster response as long as nurses have existed, nurses will continue to be key players (20) and when nurses are not involved yet in the aspects of disaster care, the involvement should become mandatory (25). particularly, nurses working in disaster-prone areas need to know their pro fessional role in a disaster (26). not every nurse is expected to fulfil any assigned role, and special roles before, during and after a disaster are assigned to nurses with different qualifications (table 1). table 1. general and special roles of nurses nurses meeting surge capacity needs (20) nurses within hospitals (20,27) nurses in general (28-30) nursing executives (31) public health nurses (20) conducting surveillance in the field dispensing mass medication or vaccination in shelters staffing information hotlines in departments of health admitting patients in hospitals identify signs and symptoms of injuries and exposures work in a disciplined team follow clear lines of communication perform according their assigned role directions and responsibilities establish disaster plans train responders coordinate the disaster response provision of care for disaster victims support and protect others from health hazards make life-and-death decisions and decisions about prioritization preserve open lines of communication ensure the quality of patient care, provide current education influence policy and political decisions provide security for staff, patients and families. screening administer first aid and psychosocial support implement infection control procedures and monitoring assignments of medical tasks: during a disaster, nurses are expected to be able to fulfil the role of a medical practitioner in some ways. this role can be described as outside of the nor mal scope of nursing practice, their knowledge or their abilities (32). nevertheless, it is im groups of persons role description 54 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 perative that nurses are trained in disaster medicine in order to be assigned to medical tasks in emergency response (30). the task of triaging patients as an assigned medical task is figured prominently in the literature (19,29,32). special role during a pandemic influenza and biological terrorism: the tasks during epi demic situations are contact tracing, conducting case investigations, engaging in surveillance and reporting, collecting specimens, administering immunizations and educating the commu nity (20). furthermore, in hospital settings, it is expected from nurses to be able to identify, manage and treat infectious outbreaks (32). role conflicts during a disaster and willingness to respond to a disaster: nurses might have conflicts between their professional, their private and their community role, respectively (33). nurses might be therefore less willing to respond to work during a disaster. other reasons influencing the willingness to respond are low baseline knowledge, low perception of per sonal safety, and low perception of clinical competence (34). it is also stated that these fac tors will lead to a shortage of nurses to provide care during a disaster. nurses not responding to a disaster describe having feelings of guilt towards their jobs and co-workers, recognizing the impact of their decision. on the other hand, it is also possible that nurses maintain being able to respond to disasters beyond normal working hours (33). disaster preparedness and knowledge of nurses the six identified sub-themes include definition of a disaster, core competencies and curricu lum, undergraduate nursing education and continuing education programs, disaster drills, training and exercises, as well as preparedness. definition of a disaster: it is acknowledged that nurses might perceive a disaster differently than described from official definitions and classifications such as the one of the cred (1,2). in a study by fung et al. (29), nurses described their perception of a disaster in a fourfold manner. most of the nurses attributed specific characteristics to disasters. exemplarily, these characteristics are being unpredictable, sudden, unexpected or unpreventable, being out of control and not manageable, urgent response, horrible crisis or unknown disease with no treatment available. another way of describing a disaster is by impact, as for example: large numbers of victims, damage to the environment, adverse psychological effects, loss of fam ily, and serious consequences. moreover, disasters were described as demanding emergency services and care. examples are being in need for immediate medical attention, a challenge to professional services or requiring extensive work force to cope. only few nurses described disasters in a way a definition would do: epidemics, accidents, terrorist attacks, natural disas ters, extreme weather and war. core competencies and curriculum: for preparedness purposes, it is very important to have core competencies for education and training as well as for the effectiveness and efficiency of response during a disaster (35). the identification of core competencies and knowledge needed to help and protect self and others during a disaster is an important first step to qualify nurses for disaster response (20,35). weiner (36) refers to the core competencies defined by the nursing education preparedness education coalition (nepec) (table 2). when compar ing knowledge and experiences underpinning these competencies with nursing practice, it can be concluded that many of them are basic to a nursing curriculum (35). furthermore, others claim that nurses already possess the skills enabling them to respond to a disaster. these are purported to be the values of human caring, creativity, the ability to improvise, communica tion and management skills (20,23). on the other hand, usher and mayner (22) state that working in an emergency department or a similar area is (still) not good enough to meet the 55 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 required competencies to respond to a disaster. others claim that nurses working in acute care already have specific disaster nursing core competencies (28). some authors annotate that the area of disaster nursing is underrepresented or lacking in un dergraduate nursing curricula, nurses and nurse practitioners are not able to meet required disaster nursing competencies and that it is urgent to include content in order to enable nurses to respond in times of disasters (6,12,15,17). nursing educators are hold accountable to pre paring nurses for disasters, for example by adjusting the curricula and by meeting the in creased need for education and training in disaster nursing for all groups of nurses (6,17,37). concerning a disaster curriculum, lund et al. (30) propose seven modules for a comprehen sive nursing curriculum to address chemical and biological warfare (table 2). elsewhere, such a training of specialized skills and knowledge is criticized because they are unlikely to be retained until an opportunity to use them is afforded (38). others propose educational components that are more medically oriented (table 2) (14,24). undergraduate nursing education and continuing education programs: the fields of under graduate education and continuing education programmes for nurses are widely discussed in the literature. because nurses have to be aware of disasters and be prepared for them, it is imperative that disaster management and nursing contents and experience are integrated into undergraduate nursing and continuing education programme curricula (15,17,22,24,35,39 41). it has to be acknowledged that all nurses, irrespective of being educated and trained or not, may be called during a disaster and therefore, all nurses must have a minimal knowledge and skills for appropriateness of their response (17,26,29,35). education is critical to the feel ing of safety and competence as well as the willingness to participate in an emergency (32,34), but it needs to be tailored according to the specific needs of the location such as ca pacity and expected role of nurses (16). for australia, usher and mayner (22) state that the theoretical and practical preparation of disaster nursing competencies in undergraduate nurs ing courses are inadequate or only little is known about the inclusion and that professional development opportunities are needed. one possibility for an adequate provision of knowledge and skills required in a disaster could be the collaboration and sharing of knowledge between nursing schools and the military medical communities as well as other trained medical professionals, for example volunteers from the red cross or red crescent and other medical response teams (17). another effec tive strategy might be the dissemination of information and educational materials related to disasters (18). it is central that nurses receive education which is specific to their actual knowledge and skills in order to not duplicate efforts or miss important content because the more advanced nurses are, concerning both experience and knowledge, the more likely they are to implement advanced disaster nursing (15,32,35). disaster drills, training and exercises: drills and training play also an important role for dis aster preparedness. it is concluded, that intensive training and periodical drill programs simu lating hospitals‟ emergency plans will improve capabilities of nurses for emergency response (15,20,21,31,42,43). all nurses are recommended to participate in periodic emergency re sponse drills and disaster training, and nursing schools should collaborate with the local ems to give their students a disaster field experience and to expedite teamwork between first re sponders and first receivers, because during a disaster an enormous pool of nurses will be needed (20,21,23,25,35). further reasons for participating in and specific issues for disaster training are described in table 3. others contrarily describe specific medical tasks and conclude that these tasks should be tailored to the nurses‟ background knowledge and clinical experience (13,16). 56 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 with any disaster training, a broad range of topics should be covered in order to prepare nurses to function in disasters due to any hazard and settings other than their work settings (41). goodhue et al. (21) conclude that having disaster training, besides having a specified role in the workplace disaster plan, is the most easily modifiable variable with the most im pact on increasing the likelihood of response in the event of a disaster. preparedness: disaster preparedness of nurses is pivotal to the ability and capacity to re spond as well as the delivery of effective disaster response (6,18,24,33). there are two ways of viewing preparedness, personal preparedness and professional preparedness. special atten tion is given to bioterrorism preparedness, because being especially prepared for bioterrorism and thus infectious disease emergencies, has a positive impact on patients, families and the nurses themselves, for example by preventing a secondary spread (18,45). furthermore, bioterrorism preparedness readies nurses for other disasters, because the skills and response actions are the same and misconceptions can be prevented (46). due to this importance, bioterrorism preparedness should be part of continuing education and nursing school curric ula (18,43). other special fields where preparedness is necessary are described in table 4. 57 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 table 2. core competencies and disaster curriculum core competencies de fined by the nursing emergency preparedness education coalition (nepec) (36) already existing specific disaster nursing core competencies of nurses working in acute care (28,41) disaster curriculum modules of lund et al. (30) nursing curriculum to address chemical and biological warfare (40) medically oriented edu cational components (14,24) protect self and others from harm participate in a multidisciplinary, coordinated response communicate in a professional manner recognize disaster situations and potential for mass casualty events seek additional information and resources needed to manage the event recognize your roles and limitations in disaster response efforts cope with challenges that occur in disaster situations define terms relative to disaster management response discuss ethical issues related to mass casualty events describe community health issues related to mass casualty events triage securing of personnel, supplies and equipment recordkeeping patient transport decontamination patient management of specific illnesses and injuries patient management of special needs population evacuation development of disaster plans ethics response to stress reactions anatomy of a disaster epidemiology of disaster disaster planning communications in disaster introduction to disaster medicine introduction to pathophysiology of disaster the disaster response introduction to biological and chemical terrorism surveillance systems for bioterrorism identification of agencies communication response systems biological and chemical agents of concern mass immunization decontamination and mass triage therapy and pharmacology psychosocial effects of terrorism nursing leadership during emergencies first aid basic life support advanced cardiovascular life support infection control field triage pre-hospital trauma life support advanced trauma care nursing post-traumatic psychological care peri-trauma counselling description contents 58 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 table 3. reasons for participating and specific issues for disaster training reasons for participating in disaster training (10,13,15,18,21,24,26,27) specific issues for disaster training (38,43,44) specific medical tasks (13,16) test and maintain disaster preparedness create awareness for disasters in general create awareness for physical and mental limits increase personal safety increase confidence in disaster management minimize emotional and psychological trauma triage mass casualty management (bio-) terrorism preparedness communications command and control interagency cooperation waste management decontamination personal protection cardiopulmonary resuscitation central venous catheter insertion trauma care table 4. personal and professional disaster preparedness personal preparedness (15,18-20,27,47) professional preparedness (15,19,26,27,29,47) special fields of disaster preparedness (33,34,40) go-pack containing essential personal supplies preparing and protecting the family personal plan for times of disaster knowing employment contract statement about obligation to report to duty during a disaster pre-registering in a disaster registry developing and knowing disaster plans assembling emergency supplies studying evacuation or shelter options ongoing training and drills experience in disaster nursing bioterrorism disasters involving special need populations chemical or radiation disasters according to al khalaileh et al. (15), jordanian nurses consider themselves being weakly to moderately prepared for a disaster and think that additional training would be beneficial. the same issues are made out for hong kong nurses and the existence of a lack of understanding their preparedness needs with regard to disaster is concluded (24,29). being prepared for a disaster as a nurse might maximise safe conditions, decrease vulnerability and minimise risk to individuals during a disaster (12). disaster experiences of nurses the six identified sub-themes are work environment, nursing care, feelings, stressors, and willingness to respond to disasters and to treat patients as well as lessons learned and impacts. description contents description contents 59 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 work environment: nurses will experience challenging working conditions, an environment of fear and difficult infection control requirement conditions during a bioterrorist event (10). nurses believe that during a disaster will be a chaotic clinical environment without a clear chain of command, with insufficient protective equipment and little freedom to leave (47). manley et al. (38) assume, even if hospitals are well prepared, that during a disaster will be chaos, inadequate resources, deaths and injuries, confusion and contention over who is in command, lapses in security and breakdowns in communication. during a disaster, problems concerning organizational and social supports caused by challenges with care for children, elderly or pets during prolonged shifts and quarantine might also prevail (48). nursing care: nursing care during a disaster is a special type of care because of the excep tional situation and the change of routine. during a disaster, care is provided by an interde pendent team of nurses, clinicians and ems professionals, each playing unique roles (41). thus, nurses especially feel as advocates for their patients, especially those who are fright ened or most vulnerable, and their merits of caring and unity are the most appreciated aspects of their rescue experience, reinforced through communal sprit with their colleagues and the feeling of being rewarded by the victims (7,27). nurses are confronted with conflicts and ethical issues when working during a disaster. because of increased staff requirement and the allocation of resources nurses come into conflict with the delivery of dependent care (27,48). other challenges for nurses are the identification of unfamiliar infectious agents, long work ing hours, limited supplies, unfamiliar environments, provision of care to infected patients, or fear of infection (10). chaffee (49) concludes that tasks like triage, quarantine and mandatory administration of medication might be ethically challenging during a disaster. if uncertainty of the conditions worsens, nurses might experience discouragement and fear (7). feelings: on the one hand, nurses feel guilty when taking leave, are concerned about causing pain and distress to their patients, are overwhelmed by the scale of the tragedy, feel disgusted or distressed at the nature of the injuries and the scale of the suffering or felt apprehensive about being able to cope. on the other hand, nurses also feel excited and challenged by what they have to do, or feel to be valued as much-needed colleague (50). anger towards people in authority, because of the expectation to fulfil the duty to care, is another feeling described by nurses (7). fear, anxiety, stress and confusion are perceived to be felt in the event of bioter rorism. fears might arouse in consequence of the possibility of acquiring a lethal disease from exposure to an infectious agent, transmitting an infectious agent to other patients or the family, lack of knowledge about disease agents, isolation procedures, and access to content resources (47). other feelings might be uncertainty, hopelessness, or abandonment related to the issue of chaos in general and evacuation in special (7). stressors: there is a widespread assumption that nurses “by virtue of their training and per sonality traits are relatively impervious to the effects of distressing experiences”, such as dis asters (50). newer studies disqualify this assumption, because for example, the work of nurses can be compromised when a lack of adequate rest, poor nutrition, erratic eating pat terns and insufficient fluid intake prevails (26). other stressors might be information and work overload, crisis, confusion, uncertainty, chaos, disruption of services, casualties, or dis tractions with crowds and media, decline of infrastructure, limited medical supplies and loss of electricity and potable water (7,25,31,47,48). moreover, poor knowledge and working skills, combined with a heavy workload and lack of equipment, leads to emotional distress during a disaster (25). a disaster can also lead to personal trauma because of the experienced loss of homes, workplaces, and close relationships as well as suffering or dying patients (7). willingness to respond to a disaster and to treat patients: main issues related to a reduced willingness to treat patients during an epidemic include having a high level of concern about 60 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 an infection and lack of medical knowledge (46). during a disaster, nurses will have the same vulnerability to property damage, injury or displacement, will have fear and concern about own and family‟s safety and will, therefore, have to make a decision whether to report to work or to care for oneself, one‟s family, or personal property (49). other reasons for unwill ingness to respond to a disaster are responsibilities to children or elderly, a second job, trans portation issues or obligations to care for a pet (49). goodhue et al. (21) found out in their study that less than one third of paediatric nurse practitioners would definitely respond during a disaster. one result of the study of o‟boyle et al. (47) is that many nurses would leave hos pitals or would not report for work when a bio-terroristic event occurred. not all nurses will be willing to respond to chemical, biological or radiological disasters, because of personal risk and not all nurses will be able to respond because of the unavailability of personal pro tective equipment (33). in order to raise the willingness to respond to a disaster, nurses need to be educated on what the hospital expects from them and what the implications of certain choices of not responding to work will be (49). other factors might be: knowing that family members are safe and pro vided for, having a home disaster plan, having disaster training, having an assigned role in the workplace disaster plan and prior disaster experience (21). lessons learned and consequences: based on experience, often lessons learned and conse quences for the future are stated. ammartyothin et al. (42) conclude that medical personnel, such as volunteers, should be incorporated into the organic medical staff during a disaster as well as that communication systems are important for disaster management and have to with stand the actual event and the unavoidable. as a health institution, it is important to find out about the nurses‟ determinants of reporting for work when a disaster strikes in order to be better prepared (46). during a disaster, it is imperative, that food, water and a place to sleep or a quiet area are available for continued functioning of nurses. in order to ensure an effec tive response, nurses need to build functional partnerships with physicians, to support one another and to express a sense of responsibility and empathy for colleagues and patients (7,25,39). for future disaster responses, the performance of nurses during a disaster needs to be evaluated and the most frequently used skills need to be identified for further training (13). discussion concerning the general role of nurses in disasters, different attributions are observed. on the one hand, there is international consensus that nurses are key players in emergency response is somehow contemporary. on the other hand, it does not seem finally clear which expecta tions are cherished towards nurses. is it only the continuation of the provision of care in dif ferent circumstances or is the assumption of medical tasks, in fact? of course, not every nurse needs to be able to fulfil every role, but medical tasks during a disaster might be mandatory to undertake. it does not become finally clear from the literature review which medical tasks most certainly are needed in general and particularly for specific disasters. moreover, hetero geneity about the field of application of nurses exists in the literature. in some it is described, that nurses will work on-site of the disaster area in others nurses will be deployed in their own hospital or in a hospital in the proximity of the disaster area and yet in others nurses will work in the community. these heterogeneities surely are due to the different healthcare sys tems and professional qualifications in the different countries, a diversity that is remains un answered in this review. however, it seems convincing that preparedness for a disaster as well as an effective response are expectations of the public towards nurses in all countries. special attention is given to the roles of nurses before and during a pandemic influenza and biological terrorism. nurses have a share in the identification, management and treatment of 61 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 infectious outbreaks. again, the specific tasks during such an event are dependent on the pro fessional education of the nurses. the professional roles during a disaster might be in conflict with the personal duties in the family and in the community. such conflicts can undermine supply of work force during a disaster immensely. the definition of disaster is perceived differently by nurses than from the officially used defi nitions. officially used definitions mainly focus on the cause of a disaster. thereby, the pas sage between a mass casualty event and a disaster is fluent. for nurses, a disaster is mainly considered through the impact it has for their daily work, the persons who they care for and their own life. thus, the unpredictability and suddenness as well as the number of victims, their injuries and clinical picture play a greater role in the perceptions of nurses. furthermore, terrorism does not explicitly appear in the disaster classification of the cred; yet, nurses do think that terrorism might be a threat for their country (2). in order to be prepared for a disaster, it is important to define core competencies applicable to the different professional qualifications of nurses. a comprehensive list might be the who and icn in their framework of disaster nursing competencies (8). this supranational framework has to be broken down into national core competencies for nurses and a list of competencies for undergraduate and continuous nursing education, at the end, because it may very well be the case that some knowledge and skills acquired through basic nursing curricula already equip nurses for disaster response. on the other hand, some disaster nursing compe tencies might be highly specialized, and thus uncommon in practise as well as unlikely to be retained. thereby, a careful choice between specialization and generalization of skills and knowledge for undergraduate and continuous nursing education should be made. both, undergraduate education and continuing education programmes have to raise awareness and preparedness for a disaster adequately. by tailoring education to the local needs, such as the likelihood of specific disasters or existing disaster plans, and the needs of the nurses, such as the requirements for general disaster management knowledge or specialized medical skills, all nurses should be able to respond to a disaster appropriately. it remains unclear which strategy for the education of nurses in disaster management is the most effective. the col laboration with medical communities and other medical response teams, as well as the dis semination of information materials on the topic seem to be promising, not only for education but also for drills and training. emergency response drills and disaster training are important elements of individually and professionally preparing nurses for disaster and evaluating exist ing disaster plans. again, emergency response drills and disaster training need to be tailored according to the local needs and the needs of the nurses, leading to an improvement of the nurses‟ willingness to respond to a disaster and the response as such. being prepared for a disaster as a nurse means being personally and professionally prepared. nurses are considered to be personally prepared, when they are able to protect their family as well as when they know their obligation to report to duty during a disaster and have all their essential personal supplies standing by. professional preparedness of nurses means the regis tration in a relevant disaster registry, knowing the disaster plans and being trained. further more, special preparedness is needed for nurses‟ working areas with special needs popula tions and specific disaster types. the work environment of a nurse during a disaster will likely be challenging and chaotic. nurses need to know beforehand what they might expect; therefore, preparing them through education and training is essential. furthermore, a need for a good disaster plan, where chains of command and effective alternatives in communication are described, arises considering the high possibility of an adverse work environment. for nurses, it has to be clear, that care dur 62 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 ing a disaster differs from the routine work. interdependence in a team will become even more important as well as advocacy for patients, the allocation of resources and ethically challenging decisions (for example, during triage). during a disaster, negative feelings, such as guiltiness, disgust, anger or fear, are dominant in descriptions of nurses‟ experiences, besides positive feelings of excitement or being chal lenged. no information is given on the impacts of those feelings on working capacity and mental health. nurses also experience specific stressors during a disaster, likely leading to emotional distress and possibly to personal trauma. these stressors can either have a personal character, such as uncertainty about the safety of the family or themselves, an organizational character, such as being cut-off from support sources, and an occupational character, such as hazards, lack of equipment or high workload. the willingness to respond to a disaster is dependent on the level of concern, responsibilities and the medical knowledge of nurses. concern may exist for example due to property dam age or own and family‟s safety, responsibilities may be towards children, elderly or another employer. it is important that nurses are educated and trained on the expectations of the hos pitals and that they have their own disaster plan. disaster experiences importantly should lead to impacts for the future, the so-called lessons learned. often, these lessons learned refer to optimizing communication systems, nurses‟ determinants of reporting for work, controlling the hospital environment during a disaster and the knowledge and skills of nurses. nurses themselves will acquire experience, and might rethink their commitment to nursing. in summary, it can be stated that, after a disaster is, with all probability, before a disaster and it is therefore inevitable to prepare anew. conclusions and implications it seems self-evident that nurses are key players in emergency response. in order to prepare nurses for disasters, clear roles should be defined according to the professional education of the nurses, which should be communicated beforehand. these roles of nurses during a disas ter should be realistic in relation to their skills and practical experiences. in order to raise the availability of nurses during a disaster, roles should be adjusted to each nurses‟ personal du ties in the family and in the community, in the best case. roles should also be tailored ac cording to the characteristics of the different disaster types, with special attention to pan demic influenza and biological terrorism. in order to satisfy public expectations towards nurses, national directives and concepts for disaster nursing should be developed, where non existent, and nurses have to be called attention to their duties. moreover, distinctions towards roles of physicians and nurses during a disaster are needed in order to define the medical tasks of nurses clearly, which have to be trained and performed during a disaster. existent definitions of disasters seem not to be appropriate for the working environment of nurses. defining disasters out of the experience of nurses could help to give a better under standing for such a sweeping event. a definition from the perspective of a nurse could be an unpredictable, sudden event that is hardly but urgently manageable with serious conse quences to the population and environment demanding an extensive need for professional health services personnel. in order to develop national disaster nursing core competencies, the framework of disaster nursing competencies from the who and icn (8) should be interpreted for the needs of each professional group of nurses. national disaster nursing core competencies then should be adjusted to the demands formulated in the undergraduate nursing curricula in order to meet the national criteria. nurses should receive education and training tailored to the local needs and their actual competencies. collaboration with relevant national institutions and organiza 63 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 tions is indicated for making education and training in disaster nursing more efficient, pre cisely if nursing educators are not knowledgeable in the field of disaster nursing. for personal and professional preparedness and in order to raise willingness to respond, nurses need to pack their essential personal supplies standing by for emergencies, need to know that their families are protected and need to be registered in a disaster registry as well as know their relevant disaster plan. a personal disaster plan will help to arrange personal matters when responding to a disaster. in order to counteract the high possibility of challenging and chaotic working conditions dur ing a disaster, nurses need to be prepared for many situations and hospitals need to develop or improve their disaster plans. it has to become a given for every nurse, that nursing care dur ing a disaster will change from its routine way, including all consequences, such as the allo cation of resources. not much is known about the feelings of nurses responding to a disaster and their resistance to stressors. in order to be able raise the willingness to work in a disaster, it is imperative that possible distressing situations during a disaster are identified and reduced, and nurses become prepared for coping. it is central to learn from a disaster experience and to prepare anew. not only will the optimizing of processes during a disaster written down in a disaster plan have to be evaluated, but the performance of the nurses who were on duty and the reasons of the non performance of the nurses who were not able or not willing to respond to the disaster, as well. an overview of the implications and the relevance to nursing practice, nursing education and research is presented in table 5. table 5. relevance to nursing practice, nursing education and research all nurses, regardless of their professionalization, need to receive disaster preparedness education in their undergraduate and continuous nursing education, in order to have a great pool of nurses during a disaster. all nurses should periodically take part in emergency response drills and disaster training in order to be prepared for disasters. for being prepared for a disaster and willing to respond, nurses need to be personally and profession ally prepared. a personal disaster plan will help to arrange personal matters. hospitals need to have a disaster plan, wherein chains of commands, alternative communications and task descriptions for groups of nurses during disasters are described. during a disaster, the routine way of nursing care changes and nurses need to be prepared to make ethically challenging decisions. nursing educators should prepare nurses for disasters, by adjusting the curricula and by meeting the increased need for education and training in disaster nursing for all groups of nurses. nursing research should find definitions of disasters appropriate for the working environment of nurses. research should be done in order to review the appropriateness of theoretical and practical preparation of disaster nursing competencies in undergraduate nursing courses and continuing educa tion programmes. disaster preparedness of nurses needs to be evaluated regularly in order to maximise safe conditions, decrease vulnerability and minimise risk to individuals during a disaster. distressing situations for nurses during a disaster should be identified and reduced, nurses should be prepared by equipping them with possible coping strategies through education and post-disaster psy chosocial care should be ensured. relevance to nursing practice: relevance to nursing education and research: 64 grochtdreis t, de jong n, harenberg n, görres s, schröder-bäck p. nurses’ roles, knowledge and experience in national disaster preparedness and emergency response: a literature review (review article). seejph 2016, posted: 16 december 2016. doi:10.4119/unibi/seejph-2016-133 references 1. guha-sapir d, vos f, below r, ponserre s. annual disaster statistical review 2011: the numbers and trends. université catholique de louvain, brussels, belgium, 2012. http://cred.be/sites/default/files/2012.07.05.adsr_2011.pdf (accessed: december 13, 2016). 2. international federation of red 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conflict among nurses during large-scale outbreaks. prehosp disaster med 2009;24:321-5. 49. chaffee mw. disaster care. making the decision to report to work in a disaster: nurses may have conflicting obligations. am j nurs 2006;106:54-7. 50. alexander da. burn victims after a major disaster: reactions of patients and their care-givers. burns 1993;19:105-9. © 2016 grochtdreis et al; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0)� 67 senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 review article the emerging public health legislation in ukraine iryna senyuta1 1 danylo halytskyi lviv national medical university, lviv, ukraine. corresponding author: assoc. prof. iryna senyuta, ph.d. in law, head of the department of medical law of the danylo halytskyi lviv national medical university; address: solodova street 10, 79010, lviv, ukraine; email: prlawlab@uk.net mailto:prlawlab@uk.net� 68 senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 abstract as ukraine has started the legal process for a public health legislation, this narrative review attempts to: i) characterize recent legal acts (which are current as well as drafts) and international standards in the sphere of public health; ii) analyze the definitions of public health legally relevant to ukraine, in particular: public health and public health protection; iii) discuss related definitions relevant to the health sector; iv) characterize the main subjects tasked to protect public health; v) and clarify the necessary educational innovations, which are the basis in the preparation of human resources for an efficient implementation of the public health concept. after referring to the current legislative process and a discussion of some of the concepts and terminologies available in the literature, the following understanding of the terminology is proposed here: i) ‘public health’ should be understood as mental and physical health of the population in a certain territory, determined by the best achievable demographic indicators, characterized by decreasing morbidity and mortality and increasing the potential to lead an active and long life; ii) the term ‘public health protection’ (or, ‘protection of public health’) should address a system of measures which are aimed at prevention and control of morbidity, optimization of demographic indicators, promoting a value-oriented state policy, securing biological and genetic safety and relying on joint societal efforts. it is essential that the implementation of a public health law is underpinned by adapting the postgraduate educational system to the new challenges in ukraine. keywords: health care, multiprofessionality, public health, public health protection, ukraine. conflicts of interest: none. acknowledgements: the author expresses her cordial gratitude to prof. ulrich laaser, faculty of health sciences, bielefeld, germany, for his valuable comments and input. 69 senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 introduction ukraine entered an active process to integrate public health into the national health system as part of the wide spectrum of transformations of all ukrainian systems. the “embryo” of public health has a long national history. in the historical context, it is worth paying attention to the state sanitary-epidemiological service, which was responsible for protection of public health and had two main functions, i.e. control of communicable diseases and environmental protection (monitoring the quality of water, air, soil and food) (1). scholars, who worked on various aspects of public health development in ukraine include y. bazylevych, i. gryga, n. chala, v. moskalenko, v. lekhan, v. rudiy and others. in particular i. gryga researched the issue of public health funding in ukraine and proved the idea of introducing official patient payments in ukraine in order to avoid informal or quasi official payments (2). the system of state bodies responsible for public health protection was the focus of interest of v. lekhan and v. rudiy (1). this process started to actively develop when ukraine signed the association agreement with the european union in 2014 (3). the article 426 of chapter 22 of the association agreement foresees that the parties shall develop their cooperation in the field of public health, to raise the level of public health safety and protection of human health as a precondition for sustainable development and economic growth. a conceptual provision of the association agreement within its chapter 22 is the “health in all policies” approach. hence, public health and health care should be a starting point for the state authorities to develop policies benefitting their population, since human wellbeing constitutes the core of any health system. correspondingly, the article 3 of the constitution of ukraine states that an individual, his or her life and health, honour and dignity, inviolability and security shall be recognized in ukraine as the highest social value. value-oriented law-making foresees the satisfaction of universal human needs and interests and it creates a relevant social toolset to meet these objectives. in the philosophical-legal interpretation, a value means objects, phenomena, social processes and their features, which are treated by a human being as those, which satisfy his or her social needs, interests, desires and which he or she involves to one’s sphere of life activity (4). public health is a collective good, which has an individual value effect – human health. in this paper i try to elucidate some aspects of the formation and development of the public health concept as a national ukrainian paradigm; to clarify the terminological framework as a basis for the creation of the forthcoming public health legislation; to define public health in the ukrainian environment and characterize the main educational innovations to support the preparation of well-trained human resources. in order to achieve these objectives the following is required: i) to characterize recent legal acts (which are current as well as drafts) and international standards in the sphere of public health; ii) to analyze the definitions of public health legally relevant to ukraine, in particular: public health and public health protection; iii) to discuss related definitions relevant to the health sector; iv) to characterize the main subjects tasked to protect public health; v) and to clarify the necessary educational innovations, which are the basis in the preparation of human resources for an efficient implementation of the public health concept. recent legal initiatives in ukraine currently, the establishment of an effective public health system is one of the priorities of the ukrainian ministry of health (3). in a strategic document of the world health organization (who) regional office for europe, issued in 2012: “health 2020: a european policy framework supporting action across government and society for health and well-being” (5), it 70 senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 is noted that “...all 53 member states in the who european region have agreed on a new common policy framework – health 2020. their shared goals are to “significantly improve the health and well-being of populations, reduce health inequalities, strengthen public health and ensure people-centred health systems that are universal, equitable, sustainable and of high quality”. recommendations of the parliamentary hearings on the topic: “on health care reform in ukraine” of 21 april 2016 (6), which is currently the sole strategic document for the envisaged transformations of the health system, also encompasses the public health sector. the ‘recommendations’ define the list of tasks of the state bodies with regard to public health, including: • development and approval of the concept of the public health system reform; • preparation of a draft-law on the public health system in ukraine; hence, the government started coordinating a process aiming at the legal foundation of a national system of public health, which should include the following elements: • a modern system of epidemiologic surveillance of communicable diseases; • a modern system of epidemiologic surveillance of non-communicable diseases; • creating a system of public health, which is based on the principle “ukraine 80+”. for the first time the principle “ukraine 80+” was mentioned in the agenda of the head of the committee on health of the verkhovna rada of ukraine, namely professor o. bogomolets (“health care reform: 25 steps to happiness”). in order to implement this principle it was foreseen that there should be developed such a system of public health which would secure an increase in life expectancy of the ukrainian people. however, this principle was not further legally established in order to be implemented, except for some initial measures of organizational character, in particular official meetings with the european union representatives. subsequently, the “concept of public health system development in ukraine” (7) (hereinafter – the “concept”) and the draft “law on principles of state policy of health care” (8) (hereinafter the “draft law”) have been issued. for the first time, the draft concept foresees the definition of the term ‘system of public health’, which is a set of instruments, procedures and measures, which are implemented by state and non-state institutions in order to strengthen the health of the population, prevent disease, support an active aging, and promote a healthy lifestyle, as a joint effort of the whole society. the draft law attempts to provide a legal definition of the public health notion as a set of activities aiming at the maintenance and strengthening of the health of the population and increasing life expectancy. the state agencies and the bodies of local self-government are responsible for the organization of these societal efforts. definitions of public health legally relevant to ukraine since the legal framework for a system of public health is under consideration, the terminology and meaning of the central term ‘public health’ has to be thoroughly examined. there are many scientific and legal definitions of this term. therefore, a comparative discussion has to be conducted with regard to terms and concepts relevant to the health system. one of the oldest definitions has been formulated by charles-edward winslow in 1920: “public health refers to the science and art of preventing disease, prolonging life and promoting health through organized efforts and informed choices of society, organizations, public and private, communities and individuals” (9). according to the who definition in 1978 (10): “public health is the science and art of preventing disease, prolonging life and https://en.wikipedia.org/wiki/health� 71 senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 promoting mental and physical health and efficiency through organized community efforts for the sanitation of the environment, the control of communicable infections, the education of the individual in personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of social machinery to ensure to every individual a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity”. the dimension of health according to who refers to “...a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. also, this understanding of public health incorporates the interdisciplinary approaches of epidemiology, biostatistics, community health, behavioural health, health economics, health management, health policy, health insurance, mental health, and occupational health as important subfields. however, probably, the most common definition has been coined by donald acheson in 1988 (11): “public health is the science and art of preventing disease, prolonging life and promoting health through organised efforts of society”. in contrast, in john last’s famous dictionary of public health in 2006 (12), it reads as follows: “the mission of public health is to protect, preserve and promote the health of the public. public health is the art and science of promoting and protecting good health, preventing disease, disability, and premature death, restoring health when it is impaired, and maximizing the quality of life when health cannot be restored. public health requires collective action by society; collaborative teamwork involving physicians, nurses, engineers, environmental scientists, health educators, social workers, nutritionists, administrators, and other specialized professional and technical workers; and an effective partnership with all levels of government”. ukrainian laws in force do not foresee a legal definition of the term public health; the above mentioned draft legal acts do that for the first time. it is worth paying attention to the legislation of other countries, which have special laws with a relevant legal glossary. for instance, the article 3 of the ‘law of georgia on public health’ of 27 june 2007 (13) provides a definition of the term ‘protection of public health’ as a set of measures aimed at improving the health of the population, prevention and monitoring of diseases. the article 1 of the ‘law on public health’ of the kyrgyz republic of 25 june 2009 (14) defines ‘public health’ as the health of the population or certain groups and communities defined by a geographic, social or another characteristic, which is evaluated by demographic indicators, characteristics of physical development, morbidity and disability, whereas ‘public health protection’ is defined as a system of measures, directed at the protection of public health, prevention of diseases, prolongation of life and strengthening of human health owing to organizational efforts of all parties, the population, public and private organizations, communities and individuals. these two examples demonstrate that the respective legislators have adapted elements from the aforementioned definitions which are deemed relevant in their national contexts. related definitions relevant to the health sector however, terminological problems can easily occur importing and translating terms during the process of their adaptation to national legal systems. for example, in chapter 22 of the association agreement (3), the term ‘public health’ is used solely to define the name of the chapter but in the text of the agreement the term ‘health care’ is used, which has a different meaning underlining individual health rather than population health. https://en.wikipedia.org/wiki/interdisciplinary� https://en.wikipedia.org/wiki/epidemiology� https://en.wikipedia.org/wiki/epidemiology� https://en.wikipedia.org/wiki/epidemiology� https://en.wikipedia.org/wiki/community_health� https://en.wikipedia.org/wiki/community_health� https://en.wikipedia.org/wiki/community_health� https://en.wikipedia.org/wiki/health_economics� https://en.wikipedia.org/wiki/public_policy� https://en.wikipedia.org/wiki/insurance_medicine� https://en.wikipedia.org/wiki/occupational_safety_and_health� 72 senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 taking into consideration the definitions of public health discussed so far, it is worthwhile to relate the term ‘public health’ to other terms in the field of health care and identify its place in the relevant system. especially relevant for the ukrainian legislatory process is the understanding of public health as the health of the population impacted by activities which are not restricted to the public sector – a common misunderstanding of the terminology. therefore, we propose to consider in addition the term “public health protection” which denotes the set of activities to be performed not only by the public services in order to achieve the best possible public health (health of the population) as a vision and objective. also, verweij and dawson (15) for example argue that the term ‘public health’ combines two words, each of which can be ambiguous and that among the many definitions of public health, the word “public” has two general interpretations. in a straightforward interpretation, “public” is an aggregate concept and is equated with the “population”. in this meaning, “public health” refers to the state of population’s health in general or a certain population group. the second interpretation of “public” is in terms of “collective action”, which has the goal to protect and promote a population’s health alongside efforts to prevent diseases. although historically, the same term “public health” was used in both meanings to characterize the state of the population in general and to define joint measures, which have to be taken in order to protect and improve such health (16). in the ukrainian context, it seems preferable to apply two different terms: “public health” – to define a state of health of the population and “public health protection (or: “protection of public health” – to describe collective measures. however, most scholars agree that the essence of public health is the prevention of diseases, in order to maintain and strengthen both individual and collective (population’s) health (17). with reference to the above considerations, in the ukrainian legislatory process, the following understanding of the terminology should be adopted: • public health is understood as mental and physical health of the population in a certain territory, determined by the best achievable demographic indicators, characterized by decreasing morbidity and mortality and increasing the potential to lead an active and long life. • under the term ‘public health protection’ (or, ‘protection of ‘public health’) we understand a system of measures, which are aimed at prevention and control of morbidity, optimization of demographic indicators, promoting a value-oriented state policy, securing biological and genetic safety and relying on joint societal efforts. according to article 3 of the law of ukraine on: “principles of ukrainian health care legislation” (18), medical care is the activity of the professionally trained medical workers, aimed at prophylaxis, diagnosis, treatment and rehabilitation pertinent to diseases, injuries, intoxications and pathological conditions, as well as pregnancy and childbirth. consequently, the complexity of public health’s legal nature is caused by its multidisciplinary character, which generates the following formula: “medical care” and “public health protection” are partially overlapping in the area of prophylaxis. at the same time, both terms are part of the umbrella term ‘health care’. hence, both terms are within the realm of ‘health care’. the term ‘medical care’ by its content is narrower than ‘public health protection’, since providing equal access to effective and high quality medical care is only one of the functions of the protection of public health. on this basis, the main functions of the protection of public health include: • monitoring: evaluation, analysis, and comparison of the state of health of the population in order to identify the existing problems and develop priorities. 73 senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 • control: provision of biological and genetic security, decreasing the morbidity level. • prevention: prophylaxis of diseases and formation of a healthy lifestyle of the population. • strategy and coordination: formation of the state and local policy on the basis of “health in all policies”. • communication: interaction of different subjects in terms of implementing the values of public health protection into social and state life. • medical: securing equal access of the population in general and each person in particular to high-quality and effective medical services. • integration: consolidation of the national and international efforts aimed at the protection of public health. public health service according to paragraph 1.2 of the concept (7), the key central body of executive power, which is responsible for the management of public health system, is the ministry of health of ukraine. the department of public health as a structural subdivision is targeted at securing proper management of the public health system. in order to implement policy and provide services in the sphere of public health at the national level, on 31 may 2016, the government established a state institution “centre of public health of the ministry of public health of ukraine” (hereinafter – the centre). according to its charter, the centre is a scientific and practical institution of medical profile, which fulfils the following functions: ensure the permanent strengthening of the population’s health; carrying out social and hygienic monitoring of diseases; epidemiological supervision and biological security; conducting the group and population oriented prophylaxis of morbidity; combating epidemics; and execute the strategic management of all public health issues. at the regional level, it is foreseen to create regional centres of public health. at the level of districts and cities, the provision of public health services will be coordinated by a public health specialist (epidemiologist) of the regional centre who will be appointed to a certain territory. the concept also envisages that family doctors, mid-level medical personnel and representatives of the civil society should be involved in public health services. preparing human resources for the implementation of the upcoming public health legislation when creating a new structure no less important are the human resources, which will be the element of the system that takes responsibility to implement a state policy in the sphere of public health. an important step in area of education was made after the resolution of the cabinet of ministers of ukraine passed on 23 november 2016. according to this resolution, a new specialty labelled “public health” was added to the list of fields of knowledge and specialties, according to which, persons who receive higher education, are trained. this step became a foundation for the implementation of bachelor and master programs on public health. consequently, this new sector will promote the professionalization of the public health workforce. currently, in ukraine, schools of public health are being actively established and these schools will be the major centres responsible for educating the new generation of public health professionals. on the one hand, according to the multidisciplinary character of public health, specialists can be trained after different undergraduate studies (bachelor programs) and, on the other hand, training of professionals is conducted with a focus on different competencies, which are necessary for the public health sphere (for instance, with a legal specialization). 74 senyuta i. the emerging public health legislation in ukraine (review article). seejph 2017, posted: 03 april 2017. doi:10.4119/unibi/seejph-2017-141 one of the examples of innovations in the sphere of education includes the departments of medical law, which were established within medical schools. these departments are to provide advanced training for health care managers and physicians. therefore, they should be involved in the training of public health professionals, especially for those who are going to specialise on legal issues of public health. in this respect, the example of the department of medical law of the danylo halytskyi lviv national medical university is of interest, which became already an associated member of aspher (19). at this department, a postgraduate course on medical law has been established targeting physicians, health care managers, and lawyers. in addition, this department has implemented other innovative educational programs, among them for example “leadership in the sphere of health care, human rights and public health law”, focusing on an advanced training of health care managers and comprising 78 hours, including lectures, practical classes and individual work. conclusions the legislative initiative to formulate a public health law for ukraine requires a careful analysis of the concepts and the term ‘public health’ and the pre-existing services and service providers in ukraine. after referring to the current legislative process and a discussion of some of the concepts and terminologies available in the literature, the following understanding of the terminology is proposed here: • ‘public health’ should be understood as mental and physical health of the population in a certain territory, determined by the best achievable demographic indicators, characterized by decreasing morbidity and mortality and increasing the potential to lead an active and long life. • the term ‘public health protection’ (or, ‘protection of public health’) should address a system of measures which are aimed at prevention and control of morbidity, optimization of demographic indicators, promoting a value-oriented state policy, securing biological and genetic safety and relying on joint societal efforts. it is essential that the implementation of a public health law is underpinned by adapting the postgraduate educational system to the new challenges in ukraine. references 1. lekhan v, rudiy v, richardson e. ukraine: health system review. health syst transit 2010;12:1-183. 2. gryga i, stepurko t, danyliv a, gryga m, lynnyk o, pavlova m et al. attitudes towards patient payments in ukraine: is there a place for official patient charges? zdrowie publiczne i zarządzanie-zeszyty naukowe ochrony zdrowia. 2010;8:74-5. 3. association agreement between the european union and its member states, of the one part, and ukraine, of the other part; 2016. 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and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-135 short report protecting the planet and sustainable development laura h. kahn1 1program on science and global security, woodrow wilson school of public and international affairs, princeton university, new jersey, usa. corresponding author: laura h. kahn, md, mph, mpp, woodrow wilson school of public and international affairs, princeton university; address: 221 nassau street, 2nd floor, princeton, new jersey 08542, usa; telephone: 609 258 6763; email: lkahn@princeton.edu mailto:lkahn@princeton.edu� 77 kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-135 abstract the united nations has made a commitment for sustainable development. an important component of this is a healthy environment. but what exactly is a healthy environment? environmental health specialists typically focus on occupational exposures in workers; the field mainly addresses the abiotic (i.e. non-living) aspects of environments. ecosystem health addresses biotic (i.e. living) aspects of environments. merging these two realms is essential for sustainable development but will be challenging because the fields are so different. the united nations, individual countries, and schools of public health could do much to help merge these realms by implementing environmental/ecosystem health into their missions and curriculums. keywords: ecosystem, healthy environment, planet, sustainable development. conflicts of interest: none. 78 kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-135 expanding the definition of environmental health the definition of environmental health must be expanded. the twenty-first century presents many challenges to global health. a growing human population, estimated to reach approximately 9 billion by 2050 if estimated growth rates continue, will require food, water, and other natural resources to survive. meeting humanity’s demands for natural resources threatens the environment including worsening deforestation, land degradation and contamination, water contamination, diminishing biodiversity, and spreading vector-borne and other zoonotic diseases. a warming climate with extreme weather conditions including drought and floods threatens agriculture and food security, the foundation of civilization. in the midst of all of these developments, a healthy environment seems almost impossible. but, the need for a healthy environment is imperative for life to continue, and the need to educate the next generation on the importance of sustainable development in a habitable world is essential (1,2). the question is:“what exactly is a healthy environment and how should it be defined?” the national environmental health association (neha) defines environmental health as “the science and practice of preventing human injury and illness and promoting well-being by identifying and evaluating environmental sources and hazardous agents and limiting exposures to hazardous physical, chemical, and biological agents in air, water, soil, food and other environmental media or settings that may adversely affect human health”(3). this definition focuses primarily on the hazards that affect humans. from a one health perspective, however, it leaves out animals and the environment, itself. one health is the concept that human, animal, and environmental health are linked, and because they are linked, complex subjects such as emerging diseases, food safety and security, antimicrobial resistance, and waterborne illnesses must be examined and addressed in an interdisciplinary, holistic way. the term is relatively new, but the concept is ancient. nevertheless, environmental health has been difficult to integrate into one health for a variety of reasons. first, those who work on environmental health, such as occupational and environmental physicians, nurses, and environmental health specialists, focus their work primarily on abiotic (i.e. non-living) contaminants, pesticides, and toxic waste exposures in occupational settings that affect workers. while this is extremely important, it is not the only aspect of what constitutes a healthy environment. ecosystem health focuses on the biotic (i.e. living) components of an environment and their interactions. many scientists and other professionals from a variety of academic disciplines work on ecosystem health such as wildlife veterinarians, biologists, geologists, ecologists, plant pathologists and others. they study the web of life, complex interactions between many interconnecting systems. man-made alterations to entire ecosystems have many consequences, both intentional and unintentional, potentially harming the health of current and future generations (4). environmental/ecosystem health would address the inter-action between the biotic (i.e. living) and abiotic components of environments and ecosystems. unchecked development, including the destruction of ecosystems for agricultural or other purposes, potentially jeopardizes the health of regions, including the health of animals and humans. the challenge is integrating both the environmental and ecosystem health realms into a unified field that incorporates the one health paradigm. a new inclusive term should be developed to reflect the expanded mandate. efforts are underway to establish new integrated environmental/ecosystem health fields. one is called “planetary health” (5). advocates for planetary health seek to educate a new cadre of individuals (6). the challenge with this strategy is that it focuses primarily on humans and the 79 kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-134 environment, minimizing the importance of animal health and zoonotic diseases. also, planetary health is a broad, general term; it’s not entirely clear what exactly its practitioners would do, or who would hire them. one health recognizes the vast breadth of knowledge and skills needed for human, animal, and environmental/ecosystem health and seeks to increase communication and collaboration between medical, veterinary medical, and public health professionals and scientists to achieve these goals. a global international body and environmental protection a global, coordinating international body must be in charge of environmental monitoring and protection. currently, there is no united nations environmental protection organization, but there is an environment programme that was established in 1972 with the mission to promote wise use of the environment and assess global trends (7). for the fiscal year 2014-2015, its total planned budget, from voluntary contributions from member states, was approximately $619 million, which was a 134 percent increase from the previous fiscal year(8). to put this budget into perspective, the world health organization’s budget for 2014-2015 was almost $4 billion (9) (who has an environmental health section that addresses sanitation and water and air pollution but not necessarily ecosystems). the 2014-2015 budget for the food and agriculture organization (fao) was approximately $2 billion (10). fao focuses primarily on food safety and security. in contrast, the 2014-2015 budget for the world organization for animal health (oie) was €22 million (approximately $17.2 million in 2014 usd) (11,12). the oie’s mission is to ensure healthy food animals for food safety. vast disparities in international funding between human, animal, and environmental health makes implementing a global one health strategy extremely difficult, if not impossible. if world leaders were serious about protecting the environment/ecosystems of the planet, they should consider establishing a world environment/ecosystem protection organization with a mandate to examine and address environmental/ecosystem alterations and their resulting outcomes; the organization should have a budget at least comparable to the fao, and it should have enough power to influence nations to act in the best interest of humanity to ensure planetary habitability and survival. countries’ commitments countries must make commitments to study and protect their environments/ecosystems. analogous to the international level, many nations such as the u.s., allocate little for analyzing, managing, and protecting their environments/ecosystems. in the u.s., responsibilities for environmental/ecosystem health are split between government agencies, which can dilute the overall effectiveness of efforts. the u.s. department of the interior oversees the u.s. fish and wildlife service, which has the responsibility to manage biological resources and enforce laws like the marine mammal protection act and the endangered species act (13). in the fiscal year 2012, its budget was $1.48 billion, a two percent decrease from the previous year (14). the environmental protection agency (epa), established in 1970 because of public concern about environmental pollution, conducts monitoring, standard-setting, research, and enforcement activities to protect the public from environmental contaminants, toxic wastes, and other health hazards (15). in the fiscal year 2015, its budget was $7.89 billion, a 4 percent decrease from the fiscal year 2014 (16). president donald trump has vowed to eviscerate, and possibly eliminate, the epa (17). the us geological survey, under the aegis of the department of the interior, was created in 1879 to provide scientific information to understand the earth and to manage the nation’s water, biological, energy, and mineral resources in order to protect life (18). the usgs 80 kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-134 monitors, collects, and analyzes data concerning natural resources. they provide scientific information to policy makers, planners, and others (18). in the fiscal year 2012, the u.s. fish and wildlife service’s budget was approximately $ 1.48 billion, an approximate 2 percent decrease from the previous year (19). these entities do work together, but funding is tight, and efforts might not necessarily be coordinated. the trump administration and the republican-controlled congress threaten to undo many of the conservation and environmental/ecosystem protection efforts over the past sixty years (20). the role of schools of public health schools of public health should offer interdisciplinary courses in conjunction with geological sciences and agriculture and forestry on environmental and ecosystem health, sustainable agriculture and biodiversity, food safety and security, water management and others. schools of public health traditionally teach subjects such as biostatistics, epidemiology, health policy and management, socio-medical sciences, population and family health, and environmental health. environmental health concentrates primarily on reducing carcinogens, toxic waste exposures, and other harmful chemicals. however, the health threats we face in the 21st century extend well beyond traditional public health subject areas. massive waste production from megacities and large animal production facilities threatens water and land quality as run-off from sludge seeps into soils and groundwater. sanitation and hygiene will become one of the most important fields of public health, particularly in an era of worsening antimicrobial resistance. preventing disease by lowering microbial burdens must be a global priority. contaminated land and water contributes to food and water-borne illnesses. severe droughts, floods, and unpredictable weather threaten food security as well as food safety. arthropod-borne diseases are spreading, and will continue to do so with on-going deforestation, upending delicate ecosystems. the curricula of schools of public health need to change to meet the challenges of the 21st century. much more emphasis should be given to emerging zoonotic diseases, entomology, parasitology, virology, and bacteriology. food safety and security should to be taught along with sanitation and hygiene, environmental and ecosystem health, climate and health. one health policy should be taught to examine the intersection between public health, agriculture, and environmental/ecosystem health. the importance of agriculture is rarely discussed outside of agriculture and animal husbandry courses. this must change. with worsening climate change, agriculture will be threatened in unprecedented ways. food security and its impact on civil society will be an increasingly important subject in the decades ahead. one health education should be team-based (analogous to business schools) and should be focused on researching and analyzing national and international government infrastructures relevant to human, animal, and environmental health. most health policy courses focus on healthcare delivery such as in hospitals and clinics. health insurance coverage is another common area of study. but, policy education must be expanded to examine the larger issues such as biodefense, food safety and security, and disaster preparedness. the world needs creative thinkers and problem solves who can conduct fieldwork projects at local, regional, national, and international levels to improve global one health. conclusion in conclusion, environmental/ecosystem health must be better defined to meet the challenges of the 21st century. expanding human populations, deforestation, land degradation, water contamination, massive human and animal manure production, crumbling sanitation 81 kahn lh. protecting the planet and sustainable development (short report). seejph 2017, posted: 05 february 2017. doi:10.4119/unibi/seejph-2017-134 infrastructures, the growth of megacities, diminishing biodiversity, food safety and security, agriculture and animal husbandry, emerging zoonotic diseases are all tied together and adversely impact the world’s environments/ecosystems, and ultimately, global health. these subjects must be examined and taught using an integrated one health framework to adequately understand and address them. united nations member states have already made a commitment for sustainable development. at a united nations sustainable development summit meeting in september 2015, world leaders adopted 17 sustainable development goals for the 2030 agenda for sustainable development. world leaders recognize the importance of setting goals for leaving future generations a habitable planet. expanding the definition of environmental health to include ecosystems and integrating it into a holistic, interdisciplinary one health framework would be an important first step forward. 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email: manushaqebatku@yahoo.com http://wikimapia.org/street/16408710/sq/rruga-arkitekt-kasemi� mailto:manushaqebatku@yahoo.com� 84 rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 abstract aim: the aim of our study was to assess the distribution of socio-demographic factors and the clinical profile of individuals diagnosed with retinal vein occlusion (rvo) in albania, a former communist country in south-eastern europe which has been undergoing a rapid transition in the past decades. methods: this study was carried out in 2013-2016 at the primary health care centre no. 2 in tirana municipality, which is the capital of albania. during this timeframe, on the whole, 44 patients were diagnosed with rvo at this primary health care centre (17 women and 27 men; overall mean age: 69.5±11.5 years). the diagnosis of rvo was based on signs and symptoms indicating a quick reduction of the sight (vision), fundoscopy, fluorescein angiography and the optical coherence tomography. data on socio-demographic factors and clinical characteristics were also gathered for each study participant. results: the prevalence of glaucoma was considerably higher in men than in women (67% vs. 24%, respectively, p=0.01). diabetic retinopathy was somehow more prevalent in women than in men (18% vs. 11%, respectively), whereas an opposite finding was noted for the presence of hypertensive retinopathy (6% vs. 11%, respectively). the prevalence of cataract was higher in female patients compared with their male counterparts (18% vs. 7%, respectively, p=0.36). both macular oedema and papillary oedema were almost equally distributed in men and in women (22% vs. 18% and 4% vs. 6%, respectively). all female patients had comorbid conditions compared to 85% of their male counterparts (p=0.15). the prevalence of hypertension was almost identical in both sexes (52% in men vs. 53% in women), whereas the prevalence of diabetes was somehow higher in men than in women (26% vs. 18%, respectively). conclusion: this is one of the very few studies informing about the distribution of socio demographic factors and selected clinical characteristics of individuals diagnosed with rvo in transitional albania. keywords: albania, clinical profile, ophthalmology, retinal vein occlusion, socio demographic factors. conflicts of interest: none. 85 rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 introduction retinal vein occlusion (rvo) is a major reason for severe ocular impairment and blindness (1,2). the available evidence, based on many studies carried out in different countries of the world, indicates that rvo is linked to an increased risk of cardiovascular disease, especially hypertension, diabetes mellitus, and coronary artery disease (3-5). the incidence and prevalence of rvo is substantially higher among older people, notwithstanding the fact that this condition is a frequent cause of painless visual loss also in middle-aged individuals (6-8). data from the global burden of disease (gbd) 2010 study indicate that albania is the only country in the south-eastern european region that has experienced an increase in the mortality rate from ischemic heart disease and cerebrovascular diseases in the past two decades (9), exhibiting an early evolutionary stage of the coronary epidemic, which was evident many decades ago in the western countries (10). indeed, ischemic heart disease and cerebrovascular disease were among the highest ranking causes regarding the number of years of life lost due to premature mortality in albania in 2010 (9). furthermore, the burden of diabetes mellitus has almost doubled in albania in both sexes in the past two decades (10). in males, there was an increase of 96% in disability-adjusted life years (dalys) from diabetes, whereas in females this increase was 85%. overall, the sex-pooled proportional dalys for diabetes in albania in 2010 increased 50% compared with 1990 (9). currently, there is evidence of a gradual increase in the diabetes burden which is also due to improvements in the accessibility of health care (that is adequate registration and management of all cases with diabetes) coupled with a steady increase in the ageing population (which, in turn, is associated with an increase in the prevalence of diabetes) (10). yet, data on the prevalence and determinants of rvo in albania are scarce. indeed, to date, there are no scientific papers available providing evidence about the magnitude and occurrence of rvo in the population of albania. in this context, the aim of our study was to assess the distribution of socio-demographic factors and the clinical profile of individuals diagnosed with rvo in albania, a former communist country in south-eastern europe which has been undergoing a rapid transition in the past decades. methods a case-series study was carried out at the primary health care centre no. 2 in tirana municipality during the time period 2013-2016. overall, the number of patients diagnosed with rvo in this health centre during the study period was 44. of these, 27 (61%) patients were males and 17 (39%) were females. on the whole, mean age of the patients was 69.5±11.5 years (with a range from 42 years to 93 years). median age was 70.5 years (interquartile range: 60.3-77.8 years). the diagnosis of rvo was based on the following criteria: i) signs and symptoms indicating a quick decrease and reduction of the unilateral sight; ii) fundoscopy, a conventional examination technique of the fundus employed at the primary health care services in albania (a procedure which indicates the retinal veins that are dilated or tortuous, as well as the retinal haemorrhages); iii) fluorescein angiography, which was the main examination procedure in this study, and; iv) the optical coherence tomography (oct). furthermore, information about selected clinical characteristics of each patient diagnosed with rvo was gathered. more specifically, the clinical information for all the patients diagnosed with rvo included the presence of glaucoma (yes vs. no), the type of glaucoma (open angle, closed angle, secondary, or absolute glaucoma), presence of diabetic 86 rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 total (n=44) p* women (n=17) men (n=27) variable retinopathy, hypertensive retinopathy, cataract, macular oedema, papillary oedema, or comorbidity (all dichotomized into: yes vs. no), as well as the type of comorbidity (hypertension, diabetes, or both conditions). information on socio-demographic characteristics was also collected based on a structured interview. more specifically, for each patient it was gathered information on demographic factors (age and sex) and selected socio-economic characteristics [place of residence (dichotomized into: urban vs. rural areas) and employment status (trichotomized into: employed, unemployed, retired)]. the study was approved by the faculty of medicine in tirana and all patients who agreed to participate in this study gave their informed consent. mean values and the respective standard deviations were calculated for the age of the overall sample of study participants, as well as separately in men and in women. conversely, absolute numbers and their respective percentages were calculated for the other socio demographic factors (place of residence and employment status) and all the clinical characteristics of the patients. mann-whitney u-test was used to compare the age between male and female patients diagnosed with rvo. on the other hand, fisher’s exact test was used to assess sex-differences in the distribution of the other socio-demographic factors (see table 1) and all the clinical characteristics in the sample of patients included in this study (table 2). a p-value of≤0.05 was considered as statistically significant in all ca ses. statistical package for social sciences (spss, version 17.0) was used for all the statistical analyses. results the distribution of socio-demographic characteristics of the patients included in this study is presented in table 1. mean age in men was 71.1±10.9 years, whereas in women it was 67.0±12.4 years. yet, there was no evidence of a significant sex-difference in the mean age of the patients included in this study (mann-whitney u-test: p=0.27). about 19% of male patients and 29% of females were residing in rural areas, without evidence of a sex-difference though (p=0.47). similarly, there was no evidence of a statistically significant difference in the distribution of employment status between genders, regardless of a higher rate of unemployment in women compared to men (29% vs. 15%, respectively, p=0.51) [table 1]. table 1. socio-demographic characteristics of a sample of patients diagnosed with rvo during 2013-2016 in tirana, albania age (in years) [mean±sd] 71.1±10.9 67.0±12.4 0.272 69.5±11.5 place of residence [n (column %)] urban areas 22 (81.5) 12 (70.6) 0 473 34 (77.3) rural areas 5 (18.5) 5 (29.4) 10 (22.7) employment status [n (column %)] employed 2 (7.4) 1 (5.9) 3 (6.8) unemployed 4 (14.8) 5 (29.4) 0.505 9 (20.5) retired 21 (77.8) 11 (64.7) 32 (72.7) * mann-whitney u-test was used for the comparison of age between men and women, whereas fisher’s exact test was used to test sex-differences regarding the distribution of place of residence and employment status. 87 rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 the distribution of selected clinical characteristics of the patients included in this study is presented in table 2. the prevalence of glaucoma was considerably and significantly higher in men than in women (67% vs. 24%, respectively, p=0.01). absolute glaucoma was found in 26% of men, but only in 6% of women, notwithstanding the lack of a statistically significant sex-difference in the distribution of glaucoma types (p=0.26), possibly due to the modest sample sizes. diabetic retinopathy was somehow more prevalent in women than in men (18% vs. 11%, respectively), whereas an opposite finding was noted for the presence of hypertensive retinopathy (6% vs. 11%, respectively). yet, none of these differences was statistically significant. the prevalence of cataract was higher in female patients compared with their male counterparts (18% vs. 7%, respectively), regardless of the lack of statistical significance (p=0.36). both macular oedema and papillary oedema were almost equally distributed in men and in women (22% vs. 18% and 4% vs. 6%, respectively). table 2. distribution of clinical characteristics in a sample of patients diagnosed with rvo during 2013-2016 in tirana, albania clinical characteristic men (n=27) women p† (n=17) total (n=44) no 9 (33.3)* 13 (76.5) 0.012 22 (50.0) yes 18 (66.7) 4 (23.5) 22 (50.0) glaucoma type: open angle 5 (18.5) 5 (29.4) 10 (22.7) closed angle 4 (14.8) 5 (29.4) 0.261 9 (20.5) secondary 11 (40.7) 6 (35.3) 17 (38.6) absolute 7 (25.9) 1 (5.9) 8 (18.2) diabetic retinopathy: no 24 (88.9) 14 (82.4) 0.662 38 (86.4) yes 3 (11.1) 3 (17.6) 6 (13.6) hypertensive retinopathy: no 24 (88.9) 16 (94.1) 0.999 40 (90.9) yes 3 (11.1) 1 (5.9) 4 (9.1) cataract: no 25 (92.6) 14 (82.4) 0.359 39 (88.6) yes 2 (7.4) 3 (17.6) 5 (11.4) macular oedema: no 21 (77.8) 14 (82.4) 0.999 35 (79.5) yes 6 (22.2) 3 (17.6) 9 (20.5) papillary oedema: no 26 (96.3) 16 (94.1) 0.999 42 (95.5) yes 1 (3.7) 1 (5.9) 2 (4.5) comorbidity: no 4 (14.8) 0 (-) 0.147 4 (9.1) yes 23 (85.2) 17 (100.0) 40 (90.9) type of comorbidity: hypertension 14 (51.9) 9 (52.9) 23 (52.3) diabetes 7 (25.9) 3 (17.6) 10 (22.7) both 6 (22.2) 5 (29.4) 11 (25.0) 88 rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 * absolute numbers and the respective column percentages (in parentheses). † fisher’s exact test was employed to test sex-differences regarding the distribution of all clinical characteristics presented in the table. all female patients had comorbid conditions compared to 85% of their male counterparts (p=0.15). the prevalence of hypertension was almost identical in both sexes (52% in men vs. 53% in women), whereas the prevalence of diabetes was somehow higher in men than in women (26% vs. 18%, respectively) [table 2]. discussion this study provides evidence about the distribution of socio-demographic factors and the clinical profile of individuals diagnosed with rvo at primary health care services in tirana, the capital and the largest city in post-communist albania. essentially, the main findings of this study consist of a higher prevalence of glaucoma, hypertensive retinopathy and diabetes in men than in women. on the other hand, women exhibited a higher prevalence of diabetic retinopathy, cataract and comorbid conditions. it should be noted that there are no previous studies describing the socio-demographic factors and clinical characteristics of albanian patients with rvo. the incidence and prevalence of rvo will increase steadily in albania in line with the population aging. thus, according to the last census conducted by the albanian institute of statistics in 2011, the proportion of individuals aged 65 years and over increased to 11% (11). this gradual increase of the older population bears important implications for the heath care sector including also provision of more specialized care against visual impairment. several systemic risk factors for rvo are also associated with arterial thromboembolic events including myocardial infarction and cerebrovascular disease (12,13). from this perspective, it has been shown that the retinal blood vessels exhibit similar anatomic features and physiologic characteristics with cerebral vessels (1,14). based on this evidence, it has been convincingly argued that there might be an association between rvo and myocardial infarction and cerebrovascular disease occurrence (1,14). our study may have several potential limitations due to the sample size and, particularly, sample representativeness. from this point of view, the number of individuals involved in this study was small and was confined only to one of the eleven primary health care centres of the municipality of tirana. in addition, some individuals suffering from rvo might have not preferred to seek care in primary health services. instead, some patients might have preferred more specialized care which is available at the university clinic of ophthalmology as a part of the university hospital centre “mother teresa”, the only public hospital in tirana. also, some patients might have used private ophthalmology clinics which may currently provide better care in albania. based on these considerations, the representativeness of our study sample may be questionable and, therefore, our findings should not be generalized to the general population of tirana and the overall population of albania. instead, findings of this study should be interpreted with extreme caution. on the other hand, the diagnosis of patients with rvo in our study was based on standardized and valid instruments, similar to studies conducted elsewhere. nonetheless, we cannot entirely exclude the possibility of information bias related to socio-demographic data, in particular regarding the employment status of study participants. 89 rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 in conclusion, notwithstanding some possible limitations, this study offers useful information about the distribution of socio-demographic factors and the clinical profile of primary health care users diagnosed with rvo in transitional albania, an under-researched setting. population-based studies should be carried out in the future in albania in order to determine the magnitude and occurrence of rvo in the general population. 90 rustani-batku, tonuzi a. socio-demographic factors and selected clinical characteristics of patients with retinal vein occlusions in transitional albania (short report). seejph 2017, posted: 16 march 2017. doi:10.4119/unibi/seejph-2017-139 references 1. zhong c, you s, zhong x, chen gc, xu t, zhang y. retinal vein occlusion and risk of cerebrovascular disease and myocardial infarction: a meta-analysis of cohort studies. atherosclerosis 2016;247:170-6. 2. david r, zangwill l, badarna m, yassur y. epidemiology of retinal vein occlusion and its association with glaucoma and increased intraocular pressure. ophthalmologica 1988;197:69-74. 3. o’mahoney pr, wong dt, ray jg. retinal vein occlusion and traditional risk factors for atherosclerosis. arch ophthalmol 2008;126:692-9. 4. klein r, moss se, meuer sm, klein be. the 15-year cumulative incidence of retinal vein occlusion: the beaver dam eye study. arch ophthalmol 2008;126:513-8. 5. werther w, chu l, holekamp n, do dv, rubio rg. myocardial infarction and cerebrovascular accident in patients with retinal vein occlusion. arch ophthalmol 2011;129:326-31. 6. li m, hu x, huang j, tan y, yang b, tang z. impact of retinal vein occlusion on stroke incidence: a meta-analysis. j am heart assoc 2016;5. pii: e004703. doi: 10.1161/jaha.116.004703. 7. mcintosh rl, rogers sl, lim l, cheung n, wang jj, mitchell p, et al. natural history of central retinal vein occlusion: an evidence-based systematic review. ophthalmology 2010;117:1113-23. 8. rogers sl, mcintosh rl, lim l, mitchell p, cheung n, kowalski jw, et al. natural history of branch retinal vein occlusion: an evidence-based systematic review. ophthalmology 2010;117:1094-101. 9. institute for health metrics and evaluation (ihme). global burden of disease database. seattle, wa: ihme, university of washington; 2014. http://www.healthdata.org (accessed: march 10, 2017). 10. albanian institute of public health. national health report: health status of the albanian population. tirana, albania; 2014. 11. institute of statistics (instat). population and housing census, 2011. tirana: instat; 2012. http://www.instat.gov.al/media/178070/rezultatet_kryesore_t censusit_t popullsis d he_banesave_2011_n shqip_ri.pdf (accessed: march 10, 2017). 12. elkind ms, sacco rl. stroke risk factors and stroke prevention, semin neurol 1998;18:429-40. 13. yusuf s, hawken s, ounpuu s, dans t, avezum a, lanas f, et al. effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the interheart study): case-control study. lancet 2004;364:937-52. 14. tso mo, jampol lm. pathophysiology of hypertensive retinopathy. ophthalmology 1982;89:1132-45. © 2017 rustani-batku; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.ncbi.nlm.nih.gov/pubmed/?term=zhong%20c%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26922716� https://www.ncbi.nlm.nih.gov/pubmed/?term=zhong%20c%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26922716� https://www.ncbi.nlm.nih.gov/pubmed/?term=zhong%20c%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26922716� https://www.ncbi.nlm.nih.gov/pubmed/?term=zhong%20x%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26922716� https://www.ncbi.nlm.nih.gov/pubmed/?term=zhong%20x%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26922716� https://www.ncbi.nlm.nih.gov/pubmed/?term=zhong%20x%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26922716� https://www.ncbi.nlm.nih.gov/pubmed/?term=xu%20t%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26922716� https://www.ncbi.nlm.nih.gov/pubmed/?term=xu%20t%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=26922716� https://www.ncbi.nlm.nih.gov/pubmed/?term=retinal%2bvein%2bocclusion%2band%2brisk%2bof%2bcerebrovascular%2bdisease%2band%2bmyocardial%2binfarction%3a%2ba%2bmeta-analysis%2bof%2bcohort%2bstudies� https://www.ncbi.nlm.nih.gov/pubmed/?term=li%20m%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=28007745� https://www.ncbi.nlm.nih.gov/pubmed/?term=hu%20x%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=28007745� https://www.ncbi.nlm.nih.gov/pubmed/?term=huang%20j%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=28007745� https://www.ncbi.nlm.nih.gov/pubmed/?term=huang%20j%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=28007745� https://www.ncbi.nlm.nih.gov/pubmed/?term=huang%20j%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=28007745� https://www.ncbi.nlm.nih.gov/pubmed/?term=huang%20j%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=28007745� https://www.ncbi.nlm.nih.gov/pubmed/?term=yang%20b%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=28007745� https://www.ncbi.nlm.nih.gov/pubmed/?term=yang%20b%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=28007745� https://www.ncbi.nlm.nih.gov/pubmed/?term=impact%2bof%2bretinal%2bvein%2bocclusion%2bon%2bstroke%2bincidence%3a%2ba%2bmeta-analysis� https://www.ncbi.nlm.nih.gov/pubmed/?term=impact%2bof%2bretinal%2bvein%2bocclusion%2bon%2bstroke%2bincidence%3a%2ba%2bmeta-analysis� http://www.healthdata.org/� http://www.instat.gov.al/media/178070/rezultatet_kryesore_t� https://www.ncbi.nlm.nih.gov/pubmed/?term=elkind%20ms%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=9932614� https://www.ncbi.nlm.nih.gov/pubmed/?term=sacco%20rl%5bauthor%5d&amp;amp%3bcauthor=true&amp;amp%3bcauthor_uid=9932614� http://creativecommons.org/licenses/by/3.0)� jacobs verlag executive editor assistant executive editors editors regional editors advisory editorial board publisher table of contents editorial the mark of women’s leadership on solutions to global health problems conflicts of interest: none. original research ethnic differences in smoking behaviour: the situation of roma in eastern europe abstract conflicts of interest: none. introduction methods data and samples statistical analysis results determinants of cigarette consumption smoking and discrimination discussion conclusions references original research the relevance of ethics in the european union’s second public health programme nelly k. otenyo1 abstract conflicts of interest: none. theoretical framework table 1. overview of ethical principles and health strategy values (source: references 11-13) methods methodological and theoretical limitations including other potential challenges results table 2. presentation of the findings ethical concepts and shared health values in the php-2008-2013 objectives table 3. shared health values in the php-2008-2013 objectives (source: adapted from reference no. 15) ethical principles in the php 2008-2013 project proposals table 4. efficiency aspects identified in project proposals table 5. accessibility to quality health care as identified in the summaries of the project-proposals ethical concepts or aspects in the php 2008-2013 discussion ex-post evaluation of the health programme conclusions references original research giovanni piumatti1 abstract conflicts of interest: none. introduction the italian context methods sample measures analysis results development of life satisfaction identifying life satisfaction trajectories differences in achievement strategies and criteria for adulthood discussion study limitations and conclusions references review article abstract introduction methods search strategy selection criteria figure 1. flow chart of the selection process data analysis results roles of nurses during emergency response table 1. general and special roles of nurses disaster preparedness and knowledge of nurses table 2. core competencies and disaster curriculum table 3. reasons for participating and specific issues for disaster training table 4. personal and professional disaster preparedness disaster experiences of nurses discussion conclusions and implications table 5. relevance to nursing practice, nursing education and research references review article the emerging public health legislation in ukraine abstract conflicts of interest: none. introduction recent legal initiatives in ukraine definitions of public health legally relevant to ukraine related definitions relevant to the health sector public health service preparing human resources for the implementation of the upcoming public health legislation conclusions references short report protecting the planet and sustainable development abstract conflicts of interest: none. a global international body and environmental protection countries’ commitments the role of schools of public health conclusion references short report manushaqe rustani-batku1, ali tonuzi2 abstract conflicts of interest: none. methods results discussion references health systems and their evidence based development h e a lt h s y s t e m s a n d t h e i r e v i d e n c e b a s e d d e v e l o p m e n t a handbook for teachers, researchers and health professionals editors: vesna bjegovi] and don^o donev editorial assistance: bosiljka \ikanovi} ph-see project coordinators: ulrich laaser and luka kova~i} doris bardehle, germany vesna bjegovi}, serbia and montenegro jadranka bo`ikov, croatia birgit cornelius taylor, world health organisation viktorija cuci}, serbia and montenegro don~o donev, macedonia bosiljka \ikanovi}, serbia and montenegro adriana galan, romania thomas hofmann, germany bajram hysa, albania enida imamovi}, bosnia and herzegovina luka kova~i}, croatia ulrich laaser, germany aurelia marcu, romania jelena marinkovi}, serbia and montenegro bojana mateji}, serbia and montenegro dragana nik{i}, bosnia and herzegovina silvia gabriela scîntee, romania sne`ana simi}, serbia and montenegro kancho tchamov, bulgaria zorica terzi} [upi}, serbia and montenegro lijana zaletel kragelj, slovenia rudolf welteke, germany helmut wenzel, germany khaled yassin, germany belgrade 2004 3 bibliographische information der deutschen bibliothek die deutsche bibliothek verzeichnet diese publikation in der deutschen nationalbibliographie; detaillierte daten sind im internet über http://dnb.ddb.de abrufbar. this publication has been supported by the german academic exchange service (daad) with funds from the stability pact, „academic programmes for training and research in public health in south eastern europe" (ph-see). publisher: hans jacobs publishing comany graphic design: branislav radoti} cover design: alma [imunec-jovi} printed by: sprint-beograd number of copies: 400 copyright 2004 by hans jacobs publishing company hellweg 72, 32791 lage, germany isbn 3-89918-123-9 4 preface this books' title „health systems and their evidence based development” comprises some key features of health care in the 21st century: 1) the organisation of health care delivery is of utmost importance for the post-modern state in europe and north-america as it is in a different way for the developing world. this is the case because of its economic importance signified by the spending of between 5 and 15% of the gross domestic product for health but even more because of the growing relevance of excellent population health for economic development in low-tension open societies (1); 2) modern health systems are not to be looked at as static structures, the best example being provided by the german bismarckian system which maintained for more than hundred years i.e. since 1883, some essentials like the obligatory membership (up to an income threshold for high earners), a multiplicity of fee-based health insurances, and the sharing of the contributions between employers and employees (2). today health care systems undergo continuous reform, mainly to curb expenditure but also to guaranty access and quality of service to everybody (see for example the dubrovnik pledge of the ministers of health in south east europe in 2001 (3) or the conclusions at the ljubljana conference in 1996 (4)). one example of this is the existence of long waiting queues for specific operations for hip or knee replacements in the taxbased beveridge systems especially in northern europe. 3) health systems reform and development, however, require thorough scientific analysis to identify the options available to the politician. the term coined for this demand in today's discussion refers to the evidence base of decision making (see who-euro 2003 (5)). unfortunately still the reform legislation in most countries orients towards the uni-dimensional consideration of financial constraints, missing the chance of exploring real improvement and instead modifying repeatedly the various models of co-payment. 4) the title refers implicitly to a comparative approach between national health systems. especially in europe with her different historical lines of development this is an essential element if the european unification process is taken into account. only recently the european high court has issued strategic decisions on the universal access to health care in the european union wherever a patient seeks care and wherever she or he is insured. a public health mandate of the european commission has been formulated already in the maastricht treaty of 1992 (6). converging trends can also be recognized with regard to the development of „mixed” systems containing elements of the bismarck as well as of the beveridge model. 5 as this handbook is devoted to all teachers, researchers, postgraduate students and professionals in the health field the question arises who in the end is responsible for the organization and further development of the health system. the answer can only be that this field is essentially characterized by multiprofessionality and inter-disciplinarity comprising all parties including the patients and the population themselves. however, the steering of such systems, the balancing of input and output, and their evaluation are mainly considered to be subject to the health sciences, i.e. a part of the public health. therefore it is not by chance, that this handbook has been developed in the context of a research & development project in order to enable and improve the teaching for research and practice in public health: the public health collaboration in south eastern europe (ph-see), funded since the year 2000 by the stability pact through the german academic exchange service (daad). on the phsee website (7) maintained by the andrija [tampar school of public health in zagreb, croatia, the abstracts of teaching modules in a number of public health fields can directly be accessed like „methods and tools in health sciences”, „determinants of health”, „disease prevention and health promotion”, „health care and health services” or „public health strategies” and in addition the chapters of this handbook in full text. this handbook is likely to be the first compendium on the main issues in evidence based health systems development with a focus on the situation and the experience in south eastern europe, and more general in all of the former socialist economies in transition, most of them in a process of accession to the european union. the book comprises three main chapters: (1.0) health systems analysis, (2.0) health systems management and (3.0) health policy. this agenda describes the full cycle of scientific analysis and evaluation, the operational steering of the system, and the developmental aspects of change and reform. within these three sections the reader finds basic texts in the format of teaching modules including exercises for students and reference material, complemented by case studies for study work. deliberately the conceptual approach of this handbook goes beyond the usual listing of topics to be dealt with in teaching public health as it is obvious that most readers would expect and need more than a reference to knowledge and expertise elsewhere. thus the volume can be used as a teaching book as well as a compendium or handbook in the field. it corresponds to a total student workload of 12 ects (european credit transfer system) and its contents may be combined with other modules. other handbooks will follow this first edition covering the areas listed above as on the website (7). finally as the principle investigators of the public health 6 health systems and their evidence based development collaboration in south eastern europe we have to express our sincerest thanks to the editors and authors for their dedication and patience and an enormous amount of unpaid work, which gave this endeavour a special flavour and unique value. may this cooperative work also serve as an example for a brighter future in a war-torn region and the re-establishment of cooperation and peace building, collegiality and togetherness in the service to the people. prof. dr. med. ulrich laaser prof. dr. med. luka kova~i} faculty of health sciences andrija [tampar school of public health university of bielefeld, germany medical faculty of zagreb, croatia references 1. who. macroeconomics and health: investing in health for economic development. report of the commission on macroeconomics and health. chaired by jeffrey d. sachs. geneva: who publication office 2001. 2. bärnighausen t, sauerborn r. one hundred and eighteen years of the german health insurance system: are there any lessons for middleand low-income countries? social science and medicine 2002; 54: 1559-1587. 3. the health ministers forum. the dubrovnik pledge: meeting the health needs of vulnerable populations in south east europe (dubrovnik, croatia august 31-september 2, 2001). copenhagen: who regional office for europe 2001. 4. who. the ljubljana charter on reforming health care. copenhagen: who regional office for europe 1996. 5. who. the health evidence network (hen). (cited 2004, april 12). available from url: www.euro.who.int/hen 6. eu. treaty on european union, signed at maastricht on 7 february 1992. (cited 2004, april 12). available from url: www.europa.eu.int 7. ph-see. public health collaboration in south eastern europe: programmes for training and research in public health. (cited 2004, april 12). available from url: www.snz.hr/ph-see 7 preface 8 health systems and their evidence based development contents preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 list of authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.0 health systems analysis (ects 4.75) 1.1 don~o donev the role and organization of health systems . . . . . . . 19 1.2 enida imamovi}, dragana nik{i} case study: the health system of bosnia and herzegovina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 1.3 jelena marinkovi}, vesna bjegovi} electronic health records – the core of the national health information system . . . . . . . . . . . . . . . . . . . . . . . 63 1.4 doris bardehle health indicators and health reporting . . . . . . . . . . . . . 102 1.5 zorica terzi} [upi}, bojana mateji} quality of life: concept and measurement . . . . . . . . . . 116 1.6 adriana galan disability-adjusted life years: a method for the analysis of the burden of disease . . . . . . . . . . . 141 1.7 aurelia marcu calculating the potential years of life lost. . . . . . . . . . . . . 1.8 khaled yassin, adriana galan case study: inequalities in health as assessed by the burden of disease method . . . . . . . . . . . . . . . . . . . . 1.9 jelena marinkovi} health technology assessment as a tool for health systems development. . . . . . . . . . . . . . . . . . . . . . . . . . . 172 1.10 birgit cornelius taylor, ulrich laaser comparative research on regional health systems in europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 9 2.0 health systems management (ects 5.50) 2.1 vesna bjegovi} health management: theory and practice . . . . . . . . . . . 241 2.2 silvia gabriela scîntee human resource management. . . . . . . . . . . . . . . . . . . . 263 2.3 adriana galan information systems management . . . . . . . . . . . . . . . . . 288 2.4 don~o donev, jadranka bo`ikov the financing of health care . . . . . . . . . . . . . . . . . . . . 304 2.5 don~o donev, luka kova~i} payment methohds and regulation of providers . . . . . 325 2.6 don~o donev case study: the current health insurance system in the republic of macedonia . . . . . . . . . . . . . . 343 2.7 vesna bjegovi}, adriana galan case study: swot analysis of the serbian health insurance system . . . . . . . . . . . . . . . . . . . . . . . . 364 2.8 helmut wenzel, bajram hysa economic appraisal as a basis for decision making in health systems . . . . . . . . . . . . . . . 376 2.9 viktorija cuci} quality improvement in health care and public health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404 2.10 vesna bjegovi}, sne`ana simi} accreditation of health institutions as an external tool for quality improvement . . . . . . . . 424 2.11 silvia gabriela scîntee, adriana galan project management . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443 2.12 kancho tchamov planning and programming of health care . . . . . . . . . . 473 3.0 health policy (ects 1.75) 3.1 vesna bjegovi}, bosiljka \ikanovi} informed health policy and system change . . . . . . . . . 495 3.2 thomas hofmann public health policy of the european union . . . . . . . . . 525 10 health systems and their evidence based development 3.3 rudolf welteke targets for health development. . . . . . . . . . . . . . . . . . . 537 3.4 lijana zaletel kragelj health legislation: procedures towards adoption . . . . . 568 11 comparative analysis of regional health care systems in the european union list of authors doris bardehle, dr. med. professor at the university of bielefeld, faculty of health sciences, department of epidemiology and medical statistics, universitätsstraße 25, d-33615 bielefeld, germany. e-mail: doris. bardehle@loegd.nrw.de vesna bjegovi}, md, msc, phd. professor at the school of medicine, institute of social medicine, university of belgrade, dr suboti}a 15, 11000 belgrade, serbia and montenegro. tel: +381 11 643 830, fax: + 381 11 659 533, e-mail: bjegov@eunet.yu jadranka bo`ikov, mph, phd. professor at andrija [tampar school of public health, medical school, university of zagreb, rockefeller st. 4 hr-10000 zagreb, croatia. e-mail: jbozikov@snz.hr birgit cornelius taylor, mph. who european office for integrated health care services, marc aureli 22-36, e-08006 barcelona, spain. tel: +34 93 241 8270, fax: +34 93 241 8271, e-mail: bct@es.euro.who.int viktorija cuci}, md, phd. professor emeritus. institute of social medicine, school of medicine, university of belgrade, dr suboti}a 15, 11 000 belgrade, serbia and montenegro. tel: +381 11 643 830, fax: + 381 11 659 533, home: ^ingrijina 13, 11 000 belgrade, e-mail: ecucic@eunet.yu bosiljka \ikanovi}, md, editorial assistance, a handbook for teachers, researchers and health professionals: health systems and their evidence based development. home: cviji}eva 44, 11 000 belgrade, serbia and montenegro. tel: +381 63 273 672, e-mail: boss@bitsyu.net don~o donev, md, phd. professor at the institute of social medicine, joint institutes, medical faculty, university of skopje, 50 divizia no.6, 1000 skopje, republic of macedonia. tel: +389 2 3147 056, fax: +389 2 3298-581, e-mail: donev@freemail.org.mk adriana galan, it specialist. part-time senior lecturer at the university of medicine and pharmacy, department of public health and management, at postgraduate level. institute of public health bucharest, 1-3 dr. leonte street, 76256 bucharest, romania. tel: (4021) 2249228 / ext.188, fax: (4021) 3123426, e-mail: agalan@ispb.ro thomas hofmann, mhcm, mph. federal ministry of health and social security, d-53108 bonn, germany. tel: +49 228 9411831, fax: +49 228 9414945, e-mail: thhofmann@yahoo.com 12 health systems and their evidence based development bajram hysa, economist, associated professor at department of public health, faculty of medicine, rr. „dibres”, no.371, tirana, albania. e-mail: b_hysa@yahoo.com enida imamovi}, md. specialist of social medicine. public health institute of federation of b&h; titova 9, 71000 sarajevo, bosnia and herzegovina. tel: + 387 33 20 88 13, fax: +387 33 22 05 48, e-mail: imamovic@bih.net.ba luka kova~i}, md, phd. andrija štampar school of public health, medical school, university of zagreb, rockefeller st. 4, hr-10000 zagreb, croatia. email: lkovacic@snz.hr ulrich laaser, dtm&h, mph, dr. med. professor, section of international public health (s-iph), faculty of health sciences, university of bielefeld, pob 10 01 31, d-33501 bielefeld, germany. tel/am/fax: +49 521 450116, e-mail: ulrich.laaser@uni-bielefeld.de aurelia marcu, md, phd. public health consultant, head of department of strategies and forecasts in public health, institute of public health bucharest, 1-3 dr. leonte street 76 256 bucharest, romania. tel: (4021) 2249228 / ext.188, fax: (4021) 3123426, e-mail: amarcu@ispb.ro jelena marinkovi}, bm, phd. professor at the school of medicine, university of belgrade, institute of medical statistics and informatics, school of medicine, belgrade university, dr suboti}a 15, 11000 belgrade, serbia and montenegro. tel: +381 11 685 888, fax: + 381 11 659 533, e-mail: jelena@pcpetak.com bojana mateji}, md, msc. teaching assistant at the institute of social medicine, school of medicine, university of belgrade, dr suboti}a 15, 11000 belgrade, serbia and montenegro. tel: +381 11 643 830, fax: + 381 11 659 533, e-mail: bojana_boba@yahoo.com dragana nik{i}, md, phd. ass. professor of social medicine, medical faculty, university of sarajevo, ^ekalu{a 90, 71 000 sarajevo, bosnia and herzegovina. tel: +387 33 202 051, +387 33 663 742 loc.160, fax: +387 33 202 051, e-mail: h.niksic@bih.net.ba silvia gabriela scîntee, md, msc. part-time lecturer at the university of medicine and pharmacy „carol davila” bucharest, department of public health and management, public health consultant at the institute of public health bucharest, 1-3 dr. leonte street 76 256 bucharest, romania. tel: (4021) 2249228 / ext.188, fax: (4021) 3123426, e-mail: gscintee@ispb.ro 13 comparative analysis of regional health care systems in the european union sne`ana simi}, md, msc, phd. professor at the school of medicine, institute of social medicine, university of belgrade, dr suboti}a 15, 11000 belgrade, serbia and montenegro. tel: +381 11 643 830, fax: + 381 11 659 533, e-mail: snezanas@eunet.yu kancho tchamov, mph, phd. associate professor on faculty of public health, medical university – sofia, hospital „tzariza joanna” 8, bjalo more str. 1527 – sofia, bulgaria. tel: +359 2 9225197; fax: +359 2 9432304, e-mail: tchamov@bulinfo.net zorica terzi} [upi}, md, msc. teaching assistant at the institute of social medicine, school of medicine, university of belgrade, dr suboti}a 15, 11000 belgrade, serbia and montenegro. tel: +381 11 643 830, fax: + 381 11 659 533, e-mail: vlazo970@yahoo.com lijana zaletel kragelj, md, phd. teaching assistant at department of public health – social medicine, faculty of medicine, university of ljubljana, zalo{ka 4, 1000 ljubljana, slovenia. fax: + 386 1 543 75 41, e-mail: lijana.kragelj@mf.uni-lj.si rudolf welteke, dr. med. state institute of public health of northrhinewestphalia (loegd) westerfeldstr. 35/37, d-33611 bielefeld, germany. email: rudolf.welteke@loegd.nrw.de helmut wenzel, m.a.s. health economist, roche diagnostics company, mannheim, germany. home: friedrichstrasse, 61, d-78464 konstanz, germany. e-mail: hkwen@aol.com khaled yassin, dr. med dr. ph. section of international public health, faculty of health sciences, university of bielefeld, pobox 100131 d-33501 bielefeld, germany. e-mail: kyassin@gmx.de 14 health systems and their evidence based development health systems analysis 15 prazna 16 17 the role and organization of health care systems health systems and their evidence based development a handbook for teachers, researchers and health professionals title the role and organization of health care systems module: 1.1 ects (suggested): 0.75 author(s), degrees, institution(s) doncho donev, md, phd, professor institute of social medicine, joint institutes, medical faculty, university of skopje 50 divizia no.6 1000 skopje, republic of macedonia address for correspondence doncho donev, md, phd institute of social medicine, joint institutes, medical faculty, university of skopje 50 divizia no.6 1000 skopje republic of macedonia tel: +389 2 3147 056 fax: +389 2 3163 866 e-mail: donev@freemail.org.mk keywords health care; health systems; health systems organization and performance; primary health care; hospital care; health care reforms learning objectives after this module, students and health professionals should: • increase understanding of health care systems organization, their historical development and respective functions; • distinguish national health care systems based on sources of funding (beveridge, bismarck and private insurance model); • be able to describe scope of activities of health organizations on different levels (self care, primary, secondary and tertiary level of care); • be able to classify health service organizations depend on various criteria (type of service, length of stay, type of control or ownership); • describe three generations of reforms in health system; • identify main goals and objectives of national health systems; and • identify common problems and new challenges of health care systems. abstract the health of the people is always a national priority. health care system (hcs) infrastructure includes services, facilities, institutions/establishments, organizations, and those operating them for conducting the delivery of a variety of health programmes. they provide individuals, families, and communities with health care, which consists of a combination of promotive, protective, preventive, diagnostic, curative and rehabilitative measures. hcs are different all over the world and strongly influenced by each nation's unique history, traditions, socio-cultural, economic, political and other factors. but, regardless of all present differences, there are still some common characteristics, typical for all hcs. in this module three levels of healthcare (primary, secondary, tertiary) are described, as well as their historical development. concerning sources of funding, main models of national hcs are: the beveridge model, the bismarck model and the private insurance model. hcs are continuously evolving. there are presented three generations of hcs reforms. improvement of population's health is often expressed as improved coverage, access, equity, quality of care, but also efficiency in use of resources, and financing. hcs facing new challenges, among them are aging of the population, medical technology innovations, pressure to constraint costs, community involvement and intersectoral action. those principles will be important more then ever. 18 health systems and their evidence based development teaching methods teaching methods include lectures and interactive group discussion. specific recommendations for teacher this module should be organized within 0.75 ects, out of which one third are lectures and group discussion supervised by the lecturer. the rest is individual work (searching internet mainly) in order to prepare seminar paper. assessment of students assessment should be based on the quality of seminar paper, which presents the national health system of the students’ country. oral exam is also recommended. the role and organization of health systems dončo donev introduction health systems have a vital and continuing responsibility to people throughout the lifespan. they are crucial to the healthy development of individuals, families and societies everywhere. the real progress in health towards the united nations millennium development goals* and other national health priorities depends vitally on stronger health systems based on primary health care (1). improving health is clearly the main objective of each health system, but it is not the only one. the objective of good health itself is really twofold: the best attainable average level – goodness and the smallest feasible differences among individuals and groups – fairness. goodness means a health system responding well to what people expect of it, and fairness means it responds equally well to everyone, without discrimination (2). each national health system should be directed to achieve three overall goals: good health, responsiveness to the expectations of the population, and fairness of financial contribution. progress towards them depends crucially on how well systems carry out four vital functions. these are: service provision, resource generation, financing and stewardship. comparing the way these functions are actually carried out provide a basis for understanding performance variations over the time and among countries. there are minimum requirements which every health care system should meet equitably: access to quality services for acute and chronic health needs; effective health promotion and disease prevention services; and appropriate response to new threats as they emerge (emerging infectious diseases, growing burden of non-communicable diseases and injuries, and the health effects of global environmental changes) (1,2). the overall mission of who is the attainment by all people of the highest possible level of health, with special emphasis on closing the gaps 19 the role and organization of health care systems * the goals in the area of development and poverty eradication (to reduce poverty and hunger and to tackle ill-health, gender inequality, lack of education, access to clean water and environmental degradation). these goals are included in the united nations millennium declaration adopted at the millennium summit in new york in september 2000, and are now widely referred to as millennium development goals. within and among countries. the ability of who to fulfill this mission depends greatly on the effectiveness of health systems in member states – and strengthening those systems is one of who’s four strategic directions. it connects very well with the other three: reducing the excess mortality of poor and marginalized populations; dealing effectively with the leading risk factors; and placing health at the center of the broader development agenda because population health contributes crucially to economic and social development (1,3). health systems have contributed enormously to better health for most of the global population during the 20th century. today, health systems, in all countries, rich and poor, play a bigger and more influential role in people’s lives than ever before. health systems of some sort have existed for a long as people have tried to protect their health and treat diseases. traditional practices, often integrated with spiritual counseling and providing both preventive and curative care, have existed for thousands of years and often coexist today with modern medicine. many of them are still the treatment of choice for some health conditions, or are resorted to because modern alternatives are not understood or trusted, or fail, or are too expensive. health systems have undergone overlapping generations of reforms in the past 100 years, including the founding of national health care systems and the extension of social insurance schemes. later came the promotion of primary health care as a route to achieving affordable universal coverage – the goal of health for all. in the past decade or so there has been a gradual shift of vision towards what who calls the „new universalism”. rather than all possible care for everyone, or only the simplest and most basic care for the poor, this means delivery to all of high-quality essential care, defined mostly by criteria of effectiveness, cost and social acceptability. this shift has been partly due to the profound political and economic changes of the last 20 years or so. these include the transformation from centrally planned to market-oriented economies, reduced state intervention in national economies, fewer government controls, and more decentralization (2). within all systems there are many highly skilled, dedicated people working at all levels to improve the health of their communities. as the new century began, health systems have the power and the potential to achieve further extraordinary improvements. unfortunately, health systems can also misuse their power and squander their potential. poorly structured, badly led, inefficiently organized and inadequately funded health systems can do more harm than good. the ultimate responsibility for the overall performance of a country’s health system lies with government, which in turn should involve all sectors of society in its stewardship. the careful and responsible management of the well-being of the population is the very essence of good government. for 20 health systems and their evidence based development every country it means establishing the best and fairest health system possible with available resources. the health of the people is always a national priority and the government responsibility for it should be continuous and permanent. ministries of health must therefore take on a large part of the stewardship of health systems. healthy policy and strategies need to cover the private provision of services and private financing, as well as state funding and activities. only in this way can health systems as a whole be oriented towards achieving goals that are in the public interest (2). health care services and health services organizations health care is the comprehensive social effort, organized or not, private or public, that attempts to guarantee, provide, finance, and promote health. health care consists of measures, activities and procedures for maintaining and improvement of health, living and working environment, as well as measures, activities and procedures which are undertaken in the field of health care for maintaining and improvement of people’s health; prevention and control of specific diseases; early detection of the diseases and conditions of ill health, timely and efficient treatment and rehabilitation. it changed markedly during the 20th century moving toward the ideal of wellbeing and prevention of disease and disability. delivery of health care services involves the organized public or private efforts that assist individuals primarily in regaining health, but also in preventing disease and disability (2,4). delivery of services to patients / consumers occurs in a variety of organizational settings (“patient” is anyone served by health services organization). health services is a permanent countrywide system of established institutions, the multipurpose objective of which is to cope with the various health needs and demands of the population and thereby provide health care for individuals and the community, including a broad spectrum of preventive and curative activities. all health services organizations can be classified by ownership and profit motive. in addition, they can be classified by whether the patient is admitted as an inpatient or outpatient and, for an inpatient, by the average length of stay (4,5). historically, hospitals and nursing facilities have been the most common and dominant health services organizations engaged in delivery of health services. they remain prominent in the contemporary health care systems, but other health services organizations have achieved stature. among them are outpatient clinics, imaging centers, free-standing urgent care and surgical centers, large group practices, and home health agencies. multi-organizational systems, 21 the role and organization of health care systems both vertically and horizontally integrated, are widespread. these various health services organizations and others face new environments containing a wide range of external pressures, including new rules and technologies, changed demography, accountability to multiple constituents, and constraints on resources. as a result, health services organization must allocate and use resources more effectively and strive for continuous improvement and continued excellence in an increasingly restrictive environment (5). what is a health system? in today’s complex world, it can be difficult to say exactly what a health system is, what it consists of, and where it begins and ends. health system includes all the activities, which primary purpose is to promote, restore and maintain health. it means that the health system is the complex of interrelated elements that contribute to health in homes, educational institutions, workplaces, public places, and communities, as well as in the physical and psycho-social environment and the health and related sectors. a health system is usually organized at various levels, starting at the most peripheral level, also known as the community level or the primary level of health care, and proceeding through the intermediate (district, regional or provincial) to the central level. the intermediate and central levels deal with those elements of the health system that provide progressively more complex and more specialized care and support. it is not easy to conceive such multifaceted health system, to maintain its cohesion and to ensure that it functions in compliance with agreed policies. a comprehensive health system denotes one that includes all the elements required to meet all the health needs of the population. health system infrastructure includes services, facilities, institutions or establishments, organizations, and those operating them for conducting the delivery of a variety of health programmes. they provide individuals, families, and communities with health care that consists of a combination of promotive, protective, preventive, diagnostic, curative and rehabilitative measures. health resources are all the means of the health care system available for its operation, including manpower, buildings, equipment, supplies, funds, knowledge and technology. health sector includes governmental ministries and departments, organizations and services, social security and health insurance schemes, voluntary organizations and private individuals and groups providing health services. intersectoral action is an action in which the health sector and other relevant sectors collaborate for the achievement of a common goal, the contributions of the different sectors being closely coordinated. multisectoral action is synonymous term to the intersectoral action. the former (intersectoral) perhaps emphasizing the 22 health systems and their evidence based development element of coordination, the latter (multisectoral) the contribution of a number of sectors (4,6). health systems are defined by who as comprising all the organizations, institutions and resources that are devoted to producing health actions. a health action is defined as any effort, whether in personal health care, public health services or through intersectoral initiatives, whose primary purpose is to improve health (2,6). formal health services, including the professional delivery of personal medical attention, are clearly within these boundaries. so are actions by traditional healers, and all use of medication, whether prescribed by a provider or not. so is home care of the sick, which is how somewhere between 70% and 90% of all sickness is managed. such traditional public health activities as health promotion and disease prevention, and other health-enhancing interventions like road and environmental safety improvement, are also part of the system. beyond the boundaries of this definition are those activities whose primary purpose is something other than health – education, for example – even if these activities have a secondary, health-enhancing benefit. hence, the general education system is outside the boundaries, but specifically health-related education is included. so are actions intended chiefly to improve health indirectly by influencing how non-health systems function – for example, actions to increase girls’ school enrolment or change the curriculum to make students better future caregivers and consumers of health care (2,6). nearly all the information available about health systems refers only to the provision of, and investment in, health services: that is, the health care system, including preventive, curative and palliative interventions, whether directed to individuals or to populations. efforts are needed to quantify and assess those activities implied by the wider definition, so as to begin to gauge their relative cost and effectiveness in contributing to the goals of the health system. even by this more limited definition, health systems today represent one of the largest sectors in the world economy. global spending on health care was almost 8% of world gross domestic product (gdp), in 1997 (2). with rare exceptions, even in industrialized countries, organized health systems in the modern sense, intended to benefit the population at large, barely existed a century ago. hospitals have a much longer history than complete systems in many countries. until well into the 19th century they were for the most part run by charitable organizations, and often were little more than refuges for the orphaned, the crippled, the destitute or the insane. and there was nothing like the modern practice of referrals from one level of the system 23 comparative analysis of regional health care systems in the european union to another, and little protection from financial risk apart from that offered by charity or by small-scale pooling of contributions among workers in the same occupation. towards the close of the 19th century, the industrial revolution was transforming the lives of people worldwide. at the same time societies began to recognize the huge toll of death, illness and disability occurring among workers, whether from infectious diseases or from industrial accidents and exposures. about the same time, workers’ health was becoming a political issue in some european countries, but for quite different reasons. bismarck, chancellor of germany, in 1883, enacted a law requiring employer contributions to health coverage for low-wage workers in certain occupations, adding other classes of workers in subsequent years. this was the first example of a state-mandated social insurance model. the popularity of this law among workers led to the adoption of similar legislation in belgium in 1894, norway in 1909, denmark in 1935 and in netherlands a few years later. the influence of the german model began to spread outside europe after the first world war (in 1922, japan, in 1924, chile) (2,7). in the late 1800s, russia had begun setting up a huge network of provincial medical stations and hospitals where treatment was free and supported by tax funds. after the bolshevik revolution in 1917, it was decreed that free medical care should be provided for the entire population, and the resulting system was largely maintained for almost eight decades. this was the earliest example of a completely centralized and state-controlled model. not least among its effects, the second world war damaged or virtually destroyed health infrastructures in many countries and delayed their health system plans. paradoxically, it also paved the way for the introduction of some others. wartime britain’s national emergency service to deal with casualties was helpful in the construction of what became, in 1948, the national health service, perhaps the most widely influential model of a health system. the beveridge report of 1942 had identified health care as one of the three basic prerequisites for a viable social security system. the government’s white paper of 1944 stated the policy that „everybody, irrespective of means, age, sex or occupation shall have equal opportunity to benefit from the best and most up-to-date medical and allied services available”, adding that those services should be comprehensive and free of charge and should promote good health, as well as treating sickness and disease (2,7). today’s health systems are modeled to varying degrees on one or more of a few basic designs that emerged and have been refined since the late 19th century. one of these aims to cover all or most citizens through mandated employer and employee payments to insurance or sickness funds, while pro24 health systems and their evidence based development viding care through both public and private providers. much debate has centered on whether one way of organizing a health system is better than another, but what matters about a system’s overall structure is how well it facilitates the performance of its key functions. models of national health care systems based on the sources of funding based on the source of their funding, three main models of national healthcare systems can be distinguished: the beveridge model, the bismarck model and the private insurance model (7,8,9) (table 1). table 1. three main models of health care systems based on the sources of funding (7,8,9) the beveridge „public” model was inspired by the william beveridge report for social insurance presented in the english parliament in 1942. funding is based mainly on taxation and is characterized by a centrally organized national health service where the services are provided by mainly public health providers (hospitals, community gps, specialists and public health services). in this model, healthcare budgets compete with other spending priorities. the countries using this model, beside united kingdom, are ireland, sweden, 25 the role and organization of health care systems model oof hhealth ccare system country iin wwhich tthe model eexists source oof ffunding type oof pproviders beveridge model uk, ireland, sweden, norway, finland, denmark, spain, portugal, italy, greece, canada, australia taxation (state budget) universal scope (all citizens) not related to income public: predominantly public providers and governmental ownership national health service complete coverage with basic health benefits and free access to all citizens bismark model germany, holland, belgium, france, austria, switzerland, israel, japan, csee and fsu countries compulsory health insurance premiums paid by employers and employees selective scope related to income mixed: public and private providers with dominant social ownership coverage of 60-80% with basic insurance „basket" of health services private insurance model usa predominantly private insurance and funding medicare medicaid predominantly private providers managed care norway, finland, denmark, spain, portugal, italy, greece, canada and australia. the bismarck „mixed” model was inspired by the 1883 germany social legislation and national health insurance plan for workers introduced by otto von bismark, the chancellor of germany. funds are provided mainly by premium-financed social/mandatory insurance and, beside germany, is found in countries such as holland, belgium, france, austria, switzerland, israel, japan, central and south east european (csee) countries and former soviet union (fsu) countries. also japan has a premium-based mandatory insurance funds system. this model results in a mix of private and public providers, and allows more flexible spending on healthcare. the „private” insurance model is also known as the model of „independent customer”. funding of the system is based on premiums, paid into private insurance companies, and in its pure form actually exists only in the usa. in this system, the funding is predominantly private, with the exception of social care through medicare and medicaid. the great majority of providers in this model belong to the private sector. all three models of health care are imperfect and expensive, too. all healthcare systems are aiming at „perfection”, i.e. they try to achieve an optimal mixture of access to healthcare, quality of care and cost efficiency. according to the world health organization (who), the healthcare systems present in different countries are strongly influenced by the underlying norms and values prevailing in the respective societies. like other human service systems, health care services often reflect deeply rooted social and cultural expectations of the community. although these fundamental values are generated outside the formal structure of the healthcare system, they often define its overall character and capacity. healthcare systems are therefore different all over the world and are strongly influenced by each nation’s unique history, traditions and political system. this has led to different institutions and a large variation in the type of social contracts between the citizens and their respective governments. in some societies, healthcare is viewed as a predominantly social or collective good, from which all citizens belonging to that society should benefit, irrespective of whatever individual curative or preventive care is needed. related to this view is the principle of solidarity, where the cost of care is cross-subsidized intentionally from the young to the old, from the rich to the poor and from the healthy to the diseased. 26 health systems and their evidence based development other societies, more influenced by the market-oriented thinking of the 1980s, increasingly perceive healthcare as a commodity that should be bought and sold on the open market. these marketing incentives possibly allow a more dynamic and greater efficiency of healthcare services and a better control of growth in health care expenditure. but, nowadays, this concept, which perceive health care services as a commodity does not prevail in europe. levels of organization of health care systems and health care delivery all models of health care systems are imperfect and there is no a model which is the best and broadly accepted and recommended. there are big differences among countries in relation to the goals, structure, organization, finance and the other characteristics of the health care systems. these differences are influenced by history, traditions, socio-cultural, economic, political and other factors. but, regardless of all present differences, there are same common characteristics, typical for all organized health care systems. first of all those characteristics relate to the so called „levels of health care”. in accordance with the size of the population served, and specificities of the diseases and conditions treated at certain level, as well as with some organizational characteristics, it is possible to recognize four levels of the health care system and health care delivery (7,9,10,11,12,13,14,15) (figure 1). figure 1. levels of care within the health care system size of the population 27 the role and organization of health care systems subspecialist general specialist 500 000 5 000 000 100 000 500 000 2000 50 000 1 10 c a r e self care primary professional care administration unit family (households) community (locality) district region self care is the first level, which is nonprofessional care. it is performed within the family, and the population group counts from one to 10 persons. self-care implies largely unorganized health activities and health-related decision-making carried out by individuals, families, neighbors, friends and workmates. these include the maintenance of health, prevention of disease, self-diagnosis, self-treatment, including self-medication, and self-applied follow-up care and social support to the sick and weak members of the family after contact with the health services. by community involvement and participation, individuals and families accept responsibility for their, and the community’s health and welfare and develop the capability to contribute to their own and the community’s development (4). this type of care has its own long tradition and it is a part of all cultures. who has shown interest and pointed out that traditional and alternative medicine consist big potential, which might be useful for improvement of the health status of the population. who strategy „health for all” and the concept of primary health care paid an appropriate attention to self care and need for health education of the individuals, family and population as a whole in order to enable and to empower them in taking responsibilities and making decisions about their own health and the factors which influenced the health (6,11,15). health promotion advice on important lifestyle issues such as nutrition, exercise, consumption of alcohol and cessation of smoking is most effective if it is persistent, consistent and continuous, and if it is offered to families and communities at all levels. within this population context, individual advice can be given on an opportunistic basis to those who attend health services for whatever reason (6,16). primary professional (medical) care is a care of the „first contact” of the individual with the health care service, which is provided in ambulatory settings by qualified health professionals (general practitioner-gp, family doctor, or nurse) when a patient came, usually for the first time, with certain symptoms or signs of disease. the primary professional level of care includes a doctor and members of its team: nurse, birth attendant, home visiting nurse, social worker, and sometimes a physiotherapist, too. the administration/territorial unit for this type of care is a local community, and the population size vary from 2000 persons per one gp or family doctor to 10000 50000 inhabitants per health facility within the community/municipality (health station, health center). beside medical care (diagnostics, treatment and rehabilitation) the primary professional care team performs various activities toward maintenance and improvement of the health and prevention of diseases. the most common role of the physician is „gate keeper”, which means that the doctor is motivat28 health systems and their evidence based development ed and empowered to treat and cure broader scope of illnesses and conditions (up to 85% of health care problems in a community without recourse to specialist), and to select and refer patients to higher levels of the health care system when necessary. secondary or intermediate level of care is general specialist care, delivered by „general specialist doctor” for more complex conditions, which could not be resolved by the general practitioner or primary professional care level. general specialists (surgeons, internal medicine specialists, gynecologists, psychiatrists etc.) usually deliver this type of care through specialized services of district or provincial „general hospitals”. the administrative unit for secondary level of care is a district, and the population size is from 100000 to 500000 inhabitants. usually patient is directed by the general practitioner from primary professional level to the secondary level as the first referral level of care through referral. tertiary or central level of care is sub-specialist care including highly specific services, which might be delivered in specialized institutions or by highly specialized health professionals sub-specialists i.e. neurosurgeons, plastic surgeons, nephrologists, cardiologists etc. the specialized institutions, which provide this type of care are, also, educational institutions for health manpower (university hospitals, university clinics, etc.). the administrative unit for tertiary level of care is a region, and the population size is from 500000 to 5000000 inhabitants. in some countries, mainly developing countries, this level of care is the same as the national level. a patient should be referred to this level from primary or secondary level of care. secondary and tertiary care support primary health care by providing technologically-based diagnosis, treatment and rehabilitation. who recommends that in most member states, secondary and tertiary care should more clearly serve and support primary care, concentrating on those functions that cannot be performed effectively by the latter. planning secondary and tertiary care facilities in accordance with the principle of a population-based „regionalized” system allows for more rational use of expensive technologies and of the expertise of highly trained personnel (6). typical functions of the overall health care system are: • health services (environmental, health promotion, prevention of diseases and injuries, primary care, specialist medicine, hospital services, services for specific groups, self-help); • financing health care (mobilization of funds, allocation of finances); 29 the role and organization of health care systems • production of health resources (construction and maintenance of health facilities, production and distribution of medicines, production, distribution and maintenance of instruments and equipment); • education and training of health manpower (undergraduate training, postgraduate training); • research and development (health research, technology development, assessment and transfer, quality control); • management of a national health system (policy and strategy development, information, coordination with other sectors, regulation of activities and utilization of health manpower, physical resources and environmental health services). the main objectives of each national health system should be (7): 1) universal access to a broad range of health services; 2) promotion of national health goals; 3) improvement in health status indicators; 4) equity in regional and socio-demographic accessibility and quality of care; 5) adequacy of financing with cost containment and efficient use of resources; 6) consumer satisfaction and choice of primary care provider; 7) provider satisfaction and choice of referral services; 8) portability of benefits when changing employer or residence; 9) public administration or regulation; 10) promotion of high quality of service; 11) comprehensive in primary, secondary, and tertiary levels of care; 12) well developed information and monitoring systems; 13) continuing policy and management review; 14) promotion of standards of professional education, training, research; 15) governmental and private provision of services; and 16) decentralized management and community participation. outpatient care outpatient care is very important part of the health care system representing the first contact of the consumer with the professional health care and the first step of a continuous health care. outpatient care is delivered to a „moving” patient (not tight to bed), through institutions in which the consumer come for a short visit for consultation, examination, treatment and follow-up, usually once a week or rarely, and in the most of the cases, the contact is realized with an individual health worker. such kind of services and institutions might be a part of the hospital, community health center or certain polyclinic and dispensaries (4,10,13,15). historically beginnings of outpatient care appeared in 16th century, when medical care organized mainly through in-patient institutions connected 30 health systems and their evidence based development to churches and monasteries started to change and move to be under the state authorities. differentiation within the medical profession started by dividing the doctors into two basic groups: the first group continue to be tighten to hospitals, but delivering also outpatient services from the position of specialists or consultants, and the other group of doctor were oriented to work in out-patient offices for poor or in doctor’s offices with advanced payment for treatment for defined period of time, usually for a week. in that way started differentiation of the profession, which is a synonym for outpatient care – a general practitioner. an official act on health insurance was adopted in great britain in 1911 and a doctor of general medicine or general practitioner was authorized as a main provider of outpatient care, usually through independent doctor’s offices for general medicine and, later on, through health centers. the importance of the outpatient care and responsibility of the governments for improving the health status of the population in their own countries was emphasized by who at the historical conference on primary health care, held in alma ata in 1978, based on the core principles of primary health care formulated in the declaration of alma ata: universal access and coverage on the basis of need; health equity as part of development oriented to social justice; community participation in defining and implementing health agendas; and intersectoral approach to health (7,17). primary health care is essential health care made universally accessible to individuals and families in the community by means acceptable to them and at a cost the community and country can afford, with methods that are practical, scientifically sound and socially acceptable. everyone in the community should have access to it, and everyone should be involved in it. it means that „people have the right and duty to participate individually and collectively in the planning and implementation of their health care. related sectors should also be involved in it in addition to the health sector. at the very least, it should include education of the community on the health problems prevalent and on methods of preventing health problems from arising or of controlling them; the promotion of adequate supplies of food and of proper nutrition; sufficient safe water and basic sanitation; maternal and child health care, including family planning, the prevention and control of epidemic and locally endemic diseases; immunization against the main infectious diseases; appropriate treatment of common diseases and injures; and the provision of essential drugs. primary health care is the central function and main focus of a country’s health system, the principal vehicle for the delivery of health care, the most peripheral level in a health system stretching from the periphery to the centre, and an integral part of the social and economic country development. the form it takes will vary according to each country’s political, economic, social, cultural and 31 the role and organization of health care systems epidemiological patterns. the relationship between patient care and public health functions is one of the defining characteristics of the primary health care approach (1,4,17). outpatient institutions and services there is a variety of organizational forms of the outpatient care across the world. the main objective of the outpatient care is to reduce hospitalization and to provide treatment of diseases and injuries in much cheaper conditions, whenever it is possible. the outpatient departments of hospitals were the first institutions described which are still available nowadays. they provide services in some urgent and life threatening conditions, in some acute diseases that require urgent intervention, in chronic diseases that require follow-up and control measures, as well as act as a referral level for primary health care or make decision for hospital admission when necessary. the reorganization and reform of the outpatient care, after establishment of the ministry of health in great britain, in 1919, was directed toward creating a new institution of outpatient care so called health center. health center, in accordance with the bertrand dawson’s commission for health care reform in great britain in 1920s, is an institution which is responsible to integrate preventive and curative activities, to provide health care to the population living within certain territorial units, and to collaborate with the local authorities for all issues related to the health of the population. additional equipment for laboratory and x-ray diagnostic services within the health center should be available, as well as general practitioners and nurses for team work. and, later on, in 1948, when national health service in great britain was established, the general practitioner became the most important gate-keeper at the entrance to the other levels of health care system. the development of health centers in great britain was facilitated by the act on family doctor, adopted in 1966. the idea for establishing health centers for outpatient care was accepted in many european countries, especially in former soviet union after the bolshevik revolution (2,7). after the alma ata conference, held in 1978, primary health care became more and more important part of the health care system in each country – member of who. even health services continued to have various organizational forms in different countries the health center was the most typical institution for outpatient care. the institutions for primary health care have special importance playing a role as institutions of the „first contact” of the patient with health care 32 health systems and their evidence based development system. beside primary medical services those institutions contribute to maintain and improve overall physical, mental and social health and well being of the individuals, groups and of the population as a whole. the institutions for primary health care provide individual and group practice/services delivered through health centres or independent outpatient doctor’s offices, as well as within the home of the patient, school and workplace. consultative-specialist health care is an intermediary level of providing health care, between primary health care and hospital treatment, where in the shortest period of time all necessary examinations and analyses should be performed, and a decision should be brought whether the patient is going to be referred to hospital treatment, or sent back on the level of primary health care, usually with precise diagnosis and certain directions for further treatment. home care or „hospital at home” is treatment at home of the diseased, which includes examination, diagnostic procedures, therapeutic and rehabilitation measures. home care, as alternative of stationary treatment is a combination of medical and non-medical treatment and a factor that connects primary and hospital health care. it should be conducted in an organized way by hospitals and in accordance with certain programmes, which in addition to health service include other factors, such as: social protection services, children’s public care, health insurance and pension-invalidity insurance funds as well as local communities. home visiting by a doctor and medical technicians in the function of home care should be performed in a series and successively, according to a programme defined by the same physician, and keeping evidence should be performed on special hospital-temperature lists, which are going to be a base for compensation of the performed tasks. several researches have demonstrated that for about 30%, or even more, of the treated patients in hospitals there were no real indications for hospital treatment, which means that their treatment could successfully be conducted through introduction of „substitution policies” i.e. day care hospitals, ambulatory care or organized home care by hospitals if there is satisfactory standard for accommodation of the patient at home, under supervision of the team for primary health care (4,6). home visiting by a doctor and medical technician considered as an »emergency medical service« is performed without formerly determined plan and on a patient’s call and are shown as individual services through ambulatory protocols and reports for the performed home visiting. 33 the role and organization of health care systems in-patient care and institutions in-patient/hospital care means admission into hospital or other stationary health organization, including diagnosis, treatment and rehabilitation, with in-patient care and treatment of the most severely ill patients who cannot be treated in ambulatory-polyclinic institutions or at home. stationary health organizations are institutions, which, in addition to supplying diagnosis, treatment and medical rehabilitation, also provide hospital accommodation, treatment, care and food. they include hospitals, nursing homes, health resorts and rehabilitation centers. hospital is a health organization which provides consultative-specialist health care and accommodation, treatment and food for the patients in a certain area and for more types of diseases and for persons of all ages, or only for persons diseased from certain illnesses, or for certain group of citizens (4,10). hospitals have been present in a variety of forms for millennia. almost 5,000 years ago, greek temples were the first, but similar institutions can be found in ancient egyptian, hindu, and roman societies. these „hospitals” were very different than the hospitals of today, and over the span of time they have gone through a dramatic evolution from temples of workship and recuperation to almhouses and pest houses and finally to sources of modern-day miracles. the word „hospital” comes from the latin hospitalis. although well regarded earlier in history, hospitals in the middle ages and later had unsavory reputations and primarily served the poor. until well into the 20th century physicians provided charity care in hospitals but treated private (fee-for-service) patients at home. new medical technology made treatment efficient, especially with surgical intervention, and this focused attention on acute care hospitals. treatment of private patients brought acute care hospitals new prestige and acceptance. this evolution was well underway by the 1920s as acute care hospitals became differentiated and specialized to organize and deliver an expanded scope of services. many acute care hospitals were small and owned by physicians as a convenient way to hospitalize their patients (5,10). hospitals are institutions whose primary function is to provide diagnostic and therapeutic medical, nursing, and other professional services for patients in need of care for medical conditions. hospitals have at least six beds, an organized staff of physicians, and continuing nursing services under the direction of registered nurses. the who considers an establishment a hospital if it is permanently staffed by at least one physician, can offer in-patient accommodation, and can provide active medical and nursing care (7). by convention of common use, a general (community or district) hos34 health systems and their evidence based development pital is an acute care hospital that provide diagnoses and treatment for patients with a variety of medical conditions or for more than one category of medical discipline for general medical and surgical problems, obstetrics and pediatrics. the title is used whether the hospital is not for profit or for profit. a general hospital provides permanent facilities, including inpatient beds, continuous nursing services, diagnosis, and treatment, through and organized professional staff organization, for patients with a variety of surgical and non-surgical conditions. this is in contrast to special hospitals, which admit only certain types of patients by age or sex, or those with specified illnesses or conditions such as a children’s, maternity, psychiatric, tuberculosis, chronic disease, geriatric, rehabilitation, or alcohol and drug treatment center which provide a particular type of service to the majority of their patients (5,7). hospital bed is any bed that is set up and staffed for accommodation and full-time care of in-patients and is situated in a part of the hospital where continuous medical care is provided. a bed census is usually taken at the end of a reporting period. the supply of hospital beds is measured in terms of hospital beds per 1000 population. this varies widely between and within countries. in addition closing of hospital beds is one of the difficult and controversial issues in health planning and health policies. it is even more difficult to close redundant or uneconomic hospital beds, because this means a loss of jobs in the community unless coupled with transfer of personnel to other services, itself a painful procedure. total beds per 1000 population include all institutional beds utilized for in-patient medical care, but not geriatric custodial care. acute care bed ratio is a more precise and comparable indicator representing the number of general, short-term care beds per 1000 population. hospitals are increasingly technologically oriented and costly to operate. hospital services in the european region underwent considerable expansion in during the 1960s, 1970s and the beginning of the 1980s but have since experienced increasing difficulties. managing health systems with a fewer hospital days requires reorganization within the hospital to provide the support services for ambulatory diagnostic and treatment services as well as home care. the interactions between the hospital-based and community-based services require changes in the management culture and community-oriented approaches. many developed countries are actively reducing hospital bed supplies, facilitating alternatives to hospital care, using incentive payments to promote dayhospital treatments, ambulatory and home care. in the more eastern part of the region, the very large number of hospital beds (a legacy of health care policy in the past), combined with a severe economic crisis during the 1990s has created an extremely difficult situation characterized by dilapidated buildings, 35 the role and organization of health care systems worn-out equipment, lack of basic supplies and a financial inability to profit from new breakthroughs in hospital technology (6). during 1980s and 1990s in usa, especially in california, an intensive process of mergers or acquisitions of for-profit hospitals was taking place aimed to increase organization’s capacity, financial viability and efficiency of the new unit, and ability for competition in its current markets (7,18). classification of hospitals hospitals are classified in several ways: length of stay, type of service, and type of control or ownership, as well as size of the hospital (4,5,6,7,10,12). length of stay is divided into acute care (short term) and chronic care (long term). acute care (of short duration or episodic) is a synonym for short term. chronic care (or long duration) is a synonym for long term hospitals. short-term stay hospitals are those in which more than half of patients are admitted to units in the facility with an average length of stay shorter than 30 days. long-term stay hospitals are those in which more than half of patients are admitted to units in the facility with an average length of stay of more than 30 days (7). the most of hospitals are short term. community hospitals are acute care (short term). rehabilitation and chronic disease hospitals, nursing homes and hospices are long term. psychiatric hospitals are usually long term. some acute care hospitals have units to treat acute psychiatric illness. hospitals in the european region now often serve both acute and chronic patients, but these two categories need to be better differentiated in order to optimize the use of resources and staff expertise (6). day care hospitals provide stay and treatment of patients during the day-time in the premises of the hospital, not including accommodation for lodging. day care hospital is an important novelty in the hospital treatment, which has positive social, psychological and economical implications, if its work is adequately organized (4,6,12). types of service denote whether the hospital is „general” or „special”. general hospitals provide a broad range of medical and surgical care, to which are usually added the specialties of obstetrics and gynecology; rehabilitation; orthopedics; and eye, ear, nose, and throat services. „general” can describe both acute and chronic care hospitals, but usually applies to short-term hospitals. „special” hospitals offer services in one medical or surgical specialty (e.g., pediatrics, obstetrics/gynecology, rehabilitation medicine, or geriatrics) or treatment to certain diseases or groups of diseases (tbc, psychiatric diseases, heart and lung diseases etc.). although special hospitals are usually acute, they 36 health systems and their evidence based development may also be chronic. a tuberculosis hospital is an example of the latter. university hospital as a special or specialized health institution for the education and training of health manpower with secondary and advanced training in health with university degrees in medicine, medical research and specialist treatment of in-patients (4,10). a third classification divides hospitals by type of control or ownership: for profit (investor owned), or not for profit, governmental (federal, state, local, or hospital authority), religious or voluntary organizations. functions of the hospitals the basic function of acute care hospitals is to diagnose and treat the sick and injured. the nature and severity of a patient’s illness determine the care received and, to some extent, the type of hospital in which it is provided. care might be delivered on an in-patient or out-patient basis. all acute care hospitals treat the sick and injured. their emphasis on the other functions noted here depends on organizational objectives (5). a second function is preventing illness and promoting health. examples are instructing patients about self-care after discharge, referring them to other community services such as home health services, conducting disease screening, and holding childbirth and smoking cessation classes. the competitive environment has caused hospitals to mix illness prevention and health promotion with generous amounts of marketing. a third function is educating health services workers. physician education in residencies and fellowships is common. acute care hospitals train staff such as nurse aid who will work in them. acute care hospitals are a setting for many different types of health services workers who need clinical experience to receive a state license or professional society certification. many health services management education programs require a residency, and it is common for managers to have spent time in an acute care hospital as an administrative resident or fellow. clinic is a health organization that performs educational activities, professional training of health workers and scientific-research activity. the clinic performs the most complex types of health care from a certain medical branch that is from dentistry, creates and carries out professional and medical doctrinaire criteria from their field and offers professionallymethodological help to the health organizations from the related medical branch or dentistry. a fourth function is research. clinical trials for new drugs and devices come to mind first, but are the least common. research such as assessing uti37 the role and organization of health care systems lization of intensive care units and determining why staff ignores universal precautions when treating emergency room patients are more common. one type of non-clinical research focuses on improving hospital processes through quality improvement. this could include using patient satisfaction surveys, increasing efficiency in patient billing, and improving ways to deliver supplies to nursing units. three generations of health care system reforms health care systems are continuously evolving. impetus for reform of a health system may derive from a need for cost restraint, universal coverage, or efficiency in use of resources, or an effort to improve satisfaction of consumers or providers. the objective of improving the health of the population is also a motive, but this is often expressed as improved access, equity, efficiency, quality of care, and outcomes (7). during the 20th century, there have been three overlapping generations of health system reforms. they have been prompted not only by perceived failures in health but also by a quest for greater efficiency, fairness and responsiveness to the expectations of the people that systems serve. the first generation of reforms saw the founding of national health care systems, and the extension to middle income nations of social insurance systems, mostly in the 1940s and 1950s in richer countries and somewhat later in poorer countries. by the late 1960s, many of the systems founded a decade or two earlier were under great stress. costs were rising, especially as the volume and intensity of hospital-based care increased in developed and developing countries alike. among systems that were nominally universal in coverage, health services still were used more heavily by the better-off, and efforts to reach the poor were often incomplete. too many people continued to depend on their own resources to pay for health, and could often get only ineffective or poor quality care (2). these problems were apparent, and increasingly acute, in poorer countries. in low-income countries, the health system had therefore never been able to deliver even the most basic services to people in rural areas. health facilities and clinics had been built, but primarily in urban areas. in most developing countries, major urban hospitals received around two-thirds of all government health budgets, despite serving just 10% to 20% of the population. studies of what hospitals actually did revealed that half or more of all inpatient spending went towards treating conditions that could often have been managed by ambulatory care, such as diarrhea, malaria, tuberculosis and acute respira38 health systems and their evidence based development tory infections. there was, therefore, a need for radical change that would make systems more cost-efficient, equitable, and accessible. a second generation of reforms thus saw the promotion of primary health care as a route to achieving affordable universal coverage. there was a very strong commitment to assuring a minimum level for all of health services, food and education, along with an adequate supply of safe water and basic sanitation. these were the key elements along with an emphasis on public health measures relative to clinical care, prevention relative to cure, essential drugs, and education of the public by community health workers. by adopting primary health care as the strategy for achieving the goal of „health for all” at the joint who/unicef international conference on primary health care held at alma ata (now almaty, kazakhstan) in 1978, who reinvigorated efforts to bring basic health care to people everywhere. the main aspects of the reorientation of primary health care related to the new focus from illness to health and from care to prevention; to the new content from treatment to health promotion and from episodic care to continuous care; to the new organization from specialist to general practitioner and from physician to nurse; and to the new responsibilities from passive reception to self-responsibility and from professional dominance to community participation (2,17). the term „primary” quickly acquired a variety of connotations, some of them technical (referring to the first contact with the health system, or the first level of care, or simple treatments that could be delivered by relatively untrained providers, or interventions acting on primary causes of disease) and some political (depending on multi-sectoral action or community involvement). the multiplicity of meanings and their often contradictory implications for policy help explain why there is no one model of primary care, and why it has been difficult to follow the successful examples of the countries or states that provided the first evidence that a substantial improvement in health could be achieved at affordable cost. there was a substantial effort in many developing countries to train and use community health workers who could deliver basic, cost-effective services in simple rural facilities to populations that previously had little or no access to modern care and by placing major emphasis on the economic benefits of prevention and cost-effective measures to reduce the burden of disease (2,7,9,19). despite these efforts, many such programs were eventually considered at least partial failures. funding was inadequate; the workers had little time to spend on prevention and community outreach; their training and equipment were insufficient for the problems they confronted; and quality of care was often so poor as to be characterized as „primitive” rather than „primary”, par39 the role and organization of health care systems ticularly when primary care was limited to the poor and to only the simplest services. referral systems, which are unique to health services and necessary to their proper performance, have proved particularly difficult to operate adequately. lower level services were often poorly utilized, and patients who could do so commonly bypassed the lower levels of the system to go directly to hospitals. partly in consequence, countries continued to invest in tertiary, urban-based centers. in developed countries, primary care has been better integrated into the whole system, perhaps because it has been more associated with general and family medical practice, and with lower-level providers such as nurse practitioners, and physician assistants. greater reliance on such practitioners forms the core of many developed countries’ current reform agendas. managed care, for example, revolves to a large extent around the strengthening of primary care and the avoidance of unnecessary treatment, especially hospitalization (2,9). the approach emphasized in the primary health care movement can be criticized for giving too little attention to people’s demand for health care, which is greatly influenced by perceived quality and responsiveness, and instead concentrating almost exclusively on their presumed needs. systems fail when these two concepts do not match, because then the supply of services offered cannot possibly align with both. the inadequate attention to demand is reflected in the complete omission of private finance and provision of care from the alma ata declaration, except insofar as community participation is construed to include small-scale private financing (2). universal access to health care does not necessarily address social inequalities in health. removal of financial barriers by itself does not guarantee good health. many social, cultural, and environmental health risk factors are not correctable or preventable by medical or hospital care. they may be of greater importance than the medical care provided. it is therefore useful to understand how the models for reform evolved, their successes and failures, and how they are continuing to develop (7). poverty is one reason why needs may not be expresses in demand, and that can be resolved by offering care at low enough cost, not only in money but also in time and non-medical expenses. but there are many other reasons for mismatches between what people need and what they want, and simply providing medical facilities and offering services may do nothing to resolve them. in general, both the first-generation and second-generation reforms have been quite supply-oriented. concern with demand is more characteristic of changes 40 health systems and their evidence based development in the third generation currently under way in many countries, which include such reforms as trying to make „money follow the patient” and shifting away from simply giving providers budgets, which in turn are often determined by supposed needs (2,3). if the organizational basis and the quality of primary health care often failed to live up to their potential, much of the technical footing remains sound and has undergone continuous refinement. this development can be sketched as a gradual convergence towards what who calls the „new universalism” – high quality delivery of essential care, defined mostly by the criterion of costeffectiveness, for everyone, rather than all possible care for the whole population or only the simplest and most basic care for the poor (see figure 2). figure 2. coverage of population and of interventions under different notions of primary health care (2) there were common notions that health and nutrition interventions can make a substantial difference to the health of large populations and of obtaining „good health at low cost” by selectively concentrating efforts against diseases that account for large, avoidable burdens of ill-health. that was the basis for a set of core public health interventions and a package of essential clinical services influenced by phc models, variously called „basic” or „essential” or „priority” that have been recommended by the world bank and developed in several countries, in the 1990s, from epidemiological information and estimates of cost-effectiveness of interventions. and the common failures in diagnosis and treatment due to inadequate training and excessive separation among disease control efforts have led to the development of clusters of interventions and more through training to support their delivery, most notably in the integrated management of childhood illness (2,9,19). this evolution also implies an emphasis on public or publicly guaranteed and regulated finance, but not necessarily on public delivery of services. 41 the role and organization of health care systems population covered interventions included only the poor everyone "basic" or simple "primitive" health care original concept "selective" primary health care new universalism (never seriously contemplated) classical universalism "essential" and costeffective everything medically useful and it implies explicit choice of priorities among interventions, respecting the ethical principle that it may be necessary and efficient to ration services but that it is inadmissible to exclude whole groups of the population. however, it is easier to define a set of interventions that would preferentially benefit the poor if fully applied to the population, than it is to assure either that most of the poor actually do benefit, or that most of the beneficiaries are poor. government health care services, although usually intended to reach the poor, often are used more by rich. despite the health reforms of recent decades, inadequate progress has been made in building health systems that promote collective health improvement. the 1990s was a decade of major reforms in national health systems. all countries are struggling to develop adequate prevention models to reduce the burden of disease that can bankrupt a national health system. the ideas of responding more to demand, trying harder to assure access for the poor, and emphasizing financing, including subsides, rather than just provision within the public sector, are embodied in many of the current third-generation reforms. these efforts are more difficult to characterize than earlier reforms, because they arise for a greater variety of reasons and include more experimentation in approach. in part, they reflect the profound political and economic changes that have been taking place in the world. by the late 1980s, the transformation from communist to market-oriented economies was under way in china, central and south east europe, and the former soviet union (2,7). health systems have not been immune from these large-scale changes. one consequence has been a greatly increased interest in explicit insurance mechanisms, including privately financed insurance. in developed countries, which already had essentially universal coverage, usually less drastic changes have taken place in how health care is financed. but there have been substantial changes in who determines how resources are used, and in the arrangements by which funds are pooled and paid to providers. general practitioners and primary care physicians, as „gatekeepers” to the health system, have sometimes been made accountable not only for their patients’ health but also for the wider resource implications of any treatments prescribed. in some countries this role has been formalized through establishing „budget holding” for general practitioners and primary care physicians, for example, through general practice „fund holding” in the uk, health maintenance organizations in the usa, and independent practice associations in new zealand. and in the united states, there has been a great shift of power from providers to insurers, who now largely control the access of doctors and patients to one another. in the european region, in recent years, many health care reforms 42 health systems and their evidence based development have taken place. many governments started to introduce various market mechanisms into service delivery by purchaser/provider split, introduction of competitive elements into health services, and various payment mechanisms. the ljubljana charter, adopted by all member states in 1996, emphasized that health care reforms should be an integral part of an overall health policy and that health care systems need to: • be governed by the principles of human dignity, equity, solidarity and professional ethics; • relate to clear targets for health gain; • address citizens’ needs; • aim at continuous improvements in the quality of care; • ensure financing that will enable health care to be provided to all citizens in a sustainable way; and • be oriented towards primary health care. it means that the reform of health care provision and its financing should be comprehensive in order to safeguard the development of adequate and affordable health care services. for example, reforms in the organizational structure of the health system should be accompanied by legislative adaptations, or reforms in secondary and primary care provision should be accompanied by reform in the health financing system. in csee countries, after the breakdown of the state socialism, a number of changes have occurred in the legal framework, as well as governmental policy, ownership, production, financing and reimbursement of health care providers. priority setting was necessary step to ensure the efficient use of insufficient public funds for health. because of shortage of funds many costeffective interventions were neglected, under funded or provided with low quality standards. it was necessary in these countries the priority setting in health care to be driven by new democratic values and the new systems to be people-centered and more oriented to the needs of individual patient and specific groups, and sensitive to inequalities, unemployment, and social poverty. health systems also should be health-focused and evidence based, and oriented towards primary health care (20). despite the structural diversity and underlying philosophical differences in national health systems, there are important common elements. they are large employers and among the largest industries in their respective countries. all face problems of financing, cost constraint, overcoming structural 43 the role and organization of health care systems inefficiencies, and, at the same time, finding incentives for high quality and efficiency (7). in the years ahead health systems will face new challenges, because of the aging of the population, medical technology innovations, and high professional and public expectations, and new pressures to constrain costs and resolute commitment to the primary health care values of equity, universal access to care, community involvement and intersectoral action. those principles will be more important than ever. still, much remains to be understood about how health systems function, why they fail or respond slowly to some crises, and about how primary health care principles can be translated into practice policies that will yield health improvements for communities (1). 44 health systems and their evidence based development exercise: the role and organization of health care system task: students should visit www.observatory.dk to become familiar with different health care systems and actual reforms initiatives. students are encouraged to write draft describing hcs in their respective country, using production template questionnaire, which is available on site given above. 45 the role and organization of health care systems references 1. who. shaping the future. the world health report 2003. who, geneva, 2003: 143. 2. who. improving performance. the world health report 2000, health systems: who, geneva, 2000: 151. 3. who. health, economic growth, and poverty reduction. the report of working group i of the commission on macroeconomics and health executive summary. who, geneva, 2002: 12. 4. donev d, ivanovska l, lazarevski p, ruzin n. glossary of social protection terms. phare consensus programme project: dictionary and glossary of social protection terms. european commission, 2000: 472. 5. rakich j, longest b, darr k. managing health services organizations. health professions press, inc. baltimore, maryland, 1992: 684. 6. who. health 21 health for all in the 21st century. european health for all series no 6. who-euro, copenhagen 1999: 217. 7. tulchinsky th, varavikova ea. the new public health: an introduction for the 21st century. san diego: academic press, 2001. 8. lameire n, joffe p, weidemann m. healthcare systems an international review: an overview. nephrol dial transplant 1999; 14(6): 3-9. 9. the world bank. world development report 1993: investing in health. the world bank, 1993: 329. 10. cuci} v, simi} s. osnovni principi organizacije zdravstvene slu`be. in: cuci} v, simi} s, bjegovi} v, @ivkovi} m, danki}-stefanovi} d, vukovi} d, ananijevi} pandej j. social medtextbook, savremena administracija a.d. belgrade 2000: 195-238. 11. kova~i} l. primarna zdravstvena za{tita. in. jak{i}, kova~i} l at all. social medicinetextbook. medicinska naklada, zagreb 2000: 180-3. 12. stamatovi} m, jakovljevi} dj, martinov-cvejin m. zdravstvena za{tita. zavod za ud`benike i nastavna sredstva, beograd 1995: 92-136. 13. stamatovi} m, jakovljevi} dj, legeti} b, martinov-cvejin m. zdravstvena za{tita i osiguranje. zavod za ud`benike i nastavna sredstva, beograd 1997: 140-210. 14. dovijani} p, janjanin m, gaji} i, radonji} v, djordjevi} s, borjanovi} s. socijalna medicina sa higijenom i epidemiologijom. zavod za ud`benike i nastavna sredstva, beograd 1995: 4576. 15. dovijani} p. savremena organizacija zdravstvena slu`be i ustanova. i.p. „obele`ja" beograd 2003: 43-52. 16. who. reducing risks, promoting healthy life. the world health report 2002. who, geneva, 2002: 235. 17. who. declaration of alma ata. in: international conference on primary health care, alma ata, ussr, september 6-12, 1978. who health-for-all series, no. 1, geneva, 1978. 18. angrisani d, goldman r. predicting successful hospital mergers and acquisitions: a financial and marketing analytical tool. the haworth press, inc. new york, 1997: 126. 19. bobadilla jl, cowley p, musgrove p, saxenian h. design, content and financing of an essential national package of health services. the world bank group private and public initiatives: working together in health and education. the world bank, march 17, 1995:110 (http://www.worldbank.org/html/extdr/hnp/health/hlt_svcs/pack1.htm, accessed jan 11, 2004). 20. ore{kovi} s. new priorities for health sector reform in central and eastern europe. croatian med j 1998; 39: 225-33. 46 health systems and their evidence based development 47 health care system of the federation of bosnia and herzegovina health systems and their evidence based development a handbook for teachers, researchers and health professionals title health care system of the federation of bosnia and herzegovina module: 1.2 ects (suggested): 0.25 author(s), degrees, institution(s) dr enida imamovic, specialist of social medicine, public health institute of federation of b&h; dragana niksic, md, phd, ass. professor of social medicine, medical faculty, university of sarajevo address for correspondence enida imamovic, public health institute of fb&h, titova 9 71000 sarajevo bosnia and herzegovina tel: +387 33 20 88 13 fax: +387 33 22 05 48 e-mail: imamovic@bih.net.ba keywords organization, health care system, reform, indicators learning objectives at the end of this module case study, students would become familiar with the organization of the health care system and health care reform process of the federation of bosnia and herzegovina. abstract according to the b&h constitution, health care regulation and competence are transferred to the entity level. federation b&h consists of ten cantons, health care system is decentralized. the transition of the health care system has started in early 1990s and it has been continued after the war ended in 1995. the main aim of the health care system reform in fb&h is to rationalise health care on the basis of phc strengthening. in line with the law, there are three levels of health care: primary care level, specialists or consultant's level, and tertiary care level. within primary health care (phc), family medicine teams are implemented. on this level are also implemented community mental health centres and physical rehabilitation centres. strengthening of phc is accompanied by rationalisation of hospital care. hospital care capacities have been decreasing, as outlined in the reform documents. although the use of capacities has slightly grown it is still under standard occupancy, which means that capacities are insufficiently used. the package of patient's rights is not defined yet. teaching methods after an introduction lecture students will work in small groups on recognizing strengths and weaknesses of the health care system and health care reform process of the federation of bosnia and herzegovina, which will be followed by group reports and overall discussion. specific recommendations for teacher this module to be organized within 0.25 ects credit. beside supervised work, students should be informed about who indicators and specific indicators for their country regarding health care organization in order to describe main principles/problems respective to their country. assessment of students practical work: health care system in line with who indicators (in students' countries), improvement in health care system proposal/reform proposal (papers and discussions). health care system of the federation of bosnia and herzegovina enida imamović, dragana nikšić introduction as a republic of former yugoslavia, bosnia and herzegovina had a health system financed by „self-managed” communities, which ran health insurance, social security and disability insurance for employees and their families at the municipal level. from 1991, at the federal level, risk pooling took place through a republic-wide, compulsory health insurance scheme, administered by a central insurance fund. during the war from 1992-95 health financing was organized directly by the republic's then ministry of health, while the health insurance fund practically ceased to operate. provision of elective health care was reduced to a minimum, and a number of new provider units were established for emergency care. however, it is estimated that about 30% of health care facilities were destroyed or heavily damaged during the war (1). dayton peace agreement of 1995 has divided bosnia and herzegovina (b&h) in two entities: federation b&h and republic of srpska. according to the b&h constitution health care regulation and competence are transferred to the entity level. within federation b&h, health care competence is divided between federal and cantonal authorities which resulted with decentralisation of health care while coordination role is attributed mainly to the federal level. a third health system was created in 2000 in the district of br~ko, as an administrative unit under the federal sovereignty of b&h and international supervision that covers an estimated 90,000 population. in addition to republic srpska and district of br~ko, federation of b&h consists of ten cantons and each of them has its own government and assembly. the cantons involve 79 municipalities, which are basic social and political communities. method this outline is focused on the representation of fb&h health care system resources in 2002 in line with who indicators. the outline is based on data available from official statistics. for comparative survey are chosen countries in transition which by health related factors are the most matching the federation b&h (albania, bulgaria, croatia, macedonia, romania, cee central and east european countries). 48 health systems and their evidence based development demographic indicators federation of bosnia and herzegovina covers 25 989 km2, which is about 51% of the whole b&h territory. in 2002, on the territory of the federation lived 2 315 270 inhabitants. according to the data of federal ministry of displaced people and refugees, in the federation b&h in 2002 lived 199 093 displaced persons or 8.6%. the average density of the population is 89 persons per square kilometre. the regional diversity is evident. the persons over 65 years make 11% of the total population, while the age group 0-14 years makes 20.6%, so that the population of fb&h may be classified as stationary regressive by its biological type. socioeconomic indicators in 2001, gdp per capita was 1,176 us$ (2). average monthly pay in 2002 was 279,3 us$ or 482,71 bam (on 14.07.2003, 1 us$ mean value was 1,7285 bam). the working age population makes 57.40% of the total population. in 2002, the percent of unemployed reached 42.45% and was increased related to the previous years (1998, it was 39.34%). according to the estimations, in 2002, the general socio-economic situation is very complex as 10% of total population are persons with different levels of disability, and 3.9% of population is on social benefits, out of which 14.1% are children. health care system reform the transition of the health care system has started in early 1990s. the war in 1992 ceased the reform process but it has been continued in 1995. the law on health care (3) and the law on health insurance (4), both adopted in 1997, support the reform. in 2002, the health care standards and norms for obligatory health insurance were adopted. some of the reasons that incited the reform are new socio-political and socioeconomic changes; still existent war implications in health care resources, increase of health care demands, etc. the main aim of the health care system reform in fb&h is to ensure more rational health care on the basis of primary health care (phc) strength49 health care system of the federation of bosnia and herzegovina ening as outlined in the reform documents (5) and in health for all in the 21st century (6). within phc, family medicine teams are implemented. also, on this level are implemented community mental health centres and physical rehabilitation centres. strengthening of phc is accompanied by rationalisation of hospital care. the social, political and economic changes in the society were followed by the process of health care sector privatization. in addition, it should be stressed that premises and equipment in health sector is partly destroyed, damaged, or obsolete and that slow down the reform trends (7). health system organization in accordance with the law (3), there are three levels of health care: primary care level, specialists or consultant's level, and tertiary care level (scheme 1). municipality level includes: health centres with health services in community and pharmacies. cantonal level includes: ministry of health, general hospital, cantonal hospital, special hospitals, institute for blood transfusion, public health institute and health insurance fund. federal level includes: ministry of health, clinical centres, institute for blood transfusion, public health institute, institute for drug control, and health insurance fund. 50 health systems and their evidence based development scheme 1. health system organization in the fb&h source: strategic health system plan, the federation of b&h, july 1998 survey of health professionals in fb&h in comparison with some countries in transition the comparative survey of health care professionals shows that, by number of doctors in 2002 (144 doctors per 100000 people) and by the number of nurses fb&h is on the bottom. only albania has even smaller number of dentists per 100000 populations; albania and romania are behind fb&h by the number of pharmacists (8,9). 51 health care system of the federation of bosnia and herzegovina federal ministry of health federal institute for health insurance clinical centres 3 public health institute institute for drug contol institute for transfusiology cantonal ministry of health cantonal health insurance fund cantonal hospital health centre health station pharmacy cantonal public health institute cantonal institute for blood transfuzion federal level cantonal level municipal level general hospital ministry of health figure 1. health professionals per 100000 population in some countries in transition (data for year 2002) source: who regional office for europe health for all database 2002, 2003 and public health institute of federation of b&h (data for federation b&h) primary health care the institutions that provide primary health care are health centers (dom zdravlja). medical services delivered by health centers include: general practice, maternal and child health, school medicine, health care for specific and non-specific lung diseases, and dental care; they also ensure hygiene services (epidemiological activities), emergency medical aid, laboratory, radiology and other diagnostic services. within the area of each health center, there is an outpatient service located in the district (10). 52 health systems and their evidence based development 133 344 238 144 219 189 244 368 450 500 328 518 403 516 0 100 200 300 400 500 600 albania bulgaria croatia federation b&h macedonia rom ania cee average n u m b e r p e r 1 0 0 0 0 0 p o p u la ti o n doctors nurses 9 32 68 20 55 23 40 3 12 50 9 15 7 36 0 20 40 60 80 100 albania bulgaria croatia federation b&h macedonia rom ania cee average n u m b e r p e r 1 0 0 0 0 0 p o p u la ti o n dentists pharmacists in line with the reform trends, the family medicine concept has been successively implemented. within health care system, family medicine services are the places of the first contact with patient. at the same time, family medicine teams (one team consists of gp and nurse) carry out activities on prevention and treatment of the population, in line with the european definition of family medicine (wonca). these teams are providing services for around 1,500-2,500 people. family medicine teams should meet about 80% of demands for health care (3,5,11). in federation b&h, in the year 2002, primary health care was delivered within 872 units. there were 55 doctors and 120 nurses per 100000 populations. moreover, on this health care level, already exist community mental health centres and physical rehabilitation centres. there were 20 dentists and 9 pharmacists per 100000 populations. table 1. primary health care indicators in the fb&h in 2002 source: public health institute of federation of b&h usually, phc teams appropriately cover the population, but availability is not equal in terms of geographical regions. data related to the private health sector are not available. specialist's or consultant's health care health centres have also organised units to deliver specialists or consultants services, if such services were not organised within other health institutions (10). during the year 2002, this type of health care was delivered in fb&h within 424 units involving 436 working teams. there were 19 doctors and 26 nurses per 100000 populations. 53 health care system of the federation of bosnia and herzegovina who indicators value units (number) 872 physicians/100000 55 dentists/100000 20 pharmacists/100000 9 nurses/100000 120 table 2. changes in network and manpower of the phc and consultants/ specialists hc in fbh in the period 1998-2002 source: public health institute of federation of b&h consultants/specialists health services are also provided in institutes for blood transfusion, occupational medicine, sport medicine and physical medicine and rehabilitation. although the health care policy of federation b&h is oriented towards strengthening primary health care, the data related to the previous period demonstrates more extensive development of consultants/specialists care (12,13,14). hospital care secondary level, i.e. hospital care, includes services delivered within general, cantonal and special hospials and partly clinical centres. tertiary care is provided within clinical centres (university hospitals). hospital care in the year 2000 involved 48.7 % of all medical doctors, and 55.4 % of nurses. comparative survey shows that by percentage of physicians working in hospitals fb&h is somewhere in the middle. figure 2. physicians working in hospitals (%) in some countries in transition in 2002 network and manpower levels of health care primary health care consultants/specialist health care 2002 1998 index 2002/1998 2002 1998 index 2002/1998 units 872 904 96.4 424 302 140.4 doctor's offices 1194 1238 96.4 429 244 175.8 doctors 1269 1364 93.0 436 315 138.4 nurses 2776 3078 90.2 604 435 138.8 54 health systems and their evidence based development 45 50 54 49 35 51 0 20 40 60 albania bulgaria croatia federation b&h macedonia romania % w o rk in g i n h o s p it a ls source: who regional office for europe health for all database, 2003 and public health institute of federation of b&h (data for federation b&h) significant decrease in hospital capacities occurred during the last years. hospital bed rate per 100000 population was reduced from 400 beds in 1998 to 350 beds in 2002. there were 5.0 beds per one doctor, and 1.9 beds per one nurse, which is very high standard. table 3. hospital care indicators in the fb&h in 2002 source: public health institute of federation of b&h the bed occupancy was 68.4%, which is still very low showing insufficient use of existing bed capacities. the decrease in hospital beds was not followed by the decrease of number of doctors working in hospitals. compared with the countries in transition, federation b&h, with 350 beds per 100000 population, left only albania behind. figure 3. hospital beds per 100000 population in some countries in transition in 2002 55 health care system of the federation of bosnia and herzegovina who indicators value % physicians working in hospitals 49 % nurses working in hospitals 55 number of hospital beds/100000 350 bed occupancy rate 68,4% 326 720 600 350 493 646 749 0 100 200 300 400 500 600 700 800 source: who regional office for europe health for all database, 2003 and public health institute of federation of b&h (data for federation b&h) albania bulgaria croatia federation macedonia romania cee b&h average h o s p it a l b e d s p e r 1 0 0 0 0 0 p o p u la ti o n average length of stay (in days) in 2002 was 10 days and did not indicate more significant changes in the observed period. in 2002, the beds occupancy was 68.4%, showing a decrease related to the two previous years, and demonstrating inadequate use of existing bed capacities. figure 4. use of hospital resources in fb&h in the period 1998-2002 source: public health institute of federation of b&h hospital care capacities have been decreasing, as outlined in the reform documents, but the use of capacities was still under standard occupancy. funding the reform includes health care funding, also. about 17% of gross wages (without deductions) go to the health care funds. funds are raised and allocated at the cantonal level. recent legislation allows some transfer of resources across the cantons to be redistributed by the federal health insurance fund. the establishment of the „federal solidarity fund" in january 2002 aims at increased intercantonal cooperation to diminish inequities in access to health care by reducing duplication of services, enabling the movement of patients across locations to receive needed services where available, and potentially reducing the fragmentation of services between cantons. moreover, lower income cantons will be able to benefit from expensive interventions. the fund is financed by contributions from cantonal health insurance funds (8% of their 56 health systems and their evidence based development 63.2 65.9 70 74.7 68.4 10.3 11.3 1010.2 10.5 0 20 40 60 80 100 1998 1999 2000 2001 2001 year b a d o c c u p a c y r a te ( % ) 0 2 4 6 8 10 12 a v e ra g e l e n g h t o f s ta y (d a y s ) bad occupacy rate (%) average lenght of stay (in days)bed occupacy rate (%) average lenght of stay (in days) year a v e ra g e l e n g h t o f s ta y (d a y s ) b e d o c c u p a c y r a te ( % ) overall income), and general revenues. the aim is to resolve the problem of lack of contributions by non-earners and to help to equalise health revenues across fb&h. on the basis of the proposal of federal government, federal parliament adopts each year „the package of patient's rights". the aim is to establish a uniform, federation-wide package to ensure equal access. this „package", to be provided under compulsory social insurance is still under development (1,4). conclusions 1. health care system in the federation b&h is going through the process of transition. this process has started in early 1990s, before the war and it has been continued in 1995. currently, the reform is stipulated by democratic changes and market economy. 2. the reform includes changes of legislation, foundation and management of health facilities, raise and distribution of financial resources, etc. 3. as a result of dayton peace agreement, the health sector is decentralised; large rights are given to the cantons, while federation is acting as a coordinator. 4. the process of privatisation has started in early 1990s although (many questions were still unsolved) with insufficient regulation. 5. facilities and equipment are partly destroyed, damaged, or outdated slackening the reform trends. 6. health sector reform is based on strengthening of primary health care (phc) and rationalisation of hospital care. in average, phc teams appropriately cover the population, but availability is not equal. family medicine teams, community mental health centres and physical rehabilitation centres are still in the phase of implementation. 7. during the reform period, hospital bed number was reduced although the occupancy is still low indicating the inadequate use of hospital capacities. 8. the package of patient's rights is not defined yet. 9. comparative analysis of indicators of health care system showed that federation b&h, related to other observed countries, is amongst the last ones. moreover, the available data demonstrated inadequate use of the existing capacaties. therefore, due to the shortage of comprehensive data 57 health care system of the federation of bosnia and herzegovina for both private and public sector, the targeted operational research is necessary for the identification of actual status of organization and use of resources. 58 health systems and their evidence based development exercise: health care system of the federation of bosnia and herzegovina task: after reading this case study under the supervision of lecturer, students are asked to split and work in small groups (4-6 students) in order to discuss and decide possible recommendations they would make for the improvement of health care system in bosnia and herzegovina, following conclusions which were given above. written recommendations will be presented to the whole group. 59 comparative analysis of regional health care systems in the european union references 1. jacubowski e, cain j. health system decentralisation in bosnia and herzegovina. euro observer 2003; 5 (1): 6-8. 2. statisti~ki godišnjak/ljetopis federacije bosne i hercegovine 2002. federalni zavod za statistiku. sarajevo 2002. 3. zakon o zdravstvenoj zaštiti. slu`bene novine federacije bih. sarajevo 1997: 4 (29). 4. zakon o zdravstvenom osiguranju. slu`bene novine federacije bih. sarajevo 1997: 4 (30). 5. strategic health system plan, the federation of b&h. sarajevo, july 1998. 6. who: health for all in the 21st century. who regional office for europe copenhagen. 1999. 7. smajki} a et al: health and social consequences of the war in bosnia and herzegovina sanation proposal. svjetlost. sarajevo, 1997. 8. who: health for all statistical database. regional office for europe. copenhagen. 2002. 9. who: health for all statistical database. regional office for europe. copenhagen. 2003. 10. cain j et al: european observatory on health care systems. health care systems in transition. bosnia and herzegovina. 2002: 4 (7). 11. wonca. evropska definicija porodi~ne/obiteljske medicine. udru`enje specijalista i specijalizanata porodi~ne/obiteljske medicine bosne i hercegovine, 2003. 12. mre`a, kapaciteti i djelatnost zdravstvene slu`be u federaciji bosne i hercegovine u 1998. godini, zavod za javno zdravstvo federacije bosne i hercegovine, sarajevo, 1999. 13. mre`a, kapaciteti i djelatnost zdravstvene slu`be u federaciji bosne i hercegovine u 1999. godini, zavod za javno zdravstvo federacije bosne i hercegovine, sarajevo, 2000. 14. mre`a, kapaciteti i djelatnost zdravstvene slu`be u federaciji bosne i hercegovine u 2000. godini, zavod za javno zdravstvo federacije bosne i hercegovine, sarajevo, 2001. recommended readings • national law on health care • national law on health insurance • national standards and regulations. • who: health for all in the 21st century. who regional office for europe copenhagen, 1999 • who: health for all statistical database. regional office for europe. copenhagen 60 health systems and their evidence based development 61 electronic health records the core of the national health information system health systems and their evidence based development a handbook for teachers, researchers and health professionals title electronic health records the core of the national health information system module: 1.3 ects (suggested): 0.75 author(s), degrees, institution(s) prof. jelena marinkovic, bm, phd prof. vesna bjegovic, md, phd the authors are professors at the school of medicine university of belgrade, serbia and montenegro address for correspondence institute of medical statistics and informatics / institute of social medicine; school of medicine, belgrade university dr suboti}a 15 11000 belgrade, serbia and montenegro tel: +381 11 685 888 / +381 11 685 451 fax: + 381 11 659 533 e-mail: jmarinkovic@med.bg.ac.yu; bjegov@eunet.yu keywords health information, electronic health record (ehr), information and communication technology (ict), ehr context/building blocks learning objectives after completing this module students and public health professionals should have: • increased their knowledge about the health information systems and accepted a basic of electronic health record (ehr); • learnt about electronic health record architecture, which represents the generic structural components upon all ehrs are built;· • understood principles underpinning the ehr; • learnt about necessary context blocks: person identifier, facility identifier, provider identifier, health information generated through health events in a form of event summaries and administrative information; • gained knowledge of necessary building blocks, such as privacy, confidentiality, and security; standards; telecommunication infrastructure and encouraging uptake and use of information and communication technology (ict); • highlighted difficulties and risks associated with ehr development; • recognized the importance of ehr for the future development of (national) health information system, especially in countries in transition; and • increased their skills necessary to participate in the process of ehr development in their own countries. abstract modern information and communication technologies offer an opportunity to improve health information systems, reengineer and revitalise the processes and procedures currently in place. at the same time, modern health care is not provided by one institution or by one group of health care professionals alone. hence, today it is considered that the keystone of a system for sharing data, information and knowledge between different partners in health system is the electronic health record (ehr). through an interoperable ehr the sources of information available to all partners in health system, primary and secondary users, can be extended, expanded and harmonized. as such, the ehr should be the core of the new generation of health information systems. ehr, as longitudinal collection of personal health information and under the control of a known party by an agreed access policy, requires at least next components: 62 health systems and their evidence based development person identifier, facility identifier, provider identifier, health information generated through health events in a form of event summaries and administrative information. the shared electronic health record model is one that essentially provides for the systematic collection (at point of care), transfer, storage and retrieval of basic health, demographic, prescription and administrative data in the form of event summaries to be presented with appropriate authorization, via meaningful views and reports. ehr systems provide mechanism for the communication of records or their parts through a network of electronic health records. teaching methods lecture, individual work, group work specific recommendations for teacher this module should be organized within 0.75 ects, out of which one third will be under the supervision of teacher. after an introductory lecture the students should work individually to fill in the questionnaires, which have to explore their knowledge and attitudes towards time of different ehr data storage and the concept of data privacy and security. students will analyse the questionnaires in small groups and discussed in plenary session. in addition teacher should be ready to help the students in searching the internet to find different national examples of the ehr development. assessment of students multiple choice questionnaires, written report with comparison of different ehr development. electronic health records the core of the national health information system jelena marinković, vesna bjegović the health sector is arguably one of the most information-dependent businesses of all in which information requirements can be classified, for example, as: information for citizens, patient education services, health management information, personal health data, decision support systems for health care professionals and life long learning for health care professionals. the development of the national health information system is seen as one of the most important infrastructure prerequisite for initiating, implementing, monitoring, evaluating and targeting the changes within the health care reform. the support to the reform process is based on the development and improvement of management in the health care system, that is: creation of conditions for evidence-based decision making provided for health care providers, patients/citizens and health-care policy makers, and measurement of key dimensions of the health care system, that is: its availability, equity, quality, efficiency, financial and institutional sustainability (1). there is widespread consensus that the underlying rationale for information management and information & communication technology (im&ict) driven health reform is to improve health outcomes for citizens while containing health system costs. however, while sharing this overarching objective, different stakeholder groups are pursuing a range of different outcomes. figure 1 shows the specific outcomes sought by five key stakeholder groups through the application of information management tools and technology as well as information and knowledge (2). 63 electronic health records the core of the national health information system figure 1. stakeholder objectives for im&ict source: the boston consulting group, national health information management and information & communications technology strategy, australia 2004 (2) background the fundamental changes are occurring in the health care sector worldwide. economic, social and many other drivers are forcing changes to the focus of health care. as written and visually displayed in canada ehrs blueprint, first and foremost, health care is becoming a more patient-driven (figure 2 (3)). similarly, there is a demonstrated understanding of the need to shift the focus of health care efforts from the management of illness to the maintenance/promotion of wellness. as a result, we are seeing increased emphasis on the management of diseases across the continuum of care and along the lifecycle of the disease (3). 64 health systems and their evidence based development figure 2. the changing world of healthcare (3) source: ehrs blueprint version 1.0 page 15 © 2003 canada health infoway inc. while many of these changes are driven by advances in technology, they also require a capability from the health infostructure a capability that does not fully exist today. in the new world we require access to health information not only across different systems but across different jurisdictions and domain boundaries. we require the ability to view health information from all sources and to use the infostructure to initiate orders and referrals to a broader range of care and service providers than is currently available through traditional mechanisms. this happens by extending the capabilities to work within a framework of interoperability. through an interoperable electronic health record (ehr) we can extend, expand, and harmonize the sources of information available to clinicians in their work. therefore, the ehr is a neccessary tool for providing person-centred and continuing health care safely and efficiently (3). there is a growing consensus on the value of an ehr. only to cite medirec lisbon declaration where it is recommended that the member states promote a framework for action within europe to further develop common aspects of the ehrs based on the following: „the ehr is the nucleus of the relationship between the patient, the health care delivery system and all its professionals. as such, the ehr should be the core of the new generation of health information systems. the main objective of the use of any ehr must be to improve quality 65 electronic health records the core of the national health information system in care by having record and its associated information always available for the health care professionals when needed at point of care. the use of ehr should lead to direct benefits for the professionals by making their work more efficient. this will arise from supporting the diagnostic process, enhancing accuracy and completeness, improving medical knowledge and disease management, and allowing better preventive care and patient handling. within health care systems, either european, national, regional or local level, the use of appropriate ehrs, will also contribute to adequate planning and resource management, facilitation of continuity of care, registration of health care interventions, improvement of epidemiological and morbidity information, and hence, a more cost-effective care process. the european citizens shall by means of any ehr have: guaranteed right of access to the health care he is entitled for, right of access to his individual data and related services, and the effective protection of his rights of free circulations with respect to the confidentiality of his individual data. further actions and developments on ehr's should be based upon standards and consensus that ensure interoperability, and allow ehr's coming from different origins to be reliable, communicable, recognisable and comparable” (4). defining electronic health record the terms 'computerised patient record' (cpr), 'computer-based patient record' (cpr), 'electronic medical record' (emr), 'computerised medical record' (cmr), 'electronic health care record' (ehcr), 'electronic patient record' (epr) and 'electronic health record' (ehr) are terms often used to describe similar concepts. it is important to clearly define how these terms should be used to avoid confusion. the united states uses the term computer-based patient record or cpr and the institute of medicine defines it as „an electronic patient record that resides in a system specifically designed to support users through availability of complete and accurate data, practitioner reminders and alerts, clinical decision support systems, links to bodies of medical knowledge, and other aids” (5). the united kingdom has accepted two kinds of electronic records in health care the electronic patient record (epr) and the electronic health record (ehr) (6). electronic patient record (epr) describes the record of the 66 health systems and their evidence based development periodic care provided mainly by one institution. typically this will relate to the health care provided to a patient by an acute hospital. eprs may also be held by other health care providers. thus, eprs are considered proprietary and it is usual for eprs not to be able to be transferred even to another site using the same epr system. electronic health record (ehr) is used to describe the concept of a longitudinal record of patient's health and health care from cradle to grave, figure 3. it combines both the information about patient contacts with primary health care as well as subsets of information associated with the outcomes of periodic care held in the eprs. for the purposes of this text we shall consider the electronic health record to be an electronic longitudinal collection of personal health information, usually based on the individual or family, entered or accepted by health care professionals which can be distributed over a number of sites or aggregated at a particular source including a hand-held device. the information is organised primarily to support continuing, efficient and quality health care. the record is under the control of a known party. in certain circumstances, and with agreement of the appropriate professional and patient representative bodies, information from records held by social care organisations may also contribute to the ehr. in theory the ehr is therefore a combination of the bulk of the primary care epr for a patient together with linking information from other record systems for that patient. figure 3. the electronic health record after murphy et al, 1999 (7) 67 electronic health records the core of the national health information system source: heard et al (2000). the benefits and difficulties of introducing a national approach to electronic health records in australia. commonwealth department of health and aged care, australia (8). the electronic health record (ehr) is an unusual concept it is a record, a set of data but it is not accessible without a computer system to interpret it. ehr systems provide the mechanism for the communication that records from part, a feature which differentiates such systems from stand-alone medical record systems. ehr systems operate in a defined technical environment with organised and interoperable components enabling management of and efficient access to information by qualified users via a graphical and potentially interactive multimedia user interface. having launched an ehr within a system, the data within the ehr can at once be manipulated, viewed in different ways and processed into information which assists in the provision of health care. ehr systems also ensure security of the record and the confidentiality of personal health information. precisely, an ehr system is a combination of people, organizational entities, business processes, systems, technology and standards that interact and exchange clinical data to provide high quality and effective healthcare. it is made up of: mechanisms to find and uniquely identify people, providers and locations; patient-centric electronic health records (ehr); presentation solutions and intelligent agents; common services and standards to enable integration and interoperability; workflow and case management; decision support services; services to support health surveillance and research; services to ensure privacy and security; and physical infrastructure to support reliable and highly available electronic communications across defined territory. ehr architecture (ehra) represents the generic structural components from which all ehrs are built, defined in terms of an information model; i.e., it is a model of the generic features necessary in any electronic healthcare record in order that the record may be communicable, complete, a useful and effective ethico-legal record of care, and may retain integrity across systems, countries, and time, independent of the technology used to implement the ehr system (9). an open standardised ehra is the key to interoperability at the information level. the framework used for the ehra requirements comprises: structure (record organization, data organization, type and form of data, supporting health concept representation), process (clinical processes, record processes), communication (messaging and record exchange), privacy and security (privacy and confidentiality, consent, access control, data integrity, auditability of access), medico-legal aspects (support for legal requirements, actors), ethical aspects (support for ethical justification), consumer/cultural aspects (consumer issues, cultural issues) and evolution (support for ehra and ehr system evolution) (10). 68 health systems and their evidence based development an ehr infostructure (ehri) is a collection of common and reusable components in the support of a diverse set of health information management applications. it consists of software solutions, data definitions and messaging standards for the ehr (3). it is made up of: • registry systems to manage and provide peripheral information required to uniquely identify the actors in the ehr. specifically, these are the patient/person, the provider of care, and the location of care. registries which hold patient/person consent information are part of the ehri as well. • domain repositories that manage and persist subsets of clinical data that pertain to the ehr domain. a pacs system is an example of a domain repository. • an ehr system to manage and persist person-centric clinical information. • standardized common services and communication services to sustain the interoperability of the different components within the infostructure, as well as to sustain the interoperability between infostructures and with feeder or application systems. • standardized information and message structures as well as business transactions to support the storage and exchange of information in and out of the ehr. the health information access layer (hial) is an interface specification for the ehr infostructure that defines service components, service roles, information models and messaging standards required for the exchange of ehr data and the execution of interoperability profiles between ehr services (3). the hial is broken down into two layers of services: the common services and the communication bus services. the common services layer is an aggregation of services that accomplish generic functions potentially reusable for any registry, domain repository or ehr system available in a given ehri. the communication bus services layer is an aggregation of services that pertain specifically to enabling communication capabilities in a peer-to-peer, highly distributed network of ehri systems. this layer handles the receiving and sending of messages between any two systems in an ehrs. the standard of the ehr is technology neutral. this means that the ehr can be printed out and transported by a patient or other authorized person, sent as a standard hl7 message, or sent as an xml message to be integrated into the patient information system. purpose of the ehr according to iso/ts 18308 (10) primary purpose 69 electronic health records the core of the national health information system of the ehr is to provide a documented record of care which supports present and future care by the same or other clinicians. the primary beneficiaries are the patient/consumer and the clinician(s). any other purpose for which the record is used is considered secondary, as is any other beneficiary. the secondary uses are: medico-legal (evidence of care provided, indication of compliance with legislation, reflection of the competence of clinicians), quality management (continuous quality improvement studies, utilisation review, performance monitoring, benchmarking, accreditation), education (of students of the health professions, patients/consumers, and providers), research (development and evaluation of new diagnostic modalities, disease prevention measures and treatments, epidemiological studies, population health analysis), public and population health, policy development (health statistics analysis, trend analysis, case mix analysis), health service management (resource allocation and management, cost management, reports and publications, marketing strategies, enterprise risk management), bulling/finance/reimbursement (insurers, government agencies, funding bodies). principles underpinning the ehr, as defined by iso/ts 18303 (10), are : • the ehr should be timely, reliable, complete, accurate, secure and accessible and designed to support the delivery of healthcare services regardless of the model of healthcare being applied. it should interoperate in a way which is truly global yet respects local customs, language and culture. • the ehr should not be considered applicable only to patients, individuals with the presence of some pathological condition. rather, the focus should be on individual's health, encompassing both well-being and morbidity. • the ehr recognises that an individual's health data will be distributed over different systems, and in different locations around the world. to achieve the integration of data, the ehr will require the adoption of a common information model by compliant systems and the adoption of relevant international standards wherever possible. • to permit the development of meaningful ehr standards, boundaries must exist to define what is and is not regarded as part of the ehr at the time of standardization. characteristics of the ehr are according to beale et al, 2002 (11): • the ehr is patient/consumer-centred, and ideally includes information relevant to all kinds of carers, including allied health, and emergency services as well as patients themselves. 70 health systems and their evidence based development • the ehr contains observations (what occurred), opinions (decisions about what should occur), and care plans (plans for what should occur). • the level of abstraction of the ehr is generalist, that is to say, specialised information such as images, guidelines or decision support algorithms are not typically part of the ehr per se; rather interfaces exist to standards for other, specialized systems. • the ehr is a sink of diagnostic and other test data. • the ehr is a source of clinical information for human carers, decision support, research purpose, governments, statistical bureaux, and other entities. • the ehr is a long term accumulator of information about what has happened to or for the patient. therefore ehr is not: • an alternative for the detailed information concerning all diagnostic and treatment information held in local clinical systems; • the source of decision support, although it supports and extends the value of decision support systems, or • a full copy of all patient records in electronic form. building electronic health records an overview of ehr building path comes out from an excellent report done by office of technology and information highway canada. figure 4 illustrates the sequence of building the ehr. diagram depicts an oversimplified view of the ehr. to gain a more accurate appreciation of its complexity and breadth of information, one must recognize the wide range of health information sources. each time an individual visits a health care provider, data are generated. 71 electronic health records the core of the national health information system figure 4. creation of an electronic health record source: toward electronic health records. office of technology and information highway canada, 2001 (13). the following diagram, figure 5, identifies some of the sources of data for an ehr as listed by the usa institute of medicine (committee on data standards for patient safety, 2003) (12). figure 5. sources of health related data source: toward electronic health records. office of technology and information highway canada, 2001 (13). once the data have been collected, they are placed in many repositories or databases that are part of many health systems. from these systems, specific pieces of a patient's information are combined to create a core data set that is made available to other systems. the core data set includes health and administrative data. its format must be agreed to by all stakeholders. the sys72 health systems and their evidence based development tems providing the information are referred to as feeder systems (e.g. laboratory systems). other systems that use the data are called support systems (e.g. billing systems), figure 6. to provide a comprehensive ehr, these systems must be linked, thereby allowing access to patient data regardless of their physical location. this introduces another level of complexity system interoperability. figure 6. system network interoperability source: toward electronic health records. office of technology and information highway canada, 2001 (13). the figure 7 presents the conceptual overview, divided into two major sections: the left side depicts the components involved in the creation of an ehr, and the right side identifies the users and tools required to access the network. the creation of the health network (left side) involves the interaction of a person with a health care provider or health facility. the data are captured, subjected to standards and policies, and will then be stored with identifiers (person, facility and provider) as well as health and administrative data in interoperable databases. the right side of the health network illustrates how various stakeholders access the data stored in the databases by using userfriendly interfaces, security levels (to protect privacy and confidentiality) and various tools. in other words, once the requirements of an ehr are identified, an infostructure is required within which the ehr system will function. as previously stated, the ehr contains all health information generated by all the health care providers an individual interacts with over that person's lifetime. each interaction will result in an incident record that will reside in a system. when these systems become interoperable, the building of the health infostructure begins. 73 electronic health records the core of the national health information system figure 7. conceptual overview of the ehr source: toward electronic health records. office of technology and information highway canada, 2001 (13). necessary context blocks (identifiers and minimum data sets: health, administrative, medication and social data) electronic health record is the health record of an individual that is accessible online from many separate, interoperable automated systems within an electronic network. to facilitate this functionality, the proposed ehr would require next components (13): person identifier: a universal code that uniquely identifies each individual (patient, person, citizen) within the health system. facility identifier: a universal code that uniquely identifies each institution or centre that provides services within the health system. provider identifier: a universal code that uniquely identifies each health care provider within the health system. health information: health data in a standardized format (e.g. diagnosis, x-rays, prescriptions) that are the result of interactions between individuals 74 health systems and their evidence based development and their health care providers. they are generated through health events in a form of event summaries. administrative information: standardized data that support administrative functions, such as billing. as seen out of australia and new zaeland experience the core part of the ehr concept are event summaries the underlying principle of electronic health records is that a useful picture of the health of an individual can be created from knowing key details of the health events that they have been involved in (14). event summaries provide an electronic overview of a health care event, such as a visit to a general practitioner or hospital. that is, they contain only the information that is relevant to the future health and care of health consumers, such as their condition, diagnosis and treatments, rather than every detail collected during a consultation. the collection of event summaries relating to an individual over time will constitute that person's electronic health record. given the large range in potential information processing that can, and often is undertaken by individual service providers, together with the almost infinite variability in the health status and requirements of individual patients at an encounter, it might appear counter-intuitive to prescribe or specify, a priori, what information should be captured under generic circumstances. however, just as the standardization of care processes through the use of evidence-based clinical guidelines has shown beneficial outcomes, so too, can the standardization of information recording potentially show benefits. a key area of development work is the development of a framework that specifies what information should be included in event summaries and how this will be recorded. the framework should include the types of event summaries such as a health service discharge, prescription or diagnostic test result as well as defining what information is collected for such events. event summaries would also need to accommodate the provision of care for groups as well as individuals, and would need to be appropriate to all care types and settings, for example: allied health, community nursing and rehabilitation, as well as hospital based inpatient and emergency. ehr lists event summaries will provide information relevant to a specific consultation or event. it will contain details of a diagnosis or allergy identified as part of the consultation but will not include previous diagnoses or allergies. a view of the event summary will therefore not give a full picture of 75 electronic health records the core of the national health information system the health status of the consumer. ehr lists are small collections of data describing key aspects of an individual's health for which there is a benefit in maintaining and viewing together. for example, it is important that allergies and alerts are viewed together rather than as part of numerous individual event summaries. ehr lists will enable data in event summaries to be stored in a fashion that allows rapid retrieval of the desired view through eliminating the need to hunt through all event summaries to find the information needed. ehr lists will commonly form major components of ehr views. populating ehr lists will also be the means by which a consumer's initial health profile would be created. examples of ehr lists include family history, risk factors, allergies and alerts, recent events, current medications list, current diagnoses and/or conditions, list of test results, and lists of care plans (14). ehr views and reports one of the major challenges of ehr model is to present the information collected in a useful and meaningful way to the specific requestor of the information. core to the development would be the provision of a range of 'views'. views would need to differ according to the provider type specialists would be interested in different types of data to community health workers, and they will also need to differ depending on the issue being addressed. a chronological list of events would be of some, but limited, use. this simple approach would quickly overwhelm the viewer as he or she hunts through the event summaries to find the information needed. ehr model should be able to 'extract' relevant data from event summaries and present meaningful packages of information. the electronic health record lists will assist the development of key views (14). an important division in the classification of these 'views' is the distinction between 'electronic health record views' and 'electronic health record reports'. electronic health record views are designed primarily to serve the needs of the primary participants, that is, consumers and providers and contain information about an identified individual. while 'reports', on the other hand, are designed to serve the needs of secondary participants, such as managers and researchers, and would usually take the form of aggregated data. under controlled circumstances de-identified unit records could be provided for approved research. in some circumstances, an electronic health record view, that is, identified information, could be supplied to a secondary participant, for instance to a disease register where consent existed or reporting was required by legislation, or for research where a consumer has provided express consent for information to be provided. 76 health systems and their evidence based development introduction of a national health identifiers to be used only in the health care sector under strict privacy protocols and which is to be implemented concurrently with ehr system should follow the basic principle where the unified patient identification (upi) is used for clinical or administrative purposes, as well as to link records for statistical purposes, the personnel who use the upi for clinical or administrative purposes should not normally be able to access additional information on identified clients who have not consented to this access (14). development of identification systems for providers, locations/facilities and possibly items of equipment (for example, mri machines) is a part of a process which aims to identify the online security requirements for the electronic health records system such as access and usage controls. necessary building blocks (privacy, confidentiality and security; standards; telecommunication infrastructure; encouraging uptake and use of ict) (note: the following text is taken from the national electronic health records taskforce final report: „a health information network for australia". commonwealth department of health and aged care, australia, 2000 (14)) the best way to address objectives for electronic health records is to develop a general approach to health information exchange, rather than to build a structure designed just to support a system of electronic health records. this has to be achieved through putting in place the underlying 'building blocks', or infostructure components, that would be critical to underpin any national system of electronic health information interchange. infostructure may be defined as: 'information infrastructure for health that provides shared resources and standards for health care agents/parties that enable information to flow in appropriately structured, identifiable (unambiguous) and secure ways' (3). the headings that define the building blocks are: • privacy, confidentiality and security; • standards (messaging and communications, data standards, coding and classifications); • architecture; and • encouraging uptake and use of information technology. privacy is a fundamental principle underpinning quality health care. with the uptake of new technologies, such as electronic health records, it will 77 electronic health records the core of the national health information system be especially important that trust is maintained so that consumers can reap the benefits from improved information flow at the point of care, knowing that their privacy will be maintained. the objective for privacy is the establishment of a uniform data protection regime across the country to apply to personal health information a regime that enhances the privacy and respects the dignity of individuals. health privacy is currently provided by a patchwork of legislation and administrative regimes. this means that there is no uniform health privacy protection for personal health information moving between the public and private sectors or across jurisdictional boundaries. this is an increasing problem, as the boundaries between the public and private sectors become less distinct in health care provision. increasingly, single episodes of care involve multiple health care providers (such as general practitioners, diagnostic services and specialists) who may work in both the public and private sectors. it can then become unclear which privacy regime applies to any single practitioner, or any single episode of care. security and authentication specific standards and guidelines will need to be developed or modified to support the implementation of emerging policies and codes of practice for managing health information in an online environment. appropriate security measures must be put in place wherever health information is collected and stored. with the increasing use of online information and communication technologies to facilitate the timely exchange of and access to health information, it is imperative that robust security measures support these processes to maintain and strengthen consumer and provider trust. similarly, authentication measures must be in place when information is transferred or exchanged, to ensure that information is sent to the appropriate person at the correct destination. the broad objective is to develop a sound security framework which mandates security standards for the health care sector to prevent unauthorised access to, and misuse of, online health information. it is expected that this will include security standards in the following areas: • authentication of health care locations, individuals, health care workers and their roles; • access; • data management, transfer and use; • data integrity; and • system administration. 78 health systems and their evidence based development a further objective is to develop a comprehensive and coherent information security domain spanning the national health sector and incorporating the harmonisation of the security domains of major health agencies. these include public key infrastructure (pki) and health esignature authority. pki is the enabling technology that will allow for the provision of security for the online transmission of data including patient information. pki provides a security mechanism that is used to facilitate online communication between the health sector and other health agencies such as the health insurance and the national institute for health. the health esignature authority (hesa) has to be established as an independent subsidiary of health insurance to facilitate the introduction of pki in the national health sector. hesa performs essential user identity checks before issuing digital certificates. standards activities messaging and communications uniformity in messaging and communication standards and protocols, and consistent interpretation of these standards across the health sector is a crucial infostructure element. this is because information related to consumer health care is held in a variety of data formats and information structures using a range of health care computer applications as well as paper-based systems. the development and adoption of common messaging standards will assist with the communication and sharing of consumer health information between disparate systems without customised interfaces. however, to achieve interoperability, agreed and implemented messaging standards will need to be supported by a number of other 'building blocks'. these include national data definitions and domains, terminology and coding, and identifiers. for example, interoperability will be considerably more difficult if two systems are exchanging messages using different coding schemes for medication types, or different means of patient identification. achieving success with messaging interoperability nationally will thus depend on progress and outcomes of national strategies for other key standards and building blocks. standards activities data standards, classification and coding systems explicit reference terminologies are necessary to allow health care providers to communicate, undertake business and share information electronically within and across sectors. national and international data standards are necessary to describe measure and communicate concepts about a person's health in ways which are uniformly understandable across the sector, and which will safely interface to decision support technology. objectives of these activities are to: • establish a sustainable process for the national maintenance of classifications and terminologies, and mechanisms to facilitate interoperability 79 electronic health records the core of the national health information system through the use of an appropriate national reference terminology; • agree upon national classification systems for all sectors identified within the framework (taking the who family of health classifications work as a starting point); and • establish a national mechanism for the assessment and accreditation of interface terminologies in use in all health care settings. standards requirements include at least: • data definition (for example, expansion of the national health data dictionary, national minimum data sets); • health record architecture/structure (for example, good electronic health record, cen 13606, hl7 reference information model and clinical document architecture, iso/ts 18308); • coding and classification, terminology (for example, icd10, icpc 2, loinc, drg, …); • messaging and communication (for example, xml-protocol, hl7, un/edifact, corba); • identification (for example, for client, health care provider, and location); and • access control and security (encryption, public key infrastructure, security socket layer (ssl)). health information network architecture a system of electronic health records will require appropriate infrastructure on which to run. networks provide a physical channel for exchange of data between computers and have become commonplace in most settings heavily dependent on computer-aided assistance. substantial groundwork is needed to ensure that it can deliver the potential benefits to all citizens in the most cost-effective and sustainable way. for each country, it will set the agenda for component development and the information and technology systems required to support these components that will work together to implement the overall system. the objectives for architecture are the establishment of a health information network architecture comprising source systems, event summaries, storage nodes/central services, applications and access points. electronic health record: architecture and information content ehr model is conceived as an opportunity to develop and deploy basic health information infrastructure. two closely related goals of health information exchange are important to this objective: (a) interoperability that is, the ability for records to pass between or be viewed by different systems (using diffe80 health systems and their evidence based development rent technologies, software, hardware and database platforms), and still be handled consistently, and, (b) utility and uniform understandability that is, the appropriateness of and ability of the information content to be consistently interpreted across different settings, by different players, including by electronic decision-support tools without human intervention. to support these goals, and conscious of the need to maximise value adding of the information collected and stored, a crucial component is the use of standards to define the structure of the storage facilities wherever they are located. unless a standard format is used for storage the value of the network will be seriously compromised information will not be able to be shared, and the various network applications will not function. the objective of standardisation of electronic health record architecture is to maximise the benefits of distributed information processing to be realised in an environment of heterogeneous information technology resources and systems, and multiple organisational domains. the international standards organisation (iso)'s reference model for open distributed processing states that: building (distributed) systems is not easy. it requires an architecture and, because a single engineering solution will not meet all requirements, it must be a flexible architecture. moreover, since a single vendor will not have all of the answers, it is essential that the architecture, and any functions necessary to implement the architecture, be defined in a set of standards, so that multiple vendors can collaborate in the provision of distributed systems. such (architectural) standards will enable systems to be built that: • are open providing both portability and interworking; • are integrated incorporating various systems and resources into a whole without costly adhoc developments; • are flexible capable of both evolving and of accommodating the existence and continued operation of legacy systems; • are modular allowing parts of a system to be autonomous, but interrelated; • can be federated allowing a system to be combined with systems from different administrative or technical domains to achieve a single objective; • are manageable; • meet quality of service needs; • are secure; and 81 electronic health records the core of the national health information system • offer transparency masking from applications the details and the differences in mechanisms used to overcome problems caused by distribution. the advantages of a standardised ehr architecture include: • maximising the ability of information to 'self-describe' to various systems, so that dependence on highly structured, 'static' interfaces is reduced; • movement towards architectural convergence, as vendors increasingly comply with the standard, therefore increasing the ease of information interchange; • establishing a common middleware specification for ehrs; that is, an ehr interoperability platform which takes care of difficult aspects of information processing and security, and allows application developers to concentrate on high quality applications; and • the lifetime aspect of ehr will introduce the need for very long-term 'persistent' data. information holdings that have been explicitly designed ('architected') to be self-describing or 'context conscious' but which are not explicitly linked to particular technologies, have a much greater chance of persisting that is, moving into new technologies without unacceptable cost. encouraging uptake and use of information technology health care providers, who will bear the main responsibility for entering the information to form the basis of a national system of electronic health records, will need to be supported and encouraged in this vital work. this will mean assistance in acquiring the necessary hardware and software top connect to health information network, along with appropriate training and support. 82 health systems and their evidence based development benefits of electronic health records current paper-based record keeping means that valuable health information is not readily available where it is needed most at the point of clinical care. such 'information silos' inhibit major health care reforms aimed at achieving better integration and coordination of care. in this context, this concept aims to improve the flow of information across the health sector to ultimately improve the overall quality and safety of the health care system. fully developed, ehr system would enable consumer health information to be collected electronically, safely stored and exchanged between authorised health care providers, within strict privacy safeguards. some of the anticipated, key benefits of ehr system include (13): • empowerment of consumers through being able to access their own health information and therefore being able to make more informed decisions about their health care; • reductions in adverse events through providers having rapid and improved access to critical patient information held elsewhere; • improved provider access to evidence-based information at the point of care; • efficiency gains through reduced time spent accessing information, together with reductions in unnecessary duplication of tests; • better care coordination across the continuum through improved information flow between providers and services; and • providing an invaluable evidence base for informing health care policy, planning and research activities, leading ultimately to more effective and efficient health care delivery nationally. in addition to the obvious and vital benefits to individual consumers and their providers, better clinical information has an important role in securing long term benefits for all through improved policy, planning and management of the health system. despite the myriad of different data collections that exist, there is still relatively little information readily available about how well any health care system actually delivers care, or the extent to which it actually improves health outcomes. the following table summarizes some of the potential benefits to different stakeholders (13). 83 electronic health records the core of the national health information system table 1. stakeholder's benefits source: toward electronic health records. office of technology and information highway canada, 2001 (13). difficulties and risks associated with electronic health records however, while the benefits of ehr system are both readily accepted and understood by consumers, providers and policymakers, there are risks and barriers that would need to be addressed in implementing an initiative on the scale of ehr system. as evidenced by other's experiences, successful implementation of ehr system would require commitment at all levels of the health care system from the end users right through to heads of government. failure to obtain such commitment is likely to result in fragmentation and lack of connectivity across the health sector. in broad terms, issues to be overcome include (14): 84 health systems and their evidence based development stakeholders potential benefits public expanded reach of effective health care, more secure information, improved sense of well-being, access to information about how the health care system works patients or their representatives improved health care and decreased risks (e.g. adverse drug reactions), integrated health services, do not have to repeat basic information, such as name, address increased confidence knowing that all health care professionals have access to all relevant parts of their medical history, access to their own health records helps patients to make informed decisions about their health, avoidance of duplicate, invasive and/or expensive tests, reduced waiting lists health professionals integrated view of patient data, increased access to other related and integrated patient information, improved access through a portal to related health services, improved decisions with up-todate patient information on an as-needed basis, improved seamless care through the coordination of multi-professional and multi-agency care, improved development of decision support systems health administrators increased patient care time, access to data to support clinical governance and local planning, reduced health care costs, improved health care quality policymakers (including governments) improves effective health maintenance and education, supports medical and administrative decision-making processes, provides for improved long-term planning researchers (including governments) access to timely high-quality data for research, access to up-todate research findings, treatment and medication options, improved data quality, to aggregate data, allows for improved trend analysis governments improved accountability, improved health resource allocation • concerns about privacy, security and confidentiality of information in the system; • gaining the acceptance of health professionals and other users; • actual implementation; • technical issues; and • level of investment and political commitment required. to address these issues (privacy, security and confidentiality of information in the system) would require a multi-layered approach to privacy and security, including both legislative and technical mechanisms for ensuring a robust privacy framework is in place for ehr system. key to achieving acceptance of health professionals and other users includes: involving end users at all stages of development to ensure that ehr system meets user requirements providing education, training and support as part of an appropriately resourced, overarching change management strategy; and addressing identified medicolegal issues ahead of implementation. when actual implementation is in question and having the rapidly changing health information environment, cooperation between the major parties, particularly state and district governments, is crucial to successful implementation of ehr system. sustaining national cooperation requires adequate resorting in terms of both governance and project management. other such risks to be addressed include: ensuring the ehr system design integrates with work practices; developing sustainable registration and identification processes; and ensuring standards development is given sufficient priority. technical issues include: lack of provider infrastructure, support and expertise; provider system changes too complex; internet reliability; insufficient or absent standards leading to greater maintenance effort once ehr system has been implemented; and poor management resulting in a flawed technical solution. the level of funding made available for ehr system will determine the speed of implementation. 85 electronic health records the core of the national health information system national approaches: examples a number of countries and regions (in the case of europe) have embarked on electronic health record initiatives. the european, as well as australian and new zealand experience, has been driven by the high percent of physicians who use computers in their practice for example, over 90% of general practitioners in the netherlands and the uk up to 58% in portugal and 43% in greece. the high use of computers by physicians in europe and australia has been supported by legislation and financial incentives. only recently has the focus turned to hospital and regional ehr implementations. the north american experience has had a different starting point from europe in hospitals rather than physician offices. this is in large part due to the large investment in commercial hospital-based information systems in north america and less focus on general practitioners. in developing countries the key initiatives come from government and cover an introduction of health management information systems. but it is recognized that they should have a strong patient-centered orientation. for that reason they implicitly are looking for an electronic health record as a building block. for countries in transition which generally are covered with amazing flow of health data, mostly in paper form, with well established health and social rights, but unfortunately with lack of money, informatization is seen as a one of the best infrastructure steps in overcoming the current situation. the most notable electronic health record initiatives include (compiled mostly from: health connect program office. international approaches to electronic health record. department of health and ageing. commonwealth of australia. 2003. www.healthconnect.gov.au and canada health infoway. ehrs blueprint – an interoperable ehr framework. version 1.0. 2003. http://knowledge.infoway-inforoute.ca): • europe good european health record project, medirec, prorec initiative (for more information see: electronic health records and communication for better health care. proceedings of eurorec 2001. ed. mennerat f. ios press 2002, and also www.chine.ucl.ac.uk/health/gehr and www.cenorm.be) • united kingdom information for health, erdip (electronic record development and implementation programme). see: www.nhsia.nhs.uk/erdip 86 health systems and their evidence based development • the netherlands see: kieke, o 2002, 'experience with information technology in dutch health care: promises and pitfalls, global insights seminar', healthlink, november 15-18, 2002, monterrey, california. • sweden see: taylor, h and leitman, r (eds) 2002, 'european physicians especially in sweden, netherlands and denmark lead us in use of electronic medical records', harris interactive healthcare news, vol. 2, issue 16. • denmark see: lippert s, kverneland a. the danish national health informatics strategy. in: the new navigators from professionals to patients. r. baud et al. (eds). ios press 2003, and also at www.im.dk/index/dokumentoversigt.asp • ireland see: information for action. a national health information strategy for 2002-2009. a consultation document. draft 1. department of health and children. 2001. • new zealand see www.nzhis.govt.nz • australia see www.health.gov.au/healthonline, www.gehr.org, www.healthconnect.gov.au, and next documents: department of health and aged care 2000, a health information network for australia, report to health ministers by the national electronic health records taskforce, department of health and ageing, canberra, viewed at http: //www.healthconnect.gov.au/pdf_docs /ehr_rep.pdf; national electronic health records taskforce 2000, a health information network for australia: report to health ministers, department of health and aged care, canberra, viewed at http://www.healthconnect.gov.au/pdf_docs/ehr_rep.pdf • hong kong see: yeoh, ek. secretary for health and welfare, hong kong, health services, policy objective and key result areas, a t : w w w. p o l i c y a d d r e s s . g o v. h k / p a 0 1 / p d f / h e a l t h e . p d f , www.hwfb.gov.hk/hw/english/archive/consult/hcs/hcs.htm and www.info.gov.hk/hwb • united states see www.iom.edu • canada see www.hc-sc.gc.ca/ohih-bsi and http://knowledge. infoway-inforoute.ca • south africa see www.uneca.org/aisi/health1.htm and www.angelfire.com/ok3/peaceportal/telehealth.html 87 electronic health records the core of the national health information system • brazil see: lemos, m and de faria leao, b 2003, 'the brazilian national health card project, ni2003: proceedings of the 8th international congress', nursing informatics 2003, june 20-25, 2003, rio de janeiro, brazil. 88 health systems and their evidence based development exercise: ehr development data storage, data privacy and security task 1: data storage electronic health record (ehr) is representing personal health information in electronic form, which are following the patient from birth until death. in ehr information about health events contacts of the patient/consumer with primary health care, are combined with health events information about patient's contacts with all other health care levels. ehr is usually based on individual or family data, authorised health care professional is filling necessary information in ehr, and some of these information afterwards can be aggregated and distributed to other predefined ehr users, participants in the system. ehr is promoting data exchange about patient on higher level, so that health care professionals can communicate easily, everyday contacts between patient/consumer and doctor/provider are facilitated, accuracy of documents is upgraded, efficacy and quality of health care is also promoted, and, above all, infrastructure for decision making can be built, in the sence of evidence based decision making, based on information stored in electronic form. students should fill in the questionnaire and then discuss their attitudes in small groups, with presentation of summary in the plenary session. in this questionnaire data are listed to be included in electronic health record (ehr). some data in ehr are permanent, long-life data, since others are changeble they can be stored for one year period maximum. please, mark with x which data can be permanent / changeble, according to your experience: 89 electronic health records the core of the national health information system information type information storage period non-relevant information for ehr permanent up to 1 year identification information (date, time, place, sex on birth, blood group) administrative data: • family name, middle name, name • date and place of birth, sex • address and phone number • iso country code • compulsory insurance • name of employees establishment • professional code no • register no 90 health systems and their evidence based development • health insurance booklet no • validity date • insurance legal basis • voluntary insurance • type of insurance • chosen doctor • medical documentation no • organ / body donor • ehr status • other (please, specify): social data: • marriage status • number of children, occupation • education • living conditions • occupational status • social support • invalidement • child family social status • life style (smoking, alcohol) • other (please, specify): medical data: • drug allergies, vaccinations and serum if received • congenital anomalies • chronically diseases • active form of tbc • professional diseases • surgeries performed • current therapy (insulin, dialisys) • other (please, specify): general practitioner: • electronic provider / consumer identification • date, time and place reason for event • diagnosis: current principal • intervention • immunisation • referrals • prescription • appointments • other (please, specify): 91 electronic health records the core of the national health information system ambulatory care: • electronic provider / consumer identification • date, time and place • reason for event • diagnosis: current principal • pathology results • intervention • referrals • appointments • other (please, specify): hospital: • electronic provider / consumer identification • date, time and place • diagnosis: principal secondary, additional and complications • injury (at work, place, cause of injury) • pathology results • therapy (drugs, surgery procedures, rehabilitation,recommendation) • result of care healthy transfer in other hospital transfer on rehabilitation • death time of death cause of death autopsy result • other (please, specify): current medication list: • date started to take drugs • name of drug(s) • dosage of drug(s) • other (please, specify): list of recent pathology, radiology and laboratory test results: • only the test results available in electronic form • other (please, specify): task 2: ehr data privacy and security students will fill in the questionnaire and then discuss the possibilities in their own countries to implement ehr. 1. according to you, is it necessary to establish ehr under special legislative frame? yes no 2. according to recent legislative in health care system, it is very important to keep privacy and security of patient/health care consumer. approach to data in ehr can be regulated on different levels. some information can be available only to gp, some of them can be available to gp and to ehr owner patient, and some of them are available to other ehr users (doctor specialist, pharmacist, health insurance fund, social insurance fund, ministry of health, institute for public health). please, mark with x in the table / field below who can approach to data in ehr, according to you: 92 health systems and their evidence based development information type ordinated gp ehr owner (patient, consumer) doctor specialist in second health care level others (pharmacist, insurance, ministry, inst. for public health) identification data administrative data social data medical data current therapy recent laboratory, radiology test results glossary of key terms note: the following terms are defined according to the canada health infoway inc. (2003) (3). ehrs blueprint – an interoperable ehr framework, version 1.0. available at: http://knowledge.infowayinforoute.ca access control a security technology that selectively permits or prohibits certain types of data access based on the identity of the accessing entity and the data object being accessed. a process that determines who is given access to a local or remote computer system or network, as well as what and how much information someone can receive. architecture – 1. a software architecture is an abstraction of the run-time elements of a software system during some phase of its operation. a system may be composed of many levels of abstraction and many phases of operation, each with its own software architecture. 2. architecture is a term applied to both the process and the outcome of specifying the overall structure, logical components, and the logical interrelationships of a computer, its operating system, a network, or other conception. 3. the software architecture of a program or computing system is the structure or structures of the system, which comprise software components, the externally visible properties of those components, and the relationships among them. authentication in computer security, the act of identifying or verifying the eligibility of a station, originator or individual to access specific categories of information. in data security, a measure designed to provide protection against fraudulent transmissions by establishing the validity of a transmission, message, station or originator. in data security, processes that ensure everything about a teleprocessing transaction is genuine and that the message has not been altered or corrupted in transmission. in computer security, the process that verifies the identity of an individual as established by an identification process. in data security and data communications, both the prevention of undetected alteration to data and peer entity (mutual verification of each other’s identities by communicating parties) authentication. a process verifying that users are who they say they are. an example of authentication is requiring users to identify themselves with a password. authorization – 1. process of determining what activities are permitted, usually in the context of authentication. 2. the permission to perform certain operations or use certain methods or services. 3. the process that grants access to a local or remote computer system, network or to online information. business architecture defines the organization and functions of the business and the business processes that support those functions. business process a set of interacting activities that produce one or more products or services for customers of the business enterprise. clinical data any information element obtained during an encounter relating to the assessment of a client’s health state, diagnostic of diseases and/or treatments. clinical data repository an operational data store that holds and manages clinical data collected from service encounters at the point of service locations (e.g. hospitals, clinics, etc.). data from a cdr can be fed to the ehr for that client, in that sense the cdr is recognized as a source system for the ehr. clinical information system a clinical information system is a system dedicated to collecting, storing, manipulating and making available clinical information important to the delivery of healthcare. clinical information systems may be limited in scope to a single area (e.g. lab system, ecg management system) or they may be comprehensive and cover virtually all facets of clinical information (e.g. electronic patient/person the original discharge summary residing in the chart, with a copy of the report sent to the admitting physician, another copy existing on the transcriptionist’s machine, etc.) clinically relevant data any clinical data about a client that is deemed necessary or desirable to have available during an encounter. relevance is expressed in relation to different perspectives set by factors such as disciplines in healthcare practice or context around an episode of care or elapsed time. therefore relevance of data varies greatly and is hard to assess firmly. 93 electronic health records the core of the national health information system coding the process of assigning an alphanumeric code to a concept in accordance with an agreed classification system e.g. icd10 (international classification of disease version 10). conceptual architecture – 1. a general design that indicates the overall intent and outline of the target architecture, architecture lays the foundation and defines the process that will be used to develop the target architecture. 2. a conceptual architecture describes or defines a technology solution at the functional level, without regard to a particular physical implementation. the conceptual architecture is used to create a comprehensive view of the system components, relationships, and interfaces needed to meet a technology requirement. confidentiality – 1. a security technique that permits read access and retrieval by authorized entities only. 2. confidentiality protects the privacy of information being exchanged between communicating parties. in computer security, a concept that applies to data that must be held in confidence and that describes the status and degree of protection that must be provided for such data about individuals as well as organisations. consent explicit granting of access to specified information. continuum of care a holistic approach to healthcare delivery across multiple providers, aiming to improve the quality of care and promote wellness. data model describes the organization of data in an automated system. the data model includes the subjects of interest in the system (or entities) and the attributes (data elements) of those entities. it defines how the entities are related to each other (cardinality) and establishes the identifiers needed to relate entities to each other (primary and foreign keys). a data model can be expressed as a conceptual, logical, or physical model. data warehouse a database of information intended for use as part of a decision support system. the data is typically extracted from an organization’s operational databases. database management system systems that manage large structured sets of persistent data, offering ad hoc query facilities to many users. they are widely used in business applications: commercial examples include db2, oracle, sql-server, sybase etc. decision support system software that taps into database resources and massages and presents data to assist users in making business decisions. a clinical decision support system gives physicians structured (rules-based) information to help make decisions on diagnoses, treatment plans, orders and results. de-identified data data are termed ‘de-identified’ when an individual’s identity is not apparent, and cannot reasonably be ascertained by the user, from the record elements. guidelines for de-identification and the use of de-identified information will be required. digital certificate a digital document issued by a certification authority that contains the holder’s name, serial number, public key and the document’s expiration date. digital certificates are used in public key infrastructure to send and receive secure, encrypted messages. digital signature an electronic equivalent of a signature used to verify authorship or information source. domain data clinical data that is specific to a particular domain. (e.g. drug, lab, diagnostic imaging, etc.) domain repository a domain repository is a component of an ehri that stores, maintains and provides access to specific clinical subset of data at a jurisdictional level. the key data domains recognized as part of an ehr are drugs, laboratory and diagnostic imaging. in canada today, some of these data domains may be already deployed as jurisdictional level systems in given jurisdictions. an ehr infostructure must be able to assemble information transparently from these domains in order to provide the complete clinical picture of a patient/person. ehr – data. the collection of all important clinical data related to a particular patient/person. 94 health systems and their evidence based development ehr infostructure collection of common and reusable components in the support of a diverse set of health information management applications. it consists of software solutions for the ehr, data definitions for the ehr and messaging standards for the ehr. electronic health record 1. an electronic health record (ehr) provides each individual in country with a secure and private lifetime record of their key health history and care within the health system. the record is available electronically to authorized health care providers and the individual anywhere, anytime in support of high quality care. 2. in an ehri, the ehr is the central component that stores, maintains and manages clinical information about patients/persons. the extent of the clinical information sustained by the ehr component may vary based namely on the presence or absence of domain repositories in any given jurisdiction. electronic health record system combination of people, organizational entities, business processes, systems, technology and standards that interact and exchange clinical data to provide high quality and effective healthcare. electronic patient record electronic set of information about a single patient/person. an electronic patient record system is a system specifically designed to provide patient/person records electronically. this is not necessarily restricted to a single clinical information system. encounter an encounter is a service event that occurs within an episode of care. enterprise architecture a framework that defines the overall structure of a business. it uses different perspectives or views such as business processes, information, systems and technology required to operate a business. enterprise master patient index / enterprise master person index an empi (enterprise master person index) is a system which coordinates client identification across multiple systems namely by collecting and storing ids and person-identifying demographic information from source system (track new persons, track changes to existing persons). these systems also take on several other tasks and responsibilities associated with client id management. episode of care an encounter or series of encounters related to the detection and subsequent care for a particular healthcare requirement. extensible mark-up language xml is a mark-up language for structuring arbitrary data based on element tags and attributes. describes a class of data objects called xml documents and partially describes the behavior of computer programs which process them. xml is an application profile or restricted form of sgml, the standard generalized mark-up language [iso 8879]. by construction, xml documents are conforming sgml documents. facility a type of delivery site that has constant capability and capacity to provide health services, and is administered by a health service organization. feeder systems operational systems that will feed patient/person data to the ehr in the form of realtime single, multiple messages or batch file uploads. file transfer protocol – 1. a standard high-level protocol for transferring files of different types between computers over a tcp/ip network. ftp can be used with a command line interface or graphical user interface. 2. the name of a utility program available on several operating systems which makes use of this protocol to access and transfer files on remote computers. framework in object-oriented systems, a set of classes that embodies an abstract design for solutions to a number of related problems. frameworks can be horizontal or vertical. an example of a horizontal framework is the presentation framework (gui); and example of a vertical framework is a business accounting framework. health information access layer the health information access layer is an interface specification for the ehr infostructure (osi layer 7) that defines service components, service roles, information model 95 electronic health records the core of the national health information system and messaging standards required for the exchange of ehr data and execution of interoperability profiles between ehr services. identifiable data data are termed ‘identifiable’ when an individual’s identity is readily apparent, or can reasonably be ascertained by the user, from the record elements. identification a person identifier is a universal code that uniquely identifies each individual of consumers, within the health system. such an identifier can be simply assigned or based providers, locations/ on some unique characteristic of the individual (called biometric identification) facilities and devices. similarly providers, facilities, individual devices and the location of the point of care may all have to be capable of unequivocal identification to guarantee the integrity of a system of electronic health records. implementation implementation is the carrying out, execution, or practice of a plan, a method, or any design for doing something. implementation is the action that must follow any preliminary thinking in order for something to actually happen. information model a structured specification of the information requirements of a project. an information model expresses the classes of information required and the properties of those classes, including attributes, relationships, and states. examples are the domain reference information model, reference information model, and refined message information model. infostructure this is a concatenation of the phase information infrastructure. it covers both physical (e.g. computers and cables) and abstract (e.g. standards, data sets, terminologies, workforce capacity) infrastructure elements. internet the internet is behind much of the explosive growth in data communications. often characterised as a network of networks, the internet is a set of protocols for enabling computers to connect and communicate with each other. viewed in another way, it is like a communications platform that enables a range of other, internet-specific programs to run. a major stimulus to growth in recent years has been the universal adoption of the hypertext transport protocol (http) and the easy-to-use web browsers that emerged to exploit it. indeed, so ubiquitous is web-browsing-based internet usage that for many people the internet and the world wide web are synonymous. indeed, given the ability of web-browsers to emulate a wide range of more function-specific client programs (e.g. email), many other internet programs have, fact, been absorbed into browser-based functions. the internet was not originally designed with businesses in mind. it lacks the technology required for secure business communications and transactions. a worldwide system of computer networks. networks connected through the internet use a particular set of communication standards, known as tcp/ip, to communicate. interoperability – 1. the ability of hardware and software from different vendors to understand each other and exchange data, either within the same network or across dissimilar networks. 2. the ability of autonomous systems to work with other dissimilar systems. interoperable systems interact through standardized interfaces. they are often loosely coupled and exchange information in an asynchronous manner. interoperable systems can function without knowing the internal processes, functions, and data representations of other systems. the ability of two or more systems to exchange information or function together. iso international organization for standardization. note that iso is not an acronym; instead, the name derives from the greek word „isos” which means equal. founded in 1946, iso is an international organization composed of national standards bodies from over 75 countries. for example, ansi (american national standards institute) is a member of iso. iso has defined a number of important computer standards, the most significant of which is perhaps osi (open systems interconnection), a standardized architecture for designing networks. logical observation identifiers, names and codes a database protocol aimed at standardizing laboratory and clinical codes for use in clinical care, outcomes management and research. developed by the regenstrief institute for health care, loinc is touted as a middleman solution to potential translation problems between labs that use hl7 reporting and recipient systems that may not be able to translate such data. 96 health systems and their evidence based development longitudinal involving the repeated observation or examination of a set of subjects over time with respect to one or more study variables (as general health, the state of a disease, or mortality). longitudinal record patient/person centric electronic health information spanning from the earliest event to the most recent encounter. message a package of information communicated from one application to another. messaging the activity and associated processes of sending or receiving a message. metadata data about data. metadata describes how and when and by whom a particular set of data was collected, and how the data is formatted. metadata is essential for understanding information stored in data warehouses. data definitions describing aspects of the actual data items, such as name, format etc. middleware software systems that facilitate the interaction of disparate components through a set of commonly defined protocols. the purpose is to limit the number of interfaces required for interoperability by allowing all components to interact with the middleware using a common interface. model a representation of a problem or subject area that uses abstraction to express the relevant concepts. a model is often a collection of schema and other documentation. modularity the design goal of separating code into self sufficient, highly cohesive low coupling pieces. network in information technology, a network is a series of points or nodes interconnected by communication paths. networks can interconnect with other networks and contain sub-networks. nodes in a network, a node is a connection point, either a redistribution point or an end point for data transmissions. in general, a node has programmed or engineered capability to recognise and process or forward transmissions to other nodes. openehr openehr, formerly known as the good electronic health record, provides an open architecture and a standard format for electronic health records. open source software open source refers to any program whose source code is made available for use or modification as users or other developers see fit. oss is developed as a public collaboration and made freely available. definition model of distribution terms require that: (1) the software must be redistributed without any restriction, (2) the source code must be made available (3) the license can require improved versions of the software to carry a different name or version from the original software. linux is the most common form of oss. open systems interconnection a seven-layer reference model developed by iso as a framework for the development of standards for interconnecting heterogeneous computers. the layers from the top are application, presentation, session, transport, network, data link and physical. person centric/patient centric a design goal or characteristic that establishes that all information in an application system shall be grouped and/or indexed according to the patient/person. person centric patient centric. privacy freedom from intrusion into the private life or affairs of an individual when that intrusion results from undue or illegal gathering and use of about that individual.the right of an individual to live free of intrusive monitoring of their personal affairs by third parties not of their choosing. privacy enhancing technologies technologies used to protect privacy rights and secure transactions on the internet or other networks. it includes methods such as encryption, digital signatures and digital certificates as well as both private and public key methods encryption environments. provider any supplier of a healthcare service. provider registry a provider registry is a system or a combination of systems where a health care 97 electronic health records the core of the national health information system provider’s information (i.e. name, address, practice licences, etc…) is securely stored, maintained and made available to other systems and users. public key infrastructure the architecture, organization, techniques, practices and procedures that collectively support the implementation and operation of a certificate based public key cryptographic system. public key public key infrastructure (pki) is a set of procedures and technology that infrastructure (pki) enables users of a network such as the internet to authenticate identity, and to securely and privately exchange information through the use of public key cryptography. to achieve this, public and private keys and a digital certificate can be obtained through a trusted third party authority, known as a certification authority (ca). the ca links the public key to the digital certificate and vouches for the identity of the key holder. in order for the system to operate, a process must be established to accurately identify a person via something like a 100 point test. registration authorities (ras) undertake this role by collecting and managing the appropriate levels of evidence of identity (eoi) from applicants for digital certificates. dependent upon the pki business model employed, appropriately accredited ras may also create keys and certificates. the use of pki ensures authentication, integrity, non-redudiation and confidentiality for e-commerce applications. reference architecture generalized architecture of several end systems that share one or more common domains. the reference architecture defines the infrastructure common to the end systems and the interfaces of components that will be included in the end systems. the reference architecture is then instantiated to create a software architecture of a specific system. the definition of the reference architecture facilitates deriving and extending new software architectures for classes of systems. a reference architecture, therefore, plays a dual role with regard to specific target software architectures. first, it generalizes and extracts common functions and configurations. second, it provides a base for instantiating target systems that use that common base more reliably and cost effectively. registration authority a registration authority is an authority in a network that verifies user requests for a digital certificate and tells the certificate authority (ca) to issue it. ras are part of a public key infrastructure (pki), a networked system that enables companies and users to exchange information and money safely and securely. registry directory like system that focuses solely on managing data pertaining to one conceptual entity. in an ehri, registries store, maintain and provide access to peripheral information not categorized as clinical in nature but required to operationalize an ehr. the primary purpose of a registry is to respond to searches using one or more pre-defined parameters in order to find and retrieve a unique occurrence of an entity. examples of registries include: client registry, provider registry, location registry, and consent registry. scalability the ability to support the required quality of service as load increases. security the ability to ensure that information is neither modified nor disclosed except in accordance to the security policy. security architecture a plan and set of principles for an administrative domain and its that describe the that a system is required to provide to meet the needs of its users, the system elements required to implement the services, and the performance levels required in the elements to deal with the threat environment. a complete security architecture for a system addresses administrative security, communication security, computer security, emanations security, personnel security, and physical security, and prescribes security policies for each. complete security architecture needs to deal with both intentional, intelligent threats and accidental threats. security architecture should explicitly evolve over time as an integral part of its administrative domain’s evolution. systems architecture describes how the business process models defined in the business architecture can be implemented from a systems (data, applications and technology) perspective. technical architecture – 1. a technical architecture identifies and describes the types of applications, platforms, and external entities; their interfaces; and their services, as well as the context within which the entities interoperate. the technical architecture is the basis for selecting and implementing the infrastructure to establish the target architecture. 2. the specific code plans to build an it solution is called the technical architecture. it is the it „blue print” of the planned technical roll out. 98 health systems and their evidence based development virtual private network refers to a network in which some of the parts are connected using the public internet, but the data sent across the internet is encrypted, so the entire network is „virtually” private. a vpn is a data network that adds certain quality-of-service features, at least network (vpn) privacy and security, to the internet. an internet-based system for information communication and enterprise interaction. a vpn uses the internet for network connections between people and information sites. however, it includes stringent security mechanisms so that sending private and confidential information is as secure as in a traditional closed system. web services an application capable of being defined, located via the internet protocol, and interacting with other software applications, identified by a uniform resource identifier. web services description language provides a model and an xml format for describing web services. wsdl enables one to separate the description of the abstract functionality offered by a service from concrete details of a service description such as „how” and „where” that functionality is offered. 99 electronic health records the core of the national health information system references 1. serbian health information system committee (2002). building information core national health information system. belgrade: ministry of health, republic of serbia. 2. the boston consulting group (2004). final report on national health information management and information & communications technology strategy. 3. canada health infoway inc. (2003). ehrs blueprint an interoperable ehr framework, version 1.0. available at: http://knowledge.infoway-inforoute.ca 4. mennerat f (2002). welcome at eurorec 2001. in mennerat f, ed. electronic health records and communication for better health care, proceedings of eurorec 2001, amsterdam: ios press. 5. dick r, steen e (1997). the computer-based patient record: an essential technology for health care. national academy press, washington, usa. 6. royal college of general practitioners health informatics taskforce (1998). scopeepr. rcpg. available at: www.schin.ncl.ac.uk/rcgp 7. murphy g, hanken am, waters ka (1999). electronic health records: changing the vision. w.b. sanders company, philadelphia. 8. heard s, grivel t, schloeffel p, doust j (2000). the benefits and difficulties of introducing a national approach to electronic health records in australia. report to the electronic health records taskforce. commonwealth department of health and aged care, australia. 9. iso/tc 215 technical report electronic health record definition, scope and context. third draft, december 2003. 10. iso/ts 18308:2003 health informatics requirements for an electronic health record architecture (18-05-2003). 11. beale t, heard s, kalra d, lloyd d (2002). the openehr technical roadmap. revision 1.2. the openehr foundation. 12. committee on data standards for patient safety (2003). key capabilities of an electronic health record system. board on health care services. institute of medicine. the national academies press, washington, d.c. 13. office of technology and information highway canada (2001). toward electronic health records. 14. national electronic health records taskforce, (2000). a health information network for australia. commonwealth department of health and aged care, australia. recommended readings 1. dick rs, steen eb, detmer de, eds (1997). the computer-based patient record: an essential technology for health care. iom, national academy press, washington. 2. mennerat f (2002). electronic health records and communication for better health care, proceedings of eurorec 2001, amsterdam: ios press. 3. shortliffe eh, perreault le (2001). medical informatics – computer apllications in health care and biomedicine. second edition. new york: springer-verlag. 4. van bemmel jh, musen ma (1997). handbook of medical informatics. new york: bohn stafleu van loghum, and springer-verlag. 100 health systems and their evidence based development 101 health indicators and health reporting health systems and their evidence based development a handbook for teachers, researchers and health professionals title health indicators and health reporting module: 1.4 ects (suggested): 0.50 author(s), degrees, institution(s) doris bardehle, private lecturer, dr. med. address for correspondence universität bielefeld, fakultät für gesundheitswissenschaften, arbeitsgruppe epidemiologie & medizinische statistik, universitätsstraße 25, 33 615 bielefeld germany e-mail: doris.bardehle@loegd.nrw.de keywords health indicators, health indicator sets, health reporting, hfa 21, new public health programme of the european union learning objectives at the end of the module, the students should be familiar with: • public health-oriented health data and their interpretation; • different kinds of indicator sets; • definition/characteristics of basic indicators; • use of indicators for health reporting; • use of indicator sets for policy-making. abstract this topic covers: different indicator sets; classification and evaluation methods of indicators; comparison methods and benchmarking; the use of health indicators for health reporting and health policy. teaching methods the recommended teaching method is: • study of literature and available health indicator databases in small groups (3-4 students) • guided discussion of a health indicator set for a certain region (examples) • use and presentation of health indicators in a health report • exercise: to collect data from public health databases, to prepare a health report on one topic for a certain region (e.g see or cee countries) specific recommendations for teachers it is recommended that this module be organized within 0.50 ects credit. the work under supervision consists of lecturing and use of the hfa database, while individual work will comprise the selection of a set of indicators from the hfa database and use of the data for health reporting and health policy. each of the students or at least two students need a pc with internet-connection. data on health statistics and software must be available. assessment of students essay on priority setting based on indicator analysis for a certain country/region. health indicators and health reporting doris bardehle classification and evaluation method of indicators this lecture follows the lines of the documents of who, regional office for europe, and of the european union, based on the new public health programme (2003-2008) and the former health monitoring programme (hmp): • new public health programme 2003-2008: action programme of the european union in the field of public health for the year 2003 (1). • „set of community health indicators (echi i)” of the european commission (2). • „catalogue of health indicators” of the hfa 21 health for all strategy (3). • „health interview survey” of who, regional office for europe (4). • „common minimum indicator set”. who europe. regions for health network (5). • „establishment of a set of mental health indicators for the european union” (6). • „reproductive health indicators for global monitoring”. who geneva (7). • „minimum health indicator set for ph-see countries”. final report (8). the types of different indicator sets a design for a „set of community health indicators (echi i)“ was developed by the european commission under the health monitoring programme (hmp) which contributes to the establishment of a community health monitoring system in order to: 1. measure the health status, its determinants and trends throughout the community; 2. facilitate the planning, monitoring and evaluation of community programmes and actions; 3. provide member states with appropriate health information to make comparisons and support their national health policies (2, p.5). the new public health programme of the eu replaces all former public health programmes. it will focus on three types of activity: 1. to improve the quality and transparency of health information; 2. to improve current abilities to respond rapidly to health threats; and 3. to find effective ways to tackle health determinants – the underlying causes of disease (9, p.1-3). 102 health systems and their evidence based development the new public health programme will provide policy makers, health professionals and the general public with the key health data and information that they need. the programme will primarily transmit and act on new information about health threats that require immediate action to prevent further harm. instead of concentrating on specific diseases, actions addressing health determinants will tackle the root causes of diseases or „health determinants” through effective health promotion and disease prevention measures. under the health monitoring programme, the european community health indicators (echi i) project was developed. under the new public health programme, the echi project will be continued and a final version be expected (echi ii). with regard to the preparation of the „health 21 – health for all strategy for the 21st century”, the development of a new „catalogue of health indicators” was started by who. meanwhile this catalogue has been published and contains around 200 indicators (3). indicators on reproductive health developed by who geneva relate to the health indicators’ methodological concept of who, too (7). eurostat, the statistical office of the eu is responsible for coordinating health statistics as causes of death statistics, health interviews and health examination surveys and health care data groups. population data are included in the new cronos database. via a public health portal (controlled by the commission services), health data will be presented within the eu public health information network and include databases such as euphin hiems which was established under the hmp programme and continued under the new public health programme (1). one of the sources of health indicators is the health interview survey (who europe, 1996) and the health examination survey, which have meanwhile been internationally harmonized in terms of methods and instruments used (4). meanwhile the database of health surveys conducted in the eu member states is available on the internet at url: http://www.iph.fgov.be/hishes. the survey methods, the content of the questionnaire and the examination protocol are available through the database and can be compared from one country to another. with the support of eurostat the inventory will now be extended to include the candidate countries. measurement and reporting of health conditions and actions for health improvement through „internationally agreed” indicators have been a favorite strategy of international organizations. who used this concept for promoting the health for all concept strategy (see health indicators for hfa 2000 and hfa21 (r1 and r2)). the result has been a long list of indicators to be collected by the countries and to be delivered to international organizations. the development of a minimum data set of european mental health indicators was the result of a two-year action project, aimed at establishing mental health indicators in europe, coordinated by stakes (finland) (1999-2000). under the health monitoring programme, a subset of health indicators was developed in the field of mental health indicators, published in 2002 and based on the same rules as the echi i indicator set (6). 103 health indicators and health reporting a list of 36 indicators was developed and proposed for usage in europe. the 36 indicators are divided into the following main domains: 1. demographic and socio-economic factors 2. health status 3. determinants of health 4. health systems to determine the volume of essential health indicators for monitoring the health status and health system performance lies within the responsibility of each country and has to be done in accordance with specific health policies. now new proposals have been made for health indicator sets issued by who, the eu countries and organizations which make it difficult to select a defined indicator set to be used (7,8,10,11,12). it is not proven which indicators are useful and feasible for the national health programmes’ management process. within the framework of the stability pact, a minimum indicator set was developed for the south eastern european countries which started in 2001 (8). the draft of the minimum indicator set was based on the experience made collected with the common minimum indicator set (cmis) of the regions for health network, who-euro, agreed with 8 european regions in 1999 and selected from a list of 224 indicators for the who hfa 21 strategy (5). the indicators for the pilot testing carried out in 2002 covered: • the socio-demographic profile (percent of population aged 65+ years), • mortality (life expectancy at birth, in years, males/females; infant mortality rate; maternal deaths, all causes; standardised death rate-sdr, circulatory system diseases, all ages, males/females; sdr malignant neoplasms, all ages, males/females; sdr external causes injury and poison, all ages, males/females; sdr infectious and parasitic diseases, all ages, males/females) • morbidity (number of newly diagnosed tuberculosis cases, all forms; number of decayed, missing or filled teeth at age 12) • environment (percent of population whose homes are connected to water supply system, total; percent of population with access to hygienic on sewage disposal, total) • health care resources indicators,(number of primary health care units per 100,000 population; number of hospital beds per 100,000 population; number of physicians per 100,000 population; number of general practitioners in phc per 100,000 population; number of dentists per 100,000 population; number of nurses graduated per 100,000 population) • health care utilisation and costs (average length of stay, all hospitals; total health expenditures as percent of gross domestic product) • maternal and child health (percent of infants vaccinated against diphthe104 health systems and their evidence based development ria; percent of infants vaccinated against tetanus; percent of infants vaccinated against pertussis; percent of infants vaccinated against measles; percent of infants vaccinated against poliomyelitis) this indicator set contains 30 indicators. all indicators which were included in the list, had to reflect the special situation of the south eastern european region (see). after the pilot phase, 22 of the selected indicators proved to be qualified enough to reflect the health and social as well as health care situation in the ph-see countries. 8 indicators did not meet the quality criteria for an indicator or had to be replaced because of the poor data situation. other indicators had to be added after analysing the health situation within the ph-see countries and in consideration of the main topics of health policy (8). the indicators have to meet specific criteria such as: • relevant (regarding priorities) • valid (regarding determinants of health) • measurable (in quantitative and qualitative terms) • sensitive (to changes and differences) • comparable (inter-territorial) • repeatable (for time series) • affordable (in terms of relative costs) • useful (for intervention) • ethical (e.g. respect personal autonomy) definitions for all above-mentioned indicators are available at http://www.who.dk/country/hfadbbook.pdf (r3) the following chapters will help to explain the meaning and composition of an indicator set. indicator classification and evaluation methods definitions of „health indicators” (www.who.deficrit.htm) indicators are markers of the health status, healthcare system performance or availability of resources, defined in a way to allow the monitoring of objectives, targets and performance. thus they cannot be confused with objectives and targets. objectives are statements aiming to improve health or to reduce the frequency of certain diseases, expressed in a quantitative manner, within a given time frame. targets are usually expressions of the desired service performance, for example, output or coverage, desired to be achieved at some time point in the future. indicators are defined as variables able to measure the changes in the level of health target achievement i.e. health for all (hfa) targets. 105 health indicators and health reporting indicators are used for health monitoring and health surveillance. health monitoring is defined as the maintenance or regular checking of ongoing activities or programmes with respect to predefined objectives. the purpose is to record what the system is actually achieving at present and to detect possible deviations from the decided course of action. surveillance refers to the ongoing observation of the health status of a population and the factors that may affect it, and its purpose consists in detecting possible changes at an early stage and initiating appropriate action (4, p.4). types of indicators there are three types of hfa indicators which are defined in the hfa 21 catalogue of health indicators (3). definitions and criteria are: 1. outcome (health status or death) 2. process (health care delivery and management, including resources) 3. determinant (e.g. behavioural factors and public knowledge) all hfa 21 indicators (3) can be used to measure progress towards established targets and goals, including the monitoring of changes in the health status of the population. most of them can be used to monitor service performance at the facility, district and national levels. generic indicators are broadly defined areas of measurements linked to specific parts of the hfa policy framework (hfa targets) and traditionally constitute an integral part of the hfa policy document. operational indicators are precisely defined numerical data items as recorded in the hfa statistical database (3). an indicator can be defined at the generic level, e.g. „smoking behavior”, or in an operational manner, e.g. „% of women in x age group, x smoking between y and z cigarettes per day”. operational indicators are always expressed in a numerical way, calculated from primary data in a more or less complex manner. an example of a complex calculation is „life expectancy at birth”, which is calculated from a large set of age-specific mortality data. indicators are usually numerical (rations, proportions, rates), although they can also be qualitative (e.g. existence or absence of a sign, event, etc. that has been shown to be important). quality criteria for health indicators with regard to the selection of indicators, the following prerequisites are necessary: • the actual selection and definition of indicators within a specific public health area should be based on scientific principles. • indicators (and underlying data) should meet a number of methodological and quality criteria concerning e.g. quality, validity, sensitivity and comparability. 106 health systems and their evidence based development • the probability of changing policy priorities/interests calls for a high degree of flexibility, made possible through current electronic database systems. • the selection of indicators should be based on existing and comparable data sets for which regular monitoring is feasible, but should also indicate data needs and development areas (2). the quality of indicators will be measured according to the following four criteria: 1. validity: i.e. it is a true expression of the phenomena it is measuring; 2. objectivity: i.e. it is able to provide the same result if measured by different people under similar circumstances; 3. sensitivity: i.e. it is capable of reflecting changes in the phenomena of interest; 4. specificity: i.e. it reflects changes in the specific phenomena of interest only. additionally, the following criteria are relevant for the use of an indicator and the methodology employed to collect the data: • the data required for the indicator are useful for case management or taking action in the community for the staff who originally recorded the data, or the service unit from which the data originated. • it should be feasible to obtain the data needed for each indicator and that these data should be generated, as far as possible, through routine service processes or through easily and rapidly executable surveys. • the indicators should be simple and understandable, measuring a health condition or aspect of service. composite indicators should be avoided. • the indicator and the process of collecting and processing the relevant data are ethical (3). health indicators serve several purposes: 1. they are an important tool of for health policy formulation and implementation. 2. they are used to track progress, i.e. they are used for monitoring and evaluating the health situation with respect to specified objectives. 3. they can provide yardsticksbenchmarks whereby countries can compare their own progress with that of other countries, especially those at similar levels of socio-economic development. 4. they cannot be measured at present because no adequate information is in place; they are nevertheless adopted for use because they point to what needs to be done (guidance for action, including information systems’ development). 107 health indicators and health reporting 5. indicators have a communication and coordination function: for example, when decided in a proper consultation process they constitute an important message to the community about agreed priorities (4, p.7). main categories of an indicator set the following main categories of a set of community health indicators (echi indicator set) were proposed: 1. demographic and socio-economic factors 1.1. population 1.2. socio-economic factors 2. health status 2.1. mortality 2.2. morbidity, disease-specific 2.3. generic health status 2.4. composite health status measures 3. determinants of health 3.1. personal and biological factors 3.2. health behaviors 3.3. living and working conditions 4. health systems 4.1. prevention, health protection and health promotion 4.2. health care resources 4.3. health care utilization 4.4. health expenditures and financing 4.5. health care quality / performance the european commission (2, p.12) developed a concept according to which indicators can be divided into the following categories: 1. cockpit information: to have a quick view on the major trends in public health, including recent relevant signals, for medium or long-term policy strategies; 2. eu priority list: to follow developments for specific eu policy areas or targets, programmes or projects; 3. the who / hfa 21 indicator set: to follow this list of indicators for the eu countries; 4. health and services for mother and child: to focus on reproductive health, health of children and family structure. 108 health systems and their evidence based development who regional office for europe revised the indicator list during the transition period from hfa 2000 to health 21 (3). the main change was a reduction in the total number of generic indicators from 112 to 59. about 50 indicators from hfa 2000 have been maintained and 9 new indicators have been adopted. the current indicators will cover such fields as: • health status, • health determinants, and • socio-economic background. the operational indicators of the health 21 strategy are divided into the following groups (3, p.5): mortality, morbidity, disability, maternal / child health, other health status indicators, lifestyle, environment, health care resources, health care utilization, quality of care, health expenditure, and demographic and socio-economic indicators. data for indicators are being collected from various sources (hfa 21). the main information sources are: • comprehensive statistical records already established for health or other purposes • ad hoc investigation or surveillance systems within the health services and • population surveys all efforts are made to use information from available sources to avoid duplicating requests to countries. in 1988, 1990 and 1992 the who regional office for europe and statistics netherlands organized consultations to develop common methods and instruments for a health interview survey at the european level (4). the objective was that this health interview survey should be used countries in order to achieve better international comparability and enhance the value and use of survey results. 109 health indicators and health reporting recommended instruments for health interview surveys are: 01. perceived health 02. temporary disability 03. long-term disability 04. disability-free life expectancy 05. chronic conditions (mental) 06. smoking 07. physical activity 08. birth weight 09. breast-feeding 10. body-mass-index 11. socio-economic classification (education, wealth, income, occupation, economic position). methods of comparison and benchmarking the application of statistical methods will be the subject of other parts of the curriculum. to complete the establishment of indicator sets and use of health indicators, it has to be mentioned that comparability must be guaranteed with the help of the following methods. the use of statistical methods for comparing data of different regions includes: • age standardisation incl. calculation of confidence intervals, • significance check-ups, • definitions of the included regions concerning the application of further statistical methods, • calculations such as „pyll: person years life lost“, • calculations for time trends, and • meta-database description of the data used incl. definitions. the use of health indicators for health reporting today, various methods are used for health reporting: • indicator-based health reporting on the basis of a well-defined indicator set, periodic health reporting is done to follow the indicators and trends. changes of in the indicator level are analysed and described within the different chapters of periodic health reporting. • indicator sets and their use for health reporting for writing health reports with the help of experts or for special topics (e.g. women’s health) a part of the indicators sets can probably be used, but usually not the complete indicator set. the advantage consists in the flexibility of the reporting, the disadvantage is the discontinuity of a frame for reporting such as „health situation in south eastern europe”. however, within the stability pact a report based on 110 health systems and their evidence based development the minimum indicator set for south east european countries was produced in 2003 (8) and can serve as a model for future similar reports aiming to support the decisionmaking process in the area and to track progress of these countries towards the goals of integration in the european union. • health targets, health indicators and health reporting who prefers health reporting on the basis of health targets. the advantage is the good tracking of the targets. a good example is the uk model or the „healthy people” strategy of the united states (www.health.gov/healthypeople). the disadvantage lies in the time-consuming process of formulating common targets for several countries. also the establishment of an indicator set with benchmarking criteria based on health targets takes a lot of time and is a difficult undertaking. some targets may change in the course of the years and so you have to change your indicator set, too. here who has made some experience. thus the indicators of based on the new strategy hfa 21 are more „generic” and less „operational”. a review on health target settting in 18 european countries (13) demonstrated that health for all strategy has influenced the health policy of almost all of the 18 countries. 111 health indicators and health reporting exercise: health indicators and health reporting task 1: after being familiar with the hfa software, students are asked to select a set of relevant indicators from this database and to prepare a report describing the situation from a certain country/region for the purpose of priority setting. time: 120 minutes. task 2: students are asked to search the minimum indicator set (10) and make comparisons between see countries (e.g. in life expectancy at birth, infant mortality rate and sdr due to different causes) and try to find possible explanations. task 3: review existing national data sources (available in your country) and look for available indicators also describing the local levels (e.g district, country, etc.) and make geographical comparisons. commonly, reports or databases are reported by national statistical institutes/bureaus and institutes of public health. 112 health systems and their evidence based development references 1. european union, health and consumer directorate general. new public health programme 20032008. available from url: http://europa.eu.int/comm/health/ph_programme 2. european community. design for a set of european community health indicators (echi). final report by the echi project. bruxelles. european commission; 2001. 3. who, regional office for europe. who hfa indicators for the new health policy for europe. the hague, netherlands, 2-3 march 2000. copenhagen: who, regional office for europe; 2000. eur/00/501872 unedited. 4. who, regional office for europe. health interview survey. towards international harmonization of methods and instruments. copenhagen: who; regional office for europe; 1996. 5. institute of public health north rhine-westphalia. common minimum indicator set (cmis). who europe: regions for health network. bielefeld: institute of public health north rhine-westphalia; 2001. 6. european commission. establishment of a set of mental health indicators for european union. final report. project under the health monitoring programme of ec. bruxelles; 2002. 7. who. reproductive health indicators for global monitoring. report of the second interagency meeting. who geneva 17-19 july 2000. geneva: world health organization; 2001. 8. zalatel-kragelj l, bardehle d, burazeri g, donev d, laaser u. minimum health indicator set (mhis) for ph-see countries. final report. bielefeld: ph-see programmes for training and research in public health. bielefeld; 2003. available from url http://www.snz.hr/ph-see/docs.html 9. european commission. health and consumer protection directorate general. consumer voice. 2002; (3)april. 10. tamburlini g, ronfani l, buzzetti r. development of a child health indicator system in italy. european journal of public health 2001; 11(1): 11-17. 11. conference of the health ministers of the german states. indicator set for health reporting for the german states. 3rd ed. bielefeld: institute of public health nrw; 2003. (content and list of indicators in english) 12. rognerud m, stensvold i, hesselberg o, lyshol h. the national health indicator system and the data base norgeshelsa in year 2000. forkhelsa institute. oslo: national institute of public health (folkehelsa); 2000. 13. herten l v, water hpa v.d. health policies on target? review on health target settings in 18 european countries. european journal of public health 2000. supplement; 10(4): 11-16. databases for health indicators who: r1 synopsis of hfa-indicators at who-euro in copenhagen: http://www.who.dk/cpa/pb9912e.htm r2 hfa statistical database at who-euro: http://www.who.dk/country/country.htm r3 manual with description of hfa-indicators: http://www.who.dk/country/hfadbbook.pdf r4 country profiles based on hfa-indicators: http://www.who.dk/country/country.htm r5 euphin east network indicators: http://www.euphin.dk/hfa/phfa.asp r6 indicators in the healthy cities network (including questionnaire for data collection): http://www.who.dk/healthy-cities/pdf/quest.pdf eu & oecd: r7 european community health indicators (echi): description of project: http://europa.eu.int/comm/dgs/health_consumer/library/tenders/call26_9_en.pdf r8 eurostat health indicators as a section of the area „population & social conditions”: http://europa.eu.int/comm/eurostat/public/datashop/print-catalogue/en?catalogue=eurostat r9 oecd statistical portal / health statistics (excel tables): http://www.oecd.org/oecd/pages/home/displaygeneral/0,3380,en-statistics-194-5-no-no-no-194,ff.html r10 european community. health interview and health examination survey databases http://www.iph.fgov.be/hishes/ 113 health indicators and health reporting 114 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title quality of life: concept and measurement module: 1.5 ects (suggested): 0.50 author(s), degrees, institution(s) asis. zorica terzic, md, msc.¹ asis. bojana matejic, md, msc.¹ ¹ teaching assistant at the school of medicine, university of belgrade, serbia and montenegro address for correspondence zorica terzic, institute of social medicine, school of medicine, belgrade university dr suboti}a 15 11000 belgrade serbia and montenegro tel: +381 11 643 830 fax: + 381 11 659 533 e-mail: vlazo970@yahoo.com keywords quality of life, health related quality of life, measuring quality of life, sf – 36, minnesota questionnaire learning objectives after completing this module students and public health professionals should have: • increased their understanding and knowledge of quality of life and measuring quality of life • get knowledge about differences among global, generic and specific instruments of quality of life • improve their skills in processing the short form, sf 36 abstract public workers and media use the term quality of life (qol) related to the environment, physical and social: air pollution, soil and water pollution, living standards, and crime rates. the qol term is used in philosophy literature, sociology, geography, health economics, medicine, psychology, and pharmaceutics industry. during the last years, quality of life is said to be „overwhelming” or „global”, it is separated from the term health related quality of life. measuring qol is important because it is used for decision making especially about non-clinical aspects of disease, for improvement of the doctor – patient relationship, in discovering of functional and psychological limitations, in choosing the treatment in initial phase of disease, when the efficiency of a applied therapy is temperate (for example remedies just modify a disease). measuring of quality of life and health related quality of life (hrqol) could be: unidimensional and multidimensional. measuring qol and hrqol can be: global and specific (specific in relation to disease and in relation to medical treatment). teaching methods teaching methods include lectures, students individual work under the supervision of teacher and interactive methods such as small group discussion. before introductory lecture, the small exercise could be organised as brainstorming (“what is quality of life for you?”), in order to increase students’ motivation for learning and interest in the content of the module. after the introductory lecture 115 quality of life: concept and measurement students will work individually on comparison of dimensions among global, generic and specific instruments. students should discuss in small groups what kinds of dimension of quality of life are in the general and specific instruments. they would also have opportunity to search through the internet under the supervision of teacher in order to explore some of the web site concerning qol and some bases of the quality of life questionnaire. specific recommendations for teachers teacher should be familiar with the process of sf-36 and minnesota questionnaire analysis, especially standardization procedure and cultural adaptation. assessment of students multiple choice questionnaire. quality of life: concept and measurement zorica terzić, bojana matejić definition of quality of life and health related quality of life in everyday speech quality of life (qol) suggests many outer conditions and personal features. because of them an individual can feel satisfaction and dissatisfaction, he/she can plan keeping or changing the conditions one lives in. public workers and media use the term related to the environment, physical and social: air pollution, soil and water pollution, living standards, and crime rates (1). the qol term is used in philosophy literature, sociology, geography, health economics, medicine, psychology, and pharmaceutics industry. during the last years, quality of life is said to be „overwhelming” or „global”, it is separated from the term health related quality of life, so the consensus has been reached among experts on two important issues in the health related quality of life (hrqol) field (2,3): • it is recognized that the patient rather than a doctor or a nurse is the best source for obtaining hrqol information. • hrqol is viewed as a multidimensional concept, which should include the four primary dimensions: physical functioning, encompassing self-care activities (eating, dressing), physical activities (walking, climbing stairs), and social activities (working, household, school); physical symptoms related to the disease or treatment (pain, diarrhea, neuropathy); psychological functioning, including emotional state and cognitive functioning; social functioning referred to the activities and association with friends, relatives and other acquaintances. there are many definitions for qol term, because of different approaches while considering it. its meaning is differently explained and it depends on the user’s age and position in social and political structure (4). qol definition can be separated in general definitions, definitions specially related to health, and qol definition specially related to disease (5) (table 1). 116 health systems and their evidence based development table 1. general definitions and definitions specifically related to health and disease 117 quality of life: concept and measurement author global definitions calman, 1984 (6) the extent to which hopes and ambitions are matched by experience. ferrams and powers, 1985 (7) an individual’ s perceptions of well-being that stem from satisfaction or dissatisfaction with dimensions of life that are important to the individual. grant et al, 1990 (8) a personal statement of the positivity or negativity of attributes that characterizes one’ s life. author definitions specifically related to health schipper, 1990 (9) a pragmatic, day to day, functional representation of a patient’ s physical, psychological, and social response to a disease and its treatment. cella and tulsky, 1990 (10) patient’s appraisal of and satisfaction with their current level of functioning as compared to what they perceive to be possible or ideal. gotay et al, 1992 (11) a state of well-being which is a composite of two components: the ability to perform everyday activeties which reflect physical, psychological and social well-being, and patient satisfaction with levels of functioning and the control of disease and/or treatment related symptoms. whoqol group, 1993 (12) quality of life is defined as an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. it is a broad ranging concept affected in a complex way by the person’s physical health, psychological state, level of independence, social relationships, and their relationships to salient features of their environment. testa and simpson, 1996 (2) the physical, psychological, and social domains of health, seen as distinct areas that are influenced by a person’ s experiences, beliefs, expectations, and perceptions. author definitions specifically related to disease cella and tulsky, 1990 (10) hrqol is more specific and more appropriate term than quality of life, because it refers to patients’ assessment and satisfaction of their current level of functioning with it compared to what they consider to be possible or to be ideal. padila et al, 1998 (13) the term hrqol, connotes a personal, evaluative statement summarizing positive and negative attributes that characterize one’ s psychological, physical, social, and spiritual well – being at a point in time when health, illness and treatment conditions are relevant. measuring quality of life measuring qol is important because it is used for making decisions especially about non-clinical aspects of disease. it is also used for improvement of the doctor – patient relationship. it is important in discovering of functional and psychological limitations, in choosing the treatment in initial phase of disease, when the efficiency of applied therapy is temperate (for example remedies just modify a disease). it is also important when you chose therapies that are little different, when you chose among a few efficient, different, clinical therapies, when there are dilemmas in applied therapies because of toxins, costs as well as for supplying information about using resources (16,17). measuring of quality of life and health related quality of life could be unidimensional and multidimensional (18,19). unidimensional measuring refers to one dimension hrqol. when they are used in clinical researches they can limit clinical information. they can show whether the treatment improves qol, but they do not speak about the way of improvement. multidimensional measuring is used in clinical researches. qol assessment based on multidimension is important when there is a little information about the effects of a disease and/or treatment of a disease (20). multidimensional measuring in the informal way points out which health intervention justifies invested money, but they can not be used for cost benefits analysis (21). also, measuring qol and hrqol can be: global and specific (specific in relation to disease, and in relation to medical treatment) (18,19). global measuring is used in general population to measure health status of population and to compare different health conditions or diseases. they are also focused on the basic human values such as emotional well-being and on the possibility of everyday functioning (2,22,23). specific measuring is related to the domains, which are important for a disease; and for different states, that has priority for a patient. most usually they are used in clinical researches of drugs or therapeutics’ intervention (2). 118 health systems and their evidence based development van schayck, 1998 (14) this concept, hrqol is used to description of how patients experience their disease, actually how the severity of disease has possibly decreased the quality of life. patric and erikson, 1998 (15) hrqol is the value assigned to duration of life as modified by the impairments, functional states, perceptions, and social opportunities that are influenced by disease, injury, treatment or policy. if hrqol is included in the clinical research, it has three important characteristics. first of all, the researchers, doctors, describe given conditions or a disease in terms, which are clinically important, and the patient can understand them easily. the second thing is that hrqol domains can be independent predictor of the important clinical results – such as observing treatment, morbidity and mortality. these data insure precious consideration in history and prognoses of different states and diseases. the third thing, we can get data about the treatment, which determine individual daily functioning from the patient’s point of view, what we can get or lose during the therapy. this can help a doctor to make decision to modify specific elements of therapy such as drugs, consultative health care, education of patients or help to the service (24,25). all these information should be added to the information that the doctor gets during physical examination, laboratory tests and medical history. however, measuring hrqol is used in small number of clinical researches as a primary goal, although quality of life is often better prognostic indicator than factors connected to the disease or treatment (18). measuring qol (and health related quality of life) can be done into three domains, that agrees with the health definition who: physical functioning (that includes symptoms, functional difficulties), psychological state (emotional and cognitive functions) and social interaction (work, daily activities, public relations). in case that measuring does not include one of these domains, hrqol has negative assessment. however, number of dimensions can be much bigger (26). measuring qol is not direct. an individual gives attributes (characteristics) that are measured and in the case of qol that would be the level of physical functioning, mental health or social functioning (27). measuring qol must take into consideration subjective indicators (based on self-assessments). subjective measuring qol depends on personal preferences about determinants that are individual qol. that is so called ‘inner state’ of qol. there are also ‘outer aspects’ of qol that are evaluated by self-report (obviously subjective) and by observing (obviously objective) (28). the subjective indicators represent all nonbiological factors that have influence on the recovery and they include patient’s psychology, motivation and therapy acceptance, socioeconomic status, health protection, welfare work, personal and cultural convention and behavior (29). indicators based on the patient are not in the indispensable correlation with the objective measures (for example: level of physical functioning) (30). they are more and more popular because of the importance of patient’s satisfaction. it is also important what an individual feels in relation to what the statistics says that the individual should feel (31). 119 quality of life: concept and measurement subjectivity is the key element in the assessment and measuring qol. ‘subjective experiences’ are usually signified as potentially „soft data” or „soft science” contrary to the objective data. that are represented as „hard data” or „hard science” (17,32). the instruments for measuring quality of life the instruments for measuring qol are multidimensional, complex and indirect. multidimensionality demands combination of different terms and domains. complexity means simple questions or sums (they refer to the measured term) that are grouped into subscales, and the subscales form wider scales. casual effects that appear indirectly are connected to the variability, which can be in relation to the questionnaire respondents and the period needed for questioning (33). the instruments for measuring quality of life can be global, generic and disease specific. global measures (instruments) are designed to measure qol in the most comprehensive or overall manner. this may be a single question that asks the respondent to rate his/her overall qol or this may be an instrument such as the flanagan quality of life scale that asks people to rate their satisfaction in 15 domains of life (34). generic measures (instruments) have much in common with global measures, but they are designed primarily for description. they are used in general population for the assessment of health status, different conditions or diseases. usually, they are not specific for a particular disease or vulnerable population of patients and they are much more useful in general health researches, comparisons of different diseases and several studies. general instruments include large number of quality of life dimensions but at first place physical, mental and social dimension (2,34). deficiency of generic instruments is (35,36,37): – they are unable to identify condition – specific aspects of disease that are significant for the measurement qol – if the data is necessary for major number of conditions, the instruments would have to be of enormous length – an addition to specific instruments for a disease is needed to detect important clinical changes 120 health systems and their evidence based development table 2. generic instruments for measuring qol disease specific instruments are orientated on the domains most relevant to the disease, condition or characteristics of patients in whom the condition is most prevalent. they use of a particular treatment or clinical trial and they may be called „treatment specific” or „trial specific”, apropos by one name „situation – specific” (38). 121 quality of life: concept and measurement generic instruments for measuring qol author, year quality of well-being scale qwbs fanshel & bush, 1976 sicknes impact profile sip gilson & bergner, 1976 (revidirana 1981) mcmaster health index questionnaire mhiq chambers, 1976 nottingham health profile nhp hunt et al, 1985 medical outcomes study (mos) short form 36 – item mos – sf 36 ware, 1992 medical outcomes study (mos) short form 12 – item mos – sf 12 ware, 1994 assessment of quality of life aqol hawthorne & richardson comprehensive assessment and referral evaluation care fretwell eq – 5d eq – 5d euroqol group, 1991 dartmouth coop function charts coop c dartmouth coop project, 1987 visual analogue scale vas fryed, 1923 functional limitations profile flp patrick general health questionnaire ghq goldberg&williams, 1978 health and daily living form hdl moos health measurement questionnaire hmq gudex & kind healthy people 2000 years of healthy life hp 2000 erickson, 2000 health status questionnaire 2.0 hsq rand corporation, 1976 quality of life questionnaire-evans qlq e evans & cope symptom checklist-90-revised (scl90-r) care derogatis schedule for the evaluation of individual quality of life seiqol o’boyle & mcgee, 1994 who quality of life assessment whoqol whoqol, 1993 group, who specific instruments are needed for their homogeneity/brevity, and to ensure sensitivity for sometimes small, but clinically significant changes in health state and intensity of a disease (31). the recommendation is to use the combination of generic and specific instruments in the case when an overall qol instruments are not satisfied for specific diseases (31). quality of life instruments database (qolid) is made in the joined project of the french mapi institute and the italian national institute for cancer. this base contains 1000 globals, generic and specific questionnaires. generic measuring instruments are represented in the table 2. some of the specific measuring instruments selected on the number of performed cultural adaptations are represented in the table 3 (39,40). table 3. specific instruments for measuring qol 122 health systems and their evidence based development specific instruments for measuring qol cardiovascular diseases minnesota living with heart failure questionnaire mlhf seattle angina questionnaire saq angina battery gastroenterology inflamatory bowel disease questionnaire ibd qol personal health survey (hepatitis) 2 – item chromic idiopathic constipation cis 2 irritable bowel syndrome qol ibsqol battery respiratory diseases st george’s hospital respiratory questionnaire sgrq chronic bronchitis questionnaire chrobron adult asthma qol questionnaire aqlq rheumatology osteoporosis and qol ostop battery osteoporosis targeted – qol questionnaire optqol health assessment questionnaire haq endocrinology impact of weight questionnaire iwqol diabetes impact measurement scale dims experience of treatment benefits and barriers etbb diabetic foot ulcer scale dfus 123 quality of life: concept and measurement neurology quality of life for patients with newly diagnosed newqol quality of life in epilepsy qoli-3 side – effects and life satisfaction inventory seals functional assessment of multiple sclerosis fams psychiatry psychological general well – being index pgwbi drug attitude inventory dai wisconsin quality of life index wqli sleep jebnkins sleep questionnaire mos sleep module questionnaire mos – sleep mos sleep questionnaire (short version: 6 items) sexuality erectile dysfunction quality of life questionnaire ed mos sexual function mos – sexual sexual function index (male) gynecology women’s health questionnaire whq menopause quality of life questionnaire meqol quality of life in menopause meno pediatric pediatric asthma qol questionnaire paq pediatric rhinoconjunctivitis qol questionnaire rcqlq dermatology hair growth questionnaire infant’s eczema life quality index ielqi children’s dermatology life quality index cdlqi oncology quality of life index qli – ostomy europen organization for research and treatment of cancer’s quality of life questionnaire 30 eortc – qlq – c30 europen organization for research and treatment of cancer’s quality of life questionnaire 33 eortc – qlq – c33 generic questionnaire sf – 36 the example of generic instruments of quality of life is sf – 36. the sf – 36 was developed in the united states in the late 1980s as part of the medical outcomes study (mos), a longitudinal investigation of the selfreported health status of patients with different chronic conditions. the questionnaire enables an acceptable, psychometrically correct and efficient way to measure the quality of life from the patient’s point of view through answers to questions from a standardized questionnaire. the sf – 36 questionnaire was constructed to measure eight most important health dimensions by using eight groups of questions. the groups include two to ten questions and each of them offers several responses in the form of two levels, three levels and five level scales (41). the sf – 36 questionnaire consists of 36 questions, and 35 questions of them are grouped in eight dimensions: physical functioning, role – physical, bodily pain, general health, vitality, social functioning, and role – emotional and mental health. one question is not included in these eight dimensions and it is observed independently. it concerns health change compared to the status one year ago, is current health better, whether it is the same or worse, unlike all other questions that refer to the period of the previous four weeks (41). physical functioning dimension has 10 questions, and it refers to the possibility of practicing different physical activities during a typical day and the level of limits in those activities provoke by current health status. these activities are: vigorous activities (running, lifting heavy objects, participating in strenuous sports), moderate activities (moving a table, pushing a vacuum 124 health systems and their evidence based development urology incontinence qol questionnaire coat benign prostatic hyperplasia urolife benign prostatic post – operative pain hypertrophy impact index bphii pain migraine specific quality of life questionnaire mig16 pain management satisfaction questionnaire pop2 post – operative pain pop aids mos hiv sf – 30 citomegalovirus specific questionnaire cmv cleaner, bowling or playing golf), lifting or carrying things, climbing stairs, bending, kneeling or stooping, possibility of walking and self-care (bathing or dressing). physical role dimension comprises four questions. the questions refer to problems with work or other regular daily activities as a result of your physical health. dimension body pain is based on two questions: one question concerns the existence of body pain and its intensity during the past 4 weeks, and the other question concerns interference of pain with normal work outside the house and housework. dimension general health has five questions. the questions refer to the assessment of current health, and the respondent’s opinion about the accuracy of certain claims about resistance to illness, health prognosis and opinion about present health. dimension vitality consists of four questions, that refer to how the patients felt and how successful they were in doing things during the past 4 weeks and how much of the time they feel like that (all the time, most of the time, a good bit of the time, some of the time, a little of the time, none of the time) during that 4 weeks. the questions include the exhaustion, tiredness, feeling that they are full of life and the assessment of their energy. dimension social functioning consists of two questions, the one question concerns on interfered physical health or emotional problems with usual social activities with family, friends, neighbors or other during the past 4 weeks, and the other question refers to the period of limitation, i.e. the negative effect of damaged physical or emotional health on social activities, such as visiting with friends or relatives during the past 4 weeks. dimension role – emotional represents three questions concerns on problems with work or other regular daily activities as a result of any emotional problems, such as feeling depressed or anxious in the past four weeks. dimension mental health comprises five questions that refer to the presence of anxiety, sadness, peace, depression and happiness and how long they were feeling like that. standardization procedure of sf – 36 the standardization and scoring are basic procedures in the interpretation of the sf – 36 questionnaire whose comparison of results among studies 125 quality of life: concept and measurement makes possible. there are two reasons for conveying standardization. first, to enable scoring with same reliability and validity as reported in medical outcomes study (mos) publications. the second reason is enabling the comparison of results between all studies that are using the standardization content and standards for scoring (41). scoring questionnaire sf – 36 is conducted through several steps: entering data, recording out-of-range item values as missing, reverse scoring and/or recalibrate scores for 10 items, recording missing item responses with mean substitution (where warranted), computing raw scale scores, transformation of raw scale scores to 0 – 100 scale, performing scoring checks (41). specific questionnaire – the minnesota living with heart failure (mlhf) the example of the specific instrument is minnesota living heart failure (mlhf). the mlhf questionnaire was arised for need that through self-assessment evaluated the answer for applied therapy in the case of heart failure. several criteria were used for developing the questionnaire mlhf (42). the first criterion is used for the questionnaire which should measure what it is defined to. the second one: the questionnaire should be applied in clinical practice. the third one: the numeric values are assigned to responses. the fourth one: the score is reliable during the stable clinical condition, so that it can identify the changes during interventions. there is also the fifth one: the questionnaire is valid measure of the quality of life. in relation with the other specific instruments which measure qol of patients with heart failure, its advantages are (43): • it includes optimal number of questions about physical activities, which at the same time can demonstrate even the different degree of limitations during physical activity. • at the same time, it also follows dispnea and fatigue during the specific activities, as well the other signs and symptoms of a disease. • patient’s point of view is also included in the score about the importance of different symptoms. • the only specific instrument which has represented itself as being reliable in double blind clinical trials. the questionnaire mlhf consists of two parts; first one is instruction for use and intended for the researchers, and second one is the questionnaire itself. 126 health systems and their evidence based development the instructions are given to the researcher to help him interview patients and how he can process the results. the questionnaire should be selfadministered or researcher may read it directly to the patient, before any medical intervention, so that we can get whole impression about patients’ health condition before applied medical intervention. the patient should have enough time to fulfill questionnaire and he should not be disturbed. before, the participants started responding, the instructions should be given: you should read the introductory paragraph at the top of the questionnaire and explain the way the questionnaire should be completed. you should emphasize that all the questions are about the changes caused by heart failure. the questionnaire itself consists of the introductory paragraph and 21 questions with answers. introductory paragraph emphasizes that all the changes caused by heart failure happened during the last month. the questions refer to present disease symptoms (short of breath, fatigue, outworn, loss of energy), signs of heart failure (swelling ankles, legs), limitations caused by disease (difficulties during climbing stairs, working around the house, going away from house, difficulties in earning for living, in relations with family and friends, difficulties while making recreation, pastimes, sports and hobbies, sleeping and sexual problems, taking rest during the day, eating less). it also includes questions about staying in hospital, medical car costs, medications’ side effects as well as emotional problems (their feeling that they are burden to the family or friends, loosing self-control in their lives, presence of worriness, depression, and difficulties to concentrate or remember things). the answers are represented as six grade scale from „no” (0) over very little (1) to very much (5). lower values are the signs of better life quality. the steps in the cultural adaptation: an example of serbian minnesota questionnaire the cultural adaptation demands use of a proper language so that the translated questionnaire should be conceptual equivalent to the original and clear and understandable for a patient. the conceptual equivalence means that the translation should faithfully reflect the (items) notions investigated in the questionnaire, without repeated interpretation the original formulation of the questionnaire and without limitation of original means. during this, we face several problems and these are ambiguous words in the questionnaire and impossible translation for a certain english term. if a formulation in the original questionnaire is ambiguous, than mapi research institute solves that ambiguousity by asking the author for cla127 quality of life: concept and measurement rifications, in order to know exactly what is the concept investigated in the original and consequently in the translations. if there is not equivalent in the target language (in this case – serbian) for an english term in the original questionnaire then the word closest in meaning to the original word should be chosen in the target language. in the case that the english term cannot be replaced by 1 word only, than is better to use 2 or 3 words instead, that could cover the meaning of the original term. the comprehension of the language used means to use simple, clear and easily understandable words, expressions and sentence structures. also, the recommendation is to use the expressions, which are used in everyday language. actually it is better to use expressions from everyday language than the expressions which could be found in the books and newspapers. this recommendation should be achieved, because it deals with the population of patients with high level of education (university educated). also, if there are two expressions, which are easily understandable, we should use the expression more frequently used in everyday speech. on respecting these rules, in some cases it happens that grammatically incorrect language structure is used. it might happen, that grammatically correct expressions need request complex and massive structure, which are never used in everyday conversation. than, we can use expressions, which are very often used in conversation, but they are not completely grammatically correct. also, it’s possible that a literal translation of the original questionnaire refers to the same concept as in the original, and at the same time it is clear and easily understandable. such literal translation should be kept. the process of cultural adaptation (translation) is implemented through three steps: forward translation, backward translation and patient testing. forward translation forward translation consists of a few phases: engagement of two profession translators, making reconcile – the first intermediary version (forward translation), making the report for mapi research institute and making the final first intermediary version. the native language of the engaged professional translators must be serbian and their english must be very good, too. they are independent in translating instruction for use and the questionnaire (instruction for filling, 128 health systems and their evidence based development original questions and responses) and they produce two version of forward translation (every translator gives an independent forward translation). the reconciled – first intermediary version is created during the meeting of both translators and the local project manager (author of this paper). the translators compare their translations among themselves and compare them with the original questionnaire. the aim is to produce a conceptually equivalent translation of the original questionnaire and the language used which should be colloquial and easily understandable. the project manager makes the report for mapi institute for each question in english. also, the project manager explains translation problems, difficulties in translation, offers and accepts solutions and options of the first reconciled intermediary version of forward translation, explaining translation problems, disagreements of the translators in the translation, offered and accepted solutions. the final reconciled, intermediary version of the translation arises after the mapi institute has analyzed the report and after their suggestions have been loaded into the first intermediary version. backward translation the forward translation implies a few phases: the engagement of the professional translator, making backward translation, loading the changes into the first intermediary version, making the report for mapi institute and making the second intermediary version. the native language of the engaged professional translator must be english and his serbian must be very good, too. his task is to translate the first reconciled intermediary version of forward translation into english as more literal as possible. the translator must not see the original english questionnaire before he begins to translate. backward translation emphasizes disagreements and differences (that exist) between the first intermedialy version and the original questionnaire. this is achieved by translating the backward translation and the original questionnaire. the aim of the meeting between project manager and translator is: to go carefully though the whole questionnaire, question by question, sentence by sentence and make comparison of three documents (the backward translation into english, the english original questionnaire and the first intermediary version for each single part of the questionnaire). the differences that the project manager and translator of backward 129 quality of life: concept and measurement translation should notice when making the comparasion should be: faulty backward translation, faulty forward translation and structural differences between backtranslation and the original questionnaire. the revision of the whole questionnaire was made at the meeting between the project manager and the translator. also, project manager establishes the changes that should be made to the first intermediary version. the first intermediary version with the report of modification after backtranslation, and the backtranslation itself are sent to the mapi institute. the report should mention all the discrepancies between the backtranslation and the english original as well as the explanations of all fond differences caused by faulty backward translation or faulty forward translation or structural differences between backtranslation and the original questionnaire. also, the report should mention the explanation of the changes that have or have not been brought in the first intermediary version. mapi institute reviews the backtranslation and report. all disagreements with respect to the original questionnaire are discussed with the local project manager. the second intermediary target (serbian) version arises after agreement on all the changes that were made into the first intermediary version. patient testing or cognitive debriefing this step, patient testing, includes: testing of the second intermediary version of the questionnaire, making reports for mapi institute, acceptance of the second intermediary version or making the third intermediary version that would be more clear than the previous one and more acceptable for all persons who use it. mapi institute should engage translators whose native language is serbian and their task is to make the final version of the questionnaire. the aim of the patient testing is: to test the comprehension and acceptability of the second intermediary version; to identify questions that are problematic as well as the reason for it; and to write down possible suggestions for understanding the formulation of questions. the second intermediary version questionnaire is tested on a panel discussion, face to face with 5 patients who are suffering from heart failure. the idea was to choose five patients who would be representatives of patient population in our country. there are following criteria that are recommended while choosing patients: their education, profession and age. when we speak about education, it is better that patients are with lower 130 health systems and their evidence based development level of education. previous experiences have shown that people with a high level of education (professors, teachers, scientists, and doctors) never have difficulties in understanding while testing the questionnaire. it is preferable to have patients from several professional groups, but this should not be in contradiction with their education. the role of the project manager is to discover all misunderstanding or misinterpretations and to identify words or wordings that may be inappropriate and to write down. for the project manager is also important to express patient’s feeling when answering some questions (face expression shows agreement or disagreement). throughout panel discussion project manager asks questions to the respondents about their general impression about questionnaire: is it globally clear, easy to understand, easy to answer, is it too long, is it adapted for the condition, are the instructions clear? after that, together with patients, he goes through to whole questionnaire, question by question and checks: • are the questions difficult for understanding? if so, why? • are the offered answers clear and consequent with the questions? • is the primary concept of questions interpreted correctly? is there ambiguous formulation that would make more than one possible interpretation? • is the language used easy to understand and is the language used as daily speech? then the project manager makes one independent report of the panel discussion. he has to explain suggested changes that project manager finds to be relevant and the changes he suggested to be kept. after the report has been examined and after discussion of patient testing results with mapi institute, the third intermediary version of the questionnaire is made by integration of all changes into next intermediary version. it is also possible to keep the second intermediary version if there are not any significant changes. mapi institute engaged two local translators whose native language is serbian and their english is also very good, so they can translate the third (or second) intermediary version (serbian) of questionnaire in english. during the meeting of these two translators they compare translations to the original. 131 quality of life: concept and measurement changes that local translators suggest are discussed with project manager. the final version of the questionnaire is created and it is based on the results of this discussion. 132 health systems and their evidence based development exercise: measuring quality of life the purposes of the exercises are to provide students with basic information about quality of life and measuring quality of life. task 1: comparison of dimensions between generic and specific instruments students work individually. the students are given the generic questionnaires sf – 36, sf – 12, sf – 8 and specific minnesota living with heart failure questionnaire. they should notice the differences between these four questionnaires and discuss about dimensions from these questionnaires. some of students will report what they understand from comparison. time: 90 min. the questionnaires sf – 36, sf – 12 and sf – 8 are available from http:// www.qualitymetric.com the specific minnesota living with heart failure questionnaire is given below in this task. task 2: filling in sf – 36 the students fill in sf – 36 and with instruction for scoring: they are getting their scores of quality of life. they can compare their score with national’s standards. the instruction for scoring sf – 36 is available from http:// www.qualitymetric.com. the national’s standards are given in the table 4. time: 180 min. living with heart failure questionnaire instructions for use 1. patients should respond to the questionnaire prior to other assessments and interactions that may bias responses. you may tell the patient that you would like to get his or her opinion before doing other medical assessments. 2. ample, uninterrupted time should be provided for the patient to complete the questionnaire. 3. the following instructions should be given to the patient each time the questionnaire is completed. a. read the introductory paragraph at the top of the questionnaire to the patient. 133 quality of life: concept and measurement b. read the first question to the patient „did your heart failure prevent you from living as you wanted during the past month by causing swelling in your ankles or legs”? tell the patient, „if you did not have any ankle or leg swelling during the past month you should circle the zero after this question to indicate that swelling was not a problem during the past month”. explain to the patient that if he or she did have swelling that was caused by a sprained ankle or some other cause that was definitely not related to heart failure he or she should also circle the zero. tell the patient, „if you are not sure why you had the swelling or think it was related to your heart condition, then rate how much the swelling prevented you from doing things you wanted to do and from feeling the way you would like to feel”. in other words, how bothersome was the swelling? show the patient how to use the 1 to 5 scale to indicate how much the swelling affected his or her life during the past month from very little to very much. 4. let the patient read and respond to the other questions. the entire questionnaire may be read directly to the patient if one is careful not to influence responses by verbal or physical cues. 5. check to make sure the patient has responded to each question and that there is only one answer clearly marked for each question. if a patient elects not to answer a specific question(s) indicate so on the questionnaire. 6. score the questionnaire by summating the responses to all 21 questions. in addition, physical (items 2, 3, 4, 5, 6, 7, 12 and 13) and emotional (items 17, 18, 19, 20, and 21) dimensions of the questionnaire have been identified by factor analysis, and may be examined to further characterize the effect of heart failure on a patient’s life. 134 health systems and their evidence based development living with heart failure questionnaire these questions concern how your heart failure (heart condition) has prevented you from living as you wanted during the last month. the items listed below describe different ways some people are affected. if you are sure an item does not apply to you or is not related to your heart failure then circle 0 (no) and go on to the next item. if an item does apply to you, then circle the number rating how much it prevented you from living as you wanted. did your heart failure prevent you from living as you wanted during the last month by: copyright university of minnesota 1986. 135 quality of life: concept and measurement no very very little much 1. causing swelling in your ankles, legs, 0 1 2 3 4 5 etc.? 2. making you sit or lie down to rest during 0 1 2 3 4 5 the day? 3. making your walking about or climbing 0 1 2 3 4 5 stairs difficult? 4. making your working around the house 0 1 2 3 4 5 or yard difficult? 5. making your going places away from 0 1 2 3 4 5 home difficult? 6. making your sleeping well at night 0 1 2 3 4 5 difficult? 7. making your relating to or doing things 0 1 2 3 4 5 with your friends or family difficult? 8. making your working to earn a living 0 1 2 3 4 5 difficult? 9. making your recreational pastimes, sports 0 1 2 3 4 5 or hobbies difficult? 10. making your sexual activities difficult? 0 1 2 3 4 5 11. making you eat less of the foods you 0 1 2 3 4 5 like? 12. making you short of breath? 0 1 2 3 4 5 13. making you tired, fatigued, or low 0 1 2 3 4 5 on energy? 14. making you stay in a hospital? 0 1 2 3 4 5 15. costing you money for medical care? 0 1 2 3 4 5 16. giving you side effects from 0 1 2 3 4 5 medications? 17. making you feel you are a burden to your 0 1 2 3 4 5 family or friends? 18. making you feel a loss of self-control 0 1 2 3 4 5 in your life? 19. making you worry? 0 1 2 3 4 5 20. making it difficult for you to 0 1 2 3 4 5 concentrate or remember things? 0 1 2 3 4 5 21. making you feel depressed? 0 1 2 3 4 5 table 4. item means of dimensions of sf – 36 by country 136 health systems and their evidence based development item cr de fr ge it ne no sp uk physical functioning (pf) pf01 2.04 2.36 2.29 2.26 2.38 2.17 2.16 2.43 2.25 pf02 2.34 2.73 2.59 2.62 2.75 2.63 2.75 2.74 2.58 pf03 2.40 2.76 2.64 2.60 2.72 2.58 2.72 2.78 2.61 pf04 2.28 2.81 2.78 2.72 2.78 2.63 2.75 2.81 2.63 pf05 2.48 2.79 2.76 2.66 2.78 2.67 2.75 2.77 2.71 pf06 2.29 2.81 2.73 2.67 2.80 2.66 2.84 2.82 2.65 pf07 2.36 2.89 2.88 2.75 2.90 2.80 2.90 2.86 2.76 pf08 2.51 2.88 2.84 2.81 2.89 2.81 2.92 2.86 2.80 pf09 2.62 2.91 2.91 2.84 2.93 2.86 2.94 2.90 2.88 pf10 2.66 2.91 2.92 2.87 2.95 2.93 2.95 2.93 2.92 role physical (rp) rp1 1.67 1.79 1.78 1.79 1.80 1.73 1.72 1.85 1.78 rp2 1.60 1.89 1.90 1.83 1.86 1.81 1.84 1.87 1.85 rp3 1.65 1.84 1.84 1.82 1.83 1.77 1.81 1.87 1.80 rp4 1.60 1.85 1.82 1.81 1.82 1.75 1.80 1.87 1.80 general health (gh) gh1 2.68 3.53 3.36 3.03 3.06 3.28 3.57 3.08 3.50 gh2 3.60 4.13 3.82 3.56 3.52 3.74 4.32 4.03 3.91 gh3 3.26 3.90 3.66 3.45 3.91 3.85 4.01 3.75 3.69 gh4 3.19 4.00 3.65 3.77 3.78 3.71 3.86 3.90 3.61 gh5 2.95 4.43 4.27 4.17 4.28 4.36 4.49 4.35 4.35 vitality (vt) vt1 3.41 4.34 4.01 3.96 3.89 4.55 3.61 4.29 4.09 vt2 3.38 4.04 3.43 3.99 4.12 4.26 3.45 4.16 3.95 vt3 3.90 5.14 4.70 4.47 4.90 4.79 4.50 4.81 4.50 vt4 3.68 4.55 4.07 3.99 4.02 4.19 4.51 4.50 4.17 role emotional (re) re1 1.76 1.81 1.79 1.85 1.77 1.79 1.75 1.89 1.85 re2 1.70 1.91 1.90 1.91 1.84 1.84 1.88 1.90 1.89 re3 1.71 1.90 1.82 1.89 1.76 1.84 1.84 1.90 1.89 mental health (mh) mh1 4.09 4.48 3.83 4.31 4.03 4.44 4.31 4.18 4.17 mh2 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measurement of quality of life in patients with chronic obstructive pulmonary disease. in: quality of life assessment. last advances in the measurement and application of quality of life in clinical studies, chester england: adis international limited; 1998; p. 87-92. 15. patrick dl, erickson p. health status and health policy. new york: oxford university press, 1993. 16. bech p. quality-of-life measurements for patients taking which drugs? in: mallarkey g ed. quality of life assessment. last advances in the measurement and application of quality of life in clinical studies, chester england: adis international limited; 1998; p. 93-103. 17. wagner ak, vickrey bg. the routine use of health-related quality of life measures in the care of patients with epilepsy: rationale and research agenda. qual life res 1995; 4: 169-77. 18. michael m, tannock if. measuring health related quality of life in clinical trials that evaluate the role of chemotherapy in cancer treatment. can med assoc j 1998; 158: 1727-34. 19. ta 101. glossary. in: introduction to health care technology assessment. national information center on health services research & health care technology (nichsr) (cited 1998, august 11); available from url: http://www.nlm.nih.gov/nichsr/ta101. 137 quality of life: concept and measurement 20. shumaker sa, anderson rt, czajkowski sm. psychological test and scales. in: spilker b, ed. quality of life assessment in clinical trials. new york: ravan press, 1990: 95-114. 21. hyland me. quality-of-life measures as providers of information on value-for-money of health interventions: comparison and recommendations for practice. in: mallarkey g ed. quality of life assessment. last advances in the measurement and application of quality of life in clinical studies, chester england: adis international limited; 1998; p. 21-33. 22. ware je. conceptualizing and measuring generic health outcomes. cancer 1991; 67:774779. 23. eiser c, tooke j. quality of life in type ii diabetes in: mallarkey g ed. quality of life assessment. last advances in the measurement and application of quality of life in clinical studies, chester england: adis international limited; 1998; p. 115-123. 24. berzon ra. understanding and using health-related quality of life instruments within clinical research studies. in: staquet mj, hays rd and fayers pm, ed. quality of life assessment in clinical trials, new york: oxford university press; 1998. p. 3-18. 25. lydich e, yawn bp. clinical interpretation of health-related quality of life data. in: staquet mj, hays rd and fayers pm, ed. quality of life assessment in clinical trials. methods and practice, new york: oxford university press; 1998. p. 299-314. 26. kaplan rm. quality of life measurement. in: p. karoly ed. measurement strategies in health psychology. new york: john wiley, 1985. 27. revecki da, kline leidy n. questionnaire scaling: models and issues. in: staquet mj, hays rd and fayers pm, ed. quality of life assessment in clinical 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//www.glamm.com /gl/tambu.htm 33. testa ma, nackley jf. methods for quality of life studies. annu. rev. public health 1994; 15: 535-59. 34. center for quality of life research in nursing science. quality of life compendium. measuring quality of life (cited 1999, february 4); available from url: http:// www.uib.no 35. hutchinson a, fowlert p. outcome measures for primary health care: what are the research priorities? british journal of general practice 1992; 42: 227-31. 36. goligher jc. judging the quality of life after surgical operations. journal of chronic diseases 1987; 40: 631-633. 37. guyatt gh, bombardier c, tugwell p. measuring disease specific quality of life in clinical trials. can med assoc j 1986; 134: 895-9. 38. osoba d. guidelines for measuring health-related quality of life in clinical trials. in: staquet mj, hays rd and fayers pm, ed. quality of life assessment in clinical trials. methods and practice, new york: oxford university press; 1998. p. 19-36. 39. mapi research institute. cultural adaptation of quality of life instruments by mapi research institute. quality of life newsletter 1998; 20: 4-5. 138 health systems and their evidence based development 40. mapi research institute (cited 2001, december); available from url: htpp//www.mapiresearch-inst.com 41. medical outcome trust. how to score the sf – 36 health survey. boston, medical outcomes trust, 1994 42. rector ts, kubo sh, cohn jn. patients’ self-assessment of their congestive heart failure. part 2: content, reliability and validity of a new measure, the minnesota living with heart failure questionnaire. heart fail 1987; 3(5): 198-209. 43. guyatt gh, feeney dh, patric dl. measuring health – related quality of life. ann innern med 1993; 118: 6229. 139 quality of life: concept and measurement 140 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title disability-adjusted life years: a method for the analysis of the burden of disease module: 1.6 ects (suggested): 0.25 author(s), degrees, institution(s) adriana galan, it specialist part-time senior lecturer at the university of medicine and pharmacy, department of public health and management, at the master course in management of public health and health services address for correspondence institute of public health bucharest 1-3 dr. leonte street 76256 bucharest romania tel: (4021) 2249228 / ext.188 fax: (4021) 3123426 e-mail: agalan@ispb.ro keywords population health status, global burden of disease, premature death, disability learning objectives at the end of this course, students should: • identify the basic concepts of the global burden of disease assessment; • be able to describe the factors influencing the calculation of dalys (age-weights, discount rate, severity of disability); and • be able to describe and compare the health status of population based on global burden of disease methodology. abstract this course covers the following topics: definitions and basic concepts; health status assessment by use of daly; exercise. teaching methods teaching methods include lecture, interactive presentation of key concepts, overheads or powerpoint presentation. exercise will be solved in small groups (4-5 persons) and an overhead will be presented by each group with their comments. specific recommendations for teacher it is recommended that the module will be organized within 0.25 ects credits, out of which 3 hours will be done under supervision (lecture and exercise solving), and the rest is individual student's work. examples of studies performed in their own countries should be used. assessment of students 1. reports presented by each group are considered as assessment. 2. an essay on the types of interventions required in own countries based on information from who sites or studies performed at national/local level. disability-adjusted life years: a method for the analysis of the burden of disease adriana galan definitions and basic concepts generally, statistics describing the health status of population suffer some limitations, reducing their practical value for the decision-making process: • first, the data are incomplete and fragmented. even if for example, the mortality data are available, they cannot describe the impact on health status of the different diseases or non-fatal disorders (like dementia or blindness for instance); • second, the estimates of death cases of different diseases can be inflated by epidemiologists acting as advocates for a target population, in order to obtain more resources; • last, but not the least, traditional statistics don’t allow decision-makers to compare the relative cost-effectiveness of different interventions (1). this is why a new approach called the „global burden of disease” was proposed, trying to solve the above-mentioned problems and having three explicit goals: • to include the non-fatal conditions into the health status evaluation; • to produce objective, independent and demographically credible evaluation of the burden of disease; • to convert the burden of disease into a general currency, in order to calculate the cost-effectiveness of different interventions. in order to integrate both the impact of premature death and disability into one single currency, time measurement was considered to be an important integrative factor: time (years) lost by premature death and time (years) lived with disability. a standardized indicator called disability adjusted life year (daly) was proposed for the measurement of the global burden of disease. daly represents the years of life lost due to premature death and years lived 141 disability-adjusted life years: a method for the analysis of the burden of disease with disability of a specified degree of severity and duration. therefore, one daly represents one year of healthy life lost. premature death is defined as one that occurs before the age to which a dying person would have expected to survive, if this person would belong to a standardized population pattern having the longest life expectancy at birth in the world, meaning the female population of japan. to calculate the total number of daly for a certain condition in a population, years of life lost (yll) and years lived with disability (yld) of a certain degree of severity and duration must be estimated. then, these estimates must be summed up. for instance, to calculate daly due to traffic accidents for one year, the total number of years of life lost due to fatal traffic accidents and the total number of years lived with disability by the accidents survivors must be summarized. even if to quantify the burden of disease looks like a simple exercise, a society must define first its ideal health status, considered to be the reference one. this means to find the answer for fundamental basic questions: what would be the ideal life expectancy? are all people equal? the researchers must decide on the expected number of years a person of a certain age would live in a reference (ideal) population. daly is based on egalitarian principle. only age and gender were considered for calculating the burden of disease, these two characteristics not being directly related to health. there were not considered characteristics such as: socioeconomic level, ethnicity or level of education. according to these principles, for calculating daly a standard life-table was used for all populations, life expectancy at birth being 82.5 years for females and 80 years for males. are the healthy life years more precious for young adults than for infants or elderly? generally, if one should choose between saving a life of a 2 years old child and of a 22 years old person, most people would prefer the 22 years old person. this is due to the fact that an adult plays a more important role in family, community and society. this was the reason for the researchers to include an age-weighting to calculate daly. it was assumed that the relative value of one life year rapidly increases from zero (at birth) to a peak around 20 years of age, decreasing after this age but less sharply (see figure 1). 142 health systems and their evidence based development figure 1. relative value of one year lived at different ages, included into daly is a healthy life year more important now for a society than 30 years later? it is very likely that a person would prefer to receive today 100 e rather than after one year. like the depreciation of one euro over time, it seems that the value of healthy life is depreciating over time. usually it is preferred to experience a healthy year of life now rather than some years thereafter, even if this opinion has initiated lots of debates among economists, experts in medical ethics and public health decision-makers. despite these debates, the researchers decided to discount the future years of life, e.g. by 3% per year. discounting looks like an exponentially decreasing function. due to the fact that the discount is significant, the researchers are usually publishing also daly calculated without the discount factor. discounting future health reduces the value of interventions having a long-term impact – for example the impact of vaccination against hepatitis b, which can prevent thousands of future cases of liver cancer, however many years later. how can one compare yll with yld? while death can be easily defined, the definition of disability is more complicated. usually, there are two methods used to evaluate the social preferences of certain health states. both methods involve peoples’ judgement on the compromise between quantity (length) and quality of life. this can be expressed as a compromise for time (how many years lived with disability would be changed for a fixed period of perfect health) or a compromise between persons (the choice between saving one year of life for 1000 healthy people or half a year of life for 2000 persons having health problems). a protocol based on person trade-off method was established. this was possible due to a formal exercise organized by 143 disability-adjusted life years: a method for the analysis of the burden of disease 0 0.5 1 1.5 2 0 20 22 40 60 80 100 age (years) re la ti v e w e ig h t who in 1995 (2), where worldwide health professionals have participated. the severity for 22 disability conditions was weighted between 0 (perfect health) and 1 (equivalent of death) (table 1). these weights for the 22 disability conditions were grouped into 7 classes. table 1. severity of disability: disability classes and weights set for 22 indicator conditions source: who. available at http:\\www.who.int. to assess the impact of varying these social choices on the final measures of burden of disease, the researchers have calculated daly with alternative age-weighting and discount rates, and with alternative methods for weighting the severity of disability. generally, the ranking of diseases and the distribution of burden by cause groups are substantially not affected by age-weighting and slightly affected by the method for weighting disability. by contrast, changes of the discount rates may have a more significant effect on overall results. the most significant effect of changing the discount rate and age weights is to reduce the relative importance of psychiatric conditions. however, the accuracy of basic epidemiological data from which daly is calculated will influence the final results much more than any of the above-mentioned weights. we can conclude that efforts should be firstly invested in improving the basic epidemiological data. 144 health systems and their evidence based development disability class severity weights indicator conditions 1 0.00 – 0.02 vitiligo on face, weight-for-height less than 2 standard deviations 2 0.02 – 0.12 watery diarrhea, severe sore throat, severe anemia 3 0.12 – 0.24 radius fracture in a stiff cast, infertility, erectile dysfunction, rheumatoid arthritis, angina 4 0.24 – 0.36 below-the-knee amputation, deafness 5 0.36 – 0.50 rectovaginal fistula, mild mental retardation, down syndrome 6 0.50 – 0.70 unipolar major depression, blindness, paraplegia 7 0.70 – 1.00 active psychosis, dementia, severe migraine, quadriplegia health status assessment by use of daly a who study on the world burden of diseases showed that the top 10 causes of disease burden are responsible for 46% of all daly (see table 2). it was also shown that five of the top 10 causes of daly primarily affect children under 5 years of age. two of the top 10 causes (malaria and hiv) predominantly affect poor populations. these 7 causes are all part of infectious diseases, perinatal conditions and nutritional disorders, representing who priorities. the remaining 3 causes (unipolar major depression, ischemic heart disease and cerebrovascular disease) are chronic diseases. rankings based on daly differ substantially from rankings based on the number of deaths. the importance of major depression worldwide, even if it generates only few deaths, was one of the key findings of this study. the weight of certain causes of total daly differs significantly if the results are analyzed by geographical distribution. for example, in sub-saharan africa, hiv accounted for 20% of the burden of disease in the region; malaria, tuberculosis and vaccine-preventable childhood diseases were responsible for another 20%. on the other hand, although road traffic accidents, falls and self-inflicted injuries account for 6.7% of total dalys, their prevention was not a key issue of the public health policy in developing countries. if we analyze the burden of disease attributable to different risk factors, we notice that in 1990, malnutrition accounted for almost 6 million deaths (11.7% overall) and 220 million dalys (15.9% overall); tobacco use accounted for 3 million deaths and 36 million dalys (see table 3). similar studies were performed in usa. in 1996, 34.5 million dalys were lost: 18.5 million for men and 16 million for women. it’s worthwhile to notice that the major causes of dalys differ significantly between developed countries and the rest of the world. e.g. in usa the 9 of the top 10 causes of dalys include injuries and non-communicable diseases. 145 disability-adjusted life years: a method for the analysis of the burden of disease table 2. leading causes of daly for the world in 1999 table 3. burden of disease attributable to selected risk factors in the world, 1990 146 health systems and their evidence based development rank cause dalys* % of total dalys deaths* % of total deaths 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 all conditions lower respiratory tract infections hiv conditions during perinatal period diarrheal diseases unipolar major depression ischemic heart disease vaccine-preventable diseases cerebrovascular diseases malaria nutritional deficiencies road traffic accidents chronic obstructive pulmonary disease (copd) congenital abnormalities tuberculosis falls maternal conditions self-inflicted sexually transmitted diseases (excluding hiv) alcohol use bipolar disorder 1 438 154 96682 89819 89508 72063 59030 58.981 54638 49856 44998 44539 39573 38156 36.557 33287 30950 26101 25095 19747 18743 16368 100 6.72 6.25 6.22 5.01 4.10 4,10 3.80 3.47 3.13 3.10 2.75 2.65 2.54 2.31 2.15 1.81 1.74 1.37 1.30 1.14 55 965 3963 2673 2356 2213 1 7089 1554 5544 1086 493 1230 2660 652 1669 347 497 893 178 60 5 100 7.08 4.77 4.20 3.95 0.00 12.66 2.75 9.90 1.94 0.88 2.19 4.75 1.16 2.98 0.62 0.88 1.59 0.31 0.10 0.00 * values are expressed in thousands. data source: who global burden of disease study, 1999. risk factor deaths* % of total deaths daly* % of total daly malnutrition poor water supply, sanitation and personal and domestic hygiene unsafe sex tobacco use alcohol use occupational hypertension physical inactivity illicit drug use air pollution 5881 2668 1095 3038 774 1129 2918 1991 100 568 11.7 5.3 2.2 6.0 1.5 2.2 5.8 3.9 0.2 1.1 219575 93392 48702 36182 47687 37887 19076 13653 8467 7254 15.9 6.8 3.5 2.6 3.5 2.7 1.4 1.0 0.6 0.5 * values are expressed in thousands data source: who world study. projections of future burden of disease and risk factors are extremely useful for the decision-making process. the secular trend analyses allow for an approximate prediction of the burden of disease at any moment in the future. at harvard school of public health, murray and lopez (3) performed a study, which revealed that by 2020, the ranking of burden of disease is expected to be dominated by ischemic heart disease, unipolar major depression and road traffic accidents (see table 4). by contrast, diseases affecting mostly children at present are projected to decrease due to the globalization of immunization campaigns. table 4. projected change in rank order of dalys for the 15 leading causes in 2020 compared with 1990 in romania, the institute of public health bucharest has also performed a study aiming to assess the burden of disease for 1998. the study revealed that the predominant causes of dalys in romania are the non-communicable diseases and accidents, a pattern similar with the american one rather than the world pattern. ranking order of dalys in romania is presented in table 5. table 5 shows that the burden of mental and behavioral disorders is placed on the third rank, like in the predicted american pattern for 2020. the same study revealed that there are 7 deprived districts in romania, clustering in the south and western part of the country. 147 disability-adjusted life years: a method for the analysis of the burden of disease rank by year: 2020 1990 disease or injury 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 5 4 9 6 12 1 7 16 2 28 3 19 10 17 33 ischemic heart disease unipolar major depression road traffic accidents cerebrovascular disease copd lower respiratory tract infections tuberculosis war diarrheal disease hiv perinatal conditions violence congenital abnormalities self-inflicted injuries trachea, bronchus and lung cancers reprinted from murray and lopez study table 5. ranking order of daly in romania, 1998 148 health systems and their evidence based development group of diseases dalys (years) % of total daly 1. cardiovascular diseases 1 350 203 31,88 2. cancers 426 951 10,10 3. mental and behavioral disorders 422 853 9,98 4. accidents, injuries, poisonings 376 500 8,89 5. central nervous system diseases 307 684 7,26 6. digestive system diseases 267 621 6,32 7. respiratory system diseases 242 524 5,72 8. infectious diseases 82 802 1,95 9. congenital abnormalities 69 715 1,64 10. perinatal conditions 52 317 1,23 11. genitourinary system diseases 46 550 1,09 12. endocrin and nutrition diseases 44 032 1,04 13. blood diseases 39 615 0,93 14. diabetes 24 916 0,58 15. bones diseases 14 877 0,35 16. pregnancy, delivery conditions 13 174 0,31 17. organic mental disorders 10 183 0,24 18. tuberculosis 2 049 0,04 19. skin diseases 1 358 0,03 20. other 438 963 10,41 total 4 232 887 100 data source: study performed by iphb. exercise: disability-adjusted life years as a key tool for the analysis of the burden of disease task: students read the two files containing who reported data on mortality and daly (www.who.int/whosis/menu.cfm). after that, they should: – compare the mortality rankings with daly rankings and comment the differences; and – compare daly rankings between different who areas and comment the differences. 149 disability-adjusted life years: a method for the analysis of the burden of disease references 1. michaud c, murray cjl, bloom b. burden of disease – implications for future research, jama, vol. 285(5), february 7, 2001. 2. world health organization. the world health report 2000: health systems: improving performance, geneva: world health organization, 2000. 3. murray cjl, lopez ad. the global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 projected to 2020, cambridge, harvard school of public health, 1996. recommended readings • www.who.int/whosis/menu.cfm click on burden of disease project, then on gbd 2000 documentation. you can find there: guidelines (gbd 2000 guidelines for epidemiological reviews), paper 36 (this discussion paper provides an overview of the global burden of disease 2000 project: its aims, methods and data sources, and version 1.0 results as reported in the world health report 2001), paper 50 (this discussion paper provides an overview of the global burden of disease 2000 project: its aims, methods and data sources, and version 2.0 results consistent with the estimates for 2001 reported in the world health report 2002), summary measures of population health (recent who publication addressing a wide array of critical issues regarding the measurement of population health using comprehensive indices combining information on mortality and ill-health). in bmj collection (http://bmj.com): search/archive keywords: disability adjusted life years: • trude arnesen, erik nord. the value of daly life: problems with ethics and validity of disability adjusted life years, bmj november 1999 • john wright, john walley. health needs assessment: assessing health needs in developing countries, bmj june 1998 • luc bonneux, jan j barendregt, wilma j nusselder, paul j van der maas. preventing fatal diseases increases healthcare costs: cause elimination life table approach, bmj january 1998 • kamran abbasi. the world bank and world health: under fire, bmj april 1999 150 health systems and their evidence based development 151 calculating the potential years of life lost health systems and their evidence based development a handbook for teachers, researchers and health professionals title calculating the potential years of life lost module: 1.7 ects (suggested): 0.25 author(s), degrees, institution(s) aurelia marcu, md, phd public health consultant, phd, head of department of strategies and forecasts in public health address for correspondence institute of public health bucharest 1-3 dr. leonte street 76256 bucharest romania tel: (4021) 2249228 / ext.188 fax: (4021) 3123426 e-mail: amarcu@ispb.ro keywords premature death, potential years of life lost, mortality pattern, trend analysis, priority setting learning objectives at the end of this course, students should: • identify the basic concepts of potential years of life lost assessment; • be able to des cribe the factors influencing the calculation of pyll; and • be able to describe and compare the health status of population based on potential years of life lost methodology. abstract this course covers the following topics: the concept of premature death historical background; computing methods for pyll; other approaches for calculating pyll; main domains where pyll is a useful tool; examples from romania; and exercise. teaching methods this course covers the following topics: the concept of premature death historical background; computing methods for pyll; other approaches for calculating pyll; main domains where pyll is a useful tool; examples from romania and exercise. specific recommendations for teacher it is recommended that the module will be organized within 0.25 ects credits, out of which 3 hours will be done under supervision (lecture and exercise solving), and the rest is individual student's work. examples of studies performed in their own countries should be used. assessment of students 1. reports presented by each group can be considered as assessment. 2. an essay on the types of interventions required in their own countries based on information existing on who site, or studies performed at national / local level. calculating the potential years of life lost aurelia marcu potential years of life lost (pyll) represent a part of potential demography, based on the primary concept "potential of life". this concept is defined as the number of years a person / a group / a population is expected to live between certain ages or until end of life. these years can be lost due to premature death. the concept of premature death historical background the concept was used for the first time by petti during the xvii century. it was further used in '70s by canadian and french researchers. in 1977, romeder and mcwhinner proposed a new indicator "potential years of life lost between 1 and 70 years of age" for the purpose of ranking the causes of death (1). since then, this indicator was used for health planning as a "social indicator". computing methods for pyll i. the classical approach: the most used formula to compute pyll is: pyll = = where: i = number of 5-years age groups (see the table below) di = number of deaths within each age group 65 = upper limit for which a death is considered premature ai = age group middle point 152 health systems and their evidence based development 13 1 (65 ) i i i d a = −∑ i id w∑ due to the fact that age represents a continuous quantitative measure, one can use the following formula to calculate ai: some comments are necessary concerning the interval limits used to compute pyll: a) lower age limit: some authors do not take into account the first year of life because the maximum risk of death is encountered close to the delivery time; also during this period of time most causes of death are different from other age groups resp. of endogenous nature; economic investment is modest during this period etc. other researchers set the lower limit to "0" years, justified by the deficiencies of the reporting systems (in most current health information systems there are data related to infant deaths (0-1) at national level as total number of deaths but not for all causes of death. class no. age group ai wi = 65 ai di di wi 0 1 2 3 4 5=3 x 4 1 < 1 0,5 64,5=65-0,5 2 1 4 3 62 3 5 9 7,5 57,5 4 10 14 12,5 52,5 5 15 19 17,5 47,5 6 20 24 22,5 42,5 7 25 29 27,5 37,5 8 30 34 32,5 32,5 9 35 39 37,5 27,5 10 40 44 42,5 22,5 11 45 49 47,5 17,5 12 50 54 52,5 12,5 13 55 59 57,5 7,5 14 60 64 62,5 2,5 σ = 153 calculating the potential years of life lost i lower limit of class "i" upper limit of class "i 1" a 2 + + = b) the upper age limit (65 years) is established according to the existing level of crude mortality rate and of life expectancy at birth. for countries having a low economic level of development, with a low level of life expectancy at birth, the upper age limit must be decreased, in any case below the level of life expectancy at birth. conversely, for the developed countries, where the life expectancy at birth is higher than 70 years, the upper age limit should be established at 70 or even 75 years. for the potential years of life lost due to a certain disease or groups of diseases, age limits are established according to the natural history of this disease and to the research objectives. examples are aids, liver cirrhosis, and suicide: • in spain, the age limits for aids were established at 25-44 years (2) or 2039 (3); the key argument for choosing these limits was the natural history of disease: in spain, the main ways of transmission were sexual intercourse and intravenous drug abuse. in canada, hogg (4) recommended in 1996 the use of 1-75 years interval for aids. • for liver cirrhosis, lessa (5) recommended in 1996 to establish the age interval at 20-59 years for calculating pyll; he considered that before the age of 20, it is almost impossible that somebody dies from liver cirrhosis. • for suicide, a cause of death with an increasing frequency, mainly among men and in youth in romania, darragh (6) or riley (7) used the potential years of life lost before 45 years of age. as a general remark, no matter of country or researcher, for chronic diseases with a long duration, the classical age limits for calculating pyll are 1-65 or 75 years. ii. other approaches for calculating pyll: during the last 3-4 decades, more refined approaches to calculate pyll were proposed. 1) calculation of the absolute number of years lost by death before the age of 65 70 75 years: this number can be computed for the national level, for a geographical area (district, city), for urban / rural area, for men / women, or by group of diseases or even group of diagnoses (if the frequency of a diseases is high, especially among youth). two, at maximum three characteristics can be commonly combined to compute pyll. 2) calculation of the structure of pyll according to certain characteristics: the proportion of pyll can offer valuable information about the relative importance of each characteristic in generating premature death. it also 154 health systems and their evidence based development offers the possibility of problem ranking, thereby facilitating the priority setting process. when pyll is calculated for geographical areas (by district, by country), confidence limits can be estimated for the country mean. this method allows the identification of those areas where the number of deaths is significantly higher than the "expected" one. according to the calculated confidence limits, the districts can be split in three categories: • districts placed inside the confidence limits. for these districts, the level of pyll is close to the country mean, observed variations being explained only by the intrinsic variability of the phenomenon. • districts placed below the lower limit of the confidence interval. for these districts, the number of potential years of life lost is significantly lower than the country mean, therefore being in a favorable position. • districts placed above the upper limit of the confidence interval. these are deprived areas, where a significantly higher number of potential years of life are lost. from a public health view point, these districts represent a priority for intervention. 3) for the calculation of the geographical disparities of pyll, also specific techniques to characterize frequency distributions can be used (8): quartiles, medians, and percentiles. in order to apply these statistical parameters, several common steps must be accomplished: • ranking the districts (areas) according to a certain characteristic proportion (e.g. proportion of pyll by an infectious disease like tuberculosis), in ascending order; • computing the cumulative frequency; • calculating the median value. districts placed within the upper half of the ordered series representing high proportions of pyll can be considered as deprived. the quartiles basically divide the ordered series into 4 equal sub-series (q1 q4). districts are then placed accordingly within any quartile. districts placed within the first quartile (q1) are in a favorable situation, while districts placed within the fourth quartile (q4) are the deprived ones. districts placed within q2 and q3 can be considered as having a middle position. percentiles can be calculated starting from the relative cumulative frequency (presented as percent). a threshold percentile has to be established. 155 calculating the potential years of life lost 4) the average number of years lost per premature death (before age of 65, 70 or 75): it represents a simple mean. a higher value of this mean emphasizes a higher death frequency among young age groups, consequently a higher social impact of premature death. the formula for calculating the average number of years lost with a premature death is: different characteristics can again be considered for calculating the average number of years lost for a premature death: by district (administrative unit), by residence (urban/rural), by group of diseases, by gender. the results can be used as a guideline for a priority setting process identifying geographical disparities. 5) calculation of the number of potential years of life lost per 1000 inhabitants: this calculation reflects the impact of premature death on the whole population. this indicator was used to underline the impact of pyll (calculated for 5 causes of premature death: cardiovascular diseases, neoplasm, digestive system diseases, accidents and respiratory system diseases) at whole population level. 6) the standardized pyll ratio: it is well-known that the risk of death is strongly influenced by age. this is why dever (9) proposed the use of standardized pyll ratio. it is recommended to use this indicator only for comparisons, as it does not describe the real magnitude. an expected number of pyll is calculated under the hypothesis that the frequency of premature death in all areas is the same within each age group (a standard mortality pattern is used). the observed value (calculated from real data) is divided by the expected value. if the ratio is higher than 1, it means that the frequency of premature death is higher than expected. this result can emphasize a health problem in the area. it is obvious that the favorable situation is represented by a ratio smaller than 1, suggesting that the premature deaths do not represent a problem in the area. 156 health systems and their evidence based development total number of pyll average number of pyll / premature death number of premature deaths = st absolute number of pyll 1000 population at 1 july x the formula for calculating the direct standardized pyll ratio is: where: n = total number of population under study ni = number of population within "i" age group n0 = total number of standard population ni0 = number of standard population within "i" age group n0 = σ ni0 n = σ ni di = number of deaths within "i" age group of population wi = 65 ai 7) pyll related to the life expectancy: the following formula was used: pyll = σ diei where: di = observed deaths within "i" age group ei = life expectancy for "i" age group main domains where pyll is a useful tool 1) the analysis of mortality patterns impact evaluation of certain causes of death the concept of premature death is more and more used for the analysis of mortality patterns due to the increase of life expectancy at birth, the slightly increasing trend of the crude mortality rate, the change of morbidity patterns (decreasing frequency of communicable diseases together with an increasing trend of chronic disease prevalence). 157 calculating the potential years of life lost 13 i0 i 0 ii 1 n d pyll n n n ix w = = ∑ the relative importance of the different causes of death is clearly distinct depending on the method used: pyll reflect those causes of death affecting mainly the young population, the active one, consequently causing the biggest economic loss. the economic loss includes the visible loss (the person ends to produce) and the hidden loss (the society doesn't recover the educational investments for the young lost person). for example, in developed countries the hierarchy of the main causes of death is: cardiovascular diseases, tumors and accidents. the same hierarchy according to pyll is: accidents, tumors and cardiovascular diseases. some examples of pyll analysis: in spain 52,3% out of all premature deaths are due to accidents (10), in denmark 34% (11). 2) descriptive epidemiology of diseases (groups of diseases) trend analysis in the framework of descriptive epidemiology, the concept of pyll is used to describe the different diseases according to some characteristics (gender, age group, residence, and district). pyll was used most frequently to describe: accidents suicide cancer repeated cross-sectional studies allow identifying the changes in the hierarchy causes of premature death due to interventive actions. 3) to identify and rank health problem pyll are often used to identify and rank the health problems at different levels: national, district, city. the decision-makers can plan the interventive actions based on pyll hierarchy. 4) useful for the design of health programs pyll are useful for: identifying the persons to be included in the health programs (target population), establishing the health programs objectives, evaluating the intervention / health programs results / outcomes, cost-effectiveness analysis. 158 health systems and their evidence based development in 1990, in japan (12) have used pyll to evaluate the efficacy of a screening program for uterine cancer. the efficacy criterion was the degree (%) of pyll reduction. the reduction percent was directly correlated with the screening coverage degree for the female target group. in canada (13), 2 risk factors have been addressed: smoking and alcohol consumption, both of them responsible for several non-communicable diseases. consequently, 10% of pyll in canada were attributable to smoking, associated with alcohol consumption. wigle estimated (14), also in canada, that 50% of premature deaths can be prevented by control of smoking, hypertension, hypercholesterolemia, diabetes and alcohol abuse. only 12% of premature deaths can be prevented by improving the health care services. examples from romania the institute of public health in bucharest has performed several studies to evaluate the health status of the romanian population, using different methods, in order to support the ministry of health in developing adequate health policies and programs. one of these studies was based on the evaluation of the impact of premature death (before the age of 65) by calculating the potential years of life lost for the period 1994 2000. according to this study, during this period of time, the ranking of pyll due to the top 5 causes was relatively stable among men: 1. accidents, injuries and poisonings (25% of total pyll) 2. cardiovascular diseases (20-21%) 3. cancers (12-14%) 4. respiratory diseases (12-10%) 5. digestive diseases (8-9%) among men, the weight of premature death due to cancers has increased, while the weight of premature death due to respiratory diseases has decreased during this period. considering the same ranking among women, it can be noticed that the pattern is variable year by year. nevertheless, the most important cause of premature death among women for the whole period was cancer, with an increasing trend from 17% in 1994 to 22% in 2000. table 1 is summarizing the results for the year 2000. 159 calculating the potential years of life lost table 1. structure of pyll by top 5 causes, romania, 2000 source: iphb study, 2002 it can also be noticed that the ratio pyll / 1000 men to pyll / 1000 women was almost stable. according to these findings, two health priorities have been identified for the decision-makers: accidents among men and cancers among women. rank total % rank men % rank women % 1 accidents 21.1 1 accidents 24.8 1 cancers 21.9 2 cardiovascular 20.4 disease 2 cardiovascular 21.5 disease 2 cardiovascular 18.2 disease 3 cancers 17.1 3 cancers 14.6 3 accidents 13.9 4 respiratory 11.3 diseases 4 respiratory 10.4 diseases 4 respiratory 13.2 diseases 5 digestive 8.7 diseases 5 digestive 8.6 diseases 5 perinatal 7.7 conditions 160 health systems and their evidence based development exercise: how to calculate potential years of life lost (proposed by adriana galan) task: students should read the two files containing who reported data on mortality and yll (years of life lost due to premature deaths) 2001, available at url: http://www3.who.int/whosis/menu.cfm?path=whosis,burden,burden_estimates&language=english. after that, they should: compare the mortality rankings with yll rankings and comment the differences; and compare yll rankings between who areas and comment the differences. 161 calculating the potential years of life lost references 1. romeder jm, mcwhinnie jr. potential years of life lost between ages 1 and 70: an indicator of premature mortality for health planning. int j epidemiol 1977; 2: 143-51. 2. castilla j. impact of human immunodeficiency virus infection on mortality among young men and women in spain. int j epidemiol 1997; 6: 1346-51. 3. mur c. the impact of aids in the global mortality in catalonia 1981-1993. med clin (barcelona) 1995; 14: 528-31. 4. hogg rs. health, hiv/aids mortality in canada: evidence of gender, regional and local area differentials. aids 1996; 8: 889-94. 5. lessa. i liver cirrhosis in brasil: mortality and productive years of life lost premature. bol ofic sanit panam 1996; 2: 111-22. 6. darragh pm. epidemiology of suicides in northern ireland 1984 1989. ir j med sci 1991; 11: 354 -7. 7. riley r, paddon p. accidents in canada: mortality and hospitalization. health rep 1989; 1: 23-50. 8. gomez mo. a proposal to use the media and percentiles vs. mean in the analysis of pyll. gac sanit 1992; 32: 229-30. 9. dever a. epidemiology in health services management. aspen publications 1984. 10. graells m, garcia p. alcohol-related mortality in catalonia 1994. rev esp salud publica 1998; 1: 25-31. 11. bjerregaard p. fatal non-intentional injuries in greenland. arctic med res 1992; 7: 22-6. 12. kuroishi t, hirose k. evaluation of the effectiveness of mass screening for uterine cancer in japan: the pyll. environ hlth perspect 1990; 87: 51-6. 13. romeder jm, mcwhinnie jr. the development of potential years of life lost an indicator of premature mortality. rev epidemiol sante publique 1978; 1: 97-115. 14. wigle dt. premature deaths in canada: impact, trend and opportunities for prevention. can j public hlth 1990; 5: 376-81. recommended readings in bmj collection (http://bmj.com): search/archive keywords: potential years of life lost • david blane, frances drever. inequality among men in standardised years of potential life lost, bmj july 1998 • janice hopkins tanne. cause of death among americans differs with race and education, bmj november 2002 • martin mckee, vladimir shkolnikov. understanding the toll of premature death among men in eastern europe, bmj november 2001 • zosia kmietowicz. government policies set to narrow „health gap”, bmj september 2000 162 health systems and their evidence based development 163 case study: inequalities in health as assessed by the burden of disease method health systems and their evidence based development a handbook for teachers, researchers and health professionals title case study: inequalities in health as assessed by the burden of disease method module: 1.8 ects (suggested): 0.25 author(s), degrees, institution(s) khaled yassin, dr. med dr.ph section of international public health, faculty of health sciences, university of bielefeld, pobox 100131 d-33501, bielefeld adriana galan, it specialist part-time lecturer at the university of medicine and pharmacy, department of public health and management, at the master course in management of public health and health services, bucharest address for correspondence section of international public health faculty of health sciences, university of bielefeld pobox 100131 d-33501 bielefeld, germany institute of public health bucharest 1-3 dr. leonte street, 76256 bucharest, romania tel: (4021) 2249228 / ext.188 fax: (4021) 3123426 e-mail: agalan@ispb.ro keywords health inequalities, burden of disease, health vulnerability, non-fatal health outcomes learning objectives at the end of this exercise, students should: • be aware of the complexity of health inequalities assessment; • be able to describe the weaknesses of present studies aiming to assess the health inequalities; • be able to describe the advantages of using disability adjusted life years (daly) as a composite indicator in studies of health inequalities. abstract this course gives a short literature review on studies about health inequalities, along with their weaknesses (shortcomings of research, descriptive rather than analytical, methodological and conceptual problems, and study design problems). here are also short presentation of daly concept and the advantages of using this composite indicator in studies aiming to assess the health inequalities. teaching methods interactive group discussion of each paragraph, revealing the key concepts and main conclusions. each concept or general remark will be written on a flipchart. specific recommendations for teacher this module to be organized within 0.25 ects credits, out of which case study takes 2 hours of discussions and will follow the module of disability-adjusted life years as a key tool for the analysis of the burden of disease. another 4 hours will be destined to individually review electronic and printed literature in the field. assessment of students a short (max. one page) essay developing the three main ideas selected during the exercise will be assessed. case study: inequalities in health as assessed by the burden of disease method khaled yassin, adriana galan today there is a general consensus that health inequalities still persist and in some cases have even been increasing not only in developing countries, but in europe as well. since the late 1970s, an increasing number of studies have provided ample evidence of the growing gap in health between different social groups. for example, it was consistently proven that people at a socioeconomic disadvantage suffer a heavier burden of illness and have higher mortality rates than their well-off counterparts (1,2,3,4,5,6,7,8). these observations have refuted previous arguments that health inequalities were disappearing, or had disappeared in european societies. these socio-economic inequalities in health are a major challenge for health systems, not only because most of these inequalities can be considered unfair, but also because a reduction in the burden of health problems in disadvantaged groups offers a great potential for improving the average health status of the population as a whole. furthermore, understanding health inequalities in a given community can improve the effectiveness and efficiency of the health care delivery by ensuring that appropriate interventions are delivered to the population at risk. recognizing the need to devote research attention to the question of health inequalities in modern industrial societies, we carried out a situation analysis in order to identify needs and, on this basis, prioritize areas for research. this review revealed the following points: firstly, while some progress has been made in studying health inequalities, this progress is not evenly witnessed in all european countries. the question has been explored more in countries such as the united kingdom, finland and sweden than, say, in germany, italy and spain. secondly, research studies of health inequalities focus traditionally on proving the existence of inequalities among broad social groups, rather than investigating or illuminating the reasons for such inequalities and the dynamics of their occurrence. equally neglected is the description of the most vulnerable groups. as a result, outcomes of many of these studies have been too general to form the basis for concrete action. 164 health systems and their evidence based development thirdly, the concepts of health vulnerability and strategies for coping with socio-economic disadvantage have been seldom considered in research of health inequalities in europe or elsewhere. inequalities have been examined among different social groups using various indicators for poverty, income, occupation, education, etc. whereas poverty is basically an absolute and economically determined concept, vulnerability is a relational and social one. it does not conceive inequalities as numbers of people with certain occupations, level of education, or of a certain gender having heavier burden of mortality or morbidity from certain diseases. rather, vulnerability research attempts to understand inequalities as real people coping with uncertainty and risk within real societies. health vulnerability is not defined in terms of percentage of income relative to national standards, but a question of defenselessness, insecurity and exposure to risk, shocks and stress. the point is that although poverty may be a proxy indicator, it does not necessarily amount to the vulnerability. the feasibility of action plans based on vulnerability findings differs from one based on results of poverty research. vulnerability has three dimensions: (1) the risk of exposure to health threats; (2) the risk of inadequate capacities to cope with the imposed health threats; and (3) the risk of severe consequences. consequently, the most vulnerable groups are those most exposed to health threats and those possess the most limited coping capabilities and suffer from the most severe consequences and are endowed with the most limited capacity for recovery. fourthly, there are several design problems that adversely affect the validity and comparability of studies of health inequalities. such studies were to attain the twin goals of measuring health and measuring inequalities. several indicators are traditionally used to measure health such as perinatal and infant mortality, all-cause and major-cause mortality, reported chronic illness, subjective sense of wellbeing, and the incidence of certain diseases. mortality indicators, although helpful, do not include the level of suffering and disability from non-fatal outcomes of diseases. subjective ratings of health are shown to be confounded by the differing thresholds among different social class groups for recognizing or reporting ill-health or disability. disease-specific measures are very selective because while the morbidity from some diseases is more prevalent in disadvantaged social groups, some others are more prevalent in the more advantaged ones. measuring inequalities is not less troublesome than measuring health as about dozen different methods are being currently used. they vary in accuracy, complexity and ‘informativity’. it is quite obvious that there are huge di165 case study: inequalities in health as assessed by the burden of disease method fferences between the measures used in the study of health inequalities (9,10,11,12,13,14,15,16,17). these differences in addition to differences in the quality of data collected over different periods of time or among countries are good justifications for interpreting them cautiously. studies of health inequalities have focused on comparing mortality indices among different social groups. such approach assumes death alone can reflect the burden of disease and differentials in mortality indicators can therefore mirror the health inequalities between these groups. death, however, is not the only consequence of disease. a wide array of scenarios can follow a morbid condition. this can include full recovery, a period of disability followed by full recovery, a period of disability followed by death or permanent disability. these non-fatal outcomes constitute a significant part of the burden of disease, which has been ignored by the previously mentioned indicators. the few studies that considered the burden of non-fatal health outcomes were tailored to specific diseases (diabetes, rheumatoid arthritis, etc.) in particular groups. furthermore, the fact that nearly all these measures are based on self-reports explains why the reliability and validity of such measures have been long questioned especially when inter-community and inter-temporal comparisons are attempted. given these shortcomings in current measures of the burden of fatal and non-fatal consequences of disease, the world health organization and the world bank endeavored the disability adjusted life years (dalys) as a measurement unit of the burden of disease (18). the daly has been successfully used to assess the global burden of disease and the who has advocated the use of daly to study health inequalities as well. the daly is a composite indicator of the burden of disease, which incorporates both the years of life lost due to premature mortality and varying degrees of disability. the daly expresses therefore years of life lost due to premature death and years lived with a disability of specified severity and duration secondary to these priority diseases. one daly is thus one lost year of healthy life. a premature death is defined as one that occurs before the age to which the dying person could have been expected to survive according to the life expectancy in the european society. using the daly in studies of health inequalities envisages several advantages. first, the daly is the only measure that can infuse information about non-fatal health outcomes into debated of health inequalities. second, the daly uncouples social and epidemiological assessment of health inequalities from advocacy. third, the daly can measure the magnitude of premature 166 health systems and their evidence based development death and non-fatal health outcomes attributable to proximal biological causes, including diseases and injuries or attributable to more distal causes such as poor living standards, tobacco use or socio-economic determinants. fourth, the daly is a stable measure that can be used for purposes of comparisons either between different communities or between different points of time. 167 case study: inequalities in health as assessed by the burden of disease method exercise: inequalities in health in the european region: what can the burden of disease methodology offer? task: based on the list of key concepts and conclusions revealed under supervision during the group discussion, students will be asked to make a summary of these ideas and select the most 3 important and useful of them on their opinion. give some reasons for this selection. 168 health systems and their evidence based development references 1. mackenbach jp. socio-economic health differences in the netherlands: a review of recent empirical findings. soc sci med 34/3, 213-26, 1992. 2. kunst ae, groenhof f, borgan jk et al. socio-economic inequalities in mortality. methodological problems illustrated with three examples from europe. rev epidemiol sante publique 46/6, 467-479, 1998. 3. mackenbach jp, kunst ae. measuring the magnitude of socio-economic inequalities in health: an overview of available measures illustrated with two examples from europe. soc sci med 44/6, 757-71, 1997. 4. van de mheen h, stronks k, schrijvers ct et al. the influence of adult ill health on occupational class mobility and mobility out of and into employment in the netherlands. soc sci med 49/4, 509-18, 1999. 5. blank n, diderichsen f. inequalities in health: the interaction between socio-economic and personal circumstances. public health 110/3, 157-62, 1996. 6. marmot m, ryff cd, bumpass ll et al. social inequalities in health: next questions and converging evidence. soc sci med 44/6, 901-10, 1997. 7. mackenbach jp, van de mheen h, stronks k. a prospective cohort study investigating the explanation of socio-economic inequalities in health in the netherlands. soc sci med 38/2, 299-308, 1994. 8. williams k. inequalities in health. are they increasing? bmj 310/6976: 399, 1995. 9. mackenbach jp, kunst ae, cavelaars ae et al. socioeconomic inequalities in morbidity and mortality in western europe. the eu working group in socioeconomic inequalities in health. lancet 349/9066, 1655-9, 1997. 10. kunst ae, groenhof f, mackenbach jp. mortality by occupational class among men 30-64 years in 11 european countries. eu working group in socioeconomic inequalities in health. soc sci med 46/11, 1459-76, 1998. 11. wagstaff a, paci p, van doorslaer e. on the measurement of inequalities in health. soc sci med 33/5, 545-57, 1991. 12. valkonen t. problems in the measurement and international comparisons of socio-economic differences in mortality. soc sci med 36/4, 409-18, 1993. 13. murray cj, gakidou ee. health inequalities and social group differences: what should we measure? bull world health organ 77/7, 537-43, 1999. 14. locker d. measuring social inequality in dental health services research: individual, household and area-based measures. community dent health jun 10/2, 139-50, 1993. 15. valerio m, vitullo f. dagli indicatori di sanità e diseguaglianza globali a quelli per microaree (health inequalities: from macro to micro level indicators). giornale italiano di farmacia clinica 12: 146-156, 1998. 16. vitullo f, marchioli r, di mascio r et al. family history and socioeconomic factors as predictors of myocardial infarction, unstable angina and stroke in an italian population. eur j epidemiol 12, 177-185, 1996. 17. koskinen s. västöryhmien terveysja muut hyvinvointierot. tutkimusohjelman taustaselvitys. (variations in health and other dimensions of wellbeing). background report for a research programme (in finish, with english summary). publications of the academy of finland 3/1997. edita, helsinki, 81 pages, 1997. 18. murray cj, lopez j. global burden of disease. world health organisation, world bank and harvard school of public health publications, 1998. 169 case study: inequalities in health as assessed by the burden of disease method 170 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title health technology assessment as a tool for health systems development module: 1.9 ects (suggested): 0.50 author(s), degrees, institution(s) prof. jelena marinkovic, bm, phd the author is professor at the school of medicine at belgrade university. address for correspondence institute of medical statistics and informatics school of medicine, belgrade university dr suboti}a 15 11000 belgrade serbia and montenegro tel: +381 11 685 888 fax: + 381 11 659 533 e-mail: jelena@pcpetak.com keywords health technology assessment, decision-making in health purchasing, policy and practice, quality of care, outcomes research, decentralization/centralization, evidence-based knowledge learning objectives for many years this topic covered financial analysis and acquisition planning for high technology in health care. the basic premise of this course is that the purpose of assessment of a particular technology (including elements of technology itself, patient/citizen, organization and economy) is to discover the „true cost” of health produced by application of that technology. after completing this module students and public health professionals from a variety of backgrounds should: obtain • an overview of a background and origins of health technology assessment • an introduction to the scientific methods and instruments in health technology assessment summarize • the four main elements of a health technology assessment analysis the technology, the patient/citizen, the organization and the economy. • the steps that have to led to the assessed health technology examine • how decision-maker's questions are specified in health technology assessment • how literature is searched and collected • how studies could be designed • how data can be collected and analyzed • how published health technology assessments could be validated abstract health technology assessment methods are evolving and its application are increasingly diverse. this module introduces certain fundamental aspects and issues of a dynamic field of inquiry. broader par 171 health technology assessment as a tool for health systems development ticipation of people with multiple disciplines and different roles is enriching the field. like the information required conducting most assessments, the body of knowledge about health technology assessment cannot be found in one place and is not static. practitioners and users of health technology assessment should not only monitor changes in the field, but they should contribute to its development. content background origins what is health technology? what is health technology assessment? what is the purpose of health technology assessment? is it health technology assessment or a different approach that is needed? what are the main elements of hta analysis? when are health technologies assessments requested? what is the role of ethics in health technology assessment? how is health technology assessment conducted? selected issues in health technology assessment case example references teaching methods teaching methods include: lectures; study of literature in small groups (up to five students); guided discussion on previously done exercises and case problems; preparing a project report (in a group of three students) on one topic for a certain health technology. specific recommendations for teacher the topic allows a good combination of theoretical knowledge with practical skills. knowledge in quantitative and qualitative research designs and measurement issues; various methods from statistical, over informatics to economic is already expected from the student, as well as skills in computer and language.this module should be only first in line with three lectures, 6 exercises and group/individual work (three times). assessment of students project work with defense of the study; and multiple choice questionnaire. h e a l t h t e c h n o l o g y a s s e s s m e n t a s a t o o l f o r h e a l t h s y s t e m s d e v e l o p m e n t jelena marinković worldwide, publicly funded health services are under pressure due to demographic changes, growing expectations, and the development of new technologies. of these three major pressures, new technologies are generating the most concern and the most dramatic response (1,2,3). still, new technologies can benefit health and disability service consumers in many ways. some directly improve quality of life or life expectancy. others act more indirectly, for example, by increasing the efficiency of the health system. however, new technologies are often introduced before there is adequate information about safety, effectiveness and ethical and social acceptability. origins technology assessment (ta) arose in the mid-1960s from an appreciation of the critical role of technology in modern society and its potential for unintended, and sometimes harmful, consequences. experience with the side effects of a multitude of chemical, industrial and agricultural processes, and such services as transportation, health and resource management contributed to this understanding (4). ta was conceived as a way to identify the desirable first-order, intended effects of technologies as well as the higher-order, unintended social, economic and environmental effects (5). health technologies (ht) had been studied for safety, effectiveness, cost, and other concerns long before the advent of health technology assessment (hta). development of ta as a systematic inquiry in the 1960s and 1970s coincided with the introduction of health care technologies that prompted widespread public interest in matters that transcended their immediate health effects. health care technologies were among the topics of early tas. multiphasic health screening, in vitro fertilization, predetermination of the sex of children, retardation of aging and modifying human behavior by neurosurgical, electrical or pharmaceutical means were among the first, „experimental” assessments. 172 health systems and their evidence based development since its early years, hta has been fueled in part by emergence and diffusion of technologies that have evoked social, ethical, legal, and political concerns. among these technologies are contraceptives, organ transplantation, artificial organs, life-sustaining technologies for critically or terminally ill patients, and, more recently, genetic testing and genetic therapy. these technologies have challenged certain societal institutions, codes, and other norms regarding fundamental aspects of human life such as parenthood, heredity, birth, bodily sovereignty, freedom and control of human behavior, and death (6). hta is the only field of ta so far which has gained a distinctive profile in the sense of a particular subject, client, expertise and specialized institutions. hta like ta in general aims at supporting decision making by providing comprehensive information on the preconditions for, and consequences of the implementation of new technologies (7). what is health technology? goodman defines technology as the application of scientific or other organized knowledge including any tool, technique, product, process, method, organization or system to practical tasks. in health care, technology includes drugs; diagnostics, indicators and reagents; devices, equipment and supplies; medical and surgical procedures; support systems; and organizational and managerial systems used in prevention, screening, diagnosis, treatment and rehabilitation (4). according to the world health organization's (who) „health for all policy in the 21st century”, released in january 1998, the scope of technologies for health, extends from those technologies that provide a direct benefit to health (such as molecular genetics, biological, pharmaceuticals, and medical devices), to those that support health system functions (like telecommunications, information technologies, devices for environmental protection and food technologies). the international network of agencies for health technology assessment (inahta) defines health technology as prevention and rehabilitation, vaccines, pharmaceuticals, and devices, medical and surgical procedures, and the systems within which health is protected and maintained (8). under broad definitions such as these, the phrase „health (healthcare, medical) technology” can be used in both diagnostic and therapeutic settings and under either individual or population health approaches. health technologies might include, for example, chemotherapy for cancer, hearing aid techno173 health technology assessment as a tool for health systems development logy, electronic fetal monitoring, population screening for breast cancer, coronary artery bypass surgery, and magnetic resonance imaging. as the field of health technology assessment has evolved, these definitions have come to be seen as a fairly narrow definition of technology. in part, this has been due to a growing recognition that the arrangements and structures for delivery of drugs, device and procedures can have far reaching impacts not only on the use of technology but also outcomes of patients. to reflect the importance of these and other factors a more comprehensive definition of health technology is given by kristensen. he defines very broadly that health technology is the practical application of knowledge in relation to health and disease (9). with the health problem as the starting point, according to bakketeig (10), the aim of the technology can roughly be divided into following: preventive care (aimed at preventing diseases from occurring), screening (aimed at detecting early signs of diseases or risk factor, with the aim to slow down the development of the disease), diagnosis (aimed at identifying the diseases in patients with clinical signs and symptoms), treatment (seeking to maintain health status, cure the patient or provide palliation), rehabilitation (which takes its starting point in the treated, but still ill patient and seeks to restore the functioning or minimize the consequences of dysfunction or defects). what is health technology assessment? while there is no widespread consensus on the definition of health technology assessment, for a long time a widely accepted definition was that of the united states office of technology assessment (ota) that it is the field of research that evaluates the short and long-term consequences of individual medical technologies on individuals and society (11). hta is related to research due to its methods, but is also related to planning, administration, and management due to its focus on decision-making. thus, hta can be seen as a bridge between science paradigm and a policy paradigm (12). in europe in mid nineties hta is seen as a structured analysis of a health technology, a set of related technologies, or a technology-related issue that is performed for the purpose of providing input to a policy decision (13). hta beside the benefits and financial costs of a particular technology or group of technologies also includes studies of ethical and social consequences of technology; factors speeding or impeding development and diffusion of health technology; the effects of public policies on diffusion and use of health tech174 health systems and their evidence based development nology and suggested changes in those policies; and studies on variation in use of technologies (13). goodman defines hta as a systematic evaluation of properties, effects, and/or impacts of health technology. it may address the direct, intended consequences of technologies as well as their indirect, unintended consequences. its main purpose is to inform technology-related policymaking in health care. hta is conducted by interdisciplinary groups using explicit analytical frameworks drawing from a variety of methods (4). the international network on agencies for health technology assessment defines hta as multidisciplinary field of policy analysis that studies the medical, social, ethical, and economic implications of development, diffusion, and use of health technology (8). the broadest one is given by kristensen who defines health technology assessment as a research based, applied assessment of relevant available knowledge of problems, when applying technology in relation to health and disease. hta is a comprehensive, systematic assessment of the conditions for, and the consequences of using health technology (9). what is the purpose of health technology assessment? the purpose of hta is to assist health policy makers, managers and health professionals at local and national levels in making informed decisions both in health purchasing, policy and practice. hta information may be particularly useful in supporting decisions when: an established technology is associated with significant variations in utilization or outcomes, a technology is highly complex or involves significant uncertainty, a technology has high unit or aggregate cost, explicit trade-off decisions must be made in allocating resources among technologies, or a proposed provision is innovative or controversial. the essential properties of hta are the orientation to decision-making and its multidisciplinary and comprehensive nature. the goal of hta is change. that is, it encompasses all methods used by health professionals to promote health, prevent and treat disease, and improve rehabilitation and longterm care. 175 health technology assessment as a tool for health systems development is it health technology assessment or a different approach that is needed? it is useful to clarify whether hta is the right instrument to use for the particular problem because it may conceivably be more beneficial to apply a different approach. according to kristensen et al (9), the set of alternative procedures to clarify the problem are: source: kristensen fb, horder m, poulsen pb (eds.). health technology assessment handbook. danish institute for health technology assessment, 2001. what are the main elements of hta analysis? hta includes analysis and assessment of a number of areas, where use of the health technology may have consequences. these can be divided into four main elements: the technology, the patient/citizen, the organization and the economy. technology. assessment of technology includes the following main aspects that need to be assessed: field of application, effectiveness and risk assessment. this aspect is covered in more details later on. 176 health systems and their evidence based development alternative procedures to clarify the problem 1. health technology assessment 2. a quality-assurance project (if one knows what should be done in particular organizational situation, but what is presently done, is not the right approach). 3. a basis for decision-making developed in the usual administrative framework (if, for instance, a national hta or an hta from region is available). 4. a traditional expert and/or stakeholder committee (if the aspect of stakeholders is very important, or if the opinion of particular expertise desired, or if only little time is available). 5. exclusively a systematic literature review, possibly a meta analysis, to determine the clinical effects and efficiency of the technology. 6. an economic analysis (if sufficient knowledge of the effect and efficiency of the technology is available, and if there are no specific organizational questions). 7. a (primary-) research project (if documented research is simply not available, especially of the clinical effects). patient / citizen. examining the patient / citizen element in hta is covered with very different methods, as regards theoretical basis and application; from field research that includes participant observation, interviews that include focus group, questionnaire surveys to prospective methods. frequently measurement process is based on health status and health-related quality of life concept (4,14,15). organization. the aim of organizational analysis is to pinpoint some of the dimensions, which can be of importance for how interaction between technology, organization and administration develops, i.e. to describe some of the elements, which could play a part in the interaction between the behavioral patterns around technology, and point out possible consequences of different directions (16,17). economy. economy aspect includes economic, budget or business analysis. the first one is far more important and is mainly conducted at societal level, where economic consequences for society, which means everyone who is directly or indirectly affected by technology, are assessed and included. budget analysis is applied when investigating who carries the burden in terms of expenditures and who will benefit from the use of technology. at last, business analysis is conducted when the information about needs for investment and the running costs with respect to a technology are important (18). when are health technology assessment requested? assessments can be requested and conducted at any stage in a technology's life cycle. stages include: conceptual (in the earliest stages of development), experimental or investigational (undergoing initial testing and evaluation), preestablished (adoption of an innovation by certain individuals and institutions); established (considered to be a standard approach and diffused into general use); and outmoded (superseded by another technology or demonstrated to be ineffective or harmful). since technology is constantly evolving, hta must be viewed as an iterative process. it may be necessary to reassess a technology when competing technologies are developed, the technology itself evolves or new information is introduced. 177 health technology assessment as a tool for health systems development what is the role of ethics in health technology assessment? since hta is used to make judgments about what ought to be done with health technologies, there is significant overlap between it and medical ethics. according to goodman (19), conducting a technology assessment requires careful attention to ethical questions, such as: • should all assessments be driven by cost concerns? • are the individuals involved in the selection of topics, the conduct of the assessment, and the use of its results free of conflicts of interest? • are judgments of value implicit in the statement of the assessment problem or the choice of methodology? • are informed consent, patient confidentiality and related means for protecting patient welfare in clinical investigations properly implemented? • do assessments provide means (e.g., in data collection, synthesis and reporting) to determine how technologies challenge prevailing legal standards and societal norms? • are the assessment's recommendations ethically justified? how is health technology assessment conducted? hta process involves: the identification of technology, health or health care problems and possible assessments to address these; the priorization of possible assessments; assessment; dissemination of the findings and conclusions of assessments; the implementation of findings and conclusions in policy and practice, and impact assessment of resulting change. the ten steps listed below, according to goodman, provide a basic classical framework for conducting a health technology assessment (not all assessments involve each of these steps or conduct them in the same sequence) (19): 178 health systems and their evidence based development source: goodman c, snider g, flynn k. health care technology assessment in cva. boston, mass: management decision and research center, washington, dc: health services research and development service, 1996. when new technology is in question this framework has somewhat different stages: source: national health committee. new technology assessment in new zealand. discussion document, 2002. the source of next definitions and descriptions is publication „new technology assessment in new zealand”, published in year 2002 (20). horizon scanning is the process of identifying new and emerging technologies that have the potential to impact on a health system. it essentially involves formal or informal communication between policy makers and experts (21). 179 health technology assessment as a tool for health systems development ten steps of health technology assessment 1. identify and rank assessment topics 2. specify assessment problem 3. determine locus or responsibility of assessment 4. retrieve available evidence 5. collect primary data (as appropriate) 6. interpret evidence 7. synthesize evidence 8. formulate findings and recommendations 9. disseminate findings and recommendations 10. monitor impact of assessment reports a framework for new technology assessment 1. horizon scanning the identification of emerging technologies before they become available for introduction. 2. prioritization for assessment deciding which new or emerging technologies should undergo further assessment. 3. assessment a research-based process designed to determine whether a new technology is safe, efficacious, effective and efficient. 4. appraisal a judgment on the social and ethical acceptability and appropriateness of a new technology. this includes consideration of community need, equity, and opportunity cost. 5. adoption and diffusion the process whereby new technologies are taken up in clinical practice. 6. evaluation the ongoing assessment of a new technology following its introduction. new technology assessment requires significant time, expertise and resources. consequently, it is impossible to assess all emerging technologies. therefore, prioritization for assessment is an essential and crucial part of the framework. there should be an agreed set of criteria against which emerging technologies are prioritized for assessment. the assessment stage is based on empirical research. it aims to establish the effect (safety, efficacy and effectiveness) and efficiency of a new technology. this phase can be costly and labour intensive as it may involve primary research. where possible, a systematic review of the scientific evidence is performed (mainly using scientific literature from peer-reviewed journals). the gold standard test for safety, efficacy and effectiveness is a double-blind randomized controlled trial (rct). however, for several logistical and ethical reasons, it is not possible to conduct double-blind rcts for all new technologies. where double-blind rcts cannot be carried out, it is necessary to rely on the best alternative source of evidence. the task of selecting the best source of evidence is made easier by using well-accepted‚ levels of evidence (22). the efficiency (value for money) of a new technology is predicted by economic evaluation. there are several types of economic analysis that can be used to determine „value for money". these include cost-minimization analysis (cma), cost-effectiveness analysis (cea), cost-benefit analysis (cba) and cost-utility analysis (cua). these may be referred to collectively as efficiency analysis. the appraisal of a new technology involves taking into consideration community need, equity, appropriateness and acceptability, and opportunity cost. in contrast to the assessment phase, appraisal is more of an art than a science. it requires judgments to be made on social values and is informed by understanding of the health and disability sector and society in general. inputs from professionals, consumers and the wider community are considered to be particularly important at the appraisal stage. the adoption and diffusion stage is relatively self explanatory. as a new technology appears to be of value, patients begin to request it and clinicians begin to use it. ideally, a new technology that has been assessed and appraised and found to have a potential benefit will be adopted and diffused into the health and disability sector in a controlled manner; that is, the circumstances in which it is used will be agreed on before the technology has been adopted and diffused. in reality, new technologies tend to be adopted and diffused in a rather dis-organized manner. 180 health systems and their evidence based development new technology assessment should be an iterative process rather than a one-off study. evaluation helps to ensure that this is the case. it involves the monitoring and further studying of a technology once it has been introduced. this might include: preparation of qualitative and quantitative data collection systems to receive data for side effects and complications, appropriateness and acceptability of the community for the new technology and outcome measures conducting scheduled milestone evaluation to determine achievement of target evaluation measures collaboration with clinical evaluation and quality improvement programs (23). evaluation is important because the disease patterns and other characteristics of the population using the technology will inevitably change, and this may have implications for safety, effectiveness, efficiency and so on. in addition, during the initial stages of a technology's life cycle, the skills of practitioners in using the technology are not likely to be much higher. as skill level increases, the balance of risks and benefits associated with the new technology may change considerably. selected issues in health technology assessment quality of care and hta. quality of care is a measure or indicator of the degree to which health care is expected to increase the likelihood of desired health outcomes and is consistent with standards of health care. quality assurance involves a measurement and monitoring function (i.e., quality assessment). hta and quality assurance are distinct yet interdependent processes that contribute to quality of care. hta generates findings that add to our knowledge about the relationship between health care interventions and health care outcomes. this knowledge can be used to develop and revise health care standards, e.g., manufacturing standards, clinical laboratory standards, practice guidelines, and other agreed upon criteria, practices and policies regarding the performance of health care. in summary, hta contributes knowledge used to set standards for health care, and quality assurance is used to determine the extent to which health care providers adhere to these standards (24,25). outcomes research and hta. outcomes research concerns any inquiry into the health benefits of using a technology for a particular problem under general or routine conditions (26). in practice, the term outcomes research has been used interchangeably with the term effectiveness research since the late 1980s to refer to a constellation of methods and characteristics that overlap considerably with hta. centralization and decentralization of hta. although technology assessment have originated as a centralized function conducted by government 181 health technology assessment as a tool for health systems development agencies or other nationalor regional-level organizations, hta is also a decentralized activity conducted by a great variety of organizations that make technology-related policy decisions (27). as noted before, a hta done from a particular perspective may not serve the technology-related policymaking needs of other perspectives. evidence-based health technology assessment. eisenberg considers the next ten lessons for evidence-based technology assessment: innovation and flexibility should guide assessment; technology is more than devices; research and assessments should be linked with coverage; technology assessment is not a one-time exercise; new measures of outcomes should be developed; the community of practice is a laboratory for technology assessment; training and capacity building in technology assessment should be emphasized; better international collaboration will result in global synergy; national resources on technology assessment should be linked and technology assessments should be translated into improved practice (28). the same author writes that „evidencebased technology assessment is a critical public good that can benefit all who are concerned about appropriate use of health services and products. technology itself is rarely inherently good or bad, always or never useful. the challenge is to evaluate when it is effective, for whom it will enhance outcomes, and how it should be implemented or interpreted. health technologies will not reach their potential unless they are translated, used, and continuously evaluated”. case example: the example is related to computer-based delivery of health evidence done as a health technology assessment in report „computer-based delivery of health evidence: a systematic review of randomized controlled trials and systematic reviews of the effectiveness on the process of care and patient outcomes” done by cramer et al from the alberta research centre for child health evidence, university of british columbia, 2003 (29). the basic framework and the explanation are suggested by goodman (19). step 1. identify and rank assessment topics identifying potential topics. /to a large extent, assessment topics are determined, or at least bounded, by the mission or purpose of an organization./ the perspectives opened up by information and communication technology for health and health care go beyond problems of the clinical setting and relate health to general problems of the so called information society. over the past decade, in an effort to assist health professionals with successful182 health systems and their evidence based development ly searching for, translating, and integrating the best clinical evidence at the point-of-care, computer-based evidence delivery systems have been developed. these systems have been designed to assist providers with diagnosis, prescription, managing diseases, and preventing diseases. in addition to assisting health professionals, these systems have been designed to assist health care consumers by guiding them in their health behaviors, treatment options and disease management. ranking topics. /some assessment programs have explicit procedures for setting priorities. others set priorities in ad hoc or informal ways. the following are examples of criteria listed in no particular order that might be used to set assessment priorities: high burden of morbidity or mortality; large number of patients affected; high unit or aggregate cost of a technology or health problem; substantial variations in practice; high potential to improve health outcomes or reduce health risks; availability of sufficient research findings to perform the assessment; scientific, professional or public controversy; need to make regulatory decision; need to make payment decision; available findings not widely disseminated or used by practitioners./ selected topic fulfill most of the criteria listed above and has almost the greatest importance of all ict application in the field of health. step 2. specify assessment problem. /one of the most important aspects of an assessment is to specify clearly the question(s) to be addressed; this will affect all subsequent aspects of the assessment. assessment problem statements should recognize the relation of the new technology to existing technology./ as with any innovative health care intervention, computer-based evidence delivery system need to be rigorously evaluated before their use become widespread (get acquainted with a health on the net foundation hon principles, http://www.hon.ch). the objective of this assessment was to systematically identify and synthesize randomized controlled trials (rct) and systematic reviews (sr) that evaluate the effectiveness of computer-based health evidence delivery systems on the process of care (e. g., compliance with evidence) and / or patient outcomes (e.g., blood pressure). step 3. determine locus of assessment. /the nature of an assessment problem will affect the determination of the most appropriate organization or group to conduct the assessment. a comprehensive assessment addressing multiple attributes of a technology can be very resource-intensive. it can require considerable training and experience in the methods of evidence-based medicine. factors that influence a hta „make or buy” decision include: is an exist183 health technology assessment as a tool for health systems development ing assessment available? if an existing assessment is available, does it address the specific issues of concern to the organization? how recently was it conducted? is the methodology used sufficiently credible? if an existing assessment needs to be updated or is not available, do people in the organization have the time and expertise to perform the required data collection and analyses? if a synthesis of existing information is needed, does the organization have database searching capabilities, staff to retrieve full text articles, and staff trained in the conduct of systematic reviews? if new data are needed, does the organization have the requisite resources and expertise? what methodology will be used? if a consensus of clinical experts is the preferred methodology, does that consensus need to incorporate and reflect the opinions of the organization's own clinicians? will local clinicians accept the results and report recommendations if they do not participate in the assessment?/ step 4. retrieve available evidence. /one of the great challenges in hta is to assemble all of the evidence relevant to a particular technology before conducting a qualitative or quantitative synthesis. although some sources are devoted exclusively to health care topics, others cover the sciences more broadly. multiple sources should be searched to increase the likelihood of retrieving all relevant reports. useful sources for relevant evidence include: computer databases of published literature; computer databases of clinical and administrative data; printed indexes and directories; government reports and monographs; reference lists in available studies, reviews and meta-analyses; special inventories of reports; health newsletters and newspapers; company reports; and colleagues and other investigators. increasingly, most of the sources are accessible via the internet./ evidences are taken from published and unpublished randomized clinical trials and systematic reviews that assess the effectiveness of computerbased evidence delivery systems. in this reviews, a comprehensive search of the literature using following databases: medline (1990-2002), embase (1990-2002), cinahl (1990-2002), cochrane controlled trials register (1990-2002), web of science (1990-2002), and the trial registry of the cochrane effective practice and organization of care group (1990-2002) was done. in addition, two reviewers independently hand-searched the health information and libraries journal (1990-2002), journal of the medical library association (1990-2002), medical reference services quarterly (1990-2002), and the proceedings of the american medical informatics association (19912002). in addition, individuals from companies (more than 60) that produce relevant products were contacted for information about relevant studies. finally, authors of all relevant articles and experts in the field are being con184 health systems and their evidence based development tacted for information on recent, ongoing, or unpublished studies. this comprehensive search of literature at last identified 13 570 documents of which 525 were deemed potentially relevant for the selected assessment question. step 5. collect primary data. /compiling evidence for an assessment may entail collecting new primary data after determining that existing evidence will not adequately address the assessment question(s). methods for generating new data on the effects of health technology ranges from case reports to metaanalysis. the demand for studies of higher methodological rigor (e.g., metaanalysis or rcts) is increasing among health care technology regulators, payers, providers and other decision makers./ step 6. interpret evidence. /evidence interpretation involves classifying the studies, grading the evidence and determining which studies will be included in the synthesis. assessors should use a systematic approach to critically appraise the quality of the available studies. interpreting evidence requires knowledge of investigative methods and statistics./ two reviewers independently screened 525 articles for relevance using a predetermined set of inclusion criteria and identified 57 relevant randomized controlled trials (rct) and 10 relevant systematic reviews. the majority of these studies was rated as having low methodological quality and was therefore open to substantial bias. the majority of the rcts, as well as systematic reviews, were published between 1995-2001 (33 and 9 respectively), and were conducted in north america (46 and 6). step 7. synthesize and consolidate evidence. /for many topics in technology assessment, a definitive study that indicates one technology is better than another does not exist. even where definitive studies do exist, findings from a number of studies often must be combined, synthesized or considered in broader social and economic contexts in order to respond to the particular assessment questions. methods used to combine or synthesize findings from different studies include: systematic reviews, meta-analysis, decision analysis and group judgment or consensus development./ one method for providing an evaluation is to summarize the existing evidence in a systematic review. systematic reviews use explicit and reproducible methods for identifying and selecting primary or integrated studies and assess the methodological quality of each study with respect to the strength of evidence it contains. eighteen of the 57 randomized controlled trials investigated systems designed specifically for patient users, 37 studies investigated systems 185 health technology assessment as a tool for health systems development designed specifically for health care providers, and two studies investigated systems designed for use by both patients and health care providers. five studies investigated diagnosis systems, 30 investigated management systems, one investigated a prediction system, four investigated prescription systems, nine investigated prevention systems, six investigated support systems, and two investigated treatment systems. the primary outcomes measured varied considerably from study to study and were categorized into one of three groups: process of care (e.g., compliance with medical guidelines), patient health (e.g., blood pressure), and other (e.g., knowledge). when the data from these studies were pooled, use of these systems was found to enhance the process of care. however, some studies showed a positive effect of these systems on the process of care whereas other studies did not. the variability among the findings of these studies is likely a result of the various differences between the studies such as the intervention studied, the methodological quality, or the specific outcomes assessed. overall, the use of computer-based evidence delivery systems was not found to have an impact on patient health outcomes. however, there were very few studies that investigated patient health outcomes and in most cases, the studies were too small to detect an effect. in addition, to have an effect on patient health outcomes, these systems must first have an effect on the process of care. thus it may be too early to investigate patient health outcomes. the effect of these systems on the process of care needs to be enhanced prior to investigating their effect on patient health outcomes. six of the ten systematic reviews included studies with experimental designs other than randomized controlled trials and three of the ten assessed studies with designs other than controlled clinical trials. two included investigations of non-computerized as well as computerized information systems. eight reviews investigated the effects of these systems on the process of care and seven found a benefit. the effect of these systems on patient health outcomes was tested in eight systematic reviews and four documented a benefit. these findings are consistent with the findings of the review of randomized controlled trials. step 8. formulate findings and recommendations. /although the terms „findings” and „recommendations” are sometimes used interchangeably, they have different meanings. findings are the results or conclusions of an assessment; recommendations are the suggestions, advice, or counsel that follow from the findings. recommendations can be made in various forms, such as options, practice guidelines or directives./ 186 health systems and their evidence based development firstly, findings compromise that there exists great variability among these computer-based systems and the findings of the studies. thus, there may not be one generic system that works in all environments. there is a need to identify factors that contribute to successful and unsuccessful systems. and, every system needs to be evaluated in the environment where it is implemented. secondly, compliance with evidence is low with and without the use of these systems. therefore, there is the need to identify barriers to the uptake of evidence, and where the barriers are inappropriate, to identify methods to remove them. broadly, several implications and recommendations for future areas of research can be suggested from this review. first, there is considerable potential for improving the dissemination and use of medical evidence. future studies employing a qualitative approach are required to identify the barriers to using medical evidence and, where these barriers are inappropriate, the methods to remove them. in addition, because the results of the included studies varied (i.e., some found a benefit of using a computer-based evidence delivery system others did not) further research needs to focus on identifying the specific aspects of a system that contribute to its success or failure. this information will prove key to developing and implementing computer-based evidence delivery systems in the future. step 9. disseminate the findings and recommendations. /dissemination strategies depend upon the mission or purpose of the organization sponsoring the assessment. dissemination should be planned at the outset of an assessment along with other assessment activities and should include a clear description of the target audience as well as appropriate mechanisms to reach them. the costs, time and other resources needed for dissemination should be budgeted accordingly. dissemination plans do not have to be rigid. the nature of the findings and recommendations themselves may alter the choice of target groups and the types of messages to be delivered. dissemination should be designed to influence the behavior of relevant decision makers./ new primary studies, new technology assessments, new policy on ict by increasing relevance and delivery of information to health professionals and health consumers (get information on health internetwork hin united nations millennium action plan, http://www.healthinternetwork.org /index.php). step 10. monitor impact of assessment reports. /the impact of htas is variable and inconsistently evaluated. plans for monitoring the impact of an assessment report should be considered in the assessment design. some of the 187 health technology assessment as a tool for health systems development effects of a hta report include: acquisition or adoption of a new technology; reduction or discontinuation in the use of a technology; change in behavior; change in the organization or delivery of care; reallocation of national or regional health resources; change in regulatory policy; modification of marketing plan for a technology, … ./. yet too early to say in this case example. 188 health systems and their evidence based development exercises: introduction to health technology assessment task 1: selection and prioritization identify possible health technologies in your country, region or institution that would be worth of assessment. define the criteria for prioritization and select the one technology worth assessing. task 2: planning / policy questions should there be a wish to introduce a public offer of influenza vaccination of the elderly, how should this be organized and what would the effects and costs be? task 3: hta questions derive hta questions for influenza vaccination of the elderly keeping in mind that they have to be clearly worded, defined, answerable and limited in number. task 4: define project group define complete project management for assessment of influenza vaccination of the elderly. task 5: a hta is to a large extent based on available evidence. list possible sources for any literature review. perform a literature review with previously defined search protocol for „influenza vaccination of the elderly” concerning hta question technology: what is the expected survival of the elderly, who are vaccinated against influenza, compared to elderly, who are not vaccinated? perform a literature review with previously defined search protocol for „influenza vaccination of the elderly” concerning hta question patient: what do the elderly think of influenza vaccination? task 6: if the literature review didn't give enough scientific documentation there is a need for performing one's own study of the effect of health technology. design studies for hta questions cited in e2-e5. what are possible sources of bias in selected designs? define advantages and disadvantages in selected designs. how would you measure validity in previously designed studies? if you choose to measure health status, what type of instruments can you use? 189 health technology assessment as a tool for health systems development case problems: a. most of the studies on health technology assessment covered new therapeutic and diagnostic health technologies and medical treatments basically concerning economic aspect and medical or patients benefits. this is a common result of few studies realized and published in mid nineties. what is situation today? b. the inclusion of an unbiased sample of relevant studies is central to the validity of systematic reviews and meta-analysis. time-consuming and costly literature searches, which cover the grey literature and all relevant languages and databases, are normally recommended to prevent reporting biases. however, the size and direction of these effects is unclear at present. there may be trade-offs between timeliness, cost and the quality of systematic reviews. it seems that there has to be an answer on the question: how important are comprehensive literature searches and the assessment of trial quality in systematic reviews? c. telehealth has become widespread in the last two decades in developed countries, despite the generally poor scientific evidence available to support its use. telehealth, telemedicine, or e-health is defined as the use of information and communication technologies to deliver health services, expertise and information over distance, geographic, time, social and cultural barriers. telehealth encompasses internet or web-based „e-health", as well as videobased applications. applications can be real-time or store-and-forward. how would you provide an information base to assist policyand decision-makers, researchers and health professionals in their deliberation about telehealth? provide an overview of the areas of strength and weakness, identify gaps and review policy implications. d. screening for gestational diabetes mellitus has been controversial, with some expert bodies advising universal screening, others selective screening, and yet others advising against screening at all. this has partly been a result of debate about the definition of gestational diabetes mellitus, and partly because of the profusion of different tests available, both for screening and definitive diagnosis. in the country x, there is no national policy on screening, and a variety of practices exist in different parts of the country. there 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donaldson ms, sox hc. setting priorities for health technology assessment: a model process. national academy press, washington, d.c. 1992. 12. battista rn, hodge mj. the development of the health care technology assessment: an international perspective. international journal of technology assessment in health care 1995: 11(2): 287-300. 13. eur assess project subgroup. introduction to the eur assess report. international journal of technology assessment in health care 1997: 13:133-143. 14. poulsen b. the patient: measurement of health status. in: kristensen fb, horder m, poulsen pb (eds.). health technology assessment handbook. danish institute for health technology assessment, 2001. p. 56-65. 15. timm h, hanses hp, morgall j, sigmund h. the patient: field research, interview and questionnaire studies. in: kristensen fb, horder m, poulsen pb (eds.). health technology assessment handbook. danish institute for health technology assessment; 2001. p. 37-55. 16. vrangboek k. the organisation: hta administration and organisation. in: kristensen fb, horder m, poulsen pb (eds.). health technology assessment handbook. danish institute for health technology assessment; 2001. p. 67-84. 17. tryggestad k, borum f. the organisation. in: kristensen fb, horder m, poulsen pb (eds.). health technology assessment handbook. danish institute for health technology assessment; 2001. p. 85-95. 18. poulsen pb. the economy. in: kristensen fb, horder m, poulsen pb (eds.). health technology assessment handbook. danish institute for health technology assessment; 2001. p. 96-121. 19. goodman c, snider g, flynn k. health care technology assessment in cva. boston, mass: management decision and research center, washington, dc: health services research and development service, 1996. 191 health technology assessment as a tool for health systems development 20. national health committee. new technology assessment in new zealand. discussion document, 2002. 21. banta d, gelijns a. an early system for the identification and assessment of future health care technology: the dutch stg project. international journal of technology assessment in health care 1998: 14(4): 607-612. 22. centre for evidence-based medicine. levels of evidence and grades of recommendations, 2002, http://cebm.jr2.ox.ac.uk/docs/levels.html (10.06.2003.) 23. stevens a, robert g, gabbay j. identifying new health care technologies in the united kingdom. international journal of technology assessment in health care 1997: 13(1): 5667. 24. lohr kn ed. institute of medicine. medicare: a strategy for quality assurance. volume i. washington, dc: national academy press, 1990. 25. lohr kn, rettig ra, eds. quality of care and technology assessment. report of a forum of the council on health care technology. washington, dc: national academy press, 1988. 26. brook rh, lohr kn. efficacy, effectiveness, variations, and quality: boundary-crossing research. medical care 1985: 23 (5): 710-722. 27. rettig ra. healthcare in transition: technology assessment in the private sector. santa monica, ca.: rand, 1997. 28. eisenberg jm. ten lessons for evidence-based technology assessment. jama 1999: 282 (19): 1865-1869. 29. cramer k, hartling l, wiebe n, russell k, crumley e, pusic m, klassen tp. computerbased delivery of health evidence: a systematic review of randomised controlled trials and systematic reviews of the effectiveness on the process of care and patient outcomes. alberta heritage foundation for medical research 2003. http://www.ahfmr.ab.ca/grants/ state_of_science_final_reports.shtml (15.07.2003) recommended readings 1. goodman c. ta101. introduction to health care technology assessment. national information center on health services research & health care technology (nichr), 1998. national library of medicine: http://www.nlm.nih.gov (20.06.2003). 2. kristensen fb, horder m, poulsen pb (eds.). health technology assessment handbook. danish institute for health technology assessment, 2001. 3. sox hc, blatt ma, higgins mc, marton ki. medical decision making. butterworths, boston, 1988. 4. drummond mf, o'brien b, stoddart gl, torrence gw. methods for the economic evaluation of health care programmes. oxford medical publications, oxford, 2nd edition, 1997. 192 health systems and their evidence based development 193 comparative research on regional health systems in europe health systems and their evidence based development a handbook for teachers, researchers and health professionals title comparative research on regional health systems in europe module: 1.10 ects (suggested): 0.75 authors, degrees, institutions birgit cornelius – taylor, mph who european office for integrated health care services marc aureli 22-36 e-08006 barcelona spain tel: +34 93 241 8270 fax: +34 93 241 8271 e-mail: bct@es.euro.who.int ulrich laaser, dtm&h, mph, professor faculty of health sciences, section for international public health, university of bielefeld, germany address for correspondence prof. dr. med. ulrich laaser dtm&h, mph section of international public health (s-iph) faculty of health sciences university of bielefeld pob 10 01 31, d-33501 bielefeld germany tel/am/fax: +49-521-450116 e-mail: ulrich.laaser@uni-bielefeld.de keywords health systems, benchmarking, tracer concept, regional health management, measles vaccination, breast cancer screening, european union learning objectives after completing this module students and public health professionals should have: • explored the methodology of comparative analysis of regional health services in europe, • received a sound knowledge of 2 selected public health programmes in 4 of 8 european regions, • completed an analogous analysis of their region of origin. abstract because of the rapid changes and in search for cost-efficiency, quality and professional excellence, the health systems in europe are undergoing comparative analysis tends to focus on selected services in defined subnational regions in order to obtain relevant information for benchmarking. in this module 2 programmes (measles vaccination and breast cancer screening) are described in detail for 8 european regions according to defined categories. teaching methods teaching methods include an introductory lecture based on the introductory module, students’ individual work under the supervision of teacher and interactive methods such as small group discussion. after the introductory lecture students will work individually or in teams of 2 or 3 on the exercises, each followed by a small presentation and discussion with the full group. specific recommendations for teacher it is recommended that the module should be organized within 0.75 ects credits, out of which one third will be done under supervision, while the rest is individual student’s work. teacher should advise students to use as much as possible electronic libraries during individual work to gather ideas how to write and present their own case problems. assessment of students individual presentation and group reports. comparative analysis of regional health care systems in the european union birgit cornelius – taylor, ulrich laaser in the european union the health sector until very recently remained exclusively a national domain. however repeated decisions of the european high court during the last years made clear that health services are to be considered as subject under the so-called four freedoms (full mobility of persons, goods, services and capital within the european union) even though the health market is not an unrestricted competitive market (1). this means e.g. that in the future patients can ask for medical services throughout the eu and will be covered by their health insurance or other payment mechanisms at home. an electronic health insurance card is presently tested and will be introduced in 200406. in the public health field this harmonisation of inherited national structures is even more advanced, very much enhanced by the treaties of maastricht and amsterdam with their articles on the public health mandate of the european commission acc. to article 129 resp. 152 (2). all health systems in europe are presently under reform, be it in the western states because of the need to curb costs especially for the employers in order to remain competitive in a globalising world economy, or be it in the eastern states regarding the transition from the prior socialist system to a modern one, usually a mix of beveridge and bismarck elements. this makes a comparative analysis difficult because of the frequent legislative changes as well as because of the emergence of regional solutions, e.g. in the so-called euroregions in border areas between member states (foremost between germany, france and benelux but developing also between germany and poland). it is against this background that analysts prefer to concentrate on selected services as so-called tracers in defined regions to establish valid comparisons which can be used for benchmarking or measuring relative performance for a selected set of defined criteria (e.g. 3). for the following analysis preference has been given to the public health aspects and to this purpose measles immunisation programmes and breast cancer screening programmes have been chosen in selected countries and regions (table 1). the descriptive part is taken with permission from the eu-project „benchmarking regional health management ben rhm” (4). 194 health systems and their evidence based development table 1. comparative analysis of regional health care systems for a comparative analysis specific categories are employed (table 2): table 2. analytic categories for regional comparison of preventive health care of the 8 regional reports listed in table 1 the following 4 are made available below. 195 comparative research on regional health systems in europe no. country region 1) austria upper austria 2) czech republic moravian-silesian region 3) united kingdom england 4) greece western greece 5) germany northrhine-westphalia 6) ireland eastern / midland / north-eastern regions 7) italy veneto 8) sweden stockholm no. category 1 demography 2 organisation and structure of the regional health system 3 measles immunisation programmes 3.1 organisation of programmes 3.2 vaccination strategy 3.3 information and education 3.4 programme related projects/campaigns 3.5 vaccination documentation and data collection 3.6 programme monitoring and evaluation 3.7 disease surveillance 4 breast cancer screening programmes 4.1 screening strategy 4.2 dissemination of results 4.3 information and education 4.4 programme related projects/campaigns 4.5 programme monitoring and evaluation 4.6 disease surveillance 2) moravian-silesian region – czech republic 2.1 demography moravia-silesia is one of 14 regions in the czech republic with about 1.26 million of the country’s roughly 10 million inhabitants. 0.62 million of the inhabitants are male and 0.65 million female. the region lies in the eastern part of the country, which shares borders to poland and slovakia, and is divided into six districts. moravia-silesia covers an area of 5 554 km2 with a population density of 234 inhabitants per km2. 2.2 organisation and structure of the health system the health system in the czech republic has undergone several changes and reforms, some of which are still ongoing. decentralisation of the health care system (mainly focused on ambulatory services) is a major feature of the reforms, but its implementation is not yet complete. the task of health care has been delegated to health insurance funds, which are under the supervision of the state. the ministry of health is responsible for the preparation of health care legislation, health and medical research, for the licensing of pharmaceuticals and medical technology and for the management of two institutes for postgraduate education and training of health professionals. it also organises the joint negotiations concerning the list of services covered by health insurance which serves as the fee schedule. the ministry directly manages regional hospitals, university hospitals, specialised health care facilities and institutions for research and postgraduate education. following the dissolution of both the district institutes of national health and the regional institutes of national health, state health administration was incorporated into the district authorities in the form of health offices headed by district health officers. the district health officers are under the direct supervision of the ministry of interior affairs, whilst the ministry of health provides methodological guidance and supervision. the district health officers are, however, legally responsible for ensuring that accessible health services are provided in their areas. in line with recent reforms, hygienic services (public health services) no longer exist at the district level. the whole system is now based at the regional level, with the regional public health institutes being responsible for public health in the whole region. these institutions are responsible for 196 health systems and their evidence based development epidemiological surveillance, immunisation logistics and safety measures concerning environmental hazards, food and other areas (european observatory on health care systems 2000a). 2.3 measles immunisation programmes immunisation programmes are generally covered by the national legislation within the public health protection act from the year 2000. the provision of immunisation by the responsible organisations is obligatory and parents have to have their children immunised against diseases covered in the child immunisation programme. the state is responsible for the welfare of children and youth up to the age of 21 and has the right to force parents to have their children immunised. the routine obligatory vaccination against measles started in 1969 in the czech republic. a two doses strategy was introduced in 1974. organisation of programmes the ministry of health together with the public health institutions at regional level plans the national immunisation programmes. the national institute of public health, which falls under the department of public health in the ministry of health, in co-operation with regional public health institutes prepared a national public health policy which includes the targets of the immunisation programmes. regional measles immunisation programmes are part of the national immunisation programme and are basically organised similarly in all regions. regional immunisation programmes are drawn up by district public health officers who prepare the programmes to reflect the national policy. the programmes are financed from the national budget via the regional public health institutes. the department of epidemiology in each regional public health institute is responsible for the implementation of the measles immunisation programmes. paediatricians, in their role as primary health care providers are responsible for preventive services such as immunisation and co-operate with the public health institutes at both regional and district level (figure 1). 197 comparative research on regional health systems in europe figure 1. organisation plan for the measles immunisation programme in moravia-silesia statutory accountability co-operation vaccination strategy the two dose mmr vaccine is carried out with the first dose being given at 15 months and the second at 21-25 months of age. the mmr vaccine was introduced in the czech republic in 1996, prior to which a local vaccine called mopavac divacine had been given. the moravian-silesian region has a special computerised system, isid (information system for immunisation of children) which it uses to invite and remind parents to take their children for vaccination. this system is not used by all other regions in the country. at birth, each child is registered, and allocated a paediatrician by the respective district public health institute, which forwards the information to the regional public health institute. the regional public health institute maintains a register of all children in the region and their respective 198 health systems and their evidence based development ministry of health department of public health moh regional public health institutions (rphi) department of epidemiology (doepi) national institute of public health paediatricians district health officers paediatricians. when a particular vaccination is due, the regional institute sends a letter of invitation to the parents, giving information about which inoculation is necessary and their appointment at the paediatrician. the paediatrician is informed of those children required to attend for vaccination on a particular day and is expected to inform the regional public health institute of available appointments for the administration of vaccinations. in the case of non-attendance, the paediatricians send a reminder to the parents. should the child still not attend, the regional public health institute then explains the importance of the vaccination to the parents. two of the 6 districts in the region do not have the computerised system and the paediatricians there have to organise the invitation of parents themselves. the invitation system run by the regional office is financed by the municipality in ostrava, where the office is located. the ministry of health provides each region with vaccine, which is distributed as necessary to the district public health institutes, from which paediatricians order their vaccines. the regional public health institute is responsible for checking that appropriate conditions are maintained for the storage of vaccines. information and education although no systematic measurement of public opinion has been undertaken, the measles vaccination programme is generally considered to be good and well accepted. public health authorities organise special training workshops for paediatricians in the districts once or twice a year. the participation is voluntary and carried out by the health insurance companies and medical board. programme related projects/campaigns at present there are no campaigns or projects related to measles immunisation being organised. the measles uptake rate is very high for both the first and second doses of mmr and the region of moravia-silesia has had no measles incidence in the past 4 or 5 years. 199 comparative research on regional health systems in europe 200 health systems and their evidence based development vaccination documentation/data collection there are three levels of vaccination documentation in moraviasilesia, two of which are country-wide. it is the duty of the paediatrician to record the date, type and batch number of the vaccine given in the child’s medical record. secondly, the paediatrician has to enter the vaccination details on the child’s vaccination certificate, which is held by the parents. the third form of documentation, which is only regional involves the computerised documentation of the vaccination details. the paediatrician returns the list of children he/she received from the regional public health institute, having marked the children who attended. information such as vaccination coverage of children of a particular age can be obtained from the computerised system for any chosen period or point in time. paediatricians also check the immunisation of their patients in the vaccination certificates during each medical or preventive examination. disease surveillance together with the introduction of the obligatory measles vaccination programme in 1969, a national surveillance system for measles was introduced. the national institute of public health in prague is responsible for the national surveillance of measles in the czech republic; there are two national reporting systems, one for all infectious diseases in the country and one covering vaccine related complications. annual reports on the data are published in print form and on the internet. 2.4 breast cancer screening programmes a professional breast examination programme has been included in the czech national oncological prevention programme since 2002. gps and gynaecologists carry out breast examination as part of preventive examinations offered to women between 45 and 69 years of age every two years. there are no special campaigns, information events or projects held in relation to professional breast examination, as the participation in the oncological prevention programme is assumed to be quite high, though dependant on educational and social background. breast self examination has been part of the national public health promotion agenda for a long time. although strictly speaking no programme exists, a lot of information (pamphlets, brochures, booklets, posters) have been published and distributed to the public in general. discussions are held in schools and clinics and gps and gynaecologists discuss the issue with their patients. mammography screening programmes are in the process of being implemented in some parts of the czech republic. in the moravian-silesian region, the programme officially started on the 2nd of september 2002 and up to the end of march 2003, eight screening units were involved, four of them based in ostrava, the regional capital city. at this time, there are 49 accredited screening units nation-wide. organisation of programmes the mammography screening programme was suggested by physicians, who felt the need to have a proper screening methodology for the population. endorsed by the ministry of health, a national committee consisting of radiologists and other specialists was established with the responsibility of accrediting and organising quality assurance checks of the workplace-units. each unit must conduct a minimum of 5000 mammographies per year and fulfil the technical requirements to achieve and maintain accreditation. although health insurance companies are not directly involved in the organisation and implementation of the screening programmes, the accredited screening units negotiate directly with health insurance companies over finances. even though national meetings are organised for all screening units within the mammography screening programme, no real co-operation amongst units in the same region is evident. screening strategy the screening programme is targeting women in the 45-69 years agegroup. since no invitation system operates in the moravian-silesian region, patients are referred by their gynaecologist or gp. following their first appointment the unit’s computer uses the stored patient data to generate invites for repeat checks. at the initial attendance, women are requested to complete questionnaires on family risk factors, breast self-examination experience and results, hormonal therapy and general medical history. 201 comparative research on regional health systems in europe dissemination of results the national screening programme recommends that mammograms are to be read by two experienced radiologists whilst the patient is waiting, and results given out immediately. this is however not always possible, as some units do not have the necessary number of radiologists to do this, in which case, the results are sent to the referring physician within three days of the mammogram. should the mammogram be unclear or abnormalities are seen, the woman is invited for further assessment. information and education a lot of publicity, mainly through the popular media, has accompanied the establishment of mammography screening programmes. this, together with the recent rising interest of citizens in matters concerning their health, has led to a lot of interest from the public in general and women in particular. women in moravia-silesia have been known to go to their gynaecologist and request to be referred for mammography screening. gynaecologists, thus, find it easier to convince their patients of the necessity of the screening procedure. one problem, which still has to be solved, is that of how to approach and also raise the interest of women with low educational backgrounds and/or from the lower social class. information events are also organised for gynaecologists where they are informed about the aims and objectives of the programme. further education / training courses and meetings are also organised for radiologists and other professions involved in the programme. programme monitoring and evaluation in moravia-silesia no programme evaluation has been conducted up to date, as the programme itself is still quite young; it is however, planned on an annual basis. the national committee responsible for accreditation of units will inspect all units yearly and the accreditation will be renewed annually. the success of the screening programme will be measured using determinants such as attendance rates, cancer detection rate and further assessment referral rate. disease surveillance cancer registration is maintained nationally by the institute of informatics and statistics in prague. all gynaecologists and physicians are bound by law to report all cases of cancer diagnosed to the nearest public health authority at the district or regional level. the public health authorities 202 health systems and their evidence based development then forward the information to the institute of informatics and statistics for entry into the national cancer registry. 5) north rhine-westphalia, germany 5.1 demography north rhine-westphalia (nrw) is one of the 16 german federal states with a total population of 18 million inhabitants. this corresponds to about 22% of the german population. it covers an area of 34,080 km2. with 530 persons per km2, nrw’s population density is more than twice as high as the german average. further demographic characteristics of the state of nrw are as follows: with 2 million people, nrw’s migrants account for about 11.4% of the state’s population. 5.2 organisation and structure of the health care system germany is a federal republic with 16 federal states, and each of them has its own constitution which is in accord with the german federal constitution. the sharing of decision-making powers between federal and state level is a fundamental aspect of the political system and thus also of the health system. the german health care system is primarily characterised through the development of health insurance funds. the statutory health insurance system (gkv), which was set up under the federal government’s social legislation scheme, provides insurance protection for about 90% of germany’s citizens since gkv membership is obligatory for employees up to a fixed income level. 203 comparative research on regional health systems in europe males: 8.82 million (49%) females: 9.18 million (51%) of the almost 880,000 inhabitants of the age group 0-4 years, 450,000 are males and 430,000 females. the female population of the age groups 50-69 years targeted for mammography screening (a total of 2.13 million) can be broken down into the following categories: age group in years number 50 – 54 470,000 55 – 59 490,000 60 – 64 590,000 65 – 69 580,000 in addition to the health insurance funds as financing bodies on the one hand, germany’s health care system is characterised through its doctors, dentists, pharmacists and hospital organisations as service providers on the other hand. like health insurance funds they are organised as public corporations and/or associations and perform their tasks as self-administered bodies, i.e. within the framework of federal government regulations and supervision they are authorised to perform all functions under their own responsibility. the federal government defines the organisational structure of the self-government system through legislation and decrees in the social codes (above all social code v). at regional level, the german states are responsible for hospital planning, hospital investments and for the public health service. for these areas they have their own decision-making powers but also the possibility to exert influence on the governments’ statutory health insurance legislation through their representatives in the german bundesrat. 5.3 measles vaccination programmes before the reunification of the former gdr and west germany in 1990, both countries differed considerably in their approaches to measles surveillance, vaccination strategies and the provision with vaccines. the former gdr had a highly centralised health system. in 1970, the voluntary single measles vaccination, which had been introduced in 1967, was made obligatory by law for children aged 8 months or older. the public health service played a central role in the implementation and registration of the vaccination. in 1986, a second vaccination was introduced as a matter of routine 6-12 months after the first vaccination. in the federal republic of germany, measles vaccination was generally carried out on a voluntary basis and recommended for infants aged 12 months or older. in 1980, the combined measles, mumps, and rubella vaccination was introduced, with a recommended second vaccination from the year 1991 onwards. after the german reunification, this practice was also adopted for the states of the former gdr. 204 health systems and their evidence based development organisation of vaccination programmes the legal basis for the prevention and fighting of infectious diseases – among others also for protective vaccinations – in the federal republic of germany is the infectious disease control act (ifsg) which entered into force on 1 january 2001. under this act obligatory notification of measles cases was introduced for the first time all over germany and the health departments were obliged to ascertain the vaccination status of children during school entrance examinations. up to that time, the vaccination status had been identified during school entrance examinations in nrw on a voluntary basis. there is no compulsory vaccination in the federal republic of germany. recommendations for vaccinations are worked out in accordance with state-of-the-art-knowledge by an expert committee, the standing vaccination committee (stiko) of the robert-koch-institute in berlin. the list of vaccinations recommended by stiko comprises standard vaccinations for infants, children, adolescents and adults including the recommended age at which the vaccination should be taken and the minimum intervals between the vaccinations. the individual german states decide for themselves whether they will adopt these recommendations without any changes. in nrw, the correspondingly latest stiko recommendations are regarded as official recommendations. the individual german states also decide for themselves about the planning and implementation of vaccination programmes as well as about their main focuses. vaccination programmes can be carried out both at state and local level, as single actions or as concerted actions. the who target to eliminate measles by the year 2007 is explicitly supported by the federal republic of germany. so at the 71st health ministers’ conference (gmk) in 1998, the responsible health ministers and senators decided to take concerted measures for the combat of measles together with the federal government, the public health service (ögd), the health insurance funds, the chambers of physicians and further partners. participation in measles’ vaccination programmes shall be considerably increased and the incidence of measles reduced by 90% in germany within the next years. in a move to implement this resolution, an action programme for the prevention of measles, mumps and rubella was adopted at nrw’s 10th state health conference which includes all major actors involved in nrw’s health care sector. members of this body are representatives of the chambers of the medical care professions, associations of panel doctors, social insurance funds, 205 comparative research on regional health systems in europe hospital society, charitable organisations, self-help initiatives, trade unions, employers’ associations and of the public health service. this action programme in nrw provides for various measures at different levels (state and local level) which support and supplement each other. the different organisations and authorities which are involved in implementing the measles’ vaccination programmes in nrw as well as the levels at which they act, can be taken from the following organisation plan (organograph) below (figure 2). 206 health systems and their evidence based development figure 2. organisation plan for the measles immunisation programme in north-rhine westphalia instructions development of programmes notification vaccination strategy recommendations for a first and second measles, mumps and rubella vaccination have been in force for germany since 1991. in its july 2001 recommendations, stiko supports the first mmr vaccination for children between their completed 11th and 14th month of life and the second between their completed 15th and 23rd month of life. missing vaccinations should be received by the 18th year of life at the latest. 207 comparative research on regional health systems in europe federal government federal ministry for health and social security standing vaccination committee (stiko) infectious disease control act ifsg sickness funds vaccination programmes doctors (family doctors, paediatricians) preparatory committee of the nrw state health conference institute of public health (lögd) local health departments robert-koch-institute (rki) nrw state government ministry for health, social affairs, women and family nrw vaccinations are given following consent from the parents/legal guardians who also have the right to opt against vaccination for their children. there is no automatic invitation or reminder system for vaccination attendance. at the birth of their children, parents are issued with a vaccination card together with a child health record booklet which they should bring with them each time they see their doctor. parents learn about the stiko recommendations from a vaccination plan they can get from their paediatrician, family doctor or from the sickness funds. thus it is in most cases within the responsibility of the parents to survey and observe these deadlines and to make the required appointments with their paediatrician or family doctor. the vaccinations are mostly carried out by the paediatrician or family doctor in his/her practice rooms. doctors order the vaccines from pharmacies and forward their claims to the statutory health insurance funds (gkv) via the association of panel doctors. information and education parents/legal guardians are amongst others also informed about the procedure and necessity of measles vaccinations when they see their paediatrician or family doctor. another opportunity for information is provided by the school entrance examination, which is carried out by the medical staff of the health departments. surveys in germany have shown that the doctor’s advice is paramount in influencing the decision for vaccination. information campaigns on vaccinations therefore regularly include doctors and physicians. the latest stiko recommendations are conveyed by the federal chamber of physicians to the chambers of physicians at state level which then inform the doctors. at the same time doctors are informed through publications in the corresponding medical journals or through additional vaccination seminars which are organised by the chamber of physicians. to inform the population about vaccinations, north rhine-westphalia uses various methods. these include the telephone announcement service of the ministry for health, social affairs,women and family (mgsff). under a service telephone number interested citizens are informed at two-week intervals about topical issues from the health care sector through the announcement service. this also includes an announcement text on vaccinations. through publications from the press release office of the mgsff, the population in nrw is also informed about this issue. moreover, mgsff has also issued its own flyer on measles, mumps and rubella which can also be used by the health departments in nrw for vaccination campaigns. 208 health systems and their evidence based development for local vaccination campaigns, the health departments turn directly to the regional media (e.g. local press, radio stations) and issue their own press releases. health insurance funds use their magazines to inform their members at irregular intervals. programme-related projects/campaigns the action programme for the prevention of measles, mumps and rubella adopted by the 10th state health conference in august 2001 is aimed at a permanent increase in vaccination levels among children and adolescents in nrw. the background are the presently still high incidence figures particularly for measles as well as the risk potential resulting from inadequate vaccination levels against mumps and rubella. activities at state level for the planning, coordination and implementation of supra-regional vaccination programmes, nrw has the institute of public health nrw (lögd) at its disposal. in addition to its functions stipulated in nrw’s legislation as a „public health coordination centre” and „official nrw authority for the surveillance of infectious diseases” (in accordance with sec 11 infectious disease control act) the management of local vaccination data through the lögd as a service provider supplements the requirements for this function. the list of measures conceived by the lögd is aimed at abolishing deficits in knowledge, motivation and implementation of the vaccination idea both within the population and in the health sector. important single measures of this campaign are the early identification of the vaccination status as early as at kindergarten entrance, improved vaccination information campaigns in schools and companies, improved qualifications of those working in the health sector, the targeted improvement of vaccination levels by sending a mobile vaccination unit to the municipalities as well as a continuous evaluation and publishing of the activities carried out. important partners during implementation phases are in particular the local health conferences as well as the health departments in the municipalities. activities of the local health conferences an important body for the discussion and implementation of measures also with regard to protective vaccinations in nrw are the local health conferences. members are health care actors involved in health promotion and health care for the population, self-help groups and institutions for health care 209 comparative research on regional health systems in europe and patients’ rights protection as well as members of the council or district assembly responsible for health. together, as an independent body, the local health conferences deliberate on various thematic topics and questions of interest in health care at the local level with the objective of coordinating them and if required give recommendations for action. these recommendations are implemented under the self-commitment of the actors involved. these agree joint solutions at the local level and initiate their own actions such as for example actions for the prevention of measles, mumps and rubella. to support these activities, the lögd has developed a planning programme for mmr. activities of the individual health departments there are 54 health departments in nrw which are part of the local self-government system. as implementation level of the public health service, they are among other things responsible for important tasks pertaining to hygiene control and the promotion of health protection at population level. in addition to the identification of the vaccination status at school entrance examinations, these tasks also include vaccination activities which are based on recommendations for action given by the local health conferences or which can be decided by the health departments themselves. they are primarily guided in their actions by the principle of respecting the subsidiary sharing of tasks according to which the implementation of officially recommended regular vaccinations primarily falls within the responsibility of practising doctors and measures of the public health service should only be aimed at improving vaccination levels. vaccination documentation/data collection in accordance with the infectious disease control act (ifsg), the vaccinating doctor is obliged to register every protection vaccination on a vaccination card or, if it has not been submitted, to issue a vaccination certification. the kind of data to be documented is also fixed in the infectious disease control act. there are no further documentation methods such as for example a vaccination register. the vaccination status of children is identified during school entrance examinations which are required for school entrance. all children and/or their accompanying parents are requested but not forced to bring the vaccination card. for nrw figures from the year 2000 show that of 137,284 children who 210 health systems and their evidence based development had participated in the school entrance examination and had been issued with a vaccination card almost 90% had received the first mmr vaccination but only 14% the second vaccination. as stipulated in the infectious disease control act, the health departments are obliged to transmit vaccination data collected during school entrance examinations in an anonymised and aggregate form to the robertkoch-institute via the superior state health authorities. the institute of public health annually publishes the data available from school entrance examinations in nrw and thus also the vaccination data. disease surveillance with the entering into force of the infectious disease control act on january 1st 2001 all clinically and laboratory-confirmed measle cases were made notifiable in germany. the infectious disease control act stipulates that independently from each other both the attending doctor and the confirming laboratory are obliged to report the name of the measles patient. the task of putting both kinds of information together into one case and if necessary to conduct further inquiries falls within the responsibility of the health department. the notification deadline of 24 hours and the extent of facts and information to be notified are also stipulated by law. this process has to be distinguished from the notification procedure from the health department to nrw’s state authorities and rki. it differs from the above-described procedure both with regard to the extent and deadline of the notification. in accordance with sec 11 of the infectious disease control act, anonymised data have to be transferred to nrw’s state authority by the third working day of the following week after the health department has received the notification. the state authority again has to transfer the data within one week to the rki. the responsible state authority at the lögd is charged with the tasks of pooling, quality control and surveillance of the notifications they receive from all 54 districts and/or self-administered cities in nrw. this also includes publishing the information on the internet without delays to ensure a backflow of information as part of a closed data cycle. at federal level, the same tasks are performed by the robert-koch-institute. with the publication of the data in the „epidemiologisches bulletin”, on average about 3 weeks after having registered the notification, the data are given official character. to complement this routine notification procedure, in october 1999 a measles sentinel for the continuous and immediate registration of measles 211 comparative research on regional health systems in europe cases was set up at the national level. in this study called „arbeitsgemeinschaft masern” (agm) about 1.200 physicians, in most cases paediatricians, on a voluntary basis collect data on the seasonal, regional and age-specific distribution of measles in germany. of special importance are data which can only be gained through this – from the ifsg notification procedure – independent system on the individual development of the disease, on the precise vaccination status and on the results of comprehensive laboratory diagnoses. the latter in particular provide indisputable contributions to assessing the effectivity of the vaccination. both registration systems, which presently exist simultaneously, ensure good national surveillance as a prerequisite for the further systematic fighting of measles with the objective of their eradication. 5.4 breast cancer screening programmes medical breast examinations are carried out throughout germany based on the early cancer detection act contained in social code v in accordance with the guidelines of the german national doctors’ and sickness funds’ associations. they are part of the annual cancer screenings which are offered to all women aged 30 years and/or older and include palpation of the breast and lymphatic nodes and an instruction for breast self-examination. in the case of suspicious palpation findings further steps are taken in cooperation with the correspondingly specialised diagnosis and treatment centres. both sickness funds and panel doctors’ associations as well as organisations for the combat of cancer at the regional level and self-help groups are involved in informing the public about screening programmes which include breast examinations. breast self-examination in the same way there is no programme for breast self examination. women take their instructions from flyers or brochures they get from their gynaecologists or from information campaigns. according to nrw’s health ministry, less than 50% of the women take part in cancer screening programmes in north rhine-westphalia. to encourage women to take part in these examinations which are generally paid by the sickness funds, in 2001 nrw launched an intensive campaign against breast cancer. the campaign was carried out by various organisations in nrw including 212 health systems and their evidence based development chambers of physicians, hospitals, sickness funds and cancer organisations. it encouraged women to examine their breasts and called upon doctors to provide the corresponding instructions. in addition, more than 300 seminars on breast self examination are each year organised throughout the state of nrw. similar to the medical examination of the breast, breast self-examination plays an important role for cancer prevention because a great number of women consult their gynaecologist after having discovered an irregularity. this also applies to women who perhaps would normally not participate in cancer screening programmes. mammography screening programmes mammography screening programmes are presently still in their initial phase of initiation in germany. the precise conditions and regulations according to which the programmes are to be carried out are presently being established in accordance with the european guidelines for quality assurance of mammography screenings (euref). this concerns the technological and qualitative standards to be fixed for the institutions in which mammography screenings will be carried out. mammography pilot programmes, which were carried out between 2001 and 2002 in the three regions of bremen, weser-ems and wiesbaden, serve to introduce blanket coverage with screening programmes which cannot be achieved before 2005. they were carried out following international standards such as the european guidelines for quality assurance of mammography screenings. in a special invitation letter all women between 50 and 69 years of life are called upon to participate in the programmes. the programme is aimed at a high participation rate, attaches considerable importance to interdisciplinary teamwork and ensures high quality standards in accordance with euref. 213 comparative research on regional health systems in europe 6) eastern / midland / north-eastern regions – ireland 6.1 demography the eastern regional health authority (erha) with its three constituent health boards, and the midland and north-eastern health boards respectively, cover the combined eastern, midland and north-eastern regions. the health boards executive (hebe) was established in february 2002 to enable health boards, the eastern regional health authority and nonstatutory provider agencies to work together on an agenda to develop and modernise the health delivery system. the board of hebe is comprised of the chief executives of the health boards and the erha and also has representation from the chief executives of the dublin major teaching hospitals. the demographic characteristics of the combined three regions are as follows: 6.2 organisation and structure of the regional health system health services in the republic of ireland are financed through general taxation, with funding for programmes being provided to the health boards by the department of health and children. the description of the structure and organisation of the irish health system, which also applies to the eastern regional health authority with its three area health boards, is taken from „quality and fairness”, a paper of the department of health and children explaining the new health strategy 2001: 214 health systems and their evidence based development male population: 0.89 million female population: 0.92 million of the 126,800 inhabitants in the 0-4 years age-group 65,400 are male and 61,400 are female. the female population in the age-group targeted by mammography screening programmes is divided as follows: age group in years number 50 – 54 46,000 55 – 59 38,100 60 – 64 34,000 total 118,100 (1996 census of population) “the government, the minister for health and children and the department are at the head of health service provision in ireland. the department’s primary role is to support the minister in the formulation and evaluation of policies for the health services. it also has a role in the strategic planning of health services in consultation with health boards, the voluntary sector, other government departments and other interests. the department has a leadership role in areas such as equity, quality, accountability and value for money. the health boards, established under the health act, 1970 are the statutory bodies responsible for the delivery of health and personal social services in their functional areas. they are also the main providers of health and personal social care at regional level. health boards are composed of elected local representatives, ministerial nominees and representatives of health professions employed by the board. each health board has a chief executive officer (ceo) who has responsibility for day-to-day administration and is answerable to the board. the health (amendment) (no. 3) act, 1996 clarified the respective roles of health boards and their ceos by making boards responsible for certain reserved functions relating to policy matters and major financial decisions and ceos responsible for executive matters. in addition, many other advisory, executive agencies and voluntary organisations have a role to play in service delivery and development in the health system.” (department of health and children 2001) as regards the health boards within the combined eastern/ midland/north-eastern regions, their main role can be considered as the planning, arranging, co-ordination and delivery of health and personal social services in the region in co-operation with the local voluntary service providers. 6.3 measles immunisation programmes measles vaccination was introduced country-wide in 1985; the combined mmr vaccine was introduced in october 1988. in 1992, a second dose of mmr was recommended for boys and girls aged 10-14 years. the introduction of measles vaccine and the combined mmr vaccine has led to a decrease in the numbers of measles notifications. however, the uptake of mmr in ireland has not yet reached the target of 95% and outbreaks continued to occur in 1993 and 2000 (the health boards executive 2002a). therefore the health board chief executive officers initiated a „review of immunisation/ vaccination programmes” which was to examine the policy, practice and procedures of all immunisation/vaccination programmes. an increasing emphasis on the need to improve the uptake of immunisation/vaccination programmes e.g. mmr, and the increasing public and media discussion of immunisa215 comparative research on regional health systems in europe tion/vaccination issues such as vaccine safety were part of the background against which the review was established (the health board executive 2002b). organisation of programmes the different organisations and agencies involved in the realisation of measles immunisation programmes as well as the levels at which the programmes are planned and co-ordinated are illustrated in the organisation plan below (figure 3). 216 health systems and their evidence based development figure 3. organisation plan of the measles immunisation programme for eastern/midland/north-eastern regions 217 comparative research on regional health systems in europe national level regional level health boards (hb's) local level communications working group the health boards executive (hebe) national immunisation steering committee (nisc) national immunisation implementation group (niig) vaccine stock management working group central purchasing erha/hb's gps statutory accountability service accountability reporting general medical services (payments) board (gmspb) immunisation advisory committee of royal college of physicians of ireland (iac of rcpi) irish medicines board (imb) national disease surveillance centre (ndsc) erha + all health boards (hb's) department of health & children (doh&c) it working group department of health and children (doh&c): formulates immunisation targets on advice of iac of rcpi decides on programme policy and funding (financing is through general taxation) provides hb’s with funding for immunisation programmes together with hb’s, is responsible for health education in general immunisation advisory committee of royal college of physicians of ireland (iac of rcpi): draws up guidelines and advises on targets for measles immunisation programme based on who and other international guidelines irish medicines board (imb): decides on licences and conditions of use of vaccines and monitors adverse reactions to vaccines health boards executive (hebe): co-ordinates the planning and implementation of immunisation programmes with hb’s at regional level facilitates a co-ordinated national response involving all key actors e.g. hb’s, dohc, ndsc, imb etc. together with hb’s, is responsible for specific information on immunisation programmes and actions together with hb’s and dohc, is responsible for national promotion and public information campaigns on immunisation informs nisc of matters of common operational or policy significance discussed with hb’s national immunisation steering committee (nisc): is a newly established body representative of all key interest groups dealing with immunisation in general under the aegis of hebe, co-ordinates activities of measles immunisation programme at national level will in future address the evaluation of projects or campaigns relating to measles immunisation national immunisation implementation groups (niig): acts as a practical coordinating mechanism between nisc and health boards, as each health board is represented on niig by its regional immunisation coordinator provides feedback and policy advice to nisc 218 health systems and their evidence based development national disease surveillance centre (ndsc): evaluates immunisation programmes at national level (monitors vaccine uptake and incidence of disease) analyses data from all health boards and publishes quarterly reports health boards (hb’s): responsible for planning and implementation of immunisation programmes order vaccine from supplier and distribute them to gp practices and other required locations implement special campaigns or projects relating to measles immunisation at regional level are responsible for regional surveillance and for documentation of vaccines given primarily responsible for operation of call/recall systems general medical services (payment) board (gmspb): pays gps for immunisation services provided on behalf of hb’s general practitioners (gps): provide immunisation services and have responsibility to identify children who have been immunised and to follow up defaulters maintain records of children immunised and forward immunisation and/or disease data to hb’s and to doh&c as required responsible for updating their knowledge on immunisation and to promote childhood immunisation vaccination strategy in accordance with the rcpi guidelines, two doses of mmr have been recommended in the republic of ireland since 1992, with the first dose being given at 12–15 months of age and the second at 4–5 years of age. parents are personally invited to bring their children for vaccinations and this is occasionally supplemented by public information through the media. vaccine procurement is organised centrally by the hebe and it is distributed directly from the supplier to each health board in the quantities requested by them. it is then distributed to gp practices and to other required locations for use in schools or special clinics. a new system of direct distribution from supplier to end user is being piloted in order to shorten the supply chain and to better avoid any vaccine deterioration e.g. due to storage at sub-optimum temperatures. individual immunisation is free of charge and delivered through gp practices but also through health board medical officers in schools and in ‘black-spot’ areas. 219 comparative research on regional health systems in europe immunisation services provided by gps are paid for by the health boards through the general medical services (payment) board. theoretically, gps who achieve a 95% vaccination uptake level are supposed to receive a financial bonus for each child on their panel who has reached his/her second birthday in the calculation period. this, however, doesn’t always occur due to communication / documentation problems. information and education various means are being used to inform the public, particularly parents, about measles immunisation. a tv cartoon type infomercial, features and interviews involving authoritative medical figures on radio and in the press have been used. however, the findings of the national review of immunisation programmes (the health board executive 2002b), made it clear that a more systematic, varied and targeted public information approach is needed. information leaflets have since been made available to parents. a major initiative in 2002 by the hebe has been the production of a comprehensive information and discussion pack on mmr for use by health professionals and by parents. the reported links between mmr vaccine, autism and inflammatory bowel disease (crohn’s disease) in children have been of interest to the press, radio and tv and have been the subject of news stories, interviews and features involving researchers and parents of autistic children. a report of a study carried out by one health board in 2002 showed that parents felt insecure and confused by such media coverage and are then hesitant to have their children vaccinated. programme related projects/campaigns special projects relating to measles immunisation are implemented by the hebe at the national level and by the health boards at the local level. such projects include the production of information packs and public information campaigns. there is however limited evaluation of such projects, an area which is to be addressed by the new national immunisation steering committee. 220 health systems and their evidence based development vaccination documentation and data collection the gps and health boards are responsible for the documentation of vaccinations given. neither vaccination certificates nor chip cards are routinely issued. an individual child health record booklet to help parents keep a record of their child’s health history, including sections to be completed by a doctor or nurse e.g. on vaccinations given, is available but not in universal use. data on immunisation status, vaccine uptake and measles incidences are routinely reported to the national disease surveillance centre by each health board and published in a quarterly report. at local level data is collected by the health boards through gps and other medical staff. at present this data is sent electronically for entry into a separate central surveillance system. it is planned to transfer the data directly into a new single integrated system, however, at the moment, information about immunisation and vaccination can only be accessed in a number of separate health board databases, a process which requires time and effort. the main data gathering method is linked to gp claims for payment which must provide data over a range of fields. data is also provided by health board medical officers in respect of school or special clinics. both of these data collection methods support continuous systematic reporting but some gp claims are sporadic and time lagged. programme monitoring and evaluation the performance of measles immunisation programmes are assessed using criteria such as the percentage uptake rate and the incidences of measles. a number of marketing type criteria have been piloted to measure the impact of public information campaigns related to immunisation and will be developed further in line with the development of more systematic, targeted campaigns mentioned earlier. the erha has one of the lowest measles vaccination uptake rates in the republic of ireland and as a consequence the highest measles incidence rate. the last measles outbreaks which have occurred in ireland have been in this region. however, the low vaccination levels in the region reflect the situation in the whole country, (eastern health board 2000). the new organi-sational and governance approach outlined in fig.3 is aimed at improving this situation. disease surveillance as soon as a medical practitioner becomes aware of or suspects that a person on whom he/she is in professional attendance is suffering from, or is the 221 comparative research on regional health systems in europe carrier of an infectious disease, he/she is required to transmit a written notification to the relevant medical officer in his health board. under new regulations in 2000, the national disease surveillance centre (ndsc) was assigned responsibility for the collation and analysis of weekly notifications of infectious diseases, taking over from the department of health and children. thus the ndsc is responsible for the national surveillance of vaccine uptake and incidence of measles disease, with the department of public health medicine in each health board being responsible at the next level. since 1999, the ndsc publishes quarterly reports showing uptake levels for all health board areas and this receives wide dissemination, including to the media, which from time to time carry reports on low uptake concerns. the ndsc may also issue a press release specifically relating to measles, e.g. linking incidence of the disease to low immunisation rates. for the period 1997-2001, in measles immunisation and incidence data collected from the participating regions, it was not possible to differentiate between confirmed and just clinically diagnosed cases. limited information on hospital admissions due to measles is available. an enhanced surveillance system for measles commenced at the beginning of 2003 in the whole country which aims to correct the above points amongst others. it is hoped to have more detailed information on measles cases in the near future. 6.4 breast cancer screening programmes there are no defined programs of professional breast examination and it is usually carried out by a breast surgeon or specialist breast nurse in specialised breast clinics in some hospitals. breast self-examination is not promoted in ireland as it was feared that it could either cause anxiety by omission (women who do not self-examine may feel guilty for not doing so) or by a lack of knowledge (women who think that they have found something may worry unnecessarily). mammography screening programmes are the only official breast cancer screening programmes being used in ireland. the national breast screening programme, known as breastcheck, was established in 1998 following a pilot period from 1989 to 1994, with the aim of reducing mortality from breast cancer by 20% over a 10 year period. phase 1 of the programme started in february 2000 with the screening of women between 50 and 64 years of age in the combined eastern/midland/north-eastern region. 222 health systems and their evidence based development organisation of programmes breastcheck is jointly overseen by the health boards for the early diagnosis and primary treatment of breast cancer in women. a statutory joint board, the national breast screening board, was established by the minister for health and children whose members consist of the chief executive officers of the health boards and other nominees drawn from the disciplines involved in the early diagnosis and treatment of breast cancer in women, and a consumer representative (the national cancer forum 2003). this board, under the direction of the health boards, is responsible for instituting, coordinating and carrying out the programme. the breastcheck programme is managed locally by clinical directors who are responsible for their unit and its team, they report to the project director. the programme also has its own it system, epidemiologist, statistician and researcher. funding for the programme is provided from national taxation by the minister of health and children to the erha and health boards in the combined regions covered by the current phase 1 of the programme and they are required to meet the expenses of the national breast screening board in such proportions as they may agree, or, failing such agreement, as may be determined by the minister. the breast screening programme is managed and organised centrally with decentralised multi-disciplinary clinical units for screening, recall and assessment which are adjacent to a host hospital for the provision of primary treatment. screening strategy women aged 50-64 years living in the combined regions covered by the current phase of the programme are personally invited in writing to attend for screening at either a static or mobile unit, at a specific time and date, which can be changed to suit their convenience. women are given seven days of notice before their appointment. the population database for the areas concerned is used as a source of personal details for the women resident there. the database is formed using data from the following sources: voluntary health insurance, general medical services and department of social and family affairs; and self-registration is used to supplement the database. screening for the breastcheck programme is done at two clinical units, each of which has two mobile units. the two centres were chosen on the basis of established expertise in breast cancer at both hospitals. 223 comparative research on regional health systems in europe two view mammography is carried out at every round and the european quality assurance guidelines are followed very closely. there are no charges demanded for individual mammography provided under the programme; targets are set for each quality parameter of performance such as percentages of attendance, recall, and cancer detection rate. a plan for the roll out of phase 2 of the programme – expansion of the programme nation-wide – was submitted to the department of health and children in 2002. dissemination of results mammography is carried out by radiographers and the mammograms are read by two radiologists. following mammographic screening, a woman is either informed that her mammogram is normal and that she will be recalled in two years (provided she remains within the specified age range of 50-64 years at that time) or is recalled for further assessment if an abnormality is detected. breastcheck runs assessment sessions once or twice a week. the programme aims to send out results within three weeks of the mammogram and to ensure that women are offered an appointment for an assessment clinic within two weeks of being notified of an abnormal result. at the assessment clinic, the women are seen by a consultant doctor and supported by breast care nurses. assessment results are sent within a week and women are kept informed of any delays regarding results. women diagnosed as having cancer are fully informed about the treatment available to them and have the right to refuse treatment, obtain a second opinion or choose alternative treatment without prejudice to their beliefs or chosen treatment. there are special breast care nurses to support the women before and during treatment. information and education there is a lot of media interest in the success and usefulness of mammography screening and also in the extension of the current phase 1 of the programme to a fully national programme. a women’s charter was established within the breastcheck programme to inform and encourage women to give their views about the programme and any other related points of importance to them (breastcheck 2002). health professionals involved in the programme are regularly informed about current recommendation and new developments via relevant jour224 health systems and their evidence based development nals, articles and press cuttings which are circulated. monthly staff meetings are also held and radiographers have joint meetings 3 times a year. programme related projects/campaigns at present the only campaigns held in relation to the breast cancer screening programme are media campaigns. success of such campaigns is assessed by the attendance rates, which for breastcheck are over 70% to date. programme monitoring/evaluation data on different aspects of the programme such as numbers of women invited, attendance rate, referrals for further assessment and cancer detection rates are collected by breastcheck in its centralised database. rigorous audit and quality assurance is an integral part of the screening programme to ensure that women invited for screening receive the best quality of service. the performance of the programme is compared with predetermined standards based on the third edition of the european guidelines for quality assurance in mammography screening. in 2001, a team of experts in radiography, radiology, pathology, surgery, physics and epidemiology validated breastcheck’s guidelines for quality assurance in mammography screening. this was done in agreement with the european centre for quality assurance in breast cancer screening (euref). recommendations from this evaluation and the input from the european manual on quality assurance provide assurance that the quality parameters reached by the irish national breast cancer screening programme are to internationally approved standards (breastcheck 2002). disease surveillance breastcheck has centralised data on all cancers detected. there is also a national cancer registry in ireland where all cancer cases are documented by so called ‘tumour registration officers’ (tro). these are qualified nurses who undergo specialised training in cancer registration. the national cancer registry (ncr) has eighteen such officers and between them they cover all the hospitals, hospices, nursing homes etc. in the republic of ireland where the data is actively collected. confirmation of exact recording of tumours is facilitated by assistance from pathologists and clinicians to whom the tro will go to if extra verifica225 comparative research on regional health systems in europe tion is required. the data is recorded onto a laptop computer on site and is transferred electronically to the ncr headquarters for quality control. once quality control is complete, an annual report is produced on the incidence of cancer in ireland. the ncr analyses national data whilst breastcheck analyses its own data. 7) veneto – italy 7.1 demography veneto is one of 20 regions in italy, and each of them is governed by an executive and a regional council, both democratically elected. 4.5 million of the country’s 57.7 million inhabitants live in the region of veneto, an area of 18,364 km2. of the female population 0.56 million are in the 50-69 year old agegroup targeted for mammography screening. 7.2 organisation and structure of the health care system italy’s health care system is a regionally based national health service that, like the uk, provides universal coverage free of charge at the point of service. the system is organised at three levels: national, regional and local. the national level is responsible for ensuring the general objectives and fundamental principles of the national health care system whilst the regional governments, through the regional health departments, are responsible for ensuring the delivery of a benefit package through a network of population-based health management organisations (local health units) and public and private accredited hospitals. the ministry of health, the main central institution responsible for health, manages the national health fund and distributes resources to the regions. its role in financing is restricted to allocating the resources from the global national budget and ensuring uniform availability of resources in the regions. the regions finance the remaining health care expenditure from their own sources. in accordance with the decentralisation process occurring in italy’s national health service since 1992, regional governments, through their regional health departments, are responsible for legislative and administrative functions, for planning health care activities, for organising supply in relation to population needs and for monitoring the quality, appropriateness and effi226 health systems and their evidence based development ciency of the services provided (european observatory on health care systems 2001b). regions are also responsible for determining the size and organisation of local health units and monitoring their operation. local health units are geographically based organisations responsible for assessing needs and providing comprehensive care to a defined population. veneto has 21 local health units. 7.3 measles immunisation programmes the measles vaccine was introduced in 1979 in italy as a single vaccine which was replaced by a single dose mmr vaccine in 1982 (european sero-epidemiology network esen 1998). organisation of measles immunisation programmes the ministry of health compiles the national immunisation regulations and policies together with the inter-regional infectious diseases and immunisation committee. it also evaluates obligatory notification of diseases preventable by vaccination. the health prevention department is responsible for disease surveillance at the national level. there is a national plan which determines the vaccines which are to be given by statutory law (obligatory on the part of the provider) and recommended ones. the planning, organisation and implementation of programmes is the responsibility of the regions, which work together towards the elimination of measles. the regional governments determine the immunisation programmes, which are then organised and managed by the regional public health service and the local health units. the regional programme is implemented by the epidemiological and public health services of the health prevention department and by the public health services of the health prevention department at the local level (local health units). these organisations also coordinate the programmes at their respective levels. the regions instigated an inter-regional infectious diseases and immunisation committee, which together with the ministry of health and the national health institute formulate targets for the immunisation programmes. the targets are in line with those set by the who for the european region, e.g. 95% vaccination uptake rate. a measles immunisation programme which includes programme guidelines is currently being established by the regions together. 227 comparative research on regional health systems in europe the organisations involved in the realisation of measles immunisation programmes as well as the levels at which they operate are illustrated in the organigraph below (figure 4). figure 4. organisation plan for the measles immunisation programme in veneto region, italy 228 health systems and their evidence based development national level regional level local level statutory accountability reporting regional governments (rg) immunisation services: public health services inter-regional infectious diseases and immunisation committee program (i-ridicp) regional health departments (rhd) ministry of health (moh) health prevention department (hpd) regional public health services (rphs) local health units (lhu) local public health services (lphs) regional health fund (rhf) vaccination strategy in the veneto region, mmr is given as a single dose to children at the age of 12-15 months. all children are invited to be vaccinated and a recall system is used for those who do not turn up. the public health services of the local health units are responsible for the written invitations and they also maintain vaccination registers. vaccines are procured by the local health units, who distribute them to the immunisation services public health practitioners, paediatricians and health workers in their areas. vaccination is only carried out with informed parental consent; however written consent is not required. information and education parents, and the public at large, are informed about the immunisation programme via campaigns in the forms of posters, pamphlets available in the local health units, and information forms given to parents during the vaccination notifications. the general public opinion is not measured. vaccination services personnel are informed about changes or new information regarding measles and/or immunisation through circular letters containing recommendations and immunisation campaign results. currently there are no structured programmes involving the media dealing with measles immunisation. programme related projects/campaigns following the measles outbreak which occurred in the veneto region in 1997, the region enforced a measles immunisation programme for a period of 4 years (1998 2001). the programme entailed cohort catch up vaccinations for the groups with low vaccination coverage. during the campaign, more than 150,000 infants and approximately 69,000 individuals between 2 and 21 years of age were vaccinated, the latter comprising the ‘catch-up’ group. the programme was evaluated through data collection of the vaccine coverage in the cohorts involved in the programme. the regional annual incidence rate went down dramatically in 1998 and the following three years of the campaign. 229 comparative research on regional health systems in europe vaccination documentation/data collection the public health services of the local health units maintain vaccination registers and are responsible for the overall documentation of immunisation details. they collect immunisation and disease data at the local level whilst the regional epidemiological and public health services do so at the regional level and the health prevention department of the ministry of health at national level. immunisation status is checked biannually and at school entry. programme monitoring and evaluation all regions have to supply data relative to the number of vaccine doses administered each year and the vaccine coverage at 24 months of age for mmr and other vaccines to the ministry of health. the ministry of health uses these figures to evaluate the programme. it also evaluates the obligatory notification of diseases preventable by vaccines. disease surveillance measles surveillance is maintained on a national level with data transferred through the health service levels to the department of health prevention in the ministry of health. the measles data collected by gps or paediatricians is transferred to the public health services of the local health units where it is stored in a regional software programme before being forwarded on a monthly basis to the regional epidemiological and public health service who in turn forwards the data to the ministry of health. the regional epidemiological and public health service analyses all data collected in the region and prepares annual reports which are then sent to the services of the local health units for distribution to the immunisation services providers and to paediatricians. 7.4 breast cancer screening programmes mammography screening is the methodology being used for breast cancer screening in the veneto region. although professional breast examination is offered within a normal clinical work context, e.g. during gp or gynaecological consultations, no programmes for professional breast examination exist and no data is collected. breast self-examination is at times promoted within health education activities, but again without any clearly defined programme. in some mammo230 health systems and their evidence based development graphy screening programmes, after a negative mammogram, women are advised to regularly perform breast self-examination, but no practical training is given. organisation of programmes the veneto mammography screening programme started inviting women in 1999 in 10 of the region’s 21 local health units. in 2000, the programme was initiated in two more local health units. meanwhile, 17 units are implementing the programme. the public health departments of the local health units together with radiology, surgery, oncology and radiotherapy departments are responsible for the planning of the mammography screening programmes in the region. the coordination of the programmes is normally done by the public health department, however, a few are coordinated by the radiology department. radiology departments are mainly responsible for the implementation of the programmes, which are run according to guidelines issued by the national oncology commission which are in turn based on the european guidelines. screening programmes are part of the „lea” (essential health services) and as such are financed entirely by the government within normal budget. nevertheless, to promote the implementation the regional government and the ministry of health have repeatedly granted additional funds. screening strategy the primary aims as stated in the regional program reports include the early diagnosis and treatment of breast cancer and the associated mortality reduction, whilst the secondary aims concern the use of conservative and, as far as the women concerned, acceptable therapy. all women between 50 and 69 years of age who are registered as resident in the 17 local health units, where the programme has been implemented, are personally invited (with appointment) every two years for a twoview mammography examination. self-registration is also used to supplement the registers and services provided free of charge to all women who attend. a special information system is being developed for the screening programme. the computerised system will not only be used for invitation purposes but also for the storage and retrieval of programme data. 231 comparative research on regional health systems in europe the regional targets set for the screening programme include, expanding the programme to all 21 units, a participation rate by targeted women of at least 70% and that screening is available biannually. dissemination of results results are disseminated differently in each region, in 8 local health units, a so-called ‘standard organisation model’ is in operation. first, all the mammograms are read, and then participating women are recalled for further assessment. three local health units use a system where the reading of the mammograms and the conduction of non-invasive further examinations are done in one sitting. in the units where the standard organisation model is followed, an average of 88% of negative results were sent out within 21 days from the day of examination. in case of a positive or unclear result, the woman concerned is invited by telephone to an assessment session. 73% of the further assessments were achieved within 21 days of the initial examination. information and education there is a lot of interest in the mammography screening in the media as well as within the population, with a generally positive opinion reported from women and the general public. posters and meetings with population groups are used as means of disseminating information about the programme. invited women also receive information leaflets and are given a free telephone number where they can get more information or raise questions. professional training meetings are organised once or twice a year for those involved in the realisation of the programmes. programme related project/campaigns apart from the information sessions with population groups, there are currently no projects or campaigns being held in relation to mammography screening programmes. however, there are plans for implementing campaigns in the future. programme monitoring/evaluation data on different aspects of the programmes such as number of women invited, participation rate, referrals for further assessment and cancer detection rates are collected by the local health units. the coordinating department of each local health unit uses these figures to monitor and evaluate their 232 health systems and their evidence based development respective programmes. a common and specific information system is adopted by each unit and the data collected is forwarded to the regional reference centre for monitoring and evaluation on a yearly basis. disease surveillance personnel at the regional cancer registry in the veneto region are responsible for the documentation of cases in the cancer registry. data are provided from the local health units, analysed, and published on an annual basis. 233 comparative research on regional health systems in europe exercise: comparative research on regional health systems in europe task: students will work individually in the first phase of reading the introductory material (8 regional reports), while in the second phase they will discuss their findings in small groups (3 to 5 students). third phase will be plenary presentations of small-group work. the whole exercise requests 4 hours, because students are obliged to deliver written reports. instructions for students: 1) choose the best measles vaccination programme and the best breast cancer screening programme and present your arguments. 2) think of other services suitable for benchmarking. 3) collect the appropriate information on measles vaccination and breast cancer screening from your own region of origin. 4) using the example of your own region, what is your judgement with regard to the significance of the 2 selected programmes as indicators for the quality of health care in your region in general? 5) think of how benchmarking would look like using health indicators (5). 234 health systems and their evidence based development references 1. mossialos e, mckee m, palm w, karl b, marhold f: the influence of eu law on the social character of health care systems in the european union. report submitted to the belgian presidency of the european union. final version, brussels, november 19, 2001. 2. available from url: http://www.europa.eu.int 3. daniels n, bryant j, castanao ra, dantes og, khan ks, pannarunothai s: benchmarks of fairness for health care reform: a policy tool for developing countries. bulletin of the world health organisation 78(6), 2000: 740-750. 4. eu-project „benchmarking regional health management ben rhm” (final report, loegd, bielefeld/germany 2003. 5. bardehle, doris: minimum health indicator set for south eastern europe. croatian medical journal 43/2 (2002), 170-173 (the paper can be downloaded from www.cmj.hr/ph-see). 235 comparative research on regional health systems in europe health systems management 237 238 health systems and their evidence based development 239 health management: theory and practice health systems and their evidence based development a handbook for teachers, researchers and health professionals title health management: theory and practice module: 2.1 ects (suggested): 0.75 author(s), degrees, institution(s) prof. vesna bjegovic, md, msc, phd professor at the school of medicine, university of belgrade, serbia and montenegro address for correspondence institute of social medicine, school of medicine, belgrade university dr suboti}a 15 11000 belgrade serbia and montenegro tel: +381 11 643 830 fax: + 381 11 659 533 e-mail: bjegov@eunet.yu keywords health services management, planning, organizing, staffing, leadership, controlling, evidence based learning objectives after completing this module students and public health professionals should have: • increased their understanding of management theory and practice, and development of interest for health services management, • explored the current ideas and trends in health services management, as well as basic characteristics of managing health services organization, • identified key interrelated components in health services management (planning, organizing, staffing, leadership and controlling), • improved their skills in management and raised their understanding of modern evidence based management, • explained and justified their intentions for seeking a higher standard of management at their own place of work. abstract modern management is a process of creating and maintaining an environment in which people working together may accomplish predetermined objectives. it occurs in a formal organizational setting through utilization of human and other resources by which demands for health and medical care are fulfilled by provision of specific services to individual consumers, organizations and communities. management, as a universal and complex process, open towards its environment, consists of five essential components: planning, organizing, staffing, leadership and controlling. the activities of an effective manager imply basic skills providing the balance among these interrelated components and skills in evidence based management. teaching methods teaching methods include lectures, students' individual work under the supervision of teacher and interactive methods such as small group discussion. before introductory lecture the small exercise could be organised as brainstorming („what does management mean to us?”), in order to increase students' motivation for learning and interest in the content of the module. after the introductory lecture students will work individually by writing down the framework for their own professional development. this work will followed by the lecture and exercises focused on the health services management. students would have opportunities to discuss in small groups different case problems and to present possible solutions. as an example of, the case problem is presented in this module. they would also have opportunity to search through the internet under the supervision of teacher in order to explore some of the famous electronic libraries and to select examples of good managerial practice based on evidence. these will serve as base for individual work which is supposed to have a written case problem of national health service as output. 240 health systems and their evidence based development specific recommendations for teacher it is recommended that the module should be organized within 0.75 ects credit, out of which one quarter of ects credit will be done under supervision, while the rest is individual student's work. it is supposed the 1 ects is equal to 30 hours. teacher should advise students to use as much as possible electronic management libraries during individual work to gather ideas how to write and present their own case problems. assessment of students multiple choise questionnaire and case problems presentations. health management: theory and practice vesna bjegović management in health care system is an area of scientific management to which an ever-increasing attention has been paid under conditions of economic and socio-political changes. nowadays, the importance of an effective and competent manager is emphasized in solving problems referring to functioning of health organizations and related services in changing environment. development of management theory organizing of people for achieving common goals and utilizing management principles have been a phenomenon known for centuries, its development and changes running parallel with human society. however, not before the very close of the xixth century did the first scientific theories on management appear when there imposed itself, as a goal of economic and noneconomic companies, the basic economic principle: achieving maximal results with minimal investment (1). in that period, frederick w.taylor (1856-1915) may be viewed as an author of 'scientific management'. in his research in the field of work organization, he recognized the importance of achieving cooperation and harmony in teamwork, as well as workers' improvement in accomplishing better job results. his capital work 'principles of scientific management' expanded the management utilization. nevertheless, many hold the view that greater merit for the real beginning of the science in question should be given to henry fayol (1841-1925) and his work 'general and industrial rights'. he pointed out general management principles: linkage between authority and responsibility, the unity of leadership and teamwork, all of which represent the basis of classical school of management even at present. also, studies of other scientists in the same period, such as frank b.gilberth (1868-1924), lillian m.gilberth (1878-1924), max weber (1864-1920), contributed to further management theory development. the famous hawthorne experiment carried out with workers of the western electrical company powerplant in chicago from 1927 till 1932, as well as the findings of the researcher named elton mayo (1880-1949) threw a new light on classical theories. the study was begun as research into the impact of 241 health management: theory and practice illumination on work productivity of experimental group of workers. regardless of the illumination level being increased or decreased, the productivity kept rising. furthermore, there were experiments with modifying resting periods, working hours' reduction and wage changes. none of these could have explained the alterations in work productivity of the experimental group. the researchers ascribed the productivity modifications to social attitudes and relationships in the working group. namely, the group started regarding itself as 'noticeable', gaining the feeling of being important. this experiment outlined the significance of work motivation and initiated a series of psychological theories of management. after 1950, behavioral sciences showed great interest in studying motivation as an important means for achieving predetermined goals. the authors of motivation theories, still applied in management practice, are: abracham maslow, frederick herzberg and douglas mcgregor. studying individual and collective behavior at place of work, they noticed that management was not only a technical process and stressed the importance of a positive attitude towards people being managed. due to an extraordinary concern for management over the recent years there have been encountered the most diverse approaches to studying and analyzing its theory and practice. there have been numerous operational approaches analyzing management as a complex and open system in a dynamic balance with the environment (economic, technological, sociological, political, legal, ethical and cultural) (2,3). development of interest for health services management it may be noticed that only within the last three decades has the management become an area of significant interest in health systems, too. until that time, the management was regarded as a scientific discipline suitable only for big corporations and commercial companies, and not for social domain like health care (4). this is understandable bearing in mind that health services organizations used to be less complex, with significantly lower costs and underdeveloped technology. at the beginning of the xxth century, managerial roles were assumed by a physician-administrator, appointed by the managerial board with an exclusively autocratic managing style and one-dimensional distribution of authority and responsibility. only two professional groups were in charge of providing health care services, namely a physician and a nurse. still, with making health services organizations more complex, increasing gaps between medical technologies advanced and limited resources as well as by environmental changes, objectives of health services organizations have been changed and made complex in relation to the society as a whole. the situation 242 health systems and their evidence based development in terms of showing concern for management has also changed and presently there is an ongoing affirmation of the managerial skills application in health services organizations, too. the essential characteristics of external environment in which today's management of health services organizations is taking place include population aging, miraculous but costly diagnostic and treatment technologies, efforts to modify life styles and underscore health promotion and prevention (5). also, modern health systems in numerous countries are faced with ethical and economic crisis of unpredictable level. political, social and, most frequently, professional groups are trying to solve the crisis by introducing various changes in health legislation and functioning of health services organizations. in view of the alterations mentioned, peter drucker, a distinguished management theoretician, has noticed a paradox in health services organizations in which there is a growing work pressure on employees, but at the expense of additional activities being minimally or completely unrelated to those jobs for which the employees were qualified (6). an illustrative example makes an increasing number of nurses in hospitals, while there have been a decreasing number of hospitalized patients. a paradoxical situation occurs: nurses spend only half of their working hours doing jobs for which they are qualified and paid for. the other half of the time spent at work they devote to activities for which neither their nursing degree nor skills are required, that is filling in various blank documents and forms. likewise, in the last decade of the xxth century, there was a growing recognition of a conflict between doctors (as leading professional group in a health services organization privileged to do autonomous clinical work) on one hand, and managers (whose job includes controlling the work of employees), on the other. in accomplishing effectiveness, managers traditionally analyze resources, while doctors review clinical activities and patients' outcomes. in this way, a potential conflict is stressed in which a lot of energy is needlessly wasted in many health services organizations. such environment makes a challenge for successful managers, with the practice of effective leadership becoming one of rare solutions for the survival and development of health services organizations (7,8). the majority of health systems in central and eastern europe are undergoing the process of transition from bureaucratic, centralized to much more efficient systems with decentralized responsibilities, private sector introduction as well as more effective trends towards a higher level of health care quality (9). in these countries, there has been a significantly growing interest in professional management of health services organizations and continuing education in the field. 243 health management: theory and practice characteristics of managing health services organizations basic concepts, principles and skills in management encountered in industrial and other organizations may also be applied in health care institutions by respecting their social roles. seven principal roles of health care service are distinguished in each society: • it represents a part of national state policy; • it employs a large number of people; • it provides health care; • it does different kinds of research; • it educates on a continuing basis; • it represents significant economical factor; and • it plays an important role as a country's social stability factor, taking into account people's expectations and trust put in this service. the specificities of managing health services organizations are determined by the vital roles outlined above. health services organizations nowadays are known, in the management theory, to be the most complex organizations with the most complex management, a modern hospital being top ranking by its complexity. extensive working activities' differentiation and specialization are obvious, and working tasks are accomplished by a number of different participants in terms of educational level, training and functions. contrary to a typical business organization, the authority structure in managing a health services organization is divided among three authority and responsibility centres: managerial board, doctors and administration (4). managerial board is legally responsible for the organization as a whole, including provision of health care, public relations and assistance in resources supply for its functioning. if an aspect of basic social roles of a health service is viewed, it is the managerial board that most commonly reflects a profile of the community comprising a health services organization. it means that the former consists of delegates from various social groups of certain educational level and experience. doctors, comprising a medical board, but others as well, have a powerful role in management, since they are held responsible for the majority of cost rendering decisions made. as a predominant profession, doctors in health services organizations participate, at least, in three management 244 health systems and their evidence based development processes: managing a patient, managing a doctors' team and managing a health services organization. this makes them 'the potentially best managers in health services organizations' (10). related to this centre of management structure, many underline a typical phenomenon of health services organizations: for doctors, having power and authority does not imply being also responsible for financial risks. in spite of being highly educated in the medical area, most doctors are very little acquainted with their real working environment, since they spend most of their working hours with patients or are devoted to their own advanced training. thus, there occurs a phenomenon of separation between clinical autonomy (freedom and opportunity for doctors to work in the best possible way to help their patients) on one hand, and institutional interests, on the other. due to increasing costs of health care service provision, doctors are no longer in a position to make independent clinical decisions and provide patients with all the services they find beneficial for them. for this reason, it is impossible to enable effective management of health services organizations without a considerable doctors' participation in decision-making concerning leadership. administration, composed of director, heads of departments and chiefs of assisting services, is the third and last authority centre in managing health services organizations, responsible for operational management, but with both limited scope of authority and knowledge about the process of working directly with patients. the task of the director of the institution is to plan, make decisions, coordinate and control activities of the employees in order to ensure efficient and effective work with patients. in numerous health services organizations doctors used to hold the position of directors (operational managers). however, in the course of time they kept being replaced, in highly developed countries, by professional managers who were not doctors (9). such practice was not the same in some developing countries as well as countries of the eastern europe till 1990s. the managers role has always been attractive, but most frequently without either any improvement in the field of management or knowledge about managerial skills. in the study of managing health services organizations, unlike other business companies, apart from the triple power and authority distribution outlined, there exist its specific responsibilities that must also be taken into account (11): • responsibility for the patient, above all, within the scope of modern medicine and health promotion movement, with provision of the best possible health care, with minimal costs; 245 health management: theory and practice • responsibility for the employed health workers by recognizing their sensible requirements for safety in terms of wages, appropriate working conditions, promotions, but also identifying their fears caused by uncertainty due to positive effects at work (outcomes concerning the treated patients' health); • responsibility for a financier and different social groups (donors, sponsors) supplying resources for functioning of the institution; • responsibility for the community (public) in determining means for meeting the population health care needs; and • responsibility for oneself by making efforts to perfect one's knowledge and skills related to management as well as readiness to make effective responses under conditions of continuing environmental changes. definition and key management components there are many definitions of management and the following is very often cited: „management is the process, composed of interrelated social and technical functions and activities (including roles), occurring in a formal organizational setting for the purpose of accomplishing predetermined objectives through utilization of human and other resources” (12). management, as a universal and complex process, open towards its environment, consists of five essential components: planning, organizing, staffing, leadership and controlling. planning in management planning in management basically includes decision-making related to prospective services activities and objectives as well as how they may be accomplished. decision-making implies the following: problem definition, information gathering, alternative solution making, the best option choice, policy planning, policy undertaking and evaluation of the results obtained. the most varied methods, more or less effective, facilitate decision-making, and thay are one of the basic topics in modern schools and courses for managers, such as: intuitive methods; simulation methods, models and role-plays; decision tree; pert; linear programming and others (5). success in all other managerial roles depends on planning, since it also 246 health systems and their evidence based development implies a selection of the single solution among different alternative ones offered. efficient managers spend a lot of their working hours, perhaps even up to 40%, developing and improving the company's work schedules, formulating them in such a manner that both the organization's short-term management is successful and, at the same time, its long-term business activities more effective. beside classical classification of plans according to planning time perspective, cohen's division is also very useful for managerial staff, and is the following (13): corporate plans cover the company as a whole most frequently for the period of 5 to 25 years. strategic plans refer to changes introduction, most often in specific organizational areas, for the period of 2 to 5 years. leadership plans represent implementation of steps outlined for strategic plans and are related to improving the organization's activities, correcting weak points and possible flaws, allocating current resources for accomplishing the predetermined objective and adjusting to the existing environmental changes. these are usually annual plans. operational plans are associated with shorter-term steps outlined for leadership plans as well as common activities of certain organizational sections. financial plans determine financial resources and equipment required for accomplishment of goals, most frequently for a year. within planning, the vital issue in modern management theory and practice comprises the development of goals in the form of plans expressing the type of final results of organizational activities (4). sound management is considered to imply an ability to point out goals and rank them according to their priority, as well as the ability to utilize proper means to maximize those objectives. although there is a tendency to express the goals in quantitative manner, it is this 'virtue of vagueness' that is significant in determining general objectives and the necessity for their continuous reconsideration. both managers and employees should take part in establishing objectives, and numerous studies have shown that such approach leads to increased working performance since it is clear to the individual what is expected of him/her to do. also, people are ready to work on more demanding goals if they have participated in their development. therefore, one of the management types frequently applied in health care is 'management by objectives' whose concept 247 health management: theory and practice was introduced by peter drucker as early as in the middle of the xxth century. 'management by objectives' is a process in which both superiors and subordinates collectively identify general objectives defining, for each individual, a scope of responsibilities for fulfilling the expected results, as well as criteria upon which individual contribution to working process is monitored and assessed. the goals may have a great impact on the employees' participation in managing a health services organization. provided that the course of action directed towards economic acquisition is imposed upon by the objectives, the doctors' activities may be restricted by the necessity for cost containment and profit enlargement. on the other hand, if the objectives favor competence and public health orientation, a greater participation of doctors in management may be expected. organizing in management after the designing of plans, the next management component organizing, becomes significant. organizing implies interaction of all organizational resources (manpower, capital, equipment) in order to accomplish the goals most efficiently. organizing, thus, includes resources organization: individual or group task assignment and responsibility shift to individuals for achieving group goals. good organizational development and maintenance have been considered as crucial factor of successful companies with organizations representing social subsystems mobilizing people, power and resources in terms of attaining determined, collective social objectives. this is achieved through appropriate organizational structure. structure, according to management theory, represents establishment of patterns of either interrelated organizational unit components or management components (14). after the work division, it is necessary to group works and individuals who will perform those works, through the establishment of adequate organizational units, such as sectors, services, departments, etc. this process is usually termed departmentation (sometimes called departmentalization), which recognizes relationship between dividing work and the need to then coordinate divided work to achieve satisfactory results. bases for departmentation have increased, but the basic concept is largely unchanged. mintzberg suggest six bases for grouping workers into units and units into larger units (5,15): • knowledge and skills (hospitals group surgeons in one department, pediatricians in another), • work process and function (for example: department of finance in health services organization), 248 health systems and their evidence based development • time (hospitals and other health services organizations are 24 houra-day operations; some workers are grouped into day, evening, and night shifts), • output (many health services organizations group workers by whether they produce inpatient or outpatient services), • client (workers are grouped by patients / consumers served; for example geriatric or women's health programmes), and • place (workers are grouped by physical location, ambulatory health services downtown or in suburban locations). each organizational unit performs a part of the overall company's task. in the realization of its duties, it is connected to other organizational units. after determing the organizational units, managers for each of the units are also selected, and they are given authority and responsibility to direct the work of these organizational units. organization may be formal or informal. the first is characterized by firmly formulated policy clearly expressing what each employee's task is, as well as field of action in which an individual may work freely and creatively. the second, aimed at enabling successful company's functioning, has to be based on excellent interpersonal contacts. organizations may also be divided into simple and complex. simple organizations have one manager and several employees. they are usually informal, flexible, with supreme structure authority. as opposed to them, complex organizations consist of big hospital institutions compared to labyrinths. they are usually of a hierarchical, bureaucratic organizational structure with the stress on planning and rigorous control (4). forming the organizational structure can be achieved in different ways. the most acknowledged and used ways of forming organizational structure are: as per functions, products, territory, the project, matrix, and others. functional organizational structure designs grouping activities, and defining the organizational units according to certain functions, which comprise an array of uniform and interconnected activities, by which a certain task or a part of the company's business process is realized in the best way. the essential advantage of a functional organization is that the staff is grouped according to specialties and is always at disposal. however, functional structure is characterized by inflexible hierarchical nature, autocratic style of leadership, rigidity and one-way superior-subordinate-directed communica249 health management: theory and practice tions. product organizational structure devises an organizational unit to be formed for each kind of product. the advantage of such structure is that it can direct all resources and all activities onto a single product. the basic disadvantage of the product organizational structure is that it doubles the organizational units and cadre, which is unacceptable to smaller companies. territorial organizational structure implies that organizational units are formed according to geographical regions they supply. this manner of forming the organization is rather convenient for big companies, widely extending their business on national or international level. in such an organization it is necessary to have a decentralized management, which requires additional control by the company's head management. problems may also arise with transportation costs and due to the need for large number of personnel as manager for each particular region. project organizational structure implies creation of a special organizational unit, a project team whose task is to realize the particular project. the advantage of such an organizational structure is its direct orientation to the realization of the task, an the fact that it enables more efficient realization, while the drawback of the project is mainly connected to duplication of the human resources, and problems with personnel after the project team is dismissed. matrix structure is designed to ensure modern people-oriented management, it is flexible, with two-way superior-employee communications and good coordination among different units. it is a combination of the functional and project organizations. the idea is to benefit from the advantages, and diminish some disadvantages of the project and functional organizations. the advantage of the matrix organization is that it enables efficient management of a great number of projects and efficient utilization of resources, and it also alleviates conflicts between managers. disadvantages are connected to more complex communication and reporting, as well as to potential instigation of conflicts in relation to resources allocation. the most varied organizational forms may be encountered in health services organizations ranging from bureaucratic structure with clear-cut hierarchy, to matrix structure in which power of decision making is closer to those working with patients. each organizational form has to be made in such a manner so as to be capable of functioning, enable each member to make his/her own contribution, and assist people to effectively accomplish common goals even under altered circumstances. this means that a good organizational structure is never static. nevertheless, a bureaucratic structure is considered to be capable of functioning well in routine tasks. for organizations whose main purpose is research, different adaptive models make a far more adequate solution. an example of such model is a project structure ensuring swift switches of employees from one to the other project work phase with holding 250 health systems and their evidence based development flexibility in certain areas (such as research autonomy) and having rigorous control in others (e.g. financial resources). within organizing, coordination is an important activity related to providing conditions under which all the activities, inside the company, are realized through simple steps. in the early phase of management, this was considered to be the most important element. nowadays, this is regarded as good for unplanned activities, or the periods known as 'management crises'. as organizations grew bigger, and planning much more important, the need for coordination kept decreasing. presently, it is normal that with the plans falling through, the need for coordination is increasing. typically, managers make three simple errors in organizing, as a management component: 1) managers do not leave enough freedom for decision making to their subordinates. 2) too few subordinates are held responsible to a single manager. interestingly enough, managers prefer organizing too few to too many workers, which results in unnecessary double cost expenditure for leadership jobs and forming of bureaucratic apparatus in the company. 3) managers, in organizing, generally do not apply motivating methods: employee remuneration by work successfully performed and/or penalty in case of unsatisfactory work performance. staffing in management staffing is the third vital component exclusively related, as opposed to the previous two, to human resources planning. this role may be particularly conflicting for managers, since they are individually well aware of the staff significance for the company's successful operation, but also of a simultaneous restriction of methods available for effective staff policy implementation. staffing has its technical and social aspects (13). technical aspects refer to human resources planning, job analysis, candidate recruitment for vacancies, their testing, selection, then performance appraisal, compensation and benefits, as well as employee assistance. social aspects, directly associated with the impact on employee behavior and striving at work, are related to training and development, promotions, counseling and discipline. the basic problems of staffing are the following: role defining of the newly employed, candidate working ability assessment and his/her 251 health management: theory and practice simultaneous getting acquainted with job tasks, evaluation of the success rate of the job done, and, finally, criteria establishment. in any job dependent upon staff quality and competence, staffing has to achieve high standards. thus, for example, it is upon a manager to ensure that vacancies are filled with people who are: • capable of fulfilling their intended role successfully; • willing to make necessary decisions and perform an assigned task; • planning to remain at their place of work for a reasonably long period of time; and • getting along well and cooperating with other employees at place of work. a very frequently asked question relates to staff norms, which would serve as guidelines in planning and employing. norms for a so-called 'ideal service' are non-existent and will probably remain so, at least in the foreseeable future, due to, above all, relatively frequent technological changes in medicine as well as gradual alterations in the kind and nature of health problems. „political norms” exist and usually represent combined study results of proper practice and expert opinions at a given moment, or result from negotiations of those concerned (the role of practice guidelines in the total quality management approach). in local circumstances, they may be of little use since they do not cover patient structure, assisting staff existence, department location and related factors. there are also so-called „if-then” norms based on somewhat more objective staff needs assessment, relying on the workload studies. namely, if it is necessary to provide x services, and an employee may make a daily provision for y services, then z staff members should be engaged. common mistakes in staffing are the following: lack of human resources planning, inadequate monitoring and insufficient staff training and promotion. it is important to stress that decision making related to organizational staffing, lying at the root of effective management, is often a neglected activity. managers in health (and other fields, too) frequently spend much more time in making decisions on the introduction of a new apparatus (diagnostic and/or therapeutic) than on employees, their promotion, transfer to new working posts, or engaging new employees. 252 health systems and their evidence based development leadership in management directing involves a process of influencing employees to do their best to achieve group goals by team work. a good manager accomplishes this role using different motivating methods simultaneously, knowing the true nature of communication as well as successful communication with different social structures. the importance of employees’ motivation is unquestionable and over the recent years there has been a tendency to replace „directing” by „motivating” (5). however, a person with excellent motivation, interested in his/her job, still has a need to be directed in his/her activities, since many people, in certain circumstances, prefer clear „orders” to individual decision making. nevertheless, styles of the most effective managers necessarily include perfection in employees' communicating and motivating skills (16,17). a managerial style is a kind of behavior in which a leader influences other people’s work. most frequently mentioned basic managerial styles are the following (1): • autocratic (with high managerial authority, commanding, not leaving space for interaction or participation of others in decision making), • democratic (enabling permanent interactions between superiors and subordinates, employee participation in decision making and creativity) and • laissez-faire style („let (people) do (as they please)” style, based on complete individual freedom in decision making and work). a style a manager will utilize is considered to be dependent upon his/her situation, and is characterized by critical dimensions such as (14): • result significance if a working activity has to be performed quickly, perhaps due to accidents or under conditions of crisis, health manager should adopt autocratic style, another style being required for other circumstances; • job nature if the job is routine and requires temporary influence, a manager must be more autocratic than democratic in determining what, how and where it will be done, however, if the job is creative, flexible, with other departments being time independent from job completion, a manager should adopt a democratic style; 253 health management: theory and practice • employee qualities their training, education, motivation and experience may determine adoption of a particular style; if employees are untrained and inexperienced, a manager must make most decisions and vice versa; there are even such employees who, due to their own value system or previous experience, are unwilling to be accountable for decision making; • personal managerial qualities some managers because of their personality nature, prior experience, values or cultural features, function better adopting one style or another. none of the styles mentioned is appropriate in all situations, although, nowadays, different forms of democratic style are regarded as more appropriate and, long-term, more efficient than the authoritarian styles. if only clinical practice and doctors as team managers including nurses, technicians and others are looked upon, it may be noticed that they usually utilize the autocratic style since they are held individually responsible for treatment. different forms of democratic style are common for heads of departments and chiefs of staff. kenneth blanchard, a psychologist, holds the view that an effective manager has to assume various styles in his/her work with employees (18). which style the manager will adopt, apart from the given situation, also depends upon a developmental level of an individual. he defines the developmental levels according to employees' work competence and sense of commitment: • if persons are incompetent for the job, but hard-working and zealous, they should be directed: clearly told what they should do, how, where and when, and then carefully supervised. • persons competent for the job, but lacking motivation or selfconfidence are better suited to a supportive style: they should be listened to, encouraged, involved in problem solving and decision making. • for those who are neither competent enough for the job nor devoted, an instructional style is the most convenient, providing support and directing. • in highly competent and zealous workers, delegating is the best style. little support and directing are implied just to keep abreast of their work. 254 health systems and their evidence based development among many attributes of effective managers cited as important are the following: high standard of personal honesty, firmness, ability to identify crucial problems, serenity, vitality, persuasiveness, decisiveness, consistency, personal integrity, enthusiasm, showing understanding for subordinates' attitudes and suggestions, anticipatory abilities and so on. although the majority of remarkable leaders possess most of the personality traits outlined, there is no evidence that each one of them is really required. however, vanity, arrogance and breaking one's own rules are the least favorable attributes of managers. controlling in management controlling is a subsystem important for all the management components. it is most commonly defined as measuring and correcting the company's efficiency so as to ensure both achievement of goals and realization of plans (5). the controlling process in management involves the following: establishing standards, measuring efficiency, and comparing results against the established standards, correcting irregularities and timely informing. controlling has to cover services functioning; health services provision costs, revenues, employees' discipline and informing (health care information system). although necessarily pervading the whole managing process, the scope of controlling must not be large, so that by using it a manager has no time to pay attention to human interactions, that is paying attention to each individual, as well as suggestion acceptance and understanding the employees' existing problems. the most varied types of control have been mentioned in literature: visual, automatic, control of exceptions, motivation-assisted control, budget control, daily charts, gant's maps, network analysis, computer use (5). in small organizations, personal control of all functions and all employees may be established. the higher is the organizational magnitude and complexity, the harder is the control. today, a good informational system is considered to be the most powerful control means. the importance of strategic control has been particularly emphasized at times of big economic crises and extraordinary circumstances. since the controlling system provides a signal to a manager for failure correction, identification of explicit strategic control would prevent „falling through” of many long-term plans, which makes a typical problem of less developed countries. some managers make mistakes believing that successful leadership means carrying out control by reviewing different routine reports. however, 255 health management: theory and practice the essence of control is correcting deviations from the predetermined objectives. modern managing health services organizations is increasingly turning its attention to quality control in health care provision, too (19). it has been noticed that some managers are frightened and avoid applying quality control within a regular controlling system, being under impression that possible quality lacks might lead to additional, unnecessary expenditures. however, it is both in managers' ethical and commercial interest to minimize errors and incidents leading to patients' complaints and poor public reputation. skills of modern managers in health services organizations modern health care outcomes are greatly determined by health professional activities in that management effects may instantly be analyzed, based on managerial abilities to act upon behavior of doctors, nurses and other health care workers to do their utmost in achieving the best possible outcomes for patients. the efficiency of the management itself, beside theoretical knowledge and training, mainly depends upon the existing evidence on possibilities of acting upon health care workers' behavior. the starting point is making efforts for organizational development characterized by decentralization in decision making, professional linkages and cooperation, demanding objectives, acceptable and transparent standards, responsibility division and decreasing job failures (20). in such organization, evidence based management should be developed. within the programmes for education and development, there must be those oriented towards evidence using skills on the part of managers themselves. a „complete manager” of evidence based health care should possess, apart from general managerial skills, evidence based decision making skills, as well. these skills comprise the following (21): • reference and abstract application, • the use of individually defined key words, • individual use of computers for search, • reference management database search, including, beside cochrane base, the bases covering topics in the field of health care administrations, economy and planning (2,3,22). apart from the skills mentioned, requiring, in most cases, special education, managers of health services organizations should also possess skills 256 health systems and their evidence based development of research evidence implementation into everyday practice, as well as skills of managing alterations, projects and, finally, team work. unfortunately, certain studies have shown that, when specific skills needed for evidence based management of health services organizations are taken into account, managers themselves inhibit the development of such approach. in the past, managers of health services organizations were responsible for organization and system, but nowadays, with the shift towards evidence based health care, they have to balance among clinical, managerial and organizational performance (23). having in mind numerous restrictions and the time required for the development of such approach, as well as suspicion among certain theoreticians concerning uncertainty of its possible implementation due to those restrictions, evaluation informed management has been recommended, as a transitional strategy (24). besides, an important recommendation for evidence based management is the one related to modifying existing educational programmes via multidisciplinary teams, so that clinicians may educate themselves from management area, and managers of health services organizations from clinical research. 257 health management: theory and practice exercise: managing health services organizations the purpose of the exercise is to provide students with basic information on managing health services organizations and their functions (components), and also to find out how managerial skills may be mastered by learning and training. task 1: professional development (career) plan design students work individually, by writing down their own goals in professional development for a ten-year period, as well as conditions required for their accomplishment. several students present their reports. a teacher, after that, points out planning as one of the important functions of management being especially aggravated under conditions of critical environment. also, the term „management” is defined, and its other functions quoted, such as: organizing, staffing, directing and controlling. time: 30 minutes. task 2: case problem: how is group work to be maintained? the teacher introduces the topic by outlining possibilities of managerial skills training and stresses „case problem” solving as one of the ways of its achievement. then, the supplemented practical case is read. students, in groups of 5-6, discuss solutions, and then each group presents its reports. the teacher, upon that, provides a summary with a suggested solution, unless the students have discussed all the possibilities. time: 60 minutes. case problem: „how will you maintain group work?” dr branislava petrovi}, a newly appointed chief of staff in gp outpatient department of a health care centre, is worried about starting her new job properly. just after several weeks at work, she noticed that the majority complained of being overworked. when she seemed to notice that one nurse was too slow in answering the telephone, dr petrovi} gloomily asked: „why's it taking you so long to answer the phone? that's a very important thing for our service and i think it should be answered after the second ring!” the nurse answered: „we've so much work to do; i simply can't jump after hearing a ring.” as the others were also making similar remarks, that still did not convince branislava that they were overworked. in fact, branislava knew that the new health centre manager was seriously considering cutting down of staff in the outpatient department unless their working hours were truly totally spent. dr petrovi} was particularly unhappy about the time wasted by many of her employees on coffee breaks. to quote her own words: „on tuesday i came 258 health systems and their evidence based development back from a meeting at 9.30 and offices were almost empty. the employees went for a coffee break and didn't come back even after 45 minutes!” this made branislava issue an order for both morning and afternoon coffee breaks to last no longer than 15 minutes; also, no more than two employees could have a coffee break at the same time. employees remained at their places of work, but it seemed that it took even longer to carry out examinations, interventions and administrative work. branislava noticed that several doctors and nurses spent quite a long time on making personal telephone calls, while the waiting rooms were full of patients. in issuing her second order, dr petrovi} announced: „personal telephone calls shall last 2 minutes at most and there are to be no more than two such calls daily. in addition, our work is too slow! we keep our patients waiting too long and prescribe too many drugs!” in spite of dr petrovi}'s efforts, there were no improvements in the work performance of the outpatient department. only one nurse (marija) started showing quite unpleasant manners towards her chief of staff. after the latest order, marija told dr petrovi}: „you're really trying hard to make an impression, maybe wishing to be promoted to the assistant manager. when you leave, we'll be left with all these new changes: restricted drug prescriptions, patient referrals to specialists, sick leave reductions... all this, of course, unless we're fired beforehand!” branislava was very frustrated. she was aware that her employees were doing their jobs below their abilities, but did not know what to do. questions: suggest specific steps dr petrovi} should undertake to solve the problem. what should dr petrovi} do if the suggested steps prove unhelpful? learning from anecdote: „report: schubert's unfinished symphony” during considerable periods of time the four musicians on the oboes had nothing to do. their numbers should be reduced and their work distributed to the rest of the orchestra. forty violins are playing the same notes. this seems to be an unnecessary duplication, so this part should be drastically cut. if you want more volume, an electronic amplifier should be used. there is no need to repeat on the horns the passage already played by the string instruments. if these parts were eliminated, the concert would be reduced to 20 minutes. if schubert had worried about these problems, he probably would have finished his „unfinished symphony”. 259 health management: theory and practice references and recommended readings 1. torrens pr. management sciences and planning studies. in: holland ww, detels r, knox d, ed. oxford textbook of public health. 2nd edition. volume 2: methods of public health. oxford: oxford university press 1991. 363-84. 2. mcnamara c. free management library (cited 2003, may 20). available from url: http://www.managementhelp.org/ 3. management sciences for health (cited 2003, june 15). available from url: http://www.msh.org 4. boissoneau r. health care organization and development. rockville, maryland: an aspen publication 1986. 5. rakich js, longest bb, darr k, managing health services organizations. 3rd edition. baltimore, maryland 1993. 6. drucker pf. managing for the future, the 1990s and beyond. new york: truman talley books/dutton 1992. 7. simpson j, smith r. management for doctors. london: bmj publishing group 1995. 8. williams sj, ewell cm. medical staff leadership: a national panel survey. health care manage rev 1996; 21(2): 29-37. 9. hunter dj. doctors as managers: poachers turned gamekeepers. soc sci med 1992; 35(4): 557-66. 10. smith r, grabham a, chantler c. doctors becoming managers. bmj 1988; 298: 311-14. 11. mcconnell cr. the effective health care supervisor. 2nd edition. gaithersburg, maryland: aspen publishers, inc. 1988. 12. koontz h, o'donnel c, weihrich h. essentials of management. 4th edition. new york: mc graw-hill book company 1986. 13. cohen jg. the nature of management. 2nd edition. london: banking and finance series, graham & trotman 1988. 14. rowland hs, roeland bl. nursing administration handbook. germantown, maryland: aspen systems corporation 1980. 15. mintzberg h. mintzberg on management: inside our strange world of organizations. new york: the free press 1989. 16. quinn jb, anderson p, finkelstein s. managing professional intellect: making the most of the best. harvard business rev 1996; 74(2): 71-80. 17. elwyn g greenhalgh t, macfarlane. groups a guide to small group work in healthcare, management, education and research. abingdon, oxon: radcliffe medical press ltd 2001. 18. blanchard k, zigarmi p, zigarmi d. leadership and the one minut manager. glasgow: fontana paperbacks 1990. 19. borgenhammar e. quality of management in the health care system. quality assurance in health care 1990; 2(3/4): 297-307. 260 health systems and their evidence based development 20. smith kpd. evidence based management in health care. in: peckham m, smith r, ed. the scientific basis of health services. 2nd edition. london: bmj publishing group 1997. 9299. 21. gray mja. evidence-based health care. how to make health policy and management decisions. new york: churchill livingstone inc., 1997. 22. the cohrane library, oxford (cited 2003, june 20). available from url: http://www.hiru.mcmaster.ca/cochrane/revabstr 23. clarke j, wentz r. pragmatic approach is effective in evidence based health care. bmj 2000; 321: 566. 24. overtveit j. evidence-based medicine: evaluation informed management. healthcare review online 1998; 2(9): http://www.enigma.co.nz/hero_articles/9807 261 health management: theory and practice 262 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title human resource management module: 2.2 ects (suggested): 0.50 author(s), degrees, institution(s) silvia gabriela scintee, md, msc part-time lecturer at the university of medicine and pharmacy „carol davila” bucharest, department of public health and management public health consultant at the institute of public health bucharest address for correspondence institute of public health bucharest 1-3 dr. leonte street 76256 bucharest romania tel: (4021) 2249228 / ext.188 fax: (4021) 3123426 e-mail: gscintee@ispb.ro keywords human resource management, human resource planning, job analysis, recruiting and selection of personnel, employees training and development, motivation, evaluating employee performance learning objectives at the end of this module, students should be able to: • define human resource management and identify its functions, • describe the steps involved in the human resource planning process, • define the term of job analysis, • describe the recruiting and selection processes, • identify methods for employees training and development, • describe methods for evaluating employee performance. abstract this course covers the following topics: fundamentals of human resource management, staffing the organisation, employees training and development, personnel motivation, employees maintenance. teaching methods teaching methods include lectures, interactive presentation of key concepts, group discussions, groups assignments, role playing for job interview. specific recommendations for teacher teaching methods include lectures, interactive presentation of key concepts, group discussions, groups assignments, role playing for job interview. teacher should discuss the concepts and methods in comparison with the practice in see countries.this course takes 2 hours of lecture and 4 hours practical session including role-playing. the rest is individual work. assessment of students 1. reports presented by each group during the working sessions could be considered as part of assessment. 2. a multiple-choice test containing questions from all topics, at the end of the course could be used for final assessment. human resource management silvia gabriela scintee fundamentals of human resource management human resource is the most important asset of an organization, and has a crucial importance for management, as the management is the process of efficiently achieving the strategic objectives of the organization through people. human resource management is responsible for the people dimension of the organization and is concerned with getting competent people, training them and motivating them to perform at high levels (1). human resource management is the process that assures the utilization of the employees so that both the organization and the employees obtain the highest possible benefit. some authors make a distinction between human resource management and personnel function. in this view, while human resource management has a strategic role, assuming human resource policies development for the entire organization, the personnel function is supposed to have an operational role, being considered as a tool for human resource policies implementation. thus, while human resource management is the responsibility of a special department, the personnel management is one of the duties of the managers from all levels in the organization. according to other authors personnel management is the historical term of human resource management and the change appeared with the changing roles of professionals in human resource area (2,3). the main functions of the human resource management are staffing, training and development, motivation and maintenance. staffing function in order to implement strategies and achieve the stated goals and objectives, an organization must be staffed with adequate numbers of properly trained personnel. the staffing function is a continuation of strategic planning process, when after determining how goals and objectives will be attained, the managers should determine what jobs need to be done and by whom. these activities are included in the human resource planning process that determines staffing needs. the outcome of this process will be either recruitment or decruitment (1). when acquisition of personnel is needed, the manager should 263 human resource management gather two types of information: information on the job and information on the persons eligible for the job, than to match skills, knowledge and abilities to required job. when manager has to sever people from the organization, he/she should engage in activities to assist and monitor exit. the staffing function includes: human resource planning, job analysis, job description, recruitment, selection, integration of the new employee, assistance and monitoring personnel exit. human resource planning is the process by which an organization ensures that it has the right number and kinds of people able of efficiently and effectively performing the tasks required for achieving the strategic objectives of the organization (1,4). as organizations are dynamic, permanently under the influence of external environment and internal factors, planning should be a continuous process. the main steps of human resource planning are: strategic objectives analysis, estimating staffing needs, assessment of current human resources, forecasting changes in the present workforce, and development of an action plan. strategic objectives analysis. strategic objectives are broad statements that establish targets the organization will achieve in a certain period of time. the analysis of the current strategy determine how goals and objectives will be attained and to what extent the organization can meet its objectives given the internal strengths and weaknesses and external opportunities and threats. commonly referred to as swot analysis, this managerial tool could bring information on what skills, knowledge and abilities are available internally, and where the shortages in terms of people skills or equipment may exist (1). the analysis should take into account influencing factors such as: anticipated demand for services, changes in professional practice or labour supply, development of new technologies. estimating staffing needs. the analysis of the objectives and of the ways in which they will be attained gives information on the number and types of the jobs needed and the skills and knowledge required for the jobs. unless drastic changes will occur, such as reengineering initiatives, major organizational changes, human resources needs estimates could be made for a certain time period, using the established staffing ratios for most major functions. for example, for the further development of an outpatient department at a hospital, projection of the needed staff can be made (2). using the projected volume of service and the accepted nurse staffing ratio, it can determined the number of nurses needed. 264 health systems and their evidence based development assessment of current human resources. assessment of current human resources is a valuable input in the human resource planning process by determining what skills are currently available in the organization and how are they used. each organization should generate a detailed human resources inventory report listing all employees by title of the job, education, training, prior employment, performance ratings, salary level, languages spoken, abilities and specialized skills (2). such an inventory could be also used for other activities such us internal recruitment or selecting individuals for training and development. forecasting changes in the present workforce. an organization will experience turnover through retirement, death, voluntary separation, etc. based on historical data the changes in the present workforce could be forecast. for managerial positions some organizations use the replacement chart (1). this is a diagram that determines if there is within organization a sufficient managerial potential to cover future vacancies. the main information listed for each individual is: the current position, expected replacement time, and possible replacements with their potential and readiness in occupying the job. development of an action plan. the previous steps bring the necessary information for developing an action plan to fill the staffing needs through recruiting and hiring, transferring or enhancing the skills of existing employees by training and development. the action plan will specify: the jobs to be created, transformed or cut off, the implications at institutional level, the number of persons to be hired and specifications of their characteristics, the movement of the personnel within the organization and the training needs, the methods of sorting out the unpredictable losses, the costs of covering staffing needs and the timetable of each activity. job analysis and job description. job analysis is a systematic examination of the activities within a job (1). this analysis involves the description of the job content (the goal of the activity, tasks to be fulfilled, duties and responsibilities, resources used, expected results), what are the job requirements (knowledge, abilities, skills required), what are the working conditions (physical environment, hazards), and the social environment (individual or group work, communication skills required, relationships to other jobs). there are three basic methods for job analysis: observation, questionnaire and interview. observation provides firsthand information. this can be done directly or reviewing films of workers on the job. observation can not bring exact information as people being watched act differently than in their day to day activity. the interview has an increased accuracy in assessing jobs by involving employees in analysis. in order to increase the effectiveness of this method it 265 human resource management is recommended a combination between individual and group interview. structured questionnaires could also be used for gathering information about a job. the disadvantage of this method is that exceptions to a job may be left out and there is no opportunity to ask follow-up questions. other methods that can be used for job analysis are technical conference (specific job characteristics are obtained from experts) or diary method (workers are asked to record their daily activities). the main purpose for job analysis is to gather information in order to develop: job descriptions, job specifications and job evaluation (1). a job description is a written statement of what the jobholder does, why and under what conditions. the content and format of job descriptions vary among organizations. yet, the general job description format include (1,5): name of organization name of division/department job title grade of job job purpose duties to be performed authority and responsibilities of the job holder supervision given or received relationships with other jobs environmental working conditions special provision (e.g. confidentiality) terms and conditions (e.g. salary, working hours, holidays) job specifications states the characteristics that the jobholder must posses in order to perform the job successfully. these characteristics are identified also during job analysis and refer to the knowledge, skills, education, experience, certification and abilities needed to do the job effectively. job description and job specifications are used in activities such as human resource planning, recruitment, selection, performance evaluation, compensation plans. job evaluation is the process of determining the value of each job in relation to the other jobs within organization. on the basis of job evaluation, the jobs in an organization are ranked and placed in a hierarchical order (3,6). the resulted ranking should be used in order to establish the compensation programme. 266 health systems and their evidence based development recruitment is the process of searching and attracting potential candidates for present or anticipated vacancies. the recruitment sources could be either internal or external (2). the internal search attempts to identify present employees who can fill a vacancy by transfer or promotion. this method is cost effective, quick and motivating for the employees. the external search is done mainly by advertisements that can be placed in different newspapers, magazines, electronic sites or public places, depending on the type of the job. the main elements to be included in a vacancy announcement are given below (6): organization name title of the job location of the job employment duration description of duties job specifications salary and employment terms application procedure other external sources are employment agencies, schools, colleges, universities, professional organizations or even unsolicited applications. the selection of the recruitment source depends on the job characteristics, labour market supply, geographic workforce distribution. the success of the recruitment process is influenced by factors such as: organization reputation, the attractiveness and nature of the job, internal policies of the organization, legal requirements, and the recruitment budget (4). selection. the next step in acquisition of personnel is to choose from all qualified applicants for a job identified through recruiting the „right” one. this is a very important decision, as a good selection process can save costs for personnel replacement or training and can increase the work productivity. there could be considered two steps of the selection process: initial screening and final selection. initial screening consists in gathering preliminary information about candidates and excluding those who are not suited for the job in terms of training, experience and ability. among methods used for initial screening are curriculum vitae, intention letter, application form, letter of recommendation, employment tests. 267 human resource management curriculum vitae (cv) cvs bring information mainly on training and experience, but also give some insights about candidate personality, when looking at its clarity, stile and logic sequence of ideas (6). the information to be included in a cv is: • personal data and characteristics (name, surname, contact details, date of birth, nationality, marital status) • education (institutions, dates, degree or diplomas obtained) • present position (company, location, description of main tasks) • work experience (employment record, institutions, dates, main tasks and responsibilities) • scientific activity (papers, presentations, publications) • other skills (e.g. proficiency in foreign languages, computer literacy) • other information (if appropriate, e.g. hobbies, preferences for leisure time) intention letter while cv is just an inventory of the person’s history regarding training and experience, the intention letter is the mean by which the candidate exposes his motivation and desire to get the job. the intention letter also talks about candidate’s professional and human qualities and about his compatibility with the job. no longer than one page, an intention letter should not contain the information from cv, but has to wake up the reader interest in setting an appointment for the candidate. application form there is not a general format for the application forms. each organization has its own format, some of them requiring may be only applicant name, address and telephone number, others requesting the completion of a more comprehensive profile. in general, application forms bring less information than a cv, but they are very common, representing a standardized tool for information gathering which makes comparison between candidates easier (6). some application forms could include statements giving the employer the right to obtain previous work history of the candidate, to dismiss him for falsing information or to end the work relationship at the employer will. if the candidate does not sign such a form his application is removed from consideration (1). 268 health systems and their evidence based development letter of recommendation information about candidates could be obtained from other persons, too. even criticized as being subjective, recommendation letters are still very common. they depend on the intention and the degree of information of the person who issues it. usually there are requested two or more recommendation letters. the initial screenings will shortlist the candidates for the final selection. both shortlisted and not shortlisted candidates should be announced about their results through an official letter. the shortlisted candidates are asked to come for the final selection that can be done by employment tests or by interview. employment tests tests are used mainly for two purposes: the assessment of the candidates’ knowledge, abilities and skills, and the psychological evaluation of the candidates. the second category is given more importance as many studies have shown that the employees performance is more related to their personality characteristics than to the knowledge they have. there are hundreds of tests that can be used by an organization in selection purposes. they are measuring intellect, memory, perception skills, spatial ability, motor ability, personality traits, etc. bringing information that can not be obtained from the candidate and that can make predictions on the person behaviour. tests can be written tests or simulation tests. the last ones require the applicant to engage in specific activities and behaviours necessary for doing the job. assessment centres an organization can also address for initial screening of its candidates to an assessment centre. these are specialized institutions that combine more methods in selecting candidates. all applicants are received at such a centre for a 2-4 days period, being subjected to individual and group testing by: interviews, solving problem exercises, group discussions, role playing, personality and general ability tests, etc. in the same time it is assessed the candidates social behaviour (1). interview interview is almost universal accepted as the final selection tool, evaluating the candidates’ compatibility with the job, motivation and abilities of integrating themselves in the organization. the interview gives the opportunity of clarifying the previous gathered information on the candidate and also can 269 human resource management test the candidate reaction under particular situations such as stress, conflicts, etc. the interview’s validity and reliability are subject of criticism (1). in order to increase the effectiveness of the interview, it should be conducted by a person familiar with the interview technique and having some specific qualities: determination, discipline, self-control, tolerance, empathy, lack of prejudices. an interview should be careful prepared, paying attention to the place where it will be held, obtaining detailed information about the job and its requirements, studying applicants information gathered in the initial screening stage, planning time, developing guidelines for interview and a list of criteria to be evaluated during the interview (5,6). integration of the new employee. after selection, the new employee is helped to integrate in the organization, in order to become productive as soon as possible. the human resource department is responsible with enrolling new employee in benefit plans, issuing an identification badge/card. the chief of the department in which the new employee will work will take care of preparing the work place, and will delegate a supervisor to prepare and implement an orientation programme (4). the supervisor will introduce the new employee to other colleagues, will explain the organizational structure and function, will explain in detail the department specific work methods and internal norms and rules. the supervisor also helps the new employee to gain acceptance by others and will morally support him with any personal problems. usually, in a month time the manager will meet the new employee in order to evaluate the extent to which he integrated in the organization. assistance and monitoring personnel exit. sometimes the employees have to leave the organization from various reasons. the personnel exit should also be assisted and monitored. besides activities like completing personnel records, collecting employer-provided equipment and processing final pay, a manager could involve in activities oriented to the alleviation of psychological impact of leaving the job and to assisting employees in finding employment (2). thus, some organizations have a preretirement programme consisting in preparing employee for the psychological, emotional and financial changes in retirement. when jobs are eliminated for various reasons (changing demand, downsizing, mergers, etc.) the leaving employee should receive an earlier notice and should be helped in finding a new working place. also, the employee could be tested for discovering abilities for other jobs and helped in the process of professional re-orientation and re-location. 270 health systems and their evidence based development training and development function training and development is a key element in helping employees to maximize their potential. the goal of training and development function is to have competent employees who possess the up-to-date skills, knowledge and abilities needed to perform their current jobs more successfully. although there are similarities in the methods used to affect learning, the terms of education, training and development are different (6). education refers to a basic teaching, a long term learning process, directed to obtaining knowledge, abilities and skills that allow individuals or groups to perform the social roles. education is focused mainly on individual needs and also on community needs. training is a learning process oriented to the acquiring of specific knowledge, abilities and skills necessary to the individuals or groups for performing a job. training is job or tasks oriented, it has a continuous character and it might assume changing of skills, attitudes or behaviour in order to immediately adapt to the present job requirements. development is a learning activity oriented rather to the future needs than to the present ones. employee development focuses on the future jobs in the organisation and career progress for which new skills and abilities will be required. each organisation should have a continuous training and development programme. specific training and development needs are given by: hiring new employees, acquisition of new technology and equipment, low performance of the organisation, occurrence of some events with a higher frequency than usual (e.g. nosocomial infection in a hospital), changing demand for services, organisational changes. the development of a training and development programme has the following steps (6): 271 human resource management training and development policy internal needs evaluation external factors factors plan implementation programme evaluation training and development policies are included in overall human resource policies of an organization and have to be in accordance with its general policies (6). training and development programmes should take into account the training and development policies that usually state the organization’s commitment of assuring to the employees the appropriate means for training in order to successfully perform their jobs. elaboration of a training and development programme should be preceded by training and development needs assessment. the training need is represented by the deficit of knowledge, abilities and skills in relation to the level required by the job or by the organizational changes (3,6). the main information sources for needs assessment are: • the organization – we will look at the organization’s goals, structure and functioning, • the job – what tasks have to be completed to achieve the organization’s goals, what are the requirements for effectively performing the job, • the employee – what is the level of employee’s performance, what are the deficiencies he has in the skills, knowledge or abilities required to perform the job. training and development needs assessment has to take also in account 272 health systems and their evidence based development training / development plan all internal and external factors that might contribute to the changing of the organization needs. once it has been determined that further training and development is necessary, an action plan will be developed (6). the structure of the training / development plans: training goals training objectives target groups training content training methods time schedule estimated necessary resources evaluation and monitoring tools training goals should be clearly stated and they can refer to: increasing capacity for problem solving, enhancing ability for performing specific activities, acquiring skills for performing new tasks, increasing communication skills, modifying attitudes towards change. training objectives should be tangible, verifiable, timely and measurable. they have to reflect the real changes in the employees knowledge, abilities, skills or attitudes. training content will be established in accordance with the training objectives and the level of previous training of the target group. training methods can be classified as either on-the-job or off-the-job training (1). on-the-job training method is the most used, being simple and less expensive. it is a learning by doing method, placing the employee in actual work situations and asking him to do the tasks. this method is more appropriate for jobs that are difficult to simulate or for those that can be easily learned by watching and doing. examples of on-the-job training are: • apprenticeship – is used for training in different trades where skills are so complex that can not be acquired on theoretical basis or by simulation. it consists in putting the trainee under the guidance of a skilled master. • job instruction training – consists in explaining the trainees what they are suppose to do, verifying their understanding and placing them in the job under a supervisor to call upon if they need assistance. 273 human resource management on-the-job training has the risk of low productivity, but has the advantage of motivating workers, increasing employee morale and understanding. off-the-job training has a various number of techniques: • lectures – designed to communicate theoretical concepts, to describe tools or to present technical, problem-solving skills, • seminars and workshops – for more interactive discussions and practical exercises in which to apply theoretical knowledge, • simulation exercises – in which trainees are performing different tasks in a working like situation; this also may include: case studies, role playing, group decision-making, computer based simulation, training on real equipment away from the work setting, • videos and films – use media production to demonstrate specialised skills that can not be easily presented by other methods. developing methods can also take place on-the-job or off-the-job (1). among on-the-job techniques there are: • job rotation – consists in moving employees to various jobs in the organisation, either on horizontal or vertical, with the purpose of expanding their skills, knowledge and abilities. this method gives the employee an overall view on the organisation activities, turns him from a specialist to a generalist, avoids boredom and stimulates the development of new ideas. • working as staff assistant – the employee works as the „shadow” of an experienced person from the next higher level. working as an assistant, the employee has the opportunity to be exposed to the whole range of the activities in that position, he learns by performing many duties under direct supervision and get used with assuming the duties and responsibility of the higher level. • committee assignment – the employee is appointed to temporary or permanent committees. this allows employee to take notice about specific organisational problems and to learn from the others example how to solve different problems and to participate in decision making. off-the-job methods could be done by traditional forms of instruction such as lectures, seminars, simulation exercises or by modern techniques like outdoor training. 274 health systems and their evidence based development • lectures and seminars – they are offered for acquiring knowledge or for developing employees conceptual and analytical abilities and could be organised either in class or by distance learning. • simulations – as seen above, simulations are exercises in which employees are performing different tasks in a working like situation. the most used are: case studies, role playing, decision games. • outdoor training – also called wilderness or survival training, this method teach the importance of working together and involve emotional and physical challenge. the most known techniques are: whitewater rafting, mountain climbing, paint-balls games or surviving one week in the jungle. motivation function motivation is a key determinant of employees performance. the concept of motivation is based on the way in which people are given attention and on the feelings that they have in relation with their work. to motivate employees means to satisfy their unmet needs, to stimulate them to work better in order to achieve the organization’s goals. unmet needs cause discontent which is reflected in employee’s negative behaviour and attitudes, producing tension and low productivity. the motivation process is cyclical (2). it starts from identifying individuals unmeet needs, after that ways to satisfy the needs are searched for and the most convenient is chosen. the needs satisfaction is recommended to be followed by the assessment of needs satisfaction level, which may confirm the failure of satisfying the need, or identifies a new need and the cycle is restarted. 275 human resource management searching ways to satisfy the needs choosing the way to satisfy the needs unmet needs identification unmet existing needs & new needs identified assessment of needs satisfaction level the motivation theories. the multitude and diversity of theories developed to explain human motivation reflects its complexity. the most important motivation theories can be divided in two categories: content theories and process theories (2,3,5). while content theories focus on „what” motivates people, process theories focus on „how” motivation is initiated and sustained. among content theories there are: maslow’s hierarchy of needs – considers people needs arranged in the following hierarchy (from lowest to highest): physiological, safety and security, social activity, ego and self-actualization (figure 1). figure 1. hierarchy of people needs according to this theory, only needs not yet satisfied influence behaviour and once the needs from a level are fulfilled, the individual moves up to the next level. primarily, an individual has physiological needs, such as air, water, food, shelter and sex are basic for an individual. once these survival needs are met, the individual turns to the next level: safety and security, represented by needs for health insurance and other benefits that ensure protection against physical harm and deprivation. the third level of needs includes the need for belonging, friendship affection and love. examples of ego needs are the need for independence, achievement, recognition, self-esteem and status. in the top of the hierarchy are self-actualisation needs, represented by continuing growth and development, opportunities for self-expression and self-fulfilment. 276 health systems and their evidence based development selfactualization ego social activity safety and security physiological state alderfer’s erg theory – refers to the three categories of needs: existence needs – including material and physical needs that can be satisfied by air, water, money and working conditions, relatedness needs – that involve other people and are satisfied by social and interpersonal relationship, and growth needs – including all needs satisfied by an individual through creative or productive contributions. similar to maslow’s theory, people focus first on needs that are satisfied by more concrete ways. herzberg’s two-factor theory – say that job satisfaction consists of two separate and independent factors: intrinsic job factors such as responsibility and recognition which motivate when they are adequate, and extrinsic factors called also „hygiene factors” that only placate employees when are present, but they cause dissatisfaction when they are deficient. among the hygiene factors identified by herzberg there are: organisational policy and administration, interpersonal relationships, salary, job security, working conditions. mcclelland’s learned needs theory – states that people learn about their needs through life experiences and there are three major needs in workplace situations: the need for achievement, the need for power and the need for affiliation. the most known process theories are: vroom’s expectancy theory – based on the concept that people have preferences for outcomes and if they have a strong preference for a particular outcome, they will attach to that outcome a high valence. adam’s equity theory – focus on people desire of being treated fairly and states that individuals assess whether rewards are equitably distributed within organisation by calculating the ratios of their efforts to the rewards they receive and compare them to the ratios for others in similar situations. locke’s goal setting theory – affirms the importance of goals in motivation as people focus their attention on the concrete tasks that are related to attaining their goals and persist in the task until the goals are achieved. all the above mentioned theories are based on the mcgregor observation of the importance of managers’ attitudes about people in determining their approach to motivation. in 1960s douglas mcgregor proposed two alternative sets of assumptions that managers hold about human nature in workplaces: theory x – according to which managers view people in negative ways and theory y – that argues that managers view people in positive ways. according to mcgregor theory y assumptions are more valid than theory x and employee motivation would be maximised by giving workers greater job involvement and autonomy. 277 human resource management motivation principles (1): • put the right person in the right place. no reward or stimulating factor could increase a person’s productivity if that person lacks the ability to perform the job. matching properly the employee to the job should be an objective of recruiting and selection. • managing by objectives. people work better when their activity is goal-directed because this is challenging and it is clear to the employee what is to be done. the results are even better if individual objectives are mutually set and are in accordance with the department and organisation objectives. continuous feedback is also important for increasing individual’s performance. • understanding individual needs. individuals are different, and each individual has its own set of needs. so, unmet needs assessment should be done for each employee. • individualise rewards. as the individual needs are different from a person to another, rewards should also be different. what motivate an individual, could not be motivating for another one. • reward performance. the best way to encourage increasing performance is to reward individuals for their performance or to relate any other reward they receive with the achievement of the organisation goals. • use an equitable rewarding system. people are concerned not only with the rewards they receive, but also with the equity of their rewards compared to what others receive. so, efforts must be made in order to ensure that the reward system is fair, consistent and objective. • money is the best reward. as money is the main reason for people to work, no other reward would be appreciated if they were not paid sufficiently to cover their basic needs. 278 health systems and their evidence based development possible ways to increase motivation: job related rewards • job characteristics such as: the requirement for using various skills and talents, the requirement of completion of a whole and identifiable piece of work, the impact the job has on the lives or work of other people, a high degree of autonomy, a high degree of information received back on the effectiveness of his/her performance. • job enrichment – the worker is allowed to assume some of the tasks executed by his/her direct manager. • job rotation – the employee has the opportunity to diversify its activity and offset the occurrence of boredom. • work at home – this affords employee, especially women, to combine both their careers and family responsibility. • flexible hours – increases workers’ freedom; employees assume responsibility of completing a specific work in a specific time, and this increases their feeling of self-worth. • training courses. • assuring a safe, pleasant and practical working environment. rewards not related to the job • tangible rewards: premiums, stocks, insurances, presents, free lunches, free snacks and coffee at the break, etc. • social rewards: free tickets for spectacles, picnics, trips, free access to company clubs, etc. • acknowledgements – diplomas, certificates, mentioning in the panel of honour, informal acknowledgements. maintenance / retaining function another function of human resource management is to put into place activities that will help retain productive employees. these activities includes: appraising employees performance, moving employees within the organization through promotion or transfer, providing employee assistance and career counseling, administering compensation and benefits, ensuring a healthful workplace and personal safety (2). 279 human resource management performance appraisal evaluates an employee’s work by comparing actual with expected results. it should be done at any level, from employees and managers. uses of performance appraisal are (6): • to collect information in order to evaluate if work results are those expected and, if not, to determine why not, • to help decision-making in regards with compensation schemes and other benefits, • to determine the further use of the employee (if he/she should stay at the same work place, or should be transferred, promoted, demoted or deployed), • to evaluate training needs by identifying areas in which performance could be increased in proper training is undertaken, • to motivate employees for working better by providing feed-back and making the results available to the others, too, • to increase communication between employee and supervisor, allowing the opportunity to discuss the problems that are responsible for a low performance, and • to provide information on employee assistance and counseling needs. performance appraisal principles are: • evaluation criteria should be formulated according to job description. they have to be clearly stated, easy to measure and in small number. examples of evaluation criteria are: the degree of fulfilling with tasks, the degree of assuming responsibility, initiative and creativity, etc. • the measuring of performance should be done against specific standards. these are established by job analysis, which gives information on the tasks that have to be fulfilled, the way in which the tasks should be performed. the performance standards cover: the quantity and quality of work, the efficient use of resources in order to maintain costs, the compliance with the time schedule, the specific requirements for the job (such as team work abilities, flexibility, communication skills, etc.). 280 health systems and their evidence based development • the appraisal should be prepared and scheduled in advance. the employee should have permanently access to his job description, which should also have attached the list of performance appraisal standards and the schedule of the periodical evaluations. thus the employee has the opportunity to prepare in advance. on the other hand, the manager should be prepared in advance reviewing the employee’s job description and his previous performance measures. • the employee should be involved in appraisal by taking active part in the discussion, raising questions, adding his own perceptions about his work and also by a self-evaluation. • the employee should be familiar with the purpose of the appraisal and the evaluator should behave in a way that the employee understand that the appraisal has the role of helping him and not of punishing him. performance appraisal methods can be classified according to the approach in: methods based on absolute standards, methods based on relative standards, and methods based on objectives (1,7). among the methods based on absolute standards there are: • essay method – the appraiser writes a narrative description of employee’s strengths, weaknesses, potential and suggestions for improvement. this method can provide specific information, but makes difficult the comparisons between individuals. • critical incident method – looks mainly at behaviours, focusing on those critical aspects that make a difference between doing a job effectively and doing it ineffectively. the comparison and ranking of employee is difficult by this method. • checklist – the evaluator uses a list of behavioural descriptions and checks off those behaviours that apply to the employee. the list is evaluated by another person and this reduces some bias as the rater and the scorer are different persons. • rating scale – the most common method, it can be used to assess job dimension attributes such as quantity and quality of work, job knowledge, or personal traits and behaviours such as cooperation, dependability, loyalty, attendance, honesty, attitudes, initiative. for each scale there is a scoring mechanism using descriptive adjectives from „poor” to „excellent” or numerical values that often range from 1 (poor) to 10 (excellent). 281 human resource management • forced-choice method – is a special type of checklist where the rater must choose between two or more statements, each statement being favorable or unfavorable. the appraiser will identify which statement is most/least descriptive for the individual being evaluated. in the category of appraisal methods based on relative standards there are: • group order ranking – this requires the evaluator to place employees into a particular classification, such as „top 10”. this method prevents raters from inflating their evaluation by rating everyone as good. • individual ranking – requires the evaluator to list the employees in order from highest to lowest. • paired comparison – it ranks each individual in relationship to all others on a one-on-one basis. each person is scored by counting the number of pairs, among his colleagues, in which he is preferred member. the third approach to performance appraisal makes use of objectives, being commonly referred to as management by objectives (mbo). it consists in four steps: goal setting, action planning, self-control and periodic reviews. for each employee specific objectives are established jointly by the supervisor and the employee, and also realistic plans are developed in order to attain the objectives. the employee is monitoring and measures its performance, with periodic progress reviews done by supervisor. performance appraisal errors. the main problem with the performance appraisal methods is that all of them allow some bias (1,7). the most common errors are described below: • leniency / severity errors – the individuals within an organization are evaluated by different persons. some evaluators are more generous than anothers, so the performance is evaluated either higher or lower than it really is, and comparisons between individuals are not reliable. • halo effect – the evaluator’s general opinion on an employee is influenced by a single specific aspect. • central tendency – is the evaluator tendency of avoiding the extremes and rating everyone in the middle. 282 health systems and their evidence based development • similarity error – is given by the fact that the evaluator rate other people in the same way that they perceive themselves, by projecting those perceptions onto others. • other errors are given by: prejudices, different cultures, recent influencing events. in order to reduce appraisal errors a combination of two or more methods is recommended. 283 human resource management exercise: human resource management students will perform 4 exercises, after each introductory lecture. total time requested for exercises is 4 hours. task 1: small group discussion recommended subjects for group discussion are: • human resource planning advantages and limits. • the possible recruitment sources for managerial jobs in health sector. • how doctors in your country are best motivated. • how performance is assessed in different organizations in your country (from students experience or after visiting some organizations and collecting information) task 2: developing skills in human resources management recommended assignments for group work. prepare the following: • job description • write the job advertisement • cvs and intention letters • find different blank application forms from different organizations and compare them. application form which is most preferred overall by the class. develop a training plan for middle-level hospital managers. task 3: web-wise exercises search the web to identify current job opportunities: http://www.careermosaic.com http://www.occ.com http://www.who.ch look also for other sites. 284 health systems and their evidence based development task 4: role play job interview: choose up to 7 applicants for a certain job who will submit their cvs and intention letters for applying to a job. a small group (4-5 persons – the interview commission) will shortlist 2-3 candidates for interview. than the interview will be conducted and it will be chosen the best person for the job. the other persons in the class will discuss at the end the positive and negative aspects observed during the interview. 285 human resource management references 1. de cenzo ad, robbins ps. human resource management. 6th ed. new york: john wiley & sons inc. 1999. 2. longest jbb, rakich js, darr k. managing health service organizations and systems. 4th ed. baltimore: health professions press 2000. pp. 531-586, 771-800. 3. armstrong m. a handbook of personnel management practice. london: kogan page 1996. 4. higgins mj. the management challenge. 2nd ed.. new york: macmillan publishing company 1994. pp. 419-458. 5. mullins jl. management and organisational behaviour. 4th ed. london: pittman publishing 1996. pp. 625-706. 6. cole ga. personnel management, 3rd ed. london: dp publications ltd 1993. 7. pitaru hd. managementul resurselor umane. masurarea performantelor profesionale, bucuresti ed. all, 1994. recommended readings available from url http://www.bmj.com: • leung wc. managers and professionals: competing ideologies. bmj 2000; 321: 2. • singh d. hospitals must use london’s appeal to tackle workforce shortages. bmj 2003; 327: 70. • macdonald r. implementing the european working time directive. bmj 2003; 327: 9-11. • dosani s, adsett j. the staff grade dilemma. bmj 2002; 325: 170 s. • west m. how can good performance among doctors be maintained? bmj 2002; 325: 669–670. • edwards n, kornacki mj, silversin j. unhappy doctors: what are the causes and what can be done? bmj 2002; 324: 835-838. • leung wc. studying for an mba. bmj 2000; 320: 2. • cockcroft a, williams s. staff in the nhs. bmj 1998; 316: 381. • delva md, kirby jr, knapper ck, birtwhistle rv. postal survey of approaches to learning among ontario physicians: implications for continuing medical education. bmj 2002; 325: 1218. • stockdale s. how to stay motivated with an impossible workload. bmj 2002; 324: 141. • king j. giving feedback. bmj 1999; 318: 2. • ham c. improving nhs performance: human behaviour and health policy. bmj 1999; 319: 1490 – 1492. • king j. dealing with difficult doctors. bmj 2002; 325: 43. • wood lep, o’donnell e. assessment of competence and performance at interview. bmj 2000; 320: 2. 286 health systems and their evidence based development 287 information systems management health systems and their evidence based development a handbook for teachers, researchers and health professionals title information systems management module: 2.3 ects (suggested): 0.25 author(s), degrees, institution(s) adriana galan, it specialist part-time senior lecturer at the university of medicine and pharmacy, department of public health and management, at postgraduate level address for correspondence institute of public health bucharest 1-3 dr. leonte street 76256 bucharest romania tel: (4021) 2249228 / ext.188, fax: (4021) 3123426 e-mail: agalan@ispb.ro keywords information system, management of information system, decision making, problem solving, management cycle learning objectives at the end of this course, students should: • identify the basic concepts of the management of information systems; • be able to describe the existing types of applications in the medical field; • identify the need and role of information in a managerial cycle; • be able to make the difference between the types of decision and the information system required by each type of decision; and • learn the medical fields where an information system can offer support. abstract this course covers: definitions and basic concepts, existing types of applications in the medical field, managerial cycle and information support, and types of decisions and the related information systems. recommended readings are also given. at the end of this course, the case study is proposed to be solved. teaching methods teaching methods include lecture, interactive presentation of key concepts, overheads or powerpoint presentation. case study will be solved in small groups (4-5 persons) and an overhead will be presented by each group with their findings. specific recommendations for teacher it is recommended that this module is organized within 0.25 ects credit. the work under supervision is consisting from lecture (2 hours), case study reading (1 hour), and case study solving (1 hour), while individual work is related to review literature to prepare an essay (3,5 h). assessment of students 1. reports presented by each group can be considered as assessment. 2. an essay on the types of information systems used in their own organizations (functions, what type of decisions are supported etc.) information systems management adriana galan definitions and basic concepts there are many definitions of information systems, based on the definition of a general system, representing a group of interrelated elements organized to achieve a common purpose. out of these definitions, here are presented: • information system represents that type of system trying to solve the problems in an appropriate manner, able to generate the information at right time and place, in an understandable format, in order to be used in the managerial process. • information system is a special class of system whose components are people, procedures and equipment that work interdependently under some means of control to process data and provide information to users (1). figure 1 summarises this definition: figure 1. system engineering components (2) organisation procedures training 288 health systems and their evidence based development software hardware facilities people contingencies algorithms management of information systems (mis) are orderly methods of gathering, storing, organizing, analysing, and reporting data in a manner that is meaningful, useful, and quickly to retrieve. the direction of data aggregation is given on figure 2. mis provides a foundation upon which a hospital / health organization can develop its information resources and enhance decision-making, strategic planning, and quality of clinical services. figure 2. levels of information systems basically, any information system is working with three key concepts: • data: facts obtained by observation, counting, measuring, weighing from the surrounding environment (for example: patient temperature is measured as 39.5°c) • information: follows that data which have been analysed, summarized or processed in some fashion to produce a message or a report; becomes information only if it is understood by the recipient (for example: t=39.5°c, headache, photophobia (possible meningitis) • knowledge: represent the result of combining meaningful information there is not a clear distinction between the three concepts, many times information can be considered as data for the higher level inference. components of health information system are given on figure 3. 289 information systems management international national regional institutional locald ir e c ti o n o f d a ta a g g re g a ti o n doc tor’s office, hospital ward hospital iphs figure 3. health information system existing types of applications in the medical field the main types of it applications in the medical field developed worldwide are (3): patient registration and hospital admission systems the main functions of this application are: • data collection: demographic, clinical and financial • reporting: generates different types of documents based on data analysis and also administrative reports • operations management: keep track of patient transfers and discharges patient accounting • prices of provided services per patient: attach a price for each service received by a patient. the price can be established according to different criteria: • based on the range of services contracted with the insurer • based on drg system (diagnosis related groups) • based on the type of patient: inpatient, outpatient, emergency 290 health systems and their evidence based development informati on generation & communication data bases hardware softwarepeople co mputers networks system applicatio ns useres participants sp ecialist users depending on the type of contract between providers and insurer, the output of this application can be some other unit than the monetary one (e.g. number of points, credits, etc.). the insurer can further transform these units into monetary ones. • patient bill: calculate the patient bill to be sent to the insurer • electronic data interchange: between the health care provider and the insurance financial management • payroll system: calculate employees' workload, calculate the taxes, produces the salaries forms together with control reports, forms for tax declaration • staff registry: manages a history of employment for each employee (payment reports, licenses, continuous education training, etc.) • assets registry: manages the registry of organizational assets (fix properties, physical site, depreciation planning etc.) • general financial registry: collect data from all financial applications having as result the financial balance sheet (debts and credits) and the annual financial management patient registry and management of care • patient index: collects and manage a summary of patient record for all in-patients and out-patients • procedures and diagnosis coding: check the accuracy of disease codification according to international codification system, build the drg classes • monitoring the transfers: monitor the link between clinical wards and ancillary departments (radiology, pharmacy, labs, etc.) pharmacy systems physician's orders for drugs are registered. the system is monitoring each patient: what and when must receive the drugs. also keeps a drug inventory and can act as a warning system for the incompatibility of 2 or more drugs for a patient. 291 information systems management management of primary care patient big efforts were done in the last decade for developing this system due to the increasing weight of ambulatory care. some functions can be mentioned: • visit scheduling • patient registration • medical records and monitoring the consultations • financial module • pharmacy module • communication module (electronic data interchange) electronic medical records (4) very modern in usa, even at early stages of implementation, is the concept of „electronic medical record” (emr). the traditional medical record has been exposed to a rethinking process, in order to provide the needed information for: • clinical care • billing • research tool • communication tool communication was a key issue in these modern clinical systems, unlike the old clinical systems. emr must be accessible for all the clinical care providers of a patient (family doctor, outpatient clinics, hospitals), but can be accessed by the patient himself. at the same time, clinical databases are a powerful research tool. another important step forward is represented by the accessibility of emr via internet. what are the main information areas in an emr? • id • history of present illness • current medication • past medical history • past surgical history • family history 292 health systems and their evidence based development • physical examination • laboratory database (including images) • procedure note • problem list (assessment) • plan (diagnostic / therapeutic) managerial cycle and information support information systems can essentially contribute to increase the manager's degree of confidence in the validity of alternatives that are the basis of organizational strategic decisions. also within the health units, information can represent a valid support for problem solving, like: • cost control and productivity enhancement (financial information systems) • medical quality assurance and outcomes assessment (clinical information systems) • health care organizations must frequently monitor and evaluate their performance, both for internal purposes and to meet external regulations and accreditation criteria (administrative information systems) the basic management process in any health care organization can be described in terms of a cycle that includes the following components (5): • establish goals and objectives • estimate demand for services • allocate resources to meet demand • control the quality of performance • evaluate programs impact cycle is repeated after each evaluation. information management should play an important role in each element of this basic management cycle. examples of types of information that can help decision making in each category, can be described as follows: 1. establishment of institutional goals and objectives • problem indicators, direct and indirect (direct: morbidity and mortality data, social indicators, economic data on the community; 293 information systems management indirect: data on personal health habits of members of the community) • data on services being delivered by other community health organizations • available resources 2. demand estimation • historical data on utilization of health services • demographic data • community projections 3. resource allocation • work force data • financial information • short-term demand forecasts 4. performance and quality control • output measures (statistics: number of inpatient days, patient visits in outpatient department, number of delivered procedures etc.) • quality control data • work sampling and measurement • medical audit 5. evaluation of program impact • changes in problem indicators • cost-benefit analysis types of decisions and the related information systems from the informational point of view, herbert simon (6) has described two types of decisions: • programmed (structured) decisions these are periodical decisions, repetitive and routine; • non-programmed (unstructured) decisions these are occasional decisions, irregular and must be treated in a new manner each time they occur. 294 health systems and their evidence based development simon classification is based on the manner in which a manager deals with existing problems. a well-designed information system is obviously influenced by the periodicity or non-periodicity of decision. there are two approaches for an information system to meet the need of non-programmed decision making process: • to organize special studies in order to collect necessary information, involving a big effort and being time-consuming; costs and benefits of this approach must be analysed in advance; • to be operational a general information management system, where relevant information have to be only retrieved and analysed. robert anthony (7) has developed a theory that represents the basis for the process of analysing and planning the information systems. he described the managerial activity consisting of three categories, arguing that these categories are activities sufficiently different to require the development of different information systems (figure 4). strategic planning is the process of deciding on organizational objectives, changes of objectives, resource allocation to attain these objectives and on policies that govern the acquisition and use of these resources. the major problem of this type of activity is to predict the future of the organization and its environment. this level typically involves a small number of high-level people who operate in a very creative way. the complexity of problems that arise at this level, as well as the nonroutine way in which they are handled, make it difficult to design an adequate information system. usually, in this planning process aggregated information is needed, most often obtained from external information systems. at this level most of the decisions are unstructured (see definition above) and irregular. management control the process by which managers assure that resources are obtained and used effectively and efficiently for the accomplishment of the organization's objectives. this type of activity involves interpersonal interaction. it also takes place within the context of the policies and objectives developed in the strategic planning process. the main goal of management control is the assurance of effective and efficient performance. the relevant information for this level is mainly obtained during the human interaction process. operational control represents the process of assuring that specific tasks are carried out effectively and efficiently. 295 information systems management the basic distinction between management control and operational control is that operational control is concerned with tasks, whereas management control is mostly often concerned with people. this level requests clearly defined information for very specific tasks. information must be detailed, accurate and is obtained mainly from inside the organization. for each managerial level described by anthony, a specific information system must be designed. each level of decision-making process corresponds to a different administrative level of the health system. the operational level corresponds to the health care units (hospitals, primary care units, ambulance, etc.) where huge amounts of detailed and updated information exist and are reported to the upper levels. the control level corresponds to the local health authorities (for instance, in romania the district public health authorities exist in each of the 42 districts, one district covering 500,000 inhabitants on average), information being here aggregated for the local level. the strategic level corresponds to the ministry of health, where information is highly aggregated for the national level, but often being rather old (a 2-years time lag). figure 4. hierarchical model of decision-making process proposed by anthony (7) strategic level (senior management) planning control level (middle-level management) control process operational level (junior management) common database 296 health systems and their evidence based development within the managerial process of decision-making, an information system can offer support for the following areas (8): • medical quality assurance and outcomes assessment. clinical information abstracted from patient medical records provides the basis for health professionals in peer review systems to assess diagnosis and treatment practices. such information must be readily accessible and retrievable from a central patient data file. • cost control and productivity enhancement. such systems require the ability to integrate clinical and financial information system. computerized information systems offer the possibility for providing cost analysis and productivity reports in order to improve the efficiency of operation. • utilization analysis and demand estimation. such systems should be able to provide current and historical data on utilization of health services. these data assist in current analysis of utilization of resources and also provide a basis for predicting future demand for services. • program planning and evaluation. information obtained for the previous above-mentioned domains serves as the basic input for management decisions related to evaluation of present programs and services. when combined with projections about future changes in the demographic characteristics of the population and other external information about the service market, the information system can be an important resource for planning future programs and services. simplification of reporting. information processing costs consume an important proportion of the budget of a complex health organization. on the other hand, external reporting requirements are growing exponentially. therefore, an important goal for an information system is to simplify the preparation of these various reports, often a difficult repetitive task. 297 information systems management exercise: management of information systems task 1: recognizing different types of information system, and their importance in decision-making process the purpose of the exercise is enabling students to recognise different types of information systems, and their importance in decision-making process. students are asked to split in small group, in order to read this case study, and then discuss, following suggestions given below (30 minutes for reading the case study, 60 minutes for work in a small group, 30 minutes for discussion in whole group). total time for exercise: 2 hours. case study* an usual manager's working day by january 15, 2002, the user of different types of information systems was doctor escu, the director of „wonderland” district public health authority (dpha). doctor escu has the responsibility of developing and implementing health policies at „wonderland” district level. doctor escu lives in a neighbourhood located far enough from dpha site. in the morning, after waking up, he listen first the radio news in order to decide if he would rather use his own car or the dpha car. because bad weather was forecasted, he decided to use the office car. on the way to dpha location, the driver didn't give priority to the pedestrians, so that a policeman stopped him. apart from the fine, he was also registered in the police files. once arrived at dpha, doctor escu turns on the computer and check first his meeting's schedule for the day, file already updated by his secretary. after reading his messages, he answers himself to two of them. for the rest of the messages, he forwards the messages to the secretary and asks her to answer. after that, he invites the head of human resources department and the economic manager to try to solve together the problem of the hundred junior physicians applying for a job in the district. at noon, a meeting with a foreign expert's team was scheduled. the foreign experts were willing to help the dpha to implement an intervention project to reduce some risk factors in order to improve the health status of „wonderland” district population. the experts were bringing a software for modelling and simulation of the impact of reduction of risk factors on health. doctor escu has also invited to attend this meeting the head of „health status evaluation” department, as well as public health specialists and epidemiologists. 298 health systems and their evidence based development * case study adapted by adriana galan, based on a case study developed by g.lucas jr. around 6 pm, doctor escu leaves the dpha, and on the way back he stops to a supermarket to make some shopping. once arrived at home, he watches the tv news, then he reads the financial report for the previous month in order to prepare the next day meeting with the economic manager. finally he decides to go to bed because he felt very tired. please observe carefully the activity of doctor escu during the whole working day and determine what type of information systems he was using in each circumstance. for each information system you discovered, please mention for what type of decision it was useful (use anthony theory and mention if the decision was programmed or non-programmed). 299 information systems management moment of the day what type of information system was used type of decision during the morning during afternoon during the evening references 1. reynolds gw. information systems for managers. second edition. st.paul (mn): west publishing company; 1992. 24-39. 2. longest bb, rakich js, darr k. managing health services organizations and systems. fourth edition. baltimore (my): health professions press; 2000. p. 291. 3. austin cj. hospital information systems and the development of a national health information system. journal of medical systems 1982; 6: 4-5. 4. van bemmel jh, musen ma. handbook of medical informatics. heidelberg (germany): springer-verlag; 1997. 331-356. 5. austin cj. information systems for health services administration. aupha press; 1992. 3-26. 6. simon ha. the new science of management decision. new york: harper & row; 1960. 5-6. 7. anthony rn. planning and control systems: a framework for analysis. boston: harvard business school division of research press, 1965. 8. gorry ga, scott morton ms. a framework for management information systems. sloan management review 1989; 30: 49-61. recommended readings in bmj collection (http://www.bmj.com): search/archive keywords: healthcare information systems • littlejohns p, wyatt jc, garvican l. evaluating computerised health information systems: hard lessons still to be learnt. bmj 2003; 326: 860-863. • heathfield h, pitty d, hanka r. evaluating information technology in health care: barriers and challenges. bmj 1998; 316: 1959-1961. • mandl kd, szolovits p. public standards and patients' control: how to keep electronic medical records accessible but private. bmj 2001; 322: 283-287. • rigby m, roberts r. integrated record keeping as an essential aspect of a primary care led health service. bmj 1998; 317: 579-582. • rigby m, forsstrom j, roberts r, wyatt j. verifying quality and safety in health informatics services. bmj 2001; 323: 552-556. • terry n, stanberry ba. regulating health information: a us perspective; legal aspects of health on internet: a european perspective. bmj 2002; 324: 602-606. • majeed a, bindman ab, weiner jp. use of risk adjustment in setting budgets and measuring performance in primary care ii: advantages, disadvantages, and practicalities. bmj 2001; 323: 607-610. • simpson k, gordon m. the anatomy of a clinical information system. bmj 1998; 316: 16551658. • lærum h, ellingsen g, faxvaag a. doctors' use of electronic medical records systems in hospitals: cross sectional survey. bmj 2001; 323: 1344-1348. 300 health systems and their evidence based development • bodenheimer t, majeed a, bindman ab. primary care in the united states: innovations in primary care in the united states o commentary: what can primary care in the united states learn from the united kingdom?. bmj 2003; 326: 796-799. • rousseau n, mccoll e, newton j, grimshaw j, eccles m. practice based, longitudinal, qualitative interview study of computerised evidence based guidelines in primary care. bmj 2003; 326: 314. • rundall tg, shortell sm, wang mc. as good as it gets? chronic care management in nine leading us physician organisations. bmj 2002; 325: 958-961. • neame r, kluge eh. computerisation and health care: some worries behind the promises. bmj 1999; 319: 1295. • woolf sh, grol r, hutchinson a, eccles m, grimshaw j. clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. bmj 1999; 318: 527-530. • thiru k, hassey a, sullivan f. systematic review of scope and quality of electronic patient record data in primary care. bmj 2003; 326: 1070-0 • delaney bc, fitzmaurice da, riaz a, hobbs fdr. can computerised decision support systems deliver improved quality in primary care?. bmj 1999; 319: 1281. • mair f, whitten p. systematic review of studies of patient satisfaction with telemedicine. bmj 2000; 320: 1517-1520. in national academy press books collection (accessible at url http://www.nap.edu) search all texts under title healthcare information systems • committee on enhancing the internet for health applications networking health: prescriptions for the internet (2000, 388 pp.) • committee on maintaining privacy and security in health care applications of the national information infrastructure, national research council for the record: protecting electronic health information (1997, 288 pp.) • edward b. perrin, jane s. durch, and susan m. skillman health performance measurement in the public sector: principles and policies for implementing an information network (1999, 192 pp.) • richard s. dick, elaine b. steen, and don e. detmer the computer-based patient record: an essential technology for health care, revised edition (1997, 256 pp.) • maria hewitt and joseph v. simone enhancing data systems to improve the quality of cancer care (2000, 176 pp.) • committee on quality of health care in america crossing the quality chasm: a new health system for the 21st century (2001, 364 pp.) 301 information systems management 302 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title financing of health care module: 2.4 ects (suggested): 0.50 author(s), degrees, institution(s) doncho donev, md, phd institute of social medicine, joint institutes, medical faculty, university of skopje 50 divizia no.6, 1000 skopje, republic of macedonia jadranka bozikov, mph, phd andrija štampar school of public health medical school, university of zagreb rockefeller st. 4, hr-10000 zagreb, croatia address for correspondence doncho donev, md, phd institute of social medicine, joint institutes, medical faculty, university of skopje 50 divizia no.6 1000 skopje republic of macedonia tel: +389 2 3147 056; fax: +389 2 3163 866 e-mail: donev@freemail.org.mk keywords sources for financing of health care; taxation; health insurance; health care costs; health expenditures; hospital costs; europe, south eastern; health planning learning objectives at the end of this module students and health professionals should be able to: • identify common reasons for increasing trend of expenditures in developing ad developed countries; • compare inequalities in global health spending; • explain the purpose and the scope of each source for financing of health care (state budget, health insurance, external sources, private sources); and • describe and justify two basic principles: efficiency and equity in health care delivery. abstract financing of health care and making balance between revenues and expenditures for health care is very intricate problem and source of serious concerns in practically all countries in the world. permanent increasing of elderly, patients with chronic diseases, use of expensive health technologies and their non-critical implementation, and some other factors are causing increase of the expenditures for health care. big inequalities are recognized among countries in global health spending and many health system reforms are characterized by transformation from central planning to market-based. there are four basic sources for collecting of financial resources for health care: taxation, social health insurance, private sources and external sources of financing. they are presented in different proportions among countries. each source for financing of health care has its own specificities, strengths and weaknesses, and each may be appropriate alone or in combination with other, which depends on various circumstances and environment. teaching methods teaching method will include combination of introductory lectures, group work and discussion followed by group report presentations and overall discussion, as well as practical individual work assignment. 303 financing of health care specific recommendations for teacher this module to be organized within 0.50 ects credit. beside supervised work, students, as a practical work assignment, should collect some specific indicators (hfa database and other sources) and to prepare a seminar paper about the source(s) of financing of health care in their respective countries. assessment of students the final mark should be derived from assessment of the theoretical knowledge (oral exam), contribution to the group work and final discussion, and quality of the seminar paper. financing of health care dončo donev, jadranka božikov adequate financial resources are a prerequisite for the operation of health services and the delivery of care. resources can be released if steps are taken to focus attention on the quality of care and on planning and managing the whole health sector, weighing up the relative values of health promotion, disease prevention, diagnosis/treatment, rehabilitation and care, as well as to fund some of the new investments that will be required to apply more effective (but often expensive) new technologies. sources for financing of health care vary from country to country, ranging from tax-based to insurance-based systems. there is considerable debate about how best to fund services so as to maintain universal access and financial sustainability. most often, a mix of these systems is seen. available resources for health care should be allocated in the light of a society's needs and priorities. choices have to be made between geographical areas and services, and between particular forms of treatment, and whether to provide innovative or expensive procedures. the health for all policy framework for the who european region „health 21” address the issue of funding health services and allocation of resources as target 17 in the following way: „by the year 2010, member states should have sustainable financing and resource allocation mechanisms for health care systems based on the principles of equal access, cost-effectiveness, solidarity, and optimum quality” (1). financing of health care means mechanisms by which money is mobilizing (raising or collecting revenue from individuals, groups and firms) to fund health sector activities and to pay for the operation of the health system (2). financing of health care is a source of serious concerns in practically all countries in the world. the question of how to generate sufficient revenues to pay for health care worries policy makers in the countries whose total health care expenditures are 1-3% of their gdp, as well as those who are spending more than 10% of gdp for health care. countries of the oecd accounted for less than 20% of the world's population in the year 2000 but were responsible for almost 90% of the world's health spending. the african region accounts for about 25% of the global burden of diseases but only about 2% of global health spending (3,4,5). shortage of funds for health care affects both, the countries who are spending less then 10 us$ per capita per year and the countries who are spending more than 2000 us$ per capita per year (table 1). 304 health systems and their evidence based development 305 financing of health care table 1. inequalities in global health spending in 2001 (3,4,5) although the causes are different, the problem is the same: how to balance revenue and expenditure for health care? it is not only the question of collecting of financial resources and pooling of funds but also of purchasing of services and reallocation mechanisms i.e. of transfer of revenue to service providers who deliver the health care to population for which the funds were pooled. the level of financial resources required to operate a health service is impossible to specify in absolute terms. certainly the amount should be affordable by the country and enough to meet the needs of both health promotion and the provision of effective and high quality care. a comparative analysis of current european experience suggests that 7-10% of gdp may provide for a reasonable spread of health system capacity and performance, dependent of course on an adequate overall level of national gdp. furthermore, in most countries expenditure trends over time ought to show an increase in the share of resources allocated to health promotion and disease prevention, and to primary health care (phc). this range is indicative only and individual countries must determine the best level based on their economic resources, their health experience, and their need for health promotion and the provision of effective and high-quality care (1). most countries feel constant pressure because expenditure is increasing and resources are scarce. policy-makers have three options: containing costs, increasing funding for health services or both. concern about an expenditure crisis in health care has led to the introduction of major changes in how health care is organized and financed. cost containment has been driving health policy discussions in industrialized countries since the 1970s (6). the problem of scarce resources is particularly pronounced in south eastern european (see) countries that have faced many difficulties in the process of transition in 1990-ties, after the breakdown of former communist/socialist system. social and economic transition in central and eastern european (cee) and the former soviet union (fsu) countries included health system reform characterized by transformation from central planning to market-based. this has included reducing of direct state involvement and introduction of market forces and competition through decentralization, privatisation and organizational reform of health care, which emphasized the shortage of the resources for health care (7) (table 2). 306 health systems and their evidence based development table 2. health care expenditures in usa and european countries in 2000 (7) 307 financing of health care country total expenditure on health as % of gdp per capita total expenditure per capita gdp public health expenditure private expenditure in us $ in int. dollars in int. dollars (% of total) (% of total) united states of america 13.0 4499 4499 34,637 44.3 55.7 european countries* israel 10.9 2,021 2,338 21,552 75.9 24.1 switzerland 10.7 3,573 3,229 30,161 55.6 44.4 germany 10.6 2,422 2,754 25,996 75.1 24.9 france 9.5 2,057 2,335 24,702 76.0 24.0 belgium 8.7 1,936 2,269 26,054 71.2 28.8 sweden 8.4 2,179 2,097 24,819 77.3 22.7 denmark 8.3 2,512 2,428 29,143 82.1 17.9 portugal 8.2 862 1,469 17,981 71.2 28.8 italy 8.1 1,498 2,040 25,308 73.7 26.3 netherlands 8.1 1,900 2,255 27,783 67.5 32.5 austria 8.0 1,872 2,171 26,970 69.7 30.3 norway 7.8 2,832 2,373 30,344 85.2 14.8 spain 7.7 1,073 1,539 20,071 69.9 30.1 armenia 7.5 38 192 2,546 42.3 57.7 united kingdom 7.3 1,747 1,774 24,462 81.0 19.0 czech republic 7.2 358 1,031 14,236 91.4 8.6 georgia 7.1 41 199 2,768 10.5 89.5 hungary 6.8 315 846 12,493 75.7 24.3 ireland 6.7 1,692 1,944 28,944 75.8 24.2 finland 6.6 1,559 1,667 25,122 75.1 24.9 estonia 6.1 218 556 9,123 76.7 23.3 kyrgyzstan 6.0 16 145 2,426 61.7 38.3 lithuania 6.0 185 420 6,941 72.4 27.6 poland 6.0 246 578 9,590 69.7 30.3 latvia 5.9 174 398 6,888 60.0 40.0 slovakia 5.9 210 690 11,654 89.6 10.4 belarus 5.7 57 430 7,598 82.8 17.2 turkmenistan 5.4 52 286 5,269 84.9 15.1 russian federation 5.3 92 405 7,621 72.5 27.5 turkey 5.0 150 323 6,455 71.1 28.9 ukraine 4.1 26 152 3,689 70.1 29.9 kazakhstan 3.7 44 211 5,677 73.2 26.8 uzbekistan 3.7 30 86 2,333 77.5 22.5 tajikistan 2.5 4 29 1,154 80.8 19.2 azerbaijan 2.1 14 57 2,676 44.2 55.8 * european countries here means countries belonging to who office for europe with population above one million excluding see countries (i.e. members of ph-see network) that are presented separately. source: who (7). ** the international dollar is a common currency unit that takes into account differences in the relative purchasing power of various currencies. figures expressed in international dollars are calculated using purchasing power parities (ppp), which are rates of currency conversion constructed to account for differences in price level between countries. developing countries who were hardly providing funds for essential health needs were seriously affected with the economic crisis, which started in 1970s. those countries were forced to further decreasing of already scarce funds for health care. continuous debts, dependency for import of drugs, vaccines, equipment and other supplies with very high and continuously increasing prices led to hopeless situation in most of the developing countries. much progress has been made in rationalizing the choice of priority interventions since the time of standard „minimum package” of the early 1990s. prioritising cost-effective interventions (preventive, promotive, curative and rehabilitative), that gives the most value for money, is all the more important as new funds become available to the health sector (3-5,8,9,10,11,12). developed countries, especially usa and some western european countries (table 2), recognized very fast increase of the required funds for health care and came to conclusion that the health care expenditures are threatening further economic development and that it is necessary to stop those trends or even to tend to decrease those expenditures. that is why the most of the developed countries are reconsidering the ways of financing of health care, taking into consideration the reasons, which caused misbalance among needs and available funds. in the us health care delivery system, faced with an exponential increase in expenditures during the second part of the 20th century, was forced to explore ways to reduce costs and, at the same time, maintain a high quality of care. managed care emerged as one of the answers and quickly became one of the predominant health care delivery models (13). the most common external reasons and pressures for increasing trend 308 health systems and their evidence based development south eastern european countries (see)* slovenia 8.6 788 1,462 16,927 78.9 21.1 croatia 8.6 353 638 7,390 84.6 15.4 greece 8.3 884 1,390 16,843 55.5 44.5 macedonia 6.0 106 300 5,001 84.5 15.5 serbia and montenegro 5.6 50 237 4,242 51.0 49.0 bosnia and herzegovina 4.5 50 319 3,404 69.0 31.0 bulgaria 3.9 59 198 5,021 77.6 22.4 moldova 3.5 11 64 1,802 82.4 17.6 albania 3.4 41 129 3,727 62.1 37.9 romania 2.9 48 190 6,475 63.8 36.2 of expenditures for health care from outside the health care system, which cannot be directly controlled by the providers of health care services, are the changes in all fields of life and human activities, i.e. economy, health, sociology, culture, demography and political sphere. demographic changes with growth and ageing of the population, societal changes and health problems related to poverty and life-styles (smoking, poor diet, drug abuse, aids), as well as changes in health status of the population objectively influenced the increase of the expenditures for health care because the permanent increasing of elderly proportion and dependency ratio, and patients with chronic diseases requiring long term care increase the needs and demands for health care and use of expensive health technologies. political changes, often followed by broadening of the scope of social rights to the population, have influenced to increasing coverage of the population with health insurance and health care services. from the other side, there are some internal factors within the health care industry, which might be controllable by health care providers and management structures, related to increases in technology and labour costs, inefficient use of available resources, insufficient preventive services and the practice of defensive medicine. the costs for introducing new drugs in increasing number and non-critical implementation of new technologies caused increase of the expenditures for health care, even though it doesn't belong in the category of the objective reasons (3,5,8) (table 3). table 3. main reasons for increasing trend of health care expenditures (3,5,8) 309 financing of health care external factors (outside the health care system) internal factors (inside the health care system & industry) • demographic transition (growth and ageing of the population) • epidemiological transition changes in the health status (increase of chronic conditions and non-communicable diseases) • societal and cultural changes and health problems related to poverty and life-styles (smoking, poor diet, drug abuse etc.) • political and environmental changes (rising expectations for health care rights, increased insurance and health care coverage) • economic changes and inflation • rapid innovations / changes in technology and non-critical implementation of new technologies • introducing new drugs in increasing number • developments in science (accurate genetic tests and the genetic make-up of an individual) • increases in labor costs (further specialization and sub-specialization of manpower in complex institutions of labor-intensive or „handicraft” industry) • inefficient use of available resources (inappropriate allocation to primary health care vs. hospital care) • insufficient preventive services (the practice of defensive medicine) all those changes influenced the ways and extend of financing of health care, but, in most of the cases, an individual and a family were not able to carry the risk and burden of disease. because of that the state and the government were pressed to take active role in providing health care of the citizens by directing a part of the budget funds for health care or by introducing compulsory health insurance. nevertheless, within the new contemporary conditions the sources for financing of health care and relationships among them are often changing. there are big differences and variations in proportions of public and private sources of health care expenditures, both among developed (usa, european and other) countries and among see and fsu countries (7) (table 4). 310 health systems and their evidence based development table 4. sources of public and private health care expenditures in usa and european countries in 2000 (7) 311 financing of health care country sources of public health expenditure sources of private health expenditure social health insurance (%) external resources (%) prepaid plans (%) united states of america european countries* israel 25.8 0.4 switzerland 72.7 42.4 germany 91.7 5.3 france 96.8 53.1 belgium 82.1 6.8 sweden denmark 8.9 portugal 7.2 5.5 italy 0.1 3.4 netherlands 94.1 76.7 austria 61.0 23.2 norway spain 11.7 armenia 4.9 united kingdom 11.2 16.9 czech republic 89.4 georgia 14.6 9.7 hungary 83.2 0.8 ireland 12.9 23.8 finland 2.4 12.0 estonia 86.0 0.5 4.1 kyrgyzstan 5.8 2.4 lithuania 9.7 poland latvia 65.4 0.7 slovakia 96.8 belarus 0.1 turkmenistan 18.9 0.8 russian federation 24.5 4.4 4.3 turkey 28.4 0.1 0.1 ukraine kazakhstan 26.4 2.4 uzbekistan 1.3 tajikistan 19.5 azerbaijan 8.8 * european countries here mean countries belonging to who office for europe with population above one million excluding see countries (i.e. members of ph-see network) that are presented separately. the countries are sorted by the percentage of their total expenditure on health. source: who (7). markets in health care available evidence from both western and eastern europe indicates that unfettered markets are not compatible with the nature of health as a social good. market mechanisms in health care are likely to be more successful, financially and operationally, if they are focused on hospitals and physicians; in contrast, efforts to create competition among multiple private insurers or to require increased co-payments from patients have been notably less successful. for the application of market mechanisms to service providers to work well, the state needs to steer and regulate these relationships by creating or improving market competition, opening up choice of provider in public health or insurance financing „money follow the patient”, quality regulation and contracting with providers. while the mix of public/private ownership of provider institutions varies greatly across europe, both efficiency and equity require consistent and stable state regulation (14,15). the health care triangle the provision and financing of health care can be simplified as an exchange or transfer of resources: the providers transfer health care resources to patients and patients or third parties transfer financial resources to the providers (figure 1). 312 health systems and their evidence based development south eastern european countries (see)* slovenia 82.0 0.8 48.9 croatia 96.5 0.4 greece 36.9 4.9 macedonia 87.5 3.7 serbia and montenegro 6.2 bosnia and herzegovina 2.0 bulgaria 16.0 18.0 moldova 13.9 albania 26.1 12.6 36.4 romania 13.3 1.1 figure 1. the health care triangle (6) citizen delivery provider funding allocation third-party (insurer or purchaser) the simplest form of transaction for a good or service is direct payment. the consumer (the first party) pays the provider (the second party) directly in return for the good or service. health care systems have developed in which a third party offers protection to a population against the financial risk of falling ill. the third party may be a public or private body. the development of the third-party payment mechanism in health care results in part from the uncertainty of ill health; it allows risks to be shared. however, it is also a means to achieve interpersonal redistribution. to finance health care services, the third party must collect revenue directly or indirectly from the population it protects (this may cover the whole population or a subgroup of the population such as those who are employed). this revenue is then used to reimburse the patient or the provider (6). basic sources for financing of health care there are four basic sources of revenue collection for financing of health care (2,5,6): 1. taxation (state budget) 2. social health insurance 3. private sources for financing (private health insurance and out-ofpocket payments etc.) 4. external resources (foreign aid, loans, grants and donations) there is no model for financing of health care in which exists exclusively only one out of four mentioned basic sources for financing of health care. all four sources are present in practice in the developed and in deve313 financing of health care loping countries. in some countries, the funds coming from the state budget are predominant at all levels of governance (from local to central), in other countries health insurance funds are basic, and in certain number of countries the most of the funds for health care are from private sources. all the funds collected by any financial method (except for foreign aid) are coming, directly or indirectly, from citizens. each country has to decide what sources to use, and to what extend. revenue collection must be distinguished from fund pooling, as some forms of revenue collection do not enable financial risks to be shared between contributors, such as medical savings accounts and out-of-pocket payments. kutzin (2001) defined fund pooling as the „accumulation of prepaid health care revenues on behalf of a population”. the importance of fund pooling is that it facilitates the pooling of financial risk across the population or a defined subgroup (16). the role of the state in financing of health care the purpose and the scope of the sources used for financing of health care by the state are different. in general revenue financing many kinds of taxes are used to support a broad scope of government activities. taxes can be levied on individuals (earmarked social security taxes), households and firms (direct corporate profit taxes) or on transactions and commodities (indirect taxes). direct and indirect taxes can be levied at the national, regional or local levels. indirect taxes can be general, such as a value-added tax, or applied to specific goods, such as an excise tax, import duties, and severance taxes on minerals etc. most tax-based systems rely on a mix of different taxes (5,6,14). the health system is financed through the regular government budget process. in almost every country the state through the budget provides sources for prevention and eradication of communicable diseases, hygienic control of the drinking water, food, objects for general use, sanitary monitoring over certain objects, health statistic and other activities of particular interest. in some industrial developed countries, as great britain, nordic countries, france, italy, belgium, greece, spain, portugal, as well as in the former socialistic (central and eastern european) countries (poland, albania etc.) the greatest part of the sources for health care are provided, or were provided, from the state budget, with taxes on national-central level, and from there the sources are distributed in the regions and communities where together with the local sources are used for health care of all citizens. in the developing countries the budget sources are mainly used for prevention and eradication of communicable diseases and for curing of the poorest social strata of the population (3,6). 314 health systems and their evidence based development financing of health care through the budget has an important role and advantage in providing equal conditions in health care consumption for all citizens, independently of the social status and economic power, the place of living and working. the weaknesses of this system are that it has insufficient creativity in the process of improving of efficiency and quality of the health care, as well as the fact that the taxpayers from whom the sources are taken, have no influence in their use. in the last 10 15 years most of the countries with this model of financing are reconsidering this system and looking for new solutions. some of those countries already have introduced health insurance system (russian federation) while other countries are still looking for solutions in direction of more rational usage of resources and for improving quality without changing the basis of financing of the system. the role of the health insurance in financing of health care the social or compulsory health insurance has a long tradition in the western and southern european countries, although with variable scope of coverage of population. some of the countries are broadening the coverage, and others are reducing it by abolition of the compulsory health insurance if the annual income is above the certain amount. the developing countries, as a rule, are introducing a system of health insurance (latin america, south asian countries, and most of the african countries), as well as the former socialistic central and eastern european countries (bulgaria, hungary, poland, czech republic). social health insurance contributions are usually related to income and shared between the employees and employers, at levels that may be set nationally by parliament (the netherlands) or individually by each social insurance or „sick” fund. contributions may also be collected from self-employed people, for whom contributions are calculated based on declarations of income or profit (this income may be under-declared in some countries). contributions on behalf of elderly, unemployed or disabled people may be collected from designated pension, unemployment or sickness funds, respectively, or paid for from taxes. social health insurance revenue is generally earmarked for health and collected by a separate health insurance fund (6,14). more and more countries decide to establish a health insurance system because the sources from the health insurance are significant additional sources for the health sector, as well as because the sources from the health insurance, as a rule, are restricted funds used only for health purpose, and for no other purposes as in the case of the budget. as an advantage of this model 315 financing of health care of health insurance system is considered the connecting of the income with the profit in which take part the employees as well as the employer, which the most often is an organization/enterprise. thus, if the real profits increase the sources of health insurance funds will be higher, and if the profits decrease the sources of the funds (and income of) will be lower (17). in indirect way the same happens with the tax payment from which depends the amount of the budget. the main function of the insurance contract is to reduce risk faced by the person who buys it. risk and uncertainty are significant elements in medical care. the idea of health security „incorporates certain funding and service elements... that either protect against or alleviate the consequences of trauma, illness or accident” (17,18). in fact, the advantage of the health insurance system is the complete implementation of two basic principles: efficiency and equity in health care providing. the efficiency of the health insurance system depends on relationship between health insurance institutions and health care providers, in which way the obligations of both sides are precisely determined. health insurance funds have a long-term interest to accept funding also for some services that will bring to additional total running expenditures (measures for prevention, early detection of the diseases, usage of adequate health technologies). on the other side, the policy for participation of the users in the expenditures for the received health services tends toward decreasing of total health expenditures through reduction of the excessive and unnecessary consumption of health services. as a rule the administrative costs are low (5% of the total expenditures), although in the systems that lack adequate personnel and technology those expenditures could be even higher than 20% of the total health care expenditure. the equity is one of the basic principles of the health insurance by which the healthy people pay for the sick people, the young people for the elderly, and the rich people for the poor people. everyone pays a contribution proportional to his economic situation, and use the health care according his needs. the critiques of the health insurance systems are directed toward determination of which groups of insured persons have more and which fewer privileges. this type of investigations in many developing countries have shown that insured persons in the urban environments use much more health care than those in the rural environments, first of all because of the higher accessibility of the health organizations and services to the population in the cities. according to some other investigations the poor social layers are in more 316 health systems and their evidence based development favourable situation in spending health insurance funds because they become ill more often and use the health care and services much more, even they contribute less in real quantity of sources. because of that in the compulsory health insurance systems, which includes the whole population, the principle of equity is much more expressed than in the other types of health insurance (for example: branch-sectoral insurance). in some social health insurance systems, eligibility is based on employment or linked to contributions. this may limit the access of the non-employed population, including elderly and unemployed people and dependants, to health services. as the link between benefits and contributions remains strong, coverage also tends to be limited to curative and medical interventions and few, if any, public health interventions. because social health insurance relies on a narrow revenue base dependent on the contributions of employed people, it may not generate sufficient revenue, especially in countries with low participation in the formal labor force. an increasing proportion of the workforce is self-employed or in multiple occupations, which also increases the difficulty of collecting social insurance contributions. if social insurance is not mandatory for the entire working population, it can create a perverse incentive for employers. thus, they may offer (part-time) jobs that pay below the minimum threshold, outsource employment so that contractors are self-employed or create jobs in the shadow or unofficial sector. these practices are common in cee and fsu countries with newly established social health insurance schemes: employers, faced with an adverse economic climate, have tried to minimize labor costs by evading contributions to social health insurance. a single fund may produce low administration costs, ease regulation and make the risk pool universal. however, subscribers have no choice, and some conservative commentators fear inefficiency and a lack of consumer responsiveness (6,17). the role of the private sources in financing of health care the role of the private sector in the area of health care is becoming stronger in developed, but in developing countries, too, observed in general, as well as the private sources in financing of health care as an effect of that. that is a result of the liberalization in regard to the possibilities for establishment and functioning of private health institutions and more favourable conditions that enables the health care professionals to work in the public and the private sector at the same time. a limited privatization is accepted as a principle for all countries, not only because of economic but because of professional-medical reasons, too. many countries in which the private practice was prohibited or limited, now reintroduce it again in a manner to act equally with the public sector as a part of the health care system as a whole. 317 financing of health care there are also countries that have created legislative preconditions for functioning of private ordinations within the public health institutions after working hours. in many countries there are also legislative possibilities that enable private practitioners to have a certain number of hospital beds in the public hospitals for their own patients. in a small number of countries there is an intensive process of privatization with tendency to decrease the influence of the state in the health sector and to preserve it only in the sphere of preventive medicine (public health), and everything else to transfer into the private sector, including the private health insurance. private health insurance premiums are paid by an individual, shared between the employees and the employer or paid wholly by the employer. premiums can be: individually risk rated, based on an assessment of the probability of an individual requiring health care; community rated, based on an estimate of the risks across a geographically defined population; or group rated, based on an estimate of the risks across all employees in a single firm. the agents collecting private health insurance premiums can be independent private bodies, such as private for-profit insurance companies (commercial insurers) or private not-for-profit insurance companies and funds. substitutive insurance is an alternative to statutory insurance and is available to sections of the population who may be excluded from public cover or who are free to opt out of the public system. in germany and the netherlands, individuals with high incomes may purchase substitutive health insurance. where health insurance is supplementary, it may allow quicker access to services or increase the quality of „accommodation” facilities in the public sector. this can result in differential access between those with and those without private insurance. complementary health insurance offers full or partial cover for services that are excluded or not fully covered by the compulsory health insurance system (6,14). in some countries are present opposite processes, where the private sources for financing of health care represent a small part in the health care expenditures. in those countries there is a tendency for achieving a balance in which the state as well as the compulsory health insurance and the private sources will have an equal role in financing of health care. in many countries, the transfer of the health care expenditures onto the private sources most often is connected with a tendency for stopping of its increasing, in other words to bring the health care expenditures down within the real possibilities related to the increase of the gross national income. out-of-pocket payments include all costs paid directly by the consumer, including direct payments, formal cost sharing and informal payments. direct payments are for services not covered by any form of insurance 318 health systems and their evidence based development (the purely private purchase of uncovered services). other payments are for services included in the benefit package but not fully covered (e.g. formal costsharing) or for services that should be fully funded from pooled revenue but additional payment is demanded (e.g. informal payments in cee and fsu countries) (6,19). however, in regard to this approach arise many problems among which especially important is the problem of providing equity in health care consumption and its accessibility to some population groups, which have no possibility to pay for health care services out of pocket or to purchase insurance policy from the private health insurance agencies. investigations about the efficiency and quality of the health care didn't show advantages in the nonprofit institutions that as a rule provide services under lower prices, although there is a higher administrative efficiency. therefore, the privatization and deprivatization of the sources for financing of health care present two opposite processes that run simultaneously in various countries. the goal of both processes is to achieve a balance between health care expenditures and the real financial possibilities. in spite of all there shouldn't be disregard the fact that health is one of the basic human rights, and the equity in providing health care is one of the indicators for the level of respecting human rights. in developed countries the participation of the private sources for financing of health care/ expenditures goes from 14.8% in norway and 17.9% in denmark to near 60% in usa, and in the see countries from 15.4% in croatia and 15.5% in macedonia to 49.0% in serbia and montenegro (table 2). this type of differences in financing of health care, as well in regard to the real possibilities for increasing of the sources for health care in developing countries, clearly show that financing in health care is a very intricate problem. external sources for financing of health care the foreign aid, as an external financing source for health sector in many poor countries, by the international health and other organizations and from the other countries, as a manner of bilateral cooperation, usually is too small to give bigger effects in regard to the financing of health care. this help, as a rule, is directed to certain developmental projects and specific programmatic objectives in developing countries with measurable outcomes (vaccination, disease elimination, safe childbirth). this help usually mitigates the situation, but doesn't solve the problems in a long run. care must be taken to ensure that external funding is additional to, and, not a substitute for, domestic financing, but also that financing which flows from outside sources does not lead to (further) fragmentation of the national health system (3). 319 financing of health care other external sources, such as donations from non-governmental organizations, transfers from donor agencies and loans from who and other un agencies, the world bank and other international banks and funds, also contribute significantly in some countries, especially lowand middle-income countries (6). multilateral development banks are coming under increasing pressure to finance multi-country initiatives directly, rather than through conventional country-based grants or loans (20). 320 health systems and their evidence based development exercise: financing of health care task: seminar paper students should use additional recommended readings in order to increase their knowledge and understanding of health care financing. as output, students should write a seminar paper, stressing the importance of different sources of financing health care, giving the reasons for permanent shortage of resources, discussing percentage of gdp input and overall, make comparison between global and their own country ways of health care financing. in addition, students should be encouraged to make an investigation regarding the financing of health care in their own region (local, municipality, county/regional within the country, as well as at country level) and compare the facts with those for neighbouring countries (see) and widely at international level. they should be asked to search the internet in order to find the data and write their seminar papers not repeating the data from the module itself but to interpret their own findings in context of the facts from module. moreover, they should be able to place the data collected in field study into the context of the module, they need to see how the data feet together. not only data but also regulations are different and important and all the information about the kinds of compulsory (national) and private (voluntary) insurance could be find, for each see country, on the health insurance fund web-sites (for example: for croatia visit http://www.hzzo-net.hr and for slovenia visit http://www.zzzs.si/). public health lecturers in each see country should be qualified to direct the students to data sources in their countries (provide respective web-sites in see countries and not only at country level but also at local municipal, county, regional level). students ought to be able to investigate the ways in which health care is financed and how revenues are pooled (much more could be find at local level). students must be able to find very new data about gdp and health expenditures, and to calculate percentage of gdp spent on health care. to manipulate data is important not because of making calculations but in order to get a perception of data, data sources and the students ought to know (or they need to be instructed and trained) where to find the information on regional, national and international level. students have to know where to look for example for current gdp it is usually national statistical office web-site (in macedonia www.stat.gov.mk; in croatia www.dzs.hr) or printed publications as statistical yearbooks. 321 financing of health care references 1. who. health 21 health for all in the 21st century funding and allocation of resources for health services and care. european health for all series no 6. who-euro, copenhagen 1999: 131-5. 2. the world bank group. funding and remuneration in health care. distance learning flagship course on health sector reform and sustainable financing, 2001. (cited 2004, january 14). available from url: http://www.worldbank.org/wbi/healthflagship/module1/ sec7i.html 3. who. shaping the future. the world health report 2003 financing health systems. who, geneva, 2003: 119-21. 4. the world bank. world development report 1993: investing in health. the world bank, 1993: 25-71. 5. tulchinsky th, varavikova ea. the new public health: an introduction for the 21st century. chapter 11: measuring costs: the economics of health. san diego: academic press, 2000: 549-88. 6. mossialos e, dixon a, figueras j, kutzin j. funding health care: options for europe. (european observatory on health care systems). buckingham: open 11university, 2002. 7. world health organization (who). who: countries. (cited 2003, october 30) available from url: http://www.who.int/country 8. who. health systems: improving performance. the world health report 2000, who, geneva, 2000: 47-116. 9. ore{kovi} s. new priorities for health sector reform in central and eastern europe. croatian med j 1998; 39: 225-33. 10. hutubessy r, chisholm d, edejer tt. generalized cost-effectiveness analysis for nationallevel priority setting in the health sector. cost effectiveness and resource allocation 2003, 1(8). (cited 2004, february 24). available from url: http://www.resourceallocation.com/content/1/1/8/ 11. johns b, baltussen r, hutubessy r. programme cost in the economic evaluation of health interventions. cost effectiveness and resource allocation 2003, 1(1). (cited 2003, july 17). available from url: http://www.resource-allocation.com/content/1/1/1 12. bobadilla jl, cowley p, musgrove p, saxenian h. design, content and financing of an essential national package of health services. the world bank group private and public initiatives: working together in health and education. the world bank. march 17, 1995: 110 (cited 2004, january 11). available from url: http://www.worldbank.org/html /extdr/hnp/health/hlt_svcs/pack1.htm 13. gill as, parpura-gill a. united states health care delivery system, reform, and transition to managed care. croat med j. 1999; 40(2): 273-9. available also through url: http://www.cmj.hr 14. saltman rb, figueras j. european health care reform: analysis of current strategies. who regional office for europe, copenhagen, 1997 (who regional publications, european series, no. 72). 15. berman p. overview of the organization control knob. the world bank institute health system group. harvard school of public health conference, jan, 26, 2003. (cited 2004, january 20). available from url: http://www.dosh.gm/conferences/hsr/course/ week3/day1/s1/presentation.ppt 16. kutzin j. a descriptive framework for country-level analysis of health care financing arrangements. health policy. 2001; 56: 171-204. 17. hofmarcher mm. health insurance and productivity. croat med j, 1999; 40/2: 260-5. 18. saltman rb. the idea of health security. eurohealth 2002; 8(2):18-9. 322 health systems and their evidence based development 19. belli p, berman p, bossert t et all. formal and informal household spendings on health: a multicountry study in central and eastern europe. harvard school of public health international health systems group, 2002. (cited 2004, january 14). available from url: http://www.hsph.harvard.edu/ihsg/publications.html 20. world health organisation. macroeconomics and health: global public health goods for health. the report of the commission on macroeconomics and health, working group 2 presented on december 20, 2001. recommended readings 1. mills ea, zwi ab, editors. health policies in developing countries. special issue of the journal of international development, vol 7, no 3, chichester: wiley, 1996. 2. saltman rb, figueras j. european health care reform: analysis of current strategies. who regional office for europe, copenhagen, 1997 (who regional publications, european series, no. 72). 3. marrée j, groenewegen pp. back to bismarck: eastern european health care systems in transition. ashgate avebury, 1998. 4. world health organisation. macroeconomics and health: investing in health form economic development. report of the commission on macroeconomics and health presented by jeffrey d. sachs, chair, to gro harlem brundtland, director-general of the who on 20 december 2001. available also at url http://www.who.int 5. organisation for economic co-operation and development (oecd). available from url: http://www.oecd.org; topic: health 6. united nations development programme (undp). undp home page. available from url: http://www.undp.org 7. donev d. health insurance system in the republic of macedonia. croat med j 1999; 40(2): 185-80. available also through url: http://www.cmj.hr 8. ivanovska l, ljuma i. health sector reform in the republic of macedonia. croat med j 1999; 40(2): 181-9 9. kova~i} l, šoši} z. organization of health care in croatia: needs and priorities. croat med j 1998; 39: 249-55. available also through url: http://www.cmj.hr 10. markota m, švab i, sara`in klemeni~i} k. slovenian experience on health care reform, croat med j 1999; 40(2): 190-4. available also through url: http://www.cmj.hr 11. hofmarcher mm. health insurance and productivity. croat med j, 1999; 40(2): 260-5. available also through url: http://www.cmj.hr 12. hermans hegm, den exte a. cross-border alliances in health care: international co-operation between health insurers and providers in the euregio meuse-rhine. croat med j. 1999; 40(2): 266-72. available also through url: http://www.cmj.hr 13. gill as, parpura-gill a. united states health care delivery system, reform, and transition to managed care. croat med j. 1999; 40(2): 273-9. available also through url: http://www.cmj.hr 14. kanavos p. financing phamaceuticals in transition economies. croat med j 1999; 40(2): 244-59. available also through url: http://www.cmj.hr 323 financing of health care 324 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title payment methods and regulation of providers module: 2.5 ects (suggested): 0.25 author(s), degrees, institution(s) doncho donev, md, phd institute of social medicine, joint institutes, medical faculty, university of skopje 50 divizia no.6, 1000 skopje, republic of macedonia luka kovacic, md, phd andrija štampar school of public health medical school, university of zagreb rockefeller st. 4, hr-10000 zagreb, croatia address for correspondence doncho donev, md, phd institute of social medicine, joint institutes, medical faculty, university of skopje 50 divizia no.6, 1000 skopje, republic of macedonia tel: +389 2 3147 056; fax: +389 2 3163 866 e-mail: donev@freemail.org.mk keywords resource allocation, health payments; regulation of providers; budgeting; fee-for-service; capitation; case-base payment, diagnosis related groups, resource allocation reform, europe, south eastern; health planning learning objectives at the end of this module students and health professionals should be able to identify: • resource allocation mechanisms and payment methods for regulation of providers, • methods of payment for primary health care providers, • payment and regulation of hospitals and other health facilities. abstract allocation mechanisms and provider payment methods refers to the ways in which money are distributed from a source of funds to an individual provider or to a health care facility. there are three main methods for payment for doctor's services: fee-for-service, capitation and salary payment; and four basic methods for payment and regulation of hospitals and other health facilities: global budgeting, line item budgeting, per diem and case-based payment (drgs).each method for payment to providers has its own specificities, strengths and weaknesses, and each may be appropriate alone or in combination with other, which depends on various circumstances and environment. teaching methods teaching method will include combination of introductory lectures, group work and discussion followed by group report presentations and overall discussion, as well as practical individual work assignment. specific recommendations for teacher this module to be organized within 0.25 ects credit. beside supervised work, students, as a practical work assignment, should collect some specific indicators (hfa database and other sources) and to prepare a seminar paper about the allocation mechanisms and payment methods to providers in their respective countries. assessment of students the final mark should be derived from assessment of the theoretical knowledge (oral exam), contribution to the group work and final discussion, and quality of the seminar paper. payment methods and regulation of providers dončo donev, luka kovačić resource allocation and provider payment methods in the health care system can have impact on provider’s behavior, and therefore on the achievement of the objectives of the health care system (efficiency, equity, cost containment). the allocation of financial resources should reflect the outcomes achieved, and include incentives for improving the quality of care (1). provider payment method refers to the way in which money are distributed from a source of funds, such as the government, an insurance company or other payor (all also referred to as fund-holders), to a health care facility (hospital, phc centre etc.) or to an individual provider (physician, nurse etc.). each provider payment method carries a set of incentives that encourage providers to behave in specific ways in terms of types, amounts, and quality of services they offer (2). it means that the payment system should be directed to provide the right incentives (or disincentives) in order to promote (or discourage) certain types of behaviour, and therefore to improve the efficiency and the quality of health services and to provide equitable financial access to care with the use of existing resources effectively. it is not easy to develop payment system and to provide right incentives (or disincentives) and to measure related performance. in general, health outcomes are problematic to measure, and may not be directly attributable to the performance of the individual health care provider, but rather to their team or other determinants of health status. it is also difficult to measure the behavioural response of providers to changes in payment systems (3). provider payment reform is often linked to government efforts to improve the efficacy of the health care system through various means, among others: 1) decentralizing the management of the health system; 2) separating health financing functions from the institution providing care; 3) contracting for public health services with private sector providers and non-governmental organizations; 4) developing or reforming public or private health insurance to expand coverage of the population; 5) promoting primary and preventive care over reliance on expensive curative and hospital-based care; and 6) improving hospital management and quality of care (2). 325 payment methods and regulation of providers 326 health systems and their evidence based development incentives and disincentives for efficient care include how providers and facilities are paid, and how services are organized. resource allocation according to needs the evidence suggests that a strategic approach to resource allocation and priority-setting is needed, in order to coordinate decision-making at different levels, and this should start with a discussion and a decision on the values and principles to be applied when determining need and selecting priorities. a debate (involving government, health service and care providers, the public and patients) on the ethical, political and social questions that need to be addressed must precede any decision on the rationing of resources. the term „funding” is used to describe allocating the revenues, that have been already raised, to health care organizations and to alternative activities within the health care sector, usually through budgets or payments to providers, public not-for-profit and for-profit institutions and firms (3). any rationing of access to necessary services should be preceded by a thorough scrutiny of the overall organization and of the cost and effectiveness of the services and care provided. needs-based resource allocation formulae have been introduced into some countries in the western part of europe and are now being developed in some countries in the eastern part, in particular regarding the geographical allocation of resources and services. contracting is a mechanism that offers an alternative to traditional models of resource allocation, binding third-party payers and providers to explicit commitments and generating the economic motivation to meet these commitments. four major reasons have been put forward for introducing contractual relationships into tax-based systems, based on the long experience of health insurance systems: 1) to encourage decentralization; 2) to improve the performance of providers; 3) to improve the planning of health service and care development; and 4) to improve management (2). contracts can support equity if, through needs assessment, resources are allocated as a priority explicitly to disadvantaged population groups. the role of governments should be to ensure equity, in order to avoid over-emphasizing profitable, rather than effective, services. basic arrangements for resource allocation there are three different basic arrangements by which to distribute revenue to health care providers: 1) the reimbursement model; 2) the contract model; and 3) the vertically integrated model. combined, there are thus at least seven major payment methods or alternative ways for payment to health care providers (4). payment for primary health care (phc) providers payment system for phc providers should contribute to achievement of the best possible health outcomes. an optimum payment system for phc providers should also ensure the following: financial management of the different components of phc within a country’s total health care expenditure; a balanced package of health promotion, disease prevention, treatment, and rehabilitative services; a free choice of health care provider for all individuals; a structure of fair rewards for practitioners which recognizes workload and professional merit; acceptance of health care providers’ responsibility for and accountability to the population and responsiveness to the needs of the community, the family and the individual; promotion of close collaboration among health care providers; and a democratic system of decision-making. finally, the system should allow purposeful, flexible management aimed at achieving continuous quality development and greater cost-effectiveness (1). the main methods of remuneration or paying doctors and other health care professionals for their labour at phc level are: fee-for service, capitation and salary, or some combination of these methods. each of them has its historical roots, advantages and disadvantages, and the incentives they create for providers, payors and consumers (1,5,6). 1. fee-for-service is payment for each unit of service or intervention provided (visit to doctors office for counselling, testing or treatment prescription, intervention or surgical procedure), which can be paid directly by the patient (user charges) or by the third party payer (insurer or government). feefor-service is a common method of payment for doctor’s services in many countries, such as germany, usa, canada and other countries (5,8). in most countries fee-for-service payment is regulated by a prospectively fixed fee schedule, negotiated by the fund-holders and the provider’s representative. because of incomplete information and so called information asymmetry as a result of superior knowledge of the health care providers, doctor helps 327 payment methods and regulation of providers the patient to make choices and patient may be unable to judge the performance of the doctor, before or even after the intervention. disadvantage of this method of payment is that provider might neglect codes of medical ethics in protecting the consumer’s best interests and to influence patient’s demand for health care, especially for more expensive kinds of care, including surgery, for the providers’ own self-interest (income). this creates potential incentives for inappropriate services and over-treatment (over-servicing), in excess of real needs, especially when the patient is fully covered by health insurance and when the specific actions undertaken by the physician cannot be monitored, measured, or well understood. that is known as supplier induced demands. fee-for-service and other retrospective forms of payment result in an inputintensive, gold-plated form of service that often extensively expends resources. on the other side, fee-for-service method of payment discourages provision of care not defined as a service in the fee schedule (because a „covered” service is the unit of payment) (3,6,7). some fund-holders introduce participation of the user in the cost of service (user fees or charges), which is called co-payment. in fact, co-payment is the portion of covered health care cost for which the person insured has the responsibility to pay, usually based on a fixed percentage. the method of copayment is a regulative mechanism for rationing the health care, in order to prevent consumers to seek unnecessary care, as well as a source for additional funds for health care (financial input). co-payment often is an issue for political debate (hot potato) because the opponents argue that user fees affect the poorer strata of the population disproportionately and discourage preventive care services/activities (3,5). case-based payment to physicians at primary level is not common, but might be popular prospective form of payment for specialty physicians and for hospital outpatient services builds on the episode-of-illness payment methodology. that is payment per case-rates or episode of illness i.e. for obstetrical care as a complete service including prenatal care and delivery, or certain surgical, cardiological etc. package of care over an illness or period of care, usually on a monthly basis (fee for the preoperative/pre-intervention workup, the procedure itself, and postoperative monitoring) (5,6). 2. capitation for doctor’s services is advanced payment by a fixed sum of money for the persons registered for care with the physician for a defined period of time. it means that capitation is prepayment for services on per member pre month (pre year) basis by some amount of money every month (year) for a member regardless of whether that member receives services and regardless of how expensive those services are. this method of payment pro328 health systems and their evidence based development vides good cash flow, less lost-costs and applied and good case management, and can be for a comprehensive health services or for general practitioner services. in the uk, for example, around 60% of general practitioners’ income is derived from an annual fee paid by the national health service (nhs) for each patient on a gp’s list. the costs might be predicted because the fee depends on the age and sex of the patient (age/sex adjustment of physician capitation rates), and the level of the deprivation of the area. capitation payment put risk on provider and has the advantage for utilization control because it does not contain incentives for provider to over-treat the patient. there is some incentive for the doctor to maintain quality of care in order to attract and retain patients even this is limited by information problems. providers are also motivated to undertake health promotion and preventive care as this may reduce costs later in the health care process. in uk recently were introduced incentive fees for full immunization and screening programs in order to improve the performance in these areas. main weaknesses might be to adjust capitation payment adequately to reflect the diversity in disease severity among patients, which leads to incentives for adverse selection and patient dumping, difficulties to determine break-even point (volume), avoiding high-risk and high-cost patients or reducing treatment for them, inappropriate under-utilization (narrow scope practice), and misunderstanding of the meaning of capitation by provider. there may be incentives to under-treat (subject to keeping patients happy and therefore retaining them), and to shift costs to elsewhere in the health care system (for example from primary to secondary care). the interaction among payment mechanisms (capitation at primary level and fee-for-service payment at secondary level) might provide incentive for over-referral and convert primary care physicians into triage agents (3,5,6). 3. salary payment for doctors and other health workers is the final payment mechanism in form of salary where doctors are paid to provide a certain amount of their time to carry out specified responsibilities for an organization and to perform a defined role, usually being available to provide needed health care services at specified times (and places). the salary level is likely to be negotiated between the professional associations (or health workers trade unions) and fund-holders (government, insurance company or managed care organization), and will vary according to the age, experience, grades or levels of education and responsibilities of the health workers. the advantage for providers is predictability and stability of income, and it gives less incentive to over-treat, but may contain incentives to under-treat or shift costs from primary to higher levels. in addition, a hospital doctor paid a salary may choose, with a given availability of beds, to have a longer average length of stay (reducing overall workload) rather than faster throughput (which would increase work 329 payment methods and regulation of providers without increasing income. in general, salary payment undermines productivity, condones on-the-job leisure and fosters a bureaucratic mentality. it means that provider might consider that every procedure is someone else’s problem because payment is based on minimally meeting responsibilities (to retain one’s position) (3,6,7). that is why salary payment is often combined with incentive payments for additional services. wage is a payment mechanism whereby a provider receives a prespecified sum of money for each hour of work they provide to an organization. it can be used only for remuneration. although the wage is normally pre-set, the total payments depend on the number of hours worked. the incentives are similar to salary, except that payment is even more closely tied to time spent at the workplace (7). the type of payment system depends of the financing of the health care system and the public-private mix of financing, as well as of the provision and the desired activity levels of physicians and other health workers. payment systems are therefore likely to involve a mix of methods. increasingly mixed systems of payment are emerging, with capitation as a predominant method at the primary health care level (5). payment and regulation of hospitals and other health facilities there are four main mechanisms for paying hospitals and each of them create different incentives for the service provider and different effects in relation to the objectives of equity, quality of care, efficiency and cost control / cost containment (3,5). it is not easy to measure efficiency and outcomes of health care in the hospital sector. efficiency should be measured through input (resources used in delivering care), process (method of delivering care, day cases and inpatient cases, length of stay etc.), and outcome indicators (the result of care – whether or not it has been of benefit to the patient). measuring outcomes of health care is often attempted to estimate process and hospital activity through some indicators (average length of stay, bed occupancy and turnover rate), which have uncertain relationships with cost, patient outcomes and efficiency. if activity measures are used in payment systems for providers, they should be good proxies for outcome. rewarding turnover of patients may give incentives for discharging patients „quicker but sicker”. nevertheless, too many indicators can create confusion and dilute incentives. prospective budgeting has evident merits: it limits expenditure to funding a given level of ser330 health systems and their evidence based development vice provision that is determined in advance for a defined period. a prospective budgeting system can be recommended if it incorporates the use of casemix controls and output measures. classification systems based on diagnosis or on the characteristics of the patients can be used to better analyse cost structures, evaluate hospital performance and quality of care, and make comparisons between hospitals in terms of costs and quality, as well as in negotiating contracts between hospitals and those purchasing services. alternatively, a volume-based approach can be made to work by using prospective pricing and contracting or planning agreements for agreed levels of service provision. in this way, hospitals can be obligated to achieve specific objectives of cost control and effective resource utilization, stimulating them to review and adjust their current organization, staffing levels and internal resource allocation (1,3). 4. global budgeting is defined as a total payment, almost always prospectively, fixed in advance as a constraint on providers to limit the price and the quantity of service, to be provided in a specified period of time. global budgets are difficult to amend over the budget period, but some end-of-year adjustments may be allowed. it means that the global budget becomes a financial plan (and resource constraint) within which the hospital or other health facility has to operate. resource allocation decisions are made among the many diverse, but interdependent activities and programs of the health care providers. the global or operating budget is always for a specified period, usually one year (calendar or fiscal), although it might be a biennial or a semiannual budget (5,7,8). various formulas can be used for establishing a global budget for a hospital or other health facility. because global budgets do not contain incentives for good performance, it is important to specify either the volume of activity or the price of each of the services included within the budget. in order to prevent the provider to minimize the number of patients treated and the amount of care given to each patient, since the money received will be the same, it is necessary to determine the scope of services included, patients eligible for treatment and methods of care delivery (i.e. inpatient, outpatient, day case, diagnostic testing). the global budget may reflect the anticipated volume of activity and services derived from the utilization rates for the previous year or to be based on per capita rates with various adjustments (age, sex). global budgeting usually relates the level of resources provided (the budget) to the level of activity to be undertaken, and is therefore focused on inputs and not on outputs. because the determination of the process of delivery of care is left to the provider, who tends to maximize profits (by undertaking the required activity for easy cases as cheaply as possible, with potential for cost shifting and 331 payment methods and regulation of providers the quality to be compromised), additional regulation is needed for quality to be maintained and clear quality standards to be specified by global budgeting agreements / contracts between purchaser and provider. the global budget can include also some capital costs if necessary to built / broaden or renovate the capacities or purchase some capital / costly equipment (3,5,9). the main advantage of a global budget for cost-containment is that the cost paid by the fund-holder / purchaser is fixed, and therefore the financial risk is transferred to the provider, assuming that there are „good” and well-constructed activity targets. the advantage for local managers is flexibility about the use of resources and the methods of undertaking care within the budget limits. disadvantage of global budgets is that it provides incentives to skim on quality of care, engage in risk-selection, and provides few incentives to improve micro-efficiency despite helping contain costs. there is no control of quality inherent in global budget framework. furthermore, global budgets provide incentives for hospitals to avoid complicated cases and seek out simple ones. in order to address these problems, activity targets including expected case-mix is important (3,7). 5. line item budgeting is a variant of global budgeting with subdivision of the budget allocated according to specific input categories of resources or functions (salaries, medicines, equipment, food, maintenance etc.). this method of hospital budgeting process and contracting methodology is generally similar to that for global budgeting, but more complex and more difficult to monitor with much more details, since each item of expenditure might be subject to an individual contract and possibly a service specification (3,5,7). initial step of the budgeting process is gathering retrospective data and financial information including all expenses and revenues, units of services (case mix index), staffing information including a breakdown by job code and type of working day-time hours (e.g. base staffing, overtime, non-productive), and current year projections with detailed analysis and evaluation. the second step relate to determining the units of services and expected changes in number of patients, which is driving force for changes in both revenues and certain types of expenses. special attention should be paid to the inpatient routine units of services – patient days, discharges (or admissions), adjustments for intensity of care, as well as to ancillary units of services. the third step of the budgeting process relates to staffing and payroll, which is the most important, high time-consuming and the single largest portion of the budget. special attention should be paid to the base staffing and payroll, overtime, other budgeted hours, contract codes, pay increases, occurred vs. paid staffing and payroll, and productive vs. non-productive time. the next separate category of the budget are 332 health systems and their evidence based development the fringe benefits (social security, pension and retirement, health insurance, disability, unemployment and life insurance, tuition reimbursement etc.). special category of the budget is non-salary fixed and variable expenses (medical/surgical suppliers, drugs and pharmaceuticals, general suppliers, professional and physician fees, insurance, interest and depreciation, purchased services, travel costs, and utilities). and, the last category of the budget are revenues and allowances: gross and net patient revenue, rate charges, allowances and deductions from revenue, contractual allowances and other operating and non-operating revenue (3,5,7). line item budgeting, in general, offers similar incentives as global budgeting, with an exception with limited or no possibility of reallocation of resources between cost units/ categories. that might be a limitation for hospitals for efficient methods of service delivery because of few incentives for efficient production of health services, and little flexibility of managers (2). advanced budgeting, as an alternative method of variance reporting and adjustment of revenues and expenses based on increases or decreases in unit services, is more flexible budgeting. reports on advanced budgeting cover flexible budget as compared to actual and fixed (static) budget. main strengths of advanced budgeting are that budget can be adjusted in order to reflect actual activity level, it is easier to obtain meaningful variance analysis, and to generate a more enthusiastic acceptance by department managers. in line item budgeting the recurrent (operational) costs should be separated from capital costs, too. 6. per diem or flat rate per patient-day is retrospective method for payment of hospital activity. this method, as well as other retrospective methods of payment (fee-for-service or per procedure, course of treatment, per admission or cost-per-case based payment) encourages hospitals to maximize income by maximizing the volume of activity. per diem method gives incentives to hospitals to increase the number of admissions to hospital for diagnostic tests or care that could be provided in alternative and less costly ways (ambulatory or day care services), to hospitalise and provide prolonged care for a relatively well patient and to avoid or refer the sicker patient to other hospital/university clinic (cost shifting), or to prolong length of stay, particularly as the cost per day of care declines as length of stay increases (3,7). fee-for-service payment for each service, procedure or course of treatment in hospitals, as well as cost-per-case based payment (per admission), favours unnecessary marginal care, long lengths of stay, high admission rates, and provision of duplicative or unnecessary services (5). 333 payment methods and regulation of providers per-diem payment and other retrospective methods of payment provides no direct incentives to ensure quality of care, efficiency and cost-containment. 7. diagnosis related groups (drgs) is prospective method for payment of hospitals by predefined charge per case, within the payment rates for each type of case being determined in advance. patients/diagnoses should be categorized into disease categories, so called diagnosis related groups, in order to facilitate billing and reimbursement by estimate cost of individual treatment. reimbursement rates are negotiated between purchaser and provider and they are set to reflect the expected average cost for particular drg. reimbursement payments are divided into four major components: 1. room and board, 2. professional service, 3. diagnostic tests and special therapies, and 4. consumables and drugs (5,7). the number of drgs vary from 470, or even more, in usa (introduced in early 1980s for medicare program for elderly) to around 20 diagnostic groups in chile, which greatly simplifies the classification process and accounting around 60 percent of inpatient care expenditures. the remaining 40 percent of procedures are covered under management contracts and prospective budgets. during 1990s this method of prospective payment to hospitals was introduced in norway (1991), sweden and ireland (1992), hungary (19871993), united kingdom (1993), italy (1994), germany, belgium and spain (1995), czech republic (1996), and than in some other countries (canada, denmark, australia and philippines). anyhow, for implementation of this method of payment should be available a reliable patient information system in order to record diagnoses, procedures, and important items of resource use such as diagnostic testing and length of stay (3,5). drg payment method has advantages of reducing incentives to overtreat, permitting cost containment and generating data and information. there are also some limitations and adverse effects in using drgs payment method: 1) incomplete coverage of drgs (they do not cover psychiatry, outpatients or physician fees for the uncovered items); 2) promoting technological changes (day case surgery), which might be beneficial but in many cases are with unproven efficiency; 3) sticky prices, once fixed, are difficult to change, regardless of advances in technology and falling unit costs, and therefore offer providers increasing profits over time; 4) drg creep activity of classifying patients into the most remunerative drgs possible through undertaking additional diagnostic tests and identifying additional health defects and problems; 5) data requirements can limit the use of drgs in countries with insufficiently developed health information system, particularly in developing countries (3,7). 334 health systems and their evidence based development the main objective of drgs prospective payment is to control costs by motivating providers to deliver care as cheaply as possible. hospitals have incentives to improve performance and to reduce expenditure by reducing length of stay, cutting out unnecessary tests and avoiding duplication. the tendency of hospitals to reduce costs sometimes may compromise the quality of services provided and health outcomes to be worsened, i.e. earlier discharge could lead to higher rates of mortality, morbidity and readmission to hospital – a „quicker – sicker” problem. drgs with fixed prices across all providers stimulate competition based on non-price factors, notably on the quality of services, short waiting times and the quality of he hospital environment. quality competition is likely for profitable patients, i.e. those whose treatment is expected to cost less than the drg reimbursement level. perverse incentives for providers appear when case-mix selection is allowed and hospitals may select the patients they treat. it means that hospitals have incentive to avoid and not to treat patients who are older, sicker or more likely to have complications because the treatment costs for them will probably be in excess of the drg average (adverse selection). such hospitals would prefer to treat simple cases and to minimize costs and maximize profit (cream-skim phenomenon) (3,5,7). case mix selection can occur if providers are allowed to select the patients they treat. this is important because even within drgs, some patients may be older, sicker, or more likely to have a treatment cost in excess of the drg average. if payments are made on the basis of drg average cost, profitmaximizing hospitals have an incentive not to treat these patients. such hospitals would prefer to cream-skim treating simple cases, minimizing costs and retaining any excess of income over expenditure. to avoid cream skimming there must be adequate case-mix adjustment within drgs, which can be complex. case-mix can be measured based on patient’s diagnoses or the severity of their illnesses, the utilization of services, and the characteristics of a hospital. case-mix influences the average length of stay, cost, and scope of services provided by hospital (3,7). conclusion there are three main methods for paying doctors: fee for service, capitation and salary, and four main methods for paying hospitals: global budget, line-item budget, per diem and case based payment (drgs). the practice shows that there is no ideal method for payment of providers. resource allocation decisions should be made among the many diverse, but interdependent activities and programs of the health care providers, and because of that the reimbursement or budgeting is a complex process, usually involving input 335 payment methods and regulation of providers from many sources. anyhow, the creation and maintaining of a detailed operating budget is an important component of cost control. it means that each method for payment to providers has strengths and weaknesses, and each may be appropriate alone or in combination with other, which depends on various circumstances and environment. nevertheless, many health care systems have moved away from fee-for-service as predominant payment. mixed payment systems, with a prospective component based on capitation together with feefor-service for selected items, seem to be more successful in controlling costs at the macro level, while ensuring both patient and provider satisfaction and achieving efficiency and quality at the micro level. the tools available for management include the use of different incentives to influence patterns of care (e.g. to offer more preventive services) and ensure equitable distribution of primary care providers throughout the country (1,9,10,11,12). reimbursement of the hospital providers is complex, and depends on specialization or complexity of hospital services. for example, to use a global budget might be appropriate for well-defined care, such as maternal services. but, when services are more complex and variable, such as oncology or trauma, payment through global budget might be less appropriate. choice of payment method for health care providers is a long, complex and detailed process including appropriate devising of incentives and contract specifications in order to achieve health care objectives (efficiency, quality, equity and cost-containment, as well as consumer satisfaction). difficulties in selection of the method for reimbursement of providers are springing out from the specific subject and product thousand of different illnesses and treatments, and, for the same illness, treatment patterns can be substantially different for different physicians and providers. from the other side, the quality of health care services and outcomes is very difficult to quantify and measure. projection of net revenue is difficult to determine because of different payors and payment methods, and because of rapidly changing of payment methods. when a third party payor (insurance agency) contracts with providers to pay for the care of covered patients by health insurance, it is recommended for each of the payment methods to be accompanied by some payment out of pocket of the patient (1-3,5,9). each payment method should be supported by legal framework and management information system, effective referral system, and financial and management autonomy of the providers. the main characteristics and differences, as well as the distribution of the financial risk between payors / purchasers and providers, are summarized in the attached table 1 (2,3,6,7). 336 health systems and their evidence based development table 1. seven major payment methods: advantages and disadvantages 337 payment methods and regulation of providers payment method unit of payment prospective or retrospective description 1. fee-for-service per unit of service or intervention provided retrospective separate fees for different service item e.g. medicines, consultation, tests, surgical procedures 2. capitation per person per year (month) prospective a payment made by fix sum of money directly to health care provider for each individual enrolled with that provider for a defined period of time. the payment covers the costs of a defined package of services for a specified period of time. in some instances, the provider may then purchase services which it cannot (or choose not to) provide itself from other providers. 3. salary payment to providers, usually on a monthly basis retrospective individual payment to doctor and other health worker, in accordance with the age/experience, grade/level of education and responsibilities of the providers, for their performance for defined period of time (week, month). 4. global budget health facility: hospital, clinic, health centre prospective total payment fixed in advance to cover a specified period of time. some end-of-year adjustments may be allowed. various formulas can be used: historical trends, per capita rates with various adjustments (age, sex), utilization rates for the previous year/s. 5. line item budget functional budget categories, usually on an annual basis either budget is allocated according to specific input categories of resources or functions, usually on an annual basis. budget categories include: salaries, medicines, equipment, food, overhead, administration. 6. per diem per day for different hospital departments retrospective an aggregate payment covering all expenses incurred during one inpatient day. 7. case-based payment (drgs) per case or episode prospective a fixed payment covering all services for a specified case or illness. patient classification systems (such as diagnosis related groups drgs) group patients according to diagnoses and major procedures performed. most frequently applied to inpatient services, although outpatient groups are being developed. 338 health systems and their evidence based development payment method method efficiency quality and equity management and information systems financial risk 1. fee-forservice + flexibility in resource use tendency for provider to increase number of services in order to increase revenue (supplier induced demands) + payment is directly related to intensity of service required there is a tendency to over-service or provide unnecessary interventions. providers must record and bill for each medical service transaction. provider = low payer = high 2. capitation + flexibility in resource use with good cash flow and less lost-costs + the more services included in the package the less the scope for cost shifting + resources closely linked to size of population served and their health needs + good case management providers may sacrifice quality in order to contain costs rationing may occur if capitation is too low (narrow scope practice) may encourage providers to enroll healthier patients (adverse selection) patient choice of provider is generally restricted + adjusters in capitation formula can adjust payment to special population groups by age/sex management system required to ensure that each beneficiary registers with one provider and primarily uses that provider. utilization management and quality assurance programs are essential to prevent under-servicing. if payment covers primary and secondary services, providers at different levels of the system must establish contractual links with each other in order to prevent over-referral. provider = high payer = low 3. salary little flexibility in resource use usually not linked to performance indicators (e.g. volume, quality) gives incentives to under-treat and undermined productivity + payment is fixed and stable no incentives for physicians to improve quality of care and scope of services (gatekeepers) traffic-policeman role with tendency to over-referral and shift costs relatively simple provider = low payer = low 4. global budget + flexibility in resource use spending set artificially rather than through market forces not always linked to performance indicators (e.g. volume, quality, case-mix), low micro-efficiency rationing may occur if budget is too low if rationing occurs more complex cases may be referred elsewhere requires ability to track efficiency and effectiveness of resource use in different departments, and mechanisms to switch resources to most effective uses. provider = high payer = low 339 payment methods and regulation of providers cost-shifting possible if global budget covers limited services; one provider may refer patient to another who is outside purview of global budget to minimize expenditures under global budget + case-mix adjustments in global formulas link budget amounts to complexity of cases; other adjustors may be used to adjust payment for special population groups. 5. line item budget little flexibility in resource use tendency to spend entire budget even if unnecessary, to ensure that level of budget support is maintained rationing may occur if budget is too low more complex cases may be avoided or referred elsewhere more complex and more difficult to monitor with much more details provider = low payer = low 6. per diem + flexibility in resource use tendency for hospitals to increase admissions and length of stay in order to increase revenue + per diem rates allow longer stays for more complex cases prolonged care for relatively well casesavoid or refer the sicker patientss need to track inpatient days by department and ensure costs are covered. provider = low payer = high 7. case-based payment (drgs) + flexibility in resource use tendency for hospitals to increase cases (by increasing admissions or double-counting admissions) + no incentives to over-treat + permitting costcontainment + case-based payment links payment directly to the complexity of cases + generating data and informationshortening length of stay by earlier discharging of patients (quicker-sicker)adverse selection and „cream-skim” providers need reliable patient information system and ability to record and bill by defined case, which generally entails collecting a large volume of relevant information on patient characteristics, diagnoses and procedures. provider = moderate payer = mo-derate exercise: financing of health care and regulation of providers task: seminar paper. students should use additional recommended readings in order to increase their knowledge and understanding of allocation mechanisms and payment methods for regulation of providers. as output, students should write a seminar paper, stressing the importance of different payment methods for regulation of providers. students ought to be able to investigate the ways in which revenues are pooled and how they are distributed to health providers (much more could be find at local level). 340 health systems and their evidence based development references 1. who. health 21 – health for all in the 21st century funding and allocation of resources for health services and care. european health for all series no 6. who-euro, copenhagen 1999: 131-5. 2. wouters a, bennett s, leighton c. alternative provider payment methods: incentives for improving health care delivery. partnership for health reform primer. http://www.phrplus.org/pubs/pps1.pdf 3. maynard a, bloor k. payment and regulation of providers. flagship course on health sector reform and sustainable financing background material. the world bank institute and semmelweis university health services management training centre, budapest, hungary, june 30 july 11, 2003. 4. saltman rb, figueras j. european health care reform: analysis of current strategies. who regional office for europe, copenhagen, 1997 (who regional publications, european series, no. 72). 5. tulchinsky th, varavikova ea. the new public health: an introduction for the 21st century. chapter 11: measuring costs: the economics of health. san diego: academic press, 2000: 549-88 6. robinson j. theory and practice in the design of physicians payment incentives. the milbank quarterly journal of public health and health care policy. university of california, berkeley, 2001; 79(2). (cited 2003, june 29). available from url: http://www.milbank.org/quarterly/7902feat.html 7. the world bank group. funding and remuneration in health care. distance learning flagship course on health sector reform and sustainable financing, 2001. (cited 2004, january 14) available from url: http://www.worldbank.org/wbi/healthflagship/module1/sec7i.html 8. anthony n. robert, young w. david. management control in non-profit organizations fifth edition. richard d. irwin, inc., bur ridge, illinois, usa, sydney-australia; 1994: 902. 9. who. health systems: improving performance. the world health report 2000, who, geneva, 2000: 47-116. 10. who. shaping the future. the world health report 2003 financing health systems. who, geneva, 2003: 119-21. 11. the world bank. world development report 1993: investing in health. the world bank, 1993: 2571. 12. bobadilla jl, cowley p, musgrove p, saxenian h. design, content and financing of an essential national package of health services. the world bank group private and public initiatives: working together in health and education. the world bank, march 17, 1995:1-10. (cited 2004, january 11). available from url: http://www.worldbank.org/html/extdr/hnp/health/ hlt_svcs/pack1.htm 341 payment methods and regulation of providers 342 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title case study: the current health insurance system in the republic of macedonia module: 2.6 ects (suggested): 0.25 author(s), degrees, institution(s) doncho donev, md, phd institute of social medicine, joint institutes, medical faculty, university of skopje 50 divizia no.6, 1000 skopje, republic of macedonia address for correspondence doncho donev, md, phd institute of social medicine, joint institutes, medical faculty, university of skopje 50 divizia no.6, 1000 skopje, republic of macedonia tel: +389 2 3147 056; fax: +389 2 3163 866 e-mail: donev@freemail.org.mk keywords health care; health expenditures; health insurance; health payments; health care costs; resource allocation reform; health plan implementation; macedonia learning objectives at the end of this module case study, students would become familiar with the health insurance system in macedonia. abstract the current health insurance system in macedonia was introduced by the health insurance law, which was adopted in 2000. according to this law, health insurance was established as an obligatory and voluntary insurance for certain kinds of health care. this case study gives an insight to the specificities and practice of both mentioned types of insurance in macedonia, to the scope of the insured persons and their rights and obligations, the way of realization of health insurance in practice. calculation and payment of the contributions and the other sources of revenues, co-payments, autonomy and scope of activities of the health insurance fund, as well as health care and health insurance reforms within the last 12 years. teaching methods teaching methods will consist of combination of an introductory lecture, group work followed by group reports and overall discussion, practical work. specific recommendations for teacher this module to be organized within 0.25 ects credit. beside supervised work, students should collect some specific indicators (hfa database and other sources) and readings about the health insurance system in their respective countries in order to prepare a seminar paper as practical work. assessment of students the final mark should be derived from assessment of the theoretical knowledge, contribution to the group work and final discussion, and quality of the seminar paper. case study: the current health insurance system in the republic of macedonia dončo donev health insurance, as one of the most significant civilization gains of the contemporary world, presents a legal normative and regulatory organized mechanism for acquiring funds on different bases, in order to provide prompt quality and efficient prevention and protection of people’s health. the current health insurance system in the republic of macedonia was introduced by the health insurance law (1), which was adopted in march 2000, and modified and supplemented by the amendments in 2000 (2) and 2001 (3). the health insurance law was empowered on april 7th, 2000, and at the same time the articles of the 1991 health protection law (4) related to the health insurance were put out of power. in fact, the current health insurance system in the republic of macedonia is somehow continuation of the previous one (5), with some modifications and new way of regulation of the relationships within the health insurance related to the obligatory and voluntary insurance, the scope of the insured persons and their tights and obligations, the way of calculating and payment of the contributions and the other sources of revenues for health insurance, user participation in health care expenses, as well as the scope of activities and responsibilities of the health insurance fund that was established as an independent institution outside of the ministry of health. there are two types of health insurance according to the law on health insurance: obligatory and voluntary insurance for some kinds of health care. obligatory health insurance was established for all citizens of the republic of macedonia in order to provide social and health security and to realize certain rights in case of disease or injury and other rights from health care established by health insurance law. obligatory health insurance is based on the principles of obligation and universal coverage, solidarity, equity and effective usage of the financial resources in accordance with the law. it means that when necessary, each insured person can use the health care and the rights from health insurance, in an unlimited amount for basic health care rights, covered by the obligatory health insurance. on the other side, there is an obliga343 case study: the current health insurance system in the republic of macedonia tion to all employees and other bearers of insurance for continuous payment of contributions for health insurance. the contribution rate is the same for all employees, regardless, of the level of salary or income, or the frequency and amount of the health services use on the account of the health insurance funds. the principles of solidarity and equity are compulsory (1,4,5,6). some special risks and services, which are not covered by the obligatory health insurance, should be provided to certain groups of workers by their employers. it includes preventive and screening measures and use of health care in case of injury at work and occupational diseases of the insured on the employment basis, due to the increased risk at work. it also applies to the insured professional sport persons, drivers, pilots and other aircraft crew etc. voluntary health insurance was introduced for the health services that were not covered by the obligatory health insurance. it covers use of some specific health care services, as well as services at a higher level of standard or comfort than those offered by the obligatory health insurance, in accordance with the agreements and norms set by the agency / company that provide voluntary insurance. voluntary health insurance is an additional insurance, allowed only for the insured within the obligatory health insurance. however, due to the lack of interest shown by the citizens for realization of the voluntary health insurance rights, as well as due to the wide range of obligatory health insurance rights, voluntary health insurance has not yet been implemented in practice. modalities of becoming an insured through obligatory health insurance 2000 health insurance law promotes various modalities for a person to become the member of the obligatory health insurance offered by the health insurance fund (hif). almost all citizens (more than 80% of the total population) of the republic of macedonia are insured by the obligatory health insurance system, in various modalities: (a) on the basis of their employment employed individuals (workers), individuals working in the private sector, and individuals performing agrarian activity (farmers); (b) on the basis of their retirement rights retirement, disability and family pensions, as well as pensions and disability rents from foreign insurance bearers; and (c) on other grounds unemployed persons registered by the employment office, users of basic social care rights, war-disabled soldiers, disabled civilians from the war, family members of the insured who serve in the army of the republic of macedonia, persons who are in prison, or are sentenced to correction measures, 344 health systems and their evidence based development persons who have been hired and imprisoned for the ideas for sovereignty of macedonia and it’s independence as a state, persons in religious communities (monks, nuns) etc. (1,6). citizens who are not included in any of the above-mentioned groups, because of various reasons, can voluntary obtain obligatory health insurance, for themselves and for the members of their families, by paying the health insurance contribution in accordance with the law. the obligatory health insurance, apart from covering the active insured (bearer of insurance), also covers his/her close family members: spouse and children up to the age of 18, or to the age of 26 if they are students involved in regular education. in addition to the citizens of the republic of macedonia, obligatory health insurance is also valid for foreign citizens and individuals without any citizenship, if they are employed on the territory of the republic of macedonia, in domestic or foreign firms, in international organizations or diplomatic residencies, or if they are involved in an expert training or education in the republic of macedonia. foreign citizens from countries having international agreements with the republic of macedonia for social insurance, use health care rights according to those agreements (1,6,7). the expenses of the health care services for the citizens of the republic of macedonia who do not undergo any form of the obligatory health insurance, i.e., who are not fund insurees, are covered by the state budget in the following cases: (a) health care of children and adolescents up to the age of 18, and pupils and students up to the age of 26; (b) health care of women related to pregnancy and delivery; and (c) treatment of infectious diseases, mental diseases, rheumatic fever with complications, malignant diseases, diabetes, chronic dialysis, progressive nervous and muscle diseases, cerebral paralysis, multiple sclerosis, cystic fibrosis, hemophilia, thalassemia and similar diseases, epilepsy, alcoholism and drug addiction (1,6). rights from the obligatory health insurance health insurance fund provides the right to health care, as well as the right to a sick-leave and other financial reimbursements to the insured (1,6,7). the obligatory health insurance, on the principle of solidarity as a key element for providing the health care rights, provides the insured with the following basic health care rights / benefits or „basic package of health care services”: 345 case study: the current health insurance system in the republic of macedonia i. health care rights/benefits at the primary health care (phc) level: (a) medical examinations and other kinds of medical assistance in order to determine the diagnosis, follow-up, or check the health status; (b) undertaking expert medical measures, other measures and procedures for promoting the health condition, i.e. prevention and early detection of diseases and other health disorders; (c) providing emergency medical assistance; (d) outpatient treatment or home care treatment at the user’s home; (e) health protection related to pregnancy and delivery; (f) implementation of preventive, therapeutic and rehabilitation measures; (g) prevention and treatment of oral and dental diseases; (h) providing medicines in accordance to the list of medicines, issued by the hif and approved by the minister of health; ii. health care rights/benefits at the specialist-consultative health care level: (a) examination of the health status of the insured and establishing diagnosis and giving recommendation for further treatment; (b) performing specialized diagnostic, therapeutic and rehabilitation procedures; (c) prosthetic, orthopedic, and other facilities, supporting and sanitary instruments, and dental technical devices according to the general act issued by the hif and approved by the minister of health; and iii. hospital (in-patient short-term and long-term) services: (a) examination of the health status, providing treatment, rehabilitation and care, accommodation (in standard conditions hospital room with two or more beds) and meals during hospitalization; (b) providing medicines in accordance to the list of medicines, issued by the hif and approved by the minister of health, as well as supporting materials for application of medicines and sanitary materials needed for treatment; (c) accommodation and meals for the accompanying person of the child up to 3 years of age, during hospitalization, if necessary up to 30 days (1,6,7). the following services are not covered by the obligatory health insurance and might be a subject to the voluntary health insurance: (a) aesthetic surgery, sanatorium treatment and medical rehabilitation of certain chronic non-communicable diseases (except for children up to 18 years of age); (b) inpatient health services with higher standard or comfort; (c) medicines not included in the list of medicines determined by the hif and approved by the minister of health; (d) orthopedic facilities and instruments not included in the list prepared by the hif and approved by the minister of health, or made of higher standard of materials; (e) accommodation and care in gerontology facility etc. (1,6,7). in addition to the basic health care rights, the obligatory health 346 health systems and their evidence based development insurance also provides some other rights to the active insured: (a) reimbursement of salary due to illness or injury, medical examination, voluntary donation of blood or biological tissues, during the sickness leave or due to the pregnancy and maternity leave for 9 months, as well as for the care of a sick child up to age of 3 years (no limit) or other family member (up to 30 days); (b) all insured have the right to the reimbursement of the travel expenses for usage of health services, and some other reimbursements (1,6,7). realization of the rights to health care the obligatory health insurance rights are used by the insured and their family members through health insurance fund on the basis of the issued health book, and a confirmation of paid health insurance contributions (blue tickets/marks) (1,6,7,8). the insured person has a right and obligation to choose a physician (doctor of choice) within the appropriate service at the phc level (service of general medicine, occupational medicine, service for health care of the children up to 6 years of age or school medicine for school children and adolescents up to 18 years of age, and students au to 26 years of age, service for health care of the women related to their reproductive functions, for women over 14 years of age, and dental service for general dental care, for all insured). the doctor of choice is responsible to follow the health status and to provide preventive measures and activities for health promotion and prevention and early detection of diseases, as well as treatment of diseases and injuries, to determine the need for sickness leave and referral of the patient to the higher levels of the health care system, if necessary. basic health care rights might be realized on all levels of the health care system as follows: 1) primary health care, including general practice, occupational medicine, pediatrics, school medicine, gynecology, and general dental practice; primary health care also covers emergency medical assistance and home treatment; 2) consultative-specialist health care provided in health centers and medical centers; 3) sub-specialist health care provided at the clinics and institutes of the medical faculty in skopje and some other health institutions at the national level; 4) hospital health care; and 5) medical rehabilitation at outpatient services, medical centers, and hospitals during the hospital treatment, as well as, specialized medical rehabilitation in specific rehabilitation centers as a continuation of the hospital treatment (7). an insured has a right to the treatment in a foreign medical institution if the disease can not be treated in the republic of macedonia and if there is a 347 case study: the current health insurance system in the republic of macedonia possibility for a successful treatment in some foreign country. the conditions and procedure for sending the insured abroad for health care treatment are regulated precisely by the general act of the hif approved by the minister of health. physician recommendation and the approval for treatment abroad by the health insurance fund committee is required before granting the insurance coverage. coverage for services obtained abroad that are available in macedonia is not provided, in order to protect against erosion in utilization of macedonian medical care (1,6,7,9). resources for health financing health care system services and certain broader public health activities are financed by the monthly payroll (profit) contributions of the employed persons in public and private sector and contributions from the general budgetary revenues, external assistance and limited imposition of users fees (1,6,10,11). most of the revenues (over 90%) are raised from the health insurance contributions in accordance with determined rates. about 57.4% of domestic health sector revenues, in the year 2002, were derived directly or indirectly from payroll contributions to the health insurance fund. direct contributions from public and private sector wage-earners (all persons engaged in different forms of socially organized or personal labor) were equal to 8.6% up to june 2001 when the contribution rate was formally increased to 9.2% because of the changes in the basis and the way of calculation of the health insurance contributions. in fact, this change was induced by the decrease of the personal income tax (as a part of the gross wages) from 23% to 15%, which means that the real contribution for health insurance by rate of 8.6% and personal income tax of 23% is about equal to the contribution by rate of 9.2% and personal income tax of 15% within the gross earned wages and reimbursements during sickness leave (12). direct payroll contributions to the health insurance fund were withheld from the source (employer). certain percentage of money from payroll contributions to the pension and disability fund and the employment fund is transferred to the health insurance fund for health coverage of the retired/pensioners, disabled and eligible unemployed persons. for pension beneficiaries, the contribution rate (14.694%) is applied to the net pension reimbursement, while for the unemployed and for the recipients of social assistance, the contribution rate of 8.6% is applied to 65% of the average net salary in the country to the insured from „social categories” in case they are not employed. these funds are transferred to the health insurance fund by the pension and disability fund, the employment fund, and by the ministry of labor and social policy. about 22% 348 health systems and their evidence based development of domestic health revenues in 2002 were transferred from the pension and disability fund, and about 12.6% from the employment fund. farmers have to contribute 9.2% of the cadastre income. for the citizens with a private enterprise and their employees, the rate is 9.2% of the gross earned wages and reimbursements. additional contributions for health insurance in case of injury at work and professional disease, for the employees in public and private sector who are exposed to an increased risk for injury at work and professional disease, are determined by rate of 0.5% of the gross earned wages and reimbursements (6,10). the general budget was also a negligible source of revenue for the health sector until 1992, when financing of the most prevention programs was shifted from health insurance fund to the budgetary financing. the general budget in 2002 accounted 5.9% of domestic health revenues, which is remarkable increase comparing with 1996 when accounted about 3.5% (5,13). revenues generated through user fees for health services and applied devices in the public health system amounted 1-2% of domestic health revenues. user participation in health care expenses (co-payment) the insured and their family members for the health care have to pay from their personal funds a certain percentage of the health services price, but not more than 20% of the total cost of the health service or drug. in 2001 hif came to a decision about the level of user’s participation in the health care expenses, as follows: (a) 10-20% of the price of health services and of medicines at the phc level; (b) 10-20% of the price of health services for treatment of oral and dental diseases (except prosthetic devices); (c) 10-20% of the costs of services in the specialist-consultative care and hospital treatment, including all costs for services and medicines; (d) 20% of the total expenses for approved treatment abroad; (e) 20-50% of the price of hearing and visual (eye’s) facilities; (f) 20% of the costs of dental prosthetic devices; and (g) 20-50% of the price of some other prosthetic devices in accordance with the general act issued by the hif and approved by the minister of health (6,11,14,15). introducing co-payments for health care services and drugs was one of the most controversial questions in macedonia after gaining the independence in 1991. an attempt of the ministry of health, through health protection law in the 1991, to introduce co-payments on all goods and services covered by the health insurance, was struck down by the constitutional court as infringing on the fundamental rights to health care. in order to erase financial constraints in 349 case study: the current health insurance system in the republic of macedonia the health sector, ministry of health once again, by the 1993 amendment, proposed co-payments on all insured goods and services (20% for outpatient care, drugs, hearing aids and dental devices; 10% for hospital care; 50% for prosthetic and orthopedic devices). the amendment was adopted. 2000 health insurance law continued this practice for co-payments by introducing a general principle of adversity of the level of user’s charge and the price of a service or drug. it means that the co-payment rate / percentage is higher for the lower price services, but not more than 20% of the service / drug price, and the opposite, lower co-payment rate for the higher price services / drugs (1,5,6,11). there is no co-payment for health care in the following cases: (a) follow-up of the health status of the insured by the physician of choice, and for emergency medical services on call; (b) users who receive permanent social assistance, persons placed in the institution for social protection or in other family, except for medicines prescribed at the phc level and for the treatment abroad; (c) psychiatric patients placed in psychiatric hospitals and persons with mental retardation without parent’s care; (d) insured who, during the calendar year, have paid user charges for specialist-consultative and hospital treatment (except for medicines prescribed at the phc level and for treatment abroad) in cumulative amount over 70% of the average income per month in the country in the previous year. certain age categories of citizens might be excluded of copayment when they reach reduced level/limit of user charges paid during the year; (e) additional exemptions, in accordance with some special health care programs with social dimensions and related to the entire population, adopted and financed by the government of the republic of macedonia each year, are determined for users of health services in relation to the treatment of certain debilitating, costly, and often life-threatening diseases (rheumatic fever, progressive nervous and muscle diseases, cerebral paralysis, multiple sclerosis, cystic fibrosis, epilepsy, penfigus, lupus erithematodes, infectious diseases list of about 20 diseases, drug-addiction and alcoholism, up to 30 days, chronic dialysis, conditions after transplantation of the organs, malignant diseases, hemophilia and diabetes, hormones for growing-up the children and compulsory immunization); (f) prosthetic, orthopedic and other devices for children up to the age of 18; (g) women in relation to pregnancy and delivery; (h) infants, up to one year of age; (i) blood donors who voluntary have donated blood more than 10 times; and persons exempted by some special regulations (war disabled persons or family of soldiers who were killed in action), (6,11). 350 health systems and their evidence based development payment to the health care providers according to the law on health insurance, health care organizations and the hif are obliged to plan the necessary funds for providing health care services and realization of the rights to health care to the insured coming from the obligatory health insurance. each year hif prepare a plan and program for health services to be financed from the obligatory health insurance, as well as determine criteria, by the general act approved by the minister of health, for contracting with health care organizations and for the ways of payment to the providers of health care services (6,16). according to the law in health insurance, there are three basic methods of payment to the providers for health services: (a) number of insured persons registered for health care on the list of the physician (doctor of choice) at the phc level (capitation); (b) determined price for each unit of health service or intervention (fee-for-service); and (c) programs for certain kinds of health services. in addition to that, hif determine some other criteria for coverage emergency medical services for entire population, home visits by nurse (patronage) to pregnant women and babies regardless to the status of insurance, providing continuous health care during the day and night (24 hours) and during the holidays and weekend days, etc. the law doesn’t make any difference between public and private health care providers, in relation to the possibilities for contracting with the hif, in order to provide equal financial conditions and incentives for efficient performance in delivering health care, for both types of providers (6,17). revenues and expenditures of the health insurance fund in the year 2002 the revenues of the hif are used to fund the programs for which the hif is responsible and to finance the government’s share of the health insurance costs for those enrolled in the program. direct contributions by employers and workers for health insurance were 57.4% of the total hif revenues in 2002 (table 1). in addition, their contributions to pension and unemployment benefits include components that are used for health insurance premiums for persons who are retired, unemployed, disabled veterans, or recipients of social (welfare) benefits. these amounts, which were about 35.1% of the hif revenues, are paid by the state funds for pension, unemployment, and other social programs. hif revenue from the general budget in 2002 accounted 5.9%. 351 case study: the current health insurance system in the republic of macedonia table 1. revenues of the health insurance fund of the r. macedonia 2002 (in 1000 denars) (18,19). health care expenditures of the hif in 2002 are about 83.2% of total expenditures. salary reimbursements accounted another 6.5%, and the capital investments 6.3% of the total hif expenditures (table 2). the structure of the health care services expenditures of the hif in 2002 is presented on the table 3. outpatient services at the phc level accounted for about 18.2% in comparison with higher outpatient specialist-consultative health care services 23.6% and hospital care / services with 42.6%. prescription drugs were 9.9% and dental care expenditures 4.3%. 352 health systems and their evidence based development sources of revenue budget plan actual percent variance structure (%) 1. employee's gross salaries 2. self employed 3. farmers 4. additional contributions (workers at risk) 5. other insured 6. contributions from previous years 6,498,120 268,856 60,258 372,228 101,112 450,275 6,755,479 225,640 60,369 432,890 101,335 435,957 104.0% 83.9% 100.2% 116.3% 100.2% 96.8% 48.4% 1.6% 0.4% 3.1% 0.7% 3.1% total employment revenue 7,750,849 8,011,670 103.4% 57.4% 7. pension fund 8. unemployment fund 9. social, veterans, disabled funds 10. budget 2,945,560 1,759,523 52,000 489,769 3,074,632 1,763,354 53,582 821,259 104.4% 100.2% 103.0% 167.7% 22.0% 12.6% 0.4% 5.9% total transfers 5,246,852 5,712,827 108.9% 41.0% 11. other revenue 232,776 241,496 103.7% 1.7% 12. transfer from previous year 95,886 95,886 100% — total revenue 13,326,363 14,061,878 105.5% 100% table 2. expenditures of the health insurance fund of the r macedonia, 2002 (1000 denars), (18,19) table 3. structure of the health care services expenditures of the health insurance fund of the republic of macedonia, 2002 (1000 denars), (18,19) 353 case study: the current health insurance system in the republic of macedonia expenditures budget plan actual percent variance structure (%) health care expenditures 11,353,834 11,629,454 102.4% 83.2% salary reimbursements 876,661 908,648 103.6% 6.5% orthopedic devices 135,000 112,813 83.6% 0.8% hif operating expenses 426,189 331,648 77.8% 2.4% capital investments 441,679 875,070 198.1% 6.3% capital transfers 33,000 25,482 77.2% 0.2% past-year obligations 60,000 88,004 146.7% 0.6% total expenditures 13,326,363 13,971,119 105.0% 100% expenditures budget plan actual percent variance structure (%) outpatient services (phc) 2,487,332 2,113,607 85.0% 18.2% specialist-consultative health care services 2,310,770 2,750,143 119.0% 23.6% dental care 530,730 499,856 94.2% 4.3% hospital care/ services 4,449,330 4,953,327 111.0% 42.6% other health care services 21,000 19,597 93.3% 0.2% prescription drugs 1,250,437 1,149,804 92.0% 9.9% treatment abroad 130,000 143,120 110.1% 1.2% program related expenditures 174,235 – – – total 11,353,834 11,629,454 102.4% 100% health insurance system in the health care reform in macedonia after its newly gained independence in 1991, the republic of macedonia inheritance from the social system of the former yugoslavia was a social model of obligatory health insurance and highly decentralized and locally funded public health care system. the main weak points of the system were tendency toward further fragmentation and duplication of unsustainable services, excessive staffing that exacerbated the duplication of care, interregional differences and inequities in the amount and quality of care. that system became unsustainable, particularly in actual economic circumstances and economic transition. up to 1991, there were 35 independent self-management communities of interest for health care on the municipal level and one on national level. all of them were replaced by a single centralized health insurance fund within the newly created ministry of health, with branchoffices of the health insurance fund on the local level. centralization was an attempt aimed, first of all, for stronger control of resource utilization and more equitable distribution during the transition period and economic crisis. in the period after 1991, both the health insurance system and health care system, were faced with numerous problems, as a result of: (a) the war conditions in former yugoslavia, (b) the economic and transportation blockades; (c) drained inflow of funds from health services given to patients coming from other places out of macedonia; (d) the decreased funds from the insurance for more than 40% in real terms, due to the great number of unemployed persons, breakdown of socially-owned enterprises, and reduction of employee income; and (e) different types of tax evasions and other manipulations with obligatory health care payments (5). total national health expenditure, expressed as a percentage of gdp, decreased from 6.2 in 1990 to 4.8 in 1992, compared with 7.6% of gdp in 1998 and 4.7% in 2002. per capita health spending decreased from us $66.8 in 1990 to 39.2 in 1992, compared with us $97 in 1998 and us $93,3 in 2002 (5,13). salaries were a fixed expense and this caused a serious shortage of supplies and equipment for primary health care. thus, at the very beginning of the independence, there emerged an inevitable necessity to undertake urgent measures to prevent further erosion of the health system, provide sustainable volume and quality of the health services, and introduce urgent long-term reforms of the health care system and health insurance system. the health protection law, adopted in 1991, also authorized private health services and pharmacies but did little to streamline the public health system, create incentives for increasing efficiency, or define 354 health systems and their evidence based development legal and regulatory environment for the private providers. shortages of medications were mitigated only modestly by humanitarian assistance, which covered the essential needs for medicines and medical materials. negotiations with the world health organization and the world bank were also initiated to acquire loans and technical support for the implementation of the health sector reforms. in 1993, ministry of health undertook activities for a reform process aimed mainly at: (a) allocating the resources on areas with an immediate impact on the health status of the population and maintaining the basic health services operational through provision of adequate drugs and other consumables; (b) undertaking structural reform and reorganizing of the health care system; and (c) facilitating privatization and development of private health services in order to stimulate competition and improve quality of care and health services (4,5). ministry of health asked the world bank for assistance for further implementation of the reform, and macedonia became a member of the world bank in december 1993. the health sector transition project was the first funded project of the international development association of the world bank in the social sector in the republic of macedonia, and the first donor intervention for reform and restructuring of the health sector. one of the components of the health care reform strategy was financing. it included defining the reforms in pricing policy, benefit packages, and reimbursement mechanisms for ambulatory and hospital services. the objective was to develop new policies and mechanisms which would: (a) maintain broad access to care; (b) create financial incentives for efficiency and cost containment; and (c) remunerate public and private providers equally on the basis of the performed services. co-payments for health care services were introduced in 1993 as an alternative option for supplementary funds, as well as to prevent excess utilization of services, but because of the wide range of exemptions (determined by age, sex and disease) the financial effects were very poor (only about 4 -5% of the revenues of the health institutions). the long list of exemptions proved that users fees were not only unlikely to be an affective policy mechanism to collect revenues but, more importantly, they encouraged greater use of health care services for exempted groups, with associated higher costs for the health insurance fund, especially in cases certain health conditions involving extensive and costly care. those provisions had substantially weakened the initiated impact of the participation policy (5). during 1991-1995, the revenues collected from contributions decreased by approximately 40% in real terms as a result of lower salaries, 355 case study: the current health insurance system in the republic of macedonia bankruptcy of socially-owned enterprises, and evasion of payments by many enterprises, and, of course, increased unemployment. consequently, the revenues of the health insurance fund significantly decreased, resulting in decreased funding of the health care institutions. regardless of all the efforts, the expected results did not come and, in the end of 1994 and the beginning of 1995, health insurance fund entered a very difficult phase, with obvious symptoms of breaking down the health system, which was built over for a very long period of time. in early 1995, with the assistance of local and foreign experts and in cooperation with the world bank, an urgent analysis of the conditions in the health system was made, and a strategy for undertaking sanitation measures was established, simultaneously determining the short-term measures and activities for long-term reform of the health sector. the health care system was analyzed in three segments: (a) financing and management; (b) primary health care and health promotion; and (c) supply of drugs and medical materials. the primary objective was to find the most appropriate solutions for redesigning the health care network and functions of the system in order to meet the demands of the citizens for high quality health services (5,20). an extreme rationing of medication and medical necessities and other material expenses of all health organizations was undertaken by organizing tenders and bidding for central purchase of drugs, sanitary materials and equipment, which resulted in price reduction. in order to achieve equal distribution a central pharmacy store was formed, which, according to the health insurance financial reports for 1995 and 1996, saved millions of dollars, or about 20% of the funds spent on the same materials during the period up to 1994. the competition principle and competitive conveniences for more efficient and rational provision of health services were introduced. this was made possible by the newly imposed legal opportunity to sign an agreement with private organizations and with health professionals for providing health services by personal labor at the account of health insurance fund and in accordance with the norms and standards. this created possibilities for more economic performance of health services. many other organizational measures were also undertaken, which started to improve the global financial situation of health insurance fund (21,22). the main principle of the reallocation mechanism of the funds from health insurance fund to health institutions was financing on a contractual basis and invoicing of services according to the official price list. this principle was implemented only for financing the private health sector. the public health institutions expenditures were covered by the health insurance fund in 356 health systems and their evidence based development order to cover the wage costs, material costs and maintenance, even without signing any contract for the scope and quality of the services. because of this, measures to restructure organization and management in the public health sector were delayed, and the quality of health services and motivation of the health workers decreased, resulting in an inefficient use of the resources. the previous system of referral practice, i.e. in a necessity of a written referral to the specialist from primary health care physician, was abandoned soon after macedonia gained independence, as part of the changes in the socio-economic and political context and general movement to increase personal freedom and freedom of choice. this aggravates the budget problems to the health insurance fund because of the increase in specialist costs and hospitalizations. by 1995, amendments to the health protection law reestablished the referral practice by providing direct specialist-consultative and hospital health care only in emergency cases. the same revision of the law requires that each insured person selects a primary physician from the same municipal area, who will be responsible for the follow-up of the health status of the insured, provision of medical assistance, prescription of medicines, issuing the certificate for sick leave and referral to higher level services. the physician has been chosen from one of the following fields/ disciplines: general medicine, occupational medicine, pediatrics, school-age children medicine or gynecology. however, a widespread opinion is that many primary physicians are still more „traffic policemen”, directing patients toward specialists, than „gate keepers”, motivated and empowered to treat and cure broader scope of illnesses and conditions. according to the results of a survey done by the doctors’ chamber of macedonia in 1998, low payments and bad working conditions caused frustration and low self-esteem of the physicians, as well as low motivation and satisfaction with their work (the average salary of the general practitioners in 1998 was about us $200) (5). in 1996, comprehensive health care reform was undertaken when the world bank awarded the ministry of health of the republic of macedonia a loan of us $19,4 million. the basic goals of the reform were to achieve universal access to high quality primary health care and establish cost effective finance and delivery systems. the initial reform efforts were supported by a grant from the world bank. technical assistance was provided by the rand corporation from the usa. they joined a team with policy-makers of the ministry of health, health insurance fund and other health professionals in the republic of macedonia in order to initiate reform analysis and create new strategies. the proposed new health care policies were directed to 357 case study: the current health insurance system in the republic of macedonia the following specific objectives: (a) identification of the health care priorities in the republic of macedonia through assessing the burden of diseases and effectiveness of available treatment; (b) reduction of the overall health expenditures and put them in balance with revenues; (c) shifting health care utilization patterns away from expensive forms of care; (d) producing a benefit package that is more cost-effective and co-payment structure that improves sectoral efficiency in order to reduce the existing gap between financial resources and given health benefits to the citizens; (e) developing a capitation plan for primary health care providers and concept of family medicine in primary health care, or reorganize the concept of general practitioner’s; (f) establishing an integrated and automated health information system as a support for better management in health care system; and (g) proposing an advocacy information strategies that facilitates the reform process. in the last five years, activities have been taken for implementation of the principle of capitation within the primary health care level, for strengthening the citizen’s right for choosing the doctor and creating a basic package of health care services, as well as fee for service payment on the secondary and tertiary level according to the official price list. to support these activities, adjustment of the health information system and management of the health institutions through training of the managers and other employees was introduced. however, the activities for acquiring humanitarian aid and other kinds of support did not stop. macedonia also entered several programs of the european union (phare) for solving few substantial problems through nonrefundable financing. it must be emphasized that all undertaken measures and activities resulted in partial and temporary alleviation of the problems during the painful transition period in the republic of macedonia. the most recent activities within the reform of the health insurance system were directed to the preparing of a new law on health insurance, which has been adopted by the parliament of the republic of macedonia on march 30 and enforced on april 7, 2000. the health insurance fund was established as an independent institution outside of the ministry of health. the executive board of the health insurance fund already adopted many general acts, approved also by the minister of health, which approach in more details the most important issues for efficient implementation of the law in practice, i.e. strengthening the mechanisms for collecting of regular revenue for the health insurance fund, introducing methodology for calculating the new methods of user participation in health care expenses (co-payments), as well as 358 health systems and their evidence based development more precise regulation of the relationships within the health insurance related to the obligatory and voluntary insurance, the categories of the insured persons and their rights and obligations, and the scope of activities and responsibilities of the health insurance fund. 359 case study: the current health insurance system in the republic of macedonia exercise: specificities of the current health insurance system in the republic of macedonia task 1: comparing health expenditures between countries students should collect data about health care expenditures from their respective countries. in addition to that, they have to be compared with macedonian expenditures. an analytical approach about the percentages of the funds spent on primary health care, hospital care, medicines, treatment abroad etc. will be considered through group discussion. time proposed is 60 minutes. task 2: health insurance system students are asked to collect some specific indicators (hfa database and other sources) and readings about health insurance system in their respective countries in order to prepare a seminar paper as practical work. this task will be done individually, as homework. 360 health systems and their evidence based development references 1. zakon za zdravstvenoto osiguruvanje. skopje: slu`ben vesnik na republika makedonija 2000; 25: 1455-65. 2. zakon za izmeni na zakon za zdravstvenoto osiguruvanje. skopje: slu`ben vesnik na republika makedonija 2000; 96: 5287. 3. zakon za izmeni na zakon za zdravstvenoto osiguruvanje. skopje: slu`ben vesnik na republika makedonija 2001; 50: 3510. 4. zakon za zdravstvenata za{tita. skopje: slu`ben vesnik na republika makedonija 1991; 38: 613-31. 5. donev d. health insurance system in the republic of macedonia. croatian medical journal, june 1999, vol. 40(2): 175-80. 6. mi{ovski j. zdravstveno osiguruvanje. komentar na zakonot za zdravstvenoto osiguruvanje so podzakonski akti. skopje: ami grafika doeel, 2001. 7. fond za zdravstveno osiguruvanje na republika makedonija. pravilnik za sodr`inata i na~inot na ostvaruvanjeto na pravata i obvrskite od zadol`itelnoto zdravstveno osiguruvanje. skopje: slu`ben vesnik na republika makedonija 2000; 111: 5733-53. 8. fond za zdravstveno osiguruvanje na republika makedonija. pravilnik za formata i sodr`inata na zdravstvenata legitimacija i za na~inot na nejzinoto izdavanje, vodenje i koristenje. skopje: slu`ben vesnik na republika makedonija 2000; 111: 5706-8. 9. fond za zdravstveno osiguruvanje na republika makedonija. pravilnik za na~inot na koristenje na zdravstvenite uslugi na osigurenite lica vo stranstvo. skopje: slu`ben vesnik na republika makedonija 2000; 111: 5708-10. 10. fond za zdravstveno osiguruvanje na republika makedonija. odluka za stapkite, osnovicite i visinata na pridonesite za zadol`itelno zdravstveno osiguruvanje. skopje: slu`ben vesnik na republika makedonija 2001; 4: 65-6; 2001; 50: 3510. 11. fond za zdravstveno osiguruvanje na republika makedonija. odluka za utvrduvanje na visinata na u~estvoto na osigurenite lica vo vkupnite tro{oci na zdravstvenite uslugi i lekovite. skopje: slu`ben vesnik na republika makedonija 2001; 48: 3382-4. 12. ministerstvo za finansii na republika makedonija. zakon za izmenuvanje i dopolnuvanje na zakonot za personalniot danok na dohod. skopje: slu`ben vesnik na republika makedonija 2001; 50: 3504-5. 13. fond za zdravstveno osiguruvanje na republika makedonija. budzet na fondot za zdravstveno osiguruvanje na makedonija za 2002 godina. skopje: slu`ben vesnik na republika makedonija 2002; 46: 237-40; 93/02: 229-32. 14. fond za zdravstveno osiguruvanje na republika makedonija. lista na lekovi koi pagjaat na tovar na fond za zdravstveno osiguruvanje na makedonija. skopje: slu`ben vesnik na republika makedonija 2001; 4: 87-96. 15. fond za zdravstveno osiguruvanje na republika makedonija. pravilnik za indikaciite za ostvaruvanje na pravoto na ortopedski i drugi pomagala. skopje: slu`ben vesnik na republika makedonija 2000; 111: 5711-32. 16. fond za zdravstveno osiguruvanje na republika makedonija. pravilnik za izgotvuvanje i utvrduvanje na budzetot na fondot za zdravstveno osiguruvanje na makedonija. skopje: sluzben vesnik na republika makedonija 2001; 55: 3713-16. 17. pravilnik za na~inot na pla}anjeto na zdravstvenite uslugi vo primarnata zdravstvena zastita. skopje: slu`ben vesnik na republika makedonija 2001; 48: 3384-6. 18. health insurance fund of macedonia. budget of the health insurance fund of macedonia for the year 2002. official gazette of the republic of macedonia [in macedonian]. skopje: the state; no. 93: 228-32. 361 case study: the current health insurance system in the republic of macedonia 19. state statistical office of the republic of macedonia. utilization of benefits and health care expenditures in 2002. in: statistical yearbook of the republic of macedonia. skopje; 2003: 110-1. 20. ivanovska l. health status of the population and health care system in r. macedonia. undp human development report ‘98 of r. macedonia. ministry of development of r. macedonia, skopje; 1998: 61-70. 21. ministerstvo za zdravstvo na r. makedonija. informacija za materijalno-finansiskoto rabotenje na fondot za zdravstveno osiguruvanje i zdravstvenite organizacii vo republika makedonija vo 1996 godina. skopje, 1997. 22. ministry of health of r. macedonia. bulletin of the health insurance fund. skopje, ministry of health of r. macedonia, 1998. 362 health systems and their evidence based development 363 case study: swot analysis of the serbian health insurance system health systems and their evidence based development a handbook for teachers, researchers and health professionals title case study: swot analysis of the serbian health insurance system module: 2.7 ects (suggested): 0.25 author(s), degrees, institution(s) vesna bjegovic, md, phd adriana galan, it specialist the first author is professor at the school of medicine, university of belgrade the second author is lecturer at the university of medicine and pharmacy bucharest, department of public health and management, at the master course in management of public health and health services address for correspondence institute of social medicine, school of medicine, belgrade university dr suboti}a 1511000 belgrade serbia and montenegro tel: +381 11 643 830; fax: + 381 11 659 533 e-mail: bjegov@eunet.yu keywords health insurance, management, swot analysis, change learning objectives at the end of this module, students should be able to analyze present status of health insurance management by using swot analysis and to propose possible changes and improvements. abstract the reform of health system must inevitably reconsider the management of all institutions, such as health insurance institutions. the first step in this process is to analyze the present status. one of the tools used for this assessment is swot analysis. teaching methods after reading the case study, students will work in small groups and produce written recommendations. specific recommendations for teachers it is recommended that this module is organized within 0.25 ects credit. the work under supervision is consisting from case study, small group discussions, while individual work is related to review electronic and printed literature in the field. assessment of students written report produced by each group. case study: swot analysis of the serbian health insurance system „when a manager leads from one crisis to another, it is time for the next manager”* vesna bjegović, adriana galan current trends in health care system reforms at present, almost all the countries, including the developed ones, are facing the problem of health care system reforming. the reform of health sector is a multidimensional process. as noticed in the reform strategies in other countries, „one part of the scale involves administrative and managerial pressure for cost-containment, and the individual citizen wanting the best possible care at the moment of utilization. at first sight, there seems to be an insoluble dilemma between the two respective opposites” (1). however, one of the who experts for health system reforms vividly observed, „since citizens are the final payers of any health care service public or private it is in their interest to spend a dollar, mark or ruble for health in the most efficient and effective manner, and for real priorities” (1). this is actually one of the basic management principles, which has been neglected in health care for a long time. consequently, the reform of health system must inevitably reconsider the financial component, regardless of the model applied, in order to ensure maximal benefits with minimal investments (2,3). a theoretical approach for the management of health insurance is neither unique for all countries, nor is in place an optimal management structure that is reproducible, since it is dependent on a number of factors like (4): • the level of political independence of health insurance funds, • possibility of choice for potential insured persons, between one or several health insurance funds, • organization of health care services (whether health care providers are employed by health insurance companies or are under contracts for providing health services with insurance), 364 health systems and their evidence based development * wahba aw. „appropriate technology”. the road to happiness.2nd edition. copenhagen 1985: p. 43-9. • historical factors (existing administrative structure of the ministry of health) and country's political system (federal state, centralized state, level of political responsibility etc.), • economic and social situation of the country, • health policy objectives that need to be achieved by health insurance. the basic trends in the reforms of health care financing in the european community countries, both developed and developing, have been determined by factors related to a decreasing role of the state and introduction of a controlled market, reorganization of the whole health care system in terms of decentralization, re-centralization and privatization, civil rights, individual's choice and participation, as well as enhancing the role of public health (5). historical background of the health insurance system development in the republic of serbia the health insurance law in serbia passed the parliament in 1992. according to this law, the health insurance system was established, with mandatory health insurance for the whole serbian population. the republic health insurance fund was then created, having a „declarative” independent statute. this national company has 30 subordinated branch offices located in each district of serbia. according to the above-mentioned law, the managerial board of the republic health insurance fund consists of the following structures: the insured representatives body, the managerial board, the director and the supervising board (6). the insured representatives body consisted mainly of insured persons' representatives. in 1998 the law from 1992 was modified and amended. this amended law dissolved the insured representatives body, and a formally representative body of the insured population replaced it. by these amendments, the shift towards a complete centralization of the health insurance management, only perceptible in the health insurance law from 1992 or various governmental acts has gained finally a complete legal support. the present managerial structure of the health insurance institution in serbia, being completely dependent of the government of the republic of serbia, consists of: the managerial board, the supervising board and the director. this structure is presented in figure 1. the director and vice-director are directly appointed or set free by the serbian government, while the managerial board and the supervising 365 case study: swot analysis of the serbian health insurance system board are elected on the basis of proposals made by the insured' representatives: the serbian trade unions, the association of pensioners, the cooperative association of serbia, the serbian chamber of commerce and the director of the republic health insurance fund. the managerial board consists of 21 members, out of whom 14 are the insured representatives (from the employees category), 2 insured pensioner representatives, 2 insured farmer representatives, 2 insured independent activity representatives and one company employee representative, respectively. this case study is based on swot analysis in order to depict the strengths, weaknesses, opportunities and threats in the serbian health insurance system management. figure 1. organizational structure of health insurance system in the republic of serbia strengths all former republics of yugoslavia were much earlier than other see countries experiencing some kind of health insurance system. serbia started to change the old type of insurance system „based on self-management community of interest” in 1989, and afterwards in 1992 when the health insurance law passed the parliament. it was a radical change in the financing of health care system. 366 health systems and their evidence based development the government of the republic of serbia the ministry of healththe cooperative association of serbia the association of pensioners the serbian trade unions the serbian chamber of commerce the director of the republic health insurance fund proposals the managerial board 21 members president vice-president the supervising board 7 members president the director of health insurance fund 30 local communities funds the existence of such kind of health care financing is one of the basic strengths because the physical infrastructure for the present 30 local branches was already in place. in this way, no additional funds were necessary to create this infrastructure. at least, at a declarative level, the insured persons are well represented in the managerial board of the republic health insurance fund according to the health insurance law from 1992. another positive aspect of the present managerial structure is that the administrative body is relatively small, since the total number of employees in the republic health insurance fund, including all branch offices, is 1921 (7). although the number of employees may appear to be high, it is in fact far smaller than in other systems having a longer tradition of health insurance, with less number of insured. for example, according to the data available from 1998, there were 2621 registered insured persons per an employee in the republic health insurance fund. this is low compared to germany for instance, where commonly the number of registered insured persons per an employee in health insurance ranges from 220 to 690 (4). although there were no studies to evidence the motivation of the employees, or the level of their skills for specific jobs, qualitative methods (e.g. financial policy analysis) have revealed that the number of employees is yet insufficient for achieving effective and good quality results. weaknesses since the beginning, the health insurance system in serbia was characterized by a marked centralization and a strong dependence in the process of decision-making on other governmental authorities (even outside of the health care system). such „quasi-autonomy” of the health insurance and its strong political dependence prevent any initiative or enterprising, and the management effectiveness has been additionally decreased by strict and often out of date legal regulations. from organizational point of view, it can be noticed that the branch offices of the republic health insurance fund have actually no responsibility of managerial decision-making. they don't have even a uniform organizational structure. the representative body of the insured within the health insurance fund board has an inadequate structure according to the existing consumer categories. it is unbalanced in terms of the number of the insured (one mana367 case study: swot analysis of the serbian health insurance system gerial body per around 7.5 million of potential consumers) and local consumer representatives (from 30 local communities) are not allowed to participate in the decision-making process for adequate allocation of the financial resources collected in their own territory. in this way, the stipulations of the supreme legislative act at the republic level the constitution of the republic of serbia from 1990 have not been achieved (articles 40 and 68) which guarantee the participation of each citizen in the decision-making process related to mandatory social insurance (8). the mechanisms of delegating the managerial and supervising board representatives are not democratic and furthermore, they are not based on the real structure and number of the insured paying the contribution for health insurance. for example, 14 insured representatives within the employee category are proposed by the serbian trade union. even if this is the biggest trade union, it is not the solely one representing the interests of all insured employees. a big number of employees belong to other unions like the trade branch unions „independence”, the association of independent and autonomous unions of serbia, the independent unions of serbia and many others. it can be also mentioned that, unlike other european countries (4), the managerial board in serbia do not comprise health worker representatives. management of the present health insurance has not been supported by an adequate information system, although several years ago the bull hn bg company designed a major project for its implementation. this was the proposal for the „national project and implementation project for management and decision-making support” within the development of information system of the republic health insurance fund in 1994, but never implemented in total as it has been planned. according to some estimation, to complete the performance control only in the area of contribution payment, with the existing personnel and without information system, there are needed 20 to 25 years (9). the lack of information system facilitates non-allocated use of the republic health insurance fund resources, ineffective use of the working hours, and so on. with such rationales, upon a minor revision of the major project, in 1997, there started its practical use introduction of the health insurance information system, which, unfortunately, failed and ended up with one of the major financial scandals. nevertheless, local brunch offices succeeded to develop some kind of information systems. the lack of an information system reduce also the effectiveness of other management functions in health insurance, such as planning, accounting, financial management, external and internal audit. thus a special problem, recently emphasized, was the lack of relevant, reliable and timely information 368 health systems and their evidence based development for effective management, and monitoring of health insurance functioning at the central level. such state of affairs enables numerous speculations and is conflicting to the good recommended practices, the health insurance management not being at all transparent for the general public. health insurance staff are very low motivated, neither for quality of work, not for career improvement because of low level of salaries and lack of other incentives. opportunities due to the scarcity of financial resources available for health care system, it would be necessary to put into practice marketing techniques for the extension of these resources, attracting other funds or obtaining donors aid. also, some management techniques in health insurance would be necessary for motivating health care providers to work in a more efficient manner and with acceptance of financial responsibility. opportunities exist because of positive changes in the postgraduate education for health professionals (continuing education in health management, initiatives to establish a school of public health). additionally, these techniques can also help in better control regular payments of established contributions of insured (particularly employers). another opportunity for improving the management of health insurance system can be the adoption of gtz (gesellschaft für technische zusammenarbeit) methodology, aiming to examine and promote access of all population groups (especially the vulnerable ones) to health insurance system. the german company gtz, together with the institute for tropical medicine in belgium, have developed infosure, a standardized evaluation methodology (health insurance evaluation methodology and information system). the evaluation is focusing on the following issues: the ways in which health insurance is organized in developing countries; practical experience with the set-up of insurance schemes; sustainability; administrative concepts; experience with certain target groups and special problems. infosure consists of a questionnaire and a corresponding software product. the questionnaire consists of three parts: a qualitative one, a multiple choice one and a statistical one for quantitative values. the outcome of the evaluation is a case study. further, the case studies are processed in an information system, which can be accessed, via the internet. this methodology permits a comprehensive analysis of a health insurance scheme in order to identify the factors contributing to the success or failure of an insurance scheme (10). 369 case study: swot analysis of the serbian health insurance system due to the fact that the political environment became more favorable, the existing law can be again amended in order to secure an adequate degree of autonomy to the health insurance fund. in this way, there will exist an open door for enterprising, initiative and putting into practice marketing mechanisms for effective achievement of the objectives of health insurance. on the other hand, law can also regulate decentralization process. this means delegating the management empowerment and responsibility to branch offices at lower organizational level, their legal status being thus regulated by law. consequently, transparency can be secured for the consumers, as well as more effective control of quality and costs of health care services provided. in addition, different international technical assistance (e.g. world bank, european agency for reconstruction, etc.) are in place, aiming to support further changes in improving the management of health insurance. threats serbia, like other surrounding countries, is marked by a deep economic crisis, inherited on one hand from the past communist regime and extended by the world economic crisis. the poor performance of economy has a deep negative impact on the social sectors, including health and education. unlike other countries, serbia has also to face the devastating consequences of the war during the 1990s, which have further deepened the scarcity of resources available for the social sector. it is not foreseen an immediate growth of economic level, therefore the health care system performance has little chances to improve in a short period of time. this is also true for the health insurance system. the real income of a large number of households has dramatically decreased, affecting directly the health insurance fund. political involvement at almost all administrative levels has also affected in a negative way the proper management of the health insurance system. also the political instability has often induced changes in human resources structure (especially top managers) affecting in this way the continuity of strategic thinking at republic health insurance fund level. potential consumers have still no alternatives to choose among insurance funds, since private insurance appear very slowly in serbia. there exists only one mandatory health insurance fund, those created in 1992. educational system is not yet prepared to properly train future managers of the health insurance system. the future managers working in health insurance system must achieve specific skills, like: knowledge of effective 370 health systems and their evidence based development collection of contributions, how to identify health care rights, how to ensure available services for all insured and how to monitor the quality of care (4). 371 case study: swot analysis of the serbian health insurance system exercise: how can the health insurance management be restructured? task 1: after reading this case study under the supervision of lecturer, students are asked to split and work in small groups (4-6 students) in order to discuss and decide possible recommendations they would make for the improvement of health insurance management in serbia (2 hours for reading the case study, 1,5 hour for group discussion and 1 hour to produce written recommendations to be presented to the whole group). task 2: in the case of a see workshop on „health care management and financing”, students are asked to split in country based groups and draft similar swot analysis for their own countries, further discuss the similarities and differences and finally make recommendations (3 hours). 372 health systems and their evidence based development references and recommended readings 1. vienonen m. health care reform (cited 1997, february 14). available from url: http://www.who.dk 2. wiewiora-pilecka d. why health reforms projects are poorly implemented (cited 1999, november 15). available from url: http://www.atm.pl/~danapil/reform1.html 3. cahi. state based guaranted access programs: the best health insurance safety nets. council for affordable health insurance 1999; 3(6): 1-5. 4. normand c, weber a. social health insurance. a guidebook for planning. geneva: who, ilo 1994. 5. who regional office for europe. reform strategies (cited 1997, december 2). available from url: http://www.who.dk/hcs/chap02.htm 6. law on health insurance. official newsletter of republic of serbia 18/1992. 7. republic health insurance fund. report on work and financial bussiness of republic health insurance fund for 1998. belgrade: republic health insurance fund 1999. 8. constitution of republic of serbia and constitution of republic of montenegro with constitutional laws for their implementation. second edition. belgrade: niu slu`beni list srj 1997. 9. ahcpr (the agency for health care policy and research). structuring health insurance markets: protecting consumers and promoting competition (cited 2003, july 24). available from url: http://www.ahcpr.gov/research/ulpmarkt.htm 10. hohmann j, weber a, herzog c, criel b. infosure. health insurance. evaluation methodology and information system. introduction, guideline and glossary. first edition. eschborn: gtz 2001. available at url: http://www.gtz.de 373 case study: swot analysis of the serbian health insurance system 374 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title economic appraisal as a basis for decision making in health systems module: 2.8 ects (suggested): 0.75 author(s), degrees, institution(s) helmut wenzel, m.a.s. bajram hysa the first author is health economist employed by roche diagnostics company, mannheim, germany the second author is associated professor at department of public health, faculty of medicine, tirana, albania address for correspondence ulrich laaser, section of international public health (s-iph), faculty of health sciences, university of bielefeld pob 10 01 31, d-33501 bielefeld, germany. tel/am/fax: +49 521 450116, e-mail: ulrich.laaser@uni-bielefeld.de keywords health economics, efficiency, economic appraisal, cost-benefit analysis, quality assurance learning objectives after completing this module, students and public health professionals should have an increased understanding of: • health economics as a scientific discipline and the relationship between evaluation and economic theory; • the options to manage scarcity in health care systems; • the key evaluation methods in health economics; • setting up an evaluation; and • how to judge the quality of published economic evaluations. abstract this module gives a short overview on the basics of health economics. economic appraisal is an instrument for health care decisionmaking, which is influenced by many characters. there are three types of costs: direct, indirect and intangible. costs and benefits can be calculated in a cost-benefit (cba), cost-effectiveness (cea), cost-utility analysis (cua) etc., depending on society, patient, payer or provider' point of view. when comparing two alternatives, it is important to understand the additional costs and effects. marginal analysis looks at the extra cost of extra effects in the same programme; incremental analysis looks at the differences between programmes. alternative projects costs and benefits may occur at different points in time. in order to compare them in a money term, discounting is needed. a discount rate is a number relating the value of one year to the value in the next or previous year. having unbiased economic evaluation is very important for quality of study. this led to the development of guidelines which regulated many things, but aside of that every reader or decision-maker can make his quality, checking drummond's „ten commandments” of good appraisal practice. teaching methods after introductory lecture, students will work in small groups, in order to discuss efficiency as a prerequisite for an appropriate health care system. basic skills like discounting and choosing a decision have to be trained. to do so, financial and mathematical exercises have to be solved (calculated). students will be learned how to judge the quality of health economics publications that are delivered by teachers. 375 economic appraisal as a basis for decision making in health systems specific recommendations for teacher this module to be organized within 0.75 ects credit, out of which one third will be under the teacher supervision. it is recommended that mathematical calculations are prepared. pocket calculators are obligatory. a selection of publications with different quality levels should be available to the students. assessment of students multiple choice questionnaire and written design proposal. economic appraisal as a basis for decision making in health systems helmut wenzel, bajram hysa the aim of the module is to give a short overview on the basics of health economics and to provide more in depth information on economic evaluation tools (economic appraisal). current problems of many health care systems as well as approaches to solve those problems are described. thereafter a short overview on the basics of health economics is given and in depth information on economic evaluation tools (economic appraisal) and their application is provided. it would be wrong to suggest that health economics is identical with economic evaluation tools like cost-benefit analysis. these techniques are undoubtedly the most relevant and mostly known tools from health economics. this obviously leads to the misunderstanding on the true nature of health economics, then. today, many health care professionals seem to be familiar with those tools. nevertheless, it still remains the case that the underlying economic principles and theories are unknown to many. therefore the paper puts some stress on the economic background of economic evaluation. health care and limited resources all over the world health policy is faced with an increasing demand and declining financing power at the same time. particularly decentralised health care systems are unable to describe the relationship between resources used and outcomes achieved, due to the fact that the amount of money spent is known but the „health production” processes is unknown. as a consequence the efficiency1 of the health care delivery process cannot be controlled or influenced. thus, this leads to rationing of services rather than to increasing productivity. as a first step politicians tend to cut down expenditures by different administrative means. this is followed by reducing the number of covered 376 health systems and their evidence based development 1 in economics, the term 'efficiency' is used when resources (e.g. medical services, drugs, and diagnostics) are used in such a way that nothing is wasted. this means that, in an efficient situation, without adding any more resources, further products can only be produced by sacrificing a quantity of another product. services (exclusion from reimbursement scheme etc.), and different approaches to lower prices of products. health authorities right now are targeting more and more the productivity and the quality of the process of care (or production of health) by promoting evidence based medicine and as an evaluation tool outcomes research. „evidence based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. the practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research” (1). outcomes research is defined as „assessment of the effect of a given product, procedure, or medical technology on health and/or cost outcomes” (2). disease management (dm) can be described best as „a comprehensive, integrated approach to care and reimbursement based on the natural course of a disease, with treatment designed to address an illness with maximum effectiveness and efficiency (2). if dm concepts are implemented in a proper way, one can assume a less costly but even more effective health care system. allocation of limited resources are there alternatives to efficient health care systems? if there are more needs and wants than resources available, alternatively two administrative measures could be applied: rationing and allocation of resources due to defined priorities. in modern democratic societies some questions arise, then: • who will have the right to define the criteria for rationing or for any priority setting? • what is the final ethical basis for those decision processes? • whose values are the final yardstick for setting up priorities? • isn’t it even unethical to make those kinds of decisions? first of all, it is unethical to spend money (resources) in such a way that we do not produce the best outcome in terms of care or finally health. overspending in one area (selected diseases, specific patient groups, provision of care like prevention vs. cure) very often goes along with under-spending in other areas. so, it is an ethical must to deal with that problem. 377 economic appraisal as a basis for decision making in health systems rationing is an ethical issue as well and ought to be based on the principal agreement of a population. in an implicit rationing procedure the decisions and the preferences are not revealed. from the viewpoint of modern societies this is not acceptable. explicit rationing is an outcome of political processes where the consent of society could be received by either lay participation in the decision processes or by the anticipation of the citizen needs by experts. in the late sixties this kind of integrating as many citizen and their needs in any planning process was called advocacy planning. the basic idea was that experts (and politicians) should be able to anticipate the problems of those people that have not the ability to take part in political processes in an adequate way. this approach was not very successful. for reaching the humanitarian goal of equity, and also more objective ways of comparing the alternative use of modest resources, technical solutions and evaluation tools are inevitable. this is how health economics is coming in. alternative ways of allocating limited resources are presented in figure 1. figure 1. alternative ways of allocating limited resources (3) source: coast j. et al., in: priority setting: the health care debate, wiley, 1996 main features of health economics economics is a discipline, a recognized body of thought and not just a set of tools. consequently, health economics is the discipline of economics applied to the topic of health care, and deals with the factors that determine the individual’s demand for health services. health economics research tries to answer the question what kind of goods and services have to be offered in a health care system, what quality and quantity would be appropriate, and to 378 health systems and their evidence based development allocation of limited resources implicit rationing explicit priority setting political processes technical methodologies lay participation medical paternalism (advocacy planning) equity efficiency what extent services and goods should be produced by public funds (see public goods, welfare theory). moreover, health economics deals with the different ways of financing the health care system, and the system’s interdependence with and interconnection to the other sectors of the national economy. research tools are coming from different disciplines like: epidemiology, statistics, medicine, economy (or, decision analysis, scenario techniques, game theory), and modelling. economic appraisal techniques (like cost-benefit analyses) are important instruments of this discipline. those evaluation techniques are going through considerable methodological development, since efficiency gaps in the production of health services still exist. know-how that comes from other scientific disciplines has been incorporated. looking at the very nature of health economics our starting point is simple scarcity of resources, and the issue of choice. taking a choice means that a decision has to be made not only about what to do, but also what to leave undone. the concept of cost in health economics is different to the concept of cost in accounting, which relates to cash outlays. therefore, when economists argue that attention should be paid to efficiency in health care, they are implying that health care programmes, treatments and procedures should be compared not only in terms of their relative benefits, but also in terms of their relative costs (i.e. benefits forgone). economic appraisal as an instrument for supporting decision making as mentioned above, the core of health economics is choice and decision making. to prepare decision making, information is needed on the desirability of the choice, and the possible outcome in the future. the desirability (or anticipated satisfaction) of a good is described by its value. these values have to be put into an evaluation framework that based on decision rules recommends what should be done in order to improve the situation in a rational way. before explaining the different methods of economic evaluation, a short brush-up is given to introduce the economic concept of value, the theoretical background of deriving and describing value, and the concept of efficiency. these are underlying principles. 379 economic appraisal as a basis for decision making in health systems the concept of value and efficiency the value of an object reflects its importance with respect to the potential to satisfy the individual needs. this potential is called benefit, or sometimes utility. economic theory believes in the rational nature of men (paradigm of homo economics). this further leads to the assumption that each individual wants to maximize its degree of satisfaction, which is measured in terms of benefits. in order to maximize the benefits the individual will make sure that the last unit of money spent will create the same amount of benefit. there are different ways to define and to measure those benefits. some of those methods are based on the principles of welfare-theory, some are based only on the assumption that men are deciding in a rational way. other methods incorporate the preferences of patients into the desirability of outcomes. generally, efficiency is measured by the relationship between the level of accomplishment of these goals (consequences) and the resources used or expenditures. there are two simplified viewpoints of efficiency: • cost-efficiency: product applications or intervention strategies which achieve a given health outcome at the lowest level of resource utilization are called efficient or economical. • output-efficiency: product applications or intervention strategies which generate the best possible outcome or goal achievement for a given resource input are called efficient or most productive. both perspectives of efficiency evaluation include an assessment of both resource input or costs and outcomes. claiming that a medical intervention or a diagnostic / therapeutic procedure is efficient does not necessarily mean that it will lead to cost reduction; cost reduction and efficiency generally represent two different perspectives. those diagnostic or therapeutic products which are more expensive than established alternatives but which exhibit higher predictive value, greater effectiveness, more safety, fewer sideeffects, etc. may be efficient. whereas private accounting is generally limited to factors measurable in monetary terms, classical economic analysis extends the examination to qualitative and intangible costs and consequences. it explicitly attempts to measure factors which are difficult to evaluate monetarily. 380 health systems and their evidence based development costs, costing problems and outcomes the measurement of all effects of an intervention strategy in terms of cost and outcome components (benefit, results, consequences) is based on the distinction between the input of resources used by the intervention on the one hand, and its positive and negative outcome effects on the other. generally, the three categories of direct, indirect and intangible costs and consequences are differentiated. direct costs: direct costs are defined as the utilization of resources in the form of goods and services. this includes primarily the use of health care resources as pharmaceuticals, medical-technical services, lab work, medical consultation, hospital stays, etc. the consumption of resources in the individual patient’s private sphere may also be included, such as transportation to and from health care institutions and special diet provisions. indirect costs: indirect costs are those associated with a loss production due to sick leave, disability or premature death. such losses can occur in the production process (persons gainfully employed) as well as in every day household tasks (uncompensated employment; e.g. housewives). intangible costs: intangible (direct or indirect) costs are those that are incurred by patients and their families as a result of illness or intervention but which are not measured in money terms. examples are pain or grief levels associated with disability, morbidity or death. a fundamental difficulty in the assessment of costs is the absence of (meaningful) market prices for many health care goods and services. generally, true market prices are available only for (some) direct cost and outcome components, due to third party payment. thus potential ‘cost saving’ or savings of health insurance expenditures with a new medical intervention may not be savings to the society. as an example, consider ‘average costing’ methods (total direct and overhead costs divided by number of patients). if a hospital bed is freed by a new effective treatment that allows early discharge of patients, the hospital overhead cost per patient is not saved but increased. if no one else fills the vacant hospital bed, accounting would eventually have to raise the overhead charge to the remaining patients. the results or consequences of a medical intervention can be called its medical and economic outcome. this includes changes in life expectancy and the state-of-health of a patient cohort or population. the evaluation is based on a comparison of alternative treatments, including non-treatment. the medical benefits are measured by different parameters, within life expectancy and quality of life are most important. other 381 economic appraisal as a basis for decision making in health systems medical outcome measures include progression of disease, patient compliance, frequency of complications and adverse events, etc. the methods of economic evaluation in order to ensure the rational use of national income and resources, three basic types of evaluation were developed: • cost-benefit analysis, • cost-effectiveness analysis, • cost-utility analysis. there are variations as well: cost-minimization analysis, cost-consequence analysis, and cost-of-illness analysis. but their potential to support decision making effectively is rather limited. quality-of-life studies are very important to describe the burden of illness or – in case of an intervention – the improvement of quality of life from the patient’s point of view (table 1). table 1. types of study and goals 382 health systems and their evidence based development type of study goal cost-minimization analysis determine the least expensive intervention strategy for accomplishing the same medical outcomes. cost-effectiveness analysis determine the more efficient intervention strategy for accomplishing the same type of medical results in terms of cost per medical outcome measures (cost per life years gained). cost-utility analysis determine the more efficient intervention strategy for accomplishing the same type of medical results in terms of cost per constructed summarizing unit of outcome (cost per quality-adjusted life years). cost-benefit analysis assessment in money terms of whether an intervention strategy is efficient, i.e. worth doing, and comparison with alternative intervention strategies to determine which is ‘most’ efficient. cost-consequence analysis determine a listing of the medical and economic consequences of alternative interventions used to indicate their consequences without summarizing. cost-of-illness determine of the cost of illness used to indicate the need for treatment or the potential economic benefits from improved intervention strategies. quality-of-life study relative assessment of intervention strategies regarding patient health outcome. the health outcome is measured by disease specific health status parameters or general quality of life instruments. cost-effectiveness analysis cost-effectiveness analysis (cea) is a practical way of assessing the usefulness of public projects. in usa, cea is required by law and regulation throughout the federal government to decide among certain alternative policies and projects. it has been recently required in federal regulations designed to protect human health, safety, or the environment. cost-effectiveness analysis is the process of using theory, data and models to examine both problem’s relevant objectives and alternative means of achieving them. it is used to compare the costs, benefits, and risks of alternative solutions to a problem and to assist decision-makers in choosing among them. ultimately, cea consists of methods for evaluating vectors of measures. cost-effectiveness analysis is not limited to only one specific outcome effect. an intervention-specific group of effects may be used, too. in general, the various medical outcome effects of a treatment cannot be summed up like cost figures. this aggregation necessitates complicated procedures and (potentially problematic) evaluations of the multiple outcome effects of interventions. cost-benefit analysis in a cost-benefit analysis (cba) all elements on the input side as well as on the output side have to be measured in terms of money and/or converted to money where costs are not directly observable (value of a life). the first cba in health care was possibly conducted by sir william petty in london in 1667. he tried to show the impact of fighting against plague. he found out that 1 £ invested gained 84 £. the value of a life was calculated on the basis of a slave price (4). at that time cbas were primarily conducted from a society‘s viewpoint. using this perspective we are interested to improve welfare of society. there have been a lot of discussions and theories how to define welfare and how to measure it. one important theory says that an alternative is better only when all the losers are compensated by the winners and there is still a net saving (potential pareto-optimum). we also have to keep in mind those beneficiaries and payers (investors) must not be the same. if we have a tax funded health care system (nhs) the societal viewpoint can be helpful. in the case of a contribution funded 383 economic appraisal as a basis for decision making in health systems health care system, it‘s only the payer’s perspective that really counts. the health insurance does not care for the pension funds problems. whether something is perceived as „useful”, depends on the objectives and guiding principles of that person / institution who makes the evaluation / judgment are different. e.g. in germany one day in the hospital costs between 17 dm (patient‘s view) and 600 dm (sickness fund’s view). therefore, there is not one single form of cba, it is rather a complex combination based on the perspective taken, and the cost elements included (figure 2). cost-benefit analysis is not limited to one type of outcome effect. the results of the evaluation may be presented as an excess of benefits over costs or as an incremental ratio of benefits to costs (see decision rules). in the first case the result should be a positive number, in the latter case, it should be a number greater than 1. otherwise costs would exceed benefits. with a costbenefit analysis absolute efficiency can be measured. figure 2. types of economic evaluation by type of analysis, viewpoint and effects included (5) source: bombardier c and eisenberg j (1984). in glick h, economic analysis of health care, 2.21.03, available from http://www.uphs.upenn.edu/dgimhsr/intec203.pdf the weak spot of cost-benefit analysis is found in its intention to express all the outcome effects of a medical intervention in monetary terms. this forces evaluation of medical and social aspects, human life, quality of life, etc. in monetary units. the sphere of reference is the entire economy. cost-benefit analysis requires the most comprehensive information and is therefore typically a very large-scale project. 384 health systems and their evidence based development multi-dimensional analyses and cost-consequence of interventions which cannot be evaluated monetarily classify the outcome effects into medical, social and economic dimensions and register them by description only. there is no attempt made to aggregate all of the dimensions into one unit. quality of life analysis generally speaking, quality of life is a measure of the degree of satisfaction with living conditions. here we refer to health-related quality of life (figure 3). quality of life is not an operational measure. it must be described in terms of relevant dimensions and measurement scales. the dimensions are defined according to the dimensions of health. the who in its 1948 definition describes health as the condition of ‘total physical, psychological and social well-being and not as the lack of illness and frailty’. the three dimensions physical activity, mental health and social interaction together form the nucleus of health related quality of life. the quality of life analysis covers those input and outcome elements of a medical intervention which are relevant for the patient’s ability to live a life unrestricted by health problems. ‘costs’ are considered as far as they are reflected in the patient’s quality of life (for example, an adverse effect on free-time activities, sexual life, ease of movement); ‘benefits’ are the advantages and improvements achieved within the same framework. direct and indirect money costs are ignored. consequently, such analyses are not economic evaluations in the sense of efficiency assessment. the effects of treatments on the quality of life cannot be measured directly. only partial dimensions and their respective indicators can be determined and measured directly. a generalized measure of quality of life which covers all health-related problems does not exist. which dimensions of quality of life are relevant for which indications, and which mixture of standardized or disease specific instruments are used for measurement, depends on the clinical picture, and on the pragmatic limitations of the outcome study. to select an appropriate measure of quality of life analysis the following choices might have to be made: 1st choice: standardized or non-standardised assessment: quality of measurement outcomes and ease of interpretation 2nd choice: comparison with outcomes of other diseases: global measure, or disease specific measure needed? age and/or sex specific? iq requirements to be taken into account? 3rd choice: acceptability: instrument has been used in previous evaluations; burden to the interviewee; burden to the interviewer 385 economic appraisal as a basis for decision making in health systems 4th choice: method of administration: direct observation needed/possible; face-to face interview; telephone interview; self-administered questionnaire 5th choice: length and cost of administration 6th choice: method of analysis and complexity of scoring 7th choice: presentation of data and usefulness to decision-makers: interpretation of data; degree of certainty figure 3. the principle of quality adjusted life years unfortunately, there is a trade-off between comparability across diseases and the ability to detect even minor changes in different diseases. depression might be very important in rheumatic arthritis and cancer but no that issue in the case of a broken leg and confinement to bed. here the impact of reduced mobility would be more important. standardized tools like sf 36 might not be first choice when we are aiming at detecting small changes. an essential aspect of quality of life analysis is the fact that the evaluation of medical outcome effects are generally not derived from accepted medical endpoints (e.g. blood pressure) but made by the patient him/herself by self-assessment a subjective view. these measurements are however supplemented in areas where the therapeutic progress is of a qualitative nature (i.e. suffering and/or pain relief, improvement in ease of movement, or subjective sense of well-being of the patient). the quality of life analysis identifies more efficient intervention strategies only if it measures the medical target and if costs are equal. 386 health systems and their evidence based development cost-utility analysis utilities are measured for various possible health states. this can be done by asking patients who are in that particular health state at the time of measurement or by describing health states to subjects who may or may not have had personal experience of the health state being measured. the health state utility is a cardinal number, usually between 0 and 1.0, associated with a particular health state. the conventional way of using these utilities is to convert them into quality-adjusted life-years (qalys). this is done by multiplying the utility value by the years spent in that health state. for example, 10 years in a health state with a utility value of 0.5 would result in 5 qalys (i.e. equivalent to 5 years of perfect health). balancing or weighting of target effects is needed; for example with respect to life expectancy and quality of life. there may be a trade-off, i.e. a higher life expectancy implies a lower quality of life. cost-utility analysis determines the effects of alternative therapies for each target parameter, and then rates them according to the degree of preference on a dimensionless scale, e.g. an ordinal scale from 0 to 1. the effects of each intervention strategy are classified according to their importance, and then they are attached to a onedimensional number standing for the level of utility. a special type of utility analysis is widely accepted, in which utility is measured by quality-adjusted life-years (qalys) gained. this outcome measure may be used in a multi-dimensional cost-effectiveness analysis, which looks into the changes in ‘life expectancy’ and ‘quality of life’ and costs involved. the final result of this analysis is a statement about the cost of gaining one additional quality-adjusted life-year through the use of a medical intervention. cost of illness study cost-of illness studies focus on the general costs of a disease to society. such studies are valuable to indicate the burden of illness by measuring the extent of resources lost due to illness. 387 economic appraisal as a basis for decision making in health systems decision rules: how to determine efficiency? the goal of any health economics evaluation is to determine efficiency. we can look at efficiency from different perspectives: • if it is impossible to make any person better off without making someone else worse off, an allocation of factors of production is pareto efficient. that is from more holistic viewpoint. • if the goods and services produced exactly what consumers want, an allocation of factors of production is allocatively efficient. • if the goods and services are produced for the lowest possible cost, an allocation of resources is productively efficient. this is also referred to as technical efficiency. • product applications or intervention strategies which achieve a given health outcome at the lowest level of resource utilization are called costefficient or economical. • product applications or intervention strategies which generate the best possible outcome or goal achievement for a given resource input are called efficient or most productive. that is output-efficiency. most evaluations in outcomes research are done from the view of productive efficiency. two fundamental options are available: ratios of costs and benefits, and differences, i.e. subtracting the cost from the benefits. by definition – because costs and benefits have to be both in monetary terms – the later can only be used in a cost-benefit analysis, only. for decision-making purposes data have to be summarized in an appropriate way. there are several indices available that will provide condensed information. the choice of an index has to be guided by two questions, then: • what question has to be answered? 1. would undertaking the project be better than doing nothing? 2. which of two mutually exclusive projects should be undertaken? • what are the strength and weaknesses associated with the different indices? ad 1. in the case of comparing a project to the option of „doing nothing”, cost-benefit analysis is the method of choice, displaying absolute efficiency. 388 health systems and their evidence based development ad 2. both cba, cea and cua are applicable. table 1. ratios of costs and benefits table 2. differences of costs and benefits how to make choices in a cba both a ratio and a net benefit can be calculated. in a cea or cua ratios are applicable, only. comparing two alternatives (a and b) the alternative with the biggest ratio (gross bcr) should be chosen (see figure 4). in this case a would be better because the tan(a) > tan(b). this might not be convincing in any case. sometimes we might expect a minimum effectiveness, 389 economic appraisal as a basis for decision making in health systems cost and benefits are discounted when appropriate. an alternative with a higher bcr is more favourable • gross_bcr > 1 the index is sensitive to enumeration of cost and benefits this ratio is applicable to a cea or a cua as well when benefits are measured in nonmonetary terms, i.e. saved years of life, qol an alternative with a higher gross bcr is more favourable an alternative with a higher bcr is more favourable • net_bcr > 0 gross_bcr benefits∑ costs∑ := net_bcr benefits costs−( )∑ costs∑ := index rules cost and benefits are discounted when appropriate. an alternative with a higher positive net benefit is more favourable • net_bcr > 0 an alternative with a higher net present value (npv) is more favourable • npv > 0 r = discount rate, n = number of years net_benefit benefits costs−( )∑:= net_present_value 0 n i benefits i costs i−( ) 1 r+( ) n∑ = := index rules which is marked by the horizontal line parallel to the cost axis, or a solution within a budget limit (blue line). when solutions are ruled out by setting a minimum threshold, this is called fixed effectiveness approach. whereas ruling out by a budget limit is called fixed cost approach. this makes the rules more flexible. nevertheless, economists prefer an even closer look. sometimes it is important to understand what are the additional cost and the additional effects when comparing two alternatives. this is called incremental analysis. figure 4. decision rules using cost-benefit, cost-effectiveness or cost-utility ratios there are two notions: incremental and marginal analysis. these are no synonyms. incremental analysis is the broader term and includes marginal analysis. marginal analysis looks at the extra cost of extra effects in the same programme; incremental analysis looks at the differences between programmes. decision based on average values (ratios) can be misleading. a famous example shows the importance of a marginal analysis. neuhauser and lewicki (6) undertook a cost-effectiveness analysis (model calculation) to determine whether performing all six screening tests was a reasonable strategy. in the mid-1970s, the american cancer society recommended that, when attempting to detect cancer of the colon, each stool sample should be tested six times. therefore, the first part of a sample would be tested. if the result were positive, the subject would go onto have further confirmatory tests and, if necessary, treatment. if the test were negative, the second part of the sample would be tested. if this tested positive, the subject would have further confirmatory testing and, if here, for ease of exposition): negative, the third part of their sample would be tested, and so on. a screened person would be confirmed as negative only after all six parts had tested so. neuhauser and 390 health systems and their evidence based development cost-effectiveness analysis decision rules: choose the alternative • with the highest ratio • with a requested minimum effectiveness (fixed effectiveness approach) • with a requested maximum cost (fixed cost approach) decision rules: choose the alternative • with the highest ratio • with a requested minimum effectiveness (fixed effectiveness approach) • with a requested maximum cost (fixed cost approach) cost e ff e ct iv e n e ss a b lewicki analyzed this policy based on the following (realistic) assumptions (simplified here, for ease of exposition): (1) a population of 10,000 amongst which it is known (from epidemiological studies) that there are 72 cases of cancer; (2) each test detects 91.67 percent of cases undetected by the previous test (the first test will, therefore, detect 91.67 percent of cases; the second test will detect 91.67 percent of the 8.33 percent of cases left undetected by the first test, and so on). the authors estimated the cost of guaiac cards to be $4 for the first test and $1 for each subsequent test. thus, as is shown in table 3, about 66 of the 72 cases are detected after the first round of testing, the cost of this being us$1175 per case detected. the second round of testing ensures that almost all cases are detected at an average cost of us$1,507 per case detected. six rounds of testing capture all cases at a cost of us$2,451 per case detected (table 3 and table 4). table 3. cases detected, cost and cost-effectiveness of guiac test (5) table 4. results from an incremental analysis of guiac test (5) source: bombardier c and eisenberg j (1984). in glick h, economic analysis of health care, 2.21.03, available from http://www.uphs.upenn.edu/dgimhsr/intec203.pdf a more revealing way to look at the data, however, is in terms of the extra costs incurred and the extra cases detected by each successive round of testing, as in table 2. thus, two rounds of testing lead to extra 5.5 cases detected 391 economic appraisal as a basis for decision making in health systems no. of tests total cases detected total costs (uss) average costs (us$) 1 65.0465 77,511 1175 2 71.4424 107,690 1507 3 71.9003 130,199 1811 4 71.9385 148,116 2059 5 71.9417 163,141 2268 6 71.9420 176,331 2451 no. of tests incremental cases detected incremental costs (us$) marginal costs (us$) 1 65.0465 77,511 1,175 2 5.4956 30,179 5,492 3 0.4580 22,509 49,150 4 0.0382 17,917 469,534 5 0.0032 15,024 4,724,695 6 0.0003 13,190 47,107,214 compared with one round of testing at an extra cost of us$30,179, or us$5492 per extra case detected. having six rounds of testing rather than five ads very little in terms of cases detected at an extra cost per extra case detected of over us$47million. discounting of cost and benefits alternative projects costs and benefits may occur at different points in time. differences in the timing of costs and benefits are most obvious in preventive measures. an investment made today will yield most of its effects in the future. to make money flow comparable, the money has to be adjusted at one point in time – this is called calculating its present value. the process of transferring the values of any effect in one year to the corresponding values in a different year is called discounting. there are two reasons why discounting is appropriate: 1. marginal rate of time preference. people and authorities prefer benefits sooner than later and the reverse for costs. the strength of the time preference can be indicated by the size of the discount rate. 2. opportunity cost of capital. to fund programmes, money has to be taken away from other uses (in case of a public programme, from the private sector). in the private sector the money could have been invested and produced benefits. the benefits lost are indicated by the size of the discount rate, then. the more productive the money would have been, the higher the rate (7). a discount rate is a number relating the value of one year to the value in the next or previous year. discount rates may often be thought of as interest rates. at a discount rate of 10% e 1 today is equivalent to e 1.1 next year or e 0.91 one year ago. the effect of discounting on the preferability of an alternative is very high (see figure 5). a comparison of two projects to fight malaria (8) showed that eradication seems to be less costly than controlling malaria. the ranking changes when the discount rate is higher than 12% (see figure 5). 392 health systems and their evidence based development figure 5. the effect of discount rate on the ranking of two projects (8) source: cohn e, assessing the costs and benefits of anti-malaria programs, public health 63:1086, december 1973 and amer. j. trop med hyg, 1972. the lower the discount rate, the better are projects with benefits that are far in the future. therefore the choice of the appropriate discount rate is an important issue and gives way to manipulation. to prevent manipulation by selecting a „useful” discount rate, governments of various countries have set discount rates for the evaluation of public investment projects. in the usa the rate for public investment projects is 10%, in the netherlands 5%. this is based on the long-term rate of interest for government bond issues. in the various international guidelines on the economic evaluation of health services, the interest rates for discounting are usually set from 3 to 6%. the only convincing way to control for manipulation is sensitivity analysis, where the effect of the discount rate on the outcomes and the ranking of alternatives are shown. how to perform an economic appraisal? as described above, health economics tries to answer the question by what criteria the worth of an object can be evaluated. how do we get the data needed for economic appraisal? economic evaluation has to satisfy the scientific principles of unbiased research (9). therefore all principles and methods of scientific research are applicable. there is no specific way of setting up scientific study designs except the consideration of economic principles and the393 economic appraisal as a basis for decision making in health systems ories. economic appraisal therefore benefits from developments in different research areas. in getting most useful data, techniques of experimental design are important. statistical methods are needed to estimate program effects from diverse available data. once these and other disciplines in evaluation have yielded best estimates of program effects, the stage is set for cost-benefit analysis. increasingly, program evaluators are not satisfied just to know that certain effects exist at specified levels of statistical significance. they also demand to know how various effects should be valued and how the different valued effects should be aggregated to facilitate program decisions. these decisions include: (1) comparing all the good effects of programs (benefits) with all their bad effects (costs and dis-benefits) to judge whether it is better to implement or not to implement a program; (2) determining which of alternative versions of programs are best; and (3) deciding what collection of programs or projects constitutes the best expenditure within a set, overall budget limit. these tasks are the main roles of cost-benefit analysis. techniques of operations research and systems analysis may be invoked to ensure that the cost-benefit analysis is covering the full range of relevant alternatives. organizational analysis and political science also play vital roles: (1) helping to guide the appropriate assignment and aggregation of values for the cost-benefit analysis; and (2) when the cost-benefit analysis is completed, applying it suitably within complex organizational and political structures” (10). stages in economic evaluation drummond (11) describes the process of planning an economic evaluation. he distinguishes three different areas that are connected by various interfaces. • area of technical appraisal this is the description in terms of medical/technical criteria how a technique or product performes. it is the basis of the economic appraisal. • area of economic evaluation this is the actual evaluation. it is divided into the following steps: 394 health systems and their evidence based development deciding upon the study question, statement of alternatives to be appraised, assessment of costs and benefits of the alternatives, adjustment for timing and uncertainty, decision rules. • area of decision-making this is the where decision criteria, alternatives to be appraised and timing issues are determined. those links are important. they make sure that the outcomes are relevant to the decision-maker. the research question the general objective of the evaluation study is expressed by the research question. a statement of the respective research question should be specified with respect to: • the types of medical interventions or intervention strategies compared; • the patient population considered; • the range of medical resource inputs, clinical outcomes and economic consequences analyzed. the study population the study population should be representative for the population to whom the medical intervention strategy is applied in clinical practice, i.e. the target population. depending on the intervention and its indication, this will be patients with a specific disease, stage or duration of disease or with a certain medical history, risk or symptom profile. often cohorts defined by age and sexes are analyzed. in complex studies the population will be defined by combinations of characteristics or strata. the effectiveness of an intervention strategy will often depend on how narrower the indication and the corresponding study population is defined. the study perspective in the field of health care there is a multitude of institutions and persons who are responsible for decisions concerning the availability and application of medical interventions. 395 economic appraisal as a basis for decision making in health systems the study perspective refers to the viewpoint from which the analysis is performed. typically, four major viewpoints can be taken: 1. society 2. third party payers (government, health insurance, and health maintenance organizations) 3. health provider (the hospital, physicians and other providers) 4. patients the perceptions of the study questions, the information needs and the evaluations differ according to each viewpoint. what is cost-effective for one target group (e.g. from a hospital point of view), may not be cost-effective for a third party payer. costs and consequences that are extremely relevant to one target group may be ignored by another group. for example the income of a health care provider is a cost to the health insurance, a benefit from one perspective is a cost from the other, and vice versa. the money costs of one day in hospital seen from the patient’s perspective is his co-payment, whereas a health insurance perceives it’s per day rate, and public hospital funding authorities see primarily their subsidies. the costs per hospital day to society may be more or less but will certainly be different. each of these points of view will be examined below: 1. the societal perspective: from this viewpoint an evaluation would examine all social, medical and economic effects of a new medical technology on all parts of society. this means a wide array of health outcomes and economic consequences incurred in hospital care, outpatient care, long-term care, home care, nursing homes etc. regardless of when they incur or who pays for them. moreover, a broad range of other ethical and social consequences might be examined. new medical intervention strategies should be introduced and reimbursed if they improve social welfare. not all new medical technologies warrant such a comprehensive assessment. extremely expensive technologies, whose costs may shift relatively large amounts of resources from one area of the health sector to another, may justify such comprehensive study. 2. the perspective of the third party payer: government agencies, public and private health insurance, and health maintenance organizations make decisions about the reimbursement or non-reimbursement of medical technologies. therefore these institutions are a prime target group of economic evaluation studies. in study practice many studies are performed from the more limited perspective of the third party payer. 396 health systems and their evidence based development often estimations of the annual budget impact are asked for. information on the financial impact receives high attention especially in hmo and other managed care environments. third party payers usually are not too much interested in indirect costs. 3. the perspective of the health care provider: the decision-makers on a micro level, such as physicians in outpatient care or hospital decision makers, often make their decisions under cost containment pressures and budget restrictions. their perspective and information need generally concentrate on the impact of new intervention strategies on their budgets, and not on costs to other providers or to the society. the consequences of intervention strategies in other areas of the health care system are often ignored. for example savings in the outpatient sector may have unanticipated economic consequences in the hospital sector and vice versa. generally the economic consequences of choosing medical intervention strategies on the national economy at large are often ignored. gps or hospital decision makers generally do not regard indirect costs (losses or gains in production). the perception of a disease problem is rather focused on patient cases than population oriented. 4. the patient’s perspective: from the viewpoint of the patient, costs that are not reimbursed and are out of pocket are most important. costs borne by third party payers are widely ignored. for example, a co-payment for medication in out-patient treatment may represent higher out-of-pocket expenditures to the patient than fully reimbursed in-patient treatment. the intervention related to quality of life is an important issue to patients, as well as the costs incurred due to the need for childcare or housekeeping help while receiving treatment. these costs have to be taken into account from the societal perspective too, but are ignored from other viewpoints. data sources many times there is no chance to run a study quickly enough to answer the information needs of decision-makers. most data are coming from secondary statistics and expert opinion, then. health economists are primarily interested to compare a new technology with the existing standard in an every day situation. economic evaluation can be carried out on an empirical basis (primary research design) or on a modeling basis (secondary research design). a highly appreciated design is a prospective study that proves effectiveness in a target population. this might be time consuming and costly, too. in specific situations where time for a follow-up would be very long, and data 397 economic appraisal as a basis for decision making in health systems of routine care are available, a retrospective cohort study might be appropriate as well. quality assurance at times where economic evaluations become more and more important, not only the underlying principles and theories are challenged but also the quality of studies is under debate. figure 6 shows how different agents are working together. figure 6. the network of quality assurance academics believed in unbiased studies only when sponsors (industry mostly) had no influence on the designs and the publication of study results (thus preventing publication bias, when results are not positive). at the same time representatives of governments and reimbursement authorities felt insecure and not well prepared to understand economic appraisal. this led to the development of guidelines (australia was first), which goal was to create a kind of „cookbooks”. as a consequence many things were regulated: the cost and benefits to be measured, the discounts rate, the quality of life measurement etc. unfortunately, this might be contra-productive in a situation where a very new and innovative technique (drug, intervention, screening strategy) has to be evaluated. 398 health systems and their evidence based development whereas the cookbooks (guidelines) tried to standardize the body of knowledge – instead of encouraging a proper education of evaluators – the standardizing of the process has a great impact on the quality delivered. aside of all the efforts to control the quality of both the body of knowledge and of the production processes, every reader or decision-maker can make his quality, check by following the checklist of drummond. his „ten commandmends” of good appraisal practice suggest to judge the following items (12): 1. was a well-defined question posed in answerable form? did the study examine both costs and effects of the service(s) or programmes)? did the study involve a comparison of alternatives? was a viewpoint for the analysis stated and was the study placed in any particular decision-making context? 2. was a comprehensive description of the competing alternatives given? (i.e., can you tell who? did what? to whom? where? and how often?) were any important alternatives omitted? was (should) a donothing alternative (be) considered? 3. was there evidence that the programmes’ effectiveness had been established? has this been done through a randomized, controlled clinical trial? if not, how strong was the evidence of effectiveness? 4. were all the important and relevant costs and consequences for each alternative identified? was the range wide enough for the research question at hand? did it cover all relevant viewpoints? (possible viewpoints include the community or social viewpoint, and those of patients and third party payers. other viewpoints may also be relevant depending upon the particular analysis). were capital costs, as well as operating costs, included? 5. were costs and consequences measured accurately in appropriate physical units? (e.g., hours of nursing time, number of physician visits, lost workdays, gained life-years)were any of the identified items omitted from measurement? lf so, does this mean that they carried no weight in the subsequent analysis? were there any special circumstances (e.g., joint use of resources) that made measurement difficult? were these circumstances handled appropriately? 6. were costs and consequences valued credibly? were the sources of all values clearly identified? (possible sources include market values, patient or client preferences and views, policy-makers’ views and health professionals’ judgements). were market values employed for 399 economic appraisal as a basis for decision making in health systems changes involving resources gained or depleted? where market values were absent (e.g., volunteer labour), or market values did not reflect actual values (such as clinic space donated at a reduced rate), were adjustments made to approximate market values? was the valuation of consequences appropriate for the question posed? (i.e., has the appropriate type or types of analysis – cea, cba, cua – been selected?) 7. were costs and consequences adjusted for differential timing? were costs and consequences which occur in the future ‘discounted’ to their present values? was any justification given for the discount rate used? 8. was an incremental analysis of costs and consequences of alternatives performed? were the additional (incremental) costs generated by one alternative over another compared to the additional effects, benefits or utilities generated? 9. was a sensitivity analysis performed? was justification provided for the ranges of values (for key study parameters) in the sensitivity analysis employed? were study results sensitive to changes in the values (within the assumed range)? 10. did the presentation and discussion of study results include all issues of concern to users? were the conclusions of the analysis based on some overall index or ratio of costs to consequences (e.g., cost-effectiveness ratio)? if so, was the index interpreted intelligently or in a mechanic fashion? were the results compared with those of others who have investigated the same question? did the study discuss the generalizability of the results to other settings and patient/client groups? did the study allude to, or take account of, other important factors in the choice or decision under consideration (e.g., distribution of costs and consequences, or relevant ethical issues)? did the study discuss issues of implementation, such as the feasibility of adopting the „preferred” programme given existing financial or other constraints, and whether any freed resources could be redeployed to other worthwhile programmes? 400 health systems and their evidence based development exercise: health economics task 1: health care system and efficiency after introductory lecture students will participate in small groups in order to work out the goals of health care systems. the working process will follow a brainstorming approach using meta-plan-technique. based on the existing permanent shortage of resources, possible options of managing health care systems according to the identified goals will be discussed. advantages and disadvantages of the different solutions will be evaluated. efficiency as a prerequisite for an appropriate health care system will be analysed thoroughly and described according to the theoretical background of economics. each group will nominate a person who will present the results in a plenary session, then. in a final discussion the results will be evaluated by the teachers. the assumed time span is about 1.5 hour. task 2: economic evaluation and techniques the work will continue again in small working groups (up to 5 students). in this exercise the key features of economic evaluation have to be deepened. students will learn how the different evaluation techniques can be used best. therefore the process of setting up an evaluation has to be studied, and depending on the study question, the appropriate outcomes, the proposed design and the evaluation technique have to be selected. furthermore basic skills like discounting (and selecting the appropriate discount rate) and choosing a decision criterion have to be trained. to do so, financial and mathematical exercises have to be solved (calculated). emphasis has to be laid on the understanding how the choice of a discount rate will eventually change the ranking order of efficient solutions and possibly prefer health effects in younger people. for this exercise additional 3 hours are requested. task 3: health economic publications in this exercise students will learn how to judge the quality of health economic publications. students will work in small groups and prepare a quality check of different publications of different quality that are delivered by the teachers. the result of the judgement will be presented in a plenary session and evaluated by the teachers. it is recommended to use the guidelines from m. drummond. this exercise requires 1.5 hour. 401 economic appraisal as a basis for decision making in health systems references 1. sackett d, william m c rosenberg, j a muir gray, r brian haynes, w scott richardson. evidence based medicine: what it is and what it isn’t. bmj, jan 1996; 312: 71-72. 2. zitter group. presentation in a workshop outcomes & disease management of diabetes in chicago, 1996. 3. coast j. et al. in: priority setting: the health care debate, wiley, 1996. 4. thompson ms. benefit-cost analysis for program evaluation, sage publications, beverly hills, london, 1980. p. 1. 4. bombardier c and eisenberg j (1984). in glick h, economic analysis of health care, 2.21.03, available from http://www.uphs.upenn.edu/dgimhsr/intec203.pdf 5. neuhauser d, lewicki am. what do we gain from the sixth stool guaiac? n engl j med 1975; 293: 226-8. 6. thompson ms. benefit-cost analysis for program evaluation, sage publications, beverly hills, london, 1980. p. 28. 7. cohn e. assessing the costs and benefits of anti-malaria programs, public health 63: 1086, december 1973 and amer. j. trop med hyg, 1972. 8. drummond m, stoddard gi, torrance gw. „most scientific work benefits from careful thought in the design stages, and economic appraisal is no exception”. methods for the economic evaluation of health care programmes, oxford university press, oxford, new york, london, 1987. 9. thompson ms. benefit-cost analysis for program evaluation, sage publications, beverly hills, london, 1980. p. 2-3. 10. drummond m. principles of economic appraisal in health care. oxford university press, oxford, new york, london, 1987. p. 7. 11. drummond m, stoddard gi, torrance gw. methods for the economic evaluation of health care programmes, oxford university press, oxford, new york, london, 1987. p. 18. recommended reading • gold mr, siegel je, russell lb, weinstein mc, ed. cost-effectiveness in health and medicine, new york, oxford university press, 1996. 402 health systems and their evidence based development 403 quality improvement in health care and public health health systems and their evidence based development a handbook for teachers, researchers and health professionals title quality improvement in health care and public health module: 2.9 ects (suggested): 0.25 author(s), degrees, institution(s) viktorija cucic, md, phd, professor emeritus address for correspondence insitute of social medicine, school of medicine, belgrade university dr suboti}a 15, 11 000 belgrade serbia and montenegro tel: +381 11 643 830 fax: + 381 11 659 533 home: ^ingrijina 13, 11 000 belgrade, serbia e-mail: ecucic@eunet.yu keywords health system; health care; quality improvement; evidence-based medicine (health care); determinants of health; quality indicators; standards; criteria; practice quidelines; tools for quality; models; quality cycle; change, public health expert learning objectives at the end of this topic, the students should be familiar with: • the difference between quality assurance and quality improvement approaches; • system approach to quality improvement; • key principles of quality improvement; • characteristics and roles of quality indicators, standards and practice guidelines; • tools and models of quality improvement; and • the importance of the role of public health expert in development and implementation of quality improvement policies, strategies and practical approaches at different settings. abstract the specialization of public health and its role in developing and applying the quality improvement techniques is emphasized in this module. quality is defined as a multi-dimensional phenomenon which demands specific organizational changes in order to be improved. the module explains the differences between the traditional quality assurance approach and quality improvement approach. it explains the basic principles for quality improvement, tools for quality, models and tasks for the public health experts. teaching methods teaching methods include: lectures; group discussion with topics what is quality of care, and what is the role of a public health expert in quality improvement; visit to health care institutions and group discussion with staff; seminars-practice guidelines and the role of public health expert; exercises-which data can tell us something about quality. practical experience with some tools for quality. specific recommendations for teacher stress the importance of specific skills that a public health expert needs to possess in order to contribute to the quality improvement in health care. it is recommended that the module will organize within 0.25 ects credits, out of which one third will be under teacher supervision, and the rest is individual data collecting and presentation preparing. assessment of students oral exam (the difference between quality assurance and quality improvement approaches, indicators, standards, tool, models, etc.).written report on the health care quality characteristic of one health organization using efqm model (need assessment).written report about needed data for quality improvement policy at the local level or health care organizational level. 404 health systems and their evidence based development quality improvement in health care and public health viktorija cucić quality improvement in health care is a worldwide trend and considerable efforts have been made both on national levels and on the international one. experts in almost all medical branches are seeking adequate definitions, methods and approaches to quality improvement in their respective fields in order to fulfill their professional obligations and satisfy in the best possible way the users-patients’ expectations, as well as of all others concerned upon whom the quality depends. public health experts have a twofold task in this respect. on the one hand, they are obliged to develop adequate approaches for the quality improvement in their own sphere, and on the other, the development of those approaches represents in general a domain where a special engagement of public health professionals is expected. there is a various interest in the area of public health for the health care quality. firstly, the overall philosophy of public health is based on health as a fundamental human right and obligation of the community to achieve it through common efforts. this includes interest in equal possibilities in health and health prevention, i.e., accessibility of health care of certain quality for all, disregarding any differences that may exist among people or territories. dealing in studies of health determinants, the public health also deals with health service and its influence upon improvement of health status of groups and overall population. next, the role of public health is «to contribute to health of the public through assessment of health needs policy formulation and assurance of the availability of services» (1). availability of services can also be understood as availability of effective, eficient, acceptable, accessible and relevant health services. these are in fact dimensions of a health care quality, as recognized by one of the quality theoreticians maxwell (2). the new public health strategy, adopted in 2002 by the european union, promote and bring together activities in the member states in the fields of evidence-based medicine, quality assurance and improvement, appropriateness of interventions, and health technology assessment (3). finally, in reviewing the reasons mentioned in literature as those requiring the activities aimed at quality improvement, one can conclude that a detailed analysis of those reasons, their documentation and measurement is in fact in the domain of a public health specialist. thus, referring to the european union, swow mentions the following reasons (4): • unsafe health system; • unacceptable levels of variations in performance, practice and outcomes; • ineffective or inefficient health care technologies; • users dissatisfaction; • unequal access to healthcare services; • waiting lists; • unaffordable costs to society; • waste from poor quality. the position and role of the health care service as a health determinant is mentioned with much controversy and extreme views. on the one hand is a radically negative approach founded by mckeown (5) and ilich (6) who point out that the role of health service in achieving the health improvement is minimal, and that all changes accomplished in improving the health of population were actually conditioned by changes in other determinants which are predominantly social and economic, not as influenced by the health service. on the other hand, we have an approach which could be called strictly medical, in which a better health condition is directly linked to the development of a specialized health service along with the use of high technology. without diminish the influence of numerous other determinants, somewhere in between these two views are those who claim that «health care itself (is) an important and often underestimated determinant of health« (7). certain researches prove such reasoning. thus the research published by the national institute for health 1990 suggest that, from the viewpoint of the contribution to the health status of a population, the healthcare services and interventions actually differ in as much as they are or are not evidence-based. analysing the services in the usa (8), only 21% of all diagnostic and therapeutic services are evidence-based. contrary to this, analysing the surgery services states that these are evidence-based in 95 % cases (9). 405 quality improvement in health care and public health the literature also presents numerous proofs which point to the positive influence that the multitude of primary and secondary prevention programmes have onto the improvement of health status and prolongation of life, indicating that early detection and treatment of disease gain significant survival and quality of life outcomes (e.g., screening for cervical cancer, immunisation programmes, hiv therapy, and so on). one can thus safely state that the contribution of the health service to the health status is all the more evident as it is of better quality. the quality health care is the one which is (10): • doing the right things (what) • to the right people (to whom) • at the right time (when), and • doing right things right first time development of quality concept there is much knowledge gathered on quality in health care and methods of its improvement. rich literature evidences the long and persistent quest for objective assessments in this very complex sphere, the functioning of which depends on numerous different partners. we have travelled a long way from the traditional approach such as quality assurance to the modern one, such as the total quality management (tqm), which includes, according to uehara (11): • quality control cycles (qc), • continuous quality improvement (cqi), • evidence-based medicine, • critical pathways, • practice guidelines, • customer satisfaction surveys, and • performance indicators. along the way the philosophy, concepts and methods have been changing and it seems that the process is not completed yet. 406 health systems and their evidence based development indicators, standards, criteria, guidelines the development of methods and tools to measure quality and performance in health care seems to be a fundamental component of improving quality in health care. search for the «quality indicators» is a common request by all those interested in any way for the quality, from investors, policy makers, managers, professionals, to public opinion. the indicator is expected to have »ability«, to indicate problems in health care which have to be solved by various quality improvement methods. there are numberless definitions of indicators. so, jacho (12) defines it as »a measure used to determine in a period of time whether the functions of the process and outcome were performed«. while mc glynn wrote: »an indicator is a measurable item of care which focuses upon some aspects of structure, process or outcome« (13). there are various types of indicators: • activity indicators – measure the frequency with which an event occurred (e.g., children immunisation), and • performance indicators, which should serve in formulating the appraisal of the prevention process. indicators may be defined for different levels, form the national to the level of a particular health institution. however, each country has to develop its own indicators. »it appears that indicators developed for health system in one country should not be transferred directly to another country, but it is possible to use indicators from other country as a starting point to produce own indicators« (14). today it is important to use high level performance indicators (15), which are presented below: health improvement indicators: standardised all cause mortality ratio (aged 15-64), deaths from all circulatory diseases, suicide rates. 407 quality improvement in health care and public health fair access to care indicators: surgery rates, composite, consisting of age standardised elective rates for: • coronary artery bypass grafts, • hip replacement (age 65 or over), • knee replacement, • cataract replacement, size of inpatient waiting list per head of population. efficiency indicators: case mixed adjusted length of stay. effective delivery of appropriate health care: early detection of cancer, composite, consisting of: • % of target population screened for breast cancer, • % of target population screened for cervical cancer, mental health in primary health care • volume of benzodiazepines. health outcome indicators: • contraception below 16 aged, • decayed, missing and filled teeth in five year olds, average number, • adverse events – complications of treatment, • infant mortality rate, • potentially avoidable mortality (from peptic ulcer, fracture of skull, asthma etc.), • in hospital premature deaths (30 days preoperative mortality rate; 30 days mortality rate following myocardial infarction). there are many benefits of using quality indicators. the most frequent are (14): • allow comparison to be made between practices, over time or against standards, 408 health systems and their evidence based development • facilitate an objective evaluation of quality improvement initiative, • can identify unacceptable performance, and • stimulate informed debate about quality of care. indicators are usually followed by development of criterion of care. the literature defines it in different ways, but generally they refer to »expected level of achievement in regards to which measures of performance and quality can be compared« (12). standard is «the level of compliance with a criterion or indicators». practice guidelines have a particular role in improving the quality and activities concerning their development are ongoing in many spheres. they are defined as: »systematically developed statements to assist practitioner and patient decisions prospectively for specific clinical circumstances, in essence the ‘right things to do’« (14). tools for quality improvement the most notable developmental change in the philosophy of quality in health is shifting the focus of «responsibility» for the quality and emphasizing an almost exclusive responsibility of an individual professional (meaning a physician) from the importance of structural characteristics for the good quality onto the organizational characteristics of the whole health system and the health institutions in particular, as well as to the strong leadership. at the same time, there was a shift from the «control from above» onto the organizational changes which provide conditions for the better quality. in order to get more familiar with and analyse the organizational system characteristics, and in order to describe and depict those characteristics, and with the purpose of proposing solutions for the correction of detected problems it was necessary to create or adopt special tools. one of the tools for quality improvement is the use of a statistical method for collecting, processing and graphic presentation of data on various phases of the constant improvement of quality. wilson classified these according to the purpose they are used for as those serving to (16): • present data on organization (histogram, check sheet) • analyse data (pareto diagram) • note and present convictions or opinions (fishbone diagram or cause and effect diagram) 409 quality improvement in health care and public health application of those tools, according to some authors, can solve 95 % of organizational problems and in that way improve the quality in any organization, including the healthcare one (17). strategies and models strategies, i.e., methodological approaches in improving the quality are abundant in literature, each one following the experience gained in applying it. there are numberless classifications, systematizations, divisions of those steps. one of the latest to be published by overtveit, speaking about ensuring quality in hospitals, mentions the following strategies (18): • increasing resources; • large-scale reorganization or financial reform; • strengthening management; • development of standards and guidelines; • patient empowerment and their rights; • quality management system; • quality assessment and accreditation, internal and external; • total quality management (tqm) and continuous quality improvement (cqi); • quality collaboratives; • re engineering; • quality indicator comparison; • benchmarking; and • risk management and safety. a more detailed analysis of these strategies goes beyond the scope of this module, all the more so as the publication clearly states that there is not a single approach, not one strategy that could be separated from the others according to its efficiency and influence onto the improvement of quality, or any of these could be recommended universally. generally, it is pointed out that there are very few systematic, evidence-based researches which could show how much a strategy or a methodological approach is really effective in improving the quality on a macro-level or on the level of a health institution. there is no evidence to corroborate the claims that certain noted changes are truly the result of a strategy being applied and not for some other reason. 410 health systems and their evidence based development editorial «quality and safety in health care» journal states: »from what we know, no quality improvement programme is superior and real sustainable improvement might require implementation of some aspects of several approaches – perhaps together, perhaps consecutively. we just do not know which to use, when to use them or what to expect« (19). the literature, however, stresses that application of multiple strategies gives better results in improving quality. it actually means that combining several strategies offers better prospects for success than using a single one. such undertakings of combining a larger number of strategies can be found in models for quality improvement. models for quality improvement have also changed and developed the philosophy of quality assurance toward a philosophy of quality improvement, i.e., from »systematic cyclic activity where quality is measured and standards are used» to »continual activities in improving«. the model of a «cycle» belongs to the phase of quality assurance: figure 1. quality assurance cycle (20) 411 quality improvement in health care and public health 1. quality assurance plan 10. follow-up and analysis of change 9. application of solutions 8. proposing solutions 7. problem analysis 2. setting the standards and guidelines 3. quality analysis 4. what can be improved, priorities 5. selection of problems to be improved 6. who will do what while solving the problem this systematic approach identifies the problems by one or another form of internal or external peer review, different activities in overcoming the problem, and initiates corrective activities in order to avoid the similar problems. the model known as raf (regulation, assessment, follow up), developed in the 80’s and adapted several times since then represents a shift from quality assurance approach to the continuous improvement of quality (21). the model integrates three theoretical approaches to create broad conceptual framework. those are: tracer approach, quality assurance and organizational changes. organizational changes are essential for further models of quality management which involve at least the following entities (22): • resources, • activities, • patients, and • outcome or effects. probably the best known is the conceptual quality model the european foundation for quality management efqm, or excellence model (european foundation for quality management, 1999): 412 health systems and their evidence based development l e a d e r s h i p k e y p e results f o r m a n c e people results people p r o c e s s e s policy strategy resource customer results society results the model is based on nine components. analysis of each component at any decision-making level offers a possibility to determine reasons for good or bad quality and basis for suggesting the measures for its improvement. if adequate answers are given to some of the questions asked in this text we could acquire a clear picture of the quality and everything needed to be done in the organization or at national level in order to improve the quality. 1. leadership it is important to learn: • how does the leadership (from national, regional authority to specific programmes or health care organization) demonstrates its involvement in quality management and improvement; • how does the leadership support activities directed towards quality management and improvement; • how does the leadership recognise and award improvement. 2. policy and strategy • how are policy and strategy being developed and implemented in practice (based on relevant information or not); • how are policy and strategy being communicated; • how are policy and strategy being evaluated and changed. 3. people the most important «people« are staff, or all individuals employed in the organization, programme or system being described: • is there any human recourses strategy; • how are skills and capabilities of staff being developed and preserved; • how is the involvement of all staff in quality improvement being promoted. 4. resources beside human resources there are others necessary for the quality. a detailed analysis is needed. these are: financial resources; information; suppliers, material, buildings, equipment; application of technology. 413 quality improvement in health care and public health 5. processes identification of main processes which influence quality is a complex task. primary processes relate to the procedures directly connected with providing health care. those are patient care activities (examination, treatment, discharge, follow up) but also patient information, infection prevention, safety, ethical issues. support processes are necessary for functioning of primary processes. examples include: administration, procurement, cleaning, catering, ect: • how are critical or primary processes being identified; • how are processes being managed, evaluated and improved; • how are innovation and creativity being stimulated; and • how is process change being implemented. 6. customer results here we first have to define who the customers are, what each group expects from a health institution, and then to analyse achievements regarding these. customers can be: patients / consumers (healthy people, people in care); other care providers (partners); providers of services or goods, financiers, etc. different assessment methods for the measurement of satisfaction are usually applied, directly or indirectly. 7. people results as was stated, this refers to the staff and the achievements in relation to staff satisfaction. this satisfaction can also be assessed: • indirectly, when absenteeisam, sick-leaves, percentage of people leaving organization, accidents, complaints, readiness for doing extra work, are being measured • directly, by one of structural methods for assessing satisfaction. 8. society result what is organization’s contribution to the society or community at large. are there any legal or some other impediments which obstructed the contribution of a health institution in a community where it is situated. what are facilitating factors enabling the contribution. 414 health systems and their evidence based development 9. key performance results here it is necessary to describe all the results that should have been realized according to the plan. it is also necessary to compare results achieved in a given situation or level with other results, predefined indicators, standards and criteria. it is necessary to answer: • what is achieved in relation to service objectives and in satisfying the needs and expectations of different stakeholders. • what are financial results and operational results. operational results are: • productivity (admissions, services, length of stay, bed–days), • effectiveness / non-effective actions (effective care, compared to indicators, non planned readmissions, infections, complications, incidences), • efficiency / non efficient actions (staff working hours; time per consultation / procedures, waiting time; cancellations, wrong tests, procedures, unnecessary procedures etc.), • other treatment results. iso model, which is also used in health systems, involves all the entities mentioned in efmq model and some additional areas (23): • management, • measurement, • analysis, and • ongoing improvement. the literature states other models as well which are used to improve quality, along with numerous experiences in applying certain models, but there are quite few researches to prove that application of those models contributes to some lasting changes in the organization. overtveit (24) states that two studies offered clear-cut evidence that tqm approach applied in certain period of time brings an improvement of quality, but that the repeated evaluation, after two years, shows a regression to the former state. 415 quality improvement in health care and public health current state of art in quality improvement and the role of public health professionals diversity, a great number of possibilities and options for research and practical application of models and methods for improving the quality – are the main characteristic of the present state in this field. experts agree that there is a very small possibility that any health system in any community would be able to secure the quality of health care in all its dimensions as defined by maxwell (2) and later by iom (14). experts also admit that there is no strategy to be designated the best and universally recommendable. there are, however, proofs «that some quality methods can be used to increase efficiency and reduce harm to patient« (24). it is also pointed out that there is no possibility to transfer (copy) the policy, strategy or practice of quality improvement from one country to another. each of these components, though based on identical common principles, must carry clear local characteristics and features. these are challenges defining the surroundings in which a public health expert works. to understand how health care quality can be improved it is essential for public health professional to have a framework of the dimensions of health care around which quality can be assessed and improved. a public health expert is expected to get acquainted and to adopt the three key principles of quality improvement (25): • improving the quality of health care implies change; • health care quality is multi-dimensional; • health care quality is a product of individuals working with right attitudes in the right systems and organizations. a public health expert is also expected to have a series of skills needed for the work in this field, such as need assessment skills, critical appraisal, application of evidence-based health care, management skills etc. development of the system approach is also particularly important. model pdsa or plan do study act can offer answers to many important questions in the process of quality improvement (26,12,25): 416 health systems and their evidence based development figure 2. framework for improving the system (25) besides, possessing the team-work skills, particularly for working with clinicians, is one of the most important skills that a public health specialist should possess and upgrade. 417 quality improvement in health care and public health • what we are trying to accomplish? • how will we know that a change is an improvement? • what changes can we make that will result in an improvement? act plan study do exercise: quality improvement in health care and public health task 1: variations in medical practice variations in medical practice are one of the most frequently mentioned reasons for the development and application of quality improvement mechanisms. with whatever sort of data we may gather in medical institutions (for example, the average length of treatment for the single diagnostic entity, mortality referring to the same disease at certain age groups, percentage of hospital beds occupancy, and so on) we shall notice that those vary considerably from one to another medical institution. perceiving and analysing these variations search for their causes are parts of the quality analysis process. frequency histogram is used as a tool for graphic presentation of variations. students will have assignments to collect data at three general hospitals’ surgical wards on: • time interval from admission to or for elective surgery, • number of analyses and examinations performed upon each patient prior to operation. (the collected data above are to be presented by a frequency histogram (two) and the noticed differences are to be discussed). • collect data on caesarean section rate as per regions in the country and number of obstetricians–gynaecologists in the same regions. (present data graphically, and then discuss the results). task 2: global indicators wilson (16): «because the delivery of health services is complex and has multiple goals no single measure is apt to capture overall quality. still everyone would like to have a universal quality meter that readily generates for each provider an overall score that is both valid and meaningful». students should collect data in several hospital around the country for the calculation of the following indicators, calculate the indicators and compare them in small and big group: • surgical in-patient cancellation rate, • in-patient autopsy rate, 418 health systems and their evidence based development • adult death rate, • postoperative death rate < 48 h, • hospital complication rate, • unplanned returns to intensive (or special) care unit, • no. of medical incidents, • surgical wound infection rate. collective work: choose, define, and explain some of the oncology care indicators (examples for the solutions): • screening mammography, women age 50-69, • pap smears, women age 18-69, and • quitting smoking, both sexes. collective work: choose, define, and explain some of the public health indicators (examples for the solutions): • immunization rate, • birth rate, • infant mortality rate, • mortality under 5, • mortality rate, • changes in self-reported health status, • changes in functional independence measures, • client satisfaction with health services, and • changes in health-related knowledge, attitudes, skills. 419 quality improvement in health care and public health references 1. institute of medicine. the future of public health. (cited 2000, february 15) available from url: http://www.nap.edu 2. maxwell pj. dimensions of quality revisited: from thought to action. quality in health care 1992; 1: 171-7. 3. eu commission. new public health strategy. (cited 2003, december 20). available at url: www.europa.eu.int 4. show c. framework for national quality policies. copenhagen: who, regional office for europe 2002. 5. mc keown p. the role of medicine. oxford: basel blackwell 1979. 6. ilich i. limits to medicine. medical nemesis: the expropriation of health. harmondsworth: penguin 1977. 7. bunner jp. medicine matters after all. j. roy phys. london 1995; 29: 105-12. 8. dubinski m. analysis of national institute of health. medicare coverage assessment. int.j. technic. assess. health care 1990; 6: 480-8. 9. howes n. surgical practice is evidence based. br.j. sur. 1997; 84: 1220. 10. wareham n. the meaning of quality. in: pencheon, ed. oxford handbook of public health practice. oxford: oxford university press 2001. 11. uehara n. „evolution of the concept of quality, and potentials of tqm in health services”. proceedings of asean workshop-seminar on quality management of health services 1995. 12. jcaho (joint commission on accreditation of healthcare organization). national library of health indicators. (cited 1998, april 12). available from url: http:// www.jcaho.org 13. mc glynn j. developing a clinical performance measures. american journal of preventive medicine 1998; 14: 14-21. 14. rand. measuring general practice. a demonstration project to develop and test a set of primary care clinical quality indicators. nuffield: nuffield trust 2003. 15. nhs. quality and performance. nhs, executive. (cited 1999, may 10). available at url: http:// www.doh.gov.uk 16. wilson c. qa/coi strategies in health care quality. new york: wbs company 1992. 17. cuci} v. zdravstvena zaštita zasnovana na dokazima (evidence based health care), belgrade: velarta 2000. 18. who. what is the best strategy for ensuring quality in hospitals? copenhagen: who, regional office for europe – health evidence network 2003. 19. grol r, bakerr, moss f. quality improvement research: understanding the science of change in health care. quality and safety in health care 2002; 11(2): 110-111 (editorial). 20. who / usaid/qap / danida. consultative meeting in quality assurance in developing countries. maastricht: who 1993. 21. fleishman r. the rat method for regulation, assessment, follow up and continuous improvement of quality of care. international journal of health care quality 2002; 15(7): 303-310. 22. eggli j. a conceptual framework for hospital quality management. international journal of health care quality assurance 2003; 16(1): 29-36. 23. iso. international organization norms. (cited 2000, february 20). available at url: www.iso.org 420 health systems and their evidence based development 24. overtveit j. the quality of health care purchasing. international journal of health care assurance 2003; 16(3): 116-127. 24. hicks n. improving the health care system. in: pencheon, ed. oxford handbook of public health practice. oxford: oxford university press 2001. 25. berwick d. primer on leading the improvement of system. bmj 1996; 312: 619-22. recommended readings 1. berwick d. methods and tools of quality improvement, putting theory into practice. harvard community health plan, brookline: regional authority 1991. 2. donabedian a. the definition of quality approaches to its assessment. an arbour: health administration press 1980. 3. donabedian a. exploring in quality assessment and monitoring volume ii. an arbour: health administration press 1982. 4. dixon r, munro j, silcocks p. the evidence based medicine oxford: workbook, linacre house, jordan hill 1997. 5. ishikawa k. what is total quality control? london: prentice –hall, inc 1985. 6. international journal for quality in health care, all issues. 7. jennison goonan k. the juran prescription – clinical quality management. new york: a juran institute publication 1995. 8. palmer h, donabedian a, pover c. striving for quality in health care an arbour: health administration press 1991. 421 quality improvement in health care and public health 422 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title accreditation of health institutions as an external tool for quality improvement module: 2.10 ects (suggested): 0.50 author(s), degrees, institution(s) vesna bjegovic, md, msc, phd snezana simic, md, msc, phd both authors are professors at the school of medicine, university of belgrade, serbia and montenegro address for correspondence insitute of social medicine, school of medicine, belgrade university dr suboti}a 15, 11 000 belgrade serbia and montenegro tel: +381 11 643 830 fax: + 381 11 659 533 e-mail: bjegov@eunet.yu keywords accreditation, quality assessment, visitation, standards learning objectives after completing this module students and public health professionals should have: • increased their understanding of external tools for quality improvement; • identified key four models for external quality assessment; • explored the similarities and differences between existing mechanisms; • improved their knowledge in accreditation procedure and international projects, which support national accreditation; and • understood the main trends influencing the process of external assessment as a part of continuous quality improvement in health care. abstract the main model of external quality assessment and improvement were developed particularly in the last two decades of the twentieth century. among them iso certification and efqm model are based on industrial concepts applied to health care, while visitation and accreditation were developed within the health care system itself. today many countries are interested in the process of accreditation as the systematic assessment of health institutions, which is based upon external peer review system and involve written standards. with growing interest in accreditation, the procedure for establishing accreditation bodies was simplified, and those bodies get international expert help for their development and in developing the national standards and services. an example of such help is alpha programme, which is founded within isqua (international society for quality in health care). teaching methods after introductory lecture students will participate in nominal group technique in order to recognize and to rank the field in the quality of health care where organizational, managerial, or other improvements are necessary, such as waiting lists, admission policy, medical records keeping, patient's discharge procedure, administration of drugs, working in multidisciplinary teams, patient satisfaction, etc. then they will work in small groups, divided according to country or working place, to discuss the possibilities for improvement in their own environment. the second exercise will be to discuss, within the country (or working place) small groups, the necessary procedure for development of national accreditation system. teacher will advise them to follow existing models and experience and to highlight their advantages and obstacles in the case of application within the country of see region. 423 accreditation of health institutions as an external tool for quality improvement specific recommendations for teacher it is recommended that the module will organize within 0.50 ects credits, out of which one third will be under the teacher supervision. teacher should be familiar with internet resources, where necessary evidence of well-established accreditation could be obtained. teacher should also be ready to help students to explore the website of international society for quality in health care as well as the website of joint commission on accreditation of hospitals. assessment of students multiple choice questionnaire and written design of national accreditation procedure. accreditation of health institutions as an external tool for quality improvement vesna bjegović, snežana simić examples from many countries around the world point to a growing movement aimed at continuous quality improvement in health institutions, and many authors call it a »quality revolution« (1). endeavours to provide the quality are an inseparable part of the health reforms, the dominant part of which are efforts made to increase efficiency and effectiveness, while keeping a certain level of equity in the health services provision (2,3). in the light of those strivings, the external tools for quality improvement in health institutions have their special place, while concern for their development is motivated differently in conformity to different stakeholders in the health system (4,5). thus, when it concerns the government, the external models of health care quality assessment are seen as new control mechanisms which would guarantee not only the quality of health sevices, but also higher responsibility and transparency which are neccessary for a more efficient system worth trusting. health professionals view the external tools of quality assurance from another perspective. their interest lies in increasing the efficiency of certain health institutions, in realizing the competitive advantages under the conditions of a controlled market, and in an outer incentive for further development of the internal quality system. the health professionals always wonder if various models of external quality assessment would limit their clinical freedom, and whether the health professionals would be under extreme control due to developing and applying of these models. when it refers to patients, although their position is improving in many european countries, their influence over the external quality assurance programmes is still limited. the patients’ main focus is on transparency and their higher participation in the health system decision making, based on adequate information on the quality of work. the main interest of the investors, regarding the application of external mechanisms, is in preserving the balance between the higher investments in administrative activities whose cost-effectiveness is not known and their inclination to contract services with particular suppliers under the conditions of a controlled health system market. 424 health systems and their evidence based development the quality improvement movement and the external quality assessment are both extremely actual in health systems around the world. governments, users, health professionals, managers and financiers are all trying to establish new external mechanisms in order to institute public responsibility, transparency, self-regulation, improvement of quality, and adequate »value for the invested money« (6). in an ideal situation the external tools for the improvement of organization and provision of health care are based upon (7): • explicite, valid standards, • reliable quality assessment processes, and • complementary mechanisms applied for improvement. standards are related to the level of excellence, they serve as basis for comparison, they represent a minimum to which a community is to pay attention, and are recommended as models to be emulated. standard of quality is a statement that defines expected performance, structure, or processes which must be present in a health organization if it is improve the quality of care (8). the process of quality assessment includes measurement or following of the function of secured quality so that it could be determined how well is the health care provided as compared to applicable standards or allowed limitations of health care (9). it is a process of establishing and measuring the differences between efficiency and effectiveness that can be ascribed to the health care, which is offered, including the variations among regions as well as among people. in a practical sense, it is the measurement of technical and interpersonal aspects of medical (health) care (10). explicite identification of spheres where improvement is in place, as based upon proofs found in the assessment – reaching the standards is a strong incentive for participation of all partners in the implementation of changes that lead to improvement (11). acceptance of any form of external quality system in health care is closely connected to the social, economic, and political climate of a country which is determining the advantages and obstacles for those activities. it is assumed that the external quality assessment mechanisms are introduced and developed in european countries in a context characterised by (2): • covergence of the bismarck and beverage models of health care system financing; • government policy based on deregulation, decentralization, and self-regulation, together with strengthening the role of the patient; 425 accreditation of health institutions as an external tool for quality improvement • responsibility mechanisms as the creation of a new balance between trust and control among various partners in health care; • the economic and industrial way of thinking is dominant in development of those models; • application of the public-private mixture of health service providers and their financiers with public-private agencies, mostly of nonprofit orientation. in a situation where some countries have comprehensive legislation related to the quality management in health care, and where other countries have only regulations referring to certain special mechanisms, it is only understandable that models of external quality improvement vary from country to country (12). models of external tools for quality improvement in health care system modern analyses show that the external tools for quality improvement were developed particularly in the last two decades of the twentieth century, and that four models can be identified most often. the first two of those are based on industrial concepts applied in health care, and the last two models were developed within the health care system itself (2,13,14): 1. iso certification (certification by the international standardization organization), 2. efqm model (model of the european foundation for quality management), 3. visitation programme, and 4. accreditation. 1. iso model the model was created by the international standardization organization while developing standards for the quality systems – iso 9000. as the standards refer to the administrative procedures and not to clinical results, inside the health system they are mostly used in more technical departments and wards, such as laboratory, radiology, and transportation, but sometimes they are applied onto a whole hospital or clinic. the model is particularly utilized in germany and switzerland (6). by the iso model, the national board 426 health systems and their evidence based development for the quality in health care tests and recognizes an independent agency as competent to certify those organizations which adhere to these standards. the verification process tests the adherence to the standards and it is not directed at organizational development. anyhow, the iso 9000 series is a collection of five separate but interconnected international standards for quality management and quality assurance (15). revised version iso 9000: 2000 represents an improvement as they were set up by using a simple structure based on the process. the basic units of the revised standards are responsibility of the administration, resource management, process management, measurement, analyses, and process improvement. the verification in the iso model is done by experts for iso norms, not by experts for a special type of organization, so that it is not a form of peer review (2). certification, as process of recognizing the fulfillment of certain preset standards, refers to the system of quality, not to the actual contents of work. as applied in the health care, this model helps in orientation onto the process, but it does not guarantee that the selected treatment is adequate, nor does it refer to the health outcome. basically, this model does not affect the clinical process, but only the managerial one within which the clinical decisions are made. therefore, the iso standards are easily applied by health institutions’ technical departments. unfortunately, the limitations are not always recognized by those outside the health sector (financiers, patients) so that they sometimes advocate strongly for the introduction of the iso model in the health sector. after its initial application and after the limitations were recognized, there appeared »anti-iso« movements in some countries, germany in particular. still, some countries, like the netherlands and switzerland, found ways to integrate the model into approaches which are more specific for health care, such as accreditation. 2. efqm model the model was designed by the european foundation for quality management, founded in 1988, with over 600 organizations throughout europe involved in its work. the efqm model is based on »business excellence«, and was initiated by malcolm baldrige’s model of »excellence« in the usa. it stimulates organizations and helps them improve those activities which lead to excellence in satisfying the users, to professional satisfaction, and to the improvement of management in general. it bolsters the implementation of management through total quality (14). 427 accreditation of health institutions as an external tool for quality improvement this model’s instruments are schemes of rewards (european and world schemes), as well as publication of models which may be used in selfevaluation. it is considered to be the most complicated organizational model designed to fulfill certain objetives referring to total quality management (2). however, this is still a general model, not adapted to activities such as health care. still, its attributes, such as high validity, experimentation with self-evaluation of the work quality, its simplicity and compatibility with the structureprocess-outcome approach make it rather popular with health systems of west europe, particularly in scandinavia. it is especially popular among the managers of health institutions. also, the use of self-evaluation can be considered as a certain form of peer review, where all the members of an organization are regarded as colleagues. the expenses in this model are relatively low, and there are some elements of positive competition, especially if the organization wins a citation. a weak point of this model is that, beside conferring rewards for recognized good quality, it has no other form or recognition, such as iso-certification or accreditation, specific for health care institutions. 3. visitation programme the programme of visitation, as an external peer review, is focused on clinical practice, professional development, and quality of services (6). the standards are deduced implicitly from the clinical practice guidelines and from personal experiences. visitation teams (supervision, round-ups) are clinicians mainly, most often from the same field. after the visitation by chosen colleagues, the assessment results in the form of a written report. the team reports are not publicized. visitation is a systematic form of external peer reviewing, popular in particular in the netherlands (2). the whole model was inspired by visitations to clinics, which was operationalized as part of the quality assurance ever since 1967. the visitation programme has its roots in the health profession and it is carried out by medical professionals. the emphasis is placed on clinical performance, meaning the knowledge, skill, and attitude. in time, the visitation programme encompassed the organizational aspect as well. visitation is deemed closest to the actual clinical performance out of those four models, considering the structure, process, and outcome. health professionals embrace this model most willingly, as well as accreditation, as they are the closest to their actual work performed and to peer review. 428 health systems and their evidence based development 4. accreditation the model of accreditation was developed for the joint commission on accreditation of healthcare organizations in the usa. presently, it accredits almost 20.000 health institutions – hospitals, primary health care institutions, home care, long-term nursing institutions, laboratories, and network of group practice health care (16). also, the first initiatives for accreditations started in the united states back in 1910 by dr. ernest codman, after which the american surgical college was founded in 1913, and the programme for the standardization of hospitals started in 1917, as a prototype for accreditation (17). this programme was expected to secure recognition by professionals of those institutions which provide the best health care, as well as to stimulate those with poorer standards or equipment to strive for an improvement in the quality of performance. in 1951 the joint commission on accreditation of healthcare organizations in the usa emerged out of this programme, the standards of which were initially set exclusively by health care professionals, who also made evaluation and used its results. as of 1965, when the state health care programme for the aged was established (medicare), other stakeholders in the health care system became the users of accreditation results, too: first the government, then the health insurance companies, and finally the general population (16). since 1997 the yearly reports on the performances of accredited hospitals can be found at the joint commission on accreditation of hospitals’ web site http://www.jcrinc.com (18). it is worth noting that more than 96% of hospital beds in the usa today are in accredited hospitals (16). from the usa the accreditation spread out to canada, australia, new zealand, and in the last two decades of the twentieth century also to european countries. its development is most evident in great britain, spain, portugal, the netherlands, finland, while in france and italy it is on statutory basis. the first european experiences with accreditation started much later than in the usa, though there were other external mechanisms for quality improvement in european countries which were predominantly based on medical audit and peer review (19). thus, the pilot programme of hospital accreditation which started in 1990 in great britain is a good example of developing the accreditation process. this programme was meant for small communal hospitals (57 altogether) with less than 50 beds (19,20). out of those 57 hospitals, 43 were included voluntarily in the programme, and in two years 37 became accredited by the hospital accreditation programme. the main goal of the pilot programme was to instigate effectiveness (efficiency) of hospitals in a community, and to spread the ideas of good organizational practice. local authorities 429 accreditation of health institutions as an external tool for quality improvement financed and appointed two members each for this pilot programme. an independent body for accreditation was also established. the body managed the programme and evaluated the reports on hospitals included by the programme. initial standards used for accreditation were designed according to the 1988 publication by the national association of health authorities: »towards the practice guidelines in small hospitals«. those standards were derived from systematic observation of the organizational practice in small hospitals, and were confirmed and widely accepted by 17 national bodies, including 7 royal societies. the standards themselves referred to general organization, clinical services, medical specialities, and auxiliary services. they provided for the assessment of purpose and rationale of services, managerial arrangements, equipment and hospital capacities, operational policy, staff work and their education. during the first phase the hospitals assessed the quality themselves by filling out questionnaires based on published standards. then a team of at least 2 researchers (clinical specialists, or professional managers and general practitioners) from the established accreditation body made a visit to each hospital for the first time for a day. each researcher came from a similar but distant hospital, after he went through a three-day training – theoretical and practical – in the field of standards, research evaluation, and report composition. reexamination by the accreditation body included evaluation of the written report by each member. the implementation phase entailed sending of the final report by the accreditation body to the manager of the hospital included by the programme. the managers were encouraged to discuss those reports over with their staff, but also with financiers. inspections by external teams were performed four times a year, and staffs from all the hospitals were invited to a meeting in order to exchange experiences they had in implementing the quality improvement. their experiences were related to a considerable time consumed in the preparational phase for the accreditation, as well as to a sense of pressure at the time when assessment is done by external teams. the very challenge of external assessment, however, proved to be a strong motive to reexamine (or disclose) the operational policy of the institution, the existing reports, and data, too. many of the managers were surprised at the scope of data and information referring to their hospitals which they did not use in their everyday work. explicit identification of the fields where improvement was necessary, such as correctness of data, administration of drugs, admission policy and patient’s discharge procedure, were also stimulating for a systematic participation of physicians in the hospital management to its benefit. the reasons not to accredit certain number of hospitals included by this pilot programme referred to a lower quality in the spheres of medical procedure safety, keeping of medical records, and medical organization. visits by 430 health systems and their evidence based development external professionals in the course of two years confirmed that 69% of what was recommended was implemented in the daily work. it is interesting to note that complete expenditures for this two-year pilot programme for 57 small hospitals amounted to £ 47.000, which includes two permanent employees, external assessment teams’ training, meetings of the accreditation body, visits to hospitals, and other expenses. accreditation in great britain, as opposed to the one in the usa, was not led in the beginning by medical professionals and it did not connect or integrate the existing mechanisms with the accreditation procedure itself, but that is where emphasis lies today in particular. still, following the experience they had in great britain, other countries developed similar projects as well. today it is clear that the accreditation of health institutions has its future, and discussions are centered around its integration with other external assessment mechanisms, and whether the proceedings should be regulated at the national level or not (6,21). concept of accreditation – advantages and limitations accreditation as applied to organizations refers to a systematic assessment of health institutions in relation to explicit standards by experts outside the health institutions (20). during the accreditation the assessment is done by multidisciplinary teams of health professionals in relation to published standards. although accreditation may be expensive, it is performed most often by non-profit independent organizations. it is a process in which a professional association or a non-governmental organization issues authorizations to institutions stating that they are accredited based on their ability to meet the preset criteria. it is also the process through which an authorized agency or an organization evaluates and recognizes programmes or institutions which satisfy the preset standards. accreditation as a process is to be distinguished from the process of evaluation of work in health institutions, which is an obligation done by the government or its agencies when issuing the work permits (22). good point in the accreditation as an external quality assessment model is that it reflects in detail specific features of health care offered by a health institution. it is noted to have roots in peer reviewing as a mechanism used by a medical team to evaluate the quality of total care offered by a health organization, while evaluation is performed by medical workers of the same educational level (23). advantage of the accreditation is that it uses perform431 accreditation of health institutions as an external tool for quality improvement ance indicators, insisting upon evidence based medicine, clinical indicators, and benchmarking as a process of quality assurance in which an organization sets its goals and measures up their realization comparing itself to products, services, and practice in other organizations recognized as leaders in their fields (9). the hospitals which most often participate in the accreditation process and thus have the largest experience, also note the following benefits (6): • development of multidisciplinary teams, • reexamination of the institution’s operational policy, • data system improvement, • growth of local and national prestige, and • stronger connections between hospital managers and institution (networking). comparing the accreditation with the efqm model, there is less energy invested in conceptualization and vizualization of the health institution’s nature as the organizational one. when various accreditation guidelines are analysed, it is percieved that they had originally been aimed at wards/functions in health institutions, and that only recently they were directed to the structure – process – outcome approach, the system of quality, and total quality management (2). even though it is obvious that accreditation differs from other external quality improvement mechanisms, it is still evident that it is complementary to them. besides, there is today a need for all external mechanisms to converge in order to provide the standardization and possibility of making comparisons (3). the following are cited as characteristics of an effective external quality assessment programme, including accreditation (6): • the programme gives a clear frame of reference describing the quality elements, • it publishes open standards in order to provide an objective foundation for assessment, • it is focused onto patients and it reflects horizontal clinical pathways rather than vertical managerial units, • it incorporates clinical processes and results, reflecting observations by patients, medical staffs, and public, • it instigates self-assessment providing the time framework and tools for internal assessment and development, 432 health systems and their evidence based development • it trains personnel who then assess the quality, and it promotes reliable assessments and reports, • it measures systematically – describes and evaluates objectively adherence to standards, • it renders incentives – it gives stength to improve and responses to assessment’s recommendations, • it communicates with other programmes – it promotes consistency and reciprocity, it reduces duplicating and burdening of the health care service with inspection, • it quantifies improvements in time so that it shows the programme’s effectivness, and • it secures public accessibility to standards, assessment processes and results – it is transparent and responsibe to public. accreditation procedure accreditation as a process is usually based upon the external peer review system, using written standards by which the quality of activities, the services or organizations in the health care system are assessed (6,24). medical professionals have the key role in this process. it is still debated today as how to approach the procedure of accreditation which can be (25): 1. institutional, or 2. oriented to clinical service. the institutional approach is focused onto the whole institution and its operation, it is simpler for implementation, and the responsibility in undertaking the improvement action is clearer. however, this approach does not heed patients’ experiences much. as opposed to it, the approach oriented onto the clinical service reflects experiences of individual patients, it is more encompassing, covering up all aspects of patient’s care and treatment. but, it is not always easy to define the clinical service, therefore this approach requires more time and repetition in case it should comprise all services which contribute to the health institutions’ operation. this approach is deemed more advantageous if the quality improvement is developed in the primary health care as well, though numerous pilot schemes. after the services are defined, the next step in the process of accredi433 accreditation of health institutions as an external tool for quality improvement tation is to establish an independent accreditation body. in this respect, different countries have different procedures and those bodies are established upon initiative by independent health experts, physicians’ associations, societies for quality in health care, and even by the health authorities (ministries). it is noted in literature that certain countries have no clear criteria in establishing the accreditation body (26). with growing interest in accreditation and more initiatives by the international society for quality in health care (isqua), the procedure for establishing the accreditation bodies was simplified, and those bodies get expert help for their development and in developing the national standards and services. as part of the isqua, the alpha programme was developed to supply published international standards for the accreditation bodies in health care (alpha: agenda for leadership in programs for healthcare accreditation) (21). there are 10 such standards and they can serve as guidelines in establishing the national accreditation bodies. the contents of these standards, which also incorporate the iso requirements for similar bodies, is as follows (24): 1. standard: managership of the national accreditation body with the mission, values and vision, the strategic and operational planning, keeping the external communication with users, with professional, political, and financial bodies, and with other participants interested in improving the health care. 2. standard: organization and management of preformance which assures improvement of work and the quality improvement system, defines the accreditation body’s statute, contracts, relations with accreditation users, and marketing. 3. standard: management of human resources, which includes planning, finding, selecting and appointing the persons to work in the accreditation body, their professional development and interpersonal relations. 4. standard: selection, education, and development, as well as employment of researches who are to participate in the external quality assessment, providing for their satisfaction with their work. 5. standard: management of finances and resources through systems which insure that strategies and goals will be attained with minimal risk. 6. standard: management of information which presumes gathering, keeping, and using the relevant and timely information needed by the accreditation body. 7. standard: management of quality assessment including the preparation of participants in the quality assessment procedure, satisfaction of their needs 434 health systems and their evidence based development after the assessment is done, stimulating the objective and consistent decision-making, implementation of improvement, and evaluation. 8. standard: accreditation process which implies maintaining of the accreditation system by defining clerly its purpose, responsibility in accreditation, and preserving its achievements, as well as keeping the documentation. 9. standard: development of accreditation standards which satisfy international principles to be developed, implemented, evaluated, and modernized in a planned way, together with development of clinical practice guidelines. 10. standard: educational services which are systematically designed and implemented so that they satisfy the quality standards and needs of the accreditation users. the key elements in the accreditation procedure, after defining the service to be accredited, and after the national accreditation body was established, are as follows (25): 1. setting up the standards; 2. assessment of performance in relation to set standards; and 3. consent to the assessment, and implementation of the action which is to correct shortcomings identified during assessment. setting up the standards is an integral part of continuous quality improvement in a country, with discussions still going on about the balance between the national and local standards, the level at which the standards will be set up, and as to who is to set those standards up, with a clear recommendation for them to be published (27,28). the basic characteristics of the standards in accreditation system are required to be (19,25): • explicite, • objective, • measurable, • based upon evidence, if such exist, • connected to the structure (adequacy and organization of resources – personnel, buildings, equipment, amd financial means), the process (clinical practice and interventions), and to the outcome (intervention results), and • regularly revised in light of the latest evidence and experiences. 435 accreditation of health institutions as an external tool for quality improvement upon initiative of the international society for quality in health care (isqua), as in the case of recommendations for establishing the national accreditation body, the alpha programme institutionalized international principles for formulating the national standards which are to be respected in the national accreditation procedure (21). there are six of those international principles and they refer to: 1. ways of presenting their contents, 2. clarity of definition, 3. clarity of scope, 4. comprehensive and clear structure, 5. formulation by well defined process, and 6. receptiveness to performance measurement. performance assessment in the accreditation procedure has its external elements and involves peer review. it is advisable that peer review be multidisciplinary and that it reviews contributions by all disciplines in offering the health care quality. the assessment itself is supposed to be based upon objective and written evidence, and on visits to the institution to be accredited. it should be cyclic – the external assessment is to be performed in certain intervals (differing from country to country: once a year, once in 3-4 years, etc.). also, the assessment visits are to be more often in case certain problems have been noted, and if the improvement action has been defined. it is an important fact that all accreditation systems have explicit organizational standards in reference to which the institution itself is assessed prior to the structured visit by professionals out of the institution, who then submit a written report with acclaims and recommendations for development both to the independent accreditation body and to the institution itself (6). accreditation can be conferred for certain period of time, or it can be withdrawn by the independent assessment body in case the hospital does not comply with the defined assessment programme. the body responsible for the accreditation process, assessing the compliance with defined standards, has the right to make public its findings, and to plan repeated visits to the institution for the purpose of external peer reviewing. however, the implementation action is under full responsibility of all employees in a given institution. taking into account the existing accreditation programmes in many countries, further development of this system is deemed necessary so as to (4,6,19): 436 health systems and their evidence based development • provide better co-ordination with existing external quality assessment programmes at national and international levels, • develop and institutionalize the standards which are to be relevant to patients, • emphasize the quality connected to the clinical performance, reviewing concomitantly all aspects of health care offered to patients, and • avoid separate »right« solutions for all aspects of health care quality, but to develop a general framework for constant improvement of quality in healthcare. for the accreditation procedure to start in any country, however, it is necessary to create the national strategic framework for continuous quality improvement in healthcare, where the accreditation itself is but one of its segments (4). even though the work of the accreditation body (commission, board, association) is independent, it must be acknowledged either by the government or the health institutions, or by a professional association (21,29). the strategic framework is to specify whether the accreditation procedure is to be legally regulated or voluntary, with the voluntary principle referring to the participation by health institutions in this procedure remaining quite important – the health institutions recognize their interests themselves. experience also shows that development of the accreditation procedure requires 2 to 3 years, and pilot projects are first recommended with one or several health institutions participating in those projects (6). international projects and experiences with accreditation in european countries considerable interest in the accreditation procedure is confirmed by international projects which were/are aimed at analysing its basic characteristics, advantages, and limitations in various countries. so far, the most prominent projects in the european countries are theexpert project and the alpha programme (14,21,26,30). expert project (external peer review programs) has been financed since 1996 by the european union, aimed at analysing and exchanging experiences related to external peer reviewing and organizational standards for the health service assessment, particularly the accreditation process, along with recognition of achievements and creation of network among countries for the exchange of experiences (networking). the goals of this project are also to 437 accreditation of health institutions as an external tool for quality improvement gather and disseminate various concepts and experience in implementation and training, as well as to support the integration with internal quality assessment mechanisms. countris of the european union were encompassed by this project. the iso standards model, efqm model, visitation, and accreditation were identified as basic external mechanisms in this project. alpha programme (agenda for leadership in programs for healthcare accreditation) was initiated by the international society for quality in healthcare (isqua) in italy in 1994, as a discussion forum, and as a way of learning about accreditation based upon experience of others, and the programme is active since 1999. in a sense, this programme gained ground as a response to numerous pressures to introduce iso standards for the quality assessment in health care, aimed at protecting and improving those external mechanisms originating in the health care system itself, most notably the accreditation. so far, the alpha programme is part of an important recommendation to adopt principles for the set standards for all national accreditation systems, respecting the specifics of individual countries. an alpha programme study gives recommendations for accreditation bodies which are to accredit health insitutions in a given country, as well as recommendations for the accreditation programmes themselves. today alpha leads, evaluates, and accredits the national health care accreditation bodies, helping them to achieve international »excellence«. this programme is also capable of aiding the assessment and improvement of standards of national organizations, in relation to internationally approved standard principles in health care, and to assist in developing accreditation programmes in a given country. in this way the national accreditation organization is to show not only that its system and process of operating satisfies the alpha international standards, but also that national standards are in concordance with alpha international standard principles for health care. alpha standards and principles are found at the web site http://www.isqua.org.au. members of the alpha council – accreditation federation are representatives from 13 countries with greatest experience in accreditation procedure, as well as representatives from the world health organization, the world bank, and the international hospital federation. alpha provides programme packages for the development of accreditation, and also the relevant articles published in this field. 438 health systems and their evidence based development exercises: accreditation of health institutions as an external tool for quality improvement task 1. after introductory lecture students will participate in nominal group technique in order to recognize and to rank the field in the quality of health care where organizational, managerial, or other improvements are necessary, such as waiting lists, admission policy, medical records keeping, patient’s discharge procedure, administration of drugs, working in multidisciplinary teams, patient satisfaction, etc. the necessary time for this exercise is 45 minutes, if the group is consisted from 20 students. students will be divided in two groups according to their preferences (hospitals or primary health care institution). each student will give an example of bad quality in the health care institutions, according to his – her experience and should be warned to be ready to explain it later. teacher will write down each example on the flip chart. after listing the examples students will select 5 conditions of bad quality and then rank them according to importance, by using marks from 1 to 5 (where 5 is the most important). all individual marks will be summed up and three conditions of bad quality will be selected in such way for further discussion. students who proposed the selected condition are going to explain what the reasons for their selection were. task 2. the work will continue in small groups (4 to 5 students), divided according to country or working place, to discuss the possibilities for solutions and improvement in their own environment. for this exercise additional 1,5 hour are requested. after small group discussion presentations will be in front of the whole group. teacher will summarize the reports pointing out the standards necessary to be reached in order to be ready for the accreditation procedure. it is recommended to follow existing standards of good quality in health care institutions. task 3. the third exercise will be to discuss, within the country (or working place) small groups, the necessary procedure for development of national accreditation system. teacher will advise students to follow existing models and experience and to highlight their advantages and obstacles in the case of application within the country of see region. this exercise required 3 hours under the supervision because students are obliged to search internet resources of international society for quality in health care (http://www.isqua.org.au) as well as joint commission on accreditation of hospitals (http:// www.jcaho.org/). 439 accreditation of health institutions as an external tool for quality improvement references 1. counte ma, meurer s (2001). issues in the assessment of continuous quality improvement implementation in health care organizations. international journal for quality in health care; 13(3): 197-207. 2. klazinga n (2000). re-engineering trust: the adoption and adaptation of four models for external quality assurance of health care services in western european health care system. international journal for quality in health care; 12(3): 183-189. 3. schyve pms (1998). accreditation and globalization. international journal for quality in health care; 10(6): 467-468. 4. rawlins r (2001). hospital accreditation is important. bmj; 322: p.674. 5. o’leary ds (2000). accreditation’s role in reducing medical errors. bmj; 320: 727-728. 6. shaw c (2001). external assessment of health care. bmj; 851-854. 7. shaw cd (2000a). the role of external assessment in improving health care. international journal for quality in health care; 12(3): p.167. 8. jcah (2003). national library of health indicators (with glossary). (cited 2003, may 20). available from url: http://www.jcaho.org/ 9. ta 101 (2003). glossary. in: introduction to health care technology assessment. national information center on health services research & health care technology (nischr). (cited 2003, may 29). available from url: http://www.nlm.nih.gov/ 10. cen/tc 251 (1995). glossary of medical informatics (cited 1995, june 20). available from url: http://miginfo.org.ac.be:8081 11. davies hto, nutley sm, mannion r (2000). organizational culture and quality of health care. quality in health care; 9: 111-119. 12. schilling j, cranovsky r, straub r (2001). quality programmes, accreditation and certification in switzerland. international journal for quality in health care; 13(2): 157-161. 13. west e (2001). management matters: the link between hospital organisation and quality of potient care. quality in health care; 10: 40-48. 14. shaw cd (2000b). external quality mechanisms for health care: summary of the expert project on visitatie, accreditation, efqm and iso assessment in european union countries. international journal for quality in health care; 12(3): 169-175. 15. iso. international standardization organization. (cited 2003, july 23). available from url: http://www.iso.ch 16. schyve pm (2000). the evaluation of external quality evaluation: observation from the joint commission on accreditation of healthcare organizations. international journal for quality in health care; 12(3): 255-258. 17. roberts js, coale jg, redman rr (1987). a history of the joint commission on accreditation of hospitals. jama; 258(19): 936-940. 18. jcah (2003). joint commission on accreditation of hospitals. (cited 2003, june 24. available on url: http://www.jcrinc.com/internat.htm 19. shaw c, collins c (1995). health services accreditation: report of a pilot programme for community hospitals. bmj; 310: 781-784. 20. robins r (1995). accrediting hospitals. bmj; 310: 755-756. 21. alpha (2003). agenda for leadership in programs for healthcare accreditation (cited 2003, april 22). available from url: http://www.isqua.org.au 22. biomed/cbo (1994). concerted action on quality assurance in hospitals. utrecht: national organization for quality assurance in hospitals. 440 health systems and their evidence based development 23. pam pohlys net guide (1999). glossary of terms in managed care (cited 1999, february 10). available from url: http://www.pohly.com/term-p.shtml 24. alpha (2000). international standards for health care accreditation bodies. victoria: the international society for quality in health care inc. 25. scottish office (1998). quality assurance and accreditation. in: acute services review report. edinbourgh: scottish office publication. available from url: http://www.scotland.gov.uk /library/document5/acute-o6.htm#1 26. isqua (2003). international society for quality in health care. (cited 2003, april 22). available from url: http://www.isqua.org.au 27. giraud a (2001). accreditation and the quality movement in france. quality in health care; 10: 111-116. 28. donahue kt, vanostenberg p (2000). joint commission international accreditation: relationship to four models of evaluation; 12(3): 243-246. 29. scrivens e (1998). widening the scope of accreditation – issues and challenges in community and primary care. international journal for quality in health care; 10(3): 191-197. 30. heidemann eg (2000). moving to global standards for accreditation processes: the expert project in a larger context. international journal for quality in health care; 12(3): 227-230. 441 accreditation of health institutions as an external tool for quality improvement 442 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title project management module: 2.11 ects (suggested): 1.0 authors, degrees, institutions silvia-gabriela scîntee part-time lecturer at the university of medicine and pharmacy „carol davila” bucharest, department of public health and management public health consultant at the institute of public health bucharest adriana galan, it specialist part-time senior lecturer at the university of medicine and pharmacy, department of public health and management, at postgraduate level address for correspondence institute of public health bucharest 1-3 dr. leonte street 76256 bucharest romania tel: (4021) 2249228 / ext.188, fax: (4021) 3123426 e-mail: gscintee@ispb.ro, agalan@ispb.ro keywords project management, project proposal writing, project development, project implementation learning objectives at the end of this course, students should be able to: • identify what it is needed to know and do to set up a project; • identify the needs and to set up the priorities; • prepare a preliminary brief; • plan and schedule a project; • set up a monitoring and evaluation plan; • develop a project proposal. abstract this course concerns basic concepts of project management, initiation phase, preliminary brief, detailed planning, scheduling, implementation and completion. at the end of this course, a project draft is proposed to be designed by the students. teaching methods lectures, interactive presentation of key concepts (overheads or powerpoint presentation), group discussions, groups' assignments. work in small groups (4-5 persons) and an overhead will be presented by each group after each assignment. specific recommendations for teacher it is recommended that this module is organized within 1.0 ects credit. the work under supervision is consisting from lecture (5 hours), supervised assignment solving (5 hours), while individual work is related to collect data and to prepare the project proposal draft (20 hours). assessment of students final draft of a project proposal. project management silvia-gabriela scîntee, adriana galan project is not a new concept. projects have been carried on since the inception of the organized human existence and less complex projects are very common in our daily life. any work which has a beginning and an end, is planned and controlled and creates change can be called „project” (1). very often „the project” is considered synonymous with „the programme”. still, there is a difference between the two terms. a programme is more exhaustive than a project and has larger time limits. a programme can have more projects as component parts. projects are classified under four main headings (2): 1. industrial projects (civil engineering, construction, petrochemical, mining and quarrying projects): usually large projects, requiring massive capital investment and rigorous management, that incur special risks as the implementation phase is conducted remote from project manager’s office. 2. manufacturing projects (production of equipment or machinery): these are conducted in a factory, but sometimes requiring work away from the company for installation, customer training, subsequent service and maintenance. 3. management projects: arise in each organization as a part of its work or when a change is envisaged. examples: restructuring the organization, relocating the headquarter, refurbishing an office, planning a training session or conference, introducing new service, introducing a new computer system. 4. research projects: unlike other types of projects their final objectives are difficult or impossible to define. characteristics of the project regardless their type, the project has five common characteristics (3): it creates change, it has various goals and objectives, it is unique, it is limited in time and scope, and it involves a variety of resources 1. a project creates change. when a project is conducted the routines and regular work within an organization is disrupted by unfamiliar, new activities. this could lead to resistance from the staff as people do not like to 443 project management have their existing work altered. more than that, those working in the project have to report to the supervisor of the routine work and also to the supervisor for the project work. other sources for resistance could be: conflict of interests, low tolerance to change, different perception of the need to change, misunderstanding and lack of trust. the project manager could use various methods of change management to face this resistance in accordance with how much time, money and power he has. examples of such methods are: • education and communication – the best method which unfortunately takes a lot of time and money • involvement of people in project development – also good but still takes time • supporting people to facilitate change – takes also time • negotiating with people – takes less time, but a compromise has to be reached • manipulating people – quick and cheap method, but can fail if people feel like being used • coercion – the quickest and the cheapest, but in the same time has the highest probability to fail 2. a project has various goals and objectives. there are three types of goals and objectives for any project (3): • performance and quality – the end result of the project must be fit for the purpose of which it was intended • budget – the money spent on the project must correspond to the authorised expenditure • time of completion – all stages of the project should take place at their specified dates and total completion date should correspond to the planned finish date the project manager should find a balance between these three attributes: time, quality and cost. if the project finishes before the planned completion date, money may be lost. if the project is extended beyond its scheduled finish date is likely to have increased costs. in both cases the quality might suffer. 444 health systems and their evidence based development 3. a project is unique. there are not two identical projects. despite the existence of a standard methodology for project development and of a same basic procedure no matter the complexity of the project, the work content of every project varies. the project manager needs to develop a plan taking into account the particular circumstances that is both strong and flexible enough to accommodate changes in those circumstances. 4. a project is limited in time and scope. these are the main characteristics that make the difference between the project and the programme. a programme is not necessarily limited in time and its scope is more comprehensive. a project is limited in time and scope, having a beginning and an end very well defined. a great deal of the project manager’s effort is focused on the completion of the project at the scheduled finish date. there are a lot of tools that can be used in time planning, from timetables – the simplest, which represent a list of activities with their starting and finishing dates, to gantt chart and critical path more complex methods that take into account the dependency degree between activities. 5. a project involves a variety of resources. when a project resource planning is discussed, most people will think of resources first in terms of money. but resources are also: people, equipment, materials and time. it is very difficult to forecast the precise quantity of resources and the moment when these will be used. still, the necessary resources should be estimated and scheduled. it is also necessary to specify how these resources will be obtained. as there are a lot of factors that could impede the utilization of resources according to the schedule, the project manager must periodically evaluate the progress and if necessary re-schedule resources. the phases of project management the above characteristics of the project have implications for the project management that is defined as „the process by which the project manager plans and controls the tasks within the projects and the resources on which the organisation draws to carry out the projects.” (1) all projects may be planned and carried out in the following four phases, known also as „the project’s life cycle”: initiation, planning, implementation and completion. 445 project management initiation. projects arise because of a need. so, in the initiation phase there are determined: the need for the project development, the terms of reference (what has to be done, what would be the expected results), the feasibility of the project and also it is created a workable environment for the project. this is considered the most important phase in the whole project (1), even if is the shortest one usually taking no more than 5% of the project lifetime. planning. in the planning phase, which usually takes 20% of the project duration, the tasks, resources, effects and needs of the project are examined in depth (1). planning is under the responsibility of the project manager, either done by himself in isolation or by a planning team. during this phase it is decided what should be done, by whom, at what point in time and with what resources in order to reach the project’s objectives. it is important in the planning process to forecast the potential constraints that might affect the implementation phase and to design strategies for overcoming them. implementation. implementation is the longest phase of a project (60% of the project duration) in which the project plan is put into operation. the implementation process is monitored and controlled in order to ensure the obtaining of quality results on time and within budget. monitoring is a continuous oversight of the project execution that assists in its supervision and assures that it proceeds according to plan. on the basis of controlling the project progress is checked against the plan and corrective action is taken where necessary. completion. in the last phase the whole project is reviewed, the final report is presented and the resources are re-allocated. this phase usually takes 15% of the project duration. 1. initiation (pre-planning) phase this is generally considered the most important phase in any project. during this phase, what should be done under the project is determined (1). this phase includes usually the following steps: 1. situational analysis 2. health problems identification 3. priority setting 4. establish goal and objectives 5. feasibility study 446 health systems and their evidence based development 1.1. situational analysis situational analysis represents the first step of the pre-planning phase for any project. it represents an assessment of the health status of the population (can be a „target” population) and of the health care system in relation with the internal and external environment. according to r. pineault (4), the general framework of analysis can be conceptualised as follows: the main goal of this step is to define and establish valid criteria for the identification of priority health problems. another important goal is to provide data and information necessary to design objectives and strategic choices. it also represents a support for the feasibility evaluation. data and information collected during this step cover the following domains: • assess the internal and external environment (review of economic, social and health objectives and policies) • health status and related determinants assessment (mortality and morbidity rates, disability, life expectancy, lifestyle indicators, trends etc.) • health system assessment (public/private institutions, accessibility for health care, population coverage with services, patient flow within the health care system, etc.) 447 project management present situation desired situation health determinants health determinants health status health status (health objectives) health policies services produced and used needed services (service objectives) health services policies available resources needed resources (resource objectives) health resources policies plan of actions health promotion policies • resources – human, material and financial the main output of this step is represented by a comprehensive document offering a picture of the existing situation. 1.2. health problems identification the main goal of this step, involving more or less a subjective judgement, is to obtain a list of health problems. according to r.pineault (4), a health problem represents a deficient health status as perceived by individuals, physicians or communities. there are several methods described in the literature for problem identification. r.pineault (4) has described three categories of approaches: • based on existing health system indicators • based on special surveys • based on consensus research for each approach, he described the methods used in order to identify the health problems. the following table presents the methods used within each approach: 448 health systems and their evidence based development approach methods needed information based on existing health system indicators socio-demographic (associated to the health status and service utilisation) population structure, age pyramid, natality rate, crude mortality rate, fertility rate, average income level, level/rate of poverty, rate of unemployment, level of education health (mortality, morbidity, risk factors and disability) crude and specific mortality rates, infant mortality rate, life expectancy at birth and certain ages, standardised mortality rates/ratio incidence/prevalence rates, hospitalised morbidity, frequency of different risk factors, attributable deaths for certain risk factors, potential years of life lost due to certain risk factors daly, qaly health services utilisation medical visits rate, surgical interventions rate, number of diagnosis tests (e.g. laboratory, xrays etc.), number of referrals, hospitalisation rate (number of discharges), average length of stay health resources number and types of health care units, population coverage with different types of health care professionals (physicians, nurses, dentists etc.), health care expenditures in order to judge the identification of one problem, several criteria can be used: • problem’s dimension (usually its frequency within a population) • problem’s severity (usually measured by premature deaths, potential years of life lost, disability) • trends 1.3. priority setting priority setting means to select those problems identified during the previous step that can be the object of an intervention. it is actually a process of comparisons and decision-making, based on special methods and techniques for ordering the identified problems according to their importance. the conceptual framework of priority setting process was also described by r. pineault (4): 449 project management based on special surveys sampling health interview surveys (perceived health status) health examination surveys (based on clinical exams) based on consensus research delphi technique evaluate the opinion of certain experts on prevalent problems in a community. it is based on a group process of judgement, even if the experts don't communicate directly. the experts answer to successive posted questionnaires until sufficient level of consensus is reached. nominal group technique medical visits rate, surgical interventions rate, number of diagnosis tests (e.g. laboratory, xrays etc.), number of referrals, hospitalisation rate (number of discharges), average length of stay brain writing technique the difference from the nominal group technique is that all the ideas concerning the problems are presented (written on a table) from the very beginning to all participants. it is possible to reach the consensus also by voting or by final discussion. brainstorming technique it is mainly useful to generate ideas (mostly recommended for problem analysis and judgement of choices). experts are invited and encouraged to come up with original ideas. community forum public is invited to express community problems. three main criteria are used in order to prioritise the identified problems: • problem’s dimension (incidence / prevalence, premature deaths, avoidable deaths, invalidity, the size of the population at risk, the impact on medical services, family, society, etc.) • intervention capacity (knowledge on the disease / associated risk factors, prevention possibilities) • existing resources for intervention (existing services, qualified personnel, population accessibility to health services) there is a wide range of priority setting tools (ranking methods) that can start from a simple grid analysis, and ends with complex methods. based on a large number of criteria, these tools allow the problems ranking. if the list of identified problems is too long (>40), it would be necessary to shorten this list, using the selection method. 1.3.1 selection method its main purpose consists in rejecting the less important problems from the list. the result of selection method is a shorter list of more important problems, and not necessarily a problem ranking. a selection criteria is established from the beginning. a group of 3-5 experts will select the most important and less important problems during several meetings: • first meeting: the most important and least important problems are selected from the initial list, and put on separate lists (important and less important problems); 450 health systems and their evidence based development defining clear criteria if the list of problems is too long, a selection method would be necessary estimation and comparison of problems using ordering methods determine project goal and objectives for action p ri o ri ty p ro b le m s p ri o ri ty p la n n in g • second meeting: from the remaining list, the first 2 most important problems and the last 2 less important problems are again selected and put on the 2 previous lists; • third meeting: from the remaining list after the second meeting, the first 4 most important problems and last 4 less important are again selected and put on the 2 lists; and • the process stops when the list of most important problems contains no more than 10 problems. r. pineault has grouped the priority setting (ranking) tools into two categories (4): 1. specific methods for health planning. within this category, two methods are mostly used: • grid analysis • hanlon method 2. general ranking methods. within this category, several methods can be mentioned: • anchored rating scale • paired comparison • pooled rank grid analysis it allows formulating recommendations on priorities. it takes into account the problem importance, its evidenced relationship with associated risk factors, technical potential for problem solving, and intervention feasibility. the method allows establishing 16 possibilities of recommendations in descending order of priority for each problem. a general grid analysis is presented on the next page: 451 project management the results can be summarised in a final table as follows: 452 health systems and their evidence based development according to this method, problem 1 is considered the highest priority. hanlon method it ranks the priorities taking into account 4 components: problem magnitude (a), problem severity (b), solution effectiveness (c) and intervention feasibility (d). a. problem magnitude is usually measured by rates or index (a score is assigned for each problem; score values ranges between 1 and 10. value 10 represents the highest frequency in a population). b. problem severity is usually measured by mortality rates, potential years of life lost, daly, associated costs (a score is assigned for each criteria; score values ranges between 1 and 10. a final score is calculated for each problem, as the average of previous scores. value 10 represents the most severe situation). c. solution effectiveness must measure the availability of resources and technologies able to improve the problem. a score is also assigned for each problem, ranging between 0.5 and 1.5. value 0.5 indicates that the problem is difficult to be solved, while 1.5 indicates that there are possibilities to solve the problem. it is mostly a subjective judgement. d. intervention feasibility is also a subjective judgement taking into account the following components for each problem: pertinence (p), economic feasibility (e), acceptability (a), resources availability (r) and legal framework (l). a score is assigned for each component, 1 means a positive answer, 0 means a negative answer. a final composite index is computed for each problem based on the following formula: p1……n = [(a+b) x c x d] the highest score corresponds to the most priority problem. 453 project management problem importance evidenced relationship with associated risk factors technical potential for problem solving intervention feasibility recommendation from the grid analysis problem 1 + + + 2 problem 2 + + + 9 problem n + + 10 anchored rating scale a linear scale is used, ranging between 0 and 1 (1=extremely important problem; 0.75=very important; 0.5=important; 0.25=less important; 0=problem can be neglected). each expert is asked to place every problem on this scale. finally, a mean is calculated for each problem, having in the end a hierarchy. paired comparison problems are compared two by two. during each step, a problem is compared with all the others; for each comparison the most important problem is marked. for each problem it is computed in the end of sum of favourable situations. for example, if there are 5 problems (a, b, c, d, e) to be ranked, the method can be summarised into the following table: pooled rank a group of experts is ranking the problems, starting with the most important one (highest rank) and ending with the least important (lowest rank). each problem receives a rank from each expert. a mean rank is finally computed for each problem. 1.4. establish goal and objectives in establishing the goal and the objectives, the following elements should be taken into account: • the goal and the objectives of the national health policy • the goal and the objectives of the national health programme adressing the identified problem (if there is one) 454 health systems and their evidence based development problem paired comparison (selected problem is marked) obtained score or percent a a b√ a c√ a√ d a e√ a=1 or 10% b b√ c b√ d b e√ b=3 or 30% c c√ d c e√ c=2 or 20% d d e√ d=0 or 0% e e=4 or 40% • local health policies • international health standards and objectives there is also necessary to define: • the target population • the geographical area • the extent to which the problem can be reduced or solved • the time during which the problem should be reduced or solved stages towards defining the goal and objectives are presented in the figure 1. figure 1. stages towards defining the goal and objectives 455 project management analysis of the identified health problems analisys of the intervention posibilities setting the time period for the expected results identifying the services needed for reducing/solving the problem establishing the limits to which the problem will be reduces defining the goal and the objectives a goal is a long term result toward a project is aiming. in health, a goal usually refers to the solving or reduction of a health problem. there is not necessary to specify any quantitative outcome or time limits (5). ex. „to increase the reproductive health by reducing the number of abortions and undesired pregnancies in students from bucharest university” an objective is a desired outcome to be reached in a certain period of time. an objective measures the progress towards the stated goal. for this it is necessary to be quantified and to establish time limits. in defining an objective the following have to be specified: • what will be achieved • how much (to what extent) • when is expected the result • who will benefit • where is expected the result in defining objectives could also be used the acronym smart (s = specific, m = measurable, a = agreed upon, r = realistic, t = timebound). it is recommended a limited number of objectives (3 – 5). in accordance to the project complexity there can be established different types of objectives: • general objective – which would be the result expected at the completion of the project and shows how much the situation will improve; ex. „to reduce by 50% the number of abortions and undesired pregnancies in students from bucharest university, between 2000-2002” • intermediary objective – measures the progress towards the achievement of the general objective expected at a certain point in time; ex. „to reduce by 25% the number of abortions and undesired pregnancies in students from bucharest university, until december 31, 2001” • specific objectives – represent specific results that would assure the achievement of the intermediary and general objectives; ex. „to increase the information level of the students from bucharest university in regards with contraceptive methods” • operational objectives – that are in fact, the actions to be taken in order to reach the objectives; ex. „to freely distribute 10000 brochures on contraceptive methods to the students from bucharest university, between january – june 2000” 456 health systems and their evidence based development there are sequence and interdependence between different types of objectives (figure 2). figure 2. sequence and interdependence between different types of objectives 1.5. feasibility study the aim of this step consists in the evaluation of alternative proposed strategies in order to select the best one to be further implemented. the evaluation is focusing on three main aspects (6): • political feasibility • technical feasibility • institutional feasibility • financial feasibility political feasibility is focusing on the favourable / unfavourable political environment, on the agreement / disagreement of all key stakeholders involved. 457 project management technical feasibility usually takes into account three aspects: • provision of requested services needed to achieve the proposed activities (existence and availability of necessary technology) • the proposed offer of services (meet the population needs? are the services accessible? does it attain the target population?) • impact on health status (do the proposed services improve the health status? do the services contribute to the achievement of project objectives?) institutional feasibility is focusing on: • estimation of the necessary types of institutions and their geographical distribution, for the achievement of objectives (do they exist? do they need restructuring / rethinking? new institutions are needed to be created?) • staff (existing staff has sufficient skills? are training sessions necessary? new staff is necessary to be hired?) • administrative and managerial capacity (new capacities are needed? is the logistic support available?) financial feasibility takes into account: • estimation of total costs of necessary resources • estimation of running costs of the project • identification of possible financial sources 1.6. preliminary brief a brief contains the key information about the project, having a multiple use: • to proceed a feasibility analysis • to ask for funds • to direct the further planning of the project a preliminary brief should include: • project name • background (presenting the identified problem and the chosen solution) • goal and objectives 458 health systems and their evidence based development • the expected results • the required budget and time • methods of monitoring and evaluation • information about the organization 2. detailed planning and scheduling after objectives setting, a detailed plan of action is developed for each of them. action plans specify what should be done, by whom, where and when, being the bridge between stated objectives and the practical work. action plans could be seen as means and methods by which the objectives will be reached. a project plan should be detailed enough in order to: • provide a clear image on the activities • clarify for the project team the sequence and interdependence of activities • facilitate the correct estimation of the necessary resources there are described eight steps to be taken for the detailed planning of a project (1): 1. identifying the tasks (deciding what has to be done) 2. classifying the tasks and placing them in a logical order (some tasks are concerned with running the project, others are concerned with the actual work content of the project) 3. studying the implications (how the project could affect the organization policy, what is the impact on the clients, the public, the environment, what is the relationship with other projects) 4. estimating resource requirements 5. identifying the project hierarchy 6. clarifying the levels of authority (and setting clear areas of responsibilities for each person) 7. setting up the procedures needed to monitor and control the project 8. setting ground rules (informing the team of what is expected as a group norm) in order to schedule the work content and resources of a project there 459 project management are a lot of tools that a manager could use. the most known are gantt chart, and the critical path method. the gantt chart is recommended for the uncomplicated projects. a gantt chart is a simple display of tasks (listed in the first column) together with their duration of accomplishment (presented as horizontal bars alongside each task). the time periods could be presented either in days, weeks, months, quarters or years (figure 3). for more complex projects in which the dependencies between activities need to be shown a pert diagram could be used. pert (program evaluation and review technique) is a network tool relating tasks to each other on the basis of time and precedence and producing a critical path through the project (7). each activity is represented by an arrow, on which the activity is described together with the estimated duration. critical path is the longest path through the network of tasks that defines the duration of the project (7). for this path the project manager has to worry about as any delay of an activity could lead to the delay of the project end (figure 4). 460 health systems and their evidence based development figure 3. sample of a gantt chart 461 project management figure 4. example of a critical path a-b-f-g-h-i = 7+7+14+20+10+4 = 62 days a-d-e-g-h-i = 7+2+5+20+10+4 = 48 days a-c-j-h-i = 7+3+10+10+4 = 34 days in this example the first path has to be taken as critical path. the financial resources should also be planned. this is done by using the budget. budget estimation is very important for a project because: • is one of the essential elements a funding agency is looking for • represent a basis for the financial control that will compare the plan with its execution • helps in choosing the most cost-effective projects, attaining the allocate efficiency • allows a better resource allocation within a project, attaining the operational efficiency in order to estimate the budget it is necessary to: • list all types of required resources for each activity • determinate the quantity of each type of resources • estimate the unitary cost for each type of resources • calculate the total cost of each type of resources 462 health systems and their evidence based development a = methodology development; d = informing authorities; e = accept of authorities; g = data collection; h = data analysis; i = final report; b = testing questionnaire; f = pilot survey; c = training operators; j = developing software and online data collection • discount future costs if the project duration is more than one year the costs of each activity are usually presented in four expenditure categories: • personnel (like salaries, training, per diem, etc.) • equipment and materials (including also maintenance costs) • facilities (ex. renting, modifying or building a new office) • support expenditures a special category is represented by incidentals which usually should not exceed 10% of the total cost of the project should be justified. the budget should also contain the sources of funding. these could be represented by the organization’s own funds or there could be multiple financing organizations. each source will be specified for in separate columns. the estimated costs could be presented like in the following table: 463 project management expenditure categories activity description cost per activity own funds requested funds 1. personnel salaries accomodation perdiem transport example: project coordinator salary 100$/month x 12 months 15 participants in a training course held in bucharest x 5 days x 30$per diem 2 trainers x 5 days x 50$ fee/day 1200$ 2250$ 500$ 1200$ 2250$ 500$ subtotal 3950$ 3950$ 2. equipments and materials multiplying course materials 5$/participant/day x 5 days x 15 participants 375$ 375$ subtotal 375$ 375$ 3. facilities classroom rent 100$/day x 5 days 500$ 500$ subtotal 500$ 500$ 4. support expenditures communications 300$ 300$ subtotal 300$ 300$ 5. incidentals (reimbursed on the basis of receipts) total general 5125$ 800$ 4325$ a funding agency might have its own administrative procedures, so before submitting a project the agency should be contacted and should be asked about the necessary documents and the recommended budget format. the plan is many times negotiated with the funding organization. usually the project should be in accordance with donors’ policies and priorities. when deciding to fund a project a financing organization is mainly interested in: • project justification • technical capacity for running the project • compatibility with other projects • measurable and acceptable benefits • detailed and justified costs • sustainability (how the impact of the project will be continued after the project funding has ceased) • a clear monitoring plan • previous experience of the applicant • collaboration with other partners • multiple financing sources 3. implementation the implementation phase consists in putting the project plan into operation once all approvements and authorizations have been received. the plan should be flexible as even after being approved, in the implementation phase, changes might inevitably occur because of the internal or external factors. examples of internal factors could be: a key person that leaves the team, poor communication on somebody’s part, delays in equipment procurement or in funds release. external factors are less under the project manager’s control. examples of external factors are: partners who leave the project, change in donor’s policy, change in health policy or legislation, change in organization’s structure. implementation is initiated by the project manager and the other authorities responsible for the project by developing the job description for the 464 health systems and their evidence based development project manager. than the project team will be completed and the team roles will be assigned after assuring that everyone has a clear vision about the project and, if necessary, after training the team members for working together. the project plan will be reviewed and detailed as much as possible and tasks and responsibilities will be assigned for each member of the team, as well as the relationships between them. it is very important to set clear responsibilities and communication lines and to establish the authority levels in order to avoid overlaps, misunderstandings or delays in completion of tasks. over the implementation, the project manager should ensure that the necessary resources will be released on time for each activity. he should forecast the possible risks for not getting the resources in due time and should develop strategies to overcome these problems. an ongoing process during the implementation is monitoring. monitoring focuses on periodic measurement of workplan progress and achievement of intermediate project milestones. properly performed, monitoring provides current supervision and timely opportunities for remedial action (7). factors to consider in determining the scope and magnitude of the project monitoring are: • cost of the project • previous experience of the implementing team • manager’s familiarity with and confidence in the implementing team • complexity of the project • potential for injury to the project due to delays in both reporting and responding if monitoring is a method of ongoing review and measurement of the project to gauge its progress relative to its objectives and to plan continual improvements to both activities and management, evaluation takes a broad view of the projects activities, measuring the project’s success and effects and showing what difference will the project make (8). f. champagne (6) has defined the evaluation process as being a judgement on any activity, provided service or project component. the judgement is always based on some criteria and norms (normative evaluation) – mostly used for project evaluation – or on some scientific methods (evaluative research). 465 project management during project implementation, evaluation can be done as internal and external audit (operational evaluation) which can propose ongoing corrections. usually, any evaluation is focusing on the three classical components: structure – the resources used by the project are evaluated: • human (number, level of competence, existence of incentives) • material (quantity and quality) • financial (budget) • characteristics of the responsible organisation: size, type, affiliations, degree of specialisation process – is focusing on the following aspects: • project planning (appropriateness and adequacy of activities) • project monitoring (existence of periodic and final reports) • project organisation (leadership, human relationships, responsibilities) • project stage related to established deadlines and budget ootputs / outcomes – is focusing on specific results achieved by the project as compared with established objectives: • provided activities / services in order to achieve the objectives • obtained indicators • intervention impact (follow-up of an indicator after the end of the intervention) during the implementation stage reports will be required. reporting allows project managers to share the findings of the project through monitoring and evaluation, requiring periodic documentation of the project progress. a stage report includes financial updates, implementation status report and periodic evaluations. 4. completion during this phase, the final project evaluation usually takes place. this is called a-posteriori evaluation and it measures the level of project objectives achievement, project impact on target population. 466 health systems and their evidence based development a more comprehensive evaluation (evaluative research) can also be done during this phase. it takes into account the relationships between the three components: structure, process, outputs / outcomes. for instance, a relation between different types / quantity of used resources can be estimated according to process or effects (outputs / outcomes). economic evaluation is the most appropriate tool for this purpose. there are two types of economic evaluation: • productivity analysis – establish a relation between the process (provided services / activities) and the resources used by the project (expressed as number of services per invested monetary unit, number of services per health professional etc.) • efficiency analysis – establish a relation between effects (output/outcome) and the resources used or provided services (both expressed in a monetary value) a general framework of economic analysis was presented by r.pineault (4) in figure 5. figure 5. a general framework of economic analysis by r.pineault the most important document of the evaluation is included in the final report. this document usually describes the successes and failures of the project. the content depends on the project nature. the content will generally focus on expected results versus achieved results, as well as on the short-term and long-term impact on the target population. 467 project management structure evaluation process evaluation efficiency • cost-effectiveness analysis • cost-benefit analysis • cost-efficacy analysis • cost-utility analysis outputs evaluation outcomes evaluation resources services / activities productivity objectives impact (consequences) the achieved results can be grouped as follows: • physical results degree of needs attainment reported to a reference status the achieved level of indicators as a consequence of project implementation • socio-cultural results (related to the improvement of quality of life, of the general health status, etc.) • financial and economic results (reduction of sickness rate for the active population, etc.) • non-measurable results (organisational change, capacity building, behaviour change etc.) the final report will also describe the degree of goal/objectives achievement, the quality of norms and standards used by the project, procedures and criteria requested by the financing agencies, the quality of collected information. the conclusions will outline the encountered difficulties and, if possible, their generating causes, and will make recommendations on results dissemination. this document represents a valid basis for policy-making. 468 health systems and their evidence based development exercise: project management task: students will work in groups of 4-5 persons. each group will be provided with the following model for a project proposal. after each presentation during the lectures, the students will have to prepare every chapter of the project proposal according to the below model. at the end of the course, each group will present its draft of project proposal. model for project proposal 1. project name 2. executive summary (brief statement of the problem, short description of the solution, funding requirements, brief description of the organization and its expertise) 3. background (describe the context in which the project is developed; its relationship with other projects) 4. project justification (brief description of the problem that requires the project. facts and statistics will be presented in annexes. show how the project would contribute to the problem solving or reduction and what would the consequences be in case that the project will not be done) 5. geografical coverage and target population 6. project description goal objectives action plan detailed schedule (use a gantt chart) detailed budget 7. expected results 8. monitoring, evaluation and reporting (use indices as much as possible) 9. arguments to the success and possible riscs (feasibility, sustainability etc.) 469 project management 10. supporting materials (annexes: full description of the organization, cvs for the team members, recommendation letters, articles, statistics, documents that could support project utility, feasibility and sustainability) 470 health systems and their evidence based development references and recommended readings 1. burton c, michael n. a practical guide for project management. london (uk): kogan page limited; 1992. p.4-6. 2. lock d. project management. 6th edition, hampshire (england): gower publishing limited; 1996. 3. chalkley p. project management avoiding the pitfalls!, handouts from a training workshop on project management provided by crown agents – management training centre, bucharest, 1996. 4. pineault r, daveluy c. health planning – concepts, methods, strategies. revised edition. ottawa (canada): editions nouvelles; 1995. 5. marcu a, marcu gr. guidelines for the health programmes management. institute of public health bucharest publications; 2000. 6. champagne f, contandriopoulos ap, pineault r. a conceptual framework for health programmes evaluation. montreal (canada): rev.epidemiologie et sante 1985; 33: 173-181. 7. willoughby n. incredibly easy project management. victoria (canada): nwm ltd 1994. 8. wan t, ozcan y. introduction to grant writing. handouts from a workshop held at aiha third partnership conference for central and eastern europe, bucharest (romania); 1998. 471 project management 472 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title planning and programming of health care module: 2.12 ects (suggested): 0.25 author(s), degrees, institution(s) associate professor dr. kancho tchamov, phd, mph faculty of public health medical university sofia address for correspondence faculty of public health; medical university sofia hospital „tzariza joanna” 8, bjalo more str. 1527 sofia bulgaria tel: +359 2 9225197; fax: +359 2 9432304 e-mail: tchamov@bulinfo.net keywords public health, health care planning/programming, health caremanagement, goals, strategies, objectives, financial planning, monitoring, evaluation, planning team learning objectives applying the content of this module the student will be able: • to identify the determinants and the subsequent steps in the health care planning process; • to implement the public health planning/programming methodology at institutional, regional and national level; • to apply financial planning and budgeting technologies as a part of the overall planning/programming process; and • to monitor and evaluate health care plans/programmes. abstract health care planning and programming are future oriented processes aimed at defining strategies, activities and resources needed to achieve desired goals. the planning process consists of series of steps for accomplishing a set of targets to make the vision a reality. an experienced manager at any level of an organization should monitor the changes in the internal/external environment and the strengths and weaknesses of the planning design in order to increase its implementation effectiveness. health systems have the objectives to improve health, to respond to people's expectations and to provide financial protection in cases of ill health. the careful and responsible planning as part of the managerial process, whether undertaken by government or by private bodies, often under general rules determined by government has a pervasive effect on all the workings of the system. the presence of planning and implementation competences among the executive and field staff in the health system is an asset to the achievement of the desired final results. teaching methods lecture, individual work, discussions, group work specific recommendations for teacher this module should be organized within 0.25 ects, out of which one third will be under the supervision of teacher and the rest is individual student work. after the introductory lectures the student should become familiar with the steps of the planning technology and should start preparing a pilot plan/programme of a health establishment or a regional programme for achieving specific health care objectives or for reducing existing health problems. results can be presented and discussed in groups. assessment of students presentation or essay discussing the elaborated pilot plans/programmes, tests. planning and programming of health care kancho tchamov a comprehensive planning process provides the structure and the subsequent steps for implementing a programme, serves as a guide for the effective use of human, material and financial resources, and at the same time creates a common understanding of programme goals and objectives among the programme implementation team. many perfectly feasible and well financed projects fail to achieve the expected final results mainly due to the lack of full commitment on behalf of the senior staff and due to the lack of planning and implementation competencies among the executive and field staff. the most important components of an effective programme/project are a clear vision of the future and a well thought out detailed plan describing the steps that must be taken today, next month, and the years to come in order to accomplish the targets set and to make the vision a reality. although the planning process consists of a series of steps, it should not stop once the plans have been prepared. an experienced manager at any level of an organization should be continually on the watch for changes in the external environment and should be aware of the strength and weaknesses of the programme, ready to introduce adjustments in order to increase the effectiveness of the programme (1,2). planning is a future oriented process which allows a close look at the goals of a concrete organization or a programme/project aimed at defining what strategies, activities and resources are needed in order to achieve the desired goals. plans therefore answer the following questions: • what are the programme / project trying to achieve? • what is the present status of the organization? • where the organization wants to be in a period of 2 – 5 years? • how it is going to get there? • who is going to get the job done? • how will an institution / organization finance its programme? planning thus covers a wide range of tasks. both the setting of long-range 473 planning and programming of health care goals, strategies and the detailed activity planning for the immediate future are part of the same process. the annual work plans and budgets should usually be based on long-range goals and strategies but developed in a greater level of detail. critical for any programme’s success is the involvement of the senior as well as the junior staff in the planning process. an effective planning process can create a good proposal that could easily convince potential founders of the competence and the implementation abilities of an institution’s abilities to design and implement a successful programme. managers who possess effective planning skills have better chances to find additional funding, could have better control over their resources and could more likely achieve their objectives (3,4). 1. specific issues related to the planning process building up rational plans for preparing and implementing well-organized programmes require to meet successfully the following realities and challenges related to the organization of the planning process: planning defines roles and responsibilities – plans define who is responsible for what; they set measurable objectives for a programme/project; the division of labor makes the team members accountable for the implementation activities and the achievement of objectives. planning challenges the existing situation – planning is a prospective activity which usually aims for improvement; it is expected to introduce appropriate changes in a program’s environment which often require new strategies and new implementation technologies; the planning process puts the accent on the organization’s interests rather than on the personal interests; planning is closely related to changing the existing environment. planning is a team exercise involving different levels of staff – successful planning activities are performed by a team involving key staff members in the planning process; the composition of the planning group includes representatives of all departments of an institution or a programme, all key activities and groupings; the team members should share a common vision and should be motivated to contribute to the success of the designed programme (5). planning requires the consensus of key staff – many key issues relating to organizational strategy may result in conflicts which need to be managed so that final planning decisions can be productive; consensus planning needs experienced facilitators who consider that disagreements are constructive as long as they do not degenerate into personal attacks; the involvement of specialists with different professional background depend on the planning goals 474 health systems and their evidence based development and the type of the planning process; staff at all levels should have the possibility of making their views known to the planning team and should be kept informed about the issues discussed by the planners (6). programme planning is a time consuming business – in many institutions managers and staff underestimate the fact that planning is a time consuming exercise, leaving little time for their daily responsibilities and for the concentrated effort planning requires; preparing in advance a schedule for the planning meetings and an implementation schedule is helpful for a well organized planning process; organizing „staff retreats” moving to a different physical location for the planning exercise sessions can be a rational decision (7). 2. preparing a plan steps in the planning process developing a plan requires that the new programme under consideration be broken down into smaller parts to determine which activities must be completed when and by whom in order to achieve the planned objectives. a completed plan provides the structure for implementing the programme, serves as a guide for the effective use of human, material and financial resources, and creates a common understanding of programme goals and objectives for the planning team. when you start preparing your plan, first you have to identify the need and the demand for health care, and then to determine how to meet them for the specified target groups. this is a process containing the following steps: • stating the mission, or purpose of the organization/programme, • analyzing the external environment, • assessing internal strengths and weaknesses and external opportunities and threats (swot analysis), • establishing goals, • selecting activities for each objective; developing detailed work plans, • preparing a financial plan, • introducing a monitoring and control system. 475 planning and programming of health care 2.1. stating the mission (problem statement) stating the mission is the first step when preparing an organization’s plan. usually it is a general statement for the organization „per se”, about its vision, purpose and values. on the other hand a programme or a project should be created to respond to community defined needs or problems. so the first part of the plan should justify the need for the programme. this part of the plan contains the following two sub-sections: the problem statement – contains a description of a specific problem which should be solved or reduced by the programme/project. some baseline information should be presented that helps explain the problem such as: the nature, scope or severity of the problem; geographic area, demographic, health characteristics of the population; availability of health services (primary, secondary, tertiary etc.), health personnel, financial resources etc. the proposed solution – should contain a general explanation of the intentions and the design of the programme, stressing the important methodological aspects – most appropriate to address the described problem. the programme design should include: the approaches chosen for solving the existing problem; the expected positive results; sources of support now and in the future as well as the participating partner organizations/institutions; strategic alliances etc. (8). figure 1. stages of the mission statement 476 health systems and their evidence based development 1. problem analysis problem statement 2. solution expected outcome 3. outcome actual outcome activity plan strategy components activities objectives targets monitoring and evaluation 2.2. analyzing the external environment analyzing the external environment is the next step that relates to the organization’s mission, already defined in the mission statement. in general there are three main aspects that should be included in the external environment analysis: • collection of information data related to the programme/project from statistical sources and publications. • structured and informal interviews with administration officials/managers from ministries, municipalities, major donor organizations, ngos and private sector. • guidlines and summary of the main findings compiled in an information paper prepared for the planning team (1,2). when conducting the environmental analysis one should consider the possible information sources and the necessary information data relevant for the specific programme/project. in general terms the necessary information for conducting the external environment analysis may include: • macroeconomic data • data about the geographic and climatic conditions • demographic and health indicators • socio-economic information • health services information (outpatient and inpatient facilities, human resources, financing etc.) • policies and regulations • existing plans, intervention programmes and research projects in the health and social sectors etc. 2.3. conducting the swot analysis the next step of the planning process is to conduct a swot analysis in order to identify and assess the strengths and weaknesses of the organization or programme as well as the opportunities and threats on the bases of the information gathered within the frames of the external environment analysis (9). 477 planning and programming of health care table 1. components of the swot analysis the first steps of the swot analysis are aimed at defining the internal strengths and weaknesses of the programme or organization in respect to its management, programming and financing capabilities. a planning team should consider the items listed bellow and should decide whether the answers reveal strengths or weaknesses. the analysis of strengths and weaknesses of the programme/organization should cover the following management areas: analysis of management capabilities – determining subsequently the strengths and weaknesses in areas such as: organizational structures, planning, coordination, staffing, supervision, training, monitoring and evaluation procedures and systems, management information system, material resources management etc. analysis of programming capabilities – defining the potential capabilities of the organization/programme: to provide high quality medical services, training or education; to increase its efficiency; to provide grounds for improved patient satisfaction etc. this part of the analysis should define the weak points in the programme/project. what are the reasons for these weak points? what are the strong points? what expertise potential of the programme team reliable? are there activities that could enhance the programme/project under consideration due to the lack of human or financial resources? analysis of financing capabilities – analyzing the financing capabilities one should give answers to questions such as: what are the programme’s/project’s current sources of financing? what is the self-financing part of the project? how stable are the financial sources? what changes in the external environment are supposed to generate more revenues? where one can cut costs for the programme? what level of community or donor financial support does the programme enjoy etc.? the second group of steps in the swot analysis is to focus on the process of translating the environmental analysis into opportunities and threats. concretely one should identify those points that create opportunities for the programme and those that pose threats or obstacles to the performance or implementation process. this part of the swot analysis is usually carried out in a brainstorming session of the planning team. the analysis of opportunities 478 health systems and their evidence based development positive negative internal strengths weaknesses external opportunities threats and threats can explain past performance problems and failures and highlight the opportunities and threats that could possibly affect the process of achieving one’s goals. 2.4. establishing goals and objectives selecting goals a well-designed programme/project should have programme/project related overall goals. they define in general terms the long-term changes that will be the final result of the respective programme as outlined in the problem statement. normally one or two general statements describing the expected long-range positive results for the target population are sufficient to describe the overall project goals. organizational goals usually define the internal changes and improvements that the organization/programme should make in order to achieve its goals. in setting goals one should make sure that the programme related goals do not exceed the available financial, material and human resources. established goals should not over-extend the organization’s ability to provide quality services and the work team potential. source: health 21health for all in the 21st century. who, regional office for europe, copenhagen, 1999, p. 224 selecting objectives for each overall goal developed by the planning team there should be several specific and measurable objectives. these objectives should relate to the problem statement and describe expected results achieved through changes in knowledge, behavior and attitudes of the population or the target groups. the objectives should be used to ensure that evaluations conducted later in the project will measure the results the project intends to achieve. the objectives stated should be: measurable and observable; related to qualitative and quantitative targets as much as possible; and indicative for the specific time periods for the completion of the programme (10,11). 479 planning and programming of health care example of an overall goal: the health 21 policy for the european region of who has the following main elements: • the one constant goal is to achieve full potential for all. two main aims for better health guide efforts towards this ultimate goal: • promoting and protecting people’s health throughout the course of their lives; • reducing the incidence of and suffering from the main diseases and injuries. selecting strategies the next step at this stage is to select strategies for reaching the stated goals. the process of selecting specific strategies is aimed at defining the technology of reaching the desired final results. the planning team could in a brainstorming session come up with several possible strategies that could be evaluated in terms of feasibility, financial impact, projected costs and time perspective. using the information collected during the external environment analysis the planning team can analyze the existing competition on site i.e. look at what other providers (institutions, organizations, ngo’s) are doing. at the end of this step state the strategy the planning team has chosen. if the selected strategy has several components, state each of them. although at this stage a detailed final analysis of the cost of strategies will not be conducted it will be necessary to consider the financial implications of the proposed strategies. the planning team should roughly cost the strategies taking into consideration the recurrent as well as the capital costs. selecting activities for each objective the plan of activities constitutes the core of the programme/project and should describe the detailed activities to be accomplished for each programme objective. a fully developed plan will contain listed a detailed set of activities to be carried out in order to achieve each objective. staff members of the planning/implementation team should be assigned to each activity, being kept responsible for controlling and carrying out the activity. the activity plan is supposed to provide the programme/project team with a clear picture of their responsibilities and activities during the project implementation. it can be divided in two parts: selecting detailed programme/project activities under each objective all the activities necessary for the fulfillment of each objective should be listed. the description of the activities should explain concretely how each of them would contribute to the achievement of pro480 health systems and their evidence based development well formulated objectives should be: specific – concrete, avoiding differing interpretations measurable – quantifiable, allowing continuous monitoring and evaluation appropriate – relevant to the defined problems, goals and strategies realistic – achievable, challenging and meaningful time-bound – with clearly defined time period for achievement. gramme objectives. a staffing plan of the programme/project together with job descriptions for each post should supplement the activity plan. this section should contain: a description of all the activities to be carried out that answer the questions „what, where, by whom and when”; a description of the management systems (i.e. supervisory, information management, human resources and financial management) designed to support the activities listed; partnership activities etc. preparing programme/project activity timetable a complete activity timetable is a condensed summary of the main project activities in their planned chronological sequence. it is a detailed description of the time-span in which each activity should be performed and of the team members responsible for the implementation of these activities. the programme activity timetable is an important implementation tool and should be used for monitoring the activities and the short-term results; for keeping the planned implementation on schedule; and for managing the programme’s resources. a project activity timetable developed at the start of the project can be periodically updated and referred to by project staff on regular basis. it is helping programme planners and supervisors to integrate and coordinate their work, to monitor and evaluate the progress of the interventions under way. it is useful to specify when it is aimed to start each activity. for each task or activity listed, consider who will be responsible either for doing it or, in some cases, for making sure that it is done. critical elements of the programme planning process the following four areas of critical importance should be considered by the managers in order to develop a successful plan namely: procurement of equipment and supplies; training; service delivery and sustainability. procurement – the plan should include a procurement section supposed to list the types of supplies, equipment and materials necessary for the project. tender procedures should be foreseen for the procurement of costly commodity supplies. a system for logistics management with record keeping and reporting systems should be worked out for the distribution of supplies to service points. training – the plan should contain a training programme for the implementation team as well as for the target population. this section should focus on: the programme content; the participants’ background; the criteria for selecting the participants; the resource persons and the topics to cover; logistics plan etc. 481 planning and programming of health care service delivery – if the programme/project foresees the creation of new health services or expansion of existing ones, the planning team should provide detailed information on any programme activities necessary to support the implementation plan. they may include: the replacement of existing equipment; maintenance contracts; renovation or reconstruction of service facilities; follow-up activities etc. sustainability – the important issue of sustainability is related to the capacity of the organization/programme to cope with the future changes in the external and internal environment. the ability of a programme to attract external funding or to generate income and develop self-sufficiency are the ways to establish financial sustainability. a description of the activities that will generate income and the ways that income will be used should be included in the plan. 2.5. preparing a financial plan and a budget after selecting among the possible strategies, the planning team members make approximate estimates of costs against the revenues to determine their feasibility. while preparing a financial plan one should: analyze current and potential sources of revenue and expenses for the strategies chosen; assess whether the expected revenues will cover the expenses; monitor and revise activities to ensure the financial stability of the programme; prepare detailed estimates of revenues and expenses. the next step undertaken by the planners after defining strategies, objectives and activities is to prepare a detailed year-by-year budget and a summary budget for the life-span of the programme/project. this detailed estimate or a summary budget is the financial plan. once the financial plan is completed, the planning team can draw up a work plan and budget for the first and for every subsequent year. the budget will be based on the financial plan and will describe in much greater detail sources and amounts of revenues and expenses for the year to come (12). in order to prepare the detailed budget one should carefully examine each programme activity and define the costs that are associated with its implementation. all costs will then need to be sorted into budget categories. the first draft of the budget should contain only direct programme/project costs, e.g. costs which are directly associated with specific project activity. each item listed in the budget should be clearly identifiable in the activity plan. 482 health systems and their evidence based development sample budget categories there is no single correct way to develop a budget. when preparing a programme budget, check your organization’s budget categories and the types of costs included in each category. the categories listed bellow, provide a basic guide for developing and organizing a programme budget. • salaries and wages this category includes the sums to be paid to project personnel for salaries and wages. salaries are generally paid on a monthly or annual basis, while wages are paid on an hourly basis. in a budget each position should be listed with its title, the amount of monthly or early salary, the full or part working time and the hourly wages to be paid. salaries and wages under this cost category should be planned only for employees of the programme/project. • fees this category includes individuals who are not legal employees, such as short-term consultants and those hired under contractual agreements such as auditors, lecturers, researchers, evaluators etc. this category also includes honoraria paid for professional services rendered. the type of service, the individual performing the service and the cost of the service should be listed in the budget. • benefits this category includes all expenditures for benefits in correspondence with the existing labor legislation in the country and the approved policy and practice of the programme. benefits should be included only for persons listed under „salaries and wages” if the local laws does not mandate other types of entitlements. • travel and associated expenses this category normally includes regular and customary travel associated with the activities of the project. these costs may include travel for supervisory visits, staff meetings, outreach and field visits. • supplies and equipment office and medical supplies, commodities and equipment to be purchased should be listed in this category. the cost of each piece of equipment and commodity should be shown. • education and training the expenses related to this category refer to the costs of having participants in the programme attend specific training activities such as workshops, courses, seminars or conferences. it includes all expenses for tuition, training, fees, conference registration fees, travel costs, per diem, books and others. • general administration all expenditures that are not an issue of contractual agreements can be listed in this category. they include postage, freight 483 planning and programming of health care and shipping insurance, photocopying, printing, telephone, faxing, utilities, bank charges, publications, vehicle registration, employment advertising and other customary administrative costs. • purchased services this category refers to long-term contractual services or agreements with institutions. for example building rental, maintenance contracts for equipment or vehicles, long-term leases on equipment or vehicles, advertising or promotion services that are of major importance for the project. • unforeseen costs they include costs that do not fit into the abovementioned categories. such costs could be induced by: changing price and/or exchange rates, indirect cost rates etc. which can be listed here. there are four types for funding programmes or projects namely: entirely government funding; donor funding; funding through generated revenues; and mixed type of funding. in drawing up financial plans one should distinguish between the different types of funding since the reliability of each source is different. the planning process with no doubt will vary according to whether the organization or the programme is situated in the public or in the private sector (13). a sample of a planning schedule is presented in table 2. table 2. steps in programme planning – sample schedule 484 health systems and their evidence based development steps in planning participants time needed dates mission statement top and mid-level management three-hour meeting january 14 environmental analysisreport consultants and technical staff data collection four weeks jan. 14 feb. 14 swot analysis formulating long-term goals defining strategies and objectives swot analysis preparing financial plan departmental objectives 3. programme monitoring and evaluation monitoring and evaluation plans of programmes/projects should be included in the initial programme design. the monitoring and evaluation process should be base on carefully selected indicators appropriate to the social, economic, health and information realities and possibilities. 3.1. monitoring monitoring is a process by which programme activities and the programme-budget are regularly reviewed. monitoring helps to ensure that the activities planned in the work plan are being completed and that the costs are in line with the budget provisions. financial monitoring enables the project team to: control the rational spending of the budget; to verify that the team leadership’s financial decisions are being followed; and to define whether budget revisions are needed. monitoring of implementation and evaluation of effectiveness and impact normally take place at two levels: the policy making level; and the managerial and technical levels. both levels should be interlinked (14). in monitoring programme implementation it is important to use as reference points those objectives and targets that have been set as part of the process of formulating programmes and designing the health system. it is particularly important to monitor whether priorities are being adhered to, realizing that these may have to be implemented progressively. indicators are then selected that can measure change toward attaining the objectives and reaching the intermediate and final targets (15). a monitoring plan should include at least the following: • creating a monitoring team which to include programme/project personnel who will be assigned the task to monitor the programme development, programme management and financial activities; 485 planning and programming of health care setting targets preparing work plans preparing annual budget discussion and approval of departmental plans • control over the timely monitoring procedures and their organization; • development of criteria to be used for monitoring the programme activities; • development of monitoring protocols. 3.2. evaluation the evaluation of a programme/project is a process of critical assessment of the degree to which the entire project or service components fulfill stated goals. it is important to have a plan for assessing project achievements during and after the implementation of a programme/project. the evaluation of a programme should analyze: the implementation process – referring to whether the planned activities were carried out and completed; the outcome outcome evaluation often require a long term monitoring of structures, activities and staff performance; and the impact – e.g. the long term effect that the project had on solving the target problem or on the target population. developing the evaluation section of the plan will make known in advance what elements of the programme will be evaluated, how and when the evaluations will take place. the scope and the content of the evaluation technology (i.e. what and how programme results should be measured) will help strengthening the team motivation for reaching the objectives of the project. in general terms an evaluation plan should include: • sets of evaluation criteria developed by the planning team • description of the evaluation technology used • information collection and processing • a reporting system the development of monitoring and evaluation criteria should be based on the use of appropriate indicators. the indicators to be used can be grouped into the following five categories: 1. health policy indicators; 2. social and economic indicators; 3. indicators for the provision of health care; 4. indicators of health status and the quality of life, and 5. performance indicators. 486 health systems and their evidence based development at present many health care planning decisions are based principally on values and resources, i.e. opinion – based planning/programming; insufficient attention is paid to evidence derived from new information sources or to evidence from research findings. nowadays as the pressure on the resources allocated to health care increases, there should be a transition from opinion–based planning to evidence-based planning decision making, adding sufficient evidence to this process. the management skills necessary for health care planning/programming in the 21st century will require: the planning decisions to be made explicitly and publicly; and the enough competence of those involved in planning exercises to produce sufficient evidence for efficient decision making (8,11). 487 planning and programming of health care exercise: planning and programming in health care task 1: students should use the recommended readings to increase their knowledge on the health care planning and programming technology, and the implementation of the subsequent planning steps in virtual and real situations. small groups’ planning exercises will be assigned aimed at elaboration of health care plans/programmes for pre-selected establishments at different levels of the health system. results can be presented and discussed in groups. task 2: students will be asked to prepare individually a comprehensive planning exercise for a health area close to their professional background related to curative, preventive or health promotive activities within the health care system. the selection of the problem areas and / or institutions as focal points of the planning exercise will be selected with the support of a tutor. the elaborated plans/programmes will be presented and assessed in plenary sessions. 488 health systems and their evidence based development references 1. varkevisser cm, pathmanathan i, brawnlee a. designing and conducting health systems research projects: vol.1. proposal development and fieldwork. idrc, otawa, 2003, p. 380. 2. varkevisser cm, pathmanathan i, brawnlee a. designing and conducting health systems research projects: vol.2. data analysis and report writing. idrc, otawa, 2003, p. 320. 3. ritsatakis a, barnes r, gekker e, harrington p, kokko s, makara p (editors). exploring health policy development in europe. world health organization, regional office for europe, copenhagen, who regional publications, european series no 86, 2000, p. 537. 4. the world health report 2000. health systems: improving performance. who, geneva, 2000, p. 215. 5. geller rj. the first year of health improvement programmes; views from directors of public health. j public health med 2001; 23 (1): 57-64. 6. segall m. district health systems in a neoliberal world: a review of five key policy areas. int j health plann manage 2003; 18 suppl 1: s5-26. 7. programming for adolescent health and development. report of a who/unicef study group on programming for adolescent health. who, tech. rep. ser. 1999; (886): i-iv. 1260. 8. mossialos e, dixon a, figueras j, kutzin j (editors). funding health care: options for europe. european observatory on health care systems series. open university press, buckingham-philadelphia, 2002, p. 309. 9. good practice in occupational health services: a contribution to workplace health. who regional office for europe, copenhagen, 2002, p. 80. 10. the 10/90 report on health research 2001-2002. global forum for health research. c/o who, geneva, 2002, p. 224. 11. muir gray ja. evidence-based healthcare: how to make health policy and management decisions. churchill livingstone, new york edinburgh london, 1997, p. 270. 12. saltman rb, busse r, mossialos e (editors). regulating entrepreneurial behavior in european health care systems. european observatory on health care systems series. open university press, buckingham-philadelphia, 2002, p. 240. 13. macroeconomics and health: investing in health for economic development. report of the commission on macroeconomics and health. presented by j.d.sachs. who, geneva, 2001, p. 202. 14. mckee m, healy j (editors). hospitals in a changing europe. european observatory on health care systems series. open university press, buckingham-philadelphia, 2002, p. 295. 15. saltman rb, figueras j, sacellarides c (editors). critical challenges for health care reforms in europe. open university press, buckingham-philadelphia, 1998, p. 424. 489 planning and programming of health care recommended readings 1. varkevisser cm, pathmanathan i, brawnlee a. designing and conducting health systems research projects: vol.1. proposal development and fieldwork. idrc, otawa, 2003, p. 380. 2. varkevisser cm, pathmanathan i, brawnlee a. designing and conducting health systems research projects: vol.2. data analysis and report writing, idrc, otawa, 2003, p. 320. 3. exploring health policy development in europe. ritsatakis a, barnes r, gekker e, harrington p, kokko s, makara p (editors). world health organization, regional office for europe, copenhagen, who regional publications, european series no 86, 2000, p. 537. 4. cassels a. guide to sector-wide approaches for health development. who, geneva, 1997, p. 80. useful internet sites • http://www.who.int • http://www.who.dk • http://omni.ac.uk 490 health systems and their evidence based development health policy 491 comparative analysis of regional health care systems in the european union 492 health systems and their evidence based development 493 informed health policy and system change health systems and their evidence based development a handbook for teachers, researchers and health professionals title informed health policy and system change module: 3.1 ects (suggested): 0.75 authors, degrees, institutions prof. vesna bjegovic, md, msc, phd professor at the school of medicine, university of belgrade serbia and montenegro dr bosiljka djikanovic, md address for correspondence institute of social medicine, school of medicine, belgrade university dr suboti}a 15, 11000 belgrade serbia and montenegro tel: +381 11 643 830 fax: + 381 11 659 533 e-mail: bjegov@eunet.yu (vesna bjegovic) e-mail: boss@bitsyu.net (bosiljka djikanovic) keywords health policy, strategy, priority, management of change learning objectives after completing this module students and public health professionals should: • increase their understanding of health policy; • understand the steps in the process of health policy formulation; • identify goals of health policy in a broader sense; • recognize main problems which could affect goals implementation and adopt recommendations for their solving; • explain the role and responsibility of key stakeholders in health policy; • identify similarities and differences between global and national health strategies; • realize the importance of skilled and comprehensive educated manager for implementation of health system changes, as well as their monitoring and evaluation. abstract the modern health policy in its broader sense is striving towards a continual process of the population health improvement, through implementation of goals and priorities. principal actors concerned for health policy are the government, ministry of health, health providers, health care consumers, health insurance and the general public through governmental and non-governmental organizations. for successful implementation of health policy, the number of established goals and priorities must be reasonable and wide consensus between interested groups should be achieved. the process must be followed by continuous monitoring and evaluation. the recommendations for the health policy changes refer to redefining roles of the state and the ministry of health, providing for the decentralization process at all levels, the regulation of the privatization process, sustainable financing of the health care system, the application of modern management at the system and institutional levels, the development of health information system as a support, and education of managers in this field. teaching methods teaching methods include lectures and small group discussion. teacher should advise students how to use internet source in preparing exercise comparing health policy indicators. 494 health systems and their evidence based development specific recommendations for teacher it is recommended that the module should be organized within 0.75 ects credit, out of which one third will be done under supervision, while the rest is individual student's work. teachers should be familiar to give examples of specific issues following the policy cycle. assessment of students multiple choice questionnaire and quality of seminar paper (or oral presentation) will be assessed. informed health policy and system change vesna bjegović, bosiljka đikanović a policy is a guiding principle or a plan of action agreed to by a group of people with power to carry it out and enforce it. as a discipline health policy has its roots in political science – especially public policy – which is based on sociology, law, economics, decision theory, operational analysis and history (1). public policies are aimed at the whole population or at specific, target groups and can be created by all levels of government as well as by institutions such as school boards, hospital workplaces or community organizations. public policies are made through a process involving citizens, government officials, an elected officials who, ideally, working together to set an agenda for the common good. policies shape our daily lives by regulating such things as where and when citizens may use pesticides, where we can or can not smoke, which medications and treatments health plan will cover, what is safe environment and so on. policy making process is not something that takes place only among the most powerful in society. in countries with democracy public opinion and actions of interest groups become very important. one of the key functions of public health professionals is to influence and shape policy decision at all levels for the benefit of the population. influencing policy at any level requires an understanding of public policy, how it is developed and what levers are available to influence the policy making process. the health policy, „as a series of goal-oriented actions undertaken by authorized participants (usually government and state representatives)”, is a relatively new domain of interest in professional groups even in highly developed countries (1). this interest is presumed to be a scientific response to an intensive development of the health system in the 60’s and 70’s of the twentieth century, an attempt to explain the reasons why the states tackle the actions aimed at proposing the course and contents of changes in the health system. in pluralistic democracies, health policy becomes the focusing mirror for all other policies. it encompasses debates over money, access to services, health care quality, and outcomes. it also continuously reflects changes both in social context and in the very scientific base of medicine. there are no single issues in policies, and no clear boundaries; every political issue can ebb and 495 informed health policy and system change flow, and anyone can rise up overnight to dominate debate. similarly, in health policy, every societal problem ultimately presents itself as a health problem. health care can easily find itself affected by policies about an extremely wide variety of social issues. there are few clear boundaries. social disintegration and economic trauma leads to unemployment, alcoholism, violence, drugs, teenage pregnancy – all become health care issues. the modern health policy in its broader sense is striving towards a continual process of improving the population health (2,3). it represents the formal statements or procedures within the government and institutions by which the priorities and action parameters are defined as response to health needs, available resources, and various political pressures. the health policy can also be defined as a science of the health system management (4). it comprises ideology, tradition, and aspirations of authorities, while its basic purpose is to set up the path for the health system development, its strategy, the goals, priorities and means, as well as to establish a particular mechanism of evaluation for the realization of the priorities. very often the health policy is described by using the policy cycle (figure 1). figure 1. the policy cycle the health policy is often followed by laws or other legal regulations, which define the incentives that enable the health services and programmes to 496 health systems and their evidence based development agenda setting pol icy formulation policy legitimation policy implementation policy termination or change pol icy evaluation be provided for. as is the case with other policies, the health policy arises out of the systematic processes of creating the support for evidence based public health action, and it is integrated into community’s endeavors, the political reality, and available resources (5). in the last few years, both in developed and developing countries, efforts have been visible to reform the health policies through various changes relating to priorities, institutional – organizational structures, methods of financing, and health regulations. the health policy reform are decided upon by a governmental body, but the reform also affects the public and private institutions, it is inevitably occurring in the actual political framework, and it depends on the form of a given country’s political system (parliamentary democracy, presidential democracy, one-party rule, dictatorship). the health policy as the foundation for the reform of the health system outlines the reflection of social values or ideals (such as accessibility to health care of high quality, education, government’s responsibility), which determine the choices and actions. the process of formulating the health policy undergoes at least three clearly defined steps (6): • setting the goals and resolving the priorities (a process by which public attention is drawn to it and these are placed on government’s agenda), • adoption of the policy (legislative process by which elected bodies decide upon a broad policy framework), and • implementation of the policy (a process by which administrators apply the policy, specifying numerous issues not covered by the health legislation). the reformist interventions in any health policy imply the key role and partnership for the basic interest groups in a political structure: the state, health providers, health care consumers, health insurance and the general public through governmental and non-governmental organizations (7). the state, acting through the minister of health, impels the managerial structures in all sectors to be oriented towards policies which facilitate health promotion. the partnership between the health and local authorities enables the local problems to be solved in the case both structures are directed towards the appropriate goals (8). unfortunately, it is often the case that a health policy proves inefficient, for the lack of a clear strategy, or the goals and priorities adopted by all parties involved, and if these are created by the most powerful and influential groups, such as clinicians’ »lobbies«, or by politicians outside 497 informed health policy and system change the health sector. it also happens that in the process of reform only the goals and priorities are changed, without their implementation and evaluation, while the health policy itself remains an instrument for both the actual ruling group and the opposition, or some informal centers of power and authority (4). health policy goals and priorities the goals in the broadest sense represent the desired state of affairs toward which the activities and resources are directed, but which may not be achieved necessarily (9). even though there is a tendency to quantify the goals, many distinguished authors point to a »virtue of vagueness« when setting up the general goals, and to the necessity of their constant reassessment (10). this is reflected in the fact that the health systems differ from one country to another, and even then most of them have similar general values and goals of their health policies (11): • availability of health care and equality of the consumers in the system – achieving equity in access (envisioning the existence of a minimum health care available to each citizen and an equal treatment for equal needs within the state/social health sectors); • material security of citizens (foreseeing that patients are protected from such health care payments which could seriously impair their incomes, that is, their contribution in the cost of health services is to be connected to their ability to pay); • macroeconomic efficiency (implies that the health care costs should be allocated an adequate amount out of the national income in order to secure certain level of health care for the population); • microeconomic efficiency (meaning that an improvement of population health should be maximized according to the level of resources invested in the health system, i.e., to achieve as much as possible with the allocated resources); • freedom of choice for the consumers (expects the freedom of choice among different providers to exist for the consumers of the health system); and • adequate autonomy for the service providers (implies the freedom of doctors to work in a way that they consider to be in the best interest of a patient), which is compatible to fore mentioned goals. 498 health systems and their evidence based development a characteristic of the stated general goals is that they are oriented to outcomes, and that they orient decision-makers onto outcomes, as opposed to former approaches when the goals, not so long ago, were rather oriented to expensive health care inputs (such as, for example, the number of newly provided hospital beds, or a larger sum of money spent on health services) (12). recognizing these general goals in determining the health policy most countries adhere to the recommended goals of international health organizations and the international community. among those the most cited and, according to many authors, the most ambitious health policy is the one formulated by the world health organization »health for all by the year 2000« and »health for all in the 21st century« (13,14). the literature dealing with health policy also often cites “un millennium development goals”, the health policy formulated in the united states as »healthy people«, as well as the health policy of the european union (table 1) (15,16,17). the world health organization adopted a resolution back in 1977 emphasizing as the main social goal for more than 190 countries members »the achievement of such a level of health for all people which would enable them to lead a productive social and economic life«, with an active participation of all people in the determination of health and in the development of a socially oriented primary health care. the dimensions of the european strategy »health for all« initiated in 1980 referred to the equity of all people in the health system. they were oriented to health improvement, to active participation by an informed and motivated community in achieving health, to inter-sectorial cooperation, development of the primary health care according to the health needs of the population, and to the international health cooperation concerning the problems which surpass national frontiers (13). relying on the indicated dimensions, the regional organization for europe in 1984 formulated 38 regional targets describing how the present circumstances must be changed by the year 2000 in order to achieve health for all. regional targets by the year 2000, according to the contents, are grouped into three spheres: • basic requirements for health, • necessary alterations (healthy life styles, healthy living environment, and an adequate health care), and • support systems for health development. 499 informed health policy and system change table 1. un millennium development goals (mdg) 500 health systems and their evidence based development 1. eradicate extreme poverty and hunger • reduce by half the proportion of people living on less than a dollar a day • reduce by half the proportion of people who suffer from hunger 2. achieve universal poverty education • achieve that all boys and girls complete a full course of primary education 3. promote gender equality and empower women • eliminate gender disparity in primary and secondary education preferably by 2005, and at all levels by 2015. 4. reduce child mortality • reduce by two thirds the mortality rate among children under five 5. improve maternal health • reduce by three quarters the maternal mortality ratio 6. combat hiv/aids, malaria and other diseases • halt and begin to reverse the spread of hiv/aids • halt and begin to reverse the incidence of malaria an other major diseases 7. ensure environmental sustainability • integrate the principle of sustainable development into country policies and programmes; reverse loss of environmental resources • achieve significant improvement in lives of at least 100 million slum dwellers, by 2020 8. develop a global partnership for development • develop further and open trading and financial system that is rule-based, predictable and non-discriminatory. includes a commitment to good governance, development and poverty reduction nationally and internationally • address the least developed countries' special needs. this includes tariff and quota-free access for their exports; enhanced debt relief for heavily indebted poor countries; cancellation of official bilateral debt; and more generous official development assistance for countries committed to poverty reduction • address the special needs of landlocked and small islands developing states • deal comprehensively with developing countries' debt problems through national and international measures to make debt sustainable in the long term • in cooperation with the developing countries, develop decent and productive work for youth • in cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries • in cooperation with the private sector, make available the benefits of new technologies especially information and communication technologies source: un, http://www.un.org/millenniumgoals/ such health policy has stimulated many european countries to formulate their national strategies and, in many cases, to set their own goals in order to improve health (12). the world health organization has recently reevaluated critically the achievements in the realization of the targets set for 2000 and regional organization has created a new set of goals for the health policy in europe – »21 targets for the 21st century« (14). this new health policy clearly promotes social equity, as well as definition for the key values and objectives. the european targets, 21 in number, rely on 10 global ones which may be divided into three groups (14) (the who european targets are presented at the who web page): • targets in relation to the people health outcomes, • targets in relation to health determinants, and • targets in relation to the health policy and sustainable health care system. concomitantly with formulating the targets for the european region, the world health organization also suggested some possible strategic guidelines and certain solutions for the implementation of national policies. for example, as for the health promotion, the projects and programmes with some positive experience are particularly recommended, such as »healthy cities«, »health promoting schools«, »healthy hospitals« and similar. after fifteen years of experience in designing, implementing, following, and evaluating the health policy, it is appraised that the highest achievements of this policy for health are strengthening the public health orientation through the health promotion and healthy life styles, healthy living environment, health care oriented towards quality and efficiency, and in a considerable improvement of knowledge about the creation of »the public health policy« (18,19). the public health policy is characterized by explicit care for health and equity in all spheres of politics, and by responsibility for influencing the health (5,18). the main goal of the public health policy is to create an environment which sustains and enables people to lead a healthy life. such a policy makes healthy choices possible and easy for all citizens, and it is based upon an approach which promotes health, according to which the governments are ultimately responsible for the health consequences of their policies, and for their shortcomings, too. adherence to the public health policy means that the governments are obliged to measure and report on their investments in health. investment in health is a strategy to optimize the influence of public policy onto the health promotion (18). however, questions are raised as to usefulness of formulating the precise goals as components of the health policy, and particularly of indicators 501 informed health policy and system change used in following their realization or failure (20). therefore, the recent reviews of goals point that the efficiency of a health policy is highly dependent on the implementation which is divided into three levels: • intention to define the goals on a political level, • developed plan at the political level, and • a plan for the implementation of goals at the practical level. development at a political level requires recognition of needs for an action and a political will for implementation. some countries recognize this need for action more than others. even when there is a political will to act and an agreement on the course of changes, the goals may remain unrealized. the experience of certain countries in the implementation of the formulated goals reveals the following recommendations (19): • a wide consensus among all interest groups is necessary, • the number of goals has to be limited rationally, for most of the national policies are focused onto five to ten goals, • each goal must be founded upon evidence on efficiency, which is particularly difficult when it concerns the health promotion, and • the goals must be conformed to available resources. according to one of the world health organization’s analyses of 1997, political responses in the process of the health system reforms in many countries throughout europe can be observed as distributed into two categories: formulation of goals, and classification of specific interventions (21). the first group includes: change of the role of the state and market in health care, decentralization onto lower levels in public-state sector and towards the private sector, strengthening and greater choice for the citizens, and improvement of the role of public health. the second group comprises interventions classified according to achieved outcomes, differing the successful ones from those less so. in the european union the health policy lays particular emphasis on public health in regards to the goals, as is also recognized in the ec treaties even in the maastricht treaty adopted in 1992 (17). social character of the health systems in the european union is based on the premise that „health care in not a normally traded good and access to it is a fundamental right” (22). member states have stated, in the treaties, that the organization and delivery of health services and medical care remains a matter of national competence. the driving force of the european integration process has been establishment of a single market. the european commission, the european parliament and 502 health systems and their evidence based development the council of ministers are the principal actors responsible for planning and implementing policy in the eu. this tripartite structure also ensures the process of health policy making based on the principle of subsidiarity. subsidiarity is the eu principle which states that action should not be taken by the community unless the objectives of the proposed action cannot be dealt with properly at national level. sometimes, this is used by opponents of eu health policy to say that eu should not have any powers in public health field. this means in practice that a health measure can be declared illegal if it does not improve the internal market and consequently economic interests are given political priority over health. on may 1st 2004 the eu underwent the latest enlargement as 10 new countries joined it. this one is different from those that have gone before, particularly according to the level of development between the member states and will almost certainly have implications for health and eu health policy (22). at present health and social policy in the eu is being developed in a different fashion, which follows expectations related to four freedoms (22,23): • free movement of goods, • free movement of persons, • free movement of services, and • free movement of capital. recent developments in the countries of the european union show that, notwithstanding the globalization and creation of a unified european market, this was not subject for debate when the national health policies were reviewed, and the european union itself has so far only had general recommendations for the health policy. those general recommendations were formulated through goals referring to advocating the health promotion, to the prevention of certain diseases affecting the whole of humanity, to the pertinent mechanisms for the inclusion of the community and the strengthening of research in the field of public health, particularly the health care for certain population groups, such as the elderly, the poor, the refugees and roma population. however, as a group of experts recently cited picturesquely, »the global economy (of the european union) is sitting at the table, while health politicians discuss financing the hospitals and paying the doctors at national levels« (24). as an example, the patients in the european union can now freely choose where to obtain their glasses or orthopedic appliances. the possibility of such a choice is reviewed as to the selection of hospital, which would have serious consequences in the sphere of financing the national health care systems, as 503 informed health policy and system change well as for the arrangements with hospitals. as joining of 10 central and east european countries is happened, the health policy of the european union will have to take into account the needs and expectations of their inhabitants. also, it is not only economy which is connected to the national health situation in the european union. the countries of the european union recognize the significance of other issues stemming parallel from the establishment of freedom of movement of people, goods, and services, such as ethical standards. for example, some countries forbid by their national legislation certain procedures in prenatal diagnostics, but they cannot prevent future parents from being informed about them in other european countries. also, the growth of poverty, the new and old communicable diseases, emergence of resistance to vaccines, but also the sale of body organs and pharmaceutical products, point to the necessity of comparative research, particularly the health status, and increase the need for greater coordination among the european union member states. under the conditions of exceptional mobility, the national legislatures are facing potential inefficiency. thus, the national health politicians in europe will have to find balance between the standards required by their own public and what can be achieved through their national legislation. it is assumed that the european union would have to formulate more specific goals in this sphere, while it is certain that the european health systems would not be determined in a single centre, as it is the generally accepted principle that the health service, which is to respond to the consumers’ needs, cannot be organized through »supra-national bureaucracy«. however, even the national legislation must be adapted to the change, and health politicians should take the environment in the neighboring countries into account (23). it is presumed that, beside the reviews of health policies at the political panels, such as the european health ministers’ meetings, some broader analyses are also required, performed by multidisciplinary professional teams. one of the indicators of the growing interest among the professionals is the publication started in 1999 of a bulletin where information is exchanged and challenges recorded in the fields of national health policies in europe (european health forum gastein – issues in european health policy, which is accessed free of charge on the internet). effective advocacy for health and health policy in europe is also supported through the open method of coordination, which facilitates policy reform by promoting mutual learning among member states. the open method of coordination gives a concrete meaning to the european social model, by helping to build consensus and to create a greater balance between the social and the economic dimensions in eu policy. this method includes: 504 health systems and their evidence based development • fixing guidelines for the eu combined with specific timetables for achieving their goals; • establishing indicators and benchmarks as a means of comparing best practice; • translating the eu guidelines into national / regional policies; and • periodic monitoring, evaluation and peer review. the open method of coordination is a process in three stages: 1. a political agreement on common objectives, 2. each member states submits a national action plan, explaining how it proposes to pursue the objectives (use of common indicators, easily comparable, benchmarking and good practice), and 3. follow up – joint report and corrective action used under the peer pressure. after the national goals are set in any health policy, there remain other challenges which are related to their implementation and prioritization. it is necessary to understand the actual patterns of the population health status. design and implementation of activities which are to lead to the realization of the goals require a high level of managerial skills in the sphere of public health. the following of progress requires acquaintance with the natural course of a disease. the crucial question is how much time does the achievement of goals take, and whether the set goals lead to any differences in health. the simplest answer to these questions is that it depends upon many factors, for there is no simple model for a health policy based solely on goals, just as there is no simple model of governance. measurement of progress in achieving the goals of each health policy is mainly determined by the nature of the set of goals which are to be measured, and in the european context the indicators suggested by the world health organization referring to the development of a health system founded on primary health care and on planning and managing the health system are most often used (13,14). as the external and internal environments pose numerous objectives to the health care system, a clear definition of priorities is an imperative as it secures monitoring and evaluation in the process of achieving the goals. 505 informed health policy and system change changing the legal basis for health and health policy is ongoing process everywhere and in the european union it could be recognized in the convention on the future of europe (http://european-convention.eu.int/). according to this document essential to ensure health is an objective of the eu and a shared competence of the eu and member states. the role of the state and the ministry of health in all health systems the state has the role of a collective mediator between other system actors: population – the consumers, providers, those who generate resources, other sectors. besides, it also performs a series of other functions, sometimes isolated ones, but more often combined. thus, the role of the state in the process of the health policy development refers both to guaranteeing that the changes in the health policy would be adopted by all the stated participants, and to the implementation of those changes, particularly of those that are related to the process of centralization – decentralization, privatization, and financing the health system (21). at the same time, the national health policy in the process of reform is supposed to secure an adequate approach to defining the role of the state. as can be perceived from the experiences of other european countries the role of the state goes beyond traditional measures of »command and control« and it furnishes incentives for the development of regulated market-oriented models of providing the health services. it is especially notable that the regulatory measures by the state are supposed to be more flexible and to temper through national legislation the multitude of differences (territorial, demographic) that often exist in democratic states. effective regulation by the state, too, is to be reinforced by following and evaluation of outcomes, not by contracting certain inputs (expensive equipment, enlarged hospital capacities, and similar). beside the state regulation, the health policy is to advocate the competitive state measures which are to provide for the process of active privatization, as well as for a competent supervision of contracting, and other market mechanisms by the state (24). as for the responsibility of the state, it is considered that the basic one is the responsibility referring to securing the accessibility to the nationally guaranteed set of services for each individual. besides, responsibilities of the state are also (25): • national planning and supervision of the regional plans, • incentives for offering the health care to vulnerable populations, 506 health systems and their evidence based development • to offer certain additional services out of the obligatory set of services which are financed outside the adopted model (e.g., outside the obligatory health insurance), • to organize data collection on population health status and on functioning of the health care system, and • concern for the programmes of continuous quality improvement – total quality management. according to the london institute for health sector development, the future of a health ministry, as a representative of the state, is to be freed from operational duties so that it can concentrate upon the health in its broadest sense (26). in the public sector this would mean: • the stimulation of activities which ensure that the financing process be connected to the needs of the health service, • the work with partners in the development so that duplication and administrative burden of multiple projects would be avoided, and • offering the national information on the quality, efficiency, protocols, data, and priorities. in case of the private sector the role of the health ministry refers to: • the control of the size of the private sector (too many providers means too much use), • the registration and follow-up, • the encouragement of self-regulation, • the control of the expensive technology, and • the contracting of services which are to be financed from public funds and which would have the adequate standard of quality. the position of decentralization in the health policy the issue of decentralization takes up a key position in the scope of measures of reforms of the health policy in most european countries, especially those in transition. the decentralization designates, in the broadest sense, transfer of authority and responsibilities from the higher to the lower levels of authority. the transfer of authority from the central administration to the bodies of smaller and local communities does not mean at the same time that the central administration would be deprived of all authority. on the contrary, it 507 informed health policy and system change would still retain important functions, such as legislative, financial, regulatory and other duties. the most prominent goals realized through decentralization in the field of health care are the following (23): • stimulation of improvement of offering health care services, • better allocation of resources according to the consumers’ needs, • diminishing of inequity in the sphere of health, • community involvement in the decision-making on priorities, • faster and more adequate reaction to the consumers’ needs, and other objectives. decentralization removes all those shortcomings that are ingrained in centralization, such as: inefficiency, slow acceptance of changes and innovations, delayed reactions onto factors endangering population health, susceptibility to political manipulations, and numerous other failings. decentralized institutions have multitude of advantages. they are more flexible than the centralized institutions and more effective in identifying the problems and prospects for their solutions. they generate higher morals and greater productivity. the decentralized structure also bolsters the partnership of health politicians with the citizens and local groups, and thus it also expands democracy in making political decisions concerning health at a local level. a successful decentralization requires specific social and cultural environments. certain local administrative and managerial capacity is required most of all, as well as readiness to acknowledge several interpretations of a single problem. the issue of decentralization is a very complex one, and when it is to be introduced the right measure has to be found. any excess, whether it refers to total centralization or total decentralization, affects negatively the proper course of the health care process. experience with the decentralization in many countries reveals that certain areas in decision-making should not be decentralized, and those are (21): • the basic health policy framework, • the strategic deciding on the development of health care resources, • the regulations related to public safety, and • the monitoring, estimation, and analysis of the population health status and of the health services offered. 508 health systems and their evidence based development recommendation for the health policy changes the recommendations for the health policy changes in the recent literature refer to: • redefining the roles of the state and the health ministry, • providing for the decentralization process at all levels, • the regulation of the privatization process, • sustainable financing of the health care system (elaborated in the section on financing), • the application of modern management at the system and institutional levels (also elaborated upon in the section on health management), • the development of health information system as a support to the health care system management (elaborated in a separate section), and • education of managers in the health care system. redefined roles of the state and of the ministry of health the states of countries in transition are supposed to have an important role in the whole health care systems, the one, however, which is quite different from the one that they have today, the one which is matched to the role the same bodies have in other modern countries. in a reformed health care system, the state, through its authorized ministry, must be engaged in at least the following areas: 1. adoption of documents at the government level on public health policy, i.e., the health promoting policy. the aims of such a document are to set up the health high on the priority list in the country, and also to undertake concrete activities thus oriented, with the health promotion approach. these activities do not involve only the health sector, but are obligatory for all the segments of a community that can contribute to health, or else endanger it. it is also necessary to define precisely the role of the non-governmental organizations, those directly or indirectly preoccupied with health promotion, while they can offer serious assistance to the governmental institutions in their allencompassing interventions in the education for health. 2. adoption of documents at the level of the health ministry on the health of the nation, which define the priorities in the health care system in the sphere of 509 informed health policy and system change health care, but also referring to the organizational forms. such a document is to be conformed to the mentioned documents of the european health policy, being the strategic foundation for the formulation of specific objectives evidence based from research on the health needs, financing, and functioning of the whole health care system in the country. the specific objectives are to be furnished with a time frame for their achievement and a flexible process in which the change is tested locally, or in pilot environments before it is widespread all over the country (27). 3. regulative – legislative role. beside a number of regulations and laws decreed by the state, it is of utmost importance to regulate the private sector in the health care so that active privatization is defined. 4. strategic planning aimed at the realization of defined goals of the health policy, especially to assure the guaranteed rights of citizens and their general interest in the health care. 5. initiating and financing the strategically important programmes of health care (children health, family planning, health promotion programmes, prevention of spreading of some diseases, both infectious and chronic, health care for those not insured, capital investments). 6. establishment of health institutions to perform the health care at the tertiary level and the rights stemming form it. 7. the control role, covering a range of duties at different levels and of different importance. beside the noted monitoring and control over the legislative sphere concerning the performance of the health insurance system and the health institutions of all forms of ownership, it is also necessary to set up monitoring of the quality of work, the mechanisms for the accreditation of health institutions, both state-owned and private ones, then of the individuals in those institutions, either generally or for specific services. an important control role consists of formulating the assessment mechanisms for the introduction of new technologies (health technology assessment), as well as control of the use of highly specialized health care (utilization review). 8. defining the strategy for the development of the health information system and its architecture (v. section on health information systems). 9. initiating the strategic research concerning the decision-making in the health care policy. 10. foundation of the national health council as an independent expert-advisory body for the matters concerning the health care, made up of experts and renowned professionals in certain fields. 510 health systems and their evidence based development providing the decentralization process at all levels in a reformed health system a particular place is given to decentralization. promotion of the primary health care as the foundation of the whole health system necessitates the obligation to transfer the bulk of authority from the central governmental bodies onto the local ones. in a decentralized health system, the municipality and the city are to: • follow the population health status on their territories, and to propose and undertake the required activities. • adopt and carry out the programmes for the improvement of population health status on their territories which are not encompassed by the referential programmes at the national level. • provide for the realization of the public health activities on their territories which are not encompassed by the referential programmes at the national level. • adopt and carry out the programmes for the development of a healthy living environment which are not encompassed by the referential programmes at national level. • establish the health institutions the performance of which provides the realization of the legally regulated rights of the citizens in the field of health care (primary health care center, office of physician and dentist and pharmacy). • determine the fulfillment of prescribed conditions to start operating and affecting the health care activities in regards to personnel, equipment, premises, for the state-owned health care institutions whose founders they are, and for the health care institutions or other forms of health care activities in private property. • besides controlling the lawfulness of operation, they also perform the outer checks of quality of the health care offered in cooperation with authorized bodies and chambers at the national level. • secure the financial means in their budgets for the stated and other purposes in the health care system. • this form of decentralization, including the one proposed in the section on financing the system, would greatly contribute to constant improvement of the health care quality. 511 informed health policy and system change application of modern management at the system and institutional levels the health policy entails that both the philosophy of the management at the system and institutional levels is determined, and that the management of change be applied in the implementation of the reformist endeavors. in many european countries today it is almost unimaginable that the process of decision-making is conducted by those individuals who do not possess management responsibility and professional managerial skills. for the complete system of management of the reform process it is of utmost importance that no mistakes which were recognized in former reforms in the central and east european countries are repeated. most often those mistakes were reflected in disregarding the necessity to have a qualified and efficient management, and also in the engagement of foreign experts without proper knowledge of the local circumstances, or the socio-economic and political systems in those countries. nevertheless, the good characteristic is the recognition of the partnership with high developed countries manifested in a longterm support for the programmes of »educating the educators« for management and organizational development (28). it would be advantageous if the modern system and institutional management, conditioned by permanent changes in its environments, especially so in the process of reform, is based on the philosophy of management by objectives and the total quality management. management by objectives, the concept introduced first in industrial company by peter drucker back in the ‘50s of the 20th century, can be often found today applied onto the health care system. it is a process in which both the superiors and subordinates identify general goals jointly, defining the field of responsibility while achieving the expected results, as well as criteria upon which the individual contributions for the accomplishment are followed and measured (29). attaining the goals defined in advance is the central process of each management. general goals of the health policy in the process of reforming have to rely on mandatory documents of the international health policy, while establishment of specific objectives must be based upon evidence from national health system, and it is to involve step by step in defining the priorities. it is beyond question that at the system level all interested parties must participate in this process, particularly the general public, for it enhances readiness, motivation, and endeavors in introducing the change. at the institutional level, the goals can have an enormous influence onto the participation of the employees in management, which is extremely important 512 health systems and their evidence based development for the success of any health policy. the goals of the institution should favor knowledge, public health orientation, and the quality of operation, by which greater participation can be expected, as well as higher responsibility of the doctors in the process of management. the main characteristics of this process are: • the manager and the employees understand and have a mutual consent on main duties and responsibilities of the personnel; • the employees set short-term and sometimes the long-term objectives in the execution of their work together with the management, which secures that the objectives be consistent with the organization’s goals; • the manager and the employees agree upon criteria to be used for the measurement and evaluation of attained results; • periodically, managers and the employees evaluate the progress in attaining the objectives and they carry out the alterations of the objectives in case the circumstances require them; • the manager has an active role in all coordinating mechanisms and ensures resources indispensable for the realization of the objectives, and • the estimation consists of the measurement of outcomes of operating and in identifying the achieved objectives in regards to timetable and previously established criteria. the next important instrument of the new health policy and health care system is the total quality management – the principle of doing business which holds the improved effectiveness, efficiency, and proper reacting to consumer’s requests as its basic characteristic. it is realized through active participation of all the employees within the organization in the process of improved services’ operations. the crux of the total quality management is the realization of business and organizational excellence (30). the nature of managing the quality, as well as the mechanisms for introduction of the total quality management programmes (the synonym is the term: »continuous quality improvement«) into the health care system, due to its complexity, differs considerably from those encountered in other business and industrial fields (31). the health institutions themselves are known to the theory of management to be the most complex organizations with the most complex management, while the modern hospital is on top of the list of complexity (32). there exists a triple distribution of power, responsibility, and authority (board of managers, director, and doctors), an extensive differentia513 informed health policy and system change tion and specialization of operating abilities is evident, and work duties are performed by a great number of participants who differ according to the degree of education, training, and functions. therefore, the main characteristic of the total quality management in the health care system is that it places the system, i.e., the institution to be its basic unit for analysis, and that it emphasizes the quality improvement by focusing onto prevention, not to correcting the poor quality, then onto the consumers of health care services, onto the system and its processes, and onto the organizational culture (33). in that way both the quality and productivity are enhanced, while expenses are diminished. at the national level, the total quality management is focused onto the measurement of performance and constant improvement of the quality of the whole health care (25). this entails establishment of the national goals of performance in relation to the chosen specific fields of quality, setting up the minimum standards for accessibility and quality, support to the research, assessment of technologies, development of tools to measure outcomes, evaluation of the impact of reform onto the quality of health care, the yearly reports on performances in the health care system, recommendations for the yearly alterations in the measures of quality, and establishment of five-year priority list, as well as usage of the national network of regional centers for collecting data regarding the quality health care. the national programme of quality improvement is to be supervised by an advisory board at the level of the ministry of health. the main processes of the total quality management at the institutional level are (34): • transformation of the organizational culture so that it be completely directed to the beneficiary and his or her satisfaction, • stimulation of the employees at all levels to improve the organizational process, • integration of the system and methods of support in order to motivate and reward the employees according to the quality and productivity of their work, and • engagement of systematic and institutional managers in cultural transformation, decentralization in decision-making, stimulation of the employees to approach the organizational changes management in a systematic way. therefore, for example, a hospital with the total quality management programme sets specific objectives for the quality, selects a number of priori514 health systems and their evidence based development tized fields (projects) for the improvement of quality, includes in the description of work for each employee the activities related to the quality improvement, plans time for those activities, secures the necessary resources (financial, and others), and provides for the compulsory education of the team members to be formally involved in the quality improvement activities. in the course of this process the »managers of quality« in the health care system and the health institutions are mentioned frequently, and as the critical factors which characterize the managers of quality the following are prominent: ability to motivate, to find the optimal stimulating structure, to create confidence, to delegate and decentralize. the wish to respect the will of the consumers of health services is important, just as to listen to the associates and to have a sense for subtle dimensions of interpersonal relations. a manager has an important role also as the creator of the image and vision in the programme of total quality management (35). the management is to be a catalyst in the process of permanent quality improvement, and the quality is part of the values created by all employees in the health system. the outcomes are important indeed, but the main emphasis lies upon the analysis of the process and in its improvement (36). there are various barriers in the organizational structure of the health system that have to be surpassed in order to make the total quality management programme efficient. one of the most prominent is to solve the existing conflict between a management and the professional autonomy (29). physicians with their professional autonomy have a powerful role, as they are responsible for the basic activity of the institution – providing of health services, and for the majority of decisions that create expenses. the doctors, privileged by their medical knowledge, also have the greatest organizational potential, as the nature of their profession implies a broader field than just clinical diagnosis and treatments, thus making them strive for unrestricted power over the economic and social aspects of their work, besides being of authority over the clinical aspects of diagnosis and treatment. however, as most often they are very little interested in affairs of the institution outside the domain of their own profession, the doctors contribute to organizational flows. despite their eminent knowledge of medicine, in reality most doctors know little about the surroundings they work in, as they spend most of their time working with patients or trying to gain more knowledge on their own. this phenomenon is recognized as the separation of professional autonomy from the institutional interests, which interferes not only with the total quality management, but also with the programme of reform (31). the potential spheres of conflict include (37): • responsibility – the model of clinical profession lays emphasis upon an individual, the model of total quality management stresses the process; 515 informed health policy and system change • managing – the model of clinical profession denotes the management of activities for the protection of patients by professionals, while the model of total quality management refers these to the management, with doctors to be included in the process of managerial decision-making to fully solve the problem of quality, while the initiative lays upon the management; and • autonomy and responsibility – the model of clinical profession implies full autonomy and responsibility of a physician for his or her work, and the model of total quality management means that the responsibility of the doctor lays both for the process and for the outcome of care, but with due regards to financial limitations. despite the stated limitations, adoption of the model of total quality management is a challenge to all professionals to mind the quality, to evaluate and regulate their work, and to protect their professional autonomy. doctors easily adopt this model in case necessary data are provided by the management, and when it is required from the doctors to concentrate onto clinical activities. implementation of the change management philosophy in the process of introducing the new health policy at all levels is indispensable, as some resistance and opposition is expected from all those to be affected the most by the change (doctors and managers in certain health institutions), without whose compliance and participation there can be no essential change. the management of change is a process which ensures efficient functioning of an institution under the conditions of the change being introduced (38). the efficient change management requires thorough planning, complete communication, persuasion of the employees in the validity and usefulness of the proposed change, involvement of the employees into those processes whenever possible, and following the execution of the change. the crucial factors for the success of the change are: • motivation – existence of key reasons to change the present unsatisfactory situation, • vision – clear and practical image of the desired future state of affairs, and • next moves – comprehension of all successive steps necessary for the progress toward reaching the vision. all three factors are indispensable and it is necessary to make them mutually multiply in order to effect the change: change = motivation x vision x next moves 516 health systems and their evidence based development in any management of the change as a group process special attention has to be taken in regards to the resistance of all the actors involved in the change, which is manifested as denial of the need for a change in the first place, or as passive opposition revealed in absence from the necessary activities or as active resistance, with specific engagement in blocking the introduction of a change (39). therefore, it is critical that the priorities be set as clearly as possible, and they have to be presented to everyone. it must be taken into consideration that all early reactions, whether positive or negative, are a good sign. the principal way of involving the employees is: to secure information (reasons for the change, where the change leads to, how to achieve the change – the role of the employees), one’s own planning of the activities, and demonstration of empathy and support by the managers. the key activities for an efficient change management are shown in table 2. table 2. the key activities for the efficient change management source: hutton d., managing purposeful change (cited 2004, march 23). available from url: http://www.dhutton.com/change/change.html bearing in mind that in the case of the reform of the health care system there will be individual instances of cutting down of certain capacities, special prudence is advantageous in this particular case, the one termed »reduction« in literature (34,40). the basic activities in reduction are the following (40): 517 informed health policy and system change involvement of employees • couple the change with the employees’ needs • approve one’s own planning • prepare the employees for the assigned duties • prepare the employees to manage stress • accept »resistance« as sign of personal struggle, not opposition to change • celebrate the progress assurance of involvement • establish a clear vision for the envisioned future state of affairs • assure that managers be the role models • regulate the system of recognition and awards • make the process of change a team effort • secure a current, open, two-way flow of information strategy of support to change • build partnership involving key persons • maintain support of the gained sponsors • strive for a small initial success • focus effort where it is most effective • reinforce changes neutralizing hidden opponents project management • share out responsibility for the process • develop a plan which includes both human and technical resources • establish structures for process management and backing • establish reliable system of measurement, following, feedback information, benchmarking and learning • reduction of personnel (dismissals, withdrawals, transfers); • organizational restructuring (elimination); • reduction of technical capacities (number of beds, operating theatres, sale of equipment); • change of purpose (in hospital room into an outpatient office of physician). the problems ensuing reduction are the loss of credibility of the managers, heightened »politicking« and rivalry among managers at different levels for the positions in the reduced organization, lowered motivation, and increase in voluntary discharges. possible solutions for this kind of situations are elimination of ambiguity that the reduction creates among the employees and an increase of communication between the managers and the staffs. education of managers for the new health policy the reform of the health system, particularly through decentralization and flexibility of the management, greater autonomy for providers of health care services, and introduction of active privatization, emphasizes the need for educated managers who will possess far more sophisticated skills than it was the case in managing the hierarchical administrative systems in the past (14). delegating the responsibility for the recognition of the needs for health among specific populations and their satisfying at lower referential levels also requires from the managers to be educated in public health, including epidemiology. they should be acquainted with the methodology of assessing the health status, in programming for health, and in the techniques of monitoring and evaluation. the health managers now have to possess skills both in strategic management and in managing individual institutions. at the same time it is estimated that all other health professionals must be educated in faculties of managing people, negotiating, and communicating (14). expansion of the managerial capacity requires not only the initial action, but also the medium and long-term educational programmes (28): • initial and prompt education of the managers means enabling them to manage institutions in a complex period of transition (especially the top managers in an institution). short courses are to ensure mastering the skills in the following fields: concepts of management, strategic and operational management, financial management and accounting, information management, management of interpersonal relations and conflicts, and management of change. 518 health systems and their evidence based development • the medium-term educational project is to provide for programmes of continuing education for all the existing and potential managers in the health system. • the long-term project is required to establish formal programmes of education, which would stimulate the concept of professionalism and high quality management, in the framework of postgraduate master’s studies in health care management at the university level. there exists a special need for the stimulated development of managerial activities based upon the working place of a manager, not the classroom. the educational needs can use rich experience of the european health management association – ehma, which already offered similar services to the european countries in transition. recommendations of this association refer primarily to the development of education for the management in health care as management of all resources in public funds which are directed to the improvement of population health (41). skills acquired as part of this education are related to the creation and management of the change which leads to the population health improvement, the skill of talking with and listening to a health care consumers, development of the information system which instigates the public health by integrating epidemiological data and those from sociological research, application of marketing, development of the organizational forms, and project management. in order to achieve full efficiency, the managers in public health should possess special technical skills and general managerial mastery. challenges imposed by the new health care require such an approach to the education of managers which accentuates dynamic dimensions of a »learning organization« and the management of change (42). the management principles stemming from the conventional bureaucracy in the health care system are neither relevant anymore nor are they suitable – in case they ever were. today increasing attention is focusing on the evidence based health policy and the benchmarks approach as a new tool for policy analysis (18,43). the interfaces are made between researchers and the users of research – policy makers in order to improve the health policies worldwide. „the permeability of the interfaces becomes important given the potential problems in the transmission of views and findings between researchers and policy-makers. issues around interfaces need to be considered at various stages including priority setting, commissioning of research and communication of findings” (18). the benchmarks approach focused heavily on the needs in reforming a technologically advanced but inefficient and inequitable system that lacked universal coverage and needs health policy changes (44,45). 519 informed health policy and system change exercise: health policy task 1: comparing health policies students should work individually (or in a country-based groups), in order to compare indicators of health policy in their own country and at least two countries – one from region and developed one. to fulfill this task, students should use the site http://www.observatory.dk, where are available all relevant information regarding to current health systems. they should try to use different health policy indicators listed in the who list and to use examples from good articles relate to health policy, which can be found at the internet publication of some journals (british medical journal, health research policy and systems, bulletin of the world health organization). oral presentation or seminar paper should be delivered upon this individual work. task 2: what is your policy objective in health policy cycle? students should work individually to highlight an issue or problem that the government is currently ignoring (agenda setting). then they should propose potential policy responses to a given issue (policy formulation). in the next step they would try to influence the selection of a potential policy response (policy legitimating), improve the implementation of a law / policy / programme (implementation), evaluate a law / policy / programme (evaluation) and, eventually, try to describe the change / terminate an existing policy (policy termination or change). the time necessary for individual work is 60 minutes, after that students prepare posters of their policy cycles (time available: 30 minutes) and later some of students present the results of individual work – 30 minutes. total time necessary for this task is 120 minutes. 520 health systems and their evidence based development references 1. holst e. comparative analyses of health policy. belgrade: sanu 1991. 2. mckee. health and the challenges of enlargement. european public health 2001; 59: 2-6. 3. foltz am. the policy process. in: janovsky k, ed. health policy and system development. geneva: world health organization 1996. p. 207-224. 4. wiewora-pilecka d. management of health politics in poland. 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108: 457-462. 43. hanney sr, gonzalez-block ma, buxton mj, kogan m. the utilisation of health research in policy-making: concepts, examples and methods assessment. health research policy and systems 2003; 1: 2. available at url: http://www.health-policy-system s.com/content/i/i/2 522 health systems and their evidence based development 44. daniels n, bryant j, castano ra, dantes og, khan ks, pannarunothai. benchmarks of fairness for health care reform: a policy tool for developing vountries. bulliten of the world health organization 2000; 78(6): 740-750. 45 krosnar k. could joining european union club spell disaster for the new members? bmj 2004; 328: 310. 523 informed health policy and system change 524 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title public health framework in the european union module: 3.2 ects (suggested): 0.25 authors, degrees, institutions thomas hofmann, mhcm, mph federal ministry of health and social security, bonn address for correspondence federal ministry of health and social security d-53108 bonn germany phone: +49-228-941-1831 fax: +49-228-941-4945 steering e-mail: thhofmann@yahoo.com keywords public health, european union, history, legal basis, policy development, open method of coordination (omc) learning objectives applying the content of this module the students will be able: • to differentiate the dimensions of national and european public health policy; • to identify key areas of eu's involvement to complement national policies in the field of public health; and • to put the own professional field in relation to european fields of action. abstract european activity in the field of public health started late, and the diversity of public health systems makes the development of common strategies more difficult than in other fields. the legal basis of eu's action in the field of health is fairly basic and simple but implies a broad and strong impact not only for health related matters but also for other political fields. eu's activity in the field of health is based on a public health point of view. since its start in special fields it has grown into whole programs but constantly limited by member states' responsibility to organise public health systems. besides this factual limits the role of the eu in and the implementation of its public health policy is debated by people and experts. still, the importance is growing and new strategies to develop public health policies such as the open method of coordination are implemented which becomes even more important in the light of the enlargement of the european union. teaching methods lecture, individual work, group work specific recommendations for teacher this module should be organized within 0.25 ects, out of which one third will be under the supervision of teacher, and the rest is individual students work. after an introductory lecture the student should become familiar with information sources of the european commission at the internet or by ordering through common mail. by looking for related eu legislation the students would become aware of the relevance for her/his field of profession (individual work). results can be presented and discussed in groups. assessment of students presentation or essay discussing the national or professional impact of one particular field of eu's public health policy. public health framework in the european union thomas hofmann in history, public health has been reinforced at those points when individual health care and cure of health problems were failing. the classical examples are all the epidemics in the past centuries. new problems such as aids or re-emerging of tuberculosis were again a point in time for more action in the field of public health. further, modern behavioural and social patterns and similar problems in european union countries needed an international approach since most problems did not stop at the border (1). the european union, primarily concerned with economic matters, had to develop a new basis for that kind of action. on the other hand, new structures had to be developed since the traditional “health care services in and of themselves do relatively little to bring about an improvement in the health status of populations” (2) and the european union was faced with a variety of health systems in the course of enlargement (3). moreover, traditional health services even hinder progress in public health. the dominance of treatment in the reimbursement schemes of established health care systems, the powerful role of health professions in many countries and economic restrictions kept the mostly state-dependant public health efforts off political agendas (4). public health as „the science and art of preventing disease, prolonging life and promoting health through organised efforts of society“ covers more fields than just economics, the original starting point of the european community (5). the treaty of rome did not provide any legal basis for public health activities (3). an awareness of inadequate results achieved by the established public health systems, possibly supported by a general changes and openness for new strategies to improve the health of the people (6), allowed new health threats to be dealt with. the first so-called “action plans” started in 1987 on the basis of the single european act. action was taken to prevent cancer, aids and drug consumption and trafficking. still, there was no basis for european legislation in the health sector. only in 1993, the treaty on european union (teu the maastricht treaty) created the first legal competence for the community. article 129 foresees the coordination of health programmes and policies of the member states, a significant focus on prevention of diseases, the obligation to combat major health problems (e.g. drug dependence) and the 525 public health framework in the european union community’s co-operation with other organisations. based on that article, the commission sets out indicators to determine priorities for action (7): • a disease’s impact on mortality and morbidity; • a disease’s socio-economic impact; • how far a disease is amenable to effective preventive action; and of particular importance, • how far there is scope for community action to complement and add value to what is being done by the member states. the current legal basis for public health the treaty of amsterdam changed the wording of article 129 and was renumbered article 152 of the ec treaty (see box 1). box 1. article 152 (ex article 129) 526 health systems and their evidence based development 1. a high level of human health protection shall be ensured in the definition and implementation of all community policies and activities. community action, which shall complement national policies, shall be directed towards improving public health, preventing human illness and diseases, and obviating sources of danger to human health. such action shall cover the fight against the major health scourges, by promoting research into their causes, their transmission and their prevention, as well as health information and education. the community shall complement the member states’ action in reducing drugs related health damage, including information and prevention. 2. the community shall encourage cooperation between the member states in the areas referred to in this article and, if necessary, lend support to their action. member states shall, in liaison with the commission, coordinate among themselves their policies and programmes in the areas referred to in paragraph 1. the commission may, in close contact with the member states, take any useful initiative to promote such coordination. 3. the community and the member states shall foster cooperation with third countries and the competent international organisations in the sphere of public health. 4. the council, acting in accordance with the procedure referred to in article 251 and after consulting the economic and social committee and the committee of the regions, shall contribute to the achievement of the objectives referred to in this article through adopting: (a) measures setting high standards of quality and safety of organs and substances of human origin, blood and blood derivatives; these measures shall not prevent any member state from maintaining or introducing more stringent protective measures; apparently, as in any other national legislation there are several more articles touching the field of public health. currently, the legal framework for health in the european union is provided by the ec treaties and case law from the european court of justice. besides article 152 ec, the next could also applied: • article 3 ec (the activities of the communirty shall inlude… „a contibution to the attainment of a high level of health protection”); • article 95 (3) ec internal market („the commission, in its proposals… concerning health, safety, environmental protection and consumer protection, will take as a base a high level of protection, taking account in particular of any new development based on scientific facts”); • article 174 (health and envronment: „community policy on the environment shall contribute to pursuit of the following objectives: preserving, protecting and improving the quality of the environment, protecting human health,…”) • article 30 ec (allows member states to prohibit the marketing of products from other eu countries to protect public health but only where there is scientific evidence in support, and as long as it is not a disguised restriction on trade). other legislative areas where health is mentioned are: article 39 and 46 (free movement of workers), article 137 (workers’ health and safety) and article 153 (consumer policy). however, there are also key areas where health is not mentioned: the common agricultural policy (cap) and common transport policy. nevertheless, article 152 keeps the most central role by targeting the health improvement, disease prevention, anticipation of sources of danger to health and ensuring that all ec policies protect health. 527 public health framework in the european union (b) by way of derogation from article 37, measures in the veterinary and phytosanitary fields which have as their direct objective the protection of public health; (c) incentive measures designed to protect and improve human health, excluding any harmonisation of the laws and regulations of the member states. the council, acting by a qualified majority on a proposal from the commission, may also adopt recommendations for the purposes set out in this article. 5. community action in the field of public health shall fully respect the responsibilities of the member states for the organisation and delivery of health services and medical care. in particular, measures referred to in paragraph 4(a) shall not affect national provisions on the donation or medical use of organs and blood. the community’s public health policy is still seen as subsidiary to the member states’ effort, but compared with other community policies, public health has been accorded greater weight. through certain non-binding resolutions in previous years, reports prepared by the commission, particular action programmes and funding of research work, the community has now been able to implement a genuine public health strategy (details are available from url: http://www.europa.eu.int ). according to the treaty, the protection of human health is now to be ensured in all community policies and activities, both in their definition and in their implementation. until recently it had only to be a constituent part of community policies. the meaning of the new article also goes beyond the prevention of illness and disease to include the improvement of public health and the obviation of sources of danger to human health. it is important to note that article 152 establishes a link between public health policy and the donation and use of human organs and substances of human origin, as well as between public health policy and veterinary and phytosanitary fields (7). this reflects the awareness of the importance of a common and consistent european public health policy in view of the bse crisis (“mad cow” disease). in the famous medina report on the bse crisis to european parliament, 1997, it was stated: “the eu should have a clear legal base enabling it to exercise its powers in the field of public health. it should be made impossible for the subsidiarity principle to be used as means for member states to oppose the development and application of measures… necessary to protect public health”. at several points though, the article 152 emphasises the member states’ responsibility for organising the delivery of health care, including action in the public health field. that seems to be the obvious limit for european public health policy. as the communication from the commission to the council on the development of public health policy in the european community (8) shows, there is a clear intention to act at a subsidiary level by supporting national and european legislation with tools for decision making. health monitoring, surveillance and tackling health determinants are lacking in almost all european union countries. the exchange of experience and the collation of epidemiological data should help to prevent or reduce the number of premature deaths by introducing a public health aspect into other community policies, and to cope with the enlargement of the european union (7). part of the above mentioned communication is a public health framework which includes the so-called action plans of the commission in the field of public health, since 1993. previous public health programmes were oriented towards cancer, aids and other communicable diseases, drug abuse, pollu528 health systems and their evidence based development tion related diseases, health monitoring and health promotion. up until 2000, eight programmes were set up. these action plans have now been extended to one global action plan until 2008 – public health programme (2003-2008). priority objectives of new public health programme (2003-2008) are the following (http://www.europa.eu.int ): 1. to improve information and knowledge for the development of public health; 2. to enhance the capability of responding rapidly and in coordination fashion to threats to health; and 3. to promote health and prevent disease through addressing health determinants across all policies and activities. the components of the new public health strategy of eu are a new public health framework and a coherent approach to health across community policies and actions. the first strand (improving health information) is related to health monitoring, mechanisms for analysis and reporting and information to authorities, professionals and the public. the second strand (responding rapidly to health threats) includes: work on communicable diseases (building on the network) and rare diseases, anti-microbial resistance, blood safety and quality, organs and substances of human origins, non-communicable disease threats, and actions on physical agents. the third strand (addressing health determinants) comprises: strategies and measures on lifestyle-related determinants (tobacco, alcohol, drug dependence, nutrition, physical activity, sexual behaviour, mental health), strategies and measures on socio-economic determinants (benchmarking on health inequalities, health insurance and health service arrangements, access across borders), and strategies and measures related to the environment. development and implementation of european union public health policy the commission’s public health department (directorate g), which is split into four units, is integrated into the directorate general for health and consumer protection. at the present stage, the expenses for public health are cut down, which results in a shortage of staff in the commission services (9). fruitful and successful work in the public health field was carried out immediately after the new legal basis for it was introduced in the treaty of maastricht as birt et al. (1997) describe. in 1993, the commission set up a working group consisting of nearly 70 experts taken from almost all the member states. the task was defined as being to submit proposals for policy development in cer529 public health framework in the european union tain priority areas. in the final report the expert group describes its recommendations for the short, medium and longer term in the areas of health data and information, accidents and injuries, pollution-related diseases, rare diseases and consultation mechanisms for public health, each area being split into preventive action, health data, consultation mechanisms and training and research. the expert group took into account the assessment of health needs, intervention based on evidence, as well as socially acceptable and politically credible policy development, which was based on democratic principles. in self-evaluation, the expert group rates its work as effective and efficient, but „time consuming and exceedingly expensive“(10). looking at the policies pursued by the commission since then this self-appraisal seems to be realistic, and the fact that the commission is still working with several expert groups in many areas confirms the advantages of that kind of policy development. regarding the discussion about national implementation of european union legislation it also seems to be the only way to ensure the compliance of the member states, as the nations are represented in those groups. for many years the european union has co-operated with the who and more particularly with the regional office for europe. in recent years the member states’ mandate to the commission in who negotiations has become stronger. for the first time, the commission has been representing all european union countries in the negotiations on the who framework convention on tobacco control. in other areas, inter-organisational frameworks in the public health field are being developed, and there is cooperation, particularly with regard to central and eastern european countries (6). at some occasions the development of a european public health policy is pushed forward by decisions of the european court of justice. a very famous example has been the kohll/decker file on cross-border treatment in 1998. this process is known as „negative integration” since it shifts competence to the eu without the member states positive agreement. in recent years the so-called open method of co-ordination (omc) as a working method becomes increasingly important. this process is known as part of „positive integration” since member states are actively involved in policy making. originally developed in the field of eu’s social policy since 1997 it has been introduced in the field of health after the lisbon summit 23 and 24 march 2000 to allow certain work to take place in areas where competence was not clear between the community and the member states. this method is clearly based on the principles of subsidiarity and decentralisation. especially in the light of the enlargement of the european union it seems likely to become a very important tool of policy-making as it creates soft law. soft laws are recommendations 530 health systems and their evidence based development and unsolicited agreements between several partners which are formally nonbinding but create an international and diplomatic pressure to be applied. the procedure is similar to any benchmarking process. the council decides measures which should be reflected in national policy. the member states present their efforts in reports to the council and the commission. the council formulates recommendations to be taken into account by the member states and so on. the first results of this working method are in the beginning to be evaluated (11). the view of people and experts regarding european public health policy bearing in mind the political debates in almost all countries in the field of health care, it seems self-evident that any european policy in that field needs to respect the sensitive areas in each country. as discussed above the treaty clearly mentions the organisation of health care systems as the responsibility of member states. however, interference is of course inevitable. as a representative survey among actors in the health field shows, the acceptance of such interference varies greatly between the european union member states (12). it seems that in some countries no widening of european union competence in the health care field is wanted by the people. the only fields where european union action is regarded as reasonable are health promotion, medical ethics, quality assurance and standardisation of education levels for health professionals (13). more concrete expectations from a european health policy can be noticed, when looking at recommendations developed by high-level experts. still, health care systems remain untouched. the main demands are for a stronger monitoring system, more research activity, fewer overlapping activities of member states, the european union and other international organisations in the health care field, and greater availability of shared knowledge, information and experience. in particular, evaluation and health technology assessment should play a more important role. to provide the european union with more continuity the six monthly presidential cycle should be replaced by long term health strategies related to those developed by international health organisations (14). not only content but also delivery of political strategies is seen controversial. whereas robinson/graham (15) note the lack of personnel in the commission to deal with the requirements, the european health care management association (ehma) is very sceptical regarding a growing commission and prefers the commission to play a more supportive role. 531 public health framework in the european union public health experts see further inconsistencies in european union’s health policy (14). as article 152 outlines, public health approaches should involve all policies. one reason for that could certainly be the lack of evaluation of eu’s public health programmes not having a significant impact in other political fields. the policies a major issue for the european public health policy arises in relation to the enlargement of the union. as bojar the former minister of health of the czech republic points out, there is a great need for a reduction in the differences in the quality and availability of health care in the whole of europe (1). this means that certain standards for health care systems have to be established in order to standardise. fischer, the former german minister of health, notes the same fact and points towards the necessary harmonisation of health care systems and social standards up to a certain point (16). but „there cannot be and will not be a european standardisation or even harmonisation of the national differences, because of the peculiarities of the traditionally evolved structures specific to each individual member state” (16). the similar wording clearly shows that the limits for harmonisation and standardisation are not absolutely set and the individual interpretation by each politician will lead to permanent discussions on that key topic of health policy. besides that political hot potato, policies do seem to coincide quite closely with scientific expert opinion. the summary of a meeting with european health officials presented by fischer repeats the recommendations as described above. in addition, the financial situation of health care systems is given greater attention since it seems obvious that a higher expenditure for health care does not necessarily lead to a higher life-expectancy of populations. 532 health systems and their evidence based development exercise: public health in the european union task 1: students should use recommended readings in order to become familiar with information sources of the european commission in the internet or by ordering through common mail. by looking for related eu legislation the student can become aware of the relevance for her/his field of profession (practical work). results can be presented and discussed in groups. task 2: students are asked to write an essay, discussing the national or professional impact of one particular field of eu’s public health policy. essays will be assessed and presented in group. 533 public health framework in the european union references 1. bojar m. europe without frontiers. in: normand c, e.m./vaughan p, ed. europe without frontiers. chichester-new york-brisbane-toronto-singapore: health press 1993. 2. holland ww, et al. public health policies and priorities in europe. in: holland ww, et al, ed. public health policies in the european union. new york-oxford-tokyo: oxford university press 1999. 3. scadplus. european union web-based guide to union policies. (cited 2001, august 20). available from url: http://europa.eu.int/scadplus 4. rosenbrock r. gesundheitspolitik. in: hurrelmann k, laaser u, ed. handbuch gesundheitswissenschaften. weinheim-münchen: juventa 1998. 5. winslow cea. the untilled field of public health. modern medicine 1920; 2: 183-191. 6. asvall je. the implications for health. in: normand cem, vaughan p, ed. europe without frontiers. chichester-new york-brisbane-toronto-singapore: health press 1993. 7. merkel b, hübel m (1999): public health policy in the european community. in: holland ww, et al, eds. public health policies in the european union. new york-oxford-tokyo: oxford university press 1999. 8. com (98) 230 final, 15.4.1998. 9. randall e. the european union and health policy. basingstoke-new york: publishing company 2001. 10. birt ca, gunning-schepers l, hayes a, joyce l. how should public health policy be developed? a case study in european public health. journal of public health medicine 1997; 19 (3): 262-267. 11. goetschy j. the european employment strategy and the open method of coordination: lessons and perspectives. transfer. european review of labour and research 2003; 9(2): 281301. 12. andersen consulting. die zukunft des europäischen gesundheitswesens perspektiven für deutschland. sulzbach/bonn: andersen consulting 1997. 13. hofmann t. developing european health policy. lage: jacobs 2002. 14. ehma. healthcare and european integration. dublin: european health management association 1994. 15. robinson j, graham v. the european union’s public health policy and older people. eurohealth 1997; 3(2): 23-24. 16. fischer a. a new public health policy in the european union. eurohealth 1999; 5(1): 2-4. 534 health systems and their evidence based development recommended readings • european union web-based guide to union policies at http://europa.eu.int • holland ww, et al, ed. public health policies in the european union. new york-oxford-tokyo: oxford university press 1999. • normand cem, vaughan p. europe without frontiers. chichester-new york-brisbane-torontosingapore: health press 1993. • randall e. the european union and health policy. basingstoke-new york: publishing company 2001. 535 public health framework in the european union 536 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title targets for health development module: 3.3 ects (suggested): 0.50 authors, degrees, institutions dr. rudolf welteke, state institute of public health of northrhinewestphalia (loegd), bielefeld, germany address for correspondence dr. rudolf welteke state institute of public health of northrhine-westphalia (loegd) westerfeldstr. 35/37 d-33611 bielefeld germany e-mail: rudolf.welteke@loegd.nrw.de keywords health targets, health policy, health strategy, health indicators learning objectives at the end of this topic, the students should be familiar with: • principles of target setting; • examples of world-wide health strategies and targeting settings; • process of developing and implementing a target programme. abstract health policy requires a clear outfit and a number of comprehensive and visible goals in order to become accepted within the population and the specific target groups. identification and monitoring of health targets in programmes introduce more transparency and more visible success into health policy. this paper presents highlights and the background experiences, which have been accompanying the development of health target programmes within the last three decades. moreover, you will find some aspects of developing and implementing a target programme and diagnostic tools in order to find out, if the introduction of health targets could be an appropriate tool for problem solving in a specific political environment. teaching methods after an introduction lecture students will work in a small groups on identification of health targets (based on health monitoring data) and compare international, national and their own health targets. work will be followed by group reports and overall discussion. specific recommendations for teacher it is recommended that the module should be organized within 0.50 ects credit, out of which 0.25 of ects credit will be done under supervision (lecture and group discussion), while the rest is individual student's work. it is supposed the 1 ects is equal to 30 hours. teacher should advise students to use as much as possible electronic management libraries during individual work. assessment of students multiple choice questionnaire and written report. targets for health development rudolf welteke introduction the idea to build up instruments in order to introduce more transparency and more visible success into health policy is a simple but difficult option at the same moment: the simple aspect is that health policy requires a clear outline and a number of comprehensive and visible goals in order to become accepted within the population and the specific target groups. the more difficult aspects are associated with the management process that is needed to make target programmes successful and efficient; this process has to give answers to questions like: what kind of target development should be instigated? who are the suitable persons and institutions that should get involved? what is the appropriate role and mixture of policy makers, practioners, and technical experts within the process of development and implementation of health targets? the history of health target projects is a story with ups and downs which has had to find its path between these two areas: the simplifying area on the one hand and the area of scientific approaches on the other hand. the task of the following chapters will be to give a short introduction into the highlights and the background experiences which have been accompanying the development of health target programmes over the last three decades. moreover you will find some diagnostic tools in order to find out, if the introduction of health targets could be an appropriate tool for problem solving in a specific political environment. some principles the roots of target programmes can be found in the sector of economics and project management: if you are planning to create and launch a specific product in a defined section of the market, you have to make sure that a series of consecutive elements exists: i first you have to decide, what kind of product you are going to develop – this is the first step of target setting. this step is associated with the creation of a clear outline of the product with a well defined idea what you are going to offer. 537 targets for health development ii the second step of development is developing the process goals which effect the way in which the product should be introduced into the market: which effects and gains should be achieved by the introduction of this product? this type of question is including at least two effects, which can be described in terms of target setting: target a: the aimed effects in the target group (e.g. the grade of distribution of the product x in the target group y); target b: the aimed effects according to the producing and/or selling company (e.g. number of produced elements; amount of financial advantage)... iii as the target setting process is a part of an entire planning process the combination with a time schedule is a must. matching the milestones of this schedule is another (the third) important element of the target setting process. iv a fourth target aspect is associated with the task of meeting certain pre-defined standards of quality of the product. this element leads into the area of quality assurance. if you are the only producer of this type of product you are dealing with your own standards of quality. if there are more comparable offers your product will be subject to a benchmarking process. there are a lot of more detailed aspects which are linked with the process of target setting. for example the question how to quantify the achieved effects is an important one, if you are going to set targets in the health policy sector. as you have to deal with a lot of effects in the health area, which produce some difficulties if you try to meet high standards of quantification, you have to find a smooth way in order to create a set of appropriate indicators linked with those targets and strategies you want to introduce. on the one hand, quantified targets appear to be the type of “better targets”. on the other hand you usually have to minimise the amount of resources if you want to be successful in implementing an entire health target programme – so you will have to be careful with the definition of high level standards if you are going to develop and introduce appropriate evaluation procedures. figure 1. some relevant elements of the target setting procedure 538 health systems and their evidence based development stage keyword task i definition of a product investigation of the market, designing ii introduction of the product advertising, product placement iii time schedule/milestones schedule the project, element ranking iv quality of process & results development of indicators, evaluation history the “health for all” programme of who’s european regional office the history of health targets is a story of development which took place in different core areas. from the european point of view there was a first relevant attempt to develop health targets in the nordic (scandinavian) countries especially finland in association with the european regional office of the world health organization (who) in copenhagen/denmark. this preliminary was carried out in the seventies and was confirmed in the general outline of the strategy “health for all” by the regional assembly of the european nations in 1977. a major campaign was carried out when the who publication „health for all 2000 ...” appeared in 1985 and was distributed in different languages with a large number of copies. the programme included a comprehensive health target approach which was based on 38 elaborate health targets (1). these 38 targets focused on relevant topics of health policy in western, industrialised countries. there was nearly no similarity with the „ten global health targets” which had been released by the who headquarters of geneva some years before and had been adjusted in the late 1990s (2). the 1985 european regional health targets, which were revised in 1991 (3), have always been associated with a serious attempt to lay more stress on the social equity issues of health and health care – especially by giving target number one the headline „more equity in health affairs”. this was an indisputable demand for more social justice within the european societies and health systems. this who target programme included the option for a positive social change in european countries but also contained the substrate for a lot of political controversy in the different european nations and regions. on the one hand the „health for all” strategy led in a convincing way to several interesting and sophisticated national and regional health target programmes, designed and carried out by „early adopters”. on the other hand the programme produced a lot of non-adopters, especially among more conservative health politicians, who for example did not accept the message of more equity or at least did not believe in alterations of social structure of that big size the who programme suggested. actually the entire political impact of the who target programme can only be understood in depth by reflecting on the policy differences between the socialistic and capitalistic states of the seventies and eighties of the last century. basically the health for all approach has been a comprehensive health promotion programme with a new, broader understanding and definition of 539 targets for health development healthy conditions. especially the socialistic states had been working hard in order to introduce the reflection of the healthy conditions approach into the programme. this approach was going to balance the former health education approach, which has been favoured by the western governments up to the late seventies, and which prioritised the individual health behaviour. the historical point of view creates the opportunity to ask, if who’s target inititiative would have been more successful, if it would have come with less demands about social alteration and political change. there is the suggestion that the consensus level to adopt a target programme like this at national, regional or local level would have been better, if the political power of the who programme would have been more discrete – but: probably there would have been other obstacles arising in this virtual case – e.g. the level of perception of the programme might have been deminished to a critical degree. anyway – there are some experiences with who-designed health target programmes, which are worthwhile to be mentioned (below). health21 – the renewed health target strategy of the who for the new century in the late 1990s the who published a renewed version of the “health for all” approach, called health21. the first remarkable change of the new programme was the reduction of the number of targets from 38 to 21. the reduced new who strategy was an answer to some critical remarks which stated that the former 38-target approach did not meet the requirements for a consistent and convenient programm design. another important change was introduced by the political re-mapping of eastern europe which took place in the 1990ies especially after the decline of the soviet union. the who had been facing a new and strong imbalance between eastern and western countries in the european region. on the other hand the renewed 1998 approach of the who was a change to a more economically driven policy and a change to a system of health policy based on health determinants. it has been an adaption to a radically changed economic and political situation in the european region (4,5). target programmes of members of the healthy region network especially the who-associated healthy region network has been producing some important approaches. there was a working group meeting in 1992, which led into a presentation „on the development of subnational policies for health” (6). in addition, there had been an international workshop 540 health systems and their evidence based development on target setting in brussels in 1996 with contibutions of those network members dealing with target programmes: wales (great britain), catalonia (spain), oestergoetland (sweden), north rhine-westphalia (germany) (7). an elaborate health target programme has for example been developed and implemented in wales. wales is situated in the south-west of great britain with a population of about 3 million. the wales target programme was announced in 1989 by the welsh office as an initiative: with the strategic intent and direction, which aimed to “take the people of wales into the 21st century with a level of health on course to compare with the best in europe”. the initiative covered 10 areas where health could be improved. these areas accounted for about 80 per cent of the health expenditure in wales. intervention in each of these areas had been planned by three main principles: (i) health gain: focusing on improving health by, e.g. shifting resources to more effective treatments; (ii) making services more responsive to people’s needs and preferences: e.g. considering the total effects of services on people’s lifes rather than narrower clinical perspectives; (iii) effective use of resources: e.g. providing an appropriate balance between prevention and promotion; diagnosis and assessment; treatment and care; and rehabilitation and monitoring (8,9,10). an evaluation of the welsh programme was published as an official „report by the comptroller and auditor general” in 1995 (11). the programme has been renewed after the british change of government in 1998 and was published as a (bilingual) consultation paper titled „better health. better wales” (12). a strong focus of the new approach lies on health inequalities. it includes some interesting additional remarks on „investing in the future” e.g. by mentioning strategies based on advanced health impact assessment procedures (13). the policy paper was followed by the publication of a strategic framework (14). an evaluation programme is continuously carried out – results are e.g. available via internet (15). catalonia – the 6-million-people region in north-eastern spain with its capital barcelona has been developing a health target programme which surprises by an exorbitant great number of single targets (about 600). the catalonian approach is an elaborate, high-level target programme which was published first as a framework document in 1991 (16). the first health plan for catalonia was published in 1993 (17) followed by a series of further updates and publications (18,19,20,21,22). the catalonian target programme is related to a thoroughly planned and realised health monitoring and reporting system. due to this special situation it had been possible to quantify each of the single targets. a critical assessment of the catalonian approach may produce the result that it is overdetailed and at last it might be difficult to find out in the 541 targets for health development mass of findings what really had been the (political) success of the entire programme. anyway – the catalonian example is an excellent and impressing model for studies. especially the broad range of positive opportunities, which lies in a tight linkage between health monitoring and a subsequent target programme are visible in the catalonian model. another early regional approach has been worked out in the southern part of sweden, in a region called oestergoetland (population: 400,000; capital: linkoeping). the oestergoetland 1988 health policy programme set five overall goals: (i) oestergoetland county council – a health county council; (ii) health promotion and disease prevention – that is equally accessible to all the people of oestergoetland; (iii) health promotion and disease prevention of high quality; (iv) health activities that satisfy the needs of the population; (v) community participation in health activities. the 1990 strategy for implementation focused on six areas of intervention: healthy lifestyles; accident prevention; musculosceletal disorders; health of children and youth; health of young parents; health of elderly. 26 quantified targets were defined by a 50-person expert and layman board. the positive example of this regional approach is highlighted by an ambitious organisational process combining a lot of health and social policy challenges and including in particular the opinion of ngo’s which are active in the region (23,24,25,26). healthy region network founding member north rhine-westphalia, a 17-million-population state in the western part of germany, has been starting its own health targets programme „ten priority health targets for north rhinewestphalia” in 1995 (27). the ten targets are: the north rhine-westphalian approach has been starting as an evocative political programme – after the who’s health for all programme has been treated in western germany for more than one decade in a more reserved way. the reduction to a number of 10 targets (derived from the 1985 who 38 542 health systems and their evidence based development 1. reducing cardiovascular disease 2. controlling cancer 3. settings for health promotion 4. tobacco, alcohol and psychoactive drugs 5. environmental health management 6. primary health care 7. hospital care 8. community services to meet special needs 9. health research and development 10. health information support. target programme) was a reasonable political decision in order to adapt the size of the target programme to the limited resources of the north rhine-westphalian health policy sector. up to the year 2000, which has been marking the halfway point of the declared first decade of nrw’s target programme implementation, there had been two (of ten) target implementation programmes released: target 4 “tobacco, alcohol and psychoactive drugs” and target 2 „controlling cancer” have been described by elaborate implementation brochures and set into action by expert teams. in addition to the both implementation schemes mentioned above an evaluation approach was developed and published in order to assess the realised parts of the target scheme. there has been an official declaration of all important institutions of the health care and prevention sector in north rhine-westphalia in 1995 to get involved in the programme in an active way. the scheme of this target programme and some of it’s technical patterns have become parts of the german national target approach, which begun in 1999 (see below: national approaches). a short documentation of the north rhine-westphalian target approach (28) is also available in english (29). there is a series of publications available in german language (30,31,32,33). selection of national approaches the british health target programme “health of the nation” has been focusing on more medical aspects of the broad range of public health topics. actually there was a serious approach to establish a national health target programme, which was backed and released by the national government and the parliament in 1992 (34,35,36,37). in particular the aspect of social equity in health affairs was disguised under the conservative period of mrs. thatcher’s government in terms like “social variations”. this development was stopped when labour party won the 1998 elections – but: the health of the nation target programme was assessed immediately after the political change (38) and cut down drastically – although there was a nice new label created: “our better health” (39). in order to bring the programme closer to the people’s reality the renewed strategy is said to be more “focused and disciplined”: “but operating on too broad a front risks dissipating our energies on too many goals – and achieving none. the strategy must be focused and disciplined“. that is why the government has identified four priority areas: 543 targets for health development 1. heart disease and stroke 2. accidents 3. cancer 4. mental health (39) the british target programme is worthwhile being studied thoroughly: it is a long term project which has had some important impact on the british health policy. this importance was underlined by the continuing of this policy concept even after the historical 1998 policy change. the relevance of the british health target model is based on an excellent technical advice by several expert teams. the output of these teams – which have been partly run by the government itself, partly embedded in the staff of several cooperating universities – means especially a high quality support for the continuous statistical analysis of the programme outcomes and the consecutive strategical and technical steps of adjustment. the redesigned british approach tries to get solutions in two key areas: 1. “to improve the health of the population as a whole by increasing the length of people’s lifes and the number of years people spend free from illnesses”; 2. “to improve the health of the worst off in society and to narrow the health gap” (39). so the new programme is setting high standards according to the political framework, especially in the efforts of narrowing the health gap and of tackling the health related symptoms of social inequalities. while reading the renewed strategy of 1998 and these highly ambitious target modifications in the field of social policy there is the impression arising that there is a lot of political declaration. it is obvious that this type of target setting – and especially the very enthusiastic effort to bring in the topic of combating the social inequalities, (“black report” – and consequent publications: 40,41,42,43,44) – have been inducing a lot of political discussion and producing a reasonable series of scientific investigations on this topic. on the other hand these targets don’t have the touch of “realistic targets” in a narrower sense: there are too many implications, such as addressing the current baselines of social structure and economic principles of the entire (british) political system, which probably will not change based on the demand of health policy intervention – even if the programme is declaring “we are in this for the long haul...” (39). especially it will be of some interest to observe the long term outcome of this target initiative under the auspices of the outspreading new economy. 544 health systems and their evidence based development the australian target programme (45,46) is one of the elaborate positive examples within the worldwide health target community. it has been tailored as a modification of the who target approach. the framework was developed in 1993 and included a range of goals and targets grouped in the following four areas: 1. preventable mortality and morbidity 2. healthy lifestyles and risk factors 3. healthy literacy and health skills 4. healthy environments comparable to the british approach there are concrete actions focused on cardiovascular disease, cancer, injuries and mental health, as these fields are the four national priority areas of the health ministers. the australian programme is includes quantified targets, e.g. lung cancer. lung cancer is the most common primary cancer in australian males and the third commonest in females. targets included: • to reduce mortality from lung cancer amongst males (by 12 percent by the year 2010 from a baseline in 1990 of 58.4 deaths per 100,000); and • to reduce mortality from lung cancer amongst all females (by 8 percent by the year 2010 from a baseline in 1990 of 16.8 deaths per 100,000). proposed targets included: • to reduce mortality from lung cancer amongst aborigines and torres strait islanders and all people from low socioeconomic groups (46). the healthy people 2000 target programme of the united states of america represents one of the most impressive documents of the health target literature: the initiative was prepared in the 1980ties (47,48), unveiled in 1990 and the strategy was published in 1991 (49). the 1992 edition came along with three additional big size volumes: (i) consortium action; (ii) public health service action; (iii) state action (50,51,52). these publications reflect a cooperative approach, which is the organisational backbone of the entire programme. on the other hand they produce the broad range of approx. 330 objectives and more than 600 single measures, which are related to 22 areas of activity. these year 2000 targets had been related to baseline data from the 1980ies annual nchs health reports. the sophisticated approach is 545 targets for health development characterised by a highly detailed differentiation of target groups (white, black, hispanic, american indian/alaska native, low-income people etc.) and by a high grade of quantified descriptions of health settings and trends. the 1992 edition was continued by a series of annual evaluation reports (53, 54,55,56,57,58). these have drawn a mixed picture of success, stagnation and moving away from targets. progress and failure of the programme has to be studied in detail and in the specific areas of intervention. reported declining rates of health affecting items have been partly compensated by a consistent high level of incidents (e.g. injuries by fire arms). the evaluation reports are meeting high quality standards in a technical sense of view. the main question, if – in a political sense – the entire programme includes really sufficient tools in order to tackle the most obvious unhealthy conditions which are producing negative health effects in a broad range of target groups – is not be answered by the annual reports in a sufficient way. so there remains the main impression that the healthy people programme represents mainly a big size health monitoring activity with an attached target structure. in the meantime the year 2000 targets have been replaced by year 2010 targets (59) and accomplished by a set of instruments in order to facilitate the development and implementation of objectives and measures (60). in germany the development of a national health target programme was started in 1999. a consensus platform containing a broad range of actors was established, organised by the gvg (association for social security policy & research), cologne and sponsored by the german federal ministry of health and social security, berlin. a report on the starting activities was handed over to the ministry in february 2003 (61). the technical aspects of the german health target approach are presented in the figure 2, which is an element of the internet presentation gesundheitsziele.de (62). there is a number of other national target programmes or systems of health reporting which are using targets. there is one source of information which is to be recommended first: the 1998 „review of health target and priority-setting in 18 european countries“ edited by tno prevention and health, public health division, leiden/netherlands (63,64). the 18 countries included in the study are: austria, czech republic, denmark, finland, france, germany, hungary, ireland, italy, the netherlands, norway, poland, portugal, romania, spain, sweden, switzerland, united kingdom (64). other sources that give a sound survey of a broad range of european target approaches are: a reader, edited by marshall marinker (65), and a newsletter, published by msd pharmaceutical company (66). 546 health systems and their evidence based development figure 2. main aspects of the german national health target programme some further regional target programmes in the international debate on health targets the quebec programme “policy on health and well-being” is one of the most regarded regional health target approaches. the ambitious 1992 programme is characterised by a policy focusing on health and social organisation. so the main aspects of the implementation strategy are lieing in the aspects: (i) encourage the reinforcement of the individual’s potential; (ii) provide support in social settings and develop healthy and safe environments; (iii) improve living conditions; (iv) act for and with groups at risk; (v) coordinate public policy and action to promote health and wellbeing; (vi) orient the health and social services system towards the most effective and least costly solutions. the quebec programme contains 19 targets which are related to five areas: social adjustment; physical health; mental health; public health; and social integration (67). 547 targets for health development the first regional health target programme in germany was developed in hamburg (68,69). it was published in the year 1992 as an inconspicuous part of a health report of the city of hamburg, which represents a state of its own in germany with a 1.7 million population. the 14 targets focused on child health (69). hamburg succeeded in publishing an additional evaluation report in 1994 (70), which had been reflecting a reasonable number of successful measures in order to empower the health state of the target group of the programme – with a focus on the social situation of children and adolescent persons (71). in 1998 the hamburg health target programme became a prize winner in a nationwide competition on health targets (“berliner gesundheitspreis”) in germany. another early approach by a german federal state is the sachsenanhalt health target programme (72). published in 1997 – embedded in a regional health report similar to the hamburg approach – a number of five targets was presented. the topics are: infant mortality; grade of vaccination; mortality on cardiovascular diseases; cancer; consumption and effects of alcohol and tabacco. the sachsen–anhalt approach was started by an initial health policy conference. it is backed by five expert taskforces. presently the target programme is under organisational reconstruction. selection of local health target programmes local health target programmes are usually developed in reference to the who health for all strategy. cities can also become member of the who induced healthy cities network. an early example for this type of synergism is given by the programme of sandwell, a community located near birmingham/ great britain. the ambitious target programme of the 300,000 population community is dating from 1989 and is similar to the who’s health for all paper. an interesting detail of this approach is that sandwell is a multicultural community with about 15 % people from asian descent. so there is a high attention to health inequalitity issues influencing the outfit and the details of the programme (73,74,75). another ambitious local approach can be reported from canada: edmonton, a 666,000 population city released a programme „health goals for edmonton“ in 1992 (76). the framework of this activity is set by the healthy edmonton 2000 project. the 54 goals are covering five areas of action: 1. maximising life expectancy 2. reducing risks to health 548 health systems and their evidence based development 3. improving health services 4. removing inequalities in health 5. creating a healthy environment. the goals are titled by the slogan „direction for success # x“ (e.g. x = 51 means improving drinking water) and they are linked with a series of concrete measures (called „opportunity for action“). like other target programmes the edmonton approach contains a lot of details and health data which are underlining the need for action in the five areas mentioned above. in this way the edmonton approach represents the wellknown cooperative scheme driven by a tight linkage of health monitoring resp. reporting issues and health promotion concepts. a relatively young local health target programme has been developed in bielefeld/germany (population: 300,000): based on the results of an expert workshop in 1999 and on a representative survey about health service outcomes in bielefeld and their perception by citizens in the year 2000 an expert group started to work out a target programme. three global targets have been set out in detail: 1. “a health sector which is addressing the needs of the population“ ( = „bürgerinnenund bürgerorientierung“); 2. “equity in health aspects“; 3. “prevention and health promotion“. all of these three global targets are linked to similar target formulations of the who health for all 2000 resp. health 21 programme. in addition the bielefeld global target # 1 is linked to the north-rhinewestphalian target # 8; the bielefeld global target # 3 to nrw‘s target # 3 (see above). the bielefeld target programme has been released by the city council in summer 2003. the next steps will be working on concrete objectives and measures in order to implement these global targets in priority areas with need for intervention (77). 549 targets for health development figure 3. number of areas, targets, objectives – in a selection of 14 health target programmes overview : selected target programmes source: welteke r. north rhine-westphalia’s health target concept compared at the european and international level [computer file]. bielefeld, london; 1997. 550 health systems and their evidence based development areas objectives targets who 5 38 approx. 250 finland 5 34 ? england 5 25 25 usa 22 approx. 330 approx. 600 australia 4 83 ? québec 5 (+3) 19 77 wales 10 180 180 catalonia 13 (+15) approx. 600 approx. 600 oestergoetland 4 26 26 hamburg 5 14 14 nrw 5 10 approx. 60 berlin 3 (+1) 19 approx. 45 edmonton 6 54 90 (318) sandwell 5 38 73 (100) region zielbereiche einzelziele teilziele figure 4. preferred areas and grade of quantification – in a selection of 14 health target programmes source: welteke r. north rhine-westphalia’s health target concept compared at the european and international level [computer file]. bielefeld, london; 1997. key: a. preferred areas b. grade of quantification main area (several or many all targets objectives) presented area (at least one objective) most of the targets only occasionally mentioned (target) only some of the targets ( ) only occasionally mentioned (context) ( ) no evidence not mentioned, but cross-sectional ? not examined item 551 targets for health development diseases & epidm. asp. social affairs environmt. hygiene caresystem economis acci-dents grade of quantific. who finland ? england ( ) usa ( ) australia ( ) ? québec wales catalonia ( ) ( ) östergötl. hamburg nrw optional berlin edmonton ( ) sandwell ( ) ( ) how to develop a target programme different types of target programmes an empirically based analysis of existing target programmes leads to at least two different approaches to the task of developing a target programme: a) the health monitoring based approach this is the way, which had been chosen by catalonia and by wales – for example. there has also been a proposal produced by a german research unit led by karl e. bergmann, berlin (78), which presents the steps of this approach in a convincing way: first, bring up a broad range of health monitoring facts – preferably organised in a matrix of health indicators – second, try to identify a comparable system of data, which allows you to start a benchmarking procedure. in germany this approach has been realised e.g. by sachsen-anhalt, which has compared the health monitoring findings within its population of 2.7 million with the national health data of the federal republic of germany (72). this benchmarking procedure opens the opportunity to reveal a special pattern of (regional) health problems. the findings may be helpful to start the process of a political adjusted decision making process, which means the third step of this procedure. b) the policy centered approach this procedure is based on the inverse sequence of steps of the approach which is described above under a). the first idea is a political incentive in order to introduce some change in the health policy landscape of the region or nation. usually there are a lot of topics and problems which can be easily identified as appropriate to be introduced into a setting of health targets. there seems to be no urgent need for building up a comprehensive and long term oriented quantified data system. usually there is the feeling of having enough evidence to make these topics valid in order to be chosen for a target. sometimes an ad hoc data collection is carried out to produce an empirical base. systematic aid in establishing such a policy centered health target system can be lent by other existing health target approaches. the who target approach „health for all“ has been the fostering health target model # 1 for this type of policy centered national or regional health target systems. as there had been a broad consensus of the nations of the european region to release the health for all target programme there was nearly no threshold to use the prepared technical inventory of targets, strategies, and measures of the who programme. on the other hand the who 552 health systems and their evidence based development programme itself has to be characterised as a primarily policy centered programme: the first paper versions of the 1995 edition had been including an annex with a series of health indicators. but it was obvious that there was a need for a thoroughly carried out working package to make this empirical tool suitable for health monitoring purposes. actually, this second step of establishing an indicator programme which is capable to meet evaluation needs is the difficulty of this approach b. networking for pragmatic support a realistic and pragmatic approach in order to build a target programme needs a sufficient technical support. the idea of networking to get a start up has led to a cooperation – e.g. the who associated healthy regions network, which was presented above. if there is a national or regional health target programme usually support is given to local authorities, if they are starting their own target setting process. a special example of support is given by the u.s. healthy people 2010 toolkit, which is available via internet: figure 5. action areas of the healthy people 2010 toolkit building the foundation: leadership and structure identifying and securing resources identifying and engaging community partners setting health priorities and establishing objectives obtaining baseline measures, setting targets, and measuring progress managing and sustaining the process communicating health goals and objectives source: healthy people 2010 toolkit. available from: url: http://www.healthypeople.gov /state/toolkit/default.htm another toolkit is to be provided by who for the end of 2003 (at the who europe website http://www.who.europe.dk) diagnostic tools especially for the purpose of starting development of local target programmes there are some points of interest which should be taken in account. three checklists may be helpful in order to get some more evidence for an expected sucess of a planned target programme (79): 553 targets for health development figure 6. implementing checklist # 1 figure 7. implementing checklist # 2 figure 8. implementing checklist # 3 554 health systems and their evidence based development 1. existing (and working) health monitoring and reporting system 2. actors with motivation to be successful in achieving health gains 3. communication platforms for actors involved 4. decision making process open for participation of patients and citizens 5. priority related discussions and steering of resources 6. transparency of political decisionmaking 7. sufficient criteria and tools for programme assessment 8. transparency in setting assessment criteria 9. shared responsibility for programme management and results 10. transparency and media support to programme development and assessment • implementing of local health target programmes 10 promoting elements: 1. more than 7 (of 10) points positive in checklist # 1 2. working interaction and/or professional management of the components of checklist#1 3. acceptance and support by local politicians and activity groups 4. positive motivation of actors and users of the target programme 5. promotion of target setting and implementing attempts by regional and/or national • implementing of local health target programmes 7 steps to be successful 1. do the health monitoring and reporting tools really work? 2. do the actors really want to be successful with the programme? 3. are the actors ready to communicate and to cooperate? 4. is there a policy of participation? or: is it possible to introduce participative components into local policy? 5. is there any (political) discussion on priorities in health aspects? 6. is there an opportunity for negotiation of criteria for assessment of the programme? 7. is there enough of common sense among the actors who are backing the programme? 8. is there a chance for using public relations and local media for promotion of the programme? • implementing local health target programmes 8 final questions: some final remarks this presentation of health target programmes and approaches is the attempt to give some information about a field of activity which is characterised by a high level of heterogenity. out of the variations in programme performance and in dynamics of implementation arise additional difficulties for proper analysis. last but not least health targets are usually part of a policy programme. and policy programmes are almost mixed up with some advertising components. so it is not easy to get a sufficient degree of transparency in the present situation and to give some valid remarks on the state of the art. the ambiguity of the subject is recorded by a fine dialogue “for and against health targets”, which is really worthwhile reading for those who like the flavour of dialectics and who want to get some more ideas and literature references related to this delicate topic. “i find nothing intrinsically wrong with setting targets and goals but unless these targets are accompanied by strategies to achieve them they may in the long term, because of repeated failure, do more harm than good. being in favour of something is of itself inadequate.... scepticism is the scalpel which frees accessible truth from dead tissue of unfounded belief and wishful thinking” (80). despite of this kind of scepticism, which undoubtedly has some realistic background, the motivation, the professionalism, the personal beliefs, the enthusiasm of many acting persons and institutions in the field of health targets are evident and impressive. this is encouraging indeed for everybody who gets in contact with these activities. on the other hand health targets are something of the category that means “tool”, instrument or part of a “procedure” or “system”. this side should be lead to a more realistic view: health targets are only one instrument in a pool of a variety of others. and sometimes, especially if things do not work well for some time, it gets obvious, that the developing and implementing procedures of health targets are facing similar problems as tools, instruments, and related procedures; like health monitoring and reporting, like health promotion, like health impact assessment, like public health research activities, which are also facing problems in their performance from time to time. all of these tools (in a broader sense) are dealing with the human health and they are ambitious attempts to strengthen the role and the performance of human health. but: they remain to be tools, instruments and usually they stay a little bit apart of that what really means health, health “for the people“. but sometimes, in special situations, these tools become important: there are upcoming situations which require valid and effective 555 targets for health development tools – in the right moment, on the spot. although health target programmes are instruments developed for the long term performance – sometimes there is the impression, it would be sad if all this energy was not put into the health targets process. so – this may be a little too much impassioned closing remark – but: why not? 556 health systems and their evidence based development exercise: health targets the purpose of exercises are given below, through objective, methodology and description of each task. time needed for exercise is approximatly 4,5 hours. task 1: objective of this task is identification of health targets based on health monitoring data, through group working, statistical analysis, and discussion. students can work in small, country-based groups. they should try to identify problems according to health monitoring data, calculate indicators and build up measurable and valid targets appropriate for their own country. they should develop a discussion about challenges of realisation of identified health targets within local political situation (recommended usage of implementing checklist 1). at the end they should make written comments. it is recommended to use comparable health statistical reports. use internet sources, too. timing: 1,5 hour of students work. task 2: objective of this task is identification of national/international health targets (if any), and comparison with their own health targets, through group working, statistical analysis, and discussion. students can work in small country based groups. they should search for their national health targets, compare with their own and make comments. the comparison can be made on international level. comments should be written. students should use internet sources. timing: 30 minutes for students. task 3: objective of this task is implementation of health target programme and usage of diagnostic tools for evaluation, through individual work and analyses of local health policy. every student will get previously prepared example of health target programme with defined targets but one with health monitoring based approach and the other with policy centred approach. the task will be identification of action areas in local conditions (usage of action areas of the healthy people 2010 toolkit http://www.healthypeople.gov/state/toolkit/default.htm is recommended), diagnosis of implementation of target program in local region by usage implementing checklist # 2 and # 3. they suppose to write a report about possibilities of realization of such programme and describe problems which they can find during analyses. timing: 2,5 hours for students. 557 targets for health development references 1. who, regional office for europe. targets for health for all. targets in support of the european regional strategy for health for all. (european health for all series; no.1). copenhagen: who, regional office for europe; 1985. 2. who, geneva. health for all in the twenty-first century (51st world health assembly 1998, geneva, switzerland). who document a51/5. geneva: who; 1998. 3. who, regional office for europe. health for all targets: the health policy for europe. (european health for all series; no.4). copenhagen: who, regional office for europe; 1993. 4. who, regional office for europe. health21: an introduction to the health for all policy framework for the who european region. (european health for all series; no.5). copenhagen: who, regional office for europe; 1998. 5. who, regional office for europe. health21: the health for all policy framework for the who european region. 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middelton j, editor. sandwell health. the album. the 3rd annual public health report for sandwell 1991. west bromwich: department of public health; 1991. 75. middleton j, editor. sustainable sandwell. the fourth annual public health report for the metropolitan borough of sandwell. west bromwich: department of public health; 1992. 76. edmonton board of health. health goals for edmonton. the report of the healthy edmonton 2000 project. edmonton, alberta: edmonton board of health; 1992. 77. stadt bielefeld. bielefelder gesundheitsziele. für eine bessere gesundheit. bielefeld: stadt bielefeld; in press 2003. 78. bergmann ke, baier w, meinlschmidt g, editors. gesundheitsziele für berlin. wissenschaftliche grundlagen und epidemiologisch begründete vorschläge. berlin: de gruyter verlag; 1996. 79. welteke r. ansätze zur einbeziehung von landesgesundheitszielen in die kommunalpolitik. in: kellermann k, konegen n, staeck f, editors. aktivierender staat und aktive bürger. wegweiser zu einer integrativen gesundheitspolitik. frankfurt am main: mabuse-verlag; 2001. 80. mccormick j, fulop nj. for and against health targets. in: marinker m, editor. health targets in europe: polity, progress and promise. london: bmj books; 2002; 34-48. internet linkpage linkpage 7.1. health targets – international and national : australia http://www.health.qld.gov.au/publications/infocirc/info28.pdf http://www.rmit.edu.au/departments/ps/assid/health.htm canada http://www.hc-sc.gc.ca/english/media/releases/2001/tobaccotax_2001ebk.htm (tobacco) eire/ireland http://www.issi.ie/naps/summary_resource_material.htm (social inequalities) europe http://www.who.dk/eprise/main/who/progs/hpa/targets/20020319_1 (who europa) http://www.who.dk/observatory/publications/20011008_4 (seite wird nicht automatisch per link angezeigt) daher à http://www.who.dk/ germany/deutschland http://www.gesundheitsziele.de great britain/united kingdom http://www.foe.co.uk/resource/reports/uk_progress_who_targets.pdf http://www.nwpho.org.uk/inequalities/life_expectancy_has.pdf (health inequalities targ.) 563 targets for health development http://www.ohstrategy.net/strategy/targets.shtm (occupational health targets) http://www.mbha.nhs.uk/annual_reports/ph1996/ph96-4.htm (evaluation) lithuania http://www.sam.lt/reform/objectives.htm poland http://www.medstat.waw.pl/nhp/0.html#2 united nations (un) http://www.un.org/esa/socdev/ageing/agetarg.htm http://millenniumindicators.un.org/unsd/mi/mi_goals.asp united states of america http://www.crisny.org/health/us/health7.html (healthy people 2000) http://www.health.gov/healthypeople/state/toolkit/default.htm (healthy people 2010 -toolkit) http://www.health.gov/healthypeople/state/toolkit/progress.htm (healthy people 2010-toolk.) http://www.healthierus.gov/ ( president’s healthierus initiative ) http://www.healthypeople.gov/document/tableofcontents.htm http://www.hhs.gov/news/press/2001pres/01fsasthma.html (combating asthma) world bank http://www.developmentgoals.org/research.htm (health targets) world health organization (who international, geneva) http://www.who.int/whr/1998/whr-en.htm linkpage 7.2. regional health targets: alberta (cdn) http://www.health.gov.ab.ca/rhas/rhatarge.htm essex (gb) http://www.ne-ha.nthames.nhs.uk/hsp/13.htm#top lower saxony/niedersachsen (d) h t t p : / / w w w. g e s u n d h e i t n d s . d e / f r a m e s / a r b _ s c h w p k t e / a _ s c h w p k t e . h t m l # a n c h o r _ 4 (gesundheitsziele im rahmen des modellprojekts „gesundes land niedersachsen) north rhine-westphalia/nordrhein-westfalen (d) http://www.google.de/search?q=gesundheitsziele&hl=de&lr=&ie=utf-8&start=60&sa=n (ausschnitt ziel 3) http://www.gluecksspielsucht.de/materialien/landes1d.pdf (zu ziel 4) http://www.mfjfg.nrw.de/aufgaben/gesundheit/gesund.htm (gesundheitsministerium nrw) http://www.dshs-koeln.de/soziol/gbe/einleitung.htm (kreis neuss) 564 health systems and their evidence based development oberösterreich (au) http://www.ooe.gv.at/alz/alz2000/01/08.htm http://www.sggp.ch/gpi/archiv/ghbericht_1-02.cfm sachsen-anhalt (d) http://www.asp.sachsen-anhalt.de/presseapp/data/ms/2002/034_2002.htm schleswig-hostein (d) http://www.schleswig-holstein.de/landsh/mags/gesundheit/gesundheit_13.html schottland (gb) http://www.show.scot.nhs.uk/achb/about/targets.htm http://www.ihmscotland.co.uk/conferences/dec%202001/practice%20mx%20conf/sld012.htm http://www.scotland.gov.uk/library/documents/oral03.htm (oral health targets) south-australia (aus) http://www.dhs.sa.gov.au/pehs/ ( à http://www.healthysa.sa.gov.au/) steiermark (a) http://www.landeshauptmann.steiermark.at/cms/ziel/256871/de/ http://www.aekstmk.or.at/medien/02042002.htm (provisorisch) victoria (aus) http://www.dhs.vic.gov.au/phd/hdev/hpromo/funding/nattar.htm wales (gb) health targets and indicators: a consultation document html-version www.hpw.wales.gov.uk/english/resources/reportsandpapers/ health_improvement_document_e.doc ähnliche seiten http://www.dyfpws-ha.wales.nhs.uk/compendium2000/page21.html (1995 – 1998 – 2010) http://www.dyfpws-ha.wales.nhs.uk/compendium2001/page33.html linkpage 7.3. selected publications on health targets: australia (aus) http://www.nisu.flinders.edu.au/pubs/monitor7/mon7p7.html http://www.nisu.flinders.edu.au/pubs/monitor10/monitor10-metamorp.html germany/deutschland (d) http://www.infodienst.bzga.de/medien/01_12/mabuseziele.htm http:// www.loegd.nrw.de http://www.dfi.uni-duesseldorf.de/main/04aktuelles/stvincent.shtml (diabetes – st. vincent) 565 targets for health development great britain/united kingdom (gb) http://www.dur.ac.uk/comparative.publichealth/research/bmj.htm nigeria http://www.aegis.com/news/ips/2001/ip011217.html (aids) north rhine-westphalia/ nordrhein-westfalen (d) http://www.loegd.nrw.de/publikationen/ref/refgpolitik.html http://www.loegd.nrw.de/publikationen/ref/refgpolitik.html http://www.loegd.nrw.de/loegd_english/services/health_policy.html http://www.infodienst.bzga.de/medien/01_12/mabuseziele.htm http:// www.loegd.nrw.de 566 health systems and their evidence based development 567 targets for health development health systems and their evidence based development a handbook for teachers, researchers and health professionals title health legislation: procedures towards adoption module: 3.4 ects (suggested): 0.25 authors, degrees, institutions lijana zaletel-kragelj, md phd, teaching assistant university of ljubljana, faculty of medicine, department of public health social medicine zaloška 4, 1000 ljubljana, slovenia address for correspondence faculty of medicine, department of public health social medicine, zaloška 4, 1000 ljubljana slovenia fax: + 386 1 543 75 41 e-mail: lijana.kragelj@mf.uni-lj.si keywords regulations, legislative procedure, health legislation, health law learning objectives at the end of this module, students would become familiar with the classification of legal regulations as well as the legislative procedure. they will increase their knowledge about: • different types of legal regulations, recognising the differences among them; • legal procedure in their own country; • legal areas, in which in their own countries legal regulations relating to health and health care could be found; and • the media by which the adopted laws (acts) and other adopted legal regulations as well as the obligatory explanations come into operation. abstract the public health professionals should be at least roughly familiar with different types of legal regulations and the procedures for adopting them. their possible professional role could be among others also to propose a new law or other legal regulation to an appropriate legislative body, which is responsible to adopt it or to propose the amendments or changes to already adopted laws or other legal regulations. this module is aiming at students to get familiar with the classification of legal regulations as well as the legislative procedure (the republic of slovenia example). also some contents, regulated by health legislation are described. teaching methods the teaching method recommended by the author is a combination of introductory lecture, group work and final discussion. detailed description of steps is given. specific recommendations for teacher it is recommended that the module should be organized within 0.25 ects credit. students are asked to collect some of the readings health care law, health insurance law or „national digest of legislation” by themselves. if there are students with different undergraduate background in the group they should be divided to smaller group according to this. assessment of students the final mark should be derived from assessment of practical work and from assessment of theoretical knowledge of the student. a detailed description is given as well as an example of a question (test type). health legislation: procedures towards adoption lijana zaletel-kragelj the health legislation is the common term for all legal regulations which serve to human health. the areas, which are regulated by them, are very different. in one side for example we have the regulations, which refers to control various diseases and on the other side the financing of various activities related to human health. the function of health legal regulations is thus heterogeneous. the main function is to prohibit people’s activities which are injurious to the human health (for example dumping of toxic chemicals in the environment or spreading the infectious diseases), to authorize health programmes and health services (for example authorizing of health services for mothers and children), to regulate the production of resources for health care (for example financing the construction of outpatient departments or hospitals), to provide the financing of health care (health insurance) and to authorize surveillance over the quality of health care (minimum standards for health personnel and facilities) (1). but with no regard to the content of specific legal regulation, all regulations and the procedures for adopting them are subject to common principles. the modern public health professionals should be active and creative also in this field, regardless of their basic profession. their possible professional role could be among others for example also to propose a new law or other legal regulation to an appropriate legislative body, which is responsible to adopt it or to propose the amendments or changes to already adopted laws or other legal regulations. this module thus focuses to the basic knowledge on legal regulations with special emphasis on health matters. classification and short description of the legal regulations classifications there are several different types of legal regulations known. they could be roughly classified by two classifications (2). classification 1: • general legal regulations – regulations that don’t define the number of the subjects in advance; 568 health systems and their evidence based development • individual legal regulations – regulations referring to the subject that is exactly defined; classification 2: • abstract legal regulations – regulations referring to the simulated cases (constitution, laws...); • concrete legal regulations – regulations referring to the existent concrete circumstances in which the legal subjects are asked to behave and act in a specific way. mostly the general abstract legal regulations are used in common. general abstract legal regulations among this kind of regulations we can find constitution, laws and statutes (2). 1. constitution. constitution is the most fundamental regulation that regulates the substance that is of essential importance for the certain country and its society. it is adopted by parliament (national assembly). 2. laws. laws are general legal regulations that regulate the substance that is principal and fundamental for the certain legal system. but at the same time the substance is not so important to be regulated by the constitution. they are adopted by parliament (national assembly). 3. statutes. statutes are legal regulations with less significance then the laws. there exist several statutes. the following ones are listed by the order of legislative body that adopts the particular statute: • decree – regulates and analyses relations that are defined by the law. it is adopted by the government. • ordinance – regulates individual issues and stipulates provisions that have a general meaning (is more detailed than a decree). it is also adopted by the government. • regulation – regulates the organisation of the operation or the method of the proceeding of the specific body. it is adopted by the minister. • order – intended for the implementation of the individual provisions it orders or interdicts the operation that has a general meaning. it is adopted also by the minister. • instruction – it regulates the method of proceeding of the administrative body that executes individual provisions of the law or the statute. it is adopted also by the minister. 569 health legislation: procedures towards adoption the legislative procedures the legal regulations are adopted by the official procedures, regulated by special legal acts, which regulates functioning of particular country (3). these procedures are more or less similar for majority of the countries. as an example a procedure for adopting a law will be described as follows, as laws are the main legal regulations immediately after the constitution. the process of a law becoming official is called “enactment”. also the law that has been passed by the official procedures (for example in a parliament of a country) is called no longer “a law” but “an act”. the procedures for enacting a law: the republic of slovenia case in slovenia the procedure for enacting a law is regulated by rules of procedure of the national assembly (the parliament of slovenia) (4,5). this procedure can be divided to a regular procedure or fast-track procedure. also every law can be reconsidered as well as an obligatory explanation of every single law can be made. regular procedure the regular procedure has several phases: proposal of law, first reading of a proposed law, second reading of a proposed law, third reading of a proposed law and voting on a law. in following section of the module the most important parts of single phase of this procedure are described: 1. proposal of a law every law can be proposed by the government itself, every deputy, a group of at least 5,000 voters or by the national council. the proposal of the law must contain the title of the law, an introduction, the text and an explanation. it must contain the reason/s for enacting the specific law, its goals and principles, an estimation of the financial burden for the national budget, required for its enactment. it is to be sent to the president of the national assembly. the president than forward the proposed law to deputies, to the national council and to the government, when the latter is not the proposer of the law. the president of the national assembly determines the primary standing committee to participate in the debate of a proposed law and report to the national assembly and when the proposed law contains provisions which require funds from the national budget, the president shall also assign such law for 570 health systems and their evidence based development debate to the standing committee competent for financial matters. the standing committees are working groups which study individual fields, prepare decisions on policy in these fields, formulate opinions on individual questions, and prepare, study and debate proposed laws and other acts of the national assembly. a proposed law is then discussed by the national assembly in three readings. the secretariat for legislation and legal affairs shall offer, at each reading of a proposed law and before the voting on the law, an opinion on the conformity of the proposed law with the constitution and with the legal system, and proposals in relation to the legal and technical treatment of the law. the proposer of a law may withdraw the proposed law up until the conclusion of the second reading. 2. first reading during the first reading of a proposed law, its presentation in the national assembly and then a debate on the reasons demanding its enactment and also on the principles and goals is held. the primary standing committee presents its opinion on the law, which could be positive or negative. if it is negative, the standing committee ought to formulate its own proposal for a decision which the national assembly should adopt after the conclusion of the first reading. if it is partially negative, the standing committee may formulate a proposal for opinions which the proposer should take into consideration in the preparation of the proposed law for its second reading. at the end of the first reading of a proposed law the national assembly has to decide: • to hold a second reading of the proposed law at the same or the following session with the text as submitted for the first reading, or • that the proposer of the law or the secretariat for legislation and legal affairs shall, within a given time limit, prepare the text of the proposed law for its second reading in accordance with the opinions of the national assembly adopted at the conclusion of the first reading, or • not to enact the law. if, after the conclusion of the first reading, the national assembly decides that the second reading of the proposed law shall be held, it defines the time of the second reading. if it decides not to adopt the law, the legislative procedure is terminated. 571 health legislation: procedures towards adoption the text of a law prepared for its second reading must contain explanations indicating in which articles and in what way the opinions of the national assembly have been taken into consideration. during the first reading it shall not be possible to propose amendments to individual provisions of the law. 3. second reading during the second reading of a proposed law, the national assembly debates each article of the law in the order of articles and then its title. when the national assembly concludes the debate on an individual article, deputies vote on it. at the end they also vote on the title of the law. at the proposal of the primary standing committee, a deputy group or at least ten deputies, the national assembly may decide that the second reading of a proposed law shall be conducted as a general debate on it or that the first reading shall be repeated. during this phase of the procedure, deputies, the primary standing committee, an interested standing committee and the proposer may submit amendments to propose the changes and supplementations to the proposed law. the government may also propose an amendment when it is not the proposer of the law. the primary standing committee shall state its opinion on an amendment/s. this opinion is a part of the report on the proposed law submitted by the primary standing committee to the session of the national assembly. this report shall also contain a report by the secretariat for legislation and legal affairs if the secretariat for legislation and legal affairs submitted an opinion in the debate on the amendment in the primary standing committee. deputies shall vote separately on each amendment to a proposed law. if several amendments are proposed to an article of a proposed law, deputies shall vote first on the amendment which departs most from the content of the article in the proposed law, and then, following this criterion, on other amendments. if also an amendment is proposed to an amendment, deputies shall vote first on the amendment to the amendment. if, during the second reading, no amendments were adopted to the text of the proposed law or only amendments of an editorial nature in the opinion of the secretariat for legislation and legal affairs, the national assembly may, at the same session, continue on to the third reading of a proposed law. if amendments were adopted during the second reading, the third reading is to be conducted. the secretariat for legislation and legal affairs shall prepare for the 572 health systems and their evidence based development third reading of the proposed law the complete text of the proposed law with adopted amendments and with an explanation of changes in the wording of articles submitted for the second reading. the national assembly may assign this task also to the proposer of the law. 4. third reading during the third reading of a proposed law, the national assembly has to debate the proposed law in its entirety. the separation of individual articles of the proposed law is possible only for the articles which were altered with amendments during the second reading. during this phase of the procedure an amendment also may be proposed. the procedure is the same as in second reading. the primary standing committee shall again present its opinion on the proposed law. 5. voting on a law at the end of regular procedure, the national assembly has to vote on the proposed law in its entirety. a law is enacted if the number of votes cast “for” is greater than the number of votes cast “against”, unless a different majority is provided for the enactment of a law by the constitution or by law. the secretariat for legislation and legal affairs has to prepare the final text of the law (the original) on the basis of decisions made by the national assembly. fast-track procedure in certain special circumstances it is also possible to enact a law by using the fast-track procedure. these special circumstances are extraordinary needs of the state, the interest of defence, or circumstances of natural disasters. such proposal must be specifically explained. if the national assembly determines to use the fast-track procedure, it has to merge all three readings of the regular procedure in one session. reconsideration of a law before the official proclamation of the law, the national council can impose to the national assembly its reconsideration. the president of the national assembly has to forward the request of the national council to the primary standing committee. the latter shall formulate an opinion on the content of the request by the national council. the national assembly shall conduct the vote of reconsideration at its next session. a law is enacted if the majority of deputies of the national assembly vote for it unless provisions of the constitution require a greater number of votes for enactment of a law. 573 health legislation: procedures towards adoption the procedure for the obligatory explanation of law for every law an obligatory explanation of a law also could be made. this explanation could be proposed to the national assembly by any of those having the right to propose a law (the government, every deputy, a group of at least 5,000 voters, the national council). the procedure is similar to the regular procedure for enacting a law. publication of adopted legal regulations the adopted laws and other adopted legal regulations as well as the obligatory explanations are published in slovenia in the official gazette of the republic of slovenia (uradni list republike slovenije). every year also the register of current legal regulations is published (3). prior to the adoption and prior to the publication in the official gazette every law in slovenia could be found in the bills database, attainable at the national assembly website (6). the bills database contains bills in the current term which are in parliamentary procedure (regular, fast-track procedure...) and in one of the readings (first, second, third) in the national assembly. ratification of international treaties there exist numerous legal regulations related to health and healthrelated matters at the international level. every country has its own procedure to accept or to ratificate such regulations. in slovenia the national assembly ratify every international treaty with a special law. the provisions of the fast-track procedure for adopting a law are used. the contests, regulated by health legislation as it was already mentioned in the introduction that there are many different problems relating to the peoples’ health. because of this reason the content of legal regulations relating these problems is very diverse. they can regulate for example the control over communicable or noncommunicable diseases as well as health financing, health research, health insurance, functioning of health care institutions, ethical issues, health professional’s responsibilities and many others. it is very difficult to make a one uniform classification of all the health and health care relating legal regulations as these regulations could be found in several legal areas: mostly in health care and health insurance area, 574 health systems and their evidence based development but also in the other areas as agriculture, forestry, nutrition and food, poison and other hazardous substances, occupational health and safety, environmental protection, radiation protection and many others. the distribution of health related legal regulations among legal areas depends also on the single country. review of health legislation in slovenia in slovenia health related legal regulations could be classified according to several health spheres. the following classification is according to ministry of health of republic of slovenia (only the most important acts are listed): 1. health care and health insurance sphere: • health care and health insurance act • infertility treatment and procedures of biomedically-assisted procreation act • repayment of harm to individuals with hiv infection due to blood transfusion or transfusion of blood preparations • removal and transplantation of parts of human body for the medical treatment purposes • restriction of the use of tobacco products act • health care of foreigners in republic of slovenia act • health interventions for fulfilment of right on free decisionmaking on birth of children act • occupational safety and occupational health care act • restriction of alcohol consumption act 2. health services and health activities sphere including pharmaceutical sphere: • health activities act • health inspection act • healthcare databases act • general practitioners act • pharmacy activities act • natural remedies and natural health resorts act 575 health legislation: procedures towards adoption 3. medicinal products and medicinal devices sphere: • medicinal products and medicinal devices act • supply of blood act • phytopharmaceutical remedies act 4. cosmetics sphere: • cosmetics act 5. food control sphere: • sanitary suitability of foodstuffs, products and materials coming into contact with foodstuffs act 6. communicable diseases control sphere: • communicable diseases act 7. chemicals sphere: • chemicals act • chemical weapons act • manufacture and trafficking of asbestos products and financial assurance for rearrangement of asbestos manufacture to nonasbestos manufacture act 8. humanitarian organizations sphere: • red cross of republic of slovenia act 9. illicit drugs sphere: • manufacture and trafficking of illicit drugs act • prevention of the use of illicit drugs and the treatment of drug users act • illicit drugs components act there exist also other legal regulations in slovenia that contain parts highly related to health of human beings for example veterinary medicine act, environment protection act etc. 576 health systems and their evidence based development exercise: health legislation – basic knowledge in order to fulfil objectives and according to the ects credit, student are expected to work individually for 2.5 hours (task 1) and then discus in small group about legislation in their countries (task 2). task 1: preparing individually. students are asked to inform themselves before session. they are supposed to gather all acts which are considering health system, by using “national digest of legislation”. students should make a list of laws, regulations and subregulations, also be familiar with some basic laws, such as health care law, health insurance law. task 2: students are divided into small group, in order to discuss the differences between health legislation in different countries. 577 health legislation: procedures towards adoption references 1. roemer r. comparative national public health legislation. in: holland ww, detels r, knox g, fitzsimons b, gardner l, eds. oxford textbook of public health. volume 1. oxford, oxford university press, 1997: 351-369. 2. kušej g, pav~nik m, pereni~ a. ljubljana: uvod v pravoznanstvo. (introduction to jurisprudence) (in slovene language). uradni list rs, 1993: 320. 3. register pravnih predpisov republike slovenije za leto 1999. (the register of legal regulations of the republic of slovenia for 1999) (in slovene language). ljubljana: uradni list republike slovenije, 2000: 853. 4. poslovnik dr`avnega zbora. (rules of procedures of the national assembly) (in slovene language). ur list rs, 1993; 3 (40): 5051-2076. 5. rules of procedure of the national assembly. the bills database. the national assembly of republic of slovenia official website (in english language): http://www.dz-rs.si/en/aktualno/spremljanje_zakonodaje/poslovnik/poslovnik.html 6. the national assembly of republic of slovenia. the national assembly of republic of slovenia official website homepage: http://www.dz-rs.si recommended readings 1. law, ethics, and challenges. in: holland ww, detels r, knox g, fitzsimons b, gardner l, eds. oxford textbook of public health. volume 1. oxford, oxford university press, 1997: 351-413. 2. backes o, stebner fa. gesundheistrecht. in: herrelmann k, laaser u. handbuch gesundheitswissenschaften. weinheim and muenchen, juventa, 1998: 753-777. 3. public health law. in: wallace rb, doebbeling bn, eds. maxcy-rosenau-last public health and preventive medicine. stamford, appleton and lange, 1993: 1147-1154. 4. who. international digest of health legislation. int dig hlth leg, 1999; 50: 1-160. 5. who. international digest of health legislation. who website: http://www.who.int/idhl 578 health systems and their evidence based development health systems and their preface references contents list of authors health systems analysis health systems analysis the role and organization of health introduction health care services and health services organizations what is a health system? models of national health care systems based on the sources of levels of organization of health care systems and health care delivery outpatient care outpatient institutions and services in-patient care and institutions classification of hospitals functions of the hospitals three generations of health care system reforms exercise: the role and organization of health care system references health care system of the federation introduction method demographic indicators socioeconomic indicators health care system reform health system organization survey of health professionals in fb&h in comparison with some primary health care specialist's or consultant's health care hospital care funding conclusions exercise: health care system of the federation of bosnia and references recommended readings electronic health records the core background defining electronic health record building electronic health records necessary context blocks necessary building blocks benefits of electronic health records difficulties and risks associated with electronic health records national approaches: examples exercise: ehr development data storage, data privacy and security glossary of key terms references recommended readings health indicators and health classification and evaluation method of indicators the types of different indicator sets indicator classification and evaluation methods types of indicators quality criteria for health indicators main categories of an indicator set methods of comparison and benchmarking the use of health indicators for health reporting exercise: health indicators and health reporting references databases for health indicators quality of life: concept and definition of quality of life and health related quality of life measuring quality of life the instruments for measuring quality of life generic questionnaire sf – 36 standardization procedure of sf – 36 specific questionnaire – the minnesota living with heart failure the steps in the cultural adaptation: an example of serbian forward translation backward translation patient testing or cognitive debriefing exercise: measuring quality of life living with heart failure questionnaire living with heart failure questionnaire references and recommended readings disability-adjusted life years: a definitions and basic concepts health status assessment by use of daly exercise: disability-adjusted life years as a key tool for the analysis references recommended readings calculating the potential years of the concept of premature death historical background computing methods for pyll main domains where pyll is a useful tool examples from romania references recommended readings case study: inequalities in health as exercise: inequalities in health in the european region: what can the references health technology assessment origins what is health technology? what is health technology assessment? what is the purpose of health technology assessment? is it health technology assessment or a different approach that is what are the main elements of hta analysis? when are health technology assessment requested? what is the role of ethics in health technology assessment? how is health technology assessment conducted? selected issues in health technology assessment case example: step 1. identify and rank assessment topics step 2. specify assessment problem. step 3. determine locus of assessment. step 4. retrieve available evidence. step 5. collect primary data. step 6. interpret evidence. step 7. synthesize and consolidate evidence. step 8. formulate findings and recommendations. step 9. disseminate the findings and recommendations. step 10. monitor impact of assessment reports. exercises: introduction to health technology assessment references recommended readings comparative analysis of regional 2) moravian-silesian region – czech republic 2.1 demography 2.2 organisation and structure of the health system 2.3 measles immunisation programmes 2.4 breast cancer screening programmes 5) north rhine-westphalia, germany 5.1 demography 5.2 organisation and structure of the health care system 5.3 measles vaccination programmes 5.4 breast cancer screening programmes 6) eastern / midland / north-eastern regions – ireland 6.1 demography 6.2 organisation and structure of the regional 6.3 measles immunisation programmes 6.4 breast cancer screening programmes 7) veneto – italy 7.1 demography 7.2 organisation and structure of the health care system 7.3 measles immunisation programmes 7.4 breast cancer screening programmes exercise: comparative research on regional health systems in europe references health systems management health management: theory and development of management theory development of interest for health services management characteristics of managing health services organizations definition and key management components planning in management organizing in management staffing in management leadership in management controlling in management skills of modern managers in health services organizations exercise: managing health services organizations references and recommended readings human resource management fundamentals of human resource management staffing function training and development function motivation function maintenance / retaining function performance appraisal principles are: exercise: human resource management references recommended readings information systems management definitions and basic concepts existing types of applications in the medical field managerial cycle and information support types of decisions and the related information systems exercise: management of information systems references recommended readings financing of health care markets in health care the health care triangle basic sources for financing of health care the role of the state in financing of health care the role of the health insurance in financing of health care the role of the private sources in financing of health care external sources for financing of health care exercise: financing of health care references recommended readings payment methods and regulation resource allocation according to needs basic arrangements for resource allocation payment for primary health care (phc) providers payment and regulation of hospitals and other health facilities conclusion exercise: financing of health care and regulation of providers references case study: the current health insurance system modalities of becoming an insured through obligatory health rights from the obligatory health insurance realization of the rights to health care resources for health financing user participation in health care expenses (co-payment) payment to the health care providers revenues and expenditures of the health insurance fund in the year health insurance system in the health care reform in macedonia exercise: specificities of the current health insurance system in the republic of macedonia references case study: swot analysis of the serbian health current trends in health care system reforms historical background of the health insurance system development strengths weaknesses opportunities threats exercise: how can the health insurance management be restructured? references and recommended readings economic appraisal as a basis for health care and limited resources allocation of limited resources main features of health economics economic appraisal as an instrument for supporting decision making the concept of value and efficiency costs, costing problems and outcomes the methods of economic evaluation cost-effectiveness analysis cost-benefit analysis quality of life analysis cost-utility analysis cost of illness study decision rules: how to determine efficiency? how to make choices cost-effectiveness analysis discounting of cost and benefits how to perform an economic appraisal? stages in economic evaluation the research question the study population the study perspective data sources quality assurance exercise: health economics references recommended reading quality improvement in health care development of quality concept tools for quality improvement strategies and models current state of art in quality improvement and the role of public exercise: quality improvement in health care and public health references recommended readings accreditation of health institutions models of external tools for quality improvement in health care 1. iso model 2. efqm model 3. visitation programme 4. accreditation concept of accreditation – advantages and limitations accreditation procedure international projects and experiences with accreditation in european references project management characteristics of the project 1. a project creates change. 2. a project has various goals and objectives. 3. a project is unique. 4. a project is limited in time and scope. 5. a project involves a variety of resources. the phases of project management 1. initiation (pre-planning) phase 1.1. situational analysis 1.2. health problems identification 1.3. priority setting 1.4. establish goal and objectives 1.5. feasibility study 1.6. preliminary brief 2. detailed planning and scheduling 3. implementation 4. completion exercise: project management references and recommended readings planning and programming of health 1. specific issues related to the planning process 2. preparing a plan steps in the planning process 2.1. stating the mission (problem statement) 2.2. analyzing the external environment 2.3. conducting the swot analysis 2.4. establishing goals and objectives 2.5. preparing a financial plan and a budget 3. programme monitoring and evaluation 3.1. monitoring 3.2. evaluation exercise: planning and programming in health care references recommended readings useful internet sites health policy informed health policy and system health policy goals and priorities the role of the state and the ministry of health the position of decentralization in the health policy recommendation for the health policy changes redefined roles of the state and of the ministry of health providing the decentralization process at all levels application of modern management at the system and institutional education of managers for the new health policy exercise: health policy references public health framework in the the current legal basis for public health development and implementation of european union public health the view of people and experts regarding european public health the policies exercise: public health in the european union references recommended readings targets for health development introduction some principles history health21 – the renewed health target strategy of the who for the new target programmes of members of the healthy region network selection of national approaches some further regional target programmes selection of local health target programmes how to develop a target programme different types of target programmes networking for pragmatic support diagnostic tools some final remarks exercise: health targets references internet linkpage health legislation: procedures classification and short description of the legal regulations classifications general abstract legal regulations the legislative procedures the procedures for enacting a law: the republic of slovenia case regular procedure 1. proposal of a law 2. first reading 3. second reading 4. third reading 5. voting on a law fast-track procedure reconsideration of a law the procedure for the obligatory explanation of law publication of adopted legal regulations ratification of international treaties the contests, regulated by health legislation review of health legislation in slovenia exercise: health legislation – basic knowledge references recommended readings 1 review of costing tools health system in liberia project technical assistance to support the implementation of the national health plan and the roadmap for the reduction of maternal mortality in liberia 2 epos health management in cooperation with the european union project technical assistance to support the implementation of the national health plan and the roadmap for the reduction of maternal mortality in liberia authors: natasa popovic, m.sc. public health, phd candidate, institute of social medicine, school of medicine, university of belgrade senior health economist epos health management roland y. kesselly, director of hfu mohsw nuaker k. kwenah, health financing officer mohsw ernest gonyon, health financing officer mohsw melanie s. graeser, junior health economist hfu mohsw correspondence: prof. dr. med. ulrich laaser dtm&h, mph team leader of the eu funded technical assistance to reduce maternal mortality in liberia department of planning, ministry of health congo town, monrovia, liberia epos eu ta: https://www.facebook.com/eutahealthliberia e-mail: ulrich.laaser@uni-bielefeld.de http://www.facebook.com/www.epos.de mailto:ulrich.laaser@uni-bielefeld.de 3 acknowledgements: the authors gratefully acknowledge the support of mr. david collins (management sciences and health). 4 table of contents list of acronyms .......................................................................................................................................... 5 1. introduction ......................................................................................................................................... 6 2. background .......................................................................................................................................... 8 3. marginal budgeting for bottlenecks ................................................................................................ 10 4. cost and revenue analysis tool plus .............................................................................................. 19 5. onehealth tool .................................................................................................................................. 21 5.1 modules of onehealth tool ...................................................................................................... 22 5.2. costing process ............................................................................................................................... 26 6. conclusion .......................................................................................................................................... 28 7. references: ......................................................................................................................................... 29 5 list of acronyms core plus cost and revenue analysis tool plus eu european union hfu health financing unit hiv/aids human immunodeficiency virus infection and acquired immune deficiency syndrome mbb marginal budgeting of bottlenecks mdg millennium development goals mohsw ministry of health and social welfare of liberia msh management sciences for health prsii poverty reduction strategy tb tuberculosis 6 1. introduction as a consequence of the ebola crisis, the liberian ministry of health and social welfare‘s (mohsw) adopted measures to strengthen the health sector leading to the “investment plan for building a resilient health system” (1). numerous partners assisted in this effort, including the european union (eu), which contributed to the development of the plan and participated in the revitalization of the technical working groups along with the nine pillars of intervention. the eu contributed a substantial part as it addressed with preference one of the biggest public health concerns of the country: the reduction of maternal and newborn mortality (2, 3, and 4). it predominantly supported two intervention pillars, namely strengthening leadership and governance and efficient health financing systems and contributes as well to others. these elements represent important requirements to the implementation of the "roadmap for accelerating the reduction of maternal and newborn morbidity and mortality in liberia" and the "accelerated action plan to reduce maternal and neonatal mortality", within the overall framework of the national health plan (2, 3, 4, 5). one important barrier to achieving the national health plan in liberia is a lack of funding (6). as in many developing countries, the health systems in liberia fail to reach large coverage of the population that would benefit from cost-effective interventions related to child and maternal health, malaria, tuberculosis (tb), human immunodeficiency virus infection and acquired immune deficiency syndrome (hiv/aids), and other diseases, due to missed opportunities for mobilization of financial resources or the required financial assistance. the introduction of three appropriate analytical costing tools programs cost and revenue analysis tool plus (core plus), marginal budgeting of bottlenecks (mbb) and onehealth tools, was an 7 opportunity to support health financing unit of mohsw of liberia (hfu), to manage, improve and harmonize the process of costing and budgeting plans and interventions in the health system. the aim of review of costing tools is to present costing tools that were introduced during the project "technical assistance to support the implementation of the national health plan and the roadmap for the reduction of maternal mortality in liberia", in order to implement in the liberian health system (7). 8 2. background the mohsw of liberia developed a primary health care approach encompassing decentralization, community empowerment, and partnership. these objectives have been defined in the health sector policy and plan 2011-2021 and the poverty reduction strategy – prsii 2012 – 2017, both stressing the importance of making progress in maternal and newborn health (millennium development goals mdg 5) (5). epos health management through the project technical assistance to support the implementation of the national health plan and the roadmap for the reduction of maternal mortality in liberia, contributes to the achievement of the objectives and targets set for 2016-2017 in the 10-years strategic health and social welfare plan and the roadmap for the reduction of maternal mortality (7, 2). the overall objective of this project is to contribute to improving the health status of the liberian population in general and reducing maternal mortality in particular, by improving access to as well as the quality of the essential package of health services (7). this includes mentoring of local staff to contribute to a sustainable reform and modernization of the health sector. epos health management supported to produce a needs-based comprehensive capacity development plan (human resources, institutional and system) for central office and county health team, covering: health planning and budgeting, accounting, financial management and reporting, contracting of health services; health information management; human resources management; assets management; supervision skills; logistic and supply management and quality assurance management. approach and strategy chosen to achieve one part of the goals are to provide costing tool trainings such as marginal budgeting for bottlenecks, core plus and onehealth tools, for hfu mohsw of liberia (8, 9). 9 the aim of this trainings is to strengthen health systems and to improve medium-term sector, planning, costing, budgeting, financing and analysis and to estimate the costs of individual services and packages of services under the different scenarios. table 1. list of costing tools included in the review that are introduced to health financing unit in liberia tool developed by developer marginal budgeting for bottlenecks (mbb) unicef/ world bank rudolf knippenberg, susie villeneuve, netsanet walelign, agnes soucat core plus management science for health david collins onehealth tool inter-agency working group on costing avenir health 10 3. marginal budgeting for bottlenecks the marginal budgeting for bottlenecks tool estimates the potential impact, resource needs, costs, and budgeting implications of country strategies to remove systemic bottlenecks and implementation constraints of the health system (9). mbb is intended to help formulate mediumterm (one to 10 years) national or provincial expenditure plans and poverty reduction strategies that explicitly link expenditure to health and nutrition mdgs (9, 10, 11) the model has been developed in the context of heavily indebted poor countries and prsp to respond to the request of low-income countries to plan, cost and budget marginal allocations to health services and assess their potential impact on health of the population. (9, 10). the aim of mbb is to answer the following questions (10): 1. which high impact interventions are priorities for the integration into existing service delivery arrangements, to accelerate the progress towards the health and nutrition mdgs? 2. what are the major health systems hurdles or "bottlenecks" hampering the delivery of health services, and what is the potential for their improvement? 3. what is the potential investment required by alternative options to alleviate the identified health systems bottlenecks? what would be the cost of the incremental service provision as coverage increase? 4. what is the total amount of resources required to achieve the desired coverage? 5. what could be achieved in terms of health outcomes by removing health system bottlenecks and increasing coverage of effective interventions? 6. what amount of financing could be mobilized under various fiscal and macroeconomic scenarios and how should additional funding be allocated? 11 the centerpiece of the mbb tool is the bottlenecks identification and analysis approach (9, 10). the main goal of the bottlenecks analysis is to identify the limitations in a health system which responsible of reaching a desired level of service coverage. this approach identifies any weakness and gaps across six determinants (10): ➢ availability of essential commodities, ➢ availability of human resources, ➢ geographical or financial access to health services, ➢ initial utilization of health services, ➢ continuous utilization or adequate coverage, ➢ effective coverage or quality of care. by identifying these bottlenecks, the tool’s outputs help policy makers to (10 14): ➢ select the priority health interventions, policies, and strategies they wish to implement, ➢ estimate the additional resources needed and progress toward achieving the health mdg-related goals, ➢ project the estimated impact of the chosen strategies on the health mdgs. mbb tool is organized in three main modules (10, 11): 1. bottlenecks identification 2. costing & budgeting module 3. estimation of expected impact 12 figure 1. main modules of mbb the bottlenecks identification module uses a country-specific data or default data and defines three main packages of health interventions. on the basis of present levels of effective coverage, it analyses bottlenecks in implementation and sets new performance frontiers (10, 11). the costing and budgeting module is structured to take into account the strategic changes in the health care delivery policies, addressing both supply and demand constraints. estimation of expected impact relies on the results of epidemiological modules. it shows the consequences of the choices of the policy makers and gives them a chance to change their decisions. mbb tool is built on the theoretical concept of effective coverage (15). effective coverage can be defined as the proportion of the population in need of an intervention who have received an effective intervention (15). in order to achieve a high level of effective coverage and a significant health gain, the intervention should be effective, available, accessible and acceptable (15). mbb builds upon the tanahashi modified model of effective coverage concept and used six coverage determinants to assess the capacity of the health system to deliver the full effect of mbb bottlenecks identification module costing & budgeting module estimation of expected impact 13 interventions or achieve effective coverage (16). this modified model was used to identify bottlenecks, through a step-by-step approach, that evaluates six determinants of the effective coverage of intervention. these are determinants (16): 1. availability of essential health commodities, 2. availability of human resources, 3. accessibility of distribution points for the interventions, 4. initial utilization of interventions, 5. continuity/completeness in the continuous utilization of interventions, 6. a quality of interventions delivered. figure 2. tanahashi modified model determinants of effective coverage adapted from tanahashi t. bulletin of the world health organization, 1978, 56 (2), http://whqlibdoc.who.int/bulletin/1978/vol56no2/bulletin_1978_56 (2) 295-303.pdf 14 the first three determinants focus mainly on supply-side barriers, while the other three focus on demand-side barriers. the mbb focuses on the selection of high impact interventions which are currently implemented in a country and organizes them into three service delivery modes (17, 18). within each service delivery mode, high impact interventions are grouped into four sub-packages which are based on their similarity, delivery mode, and/or beneficiaries. table 1. services delivery modes, sub-packages and tracker indicators in health system in liberia family-oriented community-based services family preventive wash services family neonatal care infant and child feeding community illness management insecticide-treated mosquito nets exclusive infant breastfeeding from the 1 to 6 months no alternative to breastfeeding community case management of pneumonia. outreach / schedulable services preventive care for adolescents and adults preventive pregnancy care hiv/aids prevention and care preventive infant and child care family planning antenatal care prevention of motherto-child transmission immunization individual-oriented clinical services maternal and neonatal care at primary clinical level management of illnesses at primary clinical level clinical first referral care clinical second referral care skilled delivery pneumonia tb treatment emergency obstetrics and neonatal care from the extensive menu of high impact interventions which are grouped into tree services delivery modes and four sub-packages, the expert group in liberia has chosen representative interventions 15 or tracer interventions. tracer interventions are considered to have the greatest impact on reducing maternal mortality, under-five mortality, neonatal mortality, malnutrition, and control of priority of diseases. analysis of "determinants of effective coverage" for each tracer intervention, through the bottlenecks analysis, allows the identification of the health system bottlenecks that constrain the achievement of a high effective coverage level. there are a major criteria for choosing a tracer intervention for a bottleneck analysis (10, 11): 1. the tracer intervention is selected only if data is available for each of its six determinants: availability of commodities, availability of human resources, geographical accessibility, initial utilization, continual utilization, and effective coverage level. 2. the tracer intervention is an internationally recommended intervention, with proven and quantified efficacy on mortality reduction. 3. the tracer intervention is nationally relevant. 4. the tracer intervention should be representative of the other indicators within its intervention group, concerning facing similar health system constraints for all tracker interventions, the expert group needs to assess baseline and coverage frontiers. that is one of the most crucial steps in the mbb exercise. coverage objectives or “frontiers” represent the highest, realistically achievable coverage level in a given period. the centerpiece of the mbb tool is the bottlenecks analysis. the main goal of the bottlenecks analysis is to identify the limitations in a health system that are responsible for reaching a desired level of coverage. bottlenecks are measured regarding the six coverage determinants, and a coverage determinant bottleneck is defined as the difference between 16 the maximum achievable coverage and the actual coverage. the result of any reduction in bottlenecks is an increase in the utilization of effective interventions. figure 3. example of bottlenecks analysis of the tracker intervention  the coverage determinant bottlenecks are hierarchical, each bottleneck having a ceiling that is set by its previous determinant and each determinant determines the ceiling of the next.  reductions in bottlenecks have a cascading effect, where changes in one produce changes in the ones that follow.  the magnitude of the cascading effect is set by the baseline ratio between coverage determinants, which is calculated by the tool. 0 10 20 30 40 50 60 70 80 90 100 availability of essential commodities availability of human resources physical access initial utilization timely continuous utilization effective coverage baseline coverage objective coverage 17 table 3. example of frequent bottlenecks and their main causes bottlenecks in the service delivery modes family-oriented, community-based services population-oriented, schedulable services individually-oriented (clinical care) services ● low availability of essential commodities and human resources ● low affordability of commodities ● low levels of knowledge ● no mainstreaming in societal/community values ● low accessibility of promotion programmes ● logistical difficulties and difficulties in sustaining efforts at outreach ● low levels of continuity, high drop-outs ● difficulties in leading qualified human resources to serve the poor ● participation of less qualified providers ● difficulties in controlling the non-retail pharmaceutical market: ● low-quality harmful pharmaceutical products. ● major problems of affordability of health care and impoverishment. table 4. example of causes and corrective actions in the service delivery modes family-oriented, community-based services population-oriented, schedulable services individually-oriented (clinical care) services ● free or subsidized supply of commodities ● increase number of community health workers ● improve social marketing ● female education ● community/ societal support mechanisms ● improve mobile, outreach, and home visits ● centralized control and planning ● community involvement in planning and monitoring ● demand-side incentives ● incentives for qualified staff to work in rural areas and development of alternative skills ● public control of provision of care and prices, regulation of private sector, and combined consumer’s information and providers’ trainings ● modulated pricing, exemptions when funded, and third-party payment mechanisms and subsidies to insurance costing module in mbb involves two basic production functions; intervention production function and health production function. the intervention production function represent the process 18 of how inputs are used to produce health outputs or health service coverage. the intervention cost is calculated by multiplying the quantity of inputs with input prices. the intervention price is the amount of money at which the intervention is bought or sold. both the intervention cost and intervention price have an impact on a budget. the budget can be compared against available financing. the health production function, represents the process of transforming health outputs into health outcomes. health outcomes are generally calculated by multiplying the quantities of interventions produced by their effectiveness. figure 4. elements in costing health interventions and health outcomes source; who, unicef, the world bank, and unfpa, in collaboration with the partnership for maternal, newborn and child health and the norwegian government (2008) technical review of costing tools for the health mdgs final report. 19 4. cost and revenue analysis tool plus cost and revenue analysis tool (core plus) is an excel‐based tool developed by management sciences for health (msh) (19). the tool estimates the costs of individual intervention (services) and packages of interventions as part of the cost of integrated primary health care facilities (19). the tool was designed to be used by planners and managers of government, private and ngo primary health care services. the tool uses a bottom‐up costing methodology to determine the standard cost of each service in the package. a standard unit cost is set for the variable costs of each service, and the total variable costs are then estimated by multiplying those unit costs by the numbers of services (19). the tool can estimate the expected number of each type of intervention provided through a primary health care facility, based on the catchment population and using disease prevalence and incidence rates and service delivery norms. it can then cost each of those interventions and the total package of interventions and can also be used to produce a budget (9, 19, 20, and 21). fees and other revenue sources can be entered for each intervention and compared with individual intervention and total facility costs (9, 19, 20, and 21). the tool defines the intervention production function by enabling the user to choose from five possible service and costing scenarios (19): 1. scenario a: actual services and actual costs; 2. scenario b: actual services and normative costs; 3. scenario c: needed services and normative costs; 4. scenario d: projected services and normative costs;  scenario e: projected services and ideal staffing 20 figure 5. core plus tool flow graphic sources: cost and revenue analysis plus tool flow graphic, (msh) potential applications core plus tool are (19, 9): ➢ to improve planning and budgeting at the national, district, and facility levels. ➢ to identify resource and service delivery gaps and assess the equitable and efficient allocation of resources. ➢ to determine staffing and treatment norms and encourage consistency in quality. ➢ to analyze current revenue streams and perform sustainability analysis. ➢ to compare performance across different facilities. ➢ to determine the cost of adding or scaling up services. ➢ to determine the volume of services that can be provided within a given budget. 21 5. onehealth tool the onehealth model is a new software tool designed to strengthen health systems, integrating planning and analysis, costing, budgeting and financing at a country level (22). the onehealth tool aims to support integrated strategic planning and costing processes in countries, by taking together disease-specific program and health systems planning (22, 23). the tool helps an assessment of costs related to the areas of maternal, newborn as well as reproductive health, child health, vaccination, malaria, tuberculosis, hiv/aids, nutrition, water sanitation and hygiene, to inform progress towards the mdgs, including assessment of achievable health impact (23). additionally, it contains modules for the areas of human resources, infrastructure, logistics, financial space, programme and channel analysis, intervention coverage and costing, bottleneck analysis, programme costing, summary outputs and budgeting. potentially, onehealth could have several users. in the most comprehensive case, health planners would be able to put together a multi-year health plan and use the tool to create a costed plan for addressing critical health needs; to compare different scenarios for reaching the health sector priority goals. the different scenarios could be used as part of a national strategic health planning exercise or as a part of a proposal to a multilateral funding organizations. health system planners from disease area can use the programme planning modules to develop plans addressing their needs concerning health systems. also, they can use the system modules to make medium and long range plans for human resources, infrastructure, logistics, etc. the advantages of onehealth software is generated when multiple modules are used at the same time, to identify synergies and to ensure that planning processes take into account systemic constraints. 22 figure 6 general structure of onehealth tool sources: stenberg k, chisholm d (2012) resource needs for addressing non-communicable disease in lowand middle-income countries. global heart 7: 53-60. doi:10.1016/j.gheart.2012.02.001. 5.1 modules of onehealth tool onehealth tool is primarily organized into three main modules: 1. health services module 2. health systems modules 3. impact modules the health services module estimates the costs of items that vary by the number of intervention recipients. these items include commodities, drugs and other supplies. the tool utilizes user defined inputs such as target populations that interventions focus and populations in need of interventions, type of interventions, percentage coverage of intervention and the delivery channel. 23 in addition of this, numerous treatment inputs related to interventions that are provided by various types of health care workers, have to be defined by the tool. the unit costs of specified inputs also have to be indicated. the average time used for each type of health workers involved in an intervention also needed for computation of staff time utilization patterns and assessment of staff time adequacy. health systems module consists of several sub-modules. they include; ➢ infrastructure and equipment module estimates the cost incurred on buildings, the cost involved in vehicles and the cost of information and communication technology equipment (construction, rehabilitation/maintenance and utility costs)human resource module, ➢ human resource module calculates the cost of paying emoluments to health staff, the cost of preservice training and cost of providing retention incentives. the staff baseline, staff distribution by various levels of health care, annual salary, incentives and increment patterns and numbers and unit costs related to preservice training of different types of staff have to be indicated. ➢ logistic module estimates the expenditure incurred on logistic activities related to a health program. the module estimates the cost of warehouses (construction, maintenance and utilities), the cost of transport and the cost of paying warehouse workers ➢ health information systems module is designed to estimate the cost of developing and maintaining the management information system related to a health program. it also involves several management functions such as training, supervision, review and updating of the information systems, etc. 24 ➢ governance and leadership module estimates the cost of governance activities such as the development or review of strategic vision and ethics, improving responsiveness, participation and consensus, carrying out legal reforms and maintaining the transparency and accountability of health programs. ➢ financing policy module contains the total resources available for the health sector including government resources, private sector and funding from external sources. impact models includes (22);  demproj demproj projects the population for an entire country or region by age and sex, based on assumptions about fertility, mortality, and migration.  famplan projects family planning requirements needed to reach national goals for addressing unmet need or achieving desired fertility.  list: lives saved tool (listchild survival). a program to project the changes in child survival in accordance with changes in coverage of different child health interventions  aim: aids impact model. aim projects the consequences of the hiv epidemic, including the number of people living with hiv, new infections, and aids deaths by age and sex; as well as the new cases of tuberculosis and aids orphans.  goals: the goals model helps efforts to respond to the hiv/aids epidemic by showing how the amount and allocation of funding is related to the achievement of national goals, such as reduction of hiv prevalence and expansion of care and support.  rapid: resources for the awareness of population impacts on development. rapid projects the social and economic consequences of high fertility and rapid population growth for such sectors as labor, education, health, urbanization, and agriculture. 25  rnm: resource needs model. this model is used to calculate the funding required for an expanded response to hiv/aids at the national level.  time: tb impact module and estimates module provides the user with smoothed estimates of historical and current tb incidence and notification as well as short term statistical projections.  ncd: the non-communicable disease impact module calculates the populations affected by, and the impact of scaling up interventions on cardiovascular and respiratory disease, diabetes, cancer, and mental health, neurological, and substance abuse disorders. 26 5.2. costing process adaptation of onehealth tool cost health programs required the adoption of a systematic process. in costing flow graphic we identified six steps in the systematic process. figure 7. costing flow graphic • identify relevant program areas and sub groups • identify interventions to cost • identify health system components involved in health program areas identify costing process • set up liberian projection • specify currency types, inflation and currency exchange rates setting up a oht projection • define program areas & sub groups • select default & create new interventions to reflect the specific program area • organize interventions • specify delivery channels outline program areas, sub group and interventions hierarchy • target populations • population in needs • intervention coverages • treatment inputs • delivery channel distributions input intervention costing parameters • determine program management activities • estimate and add annual costs specify program costing/management parameters • infrastructure baseline, unit costs and targets • human resource baseline, unit costs and targets • logistic baseline, unit costs and targets • his baseline, program activities, and unit costs specify health system costing parameters 27 cost analysis of programme management program management costs incurred by a health program may include training, supervision, monitoring and evaluation, transportation, advocacy and communication, media and outreach. these costs derived from health program managers’ inputs, and were incorporated into the annual costs at the program level. figure 8 illustrates how the cost of program management, together with the direct interventions’ cost, represents the total cost of a given health programme. total costs for health program 1 intervention a; target population size x percentage of target population in need of intervention x target coverage = number of population reached by intervention a intervention c; target population size x percentage of target population in need of intervention x target coverage = number of population reached by intervention c intervention b; target population size x percentage of target population in need of intervention x target coverage = number of population reached by intervention b total cost of drugs and commodities for health program 1 + cost of in-service training + coordination meetings + transport consultancies in supervision + monitoring and evaluation figure 8. diagram of health programmes cost analysis 28 6. conclusion epos health management through the "project technical assistance to support the implementation of the national health plan and the roadmap for the reduction of maternal mortality in liberia", contributes to the achievement of the objectives and targets set for 2016 2017 in the 10-years strategic health and social welfare plan and the roadmap for the reduction of maternal mortality. approach and strategy chosen to achieve one part of the goals were to provide costing tool pieces of training, for hfu. review of costing tools represents the collaborative effort of the epos health management and hfu, and opportunity to support hfu, to manage, improve and harmonize the process of costing and budgeting plans and intervention in the health system of liberia. the introduction of three appropriate analytical costing tools programs, core plus, mbb and onehealth tools, provided the opportunity to improve medium-term sector planning, costing, budgeting, financing and analysis. in particular, it gives a chance to estimate the potential impact on health, resource needs, costs, and budgeting implications of strategies to remove systemic bottlenecks and implementation constraints of the health system. even more costing tools can be used to estimate the costs of individual services and packages of services under the different scenarios which gives valuable insights into the costs and incomes across the clinics and health centers. one of the recommendations of the mission reports was that hfu should develop the process of applying core plus in all primary health care institutions at the county level and onehealth tool software, designed to strengthen health systems, integrating planning, costing and analysis, at a country level. 29 7. references: 1. ministry of health and social welfare of liberia. investment plan for building a resilient health system 2015-2021. monrovia; 2015. 2. ministry of health and social welfare of liberia. roadmap for accelerating the reduction of maternal and new-born morbidity and mortality in liberia (2011-2015). 2011. 3. ministry of health and social welfare of liberia. accelerated action plan to reduce maternal and neonatal mortality 2012. 2012. 4. ministry of health and social welfare of liberia. liberia community health road map july 1, 2014 – june 30, 2017. 2014. 5. ministry of health and social welfare of liberia. national health and social welfare policy and plan 2011-2021, 2011. 6. ministry of health and social welfare of liberia. department of planning, research & development, health financing unit: resource mapping liberia health sector: government fiscal year 2015-2016; 2015. 7. technical assistance to support the implementation of the national health plan and the roadmap for the reduction of maternal mortality in liberia | epos health management [internet]. epos.de. 2017 [cited 28 june 2017]. available from: http://www.epos.de/projects/technical-assistance-support-implementation-national-healthplan-and-roadmap-reduction 8. world bank, unicef, unfpa. health systems for the millennium development goals: country needs and funding gaps. 2009. 30 9. who, unicef, the world bank, and unfpa, in collaboration with the partnership for maternal, newborn and child health and the norwegian government. final reports of technical review of costing tools. 2008. 10. world bank and unicef. marginal budgeting for bottlenecks an analytical tool for evidence-based health policy, planning, costing, and budgeting technical notes (based on version 5.6). 2011. 11. world bank and unicef. marginal budgeting for bottlenecks an analytical tool for evidence-based health policy, planning, costing, and budgeting concise user guide (based on version 5.6). 2011. 12. odaga j, henriksson d, nkolo c, tibeihaho h, musabe r, katusiime m et al. empowering districts to target priorities for improving child health service in uganda using change management and rapid assessment methods. global health action. 2016; 9 (1):30983. 13. lancet series on maternal and child undernutrition. maternal and child undernutrition 1: global and regional exposures and health consequences. child: care, health and development. 2008; 34 (3):404-404. 14. jones g, steketee r, black r, bhutta z, morris s. how many child deaths can we prevent this year? the lancet. 2003; 362 (9377):65-71. 15. world health organization. background paper for the technical consultation on effective coverage of health systems. rio de janeiro, brazil; 2001. 16. tanahashi t. health service coverage and its evaluation. bulletin of the world health organization, (1978) 56(2), 295–303. 17. darmstadt g, bhutta z, cousens s, adam t, walker n, de bernis l. evidence-based, costeffective interventions: how many newborn babies can we save? the lancet. 2005; 365 (9463):977-988. 31 18. waddington h, fewtrell l, snilstveit b, white h. water, sanitation and hygiene interventions to combat childhood diarrhoea in developing countries. synthetic review 001. new delhi, india, international initiative for impact evaluation, 2009. 19. lewis e, mcmennamin t, collins d. user’s guide for core plus (analysis of cost and revenue plus) tool version 1; 2007. 20. jarrah z, collins d. costing liberia’s basic package of health services: county hospital level. 2009. 21. jarrah z, collins d. costing the basic package of health services at clinics and health centres in liberia. 2009. 22. avenir health and united nations inter agency working group on costing. onehealth tool startup manual a computer program for making informed health programming decisions. 2016. 23. stenberg k, chisholm d. resource needs for addressing noncommunicable disease in lowand middle-income countries. global heart. 2012; 7 (1):53-60. 32 health systems and their evidence based development h e a lt h s y s t e m s a n d t h e i r e v i d e n c e b a s e d d e v e l o p m e n t a handbook for teachers, researchers and health professionals editors: vesna bjegovi] and don^o donev editorial assistance: bosiljka \ikanovi} ph-see project coordinators: ulrich laaser and luka kova~i} doris bardehle, germany vesna bjegovi}, serbia and montenegro jadranka bo`ikov, croatia birgit cornelius taylor, world health organisation viktorija cuci}, serbia and montenegro don~o donev, macedonia bosiljka \ikanovi}, serbia and montenegro adriana galan, romania thomas hofmann, germany bajram hysa, albania enida imamovi}, bosnia and herzegovina luka kova~i}, croatia ulrich laaser, germany aurelia marcu, romania jelena marinkovi}, serbia and montenegro bojana mateji}, serbia and montenegro dragana nik{i}, bosnia and herzegovina silvia gabriela scîntee, romania sne`ana simi}, serbia and montenegro kancho tchamov, bulgaria zorica terzi} [upi}, serbia and montenegro lijana zaletel kragelj, slovenia rudolf welteke, germany helmut wenzel, germany khaled yassin, germany belgrade 2004 3 bibliographische information der deutschen bibliothek die deutsche bibliothek verzeichnet diese publikation in der deutschen nationalbibliographie; detaillierte daten sind im internet über http://dnb.ddb.de abrufbar. this publication has been supported by the german academic exchange service (daad) with funds from the stability pact, „academic programmes for training and research in public health in south eastern europe" (ph-see). publisher: hans jacobs publishing comany graphic design: branislav radoti} cover design: alma [imunec-jovi} printed by: sprint-beograd number of copies: 400 copyright 2004 by hans jacobs publishing company hellweg 72, 32791 lage, germany isbn 3-89918-123-9 4 preface this books' title „health systems and their evidence based development” comprises some key features of health care in the 21st century: 1) the organisation of health care delivery is of utmost importance for the post-modern state in europe and north-america as it is in a different way for the developing world. this is the case because of its economic importance signified by the spending of between 5 and 15% of the gross domestic product for health but even more because of the growing relevance of excellent population health for economic development in low-tension open societies (1); 2) modern health systems are not to be looked at as static structures, the best example being provided by the german bismarckian system which maintained for more than hundred years i.e. since 1883, some essentials like the obligatory membership (up to an income threshold for high earners), a multiplicity of fee-based health insurances, and the sharing of the contributions between employers and employees (2). today health care systems undergo continuous reform, mainly to curb expenditure but also to guaranty access and quality of service to everybody (see for example the dubrovnik pledge of the ministers of health in south east europe in 2001 (3) or the conclusions at the ljubljana conference in 1996 (4)). one example of this is the existence of long waiting queues for specific operations for hip or knee replacements in the taxbased beveridge systems especially in northern europe. 3) health systems reform and development, however, require thorough scientific analysis to identify the options available to the politician. the term coined for this demand in today's discussion refers to the evidence base of decision making (see who-euro 2003 (5)). unfortunately still the reform legislation in most countries orients towards the uni-dimensional consideration of financial constraints, missing the chance of exploring real improvement and instead modifying repeatedly the various models of co-payment. 4) the title refers implicitly to a comparative approach between national health systems. especially in europe with her different historical lines of development this is an essential element if the european unification process is taken into account. only recently the european high court has issued strategic decisions on the universal access to health care in the european union wherever a patient seeks care and wherever she or he is insured. a public health mandate of the european commission has been formulated already in the maastricht treaty of 1992 (6). converging trends can also be recognized with regard to the development of „mixed” systems containing elements of the bismarck as well as of the beveridge model. 5 as this handbook is devoted to all teachers, researchers, postgraduate students and professionals in the health field the question arises who in the end is responsible for the organization and further development of the health system. the answer can only be that this field is essentially characterized by multiprofessionality and inter-disciplinarity comprising all parties including the patients and the population themselves. however, the steering of such systems, the balancing of input and output, and their evaluation are mainly considered to be subject to the health sciences, i.e. a part of the public health. therefore it is not by chance, that this handbook has been developed in the context of a research & development project in order to enable and improve the teaching for research and practice in public health: the public health collaboration in south eastern europe (ph-see), funded since the year 2000 by the stability pact through the german academic exchange service (daad). on the phsee website (7) maintained by the andrija [tampar school of public health in zagreb, croatia, the abstracts of teaching modules in a number of public health fields can directly be accessed like „methods and tools in health sciences”, „determinants of health”, „disease prevention and health promotion”, „health care and health services” or „public health strategies” and in addition the chapters of this handbook in full text. this handbook is likely to be the first compendium on the main issues in evidence based health systems development with a focus on the situation and the experience in south eastern europe, and more general in all of the former socialist economies in transition, most of them in a process of accession to the european union. the book comprises three main chapters: (1.0) health systems analysis, (2.0) health systems management and (3.0) health policy. this agenda describes the full cycle of scientific analysis and evaluation, the operational steering of the system, and the developmental aspects of change and reform. within these three sections the reader finds basic texts in the format of teaching modules including exercises for students and reference material, complemented by case studies for study work. deliberately the conceptual approach of this handbook goes beyond the usual listing of topics to be dealt with in teaching public health as it is obvious that most readers would expect and need more than a reference to knowledge and expertise elsewhere. thus the volume can be used as a teaching book as well as a compendium or handbook in the field. it corresponds to a total student workload of 12 ects (european credit transfer system) and its contents may be combined with other modules. other handbooks will follow this first edition covering the areas listed above as on the website (7). finally as the principle investigators of the public health 6 health systems and their evidence based development collaboration in south eastern europe we have to express our sincerest thanks to the editors and authors for their dedication and patience and an enormous amount of unpaid work, which gave this endeavour a special flavour and unique value. may this cooperative work also serve as an example for a brighter future in a war-torn region and the re-establishment of cooperation and peace building, collegiality and togetherness in the service to the people. prof. dr. med. ulrich laaser prof. dr. med. luka kova~i} faculty of health sciences andrija [tampar school of public health university of bielefeld, germany medical faculty of zagreb, croatia references 1. who. macroeconomics and health: investing in health for economic development. report of the commission on macroeconomics and health. chaired by jeffrey d. sachs. geneva: who publication office 2001. 2. bärnighausen t, sauerborn r. one hundred and eighteen years of the german health insurance system: are there any lessons for middleand low-income countries? social science and medicine 2002; 54: 1559-1587. 3. the health ministers forum. the dubrovnik pledge: meeting the health needs of vulnerable populations in south east europe (dubrovnik, croatia august 31-september 2, 2001). copenhagen: who regional office for europe 2001. 4. who. the ljubljana charter on reforming health care. copenhagen: who regional office for europe 1996. 5. who. the health evidence network (hen). (cited 2004, april 12). available from url: www.euro.who.int/hen 6. eu. treaty on european union, signed at maastricht on 7 february 1992. (cited 2004, april 12). available from url: www.europa.eu.int 7. ph-see. public health collaboration in south eastern europe: programmes for training and research in public health. (cited 2004, april 12). available from url: www.snz.hr/ph-see 7 preface 8 health systems and their evidence based development contents preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 list of authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.0 health systems analysis (ects 4.75) 1.1 don~o donev the role and organization of health systems . . . . . . . 19 1.2 enida imamovi}, dragana nik{i} case study: the health system of bosnia and herzegovina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 1.3 jelena marinkovi}, vesna bjegovi} electronic health records – the core of the national health information system . . . . . . . . . . . . . . . . . . . . . . . 63 1.4 doris bardehle health indicators and health reporting . . . . . . . . . . . . . 102 1.5 zorica terzi} [upi}, bojana mateji} quality of life: concept and measurement . . . . . . . . . . 116 1.6 adriana galan disability-adjusted life years: a method for the analysis of the burden of disease . . . . . . . . . . . 141 1.7 aurelia marcu calculating the potential years of life lost. . . . . . . . . . . . . 1.8 khaled yassin, adriana galan case study: inequalities in health as assessed by the burden of disease method . . . . . . . . . . . . . . . . . . . . 1.9 jelena marinkovi} health technology assessment as a tool for health systems development. . . . . . . . . . . . . . . . . . . . . . . . . . . 172 1.10 birgit cornelius taylor, ulrich laaser comparative research on regional health systems in europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 9 2.0 health systems management (ects 5.50) 2.1 vesna bjegovi} health management: theory and practice . . . . . . . . . . . 241 2.2 silvia gabriela scîntee human resource management. . . . . . . . . . . . . . . . . . . . 263 2.3 adriana galan information systems management . . . . . . . . . . . . . . . . . 288 2.4 don~o donev, jadranka bo`ikov the financing of health care . . . . . . . . . . . . . . . . . . . . 304 2.5 don~o donev, luka kova~i} payment methohds and regulation of providers . . . . . 325 2.6 don~o donev case study: the current health insurance system in the republic of macedonia . . . . . . . . . . . . . . 343 2.7 vesna bjegovi}, adriana galan case study: swot analysis of the serbian health insurance system . . . . . . . . . . . . . . . . . . . . . . . . 364 2.8 helmut wenzel, bajram hysa economic appraisal as a basis for decision making in health systems . . . . . . . . . . . . . . . 376 2.9 viktorija cuci} quality improvement in health care and public health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404 2.10 vesna bjegovi}, sne`ana simi} accreditation of health institutions as an external tool for quality improvement . . . . . . . . 424 2.11 silvia gabriela scîntee, adriana galan project management . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443 2.12 kancho tchamov planning and programming of health care . . . . . . . . . . 473 3.0 health policy (ects 1.75) 3.1 vesna bjegovi}, bosiljka \ikanovi} informed health policy and system change . . . . . . . . . 495 3.2 thomas hofmann public health policy of the european union . . . . . . . . . 525 10 health systems and their evidence based development 3.3 rudolf welteke targets for health development. . . . . . . . . . . . . . . . . . . 537 3.4 lijana zaletel kragelj health legislation: procedures towards adoption . . . . . 568 11 comparative analysis of regional health care systems in the european union list of authors doris bardehle, dr. med. professor at the university of bielefeld, faculty of health sciences, department of epidemiology and medical statistics, universitätsstraße 25, d-33615 bielefeld, germany. e-mail: doris. bardehle@loegd.nrw.de vesna bjegovi}, md, msc, phd. professor at the school of medicine, institute of social medicine, university of belgrade, dr suboti}a 15, 11000 belgrade, serbia and montenegro. tel: +381 11 643 830, fax: + 381 11 659 533, e-mail: bjegov@eunet.yu jadranka bo`ikov, mph, phd. professor at andrija [tampar school of public health, medical school, university of zagreb, rockefeller st. 4 hr-10000 zagreb, croatia. e-mail: jbozikov@snz.hr birgit cornelius taylor, mph. who european office for integrated health care services, marc aureli 22-36, e-08006 barcelona, spain. tel: +34 93 241 8270, fax: +34 93 241 8271, e-mail: bct@es.euro.who.int viktorija cuci}, md, phd. professor emeritus. institute of social medicine, school of medicine, university of belgrade, dr suboti}a 15, 11 000 belgrade, serbia and montenegro. tel: +381 11 643 830, fax: + 381 11 659 533, home: ^ingrijina 13, 11 000 belgrade, e-mail: ecucic@eunet.yu bosiljka \ikanovi}, md, editorial assistance, a handbook for teachers, researchers and health professionals: health systems and their evidence based development. home: cviji}eva 44, 11 000 belgrade, serbia and montenegro. tel: +381 63 273 672, e-mail: boss@bitsyu.net don~o donev, md, phd. professor at the institute of social medicine, joint institutes, medical faculty, university of skopje, 50 divizia no.6, 1000 skopje, republic of macedonia. tel: +389 2 3147 056, fax: +389 2 3298-581, e-mail: donev@freemail.org.mk adriana galan, it specialist. part-time senior lecturer at the university of medicine and pharmacy, department of public health and management, at postgraduate level. institute of public health bucharest, 1-3 dr. leonte street, 76256 bucharest, romania. tel: (4021) 2249228 / ext.188, fax: (4021) 3123426, e-mail: agalan@ispb.ro thomas hofmann, mhcm, mph. federal ministry of health and social security, d-53108 bonn, germany. tel: +49 228 9411831, fax: +49 228 9414945, e-mail: thhofmann@yahoo.com 12 health systems and their evidence based development bajram hysa, economist, associated professor at department of public health, faculty of medicine, rr. „dibres”, no.371, tirana, albania. e-mail: b_hysa@yahoo.com enida imamovi}, md. specialist of social medicine. public health institute of federation of b&h; titova 9, 71000 sarajevo, bosnia and herzegovina. tel: + 387 33 20 88 13, fax: +387 33 22 05 48, e-mail: imamovic@bih.net.ba luka kova~i}, md, phd. andrija štampar school of public health, medical school, university of zagreb, rockefeller st. 4, hr-10000 zagreb, croatia. email: lkovacic@snz.hr ulrich laaser, dtm&h, mph, dr. med. professor, section of international public health (s-iph), faculty of health sciences, university of bielefeld, pob 10 01 31, d-33501 bielefeld, germany. tel/am/fax: +49 521 450116, e-mail: ulrich.laaser@uni-bielefeld.de aurelia marcu, md, phd. public health consultant, head of department of strategies and forecasts in public health, institute of public health bucharest, 1-3 dr. leonte street 76 256 bucharest, romania. tel: (4021) 2249228 / ext.188, fax: (4021) 3123426, e-mail: amarcu@ispb.ro jelena marinkovi}, bm, phd. professor at the school of medicine, university of belgrade, institute of medical statistics and informatics, school of medicine, belgrade university, dr suboti}a 15, 11000 belgrade, serbia and montenegro. tel: +381 11 685 888, fax: + 381 11 659 533, e-mail: jelena@pcpetak.com bojana mateji}, md, msc. teaching assistant at the institute of social medicine, school of medicine, university of belgrade, dr suboti}a 15, 11000 belgrade, serbia and montenegro. tel: +381 11 643 830, fax: + 381 11 659 533, e-mail: bojana_boba@yahoo.com dragana nik{i}, md, phd. ass. professor of social medicine, medical faculty, university of sarajevo, ^ekalu{a 90, 71 000 sarajevo, bosnia and herzegovina. tel: +387 33 202 051, +387 33 663 742 loc.160, fax: +387 33 202 051, e-mail: h.niksic@bih.net.ba silvia gabriela scîntee, md, msc. part-time lecturer at the university of medicine and pharmacy „carol davila” bucharest, department of public health and management, public health consultant at the institute of public health bucharest, 1-3 dr. leonte street 76 256 bucharest, romania. tel: (4021) 2249228 / ext.188, fax: (4021) 3123426, e-mail: gscintee@ispb.ro 13 comparative analysis of regional health care systems in the european union sne`ana simi}, md, msc, phd. professor at the school of medicine, institute of social medicine, university of belgrade, dr suboti}a 15, 11000 belgrade, serbia and montenegro. tel: +381 11 643 830, fax: + 381 11 659 533, e-mail: snezanas@eunet.yu kancho tchamov, mph, phd. associate professor on faculty of public health, medical university – sofia, hospital „tzariza joanna” 8, bjalo more str. 1527 – sofia, bulgaria. tel: +359 2 9225197; fax: +359 2 9432304, e-mail: tchamov@bulinfo.net zorica terzi} [upi}, md, msc. teaching assistant at the institute of social medicine, school of medicine, university of belgrade, dr suboti}a 15, 11000 belgrade, serbia and montenegro. tel: +381 11 643 830, fax: + 381 11 659 533, e-mail: vlazo970@yahoo.com lijana zaletel kragelj, md, phd. teaching assistant at department of public health – social medicine, faculty of medicine, university of ljubljana, zalo{ka 4, 1000 ljubljana, slovenia. fax: + 386 1 543 75 41, e-mail: lijana.kragelj@mf.uni-lj.si rudolf welteke, dr. med. state institute of public health of northrhinewestphalia (loegd) westerfeldstr. 35/37, d-33611 bielefeld, germany. email: rudolf.welteke@loegd.nrw.de helmut wenzel, m.a.s. health economist, roche diagnostics company, mannheim, germany. home: friedrichstrasse, 61, d-78464 konstanz, germany. e-mail: hkwen@aol.com khaled yassin, dr. med dr. ph. section of international public health, faculty of health sciences, university of bielefeld, pobox 100131 d-33501 bielefeld, germany. e-mail: kyassin@gmx.de 14 health systems and their evidence based development health systems analysis 15 prazna 16 17 the role and organization of health care systems health systems and their evidence based development a handbook for teachers, researchers and health professionals title the role and organization of health care systems module: 1.1 ects (suggested): 0.75 author(s), degrees, institution(s) doncho donev, md, phd, professor institute of social medicine, joint institutes, medical faculty, university of skopje 50 divizia no.6 1000 skopje, republic of macedonia address for correspondence doncho donev, md, phd institute of social medicine, joint institutes, medical faculty, university of skopje 50 divizia no.6 1000 skopje republic of macedonia tel: +389 2 3147 056 fax: +389 2 3163 866 e-mail: donev@freemail.org.mk keywords health care; health systems; health systems organization and performance; primary health care; hospital care; health care reforms learning objectives after this module, students and health professionals should: • increase understanding of health care systems organization, their historical development and respective functions; • distinguish national health care systems based on sources of funding (beveridge, bismarck and private insurance model); • be able to describe scope of activities of health organizations on different levels (self care, primary, secondary and tertiary level of care); • be able to classify health service organizations depend on various criteria (type of service, length of stay, type of control or ownership); • describe three generations of reforms in health system; • identify main goals and objectives of national health systems; and • identify common problems and new challenges of health care systems. abstract the health of the people is always a national priority. health care system (hcs) infrastructure includes services, facilities, institutions/establishments, organizations, and those operating them for conducting the delivery of a variety of health programmes. they provide individuals, families, and communities with health care, which consists of a combination of promotive, protective, preventive, diagnostic, curative and rehabilitative measures. hcs are different all over the world and strongly influenced by each nation's unique history, traditions, socio-cultural, economic, political and other factors. but, regardless of all present differences, there are still some common characteristics, typical for all hcs. in this module three levels of healthcare (primary, secondary, tertiary) are described, as well as their historical development. concerning sources of funding, main models of national hcs are: the beveridge model, the bismarck model and the private insurance model. hcs are continuously evolving. there are presented three generations of hcs reforms. improvement of population's health is often expressed as improved coverage, access, equity, quality of care, but also efficiency in use of resources, and financing. hcs facing new challenges, among them are aging of the population, medical technology innovations, pressure to constraint costs, community involvement and intersectoral action. those principles will be important more then ever. 18 health systems and their evidence based development teaching methods teaching methods include lectures and interactive group discussion. specific recommendations for teacher this module should be organized within 0.75 ects, out of which one third are lectures and group discussion supervised by the lecturer. the rest is individual work (searching internet mainly) in order to prepare seminar paper. assessment of students assessment should be based on the quality of seminar paper, which presents the national health system of the students’ country. oral exam is also recommended. the role and organization of health systems dončo donev introduction health systems have a vital and continuing responsibility to people throughout the lifespan. they are crucial to the healthy development of individuals, families and societies everywhere. the real progress in health towards the united nations millennium development goals* and other national health priorities depends vitally on stronger health systems based on primary health care (1). improving health is clearly the main objective of each health system, but it is not the only one. the objective of good health itself is really twofold: the best attainable average level – goodness and the smallest feasible differences among individuals and groups – fairness. goodness means a health system responding well to what people expect of it, and fairness means it responds equally well to everyone, without discrimination (2). each national health system should be directed to achieve three overall goals: good health, responsiveness to the expectations of the population, and fairness of financial contribution. progress towards them depends crucially on how well systems carry out four vital functions. these are: service provision, resource generation, financing and stewardship. comparing the way these functions are actually carried out provide a basis for understanding performance variations over the time and among countries. there are minimum requirements which every health care system should meet equitably: access to quality services for acute and chronic health needs; effective health promotion and disease prevention services; and appropriate response to new threats as they emerge (emerging infectious diseases, growing burden of non-communicable diseases and injuries, and the health effects of global environmental changes) (1,2). the overall mission of who is the attainment by all people of the highest possible level of health, with special emphasis on closing the gaps 19 the role and organization of health care systems * the goals in the area of development and poverty eradication (to reduce poverty and hunger and to tackle ill-health, gender inequality, lack of education, access to clean water and environmental degradation). these goals are included in the united nations millennium declaration adopted at the millennium summit in new york in september 2000, and are now widely referred to as millennium development goals. within and among countries. the ability of who to fulfill this mission depends greatly on the effectiveness of health systems in member states – and strengthening those systems is one of who’s four strategic directions. it connects very well with the other three: reducing the excess mortality of poor and marginalized populations; dealing effectively with the leading risk factors; and placing health at the center of the broader development agenda because population health contributes crucially to economic and social development (1,3). health systems have contributed enormously to better health for most of the global population during the 20th century. today, health systems, in all countries, rich and poor, play a bigger and more influential role in people’s lives than ever before. health systems of some sort have existed for a long as people have tried to protect their health and treat diseases. traditional practices, often integrated with spiritual counseling and providing both preventive and curative care, have existed for thousands of years and often coexist today with modern medicine. many of them are still the treatment of choice for some health conditions, or are resorted to because modern alternatives are not understood or trusted, or fail, or are too expensive. health systems have undergone overlapping generations of reforms in the past 100 years, including the founding of national health care systems and the extension of social insurance schemes. later came the promotion of primary health care as a route to achieving affordable universal coverage – the goal of health for all. in the past decade or so there has been a gradual shift of vision towards what who calls the „new universalism”. rather than all possible care for everyone, or only the simplest and most basic care for the poor, this means delivery to all of high-quality essential care, defined mostly by criteria of effectiveness, cost and social acceptability. this shift has been partly due to the profound political and economic changes of the last 20 years or so. these include the transformation from centrally planned to market-oriented economies, reduced state intervention in national economies, fewer government controls, and more decentralization (2). within all systems there are many highly skilled, dedicated people working at all levels to improve the health of their communities. as the new century began, health systems have the power and the potential to achieve further extraordinary improvements. unfortunately, health systems can also misuse their power and squander their potential. poorly structured, badly led, inefficiently organized and inadequately funded health systems can do more harm than good. the ultimate responsibility for the overall performance of a country’s health system lies with government, which in turn should involve all sectors of society in its stewardship. the careful and responsible management of the well-being of the population is the very essence of good government. for 20 health systems and their evidence based development every country it means establishing the best and fairest health system possible with available resources. the health of the people is always a national priority and the government responsibility for it should be continuous and permanent. ministries of health must therefore take on a large part of the stewardship of health systems. healthy policy and strategies need to cover the private provision of services and private financing, as well as state funding and activities. only in this way can health systems as a whole be oriented towards achieving goals that are in the public interest (2). health care services and health services organizations health care is the comprehensive social effort, organized or not, private or public, that attempts to guarantee, provide, finance, and promote health. health care consists of measures, activities and procedures for maintaining and improvement of health, living and working environment, as well as measures, activities and procedures which are undertaken in the field of health care for maintaining and improvement of people’s health; prevention and control of specific diseases; early detection of the diseases and conditions of ill health, timely and efficient treatment and rehabilitation. it changed markedly during the 20th century moving toward the ideal of wellbeing and prevention of disease and disability. delivery of health care services involves the organized public or private efforts that assist individuals primarily in regaining health, but also in preventing disease and disability (2,4). delivery of services to patients / consumers occurs in a variety of organizational settings (“patient” is anyone served by health services organization). health services is a permanent countrywide system of established institutions, the multipurpose objective of which is to cope with the various health needs and demands of the population and thereby provide health care for individuals and the community, including a broad spectrum of preventive and curative activities. all health services organizations can be classified by ownership and profit motive. in addition, they can be classified by whether the patient is admitted as an inpatient or outpatient and, for an inpatient, by the average length of stay (4,5). historically, hospitals and nursing facilities have been the most common and dominant health services organizations engaged in delivery of health services. they remain prominent in the contemporary health care systems, but other health services organizations have achieved stature. among them are outpatient clinics, imaging centers, free-standing urgent care and surgical centers, large group practices, and home health agencies. multi-organizational systems, 21 the role and organization of health care systems both vertically and horizontally integrated, are widespread. these various health services organizations and others face new environments containing a wide range of external pressures, including new rules and technologies, changed demography, accountability to multiple constituents, and constraints on resources. as a result, health services organization must allocate and use resources more effectively and strive for continuous improvement and continued excellence in an increasingly restrictive environment (5). what is a health system? in today’s complex world, it can be difficult to say exactly what a health system is, what it consists of, and where it begins and ends. health system includes all the activities, which primary purpose is to promote, restore and maintain health. it means that the health system is the complex of interrelated elements that contribute to health in homes, educational institutions, workplaces, public places, and communities, as well as in the physical and psycho-social environment and the health and related sectors. a health system is usually organized at various levels, starting at the most peripheral level, also known as the community level or the primary level of health care, and proceeding through the intermediate (district, regional or provincial) to the central level. the intermediate and central levels deal with those elements of the health system that provide progressively more complex and more specialized care and support. it is not easy to conceive such multifaceted health system, to maintain its cohesion and to ensure that it functions in compliance with agreed policies. a comprehensive health system denotes one that includes all the elements required to meet all the health needs of the population. health system infrastructure includes services, facilities, institutions or establishments, organizations, and those operating them for conducting the delivery of a variety of health programmes. they provide individuals, families, and communities with health care that consists of a combination of promotive, protective, preventive, diagnostic, curative and rehabilitative measures. health resources are all the means of the health care system available for its operation, including manpower, buildings, equipment, supplies, funds, knowledge and technology. health sector includes governmental ministries and departments, organizations and services, social security and health insurance schemes, voluntary organizations and private individuals and groups providing health services. intersectoral action is an action in which the health sector and other relevant sectors collaborate for the achievement of a common goal, the contributions of the different sectors being closely coordinated. multisectoral action is synonymous term to the intersectoral action. the former (intersectoral) perhaps emphasizing the 22 health systems and their evidence based development element of coordination, the latter (multisectoral) the contribution of a number of sectors (4,6). health systems are defined by who as comprising all the organizations, institutions and resources that are devoted to producing health actions. a health action is defined as any effort, whether in personal health care, public health services or through intersectoral initiatives, whose primary purpose is to improve health (2,6). formal health services, including the professional delivery of personal medical attention, are clearly within these boundaries. so are actions by traditional healers, and all use of medication, whether prescribed by a provider or not. so is home care of the sick, which is how somewhere between 70% and 90% of all sickness is managed. such traditional public health activities as health promotion and disease prevention, and other health-enhancing interventions like road and environmental safety improvement, are also part of the system. beyond the boundaries of this definition are those activities whose primary purpose is something other than health – education, for example – even if these activities have a secondary, health-enhancing benefit. hence, the general education system is outside the boundaries, but specifically health-related education is included. so are actions intended chiefly to improve health indirectly by influencing how non-health systems function – for example, actions to increase girls’ school enrolment or change the curriculum to make students better future caregivers and consumers of health care (2,6). nearly all the information available about health systems refers only to the provision of, and investment in, health services: that is, the health care system, including preventive, curative and palliative interventions, whether directed to individuals or to populations. efforts are needed to quantify and assess those activities implied by the wider definition, so as to begin to gauge their relative cost and effectiveness in contributing to the goals of the health system. even by this more limited definition, health systems today represent one of the largest sectors in the world economy. global spending on health care was almost 8% of world gross domestic product (gdp), in 1997 (2). with rare exceptions, even in industrialized countries, organized health systems in the modern sense, intended to benefit the population at large, barely existed a century ago. hospitals have a much longer history than complete systems in many countries. until well into the 19th century they were for the most part run by charitable organizations, and often were little more than refuges for the orphaned, the crippled, the destitute or the insane. and there was nothing like the modern practice of referrals from one level of the system 23 comparative analysis of regional health care systems in the european union to another, and little protection from financial risk apart from that offered by charity or by small-scale pooling of contributions among workers in the same occupation. towards the close of the 19th century, the industrial revolution was transforming the lives of people worldwide. at the same time societies began to recognize the huge toll of death, illness and disability occurring among workers, whether from infectious diseases or from industrial accidents and exposures. about the same time, workers’ health was becoming a political issue in some european countries, but for quite different reasons. bismarck, chancellor of germany, in 1883, enacted a law requiring employer contributions to health coverage for low-wage workers in certain occupations, adding other classes of workers in subsequent years. this was the first example of a state-mandated social insurance model. the popularity of this law among workers led to the adoption of similar legislation in belgium in 1894, norway in 1909, denmark in 1935 and in netherlands a few years later. the influence of the german model began to spread outside europe after the first world war (in 1922, japan, in 1924, chile) (2,7). in the late 1800s, russia had begun setting up a huge network of provincial medical stations and hospitals where treatment was free and supported by tax funds. after the bolshevik revolution in 1917, it was decreed that free medical care should be provided for the entire population, and the resulting system was largely maintained for almost eight decades. this was the earliest example of a completely centralized and state-controlled model. not least among its effects, the second world war damaged or virtually destroyed health infrastructures in many countries and delayed their health system plans. paradoxically, it also paved the way for the introduction of some others. wartime britain’s national emergency service to deal with casualties was helpful in the construction of what became, in 1948, the national health service, perhaps the most widely influential model of a health system. the beveridge report of 1942 had identified health care as one of the three basic prerequisites for a viable social security system. the government’s white paper of 1944 stated the policy that „everybody, irrespective of means, age, sex or occupation shall have equal opportunity to benefit from the best and most up-to-date medical and allied services available”, adding that those services should be comprehensive and free of charge and should promote good health, as well as treating sickness and disease (2,7). today’s health systems are modeled to varying degrees on one or more of a few basic designs that emerged and have been refined since the late 19th century. one of these aims to cover all or most citizens through mandated employer and employee payments to insurance or sickness funds, while pro24 health systems and their evidence based development viding care through both public and private providers. much debate has centered on whether one way of organizing a health system is better than another, but what matters about a system’s overall structure is how well it facilitates the performance of its key functions. models of national health care systems based on the sources of funding based on the source of their funding, three main models of national healthcare systems can be distinguished: the beveridge model, the bismarck model and the private insurance model (7,8,9) (table 1). table 1. three main models of health care systems based on the sources of funding (7,8,9) the beveridge „public” model was inspired by the william beveridge report for social insurance presented in the english parliament in 1942. funding is based mainly on taxation and is characterized by a centrally organized national health service where the services are provided by mainly public health providers (hospitals, community gps, specialists and public health services). in this model, healthcare budgets compete with other spending priorities. the countries using this model, beside united kingdom, are ireland, sweden, 25 the role and organization of health care systems model oof hhealth ccare system country iin wwhich tthe model eexists source oof ffunding type oof pproviders beveridge model uk, ireland, sweden, norway, finland, denmark, spain, portugal, italy, greece, canada, australia taxation (state budget) universal scope (all citizens) not related to income public: predominantly public providers and governmental ownership national health service complete coverage with basic health benefits and free access to all citizens bismark model germany, holland, belgium, france, austria, switzerland, israel, japan, csee and fsu countries compulsory health insurance premiums paid by employers and employees selective scope related to income mixed: public and private providers with dominant social ownership coverage of 60-80% with basic insurance „basket" of health services private insurance model usa predominantly private insurance and funding medicare medicaid predominantly private providers managed care norway, finland, denmark, spain, portugal, italy, greece, canada and australia. the bismarck „mixed” model was inspired by the 1883 germany social legislation and national health insurance plan for workers introduced by otto von bismark, the chancellor of germany. funds are provided mainly by premium-financed social/mandatory insurance and, beside germany, is found in countries such as holland, belgium, france, austria, switzerland, israel, japan, central and south east european (csee) countries and former soviet union (fsu) countries. also japan has a premium-based mandatory insurance funds system. this model results in a mix of private and public providers, and allows more flexible spending on healthcare. the „private” insurance model is also known as the model of „independent customer”. funding of the system is based on premiums, paid into private insurance companies, and in its pure form actually exists only in the usa. in this system, the funding is predominantly private, with the exception of social care through medicare and medicaid. the great majority of providers in this model belong to the private sector. all three models of health care are imperfect and expensive, too. all healthcare systems are aiming at „perfection”, i.e. they try to achieve an optimal mixture of access to healthcare, quality of care and cost efficiency. according to the world health organization (who), the healthcare systems present in different countries are strongly influenced by the underlying norms and values prevailing in the respective societies. like other human service systems, health care services often reflect deeply rooted social and cultural expectations of the community. although these fundamental values are generated outside the formal structure of the healthcare system, they often define its overall character and capacity. healthcare systems are therefore different all over the world and are strongly influenced by each nation’s unique history, traditions and political system. this has led to different institutions and a large variation in the type of social contracts between the citizens and their respective governments. in some societies, healthcare is viewed as a predominantly social or collective good, from which all citizens belonging to that society should benefit, irrespective of whatever individual curative or preventive care is needed. related to this view is the principle of solidarity, where the cost of care is cross-subsidized intentionally from the young to the old, from the rich to the poor and from the healthy to the diseased. 26 health systems and their evidence based development other societies, more influenced by the market-oriented thinking of the 1980s, increasingly perceive healthcare as a commodity that should be bought and sold on the open market. these marketing incentives possibly allow a more dynamic and greater efficiency of healthcare services and a better control of growth in health care expenditure. but, nowadays, this concept, which perceive health care services as a commodity does not prevail in europe. levels of organization of health care systems and health care delivery all models of health care systems are imperfect and there is no a model which is the best and broadly accepted and recommended. there are big differences among countries in relation to the goals, structure, organization, finance and the other characteristics of the health care systems. these differences are influenced by history, traditions, socio-cultural, economic, political and other factors. but, regardless of all present differences, there are same common characteristics, typical for all organized health care systems. first of all those characteristics relate to the so called „levels of health care”. in accordance with the size of the population served, and specificities of the diseases and conditions treated at certain level, as well as with some organizational characteristics, it is possible to recognize four levels of the health care system and health care delivery (7,9,10,11,12,13,14,15) (figure 1). figure 1. levels of care within the health care system size of the population 27 the role and organization of health care systems subspecialist general specialist 500 000 5 000 000 100 000 500 000 2000 50 000 1 10 c a r e self care primary professional care administration unit family (households) community (locality) district region self care is the first level, which is nonprofessional care. it is performed within the family, and the population group counts from one to 10 persons. self-care implies largely unorganized health activities and health-related decision-making carried out by individuals, families, neighbors, friends and workmates. these include the maintenance of health, prevention of disease, self-diagnosis, self-treatment, including self-medication, and self-applied follow-up care and social support to the sick and weak members of the family after contact with the health services. by community involvement and participation, individuals and families accept responsibility for their, and the community’s health and welfare and develop the capability to contribute to their own and the community’s development (4). this type of care has its own long tradition and it is a part of all cultures. who has shown interest and pointed out that traditional and alternative medicine consist big potential, which might be useful for improvement of the health status of the population. who strategy „health for all” and the concept of primary health care paid an appropriate attention to self care and need for health education of the individuals, family and population as a whole in order to enable and to empower them in taking responsibilities and making decisions about their own health and the factors which influenced the health (6,11,15). health promotion advice on important lifestyle issues such as nutrition, exercise, consumption of alcohol and cessation of smoking is most effective if it is persistent, consistent and continuous, and if it is offered to families and communities at all levels. within this population context, individual advice can be given on an opportunistic basis to those who attend health services for whatever reason (6,16). primary professional (medical) care is a care of the „first contact” of the individual with the health care service, which is provided in ambulatory settings by qualified health professionals (general practitioner-gp, family doctor, or nurse) when a patient came, usually for the first time, with certain symptoms or signs of disease. the primary professional level of care includes a doctor and members of its team: nurse, birth attendant, home visiting nurse, social worker, and sometimes a physiotherapist, too. the administration/territorial unit for this type of care is a local community, and the population size vary from 2000 persons per one gp or family doctor to 10000 50000 inhabitants per health facility within the community/municipality (health station, health center). beside medical care (diagnostics, treatment and rehabilitation) the primary professional care team performs various activities toward maintenance and improvement of the health and prevention of diseases. the most common role of the physician is „gate keeper”, which means that the doctor is motivat28 health systems and their evidence based development ed and empowered to treat and cure broader scope of illnesses and conditions (up to 85% of health care problems in a community without recourse to specialist), and to select and refer patients to higher levels of the health care system when necessary. secondary or intermediate level of care is general specialist care, delivered by „general specialist doctor” for more complex conditions, which could not be resolved by the general practitioner or primary professional care level. general specialists (surgeons, internal medicine specialists, gynecologists, psychiatrists etc.) usually deliver this type of care through specialized services of district or provincial „general hospitals”. the administrative unit for secondary level of care is a district, and the population size is from 100000 to 500000 inhabitants. usually patient is directed by the general practitioner from primary professional level to the secondary level as the first referral level of care through referral. tertiary or central level of care is sub-specialist care including highly specific services, which might be delivered in specialized institutions or by highly specialized health professionals sub-specialists i.e. neurosurgeons, plastic surgeons, nephrologists, cardiologists etc. the specialized institutions, which provide this type of care are, also, educational institutions for health manpower (university hospitals, university clinics, etc.). the administrative unit for tertiary level of care is a region, and the population size is from 500000 to 5000000 inhabitants. in some countries, mainly developing countries, this level of care is the same as the national level. a patient should be referred to this level from primary or secondary level of care. secondary and tertiary care support primary health care by providing technologically-based diagnosis, treatment and rehabilitation. who recommends that in most member states, secondary and tertiary care should more clearly serve and support primary care, concentrating on those functions that cannot be performed effectively by the latter. planning secondary and tertiary care facilities in accordance with the principle of a population-based „regionalized” system allows for more rational use of expensive technologies and of the expertise of highly trained personnel (6). typical functions of the overall health care system are: • health services (environmental, health promotion, prevention of diseases and injuries, primary care, specialist medicine, hospital services, services for specific groups, self-help); • financing health care (mobilization of funds, allocation of finances); 29 the role and organization of health care systems • production of health resources (construction and maintenance of health facilities, production and distribution of medicines, production, distribution and maintenance of instruments and equipment); • education and training of health manpower (undergraduate training, postgraduate training); • research and development (health research, technology development, assessment and transfer, quality control); • management of a national health system (policy and strategy development, information, coordination with other sectors, regulation of activities and utilization of health manpower, physical resources and environmental health services). the main objectives of each national health system should be (7): 1) universal access to a broad range of health services; 2) promotion of national health goals; 3) improvement in health status indicators; 4) equity in regional and socio-demographic accessibility and quality of care; 5) adequacy of financing with cost containment and efficient use of resources; 6) consumer satisfaction and choice of primary care provider; 7) provider satisfaction and choice of referral services; 8) portability of benefits when changing employer or residence; 9) public administration or regulation; 10) promotion of high quality of service; 11) comprehensive in primary, secondary, and tertiary levels of care; 12) well developed information and monitoring systems; 13) continuing policy and management review; 14) promotion of standards of professional education, training, research; 15) governmental and private provision of services; and 16) decentralized management and community participation. outpatient care outpatient care is very important part of the health care system representing the first contact of the consumer with the professional health care and the first step of a continuous health care. outpatient care is delivered to a „moving” patient (not tight to bed), through institutions in which the consumer come for a short visit for consultation, examination, treatment and follow-up, usually once a week or rarely, and in the most of the cases, the contact is realized with an individual health worker. such kind of services and institutions might be a part of the hospital, community health center or certain polyclinic and dispensaries (4,10,13,15). historically beginnings of outpatient care appeared in 16th century, when medical care organized mainly through in-patient institutions connected 30 health systems and their evidence based development to churches and monasteries started to change and move to be under the state authorities. differentiation within the medical profession started by dividing the doctors into two basic groups: the first group continue to be tighten to hospitals, but delivering also outpatient services from the position of specialists or consultants, and the other group of doctor were oriented to work in out-patient offices for poor or in doctor’s offices with advanced payment for treatment for defined period of time, usually for a week. in that way started differentiation of the profession, which is a synonym for outpatient care – a general practitioner. an official act on health insurance was adopted in great britain in 1911 and a doctor of general medicine or general practitioner was authorized as a main provider of outpatient care, usually through independent doctor’s offices for general medicine and, later on, through health centers. the importance of the outpatient care and responsibility of the governments for improving the health status of the population in their own countries was emphasized by who at the historical conference on primary health care, held in alma ata in 1978, based on the core principles of primary health care formulated in the declaration of alma ata: universal access and coverage on the basis of need; health equity as part of development oriented to social justice; community participation in defining and implementing health agendas; and intersectoral approach to health (7,17). primary health care is essential health care made universally accessible to individuals and families in the community by means acceptable to them and at a cost the community and country can afford, with methods that are practical, scientifically sound and socially acceptable. everyone in the community should have access to it, and everyone should be involved in it. it means that „people have the right and duty to participate individually and collectively in the planning and implementation of their health care. related sectors should also be involved in it in addition to the health sector. at the very least, it should include education of the community on the health problems prevalent and on methods of preventing health problems from arising or of controlling them; the promotion of adequate supplies of food and of proper nutrition; sufficient safe water and basic sanitation; maternal and child health care, including family planning, the prevention and control of epidemic and locally endemic diseases; immunization against the main infectious diseases; appropriate treatment of common diseases and injures; and the provision of essential drugs. primary health care is the central function and main focus of a country’s health system, the principal vehicle for the delivery of health care, the most peripheral level in a health system stretching from the periphery to the centre, and an integral part of the social and economic country development. the form it takes will vary according to each country’s political, economic, social, cultural and 31 the role and organization of health care systems epidemiological patterns. the relationship between patient care and public health functions is one of the defining characteristics of the primary health care approach (1,4,17). outpatient institutions and services there is a variety of organizational forms of the outpatient care across the world. the main objective of the outpatient care is to reduce hospitalization and to provide treatment of diseases and injuries in much cheaper conditions, whenever it is possible. the outpatient departments of hospitals were the first institutions described which are still available nowadays. they provide services in some urgent and life threatening conditions, in some acute diseases that require urgent intervention, in chronic diseases that require follow-up and control measures, as well as act as a referral level for primary health care or make decision for hospital admission when necessary. the reorganization and reform of the outpatient care, after establishment of the ministry of health in great britain, in 1919, was directed toward creating a new institution of outpatient care so called health center. health center, in accordance with the bertrand dawson’s commission for health care reform in great britain in 1920s, is an institution which is responsible to integrate preventive and curative activities, to provide health care to the population living within certain territorial units, and to collaborate with the local authorities for all issues related to the health of the population. additional equipment for laboratory and x-ray diagnostic services within the health center should be available, as well as general practitioners and nurses for team work. and, later on, in 1948, when national health service in great britain was established, the general practitioner became the most important gate-keeper at the entrance to the other levels of health care system. the development of health centers in great britain was facilitated by the act on family doctor, adopted in 1966. the idea for establishing health centers for outpatient care was accepted in many european countries, especially in former soviet union after the bolshevik revolution (2,7). after the alma ata conference, held in 1978, primary health care became more and more important part of the health care system in each country – member of who. even health services continued to have various organizational forms in different countries the health center was the most typical institution for outpatient care. the institutions for primary health care have special importance playing a role as institutions of the „first contact” of the patient with health care 32 health systems and their evidence based development system. beside primary medical services those institutions contribute to maintain and improve overall physical, mental and social health and well being of the individuals, groups and of the population as a whole. the institutions for primary health care provide individual and group practice/services delivered through health centres or independent outpatient doctor’s offices, as well as within the home of the patient, school and workplace. consultative-specialist health care is an intermediary level of providing health care, between primary health care and hospital treatment, where in the shortest period of time all necessary examinations and analyses should be performed, and a decision should be brought whether the patient is going to be referred to hospital treatment, or sent back on the level of primary health care, usually with precise diagnosis and certain directions for further treatment. home care or „hospital at home” is treatment at home of the diseased, which includes examination, diagnostic procedures, therapeutic and rehabilitation measures. home care, as alternative of stationary treatment is a combination of medical and non-medical treatment and a factor that connects primary and hospital health care. it should be conducted in an organized way by hospitals and in accordance with certain programmes, which in addition to health service include other factors, such as: social protection services, children’s public care, health insurance and pension-invalidity insurance funds as well as local communities. home visiting by a doctor and medical technicians in the function of home care should be performed in a series and successively, according to a programme defined by the same physician, and keeping evidence should be performed on special hospital-temperature lists, which are going to be a base for compensation of the performed tasks. several researches have demonstrated that for about 30%, or even more, of the treated patients in hospitals there were no real indications for hospital treatment, which means that their treatment could successfully be conducted through introduction of „substitution policies” i.e. day care hospitals, ambulatory care or organized home care by hospitals if there is satisfactory standard for accommodation of the patient at home, under supervision of the team for primary health care (4,6). home visiting by a doctor and medical technician considered as an »emergency medical service« is performed without formerly determined plan and on a patient’s call and are shown as individual services through ambulatory protocols and reports for the performed home visiting. 33 the role and organization of health care systems in-patient care and institutions in-patient/hospital care means admission into hospital or other stationary health organization, including diagnosis, treatment and rehabilitation, with in-patient care and treatment of the most severely ill patients who cannot be treated in ambulatory-polyclinic institutions or at home. stationary health organizations are institutions, which, in addition to supplying diagnosis, treatment and medical rehabilitation, also provide hospital accommodation, treatment, care and food. they include hospitals, nursing homes, health resorts and rehabilitation centers. hospital is a health organization which provides consultative-specialist health care and accommodation, treatment and food for the patients in a certain area and for more types of diseases and for persons of all ages, or only for persons diseased from certain illnesses, or for certain group of citizens (4,10). hospitals have been present in a variety of forms for millennia. almost 5,000 years ago, greek temples were the first, but similar institutions can be found in ancient egyptian, hindu, and roman societies. these „hospitals” were very different than the hospitals of today, and over the span of time they have gone through a dramatic evolution from temples of workship and recuperation to almhouses and pest houses and finally to sources of modern-day miracles. the word „hospital” comes from the latin hospitalis. although well regarded earlier in history, hospitals in the middle ages and later had unsavory reputations and primarily served the poor. until well into the 20th century physicians provided charity care in hospitals but treated private (fee-for-service) patients at home. new medical technology made treatment efficient, especially with surgical intervention, and this focused attention on acute care hospitals. treatment of private patients brought acute care hospitals new prestige and acceptance. this evolution was well underway by the 1920s as acute care hospitals became differentiated and specialized to organize and deliver an expanded scope of services. many acute care hospitals were small and owned by physicians as a convenient way to hospitalize their patients (5,10). hospitals are institutions whose primary function is to provide diagnostic and therapeutic medical, nursing, and other professional services for patients in need of care for medical conditions. hospitals have at least six beds, an organized staff of physicians, and continuing nursing services under the direction of registered nurses. the who considers an establishment a hospital if it is permanently staffed by at least one physician, can offer in-patient accommodation, and can provide active medical and nursing care (7). by convention of common use, a general (community or district) hos34 health systems and their evidence based development pital is an acute care hospital that provide diagnoses and treatment for patients with a variety of medical conditions or for more than one category of medical discipline for general medical and surgical problems, obstetrics and pediatrics. the title is used whether the hospital is not for profit or for profit. a general hospital provides permanent facilities, including inpatient beds, continuous nursing services, diagnosis, and treatment, through and organized professional staff organization, for patients with a variety of surgical and non-surgical conditions. this is in contrast to special hospitals, which admit only certain types of patients by age or sex, or those with specified illnesses or conditions such as a children’s, maternity, psychiatric, tuberculosis, chronic disease, geriatric, rehabilitation, or alcohol and drug treatment center which provide a particular type of service to the majority of their patients (5,7). hospital bed is any bed that is set up and staffed for accommodation and full-time care of in-patients and is situated in a part of the hospital where continuous medical care is provided. a bed census is usually taken at the end of a reporting period. the supply of hospital beds is measured in terms of hospital beds per 1000 population. this varies widely between and within countries. in addition closing of hospital beds is one of the difficult and controversial issues in health planning and health policies. it is even more difficult to close redundant or uneconomic hospital beds, because this means a loss of jobs in the community unless coupled with transfer of personnel to other services, itself a painful procedure. total beds per 1000 population include all institutional beds utilized for in-patient medical care, but not geriatric custodial care. acute care bed ratio is a more precise and comparable indicator representing the number of general, short-term care beds per 1000 population. hospitals are increasingly technologically oriented and costly to operate. hospital services in the european region underwent considerable expansion in during the 1960s, 1970s and the beginning of the 1980s but have since experienced increasing difficulties. managing health systems with a fewer hospital days requires reorganization within the hospital to provide the support services for ambulatory diagnostic and treatment services as well as home care. the interactions between the hospital-based and community-based services require changes in the management culture and community-oriented approaches. many developed countries are actively reducing hospital bed supplies, facilitating alternatives to hospital care, using incentive payments to promote dayhospital treatments, ambulatory and home care. in the more eastern part of the region, the very large number of hospital beds (a legacy of health care policy in the past), combined with a severe economic crisis during the 1990s has created an extremely difficult situation characterized by dilapidated buildings, 35 the role and organization of health care systems worn-out equipment, lack of basic supplies and a financial inability to profit from new breakthroughs in hospital technology (6). during 1980s and 1990s in usa, especially in california, an intensive process of mergers or acquisitions of for-profit hospitals was taking place aimed to increase organization’s capacity, financial viability and efficiency of the new unit, and ability for competition in its current markets (7,18). classification of hospitals hospitals are classified in several ways: length of stay, type of service, and type of control or ownership, as well as size of the hospital (4,5,6,7,10,12). length of stay is divided into acute care (short term) and chronic care (long term). acute care (of short duration or episodic) is a synonym for short term. chronic care (or long duration) is a synonym for long term hospitals. short-term stay hospitals are those in which more than half of patients are admitted to units in the facility with an average length of stay shorter than 30 days. long-term stay hospitals are those in which more than half of patients are admitted to units in the facility with an average length of stay of more than 30 days (7). the most of hospitals are short term. community hospitals are acute care (short term). rehabilitation and chronic disease hospitals, nursing homes and hospices are long term. psychiatric hospitals are usually long term. some acute care hospitals have units to treat acute psychiatric illness. hospitals in the european region now often serve both acute and chronic patients, but these two categories need to be better differentiated in order to optimize the use of resources and staff expertise (6). day care hospitals provide stay and treatment of patients during the day-time in the premises of the hospital, not including accommodation for lodging. day care hospital is an important novelty in the hospital treatment, which has positive social, psychological and economical implications, if its work is adequately organized (4,6,12). types of service denote whether the hospital is „general” or „special”. general hospitals provide a broad range of medical and surgical care, to which are usually added the specialties of obstetrics and gynecology; rehabilitation; orthopedics; and eye, ear, nose, and throat services. „general” can describe both acute and chronic care hospitals, but usually applies to short-term hospitals. „special” hospitals offer services in one medical or surgical specialty (e.g., pediatrics, obstetrics/gynecology, rehabilitation medicine, or geriatrics) or treatment to certain diseases or groups of diseases (tbc, psychiatric diseases, heart and lung diseases etc.). although special hospitals are usually acute, they 36 health systems and their evidence based development may also be chronic. a tuberculosis hospital is an example of the latter. university hospital as a special or specialized health institution for the education and training of health manpower with secondary and advanced training in health with university degrees in medicine, medical research and specialist treatment of in-patients (4,10). a third classification divides hospitals by type of control or ownership: for profit (investor owned), or not for profit, governmental (federal, state, local, or hospital authority), religious or voluntary organizations. functions of the hospitals the basic function of acute care hospitals is to diagnose and treat the sick and injured. the nature and severity of a patient’s illness determine the care received and, to some extent, the type of hospital in which it is provided. care might be delivered on an in-patient or out-patient basis. all acute care hospitals treat the sick and injured. their emphasis on the other functions noted here depends on organizational objectives (5). a second function is preventing illness and promoting health. examples are instructing patients about self-care after discharge, referring them to other community services such as home health services, conducting disease screening, and holding childbirth and smoking cessation classes. the competitive environment has caused hospitals to mix illness prevention and health promotion with generous amounts of marketing. a third function is educating health services workers. physician education in residencies and fellowships is common. acute care hospitals train staff such as nurse aid who will work in them. acute care hospitals are a setting for many different types of health services workers who need clinical experience to receive a state license or professional society certification. many health services management education programs require a residency, and it is common for managers to have spent time in an acute care hospital as an administrative resident or fellow. clinic is a health organization that performs educational activities, professional training of health workers and scientific-research activity. the clinic performs the most complex types of health care from a certain medical branch that is from dentistry, creates and carries out professional and medical doctrinaire criteria from their field and offers professionallymethodological help to the health organizations from the related medical branch or dentistry. a fourth function is research. clinical trials for new drugs and devices come to mind first, but are the least common. research such as assessing uti37 the role and organization of health care systems lization of intensive care units and determining why staff ignores universal precautions when treating emergency room patients are more common. one type of non-clinical research focuses on improving hospital processes through quality improvement. this could include using patient satisfaction surveys, increasing efficiency in patient billing, and improving ways to deliver supplies to nursing units. three generations of health care system reforms health care systems are continuously evolving. impetus for reform of a health system may derive from a need for cost restraint, universal coverage, or efficiency in use of resources, or an effort to improve satisfaction of consumers or providers. the objective of improving the health of the population is also a motive, but this is often expressed as improved access, equity, efficiency, quality of care, and outcomes (7). during the 20th century, there have been three overlapping generations of health system reforms. they have been prompted not only by perceived failures in health but also by a quest for greater efficiency, fairness and responsiveness to the expectations of the people that systems serve. the first generation of reforms saw the founding of national health care systems, and the extension to middle income nations of social insurance systems, mostly in the 1940s and 1950s in richer countries and somewhat later in poorer countries. by the late 1960s, many of the systems founded a decade or two earlier were under great stress. costs were rising, especially as the volume and intensity of hospital-based care increased in developed and developing countries alike. among systems that were nominally universal in coverage, health services still were used more heavily by the better-off, and efforts to reach the poor were often incomplete. too many people continued to depend on their own resources to pay for health, and could often get only ineffective or poor quality care (2). these problems were apparent, and increasingly acute, in poorer countries. in low-income countries, the health system had therefore never been able to deliver even the most basic services to people in rural areas. health facilities and clinics had been built, but primarily in urban areas. in most developing countries, major urban hospitals received around two-thirds of all government health budgets, despite serving just 10% to 20% of the population. studies of what hospitals actually did revealed that half or more of all inpatient spending went towards treating conditions that could often have been managed by ambulatory care, such as diarrhea, malaria, tuberculosis and acute respira38 health systems and their evidence based development tory infections. there was, therefore, a need for radical change that would make systems more cost-efficient, equitable, and accessible. a second generation of reforms thus saw the promotion of primary health care as a route to achieving affordable universal coverage. there was a very strong commitment to assuring a minimum level for all of health services, food and education, along with an adequate supply of safe water and basic sanitation. these were the key elements along with an emphasis on public health measures relative to clinical care, prevention relative to cure, essential drugs, and education of the public by community health workers. by adopting primary health care as the strategy for achieving the goal of „health for all” at the joint who/unicef international conference on primary health care held at alma ata (now almaty, kazakhstan) in 1978, who reinvigorated efforts to bring basic health care to people everywhere. the main aspects of the reorientation of primary health care related to the new focus from illness to health and from care to prevention; to the new content from treatment to health promotion and from episodic care to continuous care; to the new organization from specialist to general practitioner and from physician to nurse; and to the new responsibilities from passive reception to self-responsibility and from professional dominance to community participation (2,17). the term „primary” quickly acquired a variety of connotations, some of them technical (referring to the first contact with the health system, or the first level of care, or simple treatments that could be delivered by relatively untrained providers, or interventions acting on primary causes of disease) and some political (depending on multi-sectoral action or community involvement). the multiplicity of meanings and their often contradictory implications for policy help explain why there is no one model of primary care, and why it has been difficult to follow the successful examples of the countries or states that provided the first evidence that a substantial improvement in health could be achieved at affordable cost. there was a substantial effort in many developing countries to train and use community health workers who could deliver basic, cost-effective services in simple rural facilities to populations that previously had little or no access to modern care and by placing major emphasis on the economic benefits of prevention and cost-effective measures to reduce the burden of disease (2,7,9,19). despite these efforts, many such programs were eventually considered at least partial failures. funding was inadequate; the workers had little time to spend on prevention and community outreach; their training and equipment were insufficient for the problems they confronted; and quality of care was often so poor as to be characterized as „primitive” rather than „primary”, par39 the role and organization of health care systems ticularly when primary care was limited to the poor and to only the simplest services. referral systems, which are unique to health services and necessary to their proper performance, have proved particularly difficult to operate adequately. lower level services were often poorly utilized, and patients who could do so commonly bypassed the lower levels of the system to go directly to hospitals. partly in consequence, countries continued to invest in tertiary, urban-based centers. in developed countries, primary care has been better integrated into the whole system, perhaps because it has been more associated with general and family medical practice, and with lower-level providers such as nurse practitioners, and physician assistants. greater reliance on such practitioners forms the core of many developed countries’ current reform agendas. managed care, for example, revolves to a large extent around the strengthening of primary care and the avoidance of unnecessary treatment, especially hospitalization (2,9). the approach emphasized in the primary health care movement can be criticized for giving too little attention to people’s demand for health care, which is greatly influenced by perceived quality and responsiveness, and instead concentrating almost exclusively on their presumed needs. systems fail when these two concepts do not match, because then the supply of services offered cannot possibly align with both. the inadequate attention to demand is reflected in the complete omission of private finance and provision of care from the alma ata declaration, except insofar as community participation is construed to include small-scale private financing (2). universal access to health care does not necessarily address social inequalities in health. removal of financial barriers by itself does not guarantee good health. many social, cultural, and environmental health risk factors are not correctable or preventable by medical or hospital care. they may be of greater importance than the medical care provided. it is therefore useful to understand how the models for reform evolved, their successes and failures, and how they are continuing to develop (7). poverty is one reason why needs may not be expresses in demand, and that can be resolved by offering care at low enough cost, not only in money but also in time and non-medical expenses. but there are many other reasons for mismatches between what people need and what they want, and simply providing medical facilities and offering services may do nothing to resolve them. in general, both the first-generation and second-generation reforms have been quite supply-oriented. concern with demand is more characteristic of changes 40 health systems and their evidence based development in the third generation currently under way in many countries, which include such reforms as trying to make „money follow the patient” and shifting away from simply giving providers budgets, which in turn are often determined by supposed needs (2,3). if the organizational basis and the quality of primary health care often failed to live up to their potential, much of the technical footing remains sound and has undergone continuous refinement. this development can be sketched as a gradual convergence towards what who calls the „new universalism” – high quality delivery of essential care, defined mostly by the criterion of costeffectiveness, for everyone, rather than all possible care for the whole population or only the simplest and most basic care for the poor (see figure 2). figure 2. coverage of population and of interventions under different notions of primary health care (2) there were common notions that health and nutrition interventions can make a substantial difference to the health of large populations and of obtaining „good health at low cost” by selectively concentrating efforts against diseases that account for large, avoidable burdens of ill-health. that was the basis for a set of core public health interventions and a package of essential clinical services influenced by phc models, variously called „basic” or „essential” or „priority” that have been recommended by the world bank and developed in several countries, in the 1990s, from epidemiological information and estimates of cost-effectiveness of interventions. and the common failures in diagnosis and treatment due to inadequate training and excessive separation among disease control efforts have led to the development of clusters of interventions and more through training to support their delivery, most notably in the integrated management of childhood illness (2,9,19). this evolution also implies an emphasis on public or publicly guaranteed and regulated finance, but not necessarily on public delivery of services. 41 the role and organization of health care systems population covered interventions included only the poor everyone "basic" or simple "primitive" health care original concept "selective" primary health care new universalism (never seriously contemplated) classical universalism "essential" and costeffective everything medically useful and it implies explicit choice of priorities among interventions, respecting the ethical principle that it may be necessary and efficient to ration services but that it is inadmissible to exclude whole groups of the population. however, it is easier to define a set of interventions that would preferentially benefit the poor if fully applied to the population, than it is to assure either that most of the poor actually do benefit, or that most of the beneficiaries are poor. government health care services, although usually intended to reach the poor, often are used more by rich. despite the health reforms of recent decades, inadequate progress has been made in building health systems that promote collective health improvement. the 1990s was a decade of major reforms in national health systems. all countries are struggling to develop adequate prevention models to reduce the burden of disease that can bankrupt a national health system. the ideas of responding more to demand, trying harder to assure access for the poor, and emphasizing financing, including subsides, rather than just provision within the public sector, are embodied in many of the current third-generation reforms. these efforts are more difficult to characterize than earlier reforms, because they arise for a greater variety of reasons and include more experimentation in approach. in part, they reflect the profound political and economic changes that have been taking place in the world. by the late 1980s, the transformation from communist to market-oriented economies was under way in china, central and south east europe, and the former soviet union (2,7). health systems have not been immune from these large-scale changes. one consequence has been a greatly increased interest in explicit insurance mechanisms, including privately financed insurance. in developed countries, which already had essentially universal coverage, usually less drastic changes have taken place in how health care is financed. but there have been substantial changes in who determines how resources are used, and in the arrangements by which funds are pooled and paid to providers. general practitioners and primary care physicians, as „gatekeepers” to the health system, have sometimes been made accountable not only for their patients’ health but also for the wider resource implications of any treatments prescribed. in some countries this role has been formalized through establishing „budget holding” for general practitioners and primary care physicians, for example, through general practice „fund holding” in the uk, health maintenance organizations in the usa, and independent practice associations in new zealand. and in the united states, there has been a great shift of power from providers to insurers, who now largely control the access of doctors and patients to one another. in the european region, in recent years, many health care reforms 42 health systems and their evidence based development have taken place. many governments started to introduce various market mechanisms into service delivery by purchaser/provider split, introduction of competitive elements into health services, and various payment mechanisms. the ljubljana charter, adopted by all member states in 1996, emphasized that health care reforms should be an integral part of an overall health policy and that health care systems need to: • be governed by the principles of human dignity, equity, solidarity and professional ethics; • relate to clear targets for health gain; • address citizens’ needs; • aim at continuous improvements in the quality of care; • ensure financing that will enable health care to be provided to all citizens in a sustainable way; and • be oriented towards primary health care. it means that the reform of health care provision and its financing should be comprehensive in order to safeguard the development of adequate and affordable health care services. for example, reforms in the organizational structure of the health system should be accompanied by legislative adaptations, or reforms in secondary and primary care provision should be accompanied by reform in the health financing system. in csee countries, after the breakdown of the state socialism, a number of changes have occurred in the legal framework, as well as governmental policy, ownership, production, financing and reimbursement of health care providers. priority setting was necessary step to ensure the efficient use of insufficient public funds for health. because of shortage of funds many costeffective interventions were neglected, under funded or provided with low quality standards. it was necessary in these countries the priority setting in health care to be driven by new democratic values and the new systems to be people-centered and more oriented to the needs of individual patient and specific groups, and sensitive to inequalities, unemployment, and social poverty. health systems also should be health-focused and evidence based, and oriented towards primary health care (20). despite the structural diversity and underlying philosophical differences in national health systems, there are important common elements. they are large employers and among the largest industries in their respective countries. all face problems of financing, cost constraint, overcoming structural 43 the role and organization of health care systems inefficiencies, and, at the same time, finding incentives for high quality and efficiency (7). in the years ahead health systems will face new challenges, because of the aging of the population, medical technology innovations, and high professional and public expectations, and new pressures to constrain costs and resolute commitment to the primary health care values of equity, universal access to care, community involvement and intersectoral action. those principles will be more important than ever. still, much remains to be understood about how health systems function, why they fail or respond slowly to some crises, and about how primary health care principles can be translated into practice policies that will yield health improvements for communities (1). 44 health systems and their evidence based development exercise: the role and organization of health care system task: students should visit www.observatory.dk to become familiar with different health care systems and actual reforms initiatives. students are encouraged to write draft describing hcs in their respective country, using production template questionnaire, which is available on site given above. 45 the role and organization of health care systems references 1. who. shaping the future. the world health report 2003. who, geneva, 2003: 143. 2. who. improving performance. the world health report 2000, health systems: who, geneva, 2000: 151. 3. who. health, economic growth, and poverty reduction. the report of working group i of the commission on macroeconomics and health executive summary. who, geneva, 2002: 12. 4. donev d, ivanovska l, lazarevski p, ruzin n. glossary of social protection terms. phare consensus programme project: dictionary and glossary of social protection terms. european commission, 2000: 472. 5. rakich j, longest b, darr k. managing health services organizations. health professions press, inc. baltimore, maryland, 1992: 684. 6. who. health 21 health for all in the 21st century. european health for all series no 6. who-euro, copenhagen 1999: 217. 7. tulchinsky th, varavikova ea. the new public health: an introduction for the 21st century. san diego: academic press, 2001. 8. lameire n, joffe p, weidemann m. healthcare systems an international review: an overview. nephrol dial transplant 1999; 14(6): 3-9. 9. the world bank. world development report 1993: investing in health. the world bank, 1993: 329. 10. cuci} v, simi} s. osnovni principi organizacije zdravstvene slu`be. in: cuci} v, simi} s, bjegovi} v, @ivkovi} m, danki}-stefanovi} d, vukovi} d, ananijevi} pandej j. social medtextbook, savremena administracija a.d. belgrade 2000: 195-238. 11. kova~i} l. primarna zdravstvena za{tita. in. jak{i}, kova~i} l at all. social medicinetextbook. medicinska naklada, zagreb 2000: 180-3. 12. stamatovi} m, jakovljevi} dj, martinov-cvejin m. zdravstvena za{tita. zavod za ud`benike i nastavna sredstva, beograd 1995: 92-136. 13. stamatovi} m, jakovljevi} dj, legeti} b, martinov-cvejin m. zdravstvena za{tita i osiguranje. zavod za ud`benike i nastavna sredstva, beograd 1997: 140-210. 14. dovijani} p, janjanin m, gaji} i, radonji} v, djordjevi} s, borjanovi} s. socijalna medicina sa higijenom i epidemiologijom. zavod za ud`benike i nastavna sredstva, beograd 1995: 4576. 15. dovijani} p. savremena organizacija zdravstvena slu`be i ustanova. i.p. „obele`ja" beograd 2003: 43-52. 16. who. reducing risks, promoting healthy life. the world health report 2002. who, geneva, 2002: 235. 17. who. declaration of alma ata. in: international conference on primary health care, alma ata, ussr, september 6-12, 1978. who health-for-all series, no. 1, geneva, 1978. 18. angrisani d, goldman r. predicting successful hospital mergers and acquisitions: a financial and marketing analytical tool. the haworth press, inc. new york, 1997: 126. 19. bobadilla jl, cowley p, musgrove p, saxenian h. design, content and financing of an essential national package of health services. the world bank group private and public initiatives: working together in health and education. the world bank, march 17, 1995:110 (http://www.worldbank.org/html/extdr/hnp/health/hlt_svcs/pack1.htm, accessed jan 11, 2004). 20. ore{kovi} s. new priorities for health sector reform in central and eastern europe. croatian med j 1998; 39: 225-33. 46 health systems and their evidence based development 47 health care system of the federation of bosnia and herzegovina health systems and their evidence based development a handbook for teachers, researchers and health professionals title health care system of the federation of bosnia and herzegovina module: 1.2 ects (suggested): 0.25 author(s), degrees, institution(s) dr enida imamovic, specialist of social medicine, public health institute of federation of b&h; dragana niksic, md, phd, ass. professor of social medicine, medical faculty, university of sarajevo address for correspondence enida imamovic, public health institute of fb&h, titova 9 71000 sarajevo bosnia and herzegovina tel: +387 33 20 88 13 fax: +387 33 22 05 48 e-mail: imamovic@bih.net.ba keywords organization, health care system, reform, indicators learning objectives at the end of this module case study, students would become familiar with the organization of the health care system and health care reform process of the federation of bosnia and herzegovina. abstract according to the b&h constitution, health care regulation and competence are transferred to the entity level. federation b&h consists of ten cantons, health care system is decentralized. the transition of the health care system has started in early 1990s and it has been continued after the war ended in 1995. the main aim of the health care system reform in fb&h is to rationalise health care on the basis of phc strengthening. in line with the law, there are three levels of health care: primary care level, specialists or consultant's level, and tertiary care level. within primary health care (phc), family medicine teams are implemented. on this level are also implemented community mental health centres and physical rehabilitation centres. strengthening of phc is accompanied by rationalisation of hospital care. hospital care capacities have been decreasing, as outlined in the reform documents. although the use of capacities has slightly grown it is still under standard occupancy, which means that capacities are insufficiently used. the package of patient's rights is not defined yet. teaching methods after an introduction lecture students will work in small groups on recognizing strengths and weaknesses of the health care system and health care reform process of the federation of bosnia and herzegovina, which will be followed by group reports and overall discussion. specific recommendations for teacher this module to be organized within 0.25 ects credit. beside supervised work, students should be informed about who indicators and specific indicators for their country regarding health care organization in order to describe main principles/problems respective to their country. assessment of students practical work: health care system in line with who indicators (in students' countries), improvement in health care system proposal/reform proposal (papers and discussions). health care system of the federation of bosnia and herzegovina enida imamović, dragana nikšić introduction as a republic of former yugoslavia, bosnia and herzegovina had a health system financed by „self-managed” communities, which ran health insurance, social security and disability insurance for employees and their families at the municipal level. from 1991, at the federal level, risk pooling took place through a republic-wide, compulsory health insurance scheme, administered by a central insurance fund. during the war from 1992-95 health financing was organized directly by the republic's then ministry of health, while the health insurance fund practically ceased to operate. provision of elective health care was reduced to a minimum, and a number of new provider units were established for emergency care. however, it is estimated that about 30% of health care facilities were destroyed or heavily damaged during the war (1). dayton peace agreement of 1995 has divided bosnia and herzegovina (b&h) in two entities: federation b&h and republic of srpska. according to the b&h constitution health care regulation and competence are transferred to the entity level. within federation b&h, health care competence is divided between federal and cantonal authorities which resulted with decentralisation of health care while coordination role is attributed mainly to the federal level. a third health system was created in 2000 in the district of br~ko, as an administrative unit under the federal sovereignty of b&h and international supervision that covers an estimated 90,000 population. in addition to republic srpska and district of br~ko, federation of b&h consists of ten cantons and each of them has its own government and assembly. the cantons involve 79 municipalities, which are basic social and political communities. method this outline is focused on the representation of fb&h health care system resources in 2002 in line with who indicators. the outline is based on data available from official statistics. for comparative survey are chosen countries in transition which by health related factors are the most matching the federation b&h (albania, bulgaria, croatia, macedonia, romania, cee central and east european countries). 48 health systems and their evidence based development demographic indicators federation of bosnia and herzegovina covers 25 989 km2, which is about 51% of the whole b&h territory. in 2002, on the territory of the federation lived 2 315 270 inhabitants. according to the data of federal ministry of displaced people and refugees, in the federation b&h in 2002 lived 199 093 displaced persons or 8.6%. the average density of the population is 89 persons per square kilometre. the regional diversity is evident. the persons over 65 years make 11% of the total population, while the age group 0-14 years makes 20.6%, so that the population of fb&h may be classified as stationary regressive by its biological type. socioeconomic indicators in 2001, gdp per capita was 1,176 us$ (2). average monthly pay in 2002 was 279,3 us$ or 482,71 bam (on 14.07.2003, 1 us$ mean value was 1,7285 bam). the working age population makes 57.40% of the total population. in 2002, the percent of unemployed reached 42.45% and was increased related to the previous years (1998, it was 39.34%). according to the estimations, in 2002, the general socio-economic situation is very complex as 10% of total population are persons with different levels of disability, and 3.9% of population is on social benefits, out of which 14.1% are children. health care system reform the transition of the health care system has started in early 1990s. the war in 1992 ceased the reform process but it has been continued in 1995. the law on health care (3) and the law on health insurance (4), both adopted in 1997, support the reform. in 2002, the health care standards and norms for obligatory health insurance were adopted. some of the reasons that incited the reform are new socio-political and socioeconomic changes; still existent war implications in health care resources, increase of health care demands, etc. the main aim of the health care system reform in fb&h is to ensure more rational health care on the basis of primary health care (phc) strength49 health care system of the federation of bosnia and herzegovina ening as outlined in the reform documents (5) and in health for all in the 21st century (6). within phc, family medicine teams are implemented. also, on this level are implemented community mental health centres and physical rehabilitation centres. strengthening of phc is accompanied by rationalisation of hospital care. the social, political and economic changes in the society were followed by the process of health care sector privatization. in addition, it should be stressed that premises and equipment in health sector is partly destroyed, damaged, or obsolete and that slow down the reform trends (7). health system organization in accordance with the law (3), there are three levels of health care: primary care level, specialists or consultant's level, and tertiary care level (scheme 1). municipality level includes: health centres with health services in community and pharmacies. cantonal level includes: ministry of health, general hospital, cantonal hospital, special hospitals, institute for blood transfusion, public health institute and health insurance fund. federal level includes: ministry of health, clinical centres, institute for blood transfusion, public health institute, institute for drug control, and health insurance fund. 50 health systems and their evidence based development scheme 1. health system organization in the fb&h source: strategic health system plan, the federation of b&h, july 1998 survey of health professionals in fb&h in comparison with some countries in transition the comparative survey of health care professionals shows that, by number of doctors in 2002 (144 doctors per 100000 people) and by the number of nurses fb&h is on the bottom. only albania has even smaller number of dentists per 100000 populations; albania and romania are behind fb&h by the number of pharmacists (8,9). 51 health care system of the federation of bosnia and herzegovina federal ministry of health federal institute for health insurance clinical centres 3 public health institute institute for drug contol institute for transfusiology cantonal ministry of health cantonal health insurance fund cantonal hospital health centre health station pharmacy cantonal public health institute cantonal institute for blood transfuzion federal level cantonal level municipal level general hospital ministry of health figure 1. health professionals per 100000 population in some countries in transition (data for year 2002) source: who regional office for europe health for all database 2002, 2003 and public health institute of federation of b&h (data for federation b&h) primary health care the institutions that provide primary health care are health centers (dom zdravlja). medical services delivered by health centers include: general practice, maternal and child health, school medicine, health care for specific and non-specific lung diseases, and dental care; they also ensure hygiene services (epidemiological activities), emergency medical aid, laboratory, radiology and other diagnostic services. within the area of each health center, there is an outpatient service located in the district (10). 52 health systems and their evidence based development 133 344 238 144 219 189 244 368 450 500 328 518 403 516 0 100 200 300 400 500 600 albania bulgaria croatia federation b&h macedonia rom ania cee average n u m b e r p e r 1 0 0 0 0 0 p o p u la ti o n doctors nurses 9 32 68 20 55 23 40 3 12 50 9 15 7 36 0 20 40 60 80 100 albania bulgaria croatia federation b&h macedonia rom ania cee average n u m b e r p e r 1 0 0 0 0 0 p o p u la ti o n dentists pharmacists in line with the reform trends, the family medicine concept has been successively implemented. within health care system, family medicine services are the places of the first contact with patient. at the same time, family medicine teams (one team consists of gp and nurse) carry out activities on prevention and treatment of the population, in line with the european definition of family medicine (wonca). these teams are providing services for around 1,500-2,500 people. family medicine teams should meet about 80% of demands for health care (3,5,11). in federation b&h, in the year 2002, primary health care was delivered within 872 units. there were 55 doctors and 120 nurses per 100000 populations. moreover, on this health care level, already exist community mental health centres and physical rehabilitation centres. there were 20 dentists and 9 pharmacists per 100000 populations. table 1. primary health care indicators in the fb&h in 2002 source: public health institute of federation of b&h usually, phc teams appropriately cover the population, but availability is not equal in terms of geographical regions. data related to the private health sector are not available. specialist's or consultant's health care health centres have also organised units to deliver specialists or consultants services, if such services were not organised within other health institutions (10). during the year 2002, this type of health care was delivered in fb&h within 424 units involving 436 working teams. there were 19 doctors and 26 nurses per 100000 populations. 53 health care system of the federation of bosnia and herzegovina who indicators value units (number) 872 physicians/100000 55 dentists/100000 20 pharmacists/100000 9 nurses/100000 120 table 2. changes in network and manpower of the phc and consultants/ specialists hc in fbh in the period 1998-2002 source: public health institute of federation of b&h consultants/specialists health services are also provided in institutes for blood transfusion, occupational medicine, sport medicine and physical medicine and rehabilitation. although the health care policy of federation b&h is oriented towards strengthening primary health care, the data related to the previous period demonstrates more extensive development of consultants/specialists care (12,13,14). hospital care secondary level, i.e. hospital care, includes services delivered within general, cantonal and special hospials and partly clinical centres. tertiary care is provided within clinical centres (university hospitals). hospital care in the year 2000 involved 48.7 % of all medical doctors, and 55.4 % of nurses. comparative survey shows that by percentage of physicians working in hospitals fb&h is somewhere in the middle. figure 2. physicians working in hospitals (%) in some countries in transition in 2002 network and manpower levels of health care primary health care consultants/specialist health care 2002 1998 index 2002/1998 2002 1998 index 2002/1998 units 872 904 96.4 424 302 140.4 doctor's offices 1194 1238 96.4 429 244 175.8 doctors 1269 1364 93.0 436 315 138.4 nurses 2776 3078 90.2 604 435 138.8 54 health systems and their evidence based development 45 50 54 49 35 51 0 20 40 60 albania bulgaria croatia federation b&h macedonia romania % w o rk in g i n h o s p it a ls source: who regional office for europe health for all database, 2003 and public health institute of federation of b&h (data for federation b&h) significant decrease in hospital capacities occurred during the last years. hospital bed rate per 100000 population was reduced from 400 beds in 1998 to 350 beds in 2002. there were 5.0 beds per one doctor, and 1.9 beds per one nurse, which is very high standard. table 3. hospital care indicators in the fb&h in 2002 source: public health institute of federation of b&h the bed occupancy was 68.4%, which is still very low showing insufficient use of existing bed capacities. the decrease in hospital beds was not followed by the decrease of number of doctors working in hospitals. compared with the countries in transition, federation b&h, with 350 beds per 100000 population, left only albania behind. figure 3. hospital beds per 100000 population in some countries in transition in 2002 55 health care system of the federation of bosnia and herzegovina who indicators value % physicians working in hospitals 49 % nurses working in hospitals 55 number of hospital beds/100000 350 bed occupancy rate 68,4% 326 720 600 350 493 646 749 0 100 200 300 400 500 600 700 800 source: who regional office for europe health for all database, 2003 and public health institute of federation of b&h (data for federation b&h) albania bulgaria croatia federation macedonia romania cee b&h average h o s p it a l b e d s p e r 1 0 0 0 0 0 p o p u la ti o n average length of stay (in days) in 2002 was 10 days and did not indicate more significant changes in the observed period. in 2002, the beds occupancy was 68.4%, showing a decrease related to the two previous years, and demonstrating inadequate use of existing bed capacities. figure 4. use of hospital resources in fb&h in the period 1998-2002 source: public health institute of federation of b&h hospital care capacities have been decreasing, as outlined in the reform documents, but the use of capacities was still under standard occupancy. funding the reform includes health care funding, also. about 17% of gross wages (without deductions) go to the health care funds. funds are raised and allocated at the cantonal level. recent legislation allows some transfer of resources across the cantons to be redistributed by the federal health insurance fund. the establishment of the „federal solidarity fund" in january 2002 aims at increased intercantonal cooperation to diminish inequities in access to health care by reducing duplication of services, enabling the movement of patients across locations to receive needed services where available, and potentially reducing the fragmentation of services between cantons. moreover, lower income cantons will be able to benefit from expensive interventions. the fund is financed by contributions from cantonal health insurance funds (8% of their 56 health systems and their evidence based development 63.2 65.9 70 74.7 68.4 10.3 11.3 1010.2 10.5 0 20 40 60 80 100 1998 1999 2000 2001 2001 year b a d o c c u p a c y r a te ( % ) 0 2 4 6 8 10 12 a v e ra g e l e n g h t o f s ta y (d a y s ) bad occupacy rate (%) average lenght of stay (in days)bed occupacy rate (%) average lenght of stay (in days) year a v e ra g e l e n g h t o f s ta y (d a y s ) b e d o c c u p a c y r a te ( % ) overall income), and general revenues. the aim is to resolve the problem of lack of contributions by non-earners and to help to equalise health revenues across fb&h. on the basis of the proposal of federal government, federal parliament adopts each year „the package of patient's rights". the aim is to establish a uniform, federation-wide package to ensure equal access. this „package", to be provided under compulsory social insurance is still under development (1,4). conclusions 1. health care system in the federation b&h is going through the process of transition. this process has started in early 1990s, before the war and it has been continued in 1995. currently, the reform is stipulated by democratic changes and market economy. 2. the reform includes changes of legislation, foundation and management of health facilities, raise and distribution of financial resources, etc. 3. as a result of dayton peace agreement, the health sector is decentralised; large rights are given to the cantons, while federation is acting as a coordinator. 4. the process of privatisation has started in early 1990s although (many questions were still unsolved) with insufficient regulation. 5. facilities and equipment are partly destroyed, damaged, or outdated slackening the reform trends. 6. health sector reform is based on strengthening of primary health care (phc) and rationalisation of hospital care. in average, phc teams appropriately cover the population, but availability is not equal. family medicine teams, community mental health centres and physical rehabilitation centres are still in the phase of implementation. 7. during the reform period, hospital bed number was reduced although the occupancy is still low indicating the inadequate use of hospital capacities. 8. the package of patient's rights is not defined yet. 9. comparative analysis of indicators of health care system showed that federation b&h, related to other observed countries, is amongst the last ones. moreover, the available data demonstrated inadequate use of the existing capacaties. therefore, due to the shortage of comprehensive data 57 health care system of the federation of bosnia and herzegovina for both private and public sector, the targeted operational research is necessary for the identification of actual status of organization and use of resources. 58 health systems and their evidence based development exercise: health care system of the federation of bosnia and herzegovina task: after reading this case study under the supervision of lecturer, students are asked to split and work in small groups (4-6 students) in order to discuss and decide possible recommendations they would make for the improvement of health care system in bosnia and herzegovina, following conclusions which were given above. written recommendations will be presented to the whole group. 59 comparative analysis of regional health care systems in the european union references 1. jacubowski e, cain j. health system decentralisation in bosnia and herzegovina. euro observer 2003; 5 (1): 6-8. 2. statisti~ki godišnjak/ljetopis federacije bosne i hercegovine 2002. federalni zavod za statistiku. sarajevo 2002. 3. zakon o zdravstvenoj zaštiti. slu`bene novine federacije bih. sarajevo 1997: 4 (29). 4. zakon o zdravstvenom osiguranju. slu`bene novine federacije bih. sarajevo 1997: 4 (30). 5. strategic health system plan, the federation of b&h. sarajevo, july 1998. 6. who: health for all in the 21st century. who regional office for europe copenhagen. 1999. 7. smajki} a et al: health and social consequences of the war in bosnia and herzegovina sanation proposal. svjetlost. sarajevo, 1997. 8. who: health for all statistical database. regional office for europe. copenhagen. 2002. 9. who: health for all statistical database. regional office for europe. copenhagen. 2003. 10. cain j et al: european observatory on health care systems. health care systems in transition. bosnia and herzegovina. 2002: 4 (7). 11. wonca. evropska definicija porodi~ne/obiteljske medicine. udru`enje specijalista i specijalizanata porodi~ne/obiteljske medicine bosne i hercegovine, 2003. 12. mre`a, kapaciteti i djelatnost zdravstvene slu`be u federaciji bosne i hercegovine u 1998. godini, zavod za javno zdravstvo federacije bosne i hercegovine, sarajevo, 1999. 13. mre`a, kapaciteti i djelatnost zdravstvene slu`be u federaciji bosne i hercegovine u 1999. godini, zavod za javno zdravstvo federacije bosne i hercegovine, sarajevo, 2000. 14. mre`a, kapaciteti i djelatnost zdravstvene slu`be u federaciji bosne i hercegovine u 2000. godini, zavod za javno zdravstvo federacije bosne i hercegovine, sarajevo, 2001. recommended readings • national law on health care • national law on health insurance • national standards and regulations. • who: health for all in the 21st century. who regional office for europe copenhagen, 1999 • who: health for all statistical database. regional office for europe. copenhagen 60 health systems and their evidence based development 61 electronic health records the core of the national health information system health systems and their evidence based development a handbook for teachers, researchers and health professionals title electronic health records the core of the national health information system module: 1.3 ects (suggested): 0.75 author(s), degrees, institution(s) prof. jelena marinkovic, bm, phd prof. vesna bjegovic, md, phd the authors are professors at the school of medicine university of belgrade, serbia and montenegro address for correspondence institute of medical statistics and informatics / institute of social medicine; school of medicine, belgrade university dr suboti}a 15 11000 belgrade, serbia and montenegro tel: +381 11 685 888 / +381 11 685 451 fax: + 381 11 659 533 e-mail: jmarinkovic@med.bg.ac.yu; bjegov@eunet.yu keywords health information, electronic health record (ehr), information and communication technology (ict), ehr context/building blocks learning objectives after completing this module students and public health professionals should have: • increased their knowledge about the health information systems and accepted a basic of electronic health record (ehr); • learnt about electronic health record architecture, which represents the generic structural components upon all ehrs are built;· • understood principles underpinning the ehr; • learnt about necessary context blocks: person identifier, facility identifier, provider identifier, health information generated through health events in a form of event summaries and administrative information; • gained knowledge of necessary building blocks, such as privacy, confidentiality, and security; standards; telecommunication infrastructure and encouraging uptake and use of information and communication technology (ict); • highlighted difficulties and risks associated with ehr development; • recognized the importance of ehr for the future development of (national) health information system, especially in countries in transition; and • increased their skills necessary to participate in the process of ehr development in their own countries. abstract modern information and communication technologies offer an opportunity to improve health information systems, reengineer and revitalise the processes and procedures currently in place. at the same time, modern health care is not provided by one institution or by one group of health care professionals alone. hence, today it is considered that the keystone of a system for sharing data, information and knowledge between different partners in health system is the electronic health record (ehr). through an interoperable ehr the sources of information available to all partners in health system, primary and secondary users, can be extended, expanded and harmonized. as such, the ehr should be the core of the new generation of health information systems. ehr, as longitudinal collection of personal health information and under the control of a known party by an agreed access policy, requires at least next components: 62 health systems and their evidence based development person identifier, facility identifier, provider identifier, health information generated through health events in a form of event summaries and administrative information. the shared electronic health record model is one that essentially provides for the systematic collection (at point of care), transfer, storage and retrieval of basic health, demographic, prescription and administrative data in the form of event summaries to be presented with appropriate authorization, via meaningful views and reports. ehr systems provide mechanism for the communication of records or their parts through a network of electronic health records. teaching methods lecture, individual work, group work specific recommendations for teacher this module should be organized within 0.75 ects, out of which one third will be under the supervision of teacher. after an introductory lecture the students should work individually to fill in the questionnaires, which have to explore their knowledge and attitudes towards time of different ehr data storage and the concept of data privacy and security. students will analyse the questionnaires in small groups and discussed in plenary session. in addition teacher should be ready to help the students in searching the internet to find different national examples of the ehr development. assessment of students multiple choice questionnaires, written report with comparison of different ehr development. electronic health records the core of the national health information system jelena marinković, vesna bjegović the health sector is arguably one of the most information-dependent businesses of all in which information requirements can be classified, for example, as: information for citizens, patient education services, health management information, personal health data, decision support systems for health care professionals and life long learning for health care professionals. the development of the national health information system is seen as one of the most important infrastructure prerequisite for initiating, implementing, monitoring, evaluating and targeting the changes within the health care reform. the support to the reform process is based on the development and improvement of management in the health care system, that is: creation of conditions for evidence-based decision making provided for health care providers, patients/citizens and health-care policy makers, and measurement of key dimensions of the health care system, that is: its availability, equity, quality, efficiency, financial and institutional sustainability (1). there is widespread consensus that the underlying rationale for information management and information & communication technology (im&ict) driven health reform is to improve health outcomes for citizens while containing health system costs. however, while sharing this overarching objective, different stakeholder groups are pursuing a range of different outcomes. figure 1 shows the specific outcomes sought by five key stakeholder groups through the application of information management tools and technology as well as information and knowledge (2). 63 electronic health records the core of the national health information system figure 1. stakeholder objectives for im&ict source: the boston consulting group, national health information management and information & communications technology strategy, australia 2004 (2) background the fundamental changes are occurring in the health care sector worldwide. economic, social and many other drivers are forcing changes to the focus of health care. as written and visually displayed in canada ehrs blueprint, first and foremost, health care is becoming a more patient-driven (figure 2 (3)). similarly, there is a demonstrated understanding of the need to shift the focus of health care efforts from the management of illness to the maintenance/promotion of wellness. as a result, we are seeing increased emphasis on the management of diseases across the continuum of care and along the lifecycle of the disease (3). 64 health systems and their evidence based development figure 2. the changing world of healthcare (3) source: ehrs blueprint version 1.0 page 15 © 2003 canada health infoway inc. while many of these changes are driven by advances in technology, they also require a capability from the health infostructure a capability that does not fully exist today. in the new world we require access to health information not only across different systems but across different jurisdictions and domain boundaries. we require the ability to view health information from all sources and to use the infostructure to initiate orders and referrals to a broader range of care and service providers than is currently available through traditional mechanisms. this happens by extending the capabilities to work within a framework of interoperability. through an interoperable electronic health record (ehr) we can extend, expand, and harmonize the sources of information available to clinicians in their work. therefore, the ehr is a neccessary tool for providing person-centred and continuing health care safely and efficiently (3). there is a growing consensus on the value of an ehr. only to cite medirec lisbon declaration where it is recommended that the member states promote a framework for action within europe to further develop common aspects of the ehrs based on the following: „the ehr is the nucleus of the relationship between the patient, the health care delivery system and all its professionals. as such, the ehr should be the core of the new generation of health information systems. the main objective of the use of any ehr must be to improve quality 65 electronic health records the core of the national health information system in care by having record and its associated information always available for the health care professionals when needed at point of care. the use of ehr should lead to direct benefits for the professionals by making their work more efficient. this will arise from supporting the diagnostic process, enhancing accuracy and completeness, improving medical knowledge and disease management, and allowing better preventive care and patient handling. within health care systems, either european, national, regional or local level, the use of appropriate ehrs, will also contribute to adequate planning and resource management, facilitation of continuity of care, registration of health care interventions, improvement of epidemiological and morbidity information, and hence, a more cost-effective care process. the european citizens shall by means of any ehr have: guaranteed right of access to the health care he is entitled for, right of access to his individual data and related services, and the effective protection of his rights of free circulations with respect to the confidentiality of his individual data. further actions and developments on ehr's should be based upon standards and consensus that ensure interoperability, and allow ehr's coming from different origins to be reliable, communicable, recognisable and comparable” (4). defining electronic health record the terms 'computerised patient record' (cpr), 'computer-based patient record' (cpr), 'electronic medical record' (emr), 'computerised medical record' (cmr), 'electronic health care record' (ehcr), 'electronic patient record' (epr) and 'electronic health record' (ehr) are terms often used to describe similar concepts. it is important to clearly define how these terms should be used to avoid confusion. the united states uses the term computer-based patient record or cpr and the institute of medicine defines it as „an electronic patient record that resides in a system specifically designed to support users through availability of complete and accurate data, practitioner reminders and alerts, clinical decision support systems, links to bodies of medical knowledge, and other aids” (5). the united kingdom has accepted two kinds of electronic records in health care the electronic patient record (epr) and the electronic health record (ehr) (6). electronic patient record (epr) describes the record of the 66 health systems and their evidence based development periodic care provided mainly by one institution. typically this will relate to the health care provided to a patient by an acute hospital. eprs may also be held by other health care providers. thus, eprs are considered proprietary and it is usual for eprs not to be able to be transferred even to another site using the same epr system. electronic health record (ehr) is used to describe the concept of a longitudinal record of patient's health and health care from cradle to grave, figure 3. it combines both the information about patient contacts with primary health care as well as subsets of information associated with the outcomes of periodic care held in the eprs. for the purposes of this text we shall consider the electronic health record to be an electronic longitudinal collection of personal health information, usually based on the individual or family, entered or accepted by health care professionals which can be distributed over a number of sites or aggregated at a particular source including a hand-held device. the information is organised primarily to support continuing, efficient and quality health care. the record is under the control of a known party. in certain circumstances, and with agreement of the appropriate professional and patient representative bodies, information from records held by social care organisations may also contribute to the ehr. in theory the ehr is therefore a combination of the bulk of the primary care epr for a patient together with linking information from other record systems for that patient. figure 3. the electronic health record after murphy et al, 1999 (7) 67 electronic health records the core of the national health information system source: heard et al (2000). the benefits and difficulties of introducing a national approach to electronic health records in australia. commonwealth department of health and aged care, australia (8). the electronic health record (ehr) is an unusual concept it is a record, a set of data but it is not accessible without a computer system to interpret it. ehr systems provide the mechanism for the communication that records from part, a feature which differentiates such systems from stand-alone medical record systems. ehr systems operate in a defined technical environment with organised and interoperable components enabling management of and efficient access to information by qualified users via a graphical and potentially interactive multimedia user interface. having launched an ehr within a system, the data within the ehr can at once be manipulated, viewed in different ways and processed into information which assists in the provision of health care. ehr systems also ensure security of the record and the confidentiality of personal health information. precisely, an ehr system is a combination of people, organizational entities, business processes, systems, technology and standards that interact and exchange clinical data to provide high quality and effective healthcare. it is made up of: mechanisms to find and uniquely identify people, providers and locations; patient-centric electronic health records (ehr); presentation solutions and intelligent agents; common services and standards to enable integration and interoperability; workflow and case management; decision support services; services to support health surveillance and research; services to ensure privacy and security; and physical infrastructure to support reliable and highly available electronic communications across defined territory. ehr architecture (ehra) represents the generic structural components from which all ehrs are built, defined in terms of an information model; i.e., it is a model of the generic features necessary in any electronic healthcare record in order that the record may be communicable, complete, a useful and effective ethico-legal record of care, and may retain integrity across systems, countries, and time, independent of the technology used to implement the ehr system (9). an open standardised ehra is the key to interoperability at the information level. the framework used for the ehra requirements comprises: structure (record organization, data organization, type and form of data, supporting health concept representation), process (clinical processes, record processes), communication (messaging and record exchange), privacy and security (privacy and confidentiality, consent, access control, data integrity, auditability of access), medico-legal aspects (support for legal requirements, actors), ethical aspects (support for ethical justification), consumer/cultural aspects (consumer issues, cultural issues) and evolution (support for ehra and ehr system evolution) (10). 68 health systems and their evidence based development an ehr infostructure (ehri) is a collection of common and reusable components in the support of a diverse set of health information management applications. it consists of software solutions, data definitions and messaging standards for the ehr (3). it is made up of: • registry systems to manage and provide peripheral information required to uniquely identify the actors in the ehr. specifically, these are the patient/person, the provider of care, and the location of care. registries which hold patient/person consent information are part of the ehri as well. • domain repositories that manage and persist subsets of clinical data that pertain to the ehr domain. a pacs system is an example of a domain repository. • an ehr system to manage and persist person-centric clinical information. • standardized common services and communication services to sustain the interoperability of the different components within the infostructure, as well as to sustain the interoperability between infostructures and with feeder or application systems. • standardized information and message structures as well as business transactions to support the storage and exchange of information in and out of the ehr. the health information access layer (hial) is an interface specification for the ehr infostructure that defines service components, service roles, information models and messaging standards required for the exchange of ehr data and the execution of interoperability profiles between ehr services (3). the hial is broken down into two layers of services: the common services and the communication bus services. the common services layer is an aggregation of services that accomplish generic functions potentially reusable for any registry, domain repository or ehr system available in a given ehri. the communication bus services layer is an aggregation of services that pertain specifically to enabling communication capabilities in a peer-to-peer, highly distributed network of ehri systems. this layer handles the receiving and sending of messages between any two systems in an ehrs. the standard of the ehr is technology neutral. this means that the ehr can be printed out and transported by a patient or other authorized person, sent as a standard hl7 message, or sent as an xml message to be integrated into the patient information system. purpose of the ehr according to iso/ts 18308 (10) primary purpose 69 electronic health records the core of the national health information system of the ehr is to provide a documented record of care which supports present and future care by the same or other clinicians. the primary beneficiaries are the patient/consumer and the clinician(s). any other purpose for which the record is used is considered secondary, as is any other beneficiary. the secondary uses are: medico-legal (evidence of care provided, indication of compliance with legislation, reflection of the competence of clinicians), quality management (continuous quality improvement studies, utilisation review, performance monitoring, benchmarking, accreditation), education (of students of the health professions, patients/consumers, and providers), research (development and evaluation of new diagnostic modalities, disease prevention measures and treatments, epidemiological studies, population health analysis), public and population health, policy development (health statistics analysis, trend analysis, case mix analysis), health service management (resource allocation and management, cost management, reports and publications, marketing strategies, enterprise risk management), bulling/finance/reimbursement (insurers, government agencies, funding bodies). principles underpinning the ehr, as defined by iso/ts 18303 (10), are : • the ehr should be timely, reliable, complete, accurate, secure and accessible and designed to support the delivery of healthcare services regardless of the model of healthcare being applied. it should interoperate in a way which is truly global yet respects local customs, language and culture. • the ehr should not be considered applicable only to patients, individuals with the presence of some pathological condition. rather, the focus should be on individual's health, encompassing both well-being and morbidity. • the ehr recognises that an individual's health data will be distributed over different systems, and in different locations around the world. to achieve the integration of data, the ehr will require the adoption of a common information model by compliant systems and the adoption of relevant international standards wherever possible. • to permit the development of meaningful ehr standards, boundaries must exist to define what is and is not regarded as part of the ehr at the time of standardization. characteristics of the ehr are according to beale et al, 2002 (11): • the ehr is patient/consumer-centred, and ideally includes information relevant to all kinds of carers, including allied health, and emergency services as well as patients themselves. 70 health systems and their evidence based development • the ehr contains observations (what occurred), opinions (decisions about what should occur), and care plans (plans for what should occur). • the level of abstraction of the ehr is generalist, that is to say, specialised information such as images, guidelines or decision support algorithms are not typically part of the ehr per se; rather interfaces exist to standards for other, specialized systems. • the ehr is a sink of diagnostic and other test data. • the ehr is a source of clinical information for human carers, decision support, research purpose, governments, statistical bureaux, and other entities. • the ehr is a long term accumulator of information about what has happened to or for the patient. therefore ehr is not: • an alternative for the detailed information concerning all diagnostic and treatment information held in local clinical systems; • the source of decision support, although it supports and extends the value of decision support systems, or • a full copy of all patient records in electronic form. building electronic health records an overview of ehr building path comes out from an excellent report done by office of technology and information highway canada. figure 4 illustrates the sequence of building the ehr. diagram depicts an oversimplified view of the ehr. to gain a more accurate appreciation of its complexity and breadth of information, one must recognize the wide range of health information sources. each time an individual visits a health care provider, data are generated. 71 electronic health records the core of the national health information system figure 4. creation of an electronic health record source: toward electronic health records. office of technology and information highway canada, 2001 (13). the following diagram, figure 5, identifies some of the sources of data for an ehr as listed by the usa institute of medicine (committee on data standards for patient safety, 2003) (12). figure 5. sources of health related data source: toward electronic health records. office of technology and information highway canada, 2001 (13). once the data have been collected, they are placed in many repositories or databases that are part of many health systems. from these systems, specific pieces of a patient's information are combined to create a core data set that is made available to other systems. the core data set includes health and administrative data. its format must be agreed to by all stakeholders. the sys72 health systems and their evidence based development tems providing the information are referred to as feeder systems (e.g. laboratory systems). other systems that use the data are called support systems (e.g. billing systems), figure 6. to provide a comprehensive ehr, these systems must be linked, thereby allowing access to patient data regardless of their physical location. this introduces another level of complexity system interoperability. figure 6. system network interoperability source: toward electronic health records. office of technology and information highway canada, 2001 (13). the figure 7 presents the conceptual overview, divided into two major sections: the left side depicts the components involved in the creation of an ehr, and the right side identifies the users and tools required to access the network. the creation of the health network (left side) involves the interaction of a person with a health care provider or health facility. the data are captured, subjected to standards and policies, and will then be stored with identifiers (person, facility and provider) as well as health and administrative data in interoperable databases. the right side of the health network illustrates how various stakeholders access the data stored in the databases by using userfriendly interfaces, security levels (to protect privacy and confidentiality) and various tools. in other words, once the requirements of an ehr are identified, an infostructure is required within which the ehr system will function. as previously stated, the ehr contains all health information generated by all the health care providers an individual interacts with over that person's lifetime. each interaction will result in an incident record that will reside in a system. when these systems become interoperable, the building of the health infostructure begins. 73 electronic health records the core of the national health information system figure 7. conceptual overview of the ehr source: toward electronic health records. office of technology and information highway canada, 2001 (13). necessary context blocks (identifiers and minimum data sets: health, administrative, medication and social data) electronic health record is the health record of an individual that is accessible online from many separate, interoperable automated systems within an electronic network. to facilitate this functionality, the proposed ehr would require next components (13): person identifier: a universal code that uniquely identifies each individual (patient, person, citizen) within the health system. facility identifier: a universal code that uniquely identifies each institution or centre that provides services within the health system. provider identifier: a universal code that uniquely identifies each health care provider within the health system. health information: health data in a standardized format (e.g. diagnosis, x-rays, prescriptions) that are the result of interactions between individuals 74 health systems and their evidence based development and their health care providers. they are generated through health events in a form of event summaries. administrative information: standardized data that support administrative functions, such as billing. as seen out of australia and new zaeland experience the core part of the ehr concept are event summaries the underlying principle of electronic health records is that a useful picture of the health of an individual can be created from knowing key details of the health events that they have been involved in (14). event summaries provide an electronic overview of a health care event, such as a visit to a general practitioner or hospital. that is, they contain only the information that is relevant to the future health and care of health consumers, such as their condition, diagnosis and treatments, rather than every detail collected during a consultation. the collection of event summaries relating to an individual over time will constitute that person's electronic health record. given the large range in potential information processing that can, and often is undertaken by individual service providers, together with the almost infinite variability in the health status and requirements of individual patients at an encounter, it might appear counter-intuitive to prescribe or specify, a priori, what information should be captured under generic circumstances. however, just as the standardization of care processes through the use of evidence-based clinical guidelines has shown beneficial outcomes, so too, can the standardization of information recording potentially show benefits. a key area of development work is the development of a framework that specifies what information should be included in event summaries and how this will be recorded. the framework should include the types of event summaries such as a health service discharge, prescription or diagnostic test result as well as defining what information is collected for such events. event summaries would also need to accommodate the provision of care for groups as well as individuals, and would need to be appropriate to all care types and settings, for example: allied health, community nursing and rehabilitation, as well as hospital based inpatient and emergency. ehr lists event summaries will provide information relevant to a specific consultation or event. it will contain details of a diagnosis or allergy identified as part of the consultation but will not include previous diagnoses or allergies. a view of the event summary will therefore not give a full picture of 75 electronic health records the core of the national health information system the health status of the consumer. ehr lists are small collections of data describing key aspects of an individual's health for which there is a benefit in maintaining and viewing together. for example, it is important that allergies and alerts are viewed together rather than as part of numerous individual event summaries. ehr lists will enable data in event summaries to be stored in a fashion that allows rapid retrieval of the desired view through eliminating the need to hunt through all event summaries to find the information needed. ehr lists will commonly form major components of ehr views. populating ehr lists will also be the means by which a consumer's initial health profile would be created. examples of ehr lists include family history, risk factors, allergies and alerts, recent events, current medications list, current diagnoses and/or conditions, list of test results, and lists of care plans (14). ehr views and reports one of the major challenges of ehr model is to present the information collected in a useful and meaningful way to the specific requestor of the information. core to the development would be the provision of a range of 'views'. views would need to differ according to the provider type specialists would be interested in different types of data to community health workers, and they will also need to differ depending on the issue being addressed. a chronological list of events would be of some, but limited, use. this simple approach would quickly overwhelm the viewer as he or she hunts through the event summaries to find the information needed. ehr model should be able to 'extract' relevant data from event summaries and present meaningful packages of information. the electronic health record lists will assist the development of key views (14). an important division in the classification of these 'views' is the distinction between 'electronic health record views' and 'electronic health record reports'. electronic health record views are designed primarily to serve the needs of the primary participants, that is, consumers and providers and contain information about an identified individual. while 'reports', on the other hand, are designed to serve the needs of secondary participants, such as managers and researchers, and would usually take the form of aggregated data. under controlled circumstances de-identified unit records could be provided for approved research. in some circumstances, an electronic health record view, that is, identified information, could be supplied to a secondary participant, for instance to a disease register where consent existed or reporting was required by legislation, or for research where a consumer has provided express consent for information to be provided. 76 health systems and their evidence based development introduction of a national health identifiers to be used only in the health care sector under strict privacy protocols and which is to be implemented concurrently with ehr system should follow the basic principle where the unified patient identification (upi) is used for clinical or administrative purposes, as well as to link records for statistical purposes, the personnel who use the upi for clinical or administrative purposes should not normally be able to access additional information on identified clients who have not consented to this access (14). development of identification systems for providers, locations/facilities and possibly items of equipment (for example, mri machines) is a part of a process which aims to identify the online security requirements for the electronic health records system such as access and usage controls. necessary building blocks (privacy, confidentiality and security; standards; telecommunication infrastructure; encouraging uptake and use of ict) (note: the following text is taken from the national electronic health records taskforce final report: „a health information network for australia". commonwealth department of health and aged care, australia, 2000 (14)) the best way to address objectives for electronic health records is to develop a general approach to health information exchange, rather than to build a structure designed just to support a system of electronic health records. this has to be achieved through putting in place the underlying 'building blocks', or infostructure components, that would be critical to underpin any national system of electronic health information interchange. infostructure may be defined as: 'information infrastructure for health that provides shared resources and standards for health care agents/parties that enable information to flow in appropriately structured, identifiable (unambiguous) and secure ways' (3). the headings that define the building blocks are: • privacy, confidentiality and security; • standards (messaging and communications, data standards, coding and classifications); • architecture; and • encouraging uptake and use of information technology. privacy is a fundamental principle underpinning quality health care. with the uptake of new technologies, such as electronic health records, it will 77 electronic health records the core of the national health information system be especially important that trust is maintained so that consumers can reap the benefits from improved information flow at the point of care, knowing that their privacy will be maintained. the objective for privacy is the establishment of a uniform data protection regime across the country to apply to personal health information a regime that enhances the privacy and respects the dignity of individuals. health privacy is currently provided by a patchwork of legislation and administrative regimes. this means that there is no uniform health privacy protection for personal health information moving between the public and private sectors or across jurisdictional boundaries. this is an increasing problem, as the boundaries between the public and private sectors become less distinct in health care provision. increasingly, single episodes of care involve multiple health care providers (such as general practitioners, diagnostic services and specialists) who may work in both the public and private sectors. it can then become unclear which privacy regime applies to any single practitioner, or any single episode of care. security and authentication specific standards and guidelines will need to be developed or modified to support the implementation of emerging policies and codes of practice for managing health information in an online environment. appropriate security measures must be put in place wherever health information is collected and stored. with the increasing use of online information and communication technologies to facilitate the timely exchange of and access to health information, it is imperative that robust security measures support these processes to maintain and strengthen consumer and provider trust. similarly, authentication measures must be in place when information is transferred or exchanged, to ensure that information is sent to the appropriate person at the correct destination. the broad objective is to develop a sound security framework which mandates security standards for the health care sector to prevent unauthorised access to, and misuse of, online health information. it is expected that this will include security standards in the following areas: • authentication of health care locations, individuals, health care workers and their roles; • access; • data management, transfer and use; • data integrity; and • system administration. 78 health systems and their evidence based development a further objective is to develop a comprehensive and coherent information security domain spanning the national health sector and incorporating the harmonisation of the security domains of major health agencies. these include public key infrastructure (pki) and health esignature authority. pki is the enabling technology that will allow for the provision of security for the online transmission of data including patient information. pki provides a security mechanism that is used to facilitate online communication between the health sector and other health agencies such as the health insurance and the national institute for health. the health esignature authority (hesa) has to be established as an independent subsidiary of health insurance to facilitate the introduction of pki in the national health sector. hesa performs essential user identity checks before issuing digital certificates. standards activities messaging and communications uniformity in messaging and communication standards and protocols, and consistent interpretation of these standards across the health sector is a crucial infostructure element. this is because information related to consumer health care is held in a variety of data formats and information structures using a range of health care computer applications as well as paper-based systems. the development and adoption of common messaging standards will assist with the communication and sharing of consumer health information between disparate systems without customised interfaces. however, to achieve interoperability, agreed and implemented messaging standards will need to be supported by a number of other 'building blocks'. these include national data definitions and domains, terminology and coding, and identifiers. for example, interoperability will be considerably more difficult if two systems are exchanging messages using different coding schemes for medication types, or different means of patient identification. achieving success with messaging interoperability nationally will thus depend on progress and outcomes of national strategies for other key standards and building blocks. standards activities data standards, classification and coding systems explicit reference terminologies are necessary to allow health care providers to communicate, undertake business and share information electronically within and across sectors. national and international data standards are necessary to describe measure and communicate concepts about a person's health in ways which are uniformly understandable across the sector, and which will safely interface to decision support technology. objectives of these activities are to: • establish a sustainable process for the national maintenance of classifications and terminologies, and mechanisms to facilitate interoperability 79 electronic health records the core of the national health information system through the use of an appropriate national reference terminology; • agree upon national classification systems for all sectors identified within the framework (taking the who family of health classifications work as a starting point); and • establish a national mechanism for the assessment and accreditation of interface terminologies in use in all health care settings. standards requirements include at least: • data definition (for example, expansion of the national health data dictionary, national minimum data sets); • health record architecture/structure (for example, good electronic health record, cen 13606, hl7 reference information model and clinical document architecture, iso/ts 18308); • coding and classification, terminology (for example, icd10, icpc 2, loinc, drg, …); • messaging and communication (for example, xml-protocol, hl7, un/edifact, corba); • identification (for example, for client, health care provider, and location); and • access control and security (encryption, public key infrastructure, security socket layer (ssl)). health information network architecture a system of electronic health records will require appropriate infrastructure on which to run. networks provide a physical channel for exchange of data between computers and have become commonplace in most settings heavily dependent on computer-aided assistance. substantial groundwork is needed to ensure that it can deliver the potential benefits to all citizens in the most cost-effective and sustainable way. for each country, it will set the agenda for component development and the information and technology systems required to support these components that will work together to implement the overall system. the objectives for architecture are the establishment of a health information network architecture comprising source systems, event summaries, storage nodes/central services, applications and access points. electronic health record: architecture and information content ehr model is conceived as an opportunity to develop and deploy basic health information infrastructure. two closely related goals of health information exchange are important to this objective: (a) interoperability that is, the ability for records to pass between or be viewed by different systems (using diffe80 health systems and their evidence based development rent technologies, software, hardware and database platforms), and still be handled consistently, and, (b) utility and uniform understandability that is, the appropriateness of and ability of the information content to be consistently interpreted across different settings, by different players, including by electronic decision-support tools without human intervention. to support these goals, and conscious of the need to maximise value adding of the information collected and stored, a crucial component is the use of standards to define the structure of the storage facilities wherever they are located. unless a standard format is used for storage the value of the network will be seriously compromised information will not be able to be shared, and the various network applications will not function. the objective of standardisation of electronic health record architecture is to maximise the benefits of distributed information processing to be realised in an environment of heterogeneous information technology resources and systems, and multiple organisational domains. the international standards organisation (iso)'s reference model for open distributed processing states that: building (distributed) systems is not easy. it requires an architecture and, because a single engineering solution will not meet all requirements, it must be a flexible architecture. moreover, since a single vendor will not have all of the answers, it is essential that the architecture, and any functions necessary to implement the architecture, be defined in a set of standards, so that multiple vendors can collaborate in the provision of distributed systems. such (architectural) standards will enable systems to be built that: • are open providing both portability and interworking; • are integrated incorporating various systems and resources into a whole without costly adhoc developments; • are flexible capable of both evolving and of accommodating the existence and continued operation of legacy systems; • are modular allowing parts of a system to be autonomous, but interrelated; • can be federated allowing a system to be combined with systems from different administrative or technical domains to achieve a single objective; • are manageable; • meet quality of service needs; • are secure; and 81 electronic health records the core of the national health information system • offer transparency masking from applications the details and the differences in mechanisms used to overcome problems caused by distribution. the advantages of a standardised ehr architecture include: • maximising the ability of information to 'self-describe' to various systems, so that dependence on highly structured, 'static' interfaces is reduced; • movement towards architectural convergence, as vendors increasingly comply with the standard, therefore increasing the ease of information interchange; • establishing a common middleware specification for ehrs; that is, an ehr interoperability platform which takes care of difficult aspects of information processing and security, and allows application developers to concentrate on high quality applications; and • the lifetime aspect of ehr will introduce the need for very long-term 'persistent' data. information holdings that have been explicitly designed ('architected') to be self-describing or 'context conscious' but which are not explicitly linked to particular technologies, have a much greater chance of persisting that is, moving into new technologies without unacceptable cost. encouraging uptake and use of information technology health care providers, who will bear the main responsibility for entering the information to form the basis of a national system of electronic health records, will need to be supported and encouraged in this vital work. this will mean assistance in acquiring the necessary hardware and software top connect to health information network, along with appropriate training and support. 82 health systems and their evidence based development benefits of electronic health records current paper-based record keeping means that valuable health information is not readily available where it is needed most at the point of clinical care. such 'information silos' inhibit major health care reforms aimed at achieving better integration and coordination of care. in this context, this concept aims to improve the flow of information across the health sector to ultimately improve the overall quality and safety of the health care system. fully developed, ehr system would enable consumer health information to be collected electronically, safely stored and exchanged between authorised health care providers, within strict privacy safeguards. some of the anticipated, key benefits of ehr system include (13): • empowerment of consumers through being able to access their own health information and therefore being able to make more informed decisions about their health care; • reductions in adverse events through providers having rapid and improved access to critical patient information held elsewhere; • improved provider access to evidence-based information at the point of care; • efficiency gains through reduced time spent accessing information, together with reductions in unnecessary duplication of tests; • better care coordination across the continuum through improved information flow between providers and services; and • providing an invaluable evidence base for informing health care policy, planning and research activities, leading ultimately to more effective and efficient health care delivery nationally. in addition to the obvious and vital benefits to individual consumers and their providers, better clinical information has an important role in securing long term benefits for all through improved policy, planning and management of the health system. despite the myriad of different data collections that exist, there is still relatively little information readily available about how well any health care system actually delivers care, or the extent to which it actually improves health outcomes. the following table summarizes some of the potential benefits to different stakeholders (13). 83 electronic health records the core of the national health information system table 1. stakeholder's benefits source: toward electronic health records. office of technology and information highway canada, 2001 (13). difficulties and risks associated with electronic health records however, while the benefits of ehr system are both readily accepted and understood by consumers, providers and policymakers, there are risks and barriers that would need to be addressed in implementing an initiative on the scale of ehr system. as evidenced by other's experiences, successful implementation of ehr system would require commitment at all levels of the health care system from the end users right through to heads of government. failure to obtain such commitment is likely to result in fragmentation and lack of connectivity across the health sector. in broad terms, issues to be overcome include (14): 84 health systems and their evidence based development stakeholders potential benefits public expanded reach of effective health care, more secure information, improved sense of well-being, access to information about how the health care system works patients or their representatives improved health care and decreased risks (e.g. adverse drug reactions), integrated health services, do not have to repeat basic information, such as name, address increased confidence knowing that all health care professionals have access to all relevant parts of their medical history, access to their own health records helps patients to make informed decisions about their health, avoidance of duplicate, invasive and/or expensive tests, reduced waiting lists health professionals integrated view of patient data, increased access to other related and integrated patient information, improved access through a portal to related health services, improved decisions with up-todate patient information on an as-needed basis, improved seamless care through the coordination of multi-professional and multi-agency care, improved development of decision support systems health administrators increased patient care time, access to data to support clinical governance and local planning, reduced health care costs, improved health care quality policymakers (including governments) improves effective health maintenance and education, supports medical and administrative decision-making processes, provides for improved long-term planning researchers (including governments) access to timely high-quality data for research, access to up-todate research findings, treatment and medication options, improved data quality, to aggregate data, allows for improved trend analysis governments improved accountability, improved health resource allocation • concerns about privacy, security and confidentiality of information in the system; • gaining the acceptance of health professionals and other users; • actual implementation; • technical issues; and • level of investment and political commitment required. to address these issues (privacy, security and confidentiality of information in the system) would require a multi-layered approach to privacy and security, including both legislative and technical mechanisms for ensuring a robust privacy framework is in place for ehr system. key to achieving acceptance of health professionals and other users includes: involving end users at all stages of development to ensure that ehr system meets user requirements providing education, training and support as part of an appropriately resourced, overarching change management strategy; and addressing identified medicolegal issues ahead of implementation. when actual implementation is in question and having the rapidly changing health information environment, cooperation between the major parties, particularly state and district governments, is crucial to successful implementation of ehr system. sustaining national cooperation requires adequate resorting in terms of both governance and project management. other such risks to be addressed include: ensuring the ehr system design integrates with work practices; developing sustainable registration and identification processes; and ensuring standards development is given sufficient priority. technical issues include: lack of provider infrastructure, support and expertise; provider system changes too complex; internet reliability; insufficient or absent standards leading to greater maintenance effort once ehr system has been implemented; and poor management resulting in a flawed technical solution. the level of funding made available for ehr system will determine the speed of implementation. 85 electronic health records the core of the national health information system national approaches: examples a number of countries and regions (in the case of europe) have embarked on electronic health record initiatives. the european, as well as australian and new zealand experience, has been driven by the high percent of physicians who use computers in their practice for example, over 90% of general practitioners in the netherlands and the uk up to 58% in portugal and 43% in greece. the high use of computers by physicians in europe and australia has been supported by legislation and financial incentives. only recently has the focus turned to hospital and regional ehr implementations. the north american experience has had a different starting point from europe in hospitals rather than physician offices. this is in large part due to the large investment in commercial hospital-based information systems in north america and less focus on general practitioners. in developing countries the key initiatives come from government and cover an introduction of health management information systems. but it is recognized that they should have a strong patient-centered orientation. for that reason they implicitly are looking for an electronic health record as a building block. for countries in transition which generally are covered with amazing flow of health data, mostly in paper form, with well established health and social rights, but unfortunately with lack of money, informatization is seen as a one of the best infrastructure steps in overcoming the current situation. the most notable electronic health record initiatives include (compiled mostly from: health connect program office. international approaches to electronic health record. department of health and ageing. commonwealth of australia. 2003. www.healthconnect.gov.au and canada health infoway. ehrs blueprint – an interoperable ehr framework. version 1.0. 2003. http://knowledge.infoway-inforoute.ca): • europe good european health record project, medirec, prorec initiative (for more information see: electronic health records and communication for better health care. proceedings of eurorec 2001. ed. mennerat f. ios press 2002, and also www.chine.ucl.ac.uk/health/gehr and www.cenorm.be) • united kingdom information for health, erdip (electronic record development and implementation programme). see: www.nhsia.nhs.uk/erdip 86 health systems and their evidence based development • the netherlands see: kieke, o 2002, 'experience with information technology in dutch health care: promises and pitfalls, global insights seminar', healthlink, november 15-18, 2002, monterrey, california. • sweden see: taylor, h and leitman, r (eds) 2002, 'european physicians especially in sweden, netherlands and denmark lead us in use of electronic medical records', harris interactive healthcare news, vol. 2, issue 16. • denmark see: lippert s, kverneland a. the danish national health informatics strategy. in: the new navigators from professionals to patients. r. baud et al. (eds). ios press 2003, and also at www.im.dk/index/dokumentoversigt.asp • ireland see: information for action. a national health information strategy for 2002-2009. a consultation document. draft 1. department of health and children. 2001. • new zealand see www.nzhis.govt.nz • australia see www.health.gov.au/healthonline, www.gehr.org, www.healthconnect.gov.au, and next documents: department of health and aged care 2000, a health information network for australia, report to health ministers by the national electronic health records taskforce, department of health and ageing, canberra, viewed at http: //www.healthconnect.gov.au/pdf_docs /ehr_rep.pdf; national electronic health records taskforce 2000, a health information network for australia: report to health ministers, department of health and aged care, canberra, viewed at http://www.healthconnect.gov.au/pdf_docs/ehr_rep.pdf • hong kong see: yeoh, ek. secretary for health and welfare, hong kong, health services, policy objective and key result areas, a t : w w w. p o l i c y a d d r e s s . g o v. h k / p a 0 1 / p d f / h e a l t h e . p d f , www.hwfb.gov.hk/hw/english/archive/consult/hcs/hcs.htm and www.info.gov.hk/hwb • united states see www.iom.edu • canada see www.hc-sc.gc.ca/ohih-bsi and http://knowledge. infoway-inforoute.ca • south africa see www.uneca.org/aisi/health1.htm and www.angelfire.com/ok3/peaceportal/telehealth.html 87 electronic health records the core of the national health information system • brazil see: lemos, m and de faria leao, b 2003, 'the brazilian national health card project, ni2003: proceedings of the 8th international congress', nursing informatics 2003, june 20-25, 2003, rio de janeiro, brazil. 88 health systems and their evidence based development exercise: ehr development data storage, data privacy and security task 1: data storage electronic health record (ehr) is representing personal health information in electronic form, which are following the patient from birth until death. in ehr information about health events contacts of the patient/consumer with primary health care, are combined with health events information about patient's contacts with all other health care levels. ehr is usually based on individual or family data, authorised health care professional is filling necessary information in ehr, and some of these information afterwards can be aggregated and distributed to other predefined ehr users, participants in the system. ehr is promoting data exchange about patient on higher level, so that health care professionals can communicate easily, everyday contacts between patient/consumer and doctor/provider are facilitated, accuracy of documents is upgraded, efficacy and quality of health care is also promoted, and, above all, infrastructure for decision making can be built, in the sence of evidence based decision making, based on information stored in electronic form. students should fill in the questionnaire and then discuss their attitudes in small groups, with presentation of summary in the plenary session. in this questionnaire data are listed to be included in electronic health record (ehr). some data in ehr are permanent, long-life data, since others are changeble they can be stored for one year period maximum. please, mark with x which data can be permanent / changeble, according to your experience: 89 electronic health records the core of the national health information system information type information storage period non-relevant information for ehr permanent up to 1 year identification information (date, time, place, sex on birth, blood group) administrative data: • family name, middle name, name • date and place of birth, sex • address and phone number • iso country code • compulsory insurance • name of employees establishment • professional code no • register no 90 health systems and their evidence based development • health insurance booklet no • validity date • insurance legal basis • voluntary insurance • type of insurance • chosen doctor • medical documentation no • organ / body donor • ehr status • other (please, specify): social data: • marriage status • number of children, occupation • education • living conditions • occupational status • social support • invalidement • child family social status • life style (smoking, alcohol) • other (please, specify): medical data: • drug allergies, vaccinations and serum if received • congenital anomalies • chronically diseases • active form of tbc • professional diseases • surgeries performed • current therapy (insulin, dialisys) • other (please, specify): general practitioner: • electronic provider / consumer identification • date, time and place reason for event • diagnosis: current principal • intervention • immunisation • referrals • prescription • appointments • other (please, specify): 91 electronic health records the core of the national health information system ambulatory care: • electronic provider / consumer identification • date, time and place • reason for event • diagnosis: current principal • pathology results • intervention • referrals • appointments • other (please, specify): hospital: • electronic provider / consumer identification • date, time and place • diagnosis: principal secondary, additional and complications • injury (at work, place, cause of injury) • pathology results • therapy (drugs, surgery procedures, rehabilitation,recommendation) • result of care healthy transfer in other hospital transfer on rehabilitation • death time of death cause of death autopsy result • other (please, specify): current medication list: • date started to take drugs • name of drug(s) • dosage of drug(s) • other (please, specify): list of recent pathology, radiology and laboratory test results: • only the test results available in electronic form • other (please, specify): task 2: ehr data privacy and security students will fill in the questionnaire and then discuss the possibilities in their own countries to implement ehr. 1. according to you, is it necessary to establish ehr under special legislative frame? yes no 2. according to recent legislative in health care system, it is very important to keep privacy and security of patient/health care consumer. approach to data in ehr can be regulated on different levels. some information can be available only to gp, some of them can be available to gp and to ehr owner patient, and some of them are available to other ehr users (doctor specialist, pharmacist, health insurance fund, social insurance fund, ministry of health, institute for public health). please, mark with x in the table / field below who can approach to data in ehr, according to you: 92 health systems and their evidence based development information type ordinated gp ehr owner (patient, consumer) doctor specialist in second health care level others (pharmacist, insurance, ministry, inst. for public health) identification data administrative data social data medical data current therapy recent laboratory, radiology test results glossary of key terms note: the following terms are defined according to the canada health infoway inc. (2003) (3). ehrs blueprint – an interoperable ehr framework, version 1.0. available at: http://knowledge.infowayinforoute.ca access control a security technology that selectively permits or prohibits certain types of data access based on the identity of the accessing entity and the data object being accessed. a process that determines who is given access to a local or remote computer system or network, as well as what and how much information someone can receive. architecture – 1. a software architecture is an abstraction of the run-time elements of a software system during some phase of its operation. a system may be composed of many levels of abstraction and many phases of operation, each with its own software architecture. 2. architecture is a term applied to both the process and the outcome of specifying the overall structure, logical components, and the logical interrelationships of a computer, its operating system, a network, or other conception. 3. the software architecture of a program or computing system is the structure or structures of the system, which comprise software components, the externally visible properties of those components, and the relationships among them. authentication in computer security, the act of identifying or verifying the eligibility of a station, originator or individual to access specific categories of information. in data security, a measure designed to provide protection against fraudulent transmissions by establishing the validity of a transmission, message, station or originator. in data security, processes that ensure everything about a teleprocessing transaction is genuine and that the message has not been altered or corrupted in transmission. in computer security, the process that verifies the identity of an individual as established by an identification process. in data security and data communications, both the prevention of undetected alteration to data and peer entity (mutual verification of each other’s identities by communicating parties) authentication. a process verifying that users are who they say they are. an example of authentication is requiring users to identify themselves with a password. authorization – 1. process of determining what activities are permitted, usually in the context of authentication. 2. the permission to perform certain operations or use certain methods or services. 3. the process that grants access to a local or remote computer system, network or to online information. business architecture defines the organization and functions of the business and the business processes that support those functions. business process a set of interacting activities that produce one or more products or services for customers of the business enterprise. clinical data any information element obtained during an encounter relating to the assessment of a client’s health state, diagnostic of diseases and/or treatments. clinical data repository an operational data store that holds and manages clinical data collected from service encounters at the point of service locations (e.g. hospitals, clinics, etc.). data from a cdr can be fed to the ehr for that client, in that sense the cdr is recognized as a source system for the ehr. clinical information system a clinical information system is a system dedicated to collecting, storing, manipulating and making available clinical information important to the delivery of healthcare. clinical information systems may be limited in scope to a single area (e.g. lab system, ecg management system) or they may be comprehensive and cover virtually all facets of clinical information (e.g. electronic patient/person the original discharge summary residing in the chart, with a copy of the report sent to the admitting physician, another copy existing on the transcriptionist’s machine, etc.) clinically relevant data any clinical data about a client that is deemed necessary or desirable to have available during an encounter. relevance is expressed in relation to different perspectives set by factors such as disciplines in healthcare practice or context around an episode of care or elapsed time. therefore relevance of data varies greatly and is hard to assess firmly. 93 electronic health records the core of the national health information system coding the process of assigning an alphanumeric code to a concept in accordance with an agreed classification system e.g. icd10 (international classification of disease version 10). conceptual architecture – 1. a general design that indicates the overall intent and outline of the target architecture, architecture lays the foundation and defines the process that will be used to develop the target architecture. 2. a conceptual architecture describes or defines a technology solution at the functional level, without regard to a particular physical implementation. the conceptual architecture is used to create a comprehensive view of the system components, relationships, and interfaces needed to meet a technology requirement. confidentiality – 1. a security technique that permits read access and retrieval by authorized entities only. 2. confidentiality protects the privacy of information being exchanged between communicating parties. in computer security, a concept that applies to data that must be held in confidence and that describes the status and degree of protection that must be provided for such data about individuals as well as organisations. consent explicit granting of access to specified information. continuum of care a holistic approach to healthcare delivery across multiple providers, aiming to improve the quality of care and promote wellness. data model describes the organization of data in an automated system. the data model includes the subjects of interest in the system (or entities) and the attributes (data elements) of those entities. it defines how the entities are related to each other (cardinality) and establishes the identifiers needed to relate entities to each other (primary and foreign keys). a data model can be expressed as a conceptual, logical, or physical model. data warehouse a database of information intended for use as part of a decision support system. the data is typically extracted from an organization’s operational databases. database management system systems that manage large structured sets of persistent data, offering ad hoc query facilities to many users. they are widely used in business applications: commercial examples include db2, oracle, sql-server, sybase etc. decision support system software that taps into database resources and massages and presents data to assist users in making business decisions. a clinical decision support system gives physicians structured (rules-based) information to help make decisions on diagnoses, treatment plans, orders and results. de-identified data data are termed ‘de-identified’ when an individual’s identity is not apparent, and cannot reasonably be ascertained by the user, from the record elements. guidelines for de-identification and the use of de-identified information will be required. digital certificate a digital document issued by a certification authority that contains the holder’s name, serial number, public key and the document’s expiration date. digital certificates are used in public key infrastructure to send and receive secure, encrypted messages. digital signature an electronic equivalent of a signature used to verify authorship or information source. domain data clinical data that is specific to a particular domain. (e.g. drug, lab, diagnostic imaging, etc.) domain repository a domain repository is a component of an ehri that stores, maintains and provides access to specific clinical subset of data at a jurisdictional level. the key data domains recognized as part of an ehr are drugs, laboratory and diagnostic imaging. in canada today, some of these data domains may be already deployed as jurisdictional level systems in given jurisdictions. an ehr infostructure must be able to assemble information transparently from these domains in order to provide the complete clinical picture of a patient/person. ehr – data. the collection of all important clinical data related to a particular patient/person. 94 health systems and their evidence based development ehr infostructure collection of common and reusable components in the support of a diverse set of health information management applications. it consists of software solutions for the ehr, data definitions for the ehr and messaging standards for the ehr. electronic health record 1. an electronic health record (ehr) provides each individual in country with a secure and private lifetime record of their key health history and care within the health system. the record is available electronically to authorized health care providers and the individual anywhere, anytime in support of high quality care. 2. in an ehri, the ehr is the central component that stores, maintains and manages clinical information about patients/persons. the extent of the clinical information sustained by the ehr component may vary based namely on the presence or absence of domain repositories in any given jurisdiction. electronic health record system combination of people, organizational entities, business processes, systems, technology and standards that interact and exchange clinical data to provide high quality and effective healthcare. electronic patient record electronic set of information about a single patient/person. an electronic patient record system is a system specifically designed to provide patient/person records electronically. this is not necessarily restricted to a single clinical information system. encounter an encounter is a service event that occurs within an episode of care. enterprise architecture a framework that defines the overall structure of a business. it uses different perspectives or views such as business processes, information, systems and technology required to operate a business. enterprise master patient index / enterprise master person index an empi (enterprise master person index) is a system which coordinates client identification across multiple systems namely by collecting and storing ids and person-identifying demographic information from source system (track new persons, track changes to existing persons). these systems also take on several other tasks and responsibilities associated with client id management. episode of care an encounter or series of encounters related to the detection and subsequent care for a particular healthcare requirement. extensible mark-up language xml is a mark-up language for structuring arbitrary data based on element tags and attributes. describes a class of data objects called xml documents and partially describes the behavior of computer programs which process them. xml is an application profile or restricted form of sgml, the standard generalized mark-up language [iso 8879]. by construction, xml documents are conforming sgml documents. facility a type of delivery site that has constant capability and capacity to provide health services, and is administered by a health service organization. feeder systems operational systems that will feed patient/person data to the ehr in the form of realtime single, multiple messages or batch file uploads. file transfer protocol – 1. a standard high-level protocol for transferring files of different types between computers over a tcp/ip network. ftp can be used with a command line interface or graphical user interface. 2. the name of a utility program available on several operating systems which makes use of this protocol to access and transfer files on remote computers. framework in object-oriented systems, a set of classes that embodies an abstract design for solutions to a number of related problems. frameworks can be horizontal or vertical. an example of a horizontal framework is the presentation framework (gui); and example of a vertical framework is a business accounting framework. health information access layer the health information access layer is an interface specification for the ehr infostructure (osi layer 7) that defines service components, service roles, information model 95 electronic health records the core of the national health information system and messaging standards required for the exchange of ehr data and execution of interoperability profiles between ehr services. identifiable data data are termed ‘identifiable’ when an individual’s identity is readily apparent, or can reasonably be ascertained by the user, from the record elements. identification a person identifier is a universal code that uniquely identifies each individual of consumers, within the health system. such an identifier can be simply assigned or based providers, locations/ on some unique characteristic of the individual (called biometric identification) facilities and devices. similarly providers, facilities, individual devices and the location of the point of care may all have to be capable of unequivocal identification to guarantee the integrity of a system of electronic health records. implementation implementation is the carrying out, execution, or practice of a plan, a method, or any design for doing something. implementation is the action that must follow any preliminary thinking in order for something to actually happen. information model a structured specification of the information requirements of a project. an information model expresses the classes of information required and the properties of those classes, including attributes, relationships, and states. examples are the domain reference information model, reference information model, and refined message information model. infostructure this is a concatenation of the phase information infrastructure. it covers both physical (e.g. computers and cables) and abstract (e.g. standards, data sets, terminologies, workforce capacity) infrastructure elements. internet the internet is behind much of the explosive growth in data communications. often characterised as a network of networks, the internet is a set of protocols for enabling computers to connect and communicate with each other. viewed in another way, it is like a communications platform that enables a range of other, internet-specific programs to run. a major stimulus to growth in recent years has been the universal adoption of the hypertext transport protocol (http) and the easy-to-use web browsers that emerged to exploit it. indeed, so ubiquitous is web-browsing-based internet usage that for many people the internet and the world wide web are synonymous. indeed, given the ability of web-browsers to emulate a wide range of more function-specific client programs (e.g. email), many other internet programs have, fact, been absorbed into browser-based functions. the internet was not originally designed with businesses in mind. it lacks the technology required for secure business communications and transactions. a worldwide system of computer networks. networks connected through the internet use a particular set of communication standards, known as tcp/ip, to communicate. interoperability – 1. the ability of hardware and software from different vendors to understand each other and exchange data, either within the same network or across dissimilar networks. 2. the ability of autonomous systems to work with other dissimilar systems. interoperable systems interact through standardized interfaces. they are often loosely coupled and exchange information in an asynchronous manner. interoperable systems can function without knowing the internal processes, functions, and data representations of other systems. the ability of two or more systems to exchange information or function together. iso international organization for standardization. note that iso is not an acronym; instead, the name derives from the greek word „isos” which means equal. founded in 1946, iso is an international organization composed of national standards bodies from over 75 countries. for example, ansi (american national standards institute) is a member of iso. iso has defined a number of important computer standards, the most significant of which is perhaps osi (open systems interconnection), a standardized architecture for designing networks. logical observation identifiers, names and codes a database protocol aimed at standardizing laboratory and clinical codes for use in clinical care, outcomes management and research. developed by the regenstrief institute for health care, loinc is touted as a middleman solution to potential translation problems between labs that use hl7 reporting and recipient systems that may not be able to translate such data. 96 health systems and their evidence based development longitudinal involving the repeated observation or examination of a set of subjects over time with respect to one or more study variables (as general health, the state of a disease, or mortality). longitudinal record patient/person centric electronic health information spanning from the earliest event to the most recent encounter. message a package of information communicated from one application to another. messaging the activity and associated processes of sending or receiving a message. metadata data about data. metadata describes how and when and by whom a particular set of data was collected, and how the data is formatted. metadata is essential for understanding information stored in data warehouses. data definitions describing aspects of the actual data items, such as name, format etc. middleware software systems that facilitate the interaction of disparate components through a set of commonly defined protocols. the purpose is to limit the number of interfaces required for interoperability by allowing all components to interact with the middleware using a common interface. model a representation of a problem or subject area that uses abstraction to express the relevant concepts. a model is often a collection of schema and other documentation. modularity the design goal of separating code into self sufficient, highly cohesive low coupling pieces. network in information technology, a network is a series of points or nodes interconnected by communication paths. networks can interconnect with other networks and contain sub-networks. nodes in a network, a node is a connection point, either a redistribution point or an end point for data transmissions. in general, a node has programmed or engineered capability to recognise and process or forward transmissions to other nodes. openehr openehr, formerly known as the good electronic health record, provides an open architecture and a standard format for electronic health records. open source software open source refers to any program whose source code is made available for use or modification as users or other developers see fit. oss is developed as a public collaboration and made freely available. definition model of distribution terms require that: (1) the software must be redistributed without any restriction, (2) the source code must be made available (3) the license can require improved versions of the software to carry a different name or version from the original software. linux is the most common form of oss. open systems interconnection a seven-layer reference model developed by iso as a framework for the development of standards for interconnecting heterogeneous computers. the layers from the top are application, presentation, session, transport, network, data link and physical. person centric/patient centric a design goal or characteristic that establishes that all information in an application system shall be grouped and/or indexed according to the patient/person. person centric patient centric. privacy freedom from intrusion into the private life or affairs of an individual when that intrusion results from undue or illegal gathering and use of about that individual.the right of an individual to live free of intrusive monitoring of their personal affairs by third parties not of their choosing. privacy enhancing technologies technologies used to protect privacy rights and secure transactions on the internet or other networks. it includes methods such as encryption, digital signatures and digital certificates as well as both private and public key methods encryption environments. provider any supplier of a healthcare service. provider registry a provider registry is a system or a combination of systems where a health care 97 electronic health records the core of the national health information system provider’s information (i.e. name, address, practice licences, etc…) is securely stored, maintained and made available to other systems and users. public key infrastructure the architecture, organization, techniques, practices and procedures that collectively support the implementation and operation of a certificate based public key cryptographic system. public key public key infrastructure (pki) is a set of procedures and technology that infrastructure (pki) enables users of a network such as the internet to authenticate identity, and to securely and privately exchange information through the use of public key cryptography. to achieve this, public and private keys and a digital certificate can be obtained through a trusted third party authority, known as a certification authority (ca). the ca links the public key to the digital certificate and vouches for the identity of the key holder. in order for the system to operate, a process must be established to accurately identify a person via something like a 100 point test. registration authorities (ras) undertake this role by collecting and managing the appropriate levels of evidence of identity (eoi) from applicants for digital certificates. dependent upon the pki business model employed, appropriately accredited ras may also create keys and certificates. the use of pki ensures authentication, integrity, non-redudiation and confidentiality for e-commerce applications. reference architecture generalized architecture of several end systems that share one or more common domains. the reference architecture defines the infrastructure common to the end systems and the interfaces of components that will be included in the end systems. the reference architecture is then instantiated to create a software architecture of a specific system. the definition of the reference architecture facilitates deriving and extending new software architectures for classes of systems. a reference architecture, therefore, plays a dual role with regard to specific target software architectures. first, it generalizes and extracts common functions and configurations. second, it provides a base for instantiating target systems that use that common base more reliably and cost effectively. registration authority a registration authority is an authority in a network that verifies user requests for a digital certificate and tells the certificate authority (ca) to issue it. ras are part of a public key infrastructure (pki), a networked system that enables companies and users to exchange information and money safely and securely. registry directory like system that focuses solely on managing data pertaining to one conceptual entity. in an ehri, registries store, maintain and provide access to peripheral information not categorized as clinical in nature but required to operationalize an ehr. the primary purpose of a registry is to respond to searches using one or more pre-defined parameters in order to find and retrieve a unique occurrence of an entity. examples of registries include: client registry, provider registry, location registry, and consent registry. scalability the ability to support the required quality of service as load increases. security the ability to ensure that information is neither modified nor disclosed except in accordance to the security policy. security architecture a plan and set of principles for an administrative domain and its that describe the that a system is required to provide to meet the needs of its users, the system elements required to implement the services, and the performance levels required in the elements to deal with the threat environment. a complete security architecture for a system addresses administrative security, communication security, computer security, emanations security, personnel security, and physical security, and prescribes security policies for each. complete security architecture needs to deal with both intentional, intelligent threats and accidental threats. security architecture should explicitly evolve over time as an integral part of its administrative domain’s evolution. systems architecture describes how the business process models defined in the business architecture can be implemented from a systems (data, applications and technology) perspective. technical architecture – 1. a technical architecture identifies and describes the types of applications, platforms, and external entities; their interfaces; and their services, as well as the context within which the entities interoperate. the technical architecture is the basis for selecting and implementing the infrastructure to establish the target architecture. 2. the specific code plans to build an it solution is called the technical architecture. it is the it „blue print” of the planned technical roll out. 98 health systems and their evidence based development virtual private network refers to a network in which some of the parts are connected using the public internet, but the data sent across the internet is encrypted, so the entire network is „virtually” private. a vpn is a data network that adds certain quality-of-service features, at least network (vpn) privacy and security, to the internet. an internet-based system for information communication and enterprise interaction. a vpn uses the internet for network connections between people and information sites. however, it includes stringent security mechanisms so that sending private and confidential information is as secure as in a traditional closed system. web services an application capable of being defined, located via the internet protocol, and interacting with other software applications, identified by a uniform resource identifier. web services description language provides a model and an xml format for describing web services. wsdl enables one to separate the description of the abstract functionality offered by a service from concrete details of a service description such as „how” and „where” that functionality is offered. 99 electronic health records the core of the national health information system references 1. serbian health information system committee (2002). building information core national health information system. belgrade: ministry of health, republic of serbia. 2. the boston consulting group (2004). final report on national health information management and information & communications technology strategy. 3. canada health infoway inc. (2003). ehrs blueprint an interoperable ehr framework, version 1.0. available at: http://knowledge.infoway-inforoute.ca 4. mennerat f (2002). welcome at eurorec 2001. in mennerat f, ed. electronic health records and communication for better health care, proceedings of eurorec 2001, amsterdam: ios press. 5. dick r, steen e (1997). the computer-based patient record: an essential technology for health care. national academy press, washington, usa. 6. royal college of general practitioners health informatics taskforce (1998). scopeepr. rcpg. available at: www.schin.ncl.ac.uk/rcgp 7. murphy g, hanken am, waters ka (1999). electronic health records: changing the vision. w.b. sanders company, philadelphia. 8. heard s, grivel t, schloeffel p, doust j (2000). the benefits and difficulties of introducing a national approach to electronic health records in australia. report to the electronic health records taskforce. commonwealth department of health and aged care, australia. 9. iso/tc 215 technical report electronic health record definition, scope and context. third draft, december 2003. 10. iso/ts 18308:2003 health informatics requirements for an electronic health record architecture (18-05-2003). 11. beale t, heard s, kalra d, lloyd d (2002). the openehr technical roadmap. revision 1.2. the openehr foundation. 12. committee on data standards for patient safety (2003). key capabilities of an electronic health record system. board on health care services. institute of medicine. the national academies press, washington, d.c. 13. office of technology and information highway canada (2001). toward electronic health records. 14. national electronic health records taskforce, (2000). a health information network for australia. commonwealth department of health and aged care, australia. recommended readings 1. dick rs, steen eb, detmer de, eds (1997). the computer-based patient record: an essential technology for health care. iom, national academy press, washington. 2. mennerat f (2002). electronic health records and communication for better health care, proceedings of eurorec 2001, amsterdam: ios press. 3. shortliffe eh, perreault le (2001). medical informatics – computer apllications in health care and biomedicine. second edition. new york: springer-verlag. 4. van bemmel jh, musen ma (1997). handbook of medical informatics. new york: bohn stafleu van loghum, and springer-verlag. 100 health systems and their evidence based development 101 health indicators and health reporting health systems and their evidence based development a handbook for teachers, researchers and health professionals title health indicators and health reporting module: 1.4 ects (suggested): 0.50 author(s), degrees, institution(s) doris bardehle, private lecturer, dr. med. address for correspondence universität bielefeld, fakultät für gesundheitswissenschaften, arbeitsgruppe epidemiologie & medizinische statistik, universitätsstraße 25, 33 615 bielefeld germany e-mail: doris.bardehle@loegd.nrw.de keywords health indicators, health indicator sets, health reporting, hfa 21, new public health programme of the european union learning objectives at the end of the module, the students should be familiar with: • public health-oriented health data and their interpretation; • different kinds of indicator sets; • definition/characteristics of basic indicators; • use of indicators for health reporting; • use of indicator sets for policy-making. abstract this topic covers: different indicator sets; classification and evaluation methods of indicators; comparison methods and benchmarking; the use of health indicators for health reporting and health policy. teaching methods the recommended teaching method is: • study of literature and available health indicator databases in small groups (3-4 students) • guided discussion of a health indicator set for a certain region (examples) • use and presentation of health indicators in a health report • exercise: to collect data from public health databases, to prepare a health report on one topic for a certain region (e.g see or cee countries) specific recommendations for teachers it is recommended that this module be organized within 0.50 ects credit. the work under supervision consists of lecturing and use of the hfa database, while individual work will comprise the selection of a set of indicators from the hfa database and use of the data for health reporting and health policy. each of the students or at least two students need a pc with internet-connection. data on health statistics and software must be available. assessment of students essay on priority setting based on indicator analysis for a certain country/region. health indicators and health reporting doris bardehle classification and evaluation method of indicators this lecture follows the lines of the documents of who, regional office for europe, and of the european union, based on the new public health programme (2003-2008) and the former health monitoring programme (hmp): • new public health programme 2003-2008: action programme of the european union in the field of public health for the year 2003 (1). • „set of community health indicators (echi i)” of the european commission (2). • „catalogue of health indicators” of the hfa 21 health for all strategy (3). • „health interview survey” of who, regional office for europe (4). • „common minimum indicator set”. who europe. regions for health network (5). • „establishment of a set of mental health indicators for the european union” (6). • „reproductive health indicators for global monitoring”. who geneva (7). • „minimum health indicator set for ph-see countries”. final report (8). the types of different indicator sets a design for a „set of community health indicators (echi i)“ was developed by the european commission under the health monitoring programme (hmp) which contributes to the establishment of a community health monitoring system in order to: 1. measure the health status, its determinants and trends throughout the community; 2. facilitate the planning, monitoring and evaluation of community programmes and actions; 3. provide member states with appropriate health information to make comparisons and support their national health policies (2, p.5). the new public health programme of the eu replaces all former public health programmes. it will focus on three types of activity: 1. to improve the quality and transparency of health information; 2. to improve current abilities to respond rapidly to health threats; and 3. to find effective ways to tackle health determinants – the underlying causes of disease (9, p.1-3). 102 health systems and their evidence based development the new public health programme will provide policy makers, health professionals and the general public with the key health data and information that they need. the programme will primarily transmit and act on new information about health threats that require immediate action to prevent further harm. instead of concentrating on specific diseases, actions addressing health determinants will tackle the root causes of diseases or „health determinants” through effective health promotion and disease prevention measures. under the health monitoring programme, the european community health indicators (echi i) project was developed. under the new public health programme, the echi project will be continued and a final version be expected (echi ii). with regard to the preparation of the „health 21 – health for all strategy for the 21st century”, the development of a new „catalogue of health indicators” was started by who. meanwhile this catalogue has been published and contains around 200 indicators (3). indicators on reproductive health developed by who geneva relate to the health indicators’ methodological concept of who, too (7). eurostat, the statistical office of the eu is responsible for coordinating health statistics as causes of death statistics, health interviews and health examination surveys and health care data groups. population data are included in the new cronos database. via a public health portal (controlled by the commission services), health data will be presented within the eu public health information network and include databases such as euphin hiems which was established under the hmp programme and continued under the new public health programme (1). one of the sources of health indicators is the health interview survey (who europe, 1996) and the health examination survey, which have meanwhile been internationally harmonized in terms of methods and instruments used (4). meanwhile the database of health surveys conducted in the eu member states is available on the internet at url: http://www.iph.fgov.be/hishes. the survey methods, the content of the questionnaire and the examination protocol are available through the database and can be compared from one country to another. with the support of eurostat the inventory will now be extended to include the candidate countries. measurement and reporting of health conditions and actions for health improvement through „internationally agreed” indicators have been a favorite strategy of international organizations. who used this concept for promoting the health for all concept strategy (see health indicators for hfa 2000 and hfa21 (r1 and r2)). the result has been a long list of indicators to be collected by the countries and to be delivered to international organizations. the development of a minimum data set of european mental health indicators was the result of a two-year action project, aimed at establishing mental health indicators in europe, coordinated by stakes (finland) (1999-2000). under the health monitoring programme, a subset of health indicators was developed in the field of mental health indicators, published in 2002 and based on the same rules as the echi i indicator set (6). 103 health indicators and health reporting a list of 36 indicators was developed and proposed for usage in europe. the 36 indicators are divided into the following main domains: 1. demographic and socio-economic factors 2. health status 3. determinants of health 4. health systems to determine the volume of essential health indicators for monitoring the health status and health system performance lies within the responsibility of each country and has to be done in accordance with specific health policies. now new proposals have been made for health indicator sets issued by who, the eu countries and organizations which make it difficult to select a defined indicator set to be used (7,8,10,11,12). it is not proven which indicators are useful and feasible for the national health programmes’ management process. within the framework of the stability pact, a minimum indicator set was developed for the south eastern european countries which started in 2001 (8). the draft of the minimum indicator set was based on the experience made collected with the common minimum indicator set (cmis) of the regions for health network, who-euro, agreed with 8 european regions in 1999 and selected from a list of 224 indicators for the who hfa 21 strategy (5). the indicators for the pilot testing carried out in 2002 covered: • the socio-demographic profile (percent of population aged 65+ years), • mortality (life expectancy at birth, in years, males/females; infant mortality rate; maternal deaths, all causes; standardised death rate-sdr, circulatory system diseases, all ages, males/females; sdr malignant neoplasms, all ages, males/females; sdr external causes injury and poison, all ages, males/females; sdr infectious and parasitic diseases, all ages, males/females) • morbidity (number of newly diagnosed tuberculosis cases, all forms; number of decayed, missing or filled teeth at age 12) • environment (percent of population whose homes are connected to water supply system, total; percent of population with access to hygienic on sewage disposal, total) • health care resources indicators,(number of primary health care units per 100,000 population; number of hospital beds per 100,000 population; number of physicians per 100,000 population; number of general practitioners in phc per 100,000 population; number of dentists per 100,000 population; number of nurses graduated per 100,000 population) • health care utilisation and costs (average length of stay, all hospitals; total health expenditures as percent of gross domestic product) • maternal and child health (percent of infants vaccinated against diphthe104 health systems and their evidence based development ria; percent of infants vaccinated against tetanus; percent of infants vaccinated against pertussis; percent of infants vaccinated against measles; percent of infants vaccinated against poliomyelitis) this indicator set contains 30 indicators. all indicators which were included in the list, had to reflect the special situation of the south eastern european region (see). after the pilot phase, 22 of the selected indicators proved to be qualified enough to reflect the health and social as well as health care situation in the ph-see countries. 8 indicators did not meet the quality criteria for an indicator or had to be replaced because of the poor data situation. other indicators had to be added after analysing the health situation within the ph-see countries and in consideration of the main topics of health policy (8). the indicators have to meet specific criteria such as: • relevant (regarding priorities) • valid (regarding determinants of health) • measurable (in quantitative and qualitative terms) • sensitive (to changes and differences) • comparable (inter-territorial) • repeatable (for time series) • affordable (in terms of relative costs) • useful (for intervention) • ethical (e.g. respect personal autonomy) definitions for all above-mentioned indicators are available at http://www.who.dk/country/hfadbbook.pdf (r3) the following chapters will help to explain the meaning and composition of an indicator set. indicator classification and evaluation methods definitions of „health indicators” (www.who.deficrit.htm) indicators are markers of the health status, healthcare system performance or availability of resources, defined in a way to allow the monitoring of objectives, targets and performance. thus they cannot be confused with objectives and targets. objectives are statements aiming to improve health or to reduce the frequency of certain diseases, expressed in a quantitative manner, within a given time frame. targets are usually expressions of the desired service performance, for example, output or coverage, desired to be achieved at some time point in the future. indicators are defined as variables able to measure the changes in the level of health target achievement i.e. health for all (hfa) targets. 105 health indicators and health reporting indicators are used for health monitoring and health surveillance. health monitoring is defined as the maintenance or regular checking of ongoing activities or programmes with respect to predefined objectives. the purpose is to record what the system is actually achieving at present and to detect possible deviations from the decided course of action. surveillance refers to the ongoing observation of the health status of a population and the factors that may affect it, and its purpose consists in detecting possible changes at an early stage and initiating appropriate action (4, p.4). types of indicators there are three types of hfa indicators which are defined in the hfa 21 catalogue of health indicators (3). definitions and criteria are: 1. outcome (health status or death) 2. process (health care delivery and management, including resources) 3. determinant (e.g. behavioural factors and public knowledge) all hfa 21 indicators (3) can be used to measure progress towards established targets and goals, including the monitoring of changes in the health status of the population. most of them can be used to monitor service performance at the facility, district and national levels. generic indicators are broadly defined areas of measurements linked to specific parts of the hfa policy framework (hfa targets) and traditionally constitute an integral part of the hfa policy document. operational indicators are precisely defined numerical data items as recorded in the hfa statistical database (3). an indicator can be defined at the generic level, e.g. „smoking behavior”, or in an operational manner, e.g. „% of women in x age group, x smoking between y and z cigarettes per day”. operational indicators are always expressed in a numerical way, calculated from primary data in a more or less complex manner. an example of a complex calculation is „life expectancy at birth”, which is calculated from a large set of age-specific mortality data. indicators are usually numerical (rations, proportions, rates), although they can also be qualitative (e.g. existence or absence of a sign, event, etc. that has been shown to be important). quality criteria for health indicators with regard to the selection of indicators, the following prerequisites are necessary: • the actual selection and definition of indicators within a specific public health area should be based on scientific principles. • indicators (and underlying data) should meet a number of methodological and quality criteria concerning e.g. quality, validity, sensitivity and comparability. 106 health systems and their evidence based development • the probability of changing policy priorities/interests calls for a high degree of flexibility, made possible through current electronic database systems. • the selection of indicators should be based on existing and comparable data sets for which regular monitoring is feasible, but should also indicate data needs and development areas (2). the quality of indicators will be measured according to the following four criteria: 1. validity: i.e. it is a true expression of the phenomena it is measuring; 2. objectivity: i.e. it is able to provide the same result if measured by different people under similar circumstances; 3. sensitivity: i.e. it is capable of reflecting changes in the phenomena of interest; 4. specificity: i.e. it reflects changes in the specific phenomena of interest only. additionally, the following criteria are relevant for the use of an indicator and the methodology employed to collect the data: • the data required for the indicator are useful for case management or taking action in the community for the staff who originally recorded the data, or the service unit from which the data originated. • it should be feasible to obtain the data needed for each indicator and that these data should be generated, as far as possible, through routine service processes or through easily and rapidly executable surveys. • the indicators should be simple and understandable, measuring a health condition or aspect of service. composite indicators should be avoided. • the indicator and the process of collecting and processing the relevant data are ethical (3). health indicators serve several purposes: 1. they are an important tool of for health policy formulation and implementation. 2. they are used to track progress, i.e. they are used for monitoring and evaluating the health situation with respect to specified objectives. 3. they can provide yardsticksbenchmarks whereby countries can compare their own progress with that of other countries, especially those at similar levels of socio-economic development. 4. they cannot be measured at present because no adequate information is in place; they are nevertheless adopted for use because they point to what needs to be done (guidance for action, including information systems’ development). 107 health indicators and health reporting 5. indicators have a communication and coordination function: for example, when decided in a proper consultation process they constitute an important message to the community about agreed priorities (4, p.7). main categories of an indicator set the following main categories of a set of community health indicators (echi indicator set) were proposed: 1. demographic and socio-economic factors 1.1. population 1.2. socio-economic factors 2. health status 2.1. mortality 2.2. morbidity, disease-specific 2.3. generic health status 2.4. composite health status measures 3. determinants of health 3.1. personal and biological factors 3.2. health behaviors 3.3. living and working conditions 4. health systems 4.1. prevention, health protection and health promotion 4.2. health care resources 4.3. health care utilization 4.4. health expenditures and financing 4.5. health care quality / performance the european commission (2, p.12) developed a concept according to which indicators can be divided into the following categories: 1. cockpit information: to have a quick view on the major trends in public health, including recent relevant signals, for medium or long-term policy strategies; 2. eu priority list: to follow developments for specific eu policy areas or targets, programmes or projects; 3. the who / hfa 21 indicator set: to follow this list of indicators for the eu countries; 4. health and services for mother and child: to focus on reproductive health, health of children and family structure. 108 health systems and their evidence based development who regional office for europe revised the indicator list during the transition period from hfa 2000 to health 21 (3). the main change was a reduction in the total number of generic indicators from 112 to 59. about 50 indicators from hfa 2000 have been maintained and 9 new indicators have been adopted. the current indicators will cover such fields as: • health status, • health determinants, and • socio-economic background. the operational indicators of the health 21 strategy are divided into the following groups (3, p.5): mortality, morbidity, disability, maternal / child health, other health status indicators, lifestyle, environment, health care resources, health care utilization, quality of care, health expenditure, and demographic and socio-economic indicators. data for indicators are being collected from various sources (hfa 21). the main information sources are: • comprehensive statistical records already established for health or other purposes • ad hoc investigation or surveillance systems within the health services and • population surveys all efforts are made to use information from available sources to avoid duplicating requests to countries. in 1988, 1990 and 1992 the who regional office for europe and statistics netherlands organized consultations to develop common methods and instruments for a health interview survey at the european level (4). the objective was that this health interview survey should be used countries in order to achieve better international comparability and enhance the value and use of survey results. 109 health indicators and health reporting recommended instruments for health interview surveys are: 01. perceived health 02. temporary disability 03. long-term disability 04. disability-free life expectancy 05. chronic conditions (mental) 06. smoking 07. physical activity 08. birth weight 09. breast-feeding 10. body-mass-index 11. socio-economic classification (education, wealth, income, occupation, economic position). methods of comparison and benchmarking the application of statistical methods will be the subject of other parts of the curriculum. to complete the establishment of indicator sets and use of health indicators, it has to be mentioned that comparability must be guaranteed with the help of the following methods. the use of statistical methods for comparing data of different regions includes: • age standardisation incl. calculation of confidence intervals, • significance check-ups, • definitions of the included regions concerning the application of further statistical methods, • calculations such as „pyll: person years life lost“, • calculations for time trends, and • meta-database description of the data used incl. definitions. the use of health indicators for health reporting today, various methods are used for health reporting: • indicator-based health reporting on the basis of a well-defined indicator set, periodic health reporting is done to follow the indicators and trends. changes of in the indicator level are analysed and described within the different chapters of periodic health reporting. • indicator sets and their use for health reporting for writing health reports with the help of experts or for special topics (e.g. women’s health) a part of the indicators sets can probably be used, but usually not the complete indicator set. the advantage consists in the flexibility of the reporting, the disadvantage is the discontinuity of a frame for reporting such as „health situation in south eastern europe”. however, within the stability pact a report based on 110 health systems and their evidence based development the minimum indicator set for south east european countries was produced in 2003 (8) and can serve as a model for future similar reports aiming to support the decisionmaking process in the area and to track progress of these countries towards the goals of integration in the european union. • health targets, health indicators and health reporting who prefers health reporting on the basis of health targets. the advantage is the good tracking of the targets. a good example is the uk model or the „healthy people” strategy of the united states (www.health.gov/healthypeople). the disadvantage lies in the time-consuming process of formulating common targets for several countries. also the establishment of an indicator set with benchmarking criteria based on health targets takes a lot of time and is a difficult undertaking. some targets may change in the course of the years and so you have to change your indicator set, too. here who has made some experience. thus the indicators of based on the new strategy hfa 21 are more „generic” and less „operational”. a review on health target settting in 18 european countries (13) demonstrated that health for all strategy has influenced the health policy of almost all of the 18 countries. 111 health indicators and health reporting exercise: health indicators and health reporting task 1: after being familiar with the hfa software, students are asked to select a set of relevant indicators from this database and to prepare a report describing the situation from a certain country/region for the purpose of priority setting. time: 120 minutes. task 2: students are asked to search the minimum indicator set (10) and make comparisons between see countries (e.g. in life expectancy at birth, infant mortality rate and sdr due to different causes) and try to find possible explanations. task 3: review existing national data sources (available in your country) and look for available indicators also describing the local levels (e.g district, country, etc.) and make geographical comparisons. commonly, reports or databases are reported by national statistical institutes/bureaus and institutes of public health. 112 health systems and their evidence based development references 1. european union, health and consumer directorate general. new public health programme 20032008. available from url: http://europa.eu.int/comm/health/ph_programme 2. european community. design for a set of european community health indicators (echi). final report by the echi project. bruxelles. european commission; 2001. 3. who, regional office for europe. who hfa indicators for the new health policy for europe. the hague, netherlands, 2-3 march 2000. copenhagen: who, regional office for europe; 2000. eur/00/501872 unedited. 4. who, regional office for europe. health interview survey. towards international harmonization of methods and instruments. copenhagen: who; regional office for europe; 1996. 5. institute of public health north rhine-westphalia. common minimum indicator set (cmis). who europe: regions for health network. bielefeld: institute of public health north rhine-westphalia; 2001. 6. european commission. establishment of a set of mental health indicators for european union. final report. project under the health monitoring programme of ec. bruxelles; 2002. 7. who. reproductive health indicators for global monitoring. report of the second interagency meeting. who geneva 17-19 july 2000. geneva: world health organization; 2001. 8. zalatel-kragelj l, bardehle d, burazeri g, donev d, laaser u. minimum health indicator set (mhis) for ph-see countries. final report. bielefeld: ph-see programmes for training and research in public health. bielefeld; 2003. available from url http://www.snz.hr/ph-see/docs.html 9. european commission. health and consumer protection directorate general. consumer voice. 2002; (3)april. 10. tamburlini g, ronfani l, buzzetti r. development of a child health indicator system in italy. european journal of public health 2001; 11(1): 11-17. 11. conference of the health ministers of the german states. indicator set for health reporting for the german states. 3rd ed. bielefeld: institute of public health nrw; 2003. (content and list of indicators in english) 12. rognerud m, stensvold i, hesselberg o, lyshol h. the national health indicator system and the data base norgeshelsa in year 2000. forkhelsa institute. oslo: national institute of public health (folkehelsa); 2000. 13. herten l v, water hpa v.d. health policies on target? review on health target settings in 18 european countries. european journal of public health 2000. supplement; 10(4): 11-16. databases for health indicators who: r1 synopsis of hfa-indicators at who-euro in copenhagen: http://www.who.dk/cpa/pb9912e.htm r2 hfa statistical database at who-euro: http://www.who.dk/country/country.htm r3 manual with description of hfa-indicators: http://www.who.dk/country/hfadbbook.pdf r4 country profiles based on hfa-indicators: http://www.who.dk/country/country.htm r5 euphin east network indicators: http://www.euphin.dk/hfa/phfa.asp r6 indicators in the healthy cities network (including questionnaire for data collection): http://www.who.dk/healthy-cities/pdf/quest.pdf eu & oecd: r7 european community health indicators (echi): description of project: http://europa.eu.int/comm/dgs/health_consumer/library/tenders/call26_9_en.pdf r8 eurostat health indicators as a section of the area „population & social conditions”: http://europa.eu.int/comm/eurostat/public/datashop/print-catalogue/en?catalogue=eurostat r9 oecd statistical portal / health statistics (excel tables): http://www.oecd.org/oecd/pages/home/displaygeneral/0,3380,en-statistics-194-5-no-no-no-194,ff.html r10 european community. health interview and health examination survey databases http://www.iph.fgov.be/hishes/ 113 health indicators and health reporting 114 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title quality of life: concept and measurement module: 1.5 ects (suggested): 0.50 author(s), degrees, institution(s) asis. zorica terzic, md, msc.¹ asis. bojana matejic, md, msc.¹ ¹ teaching assistant at the school of medicine, university of belgrade, serbia and montenegro address for correspondence zorica terzic, institute of social medicine, school of medicine, belgrade university dr suboti}a 15 11000 belgrade serbia and montenegro tel: +381 11 643 830 fax: + 381 11 659 533 e-mail: vlazo970@yahoo.com keywords quality of life, health related quality of life, measuring quality of life, sf – 36, minnesota questionnaire learning objectives after completing this module students and public health professionals should have: • increased their understanding and knowledge of quality of life and measuring quality of life • get knowledge about differences among global, generic and specific instruments of quality of life • improve their skills in processing the short form, sf 36 abstract public workers and media use the term quality of life (qol) related to the environment, physical and social: air pollution, soil and water pollution, living standards, and crime rates. the qol term is used in philosophy literature, sociology, geography, health economics, medicine, psychology, and pharmaceutics industry. during the last years, quality of life is said to be „overwhelming” or „global”, it is separated from the term health related quality of life. measuring qol is important because it is used for decision making especially about non-clinical aspects of disease, for improvement of the doctor – patient relationship, in discovering of functional and psychological limitations, in choosing the treatment in initial phase of disease, when the efficiency of a applied therapy is temperate (for example remedies just modify a disease). measuring of quality of life and health related quality of life (hrqol) could be: unidimensional and multidimensional. measuring qol and hrqol can be: global and specific (specific in relation to disease and in relation to medical treatment). teaching methods teaching methods include lectures, students individual work under the supervision of teacher and interactive methods such as small group discussion. before introductory lecture, the small exercise could be organised as brainstorming (“what is quality of life for you?”), in order to increase students’ motivation for learning and interest in the content of the module. after the introductory lecture 115 quality of life: concept and measurement students will work individually on comparison of dimensions among global, generic and specific instruments. students should discuss in small groups what kinds of dimension of quality of life are in the general and specific instruments. they would also have opportunity to search through the internet under the supervision of teacher in order to explore some of the web site concerning qol and some bases of the quality of life questionnaire. specific recommendations for teachers teacher should be familiar with the process of sf-36 and minnesota questionnaire analysis, especially standardization procedure and cultural adaptation. assessment of students multiple choice questionnaire. quality of life: concept and measurement zorica terzić, bojana matejić definition of quality of life and health related quality of life in everyday speech quality of life (qol) suggests many outer conditions and personal features. because of them an individual can feel satisfaction and dissatisfaction, he/she can plan keeping or changing the conditions one lives in. public workers and media use the term related to the environment, physical and social: air pollution, soil and water pollution, living standards, and crime rates (1). the qol term is used in philosophy literature, sociology, geography, health economics, medicine, psychology, and pharmaceutics industry. during the last years, quality of life is said to be „overwhelming” or „global”, it is separated from the term health related quality of life, so the consensus has been reached among experts on two important issues in the health related quality of life (hrqol) field (2,3): • it is recognized that the patient rather than a doctor or a nurse is the best source for obtaining hrqol information. • hrqol is viewed as a multidimensional concept, which should include the four primary dimensions: physical functioning, encompassing self-care activities (eating, dressing), physical activities (walking, climbing stairs), and social activities (working, household, school); physical symptoms related to the disease or treatment (pain, diarrhea, neuropathy); psychological functioning, including emotional state and cognitive functioning; social functioning referred to the activities and association with friends, relatives and other acquaintances. there are many definitions for qol term, because of different approaches while considering it. its meaning is differently explained and it depends on the user’s age and position in social and political structure (4). qol definition can be separated in general definitions, definitions specially related to health, and qol definition specially related to disease (5) (table 1). 116 health systems and their evidence based development table 1. general definitions and definitions specifically related to health and disease 117 quality of life: concept and measurement author global definitions calman, 1984 (6) the extent to which hopes and ambitions are matched by experience. ferrams and powers, 1985 (7) an individual’ s perceptions of well-being that stem from satisfaction or dissatisfaction with dimensions of life that are important to the individual. grant et al, 1990 (8) a personal statement of the positivity or negativity of attributes that characterizes one’ s life. author definitions specifically related to health schipper, 1990 (9) a pragmatic, day to day, functional representation of a patient’ s physical, psychological, and social response to a disease and its treatment. cella and tulsky, 1990 (10) patient’s appraisal of and satisfaction with their current level of functioning as compared to what they perceive to be possible or ideal. gotay et al, 1992 (11) a state of well-being which is a composite of two components: the ability to perform everyday activeties which reflect physical, psychological and social well-being, and patient satisfaction with levels of functioning and the control of disease and/or treatment related symptoms. whoqol group, 1993 (12) quality of life is defined as an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. it is a broad ranging concept affected in a complex way by the person’s physical health, psychological state, level of independence, social relationships, and their relationships to salient features of their environment. testa and simpson, 1996 (2) the physical, psychological, and social domains of health, seen as distinct areas that are influenced by a person’ s experiences, beliefs, expectations, and perceptions. author definitions specifically related to disease cella and tulsky, 1990 (10) hrqol is more specific and more appropriate term than quality of life, because it refers to patients’ assessment and satisfaction of their current level of functioning with it compared to what they consider to be possible or to be ideal. padila et al, 1998 (13) the term hrqol, connotes a personal, evaluative statement summarizing positive and negative attributes that characterize one’ s psychological, physical, social, and spiritual well – being at a point in time when health, illness and treatment conditions are relevant. measuring quality of life measuring qol is important because it is used for making decisions especially about non-clinical aspects of disease. it is also used for improvement of the doctor – patient relationship. it is important in discovering of functional and psychological limitations, in choosing the treatment in initial phase of disease, when the efficiency of applied therapy is temperate (for example remedies just modify a disease). it is also important when you chose therapies that are little different, when you chose among a few efficient, different, clinical therapies, when there are dilemmas in applied therapies because of toxins, costs as well as for supplying information about using resources (16,17). measuring of quality of life and health related quality of life could be unidimensional and multidimensional (18,19). unidimensional measuring refers to one dimension hrqol. when they are used in clinical researches they can limit clinical information. they can show whether the treatment improves qol, but they do not speak about the way of improvement. multidimensional measuring is used in clinical researches. qol assessment based on multidimension is important when there is a little information about the effects of a disease and/or treatment of a disease (20). multidimensional measuring in the informal way points out which health intervention justifies invested money, but they can not be used for cost benefits analysis (21). also, measuring qol and hrqol can be: global and specific (specific in relation to disease, and in relation to medical treatment) (18,19). global measuring is used in general population to measure health status of population and to compare different health conditions or diseases. they are also focused on the basic human values such as emotional well-being and on the possibility of everyday functioning (2,22,23). specific measuring is related to the domains, which are important for a disease; and for different states, that has priority for a patient. most usually they are used in clinical researches of drugs or therapeutics’ intervention (2). 118 health systems and their evidence based development van schayck, 1998 (14) this concept, hrqol is used to description of how patients experience their disease, actually how the severity of disease has possibly decreased the quality of life. patric and erikson, 1998 (15) hrqol is the value assigned to duration of life as modified by the impairments, functional states, perceptions, and social opportunities that are influenced by disease, injury, treatment or policy. if hrqol is included in the clinical research, it has three important characteristics. first of all, the researchers, doctors, describe given conditions or a disease in terms, which are clinically important, and the patient can understand them easily. the second thing is that hrqol domains can be independent predictor of the important clinical results – such as observing treatment, morbidity and mortality. these data insure precious consideration in history and prognoses of different states and diseases. the third thing, we can get data about the treatment, which determine individual daily functioning from the patient’s point of view, what we can get or lose during the therapy. this can help a doctor to make decision to modify specific elements of therapy such as drugs, consultative health care, education of patients or help to the service (24,25). all these information should be added to the information that the doctor gets during physical examination, laboratory tests and medical history. however, measuring hrqol is used in small number of clinical researches as a primary goal, although quality of life is often better prognostic indicator than factors connected to the disease or treatment (18). measuring qol (and health related quality of life) can be done into three domains, that agrees with the health definition who: physical functioning (that includes symptoms, functional difficulties), psychological state (emotional and cognitive functions) and social interaction (work, daily activities, public relations). in case that measuring does not include one of these domains, hrqol has negative assessment. however, number of dimensions can be much bigger (26). measuring qol is not direct. an individual gives attributes (characteristics) that are measured and in the case of qol that would be the level of physical functioning, mental health or social functioning (27). measuring qol must take into consideration subjective indicators (based on self-assessments). subjective measuring qol depends on personal preferences about determinants that are individual qol. that is so called ‘inner state’ of qol. there are also ‘outer aspects’ of qol that are evaluated by self-report (obviously subjective) and by observing (obviously objective) (28). the subjective indicators represent all nonbiological factors that have influence on the recovery and they include patient’s psychology, motivation and therapy acceptance, socioeconomic status, health protection, welfare work, personal and cultural convention and behavior (29). indicators based on the patient are not in the indispensable correlation with the objective measures (for example: level of physical functioning) (30). they are more and more popular because of the importance of patient’s satisfaction. it is also important what an individual feels in relation to what the statistics says that the individual should feel (31). 119 quality of life: concept and measurement subjectivity is the key element in the assessment and measuring qol. ‘subjective experiences’ are usually signified as potentially „soft data” or „soft science” contrary to the objective data. that are represented as „hard data” or „hard science” (17,32). the instruments for measuring quality of life the instruments for measuring qol are multidimensional, complex and indirect. multidimensionality demands combination of different terms and domains. complexity means simple questions or sums (they refer to the measured term) that are grouped into subscales, and the subscales form wider scales. casual effects that appear indirectly are connected to the variability, which can be in relation to the questionnaire respondents and the period needed for questioning (33). the instruments for measuring quality of life can be global, generic and disease specific. global measures (instruments) are designed to measure qol in the most comprehensive or overall manner. this may be a single question that asks the respondent to rate his/her overall qol or this may be an instrument such as the flanagan quality of life scale that asks people to rate their satisfaction in 15 domains of life (34). generic measures (instruments) have much in common with global measures, but they are designed primarily for description. they are used in general population for the assessment of health status, different conditions or diseases. usually, they are not specific for a particular disease or vulnerable population of patients and they are much more useful in general health researches, comparisons of different diseases and several studies. general instruments include large number of quality of life dimensions but at first place physical, mental and social dimension (2,34). deficiency of generic instruments is (35,36,37): – they are unable to identify condition – specific aspects of disease that are significant for the measurement qol – if the data is necessary for major number of conditions, the instruments would have to be of enormous length – an addition to specific instruments for a disease is needed to detect important clinical changes 120 health systems and their evidence based development table 2. generic instruments for measuring qol disease specific instruments are orientated on the domains most relevant to the disease, condition or characteristics of patients in whom the condition is most prevalent. they use of a particular treatment or clinical trial and they may be called „treatment specific” or „trial specific”, apropos by one name „situation – specific” (38). 121 quality of life: concept and measurement generic instruments for measuring qol author, year quality of well-being scale qwbs fanshel & bush, 1976 sicknes impact profile sip gilson & bergner, 1976 (revidirana 1981) mcmaster health index questionnaire mhiq chambers, 1976 nottingham health profile nhp hunt et al, 1985 medical outcomes study (mos) short form 36 – item mos – sf 36 ware, 1992 medical outcomes study (mos) short form 12 – item mos – sf 12 ware, 1994 assessment of quality of life aqol hawthorne & richardson comprehensive assessment and referral evaluation care fretwell eq – 5d eq – 5d euroqol group, 1991 dartmouth coop function charts coop c dartmouth coop project, 1987 visual analogue scale vas fryed, 1923 functional limitations profile flp patrick general health questionnaire ghq goldberg&williams, 1978 health and daily living form hdl moos health measurement questionnaire hmq gudex & kind healthy people 2000 years of healthy life hp 2000 erickson, 2000 health status questionnaire 2.0 hsq rand corporation, 1976 quality of life questionnaire-evans qlq e evans & cope symptom checklist-90-revised (scl90-r) care derogatis schedule for the evaluation of individual quality of life seiqol o’boyle & mcgee, 1994 who quality of life assessment whoqol whoqol, 1993 group, who specific instruments are needed for their homogeneity/brevity, and to ensure sensitivity for sometimes small, but clinically significant changes in health state and intensity of a disease (31). the recommendation is to use the combination of generic and specific instruments in the case when an overall qol instruments are not satisfied for specific diseases (31). quality of life instruments database (qolid) is made in the joined project of the french mapi institute and the italian national institute for cancer. this base contains 1000 globals, generic and specific questionnaires. generic measuring instruments are represented in the table 2. some of the specific measuring instruments selected on the number of performed cultural adaptations are represented in the table 3 (39,40). table 3. specific instruments for measuring qol 122 health systems and their evidence based development specific instruments for measuring qol cardiovascular diseases minnesota living with heart failure questionnaire mlhf seattle angina questionnaire saq angina battery gastroenterology inflamatory bowel disease questionnaire ibd qol personal health survey (hepatitis) 2 – item chromic idiopathic constipation cis 2 irritable bowel syndrome qol ibsqol battery respiratory diseases st george’s hospital respiratory questionnaire sgrq chronic bronchitis questionnaire chrobron adult asthma qol questionnaire aqlq rheumatology osteoporosis and qol ostop battery osteoporosis targeted – qol questionnaire optqol health assessment questionnaire haq endocrinology impact of weight questionnaire iwqol diabetes impact measurement scale dims experience of treatment benefits and barriers etbb diabetic foot ulcer scale dfus 123 quality of life: concept and measurement neurology quality of life for patients with newly diagnosed newqol quality of life in epilepsy qoli-3 side – effects and life satisfaction inventory seals functional assessment of multiple sclerosis fams psychiatry psychological general well – being index pgwbi drug attitude inventory dai wisconsin quality of life index wqli sleep jebnkins sleep questionnaire mos sleep module questionnaire mos – sleep mos sleep questionnaire (short version: 6 items) sexuality erectile dysfunction quality of life questionnaire ed mos sexual function mos – sexual sexual function index (male) gynecology women’s health questionnaire whq menopause quality of life questionnaire meqol quality of life in menopause meno pediatric pediatric asthma qol questionnaire paq pediatric rhinoconjunctivitis qol questionnaire rcqlq dermatology hair growth questionnaire infant’s eczema life quality index ielqi children’s dermatology life quality index cdlqi oncology quality of life index qli – ostomy europen organization for research and treatment of cancer’s quality of life questionnaire 30 eortc – qlq – c30 europen organization for research and treatment of cancer’s quality of life questionnaire 33 eortc – qlq – c33 generic questionnaire sf – 36 the example of generic instruments of quality of life is sf – 36. the sf – 36 was developed in the united states in the late 1980s as part of the medical outcomes study (mos), a longitudinal investigation of the selfreported health status of patients with different chronic conditions. the questionnaire enables an acceptable, psychometrically correct and efficient way to measure the quality of life from the patient’s point of view through answers to questions from a standardized questionnaire. the sf – 36 questionnaire was constructed to measure eight most important health dimensions by using eight groups of questions. the groups include two to ten questions and each of them offers several responses in the form of two levels, three levels and five level scales (41). the sf – 36 questionnaire consists of 36 questions, and 35 questions of them are grouped in eight dimensions: physical functioning, role – physical, bodily pain, general health, vitality, social functioning, and role – emotional and mental health. one question is not included in these eight dimensions and it is observed independently. it concerns health change compared to the status one year ago, is current health better, whether it is the same or worse, unlike all other questions that refer to the period of the previous four weeks (41). physical functioning dimension has 10 questions, and it refers to the possibility of practicing different physical activities during a typical day and the level of limits in those activities provoke by current health status. these activities are: vigorous activities (running, lifting heavy objects, participating in strenuous sports), moderate activities (moving a table, pushing a vacuum 124 health systems and their evidence based development urology incontinence qol questionnaire coat benign prostatic hyperplasia urolife benign prostatic post – operative pain hypertrophy impact index bphii pain migraine specific quality of life questionnaire mig16 pain management satisfaction questionnaire pop2 post – operative pain pop aids mos hiv sf – 30 citomegalovirus specific questionnaire cmv cleaner, bowling or playing golf), lifting or carrying things, climbing stairs, bending, kneeling or stooping, possibility of walking and self-care (bathing or dressing). physical role dimension comprises four questions. the questions refer to problems with work or other regular daily activities as a result of your physical health. dimension body pain is based on two questions: one question concerns the existence of body pain and its intensity during the past 4 weeks, and the other question concerns interference of pain with normal work outside the house and housework. dimension general health has five questions. the questions refer to the assessment of current health, and the respondent’s opinion about the accuracy of certain claims about resistance to illness, health prognosis and opinion about present health. dimension vitality consists of four questions, that refer to how the patients felt and how successful they were in doing things during the past 4 weeks and how much of the time they feel like that (all the time, most of the time, a good bit of the time, some of the time, a little of the time, none of the time) during that 4 weeks. the questions include the exhaustion, tiredness, feeling that they are full of life and the assessment of their energy. dimension social functioning consists of two questions, the one question concerns on interfered physical health or emotional problems with usual social activities with family, friends, neighbors or other during the past 4 weeks, and the other question refers to the period of limitation, i.e. the negative effect of damaged physical or emotional health on social activities, such as visiting with friends or relatives during the past 4 weeks. dimension role – emotional represents three questions concerns on problems with work or other regular daily activities as a result of any emotional problems, such as feeling depressed or anxious in the past four weeks. dimension mental health comprises five questions that refer to the presence of anxiety, sadness, peace, depression and happiness and how long they were feeling like that. standardization procedure of sf – 36 the standardization and scoring are basic procedures in the interpretation of the sf – 36 questionnaire whose comparison of results among studies 125 quality of life: concept and measurement makes possible. there are two reasons for conveying standardization. first, to enable scoring with same reliability and validity as reported in medical outcomes study (mos) publications. the second reason is enabling the comparison of results between all studies that are using the standardization content and standards for scoring (41). scoring questionnaire sf – 36 is conducted through several steps: entering data, recording out-of-range item values as missing, reverse scoring and/or recalibrate scores for 10 items, recording missing item responses with mean substitution (where warranted), computing raw scale scores, transformation of raw scale scores to 0 – 100 scale, performing scoring checks (41). specific questionnaire – the minnesota living with heart failure (mlhf) the example of the specific instrument is minnesota living heart failure (mlhf). the mlhf questionnaire was arised for need that through self-assessment evaluated the answer for applied therapy in the case of heart failure. several criteria were used for developing the questionnaire mlhf (42). the first criterion is used for the questionnaire which should measure what it is defined to. the second one: the questionnaire should be applied in clinical practice. the third one: the numeric values are assigned to responses. the fourth one: the score is reliable during the stable clinical condition, so that it can identify the changes during interventions. there is also the fifth one: the questionnaire is valid measure of the quality of life. in relation with the other specific instruments which measure qol of patients with heart failure, its advantages are (43): • it includes optimal number of questions about physical activities, which at the same time can demonstrate even the different degree of limitations during physical activity. • at the same time, it also follows dispnea and fatigue during the specific activities, as well the other signs and symptoms of a disease. • patient’s point of view is also included in the score about the importance of different symptoms. • the only specific instrument which has represented itself as being reliable in double blind clinical trials. the questionnaire mlhf consists of two parts; first one is instruction for use and intended for the researchers, and second one is the questionnaire itself. 126 health systems and their evidence based development the instructions are given to the researcher to help him interview patients and how he can process the results. the questionnaire should be selfadministered or researcher may read it directly to the patient, before any medical intervention, so that we can get whole impression about patients’ health condition before applied medical intervention. the patient should have enough time to fulfill questionnaire and he should not be disturbed. before, the participants started responding, the instructions should be given: you should read the introductory paragraph at the top of the questionnaire and explain the way the questionnaire should be completed. you should emphasize that all the questions are about the changes caused by heart failure. the questionnaire itself consists of the introductory paragraph and 21 questions with answers. introductory paragraph emphasizes that all the changes caused by heart failure happened during the last month. the questions refer to present disease symptoms (short of breath, fatigue, outworn, loss of energy), signs of heart failure (swelling ankles, legs), limitations caused by disease (difficulties during climbing stairs, working around the house, going away from house, difficulties in earning for living, in relations with family and friends, difficulties while making recreation, pastimes, sports and hobbies, sleeping and sexual problems, taking rest during the day, eating less). it also includes questions about staying in hospital, medical car costs, medications’ side effects as well as emotional problems (their feeling that they are burden to the family or friends, loosing self-control in their lives, presence of worriness, depression, and difficulties to concentrate or remember things). the answers are represented as six grade scale from „no” (0) over very little (1) to very much (5). lower values are the signs of better life quality. the steps in the cultural adaptation: an example of serbian minnesota questionnaire the cultural adaptation demands use of a proper language so that the translated questionnaire should be conceptual equivalent to the original and clear and understandable for a patient. the conceptual equivalence means that the translation should faithfully reflect the (items) notions investigated in the questionnaire, without repeated interpretation the original formulation of the questionnaire and without limitation of original means. during this, we face several problems and these are ambiguous words in the questionnaire and impossible translation for a certain english term. if a formulation in the original questionnaire is ambiguous, than mapi research institute solves that ambiguousity by asking the author for cla127 quality of life: concept and measurement rifications, in order to know exactly what is the concept investigated in the original and consequently in the translations. if there is not equivalent in the target language (in this case – serbian) for an english term in the original questionnaire then the word closest in meaning to the original word should be chosen in the target language. in the case that the english term cannot be replaced by 1 word only, than is better to use 2 or 3 words instead, that could cover the meaning of the original term. the comprehension of the language used means to use simple, clear and easily understandable words, expressions and sentence structures. also, the recommendation is to use the expressions, which are used in everyday language. actually it is better to use expressions from everyday language than the expressions which could be found in the books and newspapers. this recommendation should be achieved, because it deals with the population of patients with high level of education (university educated). also, if there are two expressions, which are easily understandable, we should use the expression more frequently used in everyday speech. on respecting these rules, in some cases it happens that grammatically incorrect language structure is used. it might happen, that grammatically correct expressions need request complex and massive structure, which are never used in everyday conversation. than, we can use expressions, which are very often used in conversation, but they are not completely grammatically correct. also, it’s possible that a literal translation of the original questionnaire refers to the same concept as in the original, and at the same time it is clear and easily understandable. such literal translation should be kept. the process of cultural adaptation (translation) is implemented through three steps: forward translation, backward translation and patient testing. forward translation forward translation consists of a few phases: engagement of two profession translators, making reconcile – the first intermediary version (forward translation), making the report for mapi research institute and making the final first intermediary version. the native language of the engaged professional translators must be serbian and their english must be very good, too. they are independent in translating instruction for use and the questionnaire (instruction for filling, 128 health systems and their evidence based development original questions and responses) and they produce two version of forward translation (every translator gives an independent forward translation). the reconciled – first intermediary version is created during the meeting of both translators and the local project manager (author of this paper). the translators compare their translations among themselves and compare them with the original questionnaire. the aim is to produce a conceptually equivalent translation of the original questionnaire and the language used which should be colloquial and easily understandable. the project manager makes the report for mapi institute for each question in english. also, the project manager explains translation problems, difficulties in translation, offers and accepts solutions and options of the first reconciled intermediary version of forward translation, explaining translation problems, disagreements of the translators in the translation, offered and accepted solutions. the final reconciled, intermediary version of the translation arises after the mapi institute has analyzed the report and after their suggestions have been loaded into the first intermediary version. backward translation the forward translation implies a few phases: the engagement of the professional translator, making backward translation, loading the changes into the first intermediary version, making the report for mapi institute and making the second intermediary version. the native language of the engaged professional translator must be english and his serbian must be very good, too. his task is to translate the first reconciled intermediary version of forward translation into english as more literal as possible. the translator must not see the original english questionnaire before he begins to translate. backward translation emphasizes disagreements and differences (that exist) between the first intermedialy version and the original questionnaire. this is achieved by translating the backward translation and the original questionnaire. the aim of the meeting between project manager and translator is: to go carefully though the whole questionnaire, question by question, sentence by sentence and make comparison of three documents (the backward translation into english, the english original questionnaire and the first intermediary version for each single part of the questionnaire). the differences that the project manager and translator of backward 129 quality of life: concept and measurement translation should notice when making the comparasion should be: faulty backward translation, faulty forward translation and structural differences between backtranslation and the original questionnaire. the revision of the whole questionnaire was made at the meeting between the project manager and the translator. also, project manager establishes the changes that should be made to the first intermediary version. the first intermediary version with the report of modification after backtranslation, and the backtranslation itself are sent to the mapi institute. the report should mention all the discrepancies between the backtranslation and the english original as well as the explanations of all fond differences caused by faulty backward translation or faulty forward translation or structural differences between backtranslation and the original questionnaire. also, the report should mention the explanation of the changes that have or have not been brought in the first intermediary version. mapi institute reviews the backtranslation and report. all disagreements with respect to the original questionnaire are discussed with the local project manager. the second intermediary target (serbian) version arises after agreement on all the changes that were made into the first intermediary version. patient testing or cognitive debriefing this step, patient testing, includes: testing of the second intermediary version of the questionnaire, making reports for mapi institute, acceptance of the second intermediary version or making the third intermediary version that would be more clear than the previous one and more acceptable for all persons who use it. mapi institute should engage translators whose native language is serbian and their task is to make the final version of the questionnaire. the aim of the patient testing is: to test the comprehension and acceptability of the second intermediary version; to identify questions that are problematic as well as the reason for it; and to write down possible suggestions for understanding the formulation of questions. the second intermediary version questionnaire is tested on a panel discussion, face to face with 5 patients who are suffering from heart failure. the idea was to choose five patients who would be representatives of patient population in our country. there are following criteria that are recommended while choosing patients: their education, profession and age. when we speak about education, it is better that patients are with lower 130 health systems and their evidence based development level of education. previous experiences have shown that people with a high level of education (professors, teachers, scientists, and doctors) never have difficulties in understanding while testing the questionnaire. it is preferable to have patients from several professional groups, but this should not be in contradiction with their education. the role of the project manager is to discover all misunderstanding or misinterpretations and to identify words or wordings that may be inappropriate and to write down. for the project manager is also important to express patient’s feeling when answering some questions (face expression shows agreement or disagreement). throughout panel discussion project manager asks questions to the respondents about their general impression about questionnaire: is it globally clear, easy to understand, easy to answer, is it too long, is it adapted for the condition, are the instructions clear? after that, together with patients, he goes through to whole questionnaire, question by question and checks: • are the questions difficult for understanding? if so, why? • are the offered answers clear and consequent with the questions? • is the primary concept of questions interpreted correctly? is there ambiguous formulation that would make more than one possible interpretation? • is the language used easy to understand and is the language used as daily speech? then the project manager makes one independent report of the panel discussion. he has to explain suggested changes that project manager finds to be relevant and the changes he suggested to be kept. after the report has been examined and after discussion of patient testing results with mapi institute, the third intermediary version of the questionnaire is made by integration of all changes into next intermediary version. it is also possible to keep the second intermediary version if there are not any significant changes. mapi institute engaged two local translators whose native language is serbian and their english is also very good, so they can translate the third (or second) intermediary version (serbian) of questionnaire in english. during the meeting of these two translators they compare translations to the original. 131 quality of life: concept and measurement changes that local translators suggest are discussed with project manager. the final version of the questionnaire is created and it is based on the results of this discussion. 132 health systems and their evidence based development exercise: measuring quality of life the purposes of the exercises are to provide students with basic information about quality of life and measuring quality of life. task 1: comparison of dimensions between generic and specific instruments students work individually. the students are given the generic questionnaires sf – 36, sf – 12, sf – 8 and specific minnesota living with heart failure questionnaire. they should notice the differences between these four questionnaires and discuss about dimensions from these questionnaires. some of students will report what they understand from comparison. time: 90 min. the questionnaires sf – 36, sf – 12 and sf – 8 are available from http:// www.qualitymetric.com the specific minnesota living with heart failure questionnaire is given below in this task. task 2: filling in sf – 36 the students fill in sf – 36 and with instruction for scoring: they are getting their scores of quality of life. they can compare their score with national’s standards. the instruction for scoring sf – 36 is available from http:// www.qualitymetric.com. the national’s standards are given in the table 4. time: 180 min. living with heart failure questionnaire instructions for use 1. patients should respond to the questionnaire prior to other assessments and interactions that may bias responses. you may tell the patient that you would like to get his or her opinion before doing other medical assessments. 2. ample, uninterrupted time should be provided for the patient to complete the questionnaire. 3. the following instructions should be given to the patient each time the questionnaire is completed. a. read the introductory paragraph at the top of the questionnaire to the patient. 133 quality of life: concept and measurement b. read the first question to the patient „did your heart failure prevent you from living as you wanted during the past month by causing swelling in your ankles or legs”? tell the patient, „if you did not have any ankle or leg swelling during the past month you should circle the zero after this question to indicate that swelling was not a problem during the past month”. explain to the patient that if he or she did have swelling that was caused by a sprained ankle or some other cause that was definitely not related to heart failure he or she should also circle the zero. tell the patient, „if you are not sure why you had the swelling or think it was related to your heart condition, then rate how much the swelling prevented you from doing things you wanted to do and from feeling the way you would like to feel”. in other words, how bothersome was the swelling? show the patient how to use the 1 to 5 scale to indicate how much the swelling affected his or her life during the past month from very little to very much. 4. let the patient read and respond to the other questions. the entire questionnaire may be read directly to the patient if one is careful not to influence responses by verbal or physical cues. 5. check to make sure the patient has responded to each question and that there is only one answer clearly marked for each question. if a patient elects not to answer a specific question(s) indicate so on the questionnaire. 6. score the questionnaire by summating the responses to all 21 questions. in addition, physical (items 2, 3, 4, 5, 6, 7, 12 and 13) and emotional (items 17, 18, 19, 20, and 21) dimensions of the questionnaire have been identified by factor analysis, and may be examined to further characterize the effect of heart failure on a patient’s life. 134 health systems and their evidence based development living with heart failure questionnaire these questions concern how your heart failure (heart condition) has prevented you from living as you wanted during the last month. the items listed below describe different ways some people are affected. if you are sure an item does not apply to you or is not related to your heart failure then circle 0 (no) and go on to the next item. if an item does apply to you, then circle the number rating how much it prevented you from living as you wanted. did your heart failure prevent you from living as you wanted during the last month by: copyright university of minnesota 1986. 135 quality of life: concept and measurement no very very little much 1. causing swelling in your ankles, legs, 0 1 2 3 4 5 etc.? 2. making you sit or lie down to rest during 0 1 2 3 4 5 the day? 3. making your walking about or climbing 0 1 2 3 4 5 stairs difficult? 4. making your working around the house 0 1 2 3 4 5 or yard difficult? 5. making your going places away from 0 1 2 3 4 5 home difficult? 6. making your sleeping well at night 0 1 2 3 4 5 difficult? 7. making your relating to or doing things 0 1 2 3 4 5 with your friends or family difficult? 8. making your working to earn a living 0 1 2 3 4 5 difficult? 9. making your recreational pastimes, sports 0 1 2 3 4 5 or hobbies difficult? 10. making your sexual activities difficult? 0 1 2 3 4 5 11. making you eat less of the foods you 0 1 2 3 4 5 like? 12. making you short of breath? 0 1 2 3 4 5 13. making you tired, fatigued, or low 0 1 2 3 4 5 on energy? 14. making you stay in a hospital? 0 1 2 3 4 5 15. costing you money for medical care? 0 1 2 3 4 5 16. giving you side effects from 0 1 2 3 4 5 medications? 17. making you feel you are a burden to your 0 1 2 3 4 5 family or friends? 18. making you feel a loss of self-control 0 1 2 3 4 5 in your life? 19. making you worry? 0 1 2 3 4 5 20. making it difficult for you to 0 1 2 3 4 5 concentrate or remember things? 0 1 2 3 4 5 21. making you feel depressed? 0 1 2 3 4 5 table 4. item means of dimensions of sf – 36 by country 136 health systems and their evidence based development item cr de fr ge it ne no sp uk physical functioning (pf) pf01 2.04 2.36 2.29 2.26 2.38 2.17 2.16 2.43 2.25 pf02 2.34 2.73 2.59 2.62 2.75 2.63 2.75 2.74 2.58 pf03 2.40 2.76 2.64 2.60 2.72 2.58 2.72 2.78 2.61 pf04 2.28 2.81 2.78 2.72 2.78 2.63 2.75 2.81 2.63 pf05 2.48 2.79 2.76 2.66 2.78 2.67 2.75 2.77 2.71 pf06 2.29 2.81 2.73 2.67 2.80 2.66 2.84 2.82 2.65 pf07 2.36 2.89 2.88 2.75 2.90 2.80 2.90 2.86 2.76 pf08 2.51 2.88 2.84 2.81 2.89 2.81 2.92 2.86 2.80 pf09 2.62 2.91 2.91 2.84 2.93 2.86 2.94 2.90 2.88 pf10 2.66 2.91 2.92 2.87 2.95 2.93 2.95 2.93 2.92 role physical (rp) rp1 1.67 1.79 1.78 1.79 1.80 1.73 1.72 1.85 1.78 rp2 1.60 1.89 1.90 1.83 1.86 1.81 1.84 1.87 1.85 rp3 1.65 1.84 1.84 1.82 1.83 1.77 1.81 1.87 1.80 rp4 1.60 1.85 1.82 1.81 1.82 1.75 1.80 1.87 1.80 general health (gh) gh1 2.68 3.53 3.36 3.03 3.06 3.28 3.57 3.08 3.50 gh2 3.60 4.13 3.82 3.56 3.52 3.74 4.32 4.03 3.91 gh3 3.26 3.90 3.66 3.45 3.91 3.85 4.01 3.75 3.69 gh4 3.19 4.00 3.65 3.77 3.78 3.71 3.86 3.90 3.61 gh5 2.95 4.43 4.27 4.17 4.28 4.36 4.49 4.35 4.35 vitality (vt) vt1 3.41 4.34 4.01 3.96 3.89 4.55 3.61 4.29 4.09 vt2 3.38 4.04 3.43 3.99 4.12 4.26 3.45 4.16 3.95 vt3 3.90 5.14 4.70 4.47 4.90 4.79 4.50 4.81 4.50 vt4 3.68 4.55 4.07 3.99 4.02 4.19 4.51 4.50 4.17 role emotional (re) re1 1.76 1.81 1.79 1.85 1.77 1.79 1.75 1.89 1.85 re2 1.70 1.91 1.90 1.91 1.84 1.84 1.88 1.90 1.89 re3 1.71 1.90 1.82 1.89 1.76 1.84 1.84 1.90 1.89 mental health (mh) mh1 4.09 4.48 3.83 4.31 4.03 4.44 4.31 4.18 4.17 mh2 4.76 4.55 4.02 4.16 4.01 4.67 3.97 4.54 4.59 mh3 3.47 4.48 4.23 4.62 4.37 4.76 5.54 4.53 5.29 mh4 4.49 5.77 5.18 5.18 5.10 5.37 5.27 5.28 5.30 mh5 3.61 5.25 4.99 4.98 4.74 5.00 5.24 5.00 4.94 abbreviations: cr = croatia; de = denmark; fr = france; ge = germany; it = italy; ne = netherlands; no = norway; sp = spain; uk = united kingdom source: vuletic g, babic-banaszak a and juresa v. health-related quality of life (hrqol) assessment in the croation population using the sf – 36. quality of life newsletter 2002; 29: 7. references and recommended readings 1. lang s. o kvalitetu `ivota. (doktorska disertacija). zagreb: medicinski fakultet sveu~ilišta u zagrebu, 1982. 2. testa ma, simonson dc. assessment of quality of life outcomes. n engl j med 1996; 334 (13): 835-840. 3. de boer bj, van dam fsam, sprangers mag. health related quality of life evaluation in hiv infected patients. in: mallarkey g ed. quality of life assessment. last advances in the measurement and application of quality of life in clinical studies, chester england: adis international limited; 1998; p. 155-168. 4. eiser gm, farmer rg. health-related quality of life in inflammatory bowel disease. in: mallarkey g ed. quality of life assessment. last advances in the measurement and application of quality of life in clinical studies, chester england: adis international limited; 1998; p. 137-142. 5. camilleri – brennan j and steele rjc. measurement of quality of life in surgery. jr coll.surg.edinb 1999; 44: 252-259. 6. calman kc. quality of life in cancer patients – an hypothesis. j med ethics 1984; 10: 124128. 7. ferrans c, powers m. quality of life index: development and psychometric properties. adv nur sci 1985; 8: 15-24. 8. grant mm, padilla gv, ferrell br, rhiner m. assessment of quality of life with a single instrument. semin nur oncol 1990; 6: 260-270. 9. schpper h. guidelines and caveats for quality of life measurement in clinical practice and research. oncology 1990; 4: 51-57. 10. cella df, tulsky ds. measuring quality of life today: methodological aspects. oncology 1990; 4: 29-38. 11. gotay cc, korn el, mccabe ms, moore td, cheson bd. quality of life assessment in cancer treatment protocols: research issues in protocol development. j natl cancer inst 1992; 84: 575-579. 12. whoqol group. measuring quality of life: the development of the world health organization quality of life instrument (whoqol), geneva: who, 1993. 13. padila g, berkanovi} e, louie j, el al. quality of life-rheumatoid arthritis scale. quality of life newsletter 1998; 20: 11-12. 14. van schayck cp. measurement of quality of life in patients with chronic obstructive pulmonary disease. in: quality of life assessment. last advances in the measurement and application of quality of life in clinical studies, chester england: adis international limited; 1998; p. 87-92. 15. patrick dl, erickson p. health status and health policy. new york: oxford university press, 1993. 16. bech p. quality-of-life measurements for patients taking which drugs? in: mallarkey g ed. quality of life assessment. last advances in the measurement and application of quality of life in clinical studies, chester england: adis international limited; 1998; p. 93-103. 17. wagner ak, vickrey bg. the routine use of health-related quality of life measures in the care of patients with epilepsy: rationale and research agenda. qual life res 1995; 4: 169-77. 18. michael m, tannock if. measuring health related quality of life in clinical trials that evaluate the role of chemotherapy in cancer treatment. can med assoc j 1998; 158: 1727-34. 19. ta 101. glossary. in: introduction to health care technology assessment. national information center on health services research & health care technology (nichsr) (cited 1998, august 11); available from url: http://www.nlm.nih.gov/nichsr/ta101. 137 quality of life: concept and measurement 20. shumaker sa, anderson rt, czajkowski sm. psychological test and scales. in: spilker b, ed. quality of life assessment in clinical trials. new york: ravan press, 1990: 95-114. 21. hyland me. quality-of-life measures as providers of information on value-for-money of health interventions: comparison and recommendations for practice. in: mallarkey g ed. quality of life assessment. last advances in the measurement and application of quality of life in clinical studies, chester england: adis international limited; 1998; p. 21-33. 22. ware je. conceptualizing and measuring generic health outcomes. cancer 1991; 67:774779. 23. eiser c, tooke j. quality of life in type ii diabetes in: mallarkey g ed. quality of life assessment. last advances in the measurement and application of quality of life in clinical studies, chester england: adis international limited; 1998; p. 115-123. 24. berzon ra. understanding and using health-related quality of life instruments within clinical research studies. in: staquet mj, hays rd and fayers pm, ed. quality of life assessment in clinical trials, new york: oxford university press; 1998. p. 3-18. 25. lydich e, yawn bp. clinical interpretation of health-related quality of life data. in: staquet mj, hays rd and fayers pm, ed. quality of life assessment in clinical trials. methods and practice, new york: oxford university press; 1998. p. 299-314. 26. kaplan rm. quality of life measurement. in: p. karoly ed. measurement strategies in health psychology. new york: john wiley, 1985. 27. revecki da, kline leidy n. questionnaire scaling: models and issues. in: staquet mj, hays rd and fayers pm, ed. quality of life assessment in clinical trials. methods and practice, new york: oxford university press; 1998. p. 157-168. 28. bendtsen p, åkerlind i, hörnquist jo. assessment of quality of life in rheumatoid arthritis: methods and implications. in: mallarkey g ed. quality of life assessment. last advances in the measurement and application of quality of life in clinical studies, chester england: adis international limited; 1998; p.125-136. 29. bowling a. measuring health: a review of quality of life measurement scales. fourth edition. philadelphia: open university press, 1994. 30. evans rw, manninen dl, garrison lp et al. the quality of life of patients with end stage renal disease. n engl j med 1985; 312: 553-9. 31. bowling a. measuring disease: a review of disease-specific quality of life measurement scales. buckingham philadelphia: open university press, 1995. 32. tamburini m. quality of life in medicine. twenty years of research on the evaluation of quality in medicine (cited 1998, april 16); available from url: http: //www.glamm.com /gl/tambu.htm 33. testa ma, nackley jf. methods for quality of life studies. annu. rev. public health 1994; 15: 535-59. 34. center for quality of life research in nursing science. quality of life compendium. measuring quality of life (cited 1999, february 4); available from url: http:// www.uib.no 35. hutchinson a, fowlert p. outcome measures for primary health care: what are the research priorities? british journal of general practice 1992; 42: 227-31. 36. goligher jc. judging the quality of life after surgical operations. journal of chronic diseases 1987; 40: 631-633. 37. guyatt gh, bombardier c, tugwell p. measuring disease specific quality of life in clinical trials. can med assoc j 1986; 134: 895-9. 38. osoba d. guidelines for measuring health-related quality of life in clinical trials. in: staquet mj, hays rd and fayers pm, ed. quality of life assessment in clinical trials. methods and practice, new york: oxford university press; 1998. p. 19-36. 39. mapi research institute. cultural adaptation of quality of life instruments by mapi research institute. quality of life newsletter 1998; 20: 4-5. 138 health systems and their evidence based development 40. mapi research institute (cited 2001, december); available from url: htpp//www.mapiresearch-inst.com 41. medical outcome trust. how to score the sf – 36 health survey. boston, medical outcomes trust, 1994 42. rector ts, kubo sh, cohn jn. patients’ self-assessment of their congestive heart failure. part 2: content, reliability and validity of a new measure, the minnesota living with heart failure questionnaire. heart fail 1987; 3(5): 198-209. 43. guyatt gh, feeney dh, patric dl. measuring health – related quality of life. ann innern med 1993; 118: 6229. 139 quality of life: concept and measurement 140 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title disability-adjusted life years: a method for the analysis of the burden of disease module: 1.6 ects (suggested): 0.25 author(s), degrees, institution(s) adriana galan, it specialist part-time senior lecturer at the university of medicine and pharmacy, department of public health and management, at the master course in management of public health and health services address for correspondence institute of public health bucharest 1-3 dr. leonte street 76256 bucharest romania tel: (4021) 2249228 / ext.188 fax: (4021) 3123426 e-mail: agalan@ispb.ro keywords population health status, global burden of disease, premature death, disability learning objectives at the end of this course, students should: • identify the basic concepts of the global burden of disease assessment; • be able to describe the factors influencing the calculation of dalys (age-weights, discount rate, severity of disability); and • be able to describe and compare the health status of population based on global burden of disease methodology. abstract this course covers the following topics: definitions and basic concepts; health status assessment by use of daly; exercise. teaching methods teaching methods include lecture, interactive presentation of key concepts, overheads or powerpoint presentation. exercise will be solved in small groups (4-5 persons) and an overhead will be presented by each group with their comments. specific recommendations for teacher it is recommended that the module will be organized within 0.25 ects credits, out of which 3 hours will be done under supervision (lecture and exercise solving), and the rest is individual student's work. examples of studies performed in their own countries should be used. assessment of students 1. reports presented by each group are considered as assessment. 2. an essay on the types of interventions required in own countries based on information from who sites or studies performed at national/local level. disability-adjusted life years: a method for the analysis of the burden of disease adriana galan definitions and basic concepts generally, statistics describing the health status of population suffer some limitations, reducing their practical value for the decision-making process: • first, the data are incomplete and fragmented. even if for example, the mortality data are available, they cannot describe the impact on health status of the different diseases or non-fatal disorders (like dementia or blindness for instance); • second, the estimates of death cases of different diseases can be inflated by epidemiologists acting as advocates for a target population, in order to obtain more resources; • last, but not the least, traditional statistics don’t allow decision-makers to compare the relative cost-effectiveness of different interventions (1). this is why a new approach called the „global burden of disease” was proposed, trying to solve the above-mentioned problems and having three explicit goals: • to include the non-fatal conditions into the health status evaluation; • to produce objective, independent and demographically credible evaluation of the burden of disease; • to convert the burden of disease into a general currency, in order to calculate the cost-effectiveness of different interventions. in order to integrate both the impact of premature death and disability into one single currency, time measurement was considered to be an important integrative factor: time (years) lost by premature death and time (years) lived with disability. a standardized indicator called disability adjusted life year (daly) was proposed for the measurement of the global burden of disease. daly represents the years of life lost due to premature death and years lived 141 disability-adjusted life years: a method for the analysis of the burden of disease with disability of a specified degree of severity and duration. therefore, one daly represents one year of healthy life lost. premature death is defined as one that occurs before the age to which a dying person would have expected to survive, if this person would belong to a standardized population pattern having the longest life expectancy at birth in the world, meaning the female population of japan. to calculate the total number of daly for a certain condition in a population, years of life lost (yll) and years lived with disability (yld) of a certain degree of severity and duration must be estimated. then, these estimates must be summed up. for instance, to calculate daly due to traffic accidents for one year, the total number of years of life lost due to fatal traffic accidents and the total number of years lived with disability by the accidents survivors must be summarized. even if to quantify the burden of disease looks like a simple exercise, a society must define first its ideal health status, considered to be the reference one. this means to find the answer for fundamental basic questions: what would be the ideal life expectancy? are all people equal? the researchers must decide on the expected number of years a person of a certain age would live in a reference (ideal) population. daly is based on egalitarian principle. only age and gender were considered for calculating the burden of disease, these two characteristics not being directly related to health. there were not considered characteristics such as: socioeconomic level, ethnicity or level of education. according to these principles, for calculating daly a standard life-table was used for all populations, life expectancy at birth being 82.5 years for females and 80 years for males. are the healthy life years more precious for young adults than for infants or elderly? generally, if one should choose between saving a life of a 2 years old child and of a 22 years old person, most people would prefer the 22 years old person. this is due to the fact that an adult plays a more important role in family, community and society. this was the reason for the researchers to include an age-weighting to calculate daly. it was assumed that the relative value of one life year rapidly increases from zero (at birth) to a peak around 20 years of age, decreasing after this age but less sharply (see figure 1). 142 health systems and their evidence based development figure 1. relative value of one year lived at different ages, included into daly is a healthy life year more important now for a society than 30 years later? it is very likely that a person would prefer to receive today 100 e rather than after one year. like the depreciation of one euro over time, it seems that the value of healthy life is depreciating over time. usually it is preferred to experience a healthy year of life now rather than some years thereafter, even if this opinion has initiated lots of debates among economists, experts in medical ethics and public health decision-makers. despite these debates, the researchers decided to discount the future years of life, e.g. by 3% per year. discounting looks like an exponentially decreasing function. due to the fact that the discount is significant, the researchers are usually publishing also daly calculated without the discount factor. discounting future health reduces the value of interventions having a long-term impact – for example the impact of vaccination against hepatitis b, which can prevent thousands of future cases of liver cancer, however many years later. how can one compare yll with yld? while death can be easily defined, the definition of disability is more complicated. usually, there are two methods used to evaluate the social preferences of certain health states. both methods involve peoples’ judgement on the compromise between quantity (length) and quality of life. this can be expressed as a compromise for time (how many years lived with disability would be changed for a fixed period of perfect health) or a compromise between persons (the choice between saving one year of life for 1000 healthy people or half a year of life for 2000 persons having health problems). a protocol based on person trade-off method was established. this was possible due to a formal exercise organized by 143 disability-adjusted life years: a method for the analysis of the burden of disease 0 0.5 1 1.5 2 0 20 22 40 60 80 100 age (years) re la ti v e w e ig h t who in 1995 (2), where worldwide health professionals have participated. the severity for 22 disability conditions was weighted between 0 (perfect health) and 1 (equivalent of death) (table 1). these weights for the 22 disability conditions were grouped into 7 classes. table 1. severity of disability: disability classes and weights set for 22 indicator conditions source: who. available at http:\\www.who.int. to assess the impact of varying these social choices on the final measures of burden of disease, the researchers have calculated daly with alternative age-weighting and discount rates, and with alternative methods for weighting the severity of disability. generally, the ranking of diseases and the distribution of burden by cause groups are substantially not affected by age-weighting and slightly affected by the method for weighting disability. by contrast, changes of the discount rates may have a more significant effect on overall results. the most significant effect of changing the discount rate and age weights is to reduce the relative importance of psychiatric conditions. however, the accuracy of basic epidemiological data from which daly is calculated will influence the final results much more than any of the above-mentioned weights. we can conclude that efforts should be firstly invested in improving the basic epidemiological data. 144 health systems and their evidence based development disability class severity weights indicator conditions 1 0.00 – 0.02 vitiligo on face, weight-for-height less than 2 standard deviations 2 0.02 – 0.12 watery diarrhea, severe sore throat, severe anemia 3 0.12 – 0.24 radius fracture in a stiff cast, infertility, erectile dysfunction, rheumatoid arthritis, angina 4 0.24 – 0.36 below-the-knee amputation, deafness 5 0.36 – 0.50 rectovaginal fistula, mild mental retardation, down syndrome 6 0.50 – 0.70 unipolar major depression, blindness, paraplegia 7 0.70 – 1.00 active psychosis, dementia, severe migraine, quadriplegia health status assessment by use of daly a who study on the world burden of diseases showed that the top 10 causes of disease burden are responsible for 46% of all daly (see table 2). it was also shown that five of the top 10 causes of daly primarily affect children under 5 years of age. two of the top 10 causes (malaria and hiv) predominantly affect poor populations. these 7 causes are all part of infectious diseases, perinatal conditions and nutritional disorders, representing who priorities. the remaining 3 causes (unipolar major depression, ischemic heart disease and cerebrovascular disease) are chronic diseases. rankings based on daly differ substantially from rankings based on the number of deaths. the importance of major depression worldwide, even if it generates only few deaths, was one of the key findings of this study. the weight of certain causes of total daly differs significantly if the results are analyzed by geographical distribution. for example, in sub-saharan africa, hiv accounted for 20% of the burden of disease in the region; malaria, tuberculosis and vaccine-preventable childhood diseases were responsible for another 20%. on the other hand, although road traffic accidents, falls and self-inflicted injuries account for 6.7% of total dalys, their prevention was not a key issue of the public health policy in developing countries. if we analyze the burden of disease attributable to different risk factors, we notice that in 1990, malnutrition accounted for almost 6 million deaths (11.7% overall) and 220 million dalys (15.9% overall); tobacco use accounted for 3 million deaths and 36 million dalys (see table 3). similar studies were performed in usa. in 1996, 34.5 million dalys were lost: 18.5 million for men and 16 million for women. it’s worthwhile to notice that the major causes of dalys differ significantly between developed countries and the rest of the world. e.g. in usa the 9 of the top 10 causes of dalys include injuries and non-communicable diseases. 145 disability-adjusted life years: a method for the analysis of the burden of disease table 2. leading causes of daly for the world in 1999 table 3. burden of disease attributable to selected risk factors in the world, 1990 146 health systems and their evidence based development rank cause dalys* % of total dalys deaths* % of total deaths 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 all conditions lower respiratory tract infections hiv conditions during perinatal period diarrheal diseases unipolar major depression ischemic heart disease vaccine-preventable diseases cerebrovascular diseases malaria nutritional deficiencies road traffic accidents chronic obstructive pulmonary disease (copd) congenital abnormalities tuberculosis falls maternal conditions self-inflicted sexually transmitted diseases (excluding hiv) alcohol use bipolar disorder 1 438 154 96682 89819 89508 72063 59030 58.981 54638 49856 44998 44539 39573 38156 36.557 33287 30950 26101 25095 19747 18743 16368 100 6.72 6.25 6.22 5.01 4.10 4,10 3.80 3.47 3.13 3.10 2.75 2.65 2.54 2.31 2.15 1.81 1.74 1.37 1.30 1.14 55 965 3963 2673 2356 2213 1 7089 1554 5544 1086 493 1230 2660 652 1669 347 497 893 178 60 5 100 7.08 4.77 4.20 3.95 0.00 12.66 2.75 9.90 1.94 0.88 2.19 4.75 1.16 2.98 0.62 0.88 1.59 0.31 0.10 0.00 * values are expressed in thousands. data source: who global burden of disease study, 1999. risk factor deaths* % of total deaths daly* % of total daly malnutrition poor water supply, sanitation and personal and domestic hygiene unsafe sex tobacco use alcohol use occupational hypertension physical inactivity illicit drug use air pollution 5881 2668 1095 3038 774 1129 2918 1991 100 568 11.7 5.3 2.2 6.0 1.5 2.2 5.8 3.9 0.2 1.1 219575 93392 48702 36182 47687 37887 19076 13653 8467 7254 15.9 6.8 3.5 2.6 3.5 2.7 1.4 1.0 0.6 0.5 * values are expressed in thousands data source: who world study. projections of future burden of disease and risk factors are extremely useful for the decision-making process. the secular trend analyses allow for an approximate prediction of the burden of disease at any moment in the future. at harvard school of public health, murray and lopez (3) performed a study, which revealed that by 2020, the ranking of burden of disease is expected to be dominated by ischemic heart disease, unipolar major depression and road traffic accidents (see table 4). by contrast, diseases affecting mostly children at present are projected to decrease due to the globalization of immunization campaigns. table 4. projected change in rank order of dalys for the 15 leading causes in 2020 compared with 1990 in romania, the institute of public health bucharest has also performed a study aiming to assess the burden of disease for 1998. the study revealed that the predominant causes of dalys in romania are the non-communicable diseases and accidents, a pattern similar with the american one rather than the world pattern. ranking order of dalys in romania is presented in table 5. table 5 shows that the burden of mental and behavioral disorders is placed on the third rank, like in the predicted american pattern for 2020. the same study revealed that there are 7 deprived districts in romania, clustering in the south and western part of the country. 147 disability-adjusted life years: a method for the analysis of the burden of disease rank by year: 2020 1990 disease or injury 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 5 4 9 6 12 1 7 16 2 28 3 19 10 17 33 ischemic heart disease unipolar major depression road traffic accidents cerebrovascular disease copd lower respiratory tract infections tuberculosis war diarrheal disease hiv perinatal conditions violence congenital abnormalities self-inflicted injuries trachea, bronchus and lung cancers reprinted from murray and lopez study table 5. ranking order of daly in romania, 1998 148 health systems and their evidence based development group of diseases dalys (years) % of total daly 1. cardiovascular diseases 1 350 203 31,88 2. cancers 426 951 10,10 3. mental and behavioral disorders 422 853 9,98 4. accidents, injuries, poisonings 376 500 8,89 5. central nervous system diseases 307 684 7,26 6. digestive system diseases 267 621 6,32 7. respiratory system diseases 242 524 5,72 8. infectious diseases 82 802 1,95 9. congenital abnormalities 69 715 1,64 10. perinatal conditions 52 317 1,23 11. genitourinary system diseases 46 550 1,09 12. endocrin and nutrition diseases 44 032 1,04 13. blood diseases 39 615 0,93 14. diabetes 24 916 0,58 15. bones diseases 14 877 0,35 16. pregnancy, delivery conditions 13 174 0,31 17. organic mental disorders 10 183 0,24 18. tuberculosis 2 049 0,04 19. skin diseases 1 358 0,03 20. other 438 963 10,41 total 4 232 887 100 data source: study performed by iphb. exercise: disability-adjusted life years as a key tool for the analysis of the burden of disease task: students read the two files containing who reported data on mortality and daly (www.who.int/whosis/menu.cfm). after that, they should: – compare the mortality rankings with daly rankings and comment the differences; and – compare daly rankings between different who areas and comment the differences. 149 disability-adjusted life years: a method for the analysis of the burden of disease references 1. michaud c, murray cjl, bloom b. burden of disease – implications for future research, jama, vol. 285(5), february 7, 2001. 2. world health organization. the world health report 2000: health systems: improving performance, geneva: world health organization, 2000. 3. murray cjl, lopez ad. the global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 projected to 2020, cambridge, harvard school of public health, 1996. recommended readings • www.who.int/whosis/menu.cfm click on burden of disease project, then on gbd 2000 documentation. you can find there: guidelines (gbd 2000 guidelines for epidemiological reviews), paper 36 (this discussion paper provides an overview of the global burden of disease 2000 project: its aims, methods and data sources, and version 1.0 results as reported in the world health report 2001), paper 50 (this discussion paper provides an overview of the global burden of disease 2000 project: its aims, methods and data sources, and version 2.0 results consistent with the estimates for 2001 reported in the world health report 2002), summary measures of population health (recent who publication addressing a wide array of critical issues regarding the measurement of population health using comprehensive indices combining information on mortality and ill-health). in bmj collection (http://bmj.com): search/archive keywords: disability adjusted life years: • trude arnesen, erik nord. the value of daly life: problems with ethics and validity of disability adjusted life years, bmj november 1999 • john wright, john walley. health needs assessment: assessing health needs in developing countries, bmj june 1998 • luc bonneux, jan j barendregt, wilma j nusselder, paul j van der maas. preventing fatal diseases increases healthcare costs: cause elimination life table approach, bmj january 1998 • kamran abbasi. the world bank and world health: under fire, bmj april 1999 150 health systems and their evidence based development 151 calculating the potential years of life lost health systems and their evidence based development a handbook for teachers, researchers and health professionals title calculating the potential years of life lost module: 1.7 ects (suggested): 0.25 author(s), degrees, institution(s) aurelia marcu, md, phd public health consultant, phd, head of department of strategies and forecasts in public health address for correspondence institute of public health bucharest 1-3 dr. leonte street 76256 bucharest romania tel: (4021) 2249228 / ext.188 fax: (4021) 3123426 e-mail: amarcu@ispb.ro keywords premature death, potential years of life lost, mortality pattern, trend analysis, priority setting learning objectives at the end of this course, students should: • identify the basic concepts of potential years of life lost assessment; • be able to des cribe the factors influencing the calculation of pyll; and • be able to describe and compare the health status of population based on potential years of life lost methodology. abstract this course covers the following topics: the concept of premature death historical background; computing methods for pyll; other approaches for calculating pyll; main domains where pyll is a useful tool; examples from romania; and exercise. teaching methods this course covers the following topics: the concept of premature death historical background; computing methods for pyll; other approaches for calculating pyll; main domains where pyll is a useful tool; examples from romania and exercise. specific recommendations for teacher it is recommended that the module will be organized within 0.25 ects credits, out of which 3 hours will be done under supervision (lecture and exercise solving), and the rest is individual student's work. examples of studies performed in their own countries should be used. assessment of students 1. reports presented by each group can be considered as assessment. 2. an essay on the types of interventions required in their own countries based on information existing on who site, or studies performed at national / local level. calculating the potential years of life lost aurelia marcu potential years of life lost (pyll) represent a part of potential demography, based on the primary concept "potential of life". this concept is defined as the number of years a person / a group / a population is expected to live between certain ages or until end of life. these years can be lost due to premature death. the concept of premature death historical background the concept was used for the first time by petti during the xvii century. it was further used in '70s by canadian and french researchers. in 1977, romeder and mcwhinner proposed a new indicator "potential years of life lost between 1 and 70 years of age" for the purpose of ranking the causes of death (1). since then, this indicator was used for health planning as a "social indicator". computing methods for pyll i. the classical approach: the most used formula to compute pyll is: pyll = = where: i = number of 5-years age groups (see the table below) di = number of deaths within each age group 65 = upper limit for which a death is considered premature ai = age group middle point 152 health systems and their evidence based development 13 1 (65 ) i i i d a = −∑ i id w∑ due to the fact that age represents a continuous quantitative measure, one can use the following formula to calculate ai: some comments are necessary concerning the interval limits used to compute pyll: a) lower age limit: some authors do not take into account the first year of life because the maximum risk of death is encountered close to the delivery time; also during this period of time most causes of death are different from other age groups resp. of endogenous nature; economic investment is modest during this period etc. other researchers set the lower limit to "0" years, justified by the deficiencies of the reporting systems (in most current health information systems there are data related to infant deaths (0-1) at national level as total number of deaths but not for all causes of death. class no. age group ai wi = 65 ai di di wi 0 1 2 3 4 5=3 x 4 1 < 1 0,5 64,5=65-0,5 2 1 4 3 62 3 5 9 7,5 57,5 4 10 14 12,5 52,5 5 15 19 17,5 47,5 6 20 24 22,5 42,5 7 25 29 27,5 37,5 8 30 34 32,5 32,5 9 35 39 37,5 27,5 10 40 44 42,5 22,5 11 45 49 47,5 17,5 12 50 54 52,5 12,5 13 55 59 57,5 7,5 14 60 64 62,5 2,5 σ = 153 calculating the potential years of life lost i lower limit of class "i" upper limit of class "i 1" a 2 + + = b) the upper age limit (65 years) is established according to the existing level of crude mortality rate and of life expectancy at birth. for countries having a low economic level of development, with a low level of life expectancy at birth, the upper age limit must be decreased, in any case below the level of life expectancy at birth. conversely, for the developed countries, where the life expectancy at birth is higher than 70 years, the upper age limit should be established at 70 or even 75 years. for the potential years of life lost due to a certain disease or groups of diseases, age limits are established according to the natural history of this disease and to the research objectives. examples are aids, liver cirrhosis, and suicide: • in spain, the age limits for aids were established at 25-44 years (2) or 2039 (3); the key argument for choosing these limits was the natural history of disease: in spain, the main ways of transmission were sexual intercourse and intravenous drug abuse. in canada, hogg (4) recommended in 1996 the use of 1-75 years interval for aids. • for liver cirrhosis, lessa (5) recommended in 1996 to establish the age interval at 20-59 years for calculating pyll; he considered that before the age of 20, it is almost impossible that somebody dies from liver cirrhosis. • for suicide, a cause of death with an increasing frequency, mainly among men and in youth in romania, darragh (6) or riley (7) used the potential years of life lost before 45 years of age. as a general remark, no matter of country or researcher, for chronic diseases with a long duration, the classical age limits for calculating pyll are 1-65 or 75 years. ii. other approaches for calculating pyll: during the last 3-4 decades, more refined approaches to calculate pyll were proposed. 1) calculation of the absolute number of years lost by death before the age of 65 70 75 years: this number can be computed for the national level, for a geographical area (district, city), for urban / rural area, for men / women, or by group of diseases or even group of diagnoses (if the frequency of a diseases is high, especially among youth). two, at maximum three characteristics can be commonly combined to compute pyll. 2) calculation of the structure of pyll according to certain characteristics: the proportion of pyll can offer valuable information about the relative importance of each characteristic in generating premature death. it also 154 health systems and their evidence based development offers the possibility of problem ranking, thereby facilitating the priority setting process. when pyll is calculated for geographical areas (by district, by country), confidence limits can be estimated for the country mean. this method allows the identification of those areas where the number of deaths is significantly higher than the "expected" one. according to the calculated confidence limits, the districts can be split in three categories: • districts placed inside the confidence limits. for these districts, the level of pyll is close to the country mean, observed variations being explained only by the intrinsic variability of the phenomenon. • districts placed below the lower limit of the confidence interval. for these districts, the number of potential years of life lost is significantly lower than the country mean, therefore being in a favorable position. • districts placed above the upper limit of the confidence interval. these are deprived areas, where a significantly higher number of potential years of life are lost. from a public health view point, these districts represent a priority for intervention. 3) for the calculation of the geographical disparities of pyll, also specific techniques to characterize frequency distributions can be used (8): quartiles, medians, and percentiles. in order to apply these statistical parameters, several common steps must be accomplished: • ranking the districts (areas) according to a certain characteristic proportion (e.g. proportion of pyll by an infectious disease like tuberculosis), in ascending order; • computing the cumulative frequency; • calculating the median value. districts placed within the upper half of the ordered series representing high proportions of pyll can be considered as deprived. the quartiles basically divide the ordered series into 4 equal sub-series (q1 q4). districts are then placed accordingly within any quartile. districts placed within the first quartile (q1) are in a favorable situation, while districts placed within the fourth quartile (q4) are the deprived ones. districts placed within q2 and q3 can be considered as having a middle position. percentiles can be calculated starting from the relative cumulative frequency (presented as percent). a threshold percentile has to be established. 155 calculating the potential years of life lost 4) the average number of years lost per premature death (before age of 65, 70 or 75): it represents a simple mean. a higher value of this mean emphasizes a higher death frequency among young age groups, consequently a higher social impact of premature death. the formula for calculating the average number of years lost with a premature death is: different characteristics can again be considered for calculating the average number of years lost for a premature death: by district (administrative unit), by residence (urban/rural), by group of diseases, by gender. the results can be used as a guideline for a priority setting process identifying geographical disparities. 5) calculation of the number of potential years of life lost per 1000 inhabitants: this calculation reflects the impact of premature death on the whole population. this indicator was used to underline the impact of pyll (calculated for 5 causes of premature death: cardiovascular diseases, neoplasm, digestive system diseases, accidents and respiratory system diseases) at whole population level. 6) the standardized pyll ratio: it is well-known that the risk of death is strongly influenced by age. this is why dever (9) proposed the use of standardized pyll ratio. it is recommended to use this indicator only for comparisons, as it does not describe the real magnitude. an expected number of pyll is calculated under the hypothesis that the frequency of premature death in all areas is the same within each age group (a standard mortality pattern is used). the observed value (calculated from real data) is divided by the expected value. if the ratio is higher than 1, it means that the frequency of premature death is higher than expected. this result can emphasize a health problem in the area. it is obvious that the favorable situation is represented by a ratio smaller than 1, suggesting that the premature deaths do not represent a problem in the area. 156 health systems and their evidence based development total number of pyll average number of pyll / premature death number of premature deaths = st absolute number of pyll 1000 population at 1 july x the formula for calculating the direct standardized pyll ratio is: where: n = total number of population under study ni = number of population within "i" age group n0 = total number of standard population ni0 = number of standard population within "i" age group n0 = σ ni0 n = σ ni di = number of deaths within "i" age group of population wi = 65 ai 7) pyll related to the life expectancy: the following formula was used: pyll = σ diei where: di = observed deaths within "i" age group ei = life expectancy for "i" age group main domains where pyll is a useful tool 1) the analysis of mortality patterns impact evaluation of certain causes of death the concept of premature death is more and more used for the analysis of mortality patterns due to the increase of life expectancy at birth, the slightly increasing trend of the crude mortality rate, the change of morbidity patterns (decreasing frequency of communicable diseases together with an increasing trend of chronic disease prevalence). 157 calculating the potential years of life lost 13 i0 i 0 ii 1 n d pyll n n n ix w = = ∑ the relative importance of the different causes of death is clearly distinct depending on the method used: pyll reflect those causes of death affecting mainly the young population, the active one, consequently causing the biggest economic loss. the economic loss includes the visible loss (the person ends to produce) and the hidden loss (the society doesn't recover the educational investments for the young lost person). for example, in developed countries the hierarchy of the main causes of death is: cardiovascular diseases, tumors and accidents. the same hierarchy according to pyll is: accidents, tumors and cardiovascular diseases. some examples of pyll analysis: in spain 52,3% out of all premature deaths are due to accidents (10), in denmark 34% (11). 2) descriptive epidemiology of diseases (groups of diseases) trend analysis in the framework of descriptive epidemiology, the concept of pyll is used to describe the different diseases according to some characteristics (gender, age group, residence, and district). pyll was used most frequently to describe: accidents suicide cancer repeated cross-sectional studies allow identifying the changes in the hierarchy causes of premature death due to interventive actions. 3) to identify and rank health problem pyll are often used to identify and rank the health problems at different levels: national, district, city. the decision-makers can plan the interventive actions based on pyll hierarchy. 4) useful for the design of health programs pyll are useful for: identifying the persons to be included in the health programs (target population), establishing the health programs objectives, evaluating the intervention / health programs results / outcomes, cost-effectiveness analysis. 158 health systems and their evidence based development in 1990, in japan (12) have used pyll to evaluate the efficacy of a screening program for uterine cancer. the efficacy criterion was the degree (%) of pyll reduction. the reduction percent was directly correlated with the screening coverage degree for the female target group. in canada (13), 2 risk factors have been addressed: smoking and alcohol consumption, both of them responsible for several non-communicable diseases. consequently, 10% of pyll in canada were attributable to smoking, associated with alcohol consumption. wigle estimated (14), also in canada, that 50% of premature deaths can be prevented by control of smoking, hypertension, hypercholesterolemia, diabetes and alcohol abuse. only 12% of premature deaths can be prevented by improving the health care services. examples from romania the institute of public health in bucharest has performed several studies to evaluate the health status of the romanian population, using different methods, in order to support the ministry of health in developing adequate health policies and programs. one of these studies was based on the evaluation of the impact of premature death (before the age of 65) by calculating the potential years of life lost for the period 1994 2000. according to this study, during this period of time, the ranking of pyll due to the top 5 causes was relatively stable among men: 1. accidents, injuries and poisonings (25% of total pyll) 2. cardiovascular diseases (20-21%) 3. cancers (12-14%) 4. respiratory diseases (12-10%) 5. digestive diseases (8-9%) among men, the weight of premature death due to cancers has increased, while the weight of premature death due to respiratory diseases has decreased during this period. considering the same ranking among women, it can be noticed that the pattern is variable year by year. nevertheless, the most important cause of premature death among women for the whole period was cancer, with an increasing trend from 17% in 1994 to 22% in 2000. table 1 is summarizing the results for the year 2000. 159 calculating the potential years of life lost table 1. structure of pyll by top 5 causes, romania, 2000 source: iphb study, 2002 it can also be noticed that the ratio pyll / 1000 men to pyll / 1000 women was almost stable. according to these findings, two health priorities have been identified for the decision-makers: accidents among men and cancers among women. rank total % rank men % rank women % 1 accidents 21.1 1 accidents 24.8 1 cancers 21.9 2 cardiovascular 20.4 disease 2 cardiovascular 21.5 disease 2 cardiovascular 18.2 disease 3 cancers 17.1 3 cancers 14.6 3 accidents 13.9 4 respiratory 11.3 diseases 4 respiratory 10.4 diseases 4 respiratory 13.2 diseases 5 digestive 8.7 diseases 5 digestive 8.6 diseases 5 perinatal 7.7 conditions 160 health systems and their evidence based development exercise: how to calculate potential years of life lost (proposed by adriana galan) task: students should read the two files containing who reported data on mortality and yll (years of life lost due to premature deaths) 2001, available at url: http://www3.who.int/whosis/menu.cfm?path=whosis,burden,burden_estimates&language=english. after that, they should: compare the mortality rankings with yll rankings and comment the differences; and compare yll rankings between who areas and comment the differences. 161 calculating the potential years of life lost references 1. romeder jm, mcwhinnie jr. potential years of life lost between ages 1 and 70: an indicator of premature mortality for health planning. int j epidemiol 1977; 2: 143-51. 2. castilla j. impact of human immunodeficiency virus infection on mortality among young men and women in spain. int j epidemiol 1997; 6: 1346-51. 3. mur c. the impact of aids in the global mortality in catalonia 1981-1993. med clin (barcelona) 1995; 14: 528-31. 4. hogg rs. health, hiv/aids mortality in canada: evidence of gender, regional and local area differentials. aids 1996; 8: 889-94. 5. lessa. i liver cirrhosis in brasil: mortality and productive years of life lost premature. bol ofic sanit panam 1996; 2: 111-22. 6. darragh pm. epidemiology of suicides in northern ireland 1984 1989. ir j med sci 1991; 11: 354 -7. 7. riley r, paddon p. accidents in canada: mortality and hospitalization. health rep 1989; 1: 23-50. 8. gomez mo. a proposal to use the media and percentiles vs. mean in the analysis of pyll. gac sanit 1992; 32: 229-30. 9. dever a. epidemiology in health services management. aspen publications 1984. 10. graells m, garcia p. alcohol-related mortality in catalonia 1994. rev esp salud publica 1998; 1: 25-31. 11. bjerregaard p. fatal non-intentional injuries in greenland. arctic med res 1992; 7: 22-6. 12. kuroishi t, hirose k. evaluation of the effectiveness of mass screening for uterine cancer in japan: the pyll. environ hlth perspect 1990; 87: 51-6. 13. romeder jm, mcwhinnie jr. the development of potential years of life lost an indicator of premature mortality. rev epidemiol sante publique 1978; 1: 97-115. 14. wigle dt. premature deaths in canada: impact, trend and opportunities for prevention. can j public hlth 1990; 5: 376-81. recommended readings in bmj collection (http://bmj.com): search/archive keywords: potential years of life lost • david blane, frances drever. inequality among men in standardised years of potential life lost, bmj july 1998 • janice hopkins tanne. cause of death among americans differs with race and education, bmj november 2002 • martin mckee, vladimir shkolnikov. understanding the toll of premature death among men in eastern europe, bmj november 2001 • zosia kmietowicz. government policies set to narrow „health gap”, bmj september 2000 162 health systems and their evidence based development 163 case study: inequalities in health as assessed by the burden of disease method health systems and their evidence based development a handbook for teachers, researchers and health professionals title case study: inequalities in health as assessed by the burden of disease method module: 1.8 ects (suggested): 0.25 author(s), degrees, institution(s) khaled yassin, dr. med dr.ph section of international public health, faculty of health sciences, university of bielefeld, pobox 100131 d-33501, bielefeld adriana galan, it specialist part-time lecturer at the university of medicine and pharmacy, department of public health and management, at the master course in management of public health and health services, bucharest address for correspondence section of international public health faculty of health sciences, university of bielefeld pobox 100131 d-33501 bielefeld, germany institute of public health bucharest 1-3 dr. leonte street, 76256 bucharest, romania tel: (4021) 2249228 / ext.188 fax: (4021) 3123426 e-mail: agalan@ispb.ro keywords health inequalities, burden of disease, health vulnerability, non-fatal health outcomes learning objectives at the end of this exercise, students should: • be aware of the complexity of health inequalities assessment; • be able to describe the weaknesses of present studies aiming to assess the health inequalities; • be able to describe the advantages of using disability adjusted life years (daly) as a composite indicator in studies of health inequalities. abstract this course gives a short literature review on studies about health inequalities, along with their weaknesses (shortcomings of research, descriptive rather than analytical, methodological and conceptual problems, and study design problems). here are also short presentation of daly concept and the advantages of using this composite indicator in studies aiming to assess the health inequalities. teaching methods interactive group discussion of each paragraph, revealing the key concepts and main conclusions. each concept or general remark will be written on a flipchart. specific recommendations for teacher this module to be organized within 0.25 ects credits, out of which case study takes 2 hours of discussions and will follow the module of disability-adjusted life years as a key tool for the analysis of the burden of disease. another 4 hours will be destined to individually review electronic and printed literature in the field. assessment of students a short (max. one page) essay developing the three main ideas selected during the exercise will be assessed. case study: inequalities in health as assessed by the burden of disease method khaled yassin, adriana galan today there is a general consensus that health inequalities still persist and in some cases have even been increasing not only in developing countries, but in europe as well. since the late 1970s, an increasing number of studies have provided ample evidence of the growing gap in health between different social groups. for example, it was consistently proven that people at a socioeconomic disadvantage suffer a heavier burden of illness and have higher mortality rates than their well-off counterparts (1,2,3,4,5,6,7,8). these observations have refuted previous arguments that health inequalities were disappearing, or had disappeared in european societies. these socio-economic inequalities in health are a major challenge for health systems, not only because most of these inequalities can be considered unfair, but also because a reduction in the burden of health problems in disadvantaged groups offers a great potential for improving the average health status of the population as a whole. furthermore, understanding health inequalities in a given community can improve the effectiveness and efficiency of the health care delivery by ensuring that appropriate interventions are delivered to the population at risk. recognizing the need to devote research attention to the question of health inequalities in modern industrial societies, we carried out a situation analysis in order to identify needs and, on this basis, prioritize areas for research. this review revealed the following points: firstly, while some progress has been made in studying health inequalities, this progress is not evenly witnessed in all european countries. the question has been explored more in countries such as the united kingdom, finland and sweden than, say, in germany, italy and spain. secondly, research studies of health inequalities focus traditionally on proving the existence of inequalities among broad social groups, rather than investigating or illuminating the reasons for such inequalities and the dynamics of their occurrence. equally neglected is the description of the most vulnerable groups. as a result, outcomes of many of these studies have been too general to form the basis for concrete action. 164 health systems and their evidence based development thirdly, the concepts of health vulnerability and strategies for coping with socio-economic disadvantage have been seldom considered in research of health inequalities in europe or elsewhere. inequalities have been examined among different social groups using various indicators for poverty, income, occupation, education, etc. whereas poverty is basically an absolute and economically determined concept, vulnerability is a relational and social one. it does not conceive inequalities as numbers of people with certain occupations, level of education, or of a certain gender having heavier burden of mortality or morbidity from certain diseases. rather, vulnerability research attempts to understand inequalities as real people coping with uncertainty and risk within real societies. health vulnerability is not defined in terms of percentage of income relative to national standards, but a question of defenselessness, insecurity and exposure to risk, shocks and stress. the point is that although poverty may be a proxy indicator, it does not necessarily amount to the vulnerability. the feasibility of action plans based on vulnerability findings differs from one based on results of poverty research. vulnerability has three dimensions: (1) the risk of exposure to health threats; (2) the risk of inadequate capacities to cope with the imposed health threats; and (3) the risk of severe consequences. consequently, the most vulnerable groups are those most exposed to health threats and those possess the most limited coping capabilities and suffer from the most severe consequences and are endowed with the most limited capacity for recovery. fourthly, there are several design problems that adversely affect the validity and comparability of studies of health inequalities. such studies were to attain the twin goals of measuring health and measuring inequalities. several indicators are traditionally used to measure health such as perinatal and infant mortality, all-cause and major-cause mortality, reported chronic illness, subjective sense of wellbeing, and the incidence of certain diseases. mortality indicators, although helpful, do not include the level of suffering and disability from non-fatal outcomes of diseases. subjective ratings of health are shown to be confounded by the differing thresholds among different social class groups for recognizing or reporting ill-health or disability. disease-specific measures are very selective because while the morbidity from some diseases is more prevalent in disadvantaged social groups, some others are more prevalent in the more advantaged ones. measuring inequalities is not less troublesome than measuring health as about dozen different methods are being currently used. they vary in accuracy, complexity and ‘informativity’. it is quite obvious that there are huge di165 case study: inequalities in health as assessed by the burden of disease method fferences between the measures used in the study of health inequalities (9,10,11,12,13,14,15,16,17). these differences in addition to differences in the quality of data collected over different periods of time or among countries are good justifications for interpreting them cautiously. studies of health inequalities have focused on comparing mortality indices among different social groups. such approach assumes death alone can reflect the burden of disease and differentials in mortality indicators can therefore mirror the health inequalities between these groups. death, however, is not the only consequence of disease. a wide array of scenarios can follow a morbid condition. this can include full recovery, a period of disability followed by full recovery, a period of disability followed by death or permanent disability. these non-fatal outcomes constitute a significant part of the burden of disease, which has been ignored by the previously mentioned indicators. the few studies that considered the burden of non-fatal health outcomes were tailored to specific diseases (diabetes, rheumatoid arthritis, etc.) in particular groups. furthermore, the fact that nearly all these measures are based on self-reports explains why the reliability and validity of such measures have been long questioned especially when inter-community and inter-temporal comparisons are attempted. given these shortcomings in current measures of the burden of fatal and non-fatal consequences of disease, the world health organization and the world bank endeavored the disability adjusted life years (dalys) as a measurement unit of the burden of disease (18). the daly has been successfully used to assess the global burden of disease and the who has advocated the use of daly to study health inequalities as well. the daly is a composite indicator of the burden of disease, which incorporates both the years of life lost due to premature mortality and varying degrees of disability. the daly expresses therefore years of life lost due to premature death and years lived with a disability of specified severity and duration secondary to these priority diseases. one daly is thus one lost year of healthy life. a premature death is defined as one that occurs before the age to which the dying person could have been expected to survive according to the life expectancy in the european society. using the daly in studies of health inequalities envisages several advantages. first, the daly is the only measure that can infuse information about non-fatal health outcomes into debated of health inequalities. second, the daly uncouples social and epidemiological assessment of health inequalities from advocacy. third, the daly can measure the magnitude of premature 166 health systems and their evidence based development death and non-fatal health outcomes attributable to proximal biological causes, including diseases and injuries or attributable to more distal causes such as poor living standards, tobacco use or socio-economic determinants. fourth, the daly is a stable measure that can be used for purposes of comparisons either between different communities or between different points of time. 167 case study: inequalities in health as assessed by the burden of disease method exercise: inequalities in health in the european region: what can the burden of disease methodology offer? task: based on the list of key concepts and conclusions revealed under supervision during the group discussion, students will be asked to make a summary of these ideas and select the most 3 important and useful of them on their opinion. give some reasons for this selection. 168 health systems and their evidence based development references 1. mackenbach jp. socio-economic health differences in the netherlands: a review of recent empirical findings. soc sci med 34/3, 213-26, 1992. 2. kunst ae, groenhof f, borgan jk et al. socio-economic inequalities in mortality. methodological problems illustrated with three examples from europe. rev epidemiol sante publique 46/6, 467-479, 1998. 3. mackenbach jp, kunst ae. measuring the magnitude of socio-economic inequalities in health: an overview of available measures illustrated with two examples from europe. soc sci med 44/6, 757-71, 1997. 4. van de mheen h, stronks k, schrijvers ct et al. the influence of adult ill health on occupational class mobility and mobility out of and into employment in the netherlands. soc sci med 49/4, 509-18, 1999. 5. blank n, diderichsen f. inequalities in health: the interaction between socio-economic and personal circumstances. public health 110/3, 157-62, 1996. 6. marmot m, ryff cd, bumpass ll et al. social inequalities in health: next questions and converging evidence. soc sci med 44/6, 901-10, 1997. 7. mackenbach jp, van de mheen h, stronks k. a prospective cohort study investigating the explanation of socio-economic inequalities in health in the netherlands. soc sci med 38/2, 299-308, 1994. 8. williams k. inequalities in health. are they increasing? bmj 310/6976: 399, 1995. 9. mackenbach jp, kunst ae, cavelaars ae et al. socioeconomic inequalities in morbidity and mortality in western europe. the eu working group in socioeconomic inequalities in health. lancet 349/9066, 1655-9, 1997. 10. kunst ae, groenhof f, mackenbach jp. mortality by occupational class among men 30-64 years in 11 european countries. eu working group in socioeconomic inequalities in health. soc sci med 46/11, 1459-76, 1998. 11. wagstaff a, paci p, van doorslaer e. on the measurement of inequalities in health. soc sci med 33/5, 545-57, 1991. 12. valkonen t. problems in the measurement and international comparisons of socio-economic differences in mortality. soc sci med 36/4, 409-18, 1993. 13. murray cj, gakidou ee. health inequalities and social group differences: what should we measure? bull world health organ 77/7, 537-43, 1999. 14. locker d. measuring social inequality in dental health services research: individual, household and area-based measures. community dent health jun 10/2, 139-50, 1993. 15. valerio m, vitullo f. dagli indicatori di sanità e diseguaglianza globali a quelli per microaree (health inequalities: from macro to micro level indicators). giornale italiano di farmacia clinica 12: 146-156, 1998. 16. vitullo f, marchioli r, di mascio r et al. family history and socioeconomic factors as predictors of myocardial infarction, unstable angina and stroke in an italian population. eur j epidemiol 12, 177-185, 1996. 17. koskinen s. västöryhmien terveysja muut hyvinvointierot. tutkimusohjelman taustaselvitys. (variations in health and other dimensions of wellbeing). background report for a research programme (in finish, with english summary). publications of the academy of finland 3/1997. edita, helsinki, 81 pages, 1997. 18. murray cj, lopez j. global burden of disease. world health organisation, world bank and harvard school of public health publications, 1998. 169 case study: inequalities in health as assessed by the burden of disease method 170 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title health technology assessment as a tool for health systems development module: 1.9 ects (suggested): 0.50 author(s), degrees, institution(s) prof. jelena marinkovic, bm, phd the author is professor at the school of medicine at belgrade university. address for correspondence institute of medical statistics and informatics school of medicine, belgrade university dr suboti}a 15 11000 belgrade serbia and montenegro tel: +381 11 685 888 fax: + 381 11 659 533 e-mail: jelena@pcpetak.com keywords health technology assessment, decision-making in health purchasing, policy and practice, quality of care, outcomes research, decentralization/centralization, evidence-based knowledge learning objectives for many years this topic covered financial analysis and acquisition planning for high technology in health care. the basic premise of this course is that the purpose of assessment of a particular technology (including elements of technology itself, patient/citizen, organization and economy) is to discover the „true cost” of health produced by application of that technology. after completing this module students and public health professionals from a variety of backgrounds should: obtain • an overview of a background and origins of health technology assessment • an introduction to the scientific methods and instruments in health technology assessment summarize • the four main elements of a health technology assessment analysis the technology, the patient/citizen, the organization and the economy. • the steps that have to led to the assessed health technology examine • how decision-maker's questions are specified in health technology assessment • how literature is searched and collected • how studies could be designed • how data can be collected and analyzed • how published health technology assessments could be validated abstract health technology assessment methods are evolving and its application are increasingly diverse. this module introduces certain fundamental aspects and issues of a dynamic field of inquiry. broader par 171 health technology assessment as a tool for health systems development ticipation of people with multiple disciplines and different roles is enriching the field. like the information required conducting most assessments, the body of knowledge about health technology assessment cannot be found in one place and is not static. practitioners and users of health technology assessment should not only monitor changes in the field, but they should contribute to its development. content background origins what is health technology? what is health technology assessment? what is the purpose of health technology assessment? is it health technology assessment or a different approach that is needed? what are the main elements of hta analysis? when are health technologies assessments requested? what is the role of ethics in health technology assessment? how is health technology assessment conducted? selected issues in health technology assessment case example references teaching methods teaching methods include: lectures; study of literature in small groups (up to five students); guided discussion on previously done exercises and case problems; preparing a project report (in a group of three students) on one topic for a certain health technology. specific recommendations for teacher the topic allows a good combination of theoretical knowledge with practical skills. knowledge in quantitative and qualitative research designs and measurement issues; various methods from statistical, over informatics to economic is already expected from the student, as well as skills in computer and language.this module should be only first in line with three lectures, 6 exercises and group/individual work (three times). assessment of students project work with defense of the study; and multiple choice questionnaire. h e a l t h t e c h n o l o g y a s s e s s m e n t a s a t o o l f o r h e a l t h s y s t e m s d e v e l o p m e n t jelena marinković worldwide, publicly funded health services are under pressure due to demographic changes, growing expectations, and the development of new technologies. of these three major pressures, new technologies are generating the most concern and the most dramatic response (1,2,3). still, new technologies can benefit health and disability service consumers in many ways. some directly improve quality of life or life expectancy. others act more indirectly, for example, by increasing the efficiency of the health system. however, new technologies are often introduced before there is adequate information about safety, effectiveness and ethical and social acceptability. origins technology assessment (ta) arose in the mid-1960s from an appreciation of the critical role of technology in modern society and its potential for unintended, and sometimes harmful, consequences. experience with the side effects of a multitude of chemical, industrial and agricultural processes, and such services as transportation, health and resource management contributed to this understanding (4). ta was conceived as a way to identify the desirable first-order, intended effects of technologies as well as the higher-order, unintended social, economic and environmental effects (5). health technologies (ht) had been studied for safety, effectiveness, cost, and other concerns long before the advent of health technology assessment (hta). development of ta as a systematic inquiry in the 1960s and 1970s coincided with the introduction of health care technologies that prompted widespread public interest in matters that transcended their immediate health effects. health care technologies were among the topics of early tas. multiphasic health screening, in vitro fertilization, predetermination of the sex of children, retardation of aging and modifying human behavior by neurosurgical, electrical or pharmaceutical means were among the first, „experimental” assessments. 172 health systems and their evidence based development since its early years, hta has been fueled in part by emergence and diffusion of technologies that have evoked social, ethical, legal, and political concerns. among these technologies are contraceptives, organ transplantation, artificial organs, life-sustaining technologies for critically or terminally ill patients, and, more recently, genetic testing and genetic therapy. these technologies have challenged certain societal institutions, codes, and other norms regarding fundamental aspects of human life such as parenthood, heredity, birth, bodily sovereignty, freedom and control of human behavior, and death (6). hta is the only field of ta so far which has gained a distinctive profile in the sense of a particular subject, client, expertise and specialized institutions. hta like ta in general aims at supporting decision making by providing comprehensive information on the preconditions for, and consequences of the implementation of new technologies (7). what is health technology? goodman defines technology as the application of scientific or other organized knowledge including any tool, technique, product, process, method, organization or system to practical tasks. in health care, technology includes drugs; diagnostics, indicators and reagents; devices, equipment and supplies; medical and surgical procedures; support systems; and organizational and managerial systems used in prevention, screening, diagnosis, treatment and rehabilitation (4). according to the world health organization's (who) „health for all policy in the 21st century”, released in january 1998, the scope of technologies for health, extends from those technologies that provide a direct benefit to health (such as molecular genetics, biological, pharmaceuticals, and medical devices), to those that support health system functions (like telecommunications, information technologies, devices for environmental protection and food technologies). the international network of agencies for health technology assessment (inahta) defines health technology as prevention and rehabilitation, vaccines, pharmaceuticals, and devices, medical and surgical procedures, and the systems within which health is protected and maintained (8). under broad definitions such as these, the phrase „health (healthcare, medical) technology” can be used in both diagnostic and therapeutic settings and under either individual or population health approaches. health technologies might include, for example, chemotherapy for cancer, hearing aid techno173 health technology assessment as a tool for health systems development logy, electronic fetal monitoring, population screening for breast cancer, coronary artery bypass surgery, and magnetic resonance imaging. as the field of health technology assessment has evolved, these definitions have come to be seen as a fairly narrow definition of technology. in part, this has been due to a growing recognition that the arrangements and structures for delivery of drugs, device and procedures can have far reaching impacts not only on the use of technology but also outcomes of patients. to reflect the importance of these and other factors a more comprehensive definition of health technology is given by kristensen. he defines very broadly that health technology is the practical application of knowledge in relation to health and disease (9). with the health problem as the starting point, according to bakketeig (10), the aim of the technology can roughly be divided into following: preventive care (aimed at preventing diseases from occurring), screening (aimed at detecting early signs of diseases or risk factor, with the aim to slow down the development of the disease), diagnosis (aimed at identifying the diseases in patients with clinical signs and symptoms), treatment (seeking to maintain health status, cure the patient or provide palliation), rehabilitation (which takes its starting point in the treated, but still ill patient and seeks to restore the functioning or minimize the consequences of dysfunction or defects). what is health technology assessment? while there is no widespread consensus on the definition of health technology assessment, for a long time a widely accepted definition was that of the united states office of technology assessment (ota) that it is the field of research that evaluates the short and long-term consequences of individual medical technologies on individuals and society (11). hta is related to research due to its methods, but is also related to planning, administration, and management due to its focus on decision-making. thus, hta can be seen as a bridge between science paradigm and a policy paradigm (12). in europe in mid nineties hta is seen as a structured analysis of a health technology, a set of related technologies, or a technology-related issue that is performed for the purpose of providing input to a policy decision (13). hta beside the benefits and financial costs of a particular technology or group of technologies also includes studies of ethical and social consequences of technology; factors speeding or impeding development and diffusion of health technology; the effects of public policies on diffusion and use of health tech174 health systems and their evidence based development nology and suggested changes in those policies; and studies on variation in use of technologies (13). goodman defines hta as a systematic evaluation of properties, effects, and/or impacts of health technology. it may address the direct, intended consequences of technologies as well as their indirect, unintended consequences. its main purpose is to inform technology-related policymaking in health care. hta is conducted by interdisciplinary groups using explicit analytical frameworks drawing from a variety of methods (4). the international network on agencies for health technology assessment defines hta as multidisciplinary field of policy analysis that studies the medical, social, ethical, and economic implications of development, diffusion, and use of health technology (8). the broadest one is given by kristensen who defines health technology assessment as a research based, applied assessment of relevant available knowledge of problems, when applying technology in relation to health and disease. hta is a comprehensive, systematic assessment of the conditions for, and the consequences of using health technology (9). what is the purpose of health technology assessment? the purpose of hta is to assist health policy makers, managers and health professionals at local and national levels in making informed decisions both in health purchasing, policy and practice. hta information may be particularly useful in supporting decisions when: an established technology is associated with significant variations in utilization or outcomes, a technology is highly complex or involves significant uncertainty, a technology has high unit or aggregate cost, explicit trade-off decisions must be made in allocating resources among technologies, or a proposed provision is innovative or controversial. the essential properties of hta are the orientation to decision-making and its multidisciplinary and comprehensive nature. the goal of hta is change. that is, it encompasses all methods used by health professionals to promote health, prevent and treat disease, and improve rehabilitation and longterm care. 175 health technology assessment as a tool for health systems development is it health technology assessment or a different approach that is needed? it is useful to clarify whether hta is the right instrument to use for the particular problem because it may conceivably be more beneficial to apply a different approach. according to kristensen et al (9), the set of alternative procedures to clarify the problem are: source: kristensen fb, horder m, poulsen pb (eds.). health technology assessment handbook. danish institute for health technology assessment, 2001. what are the main elements of hta analysis? hta includes analysis and assessment of a number of areas, where use of the health technology may have consequences. these can be divided into four main elements: the technology, the patient/citizen, the organization and the economy. technology. assessment of technology includes the following main aspects that need to be assessed: field of application, effectiveness and risk assessment. this aspect is covered in more details later on. 176 health systems and their evidence based development alternative procedures to clarify the problem 1. health technology assessment 2. a quality-assurance project (if one knows what should be done in particular organizational situation, but what is presently done, is not the right approach). 3. a basis for decision-making developed in the usual administrative framework (if, for instance, a national hta or an hta from region is available). 4. a traditional expert and/or stakeholder committee (if the aspect of stakeholders is very important, or if the opinion of particular expertise desired, or if only little time is available). 5. exclusively a systematic literature review, possibly a meta analysis, to determine the clinical effects and efficiency of the technology. 6. an economic analysis (if sufficient knowledge of the effect and efficiency of the technology is available, and if there are no specific organizational questions). 7. a (primary-) research project (if documented research is simply not available, especially of the clinical effects). patient / citizen. examining the patient / citizen element in hta is covered with very different methods, as regards theoretical basis and application; from field research that includes participant observation, interviews that include focus group, questionnaire surveys to prospective methods. frequently measurement process is based on health status and health-related quality of life concept (4,14,15). organization. the aim of organizational analysis is to pinpoint some of the dimensions, which can be of importance for how interaction between technology, organization and administration develops, i.e. to describe some of the elements, which could play a part in the interaction between the behavioral patterns around technology, and point out possible consequences of different directions (16,17). economy. economy aspect includes economic, budget or business analysis. the first one is far more important and is mainly conducted at societal level, where economic consequences for society, which means everyone who is directly or indirectly affected by technology, are assessed and included. budget analysis is applied when investigating who carries the burden in terms of expenditures and who will benefit from the use of technology. at last, business analysis is conducted when the information about needs for investment and the running costs with respect to a technology are important (18). when are health technology assessment requested? assessments can be requested and conducted at any stage in a technology's life cycle. stages include: conceptual (in the earliest stages of development), experimental or investigational (undergoing initial testing and evaluation), preestablished (adoption of an innovation by certain individuals and institutions); established (considered to be a standard approach and diffused into general use); and outmoded (superseded by another technology or demonstrated to be ineffective or harmful). since technology is constantly evolving, hta must be viewed as an iterative process. it may be necessary to reassess a technology when competing technologies are developed, the technology itself evolves or new information is introduced. 177 health technology assessment as a tool for health systems development what is the role of ethics in health technology assessment? since hta is used to make judgments about what ought to be done with health technologies, there is significant overlap between it and medical ethics. according to goodman (19), conducting a technology assessment requires careful attention to ethical questions, such as: • should all assessments be driven by cost concerns? • are the individuals involved in the selection of topics, the conduct of the assessment, and the use of its results free of conflicts of interest? • are judgments of value implicit in the statement of the assessment problem or the choice of methodology? • are informed consent, patient confidentiality and related means for protecting patient welfare in clinical investigations properly implemented? • do assessments provide means (e.g., in data collection, synthesis and reporting) to determine how technologies challenge prevailing legal standards and societal norms? • are the assessment's recommendations ethically justified? how is health technology assessment conducted? hta process involves: the identification of technology, health or health care problems and possible assessments to address these; the priorization of possible assessments; assessment; dissemination of the findings and conclusions of assessments; the implementation of findings and conclusions in policy and practice, and impact assessment of resulting change. the ten steps listed below, according to goodman, provide a basic classical framework for conducting a health technology assessment (not all assessments involve each of these steps or conduct them in the same sequence) (19): 178 health systems and their evidence based development source: goodman c, snider g, flynn k. health care technology assessment in cva. boston, mass: management decision and research center, washington, dc: health services research and development service, 1996. when new technology is in question this framework has somewhat different stages: source: national health committee. new technology assessment in new zealand. discussion document, 2002. the source of next definitions and descriptions is publication „new technology assessment in new zealand”, published in year 2002 (20). horizon scanning is the process of identifying new and emerging technologies that have the potential to impact on a health system. it essentially involves formal or informal communication between policy makers and experts (21). 179 health technology assessment as a tool for health systems development ten steps of health technology assessment 1. identify and rank assessment topics 2. specify assessment problem 3. determine locus or responsibility of assessment 4. retrieve available evidence 5. collect primary data (as appropriate) 6. interpret evidence 7. synthesize evidence 8. formulate findings and recommendations 9. disseminate findings and recommendations 10. monitor impact of assessment reports a framework for new technology assessment 1. horizon scanning the identification of emerging technologies before they become available for introduction. 2. prioritization for assessment deciding which new or emerging technologies should undergo further assessment. 3. assessment a research-based process designed to determine whether a new technology is safe, efficacious, effective and efficient. 4. appraisal a judgment on the social and ethical acceptability and appropriateness of a new technology. this includes consideration of community need, equity, and opportunity cost. 5. adoption and diffusion the process whereby new technologies are taken up in clinical practice. 6. evaluation the ongoing assessment of a new technology following its introduction. new technology assessment requires significant time, expertise and resources. consequently, it is impossible to assess all emerging technologies. therefore, prioritization for assessment is an essential and crucial part of the framework. there should be an agreed set of criteria against which emerging technologies are prioritized for assessment. the assessment stage is based on empirical research. it aims to establish the effect (safety, efficacy and effectiveness) and efficiency of a new technology. this phase can be costly and labour intensive as it may involve primary research. where possible, a systematic review of the scientific evidence is performed (mainly using scientific literature from peer-reviewed journals). the gold standard test for safety, efficacy and effectiveness is a double-blind randomized controlled trial (rct). however, for several logistical and ethical reasons, it is not possible to conduct double-blind rcts for all new technologies. where double-blind rcts cannot be carried out, it is necessary to rely on the best alternative source of evidence. the task of selecting the best source of evidence is made easier by using well-accepted‚ levels of evidence (22). the efficiency (value for money) of a new technology is predicted by economic evaluation. there are several types of economic analysis that can be used to determine „value for money". these include cost-minimization analysis (cma), cost-effectiveness analysis (cea), cost-benefit analysis (cba) and cost-utility analysis (cua). these may be referred to collectively as efficiency analysis. the appraisal of a new technology involves taking into consideration community need, equity, appropriateness and acceptability, and opportunity cost. in contrast to the assessment phase, appraisal is more of an art than a science. it requires judgments to be made on social values and is informed by understanding of the health and disability sector and society in general. inputs from professionals, consumers and the wider community are considered to be particularly important at the appraisal stage. the adoption and diffusion stage is relatively self explanatory. as a new technology appears to be of value, patients begin to request it and clinicians begin to use it. ideally, a new technology that has been assessed and appraised and found to have a potential benefit will be adopted and diffused into the health and disability sector in a controlled manner; that is, the circumstances in which it is used will be agreed on before the technology has been adopted and diffused. in reality, new technologies tend to be adopted and diffused in a rather dis-organized manner. 180 health systems and their evidence based development new technology assessment should be an iterative process rather than a one-off study. evaluation helps to ensure that this is the case. it involves the monitoring and further studying of a technology once it has been introduced. this might include: preparation of qualitative and quantitative data collection systems to receive data for side effects and complications, appropriateness and acceptability of the community for the new technology and outcome measures conducting scheduled milestone evaluation to determine achievement of target evaluation measures collaboration with clinical evaluation and quality improvement programs (23). evaluation is important because the disease patterns and other characteristics of the population using the technology will inevitably change, and this may have implications for safety, effectiveness, efficiency and so on. in addition, during the initial stages of a technology's life cycle, the skills of practitioners in using the technology are not likely to be much higher. as skill level increases, the balance of risks and benefits associated with the new technology may change considerably. selected issues in health technology assessment quality of care and hta. quality of care is a measure or indicator of the degree to which health care is expected to increase the likelihood of desired health outcomes and is consistent with standards of health care. quality assurance involves a measurement and monitoring function (i.e., quality assessment). hta and quality assurance are distinct yet interdependent processes that contribute to quality of care. hta generates findings that add to our knowledge about the relationship between health care interventions and health care outcomes. this knowledge can be used to develop and revise health care standards, e.g., manufacturing standards, clinical laboratory standards, practice guidelines, and other agreed upon criteria, practices and policies regarding the performance of health care. in summary, hta contributes knowledge used to set standards for health care, and quality assurance is used to determine the extent to which health care providers adhere to these standards (24,25). outcomes research and hta. outcomes research concerns any inquiry into the health benefits of using a technology for a particular problem under general or routine conditions (26). in practice, the term outcomes research has been used interchangeably with the term effectiveness research since the late 1980s to refer to a constellation of methods and characteristics that overlap considerably with hta. centralization and decentralization of hta. although technology assessment have originated as a centralized function conducted by government 181 health technology assessment as a tool for health systems development agencies or other nationalor regional-level organizations, hta is also a decentralized activity conducted by a great variety of organizations that make technology-related policy decisions (27). as noted before, a hta done from a particular perspective may not serve the technology-related policymaking needs of other perspectives. evidence-based health technology assessment. eisenberg considers the next ten lessons for evidence-based technology assessment: innovation and flexibility should guide assessment; technology is more than devices; research and assessments should be linked with coverage; technology assessment is not a one-time exercise; new measures of outcomes should be developed; the community of practice is a laboratory for technology assessment; training and capacity building in technology assessment should be emphasized; better international collaboration will result in global synergy; national resources on technology assessment should be linked and technology assessments should be translated into improved practice (28). the same author writes that „evidencebased technology assessment is a critical public good that can benefit all who are concerned about appropriate use of health services and products. technology itself is rarely inherently good or bad, always or never useful. the challenge is to evaluate when it is effective, for whom it will enhance outcomes, and how it should be implemented or interpreted. health technologies will not reach their potential unless they are translated, used, and continuously evaluated”. case example: the example is related to computer-based delivery of health evidence done as a health technology assessment in report „computer-based delivery of health evidence: a systematic review of randomized controlled trials and systematic reviews of the effectiveness on the process of care and patient outcomes” done by cramer et al from the alberta research centre for child health evidence, university of british columbia, 2003 (29). the basic framework and the explanation are suggested by goodman (19). step 1. identify and rank assessment topics identifying potential topics. /to a large extent, assessment topics are determined, or at least bounded, by the mission or purpose of an organization./ the perspectives opened up by information and communication technology for health and health care go beyond problems of the clinical setting and relate health to general problems of the so called information society. over the past decade, in an effort to assist health professionals with successful182 health systems and their evidence based development ly searching for, translating, and integrating the best clinical evidence at the point-of-care, computer-based evidence delivery systems have been developed. these systems have been designed to assist providers with diagnosis, prescription, managing diseases, and preventing diseases. in addition to assisting health professionals, these systems have been designed to assist health care consumers by guiding them in their health behaviors, treatment options and disease management. ranking topics. /some assessment programs have explicit procedures for setting priorities. others set priorities in ad hoc or informal ways. the following are examples of criteria listed in no particular order that might be used to set assessment priorities: high burden of morbidity or mortality; large number of patients affected; high unit or aggregate cost of a technology or health problem; substantial variations in practice; high potential to improve health outcomes or reduce health risks; availability of sufficient research findings to perform the assessment; scientific, professional or public controversy; need to make regulatory decision; need to make payment decision; available findings not widely disseminated or used by practitioners./ selected topic fulfill most of the criteria listed above and has almost the greatest importance of all ict application in the field of health. step 2. specify assessment problem. /one of the most important aspects of an assessment is to specify clearly the question(s) to be addressed; this will affect all subsequent aspects of the assessment. assessment problem statements should recognize the relation of the new technology to existing technology./ as with any innovative health care intervention, computer-based evidence delivery system need to be rigorously evaluated before their use become widespread (get acquainted with a health on the net foundation hon principles, http://www.hon.ch). the objective of this assessment was to systematically identify and synthesize randomized controlled trials (rct) and systematic reviews (sr) that evaluate the effectiveness of computer-based health evidence delivery systems on the process of care (e. g., compliance with evidence) and / or patient outcomes (e.g., blood pressure). step 3. determine locus of assessment. /the nature of an assessment problem will affect the determination of the most appropriate organization or group to conduct the assessment. a comprehensive assessment addressing multiple attributes of a technology can be very resource-intensive. it can require considerable training and experience in the methods of evidence-based medicine. factors that influence a hta „make or buy” decision include: is an exist183 health technology assessment as a tool for health systems development ing assessment available? if an existing assessment is available, does it address the specific issues of concern to the organization? how recently was it conducted? is the methodology used sufficiently credible? if an existing assessment needs to be updated or is not available, do people in the organization have the time and expertise to perform the required data collection and analyses? if a synthesis of existing information is needed, does the organization have database searching capabilities, staff to retrieve full text articles, and staff trained in the conduct of systematic reviews? if new data are needed, does the organization have the requisite resources and expertise? what methodology will be used? if a consensus of clinical experts is the preferred methodology, does that consensus need to incorporate and reflect the opinions of the organization's own clinicians? will local clinicians accept the results and report recommendations if they do not participate in the assessment?/ step 4. retrieve available evidence. /one of the great challenges in hta is to assemble all of the evidence relevant to a particular technology before conducting a qualitative or quantitative synthesis. although some sources are devoted exclusively to health care topics, others cover the sciences more broadly. multiple sources should be searched to increase the likelihood of retrieving all relevant reports. useful sources for relevant evidence include: computer databases of published literature; computer databases of clinical and administrative data; printed indexes and directories; government reports and monographs; reference lists in available studies, reviews and meta-analyses; special inventories of reports; health newsletters and newspapers; company reports; and colleagues and other investigators. increasingly, most of the sources are accessible via the internet./ evidences are taken from published and unpublished randomized clinical trials and systematic reviews that assess the effectiveness of computerbased evidence delivery systems. in this reviews, a comprehensive search of the literature using following databases: medline (1990-2002), embase (1990-2002), cinahl (1990-2002), cochrane controlled trials register (1990-2002), web of science (1990-2002), and the trial registry of the cochrane effective practice and organization of care group (1990-2002) was done. in addition, two reviewers independently hand-searched the health information and libraries journal (1990-2002), journal of the medical library association (1990-2002), medical reference services quarterly (1990-2002), and the proceedings of the american medical informatics association (19912002). in addition, individuals from companies (more than 60) that produce relevant products were contacted for information about relevant studies. finally, authors of all relevant articles and experts in the field are being con184 health systems and their evidence based development tacted for information on recent, ongoing, or unpublished studies. this comprehensive search of literature at last identified 13 570 documents of which 525 were deemed potentially relevant for the selected assessment question. step 5. collect primary data. /compiling evidence for an assessment may entail collecting new primary data after determining that existing evidence will not adequately address the assessment question(s). methods for generating new data on the effects of health technology ranges from case reports to metaanalysis. the demand for studies of higher methodological rigor (e.g., metaanalysis or rcts) is increasing among health care technology regulators, payers, providers and other decision makers./ step 6. interpret evidence. /evidence interpretation involves classifying the studies, grading the evidence and determining which studies will be included in the synthesis. assessors should use a systematic approach to critically appraise the quality of the available studies. interpreting evidence requires knowledge of investigative methods and statistics./ two reviewers independently screened 525 articles for relevance using a predetermined set of inclusion criteria and identified 57 relevant randomized controlled trials (rct) and 10 relevant systematic reviews. the majority of these studies was rated as having low methodological quality and was therefore open to substantial bias. the majority of the rcts, as well as systematic reviews, were published between 1995-2001 (33 and 9 respectively), and were conducted in north america (46 and 6). step 7. synthesize and consolidate evidence. /for many topics in technology assessment, a definitive study that indicates one technology is better than another does not exist. even where definitive studies do exist, findings from a number of studies often must be combined, synthesized or considered in broader social and economic contexts in order to respond to the particular assessment questions. methods used to combine or synthesize findings from different studies include: systematic reviews, meta-analysis, decision analysis and group judgment or consensus development./ one method for providing an evaluation is to summarize the existing evidence in a systematic review. systematic reviews use explicit and reproducible methods for identifying and selecting primary or integrated studies and assess the methodological quality of each study with respect to the strength of evidence it contains. eighteen of the 57 randomized controlled trials investigated systems designed specifically for patient users, 37 studies investigated systems 185 health technology assessment as a tool for health systems development designed specifically for health care providers, and two studies investigated systems designed for use by both patients and health care providers. five studies investigated diagnosis systems, 30 investigated management systems, one investigated a prediction system, four investigated prescription systems, nine investigated prevention systems, six investigated support systems, and two investigated treatment systems. the primary outcomes measured varied considerably from study to study and were categorized into one of three groups: process of care (e.g., compliance with medical guidelines), patient health (e.g., blood pressure), and other (e.g., knowledge). when the data from these studies were pooled, use of these systems was found to enhance the process of care. however, some studies showed a positive effect of these systems on the process of care whereas other studies did not. the variability among the findings of these studies is likely a result of the various differences between the studies such as the intervention studied, the methodological quality, or the specific outcomes assessed. overall, the use of computer-based evidence delivery systems was not found to have an impact on patient health outcomes. however, there were very few studies that investigated patient health outcomes and in most cases, the studies were too small to detect an effect. in addition, to have an effect on patient health outcomes, these systems must first have an effect on the process of care. thus it may be too early to investigate patient health outcomes. the effect of these systems on the process of care needs to be enhanced prior to investigating their effect on patient health outcomes. six of the ten systematic reviews included studies with experimental designs other than randomized controlled trials and three of the ten assessed studies with designs other than controlled clinical trials. two included investigations of non-computerized as well as computerized information systems. eight reviews investigated the effects of these systems on the process of care and seven found a benefit. the effect of these systems on patient health outcomes was tested in eight systematic reviews and four documented a benefit. these findings are consistent with the findings of the review of randomized controlled trials. step 8. formulate findings and recommendations. /although the terms „findings” and „recommendations” are sometimes used interchangeably, they have different meanings. findings are the results or conclusions of an assessment; recommendations are the suggestions, advice, or counsel that follow from the findings. recommendations can be made in various forms, such as options, practice guidelines or directives./ 186 health systems and their evidence based development firstly, findings compromise that there exists great variability among these computer-based systems and the findings of the studies. thus, there may not be one generic system that works in all environments. there is a need to identify factors that contribute to successful and unsuccessful systems. and, every system needs to be evaluated in the environment where it is implemented. secondly, compliance with evidence is low with and without the use of these systems. therefore, there is the need to identify barriers to the uptake of evidence, and where the barriers are inappropriate, to identify methods to remove them. broadly, several implications and recommendations for future areas of research can be suggested from this review. first, there is considerable potential for improving the dissemination and use of medical evidence. future studies employing a qualitative approach are required to identify the barriers to using medical evidence and, where these barriers are inappropriate, the methods to remove them. in addition, because the results of the included studies varied (i.e., some found a benefit of using a computer-based evidence delivery system others did not) further research needs to focus on identifying the specific aspects of a system that contribute to its success or failure. this information will prove key to developing and implementing computer-based evidence delivery systems in the future. step 9. disseminate the findings and recommendations. /dissemination strategies depend upon the mission or purpose of the organization sponsoring the assessment. dissemination should be planned at the outset of an assessment along with other assessment activities and should include a clear description of the target audience as well as appropriate mechanisms to reach them. the costs, time and other resources needed for dissemination should be budgeted accordingly. dissemination plans do not have to be rigid. the nature of the findings and recommendations themselves may alter the choice of target groups and the types of messages to be delivered. dissemination should be designed to influence the behavior of relevant decision makers./ new primary studies, new technology assessments, new policy on ict by increasing relevance and delivery of information to health professionals and health consumers (get information on health internetwork hin united nations millennium action plan, http://www.healthinternetwork.org /index.php). step 10. monitor impact of assessment reports. /the impact of htas is variable and inconsistently evaluated. plans for monitoring the impact of an assessment report should be considered in the assessment design. some of the 187 health technology assessment as a tool for health systems development effects of a hta report include: acquisition or adoption of a new technology; reduction or discontinuation in the use of a technology; change in behavior; change in the organization or delivery of care; reallocation of national or regional health resources; change in regulatory policy; modification of marketing plan for a technology, … ./. yet too early to say in this case example. 188 health systems and their evidence based development exercises: introduction to health technology assessment task 1: selection and prioritization identify possible health technologies in your country, region or institution that would be worth of assessment. define the criteria for prioritization and select the one technology worth assessing. task 2: planning / policy questions should there be a wish to introduce a public offer of influenza vaccination of the elderly, how should this be organized and what would the effects and costs be? task 3: hta questions derive hta questions for influenza vaccination of the elderly keeping in mind that they have to be clearly worded, defined, answerable and limited in number. task 4: define project group define complete project management for assessment of influenza vaccination of the elderly. task 5: a hta is to a large extent based on available evidence. list possible sources for any literature review. perform a literature review with previously defined search protocol for „influenza vaccination of the elderly” concerning hta question technology: what is the expected survival of the elderly, who are vaccinated against influenza, compared to elderly, who are not vaccinated? perform a literature review with previously defined search protocol for „influenza vaccination of the elderly” concerning hta question patient: what do the elderly think of influenza vaccination? task 6: if the literature review didn't give enough scientific documentation there is a need for performing one's own study of the effect of health technology. design studies for hta questions cited in e2-e5. what are possible sources of bias in selected designs? define advantages and disadvantages in selected designs. how would you measure validity in previously designed studies? if you choose to measure health status, what type of instruments can you use? 189 health technology assessment as a tool for health systems development case problems: a. most of the studies on health technology assessment covered new therapeutic and diagnostic health technologies and medical treatments basically concerning economic aspect and medical or patients benefits. this is a common result of few studies realized and published in mid nineties. what is situation today? b. the inclusion of an unbiased sample of relevant studies is central to the validity of systematic reviews and meta-analysis. time-consuming and costly literature searches, which cover the grey literature and all relevant languages and databases, are normally recommended to prevent reporting biases. however, the size and direction of these effects is unclear at present. there may be trade-offs between timeliness, cost and the quality of systematic reviews. it seems that there has to be an answer on the question: how important are comprehensive literature searches and the assessment of trial quality in systematic reviews? c. telehealth has become widespread in the last two decades in developed countries, despite the generally poor scientific evidence available to support its use. telehealth, telemedicine, or e-health is defined as the use of information and communication technologies to deliver health services, expertise and information over distance, geographic, time, social and cultural barriers. telehealth encompasses internet or web-based „e-health", as well as videobased applications. applications can be real-time or store-and-forward. how would you provide an information base to assist policyand decision-makers, researchers and health professionals in their deliberation about telehealth? provide an overview of the areas of strength and weakness, identify gaps and review policy implications. d. screening for gestational diabetes mellitus has been controversial, with some expert bodies advising universal screening, others selective screening, and yet others advising against screening at all. this has partly been a result of debate about the definition of gestational diabetes mellitus, and partly because of the profusion of different tests available, both for screening and definitive diagnosis. in the country x, there is no national policy on screening, and a variety of practices exist in different parts of the country. there have also been doubts about the treatment of gestational diabetes mellitus, and particularly about management of minor degrees of glucose elevation, which are better described as glucose intolerance rather than true diabetes. provide an updated review of current knowledge, to clarify research needs, and to assist with policy making. 190 health systems and their evidence based development references 1. perry s, thamer m. medical innovation and the critical role of health technology assessment. jama 1999, 282 (19): 1869-1872. 2. fuchs vr, garber am. the new technology assessment. n engl j med 1990: 323: 673-677. 3. perry s, gardner e, thamer m. status of health technology assessment worldwide. international journal of technology assessments in health care 1997: 13: 81-89. 4. goodman c. ta101. introduction to health care technology assessment. national information center on health services research & health care technology (nichr), 1998. national library of medicine: http://www.nlm.nih.gov (20.06.2003). 5. brooks h, bowers r. the assessment of technology. science 1970: 222 (2): 13-20. 6. national research council, committee on the life sciences and social policy. assessing biomedical technologies: an inquiry into the nature of the process. washington, dc: national academy of sciences, 1975. 7. hennen l. ta in biomedicine and healthcare from clinical evaluation to policy consulting. ta-datenbank-nachrichten, nr. 1/10: 13-22, 2001. http://www.itas.fzk.de/deu/tadn/tadn011 /henn01a.htm (13.07.2003) 8. the international network of agencies for health technology assessment (inahta), 2000, http://www.inahta.org/ (06.03.2003). 9. kristensen fb, horder m, poulsen pb (eds.). health technology assessment handbook. danish institute for health technology assessment, 2001. 10. bakketeig l. the technology. in: kristensen fb, horder m, poulsen pb (eds.). health technology assessment handbook. danish institute for health technology assessment; 2001. p. 22-35. 11. donaldson ms, sox hc. setting priorities for health technology assessment: a model process. national academy press, washington, d.c. 1992. 12. battista rn, hodge mj. the development of the health care technology assessment: an international perspective. international journal of technology assessment in health care 1995: 11(2): 287-300. 13. eur assess project subgroup. introduction to the eur assess report. international journal of technology assessment in health care 1997: 13:133-143. 14. poulsen b. the patient: measurement of health status. in: kristensen fb, horder m, poulsen pb (eds.). health technology assessment handbook. danish institute for health technology assessment, 2001. p. 56-65. 15. timm h, hanses hp, morgall j, sigmund h. the patient: field research, interview and questionnaire studies. in: kristensen fb, horder m, poulsen pb (eds.). health technology assessment handbook. danish institute for health technology assessment; 2001. p. 37-55. 16. vrangboek k. the organisation: hta administration and organisation. in: kristensen fb, horder m, poulsen pb (eds.). health technology assessment handbook. danish institute for health technology assessment; 2001. p. 67-84. 17. tryggestad k, borum f. the organisation. in: kristensen fb, horder m, poulsen pb (eds.). health technology assessment handbook. danish institute for health technology assessment; 2001. p. 85-95. 18. poulsen pb. the economy. in: kristensen fb, horder m, poulsen pb (eds.). health technology assessment handbook. danish institute for health technology assessment; 2001. p. 96-121. 19. goodman c, snider g, flynn k. health care technology assessment in cva. boston, mass: management decision and research center, washington, dc: health services research and development service, 1996. 191 health technology assessment as a tool for health systems development 20. national health committee. new technology assessment in new zealand. discussion document, 2002. 21. banta d, gelijns a. an early system for the identification and assessment of future health care technology: the dutch stg project. international journal of technology assessment in health care 1998: 14(4): 607-612. 22. centre for evidence-based medicine. levels of evidence and grades of recommendations, 2002, http://cebm.jr2.ox.ac.uk/docs/levels.html (10.06.2003.) 23. stevens a, robert g, gabbay j. identifying new health care technologies in the united kingdom. international journal of technology assessment in health care 1997: 13(1): 5667. 24. lohr kn ed. institute of medicine. medicare: a strategy for quality assurance. volume i. washington, dc: national academy press, 1990. 25. lohr kn, rettig ra, eds. quality of care and technology assessment. report of a forum of the council on health care technology. washington, dc: national academy press, 1988. 26. brook rh, lohr kn. efficacy, effectiveness, variations, and quality: boundary-crossing research. medical care 1985: 23 (5): 710-722. 27. rettig ra. healthcare in transition: technology assessment in the private sector. santa monica, ca.: rand, 1997. 28. eisenberg jm. ten lessons for evidence-based technology assessment. jama 1999: 282 (19): 1865-1869. 29. cramer k, hartling l, wiebe n, russell k, crumley e, pusic m, klassen tp. computerbased delivery of health evidence: a systematic review of randomised controlled trials and systematic reviews of the effectiveness on the process of care and patient outcomes. alberta heritage foundation for medical research 2003. http://www.ahfmr.ab.ca/grants/ state_of_science_final_reports.shtml (15.07.2003) recommended readings 1. goodman c. ta101. introduction to health care technology assessment. national information center on health services research & health care technology (nichr), 1998. national library of medicine: http://www.nlm.nih.gov (20.06.2003). 2. kristensen fb, horder m, poulsen pb (eds.). health technology assessment handbook. danish institute for health technology assessment, 2001. 3. sox hc, blatt ma, higgins mc, marton ki. medical decision making. butterworths, boston, 1988. 4. drummond mf, o'brien b, stoddart gl, torrence gw. methods for the economic evaluation of health care programmes. oxford medical publications, oxford, 2nd edition, 1997. 192 health systems and their evidence based development 193 comparative research on regional health systems in europe health systems and their evidence based development a handbook for teachers, researchers and health professionals title comparative research on regional health systems in europe module: 1.10 ects (suggested): 0.75 authors, degrees, institutions birgit cornelius – taylor, mph who european office for integrated health care services marc aureli 22-36 e-08006 barcelona spain tel: +34 93 241 8270 fax: +34 93 241 8271 e-mail: bct@es.euro.who.int ulrich laaser, dtm&h, mph, professor faculty of health sciences, section for international public health, university of bielefeld, germany address for correspondence prof. dr. med. ulrich laaser dtm&h, mph section of international public health (s-iph) faculty of health sciences university of bielefeld pob 10 01 31, d-33501 bielefeld germany tel/am/fax: +49-521-450116 e-mail: ulrich.laaser@uni-bielefeld.de keywords health systems, benchmarking, tracer concept, regional health management, measles vaccination, breast cancer screening, european union learning objectives after completing this module students and public health professionals should have: • explored the methodology of comparative analysis of regional health services in europe, • received a sound knowledge of 2 selected public health programmes in 4 of 8 european regions, • completed an analogous analysis of their region of origin. abstract because of the rapid changes and in search for cost-efficiency, quality and professional excellence, the health systems in europe are undergoing comparative analysis tends to focus on selected services in defined subnational regions in order to obtain relevant information for benchmarking. in this module 2 programmes (measles vaccination and breast cancer screening) are described in detail for 8 european regions according to defined categories. teaching methods teaching methods include an introductory lecture based on the introductory module, students’ individual work under the supervision of teacher and interactive methods such as small group discussion. after the introductory lecture students will work individually or in teams of 2 or 3 on the exercises, each followed by a small presentation and discussion with the full group. specific recommendations for teacher it is recommended that the module should be organized within 0.75 ects credits, out of which one third will be done under supervision, while the rest is individual student’s work. teacher should advise students to use as much as possible electronic libraries during individual work to gather ideas how to write and present their own case problems. assessment of students individual presentation and group reports. comparative analysis of regional health care systems in the european union birgit cornelius – taylor, ulrich laaser in the european union the health sector until very recently remained exclusively a national domain. however repeated decisions of the european high court during the last years made clear that health services are to be considered as subject under the so-called four freedoms (full mobility of persons, goods, services and capital within the european union) even though the health market is not an unrestricted competitive market (1). this means e.g. that in the future patients can ask for medical services throughout the eu and will be covered by their health insurance or other payment mechanisms at home. an electronic health insurance card is presently tested and will be introduced in 200406. in the public health field this harmonisation of inherited national structures is even more advanced, very much enhanced by the treaties of maastricht and amsterdam with their articles on the public health mandate of the european commission acc. to article 129 resp. 152 (2). all health systems in europe are presently under reform, be it in the western states because of the need to curb costs especially for the employers in order to remain competitive in a globalising world economy, or be it in the eastern states regarding the transition from the prior socialist system to a modern one, usually a mix of beveridge and bismarck elements. this makes a comparative analysis difficult because of the frequent legislative changes as well as because of the emergence of regional solutions, e.g. in the so-called euroregions in border areas between member states (foremost between germany, france and benelux but developing also between germany and poland). it is against this background that analysts prefer to concentrate on selected services as so-called tracers in defined regions to establish valid comparisons which can be used for benchmarking or measuring relative performance for a selected set of defined criteria (e.g. 3). for the following analysis preference has been given to the public health aspects and to this purpose measles immunisation programmes and breast cancer screening programmes have been chosen in selected countries and regions (table 1). the descriptive part is taken with permission from the eu-project „benchmarking regional health management ben rhm” (4). 194 health systems and their evidence based development table 1. comparative analysis of regional health care systems for a comparative analysis specific categories are employed (table 2): table 2. analytic categories for regional comparison of preventive health care of the 8 regional reports listed in table 1 the following 4 are made available below. 195 comparative research on regional health systems in europe no. country region 1) austria upper austria 2) czech republic moravian-silesian region 3) united kingdom england 4) greece western greece 5) germany northrhine-westphalia 6) ireland eastern / midland / north-eastern regions 7) italy veneto 8) sweden stockholm no. category 1 demography 2 organisation and structure of the regional health system 3 measles immunisation programmes 3.1 organisation of programmes 3.2 vaccination strategy 3.3 information and education 3.4 programme related projects/campaigns 3.5 vaccination documentation and data collection 3.6 programme monitoring and evaluation 3.7 disease surveillance 4 breast cancer screening programmes 4.1 screening strategy 4.2 dissemination of results 4.3 information and education 4.4 programme related projects/campaigns 4.5 programme monitoring and evaluation 4.6 disease surveillance 2) moravian-silesian region – czech republic 2.1 demography moravia-silesia is one of 14 regions in the czech republic with about 1.26 million of the country’s roughly 10 million inhabitants. 0.62 million of the inhabitants are male and 0.65 million female. the region lies in the eastern part of the country, which shares borders to poland and slovakia, and is divided into six districts. moravia-silesia covers an area of 5 554 km2 with a population density of 234 inhabitants per km2. 2.2 organisation and structure of the health system the health system in the czech republic has undergone several changes and reforms, some of which are still ongoing. decentralisation of the health care system (mainly focused on ambulatory services) is a major feature of the reforms, but its implementation is not yet complete. the task of health care has been delegated to health insurance funds, which are under the supervision of the state. the ministry of health is responsible for the preparation of health care legislation, health and medical research, for the licensing of pharmaceuticals and medical technology and for the management of two institutes for postgraduate education and training of health professionals. it also organises the joint negotiations concerning the list of services covered by health insurance which serves as the fee schedule. the ministry directly manages regional hospitals, university hospitals, specialised health care facilities and institutions for research and postgraduate education. following the dissolution of both the district institutes of national health and the regional institutes of national health, state health administration was incorporated into the district authorities in the form of health offices headed by district health officers. the district health officers are under the direct supervision of the ministry of interior affairs, whilst the ministry of health provides methodological guidance and supervision. the district health officers are, however, legally responsible for ensuring that accessible health services are provided in their areas. in line with recent reforms, hygienic services (public health services) no longer exist at the district level. the whole system is now based at the regional level, with the regional public health institutes being responsible for public health in the whole region. these institutions are responsible for 196 health systems and their evidence based development epidemiological surveillance, immunisation logistics and safety measures concerning environmental hazards, food and other areas (european observatory on health care systems 2000a). 2.3 measles immunisation programmes immunisation programmes are generally covered by the national legislation within the public health protection act from the year 2000. the provision of immunisation by the responsible organisations is obligatory and parents have to have their children immunised against diseases covered in the child immunisation programme. the state is responsible for the welfare of children and youth up to the age of 21 and has the right to force parents to have their children immunised. the routine obligatory vaccination against measles started in 1969 in the czech republic. a two doses strategy was introduced in 1974. organisation of programmes the ministry of health together with the public health institutions at regional level plans the national immunisation programmes. the national institute of public health, which falls under the department of public health in the ministry of health, in co-operation with regional public health institutes prepared a national public health policy which includes the targets of the immunisation programmes. regional measles immunisation programmes are part of the national immunisation programme and are basically organised similarly in all regions. regional immunisation programmes are drawn up by district public health officers who prepare the programmes to reflect the national policy. the programmes are financed from the national budget via the regional public health institutes. the department of epidemiology in each regional public health institute is responsible for the implementation of the measles immunisation programmes. paediatricians, in their role as primary health care providers are responsible for preventive services such as immunisation and co-operate with the public health institutes at both regional and district level (figure 1). 197 comparative research on regional health systems in europe figure 1. organisation plan for the measles immunisation programme in moravia-silesia statutory accountability co-operation vaccination strategy the two dose mmr vaccine is carried out with the first dose being given at 15 months and the second at 21-25 months of age. the mmr vaccine was introduced in the czech republic in 1996, prior to which a local vaccine called mopavac divacine had been given. the moravian-silesian region has a special computerised system, isid (information system for immunisation of children) which it uses to invite and remind parents to take their children for vaccination. this system is not used by all other regions in the country. at birth, each child is registered, and allocated a paediatrician by the respective district public health institute, which forwards the information to the regional public health institute. the regional public health institute maintains a register of all children in the region and their respective 198 health systems and their evidence based development ministry of health department of public health moh regional public health institutions (rphi) department of epidemiology (doepi) national institute of public health paediatricians district health officers paediatricians. when a particular vaccination is due, the regional institute sends a letter of invitation to the parents, giving information about which inoculation is necessary and their appointment at the paediatrician. the paediatrician is informed of those children required to attend for vaccination on a particular day and is expected to inform the regional public health institute of available appointments for the administration of vaccinations. in the case of non-attendance, the paediatricians send a reminder to the parents. should the child still not attend, the regional public health institute then explains the importance of the vaccination to the parents. two of the 6 districts in the region do not have the computerised system and the paediatricians there have to organise the invitation of parents themselves. the invitation system run by the regional office is financed by the municipality in ostrava, where the office is located. the ministry of health provides each region with vaccine, which is distributed as necessary to the district public health institutes, from which paediatricians order their vaccines. the regional public health institute is responsible for checking that appropriate conditions are maintained for the storage of vaccines. information and education although no systematic measurement of public opinion has been undertaken, the measles vaccination programme is generally considered to be good and well accepted. public health authorities organise special training workshops for paediatricians in the districts once or twice a year. the participation is voluntary and carried out by the health insurance companies and medical board. programme related projects/campaigns at present there are no campaigns or projects related to measles immunisation being organised. the measles uptake rate is very high for both the first and second doses of mmr and the region of moravia-silesia has had no measles incidence in the past 4 or 5 years. 199 comparative research on regional health systems in europe 200 health systems and their evidence based development vaccination documentation/data collection there are three levels of vaccination documentation in moraviasilesia, two of which are country-wide. it is the duty of the paediatrician to record the date, type and batch number of the vaccine given in the child’s medical record. secondly, the paediatrician has to enter the vaccination details on the child’s vaccination certificate, which is held by the parents. the third form of documentation, which is only regional involves the computerised documentation of the vaccination details. the paediatrician returns the list of children he/she received from the regional public health institute, having marked the children who attended. information such as vaccination coverage of children of a particular age can be obtained from the computerised system for any chosen period or point in time. paediatricians also check the immunisation of their patients in the vaccination certificates during each medical or preventive examination. disease surveillance together with the introduction of the obligatory measles vaccination programme in 1969, a national surveillance system for measles was introduced. the national institute of public health in prague is responsible for the national surveillance of measles in the czech republic; there are two national reporting systems, one for all infectious diseases in the country and one covering vaccine related complications. annual reports on the data are published in print form and on the internet. 2.4 breast cancer screening programmes a professional breast examination programme has been included in the czech national oncological prevention programme since 2002. gps and gynaecologists carry out breast examination as part of preventive examinations offered to women between 45 and 69 years of age every two years. there are no special campaigns, information events or projects held in relation to professional breast examination, as the participation in the oncological prevention programme is assumed to be quite high, though dependant on educational and social background. breast self examination has been part of the national public health promotion agenda for a long time. although strictly speaking no programme exists, a lot of information (pamphlets, brochures, booklets, posters) have been published and distributed to the public in general. discussions are held in schools and clinics and gps and gynaecologists discuss the issue with their patients. mammography screening programmes are in the process of being implemented in some parts of the czech republic. in the moravian-silesian region, the programme officially started on the 2nd of september 2002 and up to the end of march 2003, eight screening units were involved, four of them based in ostrava, the regional capital city. at this time, there are 49 accredited screening units nation-wide. organisation of programmes the mammography screening programme was suggested by physicians, who felt the need to have a proper screening methodology for the population. endorsed by the ministry of health, a national committee consisting of radiologists and other specialists was established with the responsibility of accrediting and organising quality assurance checks of the workplace-units. each unit must conduct a minimum of 5000 mammographies per year and fulfil the technical requirements to achieve and maintain accreditation. although health insurance companies are not directly involved in the organisation and implementation of the screening programmes, the accredited screening units negotiate directly with health insurance companies over finances. even though national meetings are organised for all screening units within the mammography screening programme, no real co-operation amongst units in the same region is evident. screening strategy the screening programme is targeting women in the 45-69 years agegroup. since no invitation system operates in the moravian-silesian region, patients are referred by their gynaecologist or gp. following their first appointment the unit’s computer uses the stored patient data to generate invites for repeat checks. at the initial attendance, women are requested to complete questionnaires on family risk factors, breast self-examination experience and results, hormonal therapy and general medical history. 201 comparative research on regional health systems in europe dissemination of results the national screening programme recommends that mammograms are to be read by two experienced radiologists whilst the patient is waiting, and results given out immediately. this is however not always possible, as some units do not have the necessary number of radiologists to do this, in which case, the results are sent to the referring physician within three days of the mammogram. should the mammogram be unclear or abnormalities are seen, the woman is invited for further assessment. information and education a lot of publicity, mainly through the popular media, has accompanied the establishment of mammography screening programmes. this, together with the recent rising interest of citizens in matters concerning their health, has led to a lot of interest from the public in general and women in particular. women in moravia-silesia have been known to go to their gynaecologist and request to be referred for mammography screening. gynaecologists, thus, find it easier to convince their patients of the necessity of the screening procedure. one problem, which still has to be solved, is that of how to approach and also raise the interest of women with low educational backgrounds and/or from the lower social class. information events are also organised for gynaecologists where they are informed about the aims and objectives of the programme. further education / training courses and meetings are also organised for radiologists and other professions involved in the programme. programme monitoring and evaluation in moravia-silesia no programme evaluation has been conducted up to date, as the programme itself is still quite young; it is however, planned on an annual basis. the national committee responsible for accreditation of units will inspect all units yearly and the accreditation will be renewed annually. the success of the screening programme will be measured using determinants such as attendance rates, cancer detection rate and further assessment referral rate. disease surveillance cancer registration is maintained nationally by the institute of informatics and statistics in prague. all gynaecologists and physicians are bound by law to report all cases of cancer diagnosed to the nearest public health authority at the district or regional level. the public health authorities 202 health systems and their evidence based development then forward the information to the institute of informatics and statistics for entry into the national cancer registry. 5) north rhine-westphalia, germany 5.1 demography north rhine-westphalia (nrw) is one of the 16 german federal states with a total population of 18 million inhabitants. this corresponds to about 22% of the german population. it covers an area of 34,080 km2. with 530 persons per km2, nrw’s population density is more than twice as high as the german average. further demographic characteristics of the state of nrw are as follows: with 2 million people, nrw’s migrants account for about 11.4% of the state’s population. 5.2 organisation and structure of the health care system germany is a federal republic with 16 federal states, and each of them has its own constitution which is in accord with the german federal constitution. the sharing of decision-making powers between federal and state level is a fundamental aspect of the political system and thus also of the health system. the german health care system is primarily characterised through the development of health insurance funds. the statutory health insurance system (gkv), which was set up under the federal government’s social legislation scheme, provides insurance protection for about 90% of germany’s citizens since gkv membership is obligatory for employees up to a fixed income level. 203 comparative research on regional health systems in europe males: 8.82 million (49%) females: 9.18 million (51%) of the almost 880,000 inhabitants of the age group 0-4 years, 450,000 are males and 430,000 females. the female population of the age groups 50-69 years targeted for mammography screening (a total of 2.13 million) can be broken down into the following categories: age group in years number 50 – 54 470,000 55 – 59 490,000 60 – 64 590,000 65 – 69 580,000 in addition to the health insurance funds as financing bodies on the one hand, germany’s health care system is characterised through its doctors, dentists, pharmacists and hospital organisations as service providers on the other hand. like health insurance funds they are organised as public corporations and/or associations and perform their tasks as self-administered bodies, i.e. within the framework of federal government regulations and supervision they are authorised to perform all functions under their own responsibility. the federal government defines the organisational structure of the self-government system through legislation and decrees in the social codes (above all social code v). at regional level, the german states are responsible for hospital planning, hospital investments and for the public health service. for these areas they have their own decision-making powers but also the possibility to exert influence on the governments’ statutory health insurance legislation through their representatives in the german bundesrat. 5.3 measles vaccination programmes before the reunification of the former gdr and west germany in 1990, both countries differed considerably in their approaches to measles surveillance, vaccination strategies and the provision with vaccines. the former gdr had a highly centralised health system. in 1970, the voluntary single measles vaccination, which had been introduced in 1967, was made obligatory by law for children aged 8 months or older. the public health service played a central role in the implementation and registration of the vaccination. in 1986, a second vaccination was introduced as a matter of routine 6-12 months after the first vaccination. in the federal republic of germany, measles vaccination was generally carried out on a voluntary basis and recommended for infants aged 12 months or older. in 1980, the combined measles, mumps, and rubella vaccination was introduced, with a recommended second vaccination from the year 1991 onwards. after the german reunification, this practice was also adopted for the states of the former gdr. 204 health systems and their evidence based development organisation of vaccination programmes the legal basis for the prevention and fighting of infectious diseases – among others also for protective vaccinations – in the federal republic of germany is the infectious disease control act (ifsg) which entered into force on 1 january 2001. under this act obligatory notification of measles cases was introduced for the first time all over germany and the health departments were obliged to ascertain the vaccination status of children during school entrance examinations. up to that time, the vaccination status had been identified during school entrance examinations in nrw on a voluntary basis. there is no compulsory vaccination in the federal republic of germany. recommendations for vaccinations are worked out in accordance with state-of-the-art-knowledge by an expert committee, the standing vaccination committee (stiko) of the robert-koch-institute in berlin. the list of vaccinations recommended by stiko comprises standard vaccinations for infants, children, adolescents and adults including the recommended age at which the vaccination should be taken and the minimum intervals between the vaccinations. the individual german states decide for themselves whether they will adopt these recommendations without any changes. in nrw, the correspondingly latest stiko recommendations are regarded as official recommendations. the individual german states also decide for themselves about the planning and implementation of vaccination programmes as well as about their main focuses. vaccination programmes can be carried out both at state and local level, as single actions or as concerted actions. the who target to eliminate measles by the year 2007 is explicitly supported by the federal republic of germany. so at the 71st health ministers’ conference (gmk) in 1998, the responsible health ministers and senators decided to take concerted measures for the combat of measles together with the federal government, the public health service (ögd), the health insurance funds, the chambers of physicians and further partners. participation in measles’ vaccination programmes shall be considerably increased and the incidence of measles reduced by 90% in germany within the next years. in a move to implement this resolution, an action programme for the prevention of measles, mumps and rubella was adopted at nrw’s 10th state health conference which includes all major actors involved in nrw’s health care sector. members of this body are representatives of the chambers of the medical care professions, associations of panel doctors, social insurance funds, 205 comparative research on regional health systems in europe hospital society, charitable organisations, self-help initiatives, trade unions, employers’ associations and of the public health service. this action programme in nrw provides for various measures at different levels (state and local level) which support and supplement each other. the different organisations and authorities which are involved in implementing the measles’ vaccination programmes in nrw as well as the levels at which they act, can be taken from the following organisation plan (organograph) below (figure 2). 206 health systems and their evidence based development figure 2. organisation plan for the measles immunisation programme in north-rhine westphalia instructions development of programmes notification vaccination strategy recommendations for a first and second measles, mumps and rubella vaccination have been in force for germany since 1991. in its july 2001 recommendations, stiko supports the first mmr vaccination for children between their completed 11th and 14th month of life and the second between their completed 15th and 23rd month of life. missing vaccinations should be received by the 18th year of life at the latest. 207 comparative research on regional health systems in europe federal government federal ministry for health and social security standing vaccination committee (stiko) infectious disease control act ifsg sickness funds vaccination programmes doctors (family doctors, paediatricians) preparatory committee of the nrw state health conference institute of public health (lögd) local health departments robert-koch-institute (rki) nrw state government ministry for health, social affairs, women and family nrw vaccinations are given following consent from the parents/legal guardians who also have the right to opt against vaccination for their children. there is no automatic invitation or reminder system for vaccination attendance. at the birth of their children, parents are issued with a vaccination card together with a child health record booklet which they should bring with them each time they see their doctor. parents learn about the stiko recommendations from a vaccination plan they can get from their paediatrician, family doctor or from the sickness funds. thus it is in most cases within the responsibility of the parents to survey and observe these deadlines and to make the required appointments with their paediatrician or family doctor. the vaccinations are mostly carried out by the paediatrician or family doctor in his/her practice rooms. doctors order the vaccines from pharmacies and forward their claims to the statutory health insurance funds (gkv) via the association of panel doctors. information and education parents/legal guardians are amongst others also informed about the procedure and necessity of measles vaccinations when they see their paediatrician or family doctor. another opportunity for information is provided by the school entrance examination, which is carried out by the medical staff of the health departments. surveys in germany have shown that the doctor’s advice is paramount in influencing the decision for vaccination. information campaigns on vaccinations therefore regularly include doctors and physicians. the latest stiko recommendations are conveyed by the federal chamber of physicians to the chambers of physicians at state level which then inform the doctors. at the same time doctors are informed through publications in the corresponding medical journals or through additional vaccination seminars which are organised by the chamber of physicians. to inform the population about vaccinations, north rhine-westphalia uses various methods. these include the telephone announcement service of the ministry for health, social affairs,women and family (mgsff). under a service telephone number interested citizens are informed at two-week intervals about topical issues from the health care sector through the announcement service. this also includes an announcement text on vaccinations. through publications from the press release office of the mgsff, the population in nrw is also informed about this issue. moreover, mgsff has also issued its own flyer on measles, mumps and rubella which can also be used by the health departments in nrw for vaccination campaigns. 208 health systems and their evidence based development for local vaccination campaigns, the health departments turn directly to the regional media (e.g. local press, radio stations) and issue their own press releases. health insurance funds use their magazines to inform their members at irregular intervals. programme-related projects/campaigns the action programme for the prevention of measles, mumps and rubella adopted by the 10th state health conference in august 2001 is aimed at a permanent increase in vaccination levels among children and adolescents in nrw. the background are the presently still high incidence figures particularly for measles as well as the risk potential resulting from inadequate vaccination levels against mumps and rubella. activities at state level for the planning, coordination and implementation of supra-regional vaccination programmes, nrw has the institute of public health nrw (lögd) at its disposal. in addition to its functions stipulated in nrw’s legislation as a „public health coordination centre” and „official nrw authority for the surveillance of infectious diseases” (in accordance with sec 11 infectious disease control act) the management of local vaccination data through the lögd as a service provider supplements the requirements for this function. the list of measures conceived by the lögd is aimed at abolishing deficits in knowledge, motivation and implementation of the vaccination idea both within the population and in the health sector. important single measures of this campaign are the early identification of the vaccination status as early as at kindergarten entrance, improved vaccination information campaigns in schools and companies, improved qualifications of those working in the health sector, the targeted improvement of vaccination levels by sending a mobile vaccination unit to the municipalities as well as a continuous evaluation and publishing of the activities carried out. important partners during implementation phases are in particular the local health conferences as well as the health departments in the municipalities. activities of the local health conferences an important body for the discussion and implementation of measures also with regard to protective vaccinations in nrw are the local health conferences. members are health care actors involved in health promotion and health care for the population, self-help groups and institutions for health care 209 comparative research on regional health systems in europe and patients’ rights protection as well as members of the council or district assembly responsible for health. together, as an independent body, the local health conferences deliberate on various thematic topics and questions of interest in health care at the local level with the objective of coordinating them and if required give recommendations for action. these recommendations are implemented under the self-commitment of the actors involved. these agree joint solutions at the local level and initiate their own actions such as for example actions for the prevention of measles, mumps and rubella. to support these activities, the lögd has developed a planning programme for mmr. activities of the individual health departments there are 54 health departments in nrw which are part of the local self-government system. as implementation level of the public health service, they are among other things responsible for important tasks pertaining to hygiene control and the promotion of health protection at population level. in addition to the identification of the vaccination status at school entrance examinations, these tasks also include vaccination activities which are based on recommendations for action given by the local health conferences or which can be decided by the health departments themselves. they are primarily guided in their actions by the principle of respecting the subsidiary sharing of tasks according to which the implementation of officially recommended regular vaccinations primarily falls within the responsibility of practising doctors and measures of the public health service should only be aimed at improving vaccination levels. vaccination documentation/data collection in accordance with the infectious disease control act (ifsg), the vaccinating doctor is obliged to register every protection vaccination on a vaccination card or, if it has not been submitted, to issue a vaccination certification. the kind of data to be documented is also fixed in the infectious disease control act. there are no further documentation methods such as for example a vaccination register. the vaccination status of children is identified during school entrance examinations which are required for school entrance. all children and/or their accompanying parents are requested but not forced to bring the vaccination card. for nrw figures from the year 2000 show that of 137,284 children who 210 health systems and their evidence based development had participated in the school entrance examination and had been issued with a vaccination card almost 90% had received the first mmr vaccination but only 14% the second vaccination. as stipulated in the infectious disease control act, the health departments are obliged to transmit vaccination data collected during school entrance examinations in an anonymised and aggregate form to the robertkoch-institute via the superior state health authorities. the institute of public health annually publishes the data available from school entrance examinations in nrw and thus also the vaccination data. disease surveillance with the entering into force of the infectious disease control act on january 1st 2001 all clinically and laboratory-confirmed measle cases were made notifiable in germany. the infectious disease control act stipulates that independently from each other both the attending doctor and the confirming laboratory are obliged to report the name of the measles patient. the task of putting both kinds of information together into one case and if necessary to conduct further inquiries falls within the responsibility of the health department. the notification deadline of 24 hours and the extent of facts and information to be notified are also stipulated by law. this process has to be distinguished from the notification procedure from the health department to nrw’s state authorities and rki. it differs from the above-described procedure both with regard to the extent and deadline of the notification. in accordance with sec 11 of the infectious disease control act, anonymised data have to be transferred to nrw’s state authority by the third working day of the following week after the health department has received the notification. the state authority again has to transfer the data within one week to the rki. the responsible state authority at the lögd is charged with the tasks of pooling, quality control and surveillance of the notifications they receive from all 54 districts and/or self-administered cities in nrw. this also includes publishing the information on the internet without delays to ensure a backflow of information as part of a closed data cycle. at federal level, the same tasks are performed by the robert-koch-institute. with the publication of the data in the „epidemiologisches bulletin”, on average about 3 weeks after having registered the notification, the data are given official character. to complement this routine notification procedure, in october 1999 a measles sentinel for the continuous and immediate registration of measles 211 comparative research on regional health systems in europe cases was set up at the national level. in this study called „arbeitsgemeinschaft masern” (agm) about 1.200 physicians, in most cases paediatricians, on a voluntary basis collect data on the seasonal, regional and age-specific distribution of measles in germany. of special importance are data which can only be gained through this – from the ifsg notification procedure – independent system on the individual development of the disease, on the precise vaccination status and on the results of comprehensive laboratory diagnoses. the latter in particular provide indisputable contributions to assessing the effectivity of the vaccination. both registration systems, which presently exist simultaneously, ensure good national surveillance as a prerequisite for the further systematic fighting of measles with the objective of their eradication. 5.4 breast cancer screening programmes medical breast examinations are carried out throughout germany based on the early cancer detection act contained in social code v in accordance with the guidelines of the german national doctors’ and sickness funds’ associations. they are part of the annual cancer screenings which are offered to all women aged 30 years and/or older and include palpation of the breast and lymphatic nodes and an instruction for breast self-examination. in the case of suspicious palpation findings further steps are taken in cooperation with the correspondingly specialised diagnosis and treatment centres. both sickness funds and panel doctors’ associations as well as organisations for the combat of cancer at the regional level and self-help groups are involved in informing the public about screening programmes which include breast examinations. breast self-examination in the same way there is no programme for breast self examination. women take their instructions from flyers or brochures they get from their gynaecologists or from information campaigns. according to nrw’s health ministry, less than 50% of the women take part in cancer screening programmes in north rhine-westphalia. to encourage women to take part in these examinations which are generally paid by the sickness funds, in 2001 nrw launched an intensive campaign against breast cancer. the campaign was carried out by various organisations in nrw including 212 health systems and their evidence based development chambers of physicians, hospitals, sickness funds and cancer organisations. it encouraged women to examine their breasts and called upon doctors to provide the corresponding instructions. in addition, more than 300 seminars on breast self examination are each year organised throughout the state of nrw. similar to the medical examination of the breast, breast self-examination plays an important role for cancer prevention because a great number of women consult their gynaecologist after having discovered an irregularity. this also applies to women who perhaps would normally not participate in cancer screening programmes. mammography screening programmes mammography screening programmes are presently still in their initial phase of initiation in germany. the precise conditions and regulations according to which the programmes are to be carried out are presently being established in accordance with the european guidelines for quality assurance of mammography screenings (euref). this concerns the technological and qualitative standards to be fixed for the institutions in which mammography screenings will be carried out. mammography pilot programmes, which were carried out between 2001 and 2002 in the three regions of bremen, weser-ems and wiesbaden, serve to introduce blanket coverage with screening programmes which cannot be achieved before 2005. they were carried out following international standards such as the european guidelines for quality assurance of mammography screenings. in a special invitation letter all women between 50 and 69 years of life are called upon to participate in the programmes. the programme is aimed at a high participation rate, attaches considerable importance to interdisciplinary teamwork and ensures high quality standards in accordance with euref. 213 comparative research on regional health systems in europe 6) eastern / midland / north-eastern regions – ireland 6.1 demography the eastern regional health authority (erha) with its three constituent health boards, and the midland and north-eastern health boards respectively, cover the combined eastern, midland and north-eastern regions. the health boards executive (hebe) was established in february 2002 to enable health boards, the eastern regional health authority and nonstatutory provider agencies to work together on an agenda to develop and modernise the health delivery system. the board of hebe is comprised of the chief executives of the health boards and the erha and also has representation from the chief executives of the dublin major teaching hospitals. the demographic characteristics of the combined three regions are as follows: 6.2 organisation and structure of the regional health system health services in the republic of ireland are financed through general taxation, with funding for programmes being provided to the health boards by the department of health and children. the description of the structure and organisation of the irish health system, which also applies to the eastern regional health authority with its three area health boards, is taken from „quality and fairness”, a paper of the department of health and children explaining the new health strategy 2001: 214 health systems and their evidence based development male population: 0.89 million female population: 0.92 million of the 126,800 inhabitants in the 0-4 years age-group 65,400 are male and 61,400 are female. the female population in the age-group targeted by mammography screening programmes is divided as follows: age group in years number 50 – 54 46,000 55 – 59 38,100 60 – 64 34,000 total 118,100 (1996 census of population) “the government, the minister for health and children and the department are at the head of health service provision in ireland. the department’s primary role is to support the minister in the formulation and evaluation of policies for the health services. it also has a role in the strategic planning of health services in consultation with health boards, the voluntary sector, other government departments and other interests. the department has a leadership role in areas such as equity, quality, accountability and value for money. the health boards, established under the health act, 1970 are the statutory bodies responsible for the delivery of health and personal social services in their functional areas. they are also the main providers of health and personal social care at regional level. health boards are composed of elected local representatives, ministerial nominees and representatives of health professions employed by the board. each health board has a chief executive officer (ceo) who has responsibility for day-to-day administration and is answerable to the board. the health (amendment) (no. 3) act, 1996 clarified the respective roles of health boards and their ceos by making boards responsible for certain reserved functions relating to policy matters and major financial decisions and ceos responsible for executive matters. in addition, many other advisory, executive agencies and voluntary organisations have a role to play in service delivery and development in the health system.” (department of health and children 2001) as regards the health boards within the combined eastern/ midland/north-eastern regions, their main role can be considered as the planning, arranging, co-ordination and delivery of health and personal social services in the region in co-operation with the local voluntary service providers. 6.3 measles immunisation programmes measles vaccination was introduced country-wide in 1985; the combined mmr vaccine was introduced in october 1988. in 1992, a second dose of mmr was recommended for boys and girls aged 10-14 years. the introduction of measles vaccine and the combined mmr vaccine has led to a decrease in the numbers of measles notifications. however, the uptake of mmr in ireland has not yet reached the target of 95% and outbreaks continued to occur in 1993 and 2000 (the health boards executive 2002a). therefore the health board chief executive officers initiated a „review of immunisation/ vaccination programmes” which was to examine the policy, practice and procedures of all immunisation/vaccination programmes. an increasing emphasis on the need to improve the uptake of immunisation/vaccination programmes e.g. mmr, and the increasing public and media discussion of immunisa215 comparative research on regional health systems in europe tion/vaccination issues such as vaccine safety were part of the background against which the review was established (the health board executive 2002b). organisation of programmes the different organisations and agencies involved in the realisation of measles immunisation programmes as well as the levels at which the programmes are planned and co-ordinated are illustrated in the organisation plan below (figure 3). 216 health systems and their evidence based development figure 3. organisation plan of the measles immunisation programme for eastern/midland/north-eastern regions 217 comparative research on regional health systems in europe national level regional level health boards (hb's) local level communications working group the health boards executive (hebe) national immunisation steering committee (nisc) national immunisation implementation group (niig) vaccine stock management working group central purchasing erha/hb's gps statutory accountability service accountability reporting general medical services (payments) board (gmspb) immunisation advisory committee of royal college of physicians of ireland (iac of rcpi) irish medicines board (imb) national disease surveillance centre (ndsc) erha + all health boards (hb's) department of health & children (doh&c) it working group department of health and children (doh&c): formulates immunisation targets on advice of iac of rcpi decides on programme policy and funding (financing is through general taxation) provides hb’s with funding for immunisation programmes together with hb’s, is responsible for health education in general immunisation advisory committee of royal college of physicians of ireland (iac of rcpi): draws up guidelines and advises on targets for measles immunisation programme based on who and other international guidelines irish medicines board (imb): decides on licences and conditions of use of vaccines and monitors adverse reactions to vaccines health boards executive (hebe): co-ordinates the planning and implementation of immunisation programmes with hb’s at regional level facilitates a co-ordinated national response involving all key actors e.g. hb’s, dohc, ndsc, imb etc. together with hb’s, is responsible for specific information on immunisation programmes and actions together with hb’s and dohc, is responsible for national promotion and public information campaigns on immunisation informs nisc of matters of common operational or policy significance discussed with hb’s national immunisation steering committee (nisc): is a newly established body representative of all key interest groups dealing with immunisation in general under the aegis of hebe, co-ordinates activities of measles immunisation programme at national level will in future address the evaluation of projects or campaigns relating to measles immunisation national immunisation implementation groups (niig): acts as a practical coordinating mechanism between nisc and health boards, as each health board is represented on niig by its regional immunisation coordinator provides feedback and policy advice to nisc 218 health systems and their evidence based development national disease surveillance centre (ndsc): evaluates immunisation programmes at national level (monitors vaccine uptake and incidence of disease) analyses data from all health boards and publishes quarterly reports health boards (hb’s): responsible for planning and implementation of immunisation programmes order vaccine from supplier and distribute them to gp practices and other required locations implement special campaigns or projects relating to measles immunisation at regional level are responsible for regional surveillance and for documentation of vaccines given primarily responsible for operation of call/recall systems general medical services (payment) board (gmspb): pays gps for immunisation services provided on behalf of hb’s general practitioners (gps): provide immunisation services and have responsibility to identify children who have been immunised and to follow up defaulters maintain records of children immunised and forward immunisation and/or disease data to hb’s and to doh&c as required responsible for updating their knowledge on immunisation and to promote childhood immunisation vaccination strategy in accordance with the rcpi guidelines, two doses of mmr have been recommended in the republic of ireland since 1992, with the first dose being given at 12–15 months of age and the second at 4–5 years of age. parents are personally invited to bring their children for vaccinations and this is occasionally supplemented by public information through the media. vaccine procurement is organised centrally by the hebe and it is distributed directly from the supplier to each health board in the quantities requested by them. it is then distributed to gp practices and to other required locations for use in schools or special clinics. a new system of direct distribution from supplier to end user is being piloted in order to shorten the supply chain and to better avoid any vaccine deterioration e.g. due to storage at sub-optimum temperatures. individual immunisation is free of charge and delivered through gp practices but also through health board medical officers in schools and in ‘black-spot’ areas. 219 comparative research on regional health systems in europe immunisation services provided by gps are paid for by the health boards through the general medical services (payment) board. theoretically, gps who achieve a 95% vaccination uptake level are supposed to receive a financial bonus for each child on their panel who has reached his/her second birthday in the calculation period. this, however, doesn’t always occur due to communication / documentation problems. information and education various means are being used to inform the public, particularly parents, about measles immunisation. a tv cartoon type infomercial, features and interviews involving authoritative medical figures on radio and in the press have been used. however, the findings of the national review of immunisation programmes (the health board executive 2002b), made it clear that a more systematic, varied and targeted public information approach is needed. information leaflets have since been made available to parents. a major initiative in 2002 by the hebe has been the production of a comprehensive information and discussion pack on mmr for use by health professionals and by parents. the reported links between mmr vaccine, autism and inflammatory bowel disease (crohn’s disease) in children have been of interest to the press, radio and tv and have been the subject of news stories, interviews and features involving researchers and parents of autistic children. a report of a study carried out by one health board in 2002 showed that parents felt insecure and confused by such media coverage and are then hesitant to have their children vaccinated. programme related projects/campaigns special projects relating to measles immunisation are implemented by the hebe at the national level and by the health boards at the local level. such projects include the production of information packs and public information campaigns. there is however limited evaluation of such projects, an area which is to be addressed by the new national immunisation steering committee. 220 health systems and their evidence based development vaccination documentation and data collection the gps and health boards are responsible for the documentation of vaccinations given. neither vaccination certificates nor chip cards are routinely issued. an individual child health record booklet to help parents keep a record of their child’s health history, including sections to be completed by a doctor or nurse e.g. on vaccinations given, is available but not in universal use. data on immunisation status, vaccine uptake and measles incidences are routinely reported to the national disease surveillance centre by each health board and published in a quarterly report. at local level data is collected by the health boards through gps and other medical staff. at present this data is sent electronically for entry into a separate central surveillance system. it is planned to transfer the data directly into a new single integrated system, however, at the moment, information about immunisation and vaccination can only be accessed in a number of separate health board databases, a process which requires time and effort. the main data gathering method is linked to gp claims for payment which must provide data over a range of fields. data is also provided by health board medical officers in respect of school or special clinics. both of these data collection methods support continuous systematic reporting but some gp claims are sporadic and time lagged. programme monitoring and evaluation the performance of measles immunisation programmes are assessed using criteria such as the percentage uptake rate and the incidences of measles. a number of marketing type criteria have been piloted to measure the impact of public information campaigns related to immunisation and will be developed further in line with the development of more systematic, targeted campaigns mentioned earlier. the erha has one of the lowest measles vaccination uptake rates in the republic of ireland and as a consequence the highest measles incidence rate. the last measles outbreaks which have occurred in ireland have been in this region. however, the low vaccination levels in the region reflect the situation in the whole country, (eastern health board 2000). the new organi-sational and governance approach outlined in fig.3 is aimed at improving this situation. disease surveillance as soon as a medical practitioner becomes aware of or suspects that a person on whom he/she is in professional attendance is suffering from, or is the 221 comparative research on regional health systems in europe carrier of an infectious disease, he/she is required to transmit a written notification to the relevant medical officer in his health board. under new regulations in 2000, the national disease surveillance centre (ndsc) was assigned responsibility for the collation and analysis of weekly notifications of infectious diseases, taking over from the department of health and children. thus the ndsc is responsible for the national surveillance of vaccine uptake and incidence of measles disease, with the department of public health medicine in each health board being responsible at the next level. since 1999, the ndsc publishes quarterly reports showing uptake levels for all health board areas and this receives wide dissemination, including to the media, which from time to time carry reports on low uptake concerns. the ndsc may also issue a press release specifically relating to measles, e.g. linking incidence of the disease to low immunisation rates. for the period 1997-2001, in measles immunisation and incidence data collected from the participating regions, it was not possible to differentiate between confirmed and just clinically diagnosed cases. limited information on hospital admissions due to measles is available. an enhanced surveillance system for measles commenced at the beginning of 2003 in the whole country which aims to correct the above points amongst others. it is hoped to have more detailed information on measles cases in the near future. 6.4 breast cancer screening programmes there are no defined programs of professional breast examination and it is usually carried out by a breast surgeon or specialist breast nurse in specialised breast clinics in some hospitals. breast self-examination is not promoted in ireland as it was feared that it could either cause anxiety by omission (women who do not self-examine may feel guilty for not doing so) or by a lack of knowledge (women who think that they have found something may worry unnecessarily). mammography screening programmes are the only official breast cancer screening programmes being used in ireland. the national breast screening programme, known as breastcheck, was established in 1998 following a pilot period from 1989 to 1994, with the aim of reducing mortality from breast cancer by 20% over a 10 year period. phase 1 of the programme started in february 2000 with the screening of women between 50 and 64 years of age in the combined eastern/midland/north-eastern region. 222 health systems and their evidence based development organisation of programmes breastcheck is jointly overseen by the health boards for the early diagnosis and primary treatment of breast cancer in women. a statutory joint board, the national breast screening board, was established by the minister for health and children whose members consist of the chief executive officers of the health boards and other nominees drawn from the disciplines involved in the early diagnosis and treatment of breast cancer in women, and a consumer representative (the national cancer forum 2003). this board, under the direction of the health boards, is responsible for instituting, coordinating and carrying out the programme. the breastcheck programme is managed locally by clinical directors who are responsible for their unit and its team, they report to the project director. the programme also has its own it system, epidemiologist, statistician and researcher. funding for the programme is provided from national taxation by the minister of health and children to the erha and health boards in the combined regions covered by the current phase 1 of the programme and they are required to meet the expenses of the national breast screening board in such proportions as they may agree, or, failing such agreement, as may be determined by the minister. the breast screening programme is managed and organised centrally with decentralised multi-disciplinary clinical units for screening, recall and assessment which are adjacent to a host hospital for the provision of primary treatment. screening strategy women aged 50-64 years living in the combined regions covered by the current phase of the programme are personally invited in writing to attend for screening at either a static or mobile unit, at a specific time and date, which can be changed to suit their convenience. women are given seven days of notice before their appointment. the population database for the areas concerned is used as a source of personal details for the women resident there. the database is formed using data from the following sources: voluntary health insurance, general medical services and department of social and family affairs; and self-registration is used to supplement the database. screening for the breastcheck programme is done at two clinical units, each of which has two mobile units. the two centres were chosen on the basis of established expertise in breast cancer at both hospitals. 223 comparative research on regional health systems in europe two view mammography is carried out at every round and the european quality assurance guidelines are followed very closely. there are no charges demanded for individual mammography provided under the programme; targets are set for each quality parameter of performance such as percentages of attendance, recall, and cancer detection rate. a plan for the roll out of phase 2 of the programme – expansion of the programme nation-wide – was submitted to the department of health and children in 2002. dissemination of results mammography is carried out by radiographers and the mammograms are read by two radiologists. following mammographic screening, a woman is either informed that her mammogram is normal and that she will be recalled in two years (provided she remains within the specified age range of 50-64 years at that time) or is recalled for further assessment if an abnormality is detected. breastcheck runs assessment sessions once or twice a week. the programme aims to send out results within three weeks of the mammogram and to ensure that women are offered an appointment for an assessment clinic within two weeks of being notified of an abnormal result. at the assessment clinic, the women are seen by a consultant doctor and supported by breast care nurses. assessment results are sent within a week and women are kept informed of any delays regarding results. women diagnosed as having cancer are fully informed about the treatment available to them and have the right to refuse treatment, obtain a second opinion or choose alternative treatment without prejudice to their beliefs or chosen treatment. there are special breast care nurses to support the women before and during treatment. information and education there is a lot of media interest in the success and usefulness of mammography screening and also in the extension of the current phase 1 of the programme to a fully national programme. a women’s charter was established within the breastcheck programme to inform and encourage women to give their views about the programme and any other related points of importance to them (breastcheck 2002). health professionals involved in the programme are regularly informed about current recommendation and new developments via relevant jour224 health systems and their evidence based development nals, articles and press cuttings which are circulated. monthly staff meetings are also held and radiographers have joint meetings 3 times a year. programme related projects/campaigns at present the only campaigns held in relation to the breast cancer screening programme are media campaigns. success of such campaigns is assessed by the attendance rates, which for breastcheck are over 70% to date. programme monitoring/evaluation data on different aspects of the programme such as numbers of women invited, attendance rate, referrals for further assessment and cancer detection rates are collected by breastcheck in its centralised database. rigorous audit and quality assurance is an integral part of the screening programme to ensure that women invited for screening receive the best quality of service. the performance of the programme is compared with predetermined standards based on the third edition of the european guidelines for quality assurance in mammography screening. in 2001, a team of experts in radiography, radiology, pathology, surgery, physics and epidemiology validated breastcheck’s guidelines for quality assurance in mammography screening. this was done in agreement with the european centre for quality assurance in breast cancer screening (euref). recommendations from this evaluation and the input from the european manual on quality assurance provide assurance that the quality parameters reached by the irish national breast cancer screening programme are to internationally approved standards (breastcheck 2002). disease surveillance breastcheck has centralised data on all cancers detected. there is also a national cancer registry in ireland where all cancer cases are documented by so called ‘tumour registration officers’ (tro). these are qualified nurses who undergo specialised training in cancer registration. the national cancer registry (ncr) has eighteen such officers and between them they cover all the hospitals, hospices, nursing homes etc. in the republic of ireland where the data is actively collected. confirmation of exact recording of tumours is facilitated by assistance from pathologists and clinicians to whom the tro will go to if extra verifica225 comparative research on regional health systems in europe tion is required. the data is recorded onto a laptop computer on site and is transferred electronically to the ncr headquarters for quality control. once quality control is complete, an annual report is produced on the incidence of cancer in ireland. the ncr analyses national data whilst breastcheck analyses its own data. 7) veneto – italy 7.1 demography veneto is one of 20 regions in italy, and each of them is governed by an executive and a regional council, both democratically elected. 4.5 million of the country’s 57.7 million inhabitants live in the region of veneto, an area of 18,364 km2. of the female population 0.56 million are in the 50-69 year old agegroup targeted for mammography screening. 7.2 organisation and structure of the health care system italy’s health care system is a regionally based national health service that, like the uk, provides universal coverage free of charge at the point of service. the system is organised at three levels: national, regional and local. the national level is responsible for ensuring the general objectives and fundamental principles of the national health care system whilst the regional governments, through the regional health departments, are responsible for ensuring the delivery of a benefit package through a network of population-based health management organisations (local health units) and public and private accredited hospitals. the ministry of health, the main central institution responsible for health, manages the national health fund and distributes resources to the regions. its role in financing is restricted to allocating the resources from the global national budget and ensuring uniform availability of resources in the regions. the regions finance the remaining health care expenditure from their own sources. in accordance with the decentralisation process occurring in italy’s national health service since 1992, regional governments, through their regional health departments, are responsible for legislative and administrative functions, for planning health care activities, for organising supply in relation to population needs and for monitoring the quality, appropriateness and effi226 health systems and their evidence based development ciency of the services provided (european observatory on health care systems 2001b). regions are also responsible for determining the size and organisation of local health units and monitoring their operation. local health units are geographically based organisations responsible for assessing needs and providing comprehensive care to a defined population. veneto has 21 local health units. 7.3 measles immunisation programmes the measles vaccine was introduced in 1979 in italy as a single vaccine which was replaced by a single dose mmr vaccine in 1982 (european sero-epidemiology network esen 1998). organisation of measles immunisation programmes the ministry of health compiles the national immunisation regulations and policies together with the inter-regional infectious diseases and immunisation committee. it also evaluates obligatory notification of diseases preventable by vaccination. the health prevention department is responsible for disease surveillance at the national level. there is a national plan which determines the vaccines which are to be given by statutory law (obligatory on the part of the provider) and recommended ones. the planning, organisation and implementation of programmes is the responsibility of the regions, which work together towards the elimination of measles. the regional governments determine the immunisation programmes, which are then organised and managed by the regional public health service and the local health units. the regional programme is implemented by the epidemiological and public health services of the health prevention department and by the public health services of the health prevention department at the local level (local health units). these organisations also coordinate the programmes at their respective levels. the regions instigated an inter-regional infectious diseases and immunisation committee, which together with the ministry of health and the national health institute formulate targets for the immunisation programmes. the targets are in line with those set by the who for the european region, e.g. 95% vaccination uptake rate. a measles immunisation programme which includes programme guidelines is currently being established by the regions together. 227 comparative research on regional health systems in europe the organisations involved in the realisation of measles immunisation programmes as well as the levels at which they operate are illustrated in the organigraph below (figure 4). figure 4. organisation plan for the measles immunisation programme in veneto region, italy 228 health systems and their evidence based development national level regional level local level statutory accountability reporting regional governments (rg) immunisation services: public health services inter-regional infectious diseases and immunisation committee program (i-ridicp) regional health departments (rhd) ministry of health (moh) health prevention department (hpd) regional public health services (rphs) local health units (lhu) local public health services (lphs) regional health fund (rhf) vaccination strategy in the veneto region, mmr is given as a single dose to children at the age of 12-15 months. all children are invited to be vaccinated and a recall system is used for those who do not turn up. the public health services of the local health units are responsible for the written invitations and they also maintain vaccination registers. vaccines are procured by the local health units, who distribute them to the immunisation services public health practitioners, paediatricians and health workers in their areas. vaccination is only carried out with informed parental consent; however written consent is not required. information and education parents, and the public at large, are informed about the immunisation programme via campaigns in the forms of posters, pamphlets available in the local health units, and information forms given to parents during the vaccination notifications. the general public opinion is not measured. vaccination services personnel are informed about changes or new information regarding measles and/or immunisation through circular letters containing recommendations and immunisation campaign results. currently there are no structured programmes involving the media dealing with measles immunisation. programme related projects/campaigns following the measles outbreak which occurred in the veneto region in 1997, the region enforced a measles immunisation programme for a period of 4 years (1998 2001). the programme entailed cohort catch up vaccinations for the groups with low vaccination coverage. during the campaign, more than 150,000 infants and approximately 69,000 individuals between 2 and 21 years of age were vaccinated, the latter comprising the ‘catch-up’ group. the programme was evaluated through data collection of the vaccine coverage in the cohorts involved in the programme. the regional annual incidence rate went down dramatically in 1998 and the following three years of the campaign. 229 comparative research on regional health systems in europe vaccination documentation/data collection the public health services of the local health units maintain vaccination registers and are responsible for the overall documentation of immunisation details. they collect immunisation and disease data at the local level whilst the regional epidemiological and public health services do so at the regional level and the health prevention department of the ministry of health at national level. immunisation status is checked biannually and at school entry. programme monitoring and evaluation all regions have to supply data relative to the number of vaccine doses administered each year and the vaccine coverage at 24 months of age for mmr and other vaccines to the ministry of health. the ministry of health uses these figures to evaluate the programme. it also evaluates the obligatory notification of diseases preventable by vaccines. disease surveillance measles surveillance is maintained on a national level with data transferred through the health service levels to the department of health prevention in the ministry of health. the measles data collected by gps or paediatricians is transferred to the public health services of the local health units where it is stored in a regional software programme before being forwarded on a monthly basis to the regional epidemiological and public health service who in turn forwards the data to the ministry of health. the regional epidemiological and public health service analyses all data collected in the region and prepares annual reports which are then sent to the services of the local health units for distribution to the immunisation services providers and to paediatricians. 7.4 breast cancer screening programmes mammography screening is the methodology being used for breast cancer screening in the veneto region. although professional breast examination is offered within a normal clinical work context, e.g. during gp or gynaecological consultations, no programmes for professional breast examination exist and no data is collected. breast self-examination is at times promoted within health education activities, but again without any clearly defined programme. in some mammo230 health systems and their evidence based development graphy screening programmes, after a negative mammogram, women are advised to regularly perform breast self-examination, but no practical training is given. organisation of programmes the veneto mammography screening programme started inviting women in 1999 in 10 of the region’s 21 local health units. in 2000, the programme was initiated in two more local health units. meanwhile, 17 units are implementing the programme. the public health departments of the local health units together with radiology, surgery, oncology and radiotherapy departments are responsible for the planning of the mammography screening programmes in the region. the coordination of the programmes is normally done by the public health department, however, a few are coordinated by the radiology department. radiology departments are mainly responsible for the implementation of the programmes, which are run according to guidelines issued by the national oncology commission which are in turn based on the european guidelines. screening programmes are part of the „lea” (essential health services) and as such are financed entirely by the government within normal budget. nevertheless, to promote the implementation the regional government and the ministry of health have repeatedly granted additional funds. screening strategy the primary aims as stated in the regional program reports include the early diagnosis and treatment of breast cancer and the associated mortality reduction, whilst the secondary aims concern the use of conservative and, as far as the women concerned, acceptable therapy. all women between 50 and 69 years of age who are registered as resident in the 17 local health units, where the programme has been implemented, are personally invited (with appointment) every two years for a twoview mammography examination. self-registration is also used to supplement the registers and services provided free of charge to all women who attend. a special information system is being developed for the screening programme. the computerised system will not only be used for invitation purposes but also for the storage and retrieval of programme data. 231 comparative research on regional health systems in europe the regional targets set for the screening programme include, expanding the programme to all 21 units, a participation rate by targeted women of at least 70% and that screening is available biannually. dissemination of results results are disseminated differently in each region, in 8 local health units, a so-called ‘standard organisation model’ is in operation. first, all the mammograms are read, and then participating women are recalled for further assessment. three local health units use a system where the reading of the mammograms and the conduction of non-invasive further examinations are done in one sitting. in the units where the standard organisation model is followed, an average of 88% of negative results were sent out within 21 days from the day of examination. in case of a positive or unclear result, the woman concerned is invited by telephone to an assessment session. 73% of the further assessments were achieved within 21 days of the initial examination. information and education there is a lot of interest in the mammography screening in the media as well as within the population, with a generally positive opinion reported from women and the general public. posters and meetings with population groups are used as means of disseminating information about the programme. invited women also receive information leaflets and are given a free telephone number where they can get more information or raise questions. professional training meetings are organised once or twice a year for those involved in the realisation of the programmes. programme related project/campaigns apart from the information sessions with population groups, there are currently no projects or campaigns being held in relation to mammography screening programmes. however, there are plans for implementing campaigns in the future. programme monitoring/evaluation data on different aspects of the programmes such as number of women invited, participation rate, referrals for further assessment and cancer detection rates are collected by the local health units. the coordinating department of each local health unit uses these figures to monitor and evaluate their 232 health systems and their evidence based development respective programmes. a common and specific information system is adopted by each unit and the data collected is forwarded to the regional reference centre for monitoring and evaluation on a yearly basis. disease surveillance personnel at the regional cancer registry in the veneto region are responsible for the documentation of cases in the cancer registry. data are provided from the local health units, analysed, and published on an annual basis. 233 comparative research on regional health systems in europe exercise: comparative research on regional health systems in europe task: students will work individually in the first phase of reading the introductory material (8 regional reports), while in the second phase they will discuss their findings in small groups (3 to 5 students). third phase will be plenary presentations of small-group work. the whole exercise requests 4 hours, because students are obliged to deliver written reports. instructions for students: 1) choose the best measles vaccination programme and the best breast cancer screening programme and present your arguments. 2) think of other services suitable for benchmarking. 3) collect the appropriate information on measles vaccination and breast cancer screening from your own region of origin. 4) using the example of your own region, what is your judgement with regard to the significance of the 2 selected programmes as indicators for the quality of health care in your region in general? 5) think of how benchmarking would look like using health indicators (5). 234 health systems and their evidence based development references 1. mossialos e, mckee m, palm w, karl b, marhold f: the influence of eu law on the social character of health care systems in the european union. report submitted to the belgian presidency of the european union. final version, brussels, november 19, 2001. 2. available from url: http://www.europa.eu.int 3. daniels n, bryant j, castanao ra, dantes og, khan ks, pannarunothai s: benchmarks of fairness for health care reform: a policy tool for developing countries. bulletin of the world health organisation 78(6), 2000: 740-750. 4. eu-project „benchmarking regional health management ben rhm” (final report, loegd, bielefeld/germany 2003. 5. bardehle, doris: minimum health indicator set for south eastern europe. croatian medical journal 43/2 (2002), 170-173 (the paper can be downloaded from www.cmj.hr/ph-see). 235 comparative research on regional health systems in europe health systems management 237 238 health systems and their evidence based development 239 health management: theory and practice health systems and their evidence based development a handbook for teachers, researchers and health professionals title health management: theory and practice module: 2.1 ects (suggested): 0.75 author(s), degrees, institution(s) prof. vesna bjegovic, md, msc, phd professor at the school of medicine, university of belgrade, serbia and montenegro address for correspondence institute of social medicine, school of medicine, belgrade university dr suboti}a 15 11000 belgrade serbia and montenegro tel: +381 11 643 830 fax: + 381 11 659 533 e-mail: bjegov@eunet.yu keywords health services management, planning, organizing, staffing, leadership, controlling, evidence based learning objectives after completing this module students and public health professionals should have: • increased their understanding of management theory and practice, and development of interest for health services management, • explored the current ideas and trends in health services management, as well as basic characteristics of managing health services organization, • identified key interrelated components in health services management (planning, organizing, staffing, leadership and controlling), • improved their skills in management and raised their understanding of modern evidence based management, • explained and justified their intentions for seeking a higher standard of management at their own place of work. abstract modern management is a process of creating and maintaining an environment in which people working together may accomplish predetermined objectives. it occurs in a formal organizational setting through utilization of human and other resources by which demands for health and medical care are fulfilled by provision of specific services to individual consumers, organizations and communities. management, as a universal and complex process, open towards its environment, consists of five essential components: planning, organizing, staffing, leadership and controlling. the activities of an effective manager imply basic skills providing the balance among these interrelated components and skills in evidence based management. teaching methods teaching methods include lectures, students' individual work under the supervision of teacher and interactive methods such as small group discussion. before introductory lecture the small exercise could be organised as brainstorming („what does management mean to us?”), in order to increase students' motivation for learning and interest in the content of the module. after the introductory lecture students will work individually by writing down the framework for their own professional development. this work will followed by the lecture and exercises focused on the health services management. students would have opportunities to discuss in small groups different case problems and to present possible solutions. as an example of, the case problem is presented in this module. they would also have opportunity to search through the internet under the supervision of teacher in order to explore some of the famous electronic libraries and to select examples of good managerial practice based on evidence. these will serve as base for individual work which is supposed to have a written case problem of national health service as output. 240 health systems and their evidence based development specific recommendations for teacher it is recommended that the module should be organized within 0.75 ects credit, out of which one quarter of ects credit will be done under supervision, while the rest is individual student's work. it is supposed the 1 ects is equal to 30 hours. teacher should advise students to use as much as possible electronic management libraries during individual work to gather ideas how to write and present their own case problems. assessment of students multiple choise questionnaire and case problems presentations. health management: theory and practice vesna bjegović management in health care system is an area of scientific management to which an ever-increasing attention has been paid under conditions of economic and socio-political changes. nowadays, the importance of an effective and competent manager is emphasized in solving problems referring to functioning of health organizations and related services in changing environment. development of management theory organizing of people for achieving common goals and utilizing management principles have been a phenomenon known for centuries, its development and changes running parallel with human society. however, not before the very close of the xixth century did the first scientific theories on management appear when there imposed itself, as a goal of economic and noneconomic companies, the basic economic principle: achieving maximal results with minimal investment (1). in that period, frederick w.taylor (1856-1915) may be viewed as an author of 'scientific management'. in his research in the field of work organization, he recognized the importance of achieving cooperation and harmony in teamwork, as well as workers' improvement in accomplishing better job results. his capital work 'principles of scientific management' expanded the management utilization. nevertheless, many hold the view that greater merit for the real beginning of the science in question should be given to henry fayol (1841-1925) and his work 'general and industrial rights'. he pointed out general management principles: linkage between authority and responsibility, the unity of leadership and teamwork, all of which represent the basis of classical school of management even at present. also, studies of other scientists in the same period, such as frank b.gilberth (1868-1924), lillian m.gilberth (1878-1924), max weber (1864-1920), contributed to further management theory development. the famous hawthorne experiment carried out with workers of the western electrical company powerplant in chicago from 1927 till 1932, as well as the findings of the researcher named elton mayo (1880-1949) threw a new light on classical theories. the study was begun as research into the impact of 241 health management: theory and practice illumination on work productivity of experimental group of workers. regardless of the illumination level being increased or decreased, the productivity kept rising. furthermore, there were experiments with modifying resting periods, working hours' reduction and wage changes. none of these could have explained the alterations in work productivity of the experimental group. the researchers ascribed the productivity modifications to social attitudes and relationships in the working group. namely, the group started regarding itself as 'noticeable', gaining the feeling of being important. this experiment outlined the significance of work motivation and initiated a series of psychological theories of management. after 1950, behavioral sciences showed great interest in studying motivation as an important means for achieving predetermined goals. the authors of motivation theories, still applied in management practice, are: abracham maslow, frederick herzberg and douglas mcgregor. studying individual and collective behavior at place of work, they noticed that management was not only a technical process and stressed the importance of a positive attitude towards people being managed. due to an extraordinary concern for management over the recent years there have been encountered the most diverse approaches to studying and analyzing its theory and practice. there have been numerous operational approaches analyzing management as a complex and open system in a dynamic balance with the environment (economic, technological, sociological, political, legal, ethical and cultural) (2,3). development of interest for health services management it may be noticed that only within the last three decades has the management become an area of significant interest in health systems, too. until that time, the management was regarded as a scientific discipline suitable only for big corporations and commercial companies, and not for social domain like health care (4). this is understandable bearing in mind that health services organizations used to be less complex, with significantly lower costs and underdeveloped technology. at the beginning of the xxth century, managerial roles were assumed by a physician-administrator, appointed by the managerial board with an exclusively autocratic managing style and one-dimensional distribution of authority and responsibility. only two professional groups were in charge of providing health care services, namely a physician and a nurse. still, with making health services organizations more complex, increasing gaps between medical technologies advanced and limited resources as well as by environmental changes, objectives of health services organizations have been changed and made complex in relation to the society as a whole. the situation 242 health systems and their evidence based development in terms of showing concern for management has also changed and presently there is an ongoing affirmation of the managerial skills application in health services organizations, too. the essential characteristics of external environment in which today's management of health services organizations is taking place include population aging, miraculous but costly diagnostic and treatment technologies, efforts to modify life styles and underscore health promotion and prevention (5). also, modern health systems in numerous countries are faced with ethical and economic crisis of unpredictable level. political, social and, most frequently, professional groups are trying to solve the crisis by introducing various changes in health legislation and functioning of health services organizations. in view of the alterations mentioned, peter drucker, a distinguished management theoretician, has noticed a paradox in health services organizations in which there is a growing work pressure on employees, but at the expense of additional activities being minimally or completely unrelated to those jobs for which the employees were qualified (6). an illustrative example makes an increasing number of nurses in hospitals, while there have been a decreasing number of hospitalized patients. a paradoxical situation occurs: nurses spend only half of their working hours doing jobs for which they are qualified and paid for. the other half of the time spent at work they devote to activities for which neither their nursing degree nor skills are required, that is filling in various blank documents and forms. likewise, in the last decade of the xxth century, there was a growing recognition of a conflict between doctors (as leading professional group in a health services organization privileged to do autonomous clinical work) on one hand, and managers (whose job includes controlling the work of employees), on the other. in accomplishing effectiveness, managers traditionally analyze resources, while doctors review clinical activities and patients' outcomes. in this way, a potential conflict is stressed in which a lot of energy is needlessly wasted in many health services organizations. such environment makes a challenge for successful managers, with the practice of effective leadership becoming one of rare solutions for the survival and development of health services organizations (7,8). the majority of health systems in central and eastern europe are undergoing the process of transition from bureaucratic, centralized to much more efficient systems with decentralized responsibilities, private sector introduction as well as more effective trends towards a higher level of health care quality (9). in these countries, there has been a significantly growing interest in professional management of health services organizations and continuing education in the field. 243 health management: theory and practice characteristics of managing health services organizations basic concepts, principles and skills in management encountered in industrial and other organizations may also be applied in health care institutions by respecting their social roles. seven principal roles of health care service are distinguished in each society: • it represents a part of national state policy; • it employs a large number of people; • it provides health care; • it does different kinds of research; • it educates on a continuing basis; • it represents significant economical factor; and • it plays an important role as a country's social stability factor, taking into account people's expectations and trust put in this service. the specificities of managing health services organizations are determined by the vital roles outlined above. health services organizations nowadays are known, in the management theory, to be the most complex organizations with the most complex management, a modern hospital being top ranking by its complexity. extensive working activities' differentiation and specialization are obvious, and working tasks are accomplished by a number of different participants in terms of educational level, training and functions. contrary to a typical business organization, the authority structure in managing a health services organization is divided among three authority and responsibility centres: managerial board, doctors and administration (4). managerial board is legally responsible for the organization as a whole, including provision of health care, public relations and assistance in resources supply for its functioning. if an aspect of basic social roles of a health service is viewed, it is the managerial board that most commonly reflects a profile of the community comprising a health services organization. it means that the former consists of delegates from various social groups of certain educational level and experience. doctors, comprising a medical board, but others as well, have a powerful role in management, since they are held responsible for the majority of cost rendering decisions made. as a predominant profession, doctors in health services organizations participate, at least, in three management 244 health systems and their evidence based development processes: managing a patient, managing a doctors' team and managing a health services organization. this makes them 'the potentially best managers in health services organizations' (10). related to this centre of management structure, many underline a typical phenomenon of health services organizations: for doctors, having power and authority does not imply being also responsible for financial risks. in spite of being highly educated in the medical area, most doctors are very little acquainted with their real working environment, since they spend most of their working hours with patients or are devoted to their own advanced training. thus, there occurs a phenomenon of separation between clinical autonomy (freedom and opportunity for doctors to work in the best possible way to help their patients) on one hand, and institutional interests, on the other. due to increasing costs of health care service provision, doctors are no longer in a position to make independent clinical decisions and provide patients with all the services they find beneficial for them. for this reason, it is impossible to enable effective management of health services organizations without a considerable doctors' participation in decision-making concerning leadership. administration, composed of director, heads of departments and chiefs of assisting services, is the third and last authority centre in managing health services organizations, responsible for operational management, but with both limited scope of authority and knowledge about the process of working directly with patients. the task of the director of the institution is to plan, make decisions, coordinate and control activities of the employees in order to ensure efficient and effective work with patients. in numerous health services organizations doctors used to hold the position of directors (operational managers). however, in the course of time they kept being replaced, in highly developed countries, by professional managers who were not doctors (9). such practice was not the same in some developing countries as well as countries of the eastern europe till 1990s. the managers role has always been attractive, but most frequently without either any improvement in the field of management or knowledge about managerial skills. in the study of managing health services organizations, unlike other business companies, apart from the triple power and authority distribution outlined, there exist its specific responsibilities that must also be taken into account (11): • responsibility for the patient, above all, within the scope of modern medicine and health promotion movement, with provision of the best possible health care, with minimal costs; 245 health management: theory and practice • responsibility for the employed health workers by recognizing their sensible requirements for safety in terms of wages, appropriate working conditions, promotions, but also identifying their fears caused by uncertainty due to positive effects at work (outcomes concerning the treated patients' health); • responsibility for a financier and different social groups (donors, sponsors) supplying resources for functioning of the institution; • responsibility for the community (public) in determining means for meeting the population health care needs; and • responsibility for oneself by making efforts to perfect one's knowledge and skills related to management as well as readiness to make effective responses under conditions of continuing environmental changes. definition and key management components there are many definitions of management and the following is very often cited: „management is the process, composed of interrelated social and technical functions and activities (including roles), occurring in a formal organizational setting for the purpose of accomplishing predetermined objectives through utilization of human and other resources” (12). management, as a universal and complex process, open towards its environment, consists of five essential components: planning, organizing, staffing, leadership and controlling. planning in management planning in management basically includes decision-making related to prospective services activities and objectives as well as how they may be accomplished. decision-making implies the following: problem definition, information gathering, alternative solution making, the best option choice, policy planning, policy undertaking and evaluation of the results obtained. the most varied methods, more or less effective, facilitate decision-making, and thay are one of the basic topics in modern schools and courses for managers, such as: intuitive methods; simulation methods, models and role-plays; decision tree; pert; linear programming and others (5). success in all other managerial roles depends on planning, since it also 246 health systems and their evidence based development implies a selection of the single solution among different alternative ones offered. efficient managers spend a lot of their working hours, perhaps even up to 40%, developing and improving the company's work schedules, formulating them in such a manner that both the organization's short-term management is successful and, at the same time, its long-term business activities more effective. beside classical classification of plans according to planning time perspective, cohen's division is also very useful for managerial staff, and is the following (13): corporate plans cover the company as a whole most frequently for the period of 5 to 25 years. strategic plans refer to changes introduction, most often in specific organizational areas, for the period of 2 to 5 years. leadership plans represent implementation of steps outlined for strategic plans and are related to improving the organization's activities, correcting weak points and possible flaws, allocating current resources for accomplishing the predetermined objective and adjusting to the existing environmental changes. these are usually annual plans. operational plans are associated with shorter-term steps outlined for leadership plans as well as common activities of certain organizational sections. financial plans determine financial resources and equipment required for accomplishment of goals, most frequently for a year. within planning, the vital issue in modern management theory and practice comprises the development of goals in the form of plans expressing the type of final results of organizational activities (4). sound management is considered to imply an ability to point out goals and rank them according to their priority, as well as the ability to utilize proper means to maximize those objectives. although there is a tendency to express the goals in quantitative manner, it is this 'virtue of vagueness' that is significant in determining general objectives and the necessity for their continuous reconsideration. both managers and employees should take part in establishing objectives, and numerous studies have shown that such approach leads to increased working performance since it is clear to the individual what is expected of him/her to do. also, people are ready to work on more demanding goals if they have participated in their development. therefore, one of the management types frequently applied in health care is 'management by objectives' whose concept 247 health management: theory and practice was introduced by peter drucker as early as in the middle of the xxth century. 'management by objectives' is a process in which both superiors and subordinates collectively identify general objectives defining, for each individual, a scope of responsibilities for fulfilling the expected results, as well as criteria upon which individual contribution to working process is monitored and assessed. the goals may have a great impact on the employees' participation in managing a health services organization. provided that the course of action directed towards economic acquisition is imposed upon by the objectives, the doctors' activities may be restricted by the necessity for cost containment and profit enlargement. on the other hand, if the objectives favor competence and public health orientation, a greater participation of doctors in management may be expected. organizing in management after the designing of plans, the next management component organizing, becomes significant. organizing implies interaction of all organizational resources (manpower, capital, equipment) in order to accomplish the goals most efficiently. organizing, thus, includes resources organization: individual or group task assignment and responsibility shift to individuals for achieving group goals. good organizational development and maintenance have been considered as crucial factor of successful companies with organizations representing social subsystems mobilizing people, power and resources in terms of attaining determined, collective social objectives. this is achieved through appropriate organizational structure. structure, according to management theory, represents establishment of patterns of either interrelated organizational unit components or management components (14). after the work division, it is necessary to group works and individuals who will perform those works, through the establishment of adequate organizational units, such as sectors, services, departments, etc. this process is usually termed departmentation (sometimes called departmentalization), which recognizes relationship between dividing work and the need to then coordinate divided work to achieve satisfactory results. bases for departmentation have increased, but the basic concept is largely unchanged. mintzberg suggest six bases for grouping workers into units and units into larger units (5,15): • knowledge and skills (hospitals group surgeons in one department, pediatricians in another), • work process and function (for example: department of finance in health services organization), 248 health systems and their evidence based development • time (hospitals and other health services organizations are 24 houra-day operations; some workers are grouped into day, evening, and night shifts), • output (many health services organizations group workers by whether they produce inpatient or outpatient services), • client (workers are grouped by patients / consumers served; for example geriatric or women's health programmes), and • place (workers are grouped by physical location, ambulatory health services downtown or in suburban locations). each organizational unit performs a part of the overall company's task. in the realization of its duties, it is connected to other organizational units. after determing the organizational units, managers for each of the units are also selected, and they are given authority and responsibility to direct the work of these organizational units. organization may be formal or informal. the first is characterized by firmly formulated policy clearly expressing what each employee's task is, as well as field of action in which an individual may work freely and creatively. the second, aimed at enabling successful company's functioning, has to be based on excellent interpersonal contacts. organizations may also be divided into simple and complex. simple organizations have one manager and several employees. they are usually informal, flexible, with supreme structure authority. as opposed to them, complex organizations consist of big hospital institutions compared to labyrinths. they are usually of a hierarchical, bureaucratic organizational structure with the stress on planning and rigorous control (4). forming the organizational structure can be achieved in different ways. the most acknowledged and used ways of forming organizational structure are: as per functions, products, territory, the project, matrix, and others. functional organizational structure designs grouping activities, and defining the organizational units according to certain functions, which comprise an array of uniform and interconnected activities, by which a certain task or a part of the company's business process is realized in the best way. the essential advantage of a functional organization is that the staff is grouped according to specialties and is always at disposal. however, functional structure is characterized by inflexible hierarchical nature, autocratic style of leadership, rigidity and one-way superior-subordinate-directed communica249 health management: theory and practice tions. product organizational structure devises an organizational unit to be formed for each kind of product. the advantage of such structure is that it can direct all resources and all activities onto a single product. the basic disadvantage of the product organizational structure is that it doubles the organizational units and cadre, which is unacceptable to smaller companies. territorial organizational structure implies that organizational units are formed according to geographical regions they supply. this manner of forming the organization is rather convenient for big companies, widely extending their business on national or international level. in such an organization it is necessary to have a decentralized management, which requires additional control by the company's head management. problems may also arise with transportation costs and due to the need for large number of personnel as manager for each particular region. project organizational structure implies creation of a special organizational unit, a project team whose task is to realize the particular project. the advantage of such an organizational structure is its direct orientation to the realization of the task, an the fact that it enables more efficient realization, while the drawback of the project is mainly connected to duplication of the human resources, and problems with personnel after the project team is dismissed. matrix structure is designed to ensure modern people-oriented management, it is flexible, with two-way superior-employee communications and good coordination among different units. it is a combination of the functional and project organizations. the idea is to benefit from the advantages, and diminish some disadvantages of the project and functional organizations. the advantage of the matrix organization is that it enables efficient management of a great number of projects and efficient utilization of resources, and it also alleviates conflicts between managers. disadvantages are connected to more complex communication and reporting, as well as to potential instigation of conflicts in relation to resources allocation. the most varied organizational forms may be encountered in health services organizations ranging from bureaucratic structure with clear-cut hierarchy, to matrix structure in which power of decision making is closer to those working with patients. each organizational form has to be made in such a manner so as to be capable of functioning, enable each member to make his/her own contribution, and assist people to effectively accomplish common goals even under altered circumstances. this means that a good organizational structure is never static. nevertheless, a bureaucratic structure is considered to be capable of functioning well in routine tasks. for organizations whose main purpose is research, different adaptive models make a far more adequate solution. an example of such model is a project structure ensuring swift switches of employees from one to the other project work phase with holding 250 health systems and their evidence based development flexibility in certain areas (such as research autonomy) and having rigorous control in others (e.g. financial resources). within organizing, coordination is an important activity related to providing conditions under which all the activities, inside the company, are realized through simple steps. in the early phase of management, this was considered to be the most important element. nowadays, this is regarded as good for unplanned activities, or the periods known as 'management crises'. as organizations grew bigger, and planning much more important, the need for coordination kept decreasing. presently, it is normal that with the plans falling through, the need for coordination is increasing. typically, managers make three simple errors in organizing, as a management component: 1) managers do not leave enough freedom for decision making to their subordinates. 2) too few subordinates are held responsible to a single manager. interestingly enough, managers prefer organizing too few to too many workers, which results in unnecessary double cost expenditure for leadership jobs and forming of bureaucratic apparatus in the company. 3) managers, in organizing, generally do not apply motivating methods: employee remuneration by work successfully performed and/or penalty in case of unsatisfactory work performance. staffing in management staffing is the third vital component exclusively related, as opposed to the previous two, to human resources planning. this role may be particularly conflicting for managers, since they are individually well aware of the staff significance for the company's successful operation, but also of a simultaneous restriction of methods available for effective staff policy implementation. staffing has its technical and social aspects (13). technical aspects refer to human resources planning, job analysis, candidate recruitment for vacancies, their testing, selection, then performance appraisal, compensation and benefits, as well as employee assistance. social aspects, directly associated with the impact on employee behavior and striving at work, are related to training and development, promotions, counseling and discipline. the basic problems of staffing are the following: role defining of the newly employed, candidate working ability assessment and his/her 251 health management: theory and practice simultaneous getting acquainted with job tasks, evaluation of the success rate of the job done, and, finally, criteria establishment. in any job dependent upon staff quality and competence, staffing has to achieve high standards. thus, for example, it is upon a manager to ensure that vacancies are filled with people who are: • capable of fulfilling their intended role successfully; • willing to make necessary decisions and perform an assigned task; • planning to remain at their place of work for a reasonably long period of time; and • getting along well and cooperating with other employees at place of work. a very frequently asked question relates to staff norms, which would serve as guidelines in planning and employing. norms for a so-called 'ideal service' are non-existent and will probably remain so, at least in the foreseeable future, due to, above all, relatively frequent technological changes in medicine as well as gradual alterations in the kind and nature of health problems. „political norms” exist and usually represent combined study results of proper practice and expert opinions at a given moment, or result from negotiations of those concerned (the role of practice guidelines in the total quality management approach). in local circumstances, they may be of little use since they do not cover patient structure, assisting staff existence, department location and related factors. there are also so-called „if-then” norms based on somewhat more objective staff needs assessment, relying on the workload studies. namely, if it is necessary to provide x services, and an employee may make a daily provision for y services, then z staff members should be engaged. common mistakes in staffing are the following: lack of human resources planning, inadequate monitoring and insufficient staff training and promotion. it is important to stress that decision making related to organizational staffing, lying at the root of effective management, is often a neglected activity. managers in health (and other fields, too) frequently spend much more time in making decisions on the introduction of a new apparatus (diagnostic and/or therapeutic) than on employees, their promotion, transfer to new working posts, or engaging new employees. 252 health systems and their evidence based development leadership in management directing involves a process of influencing employees to do their best to achieve group goals by team work. a good manager accomplishes this role using different motivating methods simultaneously, knowing the true nature of communication as well as successful communication with different social structures. the importance of employees’ motivation is unquestionable and over the recent years there has been a tendency to replace „directing” by „motivating” (5). however, a person with excellent motivation, interested in his/her job, still has a need to be directed in his/her activities, since many people, in certain circumstances, prefer clear „orders” to individual decision making. nevertheless, styles of the most effective managers necessarily include perfection in employees' communicating and motivating skills (16,17). a managerial style is a kind of behavior in which a leader influences other people’s work. most frequently mentioned basic managerial styles are the following (1): • autocratic (with high managerial authority, commanding, not leaving space for interaction or participation of others in decision making), • democratic (enabling permanent interactions between superiors and subordinates, employee participation in decision making and creativity) and • laissez-faire style („let (people) do (as they please)” style, based on complete individual freedom in decision making and work). a style a manager will utilize is considered to be dependent upon his/her situation, and is characterized by critical dimensions such as (14): • result significance if a working activity has to be performed quickly, perhaps due to accidents or under conditions of crisis, health manager should adopt autocratic style, another style being required for other circumstances; • job nature if the job is routine and requires temporary influence, a manager must be more autocratic than democratic in determining what, how and where it will be done, however, if the job is creative, flexible, with other departments being time independent from job completion, a manager should adopt a democratic style; 253 health management: theory and practice • employee qualities their training, education, motivation and experience may determine adoption of a particular style; if employees are untrained and inexperienced, a manager must make most decisions and vice versa; there are even such employees who, due to their own value system or previous experience, are unwilling to be accountable for decision making; • personal managerial qualities some managers because of their personality nature, prior experience, values or cultural features, function better adopting one style or another. none of the styles mentioned is appropriate in all situations, although, nowadays, different forms of democratic style are regarded as more appropriate and, long-term, more efficient than the authoritarian styles. if only clinical practice and doctors as team managers including nurses, technicians and others are looked upon, it may be noticed that they usually utilize the autocratic style since they are held individually responsible for treatment. different forms of democratic style are common for heads of departments and chiefs of staff. kenneth blanchard, a psychologist, holds the view that an effective manager has to assume various styles in his/her work with employees (18). which style the manager will adopt, apart from the given situation, also depends upon a developmental level of an individual. he defines the developmental levels according to employees' work competence and sense of commitment: • if persons are incompetent for the job, but hard-working and zealous, they should be directed: clearly told what they should do, how, where and when, and then carefully supervised. • persons competent for the job, but lacking motivation or selfconfidence are better suited to a supportive style: they should be listened to, encouraged, involved in problem solving and decision making. • for those who are neither competent enough for the job nor devoted, an instructional style is the most convenient, providing support and directing. • in highly competent and zealous workers, delegating is the best style. little support and directing are implied just to keep abreast of their work. 254 health systems and their evidence based development among many attributes of effective managers cited as important are the following: high standard of personal honesty, firmness, ability to identify crucial problems, serenity, vitality, persuasiveness, decisiveness, consistency, personal integrity, enthusiasm, showing understanding for subordinates' attitudes and suggestions, anticipatory abilities and so on. although the majority of remarkable leaders possess most of the personality traits outlined, there is no evidence that each one of them is really required. however, vanity, arrogance and breaking one's own rules are the least favorable attributes of managers. controlling in management controlling is a subsystem important for all the management components. it is most commonly defined as measuring and correcting the company's efficiency so as to ensure both achievement of goals and realization of plans (5). the controlling process in management involves the following: establishing standards, measuring efficiency, and comparing results against the established standards, correcting irregularities and timely informing. controlling has to cover services functioning; health services provision costs, revenues, employees' discipline and informing (health care information system). although necessarily pervading the whole managing process, the scope of controlling must not be large, so that by using it a manager has no time to pay attention to human interactions, that is paying attention to each individual, as well as suggestion acceptance and understanding the employees' existing problems. the most varied types of control have been mentioned in literature: visual, automatic, control of exceptions, motivation-assisted control, budget control, daily charts, gant's maps, network analysis, computer use (5). in small organizations, personal control of all functions and all employees may be established. the higher is the organizational magnitude and complexity, the harder is the control. today, a good informational system is considered to be the most powerful control means. the importance of strategic control has been particularly emphasized at times of big economic crises and extraordinary circumstances. since the controlling system provides a signal to a manager for failure correction, identification of explicit strategic control would prevent „falling through” of many long-term plans, which makes a typical problem of less developed countries. some managers make mistakes believing that successful leadership means carrying out control by reviewing different routine reports. however, 255 health management: theory and practice the essence of control is correcting deviations from the predetermined objectives. modern managing health services organizations is increasingly turning its attention to quality control in health care provision, too (19). it has been noticed that some managers are frightened and avoid applying quality control within a regular controlling system, being under impression that possible quality lacks might lead to additional, unnecessary expenditures. however, it is both in managers' ethical and commercial interest to minimize errors and incidents leading to patients' complaints and poor public reputation. skills of modern managers in health services organizations modern health care outcomes are greatly determined by health professional activities in that management effects may instantly be analyzed, based on managerial abilities to act upon behavior of doctors, nurses and other health care workers to do their utmost in achieving the best possible outcomes for patients. the efficiency of the management itself, beside theoretical knowledge and training, mainly depends upon the existing evidence on possibilities of acting upon health care workers' behavior. the starting point is making efforts for organizational development characterized by decentralization in decision making, professional linkages and cooperation, demanding objectives, acceptable and transparent standards, responsibility division and decreasing job failures (20). in such organization, evidence based management should be developed. within the programmes for education and development, there must be those oriented towards evidence using skills on the part of managers themselves. a „complete manager” of evidence based health care should possess, apart from general managerial skills, evidence based decision making skills, as well. these skills comprise the following (21): • reference and abstract application, • the use of individually defined key words, • individual use of computers for search, • reference management database search, including, beside cochrane base, the bases covering topics in the field of health care administrations, economy and planning (2,3,22). apart from the skills mentioned, requiring, in most cases, special education, managers of health services organizations should also possess skills 256 health systems and their evidence based development of research evidence implementation into everyday practice, as well as skills of managing alterations, projects and, finally, team work. unfortunately, certain studies have shown that, when specific skills needed for evidence based management of health services organizations are taken into account, managers themselves inhibit the development of such approach. in the past, managers of health services organizations were responsible for organization and system, but nowadays, with the shift towards evidence based health care, they have to balance among clinical, managerial and organizational performance (23). having in mind numerous restrictions and the time required for the development of such approach, as well as suspicion among certain theoreticians concerning uncertainty of its possible implementation due to those restrictions, evaluation informed management has been recommended, as a transitional strategy (24). besides, an important recommendation for evidence based management is the one related to modifying existing educational programmes via multidisciplinary teams, so that clinicians may educate themselves from management area, and managers of health services organizations from clinical research. 257 health management: theory and practice exercise: managing health services organizations the purpose of the exercise is to provide students with basic information on managing health services organizations and their functions (components), and also to find out how managerial skills may be mastered by learning and training. task 1: professional development (career) plan design students work individually, by writing down their own goals in professional development for a ten-year period, as well as conditions required for their accomplishment. several students present their reports. a teacher, after that, points out planning as one of the important functions of management being especially aggravated under conditions of critical environment. also, the term „management” is defined, and its other functions quoted, such as: organizing, staffing, directing and controlling. time: 30 minutes. task 2: case problem: how is group work to be maintained? the teacher introduces the topic by outlining possibilities of managerial skills training and stresses „case problem” solving as one of the ways of its achievement. then, the supplemented practical case is read. students, in groups of 5-6, discuss solutions, and then each group presents its reports. the teacher, upon that, provides a summary with a suggested solution, unless the students have discussed all the possibilities. time: 60 minutes. case problem: „how will you maintain group work?” dr branislava petrovi}, a newly appointed chief of staff in gp outpatient department of a health care centre, is worried about starting her new job properly. just after several weeks at work, she noticed that the majority complained of being overworked. when she seemed to notice that one nurse was too slow in answering the telephone, dr petrovi} gloomily asked: „why's it taking you so long to answer the phone? that's a very important thing for our service and i think it should be answered after the second ring!” the nurse answered: „we've so much work to do; i simply can't jump after hearing a ring.” as the others were also making similar remarks, that still did not convince branislava that they were overworked. in fact, branislava knew that the new health centre manager was seriously considering cutting down of staff in the outpatient department unless their working hours were truly totally spent. dr petrovi} was particularly unhappy about the time wasted by many of her employees on coffee breaks. to quote her own words: „on tuesday i came 258 health systems and their evidence based development back from a meeting at 9.30 and offices were almost empty. the employees went for a coffee break and didn't come back even after 45 minutes!” this made branislava issue an order for both morning and afternoon coffee breaks to last no longer than 15 minutes; also, no more than two employees could have a coffee break at the same time. employees remained at their places of work, but it seemed that it took even longer to carry out examinations, interventions and administrative work. branislava noticed that several doctors and nurses spent quite a long time on making personal telephone calls, while the waiting rooms were full of patients. in issuing her second order, dr petrovi} announced: „personal telephone calls shall last 2 minutes at most and there are to be no more than two such calls daily. in addition, our work is too slow! we keep our patients waiting too long and prescribe too many drugs!” in spite of dr petrovi}'s efforts, there were no improvements in the work performance of the outpatient department. only one nurse (marija) started showing quite unpleasant manners towards her chief of staff. after the latest order, marija told dr petrovi}: „you're really trying hard to make an impression, maybe wishing to be promoted to the assistant manager. when you leave, we'll be left with all these new changes: restricted drug prescriptions, patient referrals to specialists, sick leave reductions... all this, of course, unless we're fired beforehand!” branislava was very frustrated. she was aware that her employees were doing their jobs below their abilities, but did not know what to do. questions: suggest specific steps dr petrovi} should undertake to solve the problem. what should dr petrovi} do if the suggested steps prove unhelpful? learning from anecdote: „report: schubert's unfinished symphony” during considerable periods of time the four musicians on the oboes had nothing to do. their numbers should be reduced and their work distributed to the rest of the orchestra. forty violins are playing the same notes. this seems to be an unnecessary duplication, so this part should be drastically cut. if you want more volume, an electronic amplifier should be used. there is no need to repeat on the horns the passage already played by the string instruments. if these parts were eliminated, the concert would be reduced to 20 minutes. if schubert had worried about these problems, he probably would have finished his „unfinished symphony”. 259 health management: theory and practice references and recommended readings 1. torrens pr. management sciences and planning studies. in: holland ww, detels r, knox d, ed. oxford textbook of public health. 2nd edition. volume 2: methods of public health. oxford: oxford university press 1991. 363-84. 2. mcnamara c. free management library (cited 2003, may 20). available from url: http://www.managementhelp.org/ 3. management sciences for health (cited 2003, june 15). available from url: http://www.msh.org 4. boissoneau r. health care organization and development. rockville, maryland: an aspen publication 1986. 5. rakich js, longest bb, darr k, managing health services organizations. 3rd edition. baltimore, maryland 1993. 6. drucker pf. managing for the future, the 1990s and beyond. new york: truman talley books/dutton 1992. 7. simpson j, smith r. management for doctors. london: bmj publishing group 1995. 8. williams sj, ewell cm. medical staff leadership: a national panel survey. health care manage rev 1996; 21(2): 29-37. 9. hunter dj. doctors as managers: poachers turned gamekeepers. soc sci med 1992; 35(4): 557-66. 10. smith r, grabham a, chantler c. doctors becoming managers. bmj 1988; 298: 311-14. 11. mcconnell cr. the effective health care supervisor. 2nd edition. gaithersburg, maryland: aspen publishers, inc. 1988. 12. koontz h, o'donnel c, weihrich h. essentials of management. 4th edition. new york: mc graw-hill book company 1986. 13. cohen jg. the nature of management. 2nd edition. london: banking and finance series, graham & trotman 1988. 14. rowland hs, roeland bl. nursing administration handbook. germantown, maryland: aspen systems corporation 1980. 15. mintzberg h. mintzberg on management: inside our strange world of organizations. new york: the free press 1989. 16. quinn jb, anderson p, finkelstein s. managing professional intellect: making the most of the best. harvard business rev 1996; 74(2): 71-80. 17. elwyn g greenhalgh t, macfarlane. groups a guide to small group work in healthcare, management, education and research. abingdon, oxon: radcliffe medical press ltd 2001. 18. blanchard k, zigarmi p, zigarmi d. leadership and the one minut manager. glasgow: fontana paperbacks 1990. 19. borgenhammar e. quality of management in the health care system. quality assurance in health care 1990; 2(3/4): 297-307. 260 health systems and their evidence based development 20. smith kpd. evidence based management in health care. in: peckham m, smith r, ed. the scientific basis of health services. 2nd edition. london: bmj publishing group 1997. 9299. 21. gray mja. evidence-based health care. how to make health policy and management decisions. new york: churchill livingstone inc., 1997. 22. the cohrane library, oxford (cited 2003, june 20). available from url: http://www.hiru.mcmaster.ca/cochrane/revabstr 23. clarke j, wentz r. pragmatic approach is effective in evidence based health care. bmj 2000; 321: 566. 24. overtveit j. evidence-based medicine: evaluation informed management. healthcare review online 1998; 2(9): http://www.enigma.co.nz/hero_articles/9807 261 health management: theory and practice 262 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title human resource management module: 2.2 ects (suggested): 0.50 author(s), degrees, institution(s) silvia gabriela scintee, md, msc part-time lecturer at the university of medicine and pharmacy „carol davila” bucharest, department of public health and management public health consultant at the institute of public health bucharest address for correspondence institute of public health bucharest 1-3 dr. leonte street 76256 bucharest romania tel: (4021) 2249228 / ext.188 fax: (4021) 3123426 e-mail: gscintee@ispb.ro keywords human resource management, human resource planning, job analysis, recruiting and selection of personnel, employees training and development, motivation, evaluating employee performance learning objectives at the end of this module, students should be able to: • define human resource management and identify its functions, • describe the steps involved in the human resource planning process, • define the term of job analysis, • describe the recruiting and selection processes, • identify methods for employees training and development, • describe methods for evaluating employee performance. abstract this course covers the following topics: fundamentals of human resource management, staffing the organisation, employees training and development, personnel motivation, employees maintenance. teaching methods teaching methods include lectures, interactive presentation of key concepts, group discussions, groups assignments, role playing for job interview. specific recommendations for teacher teaching methods include lectures, interactive presentation of key concepts, group discussions, groups assignments, role playing for job interview. teacher should discuss the concepts and methods in comparison with the practice in see countries.this course takes 2 hours of lecture and 4 hours practical session including role-playing. the rest is individual work. assessment of students 1. reports presented by each group during the working sessions could be considered as part of assessment. 2. a multiple-choice test containing questions from all topics, at the end of the course could be used for final assessment. human resource management silvia gabriela scintee fundamentals of human resource management human resource is the most important asset of an organization, and has a crucial importance for management, as the management is the process of efficiently achieving the strategic objectives of the organization through people. human resource management is responsible for the people dimension of the organization and is concerned with getting competent people, training them and motivating them to perform at high levels (1). human resource management is the process that assures the utilization of the employees so that both the organization and the employees obtain the highest possible benefit. some authors make a distinction between human resource management and personnel function. in this view, while human resource management has a strategic role, assuming human resource policies development for the entire organization, the personnel function is supposed to have an operational role, being considered as a tool for human resource policies implementation. thus, while human resource management is the responsibility of a special department, the personnel management is one of the duties of the managers from all levels in the organization. according to other authors personnel management is the historical term of human resource management and the change appeared with the changing roles of professionals in human resource area (2,3). the main functions of the human resource management are staffing, training and development, motivation and maintenance. staffing function in order to implement strategies and achieve the stated goals and objectives, an organization must be staffed with adequate numbers of properly trained personnel. the staffing function is a continuation of strategic planning process, when after determining how goals and objectives will be attained, the managers should determine what jobs need to be done and by whom. these activities are included in the human resource planning process that determines staffing needs. the outcome of this process will be either recruitment or decruitment (1). when acquisition of personnel is needed, the manager should 263 human resource management gather two types of information: information on the job and information on the persons eligible for the job, than to match skills, knowledge and abilities to required job. when manager has to sever people from the organization, he/she should engage in activities to assist and monitor exit. the staffing function includes: human resource planning, job analysis, job description, recruitment, selection, integration of the new employee, assistance and monitoring personnel exit. human resource planning is the process by which an organization ensures that it has the right number and kinds of people able of efficiently and effectively performing the tasks required for achieving the strategic objectives of the organization (1,4). as organizations are dynamic, permanently under the influence of external environment and internal factors, planning should be a continuous process. the main steps of human resource planning are: strategic objectives analysis, estimating staffing needs, assessment of current human resources, forecasting changes in the present workforce, and development of an action plan. strategic objectives analysis. strategic objectives are broad statements that establish targets the organization will achieve in a certain period of time. the analysis of the current strategy determine how goals and objectives will be attained and to what extent the organization can meet its objectives given the internal strengths and weaknesses and external opportunities and threats. commonly referred to as swot analysis, this managerial tool could bring information on what skills, knowledge and abilities are available internally, and where the shortages in terms of people skills or equipment may exist (1). the analysis should take into account influencing factors such as: anticipated demand for services, changes in professional practice or labour supply, development of new technologies. estimating staffing needs. the analysis of the objectives and of the ways in which they will be attained gives information on the number and types of the jobs needed and the skills and knowledge required for the jobs. unless drastic changes will occur, such as reengineering initiatives, major organizational changes, human resources needs estimates could be made for a certain time period, using the established staffing ratios for most major functions. for example, for the further development of an outpatient department at a hospital, projection of the needed staff can be made (2). using the projected volume of service and the accepted nurse staffing ratio, it can determined the number of nurses needed. 264 health systems and their evidence based development assessment of current human resources. assessment of current human resources is a valuable input in the human resource planning process by determining what skills are currently available in the organization and how are they used. each organization should generate a detailed human resources inventory report listing all employees by title of the job, education, training, prior employment, performance ratings, salary level, languages spoken, abilities and specialized skills (2). such an inventory could be also used for other activities such us internal recruitment or selecting individuals for training and development. forecasting changes in the present workforce. an organization will experience turnover through retirement, death, voluntary separation, etc. based on historical data the changes in the present workforce could be forecast. for managerial positions some organizations use the replacement chart (1). this is a diagram that determines if there is within organization a sufficient managerial potential to cover future vacancies. the main information listed for each individual is: the current position, expected replacement time, and possible replacements with their potential and readiness in occupying the job. development of an action plan. the previous steps bring the necessary information for developing an action plan to fill the staffing needs through recruiting and hiring, transferring or enhancing the skills of existing employees by training and development. the action plan will specify: the jobs to be created, transformed or cut off, the implications at institutional level, the number of persons to be hired and specifications of their characteristics, the movement of the personnel within the organization and the training needs, the methods of sorting out the unpredictable losses, the costs of covering staffing needs and the timetable of each activity. job analysis and job description. job analysis is a systematic examination of the activities within a job (1). this analysis involves the description of the job content (the goal of the activity, tasks to be fulfilled, duties and responsibilities, resources used, expected results), what are the job requirements (knowledge, abilities, skills required), what are the working conditions (physical environment, hazards), and the social environment (individual or group work, communication skills required, relationships to other jobs). there are three basic methods for job analysis: observation, questionnaire and interview. observation provides firsthand information. this can be done directly or reviewing films of workers on the job. observation can not bring exact information as people being watched act differently than in their day to day activity. the interview has an increased accuracy in assessing jobs by involving employees in analysis. in order to increase the effectiveness of this method it 265 human resource management is recommended a combination between individual and group interview. structured questionnaires could also be used for gathering information about a job. the disadvantage of this method is that exceptions to a job may be left out and there is no opportunity to ask follow-up questions. other methods that can be used for job analysis are technical conference (specific job characteristics are obtained from experts) or diary method (workers are asked to record their daily activities). the main purpose for job analysis is to gather information in order to develop: job descriptions, job specifications and job evaluation (1). a job description is a written statement of what the jobholder does, why and under what conditions. the content and format of job descriptions vary among organizations. yet, the general job description format include (1,5): name of organization name of division/department job title grade of job job purpose duties to be performed authority and responsibilities of the job holder supervision given or received relationships with other jobs environmental working conditions special provision (e.g. confidentiality) terms and conditions (e.g. salary, working hours, holidays) job specifications states the characteristics that the jobholder must posses in order to perform the job successfully. these characteristics are identified also during job analysis and refer to the knowledge, skills, education, experience, certification and abilities needed to do the job effectively. job description and job specifications are used in activities such as human resource planning, recruitment, selection, performance evaluation, compensation plans. job evaluation is the process of determining the value of each job in relation to the other jobs within organization. on the basis of job evaluation, the jobs in an organization are ranked and placed in a hierarchical order (3,6). the resulted ranking should be used in order to establish the compensation programme. 266 health systems and their evidence based development recruitment is the process of searching and attracting potential candidates for present or anticipated vacancies. the recruitment sources could be either internal or external (2). the internal search attempts to identify present employees who can fill a vacancy by transfer or promotion. this method is cost effective, quick and motivating for the employees. the external search is done mainly by advertisements that can be placed in different newspapers, magazines, electronic sites or public places, depending on the type of the job. the main elements to be included in a vacancy announcement are given below (6): organization name title of the job location of the job employment duration description of duties job specifications salary and employment terms application procedure other external sources are employment agencies, schools, colleges, universities, professional organizations or even unsolicited applications. the selection of the recruitment source depends on the job characteristics, labour market supply, geographic workforce distribution. the success of the recruitment process is influenced by factors such as: organization reputation, the attractiveness and nature of the job, internal policies of the organization, legal requirements, and the recruitment budget (4). selection. the next step in acquisition of personnel is to choose from all qualified applicants for a job identified through recruiting the „right” one. this is a very important decision, as a good selection process can save costs for personnel replacement or training and can increase the work productivity. there could be considered two steps of the selection process: initial screening and final selection. initial screening consists in gathering preliminary information about candidates and excluding those who are not suited for the job in terms of training, experience and ability. among methods used for initial screening are curriculum vitae, intention letter, application form, letter of recommendation, employment tests. 267 human resource management curriculum vitae (cv) cvs bring information mainly on training and experience, but also give some insights about candidate personality, when looking at its clarity, stile and logic sequence of ideas (6). the information to be included in a cv is: • personal data and characteristics (name, surname, contact details, date of birth, nationality, marital status) • education (institutions, dates, degree or diplomas obtained) • present position (company, location, description of main tasks) • work experience (employment record, institutions, dates, main tasks and responsibilities) • scientific activity (papers, presentations, publications) • other skills (e.g. proficiency in foreign languages, computer literacy) • other information (if appropriate, e.g. hobbies, preferences for leisure time) intention letter while cv is just an inventory of the person’s history regarding training and experience, the intention letter is the mean by which the candidate exposes his motivation and desire to get the job. the intention letter also talks about candidate’s professional and human qualities and about his compatibility with the job. no longer than one page, an intention letter should not contain the information from cv, but has to wake up the reader interest in setting an appointment for the candidate. application form there is not a general format for the application forms. each organization has its own format, some of them requiring may be only applicant name, address and telephone number, others requesting the completion of a more comprehensive profile. in general, application forms bring less information than a cv, but they are very common, representing a standardized tool for information gathering which makes comparison between candidates easier (6). some application forms could include statements giving the employer the right to obtain previous work history of the candidate, to dismiss him for falsing information or to end the work relationship at the employer will. if the candidate does not sign such a form his application is removed from consideration (1). 268 health systems and their evidence based development letter of recommendation information about candidates could be obtained from other persons, too. even criticized as being subjective, recommendation letters are still very common. they depend on the intention and the degree of information of the person who issues it. usually there are requested two or more recommendation letters. the initial screenings will shortlist the candidates for the final selection. both shortlisted and not shortlisted candidates should be announced about their results through an official letter. the shortlisted candidates are asked to come for the final selection that can be done by employment tests or by interview. employment tests tests are used mainly for two purposes: the assessment of the candidates’ knowledge, abilities and skills, and the psychological evaluation of the candidates. the second category is given more importance as many studies have shown that the employees performance is more related to their personality characteristics than to the knowledge they have. there are hundreds of tests that can be used by an organization in selection purposes. they are measuring intellect, memory, perception skills, spatial ability, motor ability, personality traits, etc. bringing information that can not be obtained from the candidate and that can make predictions on the person behaviour. tests can be written tests or simulation tests. the last ones require the applicant to engage in specific activities and behaviours necessary for doing the job. assessment centres an organization can also address for initial screening of its candidates to an assessment centre. these are specialized institutions that combine more methods in selecting candidates. all applicants are received at such a centre for a 2-4 days period, being subjected to individual and group testing by: interviews, solving problem exercises, group discussions, role playing, personality and general ability tests, etc. in the same time it is assessed the candidates social behaviour (1). interview interview is almost universal accepted as the final selection tool, evaluating the candidates’ compatibility with the job, motivation and abilities of integrating themselves in the organization. the interview gives the opportunity of clarifying the previous gathered information on the candidate and also can 269 human resource management test the candidate reaction under particular situations such as stress, conflicts, etc. the interview’s validity and reliability are subject of criticism (1). in order to increase the effectiveness of the interview, it should be conducted by a person familiar with the interview technique and having some specific qualities: determination, discipline, self-control, tolerance, empathy, lack of prejudices. an interview should be careful prepared, paying attention to the place where it will be held, obtaining detailed information about the job and its requirements, studying applicants information gathered in the initial screening stage, planning time, developing guidelines for interview and a list of criteria to be evaluated during the interview (5,6). integration of the new employee. after selection, the new employee is helped to integrate in the organization, in order to become productive as soon as possible. the human resource department is responsible with enrolling new employee in benefit plans, issuing an identification badge/card. the chief of the department in which the new employee will work will take care of preparing the work place, and will delegate a supervisor to prepare and implement an orientation programme (4). the supervisor will introduce the new employee to other colleagues, will explain the organizational structure and function, will explain in detail the department specific work methods and internal norms and rules. the supervisor also helps the new employee to gain acceptance by others and will morally support him with any personal problems. usually, in a month time the manager will meet the new employee in order to evaluate the extent to which he integrated in the organization. assistance and monitoring personnel exit. sometimes the employees have to leave the organization from various reasons. the personnel exit should also be assisted and monitored. besides activities like completing personnel records, collecting employer-provided equipment and processing final pay, a manager could involve in activities oriented to the alleviation of psychological impact of leaving the job and to assisting employees in finding employment (2). thus, some organizations have a preretirement programme consisting in preparing employee for the psychological, emotional and financial changes in retirement. when jobs are eliminated for various reasons (changing demand, downsizing, mergers, etc.) the leaving employee should receive an earlier notice and should be helped in finding a new working place. also, the employee could be tested for discovering abilities for other jobs and helped in the process of professional re-orientation and re-location. 270 health systems and their evidence based development training and development function training and development is a key element in helping employees to maximize their potential. the goal of training and development function is to have competent employees who possess the up-to-date skills, knowledge and abilities needed to perform their current jobs more successfully. although there are similarities in the methods used to affect learning, the terms of education, training and development are different (6). education refers to a basic teaching, a long term learning process, directed to obtaining knowledge, abilities and skills that allow individuals or groups to perform the social roles. education is focused mainly on individual needs and also on community needs. training is a learning process oriented to the acquiring of specific knowledge, abilities and skills necessary to the individuals or groups for performing a job. training is job or tasks oriented, it has a continuous character and it might assume changing of skills, attitudes or behaviour in order to immediately adapt to the present job requirements. development is a learning activity oriented rather to the future needs than to the present ones. employee development focuses on the future jobs in the organisation and career progress for which new skills and abilities will be required. each organisation should have a continuous training and development programme. specific training and development needs are given by: hiring new employees, acquisition of new technology and equipment, low performance of the organisation, occurrence of some events with a higher frequency than usual (e.g. nosocomial infection in a hospital), changing demand for services, organisational changes. the development of a training and development programme has the following steps (6): 271 human resource management training and development policy internal needs evaluation external factors factors plan implementation programme evaluation training and development policies are included in overall human resource policies of an organization and have to be in accordance with its general policies (6). training and development programmes should take into account the training and development policies that usually state the organization’s commitment of assuring to the employees the appropriate means for training in order to successfully perform their jobs. elaboration of a training and development programme should be preceded by training and development needs assessment. the training need is represented by the deficit of knowledge, abilities and skills in relation to the level required by the job or by the organizational changes (3,6). the main information sources for needs assessment are: • the organization – we will look at the organization’s goals, structure and functioning, • the job – what tasks have to be completed to achieve the organization’s goals, what are the requirements for effectively performing the job, • the employee – what is the level of employee’s performance, what are the deficiencies he has in the skills, knowledge or abilities required to perform the job. training and development needs assessment has to take also in account 272 health systems and their evidence based development training / development plan all internal and external factors that might contribute to the changing of the organization needs. once it has been determined that further training and development is necessary, an action plan will be developed (6). the structure of the training / development plans: training goals training objectives target groups training content training methods time schedule estimated necessary resources evaluation and monitoring tools training goals should be clearly stated and they can refer to: increasing capacity for problem solving, enhancing ability for performing specific activities, acquiring skills for performing new tasks, increasing communication skills, modifying attitudes towards change. training objectives should be tangible, verifiable, timely and measurable. they have to reflect the real changes in the employees knowledge, abilities, skills or attitudes. training content will be established in accordance with the training objectives and the level of previous training of the target group. training methods can be classified as either on-the-job or off-the-job training (1). on-the-job training method is the most used, being simple and less expensive. it is a learning by doing method, placing the employee in actual work situations and asking him to do the tasks. this method is more appropriate for jobs that are difficult to simulate or for those that can be easily learned by watching and doing. examples of on-the-job training are: • apprenticeship – is used for training in different trades where skills are so complex that can not be acquired on theoretical basis or by simulation. it consists in putting the trainee under the guidance of a skilled master. • job instruction training – consists in explaining the trainees what they are suppose to do, verifying their understanding and placing them in the job under a supervisor to call upon if they need assistance. 273 human resource management on-the-job training has the risk of low productivity, but has the advantage of motivating workers, increasing employee morale and understanding. off-the-job training has a various number of techniques: • lectures – designed to communicate theoretical concepts, to describe tools or to present technical, problem-solving skills, • seminars and workshops – for more interactive discussions and practical exercises in which to apply theoretical knowledge, • simulation exercises – in which trainees are performing different tasks in a working like situation; this also may include: case studies, role playing, group decision-making, computer based simulation, training on real equipment away from the work setting, • videos and films – use media production to demonstrate specialised skills that can not be easily presented by other methods. developing methods can also take place on-the-job or off-the-job (1). among on-the-job techniques there are: • job rotation – consists in moving employees to various jobs in the organisation, either on horizontal or vertical, with the purpose of expanding their skills, knowledge and abilities. this method gives the employee an overall view on the organisation activities, turns him from a specialist to a generalist, avoids boredom and stimulates the development of new ideas. • working as staff assistant – the employee works as the „shadow” of an experienced person from the next higher level. working as an assistant, the employee has the opportunity to be exposed to the whole range of the activities in that position, he learns by performing many duties under direct supervision and get used with assuming the duties and responsibility of the higher level. • committee assignment – the employee is appointed to temporary or permanent committees. this allows employee to take notice about specific organisational problems and to learn from the others example how to solve different problems and to participate in decision making. off-the-job methods could be done by traditional forms of instruction such as lectures, seminars, simulation exercises or by modern techniques like outdoor training. 274 health systems and their evidence based development • lectures and seminars – they are offered for acquiring knowledge or for developing employees conceptual and analytical abilities and could be organised either in class or by distance learning. • simulations – as seen above, simulations are exercises in which employees are performing different tasks in a working like situation. the most used are: case studies, role playing, decision games. • outdoor training – also called wilderness or survival training, this method teach the importance of working together and involve emotional and physical challenge. the most known techniques are: whitewater rafting, mountain climbing, paint-balls games or surviving one week in the jungle. motivation function motivation is a key determinant of employees performance. the concept of motivation is based on the way in which people are given attention and on the feelings that they have in relation with their work. to motivate employees means to satisfy their unmet needs, to stimulate them to work better in order to achieve the organization’s goals. unmet needs cause discontent which is reflected in employee’s negative behaviour and attitudes, producing tension and low productivity. the motivation process is cyclical (2). it starts from identifying individuals unmeet needs, after that ways to satisfy the needs are searched for and the most convenient is chosen. the needs satisfaction is recommended to be followed by the assessment of needs satisfaction level, which may confirm the failure of satisfying the need, or identifies a new need and the cycle is restarted. 275 human resource management searching ways to satisfy the needs choosing the way to satisfy the needs unmet needs identification unmet existing needs & new needs identified assessment of needs satisfaction level the motivation theories. the multitude and diversity of theories developed to explain human motivation reflects its complexity. the most important motivation theories can be divided in two categories: content theories and process theories (2,3,5). while content theories focus on „what” motivates people, process theories focus on „how” motivation is initiated and sustained. among content theories there are: maslow’s hierarchy of needs – considers people needs arranged in the following hierarchy (from lowest to highest): physiological, safety and security, social activity, ego and self-actualization (figure 1). figure 1. hierarchy of people needs according to this theory, only needs not yet satisfied influence behaviour and once the needs from a level are fulfilled, the individual moves up to the next level. primarily, an individual has physiological needs, such as air, water, food, shelter and sex are basic for an individual. once these survival needs are met, the individual turns to the next level: safety and security, represented by needs for health insurance and other benefits that ensure protection against physical harm and deprivation. the third level of needs includes the need for belonging, friendship affection and love. examples of ego needs are the need for independence, achievement, recognition, self-esteem and status. in the top of the hierarchy are self-actualisation needs, represented by continuing growth and development, opportunities for self-expression and self-fulfilment. 276 health systems and their evidence based development selfactualization ego social activity safety and security physiological state alderfer’s erg theory – refers to the three categories of needs: existence needs – including material and physical needs that can be satisfied by air, water, money and working conditions, relatedness needs – that involve other people and are satisfied by social and interpersonal relationship, and growth needs – including all needs satisfied by an individual through creative or productive contributions. similar to maslow’s theory, people focus first on needs that are satisfied by more concrete ways. herzberg’s two-factor theory – say that job satisfaction consists of two separate and independent factors: intrinsic job factors such as responsibility and recognition which motivate when they are adequate, and extrinsic factors called also „hygiene factors” that only placate employees when are present, but they cause dissatisfaction when they are deficient. among the hygiene factors identified by herzberg there are: organisational policy and administration, interpersonal relationships, salary, job security, working conditions. mcclelland’s learned needs theory – states that people learn about their needs through life experiences and there are three major needs in workplace situations: the need for achievement, the need for power and the need for affiliation. the most known process theories are: vroom’s expectancy theory – based on the concept that people have preferences for outcomes and if they have a strong preference for a particular outcome, they will attach to that outcome a high valence. adam’s equity theory – focus on people desire of being treated fairly and states that individuals assess whether rewards are equitably distributed within organisation by calculating the ratios of their efforts to the rewards they receive and compare them to the ratios for others in similar situations. locke’s goal setting theory – affirms the importance of goals in motivation as people focus their attention on the concrete tasks that are related to attaining their goals and persist in the task until the goals are achieved. all the above mentioned theories are based on the mcgregor observation of the importance of managers’ attitudes about people in determining their approach to motivation. in 1960s douglas mcgregor proposed two alternative sets of assumptions that managers hold about human nature in workplaces: theory x – according to which managers view people in negative ways and theory y – that argues that managers view people in positive ways. according to mcgregor theory y assumptions are more valid than theory x and employee motivation would be maximised by giving workers greater job involvement and autonomy. 277 human resource management motivation principles (1): • put the right person in the right place. no reward or stimulating factor could increase a person’s productivity if that person lacks the ability to perform the job. matching properly the employee to the job should be an objective of recruiting and selection. • managing by objectives. people work better when their activity is goal-directed because this is challenging and it is clear to the employee what is to be done. the results are even better if individual objectives are mutually set and are in accordance with the department and organisation objectives. continuous feedback is also important for increasing individual’s performance. • understanding individual needs. individuals are different, and each individual has its own set of needs. so, unmet needs assessment should be done for each employee. • individualise rewards. as the individual needs are different from a person to another, rewards should also be different. what motivate an individual, could not be motivating for another one. • reward performance. the best way to encourage increasing performance is to reward individuals for their performance or to relate any other reward they receive with the achievement of the organisation goals. • use an equitable rewarding system. people are concerned not only with the rewards they receive, but also with the equity of their rewards compared to what others receive. so, efforts must be made in order to ensure that the reward system is fair, consistent and objective. • money is the best reward. as money is the main reason for people to work, no other reward would be appreciated if they were not paid sufficiently to cover their basic needs. 278 health systems and their evidence based development possible ways to increase motivation: job related rewards • job characteristics such as: the requirement for using various skills and talents, the requirement of completion of a whole and identifiable piece of work, the impact the job has on the lives or work of other people, a high degree of autonomy, a high degree of information received back on the effectiveness of his/her performance. • job enrichment – the worker is allowed to assume some of the tasks executed by his/her direct manager. • job rotation – the employee has the opportunity to diversify its activity and offset the occurrence of boredom. • work at home – this affords employee, especially women, to combine both their careers and family responsibility. • flexible hours – increases workers’ freedom; employees assume responsibility of completing a specific work in a specific time, and this increases their feeling of self-worth. • training courses. • assuring a safe, pleasant and practical working environment. rewards not related to the job • tangible rewards: premiums, stocks, insurances, presents, free lunches, free snacks and coffee at the break, etc. • social rewards: free tickets for spectacles, picnics, trips, free access to company clubs, etc. • acknowledgements – diplomas, certificates, mentioning in the panel of honour, informal acknowledgements. maintenance / retaining function another function of human resource management is to put into place activities that will help retain productive employees. these activities includes: appraising employees performance, moving employees within the organization through promotion or transfer, providing employee assistance and career counseling, administering compensation and benefits, ensuring a healthful workplace and personal safety (2). 279 human resource management performance appraisal evaluates an employee’s work by comparing actual with expected results. it should be done at any level, from employees and managers. uses of performance appraisal are (6): • to collect information in order to evaluate if work results are those expected and, if not, to determine why not, • to help decision-making in regards with compensation schemes and other benefits, • to determine the further use of the employee (if he/she should stay at the same work place, or should be transferred, promoted, demoted or deployed), • to evaluate training needs by identifying areas in which performance could be increased in proper training is undertaken, • to motivate employees for working better by providing feed-back and making the results available to the others, too, • to increase communication between employee and supervisor, allowing the opportunity to discuss the problems that are responsible for a low performance, and • to provide information on employee assistance and counseling needs. performance appraisal principles are: • evaluation criteria should be formulated according to job description. they have to be clearly stated, easy to measure and in small number. examples of evaluation criteria are: the degree of fulfilling with tasks, the degree of assuming responsibility, initiative and creativity, etc. • the measuring of performance should be done against specific standards. these are established by job analysis, which gives information on the tasks that have to be fulfilled, the way in which the tasks should be performed. the performance standards cover: the quantity and quality of work, the efficient use of resources in order to maintain costs, the compliance with the time schedule, the specific requirements for the job (such as team work abilities, flexibility, communication skills, etc.). 280 health systems and their evidence based development • the appraisal should be prepared and scheduled in advance. the employee should have permanently access to his job description, which should also have attached the list of performance appraisal standards and the schedule of the periodical evaluations. thus the employee has the opportunity to prepare in advance. on the other hand, the manager should be prepared in advance reviewing the employee’s job description and his previous performance measures. • the employee should be involved in appraisal by taking active part in the discussion, raising questions, adding his own perceptions about his work and also by a self-evaluation. • the employee should be familiar with the purpose of the appraisal and the evaluator should behave in a way that the employee understand that the appraisal has the role of helping him and not of punishing him. performance appraisal methods can be classified according to the approach in: methods based on absolute standards, methods based on relative standards, and methods based on objectives (1,7). among the methods based on absolute standards there are: • essay method – the appraiser writes a narrative description of employee’s strengths, weaknesses, potential and suggestions for improvement. this method can provide specific information, but makes difficult the comparisons between individuals. • critical incident method – looks mainly at behaviours, focusing on those critical aspects that make a difference between doing a job effectively and doing it ineffectively. the comparison and ranking of employee is difficult by this method. • checklist – the evaluator uses a list of behavioural descriptions and checks off those behaviours that apply to the employee. the list is evaluated by another person and this reduces some bias as the rater and the scorer are different persons. • rating scale – the most common method, it can be used to assess job dimension attributes such as quantity and quality of work, job knowledge, or personal traits and behaviours such as cooperation, dependability, loyalty, attendance, honesty, attitudes, initiative. for each scale there is a scoring mechanism using descriptive adjectives from „poor” to „excellent” or numerical values that often range from 1 (poor) to 10 (excellent). 281 human resource management • forced-choice method – is a special type of checklist where the rater must choose between two or more statements, each statement being favorable or unfavorable. the appraiser will identify which statement is most/least descriptive for the individual being evaluated. in the category of appraisal methods based on relative standards there are: • group order ranking – this requires the evaluator to place employees into a particular classification, such as „top 10”. this method prevents raters from inflating their evaluation by rating everyone as good. • individual ranking – requires the evaluator to list the employees in order from highest to lowest. • paired comparison – it ranks each individual in relationship to all others on a one-on-one basis. each person is scored by counting the number of pairs, among his colleagues, in which he is preferred member. the third approach to performance appraisal makes use of objectives, being commonly referred to as management by objectives (mbo). it consists in four steps: goal setting, action planning, self-control and periodic reviews. for each employee specific objectives are established jointly by the supervisor and the employee, and also realistic plans are developed in order to attain the objectives. the employee is monitoring and measures its performance, with periodic progress reviews done by supervisor. performance appraisal errors. the main problem with the performance appraisal methods is that all of them allow some bias (1,7). the most common errors are described below: • leniency / severity errors – the individuals within an organization are evaluated by different persons. some evaluators are more generous than anothers, so the performance is evaluated either higher or lower than it really is, and comparisons between individuals are not reliable. • halo effect – the evaluator’s general opinion on an employee is influenced by a single specific aspect. • central tendency – is the evaluator tendency of avoiding the extremes and rating everyone in the middle. 282 health systems and their evidence based development • similarity error – is given by the fact that the evaluator rate other people in the same way that they perceive themselves, by projecting those perceptions onto others. • other errors are given by: prejudices, different cultures, recent influencing events. in order to reduce appraisal errors a combination of two or more methods is recommended. 283 human resource management exercise: human resource management students will perform 4 exercises, after each introductory lecture. total time requested for exercises is 4 hours. task 1: small group discussion recommended subjects for group discussion are: • human resource planning advantages and limits. • the possible recruitment sources for managerial jobs in health sector. • how doctors in your country are best motivated. • how performance is assessed in different organizations in your country (from students experience or after visiting some organizations and collecting information) task 2: developing skills in human resources management recommended assignments for group work. prepare the following: • job description • write the job advertisement • cvs and intention letters • find different blank application forms from different organizations and compare them. application form which is most preferred overall by the class. develop a training plan for middle-level hospital managers. task 3: web-wise exercises search the web to identify current job opportunities: http://www.careermosaic.com http://www.occ.com http://www.who.ch look also for other sites. 284 health systems and their evidence based development task 4: role play job interview: choose up to 7 applicants for a certain job who will submit their cvs and intention letters for applying to a job. a small group (4-5 persons – the interview commission) will shortlist 2-3 candidates for interview. than the interview will be conducted and it will be chosen the best person for the job. the other persons in the class will discuss at the end the positive and negative aspects observed during the interview. 285 human resource management references 1. de cenzo ad, robbins ps. human resource management. 6th ed. new york: john wiley & sons inc. 1999. 2. longest jbb, rakich js, darr k. managing health service organizations and systems. 4th ed. baltimore: health professions press 2000. pp. 531-586, 771-800. 3. armstrong m. a handbook of personnel management practice. london: kogan page 1996. 4. higgins mj. the management challenge. 2nd ed.. new york: macmillan publishing company 1994. pp. 419-458. 5. mullins jl. management and organisational behaviour. 4th ed. london: pittman publishing 1996. pp. 625-706. 6. cole ga. personnel management, 3rd ed. london: dp publications ltd 1993. 7. pitaru hd. managementul resurselor umane. masurarea performantelor profesionale, bucuresti ed. all, 1994. recommended readings available from url http://www.bmj.com: • leung wc. managers and professionals: competing ideologies. bmj 2000; 321: 2. • singh d. hospitals must use london’s appeal to tackle workforce shortages. bmj 2003; 327: 70. • macdonald r. implementing the european working time directive. bmj 2003; 327: 9-11. • dosani s, adsett j. the staff grade dilemma. bmj 2002; 325: 170 s. • west m. how can good performance among doctors be maintained? bmj 2002; 325: 669–670. • edwards n, kornacki mj, silversin j. unhappy doctors: what are the causes and what can be done? bmj 2002; 324: 835-838. • leung wc. studying for an mba. bmj 2000; 320: 2. • cockcroft a, williams s. staff in the nhs. bmj 1998; 316: 381. • delva md, kirby jr, knapper ck, birtwhistle rv. postal survey of approaches to learning among ontario physicians: implications for continuing medical education. bmj 2002; 325: 1218. • stockdale s. how to stay motivated with an impossible workload. bmj 2002; 324: 141. • king j. giving feedback. bmj 1999; 318: 2. • ham c. improving nhs performance: human behaviour and health policy. bmj 1999; 319: 1490 – 1492. • king j. dealing with difficult doctors. bmj 2002; 325: 43. • wood lep, o’donnell e. assessment of competence and performance at interview. bmj 2000; 320: 2. 286 health systems and their evidence based development 287 information systems management health systems and their evidence based development a handbook for teachers, researchers and health professionals title information systems management module: 2.3 ects (suggested): 0.25 author(s), degrees, institution(s) adriana galan, it specialist part-time senior lecturer at the university of medicine and pharmacy, department of public health and management, at postgraduate level address for correspondence institute of public health bucharest 1-3 dr. leonte street 76256 bucharest romania tel: (4021) 2249228 / ext.188, fax: (4021) 3123426 e-mail: agalan@ispb.ro keywords information system, management of information system, decision making, problem solving, management cycle learning objectives at the end of this course, students should: • identify the basic concepts of the management of information systems; • be able to describe the existing types of applications in the medical field; • identify the need and role of information in a managerial cycle; • be able to make the difference between the types of decision and the information system required by each type of decision; and • learn the medical fields where an information system can offer support. abstract this course covers: definitions and basic concepts, existing types of applications in the medical field, managerial cycle and information support, and types of decisions and the related information systems. recommended readings are also given. at the end of this course, the case study is proposed to be solved. teaching methods teaching methods include lecture, interactive presentation of key concepts, overheads or powerpoint presentation. case study will be solved in small groups (4-5 persons) and an overhead will be presented by each group with their findings. specific recommendations for teacher it is recommended that this module is organized within 0.25 ects credit. the work under supervision is consisting from lecture (2 hours), case study reading (1 hour), and case study solving (1 hour), while individual work is related to review literature to prepare an essay (3,5 h). assessment of students 1. reports presented by each group can be considered as assessment. 2. an essay on the types of information systems used in their own organizations (functions, what type of decisions are supported etc.) information systems management adriana galan definitions and basic concepts there are many definitions of information systems, based on the definition of a general system, representing a group of interrelated elements organized to achieve a common purpose. out of these definitions, here are presented: • information system represents that type of system trying to solve the problems in an appropriate manner, able to generate the information at right time and place, in an understandable format, in order to be used in the managerial process. • information system is a special class of system whose components are people, procedures and equipment that work interdependently under some means of control to process data and provide information to users (1). figure 1 summarises this definition: figure 1. system engineering components (2) organisation procedures training 288 health systems and their evidence based development software hardware facilities people contingencies algorithms management of information systems (mis) are orderly methods of gathering, storing, organizing, analysing, and reporting data in a manner that is meaningful, useful, and quickly to retrieve. the direction of data aggregation is given on figure 2. mis provides a foundation upon which a hospital / health organization can develop its information resources and enhance decision-making, strategic planning, and quality of clinical services. figure 2. levels of information systems basically, any information system is working with three key concepts: • data: facts obtained by observation, counting, measuring, weighing from the surrounding environment (for example: patient temperature is measured as 39.5°c) • information: follows that data which have been analysed, summarized or processed in some fashion to produce a message or a report; becomes information only if it is understood by the recipient (for example: t=39.5°c, headache, photophobia (possible meningitis) • knowledge: represent the result of combining meaningful information there is not a clear distinction between the three concepts, many times information can be considered as data for the higher level inference. components of health information system are given on figure 3. 289 information systems management international national regional institutional locald ir e c ti o n o f d a ta a g g re g a ti o n doc tor’s office, hospital ward hospital iphs figure 3. health information system existing types of applications in the medical field the main types of it applications in the medical field developed worldwide are (3): patient registration and hospital admission systems the main functions of this application are: • data collection: demographic, clinical and financial • reporting: generates different types of documents based on data analysis and also administrative reports • operations management: keep track of patient transfers and discharges patient accounting • prices of provided services per patient: attach a price for each service received by a patient. the price can be established according to different criteria: • based on the range of services contracted with the insurer • based on drg system (diagnosis related groups) • based on the type of patient: inpatient, outpatient, emergency 290 health systems and their evidence based development informati on generation & communication data bases hardware softwarepeople co mputers networks system applicatio ns useres participants sp ecialist users depending on the type of contract between providers and insurer, the output of this application can be some other unit than the monetary one (e.g. number of points, credits, etc.). the insurer can further transform these units into monetary ones. • patient bill: calculate the patient bill to be sent to the insurer • electronic data interchange: between the health care provider and the insurance financial management • payroll system: calculate employees' workload, calculate the taxes, produces the salaries forms together with control reports, forms for tax declaration • staff registry: manages a history of employment for each employee (payment reports, licenses, continuous education training, etc.) • assets registry: manages the registry of organizational assets (fix properties, physical site, depreciation planning etc.) • general financial registry: collect data from all financial applications having as result the financial balance sheet (debts and credits) and the annual financial management patient registry and management of care • patient index: collects and manage a summary of patient record for all in-patients and out-patients • procedures and diagnosis coding: check the accuracy of disease codification according to international codification system, build the drg classes • monitoring the transfers: monitor the link between clinical wards and ancillary departments (radiology, pharmacy, labs, etc.) pharmacy systems physician's orders for drugs are registered. the system is monitoring each patient: what and when must receive the drugs. also keeps a drug inventory and can act as a warning system for the incompatibility of 2 or more drugs for a patient. 291 information systems management management of primary care patient big efforts were done in the last decade for developing this system due to the increasing weight of ambulatory care. some functions can be mentioned: • visit scheduling • patient registration • medical records and monitoring the consultations • financial module • pharmacy module • communication module (electronic data interchange) electronic medical records (4) very modern in usa, even at early stages of implementation, is the concept of „electronic medical record” (emr). the traditional medical record has been exposed to a rethinking process, in order to provide the needed information for: • clinical care • billing • research tool • communication tool communication was a key issue in these modern clinical systems, unlike the old clinical systems. emr must be accessible for all the clinical care providers of a patient (family doctor, outpatient clinics, hospitals), but can be accessed by the patient himself. at the same time, clinical databases are a powerful research tool. another important step forward is represented by the accessibility of emr via internet. what are the main information areas in an emr? • id • history of present illness • current medication • past medical history • past surgical history • family history 292 health systems and their evidence based development • physical examination • laboratory database (including images) • procedure note • problem list (assessment) • plan (diagnostic / therapeutic) managerial cycle and information support information systems can essentially contribute to increase the manager's degree of confidence in the validity of alternatives that are the basis of organizational strategic decisions. also within the health units, information can represent a valid support for problem solving, like: • cost control and productivity enhancement (financial information systems) • medical quality assurance and outcomes assessment (clinical information systems) • health care organizations must frequently monitor and evaluate their performance, both for internal purposes and to meet external regulations and accreditation criteria (administrative information systems) the basic management process in any health care organization can be described in terms of a cycle that includes the following components (5): • establish goals and objectives • estimate demand for services • allocate resources to meet demand • control the quality of performance • evaluate programs impact cycle is repeated after each evaluation. information management should play an important role in each element of this basic management cycle. examples of types of information that can help decision making in each category, can be described as follows: 1. establishment of institutional goals and objectives • problem indicators, direct and indirect (direct: morbidity and mortality data, social indicators, economic data on the community; 293 information systems management indirect: data on personal health habits of members of the community) • data on services being delivered by other community health organizations • available resources 2. demand estimation • historical data on utilization of health services • demographic data • community projections 3. resource allocation • work force data • financial information • short-term demand forecasts 4. performance and quality control • output measures (statistics: number of inpatient days, patient visits in outpatient department, number of delivered procedures etc.) • quality control data • work sampling and measurement • medical audit 5. evaluation of program impact • changes in problem indicators • cost-benefit analysis types of decisions and the related information systems from the informational point of view, herbert simon (6) has described two types of decisions: • programmed (structured) decisions these are periodical decisions, repetitive and routine; • non-programmed (unstructured) decisions these are occasional decisions, irregular and must be treated in a new manner each time they occur. 294 health systems and their evidence based development simon classification is based on the manner in which a manager deals with existing problems. a well-designed information system is obviously influenced by the periodicity or non-periodicity of decision. there are two approaches for an information system to meet the need of non-programmed decision making process: • to organize special studies in order to collect necessary information, involving a big effort and being time-consuming; costs and benefits of this approach must be analysed in advance; • to be operational a general information management system, where relevant information have to be only retrieved and analysed. robert anthony (7) has developed a theory that represents the basis for the process of analysing and planning the information systems. he described the managerial activity consisting of three categories, arguing that these categories are activities sufficiently different to require the development of different information systems (figure 4). strategic planning is the process of deciding on organizational objectives, changes of objectives, resource allocation to attain these objectives and on policies that govern the acquisition and use of these resources. the major problem of this type of activity is to predict the future of the organization and its environment. this level typically involves a small number of high-level people who operate in a very creative way. the complexity of problems that arise at this level, as well as the nonroutine way in which they are handled, make it difficult to design an adequate information system. usually, in this planning process aggregated information is needed, most often obtained from external information systems. at this level most of the decisions are unstructured (see definition above) and irregular. management control the process by which managers assure that resources are obtained and used effectively and efficiently for the accomplishment of the organization's objectives. this type of activity involves interpersonal interaction. it also takes place within the context of the policies and objectives developed in the strategic planning process. the main goal of management control is the assurance of effective and efficient performance. the relevant information for this level is mainly obtained during the human interaction process. operational control represents the process of assuring that specific tasks are carried out effectively and efficiently. 295 information systems management the basic distinction between management control and operational control is that operational control is concerned with tasks, whereas management control is mostly often concerned with people. this level requests clearly defined information for very specific tasks. information must be detailed, accurate and is obtained mainly from inside the organization. for each managerial level described by anthony, a specific information system must be designed. each level of decision-making process corresponds to a different administrative level of the health system. the operational level corresponds to the health care units (hospitals, primary care units, ambulance, etc.) where huge amounts of detailed and updated information exist and are reported to the upper levels. the control level corresponds to the local health authorities (for instance, in romania the district public health authorities exist in each of the 42 districts, one district covering 500,000 inhabitants on average), information being here aggregated for the local level. the strategic level corresponds to the ministry of health, where information is highly aggregated for the national level, but often being rather old (a 2-years time lag). figure 4. hierarchical model of decision-making process proposed by anthony (7) strategic level (senior management) planning control level (middle-level management) control process operational level (junior management) common database 296 health systems and their evidence based development within the managerial process of decision-making, an information system can offer support for the following areas (8): • medical quality assurance and outcomes assessment. clinical information abstracted from patient medical records provides the basis for health professionals in peer review systems to assess diagnosis and treatment practices. such information must be readily accessible and retrievable from a central patient data file. • cost control and productivity enhancement. such systems require the ability to integrate clinical and financial information system. computerized information systems offer the possibility for providing cost analysis and productivity reports in order to improve the efficiency of operation. • utilization analysis and demand estimation. such systems should be able to provide current and historical data on utilization of health services. these data assist in current analysis of utilization of resources and also provide a basis for predicting future demand for services. • program planning and evaluation. information obtained for the previous above-mentioned domains serves as the basic input for management decisions related to evaluation of present programs and services. when combined with projections about future changes in the demographic characteristics of the population and other external information about the service market, the information system can be an important resource for planning future programs and services. simplification of reporting. information processing costs consume an important proportion of the budget of a complex health organization. on the other hand, external reporting requirements are growing exponentially. therefore, an important goal for an information system is to simplify the preparation of these various reports, often a difficult repetitive task. 297 information systems management exercise: management of information systems task 1: recognizing different types of information system, and their importance in decision-making process the purpose of the exercise is enabling students to recognise different types of information systems, and their importance in decision-making process. students are asked to split in small group, in order to read this case study, and then discuss, following suggestions given below (30 minutes for reading the case study, 60 minutes for work in a small group, 30 minutes for discussion in whole group). total time for exercise: 2 hours. case study* an usual manager's working day by january 15, 2002, the user of different types of information systems was doctor escu, the director of „wonderland” district public health authority (dpha). doctor escu has the responsibility of developing and implementing health policies at „wonderland” district level. doctor escu lives in a neighbourhood located far enough from dpha site. in the morning, after waking up, he listen first the radio news in order to decide if he would rather use his own car or the dpha car. because bad weather was forecasted, he decided to use the office car. on the way to dpha location, the driver didn't give priority to the pedestrians, so that a policeman stopped him. apart from the fine, he was also registered in the police files. once arrived at dpha, doctor escu turns on the computer and check first his meeting's schedule for the day, file already updated by his secretary. after reading his messages, he answers himself to two of them. for the rest of the messages, he forwards the messages to the secretary and asks her to answer. after that, he invites the head of human resources department and the economic manager to try to solve together the problem of the hundred junior physicians applying for a job in the district. at noon, a meeting with a foreign expert's team was scheduled. the foreign experts were willing to help the dpha to implement an intervention project to reduce some risk factors in order to improve the health status of „wonderland” district population. the experts were bringing a software for modelling and simulation of the impact of reduction of risk factors on health. doctor escu has also invited to attend this meeting the head of „health status evaluation” department, as well as public health specialists and epidemiologists. 298 health systems and their evidence based development * case study adapted by adriana galan, based on a case study developed by g.lucas jr. around 6 pm, doctor escu leaves the dpha, and on the way back he stops to a supermarket to make some shopping. once arrived at home, he watches the tv news, then he reads the financial report for the previous month in order to prepare the next day meeting with the economic manager. finally he decides to go to bed because he felt very tired. please observe carefully the activity of doctor escu during the whole working day and determine what type of information systems he was using in each circumstance. for each information system you discovered, please mention for what type of decision it was useful (use anthony theory and mention if the decision was programmed or non-programmed). 299 information systems management moment of the day what type of information system was used type of decision during the morning during afternoon during the evening references 1. reynolds gw. information systems for managers. second edition. st.paul (mn): west publishing company; 1992. 24-39. 2. longest bb, rakich js, darr k. managing health services organizations and systems. fourth edition. baltimore (my): health professions press; 2000. p. 291. 3. austin cj. hospital information systems and the development of a national health information system. journal of medical systems 1982; 6: 4-5. 4. van bemmel jh, musen ma. handbook of medical informatics. heidelberg (germany): springer-verlag; 1997. 331-356. 5. austin cj. information systems for health services administration. aupha press; 1992. 3-26. 6. simon ha. the new science of management decision. new york: harper & row; 1960. 5-6. 7. anthony rn. planning and control systems: a framework for analysis. boston: harvard business school division of research press, 1965. 8. gorry ga, scott morton ms. a framework for management information systems. sloan management review 1989; 30: 49-61. recommended readings in bmj collection (http://www.bmj.com): search/archive keywords: healthcare information systems • littlejohns p, wyatt jc, garvican l. evaluating computerised health information systems: hard lessons still to be learnt. bmj 2003; 326: 860-863. • heathfield h, pitty d, hanka r. evaluating information technology in health care: barriers and challenges. bmj 1998; 316: 1959-1961. • mandl kd, szolovits p. public standards and patients' control: how to keep electronic medical records accessible but private. bmj 2001; 322: 283-287. • rigby m, roberts r. integrated record keeping as an essential aspect of a primary care led health service. bmj 1998; 317: 579-582. • rigby m, forsstrom j, roberts r, wyatt j. verifying quality and safety in health informatics services. bmj 2001; 323: 552-556. • terry n, stanberry ba. regulating health information: a us perspective; legal aspects of health on internet: a european perspective. bmj 2002; 324: 602-606. • majeed a, bindman ab, weiner jp. use of risk adjustment in setting budgets and measuring performance in primary care ii: advantages, disadvantages, and practicalities. bmj 2001; 323: 607-610. • simpson k, gordon m. the anatomy of a clinical information system. bmj 1998; 316: 16551658. • lærum h, ellingsen g, faxvaag a. doctors' use of electronic medical records systems in hospitals: cross sectional survey. bmj 2001; 323: 1344-1348. 300 health systems and their evidence based development • bodenheimer t, majeed a, bindman ab. primary care in the united states: innovations in primary care in the united states o commentary: what can primary care in the united states learn from the united kingdom?. bmj 2003; 326: 796-799. • rousseau n, mccoll e, newton j, grimshaw j, eccles m. practice based, longitudinal, qualitative interview study of computerised evidence based guidelines in primary care. bmj 2003; 326: 314. • rundall tg, shortell sm, wang mc. as good as it gets? chronic care management in nine leading us physician organisations. bmj 2002; 325: 958-961. • neame r, kluge eh. computerisation and health care: some worries behind the promises. bmj 1999; 319: 1295. • woolf sh, grol r, hutchinson a, eccles m, grimshaw j. clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. bmj 1999; 318: 527-530. • thiru k, hassey a, sullivan f. systematic review of scope and quality of electronic patient record data in primary care. bmj 2003; 326: 1070-0 • delaney bc, fitzmaurice da, riaz a, hobbs fdr. can computerised decision support systems deliver improved quality in primary care?. bmj 1999; 319: 1281. • mair f, whitten p. systematic review of studies of patient satisfaction with telemedicine. bmj 2000; 320: 1517-1520. in national academy press books collection (accessible at url http://www.nap.edu) search all texts under title healthcare information systems • committee on enhancing the internet for health applications networking health: prescriptions for the internet (2000, 388 pp.) • committee on maintaining privacy and security in health care applications of the national information infrastructure, national research council for the record: protecting electronic health information (1997, 288 pp.) • edward b. perrin, jane s. durch, and susan m. skillman health performance measurement in the public sector: principles and policies for implementing an information network (1999, 192 pp.) • richard s. dick, elaine b. steen, and don e. detmer the computer-based patient record: an essential technology for health care, revised edition (1997, 256 pp.) • maria hewitt and joseph v. simone enhancing data systems to improve the quality of cancer care (2000, 176 pp.) • committee on quality of health care in america crossing the quality chasm: a new health system for the 21st century (2001, 364 pp.) 301 information systems management 302 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title financing of health care module: 2.4 ects (suggested): 0.50 author(s), degrees, institution(s) doncho donev, md, phd institute of social medicine, joint institutes, medical faculty, university of skopje 50 divizia no.6, 1000 skopje, republic of macedonia jadranka bozikov, mph, phd andrija štampar school of public health medical school, university of zagreb rockefeller st. 4, hr-10000 zagreb, croatia address for correspondence doncho donev, md, phd institute of social medicine, joint institutes, medical faculty, university of skopje 50 divizia no.6 1000 skopje republic of macedonia tel: +389 2 3147 056; fax: +389 2 3163 866 e-mail: donev@freemail.org.mk keywords sources for financing of health care; taxation; health insurance; health care costs; health expenditures; hospital costs; europe, south eastern; health planning learning objectives at the end of this module students and health professionals should be able to: • identify common reasons for increasing trend of expenditures in developing ad developed countries; • compare inequalities in global health spending; • explain the purpose and the scope of each source for financing of health care (state budget, health insurance, external sources, private sources); and • describe and justify two basic principles: efficiency and equity in health care delivery. abstract financing of health care and making balance between revenues and expenditures for health care is very intricate problem and source of serious concerns in practically all countries in the world. permanent increasing of elderly, patients with chronic diseases, use of expensive health technologies and their non-critical implementation, and some other factors are causing increase of the expenditures for health care. big inequalities are recognized among countries in global health spending and many health system reforms are characterized by transformation from central planning to market-based. there are four basic sources for collecting of financial resources for health care: taxation, social health insurance, private sources and external sources of financing. they are presented in different proportions among countries. each source for financing of health care has its own specificities, strengths and weaknesses, and each may be appropriate alone or in combination with other, which depends on various circumstances and environment. teaching methods teaching method will include combination of introductory lectures, group work and discussion followed by group report presentations and overall discussion, as well as practical individual work assignment. 303 financing of health care specific recommendations for teacher this module to be organized within 0.50 ects credit. beside supervised work, students, as a practical work assignment, should collect some specific indicators (hfa database and other sources) and to prepare a seminar paper about the source(s) of financing of health care in their respective countries. assessment of students the final mark should be derived from assessment of the theoretical knowledge (oral exam), contribution to the group work and final discussion, and quality of the seminar paper. financing of health care dončo donev, jadranka božikov adequate financial resources are a prerequisite for the operation of health services and the delivery of care. resources can be released if steps are taken to focus attention on the quality of care and on planning and managing the whole health sector, weighing up the relative values of health promotion, disease prevention, diagnosis/treatment, rehabilitation and care, as well as to fund some of the new investments that will be required to apply more effective (but often expensive) new technologies. sources for financing of health care vary from country to country, ranging from tax-based to insurance-based systems. there is considerable debate about how best to fund services so as to maintain universal access and financial sustainability. most often, a mix of these systems is seen. available resources for health care should be allocated in the light of a society's needs and priorities. choices have to be made between geographical areas and services, and between particular forms of treatment, and whether to provide innovative or expensive procedures. the health for all policy framework for the who european region „health 21” address the issue of funding health services and allocation of resources as target 17 in the following way: „by the year 2010, member states should have sustainable financing and resource allocation mechanisms for health care systems based on the principles of equal access, cost-effectiveness, solidarity, and optimum quality” (1). financing of health care means mechanisms by which money is mobilizing (raising or collecting revenue from individuals, groups and firms) to fund health sector activities and to pay for the operation of the health system (2). financing of health care is a source of serious concerns in practically all countries in the world. the question of how to generate sufficient revenues to pay for health care worries policy makers in the countries whose total health care expenditures are 1-3% of their gdp, as well as those who are spending more than 10% of gdp for health care. countries of the oecd accounted for less than 20% of the world's population in the year 2000 but were responsible for almost 90% of the world's health spending. the african region accounts for about 25% of the global burden of diseases but only about 2% of global health spending (3,4,5). shortage of funds for health care affects both, the countries who are spending less then 10 us$ per capita per year and the countries who are spending more than 2000 us$ per capita per year (table 1). 304 health systems and their evidence based development 305 financing of health care table 1. inequalities in global health spending in 2001 (3,4,5) although the causes are different, the problem is the same: how to balance revenue and expenditure for health care? it is not only the question of collecting of financial resources and pooling of funds but also of purchasing of services and reallocation mechanisms i.e. of transfer of revenue to service providers who deliver the health care to population for which the funds were pooled. the level of financial resources required to operate a health service is impossible to specify in absolute terms. certainly the amount should be affordable by the country and enough to meet the needs of both health promotion and the provision of effective and high quality care. a comparative analysis of current european experience suggests that 7-10% of gdp may provide for a reasonable spread of health system capacity and performance, dependent of course on an adequate overall level of national gdp. furthermore, in most countries expenditure trends over time ought to show an increase in the share of resources allocated to health promotion and disease prevention, and to primary health care (phc). this range is indicative only and individual countries must determine the best level based on their economic resources, their health experience, and their need for health promotion and the provision of effective and high-quality care (1). most countries feel constant pressure because expenditure is increasing and resources are scarce. policy-makers have three options: containing costs, increasing funding for health services or both. concern about an expenditure crisis in health care has led to the introduction of major changes in how health care is organized and financed. cost containment has been driving health policy discussions in industrialized countries since the 1970s (6). the problem of scarce resources is particularly pronounced in south eastern european (see) countries that have faced many difficulties in the process of transition in 1990-ties, after the breakdown of former communist/socialist system. social and economic transition in central and eastern european (cee) and the former soviet union (fsu) countries included health system reform characterized by transformation from central planning to market-based. this has included reducing of direct state involvement and introduction of market forces and competition through decentralization, privatisation and organizational reform of health care, which emphasized the shortage of the resources for health care (7) (table 2). 306 health systems and their evidence based development table 2. health care expenditures in usa and european countries in 2000 (7) 307 financing of health care country total expenditure on health as % of gdp per capita total expenditure per capita gdp public health expenditure private expenditure in us $ in int. dollars in int. dollars (% of total) (% of total) united states of america 13.0 4499 4499 34,637 44.3 55.7 european countries* israel 10.9 2,021 2,338 21,552 75.9 24.1 switzerland 10.7 3,573 3,229 30,161 55.6 44.4 germany 10.6 2,422 2,754 25,996 75.1 24.9 france 9.5 2,057 2,335 24,702 76.0 24.0 belgium 8.7 1,936 2,269 26,054 71.2 28.8 sweden 8.4 2,179 2,097 24,819 77.3 22.7 denmark 8.3 2,512 2,428 29,143 82.1 17.9 portugal 8.2 862 1,469 17,981 71.2 28.8 italy 8.1 1,498 2,040 25,308 73.7 26.3 netherlands 8.1 1,900 2,255 27,783 67.5 32.5 austria 8.0 1,872 2,171 26,970 69.7 30.3 norway 7.8 2,832 2,373 30,344 85.2 14.8 spain 7.7 1,073 1,539 20,071 69.9 30.1 armenia 7.5 38 192 2,546 42.3 57.7 united kingdom 7.3 1,747 1,774 24,462 81.0 19.0 czech republic 7.2 358 1,031 14,236 91.4 8.6 georgia 7.1 41 199 2,768 10.5 89.5 hungary 6.8 315 846 12,493 75.7 24.3 ireland 6.7 1,692 1,944 28,944 75.8 24.2 finland 6.6 1,559 1,667 25,122 75.1 24.9 estonia 6.1 218 556 9,123 76.7 23.3 kyrgyzstan 6.0 16 145 2,426 61.7 38.3 lithuania 6.0 185 420 6,941 72.4 27.6 poland 6.0 246 578 9,590 69.7 30.3 latvia 5.9 174 398 6,888 60.0 40.0 slovakia 5.9 210 690 11,654 89.6 10.4 belarus 5.7 57 430 7,598 82.8 17.2 turkmenistan 5.4 52 286 5,269 84.9 15.1 russian federation 5.3 92 405 7,621 72.5 27.5 turkey 5.0 150 323 6,455 71.1 28.9 ukraine 4.1 26 152 3,689 70.1 29.9 kazakhstan 3.7 44 211 5,677 73.2 26.8 uzbekistan 3.7 30 86 2,333 77.5 22.5 tajikistan 2.5 4 29 1,154 80.8 19.2 azerbaijan 2.1 14 57 2,676 44.2 55.8 * european countries here means countries belonging to who office for europe with population above one million excluding see countries (i.e. members of ph-see network) that are presented separately. source: who (7). ** the international dollar is a common currency unit that takes into account differences in the relative purchasing power of various currencies. figures expressed in international dollars are calculated using purchasing power parities (ppp), which are rates of currency conversion constructed to account for differences in price level between countries. developing countries who were hardly providing funds for essential health needs were seriously affected with the economic crisis, which started in 1970s. those countries were forced to further decreasing of already scarce funds for health care. continuous debts, dependency for import of drugs, vaccines, equipment and other supplies with very high and continuously increasing prices led to hopeless situation in most of the developing countries. much progress has been made in rationalizing the choice of priority interventions since the time of standard „minimum package” of the early 1990s. prioritising cost-effective interventions (preventive, promotive, curative and rehabilitative), that gives the most value for money, is all the more important as new funds become available to the health sector (3-5,8,9,10,11,12). developed countries, especially usa and some western european countries (table 2), recognized very fast increase of the required funds for health care and came to conclusion that the health care expenditures are threatening further economic development and that it is necessary to stop those trends or even to tend to decrease those expenditures. that is why the most of the developed countries are reconsidering the ways of financing of health care, taking into consideration the reasons, which caused misbalance among needs and available funds. in the us health care delivery system, faced with an exponential increase in expenditures during the second part of the 20th century, was forced to explore ways to reduce costs and, at the same time, maintain a high quality of care. managed care emerged as one of the answers and quickly became one of the predominant health care delivery models (13). the most common external reasons and pressures for increasing trend 308 health systems and their evidence based development south eastern european countries (see)* slovenia 8.6 788 1,462 16,927 78.9 21.1 croatia 8.6 353 638 7,390 84.6 15.4 greece 8.3 884 1,390 16,843 55.5 44.5 macedonia 6.0 106 300 5,001 84.5 15.5 serbia and montenegro 5.6 50 237 4,242 51.0 49.0 bosnia and herzegovina 4.5 50 319 3,404 69.0 31.0 bulgaria 3.9 59 198 5,021 77.6 22.4 moldova 3.5 11 64 1,802 82.4 17.6 albania 3.4 41 129 3,727 62.1 37.9 romania 2.9 48 190 6,475 63.8 36.2 of expenditures for health care from outside the health care system, which cannot be directly controlled by the providers of health care services, are the changes in all fields of life and human activities, i.e. economy, health, sociology, culture, demography and political sphere. demographic changes with growth and ageing of the population, societal changes and health problems related to poverty and life-styles (smoking, poor diet, drug abuse, aids), as well as changes in health status of the population objectively influenced the increase of the expenditures for health care because the permanent increasing of elderly proportion and dependency ratio, and patients with chronic diseases requiring long term care increase the needs and demands for health care and use of expensive health technologies. political changes, often followed by broadening of the scope of social rights to the population, have influenced to increasing coverage of the population with health insurance and health care services. from the other side, there are some internal factors within the health care industry, which might be controllable by health care providers and management structures, related to increases in technology and labour costs, inefficient use of available resources, insufficient preventive services and the practice of defensive medicine. the costs for introducing new drugs in increasing number and non-critical implementation of new technologies caused increase of the expenditures for health care, even though it doesn't belong in the category of the objective reasons (3,5,8) (table 3). table 3. main reasons for increasing trend of health care expenditures (3,5,8) 309 financing of health care external factors (outside the health care system) internal factors (inside the health care system & industry) • demographic transition (growth and ageing of the population) • epidemiological transition changes in the health status (increase of chronic conditions and non-communicable diseases) • societal and cultural changes and health problems related to poverty and life-styles (smoking, poor diet, drug abuse etc.) • political and environmental changes (rising expectations for health care rights, increased insurance and health care coverage) • economic changes and inflation • rapid innovations / changes in technology and non-critical implementation of new technologies • introducing new drugs in increasing number • developments in science (accurate genetic tests and the genetic make-up of an individual) • increases in labor costs (further specialization and sub-specialization of manpower in complex institutions of labor-intensive or „handicraft” industry) • inefficient use of available resources (inappropriate allocation to primary health care vs. hospital care) • insufficient preventive services (the practice of defensive medicine) all those changes influenced the ways and extend of financing of health care, but, in most of the cases, an individual and a family were not able to carry the risk and burden of disease. because of that the state and the government were pressed to take active role in providing health care of the citizens by directing a part of the budget funds for health care or by introducing compulsory health insurance. nevertheless, within the new contemporary conditions the sources for financing of health care and relationships among them are often changing. there are big differences and variations in proportions of public and private sources of health care expenditures, both among developed (usa, european and other) countries and among see and fsu countries (7) (table 4). 310 health systems and their evidence based development table 4. sources of public and private health care expenditures in usa and european countries in 2000 (7) 311 financing of health care country sources of public health expenditure sources of private health expenditure social health insurance (%) external resources (%) prepaid plans (%) united states of america european countries* israel 25.8 0.4 switzerland 72.7 42.4 germany 91.7 5.3 france 96.8 53.1 belgium 82.1 6.8 sweden denmark 8.9 portugal 7.2 5.5 italy 0.1 3.4 netherlands 94.1 76.7 austria 61.0 23.2 norway spain 11.7 armenia 4.9 united kingdom 11.2 16.9 czech republic 89.4 georgia 14.6 9.7 hungary 83.2 0.8 ireland 12.9 23.8 finland 2.4 12.0 estonia 86.0 0.5 4.1 kyrgyzstan 5.8 2.4 lithuania 9.7 poland latvia 65.4 0.7 slovakia 96.8 belarus 0.1 turkmenistan 18.9 0.8 russian federation 24.5 4.4 4.3 turkey 28.4 0.1 0.1 ukraine kazakhstan 26.4 2.4 uzbekistan 1.3 tajikistan 19.5 azerbaijan 8.8 * european countries here mean countries belonging to who office for europe with population above one million excluding see countries (i.e. members of ph-see network) that are presented separately. the countries are sorted by the percentage of their total expenditure on health. source: who (7). markets in health care available evidence from both western and eastern europe indicates that unfettered markets are not compatible with the nature of health as a social good. market mechanisms in health care are likely to be more successful, financially and operationally, if they are focused on hospitals and physicians; in contrast, efforts to create competition among multiple private insurers or to require increased co-payments from patients have been notably less successful. for the application of market mechanisms to service providers to work well, the state needs to steer and regulate these relationships by creating or improving market competition, opening up choice of provider in public health or insurance financing „money follow the patient”, quality regulation and contracting with providers. while the mix of public/private ownership of provider institutions varies greatly across europe, both efficiency and equity require consistent and stable state regulation (14,15). the health care triangle the provision and financing of health care can be simplified as an exchange or transfer of resources: the providers transfer health care resources to patients and patients or third parties transfer financial resources to the providers (figure 1). 312 health systems and their evidence based development south eastern european countries (see)* slovenia 82.0 0.8 48.9 croatia 96.5 0.4 greece 36.9 4.9 macedonia 87.5 3.7 serbia and montenegro 6.2 bosnia and herzegovina 2.0 bulgaria 16.0 18.0 moldova 13.9 albania 26.1 12.6 36.4 romania 13.3 1.1 figure 1. the health care triangle (6) citizen delivery provider funding allocation third-party (insurer or purchaser) the simplest form of transaction for a good or service is direct payment. the consumer (the first party) pays the provider (the second party) directly in return for the good or service. health care systems have developed in which a third party offers protection to a population against the financial risk of falling ill. the third party may be a public or private body. the development of the third-party payment mechanism in health care results in part from the uncertainty of ill health; it allows risks to be shared. however, it is also a means to achieve interpersonal redistribution. to finance health care services, the third party must collect revenue directly or indirectly from the population it protects (this may cover the whole population or a subgroup of the population such as those who are employed). this revenue is then used to reimburse the patient or the provider (6). basic sources for financing of health care there are four basic sources of revenue collection for financing of health care (2,5,6): 1. taxation (state budget) 2. social health insurance 3. private sources for financing (private health insurance and out-ofpocket payments etc.) 4. external resources (foreign aid, loans, grants and donations) there is no model for financing of health care in which exists exclusively only one out of four mentioned basic sources for financing of health care. all four sources are present in practice in the developed and in deve313 financing of health care loping countries. in some countries, the funds coming from the state budget are predominant at all levels of governance (from local to central), in other countries health insurance funds are basic, and in certain number of countries the most of the funds for health care are from private sources. all the funds collected by any financial method (except for foreign aid) are coming, directly or indirectly, from citizens. each country has to decide what sources to use, and to what extend. revenue collection must be distinguished from fund pooling, as some forms of revenue collection do not enable financial risks to be shared between contributors, such as medical savings accounts and out-of-pocket payments. kutzin (2001) defined fund pooling as the „accumulation of prepaid health care revenues on behalf of a population”. the importance of fund pooling is that it facilitates the pooling of financial risk across the population or a defined subgroup (16). the role of the state in financing of health care the purpose and the scope of the sources used for financing of health care by the state are different. in general revenue financing many kinds of taxes are used to support a broad scope of government activities. taxes can be levied on individuals (earmarked social security taxes), households and firms (direct corporate profit taxes) or on transactions and commodities (indirect taxes). direct and indirect taxes can be levied at the national, regional or local levels. indirect taxes can be general, such as a value-added tax, or applied to specific goods, such as an excise tax, import duties, and severance taxes on minerals etc. most tax-based systems rely on a mix of different taxes (5,6,14). the health system is financed through the regular government budget process. in almost every country the state through the budget provides sources for prevention and eradication of communicable diseases, hygienic control of the drinking water, food, objects for general use, sanitary monitoring over certain objects, health statistic and other activities of particular interest. in some industrial developed countries, as great britain, nordic countries, france, italy, belgium, greece, spain, portugal, as well as in the former socialistic (central and eastern european) countries (poland, albania etc.) the greatest part of the sources for health care are provided, or were provided, from the state budget, with taxes on national-central level, and from there the sources are distributed in the regions and communities where together with the local sources are used for health care of all citizens. in the developing countries the budget sources are mainly used for prevention and eradication of communicable diseases and for curing of the poorest social strata of the population (3,6). 314 health systems and their evidence based development financing of health care through the budget has an important role and advantage in providing equal conditions in health care consumption for all citizens, independently of the social status and economic power, the place of living and working. the weaknesses of this system are that it has insufficient creativity in the process of improving of efficiency and quality of the health care, as well as the fact that the taxpayers from whom the sources are taken, have no influence in their use. in the last 10 15 years most of the countries with this model of financing are reconsidering this system and looking for new solutions. some of those countries already have introduced health insurance system (russian federation) while other countries are still looking for solutions in direction of more rational usage of resources and for improving quality without changing the basis of financing of the system. the role of the health insurance in financing of health care the social or compulsory health insurance has a long tradition in the western and southern european countries, although with variable scope of coverage of population. some of the countries are broadening the coverage, and others are reducing it by abolition of the compulsory health insurance if the annual income is above the certain amount. the developing countries, as a rule, are introducing a system of health insurance (latin america, south asian countries, and most of the african countries), as well as the former socialistic central and eastern european countries (bulgaria, hungary, poland, czech republic). social health insurance contributions are usually related to income and shared between the employees and employers, at levels that may be set nationally by parliament (the netherlands) or individually by each social insurance or „sick” fund. contributions may also be collected from self-employed people, for whom contributions are calculated based on declarations of income or profit (this income may be under-declared in some countries). contributions on behalf of elderly, unemployed or disabled people may be collected from designated pension, unemployment or sickness funds, respectively, or paid for from taxes. social health insurance revenue is generally earmarked for health and collected by a separate health insurance fund (6,14). more and more countries decide to establish a health insurance system because the sources from the health insurance are significant additional sources for the health sector, as well as because the sources from the health insurance, as a rule, are restricted funds used only for health purpose, and for no other purposes as in the case of the budget. as an advantage of this model 315 financing of health care of health insurance system is considered the connecting of the income with the profit in which take part the employees as well as the employer, which the most often is an organization/enterprise. thus, if the real profits increase the sources of health insurance funds will be higher, and if the profits decrease the sources of the funds (and income of) will be lower (17). in indirect way the same happens with the tax payment from which depends the amount of the budget. the main function of the insurance contract is to reduce risk faced by the person who buys it. risk and uncertainty are significant elements in medical care. the idea of health security „incorporates certain funding and service elements... that either protect against or alleviate the consequences of trauma, illness or accident” (17,18). in fact, the advantage of the health insurance system is the complete implementation of two basic principles: efficiency and equity in health care providing. the efficiency of the health insurance system depends on relationship between health insurance institutions and health care providers, in which way the obligations of both sides are precisely determined. health insurance funds have a long-term interest to accept funding also for some services that will bring to additional total running expenditures (measures for prevention, early detection of the diseases, usage of adequate health technologies). on the other side, the policy for participation of the users in the expenditures for the received health services tends toward decreasing of total health expenditures through reduction of the excessive and unnecessary consumption of health services. as a rule the administrative costs are low (5% of the total expenditures), although in the systems that lack adequate personnel and technology those expenditures could be even higher than 20% of the total health care expenditure. the equity is one of the basic principles of the health insurance by which the healthy people pay for the sick people, the young people for the elderly, and the rich people for the poor people. everyone pays a contribution proportional to his economic situation, and use the health care according his needs. the critiques of the health insurance systems are directed toward determination of which groups of insured persons have more and which fewer privileges. this type of investigations in many developing countries have shown that insured persons in the urban environments use much more health care than those in the rural environments, first of all because of the higher accessibility of the health organizations and services to the population in the cities. according to some other investigations the poor social layers are in more 316 health systems and their evidence based development favourable situation in spending health insurance funds because they become ill more often and use the health care and services much more, even they contribute less in real quantity of sources. because of that in the compulsory health insurance systems, which includes the whole population, the principle of equity is much more expressed than in the other types of health insurance (for example: branch-sectoral insurance). in some social health insurance systems, eligibility is based on employment or linked to contributions. this may limit the access of the non-employed population, including elderly and unemployed people and dependants, to health services. as the link between benefits and contributions remains strong, coverage also tends to be limited to curative and medical interventions and few, if any, public health interventions. because social health insurance relies on a narrow revenue base dependent on the contributions of employed people, it may not generate sufficient revenue, especially in countries with low participation in the formal labor force. an increasing proportion of the workforce is self-employed or in multiple occupations, which also increases the difficulty of collecting social insurance contributions. if social insurance is not mandatory for the entire working population, it can create a perverse incentive for employers. thus, they may offer (part-time) jobs that pay below the minimum threshold, outsource employment so that contractors are self-employed or create jobs in the shadow or unofficial sector. these practices are common in cee and fsu countries with newly established social health insurance schemes: employers, faced with an adverse economic climate, have tried to minimize labor costs by evading contributions to social health insurance. a single fund may produce low administration costs, ease regulation and make the risk pool universal. however, subscribers have no choice, and some conservative commentators fear inefficiency and a lack of consumer responsiveness (6,17). the role of the private sources in financing of health care the role of the private sector in the area of health care is becoming stronger in developed, but in developing countries, too, observed in general, as well as the private sources in financing of health care as an effect of that. that is a result of the liberalization in regard to the possibilities for establishment and functioning of private health institutions and more favourable conditions that enables the health care professionals to work in the public and the private sector at the same time. a limited privatization is accepted as a principle for all countries, not only because of economic but because of professional-medical reasons, too. many countries in which the private practice was prohibited or limited, now reintroduce it again in a manner to act equally with the public sector as a part of the health care system as a whole. 317 financing of health care there are also countries that have created legislative preconditions for functioning of private ordinations within the public health institutions after working hours. in many countries there are also legislative possibilities that enable private practitioners to have a certain number of hospital beds in the public hospitals for their own patients. in a small number of countries there is an intensive process of privatization with tendency to decrease the influence of the state in the health sector and to preserve it only in the sphere of preventive medicine (public health), and everything else to transfer into the private sector, including the private health insurance. private health insurance premiums are paid by an individual, shared between the employees and the employer or paid wholly by the employer. premiums can be: individually risk rated, based on an assessment of the probability of an individual requiring health care; community rated, based on an estimate of the risks across a geographically defined population; or group rated, based on an estimate of the risks across all employees in a single firm. the agents collecting private health insurance premiums can be independent private bodies, such as private for-profit insurance companies (commercial insurers) or private not-for-profit insurance companies and funds. substitutive insurance is an alternative to statutory insurance and is available to sections of the population who may be excluded from public cover or who are free to opt out of the public system. in germany and the netherlands, individuals with high incomes may purchase substitutive health insurance. where health insurance is supplementary, it may allow quicker access to services or increase the quality of „accommodation” facilities in the public sector. this can result in differential access between those with and those without private insurance. complementary health insurance offers full or partial cover for services that are excluded or not fully covered by the compulsory health insurance system (6,14). in some countries are present opposite processes, where the private sources for financing of health care represent a small part in the health care expenditures. in those countries there is a tendency for achieving a balance in which the state as well as the compulsory health insurance and the private sources will have an equal role in financing of health care. in many countries, the transfer of the health care expenditures onto the private sources most often is connected with a tendency for stopping of its increasing, in other words to bring the health care expenditures down within the real possibilities related to the increase of the gross national income. out-of-pocket payments include all costs paid directly by the consumer, including direct payments, formal cost sharing and informal payments. direct payments are for services not covered by any form of insurance 318 health systems and their evidence based development (the purely private purchase of uncovered services). other payments are for services included in the benefit package but not fully covered (e.g. formal costsharing) or for services that should be fully funded from pooled revenue but additional payment is demanded (e.g. informal payments in cee and fsu countries) (6,19). however, in regard to this approach arise many problems among which especially important is the problem of providing equity in health care consumption and its accessibility to some population groups, which have no possibility to pay for health care services out of pocket or to purchase insurance policy from the private health insurance agencies. investigations about the efficiency and quality of the health care didn't show advantages in the nonprofit institutions that as a rule provide services under lower prices, although there is a higher administrative efficiency. therefore, the privatization and deprivatization of the sources for financing of health care present two opposite processes that run simultaneously in various countries. the goal of both processes is to achieve a balance between health care expenditures and the real financial possibilities. in spite of all there shouldn't be disregard the fact that health is one of the basic human rights, and the equity in providing health care is one of the indicators for the level of respecting human rights. in developed countries the participation of the private sources for financing of health care/ expenditures goes from 14.8% in norway and 17.9% in denmark to near 60% in usa, and in the see countries from 15.4% in croatia and 15.5% in macedonia to 49.0% in serbia and montenegro (table 2). this type of differences in financing of health care, as well in regard to the real possibilities for increasing of the sources for health care in developing countries, clearly show that financing in health care is a very intricate problem. external sources for financing of health care the foreign aid, as an external financing source for health sector in many poor countries, by the international health and other organizations and from the other countries, as a manner of bilateral cooperation, usually is too small to give bigger effects in regard to the financing of health care. this help, as a rule, is directed to certain developmental projects and specific programmatic objectives in developing countries with measurable outcomes (vaccination, disease elimination, safe childbirth). this help usually mitigates the situation, but doesn't solve the problems in a long run. care must be taken to ensure that external funding is additional to, and, not a substitute for, domestic financing, but also that financing which flows from outside sources does not lead to (further) fragmentation of the national health system (3). 319 financing of health care other external sources, such as donations from non-governmental organizations, transfers from donor agencies and loans from who and other un agencies, the world bank and other international banks and funds, also contribute significantly in some countries, especially lowand middle-income countries (6). multilateral development banks are coming under increasing pressure to finance multi-country initiatives directly, rather than through conventional country-based grants or loans (20). 320 health systems and their evidence based development exercise: financing of health care task: seminar paper students should use additional recommended readings in order to increase their knowledge and understanding of health care financing. as output, students should write a seminar paper, stressing the importance of different sources of financing health care, giving the reasons for permanent shortage of resources, discussing percentage of gdp input and overall, make comparison between global and their own country ways of health care financing. in addition, students should be encouraged to make an investigation regarding the financing of health care in their own region (local, municipality, county/regional within the country, as well as at country level) and compare the facts with those for neighbouring countries (see) and widely at international level. they should be asked to search the internet in order to find the data and write their seminar papers not repeating the data from the module itself but to interpret their own findings in context of the facts from module. moreover, they should be able to place the data collected in field study into the context of the module, they need to see how the data feet together. not only data but also regulations are different and important and all the information about the kinds of compulsory (national) and private (voluntary) insurance could be find, for each see country, on the health insurance fund web-sites (for example: for croatia visit http://www.hzzo-net.hr and for slovenia visit http://www.zzzs.si/). public health lecturers in each see country should be qualified to direct the students to data sources in their countries (provide respective web-sites in see countries and not only at country level but also at local municipal, county, regional level). students ought to be able to investigate the ways in which health care is financed and how revenues are pooled (much more could be find at local level). students must be able to find very new data about gdp and health expenditures, and to calculate percentage of gdp spent on health care. to manipulate data is important not because of making calculations but in order to get a perception of data, data sources and the students ought to know (or they need to be instructed and trained) where to find the information on regional, national and international level. students have to know where to look for example for current gdp it is usually national statistical office web-site (in macedonia www.stat.gov.mk; in croatia www.dzs.hr) or printed publications as statistical yearbooks. 321 financing of health care references 1. who. health 21 health for all in the 21st century funding and allocation of resources for health services and care. european health for all series no 6. who-euro, copenhagen 1999: 131-5. 2. the world bank group. funding and remuneration in health care. distance learning flagship course on health sector reform and sustainable financing, 2001. (cited 2004, january 14). available from url: http://www.worldbank.org/wbi/healthflagship/module1/ sec7i.html 3. who. shaping the future. the world health report 2003 financing health systems. who, geneva, 2003: 119-21. 4. the world bank. world development report 1993: investing in health. the world bank, 1993: 25-71. 5. tulchinsky th, varavikova ea. the new public health: an introduction for the 21st century. chapter 11: measuring costs: the economics of health. san diego: academic press, 2000: 549-88. 6. mossialos e, dixon a, figueras j, kutzin j. funding health care: options for europe. (european observatory on health care systems). buckingham: open 11university, 2002. 7. world health organization (who). who: countries. (cited 2003, october 30) available from url: http://www.who.int/country 8. who. health systems: improving performance. the world health report 2000, who, geneva, 2000: 47-116. 9. ore{kovi} s. new priorities for health sector reform in central and eastern europe. croatian med j 1998; 39: 225-33. 10. hutubessy r, chisholm d, edejer tt. generalized cost-effectiveness analysis for nationallevel priority setting in the health sector. cost effectiveness and resource allocation 2003, 1(8). (cited 2004, february 24). available from url: http://www.resourceallocation.com/content/1/1/8/ 11. johns b, baltussen r, hutubessy r. programme cost in the economic evaluation of health interventions. cost effectiveness and resource allocation 2003, 1(1). (cited 2003, july 17). available from url: http://www.resource-allocation.com/content/1/1/1 12. bobadilla jl, cowley p, musgrove p, saxenian h. design, content and financing of an essential national package of health services. the world bank group private and public initiatives: working together in health and education. the world bank. march 17, 1995: 110 (cited 2004, january 11). available from url: http://www.worldbank.org/html /extdr/hnp/health/hlt_svcs/pack1.htm 13. gill as, parpura-gill a. united states health care delivery system, reform, and transition to managed care. croat med j. 1999; 40(2): 273-9. available also through url: http://www.cmj.hr 14. saltman rb, figueras j. european health care reform: analysis of current strategies. who regional office for europe, copenhagen, 1997 (who regional publications, european series, no. 72). 15. berman p. overview of the organization control knob. the world bank institute health system group. harvard school of public health conference, jan, 26, 2003. (cited 2004, january 20). available from url: http://www.dosh.gm/conferences/hsr/course/ week3/day1/s1/presentation.ppt 16. kutzin j. a descriptive framework for country-level analysis of health care financing arrangements. health policy. 2001; 56: 171-204. 17. hofmarcher mm. health insurance and productivity. croat med j, 1999; 40/2: 260-5. 18. saltman rb. the idea of health security. eurohealth 2002; 8(2):18-9. 322 health systems and their evidence based development 19. belli p, berman p, bossert t et all. formal and informal household spendings on health: a multicountry study in central and eastern europe. harvard school of public health international health systems group, 2002. (cited 2004, january 14). available from url: http://www.hsph.harvard.edu/ihsg/publications.html 20. world health organisation. macroeconomics and health: global public health goods for health. the report of the commission on macroeconomics and health, working group 2 presented on december 20, 2001. recommended readings 1. mills ea, zwi ab, editors. health policies in developing countries. special issue of the journal of international development, vol 7, no 3, chichester: wiley, 1996. 2. saltman rb, figueras j. european health care reform: analysis of current strategies. who regional office for europe, copenhagen, 1997 (who regional publications, european series, no. 72). 3. marrée j, groenewegen pp. back to bismarck: eastern european health care systems in transition. ashgate avebury, 1998. 4. world health organisation. macroeconomics and health: investing in health form economic development. report of the commission on macroeconomics and health presented by jeffrey d. sachs, chair, to gro harlem brundtland, director-general of the who on 20 december 2001. available also at url http://www.who.int 5. organisation for economic co-operation and development (oecd). available from url: http://www.oecd.org; topic: health 6. united nations development programme (undp). undp home page. available from url: http://www.undp.org 7. donev d. health insurance system in the republic of macedonia. croat med j 1999; 40(2): 185-80. available also through url: http://www.cmj.hr 8. ivanovska l, ljuma i. health sector reform in the republic of macedonia. croat med j 1999; 40(2): 181-9 9. kova~i} l, šoši} z. organization of health care in croatia: needs and priorities. croat med j 1998; 39: 249-55. available also through url: http://www.cmj.hr 10. markota m, švab i, sara`in klemeni~i} k. slovenian experience on health care reform, croat med j 1999; 40(2): 190-4. available also through url: http://www.cmj.hr 11. hofmarcher mm. health insurance and productivity. croat med j, 1999; 40(2): 260-5. available also through url: http://www.cmj.hr 12. hermans hegm, den exte a. cross-border alliances in health care: international co-operation between health insurers and providers in the euregio meuse-rhine. croat med j. 1999; 40(2): 266-72. available also through url: http://www.cmj.hr 13. gill as, parpura-gill a. united states health care delivery system, reform, and transition to managed care. croat med j. 1999; 40(2): 273-9. available also through url: http://www.cmj.hr 14. kanavos p. financing phamaceuticals in transition economies. croat med j 1999; 40(2): 244-59. available also through url: http://www.cmj.hr 323 financing of health care 324 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title payment methods and regulation of providers module: 2.5 ects (suggested): 0.25 author(s), degrees, institution(s) doncho donev, md, phd institute of social medicine, joint institutes, medical faculty, university of skopje 50 divizia no.6, 1000 skopje, republic of macedonia luka kovacic, md, phd andrija štampar school of public health medical school, university of zagreb rockefeller st. 4, hr-10000 zagreb, croatia address for correspondence doncho donev, md, phd institute of social medicine, joint institutes, medical faculty, university of skopje 50 divizia no.6, 1000 skopje, republic of macedonia tel: +389 2 3147 056; fax: +389 2 3163 866 e-mail: donev@freemail.org.mk keywords resource allocation, health payments; regulation of providers; budgeting; fee-for-service; capitation; case-base payment, diagnosis related groups, resource allocation reform, europe, south eastern; health planning learning objectives at the end of this module students and health professionals should be able to identify: • resource allocation mechanisms and payment methods for regulation of providers, • methods of payment for primary health care providers, • payment and regulation of hospitals and other health facilities. abstract allocation mechanisms and provider payment methods refers to the ways in which money are distributed from a source of funds to an individual provider or to a health care facility. there are three main methods for payment for doctor's services: fee-for-service, capitation and salary payment; and four basic methods for payment and regulation of hospitals and other health facilities: global budgeting, line item budgeting, per diem and case-based payment (drgs).each method for payment to providers has its own specificities, strengths and weaknesses, and each may be appropriate alone or in combination with other, which depends on various circumstances and environment. teaching methods teaching method will include combination of introductory lectures, group work and discussion followed by group report presentations and overall discussion, as well as practical individual work assignment. specific recommendations for teacher this module to be organized within 0.25 ects credit. beside supervised work, students, as a practical work assignment, should collect some specific indicators (hfa database and other sources) and to prepare a seminar paper about the allocation mechanisms and payment methods to providers in their respective countries. assessment of students the final mark should be derived from assessment of the theoretical knowledge (oral exam), contribution to the group work and final discussion, and quality of the seminar paper. payment methods and regulation of providers dončo donev, luka kovačić resource allocation and provider payment methods in the health care system can have impact on provider’s behavior, and therefore on the achievement of the objectives of the health care system (efficiency, equity, cost containment). the allocation of financial resources should reflect the outcomes achieved, and include incentives for improving the quality of care (1). provider payment method refers to the way in which money are distributed from a source of funds, such as the government, an insurance company or other payor (all also referred to as fund-holders), to a health care facility (hospital, phc centre etc.) or to an individual provider (physician, nurse etc.). each provider payment method carries a set of incentives that encourage providers to behave in specific ways in terms of types, amounts, and quality of services they offer (2). it means that the payment system should be directed to provide the right incentives (or disincentives) in order to promote (or discourage) certain types of behaviour, and therefore to improve the efficiency and the quality of health services and to provide equitable financial access to care with the use of existing resources effectively. it is not easy to develop payment system and to provide right incentives (or disincentives) and to measure related performance. in general, health outcomes are problematic to measure, and may not be directly attributable to the performance of the individual health care provider, but rather to their team or other determinants of health status. it is also difficult to measure the behavioural response of providers to changes in payment systems (3). provider payment reform is often linked to government efforts to improve the efficacy of the health care system through various means, among others: 1) decentralizing the management of the health system; 2) separating health financing functions from the institution providing care; 3) contracting for public health services with private sector providers and non-governmental organizations; 4) developing or reforming public or private health insurance to expand coverage of the population; 5) promoting primary and preventive care over reliance on expensive curative and hospital-based care; and 6) improving hospital management and quality of care (2). 325 payment methods and regulation of providers 326 health systems and their evidence based development incentives and disincentives for efficient care include how providers and facilities are paid, and how services are organized. resource allocation according to needs the evidence suggests that a strategic approach to resource allocation and priority-setting is needed, in order to coordinate decision-making at different levels, and this should start with a discussion and a decision on the values and principles to be applied when determining need and selecting priorities. a debate (involving government, health service and care providers, the public and patients) on the ethical, political and social questions that need to be addressed must precede any decision on the rationing of resources. the term „funding” is used to describe allocating the revenues, that have been already raised, to health care organizations and to alternative activities within the health care sector, usually through budgets or payments to providers, public not-for-profit and for-profit institutions and firms (3). any rationing of access to necessary services should be preceded by a thorough scrutiny of the overall organization and of the cost and effectiveness of the services and care provided. needs-based resource allocation formulae have been introduced into some countries in the western part of europe and are now being developed in some countries in the eastern part, in particular regarding the geographical allocation of resources and services. contracting is a mechanism that offers an alternative to traditional models of resource allocation, binding third-party payers and providers to explicit commitments and generating the economic motivation to meet these commitments. four major reasons have been put forward for introducing contractual relationships into tax-based systems, based on the long experience of health insurance systems: 1) to encourage decentralization; 2) to improve the performance of providers; 3) to improve the planning of health service and care development; and 4) to improve management (2). contracts can support equity if, through needs assessment, resources are allocated as a priority explicitly to disadvantaged population groups. the role of governments should be to ensure equity, in order to avoid over-emphasizing profitable, rather than effective, services. basic arrangements for resource allocation there are three different basic arrangements by which to distribute revenue to health care providers: 1) the reimbursement model; 2) the contract model; and 3) the vertically integrated model. combined, there are thus at least seven major payment methods or alternative ways for payment to health care providers (4). payment for primary health care (phc) providers payment system for phc providers should contribute to achievement of the best possible health outcomes. an optimum payment system for phc providers should also ensure the following: financial management of the different components of phc within a country’s total health care expenditure; a balanced package of health promotion, disease prevention, treatment, and rehabilitative services; a free choice of health care provider for all individuals; a structure of fair rewards for practitioners which recognizes workload and professional merit; acceptance of health care providers’ responsibility for and accountability to the population and responsiveness to the needs of the community, the family and the individual; promotion of close collaboration among health care providers; and a democratic system of decision-making. finally, the system should allow purposeful, flexible management aimed at achieving continuous quality development and greater cost-effectiveness (1). the main methods of remuneration or paying doctors and other health care professionals for their labour at phc level are: fee-for service, capitation and salary, or some combination of these methods. each of them has its historical roots, advantages and disadvantages, and the incentives they create for providers, payors and consumers (1,5,6). 1. fee-for-service is payment for each unit of service or intervention provided (visit to doctors office for counselling, testing or treatment prescription, intervention or surgical procedure), which can be paid directly by the patient (user charges) or by the third party payer (insurer or government). feefor-service is a common method of payment for doctor’s services in many countries, such as germany, usa, canada and other countries (5,8). in most countries fee-for-service payment is regulated by a prospectively fixed fee schedule, negotiated by the fund-holders and the provider’s representative. because of incomplete information and so called information asymmetry as a result of superior knowledge of the health care providers, doctor helps 327 payment methods and regulation of providers the patient to make choices and patient may be unable to judge the performance of the doctor, before or even after the intervention. disadvantage of this method of payment is that provider might neglect codes of medical ethics in protecting the consumer’s best interests and to influence patient’s demand for health care, especially for more expensive kinds of care, including surgery, for the providers’ own self-interest (income). this creates potential incentives for inappropriate services and over-treatment (over-servicing), in excess of real needs, especially when the patient is fully covered by health insurance and when the specific actions undertaken by the physician cannot be monitored, measured, or well understood. that is known as supplier induced demands. fee-for-service and other retrospective forms of payment result in an inputintensive, gold-plated form of service that often extensively expends resources. on the other side, fee-for-service method of payment discourages provision of care not defined as a service in the fee schedule (because a „covered” service is the unit of payment) (3,6,7). some fund-holders introduce participation of the user in the cost of service (user fees or charges), which is called co-payment. in fact, co-payment is the portion of covered health care cost for which the person insured has the responsibility to pay, usually based on a fixed percentage. the method of copayment is a regulative mechanism for rationing the health care, in order to prevent consumers to seek unnecessary care, as well as a source for additional funds for health care (financial input). co-payment often is an issue for political debate (hot potato) because the opponents argue that user fees affect the poorer strata of the population disproportionately and discourage preventive care services/activities (3,5). case-based payment to physicians at primary level is not common, but might be popular prospective form of payment for specialty physicians and for hospital outpatient services builds on the episode-of-illness payment methodology. that is payment per case-rates or episode of illness i.e. for obstetrical care as a complete service including prenatal care and delivery, or certain surgical, cardiological etc. package of care over an illness or period of care, usually on a monthly basis (fee for the preoperative/pre-intervention workup, the procedure itself, and postoperative monitoring) (5,6). 2. capitation for doctor’s services is advanced payment by a fixed sum of money for the persons registered for care with the physician for a defined period of time. it means that capitation is prepayment for services on per member pre month (pre year) basis by some amount of money every month (year) for a member regardless of whether that member receives services and regardless of how expensive those services are. this method of payment pro328 health systems and their evidence based development vides good cash flow, less lost-costs and applied and good case management, and can be for a comprehensive health services or for general practitioner services. in the uk, for example, around 60% of general practitioners’ income is derived from an annual fee paid by the national health service (nhs) for each patient on a gp’s list. the costs might be predicted because the fee depends on the age and sex of the patient (age/sex adjustment of physician capitation rates), and the level of the deprivation of the area. capitation payment put risk on provider and has the advantage for utilization control because it does not contain incentives for provider to over-treat the patient. there is some incentive for the doctor to maintain quality of care in order to attract and retain patients even this is limited by information problems. providers are also motivated to undertake health promotion and preventive care as this may reduce costs later in the health care process. in uk recently were introduced incentive fees for full immunization and screening programs in order to improve the performance in these areas. main weaknesses might be to adjust capitation payment adequately to reflect the diversity in disease severity among patients, which leads to incentives for adverse selection and patient dumping, difficulties to determine break-even point (volume), avoiding high-risk and high-cost patients or reducing treatment for them, inappropriate under-utilization (narrow scope practice), and misunderstanding of the meaning of capitation by provider. there may be incentives to under-treat (subject to keeping patients happy and therefore retaining them), and to shift costs to elsewhere in the health care system (for example from primary to secondary care). the interaction among payment mechanisms (capitation at primary level and fee-for-service payment at secondary level) might provide incentive for over-referral and convert primary care physicians into triage agents (3,5,6). 3. salary payment for doctors and other health workers is the final payment mechanism in form of salary where doctors are paid to provide a certain amount of their time to carry out specified responsibilities for an organization and to perform a defined role, usually being available to provide needed health care services at specified times (and places). the salary level is likely to be negotiated between the professional associations (or health workers trade unions) and fund-holders (government, insurance company or managed care organization), and will vary according to the age, experience, grades or levels of education and responsibilities of the health workers. the advantage for providers is predictability and stability of income, and it gives less incentive to over-treat, but may contain incentives to under-treat or shift costs from primary to higher levels. in addition, a hospital doctor paid a salary may choose, with a given availability of beds, to have a longer average length of stay (reducing overall workload) rather than faster throughput (which would increase work 329 payment methods and regulation of providers without increasing income. in general, salary payment undermines productivity, condones on-the-job leisure and fosters a bureaucratic mentality. it means that provider might consider that every procedure is someone else’s problem because payment is based on minimally meeting responsibilities (to retain one’s position) (3,6,7). that is why salary payment is often combined with incentive payments for additional services. wage is a payment mechanism whereby a provider receives a prespecified sum of money for each hour of work they provide to an organization. it can be used only for remuneration. although the wage is normally pre-set, the total payments depend on the number of hours worked. the incentives are similar to salary, except that payment is even more closely tied to time spent at the workplace (7). the type of payment system depends of the financing of the health care system and the public-private mix of financing, as well as of the provision and the desired activity levels of physicians and other health workers. payment systems are therefore likely to involve a mix of methods. increasingly mixed systems of payment are emerging, with capitation as a predominant method at the primary health care level (5). payment and regulation of hospitals and other health facilities there are four main mechanisms for paying hospitals and each of them create different incentives for the service provider and different effects in relation to the objectives of equity, quality of care, efficiency and cost control / cost containment (3,5). it is not easy to measure efficiency and outcomes of health care in the hospital sector. efficiency should be measured through input (resources used in delivering care), process (method of delivering care, day cases and inpatient cases, length of stay etc.), and outcome indicators (the result of care – whether or not it has been of benefit to the patient). measuring outcomes of health care is often attempted to estimate process and hospital activity through some indicators (average length of stay, bed occupancy and turnover rate), which have uncertain relationships with cost, patient outcomes and efficiency. if activity measures are used in payment systems for providers, they should be good proxies for outcome. rewarding turnover of patients may give incentives for discharging patients „quicker but sicker”. nevertheless, too many indicators can create confusion and dilute incentives. prospective budgeting has evident merits: it limits expenditure to funding a given level of ser330 health systems and their evidence based development vice provision that is determined in advance for a defined period. a prospective budgeting system can be recommended if it incorporates the use of casemix controls and output measures. classification systems based on diagnosis or on the characteristics of the patients can be used to better analyse cost structures, evaluate hospital performance and quality of care, and make comparisons between hospitals in terms of costs and quality, as well as in negotiating contracts between hospitals and those purchasing services. alternatively, a volume-based approach can be made to work by using prospective pricing and contracting or planning agreements for agreed levels of service provision. in this way, hospitals can be obligated to achieve specific objectives of cost control and effective resource utilization, stimulating them to review and adjust their current organization, staffing levels and internal resource allocation (1,3). 4. global budgeting is defined as a total payment, almost always prospectively, fixed in advance as a constraint on providers to limit the price and the quantity of service, to be provided in a specified period of time. global budgets are difficult to amend over the budget period, but some end-of-year adjustments may be allowed. it means that the global budget becomes a financial plan (and resource constraint) within which the hospital or other health facility has to operate. resource allocation decisions are made among the many diverse, but interdependent activities and programs of the health care providers. the global or operating budget is always for a specified period, usually one year (calendar or fiscal), although it might be a biennial or a semiannual budget (5,7,8). various formulas can be used for establishing a global budget for a hospital or other health facility. because global budgets do not contain incentives for good performance, it is important to specify either the volume of activity or the price of each of the services included within the budget. in order to prevent the provider to minimize the number of patients treated and the amount of care given to each patient, since the money received will be the same, it is necessary to determine the scope of services included, patients eligible for treatment and methods of care delivery (i.e. inpatient, outpatient, day case, diagnostic testing). the global budget may reflect the anticipated volume of activity and services derived from the utilization rates for the previous year or to be based on per capita rates with various adjustments (age, sex). global budgeting usually relates the level of resources provided (the budget) to the level of activity to be undertaken, and is therefore focused on inputs and not on outputs. because the determination of the process of delivery of care is left to the provider, who tends to maximize profits (by undertaking the required activity for easy cases as cheaply as possible, with potential for cost shifting and 331 payment methods and regulation of providers the quality to be compromised), additional regulation is needed for quality to be maintained and clear quality standards to be specified by global budgeting agreements / contracts between purchaser and provider. the global budget can include also some capital costs if necessary to built / broaden or renovate the capacities or purchase some capital / costly equipment (3,5,9). the main advantage of a global budget for cost-containment is that the cost paid by the fund-holder / purchaser is fixed, and therefore the financial risk is transferred to the provider, assuming that there are „good” and well-constructed activity targets. the advantage for local managers is flexibility about the use of resources and the methods of undertaking care within the budget limits. disadvantage of global budgets is that it provides incentives to skim on quality of care, engage in risk-selection, and provides few incentives to improve micro-efficiency despite helping contain costs. there is no control of quality inherent in global budget framework. furthermore, global budgets provide incentives for hospitals to avoid complicated cases and seek out simple ones. in order to address these problems, activity targets including expected case-mix is important (3,7). 5. line item budgeting is a variant of global budgeting with subdivision of the budget allocated according to specific input categories of resources or functions (salaries, medicines, equipment, food, maintenance etc.). this method of hospital budgeting process and contracting methodology is generally similar to that for global budgeting, but more complex and more difficult to monitor with much more details, since each item of expenditure might be subject to an individual contract and possibly a service specification (3,5,7). initial step of the budgeting process is gathering retrospective data and financial information including all expenses and revenues, units of services (case mix index), staffing information including a breakdown by job code and type of working day-time hours (e.g. base staffing, overtime, non-productive), and current year projections with detailed analysis and evaluation. the second step relate to determining the units of services and expected changes in number of patients, which is driving force for changes in both revenues and certain types of expenses. special attention should be paid to the inpatient routine units of services – patient days, discharges (or admissions), adjustments for intensity of care, as well as to ancillary units of services. the third step of the budgeting process relates to staffing and payroll, which is the most important, high time-consuming and the single largest portion of the budget. special attention should be paid to the base staffing and payroll, overtime, other budgeted hours, contract codes, pay increases, occurred vs. paid staffing and payroll, and productive vs. non-productive time. the next separate category of the budget are 332 health systems and their evidence based development the fringe benefits (social security, pension and retirement, health insurance, disability, unemployment and life insurance, tuition reimbursement etc.). special category of the budget is non-salary fixed and variable expenses (medical/surgical suppliers, drugs and pharmaceuticals, general suppliers, professional and physician fees, insurance, interest and depreciation, purchased services, travel costs, and utilities). and, the last category of the budget are revenues and allowances: gross and net patient revenue, rate charges, allowances and deductions from revenue, contractual allowances and other operating and non-operating revenue (3,5,7). line item budgeting, in general, offers similar incentives as global budgeting, with an exception with limited or no possibility of reallocation of resources between cost units/ categories. that might be a limitation for hospitals for efficient methods of service delivery because of few incentives for efficient production of health services, and little flexibility of managers (2). advanced budgeting, as an alternative method of variance reporting and adjustment of revenues and expenses based on increases or decreases in unit services, is more flexible budgeting. reports on advanced budgeting cover flexible budget as compared to actual and fixed (static) budget. main strengths of advanced budgeting are that budget can be adjusted in order to reflect actual activity level, it is easier to obtain meaningful variance analysis, and to generate a more enthusiastic acceptance by department managers. in line item budgeting the recurrent (operational) costs should be separated from capital costs, too. 6. per diem or flat rate per patient-day is retrospective method for payment of hospital activity. this method, as well as other retrospective methods of payment (fee-for-service or per procedure, course of treatment, per admission or cost-per-case based payment) encourages hospitals to maximize income by maximizing the volume of activity. per diem method gives incentives to hospitals to increase the number of admissions to hospital for diagnostic tests or care that could be provided in alternative and less costly ways (ambulatory or day care services), to hospitalise and provide prolonged care for a relatively well patient and to avoid or refer the sicker patient to other hospital/university clinic (cost shifting), or to prolong length of stay, particularly as the cost per day of care declines as length of stay increases (3,7). fee-for-service payment for each service, procedure or course of treatment in hospitals, as well as cost-per-case based payment (per admission), favours unnecessary marginal care, long lengths of stay, high admission rates, and provision of duplicative or unnecessary services (5). 333 payment methods and regulation of providers per-diem payment and other retrospective methods of payment provides no direct incentives to ensure quality of care, efficiency and cost-containment. 7. diagnosis related groups (drgs) is prospective method for payment of hospitals by predefined charge per case, within the payment rates for each type of case being determined in advance. patients/diagnoses should be categorized into disease categories, so called diagnosis related groups, in order to facilitate billing and reimbursement by estimate cost of individual treatment. reimbursement rates are negotiated between purchaser and provider and they are set to reflect the expected average cost for particular drg. reimbursement payments are divided into four major components: 1. room and board, 2. professional service, 3. diagnostic tests and special therapies, and 4. consumables and drugs (5,7). the number of drgs vary from 470, or even more, in usa (introduced in early 1980s for medicare program for elderly) to around 20 diagnostic groups in chile, which greatly simplifies the classification process and accounting around 60 percent of inpatient care expenditures. the remaining 40 percent of procedures are covered under management contracts and prospective budgets. during 1990s this method of prospective payment to hospitals was introduced in norway (1991), sweden and ireland (1992), hungary (19871993), united kingdom (1993), italy (1994), germany, belgium and spain (1995), czech republic (1996), and than in some other countries (canada, denmark, australia and philippines). anyhow, for implementation of this method of payment should be available a reliable patient information system in order to record diagnoses, procedures, and important items of resource use such as diagnostic testing and length of stay (3,5). drg payment method has advantages of reducing incentives to overtreat, permitting cost containment and generating data and information. there are also some limitations and adverse effects in using drgs payment method: 1) incomplete coverage of drgs (they do not cover psychiatry, outpatients or physician fees for the uncovered items); 2) promoting technological changes (day case surgery), which might be beneficial but in many cases are with unproven efficiency; 3) sticky prices, once fixed, are difficult to change, regardless of advances in technology and falling unit costs, and therefore offer providers increasing profits over time; 4) drg creep activity of classifying patients into the most remunerative drgs possible through undertaking additional diagnostic tests and identifying additional health defects and problems; 5) data requirements can limit the use of drgs in countries with insufficiently developed health information system, particularly in developing countries (3,7). 334 health systems and their evidence based development the main objective of drgs prospective payment is to control costs by motivating providers to deliver care as cheaply as possible. hospitals have incentives to improve performance and to reduce expenditure by reducing length of stay, cutting out unnecessary tests and avoiding duplication. the tendency of hospitals to reduce costs sometimes may compromise the quality of services provided and health outcomes to be worsened, i.e. earlier discharge could lead to higher rates of mortality, morbidity and readmission to hospital – a „quicker – sicker” problem. drgs with fixed prices across all providers stimulate competition based on non-price factors, notably on the quality of services, short waiting times and the quality of he hospital environment. quality competition is likely for profitable patients, i.e. those whose treatment is expected to cost less than the drg reimbursement level. perverse incentives for providers appear when case-mix selection is allowed and hospitals may select the patients they treat. it means that hospitals have incentive to avoid and not to treat patients who are older, sicker or more likely to have complications because the treatment costs for them will probably be in excess of the drg average (adverse selection). such hospitals would prefer to treat simple cases and to minimize costs and maximize profit (cream-skim phenomenon) (3,5,7). case mix selection can occur if providers are allowed to select the patients they treat. this is important because even within drgs, some patients may be older, sicker, or more likely to have a treatment cost in excess of the drg average. if payments are made on the basis of drg average cost, profitmaximizing hospitals have an incentive not to treat these patients. such hospitals would prefer to cream-skim treating simple cases, minimizing costs and retaining any excess of income over expenditure. to avoid cream skimming there must be adequate case-mix adjustment within drgs, which can be complex. case-mix can be measured based on patient’s diagnoses or the severity of their illnesses, the utilization of services, and the characteristics of a hospital. case-mix influences the average length of stay, cost, and scope of services provided by hospital (3,7). conclusion there are three main methods for paying doctors: fee for service, capitation and salary, and four main methods for paying hospitals: global budget, line-item budget, per diem and case based payment (drgs). the practice shows that there is no ideal method for payment of providers. resource allocation decisions should be made among the many diverse, but interdependent activities and programs of the health care providers, and because of that the reimbursement or budgeting is a complex process, usually involving input 335 payment methods and regulation of providers from many sources. anyhow, the creation and maintaining of a detailed operating budget is an important component of cost control. it means that each method for payment to providers has strengths and weaknesses, and each may be appropriate alone or in combination with other, which depends on various circumstances and environment. nevertheless, many health care systems have moved away from fee-for-service as predominant payment. mixed payment systems, with a prospective component based on capitation together with feefor-service for selected items, seem to be more successful in controlling costs at the macro level, while ensuring both patient and provider satisfaction and achieving efficiency and quality at the micro level. the tools available for management include the use of different incentives to influence patterns of care (e.g. to offer more preventive services) and ensure equitable distribution of primary care providers throughout the country (1,9,10,11,12). reimbursement of the hospital providers is complex, and depends on specialization or complexity of hospital services. for example, to use a global budget might be appropriate for well-defined care, such as maternal services. but, when services are more complex and variable, such as oncology or trauma, payment through global budget might be less appropriate. choice of payment method for health care providers is a long, complex and detailed process including appropriate devising of incentives and contract specifications in order to achieve health care objectives (efficiency, quality, equity and cost-containment, as well as consumer satisfaction). difficulties in selection of the method for reimbursement of providers are springing out from the specific subject and product thousand of different illnesses and treatments, and, for the same illness, treatment patterns can be substantially different for different physicians and providers. from the other side, the quality of health care services and outcomes is very difficult to quantify and measure. projection of net revenue is difficult to determine because of different payors and payment methods, and because of rapidly changing of payment methods. when a third party payor (insurance agency) contracts with providers to pay for the care of covered patients by health insurance, it is recommended for each of the payment methods to be accompanied by some payment out of pocket of the patient (1-3,5,9). each payment method should be supported by legal framework and management information system, effective referral system, and financial and management autonomy of the providers. the main characteristics and differences, as well as the distribution of the financial risk between payors / purchasers and providers, are summarized in the attached table 1 (2,3,6,7). 336 health systems and their evidence based development table 1. seven major payment methods: advantages and disadvantages 337 payment methods and regulation of providers payment method unit of payment prospective or retrospective description 1. fee-for-service per unit of service or intervention provided retrospective separate fees for different service item e.g. medicines, consultation, tests, surgical procedures 2. capitation per person per year (month) prospective a payment made by fix sum of money directly to health care provider for each individual enrolled with that provider for a defined period of time. the payment covers the costs of a defined package of services for a specified period of time. in some instances, the provider may then purchase services which it cannot (or choose not to) provide itself from other providers. 3. salary payment to providers, usually on a monthly basis retrospective individual payment to doctor and other health worker, in accordance with the age/experience, grade/level of education and responsibilities of the providers, for their performance for defined period of time (week, month). 4. global budget health facility: hospital, clinic, health centre prospective total payment fixed in advance to cover a specified period of time. some end-of-year adjustments may be allowed. various formulas can be used: historical trends, per capita rates with various adjustments (age, sex), utilization rates for the previous year/s. 5. line item budget functional budget categories, usually on an annual basis either budget is allocated according to specific input categories of resources or functions, usually on an annual basis. budget categories include: salaries, medicines, equipment, food, overhead, administration. 6. per diem per day for different hospital departments retrospective an aggregate payment covering all expenses incurred during one inpatient day. 7. case-based payment (drgs) per case or episode prospective a fixed payment covering all services for a specified case or illness. patient classification systems (such as diagnosis related groups drgs) group patients according to diagnoses and major procedures performed. most frequently applied to inpatient services, although outpatient groups are being developed. 338 health systems and their evidence based development payment method method efficiency quality and equity management and information systems financial risk 1. fee-forservice + flexibility in resource use tendency for provider to increase number of services in order to increase revenue (supplier induced demands) + payment is directly related to intensity of service required there is a tendency to over-service or provide unnecessary interventions. providers must record and bill for each medical service transaction. provider = low payer = high 2. capitation + flexibility in resource use with good cash flow and less lost-costs + the more services included in the package the less the scope for cost shifting + resources closely linked to size of population served and their health needs + good case management providers may sacrifice quality in order to contain costs rationing may occur if capitation is too low (narrow scope practice) may encourage providers to enroll healthier patients (adverse selection) patient choice of provider is generally restricted + adjusters in capitation formula can adjust payment to special population groups by age/sex management system required to ensure that each beneficiary registers with one provider and primarily uses that provider. utilization management and quality assurance programs are essential to prevent under-servicing. if payment covers primary and secondary services, providers at different levels of the system must establish contractual links with each other in order to prevent over-referral. provider = high payer = low 3. salary little flexibility in resource use usually not linked to performance indicators (e.g. volume, quality) gives incentives to under-treat and undermined productivity + payment is fixed and stable no incentives for physicians to improve quality of care and scope of services (gatekeepers) traffic-policeman role with tendency to over-referral and shift costs relatively simple provider = low payer = low 4. global budget + flexibility in resource use spending set artificially rather than through market forces not always linked to performance indicators (e.g. volume, quality, case-mix), low micro-efficiency rationing may occur if budget is too low if rationing occurs more complex cases may be referred elsewhere requires ability to track efficiency and effectiveness of resource use in different departments, and mechanisms to switch resources to most effective uses. provider = high payer = low 339 payment methods and regulation of providers cost-shifting possible if global budget covers limited services; one provider may refer patient to another who is outside purview of global budget to minimize expenditures under global budget + case-mix adjustments in global formulas link budget amounts to complexity of cases; other adjustors may be used to adjust payment for special population groups. 5. line item budget little flexibility in resource use tendency to spend entire budget even if unnecessary, to ensure that level of budget support is maintained rationing may occur if budget is too low more complex cases may be avoided or referred elsewhere more complex and more difficult to monitor with much more details provider = low payer = low 6. per diem + flexibility in resource use tendency for hospitals to increase admissions and length of stay in order to increase revenue + per diem rates allow longer stays for more complex cases prolonged care for relatively well casesavoid or refer the sicker patientss need to track inpatient days by department and ensure costs are covered. provider = low payer = high 7. case-based payment (drgs) + flexibility in resource use tendency for hospitals to increase cases (by increasing admissions or double-counting admissions) + no incentives to over-treat + permitting costcontainment + case-based payment links payment directly to the complexity of cases + generating data and informationshortening length of stay by earlier discharging of patients (quicker-sicker)adverse selection and „cream-skim” providers need reliable patient information system and ability to record and bill by defined case, which generally entails collecting a large volume of relevant information on patient characteristics, diagnoses and procedures. provider = moderate payer = mo-derate exercise: financing of health care and regulation of providers task: seminar paper. students should use additional recommended readings in order to increase their knowledge and understanding of allocation mechanisms and payment methods for regulation of providers. as output, students should write a seminar paper, stressing the importance of different payment methods for regulation of providers. students ought to be able to investigate the ways in which revenues are pooled and how they are distributed to health providers (much more could be find at local level). 340 health systems and their evidence based development references 1. who. health 21 – health for all in the 21st century funding and allocation of resources for health services and care. european health for all series no 6. who-euro, copenhagen 1999: 131-5. 2. wouters a, bennett s, leighton c. alternative provider payment methods: incentives for improving health care delivery. partnership for health reform primer. http://www.phrplus.org/pubs/pps1.pdf 3. maynard a, bloor k. payment and regulation of providers. flagship course on health sector reform and sustainable financing background material. the world bank institute and semmelweis university health services management training centre, budapest, hungary, june 30 july 11, 2003. 4. saltman rb, figueras j. european health care reform: analysis of current strategies. who regional office for europe, copenhagen, 1997 (who regional publications, european series, no. 72). 5. tulchinsky th, varavikova ea. the new public health: an introduction for the 21st century. chapter 11: measuring costs: the economics of health. san diego: academic press, 2000: 549-88 6. robinson j. theory and practice in the design of physicians payment incentives. the milbank quarterly journal of public health and health care policy. university of california, berkeley, 2001; 79(2). (cited 2003, june 29). available from url: http://www.milbank.org/quarterly/7902feat.html 7. the world bank group. funding and remuneration in health care. distance learning flagship course on health sector reform and sustainable financing, 2001. (cited 2004, january 14) available from url: http://www.worldbank.org/wbi/healthflagship/module1/sec7i.html 8. anthony n. robert, young w. david. management control in non-profit organizations fifth edition. richard d. irwin, inc., bur ridge, illinois, usa, sydney-australia; 1994: 902. 9. who. health systems: improving performance. the world health report 2000, who, geneva, 2000: 47-116. 10. who. shaping the future. the world health report 2003 financing health systems. who, geneva, 2003: 119-21. 11. the world bank. world development report 1993: investing in health. the world bank, 1993: 2571. 12. bobadilla jl, cowley p, musgrove p, saxenian h. design, content and financing of an essential national package of health services. the world bank group private and public initiatives: working together in health and education. the world bank, march 17, 1995:1-10. (cited 2004, january 11). available from url: http://www.worldbank.org/html/extdr/hnp/health/ hlt_svcs/pack1.htm 341 payment methods and regulation of providers 342 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title case study: the current health insurance system in the republic of macedonia module: 2.6 ects (suggested): 0.25 author(s), degrees, institution(s) doncho donev, md, phd institute of social medicine, joint institutes, medical faculty, university of skopje 50 divizia no.6, 1000 skopje, republic of macedonia address for correspondence doncho donev, md, phd institute of social medicine, joint institutes, medical faculty, university of skopje 50 divizia no.6, 1000 skopje, republic of macedonia tel: +389 2 3147 056; fax: +389 2 3163 866 e-mail: donev@freemail.org.mk keywords health care; health expenditures; health insurance; health payments; health care costs; resource allocation reform; health plan implementation; macedonia learning objectives at the end of this module case study, students would become familiar with the health insurance system in macedonia. abstract the current health insurance system in macedonia was introduced by the health insurance law, which was adopted in 2000. according to this law, health insurance was established as an obligatory and voluntary insurance for certain kinds of health care. this case study gives an insight to the specificities and practice of both mentioned types of insurance in macedonia, to the scope of the insured persons and their rights and obligations, the way of realization of health insurance in practice. calculation and payment of the contributions and the other sources of revenues, co-payments, autonomy and scope of activities of the health insurance fund, as well as health care and health insurance reforms within the last 12 years. teaching methods teaching methods will consist of combination of an introductory lecture, group work followed by group reports and overall discussion, practical work. specific recommendations for teacher this module to be organized within 0.25 ects credit. beside supervised work, students should collect some specific indicators (hfa database and other sources) and readings about the health insurance system in their respective countries in order to prepare a seminar paper as practical work. assessment of students the final mark should be derived from assessment of the theoretical knowledge, contribution to the group work and final discussion, and quality of the seminar paper. case study: the current health insurance system in the republic of macedonia dončo donev health insurance, as one of the most significant civilization gains of the contemporary world, presents a legal normative and regulatory organized mechanism for acquiring funds on different bases, in order to provide prompt quality and efficient prevention and protection of people’s health. the current health insurance system in the republic of macedonia was introduced by the health insurance law (1), which was adopted in march 2000, and modified and supplemented by the amendments in 2000 (2) and 2001 (3). the health insurance law was empowered on april 7th, 2000, and at the same time the articles of the 1991 health protection law (4) related to the health insurance were put out of power. in fact, the current health insurance system in the republic of macedonia is somehow continuation of the previous one (5), with some modifications and new way of regulation of the relationships within the health insurance related to the obligatory and voluntary insurance, the scope of the insured persons and their tights and obligations, the way of calculating and payment of the contributions and the other sources of revenues for health insurance, user participation in health care expenses, as well as the scope of activities and responsibilities of the health insurance fund that was established as an independent institution outside of the ministry of health. there are two types of health insurance according to the law on health insurance: obligatory and voluntary insurance for some kinds of health care. obligatory health insurance was established for all citizens of the republic of macedonia in order to provide social and health security and to realize certain rights in case of disease or injury and other rights from health care established by health insurance law. obligatory health insurance is based on the principles of obligation and universal coverage, solidarity, equity and effective usage of the financial resources in accordance with the law. it means that when necessary, each insured person can use the health care and the rights from health insurance, in an unlimited amount for basic health care rights, covered by the obligatory health insurance. on the other side, there is an obliga343 case study: the current health insurance system in the republic of macedonia tion to all employees and other bearers of insurance for continuous payment of contributions for health insurance. the contribution rate is the same for all employees, regardless, of the level of salary or income, or the frequency and amount of the health services use on the account of the health insurance funds. the principles of solidarity and equity are compulsory (1,4,5,6). some special risks and services, which are not covered by the obligatory health insurance, should be provided to certain groups of workers by their employers. it includes preventive and screening measures and use of health care in case of injury at work and occupational diseases of the insured on the employment basis, due to the increased risk at work. it also applies to the insured professional sport persons, drivers, pilots and other aircraft crew etc. voluntary health insurance was introduced for the health services that were not covered by the obligatory health insurance. it covers use of some specific health care services, as well as services at a higher level of standard or comfort than those offered by the obligatory health insurance, in accordance with the agreements and norms set by the agency / company that provide voluntary insurance. voluntary health insurance is an additional insurance, allowed only for the insured within the obligatory health insurance. however, due to the lack of interest shown by the citizens for realization of the voluntary health insurance rights, as well as due to the wide range of obligatory health insurance rights, voluntary health insurance has not yet been implemented in practice. modalities of becoming an insured through obligatory health insurance 2000 health insurance law promotes various modalities for a person to become the member of the obligatory health insurance offered by the health insurance fund (hif). almost all citizens (more than 80% of the total population) of the republic of macedonia are insured by the obligatory health insurance system, in various modalities: (a) on the basis of their employment employed individuals (workers), individuals working in the private sector, and individuals performing agrarian activity (farmers); (b) on the basis of their retirement rights retirement, disability and family pensions, as well as pensions and disability rents from foreign insurance bearers; and (c) on other grounds unemployed persons registered by the employment office, users of basic social care rights, war-disabled soldiers, disabled civilians from the war, family members of the insured who serve in the army of the republic of macedonia, persons who are in prison, or are sentenced to correction measures, 344 health systems and their evidence based development persons who have been hired and imprisoned for the ideas for sovereignty of macedonia and it’s independence as a state, persons in religious communities (monks, nuns) etc. (1,6). citizens who are not included in any of the above-mentioned groups, because of various reasons, can voluntary obtain obligatory health insurance, for themselves and for the members of their families, by paying the health insurance contribution in accordance with the law. the obligatory health insurance, apart from covering the active insured (bearer of insurance), also covers his/her close family members: spouse and children up to the age of 18, or to the age of 26 if they are students involved in regular education. in addition to the citizens of the republic of macedonia, obligatory health insurance is also valid for foreign citizens and individuals without any citizenship, if they are employed on the territory of the republic of macedonia, in domestic or foreign firms, in international organizations or diplomatic residencies, or if they are involved in an expert training or education in the republic of macedonia. foreign citizens from countries having international agreements with the republic of macedonia for social insurance, use health care rights according to those agreements (1,6,7). the expenses of the health care services for the citizens of the republic of macedonia who do not undergo any form of the obligatory health insurance, i.e., who are not fund insurees, are covered by the state budget in the following cases: (a) health care of children and adolescents up to the age of 18, and pupils and students up to the age of 26; (b) health care of women related to pregnancy and delivery; and (c) treatment of infectious diseases, mental diseases, rheumatic fever with complications, malignant diseases, diabetes, chronic dialysis, progressive nervous and muscle diseases, cerebral paralysis, multiple sclerosis, cystic fibrosis, hemophilia, thalassemia and similar diseases, epilepsy, alcoholism and drug addiction (1,6). rights from the obligatory health insurance health insurance fund provides the right to health care, as well as the right to a sick-leave and other financial reimbursements to the insured (1,6,7). the obligatory health insurance, on the principle of solidarity as a key element for providing the health care rights, provides the insured with the following basic health care rights / benefits or „basic package of health care services”: 345 case study: the current health insurance system in the republic of macedonia i. health care rights/benefits at the primary health care (phc) level: (a) medical examinations and other kinds of medical assistance in order to determine the diagnosis, follow-up, or check the health status; (b) undertaking expert medical measures, other measures and procedures for promoting the health condition, i.e. prevention and early detection of diseases and other health disorders; (c) providing emergency medical assistance; (d) outpatient treatment or home care treatment at the user’s home; (e) health protection related to pregnancy and delivery; (f) implementation of preventive, therapeutic and rehabilitation measures; (g) prevention and treatment of oral and dental diseases; (h) providing medicines in accordance to the list of medicines, issued by the hif and approved by the minister of health; ii. health care rights/benefits at the specialist-consultative health care level: (a) examination of the health status of the insured and establishing diagnosis and giving recommendation for further treatment; (b) performing specialized diagnostic, therapeutic and rehabilitation procedures; (c) prosthetic, orthopedic, and other facilities, supporting and sanitary instruments, and dental technical devices according to the general act issued by the hif and approved by the minister of health; and iii. hospital (in-patient short-term and long-term) services: (a) examination of the health status, providing treatment, rehabilitation and care, accommodation (in standard conditions hospital room with two or more beds) and meals during hospitalization; (b) providing medicines in accordance to the list of medicines, issued by the hif and approved by the minister of health, as well as supporting materials for application of medicines and sanitary materials needed for treatment; (c) accommodation and meals for the accompanying person of the child up to 3 years of age, during hospitalization, if necessary up to 30 days (1,6,7). the following services are not covered by the obligatory health insurance and might be a subject to the voluntary health insurance: (a) aesthetic surgery, sanatorium treatment and medical rehabilitation of certain chronic non-communicable diseases (except for children up to 18 years of age); (b) inpatient health services with higher standard or comfort; (c) medicines not included in the list of medicines determined by the hif and approved by the minister of health; (d) orthopedic facilities and instruments not included in the list prepared by the hif and approved by the minister of health, or made of higher standard of materials; (e) accommodation and care in gerontology facility etc. (1,6,7). in addition to the basic health care rights, the obligatory health 346 health systems and their evidence based development insurance also provides some other rights to the active insured: (a) reimbursement of salary due to illness or injury, medical examination, voluntary donation of blood or biological tissues, during the sickness leave or due to the pregnancy and maternity leave for 9 months, as well as for the care of a sick child up to age of 3 years (no limit) or other family member (up to 30 days); (b) all insured have the right to the reimbursement of the travel expenses for usage of health services, and some other reimbursements (1,6,7). realization of the rights to health care the obligatory health insurance rights are used by the insured and their family members through health insurance fund on the basis of the issued health book, and a confirmation of paid health insurance contributions (blue tickets/marks) (1,6,7,8). the insured person has a right and obligation to choose a physician (doctor of choice) within the appropriate service at the phc level (service of general medicine, occupational medicine, service for health care of the children up to 6 years of age or school medicine for school children and adolescents up to 18 years of age, and students au to 26 years of age, service for health care of the women related to their reproductive functions, for women over 14 years of age, and dental service for general dental care, for all insured). the doctor of choice is responsible to follow the health status and to provide preventive measures and activities for health promotion and prevention and early detection of diseases, as well as treatment of diseases and injuries, to determine the need for sickness leave and referral of the patient to the higher levels of the health care system, if necessary. basic health care rights might be realized on all levels of the health care system as follows: 1) primary health care, including general practice, occupational medicine, pediatrics, school medicine, gynecology, and general dental practice; primary health care also covers emergency medical assistance and home treatment; 2) consultative-specialist health care provided in health centers and medical centers; 3) sub-specialist health care provided at the clinics and institutes of the medical faculty in skopje and some other health institutions at the national level; 4) hospital health care; and 5) medical rehabilitation at outpatient services, medical centers, and hospitals during the hospital treatment, as well as, specialized medical rehabilitation in specific rehabilitation centers as a continuation of the hospital treatment (7). an insured has a right to the treatment in a foreign medical institution if the disease can not be treated in the republic of macedonia and if there is a 347 case study: the current health insurance system in the republic of macedonia possibility for a successful treatment in some foreign country. the conditions and procedure for sending the insured abroad for health care treatment are regulated precisely by the general act of the hif approved by the minister of health. physician recommendation and the approval for treatment abroad by the health insurance fund committee is required before granting the insurance coverage. coverage for services obtained abroad that are available in macedonia is not provided, in order to protect against erosion in utilization of macedonian medical care (1,6,7,9). resources for health financing health care system services and certain broader public health activities are financed by the monthly payroll (profit) contributions of the employed persons in public and private sector and contributions from the general budgetary revenues, external assistance and limited imposition of users fees (1,6,10,11). most of the revenues (over 90%) are raised from the health insurance contributions in accordance with determined rates. about 57.4% of domestic health sector revenues, in the year 2002, were derived directly or indirectly from payroll contributions to the health insurance fund. direct contributions from public and private sector wage-earners (all persons engaged in different forms of socially organized or personal labor) were equal to 8.6% up to june 2001 when the contribution rate was formally increased to 9.2% because of the changes in the basis and the way of calculation of the health insurance contributions. in fact, this change was induced by the decrease of the personal income tax (as a part of the gross wages) from 23% to 15%, which means that the real contribution for health insurance by rate of 8.6% and personal income tax of 23% is about equal to the contribution by rate of 9.2% and personal income tax of 15% within the gross earned wages and reimbursements during sickness leave (12). direct payroll contributions to the health insurance fund were withheld from the source (employer). certain percentage of money from payroll contributions to the pension and disability fund and the employment fund is transferred to the health insurance fund for health coverage of the retired/pensioners, disabled and eligible unemployed persons. for pension beneficiaries, the contribution rate (14.694%) is applied to the net pension reimbursement, while for the unemployed and for the recipients of social assistance, the contribution rate of 8.6% is applied to 65% of the average net salary in the country to the insured from „social categories” in case they are not employed. these funds are transferred to the health insurance fund by the pension and disability fund, the employment fund, and by the ministry of labor and social policy. about 22% 348 health systems and their evidence based development of domestic health revenues in 2002 were transferred from the pension and disability fund, and about 12.6% from the employment fund. farmers have to contribute 9.2% of the cadastre income. for the citizens with a private enterprise and their employees, the rate is 9.2% of the gross earned wages and reimbursements. additional contributions for health insurance in case of injury at work and professional disease, for the employees in public and private sector who are exposed to an increased risk for injury at work and professional disease, are determined by rate of 0.5% of the gross earned wages and reimbursements (6,10). the general budget was also a negligible source of revenue for the health sector until 1992, when financing of the most prevention programs was shifted from health insurance fund to the budgetary financing. the general budget in 2002 accounted 5.9% of domestic health revenues, which is remarkable increase comparing with 1996 when accounted about 3.5% (5,13). revenues generated through user fees for health services and applied devices in the public health system amounted 1-2% of domestic health revenues. user participation in health care expenses (co-payment) the insured and their family members for the health care have to pay from their personal funds a certain percentage of the health services price, but not more than 20% of the total cost of the health service or drug. in 2001 hif came to a decision about the level of user’s participation in the health care expenses, as follows: (a) 10-20% of the price of health services and of medicines at the phc level; (b) 10-20% of the price of health services for treatment of oral and dental diseases (except prosthetic devices); (c) 10-20% of the costs of services in the specialist-consultative care and hospital treatment, including all costs for services and medicines; (d) 20% of the total expenses for approved treatment abroad; (e) 20-50% of the price of hearing and visual (eye’s) facilities; (f) 20% of the costs of dental prosthetic devices; and (g) 20-50% of the price of some other prosthetic devices in accordance with the general act issued by the hif and approved by the minister of health (6,11,14,15). introducing co-payments for health care services and drugs was one of the most controversial questions in macedonia after gaining the independence in 1991. an attempt of the ministry of health, through health protection law in the 1991, to introduce co-payments on all goods and services covered by the health insurance, was struck down by the constitutional court as infringing on the fundamental rights to health care. in order to erase financial constraints in 349 case study: the current health insurance system in the republic of macedonia the health sector, ministry of health once again, by the 1993 amendment, proposed co-payments on all insured goods and services (20% for outpatient care, drugs, hearing aids and dental devices; 10% for hospital care; 50% for prosthetic and orthopedic devices). the amendment was adopted. 2000 health insurance law continued this practice for co-payments by introducing a general principle of adversity of the level of user’s charge and the price of a service or drug. it means that the co-payment rate / percentage is higher for the lower price services, but not more than 20% of the service / drug price, and the opposite, lower co-payment rate for the higher price services / drugs (1,5,6,11). there is no co-payment for health care in the following cases: (a) follow-up of the health status of the insured by the physician of choice, and for emergency medical services on call; (b) users who receive permanent social assistance, persons placed in the institution for social protection or in other family, except for medicines prescribed at the phc level and for the treatment abroad; (c) psychiatric patients placed in psychiatric hospitals and persons with mental retardation without parent’s care; (d) insured who, during the calendar year, have paid user charges for specialist-consultative and hospital treatment (except for medicines prescribed at the phc level and for treatment abroad) in cumulative amount over 70% of the average income per month in the country in the previous year. certain age categories of citizens might be excluded of copayment when they reach reduced level/limit of user charges paid during the year; (e) additional exemptions, in accordance with some special health care programs with social dimensions and related to the entire population, adopted and financed by the government of the republic of macedonia each year, are determined for users of health services in relation to the treatment of certain debilitating, costly, and often life-threatening diseases (rheumatic fever, progressive nervous and muscle diseases, cerebral paralysis, multiple sclerosis, cystic fibrosis, epilepsy, penfigus, lupus erithematodes, infectious diseases list of about 20 diseases, drug-addiction and alcoholism, up to 30 days, chronic dialysis, conditions after transplantation of the organs, malignant diseases, hemophilia and diabetes, hormones for growing-up the children and compulsory immunization); (f) prosthetic, orthopedic and other devices for children up to the age of 18; (g) women in relation to pregnancy and delivery; (h) infants, up to one year of age; (i) blood donors who voluntary have donated blood more than 10 times; and persons exempted by some special regulations (war disabled persons or family of soldiers who were killed in action), (6,11). 350 health systems and their evidence based development payment to the health care providers according to the law on health insurance, health care organizations and the hif are obliged to plan the necessary funds for providing health care services and realization of the rights to health care to the insured coming from the obligatory health insurance. each year hif prepare a plan and program for health services to be financed from the obligatory health insurance, as well as determine criteria, by the general act approved by the minister of health, for contracting with health care organizations and for the ways of payment to the providers of health care services (6,16). according to the law in health insurance, there are three basic methods of payment to the providers for health services: (a) number of insured persons registered for health care on the list of the physician (doctor of choice) at the phc level (capitation); (b) determined price for each unit of health service or intervention (fee-for-service); and (c) programs for certain kinds of health services. in addition to that, hif determine some other criteria for coverage emergency medical services for entire population, home visits by nurse (patronage) to pregnant women and babies regardless to the status of insurance, providing continuous health care during the day and night (24 hours) and during the holidays and weekend days, etc. the law doesn’t make any difference between public and private health care providers, in relation to the possibilities for contracting with the hif, in order to provide equal financial conditions and incentives for efficient performance in delivering health care, for both types of providers (6,17). revenues and expenditures of the health insurance fund in the year 2002 the revenues of the hif are used to fund the programs for which the hif is responsible and to finance the government’s share of the health insurance costs for those enrolled in the program. direct contributions by employers and workers for health insurance were 57.4% of the total hif revenues in 2002 (table 1). in addition, their contributions to pension and unemployment benefits include components that are used for health insurance premiums for persons who are retired, unemployed, disabled veterans, or recipients of social (welfare) benefits. these amounts, which were about 35.1% of the hif revenues, are paid by the state funds for pension, unemployment, and other social programs. hif revenue from the general budget in 2002 accounted 5.9%. 351 case study: the current health insurance system in the republic of macedonia table 1. revenues of the health insurance fund of the r. macedonia 2002 (in 1000 denars) (18,19). health care expenditures of the hif in 2002 are about 83.2% of total expenditures. salary reimbursements accounted another 6.5%, and the capital investments 6.3% of the total hif expenditures (table 2). the structure of the health care services expenditures of the hif in 2002 is presented on the table 3. outpatient services at the phc level accounted for about 18.2% in comparison with higher outpatient specialist-consultative health care services 23.6% and hospital care / services with 42.6%. prescription drugs were 9.9% and dental care expenditures 4.3%. 352 health systems and their evidence based development sources of revenue budget plan actual percent variance structure (%) 1. employee's gross salaries 2. self employed 3. farmers 4. additional contributions (workers at risk) 5. other insured 6. contributions from previous years 6,498,120 268,856 60,258 372,228 101,112 450,275 6,755,479 225,640 60,369 432,890 101,335 435,957 104.0% 83.9% 100.2% 116.3% 100.2% 96.8% 48.4% 1.6% 0.4% 3.1% 0.7% 3.1% total employment revenue 7,750,849 8,011,670 103.4% 57.4% 7. pension fund 8. unemployment fund 9. social, veterans, disabled funds 10. budget 2,945,560 1,759,523 52,000 489,769 3,074,632 1,763,354 53,582 821,259 104.4% 100.2% 103.0% 167.7% 22.0% 12.6% 0.4% 5.9% total transfers 5,246,852 5,712,827 108.9% 41.0% 11. other revenue 232,776 241,496 103.7% 1.7% 12. transfer from previous year 95,886 95,886 100% — total revenue 13,326,363 14,061,878 105.5% 100% table 2. expenditures of the health insurance fund of the r macedonia, 2002 (1000 denars), (18,19) table 3. structure of the health care services expenditures of the health insurance fund of the republic of macedonia, 2002 (1000 denars), (18,19) 353 case study: the current health insurance system in the republic of macedonia expenditures budget plan actual percent variance structure (%) health care expenditures 11,353,834 11,629,454 102.4% 83.2% salary reimbursements 876,661 908,648 103.6% 6.5% orthopedic devices 135,000 112,813 83.6% 0.8% hif operating expenses 426,189 331,648 77.8% 2.4% capital investments 441,679 875,070 198.1% 6.3% capital transfers 33,000 25,482 77.2% 0.2% past-year obligations 60,000 88,004 146.7% 0.6% total expenditures 13,326,363 13,971,119 105.0% 100% expenditures budget plan actual percent variance structure (%) outpatient services (phc) 2,487,332 2,113,607 85.0% 18.2% specialist-consultative health care services 2,310,770 2,750,143 119.0% 23.6% dental care 530,730 499,856 94.2% 4.3% hospital care/ services 4,449,330 4,953,327 111.0% 42.6% other health care services 21,000 19,597 93.3% 0.2% prescription drugs 1,250,437 1,149,804 92.0% 9.9% treatment abroad 130,000 143,120 110.1% 1.2% program related expenditures 174,235 – – – total 11,353,834 11,629,454 102.4% 100% health insurance system in the health care reform in macedonia after its newly gained independence in 1991, the republic of macedonia inheritance from the social system of the former yugoslavia was a social model of obligatory health insurance and highly decentralized and locally funded public health care system. the main weak points of the system were tendency toward further fragmentation and duplication of unsustainable services, excessive staffing that exacerbated the duplication of care, interregional differences and inequities in the amount and quality of care. that system became unsustainable, particularly in actual economic circumstances and economic transition. up to 1991, there were 35 independent self-management communities of interest for health care on the municipal level and one on national level. all of them were replaced by a single centralized health insurance fund within the newly created ministry of health, with branchoffices of the health insurance fund on the local level. centralization was an attempt aimed, first of all, for stronger control of resource utilization and more equitable distribution during the transition period and economic crisis. in the period after 1991, both the health insurance system and health care system, were faced with numerous problems, as a result of: (a) the war conditions in former yugoslavia, (b) the economic and transportation blockades; (c) drained inflow of funds from health services given to patients coming from other places out of macedonia; (d) the decreased funds from the insurance for more than 40% in real terms, due to the great number of unemployed persons, breakdown of socially-owned enterprises, and reduction of employee income; and (e) different types of tax evasions and other manipulations with obligatory health care payments (5). total national health expenditure, expressed as a percentage of gdp, decreased from 6.2 in 1990 to 4.8 in 1992, compared with 7.6% of gdp in 1998 and 4.7% in 2002. per capita health spending decreased from us $66.8 in 1990 to 39.2 in 1992, compared with us $97 in 1998 and us $93,3 in 2002 (5,13). salaries were a fixed expense and this caused a serious shortage of supplies and equipment for primary health care. thus, at the very beginning of the independence, there emerged an inevitable necessity to undertake urgent measures to prevent further erosion of the health system, provide sustainable volume and quality of the health services, and introduce urgent long-term reforms of the health care system and health insurance system. the health protection law, adopted in 1991, also authorized private health services and pharmacies but did little to streamline the public health system, create incentives for increasing efficiency, or define 354 health systems and their evidence based development legal and regulatory environment for the private providers. shortages of medications were mitigated only modestly by humanitarian assistance, which covered the essential needs for medicines and medical materials. negotiations with the world health organization and the world bank were also initiated to acquire loans and technical support for the implementation of the health sector reforms. in 1993, ministry of health undertook activities for a reform process aimed mainly at: (a) allocating the resources on areas with an immediate impact on the health status of the population and maintaining the basic health services operational through provision of adequate drugs and other consumables; (b) undertaking structural reform and reorganizing of the health care system; and (c) facilitating privatization and development of private health services in order to stimulate competition and improve quality of care and health services (4,5). ministry of health asked the world bank for assistance for further implementation of the reform, and macedonia became a member of the world bank in december 1993. the health sector transition project was the first funded project of the international development association of the world bank in the social sector in the republic of macedonia, and the first donor intervention for reform and restructuring of the health sector. one of the components of the health care reform strategy was financing. it included defining the reforms in pricing policy, benefit packages, and reimbursement mechanisms for ambulatory and hospital services. the objective was to develop new policies and mechanisms which would: (a) maintain broad access to care; (b) create financial incentives for efficiency and cost containment; and (c) remunerate public and private providers equally on the basis of the performed services. co-payments for health care services were introduced in 1993 as an alternative option for supplementary funds, as well as to prevent excess utilization of services, but because of the wide range of exemptions (determined by age, sex and disease) the financial effects were very poor (only about 4 -5% of the revenues of the health institutions). the long list of exemptions proved that users fees were not only unlikely to be an affective policy mechanism to collect revenues but, more importantly, they encouraged greater use of health care services for exempted groups, with associated higher costs for the health insurance fund, especially in cases certain health conditions involving extensive and costly care. those provisions had substantially weakened the initiated impact of the participation policy (5). during 1991-1995, the revenues collected from contributions decreased by approximately 40% in real terms as a result of lower salaries, 355 case study: the current health insurance system in the republic of macedonia bankruptcy of socially-owned enterprises, and evasion of payments by many enterprises, and, of course, increased unemployment. consequently, the revenues of the health insurance fund significantly decreased, resulting in decreased funding of the health care institutions. regardless of all the efforts, the expected results did not come and, in the end of 1994 and the beginning of 1995, health insurance fund entered a very difficult phase, with obvious symptoms of breaking down the health system, which was built over for a very long period of time. in early 1995, with the assistance of local and foreign experts and in cooperation with the world bank, an urgent analysis of the conditions in the health system was made, and a strategy for undertaking sanitation measures was established, simultaneously determining the short-term measures and activities for long-term reform of the health sector. the health care system was analyzed in three segments: (a) financing and management; (b) primary health care and health promotion; and (c) supply of drugs and medical materials. the primary objective was to find the most appropriate solutions for redesigning the health care network and functions of the system in order to meet the demands of the citizens for high quality health services (5,20). an extreme rationing of medication and medical necessities and other material expenses of all health organizations was undertaken by organizing tenders and bidding for central purchase of drugs, sanitary materials and equipment, which resulted in price reduction. in order to achieve equal distribution a central pharmacy store was formed, which, according to the health insurance financial reports for 1995 and 1996, saved millions of dollars, or about 20% of the funds spent on the same materials during the period up to 1994. the competition principle and competitive conveniences for more efficient and rational provision of health services were introduced. this was made possible by the newly imposed legal opportunity to sign an agreement with private organizations and with health professionals for providing health services by personal labor at the account of health insurance fund and in accordance with the norms and standards. this created possibilities for more economic performance of health services. many other organizational measures were also undertaken, which started to improve the global financial situation of health insurance fund (21,22). the main principle of the reallocation mechanism of the funds from health insurance fund to health institutions was financing on a contractual basis and invoicing of services according to the official price list. this principle was implemented only for financing the private health sector. the public health institutions expenditures were covered by the health insurance fund in 356 health systems and their evidence based development order to cover the wage costs, material costs and maintenance, even without signing any contract for the scope and quality of the services. because of this, measures to restructure organization and management in the public health sector were delayed, and the quality of health services and motivation of the health workers decreased, resulting in an inefficient use of the resources. the previous system of referral practice, i.e. in a necessity of a written referral to the specialist from primary health care physician, was abandoned soon after macedonia gained independence, as part of the changes in the socio-economic and political context and general movement to increase personal freedom and freedom of choice. this aggravates the budget problems to the health insurance fund because of the increase in specialist costs and hospitalizations. by 1995, amendments to the health protection law reestablished the referral practice by providing direct specialist-consultative and hospital health care only in emergency cases. the same revision of the law requires that each insured person selects a primary physician from the same municipal area, who will be responsible for the follow-up of the health status of the insured, provision of medical assistance, prescription of medicines, issuing the certificate for sick leave and referral to higher level services. the physician has been chosen from one of the following fields/ disciplines: general medicine, occupational medicine, pediatrics, school-age children medicine or gynecology. however, a widespread opinion is that many primary physicians are still more „traffic policemen”, directing patients toward specialists, than „gate keepers”, motivated and empowered to treat and cure broader scope of illnesses and conditions. according to the results of a survey done by the doctors’ chamber of macedonia in 1998, low payments and bad working conditions caused frustration and low self-esteem of the physicians, as well as low motivation and satisfaction with their work (the average salary of the general practitioners in 1998 was about us $200) (5). in 1996, comprehensive health care reform was undertaken when the world bank awarded the ministry of health of the republic of macedonia a loan of us $19,4 million. the basic goals of the reform were to achieve universal access to high quality primary health care and establish cost effective finance and delivery systems. the initial reform efforts were supported by a grant from the world bank. technical assistance was provided by the rand corporation from the usa. they joined a team with policy-makers of the ministry of health, health insurance fund and other health professionals in the republic of macedonia in order to initiate reform analysis and create new strategies. the proposed new health care policies were directed to 357 case study: the current health insurance system in the republic of macedonia the following specific objectives: (a) identification of the health care priorities in the republic of macedonia through assessing the burden of diseases and effectiveness of available treatment; (b) reduction of the overall health expenditures and put them in balance with revenues; (c) shifting health care utilization patterns away from expensive forms of care; (d) producing a benefit package that is more cost-effective and co-payment structure that improves sectoral efficiency in order to reduce the existing gap between financial resources and given health benefits to the citizens; (e) developing a capitation plan for primary health care providers and concept of family medicine in primary health care, or reorganize the concept of general practitioner’s; (f) establishing an integrated and automated health information system as a support for better management in health care system; and (g) proposing an advocacy information strategies that facilitates the reform process. in the last five years, activities have been taken for implementation of the principle of capitation within the primary health care level, for strengthening the citizen’s right for choosing the doctor and creating a basic package of health care services, as well as fee for service payment on the secondary and tertiary level according to the official price list. to support these activities, adjustment of the health information system and management of the health institutions through training of the managers and other employees was introduced. however, the activities for acquiring humanitarian aid and other kinds of support did not stop. macedonia also entered several programs of the european union (phare) for solving few substantial problems through nonrefundable financing. it must be emphasized that all undertaken measures and activities resulted in partial and temporary alleviation of the problems during the painful transition period in the republic of macedonia. the most recent activities within the reform of the health insurance system were directed to the preparing of a new law on health insurance, which has been adopted by the parliament of the republic of macedonia on march 30 and enforced on april 7, 2000. the health insurance fund was established as an independent institution outside of the ministry of health. the executive board of the health insurance fund already adopted many general acts, approved also by the minister of health, which approach in more details the most important issues for efficient implementation of the law in practice, i.e. strengthening the mechanisms for collecting of regular revenue for the health insurance fund, introducing methodology for calculating the new methods of user participation in health care expenses (co-payments), as well as 358 health systems and their evidence based development more precise regulation of the relationships within the health insurance related to the obligatory and voluntary insurance, the categories of the insured persons and their rights and obligations, and the scope of activities and responsibilities of the health insurance fund. 359 case study: the current health insurance system in the republic of macedonia exercise: specificities of the current health insurance system in the republic of macedonia task 1: comparing health expenditures between countries students should collect data about health care expenditures from their respective countries. in addition to that, they have to be compared with macedonian expenditures. an analytical approach about the percentages of the funds spent on primary health care, hospital care, medicines, treatment abroad etc. will be considered through group discussion. time proposed is 60 minutes. task 2: health insurance system students are asked to collect some specific indicators (hfa database and other sources) and readings about health insurance system in their respective countries in order to prepare a seminar paper as practical work. this task will be done individually, as homework. 360 health systems and their evidence based development references 1. zakon za zdravstvenoto osiguruvanje. skopje: slu`ben vesnik na republika makedonija 2000; 25: 1455-65. 2. zakon za izmeni na zakon za zdravstvenoto osiguruvanje. skopje: slu`ben vesnik na republika makedonija 2000; 96: 5287. 3. zakon za izmeni na zakon za zdravstvenoto osiguruvanje. skopje: slu`ben vesnik na republika makedonija 2001; 50: 3510. 4. zakon za zdravstvenata za{tita. skopje: slu`ben vesnik na republika makedonija 1991; 38: 613-31. 5. donev d. health insurance system in the republic of macedonia. croatian medical journal, june 1999, vol. 40(2): 175-80. 6. mi{ovski j. zdravstveno osiguruvanje. komentar na zakonot za zdravstvenoto osiguruvanje so podzakonski akti. skopje: ami grafika doeel, 2001. 7. fond za zdravstveno osiguruvanje na republika makedonija. pravilnik za sodr`inata i na~inot na ostvaruvanjeto na pravata i obvrskite od zadol`itelnoto zdravstveno osiguruvanje. skopje: slu`ben vesnik na republika makedonija 2000; 111: 5733-53. 8. fond za zdravstveno osiguruvanje na republika makedonija. pravilnik za formata i sodr`inata na zdravstvenata legitimacija i za na~inot na nejzinoto izdavanje, vodenje i koristenje. skopje: slu`ben vesnik na republika makedonija 2000; 111: 5706-8. 9. fond za zdravstveno osiguruvanje na republika makedonija. pravilnik za na~inot na koristenje na zdravstvenite uslugi na osigurenite lica vo stranstvo. skopje: slu`ben vesnik na republika makedonija 2000; 111: 5708-10. 10. fond za zdravstveno osiguruvanje na republika makedonija. odluka za stapkite, osnovicite i visinata na pridonesite za zadol`itelno zdravstveno osiguruvanje. skopje: slu`ben vesnik na republika makedonija 2001; 4: 65-6; 2001; 50: 3510. 11. fond za zdravstveno osiguruvanje na republika makedonija. odluka za utvrduvanje na visinata na u~estvoto na osigurenite lica vo vkupnite tro{oci na zdravstvenite uslugi i lekovite. skopje: slu`ben vesnik na republika makedonija 2001; 48: 3382-4. 12. ministerstvo za finansii na republika makedonija. zakon za izmenuvanje i dopolnuvanje na zakonot za personalniot danok na dohod. skopje: slu`ben vesnik na republika makedonija 2001; 50: 3504-5. 13. fond za zdravstveno osiguruvanje na republika makedonija. budzet na fondot za zdravstveno osiguruvanje na makedonija za 2002 godina. skopje: slu`ben vesnik na republika makedonija 2002; 46: 237-40; 93/02: 229-32. 14. fond za zdravstveno osiguruvanje na republika makedonija. lista na lekovi koi pagjaat na tovar na fond za zdravstveno osiguruvanje na makedonija. skopje: slu`ben vesnik na republika makedonija 2001; 4: 87-96. 15. fond za zdravstveno osiguruvanje na republika makedonija. pravilnik za indikaciite za ostvaruvanje na pravoto na ortopedski i drugi pomagala. skopje: slu`ben vesnik na republika makedonija 2000; 111: 5711-32. 16. fond za zdravstveno osiguruvanje na republika makedonija. pravilnik za izgotvuvanje i utvrduvanje na budzetot na fondot za zdravstveno osiguruvanje na makedonija. skopje: sluzben vesnik na republika makedonija 2001; 55: 3713-16. 17. pravilnik za na~inot na pla}anjeto na zdravstvenite uslugi vo primarnata zdravstvena zastita. skopje: slu`ben vesnik na republika makedonija 2001; 48: 3384-6. 18. health insurance fund of macedonia. budget of the health insurance fund of macedonia for the year 2002. official gazette of the republic of macedonia [in macedonian]. skopje: the state; no. 93: 228-32. 361 case study: the current health insurance system in the republic of macedonia 19. state statistical office of the republic of macedonia. utilization of benefits and health care expenditures in 2002. in: statistical yearbook of the republic of macedonia. skopje; 2003: 110-1. 20. ivanovska l. health status of the population and health care system in r. macedonia. undp human development report ‘98 of r. macedonia. ministry of development of r. macedonia, skopje; 1998: 61-70. 21. ministerstvo za zdravstvo na r. makedonija. informacija za materijalno-finansiskoto rabotenje na fondot za zdravstveno osiguruvanje i zdravstvenite organizacii vo republika makedonija vo 1996 godina. skopje, 1997. 22. ministry of health of r. macedonia. bulletin of the health insurance fund. skopje, ministry of health of r. macedonia, 1998. 362 health systems and their evidence based development 363 case study: swot analysis of the serbian health insurance system health systems and their evidence based development a handbook for teachers, researchers and health professionals title case study: swot analysis of the serbian health insurance system module: 2.7 ects (suggested): 0.25 author(s), degrees, institution(s) vesna bjegovic, md, phd adriana galan, it specialist the first author is professor at the school of medicine, university of belgrade the second author is lecturer at the university of medicine and pharmacy bucharest, department of public health and management, at the master course in management of public health and health services address for correspondence institute of social medicine, school of medicine, belgrade university dr suboti}a 1511000 belgrade serbia and montenegro tel: +381 11 643 830; fax: + 381 11 659 533 e-mail: bjegov@eunet.yu keywords health insurance, management, swot analysis, change learning objectives at the end of this module, students should be able to analyze present status of health insurance management by using swot analysis and to propose possible changes and improvements. abstract the reform of health system must inevitably reconsider the management of all institutions, such as health insurance institutions. the first step in this process is to analyze the present status. one of the tools used for this assessment is swot analysis. teaching methods after reading the case study, students will work in small groups and produce written recommendations. specific recommendations for teachers it is recommended that this module is organized within 0.25 ects credit. the work under supervision is consisting from case study, small group discussions, while individual work is related to review electronic and printed literature in the field. assessment of students written report produced by each group. case study: swot analysis of the serbian health insurance system „when a manager leads from one crisis to another, it is time for the next manager”* vesna bjegović, adriana galan current trends in health care system reforms at present, almost all the countries, including the developed ones, are facing the problem of health care system reforming. the reform of health sector is a multidimensional process. as noticed in the reform strategies in other countries, „one part of the scale involves administrative and managerial pressure for cost-containment, and the individual citizen wanting the best possible care at the moment of utilization. at first sight, there seems to be an insoluble dilemma between the two respective opposites” (1). however, one of the who experts for health system reforms vividly observed, „since citizens are the final payers of any health care service public or private it is in their interest to spend a dollar, mark or ruble for health in the most efficient and effective manner, and for real priorities” (1). this is actually one of the basic management principles, which has been neglected in health care for a long time. consequently, the reform of health system must inevitably reconsider the financial component, regardless of the model applied, in order to ensure maximal benefits with minimal investments (2,3). a theoretical approach for the management of health insurance is neither unique for all countries, nor is in place an optimal management structure that is reproducible, since it is dependent on a number of factors like (4): • the level of political independence of health insurance funds, • possibility of choice for potential insured persons, between one or several health insurance funds, • organization of health care services (whether health care providers are employed by health insurance companies or are under contracts for providing health services with insurance), 364 health systems and their evidence based development * wahba aw. „appropriate technology”. the road to happiness.2nd edition. copenhagen 1985: p. 43-9. • historical factors (existing administrative structure of the ministry of health) and country's political system (federal state, centralized state, level of political responsibility etc.), • economic and social situation of the country, • health policy objectives that need to be achieved by health insurance. the basic trends in the reforms of health care financing in the european community countries, both developed and developing, have been determined by factors related to a decreasing role of the state and introduction of a controlled market, reorganization of the whole health care system in terms of decentralization, re-centralization and privatization, civil rights, individual's choice and participation, as well as enhancing the role of public health (5). historical background of the health insurance system development in the republic of serbia the health insurance law in serbia passed the parliament in 1992. according to this law, the health insurance system was established, with mandatory health insurance for the whole serbian population. the republic health insurance fund was then created, having a „declarative” independent statute. this national company has 30 subordinated branch offices located in each district of serbia. according to the above-mentioned law, the managerial board of the republic health insurance fund consists of the following structures: the insured representatives body, the managerial board, the director and the supervising board (6). the insured representatives body consisted mainly of insured persons' representatives. in 1998 the law from 1992 was modified and amended. this amended law dissolved the insured representatives body, and a formally representative body of the insured population replaced it. by these amendments, the shift towards a complete centralization of the health insurance management, only perceptible in the health insurance law from 1992 or various governmental acts has gained finally a complete legal support. the present managerial structure of the health insurance institution in serbia, being completely dependent of the government of the republic of serbia, consists of: the managerial board, the supervising board and the director. this structure is presented in figure 1. the director and vice-director are directly appointed or set free by the serbian government, while the managerial board and the supervising 365 case study: swot analysis of the serbian health insurance system board are elected on the basis of proposals made by the insured' representatives: the serbian trade unions, the association of pensioners, the cooperative association of serbia, the serbian chamber of commerce and the director of the republic health insurance fund. the managerial board consists of 21 members, out of whom 14 are the insured representatives (from the employees category), 2 insured pensioner representatives, 2 insured farmer representatives, 2 insured independent activity representatives and one company employee representative, respectively. this case study is based on swot analysis in order to depict the strengths, weaknesses, opportunities and threats in the serbian health insurance system management. figure 1. organizational structure of health insurance system in the republic of serbia strengths all former republics of yugoslavia were much earlier than other see countries experiencing some kind of health insurance system. serbia started to change the old type of insurance system „based on self-management community of interest” in 1989, and afterwards in 1992 when the health insurance law passed the parliament. it was a radical change in the financing of health care system. 366 health systems and their evidence based development the government of the republic of serbia the ministry of healththe cooperative association of serbia the association of pensioners the serbian trade unions the serbian chamber of commerce the director of the republic health insurance fund proposals the managerial board 21 members president vice-president the supervising board 7 members president the director of health insurance fund 30 local communities funds the existence of such kind of health care financing is one of the basic strengths because the physical infrastructure for the present 30 local branches was already in place. in this way, no additional funds were necessary to create this infrastructure. at least, at a declarative level, the insured persons are well represented in the managerial board of the republic health insurance fund according to the health insurance law from 1992. another positive aspect of the present managerial structure is that the administrative body is relatively small, since the total number of employees in the republic health insurance fund, including all branch offices, is 1921 (7). although the number of employees may appear to be high, it is in fact far smaller than in other systems having a longer tradition of health insurance, with less number of insured. for example, according to the data available from 1998, there were 2621 registered insured persons per an employee in the republic health insurance fund. this is low compared to germany for instance, where commonly the number of registered insured persons per an employee in health insurance ranges from 220 to 690 (4). although there were no studies to evidence the motivation of the employees, or the level of their skills for specific jobs, qualitative methods (e.g. financial policy analysis) have revealed that the number of employees is yet insufficient for achieving effective and good quality results. weaknesses since the beginning, the health insurance system in serbia was characterized by a marked centralization and a strong dependence in the process of decision-making on other governmental authorities (even outside of the health care system). such „quasi-autonomy” of the health insurance and its strong political dependence prevent any initiative or enterprising, and the management effectiveness has been additionally decreased by strict and often out of date legal regulations. from organizational point of view, it can be noticed that the branch offices of the republic health insurance fund have actually no responsibility of managerial decision-making. they don't have even a uniform organizational structure. the representative body of the insured within the health insurance fund board has an inadequate structure according to the existing consumer categories. it is unbalanced in terms of the number of the insured (one mana367 case study: swot analysis of the serbian health insurance system gerial body per around 7.5 million of potential consumers) and local consumer representatives (from 30 local communities) are not allowed to participate in the decision-making process for adequate allocation of the financial resources collected in their own territory. in this way, the stipulations of the supreme legislative act at the republic level the constitution of the republic of serbia from 1990 have not been achieved (articles 40 and 68) which guarantee the participation of each citizen in the decision-making process related to mandatory social insurance (8). the mechanisms of delegating the managerial and supervising board representatives are not democratic and furthermore, they are not based on the real structure and number of the insured paying the contribution for health insurance. for example, 14 insured representatives within the employee category are proposed by the serbian trade union. even if this is the biggest trade union, it is not the solely one representing the interests of all insured employees. a big number of employees belong to other unions like the trade branch unions „independence”, the association of independent and autonomous unions of serbia, the independent unions of serbia and many others. it can be also mentioned that, unlike other european countries (4), the managerial board in serbia do not comprise health worker representatives. management of the present health insurance has not been supported by an adequate information system, although several years ago the bull hn bg company designed a major project for its implementation. this was the proposal for the „national project and implementation project for management and decision-making support” within the development of information system of the republic health insurance fund in 1994, but never implemented in total as it has been planned. according to some estimation, to complete the performance control only in the area of contribution payment, with the existing personnel and without information system, there are needed 20 to 25 years (9). the lack of information system facilitates non-allocated use of the republic health insurance fund resources, ineffective use of the working hours, and so on. with such rationales, upon a minor revision of the major project, in 1997, there started its practical use introduction of the health insurance information system, which, unfortunately, failed and ended up with one of the major financial scandals. nevertheless, local brunch offices succeeded to develop some kind of information systems. the lack of an information system reduce also the effectiveness of other management functions in health insurance, such as planning, accounting, financial management, external and internal audit. thus a special problem, recently emphasized, was the lack of relevant, reliable and timely information 368 health systems and their evidence based development for effective management, and monitoring of health insurance functioning at the central level. such state of affairs enables numerous speculations and is conflicting to the good recommended practices, the health insurance management not being at all transparent for the general public. health insurance staff are very low motivated, neither for quality of work, not for career improvement because of low level of salaries and lack of other incentives. opportunities due to the scarcity of financial resources available for health care system, it would be necessary to put into practice marketing techniques for the extension of these resources, attracting other funds or obtaining donors aid. also, some management techniques in health insurance would be necessary for motivating health care providers to work in a more efficient manner and with acceptance of financial responsibility. opportunities exist because of positive changes in the postgraduate education for health professionals (continuing education in health management, initiatives to establish a school of public health). additionally, these techniques can also help in better control regular payments of established contributions of insured (particularly employers). another opportunity for improving the management of health insurance system can be the adoption of gtz (gesellschaft für technische zusammenarbeit) methodology, aiming to examine and promote access of all population groups (especially the vulnerable ones) to health insurance system. the german company gtz, together with the institute for tropical medicine in belgium, have developed infosure, a standardized evaluation methodology (health insurance evaluation methodology and information system). the evaluation is focusing on the following issues: the ways in which health insurance is organized in developing countries; practical experience with the set-up of insurance schemes; sustainability; administrative concepts; experience with certain target groups and special problems. infosure consists of a questionnaire and a corresponding software product. the questionnaire consists of three parts: a qualitative one, a multiple choice one and a statistical one for quantitative values. the outcome of the evaluation is a case study. further, the case studies are processed in an information system, which can be accessed, via the internet. this methodology permits a comprehensive analysis of a health insurance scheme in order to identify the factors contributing to the success or failure of an insurance scheme (10). 369 case study: swot analysis of the serbian health insurance system due to the fact that the political environment became more favorable, the existing law can be again amended in order to secure an adequate degree of autonomy to the health insurance fund. in this way, there will exist an open door for enterprising, initiative and putting into practice marketing mechanisms for effective achievement of the objectives of health insurance. on the other hand, law can also regulate decentralization process. this means delegating the management empowerment and responsibility to branch offices at lower organizational level, their legal status being thus regulated by law. consequently, transparency can be secured for the consumers, as well as more effective control of quality and costs of health care services provided. in addition, different international technical assistance (e.g. world bank, european agency for reconstruction, etc.) are in place, aiming to support further changes in improving the management of health insurance. threats serbia, like other surrounding countries, is marked by a deep economic crisis, inherited on one hand from the past communist regime and extended by the world economic crisis. the poor performance of economy has a deep negative impact on the social sectors, including health and education. unlike other countries, serbia has also to face the devastating consequences of the war during the 1990s, which have further deepened the scarcity of resources available for the social sector. it is not foreseen an immediate growth of economic level, therefore the health care system performance has little chances to improve in a short period of time. this is also true for the health insurance system. the real income of a large number of households has dramatically decreased, affecting directly the health insurance fund. political involvement at almost all administrative levels has also affected in a negative way the proper management of the health insurance system. also the political instability has often induced changes in human resources structure (especially top managers) affecting in this way the continuity of strategic thinking at republic health insurance fund level. potential consumers have still no alternatives to choose among insurance funds, since private insurance appear very slowly in serbia. there exists only one mandatory health insurance fund, those created in 1992. educational system is not yet prepared to properly train future managers of the health insurance system. the future managers working in health insurance system must achieve specific skills, like: knowledge of effective 370 health systems and their evidence based development collection of contributions, how to identify health care rights, how to ensure available services for all insured and how to monitor the quality of care (4). 371 case study: swot analysis of the serbian health insurance system exercise: how can the health insurance management be restructured? task 1: after reading this case study under the supervision of lecturer, students are asked to split and work in small groups (4-6 students) in order to discuss and decide possible recommendations they would make for the improvement of health insurance management in serbia (2 hours for reading the case study, 1,5 hour for group discussion and 1 hour to produce written recommendations to be presented to the whole group). task 2: in the case of a see workshop on „health care management and financing”, students are asked to split in country based groups and draft similar swot analysis for their own countries, further discuss the similarities and differences and finally make recommendations (3 hours). 372 health systems and their evidence based development references and recommended readings 1. vienonen m. health care reform (cited 1997, february 14). available from url: http://www.who.dk 2. wiewiora-pilecka d. why health reforms projects are poorly implemented (cited 1999, november 15). available from url: http://www.atm.pl/~danapil/reform1.html 3. cahi. state based guaranted access programs: the best health insurance safety nets. council for affordable health insurance 1999; 3(6): 1-5. 4. normand c, weber a. social health insurance. a guidebook for planning. geneva: who, ilo 1994. 5. who regional office for europe. reform strategies (cited 1997, december 2). available from url: http://www.who.dk/hcs/chap02.htm 6. law on health insurance. official newsletter of republic of serbia 18/1992. 7. republic health insurance fund. report on work and financial bussiness of republic health insurance fund for 1998. belgrade: republic health insurance fund 1999. 8. constitution of republic of serbia and constitution of republic of montenegro with constitutional laws for their implementation. second edition. belgrade: niu slu`beni list srj 1997. 9. ahcpr (the agency for health care policy and research). structuring health insurance markets: protecting consumers and promoting competition (cited 2003, july 24). available from url: http://www.ahcpr.gov/research/ulpmarkt.htm 10. hohmann j, weber a, herzog c, criel b. infosure. health insurance. evaluation methodology and information system. introduction, guideline and glossary. first edition. eschborn: gtz 2001. available at url: http://www.gtz.de 373 case study: swot analysis of the serbian health insurance system 374 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title economic appraisal as a basis for decision making in health systems module: 2.8 ects (suggested): 0.75 author(s), degrees, institution(s) helmut wenzel, m.a.s. bajram hysa the first author is health economist employed by roche diagnostics company, mannheim, germany the second author is associated professor at department of public health, faculty of medicine, tirana, albania address for correspondence ulrich laaser, section of international public health (s-iph), faculty of health sciences, university of bielefeld pob 10 01 31, d-33501 bielefeld, germany. tel/am/fax: +49 521 450116, e-mail: ulrich.laaser@uni-bielefeld.de keywords health economics, efficiency, economic appraisal, cost-benefit analysis, quality assurance learning objectives after completing this module, students and public health professionals should have an increased understanding of: • health economics as a scientific discipline and the relationship between evaluation and economic theory; • the options to manage scarcity in health care systems; • the key evaluation methods in health economics; • setting up an evaluation; and • how to judge the quality of published economic evaluations. abstract this module gives a short overview on the basics of health economics. economic appraisal is an instrument for health care decisionmaking, which is influenced by many characters. there are three types of costs: direct, indirect and intangible. costs and benefits can be calculated in a cost-benefit (cba), cost-effectiveness (cea), cost-utility analysis (cua) etc., depending on society, patient, payer or provider' point of view. when comparing two alternatives, it is important to understand the additional costs and effects. marginal analysis looks at the extra cost of extra effects in the same programme; incremental analysis looks at the differences between programmes. alternative projects costs and benefits may occur at different points in time. in order to compare them in a money term, discounting is needed. a discount rate is a number relating the value of one year to the value in the next or previous year. having unbiased economic evaluation is very important for quality of study. this led to the development of guidelines which regulated many things, but aside of that every reader or decision-maker can make his quality, checking drummond's „ten commandments” of good appraisal practice. teaching methods after introductory lecture, students will work in small groups, in order to discuss efficiency as a prerequisite for an appropriate health care system. basic skills like discounting and choosing a decision have to be trained. to do so, financial and mathematical exercises have to be solved (calculated). students will be learned how to judge the quality of health economics publications that are delivered by teachers. 375 economic appraisal as a basis for decision making in health systems specific recommendations for teacher this module to be organized within 0.75 ects credit, out of which one third will be under the teacher supervision. it is recommended that mathematical calculations are prepared. pocket calculators are obligatory. a selection of publications with different quality levels should be available to the students. assessment of students multiple choice questionnaire and written design proposal. economic appraisal as a basis for decision making in health systems helmut wenzel, bajram hysa the aim of the module is to give a short overview on the basics of health economics and to provide more in depth information on economic evaluation tools (economic appraisal). current problems of many health care systems as well as approaches to solve those problems are described. thereafter a short overview on the basics of health economics is given and in depth information on economic evaluation tools (economic appraisal) and their application is provided. it would be wrong to suggest that health economics is identical with economic evaluation tools like cost-benefit analysis. these techniques are undoubtedly the most relevant and mostly known tools from health economics. this obviously leads to the misunderstanding on the true nature of health economics, then. today, many health care professionals seem to be familiar with those tools. nevertheless, it still remains the case that the underlying economic principles and theories are unknown to many. therefore the paper puts some stress on the economic background of economic evaluation. health care and limited resources all over the world health policy is faced with an increasing demand and declining financing power at the same time. particularly decentralised health care systems are unable to describe the relationship between resources used and outcomes achieved, due to the fact that the amount of money spent is known but the „health production” processes is unknown. as a consequence the efficiency1 of the health care delivery process cannot be controlled or influenced. thus, this leads to rationing of services rather than to increasing productivity. as a first step politicians tend to cut down expenditures by different administrative means. this is followed by reducing the number of covered 376 health systems and their evidence based development 1 in economics, the term 'efficiency' is used when resources (e.g. medical services, drugs, and diagnostics) are used in such a way that nothing is wasted. this means that, in an efficient situation, without adding any more resources, further products can only be produced by sacrificing a quantity of another product. services (exclusion from reimbursement scheme etc.), and different approaches to lower prices of products. health authorities right now are targeting more and more the productivity and the quality of the process of care (or production of health) by promoting evidence based medicine and as an evaluation tool outcomes research. „evidence based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. the practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research” (1). outcomes research is defined as „assessment of the effect of a given product, procedure, or medical technology on health and/or cost outcomes” (2). disease management (dm) can be described best as „a comprehensive, integrated approach to care and reimbursement based on the natural course of a disease, with treatment designed to address an illness with maximum effectiveness and efficiency (2). if dm concepts are implemented in a proper way, one can assume a less costly but even more effective health care system. allocation of limited resources are there alternatives to efficient health care systems? if there are more needs and wants than resources available, alternatively two administrative measures could be applied: rationing and allocation of resources due to defined priorities. in modern democratic societies some questions arise, then: • who will have the right to define the criteria for rationing or for any priority setting? • what is the final ethical basis for those decision processes? • whose values are the final yardstick for setting up priorities? • isn’t it even unethical to make those kinds of decisions? first of all, it is unethical to spend money (resources) in such a way that we do not produce the best outcome in terms of care or finally health. overspending in one area (selected diseases, specific patient groups, provision of care like prevention vs. cure) very often goes along with under-spending in other areas. so, it is an ethical must to deal with that problem. 377 economic appraisal as a basis for decision making in health systems rationing is an ethical issue as well and ought to be based on the principal agreement of a population. in an implicit rationing procedure the decisions and the preferences are not revealed. from the viewpoint of modern societies this is not acceptable. explicit rationing is an outcome of political processes where the consent of society could be received by either lay participation in the decision processes or by the anticipation of the citizen needs by experts. in the late sixties this kind of integrating as many citizen and their needs in any planning process was called advocacy planning. the basic idea was that experts (and politicians) should be able to anticipate the problems of those people that have not the ability to take part in political processes in an adequate way. this approach was not very successful. for reaching the humanitarian goal of equity, and also more objective ways of comparing the alternative use of modest resources, technical solutions and evaluation tools are inevitable. this is how health economics is coming in. alternative ways of allocating limited resources are presented in figure 1. figure 1. alternative ways of allocating limited resources (3) source: coast j. et al., in: priority setting: the health care debate, wiley, 1996 main features of health economics economics is a discipline, a recognized body of thought and not just a set of tools. consequently, health economics is the discipline of economics applied to the topic of health care, and deals with the factors that determine the individual’s demand for health services. health economics research tries to answer the question what kind of goods and services have to be offered in a health care system, what quality and quantity would be appropriate, and to 378 health systems and their evidence based development allocation of limited resources implicit rationing explicit priority setting political processes technical methodologies lay participation medical paternalism (advocacy planning) equity efficiency what extent services and goods should be produced by public funds (see public goods, welfare theory). moreover, health economics deals with the different ways of financing the health care system, and the system’s interdependence with and interconnection to the other sectors of the national economy. research tools are coming from different disciplines like: epidemiology, statistics, medicine, economy (or, decision analysis, scenario techniques, game theory), and modelling. economic appraisal techniques (like cost-benefit analyses) are important instruments of this discipline. those evaluation techniques are going through considerable methodological development, since efficiency gaps in the production of health services still exist. know-how that comes from other scientific disciplines has been incorporated. looking at the very nature of health economics our starting point is simple scarcity of resources, and the issue of choice. taking a choice means that a decision has to be made not only about what to do, but also what to leave undone. the concept of cost in health economics is different to the concept of cost in accounting, which relates to cash outlays. therefore, when economists argue that attention should be paid to efficiency in health care, they are implying that health care programmes, treatments and procedures should be compared not only in terms of their relative benefits, but also in terms of their relative costs (i.e. benefits forgone). economic appraisal as an instrument for supporting decision making as mentioned above, the core of health economics is choice and decision making. to prepare decision making, information is needed on the desirability of the choice, and the possible outcome in the future. the desirability (or anticipated satisfaction) of a good is described by its value. these values have to be put into an evaluation framework that based on decision rules recommends what should be done in order to improve the situation in a rational way. before explaining the different methods of economic evaluation, a short brush-up is given to introduce the economic concept of value, the theoretical background of deriving and describing value, and the concept of efficiency. these are underlying principles. 379 economic appraisal as a basis for decision making in health systems the concept of value and efficiency the value of an object reflects its importance with respect to the potential to satisfy the individual needs. this potential is called benefit, or sometimes utility. economic theory believes in the rational nature of men (paradigm of homo economics). this further leads to the assumption that each individual wants to maximize its degree of satisfaction, which is measured in terms of benefits. in order to maximize the benefits the individual will make sure that the last unit of money spent will create the same amount of benefit. there are different ways to define and to measure those benefits. some of those methods are based on the principles of welfare-theory, some are based only on the assumption that men are deciding in a rational way. other methods incorporate the preferences of patients into the desirability of outcomes. generally, efficiency is measured by the relationship between the level of accomplishment of these goals (consequences) and the resources used or expenditures. there are two simplified viewpoints of efficiency: • cost-efficiency: product applications or intervention strategies which achieve a given health outcome at the lowest level of resource utilization are called efficient or economical. • output-efficiency: product applications or intervention strategies which generate the best possible outcome or goal achievement for a given resource input are called efficient or most productive. both perspectives of efficiency evaluation include an assessment of both resource input or costs and outcomes. claiming that a medical intervention or a diagnostic / therapeutic procedure is efficient does not necessarily mean that it will lead to cost reduction; cost reduction and efficiency generally represent two different perspectives. those diagnostic or therapeutic products which are more expensive than established alternatives but which exhibit higher predictive value, greater effectiveness, more safety, fewer sideeffects, etc. may be efficient. whereas private accounting is generally limited to factors measurable in monetary terms, classical economic analysis extends the examination to qualitative and intangible costs and consequences. it explicitly attempts to measure factors which are difficult to evaluate monetarily. 380 health systems and their evidence based development costs, costing problems and outcomes the measurement of all effects of an intervention strategy in terms of cost and outcome components (benefit, results, consequences) is based on the distinction between the input of resources used by the intervention on the one hand, and its positive and negative outcome effects on the other. generally, the three categories of direct, indirect and intangible costs and consequences are differentiated. direct costs: direct costs are defined as the utilization of resources in the form of goods and services. this includes primarily the use of health care resources as pharmaceuticals, medical-technical services, lab work, medical consultation, hospital stays, etc. the consumption of resources in the individual patient’s private sphere may also be included, such as transportation to and from health care institutions and special diet provisions. indirect costs: indirect costs are those associated with a loss production due to sick leave, disability or premature death. such losses can occur in the production process (persons gainfully employed) as well as in every day household tasks (uncompensated employment; e.g. housewives). intangible costs: intangible (direct or indirect) costs are those that are incurred by patients and their families as a result of illness or intervention but which are not measured in money terms. examples are pain or grief levels associated with disability, morbidity or death. a fundamental difficulty in the assessment of costs is the absence of (meaningful) market prices for many health care goods and services. generally, true market prices are available only for (some) direct cost and outcome components, due to third party payment. thus potential ‘cost saving’ or savings of health insurance expenditures with a new medical intervention may not be savings to the society. as an example, consider ‘average costing’ methods (total direct and overhead costs divided by number of patients). if a hospital bed is freed by a new effective treatment that allows early discharge of patients, the hospital overhead cost per patient is not saved but increased. if no one else fills the vacant hospital bed, accounting would eventually have to raise the overhead charge to the remaining patients. the results or consequences of a medical intervention can be called its medical and economic outcome. this includes changes in life expectancy and the state-of-health of a patient cohort or population. the evaluation is based on a comparison of alternative treatments, including non-treatment. the medical benefits are measured by different parameters, within life expectancy and quality of life are most important. other 381 economic appraisal as a basis for decision making in health systems medical outcome measures include progression of disease, patient compliance, frequency of complications and adverse events, etc. the methods of economic evaluation in order to ensure the rational use of national income and resources, three basic types of evaluation were developed: • cost-benefit analysis, • cost-effectiveness analysis, • cost-utility analysis. there are variations as well: cost-minimization analysis, cost-consequence analysis, and cost-of-illness analysis. but their potential to support decision making effectively is rather limited. quality-of-life studies are very important to describe the burden of illness or – in case of an intervention – the improvement of quality of life from the patient’s point of view (table 1). table 1. types of study and goals 382 health systems and their evidence based development type of study goal cost-minimization analysis determine the least expensive intervention strategy for accomplishing the same medical outcomes. cost-effectiveness analysis determine the more efficient intervention strategy for accomplishing the same type of medical results in terms of cost per medical outcome measures (cost per life years gained). cost-utility analysis determine the more efficient intervention strategy for accomplishing the same type of medical results in terms of cost per constructed summarizing unit of outcome (cost per quality-adjusted life years). cost-benefit analysis assessment in money terms of whether an intervention strategy is efficient, i.e. worth doing, and comparison with alternative intervention strategies to determine which is ‘most’ efficient. cost-consequence analysis determine a listing of the medical and economic consequences of alternative interventions used to indicate their consequences without summarizing. cost-of-illness determine of the cost of illness used to indicate the need for treatment or the potential economic benefits from improved intervention strategies. quality-of-life study relative assessment of intervention strategies regarding patient health outcome. the health outcome is measured by disease specific health status parameters or general quality of life instruments. cost-effectiveness analysis cost-effectiveness analysis (cea) is a practical way of assessing the usefulness of public projects. in usa, cea is required by law and regulation throughout the federal government to decide among certain alternative policies and projects. it has been recently required in federal regulations designed to protect human health, safety, or the environment. cost-effectiveness analysis is the process of using theory, data and models to examine both problem’s relevant objectives and alternative means of achieving them. it is used to compare the costs, benefits, and risks of alternative solutions to a problem and to assist decision-makers in choosing among them. ultimately, cea consists of methods for evaluating vectors of measures. cost-effectiveness analysis is not limited to only one specific outcome effect. an intervention-specific group of effects may be used, too. in general, the various medical outcome effects of a treatment cannot be summed up like cost figures. this aggregation necessitates complicated procedures and (potentially problematic) evaluations of the multiple outcome effects of interventions. cost-benefit analysis in a cost-benefit analysis (cba) all elements on the input side as well as on the output side have to be measured in terms of money and/or converted to money where costs are not directly observable (value of a life). the first cba in health care was possibly conducted by sir william petty in london in 1667. he tried to show the impact of fighting against plague. he found out that 1 £ invested gained 84 £. the value of a life was calculated on the basis of a slave price (4). at that time cbas were primarily conducted from a society‘s viewpoint. using this perspective we are interested to improve welfare of society. there have been a lot of discussions and theories how to define welfare and how to measure it. one important theory says that an alternative is better only when all the losers are compensated by the winners and there is still a net saving (potential pareto-optimum). we also have to keep in mind those beneficiaries and payers (investors) must not be the same. if we have a tax funded health care system (nhs) the societal viewpoint can be helpful. in the case of a contribution funded 383 economic appraisal as a basis for decision making in health systems health care system, it‘s only the payer’s perspective that really counts. the health insurance does not care for the pension funds problems. whether something is perceived as „useful”, depends on the objectives and guiding principles of that person / institution who makes the evaluation / judgment are different. e.g. in germany one day in the hospital costs between 17 dm (patient‘s view) and 600 dm (sickness fund’s view). therefore, there is not one single form of cba, it is rather a complex combination based on the perspective taken, and the cost elements included (figure 2). cost-benefit analysis is not limited to one type of outcome effect. the results of the evaluation may be presented as an excess of benefits over costs or as an incremental ratio of benefits to costs (see decision rules). in the first case the result should be a positive number, in the latter case, it should be a number greater than 1. otherwise costs would exceed benefits. with a costbenefit analysis absolute efficiency can be measured. figure 2. types of economic evaluation by type of analysis, viewpoint and effects included (5) source: bombardier c and eisenberg j (1984). in glick h, economic analysis of health care, 2.21.03, available from http://www.uphs.upenn.edu/dgimhsr/intec203.pdf the weak spot of cost-benefit analysis is found in its intention to express all the outcome effects of a medical intervention in monetary terms. this forces evaluation of medical and social aspects, human life, quality of life, etc. in monetary units. the sphere of reference is the entire economy. cost-benefit analysis requires the most comprehensive information and is therefore typically a very large-scale project. 384 health systems and their evidence based development multi-dimensional analyses and cost-consequence of interventions which cannot be evaluated monetarily classify the outcome effects into medical, social and economic dimensions and register them by description only. there is no attempt made to aggregate all of the dimensions into one unit. quality of life analysis generally speaking, quality of life is a measure of the degree of satisfaction with living conditions. here we refer to health-related quality of life (figure 3). quality of life is not an operational measure. it must be described in terms of relevant dimensions and measurement scales. the dimensions are defined according to the dimensions of health. the who in its 1948 definition describes health as the condition of ‘total physical, psychological and social well-being and not as the lack of illness and frailty’. the three dimensions physical activity, mental health and social interaction together form the nucleus of health related quality of life. the quality of life analysis covers those input and outcome elements of a medical intervention which are relevant for the patient’s ability to live a life unrestricted by health problems. ‘costs’ are considered as far as they are reflected in the patient’s quality of life (for example, an adverse effect on free-time activities, sexual life, ease of movement); ‘benefits’ are the advantages and improvements achieved within the same framework. direct and indirect money costs are ignored. consequently, such analyses are not economic evaluations in the sense of efficiency assessment. the effects of treatments on the quality of life cannot be measured directly. only partial dimensions and their respective indicators can be determined and measured directly. a generalized measure of quality of life which covers all health-related problems does not exist. which dimensions of quality of life are relevant for which indications, and which mixture of standardized or disease specific instruments are used for measurement, depends on the clinical picture, and on the pragmatic limitations of the outcome study. to select an appropriate measure of quality of life analysis the following choices might have to be made: 1st choice: standardized or non-standardised assessment: quality of measurement outcomes and ease of interpretation 2nd choice: comparison with outcomes of other diseases: global measure, or disease specific measure needed? age and/or sex specific? iq requirements to be taken into account? 3rd choice: acceptability: instrument has been used in previous evaluations; burden to the interviewee; burden to the interviewer 385 economic appraisal as a basis for decision making in health systems 4th choice: method of administration: direct observation needed/possible; face-to face interview; telephone interview; self-administered questionnaire 5th choice: length and cost of administration 6th choice: method of analysis and complexity of scoring 7th choice: presentation of data and usefulness to decision-makers: interpretation of data; degree of certainty figure 3. the principle of quality adjusted life years unfortunately, there is a trade-off between comparability across diseases and the ability to detect even minor changes in different diseases. depression might be very important in rheumatic arthritis and cancer but no that issue in the case of a broken leg and confinement to bed. here the impact of reduced mobility would be more important. standardized tools like sf 36 might not be first choice when we are aiming at detecting small changes. an essential aspect of quality of life analysis is the fact that the evaluation of medical outcome effects are generally not derived from accepted medical endpoints (e.g. blood pressure) but made by the patient him/herself by self-assessment a subjective view. these measurements are however supplemented in areas where the therapeutic progress is of a qualitative nature (i.e. suffering and/or pain relief, improvement in ease of movement, or subjective sense of well-being of the patient). the quality of life analysis identifies more efficient intervention strategies only if it measures the medical target and if costs are equal. 386 health systems and their evidence based development cost-utility analysis utilities are measured for various possible health states. this can be done by asking patients who are in that particular health state at the time of measurement or by describing health states to subjects who may or may not have had personal experience of the health state being measured. the health state utility is a cardinal number, usually between 0 and 1.0, associated with a particular health state. the conventional way of using these utilities is to convert them into quality-adjusted life-years (qalys). this is done by multiplying the utility value by the years spent in that health state. for example, 10 years in a health state with a utility value of 0.5 would result in 5 qalys (i.e. equivalent to 5 years of perfect health). balancing or weighting of target effects is needed; for example with respect to life expectancy and quality of life. there may be a trade-off, i.e. a higher life expectancy implies a lower quality of life. cost-utility analysis determines the effects of alternative therapies for each target parameter, and then rates them according to the degree of preference on a dimensionless scale, e.g. an ordinal scale from 0 to 1. the effects of each intervention strategy are classified according to their importance, and then they are attached to a onedimensional number standing for the level of utility. a special type of utility analysis is widely accepted, in which utility is measured by quality-adjusted life-years (qalys) gained. this outcome measure may be used in a multi-dimensional cost-effectiveness analysis, which looks into the changes in ‘life expectancy’ and ‘quality of life’ and costs involved. the final result of this analysis is a statement about the cost of gaining one additional quality-adjusted life-year through the use of a medical intervention. cost of illness study cost-of illness studies focus on the general costs of a disease to society. such studies are valuable to indicate the burden of illness by measuring the extent of resources lost due to illness. 387 economic appraisal as a basis for decision making in health systems decision rules: how to determine efficiency? the goal of any health economics evaluation is to determine efficiency. we can look at efficiency from different perspectives: • if it is impossible to make any person better off without making someone else worse off, an allocation of factors of production is pareto efficient. that is from more holistic viewpoint. • if the goods and services produced exactly what consumers want, an allocation of factors of production is allocatively efficient. • if the goods and services are produced for the lowest possible cost, an allocation of resources is productively efficient. this is also referred to as technical efficiency. • product applications or intervention strategies which achieve a given health outcome at the lowest level of resource utilization are called costefficient or economical. • product applications or intervention strategies which generate the best possible outcome or goal achievement for a given resource input are called efficient or most productive. that is output-efficiency. most evaluations in outcomes research are done from the view of productive efficiency. two fundamental options are available: ratios of costs and benefits, and differences, i.e. subtracting the cost from the benefits. by definition – because costs and benefits have to be both in monetary terms – the later can only be used in a cost-benefit analysis, only. for decision-making purposes data have to be summarized in an appropriate way. there are several indices available that will provide condensed information. the choice of an index has to be guided by two questions, then: • what question has to be answered? 1. would undertaking the project be better than doing nothing? 2. which of two mutually exclusive projects should be undertaken? • what are the strength and weaknesses associated with the different indices? ad 1. in the case of comparing a project to the option of „doing nothing”, cost-benefit analysis is the method of choice, displaying absolute efficiency. 388 health systems and their evidence based development ad 2. both cba, cea and cua are applicable. table 1. ratios of costs and benefits table 2. differences of costs and benefits how to make choices in a cba both a ratio and a net benefit can be calculated. in a cea or cua ratios are applicable, only. comparing two alternatives (a and b) the alternative with the biggest ratio (gross bcr) should be chosen (see figure 4). in this case a would be better because the tan(a) > tan(b). this might not be convincing in any case. sometimes we might expect a minimum effectiveness, 389 economic appraisal as a basis for decision making in health systems cost and benefits are discounted when appropriate. an alternative with a higher bcr is more favourable • gross_bcr > 1 the index is sensitive to enumeration of cost and benefits this ratio is applicable to a cea or a cua as well when benefits are measured in nonmonetary terms, i.e. saved years of life, qol an alternative with a higher gross bcr is more favourable an alternative with a higher bcr is more favourable • net_bcr > 0 gross_bcr benefits∑ costs∑ := net_bcr benefits costs−( )∑ costs∑ := index rules cost and benefits are discounted when appropriate. an alternative with a higher positive net benefit is more favourable • net_bcr > 0 an alternative with a higher net present value (npv) is more favourable • npv > 0 r = discount rate, n = number of years net_benefit benefits costs−( )∑:= net_present_value 0 n i benefits i costs i−( ) 1 r+( ) n∑ = := index rules which is marked by the horizontal line parallel to the cost axis, or a solution within a budget limit (blue line). when solutions are ruled out by setting a minimum threshold, this is called fixed effectiveness approach. whereas ruling out by a budget limit is called fixed cost approach. this makes the rules more flexible. nevertheless, economists prefer an even closer look. sometimes it is important to understand what are the additional cost and the additional effects when comparing two alternatives. this is called incremental analysis. figure 4. decision rules using cost-benefit, cost-effectiveness or cost-utility ratios there are two notions: incremental and marginal analysis. these are no synonyms. incremental analysis is the broader term and includes marginal analysis. marginal analysis looks at the extra cost of extra effects in the same programme; incremental analysis looks at the differences between programmes. decision based on average values (ratios) can be misleading. a famous example shows the importance of a marginal analysis. neuhauser and lewicki (6) undertook a cost-effectiveness analysis (model calculation) to determine whether performing all six screening tests was a reasonable strategy. in the mid-1970s, the american cancer society recommended that, when attempting to detect cancer of the colon, each stool sample should be tested six times. therefore, the first part of a sample would be tested. if the result were positive, the subject would go onto have further confirmatory tests and, if necessary, treatment. if the test were negative, the second part of the sample would be tested. if this tested positive, the subject would have further confirmatory testing and, if here, for ease of exposition): negative, the third part of their sample would be tested, and so on. a screened person would be confirmed as negative only after all six parts had tested so. neuhauser and 390 health systems and their evidence based development cost-effectiveness analysis decision rules: choose the alternative • with the highest ratio • with a requested minimum effectiveness (fixed effectiveness approach) • with a requested maximum cost (fixed cost approach) decision rules: choose the alternative • with the highest ratio • with a requested minimum effectiveness (fixed effectiveness approach) • with a requested maximum cost (fixed cost approach) cost e ff e ct iv e n e ss a b lewicki analyzed this policy based on the following (realistic) assumptions (simplified here, for ease of exposition): (1) a population of 10,000 amongst which it is known (from epidemiological studies) that there are 72 cases of cancer; (2) each test detects 91.67 percent of cases undetected by the previous test (the first test will, therefore, detect 91.67 percent of cases; the second test will detect 91.67 percent of the 8.33 percent of cases left undetected by the first test, and so on). the authors estimated the cost of guaiac cards to be $4 for the first test and $1 for each subsequent test. thus, as is shown in table 3, about 66 of the 72 cases are detected after the first round of testing, the cost of this being us$1175 per case detected. the second round of testing ensures that almost all cases are detected at an average cost of us$1,507 per case detected. six rounds of testing capture all cases at a cost of us$2,451 per case detected (table 3 and table 4). table 3. cases detected, cost and cost-effectiveness of guiac test (5) table 4. results from an incremental analysis of guiac test (5) source: bombardier c and eisenberg j (1984). in glick h, economic analysis of health care, 2.21.03, available from http://www.uphs.upenn.edu/dgimhsr/intec203.pdf a more revealing way to look at the data, however, is in terms of the extra costs incurred and the extra cases detected by each successive round of testing, as in table 2. thus, two rounds of testing lead to extra 5.5 cases detected 391 economic appraisal as a basis for decision making in health systems no. of tests total cases detected total costs (uss) average costs (us$) 1 65.0465 77,511 1175 2 71.4424 107,690 1507 3 71.9003 130,199 1811 4 71.9385 148,116 2059 5 71.9417 163,141 2268 6 71.9420 176,331 2451 no. of tests incremental cases detected incremental costs (us$) marginal costs (us$) 1 65.0465 77,511 1,175 2 5.4956 30,179 5,492 3 0.4580 22,509 49,150 4 0.0382 17,917 469,534 5 0.0032 15,024 4,724,695 6 0.0003 13,190 47,107,214 compared with one round of testing at an extra cost of us$30,179, or us$5492 per extra case detected. having six rounds of testing rather than five ads very little in terms of cases detected at an extra cost per extra case detected of over us$47million. discounting of cost and benefits alternative projects costs and benefits may occur at different points in time. differences in the timing of costs and benefits are most obvious in preventive measures. an investment made today will yield most of its effects in the future. to make money flow comparable, the money has to be adjusted at one point in time – this is called calculating its present value. the process of transferring the values of any effect in one year to the corresponding values in a different year is called discounting. there are two reasons why discounting is appropriate: 1. marginal rate of time preference. people and authorities prefer benefits sooner than later and the reverse for costs. the strength of the time preference can be indicated by the size of the discount rate. 2. opportunity cost of capital. to fund programmes, money has to be taken away from other uses (in case of a public programme, from the private sector). in the private sector the money could have been invested and produced benefits. the benefits lost are indicated by the size of the discount rate, then. the more productive the money would have been, the higher the rate (7). a discount rate is a number relating the value of one year to the value in the next or previous year. discount rates may often be thought of as interest rates. at a discount rate of 10% e 1 today is equivalent to e 1.1 next year or e 0.91 one year ago. the effect of discounting on the preferability of an alternative is very high (see figure 5). a comparison of two projects to fight malaria (8) showed that eradication seems to be less costly than controlling malaria. the ranking changes when the discount rate is higher than 12% (see figure 5). 392 health systems and their evidence based development figure 5. the effect of discount rate on the ranking of two projects (8) source: cohn e, assessing the costs and benefits of anti-malaria programs, public health 63:1086, december 1973 and amer. j. trop med hyg, 1972. the lower the discount rate, the better are projects with benefits that are far in the future. therefore the choice of the appropriate discount rate is an important issue and gives way to manipulation. to prevent manipulation by selecting a „useful” discount rate, governments of various countries have set discount rates for the evaluation of public investment projects. in the usa the rate for public investment projects is 10%, in the netherlands 5%. this is based on the long-term rate of interest for government bond issues. in the various international guidelines on the economic evaluation of health services, the interest rates for discounting are usually set from 3 to 6%. the only convincing way to control for manipulation is sensitivity analysis, where the effect of the discount rate on the outcomes and the ranking of alternatives are shown. how to perform an economic appraisal? as described above, health economics tries to answer the question by what criteria the worth of an object can be evaluated. how do we get the data needed for economic appraisal? economic evaluation has to satisfy the scientific principles of unbiased research (9). therefore all principles and methods of scientific research are applicable. there is no specific way of setting up scientific study designs except the consideration of economic principles and the393 economic appraisal as a basis for decision making in health systems ories. economic appraisal therefore benefits from developments in different research areas. in getting most useful data, techniques of experimental design are important. statistical methods are needed to estimate program effects from diverse available data. once these and other disciplines in evaluation have yielded best estimates of program effects, the stage is set for cost-benefit analysis. increasingly, program evaluators are not satisfied just to know that certain effects exist at specified levels of statistical significance. they also demand to know how various effects should be valued and how the different valued effects should be aggregated to facilitate program decisions. these decisions include: (1) comparing all the good effects of programs (benefits) with all their bad effects (costs and dis-benefits) to judge whether it is better to implement or not to implement a program; (2) determining which of alternative versions of programs are best; and (3) deciding what collection of programs or projects constitutes the best expenditure within a set, overall budget limit. these tasks are the main roles of cost-benefit analysis. techniques of operations research and systems analysis may be invoked to ensure that the cost-benefit analysis is covering the full range of relevant alternatives. organizational analysis and political science also play vital roles: (1) helping to guide the appropriate assignment and aggregation of values for the cost-benefit analysis; and (2) when the cost-benefit analysis is completed, applying it suitably within complex organizational and political structures” (10). stages in economic evaluation drummond (11) describes the process of planning an economic evaluation. he distinguishes three different areas that are connected by various interfaces. • area of technical appraisal this is the description in terms of medical/technical criteria how a technique or product performes. it is the basis of the economic appraisal. • area of economic evaluation this is the actual evaluation. it is divided into the following steps: 394 health systems and their evidence based development deciding upon the study question, statement of alternatives to be appraised, assessment of costs and benefits of the alternatives, adjustment for timing and uncertainty, decision rules. • area of decision-making this is the where decision criteria, alternatives to be appraised and timing issues are determined. those links are important. they make sure that the outcomes are relevant to the decision-maker. the research question the general objective of the evaluation study is expressed by the research question. a statement of the respective research question should be specified with respect to: • the types of medical interventions or intervention strategies compared; • the patient population considered; • the range of medical resource inputs, clinical outcomes and economic consequences analyzed. the study population the study population should be representative for the population to whom the medical intervention strategy is applied in clinical practice, i.e. the target population. depending on the intervention and its indication, this will be patients with a specific disease, stage or duration of disease or with a certain medical history, risk or symptom profile. often cohorts defined by age and sexes are analyzed. in complex studies the population will be defined by combinations of characteristics or strata. the effectiveness of an intervention strategy will often depend on how narrower the indication and the corresponding study population is defined. the study perspective in the field of health care there is a multitude of institutions and persons who are responsible for decisions concerning the availability and application of medical interventions. 395 economic appraisal as a basis for decision making in health systems the study perspective refers to the viewpoint from which the analysis is performed. typically, four major viewpoints can be taken: 1. society 2. third party payers (government, health insurance, and health maintenance organizations) 3. health provider (the hospital, physicians and other providers) 4. patients the perceptions of the study questions, the information needs and the evaluations differ according to each viewpoint. what is cost-effective for one target group (e.g. from a hospital point of view), may not be cost-effective for a third party payer. costs and consequences that are extremely relevant to one target group may be ignored by another group. for example the income of a health care provider is a cost to the health insurance, a benefit from one perspective is a cost from the other, and vice versa. the money costs of one day in hospital seen from the patient’s perspective is his co-payment, whereas a health insurance perceives it’s per day rate, and public hospital funding authorities see primarily their subsidies. the costs per hospital day to society may be more or less but will certainly be different. each of these points of view will be examined below: 1. the societal perspective: from this viewpoint an evaluation would examine all social, medical and economic effects of a new medical technology on all parts of society. this means a wide array of health outcomes and economic consequences incurred in hospital care, outpatient care, long-term care, home care, nursing homes etc. regardless of when they incur or who pays for them. moreover, a broad range of other ethical and social consequences might be examined. new medical intervention strategies should be introduced and reimbursed if they improve social welfare. not all new medical technologies warrant such a comprehensive assessment. extremely expensive technologies, whose costs may shift relatively large amounts of resources from one area of the health sector to another, may justify such comprehensive study. 2. the perspective of the third party payer: government agencies, public and private health insurance, and health maintenance organizations make decisions about the reimbursement or non-reimbursement of medical technologies. therefore these institutions are a prime target group of economic evaluation studies. in study practice many studies are performed from the more limited perspective of the third party payer. 396 health systems and their evidence based development often estimations of the annual budget impact are asked for. information on the financial impact receives high attention especially in hmo and other managed care environments. third party payers usually are not too much interested in indirect costs. 3. the perspective of the health care provider: the decision-makers on a micro level, such as physicians in outpatient care or hospital decision makers, often make their decisions under cost containment pressures and budget restrictions. their perspective and information need generally concentrate on the impact of new intervention strategies on their budgets, and not on costs to other providers or to the society. the consequences of intervention strategies in other areas of the health care system are often ignored. for example savings in the outpatient sector may have unanticipated economic consequences in the hospital sector and vice versa. generally the economic consequences of choosing medical intervention strategies on the national economy at large are often ignored. gps or hospital decision makers generally do not regard indirect costs (losses or gains in production). the perception of a disease problem is rather focused on patient cases than population oriented. 4. the patient’s perspective: from the viewpoint of the patient, costs that are not reimbursed and are out of pocket are most important. costs borne by third party payers are widely ignored. for example, a co-payment for medication in out-patient treatment may represent higher out-of-pocket expenditures to the patient than fully reimbursed in-patient treatment. the intervention related to quality of life is an important issue to patients, as well as the costs incurred due to the need for childcare or housekeeping help while receiving treatment. these costs have to be taken into account from the societal perspective too, but are ignored from other viewpoints. data sources many times there is no chance to run a study quickly enough to answer the information needs of decision-makers. most data are coming from secondary statistics and expert opinion, then. health economists are primarily interested to compare a new technology with the existing standard in an every day situation. economic evaluation can be carried out on an empirical basis (primary research design) or on a modeling basis (secondary research design). a highly appreciated design is a prospective study that proves effectiveness in a target population. this might be time consuming and costly, too. in specific situations where time for a follow-up would be very long, and data 397 economic appraisal as a basis for decision making in health systems of routine care are available, a retrospective cohort study might be appropriate as well. quality assurance at times where economic evaluations become more and more important, not only the underlying principles and theories are challenged but also the quality of studies is under debate. figure 6 shows how different agents are working together. figure 6. the network of quality assurance academics believed in unbiased studies only when sponsors (industry mostly) had no influence on the designs and the publication of study results (thus preventing publication bias, when results are not positive). at the same time representatives of governments and reimbursement authorities felt insecure and not well prepared to understand economic appraisal. this led to the development of guidelines (australia was first), which goal was to create a kind of „cookbooks”. as a consequence many things were regulated: the cost and benefits to be measured, the discounts rate, the quality of life measurement etc. unfortunately, this might be contra-productive in a situation where a very new and innovative technique (drug, intervention, screening strategy) has to be evaluated. 398 health systems and their evidence based development whereas the cookbooks (guidelines) tried to standardize the body of knowledge – instead of encouraging a proper education of evaluators – the standardizing of the process has a great impact on the quality delivered. aside of all the efforts to control the quality of both the body of knowledge and of the production processes, every reader or decision-maker can make his quality, check by following the checklist of drummond. his „ten commandmends” of good appraisal practice suggest to judge the following items (12): 1. was a well-defined question posed in answerable form? did the study examine both costs and effects of the service(s) or programmes)? did the study involve a comparison of alternatives? was a viewpoint for the analysis stated and was the study placed in any particular decision-making context? 2. was a comprehensive description of the competing alternatives given? (i.e., can you tell who? did what? to whom? where? and how often?) were any important alternatives omitted? was (should) a donothing alternative (be) considered? 3. was there evidence that the programmes’ effectiveness had been established? has this been done through a randomized, controlled clinical trial? if not, how strong was the evidence of effectiveness? 4. were all the important and relevant costs and consequences for each alternative identified? was the range wide enough for the research question at hand? did it cover all relevant viewpoints? (possible viewpoints include the community or social viewpoint, and those of patients and third party payers. other viewpoints may also be relevant depending upon the particular analysis). were capital costs, as well as operating costs, included? 5. were costs and consequences measured accurately in appropriate physical units? (e.g., hours of nursing time, number of physician visits, lost workdays, gained life-years)were any of the identified items omitted from measurement? lf so, does this mean that they carried no weight in the subsequent analysis? were there any special circumstances (e.g., joint use of resources) that made measurement difficult? were these circumstances handled appropriately? 6. were costs and consequences valued credibly? were the sources of all values clearly identified? (possible sources include market values, patient or client preferences and views, policy-makers’ views and health professionals’ judgements). were market values employed for 399 economic appraisal as a basis for decision making in health systems changes involving resources gained or depleted? where market values were absent (e.g., volunteer labour), or market values did not reflect actual values (such as clinic space donated at a reduced rate), were adjustments made to approximate market values? was the valuation of consequences appropriate for the question posed? (i.e., has the appropriate type or types of analysis – cea, cba, cua – been selected?) 7. were costs and consequences adjusted for differential timing? were costs and consequences which occur in the future ‘discounted’ to their present values? was any justification given for the discount rate used? 8. was an incremental analysis of costs and consequences of alternatives performed? were the additional (incremental) costs generated by one alternative over another compared to the additional effects, benefits or utilities generated? 9. was a sensitivity analysis performed? was justification provided for the ranges of values (for key study parameters) in the sensitivity analysis employed? were study results sensitive to changes in the values (within the assumed range)? 10. did the presentation and discussion of study results include all issues of concern to users? were the conclusions of the analysis based on some overall index or ratio of costs to consequences (e.g., cost-effectiveness ratio)? if so, was the index interpreted intelligently or in a mechanic fashion? were the results compared with those of others who have investigated the same question? did the study discuss the generalizability of the results to other settings and patient/client groups? did the study allude to, or take account of, other important factors in the choice or decision under consideration (e.g., distribution of costs and consequences, or relevant ethical issues)? did the study discuss issues of implementation, such as the feasibility of adopting the „preferred” programme given existing financial or other constraints, and whether any freed resources could be redeployed to other worthwhile programmes? 400 health systems and their evidence based development exercise: health economics task 1: health care system and efficiency after introductory lecture students will participate in small groups in order to work out the goals of health care systems. the working process will follow a brainstorming approach using meta-plan-technique. based on the existing permanent shortage of resources, possible options of managing health care systems according to the identified goals will be discussed. advantages and disadvantages of the different solutions will be evaluated. efficiency as a prerequisite for an appropriate health care system will be analysed thoroughly and described according to the theoretical background of economics. each group will nominate a person who will present the results in a plenary session, then. in a final discussion the results will be evaluated by the teachers. the assumed time span is about 1.5 hour. task 2: economic evaluation and techniques the work will continue again in small working groups (up to 5 students). in this exercise the key features of economic evaluation have to be deepened. students will learn how the different evaluation techniques can be used best. therefore the process of setting up an evaluation has to be studied, and depending on the study question, the appropriate outcomes, the proposed design and the evaluation technique have to be selected. furthermore basic skills like discounting (and selecting the appropriate discount rate) and choosing a decision criterion have to be trained. to do so, financial and mathematical exercises have to be solved (calculated). emphasis has to be laid on the understanding how the choice of a discount rate will eventually change the ranking order of efficient solutions and possibly prefer health effects in younger people. for this exercise additional 3 hours are requested. task 3: health economic publications in this exercise students will learn how to judge the quality of health economic publications. students will work in small groups and prepare a quality check of different publications of different quality that are delivered by the teachers. the result of the judgement will be presented in a plenary session and evaluated by the teachers. it is recommended to use the guidelines from m. drummond. this exercise requires 1.5 hour. 401 economic appraisal as a basis for decision making in health systems references 1. sackett d, william m c rosenberg, j a muir gray, r brian haynes, w scott richardson. evidence based medicine: what it is and what it isn’t. bmj, jan 1996; 312: 71-72. 2. zitter group. presentation in a workshop outcomes & disease management of diabetes in chicago, 1996. 3. coast j. et al. in: priority setting: the health care debate, wiley, 1996. 4. thompson ms. benefit-cost analysis for program evaluation, sage publications, beverly hills, london, 1980. p. 1. 4. bombardier c and eisenberg j (1984). in glick h, economic analysis of health care, 2.21.03, available from http://www.uphs.upenn.edu/dgimhsr/intec203.pdf 5. neuhauser d, lewicki am. what do we gain from the sixth stool guaiac? n engl j med 1975; 293: 226-8. 6. thompson ms. benefit-cost analysis for program evaluation, sage publications, beverly hills, london, 1980. p. 28. 7. cohn e. assessing the costs and benefits of anti-malaria programs, public health 63: 1086, december 1973 and amer. j. trop med hyg, 1972. 8. drummond m, stoddard gi, torrance gw. „most scientific work benefits from careful thought in the design stages, and economic appraisal is no exception”. methods for the economic evaluation of health care programmes, oxford university press, oxford, new york, london, 1987. 9. thompson ms. benefit-cost analysis for program evaluation, sage publications, beverly hills, london, 1980. p. 2-3. 10. drummond m. principles of economic appraisal in health care. oxford university press, oxford, new york, london, 1987. p. 7. 11. drummond m, stoddard gi, torrance gw. methods for the economic evaluation of health care programmes, oxford university press, oxford, new york, london, 1987. p. 18. recommended reading • gold mr, siegel je, russell lb, weinstein mc, ed. cost-effectiveness in health and medicine, new york, oxford university press, 1996. 402 health systems and their evidence based development 403 quality improvement in health care and public health health systems and their evidence based development a handbook for teachers, researchers and health professionals title quality improvement in health care and public health module: 2.9 ects (suggested): 0.25 author(s), degrees, institution(s) viktorija cucic, md, phd, professor emeritus address for correspondence insitute of social medicine, school of medicine, belgrade university dr suboti}a 15, 11 000 belgrade serbia and montenegro tel: +381 11 643 830 fax: + 381 11 659 533 home: ^ingrijina 13, 11 000 belgrade, serbia e-mail: ecucic@eunet.yu keywords health system; health care; quality improvement; evidence-based medicine (health care); determinants of health; quality indicators; standards; criteria; practice quidelines; tools for quality; models; quality cycle; change, public health expert learning objectives at the end of this topic, the students should be familiar with: • the difference between quality assurance and quality improvement approaches; • system approach to quality improvement; • key principles of quality improvement; • characteristics and roles of quality indicators, standards and practice guidelines; • tools and models of quality improvement; and • the importance of the role of public health expert in development and implementation of quality improvement policies, strategies and practical approaches at different settings. abstract the specialization of public health and its role in developing and applying the quality improvement techniques is emphasized in this module. quality is defined as a multi-dimensional phenomenon which demands specific organizational changes in order to be improved. the module explains the differences between the traditional quality assurance approach and quality improvement approach. it explains the basic principles for quality improvement, tools for quality, models and tasks for the public health experts. teaching methods teaching methods include: lectures; group discussion with topics what is quality of care, and what is the role of a public health expert in quality improvement; visit to health care institutions and group discussion with staff; seminars-practice guidelines and the role of public health expert; exercises-which data can tell us something about quality. practical experience with some tools for quality. specific recommendations for teacher stress the importance of specific skills that a public health expert needs to possess in order to contribute to the quality improvement in health care. it is recommended that the module will organize within 0.25 ects credits, out of which one third will be under teacher supervision, and the rest is individual data collecting and presentation preparing. assessment of students oral exam (the difference between quality assurance and quality improvement approaches, indicators, standards, tool, models, etc.).written report on the health care quality characteristic of one health organization using efqm model (need assessment).written report about needed data for quality improvement policy at the local level or health care organizational level. 404 health systems and their evidence based development quality improvement in health care and public health viktorija cucić quality improvement in health care is a worldwide trend and considerable efforts have been made both on national levels and on the international one. experts in almost all medical branches are seeking adequate definitions, methods and approaches to quality improvement in their respective fields in order to fulfill their professional obligations and satisfy in the best possible way the users-patients’ expectations, as well as of all others concerned upon whom the quality depends. public health experts have a twofold task in this respect. on the one hand, they are obliged to develop adequate approaches for the quality improvement in their own sphere, and on the other, the development of those approaches represents in general a domain where a special engagement of public health professionals is expected. there is a various interest in the area of public health for the health care quality. firstly, the overall philosophy of public health is based on health as a fundamental human right and obligation of the community to achieve it through common efforts. this includes interest in equal possibilities in health and health prevention, i.e., accessibility of health care of certain quality for all, disregarding any differences that may exist among people or territories. dealing in studies of health determinants, the public health also deals with health service and its influence upon improvement of health status of groups and overall population. next, the role of public health is «to contribute to health of the public through assessment of health needs policy formulation and assurance of the availability of services» (1). availability of services can also be understood as availability of effective, eficient, acceptable, accessible and relevant health services. these are in fact dimensions of a health care quality, as recognized by one of the quality theoreticians maxwell (2). the new public health strategy, adopted in 2002 by the european union, promote and bring together activities in the member states in the fields of evidence-based medicine, quality assurance and improvement, appropriateness of interventions, and health technology assessment (3). finally, in reviewing the reasons mentioned in literature as those requiring the activities aimed at quality improvement, one can conclude that a detailed analysis of those reasons, their documentation and measurement is in fact in the domain of a public health specialist. thus, referring to the european union, swow mentions the following reasons (4): • unsafe health system; • unacceptable levels of variations in performance, practice and outcomes; • ineffective or inefficient health care technologies; • users dissatisfaction; • unequal access to healthcare services; • waiting lists; • unaffordable costs to society; • waste from poor quality. the position and role of the health care service as a health determinant is mentioned with much controversy and extreme views. on the one hand is a radically negative approach founded by mckeown (5) and ilich (6) who point out that the role of health service in achieving the health improvement is minimal, and that all changes accomplished in improving the health of population were actually conditioned by changes in other determinants which are predominantly social and economic, not as influenced by the health service. on the other hand, we have an approach which could be called strictly medical, in which a better health condition is directly linked to the development of a specialized health service along with the use of high technology. without diminish the influence of numerous other determinants, somewhere in between these two views are those who claim that «health care itself (is) an important and often underestimated determinant of health« (7). certain researches prove such reasoning. thus the research published by the national institute for health 1990 suggest that, from the viewpoint of the contribution to the health status of a population, the healthcare services and interventions actually differ in as much as they are or are not evidence-based. analysing the services in the usa (8), only 21% of all diagnostic and therapeutic services are evidence-based. contrary to this, analysing the surgery services states that these are evidence-based in 95 % cases (9). 405 quality improvement in health care and public health the literature also presents numerous proofs which point to the positive influence that the multitude of primary and secondary prevention programmes have onto the improvement of health status and prolongation of life, indicating that early detection and treatment of disease gain significant survival and quality of life outcomes (e.g., screening for cervical cancer, immunisation programmes, hiv therapy, and so on). one can thus safely state that the contribution of the health service to the health status is all the more evident as it is of better quality. the quality health care is the one which is (10): • doing the right things (what) • to the right people (to whom) • at the right time (when), and • doing right things right first time development of quality concept there is much knowledge gathered on quality in health care and methods of its improvement. rich literature evidences the long and persistent quest for objective assessments in this very complex sphere, the functioning of which depends on numerous different partners. we have travelled a long way from the traditional approach such as quality assurance to the modern one, such as the total quality management (tqm), which includes, according to uehara (11): • quality control cycles (qc), • continuous quality improvement (cqi), • evidence-based medicine, • critical pathways, • practice guidelines, • customer satisfaction surveys, and • performance indicators. along the way the philosophy, concepts and methods have been changing and it seems that the process is not completed yet. 406 health systems and their evidence based development indicators, standards, criteria, guidelines the development of methods and tools to measure quality and performance in health care seems to be a fundamental component of improving quality in health care. search for the «quality indicators» is a common request by all those interested in any way for the quality, from investors, policy makers, managers, professionals, to public opinion. the indicator is expected to have »ability«, to indicate problems in health care which have to be solved by various quality improvement methods. there are numberless definitions of indicators. so, jacho (12) defines it as »a measure used to determine in a period of time whether the functions of the process and outcome were performed«. while mc glynn wrote: »an indicator is a measurable item of care which focuses upon some aspects of structure, process or outcome« (13). there are various types of indicators: • activity indicators – measure the frequency with which an event occurred (e.g., children immunisation), and • performance indicators, which should serve in formulating the appraisal of the prevention process. indicators may be defined for different levels, form the national to the level of a particular health institution. however, each country has to develop its own indicators. »it appears that indicators developed for health system in one country should not be transferred directly to another country, but it is possible to use indicators from other country as a starting point to produce own indicators« (14). today it is important to use high level performance indicators (15), which are presented below: health improvement indicators: standardised all cause mortality ratio (aged 15-64), deaths from all circulatory diseases, suicide rates. 407 quality improvement in health care and public health fair access to care indicators: surgery rates, composite, consisting of age standardised elective rates for: • coronary artery bypass grafts, • hip replacement (age 65 or over), • knee replacement, • cataract replacement, size of inpatient waiting list per head of population. efficiency indicators: case mixed adjusted length of stay. effective delivery of appropriate health care: early detection of cancer, composite, consisting of: • % of target population screened for breast cancer, • % of target population screened for cervical cancer, mental health in primary health care • volume of benzodiazepines. health outcome indicators: • contraception below 16 aged, • decayed, missing and filled teeth in five year olds, average number, • adverse events – complications of treatment, • infant mortality rate, • potentially avoidable mortality (from peptic ulcer, fracture of skull, asthma etc.), • in hospital premature deaths (30 days preoperative mortality rate; 30 days mortality rate following myocardial infarction). there are many benefits of using quality indicators. the most frequent are (14): • allow comparison to be made between practices, over time or against standards, 408 health systems and their evidence based development • facilitate an objective evaluation of quality improvement initiative, • can identify unacceptable performance, and • stimulate informed debate about quality of care. indicators are usually followed by development of criterion of care. the literature defines it in different ways, but generally they refer to »expected level of achievement in regards to which measures of performance and quality can be compared« (12). standard is «the level of compliance with a criterion or indicators». practice guidelines have a particular role in improving the quality and activities concerning their development are ongoing in many spheres. they are defined as: »systematically developed statements to assist practitioner and patient decisions prospectively for specific clinical circumstances, in essence the ‘right things to do’« (14). tools for quality improvement the most notable developmental change in the philosophy of quality in health is shifting the focus of «responsibility» for the quality and emphasizing an almost exclusive responsibility of an individual professional (meaning a physician) from the importance of structural characteristics for the good quality onto the organizational characteristics of the whole health system and the health institutions in particular, as well as to the strong leadership. at the same time, there was a shift from the «control from above» onto the organizational changes which provide conditions for the better quality. in order to get more familiar with and analyse the organizational system characteristics, and in order to describe and depict those characteristics, and with the purpose of proposing solutions for the correction of detected problems it was necessary to create or adopt special tools. one of the tools for quality improvement is the use of a statistical method for collecting, processing and graphic presentation of data on various phases of the constant improvement of quality. wilson classified these according to the purpose they are used for as those serving to (16): • present data on organization (histogram, check sheet) • analyse data (pareto diagram) • note and present convictions or opinions (fishbone diagram or cause and effect diagram) 409 quality improvement in health care and public health application of those tools, according to some authors, can solve 95 % of organizational problems and in that way improve the quality in any organization, including the healthcare one (17). strategies and models strategies, i.e., methodological approaches in improving the quality are abundant in literature, each one following the experience gained in applying it. there are numberless classifications, systematizations, divisions of those steps. one of the latest to be published by overtveit, speaking about ensuring quality in hospitals, mentions the following strategies (18): • increasing resources; • large-scale reorganization or financial reform; • strengthening management; • development of standards and guidelines; • patient empowerment and their rights; • quality management system; • quality assessment and accreditation, internal and external; • total quality management (tqm) and continuous quality improvement (cqi); • quality collaboratives; • re engineering; • quality indicator comparison; • benchmarking; and • risk management and safety. a more detailed analysis of these strategies goes beyond the scope of this module, all the more so as the publication clearly states that there is not a single approach, not one strategy that could be separated from the others according to its efficiency and influence onto the improvement of quality, or any of these could be recommended universally. generally, it is pointed out that there are very few systematic, evidence-based researches which could show how much a strategy or a methodological approach is really effective in improving the quality on a macro-level or on the level of a health institution. there is no evidence to corroborate the claims that certain noted changes are truly the result of a strategy being applied and not for some other reason. 410 health systems and their evidence based development editorial «quality and safety in health care» journal states: »from what we know, no quality improvement programme is superior and real sustainable improvement might require implementation of some aspects of several approaches – perhaps together, perhaps consecutively. we just do not know which to use, when to use them or what to expect« (19). the literature, however, stresses that application of multiple strategies gives better results in improving quality. it actually means that combining several strategies offers better prospects for success than using a single one. such undertakings of combining a larger number of strategies can be found in models for quality improvement. models for quality improvement have also changed and developed the philosophy of quality assurance toward a philosophy of quality improvement, i.e., from »systematic cyclic activity where quality is measured and standards are used» to »continual activities in improving«. the model of a «cycle» belongs to the phase of quality assurance: figure 1. quality assurance cycle (20) 411 quality improvement in health care and public health 1. quality assurance plan 10. follow-up and analysis of change 9. application of solutions 8. proposing solutions 7. problem analysis 2. setting the standards and guidelines 3. quality analysis 4. what can be improved, priorities 5. selection of problems to be improved 6. who will do what while solving the problem this systematic approach identifies the problems by one or another form of internal or external peer review, different activities in overcoming the problem, and initiates corrective activities in order to avoid the similar problems. the model known as raf (regulation, assessment, follow up), developed in the 80’s and adapted several times since then represents a shift from quality assurance approach to the continuous improvement of quality (21). the model integrates three theoretical approaches to create broad conceptual framework. those are: tracer approach, quality assurance and organizational changes. organizational changes are essential for further models of quality management which involve at least the following entities (22): • resources, • activities, • patients, and • outcome or effects. probably the best known is the conceptual quality model the european foundation for quality management efqm, or excellence model (european foundation for quality management, 1999): 412 health systems and their evidence based development l e a d e r s h i p k e y p e results f o r m a n c e people results people p r o c e s s e s policy strategy resource customer results society results the model is based on nine components. analysis of each component at any decision-making level offers a possibility to determine reasons for good or bad quality and basis for suggesting the measures for its improvement. if adequate answers are given to some of the questions asked in this text we could acquire a clear picture of the quality and everything needed to be done in the organization or at national level in order to improve the quality. 1. leadership it is important to learn: • how does the leadership (from national, regional authority to specific programmes or health care organization) demonstrates its involvement in quality management and improvement; • how does the leadership support activities directed towards quality management and improvement; • how does the leadership recognise and award improvement. 2. policy and strategy • how are policy and strategy being developed and implemented in practice (based on relevant information or not); • how are policy and strategy being communicated; • how are policy and strategy being evaluated and changed. 3. people the most important «people« are staff, or all individuals employed in the organization, programme or system being described: • is there any human recourses strategy; • how are skills and capabilities of staff being developed and preserved; • how is the involvement of all staff in quality improvement being promoted. 4. resources beside human resources there are others necessary for the quality. a detailed analysis is needed. these are: financial resources; information; suppliers, material, buildings, equipment; application of technology. 413 quality improvement in health care and public health 5. processes identification of main processes which influence quality is a complex task. primary processes relate to the procedures directly connected with providing health care. those are patient care activities (examination, treatment, discharge, follow up) but also patient information, infection prevention, safety, ethical issues. support processes are necessary for functioning of primary processes. examples include: administration, procurement, cleaning, catering, ect: • how are critical or primary processes being identified; • how are processes being managed, evaluated and improved; • how are innovation and creativity being stimulated; and • how is process change being implemented. 6. customer results here we first have to define who the customers are, what each group expects from a health institution, and then to analyse achievements regarding these. customers can be: patients / consumers (healthy people, people in care); other care providers (partners); providers of services or goods, financiers, etc. different assessment methods for the measurement of satisfaction are usually applied, directly or indirectly. 7. people results as was stated, this refers to the staff and the achievements in relation to staff satisfaction. this satisfaction can also be assessed: • indirectly, when absenteeisam, sick-leaves, percentage of people leaving organization, accidents, complaints, readiness for doing extra work, are being measured • directly, by one of structural methods for assessing satisfaction. 8. society result what is organization’s contribution to the society or community at large. are there any legal or some other impediments which obstructed the contribution of a health institution in a community where it is situated. what are facilitating factors enabling the contribution. 414 health systems and their evidence based development 9. key performance results here it is necessary to describe all the results that should have been realized according to the plan. it is also necessary to compare results achieved in a given situation or level with other results, predefined indicators, standards and criteria. it is necessary to answer: • what is achieved in relation to service objectives and in satisfying the needs and expectations of different stakeholders. • what are financial results and operational results. operational results are: • productivity (admissions, services, length of stay, bed–days), • effectiveness / non-effective actions (effective care, compared to indicators, non planned readmissions, infections, complications, incidences), • efficiency / non efficient actions (staff working hours; time per consultation / procedures, waiting time; cancellations, wrong tests, procedures, unnecessary procedures etc.), • other treatment results. iso model, which is also used in health systems, involves all the entities mentioned in efmq model and some additional areas (23): • management, • measurement, • analysis, and • ongoing improvement. the literature states other models as well which are used to improve quality, along with numerous experiences in applying certain models, but there are quite few researches to prove that application of those models contributes to some lasting changes in the organization. overtveit (24) states that two studies offered clear-cut evidence that tqm approach applied in certain period of time brings an improvement of quality, but that the repeated evaluation, after two years, shows a regression to the former state. 415 quality improvement in health care and public health current state of art in quality improvement and the role of public health professionals diversity, a great number of possibilities and options for research and practical application of models and methods for improving the quality – are the main characteristic of the present state in this field. experts agree that there is a very small possibility that any health system in any community would be able to secure the quality of health care in all its dimensions as defined by maxwell (2) and later by iom (14). experts also admit that there is no strategy to be designated the best and universally recommendable. there are, however, proofs «that some quality methods can be used to increase efficiency and reduce harm to patient« (24). it is also pointed out that there is no possibility to transfer (copy) the policy, strategy or practice of quality improvement from one country to another. each of these components, though based on identical common principles, must carry clear local characteristics and features. these are challenges defining the surroundings in which a public health expert works. to understand how health care quality can be improved it is essential for public health professional to have a framework of the dimensions of health care around which quality can be assessed and improved. a public health expert is expected to get acquainted and to adopt the three key principles of quality improvement (25): • improving the quality of health care implies change; • health care quality is multi-dimensional; • health care quality is a product of individuals working with right attitudes in the right systems and organizations. a public health expert is also expected to have a series of skills needed for the work in this field, such as need assessment skills, critical appraisal, application of evidence-based health care, management skills etc. development of the system approach is also particularly important. model pdsa or plan do study act can offer answers to many important questions in the process of quality improvement (26,12,25): 416 health systems and their evidence based development figure 2. framework for improving the system (25) besides, possessing the team-work skills, particularly for working with clinicians, is one of the most important skills that a public health specialist should possess and upgrade. 417 quality improvement in health care and public health • what we are trying to accomplish? • how will we know that a change is an improvement? • what changes can we make that will result in an improvement? act plan study do exercise: quality improvement in health care and public health task 1: variations in medical practice variations in medical practice are one of the most frequently mentioned reasons for the development and application of quality improvement mechanisms. with whatever sort of data we may gather in medical institutions (for example, the average length of treatment for the single diagnostic entity, mortality referring to the same disease at certain age groups, percentage of hospital beds occupancy, and so on) we shall notice that those vary considerably from one to another medical institution. perceiving and analysing these variations search for their causes are parts of the quality analysis process. frequency histogram is used as a tool for graphic presentation of variations. students will have assignments to collect data at three general hospitals’ surgical wards on: • time interval from admission to or for elective surgery, • number of analyses and examinations performed upon each patient prior to operation. (the collected data above are to be presented by a frequency histogram (two) and the noticed differences are to be discussed). • collect data on caesarean section rate as per regions in the country and number of obstetricians–gynaecologists in the same regions. (present data graphically, and then discuss the results). task 2: global indicators wilson (16): «because the delivery of health services is complex and has multiple goals no single measure is apt to capture overall quality. still everyone would like to have a universal quality meter that readily generates for each provider an overall score that is both valid and meaningful». students should collect data in several hospital around the country for the calculation of the following indicators, calculate the indicators and compare them in small and big group: • surgical in-patient cancellation rate, • in-patient autopsy rate, 418 health systems and their evidence based development • adult death rate, • postoperative death rate < 48 h, • hospital complication rate, • unplanned returns to intensive (or special) care unit, • no. of medical incidents, • surgical wound infection rate. collective work: choose, define, and explain some of the oncology care indicators (examples for the solutions): • screening mammography, women age 50-69, • pap smears, women age 18-69, and • quitting smoking, both sexes. collective work: choose, define, and explain some of the public health indicators (examples for the solutions): • immunization rate, • birth rate, • infant mortality rate, • mortality under 5, • mortality rate, • changes in self-reported health status, • changes in functional independence measures, • client satisfaction with health services, and • changes in health-related knowledge, attitudes, skills. 419 quality improvement in health care and public health references 1. institute of medicine. the future of public health. (cited 2000, february 15) available from url: http://www.nap.edu 2. maxwell pj. dimensions of quality revisited: from thought to action. quality in health care 1992; 1: 171-7. 3. eu commission. new public health strategy. (cited 2003, december 20). available at url: www.europa.eu.int 4. show c. framework for national quality policies. copenhagen: who, regional office for europe 2002. 5. mc keown p. the role of medicine. oxford: basel blackwell 1979. 6. ilich i. limits to medicine. medical nemesis: the expropriation of health. harmondsworth: penguin 1977. 7. bunner jp. medicine matters after all. j. roy phys. london 1995; 29: 105-12. 8. dubinski m. analysis of national institute of health. medicare coverage assessment. int.j. technic. assess. health care 1990; 6: 480-8. 9. howes n. surgical practice is evidence based. br.j. sur. 1997; 84: 1220. 10. wareham n. the meaning of quality. in: pencheon, ed. oxford handbook of public health practice. oxford: oxford university press 2001. 11. uehara n. „evolution of the concept of quality, and potentials of tqm in health services”. proceedings of asean workshop-seminar on quality management of health services 1995. 12. jcaho (joint commission on accreditation of healthcare organization). national library of health indicators. (cited 1998, april 12). available from url: http:// www.jcaho.org 13. mc glynn j. developing a clinical performance measures. american journal of preventive medicine 1998; 14: 14-21. 14. rand. measuring general practice. a demonstration project to develop and test a set of primary care clinical quality indicators. nuffield: nuffield trust 2003. 15. nhs. quality and performance. nhs, executive. (cited 1999, may 10). available at url: http:// www.doh.gov.uk 16. wilson c. qa/coi strategies in health care quality. new york: wbs company 1992. 17. cuci} v. zdravstvena zaštita zasnovana na dokazima (evidence based health care), belgrade: velarta 2000. 18. who. what is the best strategy for ensuring quality in hospitals? copenhagen: who, regional office for europe – health evidence network 2003. 19. grol r, bakerr, moss f. quality improvement research: understanding the science of change in health care. quality and safety in health care 2002; 11(2): 110-111 (editorial). 20. who / usaid/qap / danida. consultative meeting in quality assurance in developing countries. maastricht: who 1993. 21. fleishman r. the rat method for regulation, assessment, follow up and continuous improvement of quality of care. international journal of health care quality 2002; 15(7): 303-310. 22. eggli j. a conceptual framework for hospital quality management. international journal of health care quality assurance 2003; 16(1): 29-36. 23. iso. international organization norms. (cited 2000, february 20). available at url: www.iso.org 420 health systems and their evidence based development 24. overtveit j. the quality of health care purchasing. international journal of health care assurance 2003; 16(3): 116-127. 24. hicks n. improving the health care system. in: pencheon, ed. oxford handbook of public health practice. oxford: oxford university press 2001. 25. berwick d. primer on leading the improvement of system. bmj 1996; 312: 619-22. recommended readings 1. berwick d. methods and tools of quality improvement, putting theory into practice. harvard community health plan, brookline: regional authority 1991. 2. donabedian a. the definition of quality approaches to its assessment. an arbour: health administration press 1980. 3. donabedian a. exploring in quality assessment and monitoring volume ii. an arbour: health administration press 1982. 4. dixon r, munro j, silcocks p. the evidence based medicine oxford: workbook, linacre house, jordan hill 1997. 5. ishikawa k. what is total quality control? london: prentice –hall, inc 1985. 6. international journal for quality in health care, all issues. 7. jennison goonan k. the juran prescription – clinical quality management. new york: a juran institute publication 1995. 8. palmer h, donabedian a, pover c. striving for quality in health care an arbour: health administration press 1991. 421 quality improvement in health care and public health 422 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title accreditation of health institutions as an external tool for quality improvement module: 2.10 ects (suggested): 0.50 author(s), degrees, institution(s) vesna bjegovic, md, msc, phd snezana simic, md, msc, phd both authors are professors at the school of medicine, university of belgrade, serbia and montenegro address for correspondence insitute of social medicine, school of medicine, belgrade university dr suboti}a 15, 11 000 belgrade serbia and montenegro tel: +381 11 643 830 fax: + 381 11 659 533 e-mail: bjegov@eunet.yu keywords accreditation, quality assessment, visitation, standards learning objectives after completing this module students and public health professionals should have: • increased their understanding of external tools for quality improvement; • identified key four models for external quality assessment; • explored the similarities and differences between existing mechanisms; • improved their knowledge in accreditation procedure and international projects, which support national accreditation; and • understood the main trends influencing the process of external assessment as a part of continuous quality improvement in health care. abstract the main model of external quality assessment and improvement were developed particularly in the last two decades of the twentieth century. among them iso certification and efqm model are based on industrial concepts applied to health care, while visitation and accreditation were developed within the health care system itself. today many countries are interested in the process of accreditation as the systematic assessment of health institutions, which is based upon external peer review system and involve written standards. with growing interest in accreditation, the procedure for establishing accreditation bodies was simplified, and those bodies get international expert help for their development and in developing the national standards and services. an example of such help is alpha programme, which is founded within isqua (international society for quality in health care). teaching methods after introductory lecture students will participate in nominal group technique in order to recognize and to rank the field in the quality of health care where organizational, managerial, or other improvements are necessary, such as waiting lists, admission policy, medical records keeping, patient's discharge procedure, administration of drugs, working in multidisciplinary teams, patient satisfaction, etc. then they will work in small groups, divided according to country or working place, to discuss the possibilities for improvement in their own environment. the second exercise will be to discuss, within the country (or working place) small groups, the necessary procedure for development of national accreditation system. teacher will advise them to follow existing models and experience and to highlight their advantages and obstacles in the case of application within the country of see region. 423 accreditation of health institutions as an external tool for quality improvement specific recommendations for teacher it is recommended that the module will organize within 0.50 ects credits, out of which one third will be under the teacher supervision. teacher should be familiar with internet resources, where necessary evidence of well-established accreditation could be obtained. teacher should also be ready to help students to explore the website of international society for quality in health care as well as the website of joint commission on accreditation of hospitals. assessment of students multiple choice questionnaire and written design of national accreditation procedure. accreditation of health institutions as an external tool for quality improvement vesna bjegović, snežana simić examples from many countries around the world point to a growing movement aimed at continuous quality improvement in health institutions, and many authors call it a »quality revolution« (1). endeavours to provide the quality are an inseparable part of the health reforms, the dominant part of which are efforts made to increase efficiency and effectiveness, while keeping a certain level of equity in the health services provision (2,3). in the light of those strivings, the external tools for quality improvement in health institutions have their special place, while concern for their development is motivated differently in conformity to different stakeholders in the health system (4,5). thus, when it concerns the government, the external models of health care quality assessment are seen as new control mechanisms which would guarantee not only the quality of health sevices, but also higher responsibility and transparency which are neccessary for a more efficient system worth trusting. health professionals view the external tools of quality assurance from another perspective. their interest lies in increasing the efficiency of certain health institutions, in realizing the competitive advantages under the conditions of a controlled market, and in an outer incentive for further development of the internal quality system. the health professionals always wonder if various models of external quality assessment would limit their clinical freedom, and whether the health professionals would be under extreme control due to developing and applying of these models. when it refers to patients, although their position is improving in many european countries, their influence over the external quality assurance programmes is still limited. the patients’ main focus is on transparency and their higher participation in the health system decision making, based on adequate information on the quality of work. the main interest of the investors, regarding the application of external mechanisms, is in preserving the balance between the higher investments in administrative activities whose cost-effectiveness is not known and their inclination to contract services with particular suppliers under the conditions of a controlled health system market. 424 health systems and their evidence based development the quality improvement movement and the external quality assessment are both extremely actual in health systems around the world. governments, users, health professionals, managers and financiers are all trying to establish new external mechanisms in order to institute public responsibility, transparency, self-regulation, improvement of quality, and adequate »value for the invested money« (6). in an ideal situation the external tools for the improvement of organization and provision of health care are based upon (7): • explicite, valid standards, • reliable quality assessment processes, and • complementary mechanisms applied for improvement. standards are related to the level of excellence, they serve as basis for comparison, they represent a minimum to which a community is to pay attention, and are recommended as models to be emulated. standard of quality is a statement that defines expected performance, structure, or processes which must be present in a health organization if it is improve the quality of care (8). the process of quality assessment includes measurement or following of the function of secured quality so that it could be determined how well is the health care provided as compared to applicable standards or allowed limitations of health care (9). it is a process of establishing and measuring the differences between efficiency and effectiveness that can be ascribed to the health care, which is offered, including the variations among regions as well as among people. in a practical sense, it is the measurement of technical and interpersonal aspects of medical (health) care (10). explicite identification of spheres where improvement is in place, as based upon proofs found in the assessment – reaching the standards is a strong incentive for participation of all partners in the implementation of changes that lead to improvement (11). acceptance of any form of external quality system in health care is closely connected to the social, economic, and political climate of a country which is determining the advantages and obstacles for those activities. it is assumed that the external quality assessment mechanisms are introduced and developed in european countries in a context characterised by (2): • covergence of the bismarck and beverage models of health care system financing; • government policy based on deregulation, decentralization, and self-regulation, together with strengthening the role of the patient; 425 accreditation of health institutions as an external tool for quality improvement • responsibility mechanisms as the creation of a new balance between trust and control among various partners in health care; • the economic and industrial way of thinking is dominant in development of those models; • application of the public-private mixture of health service providers and their financiers with public-private agencies, mostly of nonprofit orientation. in a situation where some countries have comprehensive legislation related to the quality management in health care, and where other countries have only regulations referring to certain special mechanisms, it is only understandable that models of external quality improvement vary from country to country (12). models of external tools for quality improvement in health care system modern analyses show that the external tools for quality improvement were developed particularly in the last two decades of the twentieth century, and that four models can be identified most often. the first two of those are based on industrial concepts applied in health care, and the last two models were developed within the health care system itself (2,13,14): 1. iso certification (certification by the international standardization organization), 2. efqm model (model of the european foundation for quality management), 3. visitation programme, and 4. accreditation. 1. iso model the model was created by the international standardization organization while developing standards for the quality systems – iso 9000. as the standards refer to the administrative procedures and not to clinical results, inside the health system they are mostly used in more technical departments and wards, such as laboratory, radiology, and transportation, but sometimes they are applied onto a whole hospital or clinic. the model is particularly utilized in germany and switzerland (6). by the iso model, the national board 426 health systems and their evidence based development for the quality in health care tests and recognizes an independent agency as competent to certify those organizations which adhere to these standards. the verification process tests the adherence to the standards and it is not directed at organizational development. anyhow, the iso 9000 series is a collection of five separate but interconnected international standards for quality management and quality assurance (15). revised version iso 9000: 2000 represents an improvement as they were set up by using a simple structure based on the process. the basic units of the revised standards are responsibility of the administration, resource management, process management, measurement, analyses, and process improvement. the verification in the iso model is done by experts for iso norms, not by experts for a special type of organization, so that it is not a form of peer review (2). certification, as process of recognizing the fulfillment of certain preset standards, refers to the system of quality, not to the actual contents of work. as applied in the health care, this model helps in orientation onto the process, but it does not guarantee that the selected treatment is adequate, nor does it refer to the health outcome. basically, this model does not affect the clinical process, but only the managerial one within which the clinical decisions are made. therefore, the iso standards are easily applied by health institutions’ technical departments. unfortunately, the limitations are not always recognized by those outside the health sector (financiers, patients) so that they sometimes advocate strongly for the introduction of the iso model in the health sector. after its initial application and after the limitations were recognized, there appeared »anti-iso« movements in some countries, germany in particular. still, some countries, like the netherlands and switzerland, found ways to integrate the model into approaches which are more specific for health care, such as accreditation. 2. efqm model the model was designed by the european foundation for quality management, founded in 1988, with over 600 organizations throughout europe involved in its work. the efqm model is based on »business excellence«, and was initiated by malcolm baldrige’s model of »excellence« in the usa. it stimulates organizations and helps them improve those activities which lead to excellence in satisfying the users, to professional satisfaction, and to the improvement of management in general. it bolsters the implementation of management through total quality (14). 427 accreditation of health institutions as an external tool for quality improvement this model’s instruments are schemes of rewards (european and world schemes), as well as publication of models which may be used in selfevaluation. it is considered to be the most complicated organizational model designed to fulfill certain objetives referring to total quality management (2). however, this is still a general model, not adapted to activities such as health care. still, its attributes, such as high validity, experimentation with self-evaluation of the work quality, its simplicity and compatibility with the structureprocess-outcome approach make it rather popular with health systems of west europe, particularly in scandinavia. it is especially popular among the managers of health institutions. also, the use of self-evaluation can be considered as a certain form of peer review, where all the members of an organization are regarded as colleagues. the expenses in this model are relatively low, and there are some elements of positive competition, especially if the organization wins a citation. a weak point of this model is that, beside conferring rewards for recognized good quality, it has no other form or recognition, such as iso-certification or accreditation, specific for health care institutions. 3. visitation programme the programme of visitation, as an external peer review, is focused on clinical practice, professional development, and quality of services (6). the standards are deduced implicitly from the clinical practice guidelines and from personal experiences. visitation teams (supervision, round-ups) are clinicians mainly, most often from the same field. after the visitation by chosen colleagues, the assessment results in the form of a written report. the team reports are not publicized. visitation is a systematic form of external peer reviewing, popular in particular in the netherlands (2). the whole model was inspired by visitations to clinics, which was operationalized as part of the quality assurance ever since 1967. the visitation programme has its roots in the health profession and it is carried out by medical professionals. the emphasis is placed on clinical performance, meaning the knowledge, skill, and attitude. in time, the visitation programme encompassed the organizational aspect as well. visitation is deemed closest to the actual clinical performance out of those four models, considering the structure, process, and outcome. health professionals embrace this model most willingly, as well as accreditation, as they are the closest to their actual work performed and to peer review. 428 health systems and their evidence based development 4. accreditation the model of accreditation was developed for the joint commission on accreditation of healthcare organizations in the usa. presently, it accredits almost 20.000 health institutions – hospitals, primary health care institutions, home care, long-term nursing institutions, laboratories, and network of group practice health care (16). also, the first initiatives for accreditations started in the united states back in 1910 by dr. ernest codman, after which the american surgical college was founded in 1913, and the programme for the standardization of hospitals started in 1917, as a prototype for accreditation (17). this programme was expected to secure recognition by professionals of those institutions which provide the best health care, as well as to stimulate those with poorer standards or equipment to strive for an improvement in the quality of performance. in 1951 the joint commission on accreditation of healthcare organizations in the usa emerged out of this programme, the standards of which were initially set exclusively by health care professionals, who also made evaluation and used its results. as of 1965, when the state health care programme for the aged was established (medicare), other stakeholders in the health care system became the users of accreditation results, too: first the government, then the health insurance companies, and finally the general population (16). since 1997 the yearly reports on the performances of accredited hospitals can be found at the joint commission on accreditation of hospitals’ web site http://www.jcrinc.com (18). it is worth noting that more than 96% of hospital beds in the usa today are in accredited hospitals (16). from the usa the accreditation spread out to canada, australia, new zealand, and in the last two decades of the twentieth century also to european countries. its development is most evident in great britain, spain, portugal, the netherlands, finland, while in france and italy it is on statutory basis. the first european experiences with accreditation started much later than in the usa, though there were other external mechanisms for quality improvement in european countries which were predominantly based on medical audit and peer review (19). thus, the pilot programme of hospital accreditation which started in 1990 in great britain is a good example of developing the accreditation process. this programme was meant for small communal hospitals (57 altogether) with less than 50 beds (19,20). out of those 57 hospitals, 43 were included voluntarily in the programme, and in two years 37 became accredited by the hospital accreditation programme. the main goal of the pilot programme was to instigate effectiveness (efficiency) of hospitals in a community, and to spread the ideas of good organizational practice. local authorities 429 accreditation of health institutions as an external tool for quality improvement financed and appointed two members each for this pilot programme. an independent body for accreditation was also established. the body managed the programme and evaluated the reports on hospitals included by the programme. initial standards used for accreditation were designed according to the 1988 publication by the national association of health authorities: »towards the practice guidelines in small hospitals«. those standards were derived from systematic observation of the organizational practice in small hospitals, and were confirmed and widely accepted by 17 national bodies, including 7 royal societies. the standards themselves referred to general organization, clinical services, medical specialities, and auxiliary services. they provided for the assessment of purpose and rationale of services, managerial arrangements, equipment and hospital capacities, operational policy, staff work and their education. during the first phase the hospitals assessed the quality themselves by filling out questionnaires based on published standards. then a team of at least 2 researchers (clinical specialists, or professional managers and general practitioners) from the established accreditation body made a visit to each hospital for the first time for a day. each researcher came from a similar but distant hospital, after he went through a three-day training – theoretical and practical – in the field of standards, research evaluation, and report composition. reexamination by the accreditation body included evaluation of the written report by each member. the implementation phase entailed sending of the final report by the accreditation body to the manager of the hospital included by the programme. the managers were encouraged to discuss those reports over with their staff, but also with financiers. inspections by external teams were performed four times a year, and staffs from all the hospitals were invited to a meeting in order to exchange experiences they had in implementing the quality improvement. their experiences were related to a considerable time consumed in the preparational phase for the accreditation, as well as to a sense of pressure at the time when assessment is done by external teams. the very challenge of external assessment, however, proved to be a strong motive to reexamine (or disclose) the operational policy of the institution, the existing reports, and data, too. many of the managers were surprised at the scope of data and information referring to their hospitals which they did not use in their everyday work. explicit identification of the fields where improvement was necessary, such as correctness of data, administration of drugs, admission policy and patient’s discharge procedure, were also stimulating for a systematic participation of physicians in the hospital management to its benefit. the reasons not to accredit certain number of hospitals included by this pilot programme referred to a lower quality in the spheres of medical procedure safety, keeping of medical records, and medical organization. visits by 430 health systems and their evidence based development external professionals in the course of two years confirmed that 69% of what was recommended was implemented in the daily work. it is interesting to note that complete expenditures for this two-year pilot programme for 57 small hospitals amounted to £ 47.000, which includes two permanent employees, external assessment teams’ training, meetings of the accreditation body, visits to hospitals, and other expenses. accreditation in great britain, as opposed to the one in the usa, was not led in the beginning by medical professionals and it did not connect or integrate the existing mechanisms with the accreditation procedure itself, but that is where emphasis lies today in particular. still, following the experience they had in great britain, other countries developed similar projects as well. today it is clear that the accreditation of health institutions has its future, and discussions are centered around its integration with other external assessment mechanisms, and whether the proceedings should be regulated at the national level or not (6,21). concept of accreditation – advantages and limitations accreditation as applied to organizations refers to a systematic assessment of health institutions in relation to explicit standards by experts outside the health institutions (20). during the accreditation the assessment is done by multidisciplinary teams of health professionals in relation to published standards. although accreditation may be expensive, it is performed most often by non-profit independent organizations. it is a process in which a professional association or a non-governmental organization issues authorizations to institutions stating that they are accredited based on their ability to meet the preset criteria. it is also the process through which an authorized agency or an organization evaluates and recognizes programmes or institutions which satisfy the preset standards. accreditation as a process is to be distinguished from the process of evaluation of work in health institutions, which is an obligation done by the government or its agencies when issuing the work permits (22). good point in the accreditation as an external quality assessment model is that it reflects in detail specific features of health care offered by a health institution. it is noted to have roots in peer reviewing as a mechanism used by a medical team to evaluate the quality of total care offered by a health organization, while evaluation is performed by medical workers of the same educational level (23). advantage of the accreditation is that it uses perform431 accreditation of health institutions as an external tool for quality improvement ance indicators, insisting upon evidence based medicine, clinical indicators, and benchmarking as a process of quality assurance in which an organization sets its goals and measures up their realization comparing itself to products, services, and practice in other organizations recognized as leaders in their fields (9). the hospitals which most often participate in the accreditation process and thus have the largest experience, also note the following benefits (6): • development of multidisciplinary teams, • reexamination of the institution’s operational policy, • data system improvement, • growth of local and national prestige, and • stronger connections between hospital managers and institution (networking). comparing the accreditation with the efqm model, there is less energy invested in conceptualization and vizualization of the health institution’s nature as the organizational one. when various accreditation guidelines are analysed, it is percieved that they had originally been aimed at wards/functions in health institutions, and that only recently they were directed to the structure – process – outcome approach, the system of quality, and total quality management (2). even though it is obvious that accreditation differs from other external quality improvement mechanisms, it is still evident that it is complementary to them. besides, there is today a need for all external mechanisms to converge in order to provide the standardization and possibility of making comparisons (3). the following are cited as characteristics of an effective external quality assessment programme, including accreditation (6): • the programme gives a clear frame of reference describing the quality elements, • it publishes open standards in order to provide an objective foundation for assessment, • it is focused onto patients and it reflects horizontal clinical pathways rather than vertical managerial units, • it incorporates clinical processes and results, reflecting observations by patients, medical staffs, and public, • it instigates self-assessment providing the time framework and tools for internal assessment and development, 432 health systems and their evidence based development • it trains personnel who then assess the quality, and it promotes reliable assessments and reports, • it measures systematically – describes and evaluates objectively adherence to standards, • it renders incentives – it gives stength to improve and responses to assessment’s recommendations, • it communicates with other programmes – it promotes consistency and reciprocity, it reduces duplicating and burdening of the health care service with inspection, • it quantifies improvements in time so that it shows the programme’s effectivness, and • it secures public accessibility to standards, assessment processes and results – it is transparent and responsibe to public. accreditation procedure accreditation as a process is usually based upon the external peer review system, using written standards by which the quality of activities, the services or organizations in the health care system are assessed (6,24). medical professionals have the key role in this process. it is still debated today as how to approach the procedure of accreditation which can be (25): 1. institutional, or 2. oriented to clinical service. the institutional approach is focused onto the whole institution and its operation, it is simpler for implementation, and the responsibility in undertaking the improvement action is clearer. however, this approach does not heed patients’ experiences much. as opposed to it, the approach oriented onto the clinical service reflects experiences of individual patients, it is more encompassing, covering up all aspects of patient’s care and treatment. but, it is not always easy to define the clinical service, therefore this approach requires more time and repetition in case it should comprise all services which contribute to the health institutions’ operation. this approach is deemed more advantageous if the quality improvement is developed in the primary health care as well, though numerous pilot schemes. after the services are defined, the next step in the process of accredi433 accreditation of health institutions as an external tool for quality improvement tation is to establish an independent accreditation body. in this respect, different countries have different procedures and those bodies are established upon initiative by independent health experts, physicians’ associations, societies for quality in health care, and even by the health authorities (ministries). it is noted in literature that certain countries have no clear criteria in establishing the accreditation body (26). with growing interest in accreditation and more initiatives by the international society for quality in health care (isqua), the procedure for establishing the accreditation bodies was simplified, and those bodies get expert help for their development and in developing the national standards and services. as part of the isqua, the alpha programme was developed to supply published international standards for the accreditation bodies in health care (alpha: agenda for leadership in programs for healthcare accreditation) (21). there are 10 such standards and they can serve as guidelines in establishing the national accreditation bodies. the contents of these standards, which also incorporate the iso requirements for similar bodies, is as follows (24): 1. standard: managership of the national accreditation body with the mission, values and vision, the strategic and operational planning, keeping the external communication with users, with professional, political, and financial bodies, and with other participants interested in improving the health care. 2. standard: organization and management of preformance which assures improvement of work and the quality improvement system, defines the accreditation body’s statute, contracts, relations with accreditation users, and marketing. 3. standard: management of human resources, which includes planning, finding, selecting and appointing the persons to work in the accreditation body, their professional development and interpersonal relations. 4. standard: selection, education, and development, as well as employment of researches who are to participate in the external quality assessment, providing for their satisfaction with their work. 5. standard: management of finances and resources through systems which insure that strategies and goals will be attained with minimal risk. 6. standard: management of information which presumes gathering, keeping, and using the relevant and timely information needed by the accreditation body. 7. standard: management of quality assessment including the preparation of participants in the quality assessment procedure, satisfaction of their needs 434 health systems and their evidence based development after the assessment is done, stimulating the objective and consistent decision-making, implementation of improvement, and evaluation. 8. standard: accreditation process which implies maintaining of the accreditation system by defining clerly its purpose, responsibility in accreditation, and preserving its achievements, as well as keeping the documentation. 9. standard: development of accreditation standards which satisfy international principles to be developed, implemented, evaluated, and modernized in a planned way, together with development of clinical practice guidelines. 10. standard: educational services which are systematically designed and implemented so that they satisfy the quality standards and needs of the accreditation users. the key elements in the accreditation procedure, after defining the service to be accredited, and after the national accreditation body was established, are as follows (25): 1. setting up the standards; 2. assessment of performance in relation to set standards; and 3. consent to the assessment, and implementation of the action which is to correct shortcomings identified during assessment. setting up the standards is an integral part of continuous quality improvement in a country, with discussions still going on about the balance between the national and local standards, the level at which the standards will be set up, and as to who is to set those standards up, with a clear recommendation for them to be published (27,28). the basic characteristics of the standards in accreditation system are required to be (19,25): • explicite, • objective, • measurable, • based upon evidence, if such exist, • connected to the structure (adequacy and organization of resources – personnel, buildings, equipment, amd financial means), the process (clinical practice and interventions), and to the outcome (intervention results), and • regularly revised in light of the latest evidence and experiences. 435 accreditation of health institutions as an external tool for quality improvement upon initiative of the international society for quality in health care (isqua), as in the case of recommendations for establishing the national accreditation body, the alpha programme institutionalized international principles for formulating the national standards which are to be respected in the national accreditation procedure (21). there are six of those international principles and they refer to: 1. ways of presenting their contents, 2. clarity of definition, 3. clarity of scope, 4. comprehensive and clear structure, 5. formulation by well defined process, and 6. receptiveness to performance measurement. performance assessment in the accreditation procedure has its external elements and involves peer review. it is advisable that peer review be multidisciplinary and that it reviews contributions by all disciplines in offering the health care quality. the assessment itself is supposed to be based upon objective and written evidence, and on visits to the institution to be accredited. it should be cyclic – the external assessment is to be performed in certain intervals (differing from country to country: once a year, once in 3-4 years, etc.). also, the assessment visits are to be more often in case certain problems have been noted, and if the improvement action has been defined. it is an important fact that all accreditation systems have explicit organizational standards in reference to which the institution itself is assessed prior to the structured visit by professionals out of the institution, who then submit a written report with acclaims and recommendations for development both to the independent accreditation body and to the institution itself (6). accreditation can be conferred for certain period of time, or it can be withdrawn by the independent assessment body in case the hospital does not comply with the defined assessment programme. the body responsible for the accreditation process, assessing the compliance with defined standards, has the right to make public its findings, and to plan repeated visits to the institution for the purpose of external peer reviewing. however, the implementation action is under full responsibility of all employees in a given institution. taking into account the existing accreditation programmes in many countries, further development of this system is deemed necessary so as to (4,6,19): 436 health systems and their evidence based development • provide better co-ordination with existing external quality assessment programmes at national and international levels, • develop and institutionalize the standards which are to be relevant to patients, • emphasize the quality connected to the clinical performance, reviewing concomitantly all aspects of health care offered to patients, and • avoid separate »right« solutions for all aspects of health care quality, but to develop a general framework for constant improvement of quality in healthcare. for the accreditation procedure to start in any country, however, it is necessary to create the national strategic framework for continuous quality improvement in healthcare, where the accreditation itself is but one of its segments (4). even though the work of the accreditation body (commission, board, association) is independent, it must be acknowledged either by the government or the health institutions, or by a professional association (21,29). the strategic framework is to specify whether the accreditation procedure is to be legally regulated or voluntary, with the voluntary principle referring to the participation by health institutions in this procedure remaining quite important – the health institutions recognize their interests themselves. experience also shows that development of the accreditation procedure requires 2 to 3 years, and pilot projects are first recommended with one or several health institutions participating in those projects (6). international projects and experiences with accreditation in european countries considerable interest in the accreditation procedure is confirmed by international projects which were/are aimed at analysing its basic characteristics, advantages, and limitations in various countries. so far, the most prominent projects in the european countries are theexpert project and the alpha programme (14,21,26,30). expert project (external peer review programs) has been financed since 1996 by the european union, aimed at analysing and exchanging experiences related to external peer reviewing and organizational standards for the health service assessment, particularly the accreditation process, along with recognition of achievements and creation of network among countries for the exchange of experiences (networking). the goals of this project are also to 437 accreditation of health institutions as an external tool for quality improvement gather and disseminate various concepts and experience in implementation and training, as well as to support the integration with internal quality assessment mechanisms. countris of the european union were encompassed by this project. the iso standards model, efqm model, visitation, and accreditation were identified as basic external mechanisms in this project. alpha programme (agenda for leadership in programs for healthcare accreditation) was initiated by the international society for quality in healthcare (isqua) in italy in 1994, as a discussion forum, and as a way of learning about accreditation based upon experience of others, and the programme is active since 1999. in a sense, this programme gained ground as a response to numerous pressures to introduce iso standards for the quality assessment in health care, aimed at protecting and improving those external mechanisms originating in the health care system itself, most notably the accreditation. so far, the alpha programme is part of an important recommendation to adopt principles for the set standards for all national accreditation systems, respecting the specifics of individual countries. an alpha programme study gives recommendations for accreditation bodies which are to accredit health insitutions in a given country, as well as recommendations for the accreditation programmes themselves. today alpha leads, evaluates, and accredits the national health care accreditation bodies, helping them to achieve international »excellence«. this programme is also capable of aiding the assessment and improvement of standards of national organizations, in relation to internationally approved standard principles in health care, and to assist in developing accreditation programmes in a given country. in this way the national accreditation organization is to show not only that its system and process of operating satisfies the alpha international standards, but also that national standards are in concordance with alpha international standard principles for health care. alpha standards and principles are found at the web site http://www.isqua.org.au. members of the alpha council – accreditation federation are representatives from 13 countries with greatest experience in accreditation procedure, as well as representatives from the world health organization, the world bank, and the international hospital federation. alpha provides programme packages for the development of accreditation, and also the relevant articles published in this field. 438 health systems and their evidence based development exercises: accreditation of health institutions as an external tool for quality improvement task 1. after introductory lecture students will participate in nominal group technique in order to recognize and to rank the field in the quality of health care where organizational, managerial, or other improvements are necessary, such as waiting lists, admission policy, medical records keeping, patient’s discharge procedure, administration of drugs, working in multidisciplinary teams, patient satisfaction, etc. the necessary time for this exercise is 45 minutes, if the group is consisted from 20 students. students will be divided in two groups according to their preferences (hospitals or primary health care institution). each student will give an example of bad quality in the health care institutions, according to his – her experience and should be warned to be ready to explain it later. teacher will write down each example on the flip chart. after listing the examples students will select 5 conditions of bad quality and then rank them according to importance, by using marks from 1 to 5 (where 5 is the most important). all individual marks will be summed up and three conditions of bad quality will be selected in such way for further discussion. students who proposed the selected condition are going to explain what the reasons for their selection were. task 2. the work will continue in small groups (4 to 5 students), divided according to country or working place, to discuss the possibilities for solutions and improvement in their own environment. for this exercise additional 1,5 hour are requested. after small group discussion presentations will be in front of the whole group. teacher will summarize the reports pointing out the standards necessary to be reached in order to be ready for the accreditation procedure. it is recommended to follow existing standards of good quality in health care institutions. task 3. the third exercise will be to discuss, within the country (or working place) small groups, the necessary procedure for development of national accreditation system. teacher will advise students to follow existing models and experience and to highlight their advantages and obstacles in the case of application within the country of see region. this exercise required 3 hours under the supervision because students are obliged to search internet resources of international society for quality in health care (http://www.isqua.org.au) as well as joint commission on accreditation of hospitals (http:// www.jcaho.org/). 439 accreditation of health institutions as an external tool for quality improvement references 1. counte ma, meurer s (2001). issues in the assessment of continuous quality improvement implementation in health care organizations. international journal for quality in health care; 13(3): 197-207. 2. klazinga n (2000). re-engineering trust: the adoption and adaptation of four models for external quality assurance of health care services in western european health care system. international journal for quality in health care; 12(3): 183-189. 3. schyve pms (1998). accreditation and globalization. international journal for quality in health care; 10(6): 467-468. 4. rawlins r (2001). hospital accreditation is important. bmj; 322: p.674. 5. o’leary ds (2000). accreditation’s role in reducing medical errors. bmj; 320: 727-728. 6. shaw c (2001). external assessment of health care. bmj; 851-854. 7. shaw cd (2000a). the role of external assessment in improving health care. international journal for quality in health care; 12(3): p.167. 8. jcah (2003). national library of health indicators (with glossary). (cited 2003, may 20). available from url: http://www.jcaho.org/ 9. ta 101 (2003). glossary. in: introduction to health care technology assessment. national information center on health services research & health care technology (nischr). (cited 2003, may 29). available from url: http://www.nlm.nih.gov/ 10. cen/tc 251 (1995). glossary of medical informatics (cited 1995, june 20). available from url: http://miginfo.org.ac.be:8081 11. davies hto, nutley sm, mannion r (2000). organizational culture and quality of health care. quality in health care; 9: 111-119. 12. schilling j, cranovsky r, straub r (2001). quality programmes, accreditation and certification in switzerland. international journal for quality in health care; 13(2): 157-161. 13. west e (2001). management matters: the link between hospital organisation and quality of potient care. quality in health care; 10: 40-48. 14. shaw cd (2000b). external quality mechanisms for health care: summary of the expert project on visitatie, accreditation, efqm and iso assessment in european union countries. international journal for quality in health care; 12(3): 169-175. 15. iso. international standardization organization. (cited 2003, july 23). available from url: http://www.iso.ch 16. schyve pm (2000). the evaluation of external quality evaluation: observation from the joint commission on accreditation of healthcare organizations. international journal for quality in health care; 12(3): 255-258. 17. roberts js, coale jg, redman rr (1987). a history of the joint commission on accreditation of hospitals. jama; 258(19): 936-940. 18. jcah (2003). joint commission on accreditation of hospitals. (cited 2003, june 24. available on url: http://www.jcrinc.com/internat.htm 19. shaw c, collins c (1995). health services accreditation: report of a pilot programme for community hospitals. bmj; 310: 781-784. 20. robins r (1995). accrediting hospitals. bmj; 310: 755-756. 21. alpha (2003). agenda for leadership in programs for healthcare accreditation (cited 2003, april 22). available from url: http://www.isqua.org.au 22. biomed/cbo (1994). concerted action on quality assurance in hospitals. utrecht: national organization for quality assurance in hospitals. 440 health systems and their evidence based development 23. pam pohlys net guide (1999). glossary of terms in managed care (cited 1999, february 10). available from url: http://www.pohly.com/term-p.shtml 24. alpha (2000). international standards for health care accreditation bodies. victoria: the international society for quality in health care inc. 25. scottish office (1998). quality assurance and accreditation. in: acute services review report. edinbourgh: scottish office publication. available from url: http://www.scotland.gov.uk /library/document5/acute-o6.htm#1 26. isqua (2003). international society for quality in health care. (cited 2003, april 22). available from url: http://www.isqua.org.au 27. giraud a (2001). accreditation and the quality movement in france. quality in health care; 10: 111-116. 28. donahue kt, vanostenberg p (2000). joint commission international accreditation: relationship to four models of evaluation; 12(3): 243-246. 29. scrivens e (1998). widening the scope of accreditation – issues and challenges in community and primary care. international journal for quality in health care; 10(3): 191-197. 30. heidemann eg (2000). moving to global standards for accreditation processes: the expert project in a larger context. international journal for quality in health care; 12(3): 227-230. 441 accreditation of health institutions as an external tool for quality improvement 442 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title project management module: 2.11 ects (suggested): 1.0 authors, degrees, institutions silvia-gabriela scîntee part-time lecturer at the university of medicine and pharmacy „carol davila” bucharest, department of public health and management public health consultant at the institute of public health bucharest adriana galan, it specialist part-time senior lecturer at the university of medicine and pharmacy, department of public health and management, at postgraduate level address for correspondence institute of public health bucharest 1-3 dr. leonte street 76256 bucharest romania tel: (4021) 2249228 / ext.188, fax: (4021) 3123426 e-mail: gscintee@ispb.ro, agalan@ispb.ro keywords project management, project proposal writing, project development, project implementation learning objectives at the end of this course, students should be able to: • identify what it is needed to know and do to set up a project; • identify the needs and to set up the priorities; • prepare a preliminary brief; • plan and schedule a project; • set up a monitoring and evaluation plan; • develop a project proposal. abstract this course concerns basic concepts of project management, initiation phase, preliminary brief, detailed planning, scheduling, implementation and completion. at the end of this course, a project draft is proposed to be designed by the students. teaching methods lectures, interactive presentation of key concepts (overheads or powerpoint presentation), group discussions, groups' assignments. work in small groups (4-5 persons) and an overhead will be presented by each group after each assignment. specific recommendations for teacher it is recommended that this module is organized within 1.0 ects credit. the work under supervision is consisting from lecture (5 hours), supervised assignment solving (5 hours), while individual work is related to collect data and to prepare the project proposal draft (20 hours). assessment of students final draft of a project proposal. project management silvia-gabriela scîntee, adriana galan project is not a new concept. projects have been carried on since the inception of the organized human existence and less complex projects are very common in our daily life. any work which has a beginning and an end, is planned and controlled and creates change can be called „project” (1). very often „the project” is considered synonymous with „the programme”. still, there is a difference between the two terms. a programme is more exhaustive than a project and has larger time limits. a programme can have more projects as component parts. projects are classified under four main headings (2): 1. industrial projects (civil engineering, construction, petrochemical, mining and quarrying projects): usually large projects, requiring massive capital investment and rigorous management, that incur special risks as the implementation phase is conducted remote from project manager’s office. 2. manufacturing projects (production of equipment or machinery): these are conducted in a factory, but sometimes requiring work away from the company for installation, customer training, subsequent service and maintenance. 3. management projects: arise in each organization as a part of its work or when a change is envisaged. examples: restructuring the organization, relocating the headquarter, refurbishing an office, planning a training session or conference, introducing new service, introducing a new computer system. 4. research projects: unlike other types of projects their final objectives are difficult or impossible to define. characteristics of the project regardless their type, the project has five common characteristics (3): it creates change, it has various goals and objectives, it is unique, it is limited in time and scope, and it involves a variety of resources 1. a project creates change. when a project is conducted the routines and regular work within an organization is disrupted by unfamiliar, new activities. this could lead to resistance from the staff as people do not like to 443 project management have their existing work altered. more than that, those working in the project have to report to the supervisor of the routine work and also to the supervisor for the project work. other sources for resistance could be: conflict of interests, low tolerance to change, different perception of the need to change, misunderstanding and lack of trust. the project manager could use various methods of change management to face this resistance in accordance with how much time, money and power he has. examples of such methods are: • education and communication – the best method which unfortunately takes a lot of time and money • involvement of people in project development – also good but still takes time • supporting people to facilitate change – takes also time • negotiating with people – takes less time, but a compromise has to be reached • manipulating people – quick and cheap method, but can fail if people feel like being used • coercion – the quickest and the cheapest, but in the same time has the highest probability to fail 2. a project has various goals and objectives. there are three types of goals and objectives for any project (3): • performance and quality – the end result of the project must be fit for the purpose of which it was intended • budget – the money spent on the project must correspond to the authorised expenditure • time of completion – all stages of the project should take place at their specified dates and total completion date should correspond to the planned finish date the project manager should find a balance between these three attributes: time, quality and cost. if the project finishes before the planned completion date, money may be lost. if the project is extended beyond its scheduled finish date is likely to have increased costs. in both cases the quality might suffer. 444 health systems and their evidence based development 3. a project is unique. there are not two identical projects. despite the existence of a standard methodology for project development and of a same basic procedure no matter the complexity of the project, the work content of every project varies. the project manager needs to develop a plan taking into account the particular circumstances that is both strong and flexible enough to accommodate changes in those circumstances. 4. a project is limited in time and scope. these are the main characteristics that make the difference between the project and the programme. a programme is not necessarily limited in time and its scope is more comprehensive. a project is limited in time and scope, having a beginning and an end very well defined. a great deal of the project manager’s effort is focused on the completion of the project at the scheduled finish date. there are a lot of tools that can be used in time planning, from timetables – the simplest, which represent a list of activities with their starting and finishing dates, to gantt chart and critical path more complex methods that take into account the dependency degree between activities. 5. a project involves a variety of resources. when a project resource planning is discussed, most people will think of resources first in terms of money. but resources are also: people, equipment, materials and time. it is very difficult to forecast the precise quantity of resources and the moment when these will be used. still, the necessary resources should be estimated and scheduled. it is also necessary to specify how these resources will be obtained. as there are a lot of factors that could impede the utilization of resources according to the schedule, the project manager must periodically evaluate the progress and if necessary re-schedule resources. the phases of project management the above characteristics of the project have implications for the project management that is defined as „the process by which the project manager plans and controls the tasks within the projects and the resources on which the organisation draws to carry out the projects.” (1) all projects may be planned and carried out in the following four phases, known also as „the project’s life cycle”: initiation, planning, implementation and completion. 445 project management initiation. projects arise because of a need. so, in the initiation phase there are determined: the need for the project development, the terms of reference (what has to be done, what would be the expected results), the feasibility of the project and also it is created a workable environment for the project. this is considered the most important phase in the whole project (1), even if is the shortest one usually taking no more than 5% of the project lifetime. planning. in the planning phase, which usually takes 20% of the project duration, the tasks, resources, effects and needs of the project are examined in depth (1). planning is under the responsibility of the project manager, either done by himself in isolation or by a planning team. during this phase it is decided what should be done, by whom, at what point in time and with what resources in order to reach the project’s objectives. it is important in the planning process to forecast the potential constraints that might affect the implementation phase and to design strategies for overcoming them. implementation. implementation is the longest phase of a project (60% of the project duration) in which the project plan is put into operation. the implementation process is monitored and controlled in order to ensure the obtaining of quality results on time and within budget. monitoring is a continuous oversight of the project execution that assists in its supervision and assures that it proceeds according to plan. on the basis of controlling the project progress is checked against the plan and corrective action is taken where necessary. completion. in the last phase the whole project is reviewed, the final report is presented and the resources are re-allocated. this phase usually takes 15% of the project duration. 1. initiation (pre-planning) phase this is generally considered the most important phase in any project. during this phase, what should be done under the project is determined (1). this phase includes usually the following steps: 1. situational analysis 2. health problems identification 3. priority setting 4. establish goal and objectives 5. feasibility study 446 health systems and their evidence based development 1.1. situational analysis situational analysis represents the first step of the pre-planning phase for any project. it represents an assessment of the health status of the population (can be a „target” population) and of the health care system in relation with the internal and external environment. according to r. pineault (4), the general framework of analysis can be conceptualised as follows: the main goal of this step is to define and establish valid criteria for the identification of priority health problems. another important goal is to provide data and information necessary to design objectives and strategic choices. it also represents a support for the feasibility evaluation. data and information collected during this step cover the following domains: • assess the internal and external environment (review of economic, social and health objectives and policies) • health status and related determinants assessment (mortality and morbidity rates, disability, life expectancy, lifestyle indicators, trends etc.) • health system assessment (public/private institutions, accessibility for health care, population coverage with services, patient flow within the health care system, etc.) 447 project management present situation desired situation health determinants health determinants health status health status (health objectives) health policies services produced and used needed services (service objectives) health services policies available resources needed resources (resource objectives) health resources policies plan of actions health promotion policies • resources – human, material and financial the main output of this step is represented by a comprehensive document offering a picture of the existing situation. 1.2. health problems identification the main goal of this step, involving more or less a subjective judgement, is to obtain a list of health problems. according to r.pineault (4), a health problem represents a deficient health status as perceived by individuals, physicians or communities. there are several methods described in the literature for problem identification. r.pineault (4) has described three categories of approaches: • based on existing health system indicators • based on special surveys • based on consensus research for each approach, he described the methods used in order to identify the health problems. the following table presents the methods used within each approach: 448 health systems and their evidence based development approach methods needed information based on existing health system indicators socio-demographic (associated to the health status and service utilisation) population structure, age pyramid, natality rate, crude mortality rate, fertility rate, average income level, level/rate of poverty, rate of unemployment, level of education health (mortality, morbidity, risk factors and disability) crude and specific mortality rates, infant mortality rate, life expectancy at birth and certain ages, standardised mortality rates/ratio incidence/prevalence rates, hospitalised morbidity, frequency of different risk factors, attributable deaths for certain risk factors, potential years of life lost due to certain risk factors daly, qaly health services utilisation medical visits rate, surgical interventions rate, number of diagnosis tests (e.g. laboratory, xrays etc.), number of referrals, hospitalisation rate (number of discharges), average length of stay health resources number and types of health care units, population coverage with different types of health care professionals (physicians, nurses, dentists etc.), health care expenditures in order to judge the identification of one problem, several criteria can be used: • problem’s dimension (usually its frequency within a population) • problem’s severity (usually measured by premature deaths, potential years of life lost, disability) • trends 1.3. priority setting priority setting means to select those problems identified during the previous step that can be the object of an intervention. it is actually a process of comparisons and decision-making, based on special methods and techniques for ordering the identified problems according to their importance. the conceptual framework of priority setting process was also described by r. pineault (4): 449 project management based on special surveys sampling health interview surveys (perceived health status) health examination surveys (based on clinical exams) based on consensus research delphi technique evaluate the opinion of certain experts on prevalent problems in a community. it is based on a group process of judgement, even if the experts don't communicate directly. the experts answer to successive posted questionnaires until sufficient level of consensus is reached. nominal group technique medical visits rate, surgical interventions rate, number of diagnosis tests (e.g. laboratory, xrays etc.), number of referrals, hospitalisation rate (number of discharges), average length of stay brain writing technique the difference from the nominal group technique is that all the ideas concerning the problems are presented (written on a table) from the very beginning to all participants. it is possible to reach the consensus also by voting or by final discussion. brainstorming technique it is mainly useful to generate ideas (mostly recommended for problem analysis and judgement of choices). experts are invited and encouraged to come up with original ideas. community forum public is invited to express community problems. three main criteria are used in order to prioritise the identified problems: • problem’s dimension (incidence / prevalence, premature deaths, avoidable deaths, invalidity, the size of the population at risk, the impact on medical services, family, society, etc.) • intervention capacity (knowledge on the disease / associated risk factors, prevention possibilities) • existing resources for intervention (existing services, qualified personnel, population accessibility to health services) there is a wide range of priority setting tools (ranking methods) that can start from a simple grid analysis, and ends with complex methods. based on a large number of criteria, these tools allow the problems ranking. if the list of identified problems is too long (>40), it would be necessary to shorten this list, using the selection method. 1.3.1 selection method its main purpose consists in rejecting the less important problems from the list. the result of selection method is a shorter list of more important problems, and not necessarily a problem ranking. a selection criteria is established from the beginning. a group of 3-5 experts will select the most important and less important problems during several meetings: • first meeting: the most important and least important problems are selected from the initial list, and put on separate lists (important and less important problems); 450 health systems and their evidence based development defining clear criteria if the list of problems is too long, a selection method would be necessary estimation and comparison of problems using ordering methods determine project goal and objectives for action p ri o ri ty p ro b le m s p ri o ri ty p la n n in g • second meeting: from the remaining list, the first 2 most important problems and the last 2 less important problems are again selected and put on the 2 previous lists; • third meeting: from the remaining list after the second meeting, the first 4 most important problems and last 4 less important are again selected and put on the 2 lists; and • the process stops when the list of most important problems contains no more than 10 problems. r. pineault has grouped the priority setting (ranking) tools into two categories (4): 1. specific methods for health planning. within this category, two methods are mostly used: • grid analysis • hanlon method 2. general ranking methods. within this category, several methods can be mentioned: • anchored rating scale • paired comparison • pooled rank grid analysis it allows formulating recommendations on priorities. it takes into account the problem importance, its evidenced relationship with associated risk factors, technical potential for problem solving, and intervention feasibility. the method allows establishing 16 possibilities of recommendations in descending order of priority for each problem. a general grid analysis is presented on the next page: 451 project management the results can be summarised in a final table as follows: 452 health systems and their evidence based development according to this method, problem 1 is considered the highest priority. hanlon method it ranks the priorities taking into account 4 components: problem magnitude (a), problem severity (b), solution effectiveness (c) and intervention feasibility (d). a. problem magnitude is usually measured by rates or index (a score is assigned for each problem; score values ranges between 1 and 10. value 10 represents the highest frequency in a population). b. problem severity is usually measured by mortality rates, potential years of life lost, daly, associated costs (a score is assigned for each criteria; score values ranges between 1 and 10. a final score is calculated for each problem, as the average of previous scores. value 10 represents the most severe situation). c. solution effectiveness must measure the availability of resources and technologies able to improve the problem. a score is also assigned for each problem, ranging between 0.5 and 1.5. value 0.5 indicates that the problem is difficult to be solved, while 1.5 indicates that there are possibilities to solve the problem. it is mostly a subjective judgement. d. intervention feasibility is also a subjective judgement taking into account the following components for each problem: pertinence (p), economic feasibility (e), acceptability (a), resources availability (r) and legal framework (l). a score is assigned for each component, 1 means a positive answer, 0 means a negative answer. a final composite index is computed for each problem based on the following formula: p1……n = [(a+b) x c x d] the highest score corresponds to the most priority problem. 453 project management problem importance evidenced relationship with associated risk factors technical potential for problem solving intervention feasibility recommendation from the grid analysis problem 1 + + + 2 problem 2 + + + 9 problem n + + 10 anchored rating scale a linear scale is used, ranging between 0 and 1 (1=extremely important problem; 0.75=very important; 0.5=important; 0.25=less important; 0=problem can be neglected). each expert is asked to place every problem on this scale. finally, a mean is calculated for each problem, having in the end a hierarchy. paired comparison problems are compared two by two. during each step, a problem is compared with all the others; for each comparison the most important problem is marked. for each problem it is computed in the end of sum of favourable situations. for example, if there are 5 problems (a, b, c, d, e) to be ranked, the method can be summarised into the following table: pooled rank a group of experts is ranking the problems, starting with the most important one (highest rank) and ending with the least important (lowest rank). each problem receives a rank from each expert. a mean rank is finally computed for each problem. 1.4. establish goal and objectives in establishing the goal and the objectives, the following elements should be taken into account: • the goal and the objectives of the national health policy • the goal and the objectives of the national health programme adressing the identified problem (if there is one) 454 health systems and their evidence based development problem paired comparison (selected problem is marked) obtained score or percent a a b√ a c√ a√ d a e√ a=1 or 10% b b√ c b√ d b e√ b=3 or 30% c c√ d c e√ c=2 or 20% d d e√ d=0 or 0% e e=4 or 40% • local health policies • international health standards and objectives there is also necessary to define: • the target population • the geographical area • the extent to which the problem can be reduced or solved • the time during which the problem should be reduced or solved stages towards defining the goal and objectives are presented in the figure 1. figure 1. stages towards defining the goal and objectives 455 project management analysis of the identified health problems analisys of the intervention posibilities setting the time period for the expected results identifying the services needed for reducing/solving the problem establishing the limits to which the problem will be reduces defining the goal and the objectives a goal is a long term result toward a project is aiming. in health, a goal usually refers to the solving or reduction of a health problem. there is not necessary to specify any quantitative outcome or time limits (5). ex. „to increase the reproductive health by reducing the number of abortions and undesired pregnancies in students from bucharest university” an objective is a desired outcome to be reached in a certain period of time. an objective measures the progress towards the stated goal. for this it is necessary to be quantified and to establish time limits. in defining an objective the following have to be specified: • what will be achieved • how much (to what extent) • when is expected the result • who will benefit • where is expected the result in defining objectives could also be used the acronym smart (s = specific, m = measurable, a = agreed upon, r = realistic, t = timebound). it is recommended a limited number of objectives (3 – 5). in accordance to the project complexity there can be established different types of objectives: • general objective – which would be the result expected at the completion of the project and shows how much the situation will improve; ex. „to reduce by 50% the number of abortions and undesired pregnancies in students from bucharest university, between 2000-2002” • intermediary objective – measures the progress towards the achievement of the general objective expected at a certain point in time; ex. „to reduce by 25% the number of abortions and undesired pregnancies in students from bucharest university, until december 31, 2001” • specific objectives – represent specific results that would assure the achievement of the intermediary and general objectives; ex. „to increase the information level of the students from bucharest university in regards with contraceptive methods” • operational objectives – that are in fact, the actions to be taken in order to reach the objectives; ex. „to freely distribute 10000 brochures on contraceptive methods to the students from bucharest university, between january – june 2000” 456 health systems and their evidence based development there are sequence and interdependence between different types of objectives (figure 2). figure 2. sequence and interdependence between different types of objectives 1.5. feasibility study the aim of this step consists in the evaluation of alternative proposed strategies in order to select the best one to be further implemented. the evaluation is focusing on three main aspects (6): • political feasibility • technical feasibility • institutional feasibility • financial feasibility political feasibility is focusing on the favourable / unfavourable political environment, on the agreement / disagreement of all key stakeholders involved. 457 project management technical feasibility usually takes into account three aspects: • provision of requested services needed to achieve the proposed activities (existence and availability of necessary technology) • the proposed offer of services (meet the population needs? are the services accessible? does it attain the target population?) • impact on health status (do the proposed services improve the health status? do the services contribute to the achievement of project objectives?) institutional feasibility is focusing on: • estimation of the necessary types of institutions and their geographical distribution, for the achievement of objectives (do they exist? do they need restructuring / rethinking? new institutions are needed to be created?) • staff (existing staff has sufficient skills? are training sessions necessary? new staff is necessary to be hired?) • administrative and managerial capacity (new capacities are needed? is the logistic support available?) financial feasibility takes into account: • estimation of total costs of necessary resources • estimation of running costs of the project • identification of possible financial sources 1.6. preliminary brief a brief contains the key information about the project, having a multiple use: • to proceed a feasibility analysis • to ask for funds • to direct the further planning of the project a preliminary brief should include: • project name • background (presenting the identified problem and the chosen solution) • goal and objectives 458 health systems and their evidence based development • the expected results • the required budget and time • methods of monitoring and evaluation • information about the organization 2. detailed planning and scheduling after objectives setting, a detailed plan of action is developed for each of them. action plans specify what should be done, by whom, where and when, being the bridge between stated objectives and the practical work. action plans could be seen as means and methods by which the objectives will be reached. a project plan should be detailed enough in order to: • provide a clear image on the activities • clarify for the project team the sequence and interdependence of activities • facilitate the correct estimation of the necessary resources there are described eight steps to be taken for the detailed planning of a project (1): 1. identifying the tasks (deciding what has to be done) 2. classifying the tasks and placing them in a logical order (some tasks are concerned with running the project, others are concerned with the actual work content of the project) 3. studying the implications (how the project could affect the organization policy, what is the impact on the clients, the public, the environment, what is the relationship with other projects) 4. estimating resource requirements 5. identifying the project hierarchy 6. clarifying the levels of authority (and setting clear areas of responsibilities for each person) 7. setting up the procedures needed to monitor and control the project 8. setting ground rules (informing the team of what is expected as a group norm) in order to schedule the work content and resources of a project there 459 project management are a lot of tools that a manager could use. the most known are gantt chart, and the critical path method. the gantt chart is recommended for the uncomplicated projects. a gantt chart is a simple display of tasks (listed in the first column) together with their duration of accomplishment (presented as horizontal bars alongside each task). the time periods could be presented either in days, weeks, months, quarters or years (figure 3). for more complex projects in which the dependencies between activities need to be shown a pert diagram could be used. pert (program evaluation and review technique) is a network tool relating tasks to each other on the basis of time and precedence and producing a critical path through the project (7). each activity is represented by an arrow, on which the activity is described together with the estimated duration. critical path is the longest path through the network of tasks that defines the duration of the project (7). for this path the project manager has to worry about as any delay of an activity could lead to the delay of the project end (figure 4). 460 health systems and their evidence based development figure 3. sample of a gantt chart 461 project management figure 4. example of a critical path a-b-f-g-h-i = 7+7+14+20+10+4 = 62 days a-d-e-g-h-i = 7+2+5+20+10+4 = 48 days a-c-j-h-i = 7+3+10+10+4 = 34 days in this example the first path has to be taken as critical path. the financial resources should also be planned. this is done by using the budget. budget estimation is very important for a project because: • is one of the essential elements a funding agency is looking for • represent a basis for the financial control that will compare the plan with its execution • helps in choosing the most cost-effective projects, attaining the allocate efficiency • allows a better resource allocation within a project, attaining the operational efficiency in order to estimate the budget it is necessary to: • list all types of required resources for each activity • determinate the quantity of each type of resources • estimate the unitary cost for each type of resources • calculate the total cost of each type of resources 462 health systems and their evidence based development a = methodology development; d = informing authorities; e = accept of authorities; g = data collection; h = data analysis; i = final report; b = testing questionnaire; f = pilot survey; c = training operators; j = developing software and online data collection • discount future costs if the project duration is more than one year the costs of each activity are usually presented in four expenditure categories: • personnel (like salaries, training, per diem, etc.) • equipment and materials (including also maintenance costs) • facilities (ex. renting, modifying or building a new office) • support expenditures a special category is represented by incidentals which usually should not exceed 10% of the total cost of the project should be justified. the budget should also contain the sources of funding. these could be represented by the organization’s own funds or there could be multiple financing organizations. each source will be specified for in separate columns. the estimated costs could be presented like in the following table: 463 project management expenditure categories activity description cost per activity own funds requested funds 1. personnel salaries accomodation perdiem transport example: project coordinator salary 100$/month x 12 months 15 participants in a training course held in bucharest x 5 days x 30$per diem 2 trainers x 5 days x 50$ fee/day 1200$ 2250$ 500$ 1200$ 2250$ 500$ subtotal 3950$ 3950$ 2. equipments and materials multiplying course materials 5$/participant/day x 5 days x 15 participants 375$ 375$ subtotal 375$ 375$ 3. facilities classroom rent 100$/day x 5 days 500$ 500$ subtotal 500$ 500$ 4. support expenditures communications 300$ 300$ subtotal 300$ 300$ 5. incidentals (reimbursed on the basis of receipts) total general 5125$ 800$ 4325$ a funding agency might have its own administrative procedures, so before submitting a project the agency should be contacted and should be asked about the necessary documents and the recommended budget format. the plan is many times negotiated with the funding organization. usually the project should be in accordance with donors’ policies and priorities. when deciding to fund a project a financing organization is mainly interested in: • project justification • technical capacity for running the project • compatibility with other projects • measurable and acceptable benefits • detailed and justified costs • sustainability (how the impact of the project will be continued after the project funding has ceased) • a clear monitoring plan • previous experience of the applicant • collaboration with other partners • multiple financing sources 3. implementation the implementation phase consists in putting the project plan into operation once all approvements and authorizations have been received. the plan should be flexible as even after being approved, in the implementation phase, changes might inevitably occur because of the internal or external factors. examples of internal factors could be: a key person that leaves the team, poor communication on somebody’s part, delays in equipment procurement or in funds release. external factors are less under the project manager’s control. examples of external factors are: partners who leave the project, change in donor’s policy, change in health policy or legislation, change in organization’s structure. implementation is initiated by the project manager and the other authorities responsible for the project by developing the job description for the 464 health systems and their evidence based development project manager. than the project team will be completed and the team roles will be assigned after assuring that everyone has a clear vision about the project and, if necessary, after training the team members for working together. the project plan will be reviewed and detailed as much as possible and tasks and responsibilities will be assigned for each member of the team, as well as the relationships between them. it is very important to set clear responsibilities and communication lines and to establish the authority levels in order to avoid overlaps, misunderstandings or delays in completion of tasks. over the implementation, the project manager should ensure that the necessary resources will be released on time for each activity. he should forecast the possible risks for not getting the resources in due time and should develop strategies to overcome these problems. an ongoing process during the implementation is monitoring. monitoring focuses on periodic measurement of workplan progress and achievement of intermediate project milestones. properly performed, monitoring provides current supervision and timely opportunities for remedial action (7). factors to consider in determining the scope and magnitude of the project monitoring are: • cost of the project • previous experience of the implementing team • manager’s familiarity with and confidence in the implementing team • complexity of the project • potential for injury to the project due to delays in both reporting and responding if monitoring is a method of ongoing review and measurement of the project to gauge its progress relative to its objectives and to plan continual improvements to both activities and management, evaluation takes a broad view of the projects activities, measuring the project’s success and effects and showing what difference will the project make (8). f. champagne (6) has defined the evaluation process as being a judgement on any activity, provided service or project component. the judgement is always based on some criteria and norms (normative evaluation) – mostly used for project evaluation – or on some scientific methods (evaluative research). 465 project management during project implementation, evaluation can be done as internal and external audit (operational evaluation) which can propose ongoing corrections. usually, any evaluation is focusing on the three classical components: structure – the resources used by the project are evaluated: • human (number, level of competence, existence of incentives) • material (quantity and quality) • financial (budget) • characteristics of the responsible organisation: size, type, affiliations, degree of specialisation process – is focusing on the following aspects: • project planning (appropriateness and adequacy of activities) • project monitoring (existence of periodic and final reports) • project organisation (leadership, human relationships, responsibilities) • project stage related to established deadlines and budget ootputs / outcomes – is focusing on specific results achieved by the project as compared with established objectives: • provided activities / services in order to achieve the objectives • obtained indicators • intervention impact (follow-up of an indicator after the end of the intervention) during the implementation stage reports will be required. reporting allows project managers to share the findings of the project through monitoring and evaluation, requiring periodic documentation of the project progress. a stage report includes financial updates, implementation status report and periodic evaluations. 4. completion during this phase, the final project evaluation usually takes place. this is called a-posteriori evaluation and it measures the level of project objectives achievement, project impact on target population. 466 health systems and their evidence based development a more comprehensive evaluation (evaluative research) can also be done during this phase. it takes into account the relationships between the three components: structure, process, outputs / outcomes. for instance, a relation between different types / quantity of used resources can be estimated according to process or effects (outputs / outcomes). economic evaluation is the most appropriate tool for this purpose. there are two types of economic evaluation: • productivity analysis – establish a relation between the process (provided services / activities) and the resources used by the project (expressed as number of services per invested monetary unit, number of services per health professional etc.) • efficiency analysis – establish a relation between effects (output/outcome) and the resources used or provided services (both expressed in a monetary value) a general framework of economic analysis was presented by r.pineault (4) in figure 5. figure 5. a general framework of economic analysis by r.pineault the most important document of the evaluation is included in the final report. this document usually describes the successes and failures of the project. the content depends on the project nature. the content will generally focus on expected results versus achieved results, as well as on the short-term and long-term impact on the target population. 467 project management structure evaluation process evaluation efficiency • cost-effectiveness analysis • cost-benefit analysis • cost-efficacy analysis • cost-utility analysis outputs evaluation outcomes evaluation resources services / activities productivity objectives impact (consequences) the achieved results can be grouped as follows: • physical results degree of needs attainment reported to a reference status the achieved level of indicators as a consequence of project implementation • socio-cultural results (related to the improvement of quality of life, of the general health status, etc.) • financial and economic results (reduction of sickness rate for the active population, etc.) • non-measurable results (organisational change, capacity building, behaviour change etc.) the final report will also describe the degree of goal/objectives achievement, the quality of norms and standards used by the project, procedures and criteria requested by the financing agencies, the quality of collected information. the conclusions will outline the encountered difficulties and, if possible, their generating causes, and will make recommendations on results dissemination. this document represents a valid basis for policy-making. 468 health systems and their evidence based development exercise: project management task: students will work in groups of 4-5 persons. each group will be provided with the following model for a project proposal. after each presentation during the lectures, the students will have to prepare every chapter of the project proposal according to the below model. at the end of the course, each group will present its draft of project proposal. model for project proposal 1. project name 2. executive summary (brief statement of the problem, short description of the solution, funding requirements, brief description of the organization and its expertise) 3. background (describe the context in which the project is developed; its relationship with other projects) 4. project justification (brief description of the problem that requires the project. facts and statistics will be presented in annexes. show how the project would contribute to the problem solving or reduction and what would the consequences be in case that the project will not be done) 5. geografical coverage and target population 6. project description goal objectives action plan detailed schedule (use a gantt chart) detailed budget 7. expected results 8. monitoring, evaluation and reporting (use indices as much as possible) 9. arguments to the success and possible riscs (feasibility, sustainability etc.) 469 project management 10. supporting materials (annexes: full description of the organization, cvs for the team members, recommendation letters, articles, statistics, documents that could support project utility, feasibility and sustainability) 470 health systems and their evidence based development references and recommended readings 1. burton c, michael n. a practical guide for project management. london (uk): kogan page limited; 1992. p.4-6. 2. lock d. project management. 6th edition, hampshire (england): gower publishing limited; 1996. 3. chalkley p. project management avoiding the pitfalls!, handouts from a training workshop on project management provided by crown agents – management training centre, bucharest, 1996. 4. pineault r, daveluy c. health planning – concepts, methods, strategies. revised edition. ottawa (canada): editions nouvelles; 1995. 5. marcu a, marcu gr. guidelines for the health programmes management. institute of public health bucharest publications; 2000. 6. champagne f, contandriopoulos ap, pineault r. a conceptual framework for health programmes evaluation. montreal (canada): rev.epidemiologie et sante 1985; 33: 173-181. 7. willoughby n. incredibly easy project management. victoria (canada): nwm ltd 1994. 8. wan t, ozcan y. introduction to grant writing. handouts from a workshop held at aiha third partnership conference for central and eastern europe, bucharest (romania); 1998. 471 project management 472 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title planning and programming of health care module: 2.12 ects (suggested): 0.25 author(s), degrees, institution(s) associate professor dr. kancho tchamov, phd, mph faculty of public health medical university sofia address for correspondence faculty of public health; medical university sofia hospital „tzariza joanna” 8, bjalo more str. 1527 sofia bulgaria tel: +359 2 9225197; fax: +359 2 9432304 e-mail: tchamov@bulinfo.net keywords public health, health care planning/programming, health caremanagement, goals, strategies, objectives, financial planning, monitoring, evaluation, planning team learning objectives applying the content of this module the student will be able: • to identify the determinants and the subsequent steps in the health care planning process; • to implement the public health planning/programming methodology at institutional, regional and national level; • to apply financial planning and budgeting technologies as a part of the overall planning/programming process; and • to monitor and evaluate health care plans/programmes. abstract health care planning and programming are future oriented processes aimed at defining strategies, activities and resources needed to achieve desired goals. the planning process consists of series of steps for accomplishing a set of targets to make the vision a reality. an experienced manager at any level of an organization should monitor the changes in the internal/external environment and the strengths and weaknesses of the planning design in order to increase its implementation effectiveness. health systems have the objectives to improve health, to respond to people's expectations and to provide financial protection in cases of ill health. the careful and responsible planning as part of the managerial process, whether undertaken by government or by private bodies, often under general rules determined by government has a pervasive effect on all the workings of the system. the presence of planning and implementation competences among the executive and field staff in the health system is an asset to the achievement of the desired final results. teaching methods lecture, individual work, discussions, group work specific recommendations for teacher this module should be organized within 0.25 ects, out of which one third will be under the supervision of teacher and the rest is individual student work. after the introductory lectures the student should become familiar with the steps of the planning technology and should start preparing a pilot plan/programme of a health establishment or a regional programme for achieving specific health care objectives or for reducing existing health problems. results can be presented and discussed in groups. assessment of students presentation or essay discussing the elaborated pilot plans/programmes, tests. planning and programming of health care kancho tchamov a comprehensive planning process provides the structure and the subsequent steps for implementing a programme, serves as a guide for the effective use of human, material and financial resources, and at the same time creates a common understanding of programme goals and objectives among the programme implementation team. many perfectly feasible and well financed projects fail to achieve the expected final results mainly due to the lack of full commitment on behalf of the senior staff and due to the lack of planning and implementation competencies among the executive and field staff. the most important components of an effective programme/project are a clear vision of the future and a well thought out detailed plan describing the steps that must be taken today, next month, and the years to come in order to accomplish the targets set and to make the vision a reality. although the planning process consists of a series of steps, it should not stop once the plans have been prepared. an experienced manager at any level of an organization should be continually on the watch for changes in the external environment and should be aware of the strength and weaknesses of the programme, ready to introduce adjustments in order to increase the effectiveness of the programme (1,2). planning is a future oriented process which allows a close look at the goals of a concrete organization or a programme/project aimed at defining what strategies, activities and resources are needed in order to achieve the desired goals. plans therefore answer the following questions: • what are the programme / project trying to achieve? • what is the present status of the organization? • where the organization wants to be in a period of 2 – 5 years? • how it is going to get there? • who is going to get the job done? • how will an institution / organization finance its programme? planning thus covers a wide range of tasks. both the setting of long-range 473 planning and programming of health care goals, strategies and the detailed activity planning for the immediate future are part of the same process. the annual work plans and budgets should usually be based on long-range goals and strategies but developed in a greater level of detail. critical for any programme’s success is the involvement of the senior as well as the junior staff in the planning process. an effective planning process can create a good proposal that could easily convince potential founders of the competence and the implementation abilities of an institution’s abilities to design and implement a successful programme. managers who possess effective planning skills have better chances to find additional funding, could have better control over their resources and could more likely achieve their objectives (3,4). 1. specific issues related to the planning process building up rational plans for preparing and implementing well-organized programmes require to meet successfully the following realities and challenges related to the organization of the planning process: planning defines roles and responsibilities – plans define who is responsible for what; they set measurable objectives for a programme/project; the division of labor makes the team members accountable for the implementation activities and the achievement of objectives. planning challenges the existing situation – planning is a prospective activity which usually aims for improvement; it is expected to introduce appropriate changes in a program’s environment which often require new strategies and new implementation technologies; the planning process puts the accent on the organization’s interests rather than on the personal interests; planning is closely related to changing the existing environment. planning is a team exercise involving different levels of staff – successful planning activities are performed by a team involving key staff members in the planning process; the composition of the planning group includes representatives of all departments of an institution or a programme, all key activities and groupings; the team members should share a common vision and should be motivated to contribute to the success of the designed programme (5). planning requires the consensus of key staff – many key issues relating to organizational strategy may result in conflicts which need to be managed so that final planning decisions can be productive; consensus planning needs experienced facilitators who consider that disagreements are constructive as long as they do not degenerate into personal attacks; the involvement of specialists with different professional background depend on the planning goals 474 health systems and their evidence based development and the type of the planning process; staff at all levels should have the possibility of making their views known to the planning team and should be kept informed about the issues discussed by the planners (6). programme planning is a time consuming business – in many institutions managers and staff underestimate the fact that planning is a time consuming exercise, leaving little time for their daily responsibilities and for the concentrated effort planning requires; preparing in advance a schedule for the planning meetings and an implementation schedule is helpful for a well organized planning process; organizing „staff retreats” moving to a different physical location for the planning exercise sessions can be a rational decision (7). 2. preparing a plan steps in the planning process developing a plan requires that the new programme under consideration be broken down into smaller parts to determine which activities must be completed when and by whom in order to achieve the planned objectives. a completed plan provides the structure for implementing the programme, serves as a guide for the effective use of human, material and financial resources, and creates a common understanding of programme goals and objectives for the planning team. when you start preparing your plan, first you have to identify the need and the demand for health care, and then to determine how to meet them for the specified target groups. this is a process containing the following steps: • stating the mission, or purpose of the organization/programme, • analyzing the external environment, • assessing internal strengths and weaknesses and external opportunities and threats (swot analysis), • establishing goals, • selecting activities for each objective; developing detailed work plans, • preparing a financial plan, • introducing a monitoring and control system. 475 planning and programming of health care 2.1. stating the mission (problem statement) stating the mission is the first step when preparing an organization’s plan. usually it is a general statement for the organization „per se”, about its vision, purpose and values. on the other hand a programme or a project should be created to respond to community defined needs or problems. so the first part of the plan should justify the need for the programme. this part of the plan contains the following two sub-sections: the problem statement – contains a description of a specific problem which should be solved or reduced by the programme/project. some baseline information should be presented that helps explain the problem such as: the nature, scope or severity of the problem; geographic area, demographic, health characteristics of the population; availability of health services (primary, secondary, tertiary etc.), health personnel, financial resources etc. the proposed solution – should contain a general explanation of the intentions and the design of the programme, stressing the important methodological aspects – most appropriate to address the described problem. the programme design should include: the approaches chosen for solving the existing problem; the expected positive results; sources of support now and in the future as well as the participating partner organizations/institutions; strategic alliances etc. (8). figure 1. stages of the mission statement 476 health systems and their evidence based development 1. problem analysis problem statement 2. solution expected outcome 3. outcome actual outcome activity plan strategy components activities objectives targets monitoring and evaluation 2.2. analyzing the external environment analyzing the external environment is the next step that relates to the organization’s mission, already defined in the mission statement. in general there are three main aspects that should be included in the external environment analysis: • collection of information data related to the programme/project from statistical sources and publications. • structured and informal interviews with administration officials/managers from ministries, municipalities, major donor organizations, ngos and private sector. • guidlines and summary of the main findings compiled in an information paper prepared for the planning team (1,2). when conducting the environmental analysis one should consider the possible information sources and the necessary information data relevant for the specific programme/project. in general terms the necessary information for conducting the external environment analysis may include: • macroeconomic data • data about the geographic and climatic conditions • demographic and health indicators • socio-economic information • health services information (outpatient and inpatient facilities, human resources, financing etc.) • policies and regulations • existing plans, intervention programmes and research projects in the health and social sectors etc. 2.3. conducting the swot analysis the next step of the planning process is to conduct a swot analysis in order to identify and assess the strengths and weaknesses of the organization or programme as well as the opportunities and threats on the bases of the information gathered within the frames of the external environment analysis (9). 477 planning and programming of health care table 1. components of the swot analysis the first steps of the swot analysis are aimed at defining the internal strengths and weaknesses of the programme or organization in respect to its management, programming and financing capabilities. a planning team should consider the items listed bellow and should decide whether the answers reveal strengths or weaknesses. the analysis of strengths and weaknesses of the programme/organization should cover the following management areas: analysis of management capabilities – determining subsequently the strengths and weaknesses in areas such as: organizational structures, planning, coordination, staffing, supervision, training, monitoring and evaluation procedures and systems, management information system, material resources management etc. analysis of programming capabilities – defining the potential capabilities of the organization/programme: to provide high quality medical services, training or education; to increase its efficiency; to provide grounds for improved patient satisfaction etc. this part of the analysis should define the weak points in the programme/project. what are the reasons for these weak points? what are the strong points? what expertise potential of the programme team reliable? are there activities that could enhance the programme/project under consideration due to the lack of human or financial resources? analysis of financing capabilities – analyzing the financing capabilities one should give answers to questions such as: what are the programme’s/project’s current sources of financing? what is the self-financing part of the project? how stable are the financial sources? what changes in the external environment are supposed to generate more revenues? where one can cut costs for the programme? what level of community or donor financial support does the programme enjoy etc.? the second group of steps in the swot analysis is to focus on the process of translating the environmental analysis into opportunities and threats. concretely one should identify those points that create opportunities for the programme and those that pose threats or obstacles to the performance or implementation process. this part of the swot analysis is usually carried out in a brainstorming session of the planning team. the analysis of opportunities 478 health systems and their evidence based development positive negative internal strengths weaknesses external opportunities threats and threats can explain past performance problems and failures and highlight the opportunities and threats that could possibly affect the process of achieving one’s goals. 2.4. establishing goals and objectives selecting goals a well-designed programme/project should have programme/project related overall goals. they define in general terms the long-term changes that will be the final result of the respective programme as outlined in the problem statement. normally one or two general statements describing the expected long-range positive results for the target population are sufficient to describe the overall project goals. organizational goals usually define the internal changes and improvements that the organization/programme should make in order to achieve its goals. in setting goals one should make sure that the programme related goals do not exceed the available financial, material and human resources. established goals should not over-extend the organization’s ability to provide quality services and the work team potential. source: health 21health for all in the 21st century. who, regional office for europe, copenhagen, 1999, p. 224 selecting objectives for each overall goal developed by the planning team there should be several specific and measurable objectives. these objectives should relate to the problem statement and describe expected results achieved through changes in knowledge, behavior and attitudes of the population or the target groups. the objectives should be used to ensure that evaluations conducted later in the project will measure the results the project intends to achieve. the objectives stated should be: measurable and observable; related to qualitative and quantitative targets as much as possible; and indicative for the specific time periods for the completion of the programme (10,11). 479 planning and programming of health care example of an overall goal: the health 21 policy for the european region of who has the following main elements: • the one constant goal is to achieve full potential for all. two main aims for better health guide efforts towards this ultimate goal: • promoting and protecting people’s health throughout the course of their lives; • reducing the incidence of and suffering from the main diseases and injuries. selecting strategies the next step at this stage is to select strategies for reaching the stated goals. the process of selecting specific strategies is aimed at defining the technology of reaching the desired final results. the planning team could in a brainstorming session come up with several possible strategies that could be evaluated in terms of feasibility, financial impact, projected costs and time perspective. using the information collected during the external environment analysis the planning team can analyze the existing competition on site i.e. look at what other providers (institutions, organizations, ngo’s) are doing. at the end of this step state the strategy the planning team has chosen. if the selected strategy has several components, state each of them. although at this stage a detailed final analysis of the cost of strategies will not be conducted it will be necessary to consider the financial implications of the proposed strategies. the planning team should roughly cost the strategies taking into consideration the recurrent as well as the capital costs. selecting activities for each objective the plan of activities constitutes the core of the programme/project and should describe the detailed activities to be accomplished for each programme objective. a fully developed plan will contain listed a detailed set of activities to be carried out in order to achieve each objective. staff members of the planning/implementation team should be assigned to each activity, being kept responsible for controlling and carrying out the activity. the activity plan is supposed to provide the programme/project team with a clear picture of their responsibilities and activities during the project implementation. it can be divided in two parts: selecting detailed programme/project activities under each objective all the activities necessary for the fulfillment of each objective should be listed. the description of the activities should explain concretely how each of them would contribute to the achievement of pro480 health systems and their evidence based development well formulated objectives should be: specific – concrete, avoiding differing interpretations measurable – quantifiable, allowing continuous monitoring and evaluation appropriate – relevant to the defined problems, goals and strategies realistic – achievable, challenging and meaningful time-bound – with clearly defined time period for achievement. gramme objectives. a staffing plan of the programme/project together with job descriptions for each post should supplement the activity plan. this section should contain: a description of all the activities to be carried out that answer the questions „what, where, by whom and when”; a description of the management systems (i.e. supervisory, information management, human resources and financial management) designed to support the activities listed; partnership activities etc. preparing programme/project activity timetable a complete activity timetable is a condensed summary of the main project activities in their planned chronological sequence. it is a detailed description of the time-span in which each activity should be performed and of the team members responsible for the implementation of these activities. the programme activity timetable is an important implementation tool and should be used for monitoring the activities and the short-term results; for keeping the planned implementation on schedule; and for managing the programme’s resources. a project activity timetable developed at the start of the project can be periodically updated and referred to by project staff on regular basis. it is helping programme planners and supervisors to integrate and coordinate their work, to monitor and evaluate the progress of the interventions under way. it is useful to specify when it is aimed to start each activity. for each task or activity listed, consider who will be responsible either for doing it or, in some cases, for making sure that it is done. critical elements of the programme planning process the following four areas of critical importance should be considered by the managers in order to develop a successful plan namely: procurement of equipment and supplies; training; service delivery and sustainability. procurement – the plan should include a procurement section supposed to list the types of supplies, equipment and materials necessary for the project. tender procedures should be foreseen for the procurement of costly commodity supplies. a system for logistics management with record keeping and reporting systems should be worked out for the distribution of supplies to service points. training – the plan should contain a training programme for the implementation team as well as for the target population. this section should focus on: the programme content; the participants’ background; the criteria for selecting the participants; the resource persons and the topics to cover; logistics plan etc. 481 planning and programming of health care service delivery – if the programme/project foresees the creation of new health services or expansion of existing ones, the planning team should provide detailed information on any programme activities necessary to support the implementation plan. they may include: the replacement of existing equipment; maintenance contracts; renovation or reconstruction of service facilities; follow-up activities etc. sustainability – the important issue of sustainability is related to the capacity of the organization/programme to cope with the future changes in the external and internal environment. the ability of a programme to attract external funding or to generate income and develop self-sufficiency are the ways to establish financial sustainability. a description of the activities that will generate income and the ways that income will be used should be included in the plan. 2.5. preparing a financial plan and a budget after selecting among the possible strategies, the planning team members make approximate estimates of costs against the revenues to determine their feasibility. while preparing a financial plan one should: analyze current and potential sources of revenue and expenses for the strategies chosen; assess whether the expected revenues will cover the expenses; monitor and revise activities to ensure the financial stability of the programme; prepare detailed estimates of revenues and expenses. the next step undertaken by the planners after defining strategies, objectives and activities is to prepare a detailed year-by-year budget and a summary budget for the life-span of the programme/project. this detailed estimate or a summary budget is the financial plan. once the financial plan is completed, the planning team can draw up a work plan and budget for the first and for every subsequent year. the budget will be based on the financial plan and will describe in much greater detail sources and amounts of revenues and expenses for the year to come (12). in order to prepare the detailed budget one should carefully examine each programme activity and define the costs that are associated with its implementation. all costs will then need to be sorted into budget categories. the first draft of the budget should contain only direct programme/project costs, e.g. costs which are directly associated with specific project activity. each item listed in the budget should be clearly identifiable in the activity plan. 482 health systems and their evidence based development sample budget categories there is no single correct way to develop a budget. when preparing a programme budget, check your organization’s budget categories and the types of costs included in each category. the categories listed bellow, provide a basic guide for developing and organizing a programme budget. • salaries and wages this category includes the sums to be paid to project personnel for salaries and wages. salaries are generally paid on a monthly or annual basis, while wages are paid on an hourly basis. in a budget each position should be listed with its title, the amount of monthly or early salary, the full or part working time and the hourly wages to be paid. salaries and wages under this cost category should be planned only for employees of the programme/project. • fees this category includes individuals who are not legal employees, such as short-term consultants and those hired under contractual agreements such as auditors, lecturers, researchers, evaluators etc. this category also includes honoraria paid for professional services rendered. the type of service, the individual performing the service and the cost of the service should be listed in the budget. • benefits this category includes all expenditures for benefits in correspondence with the existing labor legislation in the country and the approved policy and practice of the programme. benefits should be included only for persons listed under „salaries and wages” if the local laws does not mandate other types of entitlements. • travel and associated expenses this category normally includes regular and customary travel associated with the activities of the project. these costs may include travel for supervisory visits, staff meetings, outreach and field visits. • supplies and equipment office and medical supplies, commodities and equipment to be purchased should be listed in this category. the cost of each piece of equipment and commodity should be shown. • education and training the expenses related to this category refer to the costs of having participants in the programme attend specific training activities such as workshops, courses, seminars or conferences. it includes all expenses for tuition, training, fees, conference registration fees, travel costs, per diem, books and others. • general administration all expenditures that are not an issue of contractual agreements can be listed in this category. they include postage, freight 483 planning and programming of health care and shipping insurance, photocopying, printing, telephone, faxing, utilities, bank charges, publications, vehicle registration, employment advertising and other customary administrative costs. • purchased services this category refers to long-term contractual services or agreements with institutions. for example building rental, maintenance contracts for equipment or vehicles, long-term leases on equipment or vehicles, advertising or promotion services that are of major importance for the project. • unforeseen costs they include costs that do not fit into the abovementioned categories. such costs could be induced by: changing price and/or exchange rates, indirect cost rates etc. which can be listed here. there are four types for funding programmes or projects namely: entirely government funding; donor funding; funding through generated revenues; and mixed type of funding. in drawing up financial plans one should distinguish between the different types of funding since the reliability of each source is different. the planning process with no doubt will vary according to whether the organization or the programme is situated in the public or in the private sector (13). a sample of a planning schedule is presented in table 2. table 2. steps in programme planning – sample schedule 484 health systems and their evidence based development steps in planning participants time needed dates mission statement top and mid-level management three-hour meeting january 14 environmental analysisreport consultants and technical staff data collection four weeks jan. 14 feb. 14 swot analysis formulating long-term goals defining strategies and objectives swot analysis preparing financial plan departmental objectives 3. programme monitoring and evaluation monitoring and evaluation plans of programmes/projects should be included in the initial programme design. the monitoring and evaluation process should be base on carefully selected indicators appropriate to the social, economic, health and information realities and possibilities. 3.1. monitoring monitoring is a process by which programme activities and the programme-budget are regularly reviewed. monitoring helps to ensure that the activities planned in the work plan are being completed and that the costs are in line with the budget provisions. financial monitoring enables the project team to: control the rational spending of the budget; to verify that the team leadership’s financial decisions are being followed; and to define whether budget revisions are needed. monitoring of implementation and evaluation of effectiveness and impact normally take place at two levels: the policy making level; and the managerial and technical levels. both levels should be interlinked (14). in monitoring programme implementation it is important to use as reference points those objectives and targets that have been set as part of the process of formulating programmes and designing the health system. it is particularly important to monitor whether priorities are being adhered to, realizing that these may have to be implemented progressively. indicators are then selected that can measure change toward attaining the objectives and reaching the intermediate and final targets (15). a monitoring plan should include at least the following: • creating a monitoring team which to include programme/project personnel who will be assigned the task to monitor the programme development, programme management and financial activities; 485 planning and programming of health care setting targets preparing work plans preparing annual budget discussion and approval of departmental plans • control over the timely monitoring procedures and their organization; • development of criteria to be used for monitoring the programme activities; • development of monitoring protocols. 3.2. evaluation the evaluation of a programme/project is a process of critical assessment of the degree to which the entire project or service components fulfill stated goals. it is important to have a plan for assessing project achievements during and after the implementation of a programme/project. the evaluation of a programme should analyze: the implementation process – referring to whether the planned activities were carried out and completed; the outcome outcome evaluation often require a long term monitoring of structures, activities and staff performance; and the impact – e.g. the long term effect that the project had on solving the target problem or on the target population. developing the evaluation section of the plan will make known in advance what elements of the programme will be evaluated, how and when the evaluations will take place. the scope and the content of the evaluation technology (i.e. what and how programme results should be measured) will help strengthening the team motivation for reaching the objectives of the project. in general terms an evaluation plan should include: • sets of evaluation criteria developed by the planning team • description of the evaluation technology used • information collection and processing • a reporting system the development of monitoring and evaluation criteria should be based on the use of appropriate indicators. the indicators to be used can be grouped into the following five categories: 1. health policy indicators; 2. social and economic indicators; 3. indicators for the provision of health care; 4. indicators of health status and the quality of life, and 5. performance indicators. 486 health systems and their evidence based development at present many health care planning decisions are based principally on values and resources, i.e. opinion – based planning/programming; insufficient attention is paid to evidence derived from new information sources or to evidence from research findings. nowadays as the pressure on the resources allocated to health care increases, there should be a transition from opinion–based planning to evidence-based planning decision making, adding sufficient evidence to this process. the management skills necessary for health care planning/programming in the 21st century will require: the planning decisions to be made explicitly and publicly; and the enough competence of those involved in planning exercises to produce sufficient evidence for efficient decision making (8,11). 487 planning and programming of health care exercise: planning and programming in health care task 1: students should use the recommended readings to increase their knowledge on the health care planning and programming technology, and the implementation of the subsequent planning steps in virtual and real situations. small groups’ planning exercises will be assigned aimed at elaboration of health care plans/programmes for pre-selected establishments at different levels of the health system. results can be presented and discussed in groups. task 2: students will be asked to prepare individually a comprehensive planning exercise for a health area close to their professional background related to curative, preventive or health promotive activities within the health care system. the selection of the problem areas and / or institutions as focal points of the planning exercise will be selected with the support of a tutor. the elaborated plans/programmes will be presented and assessed in plenary sessions. 488 health systems and their evidence based development references 1. varkevisser cm, pathmanathan i, brawnlee a. designing and conducting health systems research projects: vol.1. proposal development and fieldwork. idrc, otawa, 2003, p. 380. 2. varkevisser cm, pathmanathan i, brawnlee a. designing and conducting health systems research projects: vol.2. data analysis and report writing. idrc, otawa, 2003, p. 320. 3. ritsatakis a, barnes r, gekker e, harrington p, kokko s, makara p (editors). exploring health policy development in europe. world health organization, regional office for europe, copenhagen, who regional publications, european series no 86, 2000, p. 537. 4. the world health report 2000. health systems: improving performance. who, geneva, 2000, p. 215. 5. geller rj. the first year of health improvement programmes; views from directors of public health. j public health med 2001; 23 (1): 57-64. 6. segall m. district health systems in a neoliberal world: a review of five key policy areas. int j health plann manage 2003; 18 suppl 1: s5-26. 7. programming for adolescent health and development. report of a who/unicef study group on programming for adolescent health. who, tech. rep. ser. 1999; (886): i-iv. 1260. 8. mossialos e, dixon a, figueras j, kutzin j (editors). funding health care: options for europe. european observatory on health care systems series. open university press, buckingham-philadelphia, 2002, p. 309. 9. good practice in occupational health services: a contribution to workplace health. who regional office for europe, copenhagen, 2002, p. 80. 10. the 10/90 report on health research 2001-2002. global forum for health research. c/o who, geneva, 2002, p. 224. 11. muir gray ja. evidence-based healthcare: how to make health policy and management decisions. churchill livingstone, new york edinburgh london, 1997, p. 270. 12. saltman rb, busse r, mossialos e (editors). regulating entrepreneurial behavior in european health care systems. european observatory on health care systems series. open university press, buckingham-philadelphia, 2002, p. 240. 13. macroeconomics and health: investing in health for economic development. report of the commission on macroeconomics and health. presented by j.d.sachs. who, geneva, 2001, p. 202. 14. mckee m, healy j (editors). hospitals in a changing europe. european observatory on health care systems series. open university press, buckingham-philadelphia, 2002, p. 295. 15. saltman rb, figueras j, sacellarides c (editors). critical challenges for health care reforms in europe. open university press, buckingham-philadelphia, 1998, p. 424. 489 planning and programming of health care recommended readings 1. varkevisser cm, pathmanathan i, brawnlee a. designing and conducting health systems research projects: vol.1. proposal development and fieldwork. idrc, otawa, 2003, p. 380. 2. varkevisser cm, pathmanathan i, brawnlee a. designing and conducting health systems research projects: vol.2. data analysis and report writing, idrc, otawa, 2003, p. 320. 3. exploring health policy development in europe. ritsatakis a, barnes r, gekker e, harrington p, kokko s, makara p (editors). world health organization, regional office for europe, copenhagen, who regional publications, european series no 86, 2000, p. 537. 4. cassels a. guide to sector-wide approaches for health development. who, geneva, 1997, p. 80. useful internet sites • http://www.who.int • http://www.who.dk • http://omni.ac.uk 490 health systems and their evidence based development health policy 491 comparative analysis of regional health care systems in the european union 492 health systems and their evidence based development 493 informed health policy and system change health systems and their evidence based development a handbook for teachers, researchers and health professionals title informed health policy and system change module: 3.1 ects (suggested): 0.75 authors, degrees, institutions prof. vesna bjegovic, md, msc, phd professor at the school of medicine, university of belgrade serbia and montenegro dr bosiljka djikanovic, md address for correspondence institute of social medicine, school of medicine, belgrade university dr suboti}a 15, 11000 belgrade serbia and montenegro tel: +381 11 643 830 fax: + 381 11 659 533 e-mail: bjegov@eunet.yu (vesna bjegovic) e-mail: boss@bitsyu.net (bosiljka djikanovic) keywords health policy, strategy, priority, management of change learning objectives after completing this module students and public health professionals should: • increase their understanding of health policy; • understand the steps in the process of health policy formulation; • identify goals of health policy in a broader sense; • recognize main problems which could affect goals implementation and adopt recommendations for their solving; • explain the role and responsibility of key stakeholders in health policy; • identify similarities and differences between global and national health strategies; • realize the importance of skilled and comprehensive educated manager for implementation of health system changes, as well as their monitoring and evaluation. abstract the modern health policy in its broader sense is striving towards a continual process of the population health improvement, through implementation of goals and priorities. principal actors concerned for health policy are the government, ministry of health, health providers, health care consumers, health insurance and the general public through governmental and non-governmental organizations. for successful implementation of health policy, the number of established goals and priorities must be reasonable and wide consensus between interested groups should be achieved. the process must be followed by continuous monitoring and evaluation. the recommendations for the health policy changes refer to redefining roles of the state and the ministry of health, providing for the decentralization process at all levels, the regulation of the privatization process, sustainable financing of the health care system, the application of modern management at the system and institutional levels, the development of health information system as a support, and education of managers in this field. teaching methods teaching methods include lectures and small group discussion. teacher should advise students how to use internet source in preparing exercise comparing health policy indicators. 494 health systems and their evidence based development specific recommendations for teacher it is recommended that the module should be organized within 0.75 ects credit, out of which one third will be done under supervision, while the rest is individual student's work. teachers should be familiar to give examples of specific issues following the policy cycle. assessment of students multiple choice questionnaire and quality of seminar paper (or oral presentation) will be assessed. informed health policy and system change vesna bjegović, bosiljka đikanović a policy is a guiding principle or a plan of action agreed to by a group of people with power to carry it out and enforce it. as a discipline health policy has its roots in political science – especially public policy – which is based on sociology, law, economics, decision theory, operational analysis and history (1). public policies are aimed at the whole population or at specific, target groups and can be created by all levels of government as well as by institutions such as school boards, hospital workplaces or community organizations. public policies are made through a process involving citizens, government officials, an elected officials who, ideally, working together to set an agenda for the common good. policies shape our daily lives by regulating such things as where and when citizens may use pesticides, where we can or can not smoke, which medications and treatments health plan will cover, what is safe environment and so on. policy making process is not something that takes place only among the most powerful in society. in countries with democracy public opinion and actions of interest groups become very important. one of the key functions of public health professionals is to influence and shape policy decision at all levels for the benefit of the population. influencing policy at any level requires an understanding of public policy, how it is developed and what levers are available to influence the policy making process. the health policy, „as a series of goal-oriented actions undertaken by authorized participants (usually government and state representatives)”, is a relatively new domain of interest in professional groups even in highly developed countries (1). this interest is presumed to be a scientific response to an intensive development of the health system in the 60’s and 70’s of the twentieth century, an attempt to explain the reasons why the states tackle the actions aimed at proposing the course and contents of changes in the health system. in pluralistic democracies, health policy becomes the focusing mirror for all other policies. it encompasses debates over money, access to services, health care quality, and outcomes. it also continuously reflects changes both in social context and in the very scientific base of medicine. there are no single issues in policies, and no clear boundaries; every political issue can ebb and 495 informed health policy and system change flow, and anyone can rise up overnight to dominate debate. similarly, in health policy, every societal problem ultimately presents itself as a health problem. health care can easily find itself affected by policies about an extremely wide variety of social issues. there are few clear boundaries. social disintegration and economic trauma leads to unemployment, alcoholism, violence, drugs, teenage pregnancy – all become health care issues. the modern health policy in its broader sense is striving towards a continual process of improving the population health (2,3). it represents the formal statements or procedures within the government and institutions by which the priorities and action parameters are defined as response to health needs, available resources, and various political pressures. the health policy can also be defined as a science of the health system management (4). it comprises ideology, tradition, and aspirations of authorities, while its basic purpose is to set up the path for the health system development, its strategy, the goals, priorities and means, as well as to establish a particular mechanism of evaluation for the realization of the priorities. very often the health policy is described by using the policy cycle (figure 1). figure 1. the policy cycle the health policy is often followed by laws or other legal regulations, which define the incentives that enable the health services and programmes to 496 health systems and their evidence based development agenda setting pol icy formulation policy legitimation policy implementation policy termination or change pol icy evaluation be provided for. as is the case with other policies, the health policy arises out of the systematic processes of creating the support for evidence based public health action, and it is integrated into community’s endeavors, the political reality, and available resources (5). in the last few years, both in developed and developing countries, efforts have been visible to reform the health policies through various changes relating to priorities, institutional – organizational structures, methods of financing, and health regulations. the health policy reform are decided upon by a governmental body, but the reform also affects the public and private institutions, it is inevitably occurring in the actual political framework, and it depends on the form of a given country’s political system (parliamentary democracy, presidential democracy, one-party rule, dictatorship). the health policy as the foundation for the reform of the health system outlines the reflection of social values or ideals (such as accessibility to health care of high quality, education, government’s responsibility), which determine the choices and actions. the process of formulating the health policy undergoes at least three clearly defined steps (6): • setting the goals and resolving the priorities (a process by which public attention is drawn to it and these are placed on government’s agenda), • adoption of the policy (legislative process by which elected bodies decide upon a broad policy framework), and • implementation of the policy (a process by which administrators apply the policy, specifying numerous issues not covered by the health legislation). the reformist interventions in any health policy imply the key role and partnership for the basic interest groups in a political structure: the state, health providers, health care consumers, health insurance and the general public through governmental and non-governmental organizations (7). the state, acting through the minister of health, impels the managerial structures in all sectors to be oriented towards policies which facilitate health promotion. the partnership between the health and local authorities enables the local problems to be solved in the case both structures are directed towards the appropriate goals (8). unfortunately, it is often the case that a health policy proves inefficient, for the lack of a clear strategy, or the goals and priorities adopted by all parties involved, and if these are created by the most powerful and influential groups, such as clinicians’ »lobbies«, or by politicians outside 497 informed health policy and system change the health sector. it also happens that in the process of reform only the goals and priorities are changed, without their implementation and evaluation, while the health policy itself remains an instrument for both the actual ruling group and the opposition, or some informal centers of power and authority (4). health policy goals and priorities the goals in the broadest sense represent the desired state of affairs toward which the activities and resources are directed, but which may not be achieved necessarily (9). even though there is a tendency to quantify the goals, many distinguished authors point to a »virtue of vagueness« when setting up the general goals, and to the necessity of their constant reassessment (10). this is reflected in the fact that the health systems differ from one country to another, and even then most of them have similar general values and goals of their health policies (11): • availability of health care and equality of the consumers in the system – achieving equity in access (envisioning the existence of a minimum health care available to each citizen and an equal treatment for equal needs within the state/social health sectors); • material security of citizens (foreseeing that patients are protected from such health care payments which could seriously impair their incomes, that is, their contribution in the cost of health services is to be connected to their ability to pay); • macroeconomic efficiency (implies that the health care costs should be allocated an adequate amount out of the national income in order to secure certain level of health care for the population); • microeconomic efficiency (meaning that an improvement of population health should be maximized according to the level of resources invested in the health system, i.e., to achieve as much as possible with the allocated resources); • freedom of choice for the consumers (expects the freedom of choice among different providers to exist for the consumers of the health system); and • adequate autonomy for the service providers (implies the freedom of doctors to work in a way that they consider to be in the best interest of a patient), which is compatible to fore mentioned goals. 498 health systems and their evidence based development a characteristic of the stated general goals is that they are oriented to outcomes, and that they orient decision-makers onto outcomes, as opposed to former approaches when the goals, not so long ago, were rather oriented to expensive health care inputs (such as, for example, the number of newly provided hospital beds, or a larger sum of money spent on health services) (12). recognizing these general goals in determining the health policy most countries adhere to the recommended goals of international health organizations and the international community. among those the most cited and, according to many authors, the most ambitious health policy is the one formulated by the world health organization »health for all by the year 2000« and »health for all in the 21st century« (13,14). the literature dealing with health policy also often cites “un millennium development goals”, the health policy formulated in the united states as »healthy people«, as well as the health policy of the european union (table 1) (15,16,17). the world health organization adopted a resolution back in 1977 emphasizing as the main social goal for more than 190 countries members »the achievement of such a level of health for all people which would enable them to lead a productive social and economic life«, with an active participation of all people in the determination of health and in the development of a socially oriented primary health care. the dimensions of the european strategy »health for all« initiated in 1980 referred to the equity of all people in the health system. they were oriented to health improvement, to active participation by an informed and motivated community in achieving health, to inter-sectorial cooperation, development of the primary health care according to the health needs of the population, and to the international health cooperation concerning the problems which surpass national frontiers (13). relying on the indicated dimensions, the regional organization for europe in 1984 formulated 38 regional targets describing how the present circumstances must be changed by the year 2000 in order to achieve health for all. regional targets by the year 2000, according to the contents, are grouped into three spheres: • basic requirements for health, • necessary alterations (healthy life styles, healthy living environment, and an adequate health care), and • support systems for health development. 499 informed health policy and system change table 1. un millennium development goals (mdg) 500 health systems and their evidence based development 1. eradicate extreme poverty and hunger • reduce by half the proportion of people living on less than a dollar a day • reduce by half the proportion of people who suffer from hunger 2. achieve universal poverty education • achieve that all boys and girls complete a full course of primary education 3. promote gender equality and empower women • eliminate gender disparity in primary and secondary education preferably by 2005, and at all levels by 2015. 4. reduce child mortality • reduce by two thirds the mortality rate among children under five 5. improve maternal health • reduce by three quarters the maternal mortality ratio 6. combat hiv/aids, malaria and other diseases • halt and begin to reverse the spread of hiv/aids • halt and begin to reverse the incidence of malaria an other major diseases 7. ensure environmental sustainability • integrate the principle of sustainable development into country policies and programmes; reverse loss of environmental resources • achieve significant improvement in lives of at least 100 million slum dwellers, by 2020 8. develop a global partnership for development • develop further and open trading and financial system that is rule-based, predictable and non-discriminatory. includes a commitment to good governance, development and poverty reduction nationally and internationally • address the least developed countries' special needs. this includes tariff and quota-free access for their exports; enhanced debt relief for heavily indebted poor countries; cancellation of official bilateral debt; and more generous official development assistance for countries committed to poverty reduction • address the special needs of landlocked and small islands developing states • deal comprehensively with developing countries' debt problems through national and international measures to make debt sustainable in the long term • in cooperation with the developing countries, develop decent and productive work for youth • in cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries • in cooperation with the private sector, make available the benefits of new technologies especially information and communication technologies source: un, http://www.un.org/millenniumgoals/ such health policy has stimulated many european countries to formulate their national strategies and, in many cases, to set their own goals in order to improve health (12). the world health organization has recently reevaluated critically the achievements in the realization of the targets set for 2000 and regional organization has created a new set of goals for the health policy in europe – »21 targets for the 21st century« (14). this new health policy clearly promotes social equity, as well as definition for the key values and objectives. the european targets, 21 in number, rely on 10 global ones which may be divided into three groups (14) (the who european targets are presented at the who web page): • targets in relation to the people health outcomes, • targets in relation to health determinants, and • targets in relation to the health policy and sustainable health care system. concomitantly with formulating the targets for the european region, the world health organization also suggested some possible strategic guidelines and certain solutions for the implementation of national policies. for example, as for the health promotion, the projects and programmes with some positive experience are particularly recommended, such as »healthy cities«, »health promoting schools«, »healthy hospitals« and similar. after fifteen years of experience in designing, implementing, following, and evaluating the health policy, it is appraised that the highest achievements of this policy for health are strengthening the public health orientation through the health promotion and healthy life styles, healthy living environment, health care oriented towards quality and efficiency, and in a considerable improvement of knowledge about the creation of »the public health policy« (18,19). the public health policy is characterized by explicit care for health and equity in all spheres of politics, and by responsibility for influencing the health (5,18). the main goal of the public health policy is to create an environment which sustains and enables people to lead a healthy life. such a policy makes healthy choices possible and easy for all citizens, and it is based upon an approach which promotes health, according to which the governments are ultimately responsible for the health consequences of their policies, and for their shortcomings, too. adherence to the public health policy means that the governments are obliged to measure and report on their investments in health. investment in health is a strategy to optimize the influence of public policy onto the health promotion (18). however, questions are raised as to usefulness of formulating the precise goals as components of the health policy, and particularly of indicators 501 informed health policy and system change used in following their realization or failure (20). therefore, the recent reviews of goals point that the efficiency of a health policy is highly dependent on the implementation which is divided into three levels: • intention to define the goals on a political level, • developed plan at the political level, and • a plan for the implementation of goals at the practical level. development at a political level requires recognition of needs for an action and a political will for implementation. some countries recognize this need for action more than others. even when there is a political will to act and an agreement on the course of changes, the goals may remain unrealized. the experience of certain countries in the implementation of the formulated goals reveals the following recommendations (19): • a wide consensus among all interest groups is necessary, • the number of goals has to be limited rationally, for most of the national policies are focused onto five to ten goals, • each goal must be founded upon evidence on efficiency, which is particularly difficult when it concerns the health promotion, and • the goals must be conformed to available resources. according to one of the world health organization’s analyses of 1997, political responses in the process of the health system reforms in many countries throughout europe can be observed as distributed into two categories: formulation of goals, and classification of specific interventions (21). the first group includes: change of the role of the state and market in health care, decentralization onto lower levels in public-state sector and towards the private sector, strengthening and greater choice for the citizens, and improvement of the role of public health. the second group comprises interventions classified according to achieved outcomes, differing the successful ones from those less so. in the european union the health policy lays particular emphasis on public health in regards to the goals, as is also recognized in the ec treaties even in the maastricht treaty adopted in 1992 (17). social character of the health systems in the european union is based on the premise that „health care in not a normally traded good and access to it is a fundamental right” (22). member states have stated, in the treaties, that the organization and delivery of health services and medical care remains a matter of national competence. the driving force of the european integration process has been establishment of a single market. the european commission, the european parliament and 502 health systems and their evidence based development the council of ministers are the principal actors responsible for planning and implementing policy in the eu. this tripartite structure also ensures the process of health policy making based on the principle of subsidiarity. subsidiarity is the eu principle which states that action should not be taken by the community unless the objectives of the proposed action cannot be dealt with properly at national level. sometimes, this is used by opponents of eu health policy to say that eu should not have any powers in public health field. this means in practice that a health measure can be declared illegal if it does not improve the internal market and consequently economic interests are given political priority over health. on may 1st 2004 the eu underwent the latest enlargement as 10 new countries joined it. this one is different from those that have gone before, particularly according to the level of development between the member states and will almost certainly have implications for health and eu health policy (22). at present health and social policy in the eu is being developed in a different fashion, which follows expectations related to four freedoms (22,23): • free movement of goods, • free movement of persons, • free movement of services, and • free movement of capital. recent developments in the countries of the european union show that, notwithstanding the globalization and creation of a unified european market, this was not subject for debate when the national health policies were reviewed, and the european union itself has so far only had general recommendations for the health policy. those general recommendations were formulated through goals referring to advocating the health promotion, to the prevention of certain diseases affecting the whole of humanity, to the pertinent mechanisms for the inclusion of the community and the strengthening of research in the field of public health, particularly the health care for certain population groups, such as the elderly, the poor, the refugees and roma population. however, as a group of experts recently cited picturesquely, »the global economy (of the european union) is sitting at the table, while health politicians discuss financing the hospitals and paying the doctors at national levels« (24). as an example, the patients in the european union can now freely choose where to obtain their glasses or orthopedic appliances. the possibility of such a choice is reviewed as to the selection of hospital, which would have serious consequences in the sphere of financing the national health care systems, as 503 informed health policy and system change well as for the arrangements with hospitals. as joining of 10 central and east european countries is happened, the health policy of the european union will have to take into account the needs and expectations of their inhabitants. also, it is not only economy which is connected to the national health situation in the european union. the countries of the european union recognize the significance of other issues stemming parallel from the establishment of freedom of movement of people, goods, and services, such as ethical standards. for example, some countries forbid by their national legislation certain procedures in prenatal diagnostics, but they cannot prevent future parents from being informed about them in other european countries. also, the growth of poverty, the new and old communicable diseases, emergence of resistance to vaccines, but also the sale of body organs and pharmaceutical products, point to the necessity of comparative research, particularly the health status, and increase the need for greater coordination among the european union member states. under the conditions of exceptional mobility, the national legislatures are facing potential inefficiency. thus, the national health politicians in europe will have to find balance between the standards required by their own public and what can be achieved through their national legislation. it is assumed that the european union would have to formulate more specific goals in this sphere, while it is certain that the european health systems would not be determined in a single centre, as it is the generally accepted principle that the health service, which is to respond to the consumers’ needs, cannot be organized through »supra-national bureaucracy«. however, even the national legislation must be adapted to the change, and health politicians should take the environment in the neighboring countries into account (23). it is presumed that, beside the reviews of health policies at the political panels, such as the european health ministers’ meetings, some broader analyses are also required, performed by multidisciplinary professional teams. one of the indicators of the growing interest among the professionals is the publication started in 1999 of a bulletin where information is exchanged and challenges recorded in the fields of national health policies in europe (european health forum gastein – issues in european health policy, which is accessed free of charge on the internet). effective advocacy for health and health policy in europe is also supported through the open method of coordination, which facilitates policy reform by promoting mutual learning among member states. the open method of coordination gives a concrete meaning to the european social model, by helping to build consensus and to create a greater balance between the social and the economic dimensions in eu policy. this method includes: 504 health systems and their evidence based development • fixing guidelines for the eu combined with specific timetables for achieving their goals; • establishing indicators and benchmarks as a means of comparing best practice; • translating the eu guidelines into national / regional policies; and • periodic monitoring, evaluation and peer review. the open method of coordination is a process in three stages: 1. a political agreement on common objectives, 2. each member states submits a national action plan, explaining how it proposes to pursue the objectives (use of common indicators, easily comparable, benchmarking and good practice), and 3. follow up – joint report and corrective action used under the peer pressure. after the national goals are set in any health policy, there remain other challenges which are related to their implementation and prioritization. it is necessary to understand the actual patterns of the population health status. design and implementation of activities which are to lead to the realization of the goals require a high level of managerial skills in the sphere of public health. the following of progress requires acquaintance with the natural course of a disease. the crucial question is how much time does the achievement of goals take, and whether the set goals lead to any differences in health. the simplest answer to these questions is that it depends upon many factors, for there is no simple model for a health policy based solely on goals, just as there is no simple model of governance. measurement of progress in achieving the goals of each health policy is mainly determined by the nature of the set of goals which are to be measured, and in the european context the indicators suggested by the world health organization referring to the development of a health system founded on primary health care and on planning and managing the health system are most often used (13,14). as the external and internal environments pose numerous objectives to the health care system, a clear definition of priorities is an imperative as it secures monitoring and evaluation in the process of achieving the goals. 505 informed health policy and system change changing the legal basis for health and health policy is ongoing process everywhere and in the european union it could be recognized in the convention on the future of europe (http://european-convention.eu.int/). according to this document essential to ensure health is an objective of the eu and a shared competence of the eu and member states. the role of the state and the ministry of health in all health systems the state has the role of a collective mediator between other system actors: population – the consumers, providers, those who generate resources, other sectors. besides, it also performs a series of other functions, sometimes isolated ones, but more often combined. thus, the role of the state in the process of the health policy development refers both to guaranteeing that the changes in the health policy would be adopted by all the stated participants, and to the implementation of those changes, particularly of those that are related to the process of centralization – decentralization, privatization, and financing the health system (21). at the same time, the national health policy in the process of reform is supposed to secure an adequate approach to defining the role of the state. as can be perceived from the experiences of other european countries the role of the state goes beyond traditional measures of »command and control« and it furnishes incentives for the development of regulated market-oriented models of providing the health services. it is especially notable that the regulatory measures by the state are supposed to be more flexible and to temper through national legislation the multitude of differences (territorial, demographic) that often exist in democratic states. effective regulation by the state, too, is to be reinforced by following and evaluation of outcomes, not by contracting certain inputs (expensive equipment, enlarged hospital capacities, and similar). beside the state regulation, the health policy is to advocate the competitive state measures which are to provide for the process of active privatization, as well as for a competent supervision of contracting, and other market mechanisms by the state (24). as for the responsibility of the state, it is considered that the basic one is the responsibility referring to securing the accessibility to the nationally guaranteed set of services for each individual. besides, responsibilities of the state are also (25): • national planning and supervision of the regional plans, • incentives for offering the health care to vulnerable populations, 506 health systems and their evidence based development • to offer certain additional services out of the obligatory set of services which are financed outside the adopted model (e.g., outside the obligatory health insurance), • to organize data collection on population health status and on functioning of the health care system, and • concern for the programmes of continuous quality improvement – total quality management. according to the london institute for health sector development, the future of a health ministry, as a representative of the state, is to be freed from operational duties so that it can concentrate upon the health in its broadest sense (26). in the public sector this would mean: • the stimulation of activities which ensure that the financing process be connected to the needs of the health service, • the work with partners in the development so that duplication and administrative burden of multiple projects would be avoided, and • offering the national information on the quality, efficiency, protocols, data, and priorities. in case of the private sector the role of the health ministry refers to: • the control of the size of the private sector (too many providers means too much use), • the registration and follow-up, • the encouragement of self-regulation, • the control of the expensive technology, and • the contracting of services which are to be financed from public funds and which would have the adequate standard of quality. the position of decentralization in the health policy the issue of decentralization takes up a key position in the scope of measures of reforms of the health policy in most european countries, especially those in transition. the decentralization designates, in the broadest sense, transfer of authority and responsibilities from the higher to the lower levels of authority. the transfer of authority from the central administration to the bodies of smaller and local communities does not mean at the same time that the central administration would be deprived of all authority. on the contrary, it 507 informed health policy and system change would still retain important functions, such as legislative, financial, regulatory and other duties. the most prominent goals realized through decentralization in the field of health care are the following (23): • stimulation of improvement of offering health care services, • better allocation of resources according to the consumers’ needs, • diminishing of inequity in the sphere of health, • community involvement in the decision-making on priorities, • faster and more adequate reaction to the consumers’ needs, and other objectives. decentralization removes all those shortcomings that are ingrained in centralization, such as: inefficiency, slow acceptance of changes and innovations, delayed reactions onto factors endangering population health, susceptibility to political manipulations, and numerous other failings. decentralized institutions have multitude of advantages. they are more flexible than the centralized institutions and more effective in identifying the problems and prospects for their solutions. they generate higher morals and greater productivity. the decentralized structure also bolsters the partnership of health politicians with the citizens and local groups, and thus it also expands democracy in making political decisions concerning health at a local level. a successful decentralization requires specific social and cultural environments. certain local administrative and managerial capacity is required most of all, as well as readiness to acknowledge several interpretations of a single problem. the issue of decentralization is a very complex one, and when it is to be introduced the right measure has to be found. any excess, whether it refers to total centralization or total decentralization, affects negatively the proper course of the health care process. experience with the decentralization in many countries reveals that certain areas in decision-making should not be decentralized, and those are (21): • the basic health policy framework, • the strategic deciding on the development of health care resources, • the regulations related to public safety, and • the monitoring, estimation, and analysis of the population health status and of the health services offered. 508 health systems and their evidence based development recommendation for the health policy changes the recommendations for the health policy changes in the recent literature refer to: • redefining the roles of the state and the health ministry, • providing for the decentralization process at all levels, • the regulation of the privatization process, • sustainable financing of the health care system (elaborated in the section on financing), • the application of modern management at the system and institutional levels (also elaborated upon in the section on health management), • the development of health information system as a support to the health care system management (elaborated in a separate section), and • education of managers in the health care system. redefined roles of the state and of the ministry of health the states of countries in transition are supposed to have an important role in the whole health care systems, the one, however, which is quite different from the one that they have today, the one which is matched to the role the same bodies have in other modern countries. in a reformed health care system, the state, through its authorized ministry, must be engaged in at least the following areas: 1. adoption of documents at the government level on public health policy, i.e., the health promoting policy. the aims of such a document are to set up the health high on the priority list in the country, and also to undertake concrete activities thus oriented, with the health promotion approach. these activities do not involve only the health sector, but are obligatory for all the segments of a community that can contribute to health, or else endanger it. it is also necessary to define precisely the role of the non-governmental organizations, those directly or indirectly preoccupied with health promotion, while they can offer serious assistance to the governmental institutions in their allencompassing interventions in the education for health. 2. adoption of documents at the level of the health ministry on the health of the nation, which define the priorities in the health care system in the sphere of 509 informed health policy and system change health care, but also referring to the organizational forms. such a document is to be conformed to the mentioned documents of the european health policy, being the strategic foundation for the formulation of specific objectives evidence based from research on the health needs, financing, and functioning of the whole health care system in the country. the specific objectives are to be furnished with a time frame for their achievement and a flexible process in which the change is tested locally, or in pilot environments before it is widespread all over the country (27). 3. regulative – legislative role. beside a number of regulations and laws decreed by the state, it is of utmost importance to regulate the private sector in the health care so that active privatization is defined. 4. strategic planning aimed at the realization of defined goals of the health policy, especially to assure the guaranteed rights of citizens and their general interest in the health care. 5. initiating and financing the strategically important programmes of health care (children health, family planning, health promotion programmes, prevention of spreading of some diseases, both infectious and chronic, health care for those not insured, capital investments). 6. establishment of health institutions to perform the health care at the tertiary level and the rights stemming form it. 7. the control role, covering a range of duties at different levels and of different importance. beside the noted monitoring and control over the legislative sphere concerning the performance of the health insurance system and the health institutions of all forms of ownership, it is also necessary to set up monitoring of the quality of work, the mechanisms for the accreditation of health institutions, both state-owned and private ones, then of the individuals in those institutions, either generally or for specific services. an important control role consists of formulating the assessment mechanisms for the introduction of new technologies (health technology assessment), as well as control of the use of highly specialized health care (utilization review). 8. defining the strategy for the development of the health information system and its architecture (v. section on health information systems). 9. initiating the strategic research concerning the decision-making in the health care policy. 10. foundation of the national health council as an independent expert-advisory body for the matters concerning the health care, made up of experts and renowned professionals in certain fields. 510 health systems and their evidence based development providing the decentralization process at all levels in a reformed health system a particular place is given to decentralization. promotion of the primary health care as the foundation of the whole health system necessitates the obligation to transfer the bulk of authority from the central governmental bodies onto the local ones. in a decentralized health system, the municipality and the city are to: • follow the population health status on their territories, and to propose and undertake the required activities. • adopt and carry out the programmes for the improvement of population health status on their territories which are not encompassed by the referential programmes at the national level. • provide for the realization of the public health activities on their territories which are not encompassed by the referential programmes at the national level. • adopt and carry out the programmes for the development of a healthy living environment which are not encompassed by the referential programmes at national level. • establish the health institutions the performance of which provides the realization of the legally regulated rights of the citizens in the field of health care (primary health care center, office of physician and dentist and pharmacy). • determine the fulfillment of prescribed conditions to start operating and affecting the health care activities in regards to personnel, equipment, premises, for the state-owned health care institutions whose founders they are, and for the health care institutions or other forms of health care activities in private property. • besides controlling the lawfulness of operation, they also perform the outer checks of quality of the health care offered in cooperation with authorized bodies and chambers at the national level. • secure the financial means in their budgets for the stated and other purposes in the health care system. • this form of decentralization, including the one proposed in the section on financing the system, would greatly contribute to constant improvement of the health care quality. 511 informed health policy and system change application of modern management at the system and institutional levels the health policy entails that both the philosophy of the management at the system and institutional levels is determined, and that the management of change be applied in the implementation of the reformist endeavors. in many european countries today it is almost unimaginable that the process of decision-making is conducted by those individuals who do not possess management responsibility and professional managerial skills. for the complete system of management of the reform process it is of utmost importance that no mistakes which were recognized in former reforms in the central and east european countries are repeated. most often those mistakes were reflected in disregarding the necessity to have a qualified and efficient management, and also in the engagement of foreign experts without proper knowledge of the local circumstances, or the socio-economic and political systems in those countries. nevertheless, the good characteristic is the recognition of the partnership with high developed countries manifested in a longterm support for the programmes of »educating the educators« for management and organizational development (28). it would be advantageous if the modern system and institutional management, conditioned by permanent changes in its environments, especially so in the process of reform, is based on the philosophy of management by objectives and the total quality management. management by objectives, the concept introduced first in industrial company by peter drucker back in the ‘50s of the 20th century, can be often found today applied onto the health care system. it is a process in which both the superiors and subordinates identify general goals jointly, defining the field of responsibility while achieving the expected results, as well as criteria upon which the individual contributions for the accomplishment are followed and measured (29). attaining the goals defined in advance is the central process of each management. general goals of the health policy in the process of reforming have to rely on mandatory documents of the international health policy, while establishment of specific objectives must be based upon evidence from national health system, and it is to involve step by step in defining the priorities. it is beyond question that at the system level all interested parties must participate in this process, particularly the general public, for it enhances readiness, motivation, and endeavors in introducing the change. at the institutional level, the goals can have an enormous influence onto the participation of the employees in management, which is extremely important 512 health systems and their evidence based development for the success of any health policy. the goals of the institution should favor knowledge, public health orientation, and the quality of operation, by which greater participation can be expected, as well as higher responsibility of the doctors in the process of management. the main characteristics of this process are: • the manager and the employees understand and have a mutual consent on main duties and responsibilities of the personnel; • the employees set short-term and sometimes the long-term objectives in the execution of their work together with the management, which secures that the objectives be consistent with the organization’s goals; • the manager and the employees agree upon criteria to be used for the measurement and evaluation of attained results; • periodically, managers and the employees evaluate the progress in attaining the objectives and they carry out the alterations of the objectives in case the circumstances require them; • the manager has an active role in all coordinating mechanisms and ensures resources indispensable for the realization of the objectives, and • the estimation consists of the measurement of outcomes of operating and in identifying the achieved objectives in regards to timetable and previously established criteria. the next important instrument of the new health policy and health care system is the total quality management – the principle of doing business which holds the improved effectiveness, efficiency, and proper reacting to consumer’s requests as its basic characteristic. it is realized through active participation of all the employees within the organization in the process of improved services’ operations. the crux of the total quality management is the realization of business and organizational excellence (30). the nature of managing the quality, as well as the mechanisms for introduction of the total quality management programmes (the synonym is the term: »continuous quality improvement«) into the health care system, due to its complexity, differs considerably from those encountered in other business and industrial fields (31). the health institutions themselves are known to the theory of management to be the most complex organizations with the most complex management, while the modern hospital is on top of the list of complexity (32). there exists a triple distribution of power, responsibility, and authority (board of managers, director, and doctors), an extensive differentia513 informed health policy and system change tion and specialization of operating abilities is evident, and work duties are performed by a great number of participants who differ according to the degree of education, training, and functions. therefore, the main characteristic of the total quality management in the health care system is that it places the system, i.e., the institution to be its basic unit for analysis, and that it emphasizes the quality improvement by focusing onto prevention, not to correcting the poor quality, then onto the consumers of health care services, onto the system and its processes, and onto the organizational culture (33). in that way both the quality and productivity are enhanced, while expenses are diminished. at the national level, the total quality management is focused onto the measurement of performance and constant improvement of the quality of the whole health care (25). this entails establishment of the national goals of performance in relation to the chosen specific fields of quality, setting up the minimum standards for accessibility and quality, support to the research, assessment of technologies, development of tools to measure outcomes, evaluation of the impact of reform onto the quality of health care, the yearly reports on performances in the health care system, recommendations for the yearly alterations in the measures of quality, and establishment of five-year priority list, as well as usage of the national network of regional centers for collecting data regarding the quality health care. the national programme of quality improvement is to be supervised by an advisory board at the level of the ministry of health. the main processes of the total quality management at the institutional level are (34): • transformation of the organizational culture so that it be completely directed to the beneficiary and his or her satisfaction, • stimulation of the employees at all levels to improve the organizational process, • integration of the system and methods of support in order to motivate and reward the employees according to the quality and productivity of their work, and • engagement of systematic and institutional managers in cultural transformation, decentralization in decision-making, stimulation of the employees to approach the organizational changes management in a systematic way. therefore, for example, a hospital with the total quality management programme sets specific objectives for the quality, selects a number of priori514 health systems and their evidence based development tized fields (projects) for the improvement of quality, includes in the description of work for each employee the activities related to the quality improvement, plans time for those activities, secures the necessary resources (financial, and others), and provides for the compulsory education of the team members to be formally involved in the quality improvement activities. in the course of this process the »managers of quality« in the health care system and the health institutions are mentioned frequently, and as the critical factors which characterize the managers of quality the following are prominent: ability to motivate, to find the optimal stimulating structure, to create confidence, to delegate and decentralize. the wish to respect the will of the consumers of health services is important, just as to listen to the associates and to have a sense for subtle dimensions of interpersonal relations. a manager has an important role also as the creator of the image and vision in the programme of total quality management (35). the management is to be a catalyst in the process of permanent quality improvement, and the quality is part of the values created by all employees in the health system. the outcomes are important indeed, but the main emphasis lies upon the analysis of the process and in its improvement (36). there are various barriers in the organizational structure of the health system that have to be surpassed in order to make the total quality management programme efficient. one of the most prominent is to solve the existing conflict between a management and the professional autonomy (29). physicians with their professional autonomy have a powerful role, as they are responsible for the basic activity of the institution – providing of health services, and for the majority of decisions that create expenses. the doctors, privileged by their medical knowledge, also have the greatest organizational potential, as the nature of their profession implies a broader field than just clinical diagnosis and treatments, thus making them strive for unrestricted power over the economic and social aspects of their work, besides being of authority over the clinical aspects of diagnosis and treatment. however, as most often they are very little interested in affairs of the institution outside the domain of their own profession, the doctors contribute to organizational flows. despite their eminent knowledge of medicine, in reality most doctors know little about the surroundings they work in, as they spend most of their time working with patients or trying to gain more knowledge on their own. this phenomenon is recognized as the separation of professional autonomy from the institutional interests, which interferes not only with the total quality management, but also with the programme of reform (31). the potential spheres of conflict include (37): • responsibility – the model of clinical profession lays emphasis upon an individual, the model of total quality management stresses the process; 515 informed health policy and system change • managing – the model of clinical profession denotes the management of activities for the protection of patients by professionals, while the model of total quality management refers these to the management, with doctors to be included in the process of managerial decision-making to fully solve the problem of quality, while the initiative lays upon the management; and • autonomy and responsibility – the model of clinical profession implies full autonomy and responsibility of a physician for his or her work, and the model of total quality management means that the responsibility of the doctor lays both for the process and for the outcome of care, but with due regards to financial limitations. despite the stated limitations, adoption of the model of total quality management is a challenge to all professionals to mind the quality, to evaluate and regulate their work, and to protect their professional autonomy. doctors easily adopt this model in case necessary data are provided by the management, and when it is required from the doctors to concentrate onto clinical activities. implementation of the change management philosophy in the process of introducing the new health policy at all levels is indispensable, as some resistance and opposition is expected from all those to be affected the most by the change (doctors and managers in certain health institutions), without whose compliance and participation there can be no essential change. the management of change is a process which ensures efficient functioning of an institution under the conditions of the change being introduced (38). the efficient change management requires thorough planning, complete communication, persuasion of the employees in the validity and usefulness of the proposed change, involvement of the employees into those processes whenever possible, and following the execution of the change. the crucial factors for the success of the change are: • motivation – existence of key reasons to change the present unsatisfactory situation, • vision – clear and practical image of the desired future state of affairs, and • next moves – comprehension of all successive steps necessary for the progress toward reaching the vision. all three factors are indispensable and it is necessary to make them mutually multiply in order to effect the change: change = motivation x vision x next moves 516 health systems and their evidence based development in any management of the change as a group process special attention has to be taken in regards to the resistance of all the actors involved in the change, which is manifested as denial of the need for a change in the first place, or as passive opposition revealed in absence from the necessary activities or as active resistance, with specific engagement in blocking the introduction of a change (39). therefore, it is critical that the priorities be set as clearly as possible, and they have to be presented to everyone. it must be taken into consideration that all early reactions, whether positive or negative, are a good sign. the principal way of involving the employees is: to secure information (reasons for the change, where the change leads to, how to achieve the change – the role of the employees), one’s own planning of the activities, and demonstration of empathy and support by the managers. the key activities for an efficient change management are shown in table 2. table 2. the key activities for the efficient change management source: hutton d., managing purposeful change (cited 2004, march 23). available from url: http://www.dhutton.com/change/change.html bearing in mind that in the case of the reform of the health care system there will be individual instances of cutting down of certain capacities, special prudence is advantageous in this particular case, the one termed »reduction« in literature (34,40). the basic activities in reduction are the following (40): 517 informed health policy and system change involvement of employees • couple the change with the employees’ needs • approve one’s own planning • prepare the employees for the assigned duties • prepare the employees to manage stress • accept »resistance« as sign of personal struggle, not opposition to change • celebrate the progress assurance of involvement • establish a clear vision for the envisioned future state of affairs • assure that managers be the role models • regulate the system of recognition and awards • make the process of change a team effort • secure a current, open, two-way flow of information strategy of support to change • build partnership involving key persons • maintain support of the gained sponsors • strive for a small initial success • focus effort where it is most effective • reinforce changes neutralizing hidden opponents project management • share out responsibility for the process • develop a plan which includes both human and technical resources • establish structures for process management and backing • establish reliable system of measurement, following, feedback information, benchmarking and learning • reduction of personnel (dismissals, withdrawals, transfers); • organizational restructuring (elimination); • reduction of technical capacities (number of beds, operating theatres, sale of equipment); • change of purpose (in hospital room into an outpatient office of physician). the problems ensuing reduction are the loss of credibility of the managers, heightened »politicking« and rivalry among managers at different levels for the positions in the reduced organization, lowered motivation, and increase in voluntary discharges. possible solutions for this kind of situations are elimination of ambiguity that the reduction creates among the employees and an increase of communication between the managers and the staffs. education of managers for the new health policy the reform of the health system, particularly through decentralization and flexibility of the management, greater autonomy for providers of health care services, and introduction of active privatization, emphasizes the need for educated managers who will possess far more sophisticated skills than it was the case in managing the hierarchical administrative systems in the past (14). delegating the responsibility for the recognition of the needs for health among specific populations and their satisfying at lower referential levels also requires from the managers to be educated in public health, including epidemiology. they should be acquainted with the methodology of assessing the health status, in programming for health, and in the techniques of monitoring and evaluation. the health managers now have to possess skills both in strategic management and in managing individual institutions. at the same time it is estimated that all other health professionals must be educated in faculties of managing people, negotiating, and communicating (14). expansion of the managerial capacity requires not only the initial action, but also the medium and long-term educational programmes (28): • initial and prompt education of the managers means enabling them to manage institutions in a complex period of transition (especially the top managers in an institution). short courses are to ensure mastering the skills in the following fields: concepts of management, strategic and operational management, financial management and accounting, information management, management of interpersonal relations and conflicts, and management of change. 518 health systems and their evidence based development • the medium-term educational project is to provide for programmes of continuing education for all the existing and potential managers in the health system. • the long-term project is required to establish formal programmes of education, which would stimulate the concept of professionalism and high quality management, in the framework of postgraduate master’s studies in health care management at the university level. there exists a special need for the stimulated development of managerial activities based upon the working place of a manager, not the classroom. the educational needs can use rich experience of the european health management association – ehma, which already offered similar services to the european countries in transition. recommendations of this association refer primarily to the development of education for the management in health care as management of all resources in public funds which are directed to the improvement of population health (41). skills acquired as part of this education are related to the creation and management of the change which leads to the population health improvement, the skill of talking with and listening to a health care consumers, development of the information system which instigates the public health by integrating epidemiological data and those from sociological research, application of marketing, development of the organizational forms, and project management. in order to achieve full efficiency, the managers in public health should possess special technical skills and general managerial mastery. challenges imposed by the new health care require such an approach to the education of managers which accentuates dynamic dimensions of a »learning organization« and the management of change (42). the management principles stemming from the conventional bureaucracy in the health care system are neither relevant anymore nor are they suitable – in case they ever were. today increasing attention is focusing on the evidence based health policy and the benchmarks approach as a new tool for policy analysis (18,43). the interfaces are made between researchers and the users of research – policy makers in order to improve the health policies worldwide. „the permeability of the interfaces becomes important given the potential problems in the transmission of views and findings between researchers and policy-makers. issues around interfaces need to be considered at various stages including priority setting, commissioning of research and communication of findings” (18). the benchmarks approach focused heavily on the needs in reforming a technologically advanced but inefficient and inequitable system that lacked universal coverage and needs health policy changes (44,45). 519 informed health policy and system change exercise: health policy task 1: comparing health policies students should work individually (or in a country-based groups), in order to compare indicators of health policy in their own country and at least two countries – one from region and developed one. to fulfill this task, students should use the site http://www.observatory.dk, where are available all relevant information regarding to current health systems. they should try to use different health policy indicators listed in the who list and to use examples from good articles relate to health policy, which can be found at the internet publication of some journals (british medical journal, health research policy and systems, bulletin of the world health organization). oral presentation or seminar paper should be delivered upon this individual work. task 2: what is your policy objective in health policy cycle? students should work individually to highlight an issue or problem that the government is currently ignoring (agenda setting). then they should propose potential policy responses to a given issue (policy formulation). in the next step they would try to influence the selection of a potential policy response (policy legitimating), improve the implementation of a law / policy / programme (implementation), evaluate a law / policy / programme (evaluation) and, eventually, try to describe the change / terminate an existing policy (policy termination or change). the time necessary for individual work is 60 minutes, after that students prepare posters of their policy cycles (time available: 30 minutes) and later some of students present the results of individual work – 30 minutes. total time necessary for this task is 120 minutes. 520 health systems and their evidence based development references 1. holst e. comparative analyses of health policy. belgrade: sanu 1991. 2. mckee. health and the challenges of enlargement. european public health 2001; 59: 2-6. 3. foltz am. the policy process. in: janovsky k, ed. health policy and system development. geneva: world health organization 1996. p. 207-224. 4. wiewora-pilecka d. management of health politics in poland. (cited: 1999, november 14). available from url: http//www.atm.com.pl/~danapil/hpolpol.htm 5. nutbeam d. health promotion glossary. health promotion international 1998; 14(4): 34964. 6. lee pr, silver ga, benjamin ae. health policy and politices for health: in: last jm, wallace rb, ed. public health and preventive medicine. 13th ed. norwalk, connecticut: appleton and lange 1992. p. 1165-72. 7. janovsky k, cassels a. health policy and systems research: issues, methods, priorities. in: janovsky k, ed. health policy and system development. geneva: world health organization 1996. p. 11-23. 8. gabbay j. our healthier nation. bmj 1998; 316: 487-488. 9. who. terminology for the european health policz conference. a glossary with equivalents in french, german and russian. copenhagen: regional office for europe 1994. 10. boissoneau r. health care organization and development. rockville, maryland: an aspen publication 1986. p. 3-43. 11. barr n. economic theory and the welfare state: a survey and reinterpretation welfare state programme. discussion paper no 54. london: london school of economics and political science 1990. 12. mckee m, fulop n. on target for health? health targets may be valuable, but context is all important. bmj 2000; 320: 327-328. 13. who. targets or health for all. targets in support of the european regional strategy for health for all. copenhagen: who regional office for europe 1986. 14. who. health21. the health for all policy framework for the who european region. european health for all series no.6. copenhagen: world health organization, regional office for europe 1999. 15. un. un millenium development goals (mdg). (cited: 2004, march 21). available from url: http://www.un.org/milleniumgoals/ 16. chrvala ca, bulger rj, ed. leading health indicators for healthy people 2010. final report. washington: institute of medicine, division of health promotion and disease prevention, national academy press 1999. 17. macintyre s. evidence based policy making. bmj 2003; 326: 5-6. 18. leon d. international perspectives on health inequalities and policy. bmj 2001; 322: 591594. 19. fulop n, elston j, hensher m, mckee m, walters r. evaluation of the implementation of the health of the nation. in: department of health, ed: the health of the nation – a policy assessed. london: stationery office 1998. 20. banta dh, et al. considerations in defining evidence for public health. international journal of technology assessment in health care 2003; 19(3): 559-573. 21. who regional office for europe. reform strategies (cited 1997, december 2). available from url: http://www.who.dk/hcs/chap 02.htm 521 informed health policy and system change 22. mckee m, nolte e. the implications for health of european union enlargement. bmj 2004; 328: 1025-1026. 23. mossialos e, mckee m, palm w, karl b, marhold f. the influence of eu law on the social character of health care systems in the european union. report submitted to the belgian presidency of the european union. brussels: eu publication office 2001. 24. european health forum gastein. health policy in the year 2000 – global challenges and european answers. issues in european health policy 1999; may. 25. the white house domestic policy council. the president’s health security plan. new york: times books, random house 1993. p. 52-59. 26. institute for health sector development. health sector reform: separating public financing from provision of services. (cited 1999, december 12). available from url: http://www.ihsd.org/ online/img001.htm 27. who. the process of implementing reforms (cited 1997, may 5) available from url: http://www.who.dk/hcs/chap03.htm 28. guntert bj, berman pc. management training in health service organization in central and eastern europe (c.e.e.). in: chytil mk, eimeren wv, flagle chd, ed. fifth int. conf. on system science in health care. prague: omnipress publishing 1992. p. 1440-42. 29. rakich js, longest bb, darr jk. managing health services organizations. 3rd ed. baltimore, maryland: health professions press 1993. p. 407-438. 30. international organization for standardization. iso 9004 quality management and quality system elements – guidelines. geneva: iso 1991. 31. moss f, garside p. the importance of quality: sharing responsibility for improving patient care. in: simpson j, smith r, ed. management for doctors. london: bmj publishing group. p. 152-163. 32. drucker p. managing for the future. the 1990s and beyond. new york: triman talley books/dutton. p. 100-108. 33. berwick d. health services research and quality of care. medical care 1989; 27(8): 763-771. 34. de geyndt w. managing the quality of health care in developing countries. world bank technical paper 1995; 258: 17-30. 35. borgenhammar e. quality of management in the health care system. quality assurance in health care 1990; 2(3/4): 297-307. 36. casalou rf. total quality management in the health care system. hospital & health services administration 1991; 36: 135. 37. mclaughlin cp, kaluzny ad. total quality management in health: making work. health care management review 1990; 15: 7-14. 38. hutton d. managing purposeful change (cited 1998, december 23). available from url: http://www.dhutton.com/change/change.html 39. hirschfield r. strategies for managing change (cited 1999, december 10). available from url: http://hunter-group.com/thg/art/art10.htm 40. cameron ks, sutton ri, whetten da. readings in organizational decline. cambridge, ma: ballinger publishing 1988. 41. hunter dj. public health management: implications for training. hfa 2000 news 1993; 23: 5-7. 42. forster dp, acquilla s, halpin j, hill p, watson h, watson a. public health medecine training and nhs changes. public health 1994; 108: 457-462. 43. hanney sr, gonzalez-block ma, buxton mj, kogan m. the utilisation of health research in policy-making: concepts, examples and methods assessment. health research policy and systems 2003; 1: 2. available at url: http://www.health-policy-system s.com/content/i/i/2 522 health systems and their evidence based development 44. daniels n, bryant j, castano ra, dantes og, khan ks, pannarunothai. benchmarks of fairness for health care reform: a policy tool for developing vountries. bulliten of the world health organization 2000; 78(6): 740-750. 45 krosnar k. could joining european union club spell disaster for the new members? bmj 2004; 328: 310. 523 informed health policy and system change 524 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title public health framework in the european union module: 3.2 ects (suggested): 0.25 authors, degrees, institutions thomas hofmann, mhcm, mph federal ministry of health and social security, bonn address for correspondence federal ministry of health and social security d-53108 bonn germany phone: +49-228-941-1831 fax: +49-228-941-4945 steering e-mail: thhofmann@yahoo.com keywords public health, european union, history, legal basis, policy development, open method of coordination (omc) learning objectives applying the content of this module the students will be able: • to differentiate the dimensions of national and european public health policy; • to identify key areas of eu's involvement to complement national policies in the field of public health; and • to put the own professional field in relation to european fields of action. abstract european activity in the field of public health started late, and the diversity of public health systems makes the development of common strategies more difficult than in other fields. the legal basis of eu's action in the field of health is fairly basic and simple but implies a broad and strong impact not only for health related matters but also for other political fields. eu's activity in the field of health is based on a public health point of view. since its start in special fields it has grown into whole programs but constantly limited by member states' responsibility to organise public health systems. besides this factual limits the role of the eu in and the implementation of its public health policy is debated by people and experts. still, the importance is growing and new strategies to develop public health policies such as the open method of coordination are implemented which becomes even more important in the light of the enlargement of the european union. teaching methods lecture, individual work, group work specific recommendations for teacher this module should be organized within 0.25 ects, out of which one third will be under the supervision of teacher, and the rest is individual students work. after an introductory lecture the student should become familiar with information sources of the european commission at the internet or by ordering through common mail. by looking for related eu legislation the students would become aware of the relevance for her/his field of profession (individual work). results can be presented and discussed in groups. assessment of students presentation or essay discussing the national or professional impact of one particular field of eu's public health policy. public health framework in the european union thomas hofmann in history, public health has been reinforced at those points when individual health care and cure of health problems were failing. the classical examples are all the epidemics in the past centuries. new problems such as aids or re-emerging of tuberculosis were again a point in time for more action in the field of public health. further, modern behavioural and social patterns and similar problems in european union countries needed an international approach since most problems did not stop at the border (1). the european union, primarily concerned with economic matters, had to develop a new basis for that kind of action. on the other hand, new structures had to be developed since the traditional “health care services in and of themselves do relatively little to bring about an improvement in the health status of populations” (2) and the european union was faced with a variety of health systems in the course of enlargement (3). moreover, traditional health services even hinder progress in public health. the dominance of treatment in the reimbursement schemes of established health care systems, the powerful role of health professions in many countries and economic restrictions kept the mostly state-dependant public health efforts off political agendas (4). public health as „the science and art of preventing disease, prolonging life and promoting health through organised efforts of society“ covers more fields than just economics, the original starting point of the european community (5). the treaty of rome did not provide any legal basis for public health activities (3). an awareness of inadequate results achieved by the established public health systems, possibly supported by a general changes and openness for new strategies to improve the health of the people (6), allowed new health threats to be dealt with. the first so-called “action plans” started in 1987 on the basis of the single european act. action was taken to prevent cancer, aids and drug consumption and trafficking. still, there was no basis for european legislation in the health sector. only in 1993, the treaty on european union (teu the maastricht treaty) created the first legal competence for the community. article 129 foresees the coordination of health programmes and policies of the member states, a significant focus on prevention of diseases, the obligation to combat major health problems (e.g. drug dependence) and the 525 public health framework in the european union community’s co-operation with other organisations. based on that article, the commission sets out indicators to determine priorities for action (7): • a disease’s impact on mortality and morbidity; • a disease’s socio-economic impact; • how far a disease is amenable to effective preventive action; and of particular importance, • how far there is scope for community action to complement and add value to what is being done by the member states. the current legal basis for public health the treaty of amsterdam changed the wording of article 129 and was renumbered article 152 of the ec treaty (see box 1). box 1. article 152 (ex article 129) 526 health systems and their evidence based development 1. a high level of human health protection shall be ensured in the definition and implementation of all community policies and activities. community action, which shall complement national policies, shall be directed towards improving public health, preventing human illness and diseases, and obviating sources of danger to human health. such action shall cover the fight against the major health scourges, by promoting research into their causes, their transmission and their prevention, as well as health information and education. the community shall complement the member states’ action in reducing drugs related health damage, including information and prevention. 2. the community shall encourage cooperation between the member states in the areas referred to in this article and, if necessary, lend support to their action. member states shall, in liaison with the commission, coordinate among themselves their policies and programmes in the areas referred to in paragraph 1. the commission may, in close contact with the member states, take any useful initiative to promote such coordination. 3. the community and the member states shall foster cooperation with third countries and the competent international organisations in the sphere of public health. 4. the council, acting in accordance with the procedure referred to in article 251 and after consulting the economic and social committee and the committee of the regions, shall contribute to the achievement of the objectives referred to in this article through adopting: (a) measures setting high standards of quality and safety of organs and substances of human origin, blood and blood derivatives; these measures shall not prevent any member state from maintaining or introducing more stringent protective measures; apparently, as in any other national legislation there are several more articles touching the field of public health. currently, the legal framework for health in the european union is provided by the ec treaties and case law from the european court of justice. besides article 152 ec, the next could also applied: • article 3 ec (the activities of the communirty shall inlude… „a contibution to the attainment of a high level of health protection”); • article 95 (3) ec internal market („the commission, in its proposals… concerning health, safety, environmental protection and consumer protection, will take as a base a high level of protection, taking account in particular of any new development based on scientific facts”); • article 174 (health and envronment: „community policy on the environment shall contribute to pursuit of the following objectives: preserving, protecting and improving the quality of the environment, protecting human health,…”) • article 30 ec (allows member states to prohibit the marketing of products from other eu countries to protect public health but only where there is scientific evidence in support, and as long as it is not a disguised restriction on trade). other legislative areas where health is mentioned are: article 39 and 46 (free movement of workers), article 137 (workers’ health and safety) and article 153 (consumer policy). however, there are also key areas where health is not mentioned: the common agricultural policy (cap) and common transport policy. nevertheless, article 152 keeps the most central role by targeting the health improvement, disease prevention, anticipation of sources of danger to health and ensuring that all ec policies protect health. 527 public health framework in the european union (b) by way of derogation from article 37, measures in the veterinary and phytosanitary fields which have as their direct objective the protection of public health; (c) incentive measures designed to protect and improve human health, excluding any harmonisation of the laws and regulations of the member states. the council, acting by a qualified majority on a proposal from the commission, may also adopt recommendations for the purposes set out in this article. 5. community action in the field of public health shall fully respect the responsibilities of the member states for the organisation and delivery of health services and medical care. in particular, measures referred to in paragraph 4(a) shall not affect national provisions on the donation or medical use of organs and blood. the community’s public health policy is still seen as subsidiary to the member states’ effort, but compared with other community policies, public health has been accorded greater weight. through certain non-binding resolutions in previous years, reports prepared by the commission, particular action programmes and funding of research work, the community has now been able to implement a genuine public health strategy (details are available from url: http://www.europa.eu.int ). according to the treaty, the protection of human health is now to be ensured in all community policies and activities, both in their definition and in their implementation. until recently it had only to be a constituent part of community policies. the meaning of the new article also goes beyond the prevention of illness and disease to include the improvement of public health and the obviation of sources of danger to human health. it is important to note that article 152 establishes a link between public health policy and the donation and use of human organs and substances of human origin, as well as between public health policy and veterinary and phytosanitary fields (7). this reflects the awareness of the importance of a common and consistent european public health policy in view of the bse crisis (“mad cow” disease). in the famous medina report on the bse crisis to european parliament, 1997, it was stated: “the eu should have a clear legal base enabling it to exercise its powers in the field of public health. it should be made impossible for the subsidiarity principle to be used as means for member states to oppose the development and application of measures… necessary to protect public health”. at several points though, the article 152 emphasises the member states’ responsibility for organising the delivery of health care, including action in the public health field. that seems to be the obvious limit for european public health policy. as the communication from the commission to the council on the development of public health policy in the european community (8) shows, there is a clear intention to act at a subsidiary level by supporting national and european legislation with tools for decision making. health monitoring, surveillance and tackling health determinants are lacking in almost all european union countries. the exchange of experience and the collation of epidemiological data should help to prevent or reduce the number of premature deaths by introducing a public health aspect into other community policies, and to cope with the enlargement of the european union (7). part of the above mentioned communication is a public health framework which includes the so-called action plans of the commission in the field of public health, since 1993. previous public health programmes were oriented towards cancer, aids and other communicable diseases, drug abuse, pollu528 health systems and their evidence based development tion related diseases, health monitoring and health promotion. up until 2000, eight programmes were set up. these action plans have now been extended to one global action plan until 2008 – public health programme (2003-2008). priority objectives of new public health programme (2003-2008) are the following (http://www.europa.eu.int ): 1. to improve information and knowledge for the development of public health; 2. to enhance the capability of responding rapidly and in coordination fashion to threats to health; and 3. to promote health and prevent disease through addressing health determinants across all policies and activities. the components of the new public health strategy of eu are a new public health framework and a coherent approach to health across community policies and actions. the first strand (improving health information) is related to health monitoring, mechanisms for analysis and reporting and information to authorities, professionals and the public. the second strand (responding rapidly to health threats) includes: work on communicable diseases (building on the network) and rare diseases, anti-microbial resistance, blood safety and quality, organs and substances of human origins, non-communicable disease threats, and actions on physical agents. the third strand (addressing health determinants) comprises: strategies and measures on lifestyle-related determinants (tobacco, alcohol, drug dependence, nutrition, physical activity, sexual behaviour, mental health), strategies and measures on socio-economic determinants (benchmarking on health inequalities, health insurance and health service arrangements, access across borders), and strategies and measures related to the environment. development and implementation of european union public health policy the commission’s public health department (directorate g), which is split into four units, is integrated into the directorate general for health and consumer protection. at the present stage, the expenses for public health are cut down, which results in a shortage of staff in the commission services (9). fruitful and successful work in the public health field was carried out immediately after the new legal basis for it was introduced in the treaty of maastricht as birt et al. (1997) describe. in 1993, the commission set up a working group consisting of nearly 70 experts taken from almost all the member states. the task was defined as being to submit proposals for policy development in cer529 public health framework in the european union tain priority areas. in the final report the expert group describes its recommendations for the short, medium and longer term in the areas of health data and information, accidents and injuries, pollution-related diseases, rare diseases and consultation mechanisms for public health, each area being split into preventive action, health data, consultation mechanisms and training and research. the expert group took into account the assessment of health needs, intervention based on evidence, as well as socially acceptable and politically credible policy development, which was based on democratic principles. in self-evaluation, the expert group rates its work as effective and efficient, but „time consuming and exceedingly expensive“(10). looking at the policies pursued by the commission since then this self-appraisal seems to be realistic, and the fact that the commission is still working with several expert groups in many areas confirms the advantages of that kind of policy development. regarding the discussion about national implementation of european union legislation it also seems to be the only way to ensure the compliance of the member states, as the nations are represented in those groups. for many years the european union has co-operated with the who and more particularly with the regional office for europe. in recent years the member states’ mandate to the commission in who negotiations has become stronger. for the first time, the commission has been representing all european union countries in the negotiations on the who framework convention on tobacco control. in other areas, inter-organisational frameworks in the public health field are being developed, and there is cooperation, particularly with regard to central and eastern european countries (6). at some occasions the development of a european public health policy is pushed forward by decisions of the european court of justice. a very famous example has been the kohll/decker file on cross-border treatment in 1998. this process is known as „negative integration” since it shifts competence to the eu without the member states positive agreement. in recent years the so-called open method of co-ordination (omc) as a working method becomes increasingly important. this process is known as part of „positive integration” since member states are actively involved in policy making. originally developed in the field of eu’s social policy since 1997 it has been introduced in the field of health after the lisbon summit 23 and 24 march 2000 to allow certain work to take place in areas where competence was not clear between the community and the member states. this method is clearly based on the principles of subsidiarity and decentralisation. especially in the light of the enlargement of the european union it seems likely to become a very important tool of policy-making as it creates soft law. soft laws are recommendations 530 health systems and their evidence based development and unsolicited agreements between several partners which are formally nonbinding but create an international and diplomatic pressure to be applied. the procedure is similar to any benchmarking process. the council decides measures which should be reflected in national policy. the member states present their efforts in reports to the council and the commission. the council formulates recommendations to be taken into account by the member states and so on. the first results of this working method are in the beginning to be evaluated (11). the view of people and experts regarding european public health policy bearing in mind the political debates in almost all countries in the field of health care, it seems self-evident that any european policy in that field needs to respect the sensitive areas in each country. as discussed above the treaty clearly mentions the organisation of health care systems as the responsibility of member states. however, interference is of course inevitable. as a representative survey among actors in the health field shows, the acceptance of such interference varies greatly between the european union member states (12). it seems that in some countries no widening of european union competence in the health care field is wanted by the people. the only fields where european union action is regarded as reasonable are health promotion, medical ethics, quality assurance and standardisation of education levels for health professionals (13). more concrete expectations from a european health policy can be noticed, when looking at recommendations developed by high-level experts. still, health care systems remain untouched. the main demands are for a stronger monitoring system, more research activity, fewer overlapping activities of member states, the european union and other international organisations in the health care field, and greater availability of shared knowledge, information and experience. in particular, evaluation and health technology assessment should play a more important role. to provide the european union with more continuity the six monthly presidential cycle should be replaced by long term health strategies related to those developed by international health organisations (14). not only content but also delivery of political strategies is seen controversial. whereas robinson/graham (15) note the lack of personnel in the commission to deal with the requirements, the european health care management association (ehma) is very sceptical regarding a growing commission and prefers the commission to play a more supportive role. 531 public health framework in the european union public health experts see further inconsistencies in european union’s health policy (14). as article 152 outlines, public health approaches should involve all policies. one reason for that could certainly be the lack of evaluation of eu’s public health programmes not having a significant impact in other political fields. the policies a major issue for the european public health policy arises in relation to the enlargement of the union. as bojar the former minister of health of the czech republic points out, there is a great need for a reduction in the differences in the quality and availability of health care in the whole of europe (1). this means that certain standards for health care systems have to be established in order to standardise. fischer, the former german minister of health, notes the same fact and points towards the necessary harmonisation of health care systems and social standards up to a certain point (16). but „there cannot be and will not be a european standardisation or even harmonisation of the national differences, because of the peculiarities of the traditionally evolved structures specific to each individual member state” (16). the similar wording clearly shows that the limits for harmonisation and standardisation are not absolutely set and the individual interpretation by each politician will lead to permanent discussions on that key topic of health policy. besides that political hot potato, policies do seem to coincide quite closely with scientific expert opinion. the summary of a meeting with european health officials presented by fischer repeats the recommendations as described above. in addition, the financial situation of health care systems is given greater attention since it seems obvious that a higher expenditure for health care does not necessarily lead to a higher life-expectancy of populations. 532 health systems and their evidence based development exercise: public health in the european union task 1: students should use recommended readings in order to become familiar with information sources of the european commission in the internet or by ordering through common mail. by looking for related eu legislation the student can become aware of the relevance for her/his field of profession (practical work). results can be presented and discussed in groups. task 2: students are asked to write an essay, discussing the national or professional impact of one particular field of eu’s public health policy. essays will be assessed and presented in group. 533 public health framework in the european union references 1. bojar m. europe without frontiers. in: normand c, e.m./vaughan p, ed. europe without frontiers. chichester-new york-brisbane-toronto-singapore: health press 1993. 2. holland ww, et al. public health policies and priorities in europe. in: holland ww, et al, ed. public health policies in the european union. new york-oxford-tokyo: oxford university press 1999. 3. scadplus. european union web-based guide to union policies. (cited 2001, august 20). available from url: http://europa.eu.int/scadplus 4. rosenbrock r. gesundheitspolitik. in: hurrelmann k, laaser u, ed. handbuch gesundheitswissenschaften. weinheim-münchen: juventa 1998. 5. winslow cea. the untilled field of public health. modern medicine 1920; 2: 183-191. 6. asvall je. the implications for health. in: normand cem, vaughan p, ed. europe without frontiers. chichester-new york-brisbane-toronto-singapore: health press 1993. 7. merkel b, hübel m (1999): public health policy in the european community. in: holland ww, et al, eds. public health policies in the european union. new york-oxford-tokyo: oxford university press 1999. 8. com (98) 230 final, 15.4.1998. 9. randall e. the european union and health policy. basingstoke-new york: publishing company 2001. 10. birt ca, gunning-schepers l, hayes a, joyce l. how should public health policy be developed? a case study in european public health. journal of public health medicine 1997; 19 (3): 262-267. 11. goetschy j. the european employment strategy and the open method of coordination: lessons and perspectives. transfer. european review of labour and research 2003; 9(2): 281301. 12. andersen consulting. die zukunft des europäischen gesundheitswesens perspektiven für deutschland. sulzbach/bonn: andersen consulting 1997. 13. hofmann t. developing european health policy. lage: jacobs 2002. 14. ehma. healthcare and european integration. dublin: european health management association 1994. 15. robinson j, graham v. the european union’s public health policy and older people. eurohealth 1997; 3(2): 23-24. 16. fischer a. a new public health policy in the european union. eurohealth 1999; 5(1): 2-4. 534 health systems and their evidence based development recommended readings • european union web-based guide to union policies at http://europa.eu.int • holland ww, et al, ed. public health policies in the european union. new york-oxford-tokyo: oxford university press 1999. • normand cem, vaughan p. europe without frontiers. chichester-new york-brisbane-torontosingapore: health press 1993. • randall e. the european union and health policy. basingstoke-new york: publishing company 2001. 535 public health framework in the european union 536 health systems and their evidence based development health systems and their evidence based development a handbook for teachers, researchers and health professionals title targets for health development module: 3.3 ects (suggested): 0.50 authors, degrees, institutions dr. rudolf welteke, state institute of public health of northrhinewestphalia (loegd), bielefeld, germany address for correspondence dr. rudolf welteke state institute of public health of northrhine-westphalia (loegd) westerfeldstr. 35/37 d-33611 bielefeld germany e-mail: rudolf.welteke@loegd.nrw.de keywords health targets, health policy, health strategy, health indicators learning objectives at the end of this topic, the students should be familiar with: • principles of target setting; • examples of world-wide health strategies and targeting settings; • process of developing and implementing a target programme. abstract health policy requires a clear outfit and a number of comprehensive and visible goals in order to become accepted within the population and the specific target groups. identification and monitoring of health targets in programmes introduce more transparency and more visible success into health policy. this paper presents highlights and the background experiences, which have been accompanying the development of health target programmes within the last three decades. moreover, you will find some aspects of developing and implementing a target programme and diagnostic tools in order to find out, if the introduction of health targets could be an appropriate tool for problem solving in a specific political environment. teaching methods after an introduction lecture students will work in a small groups on identification of health targets (based on health monitoring data) and compare international, national and their own health targets. work will be followed by group reports and overall discussion. specific recommendations for teacher it is recommended that the module should be organized within 0.50 ects credit, out of which 0.25 of ects credit will be done under supervision (lecture and group discussion), while the rest is individual student's work. it is supposed the 1 ects is equal to 30 hours. teacher should advise students to use as much as possible electronic management libraries during individual work. assessment of students multiple choice questionnaire and written report. targets for health development rudolf welteke introduction the idea to build up instruments in order to introduce more transparency and more visible success into health policy is a simple but difficult option at the same moment: the simple aspect is that health policy requires a clear outline and a number of comprehensive and visible goals in order to become accepted within the population and the specific target groups. the more difficult aspects are associated with the management process that is needed to make target programmes successful and efficient; this process has to give answers to questions like: what kind of target development should be instigated? who are the suitable persons and institutions that should get involved? what is the appropriate role and mixture of policy makers, practioners, and technical experts within the process of development and implementation of health targets? the history of health target projects is a story with ups and downs which has had to find its path between these two areas: the simplifying area on the one hand and the area of scientific approaches on the other hand. the task of the following chapters will be to give a short introduction into the highlights and the background experiences which have been accompanying the development of health target programmes over the last three decades. moreover you will find some diagnostic tools in order to find out, if the introduction of health targets could be an appropriate tool for problem solving in a specific political environment. some principles the roots of target programmes can be found in the sector of economics and project management: if you are planning to create and launch a specific product in a defined section of the market, you have to make sure that a series of consecutive elements exists: i first you have to decide, what kind of product you are going to develop – this is the first step of target setting. this step is associated with the creation of a clear outline of the product with a well defined idea what you are going to offer. 537 targets for health development ii the second step of development is developing the process goals which effect the way in which the product should be introduced into the market: which effects and gains should be achieved by the introduction of this product? this type of question is including at least two effects, which can be described in terms of target setting: target a: the aimed effects in the target group (e.g. the grade of distribution of the product x in the target group y); target b: the aimed effects according to the producing and/or selling company (e.g. number of produced elements; amount of financial advantage)... iii as the target setting process is a part of an entire planning process the combination with a time schedule is a must. matching the milestones of this schedule is another (the third) important element of the target setting process. iv a fourth target aspect is associated with the task of meeting certain pre-defined standards of quality of the product. this element leads into the area of quality assurance. if you are the only producer of this type of product you are dealing with your own standards of quality. if there are more comparable offers your product will be subject to a benchmarking process. there are a lot of more detailed aspects which are linked with the process of target setting. for example the question how to quantify the achieved effects is an important one, if you are going to set targets in the health policy sector. as you have to deal with a lot of effects in the health area, which produce some difficulties if you try to meet high standards of quantification, you have to find a smooth way in order to create a set of appropriate indicators linked with those targets and strategies you want to introduce. on the one hand, quantified targets appear to be the type of “better targets”. on the other hand you usually have to minimise the amount of resources if you want to be successful in implementing an entire health target programme – so you will have to be careful with the definition of high level standards if you are going to develop and introduce appropriate evaluation procedures. figure 1. some relevant elements of the target setting procedure 538 health systems and their evidence based development stage keyword task i definition of a product investigation of the market, designing ii introduction of the product advertising, product placement iii time schedule/milestones schedule the project, element ranking iv quality of process & results development of indicators, evaluation history the “health for all” programme of who’s european regional office the history of health targets is a story of development which took place in different core areas. from the european point of view there was a first relevant attempt to develop health targets in the nordic (scandinavian) countries especially finland in association with the european regional office of the world health organization (who) in copenhagen/denmark. this preliminary was carried out in the seventies and was confirmed in the general outline of the strategy “health for all” by the regional assembly of the european nations in 1977. a major campaign was carried out when the who publication „health for all 2000 ...” appeared in 1985 and was distributed in different languages with a large number of copies. the programme included a comprehensive health target approach which was based on 38 elaborate health targets (1). these 38 targets focused on relevant topics of health policy in western, industrialised countries. there was nearly no similarity with the „ten global health targets” which had been released by the who headquarters of geneva some years before and had been adjusted in the late 1990s (2). the 1985 european regional health targets, which were revised in 1991 (3), have always been associated with a serious attempt to lay more stress on the social equity issues of health and health care – especially by giving target number one the headline „more equity in health affairs”. this was an indisputable demand for more social justice within the european societies and health systems. this who target programme included the option for a positive social change in european countries but also contained the substrate for a lot of political controversy in the different european nations and regions. on the one hand the „health for all” strategy led in a convincing way to several interesting and sophisticated national and regional health target programmes, designed and carried out by „early adopters”. on the other hand the programme produced a lot of non-adopters, especially among more conservative health politicians, who for example did not accept the message of more equity or at least did not believe in alterations of social structure of that big size the who programme suggested. actually the entire political impact of the who target programme can only be understood in depth by reflecting on the policy differences between the socialistic and capitalistic states of the seventies and eighties of the last century. basically the health for all approach has been a comprehensive health promotion programme with a new, broader understanding and definition of 539 targets for health development healthy conditions. especially the socialistic states had been working hard in order to introduce the reflection of the healthy conditions approach into the programme. this approach was going to balance the former health education approach, which has been favoured by the western governments up to the late seventies, and which prioritised the individual health behaviour. the historical point of view creates the opportunity to ask, if who’s target inititiative would have been more successful, if it would have come with less demands about social alteration and political change. there is the suggestion that the consensus level to adopt a target programme like this at national, regional or local level would have been better, if the political power of the who programme would have been more discrete – but: probably there would have been other obstacles arising in this virtual case – e.g. the level of perception of the programme might have been deminished to a critical degree. anyway – there are some experiences with who-designed health target programmes, which are worthwhile to be mentioned (below). health21 – the renewed health target strategy of the who for the new century in the late 1990s the who published a renewed version of the “health for all” approach, called health21. the first remarkable change of the new programme was the reduction of the number of targets from 38 to 21. the reduced new who strategy was an answer to some critical remarks which stated that the former 38-target approach did not meet the requirements for a consistent and convenient programm design. another important change was introduced by the political re-mapping of eastern europe which took place in the 1990ies especially after the decline of the soviet union. the who had been facing a new and strong imbalance between eastern and western countries in the european region. on the other hand the renewed 1998 approach of the who was a change to a more economically driven policy and a change to a system of health policy based on health determinants. it has been an adaption to a radically changed economic and political situation in the european region (4,5). target programmes of members of the healthy region network especially the who-associated healthy region network has been producing some important approaches. there was a working group meeting in 1992, which led into a presentation „on the development of subnational policies for health” (6). in addition, there had been an international workshop 540 health systems and their evidence based development on target setting in brussels in 1996 with contibutions of those network members dealing with target programmes: wales (great britain), catalonia (spain), oestergoetland (sweden), north rhine-westphalia (germany) (7). an elaborate health target programme has for example been developed and implemented in wales. wales is situated in the south-west of great britain with a population of about 3 million. the wales target programme was announced in 1989 by the welsh office as an initiative: with the strategic intent and direction, which aimed to “take the people of wales into the 21st century with a level of health on course to compare with the best in europe”. the initiative covered 10 areas where health could be improved. these areas accounted for about 80 per cent of the health expenditure in wales. intervention in each of these areas had been planned by three main principles: (i) health gain: focusing on improving health by, e.g. shifting resources to more effective treatments; (ii) making services more responsive to people’s needs and preferences: e.g. considering the total effects of services on people’s lifes rather than narrower clinical perspectives; (iii) effective use of resources: e.g. providing an appropriate balance between prevention and promotion; diagnosis and assessment; treatment and care; and rehabilitation and monitoring (8,9,10). an evaluation of the welsh programme was published as an official „report by the comptroller and auditor general” in 1995 (11). the programme has been renewed after the british change of government in 1998 and was published as a (bilingual) consultation paper titled „better health. better wales” (12). a strong focus of the new approach lies on health inequalities. it includes some interesting additional remarks on „investing in the future” e.g. by mentioning strategies based on advanced health impact assessment procedures (13). the policy paper was followed by the publication of a strategic framework (14). an evaluation programme is continuously carried out – results are e.g. available via internet (15). catalonia – the 6-million-people region in north-eastern spain with its capital barcelona has been developing a health target programme which surprises by an exorbitant great number of single targets (about 600). the catalonian approach is an elaborate, high-level target programme which was published first as a framework document in 1991 (16). the first health plan for catalonia was published in 1993 (17) followed by a series of further updates and publications (18,19,20,21,22). the catalonian target programme is related to a thoroughly planned and realised health monitoring and reporting system. due to this special situation it had been possible to quantify each of the single targets. a critical assessment of the catalonian approach may produce the result that it is overdetailed and at last it might be difficult to find out in the 541 targets for health development mass of findings what really had been the (political) success of the entire programme. anyway – the catalonian example is an excellent and impressing model for studies. especially the broad range of positive opportunities, which lies in a tight linkage between health monitoring and a subsequent target programme are visible in the catalonian model. another early regional approach has been worked out in the southern part of sweden, in a region called oestergoetland (population: 400,000; capital: linkoeping). the oestergoetland 1988 health policy programme set five overall goals: (i) oestergoetland county council – a health county council; (ii) health promotion and disease prevention – that is equally accessible to all the people of oestergoetland; (iii) health promotion and disease prevention of high quality; (iv) health activities that satisfy the needs of the population; (v) community participation in health activities. the 1990 strategy for implementation focused on six areas of intervention: healthy lifestyles; accident prevention; musculosceletal disorders; health of children and youth; health of young parents; health of elderly. 26 quantified targets were defined by a 50-person expert and layman board. the positive example of this regional approach is highlighted by an ambitious organisational process combining a lot of health and social policy challenges and including in particular the opinion of ngo’s which are active in the region (23,24,25,26). healthy region network founding member north rhine-westphalia, a 17-million-population state in the western part of germany, has been starting its own health targets programme „ten priority health targets for north rhinewestphalia” in 1995 (27). the ten targets are: the north rhine-westphalian approach has been starting as an evocative political programme – after the who’s health for all programme has been treated in western germany for more than one decade in a more reserved way. the reduction to a number of 10 targets (derived from the 1985 who 38 542 health systems and their evidence based development 1. reducing cardiovascular disease 2. controlling cancer 3. settings for health promotion 4. tobacco, alcohol and psychoactive drugs 5. environmental health management 6. primary health care 7. hospital care 8. community services to meet special needs 9. health research and development 10. health information support. target programme) was a reasonable political decision in order to adapt the size of the target programme to the limited resources of the north rhine-westphalian health policy sector. up to the year 2000, which has been marking the halfway point of the declared first decade of nrw’s target programme implementation, there had been two (of ten) target implementation programmes released: target 4 “tobacco, alcohol and psychoactive drugs” and target 2 „controlling cancer” have been described by elaborate implementation brochures and set into action by expert teams. in addition to the both implementation schemes mentioned above an evaluation approach was developed and published in order to assess the realised parts of the target scheme. there has been an official declaration of all important institutions of the health care and prevention sector in north rhine-westphalia in 1995 to get involved in the programme in an active way. the scheme of this target programme and some of it’s technical patterns have become parts of the german national target approach, which begun in 1999 (see below: national approaches). a short documentation of the north rhine-westphalian target approach (28) is also available in english (29). there is a series of publications available in german language (30,31,32,33). selection of national approaches the british health target programme “health of the nation” has been focusing on more medical aspects of the broad range of public health topics. actually there was a serious approach to establish a national health target programme, which was backed and released by the national government and the parliament in 1992 (34,35,36,37). in particular the aspect of social equity in health affairs was disguised under the conservative period of mrs. thatcher’s government in terms like “social variations”. this development was stopped when labour party won the 1998 elections – but: the health of the nation target programme was assessed immediately after the political change (38) and cut down drastically – although there was a nice new label created: “our better health” (39). in order to bring the programme closer to the people’s reality the renewed strategy is said to be more “focused and disciplined”: “but operating on too broad a front risks dissipating our energies on too many goals – and achieving none. the strategy must be focused and disciplined“. that is why the government has identified four priority areas: 543 targets for health development 1. heart disease and stroke 2. accidents 3. cancer 4. mental health (39) the british target programme is worthwhile being studied thoroughly: it is a long term project which has had some important impact on the british health policy. this importance was underlined by the continuing of this policy concept even after the historical 1998 policy change. the relevance of the british health target model is based on an excellent technical advice by several expert teams. the output of these teams – which have been partly run by the government itself, partly embedded in the staff of several cooperating universities – means especially a high quality support for the continuous statistical analysis of the programme outcomes and the consecutive strategical and technical steps of adjustment. the redesigned british approach tries to get solutions in two key areas: 1. “to improve the health of the population as a whole by increasing the length of people’s lifes and the number of years people spend free from illnesses”; 2. “to improve the health of the worst off in society and to narrow the health gap” (39). so the new programme is setting high standards according to the political framework, especially in the efforts of narrowing the health gap and of tackling the health related symptoms of social inequalities. while reading the renewed strategy of 1998 and these highly ambitious target modifications in the field of social policy there is the impression arising that there is a lot of political declaration. it is obvious that this type of target setting – and especially the very enthusiastic effort to bring in the topic of combating the social inequalities, (“black report” – and consequent publications: 40,41,42,43,44) – have been inducing a lot of political discussion and producing a reasonable series of scientific investigations on this topic. on the other hand these targets don’t have the touch of “realistic targets” in a narrower sense: there are too many implications, such as addressing the current baselines of social structure and economic principles of the entire (british) political system, which probably will not change based on the demand of health policy intervention – even if the programme is declaring “we are in this for the long haul...” (39). especially it will be of some interest to observe the long term outcome of this target initiative under the auspices of the outspreading new economy. 544 health systems and their evidence based development the australian target programme (45,46) is one of the elaborate positive examples within the worldwide health target community. it has been tailored as a modification of the who target approach. the framework was developed in 1993 and included a range of goals and targets grouped in the following four areas: 1. preventable mortality and morbidity 2. healthy lifestyles and risk factors 3. healthy literacy and health skills 4. healthy environments comparable to the british approach there are concrete actions focused on cardiovascular disease, cancer, injuries and mental health, as these fields are the four national priority areas of the health ministers. the australian programme is includes quantified targets, e.g. lung cancer. lung cancer is the most common primary cancer in australian males and the third commonest in females. targets included: • to reduce mortality from lung cancer amongst males (by 12 percent by the year 2010 from a baseline in 1990 of 58.4 deaths per 100,000); and • to reduce mortality from lung cancer amongst all females (by 8 percent by the year 2010 from a baseline in 1990 of 16.8 deaths per 100,000). proposed targets included: • to reduce mortality from lung cancer amongst aborigines and torres strait islanders and all people from low socioeconomic groups (46). the healthy people 2000 target programme of the united states of america represents one of the most impressive documents of the health target literature: the initiative was prepared in the 1980ties (47,48), unveiled in 1990 and the strategy was published in 1991 (49). the 1992 edition came along with three additional big size volumes: (i) consortium action; (ii) public health service action; (iii) state action (50,51,52). these publications reflect a cooperative approach, which is the organisational backbone of the entire programme. on the other hand they produce the broad range of approx. 330 objectives and more than 600 single measures, which are related to 22 areas of activity. these year 2000 targets had been related to baseline data from the 1980ies annual nchs health reports. the sophisticated approach is 545 targets for health development characterised by a highly detailed differentiation of target groups (white, black, hispanic, american indian/alaska native, low-income people etc.) and by a high grade of quantified descriptions of health settings and trends. the 1992 edition was continued by a series of annual evaluation reports (53, 54,55,56,57,58). these have drawn a mixed picture of success, stagnation and moving away from targets. progress and failure of the programme has to be studied in detail and in the specific areas of intervention. reported declining rates of health affecting items have been partly compensated by a consistent high level of incidents (e.g. injuries by fire arms). the evaluation reports are meeting high quality standards in a technical sense of view. the main question, if – in a political sense – the entire programme includes really sufficient tools in order to tackle the most obvious unhealthy conditions which are producing negative health effects in a broad range of target groups – is not be answered by the annual reports in a sufficient way. so there remains the main impression that the healthy people programme represents mainly a big size health monitoring activity with an attached target structure. in the meantime the year 2000 targets have been replaced by year 2010 targets (59) and accomplished by a set of instruments in order to facilitate the development and implementation of objectives and measures (60). in germany the development of a national health target programme was started in 1999. a consensus platform containing a broad range of actors was established, organised by the gvg (association for social security policy & research), cologne and sponsored by the german federal ministry of health and social security, berlin. a report on the starting activities was handed over to the ministry in february 2003 (61). the technical aspects of the german health target approach are presented in the figure 2, which is an element of the internet presentation gesundheitsziele.de (62). there is a number of other national target programmes or systems of health reporting which are using targets. there is one source of information which is to be recommended first: the 1998 „review of health target and priority-setting in 18 european countries“ edited by tno prevention and health, public health division, leiden/netherlands (63,64). the 18 countries included in the study are: austria, czech republic, denmark, finland, france, germany, hungary, ireland, italy, the netherlands, norway, poland, portugal, romania, spain, sweden, switzerland, united kingdom (64). other sources that give a sound survey of a broad range of european target approaches are: a reader, edited by marshall marinker (65), and a newsletter, published by msd pharmaceutical company (66). 546 health systems and their evidence based development figure 2. main aspects of the german national health target programme some further regional target programmes in the international debate on health targets the quebec programme “policy on health and well-being” is one of the most regarded regional health target approaches. the ambitious 1992 programme is characterised by a policy focusing on health and social organisation. so the main aspects of the implementation strategy are lieing in the aspects: (i) encourage the reinforcement of the individual’s potential; (ii) provide support in social settings and develop healthy and safe environments; (iii) improve living conditions; (iv) act for and with groups at risk; (v) coordinate public policy and action to promote health and wellbeing; (vi) orient the health and social services system towards the most effective and least costly solutions. the quebec programme contains 19 targets which are related to five areas: social adjustment; physical health; mental health; public health; and social integration (67). 547 targets for health development the first regional health target programme in germany was developed in hamburg (68,69). it was published in the year 1992 as an inconspicuous part of a health report of the city of hamburg, which represents a state of its own in germany with a 1.7 million population. the 14 targets focused on child health (69). hamburg succeeded in publishing an additional evaluation report in 1994 (70), which had been reflecting a reasonable number of successful measures in order to empower the health state of the target group of the programme – with a focus on the social situation of children and adolescent persons (71). in 1998 the hamburg health target programme became a prize winner in a nationwide competition on health targets (“berliner gesundheitspreis”) in germany. another early approach by a german federal state is the sachsenanhalt health target programme (72). published in 1997 – embedded in a regional health report similar to the hamburg approach – a number of five targets was presented. the topics are: infant mortality; grade of vaccination; mortality on cardiovascular diseases; cancer; consumption and effects of alcohol and tabacco. the sachsen–anhalt approach was started by an initial health policy conference. it is backed by five expert taskforces. presently the target programme is under organisational reconstruction. selection of local health target programmes local health target programmes are usually developed in reference to the who health for all strategy. cities can also become member of the who induced healthy cities network. an early example for this type of synergism is given by the programme of sandwell, a community located near birmingham/ great britain. the ambitious target programme of the 300,000 population community is dating from 1989 and is similar to the who’s health for all paper. an interesting detail of this approach is that sandwell is a multicultural community with about 15 % people from asian descent. so there is a high attention to health inequalitity issues influencing the outfit and the details of the programme (73,74,75). another ambitious local approach can be reported from canada: edmonton, a 666,000 population city released a programme „health goals for edmonton“ in 1992 (76). the framework of this activity is set by the healthy edmonton 2000 project. the 54 goals are covering five areas of action: 1. maximising life expectancy 2. reducing risks to health 548 health systems and their evidence based development 3. improving health services 4. removing inequalities in health 5. creating a healthy environment. the goals are titled by the slogan „direction for success # x“ (e.g. x = 51 means improving drinking water) and they are linked with a series of concrete measures (called „opportunity for action“). like other target programmes the edmonton approach contains a lot of details and health data which are underlining the need for action in the five areas mentioned above. in this way the edmonton approach represents the wellknown cooperative scheme driven by a tight linkage of health monitoring resp. reporting issues and health promotion concepts. a relatively young local health target programme has been developed in bielefeld/germany (population: 300,000): based on the results of an expert workshop in 1999 and on a representative survey about health service outcomes in bielefeld and their perception by citizens in the year 2000 an expert group started to work out a target programme. three global targets have been set out in detail: 1. “a health sector which is addressing the needs of the population“ ( = „bürgerinnenund bürgerorientierung“); 2. “equity in health aspects“; 3. “prevention and health promotion“. all of these three global targets are linked to similar target formulations of the who health for all 2000 resp. health 21 programme. in addition the bielefeld global target # 1 is linked to the north-rhinewestphalian target # 8; the bielefeld global target # 3 to nrw‘s target # 3 (see above). the bielefeld target programme has been released by the city council in summer 2003. the next steps will be working on concrete objectives and measures in order to implement these global targets in priority areas with need for intervention (77). 549 targets for health development figure 3. number of areas, targets, objectives – in a selection of 14 health target programmes overview : selected target programmes source: welteke r. north rhine-westphalia’s health target concept compared at the european and international level [computer file]. bielefeld, london; 1997. 550 health systems and their evidence based development areas objectives targets who 5 38 approx. 250 finland 5 34 ? england 5 25 25 usa 22 approx. 330 approx. 600 australia 4 83 ? québec 5 (+3) 19 77 wales 10 180 180 catalonia 13 (+15) approx. 600 approx. 600 oestergoetland 4 26 26 hamburg 5 14 14 nrw 5 10 approx. 60 berlin 3 (+1) 19 approx. 45 edmonton 6 54 90 (318) sandwell 5 38 73 (100) region zielbereiche einzelziele teilziele figure 4. preferred areas and grade of quantification – in a selection of 14 health target programmes source: welteke r. north rhine-westphalia’s health target concept compared at the european and international level [computer file]. bielefeld, london; 1997. key: a. preferred areas b. grade of quantification main area (several or many all targets objectives) presented area (at least one objective) most of the targets only occasionally mentioned (target) only some of the targets ( ) only occasionally mentioned (context) ( ) no evidence not mentioned, but cross-sectional ? not examined item 551 targets for health development diseases & epidm. asp. social affairs environmt. hygiene caresystem economis acci-dents grade of quantific. who finland ? england ( ) usa ( ) australia ( ) ? québec wales catalonia ( ) ( ) östergötl. hamburg nrw optional berlin edmonton ( ) sandwell ( ) ( ) how to develop a target programme different types of target programmes an empirically based analysis of existing target programmes leads to at least two different approaches to the task of developing a target programme: a) the health monitoring based approach this is the way, which had been chosen by catalonia and by wales – for example. there has also been a proposal produced by a german research unit led by karl e. bergmann, berlin (78), which presents the steps of this approach in a convincing way: first, bring up a broad range of health monitoring facts – preferably organised in a matrix of health indicators – second, try to identify a comparable system of data, which allows you to start a benchmarking procedure. in germany this approach has been realised e.g. by sachsen-anhalt, which has compared the health monitoring findings within its population of 2.7 million with the national health data of the federal republic of germany (72). this benchmarking procedure opens the opportunity to reveal a special pattern of (regional) health problems. the findings may be helpful to start the process of a political adjusted decision making process, which means the third step of this procedure. b) the policy centered approach this procedure is based on the inverse sequence of steps of the approach which is described above under a). the first idea is a political incentive in order to introduce some change in the health policy landscape of the region or nation. usually there are a lot of topics and problems which can be easily identified as appropriate to be introduced into a setting of health targets. there seems to be no urgent need for building up a comprehensive and long term oriented quantified data system. usually there is the feeling of having enough evidence to make these topics valid in order to be chosen for a target. sometimes an ad hoc data collection is carried out to produce an empirical base. systematic aid in establishing such a policy centered health target system can be lent by other existing health target approaches. the who target approach „health for all“ has been the fostering health target model # 1 for this type of policy centered national or regional health target systems. as there had been a broad consensus of the nations of the european region to release the health for all target programme there was nearly no threshold to use the prepared technical inventory of targets, strategies, and measures of the who programme. on the other hand the who 552 health systems and their evidence based development programme itself has to be characterised as a primarily policy centered programme: the first paper versions of the 1995 edition had been including an annex with a series of health indicators. but it was obvious that there was a need for a thoroughly carried out working package to make this empirical tool suitable for health monitoring purposes. actually, this second step of establishing an indicator programme which is capable to meet evaluation needs is the difficulty of this approach b. networking for pragmatic support a realistic and pragmatic approach in order to build a target programme needs a sufficient technical support. the idea of networking to get a start up has led to a cooperation – e.g. the who associated healthy regions network, which was presented above. if there is a national or regional health target programme usually support is given to local authorities, if they are starting their own target setting process. a special example of support is given by the u.s. healthy people 2010 toolkit, which is available via internet: figure 5. action areas of the healthy people 2010 toolkit building the foundation: leadership and structure identifying and securing resources identifying and engaging community partners setting health priorities and establishing objectives obtaining baseline measures, setting targets, and measuring progress managing and sustaining the process communicating health goals and objectives source: healthy people 2010 toolkit. available from: url: http://www.healthypeople.gov /state/toolkit/default.htm another toolkit is to be provided by who for the end of 2003 (at the who europe website http://www.who.europe.dk) diagnostic tools especially for the purpose of starting development of local target programmes there are some points of interest which should be taken in account. three checklists may be helpful in order to get some more evidence for an expected sucess of a planned target programme (79): 553 targets for health development figure 6. implementing checklist # 1 figure 7. implementing checklist # 2 figure 8. implementing checklist # 3 554 health systems and their evidence based development 1. existing (and working) health monitoring and reporting system 2. actors with motivation to be successful in achieving health gains 3. communication platforms for actors involved 4. decision making process open for participation of patients and citizens 5. priority related discussions and steering of resources 6. transparency of political decisionmaking 7. sufficient criteria and tools for programme assessment 8. transparency in setting assessment criteria 9. shared responsibility for programme management and results 10. transparency and media support to programme development and assessment • implementing of local health target programmes 10 promoting elements: 1. more than 7 (of 10) points positive in checklist # 1 2. working interaction and/or professional management of the components of checklist#1 3. acceptance and support by local politicians and activity groups 4. positive motivation of actors and users of the target programme 5. promotion of target setting and implementing attempts by regional and/or national • implementing of local health target programmes 7 steps to be successful 1. do the health monitoring and reporting tools really work? 2. do the actors really want to be successful with the programme? 3. are the actors ready to communicate and to cooperate? 4. is there a policy of participation? or: is it possible to introduce participative components into local policy? 5. is there any (political) discussion on priorities in health aspects? 6. is there an opportunity for negotiation of criteria for assessment of the programme? 7. is there enough of common sense among the actors who are backing the programme? 8. is there a chance for using public relations and local media for promotion of the programme? • implementing local health target programmes 8 final questions: some final remarks this presentation of health target programmes and approaches is the attempt to give some information about a field of activity which is characterised by a high level of heterogenity. out of the variations in programme performance and in dynamics of implementation arise additional difficulties for proper analysis. last but not least health targets are usually part of a policy programme. and policy programmes are almost mixed up with some advertising components. so it is not easy to get a sufficient degree of transparency in the present situation and to give some valid remarks on the state of the art. the ambiguity of the subject is recorded by a fine dialogue “for and against health targets”, which is really worthwhile reading for those who like the flavour of dialectics and who want to get some more ideas and literature references related to this delicate topic. “i find nothing intrinsically wrong with setting targets and goals but unless these targets are accompanied by strategies to achieve them they may in the long term, because of repeated failure, do more harm than good. being in favour of something is of itself inadequate.... scepticism is the scalpel which frees accessible truth from dead tissue of unfounded belief and wishful thinking” (80). despite of this kind of scepticism, which undoubtedly has some realistic background, the motivation, the professionalism, the personal beliefs, the enthusiasm of many acting persons and institutions in the field of health targets are evident and impressive. this is encouraging indeed for everybody who gets in contact with these activities. on the other hand health targets are something of the category that means “tool”, instrument or part of a “procedure” or “system”. this side should be lead to a more realistic view: health targets are only one instrument in a pool of a variety of others. and sometimes, especially if things do not work well for some time, it gets obvious, that the developing and implementing procedures of health targets are facing similar problems as tools, instruments, and related procedures; like health monitoring and reporting, like health promotion, like health impact assessment, like public health research activities, which are also facing problems in their performance from time to time. all of these tools (in a broader sense) are dealing with the human health and they are ambitious attempts to strengthen the role and the performance of human health. but: they remain to be tools, instruments and usually they stay a little bit apart of that what really means health, health “for the people“. but sometimes, in special situations, these tools become important: there are upcoming situations which require valid and effective 555 targets for health development tools – in the right moment, on the spot. although health target programmes are instruments developed for the long term performance – sometimes there is the impression, it would be sad if all this energy was not put into the health targets process. so – this may be a little too much impassioned closing remark – but: why not? 556 health systems and their evidence based development exercise: health targets the purpose of exercises are given below, through objective, methodology and description of each task. time needed for exercise is approximatly 4,5 hours. task 1: objective of this task is identification of health targets based on health monitoring data, through group working, statistical analysis, and discussion. students can work in small, country-based groups. they should try to identify problems according to health monitoring data, calculate indicators and build up measurable and valid targets appropriate for their own country. they should develop a discussion about challenges of realisation of identified health targets within local political situation (recommended usage of implementing checklist 1). at the end they should make written comments. it is recommended to use comparable health statistical reports. use internet sources, too. timing: 1,5 hour of students work. task 2: objective of this task is identification of national/international health targets (if any), and comparison with their own health targets, through group working, statistical analysis, and discussion. students can work in small country based groups. they should search for their national health targets, compare with their own and make comments. the comparison can be made on international level. comments should be written. students should use internet sources. timing: 30 minutes for students. task 3: objective of this task is implementation of health target programme and usage of diagnostic tools for evaluation, through individual work and analyses of local health policy. every student will get previously prepared example of health target programme with defined targets but one with health monitoring based approach and the other with policy centred approach. the task will be identification of action areas in local conditions (usage of action areas of the healthy people 2010 toolkit http://www.healthypeople.gov/state/toolkit/default.htm is recommended), diagnosis of implementation of target program in local region by usage implementing checklist # 2 and # 3. they suppose to write a report about possibilities of realization of such programme and describe problems which they can find during analyses. timing: 2,5 hours for students. 557 targets for health development references 1. who, regional office for europe. 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(usa): msd, merck&co 67. gouvernement du quebéc, ministère de la santé et des services sociaux. the policy on health and well-being. quebéc: gouvernement du quebéc, ministère de la santé et des services sociaux; 1992. 68. freie und hansestadt hamburg, behörde für arbeit, gesundheit und soziales, amt für gesundheitsund veterinärwesen. die gesundheit von kindern und jugendlichen in hamburg. hamburg: behörde für arbeit, gesundheit und soziales der freien und hansestadt hamburg; 1990. 69. freie und hansestadt hamburg, behörde für arbeit, gesundheit und soziales, fachdienst gesundheitsberichterstattung. stadt-diagnose. gesundheitsbericht hamburg. hamburg: behörde für arbeit, gesundheit und soziales der freien und hansestadt hamburg; 1992. 269. 70. freie und hansestadt hamburg, behörde für arbeit, gesundheit und soziales, fachabteilung gesundheitsberichterstattung. gesundheit von kindern und jugendlichen in hamburg. hamburg: behörde für arbeit, gesundheit und soziales der freien und 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middelton j, editor. sandwell health. the album. the 3rd annual public health report for sandwell 1991. west bromwich: department of public health; 1991. 75. middleton j, editor. sustainable sandwell. the fourth annual public health report for the metropolitan borough of sandwell. west bromwich: department of public health; 1992. 76. edmonton board of health. health goals for edmonton. the report of the healthy edmonton 2000 project. edmonton, alberta: edmonton board of health; 1992. 77. stadt bielefeld. bielefelder gesundheitsziele. für eine bessere gesundheit. bielefeld: stadt bielefeld; in press 2003. 78. bergmann ke, baier w, meinlschmidt g, editors. gesundheitsziele für berlin. wissenschaftliche grundlagen und epidemiologisch begründete vorschläge. berlin: de gruyter verlag; 1996. 79. welteke r. ansätze zur einbeziehung von landesgesundheitszielen in die kommunalpolitik. in: kellermann k, konegen n, staeck f, editors. aktivierender staat und aktive bürger. wegweiser zu einer integrativen gesundheitspolitik. frankfurt am main: mabuse-verlag; 2001. 80. mccormick j, fulop nj. for and against health targets. in: marinker m, editor. health targets in europe: polity, progress and promise. london: bmj books; 2002; 34-48. internet linkpage linkpage 7.1. health targets – international and national : australia http://www.health.qld.gov.au/publications/infocirc/info28.pdf http://www.rmit.edu.au/departments/ps/assid/health.htm canada http://www.hc-sc.gc.ca/english/media/releases/2001/tobaccotax_2001ebk.htm (tobacco) eire/ireland http://www.issi.ie/naps/summary_resource_material.htm (social inequalities) europe http://www.who.dk/eprise/main/who/progs/hpa/targets/20020319_1 (who europa) http://www.who.dk/observatory/publications/20011008_4 (seite wird nicht automatisch per link angezeigt) daher à http://www.who.dk/ germany/deutschland http://www.gesundheitsziele.de great britain/united kingdom http://www.foe.co.uk/resource/reports/uk_progress_who_targets.pdf http://www.nwpho.org.uk/inequalities/life_expectancy_has.pdf (health inequalities targ.) 563 targets for health development http://www.ohstrategy.net/strategy/targets.shtm (occupational health targets) http://www.mbha.nhs.uk/annual_reports/ph1996/ph96-4.htm (evaluation) lithuania http://www.sam.lt/reform/objectives.htm poland http://www.medstat.waw.pl/nhp/0.html#2 united nations (un) http://www.un.org/esa/socdev/ageing/agetarg.htm http://millenniumindicators.un.org/unsd/mi/mi_goals.asp united states of america http://www.crisny.org/health/us/health7.html (healthy people 2000) http://www.health.gov/healthypeople/state/toolkit/default.htm (healthy people 2010 -toolkit) http://www.health.gov/healthypeople/state/toolkit/progress.htm (healthy people 2010-toolk.) http://www.healthierus.gov/ ( president’s healthierus initiative ) http://www.healthypeople.gov/document/tableofcontents.htm http://www.hhs.gov/news/press/2001pres/01fsasthma.html (combating asthma) world bank http://www.developmentgoals.org/research.htm (health targets) world health organization (who international, geneva) http://www.who.int/whr/1998/whr-en.htm linkpage 7.2. regional health targets: alberta (cdn) http://www.health.gov.ab.ca/rhas/rhatarge.htm essex (gb) http://www.ne-ha.nthames.nhs.uk/hsp/13.htm#top lower saxony/niedersachsen (d) h t t p : / / w w w. g e s u n d h e i t n d s . d e / f r a m e s / a r b _ s c h w p k t e / a _ s c h w p k t e . h t m l # a n c h o r _ 4 (gesundheitsziele im rahmen des modellprojekts „gesundes land niedersachsen) north rhine-westphalia/nordrhein-westfalen (d) http://www.google.de/search?q=gesundheitsziele&hl=de&lr=&ie=utf-8&start=60&sa=n (ausschnitt ziel 3) http://www.gluecksspielsucht.de/materialien/landes1d.pdf (zu ziel 4) http://www.mfjfg.nrw.de/aufgaben/gesundheit/gesund.htm (gesundheitsministerium nrw) http://www.dshs-koeln.de/soziol/gbe/einleitung.htm (kreis neuss) 564 health systems and their evidence based development oberösterreich (au) http://www.ooe.gv.at/alz/alz2000/01/08.htm http://www.sggp.ch/gpi/archiv/ghbericht_1-02.cfm sachsen-anhalt (d) http://www.asp.sachsen-anhalt.de/presseapp/data/ms/2002/034_2002.htm schleswig-hostein (d) http://www.schleswig-holstein.de/landsh/mags/gesundheit/gesundheit_13.html schottland (gb) http://www.show.scot.nhs.uk/achb/about/targets.htm http://www.ihmscotland.co.uk/conferences/dec%202001/practice%20mx%20conf/sld012.htm http://www.scotland.gov.uk/library/documents/oral03.htm (oral health targets) south-australia (aus) http://www.dhs.sa.gov.au/pehs/ ( à http://www.healthysa.sa.gov.au/) steiermark (a) http://www.landeshauptmann.steiermark.at/cms/ziel/256871/de/ http://www.aekstmk.or.at/medien/02042002.htm (provisorisch) victoria (aus) http://www.dhs.vic.gov.au/phd/hdev/hpromo/funding/nattar.htm wales (gb) health targets and indicators: a consultation document html-version www.hpw.wales.gov.uk/english/resources/reportsandpapers/ health_improvement_document_e.doc ähnliche seiten http://www.dyfpws-ha.wales.nhs.uk/compendium2000/page21.html (1995 – 1998 – 2010) http://www.dyfpws-ha.wales.nhs.uk/compendium2001/page33.html linkpage 7.3. selected publications on health targets: australia (aus) http://www.nisu.flinders.edu.au/pubs/monitor7/mon7p7.html http://www.nisu.flinders.edu.au/pubs/monitor10/monitor10-metamorp.html germany/deutschland (d) http://www.infodienst.bzga.de/medien/01_12/mabuseziele.htm http:// www.loegd.nrw.de http://www.dfi.uni-duesseldorf.de/main/04aktuelles/stvincent.shtml (diabetes – st. vincent) 565 targets for health development great britain/united kingdom (gb) http://www.dur.ac.uk/comparative.publichealth/research/bmj.htm nigeria http://www.aegis.com/news/ips/2001/ip011217.html (aids) north rhine-westphalia/ nordrhein-westfalen (d) http://www.loegd.nrw.de/publikationen/ref/refgpolitik.html http://www.loegd.nrw.de/publikationen/ref/refgpolitik.html http://www.loegd.nrw.de/loegd_english/services/health_policy.html http://www.infodienst.bzga.de/medien/01_12/mabuseziele.htm http:// www.loegd.nrw.de 566 health systems and their evidence based development 567 targets for health development health systems and their evidence based development a handbook for teachers, researchers and health professionals title health legislation: procedures towards adoption module: 3.4 ects (suggested): 0.25 authors, degrees, institutions lijana zaletel-kragelj, md phd, teaching assistant university of ljubljana, faculty of medicine, department of public health social medicine zaloška 4, 1000 ljubljana, slovenia address for correspondence faculty of medicine, department of public health social medicine, zaloška 4, 1000 ljubljana slovenia fax: + 386 1 543 75 41 e-mail: lijana.kragelj@mf.uni-lj.si keywords regulations, legislative procedure, health legislation, health law learning objectives at the end of this module, students would become familiar with the classification of legal regulations as well as the legislative procedure. they will increase their knowledge about: • different types of legal regulations, recognising the differences among them; • legal procedure in their own country; • legal areas, in which in their own countries legal regulations relating to health and health care could be found; and • the media by which the adopted laws (acts) and other adopted legal regulations as well as the obligatory explanations come into operation. abstract the public health professionals should be at least roughly familiar with different types of legal regulations and the procedures for adopting them. their possible professional role could be among others also to propose a new law or other legal regulation to an appropriate legislative body, which is responsible to adopt it or to propose the amendments or changes to already adopted laws or other legal regulations. this module is aiming at students to get familiar with the classification of legal regulations as well as the legislative procedure (the republic of slovenia example). also some contents, regulated by health legislation are described. teaching methods the teaching method recommended by the author is a combination of introductory lecture, group work and final discussion. detailed description of steps is given. specific recommendations for teacher it is recommended that the module should be organized within 0.25 ects credit. students are asked to collect some of the readings health care law, health insurance law or „national digest of legislation” by themselves. if there are students with different undergraduate background in the group they should be divided to smaller group according to this. assessment of students the final mark should be derived from assessment of practical work and from assessment of theoretical knowledge of the student. a detailed description is given as well as an example of a question (test type). health legislation: procedures towards adoption lijana zaletel-kragelj the health legislation is the common term for all legal regulations which serve to human health. the areas, which are regulated by them, are very different. in one side for example we have the regulations, which refers to control various diseases and on the other side the financing of various activities related to human health. the function of health legal regulations is thus heterogeneous. the main function is to prohibit people’s activities which are injurious to the human health (for example dumping of toxic chemicals in the environment or spreading the infectious diseases), to authorize health programmes and health services (for example authorizing of health services for mothers and children), to regulate the production of resources for health care (for example financing the construction of outpatient departments or hospitals), to provide the financing of health care (health insurance) and to authorize surveillance over the quality of health care (minimum standards for health personnel and facilities) (1). but with no regard to the content of specific legal regulation, all regulations and the procedures for adopting them are subject to common principles. the modern public health professionals should be active and creative also in this field, regardless of their basic profession. their possible professional role could be among others for example also to propose a new law or other legal regulation to an appropriate legislative body, which is responsible to adopt it or to propose the amendments or changes to already adopted laws or other legal regulations. this module thus focuses to the basic knowledge on legal regulations with special emphasis on health matters. classification and short description of the legal regulations classifications there are several different types of legal regulations known. they could be roughly classified by two classifications (2). classification 1: • general legal regulations – regulations that don’t define the number of the subjects in advance; 568 health systems and their evidence based development • individual legal regulations – regulations referring to the subject that is exactly defined; classification 2: • abstract legal regulations – regulations referring to the simulated cases (constitution, laws...); • concrete legal regulations – regulations referring to the existent concrete circumstances in which the legal subjects are asked to behave and act in a specific way. mostly the general abstract legal regulations are used in common. general abstract legal regulations among this kind of regulations we can find constitution, laws and statutes (2). 1. constitution. constitution is the most fundamental regulation that regulates the substance that is of essential importance for the certain country and its society. it is adopted by parliament (national assembly). 2. laws. laws are general legal regulations that regulate the substance that is principal and fundamental for the certain legal system. but at the same time the substance is not so important to be regulated by the constitution. they are adopted by parliament (national assembly). 3. statutes. statutes are legal regulations with less significance then the laws. there exist several statutes. the following ones are listed by the order of legislative body that adopts the particular statute: • decree – regulates and analyses relations that are defined by the law. it is adopted by the government. • ordinance – regulates individual issues and stipulates provisions that have a general meaning (is more detailed than a decree). it is also adopted by the government. • regulation – regulates the organisation of the operation or the method of the proceeding of the specific body. it is adopted by the minister. • order – intended for the implementation of the individual provisions it orders or interdicts the operation that has a general meaning. it is adopted also by the minister. • instruction – it regulates the method of proceeding of the administrative body that executes individual provisions of the law or the statute. it is adopted also by the minister. 569 health legislation: procedures towards adoption the legislative procedures the legal regulations are adopted by the official procedures, regulated by special legal acts, which regulates functioning of particular country (3). these procedures are more or less similar for majority of the countries. as an example a procedure for adopting a law will be described as follows, as laws are the main legal regulations immediately after the constitution. the process of a law becoming official is called “enactment”. also the law that has been passed by the official procedures (for example in a parliament of a country) is called no longer “a law” but “an act”. the procedures for enacting a law: the republic of slovenia case in slovenia the procedure for enacting a law is regulated by rules of procedure of the national assembly (the parliament of slovenia) (4,5). this procedure can be divided to a regular procedure or fast-track procedure. also every law can be reconsidered as well as an obligatory explanation of every single law can be made. regular procedure the regular procedure has several phases: proposal of law, first reading of a proposed law, second reading of a proposed law, third reading of a proposed law and voting on a law. in following section of the module the most important parts of single phase of this procedure are described: 1. proposal of a law every law can be proposed by the government itself, every deputy, a group of at least 5,000 voters or by the national council. the proposal of the law must contain the title of the law, an introduction, the text and an explanation. it must contain the reason/s for enacting the specific law, its goals and principles, an estimation of the financial burden for the national budget, required for its enactment. it is to be sent to the president of the national assembly. the president than forward the proposed law to deputies, to the national council and to the government, when the latter is not the proposer of the law. the president of the national assembly determines the primary standing committee to participate in the debate of a proposed law and report to the national assembly and when the proposed law contains provisions which require funds from the national budget, the president shall also assign such law for 570 health systems and their evidence based development debate to the standing committee competent for financial matters. the standing committees are working groups which study individual fields, prepare decisions on policy in these fields, formulate opinions on individual questions, and prepare, study and debate proposed laws and other acts of the national assembly. a proposed law is then discussed by the national assembly in three readings. the secretariat for legislation and legal affairs shall offer, at each reading of a proposed law and before the voting on the law, an opinion on the conformity of the proposed law with the constitution and with the legal system, and proposals in relation to the legal and technical treatment of the law. the proposer of a law may withdraw the proposed law up until the conclusion of the second reading. 2. first reading during the first reading of a proposed law, its presentation in the national assembly and then a debate on the reasons demanding its enactment and also on the principles and goals is held. the primary standing committee presents its opinion on the law, which could be positive or negative. if it is negative, the standing committee ought to formulate its own proposal for a decision which the national assembly should adopt after the conclusion of the first reading. if it is partially negative, the standing committee may formulate a proposal for opinions which the proposer should take into consideration in the preparation of the proposed law for its second reading. at the end of the first reading of a proposed law the national assembly has to decide: • to hold a second reading of the proposed law at the same or the following session with the text as submitted for the first reading, or • that the proposer of the law or the secretariat for legislation and legal affairs shall, within a given time limit, prepare the text of the proposed law for its second reading in accordance with the opinions of the national assembly adopted at the conclusion of the first reading, or • not to enact the law. if, after the conclusion of the first reading, the national assembly decides that the second reading of the proposed law shall be held, it defines the time of the second reading. if it decides not to adopt the law, the legislative procedure is terminated. 571 health legislation: procedures towards adoption the text of a law prepared for its second reading must contain explanations indicating in which articles and in what way the opinions of the national assembly have been taken into consideration. during the first reading it shall not be possible to propose amendments to individual provisions of the law. 3. second reading during the second reading of a proposed law, the national assembly debates each article of the law in the order of articles and then its title. when the national assembly concludes the debate on an individual article, deputies vote on it. at the end they also vote on the title of the law. at the proposal of the primary standing committee, a deputy group or at least ten deputies, the national assembly may decide that the second reading of a proposed law shall be conducted as a general debate on it or that the first reading shall be repeated. during this phase of the procedure, deputies, the primary standing committee, an interested standing committee and the proposer may submit amendments to propose the changes and supplementations to the proposed law. the government may also propose an amendment when it is not the proposer of the law. the primary standing committee shall state its opinion on an amendment/s. this opinion is a part of the report on the proposed law submitted by the primary standing committee to the session of the national assembly. this report shall also contain a report by the secretariat for legislation and legal affairs if the secretariat for legislation and legal affairs submitted an opinion in the debate on the amendment in the primary standing committee. deputies shall vote separately on each amendment to a proposed law. if several amendments are proposed to an article of a proposed law, deputies shall vote first on the amendment which departs most from the content of the article in the proposed law, and then, following this criterion, on other amendments. if also an amendment is proposed to an amendment, deputies shall vote first on the amendment to the amendment. if, during the second reading, no amendments were adopted to the text of the proposed law or only amendments of an editorial nature in the opinion of the secretariat for legislation and legal affairs, the national assembly may, at the same session, continue on to the third reading of a proposed law. if amendments were adopted during the second reading, the third reading is to be conducted. the secretariat for legislation and legal affairs shall prepare for the 572 health systems and their evidence based development third reading of the proposed law the complete text of the proposed law with adopted amendments and with an explanation of changes in the wording of articles submitted for the second reading. the national assembly may assign this task also to the proposer of the law. 4. third reading during the third reading of a proposed law, the national assembly has to debate the proposed law in its entirety. the separation of individual articles of the proposed law is possible only for the articles which were altered with amendments during the second reading. during this phase of the procedure an amendment also may be proposed. the procedure is the same as in second reading. the primary standing committee shall again present its opinion on the proposed law. 5. voting on a law at the end of regular procedure, the national assembly has to vote on the proposed law in its entirety. a law is enacted if the number of votes cast “for” is greater than the number of votes cast “against”, unless a different majority is provided for the enactment of a law by the constitution or by law. the secretariat for legislation and legal affairs has to prepare the final text of the law (the original) on the basis of decisions made by the national assembly. fast-track procedure in certain special circumstances it is also possible to enact a law by using the fast-track procedure. these special circumstances are extraordinary needs of the state, the interest of defence, or circumstances of natural disasters. such proposal must be specifically explained. if the national assembly determines to use the fast-track procedure, it has to merge all three readings of the regular procedure in one session. reconsideration of a law before the official proclamation of the law, the national council can impose to the national assembly its reconsideration. the president of the national assembly has to forward the request of the national council to the primary standing committee. the latter shall formulate an opinion on the content of the request by the national council. the national assembly shall conduct the vote of reconsideration at its next session. a law is enacted if the majority of deputies of the national assembly vote for it unless provisions of the constitution require a greater number of votes for enactment of a law. 573 health legislation: procedures towards adoption the procedure for the obligatory explanation of law for every law an obligatory explanation of a law also could be made. this explanation could be proposed to the national assembly by any of those having the right to propose a law (the government, every deputy, a group of at least 5,000 voters, the national council). the procedure is similar to the regular procedure for enacting a law. publication of adopted legal regulations the adopted laws and other adopted legal regulations as well as the obligatory explanations are published in slovenia in the official gazette of the republic of slovenia (uradni list republike slovenije). every year also the register of current legal regulations is published (3). prior to the adoption and prior to the publication in the official gazette every law in slovenia could be found in the bills database, attainable at the national assembly website (6). the bills database contains bills in the current term which are in parliamentary procedure (regular, fast-track procedure...) and in one of the readings (first, second, third) in the national assembly. ratification of international treaties there exist numerous legal regulations related to health and healthrelated matters at the international level. every country has its own procedure to accept or to ratificate such regulations. in slovenia the national assembly ratify every international treaty with a special law. the provisions of the fast-track procedure for adopting a law are used. the contests, regulated by health legislation as it was already mentioned in the introduction that there are many different problems relating to the peoples’ health. because of this reason the content of legal regulations relating these problems is very diverse. they can regulate for example the control over communicable or noncommunicable diseases as well as health financing, health research, health insurance, functioning of health care institutions, ethical issues, health professional’s responsibilities and many others. it is very difficult to make a one uniform classification of all the health and health care relating legal regulations as these regulations could be found in several legal areas: mostly in health care and health insurance area, 574 health systems and their evidence based development but also in the other areas as agriculture, forestry, nutrition and food, poison and other hazardous substances, occupational health and safety, environmental protection, radiation protection and many others. the distribution of health related legal regulations among legal areas depends also on the single country. review of health legislation in slovenia in slovenia health related legal regulations could be classified according to several health spheres. the following classification is according to ministry of health of republic of slovenia (only the most important acts are listed): 1. health care and health insurance sphere: • health care and health insurance act • infertility treatment and procedures of biomedically-assisted procreation act • repayment of harm to individuals with hiv infection due to blood transfusion or transfusion of blood preparations • removal and transplantation of parts of human body for the medical treatment purposes • restriction of the use of tobacco products act • health care of foreigners in republic of slovenia act • health interventions for fulfilment of right on free decisionmaking on birth of children act • occupational safety and occupational health care act • restriction of alcohol consumption act 2. health services and health activities sphere including pharmaceutical sphere: • health activities act • health inspection act • healthcare databases act • general practitioners act • pharmacy activities act • natural remedies and natural health resorts act 575 health legislation: procedures towards adoption 3. medicinal products and medicinal devices sphere: • medicinal products and medicinal devices act • supply of blood act • phytopharmaceutical remedies act 4. cosmetics sphere: • cosmetics act 5. food control sphere: • sanitary suitability of foodstuffs, products and materials coming into contact with foodstuffs act 6. communicable diseases control sphere: • communicable diseases act 7. chemicals sphere: • chemicals act • chemical weapons act • manufacture and trafficking of asbestos products and financial assurance for rearrangement of asbestos manufacture to nonasbestos manufacture act 8. humanitarian organizations sphere: • red cross of republic of slovenia act 9. illicit drugs sphere: • manufacture and trafficking of illicit drugs act • prevention of the use of illicit drugs and the treatment of drug users act • illicit drugs components act there exist also other legal regulations in slovenia that contain parts highly related to health of human beings for example veterinary medicine act, environment protection act etc. 576 health systems and their evidence based development exercise: health legislation – basic knowledge in order to fulfil objectives and according to the ects credit, student are expected to work individually for 2.5 hours (task 1) and then discus in small group about legislation in their countries (task 2). task 1: preparing individually. students are asked to inform themselves before session. they are supposed to gather all acts which are considering health system, by using “national digest of legislation”. students should make a list of laws, regulations and subregulations, also be familiar with some basic laws, such as health care law, health insurance law. task 2: students are divided into small group, in order to discuss the differences between health legislation in different countries. 577 health legislation: procedures towards adoption references 1. roemer r. comparative national public health legislation. in: holland ww, detels r, knox g, fitzsimons b, gardner l, eds. oxford textbook of public health. volume 1. oxford, oxford university press, 1997: 351-369. 2. kušej g, pav~nik m, pereni~ a. ljubljana: uvod v pravoznanstvo. (introduction to jurisprudence) (in slovene language). uradni list rs, 1993: 320. 3. register pravnih predpisov republike slovenije za leto 1999. (the register of legal regulations of the republic of slovenia for 1999) (in slovene language). ljubljana: uradni list republike slovenije, 2000: 853. 4. poslovnik dr`avnega zbora. (rules of procedures of the national assembly) (in slovene language). ur list rs, 1993; 3 (40): 5051-2076. 5. rules of procedure of the national assembly. the bills database. the national assembly of republic of slovenia official website (in english language): http://www.dz-rs.si/en/aktualno/spremljanje_zakonodaje/poslovnik/poslovnik.html 6. the national assembly of republic of slovenia. the national assembly of republic of slovenia official website homepage: http://www.dz-rs.si recommended readings 1. law, ethics, and challenges. in: holland ww, detels r, knox g, fitzsimons b, gardner l, eds. oxford textbook of public health. volume 1. oxford, oxford university press, 1997: 351-413. 2. backes o, stebner fa. gesundheistrecht. in: herrelmann k, laaser u. handbuch gesundheitswissenschaften. weinheim and muenchen, juventa, 1998: 753-777. 3. public health law. in: wallace rb, doebbeling bn, eds. maxcy-rosenau-last public health and preventive medicine. stamford, appleton and lange, 1993: 1147-1154. 4. who. international digest of health legislation. int dig hlth leg, 1999; 50: 1-160. 5. who. international digest of health legislation. who website: http://www.who.int/idhl 578 health systems and their evidence based development health systems and their preface references contents list of authors health systems analysis health systems analysis the role and organization of health introduction health care services and health services organizations what is a health system? models of national health care systems based on the sources of levels of organization of health care systems and health care delivery outpatient care outpatient institutions and services in-patient care and institutions classification of hospitals functions of the hospitals three generations of health care system reforms exercise: the role and organization of health care system references health care system of the federation introduction method demographic indicators socioeconomic indicators health care system reform health system organization survey of health professionals in fb&h in comparison with some primary health care specialist's or consultant's health care hospital care funding conclusions exercise: health care system of the federation of bosnia and references recommended readings electronic health records the core background defining electronic health record building electronic health records necessary context blocks necessary building blocks benefits of electronic health records difficulties and risks associated with electronic health records national approaches: examples exercise: ehr development data storage, data privacy and security glossary of key terms references recommended readings health indicators and health classification and evaluation method of indicators the types of different indicator sets indicator classification and evaluation methods types of indicators quality criteria for health indicators main categories of an indicator set methods of comparison and benchmarking the use of health indicators for health reporting exercise: health indicators and health reporting references databases for health indicators quality of life: concept and definition of quality of life and health related quality of life measuring quality of life the instruments for measuring quality of life generic questionnaire sf – 36 standardization procedure of sf – 36 specific questionnaire – the minnesota living with heart failure the steps in the cultural adaptation: an example of serbian forward translation backward translation patient testing or cognitive debriefing exercise: measuring quality of life living with heart failure questionnaire living with heart failure questionnaire references and recommended readings disability-adjusted life years: a definitions and basic concepts health status assessment by use of daly exercise: disability-adjusted life years as a key tool for the analysis references recommended readings calculating the potential years of the concept of premature death historical background computing methods for pyll main domains where pyll is a useful tool examples from romania references recommended readings case study: inequalities in health as exercise: inequalities in health in the european region: what can the references health technology assessment origins what is health technology? what is health technology assessment? what is the purpose of health technology assessment? is it health technology assessment or a different approach that is what are the main elements of hta analysis? when are health technology assessment requested? what is the role of ethics in health technology assessment? how is health technology assessment conducted? selected issues in health technology assessment case example: step 1. identify and rank assessment topics step 2. specify assessment problem. step 3. determine locus of assessment. step 4. retrieve available evidence. step 5. collect primary data. step 6. interpret evidence. step 7. synthesize and consolidate evidence. step 8. formulate findings and recommendations. step 9. disseminate the findings and recommendations. step 10. monitor impact of assessment reports. exercises: introduction to health technology assessment references recommended readings comparative analysis of regional 2) moravian-silesian region – czech republic 2.1 demography 2.2 organisation and structure of the health system 2.3 measles immunisation programmes 2.4 breast cancer screening programmes 5) north rhine-westphalia, germany 5.1 demography 5.2 organisation and structure of the health care system 5.3 measles vaccination programmes 5.4 breast cancer screening programmes 6) eastern / midland / north-eastern regions – ireland 6.1 demography 6.2 organisation and structure of the regional 6.3 measles immunisation programmes 6.4 breast cancer screening programmes 7) veneto – italy 7.1 demography 7.2 organisation and structure of the health care system 7.3 measles immunisation programmes 7.4 breast cancer screening programmes exercise: comparative research on regional health systems in europe references health systems management health management: theory and development of management theory development of interest for health services management characteristics of managing health services organizations definition and key management components planning in management organizing in management staffing in management leadership in management controlling in management skills of modern managers in health services organizations exercise: managing health services organizations references and recommended readings human resource management fundamentals of human resource management staffing function training and development function motivation function maintenance / retaining function performance appraisal principles are: exercise: human resource management references recommended readings information systems management definitions and basic concepts existing types of applications in the medical field managerial cycle and information support types of decisions and the related information systems exercise: management of information systems references recommended readings financing of health care markets in health care the health care triangle basic sources for financing of health care the role of the state in financing of health care the role of the health insurance in financing of health care the role of the private sources in financing of health care external sources for financing of health care exercise: financing of health care references recommended readings payment methods and regulation resource allocation according to needs basic arrangements for resource allocation payment for primary health care (phc) providers payment and regulation of hospitals and other health facilities conclusion exercise: financing of health care and regulation of providers references case study: the current health insurance system modalities of becoming an insured through obligatory health rights from the obligatory health insurance realization of the rights to health care resources for health financing user participation in health care expenses (co-payment) payment to the health care providers revenues and expenditures of the health insurance fund in the year health insurance system in the health care reform in macedonia exercise: specificities of the current health insurance system in the republic of macedonia references case study: swot analysis of the serbian health current trends in health care system reforms historical background of the health insurance system development strengths weaknesses opportunities threats exercise: how can the health insurance management be restructured? references and recommended readings economic appraisal as a basis for health care and limited resources allocation of limited resources main features of health economics economic appraisal as an instrument for supporting decision making the concept of value and efficiency costs, costing problems and outcomes the methods of economic evaluation cost-effectiveness analysis cost-benefit analysis quality of life analysis cost-utility analysis cost of illness study decision rules: how to determine efficiency? how to make choices cost-effectiveness analysis discounting of cost and benefits how to perform an economic appraisal? stages in economic evaluation the research question the study population the study perspective data sources quality assurance exercise: health economics references recommended reading quality improvement in health care development of quality concept tools for quality improvement strategies and models current state of art in quality improvement and the role of public exercise: quality improvement in health care and public health references recommended readings accreditation of health institutions models of external tools for quality improvement in health care 1. iso model 2. efqm model 3. visitation programme 4. accreditation concept of accreditation – advantages and limitations accreditation procedure international projects and experiences with accreditation in european references project management characteristics of the project 1. a project creates change. 2. a project has various goals and objectives. 3. a project is unique. 4. a project is limited in time and scope. 5. a project involves a variety of resources. the phases of project management 1. initiation (pre-planning) phase 1.1. situational analysis 1.2. health problems identification 1.3. priority setting 1.4. establish goal and objectives 1.5. feasibility study 1.6. preliminary brief 2. detailed planning and scheduling 3. implementation 4. completion exercise: project management references and recommended readings planning and programming of health 1. specific issues related to the planning process 2. preparing a plan steps in the planning process 2.1. stating the mission (problem statement) 2.2. analyzing the external environment 2.3. conducting the swot analysis 2.4. establishing goals and objectives 2.5. preparing a financial plan and a budget 3. programme monitoring and evaluation 3.1. monitoring 3.2. evaluation exercise: planning and programming in health care references recommended readings useful internet sites health policy informed health policy and system health policy goals and priorities the role of the state and the ministry of health the position of decentralization in the health policy recommendation for the health policy changes redefined roles of the state and of the ministry of health providing the decentralization process at all levels application of modern management at the system and institutional education of managers for the new health policy exercise: health policy references public health framework in the the current legal basis for public health development and implementation of european union public health the view of people and experts regarding european public health the policies exercise: public health in the european union references recommended readings targets for health development introduction some principles history health21 – the renewed health target strategy of the who for the new target programmes of members of the healthy region network selection of national approaches some further regional target programmes selection of local health target programmes how to develop a target programme different types of target programmes networking for pragmatic support diagnostic tools some final remarks exercise: health targets references internet linkpage health legislation: procedures classification and short description of the legal regulations classifications general abstract legal regulations the legislative procedures the procedures for enacting a law: the republic of slovenia case regular procedure 1. proposal of a law 2. first reading 3. second reading 4. third reading 5. voting on a law fast-track procedure reconsideration of a law the procedure for the obligatory explanation of law publication of adopted legal regulations ratification of international treaties the contests, regulated by health legislation review of health legislation in slovenia exercise: health legislation – basic knowledge references recommended readings book review‘politics and health updated’ by marc danzon and yves charpak marc danzon is an innovative and well-rounded health policy analyst, a former colleague at who, where he was the regional director of the european office in copenhagen during the first decade of the 21st century. with his one-time scientific adviser yves charpak, dr. danzon has now published a remarkably frank commentary on the interface between the health sciences and politics – notre santé dans l’arène politique mondiale, belin (www.editions-belin.com isbn 9782 70111-9599-5). this 253 page book is presented as a dialogue between the two seasoned participants on the development of health services and their comparative performance. the key concept that the joint authors explore is ‘the context’ of health policy delivery. their candid conversations on policy and programme development are set within that extraordinary era in europe after the implosion of the soviet union, the challenges of the evangelical proponents of the ill-fated global policy of health for all by the year 2000, contrasted with danzon’s own 2008 tallinn charter. in their joint commentary, presented in the form of a recent exchange of amiable but incisive letters, they ponder again on the big questions of their days, re-examining some of the fundamental issues of the organisation, financing, management and evaluation of health services, and more pertinently services for health. by training, a psychiatrist, marc danzon won his spurs in france by heading up the comité français d’éducation pour la santé (cfes), where he took on fearlessly big tobacco and big alcohol, achieving international acclaim. for danzon and charpak the important question is not why there is such a variation between countries in the number of hospital beds per thousand population, or the expenditure on health service per capita, but why such a big divide in expectation of life, and deaths from preventable illness and accidents. the chapters in this fascinating dialogue span the obstacles to vaccination, health risks, the food industry, ebola, depression and suicide, public and private sector financing for health, and finally the strategies for the reorientation of health service towards health. the book underlines the reactionary bias of many health professionals and policy makers in their visions of health services, plus the sheer political and commercial threats of industries that kill people. this stimulating book just lacks an english edition and an index. their review, through the engaging process of dialogue, offers to the reader fresh access into the corridors of power at ministerial and international levels. in an encounter with dr. danzon in paris, on my recent travels, i was further astonished at the snowdon type revelations he cited on the clandestine snooping, with high-tech gadgets, uncovered in international health offices, that presents a sinister challenge to collegial confidence and collaboration. danzon and his colleague, after two terms at the top in the who in europe, draw back the veil on deliberations on the changing face of the health sector in the rapid period of transformation after the gorbachev years, which saw half of europe re-emerging from its http://www.editions-belin.com/ servile status under the heavy imprint of the soviet era. yet the authors see the liberation of europe as a capricious process in which the fundamentals of the welfare state, the opportunities and flaws of the free market model, the democratic process of greater freedom of speech and the re-action by ordinary people, all come into sharp confrontation with both professional authority and commercial clout. this confrontation tested the metal of those at the top. the dialogue throws new light on the way danzon and his colleagues kept the show on the road, whilst challenging the traditional inertia of health systems, by offering a fresh agenda of innovative action especially against commercial interests that were undermining health. at the same time the health press awakened by the voice of the people, vigorously questioned the role of the who and the rigid authority of health professionals. the notion of context is a leitmotif that pervades this fascinating book, for whilst international comparative analysis is deeply penetrating, the pursuit of health has to be conducted in each place in a way relevant to local capacities and priorities. for some the focus is safe water, for others mental health and wellbeing. the mission of the authors is to reveal insider dealing in the quest for improving world health. but, whilst truth is neither simple nor absolute, this important book offers a fresh motivation to analysis which should stimulate public and private reflections on health outcomes, at home and abroad. dr. john l. roberts email: john.laing@hotmail.com @ 2016 mauritian current affairs magazine weekly mailto:john.laing@hotmail.com lueddeke gr. survival: one health, one planet, one future. interview by daniele dionisio. seejph 2019, posted: 16 december 2019. doi 10.4119/seejph-3231 p a g e 1 | 7 book reviews survival: one health, one planet, one future george r. lueddeke interviewed by daniele dionisio re-published with permission from dr. daniele dionisio, member, european parliament working group on innovation, access to medicines and poverty-related diseases, and head of research project: policies for equitable access to health (peah) at: http://www.peah.it/2019/10/interview-survival-one-health-one-planet-one-future-routledge-1stedition-2019/) and https://twitter.com/danieledionisio http://www.peah.it/2019/10/interview-survival-one-health-one-planet-one-future-routledge-1st-edition-2019/ http://www.peah.it/2019/10/interview-survival-one-health-one-planet-one-future-routledge-1st-edition-2019/ https://twitter.com/danieledionisio lueddeke gr. survival: one health, one planet, one future. interview by daniele dionisio. seejph 2019, posted: 16 december 2019. doi 10.4119/seejph-3231 p a g e 2 | 7 ways forward to ensure the sustainability of people and the planet are needed at a time when the interdependencies among humans, animals, plants and the environment are to be recognized as the cornerstone to drive/steer the un 2030 sustainable development goals (sdgs). in this connection, peah had the pleasure to interview dr. george r. lueddeke as the author of the recently published cross-disciplinary book survival: one health, one planet, one future routledge, 1st edition, 2019. including contributions from the world bank, interaction council, chatham house, unesco, world economic forum, the tripartite one health collaboration (un food and agriculture organization, world organisation for animal health and world health organization), one health commission and more this book cuts across sociopolitical, economic and environmental lines. george r. lueddeke consultant in higher and medical education, southampton, uk george r. lueddeke phd med dipl.aves (hon.) is an educational advisor in higher and medical education and chairs the global one health education task force for the one health commission and the one health initiative as well as the international one health for one planet education initiative (1 hope). he has published widely on educational transformation, innovation and leadership and been invited as a plenary speaker to different corners of the world. bio https://www.routledge.com/survival-one-health-one-planet-one-future/lueddeke/p/book/9781138334953 http://www.peah.it/wp-content/uploads/2019/10/lueddeke-06.08.19-gl-short-bio-1.pdf http://www.peah.it/wp-content/uploads/2019/10/lueddeke-pic.png lueddeke gr. survival: one health, one planet, one future. interview by daniele dionisio. seejph 2019, posted: 16 december 2019. doi 10.4119/seejph-3231 p a g e 3 | 7 peah: dr. lueddeke, the international one health for one planet education (1hope) initiative was created to address perhaps the most important social problem of our time: ‘how to change the way humans relate to the planet and each other to ensure a more sustainable future to all life’. on this wavelength, what about the main purpose of your book survival: one health, one planet, one future? lueddeke: the book tries to make sense of the uncertain and tense (“rattling”) times we are experiencing and asserts that the one health & well-being concept (ohwb) that recognises the interdependencies among humans, animals, plants and their shared environment – is critical to safeguarding our future while also providing a “unity around a common purpose” that seems to be missing globally. i prefer the term one health & well-being (vs just ‘one health’) as it emphasises not only the crucial importance of human physical and mental well-being but also the need to strive toward meeting socioeconomic, geopolitical and ecological conditions to ensure the sustainability of all living species and the planet. table of contents: here i also argue that the ohwb approach ought to drive/steer the 17 un-2030 sustainable development goals (sdgs) that were agreed by all 193 member states of the united nations in september 2015. the main aim of the un global goals is to create ‘a more just, sustainable and peaceful world.’ the ohwb perspective needs to inform and encourage decision-makers at all levels – especially civil societyto get behind the un global initiative regardless of ideological persuasion or divisions. the challenge is how to get government, business and civil society behind ohwb and the sdgs across all nations – those that are more economically developed and those that are developing and of course those that are in disarray – many for reasons that defy logic. concentrating on local needs guided by global/national priorities that are in keeping with sustainability values and practices is without a doubt the best way forward. there are about 7.7 billion people on the planet, and it is estimated that there will be over 9.8 billion by 2050 and 11.2 billion in 2100. climate change, urbanisation, pandemics, conflicts (globally we spend over us $7 trillion on war and only $ 3% on peace-c. $6 billion! ) and food security are main issues we need to tackle now and feature in the book along with health care – perhaps prompting reconsideration of the term “public health” and widening its remit to the more inclusive “global health and well-being” as the focus must shift to ecocentrism. changing the way we think and behave should no longer be a question of why but how -although our main concerns continue to be political and economic rather than sustaining the planet. populism, nationalism and isolationism are the antithesis of the paths toward which we ought to be striving. the root causes of these movements need to https://www.routledge.com/survival-one-health-one-planet-one-future/lueddeke/p/book/9781138334953 https://www.routledge.com/survival-one-health-one-planet-one-future/lueddeke/p/book/9781138334953 https://www.routledge.com/survival-one-health-one-planet-one-future/lueddeke/p/book/9781138334953 http://www.peah.it/wp-content/uploads/2019/10/lueddeke-cover-image.jpg lueddeke gr. survival: one health, one planet, one future. interview by daniele dionisio. seejph 2019, posted: 16 december 2019. doi 10.4119/seejph-3231 p a g e 4 | 7 be investigated and solutions found that ensure global equity, peace and sustainability. it may be important to remind global decision-makers that if we fail to save the planet none of the other human activities will matter. shelley’s poem ozymandias (1818) comes to mind. i am also reminded of a quote by economist and author john kenneth galbraith ‘a nuclear war does not defend a country and it does not defend a system …not even the most accomplished ideologue will be able to tell the difference between the ashes of capitalism and the ashes of communism.’ peah: the book highlights two of our greatest social problems: changing the way we relate to the planet and to one another and confronting how we use technology for the benefit of both humankind and the planet. how to translate theory into practice? lueddeke: several years ago, marco lambertini, executive director at wwf, made clear why there has to be a major societal transformation. as one example, he observed that ‘in less than two human generations, population sizes of vertebrate species have dropped by half.’ further, he reminded us: ‘these are the living forms that constitute the fabric of the ecosystems which sustain life on earth and the barometer of what we are doing to our planet, our only home.’ he also warned that ‘we ignore their decline at our peril.’ echoing the book’s main theme, he also emphasised the need for ‘unity around a common cause, ’ collaboration, and leadership ‘to start thinking globally and to stop behaving as if we have a limitless world.’ in the intervening five years since the wwf report was published, too few leaders – g7 (france, united states, united kingdom, germany, japan, italy, canada [ russia suspended] and e7 (emerging – china, india, brazil, mexico, russia, indonesia and turkey) have listened. given the available evidence today (e.g., the un biodiversity report published in may 2019!), there is now, unquestionably, a pressing need to re-orient society towards a sustainable future. the challenge is to shift our perspective from two-dimensional to three-dimensional, ‘orbital’ thinking, as nasa international space station astronaut col ron garan contends –‘bringing to the forefront the longterm and global effects of every decision.’ peah: relevantly, you maintain in the book that two fundamental changes are necessary if we – and all other species – are to survive in the coming decades. tell us more, please, around these changes. lueddeke: in terms of sustainability we are challenged to make a fundamental mind shift – adopt a new worldview – to ensure our needs as human beings are compatible with the needs of our outer world – our ecosystem. education is key in this regard as are global/national/local policies and strategies that underpin ohwb and the sdgs. secondly, we must ensure that technology / ai is used only for peaceful purposes and in support of the health and well-being of all species and the planet. the dangers of techno warfare and genetically engineered viruses are all too real and we must learn from history. the late physicist, stephen hawking, said it best ‘we are all different we all share the human spirit’ but ‘unless crucial societal transformations occur, including the prevention of nuclear war, global warming and genetically engineered viruses – the shelf life of homo sapiens could be extremely short.’ lueddeke gr. survival: one health, one planet, one future. interview by daniele dionisio. seejph 2019, posted: 16 december 2019. doi 10.4119/seejph-3231 p a g e 5 | 7 the battle between technology and humanity may yet become our greatest threat. as we head further into a techno-driven society – age of quantum computers (where computations can be done in minutes vs 10,000 years on today’s supercomputers), there is a real danger that we become increasingly dehumanised rather than as klaus schwab, executive chair of the world economic forum, aspired, that we refocus on becoming ‘better humans.’ peah: summarised in *ten propositions for global sustainability*(ch. 12), the volume calls for the one health and wellbeing concept to become the cornerstone of our educational systems and societal institutions – helping to create – in keeping with the un 2030 global goals – a more “just, sustainable and peaceful world.” can you detail about the propositions in their connection with the one health and wellbeing concept? lueddeke: two of the main recommendations of survival is that the one health & well-being concept should become the cornerstone of our educational systems and society at large and that ohwb principles and approach should underpin the un-2030 sustainable development goals. the propositions cut across socioeconomic, geopolitical and environmental lines. the need for a paradigm shift and peaceful use of technology have already been mentioned. others relate to migration, genuine collaboration among government, business, civil society, and actively promoting ‘the values of equality, democracy, tolerance and respect.’ the need for global discussion on these and other propositions seems essential. the un could be best placed to lead on the initiative perhaps supported by higher education institutions (universities, colleges, etc) of which there are about 26,000 impacting on the lives of millions. to raise awareness across education systems and communities, the one health education task force along with a global planning tea mare evolving an international one health for one planet education initiative (1 hope). anyone interested in joining a working group can sign up https://tinyurl.com/y2ux5b5g peah: proposition 10, inter alia, focuses on reforming the un security council established right after wwii (1946).what does this mean? lueddeke: well, the unsc was formed after wwii (1946) consisting of 5 permanent members (us, china, russia, uk, france), while in 2019, the most densely populated regions with the greatest poverty and conflicts – africa (c. 1.2 bill), india (c.1.3 bill), se asia (c. 600 mill), middle east (c. 400 mill) – c. 50 % [3.5 bill out of c 7.7 bill] – are not permanently represented. shifting to regional (6) representation (vs countries) would clearly be in the best interest of the world given the need for global accountability and sustainability. unsc members should also beheld globally accountable by key stakeholders – government, business, civil society – for their role in maintaining world peace and security – based on a genuine commitment to shared people and planet values. the question is how we can achieve these ends when forces are pushing the world in the opposite direction. surely, these decision-makers also have children and grand-children and would like to see them thrive in a better world where hopes and dreams can be realised. https://www.un.org/sustainabledevelopment/sustainable-development-goals/ https://www.un.org/sustainabledevelopment/sustainable-development-goals/ https://myemail.constantcontact.com/one-health-education---updates-and-expansion-exploration.html?soid=1121110857318&aid=wt811s7nkn0 https://tinyurl.com/y2ux5b5g lueddeke gr. survival: one health, one planet, one future. interview by daniele dionisio. seejph 2019, posted: 16 december 2019. doi 10.4119/seejph-3231 p a g e 6 | 7 peah: as for the range of key topics covered in the book? lueddeke: this is my third book this decade and in a way represents a personal journey of discovery trying to understand the world and healthcare – first from a more narrow humancentric medical education perspective (medical education for the 21st century), moving to the wider public health horizon and recognising the limitations of my assumptions (global population health &well-being in the 21st century) to pulling various strands together in survival: one health, one planet, one future. i don’t think i could have written the latter without the former. the new publication is really a building block of personal knowledge acquisition tinged by personal and professional experience in canada and the uk plus other countries. peah: as reported ‘…the sub-discipline that has perhaps come closest to integrating other disciplines, including medicine and environmental science, is public health. in survival: one health, one planet, one future, george r. lueddeke, the chair of the one health education task force, shows how public health can be incorporated into a wide range of fields to address individual, population, and ecosystem health…’with respect to this, kindly let us know more. lueddeke: this quote appears in one of the on-line book reviews and comes from a world economic forum / political syndicate on-line article, “economics can no longer ignore the earth’s natural boundaries,” written by erik berglof at the london school of economics. three key messages are that 1) economists have treated inequality too narrowly and that income disparities within countries are caused mainly by global financial forces rather than local labourmarket conditions; 2) policies are required to make society more sustainable; and 3) a new field of planetary social science is needed to bring together ‘different perspectives, conceptual frameworks, and analytical tools.’ he affirms that public health is closest to integrating other disciplines and refers to survival: one health, one planet, one future, and ‘how public health can be incorporated into a wide range of fields to address individual, population, and ecosystem health.’ survival concludes with a discussion on the leadership role that generation z – those – the ‘fixers’ born in the mid-90s – need to play in the decades that lie ahead. they are becoming the face of the planet and are much more tolerant of others and thrive on collaboration. recalling the eloquent words of civil rights leader martin luther king jr, are certainly far from silent ‘about things that matter.’ their voices must be heard across the globe as their future depends on decisions we make today! peah: your insightful answers best enhance the book. so compounded, the volume is of great interest to policy-makers, multi-professional practitioners, academics, students across all disciplines and concerned members of the general public – especially the younger generation – in both developed and developing nations. for many reviewers to date, your book is indeed a wake-up call which needs to be heard “loud and clear” globally. just echoing a recent endorsement by tracy collins, founder at the island retreat, county cork, ireland ‘… when we accept that humankind is part of something bigger, then the world will be a better place. our natural world is not there to provide us with https://www.weforum.org/agenda/2019/08/building-a-truly-sustainable-global-economy-heres-how/; https://www.routledge.com/survival-one-health-one-planet-one-future/lueddeke/p/book/9781138334953 https://www.routledge.com/survival-one-health-one-planet-one-future/lueddeke/p/book/9781138334953 https://www.routledge.com/survival-one-health-one-planet-one-future/lueddeke/p/book/9781138334953 https://www.routledge.com/survival-one-health-one-planet-one-future/lueddeke/p/book/9781138334953 lueddeke gr. survival: one health, one planet, one future. interview by daniele dionisio. seejph 2019, posted: 16 december 2019. doi 10.4119/seejph-3231 p a g e 7 | 7 unlimited resources…it really is time to start learning to respect it. thank you george r. lueddeke for being a voice of reason in a world of chaos!’ ___________________________________________________________________________ © 2019 daniele dionisio; this is an open access article distributed under the terms of the creative commons attribution license (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1 review of costing tools health system in liberia project technical assistance to support the implementation of the national health plan and the roadmap for the reduction of maternal mortality in liberia 2 epos health management in cooperation with the european union project technical assistance to support the implementation of the national health plan and the roadmap for the reduction of maternal mortality in liberia authors: natasa popovic, m.sc. public health, phd candidate, institute of social medicine, school of medicine, university of belgrade senior health economist epos health management roland y. kesselly, director of hfu mohsw nuaker k. kwenah, health financing officer mohsw ernest gonyon, health financing officer mohsw melanie s. graeser, junior health economist hfu mohsw correspondence: prof. dr. med. ulrich laaser dtm&h, mph team leader of the eu funded technical assistance to reduce maternal mortality in liberia department of planning, ministry of health congo town, monrovia, liberia epos eu ta: https://www.facebook.com/eutahealthliberia e-mail: ulrich.laaser@uni-bielefeld.de http://www.facebook.com/www.epos.de mailto:ulrich.laaser@uni-bielefeld.de 3 acknowledgements: the authors gratefully acknowledge the support of mr. david collins (management sciences and health). 4 table of contents list of acronyms .......................................................................................................................................... 5 1. introduction ......................................................................................................................................... 6 2. background .......................................................................................................................................... 8 3. marginal budgeting for bottlenecks ................................................................................................ 10 4. cost and revenue analysis tool plus .............................................................................................. 19 5. onehealth tool .................................................................................................................................. 21 5.1 modules of onehealth tool ...................................................................................................... 22 5.2. costing process ............................................................................................................................... 26 6. conclusion .......................................................................................................................................... 28 7. references: ......................................................................................................................................... 29 5 list of acronyms core plus cost and revenue analysis tool plus eu european union hfu health financing unit hiv/aids human immunodeficiency virus infection and acquired immune deficiency syndrome mbb marginal budgeting of bottlenecks mdg millennium development goals mohsw ministry of health and social welfare of liberia msh management sciences for health prsii poverty reduction strategy tb tuberculosis 6 1. introduction as a consequence of the ebola crisis, the liberian ministry of health and social welfare‘s (mohsw) adopted measures to strengthen the health sector leading to the “investment plan for building a resilient health system” (1). numerous partners assisted in this effort, including the european union (eu), which contributed to the development of the plan and participated in the revitalization of the technical working groups along with the nine pillars of intervention. the eu contributed a substantial part as it addressed with preference one of the biggest public health concerns of the country: the reduction of maternal and newborn mortality (2, 3, and 4). it predominantly supported two intervention pillars, namely strengthening leadership and governance and efficient health financing systems and contributes as well to others. these elements represent important requirements to the implementation of the "roadmap for accelerating the reduction of maternal and newborn morbidity and mortality in liberia" and the "accelerated action plan to reduce maternal and neonatal mortality", within the overall framework of the national health plan (2, 3, 4, 5). one important barrier to achieving the national health plan in liberia is a lack of funding (6). as in many developing countries, the health systems in liberia fail to reach large coverage of the population that would benefit from cost-effective interventions related to child and maternal health, malaria, tuberculosis (tb), human immunodeficiency virus infection and acquired immune deficiency syndrome (hiv/aids), and other diseases, due to missed opportunities for mobilization of financial resources or the required financial assistance. the introduction of three appropriate analytical costing tools programs cost and revenue analysis tool plus (core plus), marginal budgeting of bottlenecks (mbb) and onehealth tools, was an 7 opportunity to support health financing unit of mohsw of liberia (hfu), to manage, improve and harmonize the process of costing and budgeting plans and interventions in the health system. the aim of review of costing tools is to present costing tools that were introduced during the project "technical assistance to support the implementation of the national health plan and the roadmap for the reduction of maternal mortality in liberia", in order to implement in the liberian health system (7). 8 2. background the mohsw of liberia developed a primary health care approach encompassing decentralization, community empowerment, and partnership. these objectives have been defined in the health sector policy and plan 2011-2021 and the poverty reduction strategy – prsii 2012 – 2017, both stressing the importance of making progress in maternal and newborn health (millennium development goals mdg 5) (5). epos health management through the project technical assistance to support the implementation of the national health plan and the roadmap for the reduction of maternal mortality in liberia, contributes to the achievement of the objectives and targets set for 2016-2017 in the 10-years strategic health and social welfare plan and the roadmap for the reduction of maternal mortality (7, 2). the overall objective of this project is to contribute to improving the health status of the liberian population in general and reducing maternal mortality in particular, by improving access to as well as the quality of the essential package of health services (7). this includes mentoring of local staff to contribute to a sustainable reform and modernization of the health sector. epos health management supported to produce a needs-based comprehensive capacity development plan (human resources, institutional and system) for central office and county health team, covering: health planning and budgeting, accounting, financial management and reporting, contracting of health services; health information management; human resources management; assets management; supervision skills; logistic and supply management and quality assurance management. approach and strategy chosen to achieve one part of the goals are to provide costing tool trainings such as marginal budgeting for bottlenecks, core plus and onehealth tools, for hfu mohsw of liberia (8, 9). 9 the aim of this trainings is to strengthen health systems and to improve medium-term sector, planning, costing, budgeting, financing and analysis and to estimate the costs of individual services and packages of services under the different scenarios. table 1. list of costing tools included in the review that are introduced to health financing unit in liberia tool developed by developer marginal budgeting for bottlenecks (mbb) unicef/ world bank rudolf knippenberg, susie villeneuve, netsanet walelign, agnes soucat core plus management science for health david collins onehealth tool inter-agency working group on costing avenir health 10 3. marginal budgeting for bottlenecks the marginal budgeting for bottlenecks tool estimates the potential impact, resource needs, costs, and budgeting implications of country strategies to remove systemic bottlenecks and implementation constraints of the health system (9). mbb is intended to help formulate mediumterm (one to 10 years) national or provincial expenditure plans and poverty reduction strategies that explicitly link expenditure to health and nutrition mdgs (9, 10, 11) the model has been developed in the context of heavily indebted poor countries and prsp to respond to the request of low-income countries to plan, cost and budget marginal allocations to health services and assess their potential impact on health of the population. (9, 10). the aim of mbb is to answer the following questions (10): 1. which high impact interventions are priorities for the integration into existing service delivery arrangements, to accelerate the progress towards the health and nutrition mdgs? 2. what are the major health systems hurdles or "bottlenecks" hampering the delivery of health services, and what is the potential for their improvement? 3. what is the potential investment required by alternative options to alleviate the identified health systems bottlenecks? what would be the cost of the incremental service provision as coverage increase? 4. what is the total amount of resources required to achieve the desired coverage? 5. what could be achieved in terms of health outcomes by removing health system bottlenecks and increasing coverage of effective interventions? 6. what amount of financing could be mobilized under various fiscal and macroeconomic scenarios and how should additional funding be allocated? 11 the centerpiece of the mbb tool is the bottlenecks identification and analysis approach (9, 10). the main goal of the bottlenecks analysis is to identify the limitations in a health system which responsible of reaching a desired level of service coverage. this approach identifies any weakness and gaps across six determinants (10): ➢ availability of essential commodities, ➢ availability of human resources, ➢ geographical or financial access to health services, ➢ initial utilization of health services, ➢ continuous utilization or adequate coverage, ➢ effective coverage or quality of care. by identifying these bottlenecks, the tool’s outputs help policy makers to (10 14): ➢ select the priority health interventions, policies, and strategies they wish to implement, ➢ estimate the additional resources needed and progress toward achieving the health mdg-related goals, ➢ project the estimated impact of the chosen strategies on the health mdgs. mbb tool is organized in three main modules (10, 11): 1. bottlenecks identification 2. costing & budgeting module 3. estimation of expected impact 12 figure 1. main modules of mbb the bottlenecks identification module uses a country-specific data or default data and defines three main packages of health interventions. on the basis of present levels of effective coverage, it analyses bottlenecks in implementation and sets new performance frontiers (10, 11). the costing and budgeting module is structured to take into account the strategic changes in the health care delivery policies, addressing both supply and demand constraints. estimation of expected impact relies on the results of epidemiological modules. it shows the consequences of the choices of the policy makers and gives them a chance to change their decisions. mbb tool is built on the theoretical concept of effective coverage (15). effective coverage can be defined as the proportion of the population in need of an intervention who have received an effective intervention (15). in order to achieve a high level of effective coverage and a significant health gain, the intervention should be effective, available, accessible and acceptable (15). mbb builds upon the tanahashi modified model of effective coverage concept and used six coverage determinants to assess the capacity of the health system to deliver the full effect of mbb bottlenecks identification module costing & budgeting module estimation of expected impact 13 interventions or achieve effective coverage (16). this modified model was used to identify bottlenecks, through a step-by-step approach, that evaluates six determinants of the effective coverage of intervention. these are determinants (16): 1. availability of essential health commodities, 2. availability of human resources, 3. accessibility of distribution points for the interventions, 4. initial utilization of interventions, 5. continuity/completeness in the continuous utilization of interventions, 6. a quality of interventions delivered. figure 2. tanahashi modified model determinants of effective coverage adapted from tanahashi t. bulletin of the world health organization, 1978, 56 (2), http://whqlibdoc.who.int/bulletin/1978/vol56no2/bulletin_1978_56 (2) 295-303.pdf 14 the first three determinants focus mainly on supply-side barriers, while the other three focus on demand-side barriers. the mbb focuses on the selection of high impact interventions which are currently implemented in a country and organizes them into three service delivery modes (17, 18). within each service delivery mode, high impact interventions are grouped into four sub-packages which are based on their similarity, delivery mode, and/or beneficiaries. table 1. services delivery modes, sub-packages and tracker indicators in health system in liberia family-oriented community-based services family preventive wash services family neonatal care infant and child feeding community illness management insecticide-treated mosquito nets exclusive infant breastfeeding from the 1 to 6 months no alternative to breastfeeding community case management of pneumonia. outreach / schedulable services preventive care for adolescents and adults preventive pregnancy care hiv/aids prevention and care preventive infant and child care family planning antenatal care prevention of motherto-child transmission immunization individual-oriented clinical services maternal and neonatal care at primary clinical level management of illnesses at primary clinical level clinical first referral care clinical second referral care skilled delivery pneumonia tb treatment emergency obstetrics and neonatal care from the extensive menu of high impact interventions which are grouped into tree services delivery modes and four sub-packages, the expert group in liberia has chosen representative interventions 15 or tracer interventions. tracer interventions are considered to have the greatest impact on reducing maternal mortality, under-five mortality, neonatal mortality, malnutrition, and control of priority of diseases. analysis of "determinants of effective coverage" for each tracer intervention, through the bottlenecks analysis, allows the identification of the health system bottlenecks that constrain the achievement of a high effective coverage level. there are a major criteria for choosing a tracer intervention for a bottleneck analysis (10, 11): 1. the tracer intervention is selected only if data is available for each of its six determinants: availability of commodities, availability of human resources, geographical accessibility, initial utilization, continual utilization, and effective coverage level. 2. the tracer intervention is an internationally recommended intervention, with proven and quantified efficacy on mortality reduction. 3. the tracer intervention is nationally relevant. 4. the tracer intervention should be representative of the other indicators within its intervention group, concerning facing similar health system constraints for all tracker interventions, the expert group needs to assess baseline and coverage frontiers. that is one of the most crucial steps in the mbb exercise. coverage objectives or “frontiers” represent the highest, realistically achievable coverage level in a given period. the centerpiece of the mbb tool is the bottlenecks analysis. the main goal of the bottlenecks analysis is to identify the limitations in a health system that are responsible for reaching a desired level of coverage. bottlenecks are measured regarding the six coverage determinants, and a coverage determinant bottleneck is defined as the difference between 16 the maximum achievable coverage and the actual coverage. the result of any reduction in bottlenecks is an increase in the utilization of effective interventions. figure 3. example of bottlenecks analysis of the tracker intervention  the coverage determinant bottlenecks are hierarchical, each bottleneck having a ceiling that is set by its previous determinant and each determinant determines the ceiling of the next.  reductions in bottlenecks have a cascading effect, where changes in one produce changes in the ones that follow.  the magnitude of the cascading effect is set by the baseline ratio between coverage determinants, which is calculated by the tool. 0 10 20 30 40 50 60 70 80 90 100 availability of essential commodities availability of human resources physical access initial utilization timely continuous utilization effective coverage baseline coverage objective coverage 17 table 3. example of frequent bottlenecks and their main causes bottlenecks in the service delivery modes family-oriented, community-based services population-oriented, schedulable services individually-oriented (clinical care) services ● low availability of essential commodities and human resources ● low affordability of commodities ● low levels of knowledge ● no mainstreaming in societal/community values ● low accessibility of promotion programmes ● logistical difficulties and difficulties in sustaining efforts at outreach ● low levels of continuity, high drop-outs ● difficulties in leading qualified human resources to serve the poor ● participation of less qualified providers ● difficulties in controlling the non-retail pharmaceutical market: ● low-quality harmful pharmaceutical products. ● major problems of affordability of health care and impoverishment. table 4. example of causes and corrective actions in the service delivery modes family-oriented, community-based services population-oriented, schedulable services individually-oriented (clinical care) services ● free or subsidized supply of commodities ● increase number of community health workers ● improve social marketing ● female education ● community/ societal support mechanisms ● improve mobile, outreach, and home visits ● centralized control and planning ● community involvement in planning and monitoring ● demand-side incentives ● incentives for qualified staff to work in rural areas and development of alternative skills ● public control of provision of care and prices, regulation of private sector, and combined consumer’s information and providers’ trainings ● modulated pricing, exemptions when funded, and third-party payment mechanisms and subsidies to insurance costing module in mbb involves two basic production functions; intervention production function and health production function. the intervention production function represent the process 18 of how inputs are used to produce health outputs or health service coverage. the intervention cost is calculated by multiplying the quantity of inputs with input prices. the intervention price is the amount of money at which the intervention is bought or sold. both the intervention cost and intervention price have an impact on a budget. the budget can be compared against available financing. the health production function, represents the process of transforming health outputs into health outcomes. health outcomes are generally calculated by multiplying the quantities of interventions produced by their effectiveness. figure 4. elements in costing health interventions and health outcomes source; who, unicef, the world bank, and unfpa, in collaboration with the partnership for maternal, newborn and child health and the norwegian government (2008) technical review of costing tools for the health mdgs final report. 19 4. cost and revenue analysis tool plus cost and revenue analysis tool (core plus) is an excel‐based tool developed by management sciences for health (msh) (19). the tool estimates the costs of individual intervention (services) and packages of interventions as part of the cost of integrated primary health care facilities (19). the tool was designed to be used by planners and managers of government, private and ngo primary health care services. the tool uses a bottom‐up costing methodology to determine the standard cost of each service in the package. a standard unit cost is set for the variable costs of each service, and the total variable costs are then estimated by multiplying those unit costs by the numbers of services (19). the tool can estimate the expected number of each type of intervention provided through a primary health care facility, based on the catchment population and using disease prevalence and incidence rates and service delivery norms. it can then cost each of those interventions and the total package of interventions and can also be used to produce a budget (9, 19, 20, and 21). fees and other revenue sources can be entered for each intervention and compared with individual intervention and total facility costs (9, 19, 20, and 21). the tool defines the intervention production function by enabling the user to choose from five possible service and costing scenarios (19): 1. scenario a: actual services and actual costs; 2. scenario b: actual services and normative costs; 3. scenario c: needed services and normative costs; 4. scenario d: projected services and normative costs;  scenario e: projected services and ideal staffing 20 figure 5. core plus tool flow graphic sources: cost and revenue analysis plus tool flow graphic, (msh) potential applications core plus tool are (19, 9): ➢ to improve planning and budgeting at the national, district, and facility levels. ➢ to identify resource and service delivery gaps and assess the equitable and efficient allocation of resources. ➢ to determine staffing and treatment norms and encourage consistency in quality. ➢ to analyze current revenue streams and perform sustainability analysis. ➢ to compare performance across different facilities. ➢ to determine the cost of adding or scaling up services. ➢ to determine the volume of services that can be provided within a given budget. 21 5. onehealth tool the onehealth model is a new software tool designed to strengthen health systems, integrating planning and analysis, costing, budgeting and financing at a country level (22). the onehealth tool aims to support integrated strategic planning and costing processes in countries, by taking together disease-specific program and health systems planning (22, 23). the tool helps an assessment of costs related to the areas of maternal, newborn as well as reproductive health, child health, vaccination, malaria, tuberculosis, hiv/aids, nutrition, water sanitation and hygiene, to inform progress towards the mdgs, including assessment of achievable health impact (23). additionally, it contains modules for the areas of human resources, infrastructure, logistics, financial space, programme and channel analysis, intervention coverage and costing, bottleneck analysis, programme costing, summary outputs and budgeting. potentially, onehealth could have several users. in the most comprehensive case, health planners would be able to put together a multi-year health plan and use the tool to create a costed plan for addressing critical health needs; to compare different scenarios for reaching the health sector priority goals. the different scenarios could be used as part of a national strategic health planning exercise or as a part of a proposal to a multilateral funding organizations. health system planners from disease area can use the programme planning modules to develop plans addressing their needs concerning health systems. also, they can use the system modules to make medium and long range plans for human resources, infrastructure, logistics, etc. the advantages of onehealth software is generated when multiple modules are used at the same time, to identify synergies and to ensure that planning processes take into account systemic constraints. 22 figure 6 general structure of onehealth tool sources: stenberg k, chisholm d (2012) resource needs for addressing non-communicable disease in lowand middle-income countries. global heart 7: 53-60. doi:10.1016/j.gheart.2012.02.001. 5.1 modules of onehealth tool onehealth tool is primarily organized into three main modules: 1. health services module 2. health systems modules 3. impact modules the health services module estimates the costs of items that vary by the number of intervention recipients. these items include commodities, drugs and other supplies. the tool utilizes user defined inputs such as target populations that interventions focus and populations in need of interventions, type of interventions, percentage coverage of intervention and the delivery channel. 23 in addition of this, numerous treatment inputs related to interventions that are provided by various types of health care workers, have to be defined by the tool. the unit costs of specified inputs also have to be indicated. the average time used for each type of health workers involved in an intervention also needed for computation of staff time utilization patterns and assessment of staff time adequacy. health systems module consists of several sub-modules. they include; ➢ infrastructure and equipment module estimates the cost incurred on buildings, the cost involved in vehicles and the cost of information and communication technology equipment (construction, rehabilitation/maintenance and utility costs)human resource module, ➢ human resource module calculates the cost of paying emoluments to health staff, the cost of preservice training and cost of providing retention incentives. the staff baseline, staff distribution by various levels of health care, annual salary, incentives and increment patterns and numbers and unit costs related to preservice training of different types of staff have to be indicated. ➢ logistic module estimates the expenditure incurred on logistic activities related to a health program. the module estimates the cost of warehouses (construction, maintenance and utilities), the cost of transport and the cost of paying warehouse workers ➢ health information systems module is designed to estimate the cost of developing and maintaining the management information system related to a health program. it also involves several management functions such as training, supervision, review and updating of the information systems, etc. 24 ➢ governance and leadership module estimates the cost of governance activities such as the development or review of strategic vision and ethics, improving responsiveness, participation and consensus, carrying out legal reforms and maintaining the transparency and accountability of health programs. ➢ financing policy module contains the total resources available for the health sector including government resources, private sector and funding from external sources. impact models includes (22);  demproj demproj projects the population for an entire country or region by age and sex, based on assumptions about fertility, mortality, and migration.  famplan projects family planning requirements needed to reach national goals for addressing unmet need or achieving desired fertility.  list: lives saved tool (listchild survival). a program to project the changes in child survival in accordance with changes in coverage of different child health interventions  aim: aids impact model. aim projects the consequences of the hiv epidemic, including the number of people living with hiv, new infections, and aids deaths by age and sex; as well as the new cases of tuberculosis and aids orphans.  goals: the goals model helps efforts to respond to the hiv/aids epidemic by showing how the amount and allocation of funding is related to the achievement of national goals, such as reduction of hiv prevalence and expansion of care and support.  rapid: resources for the awareness of population impacts on development. rapid projects the social and economic consequences of high fertility and rapid population growth for such sectors as labor, education, health, urbanization, and agriculture. 25  rnm: resource needs model. this model is used to calculate the funding required for an expanded response to hiv/aids at the national level.  time: tb impact module and estimates module provides the user with smoothed estimates of historical and current tb incidence and notification as well as short term statistical projections.  ncd: the non-communicable disease impact module calculates the populations affected by, and the impact of scaling up interventions on cardiovascular and respiratory disease, diabetes, cancer, and mental health, neurological, and substance abuse disorders. 26 5.2. costing process adaptation of onehealth tool cost health programs required the adoption of a systematic process. in costing flow graphic we identified six steps in the systematic process. figure 7. costing flow graphic • identify relevant program areas and sub groups • identify interventions to cost • identify health system components involved in health program areas identify costing process • set up liberian projection • specify currency types, inflation and currency exchange rates setting up a oht projection • define program areas & sub groups • select default & create new interventions to reflect the specific program area • organize interventions • specify delivery channels outline program areas, sub group and interventions hierarchy • target populations • population in needs • intervention coverages • treatment inputs • delivery channel distributions input intervention costing parameters • determine program management activities • estimate and add annual costs specify program costing/management parameters • infrastructure baseline, unit costs and targets • human resource baseline, unit costs and targets • logistic baseline, unit costs and targets • his baseline, program activities, and unit costs specify health system costing parameters 27 cost analysis of programme management program management costs incurred by a health program may include training, supervision, monitoring and evaluation, transportation, advocacy and communication, media and outreach. these costs derived from health program managers’ inputs, and were incorporated into the annual costs at the program level. figure 8 illustrates how the cost of program management, together with the direct interventions’ cost, represents the total cost of a given health programme. total costs for health program 1 intervention a; target population size x percentage of target population in need of intervention x target coverage = number of population reached by intervention a intervention c; target population size x percentage of target population in need of intervention x target coverage = number of population reached by intervention c intervention b; target population size x percentage of target population in need of intervention x target coverage = number of population reached by intervention b total cost of drugs and commodities for health program 1 + cost of in-service training + coordination meetings + transport consultancies in supervision + monitoring and evaluation figure 8. diagram of health programmes cost analysis 28 6. conclusion epos health management through the "project technical assistance to support the implementation of the national health plan and the roadmap for the reduction of maternal mortality in liberia", contributes to the achievement of the objectives and targets set for 2016 2017 in the 10-years strategic health and social welfare plan and the roadmap for the reduction of maternal mortality. approach and strategy chosen to achieve one part of the goals were to provide costing tool pieces of training, for hfu. review of costing tools represents the collaborative effort of the epos health management and hfu, and opportunity to support hfu, to manage, improve and harmonize the process of costing and budgeting plans and intervention in the health system of liberia. the introduction of three appropriate analytical costing tools programs, core plus, mbb and onehealth tools, provided the opportunity to improve medium-term sector planning, costing, budgeting, financing and analysis. in particular, it gives a chance to estimate the potential impact on health, resource needs, costs, and budgeting implications of strategies to remove systemic bottlenecks and implementation constraints of the health system. even more costing tools can be used to estimate the costs of individual services and packages of services under the different scenarios which gives valuable insights into the costs and incomes across the clinics and health centers. one of the recommendations of the mission reports was that hfu should develop the process of applying core plus in all primary health care institutions at the county level and onehealth tool software, designed to strengthen health systems, integrating planning, costing and analysis, at a country level. 29 7. references: 1. ministry of health and social welfare of liberia. investment plan for building a resilient health system 2015-2021. monrovia; 2015. 2. ministry of health and social welfare of liberia. roadmap for accelerating the reduction of maternal and new-born morbidity and mortality in liberia (2011-2015). 2011. 3. ministry of health and social welfare of liberia. accelerated action plan to reduce maternal and neonatal mortality 2012. 2012. 4. ministry of health and social welfare of liberia. liberia community health road map july 1, 2014 – june 30, 2017. 2014. 5. ministry of health and social welfare of liberia. national health and social welfare policy and plan 2011-2021, 2011. 6. ministry of health and social welfare of liberia. department of planning, research & development, health financing unit: resource mapping liberia health sector: government fiscal year 2015-2016; 2015. 7. technical assistance to support the implementation of the national health plan and the roadmap for the reduction of maternal mortality in liberia | epos health management [internet]. epos.de. 2017 [cited 28 june 2017]. available from: http://www.epos.de/projects/technical-assistance-support-implementation-national-healthplan-and-roadmap-reduction 8. world bank, unicef, unfpa. health systems for the millennium development goals: country needs and funding gaps. 2009. 30 9. who, unicef, the world bank, and unfpa, in collaboration with the partnership for maternal, newborn and child health and the norwegian government. final reports of technical review of costing tools. 2008. 10. world bank and unicef. marginal budgeting for bottlenecks an analytical tool for evidence-based health policy, planning, costing, and budgeting technical notes (based on version 5.6). 2011. 11. world bank and unicef. marginal budgeting for bottlenecks an analytical tool for evidence-based health policy, planning, costing, and budgeting concise user guide (based on version 5.6). 2011. 12. odaga j, henriksson d, nkolo c, tibeihaho h, musabe r, katusiime m et al. empowering districts to target priorities for improving child health service in uganda using change management and rapid assessment methods. global health action. 2016; 9 (1):30983. 13. lancet series on maternal and child undernutrition. maternal and child undernutrition 1: global and regional exposures and health consequences. child: care, health and development. 2008; 34 (3):404-404. 14. jones g, steketee r, black r, bhutta z, morris s. how many child deaths can we prevent this year? the lancet. 2003; 362 (9377):65-71. 15. world health organization. background paper for the technical consultation on effective coverage of health systems. rio de janeiro, brazil; 2001. 16. tanahashi t. health service coverage and its evaluation. bulletin of the world health organization, (1978) 56(2), 295–303. 17. darmstadt g, bhutta z, cousens s, adam t, walker n, de bernis l. evidence-based, costeffective interventions: how many newborn babies can we save? the lancet. 2005; 365 (9463):977-988. 31 18. waddington h, fewtrell l, snilstveit b, white h. water, sanitation and hygiene interventions to combat childhood diarrhoea in developing countries. synthetic review 001. new delhi, india, international initiative for impact evaluation, 2009. 19. lewis e, mcmennamin t, collins d. user’s guide for core plus (analysis of cost and revenue plus) tool version 1; 2007. 20. jarrah z, collins d. costing liberia’s basic package of health services: county hospital level. 2009. 21. jarrah z, collins d. costing the basic package of health services at clinics and health centres in liberia. 2009. 22. avenir health and united nations inter agency working group on costing. onehealth tool startup manual a computer program for making informed health programming decisions. 2016. 23. stenberg k, chisholm d. resource needs for addressing noncommunicable disease in lowand middle-income countries. global heart. 2012; 7 (1):53-60. 32 book review‘politics and health updated’ by marc danzon and yves charpak marc danzon is an innovative and well-rounded health policy analyst, a former colleague at who, where he was the regional director of the european office in copenhagen during the first decade of the 21st century. with his one-time scientific adviser yves charpak, dr. danzon has now published a remarkably frank commentary on the interface between the health sciences and politics – notre santé dans l’arène politique mondiale, belin (www.editions-belin.com isbn 9782 70111-9599-5). this 253 page book is presented as a dialogue between the two seasoned participants on the development of health services and their comparative performance. the key concept that the joint authors explore is ‘the context’ of health policy delivery. their candid conversations on policy and programme development are set within that extraordinary era in europe after the implosion of the soviet union, the challenges of the evangelical proponents of the ill-fated global policy of health for all by the year 2000, contrasted with danzon’s own 2008 tallinn charter. in their joint commentary, presented in the form of a recent exchange of amiable but incisive letters, they ponder again on the big questions of their days, re-examining some of the fundamental issues of the organisation, financing, management and evaluation of health services, and more pertinently services for health. by training, a psychiatrist, marc danzon won his spurs in france by heading up the comité français d’éducation pour la santé (cfes), where he took on fearlessly big tobacco and big alcohol, achieving international acclaim. for danzon and charpak the important question is not why there is such a variation between countries in the number of hospital beds per thousand population, or the expenditure on health service per capita, but why such a big divide in expectation of life, and deaths from preventable illness and accidents. the chapters in this fascinating dialogue span the obstacles to vaccination, health risks, the food industry, ebola, depression and suicide, public and private sector financing for health, and finally the strategies for the reorientation of health service towards health. the book underlines the reactionary bias of many health professionals and policy makers in their visions of health services, plus the sheer political and commercial threats of industries that kill people. this stimulating book just lacks an english edition and an index. their review, through the engaging process of dialogue, offers to the reader fresh access into the corridors of power at ministerial and international levels. in an encounter with dr. danzon in paris, on my recent travels, i was further astonished at the snowdon type revelations he cited on the clandestine snooping, with high-tech gadgets, uncovered in international health offices, that presents a sinister challenge to collegial confidence and collaboration. danzon and his colleague, after two terms at the top in the who in europe, draw back the veil on deliberations on the changing face of the health sector in the rapid period of transformation after the gorbachev years, which saw half of europe re-emerging from its http://www.editions-belin.com/ servile status under the heavy imprint of the soviet era. yet the authors see the liberation of europe as a capricious process in which the fundamentals of the welfare state, the opportunities and flaws of the free market model, the democratic process of greater freedom of speech and the re-action by ordinary people, all come into sharp confrontation with both professional authority and commercial clout. this confrontation tested the metal of those at the top. the dialogue throws new light on the way danzon and his colleagues kept the show on the road, whilst challenging the traditional inertia of health systems, by offering a fresh agenda of innovative action especially against commercial interests that were undermining health. at the same time the health press awakened by the voice of the people, vigorously questioned the role of the who and the rigid authority of health professionals. the notion of context is a leitmotif that pervades this fascinating book, for whilst international comparative analysis is deeply penetrating, the pursuit of health has to be conducted in each place in a way relevant to local capacities and priorities. for some the focus is safe water, for others mental health and wellbeing. the mission of the authors is to reveal insider dealing in the quest for improving world health. but, whilst truth is neither simple nor absolute, this important book offers a fresh motivation to analysis which should stimulate public and private reflections on health outcomes, at home and abroad. dr. john l. roberts email: john.laing@hotmail.com @ 2016 mauritian current affairs magazine weekly mailto:john.laing@hotmail.com